Ophthalmology Volume 105, Number 6, June I998
The only disadvantage of this technique is the uncer- minimize thermal damage at the specimen border and to
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
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