Nordic treatment practices survey and consensus for treatment of eyelid sebaceous carcinoma.

BACKGROUND: The purpose was to describe the Nordic treatment practices and to reach a Nordic consensus for the treatment of sebaceous eyelid carcinoma. METHODS: The treatment practices data was collected by a questionnaire with 37 questions to the Nordic oculoplastic surgeons and analyzed. A PubMed MEDLINE database search was done to gather data on the published treatment practices and recommendations. A working group that consisted of in minimum one senior consultant from each leading Nordic University Eye Hospital was assigned. A structured interactive method was used to establish the consensus. RESULTS: Twenty-four doctors responded to the questionnaire. 23/24 (96%) of the respondents took a biopsy before surgery. Regional lymph node scanning was routinely done by 14/23 (61%) and a systemic screening of a metastatic disease by 13/23 (57%). 6/22 (27%) never took conjunctival mapping biopsies and 12/23 (52%) never screened for Muir- Torre. Respondents used Mohs surgery, frozen section or multi-stage excision with delayed closure, and 5-6 mm was the mostly preferred margin. Sentinel lymph node biopsy was a possible option for 9/22 (41%) and cryotherapy and Mitomycin C for 6/22 (27%) respondents. 50% of respondents considered radiation as a treatment option. 15/16 (94%) respondents always followed-up their patients, most for 5 years. Two thirds scanned regional lymph nodes during the follow-up. Consensus was reached for 18 statements representing three domains: preoperative work-up, treatment and follow-up. CONCLUSION: Treatment practices differ in between the five Nordic countries which have similar public health care systems. In the article the authors present a Nordic consensus for the treatment of eyelid sebaceous carcinoma.

Fine-Needle Aspiration Biopsy as a Diagnostic Modality for Orbital Adnexal Lymphoma.

INTRODUCTION: The aim of this study was to evaluate fine-needle aspiration biopsy (FNAB) as a diagnostic tool for lymphoproliferative orbital lesions in light of recent improvements in cytomorphological and immunologic analyses. METHOD: Retrospective case series including all orbital FNABs with a lymphoproliferative outcome at Karolinska University Hospital, Stockholm, Sweden during the period 2005-2015. RESULTS: Of the 38 patients included, 31 (82%) were conclusively diagnosed as having lymphoma according to the first FNAB. Disease in 20 patients (65%) could be subclassified. The diagnosis in 7 patients (18%) was either inconclusive, suggestive of lymphoma, or reactive lymphatic infiltrate. These 7 patients were re-investigated, and the initial suspected diagnosis of malignant lymphoma was confirmed in four. Two of the remaining 3 patients were initially diagnosed as having non-lymphoproliferative disease; however, this was later changed to a lymphoproliferative diagnosis following reinvestigation, while the results of both reFNAB and incisional biopsy were inconclusive in the third. CONCLUSION: In the majority of the 38 patients, a definitive diagnosis of lymphoma could be made based on FNAB alone, using cytomorphological and immunological workup, and subclassification was possible in 20 patients (65%). Primary low-grade malignant orbital lymphomas are traditionally treated with low-dose radiotherapy regardless of subtype, and incisional biopsy was not needed to initiate treatment. Our findings suggest that FNAB is a valid first option for the diagnosis of suspected orbital lymphomas due to the minimal risk of complications compared to incisional biopsy, and the fact that it can be performed as an outpatient procedure with no anesthesia.

Anophthalmia and microphthalmia in children: associated ocular, somatic and genetic morbidities and quality of life.

PURPOSE: To report ocular outcome, somatic co-morbidities, genetics, and quality of life in children born with anophthalmia (A) or microphthalmia (M). METHODS: Thirty-five children (19 boys) with A/M underwent ophthalmological examinations and a review of medical records. Parents of 12/22 cases completed the Pediatric Quality of Life Inventory (PedsQL). RESULTS: Age at examination ranged from 7 months to 18 years (median 2.3 years). Ten cases were totally blind or had light perception. Isolated A/M occurred in 16/35 cases, while somatic, psychomotor, neuroradiological and/or genetic pathology occurred in 19/35 cases both in the bilateral (7/9) and in the unilateral group (12/26). Among 26 unilateral cases, 4/16 with one normal eye had associated problems compared to 9/10 if the contralateral eye was pathological (p < .01). There was an increased risk for heart defects in children with psychomotor delay (p = .04). Pathogenic genetic abnormalities were identified in 10/24 cases. Neuroimaging demonstrated pathology in 14/20 cases with corpus callosum dysgenesis (6/20) being the most common. The median total PedsQL score of parent reports for ages 2-12 was 52.4 (range 22.6-100). CONCLUSIONS: Somatic, psychomotor and/or neuroradiological pathologies were more common in bila-teral than unilateral cases, but the difference was not significant. There was decreased risk in unilateral cases with one normal eye. Genetic defects occurred in both unilateral and bilateral cases. Health-related quality of life was reduced.

Long-term outcome of lacrimal stent intubation for complete acquired lacrimal drainage obstructions.

PURPOSE: To investigate long-term outcome and report reoperation rate of non-infected, complete acquired lacrimal drainage obstruction (ALDO) treated with canaliculodacryocystoplasty (CDCP) depending on site of stenosis. METHOD: Consecutive adult patients with non-infected, complete ALDO treated with CDCP were followed for 76 months. Location of stenosis at preoperative visit and intraoperative probing was recorded, and during follow-up, recurrence of stenosis prompting additional surgery and complications were noted. Survival analysis was applied to compare reoperation rate depending on site of stenosis. A follow-up questionnaire was sent to patients not requiring reoperation asking to grade current epiphora problems. RESULTS: Among 85 included cases (71 patients), 57 were classified as canalicular stenosis and 28 as nasolacrimal duct obstruction (NLDO) preoperatively. At the end of follow-up, 39% (33/85) of cases had required additional surgery due to persistent/recurrent symptoms. No statistical difference was found between these groups. During CDCP, 25 of the 57 preoperatively classified canalicular stenosis were found to have an additional obstruction below the sac. The group with only canalicular stenosis had a statistically significant higher survival compared with cases with NLDO or multiple obstructions (p = 0.03). Of patients responding to the follow-up questionnaire, 11/37 cases experienced epiphora often or constant. CONCLUSION: Treating complete NLDO with CDCP results in a high reoperation rate and seems an insufficient alternative. Canaliculodacryocystoplasty (CDCP) may be discussed if preoperative examination indicates canalicular stenosis and dacryocystorhinostomy is not desirable. However, the patient needs to be aware of the higher risk for additional surgery, especially if a second stenosis is found during probing.

A comparison between patients with epiphora and cataract of the activity limitations they experience in daily life due to their visual disability.

PURPOSE: The objective of this study was to compare patients with epiphora and cataract in terms of the activity limitations they experience in daily life due to their visual disability and to validate the use of the Catquest-9SF questionnaire for epiphora patients. METHODS: Seventy-two consecutively encountered adult patients with confirmed lacrimal obstruction and listed for dacryocystorhinostomy (DCR) or lacrimal intubation at the St. Erik Eye Hospital, Stockholm, Sweden, completed the Catquest-9SF questionnaire, which measures activity limitations in daily life due to visual disability. The psychometric qualities of the Catquest-9SF results obtained from this group of patients were evaluated by Rasch analysis. Rasch analysis was further employed to convert the ordinal raw data to a Rasch score for comparison with the preoperative scores of patients registered in the Swedish National Cataract Register (NCR) during March 2013. RESULTS: The Catquest-9SF exhibited good psychometric qualities when investigating epiphora patients, with the exception of a misfit for Item 4, the item regarding facial recognition. On the Rasch scale (-5.43 = no activity limitations to +5.01 = severe activity limitations), the mean score for epiphora patients was -0.82 while for patients listed for 1st eye and 2nd eye cataract surgery it was -0.17 and -0.76, respectively. An equivalence test confirmed that the reported visual disability of epiphora patients was not significantly different from visual disability reported by patients waiting for 2nd eye cataract surgery. CONCLUSION: The Catquest-9SF is a valid measure of visual disability in patients with epiphora. Epiphora patients experience visual disability to the same degree as patients awaiting 2nd eye cataract surgery.

Fine-Needle Aspiration Biopsy in Orbital Lesions: A Retrospective Study of 225 Cases.

PURPOSE: To describe and analyze results from the fine-needle aspiration biopsy (FNAB) technique, used as a diagnostic tool, in patients with orbital lesions. DESIGN: Retrospective case series. METHODS: setting: Institutional (Karolinska Hospital, Stockholm). STUDY POPULATION: 207 patients with 210 orbital lesions. INTERVENTION: 225 FNABs of the orbit. MAIN OUTCOME MEASURES: Successful diagnosis from FNAB. RESULTS: Of the 210 orbital lesions evaluated with FNAB, a successful cytologic diagnosis was achieved in 176 (84%). In more than half of the orbital lesions (54%), the FNAB diagnosis in addition to imaging appearance, clinical appearance, and clinical history provided sufficient information for treatment, and the patient did not require an incisional or excisional biopsy. Ninety-seven patients underwent additional excisional or incisional biopsy; FNAB diagnoses and the histopathologic diagnoses corresponded in 87% of the cases with an intraclass correlation coefficient of 0.84 (95% confidence interval [CI] 0.76-0.90). The difference was statistically significant between the ability to make a successful cytologic FNAB diagnosis in palpable lesions vs nonpalpable lesions (successful diagnosis in 90% [CI = 85%-95%] vs 75% [CI = 66%-84%]; P < .01). Neither the orbital quadrant location, nor the radiologic appearance (diffuse vs encapsulated), nor size of the lesion affected the success of FNAB diagnoses (all P > .7). There was a complication in 6 cases (3%). All complications were temporary and none led to permanent damage. CONCLUSIONS: FNAB proved effective and exceedingly safe. With the current healthcare climate of minimally invasive surgery and cost control, FNAB should be considered as a valid alternative to open surgery in the evaluation and management of orbital lesions.

Complications associated with secondary orbital implantations.

PURPOSE: To evaluate complications associated with secondary procedures for orbital implants. METHODS: A retrospective review was made of the records of patients who had undergone a secondary orbital implantation at a tertiary referral centre at St Erik Eye Hospital in Stockholm, Sweden, from 1998 up to and including the first half of 2009. Implant-related complications were noted as was demographic and surgical background data. The regional ethics committee in Stockholm gave its approval for this study. RESULTS: Seventy-one patients had received a secondary orbital implant at the eye hospital. Implant-related complications were noted in 24 patients (34%), and 20 patients required reoperation/s (28%). There were five types of complications: migration of the implant (13%), insufficient orbital volume (10%), exposure/extrusion/infection (8%), mechanical obstruction (1%) and socket oedema (1%). Analyses of sizes and types of implants, wrapping and surgical techniques did not reveal any specific factor that resulted in an increased number of complications. However, there was an indication that aluminium oxide might be associated with fewer complications (2/11 = 18%). CONCLUSION: Our results show that secondary orbital implantations have high complication rates and that further surgery is needed in more than a quarter of cases. It is important to consider these facts when planning to insert secondary implants and to provide patients with accurate information about the procedure and possible outcomes.