Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014
Ipilimumab-Induced Orbital Inflammation Resembling Graves Disease With Subsequent Development of Systemic Hyperthyroidism From CTLA-4 Receptor Suppression To the Editor: Previously, we described a case of ipilimumab-induced orbital inflammatory syndrome resembling euthyroid inflammatory Graves disease1,2 Subsequently, others have described similar cases3,4 The original case was associated with positive antithyroid antibodies despite the euthyroid states. This patient, 2 years after the diagnosis and with continued exposure to ipilimumab, developed anxiety, palpitations, and 14-pound weight loss without anorexia, diarrhea, lethargy, and heat intolerance. The T3 was highly elevated at 244 and T4 at 4.8; thyroid peroxidase antibodies were elevated at 2,047 and with elevated antithyroglobulin antibodies at 64. Development of full-blown systemic hyperthyroidism in the original patient described with ipilimunab-associated inflammatory orbitopathy provides further evidence of CTLA-4 suppression in the mechanism of Graves disease. Patients with this syndrome should be followed for systemic hyperthyroidism after the orbital inflammatory presentation.
Gary E. Borodic, M.D. David Hinkle, M.D. Correspondence: Gary E. Borodic, M.D, Harvard Medical School, 1261 Furance Brook Parkway, Quincy, MA, U.S.A. ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Borodic G, Hinkle DM, Cia Y. Drug-induced graves disease from CTLA-4 receptor suppression. Ophthal Plast Reconstr Surg 2011;27:e87–8. 2. Borodic GE, Hinkle DM. Reply Re: “Drug-induced Graves disease from CTLA-4 receptor sup pression.” Ophthal Plast Reconstr Surg 2013;29:241. 3. Sohrab MA, Desai RU, Chambers CB, et al. Re: “Drug-induced Graves disease from CTLA-4 receptor suppression.” Ophthal Plast Reconstr Surg 2013;29:239–40. 4. Lecouflet M, Verschoore M, Giard C, et al. Orbital myositis associated with ipilimumab. Ann Dermatol Venereol 2013;140:448–51.
Mnemonic That Corroborates Informed Consent in Oculoplastic Surgery To the Editor: Many surgeons write the phrase “risks and benefits of surgery discussed” or some variation of same, when obtaining informed consent. Circling the bolded letters in “risks and benefits of surgery” or writing out the mnemonic “R A B OF SURG” may help abbreviate medicolegal documentation, while corroborating the content of the discussion. Each clinician can individualize their mnemonic keywords. The following keywords are possible examples:
Letters to the Editor
Recurrence of the disease process is possible Residual fat, skin, tumor, infection or material Repeat operations may be required Alternatives Anesthetic risk with “Annihilation” (Disability or Death) Asymmetry Bleeding and Bruising Blindness or Vision loss Blink (Lagophthalmos and Dry eye) Oculomotor: diplopia Overcorrection/Undercorrection/No correction Offensive, that is, the patient may not appreciate the postoperative appearance Feeling: Sensation (e.g. numbness, pain) or Mood may be altered postoperatively Fection: InFection Scar Sensitivity (including Pain and Dry eye) Suture/implant extrusion (Sight loss also mentioned in “Blindness”) (Undercorrection/Overcorrection/No correction) Uncovered, that is, procedures not covered by medical insurance Unforeseen complications RG Renounce Guarantee, that is, no guarantee is possible with surgery
Edsel B. Ing, M.D., F.R.C.S.C. Correspondence: Edsel B. Ing, M.D., F.R.C.S.C., Toronto East General Hospital, University of Toronto, 650 Sammon Ave. K306, Toronto, ON Canada M4C 5M5 ([email protected]) The author has no financial or conflicts of interest to disclose.
Management of Extruding Bicanalicular Nasolacrimal Stents: Primum Non Nocere To the Editor: We read with interest the letter by Fayet et al.1 providing management options for extruding bicanalicular nasolacrimal stents and would like to offer another simple maneuver to treat this condition: a pressure patch. We have found that placing a pressure patch over the eye and extruded stent often allows for spontaneous repositioning within 1 day. Even when unsuccessful, a patch serves as a temporizing measure to improve patient comfort and anxiety if presentation occurs when the surgeon is unavailable. Two other strategies we have found useful: sweeping a suction instrument behind, then under, the inferior turbinate during endoscopy; and finally, tying the tubes under a 4-0 vicryl collaret rather than into a knot allows for safer removal from the eyelid when repositioning maneuvers fail.
Julian D. Perry, M.D. Bryan R. Costin, M.D. Correspondence: Julian D. Perry, M.D., Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, OH, U.S.A. ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Fayet B, Racy E, Katowitz WR, et al. Management of extruding bicanalicular nasolacrimal stents: Primum non nocere. Ophthal Plast Reconstr Surg 2013;29:413–4.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
83
Ipilimumab-Induced Orbital Inflammation Resembling Graves Disease With Subsequent Development of Systemic Hyperthyroidism From CTLA-4 Receptor Suppression To the Editor: Previously, we described a case of ipilimumab-induced orbital inflammatory syndrome resembling euthyroid inflammatory Graves disease1,2 Subsequently, others have described similar cases3,4 The original case was associated with positive antithyroid antibodies despite the euthyroid states. This patient, 2 years after the diagnosis and with continued exposure to ipilimumab, developed anxiety, palpitations, and 14-pound weight loss without anorexia, diarrhea, lethargy, and heat intolerance. The T3 was highly elevated at 244 and T4 at 4.8; thyroid peroxidase antibodies were elevated at 2,047 and with elevated antithyroglobulin antibodies at 64. Development of full-blown systemic hyperthyroidism in the original patient described with ipilimunab-associated inflammatory orbitopathy provides further evidence of CTLA-4 suppression in the mechanism of Graves disease. Patients with this syndrome should be followed for systemic hyperthyroidism after the orbital inflammatory presentation.
Gary E. Borodic, M.D. David Hinkle, M.D. Correspondence: Gary E. Borodic, M.D, Harvard Medical School, 1261 Furance Brook Parkway, Quincy, MA, U.S.A. ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Borodic G, Hinkle DM, Cia Y. Drug-induced graves disease from CTLA-4 receptor suppression. Ophthal Plast Reconstr Surg 2011;27:e87–8. 2. Borodic GE, Hinkle DM. Reply Re: “Drug-induced Graves disease from CTLA-4 receptor sup pression.” Ophthal Plast Reconstr Surg 2013;29:241. 3. Sohrab MA, Desai RU, Chambers CB, et al. Re: “Drug-induced Graves disease from CTLA-4 receptor suppression.” Ophthal Plast Reconstr Surg 2013;29:239–40. 4. Lecouflet M, Verschoore M, Giard C, et al. Orbital myositis associated with ipilimumab. Ann Dermatol Venereol 2013;140:448–51.
Mnemonic That Corroborates Informed Consent in Oculoplastic Surgery To the Editor: Many surgeons write the phrase “risks and benefits of surgery discussed” or some variation of same, when obtaining informed consent. Circling the bolded letters in “risks and benefits of surgery” or writing out the mnemonic “R A B OF SURG” may help abbreviate medicolegal documentation, while corroborating the content of the discussion. Each clinician can individualize their mnemonic keywords. The following keywords are possible examples:
Letters to the Editor
Recurrence of the disease process is possible Residual fat, skin, tumor, infection or material Repeat operations may be required Alternatives Anesthetic risk with “Annihilation” (Disability or Death) Asymmetry Bleeding and Bruising Blindness or Vision loss Blink (Lagophthalmos and Dry eye) Oculomotor: diplopia Overcorrection/Undercorrection/No correction Offensive, that is, the patient may not appreciate the postoperative appearance Feeling: Sensation (e.g. numbness, pain) or Mood may be altered postoperatively Fection: InFection Scar Sensitivity (including Pain and Dry eye) Suture/implant extrusion (Sight loss also mentioned in “Blindness”) (Undercorrection/Overcorrection/No correction) Uncovered, that is, procedures not covered by medical insurance Unforeseen complications RG Renounce Guarantee, that is, no guarantee is possible with surgery
Edsel B. Ing, M.D., F.R.C.S.C. Correspondence: Edsel B. Ing, M.D., F.R.C.S.C., Toronto East General Hospital, University of Toronto, 650 Sammon Ave. K306, Toronto, ON Canada M4C 5M5 ([email protected]) The author has no financial or conflicts of interest to disclose.
Management of Extruding Bicanalicular Nasolacrimal Stents: Primum Non Nocere To the Editor: We read with interest the letter by Fayet et al.1 providing management options for extruding bicanalicular nasolacrimal stents and would like to offer another simple maneuver to treat this condition: a pressure patch. We have found that placing a pressure patch over the eye and extruded stent often allows for spontaneous repositioning within 1 day. Even when unsuccessful, a patch serves as a temporizing measure to improve patient comfort and anxiety if presentation occurs when the surgeon is unavailable. Two other strategies we have found useful: sweeping a suction instrument behind, then under, the inferior turbinate during endoscopy; and finally, tying the tubes under a 4-0 vicryl collaret rather than into a knot allows for safer removal from the eyelid when repositioning maneuvers fail.
Julian D. Perry, M.D. Bryan R. Costin, M.D. Correspondence: Julian D. Perry, M.D., Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, OH, U.S.A. ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Fayet B, Racy E, Katowitz WR, et al. Management of extruding bicanalicular nasolacrimal stents: Primum non nocere. Ophthal Plast Reconstr Surg 2013;29:413–4.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
83
