Publications by authors named "Raf Ghabrial"

31 Publications

Exophthalmos and multinodular goitre, an unusual combination.

Endocrinol Diabetes Metab Case Rep 2019 May 3;2019. Epub 2019 May 3.

Canberra Hospital, Woden, Canberra, Australian Capital Territory, Australia.

Multinodular goitre is not associated with eye disease, unless in a rare case of Marine-Lenhart syndrome where it coexists with Grave's disease. Therefore, other causes of exophthalmos need to be ruled out when the eye disease is seen in a patient with multinodular goitre. Confusion can arise in patients with features suggestive of Graves' ophthalmopathy in the absence of thyroid-stimulating hormone receptor autoantibodies and no evidence of other causes of exophthalmos. We present a case of multinodular goitre in a patient with exophthalmos which flared up after iodine contrast-based study. A 61-year-old Australian presented with a pre-syncopal attack and was diagnosed with toxic multinodular goitre. At the same time of investigations, to diagnose the possible cause of the pre-syncopal attack, computerised tomographic (CT) coronary artery angiogram was requested by a cardiologist. A few days after the iodine contrast-based imaging test was performed, he developed severe eye symptoms, with signs suggestive of Graves' orbitopathy. MRI of the orbit revealed features of the disease. Although he had pre-existing eye symptoms, they were not classical of thyroid eye disease. He eventually had orbital decompressive surgery. This case poses a diagnostic dilemma of a possible Graves' orbitopathy in a patient with multinodular goitre. Learning points: Graves' orbitopathy can occur in a patient with normal autothyroid antibodies. The absence of the thyroid antibodies does not rule out the disease in all cases. Graves' orbitopathy can coexist with multinodular goitre. Iodine-based compounds, in any form, can trigger severe symptoms, on the background of Graves' eye disease.
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http://dx.doi.org/10.1530/EDM-18-0138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6499925PMC
May 2019

Largest reported orbital solitary fibrous tumour.

Clin Exp Ophthalmol 2018 04 23;46(3):301-303. Epub 2017 Aug 23.

Department of Ophthalmology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.

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http://dx.doi.org/10.1111/ceo.13030DOI Listing
April 2018

Pediatric endonasal dacryocystorhinostomy: A multicenter series of 116 cases.

Orbit 2017 Oct 19;36(5):311-316. Epub 2017 Jul 19.

g Corneoplastic Unit, Queen Victoria Hospital , East Grinstead , United Kingdom.

We report our experience with pediatric endonasal dacryocystorhinostomy (DCR). Multicenter, retrospective, noncomparative study. Cases of pediatric endonasal DCR during 2006-2011 were included from six oculoplastic units. Patients over the age of 16 years were excluded. The outcomes of pediatric endonasal DCR are presented. Indication for surgery, demographics, previous interventions, intraoperative or postoperative complications, follow-up duration, and success rate (defined as significant improvement of epiphora) were evaluated. In total, 116 endonasal DCRs were performed for 103 patients. The mean follow-up period was 8 months (range 3 months to 4 years), with 1 patient lost to follow-up. There were 48 males (mean age 5 years and 9 months) and 50 females (range of 4 months to 16 years), with a total of 98 cases of congenital nasolacrimal duct obstruction (CNLDO) (84.5%) and 18 cases of acquired nasolacrimal duct obstruction (ANLDO) (15.5%). Previous interventions included probing 75.9% (88/116), massaging 43.1% (50/116), and intubation 39.7% (46/116). There were no intraoperative complications. There was one case of postoperative pyogenic granuloma. There were no cases of postoperative infection and postoperative hemorrhage. Ninety percent of procedures were considered successful. Complete symptom resolution was observed in 78% (90/116), significant improvement in 12% (14/116), partial improvement in 2% (2/116), and no improvement in 8% (9/116). In our series, we demonstrated that endonasal DCR is a safe operation and has an overall success rate of 90% for pediatric NLDO.
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http://dx.doi.org/10.1080/01676830.2017.1337168DOI Listing
October 2017

Increase in the length of superficial temporal artery biopsy over 14 years.

Clin Exp Ophthalmol 2016 Sep 30;44(7):550-554. Epub 2016 Mar 30.

Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.

Background: Giant cell arteritis is a systemic inflammatory vasculitis of large-sized and medium-sized arteries. Superficial temporal artery biopsy of at least 20 mm has traditionally been the standard length for histopathology to accurately diagnose giant cell arteritis. Recent studies suggest than a post-fixation superficial temporal artery biopsy length of 7 to 10 mm is adequate for diagnosing giant cell arteritis.

Design: This is a retrospective observational study.

Participants Or Samples: The participants were all patients who underwent superficial temporal artery biopsy at Royal Prince Alfred Hospital, a large tertiary teaching hospital in Sydney, Australia, from 2008 to 2014.

Methods: Patients were identified using computerized hospital databases. Superficial temporal artery biopsy lengths were obtained from the histopathology reports.

Main Outcome Measures: We aimed to compare the superficial temporal artery biopsy lengths performed at a large tertiary hospital over the past 7 years, to those performed from 2000 to 2005, and to determine the frequency of diagnosis of giant cell arteritis over the two time periods.

Results: There was a total of 96 superficial temporal artery biopsies performed from 2008 to 2014. The superficial temporal artery biopsy mean (standard deviation) length was 16.0(7.3) mm. This represented a significant (P = 0.015) increase in mean superficial temporal artery biopsy length when compared with a previous audit performed from 2000 to 2005 where the mean (standard deviation) superficial temporal artery biopsy was 11.7(6.2) mm. Of the 96 TABs, 20 (20.8%) were positive for giant cell arteritis, compared with a giant cell arteritis positivity rate of 20.4% for the previous audit period from 2000 to 2005.

Conclusion: There has been a significant improvement in the length of superficial temporal artery biopsy performed at a tertiary hospital. Despite the increase in superficial temporal artery biopsy lengths, the giant cell arteritis positivity rate has remained stable.
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http://dx.doi.org/10.1111/ceo.12733DOI Listing
September 2016

An unusual radiological presentation of optic nerve sheath meningioma.

Saudi J Ophthalmol 2016 Apr-Jun;30(2):137-9. Epub 2016 Feb 13.

Sydney Eye Hospital, Australia; Concord Repatriation General Hospital, Australia.

Our report describes an unusual radiological presentation of optic nerve sheath meningioma. The classic radiological appearance of optic nerve thickening with enhancement and calcification within the tumor was not seen; instead, an elongating gadolinium enhancing band-like area adjacent to the superomedial aspect of the left optic nerve sheath was identified. The diagnosis was confirmed on histopathology. Our report adds to the spectrum of presentations of this relatively common clinical entity.
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http://dx.doi.org/10.1016/j.sjopt.2016.01.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4908049PMC
June 2016

Surfboard-related eye injuries in New South Wales: a 1-year prospective study.

Med J Aust 2014 Nov;201(9):532-4

Save Sight Institute, Sydney, NSW, Australia.

Objective: To determine the incidence of surfboard-related eye injuries (SREIs) in New South Wales in 1 year.

Design, Setting And Participants: Prospective questionnaire-based study of SREIs through reporting on injuries, treatment and outcomes by ophthalmologists and ophthalmology trainees in NSW and by patients of all ages with any SREIs on risk factors for SREIs that occurred between 30 December 2010 and 30 December 2011.

Main Outcome Measures: Incidence, nature and severity of SREIs, defined as any injury to the eye, orbit or eyelid caused by a surfboard.

Results: 10 cases of SREIs were reported. Eight patients were male. The mean age of injured patients was 35.4 years. Two of the patients were children. Patients often had a combination of ophthalmic injuries. There were two globe ruptures, four fractured orbits, one case of fibreglass foreign bodies in the orbit and six eyelid lacerations. SREIs were caused by all sharp projections of the surfboard including the nose, fins and tail.

Conclusions: This study confirms that surfing carries a small risk of eye trauma and helps to describe and quantify SREIs. A fifth of the SREIs we report were severe. Surfboard modification and protective eyewear may help reduce the risk of SREIs.
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http://dx.doi.org/10.5694/mja14.00567DOI Listing
November 2014

One-step reconstruction of large lower eyelid defects: technique and outcomes.

Clin Exp Ophthalmol 2014 Dec 7;42(9):889-92. Epub 2014 Aug 7.

University of Sydney, Sydney, New South Wales, Australia; Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.

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http://dx.doi.org/10.1111/ceo.12362DOI Listing
December 2014

Adult ocular adnexal rhabdomyosarcoma presenting with inferior fornix lesion without proptosis.

Clin Exp Ophthalmol 2014 Sep-Oct;42(7):688-9. Epub 2014 Jan 23.

Sydney Oculoplastic Surgery, Sydney, Australia.

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http://dx.doi.org/10.1111/ceo.12282DOI Listing
March 2015

Neuro-ophthalmology of invasive fungal sinusitis: 14 consecutive patients and a review of the literature.

Clin Exp Ophthalmol 2013 Aug 24;41(6):567-76. Epub 2013 Jan 24.

Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, USA.

Background: Invasive fungal sinusitis is a rare condition that usually occurs in immunocompromised patients and often presents as an orbital apex syndrome. It is frequently misdiagnosed on presentation and is almost always lethal without early treatment.

Design: Retrospective case series of 14 consecutive patients with biopsy-proven invasive fungal sinusitis from four tertiary hospitals.

Participants: Fourteen patients (10 men and 4 women; age range 46-82 years).

Methods: Retrospective chart review of all patients presenting with invasive fungal sinusitis between 1994 and 2010 at each hospital, with a close analysis of the tempo of the disease to identify any potential window of opportunity for treatment.

Main Outcome Measures: Demographic data, background medical history (including predisposing factors), symptoms, signs, radiological findings, histopathological findings, treatment approach and subsequent clinical course were recorded and analysed.

Results: Only one patient was correctly diagnosed at presentation. Only two patients were not diabetic or immunocompromised. The tempo was acute in two patients, subacute in nine patients and chronic in three patients. In the subacute and chronic cases, there was about 1 week of opportunity for treatment, from the time there was a complete orbital apex syndrome, and still a chance for saving the patient, to the time there was central nervous system invasion, which was invariably fatal. Only two patients survived - both had orbital exenteration, as well as antifungal drug treatment.

Conclusions: Invasive fungal sinusitis can, rarely, occur in healthy individuals and should be suspected as a possible cause of a progressive orbital apex syndrome.
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http://dx.doi.org/10.1111/ceo.12055DOI Listing
August 2013

Predictors of anatomical patency following primary endonasal dacryocystorhinostomy: a pilot study.

Orbit 2011 Jan;30(1):49-53

Sydney Eye Hospital, Sydney, NSW, Australia.

Purpose: To identify factors influencing early anatomical patency following primary endonasal dacryocystorhinostomy (DCR) for nasolacrimal obstruction.

Methods: A prospective study of 50 patients who underwent primary endonasal DCR for nasolacrimal obstruction was undertaken. Age, gender, dacryocystitis, endonasal access, clearance (bony clearance superiorly from the common canaliculus after bone removal), mobility (mobility of the flaps created from the lacrimal sac once opened), marsupialization (degree of reflection of the lacrimal sac following surgical opening) and a combined score (incorporating clearance, mobility and marsupialization) were examined. Outcomes were measured 10 weeks postoperatively by assessing anatomical patency via probe and syringe and modified functional endoscopic dye test.

Results: Using the Kendall's tau-beta test, there was a significant relationship between greater mobility and better outcome (p<.03) and greater marsupialization and better outcome (p=.03). A higher combined score (incorporating mobility, marsupialization and bony clearance) was also related to better outcome (p<.02). There was no significant relationship between outcome and age, gender, dacryocystitis, endonasal access or bony clearance. Overall, 47 patients (94%) had complete or partial patency at 10 weeks and 3 patients (6%) had complete nasolacrimal obstruction at 10 weeks.

Conclusions: Greater flap mobility and greater lacrimal sac marsupialization in endonasal DCR are associated with better rates of early anatomical patency. A novel scoring system incorporating mobility, marsupialization and bony clearance also showed a significant relationship to early outcome, with higher scores being associated with better outcomes. These results may enable greater understanding of the perioperative features associated with better outcomes in endonasal DCR.
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http://dx.doi.org/10.3109/01676830.2010.516468DOI Listing
January 2011

Endoscopic dacryocystorhinostomy in acute dacryocystitis: a multicenter case series.

Orbit 2011 Jan;30(1):1-6

Discipline of Ophthalmology & Visual Sciences, University of Adelaide, South Australia, Australia.

Objective: To present our experience of early endonasal DCR (endoDCR) in the treatment of acute dacryocystitis (AD). Methods. International multicenter non-comparative retrospective study.

Results: Eighteen patients were identified. All were treated with antibiotics prior to surgery with a median of time from referral to endoDCR surgeon to surgery of 3 days (range 1-7). Surgery was performed using mechanical powered endoDCR (MENDCR) in 15/18 (83.3%) cases; mitomycin C was used in 5/18 (27.8%) and all cases underwent bicanalicular intubation. An increase in perioperative bleeding was noted in 5/18 (27.8%), causing interference in surgical technique in one (5.6%). Resolution of AD was seen in all cases, with no recurrences. 17/18 (94.4%) cases were free of epiphora at median follow-up of 12 months (range 2-36), with nasal endoscopy revealing free flow of fluorescein through the ostium in 17/18 (94.4%) of cases. The median total length of stay was 1 night (range 0-3).

Conclusions: EndoDCR surgery performed early in AD led to rapid resolution of the condition in all cases and was associated with subsequent anatomical and functional success in 94.4% of cases. Early endoDCR surgery in the context of AD and the potential associated health economic benefits are worth further consideration and study.
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http://dx.doi.org/10.3109/01676830.2010.535952DOI Listing
January 2011

Lesions mimicking lacrimal gland pleomorphic adenoma.

Br J Ophthalmol 2010 Nov;94(11):1509-12

Discipline of Ophthalmology and Visual Sciences, University of Adelaide and South Australian Institute of Ophthalmology, Adelaide, SA 5000, Australia.

Aim: To report a series of patients with lacrimal gland lesions simulating the clinicoradiological features of lacrimal gland pleomorphic adenoma (LGPA).

Methods: Multicentre retrospective, interventional case series. Clinical records of all patients with lesions mimicking LGPA seen in five orbital units were reviewed.

Results: The study included 14 patients (seven men and seven women) with a mean age of 50.9 years. The diagnosis of LGPA was made in all cases by experienced orbital surgeons, based on clinicoradiological features, and lacrimal gland excision was performed. Postoperative histology revealed lymphoma (four patients), chronic dacryoadenitis (three patients), adenoid cystic carcinoma (two patients), Sjogren's syndrome (two patients), cavernous haemangioma (one patient), benign lymphoid hyperplasia (one patient) and granulomatous dacryoadenitis (one patient). Comparison with the total number of histologically confirmed LGPA cases seen during the study period revealed that 22.6% of cases of suspected LGPA were misdiagnosed based on clinicoradiological criteria.

Conclusions: Many different lesions may mimic the clinicoradiological features of LGPA. The accepted clinicoradiological criteria used for the diagnosis of LGPA have a high false-positive rate, even in experienced hands. Based on this study, the authors believe that fine-needle aspiration biopsy or intraoperative biopsy and frozen section diagnosis may help reduce unnecessary lacrimal gland excision.
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http://dx.doi.org/10.1136/bjo.2008.156307DOI Listing
November 2010

External dacryocystorhinostomy: assessing factors that influence outcome.

Orbit 2010 Oct;29(5):291-7

Sydney Eye Hospital, Sydney, New South Wales, Australia.

Purpose: To present the experience of external dacryocystorhinostomy (DCR) at a tertiary referral center and investigate factors that may affect clinical outcomes.

Methods: The clinical records of all patients who underwent external DCR at Sydney Eye Hospital between May 2000 and August 2007 were reviewed. Data were collected in regards to patient demographics, preoperative assessment, operative details, surgical technique, postoperative management, and clinical outcomes. This information was then analyzed, with emphasis on factors that influence surgical outcomes and success.

Results: A total of 338 cases were reviewed. The mean age at time of surgery was 64.82 years and the majority of patients were female (65%). Epiphora was the major preoperative symptom. Assisted local anesthesia and day stay surgery were the most common surgical settings. There was a statistically significant difference in theatre time between consultant and trainee surgeons (P < 0.00001). The mean final follow-up time was 11 months. Overall, 77.3% of patients had full resolution of symptoms and 20.8% had partial resolution. Only five patients (1.9%) had no resolution of symptoms. There was no significant difference in outcomes between consultants and trainees. Patients with anatomical nasolacrimal obstruction had significantly better outcomes compared with functional obstruction (P = 0.04). The postoperative fluorescein dye disappearance test was a good predictor of clinical success (P = 0.005). Silicone intubation for greater than 6 months was associated with better outcomes (P = 0.002).

Conclusions: The results at our tertiary center are comparable to results stated in the literature. In our series, only the amount of nasolacrimal obstruction and duration of postoperative intubation influenced surgical success.
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http://dx.doi.org/10.3109/01676830.2010.485715DOI Listing
October 2010

The role of mucosal flaps in external dacryocystorhinostomy.

Orbit 2010 Dec 4;29(6):324-7. Epub 2010 Oct 4.

Sydney Eye Hospital.

Purpose: To determine whether a mucosal anastomosis fashioned at the time of external dacryocystorhinostomy (DCR) influences postoperative outcome.

Methods: The clinical records of all patients who underwent external DCR at Sydney Eye Hospital between May 2000 and August 2007 were reviewed. Data were collected in regards to surgical technique, clinical outcomes and postoperative management. Chi-square statistical analysis was done to determine the significance of the different flap techniques on surgical success.

Results: A total of 260 medical records were reviewed. The main outcome measure was postoperative resolution of symptoms. The mean final follow-up time was 11 months. There was no statistically significant difference in outcome between patients who had both anterior and posterior flaps sutured, compared to those who had anterior flap sutures only (73% vs 79%, p = 0.51). Patients who had no sutured flaps had an overall success rate of 89% compared to those that had at least the anterior flaps sutured together (76%); this difference was not significant (p = 0.45).

Conclusion: There was no statistical difference in symptom outcome between patients in whom both mucosal flaps were sutured, those who had only the anterior flap sutured, or those who did not have either flap sutured at the time of surgery.
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http://dx.doi.org/10.3109/01676831003664392DOI Listing
December 2010

Posterior scleritis mimicking orbital cellulitis.

Med J Aust 2010 Sep;193(5):305-6

Department of Ophthalmology, Concord Repatriation General Hospital, Sydney, NSW, Australia.

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http://dx.doi.org/10.5694/j.1326-5377.2010.tb03915.xDOI Listing
September 2010

Subconjunctival "ring" recurrence of Basal cell carcinoma of the globe.

Ophthalmic Plast Reconstr Surg 2010 Mar-Apr;26(2):117-8

Sydney Eye Hospital, Sydney, New South Wales, Australia.

Basal cell carcinoma is the most common indication for orbital exenteration. The recurrence rate of BCC removed with microscopically controlled histology sections is up to 6%. The authors describe the recurrence of a lower eyelid BCC resected with microscopic control that did not manifest itself until 15 years later as a subconjunctival lesion, encircling the globe, and without apparent skin involvement. BCC can present in any manner following surgery, and therefore, judicious follow-up is necessary even after microscopically controlled resection.
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http://dx.doi.org/10.1097/IOP.0b013e3181b8dd47DOI Listing
June 2010

Revision endoscopic dacryocystorhinostomy with betamethasone injection under assisted local anaesthetic.

Orbit 2009 ;28(6):328-31

Sydney Oculoplasty Surgery, Eye Associates, Sydney, Australia.

Purpose: To determine the success rate of revision endoscopic dacryocystorhinostomy (DCR) with an injection of intraoperative betamethasone under local anaesthetic.

Methods: In a prospective, nonrandomized consecutive case series, 16 adult patients (19 eyes) with failed primary endoscopic DCR underwent revision surgery under assisted local anaesthetic. During revision endoscopic DCR, 1mg of betamethasone was injected into the lacrimal sac and scar tissue surrounding the surgical osteum. The surgical success rate was then determined based on anatomical patency and resolution of patient symptoms.

Results: There were 16 patients (12 female, 4 male) and 3 had bilateral surgery. Patient ages ranged from 43 to 92 (mean 67). Follow up ranged from 1 to 15 months (mean 9). Anatomical patency was achieved in 16 cases (84%) and patient symptoms had improved in 17 cases (89%). Of the two cases that continued to have symptoms 1 achieved anatomical patency and the other had not.

Conclusions: Revision endoscopic DCR, under assisted local anaesthetic, had a high success rate (89%) when an injection of betamethasone was administered intraoperatively.
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http://dx.doi.org/10.3109/01676830903104686DOI Listing
January 2010

Transitional cell carcinoma of the nasolacrimal sac.

Clin Ophthalmol 2009 2;3:587-91. Epub 2009 Nov 2.

University of Sydney, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.

Tumors in the lacrimal sac are rare yet important due to their malignant and potentially lethal outcomes if there is a misdiagnosis or delay in treatment. Epithelial tumors predominate with squamous cell carcinoma. We report a transitional cell carcinoma of the lacrimal sac and management course for the patient.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2773280PMC
http://dx.doi.org/10.2147/opth.s7706DOI Listing
May 2011

Primary orbital intraosseous hemangioma.

Ophthalmic Plast Reconstr Surg 2009 Jan-Feb;25(1):37-41

Discipline of Ophthalmology and Visual Sciences, University of Adelaide, Adelaide, South Australia.

Purpose: Primary orbital intraosseous hemangioma represents a rare, histopathologically benign, vascular tumor of the bony orbit. Only 41 cases have been documented in the literature to date. The authors present 4 new cases of the disease and review the relevant literature.

Methods: Retrospective, multicenter case note analysis of 4 patients with histopathologically confirmed primary orbital intraosseous hemangioma and a systematic review of the English-language literature.

Results: Four new cases of cavernous haemangiomata are presented with varying clinical manifestations, radiologic appearances, and treatments. Literature review (including the present 4 cases) yielded 45 cases in total. Presentation is often in the fourth and fifth decades (42% cases), the frontal bone being most commonly affected, followed by the zygoma, sphenoid, and maxilla. Intracranial extension occurred in 4 cases. Median duration of symptoms before presentation was 12 months (range, 1 month to 15 years) and the most frequent presentation was a painless mass, often on the orbital rim. The radiologic findings are reviewed. Histopathologically, the lesions were cavernous in 80%, capillary in 17%, and mixed in 3%; the capillary subtype seemed to be associated with more aggressive disease. Treatment was mainly by surgical excision and occasionally complicated by significant blood loss; preoperative embolization of lesions may reduce bleeding.

Conclusions: Primary orbital intraosseous hemangioma is a rare vascular tumor that typically presents with a mass effect in the orbits of patients in the fourth and fifth decades of life. Preoperatively, it is important to be cognizant of the possible diagnosis as surgery can be complicated by life-threatening hemorrhage.
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http://dx.doi.org/10.1097/IOP.0b013e318192a27eDOI Listing
April 2009

Orbital and adnexal Rosai-Dorfman disease.

Orbit 2008 ;27(5):356-62

South Australian Institute of Ophthalmology and Department of Ophthalmology and Visual Sciences, University of Adelaide, South Australia.

Purpose: To report the clinico-radiological findings, clinical course, and treatment outcomes in five patients with orbital and adnexal Rosai-Dorfman (R-D) disease.

Methods: Analysis of case records of patients with Rosai-Dorfman disease seen at four orbital units between January 2000 and December 2006.

Results: Five patients (3 Caucasian males, 1 Hispanic female, and 1 African female), mean age 41.1 years, (range 18 months to 75 years) with orbital or adnexal Rosai-Dorfman disease were seen during the study period. Four of the patients had orbital involvement and one had eyelid involvement. Presenting features were proptosis (4 patients), diplopia (1 patient), epiphora (1 patient), and eyelid thickening (1 patient). Three of the patients with orbital involvement also had adjacent paranasal sinus involvement, and the nasolacrimal duct was involved in one patient. The patient with eyelid involvement had evidence of cutaneous R-D disease elsewhere in the body. The follow-up period (since initial diagnosis of R-D disease) ranged from 1 month to 15 years, and 2 of the patients had a history of recurrent growth despite treatment. Surgical debulking was employed in 2 patients with good results.

Conclusions: Orbital and adnexal Rosai-Dorfman disease is a condition with protean manifestations that may show indolent but unremitting growth despite treatment. The disease may remain extranodal and localized for many years. Adjacent paranasal sinus involvement is commonly seen in conjunction with orbital disease, simulating midline destructive lesions. Surgical debulking gives good results in patients with functional or significant cosmetic problems.
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http://dx.doi.org/10.1080/01676830802345083DOI Listing
November 2008

Quantitative lacrimal scintigraphy in the assessment of epiphora.

Clin Nucl Med 2008 Aug;33(8):535-41

Sydney Eye Hospital, Sydney, Australia.

The transit of Tc-99m pertechnetate through 122 lacrimal drainage systems was quantified. Systems were categorized as having presac, preduct, intraduct, or no delay. Scintigraphy indicated an obstruction in 81.3% of eyes with epiphora. Of the 18 eyes in whom only scintigraphy revealed an obstruction, all 3 who underwent surgery experienced symptom relief. In patients presenting with unilateral epiphora the mean canthus half-time (12.9 vs. 7.2 minutes), time-to-peak activity at the sac (11.6 vs. 3.1 minute), and sac half-time (19.0 vs. 10.3 minutes) were significantly prolonged in the symptomatic eye. Similarly, the sac-to-canthus (0.32 vs. 0.72), duct-to-canthus (0.32 vs. 0.99), and duct-to-sac ratios (0.48 vs. 0.79) of peak activity were all significantly reduced in the symptomatic eye. When compared with "no delay," "presac," "preduct," and "intraduct" delay were significantly associated with attenuated clearance times or reduced ratios of peak activity corresponding to the level of obstruction. We conclude that there is a significant association between symptomatic epiphora and quantitative variables at the canthus and sac in lacrimal scintigraphy. Quantitative variables help locate the level of an obstruction.
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http://dx.doi.org/10.1097/RLU.0b013e31817dea9cDOI Listing
August 2008

Orbital exenteration: a 15-year study of 38 cases.

Ophthalmic Plast Reconstr Surg 2007 Nov-Dec;23(6):468-72

Department of Ophthalmology, Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia.

Purpose: To determine the clinical indications and outcomes after orbital exenteration when histologic margins were reported as "clear," examining factors affecting local and systemic recurrences and mortality.

Methods: Retrospective case review of exenterations performed in Sydney Eye Hospital in Sydney, Australia, between 1990 and 2004. Reviewed data indications for exenteration, histopathologic diagnosis, and recurrences on follow-up.

Results: Secondary intraorbital spread of malignant adnexal tumors was the most common indication for exenteration (34 of 38). Among these, the site of the primary neoplasm was the eyelid in 19 cases and the ocular surface in 12 cases. Exenteration was total in 26 cases, subtotal in 8 cases, and extended in 4 cases. In 11 cases, a dermis-fat graft was used for socket reconstruction; 24 cases were allowed to granulate spontaneously. The average healing time was 5 months (range, 4-6 months) for spontaneous granulation, and 6 weeks (range, 4-8 weeks) for dermis-fat grafts. Perineural spread was demonstrated histopathologically in 7 specimens. During follow-up (median, 48 months), there were 9 recurrences (23.7%): 3 local and 6 systemic. Seven patients (18.4%) died of the disease during the follow-up period.

Conclusions: Dermis-fat grafts for reconstruction of the exenterated socket seem to optimize the aesthetic results. The first year is the most important period for follow-up of local recurrences, but systemic examination is needed for the longer follow-up. This may have implications in terms of reconstruction and adjunctive treatment following exenteration surgery.
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http://dx.doi.org/10.1097/IOP.0b013e318158e994DOI Listing
February 2008

Assisted local anaesthesia for endoscopic dacryocystorhinostomy.

Clin Exp Ophthalmol 2007 Apr;35(3):256-61

Sydney Oculoplastic Surgery, Department of Ophthalmology, Royal Prince Alfred Hospital, Camperdown, and University of New South Wales, Liverpool, Australia.

Background: Endoscopic dacryocystorhinostomy is traditionally performed under general anaesthesia. However, there are reports in the literature of various local anaesthetic techniques with or without sedation for this procedure. An effective and acceptable local anaesthetic technique enables the avoidance of the risks associated with general anaesthesia, particularly for elderly patients, with the added benefit of reduced bleeding, reduced nausea and vomiting, and reduced length of hospital stay and thus health care cost savings. This study aims to evaluate the safety and patient acceptance of a minimally invasive assisted local anaesthetic technique for endoscopic dacryocystorhinostomy.

Methods: A prospective questionnaire-based study is presented of 24 consecutive adult patients who underwent 26 endoscopic dacryocystorhinostomies in a day surgery including 22 primary and four revision procedures performed by one surgeon under local anaesthesia and sedation over a 4-month period.

Results: Apart from persistent postoperative vomiting in one patient there were no anaesthetic complications. There were no instances of epistaxis. The mean pain score on a visual analogue scale of 0-10 was 1.56 and 56% reported no pain. Ninety-two per cent would recommend the procedure to others.

Conclusion: This assisted local anaesthetic technique for endoscopic dacryocystorhinostomy is safe and acceptable to patients.
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http://dx.doi.org/10.1111/j.1442-9071.2006.01412.xDOI Listing
April 2007

Cicatricial ectropion: repair with myocutaneous flaps and canthopexy.

Clin Exp Ophthalmol 2006 Sep-Oct;34(7):677-81

Department of Ophthalmology, Royal Prince Alfred Hospital, Sydney, Australia.

Background: To evaluate the effectiveness of myocutaneous upper eyelid flaps combined with canthopexy to treat cicatricial lower eyelid ectropion.

Methods: A prospective non-comparative case series undertaken in a private practice setting. Consecutive patients with moderate lower eyelid cicatricial ectropion and upper eyelid dermatochalasis underwent transfer of a bipedicle or monopedicle flap from the upper eyelid combined with canthopexy. The main outcome measures included the occurrence of complications, eyelid position and cosmesis.

Results: Sixty-two consecutive cases of cicatricial ectropion repair using myocutaneous flaps and canthopexy. After a mean follow up of 20 months, 58 (93.5%) of the cases had the lower lid punctum facing posterosuperior into the tear lake, showed lid globe apposition and satisfactory eyelid position. There was mild recurrence of cicatricial ectropion in four patients (6.5%). There were no cases of graft failure or granuloma formation.

Conclusion: The use of a myocutaneous flap from the upper eyelid combined with a canthopexy suspension suture for repair of cicatricial ectropion may offer good eyelid position and function. This technique has the advantage of avoiding full thickness blepharotomy and was associated with a low incidence of early recurrence.
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http://dx.doi.org/10.1111/j.1442-9071.2006.01302.xDOI Listing
November 2006

A technique for medial canthal fixation using resorbable poly-L-lactic acid-polyglycolic acid fixation kit.

Arch Ophthalmol 2006 Aug;124(8):1171-4

Oculoplastic Units, Sydney Eye Hospital, Concord Repatriation Hospital, Sydney, Australia.

Achieving secure bony fixation of medial canthus is a challenge. We used a resorbable poly-L-lactic acid-polyglycolic acid screw (LactoSorb office fixation kit) in 5 cases: 2 with traumatic medial canthal dystopia, 1 with scleroderma and orbital fat atrophy causing malapposition of the medial canthus to globe, and 2 with invasive medial canthal tumors necessitating subtotal medial orbital exenteration. The resorbable screw with preplaced suture was drilled into the medial orbital wall, using a handheld self-drilling tap. The preplaced suture was used to anchor the medial canthus. We achieved satisfactory canthal position in all 5 cases. There were no complications in 4 cases during a mean +/- SD follow-up of 11.3 +/- 6 months; however, the scleroderma case developed wound dehiscence 6 weeks after surgery. The LactoSorb kit is a safe and effective technique to achieve bony medial canthal fixation in carefully selected cases.
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http://dx.doi.org/10.1001/archopht.124.8.1171DOI Listing
August 2006

Blue filter discs and nasal endoscopic visualization of fluorescein lacrimal drainage.

Ophthalmic Plast Reconstr Surg 2006 Jan-Feb;22(1):52-3

The University of Sydney and the Save Sight Institute, Department of Ophthalmology, Concord Repatriation General Hospital, New South Wales, Australia.

For the lacrimal surgeon, fluorescein instilled in the palpebral aperture, and combined with the use of blue filters, can assist office assessment of lacrimal drainage by nasal endoscopy. The fabrication of a separate blue filter attachment for nasal endoscopes, however, is expensive. Inexpensive, heat-stable blue filter discs were sourced from a manufacturer of fiberoptic instruments in Sydney, Australia. These discs can be made in various sizes suitable for standard battery-powered, portable nasal endoscopes. The discs were used in the postoperative assessment of a patient with lacrimal drainage-related pathology. They were easy to use and provided suitable wavelength transmission for improved assessment of fluorescein drainage through the lacrimal system.
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http://dx.doi.org/10.1097/01.iop.0000196309.45906.edDOI Listing
March 2006

Eccrine porocarcinoma of the upper eyelid.

Australas J Dermatol 2005 Nov;46(4):278-81

Department of Dermatology, Level 5 Medical Centre, Concord Hospital, Concord Road, New South Wales, Australia.

A 75-year-old Caucasian man presented with foreign-body-type irritation of the left eye. Physical examination revealed a 12 x 10-mm nodule in his left upper eyelid, which reportedly had been present unchanged for more than 40 years. No other ophthalmological abnormalities were present. Incisional biopsy of the lesion revealed a malignant tumour that was thought to possibly represent a sebaceous carcinoma. However, a subsequent wide surgical excision showed that the tumour was an eccrine porocarcinoma, a rare sweat gland adenocarcinoma arising from the acrosyringium.
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http://dx.doi.org/10.1111/j.1440-0960.2005.00201.xDOI Listing
November 2005

Orbital leiomyoma: a case report with clinical, radiological and pathological correlation.

Clin Exp Ophthalmol 2005 Aug;33(4):408-11

Department of Ophthalmology Concord Repatriation General Hospital, Sydney, New South Wales, Australia.

Orbital leiomyoma is a benign tumour of smooth muscle origin that can be clinically, radiologically and histopathologically difficult to diagnose due to the rarity of leiomyomas in this location. A 74-year-old woman presented with a 2-month history of painless proptosis. Computed tomography and magnetic resonance imaging studies revealed a well-circumscribed intraconal lesion separate from the optic nerve, and not eroding adjacent bone. A right lateral orbitotomy via a lid crease incision was performed to remove the firm lobulated lesion. Postoperatively there was an obvious decrease in proptosis. Microscopically the lesion was a well-circumscribed tumour composed of spindle cells. There were no light microscopic features to suggest malignancy, and immunohistochemistry was used to confirm the diagnosis of leiomyoma. Leiomyoma is a tumour that is rarely found in the orbit most likely due to the paucity of smooth muscle in this location. The differential diagnosis is wide, and the role of radiology, histology and immunohistochemistry in the diagnosis of leiomyoma is discussed. Surgical excision in this case excluded malignancy, provided a definitive diagnosis of a rare entity and resulted in marked clinical improvement.
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http://dx.doi.org/10.1111/j.1442-9071.2005.01034.xDOI Listing
August 2005

Donor site morbidity in free tarsal grafts.

Am J Ophthalmol 2004 Sep;138(3):430-3

Oculoplastic and Orbital Unit, Department of Ophthalmology, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia 5000, Australia.

Purpose: To determine if harvesting free tarsal grafts from the upper eyelids is associated with significant morbidity.

Design: Prospective case series.

Methods: Consecutive patients managed with free tarsal grafts by three of the authors (D.S., D.G., R.G.) over a 4-year period.

Results: Ninety-one eyelids in 75 patients were operated on using the free tarsal graft for various eyelid pathologies. Mean follow-up period was 14.83 +/- 8.45 months (range, 4 to 42 months). Contour peaking in donor upper eyelid appeared in two eyelids (2.2%), lash ptosis in four eyelids (4.4%) of three patients, and donor site infection in one eyelid (1.1%). Four patients (5.3%) complained of a transient ocular discomfort. There were no cases of postoperative changes on the eyelid height, entropion, or keratopathy in the donor site eye. Most of the donor site complications were mild or transient and required no further surgery. In three patients who underwent subsequent surgery to treat preexisting ptosis or retraction of the donor eyelid, the results were less predictable and further procedures were required.

Conclusion: Free tarsal grafts harvested from the upper eyelids, with preservation of at least 4 mm of the tarsal plate inferiorly, do not lead to significant donor site morbidity. However, subsequent procedures to alter the position of the donor eyelid may be less predictable.
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http://dx.doi.org/10.1016/j.ajo.2004.04.061DOI Listing
September 2004