[Intrapalpebral migration of a form stable contact lens: a rare complication in contact lens practice]

PURPOSE

To demonstrate a rare complication in contactology.

CASE REPORT

A 26-year-old female had "lost" her hard contact lens in the right eye 2 years previously. Afterwards, new contact lenses were not tolerated. The patient had a slight intermittent epiphora but no further complaints. She consulted her ophthalmologist for new spectacles. At presentation, there was a firm tumour without signs of inflammation in the right upper lid area. When the lid was everted a hard contact lens was found within the tarsal plate which could be easily removed in the operating room. Microbiologic investigation disclosed no bacteria. Histology showed a circumscribed papillary reaction and a chronic non-specific inflammation with few eosinophils and no giant cells. Two weeks later the lens-related cavity was only slightly filled up by granulation tissue.

CONCLUSIONS

After "loss" of a contact lens superior dislocation and finally tarsal implantation should be kept in mind. The process of contact lens migration reveals some interesting features: 1. Generally, it causes only minor symptoms though it may last for years. 2. Bacterial contamination rarely occurs. 3. Histologically, the inflammation is often mild or even absent. Eosinophils and giant cells are of minor or no importance indicating that allergy and giant-cell reaction play no significant role. 4. The lens related cavity probably heals slowly, possibly because of a (partial) epithelialization.

[Accidental retinectomy in block excision for cystic epithelial ingrowth]

A 3.5-year-old girl suffered from a penetrating injury of the left eye. One and a half years later epithelial ingrowth was detected. Although block-excision was performed in the usual manner without technical problems the retina was excised accidentally. Histology revealed that the retina had been massively displaced in anterior direction prior to surgery because of fibrovascular proliferations.

[New clinical and epidemiologic aspects of episcleritis and scleritis]

Numerous systemic diseases can cause scleritis or episcleritis. Frequently, symptoms and complications compromising vision can only be managed with systemic immunosuppressants. There are no clear guidelines on the indications for systemic immunosuppressants in patients with episcleritis and scleritis.

PATIENTS AND METHODS

The aim of the present retrospective study was to investigate how many patients with episcleritis or scleritis have an associated systemic disease and at what stage it is diagnosed. Secondly, the proportion of patients who present with episcleritis or scleritis in the first instance and then change into the other category during the course of the disease was analyzed. Finally, we checked whether the presence of an associated systemic disease indicates the necessity to treat the patient with nonsteroidal systemic immunosuppressive drugs.

RESULTS

Sixty-eight patients with inflammatory scleral diseases were treated at the University Eye Clinic between 1991 and 1995. In 13 patients an associated systemic disease was diagnosed before the appearance of ocular symptoms, and in 8 patients such an illness was diagnosed at a later stage. In 2 cases (3%) the ocular disease category changed during the course of the disease. Neither in the episcleritis nor in the scleritis population was a statistically significant correlation established between the diagnosis of an associated systemic disease and the necessity to treat the patient with nonsteroidal systemic immunosuppressive drugs.

CONCLUSION

The small number of patients who changed the ocular disease category may indicate that episcleritis and scleritis are two independent entities, which might even be caused by different mechanisms. The indications for the management of episcleritis and scleritis with immunosuppressive drugs should not only depend on the diagnosis of an associated systemic disease, but also and mainly on the severity of the ocular manifestation.

[Ocular pathology of child abuse]

BACKGROUND

In spite of a growing awareness in the population most cases of child abuse remain probably undetected. Ocular changes in this syndrome are manifold. Sometimes ocular signs can help to substantiate the suspicion of child abuse. On the other hand the ophthalmologist may be the first physician to be contacted. Thus, he plays an important role in diagnosis. Though there are a couple of clinical descriptions morphological data are almost completely missing in the German literature.

PATIENT

A two-year-old girl died two days after severe abuse because of widespread intracranial hemorrhages with brain stem insufficiency. At autopsy both eyes were enucleated and sent for histological investigation.

RESULTS

The anterior segments were unremarkable. Multiple hemorrhages were found in the inner retina bilaterally. Moreover there were preretinal, intrachoroidal, intrascleral (area of the circle of Zinn-Haller) and subdural hemorrhages. One eye showed a circular, perimacular fold of the central retina and a hemorrhagic retinoschisis.

CONCLUSIONS

Intraretinal hemorrhages alone are typical though not pathognomonic for the "battered-child syndrome". However, in combination with a crater-like appearance of the central retina, a hemorrhagic retinoschisis; and intrascleral hemorrhages in the area of the circle of Zinn-Haller they suggest child abuse almost with certainty. The pathogenic mechanisms leading to the observed fundus changes lack definite clarification. The date of violence which is essential for legal prosecution can be difficult to evaluate on morphological grounds alone.

[Insufficiency of a frontalis loop]

After 13.5 years in vivo a 2-0 Terylene frontalis loop was excised because of an insufficiency. Histology showed a persisting giant cell reaction while lymphocytes were almost totally absent. The fibrils of the suture seemed to be intact. However, they were separated by ingrowing connective tissue which, on theoretical grounds, should improve the function of the frontal muscle on the upper eyelid. Therefore, insufficiency of the loop was probably caused by the (subclinical) foreign body reaction or the long-lasting mechanical stress leading to tissue damage.

[Pericorneal vascular changes as an expression of systemic vascular processes]

BACKGROUND

To evaluate the extent of morphological changes of the perilimbal vessels of the conjunctiva in patients with general vascular disorders.

MATERIALS AND METHODS

With a questionnaire systemic vessel diseases were investigated in 285 patients (m:f = 145:140; mean age = 54 +/- 19 years) with pericorneal vessel alterations. Persons without any morphological alteration of the perilimbal vessels served as control group (n = 58; m:w = 44:14; mean age 26 +/- 13 years).

RESULTS

In the patient group we found the following pericorneal vessel alterations: vessel ectasia in 79%, vessel aneurysm in 41%, vessel interruptions in 37% and avascular regions in 12%. The distribution of the three most frequent systemic vascular processes in the patient/control group was: peripheral vascular spasm (cold hands and/or feet) in 57%/19%, migraine in 39%/14% and arterial hypertension in 33%/3%.

CONCLUSION

Alterations in perilimbal vessels seem to be correlated with systemic vascular disorders. In case of perilimbal vascular anomalies an internal medical examination should be considered.

[Massive foreign body reaction after intraocular penetration of hot, liquid plastic]

PATIENT

A 32-year-old male had an injury of his right eye by hot liquid plastic (Ultradur R). Intraoperatively, the eye was found broadly penetrated and filled up by more than 50% with ragged pieces of plastic. Computed tomography three days after wound closure revealed remaining foreign body material. As function was totally lost no further operation was considered. Seven weeks after the trauma, the eye was enucleated because of a painful phthisis. Histology showed numerous giant cells.

CONCLUSIONS

Hot liquid plastic may perforate the eye and fill it up to a great extent. Due to intraocular cooling, pieces with sharp edges may develop, thus producing further (mechanical) tissue damage. Intraocular plastic is able to induce a massive foreign body reaction. It may be detected easily by computed tomography.

[Cutaneous T-cell lymphoma of the mycosis fungoides type in the area of the eyelid and lacrimal ducts]

PATIENT

A 62-year-old former miner with silicosis of the lungs but otherwise in good general condition presented with a solid nodule in the nasal left lid area for a duration of three months. Because of a central ulceration the reference diagnosis was basalioma. The tumour infiltrated the nasal part of the upper and lower eyelid and the tear ducts so that these were unrinseable. Similar lesions have been present since two years in other skin regions.

METHODS

Two cutaneous biopsies confirmed the diagnosis of a Mycosis fungoides without detectable expression of the CD30-antigen. Medical investigation finally revealed hepatosplenomegaly and cervical, inguinal and abdominal lymph node involvement. A lymph node biopsy three months after presentation again showed a T-cell-lymphoma which was CD30-positive now.

THERAPY

Systemic polychemotherapy was started. The lid lesions completely resolved, and the tear ducts were rinseable again.

Traumatic wound dehiscence after penetrating keratoplasty

BACKGROUND

Traumatic wound dehiscence after penetrating keratoplasty is probably underestimated.

PATIENTS

From the files of the University Eye Hospital Tübingen (1981-1993), 15 patients with a traumatic wound dehiscence after penetrating keratoplasty were investigated.

RESULTS

Latency between corneal grafting and wound rupture ranged from 1 month to 25 years (mean 6.2 years). Wound dehiscence was quite evenly distributed over the circle. Intraocular tissue was lost to a variable extent. Three eyes were primarily or secondarily enucleated. Seven eyes (47%) with an originally reduced but useful vision became blind or were removed. Most (67%) of the resutured grafts lost transparency.

CONCLUSIONS

Traumatic wound dehiscence is a serious and not very rare complication after penetrating keratoplasty. Functional results are poor.

[Age-adjusted normal values with the Tübingen Automatic Perimeter TAP 2000 CC]

BACKGROUND

Evaluation of perimetric results requires a comparison with age-corrected values for the assessment of discrete light sensitivity changes. This is especially true in recording incipient glaucomatous visual field defects. The aim of the present study was to establish age-corrected normal values with the Tübingen Automatic Perimeter.

METHOD

A test group (n = 85) of ophthalmologically and clinically unremarkable subjects 18-70 years of age was examined. The criteria for exclusion from the study were glaucoma or hereditary eye disease in an immediate family relative, diabetes mellitus, unstable or manifest hypertonia, multiple sclerosis, convulsive disorders, a previous stroke, or the use of psychoactive drugs. A brief introductory program was used to familiarize the test person, together with a threshold program for values in the central visual field. In addition, the peripheral visual field was examined. The threshold-splitting program of the Tübingen Automatic Perimeter 2000cc was used for examinations. RESULTS/DISCUSSION. Age-related normal values were calculated both as regression lines and group averages by statistical analysis of the resulted data. Surprisingly, the decrease found in people 20-70 years of age was in the center with 0.5 dB clearly smaller than at the periphery with 4-6.5 dB. Details of the evaluation are described.

Leaving the eyelid to its own devices

As oculoplastic surgery is preferred for direct closure of lid defects, spontaneous wound healing after excision of lid tumors is not common. Thus, spontaneous reformation of lid defects as an alternative treatment to surgical procedures was investigated. In 12 patients with a clinical diagnosis of basal-cell carcinoma, lid tumors were removed surgically by full-thickness excision in 1 group (n = 6) or cutaneous excision only in the other group (n = 6). The mean follow-up period was 5 months in the first group and 9 months in the second group. Cosmetic and functional results were satisfactory in all patients. The scar tissue simulated the former tarsus. The wounds were completely covered by a normal-appearing epithelium. Spontaneous wound healing may lead to considerable stiffness of the lower lid and to an acceptable reformation of the lid margin. There was no elevation of the lid margin and, remarkably, no secondary surgery due to an entropion or an ectropion was necessary.

[Autologous conjunctiva-limbus transplantation in treatment of primary and recurrent pterygium]

The aim of the present study was evaluation of the efficiency of limbal autograft transplantation for primary and recurrent pterygia. The results of limbal autograft transplantation for advanced and recurrent pterygia are presented for 58 eyes of 50 patients. The pterygia were primary in 40 eyes and recurrent in 18 eyes. Free grafts from the superotemporal limbus of the same eye were used to cover the exposed sclera. Postoperative followup ranged from 2 to 26 months, with a mean of 13 months. The overall recurrence rate was 31% (22.5% in primary pterygia and 50% in recurrent pterygia). Recurrence rates were significantly higher in patients from southern Europe than in patients from northern Europe. Analysis of patients with recurrences (n = 18) revealed severe tear film abnormalities in eight cases. Seven patients were found to have transplants of insufficient size. Analysis of our results provides evidence that the experience of the surgeon is crucial for the success rate of this procedure. Three of six surgeons with limited experience had a recurrence rate of 50% or more. Additionally, 15 patients who developed recurrent pterygium had returned to unfavourable working conditions (e.g. dust, heat). Three of the 18 recurrences underwent repeated limbal transplantation and in one of these there was a further recurrence.

[Varicose vein of the iris]

A 56-year-old man presented with a pigmented iris nodule which showed prominent vessels and enlargement within 6 weeks. The tumour caused recurrent hyphemata. Differential diagnosis included a pigmented iris hemangioma and a malignant melanoma. A sectoriridectomy was performed. Histology revealed a stromal cavity filled with fibrin and abundant erythrocytes. A diagnosis of an iris varix was established. However, it has to be pointed out that the distinction between a varix of the iris and an iris hemangioma may be difficult not only clinically but also histologically, and that iris melanomas may produce hemangioma-like patterns.

[Biological corneal replacement--an alternative to keratoplasty and keratoprosthesis? A pilot study with heterologous hyaline cartilage in the rabbit model]

BACKGROUND

In patients with corneal opacity caused by diseases like okular pemphigoid, Stevens-Johnson-Syndrome or burns, visual rehabilitation can only be achieved with keratoplasty or keratoprosthesis. The first has generally a poor prognosis in these circumstances, and the latter bears several problems in the postoperative course as well. A biological, corneal replacement could possibly combine the advantages offered by keratoplasty (no interaction between host tissue and plastic) and keratoprosthesis (more permanent transparency). Theoretical considerations and practical experience suggest that the best candidate would be hyaline cartilage.

MATERIAL AND METHODS

Bovine sterni were used to obtain circular cartilage slices which were approximately 60 microns thick, having a diameter of approximately 6 mm. These slices were implanted in one eye each of 4 rabbits instead of the natural cornea. The eyes were enucleated after 8 to 29 days.

RESULTS

The cartilage remained so transparent that the iris and to a certain extent the fundus blood vessels could be visualized. Connective tissue served to bind the host cornea to the cartilage, but did not infiltrate the cartilage. Perforation was observed in 3 animals. The extent of epithelialization of the cartilage slices ranged form ca. 30% to 95%. None of the animals exhibited an intraocular inflammation. The cartilage did not proliferate and remained avascular. Secondary intraocular changes, with the exception of anterior synechiae, could not be detected.

CONCLUSIONS

A tissue for biological corneal replacement has to fulfill many requirements which to a certain extent can be achieved with the use of hyaline cartilage. Despite numerous, unsolved problems, a biological corneal replacement as an alternative to keratoplasty and keratoprosthesis in cases of corneal blindness does not seem out of imagination.

[Cogan I syndrome: too often detected too late? A contribution to early diagnosis of Cogan I syndrome]

BACKGROUND

Cogan's syndrome is an uncommon disease characterized by ocular inflammation, vestibuloauditory dysfunction and symptoms of systemic disease. The etiology is unknown, however there is evidence for an autoimmune pathogenesis. The "typical" Cogan's syndrome presents as bilateral interstitial keratitis and progressing vestibuloauditory dysfunction. The presence of other inflammatory manifestations in addition of keratitis has been termed as "atypical" Cogan's syndrome.

PATIENTS

We report on six patients presenting with typical as well as atypical ocular manifestations between 1982 and 1994. Typically, the illness was accompanied by systemic symptoms. Each patient had audiovestibular involvement, that was the initial presentation in 4 cases. Vestibular dysfunction often preceded hearing loss. Five of our patients not only presented with keratitis but also demonstrated signs of ocular inflammation diagnosed as scleritis or episcleritis. In two patients these ocular symptoms were the first signs of Cogan's syndrome, recurred periodically and did not respond to corticosteroids.

RESULTS

In 3 patients that were diagnosed early and treatment with corticosteroids was initiated early, hearing could be stabilized, in the remaining patients total bilateral deafness could not be prevented.

CONCLUSION

The importance of being aware that vestibuloauditory dysfunction may occur in patients with ocular inflammation, and the fact that early immunotherapy may prevent the risk of deafness, has to be emphasized.

[Allergic granuloma of the conjunctiva (Splendore-Hoeppli phenomenon)]

A 35-year-old woman from Georgia presented with multiple bilateral yellow nodules of the upper bulbar conjunctiva, accompanied by a severe injection of conjunctival vessels. The histologic examination of excisional biopsies showed the characteristic morphology of the Splendore-Hoeppli-phenomenon, which describes granulomas with a necrotized eosinophilic center, surrounded by a ring of epitheloid cells, giant cells and eosinophils. Although nematodes could be identified in only a few lesions, they should always be kept in mind as the causing agent of this condition. No cause of the lesions was found in our patient. The nodules may regress spontaneously. Topical application of corticosteroid eye drops, however, may give relief of symptoms, and sometimes excision of the granulomas will be necessary.

[Tarantule hairs as corneal foreign bodies]

A 22 year-old-man and owner of several tarantulas visited his ophthalmologist because of red itchy eyes. Additionally to kerato-conjunctivitis epidemica, uncommon hairs were found especially in his left cornea. Corrected visual acuity was 0.8. According to literature these spider hairs can induce granulomas in the meaning of ophthalmia nodosa, and even migrate inside the eye. Therefore we removed as many hairs as possible, but we left two, not to cause iatrogen perforation. The penetration depth was measured by laser tomography. Local steroids successfully prevented further granuloma formation. Regular ophthalmological controls are important to early detect possible changes, and if necessary to remove these hairs even from deeper corneal layers, in case by keratectomy.

Sudden increase in intraocular pressure as an initial manifestation of myelodysplastic syndrome

PURPOSE/METHODS

We studied a rare initial manifestation of myelodysplastic syndrome in an 82-year-old woman who had acute secondary glaucoma in the right eye and mature cataracts in both eyes.

RESULTS/CONCLUSION

Therapy with glaucoma control medications and cataract extraction in the right eye resulted in expulsive hemorrhage and subsequent enucleation of the right eye. After cataract extraction, examination of the left eye disclosed a central serous retinal detachment and hemorrhage. Histopathologic analysis of the right eye demonstrated myelocytic and lymphocytic infiltration.

[Benign concentric annular macular dystrophy]

In routine eye examination of a 32-year-old male patient an annular macular dystrophy was noted in absence of distinctive visual complaints. Visual acuity was 20/20, the photopic and scotopic electroretinograms were normal. The ring scotoma in perimetry and the macula finding in ophthalmoscopy corresponded to the fluorescein angiographic pattern. Color vision deficiency was only mild without any predominant axis of confusion. Benign concentric annular macular dystrophy is rarely described in literature. Differential diagnosis includes all 'bull's eye' conditions.

[Corneal manifestations in Vitamin A deficiency]

BACKGROUND

Vitamin A, the fat soluble vitamin, must be supplied orally before resorption in the mucosa of the small intestine and storage in the liver. Vitamin A deficiency can cause alterations in the anterior segment of the eye, from Bitot spots, which are reversible, to irreversible keratomalacia.

PATIENTS AND METHODS

5 patients suffering from manifestations at the cornea underwent ophthalmological, general and dermatological investigation and measurements of the vitamin A, retinol-binding protein and, in one patient, zinc were performed. 4 patients suffered from cornea manifestations, reaching from almost a reactive ulceration to spontaneous perforation. One patient had relapsing episcleritis. All patients were alcoholics, had hepatopathies and dermatological diseases. Vitamin A and retinol-binding protein were decreased and in one patient a highly decreased zinc was measured. In one patient a systemical and local substitution of vitamin A increased the clinical findings significantly. Two eyes had to undergo a keratoplasty à chaud, one evisceration had to be done.

CONCLUSION

Vitamin A deficiency can be the reason for bilateral painless cornea manifestations. An interdisciplinary cooperation is essential for the elaboration of the diagnosis and the treatment.

[Diffuse xanthogranuloma as a cause of infantile heterochromia]

A 7-month-old female infant presented with a heterochromia and an anisocoria. A spontaneous hyphema and a secondary glaucoma had developed. Under topical and systemic steroid therapy the eye improved continuously. At the time of the last ocular examination the hyphema had resorbed, and the intraocular pressure was normal. Heterochromia had almost completely vanished, and dilation of the pupil was much better. Since even a massive juvenile xanthogranuloma of the iris responds well to steroids, operative and radiation treatment should be limited to cases refractory to antiinflammatory drug therapy.

Premetastatic uveal melanoma cells do not express laminin receptors

Interactions between extracellular matrix and tumor cells are of great importance for tumor cell invasion. They are mediated by cellular surface receptors (integrins). As the glycoprotein laminin enhances invasion in some neoplasms and as the expression of laminin receptors is sometimes correlated with the invasive activity, the tumor cell-laminin receptor-laminin cascade could play a key role in melanoma cell spread as well. We therefore investigated 12 uveal melanomas with a monoclonal anti-laminin-receptor antibody. In all, 9 tumors demonstrated no reaction and 3 exhibited just a partial and slight reaction. Endothelial cells within the melanomas were laminin-receptor-positive. As laminin is found primarily in basement membranes, laminin receptors are expressed mainly by cells in contact with these structures, e.g., endothelial, epithelial, and carcinoma cells. The nonepithelial uveal melanomas, which produce only little basement membrane material, if any, seem to have no need for laminin receptors, at least provided that basement membranes do not have to be traversed. As a result, laminin receptors are not expressed.

[Meningioma of the optic nerve sheath with extensive intraocular growth]

PATIENT

We report on an elderly female patient with a diagnosis of an optic nerve sheath meningioma 11 years after onset of ophthalmological symptoms. 8 years after diagnosis and consecutive tumour-resection near the orbital apex the eye had to be enucleated because of a painful secondary glaucoma. Prior to enucleation computed tomography had revealed extra- and intraocular tumour.

MORPHOLOGY

Morphological investigations showed a neoplasia which had entered the eye via the optic nerve head. Besides severe secondary changes there was a diffuse tumour spread within the choroid and a "mushroom-like" growth towards the vitreous cavity. No differences between extra- and intraocular meningioma were found light- and electronmicroscopically.

[Stromal iris cyst]

A 50-year-old female developed a cyst of the iris stroma in her right eye. Because of slight enlargement within 10 weeks sector iridectomy was performed. Histology showed that the cyst was lined by a cellular layer resembling conjunctival or corneal epithelium. The benign clinical course (normal function, normal intraocular pressure and no recurrence after 4 years) and the intrastromal rather than epistromal localization hold evidence for a spontaneous origin. Spontaneous cysts of the iris stroma especially in adults are rarely described in the literature. The question still to be answered is whether these lesions are really spontaneous in origin or whether they represent only an intraocular epithelial invasion due to an occult perforation of the eye.

[The role of melatonin in growth of malignant choroid melanoma]

Increasing evidence of the immunomodulatory and tumor-depressing effects of melatonin prompted us to study altered concentrations of this multifunctional pineal hormone in the aqueous humor of eyes with melanoma. Eyes undergoing cataract surgery served as controls. First, RIA was used for the detection of melatonin (5 melanoma and 8 control eyes). In a second series we used ELISA with a newly developed antibody (6 melanoma and 11 control eyes). Moreover, the supernatant media of cultured melanomas were investigated for melatonin. We cautiously interpret the results as follows: (1) in the morning melatonin is detectable in the human aqueous humor at a concentration of ca. 35 pg/ml; (2) as blood serum and aqueous humor levels did not correlate, melatonin is probably actively secreted by the ciliary body rather than passively filtrated; (3) there are no significant changes in melatonin concentration in the aqueous humor of melanoma eyes; this, however, does not mean that melatonin does not play a role in uveal melanoma growth; (4) cultured uveal melanoma cells can probably synthesize melatonin.

Significance, specificity, and ultrastructural localization of HMB-45 antigen in pigmented ocular tumors

PURPOSE

To evaluate the expression of the monoclonal HMB-45 antibody in melanocytic and nonmelanocytic ocular tumors and seek "activated" cellular subpopulations in an attempt to distinguish between benign and malignant melanocytes, to compare HMB-45 and S100 activity, and to determine the specificity of this tumor marker for melanocytic ocular lesions.

METHODS

Immunohistologic investigations were performed with paraffin-embedded tissue of 10 acquired conjunctival melanoses, 19 conjunctival nevi, 34 conjunctival melanomas, 69 uveal melanomas, 20 basal cell carcinomas of the lid, 20 cystic dermoids, 15 hemangiomas of the lid, 20 conjunctival papillomas, 20 squamous cell carcinomas, 20 pterygia, 11 sebaceous gland carcinomas, 10 retinoblastomas, and 5 choroidal metastatic carcinomas. The avidin-biotin peroxidase technique and monoclonal HMB-45 antibody were used. The distribution of S100 protein was studied in the melanocytic tumors for comparison. To localize the HMB-45 antigen, lowicryl-embedded tissue of uveal melanomas was investigated immunoelectron microscopically.

RESULTS

More than 95% of the conjunctival and choroidal melanomas expressed the HMB-45 antigen, while S100 was found in all melanomas of the conjunctiva and in 91% of the uveal melanomas. In benign melanocytic lesions of the conjunctiva (nevi and melanocytes), especially the intraepithelial and junctional components stained with HMB-45, and at the site of tumor invasion, infiltrating cells showed increased HMB-45 reactivity. On the whole, HMB-45 antigen was less evenly distributed in the melanocytic tumors investigated than S100 antigen. All nonmelanocytic ocular tumors revealed no HMB-45 expression. Retinal pigment epithelium and tumor-free choroid were negative for HMB-45. The HMB-45 antigen was immunoelectron microscopically found in melanosomes at stages II and III.

CONCLUSION

HMB-45 immunohistology helps in distinguishing melanocytic from nonmelanocytic ocular tumors and often clarifies the front of tumor invasion. The stronger HMB-45 reactivity probably reflects melanocytic activation, but a sharp line between benign and malignant melanocytes cannot be drawn.

[Changes in the invasion front of uveal melanomas]

Central and peripheral cells of 12 uveal melanomas were compared by electron microscopy to determine whether infiltrating melanoma cells have special characteristics (e.g., loss of cell adherence, changes in the cytoskeleton, increase of cell organelles). No significant differences were found. The two theories of tumor invasion ("mechanical" and "locomotive" theory) and the light microscopical findings that occur in the invasion zone of uveal melanomas are discussed.

[125 years ophthalmopathology in Tübingen. Change in the times and spectrum of findings]

The beginning of ophthalmopathological activities at the University Eye Clinic Tübingen, Germany, can be dated back to the year 1868, as at this time the continuous counting of investigated, ophthalmological specimens was started. So the ophthalmopathological department in Tübingen will be 125 years old in 1993. In a review its history is described with particular regard to the first period and the change in the kind and frequence of diagnoses.

[Transient, prolonged, combined sicca syndrome of the eyes and mouth. Occurrence along with a common cold in an 8-year-old girl]

A girl of eight years fell ill with signs of common cold and bronchitis. Already on the second day of illness, before any treatment was started, she showed symptoms of a sicca-syndrome, beginning in the eyes, later the mouth. Ophthalmologic examination showed keratitis filiformis, histology of the salivary glands in the mucosa of the mouth was normal. Local substitution therapy led to subjective improvement. The disorder of secretion persisted for four months only, then rapid restitutio ad integrum of tears and saliva production occurred. Pathogenetically a parainfectious immunologic mechanism seems probable. During the observed period there were significant changes of antibody titers against RS-virus and streptococci, but it is not possible to identify the cause of the illness really. We conclude that a sicca-syndrome with normal histology of mouth-mucosa-glands is not necessarily prognostically infavorable.

[Surgical treatment of hyperplastic persistent pupillary membrane]

Clinical findings of two patients with persisting pupillary membranes are described and therapy is discussed. The indication for excision of the pupillary membrane was constituted in one patient (age 6 weeks) by complete occlusion of the optic axis, in the second (age 4 months) by absence of any recordable fixation. In both cases the pupillary membrane could be separated from the anterior lens capsule without lens damage. No strabismus or lens opacification were detected postoperatively. Surgery was undertaken with the intention of avoiding primary lentectomy, since pupillary membranes can usually be separated easily from the anterior lens capsule with viscoelastic substances.

[Metastatic eyelid tumors--description of clinical aspects and histology based on three cases]

Clinical findings and histology of secondary lid tumors are described by example of three cases. The rare lid metastases appear mainly in three different patterns. Except cytology, which depends on the primary tumor, their morphology is quite uniform. Lid metastases of a cutaneous melanoma, a contralateral uveal melanoma and, probably reported for the second time, a leiomyosarcoma are presented.

[Monoclonal antibody HMB-45 in diagnosis of intra-ocular melanoma]

69 eyes, which had to be enucleated because of an uveal melanoma, were investigated immunohistologically. HMB-45-antigen, which is supposed to be highly specific for melanocytic tumours, was found in 68 cases (sensitivity 99%) with a monoclonal antibody. S 100-antigen was positive in 63 cases (sensitivity 91%) using a polyclonal antibody. The addition of HMB-45-immunohistochemistry to routine histological diagnostic procedures is valuable, when a non-melanocytic uveal tumour cannot be ruled out or when the degree of melanoma-invasion has to be determined with greater accuracy. At the site of melanoma-invasion changes of cellular reactivity seem to occur, as 11 of the 69 studied tumours (16%) showed an increased HMB-45-expression in this area. HMB-45-antigen was detectable even in paraffin embedded material obtained from eyes enucleated 30 years ago.

[Distribution of melanoma-associated antigens (HMB 45 and S 100) in benign and malignant melanocytic tumors of the conjunctiva]

The reactivity of the monoclonal antibody HMB 45 was evaluated in melanocytic tumors of the conjunctiva. Among these are 10 acquired melanoses, 19 nevi and 34 melanomas. Results were compared with the presence of the S 100 antigen. Especially the intraepithelial and junctional components of primarily benign lesions were stained with HMB 45. Within malignant melanoma this antibody reacts with melanocytes in the epithelial, junctional and subepithelial areas. The polyclonal antibody S 100 stains all melanocytes in pigmented lesions of the conjunctiva. Intraepithelial or subepithelial malignant infiltrating tumor cells show very intense staining with HMB 45. HMB 45 has therefore high specificity for stimulated melanocytes, but it does not distinguish benign and malignant proliferating melanocytic cells.

Paraproteinemic corneal deposits in plasma cell myeloma

We treated two patients who had IgG-kappa-light chain monoclonal gammopathy with partially crystalline and partially amorphic corneal deposits. Impairment of vision made keratoplasty necessary for each patient. Histologic examination of the corneal specimens showed deposits that stained positively for Masson's trichrome in all corneal cells. Immunohistochemical tests identified these deposits as IgG-kappa-light chain immunoglobulin fragments. Electron microscopy showed intracellular, rhomboid-shaped deposits enveloped by a membrane. The same deposits appeared in the conjunctival epithelium, within subconjunctival fibrocytes, and in the plasma cells of the bone marrow. Immunoelectrophoresis showed IgG-kappa-light chain fragments in the blood serum, the lacrimal film, and the aqueous humor. This suggests that the intracellular immunoglobulin fragments may have entered the corneal and conjunctival epithelium by way of the lacrimal film, the keratocytes by way of the corneo-scleral limbus vasculature, and the endothelial cells from the aqueous humor.

Primary extraskeletal mesenchymal chondrosarcoma of the lid

A 15-year-old girl presented with a painless nodule in the nasal lower-lid portion of the left eye at the beginning of 1989. The tumor was excised in March 1989, and the histopathologic diagnosis was - erroneously - a chondromatous choristoma of the lid. The tumor recurred within several weeks. Another excision was performed, which led to the diagnosis of a malignant mesenchymal chondrosarcoma of the lid. Histopathology revealed the typical bimorphic pattern, with well-differentiated chondrocytes being surrounded by small anaplastic cells. The tumor cells stained positive for S100-protein and vimentin, were negative for cytokeratin and were studied ultrastructurally. Radical excision and adjuvant chemotherapy were performed in our patient; at 18 months after the onset of tumor growth, she is free of local or general tumor recurrence. To our knowledge, primary mesenchymal chondrosarcoma has not previously been described in the lid area.

[Cysts and Fuchs' endothelial adenomas of the pars plicata corporis ciliaris--degeneration products as an expression of various ciliary body functions?]

The pars plicata of the ciliary body of 24 eyes was investigated by light microscopy in frontal serial slides. All eyes were normal macroscopically and all anterior segments revealed no signs of inflammation or tumor microscopically. A typical Fuchs' adenoma was found in three cases (12.5%). Cysts of the ciliary epithelium had a 75% frequency (18/24 eyes). Cyst formation occurred most often within the unpigmented epithelium and between the ciliary processes. It may start before birth. A higher frequency of ciliary epithelial cysts in elder patients could not be verified. Pathogenesis of cystic lesions of the pars ciliaris retinae is discussed. To our opinion Fuchs adenomas and the frequent ciliary epithelial cysts of the pars plicata are end-stage degenerative products due to the secretory and accommodative activities of the ciliary body.

Postmortem preservation of ganglion cells in the human retina. A morphometric investigation with the carbocyanine dye DiI

Postmortem morphometric investigation of autopsy material is helpful for understanding the alterations cells undergo during life. The present work was undertaken to determine the morphologic features of human retinal ganglion cells during the first 2 days after death. Ganglion cells of 16 retinas were obtained from eyes, the corneas of which had been retrieved for keratoplasties. The ganglion cells were stained with the fluorescent carbocyanine dye Dil and investigated 12 to 36 hours postmortem. All labeled cells identified as ganglion cells had well preserved, type-specific dendritic profiles that made it possible to catalog them according to the established classes of ganglion cells. The various types of cells have in common some typical morphologic changes that occur during the postmortem period of observation: swelling and varicosity in the cell bodies and along the dendritic branches and the axons. These swellings were consistent throughout the postmortem period and did not hinder the identification of particular types of ganglion cells. The two major types (parasol and midget) and various subtypes of ganglion cells were identified morphologically. There are two distinct morphologic types of midget cells which differ from each other in the pattern of dendritic branching. Particular emphasis was given to analyze the dendritic geometry of the large parasol cells. A new finding in the human retina is the frequent presence of large parasol ganglion cells, the axons of which course along aberrant intraretinal paths, especially in the extreme periphery of the retina.

[Epidemiology, invasion and growth of non-iridic choroid melanomas and associated intraocular changes: histologic study of 223 eyes]

223 complete eyes enucleated because of a malignant uveal melanoma were studied histologically to evaluate patterns of growth and invasion and secondary intraocular changes. Eyes with primary iris melanomas or with a previous operation were excluded. The most important secondary changes are the retinal detachment usually responsible for the loss of visual function as well as the direct tumor invasion of the chamber angle and the rubeosis iridis, both able to cause a secondary glaucoma, which is often difficult to treat. The rubeosis iridis increased in frequency with increasing tumor prominence and was in no case combined with preretinal neovascularisations. The growth of malignant uveal melanomas may occur in three directions, i.e. outwards (through the outer envelope of the eye), inwards (towards the vitreous) or in the uveal plane. In any case intraocular borders manifesting different resistance against tumor invasion and thereby influencing prognosis of the disease have to be penetrated. Changes at the front of tumor invasion like loosening of the cellular union and transformation to a higher malignant cell type seem plausible but could not be demonstrated light-microscopically.

[Principles of intraocular ossification exemplified by secondary choroid ossification]

Intraocular ossification seems to follow general pathogenic principles. Ossification requires besides local changes in carbon dioxide tension and local increase of phosphate ions first a rich vascular supply--therefore the peripapillary region is always involved, alone or in conjunction with other sites--and second probably a direct or indirect influence of the Retinal Pigment Epithelium (RPE). The growth of the bone occurs slowly and leads to a relative uniform morphology. Osteogenesis is triggered by chronic intraocular changes (of the RPE), and ossification is almost always combined with a longstanding retinal detachment. The primary lesion (e.g. trauma, inflammation or tumor) plays a minor or no role. Differences between secondary intraocular bone formation (following a well known lesion) and primary choroidal osteomas could be explained by a different strength of the osteogenic (RPE-)stimulus. In the light of our investigations (29 phthitic or chronically hypotonic eyes, 12 of them with intraocular bone formation) and the literature primary osteomas of the choroid have to be interpreted more likely as secondary processes, possibly following a (birth-)trauma, than as congenital choristomas.

Simultaneous bilateral diffuse melanocytic uveal hyperplasia

A 52-year-old woman noted loss of vision in August 1984. Clinical examination disclosed iris cysts and ciliary body cysts, macular edema, and uveal nevi. Cataract extraction and pressure-lowering operations were required in both eyes because of a tumor-induced angle-closure glaucoma. Vision, however, progressively decreased to light perception in each eye. Both eyes were finally enucleated because a malignant melanoma could not be ruled out, though iris tissue obtained in 1985 suggested a nevuslike process. Histologic study indicated a bilateral uveal hyperplasia. Results of light and electron microscopy, immunologic studies, and suspension cell culture suggested that the uveal hyperplasia was more likely a melanoma of low malignancy than a nevuslike process. We could not detect an extraocular primary tumor and assumed that this condition constituted an oncogenic syndrome.

[Ultrastructural changes in the conjunctiva of Cynomolgus monkeys following pilocarpine administration?]

After a slow-release pilocarpine carrier had been applied for three months, the conjunctival epithelium of two Cynomolgus monkeys showed some remarkable changes in the structure and distribution of the cell types as defined by the authors. The goblet cells (Type I) had almost entirely disappeared, whereas the epithelial cells with secretion granules (Type II) had considerably increased in number. The morphology of the Type II cells gave clear indications of a very active metabolism. In a control experiment, in which two Cynomolgus monkeys treated with a 4% pilocarpine solution for three months, these ultrastructural changes did not occur; it must therefore be assumed that mechanical irritation of the conjunctiva was the cause.

[Eye changes in stenoses of the internal carotid artery--histologic and clinical findings]

From a group of 26 patients with proven stenosis or occlusion of the internal carotid artery, 8 were selected who had typically developing chronic ischemia of the globe. Four eyes had to be enucleated due to painful secondary glaucoma. The results of histological examination correlated with the clinical findings, showing fibrovascular occlusion of the chamber angle with incipient endothelialization, pronounced hyalinization of the ciliary body, venous stasis of the choroidal and retinal circulation, and a predominantly perivenous lymphocytic infiltration of the optic nerve. The causal mechanisms are discussed. Particular attention is given to blood flow factors in the orbital area (in 5 of the 8 patients Doppler sonography showed a reversal of flow in the supratrochlear artery on the same side as the globe ischemia). Diagnosis and therapy require an interdisciplinary approach, since besides treating the ophthalmological complications it is vital to ensure stroke prophylaxis by improving cerebral circulation.