Sudden asystole during surgery in the cerebellopontine angle

We report a case of a 40-year-old lady undergoing surgery for a tumor in the cerebellopontine angle. Intraoperatively, patient had a sudden asystole without prior warning sign of bradycardia. It could have been the severe form of trigeminocardiac reflex. The cardiac rhythm returned spontaneously once the surgical manipulation stopped. The remainder of the operation was uneventful and no complication occurred afterwards. The possible mechanism of the event is discussed.

Deep sclerectomy and low dose mitomycin C: a randomised prospective trial in west Africa

AIM

To study the efficacy and safety of deep sclerectomy (DS) augmented with intraoperative low dose mitomycin C (MMC) in a west African population.

METHODS

Prospective, randomised, controlled trial. Trial participants were Nigerian patients with medically uncontrolled primary open angle glaucoma undergoing primary surgery at Maja Hospital, Lagos, Nigeria. 39 eyes of 39 patients undergoing DS were randomised into receiving intraoperative MMC 0.25 mg/ml for 2 minutes at the end of procedure (DS-MMC) and a control group (DS-noMMC).

RESULTS

There were 21 patients in the DS-noMMC and 18 in the DS-MMC group with no difference in the preoperative characteristics of the groups. Mean follow up was 16.4 (SD 11.3) months. The probability of maintaining an intraocular pressure less than 18 mm Hg with or without additional medications (95% confidence intervals) at 1 year was 70% (47-92%, 95%) and 79% (57-100%), and at 18 months was 35% (8-62%) and 38% (7-69%) for the DS-noMMC and DS-MMC groups, respectively, with no difference in success rates (p = 0.6). An IOP of less than 18 mm Hg without additional medication was maintained in 65% (41-89%) and 73% (49-96%) at 1 year and 24% (8-48%) and 13% (13-46%) at 18 months for the DS-noMMC and DS-MMC groups, respectively (p = 0.5). There were no serious complications related to the procedure.

CONCLUSIONS

The success rates of DS in black west African glaucoma patients, as performed in this study, were low. The study did not achieve sufficient power to detect whether low dose intraoperative MMC application can increase success rates of DS.

Mitomycin C augmented glaucoma surgery: evolution of filtering bleb avascularity, transconjunctival oozing, and leaks

AIMS

To prospectively study the evolution of possible high risk features of conjunctival filtration blebs like avascularity, transconjunctival oozing (TCO), and leaks after mitomycin C (MMC) enhanced glaucoma surgery.

METHODS

Single observer, 2 year prospective study on bleb characteristics of 125 eyes of 125 consecutive patients who had MMC augmented glaucoma surgery with initially successful filtration. MMC (0.2 mg/ml for 2 minutes in most cases) was applied on the area of the scleral flap before dissection. Glaucoma surgeries included were trabeculectomy, deep sclerectomy, and combined procedures. A dry fluorescein strip was applied on the avascular part of the bleb and observed for aqueous egress with flow (point leak, PL) or without (TCO).

RESULTS

The mean time (95% CI) for observing bleb avascularity, TCO, and bleb leaks were 106 days (69 to 143), 208 days (155 to 261), and 609 days (559 to 659), respectively. Bleb leaks were observed in 17 eyes (13.6%)-15 (24.6%) in the trabeculectomy group and two (3.1%) in the deep sclerectomy group (p = 0.003). Kaplan-Meier survival analyses showed that the probability of observing bleb avascularity at sixth, 12th, and 24th month after surgery was 56%, 71%, and 73%, respectively. In eyes with avascular blebs, the probability of developing TCO and leaks was 77% and 1% at 6 months, 81% and 12% at 12 months, and 95% and 26% at 24 months, respectively. Cox's regression analyses and log rank tests showed that eyes with larger avascular blebs (>4 mm) were more likely to develop TCO (hazard ratio 3.77, p = 0.001) and delayed bleb leaks were more likely to be seen in eyes of the trabeculectomy group rather than the deep sclerectomy group (hazard ratio 0.06, p = 0.0006).

CONCLUSIONS

MMC application over the area of scleral flap dissection during glaucoma surgery is associated with a high incidence of bleb avascularity, TCO, and delayed bleb leaks. Most eyes developed bleb avascularity within the first year after surgery. TCO will eventually be seen in all eyes with avascular blebs and the incidence of leaks gradually increases with time. This study shows that patients with eyes undergoing glaucoma surgery with MMC and avascular blebs should be monitored indefinitely.

Combined cataract and glaucoma surgery with mitomycin C: phacoemulsification-trabeculectomy compared to phacoemulsification-deep sclerectomy

AIMS

To compare outcomes of phacoemulsification combined with trabeculectomy (PT) or deep sclerectomy (PDS) with intraoperative mitomycin C (MMC) application.

METHODS

Non-randomised, consecutive, retrospective comparative study. 97 eyes of 97 patients (59 PDS, 38 PT) undergoing combined surgery with intraoperative MMC (0.1-0.4 mg/ml for 1-3 minutes) were identified for inclusion in the study.

RESULTS

The probability of maintaining intraocular pressure (IOP) below 19 mm Hg and 15 mm Hg, with a 30% drop from preoperative IOP and without additional medication, 1 year after surgery were 77.6% (95% CI: 67 to 90) and 71.5% (60 to 85) for the PDS group and 89.5% (80 to 99) and 89.5 (80 to 99) for the PT group, respectively, and these differences were not statistically significant (p>0.05, log rank test). After excluding ocular co-morbidity no differences were observed in the improvement of visual acuity between the two groups. There were no major differences in the complication rates except that delayed bleb leaks were seen in seven eyes (18.4%) of the PT group (p = 0.004).

CONCLUSION

In this study, no statistically significant difference was found in the IOP and visual outcomes between PDS and PT. A significantly higher frequency of late bleb leaks after PT was observed.

Deep sclerectomy augmented with mitomycin C

AIMS

To investigate the comparative efficacy and safety of deep sclerectomy with and without intraoperative mitomycin C (MMC) application for lowering the intraocular pressure (IOP).

METHODS

A total of 71 eyes of 71 consecutive patients who had routine deep sclerectomy (DS), nonaugmented (DS-noMMC) or with mitomycin C (DS-MMC) augmentation (0.2 mg/ml for 2 min) and follow-up of 4 months or more were identified from an ongoing prospective database on glaucoma surgery. Indications for MMC use were the presence of risk factors for subconjunctival scarring and low target IOPs. MMC 0.2 mg/ml was applied in the sub-Tenons space for 2 min.

RESULTS

There were 19 eyes in the DS-noMMC group and 52 eyes in the DS-MMC group. In 11 eyes (15.5%), the procedure was complicated by intraoperative perforation of the trabeculo-Descemet's window. Eyes in the DS-MMC group had significantly lower IOPs (MANOVA, P = 0.04). Kaplan-Meier survival curve analysis showed that the probability of maintaining IOP below target IOP level, below 18 mmHg and below 14 mmHg at 1 year was 51, 67, and 35% for the DS-noMMC group and 80, 86, and 74% for the DS-MMC group. The survival rates of the DS-MMC group were not statistically significant (P = 0.06) when the success criterion was maintaining an IOP less than 18 mmHg but were significant for the other criteria, namely IOP less than target levels (P = 0.03) and less than 14 mmHg (P = 0.03). Nd:YAG goniopuncture to lower IOP to target levels was done more frequently in the DS-noMMC group (13 eyes, 81%) than the DS-MMC group (20 eyes, 45%) and this difference was significant (P = 0.03). The prevalence of avascular areas within filtration blebs and transconjunctival oozing of aqueous was significantly higher in the DS-MMC group (P < 0.01).

CONCLUSIONS

The use of intraoperative MMC during deep sclerectomy has a significant effect on the postoperative IOP and increases the probability of achieving target IOPs. However, our current technique of MMC application is associated with a higher incidence of avascular blebs and transconjunctival oozing.

Intraoperative 5-fluorouracil application during primary trabeculectomy in Nigeria: a comparative study

PURPOSE

To investigate the effect on intraocular pressure (IOP) of intraoperative 5-fluorouracil (5-FU) application during primary trabeculectomy in a West African population.

METHODS

Retrospective case note search of operating theatre records for primary trabeculectomy between 1996 and 2000 in an eye hospital in Lagos, Nigeria. For statistical analysis, patients were divided into group that received intraoperative 5-FU (50 mg/ml for 5 min) and a control group that received no intraoperative antimetabolites. Patients with a follow-up of less than 6 months were excluded. For life-table analysis, only one eye from each patient was included to maintain independent analysis.

RESULTS

A total of 154 eyes of 101 patients were included in the study. Average follow-up was 17 +/- 2.18 (95% confidence interval) months. No significant difference was found between the groups for age, sex, preoperative medication, and follow-ups. Comparison of survival curves by the log-rank test showed that the probability of maintaining an IOP of 20 mm Hg or less at 18 months was 76% in the 5-FU group and 79% in the controls (P= 0.55). However, the probability of maintaining an IOP 14 mmHg or less was significantly greater in the 5-FU group (64%) than in the controls (39%, P=0.018). Visual acuity loss of more than two Snellen-chart lines was observed in six eyes (7.9%) of the 5-FU group and in four eyes (5.1%) of the control group and this difference was not significant (P=0.49, Fisher exact test). Complication rates were similar in each group.

CONCLUSIONS

In this population, intraoperative 5-FU application during trabeculectomy appears to improve probability of maintaining an intraocular pressure of 14 mmHg or less with no additional deleterious effects on the eye.

Kinetic resolution of 1-chloro-3-(1-naphthyloxy)-2-propanol, an intermediate in the synthesis of beta-adrenergic receptor blockers

(R)- and (S)-1-chloro-3-(1-naphthyloxy)-2-propanol are intermediates in the synthesis of beta-adrenergic blocking agents and antihypertensive drugs such as propranolol and nadoxolol. Herein, improvement in the preparation of racemic 1-chloro-3-(1-naphthyloxy)-2-propanol generated from 1-naphthol and epichlorohydrin are reported. In addition, kinetic resolution studies have been conducted to obtain both (R) and (S)-1-chloro-3-(1-naphthyloxy)-2-propanol. These compounds were obtained in highly optically pure form by the stereoselective hydrolysis of its acyl derivatives using whole cell preparations containing enzymes from native sources. The results were compared with those obtained using commercial lipases.

Isolated bilateral trochlear nerve palsy as the first clinical sign of a metastatic [correction of metastasic] bronchial carcinoma

PURPOSE

To report a case with isolated, nontraumatic bilateral fourth nerve palsy as the first clinical sign of a metastatic lung carcinoma.

METHODS

Case report. A 56-year-old man presented with isolated, nontraumatic bilateral fourth nerve palsy. Magnetic resonance imaging (MRI) of the brain and orbits and, subsequently, chest x-ray and a computer tomographic (CT)-scan of the thorax, the abdomen, and the pelvis were performed.

RESULTS

Magnetic resonance imaging confirmed the presence of a midline brain stem lesion in the region of decussation of the trochlear nerves. Computed tomographic scan of the chest revealed that the lesion was caused by a metastatic lung carcinoma.

CONCLUSION

The findings of isolated bilateral fourth nerve palsy in the absence of trauma should alert the clinician to the possibility of a posterior fossa lesion in the region of the trochlear nerves. Besides urgent scanning of the dorsal midbrain, investigations should be directed to search for the primary tumor.

Trabeculectomy outcomes in advanced glaucoma in Nigeria

BACKGROUND

Trabeculectomy remains the mainstay of therapy for advanced glaucoma in Nigeria due to the unavailability and expense of topical therapy. Little is known of the medium- to long-term outcomes of trabeculectomy in West Africa. Purpose To retrospectively assess outcomes, in terms of lowering of the intraocular pressure and preserving the visual acuity, and the safety of trabeculectomy in patients with advanced glaucoma in Nigeria.

METHODS

A retrospective case-note search was carried out from operating theatre records in a private hospital at Lagos, Nigeria from 1989 to 1997. Patients undergoing primary trabeculectomy with a minimum follow-up of 6 months were included in the study. Visiting consultants and registrars from the UK performed the surgery. Descriptive statistics and life-table analysis were applied to the data.

RESULTS

One hundred and forty-two eyes of 100 patients were included in the study. When the criteria for success were an intraocular pressure (IOP) of less than 22 mmHg, 30% reduction from pre-operative levels and a decrease in visual acuity of less than 3 Snellen chart lines, then by life-table analysis success rates were 85%, 82% and 71% at the 1, 2 and 5 year post-operative intervals respectively. Success rates were lower if an IOP of less than 16 mmHg was taken as one of the criteria (65%, 61% and 46% at the 1, 2 and 5 year intervals, respectively).

CONCLUSIONS

Trabeculectomy without antimetabolite use appears to be an effective way to lower the IOP of advanced glaucoma patients in Nigeria to less than 22 mmHg but not to less than 16 mmHg. The procedure, in experienced hands, is relatively safe with few major complications.

Immunomodulatory potential of hydrophobic analogs of Rigin and their role in providing protection against Plasmodium berghei infection in mice

Here, we report the immunomodulating potential of N-palmitoyl-amino-ethyl-rigin amide (PR) and N-cholestanyl-amino-ethyl-rigin amide (CR), the two new structural analogs of rigin (an IgG-derived tetrapeptide). Their activity profiles are compared with native tuftsin (NT) and/or N-palmitoyl-amino-ethyl-tuftsin amide (PT) taken as positive control. To explore the possibility of their use as targeting molecules, they are incorporated into the liposome bilayer and, subsequently, interacted with macrophages in an in vitro study. The new analogs of rigin with the hydrophobicity introduced at the C-terminus are found to considerably improve both the cell-mediated and the humoral immune responses in mice. However, unlike tuftsin and its analog, which mainly activate polymorphonuclear leukocytes and macrophages, the rigin analogs appear to manifest their response more through lymphocytes. When administered prophylactically to a group of mice, at the dose of 100 micrograms/0.5 ml/mouse/day for 2 days (i.v.), followed by a challenge presented with 1 x 10(6) rbcs parasitised with Plasmodium berghei on day 0, substantial reduction in parasitaemia and rate of mortality is observed. This led to increase the median survival time (MST) of the treated group in comparison to the control group. The response is found to be more prominent in CR-treated mice possibly because of the presence of steroid moiety, which is likely to have more productive interaction with cell membranes. Incorporation of these peptides into the bilayer of liposomes does not alter the permeability behavior of vesicles and, in fact, enhances their uptake by the macrophages in an in vitro study. The effect, however, is dependent on both, the concentration of peptide liposomes and the time of incubation. Present study, thus, establishes the possible use of these analogs not only as adjuvant in chemotherapy, but also as a prophylactic supplement to boost the natural immune status. The activity response of rigin analogs is manifested through lymphocytes, they can also find use in the chemotherapy of diseases, like leishmaniasis, tuberculosis and leprosy, where macrophage activity is either tamed or impaired by pathogens.

Recombinant Mycobacterium tuberculosis protein associated with mammalian cell entry

The ability to gain entry and resist the antimicrobial intracellular environment of mammalian cells is an essential virulence property of Mycobacterium tuberculosis. A purified recombinant protein expressed by a 1362 bp locus (mce1) in the M. tuberculosis genome promoted uptake into HeLa cells of polystyrene latex microspheres coated with the protein. N-terminus deletion constructs of Mce1 identified a domain located between amino acid positions 106 and 163 that was needed for this cell uptake activity. Mce1 contained hydrophobic stretches at the N-terminus predictive of a signal sequence, and colloidal gold immunoelectron microscopy indicated that the corresponding native protein is expressed on the surface of the M. tuberculosis organism. The complete M. tuberculosis genome sequence revealed that it contained four homologues of mce (mce1, mce2, mce3, mce4) and that they were all located within operons composed of genes arranged similarly at different locations in the chromosome. Recombinant Mce2, which had the highest level of identity (67%) to Mce1, was unable to promote the association of microspheres with HeLa cells. Although the exact function of Mce1 is still unknown, it appears to serve as an effector molecule expressed on the surface of M. tuberculosis that is capable of eliciting plasma membrane perturbations in non-phagocytic mammalian cells.

Recurrent hepatitis B, hepatitis C, and combined hepatitis B and C in liver allografts: a comparative pathological study

Although recurrence of viral hepatitis in liver transplants is common, data comparing recurrent hepatitis B (HB), hepatitis C (HC), and co-existing dual hepatitis B and C (HB&C) are sparse. Posttransplantation liver biopsies, along with molecular, serological, immunohistochemical, and clinical data from 27 patients with pretransplantation diagnosis of chronic viral hepatitis, were reviewed. The patients were placed into 4 groups: Group I, with pretransplantation HB (n = 8); group II, with pretransplantation HC (n = 10); group III with pretransplantation HC and anti-HB surface or core antibody (n = 4); and group IV, with pretransplantation HB&C (n = 5). The histopathologic findings and patient outcome were compared in the 4 groups. A high rate of recurrence of viral hepatitis was seen for all 4 groups: Group I = 100%, group II = 90%, Group III = 100%, and group IV = 80%, with the mean (median) recurrence time of 308 (224), 82 (52), 61 (64), and 125 (70) days, respectively. The number of deaths (their median survival times) were: group I = 4 (374 days), group II = 4 (794 days), group III = 1 (1,143 days), and group IV = 5 (448 days). The earliest histological findings of lobular injury was the presence of acidophil bodies and Kupffer cell hyperplasia, the latter being more prominent in recurrent HC cases. Recurrent HB presented in 2 forms: early (before 150 days) with poor survival and with either severe necroinflammatory histology or with features of fibrosing cholestatic hepatitis, and delayed (after 150 days), with mild necro-inflammatory activity and prolonged survival. HC with or without anti-HB antibodies had early recurrence, but the course was slowly progressive. Patients with HB&C had recurrence of both viruses; however, the course was dictated by HB virus.

The effects of perioperative blood salvage and autologous blood donation on transfusion requirements in scoliosis surgery

Fifty consecutive cases of surgical instrumentation and fusion for adolescent idiopathic scoliosis were prospectively studied to test the hypothesis that the use of predonated autologous blood combined with judicious perioperative blood salvage could decrease the amount of homologous blood needed. All cases had posterior instrumentation and fusion. Nineteen patients had their rib prominence resected with an average of 4.8 ribs per patient. Our protocol called for perioperative blood salvage with the cell saver and reinfusion of postoperative drained blood if more than 300 ml were drained in 4 hours. Two units of predonated autologous blood was made available. Hypotensive anesthesia and meticulous hemostasis kept the blood loss to a minimum. The average total blood loss was 1,055 ml. Blood loss per segment was 91 ml with an average of 11 segments fused per patient. Patients with rib resection had a blood loss of 1,105 ml, while those without had a blood loss of 955 ml. The cell saver blood returned per case was 391 ml with the hematocrit of the product averaging 46%. Twelve patients were reinfused an average of 300 ml of the postoperative drained blood. The predonated autologous blood was used as part of the intraoperative fluid management. In no patient was homologous blood needed. The average starting hematocrit was 35.6%, with the hematocrit at discharge (seventh day) being 32.4%. There were no complications or blood transfusion reactions. Our results suggest that judicious perioperative blood management may decrease the need for homologous blood transfusion in selected posterior idiopathic scoliosis surgery.

Modification of trabeculectomy with single-dose intraoperative 5-Fluorouracil application

PURPOSE

To assess the outcome of trabeculectomy supplemented with intraoperative 5-Fluorouracil (5 FU) application in glaucoma patients.

METHODS

A prospective non-randomized case series of 76 eyes of 76 consecutive patients who underwent trabeculectomy with intraoperative sponge 5 FU (25 mg/ml). Minimum follow-up was 6 months. There were 31 eyes in the low-risk group and 45 eyes in the high-risk group. The reduction in intraocular pressure (IOP) and any treatment complications were noted.

RESULTS

The mean preoperative IOP was 28+/-7.72 mm Hg. The mean final postoperative IOP was 16.8+/-6.1 mm Hg. The average number of glaucoma medications required dropped from 1.8+/-0.8 preoperatively to 0.4+/-0.8 after the operation (p<0.001). Cumulative success rates (IOP less than 21 mm Hg) for all eyes were 93% and 81% at 6 and 12 months, respectively. There was no difference in outcome between the low- and high-risk groups if criteria for success were an IOP of less than 21 mm Hg or an IOP of less than 21 mm Hg and an IOP reduction of 30%. However, if success is defined as an IOP of 15 mm Hg or less and a 30% fall in IOP, then the low-risk group had significantly longer survival times than the high-risk group (p=0.033, log-rank test). Transient punctate keratitis and corneal epithelial defect were each observed in only 1 eye. Other serious complications include rapid progression of cataract in 2 eyes, endophthalmitis in 1 eye and hypotonic maculopathy after subsequent cataract extraction in 1 eye.

CONCLUSION

Single dose intraoperative 5 FU appears to be a safe and useful adjunct to trabeculectomy. IOPs in the low teens were achieved in a greater proportion of low-risk eyes than high-risk eyes.

Phacoemulsification trabeculectomy compared to other methods of combined cataract and glaucoma surgery

PURPOSE

To compare three methods of combined cataract extraction and glaucoma surgery.

METHODS

Retrospective review of 35 eyes of patients who had extracapsular cataract extraction and trabeculectomy using a corneoscleral incision (SAME), 54 eyes undergoing extracapsular cataract extraction and trabeculectomy using a separated corneal incision for cataract extraction and 43 eyes undergoing phacoemulsification and trabeculectomy.

RESULTS

Ninety-one percent of the eyes in the SAME group, 85% of the SEPARATE group and 97% of the phacoemulsification and trabeculectomy group had an IOP < 22 mmHg at 6 months with or without medication (NS). Postoperative visual acuity and astigmatism were not significantly different between the groups. The number of eyes requiring YAG laser capsulotomy was significantly greater in the extracapsular cataract extraction and trabeculectomy (same and separated incision) as compared to the phacoemulsification and trabeculectomy group (P < 0.001).

CONCLUSION

Phacoemulsification and trabeculectomy was not significantly more successful than the other methods of combined surgery. Although complication rates were similar, visual rehabilitation was faster and there was a reduced incidence of early posterior capsule opacification.

Intraoperative monitoring of motor pathways during operative fixation of acute acetabular fractures

OBJECTIVE

To determine whether intra-operative spontaneous electromyography (EMG) was superior to somatosensory evoked potentials (SSEP) in the prevention of iatrogenic sciatic nerve injury.

DESIGN

Prospective, consecutive.

SETTING

Tertiary referral, teaching Hospital in New York City.

PATIENTS

Seventy-four patients with acutely displaced acetabular fractures.

MAIN OUTCOME MEASURE

Group A consisted of 24 patients who underwent intraoperative sciatic nerve monitoring using SSEP only. Group B consisted of 50 patients who underwent monitoring using both SSEP and spontaneous EMG. Motor potentials were recorded from the tibialis anterior, peroneus longus, abductor hallucis, and flexor hallucis longus muscles. All patients had independent preoperative and postoperative evaluations by the same neurologist.

RESULTS

One iatrogenic sciatic nerve injury occurred in group A and none in group B. Prolonged sciatic nerve compromise, demonstrated by significant intraoperative SSEP changes, occurred 2.4 times per case in group A and only 0.8 times per case in group B. In group B, spontaneous EMG noted compromise an average of 3.6 times per case (p < 0.0001).

CONCLUSIONS

The results of this study support spontaneous EMG as feasible and superior to SSEP monitoring in detecting intraoperative sciatic nerve comprise in acute acetabular fracture surgery. Spontaneous EMG permits earlier detection of intraoperative sciatic nerve comprise, allowing a more rapid response of the surgical team to noxious nerve stimuli. This may prevent permanent neurologic sequellae.