Effects of Smoking on Central Corneal Thickness and the Corneal Endothelial Cell Layer in Otherwise Healthy Subjects.

OBJECTIVES: The effects of smoking on central corneal thickness (CCT), corneal endothelial cell density (ECD), and morphology were evaluated in otherwise healthy subjects. METHODS: The study included 103 current smokers and 106 healthy nonsmoking subjects without any eye disease apart from refractive errors. Endothelial cell density, percentage of hexagonality, and coefficient of variation (CV) in cell size were measured using noncontact specular microscopy. Central corneal thickness was measured by ultrasound pachymetry. RESULTS: The mean age of participants in the nonsmoker group was 31.4 ± 5.1 years (18-60) and 33.0±9.1 years (18-58) in the current smoker group. The mean CCT value was 523.7±34 µm in the nonsmoker group and 518.5±37 µm in the smoker group. The mean ECD, CV, and percentage of hexagonality values were 2,881±293.7 cells per square millimeter, 32.5±6%, and 56.6±11% in the nonsmoker group, and 2,681±323.9 cells per square millimeter, 33.4±5%, and 55.5±10% in the smoker group, respectively. Although there was no difference between the groups in terms of CCT, CV, and percentage of hexagonality values, a significant difference was determined in the case of ECD values[ZERO WIDTH SPACE][ZERO WIDTH SPACE] (P<0.001). The smoker group comprised 67 light smokers (65.0%) and 36 (35.0%) heavy smokers. Between these groups, there was no statistically significant difference in the mean values of CCT, ECD, CV, and the percentage of hexagonality. CONCLUSIONS: Although cigarette smoking has no effect on cell polymorphism and polymegethism, the results suggest that smoking reduces endothelial cell count.

In-Hospital Bleeding in Elderly Patients With Acute Coronary Syndrome: Are Potent Antiplatelet Agents Safe?

Despite implementation of new interventional techniques and therapeutic advances, elderly patients with acute coronary syndrome (ACS) continue to be susceptible to in-hospital bleeding compared with younger ones. Thus, we investigated the incidence of in-hospital bleeding events and associated risk factors in elderly (≥ 75°years) ACS patients. We also wanted to define the bleeding sites, characteristics, and associated mortality. Bleeding Academic Research Consortium (BARC) classification type 2, 3, or 5 was used to define bleeding events. Overall, 539 patients were included in the study (mean age: 82.5 ± 4.8°years; 282 (52.3%) females). Of these patients, 69 (12.8%) developed in-hospital bleeding. Factors that were independently related with in-hospital bleeding were age (odds ratio (OR): 1.08; 95% confidence interval (CI): 1.011.14, P = .01), acute kidney injury (OR: 3.66; 95% CI: 2.016.69; P < .01), tirofiban (OR: 4.43; 95% CI: 1.7810.99; P < .01), and ticagrelor (OR: 1.93; 95% CI: 1.013.73; P = .04) administration. The urinary tract was the most frequent bleeding site, followed by femoral arteries. In conclusion, ticagrelor and tirofiban should be used with caution in elderly ACS patients.

Serum VEGF-C levels as a candidate biomarker of hypervolemia in chronic kidney disease.

Attaining and maintaining optimal "dry weight" is one of the principal goals during maintenance hemodialysis (MHD). Recent studies have shown a close relationship between Na load and serum vascular endothelial growth factor-C (VEGF-C) levels; thus, we aimed to investigate the role of VEGF-C as a candidate biomarker of hypervolemia. Physical examination, basic laboratory tests, N-terminal pro b-type natriuretic peptide (NT-ProBNP), echocardiography, and bioimpedance spectroscopy data of 3 groups of study subjects (euvolemic MHD patients, healthy controls, and hypervolemic chronic kidney disease [CKD] patients) were analyzed. Research data for MHD patients were obtained both before the first and after the last hemodialysis (HD) sessions of the week. Data of 10 subjects from each study groups were included in the analysis. Serum VEGF-C levels were significantly higher in hypervolemic CKD versus in MHD patients both before the first and after the last HD sessions (P = .004 and P = .000, respectively). Healthy controls had serum VEGF-C levels similar to and higher than MHD patients before the first and after the last HD sessions of the week (P = .327 and P = .021, respectively). VEGF-C levels were correlated with bioimpedance spectroscopy results (r 0.659, P = .000) and edema (r 0.494, P =0.006), but not with ejection fraction (EF) (r -0.251, P = .134), blood pressures (systolic r 0.037, P = 0.824, diastolic r -0.067, P = .691), and NT-ProBNP (r -0.047, P = .773). These findings suggest that serum VEGF-C levels could be a potential new biomarker of hypervolemia. The lack of correlation between VEGF-C and EF may hold a promise to eliminate this common confounder. Further studies are needed to define the clinical utility of VEGF-C in volume management.

The effects of remifentanil and esmolol on increase in intraocular pressure due to laryngoscopy and tracheal intubation: a double-blind, randomized clinical trial.

PURPOSE: This study aimed to compare the effects of remifentanil and esmolol on the elevation of intraocular pressure (IOP) and hemodynamic response. METHODS: After approval of the institutional Ethics Committee and obtaining informed consent, 60 adult patients with American Society of Anesthesiologists I-II status undergoing elective, nonophthalmic surgery were included in the study. Exclusion criteria were preexisting eye disease, neuromuscular disease, esophageal reflux, hiatus hernia, allergy to any of the study drugs, and the use of ß-blockers, diuretics, or other antihypertensive agents. The patients were randomized into 2 groups by using the sealed-envelope method, as follows: group E (esmolol) and group R (remifentanil). A single intravenous dose of esmolol (0.5 mg/kg) or remifentanil (1 µg/kg) just before induction agents were given to patients in groups E and R, respectively. IOP, heart rate (HR), and mean arterial pressure (MAP) values were recorded before intubation and at 1, 3, 5, and 10 minutes after intubation. RESULTS: The IOP decrease in group R was statistically significant compared with group E (P<0.01). HR values at 10 minutes after intubation were significantly decreased in group E compared with group R (P<0.05). There was no significant difference in MAP values between the groups. CONCLUSIONS: It was concluded that remifentanil is more effective than esmolol in preventing IOP elevation related to laryngoscopy and tracheal intubation, while there is no significant difference between the 2 agents in terms of HR and MAP.

Limbal relaxing incisions for primary mixed astigmatism and mixed astigmatism after cataract surgery.

PURPOSE: To evaluate the effect of limbal relaxing incisions (LRIs) in the treatment of primary mixed astigmatism and mixed astigmatism after cataract surgery. SETTING: Department of Ophthalmology, Inönü University, Malatya, Turkey. METHODS: Limbal relaxing incisions were performed to correct astigmatism in 37 eyes of 26 patients with mixed astigmatism. Twenty-four eyes had primary astigmatism, and 13 eyes had astigmatism after cataract surgery. The length, number, and depth of the incisions were determined using the Gills and Gayton nomogram. The manifest refractive astigmatism was measured preoperatively and 1 day, 1 week, and 1, 3, 6, and 12 months postoperatively. Surgically induced astigmatism using the vector method, preoperative and postoperative uncorrected visual acuity (UCVA), and best spectacle-corrected visual acuity (BSCVA) were evaluated. Follow-up was at least 6 months in all cases. RESULTS: The mean preoperative and postoperative refractive astigmatism was 3.31 diopters (D) +/- 1.50 (SD) and 1.59 +/- 1.28 D, respectively (P <.001). The mean absolute change in refractive astigmatism was 1.72 +/- 0.81 D. No patient lost lines of UCVA or BSCVA. The safety index was 1.21 and the efficacy index, 0.88. The mean preoperative and postoperative UCVA was 0.29 +/- 0.22 and 0.54 +/- 0.31, respectively (P =.0001) and the mean BSCVA, 0.61 +/- 0.30 and 0.74 +/- 0.30, respectively (P =.0001). The mean vectorial magnitude was 2.32 +/- 1.36 D at the last follow-up. There were no serious postoperative complications. CONCLUSION: Limbal relaxing incisions are a simple, safe, and effective method to correct primary mixed astigmatism and mixed astigmatism after cataract surgery.

Significance of epidermoid formations in the middle ear in fetuses and children.

OBJECTIVE: To determine the incidence, size, and location of epidermoid formations (EFs), which have been suggested to be precursors of congenital cholesteatomas, in temporal bones from fetuses and children. DESIGN: We examined temporal bones from 226 fetuses and children up to the age of 10 years for the incidence, size, and location of EFs. RESULTS: Twenty-five EFs were identified in middle ears of 3 fetuses, 7 neonates, 9 infants, and 2 children aged 2 and 3 years. There was a male-female preponderance of 5:4. Generally, we saw EFs between the anterosuperior edge of the eardrum and the anterior limb of the tympanic ring, but 4 were below the level of the handle of the malleus. Their widths ranged from 25 to 300 microns. Keratinization was not observed in any EF. Contrary to previous reports, we found EFs not only in ears of fetuses, but also in ears of infants and children. CONCLUSION: Although EFs may persist in some ears, possibly developing into congenital cholesteatomas, our findings do not provide direct support for this concept.

Histopathologic features of the temporal bone in patients with cystic fibrosis.

OBJECTIVES: To investigate the lower than expected incidence of otitis media in patients with cystic fibrosis (CF) through histopathologic evaluation of temporal bones and to document pathologic findings in the inner ears of patients with CF who received long-term administration of antibacterial and diuretic agents. DESIGN: Clinical records of patients who died of CF were reviewed. Their temporal bones were sectioned, stained with hematoxylin-eosin, and examined histologically. Additional sections were stained with Alcian blue and periodic acid-Schiff for comparison of goblet cell densities from middle ears and auditory tubes of patients with CF with those of control temporal bones. Results were analyzed using the t test. SUBJECTS: Twenty-one temporal bones from 11 patients with CF and 13 bones from 8 age-matched patients without CF were selected. RESULTS: All temporal bones with CF had well-pneumatized mastoids. Temporal bones from 2 patients (3 ears) revealed histological findings of chronic otitis media with effusion. There was a statistically significant reduction in the density of goblet cells in the medial (P = .002) and lateral (P = .05) walls in patients with CF who had no otitis media histologically compared with control temporal bones. Two patients with CF who had otitis media had increased densities of goblet cells. Inner ear damage, due to ototoxic drugs, was seen in most of the temporal bones from patients with CF. CONCLUSION: Low densities of goblet cells in temporal bones with CF may contribute reduced amounts of viscous mucus, which can lead to a low incidence of otitis media.

Surgical treatment of cholesteatoma in children.

Treating cholesteatoma in children is still controversial. This article reviews 93 cases of pediatric cholesteatoma operated on from 1983 to 1991 in the Gruppo Otologico, Placenza, Italy, and details the results in 83 children who underwent the intact canal wall technique. During second-stage surgery, residual cholesteatoma was detected in 38% of patients. Recurrent cholesteatoma was detected in 10% of patients treated with the intact canal wall technique. Residual cholesteatoma was seen in the middle ear cleft in 63%, in the epitympanum in 26%, and in the mastoid in 11% of cases. Social hearing level (< 25 dB) was achieved in 85% of cases with suprastructure, whereas only 53% of patients without suprastructure had these levels. In the treatment of cholesteatoma in children by use of the intact canal wall technique, a preplanned second-look operation is mandatory to eradicate the disease.

Tympanic membrane and middle ear pathologic correlates in mucoid otitis media.

OBJECTIVE: The goal of this study was to correlate tympanic membrane (TM) and middle ear (ME) pathologies in mucoid otitis media (MOM). METHODS AND MATERIAL: Forty ears with MOM and 56 control ears were retrospectively evaluated for TM and ME pathologies. Comparisons of TM thicknesses in MOM versus control ears were correlated with the Student t test; chi(2) analysis was used to correlate pathologic findings of the TM and ME. RESULTS: Thicknesses in all quadrants except the umbo were increased in MOM because of infiltration of inflammatory cells and fibrosis. The most common ME pathologies were granulation tissue and fibrosis. Significant correlations included (1) TM retraction and ME granulation tissue and fibrosis and (2) pars flaccida, posterosuperior, and anteroinferior thickness and ME granulation tissue and fibrosis. CONCLUSION: TM changes are likely to occur in patients with otitis media with effusion (MOM), and their presence is a strong indication of underlying ME pathology.

Histopathology of human temporal bone after cis-platinum, radiation, or both.

Preserving organs by use of multiple modalities has become protocol in treating squamous cell carcinomas of the head and neck, but cis-platinum and radiation can impair hearing. To determine the effect of cis-platinum, radiation, or a combination of these treatments on the temporal bone, we studied histopathologic slides of 15 human temporal bones: four after cis-platinum, five after radiation, two after combined treatment, and four from normal controls. Hair cells and cells in spiral ganglia were counted in reconstructed organs of Corti. Lumen-to-diameter indexes in arterioles near facial nerves were quantified for four normal controls and seven irradiated patients. Available audiograms were compared. Decreased spiral ganglion cells, loss of inner and outer hair cells, and atrophy of stria vascularis were demonstrated in groups receiving cis-platinum, radiation, and combinations, compared with age-matched controls. Arterioles around facial nerves demonstrated fibrinous clots within the intima, endothelial proliferation, and hypertrophy and fibrosis of vascular walls in smooth muscle. Fibrosis in connective tissue was clearly progressive after radiation. Cis-platinum and radiation can contribute to otologic sequelae, including sensorineural hearing losses, vascular changes, serous effusion, or fibrosis. Prophylactic treatments and techniques to deliver them should be considered for protection of temporal bones and preservation of hearing after oncologic modalities.

Sensorineural hearing loss associated with otitis media with effusion in children.

Sensorineural hearing loss (SNHL) is known to occur in various types of otitis media. Although the mechanism by which SNHL develops in association with otitis media with effusion (OME) is unknown, several hypotheses have been advocated up to now. We reviewed the clinical records of children with otitis media with effusion (OME) to reveal the association with sensorineural hearing loss. The material consisted of 71 children (119 ears) who were diagnosed as having OME and gave reliable audiograms in our clinic during an 11 month period from February 1997 through January 1998. From these cases those which showed bone conduction loss of 25 dB or higher at any one of the frequencies of 250 through 4 kHz were selected and considered to be cases of SNHL. Eight cases (9%) which had temporary threshold shift (TTS) or permanent threshold shift (PTS) were considered to be etiologically related to OME. The clinical course in each of these cases with SNHL was reviewed and evaluated in detail. We noted that all children with TTS improved completely. The result of this study indicates that we have to be aware of a possible development of SNHL during the course of OME.

Benign fibrous histiocytoma of the nasal septum.

Among the non-epithelial tumours of the nasal cavity, paranasal sinuses and nasopharynx, fibrous histiocytoma is rarely encountered. A 45 year-old male patient complaining about nasal obstruction and nasal swelling was seen in the hospital ENT department. On examination, there was a mass located on the right anterior part of the nasal septum, about 2 x 1 x 1 cm in size. The pathologic diagnosis was benign fibrous histiocytoma. In this article we discuss the clinical, radiological, histopathological characteristics of fibrous histiocytoma and its differential diagnosis.

Radiologic anatomy of the sphenoid sinus for intranasal surgery.

Endoscopic surgery of the sphenoid sinus can present the operator with a considerable challenge. The relationship of the sphenoid sinuses, in particular on the lateral wall, to the carotid artery, optic nerve, as well as the other anatomic structures, is of utmost importance. Surgical complications can occur because of a lack of orientation during dissection. To avoid the complications or lessen, somehow, the rate of complications, some described the technique consisting of the opening of the sphenoid sinus ostium medially. We studied 69 axial high resolution computed tomography (HRCT) of temporal bones to reveal the relationship of sphenoid sinus to the vital structures and to get some measurements in the sphenoid sinus. The lateral distance from the sphenoid ostium revealed that the lateral distance was about the distance between both ostea. We consider that in selected cases the dissection might be carried out laterally from the sphenoid ostium for safe enlargement of the ostium and approaching the sinus.

Anatomical guidelines for intranasal surgery of the lacrimal drainage system.

To facilitate identification of the nasolacrimal duct during intranasal surgery, we have determined the distances between the lacrimal drainage system and certain anatomical structures on the lateral wall of the nasal cavity. A total of 15 adult cadaver skulls were bisected mid-sagittally and evaluated morphometrically. In our specimens, the average distance from the natural ostium of the maxillary sinus to the nasolacrimal duct (NLD) was only 5.5 mm. This rather small distance should be taken into consideration, in order to prevent trauma of the NLD during surgical enlargement of the ostium of the maxillary sinus. The distances from NLD to the anterior surface of the bulla ethmoidalis, the free edge of the uncinate process and the attachment point of the middle turbinate on the lateral nasal wall were found to be 10.2 mm, 8.8 mm and 5.4 mm, respectively. Taking these distances into account, easy identification of the NLD during endonasal dacryocystorhinostomy surgery will be possible.

Evaluation of some important anatomical variations and dangerous areas of the paranasal sinuses by CT for safer endonasal surgery.

The purpose of this study is to determine some important variations and dangerous areas carrying risks for major complications, in the routine CT examination. We also made specific measurements to evaluate the individual differences. This prospective study consisted of 111 patients (222 sides). Eighty patients underwent coronal, and the rest coronal and axial CT. The depth of lamina cribrosa, its distance to the inferior turbinate, and the distance of anterior ethmoidal artery (AEA) either to the orbital roof or inferior turbinate were measured. Variations of the upper attachment of uncinate process were encountered in 23%. AEA coursed freely within ethmoidal cells in 43%. Anterior clinoid aeration was seen in 14%, optic canal bulging into the sphenoid sinus in 13% and an extreme medial course of the carotid canal in 12% of the patients. The mean depth of lamina cribrosa was 5.9 mm, and its mean distance to the inferior turbinate was 25.7 mm. The mean distance of AEA to the orbital roof was 13.7 mm, and to the inferior turbinate 30.05 mm. Anterior clinoid aeration correlated well with the variations of carotid and optic canals, statistically (p < 0.01). A detailed CT study will provide important information on the areas carrying risks of complications and the size of the area to be worked on.

Organized hematoma of the maxillary sinus mimicking tumor.

The authors present two cases of organized hematoma of the maxillary sinus. Both patients showed no bleeding abnormalities. Clinical symptoms, signs and radiologic appearance of the mass mimicked tumor during the initial diagnosis of the disease. To our knowledge, this is the first article describing organized hematoma in the maxillary sinus mimicking tumor without bleeding history and disorders. A provisional diagnosis of organized hematoma should be considered when a patient with history of epistaxis develops a slow-growing mass of the cheek and/or nasal obstruction.

Endoscopic dacryocystorhinostomy without stents.

OBJECTIVE: The aim of this study is to present our endoscopic DCR operation method without the use of silicone tubing and our results on the patients suffering from chronic epiphora with postsaccal stenosis. METHODS: Endoscopic dacryocystorhinostomy operations were performed to 21 sides of 18 patients who had chronic epiphora. No silicone tubing was used in any of the cases. In the postoperative healing period, the rhinostomy opening was maintained with frequent removal of nasal debris and using eyedrops. The patients were evaluated by fluoresceine test and endoscopic controls. RESULTS: Symptomatic improvement was achieved in 19 out of 21 sides of the patients (90.5%) and the results were confirmed by the fluoresceine test under endoscopic control. CONCLUSION: Our results of 21 sides of 18 cases underwent primary DCR without stents are as successful as those reported in the literature and the technique seems to be promising.

Facial neuroma in the internal auditory canal.

Authors presented two cases of facial neuromas in the internal auditory canal, one without facial palsy and the other with facial palsy. In both cases neuromas were occult and undiagnosed. Although in the first case neuroma was greater than the other, facial palsy was not developed. The mechanism of the facial palsy due to neuromas could not be clearly clarified.

Canal wall down mastoidectomy: causes of failure, pitfalls and their management.

Managing patients with failed canal wall down mastoidectomy, requires a meticulous approach to control the disease and restore hearing. The present article reviews the causes of failure of the primary procedure and pitfalls encountered in 105 patients referred to our centre for revision canal wall down mastoidectomy. At post-revision surgery there were no cases with residual or recurrent cholesteatoma. The failures in our revision procedure were due to tympanic membrane perforation which occurred in five per cent (n = 4) and intermittent otorrhoea in two per cent (n = 2). A dry cavity with adequate middle ear space allowed for optimum audiological function even in revision canal wall down procedures.

Impact of enuresis nocturna on health-related quality of life in children and their mothers.

OBJECTIVE: Nocturnal enuresis (NE) is a common childhood disorder. As children age and NE persists, it may become more stressful for both them and their caregivers. The aim of the present study was to assess the impact of NE on the quality of life of children who were diagnosed with NE, and their mothers, and to compare the results with a healthy control group. SUBJECTS AND METHOD: Eighty-two children with NE, and their mothers, and 93 healthy children and their mothers were enrolled in the study. The sociodemographic data were evaluated. The Pediatric Quality of Life Inventory 4.0 Scales (PedsQL 4.0) were used to assess the children's health-related quality of life (HRQoL); and the World Health Organization Quality of Life Instrument; short form (WHOQOL-BREF) was used for the mothers' HRQoL. RESULTS: The PedsQL 4.0 mean scores for the children with NE group were as follows: total score, 68.74; physical health score, 72.79; psychosocial health score, 66.56. The scores for the children in the control group were as follows: total score, 80.98; physical health score, 81.11; psychosocial health score, 80.88. The WHOQOL-BREF scores for the mothers of the children with NE were as follows: physical health score, 67.90; psychosocial health score, 62.66; social relationships score, 60.90; environmental area score, 61.04. The WHOQOL-BREF scores for the mothers in the control group were as follows: physical health score, 75.96; psychosocial health score, 72.39; social relationships score, 72.18; environmental area score, 67.44. CONCLUSIONS: Nocturnal enuresis negatively affects the quality of life of both children and their mothers. Therefore, when physicians see children with enuresis, they should also be aware of the effect of NE on the mothers' quality of life.