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A Novel Technique for Repositioning of a Migrated ILUVIEN(Â®) (Fluocinolone Acetonide) Implant into the Anterior Chamber. - Ophthalmology and therapy
Fluocinolone acetonide (FAc) intravitreal implant (ILUVIEN(Â®); Alimera Sciences Limited, Aldershot, UK) has been approved in the UK for the treatment of chronic diabetic macula edema, insufficiently responsive to available therapies. It is inserted into the vitreous cavity through a 25-gauge needle. Migration of the implant to the anterior chamber (AC) can occur through gaps in the posterior capsule especially in vitrectomized eyes. Early removal of AC-dislocated FAc implant is essential to prevent corneal edema and damage from raised intraocular pressure.To demonstrate a simple and novel technique, with a previous capsular tear, for removal of AC-migrated FAc implant and reinsertion into the vitreous cavity without compromising implant integrity.A side port incision was created with a keratome and an anterior chamber maintainer introduced and secured. Subsequently, a corneal incision was created at 12 o'clock through which a 23-gauge backflush needle (flute needle) was advanced into the anterior chamber and passive suction used to secure the implant. The flute needle was then placed through the defect in the posterior capsule and the exit port blocked, causing loss of suction and allowing the implant to fall into the posterior segment. The sulcus intraocular lens (IOL) was centralized simply by manipulating it approximately 180 degrees to provide adequate anterior capsule support.The FAc implant was successfully removed from AC in two patients and reinserted into the vitreous cavity without damage or complications either for the eye or the implant. IOL in both patients were repositioned to close the gap in posterior capsule. After 2Â months, the implant remains in the vitreous cavity. This paper presents data from one of these cases.Using 23-gauge flute needle to retrieve dislocated FAc implant is a safe and easy technique.Alimera Sciences Ltd.
The Case Mix of Patients Presenting with Full-Thickness Macular Holes and Progression before Surgery: Implications for Optimum Management. - Ophthalmologica. Journal international d'ophtalmologie. International journal of ophthalmology. Zeitschrift fuÌˆr Augenheilkunde
Analysis of pre-operative spectral domain optical coherence tomography (SD-OCT) characteristics of full-thickness macular holes (FTMH) and effect on optimum management.We retrospectively reviewed SD-OCT characteristics of a consecutive cohort of patients waitlisted for FTMH surgery and categorized them by current evidence-based treatments.Out of the 106 holes analysed, 36 were small, 40 medium and 30 large. Initially, 33 holes had vitreomacular adhesion (VMA). 41 holes were analysed for change in characteristics with a median duration of 8 weeks between the scans. The number of small or medium holes decreased from 20 to 6 and that of large holes doubled. The number of holes with VMA halved. Smaller hole size (p = 0.014) and being phakic (p = 0.048) were associated with a larger increase in size. The strongest predictor of hole progression into a different surgical management category was the presence of VMA.FTMH characteristics can change significantly pre-operatively and affect optimal treatment choice.
Does bone debris in anterior cruciate ligament reconstruction really matter? A cohort study of a protocol for bone debris debridement. - SICOT-J
The purpose of the current study was to determine whether a systematic five-step protocol for debridement and evacuation of bone debris during anterior cruciate ligament reconstruction (ACLR) reduces the presence of such debris on post-operative radiographs.A five-step protocol for removal of bone debris during arthroscopic assisted ACLR was designed. It was applied to 60 patients undergoing ACLR (Group 1), and high-quality digital radiographs were taken post-operatively in each case to assess for the presence of intra-articular bone debris. A control group of 60 consecutive patients in whom no specific bone debris protocol was applied (Group 2) and their post-operative radiographs were also checked for the presence of intra-articular bone debris.In Group 1, only 15% of post-operative radiographs showed residual bone debris, compared to 69% in Group 2 (pÂ <Â 0.001).A five-step systematic protocol for bone debris removal during arthroscopic assisted ACLR resulted in a significant decrease in residual bone debris seen on high-quality post-operative radiographs.
The staining pattern of brilliant blue G during macular hole surgery: a clinicopathologic study. - Investigative ophthalmology & visual science
To describe the intraoperative staining pattern of the internal limiting membrane (ILM)-specific dye Brilliant Blue G (BBG) in a cohort of patients with idiopathic macular holes; to analyze the associations of the staining pattern with pre- and postoperative variables and to correlate the staining pattern with transmission electron microscopy (TEM) of the excised ILM.Fifty-five consecutive patients were studied. The staining pattern was divided into three subtypes based on the intraoperative appearance. The presence of a narrow rim of nonstaining around the macular hole (MH) edge was noted and measured. In the final 21 patients, the excised ILM was examined with TEM.The pattern of staining observed was categorized as uniform in 33 patients (60%), patchy nonstaining in 17 (31%), and no visible staining in 5 (9%). The staining pattern correlated with the MH stage. In the patients with uniform or patchy staining, a nonstaining rim was observed in 26 (52%) of the 50. The presence of a rim was associated with a greater hole diameter and lower postoperative visual acuity. The stain pattern correlated significantly with the amount of cellular tissue on the vitreous side of the ILM on TEM, with a greater proportion of multicellular layer membranes and new collagen in the incomplete staining groups.A variety of nonstaining patterns around macular holes can be observed using BBG, and these patterns correlate to the amount of cellular tissue on the vitreous side of the ILM seen histologically. These patterns could be used to guide the ILM peeling requirement or extent in future studies.Copyright 2014 The Association for Research in Vision and Ophthalmology, Inc.
ILM peeling technique influences the degree of a dissociated optic nerve fibre layer appearance after macular hole surgery. - Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fuÌˆr klinische und experimentelle Ophthalmologie
We sought to assess the effect of two different internal limiting membrane [ILM] peeling techniques carried out during surgery for idiopathic macular holes on the postoperative extent of a dissociated optic nerve fibre layer appearance [DONFL].We collected prospective data of surgical records, videos, and pre- and postoperative imaging of a consecutive series of patients undergoing surgery for idiopathic macular hole with one of two surgeons. One surgeon used a forceps pinch-peel technique to peel the ILM, whereas the other surgeon used a diamond dusted membrane scraper. The extent of any DONFL was measured using spectral domain optical coherence tomography and blue reflectance imaging at three months postoperatively. A proportion of the ILMs removed were examined with transmission electron microscopy.Fifty-seven patients were studied, with 41 in the forceps group and 16 in the scraper group. The groups were well matched, with no significant difference in any preoperative parameters. Some degree of DONFL was observed on the 3-month blue reflectance images in 88 % of the forceps group and 100 % of the scraper group [pâ€‰=â€‰0.14]. There was a significant difference in the total number of depressions in the nerve fibre layer typical of DONFL on OCT between the two groups [pâ€‰=â€‰0.001], and general regression analysis showed that the peeling technique used had the only significant association with the degree of DONFL observed. Electron microscopy showed large patches of cellular debris on the retinal side of the peeled ILM in 3 out of 4 cases in the scraper group and 1 out of 12 cases in the forceps group.ILM peeling technique and possibly other surgeon-specific factors appear to influence the extent of DONFL observed after ILM peeling macular hole surgery.
Progressive retinal detachment secondary to juxtapapillary microholes in association with type 3 posterior staphylomas. - Clinical ophthalmology (Auckland, N.Z.)
This study describes a novel subtype of retinal detachment occurring in eyes with pathological myopia associated with type 3 posterior staphyloma and discusses the management options.We retrospectively reviewed the case notes of seven patients who presented with unilateral symptomatic rhegmatogenous retinal detachment secondary to nasal juxtapapillary microholes.All seven patients had pathological myopia and an associated peripapillary type 3 posterior staphyloma. They all presented with symptoms of acute posterior vitreous detachment and had progressive retinal detachment. All cases were discovered to have a single juxtapapillary hole less than 1 disc diameter from the optic-nerve head, within areas of nasal chorioretinal atrophy. The microholes were identified intraoperatively in six of seven cases, with one case identified preoperatively on optical coherence tomography. In the four most recent cases, successful retinal reattachment was achieved with vitrectomy and C2F6 gas tamponade. The remaining three cases were managed with vitrectomy and silicone oil.Seven patients with pathological myopia, type 3 posterior staphyloma, and progressive retinal detachment secondary to juxtapapillary microholes are presented in this paper. High clinical suspicion is required to identify these breaks. Successful retinal reattachment with pars plana vitrectomy and long-acting gas is possible.
Avascular necrosis of femoral head: a rare complication of a common fracture in an octogenarian. - Geriatric orthopaedic surgery & rehabilitation
Avascular necrosis (AVN) of the femoral head is a relatively uncommon complication following an extracapsular hip fracture. Although it can occur following fixation of unstable 3-part or 4-part intertrochanteric fractures with significant posteromedial and posterolateral comminution, it remains a rare complication. We present a case of AVN of the femoral head following fixation of a stable 2-part intertrochanteric fracture in spite of good healing at the hip fracture site. This is a rare but eminently treatable cause of persisting hip pain after hip fracture surgery, and primary or secondary care physicians should be aware of this possibility.
The challenges of caring for patients with influenza. - Nursing older people
Influenza is an acute, highly infectious viral infection. Seasonal outbreaks occur annually across the world, presenting a major public health challenge. Older people and those with chronic conditions are most at risk and for these groups secondary infection and complications can be severe. Implementing infection prevention and control measures is not straightforward because of the types of settings where many older people receive care, the special needs of frail older people likely to be most seriously affected, and because little is known about the mode of transmission of the virus.
Inadvertent screw stripping during ankle fracture fixation in elderly bone. - Geriatric orthopaedic surgery & rehabilitation
Poor screw purchase because of osteoporosis presents difficulties in ankle fracture fixation. The aim of our study was to determine if cortical thickness, unicortical versus bicortical purchase, and bone mineral density are predictors of inadvertent screw stripping and overtightening. Ten paired cadaver ankles (average donor age, 81.7 years; range, 50-97 years) were used for the study. Computed tomography scanning with phantoms of known density was used to determine the bone density along the distal fibula. A standard small-fragment, 7-hole, one-third tubular plate was applied to the lateral surface of the fibula, with 3 proximal bicortical cortical screws and 2 distal unicortical cancellous screws. A posterior plate, in which all 5 screws were cortical and achieved bicortical purchase, was subsequently applied to the same bones and positioned so that the screw holes did not overlap. A torque sensor was used to measure the torque of each screw during insertion (Ti) and then stripping (Ts). The effect of bone density, screw location, cortical thickness, and unicortical versus bicortical purchase on Ti and Ts was checked for significance (P < .05) using a general linearized latent and mixed model. We found that 9% of the screws were inadvertently stripped and 12% were overtightened. Despite 21% of the screws being stripped or being at risk for stripping, we found no significant predictors to warn of impending screw stripping. Additional work is needed to identify clinically useful predictors of screw stripping.
Prospective assessment of dorsal cheilectomy for hallux rigidus using a patient-reported outcome score. - The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons
Compared with other surgical procedures for hallux rigidus, dorsal cheilectomy involves relatively less bone removal, maintains joint motion, and leaves the potential for further salvage surgery. The Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ) has a maximum score of 64 (worst foot health) and has been endorsed by the British Foot and Ankle Society to measure surgical outcome. We prospectively assessed patient-reported outcomes after dorsal cheilectomy for hallux rigidus using the MOXFQ. Patients were deemed suitable for dorsal cheilectomy if they had painful restriction of terminal dorsiflexion, with absence of pain in the mid-range of passive movement, and radiographic evidence of dorsal osteophytosis. Twenty-five patients with a mean age of 62 years (range, 39-80 years), including 17 (68%) women, underwent dorsal cheilectomy for hallux rigidus. The mean preoperative MOXFQ score was 33.0 (95% confidence interval = 27.4-38.6), and, at a mean of 17 months (range, 9-27 months) follow-up, the mean postoperative score was 9.6 (95% confidence interval = 6.0-13.2). Eighty-four percent of patients experienced clinically significantly improved walking domain, 68% in the social domain, and 59% in the pain domain of the MOXFQ. Four patients failed cheilectomy, including 3 who subsequently underwent arthrodesis for persistent pain and 1 who experienced no improvement in any domain of the MOXFQ. This prospective study provided further evidence of the success of dorsal cheilectomy as a treatment for hallux rigidus and demonstrated the potential usefulness of the MOXFQ in assessing surgical outcomes in foot surgery.Copyright 2010 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
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