Malignant teratoid medulloepithelioma: clinical-echographic-histopathologic correlation.

INTRODUCTION: Medulloepithelioma is a rare congenital intraocular neoplasm. The authors describe a case involving a 6-year-old girl who presented with leukocoria and an inflamed red eye. The important clinical and histopathologic features of this condition are reviewed in correlation with echographic findings.

Latent intracellular Epstein-Barr Virus DNA demonstrated in ocular posttransplant lymphoproliferative disorder mimicking granulomatous uveitis with iris nodules in a child.

A case of intraocular posttransplant lymphoproliferative disorder (PTLD) is described in a 9-year-old female who underwent orthotopic liver transplantation at the age of 18 months. The prevalence of ophthalmic involvement in PTLD can be expected to rise with the increasing number of major organ transplantations, as well as improved survivorship. Children are particularly at risk for this posttransplant complication because they are usually seronegative for the Epstein-Barr virus (EBV) prior to transplant. Accurate diagnostic classification of PTLD to include confirmation of EBV infection carries significant therapeutic and prognostic implications.

Ocular injuries due to projectile impacts.

An animal model has been developed using enucleated porcine eyes to evaluate ocular trauma. The eyes were pressurized to approximately 18 mmHg and mounted in a container with a 10% gelatin mixture. The corneas of sixteen pressurized eyes were impacted by a blunt metal projectile (mass of 2.6 gm, 3.5 gm or 45.5 gm) at velocities of 4.0 to 38.1 m/s. The impacted eyes were evaluated by an ophthalmologist. A numerical classification scheme was used to categorize the severity of the ocular injury. A chi-squared test indicates that the injury level is associated with the kinetic energy (KE) and not the momentum of the projectile. The enucleated eyes began to experience lens dislocations when the KE of the projectile was approximately 0.75 Nm, and retinal injuries when the KE was approximately 1.20 Nm.

Development of evidence-based guidelines in midwifery and gynaecology nursing.

OBJECTIVE: To develop an effective and efficient method for basing nursing practice on research evidence. SETTING: The Royal Women's Hospital, Brisbane, Australia. METHOD: Nurses and midwives from various clinical areas were invited to participate in an evidence-based practice project. Standard procedures for retrieving relevant articles and evaluating their quality were observed. Where possible, raw data from studies with similar methods were summarised using appropriate statistical tests. FINDINGS: Several guidelines have been developed, staff involved with the project have become 'research literate' and the project is contributing to the hospital-wide quality improvement activities. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: It is possible to translate research findings into practice when small groups use systematic reviews to develop practice guidelines.

Recurrent bilateral spontaneous pneumothoraces associated with pulmonary angiocentric immunoproliferative lesion.

A 28-year-old man had a left pneumothorax and diffuse reticulonodular infiltrates. He subsequently had a right pneumothorax and manifested bilateral recurrences after treatment of the initial pneumothoraces. Pulmonary angiocentric immunoproliferative lesion was diagnosed by open lung biopsy. Treatment with combination chemotherapy improved the infiltrates, but failed to prevent another pneumothorax. Etiologic considerations for the recurrent pneumothoraces are proposed.

Comparison of five inservicing methods in an intensive care nursery.

OBJECTIVE: Communicating to nurses new information on therapeutics or pharmacy procedures is a frequent challenge faced by most hospital pharmacists. Pharmacists should use the most efficient and effective methods to inservice nursing staff. The purpose of this study was to compare five methods of inservicing in a neonatal intensive care unit (NICU) to determine which method resulted in the greatest knowledge retention as assessed by a ten-question quiz. DESIGN: Various combinations of written guideline alone, verbal discussion by a pharmacist with and without a written guideline, and verbal discussion by a nurse with and without a written guideline were used to introduce nurses to the use of caffeine for apnea/bradycardia of the newborn. Each nurse completed a quiz to assess knowledge retention. The written guideline and quiz were prepared by a pharmacist. PARTICIPANTS: Forty-eight nurses participated in the study: (1) group 1 (n = 11) received the written guideline only (no verbal discussion); (2) group 2 (n = 14) received verbal discussion by a pharmacist plus a written guideline; (3) group 3 (n = 9) received verbal discussion by a nurse-educator plus a written guideline; (4) group 4 (n = 9) received verbal discussion by a pharmacist (no written guideline); and (5) group 5 (n = 5) received verbal discussion by a nurse-educator (no written guideline). MAIN OUTCOME MEASURES: Mean quiz scores for all groups were compared and assessed using the Irwin-Fisher test for equality of binomial probabilities on all possible pairs of groups. RESULTS: Mean quiz scores for groups 1 and 3 were 10; for group 2, 8.6; for group 4, 9; and for group 5, 9.2. Using the Irwin-Fisher tests for equality of binomial probabilities on all possible pairs of groups, the probability of obtaining a perfect score on the quiz was the highest for groups 1 and 3 (p < or = 0.05). CONCLUSIONS: Within the limitations and the setting of this study, the two most effective methods of nursing inservice were a pharmacist-prepared written guideline followed by a quiz, and the written guideline plus a verbal discussion by a nurse-educator followed by a quiz. Use of these methods can reduce pharmacist inservice time and improve medication knowledge of the nurses and possibly reduce errors in the NICU.

Two-dimensional gel electrophoretic comparison of endothelial cell-Descemet's membrane proteins in Fuchs' dystrophy and normal corneas.

Two-dimensional polyacrylamide gel electrophoresis was used to compare the proteins isolated from the combined corneal endothelial cell-Descemet's membrane complex of three pairs of corneas with Fuchs' dystrophy with three pairs of normal corneas. Normal or Fuchs' dystrophy endothelium and Descemet's membrane was documented by pathologic analysis of each cornea. Proteins were separated by isoelectric point in the first dimension and molecular weight in the second dimension. Over 300 proteins were resolved from each sample, and similar patterns were noted in both groups. No consistent differences were detected between the corneas with Fuchs' dystrophy and the normal corneas. Allelic variations of some proteins were detected in both groups.

Supervoltage orbital radiotherapy in 36 cases of Graves' disease.

Thirty-six patients who had clinically progressive Graves' dysthyroid orbitopathy were treated with supervoltage orbital radiotherapy. Twenty-three of the patients had discontinued the use of orally administered prednisone after developing intolerable side effects. Medical contraindications prevented seven patients from receiving systemic corticosteroid treatment. Six additional patients declined to take prednisone and chose orbital radiotherapy as their primary treatment. All patients were treated with one radiotherapy protocol wherein a 6 MV linear accelerator delivered 2,000 cGy to the midplane of both orbits in ten fractions. None of the 36 patients was treated with corticosteroids during the orbital radiotherapy treatment interval. We encountered three patients who failed to respond to orbital radiotherapy and required supplemental immunosuppression to arrest progression of Graves' disease. The remaining 33 patients experienced stabilization or clinical improvement of their condition. None of the patients experienced complications from orbital irradiation. We believe supervoltage orbital radiotherapy is an effective means of treating Graves' dysthyroid orbitopathy.

Congenital hypertrophy of the retinal pigment epithelium. Electron microscopic and morphometric observations.

Congenital hypertrophy of the retinal pigment epithelium (CHRPE) is a well-circumscribed, flat, pigmented fundus lesion that is stable and generally nonprogressive. Light and electron microscopy and morphometric analysis was used to study a lesion with the clinical characteristics of CHRPE found in an eye enucleated for a posterior segment malignant melanoma. These studies showed that the lesion was composed of tall, maximally pigmented RPE cells that had a density 1.7 times greater than the density of the adjacent normal peripheral RPE. These observations suggested that cellular hyperplasia and hypertrophy may contribute to CHRPE. Ultraviolet fluorescence microscopy showed no autofluorescent granules of lipofuscin in the CHRPE, suggesting that the lesion's constituent cells lack the capacity to phagocytose and digest photoreceptor outer segments. Photoreceptor degeneration in the overlying retina consequent to this functional defect could be responsible for the localized visual field defects that typically occur in patients with CHRPE.

The use of a trochar to fixate a dislocated lens.

The surgeon can skewer a dislocated or subluxed lens with a trochar from a 25-gauge spinal needle to fixate the lens when removing it through the anterior segment.

Treatment protocol for orbital inflammatory disease.

Forty-five consecutive patients suspected of having orbital inflammatory disease (OID) were treated according to a protocol that provided specific dosages of steroids and a formula of dose reduction. Nonresponsive cases were managed with intravenous dexamethasone and, when brought under control, were switched to oral therapy. The cases that continued to be unresponsive or escaped from control were biopsied. If the frozen section was read as inflammatory, intralesional steroid was injected. For resistant or recurrent cases, 1000-3000 rads of orbital irradiation were delivered in fractionated doses. For extreme cases, radiotherapy was combined with steroids and chemotherapy (cyclophosphamide). Twenty-nine patients improved with steroids alone, four with additional intralesional steroid injections, six with radiotherapy, and two required both radiotherapy and chemotherapy.

Prescribing spectacles for anophthalmic patients.

Clinical situations exist where socket reconstruction after enucleation is incomplete and additional surgery is contraindicated. The resultant cosmetic disfigurement may have a profound effect on the patient. An illustrative case is presented. Available methods of anophthalmic camouflage are reviewed, and a relatively inexpensive technique is described that relies on optical cosmesis to give the patient a natural and symmetric appearance.

Transient bilateral blindness following blepharoplasty.

A case of bilateral transient visual loss following elective four-lid blepharoplasty is described. Postoperative retrobulbar hemorrhages developed sequentially and were immediately treated by decompression, restoring full vision. The critical importance of supervised postoperative observation and immediate availability of medical help is underscored. The etiology of retrobulbar hemorrhage following blepharoplasty, the steps necessary to reduce its incidence, and the treatment of this complication are discussed.

Rapid preparation of lecture slides using the computer.

Information displayed on a computer monitor can be easily photographed to produce attractive color slides for lectures. The authors describe a simple technique which emphasizes flexibility, convenience and expediency.

Surgical management of hemodialysis patients.

Ophthalmic surgeons can expect increased opportunities in the future to treat patients who undergo maintenance hemodialysis. Such patients often present with complex medical problems and carry high risk factors for surgery. Nevertheless, the full range of ophthalmic surgical procedures can be accomplished without increased morbidity when patient management is carefully organized between the ophthalmologist and nephrologist. In this report the physiology of the functionally anephric patient is reviewed. Attention is directed to the most commonly encountered complications: systemic hypertension, uremia, electrolyte imbalance, drug toxicity, and arteriovenous fistula thrombosis. Specific guidelines are then presented to reduce the risk of complications at each phase of hospitalization.

Surgical repair of medial wall fractures.

We treated ten patients with medial wall fractures, five of whom had concomitant floor fractures. The most consistent preoperative findings were restriction in abduction with retraction of the globe and limitation in adduction. A direct medial canthal surgical approach provided adequate exposure for removing incarcerated tissue as well as covering the defect with a thin silicone implant. There were no surgical complications or evidence of implant migration, the longest follow-up being two years. Of the ten patients, six had satisfactory results with full or nearly full ductions, one was orthophoric in the primary position but still had significant restriction in abduction, and three had persistent diplopia in the primary position.

Malignant melanoma of the lacrimal sac.

A 79-year-old man with a bloody ocular discharge and a mass above the medial canthal tendon was found to have a malignant melanoma of the lacrimal sac. Because he refused radical surgery, he was treated with radiotherapy and chemotherapy. Within a year the tumor had spread to his palate and cervical nodes. Because of the uncommon occurrence of melanoma in the lacrimal area and the fact that the microscopic appearance may resemble other malignancies, special stains are necessary for identification to implement the appropriate therapy.