Curtis E. Margo

Basal cell carcinoma of the eyelid and periocular skin

Basal cell carcinoma is the most common human malignancy. This locally invasive tumor rarely metastasizes, but can cause considerable morbidity when on the eyelids and periocular skin. The successful management of BCC requires an awareness of its broad clinical spectrum and knowledge of the risk factors associated with therapeutic failure. The optimal therapy for basal cell carcinoma is controversial. Treatment strategy is formulated on an individual basis, taking into account tumor size, anatomic location, and growth pattern. The immune status and life expectancy of the patient also must be considered. While complete eradication of the tumor is desirable, this can be challenging since basal cell carcinomas often extend beyond their apparent clinical margins. Since prevention is preferable to treatment, the public needs to be informed that the incidence of periocular skin cancers can be reduced with the longterm use of sunscreens, sunglasses, and hats with brims.

Malignant tumors of the orbit: Analysis of the Florida cancer registry

PURPOSE The purpose of the study is to determine the relative frequency and incidence of primary malignant tumors of the orbit occurring in Florida. METHODS Cases of primary orbital malignancy were identified in the Florida Cancer Data System registry from 1981 through 1993. Analysis was restricted to persons who reside within the state. RESULTS Three hundred fourteen primary orbital malignancies were reported; 55% of malignant orbital tumors were lymphoma. The average annual incidence for all malignancies was 2 cases per million. There was a steady increase in the annual incidence of orbital malignancy during the 13 years of the study. Lymphoma showed the greatest rise in annual incidence. The average annual incidence of lymphoma increased 166% the last 6 years of the study compared to the first 6 years. CONCLUSIONS A large increase in orbital lymphoma was documented in the Florida cancer registry from 1981 through 1993. The increase in incidence cannot be explained by improved compliance in reporting or by the small increase in incidence of systemic lymphoma during the survey period. Additional studies are needed to determine whether the observed increase in incidence in orbital lymphoma is genuine or spurious.

Cystoid macular edema associated with latanoprost in aphakic and pseudophakic eyes

PURPOSE To describe four patients who developed cystoid macular edema shortly after onset of treatment with latanoprost. METHOD Retrospective review of medical records of patients with open-angle glaucoma who developed cystoid macular edema shortly after starting latanoprost. RESULTS The use of topical latanoprost was temporally related to the development of cystoid macular edema in four patients (six eyes; two aphakic eyes and four pseudophakic eyes). Cystoid macular edema resolved in all patients after latanoprost was discontinued. CONCLUSIONS Cystoid macular edema is a potential complication of latanoprost therapy. Further observations are needed to determine if the risk of cystoid macular edema is limited to or greatest in patients who are pseudophakic or aphakic.

Retinal implants: a systematic review.

Retinal implants present an innovative way of restoring sight in degenerative retinal diseases. Previous reviews of research progress were written by groups developing their own devices. This systematic review objectively compares selected models by examining publications describing five representative retinal prostheses: Argus II, Boston Retinal Implant Project, Epi-Ret 3, Intelligent Medical Implants (IMI) and Alpha-IMS (Retina Implant AG). Publications were analysed using three criteria for interim success: clinical availability, vision restoration potential and long-term biocompatibility. Clinical availability: Argus II is the only device with FDA approval. Argus II and Alpha-IMS have both received the European CE Marking. All others are in clinical trials, except the Boston Retinal Implant, which is in animal studies. Vision restoration: resolution theoretically correlates with electrode number. Among devices with external cameras, the Boston Retinal Implant leads with 100 electrodes, followed by Argus II with 60 electrodes and visual acuity of 20/1262. Instead of an external camera, Alpha-IMS uses a photodiode system dependent on natural eye movements and can deliver visual acuity up to 20/546. Long-term compatibility: IMI offers iterative learning; Epi-Ret 3 is a fully intraocular device; Alpha-IMS uses intraocular photosensitive elements. Merging the results of these three criteria, Alpha-IMS is the most likely to achieve long-term success decades later, beyond current clinical availability.

Fingolimod (FTY720) as an Acute Rescue Therapy for Intraocular Inflammatory Disease

OBJECTIVES To compare the inflammatory reaction associated with the insertion of silicone and polypropylene endplates and endplates made of a new biocompatible polymer, Vivathane, in the rabbit subconjunctival space. METHODS Similar-sized endplates made of 3 different biomaterials were sutured to the sclera in the superotemporal quadrant of the rabbit eye. Thirty eyes of 15 albino New Zealand rabbits were randomly assigned to the 3 groups. Conjunctival vascular hyperemia was graded in a masked fashion among groups. At the end of 3 weeks, the enucleated eyes were examined histologically and using scanning electron microscopy. RESULTS Polypropylene and Vivathane were associated with significantly more inflammation in clinical observations and based on histological grading. Silicone was associated with the least amount of inflammation. Three polypropylene and 1 Vivathane plate were extruded between the second and third week. CONCLUSIONS Silicone is the most inert of the 3 materials tested. Inflammation associated with biomaterials may contribute to the failure of the glaucoma drainage devices. CLINICAL RELEVANCE Bleb inflammation may be related to the biomaterial being used as the endplate. Endplates should be handled carefully during surgery to avoid creating rough spots.

Wegener's Granulomatosis

Clinical manifestations of Wegeners granulomatosis are nonspecific and indistinguishable from a variety of neoplastic, infectious, and inflammatory diseases. Ophthalmic disease is the presenting feature in nearly one sixth of patients with Wegeners granulomatosis and will ultimately develop in a majority. The discovery of antineutrophil cytoplasmic antibodies, particularly antiproteinase-3, has changed the clinical approach to evaluating patients suspected of having Wegeners granulomatosis. These antibodies are distinguished from other related autoantibodies because they produce a coarse granular pattern of cytoplasmic staining on indirect immunofluorescence with ethanol-fixed neutrophils. Treatment of Wegeners granulomatosis with oral cyclophosphamide and corticosteroids has decreased morbidity and improved survival, but side effects from long-term immunosuppressive therapy are common and sometimes serious. The effectiveness of trimethoprim-sulfamethoxazole in decreasing the number and severity of recurrences of Wegeners granulomatosis is being investigated. It remains to be determined if wide use of trimethoprim-sulfamethoxazole in limited Wegeners granulomatosis could further improve the quality of life for some patients.

Congenital aniridia: a histopathologic study of the anterior segment in children

Seven eyes from seven children with congenital aniridia were studied histologically in order to assess the relationship between congenital and acquired abnormalities. At the time of enucleation the children ranged in age from six days to 14 years. There was no history of previous intraocular surgery in any of the children. Besides iridic and ciliary body hypoplasia three congenital abnormalities of the anterior segment were noted: anomalous development of the anterior chamber angle, incomplete cleavage of the anterior chamber angle, and attenuation of Bowmans membrane. Three acquired abnormalities of the anterior segment were identified: corneal pannus, peripheral anterior synechiae, and lenticular degeneration. The two cases showing anomalous development of the anterior chamber angle occurred in children with a partial deletion of the short arm of chromosome 11.

The Collaborative Ocular Melanoma study: An overview

BACKGROUND The Collaborative Ocular Melanoma Study (COMS) is a 3-arm study that includes two multicenter randomized clinical trials designed to compare the effectiveness of brachytherapy to enucleation for treatment of medium-size choroidal melanomas, and the effectiveness of enucleation with and without preoperative external-beam radiotherapy for large choroidal melanomas. The third arm is an observational study of small choroidal melanomas. Patient accrual ran from 1987 to 1998. METHODS A review of COMS published reports was conducted. RESULTS There is no difference in 5-year all-cause mortality for large- and medium-size choroidal melanomas with COMS-designated treatments. Preoperative radiation for large choroidal melanomas does not improve survival. The accuracy of the clinical diagnosis of choroidal melanoma is excellent. CONCLUSIONS Data from the trials are still being collected and analyzed, but primary outcomes will unlikely change significantly in the future. Similar rates of mortality after treatment with enucleation and brachytherapy shift the emphasis of selection of therapy to secondary outcomes such as preservation of vision. The findings highlight the need to better understand the biological mechanisms and timing of hematogenous dissemination to achieve an appreciable impact on choroidal melanoma survival.

The Placebo Effect

Placebos have been traditionally regarded as deceptive therapies and have not been understood in the broader context of social symbols and of interpersonal factors that surround the healing process itself. Although the power of inert substances to heal is well recognized, the placebo effect also influences the outcome of conventional therapies. The role of the placebo in modern medicine is poorly defined because of a lack of a common understanding of what the placebo effect is and because of the negative connotions associated with its use. The response rate to placebo varies by illness. The natural course of disease and patient or physician bias can be misinterpreted as a placebo response. In research, the placebo effect is therapeutic noise to be removed by placebo-controlled trials. Few studies are designed to measure the placebo response rate directly. Placebos are a reminder of how little is known about mind-body interaction. The placebo effect may be one of the most versatile and underused therapeutic tools at the disposal of physicians.

Tilted Optic Disks

Tilted optic disks are a common finding in the general population. An expression of anomalous human development, the tilted disk appears rotated and tilted along its axes. Visual sequelae described with tilted optic disks include myopia, astigmatism, visual field loss, deficient color vision, and retinal abnormalities. Although the natural course of tilted optic disks is nonprogressive, the anomaly can be mistaken for tumors of the anterior visual pathway, edema of the optic nerve head, or glaucoma. A thorough examination of patients with tilted disk includes refraction, dilated fundus examination, and visual field testing. At times, neuroimaging may be necessary to arrive at the correct diagnosis. Until normative data are validated for tilted disks, the role of new imaging technologies for the optic nerve head is limited. Familiarity with the spectrum of ophthalmoscopic appearance and the clinical manifestations of tilted disks may be the most critical factors in avoiding misdiagnosis.