The tear cytokine profile in patients with active Graves' orbitopathy

PURPOSE

The primary aim of this study is to isolate cytokines specific for active Graves' orbitopathy (GO) in the tears of affected patients. The secondary aim is to identify other cytokines of interest and to look at the profile of their levels over time.

METHODS

This is a prospective pilot study conducted at the Singapore National Eye Centre. A total of 10 patients with active GO and 10 patients from each of 3 control groups were recruited. The 3 control groups were the following: age-matched normal female patients, patients with GO who were clinically inactive and patients with bilateral viral conjunctivitis. Tears from patients from the control groups were collected on a single visit. For patients with active GO, tears were collected on presentation, at 6 months, 12 months and 18 months.

RESULTS

Of all the cytokines examined, only IL-7 yielded a difference when the concentration in patients with active GO was compared with concentrations in all the control groups. This difference was most significant at the 18-month follow-up visit.

CONCLUSIONS

Low concentrations of IL-7 in tears exhibit specificity for active GO in patients nearly 2 years from the clinical onset of activity. Although using IL-7 in tears as a biomarker for disease activity may be limited due to its late manifestation, targeting immune restitution using IL-7 may have disease modifying effects.

Axial Globe Position Measurement: A Prospective Multicenter Study by the International Thyroid Eye Disease Society

PURPOSE

Identify a reproducible measure of axial globe position (AGP) for multicenter studies on patients with thyroid eye disease (TED).

METHODS

This is a prospective, international, multicenter, observational study in which 3 types of AGP evaluation were examined: radiologic, clinical, and photographic. In this study, CT was the modality to which all other methods were compared. CT AGP was measured from an orthogonal line between the anterior lateral orbital rims to the cornea. All CT measurements were made at a single institution by 3 individual clinicians. Clinical evaluation was performed with exophthalmometry. Three clinicians from each clinical site assessed AGP with 3 different exophthalmometers and horizontal palpebral width using a ruler. Each physician made 3 separate measurements with each type of exophthalmometer not in succession. All photographic measurements were made at a single institution. AGP was measured from lateral photographs in which a standard marker was placed at the anterior lateral orbital rim. Horizontal and vertical palpebral fissure were measured from frontal photographs. Three trained readers measured 3 separate times not in succession. Exophthalmometry and photography method validity was assessed by agreement with CT (mean differences calculation, intraclass correlation coefficients [ICCs], Bland-Altman figures). Correlation between palpebral fissure and CT AGP was assessed with Pearson correlation. Intraclinician and interclinician reliability was evaluated using ICCs.

RESULTS

Sixty-eight patients from 7 centers participated. CT mean AGP was 21.37 mm (15.96-28.90 mm) right and 21.22 mm (15.87-28.70 mm) left (ICC 0.996 and 0.995). Exophthalmometry AGP fell between 18 mm and 25 mm. Intraclinician agreement across exophthalmometers was ideal (ICC 0.948-0.983). Agreement between clinicians was greater than 0.85 for all upright exophthalmometry measurements. Photographic mean AGP was 20.47 mm (10.92-30.88 mm) right and 20.30 mm (8.61-28.72 mm) left. Intrareader and interreader agreement was ideal (ICC 0.991-0.989). All exophthalmometers' mean differences from CT ranged between -0.06 mm (±1.36 mm) and 0.54 mm (±1.61 mm); 95% confidence interval fell within 1 mm. Magnitude of AGP did not affect exophthalmometry validity. Oculus best estimated CT AGP but differences from other exophthalmometers were not clinically meaningful in upright measurements. Photographic AGP (right ICC = 0.575, left ICC = 0.355) and palpebral fissure do not agree with CT.

CONCLUSIONS

Upright clinical exophthalmometry accurately estimates CT AGP in TED. AGP measurement was reliably reproduced by the same clinician and between clinicians at multiple institutions using the protocol in this study. These findings allow reliable measurement of AGP that will be of considerable value in future outcome studies.

Ocular manifestations and the clinical course of carotid cavernous sinus fistulas in Asian patients

PURPOSE

To study the clinical course with regard to both the angiographic and visual outcomes of carotid cavernous fistulas (CCFs).

BACKGROUND

Carotid cavernous sinus fistulas (CCFs) are conditions which often present with ocular signs and symptoms. The clinical presentation of CCFs is varied according to the anatomy, haemodynamics and size of the CCF. CCFs causing significant symptoms or vision loss should be treated with embolization.

METHODS

This is a retrospective review of the medical records of all CCF cases seen in the Singapore National Eye Centre from September 2002 to December 2011.

RESULTS

45 patients who had confirmed CCF on conventional cerebral angiography were included. Anterior draining CCFs presented with orbital congestion while posterior draining CCFs presented with pain, diplopia and cranial nerve palsies. Mild residual symptoms were still present in 85% of treated direct CCFs despite complete angiographic closure however 52% of treated dural CCFs had complete resolution of symptoms despite only half of those achieving angiographic closure. Treated and untreated dural CCFs had similar outcomes (87% versus 76% recovered or improved (p > 0.05)). Poor outcomes can result from residual diplopia or vision loss from complications of the CCF itself (e.g. compressive optic neuropathy, glaucoma, retinopathy) or complications from CCF embolization treatment (e.g. central retinal artery occlusion).

CONCLUSION

Presenting symptoms and signs are related to the angiographic drainage of CCFs. Angiographic outcomes after embolization treatment may not always correlate with clinical outcomes.

A survey of the histopathology of lacrimal gland lesions in a tertiary referral centre

PURPOSE

To describe the histopathological distribution of biopsied lacrimal gland lesions in a tertiary referral centre in Singapore.

METHODS

This was a retrospective chart review. Clinical records of patients who underwent lacrimal gland biopsy at a tertiary referral centre in Singapore between 2000 to 2010, were reviewed. Data collated included patient demographics, clinical presentation, association with systemic disease and histopathological diagnosis.

RESULTS

Sixty-nine patients were studied. Median age of presentation was 50 years. Forty patients (58%) were female and the majority (84%, n = 29) were Chinese. The mean follow-up duration was 35.0 ± 34.5 months. 30.4% (n = 21) of the patients had bilateral disease. Chronic dacryoadenitis (46%, n = 32) was the most common histopathological diagnosis, followed by lymphoproliferative disorders (38%, n = 26) and pleomorphic adenoma (10%, n = 7). The diagnoses in four other patients included adenoid cystic carcinoma, lacrimal gland hypertrophy, lacrimal duct cyst and orbital vascular malformation.

CONCLUSION

Chronic dacryoadenitis and lymphoproliferative disorders are the two commonest causes of lacrimal gland lesions in our series. Although many cases remain non-specific, about 60% have a specific inflammation that may be associated with a systemic disease. As one third of our patients with lymphoproliferative disease of the lacrimal gland had an associated systemic lymphoma, patients with such lesions should be referred for investigation of possible systemic lymphoma. The results of our study can aid in providing a more targeted approach to patient management.

An unusual causative agent for an orbital abscess: Granulicatella Adiacens

We present a patient who developed an orbital abscess secondary to a retained organic (wooden) foreign body after a fall. Clinically, he had a right sub brow fistula exuding purulent discharge, four millimetres of proptosis, limitation of ocular motility in all directions of gaze, but no signs of optic neuropathy. Preoperative computed tomography and magnetic resonance imaging of the orbits was performed to localise the abscess and to facilitate surgical planning. He underwent exploration, drainage of the abscess and removal of the wooden foreign body with good postoperative recovery. Cultures isolated Ganulicatella Adiacens, a nutritionally variant streptococcus. This is an unusual causative organism and to our knowledge, this is the first reported case of a posttraumatic orbital abscess associated with Granulicatella Adiacens. Clinical suspicion, isolation of the organism and appropriate microbial treatment requires a multidisciplinary approach, with input from the ophthalmologist, microbiologist and infectious disease team. This will ensure a good outcome in patient management.

Neuroendocrine tumors of the orbit--clinicopathological findings in 3 more cases of this rare entity and review of the literature

INTRODUCTION

Neuroendocrine orbital tumors are rare occurrences. They are poorly characterized histologically and a spectrum of different cell types exists. This short case series studies the various tumor morphologies as well as the patients' clinical profiles.

METHODS AND MATERIALS

Patients treated and followed up at the Singapore National Eye Centre over a period of 8 years from 1(st) January 2002 to 31(st) December 2009 were identified from the orbital tumor board results. The case notes of patients with the diagnosis of neuroendocrine tumors were analysed, and a review of the literature performed.

RESULTS

Three patients are described in this series. The history, clinical examination findings, imaging findings as well as tumor histology were described. The mean age was 63 years, and 2 patients were male. All presented with proptosis. Only one patient had systemic symptoms on presentation. All patients had surgical excision of the tumor and two had adjuvant radiotherapy of the orbit. Median follow-up period was 3.5 years.

DISCUSSION

Patients with a biopsy-proven diagnosis of orbital neuroendocrine tumors should be monitored even when systemic examination fails to identify peripheral disease. Such examination should always include a full endoscopic gastrointestinal review.

A 5-year Retrospective Review of Asian Ectropion: How Does It Compare to Ectropion Amongst Non-Asians?

Introduction: This study reviews the differences in demographics and surgical outcomes between ectropion in Asian and non-Asian eyes. Materials and Methods: Medical records of surgically corrected ectropion cases from January 2002 to December 2006 were reviewed. Pre- and postoperative lid-globe apposition was graded: grade 0 with normal lid-globe apposition, grade 1 with punctal ectropion, grade 2 with partial lid eversion and scleral show, grade 3 with conjunctival hyperemia and thickening and grade 4 as for grade 3 with exposure keratitis. Results: Sixty-nine eyes in 50 patients underwent surgical correction of lower lid ectropion, making up 3.3% of all lid procedures performed. Eighty-four percent of patients were above 50 years of age, 72% were males and 88% were Chinese. Involutional change was the commonest aetiology, accounting for the majority of bilateral cases. The mean duration to surgery was 10.0 ± 16.0 months. The most frequent preoperative severity grade was 2. Lateral tarsal strip (LTS) was the commonest procedure performed, comprising 91.3% of eyes. The mean duration of postoperative review was 19.4 ± 19.2 months (range, 1 to 74 months). Postoperative improvement of at least one grade was observed in 98% while normal lid-globe apposition was achieved in 76% of eyes. Conclusions: Involutional change is the most common cause of ectropion amongst both Asians and non-Asians. Ectropion is less prevalent amongst Asians as a result of anatomical differences and possibly reduced sun exposure. The LTS procedure is the most commonly performed surgical procedure for the successful correction of ectropion in both Asians and non-Asians. Keywords: Asian eyes, Lateral tarsal strip

A 5-year retrospective review of Asian ectropion: how does it compare to ectropion amongst non-Asians?

INTRODUCTION

This study reviews the differences in demographics and surgical outcomes between ectropion in Asian and non-Asian eyes.

MATERIALS AND METHODS

Medical records of surgically corrected ectropion cases from January 2002 to December 2006 were reviewed. Preand postoperative lid-globe apposition was graded: grade 0 with normal lid-globe apposition, grade 1 with punctal ectropion, grade 2 with partial lid eversion and scleral show, grade 3 with conjunctival hyperemia and thickening and grade 4 as for grade 3 with exposure keratitis.

RESULTS

Sixty-nine eyes in 50 patients underwent surgical correction of lower lid ectropion, making up 3.3% of all lid procedures performed. Eighty-four percent of patients were above 50 years of age, 72% were males and 88% were Chinese. Involutional change was the commonest aetiology, accounting for the majority of bilateral cases. The mean duration to surgery was 10.0 ± 16.0 months. The most frequent preoperative severity grade was 2. Lateral tarsal strip (LTS) was the commonest procedure performed, comprising 91.3% of eyes. The mean duration of postoperative review was 19.4 ± 19.2 months (range, 1 to 74 months). Postoperative improvement of at least one grade was observed in 98% while normal lid-globe apposition was achieved in 76% of eyes.

CONCLUSIONS

Involutional change is the most common cause of ectropion amongst both Asians and non-Asians. Ectropion is less prevalent amongst Asians as a result of anatomical differences and possibly reduced sun exposure. The LTS procedure is the most commonly performed surgical procedure for the successful correction of ectropion in both Asians and non-Asians.

Asymptomatic pancreatic adenocarcinoma presenting as an orbital metastatic tumor

Although rare, orbital metastatic tumors may be the initial presentation of an asymptomatic primary carcinoma. We report a rare case, with clinicopathological correlation, of metastatic pancreatic adenocarcinoma, presenting first in the orbit with symptoms of diplopia, blurring of vision and supraorbital ache. Computed tomography and magnetic resonance imaging of the orbit showed a left solid intraconal tumor with peripheral rim enhancement. The tumor demonstrated hypointensity on both T1- and T2-weighted sequences. Excisional biopsy was performed and histopathology confirmed a metastatic adenocarcinoma. Subsequent gastrointestinal imaging and tumor markers revealed an asymptomatic pancreatic adenocarcinoma, with multiple liver metastases. Our patient developed hepatobiliary sepsis and passed away 44 days after diagnosis. This case highlights the role of early biopsy of atypical orbital tumors in the localization of an asymptomatic primary carcinoma.

Orbital cellulitis in children-medical treatment versus surgical management

INTRODUCTION

Ophthalmologists differ in their threshold for surgical management in paediatric patients with orbital cellulitis. We studied the management choices and outcome of children admitted with this disorder.

MATERIAL AND METHODS

A retrospective review was performed on patients with orbital cellulitis admitted between January 2001 and December 2004 to a tertiary paediatric referral centre in Singapore. The patients were studied for age, associated systemic disease, medical treatment, drainage procedure undertaken, organism isolated and outcome. Statistical methods were applied for comparing medical treatment with surgical treatment with respect to recovery time, recurrence, and time between the presentation of patient and initiation of treatment.

RESULTS

Twenty patients were studied. Average age was 5.5 years. 5/20 (25%) had a preceding history of upper respiratory tract infection. From CT findings, we came to know that 3/20 (15%) were due to isolated ethmoiditis, 5/20 (25%) had obstruction of the osteomeatal complex of the paranasal sinuses, 2/10 (10%) had intracranial abscesses due to frontal sinusitis. 4/20 (20%) had all 4 ipsilateral paranasal sinuses infected. 2/20 (10%) had preseptal cellulitis with posterior extension into the orbit. 2/20 (10%) had orbital cellulitis related to dacryoadenitis and 2/20 (10%) had pansinusitis with orbital soft tissue stranding. 13/20 (65%) had orbital and /or endoscopic drainage. The remainder of the patients had good immediate response to sole medical treatment and did not require surgery. The most commonly isolated organism was Staphylococcus aureus 5/20 (25%). All patients recovered within a mean of 9.6 days with no complications or functional deficit.

CONCLUSIONS

Paediatric orbital cellulitis can be treated conservatively or with surgical drainage. Indications for surgery include pansinusitis, large abscesses with significant mass effect, concurrent intracranial involvement, poor response to initial medical treatment and the presence of an orbital abscess and gas. Sole medical treatment worked well in children with no orbital abscess, small or medial abscesses as they tend to have a single organism infection. This is also of particular significance in young children below the age of one where endoscopic surgery can be technically difficult. Intracranial involvement occurred in association with frontal sinusitis and affected patients had the longest duration of hospitalization.

Normative measurements of the Chinese extraocular musculature by high-field magnetic resonance imaging

PURPOSE

To establish the normal measurements of diameter and cross-sectional area of the Chinese extraocular muscles (EOMs) and optic nerve-sheath complex (ON) as seen on high-field (3-Tesla; 3T) magnetic resonance imaging (MRI).

METHODS

Coronal 3T MRI of the orbit (TR, 700 ms; TE, 15 ms; FOV, 160 mm; matrix, 256 x 256; slice thickness, 1 mm; and slice gap, 0) was performed on 80 normal Chinese volunteers. T1-weighted images were analyzed with computer-assisted segmentation. The diameter and the cross-sectional area of EOMs and the ON were measured from the image plane at the posterior aspect of the globe and at 7 mm behind the globe. The maximum diameter of EOM was measured from their respective reconstructed images.

RESULTS

The normal measurement (mean +/- SD) of diameter at the posterior aspect of the globe: medial rectus (MR), 3.6 +/- 0.4 mm; inferior rectus (IR), 3.7 +/- 0.8 mm; lateral rectus (LR), 2.3 +/- 0.5 mm; superior oblique (SO), 2.4 +/- 0.6 mm; and the ON, 5.4 +/- 0.7 mm. The normal measurement of diameter 7 mm behind the globe: MR, 3.2 +/- 0.6 mm; IR, 3.9 +/- 0.8 mm; LR, 4.0 +/- 0.8 mm; SO, 2.2 +/- 0.7 mm; and ON, 4.2 +/- 0.5 mm. The normal measurement of cross-sectional area at the posterior aspect of the globe: superior muscle group (SMG), 28.2 +/- 6.5 mm(2); MR, 25.5 +/- 3.2 mm(2); IR, 26.9 +/- 7.2 mm(2); LR, 17.3 +/- 3.9 mm(2); SO, 10.5 +/- 3.5 mm(2); and ON, 27.6 +/- 6.1 mm(2). The normal measurement of cross-sectional area 7 mm behind the globe: SMG, 24.1 +/- 6.6 mm(2); MR, 19.1 +/- 4.6 mm(2); IR, 29.5 +/- 6.6 mm(2); LR, 32.3 +/- 6.5 mm(2); SO, 9.7 +/- 3.9 mm(2); and ON, 17.1 +/- 2.9 mm(2). The normal measurement of maximum diameter: SMG, 4.8 +/- 1.1 mm; MR, 5.1 +/- 0.9 mm; IR, 5.4 +/- 1.0 mm; and LR, 4.5 +/- 0.9 mm.

CONCLUSIONS

The Chinese 3T MRI EOMs and ON normative data may be useful in determining pathologic enlargement of the EOMs and ON in various orbital conditions. (ClinicalTrials.gov number, NCT00348413.).

Onodi sinusitis presenting with orbital apex syndrome

This article reports the unusual presentation of a patient with an intraconal abscess secondary to sinusitis in an onodi cell in a healthy 63 year old Chinese female. She presented with limited extraocular movements, decreased corneal sensation, rapid drop in visual acuity and signs of optic neuropathy, in the absence of any inflammatory signs in the right eye. MRI scans showed a well-encapsulated mass in the posterior two thirds of the orbit, with the presence of an onodi cell on the right side. She underwent an extended lateral orbitotomy, which revealed frank pus that was positive for Staphylococcus aureus. She was treated with intravenous antibiotics with complete resolution of her presenting signs.

Orbital Metastatic Tumour as Initial Manifestation of Asymptomatic Gastric Adenocarcinoma

Introduction: Metastatic orbital tumour from gastric cancer is rare. Patients with metastatic disease may present initially to the ophthalmologist with symptoms from metastases instead of from the primary cancer. Clinical Picture: We report a case, with clinicopathological correlation, of metastatic gastric adenocarcinoma presenting first in the orbit with diplopia. Computed tomography and magnetic resonance imaging of the orbit showed a well-defined enhancing right intraconal tumour. Treatment and Results: Excisional biopsy was performed and histopathology confirmed a metastatic adenocarcinoma. Focused gastrointestinal screening revealed an otherwise asymptomatic Stage IV gastric adenocarcinoma. Chemotherapy was initiated with good tumour response. Conclusion: Early biopsy of unusual orbital tumours is critical as orbital metastases may be the initial manifestation of an asymptomatic primary. Histopathological diagnosis can aid localisation of the primary tumour and allow prompt treatment to be instituted.

Orbital metastatic tumour as initial manifestation of asymptomatic gastric adenocarcinoma

INTRODUCTION

Metastatic orbital tumour from gastric cancer is rare. Patients with metastatic disease may present initially to the ophthalmologist with symptoms from metastases instead of from the primary cancer.

CLINICAL PICTURE

We report a case, with clinicopathological correlation, of metastatic gastric adenocarcinoma presenting first in the orbit with diplopia. Computed tomography and magnetic resonance imaging of the orbit showed a well-defined enhancing right intraconal tumour.

TREATMENT AND RESULTS

Excisional biopsy was performed and histopathology confirmed a metastatic adenocarcinoma. Focused gastrointestinal screening revealed an otherwise asymptomatic Stage IV gastric adenocarcinoma. Chemotherapy was initiated with good tumour response.

CONCLUSION

Early biopsy of unusual orbital tumours is critical as orbital metastases may be the initial manifestation of an asymptomatic primary. Histopathological diagnosis can aid localisation of the primary tumour and allow prompt treatment to be instituted.

Multifocal venous malformations: two interesting case presentations

INTRODUCTION

Multiple venous abnormalities involving the orbit, head and neck regions have been previously described. We present two similar cases of low-flow orbital venous vascular malformations (VVMs) in association with multiple low-flow VVMs in the head and neck as well as in the peripheral limb. Literature search revealed that this association has not been previously reported.

METHODS

Retrospective review of two patients with multifocal VVMs was performed.

RESULTS

Case 1: A 46 year-old Chinese female had a history of multiple vascular lesions involving the right orbit, the tongue, right neck region, right arm and one finger. Valsalva manoeuvre resulted in distension of these lesions. CT scan of the orbits demonstrated bilateral low-flow VVMs. CT angiogram also revealed multiple developmental venous anomalies in the brain. Case 2: A 16 year-old Chinese female had a history of multiple venous malformations involving the neck, left forearm and oral region. Dynamic manoeuvres demonstrated the distensible nature of these lesions. MRI scans of the orbits showed bilateral extraconal low-flow VVMs. Similar mass lesions were seen on MRI scans of the neck.

CONCLUSIONS

Multiple cervicofacial venous malformations with developmental abnormalities of the intracranial venous system have been described previously. However, their associations with similar VVMs in the peripheral limb regions have not been reported. Our cases illustrate this rare association. VVMs appear to be benign in nature with symptoms mainly due to mass effect. Management can be conservative in the absence of any sight threatening complication.

Septic thrombosis of the cavernous sinus: two different mechanisms

PURPOSE

Septic thrombosis of the cavernous sinus is a rare condition that may lead to significant morbidity and mortality if not diagnosed and treated urgently. We present two recent cases of bilateral septic cavernous sinus thrombosis with differing etiologies, the first of dental origin and the second a complication of sphenoid sinusitis.

METHODS

Case report.

RESULTS

A diagnosis of cavernous sinus thrombosis was made based on clinical findings and confirmed by imaging in both patients. The etiology in the first patient was related to poor dental hygiene, with resultant spread of infection to the cavernous sinuses. The second had bilateral sphenoid sinusitis, with intravascular gas noted in both orbits and cavernous sinuses. This is the first reported occurrence of such an event associated with septic cavernous sinus thrombosis. Bilateral sphenoidotomies with evacuation of the sinuses were performed, and Haemophilus influenzae was cultured from the sphenoidotomy fluid and blood. Broad spectrum intravenous antibiotics were given in both patients, and complete recovery achieved within weeks.

CONCLUSION

In septic thrombosis of the cavernous sinus, early recognition and prompt management with broad spectrum intravenous antibiotics is crucial for full recovery. The primary source of sepsis may be a distant focus with septicemia preceding thrombosis of the cavernous sinus. Alternatively, infection may spread from facial regions via the facial venous plexus or from the sphenoid sinus directly to the adjacent cavernous sinus.

Orbital Reconstruction After Eyelid- and Conjunctiva-Sparing Orbital Exenteration

PURPOSE

To describe the technique and results of eyelid- and conjunctiva-sparing orbital exenteration with temporalis transfer and dermis-fat graft.

METHODS

Five patients who underwent this procedure were studied, based on retrospective chart review. Schematic drawings were produced to illustrate the surgical technique.

RESULTS

The study included three female and two male patients with an age range of 7 to 76 years. Two patients required surgery for invasive optic nerve sheath meningioma, one for hemangiopericytoma, and the fourth for mesenchymal chondrosarcoma. The last patient had eyelid-sparing exenteration performed more than 20 years earlier for retinoblastoma and underwent a similar reconstruction. One case was complicated by infection and graft atrophy. The remaining four cases retained orbital volume and eyelid structures with a reasonable cosmetic outcome. Average follow-up period was 21 months, during which one patient had development of intracranial meningioma at the proximal end of the optic canal.

CONCLUSIONS

Eyelid- and conjunctiva-sparing orbital exenteration with temporalis transfer and dermis-fat graft is a useful technique that minimizes the usual deformity and achieves good results. Case selection is emphasized, as this technique is mainly reserved for histopathologically benign orbital lesions that exhibit local aggressive behavior and for malignant lesions only if there is no eyelid, lacrimal gland, or orbital fissure involvement nor significant conjunctival or deep extension of an intraocular tumor.

Mantle cell lymphoma in the ocular adnexal region

PURPOSE

To study the clinicopathologic features of mantle cell lymphoma (MCL) in the ocular adnexal region.

DESIGN

Retrospective review.

METHODS

The slides of 23 suspect patients were reevaluated with a panel of monoclonal antibodies, including anti-CD20, cyclin-D1, CD5, CD3, and p53 immunostains. Patients confirmed to have MCL were examined retrospectively on the basis of chart review.

RESULTS

Ten patients with periocular MCL were included in the study on the basis of characteristic histopathologic features and coexpression of nuclear cyclin-D1. This included 1 female and 9 male patients, with an age range of 32 to 84 years (median, 73.5 years). Median follow-up was 20 months (range, 5-172 months). Six of the 10 patients died, all of lymphoma. The orbit (90%) was most commonly involved followed by the lacrimal gland (50%) and lid (50%), with 90% of cases having lymphoma present at 2 or more periocular sites. Most had a primary periocular presentation (80%) that was associated with stage III/IV disease (80%), including atypical cells in the peripheral blood smear (60%) and bone marrow involvement (70%) at presentation. Three cases were CD5-negative, and 2 other cases showed composite histologic findings (MCL and follicular lymphoma and MCL and a plasma cell neoplasm). Fluorescent in situ hybridization performed in these 2 cases demonstrated t(11;14) in the MCL component. Actuarial survivals were median progression-free (PFS) survival, 12 months; median overall survival (OS), 57 months; 5-year PFS, 0; 5-year OS, 39%.

CONCLUSIONS

Mantle cell lymphoma presenting in the ocular adnexal region has a male predominance and tends to affect an elderly age group, as is typical of MCL involving nodal sites. A higher frequency of these tumors fail to co-express CD5, and composite lymphomas were observed in 20% of patients. Mantle cell lymphoma presenting in the ocular adnexal region is associated with advanced-stage disease and short PFS but an OS similar to MCL at other sites.