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      Outcomes of ocular evisceration and enucleation in the British Armed Forces from Iraq and Afghanistan

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          Abstract

          To evaluate outcomes from all British military patients who underwent eye removal during the Iraq and Afghanistan wars. Retrospective case note review of all patients ( n  = 19) who had undergone either evisceration or enucleation, on a database of all military patients repatriated to the Royal Centre for Defence Medicine, Birmingham. Twenty eye removals were performed on 19 patients, of which 14 (70%) were eviscerations and 6 (30%) were enucleations. Orbital wall fractures were seen in 12 (61%) patients, with orbital floor fractures being the most common. The eye removal was a primary procedure in five of fourteen eviscerations, and five of six enucleations. Complications were seen after four (28.6%) eviscerations patients and two (33.3%) enucleations. Postoperative pain was problematic after three (21.4%) eviscerations but no enucleations. Orbital implants were placed during three of the five primary enucleations, with good outcomes in two. One patient however required implant retrieval and wound washout due to a high risk of infection and communication with the intra-cranial space. Evisceration and enucleation are both viable options in the management of severe ocular trauma in military patients. Evisceration and enucleation have similar complication rates and outcomes, and both have low rates of sympathetic ophthalmia. Primary orbital implants can be at high risk in cases with orbital roof fracture, but can provide good outcomes in select patients.

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          Most cited references30

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          The macrophage F4/80 receptor is required for the induction of antigen-specific efferent regulatory T cells in peripheral tolerance

          We show that the mouse macrophage-restricted F4/80 protein is not required for the development and distribution of tissue macrophages but is involved in the generation of antigen-specific efferent regulatory T (T reg) cells that suppress antigen-specific immunity. In the in vivo anterior chamber (a.c.)–associated immune deviation (ACAID) model of peripheral tolerance, a.c. inoculation of antigen into F4/80−/− mice was unable to induce efferent T reg cells and suppress delayed-type hypersensitivity (DTH) responses. Moreover, the use of anti-F4/80 mAb and F4/80−/− APCs in an in vitro ACAID model showed that all APC cells in the culture must be able to express F4/80 protein if efferent T reg cells were to be generated. In a low-dose oral tolerance model, WT but not F4/80−/− mice generated an efferent CD8+ T reg cell population that suppressed an antigen-specific DTH response. Peripheral tolerance was restored in F4/80−/− mice by adoptive transfer of F4/80+ APCs in both peripheral tolerance models, indicating a central role for the F4/80 molecule in the generation of efferent CD8+ T reg cells.
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            Combat ocular trauma visual outcomes during operations iraqi and enduring freedom.

            To report the visual and anatomic outcomes as well as to predict the visual prognosis of combat ocular trauma (COT) during Operations Iraqi and Enduring Freedom. Retrospective, noncomparative, interventional, consecutive case series. Five hundred twenty-three consecutive globe or adnexal combat injuries, or both, sustained by 387 United States soldiers treated at Walter Reed Army Medical Center between March 2003 and October 2006. Two hundred one ocular trauma variables were collected on each injured soldier. Best-corrected visual acuity (BCVA) was categorized using the ocular trauma score (OTS) grading system and was analyzed by comparing initial and 6-month postinjury BCVA. Best-corrected visual acuity, OTS, and globe, oculoplastic, neuro-ophthalmic, and associated nonocular injuries. The median age was 25+/-7 years (range, 18-57 years), with the median baseline OTS of 70+/-25 (range, 12-100). The types of COT included closed-globe (n = 234; zone 1+2, n = 103; zone 3, n = 131), open-globe (n = 198; intraocular foreign body, n = 86; perforating, n = 61; penetrating, n = 32; and rupture, n = 19), oculoplastic (n = 324), and neuro-ophthalmic (n = 135) injuries. Globe trauma was present in 432 eyes, with 253 eyes used for visual acuity analysis. Comparing initial versus 6-month BCVA, 42% of eyes achieved a BCVA of 20/40 or better, whereas 32% of eyes had a BCVA of no light perception. Closed-globe injuries accounted for 65% of BCVA of 20/40 or better, whereas 75% of open-globe injuries had a BCVA of 20/200 or worse. The ocular injuries with the worst visual outcomes included choroidal hemorrhage, globe perforation or rupture, retinal detachment, submacular hemorrhage, and traumatic optic neuropathy. Additionally, COT that combined globe injury with oculoplastic or neuro-ophthalmologic injury resulted in the highest risk of final BCVA worse than 20/200 (odds ratio, 11.8; 95% confidence interval, 4.0-34.7; P<0.0005). Nonocular injuries occurred in 85% of cases and included traumatic brain injury (66%) and facial injury (58%). Extremity injuries were 44% (170 of 387 soldiers). Amputation is a subset of extremity injury with 12% (46 of 387) having sustained a severe extremity injury causing amputation. Combat ocular trauma has high rates of nonocular injuries with better visual outcomes in closed-globe compared with open-globe trauma. The OTS is a valid classification scheme for COT and correlates the severity of injury with the final visual acuity and prognosis. Globe combined with oculoplastic or neuroophthalmologic injuries have the worst visual prognosis. The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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              Prospective surveillance of sympathetic ophthalmia in the UK and Republic of Ireland.

              To establish current epidemiological data, risks, and interventional outcomes of newly diagnosed sympathetic ophthalmia (SO). Prospective surveillance took place of all permanently employed ophthalmologists in the UK and Republic of Ireland by a monthly reporting card through the British Ophthalmological Surveillance Unit. Case ascertainment was made of newly diagnosed SO from July 1997 and questionnaire data were returned at baseline, 6 months, and 1 year after diagnosis. 23 patients with newly diagnosed SO were recruited over 15 months, corresponding to a minimum estimated incidence of 0.03/100 000. Baseline data were available on 18 patients, in whom SO occurred after surgery in 11 patients, after retinal surgery alone in six patients, and after accidental trauma in seven patients. 12 of the 16 patients with 1 year follow up had a visual acuity of 6/12 or better. Good visual outcome was related to prompt and adequate systemic immunosuppressive therapy. The incidence of sympathetic ophthalmia is very low. The main current risk is surgery, particularly retinal surgery, but visual prognosis is good if early diagnosis is made and rapid, adequate immunotherapy is commenced.
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                Author and article information

                Journal
                Eye
                Eye
                Springer Science and Business Media LLC
                0950-222X
                1476-5454
                June 5 2019
                Article
                10.1038/s41433-019-0480-5
                7002516
                31165770
                2a8ff72d-9db2-4073-9913-ea1a6026e084
                © 2019

                http://www.springer.com/tdm


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