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Treatment and long-term outcome of patients with orbital cavernomas
Treatment and Long-term Outcome of Patients With Orbital Cavernomas EDITOR:
4. Shields JA, Shields CL, Eagle RC Jr. Transconjunctival approach for orbital tumors [in reply]. Arch Ophthalmol 1988;106:14 –15. 5. Gdal-On M, Gelfand YA. Tc-99m RBC scintigraphy of orbital cavernous hemangioma. Eur J Ophthalmol 1999;9:125–129.
WE ARE SURPRISED THAT SCHEUERLE AND ASSOCIATES1
are using the frontotemporal approach for the removal of cavernous hemangiomas. Since our report2 in 1985, we have been treating such patients almost exclusively by transconjunctival cryoextraction. In 1993 Loewenstein and associates3 reported 33 of our cases, including 2 in detail (not 1, as stated in Table 4), and have now operated on over 50 cavernomas by this approach. Shields and associates4 agreed that most of these tumors can be removed transconjunctivally. The authors concede that “especially small orbital cavernomas located laterally or medially to the eyeball can be excised by a transconjunctival approach.” However, our experience2,3 has shown that the larger the tumor, the more accessible its anterior edge, making it easier to visualize and reach with the cryoprobe. Because of the compressibility of the cavernomas, we are able to remove them in their entirety without regard to their position. Only the rare small cavernoma in the apex of the orbit will not be reachable by this method. In addition, we don’t understand the authors’ attempt to minimize the significance of their severe complications, including subdural hematoma, reduced visual acuity, and loss of visual field in nearly 30% of their patients. We reported no serious complications in 33 patients using the transconjunctival approach.3 Our excellent experience continues to this day. With ultrasound, computed tomography, magnetic resonance imaging, and red blood cell scintigraphy,5 cavernous hemangiomas can be diagnosed preoperatively, reached by a transconjunctival approach, and removed safely and completely by cryosurgery with good cosmetic results and without complication. A transcranial approach with its reported morbidity should not be considered except in rare cases. M. LAZAR, MD L. ROTHKOFF, MD J. P. DREY, MD
Tel Aviv, Israel
AUTHOR REPLY LAZAR QUOTES FROM OUR ARTICLE A VARIETY OF SEVERE
complications after the transcranial approach. To preclude other readers from misunderstanding, we confirm that two of 14 patients suffered severe visual loss. One of these 2 patients also had a third-nerve paresis. Both patients initially presented with headaches and significantly impaired preoperative visual acuity due to extended compression of the optic nerve in the orbital apex. We therefore suggested immediate surgical excision of the orbital cavernomas producing the visual deficits. Another patient who was operated on by a maxillofacial surgeon developed a postoperative subdural hematoma and retained a frontal lobe syndrome. We reported this case for the very reason that a transcranial approach should be considered only by surgeons experienced in the management of the specific, possibly severe complications. Furthermore, our intention was to point out that the decision to intervene surgically has to be made with extreme caution. Besides the loss of visual acuity, muscle palsy, and permanent diplopia, a severe impairment of visual function must be considered and may follow any kind of orbital surgery. Invasive therapy should be chosen only in the presence of symptoms clearly attributable to the lesion; therefore, careful ophthalmologic examination and follow-up are always mandatory. In the literature the transconjuctival removal of large orbital tumors is reported only occasionally. Our group has no experience with cryosurgery of orbital cavernomas, but we are intrigued that the transconjunctival extraction of large orbital cavernomas using a cryoprobe is so safe that they can be removed without regard to their position. Trauma to cranial nerves by traction or compression seems to be eliminated with the transconjunctival cryoextraction. A search of MEDLINE reveals that not many other surgical centers have been able to share and to publish the advantages of this technique. ALEXANDER F. SCHEUERLE
Heidelberg, Germany
REFERENCES
1. Scheuerle AF, Steiner HH, Kolling G, Aschoff A. Treatment and long-term outcome of patients with orbital cavernomas. Am J Opthalmol 2004;138:237–244. 2. Lazar M, Rosen N, Geyer O. A transconjunctival cryosurgical approach for intraorbital tumors. Aust. N Z J Ophthalmology 1985;13:417– 420. 3. Loewenstein A, Geyer O, Lazar M. Cavernous hemangioma of the orbit: treatment by transconjunctival cryoextraction. Eye 1993;7:597–598.
VOL. 139, NO. 4
Inflow of Ocular Surface Fluid Through Clear Corneal Cataract Incisions: A Laboratory Model AN UNSUTURED CLEAR CORNEAL INCISION FOR PHACO-
emulsification is currently de rigueur, despite the fact that temporal clear corneal incisions have been shown to increase the endophthalmitis rate.1,2 In the study by
CORRESPONDENCE
753
4. Shields JA, Shields CL, Eagle RC Jr. Transconjunctival approach for orbital tumors [in reply]. Arch Ophthalmol 1988;106:14 –15. 5. Gdal-On M, Gelfand YA. Tc-99m RBC scintigraphy of orbital cavernous hemangioma. Eur J Ophthalmol 1999;9:125–129.
WE ARE SURPRISED THAT SCHEUERLE AND ASSOCIATES1
are using the frontotemporal approach for the removal of cavernous hemangiomas. Since our report2 in 1985, we have been treating such patients almost exclusively by transconjunctival cryoextraction. In 1993 Loewenstein and associates3 reported 33 of our cases, including 2 in detail (not 1, as stated in Table 4), and have now operated on over 50 cavernomas by this approach. Shields and associates4 agreed that most of these tumors can be removed transconjunctivally. The authors concede that “especially small orbital cavernomas located laterally or medially to the eyeball can be excised by a transconjunctival approach.” However, our experience2,3 has shown that the larger the tumor, the more accessible its anterior edge, making it easier to visualize and reach with the cryoprobe. Because of the compressibility of the cavernomas, we are able to remove them in their entirety without regard to their position. Only the rare small cavernoma in the apex of the orbit will not be reachable by this method. In addition, we don’t understand the authors’ attempt to minimize the significance of their severe complications, including subdural hematoma, reduced visual acuity, and loss of visual field in nearly 30% of their patients. We reported no serious complications in 33 patients using the transconjunctival approach.3 Our excellent experience continues to this day. With ultrasound, computed tomography, magnetic resonance imaging, and red blood cell scintigraphy,5 cavernous hemangiomas can be diagnosed preoperatively, reached by a transconjunctival approach, and removed safely and completely by cryosurgery with good cosmetic results and without complication. A transcranial approach with its reported morbidity should not be considered except in rare cases. M. LAZAR, MD L. ROTHKOFF, MD J. P. DREY, MD
Tel Aviv, Israel
AUTHOR REPLY LAZAR QUOTES FROM OUR ARTICLE A VARIETY OF SEVERE
complications after the transcranial approach. To preclude other readers from misunderstanding, we confirm that two of 14 patients suffered severe visual loss. One of these 2 patients also had a third-nerve paresis. Both patients initially presented with headaches and significantly impaired preoperative visual acuity due to extended compression of the optic nerve in the orbital apex. We therefore suggested immediate surgical excision of the orbital cavernomas producing the visual deficits. Another patient who was operated on by a maxillofacial surgeon developed a postoperative subdural hematoma and retained a frontal lobe syndrome. We reported this case for the very reason that a transcranial approach should be considered only by surgeons experienced in the management of the specific, possibly severe complications. Furthermore, our intention was to point out that the decision to intervene surgically has to be made with extreme caution. Besides the loss of visual acuity, muscle palsy, and permanent diplopia, a severe impairment of visual function must be considered and may follow any kind of orbital surgery. Invasive therapy should be chosen only in the presence of symptoms clearly attributable to the lesion; therefore, careful ophthalmologic examination and follow-up are always mandatory. In the literature the transconjuctival removal of large orbital tumors is reported only occasionally. Our group has no experience with cryosurgery of orbital cavernomas, but we are intrigued that the transconjunctival extraction of large orbital cavernomas using a cryoprobe is so safe that they can be removed without regard to their position. Trauma to cranial nerves by traction or compression seems to be eliminated with the transconjunctival cryoextraction. A search of MEDLINE reveals that not many other surgical centers have been able to share and to publish the advantages of this technique. ALEXANDER F. SCHEUERLE
Heidelberg, Germany
REFERENCES
1. Scheuerle AF, Steiner HH, Kolling G, Aschoff A. Treatment and long-term outcome of patients with orbital cavernomas. Am J Opthalmol 2004;138:237–244. 2. Lazar M, Rosen N, Geyer O. A transconjunctival cryosurgical approach for intraorbital tumors. Aust. N Z J Ophthalmology 1985;13:417– 420. 3. Loewenstein A, Geyer O, Lazar M. Cavernous hemangioma of the orbit: treatment by transconjunctival cryoextraction. Eye 1993;7:597–598.
VOL. 139, NO. 4
Inflow of Ocular Surface Fluid Through Clear Corneal Cataract Incisions: A Laboratory Model AN UNSUTURED CLEAR CORNEAL INCISION FOR PHACO-
emulsification is currently de rigueur, despite the fact that temporal clear corneal incisions have been shown to increase the endophthalmitis rate.1,2 In the study by
CORRESPONDENCE
753