Early onset sebaceous carcinoma.

BACKGROUND: Ocular sebaceous carcinoma can masquerade as benign lesions resulting in delay of diagnosis. Early recognition is even more difficult in young patients where the disease rarely occurs. Here, we provide a clinicopathological correlation of ocular sebaceous carcinoma in a young individual lacking history of hereditary cancer or immunosuppression. FINDINGS: A detailed histopathological study including p53 DNA sequencing was performed on an aggressive sebaceous carcinoma presenting in a healthy 32 year-old Caucasian woman. She had no history of retinoblastoma, evidence for a hereditary cancer syndrome, or radiation therapy. However, she potentially was at risk for excessive UV light exposure. A detailed review of the literature is also provided.A moderately well differentiated sebaceous carcinoma was established histopathologically arising from the meibomian gland of the upper eyelid. In most areas, the cytoplasm contained small but distinct Oil-red-O positive vacuoles. Direct sequencing of p53 identified a G:C→A:T mutation at a dipyrimidine site. The mutation results in substitution of arginine for the highly conserved glycine at residue 199 located at the p53 dimer-dimer interface. Energy minimization structural modeling predicts that G199R will neutralize negative charges contributed by nearby inter- and intramonomeric glutamate residues. DISCUSSION: This study points to the importance of recognizing that sebaceous carcinoma can occur in young patients with no evidence for hereditary cancer risk or radiation therapy. The G199R substitution is anticipated to alter the stability of the p53 tetrameric complex. The role of UV light in the etiology of sebaceous carcinoma deserves further study. Our findings, taken together with those of others, suggest that different environmental factors could lead to the development of sebaceous carcinoma in different patients.

One medial triangular Tutoplast sling as a frontalis suspension for adult myogenic blepharoptosis.

PURPOSE: The treatment of choice for medium to severe blepharoptosis with minimal or no levator function is frontalis suspension with a sling, using a rectangular or rhomboid sling placement technique. We describe the short-term, follow-up results of frontalis suspension surgery for adult myogenic blepharoptosis using Tutoplast, a commercially available fascia lata allograft. METHODS: We conducted a consecutive, interventional case study. All adult (>25 years of age) patients operated for non-traumatic myogenic ptosis during a 1-year period were included. All underwent frontalis suspension using one medial triangular Tutoplast sling. Success was judged according to lid position and complications. RESULTS: Successful surgical results were judged by lid level, lid symmetry and lid contour. During a mean follow-up of 9 months, the success rate was 91% in all three criteria and 100% in at least two out of three. No major complications were observed. The most prevalent minor complication was the need for lubrication treatment in 26% of the operated patients. CONCLUSION: The use of Tutoplast for frontalis suspension in cases of adult myogenic ptosis is safe and has a high success rate in the early postoperative period. Further large-scale studies are necessary to ascertain the longterm results and the applicability of this material to other indications.

Cosmetic oculofacial applications of botulinum toxin: a report by the American Academy of Ophthalmology.

OBJECTIVE: To determine the safety and effectiveness of botulinum toxin for cosmetic oculofacial use. METHODS: Literature searches for relevant citations were conducted in October 2003 for the years 1965 to 2003. The panel reviewed and rated the articles for study design, methods, and results. RESULTS: Randomized double-masked controlled studies showed statistically significant improvement in glabellar, frontal, and lateral canthal rhytids (wrinkles) when injected with botulinum toxin. Standardized documentation using photographs and masked grading by the patient and physician support the efficacy of botulinum toxin for treatment of dynamic rhytids in the glabellar region, forehead, and lateral canthal area. Complications and adverse effects associated with treatment are infrequent and short lived. CONCLUSIONS: Botulinum toxin is safe in the short term and effective in the temporary treatment of glabellar, frontal, and lateral canthal rhytids. Potential functional complications should be discussed with patients who are seeking cosmetic rejuvenation of the periocular and facial region. Further research is needed to determine the ideal effective dose for particular anatomic areas, ideal concentration, applicable doses across the different serotypes of botulinum toxin, duration of effect, changes in efficacy (if any) over extended periods of treatment, and long-term safety.

The smooth surface tunnel porous polyethylene enucleation implant.

BACKGROUND AND OBJECTIVE: To describe early clinical results with the porous polyethylene smooth surface tunnel (SST) enucleation implant. PATIENTS AND METHODS: Uncontrolled, prospective interventional case series of patients undergoing enucleation with placement of the SST implant. This implant consists of a porous polyethylene sphere with a smooth anterior surface containing pre-drilled tunnels to facilitate direct suturing of the rectus muscles to the implant without use of an implant wrap. Postoperatively, socket healing was assessed, and prosthesis and socket motility were evaluated by the surgeon using an ordinal scale (0 = no motility to 4 = excellent motility). RESULTS: Thirty patients received the SST implant, with a mean follow-up of more than 23 months. Two cases of exposure occurred and were managed surgically without the need for explantation. Mean socket motility was 3.1 on a 0 to 4 ordinal scale, with mean prosthesis motility of 2.8. CONCLUSION: The SST implant provides satisfactory socket motility and is generally well tolerated in the anophthalmic socket without the need for wrapping material.

Anophthalmic ptosis: investigation of the mechanisms and statistical analysis.

PURPOSE: To investigate the mechanisms producing ptosis in anophthalmic patients by comparing potential risk factors among patients with ptosis with a control group. Specific techniques for achieving optimal aesthetic results in the surgical correction of anophthalmic ptosis are recommended. METHODS: Data from 94 anophthalmic patients with ptosis and 44 control patients without ptosis were retrospectively collected and analyzed. Potential risk factors for ptosis were compared between the two groups of patients by using 2-sample binomial exact tests. Univariate and multivariate logistic regression analyses were also used. RESULTS: A direct relation between percent volume replacement by the primary implant and the occurrence of ptosis was noted (P=0.057; age adjusted, P=0.037). Those patients who had secondary implant surgery were more likely to have levator surgery for ptosis (P=0.005; age adjusted, P=0.039). A greater number of years of prosthesis wear was associated with clinical and intraoperative evidence of levator dehiscence (P=0.061). No relation was observed between the occurrence of trauma (as a reason for enucleation) and the occurrence of levator dehiscence. Thirty percent of patients with ptosis who had secondary intraconal or extraconal implants and no other surgical intervention for ptosis had improvement in ptosis. CONCLUSIONS: The mechanisms producing anophthalmic ptosis should be assessed carefully before surgical repair to achieve optimal aesthetic results. Correction of volume deficiency should be offered before levator surgery for patients with anophthalmic ptosis. The patient should be advised that tilt of the prosthesis is a possible outcome of levator repair and may reflect overcorrection or insufficient volume replacement.

Orbital implants in enucleation surgery: a report by the American Academy of Ophthalmology.

OBJECTIVE: To compare prosthetic and implant motility and the incidence of complications associated with porous and nonporous enucleation implants. METHODS: Literature searches conducted in January 2002 for 1985 to 2001 and May 2002 for October 2001 to 2002 retrieved relevant citations. The searches were conducted in MEDLINE and limited to articles published in English with abstracts. Panel members reviewed the articles for relevance to the assessment questions, and those considered relevant were rated according to the strength of the evidence. RESULTS: A randomized clinical trial and a longitudinal cohort study detected no difference in implant or prosthetic movement between nonpegged hydroxyapatite porous and spherical alloplastic nonporous implants. No controlled studies were retrieved that investigated whether pegging porous implants improves prosthetic movement. Several case series indicate that patients with pegged hydroxyapatite implants have some degree of improved prosthetic motility. Longitudinal cohort studies show that sclera-covered hydroxyapatite implants have higher exposure rates than sclera-covered silicone implants, and unwrapped porous polyethylene implants have higher exposure rates than unwrapped acrylic implants. There are numerous case series that document a wide range of implant exposure rates in patients with various enucleation implants. It is difficult to compare complication rates among implant types because patient populations vary, surgical techniques differ, and follow-up periods are often limited. CONCLUSIONS: Based on one randomized clinical trial, spherical alloplastic nonporous and nonpegged porous enucleation implants provide similar implant and prosthetic motility when they are implanted using similar surgical techniques. Coupling the prosthesis to a porous implant with a motility peg or post appears to improve prosthetic motility, but there are few available data in the literature that document the degree of the improvement. There is a widely variable incidence of porous implant exposure, but certain surgical techniques and the type of wrapping material seem to reduce the exposure rate. Additional research is needed to document the long-term incidence of complications related to porous enucleation implants and associated surgical techniques. This includes the use of wrapping materials and what procedural modifications, both surgical and prosthetic, are most effective in reducing these complications.

A simple algorithm for selection of implant size for enucleation and evisceration: a prospective study.

PURPOSE: This prospective study tested a simple formula for selecting an implant size for patients undergoing enucleation, evisceration, and secondary implantation. The formula axial length-2 mm=implant diameter (subtract 1 mm from implant diameter for evisceration and for hyperopia) was tested by the outcome measures, superior sulcus deformity, enophthalmos, and volume of the prosthesis. METHODS: Fifty-four patients undergoing primary or secondary implant surgery after enucleation or evisceration received implants based on the above formula. The volume of the eye, volume of the implant, volume of the prosthesis, and the total percent volume replacement were recorded for each patient. Outcome measures considered clinically acceptable were <2 mm enophthalmos and less than grade 1 superior sulcus deformity, which is defined as barely perceptible deepening of the medial superior sulcus. RESULTS: The average volume replacement was 101%; average prosthetic volume was 2.1 mL; average grade of superior sulcus deformity was 0.6; and average enophthalmos was 1.2 mm. CONCLUSIONS: This formula allows 100% replacement of the volume removed, leaves space for a prosthesis 1.5 to 2.5 mL, and eliminates clinically unacceptable superior sulcus deformity and enophthalmos in 85% of patients. Patients with a history of infection, radiation, buphthalmos, or large orbital fractures (15%) had residual superior sulcus deformity greater than grade 1 and enophthalmos > or =2 mm despite 100% volume replacement. Further study will elucidate the histopathologic processes responsible for residual superior sulcus deformity and enophthalmos in the latter subgroup of patients.