Teprotumumab for Thyroid Eye Disease-related Strabismus.

PURPOSE: To assess and quantify teprotumumab's effect on thyroid eye disease-related strabismus by change in measured horizontal and vertical deviations and change in extraocular motility. METHODS: We reviewed a series of patients with thyroid eye disease-related strabismus treated with teprotumumab. Exclusion criteria included age under 18 years, strabismus of alternate etiology, or thyroid eye disease-related reconstructive surgery during the treatment course. Primary outcomes were absolute (prism diopters) and relative (%) differences in horizontal and vertical deviations in primary position at distance, as well as change in ductions of the more affected eye. Secondary outcomes included incidence and timing of strabismus surgery postteprotumumab. RESULTS: Thirty-one patients were included, with mean age 63 years and thyroid eye disease duration 10 months. After teprotumumab, there was 6 prism diopters (39%) mean reduction in vertical deviation ( p < 0.001), without significant change in mean horizontal deviation ( p = 0.75). Supraduction, abduction, adduction, and infraduction significantly improved in the more restricted eye ( p < 0.01, p < 0.01, p = 0.04, and p = 0.01, respectively). Thirty-five percent of patients underwent strabismus surgery posttreatment, at an average 10 months after last infusion. CONCLUSIONS: Teprotumumab produced a statistically significant reduction in vertical but not horizontal strabismus angles in primary position at distance. Extraocular motility in all 4 ductions also improved. A substantial minority of patients still required strabismus surgery following teprotumumab.

Inferior Rectus Muscle Y-Split for Thyroid-Related Vertical Strabismus.

Incomitant hypotropia in thyroid eye disease can be difficult to manage, especially in the presence of orthotropia with fusion in down gaze and reading position. Recessing the affected ipsilateral inferior rectus muscle may result in an undesirable downgaze diplopia secondary to a hypertropia in downgaze. Various surgical techniques have been described to manage this potential complication including asymmetric recession of both inferior rectus muscles, posterior myoscleropexy operation, and the Scott recess/resect procedure of the contralateral inferior rectus. In 2004, Hoerantner et al. introduced the y-split recession of the medial rectus muscle for near esotropic deviations. The anterior portion of muscle is split and secured in a y-shaped configuration, which reduces the muscle lever arm and helps minimize incomitance and muscle slippage. Unlike the traditional Cüppers Faden, a y-split recession results in torque reduction in all gaze positions. In addition, a y-split recession does not involve scleral passes posteriorly reducing the risk of globe perforation. We report a patient with incomitant strabismus secondary to thyroid eye disease who underwent a combination of traditional recession and y-splitting recession of the contralateral inferior rectus muscle, resulting in good functional alignment in primary gaze and in the reading position.

Teprotumumab for Thyroid Eye Disease-related Strabismus.

PURPOSE: To assess and quantify teprotumumab's effect on thyroid eye disease-related strabismus by change in measured horizontal and vertical deviations and change in extraocular motility. METHODS: We reviewed a series of patients with thyroid eye disease-related strabismus treated with teprotumumab. Exclusion criteria included age under 18 years, strabismus of alternate etiology, or thyroid eye disease-related reconstructive surgery during the treatment course. Primary outcomes were absolute (prism diopters) and relative (%) differences in horizontal and vertical deviations in primary position at distance, as well as change in ductions of the more affected eye. Secondary outcomes included incidence and timing of strabismus surgery postteprotumumab. RESULTS: Thirty-one patients were included, with mean age 63 years and thyroid eye disease duration 10 months. After teprotumumab, there was 6 prism diopters (39%) mean reduction in vertical deviation ( p < 0.001), without significant change in mean horizontal deviation ( p = 0.75). Supraduction, abduction, adduction, and infraduction significantly improved in the more restricted eye ( p < 0.01, p < 0.01, p = 0.04, and p = 0.01, respectively). Thirty-five percent of patients underwent strabismus surgery posttreatment, at an average 10 months after last infusion. CONCLUSIONS: Teprotumumab produced a statistically significant reduction in vertical but not horizontal strabismus angles in primary position at distance. Extraocular motility in all 4 ductions also improved. A substantial minority of patients still required strabismus surgery following teprotumumab.

Genetic Variability of Bovine Leukemia Virus: Evidence of Dual Infection, Recombination and Quasi-Species.

We have characterized the intrahost genetic variation in the bovine leukemia virus (BLV) by examining 16 BLV isolates originating from the Western Siberia-Tyumen and South Ural-Chelyabinsk regions of Russia. Our research focused on determining the genetic composition of an 804 bp fragment of the BLV env gene, encoding for the entire gp51 protein. The results provide the first indication of the quasi-species genetic nature of BLV infection and its relevance for genome-level variation. Furthermore, this is the first phylogenetic evidence for the existence of a dual infection with BLV strains belonging to different genotypes within the same host: G4 and G7. We identified eight cases of recombination between these two BLV genotypes. The detection of quasi-species with cases of dual infection and recombination indicated a higher potential of BLV for genetic variability at the intra-host level than was previously considered.

Outcomes of Strabismus Surgery Following Teprotumumab Therapy.

PURPOSE: To investigate the results of patients undergoing surgical treatment for strabismic diplopia in thyroid eye disease (TED) following teprotumumab. DESIGN: Multicenter, retrospective, case series. METHODS: We report 28 patients who underwent extraocular muscle surgery for strabismic diplopia after treatment with teprotumumab at 7 different academic centers. Elapsed time from last teprotumumab dose to the date of surgery, previous orbital decompression, primary preoperative horizontal and vertical deviation, surgical procedure, and 2-month postoperative results were collected from the patient records. RESULTS: Sixteen (57%) patients were diplopia-free after 1 surgery. Three (11%) chose prism spectacles to correct residual diplopia, 2 (7%) used compensatory head posture to resolve diplopia, and 1 (4%) had intermittent diplopia and was functionally improved (choosing no prisms or further surgery). These were considered treatment successes. Three (11%) patients required reoperation, and all were diplopia-free after their second procedure. CONCLUSIONS: Most patients requiring surgery for strabismic diplopia following teprotumumab achieve good outcomes with success rates comparable to series published before the availability of teprotumumab.

Additive effects of TPMT and NUDT15 on thiopurine toxicity in children with acute lymphoblastic leukemia across multiethnic populations.

BACKGROUND: Thiopurines such as mercaptopurine (MP) are widely used to treat acute lymphoblastic leukemia (ALL). Thiopurine-S-methyltransferase (TPMT) and Nudix hydrolase 15 (NUDT15) inactivate thiopurines, and no-function variants are associated with drug-induced myelosuppression. Dose adjustment of MP is strongly recommended in patients with intermediate or complete loss of activity of TPMT and NUDT15. However, the extent of dosage reduction recommended for patients with intermediate activity in both enzymes is currently not clear. METHODS: MP dosages during maintenance were collected from 1768 patients with ALL in Singapore, Guatemala, India, and North America. Patients were genotyped for TPMT and NUDT15, and actionable variants defined by the Clinical Pharmacogenetics Implementation Consortium were used to classify patients as TPMT and NUDT15 normal metabolizers (TPMT/NUDT15 NM), TPMT or NUDT15 intermediate metabolizers (TPMT IM or NUDT15 IM), or TPMT and NUDT15 compound intermediate metabolizers (TPMT/NUDT15 IM/IM). In parallel, we evaluated MP toxicity, metabolism, and dose adjustment using a Tpmt/Nudt15 combined heterozygous mouse model (Tpmt+/-/Nudt15+/-). RESULTS: Twenty-two patients (1.2%) were TPMT/NUDT15 IM/IM in the cohort, with the majority self-reported as Hispanics (68.2%, 15/22). TPMT/NUDT15 IM/IM patients tolerated a median daily MP dose of 25.7 mg/m2 (interquartile range = 19.0-31.1 mg/m2), significantly lower than TPMT IM and NUDT15 IM dosage (P < .001). Similarly, Tpmt+/-/Nudt15+/- mice displayed excessive hematopoietic toxicity and accumulated more metabolite (DNA-TG) than wild-type or single heterozygous mice, which was effectively mitigated by a genotype-guided dose titration of MP. CONCLUSION: We recommend more substantial dose reductions to individualize MP therapy and mitigate toxicity in TPMT/NUDT15 IM/IM patients.

Alveolar ridge reconstruction with a digitally customized bone block allograft.

BACKGROUND: Reduced alveolar ridge volume is an often consequence after tooth loss, compromising implant placement and prosthetic rehabilitation. The digital customization of bone block allografts (BBA) is an alternative that incorporates advantages such as intimate contact with the recipient bed, increasing graft stability and reduced surgical time. In addition, enamel matrix derivate (EMD) has attracted interest for its effect on osteogenic gene expression and cell adhesion; few studies have focused on the benefits of bone regeneration with EMD. The aim of this case report is to present the reconstruction of a severely atrophic alveolar ridge defect with a digitally customized bone block allograft (CBBA) in combination with EMD as an adjuvant for bone regeneration and soft tissue healing. METHODS: Initially, the digital planning and manufacture of the BBA was performed based on an initial cone beam computed tomography (CBCT) scan. EMD was applied to the recipient site and to the CBBA before graft fixation. After 6 months, bone biopsies were obtained on re-entry surgery for prosthetically guided implant placement. RESULTS: Clinically, bone block showed good integration with the adjacent tissue and no signs of rejection or necrosis were found. On the histological evaluation, new bone was observed in intimate contact with the allograft and showed viable osteocytes and osteoblasts along its entire length. Residual allograft particles were observed to be highly osteoconductive. CONCLUSION: According to the clinical and histological results presented, the digital customization of the BBA allows an ideal graft fit to the recipient bed with excellent results in bone regeneration.

Subtotal pyloric obstruction by atypical hypertrophic pyloric muscle in a newborn.

This is a case of a neonate with suspected duodenal atresia on prenatal imaging. However, distal bowel gas was identified postnatally on regular X-rays with a possible pyloric obstructing mass visualised on ultasound. No contrast was visualised passing through the stomach on fluoroscopic studies. Operative evaluation revealed an atypical asymmetric hypertrophic pylorus with exophytic lesions of ectopic glandular tissue. Longitudinal open pyloromyotomy was performed which relieved the gastric obstruction resulting in symptomatic relief without any anatomy altering procedure required.

Retro-psoas appendicitis.

The vermiform appendix (VA) is known to exhibit a wide range of anatomic variability, with clinical presentation correlating with certain known anatomic positioning. To the best of our knowledge, we describe the second known case of a retro-psoas muscle VA variant and the first known case of appendicitis in such a location. Retroperitoneal access was obtained, and the appendix was freed from the intermuscular recess between the psoas and iliacus. The peritoneal defect was primarily repaired, and the patient was discharged on postoperative day 1 in good condition.

Midgut volvulus in a pediatric patient with chronic constipation, congenital intestinal malrotation and internal transmesocolic hernia.

Congenital intestinal malrotation occurs in 1 of 500 newborns and can predispose patients to intestinal volvulus and internal herniation, putting patients at risk for intestinal ischaemia. A male patient in early childhood with a history of severe constipation presented with acute abdominal pain, progressing rapidly to compensated shock. CT scan was suspicious for small bowel ischaemia and superior mesenteric artery compression. He underwent emergency exploratory laparotomy. Intraoperative findings were significant for partial intestinal malrotation with mobile ascending colon and high-riding caecum, and internal herniation with midgut volvulus of the ascending colon through a mesenteric defect in the proximal transverse colon. Derotation of the volvulus, reduction of the internal hernia, resection of necrotic segments of the bowel and a modified Ladd's procedure were performed. Postoperatively, the patient is total parenteral nutrition (TPN) dependent due to short bowel syndrome. A high index of suspicion with prompt imaging is paramount for paediatric patients with symptoms indicating intestinal obstruction.

Periodontal regeneration by minimally invasive procedures and its influence on pulp status.

Dental pulp and periodontium have different communication routes including, e.g., apical foramen, accessory canals and dentin tubules. Scaling, planing and root surface treatment with ethylenediaminetetraacetic acid (EDTA)-based conditioner are used in regenerative periodontal procedures. Such treatment may generate pathological communication between the two structures due to interruption of the vascular pedicle or migration of bacteria and/or inflammatory byproducts from deep periodontal pockets, which may generate pulp pathology. Aim: The aim of this study was to evaluate the influence of minimally invasive periodontal regenerative surgery on pulp vitality status in single-rooted and multi-rooted teeth associated to infraosseous defects extending to the middle and apical thirds. Materials and Method: This was a retrospective study on 30 teeth from 14 patients who received care between August 2018 and August 2019 at the postgraduate Department of Specialization in Periodontics of the Buenos Aires University School ofDentistry (FOUBA). Clinical and radiographic endodontic diagnosis was performed 6 months after the minimally invasive regenerative periodontal treatment. Results: Only two out of the 30 teeth presented changes in pulp status following regenerative periodontal procedure: irreversible pulpitis at 30 days and pulp necrosis at 180 days post-treatment. The rate for risk of change in pulp vitality status was 6.7%. Teeth with grade I and II furcation lesions (n=9) presented no change in pulp status. Conclusions: Regenerative periodontal surgery had no significant influence on pulp status in single-rooted and multi-rooted teeth with infraosseous defects extending to the level of the middle and apical third.

La pulpa dental y el periodonto presentan diferentes vías de comunicación. El foramen apical, los conductos accesorios y los túbulos dentinarios son ejemplos de ellos. Durante los procedimientos peri-odontales regenerativos se realiza el raspaje, alisado y tratamiento de la superficie radicular con un acondicionador a base de ácido etilendiaminotetraacético (EDTA). Este tratamiento podría generar una comunicación patológica entre ambas estructuras debido a la interrupción del pedículo vascular o a la migración de bacterias y/o subproductos inflamatorios provenientes de bolsas periodontales profundas que generen patología pulpar. Objetivo: El objetivo del presente estudio fue evaluar la influencia de la cirugía periodontal regenerativa mínimamente invasiva sobre el estado de vitalidad pulpar de piezas dentarias unirradiculares y multirradiculares con defectos infraóseos que se extendían hasta el tercio medio y apical. Materiales y Método: Se analizaron de forma retrospectiva 30 piezas dentarias de 14 pacientes atendidos entre el mes de agosto 2018 y agosto 2019 en el posgrado de la Especial-ización en Periodoncia de la Facultad de Odontología de la Universidad de Buenos Aires (FOUBA). Se realizó el diagnóstico endodóntico de forma clínica y radiográfica a los 6 meses post-tratamiento periodontal regenerativo mínimamente invasivo. Resultados: De las 30 piezas solo 2 presentaron cambios en el estado pulpar luego del procedimiento periodontal regenerativo, pulpitis irreversibles a los 30 días y necrosis pulpar a los 180 días post-tratamiento. La tasa de riesgo de cambios en el estado de vitalidad pulpar fue del 6,7%. En relación a las piezas dentarias que presentaban lesiones de furcación grado I y II (n=9) ninguna presentó cambios en su estado pulpar. Conclusiones: La cirugía periodontal regenerativa no tuvo influencia significativa en el estado pulpar de piezas unirradiculares y multirra-diculares con defectos infraóseos que se extendían a nivel del tercio medio y apical.

Anterior segment ischemia following strabismus surgery in a young adult using gender-affirming estrogen hormone therapy.

Well-known risk factors for anterior segment ischemia (ASI) following strabismus surgery include ipsilateral surgery on three or more rectus muscles, older age, and vasculopathy. ASI is rarely reported in young patients following uneventful strabismus surgery on two ipsilateral rectus muscles. We report a 30-year-old transgender female on long-term estrogen therapy who underwent strabismus surgery involving recessions of both lateral rectus muscles, the right inferior rectus muscle, and the left superior rectus muscle. The left eye developed severe ASI with hypotony maculopathy that was resistant to topical medications, oral steroids, anterior chamber reformation, and intravitreal steroid injection. Following phacoemulsification with intraocular lens and capsular tension ring insertion 1 year later, intraocular pressure and hypotony maculopathy improved.

Clinical and microbiological assessment in a subpopulation of young Argentine patients with severe periodontitis / Periodontitis severa en jóvenes argentinos. Evaluación clínica y microbiológica en jóvenes argentinos con periodontitis severa

ABSTRACT Aggressive periodontitis (AP) is the most serious entity of periodontal disease (stage III/IV, grade C periodontitis according to the latest classification, 2017). Aim: to enhance knowledge of periodontal microbiota in AP in native Argentine patients and describe the effect of a combined pharmacological-mechanicalperiodontal treatment on clinical and microbiological parameters. Materials andMethod: The study analyzed 42 periodontal sites in 11 patients diagnosed with AP. Clinical periodontal parameters were recorded at baseline, 45, 90 and 180 days. Microbiological samples were taken before treatment and at 180 days. PCR was used to determine presence of the periodontopathic bacteria Aggregatibacter actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), Tannerella forsythia (Tf), Treponema denticola (Td), Prevotella intermedia (Pi) and Fusobacterium nucleatum (Fn). Patients underwent periodontal therapy including antibiotics (Amoxicillin 500mg + Metronidazole 250mg; 8hs/7 days), and were reevaluated at 45, 90 and 180 days. Results: Mean age was 28.4 ± 7.9 years. The initial PCR detected the following frequencies: Aa 14.3%, Pi 61.9%, Pg 71.4%, Tf 81.0%, Fn 95.2% and Td 97.6%. Baseline microbiological samples revealed significantly higher prevalence of Pg over Aa (p=0.012). Clinical parameters improved significantly after treatment (73.8% PS<5 mm; PS, NIC, SS p<0.001). At 180 days, a significant decrease in microbiological detection rates was observed (Fn, Td, Tf, Pi, Aa p<0.05). Aa was no longer detectable while Pg did not decrease significantly (p=0.052). Fn was the only study species detected in 100% (n=11:42) of residual pockets (PS>5 mm) (p=0.053). Conclusion: In the initial samples, there was significant prevalence of Pg over Aa. Significant clinical improvement was achieved after the mechanical-pharmacological treatment, with undetectable levels ofAa, while Fn persisted in residual pockets, and Pg was present at most of the treated sites.

RESUMEN La periodontitis agresiva (PA) es la entidad más grave de la enfermedad periodontal (clasificación 2017: periodontitis estadio III/IV, grado C). Objetivo: mejorar el conocimiento sobre la microbiota periodontal de la PA en sujetos nativos argentinos y describir el efecto de un tratamiento mecánico-farmacológico periodontal sobre los parámetros clínicos y microbiológicos. Materiales y Método: se estudiaron 42 sitios periodontales correspondientes a 11 pacientes con PA. Los parámetros clínicos se registraron a 0, 45, 90 y 180 días. Las tomas microbiológicas se realizaron antes de iniciar el tratamiento y a los 180 días. La determinación de especies periodontopáticas (Aggregatibacter actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), Tannerella forsythia (Tf, Treponema denticola (Td), Prevotella intermedia (Pi) y Fusobacterium nucleatum (Fn)) se realizó por PCR. Los pacientes iniciaron terapia básica periodontal junto con antibioticoterapia (Amoxicilina 500 mg + Metronidazol 250 mg; 8 hs/7 días) y fueron evaluados a los 45, 90 y 180 días. Resultados: la edad media fue 28,4 ± 7,9 años. Las detecciones iniciales fueron: Aa 14,3%, Pi 61,9%, Pg 71,4%, Tf 81,0%, Fn 95,2% y Td 97,6%. En las muestras iniciales la prevalencia de Pg sobre Aa fue significativamente superior (p=0,012). Los pacientes tuvieron una respuesta clínica favorable al tratamiento (73,8% PS<5 mm; PS, NIC, SS p<0,001). A 180 días, se observó una disminución estadísticamente significativa en la detección microbiana (Fn, Td, Tf, Pi, Aa p<0,05). En igual plazo, Aa no fue detectado, mientras que Pg mostró una disminución no significativa (p=0,052). Fn fue el único detectado en el 100% (n=11:42) de las bolsas periodontales residuales (PS>5 mm) (p=0,053). Conclusión: Las muestras iniciales evidenciaron prevalencia significativa de Pg sobre Aa. El tratamiento logró una significativa mejora clínica con niveles indetectables de Aa. La persistencia de Fn en las bolsas residuales y de Pg en la mayoría de los sitios tratados, caracterizaron la muestra poblacional estudiada.

Periodontal regeneration by minimally invasive procedures and its influence on pulp status / Regeneración periodontal a través de procedimientos mínimamente invasivos y su influencia en el estado pulpar

ABSTRACT Dental pulp and periodontium have different communication routes including, e.g., apical foramen, accessory canals and dentin tubules. Scaling, planing and root surface treatment with ethylenediaminetetraacetic acid (EDTA)-based conditioner are used in regenerative periodontal procedures. Such treatment may generate pathological communication between the two structures due to interruption of the vascular pedicle or migration of bacteria and/or inflammatory byproducts from deep periodontal pockets, which may generate pulp pathology. Aim: The aim of this study was to evaluate the influence of minimally invasive periodontal regenerative surgery on pulp vitality status in single-rooted and multi-rooted teeth associated to infraosseous defects extending to the middle and apical thirds. Materials and Method: This was a retrospective study on 30 teeth from 14 patients who received care between August 2018 and August 2019 at the postgraduate Department of Specialization in Periodontics of the Buenos Aires University School ofDentistry (FOUBA). Clinical and radiographic endodontic diagnosis was performed 6 months after the minimally invasive regenerative periodontal treatment. Results: Only two out of the 30 teeth presented changes in pulp status following regenerative periodontal procedure: irreversible pulpitis at 30 days and pulp necrosis at 180 days post-treatment. The rate for risk of change in pulp vitality status was 6.7%. Teeth with grade I and II furcation lesions (n=9) presented no change in pulp status. Conclusions: Regenerative periodontal surgery had no significant influence on pulp status in single-rooted and multi-rooted teeth with infraosseous defects extending to the level of the middle and apical third

RESUMEN La pulpa dental y el periodonto presentan diferentes vías de comunicación. El foramen apical, los conductos accesorios y los túbulos dentinarios son ejemplos de ellos. Durante los procedimientos peri-odontales regenerativos se realiza el raspaje, alisado y tratamiento de la superficie radicular con un acondicionador a base de ácido etilendiaminotetraacético (EDTA). Este tratamiento podría generar una comunicación patológica entre ambas estructuras debido a la interrupción del pedículo vascular o a la migración de bacterias y/o subproductos inflamatorios provenientes de bolsas periodontales profundas que generen patología pulpar. Objetivo: El objetivo del presente estudio fue evaluar la influencia de la cirugía periodontal regenerativa mínimamente invasiva sobre el estado de vitalidad pulpar de piezas dentarias unirradiculares y multirradiculares con defectos infraóseos que se extendían hasta el tercio medio y apical. Materiales y Método: Se analizaron de forma retrospectiva 30 piezas dentarias de 14 pacientes atendidos entre el mes de agosto 2018 y agosto 2019 en el posgrado de la Especial-ización en Periodoncia de la Facultad de Odontología de la Universidad de Buenos Aires (FOUBA). Se realizó el diagnóstico endodóntico de forma clínica y radiográfica a los 6 meses post-tratamiento periodontal regenerativo mínimamente invasivo. Resultados: De las 30 piezas solo 2 presentaron cambios en el estado pulpar luego del procedimiento periodontal regenerativo, pulpitis irreversibles a los 30 días y necrosis pulpar a los 180 días post-tratamiento. La tasa de riesgo de cambios en el estado de vitalidad pulpar fue del 6,7%. En relación a las piezas dentarias que presentaban lesiones de furcación grado I y II (n=9) ninguna presentó cambios en su estado pulpar. Conclusiones: La cirugía periodontal regenerativa no tuvo influencia significativa en el estado pulpar de piezas unirradiculares y multirra-diculares con defectos infraóseos que se extendían a nivel del tercio medio y apical.

AAPOS Adult Strabismus Committee's Report on the Status of Adult Strabismus Telemedicine.

PURPOSE: To evaluate the utility of telemedicine in the treatment of adult patients with strabismus. METHODS: A 27-question online survey was sent to ophthalmologists of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) Adult Strabismus Committee. The questionnaire focused on the frequency of telemedicine utilization, the benefits in the diagnosis, follow-up, and treatment of adult strabismus, and barriers of current forms of remote patient visits. RESULTS: The survey was completed by 16 of 19 members of the committee. Most respondents (93.8%) reported 0 to 2 years of experience with telemedicine. Telemedicine was found to be useful for initial screening and follow-up of established patients with adult strabismus, mainly to reduce wait time for a subspecialist visit (46.7%). A successful telemedicine visit could be completed with a basic laptop (73.3%) or a camera (26.7%) or could be assisted by an orthoptist. Most participants agreed that common forms of adult strabismus (cranial nerve palsies, sagging eye syndrome, myogenic strabismus, and thyroid ophthalmopathy) could be examined via webcam. It was easier to analyze horizontal than vertical strabismus. Among the paralytic forms, sixth nerve palsy was the easiest one to assess. Latent forms of strabismus can be partially diagnosed and evaluated using telemedicine, but half of the respondents underlined the importance of in-person examinations in these cases. Sixty-nine percent believed that telemedicine could be a low-cost and time-efficient health service solution. CONCLUSIONS: Most members of the AAPOS Adult Strabismus Committee consider telemedicine to be a useful supplement to the current adult strabismus practice. [J Pediatr Ophthalmol Strabismus. 2023;60(6):386-389.].

Fast-Track for Total Ankle Replacement: A Novel Enhanced Recovery Protocol for Select Patients.

BACKGROUND: Enhanced recovery after surgery programs, also called fast-track protocols, were developed and successfully applied in the last decade for hip and knee reconstruction. Specific fast-track protocols have not yet been applied to ankle prostheses. The aim of the study was to develop and validate an enhanced recovery protocol for total ankle replacement (TAR) evaluating the clinical and radiographic results. We hypothesize that on the basis of well-defined pre- and postoperative characteristics, the current knowledge on ankle replacement, and referring to hip and knee reconstruction, it is possible to identify a "patient type" to be safely eligible to a Fast-Track Protocol with at least comparable results and without increasing the complications risk. METHODS: We identified 8 predictive variables that might affect the outcome of TAR. Those variables were the body mass index, the state of anxiety or depression, the functional preoperative status, ankle equinus, the coronal malalignment, the surgical time, the surgical accessory procedures, and the bone quality. These characteristics were evaluated for each patient with almost validated outcome tools attributing a specific score. Based on the score obtained, the patients were divided into 2 groups: the Standard Protocol group (Control Group) and the Fast-Track Protocol group (Study Group). The main difference between treatment of the 2 groups relates to the use of postoperative plaster casts: in the Fast-Track group the cast was removed the first day after surgery and walking was allowed in sports shoes assisted with crutches, whereas in the Standard Protocol group, the cast was removed after 3 weeks. Clinical and radiographic evaluation was performed for all patients preoperatively and postoperatively every 6 months. RESULTS: A total of 163 patients received a score between 1 and 5 and were included in the control group (Standard Protocol); 47 patients received a score of 0 and were allocated to the study group (Fast-Track Protocol). Clinically, except for the preoperative American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score, no statistically significant differences were recorded in the multiple comparisons between the 2 groups. No significant differences were found regarding complications. CONCLUSION: In selected patients, it is possible to apply an enhanced recovery protocol of rehabilitation, focused on immediate weightbearing and mobilization without any plaster or boot. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Is continuous Erector Spinae Plane Block (ESPB) better than continuous Serratus Anterior Plane Block (SAPB) for mitral valve surgery via mini-thoracotomy? Results from a prospective observational study.

Aims: Chest wall blocks are effective alternatives for postoperative pain control in mitral valve surgery in right mini-thoracotomy (mini-MVS). We compared the efficacy of Serratus Anterior plane block (SAPB) and Erector Spinae plane block (ESPB) on postoperative pain relief after mini-MVS. Settings and Design: It is a prospective, observational study. Material and Methods: A total of 85 consecutive patients undergoing continuous SAPB and continuous ESPB for mini-MVS from March 2019 to October 2020 were included. The primary outcome was the assessment of postoperative pain evaluated as absolute value of NRS at 12, 24 and 48 h. Secondary outcomes were assessment of salvage analgesia (both opioids and NSAIDs), incidence of mild adverse effects (i.e. nausea, vomiting, and incorrect catheter placement) and timing of postoperative course (ICU and hospital length of stay, duration of mechanical ventilation, ventilator-free days). Results: The median NRS was 0.00 (0.00-3.00) at 12 h and 0.00 (0.00-2.00) at 24 and 48 h. No significant differences were observed between groups. Postoperative morphine consumption in the first 24 h was similar in both groups (P = 0.76), whereas between 24 and 48 h was significantly less in the ESPB group compared with SAPB group, P = 0.013. NSAIDs median consumption and Metoclopramide consumption were significantly lower in the ESPB group compared to SAPB group (P = 0.002 and P = 0.048, respectively). Conclusions: ESPB, even more than SAPB, appears to be a feasible and effective strategy for the management of postoperative pain, allowing good quality analgesia with low consumption of opioids, NSAIDs and antiemetic drugs.

Nasal Transposition of the Split Lateral Rectus Muscle for Strabismus Associated With Bilateral 3rd-Nerve Palsy.

PURPOSE: To determine the success rate and complications associated with nasal transposition of the split lateral rectus muscle (NTSLR) for treating bilateral 3rd-nerve palsy. DESIGN: Retrospective, interventional case series. METHODS: An international, multicenter registry was used for the study. The study population was all patients with bilateral 3rd-nerve palsy treated with NTSLR. Sensorimotor evaluations were conducted before and 6 months after unilateral or bilateral NTSLR. Outcome measures were postoperative horizontal alignment ≤15 prism diopters (PD), intraoperative technical difficulties, and vision-threatening complications. The association of patient demographics and surgical technique with each outcome was analyzed using multivariable logistic regression. RESULTS: A total of 34 patients were included, with a median age of 46 years (interquartile range [IQR] = 25-54 years) at surgery. The most common etiologies were ischemic (29%), neoplastic (15%), and congenital (12%). NTSLR performed unilaterally with alternative surgery on the opposite eye (65%) resulted in a median postoperative exotropia of 18 PD (IQR = 7-35 PD), and when performed bilaterally (35%) resulted in postoperative exotropia of 14 PD (IQR = 5-35 PD). Success was achieved in 50% of cases, intraoperative technical difficulties were reported in 18%, and vision-threatening complications occurred in 21%. Attachment of the lateral rectus muscle ≥10 mm posterior to the medial rectus insertion was associated with increased vision-threatening complications (odds ratio = 9.0; 95% CI = 1.3-99). CONCLUSIONS: NTSLR can address the large-angle exotropia associated with bilateral 3rd-nerve palsy. Surgeons should be aware that posterior placement of the lateral rectus muscle may increase the risk of vision-threatening complications, particularly serous choroidal effusion.

Hybrid Single-Port Cholecystectomy of a Pediatric Gallbladder Volvulus.

Gallbladder volvulus is a rare gallbladder pathology that can present in adults but is exceedingly rare in children. The diagnosis itself can be very challenging due to its presentation with signs and symptoms of acute cholecystitis without specific imaging findings. The correct identification and prompt intervention with a cholecystectomy are crucial to improve patient outcomes. In this report, we discuss a pediatric patient who presented with gallbladder volvulus and subsequently underwent novel treatment with a single-port laparoscopic cholecystectomy. The patient is a 12-year-old male of Haitian descent who presented to an outside facility following the onset of persistent, right upper quadrant abdominal pain and recurrent nonbilious emesis. The diagnostic workup included serial abdominal exams, laboratory work, right upper quadrant ultrasounds, and a hepatobiliary iminodiacetic acid (HIDA) scan. The patient then underwent single-port laparoscopic removal of the torsed gallbladder with complete resolution of his symptoms. In this case report, the management and clinical presentation of gallbladder volvulus are discussed in more detail as well as the feasibility of single-port laparoscopic cholecystectomy in the setting of pediatric gallbladder volvulus.