Temperature changes associated with bone drilling in an orbital model: comparison of ultrasonic bone curette and conventional high-speed rotational drill.

Purpose: Thermal injury to the optic nerve is a potential complication of bony decompression of the orbital apex. An animal model was used to compare and contrast temperature change while removing orbital bone with ultrasonic and conventional drills. Methods: Two devices, Sonopet ultrasonic bone curette and TPS CORE Micro drill, were used to remove bone from six unpreserved exenterated porcine orbits at fixed distances from the optic canal while temperature was recorded. Increasing irrigation flow rate and decreasing saline temperature with the ultrasonic bone curette were also investigated. Results: The mean change in temperature at the optic canal using the ultrasonic bone curette with 18 ml/min 24°C irrigation was +7.2 ± 3.3°C (range 3.3-12.7°C) at 60 s, and using the rotational drill was +1.7 ± 1.3°C (range 0.1-3.3°C), representing a statistically significant increase above baseline for both drills (p < 0.01 for each). The difference in temperature change between drills was statistically significant (p < 0.01). When irrigation fluid was changed from room temperature saline (24°C), rate 18 ml/min to chilled (10°C) irrigation saline, rate 40 ml/min, the magnitude of the mean temperature increase was reduced by 3.1°C, p < 0.05. Conclusions: In this orbital decompression model, both ultrasonic and rotational drills induced a rise in temperature. This increase was significantly greater with the ultrasonic bone curette, measuring up to 13.7°C. Clinicians should be aware of the potential for temperature spikes when decompressing the orbital apex. Increasing irrigation flow rate and using chilled saline may mitigate increases in temperature.

Nonsurgical Management of Retained Needlefish Jaw.

While scuba diving, the left medial canthus of a 53-year-old man was pierced by a needlefish. He immediately lost vision in his left eye. An orbital computed tomographic scan showed the needlefish jaw in the left optic canal. The left medial orbit was explored surgically but no foreign object was removed. One month later, MRI confirmed the presence of the retained needlefish jaw. A conservative approach was taken and the patient remained stable over 3 months of follow-up.

Relative Frequencies of Arteritic and Nonarteritic Anterior Ischemic Optic Neuropathy in an Arab Population.

BACKGROUND: To evaluate the relative frequencies of arteritic and nonarteritic anterior ischemic optic neuropathy (AION) in an Arab population and to compare and contrast these findings with known epidemiological data from Caucasian populations. METHODS: A retrospective review of the medical records of all patients diagnosed with AION at the King Khaled Eye Specialist Hospital (KKESH) in Riyadh, Saudi Arabia, between 1997 and 2012. RESULTS: Of 171 patients with AION, 4 had biopsy-proven giant-cell arteritis (GCA). The relative frequencies of arteritic anterior ischemic optic neuropathy (AAION) and nonarteritic anterior ischemic optic neuropathy (NAION) in this Arab cohort were 2.3% and 97.7%, respectively. CONCLUSIONS: The relative frequencies of arteritic anterior ischemic optic neuropathy and nonarteritic anterior ischemic optic neuropathy differ between Arab and North American clinic-based populations, with giant-cell arteritis-related ischemia being much less frequent in Saudi Arabia.

Liver injury from tumor necrosis factor-α antagonists: analysis of thirty-four cases.

BACKGROUND & AIMS: Tumor necrosis factor (TNF)-α antagonists have been associated with drug-induced liver injury (DILI). We reviewed cases of DILI in the United States to identify those associated with use of TNF-α antagonists. METHODS: We searched the U.S. DILI Network (DILIN) database, from 2003 to 2011, for cases associated with TNF-α antagonists. Mean Roussel-Uclaf Causality Assessment Method scores were calculated. A DILIN severity score was assigned according to a previously published scale, and we identified 6 subjects likely to have DILI associated with use of TNF-α antagonists. We also searched PubMed for articles that reported hepatotoxicity from TNF-α antagonists, identifying 28 additional cases suitable for analysis. RESULTS: The drugs presumed to have caused DILI were infliximab (n = 26), etanercept (n = 4), and adalimumab (n = 4). The anti-TNF-α agent was the probable cause of 12 cases of DILI (35%), a very likely cause for 21 (62%), and a definite cause for 1 (3%). Median latency was 13 weeks (range, 2-104); however, 7 cases (20%) had latency periods longer than 24 weeks. Twenty-two of 33 subjects who underwent serologic analysis (67%) tested positive for anti-nuclear and/or smooth muscle antibodies. Of these 22, 17 underwent liver biopsy; 15 subjects had clear features of autoimmunity. The 22 subjects with autoimmune features had longer median latency (16 vs 10 weeks) and higher peak levels of alanine aminotransferase (784 vs 528 U/L) than the 12 without such features. There was 1 case of severe cholestasis. All but one subject improved after discontinuation of the implicated drug; 12 subjects received corticosteroid therapy. No deaths were attributed to liver injury, although one patient with preexistent cirrhosis required liver transplantation. CONCLUSIONS: Acute liver injury caused by TNF-α antagonists may be a class effect because multiple agents in this category have been implicated. The most common presentation is an autoimmune phenotype with marked hepatocellular injury, but a mixed non-autoimmune pattern or predominant cholestasis also occurs. The prognosis is usually good after drug discontinuation, although some patients may benefit from a course of corticosteroids. ClinicalTrials.gov: Number, NCT00345930.

Adult orbital trapdoor fracture.

Trapdoor fractures occur almost exclusively in the pediatric population. The authors describe an adult with an entrapped inferior rectus muscle sheath in a trapdoor fracture. A 37-year-old man presented with persistent diplopia 3 weeks after blunt right orbital trauma. The only abnormal findings on clinical examination were limited vertical ductions. No bony defect or displacement was evident on CT. However, several small pockets of air were visible adjacent to the inferior rectus muscle. On surgical exploration, a linear nondisplaced orbital floor fracture was confirmed, and the entrapped inferior rectus muscle was released. One month postoperatively, extraocular motility had improved with no diplopia in primary or reading positions. This case demonstrates that trapdoor fractures can occur in adults and should be considered when suggestive findings are encountered. Clinicians should be aware of this because timely diagnosis and treatment might achieve more favorable outcomes.