[Clinical and sonographic examination findings in patients with carotid-cavernous sinus fistulas]

BACKGROUND

Symptoms and clinical findings in patients with carotid-cavernous fistulas are specific. Nevertheless, they can be very mildly expressed. This study aims to point out the potential diagnostic value of ultrasound of the orbit.

METHODS

A total of 25 patients with a reliable angiographic diagnosis of a fistula were reviewed retrospectively. We analyzed the symptoms, clinical findings and demonstrability in ultrasound of the orbit.

RESULTS

The most common clinical findings were nerve palsy, dilation of episcleral vessels and exophthalmos. If an ultrasound had been part of the examination a dilation of the superior ophthalmic vein could be demonstrated in all cases.

CONCLUSION

The expeditious ultrasound investigation provides valuable information for the diagnosis of red eyes which are resistant to treatment. The examiner has to consider a fistula and perform an ultrasound especially when diplopia has newly occurred. Finally, the expedient neuroimaging can be arranged.

Gastric Adenocarcinoma Presenting as an Eyelid and Conjunctival Mass

A 50-year-old white man complained of “inflammation” of his right eyelid since January 1989. In June 1990, he had undergone a gastrectomy for an adenocarcinoma of the stomach. In August 1990, his right eye showed a painless, firm infiltration of the upper and lower lid, ulceration and loss of eyelashes of the upper lid and a reddish, subepithelial thickening of the medial bulbar conjunctiva. Biopsies of the right upper lid and nasal bulbar conjunctiva disclosed a metastatic, poorly differentiated adenocarcinoma of the stomach (signet ring cell carcinoma) both in the lid and conjunctival biopsies. Carcinoembryonic antigen (CEA) was detected in the tumor cells. Electron microscopic examination revealed tumor cells with signs of secretory activity. Although metastases to the eyelids and conjunctiva are rare, they may precede the clinical manifestation of the primary tumor for months or even years. In patients with chronic, recalcitrant lesions of eyelids or conjunctiva, especially if accompanied by loss of eyelashes, a primary or secondary malignancy should be excluded by early biopsies and histopathological examination.

[Immunotherapy of uveal melanoma: vaccination against cancer. Multicenter adjuvant phase 3 vaccination study using dendritic cells laden with tumor RNA for large newly diagnosed uveal melanoma]

Uveal melanomas are the most common malignant tumors of the eye. With modern molecular biological diagnostic methods, such as chromosome 3 typing and gene expression analysis, these tumors can be categorized into highly aggressive (monosomy 3, class II) and less aggressive forms. This molecular biological stratification is primarily important for determining the risk of these tumors as no therapy is currently available that is able to prevent or delay metastases. A randomized study of patients with a poor prognosis (monosomy 3) is currently being carried out in order to determine whether a cancer vaccine prepared from autologous (patient's own) dendritic cells and uveal melanoma RNA can prevent or delay progression and further metastases of this extremely aggressive form of cancer. Inclusion in the uveal melanoma study, which hopes to provide a potential therapeutic option for patients, is only possible if patients are referred to an institution that is able to manufacture and provide this vaccination before the patient is operated on or treated with radiation. Untreated tumor material is necessary for producing the vaccine on an individualized patient basis.

[Pathology and prognostic factors of conjunctival melanoma]

BACKGROUND

Conjunctival melanoma is a rare but potentially fatal disease. The 10-year melanoma mortality can be up to 30 %, recurrence rates after treatment up to 50 % and the overall incidence of metastasis is 26 %. Improved treatment options are needed to increase the tumor-free survival of affected patients.

OBJECTIVES

The aim of the study was to perform clinical and pathological staging using the TNM classification and to correlate the results with treatment modalities and recurrence rates.

MATERIAL AND METHODS

The study included a case series of 80 eyes from 80 patients (42 females and 38 males, age 28-90 years) with histopathologically proven conjunctival melanoma studied by reviewing medical records, pathology reports and color photographs. The main evaluated characteristics were demographic information, tumor size, thickness, pathological diagnosis, BRAF mutation testing, clinical and pathological staging, recurrence, metastasis and duration of follow-up (mean 48 months).

RESULTS

The lesions predominantly involved the bulbar conjunctiva (60 %) and other sites that were less often involved were the palpebral conjunctiva (23 %), conjunctival fornix (22 %) and lacrimal caruncle (15 %). Of the tumors 36 % were TNM classified as pTis, 34 % as pT1, 20 % as pT2 (palpebral, fornix and caruncle) and 10 % as pT3. Local recurrences were noted in 36 % of the patients (18 % Tis, 26 % T1, 32 % T2 and 70 % T3) and regional and distant metastasis in 20 % of the patients (0 % Tis, 10 % T1, 15 % T2 and 60 % T3).

DISCUSSION

In this study increasing T stages were more often associated with recurrences and metastasis. Future studies correlating the TNM staging with histopathological and genetic predictors may help to improve the management of patients with conjunctival melanoma.

[Sympathetic ophthalmia following repeated pars plana vitrectomy : Clinical findings and spectral domain OCT follow-up]

Sympathetic ophthalmia is a rare form of bilateral granulomatous panuveitis, occurring after penetrating trauma. Hitherto, sympathetic ophthalmia after vitrectomy has only occasionally been described in the literature. This case report presents a female patient with sympathetic ophthalmia after repeated pars plana vitrectomy on the basis of clinical findings and follow-up with fluorescein angiography, spectral domain OCT, and histopathology.

Parapapillary atrophy: histological gamma zone and delta zone

Background

To examine histomorphometrically the parapapillary region in human eyes.

Methodology/Principal Findings

The histomorphometric study included 65 human globes (axial length:21–37 mm). On anterior-posterior histological sections, we measured the distance Bruch's membrane end (BME)-optic nerve margin (“Gamma zone”), BME-retinal pigment epithelium (RPE) (“Beta zone”), BME-beginning of non-occluded choriocapillaris, and BME-beginning of photoreceptor layer. “Delta zone” was defined as part of gamma zone in which blood vessels of at least 50 µm diameter were not present over a length of >300 µm. Beta zone (mean length:0.35±0.52 mm) was significantly (P = 0.01) larger in the glaucoma group than in the non-glaucomatous group. It was not significantly (P = 0.28) associated with axial length. Beta zone was significantly (P = 0.004) larger than the region with occluded choriocapillaris. Gamma zone (mean length:0.63±1.25 mm) was associated with axial length (P<0.001;r² = 0.73) with an increase starting at an axial length of 26.5 mm. It was not significantly (P = 0.24) associated with glaucomatous optic neuropathy. Delta zone (present only in eyes with axial length of ≥27 mm) was associated with axial length (P = 0.001) and scleral flange length (P<0.001) but not with glaucoma (P = 0.73).

Conclusions/Significance

Parapapillary gamma zone (peripapillary sclera without overlying choroid, Bruch's membrane and deep retinal layers) was related with axial globe elongation and was independent of glaucoma. Delta zone (no blood vessels >50 µm diameter within gamma zone) was present only in highly axially elongated globes and was not related with glaucoma. Beta zone (Bruch's membrane without RPE) was correlated with glaucoma but not with globe elongation. Since the region with occluded choriocapillaris was smaller than beta zone, complete loss of RPE may have occurred before complete choriocapillaris closure.

[Micronodular thickening of eyelid margins. Initial findings of a general disease]

A 9-year-old boy presented with bilateral chronic thickening of the upper and lower eyelid margins with bead-like papules. The voice was hoarse due to a previously diagnosed thickening of the vocal cords. There was a history of recurrent abscesses of the parotid gland and of attention deficit hyperactivity disorder (ADHD).The eyelid changes were recognized as monoliform blepharitis and the diagnosis of lipoid proteinosis (Urbach-Wiethe disease) was confirmed by eyelid biopsy. The diagnosis of this systemic disease explained the other signs and symptoms of the patient.

[Neuroradiological diagnosis and interventional therapy of carotid cavernous fistulas]

Carotid cavernous fistulas are pathologic connections between the internal and/or external carotid artery and the cavernous sinus. According to Barrow one can distinguish between direct (high flow) and indirect (low flow) fistulas, whereby direct fistulas are often traumatic while indirect fistulas more frequently occur spontaneously in postmenopausal women. Diagnosis can easily be established using MRI and angiography, which allow exact visualization of the anatomy of fistulas to plan the interventional neurological therapy that in recent years has replaced surgical therapy. This article provides an overview on imaging findings, diagnosis using MRI and angiography as well as interventional treatment strategies.

Untreated ‘blow-in’ fracture of the orbital floor causing a mucocele: Report of an unusual late complication

BACKGROUND

Several severe complications have been described with blow-in fractures. Therefore, immediate surgical treatment of these fractures has been recommended. To date, there is only minimal knowledge on long-term complications of blow-in fractures that have remained untreated. The present case report describes a late complication of an untreated blow-in fracture of the orbital floor.

CASE

A 37-year-old male was involved in a car accident 16 years before. At that time, a non-dislocated midfacial fracture was diagnosed and remained untreated because of the lack of clinical symptoms. Four months before surgery an exophthalmos of the left globe began to develop. CT examination revealed a consolidated blow-in fracture of the left orbital floor and an opaque mass around the dislocated bony fragments. By an infraorbital approach the bony fragments and the surrounding mass were removed. Histological examination of the removed material revealed a cystic structure lined with respiratory epithelium. Therefore, the diagnosis 'post-traumatic mucocele in the orbit caused by dislocated respiratory epithelium from the maxillary sinus' was made.

CONCLUSION

Even if blow-in fractures do not cause complications immediately after trauma, late complications like mucoceles can occur after several symptom-free years. Therefore, early reconstruction should be intended even in asymptomatic cases of blow-in fractures with minimal displacement of the bony fragments.

Klassifikation der Erkrankungen der Augenoberfl�che

The ocular surface consists of the lid margin, conjunctiva and cornea which together with the tear system represent a functional entity. The diagnosis of ocular surface disease can be very difficult due to the similarity of various disease entities. The classification should be made on the pathological and pathophysiological characteristics of ocular surface disease. The first part of the classification comprises diseases of the lid margin, the tear system as well as diseases of the conjunctiva. Both the clinical presentation as well as the underlying pathophysiological and pathological characteristics of the most important ocular surface diseases are reviewed.

[Corneal lipofuscinosis--clinicopathologic study of 10 patients]

BACKGROUND

Lipofuscin pigments are considered indigestible residues of lysosomal activity associated with aging. We present the clinical and histopathological features of ten patients with corneal lipofuscinosis.

PATIENTS AND METHODS

Ten patients (five female, five male, mean age 62 years, range 53 to 77 years) underwent penetrating keratoplasty for vascularized corneal scars. The clinical diagnoses were herpes simplex keratitis (5), zoster keratitis (1), phlyctenular keratitis (1), immunologic graft rejection (2) and corneal injury (1). The mean duration of disease was 6.5 years (range 3 to 11 years). On slit lamp examination both linear and diffuse deposits of yellow pigment were noted in the corneal stroma. All corneal buttons were processed for histopathologic and electron microscopic studies.

RESULTS

The areas of yellowish pigmentation in the corneal stroma corresponded histopathologically to clusters of macrophages, keratocytes and occasional giant cells containing PAS-positive granules. The granules measured 1 to 3 micrometers and were also present extracellularly. Results of Gram stain were negative, but the material showed vivid autofluorescence.

CONCLUSION

Corneal lipofuscin can be detected at the slit lamp as focal or diffuse yellowish deposits in both the superficial and deep corneal stroma of patients with long-standing keratitis. This is in contrast to corneal iron deposits, which appear as yellowish pigment in the corneal epithelium. The identification of corneal lipofuscin is possible using histochemical and autofluorescent studies. Further studies should address whether corneal lipofuscin predisposes to suture loosening.

[Intraocular silicone oil tamponade. A clinico-pathologic study of 36 enucleated eyes]

BACKGROUND

Previous histological studies have shown that intraocular silicone oil induces irreversible changes in ocular tissues, especially the retina. The purpose of this study was to analyze, in a larger group of enucleated eyes, changes in intraocular tissue after silicone oil injection, dependent on intraocular pressure, how long the oil was in the eye, and the viscosity of intraocular silicone oil.

PATIENTS AND METHODS

We did histological examinations on 36 enucleated globes with intraocular silicone oil after vitreoretinal surgery and compared them with 68 enucleated globes treated with buckle and encircling band using immunohistochemistry (n = 5) and electron microscopy (n = 7). For statistical evaluation we used the chi(2) test and analysis of variance.

RESULTS

After silicone oil injection we observed a more pronounced reduction in corneal endothelial cells (58%), more frequent closed chamber angle (86%), atrophy of the ciliary body (80%) (P < 0.05), proliferative vitreoretinopathy (89%), and glaucomatous atrophy of the optic nerve (56%) (P < 0.01). The retinae showed independent of the use of silicone oil a loss of inner and outer segments of photoreceptors and of ganglion cells and thinning and rareficaton of all other retinal layers. Globes with silicone oil revealed vacuoles both free and incorporated by macrophages in all layers of the retina. Similar vacuoles were seen in the optic nerve, choroid, retinal pigment epithelium, ciliary body, iris, chamber angle and the corneal endothelium. Silicone oil vacuoles were seen in the retina and optic nerve by 1 month after surgery in two eyes with high intraocular pressure (42 mmHg). Six of eight eyes with normal intraocular pressure levels showed retinal vacuoles, 3 of them after 2 months. Vacuoles in the optic nerve were found in eight of nine eyes with intraocular instillation of 1000 mPa silicone oil. There was no clinicohistopathological correlation between the presence of vacuoles in the retina or optic nerve and the duration and viscosity of intraocular silicone oil.

CONCLUSIONS

This study suggests that vacuoles in eyes with silicone oil instillation can be found in the retina after 4 weeks. The period of intraocular silicone oil should be limited to 3-6 months.

[Blue nevi of the conjunctiva]

PATIENT AND METHODS

A 54-year-old man presented with multifocal pigmentations of the left bulbar and palpebral conjunctiva. He had first noticed these changes 5 years ago without any evidence of progression. The pigmented lesions were located in the plica, caruncle, the lower fornix and the mucocutaneous junction of the lower lid. The right cornea showed a focal superficial scar paracentrally due to a herpes simplex keratitis in 1970. Visual acuity was 20/20, otherwise the eyes were unremarkable. Biopsies were performed in all areas. One year after surgery, there was no recurrence of the lesions.

MICROSCOPY

Histopathologically, the conjunctival epithelium is essentially unremarkable. The substantia propria display mostly uniformly pigmented spindle-shaped melanocytic cells. Many cells contain coarsely clumped melanin granules. Other areas reveal poorly pigmented to unpigmented melanocytic cells, some of them with Schwannian features. Intranuclear vacuoles are commonly present. The tumor cells are often located in stromal areas displaying increased amounts of collagen. A few polyhydral melanophages are present within the lesion.

DIAGNOSIS

Biopsy A (plica)--blue nevus with areas of cellular blue nevus. Biopsy B (caruncle)--cellular blue nevus. Biopsy C (lower fornix)--cellular blue nevus. Biopsy D (mucocutaneous junction of left lower lid)--Blue nevus.

Schwannoma of the ciliary body treated by block excision

A 26-year-old man developed a non-pigmented ciliary body tumour of his right eye. A 7 mm block excision and tectonic corneoscleral graft were performed. The excised tissue was studied using histopathological, immunohistochemical, and electron microscopic techniques. The tumour revealed characteristic features of a Schwann cell neoplasm including Antoni A and B patterns, acid mucopolysaccharides, S-100, and vimentin positivity, and--by electron microscopy--Luse bodies. It was classified as a schwannoma. Although rare, schwannoma should be included in the clinical differential diagnosis of non-pigmented ciliary body tumours. Local excision should be considered to avoid over-treatment by enucleation.

Necrotic malignant melanoma of the choroid and concurrent intraocular manifestation of malignant non-Hodgkin's B cell lymphoma

An 80-year-old white female developed clinical signs of a large choroidal malignant melanoma in her left eye. There were no signs of metastatic disease, but an asymptomatic chronic lymphatic leukemia was discovered. Histopathologic examination of the enucleated left eye showed a mostly necrotic malignant melanoma of the choroid with areas of spindle B cell differentiation, episcleral extension and secondary angle-closure glaucoma with necrosis of the anterior segment of the eye. On the basis of immunocytochemical studies of the lymphocytic infiltrates in the iridal blood vessels, retinal blood vessels and the choroid, the leukemic disease was classified as B cell lymphoma of low malignancy (lymphoplasmacytoid immunocytoma). A reactive T lymphocytic infiltration of the conjunctival stroma was also noted. Patients with malignant melanomas of the uvea require exclusion of a second malignancy.

[Leiomyoma of the iris--a clinicopathologic case report]

A 20-year-old white man demonstrated a 2-3 mm in diameter ball like, grey white vascularized tumor at 12h in the iris stroma adjacent to the sphincter pupillae OD. The tumor was excised by sector iridectomy. Light microscopically the tumor consisted of densely packed spindle-shaped cells with oval nuclei with granular eosinophilic cytoplasm. Electronmicroscopically numerous 9nm-filaments in parallel configuration were found, fusiform dense formations, basal membranes and pinocytotic vesicles. Positive immunohistochemical reaction for Actin, Desmin and Vimentin, negative for S100.

[Ocular findings in infection-linked immune phenomena and secondary diseases (the so-called Reiter's syndrome)]

Between 1981 and 1987 the authors saw 12 patients with Reiter's syndrome. Lesions included 6 cases of bilateral conjunctivitis in patients with chlamydial infection, 3 of unilateral serofibrinous iridocyclitis in patients with Yersinia enterocolitica, 1 case of bilateral iridocyclitis in a patient with positive chlamydial complement-binding reaction, 1 case of bilateral follicular conjunctivitis following acute gonococcal urethritis, and one case of unilateral serofibrinous iridocyclitis, in a patient with Ureaplasma urealyticum. Immunohistologic work-up of the conjunctival biopsy from the patient with Urea-plasma urealyticum urethritis revealed IgM deposits in the vascular endothelium of conjunctival vessels, C-3 deposits in the conjunctival stroma, and intercellular IgG in the conjunctival epithelium. Since Reiter's syndrome is interpreted as a sequela of secondary immune diseases following a primary infection that may persist in HLA-B27-positive patients, the patients were treated with both topical and systemic anti-infectious and anti-inflammatory agents.

Proliferation of corneal epithelial and endothelial cells in the trabecular region of human donor corneas in organ culture

Thirty corneoscleral rings obtained after trephination of a 4- to 7.5-mm graft and 8 whole corneas with scleral rims were cultured up to 6 weeks. The corneal epithelium grew over the scleral rim and trabecula, and, after 3-4 weeks, was slowly invading the endothelial sheet. Endothelial cells did not show any evidence of migration unless the trabecula was removed. Even then, however, the endothelial growth was very limited and was soon suppressed by fast-growing epithelium.

[Immunocytochemical diagnosis of embryonal rhabdomyosarcoma of the orbit]

The authors report on two patients with embryonic rhabdocytosarcoma of the orbit. The tumor in a nine-year-old girl was classified histologically as being of differentiated type and was characterized immunohistochemically by myoglobin. In a two-year-old girl an embryonic rhabdocytosarcoma of a less differentiated (intermediate) type was found which was characterized immunohistochemically by desmine. The differentiated tumor containing myoglobin, in the nine-year-old girl, responded better to chemotherapy. Eighteen months after institution of therapy both patients are healthy and free of recurrences. Immunocytochemical characterization of embryonic rhabdomysarcomas is clinically important, for both diagnosis and prognosis.

[Pseudokeratoconus in trisomy 21 and posterior polymorphous corneal dystrophy]

The authors examined three members of a family with an autosomal dominant trait of posterior polymorphous corneal dystrophy of varying expressivity. The 67-year-old white mother had a visual acuity of 20/30, with only discrete irregularities at the level of Descemet's membrane. The daughter developed bullous keratopathy with polymorphous ring-shaped opacities in the central area of Descemet's membrane early, in her 34th year. The 25-year-old son, who also had Down's syndrome, presented with the clinical symptoms of acute keratoconus. Light microscopy revealed a thickened, multilaminated Descemet's membrane with vesicles, breaks, and dislocation of endothelial cells into the deep stroma. Transmission electron microscopy showed a normal anterior, ribbonlike portion of Descemet's membrane and a fibroblastic differentiation of the corneal endothelial cells.

[Listeria monocytogenes kerato-uveitis]

An 86-year-old patient with corneal gutae and diabetes presented with a Listeria monocytogenes serpent ulcer on her right eye. Smears taken from the ulcer revealed Listeria monocytogenes serotype 4b. Despite specific antibiotic therapy including cephalosporins and systemic administration of amikacin, as well as topical gentamycin drops, the eye had to be enucleated on the 16th day after hospitalization. Massive fibrinous reaction and extreme pain causing the patient to reject alimentation were the clinical signs at this time. The anterior chamber aspirate taken perioperatively was sterile.

[Phlyctenular keratoconjunctivitis in bacterial epibulbar infections]

Phlyctenular keratoconjunctivitis is now a rare clinical entity. Histologic staging has been updated by infection-immunological findings: phlyctenules have been identified as delayed-type cellmediated immune responses involving bacterial, mycobacterial, chlamydial, fungal or parasitic pathogens. Establishment of a correct diagnosis should include conjunctival and systemic work-ups for pathogenic agents. Case reports of three patients are presented.

[S-100 protein in non-pigmented melanocytic and neuro-ectodermal tumors of the conjunctiva]

Using an immunoperoxidase method, S-100 protein was localized in 51 nonpigmented or slightly pigmented nevi, eight malignant melanomas, three neurofibromas, and one neurilemmoma of the conjunctiva. Clinico-immunohistochemical correlations are presented. Cells of these neuroectodermal tumors contain S-100 protein. Epithelial invaginations arising from the conjunctival surface and lying between melanocytes are S-100 protein-negative. This facilitates the differential diagnosis of particularly amelanotic lesions of the conjunctiva. Immunohistochemical identification of the S-100 protein represents an improvement in current histochemical differential diagnosis of these tumors.

[Immunocytochemical detection of involucrin in precancerous and cancerous non-pigmented conjunctival tumors]

Involucrin is a precursor of the cross-linked envelope protein of the human stratum corneum. Its appearance in the upper layers of the epidermis reflects normal differentiation of keratinocytes. This study uses an immunoperoxidase technique for localization of involucrin in paraffin sections of normal conjunctiva, conjunctival dysplasia, carcinoma in situ, and invasive carcinoma. Clinicoimmunocytochemical correlations are presented. The results demonstrate that the distribution patterns of involucrin differ in precancerous and cancerous conjunctival lesions: normal limbal conjunctiva shows involucrin only in the three superficial cell layers; the fornix conjunctivae contains no involucrin. All 23 conjunctival dysplasias show an involvement also of deeper layers of the epithelium, sparing the basal layers. Three carcinomas in situ and one invasive squamous cell carcinoma, however, demonstrate an involvement of all layers of the epithelium. The involucrin staining pattern helps in histologic differential diagnosis of epithelial lesions of the conjunctiva.

[Malignant teratoid medulloepithelioma of the ciliary body and glial fibrillary acidic protein. Clinical, histochemical and immunohistochemical findings]

In a four-year-old boy a malignant teratoid medulloepithelioma of the ciliary body was removed by means of an 11.0 X 11.0 mm "block excision". Two years later the patients visual acuity was 0.6. The lesion originates in the nonpigmented ciliary epithelium, extending along the lens equator to the pupillary zone and through the iris stroma into the anterior chamber. The tumor shows tubular structures with hyaluronic acid, "retinal rosettes", and areas with ganglion and GFAP-positive glial cells. The immunohistochemical demonstration of the glial fibrillary acidic protein is also of diagnostic value for the classification of tumors of the nonpigmented ciliary epithelium.

[Pedicled papilloma of the conjunctiva with papilloma virus. Immunohistochemical detection of species specific papilloma-virus antigens]

Report on the immunohistochemical detection of genus-specific papillomavirus antigen with an immunoperoxidase technique - in a papilloma of the caruncle, in which papillomavirus-specific DNA was previously successfully, demonstrated in a virological examination by means of hybridization of nucleic acid.

[Intraocular pseudotumor caused by massive gliosis of the retina--detection of glial fibrillary acidic protein]

The left eye of a 43-year-old patients was removed 37 years after a perforating injury because of a painful absolute secondary closed-angle glaucoma. Histological investigation revealed a massive reactive gliosis of the retina filling the entire eye. Glial fibrillary acidic protein was demonstrated within this pseudotumor by means of an immunoperoxidase. Clinical and histopathological differential diagnoses are discussed. The diagnostic value of immunohistochemical demonstration of glial fibrillary acidic protein is pointed out.