Emergency Management and Nursing Considerations of Carotid Blowout Syndrome.

INTRODUCTION: Carotid blowout syndrome is a rare but fatal complication often witnessed secondary to treating patients with head and neck cancer. It occurs when damage and necrosis lead to the carotid artery wall rupture. The symptoms encountered in these patients range from asymptomatic to cardiac arrest. Here, we present 5 cases of carotid blowout syndrome in the emergency department. CASE PRESENTATIONS: Patients demonstrated symptoms ranging from subtle bleeding to hemodynamic instability, highlighting the diverse nature of carotid blowout syndrome in this population. Notably, while all patients had a history of radiotherapy, some had additional risk factors for carotid blowout syndrome, including prior surgery (n = 2), malnutrition (n = 3), and tracheostomies (n = 2). Definitive diagnoses were established through clinical evaluation and computed tomography angiography. Immediate interventions included bleeding control, resuscitation, and consultations with relevant specialties. Four patients underwent interventional radiology procedures, and 1 patient received otolaryngology care. While 2 patients recovered completely, 1 died in the emergency department, and 1 in the intensive care unit. One patient's clinical course was complicated by a stroke. CONCLUSION: The approach to the carotid blowout syndrome patient includes complex steps that proceed in a multidisciplinary manner, starting from triage until discharge. Emergency nurses play crucial roles at every stage. They should be aware of carotid blowout syndrome when evaluating patients with head and neck cancer presenting with bleeding. When treating these patients, emergency nurses should be ready for airway interventions, bleeding control, and massive transfusion protocol. In this context, the multifaceted approaches made by nurses contribute significantly to carotid blowout syndrome management in the emergency department.

Targeted Temperature Management Experience of an Academic Emergency Department: A 5-Year Retrospective Study.

Targeted temperature management (TTM) for postcardiac arrest syndrome patients is a cornerstone therapy to reduce mortality and neurological morbidity. The care of critical patients is provided in the emergency department (ED) when intensive care units (ICUs) are unavailable. This study aimed to determine the characteristics and mortality outcomes of postcardiac arrest patients who underwent TTM in an academic ED. Postcardiac arrest patients who underwent TTM between January 1, 2014, to November 1, 2018, at a tertiary care academic ED in Turkey were examined retrospectively. The mean age of 24 patients in whom TTM was initiated in the ED was 60.7 ± 19.2 years. Five (20.8%) of the patients who underwent TTM were discharged. Four (80%) of the discharged patients were in out-of-hospital cardiac arrest (OHCA). All patients with a total cardiopulmonary resuscitation duration of >25 minutes died. Mortality was significantly higher in patients without light reflexes (p = 0.006). Two patients who underwent TTM in the ED became organ donors after neurological determination of death. If the ICU cannot meet the needs, early initiation of TTM in the ED may contribute to good neurological outcomes. In this study, 80% of the patients who have positive neurological outcomes are OHCA. Lack of light reflex may be an evidence of poor neurological outcomes in postcardiac arrest patients. Emergency physicians should be encouraged to apply TTM.

Mammalian telomeric DNA suppresses endotoxin-induced uveitis.

Telomeric regions of mammalian chromosomes contain suppressive TTAGGG motifs that inhibit several proinflammatory and Th1-biased immune responses. Synthetic oligodeoxynucleotides (ODN) expressing suppressive motifs can reproduce the down-regulatory activity of mammalian telomeric repeats and have proven effective in the prevention and treatment of several autoimmune and autoinflammatory diseases. Endotoxin-induced uveitis (EIU) is an established animal model of acute ocular inflammation induced by LPS administration. Augmented expression of proinflammatory cytokines/chemokines such as TNFalpha, IL-6, and MCP1 and bactericidal nitric oxide production mediated by LPS contribute to the development of EIU. Suppressing these mediators using agents that are devoid of undesirable systemic side effects may help prevent the development of EIU. This study demonstrates the selective down-regulatory role of suppressive ODN after (i) local or (ii) systemic treatment in EIU-induced rabbits and mice. Our results indicate that suppressive ODN down-regulate at both the transcript and protein levels of several proinflammatory cytokines and chemokines as well as nitric oxide and co-stimulatory surface marker molecules when administrated prior to, simultaneously with, or even after LPS challenge, thereby significantly reducing ocular inflammation in both rabbit and mouse eyes. These findings strongly suggest that suppressive ODN is a potent candidate for the prevention of uveitis and could be applied as a novel DNA-based immunoregulatory agent to control other autoimmune or autoinflammatory diseases.

Impact of panretinal photocoagulation on optic nerve head parameters.

BACKGROUND: To investigate the impact of panretinal photocoagulation (PRP) on quantitative optic nerve head (ONH) assessment in patients with diabetic retinopathy. METHODS: Eighty eyes of 80 diabetic patients who did not undergo PRP and 45 eyes of 45 subjects with diabetes who underwent PRP were enrolled in the prospective, cross-sectional study. Participants were evaluated by confocal scanning laser ophthalmoscopy (CSLO). The global values of ONH parameters were compared among the groups. RESULTS: The eyes that had been treated with PRP had a significantly greater rim area (1.84 ± 0.45 vs. 1.68 ± 0.30 mm(2)), smaller cup/disc area ratio (0.14 ± 0.12 vs. 0.19 ± 0.12), smaller linear cup/disc ratio (0.34 ± 0.17 vs. 0.42 ± 0.14) and shallower cup depth (0.15 ± 0.09 vs. 0.18 ± 0.07 mm) than controls (p = 0.021, p = 0.019, p = 0.007, p = 0.04, respectively). On the other hand, PRP-treated eyes were found to have a significantly thinner mean peripapillary retinal nerve fibre layer compared with the eyes in the control group (0.21 ± 0.08 vs. 0.25 ± 0.09 mm; p = 0.029). CONCLUSIONS: These results suggest that the ONH morphology in eyes treated with PRP may be altered to mask glaucomatous cupping due to PRP itself. Therefore caution must be taken to interpret the CSLO parameters obtained from eyes that have been treated with PRP.

The relation between bevacizumab injection and the formation of subretinal fibrosis in diabetic patients with panretinal photocoagulation.

BACKGROUND AND OBJECTIVE: To report the development of subretinal fibrosis after the injection of intravitreal bevacizumab in eyes with proliferative diabetic retinopathy (PDR) refractory to panretinal laser photocoagulation (PRP). PATIENTS AND METHODS: Twenty-one eyes of 15 patients treated with PRP and intravitreal injection of bevacizumab were included in this study. The clinical outcomes of 21 eyes having subretinal fibrosis after intravitreal bevacizumab injection were reviewed. RESULTS: There were 9 men and 6 women with a mean age of 51.3 +/- 8.9 years. All eyes had PDR refractory to panretinal photocoagulation and were treated with at least one intravitreal injection of 1.25 mg of bevacizumab (mean number of injections: 1.8). Before injection, there was subretinal fibrosis in 5 eyes and vitreoretinal traction in 19 eyes. After a mean follow-up period of 7 months, the development or progression of subretinal fibrosis was detected in all eyes. CONCLUSION: Intravitreal injection of bevacizumab may cause formation or progression of subretinal fibrosis in patients with PDR refractory to PRP.

Aneurysmal bone cyst of the ethmoid presenting with proptosis and epiphora.

An aneurysmal bone cyst of ethmoid is a rare and distinct clinicopathologic entity. The diagnosis is important in this localization because it requires multidisciplinary approach in its management. We report a case of a 14-year-old woman presenting to our clinic with the complaint of epiphora and proptosis in the right eye, which were the symptomatic findings of aneurysmal bone cyst of ethmoid.

Inflammatory mediators and posterior segment involvement in ocular Behcet disease.

PURPOSE: To assess the serum level of mediators and their relation with posterior ocular involvement in patients with Behcet disease (BD). METHODS: This study was a prospective, institutional clinical trial including 43 patients with ocular BD. Patients were divided into two subgroups: those with active posterior segment involvement (Group A) and those with inactive ocular BD (Group B). Group A included patients with posterior uveitis (vitritis or chorioretinal involvement), while Group B included patients with no active intraocular inflammation within the last 3 months. Serum levels of interleukin (IL)-6, IL-8, tumor necrosis factor alpha (TNF-alpha), vascular endothelial growth factor (VEGF), and malondialdehyde (MDA) were measured by sandwich enzyme-linked immunosorbent assay and spectrophotometric assay and compared among the groups by independent sample t test and Mann-Whitney U-test. RESULTS: Serum levels of the mediators in Group A (IL-6 [23.1 pg/mL], IL-8 [161.1 pg/mL], TNF-alpha [30.5 pg/mL], VEGF [455.9 pg/mL], MDA [10.7 microm]) were found to be significantly higher than those in Group B (IL-6 [12.2 pg/mL], IL-8 [48.4 pg/mL], TNF-alpha [18.6 pg/mL], VEGF [138.0 pg/mL], MDA [5.1 microm]). CONCLUSIONS: This study demonstrated that increased serum levels of inflammatory mediators including IL-6, IL-8, TNF-alpha, VEGF, and MDA were possibly involved in the development of posterior uveitis in BD.

Choroidal mass as an initial presentation of lung cancer.

Choroidal mass may be a presenting sign of systemic malignancy. The diagnosis of metastatic ocular tumor is important because it can indicate poor prognosis. We report a case of a 45-year-old man presenting to our clinic with the complaint of decreased vision in the left eye, which is the initial finding of non-small cell lung-carcinoma.

A case report: zoledronic acid-induced anterior uveitis.

BACKGROUND: Bisphosphonates prevent bone loss by binding on active sites of bone remodeling and inhibiting osteoclast-mediated bone resorption. Zoledronic acid is recommended for patients with bone metastases from breast, prostate, and lung cancers. OBJECTIVE: To report a case of anterior uveitis after the infusion of zoledronic acid. CASE SUMMARY: A breast cancer patient with bone metastasis was admitted with pain, visual loss, hyperemia, and periorbital swelling in her right eye 24 h after the first dose of zoledronic acid. Biomicroscopic anterior segment examination of the right eye showed corneal keratic precipitates, ciliary injection, and moderate amount of cells in anterior chamber. With the diagnosis of right anterior uveitis, topical prednisolone acetate (1%) was started, and her symptoms completely resolved within 1 week. Use of the Naranjo probability scale indicated a probable relationship between uveitis and zoledronic acid therapy in our patient. DISCUSSION: Uveitis is a rare complication of zoledronic acid. The mechanism is unclear. Proinflammatory cytokines such as TNF-alpha and IL-6 may also play a role in pathogenesis of zoledronic acid-related uveitis. CONCLUSION: Zoledronic acid may be associated with inflammatory eye diseases and result in serious ocular damage.

Tissue glue in sutureless vitreoretinal surgery for the treatment of wound leakage.

BACKGROUND AND OBJECTIVE: To assess the surgical outcomes of the use of tissue glue to close sclerotomy sites when required and the views of ultrasound biomicroscopy of the sclerotomy sites in 23- and 25-gauge vitrectomy systems. PATIENTS AND METHODS: A 25-gauge transconjunctival sutureless vitrectomy was performed in 38 eyes and a 23-gauge transconjunctival sutureless vitrectomy was performed in 46 eyes for various vitreoretinal diseases. Wound leakage occurred at the sclerotomy sites at the end of the surgery in 6 eyes with 23-gauge transconjunctival sutureless vitrectomy and 7 eyes with 25-gauge transconjunctival sutureless vitrectomy. The sclerotomy sites were closed by using tissue glue to prevent wound leakage and evaluated with ultrasound biomicroscopy postoperatively. RESULTS: No wound leakage was observed at the end of the surgical procedure or during the follow-up period. Abnormal fibrous ingrowth was not detected at the sclerotomy sites by means of ultrasound biomicroscopy. CONCLUSION: The results demonstrated the efficacy of tissue glue for closing site ports when wound leakage is observed in transconjunctival sutureless vitreoretinal surgery.

Vogt-Koyanagi-Harada syndrome in children: report of a case and review of the literature.

This article reviews the therapeutic approaches in children with Vogt-Koyanagi-Harada (VKH) syndrome, and reports on a 9-year-old girl with progressive visual loss due to VKH syndrome in spite of treatment. In previous reports, corticosteroids were found to be the most effective agents in the treatment of VKH syndrome, while combination therapies with cyclosporine, methotrexate, or azathioprine were used with favorable results in refractory cases. In the current case, none of the treatments sufficiently stabilized the vision, but triple combination of corticosteroids, cyclosporine, and methotrexate suppressed the relapses of intraocular inflammation. Treatment of children with VKH syndrome is challenging. Various treatment modalities have been reported with various responses, but there is still no definite treatment regimen, and the treatment is usually individualized in pediatric VKH cases.

A case of bilateral iris mammillations with unusual pupillary appearance and pseudo-hypertension.

Iris mammillations are congenital abnormalities characterised by villiform elevations regularly spaced on the surface of the iris. The aetiology of iris mammillations is unknown. They can be either isolated or associated with melanocytosis involving the uveal tract and the periocular tissue, resulting in a risk for uveal melanoma. These lesions can be complicated by high intraocular pressure and, in the case of associated melanocytosis of the iris, sclera or periocular tissues, by uveal melanoma. Patients with iris mammillations should be followed regularly due to these potential complications. We report a case of bilateral iris mammillations with unusual pupillary appearance and pseudo-hypertension and emphasise the importance of iris mammillations and that central corneal thickness should be considered when intraocular pressure is measured.

Idiopathic bilateral bloody tearing.

Bloody tear is a rare and distinct clinic phenomenon. We report a case presenting with the complaint of recurrent episodes of bilateral bloody tearing. A 16-year-old girl presented to our clinic with complaint of bloody tearing in both eyes for 3 months. Bloody tearing was not associated with her menses. A blood-stained discharge from the punctum was not observed during the compression of both nasolacrimal ducts. Nasolacrimal passage was not obstructed. Imaging studies such as dacryocystography and gradient-echo magnetic resonance imaging (MRI) of nasolacrimal canal were normal. Intranasal endoscopic evaluation was normal. We collected samples from bloody tears two times and pathological examination was performed. Pathological analysis showed lots of squamous cells and no endometrial cells; dysplastic cells were found. Further evaluations for underlying causes were unremarkable. No abnormalities were found in ophthalmologic, radiologic, and pathologic investigations. This condition is likely a rare abnormality and the least recognized aetiology for the idiopathic phenomenon.

Best's vitelliform macular dystrophy with pseudohypopyon: an optical coherence tomography study.

PURPOSE: To report optical coherence tomography (OCT) changes in Best's vitelliform macular dystrophy (BVMD) with pseudohypopyon. DESIGN: Observational case report. METHODS: Both eyes of a patient with BVMD showing pseudohypopyon were examined with OCT. RESULTS: OCT demonstrated the presence of serous retinal elevation with normal appearing retinal pigment epithelium (RPE) superiorly, and broadening of the outer-retina-choroid-complex signal under retinal elevation, inferiorly. CONCLUSIONS: OCT findings in our study suggest the accumulation of material under neurosensory retina in BVMD with pseudohypopyon.

Vogt-Koyanagi-Harada disease: clinical and demographic characteristics of patients in a specialized eye hospital in Turkey.

PURPOSE: To evaluate clinical and demographic features of Vogt-Kayanagi-Harada disease (VKH) disease in Turkish patients and compare them with previously published data. METHODS: Demographic and clinical features of 32 patients diagnosed as VKH in a tertiary referral center were retrospectively reviewed. RESULTS: The mean age at presentation was 33.6 ± 10.4 years. Seventy-five percent of the patients were female and 62.5% of the patients presented during the last 2 years. The disease was complete in 31.2%, incomplete in 50%, and probable in 18.8% of the patients. The clinical course was acute in 50%, chronic recurrent in 34.4%, and chronic in 15.6%. The most common findings were bilateral serous retinal detachment ± papillitis in acute cases and retinal pigment epithelial changes of the macula in chronic cases. CONCLUSIONS: Although rare in Turkey, VKH disease seems to have increased during the last few years. The disease is incomplete and acute in half of the patients and has a quite good visual prognosis.

A rare ocular complication after a heart transplant: toxoplasma retinitis.

Ocular infections after a heart transplant are rare; but when present, they generally appear during the first year after surgery. Ocular infections may cause significant loss of vision and morbidity if not diagnosed early. For that reason, heart transplant patients should undergo a routine visual examination during follow-up. We report our experience regarding the followup and treatment of a case of toxoplasma retinitis diagnosed in one of our heart transplant recipients.

Changes of total antioxidant capacity and total oxidant status of aqueous humor in diabetes patients and correlations with diabetic retinopathy.

AIM: To measure changes of total oxidant status (TOS) and total antioxidant capacity (TAC) of aqueous humor (AH) in diabetic retinopathy (DR) patients, and to determine if there were any differences in TOS and TAC of AH in diabetic patients without retinopathy compared with non-diabetic patients. METHODS: One hundred and three eyes of 103 patients who were enrolled for cataract surgery were included in this study. Patients were grouped according to presence of diabetes and stage of DR. Prior to cataract surgery, 0.1mL to 0.2mL of AH was aspirated and analyzed for TAC and TOS level using a colorimetric method. RESULTS: TOS levels were highest among proliferative diabetic retinopathy (PDR) patients and lowest in patients with only cataracts. Results were statistically significant between all groups (P<0.05). Whereas result between diabetic without retinopathy patients and non-proliferative diabetic retinopathy (NPDR) patients was not statistically significant (P=0.757). TAC levels were highest in patients with only cataract and lowest among PDR patients and results were statistically significant between all groups (P<0.05). CONCLUSION: Aqueous humor TAC levels are low in diabetic patients and reduced further in DR patients, TOS levels are increased in diabetic patients and this is exacerbated in DR patients.

Localized Cystic Enlargement of the Distal Optic Nerve Sheath after Decompression Surgery.

Cystic formation of the optic meninges may occur after optic nerve sheath decompression surgery for the management of pseudotumor cerebri. A case with a cyst-like structure of the distal optic nerve sheath at the operation site in the late surgical period after nerve sheath decompression surgery is reported.