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Biomedical subjects

Robert A Goldberg

Publications and source records attributed to Robert A Goldberg.

At least 19 recordsLinked to original sources
PubMed2006

Sino-orbital fistula: a complication of exenteration.

PURPOSE: To report the incidence, characteristics, and management of sino-orbital fistulas, a complication of orbital exenteration. DESIGN: Retrospective interventional case series. PARTICIPANTS: One hundred ten patients who underwent orbital exenteration at 2 orbital units. METHODS: Retrospective chart review of all cases of orbital exenteration between 1993 and 2005 at one orbital unit and between 1999 and 2005 at a second orbital unit. MAIN OUTCOME MEASURES: Incidence of sino-orbital fistulas. RESULTS: Seventy-three and 37 orbital exenterations were performed at the first and second orbital units, respectively. Five patients developed sino-orbital fistulas, 1 of whom developed 2 fistulas at separate sites. In the first unit, 4 fistulas developed in 3 of 73 (4.1%) patients who underwent orbital exenteration. In the second unit, 2 fistulas developed in 2 of 37 (5.4%) exenterated orbits. The majority (5/6) of fistulas occurred medially to the ethmoid sinus, whereas 1 occurred superiorly to the frontal sinus. Risk factors that may have contributed to fistula formation include radiotherapy (3/6), sinus disease (3/6), intraoperative penetration into a sinus (3/6), and immunocompromise (1/6). Management was tailored to the individual case and ranged from conservative socket hygiene to surgical repair with grafts or flaps. Four of the 6 fistulas recurred after repair. Three of these subsequently were closed successfully. Only 1 fistula persisted until the patient died from malignant disease. CONCLUSIONS: Sino-orbital fistulas are uncommon but not rare complications of orbital exenteration that may be predicted by several risk factors. Bothersome symptoms may necessitate treatment, which can range from conservative management to surgical repair with various grafts or flaps. Despite repair, fistulas may be difficult to eradicate.

Adult↗
PubMed2006

Suture midface suspension.

OBJECTIVE: To describe a simple and effective facelift technique useful as an adjunct to other oculoplastic procedures METHODS: Retrospective, non-comparative case series. Thirty five patients undergoing suture midface suspension from 1998 to 2000. Suspension sutures were passed from the nasolabial fold to the temporalis fascia to elevate the midface and the corner of the mouth. RESULTS: A satisfactory and stable outcome is obtained in 2 years of follow up. CONCLUSION: Suture midface suspension is a safe and effective technique for the management of midface descent.

Adult↗
PubMed2006

Comparing outcomes of enucleation and evisceration.

PURPOSE: To compare clinical outcomes of enucleation and evisceration by functional and aesthetic measures. DESIGN: Retrospective, nonrandomized, comparative analysis. PARTICIPANTS: Eighty-four patients who underwent enucleation or evisceration. METHODS: The medical records of the participants were retrospectively reviewed. Clinical photographs were graded by blinded observers for qualitative measures. MAIN OUTCOME MEASURES: Postoperative eyelid and motility measurements, as well as subjective grades of various aesthetic and functional outcomes. RESULTS: There is no statistically significant difference in the overall aesthetic outcome of enucleation and evisceration, although several specific comparisons were found to be significant. Implant motility score is higher in eviscerated eyes (5.58+/-2.08) than in enucleated eyes (4.35+/-1.69) (P = 0.05). Adduction of the implant is significantly less than abduction in eviscerated eyes (1.34 vs. 1.44; P = 0.02). Implant motility is greater than prosthesis motility. Both enucleation and evisceration result in enophthalmos and a sulcus defect. Seven of 32 patients (21.9%) who underwent enucleation experienced a complication, whereas only of 7 of 52 patients (13.5%) who underwent evisceration experienced a complication (P = 0.0002). The 2 most common complications were implant exposure and formation of a pyogenic granuloma. CONCLUSIONS: Although enucleation and evisceration produce aesthetically similar outcomes, eviscerated eyes have better implant motility and experience fewer complications. Both enucleation and evisceration result in enophthalmos, sulcus contour defects, and incomplete transfer of implant motility to the prosthesis.

Blindness↗
PubMed2006

Subperiosteal midface lift with or without a hard palate mucosal graft for correction of lower eyelid retraction.

PURPOSE: To compare functional and surgical outcomes of a subperiosteal midface lift with and without the placement of a hard palate mucosal graft (HPMG) in patients with lower eyelid retraction. DESIGN: Retrospective, comparative, interventional case series. PARTICIPANTS: Thirty-four patients with lower eyelid retractions who underwent surgery at the Jules Stein Eye Institute in a 5-year period. METHODS: Medical record review of all patients who underwent surgery for lower eyelid retraction by a subperiosteal midface lift with or without an HPMG. Preoperative and postoperative digital photographs were taken in all patients. MAIN OUTCOME MEASURES: Change in margin reflex distance 2 (MRD2), measured from the pupillary margin to the upper margin of the lower eyelid; patient discomfort; and surgical complications. RESULTS: Thirty-four patients (20 female; mean age, 64 years) participated in the study; 11 underwent bilateral surgery, with overall 43 surgeries performed. Eighteen patients (42%) had lower eyelid retraction secondary to previous transcutaneous lower eyelid blepharoplasty. Postoperatively, patients attained a better lower eyelid position, with improvement of lower eyelid height of 1.4 mm (P<0.001, 1-sample t test). Patients operated using an HPMG (12 surgeries) achieved a greater reduction in MRD2 postoperatively as compared with patients operated by subperiosteal midface lift alone (31 surgeries; 2.2 mm vs. 1.1 mm, respectively; P = 0.02, Wilcoxon Mann-Whitney). One patient needed reoperation secondary to symptomatic lower eyelid retraction postoperatively. CONCLUSIONS: The subperiosteal midface lift is effective in correction of lower eyelid retraction of various causes. The use of an HPMG spacer may enhance surgical outcomes and results in a better lower eyelid position.

Adolescent↗
PubMed2006

Periocular and orbital amyloidosis: clinical characteristics, management, and outcome.

OBJECTIVE: To present the clinical features and management outcome in a large series of patients with periocular and orbital amyloidosis. DESIGN: Retrospective, noncomparative, interventional case series. PATIENTS: All patients diagnosed with periocular and orbital amyloidosis in 6 oculoplastic and orbital units. METHODS: Clinical records of all patients were reviewed. MAIN OUTCOME MEASURES: Clinical presentation, radiological and histological findings, treatment modalities, and outcome. RESULTS: The study included 24 patients (15 female, 9 male) with a mean age of 57+/-17 years. Nineteen cases were unilateral, and 5 were bilateral. Clinical signs and symptoms included a visible or palpable periocular mass or tissue infiltration (95.8%), ptosis (54.2%), periocular discomfort or pain (25%), proptosis or globe displacement (21%), limitations in ocular motility (16.7%), recurrent periocular subcutaneous hemorrhages (12.5%), and diplopia (8.3%). Seven cases had orbital involvement, and 17 were periocular. Immunohistochemistry in 7 patients showed B cells or plasma cells producing monoclonal immunoglobulin chains that were deposited as amyloid light chains. Only 1 patient was diagnosed with systemic amyloid light chain amyloidosis. Treatment modalities were mainly observation and surgical debulking. During a mean follow-up period of 39 months, 21% showed significant progression after treatment, whereas 79% were stable or showed no recurrence after treatment. CONCLUSION: Periocular and orbital amyloidosis may present with a wide spectrum of clinical findings and result in significant ocular morbidity. Complete surgical excision is not feasible in many cases, and the goal of treatment is to preserve function and to prevent sight-threatening complications.

Adult↗
PubMed2006

Orbital invasion by recurrent maxillary ameloblastoma.

PURPOSE: To describe 2 patients with orbital invasion by maxillary ameloblastoma, a rare odontogenic tumor that is not commonly encountered in ophthalmic practice. DESIGN: Retrospective, interventional case report. METHODS: Two patients who were diagnosed with maxillary ameloblastoma several years ago sought treatment for new-onset ocular and orbital signs and symptoms. MAIN OUTCOME MEASURES: Clinical and radiological findings and outcome. RESULTS: In the first patient, tumor recurrence with orbital invasion was diagnosed, and the patient underwent a total orbital exenteration. No recurrence was noted after 18 months of follow-up. The second patient had intracranial involvement with orbital invasion and underwent an extensive resection through an intracranial approach. No recurrence was noted after a 6-month follow-up period. CONCLUSIONS: Although a slow-growing tumor, maxillary ameloblastoma can recur after surgical excision and can be locally aggressive; it can invade the orbit and result in significant ocular morbidity. Ophthalmologists should be aware of this tumor and should monitor these patients closely when orbital invasion is suspected.

Aged↗
PubMed2006

Paranasal sinus inflammation and non-specific orbital inflammatory syndrome: an uncommon association.

OBJECTIVES: The aim of this study is to present a series of patients with orbital inflammatory symptoms associated with significant paranasal sinus inflammation, and to discuss the diagnostic and management modalities. METHODS: A retrospective, non-comparative, interventional case series of all patients diagnosed with orbital inflammatory syndrome and significant sinus inflammation, seen at two Orbital Units between January 1999 and October 2005. The clinical records of all patients were reviewed. RESULTS: Of 91 cases diagnosed with non-specific orbital inflammatory syndrome, six (6.6%, four males, two females mean age 51+/-17 years) had significant sinus inflammation. Symptoms and signs were periorbital swelling and erythema, proptosis, globe displacement and ocular motility restrictions with diplopia. On imaging, there was extraocular muscle enlargement and/or orbital fat haziness, as well as almost complete ipsilateral maxillary sinus opacification with varying degrees of opacification of adjacent sinuses. Sinus biopsy in four cases showed a non-specific inflammatory reaction. Treatment with steroids alone (four cases) or a combination of oral antibiotics and systemic steroids (two cases) resulted in resolution of signs and symptoms within 24-72 h. One case of recurrence was noted during a mean follow-up period of 9 months (range, 3-24 months), and this responded well to oral steroids. CONCLUSION: Although uncommon, paranasal sinusitis can be associated with a non-specific orbital inflammatory syndrome. When an infectious etiology is excluded, systemic steroids may play a major role in the management of these patients and result in prompt resolution of orbital signs and symptoms.

Adult↗
PubMed2006

Sclerosing therapy as first line treatment for low flow vascular lesions of the orbit.

PURPOSE: To evaluate the outcome of sodium morrhuate 5% injections in patients with low flow vascular lesions, which consist of orbital lymphangiomas, and in one patient with intraosseous cavernous hemangioma. DESIGN: Prospective, interventional consecutive case series. METHODS: Intralesional sodium morrhuate 5% was injected under direct visualization or under radiographic guidance to six patients with orbital lymphangiomas and one patient with intraosseous cavernous hemangioma. Comprehensive eye examination and follow-up imaging studies were performed. main outcome measures: Lesion size was evaluated by orbital imaging and clinical examination, visual acuity, exophthalmos, and posttreatment complications. RESULTS: Seven patients (four female, three male; average age, 33 years) were included. Six patients were diagnosed with orbital lymphangioma, and one patient was diagnosed with intraosseous cavernous hemangioma. Patients received an average of 2.6+/-2 intralesional injections of sodium morrhuate, with a range of one to six injections and a mean volume of 0.9+/-0.8 ml (range, 0.2 to 2.1 ml). Lesions showed a decrease in size an average of 50% (33%) and ranged from minimal (10%) to near total resolution (85%). Visual acuity and intraocular pressure remained unchanged; exophthalmos decreased an average of 1.5+/-1.8 mm. Complications included one case of orbital hemorrhage that resolved spontaneously and transient keratopathy in all patients with anterior orbital lesions. CONCLUSION: Intralesional sclerosing therapy with sodium morrhuate 5% is effective in tumor debulking in patients with orbital lymphangioma and is not associated with vision-threatening complications. It may be a better alternative to surgery for low flow orbital tumors, which includes lymphangioma.

Adolescent↗
PubMed2006

Strabismus after deep lateral wall orbital decompression in thyroid-related orbitopathy patients using automated hess screen.

PURPOSE: To evaluate the effect of deep lateral wall orbital decompression with intraconal fat debulking on strabismus in thyroid-related orbitopathy (TRO) patients using automated Hess screen (AHS). DESIGN: Prospective nonrandomized clinical study. PARTICIPANTS: Eleven TRO patients (19 surgeries) operated on at the Jules Stein Eye Institute from January, 2004, through December, 2004. METHODS: Automated Hess screen testing was performed in all patients before surgery and 3 months after surgery; all patients received surgery in the nonactive phase of the disease. MAIN OUTCOME MEASURES: Amplitude of horizontal and vertical deviations (prism diopters) in all standard positions of gaze. RESULTS: Eleven TRO patients (7 females; mean age, 47 years) were included in the study; 8 patients underwent bilateral surgery. After surgery, exophthalmos decreased an average (+/-standard deviation) of 2.7 mm (+/-2.5 mm; P = 0.003). Before surgery, 7 patients (63%) reported primary gaze diplopia, whereas only 2 patients (18%) showed diplopia in primary gaze after surgery (P = 0.03, chi-square analysis). Orbital decompression had no statistically significant effect on horizontal and vertical ocular deviations measured by AHS. Mean amplitude of deviation in primary gaze was 1.2 prism diopters (PD) esotropia and 0.07 PD hypotropia before surgery, and 2.5 PD exotropia with 0.6 PD hypertropia after surgery (delta = 3.7 PD for horizontal deviation and -0.7 for vertical deviation; P = 0.051, paired samples t test for horizontal difference and P not significant for vertical difference). Nonsignificant P values were obtained in all 9 positions of gaze. Most patients had periocular numbness that resolved spontaneously 2 to 6 months after surgery. CONCLUSIONS: Deep lateral wall orbital decompression with intraconal fat debulking had no statistically significant effect on horizontal and vertical deviations measured by the AHS. Patients may demonstrate small angle exotropia shift, but this finding was not clinically significant.

Adipose Tissue↗
PubMed2006

Lessons learned from difficult or unsuccessful cannulations of the superior ophthalmic vein in the treatment of cavernous sinus dural fistulas.

OBJECTIVE: Retrograde cannulation of the superior ophthalmic vein (SOV) is an important route for embolization of cavernous sinus dural fistulas (CDF). We present our experience with technically difficult cases in which it was not possible to isolate or cannulate this vein. DESIGN: Retrospective, noncomparative, interventional case series. PATIENTS: All patients diagnosed with dural CDF at the University of California Los Angeles Medical Center between January, 1993, and July, 2005, and who were treated with embolization via the SOV. METHODS: The clinical records of all patients were reviewed. MAIN OUTCOME MEASURES: Patient demographics, clinical presentation, and surgical findings. RESULTS: Of 91 patients diagnosed with CDF during the study period, 25 patients (16 females, 9 males; mean age, 59 years) were treated with embolization via the SOV. In 6 of them (24%; 4 women and 2 men; mean age, 67 years), there were significant difficulties in cannulation of the SOV or in successful closure of the fistula with this approach. Three patients had a fragile or a very small vein that could not be cannulated, and 1 of the 3 also had a large, posteriorly located varix that bled extensively on attempted cannulation. In 2 other patients, the anterior segment of the SOV was clotted and the catheter could not be threaded. In 1 patient, an inferior location of the supraorbital vein resulted in difficulties in correct identification of the SOV. CONCLUSIONS: Although the SOV is a useful route for CDF embolization, the presence of fragile or clotted veins can preclude successful cannulation. Deeper orbital dissections carry a higher risk of uncontrolled bleeding and should be avoided, especially in older patients with fragile veins and those with recently diagnosed high-flow fistulas.

Aged↗
PubMed2006

Traumatic brain injury induced neuroprotection of retinal ganglion cells to optic nerve crush.

Optic nerve crush injury leads to death of retinal ganglion cells (RGCs), both as a direct result of the primary injury and via secondary degeneration induced by neurotoxins secreted by dying RGCs. Studies have shown that, if optic nerve crush is preceded by an unrelated injury to another part of the central nervous system, for example, the spinal cord, the ensuing T cell-mediated protective autoimmunity results in a significant increase in RGC survival. In this study, we used the controlled cortical impact paradigm to induce unilateral traumatic brain injury (TBI) in rats at different times before they were contralaterally subjected to a mild optic nerve crush. Survival of RGCs, assessed 2 weeks after crush injury, was significantly increased when the crush was inflicted 11 days after TBI, but not when the two injuries were concomitant. The beneficial effect was unaffected by injection of low-dose methylprednisolone MP (1 mg/kg), but was inhibited after a high-dose injection (30 mg/kg). Brain-derived neurotrophic factor (BDNF) mRNA, assayed at intervals after TBI, was increased in the retina ipsilateral to TBI but decreased in the contralateral retina. BDNF peaked 1 day after TBI, decreased on day 11, and rose again on day 21. It thus seems that brain injury sustained a certain time before optic nerve injury has a protective effect on RGC survival. This neuroprotective effect, which appears unrelated to retinal BDNF, is inhibited by high-dose MP, commonly used clinically to treat traumatic optic neuropathy.

Animals↗
PubMed2006

Pharmacological treatments for thyroid eye disease.

Thyroid eye disease (TED), which affects the majority of patients with Grave's disease, is associated with significant ophthalmic morbidity. In patients with mild disease, supportive treatment with lubricating medication can be sufficient. However, in patients with severe TED and disfiguring proptosis or sight-threatening neuropathy, more aggressive medical or surgical interventions are necessary. Corticosteroids remain the preferred pharmacological treatment modality in the majority of patients with an active inflammatory component. Other immunosuppressive drugs in combination with corticosteroids may be helpful in patients with corticosteroid-resistant TED. Newer agents such as somatostatin analogues have not shown to be of significant clinical benefit; however, initial studies on the use of antioxidants and cytokine antagonists are encouraging.

Adrenal Cortex Hormones↗
PubMed2005

Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material.

PURPOSE: To compare two sling designs (single loop or double pentagon) and a variety of suture material that was used in frontalis suspension surgery for correction of upper eyelid ptosis. DESIGN: Retrospective, nonrandomized, comparative interventional case series. METHODS: Medical record review of 99 patients (164 surgeries) who underwent frontalis suspension surgery for upper eyelid ptosis was conducted at the Jules Stein Eye Institute in 1996 to 2002. Functional and cosmetic success, margin reflex distance (MRD) and lagophthalmos were evaluated. RESULTS: MRD increased an average of 1.1 mm after the operation (P < .001). Ptosis recurrence was noticed in 42 cases (26%); polytetrafluoroethylene achieved the lowest recurrence rate (15%), although not statistically significant. No difference in functional success, ptosis recurrence, or change in MRD was noticed between single loop and double pentagon design. A better cosmetic outcome was noted in cases in which nylon suture was used. Complications included four cases (2.4%) of over-correction, three cases (1.8%) of suture infection (all in polytetrafluoroethylene), two cases of pyogenic granuloma (1.2%), and two cases (1.2%) of suture exposure. CONCLUSION: Frontalis suspension for upper eyelid ptosis resulted in 26% ptosis recurrence after a mean of 12 months from first surgery. Polytetrafluoroethylene showed the lowest incidence of ptosis recurrence. No statistically significant difference was found between different suture materials or loop shape that was used in the surgical technique. A better cosmetic outcome, as graded by different observers, was noted in cases in which a nylon sling was used.

Adult↗
PubMed2005

Minimally invasive orbital decompression: local anesthesia and hand-carved bone.

OBJECTIVE: To investigate the safety and efficacy of a conservative orbital decompression using sharp-curette bony decompression and intraconal fat debulking through a transconjunctival incision in patients with thyroid-related orbitopathy and mild to moderate proptosis. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS AND METHODS: Data from all patients undergoing minimal orbital decompression at the Jules Stein Eye Institute, Los Angeles, Calif, over a period of 4(1/4) years were collected and analyzed. Data included visual acuity, exophthalmometry measurements, intraocular pressure, complete slitlamp examination results, ocular ductions, new-onset primary or downgaze diplopia, and patient satisfaction. Conservative decompression was performed through a transconjunctival incision using a manual curette and by removing cortical bone from the zygomatic marrow space on the anterior rim of the inferior orbital fissure; intraconal fat was bluntly dissected and excised or suctioned with a Frasier tip aspirator. MAIN OUTCOME MEASURES: Patient perception of pressure pain and ocular discomfort, proptosis, visual acuity, intraocular pressure, postoperative complications, and new-onset primary or downgaze diplopia. RESULTS: Eighty minimally invasive orbital decompression surgeries were performed in 48 patients (6 male, 42 female). Six surgeries (4 patients) were performed for prominent globes with relative proptosis and no thyroid-related orbitopathy (non-Graves proptosis). All patients had improvement in congestive orbitopathy and pressure pain associated with thyroid-related orbitopathy. Exophthalmos decreased by a mean +/- SD of 2.4 +/- 2.6 mm from 22.7 +/- 2.5 mm (range, 17-29 mm) to 20.3 +/- 2.3 mm (range, 14-25 mm) (P<.001 [95% confidence interval, 1.8-3.0]). Mean visual acuity improved after surgery (P = .02). One patient (2.1%) developed postoperative primary or downgaze diplopia; he underwent successful eye muscle surgery at a later stage. No complications were associated with orbital decompression. CONCLUSIONS: Minimally invasive orbital decompression surgery with intraconal fat debulking in this group of patients was effective in proptosis reduction; improvement in subjective pressure pain and high patient satisfaction were noticed. Surgery was associated with a low rate (2.1%) of new-onset primary or downgaze diplopia. Proptosis reduction using a graded approach accounting for 4 mm of retrodisplacement was achieved.

Adipose Tissue↗
PubMed2005

Orbital exenteration: one size does not fit all.

PURPOSE: To evaluate the clinical indications for orbital exenteration in a tertiary referral center and to compare clinicopathologic correlation and cosmetic outcome with previously reported data. DESIGN: Retrospective, nonrandomized, consecutive case series. METHODS: Review of Electronic Medical Record system, Orbital Clinic, Jules Stein Eye Institute, between January 1999 and December 2003. main outcome measures: Surgery type, clear margins histologically, survival, and wearing an eye patch. RESULTS: Thirty-four patients (mean age 67 years) underwent orbital exenteration; mean follow-up 1.2 +/- 1.5 years (6 months to 6 years). Diagnosis included orbital, ocular, and adnexal malignancies, with squamous and basal cell carcinoma being the most common. Twenty-one patients (62%) underwent total or extended orbital exenteration, and 13 patients (38%) underwent subtotal exenteration including tissue reconstruction. Clear surgical margins were obtained in 23 cases (68%), whereas positive margins were left in 11 cases (32%). Many of the patients preferred an eye patch to cover the surgical region regardless of surgical reconstruction. Only 4 patients (11.8%) who underwent subtotal exenteration with orbital prosthesis did not use a patch. During follow-up period 3 patients expired, only 1 of which was tumor-related. CONCLUSIONS: Clinical indications for orbital exenteration remain similar over the last four decades with a higher prevalence of squamous cell carcinoma in our institute. Orbital exenteration is considered curative in cases of basal or squamous cell carcinoma but not in cases of malignant infiltrative processes such as adenoid cystic carcinoma of the lacrimal gland. Patients are likely to wear an eye patch regardless of any attempt at surgical reconstruction.

Adult↗