Pigmented onychomatricoma may originate from a childhood trauma: A case report

Pigmented onychomatricoma (OM) is a very rare benign fibroepithelial tumor of the nail matrix. We report the case of a 23-year-old Lebanese man with 15-year history of nail plate dystrophy with longitudinal ridging, yellowish discoloration, excessive transverse curvature and late-onset melanonychia along the medial third of the right thumb nail. Excisional biopsy was performed and confirmed OM. We outline the clinical history, radiological and histopathological findings as well as the surgical and reconstructive technique of this unusual case of OM. The age group, history of crush injury, and pigmentation of the nail plate make of this rare form of ungual tumor an interesting case report.

Single-piece femtosecond-assisted mushroom keratoplasty in children

PURPOSE

To report outcomes of femtosecond-assisted single-piece mushroom keratoplasty for the treatment of full-thickness corneal disease in pediatric patients with healthy endothelium.

METHODS

Femtosecond-assisted mushroom keratoplasty was performed in 8 eyes of 8 patients (age range, 8-17 years) with central full-thickness corneal opacity. The single-piece mushroom-shaped graft consisted of a large anterior portion (9 mm in diameter; 250 μm in thickness) and a small posterior portion (6-6.5 mm). Donor and recipient corneas were prepared using the WaveLight FS200 laser (Alcon Laboratories, Fort Worth, TX). The donor cornea was oversized by 0.2 mm. Outcome measures were best spectacle-corrected visual acuity, spectacle refraction, topographic astigmatism, endothelial cell density, graft rejection, and graft failure at 1, 3, 6, and 12 months.

RESULTS

Mean best spectacle-corrected visual acuity at 1, 3, 6, and 12 months was 0.28, 0.16, 0.13, and 0.10 logMAR; all patients achieved logMAR of at least 0.4 at 1, 3, 6, and 12 months. The mean refractive cylinder was 2.6 D, and mean endothelial cell loss was 13.3% at 12 months postoperatively. Two eyes had immunologic rejection episodes that were reversed with topical steroids. All corneas remained clear at final follow-up.

CONCLUSIONS

Femtosecond-assisted mushroom keratoplasty is a viable surgical option for eyes of older pediatric patients with full-thickness corneal stromal disease and healthy endothelium. Mushroom keratoplasty combines the refractive advantage of a large keratoplasty with the immunologic advantage of a small keratoplasty. Single-piece femtosecond-assisted mushroom keratoplasty may have a mechanical advantage over regular penetrating keratoplasty.

Descemet stripping automated endothelial keratoplasty in phakic eyes: incision modification reducing cataract formation

AIM

To evaluate the efficacy of a technical modification to reduce the incidence of traumatic cataract induced by Descemet stripping automated endothelial keratoplasty (DSAEK) performed in phakic eyes.

METHODS

A retrospective cohort study. The records of all patients with a clear crystalline lens and endothelial failure that underwent modified DSAEK at our insitution were reviewed. In this modification, in order to avoid inadvertent touch of the insertion forceps against the exposed crystalline lens while passing across the anterior chamber, the incision sites were shifted from the standard 9 and 3 o'clock positions, superiorly to the 10 and 2 o'clock position respectively. Formation of typically traumatic, anterior subcapsular cataract in these patients was compared to that observed in a cohort including all the patients with a clear crystalline lens and endothelial failure that underwent conventional DSAEK at our institution.

RESULTS

The study group included 49 eyes following modified DSAEK and the control group included 35 eyes following DSAEK with conventional incision sites. Anterior subcapsular cataract occurring 4mo or less postoperatively was identified in 2 of 49 (4%) eyes in the study group and 7 of 35 (20%) eyes in the control group. The rates of traumatic cataract were significantly higher in the control group in comparison to the study group (P=0.03, RR=4.9, 95%CI 1.08-22.1).

CONCLUSION

Traumatic cataract formation following phakic DSAEK may be avoided with a simple modification to the position of the incision sites.

A Two-Piece Microkeratome-Assisted Mushroom Keratoplasty Improves the Outcomes and Survival of Grafts Performed in Eyes with Diseased Stroma and Healthy Endothelium (An American Ophthalmological Society Thesis)

PURPOSE

To test the hypothesis that a new microkeratome-assisted penetrating keratoplasty (PK) technique employing transplantation of a two-piece mushroom-shaped graft may result in better visual outcomes and graft survival rates than those of conventional PK.

METHODS

Retrospective chart review of 96 eyes at low risk and 76 eyes at high risk for immunologic rejection (all with full-thickness central corneal opacity and otherwise healthy endothelium) undergoing mushroom PK between 2004 and 2012 at our Institution. Outcome measures were best-corrected visual acuity (BCVA), refraction, corneal topography, endothelial cell density, graft rejection, and survival probability.

RESULTS

Five years postoperatively, BCVA of 20/40 and 20/20 was recorded in 100% and over 50% of eyes, respectively. Mean spherical equivalent of refractive error did not vary significantly over a 5-year period; astigmatism averaged always below 4 diopters, with no statistically significant change over time, and was of the regular type in over 90% of eyes. Endothelial cell density decreased to about 40% of the eye bank count 2 years after mushroom PK and did not change significantly thereafter. Five years postoperatively, probabilities of graft immunologic rejection and graft survival were below 5% and above 95%, respectively. There was no statistically significant difference in endothelial cell loss, graft rejection, and survival probability between low-risk and high-risk subgroups.

CONCLUSIONS

Refractive and visual outcomes of mushroom PK compare favorably with those of conventional full-thickness keratoplasty. In eyes at high risk for immunologic rejection, mushroom PK provides a considerably higher probability of graft survival than conventional PK.

Descemet stripping automated endothelial keratoplasty for endothelial decompensation in buphthalmos

PURPOSE

To report the results of Descemet stripping automated endothelial keratoplasty (DSAEK) to treat endothelial failure in eyes with buphthalmos.

DESIGN

Prospective interventional case series.

METHODS

All buphthalmic eyes with endothelial failure undergoing DSAEK by the same surgeon (M.B.) between March 2007 and January 2012 were included. Outcome measures included best spectacle-corrected visual acuity (BSCVA), refraction, and endothelial cell loss (assessed 6, 12, 24, 36, and 48 months postoperatively). Standardized DSAEK was performed in all cases, with minor modifications in phakic and aphakic eyes. Other outcomes included comparisons to penetrating keratoplasty (PK) published results and comparisons to visual outcomes in DSAEK for other indications.

RESULTS

There were 14 transplants performed in 12 eyes (11 patients). Mean age was 34.9 years (range 15-54 years). The average follow-up was 21.7 ± 13.8 months (range 6-48 months). At last follow-up examination, BSCVA had improved in 11 of 13 cases, with a logMAR average value ± standard deviation of 0.74 ± 0.66 from the preoperative value of 2.07 ± 0.80. Eleven eyes reached Snellen acuity of 20/200 or better, and 5 eyes reached 20/40 or better. Mean endothelial cell loss was 40.5% ± 8.9% (range 23.7%-53.1%). Complications included graft detachment (n = 2), glaucoma progression (n = 1), and late endothelial failure (n = 1). All complications were managed successfully either by repeat DSAEK (n = 2), rebubbling (n = 1), or cyclocryocoagulation (n = 1).

CONCLUSIONS

DSAEK may be performed safely and effectively in buphthalmic eyes, with comparable results to outcomes after PK. Visual outcomes are not substantially different after DSAEK for this indication compared to DSAEK for other indications.

Ultrathin descemet's stripping automated endothelial keratoplasty with the microkeratome double-pass technique: two-year outcomes

PURPOSE

To evaluate the outcomes and graft survival rates after ultrathin (UT) Descemet's stripping automated endothelial keratoplasty (DSAEK) using the microkeratome-assisted double-pass technique.

DESIGN

Prospective, consecutive, interventional case series.

PARTICIPANTS

Patients with endothelial decompensation of various causes (Fuchs endothelial dystrophy, pseudophakic or aphakic bullous keratopathy, failed previous graft, herpetic endotheliitis, or buphthalmus; n = 285 grafts).

INTERVENTION

Donor preparation was performed using the microkeratome-assisted double-pass technique. Stripping of the Descemet's membrane was performed under air and the graft was delivered into the anterior chamber using the pull-through technique through a 3-mm clear-cornea incision using a modified Busin glide.

MAIN OUTCOME MEASURES

Best spectacle-corrected visual acuity (BSCVA), manifest refraction, endothelial cell density, and graft thickness (GT).

RESULTS

Excluding all eyes with pre-existing ocular comorbidities, mean BSCVA at 3, 6, 12, and 24 months was 0.16, 0.11, 0.08, and 0.04 logarithm of the minimum angle of resolution units, respectively. The percentage of patients achieving BSCVA of 20/20 or better at 3, 6, 12, and 24 months was 12.3%, 26.3%, 39.5%, and 48.8%, respectively. A statistically significant (P < 0.0001) hyperopic shift of 0.78 ± 0.59 diopters (D; range, -0.75 to 1.75 D) was found at 1 year. The endothelial cell loss at 3, 6, 12, and 24 months was 29.8 ± 14.3%, 33 ± 15.5%, 35.6 ± 14.1%, and 36.6 ± 16.0%, respectively. The mean central GT recorded 3 months after surgery was 78.28 ± 28.89 μm. Complications included microkeratome failure to achieve perfect dissection in 21 donor tissues (7.2%), with 6 (2.1%) being discarded; total graft detachment in 11 cases (3.9%); primary failure in 4 cases (1.4%); and secondary failure in 4 additional cases (1.4%). Kaplan-Meier cumulative probability of a rejection episode at 3, 6, 12, and 24 months was 0%, 0.4%, 2.4%, and 3.3%, respectively.

CONCLUSIONS

The visual outcomes of UT DSAEK are comparable with those published for Descemet's membrane endothelial keratoplasty and better than those reported after DSAEK in terms of both speed of visual recovery and percentage of patients with 20/20 final visual acuity. However, unlike with Descemet's membrane endothelial keratoplasty, preparation and delivery of donor tissue are neither difficult nor time consuming. Complications of UT DSAEK do not differ substantially from those recorded with standard DSAEK but are much less frequent than those reported after Descemet's membrane endothelial keratoplasty.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Descemet stripping automated endothelial keratoplasty in pediatric age group

PURPOSE

To report the outcomes of DSAEK surgery performed in pediatric patients.

DESIGN

Noncomparative interventional case series.

SUBJECTS AND METHODS

All pediatric patients (age up to 16 years) undergoing Descemet automated stripping endothelial keratoplasty (DSAEK) at our Institution since January 2008 have been enrolled in a prospective study. A standard DSAEK, involving delivery of an 8.5-9.5 mm graft by Busin glide, was performed under general anesthesia in 19 eyes of 11 pediatric patients (congenital hereditary endothelial dystrophy n = 13; congenital glaucoma n = 2; posterior polymorphous dystrophy n = 2, and failed penetrating keratoplasty n = 2). Slit-lamp examination, refraction and visual acuity as well as endothelial cell density were evaluated preoperatively as well as 1, 3, 6, 12, and 18 months postoperatively.

RESULTS

All surgical procedures were uneventful. Graft detachment occurred in 4 cases and was managed successfully with repeat air injection. All corneas cleared within a week from surgery. Follow-up was 3-18 months. At last follow-up examination, best-corrected visual acuity (BCVA) was better than 20/40 in 8 of the 13 cases of patients old enough to assess vision. A graft rejection episode was seen in 1 case within 3 months from surgery but was reverted with steroidal treatment. No graft failures were observed.

CONCLUSIONS

DSAEK is an appropriate surgical intervention for children with corneal endothelial failure. In contrast to penetrating keratoplasty (PK), DSAEK is performed under "closed system" conditions, thus minimizing intraoperative risks. Finally, healing is much faster than with PK and all sutures can be removed within 2-4 weeks from surgery, thus allowing fast visual recovery and prompt starting of amblyopia treatment.

Differential brain responses when applying criterion attribute versus family resemblance rule learning

Subsystems of category learning have been identified on the basis of general domains of content (e.g., tools, faces). The present study examined categories from the standpoint of internal structure and determined brain topography associated with expressing two fundamentally different category rule structures (criterion attribute, CA, and family resemblance, FR). CA category learning involves processing stimuli by isolated features and classifying by properties held by all members. FR learning involves processing stimuli by integral wholes and classifying on overall similarity among members without sharing identical features. fMRI BOLD response to CA and FR categorization was measured with pseudowords as stimuli. Category knowledge for both tasks was mastered prior to brain imaging. Areas of activation emerged unique to the structure of each category and followed from the nature of the rule abstraction procedure. CA categorization was implemented by strong target monitoring and expectation (medial parietal), rule maintenance in working memory, feature selection processes (inferior frontal), and a sensitivity to high frequency components of the stimulus such as isolated features (anterior temporal). FR categorization, consistent with its multi-featural nature, involved word-level processing (left extrastriate) that evoked articulatory rehearsal (medial cerebellar). The data suggest category structure is an important determinant of brain response during categorization. For instance, anterior temporal structures may help attune visual processing systems to high frequency components to support the learning of criterial, highly predictive rules.

Functional MR imaging of the human cervical spinal cord

BACKGROUND AND PURPOSE

Although research with functional MR imaging of the brain has proliferated over the past 5 years, technical limitations, such as motion, chemical shift, and susceptibility artifacts, have impeded such research in the human spinal cord. The purpose of this investigation was to determine whether a reliable functional MR imaging signal can be elicited from the cervical spinal cord during simple motor activity.

METHODS

Subjects performed three different motor tasks that activate different segments of the spinal cord. Gradient-echo-planar imaging on a 1.5-T clinical unit was used to image cervical spinal cords of human subjects. Another group of subjects was imaged while performing isometric exercise to study the relationship between the blood oxygenation level-dependent (BOLD) signal and applied force.

RESULTS

Task-dependent BOLD activity was detected in all subjects. Signal amplitude varied between 0.5% and 7%. Moreover, a linear relationship was found between the applied force and the signal amplitude during isometric exercise. While regions of activation were distributed throughout the spinal cord, concentrated activity was found in the anatomic locations of expected motor innervation.

CONCLUSION

The functional MR imaging signal can be reliably detected with motor activity in the human cervical spinal cord on a 1.5-T clinical unit. The location of neural activation has an anatomic correspondence to the myotome in use. The strength of the BOLD signal is directly proportional to the level of muscular activity.

An epidemiologic, clinical, and therapeutic study of childhood Guillain-Barré syndrome in Kuwait: is it related to the oral polio vaccine?

We studied Guillain-Barré syndrome, affecting children 12 years old or less, throughout Kuwait, in the period between January 1, 1992, and March 31, 1997. Nineteen children had the diagnostic criteria of Guillain-Barré syndrome, with an overall annual incidence rate of 0.95/100,000 population at risk. Female patients outnumbered male patients with a sex ratio of 1.4:1. There was a clustering of cases in winter and spring and in the year 1996. The disease symptoms were relatively severe in our patients because only 16% (3 of 19) of them were able to walk at the height of their illness, whereas the rest were bed or chair bound or needed assisted ventilation. Two patients had the electrodiagnostic features of axonal neuropathy and both had residual deficits on follow-up, whereas the rest recovered fully. All the patients received intravenous immunoglobulin. The mean time to walk unaided was 23.5 days (range, 2-84 days) after intravenous immunoglobulin and excluding the two patients with axonal neuropathy, and full recovery was achieved in a mean time of 103 days (range, 30-300 days). Contrary to previous studies, we found no correlation between oral polio vaccine administration and Guillain-Barré syndrome in 2 successive years (1995 and 1996) during a nationwide campaign targeting children less than 5 years old.

Infective endocarditis: a prospective study of 60 consecutive cases

Sixty cases of infective endocarditis were studied prospectively between May, 1985 and December, 1988. There were 40 males and 20 females with a mean age of 28 years. Endocarditis was found on normal valves in 13 patients, on rheumatic valves in 30, on congenital lesions in 8, on prosthetic valves in 4 and on mitral valve prolapse in 5 cases. Positive blood cultures were detected in 35 patients (58%). In addition bone marrow culture was positive in 1 and valves removed on surgery grew causative organisms in eight. Thus the total culture positive cases were 44 (73%). The commonest infective organism was Streptococcus viridans. Uncommon organisms accounted for 10 cases (17%). Two dimensional echocardiography (2D-Echo) was done in all cases and vegetations were detected in 48 patients (80%). 2 D-Echo was helpful not only in the detection of vegetations but also in the demonstration of other complications of endocarditis like ring abscesses, ruptured chordae, ulceration of aortic root, interventricular septum abscess, and mitral xenograft obstruction. Early surgery was performed in 31 patients. In this group of patients severe heart failure was present in 21, embolization in 10, persistence of fever in 15 and large vegetations in 19. Of the 29 patients treated medically, 2 died. The mortality in the surgical group was seen in 5 (16%) with a mean follow-up of 15 months. The major reason for a large number of our patients undergoing surgery is the fact that this is a referral Center and patients were sent later or when there was a failure of medical treatment.

[Postoperative agitation. A new cause]

Thirty-three patients, operated on between 1981 and 1986, and presenting post-operative confusion and restlessness are analyzed. Two groups are identified: group 1 are patients who regularly received BZD before their present hospitalization; in group 2 patients were given high-dose BZD in the early postoperative period. Symptoms were anxiousness in 15 patients, restlessness in 14, myoclonia in 14, delirium in 3, coma and seizures in 1. BZD withdrawal syndrome was considered after the other causes of post-operative agitation were eliminated and the diagnosis was confirmed by the administration of BZD that relieved the symptoms and by the plasmatic concentration of BZD. This syndrome appears 1 to 5 days after BZD withdrawal and severity of symptoms seems to be directly proportional to the doses and duration of BZD therapy. Propranolol was proposed to reduce the intensity of the symptoms. Nevertheless, progressive withdrawal of BZD remains the best way for managing such patients.