Bilateral ocular panadnexal mass as initial presentation of systemic blastoid variant of mantle-cell lymphoma.

A 66-year-old man developed a slowly enlarging, bilateral, painless, periorbital, and orbital swelling with ptosis, nonaxial proptosis, chemosis, exposure keratopathy, and decreased vision in both eyes. He had fever, night sweats, and weight loss (B-symptoms), along with lymphadenopathy and elevated serum lactate dehydrogenase, with no prior history of lymphoma. A transpalpebral incisional biopsy revealed a rare case of mantle-cell lymphoma of blastoid variant, stage IVB. The main immunophenotype characteristics were cyclin D1+, CD5+, CD10-, CD23-, Bcl-6-/+, and a high (up to 80%) Ki-67 proliferation index. Following an excellent response to the immune-chemotherapy treatment plan, all ocular adnexal lymphoma manifestations disappeared completely; however, 13 months after the initial presentation, there was a recurrence of the disease with rapid worsening and death. The blastoid variant of mantle cell lymphoma, a rare subtype of mantle-cell lymphoma, is a highly aggressive neoplasm, ultimately having a fatal outcome. As the initial manifestation of the disease, ocular adnexal region blastoid variant of mantle-cell lymphoma is an exceptional event, with only one previous case reported.

Comparison of postoperative pain and satisfaction after dacryocystorhinostomy in patients operated on under local and general anesthesia.

BACKGROUND: There has been only 1 study on postoperative pain after external dacryocystorhinostomy (DCR) that compared pain between 2 groups of patients; 1 group received local anesthesia and the other received general anesthesia. To further characterize the relationship between these 2 types of anesthesia and postoperative pain, we designed a study in which a single patient received these 2 different anesthesia modalities for a short interval on 2 different sides. MATERIAL/METHODS: There were 50 participants in this study. External DCR was performed on the same participant on both sides using local anesthesia on 1 side and general anesthesia on the other. Postoperative pain was measured using the visual analogue scale (VAS), and localization and timing of pain were reported by the participants. Postoperative nausea and vomiting (PONV) were documented if present. RESULTS: Pain levels were significantly higher with general anesthesia 3 hours post-surgery, and 6 hours post-surgery the pain remains higher following general anesthesia but is borderline insignificant (p=0.051). However, 12 hours post-surgery, there is no significant difference in the pain level (p=0.240). There was no significant difference in the localization of pain with local and general anesthesia. Postoperative nausea is significantly more frequent after general anesthesia, and vomiting only occurs with general anesthesia. Local anesthesia was preferred by 94% of the participants (47 out of 50). CONCLUSIONS: The vast majority of patients in our study who have undergone both GA and LA DCR would choose LA again, providing a compelling case for use of the LA technique.

Cervical plexus block versus general anesthesia in carotid surgery: single center experience.

INTRODUCTION: Carotid endarterectomy may be performed under general (GA) or regional anesthesia (RA). The aim of this study was to evaluate the influence of anesthetic techniques on perioperative mortality and morbidity in patients undergoing carotid surgery. MATERIAL AND METHODS: This prospective study included 1098 consecutive patients operated on between 2003 and 2009 (773 underwent cervical plexus block and 325 underwent general anesthesia). RESULTS: There were 6 deaths, 3 (0.9%) after GA and 3 (0.4%) after RA (p = 0.272). Neurological complication rates were not significantly different (GA 2.1% vs. RA 1.1%, p = 0.212). Incidence of myocardial infarction was similar (GA 0.31% vs. LA 0.39%, p = 0.840). Shunt placement rate was the same in both groups, 11.1%. Total operating time and carotid clamping time were significantly shorter in RA patients (RA: 92 min vs. GA: 106 min; p < 0.001 and RA: 18 min vs. GA: 19 min; p = 0.040). There was no significant difference in number of reinterventions (RA: 1.0% vs. GA: 0.6%; p = 0.504). Pulmonary complications were common in the GA group (RA: 0 vs. GA 0.9%; p = 0.007). Time to first postoperative analgesic was significantly shorter in the GA group (RA: 226 min vs. GA: 139 min; p < 0.001). CONCLUSIONS: Type of anesthesia does not affect the outcome of surgical treatment of carotid disease. However, it should be stressed that fewer respiratory complications, later requirement for first postoperative analgesic, and an awake patient who can continue oral therapy early after surgery, give priority to regional techniques of anesthesia.

Pain during external dacryocystorhinostomy with local anesthesia.

BACKGROUND: External dacryocystorhinostomy (DCR) is often performed under local anesthesia (LA) without adequate knowledge of the pain experienced by the patient. MATERIAL/METHODS: We subdivided our surgical technique into stages easily understood by the patients (introducing cotton tipped applicators, performing parabulbar injection, creating the incision, bone cracking (opening the ostium), manipulating the nose, intubating, closing the wound, and packing with gauze). A total of 50 patients ranging in age from 31 to 83 years of age (63.64±9.64) underwent external DCR. Each patient was asked 30 minutes after surgery to indicate the intensity of pain experienced at each stage of the surgery and during intramuscular (i.m.) injection of an antibiotic using a visual analog scale (VAS). RESULTS: Analysis of the VAS-based pain scores indicated 3 statistically equal occurrences of pain coinciding with the opening of the ostium, and receiving both parabulbar anesthetic and i.m. antibiotic injections. CONCLUSIONS: The level of pain experienced during the most unpleasant stage of external DCR (ostium opening) was similar to the pain experienced from an i.m. injection. Patients can be informed that pain during external DCR with local anesthesia is comparable to receiving an i.m. gluteal injection.

Perioperative fluid balance in patients with heart failure.

Careful assessment of fluid balance is required in the perioperative period since appropriate fluid therapy is essential for successful patient outcomes. Volume status is frequently assessed by different hemodynamic variables that could be targeted as endpoints for fluid therapy and resuscitation. Goal directed fluid therapy is a method for correction of fluid status in individual patients that includes invasive hemodynamic monitoring and aggressive perioperative correction of hemodynamics. Heart failure is a syndrome of ventricular dysfunction. It is associated with a variety of patophysiological disturbances, hydro-electrolyte balance disorders and compensatory mechanisms. Heart failure indicates careful assessment of fluid balance in perioperative period. The aim of this article is to describe actual techniques of hemodynamic measurements as well as main principles of fluid therapy to maintain hydro-electrolyte balance in patients with heart failure.

The addition of fentanyl to local anesthetics affects the quality and duration of cervical plexus block: a randomized, controlled trial.

BACKGROUND: Cervical plexus block is frequently associated with unsatisfactory sensory blockade. In this randomized, double-blind, placebo-controlled trial, we examined whether the addition of fentanyl to local anesthetics improves the quality of cervical plexus block in patients undergoing carotid endarterectomy (CEA). METHODS: Seventy-seven consecutive adult patients scheduled for elective CEA were randomized to receive either fentanyl 1 mL (50 microg) or saline placebo 1 mL in a mixture of 10 mL bupivacaine 0.5% and 4 mL lidocaine 2% for deep cervical plexus block. Superficial cervical plexus block was performed using a mixture of 10 mL bupivacaine 0.5% and 5 mL lidocaine 2%. Pain was assessed using the verbal rating scale (0-10; 0 = no pain, 10 = worst pain imaginable), and propofol in 20-mg IV bolus doses was given to patients reporting verbal rating scale >3 during the procedure. Rescue medication consumption during surgery and analgesia requirements over the next 24 hours, as well as onset of sensory blockade, were recorded. A P value <0.05 was regarded as statistically significant. RESULTS: Fewer patients in the fentanyl group (4 of 38, 10.5%) required propofol compared with the placebo group (26 of 39, 66.7%; P < 0.001). In comparison with the placebo group, the fentanyl group consumed less propofol (median 0 [0-60] vs 60 [0-160] mg, respectively; P < 0.001), required postoperative analgesia less frequently (22 of 38 patients, 57.9% vs 35 of 39 patients, 89.7%, respectively; P = 0.002), and requested the first analgesic after surgery later (median 5.8 [1.9-15.6] vs 3.1 [1.0-11.7] hours, respectively; P < 0.001), whereas the onset time of sensory blockade was similar in both groups (median 12 [9-18] vs 15 [9-18] minutes, respectively; P = 0.18). CONCLUSIONS: The addition of fentanyl to local anesthetics improved the quality and prolonged the duration of cervical plexus block in patients undergoing CEA.

[Patient suitability for cataract surgery under local anesthesia]. / Podobnost bolesnika za operaciju katarakte u lokalnoj anesteziji.

In the past two decades local anesthesia has emerged as a reliable, safe and cost-effective first choice for cataract surgery in adults. However, the technique is not totally devoid of inherent risks, and requires not only an experienced and well-trained surgeon but also a cooperative patient. Thus, only the patient who is able to communicate, lie still in the supine position, and tolerate their face being covered by a drape is a suitable candidate for local anesthesia. In addition, the preoperative assessment should include particular features of the globe and orbit which may affect the operation as well as a history of allergy to local anesthetics. Finally, it is important to respond to patient preferences and wishes. A careful, patient selection for local anesthesia reduces the risk of surgical cancellation or delay and is essential for patient satisfaction and a successful visual outcome following cataract surgery.

Management of right ventricular myxoma diagnosed at full-term pregnancy.

BACKGROUND: The diagnosis of cardiac myxoma in a woman at term pregnancy is extremely rare. Prompt surgical removal of the tumor is generally advised because of the high risk of potentially fatal complications. On the other hand, cardiac surgery during pregnancy is a delicate procedure which carries a significantly increased maternal risk when performed at or immediately after delivery. CASE REPORT: A previously healthy 23-year-old woman at 38 weeks' gestation was diagnosed with myxoma in the right ventricle on the basis of clinical and echocardiographic examination. The patient went into labor while awaiting urgent Cesarean section. Severe right heart failure developed which completely resolved after delivery of a healthy baby. After balancing the risks of uncontrolled uterine bleeding associated with cardiopulmonary bypass against those of thromboembolism and valvular obstruction associated with the presence of myxoma itself, emergency cardiac surgery was rejected. The tumor was successfully removed five days after Cesarean section and the patient recovered uneventfully. CONCLUSIONS: Cesarean section should be done as soon as possible. Considering the increased maternal morbidity and mortality when delivery is immediately followed by cardiopulmonary bypass, urgent cardiac surgery may be more reasonable than an emergency one for a patient who is clinically stable and at low risk of thromboembolism.

[Retrobulbar diameter of optic nerve in glaucoma].

INTRODUCTION: The ultrasound diagnostics of the optic nerve includes the analysis of the optic nerve disc (PNO) and measuring of its retrobulbar diameter. With B-scan, by Schraeder's method, it is possible to measure very precisely the optic nerve, the pial diameter, the normal values for the pial diameter being 2.8-4.1 mm. In glaucoma, the disease that is most frequently associated with higher intraocular pressure, there comes the destruction of nerve fibres, which can be visualized as the excavation of the optic nerve disc. OBJECTIVE: In this paper, we were interested in finding whether in glaucoma, and in what phase of the disease, the optic nerve starts growing thinner. Aware of many forms of this very complex disease, we were interested in knowing if the visualization of excavation on the optic nerve disc is related to diminishing of the pial diameter of the retrobulbar nerve part. METHODS: There were treated the patients who had already had the diagnosis of glaucoma and the visualized excavation of the optic disc of various dimensions. Echographically, there was measured the thickness of the retrobulbar part of the optic nerve and the finding compared in relation to the excavation of the optic disc. RESULTS: In all eyes with glaucoma, a normal size of the retrobulbar part of the optic nerve was measured, ranging from 3.01 to 3.91 mm with the median of 3.36 mm. Also, by testing the correlation between the thickness of the optic nerve and the excavation of the PNO, by Pearson test, we found that there was no correlation between these two parameters (r = 0.109; p > 0.05). CONCLUSION: In the patients with glaucoma, the retrobulbar part of the optic nerve is not thinner (it has normal values), even not in the cases with a totally excavated optic disc. There is no connection between the size of the PNO excavation and the thickness of the retrobulbar part of the optic nerve.

[Endotracheal intubation without the use of muscle relaxants in patients with myasthenia gravis].

INTRODUCTION: Although muscle relaxants have been widely used to facilitate endotracheal intubation, the administration of these drugs in myasthenic patients may be associated with adverse events. MATERIAL AND METHODS: After obtaining Institutional Reviewing Board approval and informed, patient consent, 30 patients with myasthenia gravis were enrolled in a prospective, double-blind, randomized clinical trial. We compared intubating conditions (ease of laryngoscopy, vocal cords, cough, jaw relaxation, limb movement) following fentanyl 2 mg/kg and propofol 2 mg/kg (group PRO, n = 15) vs fentanyl 2 mg/kg and sevoflurane 5% in a 1:2 mixture of oxygen and nitrous oxide (group SEVO, n = 15). The statistical analysis was performed using Student's t test and Chi-quadrate test, p < 0.05 being regarded as significant. RESULTS: The overall intubating conditions were excellent in 67% of patients in the group PRO vs 80% of patients in the group SEVO (p > 0.05). One patient in each group had clinically unacceptable conditions for intubation. The mean intubation score was 5.7 +/- 1.0 in the group PRO vs 5.9 +/- 0.9 in the group SEVO (p > 0.05). Three patients receiving propofol and one patient receiving sevoflurane had mild hoarseness after the surgery (p > 0.05). CONCLUSION: Both propofol and sevoflurane, supplemented with fentanyl, provide good intubating conditions without the use of muscle relaxants in patients with myasthenia gravis.

[Keratometric measurements of cornea in first three years of life in children with congenital cataract].

INTRODUCTION: Keratometry is a measurement curvature of the central 2-3 mm of the anterior cornea and main meridians (horizontal and vertical) and secondary calculation of the full optic power of the cornea. Congenital cataract is opacity of the lens that a neonate is coming to life with. OBJECTIVE: To measure a real curvature of the horizontal and vertical meridians of the cornea in the babies with and without congenital cataract (mostly with diseases of the eye adnexes) in one or both eyes, and to compare it. METHOD: We examined 30 patients (60 eyes) with congenital cataract in one or both eyes (48 eyes were with and 12 eyes without congenital cataract), the study group, and 15 patients (30 eyes) with diseases of the eye adnexes, the control group. All patients were hospitalized at our clinic in the period 2002-2004, and were 2-36 months old. RESULTS: Keratometric measurements of the cornea in the study group: the eyes with congenital cataract 40-45.5 D, the eyes without congenital cataract 40-42.8 D. Keratometric measurements of the cornea in the control group were 39.9-45 D. CONCLUSION: There was no statistically significant difference between the horizontal and vertical meridian measurements of the cornea's curvature neither in the study nor in the control group.

[Axial length of the eye in the first three years of life in children with congenital cataract in one or both eyes].

INTRODUCTION: Ultrasound has an important role in the diagnostics of the posterior segment of the eye, when clinical examination is not possible. One of problems is congenital cataract. Using ultrasound biometry it is possible to measure the axial length of the eye in all ages and axial growth from the very beginning to its termination. OBJECTIVE: To ratify growth of the infant's eye with and without congenital cataract, and to determine the accuracy of ultrasound measuring with and without general anaesthesia. METHOD: In our study we analyzed 30 patients (48 eyes) who had congenital cataract in one or both eyes (observed group) and 20 patients (40 eyes) in whom no eye disease was diagnosed (control group). RESULTS: The observed group of 30 patients (48 eyes) with congenital cataract was divided according to age into three subgroups: 1) 4-12 months, 11 patients, 18 eyes; II) 13-24 months, 7 patients, 11 eyes; III) 25-36 months, 12 patients, 19 eyes. In control group we analyzed 20 patients (40 eyes) without congenital cataract. These patients were also divided, according to age, into three subgroups: 1) 2-12 months, 5 patients, 10 eyes; II) 13-24 months, 6 patients, 12 eyes; III) 25-36 months, 9 patients, 18 eyes. CONCLUSION: Comparing the average axial lengths of the eye in the first, second and third year of life between the observed and control groups, we did not find any statistical significance in the obtained values. When determining the accuracy of the ultrasound measuring of the axial length of the eye in the observed group, we found no statistical significance between the determined values weather the measurements were done with or without general anaesthesia (p>0.05).

Emergence delirium in children: many questions, few answers.

The introduction of a new generation of inhaled anesthetics into pediatric clinical practice has been associated with a greater incidence of ED, a short-lived, but troublesome clinical phenomenon of uncertain etiology. A variety of anesthesia-, surgery-, patient-, and adjunct medication-related factors have been suggested to play a potential role in the development of such an event. Restless behavior upon emergence causes not only discomfort to the child, but also makes the caregivers and parents feel unhappy with the quality of recovery from anesthesia. Although the severity of agitation varies, it often requires additional nursing care, as well as treatment with analgesics or sedatives, which may delay discharge from hospital. To reduce the incidence of this adverse event, it is advisable to identify children at risk and take preventive measures, such as reducing preoperative anxiety, removing postoperative pain, and providing a quiet, stress-free environment for postanesthesia recovery. More clinical trials are needed to elucidate the cause as well as provide effective treatment.

Long-term outcome of strabismus and ptosis surgery in a mother and daughter with congenital fibrosis of extraocular muscles.

BACKGROUND: Congenital fibrosis of extraocular muscles (CFEOM) is a very rare congenital condition, characterized by variable amounts of restriction of the extraocular muscles, with or without ptosis. The aim of this report was to describe a severe, atypical, exposure-induced corneal stromal lysis in two patients. CASE REPORT: A mother and a daughter with a severe CFEOM were presented. The surgery of both extraocular muscles and ptosis led to a fair outcome in mother even 30 years after, and a very good outcome in daughter 4 years after the treatment. CONCLUSION: Though frequently challenging and dissapointing the outcome of surgery of both extraocular muscles and ptosis in CFEOM can be favorable even in rather severe cases. To the best of our knowledge, the atypical keratolysis we described has not been highlighted in the literature on CFEOM so far.

Pain associated with carotid artery surgery performed under carotid plexus block: preemptive analgesic effect of ketorolac.

Carotid artery surgery (CAS) performed under cervical plexus block is frequently associated with significant intra- and postoperative pain. To evaluate whether preoperative administration of ketorolac may improve analgesia in this type of surgery, 80 patients scheduled for CAS under cervical plexus block were randomly allocated to receive intravenously either 30 mg of ketorolac or placebo 30 minutes before surgery. Verbal rating scale pain scores during surgery and 3 and 6 hours after surgery, the number of patients requiring additional analgesia, and the total analgesic consumption both during and within 6 hours after surgery were significantly lower, whereas the time to first postoperative analgesia was significantly shorter in the ketorolac group than in the control group. The results of this prospective, randomized, double-blind study show that a single 30 mg dose of ketorolac administered intravenously 30 minutes before surgery reduces intraoperative pain and preempts postoperative pain in patients undergoing CAS under carotid plexus block.