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Age-related divergence insufficiency-esotropia (ARDIE) is characterized by greater esodeviation at distance than near. This study aims to compare the outcomes of unilateral and bilateral surgical approaches.Sixty-two cases treated at the Kellogg Eye Center, the University of Michigan, from 1995 to 2018 were retrospectively reviewed. One surgeon used unilateral procedures including unilateral medial rectus recession (n = 24, group 1) or unilateral recession-resection (n = 18, group 2) with an adjustable suture. Another surgeon used bilateral medial rectus recession with fixed sutures (n = 20, group 3).For patients with distance esodeviation15∆, postoperative distance deviations in both group 1 and group 3 were not statistically different (p = .352). For patients with esodeviations 15-20∆, postoperative distance deviations in all 3 groups were also not statistically different (p = .142). Similarly, patients with deviations20∆ did not show significantly different postoperative distance alignment (p = .082) between group 2 and 3. Overall, group 2 had the highest overall success rate (90%) (mean at distance = 1.17∆ exodeviation, at near = 2.33∆ exodeviation).Both unilateral medial rectus recession ± lateral rectus resection and bilateral medial rectus recession surgical approaches produced similar favorable outcomes in ARDIE.

Previous studies examining the association of retinal vein occlusion (RVO) and cardiovascular events have been inconsistent and have mostly focused on stroke and myocardial infarction. The goal of this study is to use meta-analysis to examine the available evidence examining the association of RVO with incident cardiovascular events and mortality.Systematic review and meta-analysis of all longitudinal cohort studies published in PubMed, Embase, and the Cochrane Library from inception to April 7, 2018, that evaluated the association of baseline RVO and incident cardiovascular events and/or mortality, that provided multivariate-adjusted risk estimates with 95% confidence intervals (95% CIs), and that had average follow-up ≥1 year. The Newcastle-Ottawa scale was used to assess study quality. Multivariate-adjusted risk estimates with 95% CI along with study characteristics were extracted from each study, and pooled risk ratios (RRs) with 95% CI were generated using a random-effects model with inverse-variance weighting to account for heterogeneity. Main outcomes were incident stroke (fatal or nonfatal), myocardial infarction, heart failure, peripheral arterial disease, all-cause mortality, and cardiovascular mortality.Fifteen cohort studies with a total of 474,466 patients (60,069 with RVO and 414,397 without RVO) were included. Each study had Newcastle-Ottawa scale score ≥6, indicating moderate-to-high quality. Retinal vein occlusion was associated with increased risk of stroke (RR = 1.45; 95% CI, 1.31-1.60), myocardial infarction (RR = 1.26; 95% CI, 1.17-1.37), heart failure (RR = 1.53; 95% CI, 1.22-1.92), peripheral arterial disease (RR = 1.26; 95% CI, 1.09-1.46), and all-cause mortality (RR = 1.36; 95% CI, 1.02-1.81), but was not associated with increased risk of cardiovascular mortality (RR = 1.78; 95% CI, 0.70-4.48).This review suggests patients with RVO have an increased risk of cardiovascular events and all-cause mortality. More studies are needed to determine the highest risk periods for cardiovascular events and mortality after RVO and whether immediate cardiovascular evaluation and intervention will improve outcomes.

Orbital arteriovenous malformations are rare congenital vascular anomalies that can cause eyelid distortion, proptosis, diplopia, and vision loss. The current treatment paradigm involves endovascular embolization followed by resection, with delayed reconstruction. The authors report 2 young adult patients with orbital arteriovenous malformations, who underwent embolization followed days to months later by resection with immediate soft tissue reconstruction. For both patients, the immediate outcome provided good functionality and cosmesis. The authors conclude that immediate reconstruction after embolization-resection of orbital arteriovenous malformations may facilitate early return of form and function for patients, improve quality of life, and potentially reduce the need for further reconstructive procedures.

ObjectiveFovea-involving subretinal haemorrhage is challenging to manage with uncertain visual outcomes. We reviewed outcomes of patients with fovea-involving macular haemorrhage treated with pars plana vitrectomy (PPV) and subretinal tissue plasminogen activator (tPA) with pneumatic displacement.Methods and AnalysisThis is a retrospective interventional case series. All patients with submacular haemorrhage who underwent PPV with subretinal tPA injection were included. Reasons for exclusion encompassed patients who underwent intravitreal tPA injection in the office without surgery, insufficient follow-up or documentation. Primary outcomes of interest were postoperative visual acuity (VA) at month 1 and 3. Secondary outcomes were median VA at month 3 by location of haemorrhage and underlying diagnosis.ResultsThirty-seven total patients were included. The mean age was 68.2 years, with 54.1% (20/37) females. The most common aetiology was exudative macular degeneration (43.2%), followed by undifferentiated choroidal neovascularisation (CNV) (18.9%), polypoidal choroidal vasculopathy (18.9%), traumatic CNV (10.8%), macroaneurysm (5.4%) and proliferative diabetic retinopathy (2.7%). Median preoperative VA was 20/2000, postoperative month 1 was 20/347 (pConclusionsPPV with subretinal tPA injection and pneumatic displacement of submacular haemorrhage offers modest visual recovery for a diverse group of patients. Location of haemorrhage or specific diagnosis may not predict outcome.

Geriatric patients (age ≥ 65) are prone to complications after surgery and are at risk for severe thyroid eye disease (TED). In this study, we aim to identify preoperative demographic and TED patterns associated with geriatric patients who underwent decompression surgery, to examine the effect of age on postoperative strabismus rates, and to identify factors that may contribute to postoperative strabismus in the geriatric subgroup. We retrospectively reviewed patients who underwent thyroid-related orbital decompression surgery at the Kellogg Eye Center, University of Michigan, between 1999 and 2014. Primary outcome was postoperative strabismus requiring palliation with prisms and/or strabismus surgery. Descriptive, univariate, and multivariable logistic regression analyses were used to define association of geriatric age with postoperative strabismus and determine predictors of postoperative strabismus. Of 241 patients, 41 (17.0%) were geriatric. They were less likely to undergo bilateral decompression (P = 0.012), less likely to be current smokers at time of decompression (P = 0.002), and more likely to have preoperative primary gaze diplopia (P = 0.001). Postoperative strabismus rates for geriatric patients (≥ 65 years of age), versus ages 50–65, 30–50, and < 30, were 73.2%, 41.3%, 31.9%, and 15.8%, respectively (P = 0.002). On multivariable analysis, geriatric age remained an independent risk factor for postoperative strabismus when compared to each age group (P ≤ 0.001). Among geriatric patients in subgroup multivariable analysis, balanced as opposed to lateral wall decompression (P = 0.038) and shorter TED duration (P = 0.031) were independently predictive of postoperative strabismus.

Purpose To compare the visual and exophthalmometry outcomes of simultaneous versus staged balanced decompression in patients with thyroid-related compressive optic neuropathy (CON). Methods All consecutive patients who underwent simultaneous or staged balanced decompressions for clinically diagnosed thyroid-related CON performed by 4 surgeons at the Kellogg Eye Center of the University of Michigan between 1999 and 2014 were included in the study. Demographic, medical, and surgical covariates were collected. Orbits were stratified by decompression technique. Primary outcomes were improvement in CON score (which quantifies visual dysfunction using logarithm of the minimum angle of resolution, color vision, and Humphrey visual field mean deviation), and improvement in proptosis. The authors performed univariate and descriptive statistics to identify baseline differences and covariates associated with the outcomes of interest; multivariate mixed linear regression models (to adjust for interorbit correlation) were then constructed with inclusion of potential confounders with p value ≤0.1. Results In total, 80 orbits of 53 patients were included in the study. Of the 80 orbits, 61% underwent simultaneous balanced decompression, and 39% underwent staged balanced decompression. Mean CON score reduction was 6.12 ± 9.7 and mean proptosis reduction was 5.63 ± 2.6 mm. Staged balanced decompression was significantly associated with greater CON score reduction (p = 0.038). However, staged (vs. simultaneous) decompression technique did not remain an independent predictor (p = 0.950) after multivariate analysis adjusted for confounders. For proptosis reduction, there were no statistically significant differences between simultaneous and staged balanced decompression on univariate (p = 0.122) or multivariate mixed linear regression models (p = 0.812). Conclusion Simultaneous and staged balanced decompression are equally efficacious in treating visual dysfunction and exophthalmos due to thyroid eye disease in patients with clinically diagnosed CON. Patient choice should be the primary consideration and care should be individualized. Further studies validating the CON score used in the study and comparative studies individualizing surgical treatment of thyroid eye disease are warranted.

This study examines the association between cannabis use and the hospital course of patients admitted to the psychiatric inpatient unit with a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder. Many confounding variables potentially contribute to the clinical presentation of hospitalized patients in the psychiatric unit. Illicit drug use, in particular, has been associated with acute agitation, and questions can be raised as to what lasting effects drug use prior to admission may have throughout a patient's hospital stay.Subjects with a discharge diagnosis of bipolar disorder, schizophrenia, schizoaffective disorder, or psychosis not otherwise specified (N = 201) were retrospectively identified, and those with positive results of urine drug screen for cannabis on admission were compared to negative counterparts. Agitation and aggression were measured using an adaptation of the Excited Component of the Positive and Negative Syndrome Scale (PANSS-EC). These markers were also quantified by comparing charted episodes of restraint and seclusion and administration of as needed medications, such as benzodiazepines and antipsychotics.Positive urine drug screen results for cannabis was correlated with young (p = .001) males (p = .003) with bipolar disorder (p = .009) exhibiting active manic symptoms (p = .003) at the time of admission. Cannabis use was further associated with a shorter length of stay (p = .008), agitation triggering adapted PANSS-EC nursing assessments (p = .029), and oral medications as needed (p = .002) for agitation.Cannabis use, as defined by positive urine drug screen results, was more common in patients with bipolar disorder and was accompanied by a higher incidence of inpatient agitation. Although these patients also had short hospital lengths of stay, there was no clear relationship between level of agitation and length of stay across all patient groups. One possible explanation for patients with bipolar disorder experiencing short lengths of stay is that their source of agitation may be more closely related to a complex effect of cannabis use rather than a sole etiology of mental illness. Inpatient clinicians should be aware of patient cannabis use proximate to admission.

Thyroid eye disease (TED) usually has mild manifestations in pediatric patients, and orbital decompression is rarely necessarily. The authors present the clinical course of 3 pediatric patients age 16 or younger at the time of decompression surgery with severe orbitopathy. Case 1 is a 9-year-old prepubertal Asian-American female with Graves' disease and TED who underwent balanced decompression for compressive optic neuropathy. Case 2 is a 14-year-old white female with Graves' disease and TED who underwent balanced decompression for compressive optic neuropathy, stretch optic neuropathy, and globe subluxation. Case 3 is a 14-year-old African-American male with unilateral euthyroid TED who underwent staged right-sided lateral, medial, and floor decompressions for asymmetric proptosis. All cases also had disfiguring proptosis and exposure keratopathy, and in all cases, surgery successfully ameliorated the indications. Children, both pre- and post-pubertal, can rarely manifest visually threatening severe orbitopathy due to TED. This represents the first reports of thyroid-related optic neuropathy and globe subluxation in pediatric patients. Further studies examining the mechanism responsible for the disparities in pediatric and adult TED are warranted.

Obstructive sleep apnea (OSA) has been associated with an array of ocular disorders. This systematic review aims to investigate the association of OSA with central serous chorioretinopathy (CSCR) and subfoveal choroidal thickness changes on enhanced depth imaging optical coherence tomography.Systematic review and meta-analysis of all articles published up to November 2017 examining rate of OSA in patients with CSCR versus controls or examining subfoveal choroidal thickness measurements on enhanced depth imaging optical coherence tomography in patients with OSA versus controls. Pooled odds ratios and weighted mean difference with 95% confidence intervals (CIs) were calculated.For the CSCR/OSA analysis, 7,238 patients (1,479 with CSCR and 5,759 controls) from 6 studies were eligible. For the choroidal thickness/OSA analysis, 778 eyes of 778 patients (514 with OSA and 264 controls) from 9 studies were eligible. Patients with CSCR had a 1.56 increased odds of having OSA than controls (odds ratio, 1.56; 95% CI, 1.16-2.10). There was no statistically significant difference in choroidal thickness between mild OSA subjects and controls (weighted mean difference = -3.17; 95% CI, -19.10 to 12.76). Patients with moderate OSA (weighted mean difference = -24.14; 95% CI, -42.16 to -6.12) and severe OSA (weighted mean difference = -51.19; 95% CI, -99.30 to -3.08) had thinner choroidal thickness measurements than controls.In summary, our results suggest that patients with CSCR are more likely to have OSA, and that moderate/severe OSA is associated with smaller subfoveal choroidal measurements on enhanced depth imaging optical coherence tomography.

Importance Solar retinopathy is a rare form of retinal injury that occurs after direct sungazing. Objective To enhance understanding of the structural changes that occur in solar retinopathy by obtaining high-resolution in vivo en face images. Design, Setting, and Participant Case report of a young adult woman who presented to the New York Eye and Ear Infirmary with symptoms of acute solar retinopathy after viewing the solar eclipse on August 21, 2017. Main Outcomes and Measures Results of comprehensive ophthalmic examination and images obtained by fundus photography, microperimetry, spectral-domain optical coherence tomography (OCT), adaptive optics scanning light ophthalmoscopy, OCT angiography, and en face OCT. Results The patient was examined after viewing the solar eclipse. Visual acuity was 20/20 OD and 20/25 OS. The patient was left-eye dominant. Spectral-domain OCT images were consistent with mild and severe acute solar retinopathy in the right and left eye, respectively. Microperimetry was normal in the right eye but showed paracentral decreased retinal sensitivity in the left eye with a central absolute scotoma. Adaptive optics images of the right eye showed a small region of nonwaveguiding photoreceptors, while images of the left eye showed a large area of abnormal and nonwaveguiding photoreceptors. Optical coherence tomography angiography images were normal in both eyes. En face OCT images of the right eye showed a small circular hyperreflective area, with central hyporeflectivity in the outer retina of the right eye. The left eye showed a hyperreflective lesion that intensified in area from inner to middle retina and became mostly hyporeflective in the outer retina. The shape of the lesion on adaptive optics and en face OCT images of the left eye corresponded to the shape of the scotoma drawn by the patient on Amsler grid. Conclusions and Relevance Acute solar retinopathy can present with foveal cone photoreceptor mosaic disturbances on adaptive optics scanning light ophthalmoscopy imaging. Corresponding reflectivity changes can be seen on en face OCT, especially in the middle and outer retina. Young adults may be especially vulnerable and need to be better informed of the risks of viewing the sun with inadequate protective eyewear.

Quetiapine, dispensed as Seroquel, has become 1 of the 100 most commonly prescribed medications in the United States in the past 10 years. It has fewer extrapyramidal side effects than first-generation antipsychotics, but it has been associated with low to moderate weight gain, hyperlipidemia/hypercholesterolemia, and new-onset diabetes, with half of these cases manifesting as diabetic ketoacidosis (DKA). We present a case of a middle-aged man who developed diabetes mellitus (DM) manifesting as hyperglycemic crisis and severe reversible hyperlipidemia. Literature on antipsychotic-associated metabolic adverse effects and clinical recommendations is presented.

Despite the number of publications on orbital decompression surgery for thyroid eye disease, there are few comparative studies and most studies are underpowered. The goal of the study is to use multivariable analysis to identify independent patient and disease-related predictors of response to decompression surgery and of need for secondary decompressions. The authors retrospectively reviewed all patients who underwent transorbital thyroid-related orbital decompression surgery at the Kellogg Eye Center of the University of Michigan between 1999 and 2014. Demographic, medical, and surgical covariates were collected. Decompression techniques included medial, lateral, and balanced decompressions, with or without orbital fat removal. Main outcomes included proptosis reduction and secondary decompressions, both analyzed at the orbital level. Univariate and multivariable analyses (with adjustment for interorbit correlation) were conducted to determine predictors of the outcomes of interest. Mean proptosis reduction was 3.8 ± 2.4 mm (mean ± standard deviation, N = 420 orbits). The secondary decompression rate was 13.8% (82/594). On multivariable mixed linear regression, larger preoperative proptosis (p < 0.0001), balanced decompression (p = 0.0002), thyroid eye disease duration < 4 years (p = 0.0093), and history of orbital radiation (p = 0.0111) were all predictive of greater proptosis reduction. On multivariable survival modeling, factors associated with increased hazard for secondary decompression include younger age (p = 0.0434), larger preoperative proptosis (p = 0.0001), unilateral decompression (p = 0.0272), preoperative steroid treatment (p = 0.0200), and normal thyroid function (p = 0.0148). Factors associated with decreased hazard include adjunctive fat decompression (p = 0.0004), balanced decompression (vs. lateral, p = 0.0039), and African-American ethnicity (p = 0.0076). Despite a diverse study cohort, the authors have identified factors associated with clinically relevant outcomes of decompression surgery for thyroid eye disease, including proptosis reduction and incidence of secondary decompression. Randomized controlled trials of different treatment algorithms for TED are needed to devise optimized guidelines for individualizing surgical care.

Incidence and predictors of neurosurgical interventions following nonsevere traumatic brain injury (TBI) with mildly abnormal head computed tomographic (CT) findings are poorly defined. Despite this, neurosurgical consultation is routinely requested in this patient population. Our objective was to determine incidence of neurosurgical intervention in this patient population and identify clinical and radiographic features predicting the subsequent need for these interventions.We identified all consecutive adult patients with nonsevere TBI admitted from January 1, 2001, through December 31, 2010. The definitions of "mildly abnormal initial head CT findings" and "neurosurgical interventions" were determined a priori by author consensus. Cumulative incidence of neurosurgical interventions was determined, and multivariate logistic regression was used to identify independent predictors of neurosurgical intervention.Of 677 patients, 51 underwent neurosurgical intervention for a cumulative incidence of 7.5%. Only 1.6% required an intracranial procedure. In adjusted analysis, presence of coagulopathy (odds ratio [OR], 2.21; 95% confidence interval [CI], 1.13-4.3; p = 0.02), suspected cerebrospinal fluid leak (OR, 11.36; 95% CI, 2.83-45.58; p = 0.001), any basal cistern or sylvian fissure subarachnoid hemorrhage (OR, 2.94; 95% CI, 1.56-5.57; p = 0.001), depressed skull fracture (OR, 2.84; 95% CI, 1.29-6.28; p = 0.01), or unstable repeated head CT findings (OR, 2.81; 95% CI, 1.52-5.2; p = 0.001) remained an independent predictor of the need for subsequent neurosurgical intervention.Among patients with nonsevere TBI and mildly abnormal head imaging findings in which routine neurosurgical consultation is obtained, there is a low incidence of neurosurgical interventions. Our findings suggest that routine early neurosurgical consultation in this patient population may not be necessary; however, this should be tested in a prospective, comparative study.Prognostic study, level III; therapeutic study, level IV.

Object The extent of resection (EOR) is a known prognostic factor in patients with glioblastoma. However, gross-total resection (GTR) is not always achieved. Understanding the factors that prevent GTR is helpful in surgical planning and when counseling patients. The goal of this study was to identify demographic, tumor-related, and technical factors that influence EOR and to define the relationship between the surgeon's impression of EOR and radiographically determined EOR. Methods The authors performed a retrospective review of the electronic medical records to identify all patients who underwent craniotomy for glioblastoma resection between 2006 and 2009 and who had both preoperative and postoperative MRI studies. Forty-six patients were identified and were included in the study. Image analysis software (FIJI) was used to perform volumetric analysis of tumor size and EOR based on preoperative and postoperative MRI. Using multivariate analysis, the authors assessed factors associated with EOR and residual tumor volume. Perception of resectability was described using bivariate statistics, and survival was described using the log-rank test and Kaplan-Meier curves. Results The EOR was less for tumors in eloquent areas (p = 0.014) and those touching ventricles (p = 0.031). Left parietal tumors had significantly greater residual volume (p = 0.042). The average EOR was 91.0% in this series. There was MRI-demonstrable residual tumor in 69.6% of cases (16 of 23) in which GTR was perceived by the surgeon. Expert reviewers agreed that GTR could be safely achieved in 37.0% of patients (17 of 46) in this series. Among patients with safely resectable tumors, radiographically complete resection was achieved in 23.5% of patients (4 of 17). An EOR greater than 90% was associated with a significantly greater 1-year survival (76.5%) than an EOR less than 90% (p = 0.005). Conclusions The authors' findings confirm that tumor location affects EOR and suggest that EOR may also be influenced by the surgeon's ability to judge the presence of residual tumor during surgery. The surgeon's ability to judge completeness of resection during surgery is commonly inaccurate. The authors' study confirms the impact of EOR on 1-year survival.

Carcinoid tumors are rare, slow-growing, low-grade neuroendocrine tumors with a propensity for orbital metastatic spread. The typical treatment paradigm for localized orbital disease involves excision, adjuvant radiotherapy, and/or receptor-targeted chemotherapy, followed by delayed evaluation for reconstructive strabismus surgery. We present a 58-year-old female patient with carcinoid tumor metastatic to the right inferior rectus muscle who presented with worsening binocular diplopia. The patient underwent coordinated "tag-team" orbital and strabismus surgeries that included excision of the right inferior rectus muscle to the annulus of Zinn followed immediately by reconstructive strabismus surgery. The patient required 1 additional strabismus surgery 1 year later. Follow up revealed no tumor recurrence at 4 years, and excellent binocular vision with good function. Deep orbital and strabismus surgeries, when performed simultaneously in a "tag-team" approach, may offer superior functional outcomes and improved patient quality of life, with expedited functional recovery. This approach may become a new treatment paradigm for surgical disease processes localized to the extraocular muscles.

Although imaging surveillance is mandatory for all patients after endovascular aneurysm repair (EVAR), many patients are not compliant with follow-up. We sought to determine predictors of compliance with EVAR surveillance and to examine how compliance with current surveillance protocols correlates with survival.We analyzed 188 patients who underwent EVAR at our institution for infrarenal abdominal aortic aneurysms (AAAs) between 2001 and 2011. The primary end point was compliance with post-EVAR surveillance recommendations. Univariate analysis included patient demographics and socioeconomic information, AAA characteristics, EVAR hospital course variables, late complications and secondary interventions, length of follow-up, smoking status, family history of AAA, driving distances, primary care providers, and medical comorbidities. Mortality was determined by the Social Security Death Index. Multinomial logistic regressions were fit to identify independent predictors of compliance. Survival plots were generated with the Kaplan-Meier method and compared with the log-rank test. Univariate and multivariate Cox regression analysis was used to determine effect of compliance on survival after adjusting for confounders.Of 188 patients, 89 (47.3%) were 100% compliant with follow-up visits and imaging, 21 (11.1%) were moderately compliant by missing appointments, and 78 (41.4%) were lost to follow-up completely. Overall median age was 74 years, and 81.9% of patients were male. Late complications occurred in 77 patients (40.9%), secondary interventions were performed in 32 patients (17%), and 5-year mortality was 21.2%. Mean follow-up interval was40 months for 100% compliant and moderately compliant patients and20 months for those lost to follow-up (P.0001). In adjusted analysis, late complications (odds ratio [OR], 2.71; 95% confidence interval [CI], 1.32-5.55; P = .007), absence of social work consultation (OR, 2.43; 95% CI, 1.12-5.27; P = .024), and family history of AAA (OR, 2.67; 95% CI, 1.06-6.75; P = .037) were associated with 100% compliance, whereas shorter driving distances (P = .051) and shorter hospital stay (P = .056) approached significance. Transient ischemic attack or stroke (OR, 3.59; 95% CI, 1.18-10.91; P = .024) was the only variable independently associated with moderate compliance. Compared with patients lost to follow-up, 100% compliant patients had worse survival (log-rank test, P = .033), whereas moderately compliant patients' survival was not significantly different (log-rank test, P = .149). In adjusted Cox regression analysis, 100% compliant patients had decreased survival duration (rate ratio, 2.67; 95% CI, 1.18-6.06; P = .018) compared with those lost to follow-up.Follow-up surveillance is incomplete for more than half of patients who undergo EVAR at our institution, and patient compliance can be predicted by covariates mentioned before. Compliance with current surveillance regimens does not confer a survival benefit. Further research individualizing surveillance protocols based on risk level of late complications and noncompliance and prospective studies examining resulting survival benefits of compliance are warranted.

Chronic spontaneously thrombosed abdominal aortic aneurysms (AAAs) are rare. We present a patient with a completely thrombosed abdominal aortic aneurysm found incidentally on imaging for evaluation of unrelated abdominal pain. The patient was asymptomatic with regards to the aneurysm due to extensive collateralization of the intercostal and lumbar arteries to the bilateral hypogastric and internal mammary arteries to the common femoral arteries bilaterally. Follow-up imaging after 10 months showed no aneurysmal change. Further study is needed regarding indications for elective repair, medical therapy, and surveillance modality and schedule for patients with chronically occluded AAAs as these patients are at risk for aneurysm rupture and thrombus propagation.