Venous thromboembolism chemical prophylaxis after endoscopic trans-sphenoidal pituitary surgery.

PURPOSE: There is no compelling outcome data or clear guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using low molecular weight heparin (chemoprophylaxis) in patients undergoing pituitary surgery. Here we describe our experience of early chemoprophylaxis (post-operative day 1) following trans-sphenoidal pituitary surgery. METHODS: Single-centre review of a prospective surgical database and VTE records. Adults undergoing first time trans-sphenoidal pituitary surgery were included (2009-2018). VTE was defined as either deep vein thrombosis and/or pulmonary embolism within 3 months of surgery. Postoperative haematomas were those associated with a clinical deterioration together with radiological evidence. RESULTS: 651 Patients included with a median age of 55 years (range 16-86 years). Most (99%) patients underwent trans-sphenoidal surgery using a standard endoscopic single nostril or bi-nostril trans-sphenoidal technique. More than three quarters had pituitary adenomas (n = 520, 80%). Postoperative chemoprophylaxis to prevent VTE was administered in 478 patients (73%). Chemoprophylaxis was initiated at a median of 1 day post-procedure (range 1-5 days postoperatively; 92% on postoperative day 1). Tinzaparin was used in 465/478 patients (97%) and enoxaparin was used in 14/478 (3%). There were no cases of VTE, even in 78 ACTH-dependent Cushing's disease patients. Six patients (1%) developed postoperative haematomas. Chemoprophylaxis was not associated with a significantly higher rate of postoperative haematoma formation (Fisher's Exact, p = 0.99) or epistaxis (Fisher's Exact, p > 0.99). CONCLUSIONS: Chemoprophylaxis after trans-sphenoidal pituitary surgery on post-operative day 1 is a safe strategy to reduce the risk of VTE without significantly increasing the risk of postoperative bleeding events.

Iatrogenic syringomyelia secondary to lumboperitoneal shunt altered by the raised intra-abdominal pressure of pregnancy.

We report a case of a 37 year old female with syringomyelia secondary to lumboperitoneal (LP) shunt. Syrinx regression occurred with raised intra-abdominal pressure due to pregnancy and subsequently redeveloped after parturition. To our knowledge a case of pregnancy associated syringomyelia regression has not been previously reported.

Delayed bubble, coil and trouble: young stroke as a presentation of paradoxical embolism from previously unrecognised pulmonary arterio-venous malformation (PAVM).

Young stroke patients should be investigated thoroughly to look for cardiac and extra-cardiac sources of emboli. We present a patient who was investigated for a cardiac source of emboli following an ischemic stroke. She was found to have a small patent foramen ovale (PFO), but due to the late appearances of bubbles on the bubble study it was thought that this was an incidental finding. Further investigation confirmed a PAVM was the source of emboli causing her stroke.

Cataract surgery with toric intraocular lenses can optimize uncorrected postoperative visual acuity in patients with marked corneal astigmatism.

PURPOSE: To study the change in visual acuity and refraction after cataract surgery using a toric posterior chamber intraocular lens in patients with astigmatism after penetrating keratoplasty. METHODS: A retrospective case note analysis of cataract surgery involving toric lens implants performed at the Norfolk and Norwich University Hospital was conducted. The pre- and postoperative visual acuities and refractions were recorded. RESULTS: Seven consecutive patients are described (5 men and 2 women) with a mean age of 62 years. They all underwent penetrating keratoplasty, and in every case, all sutures were removed (mean, 11.2 months before cataract surgery). A marked improvement in both unaided visual acuity and astigmatism was shown after the procedure. The average preoperative unaided acuity was 6/120 (range, 6/24 to counting fingers) compared with a postoperative unaided visual acuity average of 6/15 (6/9-6/24). The average preoperative cylinder was 10.12 D (range, 3.40-17.89 D); postoperatively, this fell to 2.75 D (range, 0.75-4.25). CONCLUSIONS: Cataract surgery with toric intraocular lenses allows the correction of high degrees of regular corneal astigmatism. We discussed the potential advantages and complications of performing toric lens cataract surgery as a secondary procedure.

A report of paracentric inversion of chromosome 8 in Moebius syndrome.

An eight-year-old girl with bilateral facial paresis and restricted eye movements was diagnosed with Moebius syndrome. A chromosomal analysis showed a paracentric inversion on the long arm of chromosome 8 (46, XX, inv(8) (q21.3q24.13)). Candidate genes have been found on chromosomes 3q21, 10q21, and 13q12. We discuss the genes which are known to have associated ocular movement dysfunction in the 8q21-24 region. We hope this case will add to the current body of knowledge regarding Moebius syndrome and its genetics.

Pupil block glaucoma after neodymium:YAG capsulotomy in a patient with a partially subluxated posterior chamber intraocular lens.

A 73-year-old-woman presented following neodymium:YAG capsulotomy for posterior capsular opacification with acute glaucoma. Previous cataract surgery had left her with a subluxated lens. Cornea edema obscured detail of the anterior chamber, but the edge of the lens could be seen clearly within the pupillary space. This produced a diagnostic dilemma because no obvious cause for pupil block could be seen. She failed to respond to medical therapy and had a laser iridotomy, following which her symptoms resolved. We believe this case demonstrates the importance of a laser iridotomy to exclude pupil block glaucoma when adequate visualization of the pupillary space is obscured.

Clinical Pearls and Management Recommendations for Strabismus due to Thyroid Orbitopathy.

Thyroid orbitopathy causes a unique form of strabismus with adult-onset diplopia. Prisms can be a temporizing measure, but many patients require strabismus surgery, which can be challenging. In this article, we highlight clinical guidelines for addressing strabismus due to thyroid orbitopathy and review our surgical experience.

The effect of changing oxygen saturation protocols on the incidence of laser treatment for retinopathy of prematurity.

OBJECTIVE: To compare the incidence of retinopathy of prematurity (ROP) requiring laser treatment among infants with birth weights of ≤ 1250 g before and after the implementation of a new oxygen saturation protocol in the neonatal intensive care unit of British Columbia Children's Hospital. DESIGN: Retrospective, comparative review of medical records. PARTICIPANTS: Premature infants with birth weights of ≤ 1250 g who were screened for retinopathy of prematurity from November 2003 to October 2005 and February 2006 to January 2008 (269 patients). METHODS: The hospital's ROP database was reviewed, and the patients were divided into 2 groups. The preprotocol group (November 2003-October 2005) consisted of patients who were screened before the new oxygen monitoring protocol was instituted and the postprotocol group (February 2006-January 2008) consisted of patients screened after its implementation. RESULTS: A total of 141 patients were in the preprotocol group and 128 patients in the postprotocol group. The mean birth weight and gestational age of the 2 groups were comparable (p = 0.81, 0.71, respectively). There was a 30% reduction in the incidence of laser treatment in the postprotocol group (preprotocol group = 22/141 [15.6%] vs postprotocol group = 13/128 [10.2%]; p = 0.19). CONCLUSIONS: We observed a decrease in the rate of severe ROP requiring laser treatment after the implementation of the new oxygen monitoring protocol. While not statistically significant, this is consistent with what has been found at other centres.

Mitomycin and amniotic membrane: a new method of reducing adhesions and fibrosis in strabismus surgery.

The effectiveness of complex strabismus surgery is often limited by the development of fibrosis postoperatively. The use of mitomycin C to reduce fibrosis in strabismus surgery has been reported, but the use of amniotic membrane has not. We describe a technique which uses both mitomycin C and amniotic membrane patches to reduce fibrosis. We describe this technique for two patients with complex strabismus who were treated with this technique.