Ophthalmological Problems Research Articles

PERIPHERAL BLOOD SUBPOPULATION OF LYMPHOCYTES OF PATIENTS WITH AGE-RELATED MACULAR DEGENERATION

The article presents results of studies concerning subрopulations of peripheral blood lymphocyte in the patients at early stages of age-related macular degeneration (AMD), being compared with healthy elderly persons (risk group for AMD), and young adults without ophthalmological problems. We have revealed an increase in absolute counts and percentages of the cytotoxic cells (СD3+СD8+), and double-positive T cell subpopulations (СD3+CD4+СD8+), like as of B-lymphocyte contents, higher frequency of their increased content in peripheral blood of the patients with early and intermediate stages of AMD and healthy older people, as compared with young controls, thus allowing to suggest a potential role of these shifts in lymphocyte subpopulations for the AMD pathogenesis.

Electroretinogram assessment of children with sensorineural hearing loss: implications for screening.

The guidelines of the National Deaf Children's Society recommend that children with sensorineural hearing loss (SNHL) be routinely screened for ophthalmological problems and suggest electroretinography (ERG) to exclude Usher syndrome. The present study reports the nature and prevalence of abnormal ERG findings in a cohort of children with SNHL undergoing ERG with the aim of identifying risk factors for the diagnosis of Usher syndrome. The medical records of children (<18 years of age) with SNHL referred for ERG at Moorfields Eye Hospital, London, between January 2009 and December 2011 were retrospectively reviewed. Patients were included if they had been referred with SNHL by an audiological medicine consultant and the primary indication for electrodiagnostic testing was possible Usher syndrome. A total of 84 cases met inclusion criteria of which 13 (15%) had ERG findings showing rod-cone dysfunction consistent with a diagnosis of Usher syndrome. Two patients with retinal pigmentary changes had normal ERGs and were diagnosed with rubella retinopathy based on the clinical findings. Risk factor analysis showed that age of ≥8 years at the time of ERG, sex, and bilateral hearing loss were not predictive of a diagnosis of Usher syndrome. However, the presence of or referral for cochlear implants, having relevant symptoms and/or clinical signs consistent with a retinal dystrophy, and profound hearing loss were all highly predictive. ERG is a useful diagnostic tool in children with SNHL and should be performed in children with SNHL who have cochlear implants and/or have signs or symptoms of retinal dystrophy. A focused approach could have potential cost-saving benefit.

Ophthalmological Findings of Turkish Children With Muscular Dystrophies.

To present the results of ophthalmological examinations in children with muscular dystrophies and highlight the importance of their ophthalmological evaluation. Retrospective analysis of the ophthalmological examination records in 74 children with a type of muscular dystrophy, examined between January 2011 and January 2015, was performed. The most common type of muscular dystrophy observed in our patients was Duchenne muscular dystrophy (67.5%), followed by Becker muscular dystrophy (9.4%), myotonic dystrophy (8%), limb-girdle muscular dystrophy (6.7%), merosin-negative muscular dystrophy (4%), and Ullrich muscular dystrophy (4%). Ten cases of Duchenne muscular dystrophy had both macular and retinal pigmentary changes (20%) and 9 had abnormal electroretinographies with decreased photopic and scotopic responses. Ptosis was the most common finding (83.3%). No abnormalities of light reflexes, pupil size, or saccadic and smooth pursuit movements were seen among cases with myotonic dystrophy. Ophthalmological problems are commonly seen in children with muscular dystrophies. Simple ophthalmological screening and early intervention can improve their communication skills by way of increasing their visual talents.

Torticollis in children: an alert symptom not to be turned away.

The aim of this study is to investigate the spectrum of underlying disease in children with torticollis. We investigated the spectrum of underlying disease and to evaluate the clinical features of the children presented with torticollis in the last 2 years. Of the 20 children (13 girls and 7 boys with the mean age of 8 years, ranging 2 months-12 years), eight of them have craniospinal pathologies (cerebellar tumors in three, exophytic brain stem glioma, eosinophilic granuloma of C2 vertebra, neuroenteric cyst of the spinal cord, Chiari type 3 malformation, arachnoid cysts causing brainstem compression, and cerebellar empyema), followed by osseous origin in five (congenital vertebral anomalies including hemivertebrae, blocked vertebra, and segmentation anomalies), two muscular torticollis (soft tissue inflammation due to subclavian artery catheterization, myositis ossificans with sternocleidomastoid muscle atrophy), and ocular (congenital cataract and microphthalmia), Sandifer syndrome, paroxysmal torticollis, retropharyngeal abscess each in one patients were detected. Ten patients underwent surgery; two patients received medical therapy for reflux and benign paroxysmal torticollis; and one patient with torticollis due to muscle spasm and soft tissue inflammation was treated with physiotherapy. Various underlying disorders from relatively benign to life-threatening conditions may present with torticollis. The first step should be always a careful and complete physical examination, which must include all systems. Imaging must be performed for ruling out underlying life-threatening diseases in children with torticollis, particularly, if acquired neurological symptoms exist. Besides craniospinal tumors, ophthalmological problems and central nervous system infections should also be kept in mind. Moreover, early diagnosis of these disorders will reduce mortality and morbidity. Therefore, alertness of clinicians in pediatric and pediatric neurosurgery practice must be increased about this alert symptom.

Pompe disease and ophthalmopathy: literature review

Large number of ophthalmological problems has been found in patients with glycogenosis type II (Pompe disease, PD). Since enzyme replacement therapy (ERT) has been introduced ophthalmic examination in the routine follow-up gained a special role in infantile-onset Pompe disease and prolonged survival. Currently a number of cases with ophthalmic disorder as the first sign of PD is known. Histopathological features of glycogen deposits in various eye structures has been described. Current review summarizes PubMed data on ophthalmopathy in PD.

Molecular mechanisms of synergy of corneal muscarinic and nicotinic acetylcholine receptors in upregulation of E-cadherin expression

Corneal epithelial erosion is one of the most common problems in clinical ophthalmology. Despite significant progress in understanding how the cornea heals, clinically available pharmacological therapies that can promote repair and prevent visual complications remain limited. We have recently demonstrated that the acetylcholine (ACh) axis of corneal epithelium plays an important role in regulation and coordination of distinct activities of corneal epithelial cells (CEC) mediating re-epithelialization, but mechanisms remained unclear. We hypothesized that the grounds for synergistic effects of corneal ACh receptors lie within the signaling pathways linking different receptors to specific elements of the CEC pro-epithelialization activities. In this study, we sought to elucidate the molecular mechanisms of cooperation of corneal muscarinic and nicotinic ACh receptors (mAChRs and nAChRs) in upregulation of E-cadherin expression. The roles of individual corneal mAChRs and nAChRs subtypes were investigated by in-cell western assay of the ACh-treated CEC, in which different ACh receptor genes were silenced by receptor-specific shRNAs. Functional inactivation of M3, but not M4, mAChR subtype, or α3 or α7, but not α9, nAChR subunit significantly inhibited E-cadherin expression. To gain a mechanistic insight, we blocked the key steps of the downstream signaling pathways. Results demonstrated that cholinergic agonists can upregulate E-cadherin expression by activating M3 mAChR, and α3β2 and α7 nAChRs via the common signaling cascade Ca2+–CaMKII–PKC–Ras–Raf–MEK–ERK. Activation of α7 nAChR can launch the Ras–Raf–MEK–ERK cascade both indirectly, through the Ca2+–CaMKII–PKC step, and directly, perhaps, due to its direct interaction with Ras. Although the biological significance of such redundancy remained to be elucidated, results of the present study point to a new direction to pharmacologically accelerate corneal re-epithelialization, and should have salient clinical implication.

Vision problems in Down syndrome adults do not hamper communication, daily living skills and socialisation.

Down syndrome is the most commonly occurring chromosomal condition with a prevalence of 11.2-10000 life-births in Europe. The most important concern consists of various degrees of intellectual disability and sensory deficits. The overall prevalence of ophthalmologic abnormalities has been reported to be as high as 46-100%. Impairment of vision potentially hampers the capacity of learning and communication and thus of social integration. The aim of our study is to assess prospectively the occurrence of vision problems in patients with DS with special emphasis on adaptive behaviour and cognition. Assessments included Hirschberg's corneal reflex method, eye alignment, cover test, Vineland Adaptive Behaviour Scales (VABS) for adaptive behaviour and Coloured Progressive Matrices (CPM) for cognitive abilities. We included prospectively 49 individuals from 19-52 years. Ophthalmologic problems were observed in 81.6% of our DS patients. The total number of visual disorders and symptoms was equally distributed with respect to ID-group and to levels of adaptive behaviour (p > 0.050). When comparing individuals matched for age, gender, cognitive skills and sociocultural background in a subset of individuals, vision problems did not decrease adaptive behaviour skills of our patients with visual disorders and daily living skills even fared better (p = 0.046). Effective early correction and intervention on visual-motor deficits seem to be important, but nevertheless personal autonomy is not seriously detained.

Decision support systems and applications in ophthalmology: literature and commercial review focused on mobile apps.

The growing importance that mobile devices have in daily life has also reached health care and medicine. This is making the paradigm of health care change and the concept of mHealth or mobile health more relevant, whose main essence is the apps. This new reality makes it possible for doctors who are not specialist to have easy access to all the information generated in different corners of the world, making them potential keepers of that knowledge. However, the new daily information exceeds the limits of the human intellect, making Decision Support Systems (DSS) necessary for helping doctors to diagnose diseases and also help them to decide the attitude that has to be taken towards these diagnoses. These could improve the health care in remote areas and developing countries. All of this is even more important in diseases that are more prevalent in primary care and that directly affect the people's quality of life, this is the case in ophthalmological problems where in first patient care a specialist in ophthalmology is not involved. The goal of this paper is to analyse the state of the art of DSS in Ophthalmology. Many of them focused on diseases affecting the eye's posterior pole. For achieving the main purpose of this research work, a literature review and commercial apps analysis will be done. The used databases and systems will be IEEE Xplore, Web of Science (WoS), Scopus, and PubMed. The search is limited to articles published from 2000 until now. Later, different Mobile Decision Support System (MDSS) in Ophthalmology will be analyzed in the virtual stores for Android and iOS. 37 articles were selected according their thematic (posterior pole, anterior pole, Electronic Health Records (EHRs), cloud, data mining, algorithms and structures for DSS, and other) from a total of 600 found in the above cited databases. Very few mobile apps were found in the different stores. It can be concluded that almost all existing mobile apps are focused on the eye's posterior pole. Among them, the most intended are for diagnostic of diabetic retinopathy. The primary market niche of the commercial apps is the general physicians.

Models of shells and plates in the problems of ophthalmology

This review is devoted to mathematical models created jointly with ophthalmologists. Models for calculating the stress-strain state of an eye shell after surgeries related to the treatment of retinal detachment and models of the theory of accommodation have been described briefly. Mathematical models describing the determination of the actual intraocular pressure (IOP) using application techniques have been discussed. Models making it possible to assess the effect of deviations of the shapes of the cornea and sclera from a spherical shape based on the IOP parameters and the effect of the cornea thickness on them have been also considered. It has been noted that models of ocular biomechanics helped in obtaining a number of new results in mechanics of solids, for example, in solving the problem on the stability of a spherical shell under a concentrated force and normal internal pressure, the stability of an axisymmetric equilibrium form of orthotropic nonuniform circular plates under normal pressure, the problem on the stability of a segment of an orthotropic shell under normal internal pressure and an applied load with a flat base, and solving problems of deformation of transversely isotropic spherical and cylindrical layers under internal and external pressures. The comparison of these solutions with those obtained using nonclassical shell theories made it possible to assess the precision of some theories.

Plasma metabonomics study of the patients with acute anterior uveitis based on ultra-performance liquid chromatography–mass spectrometry

The identification of the biomarkers of patients with acute anterior uveitis (AAU) may allow for a less invasive and more accurate diagnosis, as well as serving as a predictor in AAU progression and treatment response. The aim of this study was to identify the potential biomarkers and the metabolic pathways from plasma in patients with AAU. Both plasma metabolic biomarkers and metabolic pathways in the AAU patients versus healthy volunteers were investigated using ultra-performance liquid chromatography-mass spectrometry (UPLC-MS) and a metabonomics approach. The principal component analysis (PCA) was used to separate AAU patients from healthy volunteers as well as to identify the different biomarkers between the two groups. Metabolic compounds were matched to the KEGG, METLIN, and HMDB databases, and metabolic pathways associated with AAU were identified. The PCA for UPLC-MS data shows that the metabolites in AAU patients were significantly different from those of healthy volunteers. Of the 4,396 total features detected by UPLC-MS, 102 features were significantly different between AAU patients and healthy volunteers according to the variable importance plot (VIP) values (greater than two) of partial least squares discriminate analysis (PLS-DA). Thirty-three metabolic compounds were identified and were considered as potential biomarkers. Meanwhile, ten metabolic pathways were found that were related to the AAU according to the identified biomarkers. These data suggest that metabolomics study can identify potential metabolites that differ between AAU patients and healthy volunteers. Based on the PCA, PLS-DA, several potential metabolic biomarkers and pathways in AAU patients were found and identified. In addition, the UPLC-MS technique combined with metabonomics could be a suitable systematic biology tool in research in clinical problems in ophthalmology, and can provide further insight into the pathophysiology of AAU.

Diagnosis of dry eye disease and emerging technologies

Dry eye is one of the most commonly encountered problems in ophthalmology. Signs can include punctate epithelial erosions, hyperemia, low tear lakes, rapid tear break-up time, and meibomian gland disease. Current methods of diagnosis include a slit-lamp examination with and without different stains, including fluorescein, rose bengal, and lissamine green. Other methods are the Schirmer test, tear function index, tear break-up time, and functional visual acuity. Emerging technologies include meniscometry, optical coherence tomography, tear film stability analysis, interferometry, tear osmolarity, the tear film normalization test, ocular surface thermography, and tear biomarkers. Patient-specific considerations involve relevant history of autoimmune disease, refractive surgery or use of oral medications, and allergies or rosacea. Other patient considerations include clinical examination for lid margin disease and presence of lagophthalmos or blink abnormalities. Given a complex presentation and a variety of signs and symptoms, it would be beneficial if there was an inexpensive, readily available, and reproducible diagnostic test for dry eye.

Life journey and scientific heritage of professor M.B. Vurgaft (to the 100th anniversary)

In 2013 it is 100th birthday anniversary of M.B. Vurgaft - world known scientist, one of the founders of the aqueous humour production and drainage examination by compression tests and tonometry in a normal eye and in glaucoma patients. Moisey Bencionovich Vurgaft, professor, PhD, headed the department of ophthalmology of Kazan State Institution for Post-Graduate Medical Education, later renamed to Kazan State Medical Academy. The student of outstanding scientists - academician V.P. Filatov and professor S.F. Kalf, M.B. Vurgaft has devoted all his life to studying one of the leading problems of ophthalmology - glaucoma. He was the first in The Soviet Union who has started to study the eye fluid flow, and developed original and easily assessable study methods that are still important nowadays. A new direction of scientific research of the department targeted on glaucoma studies was formed under the guidance of M.B. Vurgaft. Moisey Bencionovich had always tried to link the scientific research with the needs of healthcare practice. He was an outstanding diagnostician, clinician and ophthalmic surgeon. Professor M.B. Vurgaft had always shared his experience and had mentored a number of outgoing students, who are currently working all over the country. He is the author of over 140 academic papers, 6 textbooks, several patents covering various questions of ophthalmology. Using the scientific data, originally gained by M.B. Vurgaft, 16 master and 6 doctoral degrees (PhDs) were completed in different institutions of CIS, Bulgaria and Hungary. During 13 years he was an eternal head of the Tatarstan Scientific Society of Ophthalmologists, an honoured member of All-Russia and Soviet Union Scientific Society of Ophthalmologists, member of the expert board of the Central (awarded with the order of Lenin) Institution for Post-Graduate Medical Education of the responsible for the development of post-graduate educational programs in ophthalmology, member of the of surgical faculty of Kazan State Institution for Post-Graduate Medical Education.

Wrinkled Skin and Fat Pads in Patients with ALG8‐CDG: Revisiting Skin Manifestations in Congenital Disorders of Glycosylation

Glycosylation is the posttranslational coupling of sugar chains to proteins or lipids. Proper glycosylation is essential for normal protein structure, function, and trafficking. Mutations in the glycosylation pathway lead to a phenotypically heterogeneous group of metabolic disorders, the congenital disorders of glycosylation (CDG). Some of these conditions, including PMM2-CDG, frequently present with recognizable skin abnormalities such as abnormal fat distribution, skin wrinkling, or peau d'orange, whereas others, such as COG7-CDG and ATP6V0A2-CDG, have been described in association with cutis laxa: wrinkled, inelastic, and sagging skin. Ichthyosis is also common in several types of CDG. ALG8-CDG is a severe disorder characterized by dysmorphic features, failure to thrive, protein-losing enteropathy, neurologic and ophthalmologic problems, and developmental delay. We reviewed the clinical features in all nine previously reported patients diagnosed with ALG8-CDG with a special focus on their skin signs. Three of the nine patients had abnormal fat distribution and skin wrinkling. As the spectrum of CDG presenting with skin signs expands further, we suggest screening for CDG in all patients presenting with any type of central nervous involvement and wrinkled skin, cutis laxa, severe ichthyosis, or abnormal fat distribution.

Literature-related discovery techniques applied to ocular disease

Literature-related discovery and innovation (LRDI) is a text mining approach for bridging unconnected disciplines to hypothesize radical discovery. Application to medical problems involves identifying key disease symptoms, and identifying causes and treatments for those symptoms from throughout the biomedical literature. LRDI has not been applied to vitreoretinal ophthalmological problems previously. This review illustrates the use of LRDI for potential restoration of degenerated vitreous. Vitreous restoration literature is very small; much research is aimed at vitreous composition and degradation, improving vitrectomy, and pharmacological vitreolysis. LRDI has the potential to find ways to slow, halt, or reverse the degradation through systemic improvement and myriad local treatments, some not ordinarily used by the ophthalmology community. The many potential discoveries and innovations were generated within a larger context, namely that timely healing required cause removal, healing obstacle removal, and healing acceleration (focused treatments) in an integrated manner. Although many potential causes, healing obstacles, and healing accelerations were identified strictly from the premier published literature, causes and obstacles that may have been operable but were not found in the literature were also postulated, as were gaps in the research that covered these potential causes and obstacles and unresearched treatments as well.

Bilateral ocular anomalies in a South African fur seal (Arctocephalus pusillus pusillus)

A female South African fur seal (Arctocephalus pusillus pusillus) began having obvious clinical ophthalmologic problems by 8 weeks of age. The initial clinical sign was diffuse corneal edema, which progressed to bullae formation and ulcers; the underlying cause of corneal edema and bullous keratopathy was not identified antemortem.An ophthalmological evaluation was performed when the fur seal was approximately 6 months of age, but due to the diffuse corneal edema, intraocular structures could not be easily evaluated. An underlying infectious etiology was suspected; therefore,appropriate diagnostics were pursued, but did not identify a cause. Initial improvement was noted, but the fur seal then became blind and eventually became very painful.Due to decreased quality of life and aggressive behavior, the fur seal was euthanized.Histopathological diagnoses were persistent tunica vasculosa lentis and persistent hyperplastic primary vitreous with bilateral hypermature resorbed cataracts and retinal detachments with rosette formation.

Recurrent headache in pediatric outpatients at a public hospital in Delhi

This observational, descriptive study was conducted to study the clinical profile of children presenting with recurrent headaches to the general pediatric services of a tertiary-care, public hospital in northern India. 43 children, 3-18 year old (23 females, median age 10 years), were enrolled between April, 2011 to January, 2012. History, clinical examination (including fundus evaluation and detailed ophthalmological evaluation) and follow-up were done using a structured proforma. Headache diagnosis was made on the basis of International Classification of Headache Disorders, 2nd edition (ICHD-II). Headache disability and severity were assessed by pedMIDAS, and Visual analog scale and Faces scale, respectively. 26 patients (60.5%) had headache with migraine features (20, migraine without aura), 11 (25.6%) had Tension type headache (TTH), and 4 (9.3%) children had non-specific headache. Stress was the commonest (42.3%) trigger identified by children with migraine. No patient in the study had an ophthalmological problem as cause of headache. 69.2% of migraine patients and 36% of TTH patients had been suffering from it for 1-2 years before reporting to the hospital. Majority of children with recurrent headache present late for medical attention. Ophthalmological problems are an infrequent cause of recurrent headache in these children.

Biological lasers theory, vol.II vision holographic theory ‐ Eye and vision

AbstractPurpose The romanian book deals with the Biological Laser Theory BLT and its applications ‐ the Vision Holographic Theory VHT. The book has about 465 pages, 7 chapters, and 151 figures (85 original figures), 15 tables. After introduction of the actual problems in ophthalmology, are presented: the purpose of the book ‐ to verify some old theory about an up‐down image on retina, to demonstrate by theoretical and experimental studies that human eye structure is a bifocal laser system with holographic system included, the bio luminescence is a biological laser phenomena, laser holographic biophotonic mechanism of the sight, and applications;Methods Theoretic method: a short history of the sight mechanism. Our old studies on characteristics of cell biological laser systems; the VHT hypothesis about eye and vision, the coherent transformation of light in bio luminescence, as laser phenomena; multidisciplinary arguments for laser‐holographic structures and function hypothesis are from ophthalmology, lasers, holography, liquid crystals, electronics, biophotonic and bionics.As experimental method we present two original apparatus for human vision study acknowledged at EuroInvent Iași 2011, and CIGIG 2012.Results Both apparatus proves the right position of holograms on retina, due to eye, not to brain. We describe some other holographic‐biophotonic mechanism for biological (muscle contraction) and psychic processes (vision, memory, thinking, speech etc), and increasing the power and information along nervous system.Conclusion Important applications are in medicine teaching, physics and bionics. Keywords: eye, bioluminescence, bifocal laser system, holography, image, nervous system, biophotonic mechanism, biologic process, psychic process Commercial interest

Rescue therapy with subcutaneous anti‐TNF‐α agents for idiopathic non‐infectious uveitis

AbstractChronic non‐infectious uveitis (NU) remains one of the most challenging problems in ophthalmology. Often, early and aggressive treatment is needed for a good visual acuity outcome. Local and oral corticosteroids remain the first line of treatment, even though side effects, such as glaucoma, cataract and Cushing Syndrome, can be serious and not tolerable. Therefore, a variety of immunosuppressive agents are used. Recently, new types of drugs, called “biologic agents”, are available. In the model of experimental autoimmuneuveitis (EAU) it has been demonstrated that tumor necrosis factor‐alpha (TNF‐α) may play a key role in uveitis. Beside the well known intravenous anti‐ TNF‐α agent called infliximab, other sub cutaneous anti‐ TNF‐α drugs have been introduced, such as Adalimumab and Golimumab. Adalimumab presents a stronger medical literature and it seems to present promising qualities. Few reports are available for Golimumab in uveitis at this time. Adalimumab can control uveitis unresponsive to the traditional immunosuppressive agents and, moreover, its subcutaneous administration makes the procedure user friendly. This drug can be used in selected cases as a rescue therapy for idiopathic non‐infectious uveitis.

An interesting case of implantable contact lens

Refractive errors are one of the most common ophthalmologic problems. Implantable contact lens (ICL) implantation has received attention for its excellent and rapid visual and refractive results in eyes with high myopia. There are still concerns about complications such as anterior capsule opacity, cataracts,1,2 pupillary block glaucoma,3,4 chronic inflammation,5 pigmentary dispersion syndrome,6,7 and pigmentary glaucoma.8 We report an interesting case of a patient who had undergone ICL implantation presenting as a case of pupillary block glaucoma and how the patient was effectively managed.

A CURRENT 4-YEARS RETROSPECTIVE SURVEY OF 64 SURGICALLY TREATED ZYGOMA COMPLEX FRACTURES IN DEPARTMENT OF MAXILLO-FACIAL SURGERY, UNIVERSITY HOSPITAL ‘ST. ANNA’, SOFIA, BULGARIA.

Purpose: The goal of this material was to be an example of the complications that can occur in cases of zygoma fractures and to draw the attention of the clinicians to the need of accurate diagnose and early treatment of the associated with zygoma fractures traumas. Materials and methods: Medical records of 276 patients with different traumas in face and neck area treated in our department ware reviewed. Of those 64 suffered from zygoma fractures and they ware classified according to age, sex, cause of trauma, presence or absence of associated trauma, etc. Results: As other studies also show, we determined that the most common cause of injury was assault and road accidents, fallowed by sport, industrial, etc. Males between 20 and 40 years old ware the biggest group of patients, often after alcohol consumption. Associated traumas occurred more frequently in cases of motor vehicle accident than in other cases and ware presented by closed head trauma, ophthalmologic problems, extremities fractures, etc. Conclusion: Delayed treatment of zygoma injuries is feasible and yields in good results when the severity of trauma needs it, but early repair of such injuries prevent late complications and should be preferred when possible.