Ross Benger

Idiopathic orbital inflammatory syndrome : Clinical features and treatment outcomes

Aim: To characterise the clinical and pathological features of 24 patients with biopsy proven Idiopathic Orbital Inflammatory Syndrome (IOIS). Methods: Retrospective case series. Results: The study included 14 men and 10 female patients, ranging in age from 14 to 75 years. The presenting symptoms and signs included pain (14/24), swelling/mass (19/24), diplopia (9/24), proptosis (15/24), extraocular muscle restriction (13/24), decreased vision (5/24) and ptosis (4/24). Histopathology was varied and included classical orbital pseudotumour (9/24), sclerosing orbital pseudotumour (13/24), vasculitic orbital pseudotumour (1/24) and granulomatous orbital pseudotumour (1/24). Treatments included oral steroids (19/24), intravenous steroids (1/24), methotrexate, azathioprine, mycophenalate and ciclosporin. Forty-two per cent of the patients had recurring episodes during the follow-up period, with 29% of patients requiring two or more treatment regimens to maintain remission. Two-thirds of patients (16/24) had complete resolution of their symptoms and signs. There was no correlation between the histopathological subtype, relapse rate or symptoms and resolution of signs. Conclusion: Idiopathic Orbital Inflammatory Syndrome has variable clinical and pathological features. Although, in some patients, symptoms and signs resolve spontaneously, most require treatment with oral steroids and additional immunosuppressant drugs or radiotherapy. The clinical and pathological features do not correlate with treatment outcomes.

Perineural Spread of Cutaneous Squamous Cell Carcinoma via the Orbit: Clinical Features and Outcome in 21 Cases

OBJECTIVE To describe the clinical features, treatment, and outcome of a series of patients with perineural spread (PNS) of cutaneous squamous cell carcinoma (SCC) via the orbit. DESIGN A cohort study. PARTICIPANTS Twenty-one patients identified with PNS of cutaneous SCC via the orbit. INTERVENTION Patients were treated with various combinations of conservative or radical surgery, external beam radiation therapy, and chemotherapy. RESULTS Of 21 cases, 17 (81%) were male. Age at presentation with PNS ranged from 38 to 82 years (median, 66 years). The forehead and eyebrow were the most common site of the primary lesion. All but one had altered or decreased sensation, but only nine presented with pain. Fourteen (67%) had ophthalmoplegia at presentation, and 14 (67%) had evidence of PNS involving branches of the facial nerve. Despite combinations of radical surgery, conservative surgery, and radiation therapy, no method of treatment appeared more effective, and 14 patients died from 9 months to 5 years after presentation with PNS (median, 3 years), usually from local and intracranial disease. Two survived to 14 and 18 years, one is alive at 3 years with recurrent local and distant disease, and four are alive without evidence of disease at 2, 3, 4 and 12 months after radiation therapy. CONCLUSIONS Perineural spread of cutaneous SCC via the orbit carries a poor prognosis. Early radiation therapy may offer the best form of palliation. The role of radical surgery probably is limited once orbital involvement is apparent, as the cavernous sinus and facial nerve branches usually are involved.

A comparative study of eyelid parameters in involutional entropion

A comparative study of eyelid parameters reported to be important in involutional entropion was made. Males and females aged 65 years with normal eyelids, acute involutional entropion (history <6 weeks), and chronic involutional entropion (history 6 weeks) were entered into the study. Significant findings were increased vertical laxity in each entropion group and increased horizontal laxity in the chronic entropion group. The upper eyelid action had an essential role in the turning in of affected lower eyelids. The degree of pretarsal overriding in the lower eyelid was not a significant differentiating feature when the groups were compared. The findings of this comparative study provide the basis for suggesting the pathophysiology of involutional entropion.

Orbital exenteration: a 15-year study of 38 cases.

Purpose: To determine the clinical indications and outcomes after orbital exenteration when histologic margins were reported as “clear,” examining factors affecting local and systemic recurrences and mortality. Methods: Retrospective case review of exenterations performed in Sydney Eye Hospital in Sydney, Australia, between 1990 and 2004. Reviewed data indications for exenteration, histopathologic diagnosis, and recurrences on follow-up. Results: Secondary intraorbital spread of malignant adnexal tumors was the most common indication for exenteration (34 of 38). Among these, the site of the primary neoplasm was the eyelid in 19 cases and the ocular surface in 12 cases. Exenteration was total in 26 cases, subtotal in 8 cases, and extended in 4 cases. In 11 cases, a dermis-fat graft was used for socket reconstruction; 24 cases were allowed to granulate spontaneously. The average healing time was 5 months (range, 4–6 months) for spontaneous granulation, and 6 weeks (range, 4–8 weeks) for dermis-fat grafts. Perineural spread was demonstrated histopathologically in 7 specimens. During follow-up (median, 48 months), there were 9 recurrences (23.7%): 3 local and 6 systemic. Seven patients (18.4%) died of the disease during the follow-up period. Conclusions: Dermis-fat grafts for reconstruction of the exenterated socket seem to optimize the aesthetic results. The first year is the most important period for follow-up of local recurrences, but systemic examination is needed for the longer follow-up. This may have implications in terms of reconstruction and adjunctive treatment following exenteration surgery.

A prospective randomized study comparing division of the pedicle of modified hughes flaps at two or four weeks.

Purpose To compare the incidence of upper and lower eyelid malposition or other complications when the pedicle in modified Hughes flap repair of the lower eyelid is divided at 2 versus 4 weeks. Methods A prospective randomized study. Data were collected on patient age and sex, horizontal tumor dimension, upper and lower eyelid position before surgery and 3 months after division of the pedicle, and any complications. Results Complete data from 60 patients were collected, with 32 patients in the 2-week group and 28 patients in the 4-week group. The two groups were not significantly different in terms of sex, age, or tumor dimensions. In the 2-week group, the upper eyelid was within 1 mm of its preoperative position at 3 months in 25 of 32 patients (78.1%) and in 26 of 28 (92.8%) in the 4-week group. The lower eyelid was within 1 mm of its normal position in 27 of 32 patients in the 2-week group (84.4%) versus 25 of 28 (89.3%) in the 4-week group. Statistical analysis showed no significant difference between the 2- and 4-week groups for upper and lower eyelid position at 3 months. Other complications were uncommon and evenly spread between the two groups. Conclusions A modified Hughes flap pedicle may be divided at 2 weeks with no increased incidence in upper or lower eyelid malposition or other complication.

Lung metastases in a case of metatypical basal cell carcinoma of the eyelid: an illustrative case and literature review to heighten vigilance of its metastatic potential.

Basal cell carcinoma (BCC) is an extremely common malignancy; however, unlike other skin cancers, they very rarely metastasize. Here we present an unusual case of metatypical BCC of the eyelid which metastasized to the lung nine years after initial surgical treatment. We include a review of the literature regarding metastatic BCC and suggest that metatypical features in primary BCC should prompt careful patient monitoring and consideration of adjuvant treatment at the time of diagnosis.

Cicatricial entropion repair with hard palate mucous membrane graft: surgical technique and outcomes

Background:  The use of a hard palate mucous membrane graft (HPMMG) has been previously described for upper and lower eyelid cicatricial entropion repair. The objective of this paper is to review the surgical technique and postoperative complications in a large series of patient who underwent hard palate grafting for the management of cicatricial entropion.

External Dacryocystorhinostomy: Assessing Factors that Influence Outcome

Purpose: To present the experience of external dacryocystorhinostomy (DCR) at a tertiary referral center and investigate factors that may affect clinical outcomes. Methods: The clinical records of all patients who underwent external DCR at Sydney Eye Hospital between May 2000 and August 2007 were reviewed. Data were collected in regards to patient demographics, preoperative assessment, operative details, surgical technique, postoperative management, and clinical outcomes. This information was then analyzed, with emphasis on factors that influence surgical outcomes and success. Results: A total of 338 cases were reviewed. The mean age at time of surgery was 64.82 years and the majority of patients were female (65%). Epiphora was the major preoperative symptom. Assisted local anesthesia and day stay surgery were the most common surgical settings. There was a statistically significant difference in theatre time between consultant and trainee surgeons (P < 0.00001). The mean final follow-up time was 11 months. Overall, 77.3% of patients had full resolution of symptoms and 20.8% had partial resolution. Only five patients (1.9%) had no resolution of symptoms. There was no significant difference in outcomes between consultants and trainees. Patients with anatomical nasolacrimal obstruction had significantly better outcomes compared with functional obstruction (P = 0.04). The postoperative fluorescein dye disappearance test was a good predictor of clinical success (P = 0.005). Silicone intubation for greater than 6 months was associated with better outcomes (P = 0.002). Conclusions: The results at our tertiary center are comparable to results stated in the literature. In our series, only the amount of nasolacrimal obstruction and duration of postoperative intubation influenced surgical success.

One-Stage Alternatives to the Hughes Procedure for Reconstruction of Large Lower Eyelid Defects: Surgical Techniques and Outcomes.

Purpose: To present the results of 1-stage surgical advancement flaps for the repair of large full thickness lower eyelid defects. These avoid the disadvantages of the 2-stage Hughes procedure and provide favorable functional and aesthetic outcomes. Methods: A retrospective case series of 36 lower eyelid repairs performed on 31 patients by a single surgeon in Sydney, Australia is presented. The selection criterion was a horizontal defect size 10 mm or greater that could have “classically” been repaired with a 2-stage Hughes procedure. Three different 1-stage surgical repair techniques were utilized, all incorporating local advancement-type flaps: 1) a lateral-based full thickness advancement flap; 2) a vertical tarsal plate advancement flap combined with a full thickness skin graft; and 3) a vertical skin advancement flap combined with a mucosal graft. The postoperative outcomes evaluated included flap viability, lower eyelid margin position and contour, characteristics of the new eyelid margin and patient satisfaction. Results: Thirty-six lower eyelid repairs were performed in 31 patients. There were no cases of flap ischemia, necrosis, or failure. There was 1 case (3%) of postoperative eyelid retraction, 1 case (3%) of eyelid entropion requiring surgical repair, 1 case (3%) of pyogenic granuloma, 2 cases (6%) of eyelid margin cyst, and 7 cases (19%) of eyelid distichiasis. In 34 cases (94%), the patient was satisfied with the aesthetic result. Conclusion: The techniques described provide successful alternatives to the Hughes procedure. They are 1-stage and do not render the patient temporarily monocular, or alter the upper eyelid anatomy or function. All maintained favorable long-term functional and aesthetic outcomes for the reconstructed lower eyelid.

The Method of En Face Frozen Section in Clearing Periocular Basal Cell Carcinoma and Squamous Cell Carcinoma

Background: The senior consultants Ross Benger and Andrew Gal have been using en face frozen section histological margin control in removing cancer from the periocular region since 1985. The aim of this study was to determine the percentage of cases in which more than one resection was necessary in order to achieve clear margins. Methods: This is a retrospective study of patients treated at Drummoyne Eye Surgical Centre in the period 1999–2007, in whom removal of the eyelid cancer was decided to be with en face frozen section histological control. A record was kept of how many resections were necessary to achieve clear margins. Paraffin sections were subsequently examined for a final histopathological diagnosis. Results: Two hundred and fifty people were included in the study, of whom 204 had basal cell carcinoma (BCC) and 32 had squamous cell carcinoma (SCC). One hundred and twenty BCCs had a full-thickness eyelid “wedge” resection, of which 45% needed more than the standard two frozen sections taken to achieve clear margins. Eighty-four BCCs were removed using ring resection, of which 35.7% needed more than the standard initial resections (peripheral annulus and deep disc) to achieve clear margins. Conclusions: Our study showed that a significant percentage of BCC and SCC lesions needed further resection after the initial frozen section edge checks to achieve clear margins. Intraoperative presence of the histopathologist increased the likelihood of achieving clearance of the cancer at a single operating session.