Early versus delayed timing of primary repair after open-globe injury: a systematic review and meta-analysis.

TOPIC: The timing of primary repair of open-globe injury is variable in major trauma centres around the world and there is a lack of consensus on optimal timing. CLINICAL RELEVANCE: Surgery is the mainstay of open-globe injury management, and appropriate timing of surgical repair may minimise the risk of potentially blinding complications such as endophthalmitis, thereby optimising visual outcomes. METHODS: A systematic literature review was performed following PRISMA guidelines (PROSPERO registration number: CRD42023442972). CENTRAL, MEDLINE, Embase, ISRCTN registry and ClinicalTrials.gov were searched from inception to 29 October 2023. Prospective and retrospective non-randomised studies of patients with open-globe injury with a minimum of one month follow up after primary repair were included. Primary outcomes included visual acuity at last follow-up, and the proportion of patients who developed endophthalmitis. Certainty of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach. RESULTS: A total of 16 studies met inclusion criteria, reporting a total of 8497 eyes. The most common injury types were penetrating and intraocular foreign body (IOFB). Meta-analysis found that primary repair less than 24 hours after open-globe injury was associated with an odds of endophthalmitis of 0.30 compared to primary repair conducted more than 24 hours after trauma (OR 0.39; 95% CI 0.19-0.79; I2 95%; p = 0.01). There was no significant difference in reported visual outcomes between patients whose open-globe injuries were repaired more than, compared to less than, 24 hours after trauma (OR 0.89; 95% CI 0.61-1.29; I2 70%; p = 0.52). All included studies were retrospective and non-randomised, demonstrating an overall low certainty of evidence on GRADE assessment. CONCLUSION: Only retrospective data exist around the effect of timing of open-globe repair, causing low certainty of the available evidence. However, this review of the current body of evidence, predominantly including penetrating and IOFB injuries, suggests that primary repair performed less than 24 hours after open-globe injury was associated with a reduced endophthalmitis rate, compared to longer delays, consistent with delay to primary repair increasing endophthalmitis risk.

Temporary keratoprosthesis and primary corneal graft for ocular trauma: a systematic review and meta-analysis.

PURPOSE: When severe retinal and corneal injury occur together, a temporary keratoprosthesis (TKP) is often a last resort to allow posterior segment visualization to enable vitreoretinal surgery, followed by a penetrating keratoplasty (PKP) which can restore corneal clarity in a single operation. We aimed to assess visual outcomes following combined PKP and vitreoretinal surgery with the use of a TKP for cases of ocular trauma. DESIGN: A systematic literature review was performed following PRISMA guidelines (PROSPERO registration number: CRD42023423518). METHODS: CENTRAL, MEDLINE, Embase, ISRCTN registry and ClinicalTrials.gov were searched from inception to 27 April 2023. Randomized and non-randomized studies assessing visual outcomes after combined vitreoretinal surgery and PKP with the use of a TKP after ocular trauma were eligible for inclusion. Outcomes included change in best corrected visual acuity, corneal graft survival and retinal reattachment at final follow up. Proportional meta-analysis was used to estimate the overall rate of the primary outcomes. Risk of bias for non-randomized studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist for case series. RESULTS: A total of 19 studies met inclusion criteria reporting a total of 352 eyes. All studies were retrospective and non-randomized with follow up times ranging from 6 to 91 months, with at least 79% of outcomes reported after 6 months. After combined surgery the rate of corneal graft survival was 52% (95% CI 0.41-0.62; I2 60%) successful retinal attachment was 79% (95% CI 0.73-0.84; I2 0%). and improved visual acuity, when compared to no change or decrease in visual acuity, was 45% (95% CI 0.32-0.59; I2 66%). CONCLUSION: Patients with severe injury affecting the anterior and posterior segments have very limited treatment options. This systematic review found that when combined vitreoretinal surgery and PKP with a TKP are performed, approximately half of corneal grafts survive, anatomically successful retinal reattachment is likely, and a similar proportion of patients benefit in terms of improved visual acuity, compared to their preoperative function. This systematic review of the available literature may help inform surgeons of the benefits of using a TKP for cases of ocular trauma.

The Risk of Sympathetic Ophthalmia Associated with Open-Globe Injury Management Strategies: A Meta-analysis.

TOPIC: Sympathetic ophthalmia (SO) is a sight-threatening granulomatous panuveitis caused by a sensitizing event. Primary enucleation or primary evisceration, versus primary repair, as a risk management strategy after open-globe injury (OGI) remains controversial. CLINICAL RELEVANCE: This systematic review was conducted to report the incidence of SO after primary repair compared with that of after primary enucleation or primary evisceration. This enabled the reporting of an estimated number needed to treat. METHODS: Five journal databases were searched. This review was registered with International Prospective Register of Systematic Reviews (identifier, CRD42021262616). Searches were carried out on June 29, 2021, and were updated on December 10, 2022. Prospective or retrospective studies that reported outcomes (including SO or lack of SO) in a patient population who underwent either primary repair and primary enucleation or primary evisceration were included. A systematic review and meta-analysis were carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effects modelling was used to estimate pooled SO rates and absolute risk reduction (ARR). RESULTS: Eight studies reporting SO as an outcome were included in total. The included studies contained 7500 patients and 7635 OGIs. In total, 7620 OGIs met the criteria for inclusion in this analysis; SO developed in 21 patients with OGI. When all included studies were pooled, the estimated SO rate was 0.12% (95% confidence interval [CI], 0.00%-0.25%) after OGI. Of 779 patients who underwent primary enucleation or primary evisceration, no SO cases were reported, resulting in a pooled SO estimate of 0.05% (95% CI, 0.00%-0.21%). For primary repair, the pooled estimate of SO rate was 0.15% (95% CI, 0.00%-0.33%). The ARR using a random effects model was -0.0010 (in favour of eye removal; 95% CI, -0.0031 [in favor of eye removal] to 0.0011 [in favor of primary repair]). Grading of Recommendations, Assessment, Development, and Evaluations analysis highlighted a low certainty of evidence because the included studies were observational, and a risk of bias resulted from missing data. DISCUSSION: Based on the available data, no evidence exists that primary enucleation or primary evisceration reduce the risk of secondary SO. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Comparison of hamate versus second or third toe osteochondral graft using magnetic resonance imaging for reconstruction of proximal interphalangeal fracture-dislocations.

Hemi-hamate arthroplasty is a method used to reconstruct complex fracture-dislocations of the proximal interphalangeal joint of the fingers. Other graft sites, including the toe second and third phalanges, have been proposed as alternatives to hemi-hamate arthroplasty due to variable clinical outcomes and anatomy. Through a prospective magnetic resonance imaging (MRI)-based study in asymptomatic individuals, we aimed to characterize the anatomy of the proximal interphalangeal joint and compare this with the hamate, second and third toes to determine the closest anatomical match using pre-determined measurements. Our results show that the second and third toes have greater anatomical similarity to the proximal interphalangeal joint of the fingers compared to the hamate. High-resolution MRI is a reliable method of characterizing the anatomy of these structures and could be a useful clinical tool in determining reconstructive options in the management of this challenging injury.Level of evidence: II.

Long-term follow-up of keystone perforator island flap in reconstructed myelomeningocele defects.

Myelomeningocele (a type of spina bifida) is the most common congenital condition that causes lifelong physical disability and requires multi-system surgical procedures. Therefore, it is paramount to reconstruct them using a stable and robust method that heals with minimal wound issues and produces maximum durability. We published a case series on reconstruction of myelomeningocele defects using keystone perforator island flap in the Annals of Plastic Surgery in 2016.1 We aim to report the results of long-term follow-up of 14 years on our case series, where we assessed their scars using POSAS 3.0. We also assessed their quality of life using the QUALAS tool for teenagers. While there are multiple reconstructive options for the closure of myelomeningocele defects, we believe that the keystone perforator island flap technique is reliable and safe as it utilizes the en bloc movement of a large flap of well-vascularized skin, cutis, and muscular fascia to close large defects in the lumbar-sacral regions in newborns, resulting in stable scars.2-7.

The Use of Preoperative Prophylactic Systemic Antibiotics for the Prevention of Endopthalmitis in Open Globe Injuries: A Meta-Analysis.

TOPIC: This study reports the effect of systemic prophylactic antibiotics (and their route) on the risk of endophthalmitis after open globe injury (OGI). CLINICAL RELEVANCE: Endophthalmitis is a major complication of OGI; it can lead to rapid sight loss in the affected eye. The administration of systemic antibiotic prophylaxis is common practice in some health care systems, although there is no consensus on their use. METHODS: PubMed, CENTRAL, Web of Science, CINAHL, and Embase were searched. This was completed July 6, 2021 and updated December 10, 2022. We included randomized and nonrandomized prospective studies which reported the rate of post-OGI endophthalmitis when systemic preoperative antibiotic prophylaxis (via the oral or IV route) was given. The Cochrane Risk of Bias tool and ROBINS-I tool were used for assessing the risk of bias. Where meta-analysis was performed, results were reported as an odds ratio. PROSPERO registration: CRD42021271271. RESULTS: Three studies were included. One prospective observational study compared outcomes of patients who had received systemic or no systemic preoperative antibiotics. The endophthalmitis rates reported were 3.75% and 4.91% in the systemic and no systemic preoperative antibiotics groups, a nonsignificant difference (P = 0.68). Two randomized controlled trials were included (1555 patients). The rates of endophthalmitis were 17 events in 751 patients (2.26%) and 17 events in 804 patients (2.11%) in the oral antibiotics and IV (± oral) antibiotics groups, respectively. Meta-analysis demonstrated no significant differences between groups (odds ratio, 1.07; 95% confidence interval, 0.54-2.12). CONCLUSIONS: The incidences of endophthalmitis after OGI were low with and without systemic antibiotic prophylaxis, although high-risk cases were excluded in the included studies. When antibiotic prophylaxis is considered, there is moderate evidence that oral antibiotic administration is noninferior to IV. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Modern Solutions for Ancient Pathogens: Direct Pathogen Sequencing for Diagnosis of Lepromatous Leprosy and Cerebral Coenurosis.

Microbes unculturable in vitro remain diagnostically challenging, dependent historically on clinical findings, histology, or targeted molecular detection. We applied whole-genome sequencing directly from tissue to diagnose infections with mycobacteria (leprosy) and parasites (coenurosis). Direct pathogen DNA sequencing provides flexible solutions to diagnosis of difficult pathogens in diverse contexts.

The arterialised saphenous venous flow-through flap for managing the radial forearm free flap donor site.

BACKGROUND: The radial forearm fasciocutaneous flap (RFFF) is a workhorse flap, however concerns with donor site morbidity include tendon exposure, delayed wound healing, impaired sensitivity, and poor cosmesis, have seen it fall out of favor. We present a method of using an arterialised saphenous flow through flap to reconstruct the RFFF donor site. METHOD: A cohort study of six patients (five male, one female; mean age 59 [range 19-90]) who had their RFFF donor site reconstructed with an arterialised saphenous flow through flap is presented. The use of multiple peripheral efferent venous anastomoses, flap rotation 180 degrees prior to inset, and the ligation of intra-flap connecting veins were three modifications employed. Primary outcomes include complication rates. Secondary outcomes were patient reported outcome measures via the Michigan Hand Outcomes Questionnaire, and patency and flow through the flap. RESULTS: In all six cases, there was flap survival. RFFF dimensions ranging from lengths of 6-15 cm (mean 11.5 cm) and widths of 4-6 cm (mean 5.3 cm), with an average flap area of 58 cm2 (range 24-90). There were no total flap losses, one partial superficial flap loss and one minor donor site delayed healing, over a mean follow-up of 6 months (4-24 months). The average overall patient satisfaction was 91 on Michigan Hand Outcomes Questionnaire. Pain was well tolerated with a low average pain score of 15. CONCLUSION: The modified arterialised saphenous flow through flap is a useful option for reconstructing the soft tissue defect and reconstituting the radial artery after RFFF harvest.

Decreasing extents of Archean serpentinization contributed to the rise of an oxidized atmosphere.

At present, molecular hydrogen (H2) produced through Fe(II) oxidation during serpentinization of ultramafic rocks represents a small fraction of the global sink for O2 due to limited exposures of ultramafic rocks. In contrast, ultramafic rocks such as komatiites were much more common in the Early Earth and H2 production via serpentinization was a likely factor in maintaining an O2-free atmosphere throughout most of the Archean. Using thermodynamic simulations, this work quantifies the global O2 consumption attributed to serpentinization during the past 3.5 billion years. Results show that H2 generation is strongly dependent on rock compositions where serpentinization of more magnesian lithologies generated substantially higher amounts of H2. Consumption of >2 Tmole O2 yr-1 via low-temperature serpentinization of Archean continents and seafloor is possible. This O2 sink diminished greatly towards the end of the Archean as ultramafic rocks became less common and helped set the stage for the Great Oxidation Event.

A novel technique for proximal interphalangeal joint fracture-dislocations: the second toe middle phalanx osteochondral graft.

Many different surgical techniques have been used to treat unstable dorsal proximal interphalangeal joint fracture-dislocations. The authors have used the base of the middle phalanx of the second toe base as an alternative autograft to treat this type of injury. This retrospective study assessed the clinical outcomes of this procedure in 11 patients. Range of motion, grip strength, Disability of the Arm, Shoulder and Hand score and donor site morbidity were assessed at regular intervals postoperatively. Nine patients had acute injuries and two had chronic injuries. The mean range of motion in the proximal interphalangeal joint at final review was 65° for patients with acute injuries and 41° for patients with chronic injuries. Other outcomes were satisfactory and there were no complications.Level of evidence: IV.

Panuveitis in Sweet syndrome.

Ocular manifestations of Sweet syndrome, or acute febrile neutrophilic dermatosis, are usually limited to the anterior segment. We report the case of a patient with bilateral panuveitis and retinal vasculitis associated with Sweet syndrome. A 45-year-old Asian female with an undiagnosed febrile illness with rash presented with bilateral panuveitis with haemorrhagic occlusive retinal vasculitis. Skin biopsy confirmed Sweet Syndrome. Intraocular inflammation resolved with a combination of topical and systemic corticosteroids as well as intravenous cyclophosphamide, with resulting permanent severe right visual impairment. Although an uncommon condition, Sweet syndrome should be considered in any febrile patient with skin lesions and uveitis.

Collagenase Management of Multicord Dupuytren's Disease under Intravenous Sedation: A Prospective Cohort Study.

BACKGROUND: Surgery has been the standard of care in managing Dupuytren's disease (DD). Recently collagenase of Clostridium histolyticum (CCH) has provided a less invasive alternative. The purpose of the current study is to present the early outcomes of a protocol for CCH involving treatment of multi-cord disease, and large patient cohorts. METHODS: A cohort of 137 consecutive patients (Mean age 66 years, SD 9.85) with 225 joint contractures was treated with CCH at our institution between December of 2014 and January of 2017. A single standardized concentration of collagenase 2.31 mg/ml or 0.58 mg/dose was used for the treatment of up to 5 cords at a single session, and manipulation was 48 hours post-injection under intravenous sedation (IV). Patient complications, reduction in joint contracture, patient satisfaction and patient reported functional outcomes were assessed after one month. RESULTS: 137 patients received a total of 214 doses 0.58mg of CCH to treat 225 PIP and MCP joint contractures. The mean correction of joint contractures was 39.8 ± 2.2 and 27.9 ± 3.9 degrees for MCP and PIP joints respectively. 80% of patients, reported improved function and 89% of patients who were satisfied with the treatment. CONCLUSIONS: This study demonstrates a protocol for high throughput management of DD using collagenase and IV sedation for manipulation, logistically suited to the hospital setting. Efficacy was demonstrated treating patients with up to 5 cords, including those with bilateral disease. Future studies are needed to evaluate the durability of response in the medium and long term, and to evaluate cost benefits.

Distraction ligamentotaxis for complex proximal interphalangeal joint fracture dislocations: a clinical study and the modified pins rubber band traction system revisited.

BACKGROUND: The purpose of this study is to present our experience with the modified pins and rubber band traction system, discuss problems encountered, and make recommendations to optimize outcomes. METHODS: Data was collected prospectively from November 2013 to March 2017 at a tertiary referral hospital in Melbourne, Australia. Patients with closed complex proximal interphalangeal joint fracture dislocations that were considered unsuitable for other surgical options were included in the study. Patients underwent dynamic skeletal distraction using the modified (Deshmukh) pins rubber band traction system. Outcomes were measured using the Nominal Rating Scale for pain; Disabilities of the Arm, Shoulder, and Hand (DASH) score; active and passive range of motion; patient rating scale; and complications. RESULTS: Twenty patients underwent the procedure, and 19 were included in analyses. At the final follow-up assessment, an average of 62° and 77° was achieved for proximal interphalangeal joint active and passive range of motion, respectively. Pain levels were low (median score of 0 at rest and 1 ranging, out of 10). Four patients suffered minor pin site infections. CONCLUSION: Distraction ligamentotaxis is a useful part of the armamentarium, especially in the absence of more suitable procedures. It is important to select appropriate patients, educate, and ensure adherence to postoperative therapy. Employing the Deshmukh frame modification streamlines the theatre processes, and removal of wires at approximately 4 weeks minimizes risk of pin site infection.

Hibernoma: a rare benign soft tissue tumour resembling liposarcoma.

Hibernoma is a rare benign soft tissue tumour that can mimic a liposarcoma on radiographic imaging. Our case series review illustrates the clinical presentation and radiographic appearances of four patients with histologically confirmed hibernoma. Hibernoma is usually hypointense relative to subcutaneous fat on T 1 weighted MRI and demonstrates partial fat suppression on fat-saturated sequences. Large intratumoral vessels likely support the diagnosis of hibernoma but are not invariably present. Fludeoxyglucose avidity on PET scan is not beneficial in distinguishing hibernoma from soft tissue malignancy because of its inherent, metabolically active property. Owing to the radiographic heterogeneity of hibernoma, it is currently not possible to diagnose hibernoma based on imaging characteristics alone. Given the excellent prognosis of hibernoma with marginal excision alone, an appreciation of the radiographic features is helpful in the appropriate pre-operative workup of soft tissue tumours.

Does Delay to Theater Lead to Increased Infection Rates in Hand Trauma? A Retrospective Cohort Study.

BACKGROUND: In an ideal health system, traumatic wounds would be surgically managed within 24 hours; however, resource constraints result in patients with open wounds commonly waiting much longer for surgery. Does this result in increased morbidity? This study compares infection rates over time for patients who received operative management of traumatic hand injuries. METHODS: A retrospective analysis was undertaken of patients admitted between July 2014 and June 2015 who presented within 24 hours of sustaining a hand injury and subsequently underwent operative repair. Patient and injury data were collected from arrival time at emergency departments across 3 Victorian metropolitan hospitals within the same network. Admission and outpatient follow-up of these patients was reviewed for signs of infection and treatment with antibiotics. RESULTS: Six hundred thirty-eight patients met inclusion criteria, 8 of the 429 patients treated within 24 hours of presentation developed an infection (1.86%) compared with 11 of the 209 patients treated after 24 hours of presentation (5.26%). Using Fisher's exact analysis, a statistically significant association was identified (P = 0.024). An odds ratio of 2.924 was calculated, with a number needed to harm of 26. When time was analyzed as a continuous variable using logistic regression, there was no statistical significance. CONCLUSION: This study shows some evidence that a timing may be important to reduce the rates of infection and raises the possibility that there may be a double peak for infection risk at the 6-hour and 24-hour marks. This gives a basis of potential further study.

Medium-term Anatomical Results of Laser Peripheral Iridoplasty: An Anterior Segment Optical Coherence Tomography Study.

AIM: To evaluate by anterior segment optical coherence tomography (AS-OCT) the medium-term (mean duration 3.2 years) anatomical changes in the anterior chamber angle (ACA) after laser peripheral iridoplasty. MATERIALS AND METHODS: This is a longitudinal, retrospective case series of 31 eyes of 31 patients with primary angle-closure suspicion, primary angle closure (PAC), or primary angle-closure glaucoma (PACG) who underwent laser peripheral iridoplasty. All patients had persistent iridotrabecular contact (ITC) despite the presence of a patent peripheral iridotomy (PI). An AS-OCT was performed in dark conditions before and after laser iridoplasty. Quadrants of ITC, intraocular pressure (IOP), and the AS-OCT parameters of the temporal and nasal ACAs were measured and analyzed. RESULTS: Prior to iridoplasty, the average number of quadrants of ITC was 3.3. At the first postiridoplasty visit (mean duration 6.8 weeks), this reduced to 1.7 quadrants but increased to 1.9 by the final follow-up visit (mean duration 3.2 years). Twenty-five patients (80.1%) had less ITC at the first postlaser visit increasing to 27 (87.1%) patients by the final visit. Two (6.5%) required a second iridoplasty, while 3 (9.7%) required cataract surgery. All parameters of angle width showed a statistically significant increase in magnitude. All patients maintained IOP ≥ 21 mm Hg throughout the follow-up period. CONCLUSION: Iridoplasty is a useful adjunct in widening the ACA, particularly in those with persistent angle closure after iridotomy but with no cataract. While not successful in all patients, it can act as a temporizing measure to widen the drainage angle until such time that cataract surgery can be performed. CLINICAL SIGNIFICANCE: Laser peripheral iridoplasty can be used as an adjunct in angle-closure glaucoma patients with no cataract.How to cite this article: Hooshmand J, Leong JCY, O'Connor J, Ang GS, Wells AP. Medium-term Anatomical Results of Laser Peripheral Iridoplasty: An Anterior Segment Optical Coherence Tomography Study. J Curr Glaucoma Pract 2017;11(3):113-119.

End-to-End versus End-to-Side Microvascular Anastomosis: A Meta-analysis of Free Flap Outcomes.

Background Optimal outcomes in microsurgery have been attributed to a range of factors, with performing of end-to-end (ETE) versus end-to-side (ETS) influencing anastomotic complications and flap outcomes. Methods A systematic review of the literature and meta-analysis was undertaken to evaluate the relative risks of anastomotic complications with ETE versus ETS approaches, for arterial and venous anastomoses looking at risk ratios (RRs) for thrombosis and overall flap failure. Results RRs of thrombosis and flap failure in ETS versus ETE venous anastomosis groups were 1.30 (95% confidence interval [CI]: 0.53-3.21) and 1.50 (95% CI: 0.85-2.67), respectively. The RRs of thrombosis and flap failure in ETS versus ETE arterial anastomosis groups were 1.04 (95% CI: 0.32-3.35) and 1.04 (95% CI: 0.72-1.48), respectively. Conclusion Differences in rates of thrombosis and flap failure between ETE and ETS venous and arterial anastomoses are marginal and nonsignificant. As such, the type of anastomotic technique is best decided on a case-by-case basis, dependent on anatomical, surgical, and patient factors.