Difficult mask ventilation: does it matter?

We discuss the relevance of finding a patient's lungs difficult to ventilate by facemask during the course of anaesthetic induction. In particular, we discuss the issue of whether it is advisable or unnecessary to check the ability to ventilate by facemask before administering a neuromuscular blocking agent. In the light of advances in supraglottic airway technology it has become possible to insert these devices very soon after induction and in a wider variety of patients. Similarly, the development of videolaryngoscopes and rapidly acting drugs such as rocuronium have raised the possibility of earlier, and possibly more successful, tracheal intubation, with the potential result that mask ventilation becomes redundant. However, we conclude by reaffirming its value in airway management strategies.

A call for a national transplant surgical quality improvement program.

The severity of illness in transplant patients and the complexity of transplant operations results in significant postoperative morbidity and mortality. Remarkable efforts have been made by transplant physicians to study and improve organ allocation, graft and patient survival, immunosuppression and the long-term management of post-transplant complications. Less effort has been spent studying the actual transplant operation and systems of acute transplant care. The National Surgical Quality Improvement Program (NSQIP) has provided a standardized approach to quality improvement and has demonstrated significant potential for a reduction in postoperative morbidity and mortality in other surgical disciplines. Medical centers are under increasing pressure to measure surgical quality and the nexus of transplant surgical quality improvement should not lie in the hands of CMS or JACHO, but rather it should be created and developed within the transplant community. The time has come for a national transplant surgical quality improvement program based on the NSQIP infrastructure. Such a proactive approach toward quality improvement from the transplant community is an excellent investment for patients, providers and health care payers.

Simultaneous posterior chamber intraocular lens implant combined with vitreoretinal surgery for intraocular foreign body injuries.

UNLABELLED: To evaluate the safety of simultaneous posterior chamber intraocular lens (IOL) implant combined with complex vitreoretinal surgery for ocular trauma due to intraocular foreign body (IOFB). METHODS: We undertook a retrospective analysis of 10 patients who had undergone simultaneous cataract extraction, vitreoretinal surgery, removal of IOFB and posterior chamber IOL implant, for ocular trauma due to IOFB. The visual outcome and complications were noted. The surgical procedure is described. RESULTS: Ten young, male patients were followed for 5-30 months post-operatively. The post-operative visual acuity in the operated eye remained the same or improved as compared with their pre-operative vision. Eight patients had a visual acuity of 6/9 or better. One patient developed post-operative infective endophthalmitis. Three patients had retinal detachment post-operatively. The IOL was stable in all patients. CONCLUSIONS: Simultaneous posterior chamber IOL implant with vitreoretinal surgery is safe in selected cases of severe ocular trauma due to IOFB. It allows early visual rehabilitation of young, working patients.

Trabeculectomy augmented with mitomycin C application under the scleral flap.

AIM: The authors investigated the safety and intraocular pressure (IOP) lowering effectiveness of trabeculectomy augmented with mitomycin C application beneath the scleral flap, and assessed the influence of preoperative risk factors on the surgical outcome. METHODS: A retrospective study of 72 consecutive high risk eyes undergoing trabeculectomy with adjunctive mitomycin C (0.2 mg/ml) applied under the scleral flap for 5 minutes was performed. Each eye was ascribed a score based on the number of preoperative risk factors, and categorised into one of three risk factor groups. Success was described as unqualified where IOP was < or = 21 mm Hg without medication and qualified where antiglaucomatous therapy was required to maintain it at such a level. A life table analysis of IOP control was calculated. RESULTS: The mean IOP (SD) fell from a preoperative level of 28.4 (6.9) to a level of 16.63 (8.06) mm Hg at the last follow up (paired Student's t test: p < 0.0001). Fifty two eyes (72%) were classed as unqualified successes. The survival rates did not differ significantly between different risk factor groups (log rank test: chi 2 = 0.967, p > 0.1). The incidence of postoperative complications compared favourably with reports of mitomycin C application between Tenon's capsule and the undissected scleral bed. CONCLUSION: The results illustrate that mitomycin C applied beneath the scleral flap during trabeculectomy in high risk eyes is associated with a success rate comparable to other modes of application. The incidence of potentially serious complications such as conjunctival wound leak and prolonged hypotony was lower than previously published data reporting sub-Tenon's administration of mitomycin C. The number and nature of preoperative risk factors do not appear to influence the surgical outcome. A possible mechanism of action is proposed.

Combined chemoreduction and adjuvant treatment for intraocular retinoblastoma.

OBJECTIVE: The purpose of the study is to investigate chemoreduction and adjuvant treatment (AT) for retinoblastoma and its effect on complete retinal tumor control, vitreous seed control, and subretinal seed control. DESIGN: The study design was a prospective, nonrandomized clinical trial. PARTICIPANTS: There were 130 intraocular retinoblastomas in 52 eyes of 32 consecutive patients observed for at least 1 year after initiation of treatment. INTERVENTION: Treatment with chemoreduction using vincristine, etoposide, and carboplatin (VEC) and adjuvant treatment (+ AT) (cryotherapy, laser photocoagulation, thermotherapy, chemothermotherapy, plaque radiation therapy, or external beam radiation therapy) were assessed. MAIN OUTCOME MEASURES: The effect of chemoreduction for 6 cycles (VEC x 6) versus fewer than 6 cycles (VEC x <6) on retinoblastoma control was analyzed. Furthermore, the impact of adjuvant treatment (+ AT) versus no adjuvant treatment (no AT) on retinoblastoma control was analyzed. RESULTS: Retinal tumors showed favorable initial regression with chemoreduction. Adjuvant treatment was applied to 93% of the retinal tumors after chemoreduction and only 2% recurred over the mean follow-up of 17 months (range 13-27 months). Vitreous seeds and subretinal seeds showed initial regression and often complete disappearance with chemoreduction. In those eyes with seeds before treatment, the addition of AT to VEC for 6 cycles decreased the vitreous seed recurrence from 75% to 0% (P = 0.04) and also decreased the subretinal seed recurrence from 67% to 0% (P = 0.003). More important, when considering that enucleation or external beam radiation therapy was the only other treatment option for these 52 eyes, the authors were successful in avoiding these methods in 42% of cases. Of the 36 eyes classified as Reese-Ellsworth group 5, there was 78% ocular salvage, and external beam radiation therapy was avoided in 25% of these eyes. There was a 100% ocular salvage in the group 5 eyes that received VEC for 6 cycles + AT to retinal tumors and seeds. CONCLUSIONS: Chemoreduction and AT to intraocular retinoblastoma and its seeds provides good retinal tumor control, even in eyes with advanced disease. Chemoreduction alone generally is not adequate to achieve complete tumor seed control. Cautious follow-up of affected patients is recommended because the risk for recurrent vitreous and subretinal seeds is substantial and proper treatment is critical for salvaging the eye.

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.

Transpupillary thermotherapy in the management of choroidal melanoma.

BACKGROUND: Several methods of treatment have been used for choroidal melanoma. The purpose of this report is to evaluate the effectiveness of transpupillary thermotherapy using near-infrared radiation to treat choroidal melanoma. METHODS: A prospective study was conducted to evaluate the clinical features, treatment results, and complications of patients with choroidal melanoma who were treated with transpupillary thermotherapy delivered over one to four sessions and followed for at least a 6-month period. All treated tumors had either documentation of growth or ophthalmoscopic risk factors for future growth and/or metastasis. RESULTS: There were 17 patients with choroidal melanoma treated with transpupillary thermotherapy. The mean tumor size before treatment was 6.6 mm in base and 3.0 mm in thickness. The tumor margin was a mean of 2.3 mm from the optic disc and 2.7 mm from the foveola. Seven tumors (41%) touched the optic disc margin and three (18%) were under the fovea. The tumor responded to treatment in all patients, with a decrease in thickness and resolution of associated subretinal fluid. At a minimum of 6 months of follow-up, the mean tumor thickness was 1.7 mm, and the tumor site was a residual chorioretinal scar with partial visibility of the sclera in all patients. Despite the proximity to the optic disc and foveola, the final visual acuity was the same or improved in ten eyes (59%) and decreased in seven (41%). The improved vision was due to resolution of subfoveal fluid, whereas the decreased vision was primarily the result of treatment in the fovea with ultimate retinal vascular occlusion or preretinal traction. Although long-term follow-up is not yet available, there were no patients with tumor recurrence or tumor metastases. CONCLUSIONS: This preliminary study demonstrates that transpupillary the thermotherapy appears to be an effective treatment for selected small choroidal melanomas and may be a particularly useful modality for treating those tumors near the foveola and optic disc. Longer follow-up is necessary to assess for local recurrence and the impact of treatment on survival.

Reliability of visual acuity in children with reduced vision.

We examined the test-retest reliability of visual acuity in 18 children referred to the Hospital Eye Service with reduced vision. Unaided distance acuities were recorded, using logarithmically scaled letter charts, on two occasions separated by an interval of one week during which no clinical intervention took place. Coefficients of repeatability were found to be +/- 0.25 and +/- 0.21 log units in left and right eyes, respectively. A further analysis of 14 subjects' data each of whom had one eye with consistently poorer acuity in both test sessions yielded coefficients of repeatability of +/- 0.15 and +/- 0.22 log units in, respectively, the better and poorer eyes. The reliability of visual acuity recorded in the better eye closely approximates to that previously found in normal adults, whilst that of the poorer eye appears more comparable to that of adult clinical populations.

Day-case trabeculectomies: safety and efficacy.

A comparison of 90 day-case and 102 in-patient trabeculectomies is presented. There was no statistically significant difference in the incidence of post-operative hyphaema (Chi-squared test p = 0.84), shallow anterior chamber (p = 0.46), flat bleb (p = 0.84) or hypotony (p = 0.87) between the two groups. Casualty attendances, readmissions and further surgery in the postoperative period were seen with similar frequency in each group. Intraocular pressure control three months following surgery was not compromised by undergoing the procedure as a day-case (p = 0.29). This study demonstrates the safety and efficacy of ambulatory filtration surgery.

Imaging of optic disc drusen: a comparative study.

The choice of imaging technique to identify the presence of optic disc drusen has not been well established. We performed computed tomography (CT), magnetic resonance imaging (MRI), fundus fluorescein angiography and B-mode ultrasonography (B-USG) on four patients with optic disc drusen as the sole identifiable pathological process. CT, MRI and examination for autofluorescence demonstrated the presence of drusen in only one case each. B-USG showed characteristic features of optic disc drusen in all cases. We suggest that B-USG, a non-invasive and inexpensive technique, may be the imaging method of choice in identifying the presence of disc drusen.

General practice referral letters to a regional ophthalmic accident and emergency department.

A significant proportion of patients seen in ophthalmic Accident and Emergency departments are referred by other medical practitioners. Two hundred and twenty-six referral letters from general practitioners to the Accident and Emergency Department of a large regional ophthalmology centre were examined. Information that was poorly recorded in the referral letters included social and personal background details, examination findings, management plans and investigation results. Analysis revealed that 50-70% of referrals did not constitute accidents or urgent conditions and could have been more properly assessed within usual secondary referral outpatient clinics. Ophthalmic Accident and Emergency is therefore providing a service for general practitioner referrals in excess of its defined function. The impact on purchaser/provider arrangements if appropriate redirection to outpatients were to occur would be significant.

Previously undiagnosed lymphoma presenting as recurrent dacryocystitis.

Lymphoma occurring in the lacrimal sac is uncommon and usually occurs in patients with known systemic disease. We report the case of an 82-year-old woman who presented with recurrent right dacryocystitis and a mass in the left lower eyelid. The results of the biopsy of the eyelid and fine-needle aspiration of the swelling arising from the lacrimal fossa demonstrated low-grade B-cell non-Hodgkin's lymphoma. This unusual presentation and the histopathological features are described.

Extensive visual loss with topical facial steroids.

Steroid creams applied topically to the skin are routinely used in the treatment of many dermatoses. Their use on the face in severe atopic eczema is relatively common. We report a series of three patients who whilst using topical facial steroids developed advanced glaucoma. A further two cases of ocular hypertension secondary to topical facial steroids are also described. This is the first series of cases to be reported demonstrating the potentially blinding complications of topical facial steroids. Recommendations are made with regard to screening such patients for glaucoma.

A case of polycythaemia vera presenting with intramuscular chest wall haematoma.

A 40 year old male, previously well, presented with a posterior chest wall haematoma. Computerized tomography and ultrasound showed this to be intramuscular. Haematological indices were consistent with a diagnosis of polycythaemia vera. The haematoma and indices responded to hydroxyurea and venesection. This rare presentation of polycythaemia vera in a young person is described and the haemorrhagic complications of polycythaemia vera discussed.