indian journal of ophthalmology

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INDIAN JOURNAL OF OPHTHALMOLOGY Contents Vol. 56

No. 3

May-June 2008

Editorial Marching ahead with clinical trial registration

175

Barun Kumar Nayak

Editorial Policy Statement Statement on publishing clinical trials in Indian biomedical journals

177

K Satyanarayana, Anju Sharma, Purvish Parikh, VK Vijayan, DK Sahu, Barun K Nayak, RK Gulati, Mahendra N Parikh, Prati Pal Singh, SB Bavdekar, U Sreehari, Peush Sahni

Review Article Diabetic retinopathy: An update

179

Ramandeep Singh, Kim Ramasamy, Chandran Abraham, Vishali Gupta, Amod Gupta

Original Articles An observational study of the proceedings of the All India Ophthalmological Conference, 2000 and subsequent publication in indexed journals

189

Upreet Dhaliwal, Rajeev Kumar

Transconjunctival penetration of mitomycin C

197

T Velpandian, Ramanjit Sihota, Ankur Sinha, Viney Gupta

Symposium Distinguishing infectious versus noninfectious keratitis

203

M Srinivasan, Jeena Mascarenhas, CN Prashanth

Investigative modalities in infectious keratitis

209

Noopur Gupta, Radhika Tandon

Medical management approach to infectious keratitis

215

Nikhil S Gokhale

First aid for complications of infectious keratitis

221

Vinaykumar Agrawal

Ophthalmology Practice Practical approach to medical management of glaucoma

223

Rajul S Parikh, Shefali R Parikh, Shoba Navin, Ellen Arun, Ravi Thomas

Brief Communications Periocular necrotizing fasciitis associated with kerato-conjunctivitis and treated with medical management: A case report 231 Debraj Shome, Vandana Jain, Chaitra Jayadev, Kiran Shah, Sundaram Natarajan

Calculating graft size and position in rotational corneal autografting: A simplified approach 233 Srinivas K Rao, Dennis SC Lam

CMYK

15

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Sudoriferous cyst of the orbit of adult origin after trauma

235

Anjali Mehta, Aparna Rao, Apoorva Khanna

Recurrent neovascularization of the disc in sympathetic ophthalmia

237

Raju Sampangi, Pradeep Venkatesh, Subrata Mandal, Sat Paul Garg

Giant hanging melanoma of the eyelid skin

239

Radha R Pai, Hema Kini, Sai Giridhar Kamath, Suneet Kumar

Descemet’s membrane detachment caused by inadvertent vancomycin injection

241

Harsha Bhattacharjee, Kasturi Bhattacharjee, Jnanankar Medhi, Abu Altaf

Voriconazole for the treatment of refractory Aspergillus fumigatus keratitis

243

Hijab Mehta, Hitendra B Mehta, Prashant Garg, Harish Kodial

Acute orbital abscess complicating deep posterior subtenon triamcinolone injection

246

Jaspreet Sukhija, Mangat R Dogra, Jagat Ram, Parul Ichhpujani, Amod Gupta

Transconjunctival orbital emphysema caused by compressed air injury: A case report

247

Mathew Sunu, Vasu Usha, Francis Febson, Nazareth Colin

Isolated and silent spinal neurocysticercosis associated with pseudotumor cerebri

249

Rabindra N Mohapatra, Jaya K Pattanaik, Sanjoy K Satpathy, Sonia Joshi

Letters to the Editor Sterilization of phacoemulsification handpieces

253

Ravi Thomas

Right traumatic carotico-cavernous fistula with bilateral eye signs and post-treatment right pseudo Argyll Robertson pupil

253

Mary Santhosh, Santhosh Joseph, Priyanka Doctor

Debate on the various anti-vascular endothelial growth factor drugs

255

Mohammad Reza Khalili, Hamid Hosseini

Authors’ reply

256

Manish Nagpal, Kamal Nagpal, PN Nagpal

Primary 25-guage transconjunctival sutureless vitrectomy in pseudophakic retinal detachment

256

Arvind K Dubey, Benu Dubey

Authors’ reply

257

Fatih Horozoglu, Ates Yanyalı, Erkan Celık, Banu Aytug, Ahmet F Nohutcu

Intra-cameral injection of bevacizumab (Avastin) to treat anterior chamber neovascular membrane in a painful blind eye

258

Manisha Agarwal, Suneeta Dubey

Intravitreal bevacizumab (Avastin) for the treatment of proliferative sickle retinopathy

259

Saad Shaikh

16

CMYK

Journal Abstracts

261

Training Program

264

Continuing Medical Education

265

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Brief Communications

Another important manifestation in this case was NVD. Although occurrence of NVD is known in Behcet’s disease, chronic uveitis4 and Vogt Koyanagi Harada disease,5 it has not been reported in SO to the best of our knowledge. NVD was of recurrent nature with the recurrence of inßammation. In our patient the clinical setting of previous ocular surgery and Þndings in the left eye were consistent with a diagnosis of SO. Early and prompt use of immunosuppressive therapy with systemic steroids and steroid-sparing agents such as cyclosporin A,6 azathioprine,6 chlorambucil have improved the prognosis in patients with SO. In our case we were able to use methotrexate to successfully control the inßammation after initial treatment with a combination of intravenous, oral and topical steroids. After the initial control of inflammation the patient developed NVD after 14 weeks of immunosuppressive treatment. Considering that this was the only seeing eye of the patient and also the lack of a well-deÞned protocol for treating such NVD in chronic uveitis, we decided to treat the patient with PST injection of triamcinalone acetonide. A PRP was also done considering the one-eyed status although there was no ischemia on FFA. The combined therapeutic approach was initially effective and resulted in regression of the NVD after 12 weeks. However, the NVD recurred within 8 weeks and was associated with multifocal serous detachments and inßammation in the vitreous cavity. On restarting steroids with another PST injection of triamcinalone acetonide the serous detachments resolved within four days.

239

Although the initial occurrence of NVD was not associated with increased activity in vitreous its prompt response to steroids (systemic + PST) and its later recurrence with inßammation is suggestive of an inßammatory pathomechanism. The role of PRP in this case is unclear, however, the recurrence of NVD with ßare-up of inßammation suggests that PRP may not be useful in this setting. We suggest that systemic immunosuppression along with repeated PST injection of triamcinalone acetonide may be useful in treating such NVD in chronic uveitis.

References 1.

Kilmartin DJ, Dick AD, Forrester JV. Prospective surveillance of sympathetic ophthalmia in the United Kingdom and Republic of Ireland. Br J Ophthalmol 2000;84:259-63.

2.

Kilmartin DJ, Dick AD, Forrester JV. Sympathetic ophthalmia risk following vitrectomy: Should we counsel patients? Br J Ophthalmol 2000;84:448-9.

3.

Pollack AL, McDonald HR, Ai E, Green WR, Halpern LS, Jampol LM, et al. Sympathetic ophthalmia associated with parsplana vitrectomy without antecedent penetrating trauma. Retina 2001;21:146-54.

4.

Sanislo SR, Lowder CY, Kaiser PK, Gutman FA, Zegarra H, Dodds EM, et al. Corticosteroid therapy for optic disc neovascularization secondary to chronic uveitis. Am J Ophthalmol 2000;130:724-31.

5.

To KW, Nadel AJ, Brockhurst RJ. Optic disc neovascularization in association with Vogt-Koyanagi-Harada syndrome. Arch Ophthalmol. 1990;108:918-9.

6.

Vote BJ, Hall A, Cairns J, Buttery R. Changing trends in sympathetic ophthalmia. Clin Exp Ophthalmol 2004;32:542-5.

Giant hanging melanoma of the eyelid skin

Nodular melanoma of a large size arising and hanging from the skin of the upper eyelid as seen in this case, is an unusual Þnding.

Radha R Pai, MD; Hema Kini, MD; Sai Giridhar Kamath, MS, FRCS; Suneet Kumar, MBBS

Case Report

Cutaneous melanoma of the eyelid is a rare entity. We present a 53-year-old male who had a nevus on the left upper eyelid skin since childhood, which transformed into a huge ulcerated hanging mass in the same region. Excision of the mass was done and histopathology conÞrmed the diagnosis of nodular malignant melanoma. A small preauricular lymph node showed metastatic melanoma on Þne needle aspiration cytology. Key words: Eyelid neoplasms, malignant melanoma Indian J Ophthalmol 2008;56:239-40

Melanoma of the eyelid has an incidence of approximately 1% of all eyelid tumors, the conjunctival surface being excluded.1,2

Departments of Pathology (RRP, HK, SK) and Ophthalmology (SGK), Kasturba Medical College, Mangalore, India Correspondence to: Dr. Radha R Pai, Department of Pathology, Kasturba Medical College, P. O. Box 53, Mangalore - 575 001, Karnataka, India. E-mail: [email protected] Manuscript received: 16.03.07; Revision accepted: 31.07.07

A 53-year-old male presented with an enlarging mass of the left upper eyelid since one year. He gave history of a nevus in the same location since childhood. On examination, a protuberant, nodular, ulcerated brown to black mass measuring 5 × 4.5 × 4 cm was seen arising from the skin of the upper eyelid and hanging downwards over the cheek [Fig. 1]. The lid margin was not involved. The conjunctiva was normal. The best corrected visual acuity was 20/30 N6 and 20/40 N8 in the right and left eyes respectively. Vision did not improve beyond that due to nuclear sclerosis and posterior subcapsular cataract. A small preauricular lymph node was palpable on the left side. Excision of the mass was done maintaining a margin of 8 mm around the tumor base to ensure adequate excision. There was loss of about three-fourths of the upper eyelid. Hence, for reconstruction a free tarsal graft was sourced from the right upper eyelid and sutured in position to the remnant of the tarsus on the excised eyelid of the left eye. The skin and orbicularis oculi muscle were undermined from the area above the eyelid and then advanced inferiorly to cover the tarsal graft. Postoperative appearance was cosmetically acceptable and there was neither lagophthalmos nor corneal exposure on closure of the eye. Histopathologically, features were of malignant melanoma (Clark’s level V, Breslow thickness 45 mm). Epithelioid and spindle tumor cells containing melanin pigment

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240

Indian Journal of Ophthalmology

Figure 1: Photograph showing the ulcerated tumor of the eyelid hanging on the cheek

Vol. 56 No. 3

the sixth to seventh decade of life. Either the upper or lower eyelid may be involved and predominantly it is of nodular type.1,3 To the best of our knowledge in the available literature, among the nodular melanomas the present case is the largest.1,36 The maximum size recorded is 40 × 42 mm but the type of melanoma is not mentioned.6 Among the different types of melanomas, lentigo maligna melanoma was among the largest tumors at presentation (750 mm2), which despite being thinner, was considered to be a greater surgical challenge.7 Melanoma of the eyelid skin has slightly better prognosis than its counterpart elsewhere. Though melanomas developing at the mucocutaneous lid margins were described to be at a greater risk of metastasis in one series,1 the same was not conÞrmed by the other.3 Simple thickness measurement is preferred to stage melanoma of the eyelid skin since the total dermis is exceptionally thin in this region and a Stage V melanoma on Clark’s scale would often be a much smaller lesion than such a lesion at other sites.7 The recommended treatment is complete surgical excision with a margin of normal skin to surround the tumor. A narrow excision margin of 5 mm or less is associated with a greater frequency of recurrence.7 Regional lymph node dissection in cases of completely excised cutaneous melanoma of head and neck did not result in increased survival, regardless of depth of tumor invasion.8 About 15 months later the patient presented with marked enlargement of the left preauricular metastatic lymph node. There was no local recurrence. Clinically, there was no evidence of metastatic disease at any other site. The patient refused further radiological investigations and treatment.

References

Figure 2: Histopathology showing skin with in ltrating melanin pigment containing epithelioid tumor cells (Hematoxylin and Eosin ×100)

were seen with brisk mitoses (3 to 5 mitoses/high-power Þeld) and junctional activity [Fig. 2]. There was no evidence of the nevus. Nontumorogenic radial growth phase was absent. Fine needle aspiration cytology of the preauricular lymph node showed metastatic melanoma. The patient was briefed about additional investigations for staging, further surgery and radiotherapy/chemotherapy as advised by the oncologist. He was not willing to undergo further treatment. Keeping in mind the poor prognosis for survival in melanoma with metastasis the patient was discharged after palliative surgery.

Discussion Melanoma of the eyelid accounts for less than 7% of head and neck region cutaneous melanomas.1 The majority are seen in

1.

Garner A, Koorneef L, Levene A, Collin JR. Malignant melanoma of the eye lid skin: Histopathology and clinical behaviour. Br J Ophthalmol 1985;69:180-6.

2.

Sunderraj P. Malignant tumours of the eye and adnexa. Indian J Ophthalmol 1991;39:6-8.

3.

Grossniclaus HE, McClean IW. Cutaneous melanoma of the eye lid-Clinicopathologic features. Ophthalmology 1991;98:1867-73.

4.

Tahery DP, Goldberg R, Moy RL. Malignant melanoma of the eyelid. J Am Acad Dermatol 1992;27:17-21.

5.

Malhotra R, Chen C, Huilgol SC, Hill DC, Selva D. Mapped serial excision for perioricular lentigo maligna and lentigo maligna melanoma. Ophthalmology 2003;110:2011-8.

6.

Chan FM, O’Donnell, Whitehead K, Ryman W, Sullivan TJ. Treatments and outcomes of malignant melanoma of the eyelid a review of 29 cases in Australia. Ophthalmology 2007;114:187-92.

7.

Vaziri M, Buffam FV, Martinka M, Oryschak A, Dhaliwal H, White VA. Clinicopathologic features and behaviour of cutaneous eye lid melanoma. Ophthalmology 2002;109:901-8.

8.

Wanebo HJ, Cooper PH, Young DV, Harpole DH, Kaiser DL. Prognostic factors in head and neck melanoma: Effect of lesion location. Cancer 1988;62:831-7.