[Reparative giant cell granuloma with orbital involvement]

A 54-year-old woman was evaluated for a left orbital mass that had been present for one year. Examination showed mild superolateral displacement of the normal left eye and a firm medical orbital mass. A complete resection of the lesion was accomplished via a combined neurosurgical, otolaryngologic and ophthalmologic superior orbital approach. Histologic features of the mass were consistent with giant-cell (reparative) granuloma. However, it has to be pointed out that fibroosseous lesions with giant-cells display similar histologic features and require clinicopathologic correlation including radiographic studies for final diagnosis.

Clear cell differentiation in choroidal melanoma. COMS report no. 8. Collaborative Ocular Melanoma Study Group

OBJECTIVE

To describe 2 enucleated eyes of patients enrolled in the Collaborative Ocular Melanoma Study that contained primary choroidal melanoma with clear cell features.

METHODS

During a 9-year period, 1493 eyes enucleated as part of the Collaborative Ocular Melanoma Study routinely processed for histologic examination were evaluated by the pathology review committee (H.E.G, D.M.A, and W.R.G). Two eyes with unusual variants of choroidal melanoma were identified and immunostained for S100 protein and HMB 45. Portions of the tumors were processed for electron microscopic examination.

RESULTS

Results of electron microscopic examination of both tumors displayed malignant melanoma (mixed cell type with many malignant cells with clear cytoplasm). The cytoplasm of the clear cells stained with periodic acid-Schiff and failed to stain when pretreated with diastase. Results of immunohistochemical stains in both tumors were positive for S100 protein and HMB 45 in the tumor cells. Results of electron microscopic examination showed that the cytoplasm of the clear cells contained scattered glycogen granules, premelanosomes, and melanosomes.

CONCLUSION

These cases represent a clear cell variant of malignant melanoma of the choroid. This tumor should not be confused with metastatic clear cell carcinoma to the choroid.

Vitreous Hemorrhage

The incidence of spontaneous vitreous hemorrhage is approximately 7 cases per 100,000 population. Proliferative diabetic retinopathy (32%), retinal tear (30%), proliferative retinopathy after retinal vein occlusion (11%) and posterior vitreous detachment without retinal tear (8%) are the most common causes of spontaneous vitreous hemorrhage. Vitreous hemorrhage can be caused by the pathologic mechanisms of disruption of normal retinal vessels, bleeding from diseased retinal vessels or abnormal new vessels, and extension of hemorrhage through the retina from other sources. Hemorrhage into the vitreous gel results in rapid clot formation and is followed by slow clearance of approximately 1% per day. The cellular response to vitreous hemorrhage is unusual with regard to hemorrhage in any tissue outside the vitreous cavity and has been compared to a "low-turnover" granuloma. Unique clinicopathologic features of long-standing vitreous hemorrhage include cholesterolosis bulbi (synchysis scintillans), hemoglobin spherulosis, and vitreous cylinders. Complications of nonclearing vitreous hemorrhage are hemosiderosis bulbi and glaucoma. Ghost cell glaucoma, hemolytic glaucoma, and hemosiderotic glaucoma may result from vitreous hemorrhage. The established treatment option for nonclearing vitreous hemorrhage is pars plana vitrectomy. Experimental nonsurgical treatment options involve improvement of physiologic clearance mechanisms in order to accelerate fibrinolysis, liquefaction, hemolysis and phagocytosis.

[Idiopathic polypoid choroid vasculopathy]

BACKGROUND

The idiopathic polypoidal choroidal vasculopathy, also known as "posterior uveal bleeding syndrome" or "multiple recurrent serosanguineous retinal pigment epithelial detachments in black women" is a rare disease entity. A clincopathologic correlation of a patient with this disease is presented.

CASE REPORT

A 47-year-old black woman was evaluated for a decrease of visual acuity in her right eye which had occurred over the last 3 months. Ophthalmic examination of her right eye revealed sub-RPE hemorrhage associated with a reddish-orange subretinal vascular-like lesion. In addition, both eyes displayed a few choroidal vascular-like bulbous structures in the superior temporal peripapillary region. The patient developed an extensive choroidal hemorrhage that led eventually to the enucleation of the eye.

CONCLUSION

Choroidal neovascular membranes (CNV) secondary to idiopathic polypoidal choroidal vasculopathy differs in many aspects from other entities associated with CNV including clinical and fluorescein angiographic features, clinical course, and prognosis.

Comparison of transillumination and histologic slide measurements of choroidal melanoma

OBJECTIVE

To compare transillumination and histologic slide measurements of choroidal melanomas in 479 eyes randomized to enucleation in the Collaborative Ocular Melanoma Study.

DESIGN

Transillumination defects were measured during gross examination of enucleated eyes. Tumor basal diameter and height were measured on histologic slides and each tumor was assigned to 1 of 8 distinct shape categories. Comparison of the transillumination and histologic slide measurements revealed 3 categories of difference: underestimation (transillumination measurement more than 4 mm smaller than the histologic slide measurement), overestimation (transillumination measurement more than 4 mm larger than the histologic slide measurement), and agreement within 4 mm.

RESULTS

There was good correlation between transillumination and histologic slide estimates of largest basal diameter, particularly when the basal diameter was 16 mm or less. Measurement discrepancies were related to the shape of the tumors but not to the presence of subretinal fluid or fixation.

CONCLUSION

Agreement was high between measurements of transillumination defect and histologic sections.

[Granular cell tumor of the eyelid]

A 54-year-old woman was evaluated for a right lower eyelid lesion that had been present for four months. Examination showed a firm, yellow to brown mass with associated loss of eyelashes. A complete resection of the lesion was performed and the lid was reconstructed with the Hughes procedure. Histologic features of the excised mass were consistent with a granular cell tumor. Immunohistochemical stains were positive for S-100 protein, neuron specific enolase, laminin, and various myelin proteins in the tumor cells. Ultrastructural examination displayed that tumor cells were distended by autophagic granules and some cells contained angulated bodies (Bangle bodies). Granular cell tumors probably origin from Schwann cells and rarely involve the eyelids.

Strabismus and mitochondrial defects in chronic progressive external ophthalmoplegia

PURPOSE

To describe the results of strabismus surgery on three patients with chronic progressive external ophthalmoplegia, a group of rare disorders characterized by ptosis and slowly progressive ophthalmoparesis that has been shown to result from defects in mitochondrial DNA.

METHODS

Strabismus surgery using the adjustable suture technique was performed in three patients with strabismus and chronic progressive external ophthalmoplegia confirmed by clinical, biochemical, histopathologic, and genetic criteria. All three patients had mitochondrial DNA deletions. Two patients were exotropic; one patient was esotropic.

RESULTS

Rectus muscle recessions were initially unsuccessful in correcting strabismus in one patient, although a subsequent procedure employing rectus muscle resections was successful in alleviating a significant head turn and improved ocular alignment. In the two other patients, a single procedure consisting of rectus muscle recessions combined with large rectus muscle resections successfully achieved good postoperative alignment. The amount of surgery performed in these three patients exceeded that predicted in standard strabismus tables.

CONCLUSIONS

The myopathic process that results in chronic progressive external ophthalmoplegia renders rectus muscle recessions less effective compared with resections for correcting the associated strabismus seen in these patients. Rectus muscle resections therefore should be an integral procedure in the surgical management of the strabismus associated with chronic progressive external ophthalmoplegia.

Characteristics of Drusen and Bruch's membrane in postmortem eyes with age-related macular degeneration

We performed a histopathologic study to compare eyes with different stages of age-related macular degeneration (AMD) with age-matched eyes to identify characteristics associated with exudative vs nonexudative AMD. We analyzed 51 eyes, which were obtained from an eye bank, from 40 donors with different stages of AMD and compared them with 40 age-matched control eyes. The eyes were processed for light microscopy, and the degree of calcification of Bruch's membrane, fragmentation of Bruch's membrane, the number of different types of drusen, and the presence of basal laminar (linear) deposit were assessed in the macular and extramacular regions. In the macular area, a statistically significant difference was observed for the degree of calcification (P = .02) and fragmentation (P = .03) of Bruch's membrane in eyes with exudative AMD (1.6 and 5 per eye, respectively) compared with eyes with nonexudative AMD (0.8 and 1 per eye, respectively) and control eyes (0.8 and 0 per eye, respectively). Eyes with AMD displayed notably softer, more confluent, and larger drusen and basal laminar (linear) deposit in the macular area compared with control eyes. Calcification and fragmentation of Bruch's membrane, soft, confluent, and large drusen, and basal laminar (linear) deposit but not hard drusen correlate with the histological presence of AMD. The degree of calcification and fragmentation of Bruch's membrane is greater in eyes with exudative compared with nonexudative AMD.

Intraocular lens implantation in infant monkeys: clinical and histopathological findings

PURPOSE

To determine the long-term effects of intraocular lens (IOL) implantation in infant monkey eyes.

SETTING

Yerkes Regional Primate Research Center, Emory University School of Medicine, Atlanta, Georgia, USA.

METHODS

A 30.00 diopter (D), all-poly(methyl methacrylate) IOL with an overall diameter of 10.0 mm was implanted in the right eye of 11 infant monkeys. Seven monkeys developed postoperative complications and were not followed on a long-term basis. However, 4 monkeys were followed clinically for 4 1/2 years, after which their pseudophakic eyes were examined histopathologically.

RESULTS

The final refractive error in the four pseudophakic eyes with long-term follow-up ranged from -4.75 to +0.75 D. Three of the four eyes had a Soemmering's ring. Only one haptic was in the capsular bag. whereas five had eroded into the iris root/ciliary body. The corneas and posterior segments of the eyes were normal.

CONCLUSION

Two-thirds of the eyes having neonatal IOL implantation experienced significant postoperative complications. Haptic location was suboptimal in all four eyes followed for 4 1/2 years. The diameter of the IOLs implanted in these eyes was probably too large. Some of these complications might have been averted by implanting an IOL with a smaller diameter.

Adenocarcinoma of the iris pigment epithelium

We treated an 81-year-old man with a pigmented lesion of his right iris. The lesion was locally excised. Light microscopic examination, including immunohistochemistry, and electron microscopic examination were performed. The diagnosis was low-grade adenocarcinoma arising from the iris pigment epithelium. Adenomatous proliferations of the iris pigment epithelium are exceedingly rare and have not been shown to metastasize. Local resection is recommended if the lesion exhibits growth.

Subfoveal choroidal neovascularization in punctate inner choroidopathy. Surgical management and pathologic findings

PURPOSES

To evaluate submacular surgery for the management of subfoveal choroidal neovascularization in punctate inner choroidopathy, to describe the histopathology and ultrastructure of the excised subretinal tissue, and to propose a staging system that characterizes the development of choroidal neovascularization with associated subretinal fibrosis.

METHODS

The authors reviewed the records of five patients (6 eyes) with punctate inner choroidopathy who underwent submacular surgery for subfoveal choroidal neovascularization. Surgical specimens were examined using light and transmission electron microscopy.

RESULTS

Visual improvement was noted postoperatively in all six eyes, with follow-up ranging from 8 to 36 months (median, 14 months). Recurrences (6 in 4 eyes) were common. Five of the six recurrences required additional procedures: three were managed surgically, two with laser photocoagulation, and one with observation. "Bridging" of separate foci of choroidal neovascularization resulted in stellate or "dumbbell-shaped" areas of subretinal fibrosis in four of six eyes. Histopathologic evaluation of the excised tissue showed endothelial-lined vascular channels, retinal pigment epithelium, lymphocytes, plasma cells, fibrocytes, collagen fragments, and rarely, outer retinal elements.

CONCLUSIONS

Subfoveal choroidal neovascularization in punctate inner choroidopathy may be managed with submacular surgery. Recurrences are common and may result in substantial loss of vision. Choroidal neovascular membranes with an accompanying fibrotic reaction are responsible for the stellate or dumbbell-shaped areas of subretinal fibrosis. No beneficial effect was demonstrated using corticosteroid treatment of the choroidal neovascularization.

Morphometric analysis of the choroid, Bruch's membrane, and retinal pigment epithelium in eyes with age-related macular degeneration

PURPOSE

To quantify morphologic changes in the choroid, including choriocapillaris and larger choroidal vessels, Bruch's membrane, and retinal pigment epithelium in eyes with age-related macular degeneration (AMD) and late ARM (age-related maculopathy).

METHODS

The authors analyzed 40 eye bank eyes with late ARM (21 with the neovascular AMD and 19 with nonneovascular AMD) and compared them with 40 age-matched eyes without signs of late ARM (AMD). The eyes were processed for light microscopy, and seven variables were measured in the macular and peripheral regions with a digital filar micrometer.

RESULTS

There were no statistically significant differences observed between eyes with neovascular versus nonneovalcular AMD. The single most important difference between eyes with and without AMD was the amount of basal laminar deposit (P < 0.001). Eyes with AMD displayed fewer large choroidal vessels in the submacular choroid than eyes without AMD (3.5 +/- 1.5 mm-1 and 5.7 +/- 1.6 mm-1; P < 0.001). The submacular choriocapillaris density was higher in eyes with AMD (0.62 +/- 0.06) than in eyes without AMD (0.51 +/- 0.08; P < 0.001). The diameter of the large choroidal vessels in the peripheral choroid was increased in eyes with AMD (30 +/- 8 microns) compared to eyes without AMD (21.4 +/- 6.2 microns; P < 0.001). The peripheral choriocapillaris density displayed the same pattern as in the macular region in eyes with and without AMD.

CONCLUSIONS

The amount of basal laminar deposit strongly correlates with the histologic presence of AMD. Eyes with AMD show differences of the density and diameter of choroidal blood vessels compared to eyes without AMD.

The corneal epithelium after optisol-GS storage

The objective of this study was to evaluate the epithelium of human corneas stored in Optisol-GS (Chiron Intraoptics, Irvine, CA) for extended periods (2-34 days). Human corneas stored in Optisol-GS (n = 64) were obtained from the Georgia Eye Bank. Corneal epithelial viability was assessed by using the Calcein-AM (Molecular Probes, Inc., Eugene, OR) ethidium homodimer stain, a fluorescent assay used to distinguish live from dead cells. Scanning and transmission electron microscopy was used to evaluate epithelial ultrastructure. The results showed that corneas stored up to 6 days in Optisol-GS had minimal damage of the epithelium. Calcein-AM ethidium homodimer staining showed 20-25% epithelial damage. Corneas stored 7-10 days had a further increase in epithelial damage (30-35%). Corneas stored for 11-15 days had marked increases in epithelial damage (40-50%), and corneas stored 16-34 days showed significant epithelial damage (60-70%). The data show that corneas stored in Optisol-GS are able to maintain the epithelium up to 6 days. A gradual decrease in epithelial viability and loss of epithelial cells occurs in corneas stored 6-10 days. Corneas stored for > 10 days have a marked loss of epithelial cells with extensive epithelial damage.

Anterior vs posterior intraocular melanoma. Metastatic differences in a murine model

OBJECTIVE

To study differences in metastatic rate of anterior vs posterior ocular melanoma in a murine model.

METHODS

Thirty-eight 12-week-old C57BL6 mice were inoculated into the anterior chamber (AC) or posterior compartment (PC) of the right eye with 5 x 10(5) tissue culture Queens melanoma cells per 5 microL. The right eye was enucleated 14 days after inoculation, and the animal was killed 28 days after inoculation and a necropsy was performed. The eye was evaluated for the presence of melanoma and the mean of the 10 largest nucleoli in tumor cells. Eyes with orbital invasion of the melanoma were excluded. The number of metastases was determined at necropsy.

RESULTS

Melanomas grew in 30 of 38 eyes. After exclusion of 9 eyes with orbital invasion of tumor, melanoma was found in 12 mice in the AC group and 9 mice in the PC group. The metastatic rate was significantly lower for AC tumors (33%) than for PC tumors (89%) (P = .02). All AC tumors that metastasized to lungs also metastasized to ipsilateral cervical lymph nodes, and no PC tumors metastasized to ipsilateral cervical lymph nodes. The median number of pulmonary metastases per tumor was significantly smaller for AC tumors than for PC tumors (P = .01) There was a median of 0 metastases (range, 0-14) per AC tumor and 4 metastases (range, 0-38) per PC tumor.

CONCLUSION

Posterior ocular melanoma metastasizes more often than anterior ocular melanoma in this murine model.

Mushroom-shaped choroidal hemangioma

PURPOSE

We examined the clinicopathologic features of a mushroom-shaped choroidal tumor that originated in the right eye of a 13-year-old girl.

METHODS

The clinical, ultrasonographic, and histopathologic features of the enucleated eye were studied.

RESULTS

On clinical examination, the choroidal tumor appeared mushroom-shaped with ultrasonic characteristics of high internal reflectivity and choroidal excavation. The enucleation specimen contained a cavernous hemangioma that extended through Bruch's membrane.

CONCLUSION

Choroidal hemangioma may extend through Bruch's membrane and be mushroom shaped.

Tumors of the cornea and conjunctiva

This article reviews literature regarding tumors and tumor-like lesions of the conjunctiva and cornea as published in 1995. Causative and prognostic factors, as well as treatment options, are discussed. Ocular surface squamous neoplasia has been suggested as an "umbrella" term for dysplastic and carcinomatous lesions of the cornea and conjunctiva. Squamous cell carcinoma shows a higher incidence in patients with AIDS. A high prevalence (36%) of primary acquired melanosis is reported in one article, and the need for biopsy of all these lesions is questioned. Reviews of conjunctival myxoma, corneal pyogenic granuloma, and limbal juvenile xanthogranuloma are also included. The pathogenesis and newer treatment options for pterygia are discussed. Simple excision or resection of the pterygium followed by conjunctival autografting or intraoperative or postoperative mitomycin C application seems to be equally effective in reducing the rate of recurrence.

Familial bilateral perilimbal cystic benign melanosis with lipid keratopathy--a new entity?

We examined the clinicopathologic findings in two sisters with pigmented conjunctival lesions. Slit-lamp examination showed bilateral, circumferential cystic pigmented perilimbal lesion and prominent lipid keratopathy. The pigmented lesions were examined via biopsy, and histologic and ultrastructural examination of the biopsy specimens showed secondary melanosis of numerous conjunctival epithelial inclusion cysts. The two sisters have familial bilateral perilimbal cystic benign melanosis with lipid keratopathy, an idiopathic condition that requires no further surgical management.

Ultrastructural features of tissue removed during idiopathic macular hole surgery

PURPOSE

To compare the ultrastructural features of excised tissue removed during surgery for idiopathic macular holes with the preoperative stage of the macular hole.

METHODS

Twelve consecutive patients with a unilateral idiopathic macular hole underwent vitrectomy with surgical removal of the internal limiting membrane of the retina and epiretinal tissue overlying and surrounding the hole. The excised specimens were evaluated with transmission electron microscopy, and findings were compared with the preoperative stage of the macular hole according to the classification of Gass.

RESULTS

Surgery was performed on 12 eyes of 12 patients with stage 2, 3, or 4 macular holes. Internal limiting membrane was present in 11 of 12 specimens. Tissue from one of two eyes with stage 2 holes showed cellular elements enmeshed in cortical vitreous. Tissue from four of seven eyes with stage 3 holes and three of three eyes with stage 4 holes had cellular proliferation on the internal limiting membrane. Cells with myofibroblastic differentiation were present in five of the eight cellular proliferations.

CONCLUSION

Our results support the clinical stages of idiopathic macular holes described by Gass. Idiopathic macular holes appear to form from contraction of the prefoveal vitreous, and the hole enlarges because of contraction of myofibroblasts on the inner surface of the internal limiting membrane. On the basis of the mechanical mechanisms of idiopathic macular hole formation, removal of the internal limiting membrane and adherent epiretinal tissue surrounding and overlying the macular hole is a reasonable surgical approach to close idiopathic macular holes.

Primary orbital melanomas

PURPOSE

Primary orbital melanomas are rare tumors with a poorly defined biologic course. Most recorded experiences concern single case reports. The authors evaluated the applicability of several of the histopathologic prognostic indicators used for uveal melanomas to a series of primary orbital melanomas with known clinical follow-up.

METHODS

Twenty-one primary orbital melanomas, each with at least a 1-year follow-up after diagnosis, were evaluated for (1) modified Callender cell type, (2) mitotic count per 40 high-power fields, (3) lymphocyte count (less than versus greater than 100/20 high-power fields), (4) blue nevus component, and (5) largest tumor diameter.

RESULTS

All patients for whom race was recorded were white. The mean age at diagnosis was 42 years (range, 15-84 years). There was an associated blue nevus in 19 patients (90 percent), and in 10 patients (47.5 percent) there was some form of congenital melanosis. With a mean follow-up period of 4.5 years (range, 1-13 years), mortality from metastatic tumor occurred in 8 (38 percent) of 21 patients. Of these eight patients, there were liver metastases in seven (88 percent) and brain metastases in one (12 percent). Indicators of poor prognosis were tumors of mixed cell type with high mitotic count and greater patient age with underlying congenital melanosis.

CONCLUSION

Most primary orbital melanomas occur in white patients and are associated with blue nevi. These tumors are similar to uveal melanomas with respect to prognostic indicators and pattern of metastasis.

Invasive keratoacanthoma of the eyelid and ocular adnexa

PURPOSE

To report three patients with superficially invasive crateriform squamous proliferations of periocular tissue.

METHODS

The authors identified three patients with superficially invasive periocular tumors that had clinical features of keratoacanthoma. Clinical histories, radiographs, and surgical pathologic specimens were reviewed.

RESULTS

All three tumors arose over several weeks, had a crateriform configuration, and exhibited superficial invasion of underlying tissues, including perineural invasion and infiltration into skeletal muscle. All three tumors were classified as invasive keratoacanthoma. One tumor exhibited late perineural extension into the cavernous sinus and convincing histologic features consistent with squamous cell carcinoma.

CONCLUSION

The clinical importance of recognizing invasive keratoacanthoma is that although the tumor has the potential for spontaneous involution, locally aggressive behavior with deep perineural invasion is possible. This tumor is considered to represent a variant of squamous cell carcinoma. The authors recommend complete surgical excision of crateriform squamous proliferations with frozen section control of margins of resection.

Corneal endothelial deposits in patients with cytomegalovirus retinitis

PURPOSE

We studied six patients with human immunodeficiency virus (HIV) who had cytomegalovirus retinitis and abnormal endothelial deposits in at least one eye, to characterize their corneal endothelial deposits.

METHODS

The corneas of the six patients were examined by slit-lamp biomicroscopy and specular microscopy with morphometric analysis. The eyes of one patient with endothelial changes were obtained post mortem for histopathologic and ultrastructural examination.

RESULTS

There were multiple diffuse, fine refractile, stellate-shaped deposits on the corneal endothelium in all affected eyes. The deposits were best seen with retroillumination. Two of six patients examined with specular microscopy showed severe abnormalities, which included marked areas of polymegathism and decreased endothelial cell counts. Examination of one eye obtained post mortem disclosed chains of dendritic macrophages and fibrin adherent to the apical surface of the corneal endothelium. There was no evidence of direct infection of the corneal endothelium by cytomegalovirus.

CONCLUSIONS

Deposits on the corneal endothelium in patients with cytomegalovirus retinitis most likely result from an anterior uveitis. A preponderance of macrophages observed by histopathologic examination may be related to the inability of the immunodeficient patient to mount a normal T-cell response.

Focal posttraumatic choroidal granulomatous inflammation

PURPOSE

This study was performed to describe the clinicopathologic features of a group of patients with posttraumatic unilateral focal choroidal granulomatous inflammation.

METHODS

Enucleated eyes with focal choroidal granulomatous inflammation without clinical signs of contralateral ocular inflammation were identified. Clinical and pathologic features were recorded.

RESULTS

Six enucleated eyes that had been injured by projectiles had focal uveal granulomatous inflammation of the posterior choroid. Four eyes had uvea attached to or incarcerated into the wound. Two eyes had foreign material associated with the granulomatous inflammation, and two eyes had a disrupted lens with lens-induced inflammation. Two eyes exhibited the focal granulomatous inflammation at the site of a choroidal rupture. None of the six enucleated eyes contained Dalen-Fuchs' nodules.

CONCLUSIONS

Focal choroidal granulomatous inflammation may occur as a result of penetrating ocular trauma. The origin of this condition is unknown, although it likely represents a reaction to a foreign body.