Geoffrey E. Rose

Histological features of ocular adnexal lymphoma (REAL classification) and their association with patient morbidity and survival

BACKGROUND The histological characteristics of ocular adnexal lymphomas have previously provided only a limited guide to clinical outcome for affected patients. This clinicopathological relation was re-examined using the Revised European American Lymphoma (REAL) system to classify the tumours in a large cohort of patients. METHODS The biopsies and clinical follow up data for 192 patients with ocular adnexal lymphoma were reviewed, the biopsies being regraded in accordance with the REAL classification. For each of five histological groups, logistic regression analysis was used to determine the odds ratios (OR) for the presence of systemic disease at the time of orbital diagnosis and Cox regression analysis was used to assess the hazard ratios (HR) for disseminated disease and lymphoma related death. For 108 patients in whom extraorbital spread occurred, the histological category of lymphoma was compared with the sites of dissemination. RESULTS At presentation, the frequency of previous or concurrent extraorbital disease increased from marginal zone lymphoma (OR 1.0), diffuse lymphoplasmacytic/lymphoplasmacytoid lymphoma (OR 2.3), follicle centre lymphoma (OR 3.8), diffuse large B cell lymphoma (OR 4.0) to other histological lymphoma variants (OR 26.8). For all histological types, the estimated risk of extraorbital disease and lymphoma related death continued for many years and the proportion of patients with at least one extraorbital recurrence after 5 years was 47% for MZL, 48% for LPL, 64% for FCL, 81% for DLCL, and 95% for other lymphoma variants. The corresponding estimated rates for 5 year lymphoma related mortality were 12%, 19%, 22%, 48%, and 53% respectively. CONCLUSIONS Patients with ocular adnexal lymphoma can be classified by REAL into five distinct groups, which show a progressive increase in the risks of extraorbital disease at diagnosis, of disease dissemination with time, and of tumour related death.

Primary malignant neoplasms of the lacrimal gland.

The clinical characteristics and outcome of 50 primary malignant neoplasms of the lacrimal gland are reviewed: 38 (76%) adenoid cystic carcinomas, six (12%) carcinomas arising in pleomorphic adenoma, and six (12%) adenocarcinomas or other types of carcinoma. Most patients presented with a short history and pain, though pain tended to occur less often and later with adenocarcinoma than with adenoid cystic carcinoma. Pain was unrelated to the duration of symptoms, invasion of bone, loss of trigeminal nerve function, or the frequency and time of tumour recurrence. The estimated disease-free survival for patients with adenoid cystic carcinoma was significantly (p less than 0.01) reduced where half or more of the biopsy specimen showed basaloid differentiation. Eleven patients underwent extended cranio-orbital resection, and the others received a combination of total dacryoadenectomy adenectomy and/or radiotherapy. Survival after adenoid cystic carcinomas appears to be significantly (p less than 0.05) greater when tumour resection is combined with radiotherapy than after radiotherapy alone. At present, however, the rate of disease-free survival after treatment of adenoid cystic carcinoma appears unaltered by cranio-orbital resection, though these latter patients form a relatively greater proportion of those surviving for more than 10 years. Further long-term follow-up is needed to see if this technique does influence survival.

Factors affecting the success of nasolacrimal duct probing for congenital nasolacrimal duct obstruction

PURPOSE To ascertain the effect of certain parameters on nasolacrimal duct probing. METHODS In a retrospective study of 142 infants and children who underwent nasolacrimal duct probing for congenital nasolacrimal duct obstruction, age at time of probing, gender, symptom severity, presence of mucous discharge, and history of probing were correlated with success of nasolacrimal probing. Success of probing was defined as complete resolution of signs and symptoms of nasolacrimal duct obstruction. Chi-square test was used to analyze covariance. RESULTS Success of nasolacrimal duct probing was negatively correlated with increasing age: 92%, 89%, 80%, 71%, and 42% at age 12, 24, 36, 48, and 60 months, respectively (P = .001 at each interval). Increasing severity of epiphora was correlated with increased failure of nasolacrimal duct probing (P = .05). CONCLUSIONS Although the success of nasolacrimal duct probing declines with age, probing in older children can remain the first line of treatment. Because increasing frequency of epiphora correlates with failure of nasolacrimal duct probing, children with daily epiphora should undergo early nasolacrimal duct probing.

Clinical features associated with survival of patients with lymphoma of the ocular adnexa

AbstractPurpose Although systemic or eyelid involvement by ocular adnexal lymphoma carries a worse prognosis, there have been few reports of the outcome in relation to clinical presentation. The outcome of malignant ocular adnexal lymphoma was, therefore, related to presenting clinical symptoms and signs.Design and Methods A retrospective, noncomparative case-note review of 326 patients treated in the Orbital Clinic at Moorfields Eye Hospital. The associations between presenting symptoms or signs and three outcome measures (v.i.) were assessed by univariate and multiple variable regression together with Kaplan–Meier analysis.Main Outcome Measures (i) Presence of extra-orbital disease at the time of presentation; (ii) development of systemic lymphoma after new presentation with solely ocular adnexal disease; and (iii) death attributable to widespread lymphoma.Results Presentation with disseminated disease was rarer with over 1 years ophthalmic symptoms (odds ratio (OR) 0.7; 95% CI 0.5–0.9) and much more frequent with bilateral adnexal disease (OR 5.8; 95% CI 3.0–11.2). With solely adnexal disease at presentation, subsequent extra-orbital lymphoma was more frequent and earlier with lacrimal gland disease (as compared to those without; hazard ratio (HR) 1.9; 95% CI 1.2–4.5) or with eyelid disease (compared to those without; HR 2.4; 95% CI 1.2–4.5), or with bilateral disease (compared to unilateral disease; HR 2.6; 95% CI 1.4–5.2).Prior or concurrent systemic disease was the most significant predictive factor for lymphoma-related death (HR 6.8; 95% CI 4.3–10.9), but tumour-related death was also commoner and earlier with bilateral disease (HR 2.4; 95% CI 1.4–4.0) or where a relative afferent papillary defect was present (HR 2.8; 95% CI 1.6–4.9). Similarly, the rate of tumour-related death was slightly less where symptoms had been present for more than a year (HR 0.8; 95% CI 0.7–1.0) and slightly greater in the elderly (HR 1.03; 95% CI 1.01–1.05). Conjunctival lymphoma had the lowest rate of extra-orbital spread and lymphoma-related death, the rate of these two events being sequentially greater for patients with predominantly deep orbital lymphoma, lacrimal gland lymphoma, or eyelid lymphoma.Conclusion These data suggest that presenting symptoms and signs of patients with ocular adnexal lymphoma are significantly associated with the risk of systemic disease at orbital presentation, the rate of subsequent spread, and the rate of lymphoma-related death.

Outcome of Orbital Myositis: Clinical Features Associated with Recurrence

PURPOSE Although orbital myositis usually responds to prompt systemic therapy, recurrent or persistent episodes often require prolonged therapy. This study presents the clinical and radiologic features of 26 patients with orbital myositis and suggests a treatment regimen with special emphasis on recurrent or persistent orbital myositis. METHODS Retrospective analysis and comparison of clinical and radiologic parameters with clinical outcome in 26 patients with strictly defined orbital myositis was performed. A consultant radiologist reviewed computed tomography studies without knowledge of the clinical data or outcome. The frequency of certain clinical and radiologic parameters among two outcome groups was analyzed using Fishers exact test. RESULTS Comparison of clinical and radiologic features of 20 patients with a single acute episode and 6 patients with recurrent episodes disclosed several characteristics associated with recurrence. Male gender, lack of proptosis, eyelid retraction, horizontal extraocular muscle (EOM) involvement, multiple or bilateral EOM involvement (P = 0.05), muscle tendon sparing, and lack of response to systemic corticosteroids (P = 0.01), or nonsteroidal anti-inflammatory agents (P = 0.01) were associated with recurrent orbital myositis. CONCLUSIONS A treatment algorithm is suggested for patients with orbital myositis. Those patients whose clinical or radiologic features are associated with recurrence may benefit from early systemic steroid therapy.

Major orbital complications of endoscopic sinus surgery.

BACKGROUND The paranasal sinuses are intimately related to the orbit and consequently sinus disease or surgery may cause severe orbital complications. Complications are rare but can result in serious morbidity, the most devastating of which is severe visual loss. METHODS A retrospective review was undertaken of four cases of severe orbital trauma during endoscopic sinus surgery. RESULTS All the cases suffered medial rectus damage, one had additional injury to the inferior rectus and oblique, and two patients were blinded as a result of direct damage to the optic nerve or its blood supply. CONCLUSION Some ophthalmic complications of endoscopic sinus surgery are highlighted, the mechanisms responsible are discussed, and recommendations for prevention, early recognition, and management are proposed.

Autogenous hard palate mucosa: the ideal lower eyelid spacer?

BACKGROUND/AIMS Raising a displaced lower eyelid frequently involves recession of the lower eyelid retractors with interposition of a “spacer,” and several materials for this purpose have been described. This study reviewed the results of autogenous palatal mucosa in the treatment of lower eyelid displacement, including assessment of any donor site morbidity. METHODS A retrospective case note review of consecutive patients treated at Moorfields Eye Hospital between 1993 and 1998. All patients underwent insertion of hard palate mucosa between the inferior border of the tarsus and the recessed conjunctiva and lower eyelid retractors. Parameters studied included the underlying diagnosis, measurements of lower lid displacement or retraction, related previous surgery, the experience of the operating surgeon, intraoperative and postoperative complications, surgical outcome, and length of follow up. The main outcome measure was the position of the lower eyelid relative to the globe in primary position of gaze. RESULTS 102 lower eyelids of 68 patients were included and a satisfactory lid position was achieved in 87/102 (85%), with inadequate lengthening or significant recurrence of displacement occurring in 15 cases. Donor site haemorrhage requiring treatment in the early postoperative period occurred in seven patients (10%). CONCLUSION Autogenous hard palate mucosa is an effective eyelid spacer and provides good long term support for the lower eyelid. Donor site complications are the main disadvantage, but may be minimised by attention to meticulous surgical technique and appropriate postoperative management.

Ultrasonic assessment of rhinostomy size following external dacryocystorhinostomy

AIM To assess the dimensions and patency of the surgical epithelial fistula after external dacryocystorhinostomy, using B mode ultrasonography to define the postoperative soft tissue anastomosis. METHODS 12 patients undergoing 16 external dacryocystorhinostomies, with the creation of large osteotomies, were included in a prospective study. The horizontal and vertical dimensions of the bone ostium was recorded during surgery and compared with the ultrasonographic dimensions of the soft tissue anastomosis at 1 day, 2 weeks, and 6 months after surgery. Functional patency was confirmed with dye testing and irrigation. RESULTS Compared with an osteotomy of between 100 and 380 mm2 (mean 235 mm2), the soft tissue anastomosis on the day after surgery was, in all cases, markedly smaller (72–252 mm2; mean 144 mm2, or 61% of the bone window). The soft tissue anastomosis decreased to between 8 and 208 mm2 (mean 98 mm2; 68% of immediate postoperative value) at 2 weeks and 3–208 mm2 (mean 71 mm2; 49% of immediate postoperative value) at 6 months. 14 of the 16 (88%) dacryocystorhinostomies were functional at the end of the study, the two failures being associated with marked contracture of the soft tissue anastomosis; the outcome of surgery correlated significantly with the area of the anastomosis at 2 weeks (χ2 = 16.3; p<0.01) and at 6 months (χ2= 16.0, p= 0.01). CONCLUSIONS B mode ultrasonography provides a simple and effective method for assessing the size of the soft tissue anastomosis after external dacryocystorhinostomy and there is a significant reduction in size after surgery, to which the functional outcome of surgery appears related. As the initial soft tissue anastomosis cannot be larger than (and is, on average, about 60% of) the area of the osteotomy, this emphasises the paramount importance of a large rhinostomy to the success of lacrimal surgery.

The effect of silicone intubation on failure and infection rates after dacryocystorhinostomy.

Of 388 cases of dacryocystorhinostomy eligible for silicone intubation, intubation was used in 238 (61%) and not used in 150 (39%). The indications for intubation were canalicular disease or sac characteristics predisposing to failure. No significant difference was found in the rate of failure (.5 < P < 1.0) or soft-tissue infection (.25 < P < .5) for either primary or repeated surgery. Antibiotic prophylaxis did not alter these risks in relation to silicone intubation.

Involutional lower lid entropion: to shorten or not to shorten?

OBJECTIVE Involutional entropion of the lower eyelid is a common problem in the aging population, and manifest horizontal laxity is often present. The authors therefore examined the cure rate, dependent on whether the lid had been shortened horizontally. DESIGN A retrospective case series. PARTICIPANTS Five hundred eighty-three surgical records of entropion surgery at Moorfields Eye Hospital over a 4-year period (1993-1996, inclusive) were examined, and those patients with involutional entropion and adequate follow-up data were selected. INTERVENTION One hundred eighty of the 313 primary procedures included horizontal shortening, as did 28 of the 47 reoperations for recurrent entropion or consecutive ectropion. MAIN OUTCOME MEASURES Surgical success was analyzed after primary correction or after reoperation, and the groups were compared with respect to age, gender, and length of follow-up. RESULTS A cure after primary surgery was achieved in 178 (99%) of 180 patients in whom the lower eyelid was shortened compared with 104 (78%) of 133 patients in whom the eyelid was not shortened (P < 0.001). Reoperation for recurrent eyelid malposition cured 28 (100%) of 28 patients if the eyelid was shortened and 12 (63%) of 19 patients if the eyelid was not shortened (P < 0.001). CONCLUSIONS Recurrent malposition of the eyelid was significantly more likely when horizontal eyelid shortening was not included at either primary repair or at reoperation for recurrence or overcorrection. As horizontal laxity is probably the main pathogenic factor for age-related entropion, it is doubtful whether surgical correction without horizontal shortening of the eyelid has any role in the treatment of this condition.