Severe chemical eye injuries - clinical outcomes and associated socio-economic factors.

Aims: To describe clinical outcomes, management, and socio-economic impact of severe acute chemical eye injuries in a tertiary hospital. Methods: 37 patients required emergency admission to the Royal Victoria Infirmary eye ward between April 2013 and September 2015. Demographics, best corrected distance visual acuity (BCDVA), causative agent, degree of limbal stem cell deficiency (LSCD), management and socio-economic data were evaluated. Results: Mean age on admission was 34.5 years (SD 16.3; range 16-82); 30 males (81.1%); 22 bilateral (59.5%). Causative agent: alkali in 30 cases (81.1%); acid in three cases (8.1%); and unknown in four cases (10.8%). Fifteen cases (40.5%) were assaults, 12 (32.5%) work-related accidents, nine (24.3%) domestic accidents and one (2.7%) undetermined. Eleven patients (29.7%) were unemployed, 18 (48.6%) were labourers, three (8.1%) were students, three (8.1%) were retired and two (5.4%) were professionals. Mean admission time was five days (SD 3.2; range 1-12). Mean follow-up time was 170.5 days (range 1-946). Mean cost of admission was £2478 (range £274-5785). Five patients (13%; seven eyes) developed total or partial limbal stem cell deficiency, all being assaults. Conclusions: Main causative agent in our study was alkali, with young men in the working age being most frequently involved. Many patients required prolonged hospital admission and costly follow-up. The majority of cases were assaults, mostly occurring in unemployed patients. All the limbal stem cell deficiency cases were due to assaults. We believe that socio-economic factors play an important role in the cause, severity and cost of chemical eye injuries. Lay Summary: Acute chemical eye injuries have a significant and extensive impact on patients' visual function outcomes and vision-related quality of life, with consequent enormous burden to affected individuals, their families and society. We believe that by understanding the socio-economic environment, we may not only be able to enforce safety measures to tackle the increasing rate of severe chemical eye injuries in our community, but also to develop collaborative programmes with the community, educating the population on the seriousness of chemical eye injuries, and with the local authorities, trying to understand the clustering of assaults in areas and tackling the associated socio-economic risk factors, such as unemployment. Given the increasing rate of assaults using chemicals in recent times, it is also important to assess availability of adequate victim support programmes and develop good interaction with relevant local, regional and national authorities to ensure all aspects of community security service are in place to be able to address any potential deficiencies in line with police and home office guidelines. Keeping in mind that the best action plan is always prevention. However, when an ocular injury does occur it is evident that significant morbidity and visual sequelae can result and affect the socio-economic status of the victims despite our best current medical and surgical care.

CT dimensions of the lacrimal gland in Graves orbitopathy.

PURPOSE: To determine if lacrimal dimensions are enlarged in Graves orbitopathy on CT and to correlate size with clinical data. METHODS: One hundred and twenty-eight adult Caucasian patients with Graves orbitopathy who had CT at initial presentation to the authors' clinic were identified. The lacrimal gland width and length were measured on axial and coronal scans using the OsiriX software according to an established protocol. Comparison of dimensions with a published normal population was made. Clinical data near the time of CT were collected, including gender, age, smoking, subjective diplopia, exophthalmometry, intraocular pressure, corneal staining, and the VISA activity score for correlation with gland size. RESULTS: The lacrimal glands in Graves orbitopathy were significantly larger in all measured dimensions (p = 0.0001 for each dimension). There were no differences between the genders (p values ranged between 0.3855 and 0.8699). Exophthalmometry showed weak correlation with gland size in all dimensions (p value range, 0.0058 to <0.0001; r value range, -0.2616 to 0.4181). Smoking correlated significantly with gland enlargement in right coronal and axial width dimensions (p = 0.0150 and p = 0.0232, respectively). VISA inflammatory score was borderline correlated with right axial width. Lacrimal gland size did not correlate with diplopia, intraocular pressure, or corneal staining. CONCLUSIONS: The lacrimal gland is statistically significantly enlarged in Graves orbitopathy. Only weak correlation was found between gland enlargement and smoking, proptosis, and inflammatory activity. Future research will address the causal changes of enlargement and their effect on lacrimal function.

A review of intrathecal morphine therapy related granulomas.

The development of catheter associated granulomatous masses in intrathecal morphine therapy is an uncommon, but potentially serious problem. While these systems have historically been used in patients with short life expectancies, more recently patients with pain from a benign source have benefited from this therapy, and new complications are being encountered secondary to the patients' longer life spans. Morphine is the most commonly used intrathecal opioid and evidence exists that the formation of granulomatous masses are related to the use of higher doses. When the patients' requirement of morphine increases significantly, the physician should be alert for signs of spinal cord compression, such as new neurological deficits, myelopathy, or radiculopathy. Patients that require these higher doses should be properly informed of the association with granulomas and their associated risks. Indolent infection may also be the etiology of granulomatous masses, and the presence of organisms, both aerobic and anaerobic, should be routinely investigated. Patients with catheter-associated granulomas appear to share several features. They exhibit the onset of symptoms several months following the initiation of intraspinal opioids and commonly present with an increase in pain that precedes signs and symptoms of neurological deterioration. While MRI might be the preferred method of detection of intrathecal granulomas, its cost and availability are prohibitive for routine screening. CT myelogram via pump side port injection of contrast can also be performed to detect catheter tip related granulomas/obstructions. Serial neurological examinations for new deficits may be performed and recorded during pump refill visits to recognize a granulomatous mass in its early stages. If an abnormality is identified, imaging studies are appropriate. Awareness of the condition and vigilance are the keys to successful management of this complication.

Intrathecal morphine therapy related granulomas: two case reports.

Intrathecal morphine infusions have historically been used in patients with short life expectancies. More recently, patients with pain from a benign source have benefited from this therapy. While use in this population has been well documented and found to be relatively safe, new complications are being encountered secondary to the patients' longer life spans. The development of granulomatous masses from catheter use in intrathecal morphine therapy is an uncommon, but potentially serious problem. At West Virginia University Hospital, we have implanted more than 700 intrathecal drug delivery systems (IT-DDS) since 1989, and have encountered two cases of granulomatous masses developing at the tip of the intrathecal catheter. This report describes these illustrative cases and provides a review of the literature.