AOSpine Consensus Paper on Nomenclature for Working-Channel Endoscopic Spinal Procedures

Study Design: International consensus paper on a unified nomenclature for full-endoscopic spine surgery. Objectives: Minimally invasive endoscopic spinal procedures have undergone rapid development during the past decade. Evolution of working-channel endoscopes and surgical instruments as well as innovation in surgical techniques have expanded the types of spinal pathology that can be addressed. However, there is in the literature a heterogeneous nomenclature defining approach corridors and procedures, and this lack of common language has hampered communication between endoscopic spine surgeons, patients, hospitals, and insurance providers. Methods: The current report summarizes the nomenclature reported for working-channel endoscopic procedures that address cervical, thoracic, and lumbar spinal pathology. Results: We propose a uniform system that defines the working-channel endoscope (full-endoscopic), approach corridor (anterior, posterior, interlaminar, transforaminal), spinal segment (cervical, thoracic, lumbar), and procedure performed (eg, discectomy, foraminotomy). We suggest the following nomenclature for the most common full-endoscopic procedures: posterior endoscopic cervical foraminotomy (PECF), transforaminal endoscopic thoracic discectomy (TETD), transforaminal endoscopic lumbar discectomy (TELD), transforaminal lumbar foraminotomy (TELF), interlaminar endoscopic lumbar discectomy (IELD), interlaminar endoscopic lateral recess decompression (IE-LRD), and lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD). Conclusions: We believe that it is critical to delineate a consensus nomenclature to facilitate uniformity of working-channel endoscopic procedures within academic scholarship. This will hopefully facilitate development, standardization of procedures, teaching, and widespread acceptance of full-endoscopic spinal procedures

A case report of Epstein–Barr virus-associated retinal vasculitis: successful treatment using only acyclovir therapy

Narumon Keorochana Department of Ophthalmology, Phramongkutklao Hospital, Bangkok, Thailand Abstract: The purpose of this study was to describe a presumed case of Epstein–Barr virus (EBV)-associated retinal vasculitis in a 42-year-old female with sudden unilateral vision loss and successful treatment with acyclovir therapy. Diagnostic vitreous biopsy of the right eye was performed to test for EBV and other known infectious causes of retinitis and evaluate vitreous cells and serological testing. Vitreous polymerase chain reaction viral DNA testing result was positive for EBV but negative for herpes simplex virus, varicella-zoster virus, and cytomegalovirus. Serologic testing was negative for toxoplasma gondii, syphilis, tuberculosis, and HIV. Histopathologic analysis of vitreous cells revealed atypical lymphocytes. Fluorescein angiography showed disk leakage, occluded retinal artery, peripheral vascular leakage, and ischemic area of the right eye. Intravenous acyclovir, 10 mg/kg/d, was prescribed for 14 days followed by oral acyclovir for 3 months. All lesions have become quiet. EBV may be a cause of retinal disease, and intravenous acyclovir is a successful treatment choice. Keywords: Epstein-Barr virus, retinal vasculitis, acyclovir, treatmen

Combined central retinal vein, central retinal artery and cilioretinal artery occlusion with ischemic macular hole secondary to severe orbital cellulitis after black fly bite

Narumon Keorochana,1 Sritatath Vongkulsiri,2 Raveewan Choontanom31Ocular Inflammatory and Uveitis Division, Department of Ophthalmology, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand; 2Retina Division, Department of Ophthalmology, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand; 3Oculoplastic and Reconstruction Division, Department of Ophthalmology, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, ThailandBackground: Orbital cellulitis is an infection of the ocular adnexal and orbital tissues behind the orbital septum. The complications are poor prognosis. This paper is to describe some severe rare complications of orbital cellulitis.Case presentation: A case of 32-year-old female presented with acute severe progressive orbital cellulitis on the right eye after a black fly (Simuliidae spp.) bite. Orbital imaging with computed tomography and magnetic resonance imaging showed eyelid abscess with orbital abscess formation and superior ophthalmic vein thrombosis. She was promptly treated with intravenous vancomycin, piperacillin and had surgical procedures to release orbital pressure including lateral canthotomy, lateral cantholysis, and eyelid with orbital abscess drainage. Pus collection culture was positive for Staphylococcus aureus. Even though she responded well to antibiotics treatment, progression involved severe orbital inflammation with marked increased orbital pressure, and her visual acuity was such that she had no light perception. Combined central retinal vein, central retinal artery and cilioretinal artery occlusion were identified. Fundus examination showed retinal whitening at the posterior pole and a few scattered flame-shaped retinal hemorrhages. The cilioretinal artery presented with perivascular retinal whitening. A fundus fluorescein angiogram revealed cilioretinal and retinal artery filling delay and also delayed arteriovenous transit time. She also developed an ischemic macular hole after a week of treatment. We demonstrate an optical coherence tomography image showing the intact posterior hyaloid membrane that represents no traction on the macula to support the ischemic cause.Conclusion: Multiple retinal vascular occlusion and ischemic macular hole could be an early complication of severe orbital cellulitis from increased orbital pressure; therefore, close monitoring of visual acuity with IOP, and prompt treatment when indicated might reduce the risk of consequent blindness.Keywords: black fly, orbital cellulitis, central retinal vein occlusion, central retinal artery occlusion, cilioretinal artery occlusion, macular hol

Normal flora of conjunctiva and lid margin, as well as its antibiotic sensitivity, in patients undergoing cataract surgery at Phramongkutklao Hospital

Ravee Ratnumnoi, Narumon Keorochana, Chavalit Sontisombat Department of Ophthalmology, Phramongkutklao Hospital, Bangkok, Thailand Objective: This study aimed to evaluate the normal flora of conjunctiva and lid margin, as well as its antibiotic sensitivity. Design: This was a prospective cross-sectional study. Patients and methods: A prospective study was conducted on 120 patients who underwent cataract surgery at the Phramongkutklao Hospital from September 2014 to October 2014. Conjunctival and lid margin swabs were obtained from patients before they underwent cataract surgery. These swabs were used to inoculate blood agar and chocolate agar plates for culturing. After growth of the normal flora, the antibiotic sensitivity method using tobramycin, moxifloxacin, levofloxacin, and cefazolin was applied. Main outcome measures: Normal flora of conjunctiva and lid margin, along with its antibiotic sensitivity, from patients who underwent cataract surgery was assessed. Results: A total of 120 eyes were included in this study, and bacterial isolation rates were identified. Five bacteria from the lid margin were cultured, namely, coagulase-negative staphylococcus (58.33%), Streptococcus spp. (2.5%), Corynebacterium (1.67%), Micrococcus spp. (1.67%), and Staphylococcus aureus (0.83%). Two bacteria from the conjunctiva were cultured, namely, coagulase-negative staphylococcus (30%) and Streptococcus spp. (0.83%). Results of antibiotic sensitivity test showed that all isolated bacteria are sensitive to cefazolin 100%, tobramycin 98.67%, levofloxacin 100%, and moxifloxacin 100%. Conclusion: Coagulase-negative staphylococci are the most common bacteria isolated from conjunctiva and lid margin. Keywords: conjunctival flora, lid margin flora, cataract surgery, sensitivity, antibiotic

Herpesviridae prevalence in aqueous humor using PCR

Narumon Keorochana, Wasamon Intaraprasong, Raveewan Choontanom Department of Ophthalmology, Phramongkutklao hospital, Phramongkutklao College of Medicine, Bangkok, Thailand Objective: The aim of this study was to determine the prevalence of Herpesviridae family in aqueous humor and the prevalence of antibodies against Herpesviridae family in serum.Methods: Participants undergoing cataract surgery were included in the study. Serum for viral serology including herpes simplex virus (HSV), varicella zoster virus (VZV), Epstein–Barr virus (EBV), and cytomegalovirus (CMV) was collected. Aqueous humor specimen was tapped for PCR analysis.Results: Ninety-two participants were included with a mean age of 67.67 years (SD ±12.51). The prevalence of positive serology tests was 83.3% for HSV, 94.0% for VZV, 98.8% for EBV, and 97.6% for CMV. A total of 66 aqueous humor specimens were negative for PCR of Herpesviridae family.Conclusion: This study showed previous HSV, VZV, EBV and CMV infections in >90% of the Thai population, while no viral presence was detected in aqueous humor. Thus, the serology test is unrelated to the presence of virus in the eye. We suggest that PCR is a valuable tool to diagnose intraocular viral infection and detect virus presenting active infection. Keywords: Herpesviridae, prevalence, aqueous humor, PCR, serology, uveiti

Necrobiotic xanthogranuloma scleritis in a case of granulomatosis with polyangiitis (Wegener’s granulomatosis)

Narumon Keorochana,1 Kanaspana Klanarongran,2 Kantang Satayasoontorn,3 Sumapa Chaiamnuay4 1Department of Ophthalmology, Ocular Inflammatory and Uveitis Division, 2Department of Ophthalmology, External Disease and Cornea Division, 3Department of Anatomic Pathology, 4Department of Medicine, Rheumatology Division, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand Abstract: The purpose of this study was to describe a case of necrobiotic xanthogranuloma scleritis in a 53-year-old male with unilateral progressive visual loss, scleritis, prolonged fever, and multiple mononeuropathy. Scleral biopsy showed necrosis with small abscess, and the pathological tissues revealed submucosal infiltration of mononucleated foamy histiocytes (xanthoma cells), hemosiderin-laden macrophages, neutrophils, lymphocytes, plasma cells, and erythrocytes without Touton giant cells or cholesterol clefts. Serum protein electrophoresis showed polyclonal gammopathy. All infectious investigations were negative. Afterward, this patient was diagnosed with granulomatosis with polyangiitis based on granuloma found in scleral tissue, vasculitis seen in sural nerve biopsy and positive serologies (C-ANCA and anti-PR3 antibody). He was treated with high-dose corticosteroid and later with intravenous cyclophosphamide monthly. He responded well to treatment, both eye and systemic conditions. Necrobiotic xanthogranuloma scleritis could be an early presentation of granulomatosis with polyangiitis. Keywords: scleritis, uveitis, ocular inflammation, pathology, autoimmune, xanthoma cells, GC

The efficacy of preoperative posterior subtenon injection of triamcinolone acetonide in noninfectious uveitic patients with secondary glaucoma undergoing trabeculectomy

Narumon Keorochana, Sutheera Kunasuntiwarakul, Isaraporn Treesit, Raveewan Choontanom Department of Ophthalmology, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand Objective: The aim of this study was to evaluate the efficacy and safety of preoperative posterior subtenon injection of triamcinolone acetonide (PSTA) in noninfectious uveitic patients with secondary glaucoma undergoing primary trabeculectomy with mitomycin C.Design: This was a retrospective study.Patients and methods: We reviewed the medical records of 10 noninfectious uveitic patients, who had received a single preoperative PSTA 40 mg/1 mL, with secondary glaucoma undergoing primary trabeculectomy with mitomycin C. We collected data before and after surgery on intraocular pressure (IOP), anterior chamber (AC) cells, best-corrected visual acuity (BCVA), morphologic characteristics of the filtering bleb and complications.Results: The mean time between injection and surgery was 7.8±3.88 days. Postoperative IOP level was significantly lower than preoperative level (31.3±11.44 mmHg) at all visits (P<0.02). Antiglaucoma medications were decreased from preoperative (4.9±0.88) to 12-month postoperative (0.8±1.31; P-value <0.001) and also discontinued in seven eyes (70%). About 12 months after surgery, eight eyes (80%) with qualified success and two eyes (20%) with failed treatment were recorded. AC cells and BCVA did not differ significantly from baseline; however, all inflammations were controlled successfully. Most desirable bleb morphology was shown at 12 months as well. Complications were blepharoptosis and hypotony maculopathy in two eyes (20%).Conclusion: A preoperative PSTA may be an effective and safe option in controlling intraocular inflammation and maintaining bleb function after trabeculectomy in noninfectious uveitic patients with secondary glaucoma during a 12-month period. Keywords: periocular injection, steroid, uveitis, triamcinolone acetonid

Development of a standardized histopathology scoring system for intervertebral disc degeneration in rat models: An initiative of the ORS spine section

International audienceBackground:Rats are a widely accepted preclinical model for evaluating inter-vertebral disc (IVD) degeneration and regeneration. IVD morphology is commonlyassessed using histology, which forms the foundation for quantifying the state of IVDdegeneration. IVD degeneration severity is evaluated using different grading systemsthat focus on distinct degenerative features. A standard grading system would facili-tate more accurate comparison across laboratories and more robust comparisons ofdifferent models and interventions.Aims:This study aimed to develop a histology grading system to quantify IVD degen-eration for different rat models. Materials & Methods:This study involved a literature review, a survey of experts inthe field, and a validation study using 25 slides that were scored by 15 graders fromdifferent international institutes to determine inter- and intra-rater reliability.Results:A new IVD degeneration grading system was established and it consists ofeight significant degenerative features, including nucleus pulposus (NP) shape, NParea, NP cell number, NP cell morphology, annulus fibrosus (AF) lamellar organization,AF tears/fissures/disruptions, NP-AF border appearance, as well as endplate disrup-tions/microfractures and osteophyte/ossification. The validation study indicated thissystem was easily adopted, and able to discern different severities of degenerativechanges from different rat IVD degeneration models with high reproducibility forboth experienced and inexperienced graders. In addition, a widely-accepted protocolfor histological preparation of rat IVD samples based on the survey findings includeparaffin embedding, sagittal orientation, section thickness < 10μm, and staining usingH&E and/or SO/FG to facilitate comparison across laboratories.Conclusion:The proposed histological preparation protocol and grading system pro-vide a platform for more precise comparisons and more robust evaluation of rat IVDdegeneration models and interventions across laboratories