Collagen vascular diseases: cutaneous manifestations in ophthalmology.

PURPOSE: To describe the effects of collagen vascular diseases on the eyelids and periorbital tissues. METHODS: Retrospective review of dermatologic pathology slides at Massachusetts General Hospital and eye pathology slides at Massachusetts Eye and Ear Infirmary, Boston, Massachusetts. RESULTS: A spectrum of dermatologic manifestations of collagen vascular diseases was observed, affecting the eyelids and periorbital region. CONCLUSIONS: Collagen vascular diseases may present complicated diagnostic and clinical challenges for the practicing ophthalmologist. Familiarity with the cutaneous periocular manifestations of these diseases may facilitate early recognition, diagnosis, and ophthalmologic intervention where necessary.

A brief history of the randomized controlled trial. From oranges and lemons to the gold standard.

This article discusses the history and development of randomized clinical trial methodology, the reasons for its status and authority as a method of therapeutic evaluation, and the continuing role of clinical judgement in designing, interpreting, and applying the findings of trials.

Necrotizing fasciitis after cosmetic blepharoplasty.

PURPOSE: To report a case of necrotizing fasciitis after cosmetic blepharoplasty. METHOD: Case report. A 74-year-old woman with history of type II diabetes mellitus underwent bilateral upper eyelid blepharoplasty. Postoperatively she developed fever, grayish discoloration of the skin, violaceous bullae, and a right facial nerve palsy. Necrotizing fasciitis was diagnosed and treated with intravenous antibiotics, debridement of necrotic tissue, and hyperbaric oxygen therapy. RESULTS: The infection resolved, but the patient required reconstruction for correction of cicatricial ectropion. CONCLUSION: Necrotizing fasciitis is a potentially fatal infection that typically occurs in the setting of trauma. Early recognition of its pathognomonic signs and aggressive management are paramount.

Desmoplastic spindle-cell melanoma of the eyelid with orbital invasion.

PURPOSE: To describe the clinicopathologic features of a patient with a spindle-cell melanoma of the eyelid that exhibited orbital invasion. METHODS: Case report. RESULTS: A slowly enlarging mass developed in the eyelid of a 50-year-old woman. Excision of the mass showed desmoplastic spindle-cell melanoma. The tumor recurred in the orbit, and an exenteration was performed. A second recurrence 7 months later was treated with radiation therapy. CONCLUSIONS: There is a continuum of spindle-cell to desmoplastic melanoma. The prognosis of patients with orbital invasion of melanoma is poor, and adjuvant treatment including radiation and chemotherapy has little benefit.

Neoadjuvant intracarotid chemotherapy for treatment of advanced adenocystic carcinoma of the lacrimal gland.

OBJECTIVE: To investigate a new chemotherapeutic regimen as an adjunct to the conventional surgical management of patients with advanced adenocystic carcinoma of the lacrimal gland. PATIENTS AND METHODS: Two patients with extensive adenocystic carcinoma of the lacrimal gland were treated with intracarotid cisplatin and intravenous doxorubicin hydrochloride prior to orbital exenteration. Postoperatively, the patients received 55 to 60 Gy of orbital irradiation, augmented by additional intravenous cisplatin and doxorubicin. Serial clinical and computed tomographic scan examinations were performed to monitor for evidence of recurrent disease. RESULTS: Tumor shrinkage was documented radiographically following this preoperative chemotherapy regimen, downstaging the disease in one case from intracranial involvement to a more surgically amenable intraorbital process. Tumor necrosis was confirmed in the exenteration specimen. Limited morbidity was experienced and both patients have achieved long-term survival to date of 9 1/2 years (114 months) and 7 1/2 years (94 months). CONCLUSIONS: To our knowledge, this is the first report of the efficacy of neoadjuvant intracarotid chemotherapy in the treatment of an advanced adenocystic carcinoma of the lacrimal gland. The combination of cisplatin and doxorubicin and the methods of drug delivery may be factors contributory to the favorable response. The results of this new treatment regimen are encouraging and justify further investigation.

Cataract extraction after silicone oil repair of retinal detachments due to necrotizing retinitis.

Cataract is common after silicone oil repair of retinal detachment due to necrotizing retinitis in acquired immunodeficiency syndrome. Surgical management has not been reported. Twenty-two eyes of 19 patients were reviewed. The majority underwent phacoemulsification with a posterior chamber convexoplano implant without iridotomy Complications included capsular fibrosis and hyphema. Unpredictable refractions in the first 16 eyes prompted refinement of lens calculations and resulted in a reduction in refractive errors. A 3-step modification of intraocular lens calculations is recommended: (1) use of specific sound velocities to calculate axial length; (2) use of convexoplano lenses; and (3) addition of a constant to the lens power to compensate for the refractive index of silicone oil. Good surgical technique and accurate lens calculations should improve management of cataracts that arise after retinal detachment repair with silicone oil in patients with acquired immunodeficiency syndrome.

"Simple methods" and "determined contraceptors": the statistical evaluation of fertility control, 1957-1968.

PIP: This paper discusses the use of two US research projects in legitimizing fertility control through the authority of scientific research. The projects included field trials of "simple methods of contraception" and IUDs that were sponsored by the US Population Council and the Planned Parenthood Federation of America (PPFA). Research was used to test whether simple methods and the IUD were safe and effective. In 1957, contraception research did not have the support of the academic medical leadership, and most state health departments did not distribute birth control literature. The clinical field trials were conducted through 95 PPFA-affiliated centers under the direction of PPFA's Medical Director Mary Calderone during 1957-64. The institutional affiliation served to give legitimacy to PPFA and to validate use-effectiveness of creams, jellies, or spermicides with a diaphragm. The Population Council reactivated the National Committee on Maternal Health (NCMH) with Christopher Tietze as head and as a member of the Advisory Committee of the new PPFA Clinical Investigation Program. Clarence Gamble, who believed in the "anything that works approach," severed his relationship with NCMH. Calderone thought that "any method was better than no method, but the most critical factor in effectiveness was availability." What was innovative about these trials was the study of the practice of contraception and the use of a statistical measure. The trials found that the diaphragm was the most effective and acceptable method. The EMKO brand was the most popular foam. Tietze's evaluation of five different IUDs during 1963-68 did not meet the rigorous criteria of Louis Lasagna, but did determine the regularity and continuity of contraceptive practice. Life table methods were used to demonstrate a statistically valid result. By 1964 contraception became recognized in the medical field. By 1968 a statistically valid result among "determined contraceptors" established the medical legitimacy of the IUD, and global distribution ensued.^ieng