Filtering blebs and aqueous pathway an immunocytological and in vivo confocal microscopy study

OBJECTIVE

To characterize and understand, at the cellular level, the aqueous humor pathways after filtering surgery, using in vivo confocal microscopy and impression cytology (IC).

DESIGN

Observational case series.

PARTICIPANTS

Thirty-two blebs of 29 patients after trabeculectomy were retrospectively evaluated.

METHODS

In vivo confocal microscopy and immunofluorescence staining of IC samples taken on and around the bleb area were performed. Impression cytology samples were examined under confocal microscopy after goblet cell and inflammatory cell immunostaining with anti-MUC5AC and antivimentin antibodies, respectively. Eyes were classified into 3 groups: (1) functioning blebs (11 eyes), (2) nonfunctioning blebs (10 eyes), and (3) functioning blebs after mitomycin C application (12 eyes). Impression cytology specimens and in vivo confocal microscopy images were analyzed and compared in a masked manner.

MAIN OUTCOME MEASURES

Conjunctival epithelium changes of each type of bleb were analyzed using both impression cytology specimens and in vivo confocal microscopy and correlated to clinical outcomes.

RESULTS

In all IC specimens, numerous MUC5AC-positive cells were observed outside the edges of the blebs. Few MUC5AC-positive cells were observed at the surface of nonfunctioning blebs. Numerous goblet cells with immunostaining that was weak or limited to the membrane were clearly visible morphologically at the surface of functioning blebs (with and without adjunctive mitomycin C). Using in vivo confocal microscopy, all functioning blebs showed numerous intraepithelial optically empty microcysts, whereas nonfunctioning blebs had none or only a few. All blebs contained dendritiform inflammatory cells, especially after mitomycin C application.

CONCLUSION

Impression cytology and in vivo confocal microscopy provide a new approach to filtering blebs. Microcysts observed at the surface of functioning blebs seemed to correspond to goblet cells, mostly containing aqueous humor instead of highly hydrophilic gel-forming mucins. Although this hypothesis requires further confirmation, the transcellular pathway of the aqueous humor could be hypothesized to occur at the level of goblet cells toward the ocular surface.

Apport de la microscopie confocale in vivo à l’étude des ptérygions

PURPOSE

To describe the pterygium structure with a high-resolution in vivo confocal microscope and to show the typical components of active pterygium.

METHODS

In this study, 15 patients with 20 pterygia were examined. None of them had had prior pterygium surgery. Slit lamp examination and in vivo confocal microscopy imaging (Heidelberg Retina Tomograph II Rostock Cornea Module) were performed.

RESULTS

The images obtained consisted of two-dimensional high-resolution optical sections. We could identify the pterygial epithelium and its border, pterygial stroma and its vascularization, the pterygium corneal limits, and numerous inflammatory cells in active pterygia.

DISCUSSION

Many reports have been written about pterygium structure. In vivo confocal microscopy imaging is a new approach to this pathology and provides a precise evaluation of active pterygium.

[Heart and heart-lung transplants thorax complications: major radiologic forms]

Bipulmonary and cardiopulmonary transplantations are among the most difficult to perform, with a 10-year survival rate estimated at 33%. This low rate can be attributed to thoracic complications that can be classified into three distinct groups: 1) early complications, occurring in the first 30 days after transplantation (hemothorax, diaphragmatic paralysis, reperfusion edema, hydric overloading, acute rejection); 2) late complications that occur beyond the first month (bronchiolitis obliterans syndrome, bronchic stenosis, sirolimus-induced lung disorders, initial disease recurrence); and 3) infections classed separately because of their high morbidity and mortality (thoracic wall abscess, bacterial and viral pneumonia, CMV, pneumocystosis, Aspergillus necrotizing bronchitis). Imaging is essential in screening and diagnosing these complications as part of the clinician's monitoring throughout the rest of the transplant recipient's life. In diagnosis, combined with clinical and biological data, imaging has its place in delaying the onset of these diseases.

[Contribution of confocal microscopy and anterior chamber OCT to the study of corneal endothelial pathologies]

PURPOSE

To describe the appearance of various endothelial diseases with in vivo confocal microscopy and anterior chamber optical coherence tomography (AC OCT).

METHODS

In this study, ten patients with five different corneal endothelial pathologies were evaluated. Three patients had cornea guttata, three had corneal endothelial precipitates, two had irido-corneo-endothelial (ICE) syndrome, one had endothelial folds, and one had breaks in the Descemet membrane. All patients had bilateral ophthalmologic examinations, in vivo confocal microscopy, and AC OCT analysis.

RESULTS

In cases of cornea guttata, AC OCT showed a finely embossed line corresponding to the empty intercellular cavities found with in vivo confocal microscopy. Corneal endothelium precipitates had the aspect of round formations suspended with the endothelium. Iris atrophy and irido-corneal synechiae resulting from ICE syndrome were precisely visualized with the AC OCT.

CONCLUSION

High-resolution images of the anterior segment could be obtained using the AC OCT. Associated with in vivo confocal microscopy, these two new imaging techniques provide a precise evaluation of endothelial pathologies.

[In vivo confocal microscopy and ocular surface diseases: anatomical-clinical correlations]

PURPOSE

To describe corneal and conjunctival epithelial changes in various ocular surface disorders with a new in vivo confocal microscope (Corneal HRT II module) and to compare these results with those obtained by immunohistology on impression cytology specimens.

METHODS

In this study, we investigated 36 eyes of 18 patients with ocular surface diseases such as corneal epitheliopathy induced by ocular rosacea (five patients), keratoconjunctivitis sicca related to tear evaporative condition in Meibomian gland dysfunction (eight patients), or tear-deficient dry eye in Sjögren's syndrome (five patients). In vivo confocal microscopy imaging (Heidelberg Retina Tomograph II Rostock Cornea Module) and impression cytology of the cornea and/or conjunctiva were performed. The images were analyzed for epithelial cell morphology at nuclear and cytoplasmic levels, in the cornea and the conjunctiva, number of goblet cells and their possible presence within the corneal epithelium, corneoconjunctival junction at the limbus, and density and presence of inflammatory cells within both epithelia.

RESULTS

Images obtained consisted of two-dimensional 400x400 microm optical sections oriented parallel to the surface of the eye and compared with impression cytology. Conjunctival and corneal epithelia showed dramatic changes in ocular surface disease. In keratoconjunctivitis sicca, we found squamous metaplasia, inflammatory cell infiltration, goblet cell depletion, as well as a nuclear snake-like chromatin pattern. In rosacea associated with corneal epitheliopathy, a corneal conjunctivalization (goblet cells together with conjunctival epithelial cells within the corneal epithelium layer) was found. The images provided by this technique are in excellent correlation with the findings using impression cytology.

CONCLUSION

The HRT II in vivo confocal microscope facilitates the study of both central and peripheral ocular surface epithelia compared to first-generation confocal microscopy devices. In vivo confocal microscopy, showing corneal and conjunctival epithelial structures in the live eye at the cellular level, is likely to open up a new promising way to investigate ocular surface involvement in complex diseases, providing a new insight on corneal and conjunctival disorders in the future.

Comparison of positron emission tomography and lymphangiography in the diagnosis of infradiaphragmatic Hodgkin's disease

PURPOSE

To evaluate the respective roles of positron emission tomography using 18F-fluorodeoxyglucose (FDG-PET) and lymphangiography (LAG) in staging Hodgkin's disease (HD) patients with negative contrast-enhanced infradiaphragmatic computed tomography (CT).

MATERIAL AND METHODS

28 patients underwent FDG-PET and LAG at initial staging. Concordant positive findings on both tests were regarded as actual HD locations and concordant negative findings as true negative. In case of discrepancy, the reference was biopsy or magnetic resonance imaging (MRI).

RESULTS

Concordant results were obtained in 26 patients (24 negative, two positive). In two of the 24 negative patients, PET showed additional lesions in the spleen and one celiac lymph node (one patient), and in the right kidney and the right iliac crest (one patient). Discordant results were obtained in two patients. Both methods indicated infradiaphragmatic involvement in different locations in one patient. In the other, PET was falsely positive (PET done within 24 hours after a negative LAG), which was confirmed by biopsy (benign inflammatory, probably due to LAG medium).

CONCLUSION

FDG-PET and LAG gave comparable results, making invasive LAG unnecessary. Furthermore, LAG, when performed before PET, can be responsible for false-positive PET results.

In vivo confocal microscopy in fungal keratitis

BACKGROUND

Fungal keratitis is a major blinding eye disease found throughout the world, particularly in developing countries. Given the recent increase in Fusarium keratitis infections in contact lens wearers owing to contact lens solutions, a warning was recently issued by the Food and Drug Administration, making it a public health concern in developed countries.

OBJECTIVE

To show the advantages of in vivo confocal microscopy imaging using the Heidelberg Retina Tomograph II-Rostock Cornea Module (HRTII-RCM) in the early diagnosis of fungal keratitis.

METHODS

HRTII-RCM confocal microscopy was performed on five patients presenting with fungal keratitis and on three donor corneas contaminated with Fusarium solani, Aspergillus fumigatus and Candida albicans.

RESULTS

Direct microscopic evaluation of corneal smears and culture revealed the presence of F solani in four cases and C albicans in one case. HRTII-RCM examination of the infected patients and contaminated donor corneas revealed numerous high-contrast elements resembling Fusarium, Aspergillus hyphae or Candida pseudofilaments in the anterior stroma.

CONCLUSION

HRTII-RCM in vivo confocal microscopy is a new, non-invasive and rapid technique for the early diagnosis of fungal keratitis, showing high-resolution images resembling fungal structures in the early phase of the disease.

Epithelial Basement Membrane Dystrophy

PURPOSE

To describe corneal changes in patients with epithelial basement membrane dystrophy (EBMD) using a new in vivo confocal microscope.

DESIGN

Observational case series.

METHODS

A retrospective chart review of 22 consecutive patients with EBMD at the Quinze-Vingts National Ophthalmology Hospital from April 2004 to March 2005 was conducted. Gender, age, history of painful episodes suggestive of recurrent erosions, best-corrected visual acuity, slit lamp findings, and in vivo confocal microscopy images were analyzed.

RESULTS

There were 8 male (36.4%) and 14 female (63.6%) subjects. Eighteen patients (81.2%) had a history of recurrent erosions in 1 or in both eyes. In 37 eyes of 19 patients (86.4%), map and/or dot and/or fingerprint changes were observed biomicroscopically. In 3 patients (13.6%) with recurrent erosions, the cornea had a normal structure on slit lamp examination and the diagnosis of EBMD was made after in vivo confocal microscopy examination. Four patients (18%), despite basement membrane abnormalities, reported no corneal symptoms suggesting recurrent erosions. In vivo confocal microscopy images showed that all patients had an abnormal epithelial basement membrane protruding into the corneal epithelium, epithelial cell abnormalities, and microcysts. No abnormalities were observed in superficial epithelial cells or the stroma.

CONCLUSION

Epithelial basement membrane dystrophy is characterized by an abnormal basement membrane protruding toward the epithelium and epithelial microcysts. In vivo confocal microscopy using the HRT II Rostock Cornea Module provides better resolution and therefore outlines distinctively in vivo microstructural characteristics of EBMD. It assists in the diagnosis of EBMD in patients suffering from recurrent erosion syndrome, particularly in patients with no corneal change visible biomicroscopically.

[Anicteric cholestasis: imaging and diagnostic strategy]

Cholestasis is due to abnormal biliary secretion, from hepatic or extra hepatic causes. The diagnostic strategy of anicteric cholestasis will be discussed, defining hepatic biologic abnormalities, and the role and sequence of imaging techniques based on clinical and biological findings. Main causes will be emphasized and illustrated with different radiological techniques (US, CT and MRI).

First a third, then a fourth nerve palsy in multiple intracranial aneurysms

BACKGROUND

Intracranial aneurysms may be a cause of ocular motor dysfunction, the third nerve being more often involved than the two other cranial ocular motor nerves.

METHODS

We report the unusual occurrence of an isolated fourth nerve palsy related to a cavernous carotid aneurysm, angiographically confirmed. The patient already underwent clipping of a ruptured posterior communicating artery aneurysm 17 years earlier, revealed at that time by a third nerve palsy.

RESULTS

Endovascular treatment of the cavernous carotid aneurysm was performed, resulting in complete recovery of the palsy.

CONCLUSION

Occurrence of an acquired fourth nerve palsy in a patient with a past history of aneurysm should prompt neurovascular imaging as multiple aneurysms may cause sequential ocular motor palsies.

Apport de la microscopie confocale in vivo dans l’exploration de tumeurs limbiques

PURPOSE

To explore tumors of the limbus with a new in vivo confocal microscope and to compare the images to histology results.

METHODS

We evaluated three tumors in three patients with the Heidelberg Retina Tomograph II, Rostock Cornea Module. A diagnostic and therapeutic excision with adjunctive cryotherapy was performed for each individual. Confocal microscopy was compared to histopathologic sections.

RESULTS

Histology identified two dysplasias and one carcinoma in situ. The main pathological features were visible on our images: cytonuclear atypias, epithelial folds into an inflammatory and vascularized conjunctival stroma, fine vessels perpendicular to the surface, a clear limit with normal epithelium, papillomatous organization, and abnormal keratinization.

CONCLUSION

Our preliminary study showed that this type of limbal tumor could be explored using in vivo confocal microscopy. We were not able to determine whether there was a microinvasion. This new method could be a diagnostic aid, especially for atypical lesions and for follow-up because of frequent recurrences. Other studies are necessary to confirm our hypothesis.

In vivo confocal microscopy study of blebs after filtering surgery

OBJECTIVE

To analyze bleb structure after filtering surgery at the cellular level using a new generation in vivo confocal microscope.

DESIGN

Observational case series.

PARTICIPANTS

We retrospectively evaluated 17 filtering blebs of 13 patients after trabeculectomy.

METHODS

Ophthalmologic examinations included slit-lamp examination, applanation tonometry, and in vivo confocal microscopy (Heidelberg Retina Tomograph II, Rostock Cornea Module). Eyes were classified into 3 groups: (1) functioning blebs (6 eyes), (2) nonfunctioning blebs (6 eyes), and (3) functioning blebs after application of mitomycin C (5 eyes). Cellular patterns, morphologic appearance, and functional aspects of functioning and nonfunctioning blebs were compared in a masked manner.

MAIN OUTCOME MEASURES

In vivo confocal microscopy images were analyzed for number of intraepithelial microcysts, density of subepithelial connective tissue, presence of blood vessels, or encapsulation.

RESULTS

All functioning blebs had numerous intraepithelial optically-empty microcysts, whereas all nonfunctioning blebs had none or few. Subepithelial connective tissue was widely spaced in all functioning blebs, whereas the tissue was dense in 83.3% of nonfunctioning blebs. Functioning blebs with mitomycin C had numerous microcysts and loosely arranged subepithelial connective tissue as compared with nonfunctioning blebs.

CONCLUSIONS

In vivo confocal microscopy study of blebs is an original method that agrees well with ex vivo histologic examination. The number of microcysts and the density of the subepithelial connective tissue observed with in vivo confocal microscopy are correlated with bleb function. By providing details of the structures of filtering blebs at the cellular level, in vivo confocal microscopy constitutes a new promising way to understand wound healing mechanisms after filtering surgery.

Complications des gestes interventionnels percutanés sous contrôle radioscopique, échographique ou scanographique

The purpose of this article is to describe potential complications following the most common image-guided (fluoroscopy, ultrasound or CT) percutaneous interventional procedures, both diagnostic and therapeutic, thoraco-abdominal and musculoskeletal, as well as to review risk factors and the best practice recommendations. Prior to any interventional procedure, it is necessary to ascertain the absence of any abnormality in coagulation, to secure enough time to explain the procedure to the patient, and to adhere to strict sterile technique. Indeed, infections and hemorrhagic complications are the principal causes of mortality and morbidity for all procedures. Following lung biopsy, CT scan detects an immediate pneumothorax in 30% of patients. Major complications following percutaneous liver biopsy occur within 3 to 6 hours. Following a percutaneous drainage, complications occur in less than 10% of cases. Following a radiofrequency thermal ablation of malignant tumors, the mortality rate is low (0,5 to 1,4%), infection and hemorrhage are the most frequent complications. While rare, septic arthritis is the main complication that can follow musculoskeletal procedures and is a cause of medical malpractice lawsuits brought by patients.

High frequency of bone/bone marrow involvement in advanced medullary thyroid cancer

High hematological toxicity has been observed with anti-carcinoembryonic antigen radioimmunotherapy (RIT) in medullary thyroid carcinoma (MTC), suggesting metastatic bone involvement (BI). This retrospective study evaluated the rate of BI in MTC patients enrolled in two phase-I/II RIT trials using anti-carcinoembryonic antigen x anti-diethylenetriamine pentaacetic acid bispecific antibodies and [(131)I]di-diethylenetriamine pentaacetic acid hapten. Thirty-five patients underwent bone scintigraphy, bone magnetic resonance imaging (MRI), and post-RIT immunoscintigraphy (IS). IS performed in MTC patients was compared with IS conducted in 12 metastatic colorectal carcinoma (CRC) patients. Quantitative analysis of bone uptake was performed in three MTC and three CRC patients. In the MTC group, bone scintigraphy detected BI in 56.6% of patients, MRI in 75.8%, and IS in 88.6%. BI was confirmed by undirected (random) bone marrow biopsy, by bone surgery, or by two positive imaging methods in 74.3% of the patients. Sensitivity per patient of bone scintigraphy, MRI, and IS were 72.7, 100, and 100%, respectively. In contrast, IS visualized BI in only 33.3% of CRC patients; bone uptake was lower in CRC than in MTC patients. Bone MRI combined with post-RIT IS disclosed a much higher BI rate in advanced MTC than previously reported in the literature.

Efficacy and safety of 0.18% sodium hyaluronate in patients with moderate dry eye syndrome and superficial keratitis

BACKGROUND

Sodium hyaluronate (SH) is used in patients with dry eye. We evaluated the efficacy and safety of SH and carboxymethylcellulose (CMC) in the treatment of dry eye syndrome with superficial keratitis.

METHODS

A total of 22 patients with moderate dry eye and superficial keratitis were enrolled in a prospective, randomised, masked-observer, parallel-group, single-centre study. Patients were randomly assigned to a 0.18% SH or 1% CMC solution for a 2-month period. In addition to the commonly assessed parameters in patients with dry eye (among others symptoms and corneal staining with fluorescein), flow cytometry analysis of CD44, HLA DR expressions in impression cytology was investigated as a potential efficacy parameter.

RESULTS

Both treatments improved the symptoms and ocular surface and were well tolerated. SH significantly (p<0.05) decreased CD44 values compared with CMC. Comfort was significantly (P<0.05) better in the SH group than that in the CMC group throughout the study. Recovery in keratitis (type, extent and depth) and symptoms were faster in the SH group than in the CMC group. Blurred vision was reported by patients in the CMC group only.

CONCLUSIONS

SH was well tolerated and tended to show a faster efficacy than did the CMC-based formulation in patients with moderate dry eye and superficial keratitis. SH could therefore advantageously be prescribed from the early stages of dry eye disease. This study also showed that flow cytometry in impression cytology specimens is a reliable tool for exploring the ocular surface at the epithelial level and that CD44, in addition to HLA DR, could be an interesting endpoint for future trials in dry eye syndrome with products based on SH.

Étude en microscopie confocale in vivo des bulles de filtration après chirurgie du glaucome

PURPOSE

To describe blebs after filtering surgery with a new in vivo confocal microscope.

METHODS

We retrospectively evaluated 20 filtering blebs of 17 patients after trabeculectomy or deep nonpenetrating sclerectomy. Ophthalmological examinations included slit-lamp examination, applanation tonometry and in vivo confocal microscopy imaging (Heidelberg Retina Tomograph II Rostock Cornea Module). Eyes were classified into three groups: filtering blebs (eight eyes), nonfiltering blebs that were encapsulated or flat (seven eyes) and filtering blebs with mitomycin C (five eyes). In vivo confocal microscopy images were compared to the morphological and functional aspects of filtering blebs.

RESULTS

Filtering blebs had numerous intraepithelial microcysts, whereas nonfiltering blebs had none or few. However, few microcysts were seen in the encapsulated filtering blebs. The connective tissue of filtering blebs was arranged loosely, whereas it was dense in nonfiltering blebs. Filtering blebs with mitomycin C had numerous microcysts and loosely arranged subepithelial connective tissue.

CONCLUSION

By evaluating filtering blebs at the cellular level, this original method is highly consistent with ex vivo histological examination. In vivo confocal microscopy constitutes a new promising way to understand the wound healing mechanism in filtering surgery.

Intérêt du microscope confocal cornéen in vivo HRT2 pour l’étude de l’épithélium cornéo-conjonctival

PURPOSE

To show the advantages of the in vivo HRT2 confocal microscope corneal module for studying the superficial and peripheral corneal and conjunctival epithelia.

MATERIAL AND METHODS

We examined 15 patients whose superficial cornea was healthy and ten patients with keratoconjunctivitis sicca and/or rosacea. Some conjunctival imprints where taken on patients with superficial ocular disease and examined by immunofluorescence.

RESULTS

We found superficial corneal epithelial cells, corneoconjunctival Langerhans and dendritic cells, goblet cells, limbic epithelial junction, new blood vessels, as well as deeper corneal structures such as Bowman's membrane, keratocytes, corneal nerves, and endothelium. We also observed pathological corneal epithelium in keratoconjunctivitis sicca and substantial inflammatory and vascular changes in rosacea. In two cases of stem cell deficiency associated with rosacea, we observed goblet cells in the corneal epithelium. An interesting anatomical-clinical parallelism between in vivo confocal microscopy images and those obtained by ex vivo immunofluorescence was observed.

DISCUSSION

Central corneal pictures after explorations by in vivo HRT2 confocal microscopy are similar to those obtained with standard confocal microscopy. But conjunctiva, peripheral cornea and limbus are better examined at the surface and at medium depth with the HRT2. Diagnosis and therapy of superficial corneoconjunctival and limbal diseases are therefore made easier in vivo.