Small-angle strabismus detection by telemedicine in an experimental model.

PURPOSE: To evaluate the ability of observers to accurately detect strabismus using an alternate cover testing approach via telemedicine and to assess the effect of various factors related to video conditions on the accuracy rate. METHODS: Videos were made by the authors in which different angles of strabismus, up to 12Δ, were induced by prism and recorded using alternate cover testing. The videos were made under a variety of conditions that incorporated various head postures, lighting, fixation target position and motion, and viewing angle. The videos were shown to observers of varying levels of expertise. The accuracy of detecting the deviation was assessed and analyzed for statistical significance. RESULTS: The overall rate of detection was significantly affected by the angle of deviation, with 12Δ being correctly detected with 94% accuracy, 8Δ with 72% accuracy, and 4Δ with <50% accuracy. Esotropia and hypertropia were more accurately detected than exotropia for all angles tested. The level of training of the observer did not correlate with detection accuracy. However, accuracy was negatively affected by backlighting and movement of the fixation target during cover testing. CONCLUSIONS: Our data demonstrate that detection of even relatively small angles of strabismus can be accomplished with a high level of accuracy using telemedicine and an alternate cover testing strategy. For optimal results, it is important to consider conditions related to the fixation target and lighting.

Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society.

BACKGROUND: Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia. METHODS: Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used. RESULTS: Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality. CONCLUSION: We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis; Level IV.

Chondroitin sulfate enhances the barrier function of basement membrane assembled by heparan sulfate.

Glycosaminoglycans are ubiquitously expressed polysaccharides that are attached to proteoglycans. Here, we showed that ablation of the heparan sulfate (HS) polymerase Ext1 in retinal progenitor cells did not affect initial progression of retinal angiogenesis, but it disrupted the pruning of blood vessels and establishment of arterioles and venules. In the absence of retinal HS, blood vessels were also vulnerable to high oxygen tension in early postnatal stages, which could be rescued by exogenous vascular endothelial growth factor (VEGF), consistent with the role of retinal HS in the fine-tuning of VEGF signaling. Furthermore, we observed that the retinal inner limiting membrane (ILM) was disrupted by deletion of Ext1 in a timing-specific manner, suggesting that retinal HS is required for the assembly but not the maintenance of the basement membrane. Lastly, we showed that further deletion of C4st1, a chondroitin sulfate (CS) sulfation enzyme, did not affect the assembly of the ILM but, when combined with Ext1 deletion, it aggravated the retinal permeability by disrupting the retinal glycocalyx. These results demonstrate an important role of CS and HS in establishing the barrier function of the extracellular matrix.

Ocular Blood Flow in Preterm Neonates: A Preliminary Report.

Purpose: Retinopathy of prematurity (ROP) is a vision-threatening complication occurring in pre-term neonates. The standard of care entails regular monitoring by dilated ophthalmoscopy examinations, which entail stress and potential morbidity. In this pilot study, we used plane-wave ultrasound (PWUS) to image, measure, and assess the association of blood-flow velocities in the retrobulbar vessels with ROP stages ranging from stage 0 (immature vessels without ROP) to stage 3. Methods: Both eyes of 14 preterm neonates at risk for ROP were examined by 18 MHz PWUS. All but two subjects had a follow-up examination. PWUS was acquired for 1.5 seconds at 3000 compound B-scans/sec. Data were postprocessed to form color-flow images and spectrograms depicting flow velocity in the central retinal artery (CRA), central retinal vein (CRV), and the short posterior ciliary arteries (SPCA). Flow parameters derived from spectrograms were compared by ROP stage. Results: ROP stage was found to correlate with flow velocities. Velocities were significantly elevated with respect to non-ROP eyes in all vessels at stage 3 and in the SPCAs at stage 2. Conclusions: PWUS measurement of blood flow may provide a quantitative, clinically important, and easily tolerated means for detecting and assessing the risk of ROP in preterm neonates. We speculate that the observed increase in flow velocity results from elevated vascular endothelial growth factor (VEGF) in ROP eyes. Translational Relevance: PWUS offers a gentle, nonmydriatic method for monitoring neonates at risk for ROP that would complement ophthalmoscopy.

Neurovascular compression of the oculomotor nerve presenting with aberrant reinnervation.

PURPOSE: To report a case of neurovascular compression in a patient presenting with ophthalmic evidence of aberrant reinnervation. OBSERVATION: A 68-year-old woman diagnosed with right partial third nerve palsy with aberrant regeneration. Suspicion was based on isolated clinical features of the right eye, including ptosis, upper eyelid elevation on adduction, mydriasis, exotropia, and hypotropia. Magnetic resonance imaging revealed atrophy of the right oculomotor nerve secondary to neurovascular compression from a prominent right superior cerebellar artery. CONCLUSION AND IMPORTANCE: This case highlights the importance of utilizing Fast Imaging Employing Steady-state Acquisition (FIESTA) for the diagnosis of oculomotor nerve palsy presenting with evidence of aberrant reinnervation.

Actual Visual Acuity Demands in the Classroom.

PURPOSE: To address the knowledge gap regarding the actual acuity requirements needed in typical kindergarten through grade 12 classrooms by determining an actual logarithm of the minimum angle of resolution (logMAR) and contrast sensitivity requirements in a sample of classrooms for kindergarten through grade 12 in New York City. METHODS: Measurements of classroom dimensions with specific attention to viewing distances were made in public and private school classrooms, at various grade levels from kindergarten through grade 12, in New York City. The dimensions of typical text shown to students on classroom smartboards and whiteboards was measured and the mean and range of logMAR values were calculated for various seating locations within the classrooms. Contrast between text and background was estimated by comparing digital images of actual classroom text to Pelli-Robson contrast sensitivity charts. RESULTS: Fourteen classrooms in five schools were evaluated. Classroom dimensions varied from 8 × 10 feet to 23 × 23 feet. Mean logMAR values of lower case text on smartboards and whiteboards varied from 0.93 ± 0.29 (range: 0.83 to 1.32) in the center of the front row to 0.46 ± 0.21 (range: 0.10 to 0.79) in the center of the back row (P < .001). Contrast was also variable, being highest for black markers on whiteboards (0.00) and lowest on smartboards (0.15 to 0.60). Neither logMAR nor contrast sensitivity values varied significantly by grade level or school (P > .50 for both). CONCLUSIONS: The data reveal that logMAR demands and contrast vary substantially from classroom to classroom and within a classroom based on room dimensions and seating. Although generally supporting current acuity-based pediatric vision screening referral guidelines, the data also provide insight into the potential impact of reduced visual acuity and seating location on visual performance in the classroom. These findings suggest the need to develop logMAR and contrast standards that optimize visual content in classrooms while accommodating a wider range of visual capabilities. [J Pediatr Ophthalmol Strabismus. 2021;58(1):48-54.].

Gangrenous appendicitis contained within a Spigelian hernia.

A 66-year-old man with abdominal pain had a 5-year-old mass subsequently identified as a Spigelian hernia. Exploratory laparotomy revealed a strangulated and gangrenous appendix contained within the hernia, necessitating an appendectomy. This case highlights the importance of early identification and exploration of this rare hernia, so that early management can prevent the development of more serious and dangerous symptoms.

Elderly adults with isolated hip fractures- orthogeriatric care versus standard care: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Elderly patients commonly suffer isolated hip fractures, causing significant morbidity and mortality. The use of orthogeriatrics (OG) management services, in which geriatric specialists primarily manage or co-manage patients after admission, may improve outcomes. We sought to provide recommendations regarding the role of OG services. METHODS: Using GRADE methodology with meta-analyses, the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review of the literature from January 1, 1900, to August 31, 2017. A single Population, Intervention, Comparator and Outcome (PICO) question was generated with multiple outcomes: Should geriatric trauma patients 65 years or older with isolated hip fracture receive routine OG management, compared with no-routine OG management, to decrease mortality, improve discharge disposition, improve functional outcomes, decrease in-hospital medical complications, and decrease hospital length of stay? RESULTS: Forty-five articles were evaluated. Six randomized controlled trials and seven retrospective case-control studies met the criteria for quantitative analysis. For critical outcomes, retrospective case-control studies demonstrated a 30-day mortality benefit with OG (OR, 0.78 [0.67, 0.90]), but this was not demonstrated prospectively or at 1 year. Functional outcomes were superior with OG, specifically improved score on the Short Physical Performance Battery at 4 months (mean difference [MD], 0.78 [0.28, 1.29]), and improved score on the Mini Mental Status Examination with OG at 12 months (MD, 1.57 [0.40, 2.73]). Execution of activities of daily living was improved with OG as measured by two separate tests at 4 and 12 months. There was no difference in discharge disposition. Among important outcomes, the OG group had fewer hospital-acquired pressure ulcers (OR, 0.30 [0.15, 0.60]). There was no difference in other complications or length of stay. Overall quality of evidence was low. CONCLUSION: In geriatric patients with isolated hip fracture, we conditionally recommend an OG care model to improve patient outcomes. LEVEL OF EVIDENCE: Systematic review/meta-analysis, level III.

Sedation and paralytic use in open abdomen patients-results from the EAST SLEEP Survey.

BACKGROUND: Patients with an open abdomen after trauma or emergency surgery may benefit from reduced sedation and chemical paralysis. We studied the effect of attending surgeon experience on sedation depth and paralytic use, as well as enteral nutrition and time between laparotomies. METHODS: We performed an institutional review board-approved survey (Sedation Level after Emergent ExLap without Primary Fascial Closure) of the senior and active Eastern Association for the Surgery of Trauma membership using Qualtrics (Qualtrics, Inc, Provo, UT). We obtained 393/1,655 responses (23.7%). Spearman's rho was used for ordinal data, and multivariate logistic regression was used to adjust for trauma center level and presence of trainees in the relationship between surgeon experience and use of deep sedation. RESULTS: Surgeon experience was associated with deep sedation (Richmond Agitation and Sedation Score ≤-3, P = .001) and chemical paralysis (P = .001). Surgeon experience was associated with less concern about delirium and more concern for evisceration as the reason for sedation depth (P = .001) and for paralysis (P = .001). Using multivariate logistic regression, surgeon experience was associated with deep sedation (odds ratio 3.6 [95% confidence interval 1.3, 10.4], P = .017 for ≥20 years; odds ratio 3.5 [95% confidence interval 1.1, 10.4], P = .025 for 15-20 years). Trauma center level was also significant (odds ratio 7.2 for Richmond Agitation and Sedation Score ≤-3 [95% confidence interval 1.7, 31.0], P = .008 for level III/IV versus level I/II). Increased surgeon experience was associated with delay of commencement of enteral feeds until return of bowel function (P = .013). Few respondents indicated willingness to extubate or mobilize open abdomen patients. Experienced surgeons were likely to wait for a defined time rather than for normalization of resuscitation markers to perform the first takeback laparotomy (P = .047) and waited longer between subsequent laparotomies (P = .004). CONCLUSION: There were significant variations in practice among respondents based on the length of time since their last residency or fellowship, including variations that deviate from current best practice for management of patients with an open abdomen.

Biomechanical Analysis of Ligatures and Technique for Managing Drainage Tubes in Pediatric Glaucoma.

PURPOSE: Absorbable ligatures are often used with glaucoma drainage tubes to avoid early postoperative hypotony. We sought to measure the force required to ligate a drainage tube, and develop a modified technique to promote earlier release in pediatric patients, where plate encapsulation occurs more quickly than adults. METHODS: A precision digital force gauge was used to measure the tensile strength of several common ophthalmic sutures, and the necessary tensile force required to achieve tube ligation. A novel technique for tube ligation was devised to allow sutures as small as 10-0 to be effectively used. RESULTS: The mean tensile strengths of unknotted sutures varied from 55.50±8.50 g for 10-0 vicryl to 477±69 g for 6-0 chromic gut. The mean tensile force required to ligate a Baerveldt or Ahmed tube was 35.9±0.9 g. However, 9-0 or 10-0 vicryl could not be reliably used for ligation, because of breakage, unless a modified technique was used, wherein the tube was first stretched to reduce its thickness and diameter. DISCUSSION: Frictional forces inherent to knot tying make it unfeasible to reliably use 9-0 or 10-0 vicryl to ligate a drainage tube, despite the unknotted threads possessing apparently sufficient tensile strength. Our modified ligation technique overcomes this issue, allowing a wider range of suture choices, and the potential for achieving more rapid release in pediatric cases.

Securing extraocular muscles in strabismus surgery: effect of cautery on suture strength.

An experimental study was performed to evaluate quantitatively the effect of cautery on the tensile strength of sutures commonly used in strabismus surgery. This in vitro study was conducted in a controlled fashion using 6-0 polyglactin 910 suture, two different forms of cautery, and a precision digital force gauge. The results suggest that thermal electrocautery with a wire tip can substantially weaken or break 6-0 polyglactin threads only if direct contact is made, but bipolar cautery at typical ophthalmic surgical settings does not.

Securing extraocular muscles in strabismus surgery: biomechanical analysis of muscle imbrication and knot tying technique.

An experimental study was performed to quantitatively evaluate the tensile strength implications of two important steps in extraocular muscle surgery: muscle imbrication and knot configuration. The study was conducted in a controlled fashion using fresh ex vivo pig eyes with extraocular muscles attached and a precision digital force gauge. The study provides clinically translatable data to inform optimal surgical technique. The results suggest that imbrication of the muscle edge is most secure when the suture is looped around itself in a manner that allows it to be tightly cinched and locked and that granny knots possess similar tensile strength to square knots.

Suicide in the Elderly: A Multidisciplinary Approach to Prevention.

Suicide in the elderly is a growing problem. The elderly population is increasing, and elderly patients have multiple issues that place them at higher risk of suicidality. These issues include physical illnesses, mental illness, loss of functional status, isolation, and family, financial, and social factors. Access to firearms is another significant risk factor, because elderly patients are more likely to use firearms in suicide attempts; interventions to reduce firearms mortality may save lives. Tackling the difficult problem of suicide in the elderly may require a multidisciplinary, community-based series of interventions.

Securing extraocular muscles in strabismus surgery: laboratory analysis of biomechanical parameters related to the suture.

PURPOSE: To investigate the tensile properties of several components used to secure extraocular muscle to sclera in strabismus surgery to determine potential failure points. METHODS: A digital force gauge measured the tensile strength of intact or damaged 6-0 Vicryl suture (Ethicon, Somerville, NJ), as well as threads tied in a 2-1-1 or 2-1-1-1 surgeon's knot configuration. Human sclera was used to test the resistance to drag of knotted and unknotted 6-0 Vicryl suture thread through partial thickness sclera. Mean values were compared using a t test. RESULTS: The mean tensile strength of 6-0 Vicryl suture was 623.5 g, but it was markedly reduced by damage from the needle (P < 0.0001) or ophthalmic needle holder (P < 0.0001). The 2-1-1 knots broke at a mean force of 307.6 g, compared with 292.8 g for 2-1-1-1 knots (P = 0.84). Drag through a 2 mm scleral tunnel was 4.6 g, compared to 13.6 g for a 4 mm tunnel (P = 0.011). The force required to pull a knotted suture through a 4 mm scleral tunnel was 254 g for a 2-1-1 knot and 367 g for a 2-1-1-1 knot (P < 0.015). CONCLUSIONS: Although 6-0 Vicryl possesses adequate tensile strength for muscle fixation, thread damage from a needle or needle holder may cause serious losses in tensile strength. Knot-breaking strength is not significantly increased by adding a fourth throw. Frictional forces of the scleral tunnel are not sufficient to provide muscle stabilization, but the presence of a knot can provide substantial resistance to suture slip into the scleral tunnel.

Evidence-Based Care of Geriatric Trauma Patients.

The doubling of the geriatric population over the next 20 years will challenge the existing health care system. Optimal care of geriatric trauma patients will be of paramount importance to the health care discussion in America. These patients warrant special consideration because of altered anatomy, physiology, and the resultant decreased ability to tolerate the stresses imposed by traumatic insult. Despite increased risk for worsened outcomes, nearly half of all geriatric trauma patients will be cared for at nondesignated trauma centers. Effective communication is crucial in determining goals of care and arriving at what patients would consider a meaningful outcome.

Securing extraocular muscles in strabismus surgery: biomechanical analysis of knot-tying technique.

BACKGROUND: The safe and precise reattachment of extraocular muscles requires a technical approach that minimizes any opportunity for the muscle to slip intraoperatively or postoperatively while minimizing surgical risk. Biomechanical testing can provide important quantitative information about the tensile properties of different knot configurations that may inform surgical technique. METHODS: A precision digital force gauge was used to assess the tensile strength created by different knot tying techniques and configurations in human sclera using 6-0 polyglactin 910 suture. RESULTS: The mean tensile strengths of the first knot throw formed with either one, two, or three loops, with widely separated scleral tunnels, were 5 g, 10 g, or 27 g, respectively. When the scleral tunnels are closely spaced in a "cross-swords" fashion, the mean strength of a first throw made with two loops increased to 385 g. If a first throw with two conventional loops was cinched against one of the scleral tunnels or a reversed first loop is used, the mean tensile strength increased to 112 g or 381 g, respectively, even with widely spaced scleral tunnels. CONCLUSIONS: Proper cinching or minor modification of the first knot throw provides excellent tensile strength, even with short, widely spaced scleral tunnels, comparable to that achieved with the technically more demanding crossed swords technique. Conventional, noncinched first throws are prone to slip at low force when scleral tunnels are widely separated, though the resistance increases as the number of loops increases.

Securing extraocular muscles in strabismus surgery: biomechanical analysis of muscle imbrication.

An experimental study was performed to quantitatively evaluate the tensile strength of extraocular muscle imbrication as it relates to the positioning of the imbricating suture. The study was conducted in a controlled fashion using fresh ex vivo pig eyes with extraocular muscles attached and a precision digital force gauge. The study provides clinically translatable data to inform surgical technique regarding secure muscle imbrication. Results suggest that imbrications performed 0.5 mm or less from the cut muscle edge or 0.5 mm or less from the lateral margin may be prone to tensile failure.

Head, Neck, and Shoulder Injuries in Ice Hockey: Current Concepts.

Ice hockey is a fast-paced contact sport that is becoming increasingly popular in North America. More than 1 million men, women, and juniors are playing hockey in the United States and Canada. With players colliding forcefully with one another and with the boards surrounding the ice, injury rates are among the highest in all of competitive sports. Physicians caring for a hockey team should be aware of the more common injuries, involving the head, the neck, and the shoulder. In this review, we discuss evaluation and treatment of these hockey injuries, return to play, and, where applicable, prevention strategies.