Evaluation of efficacy and complications: primary pediatric orbital implants after enucleation

BACKGROUND

Orbital implants are used routinely in pediatric patients at the time of enucleation. Complications, such as exposure, ptosis, and infection, may occur after implantation. Controversy continues regarding the rate of complications with newer implants in the pediatric population.

OBJECTIVE

To examine the effects of orbital implants on children whose eyes have been enucleated.

METHODS

Records of orbital implantation after enucleation performed by 5 surgeons on 120 pediatric patients (123 eyes) over a 10.5-year period were reviewed retrospectively. Demographic data, ocular diagnosis, prior ophthalmic surgery, implant characteristics, and postoperative complications were described using a standardized format for all patients, with a minimum of 6 months of follow-up (mean, 3 years).

RESULTS

Complications were observed in 7 eyes (5.7%). Implant exposure (1 [0.8%]), implant extrusion (0 [0%), and implant migration (3 [2.4%) were rare. One hundred eighteen eyes (96%) had good cosmesis and 120 (98%) had good motility.

CONCLUSIONS

Orbital implantation after enucleation is successful in the pediatric population. Complications are minimal. Hydroxyapatite implants were not associated with unacceptable complications in this pediatric population.

Combined hamartoma of the retina and retinal pigment epithelium as the presenting sign of neurofibromatosis-1

The authors report a case of combined harmartoma of the retina and retinal pigment epithelium in a 6-year-old child as the presenting sign of neurofibromatosis-1. The patient was followed closely for three years but received no treatment. Observation over these years revealed no significant change in the patient's visual acuity. A referral to the University of California San Francisco (UCSF) Neurofibromatosis Clinic resulted in a diagnosis of neurofibromatosis (NF)-1, and she continues to be observed for further systemic manifestations of this disease. Combined hamartoma of the retina and retinal pigment epithelimicrom, a rare and benign tumor, can be easily mistaken for malignant processes such as retinoblastoma or choroidal melanoma. Ophthalmologists should also be aware of the association with neurofibromatosis and consider this diagnosis when such retinal findings are observed in a child.

Siblings of retinoblastoma patients: are we underestimating their risk?

PURPOSE

To describe the clinical presentation of probable germ-line mosaicism in four retinoblastoma kindreds.

METHODS

Review of 255 retinoblastoma patients and their family records in a University of California, San Francisco-Bascom Palmer database to identify those with potential germ-line mosaicism. Parents and siblings of retinoblastoma patients were given comprehensive ophthalmologic examinations.

RESULTS

Four kindreds were identified, wherein retinoblastoma was diagnosed in two siblings and both parents demonstrated no evidence of retinoblastoma or retinocytoma.

CONCLUSION

Clinical appearance of germ-line mosaicism is demonstrated in our retinoblastoma patient populations. We recommend routine clinical screening of all parents and siblings of retinoblastoma patients to provide more accurate genetic counseling and to allow earlier examination and treatment of children at presymptomatic disease stages. Germ-line mosaicism must be considered as a genetic transmission pattern in these patients, and genetic counseling should specifically recognize this possibility. If a parent is germ-line mosaic, the possibility of bearing a second child with retinoblastoma is clearly higher than conventionally believed.

Is screening for primitive neuroectodermal tumors in patients with unilateral retinoblastoma necessary?

Retinoblastoma is the most common childhood intraocular tumor, occurring in 1 of 18,000 live births. Retinoblastoma may occur as a germinal mutation or a somatic mutation. Forty percent of retinoblastoma cases are caused by a germline mutation and include those patients with a positive family history of the disease. Children with hereditary forms usually have multifocal, bilateral retinoblastoma, whereas children with the somatic form have unilateral, unifocal disease. However, up to 15% of cases of sporadic unilateral retinoblastoma may be hereditary. It is important to recognize that this subgroup of unilateral patients remains at risk for the development of second tumors as well as second primary tumors of the intracranial midline, or "trilateral retinoblastoma." We report a case of a 2-month-old child with unilateral retinoblastoma in whom pinealoblastoma subsequently developed.

Neonatal progeroid (Wiedemann-Rautenstrauch) syndrome: report of five new cases and review

The neonatal progeroid syndrome (NPS), or Wiedemann-Rautenstrauch, is a rare autosomal recessive disorder comprised of generalized lipoatrophy except for fat pads in the suprabuttock areas, hypotrichosis of the scalp hair, eyebrows, and eyelashes, relative macrocephaly, triangular face, natal teeth, and micrognathia. We report on 5 new patients who demonstrate phenotypic variability and who represent the single largest series of NPS reported to date. Two of the patients are from an African-American kindred, an ethnic occurrence not reported previously. The fact that there are 2 pairs of sibs among the 5 patients further supports that NPS is an autosomal recessive condition. This report also includes a review of the previously reported 16 patients and compares them with the 5 new patients. Abnormalities in endocrine and lipid metabolism were found in 3 of 5 patients. Skeletal findings in 2 of our patients demonstrated some new findings as well as the typical radiological abnormalities previously noted in NPS. It is apparent, based on the 21 cases, that mild to moderate mental retardation is common in NPS. Long term follow-up of patients with NPS should provide more information relative to their ultimate psychomotor development. NPS is usually lethal by 7 months; however, on rare occasions, patients have survived into the teens. Our 3 surviving patients range in age from 16-23 months. Variability in the phenotype of NPS is clear; however, the phenotype remains distinct enough to allow a secure diagnosis.

Haloperidol-induced torsade de pointes

OBJECTIVE

To report a case of torsade de pointes related to the administration of high-dose intravenous haloperidol for the treatment of severe agitation.

CASE SUMMARY

Reports in the literature of intravenous haloperidol-induced torsade de pointes are rare. We describe the case of a 41-year-old white woman with no predisposing factors who developed torsade de pointes 55 minutes after a dose of intravenous haloperidol 80 mg (total dosage 915 mg over 7 d). The results of the electrocardiogram were consistent with torsade de pointes and showed a prolonged QTc interval of 610 milliseconds. Intravenous magnesium sulfate 2 g/100 mL NaCl 0.9% was administered, which controlled the arrhythmia. The patient received one additional 80-mg haloperidol dose six hours after the arrhythmia-triggering dose, without reoccurrence of torsade de pointes. Haloperidol was then discontinued, and the patient had no further arrhythmias.

CONCLUSIONS

Our case report and others from the literature suggest that intravenous haloperidol administration may prolong QT intervals in some patients, precipitating the potentially life-threatening arrhythmia torsade de pointes. Clinicians should be aware of haloperidol's potential to induce torsade de pointes, since it is used regularly for agitation and delirium in the critical care arena.

Spontaneous regression of orbital Langerhans cell granulomatosis in a three-year-old girl

PURPOSE

To report a case of spontaneous regression of orbital Langerhans cell granulomatosis.

METHOD

Case report. A 3-year-old girl was initially examined with a 5-week history of slowly progressive blepharoptosis and periorbital swelling of the left eye.

RESULTS

Computed tomographic scan showed a mass in the left orbit eroding into the left frontal bone; fine-needle aspiration confirmed diagnosis of Langerhans cell granulomatosis. After initial biopsy, the patient was treated by close observation alone. Six months after initial examination, the monostotic lesion had completely resolved.

CONCLUSIONS

In some cases of monostotic Langerhans cell granulomatosis, initial biopsy followed by observation alone may allow for the spontaneous regression of the lesion. This conservative approach to treatment is an important therapeutic option that may spare the patient the adverse effects of surgical resection, radiation, or chemotherapy.

Retinal hamartoma in oral-facial-digital syndrome

Only recently have intraocular findings been described in oral-facial-digital syndrome (OFDS), including 5 cases of chorioretinal colobomas and 1 case of optic nerve coloboma. We report a case of a new ocular anomaly associated with this syndrome: a retinal hamartoma in a male infant with OFDS. The patient had bilateral retinal masses that were suspicious for retinoblastoma because of a family history of retinoblastoma. Physical examination and imaging studies of the retinal masses could not differentiate between retinoblastoma, hamartoma, or persistent hyperplastic primary vitreous. Subsequent pathologic study of an enucleated globe was diagnostic of a retinal hamartoma. This case further illustrates the heterogeneity of ocular anomalies in OFDS and underscores the importance of a complete ophthalmologic evaluation in patients with this syndrome.

External beam radiotherapy in retinoblastoma: tumor control and comparison of 2 techniques

OBJECTIVE

To investigate eye conservation, local control, and complication rates among children with retinoblastoma treated with 2 different external beam radiotherapy (EBR) techniques.

METHODS

Fifty-eight eyes in 42 patients received EBR as the primary treatment modality for retinoblastoma (median follow-up, 37 months). The EBR technique was relative lens-sparing (RLS) in 26 eyes and modified lateral beam (MLB) in 32 eyes. Both groups were comparable in Reese-Ellsworth retinoblastoma classification. If necessary, patients received focal salvage therapy.

RESULTS

At 24 months, eye conservation rates were 88.5% and 89.1% among eyes treated with RLS and MLB, respectively (P = .40); tumor control rates without salvage therapy were 84.6% and 53.3% (P = .02), respectively. Among eyes with Reese-Ellsworth stage IV and V disease, eye conservation rates were 88%+/-8% and 83%+/-9% at 36 months in the RLS and MLB groups, respectively, and local tumor control rates were 81%+/-10% and 51%+/-12%. Percentages of eyes without cataract at 36 months were 83.1% and 63.0%, respectively (P = .40). Among patients observed for at least 18 months, midfacial hypoplasia developed in 38.5% and 29.4%, respectively (P = .70).

CONCLUSIONS

The EBR technique was associated with high eye conservation and local control rates. Salvage therapy was performed significantly less frequently in the RLS group compared with the MLB group, and complication rates in both groups were similar.

Intravaginal saline as a contrast agent for cervical sonography in the obstetric patient

OBJECTIVE

To determine whether intravaginal saline alters visualization of the cervix during endovaginal sonographic examinations.

DESIGN

A prospective trial with comparison of sonographic measurements of cervical length prior to and after administration of an intravaginal contrast agent.

SUBJECTS

Patients with an indication for endovaginal ultrasonographic assessment of the cervix were considered as candidates for the study.

METHODS

After assessment of cervical dimensions and contour of the internal cervical os, 10 ml of normal saline was placed intravaginally via a needleless syringe. Pre- and post-contrast sonographic examinations of the cervix were compared.

RESULTS

Twenty-six patients were enrolled. No differences were observed in the identification of funnelling (37% in each group, p = 1.0) or the quantification of cervical length for the entire cohort (p = 0.95). However, in a subset of patients in whom the external os was not satisfactorily visualized (23%), intravaginal contrast resulted in a mean difference in cervical length pre- and post-saline infusion of 6.4 mm compared to 1.4 mm in patients in whom the external os could be easily identified (p < 0.001). No patient expressed undue discomfort related to the administration of contrast.

CONCLUSION

Intravaginal saline assists in visualization of the cervix during endovaginal sonography for selected patients in whom precise identification of the external os is difficult.

European politicians need epidemiologists

This paper reviews some of the recent discussions about public health policy in Europe. In particular it points to the interest in communicable diseases and the need to extend this interest into non-communicable fields. It draws attention to the consequential need for trained and continuously updated epidemiologists.

Intraorbital implants after enucleation and their complications: a 10-year review

BACKGROUND

Many different types of orbital implants have been used after enucleation. Associated complications such as infection, exposure, extrusion, and ptosis have been reported.

OBJECTIVE

To describe 342 consecutive patients who underwent enucleation with intraorbital implant placement at the Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Fla, during the past 10.5 years and their complications.

METHODS

Medical records of orbital implantation after enucleation performed by 3 surgeons (T.G.M., D.T., and T.J.) were reviewed retrospectively. Demographic data, ocular diagnosis, previous ophthalmic surgery, implant characteristics, and postoperative complications were described in all patients, with a minimum of 2 months' follow-up, using a standardized format.

RESULTS

Eleven complications were observed in 7 patients. Four patients had exposure of the implant, and 1 of these patients developed associated infection. Three patients developed pyogenic granulomas, 1 patient developed ptosis requiring surgical intervention, 1 patient had long-term orbital discomfort, and 1 patient developed an inclusion cyst.

CONCLUSION

Complications after enucleation with orbital implant placement are minimal and are observed with both porous and acrylic orbital implants.

Epidemiological understanding: privilege for a few or obligation for many?

This paper reviews briefly the reasons for providing education in epidemiology, considers who would benefit and discusses some of the available methods and their attendant problems. It concludes with a personal view about future developments.

In vitro efficacy of carboplatin and hyperthermia in a murine retinoblastoma cell line

PURPOSE

To determine the cell-killing activity of varying doses of carboplatin, graded hyperthermia, and the combination of carboplatin and hyperthermia in the treatment of a transgenic murine retinoblastoma cell line.

METHODS

Replicate cell wells (more than six wells per dose point) from an established transgenic murine retinoblastoma cell line (Rb-6) were exposed to a single application of hyperthermia for 15, 30, 60, and 120 minutes at temperatures of 37 degrees C (control), 40 degrees C, and 43 degrees C. Carboplatin dose response treatment was studied at doses of 2000, 1000, 500, 400, 300, 200, 100, and 50 ng per well. Combined treatment studies used these carboplatin dosages with each of the graded hyperthermia exposure temperatures at each exposure time. At 24 hours, all wells were pulsed with 3H-thymidine for 24 hours, washed three times, harvested, and counted. Raw counts (3H-thymidine) were fitted to a linear regression model to calculate the lethal dose for 50% (LD50) of cells.

RESULTS

The LD50 for carboplatin exposure at 37 degrees C occurred at 542 ng. The LD50 for hyperthermia at 40 degrees C occurred at 90 minutes and at 43 degrees C it occurred at 62 minutes. Combined hyperthermia and carboplatin exposure yielded a synergistic interaction with an LD50 of 327 ng at 43 degrees C for 30 minutes. Determination of a thermal enhancement ratio yielded an enhancement range of 1.1 to 25.8.

CONCLUSIONS

The synergistic cytocidal interaction of heat and carboplatin in a transgenic murine retinoblastoma cell line has been established in this study. The increased thermal enhancement ratio documents the potential utility of combined treatment applications in reducing treatment levels of single-modality therapy, potentially allowing for a decrease in treatment-related morbidity.

Subconjunctival carboplatin therapy and cryotherapy in the treatment of transgenic murine retinoblastoma

OBJECTIVES

To determine the efficacy and dose response of subconjunctival carboplatin with and without cryotherapy in the treatment of murine transgenic hereditary retinoblastoma.

METHODS

Fifty-one 5-week-old transgenic BLH SV-40 (Charles Rivers Laboratories, Boston, Mass) T-antigen-positive mice with retinoblastoma were administered 6 subconjunctival injections of carboplatin in 1 eye at drug doses of 10, 15, 20, 25, 62.5, 125, and 250 microg. Six control eyes received 6 subconjunctival injections of balanced salt solution. Fourteen of the 51 subconjunctivally treated eyes received a single application of transconjunctival cryotherapy immediately prior to each carboplatin injection. Six control eyes received 6 single applications of transconjunctival cryotherapy using the above schedule but did not receive carboplatin. All experimental and control eyes were obtained at 16 weeks of age for histopathologic examination.

RESULTS

A dose-dependent inhibition of intraocular tumor growth by subconjunctivally delivered carboplatin was observed in these transgenic retinoblastoma mice. Tumor development was inhibited in 50% of the mouse eyes at doses of 180 microg. In animals treated with cryotherapy alone, no tumor control was noted (0 of 6). In animals treated with subconjunctival carboplatin coupled with cryotherapy, a tumor control dose of 417 microg was found. No evidence of histopathologic treatment toxicity was noted.

CONCLUSIONS

Subconjunctival delivery of carboplatin in serial doses effectively inhibits intraocular tumor growth in a dose-dependent fashion in a transgenic murine retinoblastoma model. Cryotherapy does not increase tumor control in this murine retinoblastoma model.

The management of placenta percreta: conservative and operative strategies

OBJECTIVE

Our purpose was to assess preferences for the management of placenta percreta and identify aspects of care related to an improved outcome.

STUDY DESIGN

Both an analysis of a questionnaire issued to members of the Society of Perinatal Obstetricians and a retrospective study at our institution were used to obtain case histories of women with placenta percreta during a recent 3-year period.

RESULTS

Fifty-five of the 109 cases (50%) reported by members of the Society of Perinatal Obstetricians were suspected ante partum. Complications associated with this disorder included uterine rupture (3 cases), transfusion of > 10 units (44 cases, 40%), ureteral ligation or fistula formation (5 cases each, 5%), infection (31 cases, 28%), perinatal death (10 cases, 9%), and maternal death (8 cases, 7%). Management options included surgical removal of the uterus and involved tissues (101 cases, 93%) and conservative treatment with the placenta left in situ after delivery (8 cases, 7%). More members of the Society of Perinatal Obstetricians responding to our survey opted for conservative management if adjacent tissues were involved (69% with extension into the bladder or gastrointestinal tract) compared with 31% when the percreta was confined to the uterus, p < 0.001. Conservative therapy was also associated with less blood loss in reported cases (median units red blood cells transfused, 0 vs 7, p = 0.003). Two of the three cases of placenta percreta at our institution were identified ante partum. The third case represents the first reported with antepartum identification of percreta followed by deliberate conservative treatment.

CONCLUSIONS

With greater involvement of surrounding tissues, conservative treatment was preferred in hemodynamically stable patients. If surgical excision of the placenta is attempted or necessary, physicians experienced in pelvic dissection must be involved because of the frequency of maternal morbidity and mortality.

Local carboplatin and radiation therapy in the treatment of murine transgenic retinoblastoma

BACKGROUND

Combined modality therapy in the treatment of retinoblastoma may decrease treatment-related morbidity and second tumor-associated mortality, while maintaining excellent tumor control rates.

OBJECTIVE

To evaluate tumor control and potential synergy between intravitreally delivered carboplatin and external beam radiation therapy (EBRT), using a transgenic murine model of spontaneous heritable retinoblastoma.

METHODS

Sixty-six mouse eyes from 4-week-old transgenic mice positive for the simian virus 40 large T antigen were evaluated. Thirty-three mice were treated with 5 intravitreal injections of carboplatin (ranging from 0.1-4.0 micrograms) combined with concurrent bilateral EBRT (ranging from 10-30 Gy) delivered in twice daily 5-Gy fractions. All eyes were followed up for treatment complications. Twelve weeks following final treatment, all eyes were enucleated, serial histologic sections obtained, and the eyes examined for the presence of retinoblastoma.

RESULTS

No eye treated with 0.1 microgram of carboplatin and EBRT exhibited tumor control. Three (75%) of 4 mice receiving 1.0 microgram of carboplatin combined with 10-Gy EBRT had complete tumor control. Four (100%) of 4 mice receiving 1.0 microgram of carboplatin combined with 30-Gy EBRT had complete tumor control. Nine (100%) of 9 mice receiving 4.0 micrograms of carboplatin in combination with EBRT had complete tumor control. The chemotherapeutic enhancement ratio ranged from 1.07 to 3.24.

CONCLUSIONS

Combined administration of intravitreal carboplatin and EBRT enhances local tumor control in murine retinoblastoma. Combining these treatment modalities may allow tumor control in selected patients with retinoblastoma while decreasing treatment-related morbidity and the mutagenic risks associated with radiation and systemic chemotherapy.

Radiation therapy and ferromagnetic hyperthermia in the treatment of murine transgenic retinoblastoma

BACKGROUND

Combined modality therapy for childhood retinoblastoma holds the potential of decreasing treatment-related morbidity while maintaining excellent tumor control rates.

OBJECTIVE

To evaluate the efficacy of external beam radiation therapy (EBRT), ferromagnetic hyperthermia (FMH), and the combination of both modalities in the control of ocular tumors in a transgenic murine model of retinoblastoma.

METHODS

One hundred sixty-six mouse eyes from 4-week-old animals transgenically positive for simian virus 40 large T antigen were treated with a total dose of 10, 15, 20, 30, 40, 45, or 50 Gy of EBRT in 5-Gy fractions twice daily, with 48 degrees C or 54 degrees C FMH for 20 minutes, or with combined EBRT at 10 or 30 Gy and 48 degrees C or 54 degrees C FMH for 20 minutes. Serial histologic sections, obtained 8 weeks after treatment, were examined for the presence of tumor.

RESULTS

The tumor control dose for 50% of eyes (TCD50) treated with EBRT occurred at 27.6 Gy. Ferromagnetic hyperthermia at 48 degrees C cured 30% (6/20) of eyes, while 54 degrees C FMH resulted in a 100% (20/20) cure rate. Combined treatment with 48 degrees C FMH and EBRT exhibited a TCD50 at 3.3 Gy. The thermal enhancement ratio was 8.4. Ferromagnetic hyperthermia at 54 degrees C exhibited tumor cure in all animals, but 25% of eyes were lost owing to secondary treatment complications.

CONCLUSIONS

This represents the first documentation of tumor control via EBRT, ocular FMH, and a combination of these treatment modalities in this murine transgenic retinoblastoma model. The extent of treatment synergy in this model suggests that combined treatment application may allow a reduction in total ocular and periocular radiation dose while maintaining excellent local tumor control.

Combining cyclosporin with chemotherapy controls intraocular retinoblastoma without requiring radiation

Chemotherapy without radiation has not controlled most intraocular retinoblastoma, perhaps because of the common high expression of multidrug resistance P-glycoprotein that we found in retinoblastoma. Cyclosporin blocks P-glycoprotein-induced efflux of vincristine and teniposide in vitro, and possibly modulates responses to carboplatin. To avoid eye irradiation in bilateral retinoblastoma patients with RB1 germline mutations, which incurs a high second malignancy rate, we added cyclosporin A to a vincristine-teniposide-carboplatin protocol and consolidated chemotherapy responses with focal therapy. We scored patients requiring irradiation, enucleation, or focal ablation of central vision as failures. In 21 study patients, the overall relapse-free rate at a median follow-up of 3.3 years was 76%, with a rate of 92% for newly diagnosed and 50% for previously treated, relapsed retinoblastoma. Our results for the most unfavorable tumors with vitreous seeds (86% at 3.5 years) are better than published success rates of irradiation for similar tumors, or irradiation with the same chemotherapy without cyclosporin (45% at 2. 6 years). These results also exceeded our historic success rate with similar chemotherapy without cyclosporin, focal therapy, and/or radiation in 19 equivalently poor-risk patients (relapse-free rate 37% at a median follow-up of 5.6 years, P = 0.032), 16 of whom were previously untreated (relapse-free rate also 37%, P = 0.012). A better outcome occurred with higher cyclosporin blood levels and projected tissue exposure. Cyclosporin did not enhance the usual chemotoxicity. This clinical study suggests that cyclosporin improves the long-term response of retinoblastoma to chemotherapy, possibly by more than one mechanism.