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Patel PR, Farrell MC, Peshtani A, Berkenstock MK. Bilateral anterior and posterior scleritis in a patient with acute myelogenous leukemia. Am J Ophthalmol Case Rep 2022; 26:101497. [PMID: 35372712 PMCID: PMC8971595 DOI: 10.1016/j.ajoc.2022.101497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 03/02/2022] [Accepted: 03/22/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Pujan R. Patel
- Drexel University College of Medicine, Philadelphia, PA, USA
| | | | - Ani Peshtani
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Meghan K. Berkenstock
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Corresponding author. Wilmer Eye Institute, 600 N. Wolfe St. Maumenee Third Floor Baltimore, MD, 21287, USA.
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Richardson-May J, Chihaia M, Rashid M. Surgically-induced necrotising scleritis complicated by Nocardia infection following routine cataract surgery. BMJ Case Rep 2022; 15:e247784. [PMID: 35140098 PMCID: PMC8830200 DOI: 10.1136/bcr-2021-247784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 11/04/2022] Open
Abstract
Necrotising scleritis is a rare, inflammatory condition with potentially devastating visual consequences. It can be associated with inflammatory and infectious causes, and has been linked to several different ocular procedures. We present a difficult case of a patient with surgically-induced necrotising scleritis following routine phacoemulsification cataract surgery, who developed a secondary Nocardia bacterial infection. He required a number of surgical interventions and prolonged antibiotic therapy, suffering recurrent scleral abscesses. A literature review accompanies our case report. Prompt recognition and adequate investigation for underlying inflammatory and infective causes are vital to maintain integrity of the globe and ensure suitable treatment of this challenging condition.
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Affiliation(s)
- James Richardson-May
- Ophthalmology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Madalina Chihaia
- Ophthalmology, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
| | - Mohammed Rashid
- Ophthalmology, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
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3
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Kalogeropoulos D, Katsikatsos K, Mitsis M, Kalogeropoulos C. Posterior Scleritis as a Paraneoplastic Syndrome in Colon Cancer: A Case Report. Turk J Ophthalmol 2021; 50:377-380. [PMID: 33389939 PMCID: PMC7802099 DOI: 10.4274/tjo.galenos.2020.99836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
This study presents a rare case of unilateral posterior scleritis as an ophthalmic manifestation of a paraneoplastic syndrome. A 61-year-old man presented to our department complaining of gradual worsening of vision in his left eye. Visual acuity was 10/10 and 3/10 in his right and left eye, respectively. He also mentioned that he experienced posterior ocular pain while sleeping at night, but was otherwise asymptomatic. His past ophthalmic and medical history were clear. A thorough clinical, imaging (fundus photography, optical coherence tomography, fluorescein angiography, and B-scan), and laboratory investigation was carried out. A diagnosis of posterior scleritis was made, but no obvious cause or underlying disease was identified even after a thorough systematic assessment. Regular follow-up within the next few months did not reveal any further pathological findings. Finally, 6 months after the initial presentation, the patient was diagnosed with colon cancer. Posterior scleritis can present as an ophthalmic manifestation of a paraneoplastic syndrome in patients with an underlying malignancy, even months before the presentation of systemic symptoms and diagnosis of the underlying disease. In conclusion, in patients (especially older adults) with posterior scleritis, the possibility of a malignant neoplasia must not be ignored or underestimated (paraneoplastic syndrome).
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Affiliation(s)
- Dimitrios Kalogeropoulos
- University of Ioannina School of Health Sciences Faculty of Medicine, Department of Ophthalmology, Ioannina, Greece
| | - Konstantinos Katsikatsos
- University of Ioannina School of Health Sciences Faculty of Medicine, Department of Ophthalmology, Ioannina, Greece
| | - Michail Mitsis
- University of Ioannina School of Health Sciences Faculty of Medicine, Department of Surgery, Ioannina, Greece
| | - Chris Kalogeropoulos
- University of Ioannina School of Health Sciences Faculty of Medicine, Department of Ophthalmology, Ioannina, Greece
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Shah RK, Lamichhane S. Ocular metastasis from breast carcinoma simulating anterior scleritis: a case report. J Med Case Rep 2017; 11:249. [PMID: 28844204 PMCID: PMC5572158 DOI: 10.1186/s13256-017-1416-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 07/20/2017] [Indexed: 11/18/2022] Open
Abstract
Background Breast cancer is one of the commonest sources of ocular metastasis. Patients with ocular metastatic disease can present with a variable clinical picture. Patients with a history of breast cancer presenting with any eye symptom should be evaluated with consideration of ocular metastasis. Case presentation We report a case of ocular metastasis in a 46-year-old Brahmin woman presenting with right eye pain. She had been treated for stage IIIc left-sided breast cancer 2 years ago with six cycles of chemotherapy with docetaxel, adriamycin, and cyclophosphamide after undergoing modified radical mastectomy. An ophthalmic examination revealed a tender subconjunctival swelling superotemporally on retracting right upper eyelid. This finding alone indicated anterior scleritis. On examining fundus under mydriasis, an amelanotic subretinal mass could be visualized in the posterior pole superotemporal to macula. An orbital magnetic resonance imaging revealed a mass of 2 × 1 cm in size in the subretinal space of her right eye. Computed tomography of her chest was then done and showed multiple metastases in both lungs. Conclusion This case report highlights the fact that any unusual ocular presentation, even one simulating anterior scleritis, in a patient with a history of breast cancer should raise suspicion of metastasis.
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Affiliation(s)
- Ritesh Kumar Shah
- Department of Ophthalmology, Childrens' Hospital for Eye, ENT and Rehabilitation Services (CHEERS), Bhaktapur, Kathmandu, Nepal
| | - Samir Lamichhane
- Department of Clinical Pharmacology, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
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Jakobiec FA, Ramsey DJ, Stagner AM, Wu DM, Yoon MK. Pulmonary Adenocarcinoma Metastatic to the Choroid Diagnosed by Biopsy of an Extrascleral Nodule. Ocul Oncol Pathol 2015; 2:24-8. [PMID: 27171574 DOI: 10.1159/000430098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/30/2015] [Indexed: 11/19/2022] Open
Abstract
PURPOSE/BACKGROUND To report a patient with orbital extension of a choroidal metastasis produced by a pulmonary adenocarcinoma which was diagnosed by biopsy of the extrascleral nodule. METHODS Clinical history and imaging studies (including fundus photography, autofluorescence, fluorescein angiography, B-scan, and orbital MRI) were reviewed along with histopathologic and immunohistochemical studies. RESULTS A 60-year-old woman presented with decreased vision in the right eye. Fundus examination revealed a leopard-spotted choroidal lesion and associated serous retinal detachment. Imaging disclosed an enhancing orbital lesion abutting the sclera near the choroidal mass, which had spread outside of the eye. Histopathology revealed lumen-forming cells elaborating mucin. The cells were immunohistochemically positive for epithelial membrane antigen, thyroid transcription factor 1, and cytokeratin 7 and negative for cytokeratin 20. This was consistent with a pulmonary adenocarcinoma. Widespread metastases were subsequently found. CONCLUSIONS This is the first detailed case report of a successful biopsy of the orbital extension of an essentially posterior intraocular tumor. Such a maneuver permits a much more generous tissue sample than a needle biopsy. In the current case, a large tissue sample provided the basis for complete immunohistochemical evaluation, leading to the diagnosis of an intraocular metastatic mucin-producing adenocarcinoma of lung origin.
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Affiliation(s)
- Frederick A Jakobiec
- Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Mass., USA; David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Boston, Mass., USA
| | - David J Ramsey
- Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Mass., USA
| | - Anna M Stagner
- Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Mass., USA; David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Boston, Mass., USA
| | - David M Wu
- Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Mass., USA
| | - Michael K Yoon
- Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Mass., USA
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Singh N, Kulkarni P, Aggarwal AN, Mittal BR, Gupta N, Behera D, Gupta A. Choroidal metastasis as a presenting manifestation of lung cancer: a report of 3 cases and systematic review of the literature. Medicine (Baltimore) 2012; 91:179-194. [PMID: 22732948 DOI: 10.1097/md.0b013e3182574a0b] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Symptomatic choroidal metastasis is a rare presenting manifestation of lung cancer. We describe here 3 patients with non-squamous non-small cell lung cancer who presented with choroidal metastasis and who were diagnosed and treated by the authors. We performed a systematic literature review of the previously reported patients with choroidal metastasis from lung cancer in the English-language literature. We excluded case series lacking individual patient data and identified 75 patients. In 23 of these patients, choroidal metastasis was not the presenting manifestation of lung cancer. Therefore, we included 55 patients (3 index and 52 previously reported) in the analysis. We present the demographic profile, histology, disease stage, ocular and lung lesions, diagnostic and treatment (systemic and ocular) modalities, and treatment outcomes. The majority of patients were male (67.3%) and were current or ex-smokers (78.3%); the mean age was 55.1 (standard deviation 11.2) years. Adenocarcinoma (n = 23) was the most common histologic type followed by squamous (n = 11) and small cell (n = 8). Left eye (n = 32) involvement was more common than right eye (n = 19) or bilateral (n = 4). Among patients for whom the location of primary lesion was specified, the left upper lobe (n = 13) was the most common site. The most common diagnostic modalities were bronchoscopic lung biopsy (n = 15) and enucleation (n = 13), while the liver (30.9%) was the most common extraocular metastatic site identified. Systemic chemotherapy was given in 56.4% of cases, and disease progression was the most common outcome among evaluable patients. Ocular treatment modalities included radiation (n = 23), enucleation (n = 14), and systemic steroids (n = 8). Regression of choroidal metastases with treatment was observed in 66.7% of patients who did not undergo enucleation as the primary treatment modality. Of the 3 index patients, 2 each received pemetrexed-cisplatin (as first-line therapy), gefitinib or erlotinib (as second- or third-line therapy), and intravitreal bevacizumab; and 1 patient received systemic bevacizumab. Two patients had partial response radiologically with systemic treatment, and all 3 patients had regression of choroidal metastases with ocular treatment. Recommendations regarding systemic and local (ocular) management of patients with choroidal metastasis as the presenting manifestation of lung cancer are provided.
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Affiliation(s)
- Navneet Singh
- From Departments of Pulmonary Medicine (NS, ANA, DB), Ophthalmology (PK, AG), Nuclear Medicine (BRM), and Cytology and Gynecological Pathology (NG), Postgraduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, India
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Nassr MA, Morris CL, Netland PA, Karcioglu ZA. Intraocular pressure change in orbital disease. Surv Ophthalmol 2009; 54:519-44. [PMID: 19682621 DOI: 10.1016/j.survophthal.2009.02.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Accepted: 02/25/2009] [Indexed: 01/18/2023]
Abstract
Intraocular pressure change has been found concurrent with many orbital pathologies, particularly those involving proptosis. The objective of this review is to offer an inclusive classification of orbital disease-related intraocular pressure change, not only for oculoplastics and glaucoma specialists, but also for general ophthalmologists. Various orbital conditions associated with increased intraocular pressure and glaucoma are comprehensively summarized, and pathophysiology, clinical manifestations, and treatment options of these diseases are discussed. Graves disease, arterio-venous shunts, trauma, and orbital neoplasia, and other common conditions are discussed in detail; less frequent syndromes such as orbitocraniofacial deformities, phakomatoses, and mucopolysaccharidoses are included for the sake of comprehensiveness, but discussed less extensively.
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Affiliation(s)
- Mohamed A Nassr
- Hamilton Eye Institute, Health Sciences Center University of Tennessee, Memphis, Tennessee 38163, USA
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Dotchin S, Lakosha H, Heathcote JG, Dickinson J. Uveal metastasis from testicular choriocarcinoma presenting as scleritis. Can J Ophthalmol 2009; 44:210-1. [PMID: 19491960 DOI: 10.3129/i08-182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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10
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Wickremasinghe S, Dansingani KK, Tranos P, Liyanage S, Jones A, Davey C. Ocular presentations of breast cancer. ACTA ACUST UNITED AC 2006; 85:133-42. [PMID: 17305726 DOI: 10.1111/j.1600-0420.2006.00737.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CONTEXT Breast cancer is the most common malignancy in women, with increasing incidence in Europe and North America. The frequency of involvement of the eye and visual pathways is reported to be as high as 30% in patients with known metastatic disease. In some cases, ophthalmic involvement can be the first sign of metastatic spread. Metastasis occurs via the haematogenous route and predominantly involves the choroid. Metastases to other ocular structures, the orbit and the visual pathways have also been described. Paraneoplastic effects are rare but significant. TREATMENTS Different modalities are employed in the treatment of breast cancer and its metastases. These include chemotherapy and radiotherapy. The ocular adverse effects of these have been well described, but recently developed new treatment modalities, such as monoclonal antibodies, may have different side-effects. With the increasing incidence of breast cancer and the advent of new treatment strategies, the complications of the disease and the sequelae of therapy are highly relevant to both oncologists and ophthalmologists.
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Abstract
PURPOSE To report two cases in which malignancy masqueraded as scleritis, delaying the diagnosis. METHODS Two patients initially diagnosed and treated for unilateral scleritis were referred for management of persistent inflammation. Additional evaluation uncovered underlying malignant processes. RESULTS The first patient presented with scleritis initially responsive to systemic corticosteroids, with relapse one month later. Upon referral, peripheral fundus examination revealed elevated lesions. Additional studies confirmed the diagnosis of choroidal melanoma. The patient was treated with proton-beam irradiation. The second patient developed necrotizing scleritis unresponsive to systemic steroids, methotrexate, and cyclophosphamide. A scleral biopsy disclosed an undifferentiated high-grade carcinoma, likely metastatic. Exenteration was performed. CONCLUSIONS Scleritis can present a diagnostic challenge. It is often the sole initial manifestation of an occult systemic problem. Treatment-resistant scleritis should raise the suspicion of an infectious or malignant masquerade.
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Affiliation(s)
- Chrysanthi Kafkala
- Ocular Immunology and Uveitis Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114, USA
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Abstract
Scleritis is typically a severe painful inflammatory process centered in the sclera that may involve the cornea, adjacent episclera, and underlying uvea; it poses a significant threat to vision. Careful clinical history taking, detailed ocular examination, appropriate investigation for ocular disease with or without underlying systemic disease, and timely intervention with the use of immunosuppressant drugs when necessary, has improved the long-term outcome for patients with this disease.
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Affiliation(s)
- Narciss Okhravi
- Department of Clinical Ophthalmology, Institute of Ophthalmology, Moorfields Eye Hospital, City Road, London EC1V 2PD, United Kingdom
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Abstract
BACKGROUND: Malignant melanoma of the uveal tract is a rare malignancy but a significant cause of mortality and visual loss. Approximately 50% of patients diagnosed with a melanoma of the choroid or ciliary body will die of the disease within 15 years of enucleation. METHODS: The author reviewed the current literature on the clinical findings, epidemiology, and treatment of uveal melanoma. RESULTS: Methods of diagnosis have improved substantially in the past several years, although clinical diagnosis by an experienced examiner remains the standard in eyes with clear media. Ultrasound is the most useful adjunctive technique. While enucleation has been the mainstay of therapeutic intervention, alternative therapies - especially different types of irradiation - offer hope for tumor control and vision preservation. The Collaborative Ocular Melanoma Study, a multicenter national trial, is designed to provide long-term data on the natural history as well as therapeutic intervention. CONCLUSIONS: Malignant melanoma of the uveal tract can be diagnosed clinically with more confidence than ever before. It is also possible in many cases to retain the eye and functional vision while controlling the tumor. However, unanswered questions remain about the natural history and optimal therapy of uveal melanoma.
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Affiliation(s)
- MC Kincaid
- Departments of Ophthalmology and Pathology, Saint Louis University Eye Institute, Saint Louis University School of Medicine, St. Louis, Missouri 63104, USA
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Calthorpe CM, Watson PG, McCartney AC. Posterior scleritis: a clinical and histological survey. Eye (Lond) 1988; 2 ( Pt 3):267-77. [PMID: 3402623 DOI: 10.1038/eye.1988.52] [Citation(s) in RCA: 65] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The clinical course of 47 patients with posterior scleritis is reviewed. Though clinical presentation varied widely, 73% of the patients presented with a visual acuity of 6/18 or less. Because the posterior scleritis was not always associated with pain or with anterior scleritis, the diagnosis was often not considered when the patient was first seen. The most common findings in the fundus were disc swelling, retinal detachment, and macular oedema and the most useful investigation was B scan ultrasound. No common aetiology was found, although 60% had a systemic disorder which was accompanied by a vasculitis. Those who were diagnosed and treated with the minimum delay had the most satisfactory visual outcome. However, there appears to be a group of patients with no underlying systemic disease who fail to respond to intensive therapy, and lose vision. A new sub-group of West Indians with the disease is described. The histopathology of 7 cases confirmed the presence of scleral vasculitis of the vessels in and around the sclera in all the specimens. Other significant findings include inflammatory swelling and focal loss of pigment epithelium together with choroidal vascular closure. This could account for the fluorescein angiographic findings.
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Abstract
Posterior scleritis must be considered in the differential diagnosis of many ocular conditions, including angle closure glaucoma, choroidal folds, optic disk edema, circumscribed fundus mass, choroidal detachment, and exudative retinal detachment. Because it is rare, a high index of suspicion is necessary. Anterior scleritis, pain, or a history of collagen-vascular disease, when present, help to alert the clinician to the correct diagnosis. Posterior scleritis affects women more often than men, but annular ciliochoroidal effusion and choroidal folds are more common in men. Exudative macular detachment and a circumscribed fundus mass are more common in women. This paper reviews the world literature on posterior scleritis and describes findings in a series of 43 patients seen at Wills Eye Hospital. It stresses the clinical features and ancillary diagnostic tests that help to establish the diagnosis.
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Affiliation(s)
- W E Benson
- Retina Service, Wills Eye Hospital, Philadelphia, Pennsylvania
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Jakobiec FA, Zimmerman LE, Spencer WH, Slakter JS, Krebs W. Metastatic colloid carcinoma versus primary carcinoma of the ciliary epithelium. Ophthalmology 1987; 94:1469-80. [PMID: 2825094 DOI: 10.1016/s0161-6420(87)33280-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Ocular metastases developed from breast carcinomas in two women 7 and 19 years after their mastectomies. They were both ciliary body metastases that had eroded through the root of the iris to present as unifocal globular, gelatinous (colloid) masses in the anterior chamber, and were amenable to local surgery. Histopathologically, small cellular clusters were widely separated in a sea of mucin; the tumor cells failed to display marked pleomorphism or mitotic activity. In each case, the distinction from a primary mucinous ciliary epithelial neoplasm had to be made both clinically and pathologically. For comparison, the authors also report a unique primary ciliary carcinoma that caused intractable glaucoma by spreading diffusely throughout the iris, ciliary body, and anterior chamber angle, and that necessitated enucleation. The tumor cells failed to produce hyaluronic acid but elaborated a mucosubstance which was histochemically indistinguishable from that of the metastatic carcinomas. This primary neoplasm, however, exhibited the following histologic differences from the metastases: more architectural variability, including garlands and festoons of cells not forming lumens that were suspended in a mucinous matrix; much more abundant intracellular mucin; foci of sheet-like and pleomorphic cellular proliferations with mitotic activity; and partial replacement of the ciliary processes by a comparatively benign-appearing mucinous columnar epithelium.
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Affiliation(s)
- F A Jakobiec
- Department of Ophthalmology, Manhattan Eye, Ear & Throat Hospital, New York
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