Christopher B. Chambers

A controlled study of topical 0.25% timolol maleate gel for the treatment of cutaneous infantile capillary hemangiomas.

Purpose: To evaluate the efficacy of topical 0.25% timolol maleate gel for the treatment of cutaneous infantile capillary hemangiomas. Methods: A retrospective, consecutive, nonrandomized, comparative single-masked cohort study of all patients presenting with nonvision-threatening periocular infantile capillary hemangiomas between August 2007 and January 2011 was performed. Parents chose twice daily topical 0.25% timolol maleate gel or observation. Photographs were taken at all visits and subsequently evaluated by masked examiners for change in lesion size, color, and thickness. Lesions were clinically defined as superficial, mixed, or deep. The primary outcome was response to treatment at 2 months, categorized as good (size decreased >50%), moderate (decrease 0–50%), or poor (enlarged or caused visually significant ptosis or induced astigmatism). The secondary outcome was response at latest follow-up visit. Results: Thirteen children received timolol, and 10 children were observed, with mean ages at presentation of 4.8 and 3.7 months (p = 0.31), respectively. In the treated group, good response was observed in 8 (61.5%) infants, moderate response was seen in 4 (30.8%), and poor response was seen in one patient (7.7%). In the observed group, 0 (0%) demonstrated good response, one (10%) demonstrated moderate response, and 9 demonstrated poor response (90%) (p < 0.001). Responses were consistent on long-term follow-up (range 3–41 months). Both superficial (n = 5; 100% good response) and mixed (n = 7; 43% good, 57% moderate) lesions responded well to timolol; the one deep lesion did not. No adverse ocular or systemic effects were observed. Conclusions: Topical timolol maleate gel 0.25% is effective in treatment of nonvision-threatening infantile capillary hemangiomas with a superficial component. Response at 2 months is stable over time.

Alveolar rhabdomyosarcoma masquerading as embryonal subtype: the value of modern molecular diagnostic testing.

A 3-year-old child presented with a history of conjunctivitis in her OS. She had hyperglobus of the OS and a palpable mass in the left inferior orbit. An urgent MRI revealed an enhancing mass in the left orbit. The patient underwent an incisional biopsy with pathologic assessment most consistent with embryonal rhabdomyosarcoma. However, subsequent molecular genetic testing of the biopsy specimen was positive for the PAX3/PAX7-FKHR chimeric gene, indicating the tumor was actually an alveolar rhabdomyosarcoma. The patient received a more intensive chemotherapy regimen and also was treated with proton-beam radiotherapy. After chemotherapy and proton irradiation, the patients tumor shrank considerably, and she remained in remission at over 3 years of follow up. This patient illustrates the new tools at the disposal of the orbital specialist including molecular genetic testing and proton-beam irradiation to diagnose and treat orbital rhabdomyosarcoma.

Re: "Drug-induced Graves disease from CTLA-4 receptor suppression".

Here, we took notice of the “heat generation” of this apparatus for hemostasis from the cortical bone. In usual sessions, the console is set at 70% to 90% in power and 15 ml/ minute in irrigation for safe and efficient bone curettage. With the integrated cooling function enhanced, the heat generation is reduced, leading to a lower hemostatic effect. To generate heat appropriately, we set the irrigation at 3 ml/minute and set the power at 30% to 40% to prevent excess bone curettage (Fig. A, B, and see Video, Supplemental Digital Content 1, available at http://links.lww.com/IOP/A65, which demonstrates hemostasis using the SONOPET UST-2001 during a lateral orbital decompression surgery). A dull tip is better than a fine one for this purpose. This procedure settles a troublesome problem of “hemorrhage from the cortical bone” and allows the oculoplastic surgeon to not worry about the postsurgical orbital hematoma.

Keratin Horn of the Palpebral Conjunctiva

Forty-six-year-old woman presented with a 2-month history of a progressively enlarging mass on the palpebral conjunctiva of the left lower eyelid. The lesion reportedly began as a flat white plaque, but it had recently developed a horn, grown large enough to cause spontaneous eyelid eversion, and be

Considerations in Pediatric Oculoplastic Examination

This chapter discusses the pediatric oculoplastic examination, provides tools and techniques to help aid what can be a challenging examination, and highlights important differences between the adult and pediatric examination.

Update on pediatric lacrimal disorders.

Children with tearing problems may present to the comprehensive ophthalmologist at any age. Although much of our understanding of the pathophysiology of lacrimal disorders has not changed over the recent years, treatment paradigms continue to evolve with newer devices and the options available. In the infant that presents with mattering and/or epiphora, conjunctivitis, blepharitis, and most importantly, congenital glaucoma need to be considered before diagnosis with congenital nasolacrimal duct obstruction (CNLDO). Rather than trying to acquire accurate Jones test measurements in an infant, we prefer to use the dye disappearance test to evaluate the tear drainage system. Topical anesthetic with fluorescein is placed into the fornix and the tear lake is evaluated with a blue light at 5 minutes. A normal drainage system should clear the dye by 5 minutes and the presence of fluorescein in the fornix suggests abnormal drainage. The typical approach to treating an infant with nasolacrimal duct obstruction is to manage conservatively with massage of the nasolacrimal duct system and observe. It has been shown that 90% of the obstructions resolve spontaneously by 1 year. We find it helpful to show the massage technique on the parent and the child so that the caregiver will carry out the massage correctly. Ophthalmic antibiotic ointment should be placed on the finger and firm pressure should be placed at the medial canthal angle and directed inferiorly. It has been shown that the hydrostatic pressure created by massage can help break some obstructions.