E-PIX: An enhanced grading for acute ocular burns

An enhanced online and manual grading system, based on the I’s and E’s, for acute ocular chemical injuries is being proposed. E-PIX is designed to be an online/manual grading system that includes all the parameters that adversely affect the outcome of acute chemical injuries. The importance of addressing the I’s and E’s in chemical burns cannot be underestimated. These include the need for the documentation and management of epithelial defect (E), intraocular pressure (P) (IOP), ischemia (scleral) (I), and exposure (X) (acronym - E-PIX). Epithelial defect includes that involving the limbus (L), along with conjunctival (C), corneal (K), and tarsal (T). These additional parameters are graded and represented as an annotation along with the limbal grade providing a comprehensive grading for the injury. A manual entry sheet and a freely accessible online grade generator are a part of the system. The proposed enhanced grading offers a final annotation that provides a clear understanding of all factors that can lead to vision-threatening complications ensuring their assessment and hence subsequently their addressal to improve outcomes, if abnormal. The prognostication continues to be based on the grade of limbal involvement. The additional annotations impact prognosis and outcome if not addressed. Including the laterality of injury provides, in addition, a futuristic understanding of available options. The grade generator retains the flexibility to be dynamic with changes reflecting upon the healing process in the acute stage. The proposed system aims to provide primary and tertiary caregivers alike with a uniform grading system.

Role of tenon advancement in treating limbal ischemia in acute chemical injury

Background: In acute chemical injury, damage can range from ocular surface epithelial defects to limbal and scleral ischemia. This may subsequently progress to corneal or scleral melting and perforation and finally result in phthisis bulbi. Thus, acute chemical injury is a potentially blinding condition and warrants attention. The accurate technique to assess the damage incurred should be practiced to avoid undertreatment and subsequent complications. Surgical intervention wherever needed should be appropriately timed and should be performed. The primary aim of medical or surgical intervention in acute chemical injury is to attain a stable and epithelized ocular surface. Even a conjunctival phenotype over the cornea is a desirable outcome. Purpose: This video discusses the nuances involved in the assessment and planning of Tenon advancement with amniotic membrane grafting for treating limbal ischemia in acute chemical injury. Synopsis: The video demonstrates the technique of restoration of limbal vascularization by performing Tenon advancement with amniotic membrane grafting and its outcome. Highlights: Ocular surface painting with fluorescein dye is essential to assess the areas of surface involvement. Merely instilling the fluorescein dye in the cul?de?sac will underestimate the extent of the damage. Tenon advancement should ideally be planned between 7 and 10 days following an injury when actual limbal blanching is obvious. A stable and epithelized ocular surface is the desirable outcome irrespective of the epithelial phenotype.

Chemical Injury Due to Pain Balm: Case Series

Ocular chemical injuries accounts for 11.5% to 22.1% of ocular injuries. Ocular chemical burns are an ophthalmic emergency and requires immediate treatment. We report a series of three cases of chemical injury secondary to accidental exposure to red balm used as local application for headache. In our cases menthol, cajuput oil and capsaicin might have contributed to chemical injury and nerve damage. Nerve damage might have lead to delayed epithelial healing. All three patients improved completely within 1 to 3 week.

Limbal ischemia: Reliability of clinical assessment and implications in the management of ocular burns

Purpose: Limbal ischemia is an important prognostic factor in the management of ocular burns. In this study, we evaluated the reliability of clinically assessing limbal ischemia among ophthalmic professionals. Methods: This study included 111 ophthalmic professionals who were shown 12 diffuse illumination color slit-lamp photographs of eyes with recent chemical injuries. Respondents were asked whether the photos were assessable and if yes, then to indicate the presence, location, and grade of limbal ischemia in each case. The responses were collected using a standard data collection sheet and the inter-observer agreement was calculated. Results: All participants responded to every question. Of the 1,332 responses, images were deemed assessable in 1,222 (91.7%) instances. The overall agreement (Fleiss' kappa) for the presence of limbal ischemia and severity of limbal ischemia was 0.106 and 0.139, respectively (P < 0.012). Among the four groups of observers, practicing cornea specialists displayed significantly (P < 0.003) higher kappa values (0.201–0.203) when compared to residents (0.131–0.185), fellows (0.086–0.127), and optometrists (0.077–0.102). All indicated a poor level of inter-rater consistency. Conclusion: The results indicate that clinical assessment of limbal ischemia is highly subjective and there is lack of reliability even among cornea specialists who regularly manage patients with ocular burns. A non-invasive, standardized, objective, accurate, and reliable modality for ocular surface angiography is desperately needed for proper assessment and prognostication of ocular burns.

A Case of Corneal Chemical Injury by High-dose Ethanol during Orbital Wall Fracture Repair

PURPOSE: To report a case of chemical injury of the cornea caused by high-dose ethanol during orbital wall fracture repair. CASE SUMMARY: A 56-year-old male presented with pain after blowout fracture repair surgery. During the surgery, 2% hexethanol solution (2% chlorhexidine and 72% ethanol mixture), which was used for disinfection of the face, flowed into the left eye. Conjunctival injection in the left limbus, a large corneal epithelial defect, and severe stromal edema were subsequently observed. The patient was treated with topical antibiotics, steroids, and autologous serum eye drops. After 1 week, the corneal epithelial defect was improved, but at the second month of therapy, recurrent corneal erosion with deterioration of the endothelial cell function occurred. Anterior stromal puncture and laser keratectomy were performed. The corneal epithelial defect and erosion improved, but the endothelial cell density was severely decreased. CONCLUSIONS: The 2% hexethanol solution is usually used for preoperative skin disinfection, but it contains a high concentration of ethanol. The surgeon should be aware that high concentrations of ethanol may result in severe corneal damage, including corneal endothelial dysfunction and limbal cell deficiency.

Isolation of acid from eye drop bottles being used by patients presenting with presumed scleritis

Purpose: The aim of the study was to report the occurrence of contamination/replacement of ophthalmic eye drops with liquids of acidic nature in patients treated for nonresponding scleritis. Methods: This was a retrospective interventional case series study. Results: Of the three patients (4 eyes) referred as necrotizing scleritis, two were found to have acid as the content in the bottle/s being used as eye drops, confirmed using biochemical tests. All four eyes had tarsal ischemia and tarsal conjunctival defect in addition to severe scleral ischemia involving the inferior bulbar area. All four eyes required tenonplasty with amniotic membrane transplant more than once for the ocular surface to heal. Two of the three patients were on systemic immunosuppressives including pulse cyclophosphamide for refractory necrotizing scleritis. Sulfuric and hydrochloric acid was isolated from the bottles of 2nd and 3rd patient using confirmatory biochemical tests. Conclusion: It is important to be aware of the possibility of contaminating or replacing contents of eye drops with harmful agents of acidic nature and should be considered in situations that resemble the clinical picture described herein.

Results of simple limbal epithelial transplantation in unilateral ocular surface burn

Purpose: This study aimed to report the long-term outcomes of autologous Simple Limbal Epithelial Transplantation (SLET) performed for unilateral limbal stem cell deficiency (LSCD) following chemical burn at a tertiary eye center in North India. Methods: This was a single-center prospective interventional case series of patients who developed unilateral LSCD after suffering from ocular surface burns and who underwent SLET between October 2012 and May 2016 with a follow-up period of at least 6 months. The primary outcome measure was restoration of a completely epithelized, stable, and avascular corneal surface. The secondary outcome measure was percentage of eyes, which reported visual gain. Results: The study included 30 eyes of 30 patients, 18 adults and 12 children, at a median follow-up of 1.1 years (range: 6 months to 3.5 years), 21 of 30 eyes (70%; 95% confidence interval, 53.6%–86.2%) maintained successful outcome. Visual acuity gain was seen in 71.4% of successful cases. The clinical factors associated with failure were identified as acid injury, severe symblepharon at the time of presentation, and SLET combined with penetrating keratoplasty (PK). Conclusion: Autologous SLET is an effective limbal cell transplantation technique for the treatment of unilateral LSCD. It is especially beneficial for centers where cell cultivation laboratory is unavailable. Presence of severe symblepharon, which requires PK peroperatively , has poor outcome.

Review Of Ocular Injuries In Malaysia

Ocular injuries or trauma to the eye can be caused by variety of objects resulting in a spectrum of lesions in the eye. We did a Pubmed/Google/Science Direct search to review the spectrum of ocular injuries in Malaysia. In our review, we included 28 papers providing information on ocular injuries which were published from Malaysia during the period 1991-2016 in different medical journals. Prevalence was more among males with an average age of 35 years. Among adults they were more common in the workplace but in children it occurred at home. Few wore protective glasses at work. The mode of injury was due to sharp objects hitting the eye, motor vehicle and domestic accidents, firecrackers, chemicals and rarer causes like superglue and durian fruit. Prognostic factors for outcome were the initial visual acuity, length of the wound, associated factors like hyphaema, intraocular foreign body and vitreous prolapse. Missing the diagnosis of perforation of the eyeball is possible without eliciting a proper history. Protective devices must be worn to prevent injuries. Display of health education charts showing the effect of injuries in the eye and their preventive measures in health centres, private hospitals, schools, factories and sports centres will increase the awareness of public about the ocular injuries. It is important to diagnose the tissues involved in ocular trauma by the general practitioners and primary care physicians and refer the patients to the Ophthalmologist urgently for treatment to salvage vision. Compensation mechanisms should then be put forth in terms of rehabilitation and for monetary loss.

Clinical profile of medicolegal cases presenting to the eye casualty in a tertiary care center in India.

Purpose: The purpose of this study was to analyze the clinical profile of medicolegal cases (MLCs) presenting to the eye casualty in a tertiary care hospital. Materials and Methods: Retrospective review of records. The cases were grouped according to the Ocular Trauma Classification Group classification system. Results: Out of 188 MLCs, 164 (87.2%) were male. Mean age (±standard deviation) was 31.6 (±12.7) years. Age ranged from 7 to 75 years. Twenty‑six (13.8%) patients had bilateral involvement. The fist was the most common mode of injury, which was seen in 109 (58%) cases. A total of 27 (14.3%) patients had associated extraocular injury. No evidence of ocular or orbital trauma (malingering) could be found in 13 (7%) patients. Mechanical trauma was present in 169 (90%) patients with injury to globe in 129 (69%) patients and injury to lid or orbit without damage to the globe in 40 (21%) patients. Chemical injury was observed in 6 (3%) patients. Closed globe injury (CGI) was seen in 116 eyes and open globe injury (OGI) was noted in 29 eyes. The most common type of injury, zone, pupil, and grade of injury in CGI were Type A or contusion (79%), Zone I (72%), Pupil B (absence of relative afferent pupillary defect) in 95%, and Grade A [visual acuity (VA) ≥20/40] in 68% of the eyes, respectively. The most common type of injury, zone, pupil, and grade of injury in OGI were Type B or penetrating (48%), Zone II (38%), Pupil B (59%), and Grade D (VA 4/200‑light perception) (42%), respectively. Conclusions: The most common form and mode of ocular injury in MLC were closed globe injury and fist, respectively. The most common type of injury in CGI and OGI was contusion and penetrating injury, respectively.

Developing specific drug/device combination products improves the treatment level of the acute chemical injury / 国际药学研究杂志

To deal with effectively acute chemical injury events, the service ability of protective medicine against chemical weapons has being widened from dealing with traditional chemical warfare to public chemical accident or chemical terrorist attack. Focusing on the important researching and developing of medicine for chemical defense use only, the novel drug/device combination products should be vigorously promoted including the new mechanism, good curative effect and high safety of detoxification drugs such as hydroxycobalamin used in the treatment of known or suspected cyanide poisoning in both adults and the pediatric population, and the convenient and quick drug delivering technologies such as auto-injectors with a retreat hidden needle and a smart remindful injection, which could improve greatly the emergency medical rescue ability of chemical accidents.

Developing specific drug/device combination products improves the treatment level of the acute chemical injury / 国际药学研究杂志

To deal with effectively acute chemical injury events,the service ability of protective medicine against chemical weapons has being widened from dealing with traditional chemical warfare to public chemical accident or chemical terrorist attack. Fo?cusing on the important researching and developing of medicine for chemical defense use only,the novel drug/device combination products should be vigorously promoted including the new mechanism,good curative effect and high safety of detoxification drugs such as hydroxycobalamin used in the treatment of known or suspected cyanide poisoning in both adults and the pediatric population ,and the convenient and quick drug delivering technologies such as auto-injectors with a retreat hidden needle and a smart remindful injec?tion,which could improve greatly the emergency medical rescue ability of chemical accidents.

A Two Case of 360 Degree Keratolimbal Allograft

PURPOSE: To report the clinical outcomes of 360-degree keratolimbal allograft in 2 patients. CASE SUMMARY: An 83-year-old female who had uncontrolled Mooren's ulcer invading 360 degrees of the limbus with corneal opacity received a 360-degree keratolimbal allograft (KLAL). Another 63-year-old female who had central corneal opacity and corneal neovascularization due to severe limbal cell deficiency with chemical injury received a 360-degree KLAL. During the average 17.5 months of follow-up, both eyes were tectonically maintained without severe graft rejection. CONCLUSIONS: A 360-degree KLAL may be an effective tectonic procedure for corneal opacity caused by limbal stem cell deficiency. Herein, we report 2 cases of successfully performed 360-degree KLAL with a literature review.

Trauma químico del segmento anterior / Chemical trauma of the anterior segment

Se realizó una revisión de la situación actual y manejo de la urgencia de este tipo particular de trauma ocular. Se detectó el trauma químico por álcalis (58,5 %) como el agente etiológico más importante, además de ser el más peligroso entre las sustancias que pueden provocarlo. El lavado profuso con agua o soluciones balanceadas, continúa como el tratamiento de elección en el manejo inicial, y depende de este, la integridad de las estructuras oculares y la agudeza visual final que alcanzará el paciente. Se propone un flujograma con la conducta a seguir en estos casos de forma general.

A review of the current situation and management of the ocular chemical injury in the emergency room was made. Alkalis was the most frequent and dangerous etiological agent (58,5 %) of chemical injuries in the eye. Ocular washing with abundant water or balanced solutions remains the treatment of choice as initial management, which determines the ocular structure integrity and the final visual acuity. A general flowchart containing the behavior to be adopted in these cases was submitted.

A Case of Keratoconjunctival Chemical Injury from a Topical Anesthetic Ointment

PURPOSE: To report a case of keratoconjunctival chemical injury caused by exposure to EMLA(R) 5% cream. CASE SUMMARY: A 51-year-old woman presented with ocular pain and decreased visual acuity in her left eye after an autologous fat injection for forehead lifting. At her initial visit, her best corrected visual acuity was 20/40 in the left eye. Slit-lamp examination showed a diffuse corneal epithelial defect and conjunctival injection. Based on history of inadvertent seepage of EMLA(R) 5% cream into the left eye and clinical findings consistent with chemical injury, the patient was treated with antibiotics, steroids, and artificial tears. Two weeks after treatment, several corneal erosions remained, and best corrected visual acuity improved to 20/20. After two months, the corneal and conjunctival epithelia were healed. CONCLUSIONS: EMLA(R) 5% cream is commonly used as topical anesthetic ointment for dermatologic surgery, including laser procedures. The cream is highly alkaline and can cause chemical injury to the eye, thus extreme caution should be used when applying the cream to the eyelid or face.

Devastating ocular injury by a rice black bug: a case report / 国际眼科杂志(Guoji Yanke Zazhi)

A 59-year-old female farmer presented with left painful swollen eye for 1 week after being stung by a rice black bug ( Scotinophara sp. ). It was associated with acute progressive blurring of vision. On examination of the left eye, there was a marked periorbital swelling with proptosis and complete ptosis. The extraocular movements were restricted in all the directions. The cornea was hazy with large epithelial defect. Fundoscopy showed combined features of both central retinal vein and artery occlusions with swollen optic disc and ischaemia of the macular area. CT scan and MRI of orbit and brain showed evidence of orbital soft tissue inflammation. Patient was diagnosed with left orbital cellulitis, keratouveitis and central retinal vein and artery occlusions. The periorbital swelling and proptosis were improved after treatment with systemic and topical antibiotics. However, the vision remained no perception of light(NPL)and limitation of ocular movements persisted. The potential ophthalmic insults by Scotinophara sp. Can be severe and permanent. Awareness of the debilitating insults by Scotinophara sp. To human eye should be instilled timely especially in its prone areas.

Lesiones traumáticas: conducta odontológica / Injury: dental behavior

En la cavidad bucal se pueden producir una variedad de lesiones de diferente etiología, por ello es muy importante que el odontólogo las identifique y conozca las consecuencias que ocasiona si no se previenen o tratan a tiempo. Se funda como premisa que el cuidado periodontal es, en esencia, labor del odontólogo general y que éste no puede pasar por alto la responsabilidad de proveer atención a todos los pacientes. La incidencia excesivamente elevada de los problemas periodontales entre la población, dificulta que un número reducido de especialistas los pueda enfrentar. Asimismo, el estrecho vínculo entre los tratamientos dentales restaurativos y los regímenes periodontales hace muy importante que el odontólogo general disponga de conocimientos a fondo sobre periodoncia. En la cavidad bucal se producen variedades de lesiones de origen traumático ya sea por injurias químicas, físicas y térmicas estás representan una urgencia en Odontología. El propósito de este reporte es describir las diferentes presentaciones clínicas de dicha patología, su etiología, diagnósticos diferenciales y diferentes métodos de tratamiento, para valorar sus complicaciones y cuidados postoperatorios. Para ello se realizó basado en los lineamientos de la investigación descriptiva documental, una revisión de la literatura nacional e internacional

A variety of different etiologies pathologies can affect the oral cavity, due to this reason, dentists must be able to identify them and their consequences if they are not treated on time. It is primordial for the general practitioner dentists the periodontal care of their patients. Among the population the periodontal diseases are very common and only a reduced number of specialists can treat them. The close relation between restorative dental treatments and periodontal treatment procedures lead to the tendency that de general practitioner has enough knowledge in the periodontal field. Among the variety of pathologic entities that affect the oral mucosa, that presents as ulcer and are really Traumatic lesions in its different types chemical injury, physical injury, thermal injury It is considered one of the emergencies in dentistry. Dentist must be able to recognize and treat them. The purpose of this research is to describe the possible etiologic agents, clinical features and treatment of this disease and also to recommend the multidisciplinary attention to these patient. For this paper was made a study based on the lineaments of the descriptive documental research, mainly with scientific bibliographic references literature national and international

A staged penetrating keratoplasty following limbal stem cells allograft in severe chemical injury leading to successful restoration of the ocular surface anatomy / 国际眼科杂志(Guoji Yanke Zazhi)

A 62-year-old man presented with severe bilateral ocular surface chemical injury and history of failed penetrating keratoplasty of right eye in 1996. Visual acuity was hand movement in right eye and light perception in left eye. Staged procedures of limbal stem cells allograft followed by penetrating keratoplasty have been done and resulted in good ocular surface restoration and rehabilitation of vision in right eye.

Nasal tolerance with collagen v protein reverts bronchovascular axis remodeling in experimental bronchiolitis obliterans

INTRODUCTION: The precise role of the remodeling process and possible therapies for bronchiolitis obliterans remain to be established. OBJETIVE: In the present study, we sought to validate the importance of nasal collagen V tolerance to verify whether bronchovascular axis remodeling could be reverted by this therapeutic approach when compared to steroid treatment. METHODS: Mice were randomly divided into 4 groups: control, bronchiolitis obliterans, collagen V tolerance, and prednisone groups. Morphometry was employed to evaluate bronchovascular axis dimensions, collagen density, and immune cell response. Collagen V nasal tolerance and steroid-treated mice showed significantly lower values of terminal bronchiole wall thickness and reduction in peribronchovascular cells; bronchioalveolar lymphoid tissue; and CD3+, CD4+, CD8+, and CD20+ lymphocytes. A significant decrease in CD68+ macrophage density was found in prednisone-treated mice. In addition, a strong quantitative relationship was found between collagen V tolerance, and reduction in density of immune cells and collagen. RESULTS: Our results indicate that bronchovascular axis remodeling in bronchiolitis obliterans can be reverted by collagen V nasal tolerance, possibly as the result of T-cell suppression. CONCLUSION: We concluded that the tolerance effects in this model were strongly related to the improvement in bronchovascular remodeling, and these may be an appropriate targets for further prospective studies on nasal collagen V tolerance.

INTRODUÇÃO: A participação precisa do processo de remodelamento e possíveis implicações no tratamento da bronquiolite obliterante ainda não está estabelecida. OBJETIVOS: Estabelecer a importância da tolerância nasal induzida pelo colágeno do tipo V e verificar se o processo de remodelamento do eixo broncovascular pode ser revertido com esta estratégia terapêutica comparada ao efeito do tratamento com esteróides. MATERIAL E MÉTODO: Camundongos foram divididos em quatro grupos: controle, bronquiolite obliterante, tolerância nasal com colágeno do tipo V e prednisona. Morfometria foi realizada para avaliar as dimensões do eixo broncovascular, densidade de colágeno e resposta imunocelular. Camundongos submetidos à tolerância nasal com colágeno do tipo V e tratados com prednisona exibiram significativas reduções da espessura da parede de bronquíolos terminais, da densidade de células inflamatórias ao redor do eixo peribroncovascular e da resposta imunocelular às custas de linfócitos CD3, CD4, CD8 e CD20. Houve também significativa redução da densidade de macrófagos CD68 nos camundongos tratados com prednisona. Adicionalmente, houve uma forte associação entre tolerância nasal induzida pelo colágeno do tipo V, resposta imunocelular e redução do conteúdo de colágeno peribroncovascular. RESULTADOS: O remodelamento do eixo broncovascular na bronquiolite obliterante pode ser revertido pela indução de tolerância nasal com o colágeno do tipo V, possivelmente como resultado de supressão de linfócitos T. CONCLUSÃO: Os efeitos da tolerância nasal no presente modelo estiveram fortemente relacionados à melhora no remodelamento do eixo broncovascular, despontando como um alvo promissor para estudos prospectivos.

Hepatic injury and gluconeogenesis after subcutaneous injection of monochloroacetic acid in rats

<p><b>OBJECTIVE</b>Monochloroacetic acid (MCA) is corrosive to skin, and causes not only chemical injury but also fatal systemic poisoning. Little is known about the cause of death. We studied the acute toxicity of MCA before clinical symptoms appeared in fasting rats.</p><p><b>METHODS</b>Blood samples were analyzed 2 h after subcutaneous MCA injection (Ld(90): 162 mg/ml kg body weight). Control rats were injected with saline.</p><p><b>RESULTS</b>Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were about 1.5-fold higher than in the controls, and mitochondrial AST (mAST) was 2-fold higher. Blood urea nitrogen and creatinine were significantly increased, while serum glucose was significantly decreased in the treated group. Lactate was 6-fold higher and pyruvate was 13-fold higher than in the controls.</p><p><b>CONCLUSIONS</b>MCA caused injury to the liver and kidneys but these injuries were slight. However, the larger increase in mAST indicated that hepatocellular mitochondria were selectively targeted. Hepatocellular mitochondrial injury decreased gluconeogenesis and caused hypoglycemia and extremely high levels of lactate and pyruvate. Hypoglycemia and lactic acidosis were insidious before the critical symptoms appeared and this combination accelerated to death, affecting other organs such as the heart and brain. Nosotropic therapy of these abnormalities up to the appearance of symptoms may help to establish an early therapy for skin exposure to MCA.</p>