Rachel Camargo Carneiro

Canaliculite: relato de caso e conduta

Canaliculitis is a rare infection of the lacrimal canaliculus with Actinomyces israelii as its most common etiologic agent. The objective of this paper is to report a rare pathology, as well as its clinical and surgical management. Female patient, 44 years old, presenting clinical manifestations compatible with canaliculitis, was submitted to surgical treatment preserving the lacrimal punctum. Intubation was performed into the lacrimal channel with silicone tube for three months, associated with periodical pre-programmed bathings with antibiotic, in order to avoid complications and recurrence. This case confirms the literature reports in which the surgical treatment is more effective than the conservative treatment.

Is 2-mm punch biopsy useful in the diagnosis of malignant eyelid tumors?

Purpose: Two-millimeter punch biopsy is a swift and practical diagnostic tool in the outpatient setting. However, few studies have evaluated the efficacy of the method for diagnosis of malignant eyelid tumors. Methods: This was an observational study of patients with suspicion of malignant eyelid tumor attending the Ocular Plastic Surgery Center at Hospital das Clínicas, University of São Paulo School of Medicine. Following standard procedures, preoperative biopsies were taken with a 2-mm trephine and surgical excision was performed with safety margins, followed by reconstruction. Anatomopathologic analysis of the surgical specimen was used as gold standard to evaluate the accuracy of diagnosis by punch biopsy. Results: The study included 50 periocular tumors with suspicion of malignancy. The indicators of efficacy in the identification of malignancy by 2-mm punch biopsy were: sensitivity 88%, specificity 100%, positive predictive value 100%, and negative predictive value 64%. Accuracy was 90% for malignancy and 80% for histologic type. The &kgr; index of agreement between the diagnostic methods was 0.722 (p < 0.001). Conclusion: A positive result with 2-mm punch biopsy is a safe indication for surgical excision of the tumor, whereas a negative result does not necessarily imply benignity. In cases of high clinical suspicion, a second biopsy should be taken from a different part of the tumor to rule out malignancy.

Nova modalidade no tratamento do carcinoma basocelular periocular: imiquimode

The basal cell carcinoma is the most common neoplasia of the periocular region, being responsible for 90% of the eyelid malignancies. There has been a significant rate of increase of the neoplasia during the last few years. Although of slow growth and rarely enticing metastases, its extension and location offer great therapeutic difficulties when it involves the periocular region.The surgical treatment is the one currently used for the periocular region, however, new therapeutic methods have been proposed. The reparative surgical techniques might jeopardize so much the eyelid function (ocular protection) as well as the region aesthetic balance. Recently a new approach involving a clinical treatment using topics immune response modifier has been tried. Imiquimod cream 5% is the main representative of this new class of medications, it has been widely studied in the recent past and it has shown great effectiveness in the treatment of the basal cell carcinoma.he purpose of this current work is accomplishing a systematic analysis of the relevant literature that supports the use of imiquimod cream 5% in the periocular basal cell carcinoma treatment.

Imunoterapia tópica no tratamento do carcinoma basocelular periocular

The authors describe a patient with a medial canthal nodular basal cell carcinoma treated with Imiquimod 5% cream. Pathologic evaluation of an incisional biopsy performed 12 weeks after treatment revealed complete resolution of local disease. Although the treatment of choice continues to be surgery, topical immunotherapy with imiquimod 5% cream is an emerging therapeutic option suitable for the outpatient treatment of periocular basal cell carcinoma.

Diagnosis of aggressive subtypes of eyelid basal cell carcinoma by 2-mm punch biopsy: prospective and comparative study

OBJECTIVE : to compare the accuracy of preoperative 2-mm punch biopsy at one site and at two sites in the diagnosis of aggressive subtypes of eyelid basal cell carcinoma (BCC). METHODS : we randomly assigned patients to Group 1 (biopsy at one site) and Group 2 (biopsy at two sites). We compared the biopsy results to the gold standard (pathology of the surgical specimen). We calculated the sensitivity, specificity, positive predictive value, negative predictive value, accuracy and Kappa coefficient to determine the level of agreement in both groups. RESULTS : we analyzed 105 lesions (Group 1: n = 44; Group 2: n = 61). The agreement was 54.5% in Group 1 and 73.8% in Group 2 (p = 0.041). There was no significant difference between the groups regarding the distribution of quantitative and qualitative variables (gender, age, disease duration, tumor larger diameter, area and commitment of margins). Biopsy at two sites was two times more likely to agree with the gold standard than the biopsy of a single site. CONCLUSIONS : the accuracy and the performance indicators were better for 2-mm punch biopsy in two sites than in one site for the diagnosis of aggressive subtypes of eyelid BCC. OBJETIVO comparar a acurácia da biópsia pré-operatória por trépano de 2mm em um sítio e em dois sítios no diagnóstico dos subtipos agressivos de carcinoma basocelular (CBC) palpebral. MÉTODOS os pacientes foram distribuídos aleatoriamente em Grupo 1 (biópsia em um sítio) e Grupo 2 (biópsia em dois sítios). Os resultados das biópsias foram comparados com o padrão-ouro (exame anatomopatológico da peça cirúrgica). A sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo, precisão e coeficiente Kappa foram calculados para determinar o nível de concordância nos dois grupos. RESULTADOS foram analisadas 105 lesões (Grupo 1: n = 44; Grupo 2: n = 61). A concordância foi de 54,5% no Grupo 1 e 73,8% no Grupo 2 (p-valor = 0,041). Não houve diferença significativa entre os grupos quanto à distribuição das variáveis quantitativas e qualitativas (sexo, idade, duração da doença, maior diâmetro do tumor, área e comprometimento de margens). A biópsia em dois sítios mostrou duas vezes mais chance de concordar com o padrão-ouro do que a biópsia de um sítio. CONCLUSÕES a acurácia e os indicadores de desempenho foram melhores para a biópsia por trépano de 2 mm em dois sítios do que em um sítio para o diagnóstico dos subtipos agressivos de CBC palpebral.

Acurácia do exame clínico no diagnóstico de lesões palpebrais

Objective: To analyze the accuracy of the clinical examination in the diagnosis of eyelid lesions. Methods: From the observation of thirtyfive photos of benign and malignant eyelid tumors were presented to ophthalmologists, for each picture, it was asked 3 questions: 1) the lesion is malignant or not; 2) if considered malignant, the probably histological type; and 3) the tumor is aggressive or not. The phisicians were divided into 9 groups, according to academic degree (time since graduation and Oculoplastics specialty or not). Answers were compared with the results of the histopathologic study of the surgically resected tumor. Results: In total, one hundred and six ophthalmologists were interviewed. The professional experience influenced the diagnosis of malignancy of the tumor, as the Group 1 (first year residents) had the lowest accuracy (64.5%), with lower estimated agreement (kappa = 0.13), and Group 5 (graduated 5 years ago and with expertise in Oculoplastics) the highest accuracy (77.3%), with better agreement (Kappa = 0.45), and presented the best parameters for other analyzed items. For the histological type diagnosis, accuracy was lower: group 1 had the worst performance, with 51.1% accuracy, while the best was for group 6 (graduated over 5 years and with expertise in Oculoplastics, 77.2% ). As for the criterion of tumor aggressiveness, the results were closer among the different categories. Ophthalmologists trained longer and without expertise in Oculoplastics also showed a low diagnostic accuracy for malignancy and to determine the histological type of tumor. Conclusions: The low accuracy of clinical diagnosis of eyelid tumors in the groups above reinforces the need to improve ophthalmic oncology knowledge in these groups.

Terapia fotodinâmica em carcinoma basocelular periocular: relato de caso

The authors report the use of photodynamic therapy with methyl aminolevulinate (Metvix®) in a patient with nodular and infiltrative basal cell carcinoma in the right lower eyelid. Side effects on the eye were evaluated weekly. After 12 weeks of treatment, to confirm cure the patient was submitted to a 2-mm punch biopsy, the anatomopathological findings of which were negative for neoplasia. Photodynamic therapy with methyl aminolevulinate was shown to be an attractive alternative to surgical excision¯the current gold standard treatment worldwide.

Periocular basal cell carcinoma: cost of topical immunotherapy versus estimated cost of surgical treatment

PURPOSE: The objective of this study was to compare the estimated cost of clinical and surgical treatment for basl cell carcinoma of the eyelid. METHODS: This was a pilot study of 12 patients with basal cell carcinoma receiving treatment with 5% imiquimod cream at the ocular plastic surgery center, medical school University of Sao Paulo (HC-FMUSP, Brazil). The cost of clinical treatment was estimated based on the time of treatment and amount of medication consumed by patients in the home setting. The cost of surgical treatment was estimated by ophthalmologists with experience in reconstructive plastic surgery based on analysis of images of the same patients. Surgeons responded to a questionnaire with four questions about surgical technique, surgical materials required, estimated duration of surgery and type of anesthesia. RESULTS: Immunotherapy lasted from 8 to 12 weeks.All patients reported each coldstored sachet with 5% imiquimod cream lasted 3 days.According to the institution, a box with 12 sachets costs BRL 480.00. Patients required 1.58-3.11 boxes for complete treatment, corresponding to a total cost of BRL 758.401,492.80. Based on image analysis, surgeons evaluated surgery would require 1-3 hours. The estimated cost of surgery room and staff was BRL 263.00, to which the cost of supplies was added. Thus, the total cost of surgical treatment was BRL 272.61-864.82. On the average, immunotherapy was 57,64% more costly than surgical treatment. CONCLUSIONS: Malignant eyelid tumors are a common finding in clinical ophthalmology. Surgery is still the treatment of choice at our institution, but immunotherapy with 5% imiquimod cream may be indicated for patients with multiple lesions or high surgical risk and for patients declining surgery for reasons of fear or esthetic concerns.The ability to estimate costs related to the treatment of malignant eyelid tumors is an important aid in the financial planning of health care institutions. Further studies should evaluate the possibility of institutions equating the cost of immunotherapy and surgical treatment by acquiring similar but less expensive medications.