Biomedical subjects
Publications and source records attributed to G E Rose.
Three cases of orbital inflammatory disease caused by herpes zoster are described. This extremely rare complication occurred between 5 days and 14 days following the skin eruption and slowly resolved with or without treatment. Biopsy of a chronic inflammatory lesion on the cheek of one patient demonstrated a sterile vasculitis and granulomatous liponecrosis, a process which may underlie the orbital disease in these patients.
A series of 26 patients with lacrimal dysfunction due to congenital cranial or facial anomalies are reviewed. The underlying anatomical abnormalities responsible for symptoms and their influence on surgical management and outcome are discussed and illustrated with representative cases. It is shown that by adaptation of standard surgical techniques a high success rate can be achieved.
Exenteration, or removal of the globe with part or all of the surrounding orbital contents, is generally reserved for malignancy. The procedure may, however, be of value in the management of some benign orbital diseases. The indications for exenteration in management of benign orbital disease are threefold. Firstly, patients in whom diffuse disease, such as idiopathic inflammation, has resulted in an irretrievable situation of visual loss and clinically uncontrollable pain or disfigurement; in many such cases we consider exenteration to be preferable to the (often severe) side effects of prolonged and inadequate medical therapy. The second group are those patients with grossly disfiguring orbital abnormalities, such as teratomas, extensive varices, or massive optic nerve tumours. The last group comprises patients with tumours that, while histologically benign, may have malignant potential or show a tendency to diffuse or persistent infiltration of orbital soft tissues. Sixteen illustrative cases of full or partial exenteration for benign disease are described.
Postoperative soft tissue infection may predispose to failure of open lacrimal surgical procedures. Using a retrospective analysis of 413 cases, the failure rates for primary and repeat surgery were 12.0% and 8.9% respectively (0.25 < p < 0.5). Postoperative soft tissue infection is associated with an increased risk of failure (p < 0.005); antibiotics decrease the rate of postoperative infection and may thus decrease the failure rate. Furthermore, antibiotic therapy decreases the rate of failure in cases after previous facial trauma. Curative antibiotic therapy for established postoperative infection is less effective than preventative therapy at improving the success rate after surgery. Previous trauma is also associated with a greater rate of failure (p < 0.02), possibly owing to the frequent canalicular problems in such patients. Silicone tubes appear to increase neither the rate of infection nor failure (p > 0.5). Trauma, acute dacryocystitis, and silicone tubes appear to act on outcome independently of each other.
A study was undertaken to estimate the incidence of periorbital trigeminal sensory loss with different types of orbital disease and to determine whether the area of loss is related to the location or nature of the underlying condition. A retrospective review was carried out of the clinical case notes of patients identified from the orbital diagnostic database held at Moorfields Eye Hospital. A total of 103 patients (51 male, 52 female), aged between 11 and 84 years (median 51 years), had signs of periorbital trigeminal sensory loss at the time of investigation for orbital disease and in 14/103 (13%) this sensory loss was symptomatic. Sensory loss was due to trauma in eight cases (8%), benign orbital disease in 54 (52%), and malignant disease in 41 cases (40%). The relative frequency of recorded sensory changes is about 9% for malignant tumours, 5% for benign tumours, 4% after orbital trauma, 3% for orbital inflammatory disease, and less than 1% for orbital structural anomalies. Relative corneal hypoaesthesia occurred in 40/103 (39%) cases. Periorbital sensory loss was recorded in about 3% of patients with orbital disease and, in contrast with commonly held views, malignancy was not the most common cause of sensory loss. The affected dermatome is a useful guide to the location of orbital disease, but a poor indication of underlying pathology. Relative corneal hypoaesthesia appears unrelated to the type of disease or to its location within the orbit.
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Symptoms and signs of orbital inflammation may be prominent features in the presentation of choroidal malignant melanoma, even when the tumour is solely intraocular. Three cases with this clinical presentation are described.
Appropriate axial or coronal computed x-ray tomography is the most inexpensive method to reliably supply detail in orbital disease. Magnetic resonance imaging can provide additional information and may be characteristic in some conditions. Magnetic resonance imaging is imperative for detailed imaging of disease at the orbital apex, optic canal, or chiasm. Color-coded Doppler ultrasonography allows examination of physiological blood flow within orbital vasculature and recent reports have reported the changes of flow in various orbital diseases. Limited results with computed tomographic or video-radiographic investigation of lacrimal outflow obstruction have been presented in several articles, although it remains doubtful whether these techniques are superior to the cheaper, more readily available, conventional macrodacryocystography. Endoscopy of the lacrimal drainage system is proving to be an interesting research tool, but is of uncertain applicability in the treatment of disease.
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Periorbital dermoid cysts should be removed because they commonly leak their irritant contents into the surrounding tissues. The underlying bone may, however, be involved in patients with dermoid cysts at the outer canthus. Computed tomography studies of 70 patients (43 men and 27 women, aged 30 months to 63 years, mean 29 years) with proved dermoid cysts of this type were reviewed. The lesion was always unilateral; 34 were on the left. The bone of the lateral wall and superotemporal angle of the orbit showed the following abnormalities, often in combination: pressure erosion in 61 cases and an otherwise abnormal shape, probably developmental, in 55; the dermoid cyst entered a tunnel or canal through the lateral wall in 24; a blind pit or crater in 15; and a cleft in 20; many patients also showed abnormal bone texture. These findings are extremely important for planning adequate surgery, and indicate that bony involvement is much more frequent than previously appreciated.
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Magnification dacryocystography in 18 patients with chronic infective canaliculitis showed dilatation and irregularity of the affected lacrimal canaliculi, with prominent filling defects in almost all cases. Filling defects are uncommon in other diseases of the canaliculi and serve to confirm the diagnosis.
BACKGROUND: The causes of fibrinous uveitis after cataract surgery are unclear, but surface modification of polymethylmethacrylate (PMMA) is known to influence post-operative inflammation. One hundred twenty-five patients were entered into a prospective investigation designed to assess the effect of intraoperative surface modification of PMMA, by coating with a 2% hydroxypropyl methylcellulose solution, on the incidence of fibrinous uveitis after extracapsular cataract surgery and lens implantation. METHODS: Of the 125 patients entered into this prospective study, 90 received pretreatment with a 1% indomethacin solution. RESULTS: Fibrinous uveitis developed in 18(33%) of 54 eyes with dry lens implantation and in 1 (3%) of 36 eyes with coated lens implantation (P less than 0.005). Thirty-five eyes were not pretreated with indomethacin, and fibrin formation occurred in 6 (30%) of 20 dry implanted eyes and in 0 of 15 eyes with coated lens implantation (S = 0.02). CONCLUSIONS: Intraoperative modification of the PMMA surface of an intraocular lens during implantation significantly reduces the severity of postoperative inflammation, as manifest by the incidence of fibrinous uveitis.
Orbital chondrosarcomas are extremely rare and are usually an extension of tumours involving the paranasal sinuses. A unique case of dedifferentiated chondrosarcoma arising solely within the orbit is presented.
To reduce the risk of recurrence and malignant transformation, pleomorphic adenomas of the lacrimal gland should be removed intact, without prior biopsy. Seventy one of the 78 patients in this series were referred without previous surgery, and, on clinical or radiological evidence, 63 (89%) tumours were correctly diagnosed and totally excised, with preservation of a margin of the surrounding normal tissue. Sixty three patients had tumour within the body of the gland and 55 (84%) had radiological signs or satisfied clinical criteria for pleomorphic adenoma that we suggested previously; that is, over 1 year of symptoms and absence of pain. Eight (16%) orbital lobe tumours were misdiagnosed preoperatively and biopsied; in all these patients symptoms had been present for less than 1 year, and four patients had pain. Eight patients with tumours arising in the palpebral lobe had a short history of an upper lid mass, and their tumours were excised without biopsy. With the surgical techniques described in this paper, there has been no recurrence of tumour in patients with follow-up as long as 21 years. A modification of surgical technique, with preservation of the palpebral lobe of the gland, has reduced the incidence of postoperative dry eye and distortion of the upper eyelid.
The clinical characteristics and outcome of 50 primary malignant neoplasms of the lacrimal gland are reviewed: 38 (76%) adenoid cystic carcinomas, six (12%) carcinomas arising in pleomorphic adenoma, and six (12%) adenocarcinomas or other types of carcinoma. Most patients presented with a short history and pain, though pain tended to occur less often and later with adenocarcinoma than with adenoid cystic carcinoma. Pain was unrelated to the duration of symptoms, invasion of bone, loss of trigeminal nerve function, or the frequency and time of tumour recurrence. The estimated disease-free survival for patients with adenoid cystic carcinoma was significantly (p less than 0.01) reduced where half or more of the biopsy specimen showed basaloid differentiation. Eleven patients underwent extended cranio-orbital resection, and the others received a combination of total dacryoadenectomy adenectomy and/or radiotherapy. Survival after adenoid cystic carcinomas appears to be significantly (p less than 0.05) greater when tumour resection is combined with radiotherapy than after radiotherapy alone. At present, however, the rate of disease-free survival after treatment of adenoid cystic carcinoma appears unaltered by cranio-orbital resection, though these latter patients form a relatively greater proportion of those surviving for more than 10 years. Further long-term follow-up is needed to see if this technique does influence survival.