Neurologic Complications in Percutaneous Nephrolithotomy

PURPOSE: Percutaneous nephrolithotomy (PCNL) has been the preferred procedure for the removal of large renal stones in Iran since 1990. Recently, we encountered a series of devastating neurologic complications during PCNL, including paraplegia and hemiplegia. There are several reports of neurologic complications following PCNL owing to paradoxical air emboli, but there are no reports of paraplegia following PCNL. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients who had undergone PCNL in 13 different endourologic centers and retrieved data related to neurologic complications after PCNL, including coma, paraplegia, hemiplegia, and quadriplegia. RESULTS: The total number of PCNL procedures in these 13 centers was 30,666. Among these procedures, 11 cases were complicated by neurologic events, and four of these cases experienced paraplegia. All events happened with the patient in the prone position with the use of general anesthesia and in the presence of air injection. There were no reports of neurologic complications in PCNL procedures performed with the patient under general anesthesia and in the prone position and with contrast injection. CONCLUSIONS: It can be assumed that using room air to opacify the collecting system played a major role in the occurrence of these complications. Likewise, the prone position and general anesthesia may predispose to these events in the presence of air injection.

Characteristics and surgical outcomes of rhegmatogenous retinal detachment following myopic LASIK

To describe the clinical features and surgical outcomes of rhegmatogenous retinal detachment [RRD] following myopic laser in situ keratomileusis [LASIK]. In a retrospective, non-comparative case series, 46 eyes that had undergone vitreoretinal surgery for management of RRD following myopic LASIK were identified. Data was reviewed with emphasis on characteristics of the RRD, employed surgical techniques, and anatomic and visual outcomes. Mean pre-LASIK myopia was -9.7 +/- 3.9 [range -4.00 to -18.00] diopters [D]. Mean interval between LASIK and development of RRD was 11.6 +/- 11.2 months. Posterior vitreous detachment was present in 44 eyes [95.6%]. The retinal breaks included flap tears in 36 [78.3%] eyes, giant tears in 8 [17.4%] eyes and atrophic holes in 2 [4.3%] eyes. In eyes with flap tears, the breaks were multiple, large or posterior to the equator in 24 [66.7%] eyes. Retinal breaks were related to lattice degeneration in 20 [43.5%] eyes of which, three had history of prophylactic barrier laser photocoagulation. Scleral buckling was performed as the initial procedure in 32 [69.6%] eyes and primary vitrectomy was undertaken in 14 [30.4%] eyes. The initial surgical procedure failed in 14 [30.4%] eyes due to proliferative vitreoretinopathy [PVR]. Retinal reattachment was finally achieved in 43 [93.4%] eyes. Postoperative visual acuity >/= 20/40 and >/= 20/200 was achieved in 16 [34.8%] and 25 [54.3%] eyes, respectively. Post-LASIK retinal detachment has a complex nature in eyes with moderate to high myopia. The retinal detachment is complex in terms of size, number and location of retinal breaks, is associated with a high rate of PVR and entails unfavorable visual outcomes

Comparison of the effect of adjuvant 5-fluorouracil, low molecular weight heparin and daunomycin in combination with triamcinolone during vitrectomy in advanced retinal detachment

To compare the success rate of adjunctive 5-fluorouracil [5-FU] and low molecular weight heparin [LMWH], and daunomycin in combination with triamcinolone during vitrectomy in eyes with retinal detachment [RD] and proliferative vitreoretinopathy [PVR]. In this prospective randomized clinical trial, 69 eyes from 69 patients with RD and PVR [grade B or C] randomized to 3 groups. Group 1: received 5-FU and LMWH [200 microgram/ml 5-FU and 5 IU/ml LMWH, Fragmin]; group 2: received daunomycin [0.5 mg] in 500 cc infusion fluid; and group 3: control group. In all patients, 0.1 cc intravitreal triamcinolone was used during vitrectomy. The patients visited on day 1, week 1, month 1, 3 and 6. Best corrected visual acuity [BCVA] and retinal status compared in the 3 groups. Complete data were available for 60 out of 69 patients. Thirty five patients [58.3%] were male and 25 patients [41.7%] were female. The patient age range was 19-84 years and the mean age was 49. The groups did not have significant difference in age, sex, duration of detachment, severity of PVR, preoperative visual acuity [V/A], lens status, type of tamponade and encircling band and buckle. Postoperative V/A and retina status also was the same in the 3 groups. Perioperative infusion of 5-FU, LMWH and daunomycin does not significantly increase the success rate of patients with RD and PVR comparing to control group. Although visual acuity improvement and retina reattachment rate in group 1 and 2 were better than control group, but statistical analysis failed to show significant difference between the 3 groups

Intravitreal bevacizumab versus combined bevacizumab and triamcinolone acetonide for neovascular age-related macular degeneration

To compare the short-term outcomes of intravitreal bevacizumab [IVB] with the combination of IVB and intravitreal triamcinolone acetonide [IVB/IVT] for treatment of neovascular age-related macular degeneration [AMD]. This randomized clinical trial was performed on 92 eyes of 90 patients with subfoveal and juxtafoveal choroidal neovascularization [CNV] secondary to AMD. The eyes were randomly assigned to receive IVB 1.25 mg alone [53 eyes] or in combination with IVT 2 mg [39 eyes]. Best-corrected visual acuity [BCVA] and fundus autofluorescence were assessed, and fluorescein angiography [FA] and optical coherence tomography [OCT] were performed at baseline and repeated 6 weeks after treatment. Mean age was 70.6 +/- 8.7 [range 50-89] years and 57.7% of the patients were male. BCVA improved from 1.03 +/- 0.40 to 0.93 +/- 0.38 logMAR [P=0.001] in the IVB group and from 1.08 +/- 0.33 to 0.91 +/- 0.38 logMAR [P=0.008] in the IVB/IVT group. There was a trend toward greater visual improvement with combined therapy [P=0.06]. BCVA improvement was greater in eyes with +1 versus those with +2 [P=0.049] and +3 [P < 0.001] fundus autofluorescence at baseline. Mean decrease in central macular thickness was 113 +/- 115 micro m [P < 0.001] in the IVB group versus 53.96 +/- 125 micro m [P=0.008] in the IVB/IVT group with no intergroup difference [P=0.38]. FA showed decreased leakage in 57.4%, increased leakage in 12.8% and no change in 29.8% of patients in the IVB group. Corresponding figures were 60.0%, 5.7% and 34.3% in the IVB/IVT group [P=0.556]. Addition of triamcinolone acetonide to bevacizumab for treatment of neovascular AMD does not seem to significantly increase its short-term efficacy. More severe fundus autofluorescence appears to be predictive of poorer response to treatment