[Importance of interdisciplinary collaboration for optimal treatment of orbital tumors]. / Bedeutung der interdisziplinären Zusammenarbeit für eine optimale Behandlung orbitaler Tumoren.

Optimal treatment of tumors with orbital invasion may exceed the competences of an individual medical specialty and require interdisciplinary cooperation. The aim of this article is to present an interdisciplinary treatment concept based on the examples of intraorbital hemangioma and squamous cell carcinoma of the paranasal sinuses infiltrating the orbit. In addition to a detailed medical history and a complete ophthalmological examination, a detailed imaging technique with standardized echography and tomography methods such as orbital thin-slice CT and/or in many cases MRI is essential for the primary classification of an intraorbital pathology. Depending on the type of pathology, a purely surgical procedure involving various disciplines such as ophthalmology, otorhinolaryngology, maxillofacial surgery, neurosurgery, and pathology, or an interdisciplinary treatment regimen including (neo)adjuvant radiotherapy or chemotherapy is necessary. Orbital tumors have a wide range of potential pathologies, requiring complex surgical procedures and multimodal therapies. In case of infiltration of the paranasal sinuses or intracranial structures, an interdisciplinary team including neuroradiologists, oral-maxillofacial surgeons, otorhinolaryngologists, neurosurgeons, radiation therapists, ophthalmologists, pathologists, oncologists, and psycho-oncologists is essential for successful treatment.

[Transcanalicular Laser Dacryocystorhinostomy: One-Year-Experience in the Treatment of Acquired Nasolacrimal Duct Obstructions]. / Transkanalikuläre Laserdakryozystorhinostomie--1-Jahres-Erfahrung in der Behandlung infrasakkaler Tränenwegsstenosen.

BACKGROUND: External dacryocystorhinostomy (DCR) is at present the gold standard for the surgical treatment of acquired nasolacrimal duct obstructions, but tremendous progress has been made in recent years in improving minimally invasive techniques, sparing not only the skin, but also the medial lid structures, which contribute to the physiological palpebral-canalicular pump mechanism. The purpose of this study is to report our 1-year experience with the surgical technique, complications and results of transcanalicular laser assisted DCR. PATIENTS AND METHODS: 48 consecutive transcanalicular laser-assisted DCRs combined with bicanalicular silicone intubation were performed for acquired nasolacrimal duct obstruction, and evaluated for intra- and postoperative complications, as well as subjective and objective success rates. RESULTS: Transcanalicular laser-assisted DCR combined with bicanalicular silicone intubation was surgically feasible in 45 cases (94 %). In 3 patients (6 %) it was impossible to position the aiming beam correctly at the anteroinferior rim of the middle turbinate using the superior canalicular approach, due to superior orbital rim prominence. Therefore 2 patients received no silicone intubation, despite a patent osteotomy at the back of the middle turbinate, and 1 patient underwent intraoperative conversion to external DCR due to anatomical narrowness of the nasal cavity. Perioperatively, 1 patient developed canalicular infection, 1 patient exhibited thermal injury to the canaliculus, and 4 patients exhibited premature prolapse of the silicone tube. At 6-months follow-up, functional success--defined as resolution of preoperative symptoms--was achieved in 35 of 45 surgically successful transcanalicular laser-assisted DCRs (78 %). Of the 10 postoperative failures (22 %), all patients reported epiphora, 6 patients were unable to irrigate the lacrimal drainage system, and 6 patients required surgical revision using external DCR. CONCLUSIONS: Transcanalicular laser assisted DCR is a promising minimally invasive approach for the surgical treatment of acquired nasolacrimal duct obstruction, in order to fill the gap between recanalising first step procedures and external DCR.

[Tumors of the lacrimal drainage system]. / Tumoren der ableitenden Tränenwege.

BACKGROUND: The prevalence of tumors affecting the lacrimal drainage system is low, thus generating a risk of late diagnosis and treatment in clinical routine. However, these tumors can be potentially life-threatening, which emphasizes the relevance of early diagnosis and treatment. OBJECTIVE: This review focuses on the symptoms, incidence, management, and prognosis of the different tumor entities affecting the lacrimal drainage system. METHODS: The study provides a PubMed-based literature review and presents own clinical results. RESULTS: Alongside detailed medical history taking and comprehensive clinical examination, precise inspection during external dacryocystography is important for diagnosis of tumors affecting the lacrimal drainage system. There is a wide spectrum of tumor entities located in the lacrimal drainage system. The tumors are classified into three groups: primary epithelial, primary nonepithelial, and inflammatory lesions. The most common primary epithelial tumors include papilloma, squamous cell carcinoma, and transitional cell carcinoma. The most common nonepithelial tumors include fibrous histiocytoma, malignant lymphoma, and malignant melanoma; while the most common inflammatory lesions comprise sarcoidosis, Wegener granulomatosis, and pyogenic granuloma. Treatment depends on the entity and stage of the tumor. In the case of malignancy, a multimodal and interdisciplinary approach is usually indicated. CONCLUSION: Differential diagnostic signs in favor of a malignancy include a long medical history, predisposing conditions in the patient's history, a mass above the medial canthal ligament, teleangiectasis above the mass, and serosanguinous secretion.

The fundamental flaw of the HSAB principle is revealed by a complete speciation analysis of the [PtCl(6-n)Br(n)](2-) (n = 0-6) system.

Bjerrum's model of step-wise ligand exchange is extended to compute a complete speciation diagram for the [PtCl6-nBrn](2-) (n = 0-6) system including all 17 equilibrium constants concerning the Pt(IV) chlorido-bromido exchange reaction network (HERN). In contrast to what the hard soft acid base (HSAB) principle "predicts", the thermodynamic driving force for the replacement of chloride by bromide in an aqueous matrix, for each individual ligand exchange reaction present in the Pt(IV) HERN, is due to the difference in halide hydration energy and not bonding interactions present in the acid-base complex. A generalized thermodynamic test calculation was developed to illustrate that the HSAB classified class (b) metal cations Ag(+), Au(+), Au(3+), Rh(3+), Cd(2+), Pt(2+), Pt(4+), Fe(3+), Cd(2+), Sn(2+) and Zn(2+) all form thermodynamically stable halido complexes in the order F(-) ≫ Cl(-) > Br(-) > I(-) irrespective of the sample matrix. The bonding interactions in the acid-base complex, e.g. ionic-covalent σ-bonding, Π-bonding and electron correlation effects, play no actual role in the classification of these metal cations using the HSAB principle. Instead, it turns out that the hydration/solvation energy of halides is the reason why metal cations are categorized into two classes using the HSAB principle which highlights the fundamental flaw of the HSAB principle.

A novel approach quantifying the periorbital morphology: A comparison of direct, 2-dimensional, and 3-dimensional technologies.

BACKGROUND: The measurement of anatomical structures is critical in plastic and reconstructive surgery. However, few detailed and standardized measurements have been widely used in the periorbital region. This study aimed to evaluate the feasibility of a novel detailed and standardized protocol with 2D and 3D technologies, and explore the relationship between them and direct measurements. METHODS: Fifty healthy Caucasians (100 eyes) between 20 and 68 years old were recruited and captured for 3D photographs by VECTRA M3 3D Imaging System. Subsequently, 24 landmarks were located on each 3D photographs following a standardized protocol, and then 19 linear and 3 angular periorbital variables were measured. Furthermore, two-dimensional (2D) and direct measurements were conducted on each subject and compared with 3D measurements and one another. RESULTS: The grand r means across all measurements were 0.77, 0.78, and 0.88 for direct vs. 2D values, direct vs. 3D values, and 3D vs. 2D values, respectively. The mean absolute differences were 1 mm (ranging from 0.2 mm to 3.7 mm) between direct and 3D measurements, 1 mm (ranging from 0.04 mm to 2.4 mm) between direct and 2D measurements, and 1 mm and 6.6° (ranging from 0.04 mm or 0.5° to 3 mm or 12.8°) between 2D and 3D measurements. CONCLUSIONS: This study verified the feasibility of this detailed and standardized landmark localization protocol for assessing the periorbital morphology with 2D and 3D technologies. This protocol may work as a bridge communicating with all studies involving any of the three technologies in the future.

[Surgical resection with ophthalmoplastic reconstruction : Gold standard in periocular basal cell carcinoma]. / Chirurgische Resektion mit ophthalmoplastischer Rekonstruktion : Goldstandard beim periokulären Basalzellkarzinom.

The gold standard for the treatment of periocular basal cell carcinoma is surgical resection followed by ophthalmoplastic reconstruction. The highest priority in most cases is the complete histopathologically controlled tumor excision. The histopathological preparation can be carried out in two stages by rapid overnight embedding or intraoperatively by a rapid frozen section procedure. A variety of reconstruction methods enable a customized and in most cases also a cosmetically and functionally attractive defect coverage. Postoperatively, a regularly performed tumor aftercare is essential.

[New treatment options for iridociliary tumors]. / Neue therapeutische Möglichkeiten bei iridoziliären Tumoren.

BACKGROUND: Benign iridal tumors rarely necessitate a therapeutic intervention. In contrast, malignant tumors of the iris can threaten the patient's life and eyesight and require early treatment to prevent the development of metastases. OBJECTIVE: Presentation of current treatment options for iridal tumors with special emphasis on iridal melanoma. METHODS: This article gives an overview of the current literature based on a PubMed search as well as own clinical experience. RESULTS: Treatment options for iridal and ciliary body melanomas comprise radiotherapeutic and surgical (eyeball-sparing and non-sparing) approaches. The eyeball-sparing surgical procedure of choice is block excision. While local tumor control rates and metastasis rates of block excision and radiotherapy are comparable, there are distinct differences especially between the spectra of complications. New treatment procedures include immunomodulatory approaches and targeted therapies. Using checkpoint inhibitors, no convincing enhancement of overall survival could be demonstrated for metastatic iridal melanoma, as is the case for cutaneous melanoma. In contrast, tumor vaccination with the help of tumor RNA-laden patient-derived dendritic cells seems to be a promising option for a subgroup of high-risk patients. Targeted therapies aiming to suppress the MAPK and PI3K/Akt pathways could not achieve any improvement in patient survival. CONCLUSION: For the primary treatment of iridal melanoma a surgical, eyeball-sparing approach and also when appropriate, radiotherapy can be recommended. In the future, eligible high-risk patients could profit from a tumor vaccination. To date, there is no effective systemic treatment for metastatic iridal melanoma.

[Clinico-echographic diagnostics of iris tumors]. / Klinisch-echographische Diagnostik bei Iristumoren.

BACKGROUND: The differentiation of iridic space-occupying lesions represents a regularly reoccurring diagnostic challenge. OBJECTIVE: This article presents an overview of the epidemiological data and describes the diagnostic procedure for iris tumors. MATERIAL AND METHODS: The article provides a review of the literature from PubMed and own clinical results. RESULTS: Melanocytic lesions comprise the vast majority of all iris tumors and include nevi and melanomas. Slit lamp biomicroscopy with standardized photography reveals two-dimensional planar tumor growth over time, which is the only recognized clinical surrogate finding for a malignant event. Ultrasound biomicroscopy (UBM) is additionally obligatory because it is the only method which enables documentation of the extent of tumor penetration, ciliary body involvement and internal structure of iris tumors. CONCLUSION: Serial slit lamp and UBM examinations with reproducible pupillary diameters are indispensable for the differentiation of cystic, solid and tumor-simulating lesions and for the detection of malignant transformation in iris tumors.

[Cheek-midface lift for revision following failed excessive lower eyelid blepharoplasty]. / Wangen-Mittelgesichts-Anhebung zur Revision nach unsachgemäß exzessiver Unterlidblepharoplastik.

Iatrogenic ectropion with sagging of the lower eyelid after failed excessive lower eyelid blepharoplasty is a severe complication in aesthetic surgery. Traditionally, free skin grafting is the method of choice for correction. This overview presents the cheek-midface lift as a useful and powerful method for the correction of ectropion following excessive lower eyelid blepharoplasty. This technique, which can be performed with the patient under local anesthesia, enables good functional as well as aesthetic outcomes.

[CyberKnife®: new treatment option for uveal melanoma]. / CyberKnife®: Eine neue Therapieoption bei uvealem Melanom.

BACKGROUND: CyberKnife® stereotactic radiosurgery is a new treatment option for uveal melanoma. OBJECTIVE: This review outlines the technique of robot-assisted CyberKnife® therapy, as well as the pros and cons in the treatment of uveal melanoma. METHODS: The study provides a PubMed literature review and own preliminary clinical experiences. RESULTS: CyberKnife® therapy for choroidal and ciliary body melanomas shows comparable results concerning local tumor control and overall survival matching those of conventional therapies. With only low complication rates, a high level of quality of life can be conserved by possible preservation of visual acuity as well as the ocular globe. CONCLUSION: Stereotactic radiosurgery using CyberKnife® seems to be an efficient and safe therapeutic option for malignant melanomas affecting the choroid and ciliary body. Comparative studies with conventional radiation strategies are now a high priority.

[Minimally invasive bypass surgery for nasolacrimal duct obstruction : Transcanalicular laser-assisted dacryocystorhinostomy]. / Minimalinvasive Bypasschirurgie bei infrasakkalen Tränenwegsstenosen : Transkanalikuläre Laserdakryozystorhinostomie.

BACKGROUND: In recent years, the minimally invasive surgical procedure of transcanalicular laser-assisted dacryocystorhinostomy (TKL-DCR) has gained importance in the treatment of primary acquired nasolacrimal duct obstructions (PANDO). OBJECTIVES: Surgical indications, functional success rates, potential advantages, and complications of TKL-DCR are presented and compared with the standard procedures external (EXT-DCR) and endonasal DCR (EN-DCR). METHODS: The study comprises a PubMed literature review and our own clinical results. RESULTS: Using TKL-DCR either as the primary surgical treatment for PANDO, or as a secondary procedure following failure (reobstruction of the surgical ostium) of previous EXT-DCR resulted in good functional success rates (60-90%). The duration of surgery (10-15 min) and the period of recovery are significantly shorter than in EXT-DCR. Visible cutaneous scars and significant postoperative nose bleeding are not among the complications of TKL-DCR, due to the lack of a skin incision and the coagulative ability of the diode laser. The smaller sized surgical ostium has been considered the main disadvantage of TKL-DCR, since it might be prone to earlier reobstruction. On the other hand, TKL-DCR spares the anatomical structures that form the physiological tear pump, which should favor tear drainage. In very few cases, thermal damage to the canaliculus has been observed as a complication. CONCLUSIONS: Given the satisfying functional results, TKL-DCR is a valid alternative to the "gold standard" procedure EXT-DCR, especially in patients who particularly request speedy recovery and who do not want to take the risk of visible skin scaring. Future studies will have to investigate whether the smaller surgical ostia of TKL-DCR remain patent and whether functional success rates decrease during a longer follow-up period of >2 years.

[Merkel cell carcinoma of the eyelid. An often unrecognized tumor entity : Clinical aspects and treatment strategies]. / Merkel-Zell-Karzinom des Augenlids ­ eine häufig verkannte Diagnose : Klinische Aspekte und Behandlungsmethoden.

Merkel cell carcinoma of the eyelid is an aggressive, highly malignant tumor of the skin. Totaling approximately 0.5 % of all tumors of the eyelid, it constitutes a relatively small group of lid tumors. Nevertheless Merkel cell carcinoma is of significance to the ophthalmologist. Because of its clinical presentation it can be easily confused as a chalazion, a hordeolum or the lesser aggressive basal cell carcinoma. This often leads to delayed treatment. In this article we describe clinical aspects, which aim to help the ophthalmologist suspect Merkel cell carcinoma earlier. Additionally we outline a diagnostic and therapeutic workup taking into consideration the special anatomy of the eyelid.

[Current diagnostics and therapy recommendations for ocular basal cell carcinoma]. / Aktuelle Diagnostik und Therapieempfehlungen beim Basalzellkarzinom am Auge.

The treatment options for basal cell carcinoma (BCC) have recently been augmented with the introduction of novel chemotherapeutic drugs. New S2 guidelines on the disease have also been published. The aim of this article is to present a comprehensive state of the art description of the features of ocular BCC and an overview of the various therapeutic options. Particular emphasis is placed on the clinical signs, the diagnostic tools to identify periocular BCC and interpretation of the different histopathological subtypes. Tumor staging, TNM classification, interdisciplinary tumor conference reviews as well as psycho-oncological services play an important role in patients with pronounced periocular BCC. Surgical removal with a histological R0 resection is an important component of therapy options in this disease and includes the microsurgical excision into healthy tissue and the subsequent covering of the defect. A special focus of this article is the treatment of locally extensive and metastasized BCC.

[Results of Cutler-Beard procedure for reconstruction of extensive full thickness upper eyelid defects following tumor resection]. / Ergebnisse nach Cutler-Beard-Plastik zur Rekonstruktion ausgedehnter Oberliddefekte nach Tumorexzision.

BACKGROUND: The Cutler-Beard bridge flap technique is an established method for reconstruction of large full thickness upper eyelid defects. The purpose of the present study was to report experiences with the surgical technique, complications and results of this cutaneoconjunctival flap procedure following tumor resection. PATIENTS AND METHODS: A total of 18 patients with extensive full thickness upper eyelid defects after tumor excision underwent a Cutler-Beard procedure. Of the patients four received an additional eye bank scleral implant and one received an additional free tarsal graft from the fellow upper eyelid to enhance eyelid stability. RESULTS: The Cutler-Beard bridge flap technique was surgically feasible in all patients without causing damage to the lower eyelid bridge or resulting in any infections. Out of the 13 reconstructions without additional stabilizing tissue 3 (23%) developed an upper eyelid entropion that was successfully managed using a secondary scleral implant. None of the five reconstructions using additional scleral or tarsal tissue showed an entropion of the upper eyelid. CONCLUSION: The Cutler-Beard bridge flap technique, which can be combined with grafting additional stabilization tissue in defects exceeding 75% of the upper eyelid length, is a reliable method for reconstruction of large full thickness upper eyelid defects following tumor excision.

[Ocular prosthetics. Fitting, daily use and complications]. / Augenprothetische Versorgung. Anpassung, Handhabung und Komplikationen.

BACKGROUND: Ocular prosthetics make a decisive contribution to the functional, esthetic and psychosomatic rehabilitation of patients after ocular extirpation. OBJECTIVES: This article provides an overview of the fitting, daily care and complications of ocular prosthetics. METHODS: The study comprised a PubMed literature review and own clinical results. RESULTS: Ocular prosthetics made from cryolite glass or perspex can be manufactured and fitted 5-8 weeks after removal of the eye. During this period a conformer is placed within the conjunctival sac in order to prevent scar formation and shrinking of the socket. Artificial eyes can be worn continuously, only interrupted by a short but regular cleaning procedure. Artificial tears and lid hygiene improve the comfort of wearing. Glass prostheses have to be renewed every 1-2 years, while perspex prostheses need to be polished once a year. Complications, such as giant papillary conjunctivitis or blepharoconjunctivitis sicca are facilitated by poor fit, increased age and inappropriate care of the prosthetic device. In the case of socket shrinkage or anophthalmic socket syndrome, surgical interventions are needed to re-enable the use of an artificial eye. CONCLUSION: Adequate fitting, daily care of ocular prosthetics and therapeutic management of associated complications are mandatory for a durable functional, esthetic and psychosomatic rehabilitation after ocular extirpation.

[Current aspects of eyelid, lacrimal and orbital surgery in childhood]. / Aktuelle Aspekte zur Lid-, Tränenwegs- und Orbitachirurgie im Kindesalter.

BACKGROUND: During childhood the spectrum of disorders of the eyelid, the lacrimal drainage system and the orbit as well as the subsequent therapeutic management differ from those in adults. OBJECTIVES: This review outlines the clinical picture and treatment of the most common eyelid, lacrimal drainage and orbital diseases in childhood. METHODS: The study comprises a PubMed literature review and own clinical results. RESULTS: The most common eyelid disorders in childhood include congenital malpositions, such as ptosis or entropium, which may require fast surgical correction in order to prevent amblyopia. For connatal dacryostenosis a step-by-step therapeutic approach is recommended: (1) conservative treatment using lacrimal sac massage, astringent eye and nose drops, (2) irrigation and probing of the nasolacrimal system and (3) irrigation, probing and silastic tube intubation under general anesthesia. Benign orbital lesions such as dermoid cysts can be removed at pre-school age. Using systemic beta blockers is a novel conservative approach in the treatment of capillary hemangioma, which should precede surgical interventions. CONCLUSION: Eyelid and orbital diseases during childhood may require fast surgical intervention to prevent amblyopia. Initial conservative treatment is recommended for connatal dacryostenosis and capillary hemangioma.

[Significance of transcanalicular laser assisted dacryocystorhinostomy in modern lacrimal drainage surgery]. / Stellenwert der transkanalikulären Laser-Dakryozystorhinostomie in der modernen Tränenwegschirurgie.

For the treatment of postsaccal lacrimal drainage obstructions transcanalicular laser dacryocystorhinostomy (TCL-DCR) represents a less invasive alternative to external Toti procedures. Herein, a diode laser optical fiber is inserted into the lacrimal sac via the canaliculi. Under visual control with a nasal endoscope laser energy is applied until a patent osteotomy between the sac and nasal mucosa has been created. Published success rates of 70-90% get close to the excellent results of Toti procedures. Besides describing therapy planning and surgical technique, pros and cons of TCL-DCR are discussed.