Recurrence Following Globe Sparing Excision for Basal Cell Carcinoma with Anterior Orbital Invasion.

PURPOSE: Globe-sparing excision for periocular basal cell carcinoma (BCC) with orbital invasion has evident benefits, but the ensuing morbidity and characteristics of recurrence are not well elucidated. This study aims to describe the extent of visual morbidity following globe-sparing excision, and the clinicoradiological characteristics of tumor recurrence. METHODS: Multicentre retrospective case series. RESULTS: Eight patients were identified for inclusion in this series. Time to recurrence following globe-sparing excision ranged from 3 to 12 years. Seven patients (87.5%) presented with recurrent disease originating from the medial canthus. Clinical features at presentation included contracture ( n =4, 50.0%), upper lid ptosis ( n =3, 37.5%), a palpable mass ( n =2, 25.0%), and hypoesthesia ( n =2, 25.0%). Radiologically, tumor recurrence was predominantly characterized by isointense signals on T1 and T2-weighted sequences ( n =5, 62.5%) with moderate contrast enhancement. The most common histologic subtype in recurrent tumors was a mixed nodular and infiltrative growth pattern ( n =5, 62.5%). Perineural invasion was a feature in four (50%) cases. Salvage therapy in the form of exenteration was performed in seven cases. Vismodegib and adjuvant radiotherapy were provided for one case with surgically unresectable tumor recurrence. CONCLUSIONS: Globe-sparing excision for invasive periocular BCC can be complicated by late recurrence that develops rapidly despite silent neuroimaging for years. Early clinical signs are subtle. High-risk features predictive of recurrence include medial canthus location, mixed histological subtypes, and perineural invasion. Patients with such characteristics require lifelong clinical and imaging surveillance following globe-sparing excision.

Lymphomatoid papulosis type C of the eyelid in a young girl: a case report and review of literature.

PURPOSE: To report an unusual presentation of a case of Lymphomatoid papulosis(LyP) in a young girl. MATERIAL AND METHODS: A 14-year-old female presented with a history of swelling of the left upper eyelid of two weeks duration. There was a history of trivial trauma prior to the swelling. The patient was diagnosed as having pre-septal cellulitis elsewhere and was put on oral antibiotics. The lesion was non-responsive to oral antibiotics. The patient was then referred to our hospital. Ocular examination revealed an elevated lesion measuring 15 mm × 10 mm on the left upper eyelid, associated with pre-septal swelling and induration. Ocular movements were normal. The anterior and posterior segment examination was normal. Incision biopsy was done from the eyelid lesion. Multiple cutaneous lesions were also biopsied. RESULTS: The histopathology examination confirmed the diagnosis of lymphomatoid papulosis type C. Dermatological and systemic evaluation ruled out the other aggressive forms of CD30(+) lymphoid proliferation. CONCLUSION: We report an unusual presentation of lymphomatoid papulosis(LyP) type C in a young girl. Complete systemic work up and histopathological evaluation is mandatory in cases of suspicious lesions, not responding to conservative treatment.

The role of mucosal flaps in external dacryocystorhinostomy.

PURPOSE: To determine whether a mucosal anastomosis fashioned at the time of external dacryocystorhinostomy (DCR) influences postoperative outcome. METHODS: The clinical records of all patients who underwent external DCR at Sydney Eye Hospital between May 2000 and August 2007 were reviewed. Data were collected in regards to surgical technique, clinical outcomes and postoperative management. Chi-square statistical analysis was done to determine the significance of the different flap techniques on surgical success. RESULTS: A total of 260 medical records were reviewed. The main outcome measure was postoperative resolution of symptoms. The mean final follow-up time was 11 months. There was no statistically significant difference in outcome between patients who had both anterior and posterior flaps sutured, compared to those who had anterior flap sutures only (73% vs 79%, p = 0.51). Patients who had no sutured flaps had an overall success rate of 89% compared to those that had at least the anterior flaps sutured together (76%); this difference was not significant (p = 0.45). CONCLUSION: There was no statistical difference in symptom outcome between patients in whom both mucosal flaps were sutured, those who had only the anterior flap sutured, or those who did not have either flap sutured at the time of surgery.

External dacryocystorhinostomy: assessing factors that influence outcome.

PURPOSE: To present the experience of external dacryocystorhinostomy (DCR) at a tertiary referral center and investigate factors that may affect clinical outcomes. METHODS: The clinical records of all patients who underwent external DCR at Sydney Eye Hospital between May 2000 and August 2007 were reviewed. Data were collected in regards to patient demographics, preoperative assessment, operative details, surgical technique, postoperative management, and clinical outcomes. This information was then analyzed, with emphasis on factors that influence surgical outcomes and success. RESULTS: A total of 338 cases were reviewed. The mean age at time of surgery was 64.82 years and the majority of patients were female (65%). Epiphora was the major preoperative symptom. Assisted local anesthesia and day stay surgery were the most common surgical settings. There was a statistically significant difference in theatre time between consultant and trainee surgeons (P < 0.00001). The mean final follow-up time was 11 months. Overall, 77.3% of patients had full resolution of symptoms and 20.8% had partial resolution. Only five patients (1.9%) had no resolution of symptoms. There was no significant difference in outcomes between consultants and trainees. Patients with anatomical nasolacrimal obstruction had significantly better outcomes compared with functional obstruction (P = 0.04). The postoperative fluorescein dye disappearance test was a good predictor of clinical success (P = 0.005). Silicone intubation for greater than 6 months was associated with better outcomes (P = 0.002). CONCLUSIONS: The results at our tertiary center are comparable to results stated in the literature. In our series, only the amount of nasolacrimal obstruction and duration of postoperative intubation influenced surgical success.

Successful treatment of infantile haemangiomas of the orbit with propranolol.

BACKGROUND: Propranolol is a novel therapeutic agent in the treatment of cutaneous infantile haemangiomas. We assessed the effect of propranolol therapy in infantile haemangiomas of the orbit. METHODS: A case series of four patients with orbital infantile haemangiomas were referred for management in our tertiary referral hospitals. Two of the patients had inadequate responses to prior corticosteroid therapy. One of the patients was commenced on propranolol at 2.5 years of age when the lesion was not in the proliferative phase. This represented the first case report of propranolol treatment for infantile haemangioma outside infancy. The other three children were in their infancy when propranolol was commenced. The patients were treated with oral propranolol. RESULTS: All patients had significant improvement in their physical appearance, ocular examination findings and size of their lesions on radiological evaluation. No side-effects of propranolol treatment were observed. CONCLUSIONS: Propranolol is a promising treatment against infantile haemangiomas in the orbit, not only in infants but also in an older child with a stable lesion.

Flexi vector cloning.

A protocol for ligation-dependent cloning using the Flexi Vector method in a 96-well format is described. The complete protocol includes PCR amplification of the desired gene to append Flexi Vector cloning sequences, restriction digestion of the PCR products, ligation of the digested PCR products into a similarly digested acceptor vector, transformation and growth of host cells, analysis of the transformed clones, and storage of a sequence-verified clone. The protocol also includes transfer of the sequence-verified clones into another Flexi Vector plasmid backbone. Smaller numbers of cloning reactions can be undertaken by appropriate scaling of the indicated reaction volumes.

Management of periocular basal and squamous cell carcinoma: a series of 485 cases.

PURPOSE: To analyze the outcome of management of patients with basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) in a tertiary referral eye center in Sydney, Australia. DESIGN: Retrospective case series. METHODS: Review of medical records of 485 consecutive cases (469 patients) with confirmed eyelid cancer. Intervention procedures: Surgical excision with 3- to 5-mm clinically clear margins and histologic confirmation of the surgical margins. Frozen section histology or Mohs' micrographic surgery (MMS) was used for incompletely excised cases, and those located in the medial canthus or close to the lacrimal drainage system. Standard reconstruction techniques were employed. MAIN OUTCOME MEASURES: Survival period free of tumor, incomplete excision, recurrences, type of closure, and complications. RESULTS: Excision was initially incomplete in 25.4% of all tumors. Morpheaform type of BCC (chi(2)P < .001), and medial canthus location BCCs (chi(2)P < .05) were associated with a higher incomplete resection rate. A 35.9% incomplete excision rate was associated with a significantly higher recurrence rate compared with complete excision (8.4% and 4.6%, respectively, chi(2)P < .05). Twenty-seven patients (5.6%) had a recurrent tumor. After incomplete excision, there was no recurrence with MMS, but 4.7% recurrence rate when frozen section technique was used (P < .05). Local postoperative complications occurred in 41 patients (8.5%). CONCLUSIONS: In the setting of a tertiary referral center, incomplete primary resection of an eyelid skin cancer is the main risk factor for recurrence. Incomplete resection is significantly associated with medial canthus location and morpheaform type of BCC and with moderately differentiated SCC. MMS is the safer technique after incomplete tumor excision.

A technique for medial canthal fixation using resorbable poly-L-lactic acid-polyglycolic acid fixation kit.

Achieving secure bony fixation of medial canthus is a challenge. We used a resorbable poly-L-lactic acid-polyglycolic acid screw (LactoSorb office fixation kit) in 5 cases: 2 with traumatic medial canthal dystopia, 1 with scleroderma and orbital fat atrophy causing malapposition of the medial canthus to globe, and 2 with invasive medial canthal tumors necessitating subtotal medial orbital exenteration. The resorbable screw with preplaced suture was drilled into the medial orbital wall, using a handheld self-drilling tap. The preplaced suture was used to anchor the medial canthus. We achieved satisfactory canthal position in all 5 cases. There were no complications in 4 cases during a mean +/- SD follow-up of 11.3 +/- 6 months; however, the scleroderma case developed wound dehiscence 6 weeks after surgery. The LactoSorb kit is a safe and effective technique to achieve bony medial canthal fixation in carefully selected cases.

Techniques of periocular reconstruction.

Eyelid and periocular reconstruction is often needed in ophthalmic practice, as a result of defects created by excision of lesions or following trauma. A variety of techniques have been described for the repair of these defects. However, it is important to have a knowledge of the basic principles underlying all these techniques and the advantages and disadvantages of each, so as to ensure the selection of the optimal technique in a particular case. Different authors have popularized different techniques based on individual preferences and experiences and a brief overview of the different techniques will be helpful to compare them. The articles referenced in this manuscript were looked up through PubMed by feeding the keywords 'periocular reconstruction' and 'eyelid reconstruction' and then looking for relevant cross-references. In this review, we have discussed the various techniques available and also illustrated them diagrammatically to have a quick overview of the topic.

High efficiency single step production of expression plasmids from cDNA clones using the Flexi Vector cloning system.

The success of structural genomics and proteomics initiatives is dependent on the availability of target genes in vectors suitable for protein production. Here, we compare two high-throughput methods for producing expression vectors from plasmid-derived cDNA fragments. Expression vectors were constructed for compatibility with the Gateway recombination cloning system and the Flexi Vector restriction-based cloning system. Cloning protocols for each system were conducted in parallel for 96 different target genes from PCR through the production of sequence-verified expression clones. The short nucleotide sequences required to prepare the target open reading frames for Flexi Vector cloning allowed a single-step PCR protocol, resulting in fewer mutations relative to the Gateway protocol. Furthermore, through initial cloning of the target open reading frames directly into an expression vector, the Flexi Vector system gave time and cost savings compared to the protocol required for the Gateway system. Within the Flexi Vector system, genes were transferred between four different expression vectors. The efficiency of gene transfer between Flexi Vectors depended on including a region of sequence identity adjacent to one of the restriction sites. With the proper construction in the flanking sequence of the vector, gene transfer efficiencies of 95-98% were demonstrated.

Evaluation of the cosmetic significance of external dacryocystorhinostomy scars.

PURPOSE: To evaluate the significance of the surgical scar of external dacryocystorhinostomy (DCR) as assessed by the patients. DESIGN: Cross-sectional questionnaire-based study. METHODS: Two hundred ninety-seven external DCRs were performed in 263 patients at the private practices of consultants who were attached to the Sydney Eye Hospital. Structured questionnaires were sent to patients, and the responses were evaluated. Patients were asked to assess the visibility of the scar and the significance of the scar to them on a scale of 1 (least) to 5 (greatest). RESULTS: The average age of patients was 67.9 +/- 16 years, (72% female, 28% male). Ninety-six percent of the patients were caucasians of Australian/West European descent. Sixty-one of 296 scars (20.6%) were felt to be visible by patients; 31 scars (10.5%) were rated >1 on a scale of 1 to 5 and 12 scars (4%) were rated >2. The average age of patients was highest for those patients with invisible scars, and the lowest average age was for those with scars that were rated >1. A significantly higher proportion of female patients complained of marked scarring (>1 on a scale of 1 to 5). A significantly higher proportion of patients who complained of discomfort during suture removal also complained of marked scarring. CONCLUSION: In view of the low percentage of patients who complained of marked scarring, scarring should not be the main ground for deciding the approach to DCR surgery, particularly in older patients. These results are valid for the population that was studied and may be different for different racial backgrounds.

Orbital metastasis from transitional cell carcinoma of the bladder.

Transitional cell carcinoma (TCC) is a common bladder tumour, 10-15% of which will exhibit invasive behaviour. About 50% of patients with invasive TCC will eventually develop distant metastases, usually to lymph nodes, lung or bones. The case is reported of bladder TCC metastasizing to the orbit.

'Inappropriate' attendance at an accident and emergency department by adults registered in local general practices: how is it related to their use of primary care?

OBJECTIVES: To identify the relationship between 'inappropriate' attendance at an accident and emergency department (AED) by adults registered with local general practices and their use of primary care. METHODS: A case-control study matched for age, sex, distance from the AED, social class and registered general practice and set in a single AED and two health centres in South Essex. The participants were a total of 452 patients over 15 years old from the two health centres classified as having attended the AED 'inappropriately' in 1997 as identified by a modified Sheffield process method, and 452 controls. The predictive variables were measures of utilisation in the year 1997, including number of contacts in primary care, referral and investigation costs. Measures of morbidity were collected as potential confounders. These included a recorded history of anxiety or depression in the year 1997, or being in receipt of repeat prescriptions in that year. RESULTS: The rate of 'inappropriate' attendance was 16.8% [95% confidence interval (CI): 15.7-18.0]. All measures of utilisation and markers of anxiety and depression were significantly positively associated with 'inappropriate' attendance, but there was no association with markers of chronic morbidity. Only the number of general practitioner (GP) appointments (P < 0.0001) and out-of-hours advice calls (P < 0.0001) were independently correlated with 'inappropriate' attendance in a conditional logistic regression. 'Inappropriate' attendees had approximately twice as many GP appointments and 10 times as many out-of-hours telephone contacts with the GP. CONCLUSIONS: GP-registered, 'inappropriate' attendees at AEDs utilise primary care services more than matched controls; this pattern of service utilisation appears to be unrelated to chronic physical illness. Thus, simply providing new, directly accessible primary health care services may not significantly reduce AED use.