Porous and nonporous orbital implants for treating the anophthalmic socket: A meta-analysis of case series studies

PURPOSE

To assess the efficacy and safety of porous and nonporous implants for management of the anophthalmic socket.

METHODS

Case series meta-analysis was conducted with no language restriction, including studies from: PUBMED, EMBASE and LILACS. Study eligibility criteria were case series design with more than 20 cases reported, use of porous and/or nonporous orbital implants, anophthalmic socket and, treatment success defined as no implant exposure or extrusion. Complications rates from each included study were quantified. Proportional meta-analysis was performed on both outcomes with a random-effects model and the 95% confidential intervals were calculated.

RESULTS

A total of 35 case series studies with a total of 3,805 patients were included in the meta-analysis. There are no studies comparing porous and nonporous implants in the anophthalmic socket treatment. There was no statistically significant difference between porous polyethylene (PP) and hydroxyapatite (HA) on implant exposure: 0.026 (0.012-0.045) vs 0.054 (0.041-0.070), respectively and, neither on implant extrusion: 0.0042 (0.0008-0.010) vs. 0.018 (0.004-0.042), respectively. However, there was a significant difference supporting the use of PP when compared to bioceramic implant: 0.026 (0.012 -0.045) vs. 0.12 (0.06-0.20), respectively, on implant exposure.

CONCLUSION

PP implants showed lower chance of exposure than bioceramic implant for anophthalmic socket reconstruction, although we cannot rule out the possibility of heterogeneity bias due to the nature and level of evidence of the included studies. Clinical trials are necessary to expand the knowledge of porous and nonporous orbital implants in the anophthalmic socket management.

A Biological Tissue Adhesive and Dissolvent System for Intraocular Tumor Plaque Brachytherapy

PURPOSE

To examine a novel technique for simplified placement and removal of plaque brachytherapy by fibrin glue and urokinase (medac Gmbh, Hamburg, Germany).

MATERIALS AND METHODS

In six enucleated porcine eyes, plaques were placed on the episclera and fibrin glue was applied to cover it. Urokinase was used to dissolve the glue in three eyes and saline was used in three eyes. Adhesion strength was measured further on 15 plaques affixed to porcine eyes (glued in five with intact conjunctiva, glued in five with removed conjunctiva, and sutured in five).

RESULTS

Saline had no effect on the glue-plaque-eye complex, whereas the urokinase (0.38 mL ± 0.08 mL) easily dissolved the adhesion between the glue layer and surrounding tissues. The weight required to detach the plaques was 0.349 kg ± 0.173 kg for glued eyes with intact conjunctiva, 0.405 kg ± 0.083 kg for sutured eyes (P = .59), and 0.032 kg ± 0.004 kg for glued eyes without intact conjunctiva (P ≤ .015).

CONCLUSIONS

The usage of the biological adhesive and dissolvent system was applicable for plaque surgery in an ex vivo animal model.

Corneal Ulcer Leading to Evisceration or Enucleation in a Tertiary Eye Care Center in Thailand: Clinical and Microbiological Characteristics

BACKGROUND

Very severe corneal infection can lead to permanent visual loss, and there is still inadequate knowledge about these severe cases.

OBJECTIVE

To identify clinical and microbiological characteristics of corneal ulcers resulting in evisceration or enucleation in a tertiary eye care center in Thailand.

MATERIAL AND METHOD

A retrospective chart review was performed of all patients who required evisceration or enucleation due to corneal ulcer at Rajavithi Hospital, Bangkok, Thailand between October 2008 and September 2013.

RESULTS

One hundred patients who underwent evisceration or enucleation as a result of corneal ulcer were included in the study. The mean age of the patients was 56.5 ± 12 years, most cases were referred from other hospitals (93%), and 13% of patients were diabetic. At presentation, visual acuity was worse than 5/200 in almost all cases (98%), and trauma (66%), especially by organic substances (36%), was the most common cause. Most cases had full thickness infiltration (81%) with mean size of 6.6 ± 2 mm. Corneal perforation was found in 18% of patients at presentation, and 60% of corneal scraping cultures were positive. Bacteria were the most common pathogens (65%), leading by Pseudomonas aeruginosa (10 cases), and the most common fungus was Fusarium spp. (7 cases). Secondary glaucoma (39%) and corneal perforation (25%) were the main ocular complications. Over half of the patients (52%) needed therapeutic or tectonic surgical intervention during admission. Following evisceration (94%) or enucleation (6%), 23 cases had wound complications that required further surgical treatment. Bacterial infection was found to increase the risk of wound complications more than infection by other pathogen groups (40.9%, p = 0.013).

CONCLUSION

Despite aggressive medical and surgical treatments, very severe corneal ulcers at referral can lead to loss of an eye. Bacterial infection, especially by Pseudomonas aeruginosa, following eye trauma was the most common cause. Evisceration in bacterial corneal ulcers had greater wound complications than ulcers infected by other pathogens.

Reconstruction of large facial and orbital defects by combining free flap transfer with craniofacial prosthesis

The reconstruction of complex craniofacial and orbital defects should satisfactorily restore functional and aesthetic integrity. Autologous reconstruction of nasal, periorbital and auricular facial subunits as a whole using a locoregional or a free flap is very challenging and the results are not sometimes ideal. With advanced technologies that are currently available it is possible to plan and produce authentic facial prosthesis that can satisfactory substitute these facial subunits. We demonstrate an alternative reconstructive concept for complex craniofacial defects based on a free flap combined with a facial prosthesis for the replacement of periorbital or auricular facial subunits. This approach was used in two patients with very satisfactory results. Combination of a free flap with a facial prosthesis may become a preferable approach for the reconstruction of complex craniofacial defects. Clinical outcomes of the reconstructions may be enhanced respecting the principle of aesthetic facial subunits.

Retinal Pre-Conditioning by CD59a Knockout Protects against Light-Induced Photoreceptor Degeneration

Complement dysregulation plays a key role in the pathogenesis of age-related macular degeneration (AMD), but the specific mechanisms are incompletely understood. Complement also potentiates retinal degeneration in the murine light damage model. To test the retinal function of CD59a, a complement inhibitor, CD59a knockout (KO) mice were used for light damage (LD) experiments. Retinal degeneration and function were compared in WT versus KO mice following light damage. Gene expression changes, endoplasmic reticulum (ER) stress, and glial cell activation were also compared. At baseline, the ERG responses and rhodopsin levels were lower in CD59aKO compared to wild-type (WT) mice. Following LD, the ERG responses were better preserved in CD59aKO compared to WT mice. Correspondingly, the number of photoreceptors was higher in CD59aKO retinas than WT controls after LD. Under normal light conditions, CD59aKO mice had higher levels than WT for GFAP immunostaining in Müller cells, mRNA and protein levels of two ER-stress markers, and neurotrophic factors. The reduction in photon capture, together with the neurotrophic factor upregulation, may explain the structural and functional protection against LD in the CD59aKO.

Blood flow velocity in monocular retinoblastoma assessed by color Doppler

OBJECTIVE

To analyze the flow of retrobulbar vessels in retinoblastoma by color Doppler imaging.

METHODS

A prospective study of monocular retinoblastoma treated by enucleation between 2010 and 2014. The examination comprised fundoscopy, magnetic resonance imaging, ultrasonography and color Doppler imaging. The peak blood velocities in the central retinal artery and central retinal vein of tumor-containing eyes (tuCRAv and tuCRVv, respectively) were assessed. The velocities were compared with those for normal eyes (nlCRAv and nlCRVv) and correlated with clinical and pathological findings. Tumor dimensions in the pathological sections were compared with those in magnetic resonance imaging and ultrasonography and were correlated with tuCRAv and tuCRVv. In tumor-containing eyes, the resistivity index in the central retinal artery and the pulse index in the central retinal vein were studied in relation to all variables.

RESULTS

Eighteen patients were included. Comparisons between tuCRAv and nlCRAv and between tuCRVv and nlCRVv revealed higher velocities in tumor-containing eyes (p < 0.001 for both), with a greater effect in the central retinal artery than in the central retinal vein (p = 0.024). Magnetic resonance imaging and ultrasonography measurements were as reliable as pathology assessments (p = 0.675 and p = 0.375, respectively). A positive relationship was found between tuCRAv and the tumor volume (p = 0.027). The pulse index in the central retinal vein was lower in male patients (p = 0.017) and in eyes with optic nerve invasion (p = 0.0088).

CONCLUSIONS

TuCRAv and tuCRVv are higher in tumor-containing eyes than in normal eyes. Magnetic resonance imaging and ultrasonography measurements are reliable. The tumor volume is correlated with a higher tuCRAv and a reduced pulse in the central retinal vein is correlated with male sex and optic nerve invasion.

Linezolid therapy in a perinatal late-onset Staphylococcus aureus sepsis complicated by spondylodiscitis and endophthalmitis

We report the case of a two-month-old immunocompetent girl affected by Staphylococcus aureus sepsis complicated with pneumonia and pleural effusion, spondylodiscitis and endophthalmitis treated with linezolid. She developed a S. aureus sepsis in the neonatal period antibiotically treated with clinical resolution. Ten days after therapy discontinuation, the infant experienced a new S. aureus sepsis complicated by pneumonia with pleural effusion. Due to the presence of dorsal swelling, a pulmonary computer tomography was performed that showed a dorsal D5-D6 spondylodiscitis. Since the sepsis was scarcely responsive to several appropriate antibiotics, we finally decided to treat the patient with linezolid. A few weeks after changing antibiotics, the child underwent an ophthalmologic visit. Due to the finding of ocular lesions, imaging examinations were performed. The diagnosis was compatible with retinoblastoma, such that the eye was enucleated. Nevertheless, histological and microbiological investigations did not confirm the tumour hypothesis, but revealed a S. aureus abscess with retinal detachment. The child completed antibiotic therapy with linezolid and was visited periodically at the Infectious Disease Unit for a follow-up. She underwent progressive resolution of discitis and did not present any further flare of sepsis. Nevertheless, she still has a replacement device in her right eye and a D5-D6 severe kyphosis with spinal fusion.

Quality of life in the follow-up of uveal melanoma patients after enucleation in comparison to CyberKnife treatment

PURPOSE

To compare quality of life (QoL) in patients with uveal melanoma after enucleation and stereotactic radiosurgery to that in an age-matched patient collective.

METHODS

QoL was assessed in a cross-sectional survey and compared among 32 uveal melanoma patients after enucleation, 48 patients after stereotactic radiosurgery (CyberKnife(®); Accuray(®) Incorporated, Sunnyvale, CA, USA), and an age-matched control group of 35 patients, using the SF-12 Health Survey. Statistical analysis was performed with Fisher's exact test, Student's t test, one-way ANOVA analysis, Wilcoxon rank-sum (Mann-Whitney test), and ordered logistic regression for multivariate analysis.

RESULTS

There was no significant difference in QoL between patients treated by stereotactic radiosurgery and the age-matched control group. After enucleation, patients presented significantly lower values in Physical Functioning (PF), Role Physical (RP), and Role Emotional (RE) compared to the radiosurgery and control group. To control for the overall QoL lowering effect of visual loss, the QoL of the patients who underwent enucleation was compared with the QoL of patients suffering severe functional loss after CyberKnife radiosurgery in a subgroup analysis, which showed no statistically significant difference. The number of comorbidities had a significant impact on QoL in multivariate analysis.

CONCLUSIONS

Superior performance in PF, RP, and RE suggests that CyberKnife represents a suitable first-line therapy for uveal melanoma. In cases with painful amaurosis or vast tumor recurrence, enucleation can be performed with an acceptable QoL outcome.

Retinoblastoma: diagnosis and management--the UK perspective

In the developed world, retinoblastoma is an uncommon yet highly curable ocular malignancy of childhood affecting 40-50 children in the UK each year. The presenting signs, most commonly leukocoria and squint, should alert the primary care physician or secondary care physician to examine for the red reflex, the absence of which is an indication for urgent ophthalmology assessment. Diagnosis is made by clinical examination and staging may include bone marrow sampling, lumbar puncture and MRI scanning. CT should be avoided to reduce radiation exposure in a population of whom a proportion are at considerable risk of second malignancies. Although enucleation is necessary for many children, over recent years there has been a growing emphasis on conservative management in an attempt to reduce the need for enucleation and avoid the adverse late effects associated with external beam radiotherapy. This review will describe approaches to treatment in the UK and how the stage, laterality and position of the tumour within the eye influence treatment choices.

Evidence of multisensory plasticity: Asymmetrical medial geniculate body in people with one eye

The medial geniculate body (MGB) plays a central role in auditory processing with both efferent and afferent tracts to primary auditory cortex. People who have lost one eye early in life have enhanced sound localization, lack visual over auditory dominance and integrate auditory and visual information optimally, similar to controls, despite taking longer to localize unimodal visual stimuli. Compared to controls, people with one eye have decreased lateral geniculate nuclei (LGN) volume as expected given the 50% deafferentation of the visual system. However, LGN volume is larger than predicted contralateral to the remaining eye, indicating altered structural development likely through recruitment of deafferented LGN cells.

Purpose: the current study investigated whether structural MGB changes are also present in this group given the changes they exhibit in auditory processing.

Methods: MGB volumes were measured in adults who had undergone early unilateral eye enucleation and were compared to binocularly intact controls.

Results: unlike controls, people with one eye had a significant asymmetry with a larger left compared to right MGB, independent of eye of enucleation. MGB volume correlated positively with LGN volume in people with one eye.

Conclusions: volume asymmetry in the MGB in people with one eye may represent increased interactions between the left MGB and primary auditory cortex. This interaction could contribute to increased auditory and other left hemisphere-dominant processing, including language, as compensation for the loss of one half of visual inputs early in life. The positive correlation between MGB and LGN volume is not due to space constraints but rather indicates increased plasticity in both auditory and visual sensory systems following early eye enucleation.

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We measured MGB volume in people with one eye with high resolution MRI.

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People with one eye had significantly larger left compared to right MGB volume.

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May indicate increased interactions between left MGB and primary auditory cortex.

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Positive correlation of left MGB with LGN volume indicates cross-sensory plasticity.

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Increased left hemisphere processing may compensate for the loss of one eye.

Experimental and Numerical Determination of the Local Temperature Distribution during Phacoemulsification and Comparison of Different Surgery Situations within Enucleated Porcine Eyes

Phacoemulsification, a common treatment for cataract, is accompanied by cell damage at the corneal endothelium. Thermal exposure during treatment has been considered a reason for this damage, but a thorough experimental and theoretical assessment of the local temperature distribution inside the eye had not yet been conducted. Measurements in porcine eyes and a finite-element simulation enabled such an assessment and localized the highest temperature rise very close to the probe. The results described in this study indicate that a distance of 1 mm between the probe and the endothelium should be maintained during treatment as a safety margin, especially when fluid flow is blocked. The highest measured temperature rise with surgically reasonable system settings and unblocked fluid flow was 1.11°C. The finite-element simulation described here is able to calculate the temperature rise at the endothelium and could serve as a tool for comparing arbitrary surgical situations with respect to thermal exposure of the endothelium.

Prognostic significance of polo-like kinases in retinoblastoma: correlation with patient outcome, clinical and histopathological parameters

BACKGROUND

Retinoblastoma is evolving, but it is still a therapeutic challenge for pediatric oncologists. Polo-like kinases (PLKs) plays an important role in cell cycle events. They play a crucial role in cell proliferation which may lead to tumour formation. The objective of this study is to investigate the role of PLK1 and PLK3 proteins in human retinoblastoma tissues.

DESIGN

Non-randomized, prospective study was performed in the Dr R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

PARTICIPANTS

This study included 74 primary enucleated retinoblastoma tissues.

METHODS

Expression of PLK1 and PLK3 protein were assessed in primary enucleated retinoblastoma tissues by immunohistochemistry and western blotting.

MAIN OUTCOME MEASURES

Expression of PLK1 and PLK3 protein were correlated with clinical and histopathological parameters, tumour staging and overall survival of patients.

RESULTS

Immunohistochemical results revealed expression of PLK1 in 47/74 (63.51%) cases and PLK3 in 31/74 (41.89%) cases. Western blotting confirmed the immunoreactivity results. Expression of PLK1 showed correlation with poor differentiation and tumour invasion. In addition, PLK1 was statistically significant with massive choroidal invasion, whereas PLK3 did not correlate with any of the clinical or histopathological parameters. There was no statistical correlation in the overall survival of patients with PLK1 and PLK3 expression.

CONCLUSIONS

PLK1 expression was associated with poor tumour differentiation and histopathological high-risk factors. These proteins may be involved in tumorigenesis and progression of disease. These results suggest that PLK1 may act as a potential therapeutic target and a promising marker for developing potent small molecule inhibitors of PLK isoforms in retinoblastoma.

Multidrug resistant Fusarium keratitis

CASE REPORT

We report a case of keratitis in a female contact lens wearer, who developed a deep corneal abscess. The culture of a corneal biopsy scraping was positive for multiresistant Fusarium solani. The patient has a complicated clinical course and failed to respond to local and systemic antifungal treatment, requiring eye enucleation.

CONCLUSION

Fusarium keratitis may progress to severe endophthalmitis. Clinical suspicion is paramount in order to start antifungal therapy without delay. Therapy is complex due to the high resistance of this organism to usual antifungal drugs.

[Histological workup of enucleated eyes]

The appraisal of enucleated eyes presents a particular challenge to pathologists. In German-speaking countries, this task has mostly been in the hands of ophthalmologists. It requires particular ophthalmologic knowledge including nosology, implants, surgical procedures, and nomenclature. This CME article teaches the basics needed for pathologic appraisal of enucleated eyes. The first part focusses on the macroscopic evaluation and describes the exterior and interior of the eye. Competent interpretation of the macroscopic findings is crucial to identify adequate cutting planes for histology. Anatomic landmarks on the globe's exterior and common section planes are described. Diseases that typically lead to enucleation will be explained in detail and illustrated with images. In the second part of this article, a histologic description of eye-specific tissue types is provided.

Atypical presentation of acute-onset endophthalmitis after uncomplicated pars plana vitrectomy

A 70-year-old woman presented with signs of acute-onset endophthalmitis within 24 hours of surgery, with retinal hemorrhages and vascular changes in the absence of pain or significant inflammation. She had undergone uncomplicated 25-gauge pars plana vitrectomy for epiretinal membrane with presenting visual acuity of 20/40- and significant distortion. Vitreous culture revealed Staphylococcus epidermidis. Final visual acuity was no light perception with persistent pain, and the patient ultimately underwent enucleation. Although rarely, acute-onset postoperative endophthalmitis can present as retinal vasculitis with intraretinal hemorrhages and mild inflammation.

Histopathologic grading of anaplasia in retinoblastoma

PURPOSE

To determine whether the degree of tumor anaplasia has prognostic value by evaluating its correlation with high-risk histopathologic features and clinical outcomes in a series of retinoblastoma patients.

DESIGN

Retrospective clinicopathologic study.

METHODS

The clinical and pathologic findings in 266 patients who underwent primary enucleation for retinoblastoma were reviewed. The histologic degree of anaplasia was graded as retinocytoma, mild, moderate, or severe as defined by increasing cellular pleomorphism, number of mitoses, nuclear size, and nuclear hyperchromatism. Nuclear morphometric characteristics were measured. The clinical and pathologic data of 125 patients were compared using Kaplan-Meier estimates of survival. Fisher exact test and multivariate regression were used to analyze the association between anaplasia grade and high-risk histologic features.

RESULTS

Increasing grade of anaplasia was associated with decreased overall survival (P = .003) and increased risk of metastasis (P = .0007). Histopathologic features that were associated with anaplasia included optic nerve invasion (P < .0001), choroidal invasion (P < .0001), and anterior segment invasion (P = .04). Multivariate analysis considering high-risk histopathology and anaplasia grading as predictors of distant metastasis and death showed that high-risk histopathology was statistically significant as an independent predictor (P = .01 for metastasis, P = .03 for death) but anaplasia was not (P = .63 for metastasis, P = .30 for death). In the absence of high-risk features, however, severe anaplasia identified an additional risk for metastasis (P = .0004) and death (P = .01).

CONCLUSION

Grading of anaplasia may be a useful adjunct to standard histopathologic criteria in identifying retinoblastoma patients who do not have high-risk histologic features but still have an increased risk of metastasis and may need adjuvant therapy.

Clinical features and survival among children with retinoblastoma in Uganda

AIMS

To characterise the clinical features, treatment and outcome of children diagnosed with retinoblastoma in Uganda.

METHODS

The study comprised a 6-year nationwide enrolment with follow-up.

RESULTS

In total, 282 cases were enrolled, 26% (72) were bilateral; 6% were lost to follow-up. Almost all diagnoses in the first affected eye were International Classification of Retinoblastoma group E or worse. Histology was available for 92%; of those, 45%, had extraocular tumour at diagnosis. Enucleation of the first eye was done for 271; 94 received radiotherapy to the socket and in the last 2 years, 70 children received chemotherapy. At close of study, 139 children had died. Survival, as determined in a proportional hazards model adjusted for age, sex, laterality and treatment era (pre or post introduction of chemotherapy), varied by extent of the tumour (p<0.001); children with only intraocular involvement were 80% less likely to die (HR=0.21, 95% CI 0.12 to 0.35) compared with children with extraocular involvement.

CONCLUSIONS

Diagnostic delay results in relatively high mortality among children with retinoblastoma in Uganda. There is an urgent need for more effective treatment modalities, particularly chemotherapy, and nationwide efforts to encourage earlier access to medical care.

Hydroxyapatite ocular implant and non-integrated implants in eviscerated patients

INTRODUCTION

This study compares the outcomes and complications of hydroxyapatite ocular implant and non-integrated ocular implants following evisceration.

MATERIALS AND METHODS

This is a retrospective study of 90 patients who underwent evisceration for different ocular affections, in the Ophthalmology Department of the University Emergency Hospital Bucharest, between January 2009 and December 2013. The outcomes measured were conjunctival dehiscence, socket infection, implant exposure and extrusion rate.

RESULTS

Forty-three patients had the hydroxyapatite implant (coralline-Integrated Ocular Implants, USA or synthetic-FCI, France) and forty-seven received non-integrated ocular implants (24 acrylic and 23 silicone). Five cases of socket infection, thirteen cases of extrusion and two cases of conjunctival dehiscence were encountered.

CONCLUSIONS

There was a higher rate of conjunctival dehiscence with hydroxyapatite ocular implant, but implant extrusion and socket infection were found in non-integrated ocular implants.

Visual Field Deficits After Eye Loss: What Do Monocular Patients (Not) See?

Losing an eye presents physical and visual as well as emotional challenges to patients, but few health care providers understand the challenges of monocularity. Ocularists can play an important role in helping patients adjust, including maximizing the visual field despite prosthetics and eyeglasses and giving advice for monocular living.