Blunt traumatic rupture of right ventricle and pericardium

A 60-year-old man was transferred to our hospital for blunt trauma of the chest suffered in a traffic accident. He had a weak pulse, and cardiopulmonary resuscitation was continued in the ambulance. Chest roentgenography revealed left hemothorax, and echocardiography revealed pericardial bleeding. He was immediately transported to the operating room, because of severe hypotension due to massive bleeding from the chest drainage tube. Median sternotomy was performed under stand-by cardiopulmonary bypass. There was projectile bleeding from the anterior wall of the right ventricle. The site of rupture was sutured with felt strip. A tear in the pericardium was also present at the apex. Postoperative recovery was uneventful. Fulda et al. reported that the incidence of combined pericadial and cardiac chamber rupture was 8% for those patients suffering blunt chest trauma, and that the rate of survival was less than 15% for blunt heart rupture. We have reported here successful repair of combined rupture of the right ventricle and pericardium.     

Choroidal melanoma in an African-American albino

PURPOSE: To report the rare occurrence of choroidal melanoma in an African-American albino. METHODS: A 68-year-old African-American man with oculocutaneous albinism developed an amelanotic choroidal mass in his left eye. A transvitreal fine-needle aspiration biopsy was performed to confirm the diagnosis, and the patient was treated with iodine 125 plaque radiotherapy. RESULTS: The cytology of the needle biopsy showed spindle cells with nuclear atypia and prominent nucleoli. The cells showed positive immunoreactivity for HMB-45, supporting the diagnosis of choroidal melanoma. CONCLUSION: To our knowledge, this is the first reported case of a choroidal melanoma occurring in an African-American albino.     

Photocoagulation of well-defined choroidal neovascularization in age-related macular degeneration: clinicopathologic correlation

PURPOSE: To present the clinicopathologic features of the eyes of a patient with age-related macular degeneration (ARMD): the right eye was treated for well-defined extrafoveal choroidal neovascularization (CNV), and the left eye had an untreated disciform scar. METHODS: The patient was studied ophthalmoscopically and by fluorescein angiography at the time of presentation and on follow-up examinations up to 54 days after laser treatment, when he died. The posterior portions of both eyes (obtained postmortem), including the macula and optic nerve head, were sectioned serially for light microscopy. Tissue sections from both eyes were removed from glass slides and studied by transmission electron microscopy. RESULTS: Histopathologic study of the right eye disclosed a thin layer of basal laminar deposit throughout the posterior pole. Two defects in Bruch's membrane without CNV were present within the area of laser photocoagulation located superior to the fovea. No CNV was present in the scar. Eleven areas of early CNV were present in the posterior pole. Histopathologic study of the left eye showed a prominent basal laminar deposit throughout the posterior pole. A 2.6 x 2.7 mm disciform scar was present that was located mostly in the subretinal space. Four sources of CNV were present. CONCLUSIONS: The clinicopathologic features of a treated eye with well-defined extrafoveal CNV, and the fellow eye with a disciform scar, both associated with ARMD, are presented. Although laser treatment obliterated a choroidal neovascular membrane, 11 additional areas of early, subclinical CNV were present.     

Choroidoretinal vascular anastomoses after blunt trauma to the eye

Six weeks after blunt ocular trauma in a 38-year-old white man, choroidoretinal vascular anastomoses occurred at the site of choroidal and retinal rupture. Neovascularization was not observed. Anastomoses of this type have been documented in other cicatrizing and granulomatous disease processes.     

Congenital absence of parotid glands and lacrimal puncta

The authors describe a 59-year-old woman who had a traumatic wound rupture 6 months following penetrating keratoplasty. While she was in the pre-operative holding area awaiting surgical repair, hemorrhagic choroidal detachments developed. Digital pressure was initiated on diagnosis of imminent expulsion of intraocular contents and maintained until repair of the wound rupture could be performed. Four months postoperatively, the patient's vision was 20/80 and her central pachymetry was 585 microns. This case demonstrates that a delayed-onset expulsive choroidal hemorrhage may be successfully managed with simple and rapid intervention based on knowledge of the disease process.     

Indocyanine green angiographic findings in idiopathic choroidal neovascularization

PURPOSE: Evaluation of choroidal alterations associated with idiopathic choroidal neovascularization (ICNV) and the possible relation between this affection and Multifocal Choroidopathies (MC). METHODS: The authors analysed, using high definition videoangiography, the choroidal findings in 21 consecutive patients affected by ICNV (7 males and 14 females; 19-46 years; mean age: 31.8 years); with a follow-up at 5-30 months (mean 13 months). Moreover, a retrospective study of 20 cases of ICNV (11 males and 9 females; age: 17-39 years; mean age: 29.3 years) with a follow-up at 6-11 years (mean 8.9), was performed. RESULTS: In 7 eyes, the indocyanine green angiography (ICGA) showed choroidal hypofluorescent spots similar to those observed in MC (in 3 cases even in the fellow unaffected eye), in 2 of them the regression of the spots was observed after steroid therapy. In 2 eyes, the ICGA revealed hyperfluorescent spots; in one of them the complete regression of the spots after oral cyprofloxacine was observed. In 6 patients (10 eyes), choroidal permeability alterations could be visualized (in 4 cases even in the unaffected eye). CONCLUSIONS: The indocyanine green angiographic findings (hypo and hyperfluorescent spots, choroidal permeability alterations) could support the theory of Gass which considers that ICNV is not idiopathic but secondary to a widespread choroidal inflammatory disease. The similarity of the ICGA alterations in ICNV and MC, the observation that cases of ICNV would become MC in the follow-up, could allow the hypothesis of a close connection between these two affections.     

Blunt rupture of the right hemi-diaphragm with complete dislocation of the right hepatic lobe: report of a case

We present herein a case of blunt rupture of the right hemidiaphragm occurring with complete intrathoracic dislocation of the right hepatic lobe in a polytraumatized patient. The initial chest X-ray was interpreted as right-sided hemothorax, and a thoracic drainage tube was accidentally placed into the liver. A computed tomography scan subsequently revealed diaphragmantic rupture with intrathoracic liver dislocation. It was possible to reposition the liver, and the extended dorsal diaphragmatic rupture was closed primarily through an abdominal approach. The problems associated with the diagnosis and operative treatment of fresh right-sided blunt traumatic diaphragmatic ruptures are discussed following this case report.     

Multifocal choroiditis with subretinal fibrosis

We report 2 cases of multifocal choroiditis associated with subretinal fibrosis on whom the fluorescein fundus angiography (FAG) and the indocyanine green infrared angiography (IA) were performed. Case 1 was a moderately myopic 14-year-old girl who had no ocular symptoms. She had numerous small, round, discrete, partially conflued lesions with subretinal fibrosis scattered in the periphery and one discrete relatively large lesion along the superotemporal arcade in her left fundus. Subretinal fibrosis had progressed in the superior lesion. Some lesions had coalesced into a sword-like pattern over a period of 2 years. Case 2 was a high myopic 18-year-old man who had distorted vision in his right eye. He had some small whitish round lesions with one small choroidal neovascular tissue and subretinal fibrosis in the posterior pole and a sword-like lesion in the inferior periphery. Another choroidal neovascular tissue developed near the macula during the 6-month follow-up period. In FAG, the centers of the lesions hypofluoresced corresponding to the pigmentation and the edges hyperfluoresced. Some of the lesions showed window-defects and others tissue-staining. In IA, all the whole lesions hypofluoresced from an early stage of the angiography and some major choroidal vessels were visible through them. The hypofluorescent areas persisted into the late phase. The hypofluorescent areas of the IA were larger than those seen in FAG and in funduscopy. These findings indicate that the choriocapillaris was initially damaged and consequently the structures of the lesions partly disappeared at the level of the retinal pigment epithelium-choriocapillaris complex.     

Pharmacokinetics of hydroxocobalamin in smoke inhalation victims

PURPOSE: This study was performed to describe the clinicopathologic features of a group of patients with posttraumatic unilateral focal choroidal granulomatous inflammation. METHODS: Enucleated eyes with focal choroidal granulomatous inflammation without clinical signs of contralateral ocular inflammation were identified. Clinical and pathologic features were recorded. RESULTS: Six enucleated eyes that had been injured by projectiles had focal uveal granulomatous inflammation of the posterior choroid. Four eyes had uvea attached to or incarcerated into the wound. Two eyes had foreign material associated with the granulomatous inflammation, and two eyes had a disrupted lens with lens-induced inflammation. Two eyes exhibited the focal granulomatous inflammation at the site of a choroidal rupture. None of the six enucleated eyes contained Dalen-Fuchs' nodules. CONCLUSIONS: Focal choroidal granulomatous inflammation may occur as a result of penetrating ocular trauma. The origin of this condition is unknown, although it likely represents a reaction to a foreign body.     

Krypton laser suture lysis

PURPOSE: To analyze indocyanine green angiography (ICGA) features in two cases of sympathetic ophthalmia using a standard angiography protocol for posterior uveitis. METHODS: Report on two patients who suffered from penetrating ocular injuries 45 and 8 years before sympathetic ophthalmia was diagnosed and confirmed by histopathological examination of the enucleated eye. In addition to routine examination and fluorescein angiography, initial and follow-up ICGAs were performed. RESULTS: The first patient, with a phthisic right eye following s shotgun injury, consulted 6 months after cataract extraction in his good left eye for progressive visual loss due to a neovascular membrane in a moderately inflamed eye. The second patient consulted 8 years after a perforating injury of his right eye by a metallic foreign body because of recent visual loss and inflammation in his good left eye. ICGA of both patients showed numerous hypofluorescent dark dots visible at the intermediate phase, some becoming isofluorescent at the late phase and resolving after long-term corticosteroid therapy, others remaining hypofluorescent until the late phase. CONCLUSION: The two patterns of hypofluorescent areas, either persisting throughout angiography or fading in the late phase, were interpreted respectively as cicatricial and active lesions. ICGA gave determining additional information on choroidal involvement and on subsequent evolution of lesions.     

Equivalence in periodontal trials: a description for the clinician

AIMS: To describe the clinical picture and electrophysiological findings in Müller cell sheen dystrophy, a recently reported retinal dystrophy. METHOD: A basic ophthalmological evaluation as well as recording of standard electro-oculography and electroretinography were performed in one patient at the onset of visual loss and after 1 year of follow up. RESULTS: A 61 year old woman presented with visual loss in the right eye. Multiple folds at the level of the internal limiting membrane were seen at the posterior pole in both eyes. Macular oedema was present in the right eye. The visual acuity of the right eye was 6/30 and of the left 6/9. A paracentral scotoma was found in the right eye. Electro-oculographic examination of both eyes gave normal results. Electroretinography (ERG) revealed reduced b-wave and flicker amplitudes in the right eye; these potentials were normal for the left eye. The ON response in the right eye was reduced and delayed; it was normal in the left eye. A further loss of visual function was noted 1 year later in the right eye, but the ophthalmoscopic findings were unchanged. The ERG of the right eye had a negative waveform when dark adapted. Light adapted responses showed an unusual delayed b-wave, broad and delayed ON and OFF responses and a missing flicker response, suggesting a Müller cell dysfunction. Light adapted responses were slightly reduced in the left eye. CONCLUSIONS: Electrophysiological data indicate Müller cell dysfunction as a background of functional loss in Müller cell sheen dystrophy. This is in agreement with previously reported histological findings in this disorder.     

Simultaneous enucleation of a pulmonary melanoma metastasis and myocardial revascularization

BACKGROUND: The incidence of late, recurrence of malignant melanoma, is a well known, but very rare clinical experience. CASE REPORT: We report a case of simultaneous myocardial revascularisation and resection of pulmonary melanoma metastasis. In 1963 an enucleation of the right eye was necessary due to an ocular melanoma. In 1993 the patient suffered acute left heart failure and a 3-vessel disease with severe reduced left ventricular function was diagnosed. Chest X-ray examination revealed a singular pulmonary lesion in the right lower lobe with a diameter of 5.5 cm. Myocardial revascularisation and resection of the pulmonary focus was performed simultaneously without complication. The histological examination documented a pulmonary late recurrence of malignant melanoma. Up to this time (3 years later) the patient is free of cardiac symptoms and there is no evidence of further late recurrence of malignant melanoma. CONCLUSION: The appreciable number of patients who, after a disease-free interval of 10 to 20 years, develop a late recurrence of a malignant melanoma, and in particular-as in the present case-a choroidal melanoma, is powerful evidence for a need to keep these patients under lifelong surveillance.     

Retinal detachment in Ehlers-Danlos syndrome. Treatment by pars plana vitrectomy

Ehlers-Danlos syndrome (EDS) is an hereditary connective tissue disorder caused by defective collagen synthesis, the main features being hyperelasticity and vulnerability of the skin, recurrent bleeding from fragile blood vessels, and secondary deformities of the joints. Ocular involvement is a rare occurrence, e.g., corneal and scleral rupture from minor blunt injury, lens displacement, rhegmatogenous retinal detachment. To date, few reports exist concerning the treatment of retinal detachment in Ehlers-Danlos syndrome, all of them dealing exclusively with conventional scleral buckling surgery. PATIENT AND METHODS: We report on a 47-year-old male patient suffering from EDS type VI (so-called ocular type, lysine-hydroxylase deficiency). He presented with rhegmatogenous retinal detachment in his only eye. A scleral buckling procedure was not feasible because of marked scleral atrophy. A three-port vitrectomy was therefore carried out. RESULTS: During the operation, pronounced choroidal detachment and bleeding developed, subsiding within weeks postoperatively. Closure of the sclerotomies was difficult due to scleral thinning. Two revitrectomies were necessary because anterior PVR with traction retinal detachment occurred. The last revitrectomy was performed 18 months ago, and the retina has been completely reattached under 5000 cs silicone oil since then. Visual acuity is 0.1. CONCLUSION: Primary vitrectomy permits successful treatment of retinal detachment in EDS patients if a buckling procedure cannot be performed because of scleral atrophy. However, serious complications may occur. Surgical procedures other than primary vitrectomy should therefore always be carefully considered, e.g., pneumatic retinopexy, temporary balloon, dura patch with episcleral pocket.     

Both the tool and the carpenter are important

A 67-year-old woman with a history of a skin melanoma that was excised 7 years previously had a 6-month history of decreased vision in her right eye. A choroidal melanoma was diagnosed clinically, and the eye was enucleated. The results of a histopathological examination revealed a primary uveal melanoma. Slides of the skin melanoma were obtained, and the initial diagnosis was confirmed. In an attempt to illustrate a biological difference between the 2 melanomas, immunohistochemical studies were performed on sections of the 2 specimens using S-100 protein, HMB-45, and S-100-beta. Primary cutaneous and choroidal melanomas appearing in a patient with no predisposition are rare; this is believed to be only the fifth such case reported in the literature.     

New model of conjunctival scarring in the mouse eye

AIMS: To establish a simple model of conjunctival wound healing in the mouse eye. METHODS: 4 week old BABL/c mouse eyes were studied over a 14 day period. Surgical procedure under general anaesthesia involved a blunt dissection of the conjunctiva performed by injection of 25 microliters of PBS via a 27 gauge needle into one eye, while the contralateral eye was used as control. Mice were assessed clinically and sacrificed at 1, 2, 3, 7, and 14 days after surgery. Enucleated eyes were prepared for histological analysis. Development of scar tissue was studied with haematoxylin and eosin, oxidation aldehyde fuchsin, and van Gieson stains, with assessment of cellularity, extracellular matrix formation, and wound characterisation. RESULTS: Histological analysis revealed a marked and characteristic healing response initiated by a predominantly granulocytic inflammatory reaction at day 1 with peak fibroblast activity 3 days after surgery. Oxytalan fibres and newly laid collagen fibres were detected early in the subconjunctival wound area and up to 7 days after surgery. Remodelling and complete organisation of scar tissue was evident by day 14. CONCLUSION: A single subconjunctival injection in the mouse eye results in a marked and consistent healing response. This represents a simple, inexpensive, and reliable animal model of conjunctival scarring. The mouse is a biologically well characterised animal model and allows the use of a wide variety of molecular tools. There are potentially significant clinical applications, in particular in investigating the effects of modulating agents such as antimetabolites, growth factors, and their antagonists on conjunctival scarring.     

An error in the fluorescence angiographic diagnosis of a subretinal process (author's transl)

A presentation is given of a malignant melanoma of the choroid of a 15-year-old girl. The tumor was erroneously considered as to be a subretinal hemorrhage produced by a choroidal rupture after an accident. A beginning melanosis bulbi resulted in the enucleation and the histological examination of the eye, which confirmed malignant melanoma of the choroid.     

Functional specificity of long-range intrinsic and interhemispheric connections in the visual cortex of strabismic cats

The development of both long-range intracortical and interhemispheric connections depends on visual experience. Previous experiments showed that in strabismic but not in normal cats, clustered horizontal axon projections preferentially connect cell groups activated by the same eye. This indicates that there is selective stabilization of fibers between neurons exhibiting correlated activity. Extending these experiments, we investigated in strabismic cats: (1) whether tangential connections remain confined to columns of similar orientation preference within the subsystems of left and right eye domains; and (2) whether callosal connections also extend predominantly between neurons activated by the same eye and preferring similar orientations. To this end, we analyzed in strabismic cats the topographic relationships between orientation preference domains and both intrinsic and callosal connections of area 17. Red and green latex microspheres were injected into monocular iso-orientation domains identified by optical imaging of intrinsic signals. Additionally, domains sharing the ocular dominance and orientation preference of the neurons at the injection sites were visualized by 2-deoxyglucose (2-DG) autoradiography. Quantitative analysis revealed that 56% of the retrogradely labeled cells within the injected area 17 and 60% of the transcallosally labeled neurons were located in the 2-DG-labeled iso-orientation domains. This indicates: (1) that strabismus does not interfere with the tendency of long-range horizontal fibers to link predominantly neurons of similar orientation preference; and (2) that the selection mechanisms for the stabilization of callosal connections are similar to those that are responsible for the specification of the tangential intrinsic connections.     

A case of complete circumferential aortic rupture due to blunt chest trauma

A case of complete circumferential rupture of the thoracic aorta due to blunt chest trauma is presented. A 30-year-old man was admitted after a traffic accident. The admission chest X-ray film demonstrated mediastinal widening. About 6 hours after the traffic accident, chest CT scanning demonstrated mediastinal hematoma, left pleural effusion and partial aortic dissection. Diagnoses of aortic rupture and liver injury were made, and surgery for the thoracic aorta was performed immediately. The aorta was found to be completely disrupted for the length of 2 cm, and a vascular prosthesis was interposed between the two ends of the aorta under partial cardiopulmonary bypass. We conclude that the enhanced chest CT scanning is helpful for diagnosis, and that if other organ injuries are not severe, the emergency operation should be performed.     

Choroidal melanoma: a review and case report

BACKGROUND: Choroidal melanoma is the most common primary intraocular malignancy in adults. The ongoing Collaborative Ocular Melanoma Study (COMS) was designed to provide specific answers for the management of medium and large choroidal melanomas. The present consensus among authorities is that small (< 3 mm thick) suspected choroidal melanomas can be conservatively managed with periodic observation for evidence of growth. CASE REPORT: Dilated fundus examination of a 68-year-old man revealed a pigmented uveal lesion straddling the ora serrata inferiorly at 5:30 in the right eye. It measured 5 mm in diameter with transillumination and 2.89 mm in thickness with B-scan ultrasonography. Questioning a small choroidal melanoma the patient was referred to an ocular oncologist, who confirmed the lesion was suspicious for choroidal melanoma. CONCLUSION: Although there are clinical signs that suggest lesion growth, true growth must be recorded with serial photographs, ultrasound, and transillumination. Active therapy should usually begin once lesion growth is documented.     

The effect of radial keratotomy on ocular integrity in an animal model

The safety of deep corneal incisions in radial keratotomy was evaluated in a porcine model of blunt trauma. One eye of each enucleated pair (right and left) of porcine eyes was subjected to a variation of radial keratotomy; the fellow eyes served as unoperated-on controls. All eyes were subjected to a standard injury. Control eyes ruptured at the equatorial sclera. Eyes with radial incisions cut through approximately 70% of corneal thickness also ruptured at the equator. When incisions of this depth (70%) were extended across the limbus (rather than to the corneal-scleral junction), all ruptures occurred at the limbal incisions. Eyes cut 95% to 100% of corneal thickness tended to rupture at the incisions. The safety of deep radial keratotomy incisions with respect to ocular integrity is discussed.