Modified vitreous surgery for subretinal neovascularization and hemorrhage

Chylous ascites is an extremely rare complication of abdominal aortic surgery. A case with a successful outcome is presented, followed by a review of the 17 published cases. Chylous ascites can result in nutritional imbalance, immunological deficit and respiratory dysfunction. Paracentesis confirms the diagnosis and provides symptomatic relief. Conservative management, beginning with a low-fat diet and medium-chain triglyceride (MCT) supplementation, is recommended, changing to total parenteral nutrition if unsuccessful. Failure of non-operative treatment may necessitate the need for laparotomy and ligation of leaking lymphatics or peritoneovenous shunting.     

Pneumatic displacement of subretinal hemorrhage without tissue plasminogen activator

PURPOSE: To analyze the results of excimer laser phototherapeutic keratectomy (PTK) combined with simple excision in recurrent pterygium to minimize the recurrence rate and obtain a smooth corneal surface. SETTING: Veni Vidi Eye Health Centre, Istanbul, Turkey. METHODS: Combined pterygium excision and excimer laser PTK was performed in 22 eyes with recurrent pterygium (22 patients). Both spot and scan modes of the Meditec MEL 60 excimer laser were used to produce a wide ablation layer (depth 40 to 80 microns). RESULTS: During the mean follow-up of 16.5 months (range 6 to 27 months), visual acuity, refraction, slitlamp, and corneal topography examinations were recorded. Pterygium recurred in only 1 eye (4.5%). Postoperative visual acuity improved in 15 eyes (68.2%). Keratometric readings were not accurately measured preoperatively because of corneal surface irregularities but could be easily taken after the surgery. Corneal astigmatism ranged from 0 to 2.00 diopters (D) (mean 1.23 D). Three months after surgery, no haze persisted in any eye. No significant intraoperative or postoperative complication was detected. CONCLUSIONS: Excimer laser PTK appears to simplify pterygium surgery because a superficial keratectomy is sufficient to remove pterygium. The excimer laser can be used to ablate the visible residual tissues and smooth the corneal surface, resulting in good postoperative refraction and visual acuity. Consequently, this procedure seems to be effective and safe.     

Pathophysiology and management of venous ulcers

Venous ulcers account for the majority of chronic lower extremity wounds. The cause of venous ulceration is not completely understood; however, risk factors, such as a history of deep venous thrombosis (DVT) and a family history of venous ulceration, have been identified. Venous ulceration is postulated to occur when fibrin cuffs form, leading to increased diffusion distance and impaired local perfusion. This article will review the cause, pathophysiology, clinical manifestations, and management of venous ulcers.     

Intracranial hemorrhage: diagnosis and emergency management

Intracranial hemorrhages are an important cause of acute neurologic disease presenting in the emergency setting. To optimize outcome, it is important that the physician quickly recognize intracranial hemorrhages. To minimize mortality and neurologic morbidity, it is often necessary to initiate urgent therapy in the emergency rooms and to obtain neurosurgical consultation in order to pursue early surgical therapy. This article discusses the recognition and early treatment of the various types of intracranial hemorrhages.     

Pathophysiology, prevention, and management of prosthetic infections in hernia surgery

Because hernias are repaired increasingly with mesh and plugs, surgeons performing these operations should make an extended effort to prevent infection, and, when infections occur, to treat them expeditiously. This article discusses bacterial binding, infection reduction, the patient-doctor relationship during the care of an infected wound, and other related topics.     

Suprachoroidal hemorrhage: outcome of surgical management according to hemorrhage severity

OBJECTIVE: To report the visual and anatomic outcome after surgical drainage of suprachoroidal hemorrhage according to hemorrhage severity. DESIGN: A retrospective chart review. PARTICIPANTS: Forty-eight consecutive eyes undergoing surgical drainage of a suprachoroidal hemorrhage at The Medical College of Wisconsin were examined. INTERVENTION: Demographic and clinical data were abstracted from patients' medical records. Eyes were classified into four categories of increasing hemorrhage complexity: (1) nonappositional choroidal hemorrhage without vitreous or retinal incarceration in the wound (12 eyes); (2) centrally appositional choroidal hemorrhage without vitreous or retinal incarceration in the wound (17 eyes); (3) choroidal hemorrhage with associated vitreous incarceration in the wound (11 eyes); and (4) choroidal hemorrhage with associated retinal incarceration in the wound (8 eyes). MAIN OUTCOME MEASURES: Visual acuity, rate of persistent hypotony, and incidence of irreparable retinal detachment after surgical drainage for four classes of suprachoroidal hemorrhage were defined. RESULTS: Overall, 11 (23%) of 48 eyes had no light perception (NLP) vision develop, 9 (19%) of 48 eyes had persistent postsurgical hypotony (intraocular pressure < 6), and 21 (64%) of 33 eyes with retinal detachment enjoyed successful retinal reattachment surgery. A definite trend toward an increased rate of NLP vision (P < 0.02), persistent hypotony (P < 0.05), and irreparable retinal detachment (P = 0.11) was observed with increasing suprachoroidal hemorrhage complexity. Eyes with retinal incarceration, compared to eyes without retinal incarceration, had an increased rate of NLP vision (63% vs. 15%; P < 0.01), persistent postsurgical hypotony (50% vs. 13%; P < 0.05), and irreparable retinal detachment (50% vs. 20%; P = 0.07). CONCLUSIONS: Eyes requiring surgical drainage of a suprachoroidal hemorrhage have a guarded prognosis, with a poorer outcome associated with increasing hemorrhage complexity. A classification system incorporating choroidal apposition, and vitreous and retinal incarceration in the wound, provides a format for reporting and assessing the efficacy of management strategies in this condition.     

Urokinase in the management of vitreous hemorrhage

Urokinase is a plasminogen activator of human origin which breaks up the fibrin base of blood clots. When given as an intravitreal injection it produces hypopyon and glaucoma, both of which transient. In a series of 27 patients (34 eyes) with unresolved vitreous haemorrhage, this simple and relatively atraumatic treatment has produced marked objective improvement in 10, and greatly improved the life styles of a further 9. This series brings the total of reported cases to 93. When compared with recent American reports of surgical vitrectomy for vitreous haemorrhage, intravitreal urokinase appears to have a higher success rate, with a lower complication rate both in the short and long term. This study suggests that, despite the high cost of the purified enzyme, urokinase should be come the first line of attack in vitreous haemorrhage, vitrectomy being reserved for those patients who fail to respond.     

Subarachnoid hemorrhage: an update of pathogenesis, diagnosis and management

Subarachnoid hemorrhage (SAH) remains a devastating neurological disorder, which most commonly develops after rupture of an intracranial aneurysm. Advances have occurred in the areas of epidemiology, diagnostic imaging, medical management and surgical intervention, related to aneurysmal SAH. Interested physicians must become aware of these and other advances to diagnose and manage this potentially lethal disorder more effectively. This review provides information about the pathogenesis and complications of aneurysmal SAH and an update of new and evolving treatment modalities to provide an in-depth overview for the clinician and researcher involved in this rapidly evolving field.     

Suprachoroidal hemorrhage. Clinical features and results of secondary surgical management

PURPOSE: The purposes of this study are to identify clinical features in eyes with suprachoroidal hemorrhage which portend a poor visual prognosis and to determine visual outcome in these eyes after secondary surgical management of suprachoroidal hemorrhage. METHODS: This was a retrospective study of 106 patients with suprachoroidal hemorrhages occurring in association with trauma (35), cataract surgery (30), glaucoma surgery (17), penetrating keratoplasty (6), corneal perforation (5), secondary lens implantation (3), pars plana vitrectomy (3), and other causes (7). RESULTS: Five (10%) of 49 eyes with a suprachoroidal hemorrhage and an initial retinal detachment had a visual outcome of 20/200 or better compared with 21 (43%) of 49 eyes without a retinal detachment. The presence or absence or a retinal detachment could not be determined in eight patients and all eight of these patients had a poor visual outcome. Sixteen (20%) of 82 eyes with a 360 degrees suprachoroidal hemorrhage had a visual outcome of 20/200 or better compared with 10 (47%) of 21 for those with suprachoroidal hemorrhage limited to one or two quadrants. The extent of the hemorrhage could not be determined in three eyes. Overall, 34% (14/41) of the patients with suprachoroidal hemorrhage who had a secondary surgical procedure achieved a visual outcome of 20/200 or better. Forty-three percent (6/14) who had a suprachoroidal hemorrhage during or after cataract surgery and who were treated with secondary surgical management achieved a visual outcome of 20/200 or greater. CONCLUSION: Clinical features associated with a poorer visual outcome included initial or indeterminate retinal detachment and 360 degrees suprachoroidal hemorrhage. Limited suprachoroidal hemorrhage without initial retinal detachment usually has a good visual prognosis and does not usually require secondary surgical intervention. However, if the former complication is present, secondary surgical intervention should be considered.     

Abnormal uterine hemorrhage in climacteric. Medical management

Following a review of the literature, the authors examine the drugs which are currently used to treat anomalous uterine bleeding during menopause, illustrating their aims and justifying the rationale underlying their use. They conclude by stating that a satisfactory treatment often does not exist, but it is the task of the specialist to gauge the level and sequence of treatments in order to achieve the hoped-for result.     

Uterine packing in the combined management of obstetrical hemorrhage

Alzheimer disease, Pick disease and senile dementia are all characterized by similar morphological changes, both macroscopic and microscopic, and similar psychiatric symptoms. All three should, therefore, be viewed as aspects of one disease, which is termed Alzheimer-type dementia. Nothing contradicts the view that immune complexes take part in the etiology of Alzheimer-type dementia. There are various types of immune complexes and so their points of action in the organism may vary. There might be two main means of preventing Alzheimer-type dementia: the first could be named the serological (basic) and the second relying on pharmacotherapy (additional). Pharmacological prevention of disease might be aided by the use of parasympathomimetic drugs, e.g. pilocarpine.     

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.     

Surgical removal of subretinal neovascular membranes

Although families can provide important support for individuals with life-threatening illnesses or injuries, the highly technological nature of critical care often limits opportunities for family involvement. While critical care nurses are seldom family specialists, they frequently provide support and assistance to patients' families. This paper describes four types of questions drawn from the family therapy literature that can be used by nurses who are not mental health specialists to support families and mobilize their problem solving skills. A case model of a head-injured child demonstrates the use of these questions with a family. These questions should be useful for the brief, problem-focused, family encounters which characterize critical care settings.     

Factors influencing absorption of subretinal fluid

In 200 cases of retinal detachment successfully treated without drainage of subretinal fluid complete reattachment of the retina was achieved in the first postoperative week in 76 per cent of cases. Delay in subretinal fluid absorption in the remaining 24 per cent of cases was directly related to the duration of the retinal detachment but was not influenced by the patient's age, refractive error, or the characteristics of the detachment.     

Pathophysiology of adenomyosis

Adenomyosis refers to endometrial glands and stroma located haphazardly deep within the myometrium. Similar histological alterations may be found in extrauterine locations such as the rectovaginal septum. The aetiology and pathogenic mechanism(s) responsible for adenomyosis are poorly understood. Both human and experimental studies favour the theory of endomyometrial invagination of the endometrium, although the de-novo development of adenomyosis from Mullerian rests in an extrauterine location is a possibility. The prerequisite for adenomyosis may be triggered or facilitated by either a 'weakness' of the smooth muscle tissue or an increased intrauterine pressure or both. Relatively high oestrogen concentrations and impaired immune-related growth control in ectopic endometrium may be necessary for the maintenance of adenomyosis. Smooth muscle cell hyperplasia and hypertrophy are a reflection of reactive change secondary to ectopic endometrial proliferation. Further studies are needed for insight into the precise aetiology and pathogenesis of adenomyosis. Adenomyosis is a relatively frequent endomyometrial pathology discovered in multiparous women between 40 and 50 years of age. About 2/3 of women are symptomatic with menorrhagia and dysmenorrhoea; 80% of adenomyotic cases are associated with leiomyomata uteri; and in women with endometrial adenocarcinoma, adenomyosis is relatively often seen. Definite diagnosis is made on hysterectomy specimens, although attempts are made at securing preoperative diagnosis by magnetic resonance imaging and myometrial biopsies. Definite treatment of symptomatic women is hysterectomy.     

Pathophysiology of dehydration

The pathophysiology of dehydration is reviewed. The normal response to dehydration, i.e. decreased effective arterial blood volume or effective circulating volume is described. Due to water retention and drinking following stimulation of ADH secretion and thirst, osmoregulation is overruled by volume conservatory mechanisms, which lead to hyponatremia. Only patients with impaired mental function or those who are unable to drink will develop a progressive water deficit--with or without salt depletion--recognizable by hypernatremia. Decreased effective arterial blood volume and hypernatremia affect cerebral function in a way that perception of external stimuli as well as perception of pain will be impaired. Alert dehydrated patients are disturbed mainly by thirst and dryness of the mouth. Both symptoms are perceived more intensely by young than by elderly persons. Dryness of the mouth increase thirst on its own. Distress by thirst and oral dryness increases as a function of the level and the rapidity of developing hypernatremia. The simple act of filling the oral cavity with fluid and swallowing alleviates thirst in the absence of any change in plasma sodium concentration. Thirst quenching efficacy is increased by administering chilled hypotonic fluid with lemon or other fruit acid added (for stimulation of salivation).     

Pathophysiology of delirium

Hypotheses about the pathophysiology of delirium are speculative and largely based on animal research. According to the neurotransmitter hypothesis, decreased oxidative metabolism in the brain causes cerebral dysfunction due to abnormalities of various neurotransmitter systems. Reduced cholinergic function, excess release of dopamine, norepinephrine, and glutamate, and both decreased and increased serotonergic and gamma-aminobutyric acid activity may underlie the different symptoms and clinical presentations of delirium. According to the inflammatory hypothesis, increased cerebral secretion of cytokines due to a wide range of physically stressful events plays an important role in the occurrence of delirium. Since cytokines can influence the activity of various neurotransmitter systems, these mechanisms may interact. Also, more fundamental processes like intraneuronal signal transduction, second messenger systems that at the same time use neurotransmitters as first messengers and play an important role in their synthesis and release, may be disturbed. Furthermore, severe illness and physiologic stress may give rise to modification of blood-brain barrier permeability, the sick euthyroid syndrome with abnormalities of thyroid hormone concentrations, and increased activity of the hypothalamic-pituitary-adrenal axis. These circumstances possibly also contribute to changes in neurotransmitter synthesis and release of cytokines in the brain, and consequently to the occurrence of delirium. Elderly patients are more at risk for developing delirium,very likely due to age-related cerebral changes in stress-regulating neurotransmitter and intracellular signal transduction systems. This paper will expand upon these current theories and discuss their applicability to research and clinical work with elderly patients suffering from delirium.