Magda Guareschi

Intraobserver and interobserver reproducibility in the evaluation of optic disc stereometric parameters by Heidelberg Retina Tomograph

PURPOSE To assess intraobserver and interobserver reproducibility of the measurement of stereometric parameters of the optic disc by means of the Heidelberg Retina Tomograph I (HRT). STUDY DESIGN Observational study, with interobserver variability. PARTICIPANTS Fifty-five volunteers (healthy subjects and patients with glaucoma). METHODS HRT examination of the optic disc was repeated on 3 consecutive days on 1 eye of each of the 55 subjects. During each session, five single images were randomly acquired by two independent observers. One mean topography image (MTI), based on three single images, was then built at each session. For the intraobserver intraimage evaluation, the two observers traced their own contour line on one randomly chosen MTI. This procedure was repeated three times. For the intraobserver interimage and interobserver intra/interimage evaluations, the two observers traced their own contour line on the MTI of the first session, which was then automatically superimposed on the MTIs of the other two sessions. MAIN OUTCOME MEASURES Reproducibility of the 12 stereometric parameters was calculated for each observer by means of the intraclass correlation coefficient (ICC). The expected range of variability between two independent evaluations was calculated by the scatter-plots of each test-retest difference versus their mean. The standard deviation of the mean test-retest score differences was used to describe the spread of score differences. RESULTS The ICC ranged between 0.79 and 0.99 for intraobserver intraimage and between 0.56 and 1 for intraobserver interimage evaluation. The ICC ranged between 0.54 and 0.99 for interobserver intraimage and between 0.65 and 0.97 for the interobserver interimage evaluation. ICC was almost perfect to perfect for planimetric measures (0.81 < ICC < or = 1), substantial to almost perfect for volumetric and cup measures (0.61 < ICC < or = 0.99), and moderate to almost perfect for retinal nerve fiber layer related measures (0.41 < ICC < 0.99). The expected variability was low (95% confidence interval, < +/-9%). Interimage evaluation showed a higher variability than intraimage evaluation in both of interobserver (P = 0.012) and intraobserver evaluation (P = 0.028 and P = 0.031 for the two observers). CONCLUSIONS Measurement of optic disc stereometric parameters by HRT is highly reproducible. However, the use of retinal nerve fiber layer-related parameters should be taken cautiously. The image acquisition-induced variability seems larger than the operator-induced variability.

Fibrous dysplasia of the orbital region: Current clinical perspectives in ophthalmology and cranio-maxillofacial surgery

Purpose: To describe the multidisciplinary diagnosis and treatment of patients with orbital fibrous dysplasia, a slowly progressive disease that may lead to asymmetry, disfigurement, and functional ocular problems. Methods: Ten patients with orbital fibrous dysplasia underwent bifrontal craniotomy through a coronal flap, with the removal of the supraorbital arch and dysplastic process involving the anterior and middle base of the skull. Four patients underwent superior orbital fissure and optic nerve canal decompression. Reconstruction was performed by using an autologous bone graft for both the adults and children, in whom a rib graft was preferred. The mean follow-up was 53.2 ± 18.3 months (range, 14 to 94 months). The patients’ preoperative status and postoperative status were compared. Results: The immediate and long-term morphologic and aesthetic results were good in all cases. All of the patients complained of some degree of diplopia during the immediate postoperative period, but the problem spontaneously resolved within 1 to 6 months in all but one case. No postoperative reduction in visual function was observed in the patients who underwent optic nerve decompression. The only reported complication was the irregular reabsorption of regrafted dysplastic bone in one patient. Conclusions: A multidisciplinary approach to orbital fibrous dysplasia is fundamental for treatment planning and execution.

Is Hyaluronic Acid Gel a Good Option for Breast Augmentation

To the Editor: Although nonanimal stabilized hyaluronic acid (NASHA) has not been approved for use in breast augmentation by the Federal Drug Administration (FDA), a great number of patients have been treated by this approach in Europe, South Korea, and Japan. To stimulate discussion about this procedure, which is becoming very common, we report our experience. In the past 19 months, 207 patients underwent breast augmentation with NASHA gel in our clinic using Macrolane VRF 30 (Q-Med AB, Uppsala, Sweden). The material is implanted using a minimally invasive procedure with the patient under local anesthesia. This approach results in a shorter recovery time than traditional surgical methods. Macrolane gave satisfactory natural-appearing cosmetic results for the majority of breasts treated (Fig. 1). As hyaluronic acid is degraded naturally and gradually, possible problems associated with permanent fillers, such as the permanency of technical errors or migration, are not applicable. Nevertheless, three major questions emerged from our experience. The first question relates to the duration and cost of Macrolane. Macrolane is a resorbable material, and the study of Heden et al. [1] published in Aesthetic Plastic Surgery showed 30% to 50% resorption at 12 months. Our echographic measurements showed a 60% rate of resorption at 1 year. Consequently, a second treatment usually was performed 9 months after the first treatment. The necessity of a touch-up increases the cost of breast augmentation with NASHA gel, which is as expensive as a single surgical treatment with a prosthesis after three or four touch-ups. The second question relates to the radiologic evaluation of patients. Macrolane is a new material that constitutes a diagnostic challenge for radiologists. Indeed, the appearance of NASHA gel may mimic a cyst on mammography and sonography [1]. Therefore, it is important that radiologists become familiar with the spectrum of imaging findings for Macrolane. In particular, to make an accurate diagnosis for these patients, it is important to send them to reference radiologic centers. The last open question is related to posttreatment adverse events. We did not experience any complications so severe that they required surgical removal of the product. Nevertheless, we had a high rate of minor complications. In particular, 47% of the patients had multiple lumps that disappeared completely within 30 days of treatment in 92% of the cases (Fig. 2). For seven patients, the lumps were removed by direct aspiration. Baker 2 and 3 capsule formation developed in 10 of the treated breasts. The treatment of the capsule required external manipulation (closed capsulotomy) for seven breasts and capsulotomies with a blunt cannula for three breasts. In conclusion, NASHA gel for breast volume augmentation is an interesting treatment, but the three open questions require additional studies.

Gluteal Augmentation and Remodeling

Gluteal augmentation and remodeling are generally sought by patients who desire a fuller buttock or curvier appearance. Gluteal contour defects are common and may be related to a deficiency in gluteal mass, loss of fat in the buttock area, or in the shape of the lower spine.

Fillers in Aesthetic Medicine

The pursuit of beauty and the effort to reverse the effects of ageing dates back to many centuries. Facial volume depletion and facial rhytids are a natural and inevitable part of ageing.

Forehead, Glabella, and Crow’s-Feet

Careful identification of supraorbital foramen in the medial third of the superior orbital rim is useful to avoid damage to supraorbital nerve and vessel which direct upward to frontal area starting from the foramen.