The Asian lower eyelid: a comparative anatomic study using high-resolution magnetic resonance imaging

Asian upper and lower eyelids are typically characterized by a fuller appearance than the lids of whites. Inferior extension of preaponeurotic fat and brow fat into the Asian upper lid explain the upper lid fullness and its difference from the upper lid of whites. Analogous structures in the Asian lower lid may exist to explain its full appearance. High-resolution magnetic resonance imaging (MRI) of 24 normal Asian and white lower lids was performed to evaluate differences in Asian and white lower lid anatomy. Magnetic resonance images revealed two major differences. First, the orbital fat projected further anteriorly with respect to the orbital rim in all Asian lower lids studied. No analogy with the upper lid exists for this difference. Second, the orbital fat extended further superiorly, to the inferior border of tarsus, in those Asian lower lids that did not have well defined creases. This was analogous to the preaponeurotic fat location of the Asian upper lid and different from the white lower lid. The suborbicularis oculi fat in the lower lid, the analogous structure of the brow fat pad in the upper lid, was not different in location in Asian and white lower lids. Therefore, the Asian lower lid appearance is explained by the difference in orbital fat location, which is only partly analogous to the anatomical differences between the Asian and white upper lids.

Eyelid disorders: diagnosis and management

Eyelid problems range from benign, self-resolving processes to malignant, possibly metastatic, tumors. Inflammation, infection, benign and malignant tumors, and structural problems such as ectropion, entropion and blepharoptosis may occur. Fortunately, most eyelid disorders are not vision-threatening or life-threatening; however, many cause irritative symptoms such as burning, foreign-body sensation or pain. Blepharitis, or eyelid inflammation, one of the most common problems, is characterized by erythematous eyelids with accumulation of debris along the eyelid margin. Malignant eyelid tumors may be associated with lash loss and erosion of normal eyelid structures. Recognition and diagnosis of these problems are crucial to their proper management. Warm compresses and antibiotics suffice for many conditions, while excision, cryotherapy or laser treatment are required for some.

Management of a huge tumour of the humerus by total replacement of the humerus: an 11-year follow-up

A massive tumour of the humerus was replaced using a total humerus replacement. The clinical and functional outcome at 11 years remains excellent.

Brief report: assessment of body image in survivors of childhood cancer

OBJECTIVE

To establish preliminary reliability and validity data of the Body Image Instrument (BII), a 28-item self-report measure developed to assess body image in adolescents and young adults with cancer.

METHOD

As part of a larger study assessing long-term adjustment in survivors of childhood cancer, 40 males and 27 females (mean age = 19.69 years, SD = 3.87) completed the BII and two validation measures: the SF-36 health survey and the Perceived Illness Experience measure.

RESULTS

The five BII subscales--General Appearance, Body Competence, Others' Reaction to Appearance, Value of Appearance, and Body Parts--exhibited moderate to high internal reliability and concurrent validity. No significant sex differences in body image emerged, nor was age at diagnosis or time since diagnosis significantly correlated with body image.

CONCLUSIONS

The measure may be of value in clinical settings, where it could be used to identify adjustment problems related to body image disturbance in pediatric cancer patients.

Forequarter amputation for high-grade malignant tumours of the shoulder girdle

We reviewed 20 patients after forequarter amputation performed for high-grade malignant tumours of the shoulder girdle (Enneking grades IIB to III). The operations were classified as palliative or curative according to the resection margins and the presence of disseminated disease at the time of the surgery. There were five palliative and 15 curative procedures. Two patients died from unrelated causes, septicaemia and suicide. Eight died in the first two years, four of whom had had a palliative operation. Four died between two and five years after surgery, one after a palliative operation. Five patients are alive, at a mean of 89.4 months after surgery, four of whom are free from disease. The median survival after a palliative amputation was 20.6 months. Our overall five-year survival (palliative and curative cases) was 21.2%, for curative cases it was 30.2%. None of the patients use an artificial prosthesis. Despite the disfigurement which results from this operation, it still has a useful role to play in the management of high-grade malignant tumours of the upper limb.

Growth after extendible endoprosthetic replacement of the distal femur

We report our results in 24 children with malignant primary bone tumours of the distal femur treated with a Stanmore extendible endoprosthesis (SEER). This consists of a femoral component that can be lengthened, a constrained knee and an uncemented sliding tibial component which crosses the proximal tibial physeal plate perpendicularly. The average age of the patients at diagnosis was ten years and the mean follow-up was 4.7 years (2.5 to 7.9). The mean growth of the affected tibia was 76% (18 to 136) and of the fibula 83% (15 to 750) of the growth of the unaffected limb. Measurement of growth arrest lines showed that the mean growth of the proximal tibial physis on the affected side was 69% (43 to 100) of that of the normal side. The great variability in the growth of the physis cannot yet be explained.

Reconstruction of the hemipelvis after the excision of malignant tumours. Complications and functional outcome of prostheses

We treated 35 patients with primary malignant tumours of the periacetabular area by resection and prosthetic reconstruction of the defect. At a mean follow-up of 84 months, 15 patients (43%) were free from disease. The most common complications were deep infection (26%), local recurrence (24%) and recurrent dislocation of the hip (17%). The surviving patients achieved an average of 70% of their premorbid function. This method of reconstruction has a high morbidity and should be performed only at specialist centres, but the functional and oncological outcomes are satisfactory.

The cost-effectiveness of limb salvage for bone tumours

The use of endoprostheses for limb salvage in primary bone tumours is highly specialised. Studies have shown no significant difference in survival, function or quality of life between patients with limb salvage and those with amputation. We have derived a formula for calculating the ongoing costs of limb salvage with an endoprosthesis which is based on actual costs and uses historical data to show the likelihood of further surgery or revision. Comparative data for amputation are also shown. Using current prices, the cost-effectiveness of surgery with an endoprosthesis is clearly demonstrated.

Skip metastases in Ewing's sarcoma: a report of three cases

The accurate pre-operative staging of all potentially malignant tumours of bone is essential. We report three cases of Ewing's sarcoma of bone in which MR imaging identified skip metastases not visualized on either contemporary radiographs or bone scintigraphy. The implications for patient management and possible reasons for the other imaging modalities failing to reveal the skip metastases are discussed.

Growing endoprostheses for primary malignant bone tumors

Twenty years of experience with the use of growing endoprostheses for limb salvage in skeletally immature patients is reported. Alternatives for the management of primary malignant bone tumors in this group of patients are amputation, rotationplasty, and allograft or autograft reconstruction. The development of the currently used implant is charted, with commentary on the complications and difficulties which gave rise to design changes. Over this period, 123 expanding endoprostheses have been inserted in 108 patients in this institution, and the results of a series of 54 consecutive distal femoral replacements are reported. The mean functional score was 72%, and the local recurrence rate was 11%. The technique was successful in maintaining limb-length equality. We conclude that in specialized centers of orthopedic oncology that utilize an endoprosthesis with proven reliability of the expansion mechanism, the short- and long-term results of this technique justify its continued use.

The surgical treatment and outcome of pathological fractures in localised osteosarcoma

We reviewed the surgical treatment and oncological results of 40 patients with pathological fractures from localised osteosarcoma of the long bones to determine the outcome of limb salvage in their management. All had had adjuvant chemotherapy. There were 26 males and 14 females with a median age at diagnosis of 18 years (2 to 46) and a median follow-up of 55 months (8 to 175). We performed limb salvage in 27 patients and amputation in 13. The margins of resection were radical in five patients, wide in 26, marginal in six, wide but contaminated in two and intralesional in one. Local recurrence developed in 19% of those treated by limb salvage and in none of those who had an amputation. The cumulative five-year survival of all the patients was 57% and in those treated by limb salvage or amputation it was 64% and 47%, respectively (p > 0.05). Limb-sparing surgery with adequate margins of excision can be achieved in many patients with pathological fractures from primary osteosarcoma without compromising survival, but the risk of local recurrence is significant.

The outcome and functional results of diaphyseal endoprostheses after tumour excision

Improvement in the life expectancy of patients with primary bone tumours has led to increased emphasis on limb salvage and preservation of function. Between 1979 and 1994 we used custom-made endoprostheses in 18 patients to reconstruct diaphyseal defects after excision of primary bone tumours. The mean age at operation was 26 years (9 to 64) and the median follow-up 65 months (6 to 188). Fifteen patients have survived and are free from local or metastatic disease. Local recurrence developed in one patient. Using the modified Enneking functional scoring system, 77% of the patients achieved 80% or more of their premorbid functional capability. Mechanical loosening, limb shortening and secondary osteoarthritis were the main complications. There were no infections. We conclude that diaphyseal endoprostheses offer a good clinical and functional outcome in the lower limb.

The total cost of hip-joint replacement; a model for purchasers

A computer-based model is used to investigate the total cost of primary total hip-joint replacement. The model takes into account the probability of prosthesis failure, death and re-revision. The results emphasize the importance of age at insertion, demonstrating that the expected life-span of the patient has a major influence on the total cost for a given prosthesis. The discussion considers the idea of a 'lifetime care package' to encapsulate the concept of quality when considering the purchasing of total hip replacements. If it is assumed that a primary replacement episode costs 3500 pounds and revision surgery costs twice as much, then the additional premium on the best implant currently available would be 630 pounds. The premium payable on the same patient using the worst design would be 3080 pounds. This difference reflects the importance of quality in total hip replacement surgery.

Silicone frontalis slings for the correction of blepharoptosis: indications and efficacy

PURPOSE

To determine the efficacy of silicone rod frontalis sling ptosis repair in selected patients.

METHODS

The authors retrospectively studied 35 consecutive patients who underwent silicone sling ptosis repairs in 6 lids at the University of California, San Francisco.

RESULTS

Preoperative diagnoses included congenital ptosis causing developmental delay or possible amblyopia in children younger than 3 years of age, chronic progressive external ophthalmoplegia, third-nerve palsy, myasthenia gravis, and ocular restriction secondary to glaucoma filtering valves. With a mean follow-up of 22 months, good-to excellent final lid height was achieved in all 61 lids. Recurrence of the ptosis occurred in four lids (7%), requiring replacement of the silicone rod in two lids and revision of the original sling in two lids to reach the final lid height. Chronic exposure keratopathy without corneal infection occurred postoperatively in 9 (15%) of 61 eyes, all in patients with an inadequate or absent Bell phenomenon. Chronic corneal problems did not develop in any of the children. Extrusion of the sling with or without infection occurred in three foreheads (5%) in two patients younger than 15 years of age.

CONCLUSION

Silicone rod is an effective material for use in frontalis suspension in treating severe ptosis with poor levator function. Children younger than 3 years of age with congenital ptosis and developmental delay or possible amblyopia can undergo silicone frontalis suspension to achieve good visual results. The elasticity and ease of adjustment of the silicone rod are ideal characteristics for a suspensory material used to correct severe ptosis associated with a minimal or absent Bell phenomenon, such as in chronic progressive external ophthalmoplegia, myasthenia gravis, or third-nerve palsy.

Treatment of facial palsies with external eyelid weights

PURPOSE

Because ocular exposure is a major complication of facial paralysis, an external gold eyelid load weight was evaluated for effectiveness in the treatment of this problem.

METHODS

We prospectively studied 12 patients with unilateral facial paralysis who were treated with the external eyelid weights. Follow-up examinations included corneal exposure, amount of artificial tear usage, patient comfort, and complications associated with the weights. Treatment end points were the patient's decision to undergo a canthoplasty or placement of an implanted weight or resolution of the facial paresis to better than House's grade IV/VI.

RESULTS

Of the 12 patients studied, ten had decreased corneal exposure on the affected side, with a coincident decrease in artificial tear drop use and increased comfort. One patient had no improvement in a corneal defect, and one was unable to apply the weight. Five patients had some difficulty in positioning the weight, which was related to upper eyelid dermatochalasis in four of the five. Only two weights were lost in over two years of total wearing time.

CONCLUSIONS

External eyelid weights are useful in the treatment of ocular exposure associated with facial paralysis. The weights decreased corneal exposure, decreased reliance on artificial tear drops, and increased patient comfort. The weights were helpful as a trial before implantation of eyelid weights and as a longer-term treatment for ocular exposure in patients with temporary facial paralysis. Loose upper eyelid skin may limit their usefulness in some patients.

Assessment of cocaine-like discriminative stimulus effects of dopamine D3 receptor ligands

The highly selective dopamine D3 receptor ligand, (+)-PD 128907 4aR10bR-(+)-trans-3,4,4a,10b-tetrahydro-4-n-propyl-2H5H[4,3- b]-1,4- oxazin-9-ol), and other dopamine D3 receptor ligands, (+/-)-7-hydroxy-2-(N,N-di-n-propylamino)tetralin and (+)-7-hydroxy-2-(N,N-di-n-propylamino)tetralin, substituted for the discriminative stimulus effects of cocaine in rats, an animal model of subjective effects in humans. Substitution only occurred at doses that markedly decreased responding. These results suggest that dopamine D3 receptors may be involved in the subjective effects of cocaine, and therefore may be a target for the discovery of treatments for cocaine dependence.

Macular changes in pseudotumor cerebri before and after optic nerve sheath fenestration

PURPOSES

Macular abnormalities such as chorioretinal striae, pigmentary disturbances, exudates, and subretinal hemorrhage or scar can occur in patients with pseudotumor cerebri. The purpose of this study is to determine the potential resolution of the macular abnormalities after optic nerve sheath fenestration, as well as the visual significance of these changes.

METHODS

The authors retrospectively compared the preoperative and postoperative examinations of seven patients with pseudotumor cerebri-associated macular changes who underwent unilateral optic nerve sheath fenestration.

RESULTS

Preoperatively, visual acuity was worse than 20/25 in two patients with macular exudates and in one with a subretinal scar. Chorioretinal striae and pigment mottling did not appear to decrease visual acuity. With a mean postoperative follow-up of 14 months, the patients with exudates had improvement in visual acuity and clearing of the exudates, unlike the patient with the subretinal scar. Chorioretinal striae, pigment mottling, and the subretinal scar did not resolve with surgery.

CONCLUSIONS

This study suggests that chorioretinal striae and pigment mottling in the setting of pseudotumor cerebri, unlike exudates and subretinal scars, do not have a significant effect on visual acuity. After optic nerve sheath fenestration, only macular exudates decreased. Therefore, the persistence of striae, pigment mottling, and macular scars, in the face of resolved papilledema and improved visual fields, does not indicate failure of the optic nerve sheath fenestration.

Paediatric surgical oncology. 3--Bone tumours

Bone tumours are rare--they represent less than 1% of all malignancies but about 6% in the paediatric population. Early diagnosis, chemotherapy and limb salvage surgery can result in 60% cure rates with a near normal functional outcome. Surgery plays a major part in the management of these tumours, and is technologically as well as surgically exacting.

Purification and active-site characterization of equine plasma amine oxidase

An improved purification scheme for an amine oxidase from equine plasma (EPAO), a nonruminant source, is described and the protein's active-site is characterized. EPAO is dimeric and contains one Type-2 Cu(II) ion per monomer. The EPAO Cu(II) site is spectroscopically very similar to the Cu(II) sites in other amine oxidases. Unlike the extensively investigated nonruminant amine oxidase from porcine plasma, EPAO does not display half-of-the-sites reactivity; titrations with p-nitrophenylhydrazine and phenylhydrazine indicate two active cofactors per dimer. This cofactor is determined to be the same as that of other copper-containing amine oxidases, 6-hydroxydopa quinone (topa quinone). Upon anaerobic reduction with substrate at ambient temperature, the EPR spectrum of EPAO exhibits a sharp signal at g congruent to 2, attributable to the topa semiquinone. Equine plasma amine oxidase possesses novel in vitro substrate specificity; while other mammalian amine oxidases oxidize norepinephrine only slowly or not at all, EPAO displays significant activity toward this biogenic amine.