Purpose: To compare results of sutureless transscleral intraocular lens (IOL) fixation to retropupillary iris-claw lens implantation in cases of paediatric aphakia without capsular support. Methods: Thirty eyes of children with insufficient capsular support for IOL implantation were randomized to undergo sutureless transscleral IOL fixation or iris-claw lens fixation. The primary outcome was best-corrected visual acuity (BCVA). Secondary outcomes included operative time, astigmatism, central corneal thickness, endothelial cell count (ECC), IOL decentration and tilt, central foveal thickness and complications. Results: There was a significant improvement in BCVA at all follow-up visits, with no significant difference between both groups. 53.3% in the transscleral-fixated IOL group and 80% in the iris-claw IOL group had a final BCVA ≥0.3. The operative time was significantly shorter in the iris-claw IOL group (p = 0.001). IOL decentration and tilt were higher in the transscleral-fixated IOL group, but the difference was not significant. The ECC was reduced by 14.6% in the transscleralfixated IOL group and 11% in the iris-claw group at 6 months, with no significant difference between both groups (p = 0.5). In the transscleral-fixated IOL group, two eyes developed ocular hypertension and two eyes had IOL decentration, while in the iris-claw IOL group, 1 eye developed glaucoma, three eyes had haptic disenclavation, and one eye had retinal detachment. Conclusion: Both techniques yielded a comparable visual outcome. Retropupillary iris-claw lens fixation is a shorter procedure and technically easier than sutureless transscleral fixation, but the risk of disenclavation should be considered especially in younger age groups. Scleral fixation is the only option in case of severe iris damage, but may be associated with more endothelial cell loss.

IMPORTANCE Literature suggests corneal morphologic characteristics compatible with keratoconus are present in a high percentage of patients with Down syndrome (DS), suggesting the need to perform a detailed examination of the anterior segment to try to avoid serious visual impairment in this group of patients. OBJECTIVE To characterize the abnormal features of the cornea in patients with DS and compare these with a control group. DESIGN, SETTING, AND PARTICIPANTSMulticenter case-control study at Vissum Alicante, . The study included 321 eyes of 217 participants from 2 groups: 112 participants in the DS group and 105 healthy participants in the control group.INTERVENTIONS Patients were evaluated using Placido disc/Scheimpflug camera topographer (Sirius, CSO). Visual, refractive and anterior, and posterior corneal characteristics were assessed and compared in both groups.MAIN OUTCOMES AND MEASURES Keratoconus diagnosis. Incidence of corneal morphologic irregularities similar to keratoconus in patients with DS. RESULTSIn the DS group, mean (SD) age was 14.88 (15.76) years, 54 (48%) were women, 66 (59%) were white, and 46 (41%) were Arab. In the control group, mean (SD) age was 40.29 (14.66) years, 54 (51%) were women, and all were white. Clinical assessment of corneal topography showed that 71.3% (95% CI, 45.2-97.4) of patients in the DS group showed characteristics compatible with keratoconus. Differences were found in steepest keratometry of 47.35 diopters (D) in patients with DS vs 43.70 D in control individuals (difference, 3.65 D; 95% CI, 3.23-4.35 D; P <.001) and in corneal pachymetry of 503 μm in patients with DS vs 545 μm in control individuals (difference, 42 μm; 95% CI, 38.8-56.7 μm; P <.001).CONCLUSIONS AND RELEVANCE Patients with DS have steeper and thinner corneas and more corneal aberrations than those without genetic alterations and normal corneas. The findings suggest a detailed corneal study should be considered in such patients to detect keratoconus and implement treatment as appropriate to try to avoid serious visual impairment in this group of patients. JAMA Ophthalmol. 2018;136(9):971-978.

. Purpose:  To histopathologically evaluate the effect of cryopreserved human amniotic membrane (AM) transplant on preventing the development of postoperative adhesions after extraocular muscle surgery. Methods:  Ten albino rabbits were used. The superior rectus muscles were bilaterally resected. In right eyes, the muscle was wrapped with cryopreserved human AM (group AM). In left eyes, the muscle was not wrapped with AM and served as a control group (group C). The rabbits were killed, and the eyes were enucleated 6 weeks after surgery to perform histopathological examination. Results:  On histopathological examination, the AM was present in eight eyes, surrounded by periamniotic inflammation, with no adhesions detected between rectus muscle and sclera, conjunctiva and Tenon’s capsule in the segment where the AM was present, but detected elsewhere. Adhesions were detected in the other two eyes of group AM, in which the AM was absent, and in all group C eyes. When comparing eye pairs of each rabbit, AM eyes showed significantly less adhesions between the muscle and sclera (p = 0.009) and between the muscle and Tenon’s capsule and conjunctiva (p = 0.008), in the region of AM application, and significantly more foreign body inflammation (p = 0.031), than C eyes. The differences between AM and C eye pairs, in terms of conjunctival inflammation and vascularity and muscle fibrosis, were insignificant (p > 0.05). Conclusions:  Cryopreserved AM is effective in reducing postoperative extraocular muscle adhesions. Its application is, therefore, recommended during strabismus reoperations.

Ab interno and ab externo scleral fixation, which are both blind procedures, resulted in comparable low rates of sulcus fixation.

Objectives: Tracheostomy is a very common clinical intervention in critically ill adult patients. The indications for tracheostomy procedures in pediatric patients with complex conditions have increased dramatically in recent years, but there are currently no guidelines on the optimal timing of tracheostomy in pediatric patients undergoing prolonged ventilation. Data Sources: We performed a systematic search of the existing literature in MEDLINE via PubMed and Embase databases and the Cochrane Library to identify clinical trials, observational studies, and cohort studies that compare early and late tracheostomy in children. The date of the last search was August 27, 2018. Included articles were subjected to manual searching. Study Selection: Studies in mechanically ventilated children that compared early with late tracheostomy were included. Data Extraction: Data were extracted into a spreadsheet and copied into Review Manager 5.3 (The Cochrane Collaboration, Copenhagen, Denmark). Data Synthesis: Data were meta-analyzed using an inverse variance, random effects model. Continuous outcomes were calculated as mean differences with 95% CIs, and dichotomous outcomes were calculated as Mantel-Haenszel risk ratios with 95% CIs. We included eight studies (10 study arms). These studies were all retrospective cohort studies. Early tracheostomy was associated with significant reductions in mortality, days on mechanical ventilation, and length of intensive care and total hospital stay, although the lack of randomized, controlled trials limits the validity of these findings. Although variance was imputed for some studies, these conclusions did not change after removing these studies from the analysis. Conclusions: In children on mechanical ventilation, early tracheostomy may improve important medical outcomes. However, our data demonstrate the urgent need for high-quality, randomized controlled trials in the pediatric population.

BACKGROUND:Lung ultrasound (US) is an available and inexpensive tool for the diagnosis of community-acquired pneumonia (CAP); it which has no hazards of radiation and can be easily used.AIM:To evaluate the efficacy of lung ultrasound in the diagnosis and follow-up of CAP.PATIENTS AND METHODS:100 patients aged from 40 to 63 years with a mean age of 52.3 ± 10 years admitted to the Critical Care Department, Cairo University with pictures of CAP. Lung US was performed for all patients initially, then a plain chest X-ray (CXR) was performed. Another lung ultrasound was performed on the 10th day after admission.RESULTS:Initial chest X-ray was correlated with the initial chest ultrasound examination in CAP diagnosis (R-value = 0.629, P < 0.001). Cohen’s κ was run to determine if there is an agreement between the findings of the initial chest X-ray findings and those of the initial chest ultrasound in CAP diagnosis. A moderate agreement was found where κ = .567 (95% CI, 0.422 to 0.712) and P < 0.001. Upon initial examination, the CXR diagnosed CAP in 48.0% of patients, while lung US diagnosed the disease in 70% of patients. Moreover, lung US was more sensitive than CXR (P-value < 0.001). Compared to the accuracy of computed tomography (CT) chest (100%) which is the gold standard for CAP diagnosis, the accuracy of lung US was 95.0%, while the accuracy of CXR was 81.0%.CONCLUSION:This study proved the effectiveness of lung ultrasound in CAP diagnosis.

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AIM: Failure of weaning from mechanical ventilation (MV) is a common problem that faces the intensivist despite having some prediction indices. Application of chest ultrasonography (US) may help in weaning and prediction of its outcome. METHODS: 100 patients on invasive MV fulfilling criteria of weaning shifted to spontaneous breathing trial (SBT) (using PSV 8 cm H2O) for 1 hour. Weaning failure was defined as; Failed SBT, reintubation and/or ventilation or death within 48 hours. Echocardiography was used to get Ejection fraction, E/A ratio, Doppler tissue imaging (DTI) &, lung ultrasound (LUS) was used to assess LUS score, diaphragm ultrasound was used to assess diaphragmatic thickening fraction (DTF). RESULTS: Mean age 57.1 ± 14.5, 62% were males. Weaning was successful in 80% of patients. LUS score was significantly higher in the failed weaning group: (10.8 ± 4.2) vs (16.5 ± 4.2 cm), (p: 0.001). (DTF) Was significantly higher in the successful weaning group: (43.0 ± 10.7) vs (28.9 ± 2.8 cm), (p: 0.001). DTF can predict successful weaning using Receiver operating characteristic (ROC) curves with the cutoff value: ≥ 29.5 with sensitivity 88.0% and specificity 80.0% with a p-value ˂ 0.001.LUS score can predict weaning failure by using a ROC curve with cutoff value: ≥ 15.5 with sensitivity 70.0% and specificity 82.5 % with a p-value ˂ 0.001.) CONCLUSION: The use of bedside chest US (to assess lung and diaphragm) of great benefit throughout the weaning process.