The mean age at the time of radiotherapy was 38.5 years (range, 35 to 45 years; SD, ⫾4.43). The geometric mean pretreatment Snellen acuity at distance was 20/70 (range, 20/30 to 20/200; SD, ⫾3.4 lines). Humphrey visual field indices revealed an average pretreatment mean deviation of ⫺22.87 dB (range, ⫺17.77 to ⫺29.04 dB; SD, ⫾5.55) and average foveal sensitivity of 24.5 dB (range, 14 to 33 dB; SD, ⫾8.10). Visual assessment of two patients was performed within three days after treatment. Examination of the other two patients occurred at approximately one and two weeks before the conclusion of radiotherapy. An improvement in geometric mean visual acuity to 20/24 (range, 20/20 to 20/30; SD, ⫾0.87 lines), in mean deviation of 14.59 dB (range, 3.46 to 25.74 dB; SD, ⫾9.23), and in foveal sensitivity of 9.0 dB (range, 0 to 20 dB; SD, ⫾8.25) was observed (Figure). The standard radiation dose for ONSM is 50 to 54 Gy, administered in fractions of 1.7 to 1.8 Gy over six weeks.1 This protocol was derived from retrospective studies of progression-free survival rates in patients with benign intracranial meningioma in all locations.4 Advances in radiation therapy have permitted more accurate target localization and treatment delivery, reducing complications and improving progression-free survival rates.4 No study has attempted to define the optimal dose for ONSM. The current “one dose for all” approach does not take into account the severity of visual loss, the amount of optic atrophy, the size of the tumor, or the individual variation in tumor sensitivity to radiation. It also remains unknown when radiation treatment should be administered during the natural history of an ONSM to achieve maximum benefit.5 Our experience highlights a feature of radiation therapy for ONSM that has not been appreciated widely: improvement can start to occur even before the completion of treatment. This was observed in all four patients who were tested during or immediately after radiation treatment. How often such rapid improvement occurs is unknown, because the remaining 31 patients were not tested until several months after radiation therapy. Optic nerve function can be measured with exquisite sensitivity, affording an opportunity to determine how the patient is responding even while treatment is still underway. It may be useful to assess visual function regularly during the course of radiation treatment for ONSM. We predict that those patients who show an early response will have the best long-term outcome. If visual acuity returns to normal or the visual field indices show major improvement during treatment, it may be appropriate to reduce the planned total radiation dosage. Such a strategy would decrease the risk of radiation retinopathy and optic neuropathy.6,7 A randomized trial to determine the optimum radiotherapeutic dose for ONSM remains necessary. 344
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1. Carrasco JR, Penne RB. Optic nerve sheath meningiomas and advanced treatment options. Curr Opin Ophthalmol 2004;15: 406 – 410. 2. Smith JL, Vuksanovic MM, Yates BM, Bienfang DC. Radiation therapy for primary optic nerve meningiomas. J Clin Neuroophthalmol 1981;1:85–99. 3. Lee AG, Woo SY, Miller NR, Safran AB, Grant WH, Butler EB. Improvement in visual function in an eye with a presumed optic nerve sheath meningioma after treatment with threedimensional conformal radiation therapy. J Neuroophthalmol 1996;16:247–251. 4. Goldsmith BJ, Wara WM, Wilson CB, Larson DA. Postoperative irradiation for subtotally resected meningiomas: a retrospective analysis of 140 patients treated from 1967 to 1990. J Neurosurg 1994;80:195–201. 5. Egan RA, Lessell S. A contribution to the natural history of optic nerve sheath meningiomas. Arch Ophthalmol 2002;120: 1505–1508. 6. Subramanian PS, Bressler NM, Miller NR. Radiation retinopathy after fractionated stereotactic radiotherapy for optic nerve sheath meningioma. Ophthalmology 2004;111:565–567. 7. Lessell S. Friendly fire: neurogenic visual loss from radiation therapy. J Neuroophthalmol 2004;24:243–250.
Temporary Suture Tarsorrhaphy Alan W. McInnes, MD, John R. Burroughs, MD, Richard L. Anderson, MD, and John D. McCann, MD, PhD PURPOSE: To describe a technique for performing a bolsterless temporary tarsorrhaphy. DESIGN: Retrospective analysis and surgical technique description. METHODS: Temporary suture tarsorrhaphy (TST), which consists of a suture through the upper and lower eyelid posterior lamella, was performed after eyelid or socket surgery. RESULTS: Over 15 years, >1000 patients in the practice of one of the authors (R.L.A.) had TST that successfully maintained corneal coverage without complications in all but four eyes. In two patients, replacement was required because of tissue erosion; in two patients, the suture was placed too posteriorly and caused corneal irritation that required replacement. CONCLUSION: The TST is functionally equivalent to, or superior to, traditional bolster temporary tarsorrhaphy. The TST is faster and simpler, requires fewer materials, Accepted for publication Mar 6, 2006. From the John Moran Eye Center, University of Utah Health Sciences Center (A.W.M.), and Center for Facial Appearances (J.R.B.), (R.L.A.), (J.D.M.), Salt Lake City, Utah. Inquiries to Alan W. McInnes, MD, John Moran Eye Center, University of Utah Health Sciences Center, 75 N Medical Dr, Salt Lake City, UT 84132; e-mail:
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and avoids the risks of bolsters, which include eyelid margin necrosis, irregularities, and lash loss from vascular compromise. (Am J Ophthalmol 2006;142:344 –346. © 2006 by Elsevier Inc. All rights reserved.)
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EMPORARY TARSORRHAPHY TRADITIONALLY USES A
bolster of intravenous tubing, buttons, cotton balls, or other material in an attempt to protect the skin and the underlying tissue from the effects of tension and pressurerelated injuries from the suture. The authors have found that, if the suture does not course over the skin of the eyelids and is anchored in the posterior lamella, then these risks are avoided and a bolster is not required. The bolster does not necessarily protect from pressure-related injuries, and eyelid margin necrosis, lash loss, corneal abrasions, and tissue reaction have been seen. Temporary tarsorrhaphies are placed for a variety of conditions from complications of corneal defects to prevent problems that are related to inadequate lid closure as a result of eyelid surgery. Although bolsterless techniques have been described,1–3 a MEDLINE search revealed no previously published descriptions of a technique that uses a suture through only the posterior lamella of the upper and lower eyelid with a thick 4 – 0 silk suture. Dryden and Adams1 described a more complicated technique that required multiple serpentine passes through skin tissue anterior to the tarsus, essentially through the gray line with 6 – 0 Prolene. Rosenberg2 likewise advocated placing the suture through the gray line with 5– 0 Prolene. The gray line is actually a weak separation plane and provides less strength than tarsal passes. Castillo and Remigio3 described a singlepass technique through the upper and lower eyelids with 5– 0 silk passed through the skin instead of directly through the tarsal meibomian openings.
FIGURE 2. Next, the suture is passed through the meibomian gland orifices of the tarsus of the lower eyelid. The order of passage of the suture through either the upper or lower eyelid is not important as long as the intermarginal suture entry and exit points align between the eyelids (surgeon’s view).
FIGURE 3. Successfully closed eyelids with the use of the temporary suture tarsorrhaphy technique. Caution must be exercised to avoid incorporation of lashes into the tied knot because that could cause ocular irritation from lash-to-globe contact; long (2 cm) suture tails should be left to facilitate later removal (surgeon’s view).
FIGURE 1. Temporary suture tarsorrhaphy starts with placement of a 4 – 0 silk suture through the meibomian gland orifices of the tarsus of the upper eyelid (surgeon’s view).
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The temporary suture tarsorrhaphy (TST) technique uses 4 – 0 silk that is passed intermarginally between the upper and lower eyelid meibomian orifices and incorporates a strong purchase of tarsus (Figures 1 and 2). Passing lengthy, deep suture bites through the tarsus optimizes both strength and alignment. A C-3 or P-3 needle is used commonly, although other suitably strong
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cutting needles are acceptable. The suture ends may be tied permanently or in a bowknot, depending on the need to monitor the underlying ocular surface (Figure 3). A 4 – 0 silk suture that is passed through the tarsus provides a strong closure, causes minimal tissue inflammation, and may remain for several weeks. The 4 – 0 silk is stronger than the traditionally described smaller sutures (for example, 5– 0 or 6 – 0) and is less likely to “cheese-wire” than monofilament or smaller sutures. Bolsters may be inadvisable because they may cause corneal irritation, and the authors have encountered cases of eyelid necrosis and lash loss from their use. This is likely caused by bolster-induced compression and compromise of the marginal arcade that runs 2 mm to 3 mm from the margin in the anterior lamella. Before the procedure, informed consent was obtained from each of the subjects in accord with the Health Insurance Portability and Accountability Act (HIPAA) regulations and the principles outlined in the Declaration of Helsinki. The senior surgeon (R.L.A.) has used the TST for 15 years, mostly after myectomy, on a conservative estimate of ⬎1000 patients; the cases that had complications were noted. Two patients required TST replacement after excessive posterior eyelid margin placement, which caused irritation from suture contact with the globe. Two patients required replacement because of tissue erosion because the suture passes were not placed sufficiently deep (several millimeters) in the tarsus. Also important is leaving the suture ends long (2 cm) to avoid suture contact with the globe and to facilitate removal. Generally, only a single TST is required; however, in socket reconstruction cases when a large conformer is placed, a pair of TSTs provides better closure. In summary, TST has the advantages of safety and speed compared with traditional bolster techniques. A single 4 – 0 silk simplifies the process and leaves the patient with a less conspicuous tarsorrhaphy than bolster techniques. The bowknot option allows examination access to the underlying ocular or orbital contents, and the 4 – 0 silk holds up to repeated tying and untying. Most importantly, TST avoids the potential complication of bolsters.
Carla Andreola, MD, Maria P. D. Ribeiro, MD, Carla R. S. de Carli, MD, Ana Luisa F. Gouvea, MD, and André L. L. Curi, MD, PhD To report an uncommon case of multifocal choroiditis as the result of disseminated Cryptococcus neoformans infection in a patient who is HIV-positive. DESIGN: Interventional case report. METHODS: A 27-year-old HIV-positive woman with fever, headache, and vomiting was examined. Lumbar puncture was performed and revealed C neoformans infection. Her condition evolved with sudden bilateral blindness and deafness. Ophthalmologic examination revealed multiple yellowish choroidal lesions in the posterior pole of both eyes. RESULTS: Postmortem examination showed disseminated C neoformans infection. Histologic examination of the eyes confirmed the presence of C neoformans in the choroids. CONCLUSION: Multifocal choroiditis in C neoformans infection is a rare ophthalmic manifestation. The recognition of this condition by ophthalmologists can help physicians to diagnose a disseminated and fatal disease. (Am J Ophthalmol 2006;142:346 –348. © 2006 by Elsevier Inc. All rights reserved.) PURPOSE:
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fungus that affects preferentially immunosuppressed individuals, although it can affect healthy people. The primary site of infection is the lung, but the disease usually manifests itself in the central nervous system.1,2 Ocular involvement occurs after cryptococcus meningitis and may represent hematogenous dissemination or extension through the leptomeninges. Papilledema, diplopia, nystagmus, sixth nerve palsy, ophthalmoplegia, ptosis, and optic atrophy are complications that are associated with cryptococcus meningitis. Intraocular manifestation includes choroiditis, chorioretinitis, vitritis, endophthalmitis, and neuroretinitis.1 A 27-year-old woman was examined in the emergency department with right hemiplegia and disorientation.
1. Dryden RM, Adams JL. Temporary nonincisional tarsorrhaphy. Ophthalmol Plast Reconstr Surg 1985;1:119 –120. 2. Rosenberg GJ. Temporary tarsorrhaphy suture to prevent or treat scleral show and ectropion secondary to laser resurfacing or laser blepharoplasty. Plast Reconstr Surg 2000;106:721– 727. 3. Castillo GD, Remigio D. Temporary tarsorrhaphy during facial resurfacing surgery. Arch Facial Plast Surg 2001;3: 280 –281.
Accepted for publication Mar 7, 2006. From the Department of Ophthalmology, AIDS Section, Centro Previdenciário de Niterói, Rio de Janeiro, Brazil (C.A., A.L.L.C.); Department of Infectious Disease (M.P.D.R., A.L.L.C.) and Department of Pathology (C.R.S.deC., A.L.F.G., A.L.L.C.), Federal Fluminense University, Niterói, Rio de Janeiro, Brazil; and Department of Ophthalmology, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil (A.L.L.C.). Inquiries to André L. L. Curi, MD, PhD, R. Francisco Dutra 150/801, Icarai,Niteroi,RiodeJaneiro,Brazil,CEP:24220-150;e-mail:curiall@yahoo. com
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