Frontalis Sling Using a Silicone Rod for Ptosis in Third Nerve Palsy: Cosmesis versus Safety

Purpose@#To evaluate the results of the frontalis sling operation using a silicone rod for the correction of ptosis in patients with third nerve palsy with a focus on corneal safety. @*Methods@#Patients with third nerve palsy who underwent the frontalis sling operation using a silicone rod between 2008 and 2019 were included in this study. The medical records of all patients were reviewed, and their clinical characteristics and postoperative outcomes were analyzed. In this retrospective, interventional case series, the main outcome measures were eyelid contour, eyelid height by margin reflex distance, and corneal status. @*Results@#Twenty-four eyes of 18 patients (12 male and six female patients) were included. The mean age at the time of surgery was 35.1 years (range, 5–64 years). Twelve patients underwent a unilateral ptosis operation, and six patients received a bilateral ptosis operation. The mean follow-up period was 32.1 months (range, 2–87 months). Most patients (21 of 24 eyes, 88%) showed poor Bell’s phenomenon on preoperative examination. Satisfactory eyelid height and eyelid contour were achieved in almost all patients (mean postoperative margin reflex distance, +1.2 mm) postoperatively. Although corneal erosions were detected for several months in eight of 24 eyes after surgery, these findings were well controlled medically with artificial tear eye drops and ointments. @*Conclusions@#Frontalis sling surgery using a silicone rod can safely and effectively correct ptosis without severe corneal complications in patients with third nerve palsy. Our study outlines a new method to define the postoperative safety outcome by specifically focusing on categorized corneal status.

Relationship Between Deep Vein Thrombosis and Lower Limb Swelling in Patients with Brain Lesions

The objective was to identify the correlation between the sign of lower limb swelling and unilateral deep vein thrombosis (DVT) in patients with brain lesions. A total of 194 patients, between May 12th, 2011 and December 30th, 2015, who had initially elevated plasma D-dimer level (> 0.55 mg/L) and underwent enhanced DVT computed tomography (CT) were recruited in this study. The circumference of bilateral lower limbs in CT image, below 10 cm and above 15 cm from the prominence of tibial tuberosity, were measured by a single intra-observer using NIH ImageJ software. The difference of 2 cm or more between both sides was considered as significant swelling. We also evaluated patients' range of mobility and cognitive function and its relation to lower limb swelling in DVT in patients with brain lesions. Thirty-five patients were diagnosed with DVT. The presence of lower limb swelling was not statistically significant between patients with DVT and those without DVT in the proximal limb (p = 0.330) and distal limb (p = 0.405). In DVT patients (n = 35), there was no statistically significant correlation between lower limb swelling and other covariates of the patient group. There was no statistically significant correlation between lower limb circumference and DVT.

Rapid, Objective and Non-invasive Diagnosis of Sudomotor Dysfunction in Patients With Lower Extremity Dysesthesia: A Cross-Sectional Study

OBJECTIVE: To determine whether patients with lumbosacral (LS) radiculopathy and peripheral polyneuropathy (PPNP) exhibit sudomotor abnormalities and whether SUDOSCAN (Impeto Medical, Paris, France) can complement nerve conduction study (NCS) and electromyography (EMG). METHODS: Outpatients with lower extremity dysesthesia underwent electrophysiologic studies and SUDOSCAN. They were classified as normal (group A), LS radiculopathy (group B), or PPNP (group C). Pain severity was measured by the Michigan Neuropathy Screening Instrument (MNSI) and visual analogue scale (VAS). Demographic features, electrochemical skin conductance (ESC) values on hands and feet, and SUDOSCAN-risk scores were analyzed. RESULTS: There were no statistical differences in MNSI and VAS among the three groups. Feet-ESC and hands-ESC values in group C were lower than group A and B. SUDOSCAN-risk score in group B and C was higher than group A. With a cut-off at 48 microSiemens of feet-ESC, PPNP was detected with 57.1% sensitivity and 94.2% specificity (area under the curve [AUC]=0.780; 95% confidence interval [CI], 0646–0.915). With a SUDOSCAN-risk score cut-off at 29%, NCS and EMG abnormalities related to LS radiculopathy and PPNP were detected with 64.1% sensitivity and 84.2% specificity (AUC=0.750; 95% CI, 0.674–0.886). CONCLUSION: SUDOSCAN can discriminate outpatients with abnormal electrophysiological findings and sudomotor dysfunction. This technology may be a complementary tool to NCS and EMG in outpatients with lower extremity dysesthesia.

Bulbar Myasthenia Gravis Superimposed in a Medullary Infarction Diagnosed by a Fiberoptic Endoscopic Evaluation of Swallowing With Simultaneous Tensilon Application

In the elderly, myasthenia gravis (MG) can present with bulbar symptoms, which can be clinically difficult to diagnose from other neurological comorbid conditions. We describe a case of a 75-year-old man who had been previously diagnosed with dysphagia associated with medullary infarction but exhibited aggravation of the dysphagia later on due to a superimposed development of bulbar MG. After recovering from his initial swallowing difficulties, the patient suddenly developed ptosis, drooling, and generalized weakness with aggravated dysphagia. Two follow-up brain magnetic resonance imaging (MRI) scans displayed no new brain lesions. Antibodies to acetylcholine receptor and muscle-specific kinase were negative. Subsequent electrodiagnosis with repetitive nerve stimulation tests revealed unremarkable findings. A diagnosis of bulbar MG could only be established after fiberoptic endoscopic evaluation of swallowing (FEES) with simultaneous Tensilon application. After application of intravenous pyridostigmine, significant improvement in dysphagia and ptosis were observed both clinically and according to the FEES.

Extracorporeal Shock Wave Therapy for Painful Chronic Neurogenic Heterotopic Ossification After Traumatic Brain Injury: A Case Report

Neurogenic heterotopic ossification (NHO) is a process of benign bone formation and growth in soft tissues surrounding major synovial joints and is associated with central nervous system (CNS) injuries. It is a common complication in major CNS injuries, such as traumatic brain injury, spinal cord injury, and stroke. Here, we report the case of a 72-year-old male, who experienced a traumatic brain injury and painful chronic NHO around the left hip joint. Three applications of extracorporeal shock wave therapy (ESWT) were administered to the area of NHO, which resulted in pain relief and an improvement in the loss of motion in the left hip joint. Improvements were also noted in walking performance and activities of daily living, although the size of NHO remained unchanged. Therapeutic effects of ESWT lasted for 12 weeks.

Effect of Watching 3-Dimensional Television on Refractive Error in Children

PURPOSE: To investigate the effect of watching 3-dimensional (3D) television (TV) on refractive error in children. METHODS: Sixty healthy volunteers, aged 6 to 12 years, without any ocular abnormalities other than refractive error were recruited for this study. They watched 3D TV for 50 minutes at a viewing distance of 2.8 meters. The image disparity of the 3D contents was from -1 to 1 degree. Refractive errors were measured both before and immediately after watching TV and were rechecked after a 10-minute rest period. The refractive errors before and after watching TV were compared. The amount of refractive change was also compared between myopes and controls. The refractive error of the participants who showed a myopic shift immediately after watching TV were compared across each time point to assure that the myopic shift persisted after a 10-minute rest. RESULTS: The mean age of the participants was 9.23 ± 1.75 years. The baseline manifest refractive error was -1.70 ± 1.79 (-5.50 to +1.25) diopters. The refractive errors immediately after watching and after a 10-minute rest were -1.75 ± 1.85 and -1.69 ± 1.80 diopters, respectively, which were not different from the baseline values. Myopic participants (34 participants), whose spherical equivalent was worse than -0.75 diopters, also did not show any significant refractive change after watching 3D TV. A myopic shift was observed in 31 participants with a mean score of 0.29 ± 0.23 diopters, which resolved after a 10-minute rest. CONCLUSIONS: Watching properly made 3D content on a 3D TV for 50 minutes with a 10-minute intermission at more than 2.8 meters of viewing distance did not affect the refractive error of children.

Influence of Watching 3D Television on Refractive Error in Children with Exodeviation

PURPOSE: To investigate the effects of watching three-dimensional (3D) television (TV) on the angle of deviation and refractive error in children with exodeviation. METHODS: Twenty-three volunteers with exodeviation, aged 6 to 12 years, without any ocular abnormalities other than refractive error and exodeviation were recruited for this study. The subjects watched 3D TV for 50 minutes at a viewing distance of 2.8 meters. The image disparity of 3D contents was -1 to 1 degree. Refractive errors were measured before and immediately after watching TV and after a 10-minute rest. The changes in angle of deviation were also obtained. Refractive errors and angle of deviation before and after watching 3D TV were compared. RESULTS: The mean age of the subjects was 9.30 +/- 1.58 years. The mean baseline angle of deviation was 13.04 +/- 5.25 (6-30) prism diopters (PD), which did not change significantly immediately after watching 3D TV and after a 10-minute rest (p = 0.452). The mean refractive errors were -2.15 +/- 1.55 D in the right eye and -2.06 +/- 1.55 D in the left eye before and changed to -2.14 +/- 1.57 D and -2.11 +/- 1.45 D, respectively, immediately after watching 3D TV. After a 10 minute rest, the mean refractive errors were 2.14 +/- 1.53 D in the right eye and -2.07 +/- 1.53 D in the left eye. All changes in refractive errors were not statistically significant (p = 0.991 in right eye, 0.495 in left eye). The amount of myopic shift in both eyes immediately after watching 3D TV was correlated with the angle of exodeviation (r = 0.468, p = 0.024). However, the correlation disappeared after a 10-minute rest (r = 0.345, p = 0.107). CONCLUSIONS: Watching properly made 3D contents on 3D TV for 50 minutes at more than 2.8 meters of viewing distance did not affect the refractive error in children with exodeviation. Further studies on the relationship between the amount of myopic shift and the angle of exodeviation are necessary.

Adrenomyeloneuropathy Presenting With Adrenal Insufficiency

Adrenomyeloneuropathy (AMN), one of the variants of X-linked adrenoleukodystrophy (ALD), is inherited peroxisomal disorder associated with the accumulation of very long chain fatty acids (VLCFA). AMN is characterized primarily by involvements of long ascending and descending tracts of the spinal cord and peripheral neuropathy, which leads to spastic paraparesis and urinary and erectile dysfunction. We experienced the AMN case of a 33-year-old man presenting bilateral progressive spastic paraparesis, impotence and urge incontinence with primary adrenal failures, as confirmed by increased serum of VLCFA concentrations. Considering that somatosensory evoked potentials in posterior tibial nerve was the only abnormal finding in electrophysiologic findings when compared with the severe spastic gait pattern shown, it is necessary to follow up with electrophysiologic studies.

The Influence of Suppression on Axial Length Progression in Intermittent Exotropia

PURPOSE: To evaluate the influence of suppression by intermittent exotropia on axial length progression. METHODS: The medical records of patients with intermittent exotropia who had undergone surgery at the Korea University Medical Center from 2003 to 2010 were reviewed. The age upon visit, age at operation, visual acuity, refractive error, type of strabismus, angle of strabismic deviation, suppression test (Vectographic projector test, Reneau, France), and axial length test were analyzed. Subjects with amblyopia or anisometropia were excluded. RESULTS: A total of 75 patients with intermittent exotropia who had definite suppression in 1 eye were identified. The mean age at visit was 6.87 +/- 2.73 years and mean angle of exodeviation was 25.65 +/- 6.68 / 26.17 +/- 6.59 (prism diopters, distant / near). There was no statistical difference in exotropia patients' interocular axial length value who showed suppression in 1 eye (p = 0.992 in the right-eye suppression group, and p = 0.528 in the left-eye suppression group). CONCLUSIONS: In the present study, there was no statistical difference in interocular axial length value of intermittent exotropia patients with suppression in one eye (p > 0.05).

Delayed Sealing of Macular Hole after Vitrectomy with Silicone Oil Tamponade

PURPOSE: To report a case of delayed sealing of full-thickness macular hole associated with diabetic retinopathy after vitrectomy with silicone oil tamponade. CASE SUMMARY: A 63-year-old woman visited our clinic complaining of decreased visual acuity in her left eye. Fundoscopy showed a full-thickness macular hole with vitreomacular traction in the left eye and bilateral proliferative diabetic retinopathy. The patient underwent uncomplicated phacoemulsification and pars plana vitrectomy with silicone oil tamponade because her vision in the contralateral eye was only light perception. She was unable to maintain a prone position postoperatively due to anterior chamber hyphema. At 1.5 months after surgery, vitreomacular traction was removed but the hole was not sealed as observed on optical coherence tomography. Approximately 3 months after vitrectomy, the macular hole was sealed with minimal subfoveal fluid. At 6 months after vitrectomy, the macular hole was closed completely with no subfoveal fluid.

Comparing the Effect of Botulinum Toxin Type B Injection at Different Dosages for Patient with Drooling due to Brain Lesion

OBJECTIVE: To investigate Botulinum toxin type B (BNT-B) injection's effect and duration depending on dose for patients with brain lesion. METHOD: Twenty one patients with brain lesion and severe drooling were included and divided into three groups. All patients received conventional dysphagia therapy. Group A patients (n=7) received an injection of 1,500 units and group B patients (n=7) received an injection of 2,500 units of BNT-B in submandibular gland under ultrasound guidance. Group C patients (n=7) received conventional dysphagia therapy. Saliva secretion was assessed quantitatively at baseline and at weeks 1, 2, 4, 8, and 12. The severity and frequency of drooling was assessed using the Drooling Quotient (DQ) by patients and/or caregivers. RESULTS: Group A and B reported a distinct improvement of the symptoms within 2 weeks after BNT-B injection. Compared to the baseline, the mean amount of saliva decreased significantly throughout the study. However, there was no meaningful difference between the two groups. The greatest reductions were achieved at 2 weeks and lasted up to 8 weeks after BNT-B injection. Group C did not show any differences. CONCLUSION: Local injection of 1,500 units of BNT-B into salivary glands under ultrasonic guidance proved to be a safe and effective dose for drooling in patient with brain lesion, as did 2,500 units.

Expericence of practicing a patient misdiagnosed as CRPS after cervical total disc replacement: A case report / 대한마취과학회지

Complex regional pain syndrome (CRPS) is characterized by pain, sensory, motor and autonomic symptoms. But its pathophysiological mechanisms are unclear and CRPS is quite difficult to comprehend and treat. The diagnostic criteria for CRPS at this time are purely clinical, and the use of diagnostic tests has not been demonstrated, so that misdiagnosis of CRPS is not uncommon. We report a case misdiagnosed CRPS which is due to the complication of one level total cervical disc replacement, which was treated successfully with reoperation.

Lead Breakage in Implanted Spinal Cord Stimulation Systems: A case report / 대한마취과학회지

Spinal cord stimulation (SCS) has become an established clinical option for treatment of refractory chronic pain. Current hardware and implantation techniques for SCS are already highly developed and continuously improving, however equipment failures over the course of the long-term treatment are still encountered in a relatively high proportion of treated cases. Percutaneous SCS leads seem to be particularly prone to dislocation and insulation failures. We describe our experience of lead breakage in implanted SCS which was inserted to a complex regional pain syndrome patient who obtained satisfactory pain relief after the revision of SCS.

Comparison of the Two Impairment Classes Publicized by the American Medical Association in Complex Regional Pain Syndrome Patients / 대한통증학회지

BACKGROUND: Complex regional pain syndrome (CRPS) is not regarded as an impairment in Korea. Guidelines for rating this impairment are under development by the Korean Academy of Medical Science based on that of the American Medical Association (AMA). However, no studies have been done on the validity of these guidelines in Korea. We therefore evaluated the validity of these guidelines using the criteria from the chapter on the central and peripheral nervous system (CNS-PNS class) and the worksheet for calculating total pain-related impairment score (TPRIS class). METHODS: TPRIS and CNS-PNS classes were calculated through interviews of 28 CRPS patients. The correlation between the two classes was calculated. RESULTS: TPRIS class and CNS-PNS class were well correlated (r = 0.593, P < 0.05). CONCLUSIONS: Both TPRIS or CNS-PNS classes were well correlated and could be used for evaluation of impairment. However, the CNS-PNS class is simpler and quicker to complete.

Infrared Thermography in the Assessment of Temporomandibular Joint Dysorder / 대한통증학회지

BACKGROUND: Temporomandibular joint disorder (TMD) is a group of musculoskeletal conditions characterized by pain in the pre-auricular area, limitation of jaw movement and palpable muscle tenderness. Thermography is a nonionizing, noninvasive diagnostic alternative for the evaluation of TMD. This study was conducted to evaluate the usefulness of thermography in the assessment of TMD. METHODS: Thermography was conducted on the 61 patients who had been diagnosed with TMD, and on the 34 normal symptom-free volunteers. The temperature differences between opposite sides of the temporomandibular joint (DeltaTTMJ) and the masseter muscle (DeltaTMST) were calculated. The sensitivity and specificity of thermography was calculated at the cut off values of 0.2, 0.3, and 0.4 degrees C. RESULTS: In the patient group, the DeltaTTMJ was 0.42 +/- 0.38 degrees C and the DeltaTMST was 0.38 +/- 0.33 degrees C, whereas in the control group the DeltaTTMJ was 0.10 +/- 0.07 degrees C and the DeltaTMST 0.15 +/- 0.10 degrees C. In addition, the patient group demonstrated a significantly lower level of thermal symmetry than the control group (P < 0.001) in both the temporomandibular joints and the masseter muscles. The sensitivity of thermography at the cut off values of 0.2, 0.3 and 0.4 degrees C was 67.2, 49.2, and 42.6% in the temporomandibular joint (TMJ) and 60.7, 49.2 and 37.7% in the masseter muscle, respectively. The specificity of thermography at the cut off values of 0.2, 0.3 and 0.4 degrees C was 88.2, 100, and 100% in the TMJ and 61.8, 91.2 and 100% in the masseter muscles, respectively. The accuracy of thermography at the cut off values of 0.2, 0.3 and 0.4 degrees C was 74.7, 67.4, and 63.2% in TMJ and 61.1, 64.2 and 60.0% in the masseter muscles, respectively. CONCLUSIONS: Temperature differences exist between the opposite sides of the TMD and masseter muscles in patients with TMD. Although the sensitivity of thermography in the diagnosis of TMD is low, it has high specificity in the evaluation of TMD, and is therefore applicable to patients with TMD.

Pain Management via a Subcutaneous Infusion of Ketamine in a Patient with Complex Regional Pain Syndrome: A case report / 대한통증학회지

Complex regional pain syndrome (CRPS), which is a syndrome that is defined by pain and sudomotor and/or vasomotor instability, is usually resistant to conventional treatment. Here, a case involving a 30-year-old male patient with CRPS type I who showed severe intractable right shoulder pain with allodynia and hyperalgesia despite being treated with oral medications, nerve blocks including thoracic sympathetic neurolysis, and spinal cord stimulation is described. The patient frequently visited the emergency room due to severe uncontrollable breakthrough pain. Although a favorable effect was observed in response to intermittent ketamine infusion therapies that were performed on an outpatient basis, acute exacerbation of pain occurred frequently during the night and could not be controlled. Therefore, subcutaneous ketamine infusion therapy using a patient-controlled analgesic system was attempted and found to effectively control acute exacerbation of pain during 6 weeks of infusion without serious complications.

Percutaneous Pediculoplasty and Balloon Kyphoplasty in a Vertebral Metastatic Cancer Patient: A case report / 대한통증학회지

Percutaneous vertebroplasty and balloon kyphoplasty have been accepted as effective treatment modalities for vertebral compression fractures in patients with vertebral metastasis. However, when these procedures are conducted in patients with lytic lesions of the vertebral pedicle, polymethylmethacrylate leakage through the lytic lesions that occurs during percutaneous pediculoplasty can increase the procedural risks due to the immediate vicinity of neural structures. In spite of this risk, there are not many available reports on safer methods of pediculoplasty. Here we report a case of vertebral metastasis in which the pedicle infiltration of cancer was successfully treated by pediculoplasty using a bone filler device that contained thick bone cement during a balloon kyphoplasty procedure.

Compression Fractures Diagnosed during the Treatment of Postherpetic Neuralgia : A case report / 대한통증학회지

Vertebral compression fractures can occur due to trauma, a malignancy, or most commonly, osteoporosis. These fractures are frequently seen in elderly women; 30% of postmenopausal women are affected by vertebral compression fractures. These fragile fractures frequently result in both acute and chronic pain, but more importantly, are a source of increased morbidity and possibly, mortality. These injuries can be treated both conservatively and with surgery. The use of percutaneous vertebral augmentation offers a minimally invasive approach for the treatment of vertebral compression fractures. We experienced two cases of compression fractures diagnosed during the treatment of thoracic postherpetic neuralgia. Two patients suffering from postherpetic neuralgia with a sharp and stabbing pain in the thoracic dermatomes that was unresponsive to conservative treatment were transferred to our clinic. During the management of postherpetic neuralgia, we incidentally found thoracic compression fractures after obtaining fluoroscopic guided images. After a balloon kyphoplasty, the preoperative pain related to the postherpetic neuralgia was successfully relieved soon after the procedure, and there were no complications.

Comparison of two culture media on in vitro maturation and fertilization of immature oocytes obtained from stimulated cycles / 대한산부인과학회지

OBJECTIVE: The optimal culture conditions for human immature oocytes are still investigating. We compared retrospectively the efficacy of two culture media (pyruvate-dominant YS media vs glucose-dominant G2 media) on in vitro maturation and fertilization rate of immature oocytes obtained from stimulated IVF cycles. METHODS: One hundred forty-three immature oocytes (including GV and metaphase I) were obtained from 67 cycles of IVF-ET (52 patients). The mean age of female was 32.5+/-3.7 years. Ovarian hyperstimulation was performed using hMG or rFSH with GnRH antagonist and then ovulation was triggered by urinary or rhCG. Immature oocytes were cultured for 4-24 hrs and then fertilized by ICSI. We used YS media between July 2003 and September 2004, and G2 media between October 2004 and August 2005. Each media was prepared containing 30% of patients' follicular fluid, rFSH (1 IU/mL), rLH (1 IU/mL) and rEGF (10 ng/mL). RESULTS: The in vitro maturation rate of immature oocytes (67% vs 66%) and their fertilization rate (61% vs 61%) was not different between YS and G2 media. CONCLUSION: Immature oocytes seem to have a similar developmental competency in each of pyruvate dominant YS and glucose dominant G2 media containing human follicular fluid. Further investigations will be warranted to find the optimal media which can increase the developmental potential of immature oocytes.

Inversion of the Left Atrial Appendage Misdiagnosed as a Thrombus following Cardiac Surgery: A case report / 대한마취과학회지

Transesophageal echocardiography (TEE) is now a common part of intraoperative monitoring in cardiac surgery. Intraoperative TEE offers substantial utility in detection of residual problems requiring reoperation. This report describes a 23 month old patient who was operated on for ventricular septal defect (VSD). TEE following VSD closure revealed a large thrombus in the left atrium (LA). Because of concern about the risk of thromboembolism, the LA was about to be re-explored after TEE demonstration. However, examination by the surgeon as compared with TEE revealed the mass to be an inverted left atrial appendage (LAA) that was easily everted, resulting in the disappearance of this mass on TEE. Echocardiographically, the inverted LAA appears as a mass mimicking a thrombus, a vegetation of the left atrium. Lack of awareness of this entity can result in a misdiagnosis and unnecessary procedures.