Nonparasitic splenic cysts in children: a multicentric study

PURPOSE

Nonparasitic splenic cysts (NPSCs) are uncommon in children. The aim of this multinational and multicentric study was to present the authors' experience as well as the changing trends in the management of NPSCs over the last 25 years.

MATERIAL AND METHODS

From 1981 to 2005, 50 children or adolescents were surgically treated for NPSCs in 6 paediatric surgical centres in four European countries. The medical records of these 50 patients with NPSCs were reviewed retrospectively.

RESULTS

Twenty-six male and 24 female patients were operated on. Age at surgery ranged from 1 to 17 years (mean 11.9). Seventeen patients were symptomatic. Six total (4 open and 2 laparoscopic) and 26 partial (22 open and 4 laparoscopic) splenectomies were performed. Laparoscopic fenestration or deroofing and open cystectomy was carried out in 9 patients, respectively. Histological findings revealed the lesion to be an epidermoid cyst (n = 28), a pseudocyst (n = 15) or a mesothelial cyst (n = 2). In 5 patients haemangioma or lymphangioma was the pathological diagnosis. At a mean follow-up of 2.9 years, residual cysts were found in 8 laparoscopically treated patients, 4 of whom required re-do laparoscopy or open surgery.

CONCLUSIONS

Over the last two decades, the surgical treatment of NPSCs has changed from a formerly customary total splenectomy to spleen-conserving procedures, such as total cystectomy with or without partial splenectomy or partial cystectomy. These therapeutic modalities can be performed laparoscopically, if technically possible. Fenestration or deroofing of the cyst resulted in a high recurrence rate (7/9).

The use of the G1 and Octosmart programs in detecting temporal changes in the visual field

PURPOSE

The Octopus program Octosmart is able to classify visual fields into six classes. In the program a horizontal bar indicates these classes, and an indicator points to the most probable position, related to the measured pathology. The width of this dashed indicator shows the range of possible fluctuations in the measurement and, therefore, its precision. This study sets out to analyse the suitability of this display mode using other visual-field index data.

METHODS

The visual fields of 83 glaucomatous eyes of 61 patients of various etiological groups and glaucoma suspects were studied for periods varying from 1 to 5 years in a retrospective study. All examinations were performed with the G1 Octopus program and analyzed with the Octosmart program. The statistical significance of linear trends of the visual-field indices, mean defect (MD) and corrected loss variance (CLV), and the class shown by the indicator (POI = position of indicator) were determined, and their regression coefficients were analyzed by means of a linear trend test as a function of time.

RESULTS

Of the sample of 83 tested eyes, a total of 18 significant trends were recorded after five examinations. All visual-field indices showed a trend towards amelioration.

CONCLUSIONS

The 18 significant trends observed must be attributed to perturbing long-term fluctuations and, despite their statistical significance, are of little clinical value. It is questionable whether an increased number of examinations per eye would have attenuated the threshold fluctuations sufficiently to make the change in field class more reliable.

Long-term outcome of congenital cystic adenomatoid malformation

To determine the long-term outcome of congenital cystic adenomatoid malformation (CCAM), the records of all patients with CCAM treated in three Hungarian paediatric surgical centers between 1977 and 1996 were reviewed. Patients were followed for up to 20 years following diagnosis and treatment. In 20 patients CCAM was diagnosed postnatally and in 3 prenatally. Biodata including the operative procedures are presented. Follow-up findings between 18 months and 20 years after diagnosis showed better height and weight growth in patients operated upon in later childhood compared with those operated upon in infancy. The older the patient at the time of diagnosis, the better was the long-term outcome.

Isolation and structure revision of pepluane diterpenoids from euphorbia peplus

A new pepluane diterpene polyester (2) was isolated from a CH2Cl2 extract of the whole, undried plant of Euphorbia peplus, together with the known compound 1. The structures were established by high-field spectroscopic methods, including 2D NMR techniques, and by X-ray crystallography, and the stereostructure of the first member of the pepluane diterpenoids (1) was revised.

A stilbene from the roots of leuzea carthamoides

From the roots of Leuzea carthamoides, (E)-3,3'-dimethoxy-4, 4'-dihydroxystilbene (1) has been isolated and its structure elucidated by means of NMR spectroscopy, including HMQC and HMBC measurements, mass spectrometry, and X-ray crystallography.

A myeloproliferative disorder with eosinophilia associated with a unique translocation (3;5)

An association between eosinophilia and a structural chromosome abnormality has been noted in patients with acute non-lymphoblastic leukaemia (ANLL) and a deletion of the long arm of chromosome 16. There have been a number of other associations of specific chromosome abnormalities with neoplastic diseases involving the eosinophilic lineage; these include chromosome 12 short arm rearrangements, trisomy 8, t(8;21), t(5;14) and t(5;12). We report a patient with a myeloproliferative disorder characterized by chronic eosinophilic leukaemia complicated by autoimmune haemolytic anaemia and a previously unreported translocation (3;5)(p13;q13), and discuss the possible contribution of the RASA gene, localized to 5q13.3, to the development of the malignant phenotype.

[Bilateral acute retinal artery necrosis--healing of the second affected eye]

BACKGROUND

The acute retinal necrosis syndrome (ARN) is caused by the Varicella zoster virus or the Herpes simplex virus. However the dosage and duration of the antiviral therapy for prevention of an infection in the second eye or treatment of an infection on an affected fellow eye is still not known. We discuss the timing of a possible steroid treatment and demonstrate in a case report how an acute retinal necrosis syndrome in a fellow eye was successfully treated.

PATIENT

First eye: A 27-year-old not immunocompromised patient (HIV-negative) showed 2 months after a febrile state an acute iritis in the right eye. 14 days later an acute retinal necrosis syndrome was observed. The patient received Acyclovir 3 x 750 mg i.v. for 6 days, and afterwards 5 x 200 mg orally for 5 days. The patient developed an inoperable retinal detachment despite therapy. Second eye: Eight days later the fellow eye developed a localized retinal necrosis. Varicella zoster DNA was found in the aqueous humor using the polymerase chain reaction (PCR). The antiviral therapy with Acyclovir was increased from 1.1 g q 12 h (2 x 15 mg/kg/d) to 1.0 g q 8 h (3 x 12.5 mg/kg/d). After 4 weeks the i.v. therapy was followed by an oral therapy of 5 x 800 mg for 12 weeks. This dosage was reduced to 5 x 400 mg for another 12 weeks. The oral therapy with corticosteroids started on the 11th day with 100 mg Prednisone, in slowly reducing dosage during 18 weeks. The fellow eye recovered fully with a visual acuity of 20/20 after 6 months.

CONCLUSION

The disease started in the fellow eye with an acute iritis and a secondary glaucoma. These symptoms can be a characteristic prodroma of an acute retinal necrosis syndrome caused by a varicella zoster- or Herpes simplex virus infection, which was not recognized first. Whether a long-term therapy (as described above) is necessary or not is unclear on the basis of a single case report, but we currently recommend the high-dose treatment regimen until further data emerge.

[Choroidal effusion and expulsive hemorrhage in penetrating interventions--lesson from 26 patients]

BACKGROUND

The aim of this study was, to analyze in cases of choroidal effusion and expulsive hemorrhage the surgical procedures and to derive recommendations to handle the expulsive event properly and adapted to the phase of the surgical procedure.

MATERIAL

We report on 25 patients (27 eyes), 17 women and 8 male, who suffered from choroidal effusion and/or expulsive hemorrhage during or following surgery, in which the eye was opened. The age at the time of the event was between 52 and 90 years (median 80). 21 times the complication arrived during cataract surgery (age 57-90 years (median 81), five times during or following fistulating glaucoma surgery (age 55-84 years (median 63) and once during corneal transplant surgery (age 52 years).

RESULTS

Old age (50% of the patients > or = 81 years old), local anesthesia (except in one case), then arterial hypertension, coronary heart disease, myocardial infarction are accompanying characteristics in patients with this event. Choroidal effusion and expulsive hemorrhage can usually be managed, if wound closure is always possible and the necessary counterpressure can be applied. This is the case with a step incision and with at least three preplaced strong silk "safety" sutures (7.0 silk). With this technique all our own patients could be managed, but the characteristic of the six patients who were referred to us was, that no safety sutures had been placed. Three cases developed choroidal effusion following filtering procedures in glaucomatous eyes. After revision at the 10th to 15th day following expulsive hemorrhage with evacuation of the suprachoroidal hemorrhage, restoration of the anterior segment and of the vitreous cavity, in three of five desperate patients useful function from hand movement to 0.6 could be reached. Echography is used to determine the time the coagula are liquified and the moment to evacuate the hemorrhage. This is between 10 to 15 days.

CONCLUSIONS

Basically any expulsive event has to be managed by creating counterpressure. This means working in a closed system as long as possible. As long as not a tunnel incision is made, respectively when an expression technique with a large incision is used, together with a step incision at least three strong silk 7.0 "safety" sutures have to be preplaced, to allow a secure closure of the wound in any moment during surgery. If an expulsive event is the cause of protrusion of vitreous, vitrectomy is wrong because this lowers intraocular pressure. Urgent is the closure of the wound, even if vitreous and iris become squeezed into the wound. A sclerotomy is indicated only, if the wound can't be closed. Even if the expulsive hemorrhage leads first to amaurosis, evacuation of the hemorrhage together with revision of the anterior segment, vitrectomy and refilling may bring back some useful visual function. The surgical technique for revision, but also for measures in the different phases of cataract surgery are described in detail.

[Neoplastic space-occupying lesions of the orbits. II. Space-occupying lesion in the area of the lacrimal gland]

In part two of this paper about orbital tumors, neoplasms of the lacrimal gland are discussed: These have to be properly separated from inflammations. While inflammatory affections of the lacrimal gland make up the majority of private practice consultations, in cases referred to an eye clinic the relation between inflammatory diseases and neoplasms is about equal (between 1987 and 1990, 14 neoplasias and 14 inflammations were seen at the University Eye Clinic, Zurich). The benign pleomorphic adenoma of the lacrimal gland should be removed in toto in its capsule. For this procedure a lateral orbital fenestration is required. An excisional biopsy is considered the method of choice while an incisional biopsy should be avoided because of the risk of recurrence. On the other hand, incisional biopsy is used in the cases of adenoidcystic carcinoma and lymphoma. After confirmation of an adenoidcystic carcinoma by biopsy, orbital exenteration has to follow as soon as possible. In cases of lymphoma, possible oncological treatment has to be evaluated. In order to differentiate histologically between a reactive lymphoid hyperplasia and a malignant lymphoma, immunofluorescent studies on non-fixed tissue are necessary in close collaboration with an immuno-pathologist. Because the benign pleomorphic adenoma of the lacrimal gland has to be treated by a different surgical approach than the adenoid cystic carcinoma, a proper diagnosis has to be made before any intervention; a requirement we could not always fulfill. Those mistakes made us conclude that even in the era of CT scan, MRI and angiography, the radiological diagnoses are often hypotheses which have to be confirmed by discussion.(ABSTRACT TRUNCATED AT 250 WORDS)

[Neoplastic space-occupying lesions of the orbit. I. Review; hemangioma, lymphangioma and embryonal rhabdomyosarcoma]

From 1987 to 1990 182 patients were treated for orbital lesions in the Department of Ophthalmology of the University of Zürich. 37% were tumors (without tumors of the vascular system), 20% inflammatory lesions, 12% lesions of the vascular system and tumors of it, the rest was not diagnosed. On this background the first of two chapters on orbital tumors deals with diagnosis, differential diagnosis, therapy and follow up of the capillary hemangioma, cavernous hemangioma, lymphangioma and embryonal rhabdomyosarcoma. Although ultrasound echography, CT, MRI and angiography have greatly changed the diagnostic work up of orbital lesions, diagnosis is by far not made straight forward but often only after errors. To enhance diagnosis in the future this study is meant to analyse our misinterpretations. In the case of capillary hemangioma only complications justify an active treatment, normally the lesion resolves spontaneously. The infiltration of the upper eyelid with ptosis needs to be treated because of the risk of amblyopia. Our cases demonstrate, that the attempt of treatment with steroids is justified. Embolisation in the region of the a. ophthalmica is quite dangerous. The cavernous hemangioma only needs treatment in the case of compression of the optical nerve and total excision is not mandatory. The lymphangioma, although classified as benign tumor, can only be excised subtotally and with the danger of traumatising important structures of the orbit. The infiltrative growth and tendency of recurrence in fact is dangerous. It is important to diagnose the tumor without biopsy and to wait with surgical treatment as long as possible. The embryonal rhabdomyosarcoma itself is rare but it is the most frequent primary malignant tumor in childhood. Even accounting for being familiar with mimikri-false history of trauma, inflammation, hemangioma-like angiography-the diagnosis is often made rather late. Our cases demonstrate this and also the change of treatment in the last 30 years. Unfortunately the prognosis of the good results of chemotherapy in combination with radiation if necessary is clouded by the occurrence of secondary malignant tumors.

Small infarctions of cochlear, retinal, and encephalic tissue in young women

BACKGROUND AND PURPOSE

Recently, a rare syndrome that involves uniformly the brain, inner ear, and retina in previously healthy young women has been described. Brain biopsies and ophthalmologic examinations disclosed small infarcts as a pathoanatomical substrate of the disease. In previous reports, an autoimmune disorder or a coagulopathy have been suggested as possible etiologies.

CASE DESCRIPTIONS

Both patients (aged 22 and 20 years) had brain involvement with neurological and neuropsychological deficits. Multifocal small hyperintensities were shown in magnetic resonance imaging of the brain. Findings of cerebrospinal fluid examination and electroencephalography were pathological in case 1 and of cerebral angiography in case 2. Both patients had a neurosensory hearing loss and multiple retinal branch arteriolar occlusions. Both women were on fenfluramine before onset of the disease. In case 1, attacks recurred during a follow-up of 34 months. At onset of the disease the 5-hydroxyindoleacetic acid and homovanillic acid levels of the cerebrospinal fluid were reduced; 13 months later the 5-hydroxyindoleacetic acid level was still reduced and the homovanillic acid level was low-normal. In case 2, with the longest follow-up of 13 years, the disease was active during only the initial 2 1/4 years. During this period a combination of oral anticoagulant and antiplatelet agents was ineffective.

CONCLUSIONS

Our findings could not support current etiologic hypotheses. Whether changes in 5-hydroxyindoleacetic acid and homovanillic acid levels in the cerebrospinal fluid and/or fenfluramine intake play a role in the pathogenesis of the disease remains to be elucidated.

[Results of conventional retinal detachment surgery. III. Orthoptic results]

In a comparative study we examined orthoptic side effects in 117 patients following conventional retinal detachment surgery. Of these, 54 had had a segmental scleral buckle, 18 a simple encircling band and 45 encircling band combined with a radial buckle. Persistent diplopia was found in 6% of cases following segmental buckles, in 11% following simple encircling procedures and in 20% following combined operations with encircling bands and segmental buckles. The incidence of diplopia was more than 30% in cases with high encircling buckles.

[Results of conventional retinal detachment surgery. II. Changes in refraction]

In a comparative study we examined the refractive changes in 117 patients following conventional buckling retinal detachment surgery. Of these, 54 had a segmental scleral buckle, 18, an encircling buckle, and 45, a combination of both methods. Comprising about 2D, the changes in spherical equivalent were most marked in the patients who had combined operations. A correlation exists between buckle height and extent of refractive change (p = 0.0297).

[Results of conventional detachment surgery. I. Study planning, patients and vision results]

A consecutive series of patients with retinal detachment were examined. All patients were treated primarily with buckling procedure. Patients with redetachment, bilateral detachment, vitrectomy or history of strabismus or amblyopia were excluded. Of these 155 patients, 117 could be examined. 97% of patients without macula detachment are able to keep or improve their visual acuity. 85% of those patients with macula detachment showed an improvement of visual acuity. The most important prognostic factor for the visual outcome is the duration of macula detachment. In cases of more than four days duration a visual acuity of 20/40 or more could not be expected.