Letters to the Editor
ment after clear-lens extraction in 41 eyes with high axial
myopia. Retina 1996; 16:3-6.
5. Ripandelli G. Reply [letter]. Retina 1997; 17:78-9.
Syphilis Exposure and Uveitis
Dear Editor:
Barile and Flynn recently reported the results of a retro-
spective review of syphilis exposure in patients with uve-
itis (Ophthalmology 1997; 104:1605-9). The authors re-
ported that 18 of 44 patients with presumed syphilitic
uveitis underwent cerebrospinal fluid (CSF) analysis and
that all of these studies were normal. In this series, how-
ever, two patients had posterior uveitis, three patients
had panuveitis, and three patients had concurrent HIV
infection. Were these patients among those who under-
went CSF analysis? I was wondering if the authors could
comment on the need for CSF analysis in patients with
posterior uveitis, panuveitis, optic neuropathy, or retinal
vascular invovement compared to patients with anterior
or intermediate uveitis? Is optic nerve involvement or
posterior uveitis a sign of central nervous system disease?
If so, are these findings alone an indication for CSF neuro-
syphilis regimen of penicillin treatment regardless of CSF
results?
ANDREW G.LEE, MD
Houston, Texas
Authors’ reply
Dear Editor:
Dr. Lee poses interesting questions regarding the need
for CSF studies in patients with presumed syphilitic uve-
itis when the yield of such studies is likely to be low. In
our own study, patients with presumed syphilitic uveitis
who underwent CSF analysis included one of two patients
with posterior uveitis and one of three patients with pan-
uveitis. One patient with posterior uveitis was empirically
treated with a neurosyphilis regimen without obtaining a
lumbar puncture. One of the two patients with panuveitis
did not recieve CSF analysis because of resistance on the
part of the primary care physician, and the other patient
was noncompliant with a recommended lumbar puncture.
The need for CSF examination in patients with pre-
sumed syphilitic uveitis remains controversial. If one con-
diders uveitis only a risk factor for neurosyphilis, CSF
analysis is prudent when antibiotic treatment follows the
recommended regimen for latent syphilis.’ The difficulty
lies in the low yield of CSF serologic studies even in
clinical cases of neurosyphilis.2Z3 If one considers uveitis a
sign of neurosyphilis and treats accordingly, it is arguable
whether CSF analysis is necessary at all. In this case,
however, the detection of even mild CSF abnormalities
in cell profile may allow one to monitor response to treat-
ment.*
The question of which patterns and locations of uveitis
suggest the presence of neurosyphilis is also important.
Unfortunately our study does not contain sufficient infor-
mation to answer this question. Because three of the five
patients in our study with presumed syphilitic panuveitis
or posterior uveitis did not undergo lumbar puncture, we
are unable to meaningfully comment on the CSF profiles
of such “high risk” cases. It is quite reasonable, as Dr.
Lee suggests, to consider posterior segment involvement
an indication for a neurosyphilis regimen regardless of
CSF findings. Concurrent HIV infection also argues for
a neurosyphilis regimen.4 In short, it seems reasonable to
rule out an abnormal CSF profile when treating for latent
syphilis or administer treatment for neurosyphilis in
“high risk” cases.
GAETANO BARILE, MD
THOMAS E. FLYNN, MD
New York, New York
References
1. Centers for Disease Control. 1989 Sexually Transmited
Diseases Treatment Guidelines. MMWR 1989;38(No. 5-
8):5- 15.
2. Burke JM, Schaberg DR. Neurosyphilis in the antibiotic
era. Neurology 1985;35:1368-71.
3. Davis LE, Schmitt JW. Clinical significance of cerebrospinal
fluid tests for neurosyphilis. Ann Neurol 1989;25:50-5.
4. Tramont EC. Syphilis in the AIDS era [editorial]. N Engl
J Med 1987;316:1600-1.
Microsurgery for Eyelid Margin Tumors
Dear Editor:
The paper entitled “Laser Microsurgery for Superficial
Tl-T2 Basal Cell Carcinoma of the Eyelid Margins” by
Bandieramonte et al (Ophthalmology 1997; 104:1179-
84) covered important ground, but we do think it im-
portant to clearly delineate the advantages of this surgical
method. The carbon dioxide laser has not yet been ap-
preciated for its full potential in oculoplastic surgery. Ear-
lier, we published a paper with comparable content and
similar findings.’ While we agree with the authors’ con-
clusions, we would like to add the following observations
based on our experience:
1. We also find the microscope to be very important
in the assessment of the tumor margin, but we be-
lieve that a hand-held surgical laser gives more free-
dom during the procedure, especially when separat-
ing the tumor from tissue along the base. Since the
superpulse mode diminishes the carbonization zone,
it is of further help in the assessment of the tumor
margins.
2. We do not use any postoperative antibiotic treat-
ment, and we have not observed suppuration of the
wounds. We consider CO, laser a superior tech-
nique to traditional surgical cutting because we be-
lieve it to be the most accurate method of tumor
delineation.* As blood and lymphatic vessels are
coagulated, there is no edema formation and mini-
mal wound pain. Furthermore, since repair is poor
in scar tissue, the recurrence control is also im-
proved. Finally, because of the “no touch tech-
nique,” intraoperative tumor spread is also mini-
mized.
94.5
 Ophthalmology Volume 105, Number
The only disadvantage of this technique is the uncer-
tainty of the histopathologic evaluation. We have to ac-
cept that we lose the possibility of histopathologic evalua-
tion of the peripheral 2 mm of tissue. However, since the
rate of recurrence appears to be similar with both meth-
ods, the above described drawback may have no clinical
significance.
G. RAD~, MD
St. Pdten, Austria
References
I. Radb G, Klemen UM. Langzeitergebnisse nach CO2 Laser
Excision. Spektrum Augeheilkd 1995; 163-4.
2. Verschueren Rcj. The Cob2s laser in tumor surgery. Assen:
Van Gorcum, 1976;47-52.
Authors’ reply
Dear Editor:
Dr. Rad6 offers some important comments about the laser
surgical method for treating eyelid margin tumors.
The reasons for the choice of the microscope-mounted
system in surgical oncology were fully reported in a previ-
ous paper.’ In the specific anatomic area of the eyelid
margins, we believe that the microsurgical method can
allow proper intraoperative definition of the lesion bor-
ders. Magnification of the surgical field up to 12x in-
creased the precision of the resection and maximized
healthy tissue conservation. Moreover, since the total ex-
cursion of the micromanipulator in a small surgical field
did not require position change of the operating micro-
scope, the entire surgical system was of satisfactory stabil-
ity. This advantage balanced the apparent reduction of
freedom during the surgical procedure while eliminating
the variable due to the gross incision direction of the
hand-held surgical system.
The super-pulse mode of laser emission may be prefera-
ble for the reduced carbonization zone, especially when
incising lateral borders. Less advantages of the mode are
experienced at the deep resection border, where an in-
creased coagulation capability is required, and when using
the laser for adjunctive peripheral vaporization. In the
latter case, the continuous mode of laser emission can
offer the desired surgical result with no potential risk of
tumor cell particle spreading due to the acoustic effect.2
Even though we initially used postoperative antibiotic
treatment for all patients, we now agree with Dr. Rad6 that
it is not necessary. Rarely, indications for prophylactic
antibiotic treatment remain for elderly or diabetic patients.
In our opinion, the histopathologic limitations in speci-
men evaluation at the eyelid resection margin should be
reduced to a minimum, mostly by adequately selecting
the patients and then by laser incising the critical margin
with minimal thermal injury. Laser excision of primary
superficial tumors with an “anterior” location usually
gives specimens with histologically assessable tumor-free
margins.” Conversely, when dealing with an “intermedi-
ate” location of the lesion, extended to the intermarginal
space (but not reaching the conjunctival border), a specific
ability is required for complete removal of the lesion to
946
6, June I998
minimize thermal damage at the specimen border and to
avoid cosmetic or functional complications. The latter
subgroup of lesions therefore requires the most accurate
preoperative selection and intraoperative microsurgical
precision.
GAETANO BANDIERAMONTE, MD
PAOLO LEPERA, MD
Milano, Italy
References
BandieramonteG, ChiesaF, Lupi M, DiPietroS. The useof
laserin microsurgicaloncology. Microsurgery 1986;7:95-
101.
EsenalievRO, OraevskyAA, Letokhov VS, et al. Studies
of acousticaland shockwavesin the pulsedlaserablation
of biotissue.LasersSurg Med 1993; l3:470-84.
BandieramonteG, LeperaP, Moglia D, et al. Lasermicro-
surgery for superficialTl-T2 basal-cellcarcinomaof the
eyelid margins.Ophthalmology 1997;104:1179-84.
Prism Adaptation Study
Dear Editor:
Repka, Connett, and Scott point out in their reply to
Greenwald (Ophthalmology 1997; 104:1725-6) that
comparison of overall successrates in the Prism Adapta-
tion Study (Ophthalmology 1996:103:922-S) is a bit
complicated. While I agree with their estimate of the net
benefit of prism adaptation, I believe that without correc-
tion for continuity their P value is too generous, even at
only 0.17.
Imputing the same successrate for the 63 prism re-
sponderswho underwent entry angle surgery asthat found
for the prism responderswho received adapted angle sur-
gery and normalizing for the number of actual (not im-
puted) observations gives a successrate of 98/121 (8 l%,
in agreement with the authors) for prism adaptation versus
90/121 (74%) for conventionally treated patients. Using
these numbers, with the appropriate correction for conti-
nuity, z, = 1.08, which gives a two-tailed P = 0.28.
Alternatively, Fisher’s exact test also gives P = 0.28.
This significance level falls well short of the cx= 0.05
specified in the original study design. Therefore, each
surgeon will have to decide whether the effort and ex-
pense necessary for prism adaptation are worth a l-year
motor outcome that does not meet the usual statistical
criteria for being significantly different from conventional
management.If clinicians are inclined to accept the trend
found in the Prism Adaptation Study even at this signifi-
cance level, they should recognize that there is consider-
able uncertainty associated with the sample estimate of
7% benefit. The true benefit of prism adaptation-if the
customary 95% confidence interval is applied-may be
anywhere from -3% to +17%.
STEVEN M. ARCHER, MD
Ann Arbor, Michigan
Authors’ reply
Dear Editor:
Dr. Archer proposesan alternative analysis of the l-year