Raman Malhotra

Mapped serial excision for periocular lentigo maligna and lentigo maligna melanoma.

PURPOSEnTo report the early cure rate for periocular lentigo maligna (LM) and LM melanoma (LMM), using modified Mohs surgery with vertically cut paraffin-embedded sections (mapped serial excision [MSE]). A secondary aim was to identify differences in the clinical features and outcomes between periocular LM and LMM and those found elsewhere on the head and neck.nnnDESIGNnProspective, noncomparative, interventional case series.nnnPARTICIPANTSnOne hundred thirty-five patients undergoing 141 MSE procedures.nnnMETHODSnA prospective series of 141 MSE procedures for LM and LMM over a 10-year period (1993-2002) in a single-center Mohs surgical unit.nnnMAIN OUTCOME MEASURESnRecurrence, site, size of LM or LMM, invasiveness, prior recurrence, clear margin of excision, size of final defect, and number of levels required for complete excision.nnnRESULTSnOne hundred forty-one MSE procedures, of which 23% (32/141) were for LMM and 19% (27/141) were for periocular lesions. Location or prior recurrence were not predictive of invasive disease; however, the size distribution of the initial lesion (P = 0.0354) and the final defect after MSE (P = 0.0183) were larger in LMM. Thirty-one percent of LM and 14% of LMM less than 1 mm thick required larger than 5-mm and 1-cm margins, respectively, for complete excision. Mean follow-up of 32 months (range, 1-100 months) revealed 4 recurrences (3%), of which two were periocular (P = 0.188).nnnCONCLUSIONSnOur review is the largest prospective series of MSE for LM and LMM and suggests that it is the treatment of choice in these forms of melanoma. Mapped serial excision offers a high early cure rate in conjunction with tissue conservation, which is of particular relevance in the periocular region. There were no significant differences between periocular LM and LMM and those found elsewhere in the head and neck region. It also appears that the current recommendations of 5-mm margins for in situ melanoma (LM) and 1-cm margins for melanoma less than 1 mm thick are insufficient for complete excision of LM or LMM, emphasizing the importance of margin-controlled excision of these lesions.

Efficacy of endoscopic sinus surgery for paranasal sinus mucocele including modified endoscopic Lothrop procedure for frontal sinus mucocele.

This study evaluated the efficacy of the modified endoscopic Lothrop procedure (MELP) for complicated frontal mucoceles and endoscopic marsupialization for other paranasal sinus mucoceles. It was a retrospective, consecutive case review of sinus mucoceles treated endoscopically by a single surgeon over a four-year period (1998-2002). There were 41 mucoceles in 28 patients, including 24 frontal, eight frontoethmoidal, three ethmoidal, five maxillary and one frontal mucocele. Twenty-one patients underwent the modified Lothrop procedure for frontal mucoceles, and seven underwent simple drainage and marsupialization for frontoethmoidal, ethmoidal and maxillary mucoceles. At median follow-up of 16 months, all patients had a patent mucocele opening. Patients treated by drainage and marsupialization did not have any complications or mucocele recurrence. All patients treated by the modified endoscopic Lothrop procedure had improvement in symptoms and signs. Four patients had minor complications including epistaxis and adhesions and five required further surgery. The average hospital in-patient stay was 2 +/- 1.4 days. Endoscopic techniques, including MELP are effective in the short term for the management of complex and simple paranasal sinus mucoceles. MELP has a useful place in the management of mucoceles with a significant bony partition from an adjacent sinus or nasal cavity. It is also indicated when the mucocele is associated with loss of lateral support in the sinus with risk of medial-wall collapse of the orbital contents obstructing drainage.

Endoscopic sinus surgery for paranasal sinus mucocoele with orbital involvement

AbstractPurposeu2003To evaluate the results of endoscopic sinus surgery (ESS) for paranasal sinus mucocoele with orbital involvement and assess the frequency with which a direct orbital approach is required in these cases.Methodsu2003Retrospective, consecutive series of sinus mucocoeles with orbital involvement treated by ESS by a single surgeon over a 4-year period (1998–2002).Resultsu2003A total of 24 mucocoeles of 15 patients, including 10 frontal, eight frontoethomoidal, two ethmoidal, and four maxillary. All cases demonstrated radiological orbital extension. Globe displacement was seen in 73%. At a median follow-up of 15.5 months, the mean cumulative clinical score improved from 4.2 ± 1.5 (range 1–7) to 0.4±0.7 (range 0–2). Ophthalmic symptoms and signs resolved in all patients but one who had complex sinus anatomy following neurosurgery. Minor, self-limiting complications including epistaxis and intranasal adhesions occurred in three cases. Additional endoscopic sinus surgery was required in four patients for revision of narrowed frontal sinus ostium (two), mucocoele recurrence (two), and sinus toileting (one). No cases required external sinus surgery and the average hospital in-patient stay was 2.5 ± 1.6 days. At final follow-up, sinus ostia were patent in all excluding one case that required a stent due to disrupted anatomy.Conclusionu2003ESS is effective in improving ophthalmic symptoms and signs due to paranasal sinus mucocoele. ESS may be a viable treatment for paranasal sinus mucocoele with orbital extension, and a direct orbital approach is rarely necessary.

The effect of orbital decompression surgery on refraction and intraocular pressure in patients with thyroid orbitopathy.

PurposeTo investigate the effect of orbital decompression surgery in thyroid orbitopathy (TO) on both refractive status and intraocular pressure (IOP).Patients and methodsA prospective, multicentre, consecutive audit of patients undergoing thyroid decompression surgery. Indications for surgery included cosmetically unacceptable proptosis or corneal exposure. Exclusion criteria included the following: previous orbital surgery, glaucoma, corneal disease, steroid use in the preceding 12 months, or an acute optic neuropathy. Automated refraction, keratometry, pachymetry, Hertel exophthalmometry, and IOP were recorded at 1 month pre- and 3 months postoperatively. IOP using the Tono-Pen (mean of three readings) was measured in the primary, upgaze, and downgaze positions.ResultsData were collected from 52 orbits of 33 patients (East Grinstead, New York, and Adelaide). There was no significant difference between pre- and postoperative data for sphere, cylinder, or central corneal thickness (CCT). The mean spherical equivalent was −0.43±1.49u2009D pre-operatively and −0.28±1.52u2009D postoperatively. The steepest meridian of corneal curvature was 93.1 degrees pre- and 94.2 degrees postoperatively, with no significant difference. Mean IOP significantly decreased when measuring by Goldmann applanation tonometry (GAT) (2.28u2009mmu2009Hg, * P=0.001) and Tono-Pen (3.06u2009mmu2009Hg, * P=<0.0001). IOP measured in upgaze was significantly greater than that in the primary position. Regression analysis between change in IOP and either Hertel exophthalmometry or the number of orbital walls decompressed was non-significant (*Students t-test).ConclusionPatients with TO undergoing orbital decompression had, on average, with-the-rule astigmatism not affected by orbital decompression surgery. IOP was significantly reduced by decompression surgery although no relationship between IOP and the degree of decompression was observed.

Aberrant facial nerve regeneration (AFR): an under-recognized cause of ptosis

AbstractIntroductionu2003Aberrant facial nerve regeneration (AFR) following facial nerve palsy may give rise to ptosis because of increased orbicularis tone. We describe a series of patients presenting with ptosis where the underlying aetiology of AFR was often not recognized by the referring clinicians.Methodsu2003Retrospective case review.Resultsu2003A total of 15 cases with ptosis, secondary to AFR, were seen at the Royal Adelaide Hospital Oculoplastic Clinic between 2000 and 2002. Of these, 10 (67%) were referred by general ophthalmologists. Ptosis was the only reason for referral in 11 patients (73%) and features of AFR or a past history of facial nerve palsy were not mentioned in seven referrals (overall 46%). All patients reported a previous facial palsy. The palpebral aperture was reduced on the affected side with reduction in both upper and lower margin reflex distance (MRD) by a mean of 1.5±0.7u2009mm (P<0.001) and 1.0±0.3u2009mm (P<0.001), respectively. The orbicularis tone was increased and strength reduced on the affected side in all patients. However, none had lagophthalmos. Signs of AFR were demonstrated in all patients with either an increase in ptosis or eyelid closure on the affected side during cheek puffing.Conclusionu2003Patients with AFR following facial nerve palsy may present with ptosis without recognition of the underlying aetiology. Signs of AFR ptosis include a decreased palpebral aperture with a reduced upper and lower MRD. The diagnosis can be established with demonstration of an increase in ptosis during cheek puffing. Recognition of AFR is important in these cases owing to the implications for management and post-operative patient satisfaction.

Video-endoscope assisted teaching during sub-periosteal orbital surgery.

Purpose: The authors report the novel use of the video-endoscope as an adjunct in teaching orbital surgery, in particular within the sub-periosteal orbital space. This is of most use during situations where visualisation is of critical importance and direct supervision is not possible. Materials and Methods: This technique was used for 16 cases of orbital surgery during a 12-month period. There were 5 orbital fracture repairs, 8 orbital decompressions (4 via a swinging eyelid and 4 via a transcaruncular approach), an infraorbital nerve biopsy, an eosinophilic granuloma and an orbitofrontal cholesterol granuloma. All procedures were performed by the trainee under consultant supervision with the endoscope being used when direct visualisation was not possible for the consultant. A rigid Storz 3-chip video-endoscope with 0, 30 and 70-degree tips was used to enable visual supervision. Results: The endoscope was of particular use in procedures involving the posterior orbital floor, orbital roof and medial orbital wall. It also enabled safe supervision of curettage of an orbital roof lesion which abutted the dura. The technique was easy to use; it provided good local illumination and a magnified view for supervision. Conclusion: This technique is a valuable adjunct in allowing the trainee to safely perform selected complex orbital surgery under video-endoscopic supervision.