1
|
Bladen JC, Malhotra R, Litwin A. Long-term outcomes of margin-controlled excision for eyelid melanoma. Eye (Lond) 2023; 37:1009-1013. [PMID: 36828958 PMCID: PMC10049999 DOI: 10.1038/s41433-023-02428-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 01/13/2023] [Accepted: 01/25/2023] [Indexed: 02/26/2023] Open
Abstract
OBJECTIVES To provide evidence for long-term outcomes for margin-controlled excision of eyelid melanoma. METHODS Retrospective single-centre observational case series of patients treated for eyelid melanoma between 2007 and 2016, with a minimum of 5-year follow-up. Tumour excision involved rush-paraffin en face horizontal sections and delayed repair (Slow Mohs; SM). RESULTS Twenty-two cases were seen with a survival of 91% (two deaths from nodular and lentigo maligna melanoma) and seven with melanoma in situ (MIS). Invasive melanoma includes eight lentigo maligna melanoma, four nodular, two amelanotic and one desmoplastic. Mean Breslow thickness was 6 mm for invasive (range 0.5-26). Mean excision margin for MIS was 3 mm (range 2-5 mm) and for invasive was 5 mm (range 2-10). Further excisions were performed in nine (41%); two went on to recur. Local recurrence was 36%; six invasive (27%) at a mean of 24 months (range 1.5-5 years) and two for MIS at a mean of 15 months (range 1-1.5 years). Imaging occurred for suspected advanced disease. Sentinel node biopsy was not performed. Advanced melanoma therapy was performed in two cases. No vitamin D testing occurred. CONCLUSIONS Survival rates are in line with 90% overall survival in the UK. Prescriptive excision margins are not applicable in the periocular region and margin-controlled excision with a delayed repair is recommended, but patients need to know further excision may be needed to obtain clearance. Evidence recommending vitamin D therapy needs to be put into clinical practice. In addition, upstaging of MIS occurred advocating excision rather than observation of MIS. More studies are needed to determine the best management of eyelid melanoma.
Collapse
Affiliation(s)
- John C Bladen
- Corneoplastic department, Queen Victoria Hospital, East Grinstead, UK
| | - Raman Malhotra
- Corneoplastic department, Queen Victoria Hospital, East Grinstead, UK
| | - Andre Litwin
- Corneoplastic department, Queen Victoria Hospital, East Grinstead, UK.
| |
Collapse
|
2
|
Rahman MM, Herath D, Bladen JC, Atkar R, Pirzado MS, Harwood C, Philpott MP, Neill GW. Differential expression of phosphorylated MEK and ERK correlates with aggressive BCC subtypes. Carcinogenesis 2021; 42:975-983. [PMID: 34003214 DOI: 10.1093/carcin/bgab036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/29/2021] [Accepted: 05/17/2021] [Indexed: 11/14/2022] Open
Abstract
Basal cell carcinoma (BCC) is associated with aberrant Hedgehog (HH) signalling through mutational inactivation of PTCH1; however, there is conflicting data regarding MEK/ERK signalling in BCC and the signalling pathway interactions in these carcinomas. To address this, expression of active phospho (p) MEK and ERK was examined in a panel of 15 non-aggressive and 14 aggressive BCCs. Although not uniformly expressed, both phospho-proteins were detected in the nuclei and/or cytoplasm of normal and tumour-associated epidermal cells however, whereas phospho-MEK (pMEK) was present in all non-aggressive BCCs (14/14), phospho-ERK (pERK) was rarely expressed (2/14). In contrast pERK expression was more prevalent in aggressive tumours (11/14). Interestingly, pMEK was only localized to the tumour mass whereas pERK was expressed in tumours and stroma of aggressive BCCs. Similarly, pERK (but not pMEK) was absent in mouse BCC-like tumours derived from X-ray irradiated Ptch1+/- mice with stromal pERK observed in myofibroblasts of the aggressive variant as well as in the tumour mass. RNA sequencing analysis of tumour epithelium and stroma of aggressive and non-aggressive BCC revealed the upregulation of epidermal growth factor receptor- and ERK-related pathways. Angiogenesis and immune response pathways were also upregulated in the stroma compared with the tumour. PTCH1 suppressed NEB1 immortalized keratinocytes (shPTCH1) display upregulated pERK that can be independent of MEK expression. Furthermore, epidermal growth factor pathway inhibitors affect the HH pathway by suppressing GLI1. These studies reveal differential expression of pERK between human BCC subtypes that maybe active by a pathway independent of MEK.
Collapse
Affiliation(s)
- Muhammad M Rahman
- Centre for Cutaneous Research, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Dimalee Herath
- Centre for Cutaneous Research, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - John C Bladen
- Centre for Cutaneous Research, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Ravinder Atkar
- Centre for Cutaneous Research, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Muhammad S Pirzado
- Centre for Cutaneous Research, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Catherine Harwood
- Centre for Cutaneous Research, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Michael P Philpott
- Centre for Cutaneous Research, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Graham W Neill
- Centre for Cutaneous Research, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| |
Collapse
|
3
|
Nigam C, Bladen JC. Re: Peri-operative management of ophthalmic patients on anti-thrombotic agents: a literature review. Eye (Lond) 2021; 35:1519. [PMID: 32541888 PMCID: PMC8182811 DOI: 10.1038/s41433-020-1014-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/28/2020] [Accepted: 06/01/2020] [Indexed: 11/08/2022] Open
Affiliation(s)
- Chandni Nigam
- West Kent Eye Centre, Kings College NHS Trust, London, UK.
| | - J C Bladen
- West Kent Eye Centre, Kings College NHS Trust, London, UK
| |
Collapse
|
4
|
Abstract
BACKGROUND Peri-orbital surgical emphysema is a rare complication that can occur after lacrimal surgery. It has only been described in isolated cases, following external dacryocystorhinostomy (n = 2) and Lester Jones tube insertion (n = 1). METHOD A retrospective, non-comparative case series was conducted of patients who developed surgical emphysema following endoscopic dacryocystorhinostomy. RESULTS A total of 356 endoscopic dacryocystorhinostomy cases (primary, n = 316; revision, n = 40) were performed over a six-year period. Seven cases of post-operative surgical emphysema were identified, all of which were preceded by uncontrolled sneezing, nose-blowing or coughing within the first week of surgery. The occurrence of surgical emphysema post-endoscopic dacryocystorhinostomy in our centre was 7 in 356, or 2 per cent, over six years. CONCLUSION This is the first study to report the occurrence of surgical emphysema post-endoscopic dacryocystorhinostomy. Clinicians may wish to suggest patients stifle the aforementioned triggers within the first week to reduce the potential for surgical emphysema.
Collapse
Affiliation(s)
- J C Bladen
- Corneoplastic Unit, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
| | - W F Siah
- Corneoplastic Unit, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
| | - P Tan
- Corneoplastic Unit, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
| | - A S Litwin
- Corneoplastic Unit, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
| | - S Ali
- Department of Anaesthesia, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
| | - R Malhotra
- Corneoplastic Unit, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
| |
Collapse
|
5
|
Bladen JC, Favor M, Litwin A, Malhotra R. Switchover study of onabotulinumtoxinA to incobotulinumtoxinA for facial dystonia. Clin Exp Ophthalmol 2020; 48:1146-1151. [PMID: 32710447 DOI: 10.1111/ceo.13829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/22/2020] [Accepted: 07/10/2020] [Indexed: 11/28/2022]
Abstract
IMPORTANCE When making a cost-saving it is important to ensure there is no loss of efficacy. BACKGROUND Clinical effectiveness and efficiency of incobotulinumtoxinA compared to onabotulinumtoxinA in facial dystonia is unclear. Our aim is to evaluate switching from onabotulinumtoxinA to incobotulinumtoxinA in the treatment of essential blepharospasm (EB), hemifacial spasm (HFS) and aberrant facial nerve regeneration (AFR). DESIGN A retrospective study of a prospective, single-masked switchover audit from onabotulinumtoxinA to incobotulinumtoxinA. PARTICIPANTS Twenty essential EB, 12 HFS and six AFR patients. METHODS A switchover from stable onabotulinumtoxinA to incobotulinumtoxinA using a 1:1 unit ratio and contemporaneous efficacy measures. Two nurse injectors performed the injections over a period of 6 years. Each masked patient received three onabotulinumtoxinA and three incobotulinumtoxinA over a minimum of 2 years. MAIN OUTCOME METHODS At each visit, a blepharospasm disability score (BDS), Jankovic score (JS), subjective improvement (SI), duration of maximum effect (DME) and complications were recorded. A cost comparison per unit dose was made. RESULTS Twenty EB, 12 HFS and six AFR received 114 onabotulinumtoxinA and 114 incobotulinumtoxinA treatments. Both brands had similar efficacy, but SI (P < .01) and DME (P < .05) were higher in the HFS group with incobotulinumtoxinA. Complications included bruising (two onabotulinumtoxinA, one incobotulinumtoxinA) and ptosis (three onabotulinumtoxinA, zero incobotulinumtoxinA). OnabotulinumtoxinA was 33% pricier. CONCLUSION AND RELEVANCE Switching from onabotulinumtoxinA to incobotulinumtoxinA did not result in an inferior outcome for the treatment of facial dystonia and led to a cost-saving for the department.
Collapse
Affiliation(s)
- John C Bladen
- Corneoplastic Department, Queen Victoria Hospital, East Grinstead, UK
| | - Maribel Favor
- Corneoplastic Department, Queen Victoria Hospital, East Grinstead, UK
| | - Andre Litwin
- Corneoplastic Department, Queen Victoria Hospital, East Grinstead, UK
| | - Raman Malhotra
- Corneoplastic Department, Queen Victoria Hospital, East Grinstead, UK
| |
Collapse
|
6
|
Bladen JC, Malhotra R. Reporting outcomes of hyaluronic gel filler as a treatment for epiblepharon. Graefes Arch Clin Exp Ophthalmol 2019; 257:2769-2773. [PMID: 31641882 DOI: 10.1007/s00417-019-04479-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 09/03/2019] [Accepted: 09/13/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Epiblepharon occurs when an extra skin fold overlaps on the eyelid margin with the isolated form mainly seen in children of east Asian origin. If symptomatic and the use of conservative measures such as lubricants have failed, surgery is usually indicated. This traditionally involves everting sutures or combined skin excision, such as a modified Hotz procedure. However, a temporizing non-surgical alternative to a skin removal procedure, especially if the natural history is for improvement as the child grows older, would be ideal. METHODS This is a retrospective single-centre case review of epiblepharon cases treated with hyaluronic acid (HA; Restylane, Galderma UK) treated in the past 5 years by a single surgeon (RM). Institutional review board approval was obtained. Success is defined as improvement or stabilization of the class and/or keratopathy score of the epiblepharon. RESULTS Five patients were identified with epiblepharon between 2012 and 2017 who had hyaluronic acid filler to 8 eyelids. Six eyelids had improvement, 1 remained stable and 1 was worse equating to an 87% success rate; however, 2 opted for reversal using hyaluronidase due to aesthetic reasons. Two went on to have further surgery as they partially responded to filler treatment. CONCLUSION This study provides further proof of concept that HA is a simple non-surgical and reversible option that may avoid the need for surgery for epiblepharon in selected cases. It may even be considered in older children or adolescents with the caveat that fullness may require hyaluronidase to dissolve.
Collapse
Affiliation(s)
- John C Bladen
- Corneo Plastic unit, Queen Victoria Hospital NHS Trust, East Grinstead, West Sussex, RH19 3DZ, UK.
| | - Raman Malhotra
- Corneo Plastic unit, Queen Victoria Hospital NHS Trust, East Grinstead, West Sussex, RH19 3DZ, UK
| |
Collapse
|
7
|
Abstract
Purpose: To report the occurrence of dry eye after Lester Jones tube (LJT) insertion. Methods: Retrospective case series from a single unit. The dacrocystorhinostomy (DCR) was carried out using both endoscopic and external approachs; however, insertion of LJT used the same method as either a primary or secondary procedure. Dry eye as an outcome measure was only confirmed after three separate visits using the presence of both patient symptoms and dry eye signs with none preceding tube insertion. Results: Fifty-four patients underwent consecutive LJT insertion over a 5-year period. Mean age was 52.6 (range 25-73 years). The majority were female 39 (72%). Revision surgery was required in 15 (27%) with 3 or more occurring in 6 (11%). In total, 9 patients developed dry eyes (17%). Mean age was 60 (range 47-73) years, 5 females and 4 males. Four of the dry eye individuals had undergone primary LJT insertion and the remaining five received their first LJT 6-24 (mean 15) months post-DCR. Two dry eye patients had previously undergone LASIK and radiotherapy. Conclusion: A risk of dry eye following LJT placement is higher than the literature suggests. This should be considered and counseled, especially in those who have underlying pre-disposing factors. Ease of removal may be a desirable attribute in such cases.
Collapse
Affiliation(s)
- John C Bladen
- Corneoplastic Unit, Queen Victoria Hospital NHS Trust , East Grinstead , UK
| | - Nikhil Cascone
- Corneoplastic Unit, Queen Victoria Hospital NHS Trust , East Grinstead , UK
| | - Andrew R Pearson
- Department of Ophthalmology, Royal Berkshire Hospital , Reading , UK
| | - Andre Litwin
- Corneoplastic Unit, Queen Victoria Hospital NHS Trust , East Grinstead , UK
| | - Raman Malhotra
- Corneoplastic Unit, Queen Victoria Hospital NHS Trust , East Grinstead , UK
| |
Collapse
|
8
|
Bladen JC, Moosajee M, Tracey-White D, Beaconsfield M, O'Toole EA, Philpott MP. Analysis of hedgehog signaling in periocular sebaceous carcinoma. Graefes Arch Clin Exp Ophthalmol 2018; 256:853-860. [PMID: 29423837 PMCID: PMC5856882 DOI: 10.1007/s00417-018-3900-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/14/2017] [Accepted: 01/05/2018] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Sebaceous carcinoma (SC) is a clinical masquerader of benign conditions resulting in significant eye morbidity, sometimes leading to extensive surgical treatment including exenteration, and even mortality. Little is known about the genetic or molecular basis of SC. This study identifies the involvement of Hedgehog (Hh) signaling in periocular SC. METHODS Fifteen patients with periocular SC patients were compared to 15 patients with eyelid nodular basal cell carcinoma (nBCC; a known Hh tumor), alongside four normal individuals as a control for physiological Hh expression. Expression of Patched 1 (PTCH1), Smoothened (SMO), and glioma-associated zinc transcription factors (Gli1 and Gli2) were assessed in histological sections using immunohistochemistry and immunofluorescence (IF) techniques. Antibody specificity was verified using Western-blot analysis of a Gli1 over-expressed cancer cell line, LNCaP-Gli1. Semi-quantification compared tumors and control tissue using IF analysis by ImageJ software. RESULTS Expression of the Hh pathway was observed in SC for all four major components of the pathway. PTCH1, SMO, and Gli2 were more significantly upregulated in SC (P < 0.01) compared to nBCC. Stromal expression of PTCH1 and Gli2 was observed in SC (P < 0.01). In contrast, stromal expression of these proteins in nBCC was similar or down-regulated compared to physiological Hh controls. CONCLUSIONS The Hh signaling pathway is significantly more upregulated in periocular SC compared to nBCC, a known aberrant Hh pathway tumor. Furthermore, the stroma of the SC demonstrated Hh upregulation, in particular Gli2, compared to nBCC. Targeting of this pathway may be a potential treatment strategy for SC.
Collapse
Affiliation(s)
- John C Bladen
- Eyelid Oncology, Moorfields Eye Hospital, London, UK.
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts & London School of Medicine, 4 Newark St, London, E1 2AT, UK.
| | - Mariya Moosajee
- Department of Ocular Biology and Therapeutics, UCL Institute of Ophthalmology, London, UK
| | - Dhani Tracey-White
- Department of Ocular Biology and Therapeutics, UCL Institute of Ophthalmology, London, UK
| | | | - Edel A O'Toole
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts & London School of Medicine, 4 Newark St, London, E1 2AT, UK
| | - Michael P Philpott
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts & London School of Medicine, 4 Newark St, London, E1 2AT, UK
| |
Collapse
|
9
|
Bladen JC, Moosajee M, Bassett JHD. A Tense Case—Carney's Triad. J R Soc Med 2017; 97:540-1. [PMID: 15520151 PMCID: PMC1079650 DOI: 10.1177/014107680409701109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- John C Bladen
- Department of Medicine, East Surrey Hospital, Redhill, Surrey RH1 5RH, UK.
| | | | | |
Collapse
|
10
|
Bladen JC, Moosajee M, Tumuluri K, Olver JM. The use of a pleated strip of autogenous temporalis fascia graft for frontalis suspension in recurrent poor levator function ptosis in adult patients. Orbit 2012; 31:114-8. [PMID: 22489854 DOI: 10.3109/01676830.2011.648805] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Poor levator function (LF) blepharoptosis can be corrected surgically using frontalis muscle suspension with a variety of materials. Autogenous grafts such as fascia lata are commonly used. The need for a remote surgical site and the risk of an unattractive leg scar makes the use of an autogenous temporalis fascia (ATF) graft appealing as the scar is concealed in the hair. We describe the use of a pleated, lengthened ATF graft that is easy to prepare and insert, and provides a cosmetically acceptable outcome. METHODS Prospective case series describing six patients with previous multiple failed lid surgeries and recurrent poor (≤ 5 mm) LF (mean 2.87 ± 1.72 mm) ptosis. The pleated graft technique was used to yield a strip of ATF up to 18-cm long from a short 2-cm temporal incision. Eight eyelids then underwent ATF graft frontalis suspension surgery using the modified Fox pentagon technique. Outcomes included eyelid measurements with 4.5-year follow-up. RESULTS All patients achieved good functional and esthetic outcome. The mean central palpebral aperture 6 weeks postsurgery was 7.14 ± 1.67 mm, equating to a mean increase of 3.27 mm (p < 0.05 using the paired t-test). The improvement in eyelid height was maintained at the 4.5-year follow-up in all patients, except one who died of unrelated cause. CONCLUSION A pleated strip of ATF graft provides a simpler alternative to fascia lata grafting for frontalis suspension in poor LF ptosis in adult patients with good long-term results.
Collapse
|
11
|
|
12
|
Bladen JC, Moosajee M, Angunawela R, Roberts C. Transient internal ophthalmoplegia after inferior oblique myectomy. J AAPOS 2009; 13:596-7. [PMID: 20006825 DOI: 10.1016/j.jaapos.2009.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2009] [Revised: 09/15/2009] [Accepted: 09/23/2009] [Indexed: 10/20/2022]
Abstract
Internal ophthalmoplegia causing pupillary dilatation and loss of accommodation following damage to the ciliary ganglion is a rare complication of strabismus surgery. Here we report a case of parasympathetic neuropraxia resulting in transient internal ophthalmoplegia after inferior oblique myectomy in a 12-year-old girl. Short-term symptomatic relief was achieved with 1% pilocarpine. Normal visual function returned over several months.
Collapse
Affiliation(s)
- John C Bladen
- Chelsea and Westminster Hospital, London, United Kingdom.
| | | | | | | |
Collapse
|
13
|
Affiliation(s)
- John C Bladen
- Department of Medicine, East Surrey Hospital, Redhill, Surrey RH1 5RH, UK.
| | | | | |
Collapse
|