Intravitreal bevacizumab injection in unrecognised early pregnancy.

PURPOSE: The use of intravitreal vascular endothelial growth factor (VEGF) inhibitor medications has widened considerably to include indications affecting females of reproductive age. PATIENTS AND METHODS: We present our experiences following intravitreal injection of bevacizumab during the first trimester of unrecognised pregnancies in four women. RESULTS: All our patients were inadvertently exposed to bevacizumab within the first trimester when placental growth and fetal organogenesis take place. There were three cases of pregnancy without complication and one case of complicated pregnancy in which there was a significant past obstetric history. CONCLUSION: This case series provides further insights into intravitreal injection of bevacizumab in early pregnancy. There is insufficient information to suggest that such use is safe, nor is there definitive evidence to suggest that it causes harm. We advise that ophthalmologists discuss pregnancy with women of childbearing age undergoing intraocular anti-VEGF injections. Should a woman become pregnant, counselling is needed to explain the potential risks and benefits, and the limited available data relating to the use of these agents in early pregnancy.

A novel approach for salvaging infected prosthetic mesh after ventral hernia repair.

BACKGROUND: Salvaging infected prosthetic material after ventral hernia repair is rarely successful. Most cases require mesh excision and complex abdominal wall reconstruction, with variable success rates. We report two cases of mesh salvage with a novel use of percutaneous drainage and antibiotic irrigation. CASES: Two patients developed infected seromas after laparoscopic ventral hernia repair. One patient with a remote history of methicillin-resistant Staphylococcus aureus (MRSA) mesh infection underwent laparoscopic ventral hernia repair with a 20 x 23-cm piece of Parietex composite mesh. Two weeks post-operatively, he developed fevers and MRSA was aspirated from the seroma. Another patient had a 32 x 33-cm piece of ePTFE placed for repair. He subsequently developed a massive seroma requiring repeated aspirations. Four months following the repair, he developed an infected seroma with Klebsiella pneumonia. Each patient underwent percutaneous drainage of their abscesses with a six-French-pigtail catheter under ultrasound guidance. After 2 weeks of parenteral antibiotics and clinical resolution, the patients were placed on 4 weeks of gentamicin irrigations (80 mg in 30 cc solution) via the drain three times per day. Once therapy was completed, the drains were removed. The first patient also remains on daily oral doxycycline for suppression for his MRSA. Both patients have remained free of clinical signs of infection at 12 and 16 months, respectively, following the completion of therapy. CONCLUSION: Percutaneous drainage followed by antibiotic irrigation is a potential alternative to prosthetic removal when treating infected mesh in carefully selected patients.

Complete endoscopic closure of gastrotomy after natural orifice translumenal endoscopic surgery using the NDO Plicator.

BACKGROUND: The NDO Plicator is a device developed for endoscopic treatment of gastroesophageal reflux disease (GERD) by approximation of tissues together with a double-pledgeted U-stitch. It was theorized that this device may facilitate transgastric natural orifice translumenal endoscopic surgery (NOTES) because closure of the transgastric defect remains a key component for advancement of this new technology. METHODS: A standardized 12-mm gastrotomy was created endoscopically in four pigs using a combination of needle-knife cautery and balloon dilation. As the endoscope was removed, a Savary soft-tipped wire was introduced into the stomach, and the NDO Plicator was subsequently advanced over the wire. Each defect was identified, and the device was positioned. If necessary, the Plicator's tissue grasper was used to hold the superior aspect of the gastrotomy and bring the opposed borders of the defect within the jaws of the device. The device was fired three times, leaving three pledgeted suture bundles to close the gastric defect. After closure, each animal was explored, and the integrity of the closure was assessed. The animals underwent in vivo contrast fluoroscopy and ex vivo burst pressure testing studies for assessment of leakage at the closure site. RESULTS: The first animal was used to test feasibility, refine techniques, and develop a standard procedure. All of the next three animals studied showed complete sealing of the gastrotomy site without evidence of contrast extravasation on multiplanar fluoroscopic imaging. Each stomach was excised, submerged in water, and subjected to a pressurized air leak test. No leaks were noted until pressures exceeded 55 mmHg. CONCLUSION: This study supports the use of the NDO Plicator for closure of standardized gastric defects in a porcine model. In addition to closing NOTES gastrotomies, the NDO Plicator may be a particularly useful tool for obtaining complete closure of gastric perforations and anastomotic leaks, and for performing stomal reduction after gastric bypass procedures. The mechanical properties of a closure are not the only factor determining whether a leak will develop. Tissue opposition, ischemia, and tension are important factors that are not easily or reliably measured. The physiologic relevance of gastric bursting pressure is not known. Therefore, corollary animal studies with longer-term evaluation are necessary before research proceeds to clinical trials.

Outcome of intravitreal triamcinolone acetonide in postoperative cystoid macular oedema.

AIMS: To assess the efficacy and safety of intravitreal triamcinolone in the treatment of postoperative cystoid macular oedema (CMO). METHODS: A retrospective case series review of 21 eyes (20 patients) that had an intravitreal injection of triamcinolone 4 mg for postoperative CMO. Diagnosis was confirmed by fundus fluorescein angiography and/or optical coherence tomography in all eyes. RESULTS: Mean age of patients was 71.1 years. CMO had developed following routine phacoemulsification cataract extraction (13 eyes), phacoemulsification cataract extraction complicated by posterior capsule tear and vitreous loss (two eyes), vitrectomy (three eyes), or planned combined phacoemulsification and vitrectomy (three eyes). Mean duration of CMO before triamcinolone injection was 4.9 months. Mean duration of follow-up was 7.4 months. Two eyes required a repeat injection. Mean logarithm of minimum angle of resolution (LogMAR) visual acuity (VA) before treatment was 0.53; at 1 month post injection, this increased significantly to 0.33 (P<0.001). Improvement in VA was maintained throughout follow-up; at 6 months or later, mean LogMAR VA was significantly better than baseline (0.33 vs 0.53, P=0.02). At the latest review, 43% of eyes had improved Snellen VA by two or more lines and 86% by one or more lines compared to baseline. The remaining 14% had reduced Snellen VA compared to baseline. In the post-injection period, 33% of eyes developed an intraocular pressure of 22 mm Hg or higher and all responded well to short-term topical agents. There were no other post-injection complications. CONCLUSION: Intravitreal triamcinolone results in a rapid improvement in VA that may be sustained for more than 6 months.

Ocular morbidity associated with intravitreal triamcinolone acetonide.

AIM: To report on the complications associated with the use of intravitreal triamcinolone acetonide (IVTA) in a tertiary referral hospital setting. MATERIALS AND METHODS: A retrospective case series review of all IVTA injections carried out over a period of 30 months. RESULTS: One hundred and thirty IVTA injections were performed; nine with limited local follow-up were excluded. Thus, 121 injections (108 patients, 114 eyes) were included in the study. Triamcinolone (4 mg) was used in all cases. Indications were diabetic macular oedema (n=41 eyes), retinal vein occlusions (n=27), postoperative cystoid macular oedema (n=24), exudative age-related macular degeneration (n=16), and others (n=6). No intraoperative complications were recorded. Postoperative intraocular pressure (IOP) readings of 22, 28, 35, and 40 mmHg or higher were recorded in 46.5, 29.8, 12.3, and 7.9% of eyes, respectively. IOP elevation was treated with antiglaucoma medication in all but one eye (0.9%) that required trabeculectomy and one (0.9%) that required vitrectomy with cataract extraction for suspected phacoanaphylactic glaucoma. Two eyes (1.8%) developed retinal detachment; both had previously been treated for retinal breaks. One eye (0.9%) developed culture-positive endophthalmitis. CONCLUSIONS: Significant morbidity is associated with IVTA injection; clinicians should be aware when considering treatment options.

An unusual maculopathy after routine cataract surgery.

AIMS: To report the presentation of apparent acute and transient vitreomacular traction causing reduction in visual acuity following routine cataract surgery. METHODS: A case series describing three patients that developed acute and transient vitreomacular traction following routine cataract surgery by experienced surgeons. No patients had any significant past medical or ophthalmic history. The patients presented shortly after surgery with reduction in visual acuity and dramatic optical coherence tomography (OCT) images suggesting vitreomacular traction. RESULTS: All three patients experienced spontaneous resolution of symptoms and clinical signs within the first few weeks after surgery. Two patients experienced continued mild metamorphopsia. CONCLUSION: To our knowledge, this is the first documented report of such cases with associated confirmation by OCT imaging.

Expulsion of a lacrimal dacryolith by sneezing: a rare event.

PURPOSE: To describe the case of a man presenting with intermittent epiphora of the right eye and a low grade dacryocystitis due to a dacryolith. METHODS/RESULTS: He was treated conservatively and was offered a Dacryocystorhinostomy. A few weeks before surgery, he developed swelling and pain over the right medial canthus followed by violent sneezing with spontaneous extrusion of the dacryolith. DISCUSSION: The authors propose that the dacryolith fragmented spontaneously and once it reached the nasal cavity, was expelled by violent sneezing to the nostril, a mechanism not previously reported. CONCLUSIONS: Reformation of dacryolith is a likely possibility, and recurrence of symptoms in such cases may ultimately require a Dacryocystorhinostomy.

Expulsion of a lacrimal dacryolith by sneezing: A rare event.

PURPOSE: To describe the case of a man presenting with intermittent epiphora of the right eye and a low grade dacryocystitis due to a dacryolith. METHODS/RESULTS: He was treated conservatively and was offered a Dacryocystorhinostomy. A few weeks before surgery, he developed swelling and pain over the right medial canthus followed by violent sneezing with spontaneous extrusion of the dacryolith. DISCUSSION: The authors propose that the dacryolith fragmented spontaneously and once it reached the nasal cavity, was expelled by violent sneezing to the nostril, a mechanism not previously reported. CONCLUSIONS: Reformation of dacryolith is a likely possibility, and recurrence of symptoms in such cases may ultimately require a Dacryocystorhinostomy. (Eur J Ophthalmol 2006; 16: 161-3).

A randomised, double-blind trial of topical ketorolac vs artificial tears for the treatment of episcleritis.

PURPOSE: To determine whether topical ketorolac (Acular) is more effective than artificial tears in treating the signs and symptoms of idiopathic episcleritis. METHODS: In this prospective, randomised, double-blind study, 38 eyes of 37 patients presenting with idiopathic episcleritis were allocated to receive either topical ketorolac (0.5%) or artificial tears three times a day for 3 weeks. The severity of patients' signs (episcleral injection and the number of clock hours affected) were recorded at weekly intervals. Patients' symptoms (perceived redness and pain scores) were recorded using a daily diary. RESULTS: There was no significant difference in the ophthalmic signs between the two groups at each assessment, including intensity of episcleral injection and the number of clock hours affected. No significant difference was found in the time to halve the baseline redness intensity scores (4.4 vs 6.1 days, P=0.2) or pain scores (3.6 vs 4.3 days, P=0.55). Significantly more patients on ketorolac reported stinging at the first follow-up visit (P<0.001). CONCLUSION: Topical ketorolac is not significantly better than artificial tears in treating the signs or symptoms of idiopathic episcleritis.

Troponin I, laboratory issues, and clinical outcomes in a district general hospital: crossover study with "traditional" markers of myocardial infarction in a total of 1990 patients.

AIMS: Review of the clinical outcomes and practical issues of replacing traditional cardiac enzymes with troponin I (cTnI) in a district general hospital. METHODS: Crossover study of three sequential three month stages during which serial cardiac enzymes were replaced with a single cTnI measurement available at three set times within 24 hours for the duration of the second three month stage. The study was carried out in a 630 bed district general hospital with 1990 admissions of suspected cardiac ischaemia over the study period as a whole. Account was taken of seasonal factors. RESULTS: The introduction of troponin was associated with 8.5% more patients with non-ischaemic heart disease (IHD) being discharged on the day after admission, saving approximately 107 bed days each year. Approximately 50% more patients were diagnosed with myocardial infarction during the cTnI stage. There was no increase in readmission within one month or early death with cTnI. Approximately 3% false positive and 1.5% false negative cTnI results were recorded. All false positive cTnI results were coding errors or attributable to known assay interference effects. All false negatives were potentially explained by sample timing factors. The lack of standardisation in troponin assay services impacts clinically. CONCLUSION: Younger patients without IHD were discharged earlier during the cTnI stage in apparent safety. Blood sample timing needs to be verified when cTnI is used as an adjunct to early discharge. There were no unexplained false positives or negatives. Standardisation related issues arose.

The effect of oral folic acid on glutathione, glycaemia and lipids in Type 2 diabetes.

Plasma homocysteine is an established risk factor for vascular disease and precursor of the anti-oxidant glutathione. This study was designed to investigate the relationship of changes in homocysteine (Hcy) induced by oral folate to glutathione and measures of glycaemia and lipid metabolism in Type 2 diabetes (T2DM). Twenty-seven patients (26 male, 1 female, aged 48-68 years) with T2DM and microalbuminuria were treated with folic acid 10 mg daily for 3 months. During the study, diastolic blood pressure (p=0.04), HbA1c (p=0.04), serum triglycerides (p=0.04) and serum total/HDL-cholesterol ratio (p=0.004) all increased and serum HDL-cholesterol fell (p=0.006). The increased red cell folate correlated with a reduction in microalbuminuria (p=0.001). Overall, plasma glutathione increased (p=0.016) despite reduction in its precursor Hcy (p<0.001). Change in glutathione correlated inversely with change in HbA1c (p<0.02), total cholesterol (p=0.003) and triglycerides (p<0.02) and positively with HDL-cholesterol (p=0.033). Increase in glutathione correlated with levels of vitamin B6 (p<0.05). Metformin treatment protected against the rise in blood pressure (BP) (p=0.02), independently of changes in plasma glutathione. In summary, oral folic acid supplementation in T2DM reduced plasma Hcy and increased glutathione levels. HbA1c, triglycerides and HDL-cholesterol deteriorated during the trial: their levels correlated inversely with changes in glutathione. The increase in glutathione may depend on an adequate supply of B6, as changes in glutathione correlated with vitamin B6 levels. Reduced Hcy and increased glutathione may both mediate improvement in vascular function and outcome. Some aspects of the response to folate may be different in patients on metformin.

Acute sixth-nerve palsy after vincristine therapy.

The chemotherapeutic effectiveness of vincristine was first reported in 1962, and with its increased use the incidence of reported neurologic side effects has also increased. We reported a case of acute sixth-nerve palsy occurring soon after administration of vincristine for acute lymphoblastic leukemia (ALL), a previously unreported side effect.

Failure of active extension after traumatic cubitus varus. A case report.

In children cubitus varus is common after malunion of a supracondylar fracture of the humerus. Later problems such as tardy ulnar nerve palsy, snapping of the lateral triceps tendon or ulnar nerve and posterolateral rotatory instability are well documented. We present a case of anteromedial dislocation of the entire triceps tendon with loss of extensor power and describe the method of treatment.

Why oral calcium supplements may reduce renal stone disease: report of a clinical pilot study.

AIMS: To investigate whether increasing the daily baseline of gut calcium can cause a gradual downregulation of the active intestinal transport of calcium via reduced parathyroid hormone (PTH) mediated activation of vitamin D, and to discuss why such a mechanism might prevent calcium oxalate rich stones. To demonstrate the importance of seasonal effects upon the evaluation of such data. METHODS: Within an intensive 24 hour urine collection regimen, daily calcium supplementation (500 mg) was given to five stone formers for a 10 week period during a six month crossover study. In a further population of patients on follow up for previous renal stone disease, observations were made on 1066 24 hour urine samples collected over five years in respect of seasonal effects relevant to the interpretation of the study. RESULTS: In the group of patients on calcium supplements the following results were found. During calcium supplementation, the proportion of urine calcium to oxalate was higher (increased calcium to oxalate molar ratio), the 24 hour urine product of calcium and oxalate did not rise, and urine oxalate was lower during the first six weeks of supplementation. Twenty four hour urine calcium was 10.2% higher than baseline in the final four weeks of the 10 weeks of supplementation. Twenty four hour urine phosphate was 11.4% lower during the first six weeks of supplementation, but then rose while the patients were still on supplementation; renal tubular reabsorption of phosphate (TmP/GFR) mirrored the urine phosphate changes inversely. PTH was higher after stopping supplementation, but 1,25-(OH)2-cholecalciferol changes were not detected. In the 1066 urine samples collected over five years the following results were found. Calcium and oxalate excretion correlated positively and not inversely. Urine calcium and phosphate excretion were 5.5% and 2.5% higher, respectively, in "light" months of the year compared with "dark" months. A post summer decline in both urine calcium and urine phosphate was relevant to the interpretation of the study. CONCLUSIONS: Regular calcium supplementation does not raise the product of calcium and oxalate in urine and the proportion of oxalate to calcium is reduced. The underlying mechanisms of the changes seen in phosphate, calcium, and PTH and the observations on 1,25-(OH)2-cholecalciferol are not clear. Observed changes in phosphate could possibly be part of a calcium regulating feedback loop operating over a period of weeks. In evaluating these mechanisms background seasonal effects are important. It is possible that "programming" of the gut mucosa in terms of calcium transport is a major determinant of the relation between calcium and oxalate concentrations in urine and their relative abundance. Increased oral calcium, in association with a reduction of the relative proportion absorbed, may be pertinent to the prevention of calcium oxalate rich stones.