Arash Jian-Amadi

Neutron radiotherapy for adenoid cystic carcinoma of the lacrimal gland

Purpose:Lacrimal gland adenoid cystic carcinomas are rare, aggressive orbital tumors that share histopathologic similarities with salivary gland malignancies. Neutron radiotherapy may be useful for treatment due to its high biological effectiveness for salivary malignancies. Methods:The authors retrospectively reviewed the outcomes for 11 lacrimal gland adenoid cystic carcinoma patients treated with neutrons from 1988 to 2011. Most had undergone surgery prior to radiation therapy. However, gross residual disease was present in 8 patients. The most common American Joint Committee on Cancer stage was T4cN0M0. Four patients with skull base involvement received a radiosurgery boost and 1 received a proton therapy boost. Results:Median follow up was 6.2 years. Median overall survival was 11.1 years and median disease-free survival was 6.3 years. Five-year local control was estimated by the Kaplan–Meier method as 80%. Three patients had a local recurrence; 4 developed distant metastases. Six patients died. Seven patients had intact vision in the affected eye before neutron radiation. Two required enucleation for a painful dry eye. Of the 5 who avoided an enucleation, 3 had either severe visual impairment (20/400) or only light perception and 2 were without known vision compromise or complications at the time of their death. One patient developed asymptomatic frontal lobe radionecrosis after 2 courses of radiation therapy. Conclusions:Neutron radiation therapy achieved excellent 5-year local control in this series of high-risk patients, with most cases having gross residual disease. Late recurrences and distant metastases remain a challenge. Meaningful ipsilateral vision preservation was not possible in most cases in the long term, although only 2 patients required an enucleation for treatment effects.

Decompression of the Orbital Apex An Alternate Approach to Surgical Excision for Radiographically Benign Orbital Apex Tumors

OBJECTIVE To study the outcome of patients with orbital apex lesions treated with endoscopic decompression alone. DESIGN Retrospective medical chart review with a mean follow-up of 25.6 months. SETTING Departments of Ophthalmology and Otolaryngology, University of Washington, Seattle. PATIENTS Five individuals seen at the University of Washington Medical Center from November 2003 through December 2005 with visual disturbance caused by orbital apex lesions as documented by preoperative magnetic resonance imaging or computed tomographic scan. INTERVENTION All patients underwent endoscopic decompression of the medial wall of the orbital apex with incision of the periorbita. MAIN OUTCOME MEASURES Postoperative visual acuity, presence or absence of a relative afferent pupillary defect, color vision, and visual field were recorded. RESULTS All 5 patients presented with visual field deficits, 4 of whom improved postoperatively. Three patients had dyschromatopsia preoperatively, 2 of whom improved postoperatively. Visual acuity improved or stabilized in 4 of 5 patients postoperatively. One patient had progressive visual loss during the course of her follow-up, which, after obtaining postoperative imaging, was attributed to inadequate decompression of the apex at its most posterior aspect. This same patient also developed postoperative sinusitis that resolved with antibiotic treatment. Two patients developed diplopia, 1 in primary gaze requiring treatment with prismatic lenses. All patients presented with and maintained normal intraocular pressures. CONCLUSION Orbital apex lesions can often be effectively and relatively safely treated by endoscopic decompression alone.

Orbital compartment syndrome in burn patients.

Purpose: To identify clinical characteristics of burn patients requiring emergent orbital decompression for vision-threatening orbital compartment syndrome. Methods: A retrospective review of 28 burn patients at a trauma center provided data regarding demographics, physical examination findings, and resuscitation fluid volumes. Patients requiring orbital decompression were compared with those who did not, using t tests and Fisher exact test. Linear regression was used to test for an association between peak intraocular pressure and fluid volume. Logistic regression was used to assess associations between need for orbital decompression and fluid volume. Results: Eight of 28 patients required emergent orbital decompression, which immediately reduced intraocular pressure from 59.4 ± 15.9 mm Hg to 28.6 ± 8.2 mm Hg (p < 0.001). There was a positive relationship between fluid volume in the first 24 hours and peak intraocular pressure (p < 0.001). Patients who were treated with orbital decompression were resuscitated with a higher fluid volume in the first 24 hours than those who were not (37,218 ± 14,405 ml versus 24,649 ± 12,339 ml, p = 0.015). This was no longer statistically significant when adjusted for periocular burns. The relative risk for undergoing orbital decompression in patients receiving ≥8.6 ml/kg/% total body surface area burned in the first 24 hours was 4.4 (p = 0.03). Conclusions: Risk factors for vision-threatening orbital compartment syndrome include fluid volume and periocular burns. Signs of vision-threatening orbital compartment syndrome should be addressed early with orbital decompression.

Isolated squamous cell carcinoma of the orbital apex.

A 43-year-old woman (Case 1), 63-year-old man (Case 2), and a 67-year-old man (Case 3) presented with diplopia (Cases 1, 2, and 3) and upper-eyelid ptosis (Cases 1 and 3). The cases had preceding cranial nerve V1 disturbances ranging from 3 months to 8 years. Each demonstrated complete internal ophthalmoplegia and external ophthalmoplegia. No case had a cutaneous squamous cell carcinoma (SCC) on presentation or by history. Imaging revealed isolated orbital apex masses. Tumor biopsies revealed SCCs of various differentiations. Systemic workup revealed no extraorbital malignancy. All received radiation therapy, and 2 patients underwent adjuvant chemotherapy. One patient is alive since diagnosis (49 months). In Case 2, SCC developed in the contralateral orbit, and the patient died 19 months after diagnosis; and Case 3 died 12 months after diagnosis. These isolated cases of orbital SCC may have arisen from orbital choristomatous squamous epithelium, may represent de novo or metastatic tumors, or may be manifestations of occult perineural spread.

Ocular Trauma From Dog Bites: Characterization, Associations, and Treatment Patterns at a Regional Level I Trauma Center Over 11 Years

Purpose: Canine bites frequently result in periocular injury. The authors aimed to further characterize the dog breeds, types of injuries inflicted, and treatment outcomes. Methods: A retrospective chart review was performed on all dog bites recorded in the University of Washington trauma registry from 2003 to 2013. Cases involving ocular injury were further investigated to identify ocular tissues affected, treatment patterns, and outcomes. Results: A total of 342 dog bite victims were identified, of whom 91 sustained ocular trauma (27%). The mean age of patients with ocular injuries was significantly lower than those without (14.1 ± 1.9 vs. 30.0 ± 1.3 years, p < 0.001). Children bitten by dogs were 4.2 times more likely to sustain ocular injuries than adults (45.2% vs. 10.8%). The most common breed of dog inflicting ocular injury was the pit bull (25%). Forty percent of patients with ocular trauma sustained canalicular lacerations and epiphora was noted in only 3 patients (8%) after repair. Three percent had orbital fractures and 2% sustained ruptured globes. Infections were rare, affecting only 2% of patients. Conclusions: To our knowledge, this study is the largest to date to report the incidence and characteristics of ocular injuries sustained from dog bites. These injuries were disproportionately more common in children and have a high incidence of canalicular laceration. Though rare, globe injuries and orbital fractures were seen in this population. Importantly, this study establishes that pit bulls are the most frequent breed associated with ocular injuries from dog bites.

Re: “Prospective randomized comparison of external dacryocystorhinostomy with and without silicone intubation”

We read with interest “Prospective randomised comparison of external dacryocystorhinostomy with and without silicone intubation” by Saiju et al .1 The investigators should be congratulated on their effort in performing a prospective clinical trial to address this important question. There are, however, issues that we believe limit the ability to draw definitive conclusions from their study. First, we have concerns about the randomisation process at the time of surgery scheduling that resulted in unbalanced treatment groups because of early withdrawal. This process of patient self-selection can result in unidentified differences between treatment groups that may have affected their results. Second, a χ …

Immunohistochemical profiling including beta-catenin in conjunctival melanocytic lesions

Conjunctival melanocytic lesions encompass a group of clinically diverse, benign to malignant, neoplasms that may contain overlapping histopathological features, making definitive diagnosis challenging in some cases. In this series, we compared multiple immunohistochemical (IHC) markers in 11 conjunctival nevi, 10 primary acquired melanosis (PAM) lesions, and 11 conjunctival melanomas. Immunostains included the melanocytic markers HMB-45 and Melan-A, as well as the proliferative marker Ki-67. Loss of beta-catenin expression has been associated with more aggressive clinical disease in cutaneous melanoma, but its status in conjunctival melanocytic lesions is not known, therefore we incorporated beta-catenin immunohistochemical staining in our study. In this series, conjunctival melanomas had a higher Ki-67 proliferative index and HMB-45 immunoreactivity than did PAM lesions and conjunctival nevi (P<0.001). Melan-A was highly expressed in all 3 groups. Beta-catenin was more strongly expressed in melanomas and nevi than in PAM (P<0.001). There was high inter-grader reliability (Kappa=0.53). Overall, IHC labeling of HMB-45 and Ki-67 is increased in conjunctival melanomas compared to PAM or conjunctival nevi. Beta-catenin, an IHC marker previously unstudied in conjunctival melanocytic lesions, is not preferentially expressed in benign lesions and may play a different role in conjunctival atypia than it does in cutaneous melanoma.

Intralesional Injection of Bevacizumab for the Treatment of an Apical Orbital Cavernous Venous Malformation.

Surgical excision of orbital cavernous venous malformations located in the orbital apex is challenging due to difficulty obtaining surgical exposure and higher risk of morbidity. Intralesional bevacizumab injection has been utilized for the treatment of choroidal and intracranial cavernous venous malformations. A 52-year-old woman with an orbital apical mass consistent with a cavernous venous malformation causing decreased visual acuity, diminished color vision, and visual field loss was treated with intralesional bevacizumab injected under direct surgical visualization. Subsequently, she demonstrated improved visual acuity, color vision, and slow but dramatic visual field improvement over one year. Injection of bevacizumab may be a viable alternative treatment for orbital cavernous venous malformations.

Association between pre- and intraorbital soft tissue volumes and the risk of orbital blowout fractures using CT-based volumetric measurements

ABSTRACT Orbital blowout fractures result from trauma which breaks the bony orbital wall while sparing the rim. Previous research into fracture mechanism has focused on bony anatomy. This study evaluates the role of preorbital and intraorbital soft tissue volume in fracture risk. A retrospective case–control study was conducted on 51 cases of adults with unilateral orbital blowout fracture, matched to 51 controls who had experienced orbital trauma by comparable mechanisms without sustaining a fracture. Axial Computed Tomography (CT) images with orbital fine cuts were assessed on a 3D post-processing workstation to measure the volume of the pre- and intraorbital soft tissues, then compared between the two groups using Mann–Whitney U analysis. In the case group, there were 40 males (78%), injured by assault (66%), fall (12%), motor vehicle collision (10%), or other cause (12%). The control group included 33 males (65%), injured by assault (55%), fall (22%), motor vehicle (4%), or other cause (20%). There was no significant difference in mechanism rates between case and control groups. Median preorbital volumes were 12.5 cm3 in the case group and14.1 cm3 in controls (p = 0.02). Median intraorbital volumes were 24.4 cm3 in the case group and 25.9 cm3 in controls (p = 0.003). CT volumetric analysis shows that patients who sustained blowout fractures have lower preorbital and intraorbital soft tissue volume than those who did not fracture. This underscores the significant role that soft tissues play in dissipating impact forces, both anterior to the orbital rim and within the orbit itself.

Endoscopic dacryocystorhinostomy following head and neck radiation therapy

ABSTRACT This article determines the efficacy of endoscopic dacryocystorhinostomy (endoDCR) in patients who have undergone adjuvant external beam radiation therapy (XRT) following head and neck cancer resection. A retrospective chart review was performed on all patients who underwent endoDCR between 2006 and 2014 at a tertiary referral center. Cases were reviewed and selected for the following inclusion criteria: history of adjuvant sinonasal XRT following head and neck cancer resection, preoperative probing and irrigation demonstrating nasolacrimal duct obstruction (NLDO), postoperative probing and irrigation following silicone tube extubation. Exclusion criteria included active dacryocystitis, postoperative follow-up of less than 4 months, presence of epiphora prior to XRT, lack of probing/irrigation at preoperative or postoperative visit, and lid malposition including ectropion, facial palsy, and/or poor tear pump. Six patients (7 eyes) met the selection criteria. EndoDCR was performed at a mean time of 30 months following last radiation treatment (range, 3–71 months). Mitomycin C was used in 4/7 cases. Silicone tube removal occurred between 3–8 months postoperatively. Five out of 6 patients had postoperative sinonasal debridement and nasal saline/corticosteroid irrigation. Five out of 6 patients (83%) had both resolution of epiphora and anatomic patency confirmed by probing and irrigation. Our experience suggests that endoDCR procedures can be effective in patients with NLDO following prior sinonasal XRT for head and neck neoplasms. Postoperative management with sinonasal debridement and combined saline/corticosteroid nasal irrigation may help to improve surgical success in patients with increased post-radiotherapy mucosal inflammation.