Postoperative Complications of Pars Plana Vitrectomy for Diabetic Retinal Disease.

Despite recent advances in the medical management of diabetic retinal disease, there remain established indications for vitreoretinal surgery in the treatment of severe proliferative diabetic retinopathy. These include non-clearing vitreous hemorrhage and tractional retinal detachment. Advances in surgical instrumentation, technique, and experience have led to improved visual outcomes, as well as a corresponding decrease in the incidence of postoperative complications. However, the presence of systemic and ocular factors in diabetic patients increases the risk of adverse events compared to non-diabetic individuals. This review will focus on the most important postoperative complications following pars plana vitrectomy, with specific considerations for the diabetic patient.

Forceps trauma in a newborn presenting as iris heterochromia.

Birth-associated ocular trauma is common and often minor, including subconjunctival and retinal haemorrhage and eyelid edema. Significant ocular trauma during birth, usually associated with forceps-assisted delivery, is rarer and can include Descemet's membrane rupture, lid lacerations, hyphema, Purtcher retinopathy, facial nerve palsy, corneal edema, and corneal laceration. We report the first case of ocular birth trauma from forceps presenting as isolated iris heterochromia and a pseudo rubeosis iridis, which completely resolved by 1 month of age with no known adverse ocular sequelae.

Delayed Development of Intracranial Hypertension After Discontinuation of Tetracycline Treatment for Acne Vulgaris.

A 14-year-old girl presented with a history of left-sided headache and acute bilateral blurred vision. She had a remote history of oral tetracycline use for the treatment of acne vulgaris, which had been discontinued for 1 month. The patient was diagnosed with drug-induced intracranial hypertension (IH) and treated with oral acetazolamide with subsequent resolution of symptoms. IH, a known rare complication of the tetracycline class of antibiotics, can also have a delayed presentation after discontinuation of the medication.

A child with rapidly progressive necrotizing group a streptococcal Tenon's capsule infection one day after strabismus surgery.

Periorbital infections after strabismus surgery are rare. We describe the first reported case of necrotizing group A streptococcal infection of the conjunctiva and Tenon's capsule complicating uneventful strabismus surgery in a 23-month-old boy, successfully managed with conservative intraoperative debridement and with targeted local and systemic antibiotics.

Peripapillary RNFL thickness in nonexudative versus chronically treated exudative age-related macular degeneration.

OBJECTIVE: To compare the peripapillary retinal nerve fibre layer (RNFL) thickness in nonexudative versus exudative age-related macular degeneration (wet AMD) eyes treated chronically with intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF). DESIGN: Cross-sectional study. PARTICIPANTS: Twenty-nine patients with unilateral wet AMD with at least 12 prior intravitreal anti-VEGF injections and 2 years of therapy were analyzed. The fellow eye with nonexudative (dry) AMD with no prior treatment served as the control group. METHODS: All patients were prospectively enrolled from a single academic subspecialist practice. Bilateral spectral-domain optical coherence tomography (Cirrus SD-OCT; Carl Zeiss Meditec, Dublin, Calif.) of the peripapillary RNFL was performed on all pairs of eyes. Optic nerve head (ONH) parameters were also computed. The primary outcome was mean difference in peripapillary RNFL thickness compared between the treated and the nontreated eyes. RESULTS: Mean RNFL in the chronically treated eyes (95.0 [95% CI 89.8-100.2] µm) was significantly greater than the nontreated fellow eyes (89.9 [95% CI 85.5-94.3] µm) (p = 0.01). Quadrantic optic nerve analysis revealed the temporal RNFL to be greater in the treated group (p = 0.02), whereas all other locations were similar. No significant differences were found between the 2 groups in any ONH parameters. CONCLUSIONS: This study demonstrated no deleterious optic nerve RNFL thinning in a series of wet AMD eyes with long-term repetitive exposure to intravitreal anti-VEGF injections. Furthermore, we observed that those with wet AMD have a relatively thickened temporal peripapillary RNFL layer, which is an important association for all observers of optic nerve disease.

The impact of post-mastectomy radiation therapy on male breast cancer patients--a case series.

OBJECTIVE: To assess the impact of radiation management on male breast cancer (MBC) at London Regional Cancer Program (LRCP). METHODS AND MATERIALS: Men with a diagnosis of breast cancer referred to LRCP were reviewed. The seventh American Joint Committee on Cancer staging system was used. Patients treated with and without post-mastectomy radiation therapy (PMRT) were analyzed. Disease-free survival (DFS) was defined as time duration from diagnosis to first recurrence. Overall survival (OS) was defined as time duration from pathologic diagnosis to death or last follow-up with any death defined as an event. Survival estimates were obtained using Kaplan-Meier methodology. RESULTS: From January 1977 to December 2006, 81 men had invasive ductal carcinoma. The median age was 65 (range, 35-87 years). There were 15 Stage I, 40 Stage II, 20 Stage III, and 6 Stage IV patients. Median follow-up time was 46 months (range, 1-225 months). Of the 75 patients treated with curative intent, 29 did not receive PMRT and 46 completed PMRT. Patients who received PMRT demonstrated no benefit in overall survival (p = 0.872) but significantly better local recurrence free survival (p < 0.001) compared with those who did not receive RT. There was trend toward improving locoregional recurrence with PMRT in patients with high-risk features (node-positive, advanced stage, and ≤ 2 mm or unknown surgical margin). The median, 5-year, and 10-year disease-free survival and overall survival for the 75 patients were 77.7 months, 66.3%, 32.7%, and 91.2 months, 73.9%, and 36.6%, respectively. CONCLUSION: The experience at LRCP suggests that high-risk MBC patients should consider PMRT to improve their chance of local recurrence-free survival.

Family physicians' perspectives on personal health records: qualitative study.

OBJECTIVE: To explore FPs' perspectives on the value of personal health records (PHRs) in primary care and the implementation and adoption of PHRs in Canada. DESIGN: A qualitative design using semistructured interviews. SETTING: Southwestern Ontario. PARTICIPANTS: Ten FPs. METHODS: The 10 FPs participated in semistructured interviews, which were audiotaped and transcribed verbatim. An iterative approach using immersion and crystallization was employed for analysis. MAIN FINDINGS: Participants were generally positive about PHRs, and were attracted to their portability and potential to engage patients in health care. Their concerns focused on 3 main themes: data management, practice management, and the patient-physician relationship. Subthemes included security, privacy, reliability of data, workload, remuneration, physician obligations, patient misinterpretation of medical information, and electronic communication displacing face-to-face visits. Participants identified 3 key facilitators for adoption of PHR systems: integration with existing electronic health record systems, ease of use without being a burden on either time or money, and offering a demonstrated added value to family practice. CONCLUSION: This study replicates previously published literature about FP concerns and opinions, and it further identifies remuneration as a potential barrier in Canadian fee-for-service payment models. Participants identified 3 key facilitators, which were suggested for implementation and adoption of PHRs, providing a basis for future research and development of these systems for use in Canadian family practice.

Brachytherapy with permanent gold grain seeds for squamous cell carcinoma of the lip.

PURPOSE: To describe the use of radioactive gold grain implantation for squamous cell carcinoma of the lip. METHODS: Retrospective review of 51 patients treated with permanent gold ((198)Au) grain implant brachytherapy. The seed arrangement delivered a dose of 5500 cGy at 0.5 cm from a single plane. Primary endpoints were local recurrence and cosmetic outcome. RESULTS: Median follow-up was 27 months. Median age was 69 years. The majority (90%) were T1 lesions. None of the patients had evidence of regional lymph node or distant metastasis. Twelve patients had recurrent disease with prior surgery and five patients had previous head and neck radiation. Local control was achieved in 49 patients. Good cosmesis was achieved in 48 patients. Two-year actuarial estimates for local failure-free survival, disease-free survival and overall survival were 97.9%, 94.1% and 87.9%, respectively; no deaths were attributable to lip cancer. CONCLUSIONS: Gold grain interstitial low-dose rate brachytherapy provides excellent local control and cosmesis in patients with squamous cell carcinoma of the lip. This technique provides an excellent option for patients that are elder or live remotely. It is particularly useful for lesions that are small, in previously radiated areas, or treated with prior surgery.

Intravitreal injection anesthesia--comparison of different topical agents: a prospective randomized controlled trial.

PURPOSE: To compare the anesthetic effectiveness of 3 topical agents used for intravitreal injections. DESIGN: Randomized, triple-armed, double-blinded, prospective, single-centered trial in patients receiving intravitreal ranibizumab for neovascular age-related macular degeneration. METHODS: Patients were randomized 1:1:1 to receive 0.5% tetracaine hydrochloride drops and a 4% lidocaine pledget (n = 31), 0.5% tetracaine hydrochloride drops alone (n = 31), or 4% cocaine (+ epinephrine 1/100,000) drops alone (n = 31). Patients were asked to score their pain experience using a visual analogue scale (VAS) immediately following and 15 minutes after their injection. The average of these scores was used as the primary outcome. The physician performing the procedure separately scored his perception of the patients' pain using the Wong-Baker FACES scale. RESULTS: Means of the averaged VAS pain score for Groups 1, 2, and 3 were: 19 (95% confidence interval [CI] 12-26), 21 (95% CI 13-29), and 21 (95% CI 16-27) respectively. Mean Wong-Baker pain scores for Groups 1, 2, and 3 were 1.9 (95% CI 1.3-2.6), 2.1 (95% CI 1.4-2.7), and 2.3 (95% CI 1.6-3.1) respectively. There was no significant difference (P = .549) between groups for average VAS pain score. Similarly, there was no significant difference (P = .790) for the physician-perceived pain score between groups. CONCLUSIONS: There was no clinical difference in patient pain experience between the 3 anesthetic options tested. The addition of a 4% lidocaine pledget offered no clinical advantage in pain relief compared to 0.5% tetracaine or 4% cocaine (+ epinephrine 1/100,000) drops alone.

Systematic review of baseline low-dose CT lung cancer screening.

The purpose of this systematic review was to provide physicians and patients with a synthesis of the available data and an assessment of the operating characteristics associated with baseline LDCT screening for lung cancer. Various databases, meeting abstracts, clinical trials in progress, and major textbooks for relevant data from 1966 to 2006 were searched for relevant studies. The median value of sensitivity, specificity, positive predictive value and negative predictive value were 81%, 81%, 8% and 99%, respectively. Of the studies that compared LDCT with other lung cancer screening maneuvers, it was found that LDCT detected a greater number of cancerous nodules. On average, 80% of lung cancers detected by baseline LDCT screening were categorized as Stage I cancers. Current data demonstrate that both the operating characteristics of baseline LDCT screening and the relatively high proportion of Stage I cancers detected with LDCT may potentially lead to effective screening programs. However, evidence of reduced mortality and morbidity with the use of LDCT is not established. Therefore, LDCT for lung cancer screening should be considered as investigative and needs to be confirmed by well-designed randomized controlled trials prior to community and institutional implementation.