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PubMed1998

Estimation of effective dose in some digital angiographic and interventional procedures.

In general, effective dose values for similar interventional vascular radiology (IVR) procedures are different. This is due to problems with the classification of radiological procedures, which make comparisons difficult. Patient size, examination technique and clinical condition as well as the skill of the medical radiologists also affect effective dose. Currently, there is a broad agreement on the classification of similar procedures so that effective dose estimates can be made from measurements of the dose area product (DAP). Thus, reference dose values may be established and comparative studies between different services and hospitals can be made. The objective of this study is to provide dose data for some digital angiographic and interventional procedures. Values of measured DAP for 143 patients for five types of procedures are presented. Procedures investigated were abdominal angiography, arteriography of lower limbs, biliary drainage, embolization of spermatic vein and nephrostomy. All the procedures were performed using digital equipment. Values of DAP and effective dose were 30 Gy cm2 and 6.2 mSv for arteriography of lower limbs and 150 Gy cm2 and 38.2 mSv for biliary drainage. In each one of these procedures, effective dose values per minute of fluoroscopy and per radiography film have been calculated. It is possible to use this information for the rapid estimation of effective dose.

Abdomen↗
PubMed1982

Lateral tarsal strip procedure for the correction of paralytic ectropion.

Otolaryngologists are frequently confronted with patients suffering from permanent facial paralysis. This condition often results in a severe cosmetic and functional deformity of the lower eyelid called paralytic ectropion. Conservative measures are often unsatisfactory and surgical correction is needed. Tarsorrhaphy and cautery have been advocated in the past, but are usually unsatisfactory. The most standard surgical procedure in use at the present time is a modification of the Kuhnt-Szymanowski procedure which is useful in repositioning the lax eyelid and allowing for lid shortening. This procedure involves removal of a portion of the midtarsal plate, but does not correct the lax lateral canthal tendon which is the cause of the pathology in paralytic ectropion. In 1979, in the ophthalmologic literature, Anderson and Gordy reported the tarsal strip procedure for the correction of paralytic and senile ectropion. This paper describes the lateral tarsal strip procedure which involves a lateral canthotomy, division of the lateral portion of the lower eyelid into musculocutaneous and tarsoconjunctival layers, removal of a portion of the conjunctiva and suturing the resulting tarsal strip to the periosteum of the inner aspect of the orbital rim laterally to shorten and elevate the lower eyelid. The procedure is presented in diagrams and close-up operative photographs. Before and after photographic documentations of two clinical cases are also presented. Since this procedure has been employed for only about two years, long-term results are not yet available; however, the author feels that this procedure will offer a significant improvement in the surgical treatment of paralytic ectropion.

Aged↗
PubMed1992

The role of transbronchial lung biopsy in the treatment of lung transplant recipients. An analysis of 200 consecutive procedures.

STUDY OBJECTIVE: The purposes of this study were as follows: (1) to establish the positivity rate and complication rate of transbronchial lung biopsies in the treatment of lung transplant recipients; (2) to determine the sensitivity of transbronchial lung biopsy specimens for the diagnosis of clinically suspected acute rejection and cytomegalovirus pneumonia; and (3) to examine the results of surveillance transbronchial lung biopsies in clinically and physiologically stable recipients. DESIGN: Retrospective review and analysis of 203 consecutive procedures. SETTING: Washington University Lung Transplantation Program, Washington University School of Medicine and Barnes Hospital, St. Louis, Mo. PATIENTS: Fifty-five lung transplant recipients. INTERVENTIONS: Biopsies were done with 2-mm fenestrated forceps using fluoroscopic guidance. Two hundred three bronchoscopies with transbronchial lung biopsy were performed for clinical indications (n = 88), routine surveillance (n = 90), or follow-up of a previous biopsy (n = 25). Biopsy specimens showing acute allograft rejection were classified according to the scheme recommended by the Lung Rejection Study Group. MEASUREMENTS AND RESULTS: The positivity rate and complication rate were determined for the procedures. In procedures performed for clinical indications, the sensitivity for the diagnosis of acute rejection and cytomegalovirus pneumonia was calculated by a decision-to-treat analysis. A specific histologic diagnosis was detected in 69 percent of the clinical procedures, 57 percent of the surveillance procedures, and 64 percent of the follow-up procedures. For clinical indications, the sensitivity of transbronchial lung biopsy was 72 percent for the diagnosis of acute rejection and 91 percent for the diagnosis of cytomegalovirus pneumonia. Surveillance biopsy specimens often showed clinically inapparent rejection or cytomegalovirus pneumonia. The overall complication rate was 8.9 percent; none of the complications were life threatening. CONCLUSIONS: Transbronchial lung biopsy is a useful and safe procedure in the treatment of lung transplant recipients. When performed for clinical indications, the procedure proved to be sensitive for the diagnosis of acute rejection and cytomegalovirus pneumonia. When performed for surveillance in clinically and physiologically stable recipients, the incidence of rejection and cytomegalovirus pneumonia was unexpectedly high; the potential clinical implications of these findings will require further study.

Biopsy, Needle↗
PubMed1999

Evaluation of patient-related and procedure-related factors contributing to pneumothorax following thoracentesis.

OBJECTIVE: To evaluate patient-related and procedure-related risk factors for thoracentesis-related pneumothorax. DESIGN: Prospective, nonrandomized cohort study. SETTING: Pulmonary Special Procedures Unit of a university medical center. METHODS: Thoracentesis using either a 22-gauge, a Boutin, or a Cope needle (depending on availability and operator preference) was performed by the pulmonary faculty or by pulmonary physicians-in-training under faculty supervision. In order to control for effusion size and the presence of loculations, chest radiography and pleural ultrasonography were performed prior to each thoracentesis. Potential patient-related and procedure-related risk factors for pneumothorax were analyzed at the procedure level using the presence or absence of pneumothorax on the postprocedure chest radiograph as the sole outcome variable. RESULTS: Two hundred fifty-five thoracenteses were performed in 205 adult patients (113 men and 92 women; mean age, 58.8+/-18 years) over a 3(1/2)-year period. One hundred fifty procedures were performed for diagnostic purposes, 28 procedures were performed for therapeutic purposes, and 77 procedures were performed for both diagnostic and therapeutic purposes. Based on the radiographic criteria, 152 effusions (60%) were small. Loculations were present in 76 patients (30%). Pneumothoraces occurred in 14 instances (5.4%), and chest tube drainage was required in 2 instances (0.78%). Hospitalization status, critical illness, effusion size or type, presence of loculations, operator, needle type, amount of fluid withdrawn, occurrence of dry tap, and type of thoracentesis were not associated with an increased frequency of pneumothorax. The only predictor variable demonstrating statistical significance was repeated thoracentesis. CONCLUSION: The results of a bivariate analysis suggest that pneumothorax following thoracentesis is a rare event that is not easily predictable when the procedure is performed by experienced operators in a controlled setting.

Chest Tubes↗
PubMed2006

IFCC primary reference procedures for the measurement of catalytic activity concentrations of enzymes at 37 degrees C.

This paper is the eighth in a series dealing with reference procedures for the measurement of catalytic activity concentrations of enzymes at 37 degrees C and the certification of reference preparations. Other parts deal with: Part 1. The concept of reference procedures for the measurement of catalytic activity concentrations of enzymes; Part 2. Reference procedure for the measurement of catalytic concentration of creatine kinase; Part 3. Reference procedure for the measurement of catalytic concentration of lactate dehydrogenase; Part 4. Reference procedure for the measurement of catalytic concentration of alanine aminotransferase Part 5. Reference procedure for the measurement of catalytic concentration of aspartate aminotransferase Part 6. Reference procedure for the measurement of catalytic concentration of gamma-glutamyltransferase; Part 7. Certification of four reference materials for the determination of enzymatic activity of gamma-glutamyltransferase, lactate dehydrogenase, alanine aminotransferase and creatine kinase at 37 degrees C. The procedure described here is deduced from the previously described 30 degrees C IFCC reference method. Differences are tabulated and commented on.

Alanine Transaminase↗
PubMed1982

An operant tracking procedure in the auditory assessment of profoundly retarded individuals.

The present study investigated a discrete-trials, operant tracking and a descending-series procedure for the determination of hearing levels with profoundly retarded individuals. These individuals were previously diagnosed as untestable. Following stimulus-control training with errorless discrimination procedures, hearing levels for each individual were examined with both procedures. For P-1 and P-2, the operant tracking procedure was administered following a descending-series procedure. Both were observed to "track" their own hearing levels. For P-3, the operant tracking procedure was administered first, followed by the descending-series procedure. Although P-3 also "tracked" her own hearing level, more variable responding was observed. Nonetheless, the operant tracking procedure proved quite workable and may provide for improved hearing testing with "difficult-to-test" individuals.

Adolescent↗
PubMed1993

Stimulus control and response bias in an analogue prey-detection procedure.

The present study compared the performance of 6 pigeons trained to detect luminance differences in two different signal-detection procedures. Exposed to a three-key array, the pigeons were trained to peck the left key when the brighter of two light intensities had been presented on the center key and to peck the right key when the dimmer of two light intensities had been presented on the center key. Procedure A was a standard signal-detection procedure in which left/bright and right/dim responses produced food reinforcement and left/dim and right/bright responses produced periods of timeout. Procedure B was designed to simulate some of the contingencies operating in a prey-detection situation. Left-key responses produced reinforcement following the brighter center-key stimulus and a period of timeout following the dimmer center-key stimulus. Right-key responses always produced a short period of timeout irrespective of the stimulus. Within each procedure, the duration of timeout arranged for false alarms (left/dim responses) was varied between 3 s and 120 s. Measures of accuracy and response bias were compared between the two procedures. The timeout manipulation produced systematic, but relatively small, changes in these measures when right/dim responses (i.e., correct rejections) produced reinforcement (Procedure A). Arranging timeout for right/dim responses in Procedure B produced greater variability in accuracy and response bias than did arranging reinforcement, but this variability was not related to timeout duration. Overall, discrimination accuracy was considerably higher when right/dim responses produced timeout than when they resulted in reinforcement, and accuracy was accompanied by a large bias toward the response associated with reinforcement. These results are consistent with a recently proposed model of signal detection.

Journal Article↗
PubMed2002

Attendance problems and disciplinary procedures in Nebraska schools.

STUDY PURPOSE: School principals were surveyed in rural and urban Nebraska schools to compare policies and procedures on school attendance, and to contrast the use of disciplinary procedures for attendance, violence and substance abuse. METHODS: A survey was sent to a 50 percent random sample of Nebraska schools. Respondent school addresses in metropolitan statistical areas (MSA) areas were categorized as urban, and non-MSA respondents were classified as rural area schools. RESULTS: Of the 680 surveys mailed, 464 (68.2 percent) completed surveys were returned. Overall, 86.2 percent of respondents were from rural schools and 13.8 percent from urban schools. A list of disciplinary problems and procedures was reported for a first-time offense by rural and urban schools. Both an "occasional attendance problem" and a "chronic attendance problem" were most frequently addressed through parent contact in both urban and rural areas. For "fighting with another student," rural schools most commonly reported discipline by teacher, followed by discipline by principal and parent contact. In urban schools, discipline by principal was most common. For "using drugs other than alcohol or tobacco at school" in both areas, disciplinary procedures included parent contact and short-term suspension. A list of disciplinary problems and procedures was also reported for a second-time offense and third-time offense. For "fighting with another student," the most commonly reported procedure was discipline by principal and parent contact for a second-time offense, followed by short-term suspension and long-term suspension for a third-time offense. For "using drugs other than alcohol or tobacco at school," for a second time offense was long-term suspension and semester expulsion for a third-time offense. Principals were also asked in an open-response format, what program or procedures were currently in place to prevent violence in their school. Common responses were "conflict resolution training," followed by "the Boys Town social skills and behaviors model" and "a zero tolerance policy." CONCLUSIONS: School principals generally reported similar disciplinary actions for most disciplinary problems. For recurrent offenses and for serious problems, principals generally used tougher disciplinary procedures. Some of the discrepancies in disciplinary actions, however, suggest the need for consistent enforcement and communication of policies for both urban and rural schools.

Absenteeism↗
PubMed2000

Comparison of sonographic and CT guidance techniques: does CT fluoroscopy decrease procedure time?

OBJECTIVE: Procedure times for percutaneous biopsies were compared for various guidance techniques including helical CT, CT fluoroscopy, sonography with an attached needle guide, and freehand sonography with computer guidance. MATERIALS AND METHODS: Three interventional radiologists experienced in CT- and sonographically guided procedures performed biopsies on a phantom model. The phantom simulated hepatic metastases of various sizes and depths with subcostal or intercostal locations. Lesion sizes were 7, 10, and 20 mm, at 3- and 7-cm depths. Using self-aspirating needles, two passes were performed in each lesion. Mean procedure time per biopsy pass was calculated. A two-tailed Student's t test was used to compare guidance techniques. RESULTS: Mean procedure time per biopsy pass for the four guidance techniques was sonography with a needle guide, 36+/-9 sec; sonography with computer guidance, 43+/-10 sec; helical CT, 146+/-42 sec; and CT fluoroscopy, 50+/-18 sec. CT fluoroscopy required 2.6+/-1.0 sec per biopsy. Helical CT required more procedure time than sonography with a needle guide, CT with computer guidance, and CT fluoroscopy (p < 0.0001). Sonography with a needle guide required less procedure time than sonography with computer guidance (p < 0.002) and CT fluoroscopy (p = 0.0003). Procedure times for CT fluoroscopy and sonography with computer guidance were not statistically different (p = 0.06). CT and sonographic guidance were equally effective regardless of lesion size, depth, or location. CONCLUSION: Traditional sonographic biopsy techniques are faster and more cost-effective than traditional CT techniques; however, CT fluoroscopy offers the localization advantages of CT with improved procedure times.

Abdomen↗
PubMed2000

Bacterial contamination of suction tips used during surgical procedures performed on dogs and cats.

OBJECTIVE: To determine prevalence of bacterial contamination of surgical suction tips. SAMPLE POPULATION: Surgical tips used during 44 surgical procedures performed on 42 dogs and 2 cats. PROCEDURE: Surgical procedures were classified into 1 of 3 categories according to degree of bacterial contamination of the surgical site (clean, clean-contaminated, contaminated). Two sets of suction apparatuses were used for test and control suction tips. Test tips were used normally to suction blood and fluid, whereas control tips were placed on the surgical drapes but not in the surgical wound. Suction tips were collected aseptically and placed into thioglycolate broth tubes for qualitative aerobic and anaerobic bacterial culture at the end of each procedure. RESULTS: Test and control suction tips were contaminated with bacteria during 30 of 44 (68%) procedures. Staphylococcus spp were the predominant bacteria in tips used during clean and clean-contaminated surgeries. When surgery was performed on clean-contaminated or contaminated wounds, prevalence of isolation of other bacteria such as Pseudomonas spp, Streptococcus spp, and Escherichia coli from both test and control suction tips was higher than for clean wounds. Mean time of procedures during which both test and control suction tips became contaminated was not significantly different from time of procedures during which neither tip became contaminated. CONCLUSION AND CLINICAL RELEVANCE: Surgical suction tips often become contaminated during standard veterinary surgical procedures. The risk of wound infection after surgery may be influenced by bacterial contamination of surgical suction tips.

Animals↗
PubMed1998

Development and evaluation of a procedure for fitting multi-channel compression hearing aids.

Hearing aids with multi-channel compression are often fitted on the basis of loudness scaling data obtained using narrow bands of noise or tones. Here, we report the development and evaluation of an alternative fitting procedure based on the use of speech signals. The parameters of the hearing aid (the gains in each channel for high and low input levels) are adjusted adaptively under computer control on the basis of the listener's responses. The goal is that speech at 85 dB SPL should be judged as 'loud', speech at 60 dB SPL should be judged as 'quiet', and speech at both levels should be judged as 'neither tinny nor boomy'. The procedure was evaluated using a two-channel compression hearing aid, the remote control of which allowed two programs to be stored. One program was based on our fitting procedure. The other was either based on the manufacturer's recommended full fitting procedure (which included loudness scaling with bands of noise), or was based on the audiogram alone, using the manufacturer's algorithm. After an acclimatization period of at least two weeks, subjects were then asked to fill in a questionnaire about their experiences with the two programs in different listening situations. The results generally indicated a preference for the program based on our adaptive fitting procedure. We also conducted laboratory measurements of speech intelligibility, in quiet and in a background of a single competing talker. These showed no clear difference between programs, although scores overall were very high. We conclude that our adaptive procedure gives very satisfactory results in everyday life. Parameter values giving good comfort also give good intelligibility. The procedure typically takes between five and 10 minutes per ear, which is quicker than most loudness scaling procedures.

Hearing Aids↗
PubMed1999

Frameless stereotaxy with scalp-applied fiducial markers for brain biopsy procedures: experience in 218 cases.

OBJECT: The goal of this study was to develop and assess the use and limitations of performing brain biopsy procedures by using image-guided surgical navigation systems (SNSs; that is, frameless stereotactic systems) with scalp-applied fiducial markers. METHODS: Two hundred eighteen percutaneous brain biopsies were performed in 213 patients by using a frameless stereotactic SNS that operated with either sonic or optical digitizer technology and scalp-applied fiducial markers for the purpose of registering image space with operating room space. Common neurosurgical and stereotactic instrumentation was adapted for use with a localizing wand, and recently developed target and trajectory guidance software was used. Eight (3.7%) of the 218 biopsy specimens were nondiagnostic; five of these (2.4%) were obtained during procedures in 208 supratentorial lesions and three were obtained during procedures in 10 infratentorial lesions (30%; p < 0.001). Complications related to the biopsy procedure occurred in eight patients (seven of whom had supratentorial lesions and one of whom had an infratentorial lesion, p > 0.25). Five complications were intracerebral hemorrhages (two of which required craniotomy), two were infections, and one was wound breakdown after instillation of intratumoral carmustine following biopsy. There were only three cases of sustained morbidity, and there were two deaths and one delayed deterioration due to disease progression. Two surgeons performed the majority of the procedures (193 cases). The three surgeons who performed more than 10 biopsies had complication rates lower than 5%, whereas two of the remaining four surgeons had complication rates greater than 10% (p = 0.15). Twenty-three additional procedures were performed in conjunction with the biopsies: nine brachytherapies; five computer-assisted endoscopies; four cyst aspirations; two instillations of carmustine; two placements of Ommaya reservoirs; and one craniotomy. CONCLUSIONS: Brain biopsy procedures in which guidance is provided by a frameless stereotactic SNS with scalp-applied fiducial markers represents a safe and effective alternative to frame-based stereotactic procedures for supratentorial lesions. There were comparable low rates of morbidity and a high degree of diagnostic success. Strategies for performing posterior fossa biopsies are suggested.

Adolescent↗
PubMed1995

Relationship between the auditory P300 and the procedural memory function in drug-naive patients with Parkinson's disease.

We evaluated and compared procedural memory and auditory P300 event-related potential in age-matched normal controls (n = 15) and drug-naive patients with Parkinson's disease (n = 16). We used Gollin's incomplete picture test for visual procedural memory function and Tower of Hanoi puzzle for visuomotor procedural memory function. The mean latency of P300 was significantly prolonged in the Parkinsonian group than in the controls. In the neuropsychology test, the patients group revealed selective impairment of visuomotor procedural memory against preserved visual procedural memory. In the patients group, the latency of P300 was inversely correlated with performance of visuomotor procedural memory. These results suggest that prolonged auditory P300 event-related potential show the dysfunction of visuomotor procedural memory in the basal ganglia, which appears to be more selectively impaired than visual procedural memory in drug-naive patients with Parkinson's disease.

Event-Related Potentials, P300↗
PubMed2005

The variance of d' estimates obtained in yes-no and two-interval forced choice procedures.

In studies of detection and discrimination, data are often obtained in the form of a 2 x 2 matrix and then converted to an estimate of d' based on the assumptions that the underlying decision distributions are Gaussian and equal in variance. The statistical properties of the estimate of d', d' are well understood for data obtained using the yes-no procedure, but less effort has been devoted to the more commonly used two-interval forced choice (2IFC) procedure. The variance associated with d' is a function of true d' in both procedures, but for small values of true d' the variance of d' obtained using the 2IFC procedure is predicted to be less than the variance of d' obtained using yes-no; for large values of true d', the variance of d' obtained using the 2IFC procedure is predicted to be greater than the variance of d' from yes-no. These results follow from standard assumptions about the relationship between the two procedures. The present paper reviews the statistical properties of d' obtained using the two standard procedures and compares estimates of the variance of d' as a function of true d' with the variance observed in values of d' obtained with a 2IFC procedure.

Analysis of Variance↗
PubMedDate not supplied

Treatment of ingrown toenails using a new conservative method: a prospective study comparing brace treatment with Emmert's procedure.

Ingrown toenails cause incapacitation and pain for the patient and lost time from work. Many different conservative and surgical treatment methods have been described. European chiropodists and podologists have long treated ingrown toenails with orthonyxia, which consists of implantation of a small metal brace or plate onto the dorsum of the nail. To determine whether orthonyxia is an acceptable alternative to surgery, we compared the VHO-Osthold brace (VHO-Osthold-Spange GmbH, Deisenhofen, Germany), a new method of orthonyxia, with Emmert's procedure, a standard surgical method that is virtually identical to the Winograd-type procedure, in a prospective study of 41 patients (21 in the brace group and 20 in the Emmert procedure group). Pain due to treatment was significantly lower in the brace group than in the Emmert procedure group, and patients in the brace group could wear regular shoes again without appreciable pain much earlier than those in the Emmert procedure group. In the brace group, there were four recurrences, and one patient was still receiving treatment at the end of follow-up; in the Emmert procedure group, there were three recurrences. None of the patients in the brace group had to take time off from work, whereas in the Emmert procedure group, working patients were off from work for an average of 14.7 days. Brace treatment proved to be a good conservative alternative to operative procedures.

Adolescent↗
PubMed1999

[Self-reported skills in practical procedures among young physicians].

There is at present no consensus as to which clinical procedures a student should be able to perform after graduation. The present study was undertaken to evaluate the self-reported skills level in practical procedures among graduates from the medical schools in Norway. A questionnaire was mailed to all students who entered internship between July 1996 and January 1998. They were asked to indicate on a visual-analogue scale the level of skill he or she had acquired in 88 practical clinical procedures. 519 of 621 (84%) graduates replied; 89% started internship immediately after graduation. Graduates from Tromsø reported significantly better skills than graduates from Oslo and Bergen. There was considerable variation within and between the universities with respect to several procedures. Overall, men reported a significantly better skills level than their female colleges. The present study demonstrates that the skills level in several procedures vary considerably between candidates graduating from different Norwegian universities after undergraduate medical education. For some procedures the skills level is, in our opinion, disquietingly low. The results of this survey indicate that teaching of clinical procedures in medical school is often random and of inferior quality. There is a need for a systematic approach and a national consensus on the clinical procedures to be acquired and the levels of skills to be attained.

Adult↗
PubMed2000

Results of the superior oblique tendon elongation procedure for severe Brown's syndrome.

PURPOSE: To evaluate the outcomes of the silicone tendon expander for the treatment of Brown's syndrome. METHODS: This paper consists of 2 parts: a chart review of patients who have under gone the silicone tendon elongation procedure for Brown's syndrome and a survey of the surgical experience of the members of the American Association of Pediatric Ophthalmology and Strabismus. Charts of 15 consecutive Brown's syndrome patients who underwent the superior oblique tendon expander were reviewed by the author from 1987 to 1997. An additional patient referred to the author for management of complications of the silicone tendon expander procedure after surgery elsewhere for Brown's syndrome is reported. The second aspect of the study is a fax survey sent to all 450 members of the American Association of Pediatric Ophthalmology and Strabismus listed in the 1997-1998 directory. Pediatric ophthalmologists were asked to answer questions regarding their experience using the silicone tendon expander for Brown's syndrome. RESULTS: Of 15 patients operated on by the author, preoperative limitation of elevation in adduction measured -4 in 14 patients and -3 in 1 patient preoperatively. Postoperatively, 14 of the 15 patients showed improved motility, with essentially normal versions in 10 patients (no more than +/- 1 oblique dysfunction); 3 patients were undercorrected (2 mild and 1 severely); and 2 had a consecutive superior oblique paresis (1 mild and 1 requiring an inferior oblique weakening procedure). The 1 patient with a severe undercorrection that did not improve after the silicone tendon elongation procedure showed continued restriction by intraoperative forced ductions after superior oblique tenotomy. Superior oblique tendon was not the cause of Brown's syndrome in this patient. The average final result graded on a scale of 1 to 10 (10 being best) was 8.3. Thirteen of 15 patients (87%) achieved a final result score of 7 or better with a single surgery, and an additional patient was corrected with a second surgery providing an overall success rate of 93%. Ten of the 15 patients had at least 11 months' follow-up, and 6 of the 10 patients showed a delayed improvement over a 4- to 6-month period. Five patients had more than 5 years of follow-up, and 4 (80%) had an excellent long-term outcome (final result, 9 to 10) with a single operations; all 5 had a good final outcome (final result, 7 to 10, mean 9.2) with 1 patient requiring a second surgery. There were no long-term complications, including no extrusions, no restriction of ocular rotations, and no infections. The patient who underwent the procedure elsewhere demonstrated limited movement of the eye to adduction elevation, and there was underaction of the ipsilateral superior oblique muscle. A reoperation performed by the author revealed positive forced ductions up and nasal ward. There were scars and adhesions in the area of the silicone implant, including scar to superior nasal sclera and superior rectus muscle. The silicone implant was removed and scar excised until forced ductions improved. This resulted in improved motility. Thirty-nine AAPOS members reported on 140 patients who had undergone the silicone tendon elongation procedure for Brown's syndrome. Judged by the surgeon on a scale of 1 to 10 (10 being best), 26 surgeons rated 91 patients (65%) as good with a score of 8 to 10, and 14 surgeons rated 18 patients (13%) poor with scores of 1 to 3. Complications were recorded for 9 patients and included scarring and restriction with removal of silicone implant in 4 and spontaneous extrusion in 5. Three of the 5 spontaneous extrusions came from the same surgeon, and in another case a surgeon used a 10 mm length of silicone. CONCLUSIONS: A novel procedure, the silicone tendon expander, is an effective option for correcting Brown's syndrome caused by a stiff or inelastic superior oblique tendon; long-term outcomes are excellent. Proper technique with maintenance of the tendon capsule is critical to the successful outcome of the procedure.

Eye Movements↗
PubMed2001

[Revision of failed dacryocystorhinostomies using the transcanalicular approach. Results of 118 procedures].

PURPOSE: To assess the efficacy of transcanalicular dacryocystorhinostomy for the revision of other procedures. The results are analyzed following the use of two different types of laser: the Neodymium: YAG (Nd: YAG) laser and the Holmium: YAG (Ho: YAG) laser. To study the efficacy of using two antimetabolite drugs in this context: mytomycin-C (MMC) and 5-fluoro-uracile (5-FU). METHODS: One hundred and fourteen patients were operated on. Of these, 88 had already undergone one procedure, 25 two procedures, and 5 three procedures. The Nd: YAG laser was used in 78 procedures, the Ho: YAG in 30 procedures, and both lasers in 10 procedures. Twenty patients were treated with an application of MMC and 25 patients with an application of 5-FU. RESULTS: The results are based on 106 procedures. The total success rate was 49.06% after one revision and 58.49% after two or three revisions. There is no statistically significant difference between the Nd: YAG and Ho: YAG lasers. The use of antimetabolites did not improve the success rate. CONCLUSION: Transcanalicular dacryocystorhinostomy is a very useful method because it does not cause cutaneous scarring and it has a low rate of morbidity given that it causes very little surgical traumatism. The revision of other dacryocystorhinostomy methods using the transcanalicular approach is theoretically a positive indication because it does not dissect scarring tissues and because the osteotomy has already been performed. However, the success rate is lower than for the external and endonasal approaches. The success rate is not modified by the use of antimetabolites or by the type of laser.

Adolescent↗