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Risk Factors for Orbital Exenteration in Periocular Basal Cell Carcinoma
keratoplasty: features, risk factors, and outcomes. Am J Ophthalmol 2012;153(5):949 –957.
is a risk factor. However, patients with failed PK are more likely to have factors known from PK literature to influence rejection risk, including corneal vascularization, synechiae formation, and history of glaucoma. These confounders will need to be controlled before failed PK per se can be concluded to be a risk factor. Five of the 30 rejection episodes occurred within 3 months of the DSEK procedure. All grafts had cleared sufficiently to allow visualization of rejection findings. For the 5 rejection episodes, surgical indications were Fuchs dystrophy (n ⫽ 2), pseudophakic bullous keratopathy (n ⫽ 2), and failed PK (n ⫽ 1). Two patients had history of glaucoma surgery, and 1 had medically treated glaucoma. Two patients were noncompliant with postoperative steroids. Three patients, 2 of whom had advanced rejection findings of diffuse graft edema associated with keratic precipitates at presentation, progressed to graft failure despite treatment. Because of the small number, there is no identifiable trend in the clinical profiles of these 5 patients with rejection early in their postoperative course. Eight of 30 rejection episodes did not resolve. All 8 patients had advanced rejection findings, displaying diffuse graft edema and signs of acute inflammation. The clinical profile of these patients, compared with the 22 rejection cases that resolved, showed a trend toward the following characteristics: female gender (7/8 vs 11/22), black race (4/8 vs 6/22), history of glaucoma (6/8 vs 4/22), and pseudophakic bullous keratopathy as surgical indication (5/8 vs 6/22). Our current postoperative steroid regimen is as outlined in the article. Patients are prescribed prednisolone acetate 1% or difluprednate 0.05% (for cases with more surgical manipulation or postoperative inflammation) every 2 hours for 1 week, then 4 times daily for remainder of month 1, three times daily for month 2, twice daily for month 3, and then maintained at daily. We no longer discontinue steroids without precipitating factors, as was done in our earlier cases. In instances of intraocular pressure increase resulting from steroid response, the inciting steroid is substituted with loteprednol 0.2% or 0.5% or fluorometholone 0.25% daily. These patients also are referred to the glaucoma service for management.
Risk Factors for Orbital Exenteration in Periocular Basal Cell Carcinoma EDITOR: I READ WITH GREAT INTEREST THE RECENT REPORT BY
Iuliano and associates describing orbital exenteration in patients with orbital invasion of periocular basal cell carcinoma.1 A striking finding was that the authors could achieve negative tumor margins in only half of the patients who underwent exenteration (12 of 24 patients). Typically, exenteration has a surgical goal of attaining local tumor control via negative margins when offered to patients with orbital extension of malignancy. Thus, seeing half of the patients in the study with positive margins seems high. There is no mention in the article if any of these patients underwent exenteration with a surgical goal of tumor debulking for cosmetic disfigurement, which is sometimes offered for such patients. I am also curious as to whether these 12 cases were multidisciplinary surgical cases with such services as neurosurgery and otolaryngology used as a best attempt to achieve negative surgical margins. Additionally, was frozen section intraoperative margin control used in these patients in an attempt to achieve negative margins? These are important points to address because the surgical goal in most instances during exenteration for orbital malignancy is complete tumor excision with negative tumor margins, and if this does not seem plausible after careful interpretation of preoperative orbital radiography, it is my belief that a treatment method other than surgery should be offered. ROMAN SHINDER
Brooklyn, New York CONFLICT OF INTEREST DISCLOSURES: ALL AUTHORS have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
ELAINE I. WU DAVID C. RITTERBAND GUOPEI YU REBECCA A. SHIELDS JOHN A. SEEDOR
REFERENCE
1. Iuliano A, Strianese D, Uccello G, Diplomatico A, Tebaldi S, Bonavolontà G. Risk factors for orbital exenteration in periocular basal cell carcinoma. Am J Ophthalmol 2012;153(2): 238 –241.
New York and Valhalla, New York CONFLICT OF INTEREST DISCLOSURES: SEE THE ORIGINAL article1 for any disclosures of the authors.
REPLY WE THANK DR SHINDER FOR HIS COMMENTS ON OUR ARTI-
cle.1 We reported that we were not able to achieve negative tumor margins in half of the patients who underwent exenteration because, in those 12 patients, tumor infiltration already had reached the bone. In fact, as
REFERENCE
1. Wu EI, Ritterband DC, Yu G, Shields RA, Seedor JA. Graft rejection following Descemet stripping automated endothelial
212
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
JULY
2012
is a risk factor. However, patients with failed PK are more likely to have factors known from PK literature to influence rejection risk, including corneal vascularization, synechiae formation, and history of glaucoma. These confounders will need to be controlled before failed PK per se can be concluded to be a risk factor. Five of the 30 rejection episodes occurred within 3 months of the DSEK procedure. All grafts had cleared sufficiently to allow visualization of rejection findings. For the 5 rejection episodes, surgical indications were Fuchs dystrophy (n ⫽ 2), pseudophakic bullous keratopathy (n ⫽ 2), and failed PK (n ⫽ 1). Two patients had history of glaucoma surgery, and 1 had medically treated glaucoma. Two patients were noncompliant with postoperative steroids. Three patients, 2 of whom had advanced rejection findings of diffuse graft edema associated with keratic precipitates at presentation, progressed to graft failure despite treatment. Because of the small number, there is no identifiable trend in the clinical profiles of these 5 patients with rejection early in their postoperative course. Eight of 30 rejection episodes did not resolve. All 8 patients had advanced rejection findings, displaying diffuse graft edema and signs of acute inflammation. The clinical profile of these patients, compared with the 22 rejection cases that resolved, showed a trend toward the following characteristics: female gender (7/8 vs 11/22), black race (4/8 vs 6/22), history of glaucoma (6/8 vs 4/22), and pseudophakic bullous keratopathy as surgical indication (5/8 vs 6/22). Our current postoperative steroid regimen is as outlined in the article. Patients are prescribed prednisolone acetate 1% or difluprednate 0.05% (for cases with more surgical manipulation or postoperative inflammation) every 2 hours for 1 week, then 4 times daily for remainder of month 1, three times daily for month 2, twice daily for month 3, and then maintained at daily. We no longer discontinue steroids without precipitating factors, as was done in our earlier cases. In instances of intraocular pressure increase resulting from steroid response, the inciting steroid is substituted with loteprednol 0.2% or 0.5% or fluorometholone 0.25% daily. These patients also are referred to the glaucoma service for management.
Risk Factors for Orbital Exenteration in Periocular Basal Cell Carcinoma EDITOR: I READ WITH GREAT INTEREST THE RECENT REPORT BY
Iuliano and associates describing orbital exenteration in patients with orbital invasion of periocular basal cell carcinoma.1 A striking finding was that the authors could achieve negative tumor margins in only half of the patients who underwent exenteration (12 of 24 patients). Typically, exenteration has a surgical goal of attaining local tumor control via negative margins when offered to patients with orbital extension of malignancy. Thus, seeing half of the patients in the study with positive margins seems high. There is no mention in the article if any of these patients underwent exenteration with a surgical goal of tumor debulking for cosmetic disfigurement, which is sometimes offered for such patients. I am also curious as to whether these 12 cases were multidisciplinary surgical cases with such services as neurosurgery and otolaryngology used as a best attempt to achieve negative surgical margins. Additionally, was frozen section intraoperative margin control used in these patients in an attempt to achieve negative margins? These are important points to address because the surgical goal in most instances during exenteration for orbital malignancy is complete tumor excision with negative tumor margins, and if this does not seem plausible after careful interpretation of preoperative orbital radiography, it is my belief that a treatment method other than surgery should be offered. ROMAN SHINDER
Brooklyn, New York CONFLICT OF INTEREST DISCLOSURES: ALL AUTHORS have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
ELAINE I. WU DAVID C. RITTERBAND GUOPEI YU REBECCA A. SHIELDS JOHN A. SEEDOR
REFERENCE
1. Iuliano A, Strianese D, Uccello G, Diplomatico A, Tebaldi S, Bonavolontà G. Risk factors for orbital exenteration in periocular basal cell carcinoma. Am J Ophthalmol 2012;153(2): 238 –241.
New York and Valhalla, New York CONFLICT OF INTEREST DISCLOSURES: SEE THE ORIGINAL article1 for any disclosures of the authors.
REPLY WE THANK DR SHINDER FOR HIS COMMENTS ON OUR ARTI-
cle.1 We reported that we were not able to achieve negative tumor margins in half of the patients who underwent exenteration because, in those 12 patients, tumor infiltration already had reached the bone. In fact, as
REFERENCE
1. Wu EI, Ritterband DC, Yu G, Shields RA, Seedor JA. Graft rejection following Descemet stripping automated endothelial
212
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
JULY
2012