Complete Fusion of Both Eyelids in Stevens-Johnson Syndrome: Case Report

An 18-year-old woman developed Stevens-Johnson syndrome (SJS) with ocular involvement after taking ibuprofen. She was admitted to another hospital, received saline flushes and bacitracin ophthalmic ointment to the eyes, and became unable to open them. Upon transfer to this burn center 3 weeks after symptom onset, there was complete fusion of both eyelids with no visible cornea or sclera. She underwent bilateral operative scar release. After opening the lids, meticulous debridement of cicatricial membranes and release of symblephara were performed with subsequent placement of amniotic membrane grafts. Her vision slowly improved, though her long-term visual prognosis remains guarded. Early recognition and treatment of SJS or toxic epidermal necrolysis (TEN) with ocular involvement is imperative. Even mild cases may require intensive topical lubrication, steroids, and antibiotics, with early placement of amniotic membrane grafts in severe cases. Prompt intervention and daily evaluation are paramount in preventing lifelong visual disability.

Prevalence, Patterns, and Characteristics of Eye Injuries in Professional Mixed Martial Arts

Purpose

To describe the frequency and type of eye injuries in fighters in mixed martial arts (MMA) competition.

Methods

Fight result data were collected from the Nevada Athletic Commission database from 2001 to 2020. Any fighters in a professional mixed martial arts (MMA) contest with an eye injury were included. Main outcome measures included frequency and rate of eye injuries per fight and the types of eye injuries. Secondary outcome measures were gender, laterality, decision type, and length of no-contact recommended.

Results

Of the 256 MMA events in the database, 187 events (73.3%) had at least one eye injury. Of a total 2208 fights at these events, there were 363 fighters who sustained 369 eye injuries, with the yearly rate of eye injuries per 100 fighters ranging from 2.56 to 12.22. The most common injuries were eyebrow and eyelid lacerations (n=160, 43%), lacerations around the eye (n=98, 27%), and orbital fractures (n=62, 17%). Most eye injuries were right sided (n=197, 53.3%) and the majority of fighters with eye injuries lost their match (n=228, 62.8%). Fifty-seven fighters were recommended for further ophthalmology clearance after the match. The most common reasons for recommended ophthalmology follow-up was orbital fracture (n=25, 44%) and retinal injury (n=7, 12%). Forty-three fighters received no-contact requirements relating to their injury for an average of 8.9 weeks (range 1–24 weeks).

Conclusion

Ophthalmic injuries in professional MMA were prevalent, were most often lacerations surrounding the eye, and often accompanied the fighter losing their match.

Acute Reconstruction of Periorbital Trauma Resulting in Eyelid Anterior Lamella Loss With Simultaneous Full-thickness Skin Grafting and Amniotic Membrane Grafting: A Case Report

Complex facial lacerations are frequently encountered in the combat environment. Trauma with soft-tissue loss of the periorbital region offers particular challenges in terms of operative reconstruction. Cicatricial changes in the sub-acute phase can lead to eyelid malposition and lagophthalmos. The authors present a novel technique for acute reconstruction of periorbital trauma with eyelid soft-tissue loss with simultaneous full-thickness skin grafting and amniotic membrane grafting. The technique involves standard preparation of the surgical area of injury and infiltration with local anesthetic. Initially, the area of injury is copiously irrigated, and debridement of any necrotic tissue is accomplished. Amniotic membrane grafting is then performed over the defect. Approximately 2 mm × 2 mm full-thickness skin grafts are procured and distributed over the initial amniotic membrane graft. A second amniotic membrane graft is then secured over the skin graft-amniotic membrane graft complex with cyanoacrylate tissue adhesive. A bolstered suture tarsorrhaphy is performed to minimize tissue trauma during the healing process. The operative and postsurgical outcomes were assessed. The graft site healed well without cicatricial changes or lagophthalmos. Peripheral small papillomatous lesions did develop requiring excision for cosmesis, but ultimately the graft site demonstrated appropriate coverage and healthy re-epithelialization over the previous defect. This case demonstrates the viability of simultaneous full-thickness skin grafting with concomitant amniotic membrane grafting for the acute reconstruction of periorbital trauma with eyelid anterior lamella tissue loss. An excellent cosmetic and functional outcome was attained. By providing acute reconstruction, the risk of damage secondary to cicatricial periorbital changes may be avoided.

Teleophthalmology Prevents Unnecessary Evacuation from Warzone

The purpose of this case report is to highlight the benefits of using teleconsultation to diagnose ophthalmologic conditions within the restraints of a combat environment. A previously healthy 49-year-old service member deployed in the Middle East presented with diplopia over the course of 2 weeks. Initial diagnosis by his primary care physician upon partial ophthalmologic exam was a pupil-sparing CN III palsy without ptosis. Initial teleconsultation response from Naval Medical Center Portsmouth was within 6 hours. After an ophthalmologic sensorimotor examination was videotaped and sent to the referred ophthalmologist, teleconsultation was completed and discussed with the patient. The updated diagnosis was CN IV palsy with slight right hypertropia worse on left gaze-most likely congenital in origin. Upon further follow-up stateside, his final diagnosis was diplopia related to thyroid disease. Overall, his diagnosis remained a nonurgent condition that allowed the service member to remain at his duty station and prevent an unnecessary evacuation. Ultimately, teleconsultation provided many benefits for the service member and the U.S. military.

Patterns and prognosis of commotio retinae in orbital wall fractures

Purpose:

Orbital wall fractures are a significant cause of ocular injury in trauma and are associated with posterior segment pathology. This study aims to characterize patterns and prognosis of commotio retinae following orbital wall fracture.

Methods:

This study is a retrospective analysis of 294 orbital wall fractures diagnosed by computed tomography imaging from August 2015 to October 2016 at a Level 1 trauma center. Dilated funduscopic exams were assessed for acute posterior segment pathology, focusing specifically on commotio retinae (N = 38). These were compared with patients with no traumatic retinal findings (N = 253) to indicate statistically significant differences in the mechanism of injury, fracture pattern, subjective symptoms, radiologic and exam findings, and acute interventions.

Results:

Commotio was most commonly associated with assault (60.5%, p = 0.004) in a younger patient population, whereas normal retinal exams were more likely after falls from standing (24.1%, p = 0.022). Half of all commotio was found inferiorly and most commonly occurred in medial or inferior wall fracture. Patients with commotio were more likely to have motility deficits (29.7%, p = 0.049) with clinical evidence of entrapment (13.2%, p < 0.001), requiring acute operative repair (15.8%, p = 0.005). Inferior wall fracture was associated with 19.4% surgical intervention in commotio as compared with those with normal funduscopic exams (6.1%, p = 0.012). All patients with follow-up had resolution of commotio and best-corrected visual acuity of 20/25 or better.

Conclusion:

Retinal pathology is not infrequent in orbital wall fractures. Inferior wall fracture was associated with 19.4% surgical intervention in commotio as compared to those with normal funduscopic exams (6.1%, p = 0.012). A high index of suspicion and thorough investigation is warranted in evaluating these patients.

Firing up the front line

For many organizations, achieving competitive advantage means eliciting superior performance from employees on the front line--the burger flippers, hotel room cleaners, and baggage handlers whose work has an enormous effect on customers. That's no easy task. Front line workers are paid low wages, have scant hope of advancement, and--not surprisingly--often care little about the company's performance. But then how do some companies succeed in engaging the emotional energy of rank-and-file workers? A team of researchers at McKinsey & Company and the Conference Board recently explored that question and discovered that one highly effective route is demonstrated by the U.S. Marine Corps. The Marines' approach to motivation follows the "mission, values, and pride" path, which researchers say is practical and relevant for the business world. More specifically, the authors say the Marines follow five practices: they over-invest in cultivating core value; prepare every person to lead, including front line supervisors; learn when to create teams and when to create single-leader work groups; attend to all employees, not just the top half; and encourage self-discipline as a way of building pride. The authors admit there are critical differences between the Marines and most businesses. But using vivid examples from companies such as KFC and Marriott International, the authors illustrate how the Marines' approach can be translated for corporate use. Sometimes, the authors maintain, minor changes in a company's standard operating procedure can have a powerful effect on front line pride and can result in substantial payoffs in company performance.

Analysis of the mechanism of quinolone resistance in nalidixic acid-resistant clinical isolates of Salmonella serotype Typhimurium

Over a period of 2.5 years, 42 cases of gastro-enteritis caused by nalidixic acid-resistant Salmonella serotype Typhimurium occurred in Malaga. The epidemiological relationship among the strains involved was investigated by analysis of plasmid profile and of chromosomal DNA by pulsed-field gel electrophoresis (PFGE). Despite having different plasmid profiles, all 42 nalidixic-acid resistant Typhimurium isolates had evolved from one clone as shown by analysis of chromosomal DNA by PFGE. The mechanism of quinolone resistance in these Typhimurium isolates was also investigated. Analysis of outer-membrane proteins and lipopolysaccharide from quinolone-susceptible and resistant clinical isolates tested showed no differences. All nalidixic acid-resistant isolates had MICs for ciprofloxacin of 0.25 mg/L and for nalidixic acid of 1024 mg/L. Polymerase chain reaction fragments of 285 bp, containing the quinolone resistance-determining region of the gyrA gene, and of 237 bp, containing the region of parC homologous to the quinolone resistance-determining region of the gyrA gene, were sequenced. All resistant isolates presented a change at Ser-83 to Phe in the GyrA protein, but no changes were observed in the ParC protein. These findings indicated that this mutation in gyrA plays a major role in the acquisition of nalidixic-acid resistance in clinical isolates of Typhimurium.