Videolaryngoscope-assisted flexible intubation tracheal tube exchange in a patient with a difficult airway.

An 88-year-old woman presented with acute airway obstruction caused by a large retrothyroid bleed following anterior neck trauma. Her airway was secured in the operating theatre with an awake nasal flexible optical bronchoscope tracheal intubation using an Intubating Laryngeal Mask Airway tracheal tube. Haemostasis was achieved following surgical ligation and the patient was transferred to the critical care unit. Postoperatively, a large leak around the tracheal tube was noted and a decision was made to change to an orotracheal tube with a subglottic drainage port. Our exchange technique required two experienced operators. The first operator used videolaryngoscopy with a hyperangulated blade to establish an optimal view of the larynx. The second operator placed an airway exchange catheter through the existing nasal tracheal tube to ensure airway control. The trachea was then intubated orally using a flexible optical bronchoscope observed under direct vision using the videolaryngoscope. The technique combined several simple and well-documented approaches, but importantly, the airway remained secure and visible throughout the procedure.

Long-term visual outcome in patients with anterior visual pathway gliomas.

OBJECTIVES: To investigate the visual outcomes of patients with gliomas of the anterior visual pathway and the clinical features associated with prognosis. MATERIALS AND METHODS: During retrospective review, demographic and clinical data were abstracted from medical records of patients seen at the Bascom Palmer Eye Institute between January 1, 1970 and December 31, 1998. RESULTS: Of the 42 patients identified, 68% were female, and 55% had neurofibromatosis (NF) type I. There was no substantial difference in presenting signs, symptoms, and visual acuity between the NF(+) and NF(-) groups except for nystagmus, which was more common in the NF(-) group (p = 0.014). Throughout follow-up evaluation, vision in the better eye remained stable in both groups, independent of treatment or NF status. Vision in the worse eye often declined, despite treatment. However, binocular visual status, measured as average weighted logMAR (MAR, minimum angle of resolution) vision, did not change significantly over time, regardless of treatment or NF status. CONCLUSIONS: In the NF(+) and NF(-) groups, vision in the better eye remained stable, regardless of treatment, and vision in the worse eye often declined, despite treatment. Binocular visual acuity (measured as weighted logMAR) did not change significantly over time, regardless of NF status or treatment modality.

Outcome of surgical management of superior oblique palsy: a study of 123 cases.

PURPOSE: To determine the outcome of the surgical management of superior oblique palsy at our institution. SUBJECTS AND METHODS: Retrospective review of 123 patients who underwent surgical correction of superior oblique paresis at Bascom Palmer Eye Institute from 1976 to 1996. Subject-Patients: 67% were male and 33% female. The mean age at surgery was 30.5 years (range, 2-78 years). Etiologies of the pareses were trauma (34%), congenital (33%), and acquired/non-traumatic (33%). The mean angle of preoperative vertical deviation in primary gaze was 14.0 delta (range, 0-45 delta). SURGERY: 109/123 (89%) patients underwent single muscle surgery. Of these 109, 57 had single oblique muscle surgery: a superior oblique tuck in 34/57 (60%); an inferior oblique weakening procedure in 22/57 (38%); and a Harada-Ito procedure in 1/57 (2%). The other 14 patients (11%) had bilateral surgery. RESULTS: The final postoperative vertical deviation in primary gaze was < or =3 PD in 60% of patients and < or =7 PD in 80%. The mean change in primary position vertical deviation postoperatively was 10.4 PD for distance and 13.0 PD for near. An "excellent" outcome (final vertical deviation &le3 PD in primary and reading gazes) was achieved most frequently in those patients with congenital pareses and isolated oblique muscle surgery. COMPLICATIONS: Clinically significant Brown's Syndrome occurred in 43/72 (60%) of those cases who had undergone a superior oblique tuck. The incidence of Brown's Syndrome was unrelated to tuck size. Reoperation was three times more likely to be necessary in traumatic cases than in congenital cases (35.0% vs 11.9%, p=0.02). CONCLUSIONS: Based on these results we recommend oblique muscle surgery as the initial procedure to correct superior oblique palsy when appropriate.

Synergistic divergence: saccadic velocity analysis and surgical results.

The clinical findings are described in four patients with synergistic divergence (SD), an ocular motility disorder which is considered to be a variant of Duane retraction syndrome (DRS). Saccadic velocity studies in three patients demonstrated preserved abducting saccades in the affected eye with equally reduced amplitudes on both attempted abduction and adduction. The preserved saccades on attempted abduction of the affected eye, coupled with electromyographic evidence that shows maintenance of normal reciprocal innervation with respect to gaze on attempted abduction as dictated by Sherrington's law, strongly suggest that the abducens nerve is not necessarily absent or severely hypoplastic in this condition. One patient showed typical DRS in the contralateral eye and had a son with bilateral DRS, attesting to a possible genetic and etiologic relationship between SD and DRS. Three patients underwent strabismus surgery. Review of our surgical results and an analysis of the literature indicate that a crippling procedure to the ipsilateral lateral rectus muscle, such as extirpation, may be necessary to eliminate simultaneous abduction. Overcorrection did not occur following lateral rectus extirpation.