Sorafenib dose escalation is not uniformly associated with blood pressure elevations in normotensive patients with advanced malignancies.

Hypertension after treatment with vascular endothelial growth factor (VEGF) receptor inhibitors is associated with superior treatment outcomes for advanced cancer patients. To determine whether increased sorafenib doses cause incremental increases in blood pressure (BP), we measured 12-h ambulatory BP in 41 normotensive advanced solid tumor patients in a randomized dose-escalation study. After 7 days' treatment (400 mg b.i.d.), mean diastolic BP (DBP) increased in both study groups. After dose escalation, group A (400 mg t.i.d.) had marginally significant further increase in 12-h mean DBP (P = 0.053), but group B (600 mg b.i.d.) did not achieve statistically significant increases (P = 0.25). Within groups, individuals varied in BP response to sorafenib dose escalation, but these differences did not correlate with changes in steady-state plasma sorafenib concentrations. These findings in normotensive patients suggest BP is a complex pharmacodynamic biomarker of VEGF inhibition. Patients have intrinsic differences in sensitivity to sorafenib's BP-elevating effects.

Pre-employment urine drug testing of hospital employees: future questions and review of current literature.

BACKGROUND: Patient safety and optimisation of worker performance are high current priorities. Arguments over employee drug testing have been debated over the past two decades. AIMS: To review prior information to reveal how current principles and practices regarding pre-employment drug testing of health care workers evolved, and to explore pressing current and future issues. METHODS: A literature search of Medline from 1980 to 1999 was performed. This yielded seven citations that reported results of pre-employment drug testing of health care workers, which we critically reviewed. RESULTS: The process by which a rational testing process was developed for pre-employment urine drug screening in the health care field is illustrated. Also depicted are some important principles, inequities, and shortcomings of the system. The range of positive tests was wide, from 0.25% to 12%. Testing was not always applied uniformly to all health care workers. It became apparent that positive tests also require medical review to determine if they were truly due to illicit substance use. CONCLUSIONS: Although pre-employment drug testing programmes in the health care industry have been firmly in place for many years, it is unclear whether such strategies have achieved their stated purposes. The next step is to study whether such programmes are effective at accomplishing specific goals, such as decreasing absenteeism, turnover, accidents, and medical errors, in order to justify continuing pre-employment testing versus changing to an alternative testing strategy.

Pneumatocele of the orbit.

PURPOSE: To describe an uncommon sinus condition that can cause proptosis. METHODS: Intermittent unilateral proptosis and diplopia developed in a 29-year-old man. Computed tomography showed an enlarged frontal sinus with erosion of the floor of the sinus and air in the orbit. RESULTS: Endoscopic ethmoidectomy and frontal sinusotomy corrected an outlet check valve of the nasal frontal duct and eliminated the proptosis. CONCLUSION: Pneumatocele of the orbit is an uncommon cause of proptosis and diplopia and can be corrected with endoscopic sinus surgery.

The 1998 Wendell Hughes Lecture. Evisceration: is sympathetic ophthalmia a concern in the new millennium?

PURPOSE: To investigate a possible relationship between evisceration and sympathetic ophthalmia. METHODS: Data from Mt. Sinai Medical Center and University Hospitals of Cleveland were collected and histopathologic specimens were reviewed for 51 of 90 patients who underwent evisceration between 1980 and 1996 and who returned for follow-up examinations. Additionally, a survey was sent to members of the American Society of Ophthalmic Plastic and Reconstructive Surgery, the Uveitis Society, and the Eastern Ophthalmic Pathology Society to determine the number of enucleations and eviscerations performed and the documented incidence of sympathetic ophthalmia after evisceration. RESULTS: No clinical or histopathologic evidence of sympathetic ophthalmia after evisceration was found among patients treated at the two medical centers. The collective surveys showed a strong preference for enucleation over evisceration, but did not document evidence of sympathetic ophthalmia after evisceration. CONCLUSIONS: Evisceration is an effective and safe procedure with a low risk for sympathetic ophthalmia.

Subperiosteal hematoma of the orbit: case presentation.

A 14-year-old boy was referred with complaints of decreased vision, pain, and diplopia that developed in his right eye after trauma. Radiologic studies showed an orbital roof fracture with an associated subperiosteal hematoma. Orbital exploration with surgical drainage of the hematoma and roof fracture repair was performed. Postoperatively, he experienced complete visual recovery with resolution of his proptosis and diplopia. Subperiosteal hematomas of the orbit should be considered in the differential diagnosis of acute unilateral proptosis after trauma. The authors suggest that early intervention results in rapid patient recovery.

Nontraumatic orbital leptomeningeal cyst in an adult: case report.

To our knowledge, there is no reported case of visual disturbance associated with a nontraumatic orbital leptomeningeal cyst in the literature. We report the first such case and discuss the differential diagnosis of cystic lesions of the meninges that may be found on the surface of the brain.

Osteomyelitis of the orbit.

Although rare, orbital osteomyelitis secondary to sinusitis can be devastating. Early, aggressive ophthalmologic surgical intervention, as well as otorhinolaryngologic co-management, is necessary to obtain the best outcomes. We present two cases of orbital osteomyelitis. One patient remained infected with Pseudomonas meningitis even after extensive sinus and orbital surgery, rapidly declined, and is now deceased. The other patient, after multiple sinus procedures and a medial orbitotomy, was placed on hyperbaric oxygen and is still undergoing treatment.

Carcinoid tumors of the orbit: a dilemma of diagnosis and treatment.

Carcinoid tumors arise from the gastrointestinal tract or the bronchial tree, and tumors of either origin produce symptoms locally or secrete amines that produce a carcinoid syndrome systemically. Metastatic carcinoid tumors to the orbit are rare and, thus, present a special problem in diagnosis and treatment. We describe a case of metastatic orbital carcinoid that presented itself 6 years prior to the discovery of the primary ileal lesion. This case report describes the unusual presentation, reviews previously published data, and addresses controversial opinions regarding therapy.

Malignant melanoma of the lacrimal sac.

The case of an 80-year-old woman who presented with a 1-year history of a right medial canthal mass and bloody tears and who was found to have a lacrimal sac melanoma is reported. A literature search revealed that only 16 cases of primary lacrimal sac melanoma have been reported. Current therapeutic modalities are discussed.

Metastatic basal cell carcinoma of the eyelid. Report of a case.

A patient had metastatic basal cell carcinoma of the right upper eyelid and periorbital area. Initially treated with radiation, there were multiple, extensive local recurrences requiring wide surgical excision. Ten years after the first lesion appeared, a metastasis was found in the preauricular soft tissue. A literature search found 204 previously reported cases of metastatic basal cell carcinoma, but none in the Western or European ophthalmic literature. The pathogenesis and unique features of basal cell carcinoma behavior are discussed.

Orbital inflammatory syndrome: an unusual presentation.

A 22-year-old woman had right unilateral proptosis. Evaluation revealed a large intraconal orbital mass, consistent with cavernous hemangioma. The mass was removed via a lateral orbitotomy. Histopathology, confirmed by electron microscopy, demonstrated fibroblasts with inflammatory histiocytes, but there was no evidence of cavernous hemangioma. To our knowledge, this is the first description of a well-circumscribed intraconal mass diagnosed as orbital inflammatory syndrome.

Free graft enhancement using orbicularis muscle mobilization.

PURPOSE: The purpose of this article is to demonstrate how mobilization of the orbicularis oculi muscle can improve viability, appearance, and function of free skin grafts in the periocular region. By enhancing blood supply with this technique, healing often can be achieved in difficult reconstructive cases. METHODS: Seven patients underwent orbicularis muscle mobilization before placement of free skin grafts. Two patients underwent resection of basal cell carcinomas of the lateral eyelids and canthal region requiring complex reconstructive techniques such as lateral canthal tendon reconstruction with auricular cartilage. One patient underwent upper eyelid reconstruction after total resection for sebaceous cell carcinoma with pagetoid spread. Two patients had difficult wound dehiscences that were difficult to repair primarily. In addition, the lower eyelid with recurrent basal cell carcinomas of two patients who initially had undergone reconstruction with a Hughes procedure was reconstructed using tarsal strip grafts and orbicularis muscle mobilization combined with a free skin graft. RESULTS: All seven patients have viable free grafts to date, and no further problems occurred in the two patients with wound dehiscences. Follow-up ranges from 1 to 8 years. CONCLUSION: Orbicularis oculi muscle mobilization can be combined with a variety of techniques in eyelid and periorbital surgery, including difficult wound repair, reconstruction of the lateral canthal tendon with periosteal flaps or auricular cartilage, tarsal transposition flaps, mucosal grafts, and skin grafts. The addition of this technique can enhance the blood supply to the reconstructed area and allow healing which might not be obtained otherwise.

Orbital lymphangioma with intracranial extension.

We report a case of biopsy-proven orbital lymphangioma with contiguous spread intracranially in a 14-year-old boy. The patient had a history of congenital orbital lymphangioma and hydrocephalus. Multiple functional and cosmetic periorbital surgeries were done over the years. Severe unresponsive amblyopia developed along with disfiguring anterior orbital and brow invasion of tumor. Since the age of 4 years, the patient had had 12 episodes of periorbital and orbital cellulitis, often after upper respiratory infections. CT and MRI scans have shown progression of the tumor posteriorly beyond the orbital confines. The tumor, now present in the superior and inferior orbital fissure and the paranasal sinuses, extends extradurally into the middle cranial fossa. This case is unique, with documentation of the benign tumor's progressive posterior extension intracranially, along with repeated episodes of severe periorbital cellulitis.

Maxillary sinus orbital fistula secondary to repair of an orbital floor fracture.

Orbital emphysema can occur after a blow-out fracture of the orbit, usually involving the medial wall. Repair of orbital floor fractures often involves the reduction of the herniated orbital contents and implantation of a sturdy, inelastic material to prevent the orbital contents from prolapsing into the maxillary sinus. We report a case of a maxillary sinus orbital fistula that occurred after the repair of a blow-out fracture of the right orbit, resulting in orbital emphysema. This was corrected with an autogenous fascia lata graft.

Caruncular malignant melanoma in a black patient.

An 84-year-old black woman had a right caruncular lesion that had progressively enlarged over the past 3 months. Surgical excision and cryotherapy were performed. A biopsy confirmed the diagnosis of caruncular malignant melanoma, a rare lesion which, to our knowledge, has not been previously reported in a black patient.

Systematized epidermal nevi: case report and review of clinical manifestations.

A 19-year-old woman developed papillary and pigmentary changes of the skin over her entire body with extensive eyelid involvement causing trichiasis. A four-lid blepharoplasty with rotation of the anterior lid lamella led to resolution of the ocular symptoms and secondary cosmetic improvement. Histologic examination of the tissue demonstrated epidermal nevi which are congenital abnormalities of surface or adnexal epithelium. This patient was diagnosed with systematized epidermal nevus as described by Lever's classification. There is a high association of epidermal nevi with other systemic abnormalities; that association is known as "epidermal nevus syndrome" (ENS).

Chemosis following blepharoplasty: an unusual complication.

We observed four cases of chemosis associated with otherwise uneventful four-lid blepharoplasty. These patients experienced postoperative conjunctival chemosis (without associated globe injection), varied types of congestion, subconjunctival hemorrhage, retrobulbar hematoma, or corneal involvement. Postoperatively, the patients were treated with some combination of patching, topical and/or systemic steroids, decongestant eye drops, and observation. Regardless of the treatment, the chemosis resolved by 5 months, without permanent complication. Probable causes were blockage of orbital or eyelid lymphatics and excessive cautery during surgery.

The conjunctival wart: report of a case and review of treatment options.

Human papillomavirus, a papovavirus, is the causative agent of all warts. There are at least 63 subtypes of this virus, certain ones of which are more likely to cause warts in particular locations or to be associated with malignancies. Over the last 6 years, HPV-6, HPV-11, and HPV-16 have been detected in both benign and malignant lesions of the conjunctiva. We report a patient with a large viral papilloma of the palpebral conjunctiva of the right lower eyelid. This case demonstrates that even very large viral papillomas can be treated successfully.