Endoscopic approach for orbital apex lesions: case series and review of the literature.

OBJECTIVE: The transnasal endoscopic approach may provide better visualisation and a safer approach to the orbital apex. This study presents a case series of orbital apex lesions managed by this approach. METHOD: This study was an eight-year retrospective analysis of seven patients who were operated on for orbital apex lesions in two tertiary medical centres. RESULTS: Complete tumour removal was performed in three patients and partial removal was performed in four patients. Visual acuity improved in three patients, remained stable in one patient and decreased in the other two patients. The visual field improved in four patients and did not change in two patients. Complications included worse vision and visual fields in 28.6 per cent of patients and late enophthalmos (of -1.25 ± 4.6 mm) in 2 patients. CONCLUSION: The transnasal approach to orbital apex lesions in selected cases may provide a rational alternative to transorbital surgery. Complete tumour removal should be weighed against the risk of damage to the optic nerve.

The clinical significance of class III (suspicious) urine cytology.

BACKGROUND: Urine cytology, combined with cystoscopy, is the mainstay of the diagnosis and surveillance of urothelial carcinoma (UC). While classes I and II urine cytology are considered benign and classes IV and V are considered malignant the clinical significance of class III urine cytology is unclear. We evaluated the positive predictive value of class III urine cytology for concurrent and subsequent UC. METHODS: The records of all class III urine cytology cases during a 3-year period were retrospectively reviewed for the presence of concurrent and subsequent UC, determined by cystoscopy and histological confirmation. RESULTS: Of 111 cases, 54 (48.7%) were associated with concurrent UC and 14 (12.6%) with subsequent UC after an initial evaluation negative for malignancy, with a mean time to diagnosis of 10.8 months. Of 27 cases of class III urine cytology with no prior history of UC, 13 (48.1%) had concomitant UC and none had subsequent UC. Of 84 cases of class III urine cytology with a prior history of UC, 41 (48.8%) had a concomitant diagnosis of UC and 14 (16.7%) developed UC during their follow-up, leading to a total of 55 (65.5%) cases of UC. CONCLUSIONS: Patients with class III urine cytology and a prior history of UC should undergo a full initial evaluation of their urinary tract, and should be followed vigorously if this evaluation is negative for malignancy. Patients without a prior diagnosis of UC and class III urine cytology should also undergo a full initial evaluation, while further larger studies are needed to elucidate the need for further follow-up in such patients.

Craniofacial fibrous dysplasia: clinical characteristics and long-term outcomes.

AIM: To present the clinical features and management outcomes in a large longitudinal series of patients with craniofacial fibrous dysplasia (CFD). METHODS: Retrospective interventional consecutive case series. Main outcome measures included signs and symptoms, radiographic findings, long-term outcomes, and postoperative complications. RESULTS: A total of 42 patients with CFD were identified. The mean age at presentation was 16.7 years; mean follow-up was 12.6 years. Out of these 42 patients, 37 (88.1%) had unilateral involvement and 5 (11.9%) had bilateral involvement, of which 3 (7.1%) had McCune-Albright syndrome. The commonest presenting symptom was facial asymmetry (36 cases, 86%). The frontal bone was the most commonly involved (27 cases, 64.3%), zfollowed by the sphenoid (24 cases, 57.1%). The most common pattern of bone involvement was monostotic (32 cases, 76.2%). Radiological optic canal involvement occurred in 18 eyes of 15 (37.5%) patients, with optic atrophy in 9 eyes (18.8%) of 7 patients (16.7%). Surgical intervention was performed in 30 (71.4%) cases for both functional and reconstructive reasons. Optic canal decompression was performed in three cases, in all of which stabilization of vision was achieved; no patient lost vision as a result of surgery. CONCLUSIONS: In this large longitudinal series of CFD, visual loss was not uncommon and occurred insidiously. The presenting clinical and radiological features, surgical interventions, and outcomes are discussed.

Idiopathic intracranial hypertension after 40 years of age: clinical features in 23 patients.

PURPOSE: Idiopathic intracranial hypertension (IIH) is a well-recognized disorder of unknown etiology associated with elevated intracranial pressure (ICP), normal neuroimaging, and normal cerebrospinal fluid (CSF) composition, found mostly among obese females of childbearing age. The aim of this study is to investigate the clinical features of IIH in patients older than 40 years. METHODS: This is a retrospective chart review (1998-2007) of all consecutive patients older than 40 years who were diagnosed with IIH based on the Modified Dandy Criteria. RESULTS: Twenty three of the 200 IIH patients in the institutional database fulfilled study entry criteria. They included 22 females and one male whose mean age was 51.4 years (range 41-79). Coexisting systemic arterial hypertension was found in 13 (56.5%) patients. Seventeen patients (73.9%) had symptoms attributable to elevated ICP. The most common presenting symptoms were visual; mainly blurred vision and transient visual obscuration (15/17 patients, 88.23%). Eleven patients (64.7%) complained of headache, and another 4 (23.5%) of pulsatile intracranial noise. The average follow up period was 21.8 months. CONCLUSIONS: The findings indicate that IIH among individuals older than 40 years of age may be underreported. These patients are more likely to present with systemic hypertension and with more visual disturbances, but with fewer complaints of headache than the younger IIH population.

Neuro-ophthalmic manifestations of intracranial cavernous hemangiomas.

PURPOSE: To describe the neuro-ophthalmic manifestations of patients with intracranial cavernous hemangiomas (cavernomas). METHODS: A retrospective review of all patients with intracranial cavernomas with neuroophthalmic manifestations who were treated at the Royal Adelaide Hospital in Australia between 1994 and 2004. RESULTS: There were nine patients (three men and six women), with a mean age of 39 years (range 22-61). There was one cerebellar lesion, two thalamic, four pontine, one midbrain/pontine, and one midbrain. Ophthalmic presentations included internuclear ophthalmoplegia (one patient), third cranial nerve (CN) palsy (one patient), fourth CN palsy (one patient), and sixth CN palsy (six patients). Three patients underwent extraocular muscle surgery, and six were treated medically or observed. In five patients the diplopia resolved, in three it was only mild, and in one patient no significant change was noted during the follow-up period. CONCLUSIONS: Diplopia is the main neuro-ophthalmic manifestation of intracranial cavernomas. Sixth CN palsy is the most common cause. Neurosurgical or conservative treatment leads to improvement in most cases, and later use of spectacles or extraocular muscle surgery may lead to further improvement.

Cutaneous lip tumours treated with Mohs micrographic surgery: clinical features and surgical outcome.

BACKGROUND: The Australian Mohs micrographic surgery (MMS) database was initiated in 1993 by the Skin and Cancer Foundation Australia (SCFA) with the aim of collecting prospective data, and involved all Mohs surgeons in the country. OBJECTIVES: To present a large series of patients with cutaneous lip tumours treated with MMS in Australia between 1993 and 2002. METHODS: This prospective multicentre case series included all patients with cutaneous lip tumours who were monitored by the SCFA. The main outcome measures were patient demographics, reason for referral, duration of tumour, site, preoperative tumour size and postoperative defect size, recurrences prior to MMS, histological subtypes, perineural invasion and 5-year recurrence after MMS. RESULTS: There were 581 patients (66.1% women and 33.9% men, P < 0.0001) with a mean +/- SD age of 58 +/- 15 years. The upper lip was the most common site involved (81.1%). Basal cell carcinoma (BCC) was diagnosed in 82.3%, squamous cell carcinoma (SCC) in 16.5%, Bowen's disease (BD) in 0.7% and microcystic adnexal carcinoma (MAC) in 0.5% of cases. BCC was more common on the upper lip and in women, whereas SCC was more common on the lower lip and in men (P < 0.0001). Most upper lip tumours occurred in women (75.4%), whereas most lower lip tumours occurred in men (73.6%). SCC was associated with a larger tumour and postoperative defect size compared with the other tumours. The 5-year recurrence for BCC was 3.0%, and there were no cases of recurrence for SCC, BD or MAC. CONCLUSIONS: BCC was the most common cutaneous lip tumour managed by MMS, and was significantly more common on the upper lip and in women. The low 5-year recurrence rate emphasizes the importance of margin-controlled excision.

Periocular keratoacanthoma: can we always rely on the clinical diagnosis?

AIM: To present a series of patients with a clinical diagnosis of periocular keratoacanthoma and assess the incidence of histologically proven invasive squamous cell carcinoma (SCC). METHODS: This retrospective case series included all patients with periocular tumours seen in the authors' unit between 1996 and 2004, and who were initially diagnosed with keratoacanthoma based on the clinical presentation. RESULTS: Twelve patients (eight males, four females) were clinically diagnosed with keratoacanthoma. The final histological diagnosis revealed two cases (16.7%) of invasive SCC, and 10 cases (83.3%) of keratoacanthoma. The lower lid was most commonly involved in cases of keratoacanthoma (50.0%). Six patients (60.0%) underwent Mohs surgery, and four (40.0%) were treated with excision under frozen section control. There were no cases of recurrence during a mean follow up period of 21 (SD 13) months. CONCLUSION: Although the clinical presentation of periocular keratoacanthoma is usually characteristic, a significant percentage of patients will prove to have invasive SCC. Complete excision with margin control offers a definitive diagnosis, as well as tissue conservation and a low recurrence rate.

Infectious keratitis in South Australia: emerging resistance to cephazolin.

PURPOSE: To analyze the microbiologic spectrum and patterns of resistance of infectious keratitis in patients treated at a tertiary hospital in South Australia. METHODS: Retrospective review of microbiology laboratory records of all patients with infectious keratitis who had corneal scrapings, from 1998 to 2003. All records were subsequently reviewed for Gram staining and culture results, as well as antibiotic sensitivity and resistance. RESULTS: Positive corneal cultures were obtained in 134 out of 211 patients who had corneal scrapings (63.5%). Coagulase negative Staphylococcus was the commonest pathogen identified (29.8% of positive cultures), followed by Staphylococcus aureus (18.7%), Pseudomonas aeruginosa (12.7%), Moraxella (6.7%), Streptococcus pneumonia (6.0%), and fungal keratitis (5.2%). In 43.3% of culture positive cases, the organisms were also identified in Gram stain, and in all these cases there was a full correlation between the two methods. In vitro sensitivities were highest for gentamicin. Fourteen cases (35%) of coagulase negative Staphylococcus were found to be resistant to cephazolin. No ciprofloxacin resistance was identified in all Pseudomonas isolates tested. CONCLUSIONS: Staphylococcus species continue to be the commonest causative organism for infectious keratitis; however, there is an emerging resistance to cephazolin, which is commonly used as the first-line antibiotic for Gram-positive cocci.

Incidence of host site complications in periocular full thickness skin grafts.

AIM: To evaluate the complications of periocular full thickness skin grafts (FTSG) in patients treated with Mohs' micrographic surgery (MMS) for periocular malignancy. METHOD: This prospective, multicentre case series included all patients in Australia treated with MMS for periocular malignancy followed by reconstruction with FTSG, who were monitored by the Skin and Cancer Foundation, between 1993 and 1999. The parameters recorded were patient demographics, reason for referral, histological classification of malignancy and evidence of perineural invasion, duration of tumour, site, recurrences prior to MMS, preoperative tumour size, and postoperative defect size. FTSG donor sites included upper lid, preauricular, retroauricular, inner brachial, and supraclavicular. The primary outcome measures were FTSG host site complications (partial/complete graft failure, graft infection, acute bleeding/haematoma, graft hypertrophy, and graft contracture). RESULTS: 397 patients (229 males, 168 females), mean age 60 (SD 15) years (range 20-91 years). 92.7% were diagnosed with basal call carcinoma, 2.0% with Bowen's disease, and 3.3% with squamous cell carcinoma. Medial canthus was involved in 66.5% of patients, lower eyelid in 28.0%, and upper eyelid in 5.5%. Postoperative complications were recorded in 62 patients (15.6% of all patients), and consisted of graft hypertrophy (45.1% of complications), graft contraction (29.1%), and partial graft failure (12.9%). The only statistically significant association found was a higher rate of graft hypertrophy in medial canthal reconstruction (p = 0.007). CONCLUSION: Host site complications of periocular FTSG are not common. Graft hypertrophy accounted for most complications and was more common in the medial canthal area. No other variables such as patient demographics, tumour characteristics, or donor site factors were associated with a higher risk of complications.

Infectious keratitis in South Australia: Emerging resistance to cephazolinq.

PURPOSE: To analyze the microbiologic spectrum and patterns of resistance of infectious keratitis in patients treated at a tertiary hospital in South Australia. METHODS: Retrospective review of microbiology laboratory records of all patients with infectious keratitis who had corneal scrapings, from 1998 to 2003. All records were subsequently reviewed for Gram staining and culture results, as well as antibiotic sensitivity and resistance. RESULTS Positive corneal cultures were obtained in 134 out of 211 patients who had corneal scrapings (63.5%). Coagulase negative Staphylococcus was the commonest pathogen identified (29.8% of positive cultures), followed by Staphylococcus aureus (18.7%), Pseudomonas aeruginosa (12.7%), Moraxella (6.7%), Streptococcus pneumonia (6.0%), and fungal keratitis (5.2%). In 43.3% of culture positive cases, the organisms were also identified in Gram stain, and in all these cases there was a full correlation between the two methods. In vitro sensitivities were highest for gentamicin. Fourteen cases (35%) of coagulase negative Staphylococcus were found to be resistant to cephazolin. No ciprofloxacin resistance was identified in all Pseudomonas isolates tested. CONCLUSIONS: Staphylococcus species continue to be the commonest causative organism for infectious keratitis; however, there is an emerging resistance to cephazolin, which is commonly used as the first-line antibiotic for Gram-positive cocci. (Eur J Ophthalmol 2005; 15: 23-6).

Hyperhomocysteinemia in patients with diabetes mellitus with and without diabetic retinopathy.

OBJECTIVE: To evaluate the prevalence of hyperhomocysteinaemia in diabetic patients with no diabetic retinopathy (no DR), with non-proliferative diabetic retinopathy (NPDR) and with proliferative diabetic retinopathy (PDR). RESEARCH DESIGN AND METHODS: This prospective, case-control study, included 179 diabetic patients and 156 age-matched controls with no diabetes and no history of ocular disease, who were undergoing routine physical checkups. Plasma homocysteine levels of all study participants were measured using high-performance liquid chromatography (HPLC). Hyperhomocysteinaemia was defined when homocysteine levels were higher than 15 micromol/l. RESULTS: The mean plasma homocysteine level was 11.75+-0.24 in the control group,13.46+0.74 in the no DR group, 14.56 + 0.64 in the NPDR group and 15.86 + 1.34 in the PDR group. Mean homocysteine levels were significantly elevated in the NPDR and PDR groups compared to the control group(P = 0.001 and <0.0001, respectively). The prevalence of hyperhomocysteinaemia was also higher in the NPDR and PDR groups compared to the control group (P = 0.032 and 0.011, respectively). No statistically significant difference was found between the no DR and the control group. CONCLUSIONS: Our findings suggest that hyperhomocysteinaemia may be associated with diabetic retinopathy and partially explain the increased risk of microvascular angiopathy occurring in these patients.

Axial length, refractive error, and keratometry in patients with branch retinal vein occlusion.

PURPOSE: To evaluate ocular parameters that may predispose to the development of branch retinal vein occlusion (BRVO). METHODS: This prospective study included patients with unilateral BRVO evaluated in the authors' clinic. The mean period from the acute phase was 2.29 +/- 1.57 years (range 1-6 years). All patients underwent a complete ophthalmologic examination including subjective refraction, axial length measurements, and keratometry readings. The fellow eye served as a control in each patient. The variables of interest were compared between the affected eye and the fellow eye using the parametric t-test and the nonparametric Wilcoxon test. RESULTS: Twenty-four consecutive patients (14 women, 10 men, mean age 62.4 years) were included in the study. The mean axial length in the affected eye was significantly shorter compared to the mean fellow eye length. No difference was found between the two eyes in mean subjective refraction or mean keratometry readings. CONCLUSIONS: The authors found that eyes with BRVO have a shorter axial length compared to the fellow eye in the same patient.

Analysis of the long-term outcome of surgically corrected vesico-ureteric reflux.

OBJECTIVE: To review patients who had vesico-ureteric reflux corrected surgically by ureteric reimplantation during childhood, and thus assess their long-term outcome. PATIENTS AND METHODS: Between 1970 and 1979, 322 children underwent ureteric reimplantation; 100 (79 women and 21 men) were re-assessed and the long-term results evaluated using a questionnaire, a review of the patients' current medical records and an appointment in the outpatient clinic. The evaluation focused on the frequency of late urinary tract infections (UTIs), current renal function tests, related complications during pregnancy and the incidence of hypertension at least 20 years after surgery. RESULTS: Of the study group, 51% (66% of men and 47% of women) had no long-term urological complications. The incidence of UTIs was 43% in women and 24% in men, and of pyelonephritis 27% and 9.5%, respectively. Hypertension was detected in 6% of the patients during assessment. There were new renal scars, despite surgery, in 20% of the patients. Forty-seven women had been pregnant, 28% reporting UTIs during pregnancy. In 7% of 94 pregnancies the women also had pre-eclampsia and two women had transient gestational ureteric obstruction which required drainage. Renal functional tests were worse in one man and one woman who developed end-stage renal disease and had a renal transplant. CONCLUSIONS: This series shows that even patients who were treated successfully by ureteric reimplantation during childhood are prone to recurrent UTIs, progressive renal scarring, hypertension and complications during pregnancy. There is a need to establish a protocol for the long-term follow-up of such patients.

Management options for gynaecomastia and breast pain associated with nonsteroidal antiandrogen therapy : case report series.

OBJECTIVE: To present management options for gynaecomastia and mastodynia associated with nonsteroidal antiandrogen therapy, supported by relevant data and case studies. BACKGROUND: Gynaecomastia (male breast enlargement) and breast pain/ sensitivity (mastodynia or mastalgia) are pharmacologically expected adverse effects of nonsteroidal antiandrogen therapy for prostate cancer. They are caused by proliferation of glandular tissue in response to an increase in the ratio of estrogen to androgen. Gynaecomastia and mastodynia are benign conditions, and many patients choose to tolerate them as acceptable, usually mild or moderate, adverse effects of therapy. Recent data show that nonsteroidal antiandrogen monotherapy significantly reduces disease progression in localised and locally advanced prostate cancer, a finding that may result in wider and more long-term use of this treatment. Therefore, both clinicians and patients may benefit from increased awareness of the options available for the management of gynaecomastia and mastodynia. Management options, data and case studies: Management options for gynaecomastia and mastodynia are illustrated in a schematic flow diagram. Options identified are: (1) risk reduction using pretreatment breast irradiation; (2) stopping antiandrogen therapy; (3) acceptance of gynaecomastia and/or mastodynia in the context of the significant clinical benefit of antiandrogen treatment; (4) prompt treatment (liposuction/breast tissue excision, hormonal manipulation or pain control with irradiation or analgesics); and (5) later treatment (liposuction/breast tissue excision, hormonal manipulation or pain control with irradiation or analgesics). Where available, relevant data are discussed and the options are illustrated by case studies. CONCLUSIONS: The risk of developing gynaecomastia is lessened by prophylactic breast irradiation. Following the development of gynaecomastia, treatment options include readjustment of the estrogen-to-androgen ratio using antiestrogens, surgery in the form of liposuction or, for more advanced cases, breast tissue excision. Mastodynia may be controlled by post-treatment irradiation or analgesics.

Pulmonary embolism-the initial manifestation of renal cell carcinoma in a young woman.

We report a case of massive pulmonary embolus demonstrated on CT in a young woman presenting with dyspnea, with no known risk factors for embolism. Abdominal CT on further investigation showed a renal tumor invading the left renal vein and the inferior vena cava as the cause of the pulmonary embolus. In a patient presenting with pulmonary artery embolism without venous thrombosis, the differential diagnosis should include an occult tumor as the cause of the embolus.

Combined perfluoropropane gas and viscoelastic material injection for anterior chamber reformation following trabeculectomy.

AIM: To describe a novel technique to treat hypotony and shallow anterior chamber following trabeculectomy METHODS: Three patients who underwent fornix based trabeculectomy with mitomycin C (MMC) presented in the postoperative days with a shallow anterior chamber, hypotony, and overfiltrating blebs. They were treated with an injection of 0.2 ml of 16% perfluoropropane (C(3)F(8)) to the anterior chamber followed by an injection of a viscoelastic material. RESULTS: In all patients the anterior chamber was reformed successfully without any complications. CONCLUSIONS: Patients with a shallow anterior chamber and overfiltrating blebs following a recent trabeculectomy can be treated successfully with a combination of a long acting gas and a viscoelastic material.

Massive choroidal hemorrhage associated with low molecular weight heparin therapy.

An 84-year-old woman with unstable angina pectoris was treated with subcutaneous enoxaparine (Clexane) for several days before presenting with severe pain and decreased vision in her left eye. The intraocular pressure was 70 mmHg, and fundus examination showed a pigmented choroidal lesion and associated choroidal and retinal detachment. Ultrasonography was consistent with choroidal hemorrhage, and she was diagnosed as having acute glaucoma secondary to massive subchoroidal hemorrhage. Medical control of the intraocular pressure resulted in a significant clinical improvement. Intraocular hemorrhage and angle-closure glaucoma are rare and previously unreported complications in patients treated with low molecular weight heparin. It is important to be aware of this ocular complication as these drugs are so often used.