Autoclaved autologous bone graft for orbital reconstruction for recurrent temporal bone orbital osteosarcoma.

Post-tumor excision and reconstruction of the craniofacial region is a complex and technically demanding process due to its proximity to numerous vital structures and irregularly shaped bony tissue. As such, novel methods are needed when reconstruction of irregularly shaped structures is necessary. Autoclaving of autologous bone grafts is an established practice in orthopedic and neurosurgical practice, but has only been described twice previously for orbital reconstruction. We performed grafting of an autoclaved autologous bone segment as part of surgery on a 30-year-old man to treat his recurrent temporal osteosarcoma with orbital involvement, which is rare. In addition, we went on to highlight key differences between bone autoclaving and pasteurization, an alternative heat treatment technique, for orbital reconstruction post-tumor excision. Although he suffered a second recurrence 8 months later, there was no evidence of recurrence in the autoclaved bone. To treat his second recurrence, he subsequently underwent a modified eyelid-conjunctiva sparing orbital exenteration, also an uncommonly performed procedure. Also, we subsequently examined the novel technique of a lid-sparing and conjunctiva-sparing orbital exenteration and its benefits. He continues to remain under follow-up.

Telemedicine screening for cytomegalovirus retinitis using digital fundus photography.

BACKGROUND: Screening for cytomegalovirus retinitis (CMVR) is important in patients with acquired immune deficiency syndrome and low CD4(+) counts. However, many human immunodeficiency virus (HIV) patients lack access to specialist ophthalmological care. Telemedicine screening is a cost-effective method for screening these patients. We aimed to report the use of composite nine-field digital fundus photography (DFP) images for CMVR screening. We report its sensitivity and specificity in detecting CMVR and the level of agreement with gold-standard binocular indirect ophthalmoscopy. MATERIALS AND METHODS: An audit was performed on our national CMVR screening program that screened all HIV patients referred to the Ophthalmology Department at Tan Tock Seng Hospital, Singapore. All patients underwent retinal screening with DFP. Images were categorized as CMVR-positive, CMVR-negative, suspicious, or unreadable by blinded retinal specialists. Patients subsequently underwent dilated gold-standard indirect ophthalmoscopy by a different retinal specialist. Diagnoses were categorized as CMVR-positive, CMVR-negative, or unreadable. Sensitivity and specificity of retinal findings on DFP and kappa values for level of agreement between the two screening methods were calculated. RESULTS: Three hundred seventy screenings on 188 patients were performed. Twenty-three eyes diagnosed with CMVR on indirect ophthalmoscopy were also identified on DFP (100% sensitivity). A 99.9% specificity was achieved. The fundus photograph of one eye without CMVR was read as CMVR-positive because of an artifact, accounting for a false-positive. Kappa values ranged from 0.739 to 0.987. CONCLUSIONS: DFP is a sensitive and specific method of screening HIV patients for CMVR and has a high level of agreement with indirect ophthalmoscopy.

Unusual Merkel cell carcinoma of the eyelid.

Merkel cell carcinoma of the eyelid is a rare tumor with less than 100 reported cases worldwide. We describe an unusual presentation of Merkel cell carcinoma of the eyelid in a 60 year old Asian male. He presented with multiple left lower lid conjunctival nodules, intense conjunctival erythema, as well as ipsilateral cervical lymphadenopathy. An incisional biopsy diagnosed him with Merkel cell carcinoma with a PET scan showing distant metastatic disease. He was then treated with chemotherapy. The combination of a presentation of conjunctival nodules and erythema, location in the lower eyelid and the conjunctiva, the presence of metastatic disease on diagnosis as well as an unusual immunohistochemical profile make this an unusual case.

Intraobserver repeatability and interobserver reproducibility of corneal measurements in normal eyes using an optical coherence tomography-Placido disk device.

PURPOSE: To study intraobserver and interobserver reproducibility of corneal topography and aberrometry measurements using a device combining optical coherence tomography (OCT) and a Placido disk (Visante Omni). SETTING: Singapore National Eye Centre, Singapore. DESIGN: Prospective nonrandomized study. METHOD: Measurements of simulated keratometry (K), anterior mean curvature, spherical anterior and posterior elevations, 4.5 mm diameter zone aberrometry (spherical aberration, asphericity, astigmatism), pachymetry, and white-to-white (WTW) diameter were taken in normal right eyes. Mean biases and limits of agreement (LoA) were obtained using Bland-Altman analysis. RESULTS: Regarding intraobserver repeatability, the mean biases for simulated K, anterior mean curvature, spherical anterior/posterior elevation, 4.5 mm zone aberrometry, pachymetry, and WTW diameter were not statistically significant (P > .05). The LoA for the anterior mean curvature measurements were flat K, -3.96 diopters (D) and 4.86 D; steep K, -4.50 D and 4.27 D; mean K, -2.48 D and 2.09 D. The LoA for WTW were -9.90 mm and 8.74 mm. Regarding interobserver reproducibility, the mean biases for simulated K, anterior mean curvature, spherical anterior/posterior elevation, 4.5 mm zone aberrometry, pachymetry, and WTW diameter were not statistically significant (P > .05). The LoA for anterior mean curvature were flat K, -4.05 D and 4.13 D; steep K, -5.08 D and 3.85 D; mean K, -2.65 D and 2.29 D. The LoA for WTW diameter were -8.79 mm and 8.24 mm. CONCLUSIONS: The OCT-Placido device had high intraobserver and interobserver clinical reproducibility for measurements of simulated K, 4.5 mm zone aberrometry, pachymetry, and standard anterior/posterior corneal elevation. However, intraobserver and interobserver reproducibility of anterior mean curvature measurements and WTW diameter was lower. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

A Cytomegalovirus Retinitis Screening Program: Evaluation of Enrollment Criteria for HIV Patients in Singapore.

PURPOSE: Identification of optimal enrollment criteria for a CMVR screening program suitable for a resource-limited environment. METHODS: A prospective audit was performed on newly diagnosed HIV patients referred for CMVR screening with any of the following four criteria: (1) visual symptoms, (2) low CD4(+) counts (<50 cells/µL), (3) AIDS-defining illnesses (ADI), and/or (4) opportunistic infections (OI). Odds ratios for each of the demographic factors and enrollment criteria were calculated. Sensitivities, specificities, and workload reduction for the various combinations were determined. RESULTS: A total of 348 screening visits for 176 HIV patients were performed. While individually only ADI was statistically significant for increased CMVR risk, the combination of CD4(+) counts <50 cells/µL with either ADI or visual symptoms or all 3 criteria were also statistically significant. Two enrollment criteria, ADI and ADI with CD4(+) <50 cells/µL, demonstrated good sensitivities, specificities, and workload reduction. CONCLUSION: We propose ADI and possibly CD4(+) counts <50 cells/µL as enrollment criteria for CMVR screening.