itating the patient with a properly fitted prosthesis nor of the possible
Professional Standards: Not Getting Better, Getting Older To the Editor.\p=m-\While reviewing the progress of the American Society of Ocularists (ASO) during the past 20 years, it is necessary to consider the effort put forth by many persons, including both ophthalmologists and ocularists, to make this society a real-
Our basic follows:
ity.
1. Establish
objectives
an
were
as
effective relation-
ship with the ophthalmologists to improve the results of our work with the aid of their skill and cooperation. 2. Solicit ophthalmologists, who were interested in our field, to serve on a medical advisory board and to assist in formal teaching programs. 3. Exchange technology among the ocularists to improve cosmetic results, particularly in complicated cases. 4. Provide
educational program to assist associates, as well as young people entering this field. 5. Provide a code of ethics to set standards that we felt were lacking. Today, these objectives have been achieved; many joint meetings in the past have attested to this by the overflow attendance of both ocularists and ophthalmologists. However, it is the patient that derives the greatest benefit from our common goals and from the achievement of such. The requirements for admission to the ASO as a certified ocularist are high and are similar to those of any professional seeking a degree in a teaching institution. A trainee must serve a
an
five-year apprenticeship
un¬
der a certified ocularist, and must accumulate 750 credit-hours of formal instruction taught by ophthalmolo¬ gists and ocularists. The trainee is then required to pass oral, written, and manual examinations before he or she can qualify for certification. In a' recent article that was published in a prominent opticians' magazine (Dispensing Optician, Octo¬ ber 1977, pp 14-15, 29), it was suggested that the fitting of stock artificial eyes be performed by un¬ trained personnel as another means of supplementing profit. No mention was made in the article about rehabil-
undesirable results that could cause permanent distress to the patient. No organ in our body is more exposed or has greater expression than our eyes, and I have yet to meet a patient who didn't want the best restoration possible. I would be negli¬ gent in my convictions, therefore, if I did not express my distress on reading an article of this kind, especially considering the many young people who are presently in training to achieve certification. Additionally, in consideration of the many dedicated people who have given so unselfishly of their time to elevate the standards of our profession, I wonder whether such an article does not ignore the objectives of the ASO, and instead, mirror the standards of the Egyp¬ tians, who first conceived the idea of the artificial eye. Charles E. Erickson, CO Seattle Variations of Cell Loss in
Phacoemulsification To the Editor.\p=m-\Inreading the article in the Archives by Sugar et al (96:446\x=req-\ 448,1978), I was struck by the remarkably similar results obtained in a study that I engaged in. In a retrospective study of nine patients in whom one eye had a cataract extraction by the phacoemulsification technique, a comparison was made of the endothelial cell density of the operated eye and the fellow unoperated eye. The result, reported at an in-house research meeting at the Jules Stein Eye Institute in June 1977, was of an average cell difference of 28% fewer cells in the operated eye. This closely compares with the 33.8% difference reported by Sugar et al. Furthermore, there was no substantial difference between procedures performed by house staff or faculty. I became aware, via personal communication, of notably lower cell loss found by others. Sugar et al similarly note wide discrepancies between their study and those of several others. Obviously the technique of the proce¬ dure might be implicated, although I feel that the retrospective analysis must be carefully evaluated. It was the retrospective nature of my study that I questioned. The obvious questions are: Why did the patient have a unilateral extraction?
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/04/2015
What
was
the
origin of
the cataract?
And, was there a history of trauma or
prior inflammatory disease? If the answers to these questions are indica¬ tive of the preoperative clinical sym¬ metry of the two eyes, the retrospec¬ tive results might be more rationally analyzed and accepted. The yardstick to measure endothe¬ lial cell changes, as in most other quantities in medicine, is a prospec¬ tive study. I hope that Sugar et al, with their large volume of phacoemulsifications, will provide us with this data to help resolve the wide variance in currently reported endothelial cell changes with phacoemulsification. Scott Grant, MD Los Angeles A' TTAE
To the Editor.\p=m-\As
the
necessity
resources, I
a
firm believer in
of
conserving natural applaud the increasing
of medical writers to use abbreviations. This tendency to abbreviate everything (TTAE) has the additional virtue of requiring several readings of each article to uncover the definitions (D). Very recently I have been pleased to see some authors refreshing our memories on the D of ages-old medical abbreviations, such as CBC (complete blood count), and so forth (etc). I am in the process of compiling a glossary of abbreviations in current use (GOAICU) and look forward to a brisk sale to authors (A) who wish to conserve paper and reading time by writing complete articles (CA) and even books (B) without one intelligible sentence. In summary, the TTAE has led to a
tendency
GOAICU, including, eg, CBC, etc, to assist A in preparation of CA and B. Robert J. Herm, MD Keene, NH A
Warning on Cryosurgery Eyelid Malignancies
for
To the Editor.\p=m-\Iread with interest Dr F. T. Fraunfelder's letter to the editor regarding "The Indications and Contraindications of Cryosurgery" (Archives 96:729, 1978). I was somewhat relieved to see that such a strong advocate of cryosurgery for eyelid malignancies inserted a slight note of skepticism concerning the general use of this type of therapy. I have a much stronger skepticism concerning this form of therapy for eyelid malignan-
cies. While cryosurgery certainly has indications in oculoplastics, it cannot be recommended for wholesale treatment of any and all eyelid lesions as some marketers of instruments would make us believe. It requires some knowledge of cryogenics and it is not without complications. We have treated more than 150 patients with aberrant lashes with good results by using cryosurgery and we believe that, at present, aberrant lashes are the only well-proven indication for the use of cryosurgery on eyelids. We have also treated some benign lesions of the lids (eg, hemangiomas, pigmented hairy nevi, and warts) with good results. However, I am reluctant to accept unproven ther¬ apeutic modalities for the treatment of potentially lethal conditions. Their use should be condemned except for research situations until at least fiveyear follow-up studies are available. We have seen a number of recurrences of basal cell carcinomas of the lids five to 15 years after treatment and a five-year follow-up is the minimum to report cure rates for this disease. It is unfortunate that few ophthal¬ mologists realize that the mortality from lid and canthal basal cell carcino¬ mas ranges from 2% to 11%.'^ A review of our cases at the University of Iowa showed a 4.5% mortality.1 In the past year we have exenterated six orbits with recurrent basal cell carci¬ noma following inadequate forms of therapy. There were recurrences in tWo of these cases some 15 years after the superficial portion of the tumor had been inadequately treated. We are also observing two patients with intracranial extension of this disease. Many forms of therapy will adequate¬ ly treat the superficial portion of a basal cell carcinoma but it is the deep portion that kills. Unfortunately, it may be many years before the recur¬ rence from a deep extension is noted
clinically. Many ophthalmologists, including myself, are hesitant to accept radia¬ tion as a primary therapy for basal cell carcinoma of the lids, but some will accept cryotherapy as an accept¬ able form of treatment of this disease. Both techniques fail to appreciate tumor margins and tumor depth. There is no reason that cryosurgery should give a better cure rate than radiation therapy. Cryosurgery does, however, have fewer ocular complica¬ tions than radiation therapy. Particularly in sclerosing or mor-
pheoform
basal cell carcinomas, cryo¬ surgery should be condemned. We have shown in a recent study that the tissue that has to be removed to obtain
tumor-free margins (using the freshfrozen Mohs's technique) was more than four times greater than the clin¬ ically apparent tumor size in cases of large and recurrent basal cell carcino¬ mas.4 Thus, when dealing with large or recurrent basal cell carcinomas, the area of the lid to be treated by cryo¬ surgery can only be estimated. It is impossible to estimate clinically the depth of a basal cell carcinoma and it is the deep extent that can blind or kill a patient. Preliminary work in a study that we have undertaken indicates that inadequate therapy may trans¬ form a benign form of basal cell carci¬ noma into a more malignant form. Therefore, we strongly advocate the complete removal of this tumor rather than possibly teasing it into a more aggressive form. We are unwilling to accept any form of therapy that does not obtain tumor-free margins and thus we recommend a fresh-frozen chemosurgical excision. We follow the fresh-frozen microscopically con¬ trolled excision with immediate recon¬ struction and have been successful with this technique in more than 100 difficult eyelid cases in the past two years.
One of the recommended indica¬ tions for cryosurgery is a basal cell carcinoma of the medial canthus because the lacrimal excretory system can be preserved. Unfortunately, our results and that of others indicate that the medial canthal region is the most dangerous of all locations for this tumor. Deep extent into the orbit and brain is a likely complication of a tumor in this location. Cryosurgery may be adequate ther¬ apy for the small, nodular, isolated basal cell carcinoma of the lid. Howev¬ er, simple excision and reconstruction are nearly as rapid as cryosurgery and they have less morbidity and a better cosmetic result when adequately per¬ formed. We reserve the use of cryosurgery for eyelid malignancies to those few patients who refuse surgical therapy but are willing to accept cryosurgery. Cryosurgery causes no less morbidity than fresh-frozen microscopically con¬ trolled excision and reconstruction with the patient under local anesthe¬ sia (and the reverse is frequently the case). Cryosurgery can also be recom¬ mended for hemophiliacs or those
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/04/2015
with serious coagulation disorders. It may have indications for small eyelid basal cell carcinomas in patients with the basal cell nevus syndrome where one is almost certain that a large number of eyelid tumors will present, recurrences may be difficult to differ¬ entiate from new tumors, and tissue available for reconstruction is not
easily available.
While cryosurgery certainly has a in the treatment of basal cell carcinomas elsewhere on the body, we believe that its use on the eyelids should be restricted to the above indi¬ cations or for research projects with careful controls. A minimum five-year follow-up and preferably a 15-year follow-up should be reported before results are generally accepted for this type of treatment of this insidious disease. The size, location, and histo¬ logical types of tumors should also be recorded and reported with the results. We are presently seeing more and more recurrent eyelid basal cell carci¬
place
nomas
following inadequate
probe
cryosur¬
some cases the retinal cryo¬ was even used for treatment.
gery. In
With the recent articles advocating cryosurgery, the claims made by instrument companies, and the rela¬ tive lack of expertise required to perform this procedure, the number of recurrent lesions, exenterations, and deaths from this disease may well increase. The mortality for basal cell carcino¬ mas of the skin elsewhere on the body is low, whereas that of the lids is high. Nowhere on the body is deep exten¬ sion to vital structures more accessible than from the lids. I certainly hope this somewhat jaundiced view of cryo¬ surgery for eyelid malignancies is read by those who have recently ordered or acquired their "cure-all eyelid maladies tool" or plan to try using their retinal cryoprobe to treat malignancies of the eyelids. Richard Anderson, MD Iowa City 1. Aurora AL, Blodi FC: Reappraisal of basal cell carcinoma of the eyelids. Am J Ophthalmol 70:329-336, 1970. 2. Birge HL: Cancer of the eyelids: Basal cell and mixed basal cell and squamous cell epithelioma. Arch Ophthalmol 19:700-708, 1938. 3. Payne JW, Duke JR, Butner R, et al: Basal cell carcinoma of the eyelids: A long-term followup study. Arch Ophthalmol 81:553-558, 1969. 4. Ceilley RI, Anderson RL: Microscopically controlled excision of malignant neoplasms on and around eyelids followed by immediate surgical reconstruction. J Dermatol Surg Oncol 4:55\x=req-\ 62, 1978.
Professional Standards: Not Getting Better, Getting Older To the Editor.\p=m-\While reviewing the progress of the American Society of Ocularists (ASO) during the past 20 years, it is necessary to consider the effort put forth by many persons, including both ophthalmologists and ocularists, to make this society a real-
Our basic follows:
ity.
1. Establish
objectives
an
were
as
effective relation-
ship with the ophthalmologists to improve the results of our work with the aid of their skill and cooperation. 2. Solicit ophthalmologists, who were interested in our field, to serve on a medical advisory board and to assist in formal teaching programs. 3. Exchange technology among the ocularists to improve cosmetic results, particularly in complicated cases. 4. Provide
educational program to assist associates, as well as young people entering this field. 5. Provide a code of ethics to set standards that we felt were lacking. Today, these objectives have been achieved; many joint meetings in the past have attested to this by the overflow attendance of both ocularists and ophthalmologists. However, it is the patient that derives the greatest benefit from our common goals and from the achievement of such. The requirements for admission to the ASO as a certified ocularist are high and are similar to those of any professional seeking a degree in a teaching institution. A trainee must serve a
an
five-year apprenticeship
un¬
der a certified ocularist, and must accumulate 750 credit-hours of formal instruction taught by ophthalmolo¬ gists and ocularists. The trainee is then required to pass oral, written, and manual examinations before he or she can qualify for certification. In a' recent article that was published in a prominent opticians' magazine (Dispensing Optician, Octo¬ ber 1977, pp 14-15, 29), it was suggested that the fitting of stock artificial eyes be performed by un¬ trained personnel as another means of supplementing profit. No mention was made in the article about rehabil-
undesirable results that could cause permanent distress to the patient. No organ in our body is more exposed or has greater expression than our eyes, and I have yet to meet a patient who didn't want the best restoration possible. I would be negli¬ gent in my convictions, therefore, if I did not express my distress on reading an article of this kind, especially considering the many young people who are presently in training to achieve certification. Additionally, in consideration of the many dedicated people who have given so unselfishly of their time to elevate the standards of our profession, I wonder whether such an article does not ignore the objectives of the ASO, and instead, mirror the standards of the Egyp¬ tians, who first conceived the idea of the artificial eye. Charles E. Erickson, CO Seattle Variations of Cell Loss in
Phacoemulsification To the Editor.\p=m-\Inreading the article in the Archives by Sugar et al (96:446\x=req-\ 448,1978), I was struck by the remarkably similar results obtained in a study that I engaged in. In a retrospective study of nine patients in whom one eye had a cataract extraction by the phacoemulsification technique, a comparison was made of the endothelial cell density of the operated eye and the fellow unoperated eye. The result, reported at an in-house research meeting at the Jules Stein Eye Institute in June 1977, was of an average cell difference of 28% fewer cells in the operated eye. This closely compares with the 33.8% difference reported by Sugar et al. Furthermore, there was no substantial difference between procedures performed by house staff or faculty. I became aware, via personal communication, of notably lower cell loss found by others. Sugar et al similarly note wide discrepancies between their study and those of several others. Obviously the technique of the proce¬ dure might be implicated, although I feel that the retrospective analysis must be carefully evaluated. It was the retrospective nature of my study that I questioned. The obvious questions are: Why did the patient have a unilateral extraction?
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/04/2015
What
was
the
origin of
the cataract?
And, was there a history of trauma or
prior inflammatory disease? If the answers to these questions are indica¬ tive of the preoperative clinical sym¬ metry of the two eyes, the retrospec¬ tive results might be more rationally analyzed and accepted. The yardstick to measure endothe¬ lial cell changes, as in most other quantities in medicine, is a prospec¬ tive study. I hope that Sugar et al, with their large volume of phacoemulsifications, will provide us with this data to help resolve the wide variance in currently reported endothelial cell changes with phacoemulsification. Scott Grant, MD Los Angeles A' TTAE
To the Editor.\p=m-\As
the
necessity
resources, I
a
firm believer in
of
conserving natural applaud the increasing
of medical writers to use abbreviations. This tendency to abbreviate everything (TTAE) has the additional virtue of requiring several readings of each article to uncover the definitions (D). Very recently I have been pleased to see some authors refreshing our memories on the D of ages-old medical abbreviations, such as CBC (complete blood count), and so forth (etc). I am in the process of compiling a glossary of abbreviations in current use (GOAICU) and look forward to a brisk sale to authors (A) who wish to conserve paper and reading time by writing complete articles (CA) and even books (B) without one intelligible sentence. In summary, the TTAE has led to a
tendency
GOAICU, including, eg, CBC, etc, to assist A in preparation of CA and B. Robert J. Herm, MD Keene, NH A
Warning on Cryosurgery Eyelid Malignancies
for
To the Editor.\p=m-\Iread with interest Dr F. T. Fraunfelder's letter to the editor regarding "The Indications and Contraindications of Cryosurgery" (Archives 96:729, 1978). I was somewhat relieved to see that such a strong advocate of cryosurgery for eyelid malignancies inserted a slight note of skepticism concerning the general use of this type of therapy. I have a much stronger skepticism concerning this form of therapy for eyelid malignan-
cies. While cryosurgery certainly has indications in oculoplastics, it cannot be recommended for wholesale treatment of any and all eyelid lesions as some marketers of instruments would make us believe. It requires some knowledge of cryogenics and it is not without complications. We have treated more than 150 patients with aberrant lashes with good results by using cryosurgery and we believe that, at present, aberrant lashes are the only well-proven indication for the use of cryosurgery on eyelids. We have also treated some benign lesions of the lids (eg, hemangiomas, pigmented hairy nevi, and warts) with good results. However, I am reluctant to accept unproven ther¬ apeutic modalities for the treatment of potentially lethal conditions. Their use should be condemned except for research situations until at least fiveyear follow-up studies are available. We have seen a number of recurrences of basal cell carcinomas of the lids five to 15 years after treatment and a five-year follow-up is the minimum to report cure rates for this disease. It is unfortunate that few ophthal¬ mologists realize that the mortality from lid and canthal basal cell carcino¬ mas ranges from 2% to 11%.'^ A review of our cases at the University of Iowa showed a 4.5% mortality.1 In the past year we have exenterated six orbits with recurrent basal cell carci¬ noma following inadequate forms of therapy. There were recurrences in tWo of these cases some 15 years after the superficial portion of the tumor had been inadequately treated. We are also observing two patients with intracranial extension of this disease. Many forms of therapy will adequate¬ ly treat the superficial portion of a basal cell carcinoma but it is the deep portion that kills. Unfortunately, it may be many years before the recur¬ rence from a deep extension is noted
clinically. Many ophthalmologists, including myself, are hesitant to accept radia¬ tion as a primary therapy for basal cell carcinoma of the lids, but some will accept cryotherapy as an accept¬ able form of treatment of this disease. Both techniques fail to appreciate tumor margins and tumor depth. There is no reason that cryosurgery should give a better cure rate than radiation therapy. Cryosurgery does, however, have fewer ocular complica¬ tions than radiation therapy. Particularly in sclerosing or mor-
pheoform
basal cell carcinomas, cryo¬ surgery should be condemned. We have shown in a recent study that the tissue that has to be removed to obtain
tumor-free margins (using the freshfrozen Mohs's technique) was more than four times greater than the clin¬ ically apparent tumor size in cases of large and recurrent basal cell carcino¬ mas.4 Thus, when dealing with large or recurrent basal cell carcinomas, the area of the lid to be treated by cryo¬ surgery can only be estimated. It is impossible to estimate clinically the depth of a basal cell carcinoma and it is the deep extent that can blind or kill a patient. Preliminary work in a study that we have undertaken indicates that inadequate therapy may trans¬ form a benign form of basal cell carci¬ noma into a more malignant form. Therefore, we strongly advocate the complete removal of this tumor rather than possibly teasing it into a more aggressive form. We are unwilling to accept any form of therapy that does not obtain tumor-free margins and thus we recommend a fresh-frozen chemosurgical excision. We follow the fresh-frozen microscopically con¬ trolled excision with immediate recon¬ struction and have been successful with this technique in more than 100 difficult eyelid cases in the past two years.
One of the recommended indica¬ tions for cryosurgery is a basal cell carcinoma of the medial canthus because the lacrimal excretory system can be preserved. Unfortunately, our results and that of others indicate that the medial canthal region is the most dangerous of all locations for this tumor. Deep extent into the orbit and brain is a likely complication of a tumor in this location. Cryosurgery may be adequate ther¬ apy for the small, nodular, isolated basal cell carcinoma of the lid. Howev¬ er, simple excision and reconstruction are nearly as rapid as cryosurgery and they have less morbidity and a better cosmetic result when adequately per¬ formed. We reserve the use of cryosurgery for eyelid malignancies to those few patients who refuse surgical therapy but are willing to accept cryosurgery. Cryosurgery causes no less morbidity than fresh-frozen microscopically con¬ trolled excision and reconstruction with the patient under local anesthe¬ sia (and the reverse is frequently the case). Cryosurgery can also be recom¬ mended for hemophiliacs or those
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/04/2015
with serious coagulation disorders. It may have indications for small eyelid basal cell carcinomas in patients with the basal cell nevus syndrome where one is almost certain that a large number of eyelid tumors will present, recurrences may be difficult to differ¬ entiate from new tumors, and tissue available for reconstruction is not
easily available.
While cryosurgery certainly has a in the treatment of basal cell carcinomas elsewhere on the body, we believe that its use on the eyelids should be restricted to the above indi¬ cations or for research projects with careful controls. A minimum five-year follow-up and preferably a 15-year follow-up should be reported before results are generally accepted for this type of treatment of this insidious disease. The size, location, and histo¬ logical types of tumors should also be recorded and reported with the results. We are presently seeing more and more recurrent eyelid basal cell carci¬
place
nomas
following inadequate
probe
cryosur¬
some cases the retinal cryo¬ was even used for treatment.
gery. In
With the recent articles advocating cryosurgery, the claims made by instrument companies, and the rela¬ tive lack of expertise required to perform this procedure, the number of recurrent lesions, exenterations, and deaths from this disease may well increase. The mortality for basal cell carcino¬ mas of the skin elsewhere on the body is low, whereas that of the lids is high. Nowhere on the body is deep exten¬ sion to vital structures more accessible than from the lids. I certainly hope this somewhat jaundiced view of cryo¬ surgery for eyelid malignancies is read by those who have recently ordered or acquired their "cure-all eyelid maladies tool" or plan to try using their retinal cryoprobe to treat malignancies of the eyelids. Richard Anderson, MD Iowa City 1. Aurora AL, Blodi FC: Reappraisal of basal cell carcinoma of the eyelids. Am J Ophthalmol 70:329-336, 1970. 2. Birge HL: Cancer of the eyelids: Basal cell and mixed basal cell and squamous cell epithelioma. Arch Ophthalmol 19:700-708, 1938. 3. Payne JW, Duke JR, Butner R, et al: Basal cell carcinoma of the eyelids: A long-term followup study. Arch Ophthalmol 81:553-558, 1969. 4. Ceilley RI, Anderson RL: Microscopically controlled excision of malignant neoplasms on and around eyelids followed by immediate surgical reconstruction. J Dermatol Surg Oncol 4:55\x=req-\ 62, 1978.
