Metastatic Squamous Cell Lung Carcinoma to the Optic Nerve Sheath Mimicking Retrobulbar Optic Neuritis.

Lung carcinoma is the second most common malignancy in both men and women, and may metastasize to the orbit relatively early in the disease course. Metastasis to the optic nerve or its sheath is an exceedingly rare occurrence, and diagnosis may be complicated by nonspecific clinical and radiographic features. The authors present a case of squamous cell lung cancer metastatic to the optic nerve sheath, initially diagnosed as optic neuritis based on its equivocal clinical and radiographic features. This is the first histopathologically confirmed case of squamous cell lung cancer metastatic to the optic nerve sheath in the literature.

Association Between Hay Fever and High Myopia in United States Adolescents and Adults.

OBJECTIVES: To investigate the relationship between hay fever and refractive error in a representative sample of adolescents and adults in the United States. METHODS: This cross-sectional study included 5,744 participants aged ≥12 years from the 2005 to 2006 National Health and Nutrition Examination Survey who participated in the allergy questionnaire, completed objective refraction and keratometry in both eyes, and had immunoglobulin E (IgE) serology. The primary predictor variable, refractive error, was classified as emmetropia (-0.99 to +0.99 diopters [D]), low myopia (-1.00 to -2.99 D), moderate myopia (-3.00 to -5.99 D), high myopia (≥-6.00 D), or hyperopia (≥1.00 D). Covariates included age, gender, race, asthma, eczema, total serum IgE ≥120 kU/L, corneal steepness, and corneal astigmatism. The primary outcome was hay fever. RESULTS: The study population's mean age was 41.7 years; 48.8% of subjects were men and 51.2% were women. The prevalence of hay fever was 12.1% overall. High myopes had 2.7 times higher odds of hay fever compared to emmetropes (OR 2.67, CI, 1.57-4.51, P=0.001), which was independent of demographics, atopic conditions, IgE serology, and keratometry measurements. CONCLUSIONS: The association between hay fever and high myopia identified in this large cross-sectional study remains speculative and was not mediated through corneal steepness or corneal astigmatism. Further prospective studies may help elucidate the directionality of the association between hay fever and high myopia.

Understanding Perspectives on Presbyopia and Use of Pilocarpine HCl 1.25% Twice Daily from Participants of the Phase 3 VIRGO Study.

INTRODUCTION: The phase 3, randomized, vehicle-controlled, 14-day VIRGO study evaluated the efficacy and safety of twice-daily dosing of pilocarpine hydrochloride ophthalmic solution 1.25% (Pilo) in presbyopia. On VIRGO exit, a companion study was conducted to assess the patient experience with presbyopia and satisfaction with Pilo. METHODS: Recruited individuals completed the Presbyopia Patient Satisfaction Questionnaire (PPSQ) plus a three-part exit survey, or a live interview. The PPSQ evaluated respondents' experience with Pilo. Survey parts 1 and 2 evaluated experience managing presbyopia before and during VIRGO, respectively; part 3 assessed future possibilities of using Pilo in real-world situations. The interview further informed the interviewees' experience with presbyopia and Pilo. The primary endpoint was responders (%) in each rating category of the PPSQ items 1-7; the secondary endpoints were summary of categorical (survey) and qualitative (interviews) responses. RESULTS: The PPSQ and survey included 62 participants who received Pilo (N = 28) or vehicle (N = 34) in VIRGO; the interview included ten participants (Pilo, N = 4; vehicle, N = 6). Per the PPSQ, 64.3% of Pilo users reported vision improvement, including 17.9% with complete improvement; ≥ 46.4% were satisfied/very satisfied with their ability to perform daily activities, see up close unaided, and read in dim light. Among vehicle users, these percentages were 35.3%, 0%, and ≤ 23.5%, respectively. In both subgroups, ≥ 67.9% were interested in using Pilo or Pilo and eyeglasses/contact lenses in the future. Per the interview, vehicle users (n = 6/6) found the eyedrop easy to use but none experienced meaningful near-vision improvements, stopped using other correction method(s) part of the day, were satisfied with the eyedrop, preferred it over their previous correction method(s), or would continue using it if prescribed. Conversely, 75% (n = 3/4) of Pilo users responded positively to each of these six criteria. CONCLUSIONS: Findings validate the VIRGO results and improve our understanding of the patient experience, demonstrating improved vision and satisfaction with Pilo (vs. vehicle) when performing daily activities.

Bilaterally subluxed diffractive intraocular lenses: big expectations and even bigger comorbidities.

A 78-year-old woman with an ocular history of cataract surgery with a diffractive intraocular lens (IOL) in each eye has developed fluctuating vision, greater in the right eye than the left eye, after 4 years. She has a history of inactive central serous retinopathy and a vision potential of 20/25 + 2 in the right eye and 20/25 in the left eye. She has well-controlled diabetes, hypertension, and hypercholesterolemia. She has enjoyed her spectacle independence for some time and wishes to have her vision restored. On examination, her uncorrected distance visual acuity (UDVA) was 20/50 in the right eye and 20/25 in the left eye and her uncorrected near visual acuity (UNVA) was J3 in the right eye and J1 in the left eye. Intraocular pressures (IOPs) measured 22 mm Hg in the right eye and 18 mm Hg in the left eye. Pupils had limited reactivity with irregularity in the right eye but no obvious relative afferent pupillary defect. Motility and confrontation visual fields were unremarkable in both eyes. Retinal acuity meter was 20/20 in both eyes, and manifest refraction was plano -1.25 × 105 20/40, J3 in the right eye and +0.50 × 20/25, J1 in the left eye. Pertinent findings on slitlamp examination included temporal iris atrophy and transillumination defects greater in the right eye than the left eye, peripupillary pseudoexfoliative changes in both eyes, significant inferior subluxation of a diffractive 3-piece posterior chamber IOL in the capsular bag with lens-pitting peripherally and few central, moderate pseudophacodonesis, and an open posterior capsule in the right eye. In the left eye, she had mild inferior subluxation of a single-piece acrylic diffractive IOL in the capsular bag with moderate pseudophacodonesis and an open posterior capsule (Figure 1JOURNAL/jcrs/04.03/02158034-202403000-00019/figure1/v/2024-02-20T193212Z/r/image-tiff). All other anterior segment findings were unremarkable. On dilated posterior examination, she had a cup-to-disc ratio of 0.50 in the right eye and 0.65 in the left eye without edema hemorrhage or pallor. There were attenuated vessels in both eyes, posterior vitreous detachment in both eyes, and a few small drusen peripherally in both eyes. There was retinal pigment epithelium irregularity and dropout parafoveal in the right eye and subfoveal in the left eye (Figure 2). There was no evidence of macular edema, subretinal fluid, choroidal thickening, or neovascular membranes. The periphery was unremarkable in both eyes.JOURNAL/jcrs/04.03/02158034-202403000-00019/figure2/v/2024-02-20T193212Z/r/image-tiff What testing would you obtain preoperatively to help guide your decision-making? How would you counsel the patient regarding comorbid conditions and expectations?

Outcomes of LASIK vs PRK enhancement in eyes with prior cataract surgery.

PURPOSE: To compare postenhancement visual acuity between patients who underwent postcataract laser in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK). SETTING: A private, tertiary referral practice in Sioux Falls, South Dakota. DESIGN: 3-year, retrospective chart review. METHODS: Patients who underwent postcataract extraction excimer laser enhancement surgery targeted for emmetropia (±0.50 diopter). Postenhancement uncorrected distance visual acuity (UDVA) and manifest refraction spherical equivalent (MRSE) was recorded for all available follow-ups and compared for both groups. RESULTS: 822 postcataract enhanced eyes (491 LASIK; 331 PRK). For patients with at least 6-month follow-up, mean UDVA was 0.05 ± 0.13 logMAR in LASIK-enhanced patients and 0.15 ± 0.20 in PRK-enhanced patients ( P < .001). Mean absolute value MRSE was 0.22 ± 0.36 and 0.48 ± 0.62 for LASIK-enhanced and PRK-enhanced patients at or beyond 6 months, respectively ( P < .001). 330 (67%) LASIK-enhanced patients achieved 20/20 or better postenhancement UDVA, compared with 142 (43%) PRK-enhanced patients ( P < .001). Controlling for pre-enhancement UDVA, LASIK-enhanced patients showed significantly better postenhancement UDVA than PRK-enhanced patients, except in those with pre-enhancement vision of 20/20 or better, or those worse than 20/50. LASIK-enhanced virgin corneas had mean postenhancement of 0.05 ± 0.14 UDVA compared with 0.13 ± 0.19 UDVA in PRK-enhanced virgin cornea patients ( P < .001). CONCLUSIONS: LASIK provides better and more predictable outcomes in UDVA than PRK in postcataract enhancement patients, even when controlling for pre-enhancement visual acuity and prior ocular procedures.

Clinical Outcomes of a Non-Diffractive Extended Depth-of-Focus IOL in Eyes with Mild Glaucoma.

Purpose: To evaluate the clinical outcomes of a non-diffractive, wavefront-shaping extended depth-of-focus (EDOF) intraocular lens (IOL) in eyes with mild open-angle glaucoma (OAG). Setting: Private practice; Sioux Falls, South Dakota. Design: Prospective, open-label, interventional study. Methods: In total, 52 eyes of 26 patients with mild OAG were enrolled and completed the study. All patients were bilaterally implanted with a non-diffractive, wavefront-shaping EDOF IOL. Seventy-seven percent of the patients were implanted with a trabecular microbypass stent at the time of surgery. Primary outcome measures included binocular corrected and uncorrected distance visual acuity (CDVA and UDVA), uncorrected intermediate and near visual acuity (UIVA and UNVA) and contrast sensitivity as measured by a Pelli-Robson chart. A subjective questionnaire was also administered to patients. Results: At 4 months postoperative, the mean binocular UDVA and CDVA was 0.03 ± 0.12 and -0.06 ± 0.07, respectively. The mean UIVA and UNVA were 0.18 ± 0.12 and 0.31 ± 0.18, respectively. Eighty-five percent of the subjects achieved ≥20/25 UDVA and 77% of the subjects achieved ≥20/32 UIVA at 4 months postoperative. The mean binocular mesopic contrast sensitivity was 1.76 ± 0.16 at a spatial frequency of 1 cycle-per-degree (cpd). Eighty-five percent of the subjects reported they would choose the same lens and 1 subject reported they would choose a different IOL if it meant reduced spectacle independence. Conclusion: The non-diffractive, wavefront-shaping EDOF IOL can be safely implanted in eyes with mild, pre-perimetric open-angle glaucoma with favorable uncorrected distance and intermediate visual acuity. The contrast sensitivity measurements were favorable and the subjective questionnaire revealed satisfactory spectacle independence and patient satisfaction.

Defocus Curve of Emerging Presbyopic Patients.

Purpose: To create a defocus curve of emerging presbyopic patients of various age groups. Setting: Single site private practice in Sioux Falls, South Dakota. Design: This was a non-randomized, prospective study. All subjects were enrolled from healthy volunteers. Methods: Subjects aged 37-9, 40-42, 43-45 and 46-48 that have 20/20 best-corrected distance visual acuity (BCDVA) were included. Binocular visual acuity at different defocus steps ranging from +0.5 D to -3 D was measured in each age group. Defocus curves were generated from the mean logMAR visual acuities at each defocus step, by age group. Results: Of the 60 subjects, 23.3% of subjects were between the ages of 37-39, 26.7% were between the ages of 40-42, 25% of subjects were between ages 43-45, and 25% were between the ages of 46-48. Visual acuity significantly decreased from plano to -3 D defocus steps in all groups (p < 0.0002, p = 0, p = 0 and p = 0). The 46-48-year-old group had worse visual acuity compared to the other three groups from the -1.0 to -2.0 D defocus steps (p = 0.037, p = 0.022 and 0.017, respectively). Starting at a near point of 40cm, the 37-39 group had the best logMAR vision and the 46-48 group had the worst vision (p = 0.001). Conclusion: The defocus curves of emerging presbyopic individuals demonstrate a decreasing visual acuity at near defocus steps that decreases with age. Defocus curves at different age ranges can help doctors explain various presbyopia treatment options in terms of near point capabilities at various ages.

Controlled oxidation of remote sp3 C-H bonds in artemisinin via P450 catalysts with fine-tuned regio- and stereoselectivity.

The selective oxyfunctionalization of isolated sp(3) C-H bonds in complex molecules represents a formidable challenge in organic chemistry. Here, we describe a rational, systematic strategy to expedite the development of P450 oxidation catalysts with refined regio- and stereoselectivity for the hydroxylation of remote, unactivated C-H sites in a complex scaffold. Using artemisinin as model substrate, we demonstrate how a three-tier strategy involving first-sphere active site mutagenesis, high-throughput P450 fingerprinting, and fingerprint-driven P450 reactivity predictions enabled the rapid evolution of three efficient biocatalysts for the selective hydroxylation of a primary and a secondary C-H site (with both S and R stereoselectivity) in a relevant yet previously inaccessible region of this complex natural product. The evolved P450 variants could be applied to provide direct access to the desired hydroxylated derivatives at preparative scales (0.4 g) and in high isolated yields (>90%), thereby enabling further elaboration of this molecule. As an example, enantiopure C7-fluorinated derivatives of the clinical antimalarial drugs artesunate and artemether, in which a major metabolically sensitive site is protected by means of a C-H to C-F substitution, were afforded via P450-mediated chemoenzymatic synthesis.

The Effect of Periocular Negative Pressure Application on Intraocular and Retrobulbar Pressure in Human Cadaver Eyes.

INTRODUCTION: To investigate the effect of applying negative pressure (vacuum) to the periocular space on intraocular pressure (IOP) and retrobulbar pressure (RBP) by use of the Multi-Pressure Dial (MPD) system (Equinox Ophthalmic, Inc.). METHODS: Two eyes of two full body cadavers were studied. In each subject, the retrobulbar space, posterior segment and intra-goggle space were cannulated to provide direct IOP, RBP and intra-goggle pressure measurements via a pressure transducer data acquisition system. The goggles of the MPD system were placed over the eyes of each subject, and multiple test runs were performed, with negative pressure settings programmed to 5, 10 and 20 mmHg. IOP and RBP measurements were continuously obtained during each run and plotted against time for analysis. RESULTS: For both subjects, the mean reduction (± standard deviation) in IOP was 1.6 ± 0.9 (10%), 3.5 ± 1.8 (23%) and 5.6 ± 2.0 (37%) mmHg at programmed negative pressure levels of - 5, - 10 and - 20 mmHg, respectively. The overall mean change in RBP (mmHg) during negative pressure application was 0.02 ± 0.14 at - 5 mmHg, 0.03 ± 0.19 at - 10 mmHg and - 0.01 ± 0.18 at - 20 mmHg. In both subjects, the magnitude of RBP change during application of negative pressure fell below the uncertainty of the measurement system. CONCLUSIONS: The application of negative pressure to the periocular space with the MPD decreases IOP but does not affect RBP.

The REVIVE Study: Long Term Outcomes of a Novel Non-Diffractive Extended Vision IOL versus Monofocal Control IOL.

Purpose: To evaluate the long-term (>1 yr) outcomes a non-diffractive extended vision intraocular lens (AcrySof IQ Vivity) compared to monofocal control. Setting: This was a multicenter trial that took place in 4 separate private ophthalmology practices throughout the United States. Design: This was a prospective, non-interventional, controlled, multicenter trial. All subjects were enrolled from participants in the Food and Drug Administration (FDA) clinical trial that led to the approval of the AcrySof IQ Vivity. Methods: Binocular uncorrected distance visual acuity (UCDVA), distance corrected visual acuity (DCVA), uncorrected intermediate visual acuity (UIVA) at 66cm, distance corrected intermediate visual acuity (DCIVA) at 66cm, uncorrected near visual acuity (UNVA) at 40cm, and distance corrected near visual acuity (DCNVA) at 40cm were measured. The binocular defocus curve was measured. A 23-question survey on visual performance including questions on spectacle independence, satisfaction, dysphotopsias, and likelihood of recommending their lens to another person was used administered. Results: A total of 64 eyes of 32 subjects were enrolled. Seventeen subjects had bilateral implantation of the AcrySof IQ Vivity lens, and 15 subjects had bilateral implantation of the AcrySof IQ Monofocal (SN60WF). Mean follow up time was 1078 days for the study group compared to 1067 days for the control group (p = 0.92). There were no differences in UCVA or DCVA between the two groups. Compared to control, the AcrySof IQ Vivity group had better mean binocular UIVA (logMAR 0.29 vs 0.18; p = 0.09), DCIVA (logMAR 0.33 vs 0.11; p = 0.003), UNVA (logMAR 0.49 vs 0.30, p = 0.01), and DCNVA (logMAR 0.54 vs 0.29; p = 0.001). Conclusion: The AcrySof IQ Vivity is a novel, non-diffractive extended range of vision intraocular lens that provides long-term, enhanced visual acuity at intermediate and near ranges with high levels of patient satisfaction and minimal dysphotopsias.

Immunomodulation and TNF-α inhibition for tubulointerstitial nephritis and uveitis syndrome: a case series.

BACKGROUND: Tubulointerstitial nephritis and uveitis (TINU) syndrome combines acute inflammatory nephritis (AIN) and uveitis. Uveitis in TINU often requires systemic immunomodulatory therapy (IMT), including steroid-sparing agents. Although common for other noninfectious uveitides, the use of tumor necrosis factor-α inhibitors (TNFi) in TINU has seldom been described. METHODS: This retrospective case series included patients <18 years of age with TINU followed at our tertiary care pediatric hospital. Disease characteristics at time of diagnosis and subsequent ophthalmological and rheumatologic evaluations were extracted from the record. AIN was defined as the presence of abnormal renal function and urinalysis or renal biopsy findings consistent with TINU. Uveitis grading, site of inflammation, inactivity, and flare were defined according to Standardization of Uveitis Nomenclature. RESULTS: A total of 10 patients (median age, 12.3 years; 6 females) were included. AIN preceded uveitis onset in 6 patients. Uveitis was bilateral at onset in 7 patients. Uveitis inactivity was achieved with systemic corticosteroids (CS) in 2 and with mycophenolate mofetil (MMF) in 3 patients. Because of persistent ocular inflammation, despite CS and IMT, 4 patients were treated with TNFi. All rapidly achieved uveitis quiescence and maintained prolonged inactivity under combined treatment with TNFi and MMF. CONCLUSIONS: Most patients in our study cohort required a steroid-sparing immunomodulator to achieve and maintain uveitis control. In the 50% of the cohort in whom conventional IMTs were inadequate, TNFi were able to maintain quiescence. TNF inhibition might be a useful treatment in IMT-refractory uveitis in TINU patients.

The Effectiveness and Safety of Dextenza 0.4 mg for the Treatment of Postoperative Inflammation and Pain in Patients After Photorefractive Keratectomy: The RESTORE Trial.

PURPOSE: To determine patient preference and treatment outcomes with an intracanalicular dexamethasone 0.4 mg insert compared to a standard steroid drop regimen in the contralateral eye following bilateral photorefractive keratectomy (PRK). METHODS: In this randomized, prospective, self-controlled, open-label interventional study, one eye received the dexamethasone insert and the second eye received prednisolone acetate 1% taper following bilateral PRK surgery. Postoperative evaluations were performed on day 3, day 4, month 1, and month 3. Phone call surveys were performed on week 2. The Comparison of Ophthalmic Medications for Tolerability questionnaire was used to determine patient preference between postoperative regimens and postoperative pain. Corneal endpoints included time to epithelialization, presence of corneal haze, sodium fluorescein staining, and modified Standardized Patient Evaluation of Eye Dryness (SPEED) scores. Both corrected distance visual acuity (CDVA) and uncorrected distance visual acuity (UDVA) were assessed. RESULTS: Twenty patients participated in the study. At month 3, 70% of patients preferred the dexamethasone insert, 20% preferred prednisolone acetate, and 10% expressed no preference. Patient surveys did not show a difference in postoperative pain between the study group and control group. No statistical difference was shown in time to epithelialization, 90-day CDVA or UDVA, postoperative corneal haze, corneal staining, or modified SPEED scores. CONCLUSIONS: In patients undergoing PRK, there was preference toward a dexamethasone insert in place of topical prednisolone acetate for the postoperative steroid treatment. There were no statistically or clinically significant differences between the two cohorts in regard to healing time or visual outcomes. [J Refract Surg. 2021;37(9):590-594.].

The impact of open reduction internal fixation on acute pain management in unstable pelvic ring injuries.

BACKGROUND: The management of unstable pelvic ring injuries is complex. Displacement is a clear indication for surgical intervention. However, reduction of acute pain after stabilization may have substantial clinical benefits and affect management decisions. The purpose of this study was to determine the impact of operative fixation of unstable pelvic ring injuries in diminishing acute pain. METHODS: During a 33-month period, 70 patients with isolated pelvic ring injuries were managed at a Level-1 trauma center and retrospectively reviewed. On the basis of clinical and radiographic instability, 38 patients were managed surgically and formed the study group. Pain was assessed using visual analog scales and narcotic consumption during the index hospitalization. RESULTS: In the operative group, visual analog scale scores decreased 48% after fixation from 4.71 +/- 1.8 preoperatively to 2.85 +/- 0.8 postoperatively (p < 0.001). Concomitantly, narcotic requirements decreased 25% from 2.26 mg morphine per hour preoperatively to 1.71 mg morphine per hour postoperatively (p = 0.024). The mean total length of hospital stay was 5.6 days (SD, 1.2 days), and the postoperative length of hospital stay was 4.7 days (SD, 1.2 days). CONCLUSIONS: Operative reduction and fixation of unstable pelvic ring injuries significantly decreases acute pain. This has substantial physiologic benefits, particularly by improving mobilization, and should be an additional factor when determining surgical indication and timing.

The use of self-retained, cryopreserved amniotic membrane for the treatment of Sjögren syndrome: a case series.

PURPOSE: To determine whether signs and symptoms of ocular surface disease improve after placement of a self-retained, cryopreserved amniotic membrane (CAM) in patients with Sjögren syndrome (SS). METHODS: The medical records of SS patients who received a self-retained CAM implant (Prokera or Prokera Slim; TissueTech Inc, Doral, FL) for the treatment of ocular surface disease between August 2012 and August 2016 at a single, large academic institution were reviewed retrospectively. Visual acuity, results of slit-lamp examination of the cornea and conjunctiva, and dry eye symptoms, were evaluated before and after CAM insertion. RESULTS: A total of 6 eyes of 6 patients (all female; mean age, 62.5 ± 13.0 years [range, 49-86 years]) were included. All patients were on topical medications at the time of the study and had signs of ocular surface dryness. There were reductions in corneal and/or conjunctival staining in 5 eyes (83%) after the CAM dissolved. All patients who completed therapy (5/5) experienced a relapse in their signs and symptoms within 1 month of removal of the CAM, with an average time to relapse of 24.6 days. Mean follow-up time was 54.5 days. Foreign body sensation and blurred vision were the most common complaints associated with the CAM implant. CONCLUSIONS: In this small case series, self-retained CAM implantation was found to be beneficial in SS patients with ocular surface disease that is refractory to standard therapies; however, we found that the effects were temporary. Future larger studies are needed to confirm these benefits.

The prevalence and characteristics of chronic ocular itch: a cross-sectional survey.

INTRODUCTION: In this cross-sectional study, we aimed to determine the prevalence and characteristics of chronic ocular itch in an outpatient ophthalmology and optometry clinic. METHODS: Four hundred patients from an outpatient ophthalmology and optometry clinic were enrolled. The presence and characteristics of chronic ocular itch were assessed by a questionnaire. Data regarding ophthalmologic, dermatologic, and systemic conditions as well as current medications were extracted from medical records. RESULTS: Chronic ocular itch was present in 118 (29.5%) of 400 participants. Chronic ocular pruritus was significantly more prevalent in females [P=0.015; odds ratio (OR)=1.8; 95% confidence interval (CI), 1.1-2.8] and was significantly associated with the presence of allergic conjunctivitis [51.8% (n=45); P<0.001; OR=5.0; 95% CI, 3.0-8.3], dry eye syndrome [40.1% (75); P<0.001; OR=2.6; 95% CI, 1.7-4.1], blepharitis [43.8% (n=21); P=0.021; OR=2.0; 95% CI, 1.1-3.8], and atopic dermatitis [50.0% (n=10); P=0.023; OR=2.6; 95% CI, 1.1-5.8]. Chronic ocular itch was not significantly associated with systemic conditions, or the use of prescribed ophthalmologic medications. DISCUSSION: Chronic ocular itch is common and may be related to ophthalmologic or dermatologic pathologies. The present findings highlight the importance of identifying and managing this uncomfortable symptom that may negatively impact the quality of life and sleep of affected patients.

Broken poly-L-lactic acid interference screw after ligament reconstruction.

The interference screw is a reliable method used to secure tendon to bone and bone to bone in ligament reconstruction. Historically, metal interference screws have been used for this purpose in both anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction. However, several problems associated with the use of metal interference screws have led to the increasing use of bioabsorbable implants. Poly-L-lactic acid (PLLA) biodegradable interference screws have been used successfully for graft fixation in ligament reconstruction. Although adverse reactions have been reported with the use of biodegradable implants, late screw breakage is rare. To our knowledge no case exists of late screw breakage with bioabsorbable interference screws used in ligament reconstruction. We present one case in the setting of an ACL reconstruction and one with combined PCL and posterolateral corner reconstruction.

Effects of capsular plication and rotator interval closure in simulated multidirectional shoulder instability.

BACKGROUND: Arthroscopic treatment of multidirectional shoulder instability with use of capsular plication and rotator interval closure has been shown to be effective in several clinical studies; however, the biomechanical effects of these procedures have not been elucidated. The purpose of this study was to assess biomechanically the effect of arthroscopic capsular plication combined with rotator interval closure on rotational range of motion, humeral head position throughout rotation, and glenohumeral translation. METHODS: Seven cadaveric shoulders were stretched to 10% beyond the maximum range of motion in 60 degrees and 0 degrees of glenohumeral abduction. Testing was performed for the intact and stretched conditions and following three sequential capsular repairs: anterior plication, posterior plication, and rotator interval closure. Rotational range of motion, humeral head position throughout the range of motion, and glenohumeral translations were measured in both positions. RESULTS: Stretching increased the total rotational range of motion in 60 degrees and 0 degrees of abduction. After anterior plication alone, total rotation decreased significantly (p < 0.05) in both positions and was restored to the intact state. Total translation with a 20-N load increased significantly in the 60 degrees of abduction position after stretching (p = 0.03). Anterior-posterior translation decreased significantly compared with the stretched state only after all components of the repair were completed in 60 degrees of abduction (p = 0.0003 with a 15-N load and p = 0.0001 with a 20-N load). This decrease was also found to be significantly less than the intact condition (p = 0.008 with a 15-N load and p = 0.001 with a 20-N load). A similar trend in results was found with superior-inferior translations in the 0 degrees of abduction position. CONCLUSIONS: Capsular plication alone reduces range of motion to the intact state. Reductions in translation, however, may require the addition of rotator interval closure. Changes in translation and rotation after repair are dependent on arm position. In some positions, the addition of rotator interval closure may also result in overtightening.