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TEAM “HEARTBREAK”

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Michael Lukin
Michael Lukin

Look Into My Eyes FH 36


To diagnose you, your doctor or specialist may look for hard-to-spot physical signs of FH in your eyes and on certain tendons and joints. This physical exam, along with your family history and your LDL levels, may be enough for them to go on. But they might also recommend a genetic test to confirm an FH diagnosis.




Look Into My Eyes FH 36


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Your fundal height in centimeters should be close to the number of weeks you are in pregnancy, plus or minus 2 centimeters. However, this is only the case from about weeks 20 to 36. Before 20 weeks of pregnancy, your fundus is not high enough. After 36 weeks of pregnancy, your fundus starts to go down. This is because the fetus has dropped into your pelvis to prepare for labor. If this drop doesn't happen, this can indicate the fetus is breech.


Along the way, better control measures arrived. I began taking a statin within a couple of months of the availability of the first statin. My siblings did the same, and our total cholesterol and LDL levels are now well controlled. But in the time before effective treatment, much damage was done. So now we must look to the health of our children and grandchildren, and apply all the knowledge and techniques at our disposal to protect them.


A different study looked at the Kahook Dual Blade. The retrospective study from Texas included 111 eyes of 90 patients who underwent KDB goniotomy from January to November 2016. KDB goniotomy was combined with cataract surgery in 100 eyes.2 The main outcome measures were postop IOP and the number of IOP lowering medications.


The features of Cornelia de Lange syndrome vary widely, and the severity of the disorder can differ even in individuals with the same gene variant. Researchers suspect that additional genetic or environmental factors may be important for determining the specific signs and symptoms in each individual. In general, SMC1A, RAD21, and SMC3 gene variants cause milder signs and symptoms than NIPBL gene variants. Variants in the HDAC8 gene cause a somewhat different set of features, including delayed closure of the "soft spot" on the head (the anterior fontanelle) in infancy, widely spaced eyes, and dental abnormalities. Like affected individuals with NIPBL gene variants, those with HDAC8 gene variants may have significant intellectual disability.


In about 15 percent of cases, the cause of Cornelia de Lange syndrome is unknown. Researchers are looking for additional changes in the known genes, as well as variants in other genes, that may cause this condition.


There are at least 30 different types of spinocerebellar ataxias (SCA) also referred to as autosomal dominant cerebellar ataxias (ADCA). These are divided into three categories based on they're typical presentation (See Table 2 below). The number of ADCAs increases each year as more protein products are genotyped (1).


Thrombosis of the retinal veins causes an increase in retinal capillary pressure resulting in increased capillary permeability and leakage of fluid and blood into the retina. Co-existent retinal ischaemia (see below) may exacerbate this process by the production of vascular endothelial growth factor (VEGF) which in turn promotes retinal capillary permeability and leakage into the extracellular space resulting in further development of MO. MO is the most common cause of visual impairment in RVO, followed by foveal ischaemia.


Both CRVO and BRVO can be broadly classified into ischaemic and non-ischaemic types based on the area of capillary non-perfusion, and this distinction is useful for clinical management. It is arguable if these are two separate entities or just ends of a spectrum. The Central Retinal Vein Occlusion study defined ischaemic CRVO as fluorescein angiographic evidence of more than ten disc areas (DA) of capillary non-perfusion on seven-field fundus fluorescein angiography [5, 6]. However, this definition of >10DA is not appropriate with widefield or ultra-widefield imaging given the larger area imaged and unclear clinical significance of ischaemia in the far periphery. Capillary non-perfusion >10DA in the posterior pole of eyes with CRVO irrespective of imaging modality would suggest a high risk of neovascularisation [7]. An ischaemic index (ratio of capillary non-perfusion/total area visible) of >45%, total area of nonperfusion >75DA on ultra-widefield angiography or >10DA of posterior pole nonperfusion has been found to correlate with neovascularisation [7, 8]. It is also important that a clear distinction is made between macular ischaemia and an ischaemic RVO (i.e. global retinal ischaemia). Furthermore, the definition of an ischaemic CRVO may not simply depend on angiography findings but also other parameters such as visual acuity, relative afferent pupillary defect and electrodiagnostic test findings.


Non-ischaemic CRVO may resolve without any complications. Macular oedema (MO) is the most common complication from CRVO and anti-VEGF treatment is successful at improving vision in eyes with MO secondary to CRVO.


However, 30% of eyes with non-ischaemic CRVO may convert to an ischaemic CRVO over 3 years. Prompt anti-VEGF therapy does not completely prevent worsening of retinal nonperfusion in eyes with CRVO [9]. Anti-VEGF therapy in eyes with an ischaemic CRVO retains the risk of neovascularisation and will need close monitoring following cessation of anti-VEGF therapy.


Intravitreal injections of licensed anti-VEGF or dexamethasone implant are the recommended treatment of MO secondary to CRVO, based on clinician and patient choice, taking into account treatment frequency, risk of IOP rise and cataract formation.


Eyes with a presenting vision of 6/96 or worse (eyes that were excluded from clinical trials), anti-VEGF should still be considered if there is presence of significant MO as reasonable improvements in vision may still occur. However, if oedema resolve with no improvement in visual acuity following a trial of anti-VEGF, cessation is recommended after three injections.


Study design. Healey et al pooled data from 778 eyes across 13 studies (four randomized controlled trials and nine nonrandomized or single-arm studies) to determine the effects of standalone trabecular micro-bypass glaucoma surgery with iStent devices in patients with open-angle glaucoma. The follow-up was a minimum of 6 months and up to 60 months. The study population was heterogeneous; some studies concentrated on newly diagnosed patients while others included those who were uncontrolled with one or two medications, those who were not controlled with two or three medications, and those who needed incisional surgery.


The adverse events were minimal but included progression of preexisting cataract (which is not surprising given the age of the study population) and loss of BCVA. The rates, however, were no different compared to those reported in comparative medical therapy study arms. Only 4.5% required cataract surgery, and 2.6 eyes required a secondary glaucoma intervention in the form of a filtering procedure. Personally, I don't consider that to be a complication because the iStent is not designed to replace a trabeculectomy.


Study design. Nichani and colleagues performed a review of 3,476 eyes across 20 randomized clinical trials that were published in English and were peer-reviewed. Observational studies were included with the target follow-up of at least 1 year. The study compared combined phacoemulsification and MIGS versus phacoemulsification alone. It also compared various MIGS procedures and MIGS versus topical medication.


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