Dan B. Rootman

Cavernous venous malformations of the orbit (so-called cavernous haemangioma): a comprehensive evaluation of their clinical, imaging and histologic nature

Purpose The purpose of this investigation is to describe the clinical, imaging, histologic and flow dynamic characteristics of orbital cavernous haemangioma. Methods In this clinicopathologic series, clinical features were obtained from patient records. All imaging studies were reviewed. All specimens were reviewed with haematoxylin and eosin, and 10 were subject to a staining protocol including: Movat Pantachrome, periodic acid Schiff, D2-40, CD31, GLUT-1, Ki-67, vascular endothelial growth factor receptor 1 (VEGF-r1) (flt-1), VEGF-r2 (Flk-1), VEGF, anti-smooth muscle actin (SMA), CD20, CD4, CD8 and CD68. Imaging and pathology were reviewed in a systematic fashion. Results Clinically, lesions were more common in middle-aged females presenting with axial proptosis and pain. One-third demonstrated signs of optic nerve dysfunction. Dynamic imaging revealed focal early and diffuse late enhancement. Lesions demonstrated slow growth at 0.2 cm3/year. Histologically, all lesions demonstrated large vascular channels with mature-appearing endothelium and abundant stroma. Three salient features were noted and characterised: thrombosis, nests of perivascular hypercellularity and expanded stromal elements. Acute thrombosis was a feature of each specimen (<10% of channels). Fibrin clots were lined by a layer of CD31+ endothelium. Perivascular hypercellular areas stained uniformly with CD31 and less so with VEGFr2. Additionally, focal areas of Ki67+ and CD68+ cells were found in these regions. Expanded stroma contained CD31+ microcapillary networks and stained diffusely with anti-SMA. Conclusions Cavernous haemangioma demonstrate clinical features and growth characteristics of a benign mass. Dynamic imaging highlights their slow flow vascular nature. Histologically, the hypercellularity and stromal changes identified can be understood within the pathogenic context of thrombosis and recanalisation in an organised lesion.

Repair of eroded glaucoma drainage devices: mid-term outcomes.

Purpose:Glaucoma drainage devices (GDD) are used in the surgical management of medically refractory glaucoma. One late serious complication is erosion and exposure of the tube, clip, or plate. In this study, we evaluated the effectiveness of oral buccal mucous membrane allografts with corneal lamellar grafts for the repair of GDD erosions. Methods:Retrospective consecutive observational case series. All patients who underwent buccal membrane transplants with corneal allografts for the repair of GDD erosions between 2006 and 2010 were included in this study. Primary outcomes were categorized as: (a) success: coverage of the GDD without further repair; (b) qualified success: minor perioperative complications or additional procedures required to maintain success; or (c) failure: GDD reerosion requiring surgery. Results:Nineteen eyes from 17 patients with 20 GDDs were reviewed, of which there were 19 Ahmed valves and 1 Molteno implant. There were 16 cases of tube erosion, 2 cases of plate erosion, and 2 cases of pars plana clip erosion. The mean (SD) number of ocular surgeries before the buccal membrane transplant was 4.8 (2.9). The mean (SD) time to exposure from the original GDD procedure was 4.6 (3.7) years. Analysis of tube erosions alone showed a success rate of 94% after ≥1 buccal membrane repairs. Buccal membrane repairs in total were considered a surgical success in 85% of cases with a mean (SD) follow-up of 1.7 (1.2) years. Conclusions:Buccal membrane transplants are particularly useful in cases of tube erosion.

Glaucoma aqueous drainage device erosion repair with buccal mucous membrane grafts.

PurposeGlaucoma aqueous drainage devices are important and effective in the management of recalcitrant glaucoma. One complication of this procedure is erosion and exposure of the tube or plate. Strategies to re-cover glaucoma aqueous drainage devices in such cases have met with variable success. The majority of these interventions use conjunctiva for superficial coverage. However, conjunctiva can be in limited supply, and subject to reerosion. MethodsIn this report, we discuss the use of oral buccal mucous membrane in combination with a lamellar corneal patch graft for repair of 3 exposed tubes, 2 plates, and a pars plana clip. Mean time to exposure was 4.8 years. Five eyes from 4 patients are presented and the surgical technique is described. ResultsBuccal membrane repairs were considered a surgical success in 5 out of 6 cases (83%) with mean follow-up of 1.5 years. ConclusionsWe advocate the use of buccal membrane in the repair of glaucoma aqueous drainage device tube/plate erosions in patients for whom local conjunctiva is of variable quality or limited supply. Advantages of this procedure and tissue option are discussed.

Post-LASIK ectasia treated with intrastromal corneal ring segments and corneal crosslinking.

Corneal ectasia is a serious complication of laser in situ keratomileusis (LASIK). We report the case of a 29-year-old man who underwent LASIK in both eyes and in whom corneal ectasia developed in the left eye 3 years after surgery. He was treated sequentially with intraocular pressure-lowering medication, intrastromal corneal ring segment (ICRS) implants, and collagen cross-linking. Vision improved and the ectasia stabilized following treatment. Combined ICRS implantation and collagen cross-linking should be considered early in the management of post-LASIK ectasia.

Predictors of treatment failure for pneumatic retinopexy.

OBJECTIVE The purpose of this study was to define the overall anatomic success rate in pneumatic retinopexy and to identify morphologic features that may be predictive of treatment failure in pneumatic retinopexy. DESIGN AND PARTICIPANTS Prospective consecutive interventional case series of patients with new-onset primary rhegmatogenous retinal detachments treated with pneumatic retinopexy. METHODS In this interventional case series, consecutive patients with new-onset primary rhegmatogenous retinal detachments were treated with pneumatic retinopexy and followed prospectively. Morphologic data were collected on 3-colour fundus drawings. The primary outcome measure was treatment failure, defined as requirement for scleral buckle or vitrectomy within the follow-up period. Rates of failure for each morphologic feature were compared and a logistic regression model was fit. RESULTS A total of 113 eyes were included in the study. Anatomic success was achieved in 69.6% of patients. Morphologic criteria including the position and number of breaks, position and extent of lattice degeneration, size of the detached area, and macular status were all found not to be significantly related to failure. In multivariate analysis, only 3 predictors, pseudophakic status (p < 0.05, odds ratio [OR] 2.9, 95% CI, 1.06-7.88), presence of retinal break greater than 1 clock-hour (p < 0.05, OR 3.41, 1.06-11.02), and presence of grade C or D proliferative vitreoretinopathy (PVR) (p < 0.01, OR 31.83, 95% CI, 3.59-282.24), gained statistical significance. CONCLUSIONS Only pseudophakia, a large retinal break, and/or PVR was associated with an increased likelihood of failure.

Buccal mucous membrane for the reconstruction of complicated leaking trabeculectomy blebs.

PurposeLate onset trabeculectomy bleb leaks often require surgical repair to avoid hypotony and/or infection. Repair using local conjunctiva is typically performed. However, in cases in which local conjunctiva is limited and/or has failed, buccal mucous membrane can be used as a conjunctival substitute. MethodsFour cases of buccal mucous membrane repair for leaking trabeculectomy blebs are reported. Surgical technique is described. ResultsIn each case of bleb leak, multiple nonincisional techniques failed to control the leak. In 3 of 4 cases, earlier reconstruction attempts with conjunctival advancement and/or free flaps failed. Each was ultimately repaired with buccal membrane autograft. One case required additional minimally invasive procedures to control postoperative leaking. One case required a second adjacent buccal graft for leaking residual conjunctival bleb. Each graft was functioning well at most recent follow-up ranging from 1 to 17 months. DiscussionBuccal membrane is an abundant and effective conjunctival substitute for the repair of recalcitrant leaking trabeculectomy blebs. It may be useful in cases in which earlier conjunctival-based repairs have failed.

Sterile single use cover for the G-probe Transscleral Cyclodiode.

PurposeMultiuse of the G-probe transscleral cyclophotocoagulation (TSCPC) device can lead to contamination. We evaluated the mechanical stability and clinical efficacy of a disposable sterile barrier for the G-probe footplate. MethodsWe measured diode laser output with and without the G-probe barrier both before and after cadaver TSCPC (18 shots at 2000 mW for 2000mS). Qualitative analyses of the laser aiming beam were made before each trial in the barrier and nonbarrier state. After each trial, the G-probe barrier was examined for microperforations and footplate for debris and/or damage. Microbiology was taken on the cadaver eye and the G-probe before and after 20 cycles. Histologic analysis after TSCPC with and without barrier was carried out on a cadaver eye. ResultsQualitatively, laser focus dispersion was minimized by the G-probe cover. Mean (95% CI) laser output was measured for the nonbarrier, with barrier pre-TSCPC and with barrier post-TSCPC, respectively as 980 mW (899,1061), 1247 mW (1115, 1378), and 1240 mW (1132, 1347). The difference between the nonbarrier and barrier both preTSCPC and postTSCPC was statistically significant (df=2, F=36.26, P<0.01). No perforations in the G-probe barrier were evident and no debris or damage was detected on the G-probe. Pathology was consistent with earlier reports of TSCPC in cadaver eyes. Microbial segregation of the cadaver eye and the G-probe footplate was maintained. ConclusionsThe G-probe barrier is an effective and robust method to protect consecutive patients from contamination during TSCPC. Although energy levels were slightly higher in probes with barrier, histologic differences were not evident and the clinical significance of this finding is likely limited.