George B. Peters

Management and prognosis of merkel cell carcinoma of the eyelid

OBJECTIVE To evaluate the clinical presentation, treatment, and long-term follow-up of eyelid Merkel cell carcinoma. DESIGN Retrospective noncomparative interventional case series. PARTICIPANTS Fourteen patients with primary eyelid Merkel cell carcinoma. METHODS Cases of Merkel cell carcinoma for which long-term follow-up was available were solicited from members of the American Society of Ophthalmic Plastic and Reconstructive Surgery through an on-line e-mail/news group. MAIN OUTCOME MEASURES Follow-up period, treatment history, presence and type of recurrence, and mortality. RESULTS Average follow-up was 33.4 months. Of the 14 cases identified, only 2 patients (14%) received prophylactic therapy beyond wide surgical excision. Three patients (21%) had recurrences, none of whom initially received prophylactic therapy (i.e., radiation therapy, lymph node dissection, and/or chemotherapy) beyond wide surgical excision. One patient (7%) died of metastatic Merkel cell carcinoma. CONCLUSIONS Merkel cell carcinoma is a rare skin malignancy that occasionally affects the eyelid, with the potential for regional and distant metastasis. Consideration should be given to the use of prophylactic adjunctive therapies beyond wide surgical excision while simultaneously considering the morbidity of these therapies.

Vitreous Penetration Of Topical Moxifloxacin And Gatifloxacin In Humans

Purpose: To determine the vitreous penetration of the new fourth-generation topical fluoroquinolones moxifloxacin 0.5% and gatifloxacin 0.3%. Methods: A prospective randomized clinical trial comprising 12 eyes of 12 patients scheduled for pars plana vitrectomy between August 2003 and September 2003 was performed in a clinical practice. The patients were randomly assigned to receive topical moxifloxacin 0.5% (n = 6) or gatifloxacin 0.3% (n = 6). One half the patients in each antibiotic group received 1 drop every 15 minutes for a total of 3 doses starting 1 hour before surgery, and the other one half self-administered the antibiotic drop 4 times daily for 3 days before surgery and at 7 am on the day of surgery. Undiluted vitreous samples were obtained and analyzed using high-performance liquid chromatography. Results: Either moxifloxacin 0.5% or gatifloxacin 0.3% was detected in the vitreous in all 12 patients in the study. There was no significant difference between the mean vitreous concentration of moxifloxacin 0.5% given over 1 hour preoperatively (0.012 ± 0.011 &mgr;g/mL) and that given in the 3-day regimen (0.011 ± 0.008 &mgr;g/mL) (P = 0.93). There was also no significant difference between the mean vitreous concentration of gatifloxacin 0.3% given over 1 hour preoperatively (0.001 ± 0.0003&mgr;g/mL) and that given over 3 days (0.008 ± 0.006 &mgr;g/mL) (P = 0.11). Vitreous concentrations of moxifloxacin 0.5% and gatifloxacin 0.3% in each eye were all lower than the 90% minimum inhibitory concentration for the commonest bacterial isolates causing endophthalmitis. With both dosing regimens, the mean vitreous concentration of moxifloxacin 0.5% was higher than that of gatifloxacin 0.3% administered at the same regimen, but this was not statistically significant. Conclusion: Both topical moxifloxacin 0.5% and gatifloxacin 0.3% penetrated the vitreous in the uninflamed eye, but the vitreous concentrations attained were all lower than the 90% minimum inhibitory concentration for the commonest bacterial pathogens causing acute postoperative endophthalmitis.

Role of intravitreal triamcinolone acetonide in the treatment of postoperative endophthalmitis.

Purpose: To report the use of commercially available triamcinolone acetonide as adjunct treatment for acute-onset endophthalmitis after intraocular procedures. Methods: Charts of 14 patients who received intravitreal triamcinolone in combination with intravitreal antibiotics for treatment of acute endophthalmitis were reviewed. Patients were included if they presented with pain, vision loss, and severe anterior chamber reaction or hypopyon. Visual acuities, intraocular pressures, anterior chamber reaction, and view of fundus details were recorded at baseline, 1 day, 1 week, 1 month, and 3 months to 5 months. Results: Culture-positive results were found for 57% (8/14) of patients. Isolated species included Staphylococcus epidermidis, viridans streptococcus, group D Streptococcus (nonenterococcus), Propionibacterium acnes, and diphtheroid bacilli. Visual acuities improved an average of 7.5 Snellen lines. Preendophthalmitis level visual acuities were recovered in 78.6% patients (11/14), with 64% (9/14) of patients achieving visual acuity of 20/40 or better regardless of presenting vision. Resolution of anterior chamber reaction and view of fundus details were consistent with visual acuities. Conclusions: Intravitreal triamcinolone combined with intravitreal antibiotics appears to have a safety profile similar to current modalities with a favorable effect on visual recovery and function in the setting of acute postoperative endophthalmitis.

CASE REPORT Sympathetic Ophthalmia after a Hyphema due to Nonpenetrating Trauma

Purpose: To report a case of sympathetic ophthalmia occurring after nonpenetrating ocular trauma. Methods: Interventional case report. Results: An 18-year-old white male presented with sympathetic ophthalmia four weeks after a hyphema from a nonpenetrating bungee cord injury. Vision was 20/20; there were keratic precipitates, anterior chamber cells, vitritis, and discrete yellow deep choroidal lesions consistent with Dalen-Fuchs nodules OU. The uveitis was treated with topical, oral, and periocular corticosteroids and the oral immunosuppressives cyclosporine and mycophenolate mofetil. Vision remained 20/20 OU for the first year of follow-up; vision OD then deteriorated to 20/50 over the next year with the formation of a posterior subcapsular cataract OD. Conclusion: Sympathetic ophthalmia may result from nonpenetrating ocular trauma. Ophthalmologists should be aware of this as prompt intervention is warranted.

Gorham disease of the orbit

PURPOSE To report a case of Gorham disease, also known as vanishing bone disease, of the orbit. DESIGN Interventional case report. METHODS A 43-year-old Caucasian woman developed a depression in her left temple, pulsation in her left upper eyelid and temple, and bulging of the left upper eyelid and headache. Computerized tomography revealed a lytic lesion in the roof of the left orbit. RESULTS Intraoperative examination of the lesion revealed a bony defect in the left orbital roof. Surgical intervention resulted in improvement of her symptoms, and pathology failed to reveal evidence of malignancy or other benign neoplastic process. CONCLUSION Gorham disease should be considered in the differential diagnosis of lytic bony lesions of the orbit.