Biomedical subjects

J A Garrity

Publications and source records attributed to J A Garrity.

At least 37 records · Page 2Linked to original sources

PubMed1996

The treatment of Graves' ophthalmopathy in an incidence cohort.

PURPOSE: To determine the frequencies of medical and surgical treatments in an incidence cohort of 120 patients with Graves' ophthalmopathy. METHODS: We reviewed the community medical records and administered a follow-up questionnaire. RESULTS: Of the 120 patients, 89 (74.2%) required either no therapy or only supportive measures. Six patients (5.0%) were treated with systemic corticosteroids. One patient had orbital radiotherapy. Twenty-four patients (20.0%) underwent one or more surgical procedures. The cumulative probabilities of undergoing ophthalmic surgery of any type were 5.0% by one year after the diagnosis of ophthalmopathy, 9.3% after two years, 15.9% after five years, and 21.8% after ten years. The need for surgery was significantly related to age (P < .01; Cox proportional hazards model) but was not significantly dependent on gender (P = .5) or the interaction of age and gender (P = .15). The overall risk of the need for surgery was 2.6 times greater in patients older than 50 years (95% confidence interval, 1.2 to 5.8) than in younger patients. There were no significant differences between tobacco smokers and nonsmokers in the cumulative probabilities of undergoing surgery. CONCLUSION: In 24 (20%) patients, one or more surgical procedures were used to treat Graves' ophthalmopathy. The probability of surgical intervention was significantly related to patient age (older than 50 years), but it was not related to gender or smoking.

Adolescent↗

PubMed1996

Long-term follow-up of Graves ophthalmopathy in an incidence cohort.

PURPOSE: To provide long-term follow-up data on patients with Graves ophthalmopathy in an incidence cohort of 120 patients. METHODS: Data were obtained from a comprehensive review of each patient's community medical record, a follow-up survey, or both. RESULTS: The median interval between the initial ophthalmic examination and most recent follow-up was 9.8 years (range, 64 days to 17.4 years). Follow-up of more than 5 years was available for 96 patients (80.0 percent), whereas follow-up exceeding 10 years was achieved for 59 patients (49.2 percent). Persistent visual loss from optic neuropathy occurred in two eyes, with final visual acuities of 20/30 and 20/60, respectively. None of the patients reported deterioration of vision attributable to Graves ophthalmopathy in the interval since their last ophthalmic examination at the authors' institution. Two patients (2.2 percent) had constant diplopia, but it was correctable with spectacles (prisms) in each case. Nearly one third of respondents had had ocular discomfort during the preceding 4 weeks; the most frequent cause in 72 percent of patients was dry eyes. Among the respondents to the survey, 60.5 percent believed that the appearance of their eyes had not returned to what it had been before the development of thyroid disease, 51.6 percent thought that their eyes appeared abnormal, and 37.9 percent were dissatisfied with the appearance of their eyes. CONCLUSIONS: Although with treatment few patients have long-term functional impairment from Graves ophthalmopathy, more than one third of patients are dissatisfied with their ultimate appearance. The psychologic, aesthetic, economic, and social sequelae of the disorder require further definition by formal outcomes studies.

Adolescent↗

PubMed1996

Molecular analysis of antigen receptor variable region repertoires in T lymphocytes infiltrating the intrathyroidal and extrathyroidal manifestations in patients with Graves' disease.

To determine whether T cells infiltrating thyroid, orbital and pretibial tissue of patients with Graves' ophthalmopathy (GO) and pretibial dermopathy (PTD) represent a primary immune response that is directed against certain antigenic determinants shared between these involved tissues, we characterized these T cells at the molecular level. T cell antigen receptor (TcR) variable (V) region gene usage in thyroid, orbital, pretibial tissue and peripheral blood mononuclear cells of patients with GD, GO and PTD was assessed using RT-PCR and 22 V alpha and 23 V beta gene-specific oligonucleotide primers, followed by Southern hybridization analysis using TcR C-region-specific, digoxigenin-labelled oligonucleotide probes. In some instances, CDR3- and junctional regions of TcR V beta genes were sequenced. Marked restriction and similarities of V alpha and V beta gene usage were detected in samples derived from patients with active GO and PTD of recent onset. Moreover, sequence analysis of junctional domains of V beta families revealed oligoclonality of some intrathyroidal, orbital and pretibial T cell populations as well as the presence of conserved junctional motifs shared by T cells derived the thyroid gland and the extrathyroidal sites. These data suggest that similar antigenic determinants may be responsible for the recruitment and oligoclonal expansion of T cells both within the thyroid gland and at the involved extrathyroidal sites in Graves' disease.

Eye Diseases↗

PubMed1995

The incidence of Graves' ophthalmopathy in Olmsted County, Minnesota.

PURPOSE: To determine the incidence of Graves' ophthalmopathy. METHODS: A population-based cohort of all Olmsted County, Minnesota, residents who had ophthalmopathy associated with autoimmune thyroid disease between Jan. 1, 1976, and Dec. 31, 1990, was identified through the medical diagnostic index of the Mayo Clinic and the Rochester Epidemiology Project. RESULTS: One hundred twenty incident patients were identified, of whom 103 (85.8%) were women (P = .00001; normal relative deviate test). The overall age-adjusted incidence rate for women was 16.0 cases per 100,000 population per year, whereas the rate for men was 2.9 cases per 100,000 population per year (standardized rate ratio, 5.5; 95% confidence interval, 3.3 to 9.3). The distribution of incidence rates by five-year age groups included peak incidence rates in the age groups 40 to 44 years and 60 to 64 years in women, and 45 to 49 years and 65 to 69 years in men. CONCLUSIONS: Incidence rates for Graves' ophthalmopathy exhibited an apparent bimodal peak for both men and women, although the peaks for men occurred approximately five years after those for women. No explanation for these trends was apparent from the data collected.

Adolescent↗

PubMed1994

A review of 340 orbital tumors in children during a 60-year period.

We reviewed cases of histopathologically verified orbital tumors in children at our institution over 60 years to determine the distribution of various pathologic processes and trends over time. We studied the medical records and pathology specimens from 340 patients aged 18 years or younger who underwent biopsy for orbital mass from 1932 through 1991. The most common tumors were cysts (79 of 340, 23.2%), vascular lesions (60 of 340, 17.6%), optic nerve and meningeal neoplasms (56 of 340, 16.5%), inflammatory masses (29 of 340, 8.5%), osseous and fibrocystic lesions (27 of 340, 7.9%), and rhabdomyosarcomas (24 of 340, 7.1%). The overall frequency of malignancies was 18.2% (62 of 340): 11.5% (39) were primary tumors and 6.8% (23) were secondary and metastatic. The frequency of orbital malignancies was 25.4% (36 of 142) in the first 30 years (1932 through 1961) and 13.1% (26 of 198) in the second 30 years (1962 through 1991). The percentage of primary orbital malignancies was almost identical during the first and second periods (11.9% [17 of 142] and 11.1% [22 of 198], respectively). However, secondary and metastatic orbital neoplasms occurred in 13.4% (19 of 142) of the patients during the first 30 years and in only 2.0% (four of 198) during the second 30 years. The frequency of primary orbital malignancies in biopsy material remained the same over 60 years. However, the overall incidence of orbital biopsy specimens containing a malignancy decreased as a result of a reduction in the number of secondary and metastatic neoplasms that underwent biopsy.

Child↗

PubMed1994

Idiopathic intracranial hypertension.

OBJECTIVE: This review was undertaken to summarize the significant progress that has been made in the epidemiology of idiopathic intracranial hypertension (IIH), the changing nosology, and the diagnostic criteria and therapeutic strategy. DESIGN: We reviewed the pertinent literature on IIH published in major English-language journals for the last 20 years. MATERIAL AND METHODS: The diagnosis, epidemiology, pathophysiology, complications, and treatment of IIH are described. RESULTS: IIH occurs at an average annual incidence rate per 100,000 persons of 1 to 2 for the total population and 19 to 21 in obese females of the reproductive age-group. IIH is a recognized cause of reversible vision loss in adult obese women. The diagnosis of IIH requires a documented elevation of intracranial pressure, normal cerebrospinal fluid (CSF) composition, and normal findings on neuroimaging studies. At least two primary mechanisms for the development of increased CSF pressure in IIH have been postulated and supported by experimental data: vasogenic extracellular brain edema and a low conductance of CSF outflow at the arachnoid villi. This condition may be secondarily exacerbated by compression of intracranial venous sinuses by the increased intracranial pressure, resulting in a further reduction of flow across the arachnoid villi. The therapeutic strategy is determined by visual status, which needs close monitoring. CONCLUSION: Although medical measures to lower the intracranial hypertension are successful in the majority of patients, surgical therapy should not be delayed in those with significant or progressive vision loss. Based on recent advances, a practical approach has been described for the diagnosis, early detection of visual impairment, and targeting therapy to preserve the vision or to reverse recent loss of vision in patients with IIH.

Adolescent↗

PubMed1994

Predictors of response to transantral orbital decompression in severe Graves' ophthalmopathy.

OBJECTIVE: To identify factors that may help predict the outcome after transantral orbital decompression in Graves' ophthalmopathy. DESIGN: A retrospective study was conducted of 428 patients who had undergone an initial transantral orbital decompression for severe Graves' ophthalmopathy at the Mayo Clinic between November 1969 and May 1989. MATERIAL AND METHODS: With use of logistic regression analysis, we assessed the preoperative characteristics, the early postoperative results, and the follow-up questionnaire data (obtained a median of 9.5 years postoperatively) from 304 female and 124 male patients with Graves' ophthalmopathy who had undergone transantral orbital decompression at a median age of 53 years. RESULTS: On multivariate stepwise regression analysis, young age, male sex, and long duration of eye symptoms were predictors of severe initial proptosis (P < 0.001). The only independent predictors of greater postoperative recession of proptosis were severity of initial proptosis and longer interval between operation and postoperative examination (P < 0.001). Patients with the most reduction of proptosis had the greatest improvement in visual acuity but more chance for postoperative development of continuous diplopia. Failure of prior corticosteroid or orbital radiation therapy did not affect the degree of recession of proptosis or improvement in visual acuity. On multivariate analysis for predictors of long-term overall patient satisfaction, only young age of the patient was of borderline significance (P = 0.05), and the only significant predictor of satisfaction with the postoperative eye appearance was an operation done primarily for cosmetic purposes (P = 0.012). CONCLUSION: Although various factors may influence the outcome of orbital decompression in patients with Graves' ophthalmopathy, this study showed that the more pronounced the initial proptosis, the greater the degree of recession postoperatively. A higher degree of reduction of proptosis is associated with better visual acuity but also a greater likelihood of development of continuous diplopia.

Adolescent↗

PubMed1994

The surgical management of Graves' ophthalmopathy.

The underlying cause of Graves' ophthalmopathy is unknown and therefore all treatment is palliative rather than preventive. The proximate cause of the retrobulbar swelling is an accumulation of glycosaminoglycans with subsequent water binding. Treatment, in a general sense, either attempts to shrink swollen tissues or to expand orbital volume. Expanding the orbital volume by decompression can be accomplished by many different techniques. Removal of bone is central to this theme. Another type of "decompression" removes orbital fat without any bone removal. This review highlights results of decompression by the antral-ethmoidal (transantral and anterior), transfrontal, endoscopic, and orbital defatting techniques. Diplopia can be a major source of morbidity. From a surgical perspective recessions are the most frequently performed procedure. The results of adjustable versus nonadjustable sutures are compared in one report. Various methods of performing eyelid surgery including a technique to harvest hard palate mucosa are also briefly discussed.

Diplopia↗

PubMed1994

Graves ophthalmopathy. Results of transantral orbital decompression performed primarily for cosmetic indications.

PURPOSE: Transantral orbital decompression is effective treatment for excessive proptosis and optic neuropathy due to Graves ophthalmopathy. In these sight-threatening circumstances, patients willingly accept the side effects of orbital decompression. When transantral orbital decompression is performed for cosmetic indications, patients' acceptance of side effects may be different. This study reports detailed results of transantral decompression for 34 patients in whom the indications were primarily cosmetic. METHODS: The medical records of 34 patients with Graves ophthalmopathy who had transantral orbital decompression primarily for cosmetic indications were reviewed. Preoperative and postoperative physical features of the eyes were compared. Long-term assessment was formulated from follow-up examination and a follow-up questionnaire. RESULTS: The most notable improvement was in the reduction of proptosis (mean decrease, 5.2 mm). The frequency of asymmetry of proptosis, however, did not improve. Asymmetry was more than 1 mm in 44% of patients preoperatively and in 54% postoperatively. Although the palpebral fissure was decreased by an average of 2.7 mm, upper lid retraction became worse in 12 (43%) of 28 eyes. Of 15 patients who had no diplopia preoperatively, continuous diplopia developed postoperatively in 73%. The patients underwent a total of 37 eye muscle operations and 31 eyelid operations after decompression. Of 29 patients who responded to a long-term follow-up questionnaire, 69% were satisfied with the appearance of the eyes and 31% found it acceptable. No patient was dissatisfied. Symptomatic diplopia was present in 6.9% of patients at the time of the follow-up questionnaire. CONCLUSION: Transantral orbital decompression performed for cosmetic indications in Graves ophthalmopathy may need to be followed by eye muscle and lid operations. These procedures result in a high degree of patient satisfaction. However, a small percentage of patients experience persistent diplopia, despite multiple eye muscle procedures.

Adolescent↗

PubMed1993

Results of transantral orbital decompression in 428 patients with severe Graves' ophthalmopathy.

We reviewed records from 428 consecutive patients with severe Graves' ophthalmopathy to determine early and late results after transantral orbital decompression. Optic neuropathy was present in 217 (50.7%) patients. Post-operatively, 402 (89%) of 453 eyes with preoperative visual acuity worse than 20/20 improved or remained the same. Visual field scotomas improved or resolved in 245 (91%) of 269 eyes tested pre- and postoperatively. Preoperative papilledema resolved or improved in 99 (94%) of 105 eyes, and preoperative exposure keratitis improved or resolved in 178 (92%) of 195 eyes. Average proptosis reduction was 4.7 mm. Postoperatively, new diplopia developed in 74 (64%) of 116 patients who had no diplopia before orbital decompression, although 300 patients ultimately had strabismus surgery. At late follow-up (N = 293 patients), 226 (77%) had single vision and 44 (15%) had correction with prism. Complications included sinusitis (18 patients), lower eyelid entropion (38 patients), numb lip (23 patients), cerebrospinal fluid leaks (15 patients), and one frontal lobe hematoma (one patient). The average duration of follow-up was 8.7 years. Transantral orbital decompression effectively reduces proptosis and usually corrects optic neuropathy. In other circumstances, the benefits achieved and the side effects incurred must be carefully balanced for each patient before transantral orbital decompression is considered.

Adolescent↗

PubMed1993

Optic nerve sheath decompression for visual loss in patients with acquired immunodeficiency syndrome and cryptococcal meningitis with papilledema.

Visual dysfunction developing in association with acquired immunodeficiency syndrome (AIDS) can be multifactorial. Two patients with this syndrome and cryptococcal meningitis had papilledema and visual loss. Both were treated by optic nerve sheath fenestration. One patient had bilateral nonsimultaneous optic nerve sheath fenestrations; visual function improved in one eye. The other patient had bilateral visual improvement after a unilateral optic nerve sheath fenestration. Cryptococcal organisms were present in the dural sheath specimens of both patients despite ongoing therapy with antifungal medication. Postoperative orbital infectious complications did not occur. Autopsy examination of one patient showed that the sites of fenestration were patent. Medical treatment of cryptococcal meningitis associated with AIDS has a guarded prognosis. Optic nerve sheath fenestration offers a treatment alternative for papilledema and visual loss that occur with cryptococcal meningitis.

AIDS-Related Opportunistic Infections↗

PubMed1993

Orbital decompression in Graves' ophthalmopathy associated with pretibial myxedema.

Pretibial myxedema (thyroid dermopathy), an uncommon autoimmune manifestation of Graves' disease, is almost always associated with significant ophthalmopathy and may be a marker for an unusually prolonged or different course for the ophthalmopathy. However, it is not known if the response to therapy for eye disease is different in patients with pretibial myxedema. We compared the results of orbital decompression in 385 patients without and 52 patients with pretibial myxedema operated on between 1969 and 1989. Preoperative and postoperative characteristics of severe Graves' ophthalmopathy did not differ in patients with or without pretibial myxedema except for slightly, but not significantly, more proptosis and diplopia in the pretibial myxedema group. In response to a 1989-1990 questionnaire (83% response rate, n = 364), 89.1% without (n = 319) and 88.9% with (n = 45) pretibial myxedema reported satisfactory or acceptable appearance of the eyes. Self-assessment of visual acuity, eye comfort, diplopia, and overall rate of satisfaction with the status of the eyes did not differ between the groups. The presence of pretibial myxedema does not herald an unsatisfactory response to transantral orbital decompression.

Adolescent↗

PubMed1993

The differential diagnosis of orbital calcification as detected on computed tomographic scans.

We reviewed 350 orbital computed tomographic scans to determine the frequency, significance, and differential diagnosis of calcified lesions. Of 171 suitable scans that fulfilled the study criteria, 37 (22%) showed calcific densities. The most common intraocular lesion that contained calcium was retinoblastoma, and the most frequently calcified extraocular masses were vascular lesions (hemangioma, lymphangioma, and varix). We describe two orbital tumors--metastatic colonic carcinoma and primary orbital malignant melanoma--that previously have not been reported as having calcification. The presence of calcification within lesions of the lacrimal gland fossa usually, but not always, portends malignant disease.

Calcinosis↗

PubMed1993

Transfrontal orbital decompression after failure of transantral decompression in optic neuropathy of Graves' disease.

Transantral and transfrontal orbital decompression procedures are effective for treating optic neuropathy of Graves' disease. We studied 10 patients with Graves' disease to clarify whether transfrontal decompression is effective after prior failure of transantral orbital decompression. All patients had persistent or recurrent optic neuropathy after transantral decompression and had failed to respond to systemic corticosteroid therapy. After transfrontal decompression, visual acuity improved in 70% of the eyes, and visual field scotomas decreased in 80%. No major intraoperative or postoperative complications occurred. We conclude that in optic neuropathy of Graves' disease, transfrontal orbital decompression after failure of transantral decompression is an acceptable and beneficial salvage procedure.

Adult↗

PubMed1993

Ocular motor nerve palsies in spontaneous dissections of the cervical internal carotid artery.

Cranial nerve palsies affecting ocular motor function in patients with spontaneous cervical internal carotid artery dissections are rare. Among 155 patients with spontaneous dissections of the cervical internal carotid artery, four (2.6%) had transient third, fourth, or sixth cranial nerve palsy. The third nerve was involved in two patients, the fourth nerve in one, and the sixth nerve in one. Three patients had ipsilateral headache or facial pain, one had bilateral headaches, and three had oculosympathetic palsy. None had any associated cerebral or retinal ischemic symptoms. Cervical internal carotid artery dissection should be included in the differential diagnosis of palsies of the third, fourth, or sixth cranial nerve, especially when associated with ipsilateral headache or facial pain. Interruption of the nutrient arteries supplying these cranial nerves could explain their involvement by internal carotid artery dissection.

Adult↗

PubMed1992

Torsional diplopia after transantral orbital decompression and extraocular muscle surgery associated with Graves' orbitopathy.

Graves' orbitopathy can be associated with horizontal, vertical, and torsional diplopia. Of 428 patients treated with transantral orbital decompression, 21 had incycloduction (mean, 12.8 degrees; range, 5 to 20 degrees) and five had excycloduction (mean, 12 degrees; range, 5 to 20 degrees). All 26 patients had had recessions of the medial or inferior rectus muscle (or both) before onset of torsional diplopia. Mean recession was 5.5 mm (range, 4 to 10 mm) and 5.3 mm (range, 2 to 10 mm) of medial rectus muscle and inferior rectus muscle, respectively. An A pattern was often associated with the condition. Superior oblique tenectomy and inferior oblique myectomy were performed most frequently for incycloduction and excycloduction, respectively. Superior oblique tenectomy induced a mean incycloduction decrease of 7.1 degrees (range, 0 to 12 degrees). Exotropia in downgaze was decreased, and a small ipsilateral hyperdeviation was induced. Bilateral inferior oblique myectomy in one patient decreased excycloduction 10 degrees without inducing new deviation. At follow-up (mean, 63.7 months) after last strabismus operation, 15 patients with incycloduction and two with excycloduction had no diplopia.

Adult↗

PubMed1992

Massive epithelium-lined inclusion cysts after scleral buckling.

Two patients with massive epithelium-lined inclusion cysts of the orbit became symptomatic five and 16 years after scleral buckling. Each patient described diplopia and displacement of the previously treated eye. An orbitotomy in the first patient disclosed a loculated epithelium-lined inclusion cyst that extended posteriorly from the insertion of the inferior rectus muscle nearly to the apex of the orbit. In the second patient, a loculated epithelium-lined inclusion cyst extended into the superior nasal portion of the orbit from its origin near the insertions of the superior and medial recti muscles. We speculated that epithelial cells of the conjunctiva were shed at the time of scleral buckling and became lodged in the exposed sulcus created by the surgical retraction of Tenon's capsule. Here they proliferated and formed the large epithelium-lined cysts. In each patient, removal of the cyst was followed by a decrease in diplopia as the displaced globe returned toward its normal position.

Aged↗

PubMed1992

Extensive defects of the sino-orbital region. Results with microvascular reconstruction.

We performed microvascular free-tissue reconstruction of extensive defects in the sino-orbital region in 11 patients. Reconstructions were immediate in 10 patients and delayed in one patient. There was loss of orbit in eight patients, maxilla in eight patients, cranial base in two patients, and skin and soft tissue of the face in six patients. Nine rectus abdominis flaps, one radial forearm flap, and one lateral arm flap were used. Palatal reconstruction with autologous tissue was successful in all patients. Cranial base repairs healed without sequelae or evidence of meningitis. Cosmetically, soft-tissue repair of facial skin was only satisfactory. For large defects, it was difficult to reconstruct the palate and facial soft tissue and to maintain nasal airway patency with a single microvascular procedure. Free-tissue transfers remain the safest and most versatile reconstructive procedure for massive sino-orbital defects after ablation of a tumor.

Adult↗