Roper-Hall grading for ocular burns [20].
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"10734",leadTitle:null,fullTitle:"Topics on Critical Issues in Neonatal Care",title:"Topics on Critical Issues in Neonatal Care",subtitle:null,reviewType:"peer-reviewed",abstract:"Neonatology is one of the areas of greatest development and evolution within pediatrics. Every year there are advances in the management of the different diseases that newborns develop, which makes it necessary to refresh knowledge on traditional and other emerging issues. This book includes six chapters that address critical and relevant issues in neonatal care and seeks to contribute to the clinical work of health teams in neonatal units.",isbn:"978-1-83969-452-3",printIsbn:"978-1-83969-451-6",pdfIsbn:"978-1-83969-453-0",doi:null,price:119,priceEur:129,priceUsd:155,slug:"topics-on-critical-issues-in-neonatal-care",numberOfPages:120,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"a6e1a11c05ff8853c529750ddfac6c11",bookSignature:"R. Mauricio Barría",publishedDate:"June 1st 2022",coverURL:"https://cdn.intechopen.com/books/images_new/10734.jpg",numberOfDownloads:594,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfCrossrefCitationsByBook:null,numberOfDimensionsCitations:0,numberOfDimensionsCitationsByBook:null,hasAltmetrics:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 5th 2021",dateEndSecondStepPublish:"April 29th 2021",dateEndThirdStepPublish:"June 28th 2021",dateEndFourthStepPublish:"September 16th 2021",dateEndFifthStepPublish:"November 15th 2021",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"88861",title:"Dr.",name:"R. Mauricio",middleName:null,surname:"Barría",slug:"r.-mauricio-barria",fullName:"R. Mauricio Barría",profilePictureURL:"https://mts.intechopen.com/storage/users/88861/images/system/88861.jpg",biography:"R. Mauricio Barría, DrPH, is a principal investigator and associate professor at the Faculty of Medicine, Universidad Austral de Chile. He was trained as an epidemiologist and received his MSc in Clinical Epidemiology from Universidad de la Frontera, Chile, and his DrPH from Universidad de Chile. His research interests include maternal-child health, neonatal care, and environmental health. He is skilled in epidemiological study design with a special interest in cohort studies and clinical trials. From 2010 until 2017 Dr. Barría was director of the Evidence-Based Health Office. He is currently the director of the Institute of Nursing, Faculty of Medicine, Universidad Austral de Chile.",institutionString:"Austral University of Chile",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"5",institution:{name:"Austral University of Chile",institutionURL:null,country:{name:"Chile"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1108",title:"Neonatology",slug:"neonatology"}],chapters:[{id:"80416",title:"Antenatal Corticosteroids and Magnesium Sulfate in Twin Pregnancy for the Prevention of Neonatal Morbidity",doi:"10.5772/intechopen.102611",slug:"antenatal-corticosteroids-and-magnesium-sulfate-in-twin-pregnancy-for-the-prevention-of-neonatal-mor",totalDownloads:38,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The use of corticosteroids is one of the most important therapies used in prenatal care to improve the outcomes of the newborn by reducing the rates of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis and contribute to the survival of extreme preterm infants. In addition to steroids, the use of magnesium sulfate protects the newborn from cerebral palsy in cases of extreme preterm births. All of these conditions increase perinatal morbidity/mortality and are related to potentially serious illness in the newborn requiring care in neonatal intensive units. The use of corticosteroids and magnesium sulfate are measured to prevent unfavorable outcomes of premature newborns admitted to a neonatal intensive care unit. The incidence of twin pregnancy is only 3% of all live births, however, it accounts for 15% of extreme preterm births less than 32 weeks. Women with multiple pregnancies are six times more likely to terminate the pregnancy before term compared to single pregnancies. The determination of the use of corticosteroids in multiple pregnancies remains conflicting due to the scarcity of studies related to this group. Therefore, this chapter aims to evaluate the effectiveness of the use of corticosteroids in twin pregnancies in early and late preterm, evaluating its outcome in respiratory morbidity and metabolic aspects of the newborn.",signatures:"Julio Elito Jr and Micheli Goldani Shuai",downloadPdfUrl:"/chapter/pdf-download/80416",previewPdfUrl:"/chapter/pdf-preview/80416",authors:[{id:"35132",title:"Prof.",name:"Julio",surname:"Elito Jr.",slug:"julio-elito-jr.",fullName:"Julio Elito Jr."},{id:"449972",title:"Mrs.",name:"Micheli",surname:"Goldani Shuai",slug:"micheli-goldani-shuai",fullName:"Micheli Goldani Shuai"}],corrections:null},{id:"78174",title:"Breastfeeding and the Influence of the Breast Milk Microbiota on Infant Health",doi:"10.5772/intechopen.99758",slug:"breastfeeding-and-the-influence-of-the-breast-milk-microbiota-on-infant-health",totalDownloads:160,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Nutrition is an essential condition for physical, mental, and psycho-emotional growth for both children and adults. It is a major determinant of health and a key factor for the development of a country. Breastfeeding is a natural biological process, essential for the development of the life of the newborn at least during the first six months by ensuring a nutritional contribution adapted to the needs of the latter. Thus, breast milk is the physiological and natural food best suited to the nutrition of the newborn. It contains several various components, which are biologically optimized for the infant. Cells are not a negligible component of breast milk. Breast milk is also a continuous source of commensal and beneficial bacteria, including lactic acid bacteria and bifidobacteria. It plays an important role in the initiation, development, and composition of the newborn’s gut microbiota, thanks to its pre-and probiotic components. Current knowledge highlights the interdependent links between the components of breast milk, the ontogeny of intestinal functions, the development of the mucus intestinal immune system, colonization by the intestinal microbiota, and protection against pathogens. The quality of these interactions influences the health of the newborn in the short and long term.",signatures:"Fatima Chegdani, Badreddine Nouadi and Faiza Bennis",downloadPdfUrl:"/chapter/pdf-download/78174",previewPdfUrl:"/chapter/pdf-preview/78174",authors:[{id:"416821",title:"Ph.D. Student",name:"Badreddine",surname:"Nouadi",slug:"badreddine-nouadi",fullName:"Badreddine Nouadi"},{id:"417126",title:"Dr.",name:"Fatima",surname:"Chegdani",slug:"fatima-chegdani",fullName:"Fatima Chegdani"},{id:"417127",title:"Prof.",name:"Faiza",surname:"Bennis",slug:"faiza-bennis",fullName:"Faiza Bennis"}],corrections:null},{id:"78720",title:"Neonatal Anemia",doi:"10.5772/intechopen.99761",slug:"neonatal-anemia",totalDownloads:155,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Neonatal anemia and iron deficiency are frequent founds in neonatal intensive care units (NICUs). The three major causes of anemia in neonates are blood loss, reduced red blood cell production, and increased degradation of the erythrocytes. Premature infants in ICUs have high levels of iron deficiency, and ascertaining the cause of anemia in this group of patients can be a challenge in clinical practice. This chapter provides an updated review of neonatal anemia. It will concern the pathophysiology of neonatal anemia in term and preterm infants and a detailed discussion of the traditional and innovative laboratory tests for diagnosis and assessment of this condition in the ICUs.",signatures:"Laura M. Dionisio and Thamires A. Dzirba",downloadPdfUrl:"/chapter/pdf-download/78720",previewPdfUrl:"/chapter/pdf-preview/78720",authors:[{id:"414296",title:"M.Sc.",name:"Laura M.",surname:"Dionisio",slug:"laura-m.-dionisio",fullName:"Laura M. Dionisio"},{id:"414433",title:"Ms.",name:"Thamires A.",surname:"Dzirba",slug:"thamires-a.-dzirba",fullName:"Thamires A. Dzirba"}],corrections:null},{id:"78011",title:"Prolonged Jaundice in Newborn",doi:"10.5772/intechopen.99670",slug:"prolonged-jaundice-in-newborn",totalDownloads:144,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Prolonged jaundice is defined as a serum bilirubin level higher than 85 μmol/L (5 mg/dl), which persists at postnatal 14 days in term infants and 21 days following the birth in preterm infants. It affects 2–15% of all newborns and 40% of breastfed infants. Although underlying cause can not be found in the majority of prolonged jaundice cases, this may also be the first sign of a serious causative pathology. Tests performed to determine the underlying cause and failure to determine the etiology cause anxiety for both families and physicians. The most important point is to determine whether prolonged jaundice is of a benign cause or is due to a substantial disease. For this reason, health care providers should not take unnecessary tests in normal infants, but should also recognize infants with a causative pathology. Neonatal jaundice still maintains its importance in neonatal clinical practice, since early diagnosis and treatment is feasible.",signatures:"Erhan Aygün and Seda Yilmaz Semerci",downloadPdfUrl:"/chapter/pdf-download/78011",previewPdfUrl:"/chapter/pdf-preview/78011",authors:[{id:"252617",title:"Dr.",name:"Seda",surname:"Yilmaz Semerci",slug:"seda-yilmaz-semerci",fullName:"Seda Yilmaz Semerci"},{id:"349471",title:"M.D.",name:"Erhan",surname:"Aygün",slug:"erhan-aygun",fullName:"Erhan Aygün"}],corrections:null},{id:"78162",title:"Retinopathy of Prematurity: A NICU Based Approach",doi:"10.5772/intechopen.99089",slug:"retinopathy-of-prematurity-a-nicu-based-approach",totalDownloads:4,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Retinopathy of prematurity is a fibrovascular proliferative disorder affecting the peripheral retinal vasculature in premature infants. It is one of the leading causes of preventable childhood blindness across the globe. The world is currently experiencing ROP as third epidemic, where majority of the cases are from middle-income countries. With intensive use of in-vitro fertilisation (IVF) and multiple births, ROP emerging as a significant problem globally. High quality neonatal services, better equipment, improved training, evidence-based screening protocols and access to ROP specialists preventing blindness due to ROP in most of the countries. For more than three decades, improvement in treatment strategy for severe ROP markedly decrease the incidence of ROP related blindness. Current international screening guidelines recommend ROP screening for all premature infants based on birth weight of less than 1501 g or a gestational age of 30 weeks or less, while latest Indian screening guidelines includes all premature infants with birth weight of <2000 grams or gestational age of <34 weeks. Current strategies include adoption of newer screening guidelines, telemedicine and vision rehabilitation.",signatures:"Anubhav Goyal, Shahana Majumdar, Priyanka Khandelwal, Giridhar Anantharaman, Mahesh Gopalakrishnan and Shuchi Goyal",downloadPdfUrl:"/chapter/pdf-download/78162",previewPdfUrl:"/chapter/pdf-preview/78162",authors:[{id:"351945",title:"Dr.",name:"Anubhav",surname:"Goyal",slug:"anubhav-goyal",fullName:"Anubhav Goyal"},{id:"425667",title:"Dr.",name:"Shahana",surname:"Majumdar",slug:"shahana-majumdar",fullName:"Shahana Majumdar"},{id:"425668",title:"Dr.",name:"Priyanka",surname:"Khandelwal",slug:"priyanka-khandelwal",fullName:"Priyanka Khandelwal"},{id:"425669",title:"Dr.",name:"Giridhar",surname:"Anantharaman",slug:"giridhar-anantharaman",fullName:"Giridhar Anantharaman"},{id:"425670",title:"Dr.",name:"Mahesh",surname:"Gopalakrishnan",slug:"mahesh-gopalakrishnan",fullName:"Mahesh Gopalakrishnan"},{id:"425671",title:"Dr.",name:"Shuchi",surname:"Goyal",slug:"shuchi-goyal",fullName:"Shuchi Goyal"}],corrections:null},{id:"78222",title:"Reducing Toxic Phthalate Exposures in Premature Infants",doi:"10.5772/intechopen.99714",slug:"reducing-toxic-phthalate-exposures-in-premature-infants",totalDownloads:93,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Phthalates are a ubiquitous group of industrial compounds used as industrial solvents and as additives to plastics to make products softer avnd more flexible. Phthalates are found in a variety of products including medical devices, personal care products, flooring, and food packaging. Infants in the neonatal intensive care unit are exposed to phthalates both in the building materials, but more importantly in the medical supplies and devices. Toxicity from phthalates has been of concern to researchers for many decades. Toxicity concerns to neonates includes male reproductive toxicity, hepatotoxicity, cardiotoxicity (including hypertension), neurotoxicity, and neurodevelopmental abnormalities. Limited recommendations have been given for reducing phthalate exposures to premature infants. These include avoiding infusing lipids or blood products through intravenous tubing containing phthalates. Storage of blood in containers made with phthalates has been a strong recommendation and has largely been accomplished. A comprehensive plan for phthalate reduction has heretofore been missing. This chapter has the goal of identifying the problem of phthalate exposure in premature infants, with some practical solutions that can be done today, as well as suggestions for manufacturers to complete the work.",signatures:"Randall Jenkins",downloadPdfUrl:"/chapter/pdf-download/78222",previewPdfUrl:"/chapter/pdf-preview/78222",authors:[{id:"415746",title:"Prof.",name:"Randall",surname:"Jenkins",slug:"randall-jenkins",fullName:"Randall Jenkins"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"6550",title:"Cohort Studies in Health Sciences",subtitle:null,isOpenForSubmission:!1,hash:"01df5aba4fff1a84b37a2fdafa809660",slug:"cohort-studies-in-health-sciences",bookSignature:"R. Mauricio Barría",coverURL:"https://cdn.intechopen.com/books/images_new/6550.jpg",editedByType:"Edited by",editors:[{id:"88861",title:"Dr.",name:"R. 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Larramendy and Sonia Soloneski",coverURL:"https://cdn.intechopen.com/books/images_new/5358.jpg",editedByType:"Edited by",editors:[{id:"14764",title:"Dr.",name:"Marcelo L.",surname:"Larramendy",slug:"marcelo-l.-larramendy",fullName:"Marcelo L. Larramendy"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4616",title:"Nanomaterials",subtitle:"Toxicity and Risk Assessment",isOpenForSubmission:!1,hash:"a96b5d34ca84aecacbab309ba1e7e563",slug:"nanomaterials-toxicity-and-risk-assessment",bookSignature:"Sonia Soloneski and Marcelo L. Larramendy",coverURL:"https://cdn.intechopen.com/books/images_new/4616.jpg",editedByType:"Edited by",editors:[{id:"14764",title:"Dr.",name:"Marcelo L.",surname:"Larramendy",slug:"marcelo-l.-larramendy",fullName:"Marcelo L. Larramendy"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"79778",title:"Evaluation and Management of Ocular Traumas",doi:"10.5772/intechopen.101776",slug:"evaluation-and-management-of-ocular-traumas",body:'Ocular trauma is relatively common with 20% of adults having the possibility of experiencing ocular trauma during their lives [1]. It occurs most frequently in men and young people [2]. A study estimated nearly 55 million eye injuries occur annually worldwide, and approximately 1.6 million people experience vision loss due to eye trauma [3]. In developed countries, ocular trauma is a major cause of unilateral blindness [4]. Ocular trauma affecting the anterior segment including conjunctiva, cornea, sclera, iris, and lens may be chemical, mechanical, or thermal. The most common three manifestations of eye injuries are foreign bodies (34.2%), abrasions/scratches (14.9%), and chemical burns (10.4%) [5]. Although the eyelids and tear film layer act as a barrier for mild traumas, severe traumas need thorough evaluation and prompt management to prevent catastrophic complications, such as vision or globe loss. The ocular traumas resulting from workplace accidents are at the top, followed by home accidents and leisure pursuit incidents and 90% of them are accepted to be preventable with simple approaches, such as using personal protective equipment (PPE) [6, 7, 8, 9, 10, 11]. Detailed history including the time, mechanism and nature of the trauma, visual acuity evaluation, examination of periocular adnexa with orbital rim palpation, eyelid and canalicular patency evaluation, assessment of eye movements and presence of diplopia, pupillary light reaction as well as assessing the shape, size and isocoria of the pupils, examination of cornea and conjunctiva for any laceration, perforation or foreign body, assessment of anterior chamber, the status of the lens, and fundus examination along with imaging techniques such as ultrasound and computerized tomography should be performed in a stepwise manner in any case of eye injury. The Birmingham Eye Trauma Terminology (BETT) system is developed by Ferenc Kuhn in 1996 to manage the confusion between the terms and diagnosis of the mechanical globe injury [4]. The ocular trauma score (OTS) which is also proposed by Kuhn et al. in 2002, estimates the final visual outcome in a mechanically injured eye. OTS uses six variables, as initial visual acuity, globe rupture, endophthalmitis, perforating injury, retinal detachment, and afferent pupillary defect, giving points for each, then categorizing them to give an estimation of the vision at sixth month [12]. Those two scoring and the categorizing system should be used in every mechanical injury of the eye to manage the patient properly and to estimate the final visual function.
Chemical and thermal injuries consist of 10–22% of all ocular traumas and are emergencies that should be treated in minutes to prevent severe damage to the ocular tissues [13, 14]. While two-thirds of reported cases occur in the workplace affecting young men majorly [14] household injuries by disinfectants and cleaning solutions are common in children and women besides acid attacks in hate crimes and inadvertent exposure by car battery explosions are not rare [15]. The type of chemical involved and the exposure time are the most important information to start treatment. The ischemia in the limbal area may give a clue about the severity and the extent of the injury as well as the estimated visual function [16]. Alkalis can cause irreversible damage to the eye, in between 5 and 15 minutes, and many are considered the most common cause of ocular chemical burns [16, 17, 18]. The assessment of severity involves three factors—damage to the lids and adnexes, degree of limbal ischemia, and the degree of acute corneal stromal opacification [19].
The conjunctiva, the most exterior tissue in the eye with direct contact of the causative agent, the Tenon’s capsule underlying, episclera and sclera followed by suprachoroidal space and choroid and directly cornea beginning from the epithelium down to endothelium, iris, ciliary body, lens, vitreous, and retina may be affected according to the exposure time, the nature and the type of the agent and the time from injury to initial treatment. The intraocular pressure is indirectly affected as the episcleral vessels and trabecular meshwork may be affected directly or due to ischemia.
The classification and grading of ocular chemical burns are based on the extent of involvement of the limbus, conjunctiva, and cornea [20, 21]. The main causative agents are alkalis, acids, and irritants like alcohol. Ammonia and ammonium hydroxide, sodium hydroxide, calcium hydroxide, plaster and cement, magnesium hydroxide, and lime are the alkalis. Alkalis, with their nature of being hydrophilic and lipophilic, dissolve the tissues and induce saponification of the cell membranes followed by extracellular matrix damage by thickening and shortening of collagen lamellae. The damaged cell membranes allow the alkali to deeper penetration.
Sulfuric acid found in car batteries, hydrochloric acid in swimming pool disinfectants, nitric acid in dyes, acetic acid in vinegar, trifluoroacetic acid, and hydrofluoric acid is the acidic agents. Acids cause tissue coagulation and collagen shrinkage, however, the binding of the ocular proteins to acids, creates a buffering effect, resulting in the prevention of deeper penetration of the agent. Trifluoroacetic acid and hydrofluoric acid are exceptions since they cause deeper injury by hydrogen and fluoride ions they own [22, 23, 24].
Alcohol and household detergents are irritants. Although these cause less severe injury, epithelial loss in the ocular surface including the conjunctiva and the cornea, may cause haze and result in infections.
The Roper-Hall classification is based on the limbal ischemia degree and the corneal haze and helps for grading and estimating the prognosis of the trauma (Table 1) [21]. The newer classification proposed by Dua et al., [20], is based on limbal and conjunctival involvement where limbal involvement is evaluated more objectively as the number of clock hours of limbus affected, providing a better prognostic estimation than the Roper-Hall grading (Table 2) [20, 21, 25, 26].
Grade | Cornea | Conjunctiva/Limbus | Prognosis |
---|---|---|---|
I | Corneal epithelial damage | No limbal ischemia | Good |
II | Corneal haze, iris details are visible | <1/3 limbal ischemia | Good |
III | Total epithelial loss, stromal haze, and iris details are invisible | 1/3–1/2 limbal ischemia | Guarded |
IV | Opaque cornea, iris, and pupil are invisible | >1/2 limbal ischemia | Poor |
Roper-Hall grading for ocular burns [20].
Grade | Limbal involvement | Conjunctival involvement | Analog scale | Prognosis |
---|---|---|---|---|
I | 0 | 0% | 0/0% | Very good |
II | 3 clock hours | 30% | 0.1–3/1–29.9% | Good |
III | >3–6 hours | >30–50% | 3.1–6/31–50% | Good |
IV | >6–9 hours | >50–75% | 6.1–9/51–75% | Good to guarded |
V | >9–<12 hours | >75–100% | 9.1–11.9/75.1–99.9% | Guarded to poor |
VI | Total limbus: 12 hours | Total conjunctiva: 100% | 12/100% | Very poor |
DUA classification of ocular surface burns [19].
According to McCulley’s classification [27], the natural clinical course of chemical eye injury can be divided into three distinct stages; 1st, an immediate phase which is the first 7 days with tissue necrosis and sloughing; 2nd, intermediate phase with host response as tissue healing and inflammation, which may result in corneal melting and ulceration, vessel re-canalization and hemorrhages, conjunctivalization and pannus formation with the function of the cytokines (Figure 1); 3th, as of late phase after 3 weeks, inevitable results secondary to host repair and regeneration, such as fibrovascular pannus, deep corneal vascularization, dry eye, neurotrophic keratopathy, persistent epithelial defect, and/or perforation (Figure 2). With this classification, the treatment can be prompted by this natural course of the disease, the management can be broadly divided into early (4–6 weeks) or late (>6 weeks) management approaches [28].
Corneal ulcer, vessel recanalization and severe conjunctival hyperemia in chemical eye injury.
Late phase of chemical injury with pannus formation, corneal vascularization, and conjunctivalization.
Ascertaining that the vital signs are normal is a must initially. Any edema in the larynx or esophagus or stomach injury should be excluded as missing can be fatal.
In the acute stage, the removal of the agent by vigorous irrigation from the eye should be prompted urgently before assessment of the eye. Before irrigation, it is important to use titmus paper to reveal whether the agent is acid or alkali if the patient or the host cannot give a proper history. Measuring the pH of the ocular surface may not always give the correct result, but it may give an idea of whether the irrigation is properly established or whether more irrigation is needed. The change from the basal value gives some clue since the only and the best prognosis depicting treatment is irrigation of the eye. Copious irrigation with isotonic or physiologically equivalent irrigating solutions such as lactated Ringer’s solution and balanced salt solution (BSS) for 30 minutes has been proposed as a more superior treatment than water as these cause less corneal edema [29]. In circumstances that those solutions are not available, irrigation with tap water may also work. Topical anesthesia, with drops, relieves the pain and blepharospasm and facilitates the complete irrigation of eyelid fornices, helps the removal of the agent, and provides neutralization of the pH of the tissues. It should be kept in mind that irrigation can decrease the ocular surface pH effectively, however, the pH of the aqueous humor may be lowered by 1.5 units only by irrigation. Some experimental animal studies relieve that anterior chamber paracentesis followed by irrigation with a buffered solution may reduce humor aqueous pH by 3 units. However, this procedure is very invasive hence endophthalmitis may occur in a severely traumatized eye and is not suggested [30, 31].
In the presence of amphoteric chelating agents, such as ethylenediaminetetraacetic acid (EDTA), Diphoterine®, hexafluorine, and Cederroth eye wash, the neutralization occurs more rapidly, however, these solutions are not always available [32, 33, 34, 35]. After 30 minutes of irrigation with isotonic solutions, the irrigation should be stopped for 5 minutes and the re-measurement of pH should be performed. If neutralization is still present then one may pass to the assessment of the eye.
A complete examination starting from the body (any exposure to inhalant chemical), then face, periocular region, eyelids, eyelashes, conjunctiva, cornea, limbus, sclera, iris, pupil, lens, visual acuity, intraocular pressure, corneal sensation, and retina should be prompted. The eyelids may be swollen and contracted, and lagophthalmos may occur. The tear film may be affected due to inadequate closure of the eyelids as well as the destruction of the accessory lacrimal glands. The tarsal and bulbar conjunctiva should be checked for epithelial defects by fluorescein staining, and eyelid eversion with Desmarres retractors should be performed where eyelids cannot be everted easily due to edema or contraction. Both the upper and lower fornices should be checked for any remained chemical and a deep swap by a cotton bud should be performed. The cornea may be partially or totally deepithelized due to the direct contact of the chemical. The presence and degree of limbal ischemia is important as it is the most important region for corneal epithelial regeneration by stem cells. White areas in the limbal area and the extent of these pale areas in terms of clock quarters provide an estimation for the prognosis. The haze, the opacification, edema of the cornea whether it facilitates the examination of the iris, and lens should be recorded. The iris should be checked for color, vessels, atrophy, hemorrhage, necrosis, and synechia. The pupil constricting and dilating may be disabled partially or totally. Intraocular pressure may be variable due to the extent of the trabecular meshwork dysfunction, inflammation, and ischemia [36]. Phthisis may be seen as ciliary body scarring that can occur. Edema and corneal epithelium damages may obscure measurement of intraocular pressure and digital measurement may give a clue. The lens may be swollen. Retina, optic disc, and vitreous should be assessed for inflammation and hemorrhage.
Suppressing inflammation with preservative-free dexamethasone 0.1% and prednisolone acetate 1% drops in the first 7–10 days is the mainstay of the treatment. Although corticosteroids suppress inflammation and inhibit the release of proinflammatory cytokines, they may impede corneal epithelization. Due to this possible side effect, tapering the frequency after the first week allowing epithelization is the main approach [37, 38].
Tetracycline inhibits the production of metalloproteinases which may lead to corneal ulcer and perforation [39]. Oral doxycycline 100 mg, minocycline 100 mg twice a day, or tetracycline 250 mg four times a day, topical tetracycline 1% suspension, or 3% ointment [40]. Sodium citrate 10% may be used for inhibiting PMNL chemotaxis [41]. Amniotic membrane transplantation may serve as a good option to accelerate epithelial healing, help to alleviate pain, and may improve final outcomes, especially in moderate chemical eye injuries [42, 43].
Commercially available devices or lyophilized and air-dried amniotic membranes (e.g., Omnigen ® 500 and 2000) may also be used for the same purpose [44, 45].
Preservative-free tear substitutes, vitamin C topically 5–10% and/or orally (1–2 g/day) [46] autologous serum [47], umbilical cord serum [48], platelet-rich plasma [49], fibronectin [50], chitosan [51], epidermal growth factors [52], heparin [53], regenerating agents (RCTA, CACICOL20) [54, 55], bandage contact lens [56], tenonplasty [57], free conjunctival autograft [58], amniotic membrane transplant [59], and sequential sector conjunctival epitheliectomy [60], may be used to promote healing process.
Mydriatic and cycloplegic agents other than adrenergic which may cause vasoconstriction and increase ischemia should be used for pain, iridocyclitis and prevent synechiae formation. Fluoroquinolones may be used as infection prophylaxis. Oral intraocular pressure-lowering agents may be more useful than topicals since trabecular meshwork may be damaged. Tenonplasty, free conjunctival flaps that may be secured to the ischemic areas is an early surgical intervention [57, 58].
Eyelid reconstruction, surgical approaches for glaucoma, cataract, corneal haze, or opacification are the late-stage treatment approaches for chemically injured eyes.
Skin and oral mucosal grafts, tarsorrhaphy may be performed when eyelid closure is obscured and exposure occurred. In the case of phacomorphic glaucoma, cataract removal solely with implanting an intraocular lens in another session may be preferred. Dry eye is a common problem in all cases. Frequent lubrication with preservative-free teardrops and gels, punctal occlusion, mucous membrane grafts, and salivary gland transplantation are options according to the severity of the case.
Symblepharon formation may be repaired by fornix reconstruction with amniotic membrane transplantation (AMT) or oral mucosal grafts and scar release with or without Mitomycin C or 5-Fluorouracil.
In severe epithelial defects, nerve growth factor drops (cenegermin) [61], coenzyme Q10, autologous serum, AMT, mucosal, or conjunctival flaps/grafts may be used [62].
Limbal stem cell transplantation may be performed in limbal deficiency cases (Figures 3 and 4) [63].
Limbal cell deficiency and conjunctivalization.
Conjunctivalization with deep and superficial corneal vascularization and vessel recanalization.
In cases with corneal scarring, an anterior lamellar graft, deep anterior lamellar keratoplasty or penetrating keratoplasty are the procedures of choice.
In severe cases where ocular surface reconstruction is not possible, an osteo-odonto keratoprosthesis or a Boston type 2 keratoprosthesis are the only options.
Conjunctival abrasions and lacerations result from minor or major traumas. Work injuries affect males to a much greater degree, especially those between the ages of 17 and 30 [64, 65, 66, 67]. A history of a work relation, recreation, insulting, and self-induced trauma like rubbing and contact lens fitting may be present. Lacrimation, light sensitivity, foreign body sensation, ocular pain, and subconjunctival hemorrhage are the main symptoms and signs. In a conjunctival abrasion epithelial cells are physically removed as stained by fluorescein dye, a visible conjunctival defect with sclera and Tenon’s exposure between the wound edges may be seen in biomicroscopy with the help of fluorescein staining in a conjunctival laceration case. When conjunctival laceration is diagnosed, the conjunctiva should be examined for subconjunctival hemorrhage, foreign body, an underlying scleral laceration, or globe perforation. A bullous chemosis with subconjunctival hemorrhage may be a sign of scleral rupture while subconjunctival emphysema may be a result of a sinus fracture.
Evaluation for conjunctival laceration and/or abrasion begins with history. The time, place, and activity during the injury should be recorded. The eye examination should start with a visual acuity evaluation. If the globe is intact, the upper eyelids should be everted and fornices should be examined for any hidden foreign bodies [68]. A topical anesthetic drop may alleviate blepharospasm and help evaluation. The anterior chamber depth, pupil shape, foreign body, any inflammation or hemorrhage in the anterior chamber should be recorded.
Topical antibiotic/steroid combination drops and/or ointments or antibiotic drops with topical nonsteroidal anti-inflammatory medication may be prescribed [69, 70, 71, 72].
In patients with anterior chamber inflammation, cycloplegia may be added. Conjunctival lacerations smaller than 10 mm heal within a week with medical therapy while in lacerations larger than 20 mm, surgical repair by tissue fibrin glue or suturing may be necessary. For the defects between 10 and 20 mm wide, a pressure patching for 24 hours with antibiotic ointment is usually adequate [73]. However, in lacerations at the horizontal plane where blinking may prevent epithelization, and when apposition of the wound edges is not provided, then suturing by absorbable 8/0 Vicryl or fibrin glue may be performed.
Subconjunctival hemorrhage is a painless and acute accumulation of the hemorrhage between the episclera and the conjunctiva. Ge nerally, it is a benign disorder and can be caused by minor trauma as in contact lens users or in patients with hypertension, anticoagulant therapy, elevated venous pressure (Valsalva maneuver, coughing, vomiting) and in acute hemorrhagic conjunctivitis and may be seen during vaginal delivery in newborns [74, 75, 76, 77].
Traumatic subconjunctival hemorrhage may be associated with direct trauma to the eye (Figure 5) and also in severe circumstances, such as open or close globe injuries, orbital traumas, and basilar skull fractures (Figures 6 and 7) [78]. In children, abuse should always be kept in mind in recurrent subconjunctival hemorrhage.
Traumatic subconjunctival hemorrhage.
Subconjunctival hemorrhage, chemosis, and enophthalmus in orbital floor fracture.
Retrobulbar and subconjunctival hemorrhage in resulting in proptosis in globe injury.
Although no treatment is indicated for SCH without globe perforation or foreign body, suggesting limited activity, cold compresses, teardrops, acetaminophen, or ibuprofen may relieve the discomfort and inflammation.
Eye injuries comprise 8% of the emergency cases where corneal abrasions and foreign body are the main causes with percentages of 45%, 31%, respectively [79]. Ocular injuries, including corneal foreign bodies, are generally more common in young males (Figure 8) [80]. Ocular foreign body sensation is the main complaint as accompanied by excessive tearing, pain, red eye, photophobia, itching, and stinging.
Corneal foreign body.
A thorough clinical examination in conjunction with a detailed history, the extent and the depth of the defect may be examined (Figure 9). Differential diagnoses include corneal foreign body, keratitis, contact lens trauma, recurrent erosion syndrome, staphylococcal marginal keratitis, infectious or inflammatory keratitis, trichiasis, keratoconjunctivitis sicca, and limbal stem cell deficiency [79]. Aslam et al. reported that 12% of corneal abrasion cases were contact lens related [81].
Large corneal epithelial defect.
A missed foreign body under the eyelids may be present. Vertical linear abrasions, as recognized by fluorescein staining, are pathognomonic for a missed foreign body. It is very important to evert the upper eyelid and exam the entire fornix for any retained foreign body. The eversion may be performed by a cotton-tip applicator or Desmarres retractor under topical anesthetic drops. Although embedded foreign bodies under the lids or deep in the fornix can be removed easily by a cotton swab, forceps, or a needle tip under topical anesthesia, corneal-embedded foreign bodies need more attention as they may be penetrating all the corneal layers. These kinds of corneal foreign bodies should be removed in the operating room as they have the risk of falling into the anterior chamber. Corneal superficial foreign bodies can be removed as conjunctival foreign bodies with the help of a 25-G needle. Rust rings resulting from iron foreign bodies may better be removed by a corneal burr. It is not rare that an intraorbital or intraocular foreign body may also be present especially in a patient with a history of high-speed metallic injury by grinders or hammering. The treatment goals are preventing superinfection, promoting epithelial regeneration, and subsiding the pain. Although an intact cornea epithelium is resistant to microorganisms and it often heals without complication, epithelial defects may result in sight-threatening keratitis. The main treatment approach is antibiotic prophylaxis with lubricating ointments or drops. In patients with contact lens history, fingernail trauma, or trauma with a plant-based organic material, topical fluoroquinolone drops four times a day, with fluoroquinolone ointment at bedtime are the choices of preference for their gram-negative organism coverage [82]. Antibiotic ointments, such as erythromycin, bacitracin, or polysporin 4–5 times a day, with antibiotic drops, such as polymyxin B and trimethoprim or fluoroquinolone four times a day, maybe prescribed in patients without contact lens history or trauma by an organic material [82].
Oral nonsteroidal anti-inflammatory drugs and topical cycloplegics may be used for pain. Topical steroidal and nonsteroidal drops should not be offered since they have corneal toxicity potential leading to obscure epithelial healing. Topical anesthesia should only be used for examination purposes and is a contraindication in corneal injury due to its delaying and masking effect of devastating complications like corneal ulcers and are toxic to epithelium [83].
Although patching was the mainstay of the treatment for corneal abrasions for a long time, recent studies emphasized that patching did not shorten healing time or decrease pain, when compared with using only antibiotic ointments [84, 85].
Corneal penetrating or perforating injuries may happen in work, in recreation, and by an assault. A detailed history is necessary to estimate the severity and duration of the injury, the nature of the agent (organic or inorganic), possibility of the retained metallic body, any systemic disease that may complicate the surgery as hypertension leading to suprachoroidal hemorrhage or diabetes negatively affecting wound healing and increasing the risk of infection. The reports should be recorded appropriately as most injuries include a possibility of a medicolegal problem. In an isolated eye injury, the corneal perforation should be evaluated by biomicroscope as the extent of the laceration, presence of any scleral laceration, prolapse of vitreous and/or uveal tissue, anterior chamber depth, presence of capsular and lens injury, and any foreign body; followed by visual acuity evaluation and pupil testing, and if possible visual field testing, along with imaging modalities, such as X-ray and computerized tomography for imaging metallic foreign bodies. B-scan ultrasonography can be helpful in normal-toned globes. A more extensive evaluation may be performed in the operating room under general anesthesia. The repair of a small corneal or scleral laceration although may be sutured with local anesthesia, local anesthesia usually accepted as a contraindication in these types of eye injuries because any pressure from the retrobulbar or peribulbar injection of the anesthetic drug may induce orbital and ocular complications. General anesthesia is the main approach in these patients. Corneal perforations are sutured by 10–0 monofilament nylon suture (Figure 10). Any possibilities of evisceration or enucleation of the globe due to unrepairable lacerations, optic nerve avulsion, need for lensectomy, and need for secondary interventions such as IOL implantation, vitrectomy for retinal detachment, risks as sympathetic ophthalmia, infection, hemorrhage, secondary glaucoma, corneal scarring, astigmatism, traumatic optic neuropathy, and blindness, should be informed to the patient and the patient’s family members. Written informed consent should be taken from the patient if possible as well as the family members.
Corneal perforation sutured with 10-0 monofilament nylon suture.
Perforating injuries that are small in size may be self-sealing and are observed with minimal intervention and prophylactic use of antibiotics. Patching alone, a bandage soft contact lens or tissue adhesives may help to seal a minimal leakage [86]. Any perforating injury warrants complete evaluation to exclude any foreign body presence and damage to other intraocular tissues. Sometimes a self-sealed oblique perforation, especially entering from the peripheral iris with a foreign body, may mimic partial-thickness laceration as the iris muscles contract and close the entrance region, leading to delayed diagnosis of an intraocular foreign body. The iris and the lens portion, under the corneal laceration area, should be carefully evaluated for any spot or entrance point. Taking initial cultures from the conjunctival and corneal surface before use of any prophylactic antibiotic drops or intravenous antibiotics, especially in cases with foreign body or infection risk, may help to establish a probable causative agent in case of consecutive endophthalmitis. Ophthalmic ointments should be avoided on an open eye injury and an eye shield should cover the eye to avoid any further extrusion of ocular contents. Systemic intravenous antibiotic prophylaxis may be initiated preoperatively.
Under the anesthesia, the leakage area should be identified and an anterior chamber washing with BSS may be performed from the leakage area to clear the media and to form the anterior chamber. Injecting viscoelastic into the anterior chamber helps to provide the tonicity of the eye, enabling suturing of the wound. The limbus should initially be stitched by a 10–0 nylon suture, then the suturing should extend from anterior to posterior. About 80–90% depth of suture placement is needed to provide apposition of the wound margins as interrupted sutures. Rowsey et al. stated that most peripheral cornea should be closed first to achieve the flattest topography allowing progressive steepening as sutures progress toward the corneal apex. Longer bites of tissue with more compressive effects are desired peripherally to achieve peripheral corneal flattening [87]. Repair near the optical zone and corneal apex should consist of shorter stitches placed deep within the corneal tissue. Triangular wounds should be stitched starting from the apex and then the sides of the triangle. All knots should be buried below the level of Bowman’s membrane. When extensive tissue loss has occurred, patch grafting using corneal or scleral tissue may be necessary, as well as penetrating keratoplasty or lamellar keratoplasty. Conjunctival flaps should be considered inadequate for use as a temporary measure for closing over defects of corneal tissue.
Early corneal suture removal may be indicated when sutures loosen, collect mucus, or induce vascularization. Total removal starting from the peripheral sutures to the center should be done when the wound appears healed with cicatrization. The central corneal sutures, although the timing may change according to the wound type, place, and patient’s individual health status and age, maybe removed about 3 months. Peripheral corneal sutures may be removed in 1–3 months in adults and shorter as in several weeks in infants. Scleral sutures are left in place indefinitely if they are buried well with no risk of infection and symptom. Any iris tissue prolapsed from the corneal wound for longer than 24 hours, or is highly contaminated or ischemic, should be excised. Smaller and viable prolapsed iris tissues should be reposited with the help of the viscoelastic. It is of utmost importance not to cause a cyclodialysis at this step. Iris repair may be performed with polypropylene 10–0 suture, and iris dialysis may be repaired by suturing the edge of the iris into an anatomic position at the angle.
The scleral laceration may be contiguous with a corneal laceration, may be localized between the limbus and the extraocular muscles (Figure 11), or maybe hidden in the posterior pole at the extraocular muscle insertion area. In blunt traumas, scleral rupture commonly happens at the limbus, and the equator between the muscle insertions, under the muscle insertion extending to the posterior pole [88]. A globe with scleral perforation may be hypotoned with IOP less than 5 mm Hg or maybe normal-toned when the scleral defect is occluded by tissues of a clot. The visual acuity is usually decreased to light perception or less, and the anterior chamber is shallow with intraocular and periocular hemorrhage [88, 89]. A 360-degrees peritomy and dissection of the conjunctiva and Tenon’s to posterior pole to expose the complete sclera is important for direct visualization of all extraocular muscle insertions. Two conjunctival incisions perpendicular to the limbus at the 3 and 9 o’clock quadrants may help to visualize the posterior pole up to the optic nerve. In severe injuries, lid sutures provide better visualization and decrease pressure risk than with speculums. When the limbus is accomplished with the scleral perforation, the suturing should start from the limbus with deep scleral bites by interrupted sutures using 10–0 or 9–0 nylon. Repair of a scleral laceration should proceed from an anterior to a posterior direction and in presence of a large scleral defect, a donor cadaver scleral patch graft may be used. If vitreous is prolapsed through the wound edges, it should be excised by scissor with the help of a cellular sponge, however, a vitrectomy probe is a better option for this purpose as it does not cause traction on the tissue. Generally, any prolapsed uveal tissue should be reposited as the sclera is closed. The conjunctiva is sutured by 8–0 Vicryl at the limbus.
Scleral laceration.
Hyphemas are the accumulation of blood in the anterior chamber mostly due to penetrating or blunt traumas in the eye. (Figure 12) The bleeding results from the tears in the well-vascularized ciliary body and iris [90]. A fibrin clot stops the bleeding and the clot stabilizes in 4–7 days, and the fibrinolytic system resolved clot is cleared by the trabecular meshwork [91]. Trauma history, pain, and decreased vision are the most common complaints. In a patient with hyphema associated with subconjunctival hemorrhage and glob hypotonicity, a glob perforation should always be suspected [92]. Although hyphema due to intraocular tumors, leukemia, and sickle cell anemia (SSA) is rare, it should always be suspected in patients without a history of trauma or with recurrent hyphemas. Although traumatic hyphema is more common in children, in children presenting with hyphema, physical abuse should also be questioned. Orbital/cranial CT/MRI, ultrasound, and additional blood testing should be performed in those cases [93, 94].
Grade 1 hyphema and subconjunctival hemorrhage in blunt trauma.
Visual acuity, hyphema grade, intraocular pressure, and presence of corneal staining should be performed daily in the first 5 days, and after clearance of the blood, a careful gonioscopy should be performed for the presence of angle recession and any bleeding area, followed by a dilated fundus examination [92].
Hyphemas are typically graded macroscopically due to the level of accumulation of blood in the anterior chamber. Grade 0 is microhyphema with no visible layer, only with red blood cells in the anterior chamber. Grade I is blood accumulation less than 1/3 level of blood in the anterior chamber. Grade II is 1/3–1/2 of blood accumulation in the anterior chamber, and grade III is 1/2 to near-total filling of the blood in the anterior chamber. Grade IV is total hyphema, which is defined as a blackball or 8-ball hyphema [95].
Treatment modalities include initially preventing complications as intraocular pressure increases, corneal staining, and rebleeding. Although the inpatient treatment approach was commonly used in the past, recently, outpatient management has shown to be similarly effective with appropriate precautions given to the patient [96, 97].
Inpatient hospitalization may be considered in patients with uncontrolled intraocular pressure and rebleeding risk. Limited activity and eye shield should be suggested to minimize the risk of rebleeding, especially in children. The patient should sleep in a head elevated bed to provide layering of the blood in the inferior angle to clear the visual axis. High intraocular pressure is reported in 32% of patients with hyphema on the first day [92]. Any IOP >25 mm Hg especially in a patient with SSA or SSA trait, the topical beta-blocker may be prescribed. Prostaglandins may induce inflammation, alpha agonists may lead to respiratory distress and carbonic anhydrase inhibitors may result in sickling in SSA patients, so these drugs should better be avoided [98, 99]. If corneal staining with blood is present or IOP remained high after 4–7 days, then an anterior chamber lavage should be performed.
Rebleeding occasionally occurs at 4–7 days after the trauma and the grading of the hyphema is important to discriminate fresh bleeding from an old clot. Although the implication of aspirin and other NSAIDs in the rebleeding is controversial, they are commonly discontinued in hyphema [100, 101]. Cycloplegics may be used for relaxing the ciliary muscle, and by its dilation effect on the pupil, iris vessels contract, decreasing the risk of rebleeding.
Topical steroids are commonly prescribed in hyphema due to the presence of inflammation. They should be used according to the severity of the inflammation and should be discontinued in a tapered manner as complications such as glaucoma and cataracts may occur [102, 103]. Antifibrinolytic agents such as oral aminocaproic acid and tranexamic acid stabilize the clot and decrease the risk of secondary hemorrhage, however, due to some systemic side effects, it is better to hospitalize the patient when systemic use is planned [104, 105, 106, 107]. Aminocaproic acid can be safely used in children, however, it is contraindicated in patients with thrombosis risk [108]. Tissue plasminogen activator and transcorneal oxygen therapy are used in some cases with variable results as reported in the literature [109, 110]. Anterior or posterior synechias, secondary glaucoma, and angle recession may be seen as late-term complications where the latter is reported to occur in 85% of hyphema patients and the relative risk of gl aucoma is reported to be 2.21 [111].
Traumatic IOP elevation and traumatic glaucoma are complications that can result from the trabecular meshwork dysfunction, angle recession, lens displacement, lens swelling (phacomorphic glaucoma), inflammatory response to lens proteins in a case with capsular tear (phacoantigenic glaucoma), iris damage, hyphema, inflammation, anterior synechiae, vitreous hemorrhage, and topical corticosteroid use [112, 113, 114, 115]. Ocular trauma can lead to secondary glaucoma, with a 4% risk of developing post-traumatic glaucoma. Majority of the secondary glaucoma cases (77%), resulting from closed globe injuries, whereas only 23% followed open globe injuries . The etiology of traumatic glaucoma although may differ according to the type, time, and duration of the trauma, a classification based on the timing after the trauma as reported by Bai et al., may give a basic and effective idea of the mechanism involved [116]. In the first month, inflammation, hyphema, lens dislocation, and prolonged use of potent steroids are the main causes of secondary glaucoma. Between 1 and 6 months, angle-closure glaucoma occurs due to anterior synechia and pupillary block with posterior synechia. In the late term, angle recession, siderosis may be the etiology. In patients with associated vitreous hemorrhage, ghost-cell glaucoma can be seen in 2 weeks–3 months [117].
Ocular blunt trauma can result in closed-globe injuries or open-globe injuries. In blunt trauma, compression force on the globe results in elevated pressure on the limbal area, where ciliary bodies longitudinal fibers separate from circular fibers, associated with the breakage of the vessels leading to hyphema. Angle recession is seen in 85% of traumatic hyphema and results in chronic glaucoma [111]. Cyclodialysis is relatively rare than the recession and it leads to resistant hypotony [118, 119, 120, 121]. In an examination, a widened ciliary band is seen on the gonioscopy (Figure 13). The relative risk for developing glaucoma is 2:1 in patients with recessed angles. In general, studies show the risk is significantly increased when more than 180 degrees of recession exists [122]. Prostaglandins may be used after inflammation is treated due to their uveoscleral outflow increase potential. Pilocarpine may worsen angle recession. Trabeculectomy with Mitomycin-C can be performed in patients with uncontrolled IOP with medications [123].
Angle recession observed as a widened ciliary band in gonioscopy.
The direct communication between the anterior chamber and the suprachoroidal space, in cyclodialysis, results in resistant hypotony. Although the dialysis portion is seen on gonioscopy as posterior to the scleral spur, in eyes with hyphema or corneal edema, it may be hard to visualize the angle. Ultrasound biomicroscopy (UBM) and anterior segment OCT may show cyclodialysis when gonioscopy is difficult [124, 125].
The medical treatment includes 1% atropine sulfate BID for 6–8 weeks to reoppose the ciliary body back to the scleral wall and normalize intraocular pressure. Surgery is another option in cases where the medical approach is inadequate. The ciliary body may be attached to the sclera either surgically or by facilitating inflammation by burn to help apposition. Direct cyclopexy [126], argon laser photocoagulation [127], trans-scleral YAG laser [128], and cryoablation [129], are other options.
In the dialysis of the iris at the root, small dialysis may be asymptomatic while in large dialysis cases, polycoria, glare, monocular diplopia warrants surgical intervention (Figure 14).
Large iridodialysis between 11-o’clock and 2-o’clock quadrants.
Cataracts may arise from blunt or penetrating eye traumas immediately after the injury or many years later. Lens damage is present in 30% of perforating injuries of the anterior segment of the eye [130].
If penetrating trauma is present, the use of topical medication or pressing devices that touch the eye should be avoided. Once penetrating trauma has been ruled out, ultrasound A and B may be used for further assessment of the ocular status.
Lens injury may happen in an eye trauma as direct injury of lens fibers, capsular rupture, zonular dehiscence, or all [131]. The flow of aqueous humor in the lens causes opacity. Small capsular tears less than 2 mm may heal spontaneously but defects bigger than 3 mm occasionally result in lens opacity. Large disruptions of the lens, with the obvious release of cortical material or through-and-through lens rupture with dislocation or rupture of the lens zonules, are indications for primary lensectomy at the time of primary repair.
In blunt traumas, although the capsule may be intact, a sunflower cataract (Rosette or stellate type) may be seen (Figure 15). The main symptoms are vision decrease, glare, and intraocular inflammation with or without glaucoma. In these patients, the retina should carefully be examined for any tear or detachment, or hemorrhage. When it is not possible to visualize the fundus, a B scan ultrasound may be used for probable retinal pathology or vitreous hemorrhage, or a foreign body.
Traumatic sunflower cataract.
If the lens opacity is not at the visual axis, and the visual acuity increases with a refraction correction with no inflammation, phacodonesis, vitreous prolapse, or inflammation, observation with close follow-up is the main approach.
Phacoemulsification is the best approach in patients with cataract extraction indications. Preoperatively, any risk of phacodonesis, vitreous prolapse, and zonular dehiscence should be evaluated. If a torn capsule, a phacodonesis, or subluxation are present, phacoemulsification with the help of the capsular tension ring or capsule hooks may also be facilitated, however, combined pars plana lensectomy and vitrectomy are also may be performed. Extracapsular or intracapsular cataract extraction may be facilitated when zonular and lens instability is a problem. Primary lens implantation may be considered in any approach in an intact capsule or zonules long as there is no inflammation or infection risk. Advantages of the primary placement of intraocular lens implantation include more rapid visual rehabilitation with a single surgical procedure and one anesthetic exposure [132]. The lens may be placed in the bag, in the sulcus, in the anterior chamber, or maybe fixated to the iris or sclera. However anterior placement of IOL should be avoided in patients with corneal injury and in young patients. In patients with zonular defects, capsular tension rings should be implanted. Peripheral iridectomy may be considered in eyes where the prolapsed iris could not be repositioned and when there is a possibility of a pupillary block [133].
In children, the management of traumatic cataracts requires many measures to be taken into consideration. Firstly, the timing of the cataract extraction is important as amblyopia may develop in a short period. In children with cataract removed, inflammation and synechia risk are more than the adults, and the risk to develop posterior capsular opacifications relatively soon after cataract removal is higher [134, 135]. For this reason, in children who will not be able to cooperate with YAG laser capsulotomy, a primary posterior capsulotomy and anterior vitrectomy are recommended at the time of cataract extraction. Another controversial aspect is the implantation of the lens in children. Although primary IOL implantation may be possible in most cases of closed globe injuries, in open-globe injuries, complicating factors such as poor visualization and difficulty in accurate IOL power calculation may delay IOL implantation as a secondary procedure [136]. Retinal detachment, macular scarring, amblyopia, and traumatic optic neuropathy may be seen in the late term either primary or secondary lens implantation. All children whether cataract extracted or not should be continued follow-up with a pediatric ophthalmologist.
In traumatic cataract cases with the lacerated cornea, the perforation should priorly be stitched or sealed before any intraocular surgery including cataract extraction or vitrectomy. Corneal lacerations are closed with 10–0 nylon sutures, with the sutures starting from the edges. The tissues should be opposed well as leakage of the humor aqueous will cause obstacles preoperatively and postoperatively. In eyes with the traumatized cornea, biometry and keratometry may not be accurately measured, hence intraocular lens calculation may be compromised. In these cases, an IOL calculation of the fellow eye and a keratometry of average value as 44 may be used.
During the surgery, the state of the anterior and posterior capsule and the zonules should always be taken into consideration. In intact capsules and zonules, standard phacoemulsification with or without the help of trypan blue dye may be performed.
In cases with the anterior capsular tear, the lens becomes pacified quickly and continuous curvilinear capsulorrhexis may not be completed, requiring completing the capsulorrhexis by Vannas scissors.
When lens zonules are injured, capsular or iris hooks may be used to secure the bag, and capsular tension rings should be implanted in zonular dialysis less than 120 degrees. Capsular tension rings should not be placed in dialysis with a posterior capsular rupture.
Most traumatic cataracts are soft as they may be easily aspirated by I/A tip or simcoe cannula. In traumatic cataract surgery, the parameters used during the surgery should be low, such as a bottle height of 60–75 cm, aspiration rate with 18–20 cc/min, and low vacuum as 180–200 mm Hg, however, it should be kept in mind that these settings may differ according to the case, the surgeon and the device used.
At the end of the surgery, a 0.3 mL of cefuroxime solution (concentration of 1.0 mg/0.1 mL) should be injected into the anterior chamber for prophylaxis. The wounds and the entrance areas should be carefully evaluated for any leakage as it may cause complications as endophthalmitis and hypotony.
In an eye injury, taking a detailed history is important to guide a proper evaluation, diagnostic approach, and treatment modality. Early and thorough identification of the affected anterior segment tissues involved will provide timely and appropriate management which will determine the final outcome for the visual function and globe integrity.
No funding.
The photos are published with the courtesy of Prof Dr. Cemil Tascioglu City Hospital, Department of Ophthalmology, Istanbul, Turkey.
The authors declare no conflict of interest.
Optically active materials are the fundamental constituents of the human body and its nutrients. Major part of the daily human diet is comprised of OAMs, and has a strong impact upon wellness and performance of the human body. The monitoring of OAMs in everyday nutrition is of vital importance for being healthy, lean and active. Therefore, a strong check of quality control is always the matter of concern is the industries including food, chemical, pharmaceutical, beverages etc. The OAMs cause the rotation in the angle of polarization of linearly polarized light when it pass through them. The variation in plane of polarization is different for different materials at different concentrations. OAMs are not limited to sugar (glucose, sucrose, fructose, maltose etc.), proteins, acids (tartaric acid, lactic acid etc.), cholesterol, etc.
A number of prescribed analytical techniques have been employed such as Ultra-voilet visible (UV–vis) absorption spectroscopy [1, 2], thin-layer chromatography (TLC) [3], infrared (IR) and Fourier transform infrared (FTIR) spectroscopy [4, 5] and Raman spectroscopy [6, 7]. However, optical techniques such as polarimetry [8, 9], interferometry [10, 11] and refractrometry [12] are commonly used in most of the practical applications for quantitative determination of OAMs due to their rapidity, noninvasiveness and non-destructive nature of their method of analysis.
OAMs are usually comprised of at least one asymmetric atom inside their molecular structure. The list of those atoms include carbon, sulfur, phosphorous, silicon etc. The asymmetric nature of these molecules result in the formation of two different types of isomers. The isomer of the same substance which rotates the plane of polarization of the light clockwise is called dextrorotatory or right-handed. However, those molecules which cause anti clock wise rotation of the polarization is called levorotatory or left-handed. Optical activity is the result of left–right asymmetry around the central carbon atom in the case of amorphous substances. The geometrical shape and chemical composition of both the molecules are same but left-handed isomer is mirror image of right-handed isomer and both of them are called enantiomers, as shown Figure 1 for the D and L configuration of glucose molecule. Both of the enantiomorphs rotate the plane of polarization of light exactly by same magnitude but in opposite directions.
Dextrorotatory and levorotatory configuration of glucose molecule.
The foundation of detection of analytes concentration by using optical polarimetry trace back to the observation of Biot’s in early nineteenth century [13]. The mathematical equation for the optical interaction of linearly polarized light with optically active specimen was described as below which is also called Biot’s law;
The term
Suppose two monochromatic light beams with same frequency originating from single source represented by the electric field vector
Where
The time averaged irradiance is proportional to the square of the amplitude of the electric field, i.e., for linear, homogeneous, isotropic dielectric medium;
Where
Where,
and
Where,
The I1 and I2 are the irradiance of the individual beams and I12 represents the interference term. The symbol,
and total irradiance at point P will become
The interference is called fully constructive if
Eq. (13) is called the maximum intensity or the maxima of fringes pattern (constructive interference) and can be interpreted as;
and IP will be minimum if the term
If the two interfering light waves are mutually coherent then the time averaged value of
At different points of observation (
Where Imax and Imin represents the irradiances corresponding to maximum and adjacent minimum in the interference fringes. If one beam is incident with some small angle
Where, I1 and I2 are the irradiances of reference and sample beams respectively and
The Mach-Zehnder interferometer is most commonly used for sensing applications and was first introduced by Ludwig Zehnder in 1891 and Ludwig Mach in 1892 independently. In this interferometer, a coherent light beam is split into two using beam splitter and then recombined on another beam splitter with the help of two mirrors to obtain interference pattern. One part of the splitted beam is called reference while other one is called sensing arm. The chiral sample is kept in the sensing arm of the interferometer and its effect on the contrast of the interference fringes is detected. The interference fringes are normally recorded by a camera and analyzed by image processing techniques. MZI has good potential for the detection of OAMs therefore, most of the time exercised in the literature for this purpose.
Calixto et al. proposed a Mach-Zehnder interferometer (MZI) based wavefront division polarimeter for the measurements of chiral solute concentrations in solutions as shown in Figure 2. An optically active solution was kept in a sample chamber in the sensing arm of a MZI. One beam of the polarized light was passed through a liquid sample containing dissolved OAM while the other half of the light was used as reference beam. The plane of polarization of the incident linearly polarized light was rotated when the sample beam propagated through the chiral solutions. As a result, a decrease in the visibility of the interference pattern was observed with increase in the concentration of the OAMs in the solution. Contrast of the interference fringe pattern was maximum when both the sample and reference beams presented a polarization perpendicular to the plane of incidence. However, the visibility of the fringe pattern was deteriorated fully when the polarization of the sample beam is oriented parallel to the plane of incidence. The effect of decrease in the fringes visibility was mainly due to the increase in the refractive index of the solution with increase in the concentration of the OAMs as shown in Figure 3. The following calibration equation was obtained for variation of the visibility of the fringe pattern and concentration of the fructose solution:
Schematic diagram of the Mach-Zehnder interferometer and interference fringes pattern recording system [
The effect of concentration on the visibilities of fringes pattern by solutions of (a) fructose and (b) glucose [
Where, ‘V’ is the visibility of the interference fringe pattern and ‘c’ is the concentration of the chiral materials (Figure 3).
H.A. Razak et al. proposed an optical sensor based on fiber optic MZI for food composition detection as depicted in Figure 4. The MZI structure was employed as fiber optic sensor in single mode-multimode-single mode (SMS) structural configurations using fusion splicing technique. The interferometer was investigated with 4 cm and 8 cm sensing regions. The sensor response was tested for detection of water, sugar and oil from their respective refractive indices as representative major components of food. A red-shift was seen in the wavelength for increase in the refractive index of the constituent sample. The sensitivity of the sensor was found to be directly dependent on the length of the sensing region.
(a) Basic block diagram of optical fiber MZ interferometer. (b) Schematic representation of SMS structure. (c) Schematic diagram of liquid concentration detector [
A miniature broad-band (BB) MZI was proposed by M. Kitsara et al. for the detection of label-free biochemical OAMs sensing as shown in Figure 5. A theoretical investigation was performed on Si-based MZI with BB input lights in the range 450 nm – 750 nm. They have proved that BB-MZI can be used as a miniaturized optical sensor with enhanced sensitivity, versatile biochemical sensing applications and economical fabrication and operating costs compared to its counterpart single wavelength (SW) MZI. Glucose was used as a representative biomolecular entity because of its relatively small size to demonstrate the designed BB-MZI to detect its concentration in a very diluted solutions with a higher efficiency. The phase changes of the evanescent field at Nd:YAG (532 nm) and He-Ne (633 nm) lasers were studied to evident that an optical setup could be designed where the source of light and MZI chip vary according to application. The theoretical transmission spectra of BB-MZI as a function of the refractive index of the solution were reported for 10 mM, 25 mM, 50 mM and 100 mM glucose concentrations. The recorded peak shifted with concentration of glucose. The performance of the BB-MZI was also observed with a hypothetical protein adlayer over the sensing arm of length 300 μm. An ultra-thin protein adlayer was sensed with recording of the spectral changes or by observing the variation in the integrated intensity. The potential of the designed interferometer was investigated for biomedical applications. It was observed that the performance of the BB-MZI is comparable to the SW-MZI without a requirement of a costly laser system as an input light source.
Schematic diagram of the prosed BB-MZI for detection of label-free biochemical chiral materials sensing [
A. Psarouli et al. also investigated a monolithically integrated BB-MZI for label free detection of biomolecules with high sensitivity as shown in Figure 6. A transducer based on monolithic silicon microphotonic was developed for this purpose. The MZI was fabricated from monomodal silicon nitride waveguides with silicone light emitting diodes (LEDs). BB light was injected into the interferometer setup and were sinusoidal modulated by optically active biomolecules with two different frequencies of the polarization before exiting the sensor. The distinct reporting of the two polarizations and simultaneous investigation of the TE and TM signals were performed by deconvolution in the Fourier transform. The quantitative determination of the binding adlyaers were made possible from their refractive indices by dual polarization analysis over the broad spectral range. The sensor was equipped with power and control electronics, a docking station, an off-chip fluidic circuit, a miniature spectrometer and an optical module. The set of ten interferometers were interrogated with a defined time delay by integrated LEDs which were operated by control electronics. The proposed interferometric sensor was found 60 and 550 times more sensitive than a two-lateral-mode spiral waveguide MZI [18] and polyimide-waveguide MZI [19], respectively.
(a) Schematic of the biochip showing the monolithic integration of the avalanche-type LED, the MZI, and the silicon nitride rib waveguide. (b) Layout of the 10 MZIs showing the MZI routes as well as the LED positions and metal [
An asymmetric Mach-Zehnder interferometer (aMZI) was introduced by M. J. Goodwin et al. for interferometric biosensing applications [11]. The device was manufactured using TriPleX technology. The interferometer was fabricated on a chip consist of Si3N4 waveguide with silica cladding which made a photonic integrated circuit (PIC). A sensing window was fabricated by locally removing the SiO2 cladding which given a provision to analyte to make a contact with the waveguide. In the proposed design, the incoming light was split into two arms by the waveguide. One of the arm was exposed to the analyte and the other arm was used as reference. The interference pattern was detected on at the point of recombination of the two arms due to the deliberately induced asymmetry. Subsequent to interaction of the analyte with the evanescent field of the waveguide at the sensing window, a phase shift was introduced due to variation in the refractive index. Performance of the proposed sensor platform in terms of signal-to-noise-ratio (SNR) and absolute response is compared with the commercial quartz crystal microbalance with dissipation (QCM-D). The aMZI proved itself dominated over the QCM-D due to measurement capability streptavidin binding with no need of the added complication of hydrodynamically coupled water which allow the elucidation of absolute protein adsorption. Also the aMZI presented 200 times good SNR and therefore offered a relatively lower limit of detection.
The operation of a versatile and sensitive integrated optical MZI biosensor with three-guide coupler at the output was demonstrated by B. J. Luff et al. as shown in Figure 7. The interferometric devices were designed by Ag+–Na+ ionexchange in glass substrates. The chemical modification of the waveguide surface of the interferometer made possible the detection of the biochemical species. The waveguide were designed in BGG36 glass with refractive index about 1.6 at 786 nm by Ag+–Na+ ion-exchange. Photolithographically patterned Ti film was used as the masking material with opening width of 1 μm. The fabricated device was characterized by different concentrations of sucrose solutions to vary the superstrate index. For building up multilayers of protein over the sample surface, a high affinity interaction between vitamin biotin and protein streptavidin base system was used. The refractive index and thickness of the protein multilayer system was calculated reproducibly based on waveguide model.
(a) Schematic diagram of the biosensor device configuration based on MZI. (b) MZI with three-waveguide coupler [
Fabry–Pérot interferometer (FPI) also called etalon is based on an optical cavity made from two parallel reflecting surfaces. The interferometer is named after Charles Fabry and Alfred Perot for their invention in 1899. The parallel reflecting surfaces of the FP cavity is separated by a distance ‘d’ which allows the transmission of infinite number of parallel to each other as shown in Figure 8. A sharp constructive interference can be recorded when these parallel beam superimposed with each other. Free spectral range (FSR) analysis can be used to calculate the separation between the reflective ends of the cavity from refractive index information of a known medium. The spacing between the two reflective surfaces can be calculated from the FSR from refractive index of a known medium, as follow;
Schematic diagram of the principle of the Fabry-Perot interferometer etalon. Basic structure of cavity [
Where,
The FPI is highly sensitive to any perturbation causing a variation in the optical path length between its two reflective mirrors as presented in Figure 9. Due to its compact size, high sensitivity and fast response, the FPI is applied for different physical parameters sensing, biosensing, gas sensing, current and magnetic field detection etc. [23]. FP etalons based optical sensors provide an efficient label-free biosensing capability with enhanced sensitivity. The biosensing of etalon is measured in terms of absorption or phase shift subsequent to interference between the reflected light beams from the two reflecting surfaces in its cavity [24, 25, 26, 27, 28, 29].
(a) FP interferometer having reflective surfaces with reflectivity of R1 and R2, respectively. Examples of intrinsic and extrinsic FP interferometers. (b) Schematic representation of the FP based experimental setup employed for detection of gaseous biomolecules [
G. Allison et al. investigated an efficient FP cavity coupled surface plasmon photodiode for electrical label-free biomolecular sensing [30]. The surface plasmonic sensor was developed inside a photovoltaic cell. The information of solutions containing biomolecules was extracted from its refractive indices in the form of electronic signal generated subsequent to incident light. The resultant photocurrent was enhanced due to surface plasmon mode coupling with the FP modes inside the photovoltaic cell due to its absorbing layer. An optically transparent substrate with special ability for surface plasmon resonance (SPR) was replaced by a silicone layer of semi-transparent optical nature. With the help of this mechanism, an absorbing layers was sandwiched between a metallic layer and an optically transparent conducting electrode. Photocurrent was caused as a result of incident light due to built-in potential of fabricated device in a similar nature to that of photovoltaic cell. The surface plasmon was excited in the metal layer and generated the photocurrent simultaneously by illuminating a thin silicon layer by a visible light with single wavelength at a resonant angle. The photocurrent was reduced drastically by surface plasmon due to disruption of the distribution of electric field in the silicone layer. The mechanism were further enhanced by the silicone layer as an optical FP cavity to produce the FP modes which were coupled with the plasmon mode. The mechanism was confirmed by the simulation of the distribution of electric field which was further confirmed experimentally by electric detection of mode and resultantly the variations in the refractive index and the protein – protein interactions were measured.
A microfluidic optical sensor integrated with FP etalon geometry was investigated for detection of concentrations of different biochemical species in solution by K. E. You et al. The concentration information were extracted in terms of the refractive index variation with concentration with high accuracy and sensitivity. The FP cavity was fabricated from a liquid channel with two partially reflected Ag/SiO2 reflective surfaces. The refractive index dependent interference peaks were achieved in the transmission spectra subsequent to transmission of light through the fluid channel. Concentrations of different biomolecules, i.e., glucose, potassium chloride and sodium chloride were calculated from their refractive indices in terms of a shift in the position of maxima of wavelength of the interference peaks in the transmission spectra. The devised optical sensor shown a linear response with good accuracy. Sensitivities of 10−3, 1.4x10−3 and 1.8x10−3 refractive indices per percent of glucose, KCl and NaCl, respectively were obtained. Schematic diagram of the investigated FP cavity based optical sensor and its response to the optically active glucose sample was shown in Figure 10.
Schematic diagram of the devised modified microfluidic Fabry-Perot etalon (a) 2D view, (b) simulation (c) refractive index vs. glucose concentration (%) [
A micro Fabri-Pérot interferometer (MFPI) was designed and developed for quantitative determination of sugar in a transparent solutions by G. Chavez et al. as shown in Figure 11(a). The MFPI was developed in the form of a micro bubble made of a hollow core photonic crystal fiber (PCF) as shown in Figure 11(b). The cavity was fabricated by splicing of a segment of PCF to a single mode fiber (SMF) by a conventional arc fusion splicer which form an air MFPI. The fabricated MFPI then acted like an optical cavity having two reflecting surface of different refractive indices separated by a distance d. The erbium doped fiber (EDF) was illuminated by 200 mW laser diode with 980 nm wavelength with the help of wavelength division multiplexer (WDM). Output light from EDF was incident on the MFPI subsequent to passing through a three-port circulator. The reflection from MPI was guided towards optical spectrum analyzer (OSA) by port three of the circulator. The MFPI was immersed inside a sugar solution filled cuvette and the reflected interference patterns were recorded at different concentrations of sugar solution in the range 0–30.88 g/100 ml. The contrast of the interference fringes decreases with increased in the sugar concentration in solution as illustrated in Figure 11(d). The predicted results from simulation were also experimentally confirmed with good agreement. The reflected optical power was directly decreased with increase in the concentration and resultant refractive index of solution with sensitivity of −0.0123 dBm/(g/100 ml) at 1538.27 nm wavelength.
(a) Schematic diagram of the experimental setup for MFPI based sugar concentration sensing, (b) schematic view of the fabricated MFPI, (c) reflected energy and the refractive index of the exit medium at λ = 1538.27 nm as a function of the sugar concentration (d) measured reflected power spectra for different sugar concentrations and (e) enlarged view of the spectra [
J. Martini et al. also proposed a glucose concentration sensor in interstitial fluids based on a small size double-chamber FP etalon. One of the FP chamber of the proposed sensor was used as reference to overcome the effect of ambient temperature variations. The 400 μm etalon cavity was filled with water – glucose solution which had FSR of 680 pm in response to the normal incident light of wavelength 850 nm. A wavelength shift of ∼1 pm was produces per 1 mg/dl of the optically active analyte (glucose). The light beam from an SM vertical cavity surface emitting laser (VCSEL, 850 nm) was guided towards 50/50 beam splitter and was incident on one of the FP chamber subsequent to proper collimation. The perpendicular half of the beam was redirected into the other FP chamber with the help of a prism. The transmitted light signal from FP chamber were recorded by PIN photodiodes with two active segments as shown in Figure 12. Difference in the refractive indices of the two etalon chambers produced a phases in the transmitted optical signals. The proposed optical sensor was studied in the range 0–700 mg/dl of glucose concentration with precision of ±2.5 mg/dl. The temperature compensation was confirmed in the range 32–42°C.
(a) Schematic diagram of the experimental setup of the double-chamber FP etalon (b) spectral position of FP modes for two different refractive indices (c) calibration curve of the refractive index with varied concentration of glucose [
In the Sagnac interferometer, the light beam is split to follow the same optical path but in opposite directions in the form of a closed loop. The beams get interference upon returning back to the point of entry. In the case of optical fiber Sagnac interferometer, a section of birefringent fiber is splices to the loop which causes interference between the counter propagating light beams.
A Sagnac interferometer based optical sensor system was designed, developed and demonstrated by T. Kumagai et al. for quantitative analysis of glucose in a solution. The optical rotation proportion to concentration of glucose concentration was measured in a Sagnac loop from a phase difference introduced between the clockwise (CW) and counter clockwise circularly polarized light. The proposed optical sensor was composed of a Sagnac interferometer made from a polarization maintaining fiber (PMF) and other optical components to avoid the unwanted sources of noise due to different reasons. A coherent light of wavelength 840 nm from a super luminescent diode was transmitted in the sensor system. Two orthogonal mode of polarizations with a minor difference in their propagations constants were transmitted in the interferometer. The ambient sources of noise those were temperature variations and external vibrations may vary the zero level of the output signal which were controlled by fabricating the interferometer from PMF. A quarter-wave retarder was used to convert the linearly polarized light into circularly polarized light which was subsequently passed through a low birefringence span SMF or in free space. The interference signal achieved from recombination of CCW and CW lights was confirmed from the output of a preamplifier and was physically observed on an oscilloscope. The polarization measurement system (polarimeter) was checked by measuring the phase difference with the help of Faraday effect optical rotation measurement setup. In this regard, current was applied to a 1300-turn copper coil and a span fiber was a wounded around the coil. Concentration of glucose was measured from the degree of optical rotation using Biot’s law as shown in Eq. (1). The phase difference analysis was performed in a I dm long measurement cell. The specific rotation of +51.6 and − 91.2 were measured for glucose and fructose respectively which were close to their physical properties. To make the sensor suitable for practical applications, the active length of the measurement cell was reduced to about 2 mm and the resolution of the sensor was monitored. A trial based noninvasive measurement with human body was performed by skin webbing between fingers. The resultant interference between CCW and CW lights was investigated. The skin webbing caused a bias in the interference signal which was observed in the form of noise due to a phase difference between CCW and CW light. A resolution of 1 mg/dl was achieved for glucose concentration and 0.5 mdeg resolution of optical rotation was detected for the devised sensor (Figure 13).
(a) Configuration of optical rotation measurement system with a Sagnac interferometer. (b) Concentration dependent optical rotation of sugar samples [
An optical polarimetry based Sagnac interferometry technique was investigated for noninvasive glucose sensing by A. M. Winkler et al. [34]. A phase sift in the interference fringes of the Sagnac interferometer was detected in a glucose solution as a representative OAM. The proposed method was linked with the sugar detection from the aqueous humor of human eye. The interferometer was simulated such that the counter propagating beams in which one of them passed through an optically active sample caused a difference in the optical path traversing. The effect was due to a difference in the refractive indices of the left and right circularly polarized beams.
A compact PCF Sagnac interferometer based glucose sensor was introduced by G. Ann et al. [35]. A light signal from a broadband light source was launched in a 3 dB coupler and split into two beams. A Saganac loop was mainly comprised of a polarization controller and PCF spliced with an SMF. The splitted beams counter propagated and interfered with an accumulated phase difference when passed through the PCF. The interference signal was effected greatly by the phase difference between the two orthogonal guided modes of PCF. A similar trend of phase birefringence was observed when the wavelength was varied in the range 1000–2000 nm with a gradual decrease in the maxima of the curve with increase in the glucose concentration. The nature of the devised sensor was analyzed between 15 cm to 40 cm. It was observed that the response of the sensor was highly sensitive to the PCF length. A prominent interference peaks were observed between 1050 nm to 2000 nm. The interference signatures becomes highly sensitive with good SNR for 20 cm PCF length. An average sensitivity of 0.76 mg/dL of glucose solution in water was recorded which is lower than 70 mg/dl of hypoglycemia episodes. The sensor was designed for effective sensing of glucose level in the patients with hypoglycemia.
In this type of interferometer, a coherent light beam is split into two by a beam splitter. Each of the two beams are reflected back and recombines at the same beam splitter to get interference pattern. Although, the Michelson interferometer has good potential for the detection of OAMs but rarely applied due to its relatively complex optical arranges. L. K. Chin reported a droplet Michelson interferometer for biochemical and protein detection. The interferometer was fabricated in the form of on-chip liquid grating as schematically shown in Figure 14(a). A branch of the interferometer was spared for injection of two immiscible liquids. A T-junction was developed for the formation of the liquid grating. The other branch with microchannel was filled with immersion oil which caused a phase shift due to optical path difference produced in the paths of light transmitted through the core and the cladding. A buffer solution was injected in the third branch to measure its refractive index. An optical fiber was aligned with one end of the microchannel for input/output light detection and the other end was coated with a gold film to use it as end mirror. The light was coupled from core to the cladding with the help of liquid grating. In the interferometer, the second and third branches of the microchannel was used to propagate the light which was reflected back by the gold layer which caused an optical path difference. An interference pattern was observed with attenuation band when both the light signals recombines in the core subsequent to passing through the liquid grating as shown in Figure 14(b). The microchip was fabricated in polydimethylsiloxane (PDMS) using lithography. Sputtering technique was applied to coat the sidewall of the PDMS edge. The PDMS slab with the pattern was attached with the unpatented PDMS slab using plasma bonding. The broadband light was coupled by an optical circulator with the optofluidic chip. The reflection from the optofluidic interferometer was detected by an OSA. The immersion oil and glycerol with refractive indices 1.462 and 1.420, respectively were used as carrier and dispersed flow, respectively. Reflection from the devised interferometer for different buffers with distinct refractive indices was recorded by the spectrum analyzer as shown in Figure 14(c). Two distinct attenuation peaks were observed in the overall attenuation band at slightly different positions and intensities.
Schematic illustrations of (a) the droplet Michelson interferometer and (b) the physics model of Michelson interferometer (c) reflection spectra of liquid grating Michelson interferometer [
Interferometer | Characterized material | Dynamic range | Sensitivity | Limit of detection | Reference |
---|---|---|---|---|---|
Mach-Zehnder | Protein | 50–1000 nm | 2000 nm/RIU | — | [11] |
Glucose | 625 mg/ml | −2.36o/ml | 25.5 mg/ml | [14] | |
Fructose | 922 mg/ml | 37.5 mg/ml | |||
Sucrose | — | 4.413 nm/RUI | — | [15] | |
Glucose/protein | — | — | 10 mM | [18] | |
Protein | — | 0.4 rads/ng/mm2 | 2 pg/mm2 | [20] | |
Glucose | 0–25% | 0.001 RUI/% | 10-5 RUI | [21] | |
Fabry–Pérot | glycerol | 0–50% | 1.5 μA/mRIU | 10 pg/ml | [30] |
Sugar | 0–30.88 g/100 ml | −0.0123 dBm/(g/100 ml) | — | [31] | |
Glucose | 0–700 mg/dl | 2.5 mg/dl | [32] | ||
Sagnac | Glucose | 0–0.6 g/dl | 0.5156 deg/(g/dl) | 1 mg∕dl | [33] |
Fructose | 0–0.6 g/dl | 0.9120 deg/(g/dl) | — | ||
Glucose | 0–500 mg/dl | — | — | [34] | |
Glucose | 0–120 g/l | 2.63 nm/g/l | 0.76 mg/dl | [35] |
Comparison of different OAMs analyzed by different interferometric arrangements.
In this study, different interferometric optical sensors employed for the detection and quantification of OAMs are briefly reviewed. The working principle, design and the important performance parameters including working range, sensitivity, and limit of detection were discussed in detail. Different materials analyzed in the sensors were outlined with special focus on sugar and protein being a representative OAMs. Two different interferometric arrangements, i.e., free space and optical fiber based optical sensors were discussed. It was concluded that optical fiber based interferometry has mind blowing potential for highly precise sensing of OAMs with good sensitivity and can be applied in industrial and research and development applications.
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In fact, it is quite common the production of microspheres and microcapsules designed for drug delivery systems. This review describes the different stages of the mechanism of the spray-drying process: atomization, droplet-to-particle conversion and particle collection. In particular, this work addresses the diversity of available atomizers, the drying kinetics and the importance of the configuration of the drying chamber, and the efficiency of the collection devices. The final properties of the dried products are influenced by a variety of factors, namely the spray dryer design, the feed characteristics and the processing parameters. The impact of those variables in optimizing both the spray-drying process and the synthesis of dried particles with desirable characteristics is discussed. 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In the case of nonbiodegradable inorganic compounds, bioremediation takes the form of bioaccumulation or conversion of one toxic species to a less toxic form for example Cr(VI) is converted to less toxic (III). Bioremediation is considered an environmentally friendly way for pollution clean-up. Microbial clean up can be applied in situ (in place of contamination) or ex situ (off the site of contamination). In situ remediation in the natural environment is deemed slow and often times difficult to control and optimize the different parameters affecting the bioremediation. To this end, use of engineered bioreactors is preferred. Engineered bioreactors providing for optimum conditions for microbial growth and biodegradation have been developed for use in bioremediation processes to achieve the different desired remediation goals. Bioreactors in use range in mode of operation from batch, continuous, and fed batch bioreactors and are designed to optimize microbial processes in relationship to contaminated media and nature of pollutant. Designed bioreactors for bioremediation range from packed, stirred tanks, airlift, slurry phase, and partitioning phase reactors amongst others.",book:{id:"7727",slug:"biotechnology-and-bioengineering",title:"Biotechnology and Bioengineering",fullTitle:"Biotechnology and Bioengineering"},signatures:"Memory Tekere",authors:[{id:"231753",title:"Prof.",name:"Memory",middleName:null,surname:"Tekere",slug:"memory-tekere",fullName:"Memory Tekere"}]},{id:"67432",title:"Microencapsulation and Its Uses in Food Science and Technology: A Review",slug:"microencapsulation-and-its-uses-in-food-science-and-technology-a-review",totalDownloads:1889,totalCrossrefCites:7,totalDimensionsCites:13,abstract:"Microencapsulation is a group of technologies aiming to produce small particles called microcapsules that can be released at a specific speed under certain conditions. 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In this review, we summarize current methodologies used for microencapsulation, with a focus on applications in the food industry.",book:{id:"6995",slug:"microencapsulation-processes-technologies-and-industrial-applications",title:"Microencapsulation",fullTitle:"Microencapsulation - Processes, Technologies and Industrial Applications"},signatures:"Pedro Henrique Rodrigues do Amaral, Patrícia Lopes Andrade and Leilane Costa de Conto",authors:[{id:"268220",title:"Dr.",name:"Leilane Costa De",middleName:null,surname:"Conto",slug:"leilane-costa-de-conto",fullName:"Leilane Costa De Conto"},{id:"274532",title:"Mr.",name:"Pedro Henrique Rodrigues Do",middleName:null,surname:"Amaral",slug:"pedro-henrique-rodrigues-do-amaral",fullName:"Pedro Henrique Rodrigues Do Amaral"},{id:"274534",title:"Dr.",name:"Patrícia Lopes",middleName:null,surname:"Andrade",slug:"patricia-lopes-andrade",fullName:"Patrícia Lopes Andrade"}]},{id:"64746",title:"HyStem®: A Unique Clinical Grade Hydrogel for Present and Future Medical Applications",slug:"hystem-a-unique-clinical-grade-hydrogel-for-present-and-future-medical-applications",totalDownloads:4431,totalCrossrefCites:2,totalDimensionsCites:3,abstract:"Medicine needs targeted, minimally-invasive delivery of protein-based and cell-based therapeutics to increase efficacy and reduce occurrence and severity of side effects. Local delivery requires a matrix to sequester and protect the medicine until its effect can be realized. The problem is, unlike stable small molecule drugs, proteins and cells cannot be co-packaged with a matrix in a prefilled syringe—they must be mixed with their matrix at the point of care. HyStem hydrogels fix this problem: They are arguably the first commercially available, GMP-qualified biodegradable hydrogels both with the ability to formulate with either proteins or cells in the hospital/surgical suite and with a history of safe use in humans. HyStem is designed to be protein, cell-friendly and in situ crosslinkable, permitting homogeneous mixing of therapeutics. One HyStem formulation is 510(k) cleared and another the subject of two European clinical trials. Key applications include localized delivery of therapeutic growth factors, antibodies, and cells. In the future, we envision HyStem’s flexibility and clinical use history forming the basis for a new generation of therapeutics. Two examples described here include HyStem’s use for patient-derived organoid culture to develop new drugs as well as for bioprinting to manufacture new organs.",book:{id:"8353",slug:"hydrogels-smart-materials-for-biomedical-applications",title:"Hydrogels",fullTitle:"Hydrogels - Smart Materials for Biomedical Applications"},signatures:"Thomas I. Zarembinski and Aleksander Skardal",authors:[{id:"262573",title:"Dr.",name:"Thomas",middleName:null,surname:"Zarembinski",slug:"thomas-zarembinski",fullName:"Thomas Zarembinski"},{id:"270426",title:"Dr.",name:"Aleksander",middleName:null,surname:"Skardal",slug:"aleksander-skardal",fullName:"Aleksander Skardal"}]}],onlineFirstChaptersFilter:{topicId:"154",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"80777",title:"Starch: A Veritable Natural Polymer for Economic Revolution",slug:"starch-a-veritable-natural-polymer-for-economic-revolution",totalDownloads:56,totalDimensionsCites:0,doi:"10.5772/intechopen.102941",abstract:"Amidst growing concerns for environmental degradation by anthropologic activities and use of non-biodegradable materials for industrial and household purposes, a focus on natural polymeric materials offers the veritable prospects for future survival. Although some synthetic polymers are biodegradable, the process of production that is usually non-green adds to environmental pollution. Natural polymers are naturally occurring organic molecules such as cellulose, starch, glycoproteins and proteins. They are mostly obtained from plant sources, but are also produced in animal and microorganisms. One of the most abundant natural polymers of multidimensional and multifaceted application is starch. Starch is used across wide-range applications spanning engineering, food and beverages, textile, chemical, pharmaceuticals and health, etc. This is because it can readily be modified into products of desired physicochemical characteristics, thus making starch a potential tool for industrial and economic revolution. The global trade balance for starch and derived products is about $1.12 trillion, presenting a huge opportunity for more investment in starch production. Africa’s negative starch trade balance of about $1.27 trillion makes it a potential investment destination for starch production. This chapter discusses the use of starch in various industrial sectors, its potentials for sustainable economic development and as a veritable natural polymer for economic revolution.",book:{id:"10798",title:"Starch - Evolution and Recent Advances",coverURL:"https://cdn.intechopen.com/books/images_new/10798.jpg"},signatures:"Obi Peter Adigwe, Henry O. Egharevba and Martins Ochubiojo Emeje"},{id:"79875",title:"Comparative Study of the Physiochemical Composition and Techno-Functional Properties of Two Extracted Acorn Starches",slug:"comparative-study-of-the-physiochemical-composition-and-techno-functional-properties-of-two-extracte",totalDownloads:54,totalDimensionsCites:0,doi:"10.5772/intechopen.101562",abstract:"Due to the increase of search for new promising ingredients with interesting properties to develop new industrial food products, the valorization of undervalued resources became a challenge. Considering this, various species of genus Quercus acorns represent new resources of highly-valued food ingredients such as starch which encourage its extraction and valorization in food industries. In this regard, collected data from the literature provide an evidence review on the physiochemical and techno-functional properties of different acorn starches extracted from Tunisian species, especially; Quercus ilex L. and Quercus suber L. The reported data on X-ray diffraction analysis are, also, discussed. Data highlighted the possibility of using the extracted Quercus starches to develop new functional food products and improve technological properties and shelf life of products solicited by consumers.",book:{id:"10798",title:"Starch - Evolution and Recent Advances",coverURL:"https://cdn.intechopen.com/books/images_new/10798.jpg"},signatures:"Youkabed Zarroug, Mouna Boulares, Dorra Sfayhi and Bechir Slimi"},{id:"80395",title:"History, Evolution and Future of Starch Industry in Nigeria",slug:"history-evolution-and-future-of-starch-industry-in-nigeria",totalDownloads:54,totalDimensionsCites:0,doi:"10.5772/intechopen.102712",abstract:"Starch industry has progressed into a business that is worth billions of dollars globally, as they have been found useful in the food, textile, biofuel, plastic and the pharmaceutical industries. Nigeria can be the largest producer of starch in the world. Her major sources are roots and tubers (cassava, yam, cocoyam and potato), cereals (maize, sorghum, millet and rice) and fruits (banana, plantain and breadfruit). Although, all the starch crops are abundantly produced in Nigeria, only less than 1% is processed into high quality starch for industrial processes. This chapter therefore examines the past, the progression and the current state of the starch industry in Nigeria and the roles the government and relevant stakeholders must play in order to revolutionize the industry in Nigeria.",book:{id:"10798",title:"Starch - Evolution and Recent Advances",coverURL:"https://cdn.intechopen.com/books/images_new/10798.jpg"},signatures:"Obi Peter Adigwe, Judith Eloyi John and Martins Ochubiojo Emeje"},{id:"80018",title:"Potato Starch as Affected by Varieties, Storage Treatments and Conditions of Tubers",slug:"potato-starch-as-affected-by-varieties-storage-treatments-and-conditions-of-tubers",totalDownloads:98,totalDimensionsCites:0,doi:"10.5772/intechopen.101831",abstract:"Potato is among the widely grown crop of the world. It is likely that a large portion of the crop is consumed fresh but majority of it is processed into various products, starch being the predominant one. Starch can greatly contribute to the textural properties of many foods and is widely used in food industry as raw material. Since raw potatoes are perishable and accessible only for few months of the year, the food and starch industry has to rely on stored potatoes during off-season. The various varieties of the crop available in the region, storage conditions, pre and post-storage treatments given to the tubers, packaging materials used, etc. are influencing the physical, chemical and functional characteristics of starch extracted from it. The extraction technology from tubers is also having a significant effect on the quality of starch. The knowledge of physical, chemical and functional characteristics of potato starch as affected by varieties, storage treatments and conditions of tubers will help in ensuring uniform and desirable quality of starch for food industry and also provide information for breeding programs and developing the proper postharvest management practices of potatoes.",book:{id:"10798",title:"Starch - Evolution and Recent Advances",coverURL:"https://cdn.intechopen.com/books/images_new/10798.jpg"},signatures:"Saleem Siddiqui, Naseer Ahmed and Neeraj Phogat"},{id:"80023",title:"Binary Interactions and Starch Bioavailability: Critical in Limiting Glycemic Response",slug:"binary-interactions-and-starch-bioavailability-critical-in-limiting-glycemic-response",totalDownloads:81,totalDimensionsCites:0,doi:"10.5772/intechopen.101833",abstract:"Limiting starch bioavailability by modifying food matrix dynamics has evolved over the decade, which further envisions low glycemic starch prototypes to tackle chronic hyperglycemia. The dense matrix of whole grain foods like millets and cereals act as a suitable model to understand the dynamics of binary food matrix interactions between starch-lipid, starch-protein & starch-fiber. The state and types of matrix component (lipid/protein/fiber) which interact at various scales alters the starch micro configuration and limits the digestibility, but the mechanism is largely been ignored. Various in-vitro and in-vivo studies have deciphered the varied dimensions of physical interactions through depletion or augmentation studies to correlate towards a natural matrix and its low glycemic nature. The current chapter briefly encompasses the concept of food matrix types and binary interactions in mediating the glycemic amplitude of starch. We comprehensively elaborated and conceptually explained various approaches, which investigated the role of food matrices as complex real food systems or as fundamental approaches to defining the mechanisms. It’s a fact that multiple food matrix interaction studies at a time are difficult but it’s critical to understand the molecular interaction of matrix components to correlate in-vivo processes, which will assist in designing novel food prototypes in the future.",book:{id:"10798",title:"Starch - Evolution and Recent Advances",coverURL:"https://cdn.intechopen.com/books/images_new/10798.jpg"},signatures:"Veda Krishnan, Monika Awana, Debarati Mondal, Piyush Verma, Archana Singh and Shelly Praveen"},{id:"79856",title:"Starch-Based Hybrid Nanomaterials for Environmental Remediation",slug:"starch-based-hybrid-nanomaterials-for-environmental-remediation",totalDownloads:109,totalDimensionsCites:0,doi:"10.5772/intechopen.101697",abstract:"Environmental pollution is becoming a major global issue with increasing anthropogenic activities that release massive toxic pollutants into the land, air, and water. Nanomaterials have gained the most popularity in the last decades over conventional methods because of their high surface area to volume ratio and higher reactivity. Nanomaterials including metal, metal oxide, zero-valent ions, carbonaceous nanomaterials, and polymers function as adsorbents, catalysts, photocatalysts, membrane (filtration), disinfectants, and sensors in the detection and removal of various pollutants such as heavy metals, organic pollutants, dyes, industrial effluents, and pathogenic microbial. Polymer-inorganic hybrid materials or nanocomposites are highly studied for the removal of various contaminants. Starch, a heteropolysaccharide, is a natural biopolymer generally incorporated with other metal, metal oxide, and other polymeric nanoparticles and has been reported in various environmental remediation applications as a low-cost alternative for petroleum-based polymers. Therefore, this chapter mainly highlights the various nanomaterials used in environmental remediation, starch-based hybrid nanomaterials, and their application and limitations.",book:{id:"10798",title:"Starch - Evolution and Recent Advances",coverURL:"https://cdn.intechopen.com/books/images_new/10798.jpg"},signatures:"Ashoka Gamage, Thiviya Punniamoorthy and Terrence Madhujith"}],onlineFirstChaptersTotal:9},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:31,numberOfPublishedChapters:314,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:11,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:105,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:18,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:14,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. 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His research interests and specialties include financial econometrics, financial economics, international economics and finance, housing markets, financial markets, among others.",institutionString:null,institution:{name:"University of Southampton",institutionURL:null,country:{name:"United Kingdom"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:5,paginationItems:[{id:"86",title:"Business and Management",coverUrl:"https://cdn.intechopen.com/series_topics/covers/86.jpg",editor:{id:"128342",title:"Prof.",name:"Vito",middleName:null,surname:"Bobek",slug:"vito-bobek",fullName:"Vito Bobek",profilePictureURL:"https://mts.intechopen.com/storage/users/128342/images/system/128342.jpg",biography:"Dr. Vito Bobek works as an international management professor at the University of Applied Sciences FH Joanneum, Graz, Austria. He has published more than 400 works in his academic career and visited twenty-two universities worldwide as a visiting professor. Dr. Bobek is a member of the editorial boards of six international journals and a member of the Strategic Council of the Minister of Foreign Affairs of the Republic of Slovenia. He has a long history in academia, consulting, and entrepreneurship. His own consulting firm, Palemid, has managed twenty significant projects, such as Cooperation Program Interreg V-A (Slovenia-Austria) and Capacity Building for the Serbian Chamber of Enforcement Agents. He has also participated in many international projects in Italy, Germany, Great Britain, the United States, Spain, Turkey, France, Romania, Croatia, Montenegro, Malaysia, and China. Dr. Bobek is also a co-founder of the Academy of Regional Management in Slovenia.",institutionString:"Universities of Applied Sciences FH Joanneum, Austria",institution:null},editorTwo:{id:"293992",title:"Dr.",name:"Tatjana",middleName:null,surname:"Horvat",slug:"tatjana-horvat",fullName:"Tatjana Horvat",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002hXb0hQAC/Profile_Picture_1642419002203",biography:"Tatjana Horvat works as a professor for accountant and auditing at the University of Primorska, Slovenia. She is a Certified State Internal Auditor (licensed by Ministry of Finance RS) and Certified Internal Auditor for Business Sector and Certified accountant (licensed by Slovenian Institute of Auditors). At the Ministry of Justice of Slovenia, she is a member of examination boards for court expert candidates and judicial appraisers in the following areas: economy/finance, valuation of companies, banking, and forensic investigation of economic operations/accounting. At the leading business newspaper Finance in Slovenia (Swedish ownership), she is the editor and head of the area for business, finance, tax-related articles, and educational programs.",institutionString:null,institution:{name:"University of Primorska",institutionURL:null,country:{name:"Slovenia"}}},editorThree:null,editorialBoard:[{id:"114318",title:"Dr.",name:"David",middleName:null,surname:"Rodeiro",slug:"david-rodeiro",fullName:"David Rodeiro",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bS2a8QAC/Profile_Picture_2022-04-22T08:29:52.jpg",institutionString:null,institution:{name:"University of Santiago de Compostela",institutionURL:null,country:{name:"Spain"}}},{id:"114073",title:"Prof.",name:"Jörg",middleName:null,surname:"Freiling",slug:"jorg-freiling",fullName:"Jörg Freiling",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bS2UPQA0/Profile_Picture_1642580983875",institutionString:null,institution:{name:"University of Bremen",institutionURL:null,country:{name:"Germany"}}},{id:"202681",title:"Dr.",name:"Mojca",middleName:null,surname:"Duh",slug:"mojca-duh",fullName:"Mojca Duh",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSD2dQAG/Profile_Picture_1644907300283",institutionString:null,institution:{name:"University of Maribor",institutionURL:null,country:{name:"Slovenia"}}},{id:"103802",title:"Ph.D.",name:"Ondrej",middleName:null,surname:"Zizlavsky",slug:"ondrej-zizlavsky",fullName:"Ondrej Zizlavsky",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQJQA0/Profile_Picture_1643100292225",institutionString:null,institution:{name:"Brno University of Technology",institutionURL:null,country:{name:"Czech Republic"}}},{id:"190913",title:"Dr.",name:"Robert M.X.",middleName:null,surname:"Wu",slug:"robert-m.x.-wu",fullName:"Robert M.X. 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