Short fascial strip--what next?

A surgical technique has been developed that effectively utilizes a short fascial strip to obtain the required length needed for frontalis fixation. The technique is simple and the tensile strength adequate.

Semicircular flap revisited.

The semicircular flap of Tenzel has proved to be an excellent reconstructive procedure for central eyelid defects. Although originally described for defects measuring half of the eyelid, we have found that it may be used for defects greater than 60% in the lower eyelid, if the lower eyelid retractors and inferior orbital septum are identified and severed from their attachments. This is the key factor in the mobilization and advancement of this flap. It may, in many circumstances, obviate the need for a more complicated reconstructive procedure.

Jones' tubes. How good are they?

Jones' tubes were placed in 40 patients with canalicular obstruction and epiphora. Thirty of 35 patients (85.7%) followed up for two to 86 months had good results. There were five failures due to granulation tissue formation, diplopia, and patient dissatisfaction.

Superior sulcus deformity.

Two cases of late reconstruction of the orbit in which there had been moderate disruption of orbital anatomy are presented. Emphasis is given to correction of superior sulcus deformity by implantation of a light, porous biocompatible alloplastic material--Proplast. Surgical technique is described and considerations are offered for selecting patients for this procedure.

Multifocal fibrosclerosis. Report of a case of bilateral idiopathic sclerosing pseudotumor and retroperitoneal fibrosis.

We describe a 56-year-old white man who presented with gradual and progressive visual loss and subsequent hypertension and pedal edema. A computed tomographic scan of the orbits showed bilateral diffuse retrobulbar masses, and an abdominal computed tomographic scan showed a diffuse retroperitoneal mass invading the aorta, ureters, and inferior vena cava. Biopsies of the orbit and abdomen confirmed a heterogeneous cell population and marked fibrosis consistent with a sclerosing inflammatory process. Bilateral sclerosing orbital inflammatory disease should cue the physician to suspect coexisting systemic disease. This report is the fourth to document bilateral sclerosing orbital inflammatory disease and the second to have obtained biopsies of the orbit and abdomen showing histologic similarities.

Metastatic basal cell carcinoma of the eyelid. Report of a case.

A patient had metastatic basal cell carcinoma of the right upper eyelid and periorbital area. Initially treated with radiation, there were multiple, extensive local recurrences requiring wide surgical excision. Ten years after the first lesion appeared, a metastasis was found in the preauricular soft tissue. A literature search found 204 previously reported cases of metastatic basal cell carcinoma, but none in the Western or European ophthalmic literature. The pathogenesis and unique features of basal cell carcinoma behavior are discussed.

Brown tumor and secondary hyperparathyroidism.

Brown tumor is a focal, bony lesion of hyperparathyroidism that results from parathyroid hormone on bone increasing osteoclastic activity with bone resorption and trabecular fibrosis. This leads to microfractures and hemorrhage and the appearance of brown tumors, which are seen most commonly in primary hyperparathyroidism and less frequently in secondary hyperparathyroidism. Rarely do these tumors involve the orbit. We report the sixth case, to our knowledge, of orbital involvement, in a patient with chronic renal failure (secondary hyperparathyroidism) and review the literature.

Delayed primary wound closure. Use to prevent implant extrusion following evisceration for endophthalmitis.

We used delayed primary wound closure in three cases of bacterial endophthalmitis to minimize the risk of implant extrusion following evisceration. In a fourth case, the wound was closed primarily, but wound dehiscence and implant extrusion occurred six weeks postoperatively, and reoperation was required. The advantages of delayed primary wound closure following evisceration of the globe for endophthalmitis include rapid removal of the intraocular abscess, continued drainage and mechanical débridement of the infected scleral pouch, and the development of granulation tissue resistant to bacterial growth at the wound margins prior to wound closure. These factors are important in reducing the risk of implant extrusion following evisceration of the globe for endophthalmitis.

Primary mucinous sweat gland carcinoma of the eyelid simulating metastatic carcinoma.

A 78-year-old man suffered an unusual variant of sweat gland carcinoma of the eyelid. This disorder is seldom recognized, and is frequently confused with inflammation, benign neoplasms, and metastatic carcinomas. On the basis of clinicopathologic and ultrastructural features found by both light and electron microscopy, we diagnosed sweat gland carcinoma of the eyelid. We considered the possibility of metastasis from a primary carcinoma elsewhere in the patient.

Pre-employment urine drug testing of hospital employees: future questions and review of current literature.

BACKGROUND: Patient safety and optimisation of worker performance are high current priorities. Arguments over employee drug testing have been debated over the past two decades. AIMS: To review prior information to reveal how current principles and practices regarding pre-employment drug testing of health care workers evolved, and to explore pressing current and future issues. METHODS: A literature search of Medline from 1980 to 1999 was performed. This yielded seven citations that reported results of pre-employment drug testing of health care workers, which we critically reviewed. RESULTS: The process by which a rational testing process was developed for pre-employment urine drug screening in the health care field is illustrated. Also depicted are some important principles, inequities, and shortcomings of the system. The range of positive tests was wide, from 0.25% to 12%. Testing was not always applied uniformly to all health care workers. It became apparent that positive tests also require medical review to determine if they were truly due to illicit substance use. CONCLUSIONS: Although pre-employment drug testing programmes in the health care industry have been firmly in place for many years, it is unclear whether such strategies have achieved their stated purposes. The next step is to study whether such programmes are effective at accomplishing specific goals, such as decreasing absenteeism, turnover, accidents, and medical errors, in order to justify continuing pre-employment testing versus changing to an alternative testing strategy.

Hypoplastic optic nerves studied with B-scan ultrasonography and axial tomography of the optic canals.

Radiologic studies of the optic foramina in cases of optic nerve hypoplasia have been inconsistent, some authors reporting normal foramina, others finding small foramina. The technique of axial tomography of the optic canals has been found more useful in this regard than plain foramen views, and has demonstrated small canals in cases of optic nerve hypoplasia. A case of bilateral hypoplasia is presented in which the discs were one half normal size, the optic nerves measured 2 mm in diameter on B-scan ultrasonography, and the optic canals were about 4 mm in diameter radiographically on the axial tomograms. These measurements are compared with normals of 4 to 4.5 mm for scans of the optic nerve, and a reported average optic canal width of 5.5 mm. A second case of less severe hypoplasia also presented a small ultrasonic nerve pattern of 3.5 mm. With the techniques of ultrasonography and axial tomography, the course of hypoplasic nerves can be followed from the level of the retina to the optic chiasm posteriorly. It is suggested that the optic canal dimensions correspond closely to the size of the optic nerve in cases of hypoplasia. When the nerve is only slightly hypoplastic the radiographic change in foramen or canal dimensions may not be detectable. Reasonably accurate measurements of the nerve may be more easily obtained with ultrasound.

Medical and surgical treatment of the dry eye.

An overview of the dry eye syndrome and its medical and surgical management has been presented. It is apparent that any single treatment is generally ineffective and that a combination of therapeutic modalities is required for success. The Experimental Slow Release Artificial Tear Insert (Ocusert) shows the most promise for a future solution.

Interactions between thermoregulation and the control of respiration in infants: possible relationship to sudden infant death.

In summary, there is evidence that developmental changes in respiratory control and in thermoregulation have effects upon each other. Theoretically, such effects could give rise to failure of the respiratory system and there is some circumstantial evidence to support the concept that on occasions such interactions may be of importance in sudden unexpected death in infancy. Future research in this area should focus on the nature of the interactions between thermoregulation and respiration, and on the effects of infection and infection-related mediators on those interactions.

Malignant melanoma of the lacrimal sac.

The case of an 80-year-old woman who presented with a 1-year history of a right medial canthal mass and bloody tears and who was found to have a lacrimal sac melanoma is reported. A literature search revealed that only 16 cases of primary lacrimal sac melanoma have been reported. Current therapeutic modalities are discussed.

Sorafenib dose escalation is not uniformly associated with blood pressure elevations in normotensive patients with advanced malignancies.

Hypertension after treatment with vascular endothelial growth factor (VEGF) receptor inhibitors is associated with superior treatment outcomes for advanced cancer patients. To determine whether increased sorafenib doses cause incremental increases in blood pressure (BP), we measured 12-h ambulatory BP in 41 normotensive advanced solid tumor patients in a randomized dose-escalation study. After 7 days' treatment (400 mg b.i.d.), mean diastolic BP (DBP) increased in both study groups. After dose escalation, group A (400 mg t.i.d.) had marginally significant further increase in 12-h mean DBP (P = 0.053), but group B (600 mg b.i.d.) did not achieve statistically significant increases (P = 0.25). Within groups, individuals varied in BP response to sorafenib dose escalation, but these differences did not correlate with changes in steady-state plasma sorafenib concentrations. These findings in normotensive patients suggest BP is a complex pharmacodynamic biomarker of VEGF inhibition. Patients have intrinsic differences in sensitivity to sorafenib's BP-elevating effects.