Attendance in a national screening program for diabetic retinopathy: a population-based study of 205,970 patients

AIMS

A nationwide diabetic retinopathy (DR) screening program has been established in Denmark since 2013. We aimed to perform an evaluation of adherence to DR screenings and to examine whether non-adherence was correlated to DR progression.

METHODS

The population consisted of a register-based cohort, who participated in the screening program from 2013 to 2018. We analyzed age, gender, marital status, DR level (International Clinical DR severity scale, none, mild-, moderate-, severe non-proliferative DR (NPDR) and proliferative DR (PDR)), comorbidities and socioeconomic factors. The attendance pattern of patients was grouped as either timely (no delays > 33%), delayed (delays > 33%) or one-time attendance (unexplained).

RESULTS

We included 205,970 patients with 591,136 screenings. Rates of timely, delayed and one-time attendance were 53.0%, 35.5% and 11.5%, respectively. DR level at baseline was associated with delays (mild-, moderate-, severe NPDR and PDR) and one-time attendance (moderate-, severe NPDR and PDR) with relative risk ratios (RRR) of 1.68, 2.27, 3.14, 2.44 and 1.18, 2.07, 1.26, respectively (P < 0.05). Delays at previous screenings were associated with progression to severe NPDR or PDR (hazard ratio (HR) 2.27, 6.25 and 12.84 for 1, 2 and 3+ delays, respectively). Any given delay doubled the risk of progression (HR 2.28).

CONCLUSIONS

In a national cohort of 205,970 patients, almost half of the patients attended DR screening later than scheduled or dropped out after first screening episode. This was, in particular, true for patients with any levels of DR at baseline. DR progression in patients with delayed attendance, increased with the number of missed appointments.

Factors associated with ocular surface disease and severity in adults with atopic dermatitis: a nationwide survey

BACKGROUND

Ocular surface diseases (OSDs), including conjunctivitis and blepharitis, are common in atopic dermatitis (AD) patients, but the magnitude and patient characteristics are unclear.

OBJECTIVES

To examine the prevalence of OSDs in adults with AD and identify patient characteristics and risk factors.

METHODS

We designed a cross-sectional questionnaire-based survey and sent it via a secure public mail to all adult Danes with a hospital diagnosis of AD (ICD-10 code L20.x) registered in the National Patient Register (n = 16 718) between 2000 and 2019 and 7044 (42%) participated. Primary outcomes were OSDs and severity according to Ocular Surface Disease Index (OSDI). Adjusted odds ratios (aOR) were calculated with 95% confidence intervals (CIs) using logistic regression models.

RESULTS

Respondents were mostly females and middle-aged (67.4%, mean [SD] age, 39.0 [15.5] years). Based on Patient-Oriented SCORing Atopic Dermatitis 49% had mild AD, 35% moderate, 10% severe and in 6% AD was inactive; 44.3% reported physician-diagnosed asthma bronchiale and 55.8% rhinitis. The lifetime prevalence of OSDs was 66.6% for conjunctivitis, 63.5% for hordeolum, 11.0% for blepharitis, 9.7% for keratitis, 2.0% for pterygium, 1.5% for symblepharon, 1.1% for keratoconus and 12.7% reported current conjunctivitis. Factors associated with lifetime occurrence of conjunctivitis included mild, moderate, and severe AD (aOR = 1.48 [95% CI, 1.02-2.14], aOR = 1.73 [95% CI, 1.19-2.53], aOR = 2.17 [95% CI, 1.42-3.21]), asthma bronchiale and rhinitis (aOR = 1.76 [95% CI, 1.49-2.07]), childhood-onset of AD (aOR = 1.34 [95% CI, 1.16-1.56]) and systemic AD treatment (aOR = 1.27 [95% CI, 1.08-1.50]). Use of soft and hard contact lenses (aOR = 2.15 [95% CI, 1.65-2.80], aOR = 3.35 [95% CI, 1.62-6.92]) were associated with lifetime occurrence of keratitis. Moderate and severe AD, asthma bronchiale and rhinitis were also associated with a higher OSDI level.

CONCLUSIONS

This study identified important patient factors associated with OSDs. Clinicians should be attentive of ocular signs and symptoms in AD patients and ask about these.

AB0355 THE VALUE OF PLATELET-TO-LYMPHOCYTE AND NEUTROPHIL-TO-LYMPHOCYTE RATIOS AS INFLAMMATORY MARKERS IN BIOPSY-PROVEN GIANT CELL ARTERITIS

Background:

Platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) have been shown to correlate with disease activity in various rheumatic diseases. High PLR and elevated platelet count are potentially useful in diagnosing some systemic vasculitides, eg. giant cell arteritis (GCA)1 and has been suggested predictive for diagnosing GCA, even in the absence of characteristic temporal artery involvement2.

Objectives:

To evaluate the role of PLR and NLR as inflammatory markers in the diagnosis of GCA in patients referred to temporal artery biopsy (TAB).

Methods:

During 10 months, all patients referred to TAB at the Department of Ophthalmology (Rigshospitalet, Copenhagen, Denmark) in suspected GCA were included. Immediately prior to TAB, ultrasound of bilateral temporal arteries was performed at the Center for Rheumatology and Spine Disease (Rigshospitalet, Copenhagen, Denmark) by rheumatologists experienced in vascular ultrasound. Ultrasound signs of GCA were a positive Halo sign or compression sign. Patients had C-reactive protein (CRP), erythrocyte sedimentation ratio (ESR), platelets, white blood cells with differential counts, hemoglobin and platelets measured. Final clinical diagnosis, based on rheumatological expert opinion, and fulfilment of ACR1990 classification criteria for temporal arteritis at six months was noted, with clinical diagnosis being the reference standard.

Results:

106 patients were included and had a TAB evaluated. Forty-five (42%) had a clinical diagnosis of GCA at 6 months of which 28 (62%) also were TAB positive. US was performed in 74 (70%), of these 20 (67%) of the GCA patients had a positive ultrasound for GCA (termed US GCA patients). There was no significant difference in mean age or gender distribution between GCA and non-GCA patients. ESR, CRP and platelets were significantly higher in GCA than non-GCA patients (p<0.001). PLR was significantly higher in GCA than non-GCA patients (p<0.007), while NLR was not (p=0.076). For US GCA patients vs. US non-GCA patients, platelets were significantly higher in the US GCA group (p=0.025). Both PLR and NLR were significantly higher in the US GCA group compared to the US non-GCA group (p= 0.003 and p=0.007, respectively).

Conclusion:

In this cohort of patients, suspected of GCA and referred to TAB, PLR but not NLR was significantly higher in GCA patients than in non-GCA patients. In patients with US findings of GCA, both PLR and NLR were significantly higher in GCA compared to non-GCA. An elevated PLR could be considered an additional feature in diagnosing GCA.

References:

[1]El-Dairi MA et al.: J Neuroophthalmol 2015;35:246-53

[2]Bornstein G et al.: Clin Rheumatol 2018;37:2819-2

GCA (n=45)Non-GCA (n=61)P-valueAge (years)73.6 (7.5)72.6 (10.4)0.575Females, n (%)34 (76)38 (62)0.148Fulfilling ACR1990 criteria, n (%)36 (80)16 (26)<0.001TAB positive for GCA, n (%)28 (62)0 (0)<0.001Ultrasound positive for GCA*, n (%)20 (67)9 (20)<0.001Sedimentation rate (mm/hr)58 (30)33 (31)<0.001Haemoglobin (mmol/L)7.68 (0.92)7.96 (1.05)0.154CRP (mg/L), median (IQR)38 (15-92)8 (2-40)<0.001White blood cells (109/L)9.54 (3.18)8.99 (3.63)0.407Lymphocytes (109/L)1.72 (0.78)1.87 (0.93)0.367Monocytes (109/L)0.71 (0.37)0.77 (0.41)0.441Neutrophils (109/L)6.85 (2.94)6.01 (3.02)0.157Basophils (109/L)0.05 (0.04)0.05 (0.05)0.464Eosinophils (109/L)0.15 (0.14)0.18 (0.21)0.410Platelets (109/L)400 (154)289 (111)<0.001Neutrophil-to-lymphocyte ratio4.91 (3.22)3.87 (2.52)0.076Platelet-to-lymphocyte ratio287 (189)193 (147)0.007

Values are mean and standard deviation unless noted

Comparison between groups by independent samples t-test (continuous variables), χ2-test (categorical variables) and Mann-Whitney for CRP (not normal distributed continuous variable)

ACR=American College of Rheumatology; CRP=C-reactive protein; GCA=giant cell arteritis; IQR=interquartile range; n=number; SD=standard deviation; TAB=temporal artery biopsy

*Ultrasound not done in 32 patients (15 with GCA and 17 without)

Disclosure of Interests:

None declared

SAT0164 MC2-03 (CICLOSPORIN EYEDROPS) IMPROVES TEAR PRODUCTION IN SJÖGREN’S PATIENTS WITH MODERATE-TO-SEVERE KERATITIS: RESULTS FROM A PHASE 2B RANDOMIZED, CONTROLLED TRIAL

Background:

Sjögren Syndrome (SS) is a multifaceted disease with variable symptoms, but the SS associated keratoconjunctivitis is one of the most frequent disease manifestations of the syndrome and the manifestation that has the greatest impact on the quality of life for these patients.

Objectives:

To report the clinical efficacy of MC2-03 eyedrops in Sjögren’s patients with moderate-to-severe keratitis from a 6-month trial looking at the Schirmer score which assess the tear production by the lacrimal gland. A Schirmer score of ≤5mm/5 min is one of the criteria used in the 2016 final classification of ACR/EULAR to diagnose Sjögren`s syndrome.

Methods:

The NORTHERN LIGHTS trial is a randomized, double masked, controlled multicentre European trial that assessed MC2-03 eyedrops (ciclosporin 0.03% and 0.06%) for the treatment of moderate-to-severe dry eye disease in 255 patients having corneal fluorescein staining score 3 or 4 at baseline. The Schirmer score (per 5 min) was assessed during this trial. A total of 66 patients (25.9%) with medical history of Sjögren’s syndrome were randomized in the trial.

Results:

Demographics and baseline disease characteristics were comparable between treatment arms: mean age 60.4 years, 90.9% were females (n=60) and the mean Schirmer score in the worst eye was ~3mm (2.8mm – 3.2mm, except for the vehicle, mean Schirmer score of 5.5mm).

The mean Schirmer score improved rapidly from baseline to month 1 for MC2-03 0.03% eye drops (+2.4mm) reaching statistical significance versus vehicle (-0.5mm, p=0.028) and lubricant therapy (-0.6mm, p=0.020). This improvement was maintained at month 6 where the change was +2.5mm for MC2-03 0.03% eye drops compared to -1.1mm for vehicle (p=0.028). Statistical significance was also achieved at Month 6 comparing the higher strength MC2-03 0.06% eye drops (+2.8mm) to vehicle (-1.1mm, p=0.005) and lubricant alone (-0.5mm, p=0.009).

Three in eleven (27.3%) Sjögren`s patients treated with MC2-03 0.03% eye drops improved from a diagnostically low Schirmer ≤5mm at baseline (10/12, 83.3% ≤5mm) to Schirmer >5mm at month 3 and month 6 (6/11, 54.5% ≤5mm), while on the other hand 1 in 14 (7.1%) patients worsened in the vehicle group. A similar response was seen for MC2-03 eye drops 0.06%.

For Sjögren´s patients with Schirmer ≤5mm at baseline, a greater proportion of patients improved ≥3mm at month 6 when treated with MC2-03 eye drops 0.03% (44.4%, 4/9) and 0.06% (53.8%, 7/13) compared to vehicle (0%, 0/9) and lubricant (7.7%, 1/12). At month 6, a statistically significantly higher proportion of patients achieved clinically meaningful improvements in both corneal staining (≥2 grades improvement) and Schirmer score (≥3mm/5 min) when treated with MC2-03 0.03% eye drops (45.5%, 5/11) compared to both vehicle (0%, 0/14, p=0.009) and lubricant (0%, 0/15, p= 0.007). A higher number of patients treated with MC2-03 0.06% was observed without statistical significance.

Conclusion:

MC2-03 eye drops once daily rapidly increased tear production and further improved corneal staining in Sjögren´s patients with moderate to severe keratitis, which both are objectives included as diagnostic criteria for Sjögren’s disease. MC2-03 eye drops were well tolerated with no unexpected safety findings.

Disclosure of Interests: :

Frederic Gomez Consultant of: MC2 Therapeutics, Morten Præstegaard Employee of: MC2 Therapeutics, Johan Selmer Employee of: MC2 Therapeutics, Jutta Horwath-Winter Consultant of: CromaPharma, Omnivision, MC2 Therapeutics, Speakers bureau: Allergan, Bausch&Lomb, Cromapharma, Ursapharma, Thea, TRB-Chemedica, Santen, Maite Sainz de la Maza: None declared, Steffen Heegaard Consultant of: Sanofi, MC2 Therapeutics, Speakers bureau: Santen, Sanofi, Thea, Leo

Epstein-Barr Positive T-Cell Lymphoma in the Ocular Region

Purpose

To present two cases of rapidly growing tumors in the ocular adnexa. Both tumors were Epstein-Barr virus (EBV) positive peripheral T-cell lymphoma.

Methods

Case 1 was a 60-year-old man with a non-tender ulcerating tumor involving the lateral third of both upper and lower right eyelid. Case 2 was a 55-year-old man with a swelling of the left eyelid expanding cranially and dislocating the left eye, resulting in proptosis and diplopia. Both patients underwent incisional biopsy that did not disclose the malignant nature of the tumors. Clinical evaluation resulted in suspicion of malignancy and surgical excision was performed.

Results

The tumors were found to be consistent with EBV-positive peripheral T-cell lymphoma.

Conclusions

Peripheral T-cell lymphoma is uncommon but a diagnosis to be considered in a patient with a tumorous lesion in the eye region. Furthermore, peripheral T-cell lymphoma may be EBV-positive.

Management of patients with ocular manifestations in vesiculobullous disorders affecting the mouth

Pemphigoid and pemphigus diseases as well as Stevens-Johnson syndrome present as vesiculobullous disorders of the skin and may additionally involve both the oral cavity and the ocular surface. Ocular involvement ranges from mild irritation and dry eye disease to chronic conjunctivitis, symblepharon, eyelid malposition, ocular surface scarring and severe visual loss. In addition to diagnostic assessments, ophthalmologists must treat the dry eye and meibomian gland dysfunction components of these diseases using a stepladder approach, including eyelid hygiene and lubricants. Topical anti-inflammatory therapy is used to treat acute inflammatory exacerbations of the ocular surface, but it cannot prevent scarring alone. Intralesional antimetabolite therapy can cause regression of conjunctival pathology in selected cases. Hence, patients with vesiculobullous disorders should be managed by a multidisciplinary team representing ophthalmology, dermatology, otolaryngology, oral medicine and pathology, internal medicine and intensive care. Systemic treatments including corticosteroids, azathioprine, cyclophosphamide, cyclosporine and mycophenolate mofetil help control inflammation. Intravenous immunoglobulins, plasmapheresis and targeted antibody therapy can be used in selected, severe and treatment-resistant cases. Local surgical management may include debridement of pseudomembranes, lysis of symblepharon, amniotic and mucous membrane grafting as well as reconstructive procedures. Prospective, multicentre, international studies are recommended to further support evidence-based practice.

Ophidian Spectaculitis and Spectacular Dysecdysis: A Histologic Description

The histologic features of abnormal spectacles in 60 snakes from the 5 families of Boidae, Colubridae, Elapidae, Pythonidae, and Viperidae are described in a retrospective study conducted on specimens submitted to a private diagnostic service during a period of 15 years. Fifty-two snakes had inflammatory reactions in the spectacle. The stroma and outer epithelium of the spectacle were the layers most often involved in inflammatory disease. Lesions of the outer epithelium included edema, hyperkeratosis, and granulocyte infiltration occasionally with bacterial colonies and fungal elements. The stroma had infectious agents and inflammatory reactions in vessels and between the collagen fibrils. The inner epithelium had varying degrees of hyperplasia and hypertrophy, but no infectious agents were seen. Infectious agents in these cases included mites, bacterial disease, fungal disease, or a combination of bacterial and fungal disease. Special stains identified the bacteria most commonly involved to be Gram-positive cocci. Thirteen snakes had dysecdysis of the spectacle. Of these, 5 displayed a concurrent inflammatory reaction of the spectacle, while the remaining 8 snakes had extra keratin layers on a spectacle with an otherwise normal appearance. These keratin layers were attached to serocellular crusts located on the inner surface of the periocular scales. The cause for dyskeratotic lesions of the spectacle was not always apparent, and concurrent acariasis, other forms of dermatitis, trauma, suboptimal husbandry, and visceral disease were considered possible contributing factors. It was notable that only 4% of the submitted cases were found to have spectaculitis and/or spectacular dysecdysis.

A recurrent germline BAP1 mutation and extension of the BAP1 tumor predisposition spectrum to include basal cell carcinoma

We report four previously undescribed families with germline BRCA1-associated protein-1 gene (BAP1) mutations and expand the clinical phenotype of this tumor syndrome. The tumor spectrum in these families is predominantly uveal malignant melanoma (UMM), cutaneous malignant melanoma (CMM) and mesothelioma, as previously reported for germline BAP1 mutations. However, mutation carriers from three new families, and one previously reported family, developed basal cell carcinoma (BCC), thus suggesting inclusion of BCC in the phenotypic spectrum of the BAP1 tumor syndrome. This notion is supported by the finding of loss of BAP1 protein expression by immunochemistry in two BCCs from individuals with germline BAP1 mutations and no loss of BAP1 staining in 53 of sporadic BCCs consistent with somatic mutations and loss of heterozygosity of the gene in the BCCs occurring in mutation carriers. Lastly, we identify the first reported recurrent mutation in BAP1 (p.R60X), which occurred in three families from two different continents. In two of the families, the mutation was inherited from a common founder but it arose independently in the third family.

Fungal keratitis - improving diagnostics by confocal microscopy

PURPOSE

Introducing a simple image grading system to support the interpretation of in vivo confocal microscopy (IVCM) images in filamentous fungal keratitis.

SETTING

Clinical and confocal studies took place at the Department of Ophthalmology, Aarhus University Hospital, Denmark. Histopathological analysis was performed at the Eye Pathology Institute, Department of Neuroscience and Pharmacology, University of Copenhagen, Denmark.

METHODS

A recent series of consecutive patients with filamentous fungal keratitis is presented to demonstrate the results from in-house IVCM. Based upon our experience with IVCM and previously published images, we composed a grading system for interpreting IVCM images of filamentous fungal keratitis.

RESULTS

A recent case series of filamentous fungal keratitis from 2011 to 2012 was examined. There were 3 male and 3 female patients. Mean age was 44.5 years (range 12-69), 6 out of 17 (35%) cultures were positive and a total of 6/7 (86%) IVCM scans were positive. Three different categories of IVCM results for the grading of diagnostic certainty were formed.

CONCLUSION

IVCM is a valuable tool for diagnosing filamentous fungal keratitis. In order to improve the reliability of IVCM, we suggest implementing a simple and clinically applicable grading system for aiding the interpretation of IVCM images of filamentous fungal keratitis.

Uveal and Conjunctival Malignant Melanoma in Denmark, 1943–97: Incidence and Validation Study

PURPOSE

To study the incidence of malignant melanoma in the ocular region in Denmark during the period 1943-97.

METHODS

The patients were mainly identified through the Danish Cancer Registry. Age-period-cohort modelling of the incidence rates was done based on age at diagnosis, calendar period and birth cohort in 5-year groups and for each gender.

RESULTS

The age-standardized incidence of malignant melanoma in the ocular region was 0.78 for men (N = 1327) and 0.65 for women (N = 1242) per 100,000 person-years. Calendar period and birth cohort had no effect on the incidence in the ocular region or in the topography subgroups choroid/ciliary body and conjunctiva. However, the incidence increased with birth cohort for iris melanomas.

CONCLUSIONS

The incidence of malignant melanoma in the ocular region was stable in contrast to a major increase in cutaneous melanoma in Denmark during the period 1943-97. The incidence of iris melanomas increased substantially, whereas the rate was stable for choroid/ciliary body and conjunctival melanomas.

Mantle cell lymphoma in the orbital and adnexal region

AIMS

To characterise clinicopathological features of mantle cell lymphoma (MCL) in the orbital and adnexal region.

METHODS

Data on lymphoid lesions were retrieved searching the Danish Ocular Lymphoma Database 1980-2005. Specimens were collected from Danish pathological departments and re-evaluated with a panel of monoclonal antibodies. For all patients with confirmed MCL the complete clinical files were collected and reviewed.

RESULTS

Twenty-one patients with MCL in the orbital and adnexal region were identified comprising 9% (21/230) of all lymphoma in the ocular region. There were 18 male patients and three female patients with an age range from 60 to 90 years (median 75 years). Orbital and adnexal region MCL as first presenting symptom comprised 67% of the patients. Of these, 71% had bilateral involvement. The orbit (71%) and eyelids (64%) were the most commonly affected sites. All but two presented in stage III/IV. Secondary MCL comprised 33% of the patients. Bilateral affection (29%) was less common in this patient group. The median survival was not different between the two presentation groups. Patients receiving anti-CD20 (rituximab)-containing chemotherapy had a significantly better 5-year overall survival (OS) rate (83%) than patients in treatment regimes without rituximab (5-year OS rate, 8%).

CONCLUSIONS

Orbital and adnexal region MCL presents in elderly males. The orbit and eyelid are frequently involved. There is a very high proportion of systemic involvement in general with MCL of the orbital and adnexal region. Most patients presented with stage IV disease and had multiple relapses and short survival time. Treatment with rituximab-containing chemotherapy improved survival significantly compared with combination chemotherapy without rituximab.

CNS metastasis from malignant uveal melanoma: a clinical and histopathological characterisation

AIM

To characterise uveal melanoma that has metastasised to the central nervous system (CNS).

METHODS

Review of 2365 patients constituting all patients diagnosed as having primary uveal melanoma in Denmark during the period 1943-1997. All patients with malignant uveal melanoma and metastasis to the CNS were identified. For each patient, clinical and histopathological data were gathered.

RESULTS

Sixteen patients with CNS metastasis were identified. The median age was 58 years. The majority of CNS metastases were located in the frontal and parietal lobes. Eleven patients had widespread metastases. Five patients had exclusively metastasis to the CNS. The average time from diagnosis of primary tumour to symptoms of CNS metastasis was 91 months. The average time from the initial CNS symptoms to death was 20 months. All tumours were composed of either mixed or spindle cells. The average largest basal diameter of the primary tumours was 12 mm. One tumour was a ring melanoma. The majority of tumours had a ruptured Bruch membrane. Retinal invasion was observed in 36% of tumours. No specimen had optic nerve invasion. Scleral invasion was pronounced in 36% of cases, and extrascleral extension was observed in two cases (14%). The amount of tumour infiltrating lymphocytes was pronounced in three cases (23%).

CONCLUSION

The proportion of uveal melanoma patients having CNS metastasis was 0.7%. Eleven patients had multiple organ metastases, and the average time from the initial CNS symptoms to death was 8 months. Five patients had metastasis to the CNS solely, and the average time from the initial CNS symptoms to death was 57 months.

Primary lymphoma of the lacrimal sac: an EORTC ophthalmic oncology task force study

AIM

To define the clinical and histopathological characteristics of primary lacrimal sac lymphoma in a predominantly white population.

METHODS

Specimens of lacrimal sac lymphoma and follow up data were solicited from members of the Ophthalmic Oncology Task Force of the European Organization for Research and Treatment of Cancer (EORTC) and the European Ophthalmic Pathology Society (EOPS). Specimens were stained with haematoxylin and eosin and an immunohistochemical panel against leucocyte antigens was applied. Diagnosis was reached by consensus of five experienced pathologists according to the World Health Organization classification system. The histopathological findings were correlated with the clinical data.

RESULTS

Of 15 primary lacrimal sac lymphomas, five (33%) were diffuse large B cell lymphoma (DLBCL), five (33%) were extranodal marginal zone B cell lymphoma of mucosa associated lymphoid tissue (MALT lymphoma), three were classified as "transitional MALT lymphoma," being in transition from MALT lymphoma to DLBCL, and two were unclassified B cell lymphomas. Nine of the patients were female, and the median age at the time of diagnosis was 71 years (range 45-95 years). The most frequent presenting symptoms were epiphora (85%), swelling in the region of the lacrimal sac (79%), and dacryocystitis (21%). All but one patient presented in stage I. Systemic spread occurred in three of nine patients (33%). The 5 year overall survival was 65%.

CONCLUSIONS

DLBCL and MALT lymphoma are equally common in the lacrimal sac in contrast with the remaining periorbital and/or orbital region where MALT lymphoma predominates.

An unusual retinal vascular morphology in connection with a novel AIPL1 mutation in Leber's congenital amaurosis

AIMS

To report a case of an unusual retinal vascular morphology in connection with a novel AIPL1 mutation in a patient with Leber's congenital amaurosis (LCA).

METHODS

A patient with LCA and no light perception from birth had both eyes enucleated at the age of 22 years because of excruciating pain. Mutation analysis was performed on known LCA genes. The eyes were processed for casts of the vascular tree, routine histopathology, and electron microscopy.

RESULTS

A novel H82Y (244C-->T) mutation and a H90D (286G-->C) polymorphism were detected in exon 2 of the AIPL1 gene. Both the cast and the histopathological examination showed dilated retinal vessels, mainly venules, primarily localised in the posterior pole. In the mid-peripheral retina the density of capillaries on the arteriolar side of the microcirculatory units was significantly decreased. The vascular system was seen to gradually attenuate towards the retinal periphery, and to stop at a zone located approximately 4 mm from the ora serrata along the whole circumference. In this zone pigmented aggregates characteristic of retinitis pigmentosa were seen to ensheath the retinal vessels. The photoreceptors were almost totally absent and retinal gliosis was present. A decreased number of ganglion cells and an increased vacuolisation of the nerve fibre layer were observed. The retinal pigment cells and Bruch's membrane appeared normal in all regions.

CONCLUSION

An unusual retinal vascular morphology in an LCA patient is presented and possible pathogenic mechanisms of the findings are discussed.

Establishment and characterization of human uveal malignant melanoma xenografts in nude mice

The purpose of this study was to develop a suitable animal model for the investigation of the pathogenesis and therapy of uveal malignant melanoma. Eight choroidal malignant melanomas from eight patients were transplanted into nude mice in an attempt to establish a serially transplantable tumour model. Tumour tissue blocks (2 x 2 x 2 mm) from enucleated eyes with choroidal malignant melanoma were transplanted subcutaneously into the flanks of nude mice. The growing tumours were measured and serially transplanted. The tumour samples were investigated by histology, immunohistochemistry and electron microscopy. Only one of the eight transplanted primary tumours (13%) was established as a xenograft in nude mice. Furthermore, the take rate of the transplantable tumour was low (13%). The growth of the tumour fitted a Gompertz function, and the calculated tumour volume doubling time was 54 days. The transplanted tumour cells were epithelioid and slightly larger than the primary tumour cells and had prominent nucleoli. However, the transplanted tumour retained a morphological appearance similar to that of the primary tumour. Immunohistochemical examinations demonstrated that the cells preserved the characteristic properties of malignant melanoma. However, the transplanted cells demonstrated vimentin reactivity, whereas the primary tumour cells were negative for vimentin. It can be concluded that a new experimental model of malignant uveal melanoma with tumours that were easy to observe and access was established in nude mice.

Liposarcoma metastatic to the orbit

PURPOSE

To describe a patient with liposarcoma metastatic to the left orbit.

METHODS

A 72-year-old man was admitted with diplopia and proptosis of the left eye. Previously, a retroperitoneal liposarcoma had been surgically removed followed by postoperative radiation. Visual acuity was normal. There was proptosis of the left eye, increased retrobulbar resistance and reduced mobility. Trans-septal orbital biopsies showed liposarcoma. The patient was initially treated with prednisolone and later received radio- and chemotherapy. Despite treatment he lost vision of the left eye and died a few months later.

RESULTS

Histological examination of the orbital tumor revealed a spindle-cell liposarcoma similar to the primary tumor of the retroperitoneum.

CONCLUSIONS

Liposarcoma metastatic to the orbit is rare, but should be suspected in a patient with proptosis caused by a space-occupying lesion and a history of liposarcoma.

Neoplasia versus hyperplasia of the retinal pigment epithelium. A comparison of two cases

PURPOSE

To present the clinical and histopathological characteristics of two different tumor-like lesions of the retinal pigment epithelium (RPE).

METHODS

Two cases of tumor-like lesions of the RPE were identified in the files of the Eye Pathology Institute. The clinical characteristics and the light- and electron microscopical morphology of the lesions were compared and the diagnoses were re-evaluated applying modern immunostainings.

RESULTS

Clinically, both adenoma and tumor-like hyperplasia of the RPE may present with prominent retinal feeder arterioles. The lesions are hypofluorescent in the filling phases and have multiple hyperfluorescent zones in the late phase in fluorescein angiography. They show high internal reflectivity by A-scan and appear as solid tumors by B-scan ultrasonography. Histologically, the two presented lesions of the RPE are different. The first is an adenoma of the vacuolated subtype. The other lesion is a hyperplasia of the RPE disclosing a tubular morphology. The pathologically active cells in both cases were positive for the reaction with antibodies against: cytokeratin, NSE, vimentin, S-100, HMB-45, desmin and SMA. However, only the adenoma was sporadic melan-A positive.

CONCLUSION

Adenomas and tumor-like hyperplastic lesions of the RPE are very rare lesions. They share many morphological and immunohistological characteristics. Of the presented cases only the RPE adenoma is sporadic melan-A positive.

Human papillomavirus in conjunctival papilloma

AIM

To examine conjunctival papillomas for the presence of human papillomavirus (HPV) and koilocytosis.

METHODS

Archival paraffin embedded tissue from 55 conjunctival papillomas was analysed for the presence of HPV by polymerase chain reaction and subsequent filter hybridisation. Histological sections of the 55 papillomas were evaluated for the presence of koilocytosis.

RESULTS

HPV was present in 48 of 52 (92%) beta globin positive papillomas. HPV type 6/11 were found in 40 of 47 investigated papillomas and a double infection with HPV 6/11 and 16 was identified in a single papilloma. In six papillomas the HPV type could not be identified. Koilocytosis was present in 22 of 55 papillomas (40%).

CONCLUSION

There is a strong association between HPV and conjunctival papillomas. HPV type 6/11 is the most common HPV type in conjunctival papilloma. The sensitivity of koilocytosis as an indicator of HPV in conjunctival papilloma is low.

Reflexology and bronchial asthma

Many asthma patients seek alternative or adjunctive therapies. One such modality is reflexology, whereby finger pressure is applied to certain parts of the body. The aim of the study was to examine the popular claim that reflexology treatment benefits bronchial asthma. Ten weeks of active or simulated (placebo) reflexology given by an experienced reflexologist, were compared in an otherwise blind, controlled trial of 20+20 outpatients with asthma. Objective lung function tests (peak flow morning and evening, and weekly spirometry at the clinic) did not change. Subjective scores (describing symptoms, beta2-inhalations and quality of life) and also bronchial sensitivity to histamine improved on both regimens, but no differences were found between groups receiving active or placebo reflexology. However, a trend in favour of reflexology became significant when a supplementary analysis of symptom diaries was carried out. It was accompanied by a significant pattern compatible with subconscious unblinding, in that patients tended to guess which treatment they had been receiving. No evidence was found that reflexology has a specific effect on asthma beyond placebo influence.

Foreign body orbital cyst

PURPOSE

To present the clinical and histopathological characteristics of a retained orbital foreign body.

METHODS

A 34-year-old male was hit in his left eye by a flower stake. At first examination there was a massive haematoma of the left orbit and eyelids, reduced movement of the left eye and a small conjunctival lesion beneath the upper lid. There were no signs of deeper orbital or ocular lesions. During the subsequent months the haematoma disappeared, but increased proptosis and impaired eye movements with diplopia were noticed. One year after the injury, ultrasound and CT-scan revealed an ovoid cystic tumour behind the globe. During surgery the content of the cyst appeared purulent and from the centre of the cyst a foreign body measuring 25 x 13 x 1 mm was removed.

RESULTS

Microscopy of the foreign body showed the typical structure of a decidual leaf. The superficial cells were empty, whereas the centrally located cells contained remnants of cytoplasm. Confined to the border between the empty and the filled cells, a band of cells containing groups of gram positive cocci was noted. Staining for immunoglobulins revealed traces of IgG in the superficial empty cells only.

CONCLUSION

The high degree of preservation of the leaf and the survival of the cocci may be due to a barrier function of the intact plant cell walls with their high content of cellulose.

Conjunctival papilloma. A histopathologically based retrospective study

PURPOSE

To determine morphological and clinical characteristics of conjunctival papilloma.

METHODS

Specimens of conjunctival papilloma registered during the period 1983-1997 were collected. For each case the patient's sex and age, number of papillomas/patient, seasonal debut, duration, number of recurrences, localisation and presence of dysplasia andlor inflammation in the papilloma were registered.

RESULTS

A total of 245 papillomas in 219 patients were found. 132 (60.3%) of the patients were males. The age distribution showed skewness to the left with a peak in the age groups 20-29 years and 30-39 years. No variation of seasonal debut was found. 14 patients (6%) had more than one papilloma concurrently. 24 (11%) of the patients had recurrence. Most of the papillomas were located medially and inferiorly. 98 (40%) of the papillomas were inflamed. 14 (6%) of the papillomas were dysplastic.

CONCLUSION

The conjunctival papilloma is a common tumour. More males than females develop conjunctival papillomas and the incidence is highest among patients aged 20-39 years. The conjunctival papilloma is primarily located medially and inferiorly.

Ocular changes in a case of Kyrle's disease. 20-year follow-up

PURPOSE

To re-evaluate a case of Kyrle's disease with conjunctival and corneal changes in a 52-year-old patient with onset at the age of 5 years.

METHODS

Repeated biopsies from the skin, conjunctiva and oral mucosa along with a corneal button obtained from a right eye keratoplasty were examined histopathologically.

RESULTS

The skin, oral, conjunctival and corneal histopathology showed parakeratosis, dyskeratotic cells and single cell keratinization. The clinical picture and the histopathological findings are consistent with the diagnosis of Kyrle's disease.

CONCLUSIONS

This is the first reported case of Kyrle's disease with conjunctival changes. We suggest that Kyrle's disease, although predominantly affecting young adults, may also be seen in childhood. The disease may be a genodermatosis. It is not confined only to the skin, but can be seen in mucous membranes like the conjunctiva and buccal mucosa, and in tissues having the same embryological origin as the skin, i.e. the cornea.

Orbital space-occupying lesions in Denmark 1974-1997

PURPOSE

To determine the frequency, distribution according to diagnosis and the recurrence frequency of orbital space-occupying lesions in Denmark, to determine sex and age of the patients and to establish a national orbital data register.

METHODS

All biopsied/surgically removed orbital lesions collected by Danish pathological departments during the period 1974-1997 were identified by SNOMED codes. In addition, in each case gender and age of the patients and number of recurrences were registered.

RESULTS

965 orbital lesions from 841 patients were identified during the 24-year period. The incidence of orbital lesions increased significantly over the study period and at present about 80 cases/year are registered. The ratio benign/malignant lesion per year remained constant during the observation period. Lesions in children constituted a total of 152 (16%), the percentage of lesions in children being constant during the period. Malignant tumors comprised a total of 364 (45%) in adults and 34 (22%) in children. Malignant tumors were in adults distributed with 43% primary, 48% secondary invading and 9% metastatic tumors, and in children with 65% primary, 29% secondary invading and 6% metastatic tumors. Normal tissue was only found in 6% of the cases recorded.

CONCLUSION

A registration of all histologically evaluated orbital space-occupying lesions in Denmark during a period of 24 years was performed and a national orbital database established. Orbital lesions are rare and primarily benign.

The anterior lens capsule used as support material in RPE cell-transplantation

PURPOSE

To investigate the use of an ocular basement membrane as support material for transplanted porcine RPE cells.

METHODS

Porcine RPE cells were grown on bovine corneal extracellular matrix (ECM), isolated bovine- and porcine lens capsules, and tissue culture plastic. Cell density, and cell morphology were studied by phase contrast microscopy and transmission electron microscopy.

RESULTS

RPE cells grown on porcine anterior lens capsule and on ECM obtained better morphology and higher final cell density than cells grown on plastic and on bovine anterior lens capsule. It was possible to transplant the porcine anterior lens capsule to the subretinal space in pigs. Within two weeks of observation, the lens capsule was well tolerated in the subretinal space.

CONCLUSION

The anterior lens capsule seems to be promising as support material for use in RPE cell-transplantation.

Primitive neuroectodermal tumor of the orbit in a 5-year-old girl with microphthalmia

PURPOSE

To report an orbital, intraconal, primitive neuroectodermal tumor (PNET) in a 5-year-old child with microphthalmia since birth.

METHODS

Orbitotomy was performed and a large, polycystic, retroscleral, intraconal tumor was removed and subsequent histological, immunohistochemical and electron-microscopic analyses of the excised mass were performed.

RESULTS

The tumor showed characteristic features of peripheral primitive neuroectodermal tumor including pseudorosettes, positive immunohistochemical reactions for the MIC2 gene and synaptophysin and ultrastructural finding of neurosecretory granules.

CONCLUSION

This case is the first reported intraconal PNET of the orbit, and the first orbital case that expresses the MIC2 gene. In spite of the aggressive malignant features of peripheral PNET, the orbital variety seems to be the least aggressive since most of the reported patients are still alive.

Immunohistochemical diagnosis of malignant melanoma of the conjunctiva and uvea: comparison of the novel antibody against melan-A with S100 protein and HMB-45

A novel antibody A103, which recognizes melan-A/MART-1, has been found to be more sensitive than the antibody HMB-45, which recognizes gp100, in melanocytic lesions of the skin and might therefore also be useful in the diagnosis of uveal and conjunctival melanocytic lesions. In this study we compared the staining characteristics of anti-melan-A, anti-S100 protein and HMB-45 in 13 conjunctival, 11 iris and 37 ciliary and choroidal malignant melanomas. The ciliary and choroidal melanomas comprised 13 spindle cell (10 spindle B and three spindle A), 14 mixed cell and 10 epithelioid cell tumours. In the conjunctival melanomas the diagnostic sensitivity was 100% for anti-S100 and anti-melan-A and 85% for HMB-45. In the iris melanomas the sensitivity was 100% for anti-S100 and anti-melan-A and 55% for HMB-45. A high staining intensity of anti-melan-A was particularly noticed in iris melanomas. In the choroidal malignant melanomas, the spindle cell and mixed cell types showed a sensitivity of only 69-79% with all three antibodies. In the epithelioid cell type the sensitivity was 80% for anti-S100 and 100% for HMB-45 and anti-melan-A. In conclusion, anti-melan-A was found to be a useful addition to antibody panels for ocular melanocytic lesions. Anti-melan-A has a higher sensitivity than HMB-45 in conjunctival and iris melanomas, but the sensitivity is similar to HMB-45 in choroidal melanomas. Anti-melan-A stains in a very similar pattern to anti-S100, but the staining intensity of anti-melan-A is higher than that of anti-S100 in iris melanoma.

Palpebral myiasis in a Danish traveler caused by the human bot-fly (Dermatobia hominis)

PURPOSE

To demonstrate a case of palpebral myiasis caused by Dermatobia hominis in a Dane traveling in the Brazilian rain forest.

METHODS

Surgical removal and histological examination.

RESULTS

Within three weeks after returning from the Brazilian rain forest, the patient developed a localized swelling of the left upper eyelid and follicular conjunctivitis. A funnel containing a larva was found between the cilia. The larva was excised together with surrounding inflammatory tissue. The clinical findings as well as zoological and pathological examinations indicated a case of palpebral myiasis caused by Dermatobia hominis. The larva was removed in its third stage four weeks from symptom debut.

CONCLUSIONS

Infestation with Dermatobia hominis should be suspected when itching and red swelling of the lid are present in patients who have been to Central and South America.

Malignant changes in a giant orbital keratoacanthoma developing over 25 years

PURPOSE

To report a patient with a history over 25 years of a slowly growing, large, invasive crateriform tumour filling the anterior part of the orbit.

METHODS

A 61-year-old male presented with a large tumour of the left orbit. Exenteration was performed with subsequent histological analysis of the excised mass.

RESULTS

The main tumour showed the characteristic features of a keratoacanthoma. However, the posterior aspect of the tumour disclosed the morphology of a squamous cell carcinoma. Six months later, the patient presented with metastases to lymph nodes, lung and mediastinal tissue. A leukemoid reaction was diagnosed by fine needle biopsy.

CONCLUSION

The giant variety of keratoacanthoma may fail to regress and can transform into a squamous cell carcinoma. In our patient, the development of a chronic lymphoid leukemia raises the possibility that it may be the underlying cause for the transformation of the posterior part of the keratoacanthoma into a frank squamous cell carcinoma.

Intrastromal holmium laser keratostomy: long-term results

BACKGROUND AND OBJECTIVES

A new filtering procedure, the Intrastromal Holmium Laser Keratostomy (ILK) has been developed. A laser canal is created intrastromally in the cornea anterior to Schwalbe's line in the floor of a corneo-scleral tunnel incision made with a knife from the corneal site. Theoretically, the complications of the conventional Subconjunctival Holmium Laser Sclerostomy (SLS) can thus be avoided. Experimental and clinical evaluation of the new procedure, as well as clinical long-term results are presented.

PATIENTS AND METHODS

The ILK was evaluated experimentally on bank eyes and clinically using postoperative Ultrasound Biomicroscopy (UBM). The clinical long-term effect was evaluated by a follow-up of the first 22 ILK performed on 17 eyes in 17 consecutive patients with complicated, refractory primary and secondary open angle glaucoma. Preoperative subconjunctival mitomycin-C injection (0.02 mL of 0.2 mg/mL) was used.

RESULTS

The experimental and clinical evaluations show that the collateral thermal tissue coagulation made by the Holmium laser in ILK probably is an advantage, because the subsequent shrinkage prevents postoperative self sealing of the laser canal. Complete surgical success without medication and reoperations was reached in 63% of the eyes with a mean observation time of 22.5 months (range: 16.6-26.7 mos.). Any failure appeared within the first 10 months. Only 13% of the eyes had early iris incarcerations, there were no late incarcerations. Twenty-five percent had temporary shallow anterior chambers.

CONCLUSION

The mitomycin-ILK procedure has shown obvious better results than the conventional SLS technique due to a considerable reduction in postoperative complications. Since the present material further developments in the ILK technique has made this procedure still more attractive.

Leiomyoma of the ciliary body. Report of 2 cases

PURPOSE AND METHODS

The files of the Eye Pathology Institute contain only two cases of leiomyoma of the ciliary body. The diagnoses were re-evaluated, applying modern immunostainings.

RESULTS

The tumors were composed of interlacing fascicles of spindle-shaped cells with bright eosinophilic cytoplasm and cigar-shaped nuclei. Both tumors were well-vascularized, mostly by thin, branching capillaries. Larger vessels were also seen. In one case the tumor perforated the sclera. The tumor cells reacted with the reticulum stain and the Masson trichrome and were positive for antibodies against: smooth muscle actin (SMA), muscle specific actin (MSA), laminin and vimentin (one case).

CONCLUSION

Leiomyoma of the ciliary body is a rare smooth muscle cell tumor that may arise from either pericytes, ciliary - or intrascleral heterotopic muscle.

[The hospital autopsy. An important factor in hospital quality assurance]

The frequency of hospital autopsies declined after a new autopsy law was introduced in 1990. The purpose of the study was to evaluate the frequency of autopsy over a six month period in Copenhagen county. We compared the causes of death recorded on death certificates with autopsy findings. One thousand seven hundred and four hospital deaths were followed by 534 (31%) autopsies. Neither age of the decreased nor length of the admission seemed to influence the autopsy frequency. In 20% of the autopsies we found valuable new informations compared to the causes of death recorded on the death certificates.

Immunohistochemical investigation of p53 and EGFR expression of oligodendrogliomas

The biological behavior of oligodendrogliomas is somewhat unpredictable. A supplementing prognostic factor is, therefore, desirable. Thirty-two supratentorial pure oligodendrogliomas were studied immunohistochemically by exposing the tumors to a monoclonal antibody towards the p53 protein, and a polyclonal antibody against the epidermal growth factor receptor (EGFR). A mean p53 labeling index (% of tumor cells stained) of 8.6% and a weak EGFR expression in 18 of the oligodendrogliomas were found. Univariate analysis showed no correlation between p53, EGFR expression and prognosis. Multivariate analysis showed that age was a prognostic factor for survival.

Review of 1028 bulbar eviscerations and enucleations. Changes in aetiology and frequency over a 20-year period

PURPOSE

To evaluate possible changes in aetiology and frequency of bulbar eviscerations and enucleations.

METHODS

A total of 1028 cases from three two-year periods: 1975-76, 1985-86 and 1995-96 collected by the Eye Pathology Institute were reviewed.

RESULTS

A significant decrease (p<0.001) in number of enucleations was observed from 358 in 1975-76 to 214 in 1995-96, corresponding to an almost equivalent increase in number of eviscerations from 5 in 1975-76 to 83 in 1995-96. The total number of eye removals decreased significantly (p<0.01) over the last two periods from 368 in 1985-86 to 296 in 1995-96. This was primarily caused by a decrease in the number of glaucoma-related enucleations from 32.7% in 1975-76 to 15.0% in 1995-96. The reduction in number was not fully balanced by the increase in glaucoma-related eviscerations.

CONCLUSION

Over the last 20 years there has been a change in choice of operation from enucleation to evisceration.