Journal Contents
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Ophthalmic Plastics and Reconstructive SurgeryMalignant Melanoma of the Optic Nerve De Potter P, Shields CL, Eagle RC Jr, Shields JA, Arch Ophthalmol 114:608-612, 1996 The authors present a 67 year old man initially thought to have an optic disc melanocytoma. He had experienced no change in the lesion over five years, then developed sudden painful loss of vision to no light perception, associated with enlargement of the pigmented optic disc mass. There was no clinical or histopathologic evidence of primary choroidal involvement. Preoperative ultrasonography and MRI scanning with fat suppression techniques and surface coil revealed optic nerve infiltration by the tumor. Following enucleation, the lesion was found to be a mixed cell primary optic nerve melanoma, with spindle and epithelioid cells. Also, central retinal artery thrombosis was noted on histopathologic examination. The patient was alive and free of tumor recurrence 6 months following enucleation. The differential diagnosis of pigmented tumors of the optic nerve includes melanocytoma, peripapillary choroidal melanoma with invasion of the optic nerve head, primary malignant melanoma of the optic nerve, and adenoma of the retinal pigment epithelium (from juxtapapillary RPE). True primary malignant melanoma of the optic nerve is very rare. This case was felt most likely to represent malignant transformation of an optic disc melanocytoma, which has previously been documented in the literature.
Ophthalmic Plastics and Reconstructive SurgeryTreatment of Graves' Ophthalmopathy in an Incidence Cohort: Bartley, G., Fatourechi, V., Kadrmas, E., Jacobsen, S., Ilstrup, D., Garrity, J. and Gorman, C. Amer Journal Ophthal, 1996;121:200-206 The authors sought to determine the incidence of various treatment modalities in patients diagnoses with Graves' Ophthalmopathy (GO).
Total Number: Diagnoses:
89 (74.2%) required only supportive care. 6 (5%) were treated with steroids - one of these patients also underwent Radiation therapy. 24 (20%) of patients underwent at least one surgical procedure. 22 of these were women (not statistically significant). Their average age is 52.5 +/- 17.8 with a median age of 51.6. The average age of those not needing surgery was 42.7 +/- 16.9 with a median age of 41.8. For all study patients, 23.5% over 50 years old required surgery. Only 12% of patients inder 50 years old needed surgery. The Relative Risk for requiring surgery was calculated to be 2.6 if the patient was older than 50 years. They add that cigarette smoking was not associated with the cumulative risk for undergoing surgery, which was calcuatated to be:
The importance of this paper is obscured by the authors tendency to treat GO with surgery rather than radiotherapy or immunomodulation. It nevertheless outlines the probability that a patient has an overall risk of 26% requiring intervention greater than supportive therapy. Many of these patients will require more intervention than oral steroids.
Ophthalmic Plastics and Reconstructive SurgeryHydroxyapatite Implants: a Rational Approach An editorial by Francois Codere Can J Ophthalmol , vol 30:235-236, 1995. This succinct review gives a good perspective on the role of hydroxyapatite (HA) implants, with a short list of key references. The major points stressed are listed below. (The comments in brackets are mine) HA implants were first introduced by Perry in 1985, and have markedly changed our enucleation technique. HA implants were the most widely used implants amongst a survey of 70 ASOPRS members published in 1995. (? if porous polyethylene is more popular now) However HA has several disadvantages.
(HA implants with pegs provide the best possible motility for patients. Motility is very important for cosmesis, especially in young patients.) The age, health of the patient, vascular status of the orbit, (increased risk of extrusion, and economics) should be considered prior to using hydroxyapatite.
Ophthalmic Plastics and Reconstructive SurgeryDermoid Cysts: 16-year Review Bonavolonta G, Tranfa F, de Conciliis C, and Strianese D. Ophthalmic Plastic and Reconstructive Surgery, 1995; 11(3):187-192. This retrospective 16 year review reports the demographic and clinical features of 145 cases of orbital dermoid cysts that underwent surgical excision at the Orbital Clinic, Institutue of Ophthalmology, University of Naples, between 1976 and 1992. Lesions were classified as either exophytic (Type I - 47%: external to the orbital rim) or endophytic (Type II - 53%: internal to the orbital rim). This ratio of endophytic lesions is higher than expected because this series represents a referral bias in a large academic center. Exophytic lesions tend to present early and become visible at a very young age, while endophtyic lesions are often not detected until adulthood, after they have caused proptosis and in some cases, considerable bony destruction. Dermoid cysts were noted at birth in 47 % of cases, by the age of 6 months in 56%, and before age 12 years in 81%. The median age of presentation for exophytic lesions was 3 years (range birth to 22 yrs), and the median age for presentation for endophytic lesions was 10 years (range 1 to 53 years). Male to female ratio and left to right ratio were approximately 1:1. In their series of 1500 orbital expanding mass lesions, the authors report that dermoid cysts comprised about 9% of all lesions, and about 40% of the 300 pediatric orbial neoplasms. 72% of the dermoid cysts were in the traditional superotemporal location, while 26% were superonasal, 1% were inferotemporal, and 1% were inferonasal. 30 patients (21%) had a history of adjacent inflammation. This is usually caused by rupture of the cysts with leakage of contents into nearby tissues. The most frequent clinical signs were axial displacement of the globe (28%), ptosis (24%), proptosis (22%), and inflammation (21%). Impaired vision and diplopia were each observed in less than 10% of patients. Endophytic lesions were much more likely thatn exophtytic lesions to cause all of these clinical features. Bone invasion occurred in 14% of patients and 90% of these had endophytic lesions. Direct anterior orbitotomy was perfomed on 113 patients (78%), and lateral orbitotomy was performed on the other 32 patients (22%). There were no recurrences over 1 to 15 years of follow-up. The histologic feature that differentiates dermoid cysts from epidermoid cysts is the presence of adnexal appendages, such as hair follicles, sweat glands, and/or sebaceous glands. Endophytic lesions can be difficult to differentiate from other orbital neoplams, especially when located within the lacrimal fossa. CT scanning is very helpful in evaluating dermoid cysts. One additional caveat is the bilobed or "dumbell" shaped dermoid cyst. This lesion has an external and an internal component, involving the temporalis fossa and the superotemporal orbit. This further illustrates the value of orbital imaging studies in evaluating orbital dermoid cysts. Complete surgical excision is the treatment of choice. Although most lesions can be removed through a simple anterior approach, endophytic and invasive lesions may require lateral orbitotomy with or without coronal flap exposure.
Ophthalmic Plastics and Reconstructive SurgeryExternal Dacryocystorhinsotomy: Surgical Success, Patient Satisfaction, and Economic Cost Kristin J. Tarbet, MD, Philip L. Custer, MD Ophthalmology June, 1995;102(6):929-936 Drs. Tarbet and Custer in their paper evaluating external dacryocystorhinostomy (EDCR) provide succinct well documented current information regarding the overall surgical success, long term patient satisfaction and economic cost of this procedure. Several papers introducing modern surgical skills such as lasers and endoscopes for lacrimal surgery have been published. The primary advantage of these is the avoidance of a surgical scar. Of the 93 patients undergoing EDCR evaluated by the authors, 90%(n=84) rated the appearance of their scar as excellent, 6%(n=6) good, 2%(n=2) fair, and 1%(n=1) poor. For surgery of this type, success may be defined by relief of symptoms or, reestablishment of a patent nasolacrimal system. In this study 95% of patients had patent systems and 92% were completely asymptomatic. Success for intranasal surgeries (63-82%) are significantly lower than those achieved with the external approach (Opthalmology 94;101:955-9). With health care dynamics in constant flux, outcomes assessment becomes ever more prominent. Davies listed the goals of a health care process to include: avoidance of adverse effects, improvement of a patients physiologic and functional status, reduction of signs and symptoms, patient satisfaction, minimization of cost and maximization of revenue (Comm J Qual Improv. 1994;20:6-16). EDCR certainly appears to achieve all these goals. The quest for newer more effective and cost efficient health care procedures is an ongoing process, but for now, EDCR should remain the standard of care for acquired NLD obstruction.
Ophthalmic Plastics and Reconstructive SurgeryMeasurement of the Subarchnoid Pressure of the Optic Nerve in Human Subjects Don Liu, M.D. and John Michon, M.D., Am J Ophthalmol , 119(1): 81-85, Jan 1995. The normal opening CSF pressure when measured during a supine spinal tap is 6-14 mmHg (80-180 mmH20). The authors measure the CSF pressure in the optic nerves of sixteen eyes using an electronic digital manometer under general anesthesia immediately prior to enucleation(11) or evisceration(5). Five patients had additional pressure measurements after 3 minutes in a modified (30 degree) Trendelenburg position. Mean subarchnoid pressure was 8.5 +/- 2.6 mmHg. It was slightly lower in 5 patients who had glaucoma (6.7 +/- 1.9 mmHg). No statistical difference was noted when age, gender, race or cause of blindness were analyzed. Trendelenburg positioning uniformly caused the pressure to increase 1-2 mmHg, all within 15-20 seconds. It returned to baseline 25-35 seconds after resuming the horizontal position. The authors conclude that the measurement of subarchnoid pressure of the optic nerve can safely be performed. Although simultaneous lumbar punctures were not performed, the results correlate with the currently accepted CSF pressure values. They caution that general anesthesia, positioning and associated disease states may affect the readings. The foundation has been laid to allow future investigations into the physiology of the optic nerve.
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