How accurate is the clinical and radiological evaluation of orbital lesions in comparison to surgical orbital biopsy?

AIMS: The purpose of the present study is to determine the overall and disease-related accuracy of clinical and radiological diagnosis when compared to the histology result of the surgical orbital biopsy. METHODS: A retrospective case notes analysis of patients who underwent surgical orbital biopsy during a 12-year period involving more than 100 orbital lesions. The accuracy of clinical and radiological diagnosis was compared with histological diagnosis. RESULTS: A total of 112 orbital biopsies were carried out in 104 eyes of 101 patients between 2003 and 2015. Correct diagnosis was reached in <50% of cases by both ophthalmologists and radiologists alike. Vascular lesions exhibit characteristic clinical and imaging features that allow for accurate diagnosis and can often be managed conservatively. The greatest challenge, both clinically and on imaging was in differentiating between inflammatory and haematological orbital lesions which represented half of our cases. There was no operative mortality and there were no post-operative complications recorded. CONCLUSION: Surgical orbital biopsy is a safe and accurate diagnostic tool for orbital lesions of unknown aetiology and, in our opinion, remains the gold standard.

The invention of gonioscopy by Alexios Trantas and his contribution to ophthalmology.

Gonioscopy is a technique used to examine structures in the anterior chamber angle (the fluid filled space inside the eye between the iris and the innermost layer of the cornea, the endothelium). It is an essential tool in ophthalmic practice, particularly in the diagnosis of glaucoma. In 1899, the Greek ophthalmologist Alexios Trantas was the first to visualise the angle in vivo and coined the term 'gonioscopy'. He made a number of other important contributions to ophthalmology.

External dacryocystorhinostomy in consultants and fellows - a comparison of the causes of failure.

PURPOSE: Failure of primary dacryocystorhinostomy (DCR) often requires revision surgery to inspect the cause of failure and re-establish anatomic patency. This study aims to specifcally compare the anatomical causes of failure noted during revision DCR of primary external DCR (EX-DCR) and compare the difference between consultants and fellows. METHODS: A retrospective review of 37 patients who underwent revision of a primary external approach DCR over a 7-year-period in a University Hospital. All primary surgery was performed by either a consultant surgeon or senior oculoplastic fellow. Details of the initial pathology prior to primary DCR and grade of operating surgeon were collected along with perioperative surgical findings. The cause of failure of the initial surgery was classified according to perioperative findings. Failure was classified as either inappropriately sized/located ostium or fibrous/membranous soft tissue obstruction of the newly created ostium. RESULTS: The cause of failure of the initial surgery was soft tissue obstruction in 43.3% and an inappropriately sized/located ostium in 56.7%. In those patients whose primary surgery was performed by a consultant, 73.3% were found to have a soft tissue obstruction and 26.7% were found to have an inappropriately sized/ located ostium. In contrast, if initial surgery was performed by a fellow, 22.7% were found to have a soft tissue obstruction and 77.3% an inappropriately sized/ located ostium (p =0.002). CONCLUSIONS: Where the primary surgeon has been a trainee there is a trend toward inadequately sized or located ostium being the most likely causative factor in failure of primary EX-DCR.  Hippokratia 2015; 19 (3): 216-218.

Periocular implantation cysts: a late complication of ophthalmic surgery.

PURPOSE: To describe the clinical characteristics for a group of patients presenting with acquired implantation cysts following periocular surgery. METHODS: Retrospective, non-comparative series of patients who underwent surgery at Moorfields Eye Hospital for orbital implantation cysts, with review of clinical case notes and imaging. RESULTS: Twenty-three patients (13 male; 57%) were treated between 1997 and 2011 with cystic lesions that presented at an average interval of 22.7 years after previous periocular surgery. The age at presentation ranged from 14 to 76 years (mean 45.3; median 46 years). Five patients had a history of prior enucleation or evisceration (with ball implantation in 4/5 cases) and six had undergone orbital fracture repair with either a silicone or titanium plate. Eight patients had prior strabismus surgery, three had retinal detachment repair with either a scleral buckle or vitrectomy, and one patient had repair of a conjunctival laceration in childhood. All but one patient underwent either wide marsupialisation or complete excision of the implantation cysts, with no record of recurrence. Visual acuity improved after surgery in a half of the patients, whereas remaining unchanged in the remainder. CONCLUSION: Orbital implantation cysts constitute a relatively rare complication of periocular surgery and can present decades after the causative procedure.

SU-E-T-418: Evaluation of Peripheral Dose for SRS Treatment Radiations with the VIS CyberKnife: A Phantom Study.

PURPOSE: Stereotactic radiosurgery (SRS) procedures are known to deliver a very high dose per fraction and thus, the increased risk of secondary types of cancer due to increased peripheral dose could be a limiting factor for the long term survival of the patients. The aim of this study is to evaluate the peripheral dose (PD) received at preselected anatomical sites in an anthropomorphic phantom for treatments of intracranial lesions with the CyberRnife. METHODS: Eight patients treated using the CyberRnife were selected for this study. Organs at risk and target were delineated on volumetric CT data and treatment planning (Multiplan v.4.5.0) was optimized accordingly, in order to achieve the required prescribed target dose and critical structures sparing for each patient. The final treatment plan was delivered with a CyberRnife VIS (Accuray, Inc., Sunnyvale, CA) operating with a dose rate of 1000 MU/min at a flattening filter free mode and upgraded shielding. We performed our measurements using a male anthropomorphic RANDO phantom (Alderson Research Laboratories, Inc., Stamford, CT). Groups of three TLD 100 were placed anteriorly inside RANDO at a depth of 5 cm at locations corresponding to the thyroid, breast or lung, uterus and inferior abdomen for each treatment plan. RESULTS: The average percentage dose normalized to the prescribed dose for the thyroid gland was 0.92+0.23 % with a max of 1.95%. The maximum reduction of the PD (expressed as percentage of the prescribed dose) was 80% between the thyroid gland and the lower pelvic area. Similarly the PD normalized to the number of MU showed an average of 0.84×10-3 (cGy/MU), with a max of 0.0025 (cGy/MU) for the thyroid gland region. CONCLUSIONS: It is evident that the PD is proportional to the number of MU as well as to the prescribed dose. These correlations can be utilized to estimate the PD during intracranial treatments.

Subsidence of the stem after impaction bone grafting for revision hip replacement using irradiated bone.

Loss of bone stock is a major problem in revision surgery of the hip. Impaction bone grafting of the femur is frequently used when dealing with deficient bone stock. In this retrospective study a consecutive series of 68 patients (69 hips) who had revision of a hip replacement with femoral impaction grafting were reviewed. Irradiated bone allograft was used in all hips. Radiological measurement of subsidence of the stem, incorporation of the graft and remodelling was carried out and showed incorporation of the graft in 26 of 69 hips (38%). However, there was no evidence of trabecular remodelling. Moderate subsidence of 5 mm to 10 mm occurred in ten hips (14.5%), and massive subsidence of > 10 mm in five (7.2%). The results of this study are less favourable than those of others describing studies of revision of the femoral stem using impaction bone grafting. The absence of the characteristic changes of graft remodelling noted in other series raises the question as to whether irradiated bone graft may be a significant factor influencing the post-operative outcome.

Nursing homes for the old ('Gerocomeia') in Byzantium (324-1453 AD).

BACKGROUND: Research into the welfare institutions for the elderly, which were established in the Byzantine Empire. OBJECTIVE: The purpose of the study is the research into the texts of the Byzantine chroniclers and the contemporary historical sources so as to determine the social policy of the Byzantine State regarding the homes for the aged. METHODS: The histories and chronicles of the Byzantine writers, written in the original Greek language, were studied and analysed, so as to locate the extracts in the texts concerning the interest shown by the Byzantine State to establish institutions for old and ailing people. RESULTS: The care for the elderly in Byzantium was undertaken in special infirmaries, called 'gerocomeia', which operated all over the empire mostly in or near the monasteries. All these nursing homes were highly esteemed and the governor of the institution seems to have been a person of high importance. The most important nursing home was located in Constantinople and was established by Emperor John II Comnenus in the 12th century in the famous monastery and hospital of the Pantocrator. CONCLUSION: The study and analysis of the historical texts of the Byzantine period (324-1453 AD) prove that human-oriented behaviour, which derived from the intervention of religion, contributed to the foundation of many welfare institutions for the elderly by the Byzantine emperors, the church and some individuals who showed great interest in them.

Hot-melt coating technology. I. Influence of Compritol 888 Ato and granule size on theophylline release.

The aim of this work was to study the influence of theophylline granule size and the percentage of Compritol 888 Ato on in vitro drug release from granules and tablets. The granules were coated in a fluidized bed apparatus. The dissolution profiles of these granules differed from those of granules coated with classical agents, and there were also differences between the various sieve fractions studied. Drug release was characterized by a rapid-release phase, followed by a slow-release phase. Results indicate that theophylline release can be controlled by controlling granule size. Inspection of the appearance of the tablets at the end of the dissolution test revealed that all tablets containing Compritol 888 Ato remained intact. This indicated that the Compritol 888 Ato used in the tablet formulation created an inert matrix through which the drug diffused. It was found that the Higuchi relationship of linear square root of time was the best model to describe the release kinetics of the drug from tablets. This also confirmed that a matrix diffusion-controlled mechanism was operative. Given the difference between the dissolution profiles of the granules and the tablets, it was concluded that this matrix is formed during compression.

Controlled-release behavior of diphenhydramine hydrochloride loaded neutral microgranules and coated using ethylcellulose water dispersion.

The development of a loading method of a water-soluble drug using aqueous binding solution to produce microgranules that were then coated with an aqueous ethylcellulose dispersion to sustain drug release is described. The results, in terms of drug used, showed that besides the fluidized bed parameters, the amount of drug dissolved in the binder solution plays an important role in obtaining a satisfying result during the spraying process. Thus, it seems necessary to determine the critical concentration above which the material started to adhere to the interior of the fluidization column, and the possibility of drug layering onto carrier material is aggravated. ANOVA of the time parameter for release of 63.2% of total drug (td) value showed significant influence of ethylcellulose (Aquacoat ECD-30) and dibutyl sebacate concentration on diphenhydramine hydrochloride (DPH) release. The dissolution rate decreased with an increase in polymer concentration. The diffusional exponent n of the Peppas equation indicated that the DPH release kinetic was non-Fickian but approached Fickian diffusion, particularly at higher coating levels.