Vertical systems integration.

Healthcare organizations are vertically integrating into systems for operational, economic, and quality incentives. These system transformations require that the nurse executive assume new roles, responsibilities, and skills. The authors review the trends in system integration and discuss implications for nurse administrators based on literature and structured interviews with nurse executives who have experience in integrated systems or who are engaged in integrated system planing and development.

Sector iridectomy in the management of prolonged attacks of acute congestive glaucoma.

Clinicians still encounter patients suffering from prolonged episodes of primary angle-closure glaucoma. These patients often have been misdiagnosed or neglected initially. While laser iridotomies have proven most effective in the treatment of acute angle-closure glaucoma, there is a diversity of opinion regarding the treatment of chronic forms, in particular when the congestive phase has been of long duration (e.g., 3 to 14 days). The fact that ophthalmologists must still contend with the dreaded complication of malignant glaucoma attests to the difficulty of treating this condition. A series of cases have been collected during the past 15 years, all having prolonged episodes of primary angle-closure glaucoma, where the anterior-chamber angles could not be opened medically before surgery. We found that laser iridotomy is not efficacious in this situation, and indeed often impossible to perform due to corneal edema. Our patients were treated surgically with sector iridectomies, with an extremely high degree of success, and a minimal complication rate. The results are presented in tabular form. The mechanism of action is described, and the reasons for the success of this procedure explained.

Hypotony as a late complication of trabeculectomy.

A young man with pigmentary glaucoma was treated successfully by trabeculectomy in one eye. Approximately 13 months later, relatively minor trauma produced hypotony. Despite repeated examinations, the causative factor, a minute wound leak in the filtering bleb, was not detected until the hypotony had been present for six months. During this time, vertical choroidal folds developed in the macular region, associated with a marked loss of central vision. Successful cryogenic repair of the leaking bleb and subsequent normalization of tension was achieved; however, pigmentary changes noted in the macula as induced by the choroidal folds persisted.