[Polytrauma with tension pneumothorax with inserted chest tube]. / Polytrauma mit Spannungspneumothorax bei liegender Thoraxdrainage.

The authors report a case of a 25-year-old woman with a polytrauma, caused by a free fall of 12 metres in suicidal intention. Following endotracheal intubation and mechanical ventilation by an emergency physician at the scene, the patient was delivered to the emergency room of an university hospital. An ultrasonic check of the abdomen revealed free fluid in the abdominal cavity, and a rupture of liver and spleen was suspected. Since breath sounds over the right lung were diminished, a chest tube was inserted immediately in the fifth intercostal space in the anterior axillary line. About 300 millilitres of blood were drained by the tube. Shortly thereafter, a laparotomy was performed, where spleen and liver rupture were confirmed and treated. After 60 minutes, the patient developed severe hypotension coupled with ventricular tachycardia and fibrillation, and resuscitation measures had to be initiated. Since breath sounds over the right lung were missing, a tension pneumothorax was suspected and a thoracotomy performed immediately. While huge amounts of air and blood were emerging from the thoracic cavity, a rupture of the right mainstem bronchus as well as of the right pulmonary artery and vena subclavia was identified. The chest tube was found dislocated into the subcutaneous tissue. Despite of open heart compression, application of adrenaline and noradrenaline and substitution of packed red blood cells and of crystalloid and colloid solutions, all resuscitation measures failed so that the patient died shortly after on the operation table. This case illustrates first the difficulties of an adequate thoracic trauma management, particularly, when clinical symptoms are discrete, second the problems of the insertion and control of a chest tube, and third risks associated with wrong position or secondary dislocation which may include - as in our case - "masking" of severe injury patterns and delay of life-saving measures such as an immediate thoracotomy. In order to improve prognosis of patients with poly-/thoracic trauma, establishment of spiral-CT in emergency centres, routine bronchoscopy and safe handling of chest tubes may be helpful.

Cilioretinal artery occlusion in sickle cell trait and rheumatoid arthritis.

BACKGROUND: Although once thought to be a benign condition, retinal vascular occlusive disease and proliferative retinopathy can occur with sickle cell trait (hemoglobin AS) when additional systemic diseases or trauma are present. METHODS: The authors discuss the ophthalmologic evaluation and clinical course of a 49-year-old woman with sickle cell trait and rheumatoid arthritis who presented with a cilioretinal artery occlusion. RESULTS: The patient's laboratory evaluation showed both a high rheumatoid factor titer and a mild hypergammaglobulinemia, causing increased serum viscosity. The high level of sickle hemoglobin-42.3% (range in trait, 22%-46%)-increased serum viscosity, and lower cilioretinal artery perfusion pressure relative to the central retinal artery resulted in cilioretinal artery occlusion. CONCLUSIONS: Isolated cilioretinal artery occlusions carry a good prognosis, and this patient recovered 20/20 visual acuity in the affected eye. The association between sickle cell trait and rheumatoid arthritis resulting in retinal vascular occlusive disease has not been reported previously. The presence of retinal vascular occlusion in sickle cell trait necessitates a medical evaluation for additional systemic diseases.

Posterior chorioretinopathy and retinal detachment after organ transplantation.

Four patients, three after renal transplantation and one after heart-lung transplantation, developed visual loss in both eyes associated with geographic zones of disruption and coarse clumping of the pigment epithelium in the posterior fundi. Secondary retinal detachment occurred bilaterally in three patients. Localized choroidal intravascular coagulation is the suspected but unproven cause.

The effect of tarsorrhaphy on normal healing of corneal epithelial defects in a rabbit model.

The presumed benefits of occlusive patching are patient comfort and enhancement of corneal healing. However, there is little experimental evidence to document a beneficial effect of eyelid occlusion on corneal healing. We produced corneal abrasions by mechanical debridement within a 4 mm trephine-marked area on 1 eye each of 23 New Zealand albino rabbits. Homatropine 5% solution and erythromycin ointment were instilled. Then we divided the animals into three groups. The abraded eyes of the first group (7 rabbits) were sutured shut by a temporary tarsorrhaphy. The eyes of the second group (7 rabbits) were left open until 12 h postinjury, when they were sutured shut in a similar fashion. The abraded eyes of the control group (9 rabbits) were left open for the entire observation period. We monitored fluorescein staining patterns of the epithelial defects photographically at a set focal length at 12-h intervals. By 48 h, corneal staining had resolved in 87% of eyes. We performed computerized planimetry on the photographs of wound size for each time point. There was no statistically significant difference in the rate of healing of corneal abrasions in the occluded versus of the unoccluded eyes.

Bilateral diffuse uveal melanocytic proliferation in patients with occult carcinoma.

The development of multiple, round or oval, subtle, red patches at the level of the pigment epithelium in the posterior ocular fundus and their striking early hyperfluorescence angiographically are characteristic features of the bilateral diffuse uveal melanocytic proliferation syndrome. They may be accompanied by severe visual loss and may antedate the appearance of multiple melanocytic tumors, retinal detachment, and cataract in these patients with occult systemic carcinomas. These hyperfluorescent patches are caused by focal damage to the pigment epithelium overlying an intact choriocapillaris and diffuse benign nonpigmented uveal melanocytic infiltration of the outer choroid. We suggest that outer retinal damage may not be primarily caused by melanocytic proliferation, but rather by toxic and immune factors generated by interaction between a systemic carcinoma and congenital melanocytosis of the uveal tract. We report the longest survivor of this disorder to date (102 months).

Ocular deviation after retinal detachment surgery.

Thirty patients with untreated rhegmatogenous retinal detachments underwent complete ocular muscle examinations before scleral buckling procedures. The examination was repeated three weeks, six weeks, three months, and six months after surgery. We found a high incidence of heterotropia after surgery; in most cases this resolved during the first six postoperative months. This resolution progressed from heterotropia to heterophoria to orthophoria. We believe this change results from phoria adaptation. Diplopia occurred in three patients. We found no statistically significant association between this diplopia and the type of surgery used.

Treatment of proliferative diabetic retinopathy with panretinal cryotherapy.

Panretinal cryoablation was performed on 100 eyes with retinal neovascularization and vitreous hemorrhage. Of those 100 eyes, 70 had neovascularization and recurrent hemorrhage despite previous panretinal laser photocoagulation, and 30 eyes had media opacities precluding laser treatment. Sixty applications, random and focal, were placed in each eye. Forty-six percent of eyes achieved better visual acuity, 32% were unchanged, and 22% were worse. Eighty-three percent of eyes had vision of 20/200 or better. In eyes without prior laser photocoagulation, 83% were clear of vitreous hemorrhage following cryoablation, and in eyes with previous panretinal photocoagulation, 75% were free of vitreous hemorrhage after cryoablation.

Treatment of intravitreal ciliary body neovascularization.

A patient who developed intravitreal ciliary body neovascularization following cyclocryotherapy for neovascular glaucoma is presented. Presenting vitreous hemorrhage limited her visual acuity to 20/200. After panretinal photocoagulation, the intravitreal ciliary body neovascularization regressed, the vitreous hemorrhage cleared, and the patient's visual acuity was 20/30. The possible pathogenesis of intravitreal ciliary body neovascularization is reviewed, and the reason for regression of the neovascular tissue is hypothesized.

Effects of swimming pool water on the cornea.

Eye examinations performed on 50 subjects immediately before and after swimming in a chlorinated pool showed that 34 subjects (68%) saw rainbows and/or halos around lights after swimming, a symptom indicating the presence of corneal edema. Forty-seven subjects (94%) had corneal epithelial erosions in a punctate or linear pattern demonstrated by fluorescein staining on slit-lamp examination. No subject experienced a measurable decrease in visual acuity.

Sporadic butterfly macular dystrophy.

Deutman et al. described a butterfly-shaped pigment dystrophy of the fovea that involved six members of one family. It was thought to be an autosomal dominant trait. A 23-year-old white woman was recently examined with similar ocular findings. Twelve members of her family in three generations were examined. No macular abnormalities were present in other members of her family.

The treatment of acute horseshoe retinal tears by transconjunctival cryopexy.

During the past 6 years, 59 consecutive eyes with operculated retinal tears have been treated successfully by transconjunctival cryopexy. This type of treatment risks fewer complications than scleral buckling. Its success implies that vitreous traction upon the retina may be short lived in most eyes or that its intensity diminishes considerably after the development of a retinal tear.