Roel Kloos

Worldwide Enucleation Techniques and Materials for Treatment of Retinoblastoma: An International Survey

Purpose To investigate the current practice of enucleation with or without orbital implant for retinoblastoma in countries across the world. Methods A digital survey identifying operation techniques and material used for orbital implants after enucleation in patients with retinoblastoma. Results We received a response of 58 surgeons in 32 different countries. A primary artificial implant is routinely inserted by 42 (72.4%) surgeons. Ten (17.2%) surgeons leave the socket empty, three (5.2%) decide per case. Other surgeons insert a dermis fat graft as a standard primary implant (n=1), or fill the socket in a standard secondary procedure (n=2; one uses dermis fat grafts and one artificial implants). The choice for porous implants was more frequent than for non-porous implants: 27 (58.7%) and 15 (32.6%), respectively. Both porous and non-porous implant types are used by 4 (8.7%) surgeons. Twenty-five surgeons (54.3%) insert bare implants, 11 (23.9%) use separate wrappings, eight (17.4%) use implants with prefab wrapping and two insert implants with and without wrapping depending on type of implant. Attachment of the muscles to the wrapping or implant (at various locations) is done by 31 (53.4%) surgeons. Eleven (19.0%) use a myoconjunctival technique, nine (15.5%) suture the muscles to each other and seven (12.1%) do not reattach the muscles. Measures to improve volume are implant exchange at an older age (n=4), the use of Restylane SQ (n=1) and osmotic expanders (n=1). Pegging is done by two surgeons. Conclusion No (worldwide) consensus exists about the use of material and techniques for enucleation for the treatment of retinoblastoma. Considerations for the use of different techniques are discussed.

Parallax-free exophthalmometry : a comprehensive review of the literature on clinical exophthalmometry and the introduction of the first parallax-free exophthalmometer

Abstract Purpose: To present the first parallax-free exophthalmometer design. Background: Exophthalmometry is an important clinical tool. We provide a historic overview of clinical exophthalmometer designs, and we review current problems encountered in exophthalmometry. Methods: We present a new and parallax-free exophthalmometer design that we have evaluated in 49 patients visiting our orbital clinic. Results: The mean age of the patients was 49.8 years and 72% were female. The Pearson interobserver variation was 0.97, and 94% of the Hertel values measured by the two observers were within the limits (1.6 mm) of agreement. Conclusion: This meter appears to be a reliable instrument for exophthalmometry. It is the first instrument that allows for a complete parallax-free measurement.

True abscess formation is rare in bacterial orbital cellulitis; consequences for treatment

BACKGROUND Pre- or retroseptal bacterial orbital cellulitis (pOC/rOC) is not an uncommon orbital disease. Treatment consists of antibiotics with or without surgical drainage. Several questions regarding course, complications and outcome of treatment are unanswered and the indication for surgery is not well defined. The aim of this study is to: 1. describe the outcome of orbital cellulitis (OC) in a large cohort, 2. assess the significance of Chandlers classification, 3. assess the incidence of abscess formation in OC, and 4. redefine criteria for surgery. METHODS Retrospective case series of patients with OC seen between 1-1-2007 and 1-1-2014 in a tertiary referral center. RESULTS Sixty-eight patients presented with (presumed) bacterial pOC. Two out of these 68 developed rOC. All 68 patients had a full recovery. Forty-eight patients presented with rOC. Four out of 48 (8%) had intracranial extension of the infection at the time of admission. No admitted patient developed distant seeding. Only four (8%) patients with rOC had a true orbital abscess. In the other 92% we found a diffuse orbital inflammation or a subperiosteal empyema. Forty-four (92%) patients with rOC had a full recovery. CONCLUSIONS 1. The prognosis of both pOC and rOC nowadays is generally favorable. 2. Chandlers classification is of little use. 3. True abscess formation in OC is rare. 4. The indication for surgical intervention must be based on the clinical presentation and the assessment of true orbital abscess formation.

Orbital apex cavernous hemangioma - beware of the pear!

2001). It has been discovered that Morcher occlusive IOLs transmit high levels of near infrared light permitting retinal and macular imaging with optical coherence tomography (OCT) (Yusuf et al. 2011). We sought to evaluate the clinical utility of anterior segment OCT to detect subtle degenerative changes in a Clear IOL through a Black IOL in Black-on-clear polypseudophakia. Preoperative imaging in this context would permit accurate surgical planning for a high-stakes operation in a patient’s only seeing eye. We selected six intraocular lenses and implanted them sequentially in the posterior chamber of a model eye (Fig. 1A). Topcon Spectral-Domain Optical Coherence Tomography (3DOCT 2000) was used to acquire Anterior Segment OCT (AS-OCT) profiles of the model eye with each Clear and Black IOL individually, and in combination with replicate Black-onClear Polypseudophakia (Fig. 1B–D). AS-OCT was able to clearly image the Clear IOL through Morcher occlusive IOLs in simulated Black-on-clear polypseudophakia with no attenuation of OCT signal from the Clear IOL (Fig. 1B). AS-OCT was not able to image through Dr Schmidt’s Black IOLs or Artisan phakic iris-claw IOLs with AS-OCT identifying only the anterior optical interface of both IOLs, and not the posteriorly located Clear IOL (Fig. 1C). To evaluate the clinical utility of AS-OCT in Black-on-clear polypseudophakia, pathological states such as extracellular deposition, IOL fusion, IOL degradation and flattening were replicated in the model eye. AS-OCT was able to clearly identify soft tissue deposition and fusion between the IOLs, and subtle degradation and flattening of the anterior optic of the Clear IOL through Morcher Black IOLs (Fig. 1D). This study presents original data supporting the use of Anterior Segment OCT to evaluate the position and integrity of Clear IOLs through Black Morcher IOLs in Black-onclear Polypseudophakia. Dr Schmidt’s and Artisan iris-claw Black IOLs do not transmit infrared light, and patients with these prostheses cannot undergo preoperative or follow-up AS-OCT imaging (Yusuf et al. 2012). This may impact on preoperative occlusive IOL selection in primary Black-on-clear Polypseudophakia surgery. We believe AS-OCT should be used routinely to evaluate the integrity and position of the clear IOL preoperatively in patients with Black-on-clear polypseudophakia undergoing occlusive IOL explantation. This may identify critical preoperative details such as biometric indices for iris or sulcusfixated IOLs or the likelihood of vitreo-retinal surgery should AS-OCT reveal the clear IOL nonviable with consequent risk of capsular damage. AS-OCT in this setting will provide valuable information on the integrity and configuration of the clear IOL for accurate informed consent and surgical planning before, what is by definition, a high-stakes operation on a patient’s only seeing eye.

Outcome of Inferior and Superior Rectus Recession in Graves' Orbitopathy Patients

Abstract Purpose: To evaluate the surgical effect of unilateral inferior rectus recession (IR-group) with or without a recession of contralateral superior rectus (IR-SR-group) on squint angle and motility restrictions in Graves’ Orbitopathy (GO) patients. Design: Retrospective case series. Materials and Methods: Primary outcome parameters were the changes of squint angle 3 months and 6–12 months postoperatively. As in a previous study, success was defined as a postoperative vertical squint angle of ≤3° in primary position and on downgaze. Secondary outcome parameters were the influence of surgery on duction range and influence of muscle size on dose-effect response. Results: Fifty-six patients were included in the study; 31 patients in the IR-group and 25 patients in the IR-SR-group. The amount of (fixed suture) recession ranged from 2 mm to 7 mm. Vertical deviations in primary position changed from 8.0° [95% CI 6.6–9.7°] to 1.0° [95% CI −0.4–6.5°] in the IR-group and from 17.0° [95% CI 15.7–20.0°] to 1.5° [95% CI 0.8–2.9°] in the IR-SR-group. The success rate was 74% in the IR-group and 64% in the IR-SR-group. Elevation significantly improved in both groups (IR-group p = 0.007; IR-SR- group p = 0.000). The volume of vertical rectus muscles as assessed on CT-scans did not influence the dose-effect response. Conclusions: The highest success rate and highest reduction of depression was found in the IR-group. The total duction range remained stable after strabismus surgery (IR-group) or improved (IR-SR-group). Both squint angle and cyclodeviation remained stable during long time follow-up (6–12 months after surgery).

Unilateral and bilateral medial rectus recession in Graves' Orbitopathy patients

Abstract Purpose: To evaluate the effect of uni- and bilateral medial rectus recession on squint angle and ductions in Graves’ Orbitopathy (GO) patients. Design: Retrospective case series. Materials and methods: Consecutive GO patients seen between January 2000 and March 2012 who were operated on one or both medial rectus muscles were selected for the study. Data regarding squint angle, abduction, and adduction were collected starting 3 months before surgery and 3 and 6–12 months after surgery. Results: 102 patients were eligible for inclusion. Of these, 24 patients were operated on one medial rectus and 78 on two medial rectus muscles. The dose-effect response was 1.0 [−0.6–3.8]°/mm in the unilateral and 1.4 [0.2–3.0]°/mm in the bilateral group (p = 0.000). In the bilateral group, the maximal abduction and adduction changed significantly (p = 0.000). However, the total duction range remained unchanged (unilateral: p = 0.525; bilateral: p = 0.137). The extent of the preoperative abduction did not influence the dose-effect response (r = −0.234; p = 0.040), nor did the muscle volume (unilateral p = 0.989; bilateral p = 0.397). Twenty-three patients (23%) needed additional horizontal squint surgery. Conclusion: In this large series of medial rectus recessions in patients with Graves’ disease we found significantly lower dose-effect response ratios as compared to other studies. The amount of abduction deficit does not influence outcome.

Case series: effect of dermis-fat implants in different late onset socket problems encountered in retinoblastoma patients

ABSTRACT Background: Cosmetic dissatisfaction, pain, and chronic discharge may present months till years after enucleation in patients operated because of retinoblastoma. If noninvasive treatment modalities are insufficient, socket reconstruction can be considered. In this study, we discuss the results of dermis-fat exchange to treat these problems. Method: Four patients with late onset post enucleation socket problems with a request for treatment were included in this prospective study. Socket inspection was documented and pictures at baseline and at a follow-up of at least 6 months were taken. To quantify the problem ‘pain’, a VAS score at baseline and at follow up was used. For the problem ‘cosmetic dissatisfaction’ standardized questionnaires were used. Results: Two patients were included because of cosmetic dissatisfaction; one was included with chronic pain and one with chronic discharge. Reconstruction of the socket using autologous dermis-fat insertion was done in all four. In one of them, severe shrinking of the fat developed. This patient was treated with additional injectable fillers. Both of them, ultimately, had satisfactory results. Autologous fat transplantation also solved the problem of chronic discharge and pain in the two other patients. Conclusion: Socket reconstruction by autologous dermis-fat exchange may solve different post enucleation socket problems. However, shrinking of the transplanted fat may occur and require additional procedures.