Correlation of Microcirculation Architecture with Ultrasound Backscatter Parameters of Uveal Melanoma

Ultrasound tissue characterization parameters of size and acoustic concentration can be used to sub-classify uveal melanoma and estimate the patient's risk of death. Histologically determined microcirculation patterns have also been found to sub-classify uveal melanoma and predict patient's risk of death. This study examines the spatial relationship between tumor features detected by the two techniques. Three dimensional ultrasound images that depict the size and relative concentration of scattering elements in uveal melanoma within a range of approximately 50-120 microns were compared with PAS (without hematoxylin) stained histological sections graded and localized according to tumor microvascular patterns. Both ultrasound parameter imaging and histopathology were accomplished by workers masked to the other procedure. In three of five patients vascular networks were identified histopathologically. The predominant ultrasound feature seen in the regions of the histologically identified networks were clusters of scatterers in the range of approximately 50-80 microns. In the two cases without a network vascular pattern, lower range scatterers dominated the tumor volume. All the cases could be distinguished by the size and distribution of contiguous spatial clusters of acoustic scatterers. Scatterer size features detected in three dimensional ultrasound parameter images can identify tumor regions containing a specific microvascular pattern. Ultrasound tissue characterization features used to sub-classify uveal melanoma may have a biophysical basis related to patterns of tumor microcirculation.

Malignant melanoma of the conjunctiva with intraocular extension

Intraocular extension of a malignant melanoma of the conjunctiva is a rare entity. A 75-year-old woman underwent repeated surgery after receiving the diagnosis of a multilocular recurrent malignant melanoma arising from a primary acquired melanosis. Treatment included 2 lamellar sclerokeratectomies and percutaneous radiotherapy. Five years after initial surgery, intraocular extension of the melanoma was observed, and enucleation was performed. Findings from histopathological examination revealed a malignant melanoma occupying part of the ciliary body, the trabecular meshwork, and the iris. Eyes with recurrent malignant melanoma of the conjunctiva should be carefully monitored for intraocular extension. Deep excision of conjunctival melanoma, including lamellar sclerokeratectomy, may abolish the natural barrier against intraocular extension of malignant melanomas of the conjunctiva.

Long term results after autologous nasal mucosal transplantation in severe mucus deficiency syndromes

AIM

Severe mucus deficiency syndromes may require substitution of mucous membrane for re-establishment of the ocular surfaces. The long term results after autologous nasal mucosal transplantation were investigated.

METHODS

55 eyes of 50 patients with severe mucus deficiency syndromes were followed retrospectively after free autologous nasal mucosal transplantation-group A: patients after severe lye, acid, heat burns, or radiation (n=38 eyes), group B: patients with systemic mucosal disease (n=17 eyes). The results of routine clinical examination were recorded and patients were followed for a median of 37 months. 17 biopsies of transplanted nasal mucosa were studied by light microscopy and 22 patients by impression cytology before and at several intervals after mucosal transplantation.

RESULTS

All nasal mucosal grafts healed well and no intraoperative complications occurred. During follow up 107 additional surgical procedures were performed including 16 lamellar and 21 penetrating keratoplasties. Subjective complaints improved in 44/47 patients with preoperative symptoms. Best corrected visual acuity at the end of follow up was increased in 23 eyes, 10 eyes (18. 2%) reached a final visual acuity equal to or greater than 20/200. Histopathologically, all (n=17) biopsies showed vital intraepithelial mucin producing goblet cells in the nasal mucosal graft (median 25 cells/field (400x magnification)). The mean density of goblet cells before transplantation was 48/mm(2) and after nasal mucosal grafting 432/mm(2) measured by impression cytology (p<0. 0001).

CONCLUSIONS

Functional goblet cells persist in autologous nasal mucosa for up to 10 years after transplantation. In patients with severe mucus deficiency syndromes of different origin nasal mucosal transplantation can re-establish the ocular surface, substitute the mucus components of the tear film, improve symptoms of the patients, and facilitate a moderate increase in visual acuity.

Rhegmatogenous retinal detachment after block excision of epithelial implantation cysts and tumors of the anterior uvea

OBJECTIVE

To report on frequency, time of occurrence, treatment, and final outcome of rhegmatogenous retinal detachment after block excision, combined with corneoscleral tectonic grafts, of intraocular epithelial implantation cysts and tumors of the anterior uvea involving the anterior chamber angle.

DESIGN

Noncomparative case series.

PARTICIPANTS

The study included 144 patients who had consecutively undergone scleral full-thickness block excision of tumors of the anterior uvea (n = 87) or intraocular epithelial implantation cysts (n = 57). Diameter of the block excision ranged between 5.5 and 20 mm. In 39 patients, the tumor extended posterior to the ora serrata.

INTERVENTIONS

Retinal detachment surgery.

MAIN OUTCOME MEASURES

Retinal detachment rate, visual acuity, risk factors.

RESULTS

Retinal detachment occurred in 10 (6.9%) of 144 patients (2 of 57, or 3.5% of patients with cysts; 8 of 87 or 9.2% of patients with tumors) 3 to 12 months after block excision. Six patients underwent primary pars plana vitrectomy with temporary endotamponade by silicone oil, which was removed 3 to 9 months later. In four patients, a scleral buckling procedure only was performed. After a mean follow-up of 31 months after silicone oil removal or the buckling procedure (median, 30 months; range, 13-42 months), the retina has remained attached in all patients operated on. Visual acuity increased from 2/20 (median; range, light perception-6/20) to 8/20 (median; range, 2/20-12/20). In the eyes with retinal detachment compared to the eyes without retinal detachment, the block excision was significantly larger (13.75+/-4.86 mm vs. 9.41+/-3.02; P = 0.01) and was located significantly more posteriorly (limbus distance of posterior excision margin: 6.75+/-2.87 vs. 4.35+/-3.24 mm; P = 0.01).

CONCLUSIONS

Scleral buckling procedures and primary pars plana vitrectomy with temporary ocular endotamponade can give acceptable results in eyes with rhegmatogenous retinal detachment occurring after block excision of epithelial implantation cysts or tumors of the anterior uvea. Despite intraoperative vitreous prolapse or tumor extension posterior to the ciliary body, rhegmatogenous retinal detachment occurs in fewer than 10% of patients undergoing block excision of cysts or tumors of the anterior uvea. Size and posterior location of the block excision are the main risk factors for rhegmatogenous retinal detachment, which becomes unlikely later than 12 months after surgery.

Microcirculation architecture of metastases from primary ciliary body and choroidal melanomas

PURPOSE

To describe the microcirculation architecture of metastatic choroidal and ciliary body melanoma.

METHOD

Histologic sections of 35 metastases from 19 primary melanomas were stained to demonstrate microcirculation.

RESULT

The appearance of microcirculatory networks in metastases is independent of the target organ but associated with the size of the metastatic deposit (estimated coefficient = 0.5959; SE = 0.3024; P = .0488).

CONCLUSION

The microcirculatory patterns of primary uveal melanomas that are associated with metastatic behavior appear in foci of metastasis, regardless of the site of dissemination.

Detection of varicella zoster virus DNA and viral antigen in human eyes after herpes zoster ophthalmicus

OBJECTIVE

The purpose of the study was to identify varicella zoster virus (VZV) DNA and viral antigen in human eyes at various intervals after clinical onset of herpes zoster ophthalmicus (HZO).

DESIGN

A retrospective case series.

PARTICIPANTS

There were 9 eyes and 4 corneal buttons surgically obtained from 13 patients with HZO at the University Eye Hospital of Erlangen-Nürnberg between 1984 and 1994. Specimens were examined at different timepoints after clinical onset of HZO (range, 1 day-19 years; median, 36 months).

METHODS

Histopathologic evaluation was performed on formalin-fixed and paraffin-embedded tissue by routine histology, immunohistochemistry (5-B-7 murine monoclonal antibody to VZV; peroxidase-antiperoxidase method), and DNA-in situ hybridization (35S deoxyadenosine triphosphate-labeled HindIII fragments [A and C] of VZV).

RESULTS

Typical histopathologic changes associated with HZO were identified: vascularization of the corneal stroma (11 of 13), granulomatous reaction to Descemet's membrane (8 of 13), fusiform-shaped ciliary scarring (5 of 9), optic neuritis (4 of 9), and perineuritis (8 of 9) and perivasculitis (8 of 9) of the long posterior ciliary nerves and arteries. VZV antigen was detected in two patients with acute infection 1 and 7 days after onset of HZO, respectively. VZV-DNA was identified in seven patients up to 10 years after onset of HZO in corneal epithelial cells (2 of 13), corneal stroma (5 of 13), inflammatory infiltrate of the anterior chamber (1 of 9), episclera (2 of 9), posterior ciliary nerves (1 of 9) and arteries (5 of 9), optic nerve (5 of 9), and adjacent leptomeninges (2 of 9).

CONCLUSION

Persistence of viral genomes, most likely accompanied by gene expression or slow viral replication, appears to be responsible for the often smoldering panophthalmitis and the chronic recurrent keratouveitis in patients with HZO. Localization of viral DNA in vascular structures suggests a role for vasculitis in the pathogenesis of some ocular findings associated with HZO.

The microcirculation of choroidal and ciliary body melanomas

The microcirculation of ciliary body and choroidal melanomas is remodelled into patterns. The presence of microvascular networks, composed of back-to-back loops that encircle microdomains of tumour, and parallel vessels with cross-linking, are associated with death from metastatic melanoma. The formation of these complex vascular patterns may result from reciprocal interactions between the tumour cell and the extracellular matrix, and pattern formation may reflect an invasive tumour cell phenotype. Ciliary body and choroidal melanomas are among the few forms of cancer treated before a pathologist assigns a grade to indicate whether tumour is likely to follow a benign or aggressive course. There is evidence to suggest that prognostically significant microcirculatory patterns may be detectable by non-invasive imaging techniques that may provide a substitute for biopsy to guide the clinical management of patients with these sight- and life-threatening tumours.

Cystic epithelial ingrowth after goniotomy for congenital glaucoma. A clinicopathologic report

PURPOSE

To describe the clinical and histopathologic findings of a child with congenital glaucoma who developed cystic epithelial ingrowth after goniotomy.

METHODS

A five-month-old boy was diagnosed with congenital glaucoma due to Axenfeld syndrome. Goniotomy was performed immediately after the clinical diagnosis in his left eye. Cystic epithelial ingrowth was noted two years postoperatively. The cyst was incompletely excised elsewhere, and recurred two years later.

RESULTS

Cystic epithelial ingrowth expanded from the 2 o'clock to the 4 o'clock position involving the chamber angle. Best corrected preoperative visual acuity was 20/600 in his left eye. Cystic epithelial ingrowth was treated by block excision (8.0 mm) and tectonic corneoscleral grafting (8.1 mm). Best corrected postoperative visual acuity was 20/200 and the intraocular pressure was 8 mmHg without antiglaucomatous medication. There was no recurrence of the cyst during the 31 months of follow-up. Histopathologic results found that cystic epithelial ingrowth consisted of nonkeratinizing squamous epithelium with goblet cells covering Descemet's membrane, the chamber angle structures, the anterior face of the ciliary body, and the iris.

CONCLUSIONS

Cystic epithelial ingrowth is a rare complication after goniotomy. Block excision with tectonic corneoscleral grafting is the treatment of choice for cystic and diffuse sheet-like epithelial ingrowth.

[Block excision with tectonic corneoscleroplasty for cystic and/or diffuse epithelial invasion of the anterior eye segment. Report of 51 consecutive patients (1980-1996)]

PURPOSE

Many surgical and nonsurgical techniques for the treatment of cystic and/or diffuse sheet-like epithelial ingrowth of the anterior chamber led to recurrences or even enucleation of the eye.

PATIENTS AND METHODS

There were 32 (62.7%) men and 19 (37.3%) women ranging in age from 1 month to 80 years (median, 55.5 years). Cystic epithelial ingrowth occurred in 45 patients, and diffuse sheet-like epithelial downgrowth in 6 patients. Block excision consisted of simultaneous en bloc removal of epithelial ingrowth together with adjacent iris, pars plicata of the ciliary body, and cornea and sclera in full-thickness. The resulting defect was covered with a tectonic corneoscleral graft. The median follow-up was 7.9 years.

RESULTS

The main causes for epithelial ingrowth were trauma (41.2%) and complicated cataract extractions (27.5%). Eleven patients had undergone surgery of epithelial ingrowth before block excision, elsewhere. Epithelial ingrowth involved up to 5 clock hours of the circumference of the chamber angle (median, 3 clock hours). The median preoperative visual acuity was 0.3 (range, hand motions -1.0). The median diameter of the block excision was 8.0 mm (range, 5.5-12.0 mm). The main postoperative complications were vitreous hemorrhage (27.5%) and corneal endothelial decompensation (21.6%). The median postoperative visual acuity was 0.2. Visual acuity was > or = 0.3 in 43.1% of patients and < 0.1 in 35.3% of patients. Visual results were significantly better after simultaneous cataract extraction with intraocular lens implantation (n = 5). Histopathologically, the invading epithelium mainly consisted of nonkeratinizing squamous epithelium with goblet cells (64.7%). There was a secondary proliferation of corneal endothelium on the cyst's surface in 82.4% of patients. There was no clinical evidence of recurrence of epithelial ingrowth, and no enucleation had to be performed during follow-up.

CONCLUSION

Block excision with tectonic corneoscleral grafting is the treatment of choice for cystic and/or diffuse sheet-like epithelial ingrowth of the anterior chamber or anterior uvea, retrospectively.

[Autologous early transplantation of nasal mucosa after the most severe eye chemical burns]

The treatment of severe eye burns is still complicated. Since 1984 we have performed autologous nasal mucosa transplantation for the severe mucus deficiency syndromes often occurring during follow-up. Now we report on our initial experience using nasal mucosa transplantation shortly after severe burns.

PATIENTS

Prospectively, nine patients (eight male, one female) were examined after autologous nasal mucosa grafting within 14 days after eye burns. In all patients there was an almost complete defect of limbal vascularization, large areas of necrotic conjunctiva and prolonged epithelialization problems. The patients were followed for an average of 38 months.

RESULTS

In all patients the subjective complaints lessened and sufficient ocular wetting led to rapid reepithelialization. During the follow-up period two patients showed light symblephara. In five patients visual acuity improved to > or = 20/200.

CONCLUSION

Early nasal mucosa transplantation is an additional tool in the treatment of severe ocular burns.

Block excision of tumors of the anterior uvea. Report on 68 consecutive patients

PURPOSE

This study describes the authors' surgical technique and the results in 68 consecutive patients with tumors of the iris and ciliary body involving the angle removed by block excision and tectonic corneoscleral grafting between 1980 and 1995.

PATIENTS AND METHODS

There were 41 (60.3%) women and 27 (39.7%) men whose ages ranged from 14 to 85 years (median, 41 years). Follow-up ranged from 0.5 to 15.2 years (median, 6.3 years). Tumors of the iris and ciliary body with chamber angle involvement were removed with a modified block excision consisting of simultaneous en bloc removal of the tumor with adjacent iris and cornea and sclera in full-thickness. The resulting defect of 6 to 20 mm (median, 9.0 mm) diameter is covered with a tectonic corneoscleral graft.

RESULTS

Forty-nine tumors (72.1%) were classified as malignant tumors of the iris and ciliary body. Twenty-one (44.7%) of 47 malignant melanomas showed histologic evidence of scleral invasion of more than one third of scleral thickness. Extrascleral extension of the tumor was present in seven (14.9%) patients with malignant melanomas and in four (21.1%) patients with benign tumors of the iris and ciliary body. The 10-year survival probability of patients with malignant melanomas was 91.4%. The main intraoperative complication was vitreous hemorrhage in 24 (35.3%) patients, and the main postoperative complication was complicated cataract, occurring in 22 (32.3%) patients. Two local tumor recurrences (2.9%) were observed. Four eyes (5.8%) had to be enucleated after block excision. Best-corrected postoperative visual acuity was better than 20/60 in 36 (52.9%) patients.

CONCLUSIONS

The authors' results indicate that block excision with tectonic corneoscleral grafting may be the treatment of choice for progressive circumscribed tumors of the iris and ciliary body involving the anterior chamber angle up to 150 degrees of its circumference.

[Hormonally inactive hypophyseal adenomas: the results and late sequelae after surgery and radiotherapy]

PURPOSE

External radiation therapy for non functioning pituitary adenomas is clearly indicated in inoperable patients, after incomplete transsphenoidal microsurgery and in case of tumor progression. This retrospective analysis gives results and toxicity following surgery and postoperative radiotherapy of non-functioning pituitary adenomas.

PATIENTS AND METHODS

Between 1983 and 1990, 50 patients with non-functioning pituitary adenomas received combined treatment at our institutions. Surgical approaches were transsphenoidal (61%), transcranial (24%) or a combination of both (15%) in short intervals. All 50 patients received a full-dose radiotherapy with single fractions between 1.9 and 2.1 Gy (median 1.9 Gy) and total doses between 46 and 63 Gy (median 48 Gy). Field sizes ranged between 20 and 72 cm2 (median 30 cm2). Endpoints of this study were: progression-free survival, late effects of brain, optic nerve and intracranial vessels, visual impairment and hypothalamic-pituitary dysfunction. Median follow-up was 54 months.

RESULTS

Forty-seven of the 50 patients remained progression-free. Patients over age 60 years progressed more frequently (3/17) as compared to younger patients (0/33, p = 0.034). Following radiotherapy vision improved in 8 patients (16%), 14 patients (28%) experienced a visual impairment between 10% and 60% (according to the grading system of the German Ophthalmologic Society). In multivariate analysis no influence of age (p = 0.097) or biologically effective dose (BED) (p = 0.11) was seen on visual impairment. Three patients (6%) experienced late effects with optic neuropathy in 2 cases and temporal lobe necrosis in 1 case. Only the BED had a significant impact on late effects (p = 0.0094). Adrenal, thyroid and gonadal function abnormalities were present in 58%, 66% and 96% of the patients at last follow-up, respectively.

CONCLUSIONS

Radiotherapy after incomplete transsphenoidal or transcranial surgery of non-functioning pituitary adenoma is an effective treatment. Future perspectives must include the better defining of high-risk patients and the reduction of late morbidity.

Relation between the microcirculation architecture and the aggressive behavior of ciliary body melanomas

PURPOSE

To study the relation between vascular patterns and the biologically aggressive behavior of ciliary body melanomas.

METHODS

The authors compared the frequency distribution of vascular patterns by location for 234 uveal melanomas (54 tumors involving the ciliary body, and 180 without ciliary body involvement). Stepwise Cox regressions (for the endpoint of time-to-death due to melanoma), performed separately for melanomas with and without ciliary body involvement, included the following variables: size, vascular patterns, cell type, mean of the largest nucleoli, mitoses, tumor infiltrating lymphocytes, age, and sex. A separate Cox regression procedure included the variable of tumor location. Kaplan-Meier survival curves were generated for time to melanoma death with ciliary body involvement and melanomas without ciliary body involvement for tumors containing or lacking vascular networks.

RESULTS

These vascular patterns appear more often in the ciliary body than in the choroid: parallel vessels (P = 0.022), arcs (P = 0.003), and parallel with cross-linking, arcs with branching, and loops and networks (all P = 0.0001). Stepwise regression for tumors confined to the choroid indicated that the presence of networks was the most significant variable (P = 0.0001); stepwise regression for tumors with ciliary body involvement suggested that only one variable, networks, was significant (P = 0.0066). Kaplan-Meier survival estimates indicated that the survival of patients with tumors containing networks in the ciliary body was comparable to those containing networks in the choroid.

CONCLUSION

Regardless of location, ciliary body or choroid, the presence of vascular networks shortens survival. The tumor location does not enter a stepwise Cox regression model when vascular patterns are included as variables. Therefore, the aggressive behavior of ciliary body melanomas appears to be related to the tendency for vascular networks to develop in this location.

Bilateral herpes simplex virus type 2 keratitis: a clinicopathologic report with immunohistochemical and ultrastructural observations

This report describes the clinical, histopathologic, ultrastructural, and immunohistochemical findings in two corneal buttons from a 13-year-old girl who developed bilateral progressive corneal stromal opacification during childhood. As determined by light microscopy, both corneal buttons were edematous with a chronic inflammatory infiltrate confined to the deep layers of the stroma. We detected intranuclear eosinophilic inclusions in some epithelial cells. We detected herpesvirus particles in stromal keratocytes and endothelial cells by transmission electron microscopy. Immunohistochemistry studies identified concurrent expression of specific herpes simplex virus type 2 antigen in corneal epithelial cells, in keratocytes in the deep layers of the stroma, and in endothelial cells. The cause of progressive bilateral stromal corneal opacification in this child was herpes simplex virus type 2 keratitis. This condition should be considered in the differential diagnosis of progressive, bilateral corneal opacification in children.

Mean of the ten largest nucleoli, microcirculation architecture, and prognosis of ciliochoroidal melanomas

BACKGROUND

Cytomorphometric measurements and the architecture of the microcirculation in tissue sections of eyes removed for ciliary body or choroidal melanomas have been identified independently as prognostically significant factors for survival. The relative significance of these two histologic features is addressed in this study.

METHODS

The same 234 cases used to assess the prognostic significance of the microcirculatory patterns of choroidal and ciliary body melanomas were examined by two independent observers who measured the largest diameter of melanoma cell nucleoli from digitized images at a high magnification (x 3000) using the laser scanning confocal microscope. The mean of the ten largest nucleoli was calculated for each tumor according to previously published methods. Intraobserver and interobserver reproducibility was assessed for these measurements. Several Cox multiple regression models were constructed which included this cytomorphometric variable with and without the inclusion of the microcirculatory patterns.

RESULTS

There is a high degree of intraobserver reproducibility but only a weak degree of interobserver reproducibility in measuring the mean of the ten largest nucleoli. Using multiple Cox regression models, the mean of the ten largest nucleoli from each observer failed to exert any effect on outcome after enucleation, regardless of whether the presence of networks of closed vascular loops was considered in the statistical formulation. The presence of networks of closed vascular loops was found to be the most statistically dominant histologic prognostic characteristic.

CONCLUSION

The authors have not been able to confirm the use of the mean of the ten largest nucleoli as a significant prognostic factor in the outcome of patients whose eyes have been removed for ciliary body or choroidal melanomas. Further investigation of this cytomorphometric technique by other laboratories is warranted.

Three-dimensional relationships between tumor cells and microcirculation with double cyanine immunolabeling, laser scanning confocal microscopy, and computer-assisted reconstruction: an alternative to cast corrosion preparations

The morphology of the microcirculation of uveal melanomas is a reliable market of tumor progression. Scanning electron microscopy of cast corrosion preparations can generate three-dimensional views of these vascular patterns, but this technique sacrifices the tumor parenchyma. Formalin-fixed wet tissue sections 100-150 microns thick from uveal melanomas were stained with the lectin Ulex europaeus agglutinin I (UEAI) and proliferating cell nuclear antigen (PCNA) to demonstrate simultaneously the tumor blood vessels and proliferating tumor cells. Indocarbocyanine (Cy3) was used as a fluorophore for UEAI and indodicarbocyanine (Cy5) was used for PCNA. Double labeled sections were examined with a laser scanning confocal microscope. Images of both stains were digitized at the same 5-microns intervals and each of the two images per interval was combined digitally to form one image. These combined images were visualized through voxel processing to study the relationship between melanoma cells expressing PCNA and various microcirculatory patterns. This technique produces images comparable to scanning electron microscopy of cast corrosion preparations while permitting simultaneous localization of melanoma cells expressing PCNA. The microcirculatory tree can be viewed from any perspective and the relationship between tumor cells and the tumor blood vessels can be studied concurrently in three dimensions. This technique is an alternative to cast corrosion preparations.

Microcirculation architecture of melanocytic nevi and malignant melanomas of the ciliary body and choroid. A comparative histopathologic and ultrastructural study

PURPOSE

This study was designed to (1) describe the vascular patterns of ciliary body and choroidal nevi by light microscopy, (2) compare the vascular ultrastructure of nevi with vessels of the normal uvea and uveal melanomas, and (3) compare the behavior of ciliochoroidal melanomas with and without a nevus-like vascular architecture.

METHODS

After delineating the vascular patterns of 23 choroidal and ciliary body nevi by light microscopy, the authors identified 49 melanomas that had the same vascular patterns as nevi from a previously published series of 234 uveal melanomas. The survival of these 49 patients who had melanomas with a nevus-like vascular architecture was compared with the 185 patients who had melanomas that lacked this vascular profile.

RESULTS

By light microscopy, the only vascular patterns identified in nevi are "normal" vessels, zones of avascularity ("silent" pattern), straight, and parallel vessels; closed vascular loops and networks were not detected in nevi. By transmission electron microscopy, the vascular basement membrane of malignant melanomas was multilaminar, fragmented, and significantly thicker than in normal eyes or nevi. None of the patients with nevi died of metastatic disease. Fourteen percent of patients whose melanomas had the same vascular profile as nevi died of metastatic disease, whereas 32% of patients whose melanomas had vascular patterns other than those seen in nevi died of metastatic melanoma (P = 0.012).

CONCLUSIONS

The microcirculation architecture marks tumor progression in uveal melanocytic lesions by light and electron microscopy. In the spectrum of these lesions, nevi are benign, melanomas that have the same vascular profile as nevi have an intermediate biologic behavior, and melanomas with vascular networks are strongly associated with death due to metastatic disease.

Surgical management of melanocytoma of the ciliary body with extrascleral extension

We treated four white women with extrascleral extension of suspected ciliary body melanomas with a modified block excision (three patients) or enucleation (one patient). Light and transmission electron microscopy established the diagnosis of ciliary body melanocytoma with extrascleral extension in each patient. Two eyes were irradiated before block excision. Block excision involved simultaneous removal of full-thickness cornea and sclera, iris, and ciliary body with tectonic corneoscleral grafting. The postoperative visual acuity of the three patients treated with a modified block excision was 20/25, 20/50, and 20/60, respectively. No patient experienced local tumor recurrence (30 to 60 months of follow-up). The two irradiated eyes eventually developed radiation-associated complications. After three years the other block excision patient had visual acuity of 20/25. Ciliary body melanocytoma should be included in the differential diagnosis of pigmented tumors of the anterior uvea with extrascleral extension. En bloc excision with simultaneous full-thickness corneoscleral resection is indicated in circumscribed ciliary body tumors, especially when extraocular extension is present.

Triple retinal infection with human immunodeficiency virus type 1, cytomegalovirus, and herpes simplex virus type 1. Light and electron microscopy, immunohistochemistry, and in situ hybridization

PURPOSE

This report describes the histopathologic and virologic findings of the retina from a 55-year-old bisexual patient with the acquired immune deficiency syndrome (AIDS), who had concurrent human immunodeficiency virus type 1 (HIV-1), cytomegalovirus (CMV), and herpes simplex virus type 1 (HSV-1) retinitis, and was treated with ganciclovir.

METHODS

The eyes were obtained at autopsy and processed for light microscopy and transmission electron microscopy. Immunohistochemical stains for HSV-1, CMV, HIV-1, varicella zoster virus, and glial fibrillary acidic protein were carried out using the peroxidase-antiperoxidase and streptavidin-biotin-alkaline phosphatase techniques. For in situ hybridization, a radiolabeled CMV DNA probe (Eco-RI-Y fragment of strain AD 169) was used.

RESULTS

Results of histopathologic examination showed a full-thickness necrotizing retinitis with cytomegalic and herpes viral intranuclear inclusions in cells of the neurosensory retina, retinal vascular endothelium, and the retinal pigment epithelium. Some areas of the retina were replaced by glial tissue. The choroid contained only a few chronic inflammatory cells. Immunoperoxidase studies disclosed CMV antigens diffusely distributed throughout all layers of the retina and the retinal pigment epithelium. Herpes simplex virus type 1 antigens were present in retinal cells and the retinal vascular endothelium. Human immunodeficiency virus type 1 antigens were found in mononuclear cells in all layers of the sensory retina. Dual infections with HIV-1 and CMV of individual multinucleated giant cells of glial origin were demonstrated immunohistochemically. Transmission electron microscopy showed herpes viral particles in the vascular endothelium of the retinal vessels and the choriocapillaris. Human immunodeficiency virus particles were identified in the endothelium of the choriocapillaris.

CONCLUSIONS

The possibility of multiple viral infections of the retina, mimicking classic CMV retinitis, should be considered in the clinical and histologic differential diagnosis of necrotizing retinitis in patients with AIDS.

Ocular pathology of MELAS syndrome with mitochondrial DNA nucleotide 3243 point mutation

PURPOSE

The authors describe the clinical, histopathologic, and ultrastructural findings in two eyes obtained at autopsy from a 21-year-old woman with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS syndrome).

METHODS

The eyes were obtained immediately after death. The right eye was fixed in 10% neutral-buffered formalin and processed for standard histologic examination. The left eye was fixed in a neutral-buffered 2.5% glutaraldehyde solution and processed for transmission electron microscopic examination. The authors compared the histologic and ultrastructural findings with the clinical features recorded photographically.

RESULTS

The main clinical ophthalmologic features were bilateral ptosis, chronic external ophthalmoplegia, diffuse choroidal atrophy, atypical pigmentary retinopathy with macular involvement, and patchy atrophy of the iris stroma. Molecular genetic analysis detected a tRNA Leu (UUR) point mutation at position 3243 of mitochondrial DNA (MELAS genotype). Results of histologic and ultrastructural examination showed ragged-red fibers in the rectus muscles, degeneration of photoreceptor outer segments in the macula, hyperpigmentation and atrophy of the retinal pigment epithelium of the macula, atrophy of the iris stroma, early posterior subcapsular cataract, and optic atrophy. The retinal pigment epithelium, inner segments of the photoreceptors, smooth muscle cells of the choroidal and retinal vessels, the dilator and sphincter muscle of the iris, cornea, lens epithelium, and ciliary epithelium all contained many, often enlarged, structurally abnormal mitochondria with occasional paracrystalline inclusions and circular cristae.

CONCLUSIONS

The MELAS-associated mitochondrial DNA nucleotide 3243 point mutation can cause a spectrum of ocular signs and symptoms that may be dependent on the patient's age and the amount of mutant mitochondrial DNA in the tissue. MELAS syndrome should be considered in the differential diagnosis of bilateral ptosis, external ophthalmoplegia, and atypical pigmentary retinopathy with macular involvement.

Chronic postoperative endophthalmitis following cataract extraction and intraocular lens implantation. Report on nine patients

Between 1987 and 1992, nine patients (three men and six women; mean age, 75 years) presented with chronic postoperative endophthalmitis after cataract extraction and intraocular lens (IOL) implantation. Eight patients were referred from another institution. The interval between IOL implantation and the beginning of intraocular inflammation averaged 5.6 months (range, 1-19 months). The referral diagnosis was "toxic lens" syndrome in seven patients. The main clinical findings were a hypopyon in the anterior chamber (n = 8) and in the capsule bag (n = 2), and "fibrosis" of the lens capsule (n = 7). In eight patients a vitrectomy was performed, combined with removal of the IOL in six cases and with a total posterior capsulectomy in five cases. Pathogenic organisms were identified in vitreous aspirate (6/8), in culture (3/3), and on histopathological examination (4/5) of lens capsule and included coagulase-negative staphylococci (n = 3, Staphylococcus epidermidis), Propionibacterium acnes (n = 1), Streptococcus viridans (n = 1), Rhodococcus erythropodes and R. luteus (n = 1), and one hyphomycete (Alternaria alternata). In chronic recurrent intraocular inflammations following IOL implantation, an infectious agent should be excluded by diagnostic and therapeutic pars plana vitrectomy including removal of the IOL and posterior capsulectomy.

[Clearing of the para-transplant host cornea after perforating keratoplasty in Maroteaux-Lamy syndrome (type VI-A mucopolysaccharidosis)]

BACKGROUND

The results of penetrating keratoplasty in patients with systemic mucopolysaccharidosis (MPS) type VI-A are controversial. Clouding of the transplant was often observed and was thought to be related to storage of glycosaminoglycans also in the donor button.

PATIENTS AND METHODS

We performed penetrating keratoplasties successfully in three children with MPS VI-A (severe type) at the age of 7-11 years.

RESULTS

The transplants remained clear during the follow-up of 2.5-5 years and the longterm visual acuity was encouraging. In two patients we could observe a partial, circular clearing of the host's cornea adjacent to the transplant. The related pathomechanism and the clinical, histopathological and ultrastructural findings of the cornea will be discussed.

CONCLUSION

As the intellectual development is normal, decrease of vision impairs the patient's life extremely. Thus, the indication of penetrating keratoplasty should be made early to improve the patient's quality of living, who have a reduced life-span.

The prognostic value of tumor blood vessel morphology in primary uveal melanoma

BACKGROUND

It is possible to identify at least nine vascular patterns in melanomas of the ciliary body and choroid from histologic sections. An association between the presence of at least one closed vascular loop and death from metastases was shown in a matched-pair, case-control study of 40 patients whose eyes were removed for ciliary body or choroidal melanomas.

METHODS

Two independent observers who were masked to the follow-up of patients examined histologic preparations of 234 eyes removed for ciliary body or choroidal melanomas for the presence of each of the tumor vascular patterns. Statistical analyses included tests for interobserver reliability, Kaplan-Meier survival curves, and the fitting of Cox regression models.

RESULTS

The detection of each of the nine vascular patterns is highly reproducible. The Cox model indicates that the presence of vascular networks, defined as at least three back-to-back closed vascular loops, is the feature most strongly associated with death from metastatic melanoma. Other significant factors in the Cox model include (in descending order of importance) largest tumor dimension, mitoses, the parallel with cross-linking vascular pattern, age, the presence of tumor-infiltrating lymphocytes, and male gender.

CONCLUSIONS

The presence of vascular networks provides the most significant association with death from metastatic melanoma of all variables tested. The presence of this pattern should be recorded on pathology reports. If it becomes possible to detect this vascular pattern clinically using a noninvasive imaging technique, then ophthalmologists may be able to determine the likely biologic behavior of a melanoma before resorting to the removal of tissue.

Congenital nonpigmented epithelial iris cyst after amniocentesis. Clinicopathologic report on two children

BACKGROUND

Congenital nonpigmented epithelial iris cysts are not common. They may arise spontaneously from developmental entrapment of surface ectodermal epithelium or from occult ocular trauma prenatally or at birth.

PATIENTS AND METHODS

Between 1989 and 1991, an 8-month-old child and a 6-year-old child presented with large, progressive congenital epithelial iris cysts. Both children had a maternal history of diagnostic amniocentesis after an ultrasound scan, and there was no history of postnatal ocular trauma. The cysts were successfully removed by a modified block excision and tectonic corneoscleral grafting.

RESULTS

A dense adherence of the cyst wall to Descemet's membrane resembled old anterior synechiae after occult perforation of the globe in both patients. On histopathologic examination, the epithelial lining of the cysts consisted of non-keratinizing stratified squamous epithelium with goblet cells resembling conjunctival epithelium. A perforating limbal scar with a corresponding break in Descemet's membrane could be detected in one eye. The long-term visual acuity of both children was encouraging, and there was no evidence of recurrence of the iris cyst during the follow-up period (average, 23 months).

CONCLUSIONS

The authors conclude that the clinical and histopathologic features of these congenital iris cysts may be consistent with an occult intrauterine limbal perforation of the anterior chamber with a needle during amniocentesis. Amniocentesis, when not guided by a real-time ultrasound scan, may be a risk factor for prenatal ocular trauma, which should be considered in the differential diagnosis of congenital ocular disorders.

Detection of varicella zoster virus DNA and viral antigen in human cornea after herpes zoster ophthalmicus

This article describes the histopathology, immunohistochemistry, and varicella zoster virus DNA in situ hybridization of 14 corneal buttons obtained from 14 patients (average age 69.0 years) after perforating keratoplasty (four patients) or surgical enucleation (10 patients) at different times after the clinical onset of herpes zoster ophthalmicus (average 58.7 months). The main histopathologic features were intense stromal vascular scarring (12 patients) and granulomatous reaction to Descemet's membrane (nine patients). Using the peroxidase-antiperoxidase method, varicella zoster virus (VZV) antigen could be detected by immunohistochemistry in two patients within epithelial cells of the cornea and in the limbal episclera during the active phase of herpes zoster ophthalmicus. For in situ hybridization we used the 35S-labeled HindIII A and C fragment of VZV and identified viral DNA in five corneal buttons obtained 1 day to 8 years after the clinical onset of infection. Viral DNA was mainly found in mononuclear cells with eosinophilic intracytoplasmic inclusions within vascular stromal scars, in keratocytes, and in epithelial cells of the cornea. Our results show that VZV DNA is detectable in human cornea even 8 years after the clinical onset of herpes zoster ophthalmicus and may indicate VZV persistence in a latent form in corneal tissue or reactivation of the virus from an endogenous or exogenous source causing a severe and often recurrent keratitis in the progress of herpes zoster ophthalmicus.

Epithelial transformation of the corneal endothelium in forceps birth-injury-associated keratopathy

Using light and electron microscopy, we studied four keratectomy specimens obtained by penetrating keratoplasty from four patients (ages 33-54 years; mean age: 43 years old) who had clinical evidence of Descemet's folds and bullous keratopathy after ruptures in Descemet's membrane after forceps injury at birth. Histopathologically, three patients showed the typical features of forceps birth injury: Descemet's membrane at the margin of the rupture was folded and assumed a scroll-shape configuration. The fourth patient showed clusters of proliferated endothelial cells at the site of two ruptures, and from one site of the ruptures, these cells invaded into Descemet's membrane, forming a new basement membrane. Transmission electron microscopy revealed that these proliferated cells were epithelial-like cells characterized by desmosomal junctions, basal lamina, numerous microvilli, and 8-nm cytoplasmic filaments. The epithelial transformation of the corneal endothelium was identified in cases of posterior polymorphous dystrophy and assumed to be specific for this entity. The findings in our fourth patient represent the first documentation of epithelial-like cells on the posterior corneal surface in forceps birth-injury-associated keratopathy. Our results suggest that epithelial transformation may be a nonspecific reaction of the young cornea to various stimuli.

[Persistence and transient conjunctival pathogen colonization before planned intraocular interventions]

The risk of a postoperative endophthalmitis is influenced by the presence of a significant bacterial colonisation of the conjunctiva before intraocular surgery. Between February and August 1990 we performed conjunctival smears in 481 patients 1) on the eve of the operation and 2) just before planned intraocular surgery, to evaluate a persistent or transient microbial colonisation of the conjunctiva. 352 patients showed insignificant ("negative") and 129 patients a significant ("positive") bacterial growth in the first conjunctival smear. 96% of the patients (n = 336) had a negative result in both smears. 30% of the patients (n = 37) with a positive conjunctival smear showed a persisting bacterial colonisation, whereas 70% of the patients (n = 92) had a transient colonisation of the conjunctiva with a negative second smear. As a persisting microbial colonisation of the conjunctiva may be an important factor for the development of postoperative endophthalmitis, we recommend prophylactic conjunctival smears before surgery to diminish the risk of intraocular infections after surgery.

Detection of varicella zoster virus DNA and viral antigen in the late stage of bilateral acute retinal necrosis syndrome

We describe the clinicopathologic and virologic findings in the right, blind eye of an immunocompetent 61-year-old woman. The eye was enucleated 32 months after the clinical onset of a bilateral acute retinal necrosis syndrome. Histopathologic study showed a diffuse, full-thickness, necrotizing retinitis with replacement of sensory retinal structures by glial tissue, occlusive retinal arteritis, granulomatous choroiditis, and optic neuritis with ischemic optic atrophy. Varicella zoster virus could be identified as the causative agent by DNA in situ hybridization and by immunohistochemical stains in mononuclear cells with eosinophilic intracytoplasmic inclusions. Virus was detected only within the choroid and the choriocapillaris. We conclude that these histopathologic and virologic features are consistent with a "burned-out phase" of a varicella zoster virus-induced acute retinal necrosis syndrome.

[Orbital, osseous, meningeal and cerebral findings in oculodermal melanocytosis (nevus of Ota). Clinico-histopathologic correlation in 2 patients]

In two patients suffering from congenital oculodermal melanocytosis (nevus of Ota) orbital, osseous, meningeal, and cerebral manifestations are documented. In a 38-year-old European with a nevus of Ota on the right side an ipsilateral orbital tumor was diagnosed and surgically removed. The histological examination revealed a primary spindle shaped malignant melanoma of the orbit. In addition, many benign melanocytes were found in the optic nerve, in the extraocular muscles, in the orbital fat tissue, and in the dura of the sphenoid. In a 17-year-old Ethiopian with a nevus of Ota of the right side an increase in size of the pigmented process was observed during puberty in the orbital fat tissue, in the extraocular muscles, in the optic nerve, in the periorbital bones, in the temporal muscle, and in the cortex of the frontal brain lobe. A deep excision from the lower eye lid revealed a histologically benign oculo-orbito-dermal melanocytosis. An irradiation was performed because of growth again after segmental excision, however without success. In the ipsilateral eye a secondary open-angle glaucoma was diagnosed. In the nevus of Ota an involvement of the orbit and of the meningo-cerebral tissue must be considered.

[Incidence of postoperative bacterial infections after planned intraocular interventions]

Between August 1982 and August 1984 3059 intraocular operations were performed with topical prophylactic antibiotics. Results of conjunctival cultures did not influence the surgical schedule. 8179 intraocular operations were performed between September 1984 and August 1988. An intraocular operation was postponed until conjunctival cultures were negative using topical antibiotics administered at hourly intervals. The rate of postoperative intraocular infections decreased significantly (p less than 0.0001) from 21 (0.69%) of 3059 during the first to 9 (0.11%) of 8179 intraocular operations during the second observation period. In the first period 11 vitrectomies and 2 enucleations due to bacterial endophthalmitis had to be performed. In the second period 2 vitrectomies and no enucleations were necessary (p less than 0.0001). Our results indicate, that decontamination of the conjunctiva may be an import factor for the prevention of postoperative endophthalmitis following elective intraocular surgery.

Block excision of cystic and diffuse epithelial ingrowth of the anterior chamber. Report on 32 consecutive patients

From 1980 to 1990, 32 consecutive patients with progressive cystic or diffuse epithelial ingrowth of the anterior chamber were treated successfully with block excision. This technique consists of simultaneous removal of adjacent iris, pars plicata of ciliary body, and all layers of sclera and cornea in contact with the lesion acting as a shell. The resulting defect is covered by a tectonic corneoscleral graft. Twelve patients had suffered from perforating ocular injury, 10 patients had previously undergone cataract extraction, and 10 patients had various causes of epithelial ingrowth. Cystic epithelial ingrowth occurred in 27 patients, diffuse sheetlike epithelial ingrowth occurred in four patients, and one lesion was identified as foreign body granuloma. On histopathologic examination, all but two patients revealed epithelial involvement of the surface of the ciliary body. All patients were followed up for an average of 60.1 months (range, 1 to 120 months). Long-term visual acuity was better than 20/60 in 37.5% of the patients. No recurrence of ingrowth was noted and enucleation was not necessary. Our results indicate that block excision currently may be the treatment of choice for cystic and diffuse sheetlike epithelial ingrowth of the anterior chamber.

Light and electron microscopy of the cornea in systemic mucopolysaccharidosis type I-S (Scheie's syndrome)

A 37-year-old man with coarse facies, stiff joints, corneal clouding, and normal intelligence sought medical attention. The diagnosis of a systemic mucopolysaccharidosis (MPS) type I-S (Scheie's syndrome) was confirmed by the presence of lysosomal alpha-L-iduronidase deficiency and excessive urinary dermatan and heparan sulfate excretion. The corneal button after perforating keratoplasty of the right eye demonstrated mucopolysaccharides consisting of numerous vacuoles containing fibrillogranular and partly membranebound material in epithelial cells, histiocytes, keratocytes, and extracellular matrix. Endothelial cells were distinctly free of storage material. The epithelial basement membrane showed frequent breaks, whereas Bowman's layer was only slightly attenuated. Irregular collagen fibrils and fibrous long-spacing collagen were noted near degenerating distended keratocytes. The Descemet's membrane was normal. The literature of six reported histopathological examinations of the cornea in Scheie's syndrome is reviewed. Detection of fibrous long-spacing collagen seems to be a typical abnormality of the cornea in MPS I-S.

Autologous nasal mucosa transplantation in severe bilateral conjunctival mucus deficiency syndrome

From 1984 to 1989, 24 patients with desperate ocular surface wetting problems due to mucus deficiency syndrome with extensive symblephara or lid fusion were treated by autologous free transplants of nasal mucosa from the nasal conchae. This procedure covers the ocular surface not only with nonkeratinizing epithelium but also with goblet cells and produces a mucus layer. This was proven by biopsy in three patients after 1 to 3 years. In all of the patients, conjunctival transplants were not available. Pronounced relief of pain and modest visual improvements are achieved with this procedure, and free autologous nasal mucosal grafts appear to be superior to buccal mucosa in reestablishing the anterior ocular surface. The authors recommend the technique for all patients with massive and otherwise intractable symblephara following lye burns.

[Bacterial pathogen and resistance spectrum of the non-irritated conjunctiva. 7,845 preoperative smears at the ophthalmologic clinic of the Erlangen university]

The type and extent of bacterial colonization of the conjunctiva at the time of an intraocular operation may have a major influence on the risk of post-operative endophthalmitis. Between March 1986 and December 1988 a total of 7845 preoperative conjunctival smears were therefore examined by culture of Erlangen University Eye Hospital, in cooperation with the Department of Clinical Microbiology. Altogether, 1221 (15.6%) of the smears were classified as positive. Surgery on the patients concerned was postponed and gentamicin eye drops were administered for decontamination of their conjunctivae until the smears were negative. From the positive smears 1393 strains were cultured, identified, and submitted to a resistance test. The present paper reports the frequency distribution of the species of bacteria isolated and their resistance behavior, and compares the results with those of other authors. The value of preoperative cultures in the prevention of postoperative endophthalmitis and the importance of resistance tests in the context of topical application of antibiotics are discussed.

A 32-year follow-up of the rigid Schreck anterior chamber lens. A clinicopathological correlation

We describe the clinicopathological findings in an eye after 32 years of successful anterior chamber lens implantation. In 1956, a rigid Schreck total polymethylmethacrylate anterior chamber lens was implanted in the right eye of a 28-year-old white man 1 year after corneo-scleral laceration with traumatic cataract. The postoperative clinical course was subjectively unremarkable for at least 30 years. In 1988, the patient developed secondary angle closure glaucoma, associated with a cavernous Schnabel optic atrophy that was caused by peripheral anterior synechiae and fibrovascular downgrowth into the anterior chamber. The lens implant was encapsulated "cocoonlike." Secondary proliferation of corneal endothelial cells covered the fibrous membrane and the chamber angle structures. No inflammatory reaction and only a very slight foreign-body reaction in the area of the footplate of the anterior chamber lens were present. Clinical and histopathological findings indicate that polymethylmethacrylate is sufficiently inert and biocompatible to be tolerated by the surrounding ocular tissues for more than 30 years.

Congenital nonpigmented epithelial iris cyst removed by block-excision

A 1-month-old white girl developed a rapidly progressing congenital nonpigmented iris cyst covering the pupil and displacing the lens and ciliary body. The cyst was completely removed using a modified block excision (9 x 3.5 mm). The tumor consisted of partially keratinizing cuboidal epithelium with goblet cells, which was covered by proliferating corneal endothelium on the outside. Histopathological, and scanning and transmission electron microscopic findings are described. The postoperative course is unremarkable for 1 year. To our knowledge this case is the first case of a congenital iris cyst successfully treated with block-excision.