Silicone Granulomas in the Orbit following Breast Implant Rupture: Case Report.

Introduction: A known but uncommon complication following breast augmentation with silicone implants is the rupture of these implants and subsequent silicone migration through the lymphatic system. Exceptionally, there are sporadic instances of silicone granulomas forming in distant, non-lymphatic sites, posing diagnostic and management challenges in clinical practice. Case Presentation: A 56-year-old woman presented with slowly progressive diplopia and photosensitivity during the past 12 months. Ophthalmic examination revealed restriction of movement in all gazes in the right eye. Investigation with magnetic resonance imaging and positron emission tomography-computed tomography showed enlarged superior lateral and inferior rectus muscles in the right orbit, and a diffusely enlarged lacrimal gland in the left orbit, as well as a ruptured silicone breast implant on the right side. In addition, multiple enlarged lymph nodes were found throughout the body, as well as a mass in the internal oblique muscle of the abdominal wall. Fine-needle aspiration biopsy of the axillary lymph node and surgical biopsy of extraocular muscles confirmed a diagnosis of silicone granulomas. The patient received anti-inflammatory treatment with intravenous steroids but with no effect on symptoms. Conclusions: This case illustrates a rare instance of silicone dissemination from a ruptured breast implant leading to granuloma formation in multiple organs, including the orbit. Notably, the spread of silicone appeared to occur through both lymphatic and hematogenous routes. This finding underscores the importance of considering silicone granulomas in the differential diagnosis of orbital lesions for patients with a history of silicone implants.

Fine-Needle Aspiration Biopsy as a Diagnostic Modality for Orbital Adnexal Lymphoma.

INTRODUCTION: The aim of this study was to evaluate fine-needle aspiration biopsy (FNAB) as a diagnostic tool for lymphoproliferative orbital lesions in light of recent improvements in cytomorphological and immunologic analyses. METHOD: Retrospective case series including all orbital FNABs with a lymphoproliferative outcome at Karolinska University Hospital, Stockholm, Sweden during the period 2005-2015. RESULTS: Of the 38 patients included, 31 (82%) were conclusively diagnosed as having lymphoma according to the first FNAB. Disease in 20 patients (65%) could be subclassified. The diagnosis in 7 patients (18%) was either inconclusive, suggestive of lymphoma, or reactive lymphatic infiltrate. These 7 patients were re-investigated, and the initial suspected diagnosis of malignant lymphoma was confirmed in four. Two of the remaining 3 patients were initially diagnosed as having non-lymphoproliferative disease; however, this was later changed to a lymphoproliferative diagnosis following reinvestigation, while the results of both reFNAB and incisional biopsy were inconclusive in the third. CONCLUSION: In the majority of the 38 patients, a definitive diagnosis of lymphoma could be made based on FNAB alone, using cytomorphological and immunological workup, and subclassification was possible in 20 patients (65%). Primary low-grade malignant orbital lymphomas are traditionally treated with low-dose radiotherapy regardless of subtype, and incisional biopsy was not needed to initiate treatment. Our findings suggest that FNAB is a valid first option for the diagnosis of suspected orbital lymphomas due to the minimal risk of complications compared to incisional biopsy, and the fact that it can be performed as an outpatient procedure with no anesthesia.

Evaluation of Dental and Oral Pathologies of 36 Captive Lions (Panthera leo) and Tigers (Panthera tigris).

The documented increase in the occurrence of dental diseases in captive big cats over the past decades has necessitated the need to target dental medical research accordingly. The aim of this study was the systematic evaluation of dental and oral pathologies of lions and tigers which included intraoral dental radiography. Thirty-six animals of both sexes, ranging in age from nine months to 18 years, predominantly in circus husbandry, served as the basis of the present study, and their dental health status was investigated. The preliminary report and history, adspection of the awake animal, and examination under anesthesia provided important information. Eight animals were specifically presented for oral examination because of known dental disease. The remaining 28 animals were anesthetized for other medically necessary procedures, and each animal's oral and dental health status was also evaluated while under anesthesia. In the 28 animals that underwent routine oral cavity examination, pathological changes that had not previously been noticed were found in two-thirds of the animals (19/28). One-quarter of all the animals (9/36) had no abnormal oral cavity findings. Dentoalveolar trauma such as tooth fractures and abrasion (24/36) were diagnosed most frequently. The results highlight the importance of regular oral examinations in big cats. Furthermore, the results suggest that there is a relationship between husbandry conditions and the incidence of dentoalveolar trauma in captive big cats.

A Standard Method for Intraoral Dental Radiography With Dental Photo-Stimulative Phosphor (PSP) Plates in Big Cats.

In recent years, dentistry has steadily gained more prominence in veterinary medicine, including exotic and wild animal medicine. It is known that dental diseases are among the most common diseases in captured big cats. However, so far, there is no standardized method for dental radiography in these animals. Therefore, this study aimed to develop a standardized procedure for the systematic radiographic examination of the teeth in big cats. In total, 34 big cats, including 21 lions and 13 tigers, of different ages were examined. Animals that needed treatment for known dental diseases and those that had to be anesthetized for other medically necessary procedures and dental health status examinations were included. Intraoral dental radiographs were captured with digital imaging plates designed for intraoral dental radiography in horses. Based on the intraoral dental radiography procedures used in domestic cats, both the bisecting angle technique and parallel technique were used. A hemisphere model originally developed for horses was used to describe the path and position of the x-ray beam as accurately as possible. The results demonstrated that it was possible to completely image all the teeth of big cat dentition on seven radiographs using the described method. This method can be used to acquire high-quality intraoral dental radiographs in big cats, aiding in the quick and reliable diagnosis of dental diseases.

Anophthalmia and microphthalmia in children: associated ocular, somatic and genetic morbidities and quality of life.

PURPOSE: To report ocular outcome, somatic co-morbidities, genetics, and quality of life in children born with anophthalmia (A) or microphthalmia (M). METHODS: Thirty-five children (19 boys) with A/M underwent ophthalmological examinations and a review of medical records. Parents of 12/22 cases completed the Pediatric Quality of Life Inventory (PedsQL). RESULTS: Age at examination ranged from 7 months to 18 years (median 2.3 years). Ten cases were totally blind or had light perception. Isolated A/M occurred in 16/35 cases, while somatic, psychomotor, neuroradiological and/or genetic pathology occurred in 19/35 cases both in the bilateral (7/9) and in the unilateral group (12/26). Among 26 unilateral cases, 4/16 with one normal eye had associated problems compared to 9/10 if the contralateral eye was pathological (p < .01). There was an increased risk for heart defects in children with psychomotor delay (p = .04). Pathogenic genetic abnormalities were identified in 10/24 cases. Neuroimaging demonstrated pathology in 14/20 cases with corpus callosum dysgenesis (6/20) being the most common. The median total PedsQL score of parent reports for ages 2-12 was 52.4 (range 22.6-100). CONCLUSIONS: Somatic, psychomotor and/or neuroradiological pathologies were more common in bila-teral than unilateral cases, but the difference was not significant. There was decreased risk in unilateral cases with one normal eye. Genetic defects occurred in both unilateral and bilateral cases. Health-related quality of life was reduced.

Nordic treatment practices survey and consensus for treatment of eyelid sebaceous carcinoma.

BACKGROUND: The purpose was to describe the Nordic treatment practices and to reach a Nordic consensus for the treatment of sebaceous eyelid carcinoma. METHODS: The treatment practices data was collected by a questionnaire with 37 questions to the Nordic oculoplastic surgeons and analyzed. A PubMed MEDLINE database search was done to gather data on the published treatment practices and recommendations. A working group that consisted of in minimum one senior consultant from each leading Nordic University Eye Hospital was assigned. A structured interactive method was used to establish the consensus. RESULTS: Twenty-four doctors responded to the questionnaire. 23/24 (96%) of the respondents took a biopsy before surgery. Regional lymph node scanning was routinely done by 14/23 (61%) and a systemic screening of a metastatic disease by 13/23 (57%). 6/22 (27%) never took conjunctival mapping biopsies and 12/23 (52%) never screened for Muir- Torre. Respondents used Mohs surgery, frozen section or multi-stage excision with delayed closure, and 5-6 mm was the mostly preferred margin. Sentinel lymph node biopsy was a possible option for 9/22 (41%) and cryotherapy and Mitomycin C for 6/22 (27%) respondents. 50% of respondents considered radiation as a treatment option. 15/16 (94%) respondents always followed-up their patients, most for 5 years. Two thirds scanned regional lymph nodes during the follow-up. Consensus was reached for 18 statements representing three domains: preoperative work-up, treatment and follow-up. CONCLUSION: Treatment practices differ in between the five Nordic countries which have similar public health care systems. In the article the authors present a Nordic consensus for the treatment of eyelid sebaceous carcinoma.

Long-term outcome of lacrimal stent intubation for complete acquired lacrimal drainage obstructions.

PURPOSE: To investigate long-term outcome and report reoperation rate of non-infected, complete acquired lacrimal drainage obstruction (ALDO) treated with canaliculodacryocystoplasty (CDCP) depending on site of stenosis. METHOD: Consecutive adult patients with non-infected, complete ALDO treated with CDCP were followed for 76 months. Location of stenosis at preoperative visit and intraoperative probing was recorded, and during follow-up, recurrence of stenosis prompting additional surgery and complications were noted. Survival analysis was applied to compare reoperation rate depending on site of stenosis. A follow-up questionnaire was sent to patients not requiring reoperation asking to grade current epiphora problems. RESULTS: Among 85 included cases (71 patients), 57 were classified as canalicular stenosis and 28 as nasolacrimal duct obstruction (NLDO) preoperatively. At the end of follow-up, 39% (33/85) of cases had required additional surgery due to persistent/recurrent symptoms. No statistical difference was found between these groups. During CDCP, 25 of the 57 preoperatively classified canalicular stenosis were found to have an additional obstruction below the sac. The group with only canalicular stenosis had a statistically significant higher survival compared with cases with NLDO or multiple obstructions (p = 0.03). Of patients responding to the follow-up questionnaire, 11/37 cases experienced epiphora often or constant. CONCLUSION: Treating complete NLDO with CDCP results in a high reoperation rate and seems an insufficient alternative. Canaliculodacryocystoplasty (CDCP) may be discussed if preoperative examination indicates canalicular stenosis and dacryocystorhinostomy is not desirable. However, the patient needs to be aware of the higher risk for additional surgery, especially if a second stenosis is found during probing.

A comparison between patients with epiphora and cataract of the activity limitations they experience in daily life due to their visual disability.

PURPOSE: The objective of this study was to compare patients with epiphora and cataract in terms of the activity limitations they experience in daily life due to their visual disability and to validate the use of the Catquest-9SF questionnaire for epiphora patients. METHODS: Seventy-two consecutively encountered adult patients with confirmed lacrimal obstruction and listed for dacryocystorhinostomy (DCR) or lacrimal intubation at the St. Erik Eye Hospital, Stockholm, Sweden, completed the Catquest-9SF questionnaire, which measures activity limitations in daily life due to visual disability. The psychometric qualities of the Catquest-9SF results obtained from this group of patients were evaluated by Rasch analysis. Rasch analysis was further employed to convert the ordinal raw data to a Rasch score for comparison with the preoperative scores of patients registered in the Swedish National Cataract Register (NCR) during March 2013. RESULTS: The Catquest-9SF exhibited good psychometric qualities when investigating epiphora patients, with the exception of a misfit for Item 4, the item regarding facial recognition. On the Rasch scale (-5.43 = no activity limitations to +5.01 = severe activity limitations), the mean score for epiphora patients was -0.82 while for patients listed for 1st eye and 2nd eye cataract surgery it was -0.17 and -0.76, respectively. An equivalence test confirmed that the reported visual disability of epiphora patients was not significantly different from visual disability reported by patients waiting for 2nd eye cataract surgery. CONCLUSION: The Catquest-9SF is a valid measure of visual disability in patients with epiphora. Epiphora patients experience visual disability to the same degree as patients awaiting 2nd eye cataract surgery.

Fine-Needle Aspiration Biopsy in Orbital Lesions: A Retrospective Study of 225 Cases.

PURPOSE: To describe and analyze results from the fine-needle aspiration biopsy (FNAB) technique, used as a diagnostic tool, in patients with orbital lesions. DESIGN: Retrospective case series. METHODS: setting: Institutional (Karolinska Hospital, Stockholm). STUDY POPULATION: 207 patients with 210 orbital lesions. INTERVENTION: 225 FNABs of the orbit. MAIN OUTCOME MEASURES: Successful diagnosis from FNAB. RESULTS: Of the 210 orbital lesions evaluated with FNAB, a successful cytologic diagnosis was achieved in 176 (84%). In more than half of the orbital lesions (54%), the FNAB diagnosis in addition to imaging appearance, clinical appearance, and clinical history provided sufficient information for treatment, and the patient did not require an incisional or excisional biopsy. Ninety-seven patients underwent additional excisional or incisional biopsy; FNAB diagnoses and the histopathologic diagnoses corresponded in 87% of the cases with an intraclass correlation coefficient of 0.84 (95% confidence interval [CI] 0.76-0.90). The difference was statistically significant between the ability to make a successful cytologic FNAB diagnosis in palpable lesions vs nonpalpable lesions (successful diagnosis in 90% [CI = 85%-95%] vs 75% [CI = 66%-84%]; P < .01). Neither the orbital quadrant location, nor the radiologic appearance (diffuse vs encapsulated), nor size of the lesion affected the success of FNAB diagnoses (all P > .7). There was a complication in 6 cases (3%). All complications were temporary and none led to permanent damage. CONCLUSIONS: FNAB proved effective and exceedingly safe. With the current healthcare climate of minimally invasive surgery and cost control, FNAB should be considered as a valid alternative to open surgery in the evaluation and management of orbital lesions.

Complications associated with secondary orbital implantations.

PURPOSE: To evaluate complications associated with secondary procedures for orbital implants. METHODS: A retrospective review was made of the records of patients who had undergone a secondary orbital implantation at a tertiary referral centre at St Erik Eye Hospital in Stockholm, Sweden, from 1998 up to and including the first half of 2009. Implant-related complications were noted as was demographic and surgical background data. The regional ethics committee in Stockholm gave its approval for this study. RESULTS: Seventy-one patients had received a secondary orbital implant at the eye hospital. Implant-related complications were noted in 24 patients (34%), and 20 patients required reoperation/s (28%). There were five types of complications: migration of the implant (13%), insufficient orbital volume (10%), exposure/extrusion/infection (8%), mechanical obstruction (1%) and socket oedema (1%). Analyses of sizes and types of implants, wrapping and surgical techniques did not reveal any specific factor that resulted in an increased number of complications. However, there was an indication that aluminium oxide might be associated with fewer complications (2/11 = 18%). CONCLUSION: Our results show that secondary orbital implantations have high complication rates and that further surgery is needed in more than a quarter of cases. It is important to consider these facts when planning to insert secondary implants and to provide patients with accurate information about the procedure and possible outcomes.

Chronic anophthalmic socket pain treated by implant removal and dermis fat graft.

AIMS: To report the outcome of orbital implant removal and dermis fat graft (DFG) implantation in patients with chronic anophthalmic socket pain (ASP), in whom all detectable causes of pain had been ruled out and medical management had failed. METHODS: Retrospective, multicentre case series. A review of all cases undergoing orbital implant replacement with DFG between 2007 and 2013 was conducted at the University of Iowa Hospitals and Clinics (UIHC), USA, and St. Erik Eye Hospital, Sweden. Inclusion criteria included (1) chronic ASP >2 years and unresponsive to treatment, (2) absence of pathological or structural cause for pain established by socket examination and orbital imaging, and (3) minimum 12-month post-surgical follow-up. RESULTS: Six cases with chronic ASP were identified, four were post-enucleation and two were eviscerated at an average age of 45 years. The incidence of chronic ASP among enucleations at UIHC over a 6-year period was 0.7%. Indications for enucleation and evisceration included tumours and glaucoma. Intractable ASP had been present for an average of 11 years and persisted despite medical management. All patients were free of pain within 3 months of implant removal and DFG placement and remained pain free at an average 24 months following surgery. CONCLUSIONS: Orbital implant replacement with DFG was effective at relieving chronic ASP, and pain resolution was sustained in all cases. This surgical intervention may be a useful management option for patients in whom all detectable causes of chronic pain have been excluded and have failed medical pain management.

Pain and discomfort in the anophthalmic socket.

PURPOSE OF REVIEW: The aim of this review is to summarize causes of pain and discomfort in the anophthalmic socket and to aid the clinician in evaluating anophthalmic patients. RECENT FINDINGS: Causes of pain and discomfort can be categorized into dysfunctional orbit/anophthalmic socket, phantom eye pain, and psychological/psychiatric factors. Recent research has brought attention to the role of prosthesis deposits in mucous formation, meibomian gland dysfunction causing dry socket, and the anophthalmic patients' experience of phantom eye pain. SUMMARY: Anophthalmic patients may experience pain and discomfort for a variety of reasons. The treating physician needs to recognize this as treatment options are distinctly different.

Intraoperative mitomycin C versus autologous conjunctival autograft in surgery of primary pterygium with four-year follow-up.

PURPOSE: To compare the 4-year outcome of primary pterygium excision using intraoperative mitomycin C (MMC) with suturing a free conjunctival autograft (CA). METHODS: A total of 115 eyes with nasal primary pterygium of 115 patients were included in the study. After randomization into two groups, the eyes were operated on by a single surgeon (GK). After excision of the pterygium, 56 eyes received 0.04% MMC intraoperatively on the bare sclera for 3 min and 59 eyes received a free CA sutured using 7-0 Vicryl. Postoperative follow-up was 4 years. Main outcome measures were recurrences, re-operations, surgery time, complications, visual acuity and astigmatism. Statistical evaluation was performed with the chi-squared test. RESULTS: The recurrence rate was 38% in the MMC group and 15% in the CA group (p < 0.05). The re-operation rate of the recurrences was 53% in the MMC group and 29% in the CA group. Average surgery time was 13 minutes (range: 6-22 min) in the MMC group and 26 min (range: 18-32 min) in the CA group (p < 0.01). There was no significant change in best-corrected visual acuity and astigmatism. One major complication occurred in each group. The most frequently observed complication was delayed epithelial healing (40%) and mild scleral thinning (20%) in the MMC group and suture-related inflammation in the CA group (10%). CONCLUSION: Pterygium surgery including free autologous conjunctival grafting is associated with fewer recurrences, re-operations and complications than using the bare sclera technique together with single-dose intraoperative MMC.

Toxicokinetics of acrylamide in rats and humans following single oral administration of low doses.

The rodent carcinogen acrylamide (AA) is formed during preparation of starch-containing foods. AA is partly metabolized to the genotoxic epoxide glycidamide (GA). After metabolic processing, the mercapturic acids N-acetyl-S-(2-carbamoylethyl)-L-cysteine (AAMA), rac-N-acetyl-S-(2-carbamoyl-2-hydroxyethyl)-L-cysteine (GAMA) and rac-N-acetyl-S-(1-carbamoyl-moyl-2-hydroxyethyl)-L-cysteine (iso-GAMA) are excreted with urine. In humans, AAMA can be sulfoxidized to AAMA-sulfoxide. The aim of this study was to assess potential species-differences in AA-toxicokinetics in rats and humans after single oral administration of doses similar to the daily human dietary exposure. Male Fischer 344 rats (n=5/dose group) were administered 20 and 100 microg/kg b.w. (13)C(3)-AA in deionized water via oral gavage. Human subjects (n=3/gender) were orally administered 0.5 and 20 microg/kg b.w. (13)C(3)-AA with drinking water. Urine samples were collected in intervals for 96 and 94 h, respectively. Urinary concentrations of (13)C(3)-AAMA, (13)C(3)-GAMA and (13)C(3)-AAMA-sulfoxide were monitored by liquid chromatography-tandem mass spectrometry. The recovered urinary metabolites accounted for 66.3% and 70.5% of the 20 and 100 microg/kg b.w. doses in rats and for 71.3% and 70.0% of the 0.5 and 20 microg/kg b.w. doses in humans. In rats, (13)C(3)-AAMA accounted for 33.6% and 38.8% of dose and 32.7% and 31.7% of dose was recovered as (13)C(3)-GAMA; (13)C(3)-AAMA-sulfoxide was not detected in rat urine. In humans, (13)C(3)-AAMA, (13)C(3)-GAMA and (13)C(3)-AAMA-sulfoxide accounted for 51.7% and 49.2%, 6.3% and 6.4% and 13.2% and 14.5% of the applied dose, respectively. The obtained results suggest that the extent of AA bioactivation to GA in humans is lower than in rodents.

Rapid and sensitive HILIC-ESI-MS/MS quantitation of polar metabolites of acrylamide in human urine using column switching with an online trap column.

The carcinogen acrylamide (AA) is formed during the processing of food. AA is metabolized to mercapturic acids, which are excreted with urine. A hydrophilic interaction liquid chromatography tandem mass spectrometry method (HILIC-MS/MS) using a zwitterionic stationary phase (Zic-HILIC) was developed and validated to quantitate the mercapturic acids of AA (AAMA) and glycidamide (GAMA), and AAMA-sulfoxide in human urine. In contrast to reversed phases, the application of Zic-HILIC resulted in efficient retention and separation of these highly polar compounds. Off-line sample workup was avoided by application of column switching with a Stability BS-C17 trap column prior to the analytical column, thus minimizing interferences with the urinary matrix. Limit of quantification values (LOQs) were 0.5 microg/L (AAMA), 2.0 microg/L (AAMA-sulfoxide), and 1.0 microg/L (GAMA) in human urine. Median concentrations in urine samples ( n = 54) of six nonsmoking human subjects were 24.0 microg/L (AAMA, 7.8-79.8 microg/L), 16.7 microg/L (AAMA-sulfoxide, 6.8-70.1 microg/L), and 3.82 microg/L (GAMA, 1.0-23.6 microg/L).

Choroidal biopsies for intraocular tumors of indeterminate origin.

PURPOSE: To evaluate the role of pars plana vitrectomy-assisted incisional biopsies in the management of choroidal tumors of unclear origin. DESIGN: Retrospective, noncomparative, consecutive interventional case series. METHODS: Ten consecutive patients with indeterminate choroidal tumors underwent a standardized three-port pars-plana vitrectomy-assisted subretinal biopsy using a bimanual approach with standard intraocular forceps and a diamond knife. Specimens were fixed in formaldehyde embedded in paraffin and further subjected to histopathological and immunohistochemical analyses. RESULTS: A histologic diagnosis was obtained in all (10 of 10) cases including choroidal melanoma (five of 10), metastasis (two of 10), subretinal hemorrhage (two of 10), and nodular scleritis (one of 10). Five eyes were enucleated as a result of the histologic diagnosis. Three cases of postoperative complications were seen in three patients (newly formed rhegmatogenous retinal detachment, increased serous retinal detachment, and vitreous hemorrhage). No cases of intra- or extraocular tumor spread were detected through follow-up periods ranging from 3 to 29 months. CONCLUSIONS: Pars plana vitrectomy-assisted incisional biopsy is a valuable diagnostic procedure for cases of choroidal tumors of unknown origin in selected patients. However, the relatively high frequency of postoperative complications noted in the present study and the potential risk of dissemination of tumor cells underscores the importance of rigorous case selection.

The cut-and-paste method for primary pterygium surgery: long-term follow-up.

OBJECTIVE: To evaluate the recurrence rate, reoperation rate and side-effects of a novel technique for pterygium surgery. DESIGN: Retrospective study. PARTICIPANTS: The study included 461 eyes of 381 patients operated for primary nasal pterygium by the same surgeon between 1994 and 2003 and followed for 23 +/- 20 months (range 6-112 months). METHODS: Autologous conjunctival grafts harvested at the superotemporal limbus were used to cover the sclera after pterygium excision. Using a retrospective chart review, the outcome after attaching the transplant to the sclera with a fibrin tissue adhesive (n = 325) was compared to the outcome after graft attachment using absorbable sutures (n = 136). MAIN OUTCOME MEASURES: Recurrence rate, reoperation rate and complications. RESULTS: The recurrence rate was 5.3% in the glue group and 13.5% in the suture group (p = 0.01). The reoperation rates were 1.2% and 3.3%, respectively (p = 0.31). Complications, such as transient transplant oedema and persistent corneal epithelial defects, occurred equally in both groups. CONCLUSION: Using a fibrin tissue adhesive instead of sutures when attaching the conjunctival transplant in primary pterygium surgery results in a significantly lower recurrence rate.