Postoperative Changes in Strabismus, Ductions, Exophthalmometry, and Eyelid Retraction After Orbital Decompression for Thyroid Orbitopathy.

INTRODUCTION: Surgical rehabilitation of thyroid orbitopathy involves reducing proptosis, treating strabismus, lengthening the eyelids, and managing aesthetic changes. Not all are necessary in each patient; however, they often are. The current investigation intends to describe postdecompression changes that may influence the staging of these procedures. METHODS: In this retrospective cohort study, records of 169 patients who underwent orbital decompression between 1983 and 2001 were reviewed. A single orbital specialist confirmed all measurements. Time to follow up was defined as the most recent follow up after decompression and prior to any secondary procedures. No strabismus or eyelid surgery was performed at the time of decompression. Strabismus was measured with alternating prism cover test. Ductions were estimated utilizing Hirschberg's method. Exophthalmometry was measured with Hertel. Eyelid positions were defined relative to the pupillary light reflex. Strabismus data were analyzed within eye pairs. Ductions, exophthalmometry and eyelid position were analyzed for each eye. T-test for paired data was utilized to compare means pre- and postoperatively. RESULTS: The study population was on average 45 years old and 73.4% women. Average length of follow up was 1.2 years. Esotropia was significantly increased after decompression by an average of 8.1 prism diopters (p < 0.01). Exotropia and vertical deviations were not significantly altered. Ductions decreased by >5 degrees in at least one meridian for 68.1% of the population. Upper eyelid retraction remained unchanged; however, lower eyelid retraction improved by 50% from 1.4 mm to 0.7 mm (p < 0.01). Exophthalmometry improved from 23.5 mm to 19.7 mm (p < 0.01), and this result was correlated with the number of walls removed (Pearson r = -0.302, p < 0.01). CONCLUSIONS: On average, esotropia and ductions tend to worsen with decompression surgery. This result supports the clinical dictum to avoid strabismus surgery until after decompression. The improvement in lower eyelid retraction suggests that at least lower eyelid-lengthening surgery should be reserved for after decompression, as there may be significant spontaneous improvement, while the same may not be true for upper eyelid retraction, which does not tend to change with decompression.

Outcomes of patients treated with capecitabine and temozolamide for advanced pancreatic neuroendocrine tumors (PNETs) and non-PNETs.

BACKGROUND: Retrospective studies have demonstrated high response rates among patients with advanced pancreatic neuroendocrine tumors (PNETs) treated with capecitabine and temozolamide (CapTem), while responses are infrequently seen among non-PNETs. The objective of the study was to describe progression free survival (PFS) among neuroendocrine tumor (NET) patients treated with CapTem, and to identify factors associated with better activity. METHODS: Patients who were referred to one of five provincial cancer treatment centers between 2009 and 2013 for advanced NETs and initiated CapTem were included. Patients received Cap 1,500 mg/m(2) on days 1-14 and TMZ 200 mg/m(2) on days 10-14 every 28 days. Their characteristics and outcomes were retrospectively analyzed. RESULTS: In our cohort, 29 patients (16 males) with a median age of 59 (range 26-76) received palliative CapTem, 15 of them as first-line chemotherapy. Primary tumors included pancreas (48.3%), small bowel (20.7%), lung (10.3%), unknown (10.3%), rectum (6.9%) and appendix (3.4%). Median number of cycles was three. Fifteen patients (51.7%) received CapTem as first-line chemotherapy and 14 (48.3%) as subsequent lines. Median PFS for the entire cohort was 4.7 months. PNETs had a median PFS of 4.9 months compared to 2.8 months for non-PNETs (P=0.178). Patients with PNETs who received CapTem in the first-line setting had a median PFS of 15.9 months as compared to only 3.1 months for the remainder [P=0.047, hazard ratios (HR) 0.342]. Patients with Ki67 above 5% and ≤5% had median PFS of 4.0 and 4.7 months, respectively (P=0.260). CONCLUSIONS: CapTem showed good activity among PNETs, but its broader role in the treatment of carcinoid tumors remains unclear.

Septic thrombosis of the cavernous sinus: two different mechanisms.

PURPOSE: Septic thrombosis of the cavernous sinus is a rare condition that may lead to significant morbidity and mortality if not diagnosed and treated urgently. We present two recent cases of bilateral septic cavernous sinus thrombosis with differing etiologies, the first of dental origin and the second a complication of sphenoid sinusitis. METHODS: Case report. RESULTS: A diagnosis of cavernous sinus thrombosis was made based on clinical findings and confirmed by imaging in both patients. The etiology in the first patient was related to poor dental hygiene, with resultant spread of infection to the cavernous sinuses. The second had bilateral sphenoid sinusitis, with intravascular gas noted in both orbits and cavernous sinuses. This is the first reported occurrence of such an event associated with septic cavernous sinus thrombosis. Bilateral sphenoidotomies with evacuation of the sinuses were performed, and Haemophilus influenzae was cultured from the sphenoidotomy fluid and blood. Broad spectrum intravenous antibiotics were given in both patients, and complete recovery achieved within weeks. CONCLUSION: In septic thrombosis of the cavernous sinus, early recognition and prompt management with broad spectrum intravenous antibiotics is crucial for full recovery. The primary source of sepsis may be a distant focus with septicemia preceding thrombosis of the cavernous sinus. Alternatively, infection may spread from facial regions via the facial venous plexus or from the sphenoid sinus directly to the adjacent cavernous sinus.