Porous polyethylene implants in orbital floor reconstruction

The purpose of this article is to present the authors' experience with the use of porous polyethylene ultrathin sheets for orbital floor reconstruction. Thirty-two patients with orbital floor fractures were treated with porous polyethylene ultrathin sheets. Sixteen cases corresponded to orbitozygomatic fractures, 11 cases corresponded to pure orbital floor fractures, and five corresponded to panfacial fractures. The subciliary approach was used in 15 patients and the transconjunctival approach in nine; another three patients were operated on through a preexisting eyebrow wound, two were operated on with a subtarsal approach, two were operated on through an eyebrow extension of a facial wound, and one patient was operated on through the facial wound. Intraoperatively, all patients received a prophylactic dose of intravenous antibiotics. Postoperatively, 24 patients received amoxicillin clavulanate for 5 to 7 days, two patients received clindamycin, and six patients received no antibiotics. Enophthalmos was corrected in 15 of 24 patients (62.5 percent), and hypoglobus in nine of 11 (82 percent). Diplopia was resolved in 25 of 28 patients (89.3 percent) with preoperative impairment. Extrinsic eye movement impairment was resolved in 25 of 27 patients (92.6 percent). A preoperative visual acuity deficit was present in four patients (12.5 percent) and was resolved in one (from 20/100 to 20/20). Visual acuity improved in one patient (from 20/60 to 20/30). In the other two patients, visual acuity remained altered (from 20/30 to 20/30). One patient (3.1 percent) suffered blindness induced by surgery. Nine of 26 patients (34.6 percent) had residual infraorbital nerve hypesthesia and five (19.2 percent) had residual paresthesias. Postoperatively, epiphora was present in six patients (18.8 percent) and ectropion in five (15.6 percent). Although there was no statistical significance between the surgical approach and the presence of epiphora (p = 0.211) and ectropion (p = 0.422), patients who were treated using the transconjunctival approach suffered reduced ectropion (0 percent) compared with patients treated using the subciliary approach (20 percent). However, patients treated using the transconjunctival approach suffered increased epiphora (22.2 percent) compared with those treated with the subciliary approach (13.3 percent). There were four cases (12.5 percent) of postoperative facial infections. Two of these cases were resolved with systemic antibiotics, one was resolved with bone sequestrum resection, and one patient needed removal of the implant. Orbital infections were related in all cases to titanium osteosynthesis miniplates or skull bone graft. When comparing patients who were treated with and without antibiotics, no statistical differences (p = 0.958) were found relative to the presence of infections. Correction of hypoglobus is technically easier than enophthalmos, because enophthalmic correction requires a wide, deep subperiosteal dissection and implant positioning, posterior to the equator of the globe, with the inherent risk of orbital apex injury.     

Orbital roof fractures in the pediatric population

Twenty-three patients aged 3.3 +/- 1.6 years (mean +/- SD) presented between January of 1984 and September of 1987 with fronto-orbital trauma resulting in fractures of one (N = 20) or both (N = 3) orbital roofs. All patients had computed tomography (CT) with axial and coronal sections that revealed three fracture patterns of the orbital roof (nondisplaced, superiorly displaced, and inferiorly displaced fractures). Orbital dystopia was exhibited in 35 percent (N = 8) of the patients. Exophthalmos was noted in 61 percent (N = 14) of the patients. Only 30 percent of the patients (N = 7) sustained associated maxillofacial fractures. Eight percent of fractures exhibited orbital encephaloceles. All patients lacked frontal sinus pneumatization. The majority of children with orbital roof fractures do not exhibit concomitant facial fractures. CT utilizing both axial and coronal sections is valuable in defining the extent and pattern of the fracture as well as in identifying associated neurologic injuries. Large, displaced orbital roof fractures, which occurred in 3 of 13 patients with displaced fractures in our series, should undergo early reduction to avoid late development of encephalocele.     

Penetrating keratoplasty and Verisyse iris-claw lens--is it safe for corneal graft?

The loss of the corneal endothelial cells, especially in a first postoperative year, has been observed in patients who underwent penetrating keratoplasty (PK). The implantation of new generation of "iris claw" phakic IOL (Verisyse) in refractive cases has been shown to cause clinicaly insignificant endothelial cell loss. In our prospective case series we investigated the endothelial cell loss and clinical outcome in patients that either underwent PK and implantation of PCIOL or PK and implantation of Verisyse IOL. In the first group of 9 patients scheduled for PK, implantation of Verisyse was performed due to the absence of the posterior capsule support. 2 of these patients had angle supported ACIOL, 4 patients were aphakic and 3 had posttraumatic cataract with ruptured posterior capsule. The second group of 12 patients had standard "triple" procedure (PK + ECCE + PCIOL). BCVA of both groups of patients prior the operation was hand movement in 12 patients, light perception in 7 patients and 0.05 in 3 patients. The preoperative endothelial cell count of the donor grafts obtained from the eye bank was 2800 cells/mm2 on average. The follow up was 6-10 months. Six months after the operation all "Verysise" patients maintained transparent graft. Postoperative visual acuity improvement was recorded in 18 out of 21 eyes (85.7%). Best spectacle corrected visual acuity of > or = 0.3 was achived in 55.5% in the Verisyse group and in 50.0% of "triple procedure" group. The endothelial cell count and morphology were estimated on the specular microscope on a monthly basis. Mean endothelial cells loss in patients with PK and Verysise was 40 +/- 8% and in patients with "triple" procedure was 42 +/- 12% at 10 postoperative months. There was no significant difference in the endothelial cell loss and clinical outcome between the group of patients who had PK and Verysise as compared to those with implanted PCIOL.     

A current 10-year retrospective survey of 199 surgically treated orbital floor fractures in a nonurban tertiary care center.

This study characterizes the surgically treated patient population suffering from orbital floor fractures by use of current data from a large series consisting of 199 cases taken from a nonurban setting. Data were gathered through a retrospective chart review of patients surgically treated for orbital floor fractures at the University of Michigan Health System, collected over a 10-year period. Data regarding patient demographics, signs and symptoms of presentation, cause of injury, nature of injury, associated facial fractures, ocular injury, and associated nonfacial skeleton trauma were collected. In total, there were 199 cases of orbital floor fractures among 189 patients. Male patients outnumbered female patients by a 2:1 ratio and were found to engage in a wider range of behaviors that resulted in orbital floor fractures. Motor vehicle accidents were the leading cause of orbital floor fractures, followed by physical assault and sports-related mechanisms. The ratio of impure to pure orbital floor fracture was 3:1. The most common signs and symptoms associated with orbital floor fractures, in descending order, were periorbital ecchymosis, diplopia, subconjunctival hemorrhage, and enophthalmos. Associated facial fractures were found in 77.2 percent of patients, the most prevalent of which was the zygoma-malar fracture. Serious ocular injury occurred in 19.6 percent of patients, with globe rupture being the most prevalent, accounting for 40.5 percent of those injuries. There was a 38.1 percent occurrence of associated nonfacial skeletal trauma; skull fracture and intracranial injury were the most prevalent manifestations. Associated cervical-spine fractures were rare (0.5 percent). Statistical examination, using odds ratios and chi-squared analysis, demonstrated significant associations that have not previously been reported. Impure and pure orbital floor fractures revealed striking differences in several demographic aspects, including mechanism of injury, signs and symptoms of presentation, spectrum of associated trauma, and the severity of concomitant trauma.     

Infraorbital nerve injury associated with zygoma fractures: documentation with neurosensory testing

Persistent sensibility abnormalities after correction of zygoma fractures indicate injury to the infraorbital nerve and may produce pain. To investigate this, a retrospective study of 25 patients who had undergone surgical correction of a zygoma fracture was performed. Bilateral neurosensory measurements were obtained with the Pressure-Specified Sensory Device (Sensory Management Services, Baltimore, Md.). Seven of the 25 patients had required orbital floor reconstruction. Each patient had undergone fracture correction at least 6 months earlier and was interviewed, at the time of sensibility testing, regarding symptoms related to the fracture. The data were evaluated by a blinded examiner, from a separate clinical facility, who attempted to predict the side of the fracture and the degree of zygoma displacement on the basis of measurements of sensibility of the paranasal, upper lip, and zygomaticotemporal areas. Seventy-six percent of patients demonstrated abnormal sensibility on the side of the zygoma fracture, compared with the contralateral side. Sensibility was abnormal for 100 percent of the patients who required orbital floor reconstruction. Seventy-four percent of patients with abnormal sensibility reported symptoms related to the fracture. Eighty percent of the zygoma fractures were correctly identified, with respect to the side of the fracture, by the blinded examiner on the basis of the neurosensory measurements alone (p < 0.005). Predictions proved correct for 91 percent of the patients with widely displaced fractures and none of the patients with nondisplaced fractures. The results of this study suggest that neurosensory testing is an important clinical adjunct for the evaluation of patients with facial pain or dysesthesia after facial fracture reconstruction. The results suggest the need to develop algorithms for the diagnosis and treatment of trigeminal nerve injuries after craniofacial trauma. This approach could also be applicable to dysesthesia or pain after aesthetic facial surgical procedures.     

Baseline Magnetic Resonance Imaging of the Optic Nerve Provides Limited Predictive Information on Short-Term Recovery after Acute Optic Neuritis

Background

In acute optic neuritis, magnetic resonance imaging (MRI) may help to confirm the diagnosis as well as to exclude alternative diagnoses. Yet, little is known on the value of optic nerve imaging for predicting clinical symptoms or therapeutic outcome.

Purpose

To evaluate the benefit of optic nerve MRI for predicting response to appropriate therapy and recovery of visual acuity.

Methods

Clinical data as well as visual evoked potentials (VEP) and MRI results of 104 patients, who were treated at the Department of Neurology with clinically definite optic neuritis between December 2010 and September 2012 were retrospectively reviewed including a follow up within 14 days.

Results

Both length of the Gd enhancing lesion (r = -0.38; p = 0.001) and the T2 lesion (r = -0.25; p = 0.03) of the optic nerve in acute optic neuritis showed a medium correlation with visual acuity after treatment. Although visual acuity pre-treatment was little but nonsignificantly lower if Gd enhancement of the optic nerve was detected via orbital MRI, improvement of visual acuity after adequate therapy was significantly better (0.40 vs. 0.24; p = 0.04). Intraorbitally located Gd enhancing lesions were associated with worse visual improvement compared to canalicular, intracranial and chiasmal lesions (0.35 vs. 0.54; p = 0.02).

Conclusion

Orbital MRI is a broadly available, valuable tool for predicting the improvement of visual function. While the accurate individual prediction of long-term outcomes after appropriate therapy still remains difficult, lesion length of Gd enhancement and T2 lesion contribute to its prediction and a better short-term visual outcome may be associated with detection and localization of Gd enhancement along the optic nerve.     

High-energy orbital dislocations: the possibility of traumatic hypertelorbitism

In a 4-year period from 1983 to 1987, 7160 patients with blunt injuries were admitted to the Maryland Institute of Emergency Medical Services Systems Shock Trauma Center. Facial injuries occurred in 10 percent of this population. High-energy fractures (characterized by computed tomography) were seen in approximately 10 percent of these patients. In this high-energy group, five cases of high-energy orbital dislocations, some representing examples of traumatic hypertelorbitism, were observed. They represent 1.5 percent of the 342 midface fractures observed and 4.8 percent of the naso-orbital ethmoid fractures observed (105 patients). One additional patient is described who was seen at the UCLA Medical Center for late repair of the condition. High-energy impacts of the upper midface created fractures of both orbits, zygomas, and nasoethmoidal regions permitting lateral transposition, enlargement, and divergence of the orbits. Interorbital, intercanthal, and interpupillary distances were increased, criteria that confirm the diagnosis of hypertelorbitism. Fifty percent of the patients were bilaterally blind, and one patient sustained unilateral blindness.     

Transcaruncular orbital decompression for management of compressive optic neuropathy in thyroid-related orbitopathy

This study was conducted to assess the outcome of transcaruncular orbital decompression to treat compressive optic neuropathy in thyroid-related orbitopathy. It involved a retrospective, noncomparative case series of 18 eyes of 10 consecutive patients with documented vision loss secondary to thyroid-related orbitopathy. Bony decompression of the orbital apex was performed via a transcaruncular approach. Main outcome measures were visual acuity, color vision, presence of diplopia, and reduction of exophthalmos. Of 18 eyes, 16 (89 percent) had improved visual acuity after the operation. One eye had no improvement and one had worsening of vision in the setting of diabetic retinopathy. Color vision was improved in 12 eyes (67 percent). Five of the patients did not have diplopia before the operation; none of these patients developed double vision after intervention. Exophthalmos was decreased by an average of 2.6 mm. The authors conclude that transcaruncular orbital decompression for compressive optic neuropathy in thyroid-related orbitopathy is successful in restoring visual function. Compared with other approaches used for decompression surgery, the transcaruncular approach offers direct access to the medial wall and orbital apex without a cutaneous incision or disruption of the medial canthus. In addition, this approach allows a controlled, graded removal of the ethmoidal air cells and reduced recovery time.     

Long-term physical impairment and functional outcomes after complex facial fractures

To develop an understanding of the expected functional outcomes after facial trauma, a retrospective cohort study of patients with complex facial fractures was conducted. A cohort of adults aged 18 to 55 years who were admitted to the R. Adams Cowley Shock Trauma Center between July of 1986 and July of 1994 for treatment of a Le Fort midface fracture (resulting from blunt force) was retrospectively identified.Outcomes of interest included measures of general health status and psychosocial well being in addition to self-reported somatic symptoms. General health status was ascertained using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). The Body Satisfaction Scale was used to define patient concerns about altered body image and shape. To determine whether complex maxillofacial trauma and facial fractures contributed to altered social interactions, the Social Avoidance and Distress scale was used. In addition, information about a patient, his or her injury, and its treatment were ascertained from the medical records.Using the methods described above, 265 patients with Le Fort fractures were identified. These individuals were matched to a similar group of 242 general injury patients. A total of 190 of the Le Fort patients (72 percent of those eligible for the study) and 144 (60 percent) general injury patients were successfully located, and long-term interview data were acquired.Le Fort fracture patients as a group had similar health status outcomes when compared with the group of general injury patients. However, when outcomes were examined by the complexity of the Le Fort fracture, the authors found that study subjects with severe, comminuted Le Fort injuries (group D) had significantly lower SF-36 scores (worse outcomes) for the two dimensions related to role limitations: role limitations due to physical problems and role limitations due to emotional problems (p < 0.05). SF-36 scores for all other dimensions except physical function were also lower for comminuted versus less complex Le Fort fractures, although differences were not statistically significant.Specifically, there was a direct relationship between severity of facial injury and patients reporting work disability. Of group C and D Le Fort patients (severely comminuted fractures) only 55 and 58 percent, respectively, had returned to work at the time of follow-up interview. These figures are significantly lower than the back-to-work percentage of patients with less severe facial injury (70 percent).When study participants were asked if they were experiencing specific somatic symptoms at the time of the interview that they had not experienced before the injury, a significantly larger percent of the Le Fort fracture patients (compared with the general injury patients) responded in the affirmative. Differences between the Le Fort fracture and general injury groups were statistically significant (p < 0.05) for all 11 symptoms.The percentage of patients reporting complaints increased with increasing complexity of facial fracture in the areas of visual problems, alterations in smell, difficulty with mastication, difficulty with breathing, and epiphora, and these differences reached statistical significance.Patients sustaining comminuted Le Fort facial fractures report poorer health outcomes than patients with less severe facial injury and substantially worse outcomes than population norms. It is also this severely injured population that reports the greatest percentage of injury-related disability, preventing employment at long-term follow-up. The long-term goal of centralized tertiary trauma treatment centers must be to return the patient to a productive, active lifestyle.     

Photodynamic therapy combined with intravitreal bevacizumab (Avastin) in treatment of choroidal neovascularization secondary to age-related macular degeneration

To evaluate photodynamic therapy with verteporfin combined with intravitreal bevacizumab in minimally classic and occult choroidal neovascularization secondary to age-related macular degeneration. 46 eyes of 46 patients (mean age 74.5) included in this prospective, noncomparative, interventional case series. Median follow-up was 24 weeks (12-36). Verteporfin photodynamic therapy (PDT) was followed by 0.05 mL (1.25 mg) of bevacizumab injected intravitreally within 24 hours and again after 6 weeks. Whole procedure was repeated in 3-month intervals in case of leakage. Visual acuity (VA) improved in majority of patients (baseline VA 1.041 log MAR) by mean increase of 1.45 lines (last follow-up) (p = 0.001). Central foveal thickness (CFT) and total macular volume (TMV) decreased by 53 microm (p = 0.03) and 1.04 mm3 (p < 0.001) respectively. No serious complications were observed. Combined treatment may improve outcome of monotherapy. Significant improvement in VA, CFT and TMA was noted in majority of patients and maintained during follow-up.     

Intravitreal bevacizumab (Avastin) in treatment of neovascular age-related macular degeneration

To evaluate the efficacy and safety of intravitreal bevacizumab in treatment of minimally classic and occult choroidal neovascularization secondary to age-related macular disease 48 eyes of 48 patients (mean age of 74.8) included in this prospective, noncomparative, interventional case series. Median follow-up was 18 weeks (6-24). Intravitreal bevacizumab injection of 0.05 mL (1.25 mg) was administered at baseline and in 6 week intervals until leakage resolved, and repeated in case of leakage recurrence. Visual acuity (VA) improved in the majority of patients (mean baseline VA = 1.078 log MAR) by mean increase of 1.32 lines (last follow-up) (p = 0.001). Central foveal thickness and total macular volume decreased by 51 microm (p = 0.01) and 0.84 mm3 (p < 0.0001) respectively. No serious complications were observed. As initial therapy, intravitreal bevacizumab appears to be safe and effective. A significant functional and anatomical improvement was noted in majority of patients and maintained during follow-up.     

Regulation of the ubiquitin proteasome system in mechanically injured human skeletal muscle

Metabolic consequences of direct muscle trauma are insufficiently defined. Their effects on the ubiquitin-proteasome pathway (UPP) of protein degradation in human skeletal muscles are as yet unknown. Thus, we investigated whether the UPP is involved in the metabolic response evoked in directly traumatized human skeletal muscles. Biopsies were obtained from contused muscles after fractures and from normal muscles during elective implant removal (control). As estimated by western blot analyses, concentrations of free ubiquitin and ubiquitin protein conjugates were similar in extracts from injured and uninjured muscles. Ubiquitin protein ligation rates were reduced after injury (1.5+/-0.2 vs. 1.0+/-0.15 fkat/microg; p=0.04). Chymotryptic-, tryptic- and caspase-like proteasome peptidase activities (total activity minus activity in the presence of proteasome inhibitors) increased significantly after trauma (p=0.04 - 0.001). Significant increases in total chymotryptic- and caspase-like activities were attributable to proteasome activation. Our results extend the possible role of the UPP in muscle wasting to direct muscle trauma. They further suggest that the effects of direct mechanical trauma are not limited to the proteasome and imply that ubiquitin protein ligase systems are also involved. Based on the potential role of the UPP in systemic diseases, it might also be a therapeutic target to influence muscle loss in critically ill blunt trauma patients, in which large proportions of muscle are exposed to direct trauma.     

Blue light filtering intraocular lenses in phacoemulsification cataract surgery

Blue light can damage retina and cause age related macular degeneration. After cataract surgery and lens removal retina stays unprotected. Blue light filtering intraocular lenses (IOL) increase protection of the retina. In our prospective study we investigated clinical results after bilateral implantation of Acrysof Natural IOL to 30 patients (N = 60 eyes). In a control group (N = 60 eyes, 30 patients), standard acrysof IOL was implanted bilaterally. Uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA) and Nd YAG laser capsulotomy rate were measured and compared with control group. Subjective patient's satisfaction and subjective colour perception were also investigated. There was no significant difference in UCVA, BCVA and Nd YAG laser capsulotomy rate between the two groups. High patient's satisfaction was noticed (96.7% of patients would implant Acrysof Natural IOL again). Acrysof Natural IOL enables good visual acuity VA, low rate of Nd YAG laser capsulotomy and high patient's satisfaction without colour perception disturbances.     

Dynamic versus static splinting of simple zone V and zone VI extensor tendon repairs: a prospective, randomized, controlled study

The authors present the first prospective, randomized, controlled study comparing postoperative dynamic versus static splinting outcomes of patients following extensor tendon repair. Patients who incurred simple and complete lacerations of their extensor tendons in zones V and VI were enrolled into the study and underwent either static splinting (n = 17) or dynamic splinting (n = 17) following primary acute repair of tendons. Total active motion was improved in the dynamic group when compared with the static group in the injured digits at 4 weeks (180.5 +/- 4 degrees versus 131.3 +/- 61 degrees; p = 0.006), at 6 weeks (239 +/- 21.9 degrees versus 205.5 +/- 53.4 degrees; p = 0.048), and at 8 weeks (247+/- 19.8 degrees versus 216.3 +/- 36 degrees; p = 0.051), but not at 6 months (253.1 +/-18.8 degrees versus 250.5 +/- 32 degrees; p = 0.562). Similarly, total active motion averaged for all digits (injured and noninjured) of the involved hand was improved in the dynamic group over the static group at 4 weeks (209.8 +/- 31.3 degrees versus 140 +/- 58.2 degrees; p < 0.001) and at 6 weeks (241.5 +/- 17.2 degrees versus 217.1 +/- 42.4 degrees; p = 0.024), but not at 8 weeks (249.6 +/- 16 degrees versus 234.8 +/- 24.5 degrees; p = 0.215) or 6 months (252.3 +/- 14 degrees versus 249.1 +/- 31 degrees; p = 0.450). Grip strength outcomes demonstrated improved grip force for the dynamic group when compared with the static group at 8 weeks (81.3 +/- 18.0 percent versus 59.2 +/- 20.4 percent; p = 0.004) but not at 6 months (89.6 +/- 5.6 percent versus 82.1 +/- 22.0 percent; p = 0.595). Patients demonstrated forceful grip greater than or equal to 80 percent of the noninjured hand in 55 percent of patients in the dynamic group versus 15 percent of patients in the static group at 8 weeks. Patients demonstrated forceful grip greater than or equal to 80 percent of the noninjured hand in 100 percent of patients in the dynamic group versus 73 percent of patients in the static group at 6 months. The authors' findings suggest that dynamic splinting of simple, complete lacerations of the extensor tendons in zones V and VI provides improved functional outcomes at 4, 6, and 8 weeks but not by 6 months when compared with static splinting. Therefore, they recommend dynamic splinting of simple, complete extensor tendon lacerations in zones V and VI only to select patients who are motivated and desire earlier return to full functional capacity.     

Preliminary analysis of the care of injured patients in 33 British hospitals: first report of the United Kingdom major trauma outcome study.

OBJECTIVE--To measure the effectiveness of management of major trauma in the United Kingdom. DESIGN--Review of the care of all seriously injured patients seen over two years. SETTING--33 hospitals which receive patients who have sustained major trauma. SUBJECTS--14,648 injured patients admitted for more than three days, transferred or admitted into an intensive care bed, or dying from their injuries. MAIN OUTCOME MEASURE--Death or survival in hospital within three months of the injury. RESULTS--21% of seriously injured patients (1299) took longer than one hour to reach hospital. Time before arrival at hospital was not related to severity of injury. A senior house officer was in charge of initial hospital resuscitation in 57% (826/1445) of patients with an injury severity score > or = 16. More senior staff were commonly responsible for definitive operations, but only 46% (165/355) of patients judged to require early operation arrived in theatre within two hours. Mortality for 6111 patients sustaining blunt trauma and treated in the 14 busiest hospitals was significantly higher (actual 408, predicted 295.6, p < 0.001) than in a comparable North American dataset. Large differences in the 14 hospitals assessed could not be explained by variations in case load or facilities. In contrast, the outcome of the 4.1% (597) of patients with penetrating injuries was better than that of a comparable group in the United States. Analysis of the 415 penetrating injuries with complete data showed that 15 patients died (19.3 predicted; p = 0.04). CONCLUSIONS--The initial management of major trauma in the United Kingdom remains unsatisfactory. There are delays in providing experienced staff and timely operations. Mortality varies inexplicably between hospitals and, for blunt trauma, is generally higher than in the United States.     

Anti-VEGF in treatment of diabetic macular edema

Diabetic macular edema is the leading cause of moderate visual deterioration in patients with diabetic retinopathy. Ranibizumab) blocks vascular endothelial growth factor (VEGF) induced hyperpermeability of blood vessels. In this prospective case series we investigated the efficacy and safety of anti-VEGF treatment in reduction of central retinal thickness (CRT) and improvement in visual acuity (VA) in patients with diabetic macular edema (DME). 9 patients were followed up for 6 months and treated monthly with intravitreal ranibizumab. VA and CRT were measured at each visit. Treatment was discontinued as the peak improvement of either parameter was reached and reinstituted in case of deterioration/recurrence of edema. Study endpoints included: VA using ETDRS chart, CRT and number of injections at 6 months. Mean VA from all 9 patients increased by 0.3 lines of logMAR (p < 0.05 compared to baseline), and CRT decreased from 515 +/- 123 microm to 310 +/- 110 microm. The improvement of VA after ranibizumab injection was in correlation with a decrease in CRT. Mean of 4 injections were needed to control the disease during the follow-up period. Ranibizumab treatment was effective in VA and reducing CRT. Several injections were needed to control the disease. Regular OCT examinations and retreatment are advised in order to maintain initially reached VA.     

Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture.

Pure orbital blowout fracture first occurs at the weakest point of the orbital wall. Although the medial orbital wall theoretically should be involved more frequently than the orbital floor, the orbital floor has been reported as the most common site of pure orbital blowout fractures. A total of 82 orbits in 76 patients with pure orbital blowout fracture were evaluated with computed tomographic scans taken on all patients with any suspicious clinical evidence, including nasal fracture. Isolated medial wall fracture was most common (55 percent), followed by medial and inferior wall fracture (27 percent). The most common facial fracture associated with medial wall fracture was nasal fracture (51 percent), not inferior wall fracture (33 percent). This finding suggests that the force causing nasal fracture is an important causative factor of pure medial wall fracture as the buckling force from the medial orbital rim. Of patients with medial wall fractures, 25 percent had diplopia and 40 percent had enophthalmos. On plain radiographs, diagnostic signs were found in 79 percent of medial wall fractures and in 95 percent of inferior wall fractures. On computed tomographic scans, late enophthalmos was expected in 76 percent of medial wall fractures. Therefore, the medial orbital blowout fracture may be an important cause of late enophthalmos, because it has a high incidence of occurrence, a low diagnostic rate, and a high severity of defect. Among the causes of limitation of ocular motility, muscle traction of the connective septa and direct muscle injury were found frequently, but true incarceration of the muscle was extremely rare in all fractures. The medial and inferior orbital walls are clearly demarcated by the bony buttress, which is an important structure supporting these orbital walls. Its buttress was closely correlated with the fracture of these orbital walls. Most orbital blowout fractures without collapse of the bony buttress had a trapdoor fracture with or without small fragments of punched-out fracture.     

Blow-in fractures of the orbit

A blow-in fracture is an inwardly displaced fracture of the orbital rim or wall resulting in decreased orbital volume. The purpose of this study is to classify orbital blow-in fractures, describe the distinguishing clinical and radiologic features, and review the result of treatment. The series consists of 41 patients with blow-in fractures (34 males and 7 females). The mean age of the patients was 36 years. All were treated between 1979 and December of 1986 at Sunnybrook Medical Centre in Toronto. Clinical features of blow-in fractures were primarily related to the decrease in volume of the orbital cavity. Proptosis was a consistent finding, and in 27 percent of patients, the globe was further displaced in a coronal plane. Restricted ocular motility and diplopia were documented in 24 and 32 percent of patients, respectively. Fracture fragments displaced into the orbit resulted in globe rupture in 12 percent of patients, superior orbital fissure syndrome in 10 percent, and optic nerve injury in 1 patient. Blow-in orbital injuries were classified as pure fractures, consisting of an isolated blow-in of a segment of the roof, floor, or walls, or impure fractures, where the orbital rim itself was disrupted. In all cases, early decompression of the orbit and open reduction of fractures was necessary. Late sequelae of blow-in fractures were primarily related to injuries of intraorbital contents. Twelve percent of patients underwent enucleation and 8 percent reported persistent diplopia. Despite the presence of superior orbital fissure syndrome and complete ophthalmoplegia in 10 percent of patients, early orbital decompression resulted in resolution of nerve palsies in all but one patient.     

Etiology of shock in blunt trauma.

Patients who have suffered blunt trauma and present in shock of uncertain cause represent a problem frequently encountered by emergency physicians. A retrospective review of the charts of 879 patients who had suffered blunt trauma and presented to a regional trauma unit over a 44-month period revealed that 154 of the patients had presented to either a hospital or the trauma unit in shock. The most common causes of shock when a single source of hemorrhage was identified were, in order of decreasing frequency, intraperitoneal hemorrhage, pelvic or other musculoskeletal fractures, thoracic hemorrhage, severe head injury and spinal cord injury. Severe head injuries accounted for only 8% of the single-source cases and contributed to shock in only seven of the remaining cases.     

Octreotide reduces vitreous hemorrhage and loss of visual acuity risk in patients with high-risk proliferative diabetic retinopathy.

OBJECTIVE: Growth hormone and insulin-like growth factor-I have been implicated as strong promoters of proliferative diabetic retinopathy. We studied reduction of bleeding and preservation of visual acuity by treatment with the long-acting somatostatin analogue, octreotide, in diabetic patients at an advanced stage of proliferative diabetic retinopathy. RESEARCH DESIGN AND METHODS: Randomized trial in a University hospital setting. Reading ophthalmologists were masked for octreotide use, diabetologists were aware of that treatment. Nine patients received 100 microg tid octreotide (verum) subcutaneously for a maximum of 36 months. Nine diabetics served as controls, no placebo treatment was used. Episodes of vitreous hemorrhages were counted, measurement of visual acuity, estimation of neovascularization by stereoscopic fundus photography and fluorescein angiography were carried out. RESULTS: After 3 years of treatment, the incidence of vitreous hemorrhages and the need for vitreoretinal surgery was significantly lower (log rank test p = 0.002) in the octreotide-treated patients. Visual acuity was preserved and significantly better in the octreotide treated group compared to controls (p = 0.05). CONCLUSIONS: In diabetics with high-risk proliferative retinopathy after full scatter laser coagulation, octreotide reduced the number of vitreous hemorrhages, preserving visual acuity.