Radiotherapy and Radiosurgery in the Management of Optic Nerve Sheath Meningiomas: An International Systematic Review and Meta-Analysis of Twenty Studies.

BACKGROUND: Optic nerve sheath meningiomas (ONMs) are often managed with radiotherapy (RT) with the goal of achieving radiographic local control (LC) and preventing deterioration of visual acuity (VA). We aimed to perform a systematic review and meta-analysis of outcomes for patients with ONM treated with RT. METHODS: The PICOS/PRISMA/MOOSE selection criteria were used to identify studies. Primary outcomes were stable or improved VA and radiographic LC at last follow-up. The secondary outcomes were incidences of radiation-induced retinopathy and xerophthalmia and stable or improved visual fields (VFs). Weighted random-effects meta-analyses using the DerSimonian and Laird methods were conducted to characterize effect sizes. Mixed-effects regression models were used to examine potential correlations between gross tumor volume (GTV) and outcomes. RESULTS: In total, 444 patients with ONM across 20 published studies were included. The estimated LC rate was 99.8% (95% confidence interval [CI], 98.3%-100%), and the estimated proportion of patients with stable or improved VA or VF was 89.7% (95% CI, 86.2%-92.4%) and 93.3% (95% CI, 89.5%-95.8%), respectively. Estimated incidences of radiation-induced retinopathy and xerophthalmia were 7.2% and 10.1%, respectively. GTV was significantly associated with VA (P = 0.014) with estimated VA rates of 96.4%, 91.4%, and 80.5% for GTVs of 2.0, 3.0, and 4.0 cm3, respectively. CONCLUSIONS: RT was well tolerated, with excellent LC achieved. Nearly 90% of patients noted either stability or improvement in VA and VF. Larger ONMs were associated with poorer VA.

Use of amniotic membrane graft and corneal transplantation in a patient with bilateral keratomalacia induced by uncontrolled phenylketonuria.

PURPOSE: To report a patient with a rare complication of bilateral keratomalacia induced by uncontrolled phenylketonuria (PKU) that was successfully treated with amniotic membrane transplantation in 1 eye and penetrating keratoplasty in the second eye. METHODS: Case report and literature review. RESULTS: A 9-month-old girl with uncontrolled PKU was referred to our clinic because of bilateral keratomalacia. Slit-lamp examination of the right eye revealed 2 large corneal erosions with stromal thinning on the nasal and inferior regions of the right cornea. Left eye examination revealed a large area of melting involving two thirds of the cornea with corneal perforation and iris bulging on the temporal side and no anterior chamber. She underwent amniotic membrane transplantation on her right cornea and penetrating keratoplasty on her left cornea. Treatment after surgery included antibiotic and steroid eye drops and a special diet regimen with partial phenylalanine intake. Examination under anesthesia 4 months after surgery revealed intact cornea in her right eye and a clear corneal graft with a deep anterior chamber on her left eye. Intraocular pressure was normal in both eyes. CONCLUSIONS: Bilateral keratomalacia, although a rare ophthalmic manifestation of PKU, can cause a severe corneal injury that may threaten the eyeball integrity. Surgical treatments with amniotic membrane graft and corneal transplantation, along with the appropriate diet treatment, were found to be effective procedures, yielding rapid healing of the corneal surface.

Submandibular gland transfer for severe xerophthalmia.

OBJECTIVE: To report early clinical experience with a new microvascular reconstructive procedure for patients with severe xerophthalmia. STUDY DESIGN: Retrospective clinical series. METHODS: Patients with severe xerophthalmia were referred for treatment after having exhausted all conventional means of treatment. The ipsilateral submandibular gland was transferred to the temporal fossa, as described by Macleod et al., and revascularized using the superficial temporal artery and appropriate vein(s). The submandibular duct was directed to the superolateral fornix so that the saliva produced moistened the eye. Results and complications were reviewed. RESULTS: Seven microvascular submandibular gland transfer procedures were performed in five patients, ages 6 to 54. The etiology of severe xerophthalmia was Stevens-Johnson syndrome in four and chemical burn in one. Follow-up time was 4 to 20 months. Successful transfer with revascularization was achieved in six of seven (86%) cases. Schirmer's test scores improved from 1.3 pretransfer to 8.1 posttransfer (P = .005). Patients experienced symptomatic relief within 1 month, and the microenvironment of the eye surface improved enough to make them candidates for visual restorative eye surgery. There were no major complications. CONCLUSIONS: Microvascular submandibular gland transfer is an effective approach for correcting severe xerophthalmia. The procedure should be within the skills of any reconstructive microsurgeon. This procedure offers a unique opportunity for otolaryngologist-head and neck reconstructive surgeons to help restore vision to this unfortunate group of patients.

[Transplantation of labial salivary glands for severe dry eye treatment]. / Transplante de glândulas salivares labiais no tratamento do olho seco grave.

PURPOSE: To study the clinical effects of the secretion of transplanted labial glands used as ocular lubricant to treat severe dry-eye cases, to evaluate the duration of the results and to simplify the surgical technique. METHODS: Thirty-seven surgeries were performed in twenty-one patients during the period of July 2000 to January 2004. The graft, consisting of labial mucosa and underlying salivary glands, was transplanted to the previously prepared area in the conjunctival fornix. All procedures were recommended in severe dry-eye cases, that is, eyes with total or nearly total xerophthalmia. The preoperative and postoperative protocols are presented emphasizing the items which were used in the comparative analysis of the results as well as the technical description of the surgical procedure. RESULTS: The graft survival and integration into the host tissues were observed in 97.2% of the cases. The clinical improvement, demonstrated by the disappearance of the symptoms, better biomicroscopic aspect of the ocular surface, better vision and disuse of lubricant drops, was observed in 91.9% of the cases. The follow-up showed not only persistence but also stability of the results. Infection represented one case and ptosis represented three cases of the only four observed complications. CONCLUSION: The improvement of severe dry-eye cases detected after the transplantation of labial salivary glands is significant. It demonstrates that the lubricant ocular surface produced by the salivary secretion is efficient and well-tolerated. The follow-up shows that the result persists in the long term from which it is concluded that the production of the secretion is permanent. The surgical technique of transplanting the labial salivary gland to the conjunctival fornix is very simple and easily accessible to any ophthalmic surgeon.

Treatment of dry eye by blocking the lacrimal canaliculi.

Occlusion of the lacrimal canaliculi improves the objective signs and subjective symptoms of dry eye. In this review, methods of occlusion are classified as surgical, thermal and tamponade. Surgical methods include dacryocystectomy, canalicular ligature, canalicular offset, canalicular excision, transfer of the punctum to dry dock, punctal tarsorrhaphy and punctal patch. Thermal methods include cautery, diathermy and laser burn. Tamponade methods use absorbable inserts of hydroxypropyl cellulose, gelatin, collagen and catgut, and nonabsorbable inserts of silicone (punctum plugs, canalicular plugs), polyethylene, cyanoacrylate, and others. The characteristics of all these methods are analyzed.

A comparison of two methods of punctal occlusion.

We performed punctal occlusion by thermal cautery on 23 patients (45 sides, 90 puncta). One punctum on the right side was randomly assigned to deep cauterization of the punctum and vertical canaliculus, and the other punctum assigned to cauterization of the punctum only. The two treatments were assigned to the opposite puncta on the left side. One month after cauterization, the puncta that received deep cauterization were significantly more likely to have remained closed than those that received superficial cauterization (P less than .01). Survival analysis over a period of follow-up that exceeded one year after surgery, using time to examination because of a reopened punctum as the endpoint, indicated a long-term advantageous effect of deep over superficial cauterization.

Bilateral corneal ulcers in primary vitamin A deficiency.

PURPOSE: To report a case of bilateral corneal ulcers and perforations resulting from hypovitaminosis A in an alcoholic patient. METHODS: A 38-year-old cachetic man presented with bilateral corneal ulcerations and severe visual loss. He was hospitalized, developed bilateral corneal perforations, and was treated with bilateral corneal transplants. RESULTS: Serum vitamin A level was 0.01 microg/dL (normal, 0.30-0.75). The electroretinogram was consistent with vitamin A deficiency. His clinical status improved after vitamin A replacement. CONCLUSIONS: Although rare in developed countries, the ophthalmologist must consider avitaminosis A in the differential diagnosis of corneal ulcerations in cachetic, alcoholic, or chronically ill patients. Early diagnosis and treatment can prevent unwanted outcomes.

"Practical suggestions on facial plastic surgery--how I do it". Parotid duct transfer in xerophthalmia.

Xerophthalmia, or dry eye, is an old human affliction. Among the many causes are trachoma, surgical or traumatic destruction of the lacrimal gland, and paralysis of the greater superficial petrosal nerve after Bell's palsy or from the presence or removal of an intracranial posterior fossa tumor. The technique of parotid duct transfer is a well established effective means to rehabilitate the dry eye. A method of parotid duct transfer is described.

Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip.

Lower eyelid malposition is the most common long-term complication following transcutaneous lower eyelid blepharoplasty. The malposition may include rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, or frank ectropion. The result is cosmetically unacceptable and may be associated with tearing, irritation, and other exposure keratitis symptoms. Multiple factors, including lower eyelid laxity, shortage of skin, and scarring of the middle lamella, may be responsible for this malposition. A systematic examination of the lower eyelid, as presented, helps to assess the degree to which each of these factors is responsible for the malposition. Patients with the most severe degree of lower eyelid malposition generally have middle lamella scarring. If this abnormality is not addressed, lower eyelid procedures aimed at correcting the malposition are doomed to failure. In the presence of significant middle lamella scarring, a spacer is required to provide vertical height and stiffness to support the lower eyelid following release of the cicatrix. A systematic approach aimed at addressing the underlying abnormalities was developed. In patients with significant middle lamella scarring, hard palate mucosa grafts were used as spacers in 29 eyelids (17 patients). A lateral canthotomy and transconjunctival incision allow access to the scarring in the lower eyelid retractors and septum. After careful release of all cicatrix, a hard palate mucosa graft is inserted between the lower border of the tarsal plate and the recessed conjunctiva, lower eyelid retractors, and septum. Horizontal lower eyelid laxity, when present, is corrected by performing a lateral tarsal strip. Most patients do not have a true deficiency of the anterior lamella (skin and orbicularis oculi muscle). When a moderate amount of anterior lamella deficiency is present with significant scarring of the middle lamella, the technique we describe allows correction of the lower eyelid malposition without a skin graft. After a follow-up interval of 6 to 30 months (mean 14 months), excellent results were obtained in all eyelids. Complications included corneal abrasions in two eyes before routine use of bandage cornea contact lenses at the end of surgery and a secondary bleed from the roof of the mouth in one patient. Palate mucosa closely resembles tarsus and provides excellent vertical support to the eyelid. It is stiff enough to maintain eyelid contour without causing a cosmetically unacceptable bump. Tissue can be obtained with ease. The technique, as described, addresses the underlying causes of lower eyelid malposition and gives excellent functional and cosmetic results.

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.

[Long-term follow-up after autologous submandibular gland transplantation in scarring keratoconjunctivitis with absolute dry eyes]. / Mehrjahresverlauf nach Autotransplantation der Unterkieferspeicheldrüse bei vernarbender Keratokonjunktivitis mit absolutem Tränenmangel.

INTRODUCTION: An autologous submandibular gland can be transplanted to the temporal fossa and following microvascular anastomosis to the temporal artery and vein and implantation of the secretory duct into the superotemporal conjunctival fornix to provide continuous substitute lubrication. Here we report our experiences with this procedure. PATIENTS AND METHODS: In a prospective, controlled clinical cohort study, we investigated the development of the Schirmer- test, fluorescein-break up time (F-BUT), degree of discomfort, use of pharmaceutical tear substitutes, visual acuity, Rose Bengal staining and conjunctival hyperemia in 14 eyes with a successful submandibular gland transplant and 11 dry eyes without salivary lubrication. RESULTS: Over a mean postoperative period of 3.3 years the transplantation group showed significant improvements of the Schirmer-Test, FBUT, use of pharmaceutical tear substitutes, discomfort and Rose Bengal staining up to the last follow-up when compared to the preoperative and control groups. CONCLUSION: Transplantation of an autologous submandibular gland can improve the lubrication and discomfort of absolute tear deficiency on a long term basis, but the salivary tear film only partially stabilises the ocular surface. The procedure is however able to provide symptomatic relief in extreme cases of absolute dry eyes.

Experimental approach to surgical treatment of lacrimal insufficiency by microvascular submandibular salivary gland autotransplantation.

When compared to the parotid duct transposition, the microvascular submandibular salivary gland autotransplantation presents the advantage of providing a more viscous tear substitute, and a basal flow rate unaffected by meals. If future attempts to re-innervate the graft are successful, this procedure could be promising in restoring an acceptable lacrimal function in severe xerophthalmia.

[Complications of punctum plug in the symptomatic treatment of dry eye]. / Complications des bouchons lacrymaux employés dans le traitement symptomatique des sécheresses oculaires.

76 patients with dry eyes were treated by mechanical obstruction of lacrymal puncta. The sex ratio is: 62 females and 14 males. The age average was 55, ranging from 12 to 88. The etiologies were: Sjögren's syndrome: 16 cases (21%); filamentous kerato-conjonctivitis sicca: 12 cases (15%); anxiolytical and anti-depressant treatments: 10 cases (13%); complicated viral kerato-conjonctivitis: 4 cases (5%); post radiotherapy dry syndrome: 3 cases (4%); idiopathic and various etiologies: 31 cases (40%). The 149 plugs are completely made of hydrophobic silicone; 20 had a barb inclined on the neck axis. Insertion was achieved after tropical anesthesia in 90% of the cases. 121 plugs (81%) did not lead to any anatomical complication (the average duration remaining on time interval of implantation per plug was of 5 months). Functional tolerance depends on the quality of plug-punctum adjustment. Plug protrusion is the main cause of intolerance and disappearance. The complications were: rupture of punctum during dilation: 1%; suppurative canaliculitis: 1.3%; disappearance: 16%; epiphora: 22%. No intra-canalicular migration was observed. We check canalicular permeability in 26 cases, after loss or removal: che was normal 23 times (average time-interval: 5 months). We had 3 cases of canalicular stenosis after 4 months, 5 months and 18 months of intubation.

[Treatment of dry eye by temporary punctum plug. Comparison with a control group]. / Traitement des sécheresses lacrymales par occlusion réversible des méats lacrymaux. Résultats comparés à un groupe témoin.

35 patients with chronic dry eye were treated with punctum plug on one side only. The other side was a control: after simulation dilatation, the patient underwent a simulation insertion. This is an open study in which only the patient ignored the reality of treatment. The study was prospective. 28 females and 7 males were enrolled in this study. The age' average was 53. The follow-up average is 5.3 months. The etiologies were: idiopathic dry eye: 10 cases, Sjögren's syndrome: 11 cases, drug induced dry eye: 6 cases, filamentous keratitis: 4 cases. Other: 4 cases. Enrollment criteria were: functional symptomatology not answering to topical therapy (physiological serum drops) associated with one or more of the following items: positive Rose Bengal staining and/or Schirmer lower than 5 mm in 5 min and/or filamentary keratitis. Subjective improvement is significantly better after closing the two puncta on the same side (77%) than the other side (placebo) (17%) (p less than 0.001). This difference is also demonstrated for the improvement of Rose Bengal staining (p = 0.068) and for Schirmer's test (p = 0.002). These results demonstrated the effectiveness of this therapy versus placebo. Results after closing the 2 puncta on the same side are better than after closing one punctum.

[Treatment of xerophthalmia by transplantation of autologous vascularized submandibular gland].

OBJECTIVE: To investigate the feasibility of treatment of xerophthalmia by transplantation of autologous vascularized submandibular gland (SMG). METHODS: The SMGs of 19 patients with severe keratoconjunctivitis were transferred to their temporal region by microsurgery. The arteries and veins of the SMGs were anastomosed to the super-temporal arteries and veins, the SMG ducts were implanted into the conjunctival fornix of the eye. The saliva secreted by the SMG was used as the substitute of tear. RESULTS: The transplantation succeeded in 14 patients and failed in 4. Follow up lastred for 3 months to 2 years. The symptom of corneal xerosis disappeared, the symptoms of photophobia and anemophobia were alleviated, and artificial tear substitutes were not used any more. Epiphora appeared in 4 cases and disappeared after partial resection of the transplanted gland. Atresia of orifice occurred in one case and was cured by reconstruction of the duct. CONCLUSION: Transplantation of autologous vascularized SMG is effective in treating severe keratoconjunctivitis sicca.

[Reconstructive lacrimal gland with free submandibular gland transfer for management of xerophthalmia].

OBJECTIVE: In order to seek more efficient surgical method to treat total xerophthalmia. METHOD: Microvascular submandibular gland transfer was used to reconstruct lacrimal gland for management of the dry eye. 5 cases (6 eyes) with total xerophthalmia were operated with this method. RESULTS: All the patients were followed up for 1 - 30 months. The results were satisfactory, the submandibular salivary gland relieved the dryness and improved visual acuities with negligible side effect. CONCLUSION: Microvascular submandibular gland transfer is potentially the best surgical solution to total xerophthalmia.

Allogenic submandibular gland transplantation following hematopoietic stem cell transplantation.

BACKGROUND: Autologous submandibular gland transfer for treatment of progressive dry eye symptoms requires a functionally intact submandibular gland. In cases of total function loss of both lacrimal and submandibular glands this procedure has to be modified. Here we report on the first two cases of the allogenic transplantation of a submandibular gland to treat patients suffering from complete functional loss of both glands due to graft-versus-host disease (GvHD) following stem cell transplantation. METHODS: We carried out allogenic transplantation of the submandibular gland of the matched former stem cell donor to the temporal fossa of the stem cell recipient suffering from GvHD-induced dry eye. The treatment was carried out in two male patients who showed complete donor chimerism to the stem cell donors, so that no immunosuppressive therapy was applied. RESULTS: Postoperative clinical assessment of the patients revealed primary success of the procedure. The ocular surface showed improvement of lubrication and reduction of inflammatory signs. In the long-term follow-up sialoscintigraphy revealed lower tracer activity than expected and secretion of saliva-tears decreased. CONCLUSION: Even though the so-called total donor chimerism was assessed allogenic transplantation of the submandibular gland following GvHD-induced dry eye showed signs of organ rejection and therefore initial immunosuppressive therapy after allogenic transplantation has to be considered.

[Treatment of dry anophthalmic cavities with labial salivary glands transplantation]. / Tratamento das cavidades anoftálmicas secas com transplante de glândulas salivares labiais.

PURPOSE: To study the clinical effects of labial salivary glands' secretion used as ocular lubricant in anophthalmic cavities with severe xerophthalmia; to evaluate the evolution of the results; and to present the surgical technique. This procedure application in dry anophthalmic cavities is new in the literature. METHODS: Prospective study of patients presenting anophthalmic cavities with severe xerophthalmia and conjunctival fornix retraction treated with labial salivary glands transplantation to the conjunctival fornices. The surgeries were performed in five patients during the period of July 2000 to January 2009. In two cases the fornix retraction was previously treated with mucosa or skin graft. The surgical procedure technique is described in details. The postoperative comparative analysis was based on the clinical picture, the cavity surface aspect, the dryness of the cavity and prosthesis and the frequency of lubricant eye drops use. RESULTS: In all cases both graft integration and improvement of the evaluated parameters were observed. The evolution proved the persistence and stability of the results. CONCLUSION: The salivary secretion produced by the transplanted labial glands proved to be efficient as conjunctival lubricant, well tolerated and permanent, making the use of the prosthesis more comfortable. This improvement helps to prevent the progression of the cavity retraction process. Labial salivary glands graft into the anophtalmic cavity is a simple procedure and accessible to any ophthalmic surgeon.

[Vision jeopardizing xerophthalmia in Denmark]. / Synstruende xeroftalmi i Danmark.

A 54-year-old alcoholic was admitted with keratomalacia in 2001. The right cornea had an ulceration and the left cornea had stromal necrosis and a perforation. Serum retinol and serum betacaroten were extremely low. Treatment consisted of high-dose retinol and left sided cornea transplantation. The right eye healed with little scarring, vision: 0.5. The left eye was stabilized after a second cornea transplantation and covering with conjunctiva, vision: hand movement at a distance of 1 m. This proves the existence of symptomatic vitamin A deficiency among socially exposed subjects in Denmark.