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Biomedical subjects

P L Custer

Publications and source records attributed to P L Custer.

At least 19 recordsLinked to original sources
PubMed2001

Management and prognosis of Merkel cell carcinoma of the eyelid.

OBJECTIVE: To evaluate the clinical presentation, treatment, and long-term follow-up of eyelid Merkel cell carcinoma. DESIGN: Retrospective noncomparative interventional case series. PARTICIPANTS: Fourteen patients with primary eyelid Merkel cell carcinoma. METHODS: Cases of Merkel cell carcinoma for which long-term follow-up was available were solicited from members of the American Society of Ophthalmic Plastic and Reconstructive Surgery through an on-line e-mail/news group. MAIN OUTCOME MEASURES: Follow-up period, treatment history, presence and type of recurrence, and mortality. RESULTS: Average follow-up was 33.4 months. Of the 14 cases identified, only 2 patients (14%) received prophylactic therapy beyond wide surgical excision. Three patients (21%) had recurrences, none of whom initially received prophylactic therapy (i.e., radiation therapy, lymph node dissection, and/or chemotherapy) beyond wide surgical excision. One patient (7%) died of metastatic Merkel cell carcinoma. CONCLUSIONS: Merkel cell carcinoma is a rare skin malignancy that occasionally affects the eyelid, with the potential for regional and distant metastasis. Consideration should be given to the use of prophylactic adjunctive therapies beyond wide surgical excision while simultaneously considering the morbidity of these therapies.

Aged↗
PubMed2001

Endonasal dacryocystorhinostomy: a report by the American Academy of Ophthalmology.

OBJECTIVE: This document describes endonasal dacryocystorhinostomy (DCR) and examines the evidence to answer key questions about the effectiveness of the procedure compared with external DCR; the relative indications, contraindications, advantages, and limitations of the procedure; and patient selection, surgical technique, postoperative care, and complications. METHODS: A literature search conducted for the years 1968 to 2000 retrieved 93 citations. The panel members reviewed 71 of these articles and selected 64 for the panel methodologist to review and rate according to the strength of evidence. A level I rating is assigned to properly conducted, well-designed, randomized clinical trials; a level II rating is assigned to well-designed cohort and case-control studies; and a level III rating is assigned to case series and poorly designed prospective and retrospective studies, including case-control studies. RESULTS: The published literature includes two reports that describe clinical trials comparing endonasal with external DCR with a 1-year follow-up. The success rate was 91% for the external DCR group in both reports and 63% and 75% for the endonasal DCR groups, defined by patency to irrigation. A longitudinal cohort study included a control group of age-matched external DCR patients who were compared with a study group of endonasal DCR patients. The reported success rate at 9 months following surgery for the endonasal cohort was 90% and was not statistically significantly different from the 94% success rate noted in the external DCR control group. Remaining data on reported success rates of primary and revision endonasal DCR were obtained from a collection of uncontrolled observational case studies with varying periods of follow-up and success rates ranging from 59% to 100%. CONCLUSIONS: It is difficult to make definite evidence-based determinations about the relative efficacy of endonasal and external DCR because of the deficiencies in the reported literature. Based on level III evidence, the available data suggest that endonasal DCR may be a viable option for the correction of acquired nasolacrimal duct obstruction and complex forms of congenital dacryostenosis in selected patients. This procedure may be indicated on a primary basis or as revisional surgery following failed external or endonasal DCR. Some studies comparing endonasal DCR with external DCR suggested lower success rates in the endonasal group; other studies yielded success rates comparable with or exceeding those of external surgery. Reported complications of endonasal DCR do not generally appear to be greater in frequency or magnitude than those associated with external DCR. Disadvantages of endonasal DCR include the preferred use of general anesthesia by many surgeons, the high cost of expensive equipment and instrumentation, and the relatively steep learning curve for this procedure. Depending on the preference of the surgeon, more postoperative care may be required for patients undergoing endonasal DCR than external DCR. Both the advantages and the limitations of endonasal DCR relative to external DCR should be carefully discussed with patients who are contemplating endonasal surgery.

Academies and Institutes↗
PubMed2001

The arm as a skin graft donor site in eyelid reconstruction.

PURPOSE: To report the technique, success, and complications of using the arm as a donor site for full-thickness skin grafts used in eyelid and facial reconstruction. METHODS: The charts of 42 patients were reviewed. The arm was used as a donor site for harvesting full-thickness skin grafts in 52 procedures of eyelid or facial reconstruction. RESULTS: The size of skin grafts varied from 4.0 cm2 to 59.5 cm2. There were few recipient site complications: partial necrosis (n=2), severe contraction (n=2), and hair growth (n=4). Donor site complications included wound dehiscence (n=2) and hypertrophic scarring (n=2). CONCLUSIONS: The arm is an acceptable donor site for harvesting full-thickness skin grafts for use in eyelid and facial reconstruction when either traditional donor sites are unavailable or a large amount of skin is needed.

Adolescent↗
PubMed2000

Lagophthalmos: an unusual manifestation of oculomotor nerve aberrant regeneration.

PURPOSE: To describe a patient with unusual findings after regeneration of the oculomotor nerve. METHODS: Case report. RESULTS: A 35-year-old woman developed complete right third nerve paralysis after neurosurgical ligation of internal carotid-posterior communicating and internal carotid-ophthalmic artery aneurysms. Permanent ipsilateral lagophthalmos appeared as third nerve function spontaneously recovered. CONCLUSION: Lagophthalmos may rarely develop after aberrant regeneration of the oculomotor nerve, presumably caused by co-contraction of the levator and superior rectus muscles during the Bell's phenomenon.

Adult↗
PubMed2000

Enucleation of blind, painful eyes.

PURPOSE: To determine the demographics and results of treatment in patients undergoing enucleation of blind, painful eyes. METHODS: Medical records were reviewed to determine the precipitating cause, preoperative symptoms, prior therapy, and results of treatment in 58 patients in whom enucleation was performed to relieve ocular discomfort. Patient perception of symptoms and treatment was assessed by a follow-up mail survey. RESULTS: Forty-five percent of patients had sustained prior trauma. Ocular discomfort was attributed to phthisis (43%), elevated intraocular pressure (40%), or corneal decompensation (10%). Preoperative symptoms included ocular pain (91%), periocular headache (17%), tearing (26%), and ipsilateral photophobia (26%). Eight patients experienced contralateral photophobia. Enucleation provided complete symptomatic relief in 54 patients (93%). Two of the four patients with persistent discomfort experienced painful facial paresthesias, attributed to prior retrobulbar alcohol injections. Ninety-one percent of the 32 patients who completed the follow-up survey reported pain relief after surgery, whereas 94% would recommend enucleation to others with blind, painful eyes. CONCLUSIONS: Trauma is the most common precipitating condition in patients undergoing enucleation of blind, painful eyes. These patients experience a variety of symptoms, including ocular pain, facial pain or paresthesias, tearing, and photophobia. Contralateral photophobia is not uncommon. Enucleation is highly effective in relieving these symptoms and should be considered in patients unresponsive to topical therapy. Facial paresthesias in patients who have received prior retrobulbar alcohol injections are not relieved by enucleation.

Adolescent↗
PubMed1999

Postoperative rotation of hydroxyapatite enucleation implants.

OBJECTIVE: To determine the incidence of postoperative rotation of flattened hydroxyapatite enucleation implants. METHODS: A retrospective review of patients receiving flattened hydroxyapatite enucleation implants was performed to determine the incidence and severity of postoperative implant misalignment. RESULTS: Flattened hydroxyapatite implants had been placed in 16 patients. Five were noted to have postoperative implant rotation, which was detected between 11 and 60.3 months following enucleation. The malposition was mild, inconsistent, and clinically insignificant in 2 patients. The remaining 3 patients demonstrated marked implant misalignment, which likely would have been functionally significant had motility pegs been placed. CONCLUSIONS: Postoperative rotation of flattened hydroxyapatite implants may occur late after enucleation. Such implant modification should not be performed in patients with preexisting strabismus, who have a higher incidence of this complication.

Coated Materials, Biocompatible↗
PubMed1999

Treatment choice and quality of life in patients with choroidal melanoma.

OBJECTIVE: To determine if quality of life differs between patients with choroidal melanoma treated with enucleation and those treated with radiation therapy. MATERIALS AND METHODS: Patients treated for choroidal melanoma at 5 Midwest centers were asked to participate. There were 65 participants treated with enucleation and 82 treated with radiation therapy. Quality of life was assessed using the Medical Outcome Study Short Form 36 and the National Eye Institute Visual Function Questionnaire and by the Time-Tradeoff interview method. RESULTS: The average length of follow-up was 4.9 years for the group treated with radiation therapy and 6.3 years for the group treated with enucleation (P = .05). After adjusting for age, sex, years of follow-up, and the number of chronic conditions, there were few differences in any of the quality-of-life measures by treatment status. Participants in the group treated with radiation therapy were more likely to have higher (better) scores on the Vitality and Mental Component subscales of the Medical Outcome Study Short Form 36 than participants treated with enucleation. There were no differences on the National Eye Institute Visual Function Questionnaire or the Time-Tradeoff measures of quality of life. CONCLUSION: Choice of treatment for choroidal melanoma does not seem to be associated with large differences in quality of life in long-term follow-up.

Aged↗
PubMed1999

Volumetric determination of enucleation implant size.

PURPOSE: To determine whether volumetric calculation of enucleation implant size improves the results of the enucleation procedure. METHODS: The volume of the enucleated globe was measured in 33 eyes of 33 patients, allowing intraoperative calculation of implant size. The degree of postoperative anophthalmic volume deficit was evaluated by determining the relative enophthalmic position of the implant using Hertel exophthalmometry. These results were compared with those obtained from two groups of historical control patients who had previously undergone enucleation with the insertion of standard size 18-mm or 20-mm implants. RESULTS: There was significant variability in the volume of "normal" size globes (range, 7.0 to 9.0 ml; mean, 7.9 ml; standard deviation [SD], 0.7), resulting in the placement of implants between 18 to 22 mm in diameter. Study patients undergoing volumetric determination of implant size demonstrated less implant enophthalmos (mean, 5.9 mm) than historical control patients who received 18-mm (mean, 8.5 mm; P =.0001) or 20-mm (mean, 6.8 mm, P = .0332) implants. CONCLUSIONS: Volumetric determination and individualization of enucleation implant size appears to reduce postoperative anophthalmic volume deficit.

Adult↗
PubMed1999

Comparative motility of hydroxyapatite and alloplastic enucleation implants.

OBJECTIVE: To compare the motility of scleral-covered hydroxyapatite and alloplastic enucleation implants. DESIGN: Retrospective, nonrandomized comparative trial. PARTICIPANTS: Measurements were obtained after surgery in 76 anophthalmic patients who had received either hydroxyapatite or alloplastic enucleation implants. METHODS/MAIN OUTCOME MEASURES: Horizontal and vertical excursions of the enucleation implants. RESULTS: There is no clinically important difference between the movement of hydroxyapatite and alloplastic enucleation implants. Implant movement appears to decline with advancing age. CONCLUSION: Scleral-covered alloplastic and hydroxyapatite enucleation implants show similar movement. Although directly coupling hydroxyapatite implants to the prosthesis via the motility peg provides enhanced prosthetic movement, there appears to be no motility benefit of nonpegged hydroxyapatite over spherical alloplastic implants.

Adolescent↗
PubMed1999

Matching set of enucleation retractor and scissors.

Many surgeons encounter difficulty transecting the optic nerve during the enucleation procedure. An inadequate specimen may be obtained or the surrounding orbital tissue may be traumatized. A matching set of enucleation instruments have been developed to improve the visualization and division of the optic nerve while protecting the nearby orbital structures. The new enucleation instruments have been employed in 130 consecutive enucleation procedures. There have been no complications associated with these instruments. These instruments have facilitated the visualization and transection of the optic nerve during the enucleation procedure.

Equipment Design↗
PubMed1998

Tarsal kinking after Hughes flap.

A retrospective review of 45 patients undergoing the Hughes tarsoconjuctival flap procedure for lower eyelid reconstruction detected three individuals who developed kinking of the tarsus and upper eyelid margin. This unusual complication became apparent at the time of flap division. A horizontal band of fibrosis at the superior border of the remaining upper eyelid tarsus was appreciated in two of the patients. Excision of the fibrotic tissue resulted in an immediate improvement of the deformity.

Adenocarcinoma, Sebaceous↗
PubMed1996

Merkel cell carcinoma of the eyelid.

PURPOSE: To demonstrate the clinical variability and histologic characteristics of Merkel cell carcinoma of the eyelid. METHODS: We investigated two cases of Merkel cell carcinoma of the eyelid in a 67-year-old man and an 83-year-old woman, respectively. Both lesions were initially misdiagnosed as benign tumors on clinical examination. RESULTS: After the correct diagnosis was made, both lesions were treated with wide resection aided by frozen sections, and reconstructive surgery. CONCLUSIONS: Merkel cell carcinoma is an aggressive tumor with variable clinical manifestation. Radical surgical therapy and close follow-up are indicated.

Aged↗
PubMed1995

External dacryocystorhinostomy. Surgical success, patient satisfaction, and economic cost.

BACKGROUND: External dacryocystorhinostomy (DCR) is the standard treatment for nasolacrimal duct obstruction, with success rates consistently above 90%. This study reviews the demographics, success, cost, efficiency, and patient satisfaction in external DCR. This information will be useful as comparison criteria for evaluating new surgical techniques. METHODS: Records of 169 external DCR procedures performed over an 8.7-year period were reviewed. All patients had preoperative symptoms of tearing and/or dacryocystitis with a component of nasolacrimal obstruction. Patient demographics, history, examination findings, surgical and anesthesia information, postoperative success, complications, and follow-up course were recorded. Patient satisfaction and long-term success were evaluated by telephone survey. RESULTS: External DCR often required middle turbinectomy (17%), exposure of ethmoid sinuses (17%), and removal of dacryoliths (14%). Most patients (90%) underwent silicone intubation, with the tubes removed at an average of 3.7 weeks after surgery. A patent system was established in 95% of procedures, whereas 92% remained asymptomatic. Postoperative complications included hemorrhage (3.9%) and scarring (2.6%). Of the surveyed patients, 87% denied continued or recurrent symptoms; 97% rated their incision "good" to "excellent" in appearance; and all patients stated they would recommend the procedure to others. CONCLUSION: External DCR is highly successful, requires limited follow-up, and is a cost-effective procedure. Complications are uncommon, and patient satisfaction is high. New lacrimal surgical techniques must be evaluated against the long-proven success of the external approach.

Adolescent↗
PubMed1994

Surgical excision of periorbital capillary hemangiomas.

BACKGROUND: Periorbital capillary hemangiomas of childhood can produce ptosis, strabismus, and anisometropia, resulting in amblyopia. Traditional therapy with either systemic or local corticosteroids occasionally yields incomplete resolution of these lesions and may be associated with numerous adverse complications. The authors report their experience performing surgical resection of periorbital capillary hemangiomas. METHODS: Twelve children with periorbital capillary hemangiomas were treated surgically. Six of these children had previously failed to adequately respond to steroid injections and six were primarily treated with surgical resection. All lesions were believed to be localized and did not appear to be infiltrative on preoperative computed tomographic scans. RESULTS: All lesions were completely resected, except for two in which there was a small area of residual hemangioma surrounding the lacrimal drainage system that was left intact. Controlled intraoperative hemorrhage in two patients required intraoperative directed-donor blood transfusion. Perioperatively, in one patient a wound dehiscence developed, which required minor repair. This same patient elected to have surgical scar revision postoperatively. The patients have been followed up to 5 years. All did well with improved cosmesis, and they have good lid function. No recurrences have been noted. CONCLUSION: Surgical resection of pediatric capillary hemangiomas should be considered a treatment option in those that fail to respond to corticosteroids and/or are isolated and noninfiltrative in nature.

Betamethasone↗
PubMed1994

Normal eyelid crease position in children.

Proportions of the upper lid were determined based on the following measurements in 33 children: lash-line-lid crease (LC), lashline-lower brow (LB), vertical fissure, and horizontal fissure. Age-matched mean measurements (mean LC/LB ratio = 0.33) for 26 white vs 7 black children, and for 16 males vs 17 females were not significantly different. However, the mean ratio in 15 preschool and school-age children was significantly greater than that in 18 infants and toddlers (less than 4 years old) (P < .01). We conclude that the normal eyelid crease position in children is one third up the lashline to the lower brow. However, the normal eyelid crease position in infants and toddlers is slightly less than, and, in older preschool and school-age children, slightly greater than this distance up the lashline. Thus, age may determine the surgical placement of the eyelid crease in children with indistinct creases.

Adolescent↗