M K Yang, N Kim, H-K Choung and S I Khwarg
To report long-term outcome of new surgical technique for prolapsed subconjunctival orbital fat.
Patients and methods
Retrospective study was conducted on 48 eyes of 37 patients who underwent excision of prolapsed subconjunctival orbital fat with conjunctival fixation to the sclera. Complications and recurrence were evaluated.
The mean follow-up period was 39 months (range, 8–101 months). Two eyes (4.4%) developed recurrence at 4 and 8 years after surgery. No long-term complication was found.
The new surgical technique to manage prolapsed subconjunctival orbital fat using conjunctival fixation to the sclera was very useful and effective, with few recurrence and no long-term complication.
S N Rajak, C James and D Selva
Meibomian gland ductal cysts (MGDCs) and steatocystomas are epithelial lined, keratin-containing lesions of the eyelids. MDGCs are variably called tarsal keratinous cysts, intratarsal keratinous cysts of the meibomian glands, intratarsal inclusion cysts, epidermal cysts and epidermoid cysts. Both lesions are poorly described in the literature. We report a series of seven MGDC and steatocystomas, and examine their clinical, pathological and immunohistochemistry features and their management and outcomes.
Patients and methods
A retrospective review of case notes and histopathology slides of all MGDCs and steatocystomas identified at one major histopathology service in South Australia between 2013 and 2015.
Seven cases were identified, with an average age of 64. The lesions range from 4 to 18 mm diameter and are firm, well-circumscribed and non-tender, and sometimes the keratin-filled cyst protrudes visibly under the tarsal conjunctiva. Two cases were previously misdiagnosed as chalazia but recurred after incision and curettage. Histologically, these lesions are lined by squamous epithelium but lack a well-formed stratum granulosum and can be distinguished by their immunohistochemical staining characteristics. Complete excision, including a wedge of underlying tarsal plate for MDGCs, is curative for with a follow up of 12–36 months.
MGDCs and steatocystomas should be included in the differential of benign eyelid lesions. Diagnosing and differentiating these lesions from chalazia is important for determining the optimal management strategy.
B R Mohammed and R Ford
To evaluate safety and long-term recurrence rate of entropion in patients having everting sutures (ES) for involutional entropion by ophthalmic nurses in a real clinical setting.
Patients and methods
Retrospective notes review of all patients who had an outpatient ES by our trained ophthalmic nurses over 2 year’s time period. Outcome measures were complication and recurrence rates. Those with less than 3 years’ recorded follow-up were contacted by paper questionnaire.
90 lids of 82 patients analysed. Mean age was 78 (range 54–97). In total, 82% had no entropion surgery before, whereas 13% had previous ES and 5% one or more other procedures. Questionnaires were sent to 38, with return rate of 81%. Recurrence rate was 21.1% after 36–60 months follow up from nurse-performed ES, with mean time to recurrence of 15 months (SD 13 months). A total of 32% of patients died during the follow-up period. Mean time between the procedure and death is 20.5 months. When ES were repeated twice (11 patients), recurrence rate was still 20%. No patients had any complications.
ES can be safely performed by ophthalmic nurses, with success rate comparable to the same technique performed by ophthalmologists.
T Y Chen, M G Keeney, A V Chintakuntlawar, D L Knutson, S Kloft-Nelson, P T Greipp, J A Garrity, D R Salomao and J J Garcia
Adenoid cystic carcinoma (ACC) represents ~10–15% of salivary neoplasms and almost universally exhibits a lethal clinical course. ACC is also known to occur in the lacrimal gland. ACC is characterized by its heterogeneous morphology and may demonstrate tubular, cribriform, and/or solid architectural patterns. Unfortunately, these histopathological features are not specific to ACC and can be seen in other salivary gland-type neoplasms, introducing a diagnostic dilemma. The discovery of fusion transcripts has revolutionized the diagnosis, surveillance, and treatment of epithelial malignancies. In several anatomic subsites ACC is frequently characterized by a fusion transcript involving genes MYB and NFIB; more specifically, t(6;9)(q22-23;p23-24). This study explores the incidence ofMYB rearrangement in cases of lacrimal gland ACC using fluorescent in situhybridization.
Materials and methods
Retrospective clinical and histopathological review of 12 cases of lacrimal gland ACC seen at Mayo Clinic over a 25-year period (1990–2015) was performed. Demographic and clinical data were obtained from medical records. Surgical pathology archival material including H&E slides and immunostains was re-examined. Formalin-fixed paraffin-embedded material was further evaluated using immunohistochemistry when appropriate. Fluorescent in situ hybridization (FISH) using a MYBbreak-apart probe was applied to all histologically confirmed cases of ACC and benign salivary gland parenchyma.
The median patient age was 53.6 years (range 12–64) and distributed equally by gender (six male and six female). Rearrangement ofMYB was identified using FISH in seven cases (58%). Twenty-five sections of benign salivary gland parenchyma showed no evidence of MYBrearrangement. Primary surgical resection was most common treatment, and 78% of the patient received adjuvant radiation therapy. Median overall survival (OS) was 11 years. Rearrangement of MYB did not affect OS.
In summary, our results indicate that the MYB rearrangement defines a significant subset of lacrimal gland ACCs. Importantly, FISH forMYB rearrangement may be used as a diagnostic tool during pathological examination of lacrimal gland neoplasms. Our results showed no relationship between rearrangement status and clinical outcome. Lastly, the presence of t(6;9) in ACC may provide a platform for molecular-targeting strategies in the future.
J M Wi, K H Sung and M Chi
To evaluate the effect of orbital reconstruction and factors related to the effect of orbital reconstruction by assessing of orbital volume using orbital computed tomography (CT) in cases of orbital wall fracture.
In this retrospective study, 68 patients with isolated blowout fractures were evaluated. The volumes of orbits and herniated orbital tissues were determined by CT scans using a three-dimensional reconstruction technique (the Eclipse Treatment Planning System). Orbital CT was performed preoperatively, immediately after surgery, and at final follow ups (minimum of 6 months). We evaluated the reconstructive effect of surgery making a new formula, ‘orbital volume reconstruction rate’ from orbital volume differences between fractured and contralateral orbits before surgery, immediately after surgery, and at final follow up.
Mean volume of fractured orbits before surgery was 23.01±2.60 cm3 and that of contralateral orbits was 21.31±2.50 cm3 (P=0.005). Mean volume of the fractured orbits immediately after surgery was 21.29±2.42 cm3, and that of the contralateral orbits was 21.33±2.52 cm3 (P=0.921). Mean volume of fractured orbits at final follow up was 21.50±2.44 cm3, and that of contralateral orbits was 21.32±2.50 cm3 (P=0.668). The mean orbital volume reconstruction rate was 100.47% immediately after surgery and 99.17% at final follow up. No significant difference in orbital volume reconstruction rate was observed with respect to fracture site or orbital implant type. Patients that underwent operation within 14 days of trauma had a better reconstruction rate at final follow up than patients who underwent operation over 14 days after trauma (P=0.039).
Computer-based measurements of orbital fracture volume can be used to evaluate the reconstructive effect of orbital implants and provide useful quantitative information. Significant reduction of orbital volume is observed immediately after orbital wall reconstruction surgery and the reconstruction effect is maintained for more than minimum 6 months. Patients that undergo surgery within 14 days of trauma has better reconstruction rates at final follow up, which supports the need for early surgery.
M J Lee, S I Khwarg, I H Kim, J H Choi, Y J Choi, N Kim and H-K Choung
To analyze the surgical outcomes of external dacryocystorhinostomy (DCR) and the risk factors associated with functional failure.
We reviewed the medical records of 769 patients who underwent external DCR for primary lacrimal drainage obstruction between 2005 and 2014. Recorded data included intraoperative anatomical findings, postoperative diagnosis, and surgical outcomes. We performed univariate and multivariate analyses to identify risk factors for functional failure.
Of the 769 cases, primary nasolacrimal duct obstruction (NLDO) was diagnosed in 457 cases; common canalicular obstruction in 228 cases; and canalicular obstruction in 84 cases. Anatomical success was achieved in 98.8% (760/769) and functional success in 81.9% (630/769) of the cases. An analysis of 760 anatomically successful DCRs showed that common canalicular obstruction (OR=1.752, P=0.014) and canalicular obstruction (OR=2.058, P=0.015) were independent risk factors for functional failure. In a subgroup analysis of patients with primary NLDO, patients with a small lacrimal sac had a significantly higher risk of functional failure (OR=2.500, P=0.018).
The overall surgical outcomes of external DCR were favorable in this case series. Site of obstruction was an important risk factor for functional failure in cases with primary lacrimal drainage obstruction. A small lacrimal sac was also found to be a risk factor for functional failure in cases with primary NLDO.
B Sun, Z Zhang, C Dong, Y Zhang, C Yan and S Li
As an autoimmune inflammatory disorder, active thyroid-associated ophthalmopathy (TAO) is managed optimally by immunosuppression. In this study, we aimed to evaluate octreotide scintigraphy and the level of serum extraocular muscle antibodies in TAO activity.
Patients and methods
This prospective study comprised 304 patients with active TAO (the clinical activity score; CAS≥3), 73 with inactive TAO (CAS<3), 128 with Graves’ disease (GD) without ophthalmopathy, and 100 healthy subjects. Moderate-to-severe active TAO patients (CAS≥5) received intravenous injection of methylprednisolone; mild active patients (3≤CAS≤4) received periocular injection of triamcinolone acetonide.99Tcm-octreotide scintigraphy and serum levels of calsequestrin, uveal auto-antigen with coiled-coil domains and ankyrin repeats (UACA) and G2s antibodies were detected before and after treatment.
99Tcm-octreotide scintigraphy was positive in active TAO patients (97%) with elevated uptake ratio (UR) (P<0.05), and showed a significant correlation with CAS (r=0.816, P<0.01). After treatment both UR and CAS decreased significantly (P<0.05). The receiving operator characteristic curve (ROC) showed that the best UR threshold for discriminating active and inactive TAO was 1.34 (sensitivity, 100%; specificity, 89.4%). The level of serum calsequestrin antibody was higher in active TAO (P<0.05), showed a significant correlation with CAS (r=0.738, P<0.05), and also decreased after treatment (P<0.05). The best serum calsequestrin antibody threshold of the ROC curve was 138 ng/l (sensitivity, 88.4%; specificity, 89.2%). The UACA antibody was elevated in both TAO and GD patients (P<0.05), with no significant difference (P>0.05). As to G2s, no significant difference was found between all groups (P>0.05). Moreover, six GD patients (4.69%) with elevated calsequestrin developed active TAO 12 weeks later.
99Tcm-octreotide scintigraphy played a critical role in the evaluation of the clinical activity and therapeutic efficacy of TAO. Autoimmunity against calsequestrin in the pathogenesis of the eye muscle components may provide further objective evidence of myopathy in active TAO. Furthermore, calsequestrin antibody may predict myopathy in active TAO.