Surgically-Induced Necrotizing Scleritis After Pars Plana Vitrectomy: A Case Report

Surgically induced necrotizing scleritis (SINS) is a rare delayed hypersensitivity reaction following ocular surgeries, characterized by pain and redness at the surgical site. While commonly reported in various ocular surgeries, its occurrence after vitreoretinal procedures remains infrequent. We present a case of a 61-year-old diabetic male who developed progressive scleral melting and uveal exposure two months after an uneventful 23-gauge vitrectomy for retinal detachment. The infectious and immunologic profile was negative. Despite aggressive medical and surgical interventions, the patient exhibited advancing scleral melting. The diagnostic challenge lies in determining the relative contributions of trauma, epithelial breakdown, immune activation, and infection in these patients. Our patient's uncontrolled diabetes potentially aggravated vascular disruption, contributing to delayed wound healing and immune complex deposition. The treatment involved topical steroids with broad-spectrum antibiotics, followed by conjunctival flap and oral corticosteroids. This case underscores the importance of early diagnosis, cautious immunosuppression, and thorough infection evaluation in managing postoperative scleritis. The limitations include a single culture test and the patient being lost to follow-up.

Ocular Myasthenia Gravis As Unilateral Ptosis and External Ophthalmoplegia: A Case Report

Myasthenia gravis (MG) is an autoimmune disorder characterized by fluctuating weakness and fatigue in ocular, bulbar, limb, or respiratory muscles. Initially, more than half of MG patients experience isolated ocular symptoms, such as ptosis, diplopia, or muscle paresis. This case report presents a unique occurrence of MG in a four-year-old female, showcasing a two-year history of sudden onset, persistent yet fluctuating unilateral ptosis accompanied by exo-deviation and adduction deficit in the right eye. No diplopia or systemic features were observed. Positive findings in tests, including the ice pack test, Cogan twitch sign, fatiguability, and neostigmine test, indicated ocular myasthenia. Electromyography revealed a decremental response, while anti-acetylcholine antibodies showed borderline results. Computed tomography of the brain ruled out central causes, and routine laboratory testing yielded normal results. Treatment with pyridostigmine and corticosteroids led to significant improvement in symptoms. This case emphasizes the diverse presentation of MG in ophthalmology, with ocular signs serving as indicators in approximately half of the cases. Early diagnosis and prompt treatment are crucial for enhancing long-term prognosis. Emergency physicians should consider MG as a potential cause for unilateral ocular symptoms after excluding central causes. Accurate diagnosis and comprehensive management of MG are complex yet essential for ensuring optimal patient health.

The Impact of Calcium and Vitamin D Supplementation Prior to Thyroidectomy on Mitigating Postoperative Hypocalcemia

Background Hypocalcemia remains the most frequent complication after thyroidectomy. It can either be transient or permanent, and patients often find it unpleasant due to its association with prolonged hospitalization. The objective of this study was to determine the role of preoperative calcium and vitamin D supplementation in preventing hypocalcemia after subtotal/total thyroidectomy. Material and methods This quasi-experimental study was conducted at the Department of General Surgery, Ayub Teaching Hospital, Abbottabad, Pakistan, from January 2023 to July 2023. We utilized non-probability purposive sampling. Patients undergoing total thyroidectomy were recruited and followed until discharge to ascertain outcomes. They were divided into two groups: Group A received vitamin D (200,000 IU) one week preoperatively as single intramuscular dose and calcium (1 gm) orally two times daily for one week preoperatively, while Group B served as the control. Venous blood samples were taken post-surgery, on the second and seventh day and at day 30 to assess hypocalcemia. Chi-square test was employed, comparing hypocalcemia in both groups with a p-value ≤0.05 considered significant. Results One hundred thirty-two patients underwent subtotal/total thyroidectomy, with 46.2% (n = 61) being male and 53.8% (n = 71) female. The mean age of these patients was 37.12 ± 6.22 years, ranging from 20 to 50 years, and 57.6% (n = 76) were aged over 35 years. More than half (55.3%, n = 73) hailed from rural areas, while 4.7% (n = 59) resided in urban locales. Among the patients, 15.9% (n = 21) had a history of diabetes, and 24.2% (n = 32) were hypertensive. The mean body mass index (BMI) was 23.32 ± 2.41 kg/m2, with 7.6% (n = 10) classified as obese. The mean preoperative serum calcium level was 9.87 ± 1.07 mg/dL. Postoperatively, the mean serum calcium level was 8.74 ± 0.83 mg/dL. Both Group A (preoperative vitamin D and calcium supplementation) and Group B (control) demonstrated comparable baseline characteristics before undergoing thyroidectomy. The incidence of postoperative hypocalcemia was notably lower in Group A, with only 4.5% (n = 3) experiencing this complication. By contrast, 24.2% (n = 16) of patients in Group B, the control group, developed hypocalcemia (P = 0.001). Conclusion Our study supports the use of preoperative calcium and vitamin D supplementation in patients undergoing thyroidectomy to combat hypocalcemia. The treated group showed significantly lower hypocalcemia compared to the untreated group B. We recommend preoperative calcium and vitamin D supplementation for all thyroidectomy patients to reduce related morbidities and hospitalization duration.

Advancements in Retinoblastoma Treatment: Unraveling the Potential of Intravitreal Chemotherapy

Retinoblastoma necessitates urgent attention due to its potential fatality if untreated. Multiple treatment options are available and should be employed according to size, location, and the extent of dissemination. This review emphasizes the need for increased awareness, advanced diagnostic tools, and innovative treatment approaches, especially intravitreal chemotherapy (IVitC) to address the diverse manifestations and aggressive nature of retinoblastoma. Timely diagnosis and commitment to treatment are pivotal, as delays and reluctance to undergo enucleation contribute to unfavorable outcomes. The evolving treatment landscape, spanning from traditional interventions to modern targeted therapies such as intravitreal melphalan, holds promise for improved outcomes. While the intravitreal approach presents challenges, ongoing research aims to establish its definitive role in retinoblastoma treatment. In the treatment of retinoblastoma, IVitC raises considerations about side effects. The risk of tumor spread beyond the eye is rare, emphasising the potential of IVitC in carefully selected cases. Intravitreal injections exhibit fewer local adverse effects compared to intra-arterial chemotherapy, with careful measures reducing significant ocular complications. The evaluation of ocular toxicity, particularly with melphalan, underscores the importance of a nuanced approach to achieve the right balance between therapeutic efficacy and ocular safety. This comprehensive analysis of studies on IVitC and its ocular and systemic complications provides valuable insights for enhanced patient care. The review concludes with a focus on balancing safety and efficacy in local chemotherapeutic drugs, highlighting the need for thoughtful measures and continued research to optimise treatment modalities globally.

Surgical Strategies for Ingrown Toenails: A Comprehensive Review of Techniques, Outcomes, and Advancements

Ingrown toenail (IGTN), known as onychocryptosis or unguis incarnatus, is a painful condition affecting the big toe, with symptoms including pain, inflammation, and infection. This review explores surgical options for IGTN, categorized into altering the nail plate or diminishing periungual tissues. Conservative treatments alleviate early-stage symptoms, while surgical interventions are reserved for severe cases. Various surgical techniques are discussed, such as the Winograd technique, Vandenbos procedure, chemical matricectomy, radiofrequency ablation, bipolar diathermy, carbon dioxide laser ablation, Zadik's procedure, Howard-Dubois procedure, Super U procedure, Noël's procedure, knot technique, and toenail paronychium flap. The choice of procedure depends on the severity and recurrence of IGTN.

Enhancing Documentation Precision in Ophthalmic Surgery: A Quality Improvement Project

Background Effective clinical documentation, particularly operative notes, is essential for maintaining healthcare standards and fostering interdisciplinary communication. This study focuses on improving the quality of ophthalmic operative notes by adopting the Royal College of Surgeons (RCS) guidelines for good surgical practice. Methodology A retrospective cross-sectional audit at Khyber Teaching Hospital, Pakistan, assessed 138 operative notes against the RCS criteria. After an educational session and the placement of memory aids in operation theaters, a re-audit of 125 notes was conducted. Parameters were selectively applied based on relevance to specific cases, and omissions were discussed with the local ethical committee. Results The initial audit revealed deficiencies in 10 critical areas, with only three parameters exceeding 85% accuracy. The re-audit showed significant improvement across these parameters, achieving documentation of 85.3% of all criteria. Paired t-test results indicated a substantial difference in documentation quality before and after interventions. Conclusions A combined strategy involving surgeon education, memory aids, and adherence to established standards significantly enhances operative note quality. The study underscores the importance of sustained reinforcement mechanisms for continuous improvements in documentation practices.

Child abuse and neglect and mental health outcomes in adulthood by ethnicity: Findings from a 40-year longitudinal study in New Zealand/Aotearoa

BACKGROUND

Longitudinal studies consistently report adverse long-term outcomes of childhood maltreatment. Little is known about the impact of childhood maltreatment on mental health among a marginalized population (New Zealand Māori); therefore, we cannot assume the effects of maltreatment are the same across the population.

OBJECTIVE

Associations were examined between childhood sexual abuse (CSA), childhood physical punishment (CPP) and childhood neglect (CN) (<16 years) and mental health outcomes 18-40 years, by ethnicity (Māori/non-Māori).

PARTICIPANTS AND SETTING

Data from the Christchurch Health and Development Study, a study of a birth cohort of 1265 children born in Christchurch in 1977. By age 40, 17.8 % (n = 191) reported New Zealand Māori ethnic identity; 82.2 % (n = 883) were non-Māori.

METHODS

CSA, CPP (<16 years) were measured at 18, 21 years; CN was measured at 40 years. Major depression, anxiety disorder, suicidal ideation, alcohol abuse/dependence and cannabis abuse/dependence were measured at ages 21, 25, 30, 35 and 40 years. Childhood confounding variables controlled. Analyses were extended to include Māori ethnicity.

RESULTS

After statistical adjustment, experience of severe childhood maltreatment increased odds of mental health problems 1.8-2.6×, compared to no maltreatment; the effects of maltreatment were similar for males and females. For Māori, some higher rates of mental health problems were seen among those maltreated, no statistically significant associations were detected after Bonferroni correction (among severe maltreatment vs. no maltreatment). Limitations should be considered when interpreting results.

CONCLUSIONS

Exposure to childhood maltreatment has long-term effects into middle-age. Further research employing culturally-sensitive approaches may help clarify Māori childhood maltreatment outcomes.

Neurotrophic Keratopathy and Topical Insulin Therapy: A Case Report

Neurotrophic keratopathy is a rare disorder caused by the loss of corneal sensation. It is characterized by persistent epithelial defects, corneal ulceration, and, ultimately, corneal perforation if not managed in a timely manner. The management includes aggressive lubrication, prophylactic topical antibiotics, therapeutic contact lenses, tarsorrhaphy, and amniotic membrane transplantation. Some novel therapeutic options are also available, one of which is topical insulin therapy. We report the clinical course of a patient with neurotrophic keratopathy that was successfully treated with topical insulin. A 64-year-old male presented to our outpatient department with a three-month history of painless blurring of vision following prior episodes of herpetic keratitis. Ocular examination showed a bilateral reduction in corneal sensations, bilateral corneal opacities, and a corneal ulcer in the left eye. He was diagnosed as a case of neurotrophic keratopathy secondary to prior herpetic keratitis. He was then treated with topical and oral acyclovir along with topical insulin drops. There was a remarkable improvement in his condition after a month with a reduction in the size of the ulcer and, after two months, the ulcer was completely re-epithelialized. This case report illustrates the use of topical insulin in the initial management of neurotrophic keratopathy as opposed to its conventional use in refractory neurotrophic corneal ulcers.

Analysis and computations of a non-local thin-film model for two-fluid shear driven flows

This paper is concerned with analysis and computations of a non-local thin-film model developed in Kalogirou & Papageorgiou ( J. Fluid Mech. 802 , 5–36, 2016) for a perturbed two-layer Couette flow when the thickness of the more viscous fluid layer next to the stationary wall is small compared to the thickness of the less viscous fluid. Travelling wave solutions and their stability are determined numerically, and secondary bifurcation points are identified in the process. We also determine regions in parameter space where bistability is observed with two branches being linearly stable at the same time. The travelling wave solutions are mathematically justified through a quasi-solution analysis in a neighbourhood of an empirically constructed approximate solution. This relies in part on precise asymptotics of integrals of Airy functions for large wave numbers. The primary bifurcation about the trivial state is shown rigorously to be supercritical, and the dependence of bifurcation points, as a function of Reynolds number R and the primary wavelength 2 πν −1/2 of the disturbance, is determined analytically.

Palmar uniportal extrabursal endoscopic carpal tunnel release

A new technique of endoscopic carpal tunnel release using a 1.5-cm longitudinal palmar incision was used in 280 cases. The incision allows identification of the superficial palmar arch as well as the median nerve and its branches. A new knife/sleeve device that attaches to a standard 4-mm endoscope was created to simplify the procedure. The flexor retinaculum is endoscopically divided proximally into the distal forearm; the "interthenar fascia" (fascia superficial to transverse carpal ligament) can be preserved. Early postoperative results include a mean overall return to work and full activity of 14 days. Postoperative pinch and grip strengths were near or at the preoperative level by 8 weeks after surgery. One third of patients required no postoperative analgesics with minimal scar, ulnar pillar, and radial pillar tenderness.