Conjunctival squamous cell neoplasia: the Liverpool Ocular Oncology Centre experience.

PURPOSE: To report the outcome of patients with conjunctival squamous cell neoplasia (CSCN)--including conjunctival squamous cell carcinoma (SCC), conjunctival squamous intraepithelial neoplasia (C-SIN) and carcinoma in situ (CIS)-treated at the Liverpool Ocular Oncology Centre (LOOC). METHODS: Patients treated between January 1993 and September 2011 were identified and categorised as having 'primary' or 'salvage' treatment, according to whether they had undergone a surgical procedure before referral to our centre. Invasive SCC was treated by excision with adjunctive ruthenium plaque radiotherapy. C-SIN or CIS was treated with topical 5-fluorouracil (5-FU), and in a few cases, cryotherapy. RESULTS: Primary treatment was administered to 20 patients (16 males, four females). Mean age was 62 years (range, 33-85). Histological examination revealed C-SIN/CIS in ten patients and invasive SCC in nine. Median follow-up was 69 months (range, 34-168). Three patients required further topical chemotherapy for persistent/recurrent C-SIN. Salvage therapy was administered to 21 patients (15 males, six females). Mean age was 63 years (range, 26-82). Histology showed C-SIN/CIS in 11 patients and invasive SCC in ten. Median follow-up was 54.5 months (range, 36-120). At the close of this audit, there was no recurrence of invasive or metastatic disease in either the primary or salvage groups. CONCLUSIONS: Our established protocol for treatment of CSCN has proven successful in local tumour control, and avoids ocular complications. We advocate adjunctive radiotherapy in patients with invasive SCC and chemotherapy in C-SIN/CIS. For improved patient outcome, prompt referral to a specialist centre is encouraged.

Choroidal biopsies; a review and optimised approach.

The majority of choroidal tumours are diagnosed accurately with clinical examination and the additional data obtained from non-invasive imaging techniques. Choroidal biopsies may be undertaken for diagnostic clarity in cases such as small melanocytic or indeterminate lesions, identifying the primary tumour in the case of choroidal metastases or the subclassification of rarer conditions such as uveal lymphoma. There is however an increasing use of biopsy techniques for prognostication in uveal melanoma. This review explores the main indications and surgical techniques for tumour acquisition, and the optimised approach utilised by the current authors to improve successful yield for histological and genetic analysis.

Imaging characteristics of idiopathic scleroma: a retrospective case series and review of the literature.

BACKGROUND: Idiopathic scleroma (previously coined solitary idiopathic choroiditis or focal scleral nodule) is an innocuous lesion affecting the sclera with intraocular manifestations. It is often the basis of many misdiagnoses such as amelanotic choroidal melanoma, osteoma or metastatic lesions. Patients are often asymptomatic and the course is benign. With increasing use of community based imaging, more of such cases are being identified. This paper is a retrospective case series investigating the multi-modal imaging findings of idiopathic scleroma. METHODS: A retrospective analysis of prospectively collected data were analysed. Over the course of January 2008-January 2022, 44 patients diagnosed with idiopathic scleroma and imaged with wide-field colour fundus photography, fundus autofluorescence, ocular coherence tomography (OCT) and B-scan ultrasonography. Due to a poor image, only 43 images were included for OCT review. We also reviewed our patient's demographics, symptoms and baseline ophthalmic characteristics upon presentation. RESULTS: The mean age was 52 years (range 32-79) and there was no predilection towards gender. All lesions were post equatorial with the most common location being inferotemporal (n = 16, 36%); 32 lesions (73%) were yellow on fundus photography. 82% (n = 36/44) of lesions exhibited hyperautoflourescence and 43 lesions (98%) showed hyperechogenicity on B-scan ultrasonography. 100% of lesions originated from the sclera with no lesions showing active inflammation. 20 (47%) lesions had associated blood vessels overlying them on OCT. DISCUSSION: Idiopathic scleroma is a yellow, hyperautofluorescent, hyperechogeneic scleral lesion that has no signs of active inflammation. These characteristics help define them from other more sinister cause of amelanotic fundal lesions.

Proton beam radiotherapy for choroidal and ciliary body melanoma in the UK-national audit of referral patterns of 1084 cases.

INTRODUCTION: Proton beam therapy has been utilised for the treatment of uveal melanoma in the UK for over 30 years, undertaken under a single centre. In the UK, all ocular tumours are treated at one of four centres. We aimed to understand the variation in referral patterns to the UK proton service, capturing all uveal melanoma patients treated with this modality. METHODS: Retrospective analysis of data regarding all patients treated at the Clatterbridge Proton service between January 2004 and December 2014. RESULTS: A total of 1084 patients with uveal melanoma were treated. The mean age was 57 years (range 9-90 years), basal diameter of 11.5 mm (range 2.0-23.4 mm) and tumour thickness of 3.9 mm (range 0.1-15.4 mm). The majority were TNM stage I (39%) or II (36%). The distance to the optic nerve varied from 0 to 24.5 mm with 148 (14%) of patients having ciliary body involvement. There were variations in the phenotypic characteristic of the tumours treated with protons from different centres, with London referring predominantly small tumours at the posterior pole, Glasgow referring large tumours often at the ciliary body and Liverpool sending a mix of these groups. DISCUSSION: In the UK, common indications for the use of proton treatment in uveal melanoma include small tumours in the posterior pole poorly accessible for plaque treatment (adjacent to the disc), tumours at the posterior pole affecting the fovea and large anterior tumours traditionally too large for brachytherapy. This is the first UK-wide audit enabling the capture of all patients treated at the single proton centre.

[Pseudophakic retinal detachment]. / Pseudophakie-Ablatio.

Modern phacoemulsification has established itself as a safe and very rewarding surgical procedure. Patients and surgeons may not associate late complications with the initial surgery. However, recent studies have demonstrated that such a causal relationship may persist for many years after the cataract procedure and that there is a significant increase in the risk for developing a retinal detachment during the postoperative years. The mean time period between cataract surgery and pseudophakic retinal detachment is between 3 and 4 years. Even uncomplicated cataract surgery alters the physiological processes within the eye and can lead to progressive destruction of the vitreous for many years after the surgery. Therefore, the risk for a retinal detachment is increased for at least 10 years after the initial procedure. In recent epidemiological studies, the most important risk factors for pseudophakic retinal detachment were myopia, younger age and male gender. If all factors are combined, the cumulative risk for developing a retinal detachment after cataract surgery may rise to 20 %. Additional factors that may increase this risk are additional intraoperative complications, for example, rupture of the posterior capsule, vitreous loss or dropped nucleus. Compared to phakic retinal detachments, pseudophakic patients on average present with a shorter history of visual symptoms, are older, more commonly male and display fewer, smaller and more anteriorly located retinal breaks that frequently are only detected during surgery. The anatomic success rates have improved significantly over the past years, in particular through the advances and increasing popularity of primary vitrectomy. However, functional results are still disappointing. Only about half of the patients will achieve reading ability without low vision aids. The increased and long-term risk for pseudophakic retinal detachment should be part of the preoperative consent process of any cataract surgery, in particular, in young myopic males.

Efficacy and safety of levetiracetam for outpatient alcohol detoxification.

INTRODUCTION: Anticonvulsant drugs are increasingly being used for alcohol detoxification in in- and outpatient settings. The aim of this study was to examine the efficacy, medical safety and mid-term outcome of levetiracetam, a drug with no marked liver toxicity, for outpatient alcohol detoxification. METHODS: This was an open-label observational study. After screening eligibility for outpatient alcohol detoxification, patients were seen daily for 5 days and received levetiracetam in a flexible dosage regime between 500 and 4 000 mg/d for a maximum of 7 days. Diazepam was used as a rescue medication. The severity of alcohol withdrawal was evaluated daily using the ALCOHOL WITHDRAWAL SYNDROME SCALE (AWSS). Mid-term treatment outcome was assessed at a 6-month follow-up. RESULTS: A total number of 131 consecutively admitted alcohol-dependent patients received an outpatient detoxification treatment, 122 (93.1%) completed the programme successfully. The mean initial dose of levetiracetam was 1 850 mg/d. Alcohol withdrawal syndrome as indicated by the AWSS score decreased clearly over 5 days. Overall, the medication was well tolerated. There was no treatment discontinuations due to side effects of levetiracetam. No serious medical complications, especially seizures or deliria, were observed during the detoxification. At the 6-month follow-up, 57 patients (43.5%) were still abstinent. Patients with previous detoxifications had a significant higher risk for relapse (HR=1.88; p=0.016; CI 95%: 1.12-3.14) than patients without previous treatments. DISCUSSION: The findings of this study provide some evidence that levetiracetam is an efficacious and safe treatment option for outpatient alcohol detoxification. Further randomised, controlled trials including mid- and long-term follow-ups are needed to confirm these findings.

[Alternative indications for the use of heavy silicone oil tamponades]. / Alternative Indikationen schwerer Silikonöle.

BACKGROUND: The heavy silicone oil tamponades Densiron and Oxane HD are gaining in popularity amongst vitreoretinal surgeons over recent years. In addition to the classical indications of complicated retinal detachment and PVR, the spectrum is continuously expanding and includes diseases that up to now have been treated with conventional tamponades. MATERIAL AND METHODS: Review of recent studies on vitreoretinal surgery with heavy tamponades outside of surgery for PVR and retinal detachment. RESULTS: In macular hole surgery, good to excellent anatomic and functional results have been reported using heavy tamponades with primary closure rates of up to 100 % of the cases. In reoperations of reopened macular holes, the reported success rates were between 60 % and 100 %. In the group of patients with foveoschisis or central retinal detachment in high myopia with or without macular hole, relatively high reattachment rates of up to 83 % of the cases have been reported. Other reported indications for the use of heavy tamponades are retinoschisis, retinal necrosis, endophthalmitis, proliferative diabetic retinopathy, branch retinal vein occlusion, retinopathy of prematurity, hypotony and choroidal detachment. The published complication rates are low and do not exceed those of conventional tamponades. CONCLUSION: The spectrum of indications for heavy tamponades is constantly expanding. In addition to retinal detachment and PVR surgery, macular holes, reopened macular holes and central retinal detachments or foveoschisis associated with high myopia seem to be the most important diseases that are currently treated with heavy tamponades with good to excellent results published so far. However, a comprehensive comparison with conventional tamponades cannot be made at present because of the limited number of patients and studies published on this subject.

[Anaylsis of the surgeon factor in the treatment results of rhegmatogenous retinal detachment in the "scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study"]. / Einfluss des Operateurs auf die Operationsergebnisse bei rhegmatogener Ablatio retinae im Rahmen der "Scleral Buckling versus Primary Vitrectomy in Rhegmatogenous Retinal Detachment Study".

BACKGROUND: The effect of the surgeon on the outcome of surgical treatment for rhegmatogenous retinal detachment (RRD) has previously been analysed in a few studies only. In the prospective multicentre SPR study, scleral buckling (SBS) and primary vitrectomy (PV) were compared in RRD with medium complexity in a randomised fashion. In this study, we examined the surgeon factor on the outcome of RRD surgery within the SPR study. MATERIAL AND METHODS: An analysis of the surgeon as a factor on the functional outcome (logMAR visual acuity), primary anatomic success (retinal reattachment central to the aequator without any additional retina-affecting surgery including laser, cryo and macular pucker surgery) and final anatomic success (retinal reattachment one year postoperatively) was carried out. RESULTS: Overall, 416 phakic patients (209 SBS, 207 PV) and 265 pseudophakic patients (133 SB, 132 PV) were recruited by 45 surgeons in 25 centres. In the phakic group, the mean functional outcome of individual surgeons was between 0.2 and 0.74 (mean, 0.41, SD 0.41). This difference reached statistical significance (p = 0.0398). In the pseudophakic subgroup, the mean functional outcome was between 0.09 and 0.64 (mean, 0.42, SD 0.49) without reaching a statistical significance (p = 0.0715). Primary success per surgeon varied between 41.67 % and 90.00 % (mean, 63.16 %) in the phakic subgroup and 33.33- 80.95 % (mean, 61.75 %) in the pseudophakic subgroup. Final anatomic success was achieved in 92.86 - 100.00 % (mean, 97.96 %) in the phakic subgroup and 80.00 - 100.00 % (mean, 95.44 %) in the pseudophakic subgroup. There was no statistically significant correlation between surgeon and anatomic outcomes. CONCLUSION: In the phakic subgroup, a statistically significant correlation between surgeon and functional success could be demonstrated for RRD with medium complexity. This correlation was not interrelated to the surgical method. Functional outcome in pseudophakic patients and anatomic outcomes in both subgroups of phakic and pseudophakic patients showed no statistically significant correlation between surgeon and anatomic success.

[Different indications of photodynamic therapy in ophthalmology]. / Verschiedene Indikationen der photodynamischen Therapie in der Augenheilkunde.

BACKGROUND: Photodynamic therapy (PDT) in eye disease was approved 10 years ago for age-related macular degeneration (AMD). Thereafter it was approved for choroidal neovascularisation (CNV) in pathological myopia. The treatment regimen is based on two prospective, multicentre trials (TAP and VIP studies). MATERIAL AND METHODS: In the meantime PDT has been successfully used also in several other ocular diseases. PDT is minimally invasive and has an excellent side effect profile. Different diseases and their treatment with PDT are discussed. RESULTS: The treatments of idiopathic CNV, secondary CNV in inflammatory diseases of the retina and choroid, choroidal haemangioma, vasoproliferative tumours, malignant melanoma of the choroid, and central serous chorioretinopathy with PDT are described. In most patients the disease progression can be stopped and in some the PDT treatment results in visual improvement. The prognosis is better in patients with early disease detection and small lesions. CONCLUSION: Several retinal and choroidal diseases can be treated successfully with PDT. Except for AMD and pathological myopia, PDT is an off label treatment.

Primary vitrectomy with Densiron-68 for rhegmatogenous retinal detachment.

BACKGROUND: To report a retrospective non-comparative interventional study on the effectiveness and ocular tolerance of a heavy silicone oil tamponade (HSO, Densiron-68) for primary inferior rhegmatogenous retinal detachment (RRD). METHODS: Forty-one eyes of 41 consecutive patients were recruited between January 2004 and August 2006. Primary vitrectomy with Densiron-68, a heavy silicone oil, was used in all cases. Inclusion criteria were primary RRD with at least one retinal break between 4 and 8 clock hours. The study protocol consisted of a minimum of eight clinic visits: baseline, surgery, 1 week, 1 month and 3 months after the initial surgery; removal of oil and 1 week, 1 month and 3 months postoperatively. The primary endpoint was anatomical re-attachment of the retina. Cases were judged successful when there was reattachment of the retina in the absence of any tamponade agent. The secondary endpoint was to record the visual function and any complications arising from the surgery. Out of 41 patients initially included in the study, 33 completed all follow-up visits. RESULTS: Anatomical success was achieved in 91% of cases (30 out of 33) with one retinal operation, and rose to 94% (31 out of 33) with additional surgery. Mean visual acuity improved from logMAR 1.19 (SD 0.9) to 0.5 (SD 0.51, p = 0.001). No significant ocular hypertension, clinically significant emulsification of the tamponade or inflammation developed during follow-up. CONCLUSION: With Densiron-68, high anatomical and functional success rates can be achieved with primary vitrectomy for RRD and predominantly inferior pathology.

Explanatory models of addictive behaviour among native German, Russian-German, and Turkish youth.

In Germany, the public system of addiction treatment is used less by migrants with addictive disorders than by their non-migrant counterparts. To date, the literature has focused primarily on language, sociocultural factors, and residence status when discussing access barriers to this part of the health care system. However, little attention has been paid to cultural differences in explanatory models of addictive behaviour. This is surprising when we consider the important role played by popular knowledge in a population's perceptions of and responses to illnesses, including their causes, symptoms, and treatment. In the present study, we examined explanatory models of addictive behaviour and of mental disorders in 124 native German und Russian-German youth and compared these models to those observed in an earlier study of 144 German and Turkish youth. We employed the free listing technique German and to compile the terms that participating subjects used to describe addictive behaviour. Subsequently, we examined how a subset of our study population assigned these terms to the respective disorders by means of the pile sort method. Although the explanatory models used by the German and Russian-German youth in our study were surprisingly similar, those employed by Turkish youth did not make any fundamental distinction between illegal and legal drugs (e.g. alcohol and nicotine). German and Russian-German youth regarded eating disorders as "embarrassing" or "disgraceful", but Turkish youth did not. Unlike our German and Russian-German subjects, the Turkish youth did not classify eating disorders as being addictive in nature. Moreover, medical concepts crucial to a proper understanding of dependence disorders (e.g. the term "physical dependence") were characterised by almost half of our Turkish subjects as useless in describing addictions. These findings show that it is impossible to translate medical or everyday concepts of disease and treatment properly into a different language without considering the connotations and implications of each term as it relates to the respective culture. Terms that are central to Western medical models of disease may otherwise be misunderstood, misinterpreted, or simply rejected.

[Intravitreal injection. Monitoring to avoid postoperative complications]. / Intravitreale Injektion. Kontrollen zur Vermeidung von postoperativen Komplikationen.

Intravitreal injection is generally regarded as safe. Many of the potential complications caused by this procedure are extremely rare and can be avoided by careful inspection beforehand and proper performance of the injection. In rare cases, however, the administered drugs may cause various pharmacological side effects. This article summarizes the safety profiles of Macugen and Lucentis from the drug approval studies and describes initial findings on possible or observed side effects after intravitreal administration of Avastin. In addition, important points to observe in order to avoid intra- and postoperative complications are provided.

[Scleral buckling surgery and pneumatic retinopexy. Techniques, indications and results]. / Skleraeindellende Ablatiochirurgie und pneumatische Retinopexie. Techniken, Indikationen und Ergebnisse.

For many decades, conventional buckling surgery has been the gold standard for treating rhegmatogenous retinal detachment. The surgical technique has not changed markedly during this period; the three main buckling techniques currently used are the radial sponge, segmental sponge, and encircling band. With one of these options, an anatomic success rate of over 90% can be achieved in "simple" forms of retinal detachment. In pseudophakic eyes, however, the primary reattachment rate after buckling procedures is lower. Pneumatic retinopexy, because of its lower success rate, has not found general acceptance in Europe and is used only in selected cases. Concerning the results of the SPR study, many vitreoretinal surgeons were surprised that in the subgroup of phakic eyes, scleral buckling surgery achieved a comparable reattachment rate and better functional results even in this group of patients with complex hole configuration. This gives physicians reason to critically question the current trend of primary vitrectomy even in eyes with uncomplicated preoperative pathology and to reassess scleral buckling surgery. The longer learning curve to perform buckling surgery should be accepted. Because successful repair depends on careful preoperative examination, thorough training in binocular ophthalmoscopy skills with scleral depression should remain an essential part of the surgeon's education.

[Primary pars plana vitrectomy. Techniques, indications, and results]. / Primäre Pars-plana-Vitrektomie. Techniken, Indikationen und Ergebnisse.

The choice of primary vitrectomy as the first treatment method for rhegmatogenous retinal detachment has grown in popularity over recent years. The main reason behind this trend is the improved control of more complicated situations of retinal detachment. However, clinical trials comparing primary vitrectomy with scleral buckling had failed to demonstrate an advantage of this method regarding anatomical and functional results. The Scleral Buckling Versus Primary Vitrectomy in Rhegmatogenous Retinal Detachment Study (SPR study) is a prospective, randomised, multicentre study comparing primary vitrectomy with or without additional scleral buckling to scleral buckling alone. Overall, 681 patients with more complicated retinal detachments were recruited in 25 centres. In the phakic subgroup of patients, an advantage regarding the main endpoint (change in visual acuity) was found in the scleral buckling group. In the pseudophakic subgroup, no difference in functional outcome could be seen; however, better anatomical results with a lower rate of retina-affecting reoperations was observed in the vitrectomy group, with particularly good results in the subgroup of patients receiving vitrectomy and additional scleral buckling. Based on the available data, primary vitrectomy combined with a scleral buckle is the method of choice in more complicated types of retinal detachment in pseudophakic patients. In contrast, primary vitrectomy does not seem to offer an advantage over scleral buckling in phakic patients.

[Primary 25- and 23-gauge vitrectomy in the treatment of rhegmatogenous retinal detachment--advancement of surgical technique or erroneous trend?]. / Primäre 25- und 23-Gauge-Vitrektomie in der Behandlung der rhegmatogenen Netzhautablösung--sinnvolle Ergänzung oder Schritt in die falsche Richtung?

BACKGROUND: Pars plana vitrectomy techniques with 25- and 23-gauge transconjunctival systems are rapidly growing in popularity. These systems were mainly used in the treatment of macular diseases. However, an expansion to more complicated vitreoretinal procedures including the treatment of rhegmatogenous retinal detachments can currently be observed. In this review, the results and complications of 25- and 23-gauge vitrectomy techniques are analysed. MATERIAL AND METHODS: A review has been made of the current literature concerning 25- and 23-gauge vitrectomy techniques with particular attention to the treatment of rhegmatogenous retinal detachments. RESULTS: The benefits of 25-gauge and 23-gauge vitrectomy (shorter operating times, decreased inflammation of the anterior segment, increased patient comfort and enhanced visual recovery) are of no clinical significance when treating rhegmatogenous retinal detachments and do not seem to offer an advantage over 20-gauge vitrectomy or scleral buckling techniques. Recently published series with primary anatomic reattachment rates between 71% and 93% and a mean postoperative visual acuity of 20/50 seem to suggest a worsening of the treatment results with these new techniques. In addition, 25-gauge and 23-gauge techniques are technically challenging, associated with significant complications (for example, postoperative hypotony) and increase the risk for exogenous endophthalmitis. CONCLUSION: New 25-gauge and 23-gauge vitrectomy techniques for rhegmatogenous retinal detachment show no advantage over scleral buckling techniques in phakic patients or 20-gauge vitrectomy in pseudophakic patients. Moreover, these techniques seem to worsen the outcome and increase the postoperative complication rate.