Kaan Gündüz

Topical cyclosporin treatment of keratoconjunctivitis sicca in secondary Sjögren's syndrome

Abstract. Topical cyclosporin 2% in olive oil was investigated for its possible immunoregulatory role on the dry eye state in patients with secondary Sjögrens syndrome. The study was a randomized, double‐masked, placebocontrolled trial. Thirty eyes of 15 patients were randomized to undergo treatment with topical cyclosporin in olive oil and 30 eyes of the other 15 patients received a placebo, which was the sterile olive oil used as a vehicle for the cyclosporin. The effect of the 2‐month long treatment with either medication on the status of the dry eye state was measured by Schirmer‐I test, tear film break‐up time and rose bengal staining. There was a significant increase in the break‐up time and a significant decrease in rose bengal staining score between the cyclosporin and control groups at the end of the 2‐month study period (p < 0.01). Schirmer‐I test remained unaffected (p > 0.05). These results probably indicate that topical cyclosporin modulates the goblet cell function in secondary Sjögrens associated keratoconjunctivitis sicca and through this mucus enhancing action or some other mechanism not yet known, helps to maintain the structural integrity of the epithelium.

Vascular tumors of the orbit

Eighty-five vascular lesions of the orbit examined and treated between 1963–1993 were reviewed retrospectively to reveal the types of vascular tumors, age and sex distribution, clinical characteristics, treatment options and prognosis. Capillary hemangioma was the most frequent orbital vascular tumor accounting for 37 of 85 cases making up 43.5% of the entire orbital masses. Cavernous hemangioma accounted for 35 cases (41.2%), varices for 3 cases (3.5%), anteriovenous malformations for 3 cases (3.5%), angiosarcomas for 3 cases (3.5%), lymphangiomas for 3 cases (3.5%) and hemangiopericytoma for one case (1.2%). Of the 85 vascular tumor cases 43 were encountered in children aged 18 years or less. Capillary hemangioma was the most frequent pediatric orbital vascular lesion, making up 86% of the vascular tumors in this age group. Capillary hemangiomas have been treated with observation and intralesional corticosteroid injections. Cavernous hemangiomas, vascular malformations, lymphangiomas and two cases of angiosarcomas received orbitotomy. One case each of angiosarcoma and hemangiopericytoma underwent exenteration because of the advanced stage of the lesion. There was one tumor-related death who was a 9-year-old boy diagnosed with angiosarcoma. Vascular tumors with the exception of angiosarcomas and hemangiopericytoma behaved as benign lesions.

Conjunctivodacryocystorhinostomy with Jones tube. A 10-year study.

One hundred and eight patients (111 eyes) underwent conjunctivodacryocystorhinostomy with a Jones tube for treatment of epiphora resulting from canalicular obstruction. Sixty-nine patients (63.9%) were females and thirty-nine (36.1%) were males. Their ages ranged from 9 to 64 years, the mean age being 30.1 years. The causes of lacrimal drainage abnormalities included idiopathy (76 cases, 68.5%), trauma (15 cases 13.5%), tumors (8 cases, 7.2%) congenital abnormalities (6 cases, 5.4%) and conjunctival inflammation (6 cases, 5.4%). Twenty-eight (36.8%) eyes in the idiopathic group had previous failed dacryocystorhinostomies. The operation was successful in 90.1% of the eyes with relief of epiphora. Fifty-one out of 111 (45.9%) eyes had complications. Extrusion of the tube was the most frequent complication occurring in 20 (18%) eyes. Malposition (12 eyes 10.8%), infection (12 eyes, 10.8%) and obstruction of the tube (7 eyes, 6.3%) were the other major complications. Of the 20 eyes with tube extrusion, 11 experienced recurrent tube losses. Five of 11 eyes were free of epiphora after tube loss. Four out of five had the tube in place for 2 to 5 years and one had the tube, in place for one year. The remaining 6 eyes which had the tubes for 6 months to 3 years were complicated by epiphora. Our experience confirms the general belief that the tube should stay in place forever. The large majority of our patients could wear their tubes successfully and have done so in our practice for as long as 10 years.

Orbital exenteration: a review of 429 cases.

The authors reviewed their experience with 429 cases of orbital exenteration between 1963 and 1993. Apart from the 22 cases operated in concert with other physicians, 407 cases were operated by an ophthalmologist and spontaneous granulation technique was used. Total or eyelid-sacrificing exenteration was carried out for lesions involving the eyelids and for recurrent/infiltrative malignant tumors. Two hundred and thirty-seven cases received total exenteration. The remaining 192 cases were treated with eyelid-sparing or subtotal exenteration. In each case, full exenteration was performed with the removal of the periosteum. Secondary tumors were the most frequent indication for exenterations accounting for 349 (81.3%) cases. Among the secondary tumors, there were 173 eyelid, 104 intraocular, 56 conjunctival tumors, 15 nasopharynx and one maxillary sinus carcinomas. The second leading indication was primary orbital tumors (50 cases, 11.7%). Of the primary orbital tumors, 35 were rhabdomyosarcomas, nine were neurogenic tumors, two were fibrocytic tumors, two were vascular tumors, one was teratoma and one was primary melanocytic tumor. The remaining cases included 16 lacrimal fossa tumors (3.7%), 10 lymphomas (2.3%) and four (1.0%) inflammatory pseudotumors. Squamous cell carcinoma was the single most frequent indication for which exenteration was carried out, accounting for 30.3% of the cases. Spontaneous granulation proved to be a simple technique and produces cosmetically better results for patients not wearing prosthesis.

Cystic lesions of the orbit

Background/aims: Cystic lesions of the orbit constitute a group of lesions with diverse clinical findings, histopathologic features and pathogenesis. Methods: We reviewed the histopathologic and clinical records on 128 orbital cystic lesions diagnosed during a 32-year period from 1963 to 1995. Results: Of the 128 orbital cystic lesions, dermoid cysts were the most frequent (38 cases, 29.7%). The other lesions, in decreasing order of frequency, were hydatid cysts (33 cases, 25.8%), mucoceles (31 cases, 24.2%), pyoceles (10 cases, 7.8%), meningoencephaloceles (9 cases, 7.0%), epidermal inclusion cysts (4 cases, 3.1%), hematoceles (2 cases, 1.6%) and teratoma (one case, 0.8%). Conclusions: Our review showed that 64.1% of patients with cystic lesions were aged 18 years or less. With the exception of mucopyoceles, all the other cystic lesions were more frequent in pediatric patients. Cystic lesions behaved clinically as benign lesions. At a mean follow-up of 6.7 years we did not observe development of malignancy in any of the cystic tumor cases though variable degrees of vision loss developed due to factors such as optic nerve compression, ocular damage and amblyopia.

Magnetic resonance imaging of unilateral lacrimal gland lesions

PurposeTo report the findings on magnetic resonance imaging (MRI) of various benign and malignant unilateral lacrimal gland lesions.MethodsThis is a retrospective noncomparative interventional case series. Thirty-one consecutive patients with a unilateral lacrimal gland lesion were analyzed. The preoperative MRI findings were correlated with the pathology results. The main outcome measures were anatomic extent, configuration, margins, angulation, internal features on T1- and T2-weighted images (with respect to extraocular muscles and cerebral gray matter), contrast enhancement of the lesion and adjacent bone change on MRI.ResultsOf the 31 patients, 21 had chronic dacryoadenitis, 3 had lymphoid tumors, and 7 had epithelial tumors including pleomorphic adenoma (3), adenoid cystic carcinoma (3), and pleomorphic adenocarcinoma (1). The results of the patients with chronic dacryoadenitis demonstrated involvement of the orbital lobe alone in 13 patients (62%), involvement of both orbital and palpebral lobes in 8 (38%), a molded configuration with ill-defined margins, sharp angles in 13 (62%), round angles in 8 (38%), lack of bone change, an isointense internal signal on T1-weighted images, a hypointense signal on T2-weighted images, and moderate contrast enhancement. The patients with lymphoid tumors demonstrated involvement of the orbital lobe, a molded configuration with ill-defined margins and sharp angles, lack of bone change, an isointense internal signal on T1-weighted images, an isointense signal on T2-weighted images, and moderate contrast enhancement. Those with epithelial tumors showed involvement of the orbital lobe, a well-circumscribed oval configuration, and round angles. Pleomorphic adenoma demonstrated smooth margins, bone expansion in two patients , and no bone change in one. Adenoid cystic carcinoma and pleomorphic adenocarcinoma showed irregular margins and bone destruction. All epithelial tumors demonstrated an isointense internal signal on T1-weighted images, a hyperintense signal on T2-weighted images, and moderate contrast enhancement.ConclusionsIt is difficult to uniformly correlate the MRI features and histopathologic findings in lacrimal gland lesions. However, MRI seems to be useful in determining the etiology of a unilateral lacrimal gland lesion. Internal tissue features on T1- and T2-weighted images of MRI are most helpful in categorizing these lesions. Although the number of patients is small, our findings suggest that there are differences in orbital MRI findings of inflammatory lesions and lymphoid tumors as compared to benign and malignant epithelial tumors in the lacrimal gland fossa.

Topical Cyclosporin as an Adjunct to Topical Acyclovir Treatment in Herpetic Stromal Keratitis

BACKGROUND/AIMS Immunological factors play an important role in the development of herpetic stromal keratitis. T lymphocytes are the principal cells involved in this immunologic reaction. We therefore investigated the efficacy and safety of topical cyclosporin A 2 % solution in herpetic stromal keratitis. METHODS Ten patients with herpetic stromal keratitis received topical cyclosporin A 2% 4 times daily for 2 months. Acyclovir 3% ointment 5 times daily and cycloplegic eyedrops 2 times daily were used in conjunction with cyclosporin A solution in the 1st month of treatment. Topical steroids were not used. The patients were followed for 6-9 months. Treatment efficacy was evaluated according to two parameters: resolution of stromal infiltrates and neovascularization and increase in visual acuity by two or more Snellen lines. Serum cyclosporin A levels were measured with high-performance liquid chromatography. RESULTS In all the patients, the stromal infiltration resolved completely after 2 months of treatment. Visual acuity increased by two or more Snellen lines in 8 out of 10 patients. In the remaining 2 cases, stromal scarring that was present before cyclosporin A treatment prevented vision increase. There were no serious complications from the cyclosporin treatment but 4 cases complained of severe burning upon instillation of the drug. This complication was temporary and did not result in discontinuance of the drug. Serum levels of the drug were always below toxicity levels. CONCLUSION While this is a noncontrolled study, our results show that topical cyclosporin can be a valuable adjunct to acyclovir treatment in herpetic stromal keratitis. Use of topical cyclosporin in dendritic herpetic ulcers and necrotic stromal keratitis has not been investigated in this study.

Pediatric orbital tumors in Turkey

Summary A retrospective review of 376 pediatric orbital tumor cases seen at the Ankara University Eye Clinic between 1963 and 1993 was undertaken. The diagnosis was made histologically in every case. Secondary tumors accounted for 127 cases (33.8%), cystic lesions for 82 cases (21.8%), rhabdomyosarcomas for 66 cases (17.6%), neurogenic tumors for 23 cases (6.1%), vascular lesions for 21 cases (5.6%), inflammatory lesions for 21 cases (5.6%), lymphoma and leukemias for 18 cases (4.8%), other mesenchymal tumors for 11 cases (2.9%), metastatic tumors for 5 cases (1.3%), traumatic foreign bodies for 2 cases (0.5%), and lacrimal fossa lesions for 1 case (0.3%). The most common benign orbital tumors were the cystic lesions. The most common primary malignant tumor was rhabdomyosarcoma. Overall, the most frequent orbital lesion was the secondary orbital invasion of retinoblastoma.

CLINICAL AND EPIDEMIOLOGICAL CHARACTERISTICS OF RETINOBLASTOMA: Correlation with Prognosis in a Turkish Pediatric Oncology Center

Advanced intraocular tumors and metastatic disease in retinoblastoma patients still occur frequently in developing countries. The aim of this retrospective study was to describe the clinical and epidemiological characteristics of patients with retinoblastoma and the effects of these features on disease prognosis in the authors’ pediatric oncology unit as a developing country profile to define the problem. A retrospective chart review of 91 patients who presented to the unit between May 1996 and December 2003 was conducted in this study. Patients with unilateral disease presented at a median age of 24 months and those with bilateral disease at a median age of 9.5 months (p <. 01). Most of the eyes with retinoblastoma (68.6%) had Reese-Ellsworth stage V disease. Metastatic disease was diagnosed in 19 (20.9%) patients. Cases with metastatic disease presented at a median age of 24 months and those without metastatic disease at a median age of 12.5 months (p <. 05). In 31 patients (34.1%) there was a delay in diagnosis. The enucleation ratio in eyes with advanced intraocular stage was significantly higher than in eyes with early intraocular stage (57.9 vs. 3.8%) (p <. 001). In patients with metastatic disease, tumor recurrence was more frequent than in the nonmetastatic patients (36.8 vs. 4.2%) (p <. 01). Seven children (7.7%) died due to central nervous system (CNS) metastasis (p <. 01). Advanced intraocular disease and distant metastases occur more frequently in Turkish children with retinoblastoma than in children in developed countries, causing a higher rate of enucleation and mortality. Late referral might account for the delayed diagnosis.

Biopsy-proven orbital lesions in Turkey:A survey of 1092 cases over 30 years

1092 biopsy proven orbital lesions were seen during 1963-1993. Secondary tumors were the most frequent type of lesion, accounting for 533 cases (48.9%). Cystic lesions accounted for 128 cases (11.8%), inflammatory masses (pseudotumors) for 109 cases (10%), muscle-tissue tumors for 72 cases (6.6%), vascular lesions for 63 cases (5.8%), lymphoma and leukemias for 55 cases (5%), gliomas and meningiomas for 37 cases (3.4%), other mesenchymal tumors for 32 cases (2.9%), peripheral nerve tumors for 16 cases (1.5%), metastatic tumors for nine cases (0.8%), other lesions for four cases (0.4%) and primary orbital melanoma for three cases (0.3%). The most frequent primary benign orbital tumor in adults is cavernous hemangioma and the most common primary malignant orbital tumor in adulthood are the various lymphoid tumors. The most frequent primary benign orbital lesion in children is dermoid cysts and the most common primary malignant lesion is rhabdomyosarcoma. Overall, the commonest primary benign and malignant l...