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Aujla J, Tong JY, Curragh D, Caplash Y, Chehade M, Tumuluri K, Au A, Low N, Avisar I, Sagiv O, Barequet I, Ben Simon G, Selva D. Corneal Neurotization for Neurotrophic Keratopathy: A Multicentre Experience. Ophthalmic Plast Reconstr Surg 2024:00002341-990000000-00376. [PMID: 38624152 DOI: 10.1097/iop.0000000000002684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
PURPOSE Corneal neurotization is an emerging technique that offers potential for visual rehabilitation in neurotrophic keratopathy. This study reports on a multicenter experience and outcomes for both direct and indirect methods of corneal neurotization. METHODS Retrospective case series. Sixteen patients with neurotrophic keratopathy who underwent corneal neurotization across 5 centers in Australia and Israel were identified for inclusion. Corneal neurotization was performed via direct neurotization from the ipsilateral or contralateral supraorbital/supratrochlear nerve or by the use of an interpositional sural nerve graft. Change in corneal sensitivity (measured in millimeters by the Cochet-Bonnet aesthesiometer), visual acuity, and corneal health. RESULTS Over a mean follow-up period of 31.3 months (range: 3 months-8 years), mean corneal sensitivity improved from 3.6 mm (range: 0-25 mm) to 25.3 mm (range: 0-57 mm). Visual acuity improved on average from 20/380 to 20/260. Twelve of 16 patients (75.0%) improved in at least 2 out of the 3 main outcome measures. Nine patients (56.3%) showed an improvement in visual acuity; 13 (81.3%) showed an improvement in average corneal sensitivity; and 11 (68.8%) showed an improvement in corneal health. There were no intraoperative or postoperative complications. CONCLUSIONS Corneal neurotization is an emerging surgical treatment option for the management of neurotrophic keratopathy. With appropriate case selection, outcomes are favorable and complication rates are low, for a condition that is otherwise challenging to manage. Patients with severe neurotrophic keratopathy should be considered for this surgical treatment option.
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Affiliation(s)
| | - Jessica Y Tong
- South Australian Institute of Ophthalmology
- Department of Plastic and Reconstructive Surgery, Royal Adelaide Hospital, Adelaide
| | | | - Yugesh Caplash
- Department of Plastic and Reconstructive Surgery, Royal Adelaide Hospital, Adelaide
| | | | - Krishna Tumuluri
- Save Sight Institute, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney
| | - Alicia Au
- Monash Health Clayton, VIC, Australia
| | | | | | - Oded Sagiv
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel
- Section of Ophthalmology, Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, U.S.A
| | - Irit Barequet
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel
| | - Guy Ben Simon
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel
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Gleber-Netto FO, Nagarajan P, Sagiv O, Pickering CR, Gross N, Ning J, Yeshi MM, Mitku Y, Tetzlaff MT, Esmaeli B. Histologic and Genomic Analysis of Conjunctival SCC in African and American Cohorts Reveal UV Light and HPV Signatures and High Tumor Mutation Burden. Invest Ophthalmol Vis Sci 2024; 65:24. [PMID: 38597722 PMCID: PMC11008748 DOI: 10.1167/iovs.65.4.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/12/2023] [Indexed: 04/11/2024] Open
Abstract
Purpose Conjunctival squamous cell carcinoma (conjSCC) is more prevalent and aggressive in sub-Saharan African countries compared with the rest of the world. This study aims to compare the genomic, immunophenotypic, and histologic features between patients from the United States and Ethiopia, to identify etiopathogenic mechanisms and unveil potential treatment strategies. Methods We compared histologic features and mutational profiles using whole exome sequencing, high-risk human papillomavirus (HPV) status, PD-L1 expression, and tumor-infiltrating lymphocytes in conjSCC tumors of patients from Ethiopia (ETH; n = 25) and the United States (from MD Anderson [the MDA cohort]; n = 29). Genomic alterations were compared with SCCs from other anatomic sites using data from The Cancer Genome Atlas. Results Solar elastosis was seen in 78% of ETH and 10% of MDA samples. Thicker tumors had higher density of CD8+ and CD3+ cells. HPV status was similar between the cohorts (ETH = 21% and MDA = 28%). The mean tumor mutation burden (TMB) was significantly higher in conjSCC (3.01/Mb, log10) and cutaneous SCC compared other SCC subtypes. ETH samples had higher TMB compared to the MDA cohort (3.34 vs. 2.73). Mutations in genes associated with ultraviolet light (UV) signature were most frequently encountered (SBS7b = 74% and SBS7a = 72%), with higher prevalence in the ETH cohort, whereas SBS2 and SBS13 signatures were more common among MDA HPV+ conjSCCs. Conclusions Our findings suggest that UV exposure may play a major role in conjSCC, with a higher prevalence in the ETH cohort compared with the MDA cohort, where HPV also contributes.
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Affiliation(s)
- Frederico O. Gleber-Netto
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Priyadharsini Nagarajan
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Oded Sagiv
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Curtis R. Pickering
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Neil Gross
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | | | - Yonas Mitku
- Department of Ophthalmology, Mekelle University, Mekelle, Ethiopia
| | - Michael T. Tetzlaff
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Bita Esmaeli
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
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Zloto O, Rosset A, Priel A, Landau-Prat D, Cukierman-Yaffe T, Shavit R, Agmon-Levin N, Ben Simon GJ, Sagiv O. Elevated serum thyroid stimulating immunoglobulin linked to failure of first-line intravenous methylprednisolone monotherapy in moderate-to-severe thyroid eye disease. Eye (Lond) 2024; 38:687-690. [PMID: 37821543 PMCID: PMC10920676 DOI: 10.1038/s41433-023-02748-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 04/21/2023] [Accepted: 09/12/2023] [Indexed: 10/13/2023] Open
Abstract
PURPOSE To assess factors associated with failure of intravenous methylprednisolone (IVMP) monotherapy as the first-line treatment for thyroid eye disease (TED) and to identify patients who might benefit from supplementing mycophenolate mofetil (MMF) to IVMP. METHODS Data for all patients with TED treated with IVMP according to the EUGOGO protocol in our center between 2016-2021 were retrospectively analysed. RESULTS Forty-seven patients (mean age 51.32 ± 14 years, 27 females) were enrolled. The mean time from first reported symptoms to first IVMP treatment was 12.1 ± 5.59 months (range 0-120). The mean clinical activity score (CAS) before treatment and at a mean of 5 and 12.2 weeks after treatment initiation was 6.00, 2.96, and 1.81, respectively (P < 0.01). Twenty-one patients (44.68%) were recommended second-line treatment: nine due to no response or worsening of CAS, six due to partial response, four with good response but early relapse after completion of treatment, and one due to late relapse. Eighteen of those 21 patients received second-line treatment which included rituximab (n = 7), MMF (n = 6), a second course of IVMP (n = 4), and tocilizumab (n = 1). Serum thyroid-stimulating immunoglobulin (TSI) levels were higher in patients who received second-line treatment compared with patients who responded well to first-line IVMP monotherapy at presentation (2135% vs 1159%, P = 0.05) and after completion of first-line treatment (2201% vs. 986%, P = 0.043). DISCUSSION TED patients requiring second-line treatment after failed IVMP monotherapy had higher baseline and post-first-line treatment serum TSI levels. Those with elevated TSI may benefit from dual therapy (IVMP and MMF) and require closer monitoring.
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Affiliation(s)
- Ofira Zloto
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arza Rosset
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ayelet Priel
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daphna Landau-Prat
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tali Cukierman-Yaffe
- Endocrinology Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Shavit
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nancy Agmon-Levin
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Guy J Ben Simon
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Sagiv
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Section of Ophthalmology, Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Arazi M, Leshno A, Sussman N, Smadar L, Huna-Baron R, Sagiv O. Study in Patients With Unilateral Horner Syndrome Supports the Role of Müller's Muscle in the Eyelid-Dark Reflex. Invest Ophthalmol Vis Sci 2023; 64:35. [PMID: 38010698 PMCID: PMC10683770 DOI: 10.1167/iovs.64.14.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/06/2023] [Indexed: 11/29/2023] Open
Abstract
Purpose A previous study demonstrated upper eyelid retraction synchronized with pupil dilation following a transition from photopic to scotopic conditions. The current study aimed to evaluate the role of Müller's muscle as the efferent arm of this suggested reflex arc. Methods A video scan of both eyes of patients with unilateral Horner syndrome was performed using optical coherence tomography infra-red mode to document the transition between photopic and scotopic conditions. The affected side with sympathetic denervation was the study group, whereas the contralateral unaffected side of the same patients served as the control group. The pupil diameter, upper eyelid margin-to-reflex distance 1, lower eyelid margin-to-reflex distance 2, and vertical palpebral fissure height were measured. The control group was compared to the healthy subjects of a previous study to verify any compensatory changes to the side contralateral to denervation. Results Ten patients with unilateral Horner Syndrome were included in the study. Transitioning from photopic to scotopic conditions, the mean change in margin-to-reflex distance 1 in the study and control groups was 315 ± 276 µm (P < 0.05) and 723 ± 432 µm (P = 0.005), respectively. Margin-to-reflex distance 1 and palpebral fissure height were significantly higher in the control group both in photopic (P = 0.005 and P = 0.017, respectively) and scotopic conditions (P = 0.005 and P = 0.007, respectively). The change in margin-to-reflex distance 1 and palpebral fissure height following the transition from light to dark was significantly greater in the control group (P = 0.022). Conclusions Reflexive eyelid retraction following a transition from photopic to scotopic conditions was significantly diminished in eyelids with sympathetic denervation compared with the unaffected contralateral side of the same patients. This study provides further evidence that the sympathetically innervated Müller's muscle serves as the efferent arm of this reflex.
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Affiliation(s)
- Mattan Arazi
- The Goldschleger Eye Institute, Sheba Medical Center and the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ari Leshno
- The Goldschleger Eye Institute, Sheba Medical Center and the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Sussman
- The Goldschleger Eye Institute, Sheba Medical Center and the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lital Smadar
- The Goldschleger Eye Institute, Sheba Medical Center and the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ruth Huna-Baron
- The Goldschleger Eye Institute, Sheba Medical Center and the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Sagiv
- The Goldschleger Eye Institute, Sheba Medical Center and the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Section of Ophthalmology, Department of Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, United States
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Landau Prat D, Massarwa S, Zohar A, Priel A, Sagiv O, Zloto O, Ben Simon GJ. Patient-Specific Orbital Implants Vs. Pre-Formed Implants for Internal Orbital Reconstruction. Semin Ophthalmol 2023; 38:365-370. [PMID: 36639878 DOI: 10.1080/08820538.2023.2166353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE To compare the outcome of orbital blowout fracture repair by means of pre-formed porous-polyethylene titanium implants (PFI) vs patient-specific porous-polyethylene implants (PSI). METHODS Retrospective cohort study. Baseline characteristics, ophthalmic examination results, ocular motility, fracture type, the timing of surgery, implant type, and final relative enophthalmos of all patients operated on for blow-out fractures in a single center were collected and analyzed. RESULTS Twenty-seven patients (mean age 39 years, 9 females) were enrolled. Sixteen underwent fracture repair with PFI and 11 with PSI at 11 months (median) post-trauma. Mean follow-up duration was 1.1 years. Both groups showed significant postoperative improvement in primary or vertical gaze diplopia (P = .03, χ2). Relative enophthalmos improved from -3.2 preoperative PFI to -1.7 mm postoperative PFI, and from -3.0 mm preoperative PSI to -1.1 mm postoperative PSI (P= .1). PSI patients had non-significantly less postoperative enophthalmos and globe asymmetry than PFI patients. The outcome was not influenced by previous surgery, age, sex, number of orbital walls involved in the initial trauma, or medial wall involvement (linear regression). Both groups sustained complications unrelated to implant choice. CONCLUSION Both PSI and PFI yielded good outcomes in this study. PSI may be a good alternative to PFI in primary or secondary orbital blowout fracture repair with less enophthalmos and globe asymmetry, in spite of the possible disadvantages of production time, a relatively larger design, and challenging insertion. Since it is a mirror image of the uninjured orbit, it may be beneficial in extensive fractures.
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Affiliation(s)
- Daphna Landau Prat
- Orbital Ophthalmic Plastic & Lacrimal Surgery Institute, Goldschleger Eye Institute, Sheba Medical Center Tel Hashomer, Israel.,The Sheba Talpiot Medical Leadership Program, Sheba Medical Center Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Division of Ophthalmology, Oculoplastic and Orbital Surgery Service, The Children's Hospital of Philadelphia, and The Edwin and Fannie Gray Hall, Center for Human Appearance, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
| | - Said Massarwa
- Plastic Surgery Department, Hadassah Hospital, Jerusalem, Israel
| | - Assa Zohar
- Orbital Ophthalmic Plastic & Lacrimal Surgery Institute, Goldschleger Eye Institute, Sheba Medical Center Tel Hashomer, Israel
| | - Ayelet Priel
- Orbital Ophthalmic Plastic & Lacrimal Surgery Institute, Goldschleger Eye Institute, Sheba Medical Center Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Oded Sagiv
- Orbital Ophthalmic Plastic & Lacrimal Surgery Institute, Goldschleger Eye Institute, Sheba Medical Center Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Ofira Zloto
- Orbital Ophthalmic Plastic & Lacrimal Surgery Institute, Goldschleger Eye Institute, Sheba Medical Center Tel Hashomer, Israel.,The Sheba Talpiot Medical Leadership Program, Sheba Medical Center Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Guy J Ben Simon
- Orbital Ophthalmic Plastic & Lacrimal Surgery Institute, Goldschleger Eye Institute, Sheba Medical Center Tel Hashomer, Israel.,The Sheba Talpiot Medical Leadership Program, Sheba Medical Center Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
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Zloto O, Sagiv O, Priel A, Cukierman-Yaffe T, Tirosh A, Agmon-Levin N, Madgar S, Serlin T, Winter H, Huna-Baron R, Wygnanski-Jaffe T, Ben Simon G. A Multidisciplinary Thyroid Eye Clinic: A One-stop Shop. Isr Med Assoc J 2022; 24:671-676. [PMID: 36309864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Little is known about the success of multidisciplinary thyroid eye disease (TED) clinic. OBJECTIVES To present the characteristics, treatments, and outcomes of patients treated in a multidisciplinary TED clinic. METHODS A medical record review of all patients who attended a TED clinic was performed. Data included demographics, medical history, laboratory tests, visual function tests, ocular examinations, clinical activity score (CAS), and assessment of quality-of-life (QOL). RESULTS Clinic visits included 132 patients seen during 385 appointments at a TED clinic (mean 12 appointments per patient). Management of TED included medical treatments for 48 patients (36.3%) and surgical treatment for 56 (42.4%). There was a positive significant correlation between the CAS and thyroid-stimulating immunoglobulin (TSI) activity at the first visit and at the last follow-up visit (P < 0.01 and P < 0.02, respectively). However, no correlation was found between the CAS and the thyroid-stimulating hormone levels or between the free triiodothyronine (fT3) and fT4 levels at the first or last visit. There was a significant negative correlation between the CAS and color vision (-0.347, P < 0.01, Pearson correlation) at the first visit, but not between the CAS and visual acuity and visual field at either the first or last visit. Changes in the QOL and the CAS scores were significantly negatively correlated (-0.240, P < 0.01). CONCLUSIONS Treatment and management decisions for TED should be based on multiple parameters including clinical examinations by ophthalmologists and endocrinologists, laboratory tests, and CAS and QOL scores.
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Affiliation(s)
- Ofira Zloto
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Sagiv
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ayelet Priel
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tali Cukierman-Yaffe
- Division Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Tirosh
- Division Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nancy Agmon-Levin
- Department of Clinical Immunology, Angioedema and Allergy, Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shiran Madgar
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Serlin
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Halit Winter
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ruth Huna-Baron
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamara Wygnanski-Jaffe
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Guy Ben Simon
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Leshno A, Sagiv O, Aloni R, Skaat A, Achiron A, Huna-Baron R. Cognitive Performance of Patients With Multiple Sclerosis and Optic Neuritis at Presentation. J Neuroophthalmol 2022; 42:e8-e13. [PMID: 33870943 DOI: 10.1097/wno.0000000000001245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cognitive dysfunction is common among patients with multiple sclerosis (MS), but the effect of coexisting optic neuritis (ON) at the first presentation of multiple sclerosis on the course of cognitive decline is unknown. The purpose of this study was to assess whether ON at presentation has any effect on the progression of cognitive decline in MS. METHODS Historical cohort study. We retrospectively compared the cognitive performance of patients with relapsing-remitting MS with and without ON at the time of MS diagnosis. Subjects were included if cognitive test results were available both at baseline and after at least 36 months from presentation and grouped based on the presence (MS-ON) or absence (MS-non-ON) of optic neuritis at presentation. RESULTS One hundred seventy consecutive subjects with MS were found suitable, with a 1:2 male:female ratio and a mean age at diagnosis of 33.0 ± 10.9 years. Forty-six patients (27.1%) presented with ON. No significant differences were found in cognitive performance at onset between the 2 groups. Both groups had a similar follow-up duration. The prevalence of cognitive decline in the general score was significantly higher in the MS-ON group compared with the MS-non-ON group (6.5% vs 0%, respectively; P < 0.001), as well as in the attention (8.7% vs 1.6%; P = 0.046) and the executive function (17.4% vs 2.4%; P = 0.001) domains. CONCLUSIONS Optic neuritis at presentation of MS is associated with a higher prevalence of cognitive decline over time. Potential benefit of early intervention to prevent cognitive decline may be warranted.
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Affiliation(s)
- Ari Leshno
- Goldschleger Eye Institute (AL, OS, AS, RH-B), Sheba Medical Center, Tel-Hashomer, Israel; Department of Behavioral Sciences and Psychology (RA), Ariel University, Ariel, Israel ; Multiple Sclerosis Center (RA, AA), Sheba Medical Center, Tel Hashomer, Israel ; and Sackler Faculty of Medicine (RA, AA, AL, OS, AS, RH-B), Tel Aviv University, Tel Aviv, Israel
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Zloto O, Weissman A, Moroz I, Weidenfeld J, Ben Simon G, Sagiv O, Rosner M, Priel A. Kelly Punch Punctoplasty and Simple Punctal Dilatation Are Equally Effective for Punctal Stenosis: A Prospective Study. Ophthalmic Plast Reconstr Surg 2021; 37:546-550. [PMID: 33587416 DOI: 10.1097/iop.0000000000001940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To examine the clinical, imaging, and histopathologic differences between Kelly punch punctoplasty and punctal dilatation, both with mini Monoka stent insertion. METHODS This is a prospective, comparative clinical study. Patients with bilateral punctal stenosis and for whom surgery was advised participated in the study. The right eye underwent Kelly punch punctoplasty and the left eye simple punctal dilatation, both with mini Monoka stents were participated. Data were collected and analyzed before and 3 months following the procedure and included the degree of epiphora (Munk score) and punctal size as measured by anterior segment optical coherence tomography (AC- OCT). All specimens removed by the Kelly punch punctoplasty were sent for histopathologic evaluation, including Masson's trichome muscle staining. RESULTS The study included 46 eyes of 23 patients (4 males and 19 females) whose mean age at presentation was 60.43 ± 14.81 years (range 19-84 years). There was a significant decrease in the Munk score after both punctoplasties compared with baseline values (P < 0.01, matched pairs). There were no significant differences between groups in the delta Munk score. There was a significant increase in punctal size after both procedures compared with baseline values as measured by AS-OCT. Horner-Duverney's muscle was visible in only 3 of the 23 (13.04%) specimens from patients who underwent the Kelly punch punctoplasty. CONCLUSIONS The Kelly punch punctoplasty and the simple dilator punctoplasty, both with stents, are equally effective treatments for epiphora due to acquired punctal stenosis. Only a few specimens removed during the Kelly punch method show muscle fibers.
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Affiliation(s)
| | | | | | - Jonathan Weidenfeld
- Institute of Pathology, Sheba Medical Center, Tel Hashomer, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Zloto O, Sagiv O, Priel A, Cukierman-Yaffe T, Tirosh A, Agmon-Levin N, Madgar S, Serlin T, Ben Simon G. Quality of life of patients with thyroid eye disease: 3-year follow-up in a multidisciplinary clinic in Israel. Graefes Arch Clin Exp Ophthalmol 2021; 259:2009-2015. [PMID: 33528651 DOI: 10.1007/s00417-021-05103-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/25/2020] [Accepted: 01/25/2021] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Changes in the quality of life (QOL) of patients with thyroid eye disease (TED) were examined during a 3-year follow-up in a multidisciplinary eye clinic, and factors that may improve QOL were identified. METHODS A retrospective review of medical records of all patients who attended the TED clinic at Sheba Medical Center, Israel, from May 2016 to May 2019 was performed. The retrieved data included demographics, comprehensive ophthalmic examination findings, clinical activity scores (CAS), laboratory test results, and QOL assessments by the Graves' Orbitopathy QOL (GO-QOL) questionnaire. RESULTS One hundred thirty-two TED clinic patients were examined. Thirty patients (22.72%) received medical treatment consisting of steroids according to the European Group on Graves' Orbitopathy (EUGOGO) protocol, high-dose steroids, or immunosuppressive drugs. Twenty-eight patients (21.21%) underwent surgical rehabilitation (decompression, strabismus, or eyelid surgery). There was a significant increase in total QOL score after steroid treatment according to the EUGOGO protocol, after decompression surgery, and after strabismus surgery compared to pre-treatment total QOL (p=0.04, p=0.021, and p=0.042, respectively, matched pairs). In addition, there were significant positive correlations between the changes in the total QOL score and the change in thyroid-stimulating immunoglobulin (TSI) as well as the change in CAS among the patients who underwent medical and surgical interventions. CONCLUSIONS QOL improved significantly after medical/surgical treatments. A change in the CAS and in the TSI may also correlate with change in QOL. Periodic evaluation of TED patients' QOL is recommended for enhanced and more comprehensive management.
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Affiliation(s)
- Ofira Zloto
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel. .,Sackler Faculty of Medicine, Tel-AvivUniversity, Tel- Aviv, Israel.
| | - Oded Sagiv
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel-AvivUniversity, Tel- Aviv, Israel
| | - Ayelet Priel
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel-AvivUniversity, Tel- Aviv, Israel
| | - Tali Cukierman-Yaffe
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel-AvivUniversity, Tel- Aviv, Israel
| | - Amir Tirosh
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel-AvivUniversity, Tel- Aviv, Israel
| | - Nancy Agmon-Levin
- Clinical Immunology, Angioedema and Allergy Unit, Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-AvivUniversity, Tel- Aviv, Israel
| | - Shiran Madgar
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel-AvivUniversity, Tel- Aviv, Israel
| | - Tal Serlin
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel-AvivUniversity, Tel- Aviv, Israel
| | - Guy Ben Simon
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel-AvivUniversity, Tel- Aviv, Israel
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10
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Zloto O, Sagiv O, Priel A, Cukierman-Yaffe T, Tirosh A, Agmon-Levin N, Madgar S, Serlin T, Ben Simon G. Gender differences in clinical presentation and prognosis of thyroid eye disease. Eur J Ophthalmol 2020; 31:2717-2723. [PMID: 33158379 DOI: 10.1177/1120672120964112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine the clinical differences in manifestation, treatment, and prognosis of thyroid-eye-disease (TED) between men and women. METHODS This is a longitudinal cohort study. Men and women, who diagnosed with TED and treated at a multidisciplinary TED clinic, were compared regarding differences in demographics, eye examination, disease activity, and quality of life evaluation. RESULTS TED was diagnosed in 132 patients during the study period, and they included 38 men (28.78%) and 94 women (71.21%). There were six men and 20 women with active disease (Clinical-Activity-Score (CAS) ⩾ 3) during the entire follow-up period (p < 0.01). The mean time from TED diagnosis to CAS ⩾ 3 was 4.50 years for men and 2.35 years for women (p = 0.05). There were no significant differences in mean total Graves' Orbitopathy-Quality-of-Life questionnaire (GO-QOL) score. However, mean GO-QOL subtotal score of external appearance of women was significantly lower compare to men in the first and last visit (p = 0.04, 0.03, respectively). CONCLUSION Active disease was more common in women and the time-from-diagnosis of TED to CAS ⩾ 3 was shorter among women. Moreover, the appearance QOL score of women was poorer. These findings should be taken into consideration when planning the timing of treatment and when choosing the best treatment for TED patients.
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Affiliation(s)
- Ofira Zloto
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel Sheba Medical Center, Tel-Hashomer, Israel
| | - Oded Sagiv
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel Sheba Medical Center, Tel-Hashomer, Israel
| | - Ayelet Priel
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel Sheba Medical Center, Tel-Hashomer, Israel
| | - Tali Cukierman-Yaffe
- Sackler Faculty of Medicine, Tel-Aviv University, Israel Sheba Medical Center, Tel-Hashomer, Israel.,Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel
| | - Amir Tirosh
- Sackler Faculty of Medicine, Tel-Aviv University, Israel Sheba Medical Center, Tel-Hashomer, Israel.,Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel
| | - Nancy Agmon-Levin
- Sackler Faculty of Medicine, Tel-Aviv University, Israel Sheba Medical Center, Tel-Hashomer, Israel.,Lupus Clinic, Clinical Immunology, Angioedema and Allergy Unit, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Shiran Madgar
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel
| | - Tal Serlin
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel
| | - Guy Ben Simon
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel Sheba Medical Center, Tel-Hashomer, Israel
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11
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Leshno A, Smadar L, Kapelushnik N, Serlin T, Prat D, Priel A, Ben Simon GJ, Sagiv O. New insight into the physiologic function of Müller's muscle. Exp Eye Res 2020; 202:108336. [PMID: 33130032 DOI: 10.1016/j.exer.2020.108336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/06/2020] [Accepted: 10/23/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Müller's muscle is a sympathetically innervated smooth muscle which serves as an accessory upper eyelid retractor. Its physiologic function and purpose have not yet been clearly defined. We hypothesize that sympathetic innervation to Müller's muscle serves to adjust the upper eyelid's position to variations in pupil size in response to changes in light intensity. METHODS This is a single center cross-sectional study. Healthy volunteers were asked to fixate on a distant non-accommodative target, and a video scan of the anterior segment was performed for each subject's right eye using the Heidelberg Spectralis® optical coherence tomography scanner in infrared mode. The video was taken both in photopic and scotopic conditions, recording the resultant transition of the pupil and eyelids. The pupil diameter (PD), upper eyelid margin-to-reflex distance (MRD1), lower eyelid margin-to-reflex distance (MRD2), and vertical palpebral fissure height (PFH) were measured. RESULTS Thirty-three healthy volunteers (19 women, 57.6%) with a median age of 40 years (range 30-58) were included. The mean PD under photopic conditions increased significantly under scotopic conditions, from 3483 ± 521 μm to 6135 ± 703 μm, respectively (P < 0.0001). An increase in MRD1 was observed following transition from light to dark, with a mean change of 348 ± 311 μm (P < 0.0001). There was no significant change in MRD2. CONCLUSIONS Upper eyelid retraction occurs after transition from photopic to scotopic conditions. This movement suggests the existence of an "eyelid-light reflex" involving Müller's muscle that adjusts the position of the eyelids as the pupil dilates under scotopic conditions.
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Affiliation(s)
- Ari Leshno
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lital Smadar
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Kapelushnik
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Serlin
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daphna Prat
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ayelet Priel
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Guy J Ben Simon
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Sagiv
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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12
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Xu S, Sagiv O, Rubin ML, Sa HS, Tetzlaff MT, Nagarajan P, Ning J, Esmaeli B. Validation Study of the AJCC Cancer Staging Manual, Eighth Edition, Staging System for Eyelid and Periocular Squamous Cell Carcinoma. JAMA Ophthalmol 2020; 137:537-542. [PMID: 30869769 DOI: 10.1001/jamaophthalmol.2019.0238] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance To our knowledge, there are no validation studies to date of the prognostic value of the AJCC Cancer Staging Manual, eighth edition (AJCC 8), criteria for eyelid and periocular squamous cell carcinoma. Objective To determine the association of tumor (T) category in AJCC 8 with local recurrence, nodal metastasis, distant metastasis, and disease-specific survival (DSS) for eyelid and periocular squamous cell carcinoma. Design, Setting, and Participants In this retrospective, single-center cohort study, 109 consecutive patients with eyelid and periocular squamous cell carcinoma treated from January 1999 to April 2018 were included. Patients with secondary involvement of the periocular region were excluded. Main Outcomes and Measures Local recurrence, nodal metastasis, distance metastasis, and DSS. Results Of the 109 included patients, 81 (74.3%) were male, and the median (range) age was 66 (40-91) years. At presentation, 43 patients (39.4%) had recurrent tumor, 4 (3.7%) had nodal metastasis, and 1 (0.9%) had distant metastasis. The median (range) follow-up was 23 (1-161) months. During follow-up, 11 patients (10.1%) developed local recurrence, 7 (6.4%) developed nodal metastasis, 2 (1.8%) developed distant metastasis, and 9 (8.3%) died of disease. The 5-year DSS rate was 87.7% (95% CI, 79.5-96.9). Chronic immunosuppression (hazard ratio, 47.24; 95% CI, 7.33-304.30; P < .001) and presentation with recurrent squamous cell carcinoma (hazard ratio, 5.22; 95% CI, 1.12-24.31; P = .04) were associated with local recurrence during follow-up. Of the 11 patients with local recurrence during follow-up, 7 (64%) had perineural invasion. T category was associated with nodal metastasis; clinical stage of T2c or worse at presentation was associated with higher risk of nodal metastasis and death of disease but not with a higher risk of local recurrence. Distant metastasis was associated with nodal metastasis at presentation (hazard ratio, 32.50; 95% CI, 1.97-536.40; P = .02) and during follow-up. A total of 33 patients (30.3%) had different T categories depending on whether disease was staged according to the seventh or eighth edition of the AJCC Cancer Staging Manual. Compared with AJCC 7, AJCC 8 showed a better predictive value in terms of local recurrence (T3, 17% vs 14%; T4, 11% vs 16%) and DSS. Conclusions and Relevance These findings suggest that T category in AJCC 8 is associated with nodal metastasis and DSS. Immunosuppression and presentation with recurrent disease are associated with increased risk of future local recurrence. Patients with tumors of clinical stage T2c or worse at presentation are at increased risk of nodal metastasis and worse DSS and should undergo surveillance for nodal metastasis. Future studies, ideally prospective in design, could provide greater confidence in these findings.
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Affiliation(s)
- Shiqiong Xu
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston.,Department of Ophthalmology, School of Medicine, Shanghai Jiao Tong University, Shanghai Ninth People's Hospital, Shanghai, China
| | - Oded Sagiv
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Maria Laura Rubin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Ho-Seok Sa
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston.,Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Michael T Tetzlaff
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston
| | | | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Bita Esmaeli
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
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13
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Zloto O, Matani A, Sagiv O, Prat D, Ben Artsi E, Leshno A, Priel A, Ben Simon GJ. Changes in Refraction and Visual Acuity after Upper Eyelid Blepharoplasty versus Posterior Approach Ptosis Procedures. Ophthalmic Res 2020; 63:588-592. [PMID: 32135543 DOI: 10.1159/000506951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 03/02/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate surgically induced refractive changes (SIRC) and visual acuity (VA) changes after blepharoplasty combined with posterior approach ptosis surgery (Müller's muscle-conjunctival resection [MMCR]) versus upper eyelid blepharoplasty alone. METHODS In this prospective, comparative, clinical study on patients undergoing MMCR and blepharoplasty, comprehensive ophthalmic examinations were performed preoperatively and 3 months postoperatively. SIRC were calculated with the 10-step Holladay method. RESULTS Fifty-six patients participated in the study, 31 in the blepharoplasty group and 25 in the ptosis group. logMAR VA improved significantly after surgery in both groups (p < 0.001). In both groups, most patients showed significant changes in SIRC sphere and spherical equivalent of >0.5 D (blepharoplasty group: 61.29 and 67.74%; ptosis group: 72.72 and 72.72%, respectively). Patients undergoing combined blepharoplasty ptosis surgery showed the greatest SIRC cylinder. CONCLUSIONS Upper eyelid blepharoplasty with or without MMCR is associated with significant SIRC 3 months postoperatively. This may affect decision-making for all patients, especially for those who intend to seek refractive correction in addition to the index upper eyelid surgery.
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Affiliation(s)
- Ofira Zloto
- Goldschleger Eye Institute, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Adham Matani
- Goldschleger Eye Institute, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Oded Sagiv
- Goldschleger Eye Institute, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Daphna Prat
- Goldschleger Eye Institute, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Elad Ben Artsi
- Goldschleger Eye Institute, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Ari Leshno
- Goldschleger Eye Institute, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Ayelet Priel
- Goldschleger Eye Institute, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Guy J Ben Simon
- Goldschleger Eye Institute, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel,
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14
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Nagarajan P, El-Hadad C, Gruschkus SK, Ning J, Hudgens CW, Sagiv O, Gross N, Tetzlaff MT, Esmaeli B. PD-L1/PD1 Expression, Composition of Tumor-Associated Immune Infiltrate, and HPV Status in Conjunctival Squamous Cell Carcinoma. Invest Ophthalmol Vis Sci 2019; 60:2388-2398. [PMID: 31141610 PMCID: PMC6890426 DOI: 10.1167/iovs.19-26894] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose Conjunctival squamous cell carcinoma (SCC), a type of ocular surface neoplasia, is primarily treated by surgical resection and topical immuno- or chemotherapy. Metastatic disease may be treated with systemic chemo- or immunotherapy, albeit with variable response. The purpose of this study was to determine whether immune checkpoint blockade might be considered in the management of conjunctival SCC. Methods In this retrospective study, we evaluated tumor programmed death-ligand 1 (PD-L1) expression, high-risk human papillomavirus (HPV) status, and immunohistochemical expression of cluster of differentiation 3 (CD3), cluster of differentiation 8 (CD8), and programmed death 1 (PD1) in tumor-associated immune infiltrate in a series of 31 conjunctival SCCs. Results PD-L1 expression in ≥1% of tumor cells was noted in 14 conjunctival SCCs (47%) and was more prevalent in invasive than in situ SCC and among tumors with higher American Joint Committee on Cancer (AJCC) T category (≥T3 versus ≤T2). The density of CD3-positive T cells was higher in primary than recurrent tumors and higher in invasive than in situ tumors. Density of CD3-positive and CD8-positive T cells was higher in higher AJCC stage tumors. Density of CD8-positive T cells was higher in HPV-positive than HPV-negative tumors. PD-L1 expression correlated with a higher density of CD3-, CD8-, and PD1-positive cells in the tumor-associated immune infiltrate but not with HPV status. Conclusions Our findings demonstrate that PD-L1 is expressed in almost half of conjunctival SCCs. The density of tumor-associated immune cells correlated with invasive SCC, stage, and HPV status in conjunctival SCC. Our findings support further studies to establish the potential application of immune checkpoint blockade in the management of conjunctival SCC.
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Affiliation(s)
- Priyadharsini Nagarajan
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Christian El-Hadad
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Stephen K Gruschkus
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Courtney W Hudgens
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Oded Sagiv
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Neil Gross
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Michael T Tetzlaff
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States.,Department of Translational and Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Bita Esmaeli
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
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15
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Sagiv O, Thakar SD, Kandl TJ, Ford J, Sniegowski MC, Hwu WJ, Esmaeli B. Immunotherapy With Programmed Cell Death 1 Inhibitors for 5 Patients With Conjunctival Melanoma. JAMA Ophthalmol 2019; 136:1236-1241. [PMID: 30352118 DOI: 10.1001/jamaophthalmol.2018.3488] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Conjunctival melanoma has the potential for regional lymphatic and distant metastasis. There is an urgent need for effective treatment for patients with metastatic or locally advanced conjunctival melanoma. Objective To describe the use of immune checkpoint inhibitors for the treatment of conjunctival melanoma in 5 adult patients. Design, Setting, and Participants A retrospective review was conducted of the medical records of 5 patients with conjunctival melanoma who were treated with immune checkpoint inhibitors from March 6, 2013, to July 7, 2017. Main Outcomes and Measures Response to treatment and disease-free survival. Results Of the 5 patients (4 women and 1 man) with metastatic conjunctival melanoma, 4 were treated with a programmed cell death 1 (PD-1) inhibitor, nivolumab, and had a complete response to treatment with no evidence of disease at 1, 7, 9, and 36 months after completing treatment. One patient with metastatic conjunctival melanoma was treated with another PD-1 inhibitor, pembrolizumab, and had stable metastases during the first 6 months of treatment. Later disease progression resulted in treatment cessation after 11 months and switching to another therapy. Two patients treated with nivolumab developed autoimmune colitis that necessitated stopping the immunotherapy; these patients subsequently were managed with systemic corticosteroids or infliximab. Conclusions and Relevance This case series report suggests that anti-PD-1 therapy can be used to treat metastatic conjunctival melanoma. Longer follow-up is needed to determine the long-term disease-free survival. Future studies might assess the potential for immune checkpoint inhibitors to obviate the need for orbital exenteration in selected patients with locally advanced disease.
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Affiliation(s)
- Oded Sagiv
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Sudip D Thakar
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Thomas J Kandl
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Joshua Ford
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Matthew C Sniegowski
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Wen-Jen Hwu
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Bita Esmaeli
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
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16
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Tetzlaff MT, Curry JL, Ning J, Sagiv O, Kandl TL, Peng B, Bell D, Routbort M, Hudgens CW, Ivan D, Kim TB, Chen K, Eterovic AK, Shaw K, Prieto VG, Yemelyanova A, Esmaeli B. Distinct Biological Types of Ocular Adnexal Sebaceous Carcinoma: HPV-Driven and Virus-Negative Tumors Arise through Nonoverlapping Molecular-Genetic Alterations. Clin Cancer Res 2018; 25:1280-1290. [DOI: 10.1158/1078-0432.ccr-18-1688] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/25/2018] [Accepted: 11/02/2018] [Indexed: 11/16/2022]
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17
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Leshno A, Sachs D, Sagiv O. Unilateral Triangular Cataract in an Adult. JAMA Ophthalmol 2018; 136:e182822. [PMID: 30326073 DOI: 10.1001/jamaophthalmol.2018.2822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ari Leshno
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Sachs
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Sagiv
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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Sa HS, Rubin ML, Xu S, Ning J, Tetzlaff M, Sagiv O, Kandl TJ, Esmaeli B. Prognostic factors for local recurrence, metastasis and survival for sebaceous carcinoma of the eyelid: observations in 100 patients. Br J Ophthalmol 2018; 103:980-984. [DOI: 10.1136/bjophthalmol-2018-312635] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/14/2018] [Accepted: 08/06/2018] [Indexed: 11/03/2022]
Abstract
Background/aimsTo validate the predictive value of the American Joint Committee on Cancer (AJCC) 8th-edition classification for local recurrence, metastasis and survival in patients with eyelid sebaceous carcinoma.MethodsWe performed a retrospective review of 100 consecutive patients with eyelid sebaceous carcinoma. Eyelid carcinomas were staged according to the AJCC 7th-edition and 8th-edition criteria. Associations between T and N categories and disease-related outcomes including local recurrence, lymph node metastasis, distant metastasis and survival were evaluated.Results60 women and 40 men had a median age of 67 years (range, 41–94 years). The proportions of patients who experienced local recurrence, lymph node metastasis, distant metastasis and death from disease were 6%, 21%, 7% and 6%, respectively. Two-year and 5-year disease-specific survival (DSS) rates were 93.8% and 92.0%, respectively. There were significant correlations between (1) T2c or worse category and lymph node metastasis (p=0.04) and distant metastasis (p=0.01), (2) T3b or worse category and local recurrence (p=0.01) and death from disease (p=0.01) and (3) N1 category at presentation and distant metastasis (p<0.01) and death from disease (p<0.01). The AJCC 8th-edition classification showed a better homogeneity of the T-category distribution (p<0.01) and a slightly higher discrimination ability for lymph node metastasis (C=0.734 vs C=0.728) than the 7th-edition.ConclusionsT and N categories per AJCC 8th-edition classification are predictive of local recurrence, metastasis and DSS outcomes for eyelid sebaceous carcinoma. Surgeons should perform strict surveillance testing for nodal and systemic metastases in patients with T2c or worse T category and/or N1 disease at presentation.
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19
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Thakar S, Kandl T, Sagiv O, Tripathy D, Tetzlaff MT, Kapur S, Myers J, Hwu WJ, Jaber BMY, Esmaeli B. Desmoplastic Melanoma of the Periorbital Region. Ophthalmic Plast Reconstr Surg 2018; 34:e48-e52. [PMID: 29194286 DOI: 10.1097/iop.0000000000001015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Desmoplastic melanoma (DM) is a rare subtype of melanoma and an even smaller proportion of periocular melanomas. Here, the authors report 2 cases of DM in the periocular region. Staged according to the American Joint Committee on Cancer (AJCC) eighth edition classification, patient 1 presented with a stage IIIC (pT4apN1cM0) DM in the left lateral canthus with upper and lower eyelid and patient 2 presented with a stage IIIB (T4aN1bM0) DM in the left brow and supraorbital region with a parotid lymph node metastasis. In both patients, the lesions were amelanotic, with inflammatory appearance, and had been noted for several years before the correct diagnosis was made. In both patients, wide excision led to large surgical defects, and perineural invasion prompted adjuvant radiation therapy postoperatively. Patient 2 was treated with an immune checkpoint inhibitor for his parotid metastasis. Ophthalmologists should be aware of DM, its neurotrophic nature, and potential to metastasize with locally advanced lesions.
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Affiliation(s)
- Sudip Thakar
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, Department of Pathology, Department of Translational and Molecular Pathology, Department of Head and Neck Surgery, Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A, and St. John of Jerusalem Eye Hospital Group, East Jerusalem, Israel
| | - Thomas Kandl
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, Department of Pathology, Department of Translational and Molecular Pathology, Department of Head and Neck Surgery, Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A, and St. John of Jerusalem Eye Hospital Group, East Jerusalem, Israel
| | - Oded Sagiv
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, Department of Pathology, Department of Translational and Molecular Pathology, Department of Head and Neck Surgery, Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A, and St. John of Jerusalem Eye Hospital Group, East Jerusalem, Israel
| | - Devjyoti Tripathy
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, Department of Pathology, Department of Translational and Molecular Pathology, Department of Head and Neck Surgery, Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A, and St. John of Jerusalem Eye Hospital Group, East Jerusalem, Israel
| | | | - Sahil Kapur
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, Department of Pathology, Department of Translational and Molecular Pathology, Department of Head and Neck Surgery, Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A, and St. John of Jerusalem Eye Hospital Group, East Jerusalem, Israel
| | - Jeffrey Myers
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, Department of Pathology, Department of Translational and Molecular Pathology, Department of Head and Neck Surgery, Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A, and St. John of Jerusalem Eye Hospital Group, East Jerusalem, Israel
| | - Wen-Jen Hwu
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, Department of Pathology, Department of Translational and Molecular Pathology, Department of Head and Neck Surgery, Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A, and St. John of Jerusalem Eye Hospital Group, East Jerusalem, Israel
| | | | - Bita Esmaeli
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, Department of Pathology, Department of Translational and Molecular Pathology, Department of Head and Neck Surgery, Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A, and St. John of Jerusalem Eye Hospital Group, East Jerusalem, Israel
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Thuro BA, Sagiv O, Shinder R, Debnam JM, Ozgur O, Ng JD, Rootman D, Thomas SK, Esmaeli B. Clinical Presentation and Anatomical Location of Orbital Plasmacytomas. Ophthalmic Plast Reconstr Surg 2018; 34:258-261. [PMID: 28582371 DOI: 10.1097/iop.0000000000000939] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the clinical and anatomical location of orbital plasmacytomas and assess local control following therapy. METHODS The American Society of Ophthalmic Plastic and Reconstructive Surgery Oncology Database was queried to identify patients diagnosed with orbital plasmacytoma. These patients' records were reviewed for demographic characteristics, clinical and radiologic findings, treatments, and outcomes. RESULTS Thirty patients from 4 institutions (24 from MD Anderson Cancer Center, 3 from SUNY Downstate Medical Center, 2 from University of California, Los Angeles, and 1 from Oregon Health and Science University) were identified. Eighteen patients (60%) were diagnosed with multiple myeloma (MM) before and 11 (37%) were diagnosed with MM immediately after orbital plasmacytoma. Based on imaging, 4 distinct anatomical patterns were identified: 1) bony plasmacytoma affecting the superotemporal orbit, epidural space, and temporal fossa (15 patients; 50%); 2) discrete orbital plasmacytoma (7 patients; 23%); 3) infiltrative plasmacytoma either originating from a sinus (4 patients; 13%); or 4) originating from the orbital floor and infiltrating facial soft tissue (4 patients; 13%). Of the 29 patients with available treatment data, 2 had radiation only, 3 had chemotherapy only, 6 had chemoradiation, and 18 had stem cell transplant following chemoradiation (n = 17) or only chemotherapy (n = 1). Following treatment, 10 patients achieved complete and 11 achieved partial responses. CONCLUSION Orbital plasmacytomas were found exclusively in patients with MM diagnosed before or immediately after orbital plasmacytoma. Plasmacytomas can have 4 distinct anatomical patterns of origin. Following treatment, all patients had good to excellent local control of their orbital lesions.
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Affiliation(s)
- Bradley A Thuro
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Oded Sagiv
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Roman Shinder
- Department of Ophthalmology, State University of New York Downstate Medical Center, Brooklyn, New York
| | | | - Omar Ozgur
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - John D Ng
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon
| | - Daniel Rootman
- Department of Ophthalmology, University of California, Los Angeles, Los Angeles, California
| | - Sheeba K Thomas
- Department of Lymphoma and Myeloma, M.D. Anderson Cancer Center, Houston, Texas, U.S.A
| | - Bita Esmaeli
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
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21
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Kandl TJ, Sagiv O, Curry JL, Ning J, Ma J, Hudgens CW, Van Arnam J, Wargo JA, Esmaeli B, Tetzlaff MT. High expression of PD-1 and PD-L1 in ocular adnexal sebaceous carcinoma. Oncoimmunology 2018; 7:e1475874. [PMID: 30228943 DOI: 10.1080/2162402x.2018.1475874] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/05/2018] [Accepted: 05/07/2018] [Indexed: 12/24/2022] Open
Abstract
Ocular adnexal sebaceous carcinoma (OASC) is an aggressive malignancy that frequently recurs locally and metastasizes. Surgical extirpation may produce significant aesthetic morbidity, and effective systemic therapies for locally advanced or metastatic disease are largely ineffective. Immune checkpoint inhibitors have shown efficacy in the management of several solid tumors where tumor cell PD-L1 expression correlates with improved response. To determine whether OASC might be amenable to immune checkpoint blockade, we performed comprehensive immune profiling for CD3, CD8, PD-1, FOXP3, and PD-L1 in 24 patients with primary OASC. The composition, distribution and density of the tumor associated immune infiltrate were quantified by automated image analysis and correlated with measures of clinical outcome. Tumor cells in 12 OASCs (50%) expressed PD-L1. Higher densities of CD3+ (p = 0.01), CD8+ (p = 0.006), and PD-1+ (p = 0.024) tumor-associated T cells were associated with higher T category (≥T3a per the 7th edition of the American Joint Committee on Cancer staging manual). Higher tumor cell expression of PD-L1 correlated with higher density of PD-1+ tumor-associated T cells (p = 0.021). Since a CD3+ CD8+ PD-1 + T-cell infiltrate represents a "suppressed T-cell phenotype" apparently permissive toward OASC progression, our findings provide a mechanistic rationale for the effective application of immune checkpoint blockade in OASC to abrogate PD-1/PD-L1 interaction and effectively unleash the immune infiltrate to treat higher-stage tumors.
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Affiliation(s)
- Thomas J Kandl
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Oded Sagiv
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jonathan L Curry
- Department of Pathology, Section of Dermatopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Junsheng Ma
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney W Hudgens
- Department of Translational and Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - John Van Arnam
- Department of Pathology, Section of Dermatopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jennifer A Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bita Esmaeli
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael T Tetzlaff
- Department of Pathology, Section of Dermatopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Translational and Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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22
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Sagiv O, Nagarajan P, Ferrarotto R, Kandl TJ, Thakar SD, Glisson BS, Altan M, Esmaeli B. Ocular preservation with neoadjuvant vismodegib in patients with locally advanced periocular basal cell carcinoma. Br J Ophthalmol 2018; 103:775-780. [DOI: 10.1136/bjophthalmol-2018-312277] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/01/2018] [Accepted: 06/24/2018] [Indexed: 11/03/2022]
Abstract
Background/AimsLocally advanced (T4 per American Joint Committee on Cancer (AJCC) 8th edition) periocular basal cell carcinoma (BCC) can lead to loss of the eye. We report the neoadjuvant use of vismodegib followed by surgery in patients with such lesions with eye preservation as primary goal.MethodsThis retrospective interventional study includes all patients with a T4 periocular BCC (per 8th edition AJCC for eyelid carcinoma) treated by the senior author between 2013 and 2017 with neoadjuvant vismodegib prior to definitive surgery.ResultsEight patients had a T4 tumour. Six patients presented with recurrent disease. Indications for neoadjuvant treatment were an unresectable tumour in one patient, an attempt to avoid an orbital exenteration in six patients and an attempt to avoid disfiguring facial surgery in one patient. Patients were treated for a median of 14 months (range: 4–36 months). All patients underwent an eye-sparing surgery following neoadjuvant vismodegib and all final surgical margins were negative for tumour. Five patients had a complete response to vismodegib with no microscopic residual BCC found during surgery; three patients had a significant partial response with residual tumour found on pathology. At last follow-up, a mean of 18 (range: 6–43) months after surgery, all patients were off-vismodegib and alive without evidence of disease.ConclusionsNeoadjuvant vismodegib for locally advanced (T4) periocular BCC enabled an eye-sparing surgery in all patients in our cohort. Prolonged treatment was well tolerated by most patients. Over half of patients achieved a complete response with no residual microscopic disease. Careful long-term follow-up is needed to confirm long-term disease-free survival.
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23
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Sagiv O, Stewart J, Esmaeli B. Periocular Ecchymoses in Neuroblastoma Metastatic to the Orbit. Ophthalmology 2018; 125:983. [PMID: 29935671 DOI: 10.1016/j.ophtha.2018.03.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/05/2018] [Accepted: 03/19/2018] [Indexed: 11/25/2022] Open
Affiliation(s)
- Oded Sagiv
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - John Stewart
- Department of Anatomic Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bita Esmaeli
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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24
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Sagiv O, Rosenfeld E, Kalderon E, Barazani TB, Zloto O, Martinowitz U, Ben Simon GJ, Zilinsky I. Subcutaneous tranexamic acid in upper eyelid blepharoplasty: a prospective randomized pilot study. Can J Ophthalmol 2018; 53:600-604. [PMID: 30502984 DOI: 10.1016/j.jcjo.2018.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/04/2018] [Accepted: 01/09/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Postoperative ecchymoses or hematomas can prolong healing from surgery, and a search for locally administered agents that decrease bleeding is warranted. The objective of this study is to evaluate whether preoperative subcutaneous injection of tranexamic acid (TXA) reduces intra- and postoperative bleeding or ecchymoses in skin-only upper eyelid blepharoplasty surgery. DESIGN This is a prospective randomized, double-blind, controlled study. PARTICIPANTS We included 34 consecutive patients who were referred to an upper eyelid blepharoplasty surgery in our institution. METHODS The patients were equally randomized to a preoperative local injection of lidocaine mixed with either TXA or normal saline. All patients stopped antiaggregates 1 week before surgery. All surgeries were performed by a single surgeon who was unaware of group assignment. Total surgical time, cumulative time of cautery use, blood loss, the surgeon's assessment of bleeding extent, pain level reported by the patient, periocular ecchymoses during the first postoperative week, and time for patient's return to normal daily activity were recorded. RESULTS There was a trend toward smaller ecchymoses in the TXA group compared with the placebo group on the seventh day (p = 0.072). There were no group differences in total surgery time, cumulative cautery time, net blood weight in surgical pads, patient-reported pain level, surgeon's assessment of hemostasis, or periocular ecchymosis size on the first postoperative day. CONCLUSIONS Subcutaneous TXA was associated with similar intra- and postoperative hemorrhage in upper eyelid blepharoplasty compared with placebo. The effect of TXA in patients who did not stop antiaggregate use before surgery warrants further study.
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Affiliation(s)
- Oded Sagiv
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Elkanah Rosenfeld
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Elinor Kalderon
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tamar Brutman Barazani
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ofira Zloto
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Uriel Martinowitz
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Guy J Ben Simon
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Isaac Zilinsky
- Mohs Unit, Sheba Medical Center, Tel Hashomer, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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25
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Andron A, Hostovsky A, Nair AG, Sagiv O, Schiby G, Simon GB. The impact of IgG-4-ROD on the diagnosis of orbital tumors: A retrospective analysis. Orbit 2017; 36:359-364. [PMID: 28829660 DOI: 10.1080/01676830.2017.1337192] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 05/28/2017] [Indexed: 06/07/2023]
Abstract
This study was to determine the prevalence of immunoglobulin G4 (IgG4)-related orbital disease (IgG4-ROD) among patients who have previously undergone biopsy and were diagnosed to have idiopathic orbital inflammatory disease (IOID) or orbital lymphoproliferative disease (OLD), namely, lymphoma and benign reactive lymphoid hyperplasia (BRLH). This is a retrospective cross-sectional study. The charts and slides of all patients who underwent biopsies and were histopathologically diagnosed to have either IOID or OLD were reviewed. Demographics, clinical features, initial histopathological diagnoses, treatment received, and final outcome were noted. Using the diagnostic criteria for diagnosis for IgG4 disease, those cases that would classify as "possible IgG4-related disease (IgG4-RD)" were reviewed, reclassified, and reassigned a diagnosis of IgG4-ROD. We reviewed 105 patients' clinical charts. Of these 105 patients, upon reviewing the histopathology, 18 (17.15%) patients were found to fit the diagnostic criteria for possible IgG4-ROD. Of these 18 patients who were now reassigned the diagnosis of IgG4-ROD, the most common previous histopathological diagnosis was found to be IOID, for eight patients (44%), then BRLH, which was noted in five patients (27.8%), followed by lymphoma, which was noted in two patients (11.1%). Previously diagnosed cases of IOID and OLD were found to fulfill the criteria for IgG4-ROD. Given the advent of recent diagnostic and histopathological techniques, all cases of suspected IOID and OLD should be screened for IgG4-ROD and all previously diagnosed cases must be closely followed up, given the systemic implication of IgG4-RD. Histopathological reassessment of previously diagnosed cases may be considered.
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Affiliation(s)
- Aleza Andron
- a New York Eye and Ear Infirmary of Mount Sinai , New York , New York , USA
| | | | | | - Oded Sagiv
- b Sheba Medical Center , Tel Hashomer , Israel
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26
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Sagiv O, Thakar SD, Kandl TJ, Kontoyiannis DP, Debnam JM, Esmaeli B. Clinical Course of Preseptal and Orbital Cellulitis in 50 Immunocompromised Patients with Cancer. Ophthalmology 2017; 125:318-320. [PMID: 29128228 DOI: 10.1016/j.ophtha.2017.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 10/03/2017] [Accepted: 10/03/2017] [Indexed: 11/16/2022] Open
Affiliation(s)
- Oded Sagiv
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sudip D Thakar
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas J Kandl
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - J Matthew Debnam
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bita Esmaeli
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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27
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Thakar SD, Sagiv O, Tetzlaff MT, El-Naggar A, Debnam JM, Kandl TJ, Esmaeli B. A 60-year-old woman with an asymptomatic left lacrimal gland mass found incidentally. Digit J Ophthalmol 2017; 23:27-29. [PMID: 29403339 DOI: 10.5693/djo.03.2017.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Sudip D Thakar
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery
| | - Oded Sagiv
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery
| | - Michael T Tetzlaff
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston.,Department of Translational and Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston
| | - Adel El-Naggar
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston
| | - J Matthew Debnam
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston
| | - Thomas J Kandl
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery
| | - Bita Esmaeli
- Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery
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Sagiv O, Zloto O, Moroz I, Moisseiev J. Different Clinical Courses on Long-Term Follow-Up of Age-Related Macular Degeneration Patients Treated with Intravitreal Anti-Vascular Endothelial Growth Factor Injections. Ophthalmologica 2017; 238:217-225. [PMID: 28926846 DOI: 10.1159/000479437] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 07/12/2017] [Indexed: 11/19/2022]
Abstract
PURPOSE To assess the long-term outcome of neovascular age-related macular degeneration (AMD) treated with multiple intravitreal anti-vascular endothelial growth factor (VEGF) injections. METHODS All patients treated with over 30 intravitreal anti-VEGF injections for neovascular AMD between 2007 and 2014 were retrospectively reviewed. RESULTS A total of 67 eyes received 2,960 (mean 45 ± 9.1 per eye) anti-VEGF injections. Eyes with good final visual acuity (VA) had better initial VA (p = 0.020) and maintained it. Patients with moderate-to-poor final VA improved significantly after the first 3 monthly injections, and thereafter deteriorated consistently, mostly during the third (p = 0.019) and fourth (p = 0.006) years. Eyes with worse final VA had more intraretinal fluid (p = 0.05) and subretinal fibrosis (p = 0.04). CONCLUSION Two distinct clinical courses were identified: good final VA was associated with initial and long-term stability of good VA; eyes with worse final VA had worse initial VA, progressive deterioration following the initial improvement, and more scarring and intraretinal fluid. This probably underscores the long-term benefits of early detection and treatment.
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Affiliation(s)
- Oded Sagiv
- The Goldschleger Eye Institute, Sheba Medical Center, Tel HaShomer, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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29
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Sagiv O, Kandl T, Thakar S, Czerniak B, Tetzlaff M, Su S, Esmaeli B. Clinical Outcomes and Histopathologic Features of Orbital Hemangiopericytoma/ Solitary Fibrous Tumors. Skull Base Surg 2017. [DOI: 10.1055/s-0037-1600827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Oded Sagiv
- Anderson Cancer Center, Houston, Texas, United States
| | - Thomas Kandl
- Anderson Cancer Center, Houston, Texas, United States
| | - Sudip Thakar
- Anderson Cancer Center, Houston, Texas, United States
| | | | | | - Shirley Su
- Anderson Cancer Center, Houston, Texas, United States
| | - Bita Esmaeli
- Anderson Cancer Center, Houston, Texas, United States
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30
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Zloto O, Ben Simon G, Didi Fabian I, Sagiv O, Huna-Baron R, Ben Zion I, Wygnanski-Jaffe T. Association of orbital decompression and the characteristics of subsequent strabismus surgery in thyroid eye disease. Can J Ophthalmol 2017; 52:264-268. [PMID: 28576206 DOI: 10.1016/j.jcjo.2016.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 10/31/2016] [Accepted: 11/07/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the association of orbital decompression and the characteristics and outcome of subsequent strabismus surgery in patients with thyroid eye disease (TED). METHODS Data on patients with TED who underwent orbital decompression at the Goldschleger Eye Institute, Sheba Medical Center, Israel, between January 1990 to December 2011 were extracted. The characteristics of decompression and strabismus surgeries were recorded. The outcomes and association of both surgical procedures were analyzed. Statistical analysis included distribution, Pearson correlation, and matched paired tests. RESULTS 145 eyes underwent orbital decompression, of which 45 eyes (31.0%) underwent strabismus surgery. Esotropia developed in 70% of the patients. Men and smokers underwent strabismus surgeries after decompression procedures more frequently than women and nonsmokers (χ2 test, p = 0.07, 0.002). Moreover, patients who complained of diplopia before the decompression surgery underwent strabismus surgery more frequently (χ2 test, p = 0.005). Seventy-seven percent of the patients who underwent medial wall decompression developed esotropia (χ2 test, p = 0.004). CONCLUSIONS To the best of our knowledge, this is the largest series in the literature examining the association between decompression and strabismus surgeries. The patients' characteristics and the orbital walls involved in the decompression procedures are associated with the characteristics of subsequent strabismus that develops thereafter. These findings may have significant implications in planning TED management.
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Affiliation(s)
- Ofira Zloto
- Goldschleger Eye Institute, Sheba Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel..
| | - Guy Ben Simon
- Goldschleger Eye Institute, Sheba Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ido Didi Fabian
- Goldschleger Eye Institute, Sheba Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Sagiv
- Goldschleger Eye Institute, Sheba Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ruth Huna-Baron
- Goldschleger Eye Institute, Sheba Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Itay Ben Zion
- Goldschleger Eye Institute, Sheba Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamara Wygnanski-Jaffe
- Goldschleger Eye Institute, Sheba Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Sagiv O, Satchi K, Kinori M, Fabian ID, Rosen N, Ben Simon GJ, McNab A. Comparison of lateral orbital decompression with and without rim repositioning in thyroid eye disease. Graefes Arch Clin Exp Ophthalmol 2015; 254:791-6. [DOI: 10.1007/s00417-015-3237-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 11/23/2015] [Accepted: 11/30/2015] [Indexed: 10/22/2022] Open
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Sagiv O, Sachs D. Rotation stability of a toric intraocular lens with a second capsular tension ring. J Cataract Refract Surg 2015; 41:1098-9. [DOI: 10.1016/j.jcrs.2015.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 01/13/2015] [Indexed: 11/27/2022]
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Sagiv O, Rosen N, Priel A, Rosner M, Ben Simon GJ. [Dacryocystorhinostomy (DCR) under local anesthesia]. Harefuah 2015; 154:110-135. [PMID: 25856864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Dacryocystorhinostomy (DCR) is performed using an external or endoscopic endonasal approach under general anesthesia (GA) or under sedation. In our department these operations are performed mainly under local anesthesia (LA) without sedation. PURPOSE To examine the intraoperative and postoperative success rates of primary DCR under LA and GA using the external or endonasal approach. METHODS The study group of this retrospective research included all patients who underwent a primary DCR in our department in 2009-2012 due to an acquired nasolacrimal duct obstruction. The main outcome measure was postoperative success defined as complete or significant improvement in tearing and a patent ostium. Intraoperative success rate was defined as the ability to complete the operation under LA. RESULTS The study group included 139 patients. The success rate was 87.1% (121 patients). Success rates were similar for the external and endoscopic approaches (88.6% vs. 82.4%, respectively, p = 0.348). The success rate for surgeries performed under GA was higher than LA (96.7% vs. 84.9%, respectively, p = 0.019). The mean age of patients who were operated under GA was significantly younger than those under LA (43.6 vs. 65.7 years, respectively, p < 0.005). Conversion GA was only needed in 1 patient (0.7%). CONCLUSION Most DCR surgeries can be performed under LA without sedation. Success rates found in our study are comparable with previous publications, similar for external or endoscopic approaches, and better under GA than LA. This difference may be related to the age difference between the two groups.
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Moisseiev E, Sagiv O, Lazar M. Intense exercise causing central retinal vein occlusion in a young patient: case report and review of the literature. Case Rep Ophthalmol 2014; 5:116-20. [PMID: 24847256 PMCID: PMC4025055 DOI: 10.1159/000360904] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We report a 19-year-old patient who developed a central retinal vein occlusion (CRVO) with significant macular edema and visual impairment following intense exercise and dehydration. The patient was treated with 3 intravitreal bevacizumab injections with complete resolution. A review of the literature on the cause and treatment for CRVO in young patients was performed, focusing on the role of intense exercise and dehydration as a rare pathogenesis mechanism of CRVO.
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Affiliation(s)
- Elad Moisseiev
- Department of Ophthalmology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Oded Sagiv
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel
| | - Moshe Lazar
- Department of Ophthalmology, Tel Aviv Medical Center, Tel Aviv, Israel
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Sagiv O, Fishelson-Arev T, Buckman G, Mathalone N, Wolfson J, Segev E, Peled R, Lavi I, Geyer O. Retinal nerve fibre layer thickness measurements by optical coherence tomography in patients with sleep apnoea syndrome. Clin Exp Ophthalmol 2013; 42:132-8. [DOI: 10.1111/ceo.12145] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 05/18/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Oded Sagiv
- The Bruce Rappaport Faculty of Medicine; The Technion - Israel Institute of Technology; Haifa Israel
| | - Tagil Fishelson-Arev
- Carmel Medical Center; Department of Ophthalmology; The Bruce Rappaport Faculty of Medicine; The Technion - Israel Institute of Technology; Haifa Israel
| | - Gila Buckman
- Carmel Medical Center; Department of Ophthalmology; The Bruce Rappaport Faculty of Medicine; The Technion - Israel Institute of Technology; Haifa Israel
| | - Nurit Mathalone
- Carmel Medical Center; Department of Ophthalmology; The Bruce Rappaport Faculty of Medicine; The Technion - Israel Institute of Technology; Haifa Israel
| | - Julia Wolfson
- Carmel Medical Center; Department of Ophthalmology; The Bruce Rappaport Faculty of Medicine; The Technion - Israel Institute of Technology; Haifa Israel
| | - Eitan Segev
- Carmel Medical Center; Department of Ophthalmology; The Bruce Rappaport Faculty of Medicine; The Technion - Israel Institute of Technology; Haifa Israel
| | - Ron Peled
- Sleep Laboratory; The Bruce Rappaport Faculty of Medicine; The Technion - Israel Institute of Technology; Haifa Israel
| | - Idit Lavi
- Department of Community Medicine and Epidemiology; Carmel Medical Center; The Technion - Israel Institute of Technology; Haifa Israel
| | - Orna Geyer
- Carmel Medical Center; Department of Ophthalmology; The Bruce Rappaport Faculty of Medicine; The Technion - Israel Institute of Technology; Haifa Israel
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