Retinoblastoma with necrosis of central retinal artery and vein and partial spontaneous regression

Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: A Clinical-Pathophysiological Analysis

PURPOSE

To derive novel insights into the pathophysiology of vancomycin-related hemorrhagic occlusive retinal vasculopathy (HORV) through a careful clinicopathologic correlation.

METHODS

We retrospectively reviewed the clinical and pathologic course of 2 consecutive patients who developed HORV. The clinical history, multimodal imaging, ultrasound biomicroscopy (UBM), and intraoperative and histologic findings are reported.

RESULTS

Both patients presented with decreased vision and eye pain within 1 week following otherwise uncomplicated cataract extraction and were diagnosed with HORV after endophthalmitis was ruled out. Both patients presented with significant ocular discomfort that progressively worsened, and both experienced a dismal visual outcome despite early aggressive medical and surgical therapy. One patient requested enucleation for a blind and painful eye. Upon histologic examination of this eye, the iris and ciliary body appeared to be infarcted with separation of the iris and ciliary epithelia from their adjacent stromal components. These findings were corroborated by UBM of the second patient. Histologic examination of the posterior segment demonstrated severe hemorrhagic necrosis of the neurosensory retina and an occlusive nonarteritic vasculopathy of the retina and choroid. The choroid was thickened by prominent nongranulomatous chronic inflammation accompanied by a glomeruloid proliferation of small vessels. The inflammatory infiltrate was almost exclusively confined to the choroid and consisted of predominantly T cells. There was conspicuous absence of inflammatory cells in the retina and no histologic evidence of leukocytoclastic vasculitis.

CONCLUSIONS

HORV is a rare condition that can lead to profound vision loss. Significant ocular pain can be a presenting sign of HORV in cases with severe iris and ciliary body ischemia. Although it has been suggested that HORV is a form of leukocytoclastic retinal vasculitis, the histologic findings herein indicate that the pathophysiology is more complex. It is grounded in a necrotizing retinal vasculopathy in the absence of retinal vasculitis, chronic nongranulomatous choroiditis, and an unusual glomeruloid proliferation of endothelial cells in the choroid and elsewhere in the eye.

Retinoblastoma with autoinfarction presenting as orbital cellulitis

We describe a case of unilateral retinoblastoma in a 13-month-old boy who presented with signs of orbital cellulitis. Heterochromia, hyphema, and vitreous hemorrhage were observed. Initial computed tomography (CT) imaging failed to reveal the calcified intraocular mass that was later identified on ultrasonography. Histopathology of the enucleated eye revealed diffuse inflammation and tumor necrosis but with absence of malignant retinoblastoma cells. Genetic testing was equivocal. The patient is presumed to have had retinoblastoma that underwent autoinfarction, leading to secondary inflammation. This case highlights the importance of complete ocular evaluation and proper imaging modalities in children presenting with orbital cellulitis.

Phthisis bulbi in retinoblastoma

BACKGROUND

Phthisis bulbi is a relatively uncommon and atypical clinical presentation of retinoblastoma.

DESIGN

Retrospective study conducted at a tertiary care hospital.

PARTICIPANTS

Eighteen consecutive retinoblastoma patients with primary phthisis bulbi.

METHODS

Retrospective analysis of clinical, imaging and histopathological features of all retinoblastoma patients with primary phthisis bulbi, treated at our centre between January 2005 and December 2009.

MAIN OUTCOME MEASURE

Clinical and histopathology features.

RESULTS

Eighteen (3.5%) retinoblastoma patients developed primary phthisis bulbi. The median age of presentation was 1.5 years. The median duration of symptoms before presentation was 6 months. In total, 15 out of 18 (83%) cases had bilateral disease. Among these, 80% (12/15) had advanced intraocular disease in the fellow eye. Most common first symptom was white reflex. History of orbital inflammation was present in 12/18 cases. Computed tomographic scan of orbit showed intraocular mass with calcific densities in 16 eyes. In two cases, hyperdense mass was seen without any calcification. On histopathology, residual viable tumour cells with characteristics of poorly differentiated retinoblastoma were found in 67% (12/18) eyes. High-risk factors were present in six cases with microscopic residual disease in three cases.

CONCLUSIONS

This is the largest case series of retinoblastoma patients with primary phthisis bulbi. Phthisis bulbi in retinoblastoma may be associated with bilateral disease in most cases and advanced intraocular disease in the fellow eye in a significant number of cases. Regression is incomplete in majority of these cases; therefore, enucleation must definitely be done in all cases of retinoblastoma presenting with phthisis bulbi.

Spontaneous regression of retinoblastoma in a Taiwan series

PURPOSE

To document the high occurrence of complete spontaneous regression of retinoblastoma in a Taiwan series.

PATIENTS AND METHODS

Cases of retinoblastoma (133 eyes of 110 patients) at a single Taiwanese hospital from 1978 to 2002 were reviewed.

RESULTS

Complete spontaneous tumor regression and phthisis bulbi were noted in 7 eyes of 7 patients. The regression rate was 5.3%, which is higher than previous reports of 1% to 2%. Tumor regression was associated with a common course of acute painful inflammation and ended with a shrunken, nonfunctioning eye. No residual vision was noted in any patient.

CONCLUSION

Delayed diagnosis and advanced stage of the disease in this series of Taiwanese patients probably led to the massive intratumoral necrosis and resulted in phthisic change of the globe.

Atypical presentations of retinoblastoma

PURPOSE

To study the atypical presentations of retinoblastoma in our institution.

METHOD

Retrospective, clinical study.

RESULTS

A total of 392 cases of retinoblastoma were reviewed; 72.2% of the patients had leukocoria, 13% had proptosis, 10% had strabismus, 1.5% were asymptomatic (detected on screening), and 3.3% had atypical presentations. Fourteen different atypical findings were observed including endophthalmitis (0.76%), secondary glaucoma (0.76%), uveitis (0.5%), corneal edema (0.5%), phthisis bulbi (0.5%), orbital cellulitis (0.5%), cataract (0.25%), pseudohypopyon (0.25%), iris nodules (0.25%), hyphema (0.25%), iris neovascularization (0.25%), microphthalmos (0.25%), exposure keratopathy (0.25%), and corneal blood staining (0.25%). All of the patients had Reese-Ellsworth grade V disease. On histopathology, invasion of neighboring structures was seen in 10 patients. All patients underwent enucleation with adjuvant radiotherapy, chemotherapy, or both.

CONCLUSIONS

Retinoblastoma can mimic any orbital or ocular pathology. Atypical presentations of retinoblastomas are usually associated with advanced disease. The possibility of ocular tumor should be entertained whenever there is an unusual presentation that is unresponsive to the usual therapy. Ultrasonography and computed tomography should be performed in all such patients, especially if the posterior segment is not visible.

Presentation of retinoblastoma as phthisis bulbi

PURPOSE

We sought to determine the incidence of retinoblastoma patients who presented with phthisis bulbi.

METHODS

The medical records of 272 patients in the King Khaled Eye Specialist Hospital Retinoblastoma Registry were retrospectively studied. Clinical records, radiological investigations and histopathological slides were reviewed.

RESULTS

We found that 2.7% of patients had retinoblastoma coincident with phthisis bulbi. Five of 10 patients had bilateral retinoblastoma; in the others it was unilateral. Radiologically, intraocular calcification was present in all except one case. All enucleated phthisical globes had residual viable tumour cells; optic nerve extension was found in 2 patients who had long-standing phthisis bulbi.

CONCLUSION

Phthisis bulbi is an uncommon presenting sign of retinoblastoma which often occurs after an ocular inflammatory episode possibly related to intraocular tumour infarction. In most cases the tumour is not visible because of intraocular disruption. That every enucleated eye in this series harboured well-differentiated tumour cells underlies the seriousness with which phthisis bulbi of unknown origin in children should be investigated for retinoblastoma.

Histopathologic verification of Verhoeff's 1918 irradiation cure of retinoblastoma

The authors studied an eye obtained postmortem from the first patient with a successfully irradiated retinoblastoma. This patient, first treated by Verhoeff in 1917, had been followed for 71 years. Ophthalmoscopy disclosed a depressed chorioretinal scar, approximately 3 disc diameters (DD) in size, with baring of the sclera temporal to the macula. This case is historically significant, in that Verhoeff and Reese debated as to whether this tumor regressed spontaneously or secondary to irradiation. Results of histopathologic, immunohistochemical, and ultrastructural examination showed a chorioretinal, neuroglial scar without evidence of calcification, necrotic tumor cells, or residual retinoblastoma. The authors discuss the clinical and histopathologic findings in spontaneously regressed retinoblastoma, retinoma/retinocytoma, and irradiated retinoblastoma. They believe that Verhoeff was correct in his belief that x-ray therapy had cured this patient.

Immunohistochemical diagnosis of a totally necrotic retinoblastoma: a clinicopathologic case

An 8-month-old girl underwent enucleation of her right eye because of a calcified retrolental white mass filling the entire vitreous cavity. The conventional histological examination revealed a totally necrotic unidentifiable tumor, with scattered foci of calcification. In addition, we found two islands of viable small round cells, suspected to be retinoblastoma cells, which were located in the optic nerve behind the lamina cribrosa. These cells stained positively for neuron-specific enolase (NSE), but not for glial-fibrillary-acidic-protein (GFAP), supporting the diagnosis of retinoblastoma. Because one of the latter foci of viable tumor cells was located at the cut end of the optic nerve, the baby was treated by external beam irradiation.

Spontaneously regressing retinoblastomas, retinoma, or retinoblastoma group 0

A 5-year-old boy had a gray, translucent retinal mass containing calcified nodules and surrounded by retinal pigment clumping and atrophy. The eye was enucleated and the patient has remained well for seven years. Microscopic examination disclosed an intraretinal tumor composed of benign-appearing cells in a bed of well-vascularized ground substance with calcific foci. There was surrounding retinal pigment epithelial hyperplasia but no peripheral necrosis or signs of tumor regression. There were no mitoses, cellular pleomorphism, nuclear atypia, rosettes, or other characteristics of malignancy. Tumors with this typical fundus appearance have been termed spontaneously regressing retinoblastoma or retinoma. Although the tumor in this patient was histopathologically benign, it carries the same genetic risk as a retinoblastoma. A better term for this lesion, therefore, is retinoblastoma group 0.

Significance of retinoma and phthisis bulbi for retinoblastoma

Genetic counseling of retinoblastoma (RB) patients and their families is difficult and inaccurate. The data in this paper show that two ocular lesions, retinoma and phthisis bulbi, are associated with RB and can be useful in diagnosis and counseling. Phthisis bulbi is the end result of many conditions and can only be linked to RB if other evidence is present. Retinomas, on the other hand, have three distinctive clinical characteristics (irregular translucent retinal mass, calcification, and pigment epithelial disturbance) and quite accurately predict the presence of the RB gene. Recognition of the significance of retinoma and phthisis bulbi with respect to the RB gene is critical in genetic counseling. Of 34 individuals studied, 32 with retinoma and five with phthisis bulbi, two thirds had a family history of RB or RB in the other eye, and 23/37 of their offspring developed RB. The clinical course of RB in the six children known to be at risk on the basis of detection of the gene in the parent was significantly better than in 17 children that were symptomatic at the time of diagnosis.

Spontaneous regression of bilateral retinoblastoma

A 24-year-old black man was found to have bilateral, spontaneously regressed retinoblastoma that had previously been misdiagnosed as post-traumatic chorioretinal scarring. His son and half-brother both had bilateral viable retinoblastoma. The ophthalmoscopic and fluorescein angiographic features of this patient's fundus lesions included a calcified, whitish mass located centrally in one of the scars and a fine residual vascularity in another of the fundus lesions. The authors review the pertinent literature on spontaneous regression of retinoblastoma.

Spontaneous regression of retinoblastoma

Clinicopathologic evidence of bilateral spontaneous regression of retinoblastoma in three brothers is presented. The buphthalmic right eye and phthisical left eye of one of these persons were examined histopathologically. The two brothers of this patient both had phthisical left eyes, and those eyes were examined histopathologically. Both of those brothers also had clinically detected chorioretinal scars in their right eyes from regressed retinoblastoma. Three of eight children of one of the two brothers had bilateral retinoblastoma, and two of seven children of the other brother had bilateral retinoblastoma. Reports in the literature of 50 previous cases of total spontaneous regression of retinoblastoma from 1911 to 1975 are reviewed.

Radiation treatment of retinoblastoma

In a series of 45 children with retinoblastoma, from the period 1953-1973, comprising 27 bilateral cases, 32 eyes were treated by irradiation. The different techniques of radiation are reviewed. In the present series small tumours were irradiated by local application of Stallard discs or Rosengren balls, while advanced cases were treated by external radiation. The results are discussed, and it is emphasized that the major factor of importance for the success of the treatment is the size of the tumour. Small tumours are cured, large ones are not. Future efforts must be directed towards early diagnosis. The treatment should be centralized in order to secure sufficient experience for the ophthalmologist and radiotherapist, as evaluation of the post- radiation fundus findings may present difficulties.