Pars plana vitrectomy for retinal detachment using perfluoro-n-octane as intraoperative tamponade:a multicenter,randomized,non-inferiority trial

AIM:To evaluate the efficacy and safety of perfluoro-n-octane(PFO)for ophthalmic surgery versus F-Octane as an intraoperative tamponade in pars plana vitrectomy(PPV)in management of retinal detachment.METHODS:This multicenter,prospective,randomized,double-masked,parallel-controlled,non-inferiority trial was conducted in three ophthalmology clinical centers in China.Patients with retinal detachment,who were eligible for PPV were consecutively enrolled.Participants were assigned to PFO for ophthalmic surgery or F-Octane for intraocular tamponade in a 1:1 ratio.Best-corrected visual acuity(BCVA),intraocular pressure(IOP)measurement,and dilated fundus examination were performed preoperatively and at 1,7±1,28±3d postoperatively.The primary outcome was complete retinal reattachment rate at postoperative day one.The non-inferiority margin was set at 9.8%.The secondary outcomes included intraoperative retinal reattachment rate,and mean changes in IOP and BCVA from baseline to 1,7±1,28±3d postoperatively,respectively.Safety analyses were presented for all randomly assigned participates in this study.RESULTS:Totally 124 eligible patients completed the study between Mar.14,2016 and Jun.7,2017.Sixty of them were randomly assigned to the PFO for ophthalmic surgery group,and 64 were assigned to the F-Octane group.Baseline characteristics were comparable between the two groups.Both groups achieved 100%retinal reattachment at postoperative day one(difference 0,95%CI:-6.21%to 5.75%,P=1).The pre-defined noninferiority criterion was met.No significant difference was observed in intraoperative retinal reattachment rate(difference 1.77%,P=0.61),mean changes in IOP(difference 0.36,-0.09,2.22 mm Hg at 1,7±1,28±3d postoperatively,with all P>0.05)and BCVA(difference 0.04,-0.02,0.06 logMAR at 1,7±1,28±3d postoperatively,all P>0.05)between the two groups.No apparent adverse events related to the utilization of PFO were reported.CONCLUSION:In patients with retinal detachment undergoing PPV,PFO for ophthalmic surgery is non-inferior to F-Octane as an intraocular tamponade,and both are safe and well-tolerated.

Pericardiocentesis with cisplatin for malignant pericardial effusion and tamponade

AIM:To evaluate the role and outcome of pericardiocentesis with intrapericardial cisplatin instillation for malignant pericardial effusion resulting from esophageal cancer. METHODS:We retrospectively studied 7 patients who underwent pericardiocentesis with intrapericardial cisplatin instillation for malignant pericardial effusion resulting from esophageal cancer.After pericardiocentesis,we performed catheterization of the pericardial space under ultrasonogram guidance.Malignant etiology of the pericardial fluid was confirmed by cytological examination.Subsequently,cisplatin(10 mg in 20 mL normal saline) was instilled into the pericardial space. RESULTS:The mean total volume of the aspirated effusion fluid was 782±264 mL(range,400-1200 mL) . The drainage catheter was successfully removed in all patients,and the mean duration of pericardial drainagewas 7.7±2.7 d(range,5-13 d) .No fluid reaccumulation was observed.Mean survival time was 120±71 d(range,68-268 d) . CONCLUSION:Pericardiocentesis along with catheter drainage appears to be a safe and effective for pericardial malignant effusion and tamponade,and cisplatin instillation prevents recurrence.

Vitrectomy combined with silicone oil tamponade in the treatment of severely traumatized eyes with the visual acuity of no light perception

AIM: To evaluate the efficacy of surgical treatment of vitrectomy combined with silicone oil tamponade in the treatment of severely traumatized eyes with the visual acuity of no light perception (NLP).METHODS: This was a retrospective uncontrolled interventional case-series of 19 patients of severely traumatized eyes with NLP who underwent vitrectomy surgery at the Affiliated Hospital of Medical College, Qingdao University (Qingdao, China) during a 3-year period. We recorded perioperative factors with the potential to influence functional outcome including duration from the injury to intervention; causes for ocular trauma; open globe or closed globe injury; grade of vitreous hemorrhage; grade of endophthalmitis; grade of retinal detachment; size and location of intraocular foreign body (IOFB); extent and position of retinal defect; grade of proliferative vitreoretinopathy (PVR); type of surgery; perioperative complications and tamponade agent. The follow-up time was from 3 to 18 months, and the mean time was 12 months.RESULTS: After a mean follow-up period of 12 months (3-18 months) 10.53% (2/19) of eyes had visual acuity of between 20/60 and 20/400, 52.63% (10/19) had visual acuity less than 20/400 but more than NLP, and 36.84% (7/19) remained NLP. Visual acuity was improved from NLP to light perception (LP) or better in 63.16% (12/19) of eyes and the rate of complete retinal reattachment was 73.68% (14/19). Good visual acuity all resulted from those patients of blunt trauma with intact eyewall (closed globe injury). The perioperative factors of poor visual acuity prognosis included delayed intervention; open globe injury; endophthalmitis; severe retinal detachment; large IOFB; macular defect; a wide range of retinal defects andsevere PVR.CONCLUSION: The main reasons of NLP after ocular trauma are severe vitreous hemorrhage opacity; refractive media opacity; retinal detachment; retinal and uveal damages and defects, especially defects of the macula; PVR and endophthalmitis. NLP after ocular trauma in some cases does not mean permanent vision loss. Early intervention of vitrectomy combined with silicone oil tamponade and achieving retinal reattachment of the remaining retina, may make the severely traumatized eyes regain the VA of LP or better.

Anatomical and functional outcomes after Densiron 68 heavy silicone oil tamponade for complicated retinal detachment in Chinese eyes

AIM:To evaluate the safety and efficacy of Densiron 68 heavy silicone oil (HSO) tamponade for complicated retinal detachment(RD)in Chinese eyes.METHODS:Twenty-one eyes of 21 patients with complicated RD were included in this retrospective study.All patients underwent pars plana vitrectomy with an internal tamponade using Densiron 68 HSO.Anatomical and functional results and complications were evaluated,including retinal status,visual acuity(VA),intraocular pressure(IOP),intraocular inflammation,lens opacity,and HSO emulsification.RESULTS:Allthepatients were followed up for 3mo to1y(5.8±1.16mo).Retinal reattachment was achieved in 19of 21 patients(90.5%).VA improved in 18 of 21 patients(85.7%),from 1.93 logMAR(±0.48)to 1.52 logMAR(±0.45)(P=0.001).Postoperative complications included early dispersion of HSO in 7 eyes(38.8%),cataract in 10 of 18phakic eyes(55.5%),moderate postoperative inflammation reaction in 10 eyes(47.6%),and elevated IOP in 5 eyes(23.8%),all of which were controlled by medication or by surgery.CONCLUSION:Highanatomical and functional success rates can be achieved with primary vitrectomy for complicated RD by using Densiron 68 HSO;however,it should not be ignored that Densiron 68 HSO can cause some complications in the eye.

Long-term outcome of highly myopic foveoschisis treated by vitrectomy with or without gas tamponade

AIM：To evaluate the long-term safety and efficacy of vitrectomy and internal limiting membrane（ILM）peeling with or without gas tamponade for highly myopic foveoschisis.METHODS：We performed an open-label,observerblinded clinical trial of 85 patients with myopic foveoschisis between 2000 and 2012.Patients were randomly allocated to one of two groups,those who received vitrectomy and ILM peeling without gas tamponade（no-gas group）or those who with gas tamponade（gas group）and follow up at least 5y.RESULTS：Visual acuity of gas group improved from0.82±0.33 to 0.79±0.73 in 6mo,improved to 0.71±0.67 in 1y and within this range in the following 4y.Visual acuity of no-gas group improved from 0.81±0.46 to 0.78±0.66 in 6mo,improved to 0.70±0.65 in 1y.The finial visual acuity of two groups were significantly increased compared with the baseline（P〈0.05）.The visual acuity was improved in 35 of40 eyes（87.5%）in gas group and 29 of 33 eyes（87.9%）in no-gas group,while there were no significant differences between gas group and no-gas group in the visual acuity.The foveoschisis on optical coherence tomography（OCT）completely resolved in 5 of 40 eyes in 1mo,14 eyes in 6mo and 40 eyes in 1y in the gas group.While the foveoschisis completely resolved in 4 of 33 eyes in 1mo,10 eyes in 6mo and 33 eyes in 1y in the no-gas group.CONCLUSION：Vitrectomy and ILM peeling without gas tamponade appears to be as effective in the treatment of myopic foveoschisis as vitrectomy and ILM with gas tamponade.However,eyes treated with no-gas tamponade showed more rapid resolution of myopic foveoschisis.

Air tamponade in retinal detachment surgery followed by ultra-widefield fundus imaging system

AIM： To report the surgical result of pars plana vitrectomy（PPV） with air tamponade for rhegmatogenous retinal detachment（RRD） by ultra-widefield fundus imaging system. METHODS： Of 25 consecutive patients（25 eyes） with fresh primary RRD and causative retinal break and vitreous traction were presented. All the patients underwent PPV with air tamponade. Visual acuity（VA） was examined postoperatively and images were captured by ultrawidefield scanning laser ophthalmoscope system（Optos）. RESULTS： Initial reattachment was achieved in 25 cases（100%）. The air volume was 〉60% on the postoperative day（POD） 1. The ultra-widefield images showed that the retina was reattached in all air-filled eyes postoperatively. The retinal break and laser burns in the superior were detected in 22 of 25 eyes（88%）. A missed retinal hole was found under intravitreal air bubble in 1 case（4%）. The air volume was range from 40% to 60% on POD 3. A doublelayered image was seen in 25 of 25 eyes with intravitreal gas. Retinal breaks and laser burns around were seen in the intravitreal air. On POD 7, small bubble without effect was seen in 6 cases（24%） and bubble was completely disappeared in 4 cases（16%）. Small oval bubble in the superior area was observed in 15 cases（60%）. There were no missed and new retinal breaks and no retinal detachment in all cases on the POD 14 and 1 mo and last follow-up. Air disappeared completely on a mean of 9.84 d postoperatively. The mean final postoperative bestcorrected visual acuity（BCVA） was 0.35 log MAR. Mean final postoperative BCVA improved significantly relative to mean preoperative（P〈0.05）. Final VA of 0.3 log MAR or better was seen in 13 eyes. CONCLUSION： PPV with air tamponade is an effective management for fresh RRD with superior retinal breaks. The ultra-widefield fundus imaging can detect postoperative retinal breaks in air-filled eyes. It would be a useful facility for follow-up after PPV with air tamponade. Facedown position and acquired visual rehabilitation may be shorten.

Intrauterine balloon tamponade in the management of severe postpartum hemorrhage: A case series from a busy UK district general hospital

Objective: To evaluate the effectiveness of balloon tamponade in the management of postpartum hemorrhage (PPH). Methods: Retrospective review of 58 women who underwent balloon tamponade for severe PPH, during a period of 5 years and 10 months, at Russells Hall Hospital, a busy district general hospital in UK. Clinical success was defined as control of bleeding without need for further intervention. Results: Fifty-eight women (mean age, 30 years;range, 18 - 42) underwent balloon tamponade, of which twenty seven (46.5%) women delivered vaginally and 31 (53.5%) women were delivered by cesarean section. Uterine atony was the main cause of PPH (31 cases). Balloon tamponade was used prophylactically in 11 high risk women in anticipation of potential PPH. Rusch balloon was used in 48 cases and Bakri balloon in 10 cases. Clinical success rate of balloon tamponade was 87.2%. Three patients in this study required hysterectomy. Conclusion: Balloon tamponade is an effective means of controlling severe PPH with success rates of around 87%. There should also be a low threshold for prophylactic use of balloon tamponade in women at high risk of PPH, considering its ease of use, low complication rate and ability to maintain reproductive ability.

Vitrectomy with air tamponade for surgical repair of rhegmatogenous retinal detachment by eye position guided fluid-air exchange

AIM:To observe the efficacy and safety of pars plana vitrectomy(PPV)with eye position guided fluid-air exchange(FAX)and air to mponade in the treatment of rhegmatogenous retinal detachment(RRD).METHODS:RRD patients without severe proliferative vitreoretinopathy(PVR)C1 or more were enrolled.All patients underwent PPV combining with air tamponade.During operation,the primary retinal break(s)were placed at lower site and subretinal fluid was aspirated through the break(s)at the same time when eye position guided FAX was proceeding.Sufficient laser spots were made to seal the retinal break(s)after FAX,and filtered air was left in vitreous cavity as to mponade agent finally.The main outcomes were primary and final success rates,best corrected visual acuity(BCVA),and the secondary outcomes were rate of postoperative cataract surgery and high intraocular pressure.RESULTS:A total of 37 eyes(20 males and 17 females)with a follow-up time of≥6 mo were included.The range of RRD was 5.6±1.8 h,and the number of retinal breaks was 1.9±1.2.The breaks located at inferior quadrants(between 3:00 and 9:00)in 5 cases(13.5%),and both superior and inferior breaks were found in 3 cases(8.1%).A total of 25 cases(67.6%)with macular detached involvement,9 cases(24.3%)with intraocular lens,and 8 patients(21.6%)were treated with phacoemulsification and intraocular lens implantation together.The success rate of primary retinal reattachment was 100%(37/37).At 6 mo postoperatively,BCVA(logMAR)was increased from 1.13±1.07 to 0.23±0.15(P<0.001).Phacoemulsification combined with intraocular lens implantation was performed in 2 patients(5.4%),and one of them underwent macular epiretinal membrane peeling in addition(2.7%).Furthermore,high intraocular pressure was found in 4 cases(10.8%).CONCLUSION:PPV with air tamponade by eye position guided FAX can achieve a high reattachment success rate in the management of patients with RRD,and it has the advantages of short postoperative prone time and fewer operative complications.

Delayed cardiac tamponade diagnosed by point-of-care ultrasound in a neonate after peripherally inserted central catheter placement: A case report

BACKGROUND Peripherally inserted central catheters(PICCs)have been increasingly applied worldwide owing to many advantages.Even with these advantages,the related complications should not be ignored,especially in neonates.The available evidence about PICC-related thrombosis was manifold,but the cardiac tamponade,an emergency and life-threatening complication,has been rarely reported.Early recognized cardiac tamponade by ultrasound may reduce mortality.CASE SUMMARY A neonate weighting 2.8 kg was born at 40 wk of gestation.He was admitted to the Surgery Intensive Care Unit due to suspected congenital megacolon.A PICC line was inserted via the left antecubital fossa for the administration of total parenteral nutrition.Three days later,the patient was still on total parenteral nutrition.Cardiac tamponade caused by PICC was found on ultrasound.The patient recovered spontaneously after an emergency pericardiocentesis.CONCLUSION Proficiency in the use of point-of-care ultrasound may save the life of patients,since it enables clinicians to treat patients faster,more accurately,and in a noninvasive way at the point of care.

Delayed cardiac tamponade after simultaneous transcatheter atrial septal defect closure and left atrial appendage closure device implantation: a particular case report

Percutaneous left atrial appendage(LAA)occlusion evolved as an alternative treatment to the patients who are contraindicated or cannot tolerate oral anticoagulants with nonvalvular atrial fibrillation(AF)at risk of stroke or systemic embolism.[1]Abnormal hemodynamic changes in elder atrial septal defect(ASD)patients cause remodeling of the left atrium,which eventually leads to right heart failure.[2]As the ASDs elderly are associated with a higher incidence of AF,simultaneous transcatheter ASD and LAA closure has become a new effective therapeutic strategy.However,only a limited number of articles involving cardiac tamponade complications have been published in the literature.What’s more,previous studies involving early hemodynamically irrelevant pericardial effusion after the procedure attribute to multiple repositioning attempts of LAA occluder or delivery sheath injured the atrial wall.

Outcomes and predictors of vitrectomy and silicone oil tamponade in retinal detachments complicated by proliferative vitreoretinopathy

AIM:To evaluate outcomes and determine factors influencing the outcomes of vitrectomy with silicone oil(SO)endotamponade for the management of rhegmatogenous retinal detachment(RRD)complicated by advanced proliferative vitreoretinopathy(PVR).METHODS:This is a retrospective,interventional case series of eyes with PVR grade C associated RRD with or without prior surgery that underwent vitreoretinal surgery and SO tamponade.Eyes with a minimum follow-up of 6mo after SO extraction were included.Eyes were classified into three PVR subgroups according to severity and extension of proliferation.The influence of several preoperative,intraoperative and postoperative factors upon the functional and anatomical outcomes was assessed using multivariate logistic regression analysis.RESULTS:A hundred and one eyes of 101 patients that met the inclusion criteria were studied.Seventy-five of 101 eyes(74.3%)had successful retinal reattachment after one operation.Increased aqueous cell and flare at the first week exam had a statistically significant association with redetachment,recurrent membrane proliferation and keratopathy.Visual acuity improvement was significantly associated with faint postoperative aqueous inflammation values,primary vitrectomy and PVR outside of the posterior pole.CONCLUSION:Although encouraging anatomical and functional outcomes are achieved after vitrectomy and SO tamponade in eyes with RRD complicated by PVR,an increase in aqueous flare or cells at the first week follow-up is most likely to result in postoperative late complications.Primary vitrectomy,PVR associated with minimal posterior pole extension and absent to mild postoperative aqueous inflammation are associated with improved post-operative final visual acuity.

Final anatomic and visual outcomes appear independent of duration of silicone oil intraocular tamponade in complex retinal detachment surgery

AIM： To report anatomic and visual outcomes following silicone oil removal in a cohort of patients with complex retinal detachment, to determine association between duration of tamponade and outcomes and to compare patients with oil removed and those with oil in situ in terms of demographic, surgical and visual factors. METHODS： We reported a four years retrospective case series of 143 patients with complex retinal detachments who underwent intraocular silicone oil tamponade. Analysis between anatomic and visual outcomes, baseline demographics, duration of tamponade and number of surgical procedures were carried out using Fisher＇s exact test and unpaired two-tailed t-test. RESULTS： One hundred and six patients（76.2%） had undergone silicone oil removal at the time of review with 96 patients（90.6%） showing retinal reattachment following oil removal. Duration of tamponade was not associated with final reattachment rate or with a deterioration in best corrected visual acuity（BCVA）. Patients with oil removed had a significantly better baseline and final BCVA compared to those under oil tamponade（P=0.0001, 〈0.0001 respectively）. CONCLUSION： Anatomic and visual outcomes in this cohort are in keeping with those reported in the literature. Favorable outcomes were seen with oil removal but duration of oil tamponade does not affect final attachment rate with modern surgical techniques and should be managed on a case by case basis.

Coxsackievirus B infection presenting as a hemorrhagic pericardial effusion causing tamponade

The coxsackievirus is well known for its vastly differing clinical presentations.Patients with coxsackievirus usually present with a viral prodrome which can then progress to the cardiac symptoms of chest pain and/or palpitations.Most patients improve quickly with simply supportive care and nonsteroidal anti-inflammatory medications.

Cardiac tamponade as a rare complication after giant coronary fistula percutaneous closure

We present the case of an unusual complication after percutaneous closure of a giant coronary artery fis-tula. A 76-year-old man with previous admissions due to right heart failure and previous history of atrial fibrillation under acenocumarol, was admitted to our hospital for new onset of symptoms, characterized by progressive dyspnoea and peripheral edema. Physical examination revealed signs of congestive heart failure and a continuous murmur loudest along the lower sternal border. X-Ray showed cardiomegaly due to right chambers dilatation. Transthoracic echocardiography showed right chambers pressure and volume overload, with right ventricular enlargement and dysfunction, tricuspid annulus dilatation and severe tricuspid regurgitation. Cardiac catheterization showed significant elevation of right atrial pressure, as well as significant step-up of oxygen saturation in this chamber. Coronary angiography revealed the presence of a large fistula between the circumflex coronary artery (CCA) and coronary sinus (CS), with severe dilation of the CCA (maximum diameter20 mm). An Amplatzer? PDA was implanted in a distal elbow of the fistula with initailly good results. Anticoagulant therapy was then reinitiated, and a few days later, the patient developed clinical worsening of heart failure and dyspnoea. Echocardiogram showed significant pericardial effusion. Pleuropericardial window was then made draining a500 cm3 of bloody pericardial effusion. The postoperative outcome was excellent, with symptomatic relief and no signs of heart failure.

主要胃的图章戒指房间癌作为心脏的 tamponade 介绍

Primary gastric signet ring cell carcinoma presenting as cardiac tamponade is difficult to diagnosis early.Patients are generally asymptomatic until the disease is advanced.General practitioners usually focus on the initial symptoms related to pericarditis and pericardial effusion.We report a case of signet-ring cell carcinoma of the stomach presenting as cardiac tamponade with pericarditis and pericardial effusion but without any gastrointestinal symptoms.A 49-year old woman was admitted because of progressive dyspnea and cough.Chest X-ray revealed an increased cardiothoracic ratio and a small amount of bilateral pleural effusion.Two dimensional ultrasonographic echocardiography pericardial effusions with atrial and right ventricular early diastolic collapse were found,establishing the diagnosis of cardiac tamponade.Pericardiocentesis was performed and 420 mL of bloody fluid was taken.The patient died of respiratory failure and cardiac arrest on October 28,2009.Post-mortem examination revealed diffuse gastric mucosa erosion and edema with stomach mucosa incrassation in the greater curvature.The primary lesion was histopathologically diagnosed as signet-ring cell carcinoma of the stomach.

Pericardial effusion with tamponade – an uncommon presentation leading to the diagnosis of eosinophilic granulomatosis polyangiitis: A case report

BACKGROUND Eosinophilic granulomatosis polyangiitis(EGPA)is a small vessel necrotizing vasculitis that commonly presents as peripheral eosinophilia and asthma;however,it can rarely manifest with cardiac involvement such as pericarditis and cardiac tamponade.Isolated pericardial tamponade presenting as the initial symptom of EGPA is exceedingly rare.Early diagnosis and appropriate treatment are crucial to prevent life-threatening outcomes.CASE SUMMARY 52-year-old woman with no past medical history presented with progressive dyspnea and dry cough.On physical exam she had a pericardial friction rub and bilateral rales.Vital signs were notable for tachycardia at 119 beats per minute and hypoxia with 89%oxygen saturation.On laboratory exam,she had 45%peripheral eosinophilia,troponin elevation of 1.1 ng/mL and N-terminal prohormone of brain natriuretic peptide of 2101 pg/mL.TTE confirmed a large pericardial effusion and tamponade physiology.She underwent urgent pericardial window procedure.Pericardial and lung biopsy demonstrated eosinophilic infiltration.Based on the American College of Radiology guidelines,the patient was diagnosed with EGPA which manifested in its rare form of cardiac tamponade.She was treated with steroid taper and mepolizumab.CONCLUSION This case highlights that when isolated pericardial involvement occurs in EGPA,diagnosis is recognized by performing pericardial biopsy demonstrating histopathologic evidence of eosinophilic infiltration.

Clinical effect of peripheral capsule preservation in eyes with silicone oil tamponade

BACKGROUND At present,silicone oil has been widely used in vitrectomy to deal with complex fundus diseases.Usually,cataract extraction is combined with vitrectomy.However,reducing the complications of silicone oil tamponade and facilitating the secondary implantation of intraocular lens(IOL)are still an urgent problem.AIM To evaluate the clinical effect of vitrectomy combined with peripheral capsule preservation(PCP)in eyes with silicone oil tamponade.METHODS This single-center retrospective analysis included 70 patients(73 eyes)who underwent vitrectomy and silicone oil tamponade combined with cataract surgery(stage I)between January 2015 and July 2019.All patients underwent selective reoperation for silicone oil extraction and IOL implantation(stage II)more than 3 mo after stage I.These patients were divided into three groups according to the different lens capsule preservation methods:28 patients(31 eyes)in a whole capsule preserved(WCP)group,17(17 eyes)in a capsule absent(CA)group,and 25(25 eyes)in a peripheral capsule preserved(PCP)group.Intraocular pressure(IOP),best-corrected visual acuity,surgery time,and other complications were recorded at each time point(1 d,1 wk,and 1 mo after stages I and II).RESULTS The IOP values were 14.9±8.2 mmHg in the WCP group,20.3±13.0 mmHg in the CA group,and 14.2±9.7 mmHg in the PCP group(P<0.05)at 1 mo after stage I operation.Five eyes had IOP higher than 30 mmHg,and one eye in the WCP group appeared to have silicone oil entering the anterior chamber.There was no significant difference in IOP among the three groups at any other time point(P>0.05).With IOL implantation,visual acuity improved significantly compared to stage I.The incidence rate of posterior capsule opacity was higher in the WCP group than in the other groups(P<0.001).In the CA group,IOL deviation due to suture relaxation occurred in one case.There was no significant difference in the surgery time among the three groups in stage I(P=0.618).In stage II,the surgery time of the PCP group and WCP group was significantly shorter than that of the AC group(P=0.031).CONCLUSION Preservation of the peripheral capsule in vitrectomy combined with lens removal is a better option.This method has significant advantages in reducing intraoperative and postoperative complications.

Survival outcomes and predictors of mortality,re-bleeding and complications for acute severe variceal bleeding requiring balloon tamponade

BACKGROUND Acute severe variceal bleeding(AVB)refractory to medical and endoscopic therapy is infrequent but associated with high mortality.Historical cohort studies from 1970-1980s no longer represent the current population as balloon tamponade is no longer first-line therapy for variceal bleeding;treatments including vasoactive therapies,intravenous antibiotics,endoscopic variceal band ligation are routinely used,and there is improved access to definitive treatments including transjugular intrahepatic portosystemic shunts.However,only a few studies from the current era exist to describe the practice of balloon tamponade,its outcomes,and predictors with a requirement for further updated information.AIM To describe current management of AVB requiring balloon tamponade and identify the outcomes and predictors of mortality,re-bleeding and complications.METHODS A retrospective multi-centre cohort study of 80 adult patients across two large tertiary health networks from 2008 to 2019 in Australia who underwent balloon tamponade using a Sengstaken-Blakemore tube(SBT)were included for analysis.Patients were identified using coding for balloon tamponade.The primary outcome of this study was all-cause mortality at 6 wk after the index AVB.Secondary outcomes included re-bleeding during hospitalisation and complications of balloon tamponade.Predictors of these outcomes were determined using univariate and multivariate binomial regression.RESULTS The all-cause mortality rates during admission and at 6-,26-and 52 wk were 48.8%,51.2%and 53.8%,respectively.Primary haemostasis was achieved in 91.3%and re-bleeding during hospitalisation occurred in 34.2%.Independent predictors of 6 wk mortality on multivariate analysis included the Model for Endstage Liver disease(MELD)score(OR 1.21,95%CI 1.06-1.41,P=0.006),advanced hepatocellular carcinoma(OR 11.51,95%CI 1.61-82.20,P=0.015)and re-bleeding(OR 13.06,95%CI 3.06-55.71,P<0.001).There were no relevant predictors of re-bleeding but a large proportion in which this occurred did not survive 6 wk(76.0%vs 24%).Although mucosal trauma was the most common documented complication after SBT insertion(89.5%),serious complications from SBT insertion were uncommon(6.3%)and included 1 patient who died from oesophageal perforation.CONCLUSION In refractory AVB,balloon tamponade salvage therapy is associated with high rates of primary haemostasis with low rates of serious complications.Re-bleeding and mortality however,remain high.

Cough induced syncope:A hint to cardiac tamponade diagnosis

We report a case of a 75-year-old male with history oflung adenocarcinoma who presented with shortness of breath and frequent episodes of cough-induced syncope. A large pericardial effusion was found on echocardiogram suggestive of cardiac tamponade. Pericardiocentesis was done which improved the dyspnea and eventually resolved the syncope. There are only two other cases reported in the literature with cough-induced syncope in the setting of pericardial effusion or cardiac tamponade. Our clinical vignette also highlights the importance of pulsus paradoxus identification in patients with cough induced syncope to rule out cardiac tamponade since this is the most sensitive physical finding for its diagnosis.

Cardiac tamponade as the initial manifestation of severe hypothyroidism: A case report

Background: Hypothyroidism is a commonly seen condition. The presence of pericardial effusion with cardiac tamponade as initial manifestation of this endocrinological condition is very unusual. Objectives: In hypothyroidism pericardial fluid accu-mulates slowly, allowing adaptation and stretching of the pericardial sac, sometimes accommodating a large volume. Case Report: A 39 year-old female presented with chest pain, dyspnea and lower extremity edema for 1 day. Bradycardia, muffled heart sounds and severe hypertension were noticed. Chest radiograph showed an enlarged cardiac silhouette. A bedside echocardiogram revealed a cardiac tamponade, later she developed sudden hypotension and bradycardia that resolved after pericardiocentesis of 1 liter of pericardial fluid. The further laboratory evaluation revealed a TSH value of 69.3 miU/L and low T3 and free T4. The patient later developed reaccumulation of pericardial fluid with the need for creation of pericardial window. Conclusion: When the classic Beck’s triad is not present and bradycardia accompanies a cardiac tamponade, hypothyroidism should be strongly suspected. The requirement for thyroid hormone supplement is critical and is well reported. There is a chance of recurrence even after starting levothyroxine supplementation;and the associated hypertension usually requires treatment with more than one drug.