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.

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.

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.

Enlargement of the tensor intermuscularis muscle in Graves' ophthalmopathy. A computed tomographic and magnetic resonance imaging study.

OBJECTIVE: To determine whether the tensor intermuscularis muscle (TIM), which consists of muscle fibers in the superolateral intermuscular orbital septum, is involved in Graves' ophthalmopathy (GO). DESIGN: The computed tomographic (n = 24) and magnetic resonance imaging (n = 10) appearances of the TIM were retrospectively examined in 34 patients with known GO. The severity of GO was assessed by applying a scoring system from 0 to 3 (ie, normal [0], mild [1], moderate [2], and severe [3]) to each of the rectus muscles and superior oblique muscle. The severity of exophthalmos, enlargement of the superior ophthalmic vein, and displacement of the lacrimal gland were also recorded. RESULTS: The TIM appeared as thickening of the septum immediately behind the globe, and it was best seen on coronal magnetic resonance images. There was enlargement of the TIM in 19 of the 34 patients, and it was bilateral in 17. Enlargement was present only in patients with moderate or severe involvement of other muscles (muscle index, > 7/15), and it was significantly correlated with the muscle index (P < .05), exophthalmos (P < .05), enlargement of the superior ophthalmic vein (P < .005), and anterior displacement of the lacrimal gland (P < .01). Severe enlargement of the TIM was seen in only five of the 34 patients, and it showed a close correlation with the muscle index (P < .005), exophthalmos (P < .001), enlargement of the superior ophthalmic vein (P < .001), and anterior displacement of the lacrimal gland (P < .001). CONCLUSIONS: Enlargement of the TIM in GO can be identified on computed tomographic and magnetic resonance imaging scans. It is invariably associated with moderate or severe involvement of other extraocular muscles, and it correlates closely with other well-recognized imaging features of severe GO.

The rhomboid flap in medial canthal reconstruction.

AIM: To describe a series of patients who have undergone a medial canthal reconstruction with a rhomboid flap. METHODS: A non-comparative interventional case series of 27 patients with medial canthal defects after Mohs excision of medial canthal basal cell carcinomas who underwent reconstruction using a rhomboid-shaped transpositional flap of adjoining skin and subcutaneous tissue. 25 cases were performed under local anaesthesia. The remaining two cases were combined with major lid reconstruction and performed under general anaesthesia. The outcome measures were closure of the defect, the cosmetic result, complications, and re-operations. RESULTS: Primary closure of the defect was achieved in all cases. The cosmetic result was highly satisfactory in all cases. There were no major complications or re-operations. Two cases had minor webbing of the medial upper lid. CONCLUSIONS: The rhomboid flap is an effective, quick, and simple technique for medial canthal reconstruction. It provides excellent cosmesis and is associated with minimal complications. It can be modified according to the nature of the periorbital skin and the location, size, and depth of the defect.

Everting suture correction of lower lid involutional entropion.

AIMS: To assess the long term efficacy of everting sutures in the correction of lower lid involutional entropion and to quantify the effect upon lower lid retractor function. METHODS: A prospective single armed clinical trial of 62 eyelids in 57 patients undergoing everting suture correction of involutional entropion. Patients were assessed preoperatively and at 6, 12, 24, and 48 months postoperatively. The main outcome variables were lower lid position and the change in lower lid retractor function. RESULTS: When compared with the non-entropic side, the entropic lid had a greater degree of horizontal laxity and poorer lower lid retractor function. These differences however, were not significant. At the conclusion of the study and after a mean follow up period of 31 months, the entropion had recurred in 15% of the patients. There were no treatment failures in the group of five patients with recurrent entropion. The improvement in lower lid retractor function after the insertion of lower lid everting sutures did not reach statistical significance. There was no significant difference between the treatment failure group and the group with a successful outcome with regard to: the degree of horizontal lid laxity or lower lid retractor function present preoperatively; patient age or sex; an earlier history of surgery for entropion. There was neither a demonstrable learning effect nor a significant intersurgeon difference in outcome. The overall 4 year mortality rate was 30%. CONCLUSIONS: The use of everting sutures in the correction of primary or recurrent lower lid involutional entropion is a simple, successful, long lasting, and cost effective procedure.

Phakomatous choristoma of the orbit: a case report.

We report the case of a 3-month-old infant with a rare phakomatous choristoma of the orbit. This lesion is believed to be a congenital neoplasm of lenticular anlage. The clinical, radiological, and histopathological findings are presented.

Penetrating keratoplasty for pseudophakic corneal oedema.

AIMS: The study was designed to investigate the results of penetrating keratoplasty (PK) for pseudophakic corneal oedema (PCO). METHODS: Retrospective analysis of 80 consecutive patients (82 eyes) who underwent PK for PCO between the years 1980-1992 with a minimum follow up of 12 months. RESULTS: PKs for PCO have accounted for as many as 20% of all grafts performed in the hospital in recent years. The interval between cataract extraction and PK ranged from 6 to 161 months (mean 51 months). The intraocular lens was removed in 45 (55%), left in situ in 30 (37%), and exchanged in seven (8%) of cases respectively. Of the intraocular lenses involved 62% were iris supported, 31% angle supported, and 7% were posterior chamber lenses. Actuarial analysis shows graft survival to be 91% at 1 year and 86% at 2 years after surgery. The likelihood of graft survival was significantly enhanced by removal of the intraocular lens (p < 0.01). A corrected Snellen visual acuity worse than 6/60 was present in 36% of patients with a clear corneal graft. Ocular comfort was achieved in all patients with a clear corneal graft. CONCLUSION: PK for PCO resulted in a disappointing visual result in a large proportion of patients. PK was, however, successful in relieving pain and corneal ulceration when present.

Use of Proplast II as a subperiosteal implant for the correction of anophthalmic enophthalmos.

BACKGROUND: A variety of autogenous and alloplastic materials have been used as subperiosteal implants to correct anophthalmic enophthalmos. Proplast II is a synthetic porous composite of Teflon polymer and alumina. Proplast II offers a number of advantages over other commonly used alloplastic materials such as silicone and polymethyl methacrylate. It is light, porous, resilient, malleable, and easy to shape. It can be readily sterilised after shaping. It has been found to integrate with the surrounding tissues, thereby minimising the risk of subsequent implant migration and extrusion. METHODS: Proplast II was used as a subperiosteal implant in a total of 15 anophthalmic patients during the period June 1990 to March 1994. The indication for this procedure in all patients was poor orbital volume replacement despite the prior insertion of an adequately sized spherical socket implant. RESULTS: The results were excellent with a good correction of preoperative upper eyelid sulcus deformity. There were no operative complications nor any serious postoperative complications. The implants were well tolerated. CONCLUSION: Proplast II can be highly recommended for use as a subperiosteal implant.

A clinical study of the hydroxyapatite orbital implant.

The hydroxyapatite orbital implant has been used in the anophthalmic patient to give good motility of the artificial eye and a cosmetic result which matches that of the natural eye. It is thought to reduce the unacceptable complication rate that has been associated with other implants, as its buried, vascularized state deters extrusion and migration of the implant. Eighty consecutive patients were followed, 33 of whom had been referred for primary enucleation or evisceration, and 47 for secondary implant surgery. Thirteen of the secondary patients already had implants in situ. There were 44 males and 36 females in the study. The age range was 2.5 to 72 years with a mean of 36 years. The follow-up time was 2 to 30 months with a mean of 15 months. Twenty patients had been pegged at the time of review. A standardised operative and post-operative protocol was followed. The patients were assessed for the results of the motility of the artificial eye for both smooth pursuit and saccades, and for the cosmetic result. The amount of upper lid sulcus deformity was assessed to give an indication of volume replacement by the implant. The nature of any complications was noted as well as any further surgical procedures undertaken. The results show the hydroxyapatite orbital implant to give good cosmetic results with good motility of the artificial eye and to be associated with a low rate of complications. Drilling of the implant is simple to perform and also not associated with any significant complications. The hydroxyapatite orbital implant can be used successfully not only as a primary but also as a secondary or exchange implant with very few contraindications.

Microphthalmos with cyst in monozygous twins.

We present two cases of microphthalmos with cyst affecting monozygotic twins. The etiology and pathogenesis of this developmental anomaly are discussed. The diagnostic evaluation, differential diagnoses, and management options of this unique disorder are also considered.

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.