Quality of life of eye amputated patients

Postoperative Pain Following Eye Enucleation: A Prospective Observational Study

Background and Objectives: Enucleation of an eye is the most invasive procedure in ophthalmologic surgery. It can be the result of various diseases (malignant/chronic/trauma/infection) and is nevertheless relatively rare, but leads to the loss of a strongly innervated neuronal organ. This study systematically evaluates postoperative pain levels following enucleation of the eye globe. Materials and Methods: This prospective single-center study enrolled twenty-four patients undergoing enucleation of the eye globe. Perioperatively all patients completed (preoperative day, day of surgery, 1st, 2nd, and 3rd day following surgery) standardized questionnaires concerning their pain experience and treatment-related side-effects (internal protocol, QUIPS, painDETECT®). Patients received usual pain therapy in an unstandardized individual manner. Results: Preoperatively, mean average pain intensity of all included patients was 3.29 ± 2.46 (range, 0-8), 3.29 ± 3.24 (range, 0-8) on the day of surgery, 4.67 ± 1.90 (range, 2-10) on day 1, 3.25 ± 1.39 (range, 1-6) on day 2, and 2.71 ± 1.30 (range, 1-6) on day 3 after surgery. Mean maximum pain intensity was 4.71 ± 3.28 (range, 0-10) preoperatively, 4.04 ± 3.78 (range, 0-10) on the day of surgery, 5.75 ± 2.01 (range, 2-10) on day 1, 4.25 ± 1.89 (range, 2-10) on day 2, and 3.88 ± 1.54 (range, 2-8) on day 3 after surgery. Nineteen patients (79.2%) stated that they would have preferred more pain therapy. Conclusions: Patients undergoing eye enucleation report pain sensations in need of intervention in this university hospital. Thus, effective standardized pain treatment concepts are now a high priority to be established in an interdisciplinary manner containing standardized regimens and continuous regional procedures. Awareness of this problem in the medical team should be sharpened through targeted training and information.

Prevalence, temporal course and risk factors for phantom eye symptoms in uveal melanoma

BACKGROUND

Phantom eye symptoms (PES), particularly phantom visual sensations (PVS) and phantom eye pain (PEP), are common in enucleated patients and can lead to psychological distress. Current cross-sectional studies cannot examine the temporal course of symptoms, nor can they identify dynamic risk factors or consequences of PES.

METHODS

Cohort study of 105 enucleated uveal melanoma patients returning self-report questionnaires, within 4 weeks of diagnosis and 6-, 12- and 24-months post-treatment. Questionnaires measuring PVS and PEP symptoms in the week prior to completion, pain severity, Hospital Anxiety and Depression Scale scores and the Functional Assessment of Cancer Therapy scale (FACT-G) measuring quality of life.

RESULTS

PVS and PEP emerged after 6 months, were relatively stable over the study and did not remit. PVS showed 6-, 12- and 24-month prevalence rates of 44.6%, 48.2% and 30.2%, and PEP 16.1%, 18.4% and 17.5% respectively. PVS were generally elementary, with only 10-15% of the total cohort experiencing complex sensations. PEP was generally neither prolonged nor intense, except in a small proportion. PVS and PEP were showed moderate associations but did not predict each other prospectively. Anxiety within 4 weeks of diagnosis was a risk factor for the initiation of PEP. Neither PVS nor PEP prospectively predicted anxiety, depression or quality of life.

CONCLUSIONS

PES were prevalent and non-remitting, beginning within 6 months of enucleation. PVS and PEP may not represent symptoms of a coherent syndrome. We discuss findings with reference to theories of phantom sensations, and directions for clinical practise and research.

Primary cemiplimab treatment for orbital squamous cell carcinoma is effective and may alleviate the need for orbital exenteration

PURPOSE

To evaluate the effectiveness of cemiplimab, a Programmed-cell-death-1(PD-1) protein inhibitor, for the treatment of cutaneous periocular-locally-advanced squamous-cell-carcinoma (POLA-SCC) with orbital-invasion.

METHODS

Multicentre real-world retrospective study. Demographic and clinical data were collected and analysed for patients with biopsy-proven POLA-SCC(AJCC-T4) with orbital-invasion who were treated with cemiplimab at one of four tertiary medical centres in 2019-2022.

RESULTS

The cohort included 13 patients, 8 males and 5 females, of median age 76 years (IQR65-86). The median duration of treatment was 5.0months (IQR3.5-10.5) and the median follow-up time, 15.0 months (IQR10.5-30). The overall response rate was 69.2%. Complete response was documented in seven patients (53.8%), partial response in two (15.4%), stable disease in one (7.7%), and progressive disease in two (15.4%); in one patient (7.7%), response was not evaluable. Six complete responders (46.1% of the cohort) received no further treatment and did not have a recurrence during an average follow-up of 6.14 (±6.9) months from treatment cessation. None of the patients underwent orbital-exenteration. The majority of adverse events were mild (grade-1), except for a moderate increase in creatinine level (grade-2), severe bullous dermatitis (grade-3), and myocarditis (grade-5) in one patient each. Four patients (30.7%) died during the follow-up period, all of whom had an Eastern-Cooperative-Oncology-Group score of 4 at presentation.

CONCLUSIONS

To our knowledge, this is the largest study to date on cemiplimab therapy for cutaneous POLA-SCC with orbital-invasion. Treatment was shown to be effective, with an overall response rate of 69.2%. Cemiplimab holds promise for the treatment of patients with tumours invading the orbit as it may alleviate the need for orbital exenteration.

Mapping prognostic factors for globe survival in panophthalmitis using logistic regression and Cox proportional hazard models: A retrospective study

Purpose

The aim of this study was to report the outcomes of panophthalmitis and to identify factors significantly affecting globe survival in the disease.

Methods

This was a retrospective study on patients with panophthalmitis in a tertiary hospital between January 1, 2017, and December 31, 2019. The demographics, treatment details, culture results, and final outcomes were recorded. Logistic regression and Cox proportional hazards (CPH) were calculated to identify variables associated with globe loss. A P < 0.05 was considered significant.

Results

Eighty-five eyes of 85 patients (31 culture positive) were eligible for review. The mean age of the participants was 55.21 ± 20.17 years with a male-to-female ratio of 2.04:1. Corneal ulcer (38.82%; n = 33) and open globe injuries (OGIs) (38.82%; n = 33) were the most common etiologies. Pseudomonas aeruginosa (n = 10; 11.76%) was the most common isolate. The mean duration of hospital stay was 7.58 ± 2.32 days. Overall, 44 (51.76%) globes could be salvaged. The need for evisceration (P = 0.901) and hospital stays (P = 0.095) were similar for culture-positive and -negative cohorts. The unadjusted logistic regression and CPH models showed that culture sterility did not affect globe survival [OR = 1.210 (0.501-2.950), P = 0.668; HR = 1.176 (0.617-2.243), P = 0.623]. The adjusted logistic regression and the CPH models showed that corneal ulcers [OR = 10.900 (2.460-48.200), P = 0.002; HR = 5.393 (1.603-18.140), P = 0.006] and OGI [OR = 7.360 (1.650-32.700), P = 0.009; HR = 4.548 (1.321-15.660), P = 0.016] were significantly associated with globe loss.

Conclusion

Corneal ulcer or OGI as the primary etiology is detrimental to globe survival in panophthalmitis.

Quality of life in patients treated for COVID-19-associated mucormycosis at a tertiary care hospital

OBJECTIVES

Coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM) has emerged as a formidable infection in patients with COVID-19. The aggressive management of CAM affects quality of life (QOL); thus, this study was designed to assess the QOL in patients with CAM at a tertiary healthcare institution.

METHODS

This cross-sectional study of 57 patients with CAM was conducted over 6 months using a semi-structured standard questionnaire (the abbreviated World Health Organization Quality of Life questionnaire [WHO-BREF]) and a self-rated improvement (SRI) scale ranging from 0 to 9. Cut-off values of ≤52 and <7 were considered to indicate poor QOL and poor improvement, respectively. The correlations of QOL and SRI scores were evaluated using Spearman rho values.

RESULTS

In total, 27 patients (47.4%; 95% confidence interval [CI], 34.9%-60.1%) and 26 patients (45.6%; 95% CI, 33.4%-58.4%) had poor QOL and poor SRI scores, respectively. The overall median (interquartile range) QOL score was 52 (41-63). Headache (adjusted B, -12.3), localized facial puffiness (adjusted B , -16.4), facial discoloration (adjusted B, -23.4), loosening of teeth (adjusted B, -18.7), and facial palsy (adjusted B, -38.5) wer e significantly associated with the QOL score in patients with CAM.

CONCLUSION

Approximately 1 in 2 patients with CAM had poor QOL and poor improvement. Various CAM symptoms were associated with QOL in these patients. Early recognition is the key to optimal treatment, improved outcomes, and improved QOL in patients with CAM.

Epidemiology and survival outcomes of patients with orbital region non-cutaneous squamous cell carcinoma: a population-based analysis

Background

Non-cutaneous squamous cell carcinoma (ncSCC) of the orbital region is very rare. Thus, its epidemiological characteristics and prognosis are poorly understood. The aim of the study was to assess the epidemiological characteristics and survival outcomes of ncSCC of the orbital region.

Methods

Incidence and demographic data on ncSCC of the orbital region were extracted from the Surveillance, Epidemiology, and End Results (SEER) database and analyzed. The chi-square test was used to calculate the differences between groups. Univariate and multivariate Cox regression analyses were performed to determine the independent prognostic factors for disease-specific survival (DSS) and overall survival (OS).

Results

The overall incidence of ncSCC in the orbital region from 1975 to 2019 was 0.68/1,000,000, and the incidence showed an increasing trend during this period. A total of 1,265 patients with ncSCC of the orbital region (mean age, 65.3 years) were identified in the SEER database. Of these, 65.1% were aged ≥60 years, 87.4% were White, and 73.5% were male. The conjunctiva (74.5%) was the most common primary site, followed by the orbit (12.1%), lacrimal apparatus (10.8%), and overlapping lesion of the eye and adnexa (2.7%). Multivariate Cox regression analysis revealed that age, primary site, SEER summary stage, and surgery were independent prognostic factors for DSS, whereas age, sex, marital status, primary site, SEER summary stage, and surgery were independent prognostic factors for OS.

Conclusions

The incidence of ncSCC in the orbital region has increased over the past 40 years. It usually affects White people, men, and people aged ≥60 years, and its most common site is the conjunctiva. Orbital SCC has worse survival outcomes than SCC of other sites in the orbital region. Surgery is the independent protective treatment for ncSCC of the orbital region.

Psychosocial factors among patients undergoing orbital exenteration

CLINICAL RELEVANCE

Patients undergoing exenteration have significant anxiety and depression, and lower quality of life that worsens after surgery. Therefore, counselling by an eye health-care provider along with the team of psychologist and psychiatrist could be provided pre-operatively to assess baseline psychosocial status and be continued post-operatively to look for any deterioration.

BACKGROUND

Orbital exenteration comes with psychological trauma of disfigurement of face. The study aimed to evaluate the quality of life, anxiety and depression in patients undergoing orbital exenteration, before and after the procedure; and also compared the same with patients previously rehabilitated by spectacle-mounted prosthesis after exenteration.

METHODS

It was a prospective cohort study. Group I included patients who were planned to undergo orbital exenteration, and group II were those already using spectacle-mounted prosthesis post orbital exenteration for at least 3 months. Level of depression was assessed using Patient Health Questionnaire-9(PHQ-9), anxiety using Generalised Anxiety and Depression scale-7(GAD-7), and quality of life was assessed using Functional Assessment of Cancer Therapy- General (FACT-G) score.

RESULTS

A total of 19 patients were recruited in group I and 10 patients in group II. The baseline demographic factors were comparable. The scores for PHQ-9 and GAD-7 were significantly higher at 3-month post-exenteration follow-up, indicating significantly higher levels of anxiety and depression after orbital exenteration in group I. Both these scores were significantly lower in group II compared to group I (3 months follow-up), indicating lower levels of anxiety and depression after rehabilitation with prosthesis. The FACT-G and its subscores were all significantly higher in group II patients compared to post-operative scores of group I patients, indicating higher overall quality of life after rehabilitation with prosthesis.

CONCLUSIONS

Patients undergoing exenteration have a significant level of anxiety and depression, and lower quality of life that worsens after orbital exenteration.

Motility of the Ocular Prosthesis in Anophthalmic Patients: Objective and Patient-perceived Findings

AIM

To study the impact of the prosthesis motility on the Quality of Life (QoL) in anophthalmic patients.

METHODS

Cross-sectional, observational study of 100 anophthalmic patients, of whom 64% had an acryl implant, 6% an Allen implant, 1% a hydroxyapatite implant, 4% a dermis fat graft, 16% no implant, and 9% an unknown implant. We quantitatively assessed the motility of the prosthesis with Kestenbaum glasses and the QoL with a validated questionnaire covering five domains: General functional abilities and care, wearing comfort, physical appearance, psychological and social functioning. Associations between measured prosthetic eye motility, patient-perceived motility, and satisfaction were made.

RESULTS

Motility of the prosthesis was impaired with an average loss of 76%, and correlated with Cosmetic satisfaction (adduction P = .02, abduction P = .008, elevation P = .04) and Social satisfaction (adduction P = .03, abduction P = .003). The patient-perceived motility of the prosthesis correlated with General functioning abilities (horizontal P = .0004, vertical P = .0004), Comfort (horizontal P = .001, vertical P = .003), Cosmetic satisfaction (horizontal P = .0002, vertical P = .0002), Psychological satisfaction (horizontal P = .001, vertical P = .001), and Social satisfaction (horizontal P = .002, vertical P = .003).

CONCLUSIONS

Ocular prosthetic motility has a significant impact on patient-perceived satisfaction and physical appearance, and predicts coping with the prosthetic condition on the psychosocial level. This highlights the need of introducing patient-reported outcome measures in the prosthetic rehabilitation of the anophthalmic patient.

Demography, Clinical Settings and Outcomes in Evisceration with Implant: An Electronic Medical Records Driven Analytics of 2071 Cases

PURPOSE

To describe the demography, clinical settings and outcomes in 2071 patients undergoing evisceration across a multi-tier ophthalmology hospital network and comparison of results with the global scenario of clinical settings for evisceration.

METHODS

An analysis of 2071 patients undergoing evisceration and implant between 2013 and 2019.

RESULTS

The mean age at surgery was 39 ± 22 years. Children constituted 303(15%) of the cases. The four leading indications for surgery included painful blind eye in 760(37%), phthisis bulbi in 552(27%), staphyloma in 215(10%) and open globe injury in 195(9%) patients. The clinical settings encountered were trauma in 852(41%), ocular infection in 714(34%), glaucoma in 198(10%), post ocular surgery in 146(7%), congenital in 95(5%) and uveitis in 21(1%). Trauma and infection remained the commonest clinical settings in the urban (843,75%), rural (622,77%) and metropolitan (101,71%) areas. Decade wise distribution suggested trauma to be the commonest clinical setting in the first 4 decades and infection in the next 6 decades. The mean follow-up period was 351 ± 386 days (median 194). While trauma remained one of the commonest clinical setting in both the developed and the developing economies, painful blind eye and intractable glaucoma were other common clinical settings in the developed economies and infection was one of the leading clinical setting in the developing economies.

CONCLUSION

Most patients undergoing evisceration are young. The commonest indications for surgery include painful blind eye and phthisis bulbi. Trauma and infection remain the commonest clinical settings for evisceration in developed and developing economies.

Quality of life associated with no light perception vision

OBJECTIVE

Time trade-off (TTO) utility analysis quantifies the quality of life associated with best-seeing-eye (BSE) vision. We compared the patient quality of life associated with unilateral and bilateral no light perception (NLP) with that of a control cohort without NLP.

DESIGN

Cross-sectional interviews using a validated, reliable TTO vision utility analysis instrument.

PARTICIPANTS

A total of 1598 consecutive ophthalmology patients from the authors' practices.

METHODS

Patient records were reviewed in a case-control fashion The utilities of participants with unilateral or bilateral NLP vision were compared with those from patients without NLP vision.

RESULTS

Among 99 NLP patients, 93 (94%) had unilateral NLP and 6 (6%) had bilateral NLP, for a total of 105 NLP eyes. Multiple regression analysis demonstrated the highest correlation between utility and BSE acuity (p = 0.001), with no correlation with age, ophthalmic disease, time of vision loss, race, or education. Mean unilateral NLP utility ranged from 0.55 in the counting fingers to light perception subcohort to 0.80 in the 20/20-20/25 subcohort. The 6-person bilateral NLP subcohort had a 0.54 utility. The 99-patient NLP cohort mean utility was 0.69, a 55% quality-of-life decrease versus a BSE vision-matched 0.80 in 1499 non-NLP patients (p < 0.001).

CONCLUSIONS

TTO utility in unilateral NLP patients correlated with BSE vision at a lower utility than in patients with matched BSE vision without fellow-eye NLP. Decreased unilateral NLP patient quality of life should be considered in cost-utility analysis and clinical management. Bilateral NLP patient utility (0.54) was slightly less than that (0.55) in blind unilateral NLP patients with fellow-eye counting fingers to light perception vision, suggesting that more study is needed.

The Ruptured Globe, Sympathetic Ophthalmia, and the 14-Day Rule

PURPOSE

Prophylactic enucleation of a ruptured globe with no light perception within 14 days of injury to prevent sympathetic ophthalmia (SO) has been an established dictum in academic teaching for more than 100 years. This treatment strategy was originally based on observation, speculation, and careful thought, but there was never any scientific proof. This review summarizes and updates the current state of our knowledge about globe rupture and SO, examines the origin and validity of the 14-day rule, and emphasizes the importance of trying to save the traumatized eye whenever possible.

METHODS

A comprehensive literature review of SO and globe rupture was performed.

RESULTS

SO is a rare disorder that may potentially occur following traumatic globe rupture as well as following a variety of other intraocular surgeries. Vitreoretinal surgery may be a more common cause than trauma according to some studies. SO may still occur despite having the eye removed within 14 days of the trauma. A variety of new medications including biologic agents are now available to treat SO with improved efficacy in suppressing the associated ocular inflammation and allowing retention of some useful vision. Removing the traumatized, blind eye may have other important psychological consequences associated with it that require consideration before eye removal is carried out. Retaining the blind, phthisical, disfigured eye avoids phantom vision and phantom pain associated with enucleation as well as providing a good platform to support and move an overlying prosthetic eye. Data on the occurrence of SO following evisceration and enucleation with and without predisposing factors confirms the exceedingly low risk.

CONCLUSION

Most civilian open globe injuries can be successfully repaired with modern, advanced microsurgical techniques currently available. Because of the exceedingly low risk of SO, even with the severity of open globe trauma during military conflicts being more devastating as a result of the blast and explosive injuries, today every attempt is made to primarily close the eye rather than primarily enucleate it, providing there is enough viable tissue to repair. The 14-day rule for eye removal after severe globe ruptures is not scientifically supported and does not always protect against SO, but the safe time period for prophylactic eye removal is not definitively known. In the exceptional cases where SO does occur, several new medications are now available that may help treat SO. We advocate saving the ruptured globe whenever possible and avoiding prophylactic enucleation to prevent the rare occurrence of SO. When an eye requires removal, evisceration is an acceptable alternative to enucleation in cases that do not harbor intraocular malignancy.

Health related quality of life of patients treated with bilateral enucleation for retinoblastoma

PURPOSE

Bilateral enucleation is rarely used to manage retinoblastoma (Rb). We present the health-related quality of life (HQL) and the associated factors among individuals who underwent bilateral surgical enucleation for retinoblastoma.

METHODS

Patients were interviewed via telephone in January 2020. A retinoblastoma registry was used to select patients who underwent bilateral enucleation/exenteration during 33 years. Data included age, gender, literacy, occupation, marital status, and health issues. Patients were asked eight questions on HQL. The responses were graded as 0-10. The percentage proportion of the HQL score was correlated to the determinants.

RESULTS

Twenty-one out of 24 participants were interviewed (median age, 23 years). Fourteen participants answered the HQL question themselves, and for 7, their parents answered. Twenty patients (95%) had an ocular prosthesis. The median HQL score was 58 (out of a maximum score of 80) (interquartile range (IQR): 49; 70; minimum, 0 and maximum, 74). The HQL score was positively correlated to: self-reporting than parents reporting (Mann Whitney U (MW) p = 0.05); among students versus individuals in other occupations (MW p = 0.03); interval between eye removal and interview (p = 0.02). Age at enucleation of the second eye (p = 0.001), students (p < 0.001), and self-responders (p < 0.001) were independent predictors of a high HQL score.

CONCLUSIONS

HQL of individuals having bilateral eye enucleation for retinoblastoma was reasonably good and positively correlated to self-reporting, learning as students to cope and age at 2nd eye removal. Anaplasty services to improve cosmetics seem to benefit such disabled persons.

Phantom eye pain: a multicentric study in 100 patients

PURPOSE

Phantom eye syndrome (PES) is an underestimated complication of eye amputation (EA) characterized by phantom eye pain (PEP), phantom visions and/or phantom sensations. The aim of this study was to assess PEP prevalence, features, risk factors, social and psychological consequences and associated quality of life.

METHODS

A questionnaire study was conducted in three oculoplastic departments between April 2016 and July 2017. Patients >18 years who had undergone EA ≥3 months earlier were included and asked to complete a prestamped questionnaire. Patient's characteristics, preoperative, surgical and postoperative data were collected.

RESULTS

Of the 185 questionnaires given, 115 (62%) were returned for analysis. Hundred patients with a mean age of 65.1 years (29-92; SD = 13.0) were included. Eye amputation (EA) indications were uveal melanoma (n = 24, 24%), trauma (n = 20, 20%), retinal detachment (n = 20, 20%), glaucoma (n = 14, 14%) and endophthalmitis (n = 12, 12%). Forty-seven (47%), 30 (30%) and 38 (38%) patients experienced PEP, phantom visions and phantom sensations, respectively. Anxiety and depression [Hospital Anxiety Depression scale (HADS) score ≥8 for both] were diagnosed in 34 (34%) and 42 (42%) patients, respectively. The mean EQ-5D-3L and EQ-5D visual analogue scale scores were 0.8 (0.06-1; SD = 0.2) and 68 (0-100; SD = 22), respectively. Preoperative eye pain (p = 0.031), glaucoma (p = 0.027), postoperative anxiety with HADS score ≥8 (p = 0.012) and ≥11 (p = 0.014), aesthetic discomfort (p = 0.002) and EQ-5D-3L score <0.8 (p < 0.001) were significantly associated with PEP in the univariate analysis. In the multivariate analysis, only anxiety (HADS score ≥8) was significantly associated with PEP (p = 0.009).

CONCLUSION

Phantom eye pain (PEP) is a common complication of EA strongly associated with postoperative anxiety.

Vismodegib for Preservation of Visual Function in Patients with Advanced Periocular Basal Cell Carcinoma: The VISORB Trial

Background

Basal cell carcinoma (BCC) is a common skin cancer often curable by excision; however, for patients with BCC around the eye, excision places visual organs and function at risk. In this article, we test the hypothesis that use of the hedgehog inhibitor vismodegib will improve vision‐related outcomes in patients with orbital and extensive periocular BCC (opBCC).

Materials and Methods

In this open‐label, nonrandomized phase IV trial, we enrolled patients with globe‐ and lacrimal drainage system–threatening opBCC. To assess visual function in the context of invasive periorbital and lacrimal disease, we used a novel Visual Assessment Weighted Score (VAWS) in addition to standard ophthalmic exams. Primary endpoint was VAWS with a score of 21/50 (or greater) considered successful, signifying globe preservation. Tumor response was evaluated using RECIST v1.1. Surgical specimens were examined histologically by dermatopathologists.

Results

In 34 patients with opBCC, mean VAWS was 44/50 at baseline, 46/50 at 3 months, and 47/50 at 12 months or postsurgery. In total, 100% of patients maintained successful VAWS outcome at study endpoint. Compared with baseline, 3% (95% confidence interval [CI], 0.1–15.3) experienced major score decline (5+ points), 14.7% (95% CI, 5 to 31.1) experienced a minor decline (2–4 points), and 79.4% experienced a stable or improved score (95% CI, 62.1–91.3). A total of 56% (19) of patients demonstrated complete tumor regression by physical examination, and 47% (16) had complete regression by MRI/CT. A total of 79.4% (27) of patients underwent surgery, of which 67% (18) had no histologic evidence of disease, 22% (6) had residual disease with clear margins, and 11% (3) had residual disease extending to margins.

Conclusion

Vismodegib treatment, primary or neoadjuvant, preserves globe and visual function in patients with opBCC. Clinical trail identification number.NCT02436408.

Implications for Practice

Use of the antihedgehog inhibitor vismodegib resulted in preservation of end‐organ function, specifically with regard to preservation of the eye and lacrimal apparatus when treating extensive periocular basal cell carcinoma. Vismodegib as a neoadjuvant also maximized clinical benefit while minimizing toxic side effects. This is the first prospective clinical trial to demonstrate efficacy of neoadjuvant antihedgehog therapy for locally advanced periocular basal cell carcinoma, and the first such trial to demonstrate end‐organ preservation.

This article reports the results of a prospective clinical trial of vismodegib for patients with basal cell carcinoma occurring in the orbital and periocular regions to assess whether such treatment helps to preserve visual organs and function.

Phantom vision after eye removal: prevalence, features and related risk factors

AIM

Phantom eye syndrome is a poorly understood and underestimated complication of eye removal (ER). Seeing with the amputated eye, referred to as phantom vision (PV), is undoubtedly the most intriguing and confusing complication experienced by anophthalmic patients. The aim of the study was to assess PV prevalence, clinical features and risk factors after ER.

METHODS

A multicentric questionnaire-based study was conducted between April 2016 and July 2017. Patients >18 years who underwent ER >3 months ago had a socket examination before inclusion. Data recorded included patients' demographics, and preoperative, surgical and postoperative features.

RESULTS

One hundred patients (53 men) with a mean age of 65.1 years (29-92; SD=13.0) were included. ER indications were: uveal melanoma (n=24, 24%), trauma (n=20, 20%), retinal detachment (n=20, 20%), glaucoma (n=14, 14%) and endophthalmitis (n=12, 12%). Thirty (30%) patients experienced PV. Elementary and complex visual hallucinations were experienced by 80% and 20% of patients, respectively. PV usually appeared within the first postoperative month and tended to decrease over time. Risk factors for PV were the preoperative use of proton beam therapy (p=0.006), uveal melanoma (p=0.014), enucleation (p=0.015), anxiety with a Hospital and Anxiety Depression (HAD) score ≥8 (p=0.042), depression with a HAD score ≥8 (p=0.030), phantom eye pain (p=0.044) and phantom eye sensations (p=0.002).

CONCLUSION

PV was reported by one-third of our patients. Despite being widely misunderstood, ophthalmologists and neurologists should be aware of this complication to adequately reassure patients.

The Impact of an Ocular Prosthesis on the Quality of Life, Perceived Stress, and Clinical Adaptation of Anophthalmic Patients: A Clinical and Longitudinal Trial

PURPOSE

This prospective study evaluated and correlated the impact of ocular prostheses on quality of life and stress with socioeconomic level and clinical characteristics. The clinical difficulties and perceptions of patients after ocular rehabilitation were evaluated.

MATERIALS AND METHODS

Anophthalmic patients (at least 18 years of age) who were not users of ocular prostheses were recruited. The Medical Outcomes Short-Form Health Survey (SF-36) and Perceived Stress Scale (PSS-10) questionnaires were administered before and after 3 and 6 months of prosthesis installation. Clinical characteristics, difficulties, and perceptions were evaluated by quantitative and descriptive analysis (7 days, 3 months, 6 months). Data were analyzed by the Friedman test and Pearson Correlation test (α = 0.05).

RESULTS

The final sample consisted of 26 patients. Quality of life showed improvement in the "Bodily Pain" and "General Health" domains. Wearing the prosthesis did not influence perceived stress. The clinical evaluation showed clinical discharge over 6 months and presence of pain only at 7 days. A weak correlation occurred between sociodemographic characteristics and the categories "Role-Physical" (r = 0.423) and "General Health" (r = 0.494); cause of anophthalmia and "Role-Physical" (r = -0.471); and type of surgery and "General Health" (r = -0.432).

CONCLUSIONS

According to the results of this study, the provision of ocular prostheses showed positive influence in 2 domains of quality of life and weak correlations with socioeconomic level, type of surgery, and cause of loss. Ocular rehabilitation did not influence stress. The use and care of the prostheses did not affect tissue inflammation, but the discharge was continuous.

Anxiety and depression in patients wearing prosthetic eyes

PURPOSE

To investigate anxiety and depression levels in prosthetic eye-wearing patients using standardized psychometric instruments, to define factors associated with these psychological diseases, and to identify a potential healthcare gap.

METHODS

A total of 295 prosthetic eye wearers were screened using the 7-item generalized anxiety disorder scale (GAD-7) and the 9-item patient health questionnaire (PHQ-9). Scores of GAD-7 and PHQ-9 were correlated with scores of general physical and mental health functioning, vision-related quality of life, appearance-related distress, appearance-related social function, and further biosocial factors.

RESULTS

Five patients (2%) had a pre-diagnosed anxiety disorder, and 20 patients (7%) had a pre-diagnosed depression. However, our screening revealed 26 patients (9%) with anxiety symptoms, 31 patients (11%) with depression symptoms, and 40 patients (14%) suffering from both anxiety and depression symptoms. This underdiagnosing for both anxiety and depression disorders was significant (p < 0.001, respectively). Higher GAD-7 scores were significantly associated with higher PHQ-9 scores, lower appearance-related social function, lower mental health functioning, and female gender (p ≤ 0.021, respectively). Higher PHQ-9 scores were significantly associated with lower physical and mental health functioning, higher educational degree, and non-traumatic eye loss (p ≤ 0.038, respectively).

CONCLUSIONS

Anxiety and depression disorders seem to be underdiagnosed in prosthetic eye wearers and to have higher incidence compared with the general population. Therefore, a psychometric screening should be routinely implemented in the clinical care. For a successful long-term rehabilitation, integrated care by a multidisciplinary team including ophthalmic plastic surgeons, ophthalmologists, ocularists, general practitioners, and psychologists is essential.

The prevalence of anophthalmic socket syndrome and its relation to patient quality of life

BACKGROUND

Following removal of the eye, soft tissue changes of the eyelids and orbit may develop into an anophthalmic socket (AS) syndrome, which is often attributed to orbital volume deficiency. While adequate primary orbital volume replacement is nowadays standard of care, patients may still present with facial asymmetry. The aim of this study is to provide insights into these changes and their impact on patient quality of life (QoL).

METHODS

Cross-sectional study of 59 patients with longstanding ocular prosthetic wear after enucleation or evisceration surgery. The alignment, function, and laxity of the eyelids of the anophthalmic side were compared to those of the fellow side. The QoL was assessed with a 4-item questionnaire specific for the prosthetic condition. The different aspects of AS syndrome were analysed in relation to disease-specific and prosthetic data and to the patient QoL scores.

RESULTS

Clinical AS syndrome was prevalent in 53% of patients with acquired anophthalmia. The anophthalmic side was statistically significantly different from the fellow side for the known AS syndrome features such as superior sulcus depression, margin reflex distance 1, and enophthalmia, but also for new features such as levator muscle function and lagophthalmia (P < 0.05). The difference was correlated with duration of prosthetic wear, prior orbital radiotherapy, and size of the prosthesis (P < 0.05). QoL scores were not correlated to the separate features of AS syndrome, except for a positive correlation between wearing comfort of the prosthesis and upper eyelid ptosis (P < 0.05).

CONCLUSION

Patients with an ocular prosthesis show a relatively high prevalence of one or more distinct clinical features of AS syndrome, which do not negatively affect patient QoL. These findings underscore the importance to tailor prosthetic and surgical treatment to the patient's perceived QoL rather than to the objective clinical findings.

Outcomes of Vismodegib for Periocular Locally Advanced Basal Cell Carcinoma From an Open-label Trial

Importance

The outcomes of vismodegib treatment in a relatively large cohort of study participants with periocular locally advanced basal cell carcinoma (POLA-BCC) may guide physicians when considering this treatment.

Objective

To report the outcomes of vismodegib treatment in patients with POLA-BCC in the Safety Events in Vismodegib (STEVIE) study.

Design, Setting, and Participants

This post hoc subgroup analysis from the STEVIE single-arm, multicenter, open-label cohort study screened all 1215 participants for ocular or periocular involvement and identified 244 participants with POLA-BCC or metastatic BCC. Data for the first STEVIE trial were collected from 167 treatment locations in 36 countries from June 30, 2011, to June 14, 2017. This post hoc analysis was performed from April 1 to August 31, 2019.

Main Outcomes and Measures

Response to treatment and adverse events.

Results

Ocular or periocular involvement was found in 244 of 1215 STEVIE participants (20.1%), who constituted the analytic sample. The median age of the study participants was 72.0 (interquartile range [IQR], 60.0-82.0]) years, and they included 143 men (58.6%). Locally advanced BCC was diagnosed in 238 of the 244 participants (97.5%) and metastatic BCC, in 6 (2.5%). The median duration of exposure to vismodegib was 40.0 (IQR, 20.0-78.0) weeks, specifically 39.7 (IQR, 19.9-76.0) weeks for POLA-BCC and 92.4 (IQR, 53.2-163.0) weeks for metastatic BCC. Sixty-nine participants (28.3%) sustained serious adverse events (alopecia, muscle spasms, dysgeusia, weight loss, decreased appetite, asthenia, ageusia, nausea, fatigue, and diarrhea). Two hundred thirty-two study participants (95.1%) sustained more than 1 adverse effect. The overall mean (SD) number of drug-related adverse effects per study participant by first adverse event, regardless of the severity, was 5.48 (3.84). Discontinuation of vismodegib treatment owing to an adverse event was recorded in 58 participants (23.8%). During the study, 22 participants (9.0%) died, 70 (28.7%) achieved complete response, and 94 (38.5%) achieved partial response.

Conclusions and Relevance

Vismodegib was well tolerated by the study participants with POLA-BCC. The safety of vismodegib treatment according to the STEVIE trial findings is consistent with that reported in previous studies. These data may be helpful when considering vismodegib for patients with POLA-BCC.

Orbital exenteration: Symptoms, indications, tumour localizations, pathologies, reconstruction, complications and survival

OBJECTIVE

This study aims to evaluate malignant and benign diseases that lead to orbital exenteration.

PATIENTS

From December 1999 to September 2017, patients undergoing orbital exenteration were included in this retrospective study. All of them were evaluated on clinical symptoms, indications, tumour localizations, pathologies, reconstruction techniques, complications, recurrences, and survival.

RESULTS

Of the 205 patients enrolled in this study, 94 had a carcinoma, 73 melanoma, 9 a sarcoma, 14 some other malignant disease, and 15 a benign medical condition. Sixteen patients underwent reconstruction using a local eyelid skin flap (7.8%), 6 with a split-thickness graft (2.9%), 144 with a local flap (70.2%), and 25 with a microvascular graft (12.2%), whereas 14 patients did not undergo reconstruction (6.8%). The most common complications were wound dehiscences (25 cases), pain (17 cases), and partial flap necroses (13 cases). Moreover, 62% of the patients were treated with different facial prostheses or artificial eyes. Given these results, it appears that lymph nodes and distant metastases, as well as lymphatic invasion into vessels, perineural invasion, and non-cleared resection margins, seem to affect overall survival after orbital exenteration.

CONCLUSION

Different reconstruction techniques can be used to provide the patient with maximum functionality and aesthetics after orbital exenteration. Individual concepts should be discussed at the beginning of the treatment. Using primary reconstruction and providing osseointegrated implant-retained prostheses remain the gold standard.

Carcinomas of the lacrimal drainage system

Malignant tumors of epithelial origin are the most frequent neoplasms of the lacrimal drainage system (LDS). A total of 539 cases are reported in the literature from 1960 to 2019. LDS carcinoma is a disease of the middle-aged and elderly population, with a median age at diagnosis of 57 years. Overall, there is a slight male predominance. Reported risk factors are chronic inflammation, LDS papilloma, and infection with oncogenic viruses. Symptoms of an LDS carcinoma resemble those of benign, inflammatory diseases, with epiphora from obstruction of the LDS as the most frequently encountered symptom. The median time from symptoms to diagnosis is 12 months and even longer for patients reporting epiphora as the only initial symptom. This diagnostic delay leads to a substantial fraction of patients with locally advanced tumors and lymph node spread at the time of diagnosis. Surgery with adjuvant radiotherapy is the treatment of choice for most patients; however, the extension and aggressiveness of the disease and the patient's general health and preferences determine the definite treatment. Five-year overall survival is reported to range from 61 to 87.6%. A large tumor size and positive lymph node status correlate with a decreased overall and disease-free survival.

Calcitonin Gene-Related Peptide in Blind, Painful Eyes

PURPOSE

To determine if calcitonin gene-related peptide (CGRP) is overexpressed in blind, painful eyes.

METHODS

This was a retrospective cross-sectional randomized control study conducted at a tertiary level hospital. Eight specimens of eyes enucleated by a single surgeon were included in the study. The control group patients underwent exenteration for cutaneous malignancy without intraocular involvement, while the case group was enucleated for management of blind, painful eye. Each eye was stained using immunohistochemistry for the expression of CGRP. Expression of CGRP was examined by counting the number of cells staining positive for CGRP in 5 consecutive ×40 fields in the choroid, iris, and cornea of each specimen.

RESULTS

The mean number of cells staining positively for CGRP in the choroid of blind, painful eye group was 45.5 (26.3) versus 5.5 (7.7) in nonpainful enucleated eyes. This difference was found to be statistically significant (p = 0.016). Comparison of iris and cornea did not reach statistical significance. Expression of CGRP was compared using a paired t test.

CONCLUSIONS

This study demonstrates that CGRP is overexpressed in the choroid of enucleated blind, painful eyes. Modulation of this protein may represent a meaningful, nonsurgical therapeutic strategy to addressing the blind, painful eye.

Prospective Evaluation of Health-Related Quality of Life in Patients Undergoing Anterolateral Craniofacial Resection with Orbital Exenteration

Objective  This study was aimed to evaluate health-related quality of life in patients undergoing anterolateral craniofacial resection (AL-CFR) with orbital exenteration (OE) for malignant skull base tumors and to investigate the effects of early psychiatric intervention. Design  Present study is a prospective, observational study. Setting  The study took place at the hospital department. Participants  Twenty-six consecutive patients were selected who underwent AL-CFR with OE at our hospital between 2005 and 2015. Main Outcome Measures  Health-related quality of life was assessed preoperatively and 3, 6, 12, and 24 months after surgery using the Hospital Anxiety and Depression Scale (HADS) and medical outcomes study 8-items Short Form health survey (SF-8). In all cases, psychiatric intervention was organized by the consultation liaison psychiatry team preoperatively and postoperatively. Results  Ten (38.0%) of the 26 patients died and 16 (62.0%) were alive and disease-free at the end of the study. The 3-year overall and disease-free survival rates were 64.9% and 53.3%, respectively. Twenty-one patients (80.8%) developed psychiatric complications after surgery and needed treatment with psychotropic medication. Before surgery, 28% of patients had HADS scores ≥8 for anxiety and 20% had scores ≥8 for depression. Seven of the eight items in the SF-8 were significantly lower than those for the general Japanese population. However, scores for all the SF-8 items gradually improved during postoperative follow-up, reaching approximately 50 points, which is the national standard value, at 2 years after surgery. Conclusions  Craniofacial resection with OE was feasible and well tolerated in patients with malignant skull base tumors who received early psychiatric intervention to decrease the considerable psychological impact of this procedure.

Primary replacement for the management of exposed orbital implant

Purpose: We present a series of primary orbital implant replacement for cases of implant exposure to describe our experience of this one-staged surgical approach. Methods: This study reports on a one-stage technique which involved the removal of the exposed implant or dermis fat graft (DFG) and insertion of a secondary (replacement) in the same procedure, with a variety of materials, including autologous tissue. Re-exposure in a socket where a DFG was placed was defined as a new defect in the newly epithelialized conjunctiva or dehiscence of the dermis-conjunctiva junction. All cases of primary replacement for the management of exposed orbital implant, porous and non-porous, were included, even when there were clinical signs suggestive of infection. The primary outcome was the rate of re-exposure, requiring additional surgical procedures. Infection following primary replacement was a secondary outcome. Results: Seventy-eight patients had primary replacement for the management of an exposed orbital implant. 6.4% had re-exposure at a mean follow-up of 49.7 months (9.1% for ball implants and 4.5% for DFG). The rate of exposure was higher in those with prior signs of infection than those without (8% vs. 3.6%). Re-exposure occurred in 4.5% of cases with DFG implantation, 4.3% of cases with non-porous implants and in 20% of cases with porous implants. Conclusion: Primary replacement for management of exposed orbital implant, porous and non-porous, has a high rate of successful outcome even in cases with presumed or confirmed infection.

Patient-reported Outcomes and Quality of Life After Treatment of Choroidal Melanoma: A Comparison of Enucleation Versus Radiotherapy in 1596 Patients

PURPOSE

To test the hypothesis that patients treated with radiotherapy for choroidal melanoma enjoy better quality of life (QoL) than patients who have undergone enucleation.

METHODS

In this nonrandomized study, patients with choroidal melanoma treated at the Royal Liverpool University Hospital, Liverpool, UK, were invited to complete QoL questionnaires approximately 6 months postoperatively and then on each anniversary of their primary treatment. These instruments consisted of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-OPT30 questionnaire, Hospital Anxiety & Depression Scale, and the Functional Assessment of Cancer Treatment questionnaire. Patient-reported outcomes were correlated with demographics, ocular treatment, social factors, presenting tumor and ocular status, self-reported general health, marital status, and employment status.

RESULTS

The 1596 patients were treated with radiotherapy (72.3%) or enucleation (27.7%). Enucleation was associated with male sex (χ², P = .004), older age (t test, P < .001), larger tumor diameter (t test, P < .001), monosomy 3 (χ², P < .001), depression (linear regression, 95% confidence interval [CI], .17 to 1.01), and reduced physical and functional well-being (linear regression, 95% CI, -1.14 to -0.12 and -1.96 to -0.47), respectively. Poor QoL was attributed to the ocular disease by 21% and 20% of enucleated and irradiated patients, respectively (χ², P = .938).

CONCLUSIONS

Patient-reported outcomes and QoL were worse in patients who had undergone primary enucleation for choroidal melanoma. These outcomes may partly have been caused by factors predisposing to enucleation rather than enucleation itself, because enucleated patients tended to be older, with more advanced disease at presentation, and a worse prognosis for survival. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Quality of life in children with retinoblastoma after enucleation in China

OBJECTIVE

To study the quality of life of Chinese pediatric patients with retinoblastoma (RB) after enucleation and the influencing factors.

METHODS

A questionnaire survey was performed on 71 cases of pediatric patients with RB after enucleation and 80 cases of healthy children, using the Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL™ 4.0).

RESULTS

The social dimension scores, school dimension scores, and total scores for the PedsQL™ 4.0 among the pediatric patients with RB were statistically significantly lower than those of healthy children. The influencing factors were unilateral/bilateral affected eyes, diagnosis age, and ocular prosthesis satisfaction.

CONCLUSION

Early discovery, timely treatment, increased eye salvage rate, and cosmetic effects of ocular prosthesis were key factors for increasing the quality of life of pediatric patients with RB. Attention should be paid to the health, social, and school development of pediatric patients with RB.

A Simplified Approach to Fabricate a Hollow Ocular Prosthesis

The prosthetic rehabilitation of a large anophthalmic socket is always a challenge. It demands an equally sized ocular prosthesis to replace lost tissue volume. A conventional solid acrylic ocular prosthesis may be deterrent to retention and esthetics because of its weight, which can be reduced by eliminating the mass of material within it. This article attempts to present a simplified and accurate technique to fabricate a hollow ocular prosthesis using silicone putty cavity form. It is removed prior to final processing and serves to ensure appropriate uniform thickness of acrylic resin and optimal weight reduction of the definitive prosthesis without compromising mobility, esthetics, and structural integrity.

Common Causes of Eye Enucleation among Patients

BACKGROUND

We investigated the contributing causes and factors leading to eye enucleation procedure among the patients referred to the ophthalmology clinic of the Center Eye Hospital in Tehran, Iran.

PATIENTS AND METHODS

We retrospectively analyzed the clinical records of patients referred to the ophthalmology clinic of the Center Eye Hospital in Tehran, Iran, in the past 3 years. The data retrieved were analyzed.

RESULTS

A total of 313 patients underwent eye enucleation during the past 3 years. The average age of the patients was 36.7 years (range: 20-44 years). Two hundred and eight patients (66.5%) were males and 105 (33.5%) were females. One hundred and sixty-nine patients had the right eye enucleation while 144 patients had the left eye enucleation. The various procedures included enucleation (83%), evisceration (13.4%), and exantration (3.6%). The factors leading to these procedures included trauma (33.2%), phthisis bulbi (20.7%), tumors (15.7%), and infections (10.5%).

CONCLUSION

In our study population, trauma was the main factor leading to eye enucleation. Hence, measures to increase social awareness and knowledge to reduce trauma cases are necessary as a preventive approach to reduce eye enucleation procedures. Concurrently, ophthalmologists should also pay more attention in early diagnoses and screening of eye health, especially detecting tumor cases such as retinoblastoma and postsurgical care to reduce secondary infections will be effective actions to reduce the overall rate of enucleation.

Visual recovery following open globe injury with initial no light perception

Background

The purpose of this study was to analyze eyes presenting with no light perception (NLP) after open globe injury (OGI) to determine visual outcomes and prognostic indicators for visual recovery.

Methods

The records of consecutive patients with at least 6 months of follow-up presenting with OGI and NLP to a single institution between January 1, 2003 and December 31, 2013 were reviewed for demographics, ophthalmic history, context and characteristics of injury, ocular examination findings, surgical interventions, and follow-up visual acuity. Unpaired t-tests and Fisher’s Exact tests were used for statistical analysis.

Results

Twenty-five patients met our inclusion criteria. The mean age was 50.4±25.5 (range 8–91) years. Four patients (16%) regained vision (hand motion in three patients and light perception in one patient) while 21 patients (84%) remained with NLP or had a prosthesis at final follow-up. Fourteen eyes (56%) were enucleated; nine (36%) were secondary enucleations. Although the sample sizes were small, neither ocular trauma score nor wound size was found to predict visual recovery.

Conclusion

Four patients regained some vision after presenting with NLP due to OGI. These findings suggest that, in select cases, physicians should discuss the possibility of regaining some vision.

Vision-Related Quality of Life and Appearance Concerns Are Associated with Anxiety and Depression after Eye Enucleation: A Cross-Sectional Study

Aims

To investigate the association of demographic, clinical and psychosocial variables with levels of anxiety and depression in participants wearing an ocular prosthesis after eye enucleation.

Methods

This cross-sectional study included 195 participants with an enucleated eye who were attending an ophthalmic clinic for prosthetic rehabilitation between July and November 2014. Demographic and clinical data, and self-reported feelings of shame, sadness and anger were collected. Participants also completed the National Eye Institute Visual Function Questionnaire, the Facial Appearance subscale of the Negative Physical Self Scale, and the Hospital Anxiety and Depression Scale. Regression models were used to identify the factors associated with anxiety and depression.

Results

The proportion of participants with clinical anxiety was 11.8% and clinical depression 13.8%. More anxiety and depression were associated with poorer vision-related quality of life and greater levels of appearance concerns. Younger age was related to greater levels of anxiety. Less educated participants and those feeling more angry about losing an eye are more prone to experience depression. Clinical variables were unrelated to anxiety or depression.

Conclusions

Anxiety and depression are more prevalent in eye-enucleated patients than the general population, which brings up the issues of psychiatric support in these patients. Psychosocial rather than clinical characteristics were associated with anxiety and depression. Longitudinal studies need to be conducted to further elucidate the direction of causality before interventions to improve mood states are developed.

Phantom eye syndrome: a review of the literature

The purpose of this literature review was to describe the main features of phantom eye syndrome in relation to their possible causes, symptoms, treatments, and influence of eye amputation on quality of life of anophthalmic patients. For this, a bibliographical research was performed in Pubmed database using the following terms: “eye amputation,” “eye trauma,” “phantom eye syndrome,” “phantom pain,” and “quality of life,” associated or not. Thirteen studies were selected, besides some relevant references contained in the selected manuscripts and other studies hallowed in the literature. Thus, 56 articles were included in this review. The phantom eye syndrome is defined as any sensation reported by the patient with anophthalmia, originated anophthalmic cavity. In phantom eye syndrome, at least one of these three symptoms has to be present: phantom vision, phantom pain, and phantom sensations. This syndrome has a direct influence on the quality of life of the patients, and psychological support is recommended before and after the amputation of the eyeball as well as aid in the treatment of the syndrome. Therefore, it is suggested that, for more effective treatment of phantom eye syndrome, drug therapy should be associated with psychological approach.

Visual function and quality of life in patients who had undergone eye removal surgery: a patient survey

PURPOSE

To measure aspects of self-reported vision-related health status and assess the impact of treatment in patients who have undergone eye removal surgery (evisceration or enucleation), using a patient administered questionnaire.

METHODS

In this non-randomised, questionnaire-based cohort study, patients were identified from the Artificial Eye Service referral register from 2003 to 2010. A self-administered questionnaire based upon previously published scales was completed to measure aspects of visual function and the impact of treatment.

RESULTS

Thirty-six completed questionnaires were obtained. Mean age at surgery was 54.1 years (range 13-90), with 83% male. Indication for eye-removal was trauma in 14(39%) cases. Ten (28%) had ocular co-morbidity in the fellow-eye. The main reported difficulties were with peripheral vision or distance judgements, in 64% patients. The majority of drivers (66%) had maintained the ability to drive. Self-consciousness was reported in 28(78%) patients, and 56% were able to continue work or activities with no perceived limitations. Overall comfort and aesthetic improvement were noted by the majority. Procedure-specific information leaflets for patients were appreciated.

CONCLUSIONS

This survey increases our knowledge of aspects of vision-related health status following ocular pathology or trauma that requires eye removal, and may enable improved pre-operative patient counselling. Effects on peripheral vision may be noted most significantly, but the majority can continue normal activities with little difficulty. Overall improvement in comfort and appearance occurs in most patients, although feelings of self-consciousness are common.

Understanding the impact of uveitis on health-related quality of life in adolescents

PURPOSE

A reduction in quality of life (QoL) during an active phase of disease has been shown for patients with uveitis of various age groups. Adult uveitis patients were shown to also have reduced QoL-values despite disease being quiescent, but adolescents have not been investigated in this respect.

METHODS

This clinic-based, cross-sectional pilot study assessed the overall health-related quality of life (HRQoL) in adolescents (11-18 years) with a history of inactive uveitis and good visual function. Two independent generic (non-disease-specific) instruments were applied, the Inventory for Assessing the Quality of Life and the German KINDL-R-questionnaire.

RESULTS

Thirty-seven adolescents, 20 females (54%) and 17 males with a mean age of 15 ± 3 years and diagnosis since 5 ± 2 years participated. Subgroups with a reduced HRQoL were those with anterior and intermediate localization of uveitis, bilateral disease, application of immunosuppressive therapy, a short time since diagnosis, and a high number of recurrences.

CONCLUSION

Even despite quiescence of disease and good visual function, certain risk factors may result in a decreased HRQoL in juvenile uveitis patients. Our findings support the need of further evaluation of HRQoL in this patient group, the validation of specific psychometric inventories for this disease and the establishment of interdisciplinary collaboration including psychological counselling.

Microvascular free flap reconstruction of orbitocraniofacial defects

PURPOSE

To examine the etiology, surgical extent and techniques, complications, and outcomes of microvascular free flaps (MFF) in the reconstruction of orbitocraniofacial defects.

DESIGN

A retrospective, institutional review board approved study was performed of all patients undergoing MFF to repair orbitocraniofacial defects over 51 months.

PARTICIPANTS

Fifty-eight patients undergoing MFF to repair orbitocraniofacial defects were included.

MATERIAL AND METHODS

Variables analyzed included demographics, etiology, resection area(s), donor site, flap size, duration of surgery, complications, length of hospital stay, flap survival, and mortality.

RESULTS

Fifty-eight patients underwent 61 MFFs from June 2007 to September 2011. The majority of patients were white (79.3%) and male (72.4%). The mean age was 64.1 years. The most common etiology was intraorbital and skull base extension of cutaneous squamous cell carcinoma (29.3%) followed by sinonasal squamous cell carcinoma (13.8%). Dura and/or brain were exposed in 44.8% of cases. MFFs were harvested from the anteriolateral thigh in 71.4% of cases with a 180.9 cm(2) mean flap area. The mean length of hospital stay was 15.3 days and mean length of surgical time was 11 h and 17 min.

CONCLUSIONS

Complex orbitocraniofacial defects require a multi-disciplinary team skilled in surgical extirpation and advanced reconstructive techniques. MFF should be considered in the management of large defects, especially when there is dura or brain exposure. Intensive postoperative monitoring is indicated for both systemic and flap-related complications. MMFs provide excellent coverage of large areas of exposed critical skull base structures, including dura and brain, and may allow for earlier adjuvant treatment.