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PostScript
Internal jugular vein removal and intraocular pressure I read with interest the article by Chan et al1 in which the authors report on medium-term ocular findings in patients who previously underwent unilateral neck dissection with adjuvant radiotherapy. They found no case of elevated intraocular pressure (IOP), reduced peripapillary retinal nerve fibre layer thickness (RNFLT), increased cup to disc ratio or any other ocular abnormalities on either eye, and conclude that unilateral internal jugular vein dissection is not a risk factor for secondary IOP elevation and RNFLT thinning. Though the study is well conducted and the authors indicate the limitations of their work in the discussion, their conclusion needs a comment, particularly since the authors might be unaware of some experimental and clinical articles in the field that were published more than 20 years ago.2 3 In fact, in contrast with the authors’ statement, similar investigations were published long before their current article was published. In a detailed case report,3 we presented the case of a 55-year-old male patient who underwent a left-sided radical neck dissection (excision of the left internal jugular vein, jugular lymphatic trunk and chain), repeated chemotherapies and telecobalt irradiations on both sides of the neck. One month after the last irradiation, a rapid development of a serious neck and head lymphoedema and conjunctival chemosis with a right-sided predominance developed with elevated IOP (35 and 26 mm Hg on the right and left eye, respectively) and severely reduced aqueous humour outflow facility. No other pathologies were seen in either eye. Timolol eye drops failed to reduce IOP in both eyes. Three day later, however, the lymphoedema and the chemosis disappeared, outflow facility became normal, and the IOP spontaneously decreased to 16 and 18 mm Hg on both eyes, respectively. Unfortunately, after some days, the patient died. The postmortem examination confirmed the postoperative status of the neck including cicatrisation of the right side of the neck, and intact, undilated jugular lymphatic system on the right side of the neck. The results of our case report support the findings of Chan et al.1 It is well known 416
Br J Ophthalmol March 2014 Vol 98 No 3
Downloaded from bjo.bmj.com on October 5, 2014 - Published by group.bmj.com
PostScript that the jugular lymphatic chain has an extensive collateral system that can take over its function after a radical neck dissection, if the collateral system is functioning.4 However, when this system is compressed or blocked by irradiation-related scarring (as happened on the right side of the neck in our case) this function may be reduced or missing. The contralateral collateral system may take over the lymphatic drainage, but this may take time. The temporary IOP elevation, however, may not be sufficiently long-lasting to induce ocular damage that is consistent with the signs of secondary glaucoma, thus, the mediumterm IOP and RNFLT results are within the normal ranges. Additionally, surgical and irradiation techniques have developed during the last decades. This may also have a significant beneficial influence on the IOP and RNFLToutcomes. Gábor Holló Correspondence to Professor Gábor Holló, Department of Ophthalmology, Semmelweis University, 1098. Budapest, Maria u. 39, Hungary; [email protected] Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
To cite Holló G. Br J Ophthalmol 2014;98:416–417. Received 21 October 2013 Revised 3 November 2013 Accepted 1 December 2013 Published Online First 16 December 2013 Br J Ophthalmol 2014;98:416–417. doi:10.1136/bjophthalmol-2013-304514
REFERENCES 1
2
3
4
Chan RC, Lee JW, Chan JY, et al. Effects of unilateral jugular vein removal on intraocular pressure. Br J Ophthalmol 2014;98:79–81. Holló G, Pap G, Tóth Bagi Z, et al. Does the lymph drainage from the head influence aqueous humour outflow and visual functions? Acta Ophthalmol (Copenh) 1991;69:527–9. Holló G. Bilateral intraocular pressure elevation and decrease of facility of aqueous humour outflow as a consequence of regional lymphoedema of head and neck. Acta Ophthalmol 1993;71:415–18. Casley-Smith JR, Clodius L, Földi-Börcsök E, et al. The effect of chronic cervical lymphyostasis on regions drained by lymphatics and prelymphatics. J Pathol 1978;124:13–17.
Br J Ophthalmol March 2014 Vol 98 No 3
417
Downloaded from bjo.bmj.com on October 5, 2014 - Published by group.bmj.com
Internal jugular vein removal and intraocular pressure Gábor Holló Br J Ophthalmol 2014 98: 416-417 originally published online December 16, 2013
doi: 10.1136/bjophthalmol-2013-304514
Updated information and services can be found at: http://bjo.bmj.com/content/98/3/416.full.html
These include:
References
This article cites 3 articles http://bjo.bmj.com/content/98/3/416.full.html#ref-list-1
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PostScript
Internal jugular vein removal and intraocular pressure I read with interest the article by Chan et al1 in which the authors report on medium-term ocular findings in patients who previously underwent unilateral neck dissection with adjuvant radiotherapy. They found no case of elevated intraocular pressure (IOP), reduced peripapillary retinal nerve fibre layer thickness (RNFLT), increased cup to disc ratio or any other ocular abnormalities on either eye, and conclude that unilateral internal jugular vein dissection is not a risk factor for secondary IOP elevation and RNFLT thinning. Though the study is well conducted and the authors indicate the limitations of their work in the discussion, their conclusion needs a comment, particularly since the authors might be unaware of some experimental and clinical articles in the field that were published more than 20 years ago.2 3 In fact, in contrast with the authors’ statement, similar investigations were published long before their current article was published. In a detailed case report,3 we presented the case of a 55-year-old male patient who underwent a left-sided radical neck dissection (excision of the left internal jugular vein, jugular lymphatic trunk and chain), repeated chemotherapies and telecobalt irradiations on both sides of the neck. One month after the last irradiation, a rapid development of a serious neck and head lymphoedema and conjunctival chemosis with a right-sided predominance developed with elevated IOP (35 and 26 mm Hg on the right and left eye, respectively) and severely reduced aqueous humour outflow facility. No other pathologies were seen in either eye. Timolol eye drops failed to reduce IOP in both eyes. Three day later, however, the lymphoedema and the chemosis disappeared, outflow facility became normal, and the IOP spontaneously decreased to 16 and 18 mm Hg on both eyes, respectively. Unfortunately, after some days, the patient died. The postmortem examination confirmed the postoperative status of the neck including cicatrisation of the right side of the neck, and intact, undilated jugular lymphatic system on the right side of the neck. The results of our case report support the findings of Chan et al.1 It is well known 416
Br J Ophthalmol March 2014 Vol 98 No 3
Downloaded from bjo.bmj.com on October 5, 2014 - Published by group.bmj.com
PostScript that the jugular lymphatic chain has an extensive collateral system that can take over its function after a radical neck dissection, if the collateral system is functioning.4 However, when this system is compressed or blocked by irradiation-related scarring (as happened on the right side of the neck in our case) this function may be reduced or missing. The contralateral collateral system may take over the lymphatic drainage, but this may take time. The temporary IOP elevation, however, may not be sufficiently long-lasting to induce ocular damage that is consistent with the signs of secondary glaucoma, thus, the mediumterm IOP and RNFLT results are within the normal ranges. Additionally, surgical and irradiation techniques have developed during the last decades. This may also have a significant beneficial influence on the IOP and RNFLToutcomes. Gábor Holló Correspondence to Professor Gábor Holló, Department of Ophthalmology, Semmelweis University, 1098. Budapest, Maria u. 39, Hungary; [email protected] Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
To cite Holló G. Br J Ophthalmol 2014;98:416–417. Received 21 October 2013 Revised 3 November 2013 Accepted 1 December 2013 Published Online First 16 December 2013 Br J Ophthalmol 2014;98:416–417. doi:10.1136/bjophthalmol-2013-304514
REFERENCES 1
2
3
4
Chan RC, Lee JW, Chan JY, et al. Effects of unilateral jugular vein removal on intraocular pressure. Br J Ophthalmol 2014;98:79–81. Holló G, Pap G, Tóth Bagi Z, et al. Does the lymph drainage from the head influence aqueous humour outflow and visual functions? Acta Ophthalmol (Copenh) 1991;69:527–9. Holló G. Bilateral intraocular pressure elevation and decrease of facility of aqueous humour outflow as a consequence of regional lymphoedema of head and neck. Acta Ophthalmol 1993;71:415–18. Casley-Smith JR, Clodius L, Földi-Börcsök E, et al. The effect of chronic cervical lymphyostasis on regions drained by lymphatics and prelymphatics. J Pathol 1978;124:13–17.
Br J Ophthalmol March 2014 Vol 98 No 3
417
Downloaded from bjo.bmj.com on October 5, 2014 - Published by group.bmj.com
Internal jugular vein removal and intraocular pressure Gábor Holló Br J Ophthalmol 2014 98: 416-417 originally published online December 16, 2013
doi: 10.1136/bjophthalmol-2013-304514
Updated information and services can be found at: http://bjo.bmj.com/content/98/3/416.full.html
These include:
References
This article cites 3 articles http://bjo.bmj.com/content/98/3/416.full.html#ref-list-1
Email alerting service
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions
To order reprints go to: http://journals.bmj.com/cgi/reprintform
To subscribe to BMJ go to: http://group.bmj.com/subscribe/
