Aaron Savar

Enucleation for open globe injury.

PURPOSE To report the experience of enucleation after open globe at an ophthalmic trauma referral center. DESIGN Retrospective, observational study. METHODS In an ophthalmic trauma referral center the charts of all patients having suffered an open globe injury between January 1, 2000 and June 30, 2007 were reviewed. Variables assessed were age, gender, type of injury (rupture or laceration [penetrating, intraocular foreign body, or perforating]), ocular trauma score, visual acuity, subsequent enucleation, indication for and timing of enucleation, presence of sympathetic ophthalmia, and length of follow-up. RESULTS Among 660 open globe injuries, 55 have undergone enucleation (including 4 eviscerations), 11 primarily and 44 secondarily. Eyes with ruptures were significantly more likely to be enucleated than those with injuries attributable to lacerations (P < .001). The most common reason for secondary enucleation was a blind, painful eye. Two patients (0.3%) developed sympathetic ophthalmia and have maintained good vision in the sympathizing eye. CONCLUSIONS The vast majority of open globes can be repaired without requiring primary enucleation. Secondary enucleation is most commonly carried out for pain. Eyes with no light perception can be closely observed if the patient chooses.

Sentinel Lymph Node Biopsy for Ocular Adnexal Melanoma: Experience in 30 Patients

PURPOSE To report the findings on sentinel lymph node biopsy (SLNB) in 30 patients with ocular adnexal (conjunctival or eyelid) melanomas. DESIGN Prospective nonrandomized clinical trial. PARTICIPANTS Thirty patients with diagnosis of eyelid or conjunctival melanoma. METHODS All patients with ocular adnexal melanoma who underwent SLNB at The University of Texas MD Anderson Cancer Center between December 2000 and July 2008 are the subject of this report. Sentinel lymph node biopsy was performed as previously described by our group, and patients were prospectively followed up. MAIN OUTCOME MEASURES Findings on preoperative lymphoscintigraphy, SLNB, histopathologic examination of the primary tumor and sentinel lymph nodes (SNL), and nodal recurrence after SLNB. RESULTS Tumor sites were as follows: bulbar conjunctiva only, 14 patients; palpebral conjunctiva only, 8 patients; both bulbar and palpebral conjunctiva, 4 patients; and eyelid skin only, 4 patients. At least 1 SLN was identified in all patients. The median number of SLNs removed was 2 (range, 1-5). The most common basin sampled was the intraparotid (16 patients), followed by submandibular (level I) (11 patients), preauricular (9 patients), and superior cervical (level II) (6 patients). Five patients had SLN metastasis. Among the 25 patients with negative SLNB findings, there were 2 false-negative events. There were no false-negative events among patients treated during the last 4.5 years of the study. The mean Breslow thickness was 2.57 mm (range, 0.62-12 mm) among patients with negative SLNB and 4.86 mm (range, 2.0-7.2 mm) among patients with positive SLNB findings (P = 0.055). Ulceration was present in 11 patients (39%): 4 (80%) of 5 patients with positive SLNB and 7 (28%) of 25 with negative SLNB, including both patients with false-negative results. The median time from SLNB to last contact was 2 years (range, 10 months to 6 years). CONCLUSIONS Sentinel lymph node biopsy is effective for identifying nodal micrometastasis in patients with ocular adnexal melanoma and provides important prognostic information. The false-negative event rate in our series improved in the last 4 years, most likely because of a better technique and better patient selection for SLNB. We recommend consideration of SLNB for patients with intermediate-thickness ocular adnexal melanoma and those with ulceration.

Neurofibromatosis Type I: Genetics and Clinical Manifestations

Neurofibromatosis type I is mutisystem disorder with myriad manifestations, many of which involve the eye. Diagnostic findings include neurofibromas, lisch nodules, café-au-lait macules, freckling, optic pathway gliomas, and skeletal dysplasia. The responsible gene and its protein product, neurofibromin have been identified. Advances have been made in the understanding of the functions of neurofibromin. This has allowed better understanding of the many manifestations and will help identify potential treatments.

Positive sentinel node in sebaceous carcinoma of the eyelid.

Sebaceous carcinoma is a rare cutaneous malignancy that is most frequently found in the eyelids with an estimated risk of regional lymph node metastasis in the 8% to 14% range. The authors have previously reported the use of sentinel lymph node biopsy and microscopically positive sentinel lymph nodes in various eyelid and conjunctival cancers, including conjunctival and eyelid melanoma and Merkel cell carcinoma. The authors herein describe the first successful identification of a microscopically positive sentinel lymph node in a patient with sebaceous carcinoma of the eyelid, suggesting that sentinel lymph node biopsy for sebaceous carcinoma of the eyelid deserves further investigation.

Conjunctival melanoma: local-regional control rates, and impact of high-risk histopathologic features.

Background: Conjunctival melanoma is an uncommon malignancy with the potential for significant morbidity. Ulceration is known to be an indicator of more aggressive cutaneous melanoma. This factor has not been previously evaluated in conjunctival melanoma.

Acute appendicitis after solid organ transplantation

Abstract:  Appendicitis has rarely been reported following solid organ transplantation and never following liver transplantation. We reviewed records of all patients who received solid organ transplants at UCLA between 1989 and 2002 and subsequently underwent appendectomy for presumed acute appendicitis. Of nearly 8000 transplant patients, 17 (nine male, eight female) subsequently underwent appendectomy for presumed acute appendicitis. Average age at appendectomy was 37 yrs (range 6–73 yrs). Organ transplants included liver (seven patients), heart (four), kidney (three), kidney–pancreas (two), and heart–kidney (one). The mean interval from transplant to appendectomy was 1064 d (16–2977). Presenting symptoms and signs included abdominal pain in 16 patients (94%); nausea and or vomiting in 15 (88%); right lower quadrant tenderness in 16; and leukocytosis (WBC > 10 000) in 13 (76%). Mean interval from presentation to appendectomy was 0.94 d (range 0–4). Computed tomography (CT) was performed in 16 patients and showed signs of acute appendicitis in 15. Open technique was used in all patients, preceded by laparoscopy in one. Pathology showed appendicitis in 15 patients (one with perforation), serositis in one, and a normal appendix in one. Mean duration of hospitalization was 7 d (range 1–20). Complications occurred in four patients (24%) and included intra‐abdominal abscess requiring percutaneous drainage, ventral hernia, small bowel obstruction, and hematuria in one patient each. There were no deaths and no cases of acute rejection during hospitalization. Average length of follow‐up was 712 d (range 3–2492). We conclude that appendicitis is relatively rare following solid organ transplantation. CT facilitates prompt diagnosis. The clinical presentation is similar to that of non‐transplant patients, but complications are more frequent, and hospitalization is longer.

Canalicular involvement in dog bite related eyelid lacerations.

Purpose: To evaluate the incidence of canalicular involvement in periocular dog bite injuries. The majority of eyelid injuries do not involve the canaliculi. It has been our observation that periocular dog bite injuries involve the canaliculi more frequently than lacerations due to other mechanisms. Methods: In this retrospective case series, the records of all patients referred to the oculoplastics service at the Massachusetts Eye and Ear Infirmary with a dog bite injury between 1995 and 2005 were reviewed. Sixty-eight cases of eyelid lacerations due to dog bites were identified. A control group was constructed consisting of 92 patients referred for management of periocular eyelid lacerations not due to dog bite. Variables assessed included canalicular involvement, age, sex, associated injuries, and surgical repair. Results: Canalicular injuries were present in 45 patients (66%) in the dog bite group and 34 patients (37%) in the control group (p < 0.01). In the dog bite group, 7 injuries (16%) involved only the superior canaliculus, 33 (73%) only the inferior canaliculus, and 5 (11%) involved both. In the control group, 12 injuries (35%) involved only the superior canaliculus, 18 (53%) only the inferior canaliculus, and 4 (12%) involved both. The average time from presentation to repair was 0.53 days (range, 0–3 days). Four patients had extensive tissue loss that prevented stenting. Conclusions: Periocular dog bites have a propensity for involvement of the lacrimal canaliculus. We present the largest series to date of periocular dog bite injuries. The index of suspicion for canalicular lacerations should be raised when evaluating patients with dog bite injuries.

Prognostic Accuracy of the Seventh Edition vs Sixth Edition of the American Joint Committee on Cancer Tumor Classification for Adenoid Cystic Carcinoma of the Lacrimal Gland

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Silent sinus syndrome presenting as enophthalmos long after orbital trauma

Late enophthalmos is a well-known consequence of large orbital floor fractures. In rare cases, late enophthalmos can occur after direct trauma to the maxillary ostiomeatal complex and present as silent sinus syndrome (SSS). We report two cases of SSS manifesting as enophthalmos years after facial trauma. The first patient developed SSS 4 years after a minimally displaced orbital floor fracture. The second patient had progressive enophthalmos as a result of atelectasis of the maxillary sinus years after facial trauma and surgical repair of nasal fractures. There have been two prior reports of SSS presenting after orbital trauma. Our patients differ from these prior reports in that the enophthalmos was discovered years after the initial facial trauma. In the first patient, surgery addressing the blockage of the ostiomeatal complex arrested the enophthalmos; in the second patient, it reversed the enophthalmos.

Treatment of benign lymphoid hyperplasia of the orbit with rituximab

Benign lymphoid hyperplasia is a disorder characterized by polyclonal lymphocytic infiltration of orbital tissues, predominantly with B-cells. Rituximab is a monoclonal antibody directed against CD20, a B-cell marker. Two patients with recurrent orbital masses involving the lacrimal glands were treated with rituximab. The diagnosis of benign lymphoid hyperplasia with predominance of CD20+ cells was confirmed in both cases based on a surgical biopsy. Both patients had been previously treated with standard therapies, including high-dose steroids, and one patient had failed external-beam radiation therapy. They both responded well to treatment with intravenous rituximab. Neither patient experienced any side effects associated with rituximab.