A Case of Chronic Intranasal Cocaine Abuse Masquerading and Exacerbating Underlying Orbital IgG4-Related Disease.

Chronic cocaine use may lead to widespread intranasal inflammation and necrosis. Cases of cocaine use affecting the orbit have been reported in the literature with a clinical spectrum ranging from inflammation-induced p-anti-cytoplasmic neutrophil autoantibodies positive vasculitis to severe midline destructive lesions resulting in orbital apex syndrome. Here, we present a case of chronic intranasal cocaine abuse with midline destruction that initially obscured diagnosis of, and is hypothesized to have exacerbated, underlying IgG4-Related Disease (IgG4-RD) of the orbit over a 2-year period.

Endometrial ablation plus levonorgestrel releasing intrauterine system versus endometrial ablation alone in women with heavy menstrual bleeding: study protocol of a multicentre randomised controlled trial; MIRA2 trial.

BACKGROUND: It is estimated that between 12 to 25% of women who undergo an endometrial ablation for heavy menstrual bleeding (HMB) are dissatisfied after two years because of recurrent menstrual bleeding and/or cyclical pelvic pain, with around 15% of these women ultimately having a hysterectomy. The insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) immediately after endometrial ablation may inactivate residual untreated endometrium and/or inhibit the regeneration of endometrial tissue. Furthermore, the LNG-IUS may prevent agglutination of the uterine walls preventing intrauterine adhesion formation associated with endometrial ablation. In these ways, insertion of an LNG-IUS immediately after endometrial ablation might prevent subsequent hysterectomies because of persisting uterine bleeding and cyclical pelvic pain or pain that arises de novo. Hence, we evaluate if the combination of endometrial ablation and an LNG-IUS is superior to endometrial ablation alone in terms of reducing subsequent rates of hysterectomy at two years following the initial ablative procedure. METHODS/DESIGN: We perform a multicentre randomised controlled trial in 35 hospitals in the Netherlands. Women with heavy menstrual bleeding, who opt for treatment with endometrial ablation and without contraindication for an LNG-IUS are eligible. After informed consent, participants are randomly allocated to either endometrial ablation plus LNG-IUS or endometrial ablation alone. The primary outcome is the hysterectomy rate at 24 months following endometrial ablation. Secondary outcomes include women's satisfaction, reinterventions, complications, side effects, menstrual bleeding patterns, quality of life, societal costs. DISCUSSION: The results of this study will help clinicians inform women with HMB who opt for treatment with endometrial ablation about whether concomitant use of the LNG-IUS is beneficial for reducing the need for hysterectomy due to ongoing bleeding and/or pain symptoms. Trial registration Dutch Trial registration: NL7817. Registered 20 June 2019, https://www.trialregister.nl/trial/7817 .

Management of periocular cutaneous squamous cell carcinoma with perineural invasion: a case series and literature review.

PURPOSE: To review and elucidate the complex, multimodal management of periocular cutaneous squamous cell carcinoma (SCC) with perineural invasion (PNI), and offer practical, evidence-based patient care recommendations. METHODS: Three exemplary cases of high-risk periocular cutaneous SCC with PNI were selected from a single surgeon's experience. The clinical courses, management, and clinical outcomes, with follow-up intervals of 19, 19, and 24 months after presentation, were reviewed. The English-language literature on PNI, with attention to the management of cutaneous SCC of the head and neck (SCCHN), was reviewed. RESULTS: PNI of cutaneous SCCHN portends aggressive tumor behavior and a worsened prognosis. Treatment is multimodal, with varied combinations of surgical excision, radiotherapy (RT), and systemic chemotherapy. Retrospective reports from multiple institutions involve heterogenous patient populations, treatment strategies, and confounding variables that preclude formulation of a standardized treatment paradigm. Newer, comparative studies of advanced RT techniques (e.g., hyper-fractionation), novel systemic chemotherapeutic agents (e.g., cetuximab, cemiplimab), and varied integrative regimens are providing additional insights. Prompt initiation of adjuvant therapies (within 6-8 weeks of surgery), and careful evaluation of lymphatic basins can increase oncologic control. Utilizing deep-tissue fixation of advancement flaps and eyelid stabilization can enhance functional and aesthetic results. CONCLUSIONS: Management of cutaneous SCC with PNI remains complex and in most cases requires combined-modality therapy directed by a multidisciplinary tumor board. With novel therapies and new treatment patterns, optimal combinations and intensities of individual modalities require further elucidation. The oculofacial plastic surgeon plays a pivotal role - in diagnosis, coordination of interdisciplinary management, thoughtful surgical reconstruction, and postoperative surveillance.

Monitored wet-etch removal of individual dielectric layers from high-finesse Bragg mirrors.

It is prohibitively expensive to deposit customized dielectric coatings on individual optics. One solution is to batch-coat many optics with extra dielectric layers, then remove layers from individual optics as needed. Here we present a low-cost, single-step, monitored wet etch technique for reliably removing individual SiO2 and Ta2O5 dielectric layers, in this case from a high-reflectivity fiber mirror. By immersing in acid and monitoring off-band reflected light, we show it is straightforward to iteratively (or continuously) remove six bilayers. At each stage, we characterize the coating performance with a Fabry-Pérot cavity, observing the expected stepwise decrease in finesse from 92,000 ± 3,000 to 3, 950 ± 50, finding no evidence of added optical losses. The etch also removes the fiber's sidewall coating after a single bilayer, and, after six bilayers, confines the remaining coating to a 60-µm-diameter pedestal at the center of the fiber tip. Vapor etching above the solution produces a tapered "pool cue" cladding profile, reducing the fiber diameter (nominally 125 µm) to 95 µm at an angle of ∼0.3° near the tip. Finally, we note that the data generated by this technique provides a sensitive estimate of the layers' optical depths. This technique could be readily adapted to free-space optics and other coatings.

Upper Eyelid Response to Topical 0.5% Apraclonidine.

PURPOSE: To describe the change in upper eyelid position in a self-reportedly normal population after the administration of topical 0.5% apraclonidine in each eye. METHODS: One hundred self-reportedly normal subjects received a 1-time administration of topical 0.5% apraclonidine in each eye. Digital photographs were taken at baseline and then 30 and 45 minutes following apraclonidine instillation. Marginal reflex distance 1 was determined via image analysis of acquired digital photographs (image-derived measurements are given the prefix "i" in this study). The horizontal corneal diameter was used as a constant measurement scale in each photograph. RESULTS: The mean increase in i-marginal reflex distance 1 post-administration of 0.5% apraclonidine was +0.70 ± 0.60 mm (range, -0.94 to +2.66 mm) after 30 minutes and +0.68 ± 0.59 mm (range, -0.69 to +2.54 mm) after 45 minutes. Of the 200 total eyelids in 100 subjects, 181 (90.5%) had an increase in i-marginal reflex distance 1 at 30 minutes. Of the 100 subjects, 85 (85%) had a bilateral increase in i-marginal reflex distance 1, 4 (4%) had a bilateral decrease, and 11 (11%) had a unilateral increase with a contralateral decrease. CONCLUSIONS: Given its predominant small-amplitude upper eyelid elevating effect, topical apraclonidine may be a useful off-label alternative treatment for mild upper eyelid ptosis and in eyelid asymmetry due to eyelid retraction through use in the contralateral eye.

Hering's Law in Congenital Ptosis: Evaluation of the Contralateral Response to Unilateral Congenital Ptosis Repair.

PURPOSE: To determine the applicability and clinical relevance of Hering's law for the eyelids in cases of congenital ptosis. METHODS: A retrospective chart review and digital photograph analysis of patients who underwent unilateral congenital ptosis repair at a tertiary, university-based, Oculoplastics clinic was conducted. Pre- and postoperative eyelid height (marginal reflex distance), upper eyelid symmetry, and brow position were determined using ImageJ analysis software. Changes in these values, and the relationship between the change in ipsi- and contralateral eyelid heights and brow positions, were determined. RESULTS: In 51 patients, the mean change in contralateral upper eyelid position (marginal reflex distance) following unilateral repair was -0.5 mm with 29% (n = 15) demonstrating a greater than 1 mm contralateral descent. The contralateral brow position remained stable with a mean change of +0.1 mm. No significant differences were seen between the 15 patients who demonstrated a contralateral upper eyelid descent greater than 1 mm and the remainder of the cohort in terms of amblyopia rate (p = 0.71), mean preoperative marginal reflex distance (p = 0.14), mean change in ipsilateral marginal reflex distance (p = 0.32), mean change in contralateral brow position (p = 0.44), or mean postoperative upper eyelid asymmetry (1.3 mm vs. 1.2 mm). Overall, the mean upper eyelid asymmetry improved from 2.6 mm preoperatively to 1.2 mm postoperatively. None of the 51 patients underwent subsequent contralateral ptosis repair. CONCLUSIONS: Hering's law for the eyelids applies to cases of congenital ptosis but has little clinical significance due to improved upper eyelid asymmetry following unilateral surgery.

Rethinking Our Definition of Postoperative Success: A Comparative Analysis of Three Upper Eyelid Retraction Repair Techniques Using Novel Metrics to Capture Functional and Aesthetic Outcomes.

PURPOSE: To compare 3 upper eyelid retraction repair techniques and introduce novel metrics, which enhance the analysis of postoperative aesthetic outcomes. METHODS: Retrospective review with Image J 1.48 digital analysis of patients who underwent repair of thyroid-related upper eyelid retraction at the University of Iowa from 1996 to 2014 via 1 of 3 surgical techniques, septum-opening levator recession with Muellerectomy, modified septum-preserving levator recession with Muellerectomy, and modified septum-preserving full-thickness blepharotomy, was conducted. Photographs were obtained preoperatively, 3 to 6 months postoperatively, and at last follow up (>6 months) and evaluated by digital image analysis (denoted by "i"). Outcome measures assessed were marginal reflex distance (iMRD1), temporal-to-nasal ratio, tarsal platform show (iTPS), pupil to visible eyelid crease, brow fat span (iBFS), tarsal platform show to brow fat span ratio (iTPS:iBFS), and tarsal platform show minimizing power (iTPS-minimizing power). RESULTS: A total of 121 eyelids (28 septum-opening levator recession with Muellerectomy, 66 septum-preserving levator recession with Muellerectomy, and 27 septum-preserving full-thickness blepharotomy) from 74 patients were evaluated with a mean follow up of 24.2 months. There were no statistically significant differences between techniques in terms of iMRD1 or temporal-to-nasal ratio reduction at either time point (intertechnique p values of 0.17 to >0.99). The percentage of eyelids from subjects undergoing bilateral intervention that achieved a final iMRD1 between 2.50 mm and 4.50 mm was similar (intertechnique p value of 0.23), with no difference regarding the number of subjects demonstrating iMRD1 symmetry within 1 mm (intertechnique p value of 0.15). Though iTPS elongation was greater at 3 to 6 months with septum-opening compared with the combined septum-preserving techniques (p value of 0.04), this difference was not maintained at final follow up (p value of >0.99). There was no difference in terms of iTPS symmetry at time of final follow up (intertechnique p value of 0.69). The pupil to visible eyelid crease was unchanged in all techniques (p values >0.99). Mean changes in iBFS at final follow up were -1.27 mm, -0.44 mm, and +0.55 mm for septum-opening levator recession with Muellerectomy, septum-preserving levator recession with Muellerectomy, and septum-preserving full-thickness blepharotomy (p values of 0.01, 0.49, and >0.99, respectively). Mean iTPS:iBFS ratios at final follow up were not statistically different between techniques (intertechnique p value of 0.10) and no difference in symmetry was demonstrated (intertechnique p value of 0.47). Median values for iTPS-minimizing power were: -0.83, -0.93, and -1.01 for septum-opening levator recession with Muellerectomy, septum-preserving levator recession with Muellerectomy, and septum-preserving full-thickness blepharotomy, respectively (intertechnique p value of 0.54). CONCLUSIONS: Each technique appropriately lowered the eyelid and improved contour without intertechnique variability. Septum-preserving techniques demonstrated less iTPS elongation initially, but this difference was not maintained. The visible eyelid crease height (pupil to visible eyelid crease) remained stable in all techniques, indicating that the iTPS elongation seen with each technique was secondary to reduction in iMRD1 and the iBFS reduction seen with septum-opening levator recession with Muellerectomy was due to brow descent. No intertechnique differences in the amount of iTPS elongation relative to iMRD1 reduction (i.e., the novel iTPS-minimizing power) were seen. Given that each procedure evaluated yielded similar results, technique selection may be guided by surgeon experience and preference.

A Vector Force Model of Upper Eyelid Position in the Setting of a Trabeculectomy Bleb.

PURPOSE: A vector force model for the determination of upper eyelid position in the setting of a trabeculectomy bleb is presented. The model is used to explain the clinical courses of 5 patients with bleb-induced upper eyelid malposition and the efficacy of modalities previously described for the treatment of bleb-induced upper eyelid retraction. The novel use of botulinum toxin in the treatment of bleb-induced eyelid retraction and unique surgical considerations in patients with trabeculectomy blebs undergoing upper eyelid surgery are discussed. METHODS: A vector force analysis was conducted and a force diagram constructed. The clinical and surgical courses of 5 patients with trabeculectomy blebs and upper eyelid malposition were reviewed. The vector force model was applied to these cases and the previously described treatment modalities for bleb-induced upper eyelid retraction. RESULTS: Vector force analysis demonstrates that in the case of trabeculectomy bleb-induced upper eyelid retraction, the net force vector, which represents the sum of all the individual forces acting on the eyelid, has a positive vertical component resulting in superior displacement of the eyelid. In contrast, bleb-induced ptosis results when the net force vector has a negative vertical component. In 3 patients, alterations in the bleb resulted in resolution of upper eyelid malposition. Botulinum toxin was used to achieve a normal upper eyelid position in 1 patient with lateral canthal tendon disinsertion and unilateral eyelid retraction and 1 patient with bilateral eyelid retraction. One patient developed unilateral ptosis in concert with the emergence of a large Tenon cyst that resolved with the treatment of the cyst via eyelid massage. One patient with unilateral ptosis and an ipsilateral bleb underwent external levator advancement but was unable to achieve the desired upper eyelid height as retraction over the bleb occurred with any attempt to elevate the eyelid above a marginal reflex distance of 1.5 mm. The efficacy of previously reported modalities for the treatment of trabeculectomy bleb-induced upper eyelid retraction can be explained by either a reduction in the positive vertical component of the net force vector or augmentation of the negative vertical component. CONCLUSIONS: A vector force model systematically accounts for the multiple determinants of upper eyelid position in the setting of a trabeculectomy bleb. This model provides a framework for the evaluation of bleb-induced upper eyelid malposition and offers a logical, mathematical explanation for the occurrence of bleb-induced upper eyelid retraction and the usefulness of previously reported treatment modalities for this clinical entity.

Evidence quality in clinical guidelines: a comparison of two methods.

INTRODUCTION: Guidelines report the quality of the evidence used when formulating recommendations to ensure transparency and allow end-users to assess the estimates of effect that underlie the recommendation. The aim of this study was to investigate the differences in grading of evidence quality between the Scottish Intercollegiate Guideline Network (SIGN) model and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method. MATERIALS AND METHODS: The GRADE system was used to create evidence profiles for recommendations from a guideline that used the SIGN method to assess the quality of evidence. Scores were allocated to the quality assessment in its GRADE and SIGN forms, so that the difference between the two methods could be quantified. RESULTS: The SIGN grading system led to quality ratings of the evidence of high and moderate but using the GRADE system, the majority of ratings were graded as low or very low. All of the recommendations were graded as higher quality by SIGN than by GRADE. The points' difference ranged from one to three points (maximum difference possible was four points). The most common reasons for downgrading evidence were "study limitations", "imprecision"' and "publication bias". "Indirectness" and "inconsistency" were rarely selected as reasons to downgrade the evidence. CONCLUSIONS: The GRADE and SIGN methods produce varying estimates of the quality of evidence.

Case of the weeping wound: formation of a lacrimal pseudocyst following lateral canthal surgery.

An 87-year-old woman presented with a subcutaneous fluid collection overlying the right lateral orbital rim 2 days after undergoing a lateral tarsal strip. Drainage and excision of fibrinous granulation tissue occurred twice within the first postoperative month, with the formation of a lacrimal pseudocyst. The pseudocyst repeatedly enlarged following drainage, necessitating 4 needle aspirations. A third attempt at excision, coupled with cautery to the wound base, and loose wound closure succeeded in breaking the cycle of pseudocyst recurrence. However, the wound continued to drain, so aggressive cautery and botulinum toxin were used to obliterate the area of presumed lacrimal gland laceration and slow tear production. The possibility of damage to the lacrimal system should be entertained in the scenario of a postoperative weeping wound. Formation of a lacrimal pseudocyst should be considered when a cystic lesion appears following surgical intervention in the lateral canthal region.

Intimate partner violence: an underappreciated etiology of orbital floor fractures.

PURPOSE: To evaluate the prevalence of intimate partner violence (IPV) in a large population of female orbital floor fracture patients and provide recommendations on effectively identifying and referring IPV survivors. METHODS: Retrospective review of facial fracture patients examined at the University of Iowa Hospitals and Clinics between January 1995 and April 2013. International Classification of Diseases, Ninth Revision, codes and medical record review were used to determine the prevalence of IPV victimization and clinical outcomes. RESULTS: A total of 1,354 women and 4,296 men sustained facial fractures. Of these, 405 women and 1,246 men sustained orbital floor fractures. Leading mechanisms of orbital floor fractures in women were motor vehicle collisions (29.9%) and falls (24.7%). Twenty percent had no etiology documented. Intimate partner violence-associated assault was the third leading documented cause of orbital floor fractures in women (7.6%) followed by non-IPV-associated assault (7.2%). Among women with orbital floor fractures due to assault, leading patterns of injury included the following: isolated orbital floor fractures (38.7%, 12/31 in IPV patients; 55.2%, 16/29 in non-IPV patients), zygomaticomaxillary complex fractures (35.5%, 11/31 in IPV patients; 17.2%, 5/29 in non-IPV patients), and orbital floor plus medial wall fractures (16.1%, 5/31 in IPV patients; 24.1%, 7/29 in non-IPV patients). Involvement of ancillary services was documented in 20.0% (7 law enforcement and 5 social service agencies, 12/60) of assault-related orbital floor fracture cases. Ascertainment of patient safety was documented in 1.7% (1/60) of these cases. CONCLUSIONS: Ophthalmologists treating orbital floor fracture patients should maintain a high index of suspicion for IPV and screen accordingly. Following IPV disclosure, patient safety should be assessed and referral provided.

Aesthetic Eyelid Measurements of "Beautiful People": Gender Differences and Application for Thyroid Eye Disease Patients.

There remains a paucity of studies investigating measurements of periocular structures of people popularly seen as "beautiful." Such measurements may be helpful in establishing postoperative goals and measuring aesthetic outcomes. This study (1) identifies aesthetic measurements of the periocular structures in idealized celebrities, (2) determines gender differences in such measurements, and (3) compares these measurements to patients who underwent surgical repair of upper eyelid retraction associated with thyroid eye disease. METHODS: Digital analysis of 38 celebrity photographs in People's "Most Beautiful People" and "Sexiest Man Alive" was performed to measure image-derived (denoted with an "i") margin reflex distance (iMRD1), tarsal platform show (iTPS), brow fat span (iBFS), and iTPS:iBFS ratio. The same analysis was used for 35 women who underwent surgical repair for thyroid eye disease-related upper eyelid retraction. RESULTS: Significant gender differences (P < 0.05) were observed in celebrity metrics, with women having higher upper eyelids (longer iMRD1) (3.30 mm versus 2.50 mm), longer iTPS measurements (3.90 mm versus 2.50 mm), and larger iTPS:iBFS values (0.31 versus 0.20). Postoperative thyroid eye disease patients had significantly higher upper eyelids (longer iMRD1s) (4.80 mm versus 3.30 mm), longer iTPS (5.10 mm versus 3.90 mm), and larger iTPS:iBFS (0.37 versus 0.31) than celebrities. CONCLUSIONS: There are significant gender differences in the periocular metrics of "beautiful people." Optimal aesthetic outcomes may be more effectively obtained by achieving a preferred range of ratios than by relying on independent measurements. Although aesthetic outcomes are multi-factorial, measurements of "beautiful" people provide helpful guidelines to gauge aesthetic outcomes.

Detection and Referral of Orbital and Ocular Injuries Associated With Intimate Partner Violence Following an Educational and Screening Initiative in an Emergency Department.

IMPORTANCE: Intimate partner violence (IPV) is a substantial cause of morbidity and mortality in the US. Previous studies indicate gaps in identifying and referring female patients with IPV-associated orbital and ocular injuries to ancillary services. OBJECTIVE: To determine the number of IPV-associated orbital floor fractures, zygomaticomaxillary complex (ZMC) fractures, and ruptured globes referred to ancillary services in adult female patients following an educational and screening intervention to health care professionals. DESIGN, SETTING, AND PARTICIPANTS: This single-center retrospective quality improvement analysis examined electronic medical records of adult female patients seen in a single level 1 trauma center emergency department and ophthalmology clinic between January 2015 and February 2019, after the initiative began. Female adults who sustained orbital floor fractures, ZMC fractures, or ruptured globes were included. Preinitiative data were previously collected between January 1995 and January 2015 on adult female patients and published. Data analysis for this study occurred from May 2020 to September 2020. INTERVENTIONS: A 2-part, ongoing initiative began January 2015. First, enhancement of IPV screening protocols in the emergency department was conducted. Second, an educational campaign on IPV injury patterns was presented to residents and faculty in ophthalmology, emergency, otolaryngology, and trauma departments. MAIN OUTCOMES AND MEASURES: Comparison of ancillary service involvement preinitiative (January 1995 to January 2015) and postinitiative (January 2015 to February 2019). RESULTS: A total of 216 adult female patients (mean [SD] age, 55.0 [22.7] years; age range, 18-99 years) sustained orbital floor or ZMC fractures postinitiative. A total of 22 of 216 (10.2%) sustained fractures from IPV compared with 31 of 405 (7.6%) preinitiative (95% CI, -2.2% to 7.3%; P = .28). Documented social work referrals (11 of 31 preinitiative vs 20 of 22 postinitiative; difference, 55% [95% CI, 35%-76%]; P < .001), homegoing safety assessments (1 of 31 preinitiative vs 18 of 22 postinitiative; difference, 79% [95% CI, 61%-96%]; P < .001), and law enforcement involvement (7 of 21 preinitiative vs 16 of 22 postinitiative; difference, 50% [95% CI, 26%-74%]; P < .001) were higher in patients who presented after the initiative with orbital floor and ZMC fractures. A total of 51 adult female patients (mean [SD] age, 57.7 [20.8] years; age range 20-93 years) sustained ruptured globes postinitiative. A total of 5 of 51 patients (9.8%) sustained injury due to IPV postinitiative, compared with 5 of 141 (3.5%) preinitiative (95% patients, -2.5% to 15.0%; P = .08). CONCLUSIONS AND RELEVANCE: Following the start of the initiative, referral patterns of adult female patients with IPV-associated orbital fractures improved. Targeted IPV screening of patients with orbital and ocular injuries is essential for effective intervention.

2021 American Thyroid Association Guidelines for Management of Patients with Anaplastic Thyroid Cancer.

Background: Anaplastic thyroid cancer (ATC) is a rare but highly lethal form of thyroid cancer. Since the guidelines for the management of ATC by the American Thyroid Association were first published in 2012, significant clinical and scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, and researchers on published evidence relating to the diagnosis and management of ATC. Methods: The specific clinical questions and topics addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of the Task Force members (authors of the guideline). Relevant literature was reviewed, including serial PubMed searches supplemented with additional articles. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations. Results: The guidelines include the diagnosis, initial evaluation, establishment of treatment goals, approaches to locoregional disease (surgery, radiotherapy, targeted/systemic therapy, supportive care during active therapy), approaches to advanced/metastatic disease, palliative care options, surveillance and long-term monitoring, and ethical issues, including end of life. The guidelines include 31 recommendations and 16 good practice statements. Conclusions: We have developed evidence-based recommendations to inform clinical decision-making in the management of ATC. While all care must be individualized, such recommendations provide, in our opinion, optimal care paradigms for patients with ATC.

Intimate partner violence as a mechanism of traumatic ocular injury in women.

OBJECTIVE: Determine the prevalence of intimate partner violence (IPV) as a mechanism of traumatic ocular injury in women, typical injury patterns, and the clinical course of affected patients. Encourage IPV screening and safety assessment in patients presenting with characteristic ocular trauma. METHODS: Medical records of 211 female patients with traumatic ocular injuries evaluated at the University of Iowa Hospitals and Clinics between January 1995 and January 2015 were reviewed to determine the rate of IPV as a mechanism of ocular trauma. Twenty-one patients were excluded due to no documented trauma. RESULTS: Leading causes of traumatic ocular injuries in the 190 female patients included were accidental trauma with an inanimate object (n = 70/190, 36.8%), falls (n = 52/190, 27.4%), motor vehicle collisions (n = 21/190, 11.1%), and assault (n = 16/190, 8.4%). In 2.1% of cases (n = 4/190), no mechanism of traumatic injury was documented. Assault was the fourth leading mechanism of injury accounting for 8.4% of cases (n = 16/190), with IPV accounting for more than one third of cases with a documented perpetrator (n = 5/13). No perpetrator was documented in 18.8% (n = 3/16). All 5 patients with IPV-related injuries sustained scleral laceration or rupture; 4 out of 5 patients had no light perception vision and ultimately required enucleation. CONCLUSION: IPV is an important mechanism of traumatic ocular injury. IPV-associated injuries tend to be severe in nature, as demonstrated by the high rate of globe laceration or rupture and subsequent enucleation in the study population. By appropriate screening and referral, ophthalmologists have an opportunity to redirect a potentially devastating course.

Effect of iris show on perceived upper eyelid height.

OBJECTIVE: To introduce "iris show," the amount of visible iris tissue between the superior pupil border and the upper eyelid margin, to evaluate the effect of iris show on perceived upper eyelid height, and to discuss potential nonsurgical treatment options for mild blepharoptosis. METHODS: Participants completed a survey containing 4 subject photographs. These photographs depicted images of varying iris colouration (blue, green, light brown, and dark brown) with identical upper eyelid marginal reflex distance (MRD1) values, but asymmetric pupil size/amount of visible iris show. Study participants were asked to select the eyelid that appeared "droopier," or choose "same height." Statistical analyses used 1-tailed and 2-tailed t tests. RESULTS: 390 participants completed the survey. In photographs of blue and green irides, both eyelids had equal MRD1s, but the eyelid with less iris show was perceived as more ptotic (p = 0.002 and 0.03, respectively). In patients with dark brown irides, eyelid heights were perceived as identical despite differences in iris show (p = 0.002). CONCLUSIONS: Decreased iris show corresponds to perceived lowering of the upper eyelid in light-coloured irides (e.g., blue and green), but may be less impactful in brown and/or dark brown irides where the iris tissue is less distinguishable from the pupil. Topical instillation of apraclonidine may represent a nonsurgical option for treatment of mild blepharoptosis in patients with light irides as it both elevates the upper eyelid margin and induces miosis, resulting in an increase in iris show and corresponding enhanced perception of upper eyelid elevation.

Clitolactone: a banana slug antifeedant from Clitocybe flaccida.

Clitolactone, 5-(chloromethyl)-3-methyl-2(5H)-furanone, was isolated from sporocaps of the mushroom Clitocybe flaccida. The structure was determined by HRMS, EIMS, (1)H & (13)C NMR, 2D (1)H-(13)C COSY and (1)H-(1)H COSY. This mushroom is not eaten by the banana slug Ariolimax columbianus (Gould), a mycophagist from the temperate rain forests of the Pacific Northwest. Clitolactone acts as an antifeedant because these slugs rejected 1.0 cm(2) pieces of lettuce treated with 25 µg of clitolactone.

Induced elephant (Loxodonta africana) tusk removal.

Elephant tusk removal usually requires costly surgical procedures that are time-consuming and present a significant risk to the animal when performed using general anesthesia. Such techniques require gauges, chisels, and forceps to remove the tusk. This article reports the simple removal of the tusk of an 18-yr-old African elephant (Loxodonta africana) without the use of surgical instruments and anesthesia. Rubber elastics were placed around a tusk, causing loss of alveolar bone with subsequent exfoliation of the tusk within 3 wk. The healing process was uneventful.

Future research in gynaecological surgery.

Gynaecological surgery is constantly evolving. To inform practice with high-impact research, clinicians need to focus on areas of importance. Surveys of specialist members of the British Society of Gynaecological Endoscopy have revealed a range of areas for research: diagnostic performance of laparoscopies; therapeutic laparoscopies in endometriosis; laparoscopic versus hysteroscopic sterilisation; and laparoscopic surgical techniques, among others. Clinical and economic outcomes are important in evaluating effectiveness and use of surgical health technology. For studies to be valid, reliable and generalisable, they would have to be free of bias, large and multi-centred. In a time of financial constraints, it is important to encourage clinicians and trainees to participate in important research studies to improve outcomes for patients.