The Pediatric and Young Adult Choroidal and Ciliary Body Melanoma Genetic Study, A Survey by the European Ophthalmic Oncology Group

Purpose

To explore the genetic background of choroidal and ciliary body melanoma among children and young adults, with special focus on BAP1 germline variants in this age group.

Methods

Patients under the age of 25 and with confirmed choroidal or ciliary body melanoma were included in this retrospective, multicenter observational study. Nuclear BAP1 immunopositivity was used to evaluate the presence of functional BAP1 in the tumor. Next-generation sequencing using Ion Torrent platform was used to determine pathogenic variants of BAP1, EIF1AX, SF3B1, GNAQ and GNA11 and chromosome 3 status in the tumor or in DNA extracted from blood or saliva. Survival was analyzed using Kaplan-Meier estimates.

Results

The mean age at diagnosis was 17 years (range 5.0-24.8). A germline BAP1 pathogenic variant was identified in an 18-year-old patient, and a somatic variant, based mainly on immunohistochemistry, in 13 (42%) of 31 available specimens. One tumor had a somatic SF3B1 pathogenic variant. Disomy 3 and the absence of a BAP1 pathogenic variant in the tumor predicted the longest metastasis-free survival. Males showed longer metastasis-free survival than females (P = 0.018).

Conclusions

We did not find a stronger-than-average BAP1 germline predisposition for choroidal and ciliary body melanoma among children and young adults compared to adults. Males had a more favorable survival and disomy 3, and the absence of a BAP1 mutation in the tumor tissue predicted the most favorable metastasis-free survival. A BAP1 germline pathogenic variant was identified in one patient (1%), and a somatic variant based mainly on immunohistochemistry in 13 (42%).

Subconjunctival Ocular Argyrosis following Treatment with Ruthenium 106 Brachytherapy for Choroidal Melanoma

Introduction

Ruthenium-106 (Ru-106) brachytherapy is one of the commonest eye-sparing treatments for choroidal melanoma. These patients require long-term surveillance of the treated tumour remnant to ensure there is no local recurrence. New or progressive pigmented lesions in treated eyes are often regarded as suspicious - especially if there are concerns of extra-scleral extension.

Case Presentations

We present two cases of posterior choroidal melanoma treated five and 10 years previously with Ru-106. Both cases developed subconjunctival dark/black lesions on the anterior surface of the eye in the quadrant of the conjunctival peritomy during Ru-106 treatment. Both had similar findings on histopathology: black, non-organic, particulate foreign material of varying confluence deposited on elastin and collagen fibres. Energy dispersive X-ray microanalysis confirmed the material contained silver.

Discussion

The Ru-106 applicator consists of a radioactive core of Ru-106 encapsulated within pure silver as a radiation shield. During surgical insertion, stainless steel suture needles and forceps can occasionally scratch the applicator's silver eyelets and scatter microscopic particles of elemental silver into the operative field. These particles were likely deposited within the subconjunctival tissues of these patients during brachytherapy administration, leading to localised ocular argyrosis. Iatrogenic ocular argyrosis should be considered in the differential diagnosis of new pigmented lesions in patients treated with Ru-106 brachytherapy. This study is the first to unequivocally identify the cause of some post-brachytherapy ocular surface pigmentation as caused by silver.

Oedipism: An unusual case of auto-enucleation including mechanism of avulsion

INTRODUCTION

Self-inflicted enucleation, also known as auto-enucleation (AE) or Oedipism, is an uncommon and severe form of ocular injury which presents as an ophthalmic and psychiatric emergency. Usually known to occur with untreated psychosis, this case is a rare report which demonstrates AE as a result of a subsequently diagnosed drug induced psychosis. We report the clinical presentation, management and for the first time a detailed speculative account about the mechanism of AE, based on our clinicopathologic findings.

CASE REPORT

A 53-year old Afro-Caribbean patient was arrested following an altercation and was incarcerated awaiting arraignment. The patient had no previous psychiatric history but tested positive for cannabis, opiates and cocaine as well as admitting to illicit drug use in the community. Whilst in custody, the patient self-enucleated his right eye. The patient declined consent to eye examination and was subsequently admitted under section 2 of the Mental Health Act. After full work-up including Goldmann visual fields and magnetic resonance imaging, he underwent right orbital exploration under anesthetic where AE was confirmed whilst the left eye showed evidence of attempted enucleation. The residual tenons and conjunctiva was subsequently repaired without placement of an orbital implant in the right orbit. The globe was sent for histology which revealed clues to the potential mechanism of auto-enucleation.

CONCLUSION

This case is unique as it offers an alternative presentation to those most commonly reported in the current literature, highlights the sparsity of literature detailing the mechanism of AE and stimulates discussion around various potential systemic etiological differential diagnoses, management strategies and complications of AE.

Cutaneous Malignant Melanoma Metastasis to the Pseudophakic Lens Capsule with Associated Granulomatous Intraocular Inflammation

Intraocular cutaneous melanoma metastasis (ICMM) is a rare event, accounting for only 5% of all metastases to the eye and orbit. The vast majority of such metastases primarily affect the choroid and vitreoretinal structures. Only three previous cases of predominant lens structure ICMM have been reported in the literature. Histological examination, in all three past cases, was performed on enucleation specimens of painful blind eyes. We present the first case of ICMM to the lens capsule in a comfortable, seeing, pseudophakic eye. This was histologically confirmed following diagnostic pars plana vitrectomy and capsulotomy, and was found to be associated with background granulomatous intraocular inflammation. The potential causes of the granulomatous inflammation are discussed.

Conjunctival 'mucoepidermoid carcinoma' revisited: a revision of terminology, based on morphologic, immunohistochemical and molecular findings of 14 cases, and the 2018 WHO Classification of Tumours of the Eye

In 2018, the consensus meeting for the WHO Classification of Tumours of the Eye decided that conjunctival mucoepidermoid carcinoma should be reclassified as adenosquamous carcinoma, as this represented a better morphological fit. To examine the applicability of this terminology, we studied the clinical, histopathological, immunohistochemical and molecular pathology of 14 cases that were originally diagnosed as conjunctival mucoepidermoid carcinoma. There were 7 (50%) females and 7 (50%) males. The median age was 64 years. The left eye was affected in 8 and the right eye in 6 patients. In-situ carcinoma was present in 11/14 (79%) cases and comprised in-situ squamous cell carcinoma (SCC) and conjunctival intraepithelial neoplasia with mucinous differentiation (CIN-Muc). Invasive carcinoma was present in 11/14 (79%) cases. Group 1 (1/11 cases, 9%) comprised invasive SCC only. Group 2 (6/11 cases, 55%) comprised SCC with mucinous differentiation, manifesting as scattered intracellular mucin, occasionally together with intercellular mucin, with no evidence of true glandular differentiation. Group 3 (3/11 cases. 27%) comprised true adenosquamous carcinoma. Group 4 (1/11 cases, 9%) comprised pure adenocarcinoma. Thirteen of 14 cases (93%) underwent FISH for MAML2 translocation and none were rearranged. Two cases harboured high-risk HPV (type 16 and 18). The combined findings confirm that all lesions in our study were not mucoepidermoid carcinoma, but represented predominantly SCC with mucinous differentiation and adenosquamous carcinoma. We, therefore, recommend future revision of the WHO classification to include SCC with mucinous differentiation alongside adenosquamous carcinoma.

Paraneoplastic Granulomatous Vitritis: Elaboration of 8 Cases

PURPOSE

To describe the clinical features in a series of 8 patients with cytologically proven granulomatous vitritis in the context of systemic malignancy.

DESIGN

Retrospective case review series from 2004 through 2018 to identify all cases of cytologically proven granulomatous vitritis and to analyze its disease associations and causes.

PARTICIPANTS

Twenty-three patients with a cytologic diagnosis of granulomatous vitritis were identified, 8 of whom demonstrated systemic malignancy.

MAIN OUTCOME MEASURES

To identify a clinical profile of the 8 cases of granulomatous vitritis occurring in the setting of systemic malignancy, focusing on the timing of the eye presentation compared with the timing of the systemic malignancy.

METHODS

Patients with a cytologic diagnosis of granulomatous vitritis seeking treatment from 2004 through 2018 were included in this retrospective case series. Case notes were recalled and reviewed for demographic features, medical history, presenting symptoms, investigations, surgical procedures, and follow-up.

RESULTS

Twenty-three patients were diagnosed cytologically with granulomatous vitritis. Ten of 23 patients (43%) showed autoimmune and infectious causes, 5 of 23 patients (22%) showed were idiopathic causes, and 8 of 23 patients' (35%) disease was associated with systemic malignancy. In the latter group, the median age at presentation was 70 years (range, 55-89 years). Six patients showed bilateral disease, and the remaining 3 showed unilateral disease. Three of 8 patients showed primary systemic malignancy diagnosed after eye symptoms and 5 of 8 showed malignancy before the eye symptoms. These latter 5 patients all demonstrated a major relapse, metastasis, or both at the time of eye symptoms.

CONCLUSIONS

Paraneoplastic vitritis is primarily a disease of older age, with 67% of those affected older than 65 years. Ophthalmologists should maintain a high index of suspicion of paraneoplastic cause in bilateral posterior segment inflammation of uncertain origin, presenting for the first time, or heralding malignancy recurrence or metastasis in known cases of malignancy.

Gamma-irradiated human amniotic membrane decellularised with sodium dodecyl sulfate is a more efficient substrate for the ex vivo expansion of limbal stem cells

The gold standard substrate for the ex vivo expansion of human limbal stem cells (LSCs) remains the human amniotic membrane (HAM) but this is not a defined substrate and is subject to biological variability and the potential to transmit disease. To better define HAM and mitigate the risk of disease transmission, we sought to determine if decellularisation and/or γ-irradiation have an adverse effect on culture growth and LSC phenotype. Ex vivo limbal explant cultures were set up on fresh HAM, HAM decellularised with 0.5M NaOH, and 0.5% (w/v) sodium dodecyl sulfate (SDS) with or without γ-irradiation. Explant growth rate was measured and LSC phenotype was characterised by histology, immunostaining and qRT-PCR (ABCG2, ΔNp63, Ki67, CK12, and CK13). Ƴ-irradiation marginally stiffened HAM, as measured by Brillouin spectromicroscopy. HAM stiffness and γ-irradiation did not significantly affect the LSC phenotype, however LSCs expanded significantly faster on Ƴ-irradiated SDS decellularised HAM (p<0.05) which was also corroborated by the highest expression of Ki67 and putative LSC marker, ABCG2. Colony forming efficiency assays showed a greater yield and proportion of holoclones in cells cultured on Ƴ-irradiated SDS decellularised HAM. Together our data indicate that SDS decellularised HAM may be a more efficacious substrate for the expansion of LSCs and the use of a γ-irradiated HAM allows the user to start the manufacturing process with a sterile substrate, potentially making it safer.

STATEMENT OF SIGNIFICANCE

Despite its disadvantages, including its biological variability and its ability to transfer disease, human amniotic membrane (HAM) remains the gold standard substrate for limbal stem cell (LSC) culture. To address these disadvantages, we used a decellularised HAM sterilised by gamma-irradiation for LSC culture. We cultured LSCs on fresh HAM, HAM decellularised with NaOH, HAM decellularised with sodium dodecyl sulfate (SDS) and HAM decellularised with SDS and sterilised with gamma-irradiation. We demonstrated that although HAM decellularised with SDS and sterilised with gamma-irradiation is significantly stiffer this does not affect LSC culture growth rate or the phenotype of cultured LSCs. We therefore recommend the use of SDS decellularised gamma-irradiated HAM in future LSC clinical trials.

Late Solitary Extraocular Recurrence From Previously Resected Iris Melanoma

PURPOSE

To report on cases of late extraocular relapse of previously resected iris melanoma, without concurrent intraocular recurrence.

DESIGN

Retrospective case series.

METHODS

A retrospective chart review of 4 patients diagnosed with late subconjunctival relapse of previously resected iris melanoma.

RESULTS

Three female patients and 1 male patient underwent iris tumor resection and presented to our service with suspicious conjunctival lesions at a median of 22 years later (mean: 21 years). None showed intraocular relapse. Treatment of the conjunctival tumors included excisional biopsy (n = 4), followed by cryotherapy (n = 3) and/or brachytherapy (n = 3). In all cases, histopathology confirmed malignant melanoma, with no intraepithelial component or associated melanosis. Genetic sequencing (n = 3) showed wild-type BRAF and NRAS in all. GNA11 mutation was found in 1 case. On array-based comparative genomic hybridization (n = 3), gain of 6p was found in 2 cases and gain of 8 in 2. Overall, findings were strongly suggestive of a diagnosis of late extraocular relapse from previously resected iris melanoma. In a median of 2.5 years (mean: 7.7 years) from the subconjunctival relapse, no further episodes of intraocular/extraocular recurrence were recorded, and all patients were free from distant metastasis.

CONCLUSIONS

Patients undergoing iris melanoma resection are at risk of developing late solitary extraocular relapse even more than 30 years after surgery. In the absence of an intraocular component, diagnosis may be challenging, as tumors mimic a primary conjunctival lesion. Management by excisional biopsy followed by adjuvant therapy was successful, and histopathology and genetic analysis supported a diagnosis of extraocular uveal tumor spread rather than a primary conjunctival tumor.

Early and Late Histological and Ultrastructural Findings in Resected Infantile Capillary Hemangiomas Following Treatment with Topical Beta-Blocker Timolol Maleate 0.5

Background

Infantile capillary hemangiomas (IHs) affect approximately 4-5% of infants. The systemic nonselective β-adrenergic antagonist, propranolol, has become the standard first-line treatment for severe IHs. The topical β-antagonist, timolol maleate, has also demonstrated efficacy and safety in treating superficial and some deep capillary hemangiomas. Despite their therapeutic success and prevalent use, the mechanism of action of β-adrenergic antagonists in the treatment of IHs is not well understood.

Methods

Histopathological and electron microscopic evaluation of two periocular IHs excised at 1 week and 24 months following topical timolol treatment was performed.

Results

Distinct morphological differences were observed between spontaneously regressed and β-antagonist-treated IHs. The former was characterized by diffuse collagen deposition and interstitial fibrosis, while the latter showed organized concentric collagen IV deposition within obliterated vessel lumen, suggestive of waves of endothelial cell apoptosis, leaving behind layers of basement membrane deposits as a stress response.

Conclusions

Based on these observations, we hypothesize that, apart from their well-known cardiac and vasodilatory effects, β-antagonists could induce endothelial cell apoptosis in IH leading to endovascular occlusion and we present supporting evidence to explain why this response might be specific to hypoxic tissue.

Unusual ocular presentations of ocular phaeohyphomycosis

PurposePhaeohyphomycosis are melanin-containing fungi that rarely infect the eye. We describe three cases of ocular infection with some unusual clinical features.MethodsSeries of three case reports describing three different presentations of phaeohyphomycosis of the eye, their histopathology, and management.ResultsCase 1 mimicked an inflamed conjunctival naevus and was excised on this basis, revealing a conjunctival retention cyst containing pigmented fungal hyphae. Case 2 showed a wooden foreign body incidentally associated with pigmented fungal hyphae, which required treatment with topical antifungal therapy. Case 3 clinically was thought to be a perforated uveal melanoma and comprised an extensive plaque of pigmented fungal hyphae over ulcerated cornea.ConclusionThe pigmented melanin containing hyphae of phaeohyphomycosis mimicked melanocytic lesions in two cases and was an incidental finding in the context of a surface foreign body.

Abstract 4231: Analysis of FFPE treated clinical tissue sections obtained from human intraocular malignancy, uveal melanoma by mass spectrometry imaging (MSI)

Introduction

Clinical research into human intraocular disease UM FFPE tissue sections is described. UM remains the most common intraocular malignancy in adults, with poor prognosis for UM within the choroid region and distant sites UM metastasis. Two imaging MS techniques Matrix Assisted Laser Desorption/Ionisation (MALDI) and Desorption Electrospray Ionisation (DESI) MSI were applied. Molecular profiles were obtained and analysed by multivariate statistical approaches, providing insight into the biochemical and biological differences/similarities within the patient sample cohort (n = 15).

Methods

Enucleations were collected over 6 years and subjected to the standard fixation and paraffin embedding protocols. In preparation for MS, 5 μm sections were produced with removal of the paraffin followed by heat induced antigen retrieval.

MALDI MSI tissue sections were prepared by applying a matrix solution onto the tissue sections to help ionization of molecules directly from the tissue. All MSI experiments (MALDI and DESI) were carried out using a SYNAPT mass spectrometer (Waters Corporation, Manchester, UK). Multivariate analyses were performed using MATLAB (MathWorks, Inc., Natick, MA, US) and the Eigenvector PLS_Toolbox.

Results

Initial MALDI MSI images acquired with a spatial resolution of 100 μm x 100 μm in positive ion mode showed distinct spatial distribution of many molecular species throughout the choroid, cornea, retina, lens and UM tumor regions. Further MALDI MSI experiments using consecutive tissue sections at 50 μm x 50 μm spatial resolution show substantial variation in the spatial distribution of species within the low molecular mass range. DESI MSI experiments were carried out at 200 μm x 200 μm in negative ionization mode. Deprotonated molecular ions were detected from a variety of lipid related species, localized to specific regions within the eye including the tumor region.

Multivariate analysis classified UM samples (good vs. poor prognosis). Using unsupervised PCA, an unbiased representation of the data was generated, with clear sample grouping and differentiation observed based upon tumor status. Use of the supervised PLS-DA technique provided even clearer separation between the selected samples, with tumor profiles displaying dominant discriminatory peaks. These peaks could be identified as sphingolipids and Lyso-phosphocholine, a phosphatidylcholine degradation product.

Conclusions

It was possible to analyze clinical research FFPE tissue sections by MALDI and DESI MSI, illustrating that specific small molecular species remained localized to certain tissue types including the UM tumor. Initial correlation with tumor status was determined from the statistical analysis of the MALDI MSI datasets.

Citation Format: Laura M. Cole, Hardeep S. Mudhar, Karen Sisley, Andrew Peck, Mike Batey, Emmanuelle Claude, Malcolm Clench. Analysis of FFPE treated clinical tissue sections obtained from human intraocular malignancy, uveal melanoma by mass spectrometry imaging (MSI). [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4231.

Regression of invasive conjunctival squamous carcinoma in an HIV-positive patient on antiretroviral therapy

Case history of an African woman presenting with advanced HIV and a painful conjunctival lesion is presented. A conjunctival biopsy revealed invasive squamous cell carcinoma, with orbital invasion on computed tomography scan. She was commenced on antiretroviral therapy. She refused surgery to remove the eye and orbital contents (exenteration), and was referred to palliative care. Gradually, her immune status and ocular symptoms improved. At ophthalmic review, the tumour had apparently completely regressed. This unprecedented phenomenon may be due to antiretroviral therapy. Discussion covers conjunctival carcinoma and behaviour of HIV-related tumours with antiretroviral therapy. Antiretroviral drugs may offer a better alternative to disfiguring surgery in the future.

Adult alveolar rhabdomyosarcoma of the lacrimal sac

Lacrimal sac tumours are rare, but must be considered in the diagnosis of patients presenting with masses in the medial canthal region. We report a single case of lacrimal sac rhabdomyosarcoma in a 31-year-old man. The patient self-presented to the eye department with a 4-week history of discomfort, epiphora and a medial canthal mass. After no response to 1 week of oral antibiotics for a presumed diagnosis of dacryocystitis and the presence of firm mass extending above the medial canthal tendon, surgical exploration was carried out which revealed a lacrimal sac mass. Histologically this showed an alveolar rhabdomyosarcoma, which was confirmed on immunohistochemistry. After 4 rounds of chemotherapy and 50.4Gy of radical radiotherapy, the patient is well with no signs of further local or distant disease at 11-months follow-up and 20 months following initial diagnosis. To our knowledge, there are no previously reported adult cases of lacrimal sac alveolar rhabdomyosarcoma in the peer-reviewed literature. We want to highlight the unique diagnosis in this case as well as drawing attention to the possibility of malignancy in patients responding poorly to management when an initial diagnosis of dacryocystitis is made in the presence of a medial canthal mass.

PAX6 mutation in association with ptosis, cataract, iris hypoplasia, corneal opacification and diabetes: a new variant of familial aniridia?

BACKGROUND

We report a family with ptosis, cataract, iris hypoplasia and gradual corneal opacification occurring in association with a PAX6 mutation.

DESIGN

Case-series.

PARTICIPANTS

Fourteen family members - 8 affected, 6 unaffected controls.

METHODS

All participants underwent ophthalmological assessment, including best-corrected visual acuity, slit-lamp-examination, pachymetry, endothelial cell-count, tonometry and dilated fundoscopy. All subjects underwent anthropometry and assessment of glycaemic status. Genetic analysis of the PAX6 gene was performed.

MAIN OUTCOME MEASURES

Presence of ptosis, corneal, iris and lenticular changes, gycaemic and PAX6 status.

RESULTS

All eight affected subjects had ptosis with reduced levator function, anterior polar cataracts, and corneal changes of variable severity - two patients had undergone penetrating keratoplasties, with graft histology revealing conjunctival cells on the cornea and severe fibroinflammatory change. Five patients had iris hypoplasia. One patient had aphakic glaucoma and another had hypoplastic optic discs. Four of the six controls had no ocular features of this syndrome, and two had isolated mild ptosis. There was no difference in height or body mass index between cases and family controls (p > 0.05), but Haemoglobin A1c was greater in the cases (median [interquartile range] 5.6(0.8) vs 5.1(0.3), p = 0.028). Genetic analysis confirmed a pathogenic PAX6 mutation in exon 12 (c1439delC) in all eight patients, but none of the controls.

CONCLUSION

This is the first report of this particular constellation of ocular signs occurring in association with a PAX6 mutation. There was no association with anthropometric features, but affected subjects had worse glycaemia than controls, which may be related to the known role of PAX6 in development of the pancreas.

Hypertensive iridocyclitis associated with delayed onset biopsy proven Cytomegalovirus retinitis

We describe a case of primary hypertensive iridocyclitis with biopsy-proven Cytomegaloviral retinitis. It is an observational case report of a 69-year-old diabetic gentleman on azathioprine for Crohn's disease who presented with recurrent episodes of hypertensive iridocyclitis. On the 4 th attendance in 5 months, a granular white lesion was noted in the temporal periphery of the mid-peripheral fundus and a chorioretinal and vitreous biopsy performed. Vitreous PCR was positive for Cytomegalovirus (CMV). Hematoxylin and eosin staining revealed cytomegalic-like inclusions within necrotic neural retina. Transmission electron microscopy revealed herpes family virus particles and immunohistochemistry demonstrated CMV protein. This case provides further evidence implicating CMV infection in the etiology of hypertensive iridocyclitis. With hindsight, the cumulative effect of diabetes and azathioprine on the immune surveillance system proved sufficient to render the patient susceptible to CMV retinitis.

Three cases of intraocular mesectodermal leiomyoma expressing progesterone and androgen receptors

BACKGROUND/AIMS

A prospective study identified three patients between 2004 and 2010 with mesectodermal leiomyoma. The study was conducted to analyse the presence or absence of sex steroid hormone receptors in mesectodermal leiomyomas.

METHODS

The clinical features were collated. All three patients had operative procedures to either remove or sample the mesectodermal leiomyomas. The tissue was fixed in formalin and exposed to conventional histological processing. Immunohistochemistry using antibodies to androgen (AR), oestrogen (ER), and progesterone (PR) receptors was performed, followed by stain scoring to assess for expression status.

RESULTS

All three cases were confirmed by histology to be examples of mesectodermal leiomyomas. All three expressed sex steroid hormone receptors. One case expressed both PR and AR, one case PR only and another case AR only. None of the cases expressed ER receptors.

CONCLUSION

All three cases displayed some sex steroid hormone receptor expression. This is supportive evidence that sex steroid hormones may have a role in the pathogenesis of this tumour and suggest that it may be amenable to hormonal manipulation therapy, in a manner similar to conventional uterine leiomyomas.

Diagnostic cellular yield is superior with full pars plana vitrectomy compared with core vitreous biopsy

PURPOSE

Vitreous biopsy for the cytological assessment of suspected intraocular lymphoma and vitritis of uncertain aetiology is a standard investigation. The types of specimens generated and the diagnostic rate are variable within and between centres. There are many reasons for this but one observation that has not been considered previously is the differential distribution of cells in the vitreous gel. To test this possibility, five consecutive patients with suspected vitreous involvement by lymphoma or vitritis of uncertain aetiology underwent a core vitreous biopsy immediately before a planned full pars plana vitrectomy (PPV) and the cellularity of the two sampling techniques compared.

METHODS

A prospective study of five consecutive patients requiring vitreous sampling to secure a firm diagnosis. For each of five patients, the core vitreous biopsy specimen was received in a universal tube and the PPV specimen was received in a vitreous cassette. Fluid (0.25 ml) was removed from both specimens, centrifuged and haematoxylin and eosin (H&E) stained slides prepared per sampling method. The slides were examined with a light microscope, the most cellular field selected and the number of cells per mm(2) counted and compared between sampling techniques.

RESULTS

PPV specimen's, revealed a cellularity range that was 7.4 to 78 × (average 31 ×) greater than a core vitreous biopsy. In the two cases of a final diagnosis of intraocular lymphoma, the vitreous core biopsy was non-diagnostic. Furthermore, the PPV specimen generated additional cellular material for numerous ancillary investigations to permit a secure diagnosis.

CONCLUSIONS

The results of this differential vitreous sampling study has strengthened our anecdotal slit lamp clinical observations that inflammatory cells and lymphoma cells are concentrated more in the cortical vitreous. Therefore, vitreous cells have less chance to be sampled if a single core vitreous biopsy is performed. Indeed, the two cases of confirmed lymphoma generated a non-diagnostic core vitreous biopsy. In our centre, this study has lead to PPV being performed as a gold standard on all patients with suspected intraocular lymphoma or vitritis of uncertain aetiology.

Observational prospective cohort study of patients with newly-diagnosed ocular sebaceous carcinoma

PURPOSE

To investigate the epidemiology and clinicopathological management for ocular sebaceous carcinoma (OSC) in the UK.

METHODS

Observational prospective cohort study of patients with newly-diagnosed OSC. The British Ophthalmological Surveillance Unit captured incident cases of OSC between 2008 and 2010. Incident and 6-month follow-up questionnaires from reporting ophthalmologists captured OSC demographic and clinical data.

RESULTS

Data were available on 51 patients with unilateral OSC (response rate 85%). The UK estimated annual incidence was 0.41 cases per million population (95% CI 0.31 to 0.54). Median age was 70 years (SD 14, range 28-98) with 57% women. OSC location was upper lid (54%), lower lid (20%), multicentric (14%) and caruncle (12%). Most common misdiagnoses included chalazion (42%), basal cell carcinoma (30%) and blepharoconjunctivitis (16%), with median delay in diagnosis of 10 months (SD 9, range 0.5-36). Specialist ophthalmic pathologists performed diagnostics in 62%, with pagetoid/intraepithelial spread present in 39%. Misdiagnosis of chalazion (p=0.019) and pagetoid tumour spread (p=0.016) was associated with a significant diagnostic delay (one-way ANOVA/R(2)). Primary surgical management involved excision with reconstruction (49%), primary exenteration (10%) and Mohs surgery (8%). There were three deaths (out of 51) during the study period; one patient died of OSC-related disease and the other two due to other causes.

CONCLUSIONS

This population-based prospective study confirms OSC as a rare cancer in the UK. Masquerade syndromes result in significant diagnostic delays and increase the risk of pagetoid tumour spread. There is considerable UK variation in pathological and surgical management, and ocular reconstruction and radical surgery is often required for OSC due to delayed presentation.

Lens particle glaucoma secondary to untreated congenital cataract and persistent fetal vasculature

Purpose. To present a case of lens particle glaucoma in a child with an untreated unilateral congenital cataract and persistent fetal vasculature (PFV) and to discuss the implications for the management of unilateral congenital cataract.
Methods. A 4-year-old boy presented with a unilateral congenital cataract affecting the right eye. Examination revealed a cataract and PFV. Intraocular pressure (IOP) measured 18 mmHg right, 14 mmHg left, and he was managed conservatively. Nine months later, he attended clinic with a painful right eye. He had quiet anterior and posterior segments but free lens particles in the anterior vitreous and an IOP of 12 mmHg. Over 4 weeks, the IOP rose to 23 mmHg and the patient underwent vitreolensectomy.
Results. The affected eye has at no point become inflamed but macrophages laden with lens proteins were identified during histopathologic analysis of the vitreous. The proposed mechanism in this case is that the PFV weakened the posterior capsule leading to its rupture. The resultant macrophages then caused mechanical obstruction of aqueous outflow through the trabecular meshwork.
Conclusions. Lens particle glaucoma secondary to posterior capsular rupture is a rare form of lens-induced glaucoma. It is common practice to manage conservatively those patients who present late with unilateral congenital cataract. This case highlights the need for vigilant follow-up of these patients to enable lens-induced glaucoma to be detected at an early stage.

A histopathologic study of orbital implant vascularization

PURPOSE

To histopathologically assess the extent and pattern of vascularization of explanted porous polyethylene (PP) and hyrdoxyapatite (HA) orbital implants. To compare the vascularization in PP implants harvested after enucleation versus after evisceration.

METHODS

This is a comparative case series of six orbital implants explanted between 11 months and 5 years and 4 months post implantation. The implants were subjected to histopathological examination with various stains, after complete decalcification.

RESULTS

There were 2 post evisceration, 3 post enucleation and 1 secondary implant. The size of the implants varied from 18 to 23 mm diameter. The reason for explantation was exposure in all the 6 cases with additional infection in 2 cases. Histopathology revealed complete vascularization up to the core of the implant in all the cases. There was evidence of chronic inflammation within all the explanted specimens. Acute inflammation was present at the site of exposure in four of the implants. Three of these implants had additional evidence of necrosis. Two cases with clinically evident infection had Gram positive cocci within the implant. Foreign-body type giant-cells, melanophages and haemosiderin laden macrophages were also observed. Eviscerated specimens showed scleral remodelling and thickening.

CONCLUSION

All the implants were vascularized up to the core. There was histologic evidence of chronic inflammation in all the explanted implants possibly indicating the foreign nature of the implant material. The sclera did not impede vascularization of the implants in eviscerated specimens. We found no difference in the degree of vascularization of the implant in enucleated versus eviscerated implants.

The in vivo modulatory effects of an anterior-chamber microenvironment on uveal melanoma

BACKGROUND

Primary melanoma of the iris, for reasons unknown has a lower metastatic rate compared with primary ciliary-body melanoma. Six histology cases of ciliary-body melanoma were identified that had spread onto the iris surface and into the stroma, representing a change in tumour microenvironment from aqueous humour non-exposure (ciliary-body component) to aqueous humour exposure (iris surface component). This provided an ideal paradigm for investigating the effects of different environments on melanoma.

METHOD

Conventional light microscopy was performed on stained paraffin sections of the identified cases, followed by immunohistochemistry to cell cycle proteins p27 and Cyclin D1. Fluorescence in situ hybridisation (FISH) analysis was conducted on the paraffin sections for changes of chromosomes 3 and 8, associated with poor uveal melanoma prognosis.

RESULTS

Iris surface melanoma cells were smaller compared with the adjacent deeper iris stromal melanoma cells and with those in the ciliary body. Fewer iris surface melanoma cells expressed Cyclin D1 protein, but more expressed p27 protein, compared with the larger iris stromal melanoma cells (paired Wilcoxon signed ranks test: Cyclin D1 p = 0.028; p27 p = 0.046) and with the ciliary-body melanoma cells (paired Wilcoxon signed ranks test: Cyclin D1 p = 0.028; p27 p = 0.028). With FISH, chromosome 3 and 8 alterations were less common among the iris surface melanoma cells than the deeper iris stromal melanoma cells and the ciliary-body melanoma cells, which were consistently characterised by a relative genetic imbalance for chromosomes 3 and 8.

CONCLUSIONS

These data suggest that there are tumour-modulatory factors within the anterior chamber environment that probably select populations of ciliary-body melanoma cells, with a less aggressive, better-differentiated status. Furthermore, it may help explain why iris melanomas generally have a less aggressive course than ciliary-body and choroidal melanomas.

Abscessed porous polyethylene (Medpor) orbital implant: a case report

We report the evolution of clinical features of orbital implant infection in a 42-year-old man. Despite appropriate treatment recurrent conjunctival dehiscence could not be prevented. Explanation of the implant resulted in complete resolution of symptoms. Histopathological examination confirmed focal necrotising acute inflammation with the presence of colonies of the organism in the deep substance of the implant.

Reduced expression of autotaxin predicts survival in uveal melanoma

AIM

In an effort to identify patients with uveal melanoma at high risk of metastasis, the authors undertook correlation of gene expression profiles with histopathology data and tumour-related mortality.

METHODS

The RNA was isolated from 27 samples of uveal melanoma from patients who had consented to undergo enucleation, and transcripts profiled using a cDNA array comprised of sequence-verified cDNA clones representing approximately 4000 genes implicated in cancer development. Two multivariate data mining techniques--hierarchical cluster analysis and multidimensional scaling--were used to investigate the grouping structure in the gene expression data. Cluster analysis was performed with a subset of 10,000 randomly selected genes and the cumulative contribution of all the genes in making the correct grouping was recorded.

RESULTS

Hierarchical cluster analysis and multidimensional scaling revealed two distinct classes. When correlated with the data on metastasis, the two molecular classes corresponded very well to the survival data for the 27 patients. Thirty two discrete genes (corresponding to 44 probe sets) that correctly defined the molecular classes were selected. A single gene (ectonucleotide pyrophosphatase/phosphodiesterase 2; autotaxin) could classify the molecular types. The expression pattern was confirmed using real-time quantitative PCR.

CONCLUSIONS

Gene expression profiling identifies two distinct prognostic classes of uveal melanoma. Underexpression of autotaxin in class 2 uveal melanoma with a poor prognosis needs to be explored further.

Early pathological features of the cornea in toxic epidermal necrolysis

AIM

To describe the early pathological changes in the cornea during toxic epidermal necrolysis (TEN).

METHOD

Demonstration of histological features of sequential corneal samples taken during management of complications of TEN in a young adult.

RESULTS

Early vacuolation of basal keratinocytes and late infiltration of the cornea with CD 8 lymphocytes were observed. These changes are similar to those found in cutaneous TEN and may represent weakening of the stromal-epithelium interface with resultant recurrent erosion and chronic inflammation.

CONCLUSIONS

Similar changes were found in avascular corneal tissue to those previously described in skin. The initial insult may be traumatic. We propose that a cytokine-mediated response contributes to the initial insult, either in response to and/or by accelerating severe inflammation. This precedes a cytotoxic infiltration which may exacerbate episodes of recurrent erosion. This provides a new insight into the mechanism of disease in the cornea following TEN.

Multiplex fluorescence in situ hybridization identifies novel rearrangements of chromosomes 6, 15, and 18 in primary uveal melanoma

Uveal melanomas are the commonest ocular tumour of adults and are characterized by reproducible alterations of chromosomes 1, 3, 6 and 8. These alterations are of prognostic relevance and have also be shown to correlate to high risk and low risk metastatic categories of uveal melanoma as defined by micro-array analysis. It is, however, possible that a catalogue of relevant genetic alterations, involving gene rearrangement rather than amplification, have as yet eluded identification. To address this point we examined 14 primary uveal melanomas, using 24 colour multiplex fluorescence in situ hybridization (M-FISH). All tumours were karyotyped following G-Banding, and M-FISH was performed to confirm and clarify the identity of abnormal chromosomes. M-FISH data were obtained from all tumours and was able to establish the nature of most abnormalities not fully characterized by cytogenetics. Abnormalities of chromosome 6 were far more frequent than previously indicated, in approximately 70% of cases, indicating they have been substantially underrepresented in past studies of uveal melanoma. Spindle melanomas were found to have novel rearrangements affecting in particular chromosomes 6, 15 and 18, suggesting that juxtaposition of genes through translocational events may play a role in the development of some uveal melanomas. In conclusion, this study is the largest of primary uveal melanoma analysed by M-FISH and indicates that alterations of chromosome 6 have previously been underestimated. Furthermore spindle melanomas are prone to rearrangements affecting chromosomes 6, 15 and 18, which may relate to early changes in uveal melanoma development or associate with those melanomas of a more differentiated status.

Colonic angiodysplasia and true diverticula: is there an association?

AIMS

To investigate the pathology of colectomy specimens, from patients presenting with lower gastrointestinal haemorrhage, who had undergone preoperative mesenteric angiography. The angiography diagnoses ranged from active bleeding of unknown aetiology to angiodysplasia.

METHODS AND RESULTS

The macroscopic and microscopic pathology of 11 colectomy specimens was studied. All the specimens contained blood on receipt with no obvious macroscopic source of haemorrhage identified. In all cases the large bowel demonstrated diverticula with an unusual topography. These were wide-mouthed, up to 20 mm across and exhibited a partly scattered distribution across the bowel; in two cases the diverticula contained blood clot. Histology demonstrated true diverticula invested by all muscle layers, exhibiting thick-walled vessels, within the submucosa and within the muscularis propria fibres, resembling the vascular elements identified in congenital vascular malformations. The two cases that contained blood clot revealed the thick-walled vessels to have ruptured into the diverticular lumen. Histology from the background colon between the diverticula demonstrated vascular lesions fulfilling the histological criteria for angiodysplasia; these features were also represented in the true-type diverticula. Most cases showed right-sided angiodysplasia and right-sided true diverticula. However, left-sided angiodysplastic lesions were also seen in association with left-sided true-type diverticula.

CONCLUSIONS

We have identified the dual pathologies of angiodysplasia and multiple true-type diverticula, and suggest a topographical relationship between these two lesions. Furthermore, we propose that the thick-walled vessels within the true diverticula are congenitally abnormal, and raise the possibility that these vessels exert local haemodynamic effects, that effectively predispose the colon to acquired angiodysplastic phenomena.

Mathematical modelling of comedo ductal carcinoma in situ of the breast

The growth of a tumour in a cylindrical duct with compliant walls is examined in order to model the early stages of ductal carcinoma in situ (DCIS) of the breast, the earliest known stage of breast cancer. A nutrient-limited growth model is formulated, in which cell movement is described by a Stokes flow constitutive relation. The interactions between the expansive forces created by tumour cell proliferation and the stresses that develop in the compliant basement membrane are studied using asymptotic and numerical methods. In this way we show how the duct wall deforms as the tumour grows and also how the progression of the tumour along the duct depends upon the stiffness of the wall. By varying key parameters we determine how treatment, protease production and the inclusion of the surrounding stroma affect the growth. Finally, we discuss the biological relevance of our results and suggest possible directions for future work.