Faculty Bibliography

The authors report 2 cases of apocrine cystadenoma of the eyelid, 1 of which was studied with immunohistochemical and other special stains. While a previous report describes the tumor in a palpebro-orbital location, no other detailed descriptions of a purely eyelid location are present in the literature. Apocrine cystadenoma occupies an unusual portion of the spectrum of Moll gland tumors of the eyelid. It has no definitive clinical characteristics and may be diagnosed pathologically by hematoxylin-eosin-stained sections.

PURPOSE: To evaluate the clinical behavior of spheno-orbital meningiomas with regard to World Health Organization (WHO) tumor grade and Ki-67, a cellular marker of proliferation. METHODS: A retrospective review over a 16-year period of the demographic, clinical, radiographic, and surgical data of all patients with spheno-orbital meningioma who underwent surgical resection. Tumor specimens were examined histologically using the current WHO 2016 classification and immunohistochemically using Ki-67/MIB-1 monoclonal antibody. RESULTS: Thirty-eight patients met all inclusion criteria: 78.9% of tumors were WHO grade I with a mean Ki-67 of 3.76, and 93% of patients were clinically stable at last follow up; 10.5% of lesions were WHO grade II (atypical) with a mean Ki-67 of 14.93, and 10.5% of lesions were WHO grade III (anaplastic) with a mean Ki-67 of 58.3. All grade II and III meningiomas exhibited an aggressive clinical course. There were statistically significant correlations between disease clinical progression and WHO tumor grade (p < 0.001), between disease clinical progression and Ki-67 (p < 0.001), and between increasing Ki-67 index and higher WHO grade (p < 0.001). For WHO grade I lesions, a Ki-67 of >/=3.3 correlated with recurrence (p = 0.0256). Overall, disease-specific mortality occurred in 5 (13%) patients. CONCLUSIONS: Ki-67 index is a valuable marker to use in conjunction with WHO grade to predict meningioma behavior, particularly in histologically borderline lesions, and possibly to identify a subset of WHO grade I tumors at risk of recurrence. This combination of methods can aid in tailoring treatment and surveillance strategies.

OBJECTIVE: To assess outcomes after endoscopic endonasal surgery for recurrent or residual pituitary adenomas. METHODS: We retrospectively analyzed 61 patients from 2009 - 2016 that underwent endoscopic endonasal surgery for recurrent or residual pituitary adenomas after prior microscopic or endoscopic transphenoidal operation. RESULTS: Prior surgical approach was endoscopic endonasal in 55.7% and microscopic in 44.2%. The mean preoperative maximal tumor diameter was 2.3cm. Tumor commonly invaded the suprasellar cistern (63.9%). Gross total resection (GTR) was achieved in 31 (51.7%) patients. GTR rate was 68.4% and 21.7% for Knosp grade 0-2 and grade 3-4 tumors, respectively (p<0.001). GTR was 73.1% and 35.3% for patients with previous microscopic and endoscopic transphenoidal surgery, respectively (p=0.002). On multivariate analysis, smaller tumor size (odds ratio [OR] 1.1 per cm, p=0.007), Knosp grade 0-2 (OR 9.7, p=0.002), and prior microscopic approach (OR 12.7, p=0.007) were independent predictors of GTR. Preoperative visual deficit outcome was improvement in 32.5%, unchanged in 62.5%, and worse in 5.0%. New postoperative endocrinopathies included adrenal insufficiency (6.5%), hypothyroidism (8.1%), hypogonadism (6.5%), and diabetes insipidus (4.9%). Complications included postoperative CSF leak (4.9%), meningitis (1.6%), medical complications (4.9%), and postoperative hematoma requiring re-exploration (3.2%). CONCLUSION: The endoscopic endonasal approach provides a safe and effective option for recurrent pituitary adenomas. Smaller tumor size, absence of cavernous sinus invasion, and prior microscopic approach were independent predictors of GTR. This might suggest inadequate exposure or limited viewing angle may adversely affect extent of resection in primary microscopic surgeries.

The authors describe a spindle cell lipoma that occurred in the anterior lamellae of the eyelid in a 47-year-old man. This benign tumor was reported previously only once within that location and poses histologic challenges when a "low fat" or "fat free" variant is present.

The authors describe a rare case of a primary extradural ectopic meningioma occurring in a 9-year-old female. A review of the literature with respect to clinical presentation, radiographic findings, management, and outcome among similar cases is discussed. Common features that may assist with diagnosing this unusual tumor include absence of bone or optic nerve sheath involvement, presentation at a young age, occurrence in the medial orbit, and sinus asymmetry on radiographic imaging. Preferred method of treatment is complete surgical excision.

PURPOSE: To describe two cases of choroidal hemorrhage caused by optic disk drusen-induced choroidal neovascularization simulating uveal melanoma. METHODS: Observational case reports of two patients and brief review of the literature. RESULTS: Two patients were referred with pigmented juxtapapillary lesions concerning for choroidal melanoma. Multimodal imaging revealed the presence of optic disk drusen with overlying choroidal neovascular membranes and peripapillary choroidal hemorrhage. Both patients were treated with antivascular endothelial growth factor and the lesions resolved. CONCLUSION: In the setting of diagnostic uncertainty, careful multimodal imaging can assist in distinguishing between malignant choroidal melanoma and a benign simulating lesion. Optic disk drusen with associated neovascularization and hemorrhage should be included in the list of pseudomelanomas.

IMPORTANCE: Ophthalmic artery chemosurgery (OAC) has emerged as a primary treatment for advanced-stage retinoblastoma. To our knowledge, the incidence of orbital recurrence in eyes treated with OAC has not been described. OBJECTIVE: To determine the incidence of orbital recurrence following enucleation or OAC as primary treatments for advanced-stage retinoblastoma. DESIGN, SETTING, AND PARTICIPANTS: Single-institution cohort study with retrospective record review at an academic ophthalmic oncology practice. A total of 140 eyes in 135 patients who presented between February 14, 2006, and March 4, 2014, and were classified as having Reese-Ellsworth group 5 or International Classification of Retinoblastoma (Children's Oncology Group) group D or E retinoblastoma were included; 63 patients (63 eyes) were primarily treated with enucleation and 72 patients (77 eyes) were primarily treated with OAC. This analysis was conducted between August 1, 2014, and March 1, 2015. MAIN OUTCOMES AND MEASURES: Incidence of and time to orbital recurrence, metastasis, and death. RESULTS: There were 5 orbital recurrences (incidence, 7.9%) in the primary enucleation group and 1 orbital recurrence (incidence, 1.3%) in the primary OAC group during median follow-up times of 42.6 months (range, 6.2-97.1 months) and 38.7 months (range, 9.0-104.3 months), respectively. The 24-month Kaplan-Meier estimate for orbital recurrence-free survival was worse for the enucleation group (92.1%; 95% CI, 82.0-96.7) than for the OAC group (100%) (log-rank test, P = .049). The enucleation group had 5 cases of metastatic disease (7.9%) and 2 deaths (3.2%). In the OAC group, there were 3 cases of metastatic disease (4.2%) and no deaths. Kaplan-Meier analysis of metastasis-free survival and overall survival yielded no differences between the 2 treatment groups. Analysis of a number of features of the 2 groups revealed more eyes with iris neovascularization in the enucleation group (25.4%) than in the OAC group (5.2%) and more eyes with group E retinoblastoma in the enucleation group (87.3%) than in the OAC group (29.9%), although neither of these factors was an independent predictor of orbital relapse in a Cox proportional hazards model. CONCLUSIONS AND RELEVANCE: In this single-institution retrospective study of advanced intraocular retinoblastoma, there were more orbital recurrences in the group primarily treated with enucleation. Ophthalmic artery chemosurgery for advanced intraocular retinoblastoma was not found to increase the chance of orbital recurrence, metastatic disease, or death compared with primary enucleation.

PURPOSE:: To describe a case series of ointment granuloma as a complication of sutureless transconjunctival blepharoplasty. METHODS:: A retrospective review of the medical records of 8 patients with this complication was conducted, including the histopathology of excised tissues. Institutional review board oversight was waived as this was not an institutional study but a Health Insurance Portability and Accountability Act-compliant retrospective chart review from the private medical practice of one of authors' coauthors. It adhered to the principles set forth in the Declaration of Helsinki. RESULTS:: Eight patients developed painless lower eyelid and anterior orbital masses following presumed successful blepharoplasty. Each had received intra- or immediate postoperative lubricating ointment. The mean time from surgery to appearance of the lesions was 50 days (range: 9 days-10 months). Three patients responded to intralesional injection of steroid with complete resolution. Five patients required surgical excision of the lesions without recurrence to date. Histopathological examination of the excised tissues revealed large, pleomorphic lipid-dropout pools bordered by attenuated histiocytes and giant cells. CONCLUSIONS:: The appearance of eyelid lumps or fullness in the early and mid-postoperative recovery should suggest ointment granuloma. If recognized early, management should commence with intralesional injection of steroids, although the definitive treatment is surgical excision. The authors recommend minimizing the access of topical ointments to the open inferior fornix, placing the medication sparingly onto the cornea at the close of surgery and instructing patients in avoiding overuse.