types of benign and malignant eyelid lesions, especially chronic inflammation of different types, and sebaceous carcinoma may mimic a chalazion.4 Although ...
Ophthalmology Volume 120, Number 5, May 2013
Internal Limiting Membrane Peeling For Primary Rhegmatogenous Retinal Detachment Repair The formation of macular pucker (MP) can limit functional visual recovery after rhegmatogenous retinal detachment (RRD) repair.1 The internal limiting membrane (ILM), composed of the footplate of Muller glia, has been considered a scaffold for proliferation of retinal glia, hyalocytes, and metaplastic retinal pigment epithelium after operative MP removal, contributing to recurrent MP.2 Peeling the ILM removes the posterior hyaloid and vitreous cortex, epiretinal membrane, and can relieve tractional forces, improve macular hole closure rate, and reduce secondary MP formation.3 We report a nonrandomized, multisurgeon, retrospective, 2-arm clinical trial evaluating the incidence of postoperative MP after primary RRD repair with or without triamcinolone-acetonide (TA)-assisted ILM peeling. After a coding search of a database from a large retina referral practice (The Retina Institute, St. Louis, MO) of 708 eyes, we identified 62 eyes with primary RRD that underwent repair without ILM peeling (n ⫽ 32; group 1) or with TA-assisted ILM peeling (n ⫽ 30; group 2). Patients with a history of preoperative MP, RD surgery, tractional RD, proliferative vitreoretinopathy, silicone oil tamponade, choroidal detachment, trauma, retinal dialysis, cryoretinopexy, laser retinopexy, focal or grid or pan-retinal laser photocoagulation, proliferative retinopathy owing to retinovascular disease (e.g., diabetes mellitus), infectious retinitis, intraocular lens exchange, and aphakia were excluded. In all cases, RRD repair included standard 3-port vitrectomy pars plana vitrectomy, posterior vitreous detachment, endolaser or cryotherapy for retinopexy, internal drainage of subretinal fluid via retinotomy or preexisting break, fluid–air exchange, and instillation of intraocular gas tamponade. In all cases of ILM peeling (group 2), nondiluted TA (Kenalog-40, 40 mg/ml; Bristol Myers Squibb, Princeton, NJ) was injected intravitreally to visualize the posterior vitreous cortex, hyaloid, MP, and ILM, as described previously.4 After membrane stripping of these structures, TA was completely removed by aspiration to ensure no residual TA was present before fluid– gas exchange (Video 1, available at http://aaojournal.org). Statistical comparisons were performed using the Fischer exact test, paired t test, Student t test, or Mann–Whitney U test, depending on the nature of the variable. The mean age ⫾ standard deviation of patients was 66.1⫾10.5 years in group 1 and 67.5⫾10.2 in group 2 (P ⫽ 0.65; Table 1, available at http://aaojournal.org). Baseline (20/382 vs 20/256, P ⫽ 1.00) and postoperative (20/40 vs 20/58, P ⫽ 0.11) Snellen visual acuities were similar in both groups (P ⫽ 0.43; Table 1, available at http://aaojournal.org). The mean follow-up time ⫾ standard deviation was 633⫾473 days in group 1 and 434⫾317 days in group 2 (P ⫽ 0.08; Table 1, available at http://aaojournal.org). In each group, there was a clinically and statistically significant improvement in Snellen visual acuity after RRD repair (group 1, 20/382 vs 20/40; group 2, 20/256 vs 20/58; P⬍10–3 in both groups; Table 2, available at http://aaojournal.org). There were no differences between the 2 groups with regard to gender, laterality, number of retinal breaks, macula status, duration from diagnosis to surgery, concomitant scleral buckling, or magnitude of visual acuity improvement after RRD repair. In group 1, 34.4% of eyes developed postoperative MP, with a mean Snellen acuity of 20/40. In contrast, 3.3% of eyes in group 2 developed pucker; visual acuity (n ⫽ 1) was 20/25 (P ⫽ 0.0027; Table 3, available at http://aaojournal.org). The number need to treat to prevent 1 postoperative MP is 4. Overall, 9.4% in group 1 underwent repeated surgery for removal of MP (mean preoperative acuity, 20/141 improving to a mean of 20/47 postoperatively; Table 4, available at http://aaojournal.org). No patients in group 2 underwent surgery for postoperative MP (non-clinically significant MP in 1 patient). The number need to treat to prevent 1 surgery for postoperative MP is 11. Limitations of this study include the nonuniform use of OCT, and its retrospective nature. A possible confounder in this study is the use of intravitreal TA, which was not used in group 1, but was used in group 2 for improved visualization during ILM peeling. Although the possibility remains that TA itself may prevent postoperative MP formation, TA was fastidiously removed before fluid–gas exchange because the effects and concentration of remaining TA after fluid–gas exchange cannot be predicted. In addition, the relatively small number of secondary surgeries for removal of postoperative MP limited statistical comparisons on 2 variables: improvement of visual acuity after postoperative MP removal in group 1, and rate of secondary surgery between groups 1 and 2. Although the limitations of this retrospective study preclude concluding an advantage to ILM peeling for uncomplicated, primary RRD repair to reduce MP, this pilot analysis provides insight toward devising a larger, randomized, prospective clinical trial to assess whether ILM peeling remains beneficial in this context. Such a trial would include similar inclusion and exclusion criteria, as well as control and intervention groups. Pre- and postoperative OCT analyses to assess the presence of MP in each subject should be conducted. Intraoperatively, a similar amount of TA should be injected in each patient from both groups, with consistent TA removal before fluid–air exchange. The primary endpoints would be presence of postoperative MP by OCT and/or clinical biomicroscopy, as well as rate of secondary surgery for postoperative MP. Visual acuities would be a secondary endpoint. Given a confidence interval of 5%, an approximate incidence of 30 000 RRDs per year in the United States, a sample size of 380 patients for such a prospective trial would be appropriate. Previous work has demonstrated a reduction in postoperative MP formation after ILM peeling in proliferative vitreoretinopathy-related retinal detachment.5 In this retrospective pilot series, for the first time we have demonstrated that ILM peeling during uncomplicated, primary RRD repair reduced postoperative MP. Although there was a trend toward lower MP removal rate, it was not significant.
RAJESH C. RAO, MD,1,2 KEVIN J. BLINDER, MD,1,2 BRADLEY T. SMITH, MD,1,2 GAURAV K. SHAH, MD1,2 1
The Retina Institute, St. Louis, Missouri; 2Washington University School of Medicine, Department of Ophthalmology and Visual Sciences, St. Louis, Missouri. Financial Disclosure: R.C.R. was supported by an unrestricted award from Heed Ophthalmic Foundation and Society of Heed Fellows. This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Katira RC, Zamani M, Berinstein DM, et al. Incidence and characteristics of macular pucker formation after primary retinal detachment repair by pars plana vitrectomy alone. Retina 2008;28:744 – 8. 2. Gandorfer A, Haritoglou C, Scheler R, et al. Residual cellular proliferation on the internal limiting membrane in macular pucker surgery. Retina 2012;32:477– 85. 3. Brooks HL, Jr. Macular hole surgery with and without internal limiting membrane peeling. Ophthalmology 2000;107:1939 – 48.
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Reports 4. Schadlu R, Tehrani S, Shah GK, et al. Long-term follow-up results of ILM peeling during vitrectomy surgery for premacular fibrosis. Retina 2008;28:853–7. 5. Aras C, Arici C, Akar S, et al. Peeling of internal limiting membrane during vitrectomy for complicated retinal detachment prevents epimacular membrane formation. Graefes Arch Clin Exp Ophthalmol 2009;247:619 –23.
Tuberculosis of Eyelid Presenting as a Chalazion Inflammatory and neoplastic lesions of the eyelid may present clinically as a primary or recurrent chalazion. We present a case of isolated unilateral tuberculosis of the eyelid masquerading as a partially prolapsed chalazion, missed initially because the curetted material was not sent for histopathology, but diagnosed later when the patient presented with delayed wound healing and accelerated submandibular lymphadenitis. A 17-year-old male student presented with a painless swelling and redness of the left lower lid of about 3 weeks’ duration with no other significant history. His best-corrected visual acuity was 20/20 in the right eye and 20/50 in the left eye. Intraocular pressure was 16 mmHg in both eyes. Examination showed a nodular swelling of the lid with an unremarkable skin surface. A prolapsed granuloma with erythema and congestion was noted on lid eversion. The rest of the ocular surface, anterior segment, and fundus were unremarkable. Regional lymph nodes were not palpable. With a clinical diagnosis of a partially prolapsed chalazion, incision and curettage was carried out. Curetted material was not submitted for histopathology. At 1 week follow-up, delayed wound healing was noted and secondary wound infection was suspected (Fig 1A, available at http://aaojournal.org). The patient was managed conservatively with oral antibiotics. He presented 1 week later with increased inflammation of the lower lid and a grossly enlarged, erythematous, fluctuant, and tender left submandibular lymph node (Fig 1B, available at http://aaojournal.org). A clinical diagnosis of secondary wound infection with suppurative lymphadenitis was made. Fine-needle aspiration biopsy from the lymph node yielded purulent material smears of which showed sheets of polymorphonuclear leucocytes in a background of debris (Fig 2A, available at http://aaojournal.org). Epithelioid cells, granulomas, and caseous necrosis were absent. Grams, Ziehl-Neelsen (ZN), and Gomori’s methenamine silver stains were done to look for infectious etiology. Slender acid fast bacilli were seen with ZN stain (Fig 2B, available at http://aaojournal.org). A diagnosis of tubercular lymphadenitis was thus made. Purulent material was processed for direct microscopy and culture in the microbiology laboratory. Although Gram- and Giemsa-stained smears did not show any organisms, slender acid-fast bacilli were seen with ZN-stained smears. Culture on Lowenstein-Jensen’s medium grew rough, buff, and tough colonies after 3 weeks’ incubation at 37°C, which was identified as Mycobacterium tuberculosis. Multiplex polymerase chain reaction targeting IS6110, MPB64, and protein b for M tuberculosis complex showed amplification of 2 (MPB 64, protein b) out of 3 target genes (Fig 2C, available at http://aaojournal.org).The organism was confirmed to be M tuberculosis. Biopsy from the primary surgical site showed stratified squamous to stratified columnar epithelium ulcerated at places. Stroma showed numerous well-formed granulomas (Fig 3A, available at http://aaojournal.org) composed of epithelioid histiocytes, lymphocytes, and plasma cells (Fig 3B, available at http://aaojournal.org). Numerous polymorphonuclear leucocytes were present in the lumen of the Crypts of Henle. On ZN staining, there were single, acid-fast bacillus in the granulomatous infiltrate. Gomori’s methenamine silver and Gram stain were negative for fungus and bacteria. A diagnosis of tuberculosis of the eyelid with tubercular lymphadenitis was made. Detailed systemic evaluation for tuberculosis was noncontributory, with no evidence of immunosuppression. With antitubercular treatment, the eyelid wound healed with significant regression of the lymphadenitis was evident at 2 months’ follow-up (Fig 4, available at http://aaojournal.org). A PubMed search of the literature revealed only 3 cases of tuberculosis of eyelid and tarsal conjunctiva mimicking a chalazion.1–3 Only 1 of the 3 cases had isolated unilateral tuberculosis of upper tarsal conjunctiva without systemic disease, whereas the other 2 were bilateral and associated with pulmonary tuberculosis. This case emphasizes the importance of routine histopathologic evaluation of curetted material from suspected chalazia. In a large series of 1060 clinically diagnosed chalazia, 6.4% of cases showed a discrepancy between the clinical and histopathologic diagnoses.4 Various types of benign and malignant eyelid lesions, especially chronic inflammation of different types, and sebaceous carcinoma may mimic a chalazion.4 Although rare, tuberculosis of the eyelid should be considered in the differential diagnoses of a chalazion. Suppurative inflammation without granulomas on fine-needle aspiration biopsy of regional lymph nodes in early tuberculosis is not unknown in literature,5 although not reported in ophthalmic literature. Staining of aspiration smears with inexpensive acid-fast stain can help to unmask tubercular lymphadenitis without use of more expensive molecular diagnostic techniques.
RUCHI MITTAL, MD, DEVJYOTI TRIPATHY, MD, SAVITRI SHARMA, MD, PRAVEEN K. BALNE, MSC L.V. Prasad Eye Institute, Department of Ophthalmic Pathology, Bhubaneswar, Odisha, India
References 1. Mocanu C. [Tuberculosis of the tarsal conjunctiva]. Oftalmologia 1996;40:150 –1. 2. Ozdal PC, Codère F, Callejo S, et al. Accuracy of the clinical diagnosis of chalazion. Eye (Lond) 2004;18:135– 8. 3. Aoki M, Kawana S. Bilateral chalazia of the lower eyelids associated with pulmonary tuberculosis. Acta Derm Venereol 2002;82: 386 –7. 4. Salas D, Murthy S, Champ C, Hawksworth N. Primary tuberculosis of the conjunctiva. Eye (Lond) 2001;15:674 – 6. 5. Kumar N, Jain S, Murthy NS. Utility of repeat fine needle aspiration in acute suppurative lesions. Follow-up of 263 cases. Acta Cytol 2004;48:337– 40.
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Ophthalmology Volume 120, Number 5, May 2013 Table 1. Baseline Characteristics of Group 1 and 2 Variable
Group 1
Group 2
No. of patients No. of eyes Age at diagnosis (yrs) Duration of followup (days) Gender: F/M (no. of eyes) Diabetes mellitus Laterality: right/left Lens: pseudophakic/phakic
30 32 62.6⫾10.6 633⫾473 7/25 25% (8/32) 14/18 12/20
30 30 64.0⫾9.7 434⫾317 7/23 20% (6/30) 9/27 21/9
Table 3. ILM Peeling during Primary RRD Repair Reduces Postoperative MP
P-Value
0.60 0.08 1.00 0.76 0.30 0.04*
Variable
Group 1
Group 2
P-Value
Postoperative MP rate Secondary MP removal rate
34.3% (11/32) 9.4% (3/32)
3.3% (1/30) 0% (0/30)
0.0027* 0.24
*Statistically significant.
*Statistically significant.
Table 2. Baseline Retinal Characteristics of Group 1 and 2 Variable
Group 1
Group 2
P-Value
Macula status: on/off Number of retinal breaks Diagnosis to RRD repair (days) Scleral buckling Intraoperative cryotherapy Preoperative visual acuity (LogMAR [Snellen]) Postoperative visual acuity (LogMAR [Snellen]) Visual acuity improvement after RRD repair (LogMAR) P-Value of pre- vs post-operative visual acuities
8/24 1.62⫾0.71 2.77⫾1.96 90.6% (29/32) 9.4% (3/32) 1.28⫾0.83 [20/382] 0.31⫾0.33[20/41] 0.97⫾0.82 ⬍0.001*
8/22 1.73⫾0.98 3.00⫾4.53 80.0% (24/30) 3.3% (1/30) 1.11⫾0.89 [20/256] 0.46⫾0.41[20/58] 0.65⫾0.76 ⬍0.001*
1.00 0.62 0.60 0.29 0.61 1.00 0.11 0.12
*Statistically significant.
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Reports Table 4. Characteristics of MP Variable
Group 1
Group 2
P-Value
Visual acuity of total patients with MP (LogMAR [Snellen]) Visual acuity of patients with clinically significant MP (LogMAR [Snellen]) Visual acuity after MP removal (LogMAR [Snellen])
0.30⫾0.40 (11/32) [20/40] 0.84⫾0.40 (3/32) [20/141] 0.37⫾0.24 (3/32) [20/47]
0.10 (1/30) [20/25] N/A (0/30) N/A (0/30)
N/A N/A N/A
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