Anatomical distribution of mandibular fractures from severe bicycling accidents: A 12-year experience from a Norwegian level 1 trauma center.

BACKGROUND/AIM: The mandible makes up a substantial part of the lower face, and is susceptible to injury. Even in helmeted cyclists, accidents may lead to fractures of the mandible because conventional helmets provide little protection to the lower part of the face. In addition, some studies indicate that helmets may lead to an increased risk of mandibular fractures. Thus, the aim of this study was to examine the anatomic distribution of mandibular fractures in injured cyclists and to assess if helmet use influenced the fracture locations. MATERIAL AND METHODS: Data from a Norwegian Level 1 trauma center were collected in the Oslo University Hospital Trauma Registry over a 12-year period. Of 1543 injured cyclists, the electronic patient charts of 62 cyclists with fractures of the mandible were retrospectively evaluated in detail. Demographic data, helmet use, and fracture type were assessed. RESULTS: Sixty-two patients (4%) had fractures of the mandible, and women had an increased risk (OR 2.49, 95% CI 1.49-4.16, p < .001). The most common fracture site was the mandibular body, followed by the condyle. Isolated mandibular fractures occurred in 45% of the patients and 55% had other concomitant facial fractures. There were 42% of the patients with fractures in multiple sites of the mandible, and 42% had a concomitant dentoalveolar injury. Half of the cyclists were wearing a helmet at the time of the accident and 39% were not. There was no significant difference in fracture distribution between the helmeted and non-helmeted groups. CONCLUSIONS: Fracture of the mandibular body was the most prevalent mandibular fracture type following bicycle accidents. Women had an increased risk of mandibular fractures compared with men, whereas helmet wearing did not affect the anatomical fracture site.

Dislocation of intraocular lens. / Dislokasjon av kunstig linse.

BACKGROUND: Cataract surgery with implantation of an artificial intraocular lens (IOL) in the lens capsule ('in-the-bag') is one of the world's most common surgeries. After many years, this IOL capsule complex may dislocate. This condition, called late in-the-bag IOL dislocation, has an estimated incidence of 0.5-1 %, with increasing frequency. CASE PRESENTATION: A man in his late seventies presented with monocular decreased vision and high intraocular pressure. Pupil dilation revealed the diagnosis of late in-the-bag IOL dislocation. Surgery was performed with repositioning of the dislocated complex by scleral suturing. The patient's visual acuity normalised after surgery. INTERPRETATION: Late in-the-bag IOL dislocation is no longer a rare condition. It requires surgery, which may be performed either as repositioning of the dislocated complex or by exchanging it for a new IOL. Both operation methods give a good visual outcome.

Inflammatory reaction in eyes with late in-the-bag intraocular lens dislocation.

PURPOSE: To investigate the inflammatory reaction in eyes with late in-the-bag intraocular lens (IOL) dislocation. METHODS: This prospective clinical study with fellow-eye comparison consists of 76 of the patients (76 eyes) with late in-the-bag IOL dislocation enrolled in the LION trial. The main outcome measure was anterior chamber flare before surgery measured with a laser flare meter in photon counts per millisecond (pc/ms). The dislocation was graded as 1 (small: optic still covering the visual axis), 2 (optic equator close to the visual axis) or 3 (optic decentred beyond the visual axis, but the IOL-capsule complex partly visible in the pupillary area). The secondary aim was to compare intraocular pressure (IOP) before surgery. RESULTS: Flare levels before surgery were significantly higher in the dislocation eyes than in the fellow eyes with a median flare of 21.5 (range 5.4-135.7) pc/ms versus 14.1 (2.0-42.9) pc/ms, respectively (p ˂ 0.001). A regression analysis of log-transformed flare values showed that the dislocation eyes had a non-significant tendency towards higher flare in dislocation grade 1 with a median flare of 24.6 (5.4-135.7) pc/ms compared to grade 2; 19.6 (6.5-41.5) pc/ms (p = 0.06), and no significant difference compared to grade 3; 19.4 (10.2-53.5) pc/ms (p = 0.47). The IOP was significantly higher in the dislocation eyes than in the fellow eyes (p ˂ 0.001). CONCLUSIONS: Eyes with late in-the-bag IOL dislocation had increased flare levels compared to their fellow eyes. This suggests that inflammation is part of the clinical picture of late in-the-bag IOL dislocation.

[Resting pulse rate as an indicator of health and disease]. / Hva sier hvilepulsen om helse og sykdom?

BACKGROUND: The resting pulse rate appears to be an independent cardiovascular risk factor. The paper reviews the scientific evidence in support of this assertion and discusses how the findings of this simple examination may be put to clinical use. METHOD: We have evaluated the relationship between resting pulse rate, cardiovascular disease and mortality based on evidence retrieved by a search in the Medline database. RESULTS: The resting pulse rate varies with physical fitness, and high intensity training can decrease the resting pulse. A high resting pulse rate is associated with an elevated risk of cardiovascular disease, and a poorer prognosis in established cardiovascular disease. The relationship between a high resting pulse and death from cardiovascular disease can be explained by well-known pathophysiological mechanisms, but more evidence is needed. In particular, we do not know why the associations between pulse rate and health are weaker in females. Physical exercise is beneficial in prevention and often also in the treatment of cardiovascular disease. We do not yet know how much of the beneficial effects of exercise are mediated through a lowered resting pulse. INTERPRETATION: Taking the resting pulse should form part of prophylactic health monitoring procedures the same way as the monitoring of other cardiovascular risk markers such as blood pressure, lipids, smoking status and weight. Among patients with established cardiovascular disease, the resting pulse rate is an important prognostic marker. An elevated resting pulse rate might be an incitement to recommend increased physical activity.

Long-term risk of suture breakage after scleral fixation of late in-the-bag intraocular lens dislocation with a polypropylene 10-0 suture.

PURPOSE: To investigate the long-term risk of suture breakage after scleral fixation with a polypropylene 10-0 suture in eyes with late in-the-bag intraocular lens (IOL) dislocation. SETTING: Oslo University Hospital, Oslo, Norway. DESIGN: Retrospective case series. METHODS: Patients operated with scleral suturing of late in-the-bag IOL dislocation from 2007 to 2016. 192 eyes (176 patients) operated with scleral suture (polypropylene 10-0 suture) fixation of a dislocated IOL-capsule complex were identified; 91 patients (47%) were men. RESULTS: The mean follow-up after the operation was 6.2 (95% CI, 5.7-6.7) years, and 98 patients (56%) deceased during the study. 11 eyes (6%) (11 patients) had suture breakage that required reoperation with a mean time of 5.5 (3.4-7.6) years after IOL repositioning surgery. These patients had a mean age of 73.5 (67.9-79.2) years at the time of the operation for late in-the-bag IOL dislocation vs 81.3 (79.8-82.9) years for patients who did not experience this complication ( P = .004). No cases of late endophthalmitis were registered. CONCLUSIONS: The long-term risk of suture breakage was quite low after scleral fixation of late in-the-bag IOL dislocation, particularly in the oldest patients. Hence, the polypropylene 10-0 suture seems to be a safe option for scleral fixation in this patient group.

Intraocular Inflammation in Eyes Operated for Late In-the-bag intraOcular lens dislocatioN (LION): A Randomized Clinical Trial.

PURPOSE: To compare the intraocular inflammation after 2 surgical approaches for late in-the-bag intraocular lens (IOL) dislocation. DESIGN: Prospective, randomized, parallel-group clinical trial. METHODS: We randomly assigned 100 patients (100 eyes) referred to Oslo University Hospital (tertiary referral center) with late in-the-bag IOL dislocation into IOL repositioning by scleral suturing (n=49) or IOL exchange with retropupillary fixation of an iris-claw lens (n=51). Patients were examined before surgery and 2 weeks, 6 weeks, and 6 months after surgery. The main outcome measure was anterior chamber laser flare, measured with a laser flare meter as photon counts per millisecond (pc/ms). RESULTS: Two weeks following surgery, median flare values were 28.9 pc/ms (range, 7.9-140) in the repositioning group and 31.6 pc/ms (range, 9.8-92.3) in the exchange group (P = .83). Flare levels were still elevated after 6 weeks with no difference between the groups (P = .93), whereas it decreased to baseline levels after 6 months. Six weeks following surgery, the central retinal thickness was similar (P = .97); cystoid macular edema (CME) was found in 4 and 5 patients, respectively (P = .85); and the mean best corrected visual acuity was 0.17 (95% CI 0.09, 0.25) and 0.21 (95% CI 0.09, 0.32) logarithm of the minimum angle of resolution, respectively (P = .61). CONCLUSIONS: This study revealed similar levels of intraocular inflammation following IOL repositioning and IOL exchange. There was no significant difference regarding risk of CME and visual outcome. The prolonged elevation in postoperative flare indicates a possible requirement for an extended anti-inflammatory treatment period after these operations.

Repositioning surgery of different intraocular lens designs in eyes with late in-the-bag intraocular lens dislocation.

PURPOSE: To evaluate the long-term efficacy and safety after intraocular lens (IOL) repositioning by scleral suturing of 1-piece IOL compared with other IOL designs in the treatment of late in-the-bag IOL dislocation. SETTING: Patients referred to Oslo University Hospital Oslo, Norway. DESIGN: Prospective cohort study. METHODS: The study comprised 54 patients (54 eyes) with late in-the-bag IOL dislocation treated with IOL repositioning by scleral sutures (10-0 polypropylene). All operations were performed with an anterior approach and by 1 surgeon. The following IOL designs were repositioned: 1-piece foldable (n = 17), 3-piece foldable (n = 28), plate-haptic (n = 8), and 1-piece rigid (n = 1) IOLs. Patients were evaluated comprehensively preoperatively and at 6 months (80%), 1 year (67%), and 2 years (61%) postoperatively. The main outcome measures were efficacy regarding corrected distance visual acuity (CDVA) and spherical equivalent (SE) and safety regarding complications. RESULTS: Postoperative visual acuity was similar for different IOL designs. The mean SE change to final observation was -0.08 (95% CI, -0.93 to 0.77) in the 1-piece IOL group (n = 11) and -0.98 (-1.73 to -0.23) in the 3-piece IOL group (n = 18) (P = .11). Regarding safety, no patients had uveitis-glaucoma-hyphema syndrome, retinal detachment, or endophthalmitis. The 3-piece IOL group had 1 case of redislocation and 1 case of iritis. No patients had symptoms related to clinical IOL decentration. Long-term intraocular pressure remained within normal limits with overlapping 95% CIs for different IOLs. CONCLUSIONS: Repositioning surgery of 1-piece IOLs seems as efficient and safe as that for other IOL designs in the treatment of late in-the-bag IOL dislocation.

Late in-the-bag intraocular lens dislocation.

This review aimed to evaluate the cumulative incidence, patient characteristics, predisposing conditions, and treatment outcomes for late in-the-bag intraocular lens (IOL) dislocation. Literature searches in PubMed (MEDLINE), Embase, and Cochrane Library Central database identified 1 randomized clinical trial, 1 prospective case series, 2 prospective cohort studies, and 36 retrospective studies of this condition, which showed that the cumulative incidence was 0.5% to 3%, it occurred on average 6 to 12 years after cataract surgery, and mean patient age was 65 to 85 years. Pseudoexfoliation syndrome, myopia, and previous vitreoretinal surgery were the most common predisposing conditions. Studies indicated that IOL repositioning and IOL exchange provided similar visual outcomes and were equally safe. The long-term visual outcome seemed satisfactory. However, the quality of evidence regarding treatment was in general quite low. More studies of late in-the-bag IOL dislocation are needed, and in particular, different surgical techniques should be included in high-quality clinical trials.

Longitudinal corneal endothelial cell loss after corrective surgery for late in-the-bag IOL dislocation: a randomized clinical trial.

PURPOSE: To compare safety regarding longitudinal corneal endothelial cell loss (ECL) after IOL exchange vs IOL repositioning for late in-the-bag IOL dislocation. SETTING: Oslo University Hospital, Norway. DESIGN: Prospective, parallel group, randomized clinical trial. METHODS: During a 3-year period, 104 patients were randomly assigned to groups receiving either IOL exchange with retropupillary fixation of an iris-claw IOL (n = 50) or IOL repositioning by scleral suturing (n = 54). All operations were performed by 1 surgeon with an anterior approach. Endothelial cell density (ECD) and central corneal thickness were measured preoperatively and at 6 months, 1 year, and 2 years postoperatively. A linear mixed model was applied for the longitudinal analysis, where patients with at least 1 ECD measurement were included (n = 44 exchange; n = 50 repositioning). The main outcome measure was 2-year longitudinal ECL in IOL exchange compared with IOL repositioning. RESULTS: The longitudinal ECL was similar between the IOL exchange (n = 44) and IOL repositioning (n = 50) groups during the 2 years of follow-up (17.5% vs 15.3%, P = .15). A subgroup analysis found no reason to advise against either method for patients with low preoperative ECD (<1500 cells/mm). The mean central corneal thickness was similar between the 2 groups and remained stable over 2 years of follow-up. CONCLUSIONS: This randomized clinical trial of late in-the-bag IOL dislocation surgery found that exchanging the IOL was as safe as repositioning in terms of 2-year longitudinal ECL.

Long-Term Outcomes after Surgery for Late In-The-Bag Intraocular Lens Dislocation: A Randomized Clinical Trial.

PURPOSE: To compare the long-term efficacy and safety of 2 operation methods for late in-the-bag intraocular lens (IOL) dislocation. DESIGN: Prospective, randomized, parallel group surgical clinical trial. METHODS: During a 3-year period, 104 patients (104 eyes) were assigned one group for IOL repositioning by scleral suturing (n = 54) or one group for IOL exchange by retropupillary fixation of an iris claw IOL (n = 50). A single surgeon performed all operations using an anterior approach. Patients were examined before surgery and at 6 months and 1 and 2 years after surgery. The present study included the 66 patients (63%) who completed the 2-year follow-up, and the main outcaome measurement was corrected distance visual acuity (CDVA) 2 years after surgery. RESULTS: After 2 years, the mean CDVA was 0.20 ± 0.29 logarithm of the minimum angle of resolution (logMAR) units (range, -0.18 to 1.10) in the repositioning group and 0.22 ± 0.30 logMAR (range, -0.10 to 1.22) in the exchange group (P = .69). A CDVA of 20/40 or better was achieved by 76% of all patients. Four eyes (12%) had cystoid macular edema in the repositioning group compared with 5 eyes (15%) in the exchange group. Two eyes underwent redislocation (1 in each group). There were no cases of endophthalmitis or retinal detachment. CONCLUSIONS: There were no significant differences between the visual acuity using IOL repositioning and that using IOL exchange 2 years after surgery. The two methods were equally efficient and safe from a long-term perspective and are both considered acceptable treatments.

Cost-effectiveness analysis in a randomized trial of late in-the-bag intraocular lens dislocation surgery: repositioning versus exchange.

PURPOSE: To compare the cost-effectiveness of two operation methods for late in-the-bag intraocular lens (IOL) dislocation. METHODS: In this randomized clinical trial, 104 patients were randomly assigned to IOL repositioning by scleral suturing (n = 54) or IOL exchange with a retropupillary iris-claw lens (n = 50). A cost-effectiveness analysis (CEA) was performed in conjunction with previously published 6-month efficacy and safety results. An incremental cost-effectiveness ratio was calculated as the cost difference between the operation groups relative to their difference in postoperative corrected distance visual acuity (CDVA) (mean and 95% confidence interval: minimum and maximum), reported as the cost difference in United States Dollars ($) per logMAR difference. RESULTS: Exchange surgery was $281.20 ± 17.66 more expensive than repositioning, mainly explained by the new IOL and the frequent use of anterior vitrectomy. A previous trial publication revealed no significant difference in the 6-month postoperative CDVA between the groups. In the CEA, the mean group difference yielded an incremental cost-effectiveness ratio of -$281.20 per -0.11 logMAR (-$1108/QALY) in favour of repositioning, ranging from -$281.20 per -0.29 logMAR (-$406/QALY) in favour of repositioning to +$281.20 per -0.08 logMAR (+$1522/QALY) in favour of exchange. The CEA did not include the mean 9.5 min shorter operation time for exchange. CONCLUSION: Repositioning tended to be more cost-effective than exchange; however, this is modified if also considering the operation time. Overall, it seems the cost-effectiveness is not alone sufficiently different to recommend one of the operation methods over the other for late in-the-bag IOL dislocation.