Perineural Invasion of the Orbit by Neurotropic Nondesmoplastic Melanoma

The authors report a case of neurotropic nondesmoplastic melanoma involving the ophthalmic division of the trigeminal nerve and the cavernous sinus in a patient with recurrent scalp melanoma. This case highlights the importance of earlier diagnosis of local recurrence of melanoma and the rare association of neurotropic melanoma and orbital metastasis.

Risk of Intraocular Bleeding With Novel Oral Anticoagulants Compared With Warfarin: A Systematic Review and Meta-analysis

Importance

It is unclear if the risk of intraocular bleeding with novel oral anticoagulants differs compared with warfarin.

Objective

To characterize the risk of intraocular bleeding with novel oral anticoagulants compared with warfarin.

Data Sources

A systematic review and meta-analysis was undertaken in an academic medical setting. MEDLINE and ClinicalTrials.gov were searched for randomized clinical trials published up until August 2016. This search was supplemented by manual bibliography searches of identified trials and other review articles.

Study Selection

Studies were eligible for inclusion if they were phase 3 randomized clinical trials, enrolled patients with atrial fibrillation or venous thromboembolism, compared a novel oral anticoagulant (dabigatran, rivaroxaban, apixaban, or edoxaban) with warfarin, and recorded event data on intraocular bleeding. Data on intraocular bleeding were pooled using inverse-variance, weighted, fixed-effects meta-analysis.

Data Extraction and Synthesis

The PRISMA guidelines were used for abstracting data and assessing quality. Independent extraction was performed by 2 investigators.

Main Outcomes and Measures

Intraocular bleeding events and associated risk ratio for novel oral anticoagulants compared with warfarin.

Results

Twelve trials investigating 102 627 patients were included. Randomization to novel oral anticoagulants was associated with a 22% relative reduction in intraocular bleeding compared with warfarin (risk ratio, 0.78; 95% CI, 0.61-0.99). There was no significant heterogeneity observed (I2 = 4.8%, P = .40). Comparably lower risks of intraocular bleeding with novel oral anticoagulants were seen in subgroup analyses, with no significant difference according to the indication for anticoagulation (P for heterogeneity = .49) or the novel oral anticoagulant type (P for heterogeneity = .15). Summary estimates did not differ materially when random-effects meta-analytic techniques were used.

Conclusions and Relevance

These results suggest that novel oral anticoagulants reduce the risk of intraocular bleeding by approximately one-fifth compared with warfarin. Similar benefits were seen in both patients with atrial fibrillation and venous thromboembolism. Our data have particular relevance for patients at higher risk of spontaneous retinal and subretinal bleeding. These findings may also have important implications in the perioperative period, in which the use of novel oral anticoagulants may be superior. Future studies are required to better characterize the optimal management of patients with both ophthalmic disease and cardiovascular comorbidities requiring anticoagulation.

Associations of Epicardial, Abdominal, and Overall Adiposity With Atrial Fibrillation

Background—

Although adiposity is increasingly recognized as a risk factor for atrial fibrillation (AF), the importance of epicardial fat compared with other adipose tissue depots remains uncertain. We sought to characterize and compare the associations of AF with epicardial fat and measures of abdominal and overall adiposity.

Methods and Results—

We conducted a meta-analysis of 63 observational studies including 352 275 individuals, comparing AF risk for 1-SD increases in epicardial fat, waist circumference, waist/hip ratio, and body mass index. A 1-SD higher epicardial fat volume was associated with a 2.6-fold higher odds of AF (odds ratio, 2.61; 95% confidence interval [CI], 1.89–3.60), 2.1-fold higher odds of paroxysmal AF (odds ratio, 2.14; 95% CI, 1.45–3.16) and, 5.4-fold higher odds of persistent AF (odds ratio, 5.43; 95% CI, 3.24–9.12) compared with sinus rhythm. Likewise, a 1-SD higher epicardial fat volume was associated with 2.2-fold higher odds of persistent compared with paroxysmal AF (odds ratio, 2.19; 95% CI, 1.66–2.88). Similar associations existed for postablation, postoperative, and postcardioversion AF. In contrast, associations of abdominal and overall adiposity with AF were less extreme, with relative risks per 1-SD higher values of 1.32 (95% CI, 1.25–1.41) for waist circumference, 1.11 (95% CI, 1.08–1.14) for waist/hip ratio, and 1.22 (95% CI, 1.17–1.27) for body mass index.

Conclusions—

Strong and graded associations were observed between increasing epicardial fat and AF. Moreover, the strength of associations of AF with epicardial fat is greater than for measures of abdominal or overall adiposity. Further studies are needed to assess the mechanisms and clinical relevance of epicardial fat.

Haemangiopericytoma of the lacrimal sac

Haemangiopericytomas (HPCs) are rare tumours which infrequently occur in the lacrimal sac. Only 8 cases of lacrimal sac HPC have previously been reported. The authors report 2 additional cases presenting clinically with epiphora and a mass. One case recurred 3 times during an 18-year period. The other case did not recur during 51 months of follow-up. The tumours showed immunohistochemical features consistent with a diagnosis of HPC. The authors recommend wide excision for these tumours and careful long-term follow-up to detect recurrence which is not uncommon.

Management of periorbital basal cell carcinoma with orbital invasion

Basal cell carcinoma (BCC) is the most common eyelid malignancy; however, orbital invasion by periocular BCC is rare, and management remains challenging. Established risk factors for orbital invasion by BCC include male gender, advanced age, medial canthal location, previous recurrences, large tumor size, aggressive histologic subtype and perineural invasion. Management requires a multidisciplinary approach with orbital exenteration remaining the treatment of choice. Globe-sparing treatment may be appropriate in selected patients and radiotherapy and chemotherapy are often used as adjuvant therapies for advanced or inoperable cases, although the evidence remains limited. We aim to summarize the presentation and treatment of BCC with orbital invasion to better guide the management of this complex condition.

Periocular Squamous Cell Carcinoma: TNM Staging and Recurrence

PURPOSE

To analyze the TNM stage, management, and recurrence rates of patients with histologically confirmed squamous cell carcinoma (SCC) of the eyelid.

DESIGN

Retrospective case series from 3 Australian centers.

PARTICIPANTS

A total of 254 cases of eyelid SCC from 254 patients (median age, 73 years; range, 28-102 years; 159 were male).

METHODS

Tumors were staged according to The American Joint Committee on Cancer 7th edition TNM criteria for eyelid carcinoma.

MAIN OUTCOME MEASURES

Outcomes and recurrence rates according to TNM stage at presentation.

RESULTS

A total of 25 cases (9.8%) were recurrent tumors. TNM classifications were as follows: T1N0M0, 74 patients (29.1%); T2aN0M0, 92 patients (36.2%); T2bN0M0, 50 patients (19.7%); T3aN0M0, 31 patients (12.2%); T3bN0M0, 5 patients (2.0%); T2bN0M1, 1 patient (0.4%); and T3bN1M1, 1 patient (0.4%). Perineural invasion (PNI) was present histologically in 8.3% of cases. Treatment modalities included Mohs microsurgery (31.1%), wide local excision (WLE) with paraffin section control (21.7%), WLE with frozen-section control (19.3%), and excision without margin control (24.4%). Three cases did not receive treatment. Median follow-up was 40 months (range, <1-132 months). Local recurrence occurred in 17 treated patients (6.8%). The recurrence rate was 5.3% (12/226 patients) for primary tumors and 20% (5/25 patients) for recurrent tumors (P = 0.019). Four patients (1.6%) died of their disease during follow-up. Higher T stage was significantly associated with both PNI (P = 0.035) and local recurrence (P < 0.001). We could not identify a T-stage threshold below which there was no risk of recurrence, as evidenced by 3 T1 primary tumors that recurred.

CONCLUSIONS

Higher T stage was significantly associated with local recurrence, and recurrent tumors had a 4-fold increased risk of further recurrence compared with primary tumors. Therefore, it may be reasonable to consider sentinel lymph node biopsy or close nodal surveillance and follow-up for patients with recurrent or high T-stage tumors. Of note, we could not identify a T-stage threshold below which there was no risk of recurrences; therefore, clinicians should be aware of the potential for low T-stage tumors to recur.

Endoscopic medial orbital fat decompression for proptosis in type 1 graves orbitopathy

PURPOSE

To describe the surgical technique for endoscopic medial orbital fat decompression in type 1 (lipogenic) Graves orbitopathy and report outcomes.

DESIGN

Retrospective interventional case review.

METHODS

We reviewed 108 patients (206 orbits) with inactive, type 1 Graves orbitopathy without diplopia, who underwent endoscopic medial orbital fat decompression solely for proptosis reduction. Following endoscopic transethmoid medial orbital wall decompression, extraconal and intraconal orbital fat was removed with a low-suction cutting instrument. All patients were followed up for at least 12 months. Surgical time, preoperative and postoperative Hertel exophthalmometry, incidence of postoperative diplopia within 30-degree visual field in the primary gaze, and other complications were analyzed.

RESULTS

The mean surgical time was 97.7 ± 16.7 minutes (67-136 minutes). The mean follow-up was 16.0 ± 4.2 months (12-24 months). Preoperative and postoperative proptosis values at final review were 21.1 ± 2.3 mm (17-26 mm) and 13.0 ± 0.9 mm (12-15 mm), respectively (P < .001). Median reduction in proptosis was 8.0 mm with mean of 8.2 ± 1.8 mm (4-11 mm). Symmetry to within 2 mm was achieved in 106 of 108 patients (98.1%). Twenty-five of 108 patients (23.1%) had diplopia within 30-degree visual field of the gaze, and 23 of these had complete resolution within 3 months, while the remaining 2 patients required squint surgery.

CONCLUSIONS

Endoscopic medial orbital fat decompression may be an effective technique for proptosis in selected patients with type 1 Graves orbitopathy and is associated with a low rate of surgically induced diplopia.

Orbital blowout fracture location in Japanese and Chinese patients

PURPOSE

To characterize the location of orbital blowout fractures in Asian individuals.

METHODS

This was a retrospective review of 470 consecutive Asian patients with orbital blowout fractures who presented to four tertiary care hospitals in Japan and China. Computed tomography (CT) characterized the location and severity of fractures involving the medial wall, the orbital floor, and/or the maxilloethmoidal strut.

RESULTS

A total of 475 orbital blowout fractures were identified. More than one fracture location was involved in 19% of all cases. The medial orbital wall was the most commonly involved location, presenting in 29 cases (61%), of which 204 (43%) were isolated medial blowout fractures. The orbital floor was the second most common location involved, present in 226 cases (48%) with 150 isolated orbital floor fractures (32%), while the maxilloethmoidal strut was involved in 45 cases (9%) with 30 of those being isolated strut fractures (6%). The majority of fractures (62%) were classified as moderately severe, whilst 14% were mild, and 24% were severe. Associated nasal fractures were present in 16% of the cases.

CONCLUSIONS

Orbital blowout fractures in Japanese and Chinese individuals occur most commonly in the medial wall. This is in contrast to previous reports on white individuals, who tend to sustain fractures involving the orbital floor rather than the medial wall.

Accurate ab initio-based adiabatic global potential energy surface for the 2(2)A" state of NH2 by extrapolation to the complete basis set limit

A full three-dimensional global potential energy surface is reported first time for the title system, which is important for the photodissociation processes. It is obtained using double many-body expansion theory and an extensive set of accurate ab initio energies extrapolated to the complete basis set limit. Such a work can be recommended for dynamics studies of the N((2)D) + H2 reaction, a reliable theoretical treatment of the photodissociation dynamics and as building blocks for constructing the double many-body expansion potential energy surface of larger nitrogen/hydrogen containing systems. In turn, a preliminary theoretical study of the reaction N((2)D)+H2(X(1)Σg (+))(ν=0,j=0)→NH(a(1)Δ)+H((2)S) has been carried out with the method of quasi-classical trajectory on the new potential energy surface. Integral cross sections and thermal rate constants have been calculated, providing perhaps the most reliable estimate of the integral cross sections and the rate constants known thus far for such a reaction.

Endoscopic transethmoidal approach with or without medial rectus detachment for orbital apical cavernous hemangiomas

PURPOSE

To determine the indications for the addition of a transcaruncular approach along with detachment of the medial rectus muscle during the removal of small apical cavernous hemangiomas using an endoscopic transethmoidal approach.

DESIGN

Retrospective, noncomparative case series.

METHODS

Multicenter study of 12 patients with apical orbital tumors removed using an endoscopic transethmoidal approach. The decision to detach the medial rectus muscle with the addition of a transcaruncular approach was made during surgery for tumors largely lateral to the medial rectus muscle. Tumors adjacent to the medial orbital wall were removed via an endoscopic transethmoidal approach alone.

RESULTS

Seven tumors were removed via an endoscopic transethmoidal approach combined with medial rectus muscle detachment, whereas 5 patients underwent removal without detachment of the medial rectus. All patients had visual impairment. Complete excision of the hemangiomas was achieved in all patients and tumor size ranged from 6 × 5 mm to 20 × 12 mm. The mean postoperative follow-up time was 11.8 ± 4.3 months. At final follow-up, the best-corrected visual acuity improved in 11 patients. Three patients had transient horizontal diplopia resulting from partial paralysis of the medial rectus muscle after detachment during surgery.

CONCLUSIONS

The endoscopic transethmoidal approach with or without medial rectus detachment is a promising approach for selected small cavernous hemangiomas located at the deep medial orbital apex. Detachment of the medial rectus muscle can be a useful technique for tumors located largely lateral to the medial rectus muscle. Further studies will be required to demonstrate the safety and efficacy of this technique.

Temporal and comparative outcomes of cardiac electrophysiology abstracts

Although conferences are important vehicles for discussing scientific findings, the translation of presented research into peer-reviewed manuscripts is a crucial subsequent step in the research process. Given the evolving subspecialization of cardiology, we sought to characterize the temporal and comparative outcomes of abstracts presented at a subspecialty cardiac electrophysiology conference. Abstracts presented at the Heart Rhythm Society conference (1994 through 2006; HRS abstracts) and abstracts presented at the American Heart Association conference (2003; AHA abstracts) were studied. Subsequent publications, impact factors, and citation rates were determined. A total of 3,850 HRS and 1,000 AHA abstracts were studied. More human abstracts were presented at HRS than AHA (p <0.05). Compared with HRS abstracts, more AHA abstracts were published (p <0.001) and had higher impact factors and citation rates (p <0.001 for both). These differences were attributable in part to the greater proportion of human HRS abstracts. Compared with HRS abstracts, electrophysiology-related AHA abstracts were published less (p <0.001), and these publications had similar impact factors (p = 0.38) although greater citation rates (p = 0.001). The number and publication rate of HRS abstracts increased over the 15-year period, as did their publication impact factors and citation rates (p <0.001 for all). In conclusion, there are significant differences between AHA and HRS abstracts. Although AHA abstracts were more likely to be published overall, the publication rate and impact of electrophysiology abstracts presented at both a subspecialty (HRS) and a major cardiovascular conference (AHA) were comparable. There has also been a growth in the number and impact of cardiac electrophysiology abstracts presented at HRS in recent years.