Ezekiel Weis

Epithelial lacrimal gland tumors: pathologic classification and current understanding.

OBJECTIVE To apply the updated epithelial salivary gland classification scheme to a large cohort of lacrimal gland tumors so as to provide an updated lacrimal gland tumor classification scheme. METHODS A retrospective multicenter cohort study of 118 cases of epithelial neoplasia was undertaken. Main outcome measures included pathologic analysis, subtyping, and survival. RESULTS Of 118 cases, 17 (14%) were reclassified using the proposed expanded classification scheme based on the current World Health Organization classification of salivary gland tumors. The most frequent neoplasms were pleomorphic adenoma and adenoid cystic carcinoma, of which we highlight more unusual histologic features. Three tumors were found to be unclassifiable with the updated scheme, with 2 having histologically malignant features. Deficiencies and variations in pathologic assessment were noted. Variation in the histologic findings of pleomorphic adenoma and assessment of the extent of invasion of carcinoma ex pleomorphic adenoma were highlighted. CONCLUSIONS The use of the more histologically diverse classification of salivary gland tumors can be successfully applied to the epithelial lacrimal gland neoplasms. This expanded classification system led to reclassifying 14% of cases. Currently, there are no consistent pathologic standards for processing and evaluating these lesions.

Thyroid associated orbitopathy

Thyroid associated orbitopathy, also known as Graves’ orbitopathy, is typically a self-limiting autoimmune process associated with dysthyroid states. The clinical presentation may vary from very mild disease to severe irreversible sight-threatening complications. Despite ongoing basic science and clinical research, the pathogenesis and highly effective therapeutic strategies remain elusive. The present article reviews the pathophysiology, clinical presentation, and management of this common, yet poorly understood disease, which remains a challenge to the ophthalmologist.

Primary radiotherapy in progressive optic nerve sheath meningiomas: a long-term follow-up study

Background/aims To report the outcome of primary radiotherapy in patients with progressive optic nerve sheath meningioma (ONSM). Methods The clinical records of all patients were reviewed in a retrospective, observational, multicentre study. Results Thirty-four consecutive patients were included. Twenty-six women and eight men received conventional or stereotactic fractionated radiotherapy, and were followed for a median 58 (range 51–156) months. Fourteen eyes (41%) showed improved visual acuity of at least two lines on the Snellen chart. In 17 (50%) eyes, the vision stabilised, while deterioration was noted in three eyes (9%). The visual outcome was not associated with age at the time of radiotherapy (p=0.83), sex (p=0.43), visual acuity at the time of presentation (p=0.22) or type of radiotherapy (p=0.35). Optic disc swelling was associated with improved visual acuity (p<0.01) and 4/11 patients with optic atrophy also showed improvement. Long-term complications were dry eyes in five patients, cataracts in three, and mild radiation retinopathy in four. Conclusion Primary radiotherapy for patients with ONSM is associated with long-term improvement of visual acuity and few adverse effects.

Comparison of stereoscopic digital imaging and slide film photography in the identification of macular degeneration

BACKGROUND This study compared the sensitivity and specificity of stereoscopic digital photography of the retina through a dilated pupil with a 45 degrees nonmydriatic camera and Joint Photographic Experts Group (JPEG) compression of the images with the sensitivity and specificity of 35-mm slide film photography in the identification of age-related macular degeneration (AMD). METHODS Consecutive patients with a diagnosis of AMD were enrolled. Stereoscopic retinal images of the disc, macula and temporal macula were captured with a digital 45 degrees nonmydriatic camera (then compressed into JPEG format) and with a standard fundus camera and slide film. A single retinal specialist graded both image formats in masked fashion, at least 1 month apart, using a modified Age-Related Eye Disease Study (AREDS) severity scale. The digital images were displayed on a monitor and viewed with the use of liquid crystal display shutter glasses and stereo imaging software. The film images were mounted on a light box and graded with the use of a stereoviewer. Primary outcome measures included the presence or absence of AMD pathological features. Positive and negative predictive values (PPVs and NPVs), sensitivity, specificity and weighted kappaw statistics were calculated. RESULTS We photographed 203 eyes (of 103 patients) with both digital and slide film cameras. Correlation of the 2 image formats was substantial in identifying AREDS level 3a or greater (kappaw=0.64, standard error=0.08, PPV=0.95, NPV=0.66, sensitivity=0.93, specificity=0.74) and excellent in identifying level 4b or greater (kappaw=0.83, standard error=0.05, PPV=0.81, NPV=0.98, sensitivity=0.94, specificity=0.94). INTERPRETATION High-resolution stereoscopic, mydriatic, 45 degrees digital images captured with a nonmydriatic camera and JPEG compressed correlate well with stereoscopic slide film photographs in the identification of moderate to advanced AMD (AREDS level 3a or greater).

Quantitative Computed Tomographic Predictors of Compressive Optic Neuropathy in Patients with Thyroid Orbitopathy: A Volumetric Analysis

PURPOSE To evaluate the relationship between orbital bony geometry and the volume of the intraorbital structures in predicting compressive dysthyroid optic neuropathy (DON). DESIGN Retrospective, consecutive case series. PARTICIPANTS Images of 198 orbits from 99 patients suffering from thyroid-related orbitopathy were reviewed. METHODS Clinical examination and computed tomography of the orbits, including volumetric analysis, were performed on all patients. MAIN OUTCOME MEASURES Clinical and radiologic predictors of DON. RESULTS Significant volumetric univariate predictors of compressive optic neuropathy included medial rectus volume (P = 0.005), lateral rectus volume (P = 0.011), superior muscle group volume (P = 0.04), and total rectus muscle volume (P = 0.015). Inferior rectus muscle volume, orbital volume, bony orbital apex angle, globe diameter, and bony medial wall contour were not associated with optic neuropathy. Multivariate modeling found medial rectus volume the only independently significant predictor. Univariate modeling of simple rectus diameter measurements found medial rectus axial diameter (P = 0.003) and total recti diameter (P = 0.016) predictive of optic neuropathy. Lateral rectus, superior rectus, and inferior rectus diameters were not predictive. Multivariate modeling found only medial rectus diameter to be a significant independent predictor of optic neuropathy. The area under the receiver operating characteristic curve was not different between the volumetric and rectus diameter curves. CONCLUSIONS Medial rectus size was found to be the most important quantifiable predictor of compressive optic neuropathy in patients with optic neuropathy. In this study, simple maximum medial rectus diameter, as measured on axial scans, was equally predictive of compressive optic neuropathy as the more involved volumetric calculation. Assessment of orbital geometry, including bowing of the medial wall, orbital apex angle, globe diameter, and orbital volume, were not found to be predictive of DON.

Discussing resident participation in cataract surgery

OBJECTIVE To investigate the proportion of patients who would consent to resident participation in cataract surgery. STUDY DESIGN Prospective observational case series. PARTICIPANTS Consecutive series of patients presenting for consideration of cataract surgery. METHODS A specifically worded discussion of resident participation in cataract surgery was developed on the basis of literature recommendations and was used when obtaining consent for cataract surgery from eligible patients. The main outcome measure was the proportion of patients who consented to resident participation in their cataract surgery. RESULTS Of the 106 patients eligible for enrollment in the study, 101 (95.3%) consented to resident participation in their cataract surgery. CONCLUSIONS Despite suggestions in the previous literature to the contrary, surgeons can be reassured that the vast majority of patients, when informed by means of the wording described in this study, will consent to resident participation in their cataract surgery.

Intravitreal bevacizumab alone versus combined verteporfin photodynamic therapy and intravitreal bevacizumab for choroidal neovascularization in age-related macular degeneration: visual acuity after 1 year of follow-up.

Purpose: The purpose of the study was to compare the mean change in visual acuity between bevacizumab and combined bevacizumab and photodynamic therapy for the treatment of choroidal neovascularization from age-related macular degeneration after 12 months of follow-up. Methods: This study included a retrospective cohort of patients with untreated choroidal neovascularization. The generalized estimating equation was used to account for the correlation between eyes and to construct multivariate models to control for confounding factors of visual acuity change. Results: One hundred and thirty-nine eyes treated with bevacizumab were compared with 236 eyes that received bevacizumab and photodynamic therapy (combination treatment). The monotherapy eyes showed an improvement of 0.101 ± 0.619 logarithm of minimum angle of resolution units (5.05 letters) after a mean follow-up of 409.6 days versus 0.096 ± 0.611 (4.8 letters) after a mean follow-up of 416.7 days with combination therapy; there was no difference between the groups (P = 0.970). The monotherapy eyes received 3.32 ± 1.71 injections versus 3.14 ± 1.52 injections in the combination therapy group (P = 0.665). The multivariate analysis did not show any difference between groups at the end of the study period in terms of visual improvement, worsening, stabilization, or the number of bevacizumab injections used. Conclusion: Long-term visual outcomes for the treatment of choroidal neovascularization in age-related macular degeneration are not improved with the addition of photodynamic therapy to bevacizumab nor are fewer injections needed.

A retrospective cohort study of radial optic neurotomy for severe central retinal vein occlusions

BACKGROUND Radial optic neurotomy (RON) is a new surgical procedure that has, until now, been studied only in a case series format. This study was designed to evaluate the efficacy of RON in improving visual acuity in patients suffering from central retinal vein occlusion (CRVO) with visual acuity equal to or worse than 20/100. METHODS A retrospective cohort study was conducted of consecutive CRVO patients, consisting of 19 who underwent RON and 38 observation subjects matched on presenting visual acuity. RESULTS The observation group worsened by 0.25 logMAR units from baseline, whereas the surgery group improved by 0.29 logMAR. Multivariate linear regression modelling found that, having controlled for other significant predictors and confounders, the change in visual acuity in the surgery patients was 0.63 logMAR units better than in the observation patients. INTERPRETATION Our data suggest that RON is a promising treatment for visual acuity loss in severe CRVO causing visual acuity equal to or worse than 20/100. These results should be interpreted cautiously because of the limitations of the study, including the retrospective study design and the use of Snellen visual acuity. Our data suggest that further evaluation of RON is warranted.

Endoscopic vidian neurectomy: a prospective case series.

Chronic refractory vasomotor rhinitis (VMR) is a debilitating condition that causes significant impairment of quality of life. The purpose of this study is to investigate the efficacy and potential side effects of endoscopic vidian neurectomy as treatment for patients with VMR.

Incidence of discordant temporal artery biopsy in the diagnosis of giant cell arteritis.

OBJECTIVE We investigated the rate of discordant biopsy results (i.e., 1 side negative, 1 side positive) in patients who underwent initial bilateral temporal artery biopsies for suspected giant cell arteritis (GCA). DESIGN A cohort study. PARTICIPANTS Consecutive patients undergoing temporal artery biopsy were enrolled. Of the 259 patients enrolled, 250 underwent initial bilateral temporal artery biopsies. METHODS Positive biopsies were defined based on accepted histologic definitions. Healed arteritis was considered a positive result. Clinical information was collected for all patients using a questionnaire administered by an ophthalmologist. Pathology results, including biopsy length (as measured by the pathologist), and laboratory information (i.e., serum erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP] levels) were collected from digital patient records for statistical analysis. The main outcome was the rate of discordant biopsy in consecutive patients who underwent initial bilateral temporal artery biopsy. RESULTS Giant cell arteritis was confirmed in 62 (24.2%) of the 250 patients, including 3 patients with biopsies recorded as healed arteritis. The rate of discordant biopsy was 4.4% with 11 unilaterally positive biopsies. There was no statistical difference between the length of the left- and right-sided biopsies in either the unilaterally or bilaterally positive groups (p = 0.13 and p = 0.79, respectively). The average maximum ESR value for the bilateral group (58.7 mm/h) was significantly higher than the average maximum ESR value for the unilateral group (30.7 mm/h, p = 0.03). The average maximum CRP value for the bilateral group was 59.2 mg/L and 28.6 mg/L for the unilateral group (p = 0.30). Discordance between the localization of symptoms and the side of positive biopsy occurred in 3 patients (i.e., 3 patients had left-sided symptoms only, yet a right-sided positive biopsy). CONCLUSIONS The rate of discordant biopsies in patients who underwent initial bilateral temporal artery biopsies was considerable in our patient cohort. Given this reasonably high rate of discordance between sides, as well as the lack of correlation between side of positivity and laterality of presenting symptoms, we recommend initial bilateral temporal artery biopsies to enhance the diagnostic certainty of the disease.