Emergency Management and Nursing Considerations of Carotid Blowout Syndrome.

INTRODUCTION: Carotid blowout syndrome is a rare but fatal complication often witnessed secondary to treating patients with head and neck cancer. It occurs when damage and necrosis lead to the carotid artery wall rupture. The symptoms encountered in these patients range from asymptomatic to cardiac arrest. Here, we present 5 cases of carotid blowout syndrome in the emergency department. CASE PRESENTATIONS: Patients demonstrated symptoms ranging from subtle bleeding to hemodynamic instability, highlighting the diverse nature of carotid blowout syndrome in this population. Notably, while all patients had a history of radiotherapy, some had additional risk factors for carotid blowout syndrome, including prior surgery (n = 2), malnutrition (n = 3), and tracheostomies (n = 2). Definitive diagnoses were established through clinical evaluation and computed tomography angiography. Immediate interventions included bleeding control, resuscitation, and consultations with relevant specialties. Four patients underwent interventional radiology procedures, and 1 patient received otolaryngology care. While 2 patients recovered completely, 1 died in the emergency department, and 1 in the intensive care unit. One patient's clinical course was complicated by a stroke. CONCLUSION: The approach to the carotid blowout syndrome patient includes complex steps that proceed in a multidisciplinary manner, starting from triage until discharge. Emergency nurses play crucial roles at every stage. They should be aware of carotid blowout syndrome when evaluating patients with head and neck cancer presenting with bleeding. When treating these patients, emergency nurses should be ready for airway interventions, bleeding control, and massive transfusion protocol. In this context, the multifaceted approaches made by nurses contribute significantly to carotid blowout syndrome management in the emergency department.

Targeted Temperature Management Experience of an Academic Emergency Department: A 5-Year Retrospective Study.

Targeted temperature management (TTM) for postcardiac arrest syndrome patients is a cornerstone therapy to reduce mortality and neurological morbidity. The care of critical patients is provided in the emergency department (ED) when intensive care units (ICUs) are unavailable. This study aimed to determine the characteristics and mortality outcomes of postcardiac arrest patients who underwent TTM in an academic ED. Postcardiac arrest patients who underwent TTM between January 1, 2014, to November 1, 2018, at a tertiary care academic ED in Turkey were examined retrospectively. The mean age of 24 patients in whom TTM was initiated in the ED was 60.7 ± 19.2 years. Five (20.8%) of the patients who underwent TTM were discharged. Four (80%) of the discharged patients were in out-of-hospital cardiac arrest (OHCA). All patients with a total cardiopulmonary resuscitation duration of >25 minutes died. Mortality was significantly higher in patients without light reflexes (p = 0.006). Two patients who underwent TTM in the ED became organ donors after neurological determination of death. If the ICU cannot meet the needs, early initiation of TTM in the ED may contribute to good neurological outcomes. In this study, 80% of the patients who have positive neurological outcomes are OHCA. Lack of light reflex may be an evidence of poor neurological outcomes in postcardiac arrest patients. Emergency physicians should be encouraged to apply TTM.

Idiopathic bilateral bloody tearing.

Bloody tear is a rare and distinct clinic phenomenon. We report a case presenting with the complaint of recurrent episodes of bilateral bloody tearing. A 16-year-old girl presented to our clinic with complaint of bloody tearing in both eyes for 3 months. Bloody tearing was not associated with her menses. A blood-stained discharge from the punctum was not observed during the compression of both nasolacrimal ducts. Nasolacrimal passage was not obstructed. Imaging studies such as dacryocystography and gradient-echo magnetic resonance imaging (MRI) of nasolacrimal canal were normal. Intranasal endoscopic evaluation was normal. We collected samples from bloody tears two times and pathological examination was performed. Pathological analysis showed lots of squamous cells and no endometrial cells; dysplastic cells were found. Further evaluations for underlying causes were unremarkable. No abnormalities were found in ophthalmologic, radiologic, and pathologic investigations. This condition is likely a rare abnormality and the least recognized aetiology for the idiopathic phenomenon.

A rare ocular complication after a heart transplant: toxoplasma retinitis.

Ocular infections after a heart transplant are rare; but when present, they generally appear during the first year after surgery. Ocular infections may cause significant loss of vision and morbidity if not diagnosed early. For that reason, heart transplant patients should undergo a routine visual examination during follow-up. We report our experience regarding the followup and treatment of a case of toxoplasma retinitis diagnosed in one of our heart transplant recipients.

Vogt-Koyanagi-Harada disease: clinical and demographic characteristics of patients in a specialized eye hospital in Turkey.

PURPOSE: To evaluate clinical and demographic features of Vogt-Kayanagi-Harada disease (VKH) disease in Turkish patients and compare them with previously published data. METHODS: Demographic and clinical features of 32 patients diagnosed as VKH in a tertiary referral center were retrospectively reviewed. RESULTS: The mean age at presentation was 33.6 ± 10.4 years. Seventy-five percent of the patients were female and 62.5% of the patients presented during the last 2 years. The disease was complete in 31.2%, incomplete in 50%, and probable in 18.8% of the patients. The clinical course was acute in 50%, chronic recurrent in 34.4%, and chronic in 15.6%. The most common findings were bilateral serous retinal detachment ± papillitis in acute cases and retinal pigment epithelial changes of the macula in chronic cases. CONCLUSIONS: Although rare in Turkey, VKH disease seems to have increased during the last few years. The disease is incomplete and acute in half of the patients and has a quite good visual prognosis.

Changes of total antioxidant capacity and total oxidant status of aqueous humor in diabetes patients and correlations with diabetic retinopathy.

AIM: To measure changes of total oxidant status (TOS) and total antioxidant capacity (TAC) of aqueous humor (AH) in diabetic retinopathy (DR) patients, and to determine if there were any differences in TOS and TAC of AH in diabetic patients without retinopathy compared with non-diabetic patients. METHODS: One hundred and three eyes of 103 patients who were enrolled for cataract surgery were included in this study. Patients were grouped according to presence of diabetes and stage of DR. Prior to cataract surgery, 0.1mL to 0.2mL of AH was aspirated and analyzed for TAC and TOS level using a colorimetric method. RESULTS: TOS levels were highest among proliferative diabetic retinopathy (PDR) patients and lowest in patients with only cataracts. Results were statistically significant between all groups (P<0.05). Whereas result between diabetic without retinopathy patients and non-proliferative diabetic retinopathy (NPDR) patients was not statistically significant (P=0.757). TAC levels were highest in patients with only cataract and lowest among PDR patients and results were statistically significant between all groups (P<0.05). CONCLUSION: Aqueous humor TAC levels are low in diabetic patients and reduced further in DR patients, TOS levels are increased in diabetic patients and this is exacerbated in DR patients.

Impact of panretinal photocoagulation on optic nerve head parameters.

BACKGROUND: To investigate the impact of panretinal photocoagulation (PRP) on quantitative optic nerve head (ONH) assessment in patients with diabetic retinopathy. METHODS: Eighty eyes of 80 diabetic patients who did not undergo PRP and 45 eyes of 45 subjects with diabetes who underwent PRP were enrolled in the prospective, cross-sectional study. Participants were evaluated by confocal scanning laser ophthalmoscopy (CSLO). The global values of ONH parameters were compared among the groups. RESULTS: The eyes that had been treated with PRP had a significantly greater rim area (1.84 ± 0.45 vs. 1.68 ± 0.30 mm(2)), smaller cup/disc area ratio (0.14 ± 0.12 vs. 0.19 ± 0.12), smaller linear cup/disc ratio (0.34 ± 0.17 vs. 0.42 ± 0.14) and shallower cup depth (0.15 ± 0.09 vs. 0.18 ± 0.07 mm) than controls (p = 0.021, p = 0.019, p = 0.007, p = 0.04, respectively). On the other hand, PRP-treated eyes were found to have a significantly thinner mean peripapillary retinal nerve fibre layer compared with the eyes in the control group (0.21 ± 0.08 vs. 0.25 ± 0.09 mm; p = 0.029). CONCLUSIONS: These results suggest that the ONH morphology in eyes treated with PRP may be altered to mask glaucomatous cupping due to PRP itself. Therefore caution must be taken to interpret the CSLO parameters obtained from eyes that have been treated with PRP.

The use of the QuantiFERON-tuberculosis gold test in the diagnosis of ocular tuberculosis.

Ocular tuberculosis without systemic manifestations may rarely occur. The diagnosis of ocular tuberculosis is important because it has a wide spectrum of presentations and requires a multidisciplinary approach. The QuantiFERON-tuberculosis gold test is a new diagnostic test that may be useful in making a suitable diagnosis.

Is there a change of corneal thickness in uveitis with Behçet disease?

PURPOSE: To report the measurements of central corneal thickness (CCT) in uveitic eyes with Behçet disease (BD) and compare it with age- and sex-matched healthy controls. MATERIALS AND METHODS: This study included 69 eyes with ocular BD with no history of corneal disease, glaucoma, or ocular surgery and 50 eyes of healthy controls. Eyes with ocular BD were subdivided into active and inactive groups. Active group was defined as the presence of anterior uveitis or panuveitis, whereas inactive group was defined as having had at least 1 previous attack and absence of any active inflammation in the eye within the last 3 months. CCT was measured with ultrasonic pachymeter. Statistical analyses were performed, and P < 0.05 was considered statistically significant. RESULTS: Active group had 24 patients and inactive group had 45 patients. Demographic characteristics of patients with ocular BD and control subjects were similar (P > 0.05). There was no significant difference in respect to the disease duration between active and inactive groups (P = 0.160). The mean CCT was significantly greater in active group (584.75 ± 20.94 µm) than in inactive group (540.55 ± 36.16 µm) and control group (543.04 ± 25.35 µm) (P = 0.0001). CONCLUSIONS: We found that eyes with active BD had increased CCT because of active inflammation when compared with inactive and control groups, and mean CCT of inactive BD was normal. Therefore, we assume that CCT is in normal range in the inactive phase, and recurrent uveitis does not lead to a permanent change in CCT in BD.

Mammalian telomeric DNA suppresses endotoxin-induced uveitis.

Telomeric regions of mammalian chromosomes contain suppressive TTAGGG motifs that inhibit several proinflammatory and Th1-biased immune responses. Synthetic oligodeoxynucleotides (ODN) expressing suppressive motifs can reproduce the down-regulatory activity of mammalian telomeric repeats and have proven effective in the prevention and treatment of several autoimmune and autoinflammatory diseases. Endotoxin-induced uveitis (EIU) is an established animal model of acute ocular inflammation induced by LPS administration. Augmented expression of proinflammatory cytokines/chemokines such as TNFalpha, IL-6, and MCP1 and bactericidal nitric oxide production mediated by LPS contribute to the development of EIU. Suppressing these mediators using agents that are devoid of undesirable systemic side effects may help prevent the development of EIU. This study demonstrates the selective down-regulatory role of suppressive ODN after (i) local or (ii) systemic treatment in EIU-induced rabbits and mice. Our results indicate that suppressive ODN down-regulate at both the transcript and protein levels of several proinflammatory cytokines and chemokines as well as nitric oxide and co-stimulatory surface marker molecules when administrated prior to, simultaneously with, or even after LPS challenge, thereby significantly reducing ocular inflammation in both rabbit and mouse eyes. These findings strongly suggest that suppressive ODN is a potent candidate for the prevention of uveitis and could be applied as a novel DNA-based immunoregulatory agent to control other autoimmune or autoinflammatory diseases.

Aneurysmal bone cyst of the ethmoid presenting with proptosis and epiphora.

An aneurysmal bone cyst of ethmoid is a rare and distinct clinicopathologic entity. The diagnosis is important in this localization because it requires multidisciplinary approach in its management. We report a case of a 14-year-old woman presenting to our clinic with the complaint of epiphora and proptosis in the right eye, which were the symptomatic findings of aneurysmal bone cyst of ethmoid.

Short-term effects of subconjunctival injections of 5-fluorouracil on conjunctival epithelium.

PURPOSE: To assess the changes in the conjunctival cytology of patients given a subconjunctival injection of 5-fluorouracil (5-FU) to treat failed filtering blebs. METHODS: The patients were classified into 3 groups. The first group included 15 eyes in 15 patients who were given subconjunctival injections of 5-FU after unsuccessful glaucoma surgery. The second group consisted of 15 eyes of 15 patients with primary open angle glaucoma treated with antiglaucomatous eyedrops. Twelve healthy age- and sex-matched volunteers formed the third group. Impression cytology specimens were obtained from the bulbar conjunctiva just beside the injection sites using cellulose acetate filter paper. The samples were fixed in 95% ethanol, stained with Papanicolaou stain, and evaluated under light microscopy and graded. RESULTS: In the first group, grade 0-3 cytological changes were seen in 1 eye (6.6%), 9 eyes (60%), 4 eyes (26.6%), and 1 eye (6.6%). Apoptosis was observed in 2 eyes (13%) and nuclear atypia in 7 eyes (47%). In the second group, 9 eyes (60%) were grade 0, 4 eyes (27%) were grade 1, and 2 eyes (13%) were grade 2. Also, nuclear atypia was observed in 1 eye (6.6%). In the third group, 10 eyes (83%) were grade 0 and 2 eyes (17%) were grade 1. There was no significant difference in terms of the impression cytology grades between the groups because of small sample size. CONCLUSIONS: The use of subconjunctival 5-FU injections after glaucoma surgery may lead to squamous metaplastic changes and nuclear atypia and apoptotic cell death in the conjunctival epithelium in short-term period.

Localized Cystic Enlargement of the Distal Optic Nerve Sheath after Decompression Surgery.

Cystic formation of the optic meninges may occur after optic nerve sheath decompression surgery for the management of pseudotumor cerebri. A case with a cyst-like structure of the distal optic nerve sheath at the operation site in the late surgical period after nerve sheath decompression surgery is reported.

The relation between bevacizumab injection and the formation of subretinal fibrosis in diabetic patients with panretinal photocoagulation.

BACKGROUND AND OBJECTIVE: To report the development of subretinal fibrosis after the injection of intravitreal bevacizumab in eyes with proliferative diabetic retinopathy (PDR) refractory to panretinal laser photocoagulation (PRP). PATIENTS AND METHODS: Twenty-one eyes of 15 patients treated with PRP and intravitreal injection of bevacizumab were included in this study. The clinical outcomes of 21 eyes having subretinal fibrosis after intravitreal bevacizumab injection were reviewed. RESULTS: There were 9 men and 6 women with a mean age of 51.3 +/- 8.9 years. All eyes had PDR refractory to panretinal photocoagulation and were treated with at least one intravitreal injection of 1.25 mg of bevacizumab (mean number of injections: 1.8). Before injection, there was subretinal fibrosis in 5 eyes and vitreoretinal traction in 19 eyes. After a mean follow-up period of 7 months, the development or progression of subretinal fibrosis was detected in all eyes. CONCLUSION: Intravitreal injection of bevacizumab may cause formation or progression of subretinal fibrosis in patients with PDR refractory to PRP.

Is there a correlation between diabetes mellitus and central corneal thickness?

PURPOSE: To evaluate the association of central corneal thickness (CCT) with diabetes mellitus and compare it with age and sex-matched healthy controls. MATERIALS AND METHODS: This study included 245 eyes of 245 subjects (one eye per subject). One hundred diabetic patients constituted the study group and 145 were healthy controls. The study group was subdivided into 3 subgroups: subgroup 1 (no diabetic retinopathy), subgroup 2 (nonproliferative diabetic retinopathy), and subgroup 3 (proliferative diabetic retinopathy). CCT was determined with ultrasonic pachymeter. None of the patients had glaucoma, retinal laser treatment, and history of ocular surgery. Statistical analyses were performed by analysis of variance and Kruskall-Wallis tests. Correlation analysis was performed to assess the association between disease duration and glycosylated hemoglobin levels among subgroups. RESULTS: Demographic characteristics of study and control groups were similar (P>0.05). The mean CCT was significantly greater in study group (564±30 µm) compared with control group (538±35 µm) (P=0.001). In addition, mean CCT was found to be greater in subgroup 3 (582±23 µm) compared with subgroups 1 (565±32 µm) and 2 (558±31 µm); but the difference did not reach statistical significance (P=0.056). Also, there was no significant correlation in respect to the level of glycosylated hemoglobin and disease duration among the subgroups. CONCLUSIONS: We found that the central cornea of diabetic patients is thicker when compared with nondiabetic patients. Thicker central cornea associated with diabetes mellitus should be taken into consideration while obtaining accurate intraocular pressure measurements in diabetics.

Usher syndrome associated with a variant of Dandy-Walker malformation.

Three cases of Usher syndrome associated with a variant of Dandy-Walker malformation in three siblings from consanguineous Turkish parents are described. The siblings had retinitis pigmentosa and hearing loss. Two of the siblings also had mental retardation, which is not a constant finding in Usher syndrome. Dandy-Walker malformation might have contributed to the mental retardation in two of these patients and might be a coincidental finding with Usher syndrome.

Combined cilioretinal artery and partial central retinal vein occlusion in the postpartum period.

PURPOSE: To report a combined cilioretinal artery and partial central retinal vein occlusion shortly after delivery in a twin-pregnant woman. METHODS: A 25-year-old woman presented to our clinic with the complaint of blurred vision in the right eye 1 week after delivery. She underwent detailed ophthalmic and systemic investigations. RESULTS: The patient had an uncomplicated twin pregnancy. Ocular examination showed combined cilioretinal artery and partial central retinal vein occlusion in the right eye. Systemic diseases were excluded. Laboratory evaluations revealed increased plasma d-dimer level (1.64 mg/mL). Spontaneous recovery occurred without treatment 1 month after delivery. CONCLUSION: Twin pregnancy may lead to exaggerated hypercoagulability and increased d-dimer level in pregnant women. This situation may be a risk factor for retinochoroidal vascular occlusions.