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Michael J Fliotsos,1 Donovan Stephen Reed,2 Gregory Giles,3 Adam HH Altman,2 Joseph A Santamaria,2 Sidra Zafar,1 Darrel K Carlton,3 Anthony J Johnson,3 Brett W Davies,2 Gary L Legault,3,4 Fasika A Woreta,1 Grant A Justin3,4 1Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; 2Department of Ophthalmology, Wilford Hall Eye Center, San Antonio, TX, USA; 3Department of Ophthalmology, Brooke Army Medical Center, San Antonio, TX, USA; 4Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USACorrespondence: Michael J FliotsosWilmer Eye Institute, The Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD, 21287, USATel +1-260-409-7314Email michael.fliotsos@yale.eduPurpose: To describe the frequency and type of eye injuries in fighters in mixed martial arts (MMA) competition.Methods: Fight result data were collected from the Nevada Athletic Commission database from 2001 to 2020. Any fighters in a professional mixed martial arts (MMA) contest with an eye injury were included. Main outcome measures included frequency and rate of eye injuries per fight and the types of eye injuries. Secondary outcome measures were gender, laterality, decision type, and length of no-contact recommended.Results: Of the 256 MMA events in the database, 187 events (73.3%) had at least one eye injury. Of a total 2208 fights at these events, there were 363 fighters who sustained 369 eye injuries, with the yearly rate of eye injuries per 100 fighters ranging from 2.56 to 12.22. The most common injuries were eyebrow and eyelid lacerations (n=160, 43%), lacerations around the eye (n=98, 27%), and orbital fractures (n=62, 17%). Most eye injuries were right sided (n=197, 53.3%) and the majority of fighters with eye injuries lost their match (n=228, 62.8%). Fifty-seven fighters were recommended for further ophthalmology clearance after the match. The most common reasons for recommended ophthalmology follow-up was orbital fracture (n=25, 44%) and retinal injury (n=7, 12%). Forty-three fighters received no-contact requirements relating to their injury for an average of 8.9 weeks (range 1– 24 weeks).Conclusion: Ophthalmic injuries in professional MMA were prevalent, were most often lacerations surrounding the eye, and often accompanied the fighter losing their match.Keywords: ophthalmic trauma, eye trauma, mixed martial arts, boxing, MMA, combat sports

Agricultural work involves ergonomic and psychosocial strain, which contribute to musculoskeletal conditions. The aim of this study was to assess if specific ergonomic, psychosocial, and preventive factors are linked to musculoskeletal pain or discomfort symptoms (MSS) in farmers and ranchers. We analyzed data from the Central States Center for Agricultural Safety and Health survey that was conducted in 2018 in a seven-state region of the central United States. MSS were assessed with questions from the Standardized Nordic Questionnaire. The survey included questions on demographic, ergonomic, psychosocial and preventive factors. Farm production variables were added from the Farm Market iD database. We analyzed the data using Generalized Estimating Equations. The overall prevalence of MSS for all body sites combined was 59% among 4,354 farmers and ranchers who responded (19% response rate). After controlling for age, sex, and operator status, three factors (high stress level, sleep deprivation, and exhaustion/fatigue) showed the strongest associations with MSS in any body site, with adjusted odds ratios (OR) ranging from 4.8 to 5.6. Forceful exertions, repetitive tasks, awkward postures, frequent manual labor, and vibration were also significantly associated with MSS, with adjusted ORs ranging from 1.8 to 3.3. Recommended preventive techniques were not protective for MSS. New effective strategies are needed to reduce the high burden of musculoskeletal outcomes among farmers and agricultural workers.

OBJECTIVE To evaluate inter-rater agreement for sonographic classification of stomach position (as a surrogate for liver herniation) in fetal left congenital diaphragmatic hernia (LCDH) among: (i) fetal medicine specialists from the North American Fetal Therapy Network (NAFTNet) centers within and without the fetal endoscopic tracheal occlusion (FETO) consortium and in comparison to an expert external reviewer (ER1); and (iii) among two expert ERs (ER1 and ER2). METHODS Forty-eight physicians from 26 NAFTNet centers and 2 ERs were asked to assess 13 sonographic clips of isolated LCDH and classify stomach position as "intra-abdominal," "anterior left chest," "mid to posterior left chest," or "retro-cardiac" based on the classification published by Basta et al.8 Interrater agreement was assessed by determining proportion of stomach position ratings concordant amongst NAFTNet participants and ER1. Agreement for stomach position between ERs was calculated using kappa statistics. RESULTS Agreement for stomach position was 69% (39%-85%; n = 19) and 54% (23%-92%; n = 29) among FETO and non-FETO NAFTNet participants, respectively, when compared to ER1. Most disagreement in stomach position was related to a discrepancy of one position. ERs were in agreement for stomach position in 5 of 13 cases (38.5%) and inter-rater agreement was highest for "anterior" stomach position. CONCLUSION Interrater agreement for stomach position assessment in CDH was poor across NAFTNet and indeed amongst expert reviewers.

The high risk of occupational fatalities in agriculture is well documented, but information on non-fatal injuries is lacking due to challenges in injury surveillance. This surveillance study explored the frequency, characteristics, and risk factors for non-fatal injuries among farmers and ranchers in the central United States. The Central States Center for Agricultural Safety and Health (CS-CASH), in collaboration with the USDA National Agricultural Statistics Service (NASS), conducted annual surveys (n = 34,777 sent) during 2011-2015 covering a seven-state region (Iowa, Kansas, Minnesota, Missouri, North Dakota, Nebraska, and South Dakota). The average response rate was 32% in the five consecutive annual surveys. The average injury incidence rate was 7.0 injuries/100 operators per year. Most injuries (89%) occurred during agricultural work. The most frequent sources of injury were livestock (22%), machinery (13%), and hand tools (12%). Risk factors for injury included: male gender, younger age (vs. 65+ years), farming as the primary occupation, greater work time, greater land area, ranch (vs. farm), organic farming, internet access, and production of several types of crops and animals. Most injuries (56%) required a doctor visit, and 12% required hospitalization. The average medical costs were $1,936 out of pocket and $8,043 paid by insurance. The combined average costs for most serious injuries were $7,858. Most injuries (66%) resulted in some lost time from agricultural work, and 13% were serious, resulting in more than 30 days of lost work time. The non-fatal injury rate for self-employed farmers and ranchers was higher than that of hired agricultural workers reported by the Bureau of Labor Statistics. This result reaffirms farming/ranching as a dangerous occupation and emphasizes the need for efforts to prevent agricultural injuries, especially those associated with identified injury sources and risk factors.

Amniotic membrane (AM) has been shown to enhance corneal wound healing due to the abundance of growth factors, cytokines, and extracellular matrix (ECM) proteins inherent to the tissue. As such, AM has garnered widespread clinical utility as a biological dressing for a number of ophthalmic and soft tissue applications. The preparation, sterilization, and storage procedures used to manufacture AM grafts are extremely important for the conservation of inherent biological components within the membrane. Current processing techniques use harsh chemicals and sterilization agents that can compromise the fundamental wound healing properties of AM. Furthermore, commercially available cryopreserved AM products require specific storage conditions (e.g., ultra-low freezers) thereby limiting their clinical availability in austere environments. Supercritical carbon dioxide (SCCO2) technology allows for the sterilization of biological tissues without the resulting degradation of integral ECM proteins and other factors often seen with current tissue sterilization processes. With this study we demonstrate that lyophilized AM, sterilized using SCCO2, maintains similar biochemical properties and biocompatibility as that of commercially available AM products requiring specialized cold storage conditions.

An 18-year-old woman developed Stevens-Johnson syndrome (SJS) with ocular involvement after taking ibuprofen. She was admitted to another hospital, received saline flushes and bacitracin ophthalmic ointment to the eyes, and became unable to open them. Upon transfer to this burn center 3 weeks after symptom onset, there was complete fusion of both eyelids with no visible cornea or sclera. She underwent bilateral operative scar release. After opening the lids, meticulous debridement of cicatricial membranes and release of symblephara were performed with subsequent placement of amniotic membrane grafts. Her vision slowly improved, though her long-term visual prognosis remains guarded. Early recognition and treatment of SJS or toxic epidermal necrolysis (TEN) with ocular involvement is imperative. Even mild cases may require intensive topical lubrication, steroids, and antibiotics, with early placement of amniotic membrane grafts in severe cases. Prompt intervention and daily evaluation are paramount in preventing lifelong visual disability.

Complex facial lacerations are frequently encountered in the combat environment. Trauma with soft-tissue loss of the periorbital region offers particular challenges in terms of operative reconstruction. Cicatricial changes in the sub-acute phase can lead to eyelid malposition and lagophthalmos. The authors present a novel technique for acute reconstruction of periorbital trauma with eyelid soft-tissue loss with simultaneous full-thickness skin grafting and amniotic membrane grafting. The technique involves standard preparation of the surgical area of injury and infiltration with local anesthetic. Initially, the area of injury is copiously irrigated, and debridement of any necrotic tissue is accomplished. Amniotic membrane grafting is then performed over the defect. Approximately 2 mm × 2 mm full-thickness skin grafts are procured and distributed over the initial amniotic membrane graft. A second amniotic membrane graft is then secured over the skin graft-amniotic membrane graft complex with cyanoacrylate tissue adhesive. A bolstered suture tarsorrhaphy is performed to minimize tissue trauma during the healing process. The operative and postsurgical outcomes were assessed. The graft site healed well without cicatricial changes or lagophthalmos. Peripheral small papillomatous lesions did develop requiring excision for cosmesis, but ultimately the graft site demonstrated appropriate coverage and healthy re-epithelialization over the previous defect. This case demonstrates the viability of simultaneous full-thickness skin grafting with concomitant amniotic membrane grafting for the acute reconstruction of periorbital trauma with eyelid anterior lamella tissue loss. An excellent cosmetic and functional outcome was attained. By providing acute reconstruction, the risk of damage secondary to cicatricial periorbital changes may be avoided.

Introduction Prenatal work-up for congenital diaphragmatic hernia (CDH) is important for risk stratification, standardization, counseling, and optimal therapeutic choice. To determine current practice patterns regarding prenatal CDH work-up, including prenatal ultrasound and magnetic resonance imaging (MRI) use, and to identify areas for standardization of such evaluation between fetal centers. Methods A survey regarding prenatal CDH work-up was sent to each member center of the North American Fetal Therapy Network (NAFTNet) (n = 36). Results All responded. Sonographic measurement of lung-to-head ratio (LHR) was determined by all, 89% (32/36) of which routinely calculate observed-to-expected LHR. The method for measuring LHR varied: 58% (21/36) used a "trace" method, 25% (9/36) used "longest axis," and 17% (6/36) used an "antero-posterior" method. Fetal MRI was routinely used in 78% (28/36) of centers, but there was significant variability in fetal lung volume measurement. Whereas all generated a total fetal lung volume, the planes, methodology and references values varied significantly. All evaluated liver position, 71% (20/28) evaluated stomach position and 54% (15/28) quantified the degree of liver herniation. More consistency in workup was seen between centers offering fetal intervention. Conclusion Prenatal CDH work-up and management differs considerably among North American fetal diagnostic centers, highlighting a need for its standardization.

Purpose The study objective was to test the utilization of a crosslinked, thiolated hyaluronic acid (CMHA-S) film for treating corneal chemical burns. Methods Burns 5.5 mm in diameter were created on 10 anesthetized, male New Zealand white rabbits by placing a 1N NaOH soaked circular filter paper onto the cornea for 30 s. Wounds were immediately rinsed with balanced salt solution (BSS). CMHA-S films were placed in the left inferior fornix of five injured and five uninjured animals. Five animals received no treatment. At 0 h, 48 h, 96 h, and on day 14 post chemical burn creation, eyes were evaluated by white light imaging, fluorescein staining, and optical coherence tomography (OCT). Corneal histology was performed using H&E and Masson's Trichrome stains. Results Image analysis indicated biocompatible CMHA-S treatment resulted in significant decreases in the areas of corneal opacity at 48 h, 96 h, and on day 14 postoperatively. A significant increase in re-epithelialization was seen 14 days post injury. CMHA-S treated corneas showed significantly less edema than untreated burns. No pathological differences were observed in corneal histological samples as a result of CMHA-S treatment. Conclusions CMHA-S films facilitate re-epithelialization and decrease the area of corneal opacity in our corneal alkali burn rabbit model.

Watertight closure of perforating corneoscleral lacerations is necessary to prevent epithelial ingrowth, infection, and potential loss of the eye. Complex lacerations can be difficult to treat, and repair with sutures alone is often inadequate. In this study, we evaluated a potentially sutureless technology for sealing complex corneal and scleral lacerations that bonds the amniotic membrane (AM) to the wound using only green light and rose bengal dye.The AM was impregnated with rose bengal and then sealed over lacerations using green light to bond the AM to the deepithelialized corneal surface. This process was compared with suture repair of 3 laceration configurations in New Zealand White rabbits in 3 arms of the study. A fourth study arm assessed the side effect profile including viability of cells in the iris, damage to the blood-retinal barrier, retinal photoreceptors, retinal pigment epithelium, and choriocapillaris in Dutch Belted rabbits.Analyses of the first 3 arms revealed a clinically insignificant increase in polymorphonuclear inflammation. In the fourth arm, iris cells appeared unaffected and no evidence of breakdown of the blood-retinal barrier was detected. The retina from green light laser-treated eyes showed normal retinal pigment epithelium, intact outer segments, and normal outer nuclear layer thickness.The results of these studies established that a light-activated method to cross-link AM to the cornea can be used for sealing complex penetrating wounds in the cornea and sclera with minimal inflammation or secondary effects.

Background: Treatments administered after a corneal burn injury can have long term implications on wound healing. Initial treatments can include the administration of lubricants, anti inflammatories, and antibiotic eye drops, many of which contain phosphate buffered saline (PBS) as a vehicle. As a result, the purpose of this study was to observe the effects of the commonly used PBS ophthalmic drop vehicle on corneal alkali burns over 30 days when treated 4X daily for the first 14 days. Materials and Methods: Corneal alkali burns 5.5 mm in diameter were created on 10 anesthetized, male New Zealand White rabbits Animals (5) with corneal wounds were treated with PBS 4X daily or left untreated (5). Control animals (5) were not wounded, but were treated with PBS drops 4X daily. Corneal alkali burns were created by centrally placing NaOH (1N) soaked filter paper onto the cornea for 30 seconds. After removal of the filter paper, the surface of the eye was immediately debrided with a Weck-Cel® sponge and irrigated with 15 ml of sterile buffered salt solution (BSS). At days 0, 3, 7, 14 and 30 post-chemical alkali burn creation, eyes were evaluated by white light imaging and fluorescein staining. On days 14 and 30, corneal thickness was assessed via optical coherence tomography (OCT). Results: A significant decrease in fluorescein staining indicating a significant increase in wound healing was observed on day 7 (P< 0.05) in the PBS treatment group when compared to the non-treated corneal alkali burns. A significant increase in fluorescein staining or decrease in wound healing was observed on day 30 (P< 0.0005) in the PBS treatment group when compared to non-treated corneal alkali burns. White light imaging and OCT results, respectively, showed no significant differences in corneal opacity or corneal swelling between treatment groups at any time point. Conclusions: This study suggests that the treatment of corneal alkali burns with ophthalmic solutions containing PBS may impact wound closure while having no significant effect on corneal opacity or corneal swelling.

Purpose: The Central States Center for Agricultural Safety and Health (CS-CASH) conducts surveillance to characterize occupational injury and illness frequencies, exposures, and preventive practice...

Current strategies to address corneal surface defects are insufficient to successfully resolve damage caused by injury and/or disease. To address this issue, we have developed an ocular wound chamber (OWC) that creates a fluid-filled environment by encompassing damaged ocular and periocular tissues allowing for the continuous delivery of therapeutics. This study tested human platelet lysate (hPL) as a treatment for corneal epithelial defects when used with the OWC. Corneal epithelial injuries were created in anesthetized guinea pigs by debridement of the central cornea. An OWC was placed over the injured eye and animals randomly grouped followed by injection of either 20% hPL, 100% hPL, or vehicle (balanced salt solution, BSS) into the chamber. Eyes were assessed at 0, 24, 48, and 72 h using intraocular pressure (IOP), optical coherence tomography (OCT), and fluorescein imaging. Whole globes were histologically processed, and hematoxylin and eosin (H&E) stained. No differences in IOP were recorded as a result of corneal wounding, chamber placement, and/or therapeutic application. OCT images demonstrated increased corneal swelling at 48 h and 72 h in the vehicle group compared to 20% hPL. Fluorescein staining showed increased corneal re-epithelialization in the 20% and 100% hPL groups at 48 h compared to vehicle only. H&E staining revealed increased stromal cellular infiltrate in the BSS group. This study demonstrates the delivery of hPL via the OWC improves corneal re-epithelialization and supports the expanded usage of the chamber in combination with hPL to manage a variety of corneal surface injuries, diseases and/or periocular conditions.

Our purpose is to comprehensively review the state of the art with regard to Stevens- Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to improving the management of associated ocular surface complications. SJS and TEN are two ends of a spectrum of immune-mediated disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. Part I of this review focused on the systemic aspects of SJS/TEN and was published in the January 2016 issue of this journal. The purpose of Part II is to summarize the ocular manifestations and their management through all phases of SJS/TEN, from acute to chronic. We hope this effort will assist ophthalmologists in their management of SJS/TEN, so that patients with this complex and debilitating disease receive the best possible care and experience the most optimal outcomes in their vision and quality of life.

Purpose To demonstrate that the ocular wound chamber (OWC) can be used for the treatment of bacterial keratitis (BK). Methods A blepharotomy was performed on anesthetized, hairless guinea pigs to induce exposure keratopathy 72 hours before corneal wound creation and Pseudomonas aeruginosa inoculation. Twenty-four hours postinoculation, eyes were treated with an OWC filled with 500 µL 0.5% moxifloxacin hydrochloride ophthalmic solution (OWC), 10 µL 0.5% moxifloxacin hydrochloride drops (DROPS) four times daily, or not treated (NT). White light, fluorescein, and spectral domain optical coherence tomography (SD-OCT) images; ocular and periocular tissues samples for colony-forming units (CFU) quantification; and plasma samples were collected at 24 and 72 hours posttreatment. Results White light, fluorescein, and SD-OCT imaging suggests OWC-treated eyes are qualitatively healthier than those in DROPS or NT groups. At 24 hours, the median number of CFUs (interquartile range) measured was 0 (0-8750), 150,000 (106,750-181,250), and 8750 (2525-16,000) CFU/mL for OWC, NT, and DROPS, respectively. While 100% of NT and DROPS animals remained infected at 24 hours, only 25% of OWC-treated animals showed infection. Skin samples at 24 hours showed infection percentages of 50%, 75%, and 0% in DROPS, NT, and OWC groups, respectively. OWC-treated animals had higher moxifloxacin plasma concentrations at 24 and 72 hours than those treated with drops. Conclusions OWC use resulted in a more rapid decrease of CFUs when compared to DROPS or NT groups and was associated with qualitatively healthier ocular and periocular tissue. Translational relevance The OWC could be used clinically to continuously and rapidly deliver antimicrobials to infected ocular and periocular tissues, effectively lowering bacterial bioburdens and mitigating long-term complications.

In our most recent conflicts, over 13% of all injuries suffered by combatants and noncombatants were ocular injuries, with improvised explosive devices (IED) contributing over 93% of all ocular injuries. The cornea and sclera were involved in a significant number of those injuries. To ensure optimal outcomes for individuals with corneal and scleral trauma, meticulous planning and execution from all phases of the evacuation system from prehospital care to evacuation is critical. Additionally, strict adherence to fundamental surgical principles of wound evaluation and management are key to optimizing patient outcomes. This chapter discusses a systematic approach to evaluating and treating patients with anterior segment trauma.

In order to facilitate communication between ophthalmic specialists, a common vocabulary is required. In this chapter, we describe the accepted nomenclature developed by the University of Alabama Birmingham and adopted by International Ocular Trauma Society, to describe eye trauma. The calculation of the ocular trauma score (OTS) and its use will be described and the basic tenets of damage control ophthalmology will be discussed.

Jennifer S McDaniel,1 Andrew W Holt,1 Elaine D Por,1 Elof Eriksson,2 Anthony J Johnson,1 Gina L Griffith1 1Department of Sensory Trauma, United States Army Institute of Surgical Research, San Antonio, TX, USA; 2Harvard Medical School, Boston, MA, USA Purpose: Currently available ocular moisture chambers are not adequate to manage the treatment of periocular burns, corneal injuries, and infection. The purpose of these studies was to demonstrate that a flexible, semi-transparent ocular wound chamber device adapted from technology currently used on dermal wounds is safe for use on corneal epithelial injuries.Materials and methods: A depilatory cream (Nair™, 30 seconds) was utilized to remove the excess hair surrounding the left eyes of anesthetized Institute Armand Frappier (IAF) hairless, female guinea pigs (Crl:HA-Hrhr). A 4 mm corneal epithelium defect was created using a corneal rust ring remover (Algerbrush®II). Epithelial defects were either left untreated or the eyes were fitted with an ocular wound chamber and 0.5 mL of hydroxypropyl methylcellulose (HPMC) gel (GenTeal®) or HPMC liquid (GenTeal®) was injected into each chamber (N=5 per group). At 0, 24, 48, and 72 hours fluorescein and optical coherence tomography imaging was collected and the intraocular pressure (IOP) was measured. H&E staining was performed on corneal and eyelid skin samples and evaluated by a veterinary pathologist. Results: Corneal epithelial wounds demonstrated 100% closure rates when left untreated or treated with an ocular wound chamber containing HPMC gel at 72 hours while wounds treated with an ocular wound chamber containing HPMC liquid were 98% healed. No significant differences were found in corneal thickness and wound healing, IOP, or eyelid skin pathology in any treatment group when compared to controls.Conclusions: This study indicates that adapted wound chamber technology can be safely used on sterile, corneal epithelial wounds without adverse effects on periocular or ocular tissue when filled with a liquid or gel. Keywords: corneal epithelial wound healing, periocular burns, wound chamber, exposure keratopathy, guinea pig

Current therapies available to treat and heal ocular surface injuries and periocular burns are frequently inadequate, costly, and labor intensive. To address these limitations, we have employed a flexible, semitransparent ocular wound chamber (OWC) to provide protection as well as a watertight seal to allow for the constant delivery of therapeutics to the ocular surface and surrounding periocular tissue. This study demonstrates the safety and utilization of the OWC on uninjured eyes and in our exposure keratopathy model. For initial safety studies (N = 3 per group), the eyelids remained intact and the eye uninjured. A blepharotomy (N = 6 per group) was performed to remove the upper and lower eyelids surrounding the left (OS) eye to create our exposure keratopathy model. Right (OD) eyes served as uninjured controls in all studies. Following OWC placement, 0.5 mL HPMC gel or balanced saline solution (BSS) was injected into the chamber. Animals were monitored daily and fully assessed via white light, fluorescein, and OCT imaging at least through 72 hours post OWC placement. In studies that included a blepharotomy, skin samples were analyzed by multiplex cytokine analysis. Results of safety experiments revealed no significant differences between treatment groups in corneal thickness, fluorescein staining, OCT imaging, or histological eye or skin sections when compared to control eyes. In our exposure keratopathy model, OWC treated eyes showed significantly less fluorescein uptake and also were found to have significantly lower levels of cytokines IL-13 and IL-5 in skin samples. These results demonstrate for the first time that treatment using the OWC device is not only safe, but significantly protects against blepharotomy-induced exposure keratopathy. As a whole, this study advances our overall efforts to develop a feasible solution to treat ocular surface injuries, infections, and periocular burns.

The U.S. Military Health System cares for over 9 million patients and encompasses 63 hospitals and 413 clinics worldwide. Military medicine balances the simultaneous tasks of caring for those patients wounded in military engagements, treating large numbers of families of service men and women, and training the next generation of health care providers and ancillary staff. Similar to civilian health care delivery in the United States, military medicine has also seen increased scrutiny in the areas of cost and quality. In 2014, the U.S. military medical health care system was criticized for higher than average surgical complication rates and concerns regarding patient safety, quality of care, lack of transparency, and compartmentalized leadership. The San Antonio Military Medical Center was specifically cited as having "a perennial problem with surgical infection control…the infection rate of surgical wounds was 77% higher than expected given the mix of cases, according to a Pentagon-ordered comparison with civilian hospitals." To determine the scope of complication rates, data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) were analyzed. The goal of this article is to describe the NSQIP surgical outcome data for the U.S. Military's largest medical center from 2009 to 2014 and compare national averages in the areas of mortality, morbidity, cardiac occurrences, pneumonia, unplanned intubation, ventilator use greater than 48 hours, infections, readmissions, and return to operating room.Retrospective data analysis of NSQIP data from 2009 to 2014 at the San Antonio Military Medical Center, a level I trauma center for military members and eligible dependents along with civilian trauma patients. Observed event rates were compared with expected event rates for each year with the 2-tail Fisher's exact test to determine if rates were significantly different from each other. Cochran-Armitage Trend Test was performed to compare trends in time for the observed event rates. This study was exempt from institutional review board Approval.Complication rates remained stable or decreased over the 5 years studied. Significant improvement in morbidity and surgical site infections were observed during the observation period. All other variables except urinary tract infections were within expected range or decreased during this time. Urinary tract infection rates, although decreasing, remain above the expected value.NSQIP data at the Department of Defense's largest hospital reveals complication rates similar to civilian hospitals. The majority of areas studied revealed improving or stable complication rates. The ACS NSQIP is a nationally validated, risk-adjusted, outcomes program that is widely used by many leading hospital institutions. Similar to most quality data reporting articles, a weakness of our study may have been collection of all complications. Yet, we are confident that the majority of complications were captured as we have dedicated personnel monitoring the adverse events measured by ACS NSQIP. Future areas of study should focus on continued analysis of surgical quality improvement within the entire military system.

Background The incidence of blast-induced ocular injury has dramatically increased due to advances in weaponry and military tactics. A single exposure to blast overpressure (BOP) has been shown to cause damage to the eye in animal models; however, on the battlefield, military personnel are exposed to BOP multiple times. The effects of repeated exposures to BOP on ocular tissues have not been investigated. The purpose of this study is to characterize the effects of single or repeated exposure on ocular tissues. Methods A compressed air shock tube was used to deliver 70 ± 7 KPa BOP to rats, once (single blast overpressure [SBOP]) or once daily for 5 days (repeated blast overpressure [RBOP]). Immunohistochemistry was performed to characterize the pathophysiology of ocular injuries induced by SBOP and RBOP. Apoptosis was determined by quantification activated caspase 3. Gliosis was examined by detection of glial fibrillary acidic protein (GFAP). Inflammation was examined by detection of CD68. Results Activated caspase 3 was detected in ocular tissues from all animals subjected to BOP, while those exposed to RBOP had more activated caspase 3 in the optic nerve than those exposed to SBOP. GFAP was detected in the retinas from all animals subjected to BOP. CD68 was detected in optic nerves from all animals exposed to BOP. Conclusion SBOP and RBOP induced retinal damage. RBOP caused more apoptosis in the optic nerve than SBOP, suggesting that RBOP causes more severe optic neuropathy than SBOP. SBOP and RBOP caused gliosis in the retina and increased inflammation in the optic nerve.

Blast-induced ocular trauma is a frequent cause of morbidity for survivors of improvised explosive devices. Blast overpressure (BOP) of 120 ± 7 KPa has been shown to cause damage to lungs, brain, and gut in a rat model; however, the effects of BOP on ocular tissues have not been characterized. To elucidate the pathophysiology of blast-induced ocular trauma, ocular tissues from rats subjected to blast were examined for evidence of apoptosis by the detection of activated caspase 3 and TUNEL assay in their ocular tissues.A compressed air shock tube was used to deliver 120 ± 7 KPa of BOP for duration of 2 msec to the right side of the rats. Rats were then euthanized at specific time points after blast exposure (3 hours, 24 hours, 48 hours). Ocular tissues were processed for immunohistochemistry to detect activated caspase 3 and TUNEL assay. Tissues were evaluated for relative levels of positive signal as compared to nonblast exposed controls.Activated caspase 3 was detected in the optic nerve, ganglion layer, and inner nuclear layer post blast exposure. At 24 and 48 hours, the inner nuclear layer from the right side had more cells with activated caspase 3. In the optic nerve, the highest levels of activated caspase 3 were detected on the right side at 24 hours post blast.BOP of 120 ± 7 KPa induces optic neuropathy and retinal damage. In both the optic nerve and retina, caspase 3 was activated in the right and left sides following blast exposure. The results of this study reveal that blast exposure induces apoptosis in both the optic nerve and retinal tissues.

The corneal endothelium is paramount to the health and function of the cornea as damage to this cell layer can lead to corneal edema, opacification, and ultimately vision loss. Transplantation of the corneal endothelium is associated with numerous limitations, including graft rejection, thus an alternative therapeutic treatment is needed to restore endothelial layer integrity. We hypothesize that a nanotechnology-based approach using superparamagnetic iron oxide nanoparticles (SPIONPs) can ultimately be used to guide corneal endothelial cells (CECs) to injured areas via an external magnetic force without changing their morphology or viability. In this feasibility study we examined the effects of SPIONPs on the morphology and viability of bovine CECs in the presence of a magnetic force. The CECs were exposed to increasing SPIONP concentrations and the viability and cytoskeletal structure assessed over 3 days via metabolic analysis and rhodamine phalloidin staining. Significant differences (p.05) in the metabolic activity of the CECs (100 × 10(6) SPIONP/cell) occurred in the presence of magnetic force versus those with no magnetic force. No differences were observed in the cytoskeleton of CECs in the presence or absence of magnetic force for all SPIONP concentrations. These SPIONPs will next be evaluated with human CECs for future applications.

PURPOSE: To report traumatic injury of a patient implanted with Visian Implantable Collamer (ICL) (STAAR Surgical) lenses. METHODS: A 31-year-old man underwent bilateral implantation of Visian ICLs in 2006. Eight months postoperatively, the patient was serving in a combat zone and sustained blunt and fragmentation injuries from a grenade explosion. He was wearing full battle gear, which included ballistic-tested sunglasses, at the time of the assault. RESULTS: Large intraorbital foreign bodies and globe trauma were identifi ed as a result of the grenade explosion. Visual acuity was unaffected and the phakic intraocular lenses remained stable. CONCLUSIONS: This fi rst report of combat trauma in a patient implanted with bilateral phakic ICLs emphasizes the importance of eye protection. Further study of the stability and cataract formation rates in eyes that sustain blunt trauma after ICL implantation is needed. [J Refract Surg. 2008;xx:xxx-xxx.] Implantation of phakic intraocular lenses offer a solution for the ametropic patient who would not otherwise qualify for corneal refractive surgery. The Visian Implantable Collamer Lens (ICL) (STAAR Surgical, Monrovia, Calif) is a phakic posterior chamber lens fi rst approved by the US Food and Drug Administration (FDA) in 2005 for the correction of myopia between 3.00 diopters (D) and 15.00 D and for the reduction of myopia between 15.00 D and 20.00 D. With few complications reported in the 3-year followup multicenter FDA study, the short-term safety and effi cacy of the ICL lens is well established.1 Long-term stability of these lenses is still being evaluated. We present a patient with bilateral Visian ICLs who sustained a grenade injury while in a combat zone. To our knowledge, this is the fi rst report of combat trauma in a patient with bilateral phakic ICLs. CASE REPORT A 31-year-old male active duty Army infantry soldier had bilateral Visian ICLs implanted in the right and left eyes on September 7 and October 12, 2006, respectively (4th version, size 13.2 mm, 10.00 D in both eyes). Preoperative manifest refraction was 9.75 1.00 145 (20/20) in the right eye and 9.75 1.00 017 (20/20) in the left eye. Preoperative automated keratometry was 43.25/43.75@109 and 44.25/44.25@090 in the right and left eyes, respectively. Two separate laser peripheral iridotomies were performed in each eye at least 1 week prior to the surgery. Before ICL implantation, a small, non-visually signifi cant anterior subcapsular cataract was noted in the left eye near the nasal iridotomy site. The patient was treated with prednisolone acetate 1% four times daily for 1 week after the iridotomies. Prior to the ICL placements, the patient was given gatifl oxacin 0.3% and ketorolac 0.4% four times daily for 3 days. While performing a patrol in Baghdad, Iraq, on June 28, 2006, our patient sustained an injury from a grenade while attending to a fellow wounded soldier. The grenade detonated approximately 5 feet away within a large pile of debris. The patient suffered no loss of consciousness, acute decrease in vision, and was not thrown from the blast. At the time of injury, he was wearing full battle gear to include standard issue, ballistic-tested sunglasses. The patient fi rst received a formal evaluation of his eyes at the combat support hospital in Baghdad. He was without visual complaints and had uncorrected near vision of 20/20 in both eyes. Intraocular pressure (IOP) measured with the Tono-Pen tonometer (Intermedics Intraocular, Pasadena, Calif) was 12 and 11 mmHg in the right and left eyes, respectively. Extraocular motility was normal and there was no afferent pupillary defect. Right periorbital and lower eyelid ecchymosis and edema were present, in addition to a subconjunctival hemorrhage temporally. Dilated fundus examination of the right eye revealed a 5to 6-disc diameter area of subretinal hemorrhage in the inferotemporal periphery. B-scan did not reveal any intraocular foreign body. A computed tomography (CT) scan of the orbits (Fig 1) revealed a small, metallic foreign body measuring approximately 1.3 mm adjacent to the right inferior oblique muscle insertion. A second metallic foreign body measuring 3 mm was located in the soft tissues anterior to the superior From Brooke Army Medical Center, San Antonio, Tex (McCauley, Johnson); and Tulane University School of Medicine, New Orleans, La (Anderson). The authors have no financial or proprietary interest in the materials presented herein. Correspondence: Matthew B. McCauley, MD, Brooke Army Medical Ctr, Dept of Ophthalmology, MCHE-SDO, 3851 Roger Brooke Dr, Ft Sam Houston, TX 78234-6200. Tel: 210.916.1245; Fax: 210.916.2946; E-mail: Matthew.McCauley@AMEDD.ARMY.MIL Received: December 4, 2007 Accepted: February 27, 2008

The intent of this review is to comprehensively appraise the state of the art with regard to Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to the ocular surface complications and their management. SJS and TEN represent two ends of a spectrum of immune-mediated, dermatobullous disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. The widespread keratinocyte death seen in SJS/TEN is rapid and irreversible, and even with early and aggressive intervention, morbidity is severe and mortality not uncommon. We have divided this review into two parts. Part I summarizes the epidemiology and immunopathogenesis of SJS/TEN and discusses systemic therapy and its possible benefits. We hope this review will help the ophthalmologist better understand the mechanisms of disease in SJS/TEN and enhance their care of patients with this complex and often debilitating disease. Part II (April 2016 issue) will focus on ophthalmic manifestations.

Background Adding epinephrine to lidocaine solutions for peripheral nerve block potentiates and prolongs the action, but by incompletely understood mechanisms. In an effort to discriminate the pharmacokinetic from the pharmacodynamic effects of epinephrine, the authors measured the lidocaine content of peripheral nerve over the course of block produced by 0.5% lidocaine, with and without epinephrine, and correlated it with the degree of analgesia. Methods Percutaneous sciatic nerve blocks were performed in 18 groups of rats (10 in each) with 0.1 ml of either 0.5% lidocaine or 0.5% lidocaine with epinephrine (1:100,000). Over the full course of nerve block, the authors regularly measured analgesia to toe pinch and then rapidly removed nerves to assay intraneural lidocaine content at 2-120 min after injection. Results The kinetics of lidocaine's clearance from nerve was composed of a fast-decaying transient superimposed on a very slowly decaying component. The effect of epinephrine on the intraneural lidocaine content was to increase the amount of lidocaine in the slow-decaying component by threefold to fourfold, although the total neural content was not altered by epinephrine for the first 10 min after injection. Epinephrine prolonged blockade by almost fourfold and enhanced the intensity of peak analgesia, as well as the fraction of rats with complete block, almost throughout the 2-120-min period of behavioral observation. Conclusions Adding epinephrine to lidocaine solutions increases the intensity and duration of sciatic nerve block in the rat. The early increase in intensity is not matched with an increase in intraneural lidocaine content at these early times, although the prolonged duration of block by epinephrine appears to correspond to an enlarged lidocaine content in nerve at later times, as if a very slowly emptying "effector compartment" received a larger share of the dose. The increase in early analgesia without increased lidocaine content may be explained by a pharmacodynamic action of epinephrine that transiently enhances lidocaine's potency, but also by a pharmacokinetic effect that alters the distribution of the same net content of lidocaine within the nerve.

The incidence of blast-induced ocular injury has dramatically increased due to advances in weaponry and military tactics. A single exposure to blast overpressure (BOP) has been shown to cause damage to the eye in animal models; however, on the battlefield, military personnel are exposed to BOP multiple times. The effects of repeated exposures to BOP on ocular tissues have not been investigated. The purpose of this study is to characterize the effects of single or repeated exposure on ocular tissues.A compressed air shock tube was used to deliver 70 ± 7 KPa BOP to rats, once (single blast overpressure [SBOP]) or once daily for 5 days (repeated blast overpressure [RBOP]). Immunohistochemistry was performed to characterize the pathophysiology of ocular injuries induced by SBOP and RBOP. Apoptosis was determined by quantification activated caspase 3. Gliosis was examined by detection of glial fibrillary acidic protein (GFAP). Inflammation was examined by detection of CD68.Activated caspase 3 was detected in ocular tissues from all animals subjected to BOP, while those exposed to RBOP had more activated caspase 3 in the optic nerve than those exposed to SBOP. GFAP was detected in the retinas from all animals subjected to BOP. CD68 was detected in optic nerves from all animals exposed to BOP.SBOP and RBOP induced retinal damage. RBOP caused more apoptosis in the optic nerve than SBOP, suggesting that RBOP causes more severe optic neuropathy than SBOP. SBOP and RBOP caused gliosis in the retina and increased inflammation in the optic nerve.

Twin anemia–polycythemia sequence (TAPS) is a rare variant of twin–twin transfusion syndrome (TTTS) without the characteristic twin oligohydramnios–polyhydramnios sequence and cardiovascular milieu attributed to renin–angiotensin system mediators. It can occur spontaneously or iatrogenically after fetoscopic laser surgery. We report the case of a woman, gravida 2 para 1, with a monochorionic diamniotic pregnancy who developed Quintero Stage III TTTS. She underwent laser photocoagulation of identifiable anastomotic vessels and subsequently developed suspected TAPS 2 weeks later. The pregnancy was successfully treated with serial intrauterine intraperitoneal transfusions (IUT-PTs) of red blood cells. Although TAPS is a rare condition, serial middle cerebral artery peak systolic velocity measurements are warranted as follow-up in patients who have undergone fetoscopic laser surgery for TTTS. IUT-PTs may be superior to intravascular intrauterine transfusions in the treatment of this condition. Copyright © 2009 ISUOG. Published by John Wiley & Sons, Ltd.

First-trimester growth restriction has been reported in certain aneuploid pregnancies. The purpose of this study was to evaluate this association further by comparing the crown-rump lengths (CRLs) and growth rates from 196 chromosomally abnormal fetuses with a control population of 1929 euploid fetuses. The mean CRLs and growth rates were significantly reduced (P < 0.05) in the groups of fetuses with trisomy 18 (n = 49), trisomy 13 (n = 19), and triploidy (n = 8). Using a fifth percentile cut-off, growth rate was a better discriminator than a single CRL in identifying fetuses affected with these aneuploidies. These growth parameters were not significantly reduced in fetuses with trisomy 21 (n = 92), sex chromosome trisomies (n = 20), or 45,X (n = 8). We conclude that fetal growth restriction associated with an underlying chromosome abnormality can occur as early as the first trimester. This phenomenon results from intrinsic fetal factors and not delayed ovulation. Such information is important to establish as first-trimester serum screening evolves.

The pathology of aerosolized staphylococcal enterotoxin B (SEB) was studied in the nonhuman primate. Six juvenile rhesus monkeys that received multiple lethal inhaled doses of SEB developed diarrhea and vomiting within 24 hr followed by depression, dyspnea, and shock. Three of 6 animals died by 52 hr. The most striking gross lesion in all 6 monkeys was diffuse severe pulmonary edema. Histologically, edema fluid was present within the peribronchiolar, peribronchial, and perivascular interstitium, alveolar septa, and alveoli. The adventitia of pulmonary vessels was infiltrated by lymphocytes, macrophages, and fewer neutrophils. Numerous large lymphocytes with occasional mitotic figures were within pulmonary vessels, often occluding alveolar capillaries. These cells were strongly immunoreactive with monoclonal antibodies against CD3, establishing them as T cells. Ultrastructurally, endothelial cell junctions were intact, and endothelial cells and type I pneumocytes contained numerous pinocytotic vesicles. Alveolar septal interstitial spaces were expanded by edema. The mechanism of these SEB-induced pulmonary lesions was not determined. We hypothesize that cytokine production by activated T cells may have caused vascular permeability changes leading to widespread pulmonary edema and shock.

Plasmodium falciparum chemosensitivity to the various antimalarial drugs is presently determined in the laboratory by setting up multiple microcultures of the parasite and estimating the amount of growth inhibition caused by known concentrations of drug. Parasite growth inhibition is assessed either by microscopy, radiolabeled substrate uptake, or calorimetrically. The obligate requirement for serum in this assay presents difficulties in the direct comparison of results among laboratories. We now have evidence that antimalarial drug sensitivity assays can be reliably performed in a serum-free medium. The overall comparison of 50% inhibitory concentration (IC50) values obtained with serum-free media (bovine albumin, Cohn fraction V [BAM] and BAM combined with glucose and lipids-cholesterol-rich mixture) and those obtained in serum-supplemented medium was r = 0.56; n = 60; P < 0.01.

Hemorrhagic smallpox was a rare but severe manifestation of variola virus infection that resulted in nearly 100% mortality. Here we describe intravenous (IV) inoculation of cowpox virus Brighton Red strain in cynomolgus macaques (Macaca fascicularis) which resulted in disease similar in presentation to hemorrhagic smallpox in humans. IV inoculation of macaques resulted in a uniformly lethal disease within 12days post-inoculation in two independent experiments. Clinical observations and hematological and histopathological findings support hemorrhagic disease. Cowpox virus replicated to high levels in blood (8.0–9.0 log10 gene copies/mL) and tissues including lymph nodes, thymus, spleen, bone marrow, and lungs. This unique model of hemorrhagic orthopoxvirus infection provides an accessible means to further study orthopoxvirus pathogenesis and to identify virus-specific and nonspecific therapies. Such studies will serve to complement the existing nonhuman primate models of more classical poxviral disease.

Smallpox, caused by variola virus (VARV), is a devastating human disease that affected millions worldwide until the virus was eradicated in the 1970 s. Subsequent cessation of vaccination has resulted in an immunologically naive human population that would be at risk should VARV be used as an agent of bioterrorism. The development of antivirals and improved vaccines to counter this threat would be facilitated by the development of animal models using authentic VARV. Towards this end, cynomolgus macaques were identified as adequate hosts for VARV, developing ordinary or hemorrhagic smallpox in a dose-dependent fashion. To further refine this model, we performed a serial sampling study on macaques exposed to doses of VARV strain Harper calibrated to induce ordinary or hemorrhagic disease. Several key differences were noted between these models. In the ordinary smallpox model, lymphoid and myeloid hyperplasias were consistently found whereas lymphocytolysis and hematopoietic necrosis developed in hemorrhagic smallpox. Viral antigen accumulation, as assessed immunohistochemically, was mild and transient in the ordinary smallpox model. In contrast, in the hemorrhagic model antigen distribution was widespread and included tissues and cells not involved in the ordinary model. Hemorrhagic smallpox developed only in the presence of secondary bacterial infections - an observation also commonly noted in historical reports of human smallpox. Together, our results support the macaque model as an excellent surrogate for human smallpox in terms of disease onset, acute disease course, and gross and histopathological lesions.

With the expanding list of prenatally detectable disorders, increasing numbers of patients are presented with the option of invasive prenatal diagnosis. Care providers need to address questions regarding the safety and accuracy of these procedures, as well as the indication. This article reviews these issues for genetic amniocentesis and chorionic villus sampling.

Purpose: To report a case of a spontaneous subconjunctival abscess in a patient with no previous ocular surgery or trauma. Method: Case report. Results: We report a case of a subconjunctival abscess caused by Haemophilus influenzae after several days of worsening conjunctivitis. Computed tomography scans of the orbits confirmed an abscess cavity adjacent to the globe without orbital extension. The abscess was spontaneously draining at presentation and resolved completely with topical and oral antibiotic therapy. Conclusions: To our knowledge, this is the first described case of spontaneous subconjunctival abscess formation in an immunocompetent individual unrelated to preexisting ocular pathology, previous ocular surgery, or trauma. H. influenzae species may possess the ability to penetrate an intact conjunctiva and develop subconjunctival abscess. We recommend that patients presenting with bacterial conjunctivitis be closely examined to rule out subconjunctival abscess, which may require additional aggressive medical or surgical management.

A congenic rat strain (WF.LEW) was derived from the susceptible Wistar-Furth (WF) (background strain) and the resistant LEW (donor strain) inbred strains and was used to evaluate the phenotypic expression of a dominant Mendelian gene that confers resistance to fatal hepatic disease caused by the ZH501 strain of Rift Valley fever virus (RVFV). Resistance to hepatic disease developed gradually with age, with full expression at approximately 10 weeks in the WF.LEW and LEW rat strains. The ZH501 strain caused fatal hepatitis in WF rats regardless of age. However, resistance to the SA75 RVFV strain (relatively non-pathogenic for adult rats), was age- and dose-dependent in both WF and LEW rats. The resistance gene transferred to the newly derived WF.LEW congenic rat strain appears to amplify age-dependent resistance of adult rats, resulting in protection against fatal hepatic disease caused by the virulent ZH501 strain. The congenic rat strain will be a valuable asset in elucidating the mechanism of resistance to Rift Valley fever virus governed by the dominant Mendelian gene.

Since the events of 9/11, America again views itself in a conflict of values similar to the Cold War, which witnessed the triumph of freedom and democracy over the threats of fascism and communism. The United States' current National Security Strategy (NSS) prepossess to counter the growth of radical Islam through the promotion of human rights and freedom by the process of democratization throughout the world. This paper examines the premise that "universal human rights", as the basis for democracy, is compatible with Islamic culture and is therefore a sound strategy for combating the spread of "Islamic fundamentalism" within the Muslim world. This strategy presupposes that there is a universal set of Human Rights that are acceptable and transferable to all peoples. In order for democratization to succeed the concept of individual human rights must exist. Plainly stated, the NSS presumes first, that Islam is the peaceful religion that can embrace democracy but has been influenced by extremists, and if given the opportunity Muslim people will choose freedom over tyranny. Are these presuppositions true or simply a Western culture heuristic? The question of universal human rights and its compatibility to Islamic culture becomes critical to the democratization strategy.

Purpose To document the incidence and treatment of patients with severe ocular and ocular adnexal injuries during Operation Iraqi Freedom. Design Retrospective hospital-based observational analysis of injuries. Participants All coalition forces, enemy prisoners of war, and civilians with severe ocular and ocular adnexal injuries. Methods The authors retrospectively examined severe ocular and ocular adnexal injuries that were treated by United States Army ophthalmologists during the war in Iraq from March 2003 through December 2005. Main Outcome Measures Incidence, causes, and treatment of severe ocular and ocular adnexal injuries. Results During the time data were gathered, 797 severe eye injuries were treated. The most common cause of the eye injuries was explosions with fragmentation injury. Among those injured, there were 438 open globe injuries, of which 49 were bilateral. A total of 116 eyes were removed (enucleation, evisceration, or exenteration), of which 6 patients required bilateral enucleation. Injuries to other body systems were common. Conclusions Severe eye injuries represent a significant form of trauma encountered in Operation Iraqi Freedom. These injuries were most commonly caused by explosion trauma.