Eyelid basal cell carcinoma: non-Mohs excision, repair, and outcome.

AIM: To analyse the outcome of basal cell carcinoma (BCC) excision in a subregional (non-Mohs) oculoplastic service. METHODS: A single surgeon retrospective series, medical record review of 223 consecutive cases with histologically confirmed eyelid BCC (between 1987 and 2004). Tumour recurrence rate was derived from the 69 patients with a minimum 5 year follow up. RESULTS: Of the total 223 patients, the surviving 162 were included in this study. The follow up for the whole cohort ranged from 2 months to 120 months. All cases underwent excisional biopsy. 4 mm excision margins were taken in 83% of cases. The pathology revealed 84% complete primary excision. Of those reported incompletely excised 53% contained no tumour at re-excision. 70% of lid defects were treated by primary direct closure. Following confirmed histological clearance the remainder underwent delayed direct closure (2%), full thickness skin or tarsal grafts (13%), local skin and muscle flaps (11%), and spontaneous granulation (laissez faire) (4%). No major complications were noted. There were no recurrences for non-infiltrative BCCs. The overall 5 year and over recurrence rate including previously recurrent BCCs was 4.35%, only one of which was in the primary BCC group (1.6%). All recurrences were in infiltrative BCCs. CONCLUSIONS: Non-infiltrative BCC excision with 4 mm margins gave a zero recurrence rate. Long term follow up of such patients may be unnecessary. Infiltrative BCCs should be followed up indefinitely. Previous recurrence and infiltrative histology have predictive value for recurrence. We achieved one of the lowest recurrence rates reported in non-Mohs surgical excision. Direct closure was applicable in 72% of cases.

A new grading system for assessing orbicularis muscle function.

PURPOSE: To establish an objective parameter (orbicularis function) to measure the efficacy of botulinum toxin treatment in weakening the orbicularis of blepharospasm and hemifacial spasm sufferers. METHODS: The following scale has been used by one of the authors (VTT) in his botulinum clinic for several years: Grade 0: Incomplete eyelid closure.Grade 1: Lids just closing, minimal resistance to overcome.Grade 2: Closing well, some resistance, easily overcome.Grade 3: Strong closure, can be overcome with difficulty.Grade 4: Very strong closure, cannot be overcome or overcome with extreme difficulty. In order to establish the interobserver agreement, one consultant ophthalmologist, three ophthalmologists in training, and one nurse practitioner evaluated the same 65 patients, undergoing treatment with botulinum toxin for essential blepharospasm and hemifacial spasm. Observers assessed orbicularis function by asking each patient to close both eyes forcefully, while the observer tried to open them manually. The measure of agreement across the observers was estimated by kappa statistics. RESULTS: Overall interobserver agreement (kappa=0.54) was satisfactory. We used Kruskal-Wallis nonparametric test to determine agreement between the observers. The P-values for both right and left eyes were well above 0.05, indicating good consistency between the observers when using this grading system. CONCLUSIONS: A simple, new, five-point, clinical grading system for orbicularis muscle function is presented. Medical staff with different levels of experience can use it reliably.

Bleb-limiting conjunctivoplasty for symptomatic circumferential trabeculectomy blebs.

PURPOSE: To describe a new surgical technique for limiting symptomatic circumferential conjunctival blebs, an uncommon complication after trabeculectomy. METHODS: Four eyes of 2 patients underwent conjunctivoplasty to limit the extent of symptomatic circumferential blebs. An 8/0 virgin silk corneal traction suture was used to allow better exposure of the conjunctiva. Radial conjunctival and Tenon incisions were made down to bare sclera in approximately the 10:30 and 1:30 clock hour positions. The conjunctival incisions were sutured, tacking down to the sclera. RESULTS: Immediate flattening of the interpalpebral bulbar conjunctiva was noted on the first postoperative day and there was no elevation of intraocular pressure or loss of bleb function. Both patients experienced a rapid improvement in their symptoms and no complications of the procedure were noted. Recurrence of bleb extension occurred in 1 eye 4 months postoperatively, and was treated with a repeat limiting conjunctivoplasty incision with a good result. CONCLUSIONS: Early results show that bleb-limiting conjunctivoplasty is an effective means of treating symptomatic circumferential trabeculectomy blebs.

Spontaneous eyelid expansion after full thickness eyelid resection and direct closure.

BACKGROUND/AIMS: Direct closure of eyelid defects gives excellent functional results but is usually restricted to defects measuring less than a quarter of the eyelid length for fear of distorting the palpebral aperture and compromising lid function. The authors have used direct closure in larger defects. The aim of this study was to establish the effects of direct closure of full thickness eyelid margin defects under tension on the palpebral aperture dimensions. METHODS: A consecutive series of patients who had undergone one eyelid, full thickness lid resection repaired by direct closure were identified and invited to have both eyes photographed. The palpebral apertures of both eyes were measured from the photographs by a masked observer. The amount of eyelid resected was recorded from the operation notes. The unoperated palpebral aperture was used as the control. The result were analysed using a paired samples t test. RESULTS: The photographs of 18 patients were included in the analysis. The mean width of excised full thickness lid tissue was 15 mm (range 7-26 mm). The mean vertical palpebral aperture height was 9.2 (SD 1.4) mm in the operated eye as opposed to 9.3 (SD 1.2) mm in the non-operated eye. The mean horizontal palpebral aperture width was 26.1 (SD 1.9) mm in the operated eye as opposed to 26.4 (SD 1.8) mm in the non-operated eye. There was no statistically significant difference between the operated and unoperated horizontal and vertical palpebral measurements. CONCLUSIONS: Direct closure of large full thickness eyelid defects is possible in selected patients with excellent functional and cosmetic results. Eyelid tissue expansion occurs spontaneously following direct eyelid defect closure under tension, restoring the palpebral aperture dimensions.

Depressive disorder as possible risk factor of osteoporosis.

Hypothalamo-pituitary-adrenal (HPA) axis is a very complicated control system playing an important role in stress reaction, where glucocorticoids suppress the autonomic (vegetative), endocrine, immunologic and psychic responses to stressful stimuli. We described the marked clinical, physiological, and biochemical connection between osteoporosis and major depressive disorder (MDD). Both conditions are associated with a hyperactive HPA axis and LC/NE system, and hence with increased CRH, cortisol, and catecholamine secretion. There are numerous states or diseases associated with osteoporosis and we were looking for a hypercorticism value as a one of these. Some recent studies demonstrated that earlier history of MDD was associated with marked osteoporosis. In MDD there are two well-documented biochemical abnormalities: hypercortisolism and its resistance to dexamethasone suppression. The present study included 31 MDD patients (19 males and 12 females, mean age 37 +/- 1.3, age range 29-41 years), and 17 healthy male volunteers (mean age 39 +/- 1.6, age range 34-45 years). In each of our patients 24-hour urinary free cortisol, serum cortisol level at 8 a.m. and 5 p.m., cortisol in dexamethasone suppression test and bone mineral density were measured. We have, therefore, analyzed a group of young men and women with normal menstrual cycles, who were without signs of osteoporosis in the beginning, and who received anti-depressive therapy for many years. Analysis showed that increased levels of cortisol and the occurrence of osteoporosis, that developed as the result of elevated cortisol level. For our workshop we used nonparametric rang-correlation with Spearman's rho = -0.805, with statistic significant at the 0.01 level (2-tailed). Patients under long-term history of depression could develop a very stronger type of osteoporosis i.e. it is before known that the patients with untreated Cushing syndrome developed hard osteoporosis.

The effect of pre-operative topical flurbiprofen or diclofenac on pupil dilatation.

PURPOSE: To assess the clinical benefit and relative efficacy of pre-operative diclofenac and flurbiprofen drops in routine cataract surgery. METHODS: Fifty-two patients undergoing extracapsular cataract extraction with lens implantation were randomised in a double-masked study to compare the efficacy of diclofenac, flurbiprofen and placebo drops in maintaining per-operative mydriasis and reducing post-operative inflammation. Balanced salt solution containing adrenaline was used in all patients. Pupil size was measured prior to the corneal section and after the completion of the operation. The degree of pain, redness, flare and cells in the anterior chamber and intraocular pressure were recorded on the day after surgery. The three groups were analysed with respect to change in pupil size, intraocular pressure and degree of inflammation. RESULTS: The change in pupil size was significantly different among the three groups (p = 0.01), there being a smaller decrease in the treatment groups compared with the placebo group and in the diclofenac treatment group compared with the flurbiprofen treatment group. Significantly less post-operative redness was recorded in the diclofenac treatment group compared with the other groups (p = 0.001). No significant difference was found between the groups as regards anterior chamber cells, flare or intraocular pressure change. CONCLUSIONS: Pre-operative diclofenac and flurbiprofen drops are effective in maintaining intraoperative mydriasis. Diclofenac reduces post-operative redness on day 1. These effects are of debatable clinical benefit.

The potential role of hypocortisolism in the pathophysiology of PTSD and psoriasis.

Different physical, chemical and psychological stressors can provoke a unique but different endocrine response involving activation of the hypothalamo-pituitary-adrenal (HPA) axis. Inability of adequate compensatory reaction can lead to many disorders. The aim of our study was comparison of cortisol values in diseases provoked by various stressors. Our investigation included 34 posttraumatic stress disorder (PTSD) patients, as an example of disorder caused by extremely strong, acute stressful stimulus, 19 psoriatic patients, as an example of chronic stress stimulus and 17 healthy volunteers. In each patient we determined 24-hour urinary cortisol, serum cortisol at 8 a.m. and 5 p.m., and cortisol in dexamethasone suppression test by the standard radioimmunoassay (RIA) method. PTSD patients showed lower urinary 24-hour cortisol values, (361 +/- 28 nmol/24 h), "stronger" circadian rhythm of serum cortisol (595 +/- 57 nmol/l at 8 a.m. and 242 +/- 23 nmol/l at 5 p.m.) and attenuated suppression of cortisol in dexamethasone suppression test (197 +/- 45 nmol/l) in comparison to healthy volunteers (590 +/- 87 nmol/24 h urine, 590 +/- 32 nmol/l at 8 a.m., 402 +/- 31 nmol/l, and < 86 nmol/l in dexa test). Psoriatic patients showed markedly lower 24-hour cortisol values (150 +/- 98 nmol/24 h), even in comparison to PTSD patients, then serum cortisol values (404 +/- 138 nmol/l at 8 a.m., 187 +/- 80 nmol/l at 5 p.m.) and enhanced suppression of cortisol (23 +/- 5 nmol/l). The model of attenuated feedback inhibition in PTSD patients shows that they are unusually reactive to stress and represents an alternative model of acute stress reaction to extremely strong stressful stimulus. Unusually low cortisol values in psoriatic patients correlate to our hypothesis that in chronic stress-related disease, as psoriasis is, exists, by still undefined mechanism, altered HPA axis function, which is obviously incompetent to realise its immunoregulatory function, so consequentially, clinical signs of psoriasis persist.

National survey of corneal abrasion treatment.

PURPOSE: To survey the different methods used in the management of corneal abrasions (including iatrongenic cases) nationally. METHOD: A questionnaire survey of all 162 ophthalmic units in the UK was carried out in 1997. RESULTS: The response rate was 134 of 162 (83%). The majority of units do not have an established policy for the treatment of corneal abrasions. Topical antibiotic alone and antibiotic together with a cycloplegic are the commonest immediate treatments, whilst the most common treatment course is topical antibiotic. Padding and patient follow-up is practised some of the time by most units and all of the time by the remaining minority. Use of a soft bandage contact lens is uncommon. There is no statistically significant difference (p > 0.05) between the policy-holders and non-policy-holders in their use of the various topical regimes, padding and soft bandage contact lens. CONCLUSION: The traditional trio of topical antibiotic, cycloplegic and padding is still the mainstay of corneal abrasion treatment amongst units nation-wide. However, there is a lack of reproducible scientific evidence to support this treatment. Larger randomised trials looking at the efficacy of the different treatment options are needed.

Biological markers of alcohol related disorders.

The authors in this study lay out a relatively new approach to the diagnostics of alcoholism. Measuring the biological markers of this disease is a useful extension of the standard clinical examination and a promising method for improving prevention. Studies about markers of alcoholism provide a new, exact and quantitative way of diagnosing alcoholism, by means of determining the "state" markers, which include markers of the cerebral process of dependency development and markers of acute and chronic intoxication by alcohol; and by means of determining the "trait" markers, which suggest the disposition for the development of alcohol disease. The authors believe that measuring the biological markers is a promising new approach that should improve the diagnostics and prevention of alcoholism.

Tuberculosis and alcoholism in Croatia.

Alcoholism and tuberculosis represent very difficult problem in treatment because both illnesses require complex treatment which cannot be adequately obtained on classic wards. Tuberculosis in the last 50 years showed the constant decline of incidence--in Croatia (4,500,000 inhabitants) from approximately 20,000 to approximately 2000 cases per year. This study compares preliminary results of AUDIT (Alcohol Use Disorders Identification Test) in the group of tuberculosis patients with the diagnosis of alcoholism (group 1) and in the group of tuberculosis patients who had not the diagnosis of alcoholism (group 2) and who all were admitted to the Hospital for pulmonary diseases and tuberculosis Klenovnik where is an organised unique ward management for tuberculosis and alcoholic patients functioning for the last 25 years on the basic principles of therapeutic community. Their average AUDIT score was 25.44--very high, and all patients scored above 8, what indicated on harmful and hazardous drinking. Additionally, in the group of patients admitted for hospital treatment of tuberculosis without diagnosis alcoholism there were more than 50% of harmful or hazardous alcohol drinkers who ranged 8 or more on AUDIT score, what could indicate that modern identification of hazardous drinking (for example using AUDIT) should be used in all pulmonary and tuberculosis wards. Patients for whom diagnostic procedure shows that they drink harmfully or hazardously should be treated simultaneously for tuberculosis and alcohol use disorders. Because of hidden alcohol problems the group sociotherapy should be organised for all patients at all wards for treatment of tuberculosis in a common and special alcohologic way.

Anthropological aspects of alcohol consumption and alcohol related problems.

Authors believe that drinking alcoholic beverages can be associated with customs and habits specific to small communities, societies and even entire nations. The primary family, as the foundation of customs and habits of the first generation, has a role in stimulating drinking and alcoholism. The authors have examined some sociocultural factors, mostly taking into consideration relations in the primary family, by means of a questionnaire filled out by alcoholics (N = 200) and non-alcoholics (N = 100). The alcoholics usually have their first drink earlier, start drinking regularly earlier, and in the primary family there is a high tolerance towards the use of alcoholic beverages. The authors believe that the prevention should be directed primary towards the primary family with a view to changing their customs and habits as well as attitudes towards the use of alcoholic beverages.

Psycho-social characteristics of female alcoholics.

This paper presents the survey and benefits of various questionnaires for the examination of male and female population of alcoholics. It continues to show the results of an investigation carried out at the Department for Psychiatry, Alcoholism and Other Dependences of the University Hospital "Sestre milosrdnice" in Zagreb. The aim of this study was to obtain the most accurate and recent information about alcohol dependence and the socio-psychiatric characteristic of alcoholism in the Croatian urban environment on the basis of a specially prepared questionnaire. The group of 166 treated alcoholic persons consisted of 120 males and 46 females. The age of examinees ranged between 30 to 40. The great difference in psycho-social characteristics between male and female alcoholics was confirmed. Symptomatic alcoholism observed in women was due to primary and secondary family disorders and resulted in the anxious depressive disturbance. The incidence of primary female alcoholism is on the rise. This trend can be ascribed to the changes in the life style of urban female population.

Enucleation volume measurement.

The enucleation volume of a series of 17 eyes was measured by water displacement and found to be 1-2 ml in excess of the 7 ml usually quoted. This is relevant to the development of postenucleation socket syndrome in patients who have had orbital implants of a conventional size. Enucleation volumes should be measured routinely and the implant volumes selected accordingly.