The Mini-Steamroll: An Abbreviated Variation of the Steamroller Maneuver Following Pneumatic Retinopexy for Rhegmatogenous Retinal Detachment.

PURPOSE: To describe a novel positioning maneuver for patients with rhegmatogenous retinal detachment (RRD) following pneumatic retinopexy(PnR). METHODS: Single-center prospective case series of primary RRDs referred to St. Michael's Hospital, Toronto, Canada, between 2021 and 2023. All patients underwent PnR. Baseline ultra-widefield fundus imaging and repeat imaging 10 minutes after the gas injection was performed. After PnR, patients were instructed to perform the mini-steamroll maneuver which consists of a face-down position for ten minutes followed by positioning to the retinal break. The reduction of subretinal fluid (SRF) volume after the initial face-down position was evaluated with clinical examination and ultra-widefield imaging. RESULTS: Six patients who presented with primary bullous RRD and a sizable superior break were enrolled. The mini-steamroll maneuver resulted in a rapid and significant reduction of SRF in all patients with bullous RRD and large superior breaks, allowing subretinal fluid to be expressed into the vitreous cavity with 10 minutes of face-down positioning. One patient required a sequential PnR. Primary retinal reattachment was achieved in all cases .This approach was well-tolerated by patients. CONCLUSION: This case series demonstrates that the mini-steamroll maneuver may be a suitable alternative for patient positioning following PnR in certain cases. The mini-steamroll is a simpler positioning regimen with the potential benefits of direct-to-break and full steamroller maneuver.

SMOKING IS A RISK FACTOR FOR PROLIFERATIVE VITREORETINOPATHY AFTER TRAUMATIC RETINAL DETACHMENT.

PURPOSE: To determine the incidence of retinal redetachment due to proliferative vitreoretinopathy after open-globe trauma in smokers and nonsmokers. METHODS: A total of 892 patients comprising 893 open-globe injuries, in whom 255 eyes were diagnosed with a retinal detachment, and 138 underwent surgical repair were analyzed in a retrospective case-control study. Time to redetachment was examined using the Kaplan-Meier method and analysis of risk factors was analyzed using Cox proportional hazards modeling. RESULTS: Within one year after retinal detachment surgery, 47% (95% CI, 39-56%) of all 138 repaired retinas redetached because of proliferative vitreoretinopathy. Being a smoker was associated with a higher rate of detachment (adjusted hazard ratio 1.96, P = 0.01). As shown in previous studies, the presence of proliferative vitreoretinopathy at the time of surgery was also an independent risk factor for failure (adjusted hazard ratio 2.13, P = 0.005). Treatment with vitrectomy-buckle compared favorably to vitrectomy alone (adjusted hazard ratio 0.58, P = 0.04). Only 8% of eyes that redetached achieved a best-corrected visual acuity of 20/200 or better, in comparison to 44% of eyes that did not redetach (P < 0.001). CONCLUSION: Proliferative vitreoretinopathy is a common complication after the repair of retinal detachment associated with open-globe trauma, and being a smoker is a risk factor for redetachment. Further study is needed to understand the pathophysiologic mechanisms underlying this correlation.

PARS PLANA VITRECTOMY COMBINED WITH CATARACT EXTRACTION: A Comparison of Surgical Outcomes Using Single-Piece and Multipiece Foldable Intraocular Lenses.

PURPOSE: To assess whether complication rates are comparable between phacovitrectomy using multipiece lenses versus single-piece foldable intraocular lenses. METHODS: Single-center, multisurgeon retrospective comparative consecutive interventional case series. Two hundred and seventy-one patients undergoing combined phacovitrectomy performed during a single session at a university-based ophthalmology practice from 2004 to 2013 were identified, of whom 184 met study inclusion criteria; 56.4% patients had diabetes mellitus. RESULTS: There was no difference in the total incidences of postoperative complications between combined surgery using single-piece and multipiece intraocular lenses (P = 0.80) or among individual complications between the 2 groups, including synechiae (2.7 vs. 5.3%; P = 0.61), pupillary capture (0.7 and 2.6%; P = 0.36), and lens subluxation (1.4 and 0%; P > 0.99). There was no difference in the incidences of complications in patients with diabetes mellitus compared with nondiabetic patients undergoing phacovitrectomy (P = 0.13). Complication rates did not differ between single-piece and multipiece lenses with the use of postoperative intravitreal tamponade (P = 0.67). CONCLUSION: Single-piece, acrylic intraocular lenses are associated with a low rate of surgical complications after combined phacovitrectomy and represent an acceptable alternative to multipiece foldable intraocular lenses under the circumstances and using the surgical techniques implemented in this study.

Optical Coherence Tomography Features in Fovea-Off Exudative vs Rhegmatogenous Retinal Detachment.

PURPOSE: To describe the optical coherence tomography (OCT) features that can differentiate eyes with fovea-off exudative retinal detachment (ERD) vs rhegmatogenous retinal detachment (RRD), with particular attention to outer retinal corrugations (ORCs). DESIGN: Multicenter, retrospective cross-sectional study. METHODS: Multicenter, retrospective cross-sectional study of patients diagnosed with unilateral or bilateral fovea-off ERD or primary, acute, fovea-off RRD between 2016 and 2021. This study was performed with the approval from the Research Ethics Board at the University of Toronto and was conducted in accordance with the Declaration of Helsinki. Patients with any ERD etiology and evidence of extensive, bullous fovea-off detachment and in the RRD group: consecutive patients with acute, primary fovea-off RRD with good quality baseline SD-OCT imaging were included. Patients with exudative choroidal neovascularization from any etiology, optic nerve pit, significant media opacity, or OCT images with poor quality or low signal strength were excluded. Primary outcome was to describe the morphological features of the macula using SD-OCT in patients diagnosed with ERD vs RRD, with specific interest in ORCs. RESULTS: One hundred sixty-one eyes (51 ERD and 110 RRD) of 154 patients were included. Fifty-one eyes with ERD presented with 1 of 15 etiologies. ERD were associated with a greater risk of having hyperreflective dots in the outer retina (92.2% vs 74.5%, P = .009), hyperreflective material and dots in the subretinal fluid (72.5% vs 34.5%, P < .001), internal limiting membrane and inner retinal undulations (70.6% vs 39.4%, P < .001), and retinal pigment epithelium undulations (44.9% vs 6.4%, P < .001) compared to RRD. RRD was associated with a greater risk of outer retinal corrugations (80% vs 0%, P < .001), intraretinal fluid (90.9% vs 41.2%, P < .001) and ellipsoid zone thickening (90% vs 66.7%, P < .001) compared to ERD. CONCLUSION: The presence of ORCs are highly specific for RRD and absent in ERD. This is likely related to differences in the pathophysiology of the diseases process, specifically the content of the subretinal fluid. Understanding the differences in OCT morphological features of ERD vs RRD may aid with diagnosis and management.

Systems biology-based analysis implicates a novel role for vitamin D metabolism in the pathogenesis of age-related macular degeneration.

Vitamin D has been shown to have anti-angiogenic properties and to play a protective role in several types of cancer, including breast, prostate and cutaneous melanoma. Similarly, vitamin D levels have been shown to be protective for risk of a number of conditions, including cardiovascular disease and chronic kidney disease, as well as numerous autoimmune disorders such as multiple sclerosis, inflammatory bowel diseases and type 1 diabetes mellitus. A study performed by Parekh et al. was the first to suggest a role for vitamin D in age-related macular degeneration (AMD) and showed a correlation between reduced serum vitamin D levels and risk for early AMD. Based on this study and the protective role of vitamin D in diseases with similar pathophysiology to AMD, we examined the role of vitamin D in a family-based cohort of 481 sibling pairs. Using extremely phenotypically discordant sibling pairs, initially we evaluated the association of neovascular AMD and vitamin D/sunlight-related epidemiological factors. After controlling for established AMD risk factors, including polymorphisms of the genes encoding complement factor H (CFH) and age-related maculopathy susceptibility 2/HtrA serine peptidase (ARMS2/HTRA1), and smoking history, we found that ultraviolet irradiance was protective for the development of neovascular AMD (p = 0.001). Although evaluation of serum vitamin D levels (25-hydroxyvitamin D [25(OH)D]) was higher in unaffected individuals than in their affected siblings, this finding did not reach statistical significance. Based on the relationship between ultraviolet irradiance and vitamin D production, we employed a candidate gene approach for evaluating common variation in key vitamin D pathway genes (the genes encoding the vitamin D receptor [VDR]; cytochrome P450, family 27, subfamily B, polypeptide 1 [CYP27B1]; cytochrome P450, family 24, subfamily A, polypeptide 1 [CYP24A1]; and CYP27A1) in this same family-based cohort. Initial findings were then validated and replicated in the extended family cohort, an unrelated case-control cohort from central Greece and a prospective nested case-control population from the Nurse's Health Study and Health Professionals Follow-Up Studies, which included patients with all subtypes of AMD for a total of 2,528 individuals. Single point variants in CYP24A1 (the gene encoding the catabolising enzyme of the vitamin D pathway) were demonstrated to influence AMD risk after controlling for smoking history, sex and age in all populations, both separately and, more importantly, in a meta-analysis. This is the first report demonstrating a genetic association between vitamin D metabolism and AMD risk. These findings were also supplemented with expression data from human donor eyes and human retinal cell lines. These data not only extend previous biological studies in the AMD field, but further emphasise common antecedents between several disorders with an inflammatory/immunogenic component such as cardiovascular disease, cancer and AMD.

Geriatric traumatic open globe injuries.

PURPOSE: To characterize the pattern of ocular trauma in the geriatric population. DESIGN: Retrospective, comparative case series. PARTICIPANTS: Eight hundred forty-six consecutive patients comprising 848 open globe injuries, of which 166 injuries occurred in geriatric patients (defined as 65 years old or older at the time of injury), with the remaining patients serving as control subjects. METHODS: Charts of open globe injuries (848 in total) treated surgically at the Massachusetts Eye and Ear Infirmary between January 2000 and April 2009 were retrospectively reviewed. MAIN OUTCOME MEASURES: Ocular Trauma Score, age, gender, mechanism of injury, zone of injury, site of injury, time of day, visual acuity at presentation, and best post-repair visual acuity were analyzed. RESULTS: Of 848 open globe injuries, 166 occurred in the geriatric population. The mean patient age in the geriatric group was 79.8 years. Females comprised most (58%) of this subpopulation. The most common mechanisms of injury were fall (65%), blunt trauma (16%), and motor vehicle accident (6%). The geriatric traumas tended to happen in late morning or late at night. There were no cases of endophthalmitis and fewer instances of enucleation in this group. The median raw Ocular Trauma Score was 47 in the geriatric population, compared with 70 in the younger subset (P < 0.0001). The injuries more often were in zones II and III in the geriatric population compared with the nongeriatric population (P < 0.0001). The geriatric patients were much more likely to have undergone previous intraocular surgery (P < 0.0001), which consisted of primarily cataract procedures. Visual acuity at presentation was significantly worse in the geriatric population than the nongeriatric population (P<0.0001). Similarly, the best postoperative visual acuity was worse in the elderly group than the younger group (P < 0.0001). CONCLUSIONS: The elderly represent a unique, yet neglected ocular trauma population. The pattern of ophthalmic injury and outcome differs greatly between the geriatric and nongeriatric populations. A better understanding of these injuries is necessary to improve prevention and treatment strategies for potentially devastating open globe injuries in this susceptible population.

Is there a place for music in medical school?

Music permeates the medical literature regarding disease therapy. However, there are only few articles concerning music as a tool for development of cultural competency and interpersonal relations. We share our experience of forming a musical act of students and faculty at a medical school. We believe that this group has encouraged medical humanism and enhanced communication in the learning environment.

Visual outcomes of vitreoretinal surgery in eyes with severe open-globe injury presenting with no-light-perception vision.

BACKGROUND: Severe ocular trauma causing no light perception (NLP) typically carries a dismal prognosis, and implies no further therapeutic intervention. We have identified a cohort of patients with verified NLP following open-globe injury who have recovered vision of light perception (LP) or better. We evaluated the outcomes of vitreoretinal surgery performed on eyes that were NLP post open-globe injury. METHODS: Retrospective review of outcomes of secondary vitreoretinal surgery performed at Massachusetts Eye and Ear Infirmary from 1 January 2001 to 31 December 2006 on all cases of open-globe repair (OGR) that had NLP prior to OGR or on the first post-operative day. RESULTS: A total of 648 cases of OGR were performed in the study period. Eighty-eight patients had NLP prior to OGR or on the first post-operative day after OGR. Twenty-three patients from the above group (26.1%) spontaneously recovered a vision of light perception (LP) or better. Eight of the 23 patients had a secondary vitreoretinal surgery. All eyes that did not undergo vitreoretinal surgery returned to NLP or became phthisical within 7 months. Among the eight eyes that underwent surgery, five had improvement, with vision ranging from hand motion to 20/70. Prognostic indicators for successful surgical outcome were hand motion or better vision prior to vitreoretinal surgery, recovery of vision within 5 days of OGR, and vitreoretinal intervention within 5 weeks of the initial open-globe injury. CONCLUSION: Patients with severe open-globe injury and NLP occasionally recover LP or better vision. These patients may regain useful vision after vitreoretinal surgery if prompt referral and intervention is attempted and if the spontaneous visual recovery occurs within the first week after OGR.

The NEI/NCBI dbGAP database: genotypes and haplotypes that may specifically predispose to risk of neovascular age-related macular degeneration.

BACKGROUND: To examine if the significantly associated SNPs derived from the genome wide allelic association study on the AREDS cohort at the NEI (dbGAP) specifically confer risk for neovascular age-related macular degeneration (AMD). We ascertained 134 unrelated patients with AMD who had one sibling with an AREDS classification 1 or less and was past the age at which the affected sibling was diagnosed (268 subjects). Genotyping was performed by both direct sequencing and Sequenom iPLEX system technology. Single SNP analyses were conducted with McNemar's Test (both 2 x 2 and 3 x 3 tests) and likelihood ratio tests (LRT). Conditional logistic regression was used to determine significant gene-gene interactions. LRT was used to determine the best fit for each genotypic model tested (additive, dominant or recessive). RESULTS: Before release of individual data, p-value information was obtained directly from the AREDS dbGAP website. Of the 35 variants with P < 10-6 examined, 23 significantly modified risk of neovascular AMD. Many variants located in tandem on 1q32-q22 including those in CFH, CFHR4, CFHR2, CFHR5, F13B, ASPM and ZBTB were significantly associated with AMD risk. Of these variants, single SNP analysis revealed that CFH rs572515 was the most significantly associated with AMD risk (P < 10-6). Haplotype analysis supported our findings of single SNP association, demonstrating that the most significant haplotype, GATAGTTCTC, spanning CFH, CFHR4, and CFHR2 was associated with the greatest risk of developing neovascular AMD (P < 10-6). Other than variants on 1q32-q22, only two SNPs, rs9288410 (MAP2) on 2q34-q35 and rs2014307 (PLEKHA1/HTRA1) on 10q26 were significantly associated with AMD status (P = .03 and P < 10-6 respectively). After controlling for smoking history, gender and age, the most significant gene-gene interaction appears to be between rs10801575 (CFH) and rs2014307 (PLEKHA1/HTRA1) (P < 10-11). The best genotypic fit for rs10801575 and rs2014307 was an additive model based on LRT. After applying a Bonferonni correction, no other significant interactions were identified between any other SNPs. CONCLUSION: This is the first replication study on the NEI dbGAP SNPs, demonstrating that alleles on 1q, 2q and 10q may predispose an individual to AMD.

Epidemiological trends in 1452 cases of retinoblastoma from the Surveillance, Epidemiology, and End Results (SEER) registry.

OBJECTIVE: To assess retinoblastoma epidemiological trends in the Surveillance, Epidemiology, and End Results (SEER) registry. METHODS: All cases of retinoblastoma in the SEER database from 1973 to 2009 were identified. Kaplan-Meier survival analyses were performed for pathological grade, patient age, sex, year of diagnosis, and treatment modality. Cox proportional hazards regression assessed the impact of patient and tumour characteristics on survival. RESULTS: 1452 cases of retinoblastoma were analyzed. The mean patient age at diagnosis was 1.44 years. The tumour was unilateral in 71.0% and bilateral in 29.0%. The mean follow-up was 129.1 months. Overall survival increased during the study interval. Patients with bilateral tumours were diagnosed at an earlier age (0.46 years) than patients with unilateral disease (1.77 years; p < 0.0001). Bilateral retinoblastoma (90.3% 10-year overall survival) was associated with decreased overall survival than unilateral retinoblastoma (96.1% 10-year overall survival). Bilateral retinoblastoma was also associated with an increased incidence of nonocular malignancies (7.8%) compared with unilateral retinoblastoma (1.3%; p < 0.0001). Grade 1 tumours were diagnosed at a younger age (0.94 years) than grade 3 (2.24 years) and grade 4 tumours (2.14 years; p < 0.0001). Lower grade and lower stage tumours were independently associated with increased survival. In multivariate Cox proportional hazards analysis, T stage and laterality were the only covariates that correlated with overall survival. CONCLUSIONS: There appear to be associations between retinoblastoma tumour features such as tumour stage, pathological grade, and laterality with patient characteristics such as age at diagnosis, overall survival, and second malignancies.

Epidemiological trends in malignant lacrimal gland tumors.

OBJECTIVE: To describe epidemiological trends in lacrimal gland malignancies in the United States. STUDY DESIGN: Retrospective database review. SETTING: Multicenter registry. SUBJECTS AND METHODS: A total of 702 malignant tumors of the lacrimal gland from the Surveillance, Epidemiology, and End Results database were included in the study. Disease-specific and overall survival were the primary outcome measures. Kaplan-Meier survival curves were generated for multiple patient and tumor characteristics, including race, histology, TNM tumor stage, age at diagnosis, radiotherapy, gender, and tumor grade. Cox proportional hazards regression was performed to assess the impact of patient and tumor characteristics on survival. RESULTS: Lymphoma (58.0%), adenoid cystic carcinoma (13.4%), adenocarcinoma (3.8%), and mucoepidermoid carcinoma (3.6%) accounted for most tumors. Lymphoma was associated with more favorable survival rates, while adenocarcinoma, adenoid cystic carcinoma, and mucoepidermoid carcinoma were associated with worse prognosis. There was a steady increase in the proportion of lymphoma diagnosed since 1973. In a multivariate Cox proportional hazards regression model, tumor histology remained as the only covariate correlated with disease-specific survival. CONCLUSION: Patient characteristics and survival rates differ between lymphoma, adenoid cystic carcinoma, adenocarcinoma, and mucoepidermoid carcinoma. The proportion of lacrimal gland cancer diagnosed as lymphoma has steadily increased over time. Cox proportional hazards regression analysis demonstrated tumor histology as one of the most important factors in patient survival. These results augment our understanding of the expected disease course of lacrimal gland malignancies.

Epidemiological trends in uveal melanoma.

BACKGROUND: There has been a recent evolution in the management of uveal melanoma in regard to prognostic evaluation and treatment modalities. This study aims to evaluate the epidemiological trends of uveal melanoma since 1973 by using the Surveillance, Epidemiology, and End Results (SEER) Registry. METHODS: A total of 7043 uveal melanoma cases from the SEER database were retrospectively analysed, spanning 1973 to 2009. The main outcome measures were disease specific and overall patient survival. RESULTS: The mean patient age at diagnosis was 61.4 years, which has increased over the last 37 years. The mean follow-up interval was 85.9 months. The proportion of tumours demonstrating spindle cell histology has decreased. Spindle cell tumours yielded superior disease-specific survival to epithelioid and mixed tumours. The median age at diagnosis of spindle cell tumours (60 years) was significantly younger than epithelioid tumours (65 years) and mixed tumours (64 years old; p < 0.0001). In a Cox proportional hazards regression analysis, tumour histology, T stage and age at diagnosis were associated with disease-specific survival. The prevalence of cutaneous melanoma was increased in patients with uveal melanoma, but the lifetime prevalence of other primary cancers was not appreciably increased. CONCLUSIONS: The SEER data set demonstrates epidemiological trends in patient age at diagnosis and tumour histology over the last 37 years. Several patient and tumour characteristics are predictors of disease-specific survival. These findings have implications for disease surveillance and prognostic counselling.

Feasibility and efficacy of a mass switch from ranibizumab (Lucentis) to bevacizumab (Avastin) for treatment of neovascular age-related macular degeneration.

PURPOSE: To assess the feasibility and potential obstacles of a departmental switch from ranibizumab (Lucentis, Genentech, South San Francisco, CA) to bevacizumab (Avastin, Genentech) for the treatment of neovascular age-related macular degeneration (AMD). METHODS: A total of 154 eyes treated for wet AMD with ranibizumab or bevacizumab were examined over a 10-month period. The treatment protocol was monthly induction therapy followed by injections as needed for macular edema or subretinal fluid on optical coherence tomography, new hemorrhage or edema on examination, worsening vision, or leakage on fluorescein angiography. Central subfield thickness and pinhole vision were the main treatment outcomes. Study windows were compared using t tests and Mann-Whitney U tests. Statistical significance was defined as a P value of <0.05. RESULTS: The majority of patients (88%) were willing to accept a bevacizumab injection. There was no difference in frequency of injection, central subfield thickness, visual outcome, or endophthalmitis rate between the ranibizumab and bevacizumab groups. A small subset of patients (4.5%) appeared to respond more favorably to ranibizumab than bevacizumab. CONCLUSIONS: Bevacizumab appears to be a cost-effective alternative to ranibizumab for the treatment of neovascular AMD. Patients previously treated with ranibizumab are typically willing to switch to bevacizumab. In the overwhelming majority of patients, there is no major decline in clinical status. However, select patients may respond better to ranibizumab injections.

Optical coherence tomography retinal thickness and volume measurements in X-linked retinoschisis.

PURPOSE: To analyze retinal thickness and volume measurements of X-linked retinoschisis patients by spectral-domain optical coherence tomography (SD OCT) and correlate these findings with visual acuity and patient age. DESIGN: Retrospective comparative case series. METHODS: Sixty-three eyes of 33 male patients with X-linked retinoschisis were gleaned from a SD OCT database at the University of Illinois at Chicago. Forty-one eyes of 21 patients with low refractive error, no visual impairment, and no known retinal disease served as age-similar controls. The mean age of the retinoschisis patients was 26.4 years. The mean age of patient controls was 30.0 years. Full-thickness, inner and outer retina thickness, and volume measurements were determined by SD OCT. RESULTS: Foveal schisis was observed in 81% of retinoschisis patients. Patients with foveal schisis tended to be younger than patients lacking foveal schisis. Inner and outer foveal thickness and volume measurements were increased in retinoschisis patients compared to controls. Outer retinal perifoveal and parafoveal thicknesses and volumes were consistently increased in retinoschisis patients relative to controls. In contrast, inner retinal perifoveal and parafoveal thickness and volume measurements were decreased in retinoschisis patients compared to controls. Worse visual acuity correlated with thinning of the temporal perifoveal inner retina and thickening of the inner fovea. Full-thickness measurements and inner retina and outer retina thickness and volume measurements tended to decrease with patient age. CONCLUSION: Increased inner retinal foveal thickness and decreased perifoveal inner retinal thickness correlates with worse visual acuity and overall retinal thickness decreases with age in X-linked retinoschisis.

Predictors and outcomes of ocular hypertension after open-globe injury.

PURPOSE: Evaluate predictors and outcomes of ocular hypertension after open-globe injury. PATIENTS AND METHODS: This is a retrospective, case-control study reviewing records of consecutive patients with open-globe injuries treated at Massachusetts Eye and Ear Infirmary between February 1999 and January 2007. Of 658 patients treated, 382 had at least 2 months of follow-up and sufficient data to be included. Main outcome measures are visual acuity, intraocular pressure (IOP), and type of glaucoma intervention employed. RESULTS: Sixty-five (17%) patients developed ocular hypertension defined as IOP≥22 mm Hg at >1 visit or requiring treatment. Increased age (P<0.001), hyphema (0.025), lens injury (P<0.0001), and zone II injury (P=0.0254) are risk factors for developing ocular hypertension after open-globe injury. Forty-eight (74%) patients with ocular hypertension were treated medically, 8 (12%) underwent filtering or glaucoma drainage device surgery, 5 (8%) had IOP normalization with observation, while 4 (6%) required anterior chamber washout with no other glaucoma surgery. Patients with ocular hypertension had an average maximum IOP=33.4 mm Hg at a median follow-up of 21 days, with most patients maintaining normal IOP at all follow-up time points. Visual acuity improved over time with median acuity of hand motions preoperatively, and 20/60 at 12 and 36 months. CONCLUSIONS: Ocular hypertension is a significant complication after open-globe injury that sometimes requires surgical intervention. Predictive factors can alert physicians to monitor for elevated IOP in the first month after trauma. Most patients with traumatic ocular hypertension had improved visual acuity and IOP normalization over time.

Surgical rehabilitation of the open globe injury patient.

PURPOSE: To describe the long-term surgical course of patients with open globe injury. DESIGN: Retrospective case series. METHODS: Patients with open globe injuries (848 in total) treated surgically at the Massachusetts Eye and Ear Infirmary between 2000 and 2009 were retrospectively reviewed. Data from presentation, initial repair, and follow-up surgery were analyzed. RESULTS: Among 848 injuries, 1415 surgical procedures were performed. The mean follow-up time was 19.7 months, including 6017 visits. On average, patients required 1.7 surgeries and 7.1 follow-up visits. Factors predicting follow-up surgery included more severe ocular trauma score, worse prerepair visual acuity, retinal hemorrhage, anterior vitrectomy at primary repair, pars plana vitrectomy at primary repair, and lensectomy at primary repair. Patients with zone II injury, hemorrhagic choroidal detachment, and a history of previous ocular surgery tended to require follow-up surgery less frequently. Patients requiring a second surgery tended to have worse visual acuity at presentation and postrepair. Postoperative visual outcomes were worse for patients who underwent vitreoretinal follow-up surgery, likely because of mechanism of injury. Variables associated with inferior visual outcome were worse prerepair visual acuity, postoperative afferent pupillary defect (APD), old age, scleral laceration, and retinal detachment. CONCLUSION: Open globe injuries require significant surgical follow-up. Patients requiring multiple operations tended to have worse postoperative visual acuity. Patients who underwent vitreoretinal surgery had overall worse visual outcomes. While the first year of surveillance appears to be pivotal in the course of an open globe injury, these patients can expect long-term care from comprehensive and subspecialty ophthalmologists.

Radiotherapy in parotid acinic cell carcinoma: does it have an impact on survival?

OBJECTIVE: Acinic (or acinar) cell carcinoma (ACC) represents approximately 10% of salivary gland malignant tumors and most commonly occurs in the parotid gland. It carries a propensity for locoregional and distant metastasis. Although it is selectively used as an adjuvant in this tumor, radiotherapy (RT) has not been sufficiently examined in large population studies for survival impact. DESIGN: Retrospective database review. SETTING: Tertiary care center. PATIENTS: A total of 1241 cases of parotid ACC in the Surveillance, Epidemiology, and End Results (SEER) Program database from 1988 to 2007 were identified and analyzed. INTERVENTIONS: Comparison groups were surgery and surgery plus RT. Kaplan-Meier survival curves were generated for oncologic stage and histologic grade. MAIN OUTCOME MEASURES: Overall survival. RESULTS: A total of 969 patients had sufficient staging data for inclusion. When comparing surgery with surgery with adjuvant RT, there was no statistical difference in overall survival when stratifying for stage I (P = .57), stage II (P = .37), stage III (P = .25), and stage IV (P = .24) tumors. Similarly, adjuvant RT did not demonstrate a survival advantage when stratified by histologic grade of tumor. The highest-grade and highest-stage tumors were fewer in number, however. CONCLUSIONS: To our knowledge, this study represents the largest cohort of patients treated for ACC of the parotid. Adjuvant RT does not seem to provide a significant survival advantage for early-stage or lower-grade parotid ACC. Radiotherapy for highest-stage and highest-grade tumors requires further study.

Malignant eccrine spiradenoma: a meta-analysis of reported cases.

BACKGROUND: Malignant eccrine spiradenoma is an aggressive sweat gland tumor with poorly understood behavior and no currently accepted therapeutic regimen. METHODS: An individual patient data meta-analysis with Kaplan­Meier survival curves was performed on 72 reported cases of malignant eccrine spiradenoma. RESULTS: In 35 patients with no distant metastasis, local resection resulted in 100% disease-free survival. Of 7 patients with lymph node but no distant metastasis treated with surgical resection and lymph node dissection, 6 patients remained disease-free at final follow-up evaluation. For the 24 cases with confirmed distant metastatic disease, patient survival did not significantly differ between local resection and surgery with adjuvant chemoradiotherapy (P = .8763). CONCLUSIONS: Heightened awareness is recommended among surgeons likely to treat this entity. An aggressive surgical approach is supported in the absence of metastasis. When lymph nodes are not clinically involved, sentinel node may have a role followed by lymph node dissection in patients with a positive node.