Combined neurosurgical and orbital intervention for spheno-orbital meningiomas - the Manchester experience.

PURPOSE: Surgical resection of spheno-orbital meningioma (SOM) is challenging, requiring a multidisciplinary surgical approach. We present our experience of the surgical management of patients with SOM. METHODS: A retrospective analysis of patients with SOM who underwent joint neurosurgical and orbital surgical procedures between January 2000 and June 2017. Pre-operative clinical signs, indication for surgery, surgical complications and post-operative outcomes were recorded. RESULTS: Twenty-four operations were performed. Mean age was 49.5 years. Ninety-two percent of patients were female. Pre-operatively mean Snellen acuity vision was 6/12; 13 (54%) had an RAPD; 12 (50%) had reduced colour vision; 16 (67%) had a visual field defect. The majority (21 patients, 88%) had proptosis (average 4.5 mm ± 2.8 mm). The indication for surgery was evidence of visual dysfunction in 17 (71%), the remaining 7 (29%) had high risk of visual loss clinically or radiologically. Three-months post operatively, vision was stable in 13 (58%), improved in 6 (21%) and worse in 5 (17%). Average long-term follow-up was 82 months (1-220). Fourteen (58%) maintain improved or stable visual function. Four (17%) had reduced vision due to regrowth of the tumour at an average of 24 months. CONCLUSION: SOMs are very challenging to treat surgically. In this cohort the patients were predominantly young females with aggressive disease. Visual function was improved or stabilised in 79% of the patients.

Efficacy of trichloroacetic acid (95%) in the management of xanthelasma palpebrarum.

BACKGROUND: Xanthelasma palpebrarum (XP) is a commonly occurring benign eyelid disorder. AIM: To determine the efficacy of topical trichloroacetic acid (TCA) 95% in the management of XP. METHODS: This was a retrospective review of patients treated with TCA between June 2000 and July 2007. We recorded the outcomes of patients who attended the clinic at least 3 months after their treatment. We also contacted all patients with a minimum interval of 12 months between treatment and a telephone interview to assess for recurrence/persistence of the lesion(s). RESULTS: In total, 102 patients were enrolled in the study. Of these, 44 were reviewed in the clinic. There were nine persistent lesions and four recurrences recorded at a mean follow-up of 14.3 months. Telephone interviews were conducted with 51 patients (146 lesions). Of these 51 patients, 43 had been given bilateral TCA treatment. The mean number of TCA treatments was 1.68. Mean time from the past TCA treatment to the telephone interview was 31.8 months. Of the 51 patients, 17 patients reported no recurrence, 22 patients had experienced a recurrence, 9 patients had persistence of the lesion and 3 patients undergone surgical excision of the lesion since the last TCA treatment. Overall, the success rate for TCA was 61% at a mean follow-up of 31.8 months. CONCLUSIONS: XP has a strong history of recurrence. TCA treatment may be effective in XP and is a short, simple and cheap procedure that can be repeated. Although the requirement for retreatment is high, patient satisfaction with the procedure is also high.

Ocular adnexal diffuse large B-cell lymphoma: local disease correlates with better outcomes.

PURPOSE: To describe the clinical, immunohistochemical and prognostic features, as well as outcomes of a large series of patients with orbital and periorbital diffuse large B-cell lymphoma (DLBCL). DESIGN: This study is a multicentre, retrospective non-comparative consecutive case series. METHODS: The setting for this study was institutional. A total of 37 consecutive patients identified from the institutions' databases with periorbital and orbital DLBCL were enrolled in the study. A retrospective chart review was used for observation. The main outcome measures were patient demographics, clinical features, imaging, immunohistochemical and histopathological data, treatments administered, and survival. RESULTS: A total of 20 out of 37 cases (54.1%) represented localised periorbital disease (group L), 11 of 37 (29.7%) had systemic disease at presentation with periorbital disease (group S1), and 6 of 37 (16.2%) had previous history of systemic lymphoma (group S2). In all, 28 out of 30 (93.3%) patients were CD20+, 5 of 25 (20%) were CD3+, and 11 of 11 (100%) were CD79a+ (varying denominators reflect the different numbers of patients tested). A total of 25 out of 32 patients (78.1%) received chemotherapy, 14 (43.8%) received rituxmab plus chemotherapy, and 19 (59.3%) received radiotherapy. Nine deaths occurred, one in group L (not lymphoma related), six in group S1, and two in group S2. Five-year Kaplan-Meier survival estimates were 55.9% for all cases, 90.9% for group L, 36.0% for group S1, and 0% for group S2. One-year progression-free survival estimates in groups S1 and S2 combined were 58.3% for patients treated with rituximab and 28.6% for those who were not. CONCLUSIONS: To our knowledge, this report represents the largest series of patients with periorbital and orbital DLBCL in the literature. The difference in survival between groups L, S1 and S2 was striking, reflecting the grave prognosis of systemic DLBCL, but conversely the relatively optimistic outlook for patients with localised disease. Rituximab plus chemotherapy may be associated with increased survival.

Our experience using primary oral antibiotics in the management of orbital cellulitis in a tertiary referral centre.

AIMS/PURPOSE: Orbital cellulitis is conventionally managed by intravenous (i.v.) antibiotic therapy, followed by oral antibiotics once the infection shows signs of significant improvement. We report 4 years of experience using primary oral ciprofloxacin and clindamycin in cases of orbital cellulitis. Oral ciprofloxacin and clindamycin have a similar bioavailability to the i.v. preparations and provide an appropriate spectrum of antibiotic cover for the pathogens responsible for orbital cellulitis. METHODS: A retrospective review was performed that identified all patients with orbital cellulitis and treated with primary oral antibiotic therapy admitted to the Manchester Royal Eye Hospital between March 2003 and March 2007. Age, stage of disease, surgical intervention, hospital duration, and complications were obtained. A comparison was made with patients admitted to our unit with orbital cellulitis and treated with primary i.v. antibiotics between March 2000 and March 2003. RESULTS: Nineteen patients were included in the review for the period March 2003 to March 2007, which comprised of 7 children and 12 adults. Five patients required surgical intervention. All patients responded to the oral regimen, 18 patients had no change to their oral antibiotic therapy. Mean hospital stay was 4.4 days. There were no complications. DISCUSSION: Empirical oral ciprofloxacin and clindamycin combination may be as safe and effective as i.v. therapy in the management of orbital cellulitis. Oral treatment can offer the advantages of rapid delivery of the first antibiotic dose, fewer interruptions in treatment, and simplified delivery of medication particularly in children.

Open globe injuries in children: factors predictive of a poor final visual acuity.

AIMS: Eye injuries are the leading cause of monocular blindness in children and are challenging to manage. However, limited follow-up studies currently exist. We describe the clinical characteristics and outcomes of open globe injuries presenting to a major UK centre and discuss factors affecting long-term prognosis. PURPOSE: Identification of (1) demographic features, (2) causes, types and location of injuries, (3) initial clinical features and correlation with visual outcome, and (4) predictors of poor visual outcome. METHOD: Retrospective study by reviewing and analysing records of 20 patients, aged 16 years and below, who had undergone repair of an open globe injuries at the Manchester Royal Eye Hospital, UK. Data recorded included demographic data, mechanisms and location of injury, visual acuity, clinical signs on presentation, surgical procedures, postoperative complications, and final visual acuity. RESULTS: The study group comprised of 85% male subjects, 15% female subjects. The average age was 9.8 years (range: 1-15). Average follow-up was 16.3 months (range: 3-48 months). Sharp objects (mainly glass or knife) accounted for the majority (65%) of injuries. Initial clinical signs associated with poor visual outcomes included poor initial visual acuity, cataract, RAPD, and no initial red reflex. Younger patients and blunt injuries (especially BB gun injuries) had worse visual outcomes. CONCLUSION: Factors suggesting unfavourable final visual acuity after open globe injuries in children are (1) young age at presentation, (2) poor initial visual acuity, (3) presence of a relative afferent papillary defect, (4) absence of red reflex, (5) cataract, and (6) types and number of surgeries performed.Awareness and education with regard to prevention of paediatric injuries need to be actively implemented.

Orbital decompression surgery for thyroid eye disease: implications for anaesthesia.

The management of thyroid-associated eye disease is reviewed with particular reference to surgical management and its implications for anaesthetists. Experience from a unit undertaking such surgery is presented.

Open globe injuries: factors predictive of poor outcome.

OBJECTIVE: Despite advances in ocular and orbital imaging, instrumentation, materials, and surgical procedures, the management of open globe injuries continues to pose difficult management dilemmas. In this retrospective study, we identify clinical characteristics and outcome of a series of open globe injuries presenting to a major UK centre. METHOD: Operating department records were reviewed to identify all patients who had undergone repair of an open globe injury from 1 January 1998 to 1 January 2003 at the Manchester Royal Eye Hospital. Case notes were examined to determine demographic data, mechanisms of injury, influence of alcohol/drugs, and location of injury. The Snellen visual acuity on presentation and initial clinical signs were recorded. RESULTS: In total, 115 cases of open globe injury were identified of which 107 cases notes were available for review. Injury to the eye with a sharp object accounted for 71/107 (66%) cases and blunt mechanisms for 30/107 (28%) cases. In six (6%) cases the cause of injury was unknown. The rate of secondary enucleation in our series of 107 open globe injuries was 13/107 (12%). Significant risk factors on presentation associated with eventual enucleation included relative afferent pupillary defect (P<0.001), absence of a red reflex (P<0.001), presence of a lid laceration (P<0.02), a blunt mechanism of injury (P<0.02), and an initial VA worse than 6/60 (P=0.03). CONCLUSION: From this retrospective study, we have identified several factors that may aid the clinician in deciding on the prognostic value of primary repair. Blunt injuries associated with adnexal trauma, with poor initial visual acuity, the presence of an RAPD or retinal detachment, and the absence of a red reflex are associated with a significantly higher rate of subsequent enucleation.

Mortality following exenteration for malignant tumours of the orbit.

BACKGROUND: Orbital exenteration is a rare, but disfiguring procedure reserved for the treatment of locally invasive malignancy or potentially life threatening orbital neoplasms, when less destructive techniques are inadequate. The authors report their experience and analyses of 64 cases of orbital exenteration performed over a 13 year period, looking specifically at key factors affecting mortality associated with such a destructive surgical procedure. METHODS: Records were reviewed retrospectively of all patients who had undergone exenteration of the orbit from 1 January 1991 to 1 April 2004 inclusive, at the Manchester Royal Eye Hospital. In all cases of deceased individuals, the cause of death was determined by liaison with the general practitioner and local health authority. Duplicate death certificates were requested for all deceased patients from the Registrar for Births, Deaths, and Marriages, Southport, UK. Kaplan-Meier analysis was used to estimate survival following exenteration. RESULTS: Overall, 1 year survival post-exenteration was high at 93%. After 3 years this had fallen to 67%, followed by 57% after 5 years, and 37% at 10 years. 13 patients died as a direct result of the orbital tumour. A further nine died of unrelated medical conditions, and two patients succumbed to malignant processes originating elsewhere in the body. There was no difference in survival rate at 3 years (p=0.99) and 5 years (p=0.454) between those with clear resection margins and those without. CONCLUSION: In this study it was found that there was an overall mortality rate of 38% over 12 years. The presence of clear surgical margins, although reassuring for the surgeon, should not be regarded as an indication of cure. However, an overall 1 year survival of 93% and a 10 year survival of 37% are reassuring in that a proportion of individuals achieve surgical cure following exenteration. 38% of patients died as a result of other medical causes over the 12 year follow up.

Orbital exenteration: a 13 year Manchester experience.

BACKGROUND/AIMS: Orbital exenteration is a psychologically and anatomically disfiguring procedure reserved for the treatment of potentially life threatening malignancies or relentlessly progressive conditions unresponsive to other treatments. In this study the authors aimed to review their experience with exenteration, including indications, outcomes, and reasons for the increased rate of exenterations over the past 15 months. METHOD: This retrospective study reviewed operating department records via a computerised database to identify all patients who had undergone exenteration of the orbit from 1 January 1991 to 1 April 2004 inclusive, at the Manchester Royal Eye Hospital. Where case records were unavailable, attempts were made to obtain patient data from general practitioners, local health authorities, and referring hospitals. RESULTS: 69 orbits of 68 patients were identified. The mean age of the cohort was 68.2 years, with 33 males and 35 females having undergone exenterations. In total, 31 patients had previously undergone treatments undertaken by the referring specialty with a mean time from the primary procedure to exenteration of 115 months. 14 different tumours were encountered, of which basal cell carcinoma (28), melanoma (10), sebaceous cell carcinoma (nine), and squamous cell carcinoma (six) were the most common. An increasing incidence was observed in cases of BCCs requiring exenteration. 30 patients received orbital prosthesis within an 11 month period post-exenteration. CONCLUSION: Exenteration is a procedure performed with increasing frequency in this unit over the past 15 months, the majority the result of BCCs. A large proportion of these exenterations had undergone previous treatments under a variety of non-ophthalmic specialties in other units. Exenterations are disfiguring procedures that may, therefore, be reduced in incidence by aggressive removal at the time of primary removal. Once performed, the cosmetic rehabilitation is long, with multiple postoperative visits, independent of the method used to close the orbital defect.

The 'RITE' use of the Fricke flap in periorbital reconstruction.

PURPOSE: To revisit an important but outmoded periorbital reconstructive technique. We present cases to illustrate the usefulness of the Fricke flap and describe a method of rapid intraoperative tissue expansion (RITE), which can enhance the applicability and effectiveness of the Fricke flap. A comparison between those cases performed with and without adjunctive RITE was not made due to the low numbers available. METHODS: A retrospective review of clinical cases. RESULTS: A total of 20 cases in which the Fricke flap was used for periorbital reconstruction were reviewed. The mean patient age was 64.7 years; the male-to-female ratio was 1:1. The patient follow-up ranged from 1 to 8 years with a mean of 4.2 years. The most common cause (65%) of periorbital defect was excision of eyelid malignancy. Necrosis of the terminal segment of the flap requiring further surgical intervention occurred in 10% (2/20). In both of these cases, the surgeons were trainees, with the complications being due to poor surgical technique. In the first case, the flap base was too narrow and in the second case, the distal end of the flap was thinned excessively. The functional result was excellent in 10/20 (50%), good in 5/20 (25%), fair in 3/20 (15%), and poor in 2/20 (10%). The cosmetic result was excellent in 3/20 (15%), good in 12/20 (60%), fair in 3/20 (15%), and poor in 2/20 (10%). CONCLUSION: The Fricke flap is an important and, in selected cases, an indispensable technique in periorbital reconstruction.

Patient communication during cataract surgery.

PURPOSE: Most cataract surgery is now performed under local anaesthesia on a day-case basis. As patients are fully conscious during the procedure, it is important that they remain still. There are a variety of reasons why patients may need to move, and it is important that the surgeon is made aware that this may happen. Some centres offer a nurse's hand as a means of perioperative patient communication. We sought to study the safety and efficacy of using an electronic patient-controlled alert device. METHOD: We compared hand-holding with the use of a patient alert device, and with both communication methods at the same time, on 150 subjects undergoing cataract surgery under local anaesthesia. Assessment of pre- and postoperative state anxiety was undertaken and patients' satisfaction with the communication strategies was assessed. RESULTS: There was a significant difference between pre- and postoperative state anxiety for each group (P<0.001) but no significant differences in pre-, peri-, or postoperative state anxiety between groups. There were no significant differences in confidence, pain, understanding, satisfaction, memory, and reassurance between the three groups. A total of 46% of all patients reported experiencing one or more of the potential problems enquired about, during the operation. Significant correlations were also identified between some of the psychological variables investigated. CONCLUSIONS: An electronic patient alert device is as effective a means of perioperative patient communication as holding a nurse's hand, during cataract surgery under local anaesthesia. It is safe, reassuring and it allows patients to communicate directly with the surgeon.