Predicting the Surgical Margin of Resection in Periocular Cutaneous Neoplasms and the Significance of Reconstruction Following Mohs Micrographic Surgery.

PURPOSE: To evaluate the features of periocular cutaneous malignancies that may contribute to larger surgical defects or require more complex reconstructive procedures. METHODS: A retrospective review of 181 patients with biopsy proven periocular cutaneous malignancies seen between April 2005 and September 2010, and undergoing Mohs micrographic surgery was performed. The longest horizontal and vertical diameters of the tumor and the post-Mohs surgical defect were measured in each patient. These measurements were used to calculate the relative margin of resection (MOR) required for tumor eradication as well as the size of the surgical defect. The date of surgery, histologic diagnosis and location of the tumor, type of reconstruction, and the presence of recurrence were also recorded. RESULTS: The average MOR for all tumor subtypes taken together was 3.4 mm horizontally and 2.6 mm vertically for basal cell carcinomas (BCCA). The post-Mohs defect area was 3.2 times greater than the preoperative tumor area for all BCCA subtypes, and 3.9 times greater for morphea type (p = 0.8083). The average MOR for squamous cell carcinomas (SCCA) was 5.1 mm horizontally and 3.7 mm vertically. The post-Mohs defect area was 3.8 times greater than the preoperative tumor area for SCCAs. When comparing the preoperative horizontal tumor diameter to the horizontal MOR of BCCAs and SCCAs, the correlation was 0.23 (p < 0.0001) and 0.31 (p < 0.0001), respectively. While the average MOR was within standard limits, a significant number of tumors required a greater MOR. On review of the data, 30.6% of patients with BCCA required a MOR greater than 3 mm, 17.3% of patients with BCCA required a MOR greater than 4 mm, and 29.1% of patients with SCCA required a MOR of greater than 5 mm. Tumors located at the lateral canthus required the largest MOR (p < 0.01), while those on the lower eyelid were associated with the smallest MOR in BCCAs. As expected from anatomical considerations, tumors at the medial canthus required significantly more complex reconstruction procedures (p < 0.01). An ordered logistic regression model demonstrated that BCCA preoperative clinical tumor surface area was a significant indicator for the degree of reconstruction required (p < 0.01). CONCLUSIONS: Standard 3 mm to 4 mm MOR for BCCAs, and 5 mm MOR for SCCAs could result in an unacceptable risk of tumor recurrence if the surgical margins are not examined histologically. With increasing preoperative tumor size, there is an increase in the MOR required for BCCA and SCCA, supporting that large tumors require a greater MOR.

Solitary fibrous tumor of the orbit with multiple cavities.

Solitary fibrous tumors (SFTs) are rare spindle cell neoplasms of mesenchymal origin that most commonly arise within pleura and have also been reported in many extrapleural sites including the orbit. Cavitary changes within SFT of both pleura and extrapleural sites have been documented, but remain very rare. To the authors' knowledge, the third known case of an orbital solitary fibrous tumor containing large pseudocystic cavities is described. MRI demonstrated a heterogeneous enhancing mass with multiple cavities. Excisional biopsy revealed solid tumor with large cavities filled with straw-colored fluid and tumor cells that stained positive for CD34 and CD99 antigens, consistent with SFT. The patient had an uncomplicated postoperative course with no sign of recurrence and resolution of the proptosis after 12 months of follow up. SFT are rare benign orbital neoplasms that rarely present with cavitary changes. Current treatment options include complete surgical excision, which was performed in this case. Close follow up is advised to monitor for recurrence.

Unilateral mydriasis due to hemorrhoidal ointment.

BACKGROUND: The finding of a unilaterally dilatated pupil in a patient who is otherwise alert and unimpaired can pose an interesting diagnostic problem. Algorithms have outlined the approach to evaluating anisocoria, but do not stress the importance of toxic exposures. CASE REPORT: A patient with a history of depression and chronic headaches was referred to the emergency department from an ophthalmologist's clinic with the findings of asymmetrically dilatated pupils and blurred vision. Detailed history revealed that for several weeks before the onset of symptoms, the patient applied to her eyelids hemorrhoidal ointment that contained an active ingredient known to produce mydriasis. CONCLUSION: In the absence of neurologic deficits, clinical history should search for a toxic or pharmacologic etiology of abnormal mydriasis. A detailed physical examination and bedside diagnostic maneuvers can help distinguish benign causes of an abnormally dilatated pupil from more serious causes relating to central nervous system lesions, potentially sparing the patient from unnecessary neuroimaging.