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.

Adult xanthogranulomatous disease of the orbit and ocular adnexa: new immunohistochemical findings and clinical review

BACKGROUND/AIMS

Adult xanthogranulomatous disease involving the ocular tissues is rare and poorly understood. Adult onset xanthogranuloma (AOX), adult onset asthma and periocular xanthogranuloma (AAPOX), necrobiotic xanthogranuloma (NBX), and Erdheim-Chester disease (ECD) are the four syndromes within this disorder, which is diagnosed by characteristic histopathology. Experience with eight cases prompted a multi-institutional effort to study the histopathology, immunohistochemistry, clinical findings, and systemic associations in this disorder.

METHODS

22 cases, including histopathological slides, were compiled. Published reports were identified by an English language Medline search (1966-2005) and review of reference citations. Each case in this series and the literature was classified as one of four syndromes and then analysed for age onset, sex, skin xanthoma, orbital location, immune dysfunction, internal organ and bone lesions, treatment, and outcome. The histopathology in each of these cases was reviewed by two pathologists. Immunhistochemical stains (CD3, CD4, CD8, L26) were performed in 14 cases where unstained slides were available.

RESULTS

137 cases were compiled. There was no sex or age difference between syndromes. AOX, AAPOX, NBX affect the anterior orbit, ECD tends to be diffuse and intraconal. Skin lesions are found in all the syndromes. Immune dysfunction was noted in all cases of AAPOX and NBX; 11% of NBX and all ECD patients had internal organ disease. Treatment included surgery, corticosteroids, other chemotherapeutic agents, radiotherapy, and combinations of these. No AOX or AAPOX deaths occurred; 66% of ECD patients died. All 22 cases had xanthoma cells; most had Touton giant cells. Lymphocytes were present in all cases and occurred as aggregates (mostly in AAPOX) or diffuse populations mixed with fibroblasts (mostly in ECD). Immunohistochemistry revealed the majority of these to be CD8+. Necrosis was most marked in NBX.

CONCLUSION

Adult xanthogranuloma of the orbit is rare, making prospective evaluation or meta-analysis impossible. The best treatment is unknown but seems to be with multiagent chemotherapy guided by histopathological, immunohistochemical, and systemic findings.

Factors associated with decompression and strabismus surgery in thyroid eye disease

INTRODUCTION

Prognostication of the thyroid patient with eye disease aids in the choice of treatment strategy. To facilitate this, we investigated factors associated with decompression and/ or strabismus surgery in the Singaporean population.

MATERIALS AND METHODS

A 5-year retrospective study was performed. Patients who required strabismus and/or decompression surgery (n = 23) were compared to those who did not undergo either surgery (n = 44). Individual and multivariate age-adjusted odds ratios were calculated to determine significant associations.

RESULTS

Individually, male gender [odds ratio (OR), 4.5; 95% confidence interval (CI), 1.5 to 13.4], uncontrolled hyperthyroidism (OR, 4.0; 95% CI, 1.1 to 14.3), steroid therapy (OR, 7.4; 95% CI, 2.3 to 24), diplopia (OR, 7.3; 95% CI, 2.3 to 23.1), objective vertical myopathy (OR, 11.7; 95% CI, 1.4 to 96.0), elevated intraocular pressure in the primary position (OR, 3.4; 95% CI, 1.2 to 10.0) and clinical evidence of optic neuropathy (OR, 13.1; 95% CI, 1.4 to 124.6) were significantly associated with the need for surgery. Logistic regression analysis showed the greater impact of male gender (OR, 4.2; 95% CI, 1.2 to 15.4), optic neuropathy (OR, 13.0; 95% CI, 1.2 to 143.7) and previous steroid therapy (OR, 4.2; 95%CI, 1.1 to 16.2) on prognostication.

CONCLUSIONS

Chances of requiring strabismus and/or decompression surgery are significantly higher for male patients and those with uncontrolled hyperthyroidism. In particular, male patients with optic neuropathy and a history of previous steroid therapy warrant a graver prognosis.

Localised invasive sino-orbital aspergillosis: characteristic features

BACKGROUND/AIM

To describe the characteristic constellation of historical, clinical, radiographic, and histopathological findings of localised invasive sino-orbital aspergillosis based on the authors' recent experience of four consecutive cases presenting over a 6 month period. Treatment and outcome are reviewed.

METHODS

A case series of four patients with review of the English language literature.

RESULTS

There have been 17 reported cases of invasive sino-orbital aspergillosis in healthy individuals over the past 33 years. The authors report four patients who presented during a 6 month period with persistent and significant pain followed by progressive ophthalmic signs-clinical histories reflecting the literature. Similar imaging findings were also noted: focal hypodense areas within apical infiltrates on contrasted computed tomography correspond to abscesses seen at surgery, and sinus obliteration or involvement of the adjacent sinus lining was noted on magnetic resonance imaging. Bone erosion (often focal) was also seen. There is frequently a delay in making the correct diagnosis, and often disease progression occurs despite treatment.

CONCLUSIONS

The authors encountered four cases of invasive sino-orbital aspergillosis, three of which occurred in otherwise healthy individuals. The clinician must be aware of the characteristic presentation so that earlier diagnosis, management, and improved outcomes can be achieved.

Orbital venous-lymphatic malformations (lymphangiomas) mimicking cavernous hemangiomas

PURPOSE

To illustrate that orbital venous-lymphatic malformations (lymphangiomas) may rarely simulate cavernous hemangiomas.

METHODS

Retrospective case review.

RESULTS

Five patients were identified from a series of 85 patients with venous-lymphatic malformations. The age range was 21 to 69 years, and all cases presented with a history of slowly progressive or long-standing proptosis. Computerized tomography revealed relatively homogeneous intraconal masses that were well defined anteriorly. Two of the cases had expansion of the orbit, and one had focal calcification. The three who had magnetic resonance imaging showed heterogeneous contrast enhancement. The preoperative diagnosis in every case was cavernous hemangioma, and intraoperatively the lesions resembled cavernous hemangiomas. However, posterior dissection was difficult in all patients because of dense adhesions and, in one case, led to a central retinal artery occlusion. The histology was characteristic of orbital venous-lymphatic malformations in all five cases.

CONCLUSIONS

Deep orbital venous-lymphatic malformations presenting in adulthood may be rarely confused with cavernous hemangiomas. In doubtful cases, significant intralesional heterogeneity, best seen on magnetic resonance imaging, and focal calcification may help distinguish the two entities. This differentiation is important, because dissection of venous-lymphatic malformations is fraught with more complications than surgical excision of a cavernous hemangioma.

Intraorbital rupture of a cavernous internal carotid artery aneurysm: therapeutic options

PURPOSE

To describe the use of an endovascular therapeutic technique in the management of a giant carotid cavernous aneurysm.

METHODS

We reviewed the clinical and neuroradiologic findings of a patient with an unusual case of carotid cavernous aneurysm and intraorbital rupture. The medical literature was searched for similar cases and to review the use of endovascular techniques.

RESULTS

The patient was treated by balloon occlusion of the left internal carotid artery.

CONCLUSIONS

Endovascular techniques can be used to treat complex giant cranioorbital cavernous aneurysms.

Orbital granulomatous giant cell myositis: a case report and review

To present a case of orbital granulomatous giant cell myositis and review the literature. We describe the case of a 51-year-old woman, with a past history of melanoma, who presented with an acutely painful orbital myositis. This evolved into a chronic relapsing process involving multiple muscles bilaterally; which demonstrated partial steroid responsiveness. Biopsy revealed a granulomatous giant cell myositis. Orbital granulomatous giant cell myositis is a rare histological entity which has an association with giant cell myocarditis and underlying malignancy.

Nonthyroid causes of extraocular muscle disease

Extraocular muscle involvement in orbital disease is most frequently seen as a feature of thyroid orbitopathy (Graves' disease). However, a wide range of other conditions may alter the size, shape, and function of these muscles, with characteristic clinical manifestations or abnormalities visible on orbital imaging. The differential diagnosis of muscle disease can be narrowed by careful analysis of clinical features and ancillary tests. Imaging facilitates recognition in many cases, but in some instances, accurate diagnosis requires biopsy. This review highlights the differential diagnoses for diseases of extraocular muscles based on the clinical and investigative records of 103 patients at our institution combined with data from the world literature. We found that the most common nonthyroid causes of muscle disease were inflammatory, vascular, and neoplastic processes (in decreasing order of frequency). Emphasis is placed on investigations that provide a logical approach to, and appropriate management of, disease of the extraocular muscles.

Distensible venous malformations of the orbit: clinical and hemodynamic features and a new technique of management

OBJECTIVE

To investigate distensible venous malformations of the orbit (DVMO) as part of a spectrum of orbital vascular malformations, including some that involved periorbital skin, extraorbital sites (central nervous system or nasal sinuses), or combinations of these. The authors also investigated the effectiveness of a new technique of management for selected cases.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Thirty patients had distensible venous anomalies, of which four were combined distensible venous-lymphatic vascular malformations. Distensible lesions were defined as those showing clinical or radiographic expansion with Valsalva maneuver or when the head was placed in a dependent position. These lesions were then classified as superficial (anterior to the equator of the globe), deep (posterior to the globe's equator), combined (deep and superficial), or complex (with intracranial or major extraorbital involvement).

INTERVENTION

Surgery was performed on 15 patients (50%), mainly for pain or for cosmetic indications. Six patients underwent this new technique, which involved intraoperative direct venography with control of outflow via pressure at the superior or inferior orbital fissure. The venous malformation was then embolized (by use of cyanoacrylate glue) and excised.

RESULTS

The mean age at presentation was 28.2 years (range, 8 months to 75 years). Sixty-six percent of cases involved the left orbit. Superior and medial orbital involvement was most common. Three cases (10%) were classified as superficial, and 13 (43%) as deep. Six patients (20%) had combined superficial and deep components. Eight (27%) had major extraorbital involvement (4 intracranial, 2 facial, and 2 paranasal sinus). Direct venography demonstrated complex multichannel anomalies draining to various sites, including the face and pterygopalatine fossa, without necessarily having a direct connection to the major orbital venous circulation.

CONCLUSIONS

Distensible venous malformations of the orbit are part of a spectrum of developmental venous malformations that may be localized to the orbit or involve it as part of a more extensive lesion. The authors describe their clinical and radiologic features and report a new technique of management for selected cases. This method of vascular isolation and embolization of lesions may greatly facilitate excision.

Combined venous lymphatic malformations of the orbit (so-called lymphangiomas). Association with noncontiguous intracranial vascular anomalies

OBJECTIVE

The authors present seven cases of orbital combined venous lymphatic vascular malformations (CVLVM) (lymphangioma) with evidence of noncontiguous intracranial vascular anomalies.

DESIGN

The study design was a review.

MAIN OUTCOME MEASURES

Radiologic studies of 25 patients with combined venous lymphatic vascular malformations were evaluated for noncontiguous intracranial vascular anomalies. Features of the intracranial anomalies and orbital lesions, their clinical presentation, and prognosis are described.

RESULTS

Seven patients (28%) had associated noncontiguous intracranial vascular anomalies. Intracranial hemorrhage occurred in one of these patients. The intracranial anomalies had radiologic characteristics of developmental venous anomalies (DVAs). Diffuse orbital lesions with superficial and deep components (7/7), orbital bony expansion (7/7), and intraconal and extraconal components (4/7) were most common. They involved the inferior orbital fissure and extended into the pterygopalatine fossa in five patients. Involvement of the superior orbital fissure was noted in all seven patients with extension into the middle cranial fossa in three patients. At birth, these patients generally had a visible superficial component and then had episodes of sudden proptosis associated with deep orbital hemorrhages. Visual outcome was poor (20/200 or less) in four (57%) of seven cases. Anterior extension into soft tissues of the face and forehead and other associated vascular lesions, such as palatal involvement, were relatively common. In contrast, CVLVMs (lymphangiomas) without noncontiguous intracranial vascular anomalies were more anterior, less diffuse, less likely to extend into the soft tissues of the face, have associated vascular lesions, or have a poor visual outcome.

CONCLUSIONS

Orbital CVLVMs (lymphangiomas) may be associated with noncontiguous intracranial vascular anomalies that may bleed. This association with intracranial DVAs has not been reported previously. The intracranial vasculature should be evaluated prospectively in these lesions, especially if they are diffuse.

The clinical and pathologic constellation of Wegener granulomatosis of the orbit

PURPOSE

Wegener granulomatosis (WG) may present as an orbital mass without obvious upper respiratory or systemic features. The authors examined the clinical and pathologic features of a series of cases of orbital WG to define the features of presentation and progression of this disorder.

METHODS

Thirteen subjects with orbital presentations of WG were identified from the University of British Columbia Orbit Clinic index of diseases. Clinical features were correlated with the results of computed tomography in 12 cases and orbital biopsy in 11 cases. Antineutrophil cytoplasmic antibody (c-ANCA) testing was performed in five cases.

RESULTS

The main ocular symptoms were decreased vision, redness, and ocular and facial pain, whereas the main signs were proptosis, scleritis, and lid inflammation. Progression was marked by an increased incidence of bilaterality and systemic features. Ear, nose, and throat features were discovered at presentation in 11 cases and became universal during the follow-up period. Initial antineutrophil cytoplasmic antibody test results were negative in five patients but became positive later in three patients. Orbital biopsy specimens typically had features of mixed inflammation, fat disruption, and small areas of necrosis. The combination of cyclophosphamide and oral steroids was highly effective in terminating disease episodes.

CONCLUSIONS

Orbital WG can be recognized by a constellation of clinical and radiologic findings with evidence of an often erosive, infiltrating, and restrictive fibrotic, inflammatory mass. Concurrent ear, nose, and throat or specific ocular findings such as scleritis with typical limbal infiltrate can occur. Biopsy results show mixed inflammation with evidence of necrosis that must not be regarded as a nonspecific finding.

Histopathologic findings and frequency of clonality detected by the polymerase chain reaction in ocular adnexal lymphoproliferative lesions

We report the reclassification according to recently described histologic categories of 48 patients with ocular adnexal lymphoproliferative lesions with long-term follow-up (mean, 8.1 yr). We used available formalin-fixed, paraffin-embedded, and frozen tissues to assess the frequency of immunoglobulin heavy chain gene rearrangement detectable by polymerase chain reaction in these lesions. We reviewed patient records, obtained follow-up data, and examined hematoxylin- and eosin-stained slides. DNA extracted from tissues was amplified with consensus V- and J-region primers to detect immunoglobulin heavy chain gene rearrangement. We examined 28 orbital, 10 lacrimal, and 10 conjunctival lesions, of which 2 lesions were lymphoid hyperplasias, 3 were indeterminate, and 43 were lymphomas. Of the 44 patients with follow-up, systemic lymphoma developed in 24 (55%), of whom 11 died of the disease, and 6 are alive with disease. Thirty-one patients had sufficient DNA for polymerase chain reaction analysis; 9 specimens were nonclonal, 21 were clonal, and 1 failed to amplify. The nonclonal lesions included one hyperplasia, one indeterminate lesion, and seven lymphomas; two of these patients died of the disease, and one is alive with disease. The clonal lesions included 1 indeterminate lesion and 20 lymphomas. Systemic lymphomas developed in 16 patients; 8 died of the disease, and 4 are alive with disease. Of the lesions histologically classified as lymphoma, 74% were clonal. We conclude that most ocular adnexal lymphoproliferative lesions can be histologically classified as lymphomas, that systemic lymphoma will develop in at least 50% of these patients if they are followed for sufficient time, and that most lesions classified as lymphomas will be clonal using polymerase chain reaction techniques. Lack of amplification using a consensus primer strategy may account for the inability to detect clonality by polymerase chain reaction in some histologically identified lymphomas.

Monoclonal origin of localised orbital amyloidosis detected by molecular analysis

AIMS

Primary localised orbital amyloidosis is a rare disease. The purpose of this study was to describe two cases of primary orbital amyloidosis and emphasise the value of molecular analysis of immunoglobulin gene rearrangement in identifying a monoclonal population of cells responsible for the amyloid production.

METHODS

Charts and biopsy specimens of each case were reviewed. Conventional light microscopy, immunohistochemistry, and polymerase chain reaction (PCR) analysis for immunoglobulin gene rearrangement were performed in both cases.

RESULTS

An unusual presentation of localised primary amyloidosis with bilateral and extensive enlargement of multiple extraocular muscles was seen in case 1. The presence of amyloid deposits was confirmed by biopsy in both cases. Evidence of a monoclonal population of plasma cells was shown by immunohistochemical analysis in case 2 only. The monoclonal origin of the cells responsible for the amyloid deposition was determined by PCR analysis demonstrating immunoglobulin heavy chain gene rearrangement in both cases.

CONCLUSIONS

A monoclonal population of plasma cells responsible for the amyloid deposition was present in these two cases. PCR analysis is extremely helpful in determining monoclonality, a finding that may have important therapeutic and prognostic implications.

Tumors arising in the palpebral lobe of the lacrimal gland

PURPOSE

Tumors arising in the palpebral lobe of the lacrimal gland are uncommon. There have been only eight reported patients, all of whom had pleomorphic adenomas. The authors present another six patients with primary palpebral lobe tumors.

METHODS

The clinical presentation, computed tomographic, and pathologic findings of these six patients were reviewed.

RESULTS

Tumor types include three pleomorphic adenomas, one well-differentiated adenoid cystic carcinoma, one carcinoma in pleomorphic adenoma, and one carcinoma ex pleomorphic adenoma. All six patients presented with a painless mass in the upper outer eyelid without significant displacement of the globe, but the superficial location of these lesions led to early detection. The tumors were localized to the lacrimal gland, predominantly anterior to the orbital rim. In all six patients, the involved palpebral lobe was removed, five via a direct anterior subcutaneous approach and one by superolateral orbitotomy. In two patients (adenoid cystic carcinoma and carcinoma ex pleomorphic adenoma), repeat surgery via superolateral orbitotomy was necessary to achieve complete removal of the lacrimal gland and surrounding tissue. No recurrences were detected during follow-up (range, 6 months to 7 years; mean, 26 months).

CONCLUSION

Palpebral lobe tumors of the lacrimal gland are more common and consist of a greater variety of histologic types than previously described. In our series, these tumors comprise 17% of all epithelial lacrimal gland lesions. These are the first reported cases of malignancy in this location. A longer follow-up period is necessary to determine the true recurrence rate of these tumors.

Enchondroma of the orbit

PURPOSE

To report a documented case of orbital enchondroma.

METHODS

A 25-year-old woman had an asymptomatic orbital mass. Computed tomographic scan was performed. The mass was surgically removed from the medial wall of the orbit, and the specimen was submitted for histopathologic examination.

RESULTS

The tumor showed typical radiologic and histopathologic appearance of an enchondroma with typical hypocellular lobules of cartilage enclosed by lamellar bone.

CONCLUSION

Cartilaginous neoplasms in the orbit are extremely rare.

Adverse effects of bone wax in surgery of the orbit

The goal of this article is to establish the incidence and scope of adverse reactions to bone wax in a large orbital surgical series. We report two patients with bone wax granulomas of the orbit as a remote surgical complication. These are the first reported cases of adverse reactions to bone wax in the ophthalmic literature. A chart review was conducted on all patients from the University of British Columbia Orbit Clinic that had surgery with temporary or permanent removal of orbital bone. Two patients with bone wax granulomas were identified. In one case, intraoperative cultures grew Staphylococcus aureus, confirming that the wax may indeed act as a nidus for infection. No cases of pseudoarthrosis have occurred. This syndrome of chronic granulomatous giant cell foreign body inflammation has characteristic clinical, radiologic, and histopathologic features. The literature regarding adverse reactions to bone wax is reviewed, and specific implications for orbital surgery are discussed.

Primary ductal adenocarcinoma of the lacrimal gland

PURPOSE

To their knowledge, the authors report the first recognized case of ductal adenocarcinoma of the lacrimal gland (histologic equivalent of salivary duct carcinoma). Primary adenocarcinoma of the lacrimal gland is rare and has been described generically. In contrast, primary adenocarcinomas of the major and minor salivary glands are much more common and have been classified into histopathologic subtypes that have different clinical characteristics and outcomes.

METHODS

A 68-year-old man presented with a 6-month history of a painless mass in the right upper outer eyelid. The authors describe the clinical, radiologic, and histopathologic features of this case and review the lacrimal gland literature.

RESULTS

A modified en bloc orbitectomy was performed, and postoperative radiotherapy was administered. The patient was alive and well without evidence of tumor recurrence 10 months after surgery.

CONCLUSION

The World Health Organization classification of salivary adenocarcinomas (1991) provides a framework for further insight into the presentation and biologic behavior of the less common lacrimal carcinomas.

Prognostic value of DNA ploidy as assessed with flow cytometry in uveal melanoma

OBJECTIVE

To investigate the prognostic value of tumour cell DNA content, as determined with flow cytometry, in formalin-fixed paraffin-embedded tissue from patients with uveal melanoma.

DESIGN

Case series.

SETTING

Pathology Laboratory, Vancouver General Hospital.

PATIENTS

Ninety patients with primary uveal (choroid) malignant melanoma diagnosed between 1975 and 1984 followed for at least 60 months.

OUTCOME MEASURES

Tumour cell DNA content, 5-year and 10-year disease-specific survival rates.

RESULTS

The DNA histograms were classifiable as diploid (67 cases) or aneuploid (18 cases) in 85 cases. On univariate analysis DNA content, age at diagnosis, histologic type of tumour, largest single tumour dimension and tumour volume were predictors of 10-year survival. Multivariate analysis with the stepwise Cox proportional hazards regression model did not confirm cellular DNA content as an independent prognostic factor. However, age at diagnosis, largest tumour dimension and presence of spindle vs. mixed or epithelioid cell pattern were significant predictors of death from uveal melanoma.

CONCLUSIONS

DNA ploidy of uveal melanoma is not a statistically significant predictor of survival.

Subperiosteal, subperiorbital dissection and division of the anterior and posterior ethmoid arteries for meningiomas of the cribriform plate and planum sphenoidale: technical note

Removal of meningiomas from the region of the cribriform plate and the planum sphenoidale may entail a bifrontal craniotomy and an interruption of the tumor's blood supply along the floor of the anterior cranial base. However, with this approach, the presence of bulky tumor above makes it difficult to control bleeding from multiple bony foramina in the anterior cranial base and to expose these foramina. The blood supply to the dura in this region, and, therefore, to these tumors, is predominantly from the anterior and posterior ethmoid arteries. Preoperative embolization of ethmoid arteries is not without a significant and prohibitive risk of blindness. A frontoethmoidal approach to the arteries on both sides requires two separate skin incisions. Therefore, a subperiosteal, subperiorbital dissection and division of these arteries via a bicoronal skin incision is a practical alternative.

Epithelioid sarcoma of the orbit

BACKGROUND

Epithelioid sarcoma is a rare and aggressive malignancy commonly occurring in the tendon sheaths of the distal extremities of young adults. This article presents the clinical and pathologic details of two patients with epithelioid sarcoma in the orbit, the first to be reported as occurring in this location.

METHODS

The clinical history, results of physical and radiologic examination, surgical procedures, pathologic specimens, and clinical course of each patient were reviewed and recorded.

RESULTS

Biopsies were performed of the masses that were found in the superotemporal orbit of both patients. Results of pathologic examination in each patient caused considerable difficulty, and the correct diagnosis was reached only after extensive consultation. The first patient underwent wide soft tissue and bone exenteration and is alive without recurrence at 3 years. The second patient had multiple recurrences and died of recurrent and metastatic disease at 29 months.

CONCLUSIONS

Epithelioid sarcoma must be added to the differential diagnosis of orbital sarcomas. The histology is nodular with a pseudogranulomatous appearance. Based on our limited experience, epithelioid sarcoma of the orbit may have a course similar to that which occurs elsewhere in the body, requiring aggressive surgical treatment at the outset.

Muscarinic receptor M1 and M2 subtypes in the human eye: QNB, pirenzipine, oxotremorine, and AFDX-116 in vitro autoradiography

Muscarinic cholinergic agents are used to lower intraocular pressure in the medical management of glaucoma and subtypes of muscarinic receptors have now been recognised in many tissues including the eye. To localise muscarinic receptors and their M1 and M2 subtypes in the human eye, in vitro ligand binding and autoradiographic techniques with densitometric quantitation on postmortem eye sections were used. As ligands, [3H] quinuclydinyl benzylate (QNB) (non-subtype specific muscarinic antagonist), [3H]pirenzipine (M1 antagonist), [3H]oxotremorine (M2 muscarinic agonist), [3H]AFDX-116(11[(2[diethylaminomethyl]1-piperidinyl)acetyl]5 , 11dihydro-6H-pyrido [2,3b][1,4]benzodiazepine-6-one) (M2 antagonist) were studied. Specific binding sites for QNB, pirenzipine, and AFDX-116 were localised in the entire ciliary muscle, the iris, and ciliary epithelium. [3H]oxotremorine localised only in the longitudinal portion of the ciliary muscle, and additionally, was not localised in the iris or ciliary epithelium. These results suggest that oxotremorine, by binding selectively to receptors on the longitudinal ciliary muscle and inducing its contraction, may modulate outflow facility independently from accommodation and miosis.

Idiopathic sclerosing inflammation of the orbit. A distinct clinicopathologic entity

BACKGROUND

Idiopathic sclerosing inflammation of the orbit is a poorly delineated, fibrosing, immune-mediated entity resulting in significant ocular disability. To characterize this process and propose more specific and effective therapy, clinical and pathologic findings in 16 cases are reviewed.

METHODS

The clinical records of 16 patients with biopsy-proven disease were retrospectively reviewed to determine demographic and clinical features, radiologic features, course, management, and outcome. These findings were correlated with pathologic features to describe this unique entity. Immunohistologic characteristics were compared with those of a clinically and histopathologically similar process, retroperitoneal fibrosis.

RESULTS

The study included 11 male and 5 female patients, ranging in age from 8 to 81 years. Disease onset was usually unilateral (14/16) and chronic (11/15), with two distinct anatomic presentations, lacrimal (11/16) and apical (3/16), characterized by infiltration (15/16), mass effect (12/16), and visual loss (3/16). The most common signs and symptoms were dull pain (13/16), proptosis (11/16), mild inflammation (11/16), restricted motility (9/16), swelling (9/16), and diplopia (8/16). Two features, a sparse, chronic inflammatory infiltrate, the immunopathologic characteristics of which suggested a cell-mediated process, and a desmoplastic stroma of early onset, dominated the pathologic picture. Treatment with corticosteroids (11/16), radiotherapy for steroid failures (8/11), and observation alone (3/16) was inadequate, resulting in blindness in 3/16 cases, restricted movement in 10/16, and complete resolution in only 2/16 patients.

CONCLUSION

Idiopathic sclerosing inflammation of the orbit is a unique clinicopathologic entity, similar to retroperitoneal fibrosis, that is characterized by primary, chronic, and immunologically mediated fibrosis, poor response to corticosteroid treatment or radiotherapy, and frequent visual disability. Early and aggressive immunosuppressive therapy is recommended.

Orbital decompression for disfiguring exophthalmos in thyroid orbitopathy

BACKGROUND

Progressive exophthalmos from dysthyroid orbitopathy may result in marked disfigurement. Commonly affecting middle-aged women, it can be a significant social and psychologic handicap. Cosmesis is increasingly recognized as an indication for orbital decompression. Many argue, however, that decompression carries risks of operative complications which are only warranted where vision is threatened.

METHODS

Between 1984 and 1990, the authors performed orbital decompression for cosmetic indications on 34 patients (65 orbits) with thyroid orbitopathy. The charts of these patients were reviewed to assess the results of surgery and the nature and incidence of complications.

RESULTS

The mean retroplacement achieved was 4 mm (range, -1.0 to 10 mm). In 29 (85%) of the 34 patients, there was a difference of 1 mm or less in the proptosis of the two eyes postoperatively. Diplopia arose de novo in five (18%) previously asymptomatic patients. Postdecompression strabismus was managed successfully with adjustable surgery (mean, 1.3 operations per patient). With the exception of transient infra-orbital nerve hypoesthesia, there were no surgical complications.

CONCLUSION

Decompression surgery is effective in reducing exophthalmos in dysthyroid orbitopathy. In this series of operations, complications were rare and treatable. Decompression is often the first of a series of operations that may be necessary to correct the cosmetic sequelae of this condition. It should be considered by experienced surgeons in carefully selected and counseled patients who have disfiguring thyroid orbitopathy.

Localization of M3 muscarinic receptor subtype and mRNA in the human eye

Cholinergic agents used to lower intraocular pressure in the medical management of glaucoma act on muscarinic receptors in the eye. Recently, subtypes of muscarinic receptors have been recognized in many tissues including the eye. To localize the M3 muscarinic receptor subtype and m3 messenger RNA (mRNA) in the human eye, we used in vitro ligand binding and in situ hybridization techniques on post-mortem sections. We used an M3 antagonist, [3H]-4-DAMP ([3H]-4-diphenylacetoxy-N-methylpiperidine methiodide) to identify M3-binding sites and a [35S]-labelled oligonucleotide probe to detect and localize m3 mRNA. M3 and m3 mRNA were both localized in the ciliary muscle, ciliary epithelium, iris, corneal epithelium and anterior lens epithelium. The m3 transcript was also detected in the trabecular meshwork and corneal endothelium.

Idiopathic sclerosing inflammation of the orbit: immunohistologic analysis and comparison with retroperitoneal fibrosis

Idiopathic sclerosing inflammation of the orbit is clinically characterized by an insidious, chronic and progressive fibrosing process damaging orbital structures through entrapment and mass effect. Histologically, desmoplasia and a sparse infiltrate of lymphocytes, histiocytes, plasma cells, and occasional neutrophils and eosinophils are seen. An immune pathogenesis is suspected but presently poorly understood. To characterize the inflammatory infiltrate and to compare orbital and other inflammatory fibrosing lesions, immunoperoxidase studies using the streptavidin method were performed on 16 formalin or Bouins' fixed, paraffin-embedded orbital biopsy specimens and six specimens of retroperitoneal fibrosis. Positive staining of orbital tissue occurred as follows: T-cells (UCHL-1) 94% of cases, B-cells (L26) 40%, tissue macrophages (KP-1) 56%, HLA Dr positive antigen presenting cells and activated T-cells (LN3) 44%, and immunoglobulins (kappa, 80%; lambda, 63%, IgG, 73%, IgA, 44% and IgM, 31%). Results were strikingly similar for retroperitoneal fibrosis. These findings imply a cell mediated pathogenesis in idiopathic sclerosing inflammation of the orbit that is similar to retroperitoneal fibrosis and suggest therapeutic potential for agents modifying this facet of the immune system.

Radiotherapy in the management of thyroid orbitopathy. Computed tomography and clinical outcomes

OBJECTIVE

We investigated the long-term outcome of patients with thyroid orbitopathy treated with orbital radiotherapy using quantitative clinical measurements and orbital computed tomographic morphometric changes.

DESIGN

Patients who had undergone orbital radiotherapy for thyroid orbitopathy at least 1 year previously were retrospectively recalled for follow-up examination and computed tomography. Controls were patients with similar disease activity but who had not undergone radiotherapy.

SETTING

Subspecialty clinic in a university teaching hospital.

PATIENTS

Twenty-one patients (42 orbits) who underwent radiotherapy and six clinically comparable patients who had not undergone radiotherapy (12 orbits).

INTERVENTION

Standardized, super-voltage, orbital radiotherapy.

MEASUREMENTS

Five clinical indexes of orbitopathy and six computed tomographic indexes were examined for interval changes.

RESULTS

The orbital computed tomographic muscle-diameter index enlargement ratio did not change in either group (radiotherapy group, 1.54 to 1.51, not significant; nonradiotherapy group, 1.37 to 1.36, not significant). The mean (+/- SEM) number of muscles with low-density areas increased in both groups (radiotherapy group, 1.1 [+/- 1.9] muscles per orbit; P < .001). Soft-tissue signs improved significantly with lesser improvements in extraocular muscle function in both groups. Proptosis, visual acuity, and intraocular pressure rise on upgaze did not improve significantly in either group.

CONCLUSIONS

No changes in muscle size measured with computed tomography were found in either patients undergoing radiotherapy or patients not undergoing radiotherapy after long-term follow-up. Clinical indexes of thyroid orbitopathy, especially soft-tissue signs, improved on follow-up, but this was not influenced by the method of treatment.

Conjunctival and uveal melanoma in the dysplastic nevus syndrome

The dysplastic nevus syndrome was conceptualized in the late 1970s, and the subsequent proposal of a genetic relationship with ocular melanoma has stimulated debate in the literature which remains unresolved. We present the case of a 60-year-old man with histologically proven sporadic dysplasic nevus syndrome and a prior history of nine cutaneous melanomas, who developed a large, exophytic melanoma of the cornea and limbal conjunctiva. Cytogenetic analysis of this melanoma revealed a clonal 1;14 translocation. We believe this is the first reported case to use cytogenetic techniques in the analysis of conjunctival melanoma, either associated with dysplastic nevus syndrome or in isolation. We review the clinical literature as well as the cytogenetic and molecular genetic data related to the possible association of cutaneous melanoma, conjunctival and uveal melanoma and the dysplastic nevus syndrome.

The initial clinical characteristics of Graves' orbitopathy vary with age and sex

A better understanding of the clinical nature of Graves' orbitopathy will aid in the treatment of the disease as well as help to form a basis for clinical and pathophysiologic investigations. We studied the clinical data of 557 consecutive patients who were referred for treatment of Graves' orbitopathy. Clinical indexes were calculated based on ophthalmologic variables measured, grouped in the following categories: soft tissue, proptosis, muscle limitation, increase in intraocular pressure on upgaze, corneal staining, and visual acuity. The mean age at onset of orbital disease was 43.9 years for men and 44.4 years for women, an average of 2.5 years from the onset of thyroid disease. The male-female ratio was 0.29 in all age groups. Women were more likely to present with orbitopathy and hypothyroidism than were men (20% vs 11%) and less likely to be euthyroid (16% vs 34%, P < .01). Patients older than 50 years, compared with their younger counterparts, more often had symptoms of impaired ocular motility (32% vs 12%), signs of soft-tissue involvement (77.5% vs 68.6%), asymmetric soft-tissue involvement (15.6% vs 7.8%), more limited upward duction (22.2 degrees vs 29.4 degrees), and more impaired LogMAR visual acuity (0.092 vs 0.047, P < .01). Men had more limited upward duction than women (24.6 degrees vs 27.1 degrees) and greater increases in intraocular pressure on upgaze (7.80 mm Hg vs 5.78 mm Hg, P < .001). These data show thyroid orbitopathy to be a disease most common in younger women, but more severe, by most indexes, in men and patients older than 50 years. These groups of patients are also more likely to have asymmetric or euthyroid disease.

[Assessment of anti-proliferative and anti-inflammatory drugs for treatment of ocular fibroblast proliferation using dynamic microscope image processing scanner]

Controlling ocular fibroblast proliferation may significantly improve the effectiveness of glaucoma filtration surgery. Drugs for the inhibition of fibroblast growth are currently in clinical use. However, systemic studies of drugs with different mechanisms of action have not been performed on human ocular fibroblasts. We have developed a method to evaluate the effect of chemotherapeutic agents on fibroblast proliferation, motility, and dynamic morphology. This involves the use of an automated microscope system designed for quantitative measurement of movement and morphology of live cells in tissue culture. This technique was tested on an established tissue culture fibroblast (3T3 cells) and then applied to secondary culture of human scleral and subconjunctival fibroblasts. 5-fluorouracil and colchicine were tested for their effect on fibroblast behaviour. Our data indicated that colchicine was more effective than 5-fluorouracil in inhibiting fibroblast proliferation and movement, and in changing morphology. Using this system, fundamental biological effects of various pharmacological manipulations could be studied in vitro prior to in vivo applications.

Cellular blue nevus of the conjunctiva

BACKGROUND

Cellular blue nevi of the conjunctiva are extremely rare, and their natural history and malignant potential have not been fully ascertained.

METHODS

A report of an unusually well-documented case of growth of a cellular blue nevus is presented, along with a review of current knowledge of this lesion.

RESULTS

A 71-year-old woman presented with a darkly pigmented raised lesion of the conjunctiva, which had slowly enlarged over 47 years. There were nonconfluent areas of involvement of the upper and lower lids. Results of biopsy showed the lesion to be a cellular blue nevus, with no evidence of malignancy.

CONCLUSION

This well-documented case of slow growth and spread without malignant transformation adds to the knowledge of this rare lesion.

Granulomatous orbital lesions: computed tomographic features

Orbital lesions exhibiting granulomatous inflammation represent a heterogeneous group of diseases characterized by infiltration with epithelioid cells. The authors retrospectively reviewed the orbital computed tomography (CT) scans of 39 patients who had biopsy-proven lesions with granulomatous inflammation and found that diagnosis on the basis of CT was possible in only a few patients, those with a lesion of characteristic location and attenuation (such as a dermoid cyst) or characteristic distribution (such as bilateral enlargement of the lacrimal gland occurring in orbital sarcoidosis). In patients with multicompartmental disease exhibiting bone and extraorbital involvement the site of origin of the mass, the pattern of bone involvement and the clinical findings helped in classifying the cause of the lesion as Wegener's granulomatosis, a foreign body or mucormycosis. CT was crucial in determining the intraorbital and extraorbital extent of the lesion before excision or biopsy.