Shu-Lang Liao

Intraosseous hemangiomas of the facial bone.

Background: Hemangiomas arising in the soft tissue are common in the head and neck region, but intraosseous hemangiomas of the facial bone are rare. Methods: The authors conducted a retrospective study investigating the clinical features, management, and outcomes for seven patients with facial bone hemangiomas. Results: Three of the hemangiomas arose in the orbital bones, two arose in the mandible, one arose in the frontal bone, and one arose in the zygoma. The mean follow-up was 3 years 9 months. During the first operation, total tumor resection was performed for two symptomatic patients, and partial resection with superficial osteotomy was performed for the remaining five individuals with facial contour deformity. Three patients who underwent partial resection achieved long-term aesthetically satisfactory results without recurrence; the other two developed recurrent tumors and underwent subsequent en bloc resection. No evidence of recurrence was observed in cases where primary or secondary complete tumor resections were performed. Conclusions: Although complete tumor resection represents a definitive treatment for facial bone hemangiomas, conservative partial resection offers a simple method of restoring facial contour with minimal side effects. Although it appears that recurrence cannot be avoided entirely, partial resection should be considered for patients who seek surgery for cosmetic reasons.

Malignant eyelid tumours in Taiwan

AbstractAims To describe the clinical characteristics of patients with eyelid cancers in Taiwan.Methods Between 1980 and 2000, 127 (58 males and 69 females) patients (mean age 62.6; range 10–91 years) with histologically confirmed eyelid cancers were retrospectively evaluated at the National Taiwan University Hospital and Far Eastern Memorial Hospital in Taiwan. Clinical data of all patients were reviewed from medical records. The mean follow-up period was 62.4 months (range 3–240) for 113 patients.Results The 127 eyelid cancers included 79 basal cell carcinomas (62.2%), 30 sebaceous gland carcinomas (23.6%), 11 squamous cell carcinomas (8.7%), five malignant melanomas (3.9%), one Kaposis sarcoma (0.8%), and one metastatic cancer (0.8%). Tumours developed more commonly in the lower (37.0%) than the upper eyelid (33.9%). The clinical accuracy in predicting eyelid malignancy was 90.5%. Primary treatment modality was mainly surgical excision. The recurrence, metastasis, and mortality rates at 5 years were 15.2, 11.7, and 7.3%, respectively, for all eyelid malignancies. Rates of sebaceous gland carcinoma recurrence, metastasis, and mortality were significantly higher (P<0.05) than those of basal cell carcinoma. The mean interval of recurrence or metastasis after primary treatment was 26.3 months (range 4–112) for all eyelid cancers.Conclusions Although basal cell carcinoma is the most common eyelid cancer in Taiwan, sebaceous gland carcinoma is also common. Of the two, basal cell carcinoma has a better prognosis and sebaceous gland carcinoma has a higher mortality and therefore should be treated much more aggressively. Long-term follow-up is needed after treatment of malignant eyelid tumours.

A single transcutaneous injection with Botox for dysthyroid lid retraction.

AbstractPurpose To evaluate the safety and efficacy of injections with botulinum toxin type A (BTTA, Botox®), given transcutaneously, in the treatment of upper lid retraction associated with thyroid eye disease (TED).Methods A total of 15 patients (21 eyes) with a stable (TED) condition, and a euthyroid state, were enrolled into the study. There were 12 females and three males from ages 23 to 52 years. A single injection, at the centrally superior tarsal border transcutaneously, aiming at the levator aponeurosis and Müller muscle, was administered into each eyelid with 5–6 U of Botox®. All patients were followed regularly for 4–6 months. Any complications, such as ptosis, diplopia, pain, or lid ecchymosis were recorded.Results All patients, except one, experienced much reduction of palpebral fissure. The mean difference of MRD1 between pre- and postinjections of Botox® at the first week was −3.1 mm, and the effect remained, at least, for 2 months. There were temporary complications of ptosis in three patients and vertical diplopia in two patients, lasting 3–4 weeks.Conclusions A single transcutaneous injection with Botox® for the treatment of thyroid lid retraction is safe and effective. Some minor complications may occur, such as ptosis and diplopia; however, it may offer an alternative and temporary method for patients with dysthyroid lid retraction, who are waiting for a staged operation of either an orbital decompression or a strabismus surgery or both.

Results and Predictability of Fat-Removal Orbital Decompression for Disfiguring Graves Exophthalmos in an Asian Patient Population

PURPOSE To evaluate proptosis reduction by fat-removal orbital decompression (FROD), to determine the incidence of postoperative diplopia, and to assess predictability of proptosis reduction per volume of resected orbital fat. DESIGN Cross-sectional study. METHODS One hundred and twenty patients (31 men; 89 women) with Graves ophthalmopathy were treated with FROD via the transforniceal approach on 222 orbits between April 2003 and April 2006. Fifteen (12.5%) patients exhibited preoperative diplopia; 105 (87.5%) were without diplopia; mean follow-up +/- standard deviation (SD) was 10.9 +/- 5.1 months (range, six to 37 months). Univariate and multivariate analyses were used to evaluate Hertel change with FROD by linear regression. The setting was thyroid eye disease special clinics at National Taiwan University Hospital. RESULTS Mean Hertel values +/- SD decreased from 20.3 +/- 1.8 mm (range, 16.5 to 26.0 mm) to 16.8 +/- 1.4 mm (range, 13.5 to 21.0). Mean proptosis reduction +/- SD was 3.6 +/- 1.0 mm (range, 1.5 to 7.5 mm). Mean volume of resected orbital fat +/- SD was 3.6 +/- 1.0 ml (range, 1.2 to 6.5 ml). New-onset diplopia was noted for 2.8% of patients after FROD. The final predictive equation for Hertel change is shown as: 0.72 x removal of intraconal fat (ml) - 0.001 x age (yrs) - 0.22 x gender (male, 1; female, 0) - 0.19 x preoperative diplopia (yes, 1; no, 0) + 1.02. CONCLUSIONS FROD can achieve reasonable proptosis reduction and can reduce incidence of new-onset diplopia for patients with disfiguring Graves exophthalmos. The volume of resected orbital fat correlates with mean Hertel value change. The amount of resected orbital fat may predict proptosis reduction.

Application of digital infrared thermal imaging in determining inflammatory state and follow-up effect of methylprednisolone pulse therapy in patients with Graves’ ophthalmopathy

BackgroundInflammation can cause a local increase in temperature. Digital infrared thermal imaging (DITI) has been used to monitor the temperature distribution of human skin. Graves’ ophthalmopathy (GO) is an autoimmune disease, and patients are treated with immunosuppressive agents if the ophthalmopathy is at an inflammatory state. The aim of the present study was to elucidate the feasibility of DITI in determining inflammatory state and follow-up effect of methylprednisolone pulse therapy in patients with GO.MethodsDigital infrared thermal imaging was used to measure local temperatures of lateral orbit (reference point), upper eyelid, caruncle, medial conjunctiva, lateral conjunctiva, lower eyelid, and cornea, and to make thermal density plots in 14 patients (28 eyes) with GO including inflammatory signs (mean clinical activity score 2.5), and 16 normal controls (32 eyes). We also performed methylprednisolone pulse therapy in 11 patients (22 eyes) with active GO, and measured clinical activity score and local temperatures before and after treatment. The focal change in temperature after treatment and the correlation between temperature variation and change in clinical activity score were then analyzed. Thermal density plots were also compared.ResultsLocal temperatures of the caruncle, medial conjunctiva, lateral conjunctiva, and lower eyelid of the patients were significantly higher than those of normal controls. In the 11 GO patients treated with methylprednisolone pulse therapy, the temperatures of the caruncle, medial conjunctiva, and lower eyelid were significantly decreased after treatment. Temperature variation significantly and positively correlated with a change in clinical activity score (correlation coefficient = 0.8, n = 22, p = 0.000). The temperature decreased after treatment in patients who were responsive to methylprednisolone pulse therapy, and the thermal density plot was close to that of normal controls.ConclusionsDigital infrared thermal imaging might be helpful in evaluating the inflammatory state of GO and the follow-up effect of methylprednisolone pulse therapy.

Role of macrophage infiltration in the orbital fat of patients with Graves’ ophthalmopathy

Objective  Infiltration of the retro‐ocular space by inflammatory cells, accumulation of glycosaminoglycans, and the overabundance of orbital adipose tissue are characteristic findings in Graves’ ophthalmopathy (GO). The cause of macrophage infiltration in the orbital adipose tissue of patients with GO remains to be elucidated.

Results of radiotherapy for orbital and adnexal lymphoma.

Twenty-five patients presenting with stage I primary orbital and/or ocular adnexal lymphoma from May 1990 through January 1997 were retrospectively reviewed at National Taiwan University Hospital. Staging workups included physical examination, chest radiography, blood analysis, whole-body CT scan, CSF examination and bone marrow biopsy. The histological types, based on the National Cancer Institute working formulation, were 17 cases of low-grade and 8 of intermediate lymphoma. Twenty patients received radiotherapy, while five cases refused. All patients except two received a radiation dose of 40Gy, the other two received 30Gy. The mean follow-up period was 4.7 ± 1.6 years (2–8 years). Local control of disease was achieved in all 20 patients, but one patient with low-grade lymphoma developed disseminated disease with parotid gland, bone marrow and lung involvement 43 months after radiotherapy. Two out of five patients who refused treatment with radiotherapy developed systemic involvement 24 months and 18 months after diagnosis. Dry eye (45%) and cataract formation (35%) were among the most frequent complications in this study. One patient developed a recalcitrant trophic corneal ulcer and ultimately required corneal transplantation. In conclusion, radiotherapy is a safe and effective local treatment in the management of primary orbital or adnexal lymphoma.

Clinical manifestations and management of orbital mucoceles: the role of ophthalmologists.

PurposeTo report the clinical features of orbital mucoceles and discuss the role of ophthalmologists in the management of patients with orbital mucoceles.MethodsA retrospective chart review was performed of all patients with orbital mucoceles treated at the National Taiwan University Hospital from 1990 through 2002. The basic profiles, clinical features, and the management of the patients with orbital mucoceles were recorded and analyzed.ResultsThe records of a total of 15 patients (aged 22 to 76, mean 45.5 years) with orbital mucoceles were selected for this study. The initial presentations included proptosis in ten patients (66.7%), diplopia in five (33.3%), ocular movement limitation in four (26.7%), periorbital pain in four (26.7%), palpable mass lesion in four (26.7%), ptosis in three (20.0%), decreased visual acuity in three (20.0%), headache in two (13.3%), and pupil abnormality with relative afferent papillary defect in one (6.67%). Of the 15 patients, the origins of the orbital mucocele were in the frontoethmoidal sinus in six (40.0%), the ethmoidal sinus in three (20.0%), the frontal sinus in three (20.0%), the maxillary sinus in one (6.7%), and the sphenoidal sinus in two (13.3%). The transcaruncular approach for the management of orbital mucoceles was performed in eight cases, the Lynch approach in three cases, the transforniceal approach in two cases, and functional endoscopic sinus surgery in one case. After surgery, no recurrence was noted.ConclusionsThe frontoethmoidal sinus was the commonest origin of an orbital mucocele, and proptosis was the most frequent sign in patients with an orbital mucocele. All cases showed a favorable response to surgical intervention, and the transcaruncular approach may offer a good surgical option for the management of orbital mucoceles, especially for ophthalmologists. Jpn J Ophthalmol 2005;49:239–245

Late Exposure of the Bioceramic Orbital Implant

PURPOSE To investigate the long-term outcome of the Bioceramic orbital implant. DESIGN A retrospective, comparative, nonrandomized study. METHODS Data were collected from the patients receiving Bioceramic orbital implants at National Taiwan University Hospital between June 1, 2001 and November 1, 2005. The implant was wrapped with Vicryl mesh, adding anteriorly with a scleral patch graft following enucleation with primary or secondary implantation. The unwrapped implant was inserted into an eviscerated globe with posterior sclerotomy and cornea preserved. Primary or secondary placement of sleeve was performed in some patients. RESULTS A total of 112 cases were reviewed. Four patients were excluded attributable to insufficient follow-up. The other 108 patients had a mean follow-up period of 35.8 +/- 10.6 months (range, 24 to 70 months). Fifty patients (46.3%) received the pegging procedure. Eight of 108 (7.4%) cases of late exposure were identified on average 20.7 months after implantation. We identified no cases of implant exposure in 30 cases of enucleation and eight cases of secondary implant when the implant was wrapped in Vicryl mesh and an anterior scleral cap was used. All exposures developed in eviscerated patients (70 cases): two without pegging, three with primary placement, and three with secondary placement of the sleeve. The exposure rate was higher in patients with eviscerated globes, pegged implants, and prior ocular operations (P < .005). CONCLUSIONS Late exposures of Bioceramic implants were found after long-term follow-up, associated with evisceration, pegging, and prior ocular surgeries. The modified wrapping technique can prevent exposure following secondary implantation and enucleation.

Surgical coverage of exposed hydroxyapatite implant with retroauricular myoperiosteal graft

Background: With the increasing use of hydroxyapatite orbital implants, the complication of exposure has become apparent to oculoplastic surgeons. Many kinds of patch grafts, such as sclera, dermis, and hard palate mucosa, have been used to cover exposed hydroxyapatite implants with inconsistent results. In this study, the authors use a newly developed technique, autogenous retroauricular myoperiosteal graft, and the results are reported. Methods: A piece of retroauricular muscle together with its underlying periosteum was carefully harvested. This myoperiosteal graft was patched to the debrided hydroxyapatite exposure area with the periosteal surface facing outward. The margin of periosteal surface was secured with conjunctiva and left uncovered for the surrounding conjunctiva to epithelialise. Results: Nine eyes with hydroxyapatite exposure more than 3 mm were managed with autogenous retroauricular myoperiosteal grafts. Seven cases were successfully treated with single graft surgery. The other two cases needed an additional graft surgery, and there was no re-exposure noted thereafter. Five patients received a successful insertion of the motility peg. All nine patients have been fitted with prosthesis with reasonable motility. There were no complication noted during more than 1 year of follow up. Conclusion: The thick composite nature of the myoperiosteal graft provides a durable and vascularised coverage for exposed hydroxyapatite implants. This technique offers an encouraging alternative for the management of exposed hydroxyapatite implants.