Occipito-atlantal instability in children. A report of five cases and review of the literature.

We are reporting the cases of five patients who had occipito-atlantal instability, a rare condition that may be due to either trauma or congenital abnormalities. In three of the patients the instability was secondary to trauma. The clinical and neurological manifestations were varied and included cardiorespiratory arrest, motor weakness, quadriplegia, torticollis, pain in the neck, vertigo, and projectile vomiting. All of the patients underwent posterior arthrodesis of the occiput to the first or second cervical vertebra. In the patients who had trauma-related instability, surgery was performed when immobilization in a cast failed to stabilize the spine; in the patients who had a congenital abnormality, arthrodesis was indicated because of persistent symptoms and the potential for catastrophe with minor trauma. Based on our experience, we recommend surgical stabilization by posterior arthrodesis when this form of instability of the cervical spine is diagnosed.

Autologous transfusions for orthopaedic procedures at a children's hospital.

We conducted a critical review of the use of autologous transfusions in orthopaedics at a tertiary-care children's hospital. The cases of 198 children who deposited blood before an orthopaedic operation were analyzed. There were 175 children who were enrolled in the program of preoperative deposit of autologous blood who later needed transfusion of blood; 73 per cent of them received only autologous blood. Seventy patients also had intraoperative salvage. We were unable to document a proved benefit of intraoperative salvage of blood in this group of patients. Forty patients had some difficulty donating autologous blood preoperatively, but these problems were rarely serious. Major human errors occurred in thirteen patients and resulted in some patients receiving homologous transfusions while autologous blood components were still available. Fifty-five (40 per cent) of all of the transfusions were administered in clinical circumstances that failed to meet generally accepted criteria for transfusion, and fifty-four (38 per cent) of the postoperative transfusions also failed to meet these criteria. This was true of the homologous transfusions in the study as well. Although an autologous blood transfusion is a generally safe procedure, it is not without risk, and human errors can occur. In light of the potential complications, surgeons should adhere to the standard indications for transfusion when administering autologous blood.

Fibrin reaction after extracapsular cataract extraction: a statistical evaluation.

As part of a retrospective study, 1056 eyes of 940 patients who had undergone extracapsular cataract surgery and posterior chamber IOL implantation were studied using statistical methods (chi-squared test). We studied the presence of fibrin reaction in three subgroups: diabetics without retinopathy (102 eyes), previously operated for primary open angle glaucoma "POAG" (78 eyes) and exfoliation syndrome without glaucoma (43 eyes). The results were compared for these three groups and for a group of normal individuals. The incidence of fibrin reaction was 13.7% in the diabetics, 44.8% in the group of previously operated POAG and 27.9% in the group of exfoliation syndrome without glaucoma. All the groups studied had this complication much more often than the controls (p < 0.0001). The incidence among previously operated eyes for POAG was higher than in diabetic eyes without retinopathy (p < 0.0005) and in exfoliation syndrome without glaucoma eyes (0.05 < p < 0.1). Fibrin reaction was more common in exfoliation syndrome without glaucoma than in diabetic eyes without retinopathy (p < 0.05).

Risk factors in ocular hypertension.

The aim of the study was to determine whether certain factors are related to an increased risk of developing open-angle glaucoma. A total of 345 untreated glaucoma suspects with intraocular pressure (IOP) > or = 21 mmHg, cup to disc ratio 0.4 or less and no visual field defects, were followed up for 6 to 8 years (mean 7.3). During the follow-up 71 patients developed established glaucoma and were compared to the remaining 274 patients. The following factors were analysed: age, family history of glaucoma, IOP, Humphrey 30-2 visual fields, optic disc appearance, myopia, exfoliation, arterial hypertension and diabetes. Analysis yielded statistically significant results regarding a number of these factors in the patients who subsequently developed open-angle glaucoma. A significant association with the subsequent development of field loss in ocular hypertension (OHT) included: heredity (p < 0.001), age > or = 60 years (p = 0.013), axial myopia (0.001 < p < 0.01) and arterial hypertension (p = 0.05). About 20% of patients with ocular hypertension developed glaucoma over a period of seven years. Risk factors such as heredity, age, myopia and arterial hypertension, among others, must be considered in the follow-up of glaucoma suspects.

Clinical evaluation of the effect of mitomycin-C in re-operation for primary open angle glaucoma.

The aim of the study was to evaluate the effect of mitomycin-C (MMC) in a second antiglaucoma operation after failure of the first operation. We assessed 46 patients (26 male, 20 female, mean age 64.2 years) with high intraocular pressure (IOP) (mean 32.4 +/- 5.2 mmHg) despite previous trabeculectomy (Tr-Ec) one to three years earlier and topical or systemic medical treatment. All patients underwent a second Tr-Ec and were randomly divided into two groups: group A, 24 patients, underwent a second Tr-Ec with MMC and group B, 22 patients, also underwent a second Tr-Ec but without MMC. Postoperative complications included: shallow anterior chamber (duration > 1 week), group A 29.2%, group B 13.6%; chroidal effusion, group A 8.3%, group B 0%; cystic degeneration of conjunctiva, group A 16.6%, group B 4.5%; transient maculopathy, group A 12.5%, group B 0%. IOP control (< or = 20 mmHg after 18 months) was: group A 20 patients (83.3%) with mean 12.5 +/- 3.2 mmHg and group B 13 patients (63.6%) with mean 19.6 +/- 6.1 mmHg. In conclusion, the use of MMC in re-operation for primary open-angle glaucoma is associated with a higher rate of and more severe postoperative complications than Tr-Ec alone. However, it achieves significantly lower IOP in a larger number of patients.

[Macular threshold after ECCE and posterior chamber IOL implantation]. / Seuil de sensibilité maculaire après extraction extracapsulaire de la cataracte et implant de chambre postérieure.

In the present paper, the macular threshold after ECCE and posterior chamber intraocular lens implantation, was studied in an effort to determine the time period needed for full postoperative recovery of macular function. We evaluated 22 eyes in 20 patients who underwent extracapsular cataract extraction and posterior chamber IOL implantation. There were 12 men and 8 women between the ages of 40 and 62 years with mean age of 53 years. Postoperative visual field testing was performed within the central 4 degrees with an automated static perimeter (Humphrey Visual Field Analyser), using a macular threshold test pattern. It has been established that central retinal sensitivity in pseudophakia shows a postoperative decrease and consequently recovers to almost normal levels within one month. The exact cause of this reduction remains under discussion and further control mainly with fluorescein angiography is necessary.

[Complications of secondary implantation in patients with aphakia]. / Complications de l'implantation secondaire chez les aphakes.

We analyzed retrospectively the complications and visual results of 154 cases of secondary intraocular lens implantation. The follow-up ranged from 1 to 4 years (mean 2.8 years). Best corrected final post-operative visual acuity was better or the same as the best corrected preoperative vision in 95.5% of the eyes. Vision deteriorated in 7 eyes (4.5%): in 3 eyes because of cystoid macular edema, in 2 eyes because of retinal detachment, in 1 eye because of corneal decompensation and in 1 eye because of macular hole. The incidence of complications was 15.4%. We believe that, in carefully selected patients, secondary intraocular lens implantation is highly successful.

[Ahmed valve in high-risk glaucoma surgery]. / La valve d'Ahmed dans la chirurgie des glaucomes "à haut risque".

We used the Ahmed valve for the treatment of 142 eyes with high-risk glaucoma. The glaucoma was neovascular in 74 cases, aphakic or pseudophakic in 19 eyes and occurred after previous faliure of filtering surgery in 49 eyes. Preoperative mean IOP was 31.6+/-10.4 mmHg under topical and/or systemic treatment. The success rate (IOP<22 mmHg with only topical treatment) was 56.3% with a mean follow-up of 32.4 months. Complications were fewer and milder compared with those reported for other types of drainage implants and for other types of antiglaucoma procedures.

[Otorhinolaryngologic aspects of Adamadiades-Behçet syndrome]. / Aspects O.R.L. du syndrome d'Adamadiades-Behçet syndrome.

Behçet's syndrome is a rare, progressive and systemic disease. It causes scrotal ulcers, bilateral conjunctivitis and recurrent oral aphthous ulcers. Genetic factors, mechanisms of autoimmunity as well as environmental factors interact in the etiology of the syndrome, according to the most recently developed hypotheses. The diagnostic and therapeutic traps which might appear during the contemporary O.R.L. practice are presented here, considering the oral ulcers of a frequently common appearance and especially the dysphagia which might be confused with many other clinicopathological entities.

Clinical significance of optic disc progression by topographic change analysis maps in glaucoma: an 8-year follow-up study.

Aim. To investigate the ability of Heidelberg Retina Tomograph (HRT3) Topographic Change Analysis (TCA) map to predict the subsequent development of clinical change, in patients with glaucoma. Materials. 61 eyes of 61 patients, which, from a retrospective review were defined as stable on optic nerve head (ONH) stereophotographs and visual field (VF), were enrolled in a prospective study. Eyes were classified as TCA-stable or TCA-progressed based on the TCA map. All patients underwent HRT3, VF, and ONH stereophotography at 9-12 months intervals. Clinical glaucoma progression was determined by masked assessment of ONH stereophotographs and VF Guided Progression Analysis. Results. The median (IQR) total HRT follow-up period was 8.1 (7.3, 9.1) years, which included a median retrospective and prospective follow-up time of 3.9 (3.1, 5.0) and 4.0 (3.5, 4.7) years, respectively. In the TCA-stable eyes, VF and/or photographic progression occurred in 5/13 (38.4%) eyes compared to 11/48 (22.9%) of the TCA-progressed eyes. There was no statistically significant association between TCA progression and clinically relevant (photographic and/or VF) progression (hazard ratio, 1.18; P = 0.762). The observed median time to clinical progression from enrollment was significantly shorter in the TCA-progressed group compared to the TCA-stable group (P = 0.04). Conclusion. Our results indicate that the commercially available TCA progression criteria do not adequately predict subsequent photographic and/or VF progression.

Glaucoma risk assessment using a non-linear multivariable regression method.

The present research investigates the relationship between the central corneal thickness (CCT), Heidelberg Retina Tomograph II (HRTII) structural measurements and intraocular pressure (IOP) using an innovative non-linear multivariable regression method in order to define the risk factors in future glaucoma development and patient management. The method is implemented to data from ninety-three open angle glaucoma eyes. The results show that in established glaucoma, CCT is significantly associated with HRTII structural measurements (maximum contour depression, cup volume inferotemporally) and IOP. They are also compared to those obtained from the application of standard linear regression methods, improving the coefficient determination R(2) by 35%, exhibiting thus the performance of the proposed methodology.

Omega- and Omega+ production in central Pb + Pb collisions at 40 and 158A GeV.

Results are presented on Omega production in central Pb+Pb collisions at 40 and 158A GeV beam energy. For the first time in heavy ion reactions, rapidity distributions and total yields were measured for the sum Omega(-) + Omega(+) at 40A GeV and for Omega(-) and Omega(+) separately at 158A GeV. The yields are strongly underpredicted by the string-hadronic UrQMD model but agree better with predictions from hadron gas models.

System-size dependence of strangeness production in nucleus-nucleus collisions at squareroot[sNN]=17.3 GeV.

Emission of pi+/-, K+/-, phi, and Lambda was measured in near-central C+C and Si+Si collisions at 158 AGeV beam energy. Together with earlier data for p+p, S+S, and Pb+Pb, the system-size dependence of relative strangeness production in nucleus-nucleus collisions is obtained. Its fast rise and the saturation observed at about 60 participating nucleons can be understood as the onset of the formation of coherent systems of increasing size.

Hemivertebral excision for congenital scoliosis.

We retrospectively reviewed the cases of 10 consecutive patients treated with hemivertebral excision for congenital scoliosis at The Children's Hospital, Denver, CO, between 1982 and 1992. Follow-up consisted of physical and radiographic examination and averaged 54 months (range, 4-111). Age at surgery ranged from 9 months to 10 years, 5 months (average, 3 years, 11 months). Hemivertebra levels were between T12 and L3. The average preoperative curve measured 40 degrees (range, 20-55 degrees); the average at latest follow-up was 16 degrees (range, 3-37 degrees). We found hemivertebral excision for congenital scoliosis to be a safe and effective means of treatment. Curve correction averaged 67% and seemed to be greatest in those less than 4 years of age at the time of surgery.

Central visual field changes after panretinal photocoagulation in proliferative diabetic retinopathy.

This study comprises 53 eyes, divided into two groups A and B, with proliferative diabetic retinopathy which were treated with panretinal photocoagulation (PRP). Its purpose is to investigate the alterations in the central 15 degrees and 30 degrees of the visual field and in each quadrant separately. In both groups A and B, PRP covered the periphery and mid-periphery. In group A, it stopped 2 disc diameters (DD) from the upper temporal and lower margin of the fovea including the papillomacular bundle, while in group B, PRP stopped 3 DD from the upper temporal and lower margin of the fovea and 1 DD of the nasal margin of the optic disc. The investigation revealed, in group B after PRP, an improvement of the retinal sensitivity in the central 15 degrees of the visual field (p less than 0.01). In the 30 degrees of the visual field a deterioration after PRP was noted in both groups A and B, the deterioration being however much more prominent in group A. Comparing the results between groups B and A after PRP, a difference in the retinal sensitivity in favour of group B at 15 degrees and 30 degrees of the visual field was found. As regards regression of neovascularization and visual acuity, no statistically significant difference has been observed between the two groups.

Intraoperative blood salvage in children and young adults undergoing spinal surgery with predeposited autologous blood: efficacy and cost effectiveness.

We conducted a retrospective review of 155 spinal operations at our institution to determine the efficacy of intraoperative salvage. Addition of intraoperative salvage had little effect on the success of a preoperative autologous donation program. Only patients with operative blood loss > 2,000 ml (12% of patients) benefited from this expensive source of autologous blood. The technique tended to be most effective in children aged 16-18 years. Use of intraoperative salvage for all pediatric spinal procedures is neither necessary nor cost effective.

Long-term study of patients with congenital pit of the optic nerve and persistent macular detachment.

During the period 1970-87 we evaluated the changes of the optic disc, peripapillary area, detached macula and visual acuity in 16 cases with congenital pit of the optic nerve and macular detachment. The study revealed in 9 of the 16 cases (56%) an increase of the dimension of the pit or changes in its color, findings which were directly related to the duration of the macular detachment. Chorioretinal scarring, pigment migration, or both, were also noted mainly at the temporal margin of optic disc. In 5/16 cases we found during the follow-up an extension of macular elevation. In altogether 10 out of 16 cases the retinal elevation covered the larger portion of the mid-periphery temporally. In 7/16 cases the final visual acuity remained unchanged, in 9/16 cases deteriorated. The difference, however, in the latter 9 cases between initial and final visual acuity was negligible. During the follow-up period deterioration of the visual fields was also noted.

Combined clear cornea phacoemulsification and trabecular aspiration in the treatment of pseudoexfoliative glaucoma associated with cataract.

BACKGROUND: In the present prospective randomized study the effectiveness and safety of trabecular aspiration combined with clear cornea phacoemulsification (phaco) was compared to clear cornea phaco alone in patients with pseudoexfoliation (PEX) glaucoma and visually disabling cataract. METHODS: Twenty-seven patients suffering from visually significant cataract (visual acuity < 5 Snellen lines) and PEX glaucoma were randomly assigned to either phaco combined with trabecular aspiration (14 eyes of 14 patients) or phaco alone (13 eyes of 13 patients). Inclusion criteria for glaucoma were IOP < or = 22 mmHg under treatment with up to two antiglaucomatous agents, excluding pilocarpine 4%, and no previous surgery or laser trabeculoplasty treatment. Clear cornea phaco with foldable acrylic intraocular lens (IOL) implantation was carried out in all patients uneventfully. Trabecular aspiration was performed using a special probe in the inferior 180 deg of the angle after IOL implantation. RESULTS: Follow-up duration ranged from 12 to 18 months. In the combined procedure group there was a statistically significant decrease in postoperative IOP during the whole follow-up period (P < 0.01), while in 9 of the 14 patients the IOP was controlled without medications at the last examination. In the phaco alone group a statistically significant decrease in postoperative IOP was recorded at 9 and 12 months after surgery (P < 0.05), while in 4 of the 13 patients the IOP was controlled without medications at the last examination. Comparing the two groups, a statistically significantly lower number of medications was being used in the combined procedure group at the last recorded examination (P < 0.05). CONCLUSIONS: It seems that the combined clear cornea phaco and trabecular aspiration procedure in cases of PEX glaucoma associated with cataract is a safe and effective method. This technique controls IOP more effectively and with fewer postoperative medications than clear cornea phaco alone.

Displaced supracondylar humeral fractures in children. A comparison of results and costs in patients treated by skeletal traction versus percutaneous pinning.

Clinical outcome and treatment cost were compared in 65 children treated by either percutaneous pinning or skeletal traction for displaced supracondylar humeral fractures. Clinical outcome was evaluated by loss of elbow motion and change in carrying angle. Results of treatment were basically equivalent in the two groups and were satisfactory in 90% or more. To determine treatment cost, the authors analyzed factors that vary according to the type of therapy. Cost of treatment was lowest in those who had percutaneous pinning and subsequent pin removal in the office. Compared to this group, the cost of treatment increased by 23% in those who had percutaneous pinning and removal of the pins as a surgical procedure, by 117% in those treated by traction with the olecranon pin inserted in the emergency room, and by 142% in those treated by traction with the olecranon pin inserted in the operating room.

Visual field improvement after treatment of optic disk pit maculopathy with the macular buckling procedure.

PURPOSE: To evaluate visual field changes in 18 of 21 patients with unilateral optic disk pit maculopathy who were successfully treated with the macular buckling procedure. METHODS: In this prospective study, visual field examination with the Humphrey analyzer (programs 30-2 and 10-2) was recorded before treatment, repeated 1 month after the operation, and repeated every 6 months thereafter. All 18 patients were treated with the macular buckling procedure. The operation consisted of fixation of a silastic sponge explant at the posterior pole corresponding to the macula. RESULTS: In 18 eyes included in the study and successfully treated, an improvement in visual field indices was recorded. The mean deviation improved from -7.75+/-3.15 (program 30-2) and -10.19+/-3.66 (program 10-2) decibels before surgery to -6.25+/-2.61 (P<0.0001) and -8.56+/-3.13 (P<0.0001) decibels at the last examination, respectively. No additional visual field defect was induced in any of the 18 eyes after treatment. Also, the majority of the eyes (16/18) gained from 1 to 7 Snellen lines of visual acuity (P<0.0001). CONCLUSION: Improvement of central and peripheral visual field (within 30 degrees of fixation) was recorded after the treatment of optic disk pit maculopathy with the macular buckling procedure. This technique seems to be effective for treatment of the disease with good anatomic and functional results.