The effect of intralesional steroid injections on the volume and blood flow in periocular capillary haemangiomas.

AIM: To examine the effect of steroid therapy on the volume estimates and blood flow characteristics of childhood periorbital capillary haemangiomas. PATIENTS AND METHODS: Children at risk of amblyopia due to periorbital haemangiomas were treated with intralesional steroid injections (between 1 and 4 courses) and serial assessment of the volume and blood-flow characteristics of the lesions measured using colour Doppler ultrasonography. The characteristics of the haemangiomas in these children were compared with a cohort of untreated cases. RESULTS: Eight of nine treated children were female, this proportion being significantly different from the equal sex distribution of an untreated cohort (p < 0.05). All children in the steroid-treated group presented within 1 month of birth, compared to the untreated children, who presented at an average of 2.1 months of age (range 0-14, median 2.9 months) (p = 0.04) and they required significantly longer follow-up in the Orbital service (mean 65 months, range 26-105), compared with an average of 35 months (range 4-92, median 23) in the untreated group (p = 0.002). The maximum estimated volume of the lesions were significantly larger in the treated group (treated group mean 8.9 ml, untreated group mean 4.1 ml; p = 0.016), with a trend towards higher maximum measured blood velocities in the treated group (treated mean 64 cm compared with untreated mean 52 cm; p = 0.1). Steroid injections appear to reduce the volume and blood flow of haemangiomas, this suppression persisting for several months (between 5 and 20) before the lesion later displays the cyclic fluctuations in volume and flow seen with untreated lesions. All treated haemangiomas had some residual vascular anomaly, detectable on ultrasonography, at last follow-up--this being despite absence of clinical signs in most cases. CONCLUSION: Periorbital capillary haemangiomas requiring steroid therapy for risk of amblyopia were significantly commoner in females, were larger lesions and presented at an earlier age. Intralesional steroids appear to cause a reduction of blood flow, with a transient reduction in volume and a suppression of the natural cyclic variation seen without treatment. The changes after a course of steroid therapy appear to last for between 5 and 20 months, this period of suppression of the lesion probably being particularly useful during infancy and early childhood when the child is at greatest risk of amblyopia.

Ranibizumab pretreatment in diabetic vitrectomy: a pilot randomised controlled trial (the RaDiVit study).

PurposeOur aim was to evaluate the impact of intravitreal ranibizumab pretreatment on the outcome of vitrectomy surgery for advanced proliferative diabetic retinopathy. The objective was to determine the feasibility of a subsequent definitive trial and estimate the effect size and variability of the outcome measure.Patients and methodsWe performed a pilot randomised double-masked single-centre clinical trial in 30 participants with tractional retinal detachment associated with proliferative diabetic retinopathy. Seven days prior to vitrectomy surgery, participants were randomly allocated to receive either intravitreal ranibizumab (Lucentis, Novartis Pharmaceuticals UK Ltd, Frimley, UK) or subconjunctival saline (control). The primary outcome was best-corrected visual acuity 12 weeks following surgery.ResultsAt 12 weeks, the mean (SD) visual acuity was 46.7 (25) ETDRS letters in the control group and 52.6 (21) letters in the ranibizumab group. Mean visual acuity improved by 14 (31) letters in the control group and by 24 (27) letters in the ranibizumab group. We found no difference in the progression of tractional retinal detachment prior to surgery, the duration of surgery, or its technical difficulty. Vitreous cavity haemorrhage persisted at 12 weeks in two of the control group but none of the ranibizumab group.ConclusionRanibizumab pretreatment may improve the outcome of vitrectomy surgery for advanced proliferative diabetic retinopathy by reducing the extent of post-operative vitreous cavity haemorrhage. However, the effect size appears to be modest; we calculate that a definitive study to establish a minimally important difference of 5.9 letters at a significance level of P<0.05 would require 348 subjects in each arm.

Ultrasonic examination in severe diabetic eye disease.

B-scan ultrasound of the posterior segment is reported in 154 patients with severe diabetic eye disease. Epiretinal fibrosis, vitreous haemorrhage, vitreous detachment, and retinal detachment were frequently diagnosed. The ultrasonic findings are discussed in relation to the pathological changes in the vitreous in proliferative diabetic retinopathy.

C-scan ultrasonography in orbital diagnosis.

A C-scan imaging facility has recently been added to the ultrasonic system in use at Moorfields Eye Hospital, London. The technique is explained and typical C-scans are presented to demonstrate the normal orbital fat and optic nerve, together with selected pathological conditions in the orbit. The C-scan facility permits imaging of the orbital contents in the coronal plane. This coronal plane imaging, together with high resolution and sensitivity, makes this a useful technique for demonstrating orbital lesions and it is hoped helps in the accurate measurement of the diameters of the optic nerve along its length. The problems associated with C-scanning are discussed.

Comparison of ultrasonic and photographic methods of axial length measurements of the eye.

The axial length of 25 eyes was measured by the photographic method and by ultrasonography. The photographic measurements were consistently larger than the ultrasonic, but analysis gave a correlation coefficient of r = 0-8483. The results suggest that the centre of rotation of the eye lies posterior to the anatomical centre of the globe. Using an empirical method of calculation and allowing for an error of +/-0-3 mm in the ultrasonic measurement, the photographic results were within +/-0-5 mm in 13 eyes and +/-1-0 mm in 7 eyes. The photographic method may be helpful as a guide to the power of intraocular lens implants and for comparing axial lengths in population studies.

Rapid B-scanning of the vitreous.

Ultrasonic examination is an essential investigation in most patients awaiting vitrectomy. Rapid B-scanning of the vitreous is described utilising a new system capable of high resolution and good tonal quality. Several patterns of haemorrhagic invasion of the vitreous cavity are illustrated, together with detachment, collapse, and retraction of the vitreous gel.

Ultrasonic assessment of rhinostomy size following external dacryocystorhinostomy.

AIM: To assess the dimensions and patency of the surgical epithelial fistula after external dacryocystorhinostomy, using B mode ultrasonography to define the postoperative soft tissue anastomosis. METHODS: 12 patients undergoing 16 external dacryocystorhinostomies, with the creation of large osteotomies, were included in a prospective study. The horizontal and vertical dimensions of the bone ostium was recorded during surgery and compared with the ultrasonographic dimensions of the soft tissue anastomosis at 1 day, 2 weeks, and 6 months after surgery. Functional patency was confirmed with dye testing and irrigation. RESULTS: Compared with an osteotomy of between 100 and 380 mm2 (mean 235 mm2), the soft tissue anastomosis on the day after surgery was, in all cases, markedly smaller (72-252 mm2; mean 144 mm2, or 61% of the bone window). The soft tissue anastomosis decreased to between 8 and 208 mm2 (mean 98 mm2; 68% of immediate postoperative value) at 2 weeks and 3-208 mm2 (mean 71 mm2; 49% of immediate postoperative value) at 6 months. 14 of the 16 (88%) dacryocystorhinostomies were functional at the end of the study, the two failures being associated with marked contracture of the soft tissue anastomosis; the outcome of surgery correlated significantly with the area of the anastomosis at 2 weeks (chi 2 = 16.3; p < 0.01) and at 6 months (chi 2 = 16.0, p = 0.01). CONCLUSIONS: B mode ultrasonography provides a simple and effective method for assessing the size of the soft tissue anastomosis after external dacryocystorhinostomy and there is a significant reduction in size after surgery, to which the functional outcome of surgery appears related. As the initial soft tissue anastomosis cannot be larger than (and is, on average, about 60% of) the area of the osteotomy, this emphasises the paramount importance of a large rhinostomy to the success of lacrimal surgery.

Predictive factors for the development of rubeosis following proton beam radiotherapy for uveal melanoma.

AIMS/BACKGROUND: Proton beam radiotherapy can effectively treat primary uveal melanomas of any size. Some patients, however, develop adverse late effects following treatment and the purpose of this study was to determine which factors give rise to a poor local outcome. METHODS: The hospital records from a first cohort of 127 patients treated by protons from 1989 to 1992 were reviewed retrospectively. The presence of rubeosis was selected as a measure of significant ocular damage. Split file analysis was performed with 73 cases forming a test group with the remaining 54 cases acting as a validation group. RESULTS: Large tumour size and the presence of retinal detachment were significant, independent risk factors for developing rubeosis for both the test and validation groups. These factors also predicted subsequent enucleation for uncontrolled ocular pain. Patients with tumours too large to plaque and with an associated retinal detachment had a 90% chance of developing rubeosis within 4 years of proton beam radiotherapy. CONCLUSIONS: Patients with a uveal melanoma too large for plaque therapy and an associated retinal detachment run a very high risk of developing rubeosis after proton beam radiotherapy and one third of individuals developing rubeosis required enucleation for pain even if local tumour control was satisfactory.

"Real-time" immersion B-scan and C-scan techniques in ophthalmic diagnosis.

The advent of new techniques in vitreous surgery has added an impetus to improve ultrasonic examination of the vitreous cavity. Rapid B-scanning is vital in the diagnosis of vitreo-retinal pathology when opacity prevents biomicroscopical examination. Serial B- and C-scan sectioning have also proved essential in the study of tumours. The C-scan is of particular value in the study of traction retinal detachments and tumours.

A histological procedure to determine dental age.

Sclerosis of dentine has become one of the well established indicators of ageing and age determination. In this study a new technique was reported where a photomicrographic image of a cross section of sclerotic dentine was converted to a grey scale of 256 tones and then reduced to black and white and read by computer using specially developed software. A regression analysis was applied to a sample of 62 teeth (age range 17-84 years) and an age determination within an error limit of 11 years was obtained. Using a Neural Network software however the error was reduced to 8 years.

Age determination by teeth examination: a comparison between different morphologic and quantitative analyses.

Age determination by teeth examination is one of the main means of determining personal identification. Current studies have suggested different techniques for determining the age of a subject by means of the analysis of microscopic and macroscopic structural modifications of the tooth with ageing. The histological approach is useful among the various methodologies utilized for this purpose. It is still unclear as to what is the best technique, as almost all the authors suggest the use of the approach they themselves have tested. In the present study, age determination by means of microscopic techniques has been based on the quantitative analysis of three parameters, all well recognized in specialized literature: 1. dentinal tubules density/sclerosis 2. tooth translucency 3. analysis of the cementum thickness. After a description of the three methodologies (with automatic image processing of the dentinal sclerosis utilizing an appropriate computer program developed by the authors) the results obtained on cases using the three different approaches are presented, and the merits and failings of each technique are identified with the intention of identifying the one offering the least degree of error in age determination.

Imaging the vitreous: optical coherence tomography and ultrasound imaging.

Imaging the vitreous in optically transparent and translucent ocular media using OCT and in optically opaque ocular media using ultrasound is discussed.Optical coherence tomography and colour flow mapping are briefly described. Images of tomograms, B-mode sections, and colour flow maps illustrate the use of these techniques in imaging the vitreous.

Natural history of periocular capillary haemangiomas: changes in internal blood velocity and lesion volume.

AIM: Although the clinical characteristics of childhood periocular capillary haemangiomas are well known, serial measurements of blood velocity and lesion size are unknown. This investigation was designed to measure the changes in maximum blood velocity and estimated size of lesion in children with capillary haemangioma not requiring active intervention. STUDY DESIGN: Retrospective case-note review for a cohort of children with capillary haemangioma involving the eyelid and orbit. PATIENTS AND METHODS: Children with periocular capillary haemangioma, under the care of the Orbital unit at Moorfields Eye Hospital between 1996 and 2005, were monitored clinically and with repeated ultrasonographic examination. Volume estimates were calculated as an ovoid based on the three maximum orthogonal measurements for the haemangioma, and blood velocity was assessed by Colour Flow Mapping, Colour Doppler Energy Imaging, and Spectral Doppler techniques using a Sequoia 512 Acuson scanner. RESULTS: Twenty-four children (12 boys) had initial assessment by 18 months of age, and the haemangioma increased in size in 14/24 (58%), the increase being between 4 and 931% of initial volume estimate. The largest measured size for an individual haemangioma appears inversely related to the child's age at measurement, this mirroring a similar trend in measurements for the maximum blood velocity. Blood velocity measurements also tend to decrease with time, the peak velocity being before 1 year of age in the majority (15/24; 62%). In many children, both volume estimates and blood velocities show a cyclic variation-this occurring with increasing intervals between the maxima, before a final decay in both parameters. Although, for the whole group, there was no correlation (correlation coefficient=0.29) between estimated size and measured blood velocity, some individual children showed a significant correlation between the two parameters. The age at maximum blood velocity appeared to precede the age at maximum volume in most children, and in many there was an orbital anomaly detectable on ultrasonographic examination, even with complete clinical resolution of the haemangioma. CONCLUSIONS: Ultrasonographic examination of periocular capillary haemangiomas show that these lesions have a very high blood velocity in feeding vessels-about 2-3 orders of magnitude greater than normal capillary beds-and that the velocity and volume of such lesions undergo a cyclic variation during their natural history. Evidence suggests that both velocity and volume decrease with time, although often not returning to zero on ultrasonography (unlike the clinical resolution of the lesions). In most children, blood velocity peaks before volume estimates and this might suggest that decreasing perfusion leads to later tissue atrophy and involution of the haemangioma.

Ultrasound in orbital diagnosis.

Ultrasound is a safe and useful method of detecting, localizing, and differentially diagnosing orbital lesions. Diagnosis using B-scan and C-scan techniques depends on the qualitative recognition of patterns based on the location and shape of a lesion together with the distribution in number and amplitude of echoes arising from within a lesion. In addition, the sound-attenuating properties of a lesion, determined by changes in the appearance of deeper structures, may aid in identification.

Ultrasonic Doppler studies of the vitreous.

Simultaneous 'real-time' B-mode and doppler ultrasound techniques were used to study movements of the detached vitreous gel which occurred during duction movements of the eye. The velocity of sound scatterers within the vitreous gel were measured and it was possible to differentiate quantitatively gels which were 'stiff' from those which were 'sloppy'. Information obtained using this technique may throw light on the pathogenesis of rhegmatogenous retinal detachment and assist in the quantitative assessment of retinal mobility in eyes with vitreoretinopathies.

Ultrasound in pre-vitrectomy assessment.

Ultrasonic examination helps the surgeon to select patients for vitrectomy and enables him to plan the operative procedure. A film demonstrated the advantages of rapid B-scanning over other ultrasonic techniques of previtrectomy assessment.