Diagnostic incisional biopsies in clinically indeterminate choroidal tumours

Most intraocular tumours are reliably diagnosed by a careful clinical examination combined with one or more non-invasive diagnostic techniques. However, in a small percentage of tumours, typically small and clinically amelanotic, the features are insufficiently distinct for a confident clinical diagnosis and tissue is required for diagnosis. We used a 23-G vitreous cutter to access the biopsy site in 43 patients with clinically indeterminate tumours. After retinotomy, an incisional choroidal biopsy yielded a specimen of ∼1 mm(3). Obtained tissue was routinely processed for light microscopy including an immunohistochemical panel of monoclonal antibodies. Adequate tissue for diagnosis was provided in 41/43 (95%) patients. The sensitivity and specificity to detect malignant disease were 0.97 and 1.00, respectively. The positive predictive value was 1.00. Complications included progression of pre-existing retinal detachment in 5/43 (12%) patients and transient rise in intraocular pressure to >40 mm Hg in 6/43 (14%) patients; 4 of these 6 patients had a pre-existing retinal detachment. No patient with a pre-operatively attached retina had a retinal detachment. We conclude that an incisional transretinal choroidal biopsy yields abundant material and may adequately confirm or exclude malignancy in patients with clinically indeterminate tumours. The complication rate can be minimised when patients with pre-existing retinal detachment are excluded from biopsy.

Time trends in the incidence of conjunctival melanoma in Sweden

AIM

To study time trends in the incidence of conjunctival melanoma in Sweden.

METHODS

All patients with conjunctival melanoma from 1960 to 2005 in Sweden were identified through the Swedish Cancer Registry, cross-checked against hospital files, and validated by histopathological review (97.5%) or detailed hospital records (2.5%). The crude and age-standardised incidences were estimated separately for each sex and the annual change in incidence over time was estimated using a regression model with logarithmic incidence numbers. Time trends for the largest diameter, thickness and location of the tumour when diagnosed were analysed.

RESULTS

The age-standardised incidence of conjunctival melanoma increased significantly in men (n = 89) from 0.10 cases/million to 0.74 cases/million (p = 0.001) and in women (n = 81) from 0.06 cases/million to 0.45 cases/million (p = 0.007). The annual relative change in age-standardised incidence was 16.9% (95% confidence interval (CI) 12.2 to 21.6) in men and 19.5% (95% CI 9.3 to 29.7) in women. The age-specific incidence was higher in men and women > or = 65 years (1.48 and 1.39 cases/million, respectively) than in younger men and women (0.3 and 0.2 cases/million, respectively). During the period of study, tumours became smaller (p = 0.005) and thinner (p = 0.002) at the time of diagnosis and increasingly arose from parts of the conjunctiva exposed to ultraviolet radiation (p = 0.001).

CONCLUSION

The incidence of conjunctival melanoma increased in Sweden during the period 1960 to 2005.

Transpupillary thermotherapy of occult CNV with no or minimally classic CNV in age-related macular degeneration

Transpupillary thermotherapy (TTT) has been suggested as a putative treatment for choroidal neovascularization (CNV) in age-related macular degeneration (AMD). This prospective study comprised 66 consecutive patients referred for exudative AMD with predominantly occult subfoveal CNV. Based on fluorescein angiography, there were 38 cases with occult CNV only, and 28 eyes with minimally classic CNV as well. Visual acuity was determined using the logarithmic ETDRS chart. For TTT a diode laser (810nm) with a power of 800 mW or 500-600 mW for a 3.0 mm spot was used (duration 60 sec.). Follow-up included clinical examination with biomicroscopy and fluorescein angiography at 2-3 months and 6 months in all cases. In the entire case material (n = 66), the mean visual acuity was preoperatively 20/125 (47.4 letters) and postoperatively 20/160 (41.8 letters) yielding a decay of 5.6 letters ("one line"). Visual acuity improved in 8 cases (12.1%), deteriorated in 17 (25.8%), and remained stable in 74.2%. In purely occult CNV visual acuity remained stable in 81.6% as compared to 64.3% in occult & minimally classic CNV; the former subgroup lost on the average 3.6 letters, the latter 8.3 letters (close to "two lines") over 6 months. The proportion of eyes losing at least 15 letters was 13.2% in purely occult CNV versus 35.7% in the occult & minimally classic subgroup. In 39 of 66 cases (59.1%) fluorescein leakage regressed to staining only concomitant with absorption of subretinal fluid. Complications associated with deterioration of visual acuity (17 cases) included postoperative hemorrhage, increase of exudation on angiography, and progressive fibrosis. The results indicate that TTT stabilizes visual acuity concomitant with regression of exudation and resorption of subretinal fluid in the majority of cases with predominantly occult CNV Cases with occult CNV only seem to do better than those with minimally classic CNV as well. The safety and complication rate appear to be acceptable. A randomized controlled trial is in progress.

Risk factors for endophthalmitis following cataract surgery: a retrospective case–control study

To gain further knowledge of possible risk factors for the development of postoperative endophthalmitis (POE) following cataract surgery, a single-centre retrospective case-control study was conducted for 1994-2000. In total, 46292 cataract procedures were performed during the study period. Sixty cases of POE were noted and 240 control cases were selected at random. Parameters pertaining to patient history and to peri-operative technique and complications were analysed. The relative risk of POE was calculated using univariate analyses and multi-variate forward stepwise logistic regression. In the logistic regression analyses, three statistically significant parameters were found. The use of intracameral prophylaxis with cefuroxime as opposed to topical treatment alone, and performing phaco-emulsification instead of extra- or intracapsular cataract extraction appeared to be protective against POE. Silicone intra-ocular lenses carried a higher risk than heparin surface modified poly (methyl methacrylate) implants. In summary, the important finding of this study was the protective effect against POE of intracameral prophylaxis with cefuroxime compared with topical anti-infectives alone.

Epiphora as a side effect of topical mitomycin C

AIM

To report symptoms and findings of lacrimal duct malfunction after topical mitomycin C (MMC) for conjunctival neoplasia.

METHODS

14 consecutive patients treated with 1-6 cycles of topical 0.04% MMC four times daily for periods of 2 weeks were interviewed about symptoms of lacrimal duct malfunction. Patients who complained of tearing had examination of the puncta and canaliculi including probing and lacrimal duct irrigation.

RESULTS

Nine patients complained of epiphora after topical MMC. Three of these patients had normal puncta and canaliculi, patent to irrigation. In these patients epiphora ceased spontaneously after probing and irrigation. The additional six patients had stenosis of the punctum (n = 3), the common canaliculus (n = 1), both puncta and both canaliculi (n = 1) and complete occlusion of the lower canaliculus (n = 1).

CONCLUSION

Obstruction of the puncta or canaliculi is not an infrequent event after topical 0.04% MMC.

Cut and paste: a no suture, small incision approach to pterygium surgery

AIM

Evaluation of the benefits of a new technique for pterygium surgery with respect to postoperative pain and surgery time.

METHODS

A prospective randomised clinical trial was carried out in 43 patients. 43 eyes were operated for primary nasal pterygium. Autologous conjunctival graft taken at the superotemporal limbus was used to cover the sclera after pterygium excision. After randomisation, in 20 patients the transplant was attached to the sclera with a fibrin tissue adhesive (Tisseel Duo Quick) and in 23 patients with absorbable sutures (7-0 Vicryl Rapid). The Mann-Whitney test was used as statistical analysis. Postoperative pain was graded according to the visual analogue scale (VAS) twice daily during the first week after surgery. Surgery time was noted from the first incision until the lid speculum was removed.

RESULTS

The average pain was significantly lower when glue had been used, p<0.05. Average surgery time was 9.7 minutes (range 6-13) for glue and 18.5 minutes (range 12-30) for sutures, p<0.001. No complications occurred.

CONCLUSION

Using glue instead of sutures when attaching the conjunctival transplant in pterygium surgery causes significantly less postoperative pain and shortens surgery time significantly.

The Zimmerman-McLean-Foster hypothesis: 25 years later

It is now 25 years since the publication of the landmark article by Zimmerman, McLean, and Foster, in which they cast doubts on the benefit of enucleation, which was the prevailing management of choroidal melanoma at that time. Over the past 25 years several advances have been made in the management of uveal melanoma. Research in the pathobiology of cancer metastasis in general and uveal melanoma in particular has also provided new insights. In this review, the Zimmerman-McLean-Foster hypothesis is explored in the light of current clinical, epidemiological, statistical, and experimental evidence.

The EORTC Ophthalmic Oncology Quality of Life Questionnaire Module (EORTC QLQ-OPT30). Development and Pre-Testing (Phase I-III)

AIMS

The research objective was to develop a questionnaire module to be used, in addition to the European Organisation into Research and Treatment of Cancer (EORTC) QLQ-C30, for measurement of quality of life (QL) among patients with uveal melanoma treated with methods such as transpupillary thermotherapy, plaque radiotherapy, proton beam radiotherapy, local resection, and enucleation. The present paper describes the development through Phases I-III.

METHODS

Relevant QL issues were generated from literature search and from interviews with ophthalmologists, nurses, and patients with uveal melanoma representing three major treatment options: enucleation, plaque brachytherapy, and proton beam therapy.

RESULTS

The provisional module was pretested in 61 patients from Finland, Sweden, and UK. The EORTC QLQ-OPT30 module consists of 26 items for all patients, and four additional items for patients receiving treatments other than enucleation. It measures ocular irritation, vision impairment, headache, worry about recurrent disease, problems with driving, problems with appearance functional problems due to vision impairment, and problems reading.

CONCLUSIONS

Several treatment modalities are available for uveal melanoma. There is limited knowledge of the impact of these treatments on QL in the long and short term. We hope that the OPT30 module together with the EORTC QLQ-C30 core questionnaire can be a useful tool in research.

The Swedish national survey of surgical excision for submacular choroidal neovascularization (CNV)

PURPOSE

To compare the visual outcome after surgical removal of subfoveal choroidal neovascularization (CNV) in patients younger and older than 50 years of age.

METHODS

Patient records from all Swedish centers performing submacular CNV surgery were reviewed and 90 patients treated between 1992-1999 with a follow-up of 6 months or more were included. The results obtained in 49 patients aged 51-89 years (median=72 years) with neovascular disease caused by age-related macular degeneration (AMD) were compared with the outcome of 41 patients aged 6-49 years (median=36 years) with CNV secondary to non-AMD causes. The main outcome measure was the improvement or deterioration in visual acuity (standardized in logMAR units) at 6 months following surgery. Secondary endpoints were recurrent CNV and surgical complications.

RESULTS

The level of preoperative visual acuity was not significantly different between younger patients with CNV associated with non-AMD and older patients with visual loss due to AMD (p=0.069). However, visual acuity at 6 months after surgery was better (p=0.0042) in younger patients (median improvement=0.19 logMAR) than in older patients (median improvement=0.0 log MAR). Marked visual improvement (>1 log MAR unit) was seen in 29% of non-AMD patients <50 years compared to 0% in the AMD group >50 years.

CONCLUSION

Surgical removal of submacular CNV does not appear to improve visual acuity in patients > 50 years of age. However, it may be beneficial for younger patients where a substantial improvement of visual acuity is seen in a subset of these patients. Further studies are required to assess the long-term outcome.

Direct puncture and sclerotherapy with sotradecol ((r)) . Orbital lymphatic malformations

SUMMARY

We evaluated sclerotherapy in the treatment of orbital lymphatic malformations. Six consecutive patients with unilateral orbital cystic masses and recurrent episodes of orbital swelling were included in this retrospective study. All have been treated with percutaneous puncture and injection of Sotradecol (sodium tetredecyl sulphate) under radiographic guidance, on one or more occasions. Reduction of orbital mass volume was documented clinically and radiologically within a few weeks in all cases. There was total regression of proptosis in three instances. There were no immediate complications. One subject suffered a presumably coincidental orbital hemorrhage two weeks after treatment. Follow-up times ranged between six months and four years. Sotradecol sclerotherapy appears to be a useful adjunct to the therapeutic arsenal for orbitallymphatic malformations.

Experimental transplantation of autologous iris pigment epithelial cells to the subretinal space

PURPOSE

To investigate the cellular morphology in the subretinal space following transplantation of iris pigment epithelial (IPE) cells from the same eye.

METHODS

Following an iridectomy, fresh IPE cells were prepared and no culturing performed. After pars plana vitrectomy, a suspension of autologous IPE cells was injected into the subretinal space in 37 rabbits. The grafts were monitored by ophthalmoscopy and colour fundus photography. Rabbits were sacrificed at 1, 2, 3 and 6 months, respectively, and the eyes examined with light and electron microscopy.

RESULTS

The grafted area retained the same configuration over 6 months but then appeared less pigmented. At 1-3 months, the IPE formed one or more contiguous layers on top of native RPE. At 6 months, cells compatible with grafted IPE were present in the subretinal space, often forming monolayer-like chains integrating with the native RPE. Depigmented cells of presumed IPE origin were seen and frequently in association with abundant melanin granules located in the apical portion of adjacent RPE cells. In such areas, large macrophage-like cells were observed.

CONCLUSION

Transplanted IPE cells survived for up to 6 months in the subretinal space. Our observations suggest a scenario of remodelling of the cellular layers in the subretinal space over time where grafted IPE cells formed a compound layer with the native RPE. Transplantation of autologous IPE cells may have a potential as a treatment modality in selected cases of age-related macular degeneration.

Cell proliferation activity in posterior uveal melanoma after Ru-106 brachytherapy: an EORTC ocular oncology group study

AIM

To evaluate the cell proliferation activity in posterior uveal melanomas after Ru-106 brachytherapy.

METHODS

Eyes containing choroidal or ciliary body melanoma from seven ocular oncology centres, which were enucleated after first being treated by Ru-106 brachytherapy and which had enough melanoma tissue to enable histological assessment, were included. The 57 eligible specimens were divided into a group of 44 eyes that were enucleated because of tumour regrowth, and a non-recurrent group of 13 eyes that were enucleated because of complications such as neovascular glaucoma. 46 non-irradiated eyes harbouring uveal melanoma served as a control group. All specimens underwent routine processing. They were cut into 5 microm sections, and were stained with two main cell proliferation markers: PC-10 for PCNA and MIB-1 for Ki-67. The stained sections were assessed, and the cells that were positive in the immunostaining were counted in each section. The results were evaluated by various statistical methods.

RESULTS

The PC-10 score showed a statistically significant difference across the three groups (p = 0.002). The control group showed the highest PC-10 score (median 31.0 PCC/HPF) followed by the tumour regrowth group (median 4.9 PCC/HPF). The lowest PC-10 scores were found in the non-recurrent tumours (median 0.05 PCC/HPF). The MIB-1 score in the control group (median 5.77 PCC/HPF) was similar to the regrowth group (median 5.4 PCC/HPF). In contrast, the MIB-1 score in the non-recurrent tumours was statistically significantly lower (median 0.42 PCC/HPF). The PC-10 and MIB-1 scores were similar in tumours composed of either spindle cells or epithelioid cells in all groups.

CONCLUSIONS

The non-recurrent melanomas demonstrate significantly lower cellular proliferation activity than melanomas that showed regrowth or that were not irradiated at all. In our hands, PCNA gave more meaningful information than Ki-67. Our findings strongly support the need for treating regrowing posterior uveal melanoma either by enucleation or re-treatment by brachytherapy. On the other hand, also in the non-recurrent uveal melanomas there are viable cells with potential for proliferation, although fewer in number, with unknown capacity for metastatic spread. Therefore, the irradiated tumours should be followed for many years, probably for life.

Association of HLA class I and class II antigen expression and mortality in uveal melanoma

PURPOSE

Malignant transformation of cells is frequently associated with abnormalities in human leukocyte antigen (HLA) expression. These abnormalities may play a role in the clinical course of the disease, because HLA antigens mediate interactions of tumor cells with T cells and NK cells. Uveal melanoma is a highly malignant tumor of the eye and is characterized by a hematogenic spread to the liver. Little is known about the role of HLA expression in progression of this malignant disease.

METHODS

In the present study HLA class I antigen, beta(2)-microglobulin (beta(2)-m), and HLA class II antigen expression was analyzed in primary uveal melanoma lesions by immunoperoxidase staining with monoclonal antibodies of 65 archival clinical samples. The results were correlated with the clinical course of the disease.

RESULTS

HLA class I antigen expression and beta(2)-m expression were downregulated in 40 and 35 lesions, respectively. HLA class II antigens were expressed in 30 lesions. Patients with high HLA class I, including beta(2)-m, and HLA class II antigen expression in their primary melanoma lesions had a significantly decreased survival (P = 0.009, P < 0.001, and P = 0.006, respectively).

CONCLUSIONS

The findings argue against a major role of cytotoxic T-lymphocyte (CTL)-mediated control of tumor growth in the clinical course of uveal melanoma and are compatible with a potential role of NK-cell-mediated control of hematogenic metastatic spread.

Homozygous and compound-heterozygous type I plasminogen deficiency is a common cause of ligneous conjunctivitis

Severe type I plasminogen deficiency has been recently linked to ligneous conjunctivitis, a rare and uncommon form of chronic conjunctivitis. In this study, eight unrelated ligneous conjunctivitis patients living in different parts of the world were examined. All affected subjects from which plasma was available displayed absent or markedly reduced plasminogen antigen and plasminogen functional activity. Molecular genetic studies of seven patients identified a Lys19-->Glu mutation in two boys in a homozygous state, and in two girls in a compound-heterozygous state in which the second plasminogen gene carried a missense (Arg134-->Lys) and a nonsense mutation (Cys133--> Stop), respectively. A fifth patient was shown to be homozygous for a frameshift mutation in plasminogen exon 14 (Gly565ins-G). In two unrelated subjects with ligneous conjunctivitis no mutations in the plasminogen gene were identified. Our results suggest that the Lys19-->Glu mutation is the most prevalent mutation in the plasminogen gene of patients with ligneous conjunctivitis.

Transpupillary thermotherapy as an adjunct to ruthenium plaque radiotherapy for choroidal melanoma

PURPOSE

To review the Swedish experience using transpupillary thermotherapy (TTT) as an adjunct to ruthenium plaque radiotherapy for choroidal melanoma.

METHODS

A retrospective chart review of 27 patients receiving TTT for juxtapapillary or juxtafoveal growth present at the time of diagnosis, or recurrent growth at the tumour margin, or significant exudation following ruthenium brachytherapy for choroidal melanoma.

RESULTS

Follow-up ranged from 6 to 29 months (median=20 months). Tumour growth regressed completely (n=8), regressed partially (n=11), remain unchanged (n=6) or progressed (n=2). Complications included focal lens opacity with or without associated posterior synechiae (n=3), retinal haemorrhage (n=2) and retinal vein occlusion (n=1). Seventeen patients (63%) maintained or improved visual acuity and 2 eyes were enucleated following combined treatment.

CONCLUSION

Many of the treated eyes would have been enucleated in the past, suggesting that TTT used in combination with ruthenium brachytherapy improves the short term globe salvage rate. Ocular side effects do occur but are usually not significant.

Angiolymphoid hyperplasia with eosinophilia should not be confused with Kimura's disease

PURPOSE

To emphasize the differences between angiolymphoid hyperplasia with eosinophilia (ALHE) and Kimura's disease (KD), two entities often confused in the ophthalmic literature.

METHODS

Case report of a subcutaneous mass in the periocular region of a 45-year old woman and a MEDLINE review of the ophthalmic and non-ophthalmic literature on ALHE and KD.

RESULTS

The clinical and histopathological findings of the present case were consistent with ALHE, but not with KD. A survey of the current ophthalmic literature indicates that these two designations are still often used synonymously, despite that non-ophthalmic papers now separate ALHE from KD.

CONCLUSION

The clinical and histopathological features of ALHE are most often distinctly different from KD and these entities should be clearly separated in the ophthalmic literature.

Concomitant loss of chromosome 3 and whole arm losses and gains of chromosome 1, 6, or 8 in metastasizing primary uveal melanoma

PURPOSE

To elucidate the genetic differences between metastasizing and nonmetastasizing primary tumors, uveal melanoma samples were screened for DNA copy number alterations by comparative genomic hybridization (CGH).

METHODS

DNA copy number changes were studied on 14 primary uveal melanomas that had not metastasized, 15 primary uveal melanomas that had metastasized, and on 6 metastases that were available from 6 primary uveal melanomas. CGH is based on quantitation of the fluorescence intensity of differentially labeled DNAs. Tumor DNA labeled with FITC dCTP and dUTP and normal DNA labeled with Texas red dCTP and dUTP were hybridized to normal metaphase chromosomes. The hybridizations were analyzed using an Olympus fluorescence microscope and the ISIS digital image analysis system to identify gain or loss of genetic material.

RESULTS

Primary uveal melanomas that had metastasized and metastases had significantly more changes than primary uveal melanomas that had not metastasized. Comparison between primary nonmetastasizing tumors, metastasizing tumors, and metastases showed that the most common DNA copy number changes were -3 (21%, 73%, 67%, respectively), -6q (7%, 40%, 83%), -1p (0, 33%, 33%), -13q (14%, 13%, 50%), -8p (14%, 27%, 0), -18 (7%, 13%, 33%), +8q (14%, 53%, 100%), +6p (29%, 20%, 17%), +1q (0, 7%, 33%), and +16p (0, 7%, 33%).

CONCLUSIONS

Loss of chromosome 3, loss of 6q, and gain of 8q were significantly associated with poor overall survival. In addition, losses of 1p were only found in primary uveal melanomas that had metastasized and in metastases, which suggests that this region may harbor a tumor suppressor gene important in the tumor progression. Finally, loss of chromosome 3 may be associated with isochromosome formation of 1q, 6p, 8q, 16p, 20q, and 22q.

Psychological reactions and quality of life in patients with posterior uveal melanoma treated with ruthenium plaque therapy or enucleation: a one year follow-up study

PURPOSE

To investigate psychological reactions and quality of life among patients with posterior uveal melanoma.

METHODS

Consecutive patients with uveal malignant melanoma (99/106), referred to St Erik's Eye Hospital 1995-1996, treated with rutheniuim plaque radiotherapy (n = 50) or enucleation (n = 49), were included in this non-randomised prospective comparative study. Questionnaires were completed before treatment (Hospital Anxiety and Depression Scale, HAD scale) and 2 and 12 months after diagnosis including the HAD scale, the Impact of Event Scale and the EORTC QLQ-C30. A disease-specific questionnaire was included 12 months after diagnosis. Between-group differences were analysed by chi-square, Student's t-test and ANOVA.

RESULTS

A majority of the patients reported reduced 'Quality of Life' (72-85%), 'Emotional functioning' (60-74%) and 'Cognitive functioning' (51-61%). 'Fatigue' was the most frequently reported symptom (61-72%) followed by 'Insomnia' (43-58%). Anxiety and depressive symptoms were relatively frequent up to 1 year after treatment, but the levels of anxiety decreased during the first year after treatment. Disease and treatment-related problems were reported in both treatment groups 1 year after diagnosis. Enucleated patients had more problems with appearance and judging distances, whereas those treated with radiotherapy reported vision impairment to a higher extent.

CONCLUSIONS

Enucleated patients reported high levels of emotional distress, problems with appearance and judging distances during the first year after treatment. Patients treated with radiotherapy reported similar levels of quality of life and emotional problems, but more problems with visual impairment. These differences in impact on disease-related functioning should be taken into account when treatment options are discussed.

Matrix metalloproteinase (MMP) expression in experimental choroidal neovascularization

PURPOSE

Matrix metalloproteinases (MMP) are a family of proteolytic enzymes that degrade basement membrane and extracellular matrix proteins. To gain information on the possible role of MMPs in choroidal neovascularization (CNV), we have analyzed the mRNA expression of MMP-2 and MMP-9, two forms of MMPs implicated in ocular neovascularization, in a rat model.

METHODS

Choroidal neovascularization was induced in pigmented rats by krypton laser photocoagulation of the fundus whereafter eyes were enucleated at 1, 3, 5, 7, 10 and 60 days. Antisense and sense riboprobes were generated using DNA complementary to MMP-2 and MMP-9, and mRNA expression was analyzed using in situ hybridization.

RESULTS

In the untreated eyes MMP-2 mRNA expression was weakly detected in cells within the choroid. In laser-treated eyes MMP-2 mRNA expression was markedly increased and mainly localized to macrophage-like and retinal pigment epithelial (RPE)-like cells invading the choroid, subretinal space and inner retina. This increase in MMP-2 mRNA expression peaked at day 10 whereafter a decline was detected. MMP-9 mRNA expression was low in untreated eyes and did not increase following laser treatment.

CONCLUSION

The results show that MMP-2 mRNA expression is increased in experimental CNV, and support of a role for MMP-2 in the development of CNV in age-related macular degeneration.

Cellular migration into neural retina following implantation of melanin granules in the subretinal space

BACKGROUND

In some retinal diseases and following transplantation of retinal pigment epithelium (RPE), melanin granules are liberated to the subretinal space. Our aim was to investigate the cellular response to implanted extracellular melanin.

METHODS

After pars plana vitrectomy, 17 albino rabbits received a suspension of melanin granules in the subretinal space. Postoperative examination included ophthalmoscopy, color fundus photography, histology using monoclonal antibodies identifying RPE cells (AE1/3), macrophages (RAM 11), B-lymphocytes (CD20) and T-lymphocytes (CD45), and electron microscopy. The follow-up time was 2 weeks, 4 weeks and 6 months.

RESULTS

On fundus photographs, the layer of melanin showed focal attenuation with lighter areas at 6 months. Melanin granules were phagocytosed by RPE cells and macrophages at 2 weeks, as identified by monoclonal antibodies. In areas where an abundance of melanin was present, multilayers of macrophages were seen associated with considerable photoreceptor damage. Pigment-laden cells invaded the neural retina. The cellular infiltration of the retina was focal, and when it involved the outer nuclear layer the photoreceptor damage was severe. Electron microscopy demonstrated the presence of melanosomes intracellularly in Müller glia. The process of phagocytosis and removal of melanin granules from the subretinal space was slow and not completed at 6 months.

CONCLUSION

Our experiments show that implantation of melanin granules in the subretinal space of albino rabbits may induce a considerable phagocytic cellular response featuring the host's RPE, macrophages and glial cells. The migration of pigment-laden cells into the neural retina was associated with focal photoreceptor damage.

Improvement of the recurrence-free interval using biological adjuvant therapy in uveal melanoma

This study was an attempt to compensate for an alleged aetiological deficiency in melanoma by the prophylactic oral administration of the essential biological components missing. Nine random patients suffering from high-risk uveal melanoma (T3) were, in this preliminary study, treated secondarily with biological dietary adjuvants after primary standard therapy, enucleation or brachytherapy. Secondary treatment consisted of certain natural amino-acids, trace-element salts, folic acid and a diet containing neurogenic lipid components. It entailed no side-effects, no toxicity and was inexpensive. None of these nine patients has suffered recurrent disease. The mean follow-up time was over 80 months (median 69, range 58-140 months). Local tumour control was 100%. This clinical result is significantly better (p = 0.018) as compared to similar T3 uveal melanoma patients in standard care who did not receive adjuvant dietary remedies after primary treatment. The control patients consisted of similar adjusted T3 cases selected from the Swedish official registries, and T2 patients from Germany. Based on the previous positive clinical results obtained with cutaneous malignant melanoma in bioimmunotherapy this additional positive result supports the notion that biological components administered orally may compensate for the etiological deficiency leading to malignant melanoma.

Expression of matrix metalloproteinase-2 (MMP-2) and vascular endothelial growth factor (VEGF) in inflammation-associated corneal neovascularization

Matrix metalloproteinase-2 (MMP-2), matrix metalloproteinase-9 (MMP-9) and vascular endothelial growth factor (VEGF) are all implicated in the development of neovascularization. To investigate the possible role of these factors in corneal neovascularization we have analysed the expression of MMP-2, MMP-9 and VEGF in a rat model of inflammation-associated corneal neovascularization. In this model, corneal neovascularization was induced in Long-Evans rats by krypton laser photocoagulation whereafter eyes were enucleated at 1, 4, 7, 10 and 20 days. Slit-lamp biomicroscopy and histologic analysis revealed a gradual development of corneal neovascularization that peaked 7-10 days after treatment when newly formed vessels could be seen throughout the corneal surface reaching deep into the stroma. Antisense and sense riboprobes were generated using DNA complementary to MMP-2, MMP-9 and VEGF, and mRNA expression was analysed using in situ hybridization. The expression of MMP-2 and MMP-9 in untreated corneas was low or absent whereas VEGF was weakly expressed in the corneal epithelium. MMP-2 expression was increased during corneal neovascularization and was mainly localized to the cells infiltrating areas of new vessel formation. Many of these cells appeared to be inflammatory cells. VEGF expression had a similar overall distribution to MMP-2 during neovascularization with the exception that its expression in the corneal epithelium remained and even increased slightly. MMP-9 was prominently expressed at the border of regenerating corneal epithelium in areas with epithelial wounding but was not detected in the vascularized stroma. Together, the results of the present study support a role for MMP-2 and VEGF in inflammation-associated corneal neovascularization whereas MMP-9 instead appears to be involved in corneal epithelial wound-healing.

Cyclosporine treatment of RPE allografts in the rabbit subretinal space

PURPOSE

To determine the effects of systemic cyclosporine A (CsA) on the survival of retinal pigment epithelial (RPE) allografts in the subretinal space in an animal model using atraumatic transplantation surgery.

METHODS

Following pars plana vitrectomy, an RPE cell suspension from brown rabbits was injected with a glass micropipette into the subretinal space of 39 albino rabbits. For immunosuppression, 22 rabbits were given an injection of CsA, 20 mg daily intramuscularly, 17 rabbits with RPE grafts were controls. The grafts were monitored by biomicroscopy, color fundus photography, and fluorescein angiography. Rabbits were sacrificed at 1, 3 and 6 months, respectively, and the eyes processed for light and electron microscopy including immunohistochemistry.

RESULTS

After three months, the transplanted RPE cells, in both the CsA group and the controls, formed a monolayer in the subretinal space. Although a few macrophages were encountered, there was no massive cellular infiltration and the photoreceptor layer was well preserved. After six months, however, there was a disruption of grafted RPE cells in both groups, characterized by dispersion of melanin pigment in the subretinal space, and invasion of macrophages with focal photoreceptor damage but no infiltration of lymphocytes in the retina or choroid. No significant differences between the CsA treated and the control eyes were discernible.

CONCLUSION

Although the subretinal space has been considered an immunologically privileged site, we found that the survival of RPE allografts was limited. CsA did not prevent RPE allograft destruction in the subretinal space. The transplant seems to be disrupted either by immunological mechanisms that are not inhibited by CsA, or by nonimmunologic events.

Pigmented spindle cell naevus of reed presenting in the conjunctiva

PURPOSE

This study aimed to present the clinical and histopathological features of a pigmented spindle cell naevus (PSCN) appearing in the conjunctiva.

METHODS

Histopathological examination of the lesion following excision and review of the pertinent literature.

RESULTS

The features were consistent with those previously recognized in the skin as the PSCN of Reed.

CONCLUSION

The PSCN can appear in the conjunctiva and should not be confused with conjunctival melanoma.

Differential expression of nm23 H-1 protein in conjunctival melanoma and potential precursor lesions

Loss of nm23 gene expression is believed to enhance metastatic spread in diverse human tumors, including skin melanoma. The purpose of this work was to determine the pattern and prognostic relevance of nm23 protein immunoexpression in conjunctival melanoma and potential precursor lesion. Formaldehyde-fixed, paraffin-embedded conjunctival specimens comprising 85 melanocytic lesions (nevi, primary aquired melanosis with and without atypia and primary and locally recurrent malignant melanomas) from 73 patients were used. Sections from all specimens were examined by light microscopy to assess diverse prognostic parameters. Additional sections were then immunostained for nm23 H-1 protein and the immunoreactivity was assessed semi-quantitatively. Survival data for all patients were retrieved from the National Causes of Death Registry of Sweden.Nm23 H-1 protein was differentially expressed in conjunctival melanocytic lesions, however loss of immunoexpression was not more common in melanocytic lesions asociated with a high risk of malignant transformation. Also, primary and recurrent conjunctival melanomas showed an essentially similar nm23 expression pattern and we could not associate the pattern of nm23 immunoexpression with an increased risk for malignant transformation or locally recurrent disease. While there was a tentative separation between cause-specific survival curves after excision for low and high nm23 expression conjunctival melanoma, there was no statistically significant association with metastatic death of patients. However, loss of nm23 protein immunoexpression may still be of some importance as a marker for prognosis in conjunctival melanoma because the present study could only detect large differences in survival. Our results suggest that any potential prognostic value of nm23 immunoexpression would be independent of other markers, underlining the importance of further studies.

Long-term survival after ruthenium plaque radiotherapy for uveal melanoma. A meta-analysis of studies including 1,066 patients

PURPOSE

Most case series of patients managed by brachytherapy for uveal melanoma are small and survival data show considerable inter-study variation. The aim of this study was to summarise similarly structured case series by meta-analysis.

METHODS

A systematic review generated 5 similarly structured case series including survival data for 1,066 patients treated by ruthenium plaque radiotherapy for uveal melanoma. After assessing the inter-study clinical heterogeneity, data were weighed for study size and pooled.

RESULTS

Patient and radiotherapy characteristics were largely homogenous, but tumour size varied considerably between studies. The 5-year melanoma-related mortality rate was 6% for small and medium tumours (T1/T2) and 26% for large (T3) tumours. The 5-year and 10-year melanoma-related mortality rates for a balanced set of tumours with small, medium and large tumours being present in similar proportions were 14% and 22%, respectively.

CONCLUSION

Case series of patients with uveal melanoma managed by brachytherapy may be pooled to increase sample size and study power. The present estimate of survival following ruthenium plaque radiotherapy compares favourably with previously summarised data of survival after enucleation for similarly sized tumours.

Blue light induced apoptosis in rat retina

PURPOSE

To explore cell death in blue light induced retinal damage.

METHODS

Sprague-Dawley rats reared under cyclic light were exposed continuously to diffuse blue light (400-480 nm) at 0.64 W/m2 for 3 or 6 h after 22 h of dark adaptation. The rats were kept in darkness and killed immediately, 8, 16 and 24 h following light exposure. The retinal damage by the blue light was examined with a transmission electron microscope. The cell death was characterised by in situ terminal dUTP nick end labelling (TUNEL) and gel electrophoresis.

RESULTS

During the 24 h following light exposure, photoreceptor cell death was characterised by progressive condensation and margination of the chromatin, shrinkage or convolution and fragmentation of the nucleus, condensation of the cytoplasm, and formation of apoptotic bodies along with rapid removal of dying cells from damaged areas in the absence of inflammatory response. The TUNEL-positive nuclei were scattered individually in the outer nuclear layer just after light exposure. A wave of massive TUNEL labelling of photoreceptor nuclei peaked at 8-16 h and dropped at 24 h following light exposure. The distribution of TUNEL-positive nuclei was located predominantly at the upper temporal region of the retina, which was the most sensitive area to the damage caused by blue light. Furthermore, the multiples of internucleosomal cleavage of 180-200 base pairs were demonstrated at corresponding time points.

CONCLUSION

Photoreceptor cell apoptosis is seen early after the retina is damaged by blue light.

BK virus as the cause of meningoencephalitis, retinitis and nephritis in a patient with AIDS

BACKGROUND

The two widely spread human polyomaviruses, BK virus (BKV) and JC virus (JCV) establish latency in the urinary tract, and can be reactivated in AIDS. JCV might cause progressive multifocal leucoencephalopathy, but although up to 60% of AIDS patients excrete BKV in the urine there have been few reports of BKV-related renal and/or neurological disease in AIDS.

OBJECTIVE

To report on an AIDS patient with progressive renal and neurological symptoms involving the retina.

DESIGN

Case report.

SETTING

Venhälsan, Söder Hospital, Stockholm, Sweden.

METHODS

The brain, eye tissue, cerebrospinal fluid, urine and peripheral blood mononuclear cells were analysed by nested PCR for polyoma-virus DNA. Macroscopical and microscopical examination were performed of the kidney and brain post mortem. Immunohistochemical stainings for the two BKV proteins, the VP1 and the agnoprotein, were performed on autopsy material and virus infected tissue culture cells.

RESULTS

BKV could be demonstrated in the brain, cerebrospinal fluid, eye tissues, kidneys and peripheral blood mononuclear cells.

CONCLUSION

During 6 years, approximately 400 cerebrospinal fluid samples from immunosuppressed individuals with neurological symptoms have been investigated by PCR for the presence of polyomaviruses. BKV DNA has, so far, only been found in the case reported here. Although reports of BKV infections in the nervous system are rare, there is now evidence for its occurrence in immunocompromised patients and the diagnosis should be considered in such patients with neurological symptoms and signs of renal disease. The diagnosis is simple to verify and is important to establish.

Phakomatous choristoma may be located in the eyelid or orbit or both

PURPOSE

Phakomatous choristoma is a rare congenital tumour of lenticular origin. The exact location at clinical presentation is controversial, but herein we provide evidence that phakomatous choristoma may be located in the lower eyelid or orbit or both.

METHODS

Case report of an infant presenting with a mass in the lower eyelid at birth, a systematic review of previous cases of phakomatous choristoma and an outline of the histopathological features in normal mid-facial embryonic development at different gestational ages.

RESULTS

The histopathological features of the present case were consistent with those of a phakomatous choristoma. The preoperative imaging studies and clinical findings at surgery suggested that the tumour occupied parts of both the lower eyelid and anterior orbit. Histopathological sections of a normal human embryo showed that at the 26-mm stage of development the embryonic lens is formed but the bony walls defining the orbit are not yet present.

CONCLUSION

Phakomatous choristoma arises in a setting of undifferentiated mesenchymal tissue which later may develop into the lower eyelid or orbit depending on the choristomatous elements being deposited superficial or deep to the embryonic surface.

Long-term outcome of RPE allografts to the subretinal space of rabbits

PURPOSE

To determine the long-term RPE allograft survival in the subretinal space using suspensions of RPE cells and atraumatic transplantation surgery.

METHODS

Nineteen albino rabbits were transplanted with suspensions of pigmented RPE cells from brown rabbits. Following pars plana vitrectomy, the RPE cell suspension was injected through a small retinotomy using a glass micropipette into the subretinal space under microscopic control. No immunosuppression was used. The eyes were monitored by biomicroscopy, color fundus photography, and fluorescein angiography. Rabbits were sacrificed at 1, 3 and 6 months, respectively, and the eyes processed for light and electron microscopy, using monoclonal antibodies for identifying macrophages.

RESULTS

Transplanted RPE cells were present in the subretinal space in all eyes at 6 months. There was no fluorescein leakage. Generally, the RPE allograft formed a monolayer, but focal fragmentation and disruption with dispersion of melanin pigment occurred. Foci of multilayers of cells in the subretinal space, containing large macrophages, were associated with adjacent photoreceptor damage. There was no infiltration of lymphocytes but macrophages and glial cells were contiguous to the transplant. Cells harboring intracytoplasmatic melanin pigment were observed in the neural retina.

CONCLUSION

Transplantation of RPE cell suspensions to the subretinal space generally forms a monolayer that persists at 6 months. However, in areas of multilayers of RPE cells and macrophages, graft failure occurs in combination with adjacent photoreceptor damage. Graft failure is not associated with the infiltration of lymphocytes, but other mechanisms seem to occur.

Compound-heterozygous mutations in the plasminogen gene predispose to the development of ligneous conjunctivitis

Homozygous type I plasminogen deficiency has been identified as a cause of ligneous conjunctivitis. In this study, 5 additional patients with ligneous conjunctivitis are examined. Three unrelated patients (1 boy, 1 elderly woman, and 1 man) had plasminogen antigen levels of less than 0.4, less than 0.4, and 2.4 mg/dL, respectively, but had plasminogen functional residual activity of 17%, 18%, and 17%, respectively. These subjects were compound-heterozygotes for different missense mutations in the plasminogen gene: Lys19 --> Glu/Arg513 --> His, Lys19 --> Glu/Arg216 --> His, and Lys19 --> Glu/Leu128 --> Pro, respectively. The other 2 patients, a 14-year-old boy and his 19-year-old sister, who both presented with a severe course of the disease, exhibited plasminogen antigen and functional activity levels below the detection limit (<0.4 mg/dL and <5%, respectively). These subjects were compound-heterozygotes for a deletion mutation (del Lys212) and a splice site mutation in intron Q (Ex17 + 1del-g) in the plasminogen gene. These findings show that certain compound-heterozygous mutations in the plasminogen gene may be associated with ligneous conjunctivitis. Our findings also suggest that the severity of clinical symptoms of ligneous conjunctivitis and its associated complications may depend on the amount of plasminogen functional residual activity.

Panorama of orbital space-occupying lesions. The 24-year experience of a referral centre

PURPOSE

The aim of this survey was to study the frequency and management of orbital lesions requiring incisional or excisional biopsy for diagnostic or therapeutic purposes.

METHODS

A histopathological review of specimens from 300 consecutive patients with space-occupying orbital lesions managed over a period of 24 years at a tertiary referral centre.

RESULTS

The lesions could be attributed to 73 different entities with low-grade, non-Hodgkin lymphoma being the most common. More than half (54.3%) of lesions were neoplastic and malignant disease was present in 29.0% of patients. The majority of lesions were biopsied using the anterior transseptal or transconjunctival approach.

CONCLUSION

Most orbital space-occupying lesions requiring biopsy are benign and easily accessible. However, the diversity of these rare lesions and complexity of management suggest that patient care is best provided by a team of experienced subspecialists at a designated orbital centre.

Identification of BK virus in a patient with acquired immune deficiency syndrome and bilateral atypical retinitis

OBJECTIVE

To report the clinical and histopathologic characteristics of BK virus (BKV) retinitis.

DESIGN

Case report.

TESTING

The clinical features of bilateral retinitis in a 29-year-old homosexual white male with the acquired immune deficiency syndrome (AIDS) included focal, mottled fundus pigmentation, and haloes, as documented by fundus photography. After death of the patient, the left eye was studied by light microscopic and immunohistochemical examination. The nested polymerase chain reaction (PCR) was used to detect viral deoxyribonucleic acid (DNA) in the right eye and other nonocular tissues. The specificity was then confirmed by restriction enzyme analysis.

RESULTS

The retina of the left eye showed focal necrosis and contained cells with intranuclear staining for the BKV VP1 protein. In the right eye, BKV DNA was detected in the retina and other tissues by nested PCR. Autopsy showed that BKV infection was also present in the brain, kidneys, and peripheral blood mononuclear cells.

CONCLUSIONS

A number of pathogens may cause retinitis in patients with AIDS. The authors have shown that BKV should be included among those pathogens and that some clinical features may suggest the presence of BKV retinitis.

Matrix metalloproteinases and metalloproteinase inhibitors in choroidal neovascular membranes

PURPOSE

Matrix metalloproteinases (MMP) are a family of extracellular matrix degrading enzymes associated with the development of neovascularization. To investigate the possible role of these enzymes in choroidal neovascularization, the mRNA expression of MMPs and tissue inhibitors of metalloproteinases (TIMPs) were analyzed in subfoveal fibrovascular membranes from patients with age-related macular degeneration (AMD).

METHODS

Surgically removed subfoveal fibrovascular membranes from five eyes were analyzed for the expression of MMP and TIMP mRNA. In situ hybridization anti-sense and sense riboprobes were generated using DNA complementary to human collagenase (MMP-1), 72 kDa gelatinase (MMP-2), stromelysin (MMP-3), 92-kDa gelatinase (MMP-9), TIMP-1, TIMP-2, and TIMP-3. Vascular endothelial cells were detected using immunostaining for von Willebrand factor.

RESULTS

MMP-2 and MMP-9 mRNA were detected in all specimens. Most of the membranes also expressed TIMP-1 and TIMP-3 mRNA, and two of the membranes expressed TIMP-2 mRNA. MMP-2, TIMP-1, and TIMP-2 mRNA had a similar overall distribution that was relatively uniform within the vascularized membrane stroma. MMP-2 expression appeared to be localized mainly to the vascular endothelial cells, whereas TIMP-1 and TIMP-3 were detected in other cell types such as fibroblastlike cells. MMP-9 expression was distinctly expressed by cells at the margins of the membranes and often in proximity to a thickened Bruch's membrane-like layer under the retinal pigment epithelial cells. TIMP-3 mRNA was strongly expressed within the retinal pigment epithelial cell layer and also in the stroma of one membrane. None of the membranes showed detectable MMP-1 or MMP-3 expression.

CONCLUSIONS

The results support a role for MMPs in the development of choroidal neovascularization in AMD. The localization of MMP-2 and MMP-9 to the areas of new vessel formation and to the enveloping Bruch's-like membrane, respectively, suggests that MMP-2 and MMP-9 may be cooperatively involved in the progressive growth of choroidal neovascular membranes in AMD.

Risk of acute suprachoroidal hemorrhage with phacoemulsification

PURPOSE

To establish whether small incision cataract surgery with phacoemulsification decreases the risk of acute suprachoroidal hemorrhage (ASCH) compared with traditional nucleus expression by extracapsular cataract extraction (ECCE).

SETTING

St. Erik Eye Hospital, Stockholm, Sweden.

METHODS

A retrospective study was done on the incidence of ASCH in cataract surgery between July 1990 and July 1996. During this period, 37,565 cataract extractions (phacoemulsification and ECCE) were performed at St. Erik Eye Hospital, combined procedures excluded. The criteria for diagnosis were the suspicion of ASCH during surgery and a verified diagnosis via an expulsive hemorrhage into the wound (4 cases), postoperative ultrasonic examination (20 cases), or a choroidal mass on performing ophthalmoscopy together with a postoperative history alluding to the diagnosis (2 cases).

RESULTS

Twenty-six eyes were identified with ASCH, including 7 during phacoemulsification and 19 during ECCE. The incidence of ASCH was 0.03% in the 23,213 phacoemulsification cases and 0.13% in the 14,352 ECCE cases. The difference was statistically significant (P = .0003; chi-square test).

CONCLUSION

Small incision surgery with phacoemulsification decreased the risk of ASCH in cataract surgery compared with the traditional nucleus expression technique.

Prognostic accuracy of the mean of the largest nucleoli, vascular patterns, and PC-10 in posterior uveal melanoma

OBJECTIVE

This study aimed to compare the prognostic value and the predictive accuracy of the PC-10 cell cycling marker with the largest tumor diameter, the mean of the largest nucleoli, and vascular patterns in posterior uveal melanoma.

DESIGN

The study design was a case-control study.

PARTICIPANTS

Eyes enucleated for posterior uveal melanoma from patients who either died of metastatic melanoma or survived without signs of metastatic disease 10 years or more after surgery were studied.

INTERVENTION

Three observers assessed the above prognostic indicators and standard histopathologic characteristics from microslides without access to survival data.

MAIN OUTCOME MEASURES

Univariate and multivariate Cox models for survival were constructed, and a multiparameter prognostic index was calculated for each patient, based on covariates obtained from the final Cox model. The prognostic accuracy was determined by receiver operating characteristic curve analysis.

RESULTS

The log PC-10 count, vascular networks, mean of the largest nucleoli, largest tumor diameter, age of patient, and prognostic index were independently associated with outcome. However, each of these indicators had no more than a poor-to-moderate predictive accuracy, and only the prognostic index was significantly better than the largest tumor diameter.

CONCLUSIONS

The PC-10 count retains a prognostic value in uveal melanoma when adjusting for the effect of the mean of the largest nucleoli and diverse vascular patterns. A prognostic index combining two or more indicators may improve the predictive precision.

Conjunctival melanoma

Conjunctival melanoma is an uncommon tumor that is likely to recur and carries an overall mortality rate of approximately 30%. The seemingly unpredictable and enigmatic character of this entity has initiated much debate over the past decades regarding the etiology, histogenesis, prognosis, and preferred management. This review outlines the historical perspective; incidence and demographics; etiologic factors; histogenesis; cytogenetic findings; clinical characteristics; histopathologic and ultrastructural features; differential diagnoses; classifications; management of primary, recurrent, and systemic disease; survival after conjunctival melanoma; and diverse factors of potential prognostic significance. Finally, a brief outlook on present and future research objectives is provided.

Localization of adenosine receptor messenger RNAs in the rat eye

Adenosine is present in all cells and body fluids and has been suggested to play several roles in the physiology of ocular tissues. The present study was undertaken to determine which types of adenosine receptor mRNAs are present in the rat eye, and where they are expressed. RNA or deoxyoligodeoxynucleotides complementary to rat adenosine receptor subtypes A1, A2A, A2B and A3 were used to generate 35S labeled antisense and sense probes. The probes were then used for in situ hybridization on 10 microm cryosections of the rat eye including the cornea, iris, ciliary body, lens, retina, choroid and sclera. A1, A2A and A2B receptor mRNAs were demonstrated in the ciliary processes. A1 receptor mRNA was also expressed in the ganglion cell layer of the retina. The retina also showed A2A receptor mRNA expression, which was most prominent in the inner nuclear layer and less prominent in the ganglion cell layer and outer nuclear layer. Weak A2A expression was found in the retinal pigment epithelium and choriocapillaris. No significant expression of A3 receptor mRNA was found in the rat eye. In conclusion, using in situ hybridization, we have demonstrated expression of mRNA for A1, A2A and A2B adenosine receptors in the rat eye. The expression patterns support specific roles for adenosine in the ciliary process and retina.

Photoreceptor decay over time and apoptosis in experimental retinal detachment

BACKGROUND

Data are scarce on the actual rate and mode of outer nuclear layer decay in retinal detachment (RD). We used an experimental rabbit model to assess the presence of apoptosis and rate of photoreceptor death following RD. This model included the creation of localized and stable retinal blebs, while controlling for any decline of retinal elevation over time.

METHODS

RD was produced in New Zealand white rabbits by injecting 0.05 ml of 15% sodium hyaluronate (Healon GV) under the neural retina using a microsurgical technique. Animals were killed at 1, 2, 4, 7, 14 and 29 days. Retinal tissue was processed for light and electron microscopy and for in situ end labeling of fragmented DNA using a modification of the TUNEL technique. Photoreceptor cell nuclei were counted in the RD areas of maximum retinal elevation of 28 eyes, and an additional 4 eyes were used for nick end labeling.

RESULTS

Positive DNA nick end labeling, ultrastructural features and absence of necrotic cells indicated apoptotic photoreceptor cell death. Also, there was a rapid, almost linear elimination of photoreceptor nuclei over time. At 14 days only half of the number of nuclei were discernible, while approximately one tenth remained after 29 days. There was a statistically significant, but minimal decline in RD height over the 4 weeks of study.

CONCLUSION

Following experimental RD in rabbits, apoptotic cell death is associated with an almost linear elimination of photoreceptor cells over time. The use of highly viscous sodium hyaluronate in separating the neural retina from the retinal pigment epithelium allows the RD to maintain a nearly constant height over a period of 4 weeks.

Tumour cell proliferation after failed ruthenium plaque radiotherapy for posterior uveal melanoma

Enucleation following ruthenium plaque radiotherapy for posterior uveal melanoma indicates failure of treatment. This study focused on the histopathological findings and remaining tumour cell growth fraction in 42 of 46 patients with failed ruthenium plaque treatment (of 266 patients treated) for melanoma of the choroid or ciliary body. The cause for enucleation was clinically detected tumour regrowth in 27 (64%) patients, treatment-related ocular side effects in 12 (29%) cases and the patient's personal preference in three (7%) cases. The median time elapsing from plaque radiotherapy to enucleation was not significantly different for patients with recurrent tumour growth (23 months) compared to those enucleated without clinical signs of regrowth (19 months). While all tumours showed some regressive features by histopathological examination, only five melanomas were completely necrotic and viable-appearing tumours cells were present in all of the remaining 37 (88%) irradiated tumours. Microwave processed PC-10 immunostainings increased the sensitivity to detect cycling cells compared to the sole use of mitotic cell counts. By the former technique, proliferating tumour cells were detected in 17 of 23 (74%) studied melanomas of eyes enucleated for tumour regrowth following brachytherapy. Also, the number of cycling melanoma cells was similar to that of non-irradiated controls managed solely by enucleation. In contrast, the proliferative compartments of irradiated, but non-recurrent, posterior uveal melanomas were significantly reduced compared to those of matched controls. Still, cycling tumour cells were present in four of 13 (31%) irradiated melanomas, clinically assumed to be successfully treated.

Results following episcleral ruthenium plaque radiotherapy for posterior uveal melanoma. The Swedish experience

The Swedish experience of ruthenium 106 plaque radiotherapy for posterior uveal melanoma includes 266 patients treated between 1979 and 1995. The median dose delivered at the tumour apex was 100 Gy and the median follow-up after radiotherapy was 3.6 years (range = 0.5 to 12.5 years) with no patient being lost to follow-up. Visual acuity deteriorated moderately following treatment but appeared to stabilize after 5 to 6 years. Treatment failure defined as enucleation following plaque treatment occurred in 46 of the 266 (17%) studied patients. The cumulative 5-year probability of retaining the eye after radiotherapy was 82% and by univariate analysis tumour height, tumour diameter and tumour stage each predicted subsequent treatment failure, whereas in multivariate analysis no single covariate retained a predictive value. Forty-five of the 266 patients died of any cause during follow-up; 27 of these deaths were melanoma-related. The cumulative 5-year survival proportion (based on melanoma-related deaths only) was 86%. Death in metastatic disease appeared to be more common among patients that failed ruthenium plaque radiotherapy, however these patients also tended to have large tumours.

Expression of vascular endothelial growth factor (VEGF) in retinoblastoma but not in posterior uveal melanoma

All solid tumors must acquire a vascular stroma to grow beyond a minimal size. Vascular endothelial growth factor (VEGF) is a potent and specific angiogenic growth factor both in vitro and in vivo that may participate in the formation of the vascular tumor stroma. In the present study, we examined the expression of VEGF in the paraffin sections of 20 eyes harboring retinoblastoma or posterior uveal melanoma, but also in corresponding tumor cellines. By using in situ hybridization, we found that all but one of the retinoblastomas expressed VEGF mRNA. Particularly high expression was detected in areas of loosely packed tumor cells with prominent chromatin. By contrast, none of the posterior uveal melanomas expressed significant amounts of VEGF mRNA. Immunostaining with an antibody against VEGF confirmed that retinoblastomas, but not posterior uveal melanomas, also contained detectable VEGF protein. To further study the expression of VEGF in these tumor cells we performed Northern blotting on a retinoblastoma celline, Y79, and on an uveal melanoma celline, OM431. Both of these cellines expressed low levels of VEGF mRNA under normal culture conditions. However, when the cells were cultured under hypoxic conditions, a strong increase in VEGF mRNA could be seen in Y79 cells but not in OM431 cells. By using a bioassay, we also found that hypoxia stimulated the secretion of VEGF protein into the culture medium of Y79 cells. In conclusion, we have shown that VEGF mRNA and protein are expressed in retinoblastomas but not in posterior uveal melanomas. Moreover we have shown that VEGF is hypoxia-inducible in retinoblastoma cells. These results suggest that focal hypoxia may act as a stimulus for VEGF production in retinoblastomas, that in turn may contribute to tumor growth by stimulating the formation of a vascular stroma.

Posterior uveal melanoma. The Swedish perspective

Posterior uveal melanoma is the most common primary intraocular malignant tumour and in Sweden some 70-80 new cases present each year. While uveal melanoma is more prevalent in the setting of ocular melanocytosis and neurofibromatosis, there is little conclusive data on the aetiology. Most patients experience a progressive visual field defect and present with a grey or greyish-brown mass of the posterior choroid. Diagnostic procedures include fluorescein angiography, ultrasound and magnetic resonance imaging. In some cases, intraocular biopsy may be required to make a correct diagnosis. Posterior uveal melanomas can usually be managed by any of a number of eye-preserving options like plaque radiotherapy and charged particle irradiation, but eyes containing large tumours are often enucleated. Nearly half of patients with posterior uveal melanoma, and in particular those with large tumours, ultimately succumb to metastatic disease. While most patients with tumour dissemination are treated with systemic chemotherapy possibly combined with interferon, metastatic spread confined to the liver may potentially be managed by intraarterial perfusion chemotherapy or liver resection. However, outcome of patients with systemic disease remains extremely poor with a median survival following detectable tumour dissemination of only two to five months. There are still insufficient data on the impact of various treatments on survival, but a large prospective trial addressing this issue is in progress. The present review summarizes the state-of-the-art knowledge and current management of posterior uveal melanoma from a Swedish perspective.

Subfoveal fibrovascular membranes in age-related macular degeneration express vascular endothelial growth factor

PURPOSE

Vascular endothelial growth factor (VEGF) is a potent and specific angiogenic growth factor, in vitro and in vivo, that may be associated with the development of intraocular neovascularization. In the current study, the authors analyze the expression of VEGF in subfoveal fibrovascular membranes from patients with age-related macular degeneration.

METHODS

Surgically removed subfoveal fibrovascular membranes from 18 eyes were analyzed for the expression of VEGF mRNA and protein using in situ hybridization and immunohistochemistry, respectively.

RESULTS

Most specimens expressed both VEGF mRNA and protein. The VEGF mRNA expression was particularly high in areas with a marked inflammatory response, in which the expression was concentrated to cells resembling fibroblasts and to surrounding inflammatory cells. VEGF protein expression was seen in fibrovascular parts of the membranes and was predominantly localized to the cytoplasm of fibroblastlike cells. In some of these membranes, strong VEGF protein immunoreactivity also was concentrated to extracellular matrix foci within the fibrovascular stroma.

CONCLUSIONS

Results indicate that VEGF may be of pathogenetic importance for the development of the choroidal neovascularization (age-related macular degeneration) and also may implicate a role of fibroblasts of presumable choroidal origin in this process.