A Novel Technique for Ice Water Immersion in Severe Drug-Induced Hyperthermia in the Emergency Department.

BACKGROUND: Methamphetamine can cause life-threatening hyperthermia and treatment must be aggressive and rapid. There are multiple methods of cooling, with cold-water immersion being one of the most effective treatment options. However, this method is technically difficult to institute in the emergency department setting. CASE REPORT: We report 2 patients who presented with life-threatening hyperthermia from methamphetamine and were treated in the emergency department with a novel technique of using a body bag filled with ice water to perform rapid cooling. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This method of cooling is a safe, rapid, and efficacious method for emergency physicians to perform cold water immersion in the department.

On-site treatment of exertional heat stroke.

BACKGROUND: Exertional heat stroke is a devastating condition that can cause significant morbidity and mortality. Rapid cooling is the most effective means of treating heat stroke, but little is published on the safety and logistics of cooling patients on site at a major sporting event. PURPOSE: To describe an on-site exertional heat stroke treatment protocol and to compare the outcomes of patients treated on site to those transferred to hospitals. STUDY DESIGN: Descriptive epidemiological study. METHODS: Using race-day medical records and ambulance run sheets, patients who developed exertional heat stroke at the Indianapolis half-marathon from 2005 to 2012 were identified. Exertional heat stroke was defined as runners with a core temperature measured with a rectal thermometer greater than 102° F and altered mental status. Clinical information and patient outcomes were abstracted from the race medical tent and hospital charts by 3 separate trained reviewers using structured methods and a data collection form. Two reviewers, using a RedCAP database and dual-data entry, abstracted records for each patient. A third arbitrated all discrepancies between reviewers. Clinical signs, treatments, and outcomes were calculated using descriptive statistics, and data were grouped and compared for patients treated on site or transferred to local hospitals for treatment. RESULTS: Over 235,000 athletes participated in the event over the 8-year period, with 696 seeking medical care. A total of 32 heat stroke victims were identified during the study period; of these, 22 were treated on site. Of these, 68% were treated with cold-water immersion and 59% were discharged home from the race. Ten exertional heat stroke patients were transported from the race course to local hospitals. None of them underwent cold-water immersion, and 40% of them were subsequently discharged home. No patients in the study died. CONCLUSION: On-site treatment of athletes who develop exertional heat stroke appears to be both safe and effective. On-site treatment may decrease the local burden of critically ill patients to emergency departments during large athletic events.

Management of functional epiphora in patients with an anatomically patent dacryocystorhinostomy.

IMPORTANCE: Approximately 5% to 10% of patients continue to experience persistent epiphora following an anatomically successful dacryocystorhinostomy (DCR) for nasolacrimal duct obstruction or stenosis. OBJECTIVE: To investigate the management and success rate of so-called "functional failure" of DCR for nasolacrimal duct obstruction by experienced lacrimal surgeons. DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective case series including 5 Australian and New Zealand centers. Participants included 61 patients (71% women [n = 46]; mean age, 66 years) with functional epiphora after 65 DCRs (69% transnasal) who were recruited over a mean of 7.6 years. Inclusion criteria included confirmed preoperative diagnosis of nasolacrimal duct obstruction or stenosis, age greater than 18 years, recurrent or persistent epiphora after DCR, an anatomically successful DCR, and follow-up longer than 6 months. Exclusion criteria included evidence of lacrimal hypersecretion, eyelid malposition, and punctal or canalicular abnormalities. MAIN OUTCOMES AND MEASURES: The number, type, timing, and success of all clinical interventions performed for the management of functional epiphora after DCR. RESULTS: Epiphora recurred a mean of 8.9 months after primary DCR; 89% of the cases (n = 58) had evidence of a patent ostium and 100% were patent on lacrimal irrigation. Intubation with a lacrimal stent was performed in 82% of the cases at the time of surgery, and all stents were removed a mean of 8 weeks postoperatively. Epiphora was reported immediately following DCR in 32% (n = 21) of the cases and within 6 weeks after removal of the stent in 31% (n = 20); late recurrence (>12 months after DCR) developed in 37% (n = 24) of the cases. In a total of 15% of the cases, participants declined any treatment following DCR. The remainder underwent a mean of 1.3 interventions (range, 1-3) during a mean of 23 to 41 months after primary DCR, following which 72% (n = 47) of the cases had a successful outcome; 12% (n = 8) failed to achieve improvement, and the patients declined further intervention. Thirty-nine interventions (60%) were intubation with a silicone stent with a 54% success rate. Almost half of those undergoing intubation elected to keep the stent permanently; 34% (n = 22) had an eyelid-tightening procedure with 50% success, and 15% (n = 10) required a Lester-Jones tube despite patent canaliculi, with a success rate of 90%. CONCLUSIONS AND RELEVANCE: Functional epiphora after DCR among patients with preoperative nasolacrimal duct obstruction or stenosis appears to be uncommon. Benefits can be achieved in most patients with intubation (transient or permanent) or eyelid tightening. More than one procedure is often required.

Use of x-ray film implant for the repair of orbital fractures.

PURPOSE: To evaluate the experience with sterilized x-ray film in the repair of orbital blow-out fractures (BOFs). METHODS: A retrospective review of case notes from 56 patients with orbital BOF repaired using sterilized x-ray film onlay implants at 2 institutions between November 2004 and December 2010. Patient demographics, timing of surgery, surgical approach, postoperative complications, and length of follow up were recorded. RESULTS: Fifty-six patients (44 men, 12 women) received sterilized x-ray film implants during the 6-year study period. Mean age at the time of repair was 29 years (range 4-85 years). For 68% of patients, surgical repair was performed within 2 weeks of injury. Average length of postoperative follow up was 5.5 months (range 1-36 months), 48% had follow up >3 months. Following surgical repair, diplopia in primary or down gaze reduced from 98% to 4% and enophthalmos ≥2 mm reduced from 21% to 5% cases. One patient required a second operation for repositioning of an incompletely reduced fracture. A second patient presented 9 months postoperatively with recurrent episodes of proptosis, and the implant and its surrounding pseudocapsule were subsequently removed. There were no cases of visual loss, implant infection, or migration. CONCLUSIONS: This series has demonstrated that in selected orbital fractures sterilized x-ray film can provide a safe, effective, and low-cost onlay implant.

A proposed model of the response of the anophthalmic socket to prosthetic eye wear and its application to the management of mucoid discharge.

Mucoid discharge associated with prosthetic eye wear can be a distressing condition that affects the quality of life of people who have lost an eye. Discharge is the second highest concern of experienced prosthetic eye wearers after health of the companion eye and is prevalent in anophthalmic populations. Specific causes of mucoid discharge such as infections and environmental allergens are well understood, but non-specific causes are unknown and an evidence based protocol for managing non-specific discharge is lacking. Current management is based on prosthesis removal and cleaning, and professional re-polishing of the prosthesis. Tear protein deposits accumulate on prosthetic eyes. These deposits mediate the response of the socket to prosthetic eye wear and their influence (good and bad) is determined by differing cleaning regimes and standards of surface finish. This paper proposes a three-phase model that describes the response of the socket to prosthetic eye wear. The phases are: An initial period of wear of a new (or newly-polished) prosthesis when homeostasis is being established (or re-established) within the socket; a second period (equilibrium phase) where beneficial surface deposits have built up on the prosthesis and wear is safe and comfortable, and a third period (breakdown phase) where there is an increasing likelihood of harm from continued wear. The proposed model provides a rationale for a personal cleaning regime to manage non-specific mucoid discharge. Professional care of prosthetic eyes is also important for the management of discharge and evidence for effective surface finishing is reported in this study. Taken together, the proposed regimes for personal and professional care comprise a protocol for managing discharge associated with prosthetic eye wear. The protocol describes prosthetic eye cleaning methods and frequency, and suggests minimum standards for professional polishing. If confirmed, the protocol has the potential to resolve the current varied and contradictory opinions about the management of discharge, and to clarify advice given to patients about how to personally care for their prosthetic eyes.

Deposit buildup on prosthetic eye material (in vitro) and its effect on surface wettability.

BACKGROUND: The aim of this in-vitro study was to investigate the effect of different polishing standards on prosthetic eye material (poly(methyl methacrylate) [PMMA]) on surface wettability and the rate of protein and lipid buildup. METHODS: Sample disks (12 mm diameter × 1 mm thickness) of PMMA were polished to three different standards of surface finish: low, normal, and optical quality contact lens standard. The sample disks were incubated in a protein-rich artificial tear solution (ATS) for the following periods of time: 1 second, 30 minutes, 1 hour, 4 hours, 24 hours, and 14 days. Surface wettability was measured with a goniometer before and after protein deposits were removed. One-way analysis of variance and paired-samples t-test were used for the statistical analysis. RESULTS: Between 13.64 and 62.88 µg of protein adhered to the sample disks immediately upon immersion in ATS. Sample disks with the highest polish attracted less protein deposits. The sample disks polished to optical quality contact lens standard were more wettable than those less highly polished, and wettability significantly decreased following removal of protein deposits. The addition of lipids to protein-only ATS made no difference to the amount of protein deposited on the sample disks for any of the standards of surface polish tested. CONCLUSION: The findings are consistent with the results of the in-vivo investigation reported previously by the authors. Our view that the minimum standard of polish for prosthetic eyes should be optical quality contact lens standard and that deposits on PMMA prosthetic eyes improve the lubricating properties of the socket fluids has been reinforced by the results of this study.

Orbital adherence with titanium mesh floor implants: a review of 10 cases.

BACKGROUND: Multiple materials have been used in the repair of orbital floor fractures. We report 10 cases of complications relating to the use of titanium mesh orbital floor implants. METHOD: A retrospective review of 10 cases in 2 centres in New Zealand. Patients presented with diplopia or eyelid retraction following repair of an orbital floor fracture with titanium mesh implants. RESULTS: Ten patients (7 male, 3 female) aged between 15-78 years old (mean 39 years) presented with significant restriction of eye movement and/or eyelid retraction following repair of an orbital floor fracture with a titanium mesh implant. Seven patients presented with restriction of eye movement alone. Three patients had lower lid retraction in addition to restriction of eye movement. One patient presented with epiphora following erosion of the implant through the nasolacrimal duct. Seven patients underwent surgical removal of the implant with all patients showing improvement of extraocular movement post-operatively. Three cases did not undergo implant removal with one case showing mild improvement over 9 months, and 2 cases showing no improvement. The mean interval between the initial surgery and removal of the implant was 7.1 months. DISCUSSION: In our series, 7 cases required explantation of the original titanium implant. In these cases a vigorous fibrotic reaction had taken place between the orbital contents and the titanium mesh implant. We postulate that the fibrous reaction between the implant and the orbital contents caused the eye movement restriction and the lid retraction. Implant materials used in orbital floor fracture surgery should be inert with a flat profile rather than a mesh to prevent adhesions through the mesh that may cause cicatricial eye movement restriction and eyelid retraction.

The response of the anophthalmic socket to prosthetic eye wear.

PURPOSE: The aim of this study was to investigate the inflammatory response of the anophthalmic socket to prosthetic eye wear. METHODS: One hundred and two prosthetic eye wearers were recruited for this observational study. Photographic grading scales were used to measure the severity of conjunctival inflammation and the extent and intensity of stained deposits on the prosthetic eyes. Tear volume was measured with the phenol red thread test. For mucoid discharge, visual analogue scales were used to assess frequency of occurrence, colour, volume and viscosity. For the prostheses, assessments were made of weight, shape, wearing time and frequency of cleaning. RESULTS: Anophthalmic sockets had more severe conjunctival inflammation than their companion eyes (p = 0.0001). The difference in inflammation between the companion eye and the anophthalmic socket was associated with discharge volume (p = 0.01) and discharge viscosity (p = 0.007) with greater difference in inflammation being associated with higher levels of discharge volume and viscosity. A greater difference in inflammation was also associated with less surface deposition (p = 0.009). No evidence of associations was found between difference in conjunctival inflammation and the other variables. CONCLUSIONS: Recently developed grading scales for measuring inflammation in anophthalmic sockets and deposits on prosthetic eyes were used for the first time in this study. It is recommended that in clinical practice, inflammation grades for both socket and companion eye conjunctivae be compared, when determining if prosthesis-induced inflammation is present. The finding that more discharge was associated with more conjunctival inflammation is logical but the finding that less inflammation was associated with more deposits is counter-intuitive to those familiar with the contact lens literature. The apparently benign nature of at least some deposits on the prostheses raises questions about the maintenance of prosthetic eyes. We conclude that the simple presence of deposits is unlikely to be linked with inflammation of the conjunctiva in wearers of prostheses, who like those in this study, cleaned their prostheses regularly but not frequently.

The development of measurement tools for prosthetic eye research.

BACKGROUND: The aim was to develop tools to measure the condition of ocular prostheses and the socket's response to prosthetic eyewear. METHODS: A novel staining technique for displaying deposits on prosthetic eyes was developed. Equal interval perceptual grading scales for measuring inferior palpebral conjunctival inflammation, and anterior and posterior stained surface deposits on prosthetic eyes were developed from 800 photographs of 43 volunteers. The photographs for each scale were chosen by the authors. A group of four ophthalmologists, three optometrists and three senior students was consulted about selection criteria and asked to position the photographs along a 1.5 m rule to determine equal intervals. Photographs judged not to represent exactly equal perceptual intervals were exchanged with others from the original pool. The final scales (a five-photograph scale for inflammation and two 11 photograph scales for deposits) were assessed for inter-rater reliability and test-retest reliability by groups of senior optometry students. RESULTS: Standard deviations for inter-rater reliability tests were 0.52 scale units for the inflammation scale, 0.99 for the anterior surface deposits scale and 1.03 for the posterior surface deposits scale. The standard deviation of the test-retest differences for inflammation was 0.6 scale units and for both anterior and posterior surface deposits it was 0.71. CONCLUSIONS: A novel technique for displaying and measuring the intensity and extent of deposit formation on prosthetic eye surfaces has been described. The two equal interval perceptual grading scales that have been developed to quantify the extent of deposit formation together with the equal interval perceptual scale for grading severity of palpebral conjunctival inflammation will for the first time allow the effects of prosthetic eye wear to be evaluated. Further research to validate the scale for palpebral conjunctival inflammation in a clinical setting is recommended. The technique for staining deposits on prosthetic eyes is recommended for clinical practice.

Biosocial profile of New Zealand prosthetic eye wearers.

AIM: To describe the biosocial profile of New Zealand (NZ) artificial eye wearers and establish a basis for future research and international comparison. METHODS: This retrospective study surveyed 431 NZ artificial eye wearers to investigate their ethnicity, gender, age, causes of eye loss, age of current prosthesis, ocular prosthetic maintenance regimes and the extent and severity of discharge associated with prosthesis wear. RESULTS: Approximately 3000 people wear artificial eyes in NZ. Accidents were the main cause of eye loss prior to 1990 and medical conditions have been the main cause since. In the 1960s, the ratio of men to women losing an eye from accidents was 5:1, but during the past decade the ratio was 1.4:1. Socket discharge occurred at least twice daily for one-third of the study group. CONCLUSIONS: Approximately 1 in 1440 people wear artificial eyes in NZ. Decline of eye loss due to accidents is consistent with decreasing workplace and traffic accidents and may be due to improved medical management, workplace safety standards and safer roads. Mucoid discharge is prevalent in the anophthalmic population of NZ and an evidence based treatment protocol for discharge associated with prosthesis wear is needed. Research into this distressing condition is planned.

Deposit buildup on prosthetic eyes and implications for conjunctival inflammation and mucoid discharge.

BACKGROUND: The aim of this study was to investigate deposit buildup on prosthetic eyes and the implications for conjunctival inflammation and discharge. METHODS: Forty-three prosthetic eye wearers participated in the study. Twenty-three had their prostheses polished normally before being worn continuously for 2 weeks. After this time, surface deposits were stained, photographed, and graded. The prostheses were then repolished to optical quality contact lens standard and worn for a further 2 weeks, when the deposits were again stained, photographed, and graded. Two participants had deposits on their prostheses stained, photographed, and graded on nine occasions at decreasing intervals ranging from 1 year to 1 day. Eighteen participants had the wetting angles on their prostheses measured with a goniometer before and after cleaning, after polishing normally, after polishing to optical quality contact lens standard, and after 10 minutes of wearing their optical quality contact lens polished prostheses. Concordance correlation, multiple regression, and paired t-tests were used for the statistical analysis. RESULTS: More surface deposits accumulated on prostheses polished normally than on those polished to an optical quality contact lens standard after 2 weeks of wear. The interpalpebral zone of most prostheses (observed without magnification) appeared to be clear of deposits. Removal of deposits significantly decreased surface wettability, but wettability returned after 10 minutes of wear. Optical quality contact lens polishing produced more wettable surfaces and a slower rate of deposit accumulation than normal polishing. CONCLUSION: We recommend that an optical quality contact lens standard be the minimum standard of finish for prosthetic eyes. This standard may assist the smooth action of the lids over the interpalpebral zone of the prosthesis and the cleansing action of tears. The presence of deposits in the retropalpebral zone may improve the lubricating properties of socket fluids which, in turn, may result in less frictional irritation of the conjunctiva and less mucoid discharge.

A survey of prosthetic eye wearers to investigate mucoid discharge.

BACKGROUND: This study aimed to better understand the causes and treatments of mucoid discharge associated with prosthetic eye wear by reviewing the literature and surveying anophthalmic patients. METHODS: An anonymous questionnaire was completed by 429 prosthetic eye wearers who used visual analog scales to self-measure their discharge experience for four discharge characteristics: frequency, color, volume, and viscosity. These characteristics were analyzed with age, ethnicity, years wearing a prosthesis, eye loss cause, removal and cleaning regimes, hand-washing behavior, age of current prosthesis, and professional repolishing regimes as explanatory variables. Eighteen ocularists' Web sites containing comments on the cause and treatment of discharge were surveyed. RESULTS: Associations were found between discharge frequency and cleaning regimes with more frequent cleaning accompanying more frequent discharge. Color was associated with years of wearing and age, with more years of wearing and older people having less colored discharge. Volume was associated with cleaning regimes with more frequent cleaners having more volume. Viscosity was associated with cleaning regimes and years of wearing with more frequent cleaning and shorter wearing time accompanying more viscous discharge. No associations were found between discharge characteristics and ethnicity, eye loss cause, hand washing, age of current prosthesis, or repolishing regimes. Forty-seven percent of ocularists' Web sites advised that discharge was caused by surface deposits on the prosthesis, 29% by excessive handling of the prosthesis, and 24% by other causes. CONCLUSIONS: A standardized treatment protocol for managing discharge is lacking. More frequent prosthesis removal and cleaning was associated with more severe discharge, but the direction of cause and effect has not been established. Professional repolishing regimes had limited impact on discharge experience. Further research into the socket's response to prosthetic eye wear, including the physical, chemical, and biological elements of the conjunctiva, the socket fluids, and the deposits that cover the prosthetic eye is recommended.

Modified eyelid crease approach frontalis suspension without brow incision.

A 10-year-old boy with Noonan syndrome presented with bilateral ptosis. He had a history of keloid scarring. A modified technique of frontalis suspension with autogenous fascia lata is described to avoid forehead wounds. This uses an eyelid crease incision, dissection under the orbicularis to the orbital rim, and passage of the fascia lata into a shallow arc through the frontalis muscle. It is then passed inferiorly through the septum and secured to the tarsus.

Concerns of anophthalmic patients wearing artificial eyes.

BACKGROUND: To identify the concerns of experienced artificial eye wearers and investigate whether these had changed since they lost their eye. DESIGN: A retrospective study of private practice patients. PARTICIPANTS: Sixty-three experienced artificial eye wearers. METHODS: An anonymous questionnaire was posted to participants. Paired Wilcoxon tests were used to investigate changes to concern levels over time. Ordinal logistic regression was used to investigate associations of demographic variables with concern levels. MAIN OUTCOME MEASURES: Changes in level of concern over time. RESULTS: At the time of initial eye loss, participants were mainly concerned about the health of their remaining eye, coping with monocularity and receiving good advice. Between initial eye loss and the present, reductions in concern occurred with judging distance, peripheral vision, appearance, receiving good advice, comfort, retention, colour and movement of the artificial eye, fullness of orbit, loss of balance and postoperative pain. Patients whose jobs involved the public were more concerned about appearance and reduced visual range than those in other occupations. Participants' chief present-day concerns were health of the remaining eye and watering, crusting and discharge. All results above had a probability <0.05. CONCLUSIONS: The study emphasized patients' concerns about the health of their remaining eye and their need for good advice at time of eye loss. Knowledge that their initial concerns about judging distance, reduced peripheral vision and appearance all decrease over time may help clinicians in counselling these patients. Watering, crusting and discharge was the chief present-day concern after health of the remaining eye.

Medial wall fracture- induced pneumo-orbita mimicking inferior rectus entrapment.

The authors report 2 patients who experienced medial wall blowout fractures. Both patients presented with significant restriction of upgaze, mild proptosis, and crepitus of the upper lid. Computed tomography revealed significant pneumo-orbita filling the superior orbit with inferior displacement of the muscle cone and subcutaneous emphysema. No floor fractures were seen in either patient, but in both cases, the medial wall was breached and was almost certainly the source of the intraorbital air. Patients were managed conservatively, and the vertical gaze deficiencies resolved after 3 to 5 days. Large amounts of intraorbital and extraorbital air in the absence of a floor fracture can imitate inferior rectus entrapment and could potentially lead to unnecessary surgical intervention.