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Orbital Toxicity from Insecticides
OPHTHALMOLOGY
•
JANUARY 1990
recommendation that extensive cryotherapy be limited in elderly patients followed from our beliefs that extensive follow-up care, prolonged management problems, and complications made this treatment more feasible for younger patients. The complications related to dry eye were proportional to the extent of cryotherapy needed to extirpate tumor from the involved conjunctiva. We clearly stated that if "more than one half of the epibulbar conjunctiva (is involved). . . (This) is the most likely to cause severe ocular complications." We have found that ocular dryness after cryotherapy is minimized if only one or two quadrants of conjunctiva is treated. Dr. Kass' reference to two cases of spontaneous resolution of intraepiihelial pagetoid spread does not reflect our experience. We believe that only follow-up care with repeated conjunctival map biopsies is adequate to show conjunctival epithelial involvement. The case reported by Dr. Kass, by his own admission, would not fit into our treatment protocol, since the bulbar conjunctiva was un.: involved. Dr. Kass seems greatly concerned about the reduction of vision after cryotherapy. We would balance this concern against the traditional recommendations for exenteration if tumor spreads to the bulbar conjunctiva as intraepithelial involvement. Not all physicians will medically follow every case of intraepithelial pagetoid spread, since the appropriate treatment for this tumor extension does remain controversial. Our report using cryotherapy is an alternative treatment which may be reasonable in uniocular patients, young patients, and those who refuse exenteration. Next, Dr. Kass states that the potential for multicentric origin of sebaceous carcinoma is well accepted. We maintain that this is not so well accepted and also remains controversial. After mapping conjunctival involvement on now eight patients, we have come to understand that intraepithelial pagetoid involvement can track in any and all directions and certainly produce "skip" areas. Even if the two cases of spontaneous resolution mentioned by Dr. Kass do represent true resolution, it is difficult to rely on this rare occurrence as a treatment modality. There is no evidence, whatsoever, to support the claim that our six patients (now 8) all underwent spontaneous resolution. Our patients were subjected to repeated biopsies before and after cryotherapy. Negative biopsies after cryotherapy are certainly evidence of its efficacy. We disagree that we are not justified in concluding that cryotherapy eradicated the conjunctival disease. It stretches the imagination to believe that these patients all underwent spontaneous resolution in multiple quadrants, after multiple cryotherapies on multiple surgical dates. Dr. Kass is absolutely correct that our current study does not definitively prove the efficacy of cryotherapy. This can only be demonstrated after the test of time. We firmly believe that cryotherapy does effectively treat intraepithelial conjunctival involvement. If spontaneous resolution has occurred in rare cases, it may certainly occur again. We do not believe it is justified to expect this in more than the exceptional case. 4
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VOLUME 97
•
NUMBER 1
In conclusion, Dr. Kass does state his belief that cryotherapy may be effective in the treatment of this disease; but he does not accept that we have successfully demonstrated its efficacy. We had hoped to share our findings of this experimental modality with the ophthalmic community; we expect that treatment modalities will advance in the future, but this treatment has impressed us with its usefulness in cases which have proven not only to be difficult management problems, but also to have the potential for loss of life. One must weigh our reports of visual complications against the two other currently available therapies: exenteration or expectant medical management, with its potential for reinvasion and systemic spread. Needless to say, all of the patients in our series were extensively informed of the ocular complications of cryotherapy. Each of these patients was referred to us after multiple recommendations for orbital exenteration. Their knowledge that dry eye and visual loss were likely seems to be a reasonable price to pay for keeping a globe, maintaining some vision, and hopefully ridding themselves of their tumor. To date, seven of our eight patients remain tumor-free with a follow-up period of almost 55 months. We thank Dr. Kass for his interest and concern, but still maintain that this is both an interesting and effective management in select cases of sebaceous carcinoma with intraepithelial pagetoid spread to the bulbar conjunctiva. We expect to report on the long-term follow-up of these patients who have undergone cryotherapy for sebaceous carcinoma and believe the results will speak for themselves. RICHARD D. LISMAN, MD New York, New York FREDERICK A. JAKOBIEC, MD Boston, Massachusetts PETER SMALL, MD New York, New York
Orbital Toxicity from Insecticides
Dear Editor: In a recent article by Patrinely et al (Ophthalmology 1989; 96:1038-47), one of the reported cases of orbital myositis apparently represented "an unusual orbital toxic reaction" after exposure to topical insecticide. In 1985, we saw a 42-year-old white man who 10 days previously had been exposed to insect spray in his right eye. He had rinsed the eye but stated that the eye was quite irritated. The eye became red and uncomfortable, and he was seen for evaluation at our institution. There was erythema over the medial rectus area, and 5 mm of proptosis was evident. The patient was believed to have posterior scleritis. He was treated with prednisone but did not return for follow-up examination. After reading the article by Patrinely et al in Ophthalmology, we contacted our patient and found out that he
LETTERS
was not the same patient described by Patrinely et al (no other details of that case had been given). We are unaware of an association between orbital inflammatory disease and exposure to insecticide. We wish to know if there have been other cases of this complication associated with insecticide exposure to the eye. HOWARD H. TESSLER, MD JAMES A. GOODWIN, MD CARL GARFINKLE, MD
Chicago, Illinois
Clearing of Bilirubin from Donor Corneas
Dear Editor: I especially appreciated reading the article by Phinney et al (Ophthalmology 1989; 96:1212-4) on bilirubin deposition in the cornea. The question was posed as to how
long staining persists after return of normal serum bilirubin. Some insight might be gleaned from the experience I had with corneal transplants from a donor with chronic obstructive (noninfectious) liver disease with bilirubins in the 20s who had severe icterus and corneal bilirubin staining. On the morning after corneal transplants, the donor button in each of the recipient eyes was intensely yellow stained in dramatic contrast to the normal recipient cornea and sclera. By the second postoperative day, approximately 36 hours after transplant into a normal host, the donor buttons appeared to be clinically normal with no residual yellow stain. Bilirubin can clear rapidly from a stained cornea when transplanted. In the normal host, the clearance probably depends on how rapidly the patient's bilirubin level is falling. RALPH E. WESLEY, MD
Nashville, Tennessee
5
•
JANUARY 1990
recommendation that extensive cryotherapy be limited in elderly patients followed from our beliefs that extensive follow-up care, prolonged management problems, and complications made this treatment more feasible for younger patients. The complications related to dry eye were proportional to the extent of cryotherapy needed to extirpate tumor from the involved conjunctiva. We clearly stated that if "more than one half of the epibulbar conjunctiva (is involved). . . (This) is the most likely to cause severe ocular complications." We have found that ocular dryness after cryotherapy is minimized if only one or two quadrants of conjunctiva is treated. Dr. Kass' reference to two cases of spontaneous resolution of intraepiihelial pagetoid spread does not reflect our experience. We believe that only follow-up care with repeated conjunctival map biopsies is adequate to show conjunctival epithelial involvement. The case reported by Dr. Kass, by his own admission, would not fit into our treatment protocol, since the bulbar conjunctiva was un.: involved. Dr. Kass seems greatly concerned about the reduction of vision after cryotherapy. We would balance this concern against the traditional recommendations for exenteration if tumor spreads to the bulbar conjunctiva as intraepithelial involvement. Not all physicians will medically follow every case of intraepithelial pagetoid spread, since the appropriate treatment for this tumor extension does remain controversial. Our report using cryotherapy is an alternative treatment which may be reasonable in uniocular patients, young patients, and those who refuse exenteration. Next, Dr. Kass states that the potential for multicentric origin of sebaceous carcinoma is well accepted. We maintain that this is not so well accepted and also remains controversial. After mapping conjunctival involvement on now eight patients, we have come to understand that intraepithelial pagetoid involvement can track in any and all directions and certainly produce "skip" areas. Even if the two cases of spontaneous resolution mentioned by Dr. Kass do represent true resolution, it is difficult to rely on this rare occurrence as a treatment modality. There is no evidence, whatsoever, to support the claim that our six patients (now 8) all underwent spontaneous resolution. Our patients were subjected to repeated biopsies before and after cryotherapy. Negative biopsies after cryotherapy are certainly evidence of its efficacy. We disagree that we are not justified in concluding that cryotherapy eradicated the conjunctival disease. It stretches the imagination to believe that these patients all underwent spontaneous resolution in multiple quadrants, after multiple cryotherapies on multiple surgical dates. Dr. Kass is absolutely correct that our current study does not definitively prove the efficacy of cryotherapy. This can only be demonstrated after the test of time. We firmly believe that cryotherapy does effectively treat intraepithelial conjunctival involvement. If spontaneous resolution has occurred in rare cases, it may certainly occur again. We do not believe it is justified to expect this in more than the exceptional case. 4
•
VOLUME 97
•
NUMBER 1
In conclusion, Dr. Kass does state his belief that cryotherapy may be effective in the treatment of this disease; but he does not accept that we have successfully demonstrated its efficacy. We had hoped to share our findings of this experimental modality with the ophthalmic community; we expect that treatment modalities will advance in the future, but this treatment has impressed us with its usefulness in cases which have proven not only to be difficult management problems, but also to have the potential for loss of life. One must weigh our reports of visual complications against the two other currently available therapies: exenteration or expectant medical management, with its potential for reinvasion and systemic spread. Needless to say, all of the patients in our series were extensively informed of the ocular complications of cryotherapy. Each of these patients was referred to us after multiple recommendations for orbital exenteration. Their knowledge that dry eye and visual loss were likely seems to be a reasonable price to pay for keeping a globe, maintaining some vision, and hopefully ridding themselves of their tumor. To date, seven of our eight patients remain tumor-free with a follow-up period of almost 55 months. We thank Dr. Kass for his interest and concern, but still maintain that this is both an interesting and effective management in select cases of sebaceous carcinoma with intraepithelial pagetoid spread to the bulbar conjunctiva. We expect to report on the long-term follow-up of these patients who have undergone cryotherapy for sebaceous carcinoma and believe the results will speak for themselves. RICHARD D. LISMAN, MD New York, New York FREDERICK A. JAKOBIEC, MD Boston, Massachusetts PETER SMALL, MD New York, New York
Orbital Toxicity from Insecticides
Dear Editor: In a recent article by Patrinely et al (Ophthalmology 1989; 96:1038-47), one of the reported cases of orbital myositis apparently represented "an unusual orbital toxic reaction" after exposure to topical insecticide. In 1985, we saw a 42-year-old white man who 10 days previously had been exposed to insect spray in his right eye. He had rinsed the eye but stated that the eye was quite irritated. The eye became red and uncomfortable, and he was seen for evaluation at our institution. There was erythema over the medial rectus area, and 5 mm of proptosis was evident. The patient was believed to have posterior scleritis. He was treated with prednisone but did not return for follow-up examination. After reading the article by Patrinely et al in Ophthalmology, we contacted our patient and found out that he
LETTERS
was not the same patient described by Patrinely et al (no other details of that case had been given). We are unaware of an association between orbital inflammatory disease and exposure to insecticide. We wish to know if there have been other cases of this complication associated with insecticide exposure to the eye. HOWARD H. TESSLER, MD JAMES A. GOODWIN, MD CARL GARFINKLE, MD
Chicago, Illinois
Clearing of Bilirubin from Donor Corneas
Dear Editor: I especially appreciated reading the article by Phinney et al (Ophthalmology 1989; 96:1212-4) on bilirubin deposition in the cornea. The question was posed as to how
long staining persists after return of normal serum bilirubin. Some insight might be gleaned from the experience I had with corneal transplants from a donor with chronic obstructive (noninfectious) liver disease with bilirubins in the 20s who had severe icterus and corneal bilirubin staining. On the morning after corneal transplants, the donor button in each of the recipient eyes was intensely yellow stained in dramatic contrast to the normal recipient cornea and sclera. By the second postoperative day, approximately 36 hours after transplant into a normal host, the donor buttons appeared to be clinically normal with no residual yellow stain. Bilirubin can clear rapidly from a stained cornea when transplanted. In the normal host, the clearance probably depends on how rapidly the patient's bilirubin level is falling. RALPH E. WESLEY, MD
Nashville, Tennessee
5