Future treatment options for facial nerve palsy: a review on electrical stimulation devices for the orbicularis oculi muscle

Facial nerve palsy can cause diminished eyelid closure (lagophthalmos). This occurs due to functional deficits of the orbicularis oculi muscle, potentially leading to sight-threatening complications due to corneal exposure. Current management options range from frequent lubrication with eye drops, to the use of moisture chambers and surgery. However, achieving functional restoration may not always be possible. Recent efforts have been directed towards the support of orbicularis oculi muscle function through electrical stimulation. Electrical stimulation of the orbicularis oculi muscle has been demonstrated as feasible in human subjects. This article offers a comprehensive review of electrical stimulation parameters necessary to achieve full functionality and a natural-looking eye blink in human subjects. At present, readily available portable electrical stimulation devices remain unavailable. This review lays the foundation for advancing knowledge from laboratory research to clinical practice, with the ultimate objective of developing a portable electrical stimulation device. Further research is essential to enhance our understanding of electrical stimulation, establish safety standards, determine optimal current settings, and investigate potential side effects.

Lambda-double-fixation for medial epicanthoplasty in Blepharophimosis - Ptosis - Epicanthus Inversus Syndrome

PURPOSE

This study aims to describe a novel approach to medial epicanthoplasty in patients with blepharophimosis-ptosis-epicanthus inversus syndrome (BPES) and evaluate the surgical outcome of this technique.

METHODS

A retrospective, noncomparative, interventional case series involving 22 BPES patients who underwent medial epicanthoplasty using the Lambda-Double-Fixation technique (LDFT) performed by a single surgeon. Pre- and postoperative measurements of inner intercanthal distance (DIC) and horizontal palpebral fissure (HPFL) were recorded. Concurrent or staged ptosis surgery and lateral cantholysis, along with any complications, were documented.

RESULTS

The mean age of the patients was 2.9 ± 2.2 years. Preoperatively, the mean DIC measured 34.0 ± 2.7 mm, significantly reducing to 23.7 ± 2.1 mm postoperatively (p < 0.001). A notable increase in mean HPFL was observed in both eyes postoperatively: right eye form 18.4 ± 2.4 mm to 23.7 ± 1.8 mm (p < 0.001) and left eye from 18.3 ± 2.4 mm to 23.8 ± 1.9 mm (p < 0.001). Postoperative scars were barely visible in all patients.

CONCLUSION

LDFT is a simple and reproducible technique for medial epicanthoplasty in BPES. Our results affirm that LDFT induces a physiologically concave reshaping of the medial canthal region, optimizing access to the peritarsal zone and ensuring a secure fixation of the new canthus. These benefits lead to a reduction in ICD and an increase in HPFL, leading to a cosmetically appealing postoperative outcome.

Occurrence of motility disorders in patients undergoing tube surgery-consecutive, retrospective follow-up case series analysis

BACKGROUND

The two glaucoma drainage devices (GDD) Ahmed and Baerveldt tubes are most commonly used for the treatment of refractory glaucoma. We noticed a significant number of patients with postoperative motility disorders resulting in diplopia. We investigated the occurrence and patterns of postoperative motility disorders overall and between the two GDD tubes using the Hess Screen Test.

METHODS

Retrospective single-center matched case series of 20 patients undergoing Ahmed and 20 patients undergoing Baerveldt tube implantation with a follow-up of at least 1 year. In order to investigate the dynamic of GDD-induced motility disorder over time, from 25 patients, a follow-up examination from two different time periods (3 to 6 months and 12 to 24 months postoperatively) was available. From these 25 patients, 12 had received an Ahmed and 13 a Baerveldt GDD. To compare the different Hess Screen Tests, we developed nine categories of possible emerging motility disorder in the operated eye as a primary endpoint: Motility restriction in up-gaze, in down-gaze, in abduction, in adduction; combined motility disorders in up-gaze and adduction, up-gaze and abduction, down-gaze and adduction, down-gaze and abduction. If there was no motility disorder, this was also separately classified.

RESULTS

Regardless of the used device, Ahmed or Baerveldt, most patients experienced motility disorders to some extent; mainly down-gaze and adduction were affected. However not every motility disorder resulted in diplopia. Although over time a decrease in ocular misalignment was seen, the incidence of diplopia was stable. Nevertheless, only few required therapy. We noted no difference between Ahmed and Baerveldt tube implant devices.

CONCLUSION

Ocular misalignment and restriction of motility is a common finding after GDD. Although not every motility disorder results in diplopia, it is frequent. Therefore, it needs to be taken into consideration in informed consent.

Anaesthesia and intensive care management of face transplantation

The face-grafting techniques are innovative and highly complex, requiring well-defined organization of all the teams involved. Subsequent to the first report in France in 2005, there have been 17 facial allograft transplantations performed worldwide. We describe anaesthesia and postoperative management, and the problems encountered, during the course of seven facial composite tissue grafts performed between 2007 and 2011 in our hospital. The reasons for transplantation were ballistic trauma in four patients, extensive neurofibromatosis in two patients, and severe burns in one patient. Anaesthesia for this long procedure involves advanced planning for airway management, vascular access, technique of anaesthesia, and fluid management. Preparation and grafting phases were highly haemorrhagic (>one blood volume), requiring massive transfusion. Median (range) volumes given for packed red cell (PRC) and fresh-frozen plasma (FFP) were 64.2 ml kg(-1) (35.5-227.5) and 46.2 ml kg(-1) (6.3-173.7), respectively. Blood loss quantification was difficult because of diffuse bleeding to the drapes. The management of patients with neurofibromatosis or burns involving the whole face was more difficult and haemorrhagic than the patients with lower face transplantation. Average surgical duration was 19.1 h (15-28 h). Postoperative severe graft oedema was present in most patients. Most patients encountered complications in ICU, such as renal insufficiency, acute respiratory distress syndrome, and jugular thrombosis. Opportunistic bacterial infections were a feature during the postoperative period in these highly immunosuppressed patients.

[The law number 2005-370 of April 22, 2005 concerning the patients' rights at the end of life: a case of polytrauma]

The law number 2005-370 of April 22, 2005 concerning the patients' rights at the end of life imposes from now the refusal of futility of care, a shared decision-making in unconscious patients and the duty of a palliative strategy. We describe a case of polytrauma, for which the shared decision-making process led to a palliative strategy after initial aggressive life-support treatments. This case underlines the need for a two-step model of decision-making process, which distinguishes between goals of care and withdrawal or withholding of life support. It suggests that implementation of written procedures could improve the quality of management at the end of life and traceability of decisions.

Comparison of two induction regimens using or not using muscle relaxant: impact on postoperative upper airway discomfort

BACKGROUND

Muscle relaxants facilitate tracheal intubation, but they are often not used for short peripheral surgical procedures. The consequences of this practice on the upper airway are still a matter of controversy. We therefore compared the incidence of post-intubation symptoms in a randomized study comparing patients intubated with or without the use of a muscle relaxant.

METHODS

A total of 300 adult patients requiring tracheal intubation for scheduled peripheral surgery were randomly assigned in a double-blind study to an anaesthetic protocol that either included or did not include a muscle relaxant (rocuronium). The primary end-point was the rate of post-intubation symptoms 2 and 24 h after extubation. The secondary end-points were the intubation conditions score (Copenhagen Consensus Conference), the rate of difficult intubations (Intubation Difficulty Scale), and the incidence of adverse haemodynamic events.

RESULTS

Post-intubation symptoms were more frequent in patients intubated without the use of a muscle relaxant, whether 2 h (57% vs 43% of patients; P < 0.05) or 24 h (38% vs 26% of patients; P < 0.05) after extubation. Intubation conditions were better when the muscle relaxant was used. In patients intubated without a muscle relaxant, difficult intubation was more common (12% vs 1%; P < 0.05), as were arterial hypotension or bradycardia requiring treatment (12% vs 3% of patients; P < 0.05).

CONCLUSIONS

The use of a muscle relaxant for tracheal intubation diminishes the incidence of adverse postoperative upper airway symptoms, results in better tracheal intubation conditions, and reduces the rate of adverse haemodynamic events.

Inhibition of p42/p44 mitogen-activated protein kinase by oxysterols in rat astrocyte primary cultures and C6 glioma cell lines

We previously demonstrated that oxysterols inhibit the growth of experimental glioblastoma induced in the rat brain cortex. Mechanism of action of these compounds remains obscure. In this study, we investigated the effect of 7beta-hydroxycholesterol (7beta-OHCH) and 7ketocholesterol (7k-CH) on the growth and MAP kinase activity in three in vitro biological models: rat astrocyte primary cultures, primary cultures treated by dibutyryl-cAMP (reactive cells), and the C6 glioma cell line. The oxysterols are not lethal to primary astrocytes, even if MAP kinase activity is decreased, particularly when cells were treated with 7k-CH. Both oxysterols are toxic to reactive astrocytes, and as compared with untreated primary cultures, they amplified the MAP kinase activity decrease. However, the mechanism of action of oxysterols on reactive astrocytes seems not to be linked to the MAP kinase pathway. In highly proliferating C6 cell lines, only 7beta-OHCH has an antiproliferative effect and is cytotoxic. The inhibition of MAP kinase activity is a function of 7beta-OHCH concentration. PD098059, a MAP kinase pathway inhibitor, has only a time-limited antiproliferative effect on C6 cell growth. We conclude that in C6 cells, the MAP kinase activity decrease is correlated with the toxic effect of 7beta-OHCH and occurs at first stages of 7beta-OHCH action.

Possible involvement of cholinergic and glycinergic amacrine cells in the inhibition exerted by the ON retinal channel on the OFF retinal channel

In the frog retina, the inhibition exerted by the ON channel on the OFF channel was evidenced by the increase in transient ganglion cell OFF responses, when the ON channel was blocked by 2-amino-4-phosphonobutyrate (APB). Intraocular administration of the neurotoxic choline analog ethylcholine mustard arizidinium ion (ECMA) also provoked an increase in the number of spikes of transient ganglion cell OFF responses, without suppressing the ON responses. APB, when administrated after ECMA, abolished the ON responses, but did not modify the OFF responses already increased by ECMA. Neurons located in the inner part of the inner nuclear layer were histologically altered by the toxin, and choline acetyltransferase activity was significantly depressed in ECMA-treated retinas. A double immunostaining experiment showed that amacrine cells containing glycine bear muscarinic binding sites. These results confirm the participation of cholinergic neurons in the inhibition exerted by the ON retinal channel on the OFF retinal channel, and suggest the involvement of a cholinergic/glycinergic loop of amacrine cells in this mechanism.