Botfly Myiasis Masquerading as Dacryocystitis.

Cutaneous myiasis is an infection most commonly caused globally by Dermatobia hominus , the human botfly, which is endemic to Central and South America. In North America, the most common cause of cutaneous myiasis is infestation with the larvae of Cuterebra , the North American botfly. The authors describe a 44-year-old man who presented with a 1-month history of intermittent, severe, boring pain along the side of his nose that progressed to swelling and redness along his right inferior orbital rim and lacrimal sac. CT imaging showed a rim-enhancing collection at the right medial canthus with surrounding phlegmonous changes communicating with the skin. Pathologic evaluation revealed curvilinear pigmented material associated with a granulomatous and eosinophil-rich inflammatory infiltrate, consistent with botfly myiasis. This case describes the pathogenesis of the botfly infestation in humans, as well as the clinical, radiographic, and histopathologic features of this rare orbital infection, with an emphasis on its treatment.

Ankylosis of the Temporomandibular Joint in Pediatric Patients.

INTRODUCTION: While surgical interventions for temporomandibular joint (TMJ) ankylosis are well-documented, there is lack of consensus regarding the ideal approach in pediatric patients. Surgical interventions include gap arthroplasty, interpositional arthroplasty, or total joint reconstruction. METHODS: A systematic review of PubMed (Jan 1, 1990-Jan 1, 2017) and Scopus (Jan 1, 1990-Jan 1, 2017) was performed and included studies in English with at least one patient under the age of 18 diagnosed with TMJ ankylosis who underwent surgical correction. Primary outcomes of interest included surgical modality, preoperative maximum interincisal opening (MIO) (MIOpreop), postoperative MIO (MIOpostop), ΔMIO (ΔMIO = MIOpostop - MIOpreop), and complications. RESULTS: Twenty-four case series/reports with 176 patients and 227 joints were included. By independent sample t tests MIOpostop (mm) was greater for gap arthroplasty (30.18) compared to reconstruction (27.47) (t = 4.9, P = 0.043), interpositional arthroplasty (32.87) compared to reconstruction (t = 3.25, P = 0.002), but not for gap compared to interpositional (t = -1.9, P = 0.054). ΔMIO (mm) was greater for gap arthroplasty (28.67) compared to reconstruction (22.24) (t = 4.2, P = 0.001), interpositional arthroplasty (28.33) compared to reconstruction (t = 3.27, P = 0.002), but not for interpositional compared to gap (t = 0.29, P = 0.33). Weighted-average follow-up time was 28.37 months (N = 164). 4 of 176 (2.27%) patients reported development of re-ankylosis. There was no significant difference in occurrence of re-ankylosis between interventions. CONCLUSIONS: Given the technical ease of gap arthroplasty and nonsignificant differences in ΔMIO, MIOpostop, or occurrence of re-ankylosis between gap and interpositional arthroplasty, gap arthroplasty should be considered for primary ankylosis repair in pediatric patients, with emphasis on postoperative physiotherapy to prevent recurrent-ankylosis.

The Value of Plastic Surgery Spinal Closures: A Review of 782 Spine Cases.

BACKGROUND: The role of the plastic surgeon in wound management after complications from previous spinal surgeries is well established. PURPOSE: The present study evaluates wound complications after plastic surgeon closure of the primary spinal surgery in a large patient population. STUDY DESIGN AND SETTING: This is a retrospective review of spine surgery patients undergoing plastic surgeon closure of spine surgeries at a single tertiary care center. PATIENT SAMPLE: Spine surgery patients included those who were referred for plastic surgeon closure due to (a) concerns about patient healing potential, (b) concerns about difficulty of closure, (c) patient request, or (d) difficulties with closure intraoperatively. OUTCOME MEASURES: The outcomes are physiologic measures, including intraoperative and postoperative complications, hospital length of stay, and 30-day readmissions and reoperations. METHODS: Outcomes in this sample were compared with previously published outcomes using 2-sample z tests. The authors have no conflicts of interest. RESULTS: Nine hundred twenty-eight surgeries were reviewed, of which 782 were included. Fourteen patients (1.8%) required readmission with 30 days. This compares favorably to a pooled analysis of 488,049 patients, in which the 30-day readmission rate was found to be 5.5% (z = 4.5, P < 0.0001). Seven patients (0.89%) had wound infection and 3 (0.38%) wound dehiscence postoperatively, compared with a study of 22,430 patients in the American College of Surgeons National Surgery Quality Improvement Program database, which had an infection incidence of 2.2% (z = 2.5, P = 0.0132) and 0.3% dehiscence rate (z = 0.4, P = 0.6889). The combined incidence of wound complications in the present sample was 1.27%, which is less than the combined incidence of wound complications in the population of 22,430 patients (z = 2.2, P = 0.029). CONCLUSIONS: Thirty-day readmissions and wound complications are intensely scrutinized quality metrics that may lead to reduced reimbursements and other penalties for hospitals. Plastic surgeon closure of index spinal cases decreases these adverse outcomes. Further research must be conducted to determine whether the increased cost of plastic surgeon involvement in these cases is offset by the savings represented by fewer readmissions and complications.

Analyzing Our International Facial Reconstructive Mission Work: A Review of Patients Treated by American Academy of Facial Plastic and Reconstructive Surgery Sanctioned Trips.

IMPORTANCE: To identify ways to improve care to underserved international populations. OBJECTIVE: To analyze the authors' data in hopes of meeting further needs. DESIGN: This is a retrospective review of medical missions using data from the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) Face to Face) Database. SETTING: International sites of AAFPRS approved surgical mission trips. PARTICIPANTS: One thousand six hundred forty-six patients who were seen by an AAFPRS mission trip between January 12, 2010 and April 27, 2017. OUTCOMES/MEASURES: Patient and mission data, procedure data, characteristics of cleft patients, patient follow-up data, repeat patient data, and factors affecting whether a patient was provided service were all evaluated. RESULTS: Patients were seen over the course of 26 trips to 6 different countries. Patients (n, mean, median age) who underwent a primary cleft lip repair only (175, 2.5 years, 0.6 years) and those who underwent a primary cleft palate repair only (268, 6.4 years, 3.6 years) were significantly older than what is identified as the upper range of normal in surgical literature (Wilcoxon Signed-Rank test Z = -4.3, P < 0.001 for lip and Z = -10.1, P < 0.001 for palate). Patients (n, median, mean rank) receiving a primary cleft palate repair were significantly younger in Peru (160, 3.0 years, 126) compared with patients in other countries (108, 5.0 years, 147) (Z = -2.1, P < 0.05). The odds of a patient returning unplanned were 2.8 (OR, 95% CI 1.52-4.98; P < 0.01) times higher if they were diagnosed with a cleft palate only and 0.91 (OR, 95% CI 0.90-0.93; P < 0.05) times lower if they were diagnosed with combined cleft lip with cleft palate at their first visit. Patients (median age, mean rank) who were provided a service (6.0 years, 724.70) were younger than patients who were not provided a service (8.0 years, 637.23) at their first visit (Mann-Whitney, U = 164,275; P < 0.001). CONCLUSION/RELEVANCE: This data indicates that disparities exist among patients treated on mission trips compared with those in higher income countries. Furthermore, the authors' data indicate that multiple mission trips to the same country within the same year decrease some of these disparities. Additionally, isolated cleft palate patients are most likely to return unplanned indicating need for standardized postoperative visits. The preferential care of younger patients with unrepaired clefts as compared with older patients and those with palatal fistulas indicates a need for additional resource allocation.

Disparities in NOSE Scores and Surgical Approaches among Patients Undergoing Functional Rhinoplasty.

Social determinants of health have been widely studied throughout medicine; however, their role relating to functional rhinoplasty has not been previously evaluated. The records of 178 patients who underwent functional rhinoplasty in a single health network from 2013 to 2016 were reviewed. The Nasal Obstruction Symptom Evaluation (NOSE) score was used to assess patient-reported symptoms, and patients with both preoperative and postoperative NOSE scores were included in this study. Basic demographics and surgical techniques were also collected. Differences between NOSE scores and surgical approaches to functional rhinoplasty on the basis of insurance type were measured. One hundred and sixteen patients were included for analysis, the mean age was 34.7 years (standard deviation [SD] = 16.2) and 57 (49.1%) were female. Twenty-one (18.1%) patients had public insurance and, of these, 18 patients had Medicaid. Patients (mean, SD) with Medicaid insurance (56.39, 15.6) had a slightly greater improvement in NOSE scores compared with patients with non-Medicaid insurance (47.90, 25.6) (p = 0.067). There was no statistically significant difference in preoperative NOSE scores or postoperative improvement in NOSE scores between patients with different health insurance. Furthermore, there was no statistically significant difference in surgical approaches. The majority of patients receiving functional rhinoplasty had private insurance. Medicaid patients trended toward a greater NOSE score improvement after functional rhinoplasty, but also had a closer association with a history of nasal trauma and prior surgery. Future study is needed to better understand the association between socioeconomic status and disparities in care. Understanding how social determinants of health affect patients may reveal potential inherent biases, improve delivery of care, and translate to better patient outcomes.

Living with Ultra-Low Vision: An Inventory of Self-Reported Visually Guided Activities by Individuals with Profound Visual Impairment.

PURPOSE: To understand how individuals with profound visual impairment (ultra-low vision, ULV) use their remaining vision. METHODS: Forty-six participants with ULV (visual acuity ≤ 200/500 in the better seeing eye) were divided into nine focus groups (4-6 individuals per group) and met either in person (n = 2) or over the phone (n = 7). Discussions were guided by the Massof Activity Inventory. Audio recordings were transcribed and analyzed for visual activities that were then classified along two visual categorizations - functional domains and visual aspects. The latter was based on a Grounded Theory classification of participants' descriptions. RESULTS: Seven hundred sixty activities were reported. By functional domain they were classified as reading/shape recognition (10%), mobility (17%), visual motor (24%), and visual information gathering (49%). By visual aspects, they were classified as contrast (43%), luminance (17%), environmental lighting (9%), familiarity (3%), motion perception (5%), distance (7%), size (9%), eccentricity (5%), depth perception (1%), and other/miscellaneous (1%). More than one visual aspect may be critical for an activity: participants reported that contrast plays a role in 68% of visual activities, followed by luminance (27%), environmental lighting (14%), and size (14%). CONCLUSIONS: Visual aspects, primarily contrast, were found to be critical factors enabling ULV individuals to perform visual activities. TRANSLATIONAL RELEVANCE: This inventory, part of the Prosthetic Low Vision Rehabilitation (PLoVR) curriculum development study, provides a unique perspective into the visual world of the nearly blind, and can be used in the development of a Visual Functioning Questionnaire (VFQ) and visual performance measures suited for ULV populations.

Development of the Ultra-Low Vision Visual Functioning Questionnaire (ULV-VFQ).

PURPOSE: To develop and psychometrically evaluate a visual functioning questionnaire (VFQ) in an ultra-low vision (ULV) population. METHODS: Questionnaire items, based on visual activities self-reported by a ULV population, were categorized by functional visual domain (e.g., mobility) and visual aspect (e.g., contrast) to ensure a representative distribution. In Round 1, an initial set of 149 items was generated and administered to 90 participants with ULV (visual acuity [VA] ≤ 20/500; mean [SD] age 61 [15] years), including six patients with a retinal implant. Psychometric properties were evaluated through Rasch analysis and a revised set (150 items) was administered to 80 participants in Round 2. RESULTS: In Round 1, the person measure distribution (range, 8.6 logits) was centered at -1.50 logits relative to the item measures. In Round 2, the person measure distribution (range, 9.5 logits) was centered at -0.86 relative to the item mean. The reliability index in both rounds was 0.97 for Items and 0.99 for Persons. Infit analysis showed four underfit items in Round 1, five underfit items in Round 2 with a z-score greater than 4 cutoff. Principal component analysis on the residuals found 69.9% explained variance; the largest component in the unexplained variance was less than 3%. CONCLUSIONS: The ULV-VFQ, developed with content generated from a ULV population, showed excellent psychometric properties as well as superior measurement validity in a ULV population. TRANSLATIONAL RELEVANCE: The ULV-VFQ, part of the Prosthetic Low Vision Rehabilitation (PLoVR) development program, is a new VFQ developed for assessment of functional vision in ULV populations.

Applying theories and interventions from behavioral medicine to understand and reduce visual field variability in patients with vision loss.

Visual field (VF) test results are often unreliable in visually impaired patients, but continue to be a cornerstone of clinical trials and play a vital role in clinical decision making since they are the primary method to determine patients' functional vision loss or progression. Currently, patients are typically asked to perform VF tasks with minimal instruction or consideration of their psychological experience during the test. The gradual loss of vision due to retinal diseases, such as retinitis pigmentosa (RP), age-related macular degeneration (AMD), or glaucoma can contribute to the experience of negative psychosocial states, such as anxiety, stress, and depression, as well as diminished quality of life. We hypothesize that VF testing elicits test performance anxiety and perception of functional losses of vision, which induces distracting negative thoughts that result in increased VF test variability. Resources for processing and responding to vision-related information may be diverted from task-relevant VF stimuli to task-irrelevant ones, such as internal worry and test anxiety, thereby resulting in VF test performance decrements. We present a theoretical model to support the hypothesis that VF variability is linked to patients' negative thoughts during VF testing. This conceptual framework provides a basis for the development of coping strategies and mindfulness-based interventions to be evaluated in future research aimed at improving psychosocial states and VF reliability in visually-impaired patients. It would be highly significant to intervene by modifying negative thoughts during VF testing to reduce test variability in glaucoma patients who are progressively losing vision to a blinding eye disease, but whose vision loss has not been accurately identified and treated early enough due to variable VF results. In clinical trials of potential interventions for RP and non-neovascular AMD, reducing VF variability would effectively increase the precision for detecting treatment effects and allow a reduction in the number of VF tests needed to estimate the treatment responses, thus reducing burden on investigators and patients, as well as saving time and money.

A pilot study of an acupuncture protocol to improve visual function in retinitis pigmentosa patients.

BACKGROUND: Patients with retinitis pigmentosa are motivated to try complementary or integrative therapies to slow disease progression. Basic science, clinical research and retinitis pigmentosa patients' self-reports support the hypothesis that acupuncture may improve visual function. METHODS: A prospective, case series, pilot study enrolled 12 adult patients with RP treated at an academic medical centre with a standardised protocol that combined electroacupuncture to the forehead and below the eyes and acupuncture to the body, at 10 half-hour sessions over two weeks. Pre- and post-treatment tests included Early Treatment Diabetic Retinopathy Study visual acuity (VA), Pelli-Robson contrast sensitivity (CS), Goldmann visual fields, and dark-adapted full-field stimulus threshold (FST)(n = 9). Scotopic Sensitivity Tester-1 (SST-1) dark-adaptometry was performed on the last two subjects. RESULTS: Six of 12 subjects had measurable, significant visual function improvements after treatment. Three of nine subjects tested with the FST had a significant 10.3 to 17.5 dB (that is, 13- to 53-fold) improvement in both eyes at one week after acupuncture, maintained for at least 10 to 12 months, which was well outside typical test-retest variability (95% CI: 3-3.5 dB) previously found in retinitis pigmentosa. SST-1 dark-adaptation was shortened in both subjects tested on average by 48.5 per cent at one week (range 36 to 62 per cent across 10 to 30 dB), which was outside typical coefficients of variation of less than 30 per cent previously determined in patients with retinitis pigmentosa and normals. Four of the five subjects with psychophysically measured scotopic sensitivity improvements reported subjective improvements in vision at night or in dark environments. One subject had 0.2 logMAR improvement in VA; another had 0.55 logCS improvement. Another subject developed more than 20 per cent improvement in the area of the Goldmann visual fields. The acupuncture protocol was completed and well tolerated by all, without adverse events or visual loss. CONCLUSIONS: Acupuncture entails minimal risk, if administered by a well-trained acupuncturist and may have significant, measurable benefits on residual visual function in patients with retinitis pigmentosa, in particular scotopic sensitivity, which had not previously been studied. These preliminary findings support the need for future controlled studies of potential mechanisms.