Gastric remnant perforation due to trocar site herniation after laparoscopic Roux-en-Y gastric bypass.

A 39-year-old woman was admitted with colicky left upper-quadrant pain, dyspnoea, low-grade fever, tachycardia and a subtle left upper-quadrant tenderness without leucocytosis. Computed tomography revealed a distended gastric remnant due to small-bowel loop herniation at the trocar site. The patient underwent a diagnostic laparoscopy as her general condition worsened. Perforation across the staple line was seen and repaired. The postoperative period was uneventful. As a rare complication of laparoscopic Roux-en-Y gastric bypass, small-bowel obstruction is of great importance because it can lead to gastric remnant perforation if not managed correctly. There have been rare reports of trocar site herniation as a cause of small-bowel obstruction following laparoscopic Roux-en-Y gastric bypass. Prompt diagnostic laparoscopy should be considered. This is the first case reported in which the excluded stomach was perforated due to trocar site herniation of the small-bowel loop. It should be noted that the tissue around the perforation is fragile and proper tension should be employed when it is repaired. Generally, an omental patch is not encouraged.

An unusual presentation of subacute osteomyelitis: a talus brodie abscess with tendon involvement.

Brodie abscess is a subacute localized osteomyelitis with a presenting report of intermittent pain of long duration. In this article, we report a case of talus Brodie abscess with tenosynovitis of posterior tibialis and long flexor tendons of the foot. We describe the radiologic and diagnostic features of this osteomyelitis and outline its management and prognosis. To our knowledge, this is the first report of such a case with this unusual presentation.

Effect of varying the optical zone diameter on the results of hyperopic laser in situ keratomileusis.

PURPOSE: To compare the predictability and safety of laser in situ keratomileusis (LASIK) for low to moderate spherical hyperopia using different ablation zone diameters. DESIGN: Retrospective, nonrandomized, comparative trial. PARTICIPANTS: Forty-nine eyes that underwent hyperopic LASIK. INTERVENTION: Two surgeons (JMD, RKM) performed hyperopic LASIK using the VISX STAR S2 excimer laser (VISX, Inc., Sunnyvale, CA) and the Bausch & Lomb Hansatome microkeratome (Chiron Vision, Irvine, CA) using ablation zone diameters of 5 x 9 mm, 5.5 x 8.5 mm, or 6 x 9 mm (the first number represents the optical zone diameter and the second number represents the diameter of the outer border of the ablation zone). MAIN OUTCOME MEASURES: Refractive and visual outcomes at 3 to 6 months after surgery were analyzed. Groups were compared for deviations from targeted spherical equivalent, uncorrected visual acuity, and loss of best spectacle-corrected visual acuity (BSCVA). RESULTS: The mean intended hyperopic correction was +2.48 +/- 1.13 diopters (D; 0.63-5.50 D). There were 16 eyes in the 5 x 9-mm group, 15 eyes in the 5.5 x 8.5-mm group, and 18 eyes in the 6 x 9-mm group. On average, the 5 x 9-mm group achieved 97% of the programmed correction, the 5.5 x 8.5-mm group achieved 104%, and the 6 x 9-mm group achieved 112% of the programmed correction. The tendency toward overcorrection in the 6 x 9-mm group compared with the 5 x 9-mm group was statistically significant (P < 0.05). The incidence of one line loss of BSCVA was greatest in the 5 x 9-mm group (19%) and lowest in the 6 x 9-mm group (6%). These differences were not statistically significant. No eyes experienced a loss of two or more lines of BSCVA at last examination. CONCLUSIONS: Hyperopic LASIK using the VISX STAR is safe and effective using different ablation zone diameters. There appears to be an increased tendency toward overcorrection with progressively larger optical zone diameters.

Oxygen transmissibility at various locations in hydrogel toric prism-ballasted contact lenses.

PURPOSE: Corneal metabolism is known to be adversely affected by anterior surface hypoxia. It has been demonstrated that contact lens (CL) oxygen transmissibility (Dk/L in cmmL O2/s mL mm Hg) is a direct function of the oxygen permeability (Dk in cm2 ml O2/mm Hg mL mm Hg) of the plastic divided by the thickness of the lens (L in cm). It has also been shown recently that the cornea should be sensitive to the Dk/L of that portion of a CL immediately overlying the tissue, in the absence of tear exchange and mixing; such is the case for all hydrogel CLs. Because hydrogel toric CLs are known to have anisomorphically variable thickness profiles, we have measured lens thickness along the vertical meridian and calculated local oxygen transmissibilities (Dk/L) for a series of hydrogel CLs. METHODS: Thickness was measured at 5 locations along the vertical meridian of 16 different prescription toric hydrogel CLs of each of 6 brands (5 prism-ballasted design and 1 double-slab off design) and 12 different prescription spherical CLs of 2 brands (controls). Dk (at 38 degrees C) was calculated for each material from the nominal water content by a known relation. RESULTS: We found that the average Dk/L for all lenses was greatest from the center (mean +/- SD of 8 +/- 4 x 10(-9)) to the superior portion (12 +/- 2 x 10(-9) at 6 mm from the CL center and 13 +/- 4 x 10(-9) at 3 mm from the CL center) of prism-ballast design toric CLs, and least in the lower portions (4 +/- 2 x 10(-9) at 6 mm from the lens center and 6 +/- 1 x 10(-9) at 3 mm from the CL center) of these CLs. Analysis of covariance showed that the effect of location for the prism-ballasted CLs is statistically significant (F = 203.11, p < 0.00005). One nonprism ballast toric CL design and the spherical designs showed minimal differences across the vertical meridian. We therefore conclude that clinicians should carefully monitor the physiological hypoxic response of the cornea, in particular the inferior area, during wear of prism-ballasted hydrogel lenses.

Clinical experience with piggyback contact lens systems on keratoconic eyes.

BACKGROUND: A piggyback contact lens system (PBCLS) is used when traditional lenses do not provide optimal vision or tolerance. This study assessed the use of PBCLS in keratoconic patients. METHODS: The charts of 205 keratoconic patients were retrospectively reviewed and 16 patients wearing PBCLS were identified. Visual acuity, average wearing time, and ocular complication data with PBCLS were analyzed. RESULTS: Vision and average lens wearing time were stable, if not improved, for the 16 patients when the data was compared to the patients' wear of rigid gas permeable contact lenses. Although two patients developed neovascularization and one patient developed giant papillary conjunctivitis, all pre-existing corneal complications resolved with PBCLS wear. Average Dk/L through the center and mid-periphery of the PBCLS were 8.4 +/- 1.2 x 10(-9) (mean +/- standard deviation) and 4.5 +/- 1.8 x 10(-9) cm2ml O2/sec ml mmHg (mean +/- standard deviation) respectively. No gross corneal edema was noted upon slit lamp observation. CONCLUSIONS: PBCLS can be beneficial in the management of keratoconus.

Topographic determination of corneal asphericity and its lack of effect on the refractive outcome of radial keratotomy.

PURPOSE: The normal human cornea flattens peripherally. The amount of flattening, or asphericity, has traditionally been calculated from multiple keratometric measurements. We devised a mathematical technique for determining asphericity from computed corneal topography. We then determined whether asphericity affects the refractive outcome of radial keratotomy. METHODS: One eye each of 41 patients who underwent four- or eight-incision radial keratotomy and preoperative computed corneal topography was identified retrospectively and analyzed. The asphericity, P, of each cornea was calculated by fitting Baker's equation (y2 = 2r0x-Px2) to each meridian of the topographic map. For each patient, we calculated the difference between the refractive outcome in diopters for radial keratotomy and the prediction of a quadratic least-squares best-fit model involving optical zone size and age. RESULTS: Aspericity could be calculated from the topographic maps in all 41 patients and ranged from 0.33 to 1.28, with mean +/- S.D. of 0.82 +/- 0.21. Aphericity varied among the meridians of a cornea, with an average standard deviation among meridians of 0.17. No statistical correlation was found between calculated asphericity and refractive outcome. CONCLUSIONS: Corneal asphericity can be calculated from corneal topographic maps. Asphericity is not constant in the different meridians of a normal cornea. Corneal asphericity is not useful in predicting the refractive outcome of radial keratotomy.