RESUMEN
OBJECTIVE: We report the use of CSF drainage for the management of failed Adult Chiari Malformation (ACM) decompression. METHODS: All patients with more than one year follow-up after treatment of their failed ACM were included in this study. They underwent initial decompression between September 1998 and April 2000. Clinical and radiological data were collected initially and at recurrence. Lumbar punctures (LP) were done at recurrence for diagnostic and therapeutic purposes. Opening pressures and symptomatic relief were recorded. Therapeutic options included intermittent LP and ventriculo-peritoneal shunting (VPS). RESULTS: There were 6 patients (5 females and one male). Their age ranged from 19 to 43 years. Tonsillar descent ranged from 5 to 21 mm. The symptoms recurred 1.5 to 9 months postoperatively (average 5.6 months). Postoperative imaging revealed the presence of CSF flow behind the tonsils and the formation of a retrotonsillar neocistern in all patients. On LP, the opening pressure ranged from 17 to 31 cm of water (average 23 cm). All patients improved after CSF drainage, and four patients underwent VPS. The other patients were treated with repeat LP+/-Acetazolamide. There was significant improvement in all patients, with 18 months follow-up after CSF drainage (range 16-21 months). CONCLUSIONS: Our results suggest a role for CSF drainage in the treatment of some patients with failed ACM surgery. Possible explanations for the failure of ACM surgery in this subgroup include: surgical complications leading to neural hydrodynamic alteration, inadequate initial surgery, and coexistence with another pathology, possibly a mild form of intracranial hypertension. More prospective and hydrodynamic studies are needed to further clarify these issues.
Asunto(s)
Malformación de Arnold-Chiari/cirugía , Descompresión Quirúrgica , Drenaje , Punción Espinal , Derivación Ventriculoperitoneal , Adulto , Malformación de Arnold-Chiari/patología , Femenino , Estudios de Seguimiento , Humanos , Imagen por Resonancia Magnética , Masculino , Reoperación , Factores de Tiempo , Insuficiencia del TratamientoRESUMEN
Orbital lesions are variable in nature and location. Their management can be challenging, and surgical intervention is often needed. Although a significant percentage of these tumors are treated by the ophthalmologist alone, collaboration with a neurosurgeon is often required, especially for tumors that are located deep within the orbit, are large, or have an intracranial extension. Technical advances and modifications in surgical technique have decreased surgery-related morbidity and increased its success. The authors describe their rationale in the choice of a surgical approach, the surgical techniques for extraorbital approaches, and the new surgical adjuvants.
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Craneotomía/métodos , Órbita/cirugía , Neoplasias Orbitales/cirugía , Craneotomía/instrumentación , Humanos , Procedimientos Neuroquirúrgicos/métodos , Neoplasias de la Base del Cráneo/cirugía , Cirugía Plástica/instrumentación , Cirugía Plástica/métodosRESUMEN
Orbital tumors can be excised or biopsy samples obtained via transorbital approaches, especially those located in the anterior two thirds of the orbit. The indications and various surgical steps will be reviewed for the anterior, the anteromedial, and the lateral approaches. Some of these approaches can be combined or extended to accommodate large or deep-seated tumors.
Asunto(s)
Evisceración Orbitaria/métodos , Órbita/cirugía , Neoplasias Orbitales/cirugía , Osteotomía/métodos , Humanos , Microcirugia/métodos , Instrumentos Quirúrgicos/provisión & distribuciónRESUMEN
OBJECTIVE: We report the experience of our institution in the evaluation and care of multiple simultaneous ocular trauma patients after a terrorist bomb attack on a United States military base in Saudi Arabia. DESIGN: Retrospective, noncomparative small case series. PARTICIPANTS: Three patients who received severe ocular injuries after a terrorist bombing. INTERVENTION: All patients underwent surgical repair of the injuries that were inflicted as a result of the terrorist bombing. MAIN OUTCOME MEASURES: Baseline ocular characteristics, intraoperative findings, surgical procedures, and final (3 years after injury) anatomic and visual outcomes were noted. RESULTS: Glass fragments caused by the blast were the mechanism of all the ocular injuries in these patients. All patients had primary repair of the injuries done in Saudi Arabia and were sent to our institution for tertiary care. Three of the four eyes injured had stable or improved visual acuity and one eye was enucleated. Two patients had no serious injury other than the globe trauma. One patient had extensive eyelid trauma and required serial procedures to allow fitting of a prosthesis. CONCLUSIONS: Blast-injury patients are at risk for open globe injury as a result of glass fragments. The types of injury that can occur from terrorist blasts can be extensive and involve all the tissues of the eye, the ocular adnexa, and the orbit.
Asunto(s)
Traumatismos por Explosión/patología , Explosiones , Cuerpos Extraños en el Ojo/patología , Lesiones Oculares Penetrantes/patología , Adulto , Traumatismos por Explosión/etiología , Traumatismos por Explosión/cirugía , Catarata/etiología , Catarata/patología , Extracción de Catarata , Enfermedades de la Coroides/etiología , Enfermedades de la Coroides/patología , Enfermedades de la Coroides/cirugía , Lesiones de la Cornea , Cuerpos Extraños en el Ojo/etiología , Cuerpos Extraños en el Ojo/cirugía , Lesiones Oculares Penetrantes/etiología , Lesiones Oculares Penetrantes/cirugía , Cejas/lesiones , Párpados/lesiones , Femenino , Vidrio , Humanos , Masculino , Medicina Militar , Personal Militar , Desprendimiento de Retina/etiología , Desprendimiento de Retina/patología , Desprendimiento de Retina/cirugía , Estudios Retrospectivos , Arabia Saudita , Esclerótica/lesiones , Violencia , Agudeza VisualRESUMEN
OBJECTIVE: To define the clinicopathologic features of eyelid involvement in Melkersson-Rosenthal syndrome (MRS). METHODS: Four patients with eyelid edema consistent with MRS were evaluated clinically, including diagnostic imaging in 2 patients. Eyelid tissue from these patients was examined by light microscopy and immunohistochemistry. Polymerase chain reaction for herpes simplex virus was performed in 1 case. RESULTS: The 3 men and 1 woman ranged in age from 33 to 74 years. All patients had insidious, painless, nonpitting eyelid edema. Three patients had unilateral edema; one had bilateral, asymmetric involvement. Ipsilateral lip edema was present in 1 case. Computed tomography demonstrated periorbital heterogeneous thickening that corresponded to the microscopic finding of scattered granulomas. All 4 patients demonstrated epithelioid granulomas inside and adjacent to dilated lymphatic vessels. Polymerase chain reaction testing was negative for herpes simplex virus. CONCLUSIONS: Isolated eyelid swelling that mimics thyroid-associated ophthalmopathy may occur in MRS. Computed tomography may be useful in the diagnosis. Biopsy should be performed in all cases of unexplained nonpitting eyelid edema. In the eyelid, MRS is characterized histopathologically by a granulomatous lymphangitis, a finding that seems to be unique to this condition.
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Edema/patología , Enfermedades de los Párpados/patología , Síndrome de Melkersson-Rosenthal/patología , Adulto , Anciano , Edema/diagnóstico por imagen , Enfermedades de los Párpados/diagnóstico por imagen , Femenino , Granuloma/diagnóstico por imagen , Granuloma/patología , Humanos , Linfangitis/diagnóstico por imagen , Linfangitis/patología , Imagen por Resonancia Magnética , Masculino , Síndrome de Melkersson-Rosenthal/diagnóstico por imagen , Persona de Mediana Edad , Tomografía Computarizada por Rayos XRESUMEN
Schwannomas (neurilemomas) are benign tumors that arise from Schwann cells in the peripheral nervous system. The most commonly involved nerves that cause neuro-ophthalmic manifestations are cranial nerves V and VIII. In this series of three women, schwannomas presented as intraconal masses that mimicked a cavernous hemangioma, a superior orbital mass transgressing the superior orbital fissure, and an expansive frontal lobe mass with clinical symptoms and signs of increased intracranial pressure. Although all three complained of visual blurring, none of our patients presented with Vth or VIIIth cranial nerve dysfunction. Histopathologic studies demonstrated well-circumscribed, encapsulated spindle-cell lesions with classic Antoni A and B patterns. Histopathologic examination is essential to confirm the diagnosis of a schwannoma that may be otherwise clinically confusing. Direct optic nerve compression, globe indentation with induced hyperopia, or increased intracranial pressure with optic nerve compromise may be responsible for visual symptoms. A multidisciplinary approach is often required because of the size and location of schwannomas.
Asunto(s)
Neurilemoma/complicaciones , Neoplasias Orbitales/complicaciones , Trastornos de la Visión/etiología , Adulto , Biomarcadores de Tumor , Diagnóstico Diferencial , Femenino , Humanos , Imagen por Resonancia Magnética , Persona de Mediana Edad , Neurilemoma/diagnóstico , Neurilemoma/metabolismo , Neurilemoma/cirugía , Procedimientos Quirúrgicos Oftalmológicos , Neoplasias Orbitales/diagnóstico , Neoplasias Orbitales/metabolismo , Neoplasias Orbitales/cirugía , Proteínas S100/metabolismo , Tomografía Computarizada por Rayos X , Trastornos de la Visión/diagnóstico , Trastornos de la Visión/cirugía , Agudeza VisualRESUMEN
OBJECTIVE: To highlight a troubling cause of dacryocystorhinostomy (DCR) failure and to alert ophthalmologists to the potential problems that can result when stenting material is not removed and becomes retained after DCR. DESIGN: Consecutive noncomparative case series. PARTICIPANTS: Twelve patients who underwent revision DCR from February 1994 to January 1997. INTERVENTION: Endoscopic DCR, pre- and postoperative nasal endoscopy, preoperative computerized tomography (CT), and pre- and postoperative Jones testing. RESULTS: Fourteen revision endoscopic procedures were performed on 12 patients with recurrent epiphora following DCR. Failure was due to retained stenting material in six patients, a small bony rhinostomy in three patients, excessive scar formation within the rhinostomy in two patients, and improper location of the rhinostomy in one patient. Preoperative endoscopy and CT scan each correctly identified the retained sponge or tubing in four of six patients. CONCLUSIONS: Fastening a small sponge to Silastic tubing and positioning it within the DCR site in an attempt to retard DCR stenosis can be associated with a poor outcome and should be avoided. The nasal endoscope provided excellent visualization of pathology within the lacrimal sac and was a valuable tool. Retained stenting material should be considered in patients with persistent epiphora following DCR or intubation prior to any decision to commit a patient to permanent Jones tube placement.
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Dacriocistorrinostomía/efectos adversos , Cuerpos Extraños en el Ojo/etiología , Stents , Adulto , Dacriocistitis/diagnóstico por imagen , Dacriocistitis/cirugía , Endoscopía , Cuerpos Extraños en el Ojo/diagnóstico por imagen , Cuerpos Extraños en el Ojo/patología , Femenino , Humanos , Obstrucción del Conducto Lagrimal/diagnóstico por imagen , Masculino , Reoperación , Elastómeros de Silicona , Tomografía Computarizada por Rayos X , Insuficiencia del TratamientoRESUMEN
A previously healthy 35-year-old man experiencing slowly progressive, painless proptosis of the right eye. Visual function was normal, but supraduction was limited. Computed tomography revealed a superior, extraconal orbital mass. Subtotal excision was performed, and a diagnosis of liposarcoma was rendered only with expert analysis. Despite subsequent orbital exenteration and postoperative radiation, a local recurrence developed 5 years later. The clinical features that predict recurrence, and management options that may promote longevity, are discussed.
Asunto(s)
Liposarcoma/terapia , Neoplasias Orbitales/terapia , Adulto , Exoftalmia/complicaciones , Humanos , Liposarcoma/diagnóstico por imagen , Liposarcoma/patología , Masculino , Recurrencia Local de Neoplasia , Neoplasias Orbitales/diagnóstico por imagen , Neoplasias Orbitales/patología , Radioterapia Adyuvante , Tomografía Computarizada por Rayos XRESUMEN
Periorbital masses are often referred to oculoplastic surgeons. We report a 20-year-old patient presenting with a tender supertemporal mass that on gadolinium-enhanced magnetic resonance imaging (MRI) demonstrated a prominent dural enhancement adjacent to the mass, the so-called "dural tail sign." This sign has been reported to be highly specific for a meningioma; however recent literature challenges this view. In this case as well, the "dural tail sign" was not produced by a meningioma.
Asunto(s)
Histiocitosis de Células de Langerhans/diagnóstico , Neoplasias Meníngeas/diagnóstico , Meningioma/diagnóstico , Órbita/patología , Enfermedades Orbitales/diagnóstico , Adulto , Encéfalo/patología , Diagnóstico Diferencial , Gadolinio DTPA , Histiocitosis de Células de Langerhans/cirugía , Humanos , Imagen por Resonancia Magnética , Masculino , Invasividad Neoplásica/diagnóstico , Enfermedades Orbitales/cirugía , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE: The authors determined the prevalence of ocular hypertension and its association with progression to glaucomatous damage in patients with thyroid-associated orbitopathy (TAO). METHODS: The charts of 500 consecutive patients with TAO seen at the Allegheny General Hospital (Pittsburgh, PA) between 1985 and 1995 were analyzed. The amount of proptosis, degree and duration of myopathy, exposure to corticosteroids, prior glaucoma treatment, and family history of glaucoma were evaluated. RESULTS: One hundred twenty (24%) patients with TAO were noted to have an intraocular pressure (IOP) greater than 22 mmHg but less than 30 mmHg. This ocular hypertensive group was composed of 34 men and 86 women with a mean age of 55 years and mean follow-up of 4 years. Seven patients were defined as glaucoma suspects, based on increased but nonprogressive cup-to-disc ratios or nonprogressive, atypical visual field changes in the presence of increased IOP. Two patients demonstrated progressive visual field abnormalities and cupping. Of the factors evaluated, only the duration of active orbital involvement was statistically associated with progression to glaucomatous damage. The mean duration of TAO was 3, 8, and 12 years for ocular hypertensives, glaucoma suspects, and glaucomatous damage, respectively. CONCLUSIONS: Only a prolonged duration of active TAO in association with ocular hypertension correlated with progression to glaucomatous damage. These patients with chronic TAO deserve special attention and close follow-up to prevent optic nerve damage.
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Glaucoma de Ángulo Abierto/epidemiología , Enfermedad de Graves/complicaciones , Hipertensión Ocular/epidemiología , Adolescente , Antagonistas Adrenérgicos beta/administración & dosificación , Antagonistas Adrenérgicos beta/uso terapéutico , Adulto , Anciano , Enfermedad Crónica , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Glaucoma de Ángulo Abierto/complicaciones , Glaucoma de Ángulo Abierto/tratamiento farmacológico , Glucocorticoides/administración & dosificación , Glucocorticoides/uso terapéutico , Enfermedad de Graves/diagnóstico , Enfermedad de Graves/tratamiento farmacológico , Humanos , Masculino , Persona de Mediana Edad , Hipertensión Ocular/complicaciones , Hipertensión Ocular/tratamiento farmacológico , Soluciones Oftálmicas , Prevalencia , Estudios Retrospectivos , Factores de Riesgo , Tomografía Computarizada por Rayos XRESUMEN
The diagnosis and management of diseases of the orbit, optic nerve and chiasm continue to evolve. Advances in neuroradiology are remarkable and continue to expand diagnosis and management. This review will highlight the clinical assessment of disease, orbital and neuroimaging, medical and surgical management.
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Diagnóstico por Imagen , Quiasma Óptico , Enfermedades del Nervio Óptico/diagnóstico , Enfermedades Orbitales/diagnóstico , Diagnóstico Diferencial , Humanos , Quiasma Óptico/patología , Nervio Óptico/patología , Enfermedades del Nervio Óptico/patología , Enfermedades del Nervio Óptico/terapia , Órbita/patología , Enfermedades Orbitales/patología , Enfermedades Orbitales/terapiaRESUMEN
Although the legitimate clinical use of amphetamine and amphetamine congeners is declining, the illicit use of these drugs remains high. There is a need for a rapid and conclusive method for detecting these compounds in routine urine drug testing, drug screening in drug rehabilitation centers, and as an aid in the diagnosis and treatment of potential overdoses. The Abbott ADx Amphetamine/Methamphetamine II assay (A/M II), a fluorescence polarization Immunoassay (FPIA), was compared to the Abbott TDx Amphetamine/Methamphetamine II assay (FPIA), the Syva enzyme-multiplied immunoassay technique (EMIT) and a gas chromatograph/mass spectrometry (GC/MS) method. Precision of the A/M II assay was evaluated on the ADx analyzer over a 14-day period in each of three modes of operation (batch, combination, and panel) and was based on within-run and between-run coefficients of variation (CVs). Within-run CVs for all three controls (low [L], medium [M], and high [H]) ranged from 0.40% to 10.60% and between run CVs ranged from 3.96% to 7.92%. Data indicated that the calibration curve was stable for 16 days. Each of the six calibrators and three controls were within 10% of their labeled concentrations when analyzed by GC/MS. Fifty routine clinical specimens from our laboratory and 74 specimens screened as positive for amphetamine or related compounds from a rehabilitation center were screened by ADx, TDx, and EMIT. Any specimen yielding a positive result by any of these three methods was confirmed by GC/MS. In-house controls, as well as clinical samples, which contained both amphetamine and methamphetamine in the same sample produced results greater than two times the expected response on the ADx and TDx.(ABSTRACT TRUNCATED AT 250 WORDS)
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Anfetamina/orina , Metanfetamina/orina , Estudios de Evaluación como Asunto , Inmunoensayo de Polarización Fluorescente , Cromatografía de Gases y Espectrometría de Masas , Humanos , Técnicas para Inmunoenzimas , Juego de Reactivos para Diagnóstico , Trastornos Relacionados con Sustancias/orinaRESUMEN
A modification of two commercially available enzymatic ethanol urine assays for use with the Monarch 2000 Chemistry System (Instrumentation Laboratory) is described. Both the Syva EMIT st Urine Ethyl Alcohol Assay and the Sigma Diagnostics Alcohol in Urine Assay, which utilize the reduction of nicotinamide adenine dinucleotide (NAD) to NADH associated with the oxidation of ethanol in the presence of alcohol dehydrogenase (ADH), were adapted to spectrophotometrically determine ethanol concentration. Precision was evaluated over a 3-day period. Within-day (n = 9) and total (n = 27) coefficients of variation (CV) were less than 7% for the controls greater than or equal to 200 mg/L (20 mg/dL). Enzymatic assay results utilizing the Monarch procedure were compared to a gas chromatographic (GC) reference method (n = 100 samples). Regression analysis of assay data with each reagent compared to the reference method resulted in correlation coefficients r = 0.972 (Syva) and 0.948 (Sigma). Both methods exhibited nonlinear results and therefore quantitative applications cannot be made. No false positive or negative results were encountered with either reagent, indicating that the assay is acceptable as a positive/negative screen for urine ethanol for a threshold less than or equal to 20 mg/dL.
Asunto(s)
Etanol/orina , Cromatografía de Gases/métodos , Humanos , Técnicas para Inmunoenzimas , Reproducibilidad de los Resultados , Espectrofotometría Ultravioleta/métodos , Factores de TiempoRESUMEN
MDMA and MDEA are hallucinogenic analogs of amphetamine. The need for laboratory monitoring of these substances has developed as a result of their increased recreational use. Since the Abbott TDx and Syva EMIT-d.a.u. immunoassays are commonly used tests for urine monitoring of drugs-of-abuse, the amphetamine assay of each manufacturer was assessed to determine the degree of cross-reactivity with MDMA and MDEA. Cross-reactivity was evaluated using a series of MDMA- and MDEA-spiked urine samples. Testing was performed over a two-day period with 3 runs/day and each sample run in duplicate. The Syva EMIT d.a.u. amphetamine assay was positive only at the highest concentration standard (10.0 micrograms/mL) for both MDMA and MDEA. Consequently, no further testing was performed with this assay. Calibration curves were generated for the TDx runs and percent cross-reactivity determinations were made. Precision for the TDx data was evaluated based on within-day and between-day coefficients of variation (CV). CVs for MDMA runs were below 6% for within-day and below 5% for between-day runs. Values of CV for MDEA were below 16% for both within-day and between runs; CVs were less than 2.5% for positive values. Cross-reactivity for MDMA ranged from 18% (10.00 micrograms/mL) to 118% (0.15 microgram/mL). Cross-reactivity for the MDEA standards ranged from 12% (10.00 micrograms/mL) to 47% (0.15 micrograms/mL). The presence of MDMA and/or MDEA in samples resulting in a negative EMIT-d.a.u. test and a positive TDx test was confirmed by GC/MS analysis.(ABSTRACT TRUNCATED AT 250 WORDS)