UNILATERAL DIFFUSE UVEAL MELANOCYTIC PROLIFERATION: CASE REPORT AND BRIEF REVIEW

PURPOSE

To report a case of unilateral diffuse uveal melanocytic proliferation, in a patient with history of breast cancer, with bone and hepatic metastasis.

METHODS

Case report with funduscopic examination, fundus autofluorescence, and spectral-domain optical coherence tomography.

RESULTS

A 57-year-old female patient attended at our clinic for a routine glaucoma follow-up. Fundoscopy was normal on the right eye and showed multiple red patches in the posterior pole and inferior arcade. Multimodal examination was performed, compatible to diffuse uveal melanocytic proliferation on her left eye, and excluding other conditions, such as choroidal metastasis.

CONCLUSION

Diffuse uveal melanocytic proliferation is a rare paraneoplastic condition, which usually is presented bilaterally. Unilateral cases of diffuse uveal melanocytic proliferation have been previously described only 5 times on the literature and are usually associated with breast cancer.

Use Via Early Access to Ixazomib (UVEA-IXA) Study: Effectiveness and Safety of Ixazomib-based Therapy in Relapsed/Refractory Multiple Myeloma Outside of the Clinical Trial Setting

BACKGROUND

In multiple myeloma (MM), improving our understanding of routine clinical practice and the effectiveness of agents outside of clinical trials is important. TOURMALINE-MM1 data resulted in approval of ixazomib for MM patients who have received ≥ 1 prior therapy.

PATIENTS AND METHODS

UVEA-IXA comprised a retrospective chart review in the early access program, and a prospective 1-year follow-up period. Eligible patients had had a biochemical and/or symptomatic relapse after 1-3 prior lines of therapy; no anti-MM therapy for > 3 cycles at the start of ixazomib therapy; and an Eastern Cooperative Oncology Group performance score of 0-2. Lenalidomide- or proteasome inhibitor (PI)-refractory patients were ineligible. Primary endpoints were response and progression-free survival (PFS).

RESULTS

Of 357 enrolled patients, 309 were evaluable; most patients received ixazomib alongside lenalidomide (98%) and dexamethasone (97%); 61% had received 2-3 prior lines of therapy. Median PFS was 15.6 months (95% confidence interval [CI]: 12.0-20.6) in all evaluable patients, and 19.6 (95% CI: 12.1-27.0) and 13.9 (95% CI: 10.1-18.1) months in patients who received 1 and ≥ 2 prior lines of therapy, respectively. The overall response rate was 67% in all evaluable patients, and 72% and 63%, respectively, in patients who received 1 and ≥ 2 prior lines of therapy. Median overall survival was 35.5 months. The ixazomib safety profile was consistent with previous reports.

CONCLUSION

This study supports ixazomib-based therapy as an effective and tolerable treatment in the real-world. Outcomes were favorable in patients with 1 or ≥ 2 prior lines of therapy who were not lenalidomide- or PI-refractory.

Paper 1 of 2

The uveal vascular bed is the largest vascular system in the eye and has a role in supplying almost every tissue in the eyeball. This makes it the most important ocular vascular system. This is an up-to-date review of the literature of the entire uveal vascular bed in health based on detailed anatomy of the posterior ciliary arteries (PCAs), anterior ciliary arteries, cilioretinal arteries, and vortex veins. Although postmortem injection cast preparations gave us useful information on the morphology of the choroidal vascular bed; in vivo studies showed that they misled us for centuries about the in vivo situation. According to the postmortem cast studies, the uveal vascular bed has no segmental distribution, the uveal vessels anastomose freely with one another, there are inter-arterial and arteriovenous anastomoses in the choroid, and the choriocapillaris form a freely communicating and an uninterrupted vascular bed in the entire choroid.

Paper 2 of 2

From studies on postmortem anatomical descriptions of the uveal vascular bed, it was generally concluded that occlusion of PCA or its branches should not produce an ischemic lesion. However, in vivo studies have recorded that the PCAs and their branches, right down to the terminal choroidal arterioles, and the choriocapillaris, have a segmental distribution in the choroid, and that PCAs and choroidal arteries function as end-arteries. This explains the basis of the occurrence of isolated inflammatory, ischemic, metastatic, and degenerative choroidal lesions, which are usually localized. Thus, in vivo studies have completely revolutionized our concept of the uveal vascular bed in disease.

Parvimonas micra Necrotizing Panophthalmitis Involving the Sclera, Cornea, Uvea, Retina, and Orbit

We present an unusual case of a patient who acquired a pansinusitis and orbital cellulitis with necrotizing features, subsequently developing scleritis, keratitis, and anterior uveitis. To date, there are no reported cases of the simultaneous involvement of these ocular structures from a pansinusitis. Our patient was urgently taken to the operating room for drainage of the abscesses within his sinuses and the orbit. Intraoperative cultures were positive for Parvimonas micra, an odontogenic anaerobic bacteria. He was additionally found to have a central retinal artery occlusion. He was treated with systemic and topical antibiotics as well as topical dilute hypochlorous acid. The mechanisms of virulence of P. micra, including its synergistic relationship with other bacteria, ability to bind plasminogen, and its expression of proteases, contributed to this diffuse infection.

In vivo implantation of hydrophobic acrylic intraocular lenses with surface modification

PURPOSE

To assess the surface properties of modified hydrophobic acrylic intraocular lenses (IOL) implanted in rabbits.

METHODS

The hydrophobic acrylic IOLs were modified with monomer vinyl pyrrolidone by surface modification technique. Phacoemulsification combined with IOL implantation was conducted in 9 rabbits (18 eyes). Postoperative responses were observed by slit-lamp microscope at 3, 7, 15, 30, 90 days after surgery.

RESULTS

During the early stage after IOL implantation, corneal edema and anterior chamber fibrin exudation were observed. The exudate fluid was almost absorbed at the 15th day postoperatively. At 7th day, the anterior chamber exudation in the modification group was significantly less severe than that in non-modification group (P < 0.05). Posterior capsular opacification occurred at 30th day after surgery and was aggravated 90 days later. IOL dislocation was seen in 5 eyes and occlusion of pupil in 3 eyes.

CONCLUSION

The hydrophobic acrylic IOLs with surface modification have improved surface properties and higher uveal biocompatibility.

Human melanocyte biology, toxicology, and pathology

The human melanocytes of the skin, hair, eyes, inner ears, and covering of the brain provide physiologic functions important in organ development and maintenance. Melanocytes develop from embryonic neural crest progenitors and share certain traits with other neural crest derivatives found in the adrenal medulla and peripheral nervous system. The distinctive metabolic feature of melanocytes is the synthesis of melanin pigments from tyrosine and cysteine precursors involving over 100 gene products. These complex biochemical mechanisms create inherent liabilities for melanocytic cells if intracellular systems necessary for compartmentalization, detoxification, or repair are compromised. Melanocyte disorders may involve pigmentation, sensory functions, autoimmunity, or malignancy. Environmental factors such as ultraviolet radiation and chemical exposures, combined with heritable traits, represent the principal hazards associated with melanocyte disorders.

Formalin-induced cataract in goat eyes as a surgical training model for phacoemulsification

We compared 2 techniques of inducing cataract in enucleated goat eyes as a training model for phacoemulsification. The cataract was induced using 0.2 to 0.5 mL of formalin 20%. In 10 eyes, formalin was injected through a clear corneal side port into the nucleus after capsulorhexis and in 10 eyes, through the pars plana before capsulorhexis. The pars plana technique achieved a cataract of different grades of nuclear hardness with the added advantage of anterior capsule elasticity closely simulating that of senile cataract but without compromising corneal clarity.

Mechanisms of antagonism of interleukin-1 alpha by synthetic interleukin-1 blockers

A series of interleukin-1 blockers, CK-compounds, were shown to inhibit the dose-response curve of IL-1 induced uveitis in a non-competitive manner. CK-compounds showed little or weak effects on PGE2 production, leukocyte chemotaxis, and lipoxygenase activity which were markedly inhibited by indomethacin, REV 9501, and NDGA, respectively. These results indicate that CK-compounds do not fall into the conventional class of non-steroidal arachidonate mediated anti-inflammatory agents. CK-compounds should therefore be classified as novel compounds to block IL-1 non-competitively and belong to non-steroidal, non-arachidonate mediated anti-inflammatory agents.

[Indosol--a nonsteroidal anti-inflammatory drug with therapeutic efficacy]

For the topical employing of nonsteroidal antiinflammatory drugs, some technological problems are to be solved. These were accomplished by the authors by preparing Indosol [indomethacin-TRIS (tromethamine) salt]. pH and osmotic pressure of Indosol eye-drops are similar to that of the tear fluid. The Indosol eye-drops have a great therapeutic efficacy. Indosol eye-drops do not alter tear film break up time (BUT) and do not inhibit reepithelization of the cornea. Indosol eye-drops proved to be useful in the treatment of the anterior segment and the uvea. The most important use is the pre- and post-treatment in intraocular surgery. Indosol eye-drops contribute to the safety of lens-extraction and lens implantation. The great bioavailability was also shown by the high indomethacin level of the aqueous humor after instillation Indosol eye-drops. It does not cause any deleterious side-effects even in long term treatments.

The uvea-touch syndrome and how to avoid it. Personal thoughts about lens implantation

For successful lens implantation, the quality of the cataract extraction needed to be improved. The debate whether to perform extracapsular or intracapsular extraction has not yet come to an end. For better understanding a classification of lenses is necessary in view of the clinical consequences. The contact of the lens with the eye (read: the site of lens support) determines the long-term fate of an eye with a lens. All lenses in contact with uveal tissue may cause symptoms that together constitute the uvea-touch syndrome. Capsular support is to be preferred over uvea-support. The all-in-the-bag position of a lens is superior. This can be achieved with so-called inter-capsular surgery. A new lens design that is adapted to inter-capsular surgery is presented and its use described in detail (the 'Moustache' lens). There are few restrictions to its use.

Glycosaminoglycans of cultured human fetal uveal melanocytes and comparison with those produced by cultured human melanoma cells

The glycosaminoglycans produced by human fetal uveal melanocytes and by human melanoma cells were examined. The cells were grown in the presence of [3H]glucosamine and [35S]sulfate, and the labeled glycosaminoglycans were isolated from the cells, spend medium, and intracellular material. The distribution of the glycosaminoglycans was similar in both cells and spent media, which together accounted for 95% of the total. Of the total 3H]labeled glycosaminoglycans produced by the melanocyte culture, 42% was in chondroitin 4-sulfate, 25% in heparan sulfate, 16% in chondroitin 6-sulfate, and 17% in hyaluronic acid. In contrast, HM7 human melanoma cultures produced no chondroitin 6-sulfate, increased quantities of heparan sulfate, and less hyaluronic acid. A heparan sulfate fraction obtained from melanocytes required both heparitinase and heparinase for complete degradation, indicating the presence of heparin-like molecules in this fraction. The corresponding fraction from melanoma cells was totally degraded by heparitinase alone.

Endocrine responsiveness in human melanocytes and melanoma cells in culture

Studies were performed for the investigation of endocrine responsiveness in cell lines derived from either normal human melanocytes or human melanoma cells. Alterations in differentiation (tyrosinase activity) were determined in cells exposed to either melanocyte-stimulating hormone (MSH, 10(-7) M), theophylline (10(-3) M), N6,O2'-dibutyryl cyclic AMP (db-cAMP, 10(-4) M), or prostaglandin E1 (PGE1, 10(-6) M). Cultures derived from normal uveal melanocytes demonstrated increased tyrosinase activity upon exposure to either theophylline, db-cAMP, or PGE1, but not to MSH. However, MSH responsiveness was detected in 7 of 11 human melanoma cell lines. Four cell lines demonstrated increased activity of tyrosinase after MSH treatment, whereas three lines showed an MSH-induced inhibition of enzyme activity. PGE1 was effective in stimulating tyrosinase activity in five of nine cell lines examined. Theophylline was the most effective stimulator of tyrosinase in melanoma-derived cell populations and caused increased enzyme activity in eight of eleven cell lines.

Biological and biochemical properties of a human uveal melanocyte-derived cell line

A human uveal melanocyte-derived cell line (U1I) is described. The cell line has a doubling time of 27.2 hr, a plating efficiency on plastic surfaces of 10%, and a cloning efficiency in soft agar of < 0.1%. U1I displays marked chromosomal aneuploidy and sensitivity to ultraviolet light. Biochemical studies indicate the presence of tyrosinase, which is stimulated by several compounds, including theophylline, progesterone, and nerve growth factor.

An evaluation of enucleation in the management of uveal melanomas

Uveal melanomas are slow growing tumors that may infiltrate out of the eye, mainly following ciliary vessels or nerves, or invade blood vessels, but only rarely do they produce metastatic disease before discovery and treatment. There are, however, large gaps in our knowledge of the frequency and rate of growth of small tumors to those of moderate or large size. We have estimated the mortality from untreated uveal melanomas to be 1% per year or less. Almost all information concerning prognostic factors has been gained from studies based on cases treated by enucleation. The same information is not necessarily applicable to untreated tumors. A study of deaths from metastatic uveal melanomas reveals a striking relationship to enucleation, regardless of whether one deals with cases in which the eye had been symptomatic for a long or short time. Following a low preoperative mortality of 1% or less, the annual mortality rises to about 4% during the first year and then peaks at 8 to 12% during the second year, tapering off during the next three to five years to return to a remarkably constant level of 1 to 2% thereafter. We postulated that this relationship of peak mortality to enucleation is attributable mainly to an often overwhelming dissemination of tumor cells taking place during surgery or to a lowering of the host's immunologic defense mechanisms as a consequence of the operation, or both. We urge the pooling of all available information gained from clinical studies made on untreated tumors and recommend prospective studies of a variety of other methods of treating uveal melanomas in addition to the standard enucleation.

Survival rates after enucleation of eyes with malignant melanoma

We investigated the rates of mortality for several types of malignant melanomas for evidence that surgery accelerates metastasis. Additionally, we reanalyzed uveal melanoma survival rates from the Armed Forces Institute of Pathology. Our computations showed higher death rates in years two to five after diagnosis than in years one or six to ten. The same pattern of a peak mortality in the early years after diagnosis and lower rates six to ten years thereafter was seen in all tumor types studied. Our analysis of survival rates produced no evidence to alter the existing pattern of treatment for malignant melanoma of the uvea.

Prospects for the immunodiagnosis of ocular tumours

Amongst other properties, malignant neoplasms are characterized by having antigenic determinants not normally found in mature healthy tissue. Consequently an immune response is usual on the part of the host and in recent years interest has centred on the twin possibilities of putting this property to diagnostic and therapeutic use. In our own laboratory we have concentrated on the diagnostic potential of immunological techniques in the investigation of pigmented tumours of the uvea. We have found that not only malignant melanomata, but also many naevi, can provoke an immunological reaction and we have shown that this is directed largely against contractile elements in the cytoplasm. Such reactions, which are not strictly tumour-specific, may be a source of diagnostic confusion and need to be excluded if immunology is to be of value in distinguishing malignant lesions of the uveal melanocytes from innocuous naevi.

Ocular cysticercosis

Eight cases of ocular cysticercosis are reported. A rare case of cysticercus in the anterior chamber, and another case with bilateral involvement and two cysts in one eye are reported. The reasons for its prevalence in this region are discussed.

Biomicroscopical choroidoscopy (uveoscopy) and transillumination gonioscopy

A fiber optic sleeve that fits over a Goldmann three-mirror lens, as well as an independent cable used in conjunction with the Goldmann lens, are described for transillumination biomicroscopical examination of the anterior chamber angle and the uvea. High-intensity retroillumination is provided to the anterior and posterior segments of the globe without production of heat to the eye. Present clinical uses as well as possible future research with the instruments are discussed.

[Micrometastasis of the uvea: a rare cause of uveal effusion (author's transl)]

A clinicopathological report is given on a case of spontaneous chorioideal detachment in a patient with metastatic carcinoma. Histological there was infiltration of the ciliary body and peripheral choroid and a large uveal effusion. Pain would seem to be a pathognomic sign of metastatic tumor in choroideal detachment caused by metastatic tumor.