[Current therapy aspects of intraocular tumors]

The most frequent primary intraocular malignancies are uveal melanoma in adults and retinoblastoma in children. Genetic findings in uveal melanoma now allow a better risk-prediction with regard to metastatic disease. New treatment modalities like endo-resection, trans-scleral resection, proton beam irradiation and trans-pupillary thermotherapy are now being established in clinical routine. Management of retinoblastoma has changed during the last years considerably. In hereditary retinoblastoma external beam radiotherapy (EBR) results in a sixfold increased risk for the development of secondary, non ocular malignant tumors in these patients. New treatment regimens based on systemic chemotherapy were developed to replace EBR. In combination with chemotherapy there has been a continuing trend toward more conservative focal treatment for retinoblastoma. Indications and first results of these new treatment modalities are presented.

Pathology of a lepromatous eye

Histopathological examination of an enucleated eye from a lepromatous leprosy patient showed the cornea, ciliary body, and part of the choroid to be infiltrated by macrophages filled with Mycobacterium leprae. The walls of blood vessels in the sclera, ciliary body and the anterior choroid demonstrated the presence of M. leprae, giving credence to the blood-borne entry of M. leprae into the eye. Unlike the eyes of experimental animals infected with M. leprae, histopathological study of this eye from a lepromatous leprosy patient demonstrated that M. leprae, although demonstrable in the anterior choroid, could not be found in the posterior parts of the eye, substantiating the claim that leprosy does not affect the posterior parts of the eye directly.

[Complications of hydroxyapatite orbital implants in children: a series of 105 cases]

PURPOSE

To describe the complications encountered using hydroxyapatite as an orbital implant in the pediatric population after enucleation, and try to define the risk factors for their occurrence.

MATERIAL

and methods: Retrospective review of charts of children who underwent enucleation with placement of an hydroxyapatite implant between January 1991 and 1998. Complications and their type (conjunctival, extrusion, eyelids complications) have been specifically looked for. A statistical analysis trying to isolate the risks factors was performed.

RESULTS

105 implants have been used during this period with 26.7% of complications appearing during a median followup of 22 months. Extrusion of the implant was observed in 1.9% of the cases, a chronic conjunctival erosion in 15%, a conjunctival lesion without erosion in 4.75% and no eyelid lesion could be seen. Treatment (medical or surgical) achieved 75% good results. No risk factor could be found.

CONCLUSION

Hydroxyapatite orbital implants were initially thought to have no or few complications. More recently, chronic erosions in particular were described. Little data exists on the pediatric population. Our series confirms that complications occur and that they are comparable to the adult population. Nevertheless the hydroxyapatite orbital implant seems better tolerated than other porous or non porous implants and warrants its use.

Stimulus frequency affects c-fos expression in the rat visual system

We have characterised the c-fos expression patterns in various centers of the visual pathway of adult rats monocularly stimulated either by continuous or flickering light at different frequencies. Results show different immunocytochemical patterns in all centers studied, the geniculate lateral complex (LGC), superior colliculus (SC) and primary visual cortex (Oc1), depending on the physical characteristics of the stimulus (blinking frequency and light wavelength). After stimulation of the left eye, the ipsilateral pathway presents a substantial density of immunoresponsive cells, which is greater than expected with respect to the number of fibers that project ipsilaterally from the retina to the LGC and the superficial layers of the SC. A surprisingly high positive immunoresponsiveness is obtained in all cases with coherent light stimulation in the red spectrum (634 nm).

Retinoblastoma in adults. Report of three cases and review of the literature

Retinoblastoma usually presents in children younger than 5 years. To our knowledge, 20 cases of retinoblastoma in adults (older than 20 years) have been reported in the literature. Of 173 patients with histopathologically proven retinoblastoma seen in our institute, three were adults. All the patients had endophytic tumors with vitreous seeds. Ultrasonography did not reveal calcification in two cases. Immunohistochemistry with neuron-specific enolase was used to confirm the diagnosis in two cases. All three patients ultimately required enucleation. None of the patients had been referred with a diagnosis of retinoblastoma. The diagnosis of retinoblastoma should be considered in cases of whitish mass lesion in the fundus of an adult.

[One-stage correction of the contracted eye socket and orbitozygomatic hypoplasia]

OBJECTIVE

In order to simultaneous correct the contracted eye socket and orbitozygomatic hypoplasia that caused by early ophthalmectomy and radiotherapy.

METHODS

The one-stage surgical procedure for eye socket reconstruction and bone graft coverage included rotation of a postauricular skin flap and a temporal fascial flap. Hydroxyapatite implant was inserted as an onlay bone graft substitute to enlarge the orbitozygomatic region.

RESULTS

In 16 cases using this method, the results were satisfactory and encouraging with minor complications.

CONCLUSION

This procedure is effective for radiated complex deformities in paraorbit and eye socket.

[Current therapeutic management in retinoblastoma with invasion of the optic nerve--a case report]

INTRODUCTION

Retinoblastoma is the most frequent primitive intraocular tumour in children. The extension of retinoblastoma at the optic nerve level gives a dark prognosis implying a complex treatment and a long period of supervision.

OBSERVATION

An eleven-months-old child, female, is taken in the hospital with the suspicion of retinoblastoma left eye. The diagnosis was suspected when the child was six months old within another ophthalmologic department, but the treatment was postponed. Surgical treatment consisted of enucleation with at least a 10 mm resection of the optic nerve. The anatomo-pathologic examination shows a retinoblastoma with the optic nerve invasion (stage II b 2--after Grabowski's classification). Because of the early age of the patient, we are obliged to give up applying radiotherapy (technical reasons) and systemic chemotherapy is recommended, in six cycles, under very severe clinic and paraclinic control.

CONCLUSIONS

The extension of retinoblastoma at the optic nerve level indicates a severe prognosis with high lethal risk. The correct treatment during thus phase implies the association of radiotherapy (40-45 Gy) and chemotherapy. After 24 months from the finishing of the treatment the patient is in total remission (clinic and paraclinic), but the supervision is going on for at least another 3 years. The early enucleation as well as its appliance with the removal of a large part of the optic nerve represents a therapeutical manner and leads to an important prognosis.

Is screening for primitive neuroectodermal tumors in patients with unilateral retinoblastoma necessary?

Retinoblastoma is the most common childhood intraocular tumor, occurring in 1 of 18,000 live births. Retinoblastoma may occur as a germinal mutation or a somatic mutation. Forty percent of retinoblastoma cases are caused by a germline mutation and include those patients with a positive family history of the disease. Children with hereditary forms usually have multifocal, bilateral retinoblastoma, whereas children with the somatic form have unilateral, unifocal disease. However, up to 15% of cases of sporadic unilateral retinoblastoma may be hereditary. It is important to recognize that this subgroup of unilateral patients remains at risk for the development of second tumors as well as second primary tumors of the intracranial midline, or "trilateral retinoblastoma." We report a case of a 2-month-old child with unilateral retinoblastoma in whom pinealoblastoma subsequently developed.

Choroidal Langerhans' cell histiocytosis

PURPOSE

To report a patient with choroidal Langerhans' cell histiocytosis.

METHODS

A solitary tumor was found in the left eye of a 49-year-old male who had no definite history of systemic disorders, but had observed visual disturbances for a period of 1 month. Ultrasonography, fluorescein angiography, and indocyanine green angiography were performed and the eyeball was enucleated. We prepared the specimen for microscopic examinations.

RESULTS

Fluorescein angiographic findings of the lesion were mottled hyperfluorescence in the arteriovenous phase and strong hyperfluorescence in the late phase. Hypofluorescence in both early and late phases showed on indocyanine green angiogram. The lesion of choroid was widely infiltrated by histiocytes, though no extraocular invasion was found. Immunohistochemical studies including S-100 and CD 68 staining revealed characteristic features of Langerhans' cell histiocytosis. Electron microscopic examination of the histiocytes showed histiocytosis X body (Birbeck granule) in the cytoplasm and indented nucleus.

CONCLUSION

We consider that this is a case of choroidal Langerhans' cell histiocytosis with no evidence of systemic lesions.

[Long-term results of implantation of hydroxylapatite as artificial eye]

BACKGROUND

Since its first implantation as an eyeball replacement in the United States in 1985, hydroxyapatite has been rarely used as an orbital implant in Germany. The aim of the study was to collect data on long-term tolerance, postoperative complications and the cosmetic end results.

PATIENTS AND METHODS

In the spring of 1997, 52 patients underwent a follow-up examination at our hospital. The average post-operative follow-up period was 23 (12-41) months.

RESULTS

The subjective tolerance was considered good by 3/4 of the patients. In the comparison of position and prominence of the artificial eye, 8 patients achieved complete equalization. As regards defective lid position, 8 patients had a ptosis, 6 an ectropium, and there was one case of entropium. Changes in conjunctiva stretched from muciferous secretion to follicular squamous hyperplasia. There was no case of implant extrusion in the series examined. With reference to the method of implantation, far superior motility was observed in primary implantations. Statistically significant motility differences could not be shown regarding muscle attachment because of the small number of the cases.

CONCLUSIONS

In the series examined, hydroxyapatite proved to be a generally well-tolerated orbital implant with few postoperative complications and good motility. Primary implantation with attachment of all six eye muscles gave the best results.

[Medulloepithelioma of the ciliary body. A case report]

Medulloepithelioma of the ciliary body is an uncommon intraocular tumor occurring during the first year of life. Malignant degeneration may occur. We report the case of a 4-year-old child who presented medulloepithelioma of the left eye disclosed by oesotropia at 2 years of age. Clinically, there was oesotropia, positive light perception and cataract with vascular membrane spreading to the nasal side of the irido-corneal angle. CT scan and ultrasound B revealed a ciliary body tumor involving the sclera and orbital fat. After exenteration, the pathology study reported malignant medulloepithelioma of the ciliary body with scleral extension. No local recurrence or metastasis has been observed at 8 months follow-up. We discuss the clinical, radiological and therapeutic features of this uncommon tumor.

Mononuclear cell proliferation and hyperplasia during Wallerian degeneration in the visual system of the goldfish in the presence or absence of regenerating optic axons

Patterns of proliferation and changes in non-neuronal cell number in the visual system of the goldfish have been quantitatively examined during optic axon regeneration after an optic nerve crush (ONC). In addition, in order to examine the effect of the regenerating axons on cellular responses in the visual pathways, we did a similar analysis of animals with the right eye removed (ER). Finally, we used double labeling protocols to demonstrate that the proliferating cells that we were counting were mostly phagocytic cells of the mononuclear lineage. In animals with an ONC, we observed an early burst of proliferation that peaked between 7 and 14 days after surgery in all parts of the visual system. In the optic tract, there was also a secondary rise that peaked at 21 days. Levels of proliferation returned to normal by 32 days postoperative in the tract and tectum, while they remained somewhat elevated in the optic nerve for at least 93 days. The total number of non-neuronal cells in the visual paths also rose to peak values between 7 and 14 days after ONC surgery. In the optic tract and tectum, the values fell rapidly after this time, while in the optic nerve, there was a secondary peak at 32 days after which values remained elevated for the duration of the experiment. As compared to animals with an ONC, enucleation resulted in elevated proliferation and hyperplasia at early postoperative intervals. However, because these differences occurred when axons had not yet regenerated into the affected structures, these data do not provide strong evidence for a direct effect of regenerating optic axons on the early cellular responses during Wallerian degeneration in the goldfish. In addition, in the tectum, there was an early increment in cell number that was not associated with elevated levels of proliferation. We believe that this increment represents immigration of resident microglia from other regions of the brain.

Eye-wall resection

PURPOSE

To review the ocular retention rates, visual results, and metastases in uveal tumors managed with eye-wall resection techniques.

METHODS

This was a retrospective analysis of uveal tumors selected for eye-wall resection with the surgical procedures performed by a single surgeon. All enucleation specimens were reviewed by one author. Both parametric and non-parametric analysis of data was performed.

RESULTS

A total of 132 eyes were scheduled for eye-wall resection surgery. Mean patient age was 52 years (range, 11 to 86 years). Tumors involved the iris alone in 17 cases, the iris-ciliary body in 53, the ciliary body alone in 16, and the choroid (ciliochoroidal, iris-ciliary body-choroid, or choroid) in 46 cases. A total of 114 eyes harbored melanomas; tumors located more posteriorly were more likely to have epithelioid cells (P < .05). Mean follow-up was 6 years. Mean number of clock hours in iris and iris-ciliary body tumors was 3.5. In tumors that involved the choroid, the mean largest diameter was 12.6 mm and the mean thickness was 8.2 mm. Ninety-three (70%) of 132 eyes were retained. Histologic assessment of surgical margins did not correlate with either evidence of tumor in enucleated eyes or metastatic disease. Surgical margins of tumors located more anteriorly were more likely to be clear on histologic evaluation (P < .05). Approximately 56% of retained eyes had a final visual acuity of 20/40 or better; visual results were significantly better in tumors located more anteriorly (P < .05). All retained eyes with iris tumors had a final visual acuity of 20/40 or better. In tumors that involved the choroid, 8 of 25 retained eyes kept visual acuity of 20/40 or better. Metastases developed in 8 patients; all metastatic events developed in patients with tumors that involved the choroid, and 7 of 8 were mixed cell melanomas.

CONCLUSIONS

Seventy percent of eyes were retained, and 56% of these had a final visual acuity of 20/40 or better. Only 7% of patients with uveal melanoma developed metastatic disease (mean follow-up, 6 years). Survival did not appear to be compromised with eye-wall resection, and in very thick melanomas located more posteriorly, ocular retention and visual results appeared to be better than that attained with radiation alone.

Orbital dermis-fat graft using periumbilical tissue

Dermis-fat grafts are currently used in orbital reconstruction in a variety of procedures. The most frequent harvesting site is the gluteal area. However, we encountered some patients with anophthalmic socket who wished to avoid a visible scar on the buttock. In this article, we describe the effort to offer the patient an alternative donor site. Of the last 36 patients with anophthalmic socket who needed a dermal fat implant, 11 wished to avoid a visible scar on the buttock. To satisfy their requests we have endeavored to harvest the dermis graft from the periumbilical area. The rate of absorption, the motility, and the satisfaction of the patients were used as outcome measures and were analyzed carefully. Of 11 patients, 4 were women and 7 were men. The ages of these patients ranged from 24 to 56. The maximum follow-up was 137 months and the minimum 22 months, with a mean follow-up of 79 months. Some degree of absorption of the graft developed in one patient who had a severe absorption and required further operation. Of 11 cases, there were 7 with excellent motility, 3 with good motility, and 1 not evaluated. The motility was measured with the final prosthesis. The results for all patients were satisfactory. The periumbilical area has sufficient concentration of subdermal fat, and it is a relatively hair-free region as the lateral quadrant of the buttock. This area is a suitable alternative donor site of dermal fat implant for anophthalmic socket, especially in young women.

Re-evaluation of "reactive lymphoid hyperplasia of the uvea": an immunohistochemical and molecular analysis of 10 cases

OBJECTIVE

Cases of uveal lymphoid proliferation previously classified as reactive lymphoid hyperplasia (RLH) were studied to correlate pathologic features with clinical outcome.

DESIGN

Retrospective case series.

PARTICIPANTS

Ten cases of RLH of the uvea on file at the Armed Forces Institute of Pathology with sufficient formalin-fixed, paraffin-embedded tissue for analysis.

METHODS

Clinical, histologic, immunohistochemical, and molecular (polymerase chain reaction [PCR]) characteristics of uveal lymphoid proliferations were studied.

MAIN OUTCOME MEASURES

Morphologic, immunohistochemical, and PCR characteristics of study cases.

RESULTS

Patient age ranged from 40 to 73 years at time of enucleation, with a mean age of 55 years. Retinal detachment was noted clinically in nine patients and glaucoma in eight. All patients were treated with enucleation, and three received radiotherapy. Histologically, two cases were interpreted as RLH and eight were well-differentiated small-cell lymphoma (WDSCL). Systemic lymphoid infiltrate developed in two patients, but there were no deaths with a mean follow-up of 9.9 years. Mature lymphocytes were noted in the iris and angle structures; the atypical cells of uveal lymphoma were found in the choroid and ciliary body. Eight cases were monoclonal by B-cell and T-cell markers and/or immunoglobulin light chain restriction. Amplifiable DNA was present in 6 of 10 cases by PCR. Three cases monoclonal by cell markers were also monoclonal by PCR, but two cases monoclonal by cell markers could not be confirmed by PCR. Lymphoid follicles with germinal centers were found in two cases of RLH and five cases of WDSCL. Nine specimens demonstrated extraocular lymphoid involvement of the episclera and orbit; most appeared more benign morphologically than the choroidal infiltrates. Extraocular infiltrates of WDSCL were monoclonal by immunohistochemistry in five cases, polyclonal in one case, and indeterminate in two cases.

CONCLUSIONS

Most cases (8 of 10) previously described as RLH were low-grade B-cell lymphomas histologically and by immunohistochemistry. PCR results agreed with histologic diagnosis in four of six cases. Open-angle glaucoma was common and related mostly to lymphocytic infiltration of the angle structures. Extraocular involvement is common but may not be representative of the choroidal lesion. Prognosis is excellent in low-grade uveal lymphoid neoplasia.

Conjunctival melanoma: risk factors for recurrence, exenteration, metastasis, and death in 150 consecutive patients

OBJECTIVE

To identify the risk factors of conjunctival malignant melanoma that predict local tumor recurrence, orbital exenteration, distant metastasis, and tumor-related mortality.

DESIGN

The study group consisted of 150 consecutive patients with a diagnosis of conjunctival melanoma. The clinical parameters of the patient, tumor, and treatment were analyzed in a nonrandomized fashion for their relation to 4 main outcome measures using Cox proportional hazards regression models.

RESULTS

The Kaplan-Meier estimate of local tumor recurrence was 26% at 5 years, 51% at 10 years, and 65% at 15 years. The mean number of recurrences per patient was 1 (median, 0). Ninety-eight patients (65%) had no recurrences, 28 patients (19%) had 1, 11 patients (7%) had 2, 5 patients (3%) had 3, and 8 patients (5%) had 4 or more recurrences. According to multivariate analysis, the factors that predicted local tumor recurrence were the location of the melanoma (not touching the limbus) (P = .01) and tumor-margin pathology (lateral margin involved) (P = .02). Multivariate analysis for features predictive of ultimate exenteration included initial visual acuity (20/40 or worse) (P = .0007), melanoma color (red) (P = .01), and melanoma location (not touching the limbus) (P = .02). Tumor metastasis occurred in 16% of patients at 5 years, 26% at 10 years, and 32% at 15 years. Metastasis was initially in the regional lymph nodes in 17 cases, brain in 4, liver in 3, lung in 2, and disseminated in 1 case. Risks for metastases with use of multivariate analysis included tumor-margin pathology (lateral margin involved) (P = .002) and melanoma location (not touching limbus) (P = .04). Tumor-related death occurred in 7% of patients at 5 years and 13% at 8 years. Risk factors for death with use of multivariate analysis included initial symptoms (lump) (P = .004) and pathologic findings (de novo melanoma without primary acquired melanosis) (P = .05). In a series of univariate analyses, the technique of initial surgery was shown to be an important factor in preventing eventual tumor recurrence (P = .07), metastasis (P = .03), and death (P = .006). Patients who were managed with excisional biopsy using the "no-touch technique" plus alcohol corneal epitheliectomy and supplemental cryotherapy fared far better than those treated with excisional biopsy alone. In addition, the surgical technique used before referral to us was critical. Those patients who had an incisional diagnostic biopsy prior to referral were at risk for more than 1 recurrence (P = .04), and those who had excisional biopsy alone without supplemental cryotherapy were at risk for eventual exenteration (P = .0006) and death (P = .04).

CONCLUSIONS

Conjunctival malignant melanoma is a potentially deadly tumor. In this study, metastasis was detected in 26% of patients and death occurs in 13% at 10 years. The surgical technique of tumor management was found to be possibly related to tumor metastases and death. Meticulous surgical planning, use of wide microsurgical excisional biopsy with the no-touch technique, and supplemental alcohol corneal epitheliectomy and conjunctival cryotherapy performed by experienced surgeons are advised. Incisional biopsy should be avoided.

Histopathological findings of X-linked retinoschisis with neovascular glaucoma

BACKGROUND

X-linked retinoschisis (XLRS) is rarely complicated by neovascular glaucoma. Only a few reports of XLRS histopathological findings with neovascular glaucoma have been published.

METHODS

A 41-year-old man with XLRS complicated by neovascular glaucoma in his left eye was examined with electroretinography, B-scan, ultrasound biomicroscopy and computed tomography. He was examined by ophthalmoscopy and fluorescein angiography in the other eye. An enucleation was performed in his left eye due to uncontrollable high intraocular pressure and persistent ocular pain. We examined the enucleated eye histopathologically.

RESULTS

Examination of the enucleated eye showed nuclear sclerosis of the lens, pigmented retrolental membrane and retinoschisis which separated the inner layer of the retina and made a large space in the vitreous cavity without any apparent detachment of the outer layers of the retina. Sclerotic vessels were present histopathologically in both the inner and outer layers of the retina. There was a peripheral anterior synechia, ectropion uveae and a fibrovascular membrane, which contained many lumina of neovascularization, indicating marked rubeosis iridis. Small cystic spaces were observed in both the schitic retina in the peripheral region and the foveal schisis at the outer layer of the retina. The photoreceptor cells had become markedly atrophied and multiple regions of calcification were observed. The optic nerve showed severe atrophy with gliosis, but the central retinal artery and vein were still open within the nerve.

CONCLUSIONS

These histopathological findings suggest that rubeosis iridis may have developed secondarily to retinal ischemia due to occlusion of the retinal blood vessels.

Effects of proton beam irradiation on uveal melanomas: a comparative study of Ki-67 expression in irradiated versus non-irradiated melanomas

AIMS

To assess the cellular proliferation using the monoclonal antibody Ki-67, in paraffin embedded uveal melanomas irradiated by proton beam, as well as in non-irradiated uveal melanomas.

METHODS

30 enucleated eyes were included for histopathological study and Ki-67 immunostaining. Patients were enucleated between 1991 and 1996 for uveal melanoma, 14 after proton beam irradiation and 16 without treatment (control group). The mean follow up period was 2.5 years after diagnosis and 1 year after enucleation.

RESULTS

A significant relation was found between Ki-67 score and mitotic index (r = 0.56, p = 0.001), histological largest tumour diameter (r = 0.38, p = 0. 03), fibrosis (r = -0.35, p = 0.05), absence of tumoral pigmentation (p = 0.05), and presence of vascular thrombosis (p = 0.03). The Ki-67 score was significantly higher in the non-irradiated group (p = 0.01) and in the group of patients whose cause of enucleation was tumoral evolution (p = 0.005) compared with the group of patients enucleated after neovascular glaucoma. The Ki-67 score was very high in a case of orbital recurrence of uveal melanoma and metastatic death. 70% of metastasised tumours showed a Ki-67 score higher than the median value.

CONCLUSION

Ki-67 labelling is a reliable method of estimating the proliferative activity in uveal melanomas after proton beam irradiation. The Ki-67 score is significantly correlated with prognostic variables (mitotic index and histological largest tumour diameter), and with radiation effects after proton beam irradiation.

[Histological changes related to scleral buckling for treatment of retinal detachment]

Treatment of retinal detachment frequently uses biocompatible materials to obtain scleral buckling. These materials are not devoid of consequences on surrounding tissues. In 3 eyes enucleated for failure of surgical treatment using scleral buckling materials, the changes prompted by episcleral implants could be observed. The sclera underwent both an inversion of its curvature and a reduction of its thickness under the material, as well as an encapsulation of the material was observed. While a silicone sponge was used in part to encircle one of these eyes, its capsular inner surface was regular and smooth. In contrast, hydrogel implants used in the three eyes showed a peripheral fragmentation prompting in two of them a typical foreign body giant cell granulomatous reaction. Changes in scleral curvature and scleral thinning were observed reflecting the consequences of the buckling procedure. The capsule formation occurred as it does for any nonabsorbable matérial implanted in tissues. Degradation and fragmentation of the hydrogel material suscitated a granuloma in response to fragments. These hydrogel specific changes should be recognized on microscopic examination of slides of either capsule or eyes previously in contact with this implanted material. They attested of the instability of hydrogel after implantation.