Hypotony Failure Criteria in Glaucoma Surgical Studies and Their Influence on Surgery Success.

PURPOSE: Review hypotony failure criteria used in glaucoma surgical outcome studies and evaluate their impact on success rates. DESIGN: Systematic literature review and application of hypotony failure criteria to 2 retrospective cohorts. PARTICIPANTS: A total of 934 eyes and 1765 eyes undergoing trabeculectomy and deep sclerectomy (DS) with a median follow-up of 41.4 and 45.4 months, respectively. METHODS: Literature-based hypotony failure criteria were applied to patient cohorts. Intraocular pressure (IOP)-related success was defined as follows: (A) IOP ≤ 21 mmHg with ≥ 20% IOP reduction; (B) IOP ≤ 18 mmHg with ≥ 20% reduction; (C) IOP ≤ 15 mmHg with ≥ 25% reduction; and (D) IOP ≤ 12 mmHg with ≥ 30% reduction. Failure was defined as IOP exceeding these criteria in 2 consecutive visits > 3 months after surgery, loss of light perception, additional IOP-lowering surgery, or hypotony. Cox regression estimated failure risk for different hypotony criteria, using no hypotony as a reference. Analyses were conducted for each criterion and hypotony type (i.e., numerical [IOP threshold], clinical [clinical manifestations], and mixed [combination of numerical or clinical criteria]). MAIN OUTCOME MEASURES: Hazard ratio (HR) for failure risk. RESULTS: Of 2503 studies found, 278 were eligible, with 99 studies (35.6%) lacking hypotony failure criteria. Numerical hypotony was predominant (157 studies [56.5%]). Few studies used clinical hypotony (3 isolated [1.1%]; 19 combined with low IOP [6.8%]). Forty-nine different criteria were found, with IOP < 6 mmHg, IOP < 6 mmHg on ≥ 2 consecutive visits after 3 months, and IOP < 5 mmHg being the most common (41 [14.7%], 38 [13.7%], and 13 [4.7%] studies, respectively). In both cohorts, numerical hypotony posed the highest risk of failure (HR, 1.51-1.21 for criteria A to D; P < 0.001), followed by mixed hypotony (HR, 1.41-1.20 for criteria A to D; P < 0.001), and clinical hypotony (HR, 1.12-1.04; P < 0.001). Failure risk varied greatly with various hypotony definitions, with the HR ranging from 1.02 to 10.79 for trabeculectomy and 1.00 to 8.36 for DS. CONCLUSIONS: Hypotony failure criteria are highly heterogenous in the glaucoma literature, with few studies focusing on clinical manifestations. Numerical hypotony yields higher failure rates than clinical hypotony and can underestimate glaucoma surgery success rates. Standardizing failure criteria with an emphasis on clinically relevant hypotony manifestations is needed. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Determining Outcomes in Nonpenetrating Trauma With qSOFA.

INTRODUCTION: The quick Sequential Organ Failure Assessment (qSOFA) score identifies patients with suspected infection at high risk for adverse outcomes. The qSOFA score is the sum of three variables (respiratory rate, systolic blood pressure, and Glasgow Coma Score) with binary thresholds. The role of qSOFA in predicting hospitalization outcomes in nonpenetrating trauma patients was determined at a level 1 and a level 2 trauma center. METHODS: The trauma registries at the two institutions were queried for adult (18+ y) and pediatric (0-17 y) nonpenetrating trauma hospitalizations between January 1, 2019 and September 30, 2021. RESULTS: At institution A, there were 3720 adult hospitalizations (qSOFA = 0: 2906 patients, qSOFA = 1: 677, qSOFA = 2: 124, qSOFA = 3: 13) and 418 pediatric hospitalizations (qSOFA = 0: 238 patients, qSOFA = 1: 159, qSOFA = 2: 20, qSOFA = 3: 1). At institution B, there were 3579 adult hospitalizations (qSOFA = 0: 2638 patients, qSOFA = 1: 816, qSOFA = 2: 121, qSOFA = 3: 4) and 429 pediatric hospitalizations (qSOFA = 0: 273 patients, qSOFA = 1: 149, qSOFA = 2: 6, qSOFA = 3: 1). In adults at both institutions, increased qSOFA was significantly associated with higher mortality rates. Intensive care unit (ICU) admission increased at institution A and increased at institution B to qSOFA = 2. In multivariable analyses, qSOFA predicted ICU admission and mortality. Pediatric patients had low injury severity, morbidity, and mortality. Excluding the one early qSOFA = 3 mortality, higher qSOFA scores were associated with increased ICU admission in pediatric patients. CONCLUSIONS: Elevated qSOFA scores are associated with ICU admission and mortality in adult nonpenetrating trauma patients. Further investigation on qSOFA for resource allocation is indicated.

Non-penetrating filtration surgery versus trabeculectomy in postoperative astigmatism: a meta-analysis.

OBJECTIVE: Trabeculectomy and non-penetrating trabecular surgery are common operations for glaucoma. This meta-analysis aims to compare the effect of trabeculectomy and non-penetrating trabecular surgery in postoperative astigmatism of patients with glaucoma. METHODS: A systematic literature search was performed for studies comparing trabeculectomy and non-penetrating trabecular surgery in patients with glaucoma. The time frame for the search was from the time of construction to April 2024. There were no restrictions regarding study type or type of glaucoma. The endpoint was the surgically induced astigmatism assessed 6 months after operation. We conducted this meta-analysis following the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis). RESULTS: Five eligible studies were included in this meta-analysis and presented data for 359 eyes with various types of glaucoma at different stages. The results revealed an increase in astigmatism in patients with glaucoma after trabeculectomy and non-penetrating trabecular surgery. Trabeculectomy had a higher incidence of astigmatism than in the non-penetrating trabecular surgery group at or around 6 months postoperatively, and the difference was statistically significant. (SMD = 0.40, 95% CI = 0.19 to 0.61, P = 0.02). CONCLUSION: Our results demonstrated that both trabeculectomy and non-penetrating trabecular surgery could increase astigmatism until 6 months after operation. Moreover, non-penetrating trabecular surgery group seems to have less influence on astigmatism. TRIAL REGISTRATION NUMBER: CRD42024517708.

New suture probe canaloplasty combined with suprachoroidal collagen implantation.

PURPOSE: To present the modified surgery technique of new suture probe canaloplasty with a specially prepared monofilament 4.0 polypropylene suture combined with suprachoroidal drainage (ScD) and collagen sheet implantation for non-penetrating glaucoma surgery. METHODS: Prospective study with a twelve months follow-up. A standard 4/0 polypropylene suture (ProleneTM by Ethicon; thickness: approximately 250 m) is cut and shaped with an ophthalmic knife (MANI® Crescent Knife, Mani Inc 8-3 Kiyohara Industrial Park, Utsunomiya, Tochigi 321-3231, Japan) to create a blunt end without sharp or compressed edges. This improves suture probe canaloplasty by providing a more stable and smoother probing device. Schlemm's canal is prepared using the standard technique of canaloplasty with suprachoroidal drainage. Then, instead of using the canaloplasty microcatheter or the previously published 6/0 double-helix suture, Schlemm's canal is probed with the blunt ending of the 4/0 Prolene suture. After successful 360-degree probing, a doubled 10/0 polypropylene tension suture is threaded through the tip of the 4/0 suture. The 4/0 suture is then pulled back and the 10/0 tension sutures are tied at both ends to tension Schlemm's canal. A special collagen sheet (Ologen®) is placed in suprachoroidal space, and the scleral flap is firmly sewed. RESULTS: 115 eyes were included in this prospective study. In 113 cases the Schlemm's canal could completely be probed with the suture probe and canaloplasty with ScD and collagen sheet implantation succeeded. In two cases the intervention was transformed to 360-degree suture trabeculotomy due to an intraoperative cheese-wiring. Twelve months after successful new suture probe canaloplasty with ScD and Collagen Implantation the IOP had decreased by 37.1% (from 21.6 ± 6.0 mmHg with 3.3 different IOP lowering eye drops to 13.5 ± 3.5 mmHg with 1.0 eye drops). 16 Patients did not achieve sufficient IOP levels and underwent 360-degree suture trabeculotomy during the follow-up. One patient had to be treated with further glaucoma surgery to achieve a sufficient IOP level. Complications were hyphema, postoperative IOP elevation and transient hypotony. No serious or sight-threatening complications occurred. CONCLUSION: New suture probe canaloplasty with ScD and collagen sheet implantation yields the opportunity to conduct a cost-effective canaloplasty easier and less complicated than with the previously described method with the twisted 6/0 suture. The safety profile and IOP lowering effect is comparable. In cases where complete probing fails, there is still the opportunity to switch to suture trabeculotomy over the majorly probed part of Schlemm's canal. The pressure lowering effect of the deep sclerectomy with ScD and suprachoroidal collagen sheet implant seems to have an additional impact on the sufficient pressure lowering procedure.

Value of contrast-enhanced arterial phase imaging in addition to portovenous phase in CT evaluation of blunt abdominopelvic trauma.

OBJECTIVES: Compare the diagnostic performance of the arterial phase plus portovenous phases (AP + PVP) of abdominopelvic CT (CT) with PVP alone in the detection and characterization of traumatic vascular injury and the effects on radiologists' confidence. METHODS: CT of 103 consecutive inpatients (median 36 years, 83 males) with blunt abdominopelvic injuries were retrospectively included if performed within 24 h after trauma and before definitive management. Images were re-reviewed by two blinded radiologists with disagreements resolved by the third radiologist. RESULTS: Sixty vascular injuries (liver 23, spleen 15, kidneys 9, pancreas 2, adrenals 3, mesentery, and pelvis 4 each) were found with 4 injuries (liver 2, spleen, and kidneys 1 each) not detected at initial CT. Nineteen (liver 6, spleen 10, kidneys 2, adrenal 1) were visualized only on AP. The sensitivity and accuracy of AP + PVP were 89.58-91.67% and 94.44-95.15%, compared to 61.67-62.50% and 77.67-80.00% of PVP alone. The agreements on the types of injury with final diagnoses were higher for AP + PVP than for PVP alone (78.69% vs. 44.26%). The mean diagnostic radiologist confidence ((1 = 25%, 2 = 50%, 3 = 75%, 4 > 90%) increased significantly in the detection (from 3.38 to 3.71) and characterization (from 2.46 to 3.67) of vascular injuries with AP + PVP compared to PVP alone. For 19 lesions detected only on AP, 11 (spleen 8, liver 2, adrenal 1) received nonoperative management; others had transarterial embolization or surgery. CONCLUSIONS: The addition of AP improves the detection and characterization of vascular injuries in CT evaluation of blunt abdominopelvic trauma. KEY POINTS: • AP+PVP was more sensitive and precise than PVP alone in the detection of traumatic vascular abdominopelvic injuries. • AP+PVP improved the characterization of traumatic abdominopelvic vascular injuries. • When all abdominopelvic vascular injuries were considered, AP increased radiologists' diagnostic confidence in the detection and characterization of vascular injuries.

CT-based diagnostic algorithm to identify bowel and/or mesenteric injury in patients with blunt abdominal trauma.

OBJECTIVES: To develop a CT-based algorithm and evaluate its performance for the diagnosis of blunt bowel and/or mesenteric injury (BBMI) in patients with blunt abdominal trauma. METHODS: This retrospective study included a training cohort of 79 patients (29 with BBMI and 50 patients with blunt abdominal trauma without BBMI) and a validation cohort of 37 patients (13 patients with BBMI and 24 patients with blunt abdominal trauma without BBMI). CT examinations were blindly analyzed by two independent radiologists. For each CT sign, the kappa value, sensitivity, specificity, and accuracy were calculated. A diagnostic algorithm was built using a recursive partitioning model on the training cohort, and its performances were assessed on the validation cohort. RESULTS: CT signs with kappa value > 0.6 were extraluminal gas, hemoperitoneum, no or moderate bowel wall enhancement, and solid organ injury. CT signs yielding best accuracies in the training cohort were extraluminal gas (98%; 95% CI: 91-100), bowel wall defect (97%; 95% CI: 91-100), irregularity of mesenteric vessels (97%; 95% CI: 90-99), and mesenteric vessel extravasation (97%; 95% CI: 90-99). Using a recursive partitioning model, a decision tree algorithm including extraluminal gas and no/moderate bowel wall enhancement was built, achieving 86% sensitivity (95% CI: 74-99) and 96% specificity (95% CI: 91-100) in the training cohort and 92% sensitivity (95% CI: 78-97) and 88% specificity (95% CI: 74-100) in the validation cohort for the diagnosis of BBMI. CONCLUSIONS: An effective diagnostic algorithm was built to identify BBMI in patients with blunt abdominal trauma using only extraluminal gas and no/moderate bowel wall enhancement on CT examination. KEY POINTS: • A CT diagnostic algorithm that included extraluminal gas and no/moderate bowel wall enhancement was built for the diagnosis of surgical blunt bowel and/or mesenteric injury. • A decision tree combining only two reproducible CT signs has high diagnostic performance for the diagnosis of surgical blunt bowel and/or mesenteric injury.

[Management of blunt and penetrating laryngeal trauma]. / Management von stumpfen und scharfen Kehlkopfverletzungen.

Patients presenting with laryngotracheal trauma can be in a life-threatening situation. Early recognition of the severity of the injury and, if necessary, surgical intervention within the first 24-48 h increases the chance of achieving a good functional late result. Preservation or restoration of voice and swallowing function is the long-term therapeutic goal. Precise assessment of the extent of the injury can be achieved using a combination of computed tomography and flexible laryngotracheoscopy. Symptoms often do not reflect the extent of the injury, which can vary from endolaryngeal hemorrhage to complete laryngotracheal separation. Conservative treatment consists of observation with symptomatic therapy. On the other hand, surgery may include endolaryngeal repair and/or transcervical reconstruction; securing the airways is of utmost importance.

Diagnostic accuracy of computed tomography angiography (CTA) for diagnosing blunt cerebrovascular injury in trauma patients: a systematic review and meta-analysis.

OBJECTIVES: Previous literature showed that the diagnostic accuracy of computed tomographic angiography (CTA) is not equally comparable with that of the rarely used golden standard of digital subtraction angiography (DSA) for detecting blunt cerebrovascular injuries (BCVI) in trauma patients. However, advances in CTA technology may prove CTA to become equally accurate. This study investigated the diagnostic accuracy of CTA in detecting BCVI in comparison with DSA in trauma patients. METHODS: An electronic database search was performed in PubMed, EMBASE, and Cochrane Library. Summary estimates of sensitivity, specificity, positive and negative likelihood, diagnostic odds ratio, and 95% confidence intervals were determined using a bivariate random-effects model. RESULTS: Of the 3293 studies identified, 9 met the inclusion criteria. Pooled sensitivity was 64% (95% CI, 53-74%) and specificity 95% (95% CI, 87-99%) The estimated positive likelihood ratio was 11.8 (95%, 5.6-24.9), with a negative likelihood ratio of 0.38 (95%, 0.30-0.49) and a diagnostic odds ratio of 31 (95%, 17-56). CONCLUSION: CTA has reasonable specificity but low sensitivity when compared to DSA in diagnosing any BCVI. An increase in channels to 64 slices did not yield better sensitivity. There is a risk for underdiagnosis of BCVI when only using DSA to confirm CTA-positive cases, especially in those patients with low-grade injuries. KEY POINTS: • Low sensitivity and high specificity were seen in identifying BCVI with CTA as compared to DSA. • Increased CTA detector channels (≤ 64) did not lead to higher sensitivity when detecting BCVI. • The use of CTA instead of DSA may lead to underdiagnosis and, consequently, undertreatment of BCVI.

Ventricular fibrillation arrest after blunt chest trauma in a 33-year-old man, commotio cordis?

BACKGROUND: Commotio cordis is an event in which a blunt, non-penetrating blow to the chest occurs, triggering a life-threatening arrhythmia and often sudden death. This phenomenon is often seen in young, male athletes and has become increasingly well-known over the past few decades. We present a unique case in which ventricular fibrillation occurs in an older male athlete after blunt trauma. CASE PRESENTATION: Patient with no known medical history was brought to the ER after being found unconscious after a soccer ball kick to the chest. He was found to be in ventricular fibrillation and successfully resuscitated on the soccer field. Patient was admitted to the hospital and lab workup and initial imaging were unremarkable, except elevated troponin and lactate, which returned to normal levels. An echocardiogram showed global left ventricular systolic dysfunction with a visually estimated ejection fraction of 45-50%. Coronary showed angiographically nonobstructive coronary arteries. The patient was diagnosed with commotio cordis and discharged from the hospital in stable condition. Follow-up echocardiogram continued to show low ejection fraction and event monitor demonstrated frequent polymorphic ventricular tachycardia with periods of asystole. CONCLUSION: This case is unique in that blunt trauma to the chest from a soccer ball immediately triggered ventricular fibrillation in a patient with a possible cardiomyopathy. It is possible that the blunt trauma caused primary commotio cordis that led to cardiomyopathy in a previous healthy man, or that an underlying cardiomyopathy made it more likely for this to occur. Overall, increased awareness and prevention efforts of blunt chest trauma are required to reduce the high mortality associated life-threatening arrhythmias. There is limited data regarding the interplay between these two entities.

Rotational extraction of incarcerated iris (REII): a slit lamp technique to reduce incarcerated iris after nonpenetrating deep sclerectomy for glaucoma.

PURPOSE: Iris incarceration is a complication of glaucoma filtering surgery that often requires surgery. We describe a technique for reduction of incarcerated iris at the slit lamp, dubbed rotational extraction of incarcerated iris (REII). A retrospective analysis of visual function and intraocular pressure (IOP) was done in patients treated with REII after nonpenetrating deep sclerectomy. METHODS: We retrospectively evaluated a cohort of patients who received REII for iris incarceration after nonpenetrating deep sclerectomy for glaucoma. IOP (applanation) and visual acuity (VA) were measured day-of, and 1, 3, 6, and 12 months post-REII. Adverse events were recorded. Kaplan-Meier survival analysis was done with definitions of IOP control at 15, 18, and 21 mmHg. RESULTS: Forty-one eyes of 41 patients were treated with REII. Median time to iris incarceration from glaucoma surgery was 50 days (range 1-1906). Mean pre-REII IOP ± SD was 33.7 ± 14.1 mmHg, which reduced to 11.5 ± 6.1 mmHg day-of. LogMAR VA was 0.72 ± 0.8 log units at baseline and was unchanged at 12 months (P = 0.53). Survival analysis demonstrated varying efficacy depending on the definition of success. 79.0 to 92.2% of eyes achieved IOP control immediately after REII, 39.5 to 71.1% at 1 month, 26.3 to 52.6% at 3 months, 21.1 to 44.3% at 6 months, and 10.5 to 38.0% at 12 months. Nearly half (47.4%) of eyes required a tube shunt by 12 months. CONCLUSION: REII may be a safe, minimally invasive slit lamp procedure that can reduce incarcerated iris and delay more invasive intervention for 3-6 months in most eyes.

Long-term outcomes of viscocanalostomy and phaco-viscocanalostomy in patients with narrow angle glaucoma.

PURPOSE: To assess the outcomes of viscocanalostomy and phaco-viscocanalostomy in patients with narrow angle glaucoma at a single tertiary eye centre. METHOD: All patients undergoing viscocanalostomy for narrow angle glaucoma between June 2010 and June 2017 with a minimum follow-up of 12 months were included. Data was analysed from a prospectively maintained surgical outcome database. Primary outcome was a change in intraocular pressure (IOP). Secondary outcomes were changes in LogMAR visual acuity, number of eye drops, post-operative complications and further surgical interventions. Success was defined at two IOP cut-off points: IOP ≤ 21 mmHg and IOP ≤ 15 mmHg with (qualified success) or without (complete success) drops. Failure was any repeat glaucoma surgery or loss of light perception. RESULTS: Seventy eyes of 46 patients with a mean follow-up of 41.31 months (range 12-60 months) were included. Mean IOP changed from 25.7 ± 9.6 to 15.2, 15.6, 14.6, 13.8 and 14.0 mmHg at 1, 2, 3, 4 and 5 years post-operatively. Drops reduced from 3.2 ± 1.1 pre-operatively to 0.5 at 1 year and 1.1 at all time points thereafter. Qualified success for an IOP ≤ 21 mmHg was achieved in 94.2%, 88.1%, 92.5%, 91.1% and 92.0% and complete success in 63.8%, 37.3%, 30.2%, 22.2% and 24.0% in years 1 to 5, respectively. Qualified success for an IOP ≤ 15 mmHg was achieved in 53.6%, 60.9%, 69.8%, 68.9% and 64.0% and complete success in 39.1%, 26.9%, 22.6%, 20.0% and 8.0% in years 1 to 5, respectively. IOP was significantly lower at all examined post-operative time points (41.1%, 39.3%, 43.3%, 46.4% and 45.3% at years 1 to 5, respectively, p < 0.001 at all time points). Four eyes (5.7%) failed to meet any of the success criteria. Of these, 3 eyes (4.3%) required further glaucoma surgery and one eye (1.4%) progressed to no perception of light at 48 months. No patients had an IOP ≤ 5 mmHg on two consecutive occasions after 3 months. CONCLUSION: Viscocanalostomy and phaco-viscocanalostomy are a safe and effective surgical option in the management of chronic narrow angle glaucoma.

Venous Injury in Patients with Blunt Traumatic Brain Injury: Retrospective Analysis of a National Cohort.

BACKGROUND: Cerebral venous injury (CVI) includes injury to a dural venous sinus or major vein and leads to poorer outcomes for patients with blunt traumatic brain injury (TBI). We sought to identify the incidence, associated factors, and outcomes associated with CVI in a large national cohort. METHODS: Adult patients with blunt TBI were identified from the National Trauma Databank (2013-2017). Outcomes included inpatient mortality, discharge disposition, stroke, length of stay (LOS), intensive care unit LOS, and duration of mechanical ventilation. Multivariate regression models were used to identify the association between exposure variables and CVI, as well as each outcome. RESULTS: There were 619,659 patients with blunt TBI who met the inclusion criteria. CVI occurred in 1792 (0.3%) patients. Mixed intracranial injury type had the strongest association with CVI (odds ratio [OR] 2.89, 95% confidence interval [CI] 2.38-3.50), followed by isolated TBI (OR 1.76, 95% CI 1.54-2.02) and skull fracture (OR 1.72, 95% CI 1.55-1.91). CVI was associated with increased odds of mortality (OR 1.38, 95% CI 1.19-1.60), nonroutine discharge (OR 1.26, 95% CI 1.12-1.40), and stroke (OR 1.95, 95% CI 1.33-2.86). It was also associated with longer LOS (ß 2.02, 95% CI 1.55-2.50) and intensive care unit LOS (ß 0.14, 95% CI 0.13-0.16). Among locations of venous injury, superior sagittal sinus injury had significant associations with mortality (OR 2.93, 95% CI 1.62-5.30) and nonroutine discharge disposition (OR 1.94, 95% CI 1.12-3.35), whereas the others did not. CONCLUSIONS: We identified a 0.3% incidence of CVI in all-comers with blunt TBI as well as several injury-related variables that may be used to guide investigation for dural venous sinus injury. CVI was associated with poorer outcomes, with superior sagittal sinus injury having the strongest association.

Results of modified CO2 laser-assisted sclerectomy monotherapy versus trabeculectomy combination therapy in the eyes with uveitic glaucoma.

This study compared the efficacy of modified CO2 laser-assisted sclerectomy surgery (CLASS) with combined CLASS and trabeculectomy (CLASS-TRAB) in patients with uveitic glaucoma (UG). UG patients who underwent CLASS-TRAB between August 2015 and April 2019 were retrospectively compared with a control group who underwent a modified CLASS standalone procedure during the same period. Visual acuity, intraocular pressure (IOP), use of supplemental medical therapy and postoperative complications were recorded at baseline, 1 week, 3 months, 6 months and 12 months. Forty patients (40 eyes) were enrolled, and each group had 20 patients (20 eyes). The age and sex distribution were matched between groups (P > 0.05). Both the preoperative IOP (CLASS: 34.9 ± 9.3 mmHg, CLASS-TRAB: 36.8 ± 8.7 mmHg; P > 0.05) and number of glaucoma medications (CLASS: 3.3 ± 0.4, CLASS-TRAB: 3.5 ± 0.5; P > 0.05) were relatively higher in the CLASS-TRAB group than in the CLASS group. At the final follow-up, the IOP (CLASS: 12.9 ± 3.4 mmHg, CLASS-TRAB: 11.2 ± 2.5 mmHg) and number of glaucoma medications (CLASS: 0.4 ± 0.7 and CLASS-TRAB: 0.2 ± 0.5) significantly decreased in both groups (P < 0.01). Both the complete success rate and qualified success rate were comparable between the two groups (CLASS versus CLASS-TRAB: 55% versus 80%, P = 0.09; 80% versus 95%, P = 0.34). CLASS-TRAB is as efficient as modified CLASS in terms of the IOP-lowering effect, providing a new option for patients with UG that is severe and ineligible for other treatments.

[Update on neck trauma]. / Update Halstraumata.

BACKGROUND: Important organs and structures are located in the cervical region. In case of blunt and penetrating trauma, emergency situations may arise. OBJECTIVE: Emergency management as well as diagnostic and therapeutic steps pertaining to neck injuries are presented. CONCLUSION: Shock therapy and airway management are essential, fast management of neck injuries highly relevant.

[Diagnostic difficulties in a patient with a combined gunshot injury involving non-penetrating abdominal wound and injury of superficial femoral artery]. / Sochetannaya ognestrel'naya travma bedrennoi arterii i nepronikayushchego raneniya zhivota.

Non-penetrating gunshot abdominal wounds are rare in peacetime and mainly caused by firearm traumatic weapons. The main therapeutic measure in this case is primary surgical debridement with adequate drainage. At the same time, such injuries may be accompanied by damage to internal organs. Timely diagnosis of these lesions may be difficult, and surgical treatment may be necessary. We report a patient with combined gunshot injury, damage to superficial femoral artery and non-penetrating abdominal wound followed by contusion and necrosis of small bowel. When providing medical care in patients with non-penetrating gunshot abdominal wounds, one should remember possible damage to internal organs due to high kinetic energy of the wounding projectile resulting contusion-induced necrosis.

Five-year results of non-penetrating deep sclerectomy with demineralized cancellous bone xenogenically derived collagen glaucoma implant.

PURPOSE: To investigate the long-term effectiveness of non-penetrating deep sclerectomy (NPDS) with xenogenically derived cancellous bone collagen glaucoma implant (XCB-CGI) implantation in patients with primary open-angle glaucoma (POAG). MATERIALS AND METHODS: Retrospective chart review of patients with POAG stages 2 and 3 was treated with NPDS and XCB-CGI. Follow-up was at 6 months, 1, 2, 3, 4 and 5 years after surgery. Main outcomes were intraocular pressure (IOP) and medication burden. Secondary outcomes were visual acuity, corneal hysteresis (CH), visual field (VF) and optical coherence tomography (OCT) parameter analysis. RESULTS: Among 71 patients (71 eyes), the mean age was 72.7 ± 9.8. Average initial IOP was 27.7 ± 7.9 and average initial med load was 2.36 ± 0.99. At 6 months, 1, 2, 3, 4 and 5 years, the average IOP was 14.9 ± 3.3 mm Hg (46.2% reduction), 15.3 ± 4.0 mm Hg (44.7% reduction), 14.2 ± 3.8 mm Hg (48.7% reduction), 15.2 ± 3.3 mm Hg (45.0% reduction), 15.5 ± 3.3 mm Hg (44.0% reduction) and 14.2 ± 2.8 mm Hg (48.7% reduction), respectively. In 5 years, the success rate was 34% and 67%, without, and with medications (1.8 ± 0.8 meds required), respectively. Visual acuity was not significantly different (P > .05) at all follow-up visits from baseline. Mean CH increased by 2.1 ± 0.8 (P = .05). No glaucomatous deterioration of the VF and OCT parameters was detected in 56 eyes at the 5-year follow-up. CONCLUSION: NPDS with XCB-CGI implantation is an effective procedure to normalize the level of IOP, stabilize glaucomatous changes and decrease the number of meds needed for glaucoma control.

Cataract and glaucoma combined surgery: XEN® gel stent versus nonpenetrating deep sclerectomy, a pilot study.

BACKGROUND: To compare the efficacy of phacoemulsification (PKE) combined with nonpenetrating deep sclerectomy (NPDS) with mitomycin C (MMC) versus XEN® gel stent with MMC. METHODS: In this nonrandomized, retrospective, comparative, single-center pilot study, 105 consecutive eyes of 75 patients with uncontrolled primary open-angle glaucoma (POAG) and cataract who underwent PKE combined with either XEN implantation (n = 47) or NPDS (n = 58) between May 2013 and November 2018 were included. The primary outcome was complete success at 9 months, which was defined as intraocular pressure (IOP) ≤18, 15 or 12 mmHg without treatment; qualified success was IOP ≤18, 15 or 12 mmHg with antiglaucoma medications. Secondary outcome measures included the number of antiglaucoma medications, visual acuity (VA), and postoperative adverse events. RESULTS: Using the 18 mmHg threshold, complete or qualified success was achieved in 69.6 and 89.1% in the PKE + XEN group, and 63.8 and 89.7% in the PKE + NPDS group (p = .54 and p = .93), respectively, at 9 months. The mean IOP decreased from 20.8 ± 6.8 mmHg to 16.2 ± 2.8 mmHg in the PKE + XEN group (p < .001, 18.9% mean drop), and from 21.5 ± 8.9 mmHg to 14.9 ± 3.9 mmHg in the PKE + NPDS group (p < .001, 25.6% mean drop). Best-corrected VA significantly improved (p < .001) in both groups. The mean number of antiglaucoma medications was significantly reduced from 2.66 ± 1.1 to 0.49 ± 1.0 in the PKE + XEN group (p < .001) and from 2.93 ± 0.9 to 0.69 ± 1.2 in the PKE + NPDS group (p < .001). CONCLUSIONS: The XEN stent combined with PKE seemed to be as effective and safe as PKE + NPDS at 9 months in this pilot study.

Emergency percutaneous thoracic endovascular aortic repair for patients with traumatic thoracic aortic blunt injury: A single center experience.

PURPOSE: To analyze the efficacy and outcome of percutaneous thoracic endovascular aortic repair (TEVAR) in patients with traumatic blunt aortic injury in our single-center. METHODS: From January 2014 to December 2018, a total of 89 patients with traumatic blunt aortic injuries were treated with emergency TEVAR in our center. Their clinical data such as demographics, operative details and postprocedure outcomes were analyzed retrospectively in this study using SPSS 20 software. Continuous variables were expressed as mean and standard deviation or median and interquartile range. Categorical variables are expressed as the numbers and percentages of patients. RESULTS: The median age of the patients was 37 years, and 76 (85.4%) were males. All the patients were involved in violent accidents and combined with associated injuries. Two patients died while awaiting the operations and 87 patients underwent emergency percutaneous TEVAR, with a 100% technique success. The mean time interval from admission to operating room was (90.1 ± 18.7) min, and the mean procedure time was (54.6 ± 11.9) min. Eighty (92.0%) patients were operated on under local anesthesia, while other 7 (8.0%) patients were under general anesthesia. Two cases underwent open repair of the femoral arteries because of the pseudoaneurysm formation of the access vessels. A total of 98 aortic covered stent grafts were deployed, of which 11 patients used two stent grafts (all in dissection cases). The length of the stent was (177.5 ± 24.6) mm. The horizontal diameter of aorta arch at the proximal left subclavian artery ostium was (24.9 ± 2.4) mm, the proximal diameter of the covered stent was (30.5 ± 2.6) mm, and the oversize rate of proximal site was (22.7 ± 4.0)%. The proximal landing zone length was (14.1 ± 5.5) mm. The left subclavian artery ostium was completely covered in 5 patients and partially covered in 32 patients. No blood flow reconstruction was performed. The overall aortic-related mortality was 2.25% (2/89). Among 87 patients, the median follow-up time was 24 months. Postoperative computed tomography angiography scans demonstrated no residual pseudoaneurysm, hematoma or endoleak. One patient complained of mild left upper limb weakness during follow-up due to left subclavian artery occlusion. Neither late death, nor neurological or other complications occurred. CONCLUSION: Emergency percutaneous endovascular repair is a less invasive and effective approach for the treatment of traumatic blunt aortic injuries. Long-term results remain to be further followed.

Four years of experience as a major trauma centre results in no improvement in patient selection for whole-body CT scans following blunt trauma.

INTRODUCTION: Management of major trauma patients with evidence of polytrauma involves the use of immediate whole-body CT (WBCT). Identification of patients appropriate for immediate WBCT remains challenging. Our study aimed to assess for improvement in patient selection for WBCT over time as a major trauma centre (MTC). METHODS: We conducted a retrospective study of patients who presented to our MTC during distinct two-month periods, one in 2013 and the other in 2017. Patients over 18 years of age who presented primarily following blunt trauma and activated a major trauma call were included. All patients underwent either immediate WBCT or standard ATLS workup. Those undergoing WBCT had the results of their scan recorded as positive or negative. RESULTS: A total of 516 patients were included, 232 from 2 months in 2013 and 284 from 2 months in 2017. There was no significant difference in the proportion of patients undergoing WBCT (61.6% vs 59.5%), selective CT (31.9% vs 32.4%) or no CT (6.5% vs 8.1%) between the cohorts. There was no improvement in the rate of negative WBCT observed between 2013 and 2017 (47.6% vs 39.6%, p = 0.17). CONCLUSION: There was no improvement in patient selection for WBCT following trauma at our institution over a three-year period. Optimal patient selection presents an ongoing clinical challenge, with 39-47% of patients undergoing a scan demonstrating no injuries.

[Combined laser treatment of glaucoma]. / Kombinirovannoe lazernoe lechenie glaukomy.

The main objectives of glaucoma treatment are normalization of IOP and slowing of the progression of glaucomatous optic neuropathy. They are achieved using conservative (medicated), surgical and laser methods. PURPOSE: To study the effectiveness of non-penetrating hypotensive laser sclerotomy (NHLS) in patients with non-stabilized primary open-angle (I-III) b glaucoma with previous laser trabeculoplasty and who are receiving drug therapy. MATERIAL AND METHODS: The study included 54 patients (102 eyes) with initial (38 eyes), developed (46 eyes) and advanced (18 eyes) glaucoma who were examined and operated on. 26 patients (46 eyes) were instilled a combined drug containing brinzolamide and timolol, 28 patients (56 eyes) received prostaglandin F2α analogues (PGA). Intraocular pressure (IOP) levels were 27±2.4 mm Hg. RESULTS: Reduction of IOP was observed in 89% of patients 2 weeks after NHLS with gradual improvement during the first 3 months of the follow-up; in 71% of patients the results preserved by the 6th month. Patients receiving combination of brinzolamide and timolol had more pronounced IOP reduction after NHLS amounting to 2.4±1.8 mm Hg in the first 3 months. By the end of the observation period IOP levels remained within normal range, drug therapy was ceased in 16 patients (21 eyes, 20.6%), 32 patients (67 eyes, 65.7%) achieved normalized intraocular pressure with antihypertensive therapy, and 9 patients (9 eyes, 8.8%) were referred to surgical treatment. CONCLUSION: Non-penetrating hypotensive laser sclerotomy (NHLS) allows measured reduction of IOP in various glaucoma stages achieving controlled and persistent hypotensive effect. In the group of patients receiving combination of brinzolamide and timolol, the effect is statistically significant and clinically superior when compared with patients receiving PGA.