Diplopia on vertical gaze is highly suggestive that the bony walls of the orbit are affected. Lefort type I fracture does not affect the orbital contents. Knowing this information, the only correct answer is 2. If we were in doubt about whether or not Lefort's type I fracture affects the orbit, just look at the answers. Whoever posted the question wanted to make sure that the only valid answer was number 2; that is why they added the tag line "but just in case we check it with a CT scan".

Diplopia on vertical gaze is highly suggestive that the bony walls of the orbit are affected. Lefort type I fracture does not affect the orbital contents. Knowing this information, [HIDDEN]. If we were in doubt about whether or not Lefort's type I fracture affects the orbit, just look at the answers. Whoever posted the question wanted to make sure that [HIDDEN]; that is why they added the tag line "but just in case we check it with a CT scan".

Given a direct trauma to the right side of the face after which the patient presents unilateral palpebral hematoma, diplopia in the vertical gaze and difficulty in opening the mouth, which of the following statements is true?

We are with great probability in front of a Lefort I type fracture of the middle third of the face.

This is probably a unilateral orbitomalar fracture. The diagnosis would ideally be verified by CT (computed axial tomography).

It is a fracture of the base of the skull at the level of the carotid foramen.

The probable diagnosis is fracture with dislocation of the mandibular condyle.

A mandibular fracture is probably associated with a Lefort I type midface fracture.

OTORHINOLARYNGOLOGY AND MAXILLOFACIAL SURGERY

Mandibular fracture

that becomes progressively worse to the unaffected side). When the mouth is opened, there may be deviation of the mandible towards the fractured side. Bilateral condylar fractures may cause the above signs and symptoms, but on both sides. Malocclusion and restricted jaw movement are usually more severe. Bilateral body or parasymphysis fractures are sometimes termed "flail mandible", and can cause involuntary posterior movement of the tongue with subsequent obstruction of the upper airway. Displacement of the condyle through the roof of the glenoid fossa and into the middle cranial fossa is rare. Other rare complications of mandibular trauma include internal carotid artery injury, and obliteration of the ear canal due to posterior condylar dislocation. Bilateral condylar fractures combined with a symphyseal fracture is sometimes termed a guardsman's fracture. The name comes from this injury occurring in soldiers who faint on parade grounds and strike the floor with their chin.

Which craniofacial fractures are associated with external auditory canal bleeding?

External auditory canal bleeding (EACB) after facial trauma has been strongly associated with skull base fractures; however, EACB also can occur with other craniofacial fractures. The aim of this study was to analyze the frequency and causes of EACB in different craniofacial fracture types. The investigators used a retrospective cohort study design and enrolled a sample composed of patients with craniofacial fractures evaluated and treated from April 2006 through December 2011. The predictor variable was fracture type, which was categorized into 4 types: skull base fracture, midface fracture, and mandibular fracture with and without involvement of the condyle. The frequency of EACB among fracture types was compared with SPSS 13.0 (SPSS, Inc, Chicago, IL) and χ(2) test. Computed tomographic (CT) scans were analyzed to determine the cause of EACB. EACB was found in 43 of 573 craniofacial fracture cases, with a frequency of 7.5%. There were 19 EACB sides in 123 skull base fracture cases (15.4%), 26 EACB sides in 150 mandibular fracture cases involving the 196 condyles (13.3%; of these 196 condyles, 92.3% were intracapsular condylar fractures [ICFs]), 2 EACB sides in 150 mandibular fracture cases not involving the condyle (1.3%), and 1 EACB case in 150 midface fracture cases (0.7%). Statistical analysis of EACB frequency for each fracture type showed a significant difference between skull base or mandibular fractures with condylar involvement and midface or mandibular fractures without condylar involvement (P < .05). However, there was no significant difference between skull base and mandibular fractures involving the condyle and midface fracture and mandibular fractures not involving the condyle (P > .05). EACB is uncommon in craniofacial fractures. The frequency varies significantly based on fracture type. Skull base fracture and mandibular ICF are the 2 main causes of EACB.

[Clinical study of three-dimensional reconstruction of computed tomography in diagnosis of condylar fractures].

To explore a method of getting good three-dimensional (3D) reconstruction images of temporomandibular joint (TMJ) by computed tomography (CT), and evaluate diagnosis value of 3DCT in condylar fractures. Of the 14 patients studied, 12 were male and 2 were female with age ranging from 4 to 37 years old. 4 were old fractures and the other 10 were fresh fractures. All patients' orthopanotomograms were taken first, and then were scanned with CT. The scanning conditions were 300-345 mAS and 120kV, and the scanning methods included cross-sectional (11/14), coronal-sectional (2/14) and spiral (1/14) (pitch: 1, thickness of layers: 2.5 mm) scanning. Scanning scopes: The cross-sectional and spiral scanning were from 1 cm above the Frankfort horizontal plane to the middle of the mandibular ramus or Menton; The coronal-sectional scanning was from the mastoid process to the anterior point of the mandibular ramus or Pogonion. The thickness of the scanning layers was 2.5 mm (12/14) or 5 mm (2/14). Finally, 3D reconstructed images were obtained by shaded surface display (SSD). The cross-sectional images were obtained by being removed the cervical vertebra, the styloid process, the occipital bone and part of the mastoid process with Subtract Manual Irroi before reconstruction to avoid interference with the observation of TMJ and skull basis. 1. The best 3D CT reconstructed images were obtained by 2.5 mm-thin-layer cross-sectional scanning by being removed parts of the adjacent structures, and the bone lines were clear and smooth without adjacent bone structures shading TMJ. The quality of images taken spirally was similar to those taken cross-sectionally. While the coronal scanning neglected some important anatomic symbols which might be valuable to diagnose condylar displacement. 2. Of the 14 patients, 7 were unilateral condylar fractures and 7 were bilateral (21 sides altogether), among which 18 sides were high fractures of condyles and 3 were fractures of condylar neck. High oblique line fractures and comminuted fractures had major condylar rotation displacement which moved forward, downward and inside, whereas, vertical fractures only had minor displacement. Inward rotation displacement occurred in medial bent fractures. 10 of 14 patients (15 sides) had been conducted operation, and the same situations as seen from 3DCT reconstructed images were found. 3DCT images can display condylar fractures accurately and directly, and are very useful for surgeons to select treating methods of condylar fractures.

Mandibular fracture

This type of fractured mandible can involve one condyle (unilateral) or both (bilateral). Unilateral condylar fracture may cause restricted and painful jaw movement. There may be swelling over the temporomandibular joint region and bleeding from the ear because of lacerations to the external auditory meatus. The hematoma may spread downwards and backwards behind the ear, which may be confused with Battle's sign (a sign of a base of skull fracture), although this is an uncommon finding so if present, intra-cranial injury must be ruled out. If the bones fracture and overlie each other there may be shortening of the height of the ramus. This results in gagging of the teeth on the fractured side (the teeth meet too soon on the fractured side, and not on the non fractured side, i.e. "open bite" that becomes progressively worse to the unaffected side). When the mouth is opened, there may be deviation of the mandible towards the fractured side. Bilateral condylar fractures may cause the

Mandibular condylar fractures and acute atlanto-axial subluxation. Part 1 - A new clinical and nosographic evidence.

The aim of this study was to analyze the acute repercussions of condylar mandibular fractures on occipital-atlanto-axial joint. Twenty-five non-consecutive cases (16 males and 9 females, mean age: 22.96/range 14-36 years), observed and treated in the Maxillofacial Surgery Department of the University of L'Aquila have been considered. Types of fractures examined included: unilateral: 19 cases (solitary: 12; associated with other mandibular fractures: 7; homolateral: 2); bilateral: 6 cases (equivalent: 2; not equivalent: 4). A control group was constituted of 10 patients, 5 males and 5 females, aged from 19 to 24 years (mean-range: 21.6) suffering from acute isolated cervical distorsion (whiplash). The study has been performed by means of the analysis of X-ray and computed tomography (CT)-CT/3D of the mandibular condylar regions, the occipital-atlanto-axial structures and the cervical region. In all the cases of fractures of the mandibular condyle an acute alteration of the junctional atlanto-axial structures was present. In case of unilateral solitary condylar fractures the authors have observed an atlas rotation, homolateral to the side of the condylar fracture, independent from the level of the fracture (intra- or extracapsular). The rotation seems to be proportional to the entity of the condylar fragments dislocation on the horizontal plane and it causes a modification of the articular relations between atlas and axis (atlanto-axial subluxation) and between the atlas and the occipital bone. The authors have observed a constant derangement of the cranio-axial joint on the three planes of the space. In particular, on the vertical plane the CT reconstructions show on the right and left side a different height between the atlanto-axial articular spaces. The largest one is homolateral to the side of the condylar fracture. In case of unilateral condylar fractures associated with other mandibular fracture (homolateral or not) the authors have observed the same alterations of the occipital-atlo-epistropheal joint, but while on the horizontal plane the rotation of the atlas is always homolateral to the condylar fracture, on the vertical plane the largest atlanto-axial articular space is homolateral to the mandibular fracture with more dislocation of the fragments of fracture (usually the associated not homolateral mandibular fracture). In case of bilateral condylar fractures the authors have observed no alteration of the cranio-cervical joint. In the non-equivalent fractures, they have observed the atlas rotation on the horizontal plane and the junctional derangement on the vertical plane, homolateral to the condylar fracture with greatest dislocation. In the control group the loss of the physiological cervical lordosis has been observed. Alterations on the horizontal and vertical planes, as the rotation of the atlas, atlanto-axial subluxation or the joint derangement, instead, has never revealed. The authors state that these results represent a new nosographic entity associated with the condylar mandibular fractures with important clinical, insurance and legal repercussions.

Etiology, incidence and patterns of mid-face fractures and associated ocular injuries.

A prospective study on mid-face fractures was carried out in the Department of Oral and Maxillofacial Surgery at College of Dentistry, Indore, from August 2007 to September 2009 to analyze etiology, incidence and patterns of midface fractures and associated ocular injuries. Two hundred patients were included in this study, amongst those who reported to the Department of OMFS, College of Dentistry, Indore. After confirmed diagnosis of mid face fracture all the patients were stratified according to age, sex, cause of the accident, influence of alcohol, location, type of fractures and associated ocular injuries. The study included 200 patients with a mean age of 29.6 years. The most frequently injured patients belonged to the 21-30 year-old age group. The male predilection was 76 %. Road traffic accident was the most common causative factor (64 %), followed by assault (21 %), cases of fall (9.5 %) and other causes (5.5 %). The most common fracture in this study was found to be zygomatic complex fractures (62.5 %) (more in the age group of 21-30 years). This was followed by Lefort II fractures (23 %), multiple fractures (10 %) and Lefort I fractures (6 %), Lefort III fractures (4.5 %) and Naso-ethmoidal fractures (4 %) in descending order. 84.5 % subjects were having ocular involvement. Subconjunctival hemorrhage was present mostly in 83.5 % followed by remaining as corneal injury 15 %, reduced acuity 11.5 %, diplopia 10.5 %, enophthalmos 8.5 %, telecanthus 5 %, hyphema 3.5 %, blindness 3 % and proptosis 0.5 %. Zygomatic complex fractures were the most frequent type of injury that was complicated by blindness or a serious eye injury (61 %). Collection of data regarding the epidemiology of maxillofacial fractures is important because it may assist healthcare providers to provide necessary information for the development and evaluation of preventive measures. Ocular injuries should have an early ophthalmological examination at the time of trauma to detect any kind of ocular dysfunction.

[Clinical study of mandibular condyle injury].

Mandibular condyle fractures develop frequently and show the variable type of injury and complication. New opinions have emerged from recent investigation into condylar fractures. The author investigated 246 patients with condylar fractures who visited SNUDH from January 1980 to August, 1988, 8. with regard to clinical and treatment aspects, area and displacement of fractures, associated teeth injury and other body injury, complications. At last I have got the following results. 1. The incidence to condylar fractures in a series of 765 mandibular fractures may be as high as 32.2%. 2. The male patients are 3 times more than female patients. The highest frequency was recorded in the group 21-30 years of age. (34.1%). 3. Falls caused the greatest number of condylar fractures (45.2%) and next was in assult (25.6%), traffic accidents (22.4%). 4. Unilateral condylar fractures were present in 74.8%, giving a left: right ratio of 1.2:1. In cases of unilateral fracture, subcondylar fractures were by far the commonest (32.9%) but in cases of bilateral fracture, condylar neck fractures were by far the commonest. In children under 15 years of age, condylar neck fractures were more common but in patients over 16 years of age, subcondylar fractures were common. 5. Anteromedial fracture dislocations were by far the commonest (20.3%). In children under 15 years of age, fracture deviations were common but in patients over 16 years of age, fracture displacements were common. 6. 44.7% of patients with condylar fractures sustained the teeth injuries. Teeth fractures were by far the commonest. 7. Single condylar fractures showed a frequency of 30.5%. Of the concomitant fractures elsewhere in the mandible, symphysis fractures were by far the commonest (54.1%). 8. Associated other body injuries showed a frequency of 28.0%. Of them, head injuries were by far the commonest. 9. The mean interval from injury to treatment was 14.3 days. Of the treatment of condylar fractures, open reduction was by far the commonest (70.3%). Closed reduction comprised 19.9% and functional therapy comprised 8.5%. 10. In 67 patients with possible follow up period, the following complications were developed, two ankylosis, anterior open bite, mouth opening limitation, mouth opening deviation.

Mandibular fracture

Research has shown that panoramic radiography is similar to computed tomography in its diagnostic accuracy for mandible fractures and both are more accurate than plain film radiograph. The indications to use CT for mandible fracture vary by region, but it does not seem to add to diagnosis or treatment planning except for comminuted or avulsive type fractures, although, there is better clinician agreement on the location and absence of fractures with CT compared to panoramic radiography. Classification There are various classification systems of mandibular fractures in use. Location This is the most useful classification, because both the signs and symptoms, and also the treatment are dependent upon the location of the fracture. The mandible is usually divided into the following zones for the purpose of describing the location of a fracture (see diagram): condylar, coronoid process, ramus, angle of mandible, body (molar and premolar areas), parasymphysis and symphysis.

Fractures of the mandibular condyle. Part 1: patterns of distribution of types and causes of fractures in 348 patients.

This prospective study was designed to record relevant characteristics of mandibular condyle fractures and to evaluate the relationship between these. Data were recorded on sex, age, cause of trauma, level of fracture, dislocation of the mandibular head, dental state and associated fractures of all patients diagnosed in our hospital during the period 1984-1996 with mandibular condyle fractures. Data were analysed in our Computer Department. The sample comprised 348 patients with 444 fractures, and a male:female ratio of 2:1. Traffic accidents were the most common cause: 103 (41%) of the unilateral and 54 (56%) of the bilateral fractures, followed by alleged assault and falls. Low fractures were the most common -n = 314 of 444 (71%). The causes that involved considerable force (traffic accidents and falls) resulted in more dislocations of the mandibular head, more bilateral fractures, a tendency to fractures higher on the condyle and significantly more intracapsular fractures. Absence of molar occlusion also gave more high and fewer low fractures, but played no part in dislocation of the mandibular head from the glenoid fossa.

Diagnostic accuracy of physical examination findings for midfacial and mandibular fractures.

To assess the diagnostic accuracy of physical examination findings used to identify patients at risk for midfacial or mandibular fractures. A five-year retrospective cohort was constructed from all emergency department patients with a midfacial or mandibular trauma. The sensitivity, specificity, pre-test probability, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio data was calculated for 19 and 14 physical examination findings for midfacial and mandibular fractures respectively. Computed Tomography and panoramic radiography were used as index tests. A total of 1484 patients were identified among whom 40.4% midfacial and 33.4% mandibular fractures were diagnosed. Overall, specificity was found to be higher than sensitivity. Regarding midfacial fractures, high specificity was found for raccoon eyes, malar eminence flattening and all the findings that are related to palpation, the nasal, ocular and intra-oral assessment. Malar eminence flattening, external nasal deformity, nasal septum hematoma, change of globe position and palpable step-off had ad high positive predictive value and positive likelihood ratio. Regarding mandibular fractures high specificity was found for mouth opening restriction, auditory canal bleeding, intra-oral assessment related findings, palpable step-off, inferior alveolar nerve paresthesia, the angular compression test and chin axial pressure test. The diagnostic accuracy of relevant physical examination findings were identified for the prediction of midfacial and mandibular fractures.

Mandibular fracture

Mandibular fracture, also known as fracture of the jaw, is a break through the mandibular bone. In about 60% of cases the break occurs in two places. It may result in a decreased ability to fully open the mouth. Often the teeth will not feel properly aligned or there may be bleeding of the gums. Mandibular fractures occur most commonly among males in their 30s. Mandibular fractures are typically the result of trauma. This can include a fall onto the chin or a hit from the side. Rarely they may be due to osteonecrosis or tumors in the bone. The most common area of fracture is at the condyle (36%), body (21%), angle (20%) and symphysis (14%). While a diagnosis can occasionally be made with plain X-ray, modern CT scans are more accurate.

A comprehensive classification of craniofacial fractures: postmortem and clinical studies with two- and three-dimensional computed tomography.

A comprehensive classification of midfacial/craniofacial fractures, based on two- and three-dimensional computed tomography (2D and 3D-CT) is presented. We performed a postmortem analysis of 24 patients who had died from trauma with signs of craniofacial fractures, based on 2D and 3D-CT studies with pathoanatomical findings. In addition, CT findings for 100 patients with craniofacial injuries requiring an emergency CT were correlated with surgical findings and follow-up results. On the basis of the analysis of a total of 377 fractures a classification system is proposed. The system is based on the use of the AO/ASIF (Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation) scheme, defining three types (A, B, C), three groups within each type (e.g. A1, A2, A3) and three subgroups within each group (e.g. A1.1, A1.2, A1.3) with increasing severity from A1.1 (lowest) to C3.3 (highest). The craniofacial region is divided into three units: the lower midface (I), the upper midface (II) and the craniobasal-facial unit (III). Lateral and central fractures are also distinguished. Type A fractures are non-displaced fractures, type B are displaced fractures and type C are complex/defect fractures. Groups A1, B1 and C1 comprise fractures of an isolated unit; groups A2, B2 and C2, combined fractures without involvement of the skull base; and groups A3, B3 and C3 are those combined fractures with involvement of the skull base. A correlation between the severity of the fracture and (i). the number of posttraumatic functional limitations (Spearman rank test, correlation coefficient r=0.42), (ii). the need for bone grafting or dural plastic (r=0.39) and (iii). facial asymmetry (r=0.37), was observed. The proposed classification system allows standardised documentation of midfacial and craniofacial fractures, including those not precisely defined by the Le Fort classification scheme.

Le Fort fracture of skull

A Le Fort fracture of the skull is a classic transfacial fracture of the midface, involving the maxillary bone and surrounding structures in either a horizontal, pyramidal or transverse direction. The hallmark of Lefort fractures is traumatic pterygomaxillary separation, which signifies fractures between the pterygoid plates, horseshoe shaped bony protuberances which extend from the inferior margin of the maxilla, and the maxillary sinuses. Continuity of this structure is a keystone for stability of the midface, involvement of which impacts surgical management of trauma victims, as it requires fixation to a horizontal bar of the frontal bone. The pterygoid plates lie posterior to the upper dental row, or alveolar ridge, when viewing the face from an anterior view. The fractures are named after French surgeon René Le Fort (1869–1951), who discovered the fracture patterns by examining crush injuries in cadavers. Signs and symptoms

Dislocation of jaw

may be fractured. Superior dislocations occur after being punched below the mandibular ramus as the mouth remains half-open. Since great force occurs in a punch, the angle of the jaw will be forced upward moving towards the condylar head. This can result in a fracture of the glenoid fossa and displacement of the condyle into the middle cranial fossa, potentially injuring the facial and vestibulocochlear nerves and the temporal lobe. Lateral dislocations move the mandibular condyle away from the skull and are likely to happen together with jaw fractures.

Dislocation of jaw

There are four different positions of jaw dislocation: posterior, anterior, superior and lateral. The most common position is anterior, while the other types are rare. Anterior dislocation shifts the lower jaw forward if the mouth excessively opens. This type of dislocation may happen bilaterally or unilaterally after yawning. The muscles that are affected during anterior jaw dislocation are the masseter and temporalis which pull up on the mandible and the lateral pterygoid which relaxes the mandibular condyle. The condyle can get locked in front of the articular eminence. Posterior dislocation is possible for people who get injured by being punched in the chin. This dislocation will push the jaw back affecting the alignment of the mandibular condyle and mastoid. The external auditory canal may be fractured. Superior dislocations occur after being punched below the mandibular ramus as the mouth remains half-open. Since great force occurs in a punch, the angle of the jaw will be forced

Battle's sign

Battle's sign, also known as mastoid ecchymosis, is an indication of fracture of middle cranial fossa of the skull. These fractures may be associated with underlying brain trauma. Battle's sign consists of bruising over the mastoid process as a result of extravasation of blood along the path of the posterior auricular artery. The sign is named after William Henry Battle. Battle's sign takes at least one day to appear after the initial traumatic basilar skull fracture, similar to raccoon eyes. It is usually seen after head injuries resulting in injury to mastoid process leading to bruising. Battle's sign may be confused with a spreading hematoma from a fracture of the mandibular condyle, which is a less serious injury. See also Basilar skull fracture Raccoon eyes Black eye References Traumatology Injuries

Facial trauma

Signs and symptoms Fractures of facial bones, like other fractures, may be associated with pain, bruising, and swelling of the surrounding tissues (such symptoms can occur in the absence of fractures as well). Fractures of the nose, base of the skull, or maxilla may be associated with profuse nosebleeds. Nasal fractures may be associated with deformity of the nose, as well as swelling and bruising. Deformity in the face, for example a sunken cheekbone or teeth which do not align properly, suggests the presence of fractures. Asymmetry can suggest facial fractures or damage to nerves. People with mandibular fractures often have pain and difficulty opening their mouths and may have numbness in the lip and chin. With Le Fort fractures, the midface may move relative to the rest of the face or skull.

Comparison of accuracy of computed tomography scan and ultrasonography in the diagnosis of mandibular fractures.

Ultrasonography (USG) allows to the examination of soft tissue and osseous tissues in the head-and-neck region. This study compared the accuracy of USG and computed tomography (CT) scan in the diagnosis of mandibular fractures. In this prospective observational study, spiral CT scan was prescribed for the lower face and, if necessary, midface and upper face in 42 trauma patients suspected of mandibular fractures, referring to Imam Reza Hospital in Tabriz. Two radiologists evaluated the CT scans. Then, another radiologist examined all the patients with USG with a frequency of 7-12 MHz. Ultrasonographic diagnostic results were recorded and compared with the results of the CT scan examinations. The results were reported using descriptive statistical methods. The specificity and sensitivity of USG were 100% and 91.1%, respectively. The USG sensitivities in the angle, condyle, condylar neck, and symphysis fractures were 100%, 91.6%, 85.7%, and 80%, respectively, and the specificity was 100% in all that anatomical regions. Among the confounding factors, the sensitivity of the USG (84.6%) was the lowest in the presence of hematoma; however, its specificity remained 100%. One case of symphysis fracture was not detected in the absence of any confounding factors in USG examination. Although the sensitivity, specificity, and diagnostic accuracy of the USG were at high levels, there were some limitations, making it difficult to definitively replace USG with CT scans, especially in the case of condylar fractures and in the presence of confounding factors such as hematoma and swelling.

Radiology of maxillofacial trauma.

There has been a rising incidence of maxillofacial injuries during the past decade as a result of an increasing number of assaults and motor vehicle accidents. The maxillofacial region is one of the most complex areas of the human body, and the radiographic imaging of this region becomes even more difficult in traumatized patients because of their clinical condition and their inability to cooperate. Imaging modalities used in the evaluation of the traumatized maxillofacial region include conventional (plain) films, tomography, panoramic radiography, computed tomography, three-dimensional computed tomography, DentaScan, and magnetic resonance imaging. Each modality is discussed with regard to technique, advantages, and disadvantages. Plain films and computed tomography, the modalities that are used most in evaluating maxillofacial structures, are discussed in more detail. The normal anatomy and radiologic features are presented for both of these modalities. Radiographic evaluation of maxillofacial injury begins with a knowledge of the direct and indirect radiographic signs of injury seen on most imaging modalities. Computed tomography also has allowed a method of classifying facial fractures that is based on the involvement of the facial buttresses or struts. Three horizontal, two coronal, and five sagittal oriented struts are described. Limited fractures are differentiated from transfacial fractures by the lack of involvement of the pterygoid plates in the limited fractures. Limited fractures also can be subclassified as solitary (fracture of a single strut) or complex (fractures of multiple struts). A portion of the orbit is involved in almost every form of facial fracture; therefore, evaluation of facial injuries should always include the orbital structures. Although both can occur simultaneously, orbital injuries can be divided into soft tissue and bony vault injuries. Similar to midface fractures, orbital fractures also can be classified as solitary (fracture involves a single wall) or complex (fracture involves more than one wall or a part of a midface fracture). Computed tomography is of great value in evaluating both forms of injury. Magnetic resonance imaging is becoming increasingly important in the evaluation of orbital soft tissue injuries. Classification of midface injuries includes the solitary strut fractures and the complex strut fractures. Solitary strut fractures include fractures of the nasal arch, zygomatic arch, and isolated sinus wall fractures. Complex strut fractures include the nasal complex fractures, zygomatic (tripod) and zygomaticomaxillary fractures, transfacial fractures (LeFort fractures), and facial smash fractures. Each fracture type and its radiographic appearance are discussed.(ABSTRACT TRUNCATED AT 400 WORDS)

Facial trauma

At the beginning of the 20th century, René Le Fort mapped typical locations for facial fractures; these are now known as Le Fort I, II, and III fractures (right). Le Fort I fractures, also called Guérin or horizontal maxillary fractures, involve the maxilla, separating it from the palate. Le Fort II fractures, also called pyramidal fractures of the maxilla, cross the nasal bones and the orbital rim. Le Fort III fractures, also called craniofacial disjunction and transverse facial fractures, cross the front of the maxilla and involve the lacrimal bone, the lamina papyracea, and the orbital floor, and often involve the ethmoid bone, are the most serious. Le Fort fractures, which account for 10–20% of facial fractures, are often associated with other serious injuries. Le Fort made his classifications based on work with cadaver skulls, and the classification system has been criticized as imprecise and simplistic since most midface fractures involve a combination of Le Fort fractures.

Surgical treatment on displaced and dislocated sagittal fractures of the mandibular condyle.

The purpose of this study was to evaluate the effect of surgical treatment on displaced and dislocated sagittal fractures of the mandibular condyle (SFMC). Twenty-four patients with 28 displaced and dislocated SFMCs were distinguished into type M, type C, and type L fractures according the location of the fracture line. The fractured fragment was reduced and fixated with two 0.6-mm 4-hole micro-plates via a preauricular temporal incision. The fragment was extirpated when it was too small to be fixated. The postoperative position and profile of the fragment was examined by orthopantomogram radiograph or computed tomography (CT). The function of the temporal and zygomatic branches of the facial nerve was inspected. The occluding relation was surveyed, the interincisal distance at maximum mouth opening was measured, and the deviation from the midline during mouth opening was recorded. Twenty-three condyles (82%) suffered dislocated fractures with the condylar fragment out of the glenoid fossa. Five condyles (18%) were displaced, but not dislocated. There were 2 (7%) type M, 19 (68%) type C (3 comminuted), and 7 (25%) type L fractures (1 comminuted), respectively. Twenty-one (75%) fractured fragments received free-graft procedures with 2 micro-plates. Four (14%) fragments were reduced and fixated without being dissected free of their attachments. Three (11%) fragments were extirpated. There were no permanent facial never branch injuries. Micro-plate removal was necessary because of postoperative infection and necrosis of the fractured fragment in 1 condylar process. No other patients could be found with obvious postoperative bone resorption. The average postoperative maximum mouth opening and deviation at 6 months were improved significantly. The postoperative occlusion was good in 22 cases. Access with the preauricular incision, and the dislocated and displaced fragment can be reduced and fixated to its normal position easily. Free-graft procedure is a suitable surgical treatment if the fractured fragment cannot be reduced without dissection free of the pterygoid muscle attachment. Although most fractured fragments in SFMCs have to be dissected free, there are no obvious complications in dislocated and displaced SFMCs after surgical treatment.

Mandible

Clinical significance Fracture One fifth of facial injuries involve a mandibular fracture. Mandibular fractures are often accompanied by a 'twin fracture' on the opposite side. There is no universally accepted treatment protocol, as there is no consensus on the choice of techniques in a particular anatomical shape of mandibular fracture clinic. A common treatment involves attachment of metal plates to the fracture to assist in healing. The mandible may be dislocated anteriorly (to the front) and inferiorly (downwards) but very rarely posteriorly (backwards). The articular disk of the temporomandibular joint prevents the mandible from moving posteriorly, making the condylar neck particularly vulnerable to fractures.

[Sagittal fracture of mandibular condyle: a review of 151 cases].

<bObjective:</b A retrospective research was made to summarize the clinical characteristics, treatment methods, results of the adult cases with sagittal fracture of mandibular condyle (SFMC). <bMethods:</b One hundred and fifty-one cases of hospitalized patients were enrolled. The age, sex, etiology, level of fracture, degree of displacement, associated facial fractures, treatment methods and results were retrospectively analyzed. <bResults:</b The patient's age ranged from 16 to 81 years old, with a median age of 38.5 years. The male to female ratio was 2.97∶1. The most involved age group was 20-29 years old [35.1% (53/151)]. Falls [53.6% (81/151)] were the most common cause. According to the classification of He (2009) and Duan (2011), the most common type of SFMC was type A [60.5% (130/215)] and the displacement type [80.9% (174/215)]. Eighty-six point zero percent (185/215) of SFMC were treated by surgery. The surgical rates of type A, B and M fractures were 91.5% (119/130), 79.6% (43/54) and 88.5% (23/26), with significant differences between the groups (<iP</i<0.05). The surgical rates of the displacement and dislocation type were 89.7% and 100%, with significant differences. The differences between the fixations of type A, type B and type M fractures were statistically significant. The follow-up results showed that, 78.7% (59/75) of patients treated with surgery had normal occlusion, no joint symptoms and no limited mandibular movement. Patients treated with conservative therapy had good occlusion and an average maximum mouth opening of 36.25 mm with malunion occurred in 5/6 of the condyles. <bConclusions:</b Under appropriate surgical indications, surgical treatment of SFMCs could achieve significantly better outcomes than conservative treatment.

Operator Experience and Fracture Location Affects the Rate of Facial Nerve Injury in Condylar Fractures: An Analysis of 89 Cases.

The purpose of this study was to measure the frequency and identify risk factors for facial nerve injury (FNI) in the open treatment of condylar neck and subcondylar fractures. A prospective cohort study was conducted over 5 years on patients who were treated surgically for mandibular condylar fractures using the retomandibular transparotid approach (RMTA). The primary result was FNI occurrence (yes/no). The predictor variables were demographic, fracture location, and pattern (dislocation, present or not), as well as surgeon experience. Post-treatment functional facial nerve changes were initially assessed in the operating room as the patient regained consciousness and documented thereafter within, the 1st and 3rd weeks, and 3rd and 6th months. Appropriate statistics were computed and, SPSS version 16 was used to analyze the data. χ<sup2</sup test and Fisher exact test were used to assess significance (P ≤ 0.05). Eighty-nine patients with 102 condylar fractures (63 subcondylar and 26 condylar neck), with a mean age of 28.5±7.5 years and 91% men were evaluated. There were 15 subjects (16.8%) with FNI and among them 6 subjects had persistent facial weakness for 6-8 weeks that completely resolved within 3 months, with no permanent facial nerve paralysis. The marginal mandibular (n = 7), buccal (n = 6), and zygomatic (n = 2) were the facial nerve branches involved. Risk factors for FNI were operator' inexperience, fracture-dislocation, and condylar neck fracture to the site and location of the fracture. Multivariate logistic regression showed that the location of the fracture at neck level (0.030∗), fracture dislocation (<0.001∗), and operator's inexperience (0.003∗) were significant risk factors for postoperative facial nerve injury (P ≤ 0.05). If conducted properly, the RMTA is a safe method for treating condylar fractures with rare major complications; however, fracture dislocation, fractured condylar neck, and operator' in-experience were significantly associated with increased risk of developing transient postoperative FNI.

Mandibular fracture

Epidemiology Mandible fracture causes vary by the time period and the region studied. In North America, blunt force trauma (a punch) is the leading cause of mandible fracture whereas in India, motor vehicle collisions are now a leading cause. On battle grounds, it is more likely to be high velocity injuries (bullets and shrapnel). Prior to the routine use of seat belts, airbags and modern safety measures, motor vehicle collisions were a leading cause of facial trauma. The relationship to blunt force trauma explains why 80% of all mandible fractures occur in males. Mandibular fracture is a rare complication of third molar removal, and may occur during the procedure or afterwards. With respect to trauma patients, roughly 10% have some sort of facial fracture, the majority of which come from motor vehicle collisions. When the person is unrestrained in a car, the risk of fracture rises 50% and when an unhelmeted motorcyclist the risk rises 4-fold.

[X-ray and clinical characteristics in sagittal fracture of the mandibular condyle].

To study the X-ray and clinical characteristics in sagittal fracture of the mandibular condyle (SFMC). 14 cases (15 sides) of SFMC in 48 cases who had condylar fractures were studied in the research, every patient was examined by the conventional x-ray, 2D-CT and 3D-CT, and followed up for 3-39 months. The fracture line mainly passed through lateral 1/3 and middle 1/3 of anterior condyle and the middle 1/3 of posterior condyle. Following-up (3-39 months) showed that the patients' occlusions were normal in all cases. The fracture line mainly located in the lateral pterygoid muscle fossa. Good results can be gotten by effective treatment. The 2D-CT and 3D-CT are valuable to the diagnosis.

Mandibular fracture

Other symptoms may include loose teeth (teeth on either side of the fracture will feel loose because the fracture is mobile), numbness (because the inferior alveolar nerve runs along the jaw and can be compressed by a fracture) and trismus (difficulty opening the mouth). Outside the mouth, signs of swelling, bruising and deformity can all be seen. Condylar fractures are deep, so it is rare to see significant swelling although, the trauma can cause fracture of the bone on the anterior aspect of the external auditory meatus so bruising or bleeding can sometimes be seen in the ear canal. Mouth opening can be diminished (less than 3 cm). There can be numbness or altered sensation (anesthesia/paraesthesia in the chin and lower lip (the distribution of the mental nerve).

[Statistical notes on sinusal fractures of the face].

Factors of age, sex, localization and associated lesions were analyzed for 9 319 cases of fractures of the face, using data collected by the Army Computer Centre for Medical Data Processing.

Dislocation of jaw

Posterior, superior and lateral dislocations are uncommon injuries and usually result from high-energy trauma to the chin. By contrast, anterior dislocations are more often the result of low-energy trauma (e.g. tooth extraction) or secondary to a medical condition that affects the stability of the joint (e.g. seizures, ligamentous laxity, degeneration of joint capsule). Diagnosis As with other joint dislocations, clinical history and examination are crucial for diagnosis of a jaw dislocation. Commonly, plain and panoramic X-ray radiographies are used to determine the relative position of the mandibular condyle. If a complex or unusual injury is suspected, three-dimensional computed tomography is most reliable in diagnosing dislocation and possibly associated fractures or soft tissue injuries.

Unilateral medial dislocation of the temporomandibular joint.

We present our experience of the rare condition of unilateral medial dislocation of the temporomandibular joint (TMJ) in 11 patients with head trauma who had received a direct lateral blow on the chin. The diagnosis was made by direct coronal CT of the TMJ performed from 6 h to 7 days following the injury. In 6 patients, subcondylar fracture of the ipsilateral mandibular ramus was also demonstrated. A second CT performed 11-16 months following the first one demonstrated pseudoarthrosis of the fractured ramus in these 6 patients. The second CT was identical to the first in the remaining 5 patients with pure dislocation of the condyle. All patients suffered from severe disability of the TMJ. The maximal vertical distance between the upper and lower incisors in patients with uncomplicated dislocation ranged between 8 and 12 mm. In cases with complicated medial condylar dislocation with fracture and pseudoarthrosis of the mandibular ramus, this distance ranged between 16 and 25 mm, probably because of additional movement in the area of the pseudoarthrosis. The maximal vertical distance between the incisors was compared with a control group of 20 normal adults who had values from 40 to 52 mm. Medial unilateral dislocation of the TMJ can appear in two forms: uncomplicated or complicated, with pseudoarthrosis of the ipsilateral mandibular ramus.

[The diagnosis of condylar process fractures].

The detection of condylar process fractures by clinical examination and the interpretation of radiographs belong to the stomatologist's diagnostic tasks. On the contrary, the exact location of the fracture lines and the recognition of the types of proximal fragment displacement often present problems. Diagnostic errors may also occur, mainly resulting from radiological illusions. The comprehensive evaluation of the data from 3027 patients with injuries of the facial bones, involving 1050 condylar process fractures, and the verification of the relevant radiological findings permitted to determine the location of the fracture lines and the types of fragment displacement, to recognize misinterpretations and to give suggestions for establishing a definite diagnosis.

[Sagittal fracture of the mandibular condyle (SFMC): its clinical image diagnosis].

Each of 12 SFMC patients (13 TMJs) underwent 8 X-ray examinations. It was found that SFMCs were easily missed from the conventional X-ray views, while CPMOT (Condyle pterygoid-maxillo oblique tomography) and CT were effective to demonstrate them. The reasons for SFMCs' being missed from the conventional views are discussed. It is concluded that the best procedure to show a possible SFMC is: the reversed Town's view-->TMJ coronal tomography or CPMOT-->CT (using coronal or CPMOT sections as the first choice). The authors declare that SFMC could not be explained by the acknowledged theory that the neck of condyle is a safety mechanism to protect the brain.


This question could be controversial. Option 1 is strongly discarded because endophthalmitis typically presents with a lot of pain. Option 3 of wet form of age-related macular degeneration is also ruled out, because it usually occurs in older patients, although what a patient with myopia magna may present with is myopic macular degeneration (with a similar clinical picture to AMD, but this is a different pathology). A posterior vitreous detachment (PVD) is usually not very symptomatic, producing myodesopsias but no loss of vision or pain; however, some PVDs are of the hemorrhagic type, by traction of the vessels, producing a vitreous hemorrhage that would cause loss of vision. In any case, due to the history of myopia magna and previous intraocular surgery, the first diagnosis to rule out would be retinal detachment, since these are two risk factors for this pathology. Technically, both option 2 and 4 (an acute hemorrhagic DPV) could cause these symptoms, but the most correct option is option 2 (and I am sure it is the one the examiner wants answered).

This question could be controversial. Option 1 is strongly discarded because endophthalmitis typically presents with a lot of pain. Option 3 of wet form of age-related macular degeneration is also ruled out, because it usually occurs in older patients, although what a patient with myopia magna may present with is myopic macular degeneration (with a similar clinical picture to AMD, but this is a different pathology). A posterior vitreous detachment (PVD) is usually not very symptomatic, producing myodesopsias but no loss of vision or pain; however, some PVDs are of the hemorrhagic type, by traction of the vessels, producing a vitreous hemorrhage that would cause loss of vision. In any case, due to the history of myopia magna and previous intraocular surgery, the first diagnosis to rule out would be retinal detachment, since these are two risk factors for this pathology. Technically, [HIDDEN].

A 47-year-old man with myopia magna, who underwent cataract surgery 2 years ago, comes to the emergency room reporting a profound and painless loss of vision in his right eye. Which of the following diagnoses can cause this symptomatology?

Age-related macular degeneration, wet form.

[Posterior vitreous detachment and cystoid macular oedema post-cataract surgery: a case report].

The posterior vitreous detachment consists in the separation between the posterior vitreal cortex and internal limiting membrane of the retina. This is the peak of the vitreal para-physiological age-related modifications. This problem occurs in 6% of normal people of age between 45 and 65 years and in 65% of individuals between 65 and 85 years. Several elements can be responsible for vitreous modifications, such as senility, myopia, aphakia, pseudophakia, diabetes, degeneration vitreous retinal hereditary, traumatisms, inflammation. A 75 year old male patient has come to our attention for a left eye cataract. He has undergone to a series of OCT: the first before surgery showed a perifoveal vitreous detachmen; the following ones until six months after surgery put in evidence the DPV progression accompanied by EMC, relating it with visual symptomatology. Therefore, OCT is a useful tool for a clinical analysis but also for the contribution to research concerning the pathogenesis of diseases due to vitreo-retinal modification.

Retinal detachment

Retinal detachment is more common in those with severe myopia (above 5–6 diopters), as their eyes are longer, their retina is thinner, and they more frequently have lattice degeneration. The lifetime risk increases to 1 in 20. Myopia is associated with 67% of retinal detachment cases. Patients suffering from a detachment related to myopia tend to be younger than non-myopic detachment patients. Retinal detachment can occur more frequently after surgery for cataracts. The estimated of risk of retinal detachment after cataract surgery is 5 to 16 per 1000 cataract operations. The risk may be much higher in those who are highly myopic, with a frequency of 7% reported in one study. Young age at cataract removal further increased risk in this study. Long term risk of retinal detachment after extracapsular and phacoemulsification cataract surgery at 2, 5, and 10 years was estimated in one study to be 0.36%, 0.77%, and 1.29%, respectively.

Bilateral Retinal Detachments in a Healthy 22-year-old Woman After Moderna SARS-COV-2 Vaccination.

Although uncommon, retinal detachments are medically urgent and can result in permanent vision loss if untreated. Bilateral retinal detachments in healthy individuals are even more rare. In addition, there are no cases to date of retinal detachment associated with either coronavirus disease 2019 (COVID-19) or after receiving the Moderna (mRNA-1273) severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) vaccine. A 22-year-old woman with myopia but no ocular trauma or other major medical history presented to the emergency department with 5 days of progressive, painless vision loss in her right eye. On examination, her visual acuity with corrective lenses was 20/70 in the right eye, 20/20 in the left eye, and 20/25 with both eyes open. Point-of-care ultrasound of the eye showed a retinal detachment in the right eye. She was subsequently seen by ophthalmology and diagnosed with bilateral retinal detachments (macula off in the right, macula on in the left), despite being asymptomatic in her left eye. She underwent bilateral vitrectomies for simultaneous rhegmatogenous retinal detachments. Although the patient denied any preceding trauma, she did note having received her second dose of the COVID-19 vaccine 10 days before the onset of symptoms.Why Should an Emergency Physician Be Aware of This? We present a rare and unusual case of simultaneous bilateral retinal detachments in a healthy, young woman with no major medical history or medications. She received the COVID-19 vaccine a few days prior. Our case outlines a possible association with the vaccine and emphasizes the importance of ultrasonography in diagnosing time-sensitive medical conditions.

[Pseudophakic retinal detachment].

Modern phacoemulsification has established itself as a safe and very rewarding surgical procedure. Patients and surgeons may not associate late complications with the initial surgery. However, recent studies have demonstrated that such a causal relationship may persist for many years after the cataract procedure and that there is a significant increase in the risk for developing a retinal detachment during the postoperative years. The mean time period between cataract surgery and pseudophakic retinal detachment is between 3 and 4 years. Even uncomplicated cataract surgery alters the physiological processes within the eye and can lead to progressive destruction of the vitreous for many years after the surgery. Therefore, the risk for a retinal detachment is increased for at least 10 years after the initial procedure. In recent epidemiological studies, the most important risk factors for pseudophakic retinal detachment were myopia, younger age and male gender. If all factors are combined, the cumulative risk for developing a retinal detachment after cataract surgery may rise to 20 %. Additional factors that may increase this risk are additional intraoperative complications, for example, rupture of the posterior capsule, vitreous loss or dropped nucleus. Compared to phakic retinal detachments, pseudophakic patients on average present with a shorter history of visual symptoms, are older, more commonly male and display fewer, smaller and more anteriorly located retinal breaks that frequently are only detected during surgery. The anatomic success rates have improved significantly over the past years, in particular through the advances and increasing popularity of primary vitrectomy. However, functional results are still disappointing. Only about half of the patients will achieve reading ability without low vision aids. The increased and long-term risk for pseudophakic retinal detachment should be part of the preoperative consent process of any cataract surgery, in particular, in young myopic males.

Posterior vitreous detachment

Age and refractive error play a role in determining the onset of PVD in a healthy person. PVD is rare in emmetropic people under the age of 40 years, and increases with age to 86% in the 90s. Several studies have found a broad range of incidence of PVD, from 20% of autopsy cases to 57% in a more elderly population of patients (average age was 83.4 years). People with myopia (nearsightedness) greater than 6 diopters are at higher risk of PVD at all ages. Posterior vitreous detachment does not directly threaten vision. Even so, it is of increasing interest because the interaction between the vitreous body and the retina might play a decisive role in the development of major pathologic vitreoretinal conditions, such as epiretinal membrane. PVD may also occur in cases of cataract surgery, within weeks or months of the surgery.

[Stability of posterior chamber lenses 3-5.5 years after implantation in capsular rupture].

In cases of PC-IOL implantation and ruptured capsule there will be a higher risk of the lens loosening into the vitreous, although many successful cases have been reported. Three years ago we investigated 42 eyes with PC-IOL that had experienced previous posterior capsular or zonular rents and partial vitreous loss. Three to 5.5 years after PC-IOL implantation we have now performed a second investigation on 38 of these patients to examine fixation of the lenses, visual acuity, intraocular pressure and the fundus of the eye. The 38 lenses all remained stable. The rate of patients achieving 20/40 or better visual acuity decreased from 68% at the first investigation to 55% (21/38). Excluding all patients with vision-limiting preoperative conditions such as age-related macular degeneration, we found a relation-ship of 83% to 75% (21/28). In addition to the three retinal detachments and two cases of endophthalmitis found during the first investigation, we also found another retinal detachment at the follow-up examination. Only two of these six eyes with severe complications had useful vision. We conclude from our investigation that PC-IOL implanted following a posterior capsule-zonular break during ECCE can remain stable, but still lead to serious complications.

Two-year results of surgical removal of choroidal neovascular membranes related to non-age-related macular degeneration.

To present the 2-year outcomes of surgical removal of non-age-related macular degeneration (AMD)-related choroidal neovascular membranes and to evaluate any association between visual outcome and baseline clinical factors. Retrospective consecutive case series. All patients who had surgery for non-AMD-related choroidal neovascularisation (CNV) between November 1997 and March 2003 under the care of a single surgeon (WA) were included in the study. Baseline data including patient age, duration of subfoveal CNV, preoperative visual acuity (VA), lesion size, lesion components and aetiology were collected. The primary outcome was VA change with secondary outcomes retinal detachment, operative peripheral retinal break formation, CNV recurrence and cataract. A total of 52 eyes were included in the study. The aetiology of CNV was: punctate inner choridopathy 21 (40%); idiopathic 8 (15%); pathologic myopia 6 (12%); ocular histoplasmosis syndrome 1 (2%); and other 16 (31%). The mean age of patients was 41(range 14-72) years. 24-month follow-up was available for 41 (80%) eyes. The mean logMAR equivalent baseline acuity was 1.1 and mean lesion size 1.2 disc areas. An improvement in VA >1 Snellen line was noted in 26 (63%) eyes, whereas 10 (24%) eyes remained the same (within 1 line) and 5 (12%) lost >1 line of acuity. Improvement in VA was associated with worse baseline VA (84% for eyes with VA <or=6/36 vs 31% for those with VA>6/36, p=0.001). No evidence of association between 2-year visual outcome and any other baseline factor under study was observed. Peripheral retinal breaks were noted in 5 (10%) eyes at the time of surgery, and 3 (5.8%) eyes developed postoperative retinal detachments. Persistent/recurrent CNV was noted in 17 (33%) eyes. The median time to presentation of CNV in these eyes was 27 (range 2-172) weeks. Five eyes underwent cataract surgery during the follow-up period. The mean age of these patients was significantly higher than the mean age of those who did not require cataract surgery (57 vs 37 years, p=0.014). Surgical excision of non-AMD-related CNV resulted in improvement of VA in the majority of eyes. Worse presenting acuity was associated with better visual improvements.

[Macular translocation--first experience].

The age related macular degeneration (ARMD) is the most common cause of the central visual acuity loss in persons of age more than 60 years in the well developed countries. Rotation of the macula is nowadays a progressive method of choice of treatment of the exsudative form of ARMD. The aim of this surgical technique is to relocate the neuroretinal epithelium of the central region of the retina to a position situated outside the border of the subfoveolar lesion. Three eyes of three patients (2 woman and one man) were operated on during the period between March and May 2001 at the Department of Ophthalmology of the School of Medicine, Charles University in Pilsen. The method used was the scleral imbrication, which belongs to methods designated as "limited translocation". The mean age of the patients was 62 years and the follow up period was 2 years. After the surgery the relocation of the fovea was observed in all three eyes. In two eyes, the postoperative period was complicated by tractional retinal detachment that occurred three weeks after the surgery as a consequence of progressive proliferative vitreoretinopathy (PVR). Both eyes with the retinal detachment were re-operated. In both of them, the repeated pars plana vitrectomy, epiretinal membranes removal with relaxing retinectomy was performed and after maximal mobilization of the retina, the silicone oil implantation followed. In the second patient, the postoperative period was complicated by elevation of the intraocular pressure and a radial retinal fold running from the encircling buckle indentation up to the macula. Slightly improved function was noticed only in the first patient after following cataract surgery with intraocular lens implantation. In the two other eyes, as noticed at the last follow up check, the postoperative complications caused severe decrease of the central visual acuity although the retina remained attached. Macular translocation procedure is in stage of development and its surgical techniques are being further modified. The risk of postoperative complications with profound loss of central visual acuity corresponds to the level of the technical difficulty and extent of surgical intervention.

Atul Kumar (ophthalmologist)

Achievements and positions Kumar is a specialist in diseases of the retina, vitreous and uvea and their management. His academic disciplines include Vitreoretinal surgery, Ophthalmic Lasers, Uveal diseases, Macular Hole surgery, anti-VEGF injections, Age Related Macular Degeneration, Retinal Detachment surgery, Myopic Traction Maculopathy, Pathological Myopia and Macular Hole Retinal Detachment.

Fellow eye findings of highly myopic subjects operated for retinal detachment associated with a macular hole.

To identity anatomic risk factors involved in the onset of retinal complications causing decrease of visual acuity (VA) in the fellow eyes of highly myopic patients operated for retinal detachment with macular hole (RDMH). Cohort study. Ninety-eight patients (mean age, 51.5+/-8.0 years) with bilateral high myopia (mean myopia of the fellow eye, 20.4+/-5.5 diopters) affected by RDMH in the other eye at baseline. Evaluation of the anatomic features at baseline and during 84+/-2.7 months of follow-up by biomicroscopic examination, indirect binocular ophthalmoscopy, B-scan ultrasonography, and optical coherence tomography. Detection of anatomic features associated with onset of retinal complications causing decrease of VA during the follow-up period. The fellow eyes were divided into 2 groups according to the clinical features of the RDMH eyes: Group 1, presence of posterior vitreous detachment (PVD); and Group 2, presence of posterior vitreous schisis (PVS). At baseline, the incidence of PVD in group 1 was 31 of 47 eyes (65.9%) and the incidence of PVS in Group 2 was 42 of 51 eyes (82.3%). At the end of follow-up, group 1 eyes had a lower incidence of retinal complications causing visual decrease than group 2 eyes (group 1, 2/47 eyes; group 2, 9/51 eyes). Fellow eyes of RDMH cases with higher degree of myopia and peculiar vitreoretinal features including PVS, posterior epiretinal membrane, severe posterior staphyloma, and chorioretinal atrophy are more likely to develop retinal complications causing decrease of VA.

Acute visual loss

Acute visual loss is a rapid loss of the ability to see. It is caused by many ocular conditions like retinal detachment, glaucoma, macular degeneration, and giant cell arteritis, etc. Main causes Retinal detachment Retinal detachment should be considered if there were preceding flashes or floaters, or if there is a new visual field defect in one eye. If treated early enough, retinal tear and detachment can have a good outcome. Glaucoma Angle-closure glaucoma should be considered if there is painful loss of vision with a red eye, nausea or vomiting. The eye pressure will be very high typically greater than 40 mmHg. Emergent laser treatment to the iris may prevent blindness. Macular degeneration Wet macular degeneration should be considered in older people with new distortion of their vision with bleeding in the macula. Vision can often be regained with prompt eye injections with anti-VEGF agents. Giant cell arteritis

Retinal Detachment in 31 Eyes with Retinitis Pigmentosa.

To describe clinical features and treatment outcomes of retinal detachment (RD) in eyes with retinitis pigmentosa (RP). Single-center, retrospective, interventional case series. All RP patients with RD examined between April 2003 and December 2013 and minimum 2 months of follow-up. Medical records of RP patients were screened and 31 eyes with RD were included. Family history of RP, duration of symptoms, age at presentation, associated ocular and systemic findings, and detailed ophthalmic evaluation including presenting visual acuity, type and amount of refractive error, fundus findings, electroretinogram details, surgical details, and postoperative complications and outcomes were evaluated. Univariate analysis was done to determine risk factors associated with RD in eyes with RP and risk factors associated with poor visual outcomes after treatment. Subset analysis was also done for comparing the functional and anatomical outcomes between patients undergoing scleral buckling or vitrectomy. Final surgical reattachment rate, best-corrected visual acuity. Mean age at presentation was 22 years (median, 17; range, 4-63). Mean duration of symptoms was 12 months (median, 3 months: range, 3 days-60 months). Associated ocular findings included nyctalopia (n = 23), myopia (n = 21), and hyperopia (n = 10). Systemic associations included hearing loss (n = 5), deaf-mutism (n = 1), and Bardet-Biedel syndrome (n = 1). No association between degree of myopia and RD was noted (P = 0.63). Observed retinal breaks included horse-shoe-shaped tear (n = 15), lattice with hole (n = 7), atrophic retinal hole (n = 3), retinal dialysis (n = 3), and macular hole (n = 3). The most common location of breaks was superotemporal quadrant (n = 15). Younger age, male gender, and presence of posterior vitreous detachment were strongly associated with RD with odds ratio of 1.3 (P = 0.001), 8.3 (P = 0.010), and 6 (P = 0.003), respectively. Retinal reattachment was achieved in 13 of 13 eyes (100%) with scleral buckle and 9 of 10 eyes (90%) with vitrectomy. Vision improved from 1.63±0.52 to 0.87±0.25 logarithm of the minimum angle of resolution (P < 0.001) at a mean follow-up of 33 months (median, 24, range; 1-145). Rhegmatogenous RD in eyes with RP is rare. Precocious vitreous degeneration and sparse pigmentation in younger male patients has a role in etiopathogenesis. Visual prognosis remains poor despite satisfactory surgical outcomes.

Incidence of Retinal Detachment after Macular Surgery.

Macular surgery has become an increasingly atraumatic procedure for the eye with the surgical methods that have been further developed in recent years. The most common complications include cystoid macular oedema and retinal detachment, more rarely endophthalmitis. The aim of this retrospective study is to record the number of retinal detachments following elective macular surgery. In this study we included all patients who underwent pars plana vitrectomy (ppV, 20 or 25 gauge) in the years 2009 - 2016. We then identified the patients who were hospitalised again because of retinal detachment. For the affected patients, the rate of retinal detachment, functional outcomes and possible risk factors were recorded. A total of 904 eyes were identified, of which 667 had surgery for epiretinal membrane, 188 for macular hole, and 49 for vitreomacular traction with a 20 or 25 gauge ppV. Of these 904, retinal detachment occurred in 17 (1.88%) cases. The mean time between first ppV and second ppV with retinal detachment was 248 days (3 - 1837 days). Two of the 17 patients had at least one retinal break before or during surgery. The retinal break was located inferior in six cases, superior in four; in four cases PVR retinal detachment and in three cases the foramina were distributed. Mean visual acuity was 0.27 (decimal) before macular surgery and 0.28 at the time of last presentation. Modern vitrectomy techniques reduce the complications in elective macular surgery, but do not replace the surgeon's experience.

Posterior pole retinal breaks causing posterior pole retinal detachment in a middle-aged man with retinal vasculitis and moderate myopia.

A 38-year-old man presented with sudden decreased vision in the right eye 3 years ago due to vitreous haemorrhage. During follow-up, right eye fundus showed evidence of vasculitis, non-perfusion areas and neovascularisation elsewhere. Systemic evaluation findings of positive Mantoux test, QuantiFERON Gold test and right apical pleuroparenchymal fibrosis observed on high-resolution CT of the chest were suggestive of postinfection probable tubercular aetiology. He was treated with oral steroids, antitubercular therapy, intravitreal bevacizumab and anterior retinal cryopexy, leading to resolution of vasculitis and vitreous haemorrhage. Later he developed peripheral retinal flap and posterior retinal breaks at 8-month and 11-month follow-up, respectively, which were managed by barrage laser. He maintained a stable visual acuity of 20/20, N6 for the next 2 years. He then presented with sudden decreased vision in the right eye (20/50, N10). Right eye fundus showed posterior pole retinal detachment with lifting of previously barraged posterior retinal breaks. He underwent vitreoretinal surgery with gas tamponade. Recent 1-month postoperative visit showed successful retinal reattachment and visual recovery of 20/20, N6.

Rhegmatogenous retinal detachment--an ophthalmologic emergency.

Rhegmatogenous retinal detachment is the most common retinological emergency threatening vision, with an incidence of 1 in 10 000 persons per year, corresponding to about 8000 new cases in Germany annually. Without treatment, blindness in the affected eye may result. Selective review of the literature. Rhegmatogenous retinal detachment typically presents with the perception of light flashes, floaters, or a "dark curtain." In most cases, the retinal tear is a consequence of degeneration of the vitreous body. Epidemiologic studies have identified myopia and prior cataract surgery as the main risk factors. Persons in the sixth and seventh decades of life are most commonly affected. Rhegmatogenous retinal detachment is an emergency, and all patients should be seen by an ophthalmologist on the same day that symptoms arise. The treatment consists of scleral buckle, removal of the vitreous body (vitrectomy), or a combination of the two. Anatomical success rates are in the range of 85% to 90%. Vitrectomy is followed by lens opacification in more than 70% of cases. The earlier the patient is seen by an ophthalmologist, the greater the chance that the macula is still attached, so that visual acuity can be preserved. Rhegmatogenous retinal detachment is among the main emergency indications in ophthalmology. In all such cases, an ophthalmologist must be consulted at once.

[Analysis of 100 cases of retinal detachment treated with conventional surgery in the years 1997-1998].

The observed increasing number of severe cases of retinal detachment was the ground of the attempt to state the causes of this phenomenon. Retrospective evaluation of 100 consecutive cases of retinal detachment operated on with conventional methods between September 1997 and October 1998 was performed. The following data were analysed: sex and age of patients, period between the first symptoms and time of diagnosis and surgery. The clinical characteristics of retinal surgery comprise: extent of detachment, macular involving, type and number of breaks, degenerations and PVR. In the majority of cases very severe retinal detachments were observed, including 3-4 quadrants, with large tears or multiple breaks, with PVR B or C. Duration of the detachment ranged from several days in very few cases to several months, on average lasting several weeks. Attachment of the retina was achieved in 80 cases, improvement of the visual acuity in 47. Our data indicate the necessity to improve the early diagnosis of retinal detachment and changes predisposing to its development.

MYCOBACTERIUM MANITOBENSE MASQUERADING AS CORYNEBACTERIUM PSEUDODIPHTHERITICUM IN A CASE OF POSTCATARACT SURGERY ENDOPHTHALMITIS.

To describe a case of postoperative Mycobacterium manitobense endophthalmitis with good visual outcome that is the first report of endophthalmitis by this organism. Clinical and microbiological description of a patient with postoperative endophthalmitis. A 50-year-old chronic alcoholic man was referred to us with decreased vision in his right eye for 4 days. He had undergone cataract surgery with intraocular lens implantation in his right eye a month ago. The presenting vision in his right eye was counting fingers close to face. He was diagnosed as a case of postoperative endophthalmitis. Subsequently, the patient underwent pars plana vitrectomy and vitreous biopsy. The microbiologic investigation of the vitreous biopsy showed poorly stained gram-positive beaded bacilli that were acid fast, and growth in culture was identified as Corynebacterium pseudodiphtheriticum by Vitek 2 bacterial identification system. However, DNA analysis confirmed the organism to be M. manitobense. The patient responded well to repeat interventions with intravitreal antibiotics with a final reported visual acuity of 20/30 at 4 months after first intervention. Although known to be an organism causing soft-tissue infections, M. manitobense can also cause postsurgical endophthalmitis. The diagnosis can be confused with Corynebacterium sp. on smear and culture. Subsequent DNA sequencing of the culture provides definite identification of the organism.

[Clinical observations of macular hole with and without retinal detachment in high myopic eyes].

To study the clinical features and the pathogenesis of macular hole with and without retina detachment (RD) in high myopic eyes. It was a retrospective series case study. The charts of high myopic patients with macular hole at our hospital from June 2006 to February 2007 were retrospectively reviewed and analyzed. Patients were divided into two groups (the RD group and non-RD group) depending on the presence of RD or not. Their clinical data and optic coherence tomography (OCT) results were further analyzed. SPSS 13.0 was used for the statistic analysis. When comparing the quantitative aspects like age, axial length and refraction, t-test was used. Categorical data, such as sex ratio, occurrence of vitreous traction, posterior staphyloma and retinoschisis were compared by using χ(2) test. Fisher's test was used in comparing eye laterality, incidence of white hole, visual acuity and posterior vitreous detachment (PVD). During this period, there were 43 patients fitting the including criteria. Among them, 36 patents (37 eyes) were in the RD group and 7 patients (7 eyes) in the no-RD group. In the RD group, the average age was 56.1, 24.3% of them (9/37) were male; percentage of left and right eyes was (11/37) and 70.3% (26/37), respectively; average refraction was (-8.9 ± 2.2) D; average axial length was (28.7 ± 2.0) mm. Visual acuity was ≤ 0.05 (72.2%) in 26 eyes and 0.05 - 0.2 (27.8%) in 10 patients. The incidence of complete and non-complete PVD was 89.2% (33/37) and 10.8% (4/37), respectively. White hole presented in 35.1% (3/37) patients. Vitreous traction and retinoschisis presented in 27.0% (10/37) and 35.1% (13/37) patients, respectively. In the non-RD group, the average age was 47.6; 16.7% of them (1/7) were male; left and right eyes were involved in 42.9% (3/7) and 57.1% (4/7), respectively. Average refraction was (-9.0 ± 1.9) D; average axial length was (28.9 ± 1.5) mm. Vision acuity was ≤ 0.05 in 3 patients (42.9%); between 0.05 - 0.2 in 3 eyes (42.9%) and ≥ 0.2 in 1 eye (14.3%). Incidence of complete and non-complete PVD was 85.7% (6/7) and 14.3% (1/7), respectively. White hole was observed in 14.3% (1/7) patients; 42.9% (3/7) patients were accompanied with vitreous traction and 71.4% (5/7) with retinoschisis. B-scan ultrasonography showed posterior staphyloma in all 44 eyes. The results of statistical analysis showed that the gender (χ(2) = 0.008) and eye laterality (χ(2) = 0.449) as well as refraction (t = 0.193), axial length (t = -0.25) and visual acuity (χ(2) = 4.509) of these two groups were similar (P > 0.05). The incidences of vitreous traction (χ(2) = 0.709), white hole (χ(2) = 1.179), PVD (χ(2) = 0.071) and retinoschisis (χ(2) = 3.207) were also similar (P > 0.05). But the age of the non-RD group is significantly younger than the RD group (t = 1.66, P < 0.05). Various pathogenesis may involved in the occurrence of retinal detachment in highly myopic eyes with macular hole. Further study is required to improve our understanding of this entity.

[Early posterior capsule fibrosis after combined cataract and vitreoretinal surgery with intraocular air/SF6 gas tamponade].

The surgical approach in treating coexisting vitreoretinal disease and cataract is controversial. We report on patients who developed early posterior capsular fibrosis after combined cataract and vitreoretinal surgery with air/SF6-gas tamponade. The medical records of 15 consecutive eyes (13 patients) who underwent combined phacoemulsification with intraocular lens implantation and vitreoretinal surgery with intraocular air/SF6-gas tamponade were retrospectively analyzed. The indications for vitreous surgery included: subfoveal neovascular membrane in age-related macular degeneration (5 eyes), macular hole (4 eyes), macular pucker (2 eyes), rhegmatogenous retinal detachment (2 eyes), persistent vitreous haemorrhage after branch retinal vein occlusion (1 eye), persistent vitreous haemorrhage and/or tractional retinal detachment in proliferative diabetic retinopathy (1 eye). The mean follow-up period was 7 months (1-13 months). A control group consisted of 15 eyes (15 patients) who underwent the equal combined operation without intraocular tamponade. The indications for vitreous surgery were persistent vitreous haemorrhage in proliferative diabetic retinopathy (5 eyes), persistent vitreous haemorrhage after branch retinal vein occlusion (5 eyes), asteroid hyalosis (2 eyes), macular pucker (1 eye), posttraumatic vitreous haemorrhage (1 eye), acute retinal necrosis (1 eye). The mean follow-up was 8 months (2-13 months). The posterior capsule was examined at the slit lamp microscopy with maximal dilated pupils. We defined posterior capsular opacification (PCO) as severe if posterior capsule was fibrotic, diffusely thickened and opaque. Modest PCO was characterized by focal fibrotic opacifications at otherwise clear posterior capsule. Severe posterior capsular fibrosis developed in 9 eyes (60%) after 2-14 weeks postoperatively (mean 8 weeks) including 3 of 6 eyes with air tamponade (50%) and 6 of 9 eyes with 20% SF6-gas tamponade (66.7%). In 6 eyes (40%) Nd:YAG-laser capsulotomy was performed 4-14 weeks postoperatively (mean 8.5 weeks). In the control group modest PCO developed in 8 eyes (53.3%) 1-13 months postoperatively (mean 6.5 months) none requiring Nd:YAG-laser capsulotomy during follow-up period. Combined cataract and vitreoretinal surgery with intraocular air/SF6-gas tamponade induces severe posterior capsular fibrosis in the early postoperative period. The capsular fibrosis is presumably caused by accumulation of fibrin and proliferation stimulating factors in the narrow space between intraocular lens and air/SF6-gas bubble.

[Bilateral retinal detachment and high myopia: report of nine cases].

Bilateral retinal detachments are rare, but their occurrence increases in cases of high myopia. The objective of our research is to study their incidence, management and postoperative results. This is a study of the medical records of nine patients with high myopia and simultaneous or consecutive bilateral rhegmatogenous retinal detachment. This is a retrospective study of the medical records of nine patients (18 eyes), aged 11-38 years old, with high myopia and simultaneous or consecutive bilateral retinal detachment. All had surgery on our medical service between September 1, 2010 and September 1, 2011. Bilateral retinal detachments represented 4.11% of the total cases operated during this period (219 patients) and 9.17% of the retinal detachments with high myopia (98 patients). The sex ratio is 1 male to 8 females, with an average age of 31 years old. The detachments were simultaneously bilateral for 3 patients. The initial corrected visual acuity varied between 1/40 and 4/10, macular retinoschisis was found in one case, and the breaks found were atrophic holes and horseshoe breaks. Scleral buckling with cryotherapy was performed in all patients, with a primary reattachment rate of 88.8%; and no vitreoretinal surgery was performed. The final visual acuity varied between 1/20 and 6/10. The incidence of bilateral retinal detachment increases in cases of associated high myopia; it is observed essentially among young patients. Management is difficult because of the risk of associated vitreoretinal proliferation, and the final visual recovery depends on the type of detachment and the degree of myopia. Classical surgery performed correctly and early allows for satisfactory results in most cases.

Visual impairment

The most common causes of blindness worldwide in 2010 were: Cataracts (51%) Glaucoma (8%) Age-related macular degeneration (5%) Corneal opacification (4%) Childhood blindness (4%) Refractive errors (3%) Trachoma (3%) Diabetic retinopathy (1%) Undetermined (21%) About 90% of people who are visually impaired live in the developing world. Age-related macular degeneration, glaucoma, and diabetic retinopathy are the leading causes of blindness in the developed world. Among working-age adults who are newly blind in England and Wales the most common causes in 2010 were: Hereditary retinal disorders (20.2%) Diabetic retinopathy (14.4%) Optic atrophy (14.1%) Glaucoma (5.9%) Congenital abnormalities (5.1%) Disorders of the visual cortex (4.1%) Cerebrovascular disease (3.2%) Degeneration of the macula and posterior pole (3.0%) Myopia (2.8%) Corneal disorders (2.6%) Malignant neoplasms of the brain and nervous system (1.5%) Retinal detachment (1.4%) Cataracts

[Outpatient vitreoretinal surgery without next-day examination: Feasibility and acceptability].

To assess the feasibility and acceptability of outpatient care without next-day examination for patients undergoing retinal surgery. Patients undergoing ambulatory vitreoretinal surgery between November 2013 and February 2016 at the Vienna medical center were included in this retrospective study. The age, comorbidities, indication, surgical technique and type of anesthesia used, symptoms, intraocular pressure and biomicroscopic examination data at the D0, D7 and M1 visits were recorded. Patient satisfaction with the outpatient treatment was collected by phone call in April 2016. Fifty-three surgeries on 49 patients (24 women, 25 men) with a mean age of 70 years (range, 39-91 years) were analyzed. The surgery was pars plana vitrectomy in all cases, with 26 cases of epiretinal membrane surgery, 7 vitreomacular traction syndrome, 4 vitreous hemorrhage, 6 macular hole, 4 dislocation of lens material, 5 retinal detachment and 1 macular retinoschisis in high myopia. The type of anesthesia was general in 64.1 % of cases (34) and local in 36.9 % of cases (19). Of the D0 examination data, 100 % were compatible with the patient being discharged to home. One patient consulted before the D7 exam for the occurrence of a subconjunctival hemorrhage. There were seven cases (13.2 %) of intraocular pressure elevation and two cases of vitreous hemorrhage (3.8 %) on the D7 examination data. Twenty-seven patients (55.1 %) were reached by phone and all of them were satisfied with their outpatient management. Outpatient treatment of patients without next-day examination for vitreoretinal surgery is possible and well accepted.

Posterior vitreous detachment

Complications The risk of retinal detachment is the greatest in the first 6 weeks following a vitreous detachment, but can occur over 3 months after the event. The risk of retinal tears and detachment associated with vitreous detachment is higher in patients with myopic retinal degeneration, lattice degeneration, and a familial or personal history of previous retinal tears/detachment. Causes The vitreous (Latin for "glassy") humor is a gel which fills the eye behind the lens. Between it and the retina is the vitreous membrane. With age the vitreous humor changes, shrinking and developing pockets of liquefaction, similar to the way a gelatin dessert shrinks and detaches from the edge of a pan. At some stage the vitreous membrane may peel away from the retina. This is usually a sudden event, but it may also occur slowly over months.

Treatment of Candida endophthalmitis.

A 51-year-old man who was being treated with corticosteroids for chronic extrinsic asthma developed biliary tract sepsis, candidemia, and Candida endophthalmitis with vitreous fluff-ball lesions in both eyes. Extensive vitreous fibrosis and retinal detachment with loss of useful vision occurred in his left eye, which had a vitreous biopsy. Useful vision was maintained in his right eye with two full courses of systemic amphotericin B, 5-flucytosine, and a cataract extraction. Encapsulated Candida organisms remained in the vitreous of his right eye at the time of death. Useful vision can be preserved without aggressive vitreous surgery and intravitreal anti-fungal agents in eyes with intravitreal Candida albicans.

Long-Term Safety and Efficacy of Limited Vitrectomy for Vision Degrading Vitreopathy Resulting from Vitreous Floaters.

Vitreous floaters can lower visual acuity (VA) and degrade contrast sensitivity function (CSF). Limited vitrectomy improves VA and normalizes CSF, but long-term results in a large series with objective quantitative outcome measures are lacking. Case series. One hundred ninety-five eyes of 145 patients (87 men, age = 57.6 ± 4.3 years; 58 women, age = 61.5 ± 12.0 years) reporting bothersome vitreous floaters were compared to 70 age-matched controls. Posterior vitreous detachment (PVD) alone was the cause in 96/195 (49.2%), myopic vitreopathy alone was the cause in 30/195 (15.4%), PVD with myopic vitreopathy was the cause in 56/195 (28.7%), and asteroid hyalosis was the cause in 13/195 eyes (6.7%). Limited vitrectomy with 25-gauge instruments was performed without surgical PVD induction, preserving 3 to 4 mm of retrolental vitreous in phakic eyes. Follow-up averaged 32.6 ± 23.5 months (range, 3-115 months), with 2 years or more in 144 eyes, 3 years or more in 69 eyes, 4 years or more in 51 eyes, and 5 years or more in 24 eyes. Visual acuity, 39-item National Eye Institute Visual Function Questionnaire (VFQ) results, CSF (Weber index), and quantitative ultrasonography results. After surgery, vitreous echodensity decreased by 94.1% (P < 0.0001) and VFQ results improved by 19.3% (P < 0.0001). Preoperative VA was 0.68 ± 0.21, improving to 0.77 ± 0.19 after surgery (P < 0.0001). Preoperative CSF was degraded by 91.3% compared with controls (P < 0.0001), normalizing at 1, 3, 6, 12, 24, 36, and 48 months after surgery (P < 0.00005 for each). There were no cases of endophthalmitis. There were 3 retinal tears and 3 retinal detachments that underwent successful repair. Clinically significant vitreous hemorrhage developed in 2 patients, clearing spontaneously. Two macular puckers and 4 recurrent floaters from new PVD were cured by re-operation. Cataract surgery occurred in 21 of 124 patients (16.9%; mean age, 64 ± 7 years; none younger than 53 years), an average of 13.1 ± 6.8 months after vitrectomy. Limited vitrectomy for Vision Degrading Vitreopathy decreases vitreous echodensity, improves patient well-being, improves VA, and normalizes CSF. The long-term efficacy and safety profiles suggest this may be a safe and effective treatment for clinically significant vitreous floaters, warranting a prospective randomized trial.

[The incidence of retinal tears in patients with posterior vitreous detachment].

Posterior vitreous detachment (PVD) is a common finding in older patients, characterized by detachment of the posterior hyaloid membrane (PHM) from the retinal surface. The detachment of PHM normally occurs without complications, however, one has to be aware that retinal tear is its most common complication. The aim of the study was to determine the incidence of retinal tears in eyes with PVD. A series of 40 patients (70 eyes) with PVD were included in this retrospective study. Eyes with a history of ocular trauma, surgery or intraocular inflammation were excluded. Patient charts were reviewed to collect the following information: age, sex, profession, type and duration of symptoms, best corrected visual acuity, refractive status, prior ocular disease, coincidental retinal pathology-lattice degeneration, number, type and location of retinal tears and treatment. Statistical analysis was done with the SPSS 11.0.3 software (SPSS Inc., USA). Besides descriptive statistics, Student's t-test and chi2-test were used. Among all study eyes with PVD, 34 (48.6%) were myopic, 24 (34.3%) hypermetropic and 12 (17.1%) emetropic; statistical analysis showed a significant difference (chi2 = 10.40, df=2, p < 0.01). In 6 (8.6%) eyes with PVD lattice malignant degeneration of peripheral retinal was diagnosed. Thorough examination of the fundus periphery revealed 16 (22.8%) eyes with PVD were found to have retinal tears, 11 (15.7%) had only one retinal tear and 5 (7.1%) two retinal tears. All retinal tears were treated with argon laser photocoagulation. Superotemporal eye quadrant was the most common localization of retinal tears (56.25%). These results indicate that thorough fundus periphery examination should be done in all patients with PVD because it can cause rather rarely though retinal tears that represent a potentially sight threatening condition.

Long-term effects of phacoemulsification and intraocular lens implantation in a patient with pathologic myopia and extremely long axial length: A case report.

To report a rare case of phacoemulsification cataract surgery and intraocular lens implantation that improved visual acuity and capsular stability in a patient with pathologic myopia and axial length >38 mm. A 51-year-old Chinese man with high myopia since childhood who had lost sight in his left eye at the age of 25 due to retinal detachment. He was referred for ophthalmological assessment due to decreased vision in the right eye, in which the best-corrected visual acuity at distance was hand motion. The patient was diagnosed with cataract, high myopia, subluxated lens, and loose zonules in the right eye. The left eyeball showed atrophy. The patient underwent uneventful phacoemulsification. An intraocular lens (Sensar AR40M) and capsular tension ring were implanted within the capsular bag. After surgery, the patient was given eye drops containing tobramycin and dexamethasone eye drops for 1 month and eye drops containing 0.1% sodium diclofenac for 2 months. There were no postoperative complications. During 1-year follow-up, uncorrected visual acuity was 20/80 and the manifest refraction was -2.50DS/-1.00DC*80, with corrected distance visual acuity of 20/60. Cataract surgery maintained adequate vision for daily living. Implantation of specific lens and capsular tension ring as well as prolonged use of non-steroidal anti-inflammatory drugs may help prevent capsular contraction and posterior capsule opacification in patients with pathologic myopia and extremely long axial length.

Bilateral rhegmatogenous retinal detachment.

During a 4-year period, 1978-1981, 34 patients with bilateral rhegmatogenous retinal detachment were operated on at the University Eye Hospital in Helsinki. The incidence of bilaterality in the entire detachment population was 10%, in the aphakic group it was 16%. In 24 cases (71%) the interval from the first to the second eye detachment was less than 5 years, 6 patients (18%) had bilateral detachment simultaneously. The mean age of the patients when the first eye was affected (46 years, range 6-73) was significantly younger than the mean age of those with unilateral detachment (58 years, range 6-83) (P less than 0.001). Previous eye diseases were significantly (P less than 0.01) more common in patients with bilateral than in those with unilateral detachment, but the incidences of myopia, aphakia and lattice degeneration of the retina did not differ significantly between these groups. At least one of these predisposing factors was found in 85% and two or more of them in 53% of bilateral detachments. The retina was re-attached in 80% of the 44 eyes operated on during the study period. Of the 24 eyes operated on earlier, 71% were blind (visual acuity CF 1 m or worse). The latest visual acuities in both eyes or in the better eye for all patients were: greater than or equal to 0.5 in 38%, 0.4-0.2 in 35%, 0.1-CF2 m in 12%, and less than or equal to CF1 m in 15%.

Retinal detachment

Although retinal detachment usually occurs in one eye, there is a 15% chance of developing it in the other eye, and this risk increases to 25–30% in patients who have had cataracts extracted from both eyes. Symptoms of Rhegmatogenous Retinal Detachment A retinal detachment is commonly but not always preceded by a posterior vitreous detachment which gives rise to these symptoms: flashes of light (photopsia) – very brief in the extreme peripheral (outside of center) part of vision a sudden dramatic increase in the number of floaters Sometimes a detachment may be due to atrophic retinal holes in which case it may not be preceded by photopsia or floaters. Although most posterior vitreous detachments do not progress to retinal detachments, those that do produce the following symptoms:

A Case of Rhegmatogenous Retinal Detachment at Late Stage following Endogenous Bacterial Endophthalmitis.

To report a case of rhegmatogenous retinal detachment in the late stage, despite the fact that it had previously been halted after intravitreal injection of an antimicrobial agent against endogenous bacterial endophthalmitis (EBE). This study involved a 62-year-old male who had previously been diagnosed with septicemia due to liver abscess and the detection of <iKlebsiella pneumoniae</i in a culture of his liver abscess, and who underwent ophthalmic examination after his conjunctival hyperemia had failed to improve. Visual acuity could not be measured due to his general condition being poor and his declining level of consciousness. Slit lamp examination revealed bilateral iritis and cataracts, and the fundus was invisible due to vitreous opacity. Ultrasonic B-mode examination showed subretinal abscess and exudative retinal detachment, leading to the diagnosis of EBE. Vitreous injections of antibiotics were administered to both of his eyes. His right eye became affected by phthisis bulbi, but the condition in his left eye subsided, leaving a scarred lesion near the macula. However, complete retinal detachment occurred in his left eye approximately 10 months after the vitreous injection. During vitreous surgery, proliferative membrane formation was observed in the posterior pole area, and an irregular retinal break was detected in the scar margin caused by the traction of the proliferative membrane. After vitreous surgery, the retina was reattached under silicone oil. In cases of EBE, even if the inflammation has previously subsided, strict follow-up examinations are necessary, since complications such as rhegmatogenous retinal detachment may occur at a late stage.

First_Aid_Step1

Breaks more common in patients with high myopia and/or history of head trauma. Often preceded by posterior vitreous detachment (“flashes” and “floaters”) and eventual monocular loss of vision like a “curtain drawn down.” Surgical emergency. Central retinal artery Acute, painless monocular vision loss. Retina cloudy with attenuated vessels and “cherry-red” spot occlusion at fovea (center of macula) A . Evaluate for embolic source (eg, carotid artery atherosclerosis, cardiac vegetations, patent foramen ovale). Retinitis pigmentosa Inherited progressive retinal degeneration. Nyctalopia (night blindness)  peripheral vision loss. Bone spicule-shaped deposits A . Papilledema Optic disc swelling (usually bilateral) due to  ICP (eg, 2° to mass effect). Enlarged blind spot and elevated optic disc with blurred margins A . Leukocoria Loss (whitening) of the red reflex. Important causes in children include retinoblastoma A , congenital cataract, toxocariasis.

Combined vitreous and cataract surgeries in highly hyperopic eye.

We report a case of a patient with a highly hyperopic eye who underwent cataract surgery combined with vitreous surgery to create a posterior vitreous detachment (PVD) to prevent choroidal neovascularization (CNV). A 78-year-old man noticed a decrease in his vision due to a cataract in his right eye. The patient had a severe visual loss in his left eye because of a CNV 2 years after a cataract surgery. His visual acuities were 20/30 OD and 20/600 OS, and funduscopic examination showed an orange-colored lesion OD and degenerative subretinal fibrosis OS. The posterior vitreous was attached to the retina in both eyes. The axial length was 18.9 mm OD and 19.0 mm OS. Cataract surgery combined with vitreous surgery to create PVD was performed on the right eye, and the vision improved to 20/20 with no signs of developing CNV after 5 years. We conclude that cataract surgery combined with vitreous surgery to create a PVD may prevent the development of CNV in highly hyperopic eyes.