Ophthal Plast Reconstr Surg, Vol. 30, No. 6, 2014
Reply re: “Foam Sclerotherapy for Periorbital Dermoid Cysts” To the Editor:
We thank Gupta et al. for their appreciation of our article “Foam Sclerotherapy for Periorbital Dermoids.”1 We agree with Gupta et al., that sclerotherapy is not a new technique for treatment of several head and neck lesions. The article by Golden et al.2 in 2007 represents sequential sclerotherapy of 2 dermoid cysts performed in collaboration with an interventional radiologist, both of which were orbital dermoids. In both their cases, surgery would have been extensive and orbital in nature. As stated in our article, ours was the first attempt to address periorbital cysts that were superficial, but large enough to preclude excision without visible scarring. With regards to the concerns raised about the foaming, we have only replicated the foaming technique used for other indications. It is not possible to guess the exact dose and distribution dynamics of the foam within the cyst unless a prospective trial is conducted. We did use narrow suction tip to aspirate the contents, when 18G needle did not yield a good tap. This was often assisted by manual expression. The purpose of initially using an 18G needle was to rule out an epidermoid or retention cyst that contains clear fluid, which can be easily aspirated. Occasional solid tissues within the cyst can easily be noted on computed tomography scan, and such cases can have a larger incision, or are best excised surgically. In our experience, it is rare for a dermoid to contain such solid tissues. We would allow Gupta et al. to split hairs between the definitions of a “minimally invasive” and a “nonsurgical” technique and leave them with the choice of words. In our opinion, this technique certainly is a step forward in the treatment of dermoid cysts by a less invasive approach, especially for large periorbital dermoids.1We disagree with Gupta et al., that excision is ideal for dermoids, and that scars are not a concern. Small dermoids presenting early in life can certainly be excised via hidden incisions. However, late presentations and large periorbital dermoids are difficult to excise without a conspicuous scar, and sclerotherapy is promising in these cases. All our patients were given a choice between excision and sclerotherapy, and all were willing to try sclerotherapy to avoid a scar. Similarly, Golden et al. have recommended a minimally invasive approach for orbital dermoids.2 We do not believe that an endoscopic approach as suggested by Gupta et al. is an option for large dermoids. Hiding an incision and avoiding an incision are two different philosophies. Foam sclerotherapy was simpler, shorter, and minimally invasive in our cases of large periorbital dermoids. Regarding the comment about the short follow-up, we would like to bring the attention of Gupta et al. to the Table that mentions the average follow up of 13.25 months. As already stated in the discussion, the residual asymmetry in the posttreatment photographs is due to chronic expansion of tissues, and not recurrence of the dermoid. However, we are following up these cases to watch for recurrence, which is biologically possible. As much as we would have liked to perform posttreatment CT scan for academic purposes (and to satisfy reviewers!), the patient’s motivation and willingness to undergo a computed tomography scan after a cosmetically pleasing resolution of the dermoid was extremely low. The added hazard of radiation, albeit small, precludes us from medically advising the same. We applaud Gupta et al. to envisage excision of the collapsed cyst to prove the ablated status of the epithelium. Although we are certain that Gupta et al. would be able to convince their patients to undergo this additional “show-proof ” step, we would
Letters to the Editor
continue to remain happy with a clinically resolved cyst after foam sclerotherapy. As Max Planck once said, “A scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up that is familiar with it”.
Milind Naik, Jyoti Batra, Akshay G. Nair, Mohammad Javed Ali, Swathi Kaliki, Dilip K. Mishra,
M.D. M.D. M.D. M.D. M.D. M.D.
Correspondence: Milind N. Naik, M.D., LV Prasad Eye Institute, LV Prasad Marg, Banjara Hills, Hyderabad 500034, India ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Naik MN, Batra J, Nair AG, et al. Foam sclerotherapy for periorbitaldermoid cysts. Ophthal Plast Reconstr Surg 2014;30:267–70. 2. Golden RP, Shiels WE 2nd, Cahill KV, et al. Percutaneous drainage andablation of orbital dermoid cysts. J AAPOS 2007;11:438–42.
Re: “Multidisciplinary Management of Lacrimal Sac/Nasolacrimal Duct Carcinomas” To the Editor: In a recent publication, El-Sawy et al.1 described a multidisciplinary approach, including globe-sparing surgery in a significant proportion of cases, when managing patients with tumors affecting the lacrimal drainage apparatus. The authors state that their survival rate is superior to previous studies, and they offer some guidelines when a mass is encountered in the lacrimal sac during a dacryocystorhinostomy. However, these ideas are not new and surprisingly they do not quote our multicentre study where we presented a series of 37 cases of lacrimal drainage apparatus tumors, two-thirds of which were epithelial lesions. Fourteen of our cases were carcinoma, and only 2 of these required orbital exenteration as part of their initial en bloc excision (1 additional subsequently after recurrence), a larger proportion having globe-sparing surgery as reported by El-Sawy et al. We reported an overall disease-free survival rate of 89% with a mean follow up of 38 months, and 4 of our patients died of local recurrence and/or metastatic disease. These figures are similar to those reported by El-Sawy et al. In our 2006 study,2 we presented a detailed discussion and flow chart describing a multidisciplinary approach when confronted with a tumor affecting the lacrimal drainage apparatus, based on histopathology, including the need for a biopsy when encountering a suspicious mass during a dacryocystorhinostomy and delaying this procedure until clarifying the diagnosis, as El-Sawy et al. iterate in their discussion. One possible reason that our series was not quoted is that it does not appear on a simple PubMed search using the term “lacrimal sac tumor.” It does appear, however, when the term “lacrimal drainage apparatus tumour” was searched. This emphasizes the need to use care when performing literature searches. El-Sawy et al. do quote an article (their reference 15) that is a review of the clinical features and management of lacrimal drainage apparatus tumors.3 This
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
531
Ophthal Plast Reconstr Surg, Vol. 30, No. 6, 2014
Letters to the Editor
thorough review does reference our article, and if El-Sawy et al. had checked the bibliography of this review, they would have had an additional opportunity to find our article. None of the other 5 references in their bibliography since 2006 cited our publication, so there are clearly difficulties in locating all appropriate references on this topic.
Alejandra A. Valenzuela, M.D. Alan McNab, F.R.A.N.Z.C.O. Timothy J. Sullivan, F.R.A.N.Z.C.O. Correspondence: Alejandra A. Valenzuela, M.D., Department of Ophthalmology, Tulane University & Tulane Health Sciences Centre, 1430 Tulane Ave., SL-69, New Orleans, LA 70112 ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. El-Sawy T, Frank SJ, Hanna E, et al. Multidisciplinary management of lacrimal sac/nasolacrimal duct carcinomas. Ophthal Plast Reconstr Surg 2013;29:454–7. 2. Valenzuela AA, McNab AA, Selva D, et al. Clinical features and management of tumors affecting the lacrimal drainage apparatus. Ophthal Plast Reconstr Surg 2006;22:96–101. 3. Heindl LM, Jünemann AG, Kruse FE, et al. Tumors of the lacrimal drainage system. Orbit 2010;29:298–306.
Re: “Local Steroid Injection for Management of Different Types of Acute Idiopathic Orbital Inflammation: An 8-Year Study” To the Editor: We read with great interest the recent publication by Mohammad1 on their 8-year experiences on local steroid injection for patient with idiopathic orbital inflammatory disease. The study seems to demonstrate excellent clinical efficacy in treating the disease without significant systemic or local complications. In the study protocol, patients given steroid injection were concomitantly prescribed with nonsteroidal anti-inflammatory drugs (NSAIDs) for 2 weeks after the procedure. However, NSAIDs are well known to be one of the standard treatment options in management of the disease. In the case series published by Mannor et al.,2 17 of the 26 patients (65%) showed complete clinical response with oral NSAIDs alone. We are curious if part of the treatment effect demonstrated in the study could be confounded by the NSAIDs instead of solely from the local steroid injection. A refinement of the study design such as establishing a control arm with patients only on NSAIDs or giving steroid injection without NSAIDs might be able to further validate the results of this study.
Jasper K.W. Wong, M.B.Ch.B., M.R.C.S.Ed Jacky W.Y. Lee, M.B.B.S., F.R.C.S.Ed., F.H.K.A.M.(Ophth) Can Y.F. Yuen, M.B.B.S., F.R.C.S.Ed, F.H.K.A.M.(Ophth) Correspondence: Jasper K.W. Wong, M.B.Ch.B., Department of Ophthalmology, Caritas Medical Centre, Hong Kong ([email protected])
532
The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Mohammad AEA. Local steroid injection for management of different types of acute idiopathic orbital inflammation: an 8-year study. Ophthal Plast Reconstr Surg 2013;29:286–9. 2. Mannor GE, Rose GE, Moseley IF, et al. Outcome of orbital myositis: clinical features associated with recurrence. Ophthalmology 1997;104:409–14.
Re: “Vascular Malformations of the Orbit: Classification and the Role of Imaging in Diagnosis and Treatment Strategies” To the Editor: In their interesting review article, Rootman et al.1 showed an excellent insight into the orbital vascular malformation based on hemodynamics of the lesions. In the treatment strategies for the cavernous venous malformation of the deep orbital apex, they suggested useful surgical tips and techniques and recommended conformal radiotherapy2 (not radiosurgery) for the cases which were very difficult to access. Of note, the authors described that they “do not prefer radiosurgery because risk of optic nerve damage is greater due to concentrated dosing.” We would like to comment our experience of multisession gamma knife radiosurgery (GKRS) on apical cavernous hemangioma.3 Three patients underwent GKRS for the lesion showing compressive optic neuropathy. Each patient was treated with a total radiation dose of 20 Gy in 4 sessions (5 Gy in each session with an isodose line of 50%) delivered to the tumor margin. The patients showed volume reduction of 73–76% and improvement in visual function for 24–42 months of follow-up period.3 After the case series report, four more patients have been treated with the same protocol. None of the 7 patients demonstrated any radiation-related visual morbidity during 17–79 months of follow-up. For the cases of apical cavernous venous malformations which have high surgical morbidities, multisession GKRS can be considered as one of the treatment strategies for an effective and safe treatment outcome.
Kyung In Woo, M.D., Ph.D. Yoon-Duck Kim, M.D., Ph.D. Correspondence: Yoon-Duck Kim, M.D., Ph.D., Sungkyunkwan University School of Medicine, Samsung Medical Center, 50 Irwon-dong Kangnam-ku, 135-710 Seoul, Korea (ydkimoph@ skku.edu) The authors have no financial or conflicts of interests to disclose.
REFERENCES 1. Rootman J, Heran MK, Graeb DA. Vascular malformations of the orbit: classification and the role of imaging in diagnosis and treatment strategies*. Ophthal Plast Reconstr Surg 2014;30:91–104. 2. Rootman DB, Rootman J, Gregory S, et al. Stereotactic fractionated radiotherapy for cavernous venous malformations (hemangioma) of the orbit. Ophthal Plast Reconstr Surg 2012;28:96–102. 3. Goh ASC, Kim YD, Woo KI, Lee JI. Benign orbital apex tumors treated with multisession gamma knife radiosurgery. Ophthalmology 2013;120:635–641.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Reply re: “Foam Sclerotherapy for Periorbital Dermoid Cysts” To the Editor:
We thank Gupta et al. for their appreciation of our article “Foam Sclerotherapy for Periorbital Dermoids.”1 We agree with Gupta et al., that sclerotherapy is not a new technique for treatment of several head and neck lesions. The article by Golden et al.2 in 2007 represents sequential sclerotherapy of 2 dermoid cysts performed in collaboration with an interventional radiologist, both of which were orbital dermoids. In both their cases, surgery would have been extensive and orbital in nature. As stated in our article, ours was the first attempt to address periorbital cysts that were superficial, but large enough to preclude excision without visible scarring. With regards to the concerns raised about the foaming, we have only replicated the foaming technique used for other indications. It is not possible to guess the exact dose and distribution dynamics of the foam within the cyst unless a prospective trial is conducted. We did use narrow suction tip to aspirate the contents, when 18G needle did not yield a good tap. This was often assisted by manual expression. The purpose of initially using an 18G needle was to rule out an epidermoid or retention cyst that contains clear fluid, which can be easily aspirated. Occasional solid tissues within the cyst can easily be noted on computed tomography scan, and such cases can have a larger incision, or are best excised surgically. In our experience, it is rare for a dermoid to contain such solid tissues. We would allow Gupta et al. to split hairs between the definitions of a “minimally invasive” and a “nonsurgical” technique and leave them with the choice of words. In our opinion, this technique certainly is a step forward in the treatment of dermoid cysts by a less invasive approach, especially for large periorbital dermoids.1We disagree with Gupta et al., that excision is ideal for dermoids, and that scars are not a concern. Small dermoids presenting early in life can certainly be excised via hidden incisions. However, late presentations and large periorbital dermoids are difficult to excise without a conspicuous scar, and sclerotherapy is promising in these cases. All our patients were given a choice between excision and sclerotherapy, and all were willing to try sclerotherapy to avoid a scar. Similarly, Golden et al. have recommended a minimally invasive approach for orbital dermoids.2 We do not believe that an endoscopic approach as suggested by Gupta et al. is an option for large dermoids. Hiding an incision and avoiding an incision are two different philosophies. Foam sclerotherapy was simpler, shorter, and minimally invasive in our cases of large periorbital dermoids. Regarding the comment about the short follow-up, we would like to bring the attention of Gupta et al. to the Table that mentions the average follow up of 13.25 months. As already stated in the discussion, the residual asymmetry in the posttreatment photographs is due to chronic expansion of tissues, and not recurrence of the dermoid. However, we are following up these cases to watch for recurrence, which is biologically possible. As much as we would have liked to perform posttreatment CT scan for academic purposes (and to satisfy reviewers!), the patient’s motivation and willingness to undergo a computed tomography scan after a cosmetically pleasing resolution of the dermoid was extremely low. The added hazard of radiation, albeit small, precludes us from medically advising the same. We applaud Gupta et al. to envisage excision of the collapsed cyst to prove the ablated status of the epithelium. Although we are certain that Gupta et al. would be able to convince their patients to undergo this additional “show-proof ” step, we would
Letters to the Editor
continue to remain happy with a clinically resolved cyst after foam sclerotherapy. As Max Planck once said, “A scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up that is familiar with it”.
Milind Naik, Jyoti Batra, Akshay G. Nair, Mohammad Javed Ali, Swathi Kaliki, Dilip K. Mishra,
M.D. M.D. M.D. M.D. M.D. M.D.
Correspondence: Milind N. Naik, M.D., LV Prasad Eye Institute, LV Prasad Marg, Banjara Hills, Hyderabad 500034, India ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Naik MN, Batra J, Nair AG, et al. Foam sclerotherapy for periorbitaldermoid cysts. Ophthal Plast Reconstr Surg 2014;30:267–70. 2. Golden RP, Shiels WE 2nd, Cahill KV, et al. Percutaneous drainage andablation of orbital dermoid cysts. J AAPOS 2007;11:438–42.
Re: “Multidisciplinary Management of Lacrimal Sac/Nasolacrimal Duct Carcinomas” To the Editor: In a recent publication, El-Sawy et al.1 described a multidisciplinary approach, including globe-sparing surgery in a significant proportion of cases, when managing patients with tumors affecting the lacrimal drainage apparatus. The authors state that their survival rate is superior to previous studies, and they offer some guidelines when a mass is encountered in the lacrimal sac during a dacryocystorhinostomy. However, these ideas are not new and surprisingly they do not quote our multicentre study where we presented a series of 37 cases of lacrimal drainage apparatus tumors, two-thirds of which were epithelial lesions. Fourteen of our cases were carcinoma, and only 2 of these required orbital exenteration as part of their initial en bloc excision (1 additional subsequently after recurrence), a larger proportion having globe-sparing surgery as reported by El-Sawy et al. We reported an overall disease-free survival rate of 89% with a mean follow up of 38 months, and 4 of our patients died of local recurrence and/or metastatic disease. These figures are similar to those reported by El-Sawy et al. In our 2006 study,2 we presented a detailed discussion and flow chart describing a multidisciplinary approach when confronted with a tumor affecting the lacrimal drainage apparatus, based on histopathology, including the need for a biopsy when encountering a suspicious mass during a dacryocystorhinostomy and delaying this procedure until clarifying the diagnosis, as El-Sawy et al. iterate in their discussion. One possible reason that our series was not quoted is that it does not appear on a simple PubMed search using the term “lacrimal sac tumor.” It does appear, however, when the term “lacrimal drainage apparatus tumour” was searched. This emphasizes the need to use care when performing literature searches. El-Sawy et al. do quote an article (their reference 15) that is a review of the clinical features and management of lacrimal drainage apparatus tumors.3 This
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
531
Ophthal Plast Reconstr Surg, Vol. 30, No. 6, 2014
Letters to the Editor
thorough review does reference our article, and if El-Sawy et al. had checked the bibliography of this review, they would have had an additional opportunity to find our article. None of the other 5 references in their bibliography since 2006 cited our publication, so there are clearly difficulties in locating all appropriate references on this topic.
Alejandra A. Valenzuela, M.D. Alan McNab, F.R.A.N.Z.C.O. Timothy J. Sullivan, F.R.A.N.Z.C.O. Correspondence: Alejandra A. Valenzuela, M.D., Department of Ophthalmology, Tulane University & Tulane Health Sciences Centre, 1430 Tulane Ave., SL-69, New Orleans, LA 70112 ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. El-Sawy T, Frank SJ, Hanna E, et al. Multidisciplinary management of lacrimal sac/nasolacrimal duct carcinomas. Ophthal Plast Reconstr Surg 2013;29:454–7. 2. Valenzuela AA, McNab AA, Selva D, et al. Clinical features and management of tumors affecting the lacrimal drainage apparatus. Ophthal Plast Reconstr Surg 2006;22:96–101. 3. Heindl LM, Jünemann AG, Kruse FE, et al. Tumors of the lacrimal drainage system. Orbit 2010;29:298–306.
Re: “Local Steroid Injection for Management of Different Types of Acute Idiopathic Orbital Inflammation: An 8-Year Study” To the Editor: We read with great interest the recent publication by Mohammad1 on their 8-year experiences on local steroid injection for patient with idiopathic orbital inflammatory disease. The study seems to demonstrate excellent clinical efficacy in treating the disease without significant systemic or local complications. In the study protocol, patients given steroid injection were concomitantly prescribed with nonsteroidal anti-inflammatory drugs (NSAIDs) for 2 weeks after the procedure. However, NSAIDs are well known to be one of the standard treatment options in management of the disease. In the case series published by Mannor et al.,2 17 of the 26 patients (65%) showed complete clinical response with oral NSAIDs alone. We are curious if part of the treatment effect demonstrated in the study could be confounded by the NSAIDs instead of solely from the local steroid injection. A refinement of the study design such as establishing a control arm with patients only on NSAIDs or giving steroid injection without NSAIDs might be able to further validate the results of this study.
Jasper K.W. Wong, M.B.Ch.B., M.R.C.S.Ed Jacky W.Y. Lee, M.B.B.S., F.R.C.S.Ed., F.H.K.A.M.(Ophth) Can Y.F. Yuen, M.B.B.S., F.R.C.S.Ed, F.H.K.A.M.(Ophth) Correspondence: Jasper K.W. Wong, M.B.Ch.B., Department of Ophthalmology, Caritas Medical Centre, Hong Kong ([email protected])
532
The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Mohammad AEA. Local steroid injection for management of different types of acute idiopathic orbital inflammation: an 8-year study. Ophthal Plast Reconstr Surg 2013;29:286–9. 2. Mannor GE, Rose GE, Moseley IF, et al. Outcome of orbital myositis: clinical features associated with recurrence. Ophthalmology 1997;104:409–14.
Re: “Vascular Malformations of the Orbit: Classification and the Role of Imaging in Diagnosis and Treatment Strategies” To the Editor: In their interesting review article, Rootman et al.1 showed an excellent insight into the orbital vascular malformation based on hemodynamics of the lesions. In the treatment strategies for the cavernous venous malformation of the deep orbital apex, they suggested useful surgical tips and techniques and recommended conformal radiotherapy2 (not radiosurgery) for the cases which were very difficult to access. Of note, the authors described that they “do not prefer radiosurgery because risk of optic nerve damage is greater due to concentrated dosing.” We would like to comment our experience of multisession gamma knife radiosurgery (GKRS) on apical cavernous hemangioma.3 Three patients underwent GKRS for the lesion showing compressive optic neuropathy. Each patient was treated with a total radiation dose of 20 Gy in 4 sessions (5 Gy in each session with an isodose line of 50%) delivered to the tumor margin. The patients showed volume reduction of 73–76% and improvement in visual function for 24–42 months of follow-up period.3 After the case series report, four more patients have been treated with the same protocol. None of the 7 patients demonstrated any radiation-related visual morbidity during 17–79 months of follow-up. For the cases of apical cavernous venous malformations which have high surgical morbidities, multisession GKRS can be considered as one of the treatment strategies for an effective and safe treatment outcome.
Kyung In Woo, M.D., Ph.D. Yoon-Duck Kim, M.D., Ph.D. Correspondence: Yoon-Duck Kim, M.D., Ph.D., Sungkyunkwan University School of Medicine, Samsung Medical Center, 50 Irwon-dong Kangnam-ku, 135-710 Seoul, Korea (ydkimoph@ skku.edu) The authors have no financial or conflicts of interests to disclose.
REFERENCES 1. Rootman J, Heran MK, Graeb DA. Vascular malformations of the orbit: classification and the role of imaging in diagnosis and treatment strategies*. Ophthal Plast Reconstr Surg 2014;30:91–104. 2. Rootman DB, Rootman J, Gregory S, et al. Stereotactic fractionated radiotherapy for cavernous venous malformations (hemangioma) of the orbit. Ophthal Plast Reconstr Surg 2012;28:96–102. 3. Goh ASC, Kim YD, Woo KI, Lee JI. Benign orbital apex tumors treated with multisession gamma knife radiosurgery. Ophthalmology 2013;120:635–641.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
