Müller muscle-Conjunctival Resection (MMCR) Surgery: A Comprehensive Literature Review.

PURPOSE: This literature review aims to provide a comprehensive overview of the current understanding, indications, techniques, outcomes, and complications of Müller muscle-conjunctival resection (MMCR) surgery. It also addresses areas of debate with MMCR such as predictability concerning Phenylephrine response as well as the amount of muscle resection required. METHOD: This literature review was compiled based on the available evidence from PubMed from 1975 to August 2023. RESULTS: The success rate of MMCR ranges from 72% to 95%, with high patient satisfaction reported in most studies. The exact range of eyelid elevation after MMCR is variable, with a reported average of 2.1 mm MRD1 elevation. CONCLUSION: MMCR is a well-established surgical technique used to correct upper eyelid ptosis that results from dysfunction or attenuation of the levator aponeurosis. MMCR proved to be a safe and effective procedure with a high patient satisfaction rate and low risk of complications.

Clinicopathological study of ophthalmic cutaneous and mucocutaneous non-langerhans cell histiocytic lesions.

BACKGROUND: The "C group" of the histiocytic disorders is characterized by non-Langerhans-cell histiocytic lesions in the skin, mucosal surfaces, or both, out of which Juvenile xanthogranuloma (JXG) is the most common typically affecting the skin. The eye is the most common extra-cutaneous site of JXG., we aim at providing our clinical and histopathological experience with this group of diseases including the adult-onset xanthogranuloma (AXG). METHODS: This is a retrospective cohort study of all patients with the tissue diagnosis of ocular and periocular cutaneous and mucocutaneous non-LCH disorders who presented to us over a period of 25 years (January 1993 to December 2018). RESULTS: Twenty patients were diagnosed as "Group C" disease with an age range of 2 months-60.9 years. Eleven patients were females (55%) and nine were males (45%). The involvement was mostly unilateral in 80.9%. All cases fell into the xanthogranuloma family with 11 JXG patients, 8 AXG patients of skin and ocular surface, and one patient with solitary reticulohistiocytoma (SRH). The clinical site of involvement in JXG was primarily in the eyelid in 5 patients (45%), ocular surface lesions in 2 (18%), iris in 2 (18%), choroidal and bilateral orbital lesions in 1 patient each (9%). The group of AXG, presented equally with eyelid lesions in 4/8 and ocular surface lesions in 4/8. The non-Langerhans' histiocytic infiltrate showed supportive immunohistochemical staining properties (reactive to CD68 marker and negative to S-100 and langerin markers). CONCLUSION: Among the rare histiocytic disorders, xanthogranulomatosis is the commonest and has wide clinical manifestations. Accurate diagnosis needs to be supported by typical histopathological findings. JXG was the commonest in our study with relatively older mean age at presentation and frequent eyelid rather than iris involvement. AXG is often confused with xanthelasma when involving the eyelids with corneal limbal involvement is relatively frequent.

Cosmetic outcomes of epicanthoplasty for epicanthus tarsalis.

PURPOSE: Epicanthus is a term that refers to the semilunar eyelid skin fold over the medial aspect covering the medial canthal angle. Epicanthus tarsalis is the most common type and is most evident in the Asian population with a prevalence of 40% as opposed to 2%-5% in the non-Asian population. Epicanthoplasty has not been studied in patients of a population of heavier skin pigmentation. METHODS: A retrospective review of patients that underwent Park's modified Z-epicanthoplasty from January 2018 to August 2020. They were categorized based on their Fitzpatrick skin type. Their preoperative and postoperative pictures were analyzed for epicanthal fold correction with focus on scar visibility, pigmentation, and elevation. The patients were contacted over the phone for a questionnaire about their subjective scar assessment and satisfaction rate. RESULTS: A total of 35 patients with mild epicanthus tarsalis were included in this study. Twenty-two patients had Fitzpatrick skin type 3, seven patients had type 4, and six had type 5. Normal postoperative scar pigmentation was reported 37.1% (n = 13) of patients. Scar hypopigmentation was reported in 28.6% (n = 10) and scar hyperpigmentation was reported in 34.3% (n = 12). The final cosmetic satisfaction rate score was a median of 9/10 on the 1-10 scale with 40% recording 10/10 satisfaction. On the scar visibility scale, the median was 3/10. About 82.9% (n = 29) had no scar elevation or hypertrophy. Only one patient had scar hypertrophy and elevation and three patients had a vertical depression scar. No clinical or statistical significance was found when correlating scar visibility and pigmentation with Fitzpatrick skin type. CONCLUSION: Epicanthoplasty is a commonly performed surgery, especially in China and South Korea. In our population, Z-epicanthoplasty has proven to be effective in epicanthus tarsalis with high cosmetic satisfaction rate, low scar visibility, and acceptable scar pigmentation.

Krause's accessory lacrimal gland dacryops - case report and literature review.

The authors are describing two rare cases of dacryops involving the Krause accessory lacrimal glands and affecting the orbit. In both cases, the lesion was located in the inferior fornix, with no preceding trauma, surgery or trachomatous conjunctival scarring. The first case involved a clear orbital extension with evidence of optic nerve compression. The second case extended from the anterior orbit to the limbus. Both had surgical removal with good outcome. As Krause gland dacryops are similar to other orbital cysts, clinical, imaging and histopathologic evaluation are essential to confirm the final diagnosis.

A novel technique to remove a broken tibiotalocalcaneal intramedullary nail using Moreland hip revision instrumentation.

Hindfoot intramedullary devices are increasingly used in tibiotalocalcaneal arthrodesis after failed total ankle arthroplasty or as a salvage procedure after complex trauma. Nail breakage is a well-described complication and numerous techniques for removal of broken parts can be found in the literature, especially for femoral and tibial nails. There is a relative paucity regarding techniques solving the challenge of removing a broken hindfoot intramedullary nail. We describe a novel technique using a curved thin hook from the Moreland hip revision set to remove the distal part of a broken tibiotalocalcaneal intramedullary nail.

Long-term Rescue of Photoreceptors in a Rodent Model of Retinitis Pigmentosa Associated with MERTK Mutation.

MERTK mutation reduces the ability of retinal pigment epithelial (RPE) cells to phagocytize the photoreceptor outer segments, which leads to accumulation of debris separating photoreceptors from RPE cells, resulting in their degeneration and loss of vision. In a rat model of Retinitis Pigmentosa due to MERTK mutation, we demonstrate that surgical removal of debris performed when about half of photoreceptors are lost (P38), allows the remaining photoreceptor cells to renew their outer segments and survive for at least 6 months - 3 times longer than in untreated eyes. In another set of experiments, patterned laser photocoagulation was performed before the debris formation (P19-25) to destroy a fraction of photoreceptors and thereby reduce the phagocytic load of shed outer segment fragments. This treatment also delayed the degeneration of the remaining photoreceptors. Both approaches were assessed functionally and morphologically, using electroretinography, optical coherence tomography, and histology. The long-term preservation of photoreceptors we observed indicates that MERTK-related form of inherited retinal degeneration, which has currently no cure, could be amenable to laser therapy or subretinal surgery, to extend the visual function, potentially for life.

Retinal safety of near infrared radiation in photovoltaic restoration of sight.

Photovoltaic restoration of sight requires intense near-infrared light to effectively stimulate retinal neurons. We assess the retinal safety of such radiation with and without the retinal implant. Retinal damage threshold was determined in pigmented rabbits exposed to 880nm laser radiation. The 50% probability (ED50) of retinal damage during 100s exposures with 1.2mm diameter beam occurred at 175mW, corresponding to a modeled temperature rise of 12.5°C. With the implant, the same temperature was reached at 78mW, close to the experimental ED50 of 71mW. In typical use conditions, the retinal temperature rise is not expected to exceed 0.43°C, well within the safety limits for chronic use.

Phase I study of every 2- or 3-week dosing of ramucirumab, a human immunoglobulin G1 monoclonal antibody targeting the vascular endothelial growth factor receptor-2 in patients with advanced solid tumors.

BACKGROUND: Ramucirumab is a fully human immunoglobulin G1 monoclonal antibody receptor antagonist designed to block the ligand-binding site of vascular endothelial growth factor receptor-2 (VEGFR-2). An initial phase I study evaluated ramucirumab administered weekly in advanced cancer patients. This phase I study of ramucirumab [administered every 2 or 3 weeks (Q2W or Q3W)] examined safety, maximum tolerated dose, pharmacokinetics, immunogenicity, antitumor activity, and pharmacodynamics. PATIENTS AND METHODS: Patients with advanced solid malignancies were treated with escalating doses of ramucirumab i.v. over 1 h. Blood was sampled for pharmacokinetics studies throughout treatment; levels of circulating vascular endothelial growth factor-A (VEGF-A) and soluble VEGF receptors (R)-1 and -2 were assessed. RESULTS: Twenty-five patients were treated with ramucirumab: 13 with 6, 8, or 10 mg/kg Q2W, and 12 with 15 or 20 mg/kg Q3W. The median treatment duration was 12 weeks (range 2-81). No dose-limiting toxicities were observed. The most frequently reported adverse events (AEs) included proteinuria and hypertension (n = 6 each), and diarrhea, fatigue and headache (n = 4 each). Treatment-related grade 3/4 AEs were: two grade 3 hypertension (10 and 20 mg/kg), one each grade 3 vomiting, fatigue (20 mg/kg), atrial flutter (15 mg/kg), and one each grade 4 duodenal ulcer hemorrhage (6 mg/kg) and grade 4 pneumothorax (20 mg/kg). Pharmacokinetic analysis revealed low clearance and half-life of ∼110-160 h. Analysis of serum biomarkers indicated considerable patient-to-patient variability, but trends toward elevated VEGF-A and a transient decline in soluble VEGFR-2. Fifteen patients (60%) had best response of stable disease, with a median duration of 13 months (range 2-18 months) in tumor types including colorectal, renal, liver, and neuroendocrine cancers. CONCLUSION: Ramucirumab was well tolerated. Study results led to recommended phase II doses of 8 mg/kg Q2W and 10 mg/kg Q3W. Prolonged stable disease was observed, suggesting ramucirumab efficacy in various solid tumors. CLINICALTRIALSGOV: NCT00786383.

Delayed open reduction and internal fixation of a neglected fracture dislocation of the ankle.

Neglected fracture dislocations of ankle are rare in western countries. Failure to achieve anatomic reduction is associated with a poor prognosis. We present a case of a patient with a neglected Weber B fracture of the fibula with postero-lateral subluxation of the ankle. In theatre, the subluxation could not be reduced, and a posterior and lateral soft tissue release was performed. Granulation tissue was removed from the medial gutter. The fibular fracture was reduced and fixed with a six-hole dynamic compression plate. Post-operative radiographs was satisfactory and the patient was followed up for 12 months with full range of movement and function of the joint. In our case, correction was not obtained by osteotomy of the lateral malleolus alone, and medial and posterior soft tissue release was required. This was due to disruption of the deltoid ligament and posterior tibiofibular ligament and the associated scar tissue. Previous studies have shown that, if anatomic reduction is achieved, results with delayed surgery can be as good as those obtained with immediate surgery. Surgically correcting an old fracture dislocation is a difficult undertaking due to soft-tissue contractures and malunited fractures. It is important to preserve as much soft tissue attachments and periosteum to prevent avascular necrosis.

Percutaneous vs. open repair of the ruptured Achilles tendon--a prospective randomized controlled study.

A prospective randomized controlled trial comparing open and percutaneous repair of closed ruptured Achilles tendons was performed over a period of 30 months. Sixty-six patients from seven district general hospitals were entered into the study with 33 patients randomized into each group. A modification of the technique described by Ma and Griffith was used in the percutaneous group and a Kessler suture supplemented with interrupted sutures was used in the open group. Patients were followed up for a minimum of six months. The mean age was 38.5 years (26 to 53 years). Forty patients were male and 26 female. After the rupturing event but prior to surgery, it was noted that seven patients had paresthesia in the territory of the sural nerve. The mean duration of immobilization was 12.4 weeks (10 to 14). The complications in the open group included seven wound infections (21%), two adhesions (6%) and two cases of re-rupture (6%). In the percutaneous group there were three cases of wound puckering (9%), one re-rupture (3%) and one case with persistent paresthesia in the sural nerve territory (3%). The difference in infective wound complications between the two groups was statistically significant (Fisher's exact test P = 0.01). Percutaneous repair is advocated on the basis of the low rate of complications and improved cosmetic appearance.

Novel structurally altered P(2X1) receptor is preferentially activated by adenosine diphosphate in platelets and megakaryocytic cells.

Experimental and clinical data suggest the presence of multiple types of adenosine diphosphate (ADP) receptors, one coupled to ligand-gated cation channels (P(2X)) and others coupled to G-protein-coupled (P(2Y)) receptors. This report identifies cDNA for a structurally altered P(2X1)-like receptor in megakaryocytic cell lines (Dami and CMK 11-5) and platelets that, when transfected into nonresponsive 1321 cells, confers a specific sensitivity to ADP with the pharmacologic rank order of ADP > > ATP > > > alpha,beta-methylene-ATP as measured by Ca(++) influx. This receptor (P(2X1del)) contains a deletion of 17 amino acids (PALLREAENFTLFIKNS) that includes an NFT consensus sequence for N-linked glycosylation. Glycosylated forms of the P(2X1del) and P(2X1wt) receptors were indistinguishable electrophoretically by Western blot or by immunoprecipitation using available antihuman and antirat antibodies. These results indicate that the expression of the P(2X1del) receptor results in an influx of Ca(++) induced by ADP. Expression of P(2X1del) receptor homomeric subunits is sufficient to express a receptor preferentially activated by ADP and suggests that this altered form, alone or in combination with P(2X1wt) receptors, is a component of an ADP-activated ion channel.

Molecular characterization of neurotrophin expression and the corresponding tropomyosin receptor kinases (trks) in epithelial and stromal cells of the human prostate.

The prostate is one of the most abundant sources of nerve growth factor (NGF) outside of the nervous system. NGF is a member of the neurotrophin family of growth factors which in mammals also includes brain derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3) and neurotrophin-4/5 (NT-4/5). These neurotrophins can bind with high affinity to a family of tropomyosin receptor kinases (trks). These receptors are trkA, which binds NGF; trkB, which binds both BDNF and NT-4/5; and trkC, which binds NT-3. In order to characterize the molecular expression of the neurotrophins and their corresponding trk receptors in the prostate we performed Northern blot analysis for the neurotrophins and reverse transcription-polymerase chain reaction (RT-PCR) coupled with Southern blot analysis for the trk family of receptors on smooth muscle stromal cells from the prostate, the androgen responsive LNCaP prostate tumor cell line and the androgen refractory TSU-pr1 prostate tumor cell line. The results show that smooth muscle stromal cells expressed NGF, BDNF and trkC, whereas both epithelial cell lines expressed trkA, trkB and trkC to various degrees. NT-3 was not detected in either the smooth muscle stromal cells or in both epithelial cell lines. This suggests that the stromal cell derived NGF and BDNF may interact via paracrine mechanisms with trkA and trkB receptors, respectively, on the adjacent epithelial cells. Interestingly, the androgen responsive LNCaP cell line did not express any of the neurotrophins, whereas the androgen refractory TSU-pr1 cell line expressed NGF, BDNF and NT-4/5. This suggests that the autocrine expression of NGF, BDNF and NT-4/5 is up-regulated in prostate epithelial cells following their transformation to an androgen refractory pathology. Hence, the malignant transformation of prostate epithelial tumor cells may facilitate their escape from a paracrine dependence on stromal cell derived neurotrophins by the acquisition of the autocrine expression of neurotrophins. Since the pathology of malignant cell migration within the prostate is predominantly by direct extension around prostatic nerves the upregulation of autocrine neurotrophin expression within prostate epithelial tumor cells may be concomitant with transformation to a malignant phenotype capable of invasion along the perineural space and extracapsular metastasis to distant sites of tumor formation.