Long-Term Outcomes of Eye-Sparing Surgery for Adenoid Cystic Carcinoma of Lacrimal Gland.

PURPOSE: This study's primary purpose is to assess the long-term outcomes of patients who have undergone eye-sparing surgery and adjuvant radiotherapy for adenoid cystic carcinoma of the lacrimal gland. METHODS: In this retrospective analysis, clinical records were reviewed of all patients diagnosed with adenoid cystic carcinoma of the lacrimal gland, at a single institution, between March 1998 and November 2012. Ten patients were identified as having undergone eye-sparing surgery and adjuvant radiotherapy for adenoid cystic carcinoma of the lacrimal gland. Preoperative radiographic findings, treatment modalities, histological results, and patient outcomes were analyzed. RESULTS: There were 6 male and 4 female patients. The patients' tumors were staged according to the 8th American Joint Committee on Cancer staging system, and were as follows: 1 patient was classified as T1aN0M0; 6 patients were classified as T2aN0M0; 1 patient was classified as T2cN0M0; 2 patients were classified as T3aN0M0. All patients had a histologically confirmed diagnosis of lacrimal gland adenoid cystic carcinoma, which was confined to the orbit, and was without extension into adjacent bone marrow or other organs. All patients underwent eye-sparing tumor excision followed by postoperative radiotherapy, with a median dose of 6000 cGy (range: 5000-6600 cGy). At the last follow up, 8 patients were alive without evidence of disease. One patient was deceased at 58 months post-surgery, due to esophageal carcinoma; this was unrelated to the lacrimal gland tumor. The final patient experienced tumor recurrence in the medial orbit 53 months post-surgery, and exenteration was performed. This patient was alive, without disease recurrence, at 90 months following exenteration. The median follow-up time was 89.5 months (range: 37-217 months). Systemic metastasis did not occur in any patient. CONCLUSIONS: Eye-sparing surgery and adjuvant radiotherapy have demonstrated favorable local control and long-term survival outcomes in patients with orbit-confined lacrimal gland adenoid cystic carcinoma. Consequently, eye-sparing surgery with adjuvant radiotherapy can be considered as a viable treatment option for orbit-confined lacrimal gland adenoid cystic carcinoma.

Unusual Location for a Periorbital Dermoid Cyst.

Dermoid cysts in the orbit classically present in children as a mass in the superotemporal or superonasal orbit along the zygomatico-frontal or fronto-ethmoidal suture lines. The presence of a dermoid cyst in the superficial eyelid, not associated with the tarsus, has only been reported once previously. The authors present a case of a 60-year-old man with a painless right lower eyelid mass inferonasally that was completely excised and found to be a dermoid cyst. The presence of a dermoid cyst involving the superficial lower eyelid is very rare. Furthermore, dermoid cysts in adults typically present in the setting of trauma, which was absent in this case. Therefore, it is important to consider dermoid cysts in the differential diagnosis of eyelid lesions in adults.

Eyelid Necrosis and Secondary Cicatrical Ectropion Secondary to Levamisole-Associated Vasculitis.

A 56-year-old female presented with eyelid necrosis secondary to systemic levamisole-induced vasculitis. Skin biopsy revealed necrotic epidermis with small-vessel thrombosis, fibrinoid reaction, and neutrophilic infiltration of vessel walls in the dermis with +pANCA. She was treated with plasmapheresis and steroids. Six months later, she developed severe, symptomatic cicatrical ectropion with marked anterior lamellar shortage and middle lamellar contracture. Scar release in the middle lamellar plane with lateral tarsal strip procedures was performed, with full-thickness skin grafts from the upper eyelids. She remained fully epithelialized postoperatively with improvement in symptoms, although she incomplete graft take due to her eyelid necrosis and compromised dermal blood supply.

The J-Curve for Navigating the Nasolacrimal Outflow Tract.

PURPOSE: To describe the technique of J-shaped manipulation of the metallic stent for instrument-free intubation of the nasolacrimal outflow tract after dacryocystorhinostomy. METHODS: The internal diameter of the J-shaped curve placed in the intubation stents was measured and the technique of intubation of the nasolacrimal outflow tract and out the external naris is described. In addition, the anatomic relationships of the nasolacrimal system are illustrated and videographed in relation to the described procedure. RESULTS: This technique has been used successfully on 75 consecutive endoscopic dacryocystorhinostomy cases. After completion of bony osteotomy and opening of the nasolacrimal sac, the metallic portion of the stent is bent into a J-shaped curved with an average internal diameter of 4 cm. The punctum is then canulated with the metallic stent and directed 2 mm vertically then 8 mm to 10 mm medially along the path of the canalicular system. On entering the osteotomy, the stent is directed inferior and slightly lateral in the direction of the external naris. Gentle advancement with small angle redirection of the stent as needed allows exit through the external naris without using additional instrumentation in the nose. CONCLUSION: The authors present a technique of J-shaped manipulation of the intubation stent allowing navigation of the nasolacrimal outflow tract and exit through the external naris without additional instrumentation. This technique offers advantages over instrument-assisted retrieval of the intubation tube. First, the J-Curve technique is faster than multi-instrument retrieval. Second, less damage is incurred to the mucosa of the lateral nasal wall and/or septum secondary to blind placement of a Crawford hook, hemostat, or grooved director.

Partial Orbicularis Resection for the Augmentation of Traditional Internal Brow Pexy: The "Tuck and Rise".

PURPOSE: Brow ptosis commonly occurs with aging. Minimally invasive techniques are varied and include neurotoxin paralysis of eyebrow depressors and internal brow pexy. The authors present a modification of the traditional brow-pexy surgery which incorporates weakening of the lateral eyebrow depressor, the orbicularis oculi muscle, to synergistically influence brow position. METHODS: This retrospective review includes 44 brows in 22 patients treated over a 14-month period. All patients underwent surgery by a single surgeon (RM) at UT Southwestern Medical Center. The surgical technique includes partial orbicularis resection to augment the traditional internal brow pexy. Preoperative and postoperative photographs were analyzed using ImageJ software. RESULTS: This procedure has been successfully performed on 44 brows in 22 patients with no complications and a high satisfaction rate. ImageJ analysis demonstrates an average elevation of 2.42 mm of the lateral tail of the brow with improved brow contour, volume, and symmetry. CONCLUSIONS: The "Tuck and Rise" has proven a simple, minimally invasive, and effective technique to volumize and elevate the lateral tail of the eyebrow.

The 90-degree rule in posterior ptosis surgery.

To propose a guideline for ptosis clamp positioning to minimize the risk of globe injury during posterior ptosis surgery. Measurements of 20 consecutive patients, 40 eyelids, undergoing bilateral posterior ptosis repair surgery were taken; as a surrogate for needle tip position, measurement of the distance from the clamp base to the ocular surface was taken using a caliper with the clamp held at 90-degrees to the ocular surface and again at 45-degrees to the ocular surface. These measurements were compared to geometric predictions of the distance from the clamp base to the ocular surface. The average distance from the clamp base to the ocular surface when the clamp is held 90-degrees to the ocular surface was 7 mm, this distance decreases to 5 mm when the clamp is held 45° to the ocular surface. This coincides well with geometric predictions. Posterior ptosis surgery overall has an excellent safety profile; however, complications are possible, perhaps the most severe of which is inadvertent globe and/or corneal injury. The more acute the angle the ptosis clamp is held, the closer the clamp base, and subsequently the needle tip, is to the ocular surface as would be predicted geometrically. This coincides with closer proximity of the needle to the ocular surface during surgery. The theoretical risk of globe injury should decrease as the distance of the needle from the globe increases, and this distance is greatest when the clamp is held at a 90-degree angle to the ocular surface. This distinction becomes particularly important to consider in large eye morphology patients where the distance from the needle to the globe can approach 2 mm when the clamp is held at 45-degrees.

A public health achievement under adversity: the eradication of poliomyelitis from Peru, 1991.

The fight to achieve global eradication of poliomyelitis continues. Although native transmission of poliovirus was halted in the Western Hemisphere by the early 1990s, and only a few cases have been imported in the past few years, much of Latin America's story remains to be told. Peru conducted a successful flexible, or flattened, vertical campaign in 1991. The initial disease-oriented programs began to collaborate with community-oriented primary health care systems, thus strengthening public-private partnerships and enabling the common goal of poliomyelitis eradication to prevail despite rampant terrorism, economic instability, and political turmoil. Committed leaders in Peru's Ministry of Health, the Pan American Health Organization, and Rotary International, as well as dedicated health workers who acted with missionary zeal, facilitated acquisition of adequate technologies, coordinated work at the local level, and increased community engagement, despite sometimes being unable to institutionalize public health improvements.

Metastatic neuroendocrine carcinoma presenting with left lateral rectus enlargement and orbital cellulitis.

Neuroendocrine tumors (NETs) of the orbit are a rare but increasingly recognized clinical phenomenon. The vast majority of orbital NETs are metastatic, and most metastasize from the gastrointestinal system to the extraocular muscles. While orbital metastasis typically occurs in the setting of a known primary neoplasm, some cases represent the initial manifestation of disease and can precede detection of the primary tumor by many months. We report a 58-year-old woman who presented with diplopia, unilateral orbital pain, erythema, and chemosis as the primary presentation of a metastatic small intestine NET. This case serves as a reminder that identification of orbital NETs should prompt investigation for primary gastrointestinal or pulmonary NETs. Goals of surgery include obtaining a tissue sample, debulking the lesion, and preserving visual function.

Surgical outcome of pediatric dacryocystorhinostomy in Nepal.

PURPOSE: To report the indications and surgical outcome of dacryocystorhinostomy (DCR) in children treated at a single tertiary eye hospital in Nepal. METHODS: The medical records of consecutive pediatric patients who underwent external DCR with silicon tube intubation after failed nasolacrimal irrigation and probing from January 2010 to June 2011 were retrospectively reviewed. Surgical success was defined as resolution of epiphora, normal tear film height, negative fluorescein dye disappearance test and anatomic patency determined by irrigation of the lacrimal system. RESULTS: The etiology of the nasolacrimal duct obstruction was acquired nasolacrimal duct obstruction (NLDO) in 63%, congenital NLDO in 23%, trauma in 1% and congenital bony abnormality in 1 patient. Of the 38 patients who completed follow-up, 37 (97%) had a successful result. CONCLUSIONS: External DCR effectively treated a variety of pediatric NLDO etiologies, with a low rate of complications.

Novel formulation of glycerin 1% artificial tears extends tear film break-up time compared with Systane lubricant eye drops.

PURPOSE: To evaluate the effectiveness of glycerin 1% formulated with the novel and proprietary ophthalmic excipient poly(l-lysine)-graft-poly(ethylene glycol) (PLL-g-PEG) (Eyeon Particle Sciences LLC) in extending tear film break-up time (TFBUT) compared with a market-leading artificial tear formulation of propylene glycol (0.3%) and polyethylene glycol (0.4%) (Systane(®) Lubricant Eye Drops; Alcon, Fort Worth, TX). METHODS: This prospective single-center, single visit, randomized, double-masked exploratory trial compared the new formulation and Systane using TFBUT. Noninvasive break-up time (NIBUT) was measured in subjects with asymptomatic to mild (n=5), mild to moderate (n=5), and moderate to severe (n=6) dry eye disease using the TearscopePlus™ at pre-instillation and again at 15, 30, 60, and 120 min after instillation. Fluorescein break-up time (FBUT) was measured at 120 min after instillation. RESULTS: At 15 min (N=16), the new formulation extended mean NIBUT by 14.67 s (P=0.05) compared with 7.40 s (P=0.34) by Systane. The new formulation had a mean FBUT of 4.92 s longer than Systane at 120 min (P=0.12). With outliers removed (N=13), the difference between the mean NIBUT change from baseline for the new formulation and Systane at 120 min was statistically significant (P=0.03). CONCLUSIONS: This study demonstrates that PLL-g-PEG as a polymer excipient in artificial tears is effective in improving the performance of demulcents to significantly prolong NIBUT at 15 min, and that protective activity from this artificial tear product for 2 or more hours after eye drop instillation is possible.

A erradicação da poliomielite na América Latina: comparando Brasil e Peru / The eradication of polio in Latin America: comparing Brazil and Peru

Trata das iniciativas de controle da poliomielite, a erradicação da poliomielite (1985-1994). (AU)