Amiloidose de conjuntivas palpebrais inferiores: um relato de caso / Lower eyelid conjunctival amyloidosis: a case report

RESUMO A amiloidose é caracterizada pela deposição extracelular de fibrilas amiloides proteicas nos tecidos, incluindo conjuntiva, motivada por sua insolubilidade em proteínas proteolíticas. A amiloidose conjuntival, afetando especificamente a conjuntiva palpebral, é um achado raro na prática clínica. Os autores descrevem um caso de um paciente do sexo masculino, caucasiano, de 71 anos, apresentando lesões bilaterais localizadas na conjuntiva da pálpebra inferior, elevadas, bem delimitadas, amareladas, aliadas a pálpebras desestabilizadas. Foi realizada excisão cirúrgica das lesões, e o exame histológico confirmou se tratar de amiloidose conjuntival. Não houve recorrência após o procedimento. A amiloidose conjuntival afetando ambas as pálpebras inferiores é um achado raro na literatura. O manejo da amiloidose conjuntival depende da extensão do envolvimento local e do status sistêmico do paciente, variando de sintomático, com o uso de lubrificantes, até cirúrgico, com a remoção das lesões.

ABSTRACT Amyloidosis is characterized by extracellular deposition of protein amyloid fibrils in tissues, including conjunctiva, which are insoluble in proteolytic proteins. Conjunctival amyloidosis specifically in the palpebral conjunctiva is a rare finding in clinical practice. The authors described the case of a 71-year-old caucasian male patient, with bilateral lesions located in the lower eyelid conjunctiva, elevated, well-defined, yellowish, combined with destabilized eyelids. Surgical excision of the lesions was performed, and the histological examination confirmed conjunctival amyloidosis. There was no recurrence after the procedure. Conjunctival amyloidosis in both lower eyelids is a rare finding in the literature. The management of conjunctival amyloidosis depends on the extent of local involvement and patient's general health status, varying from symptomatic, with use of ocular lubricants, to surgical, by removing the lesions.

Oftalmomiasis por Oestrus ovis en un área urbana al sur del Perú / Oestrus ovis ophthalmomyiasis at an urban area in Southern Peru

Resumen La oftalmomiasis es la infestación ocular por larvas de dípteros. Ha sido descrita en pacientes provenientes de áreas rurales, higiene deficiente o por contacto con animales. Sin embargo, existen reportes esporádicos de esta infestación en áreas urbanas. Presentamos el caso de un varón joven, sin factores de riesgo, proveniente de un área urbana al sur del Perú, que presentó 10 larvas en la conjuntiva ocular. Las larvas fueron identificadas como Oestrus ovis, una mosca que suele infestar ovejas y cabras como parte de su ciclo de vida. Realizamos una breve revisión del tema, resaltando la importancia de identificar adecuadamente la especie causante de la miasis, así como su ciclo de vida.

Ophthalmomyiasis is the ocular infestation by dipterous larvae. It has been described in patients from rural areas, poor hygiene, or contact with animals. However, there are sporadic reports of this infestation in urban areas. We present the case of a young man without risk factors, from an urban area in southern Peru, in whom we found 10 larvae at ocular conjunctiva. The larvae were identified as Oestrus ovis, a fly that usually infests sheep and goats as part of their life cycle. We made a brief review of the case, highlighting the importance of adequately identifying the species that cause myiasis as well as its life cycle.

Apresentação atípica da oftalmopatia de Graves / Atypical presentation of Graves’ ophthalmopathy

A oftalmopatia de Graves é a doença orbitária mais comum e acomete 25 a 50% dos pacientes portadores da Doença de Graves e é mais frequente no sexo feminino, entre a segunda e quinta décadas de vida. A doença apresenta uma fase aguda e uma crônica, evoluindo lenta e progressivamente até estabilizar, sendo raros os casos de resolução espontânea. O tratamento dependerá da fase em que a doença se encontra e está baseado principalmente na corticoterapia via oral e endovenosa e/ou radioterapia, sendo a colchicina empregada em casos isolados. No seguinte relato de caso, abordaremos uma forma atípica de manifestação clínica da Oftalmopatia de Graves em paciente eutireoideia com anticorpos negativos na sua apresentação inicial.

Graves ‘ophthalmopathyis themost commonorbital diseaseand affects25-50% of the patients withGraves’ disease. It`s morecommon in females, between the second andfifth life`s decade. The disease hasanacute andachronic stage, slowly progressing until it stabilizes, with rarecasesof spontaneous resolution.The treatment depends on thestage andthe disease ismainly treated withoralor intravenous corticosteroids with or without radiotherapy;colchicine is usedin individual cases. In the followingcase report, we discuss an atypicalmanifestation ofGraves’ ophthalmopathyin an euthyroid patientwith negative antibodiesin the inicial presentation.

Kimura Disease Involving a Caruncle

A 35-year-old woman presented with history of a painless, slow-growing nodule in a left eye caruncle over the last 2 months. The visual acuity was 20 / 20 and the ocular movements were in the normal range. The venereal disease research laboratory test, erythrocyte sedimentation rate, serum angiotensin converting enzyme level, and chest radiograph were all normal. An excisional biopsy was done to confirm the diagnosis. A 1.3 x 0.5 x 0.3 cm sized nodule was extracted and sent for histopathologic examination. Hematoxylin-eosin staining showed follicular hyperplasia with perifollicular fibrosis, an eosinophil infiltrate, and proliferation of capillary vessels. The capillaries were lined by normal-appearing, flat, spindle-shaped endothelial cells. On the basis of these histopathologic findings, the diagnosis of Kimura disease in a caruncle was established. This is the first report describing Kimura disease localized to a caruncle. Kimura disease should be suspected and included in the differential diagnosis of a caruncular mass lesion.

Kimura Disease Involving a Caruncle

A 35-year-old woman presented with history of a painless, slow-growing nodule in a left eye caruncle over the last 2 months. The visual acuity was 20 / 20 and the ocular movements were in the normal range. The venereal disease research laboratory test, erythrocyte sedimentation rate, serum angiotensin converting enzyme level, and chest radiograph were all normal. An excisional biopsy was done to confirm the diagnosis. A 1.3 x 0.5 x 0.3 cm sized nodule was extracted and sent for histopathologic examination. Hematoxylin-eosin staining showed follicular hyperplasia with perifollicular fibrosis, an eosinophil infiltrate, and proliferation of capillary vessels. The capillaries were lined by normal-appearing, flat, spindle-shaped endothelial cells. On the basis of these histopathologic findings, the diagnosis of Kimura disease in a caruncle was established. This is the first report describing Kimura disease localized to a caruncle. Kimura disease should be suspected and included in the differential diagnosis of a caruncular mass lesion.

Conjunctival Hypertrophic Scar Following Cryotherapy for Retinopathy of Prematurity

A 6-year-old boy was referred to our hospital with symblepharon and lateral canthal deformity in both eyes, which developed 6 years ago. The patient was born at 27 weeks gestation. He had received cryotherapy for retinopathy of prematurity. One month after cryotherapy, he developed a conjunctival scar with symblepharon in both eyes and underwent symblepharon lysis at another hospital 5 years prior. Ocular examination revealed an extensive conjunctival hypertrophic scar with symblepharon and limitation of extraocular movements. An excisional biopsy, lateral canthoplasty, and symblepharon lysis with conjunctival autograft from the contralateral eye were performed in the left eye. Histopathologic examination revealed diffuse proliferation and infiltration of collagenous tissue.

Melanoma maligno conjuntival / Malignant melanoma of the conjunctiva

INTRODUÇÃO: Os tumores melanocíticos conjuntivais compreendem lesões que podem variar desde lesões benignas como os nevos conjuntivais, lesões pré-cancerosas como melanose adquirida primária com atipia até o melanoma maligno conjuntival. O reconhecimento das características clinicas destas lesões e seu diagnóstico preciso permitem o tratamento adequado, contribuindo para a redução da morbidade e mortalidade associados ao melanoma de conjuntiva. OBJETIVO: Revisão das características clinicas, diagnóstico e modalidades de tratamento clínico e cirúrgico das lesões precursoras (Nevos e melanose adquirida primária) e do maligno conjuntival. MÉTODOS: Revisão de literatura através de pesquisa no banco de dados MEDLINE, PUBMED, LILACS e SciELO no período de 1980 a 2011. As palavras-chave utilizadas, individualmente ou em conjunto, foram: "conjunctival melanoma", "primary acquired melanosis", "nevi", "treatment", "chemotherapy", "recurrence", "metastasis" e "mortality". RESULTADO: Características clínicas que permitem o diagnóstico do melanoma conjuntival e sua diferenciação de outras lesões pigmentadas conjuntivais foram consideradas. O estadiamento clínico e patológico, assim como modalidades de tratamento para o melanoma maligno foram revisadas. CONCLUSÕES: Pacientes portadores de lesões pigmentadas conjuntivais devem ser avaliados por um oftalmologista especialista. A história oftalmológica, a história familiar de melanoma, e características clínicas da lesão necessitam de cuidadosa avaliação, incluindo-se a determinação do risco de malignidade. A documentação fotográfica deve ser realizada. O tratamento clínico e planejamento cirúrgico devem ser baseados na suspeita clinica. A análise histopatológica por patologista experiente é fundamental para orientação do tratamento e para identificação de fatores prognósticos, principalmente em casos de doença maligna.

INTRODUCTION: Melanocytic tumors comprise a wide range of lesions. These lesions can be nevi, primary acquired melanosis with or without atypia or malignant as conjunctival melanoma. Early recognition of the clinical features allows precise diagnosis and adequate intervention, reducing the rates of metastatic disease and mortality associated with conjunctival melanoma. PURPOSE: To review clinical features, diagnosis, clinical and surgical treatment modalities of the different precursor pigmented lesions (Nevi and primary acquired melanosis) and malignant melanoma. METHODS: Literature review was performed accessing the database of MEDLINE, PUBMED, LILACS e SciELO between 1980 and 2011. The keywords used, individually or combined, were: conjunctival melanoma, primary acquired melanosis, nevi, treatment, chemotherapy, recurrence, metastasis e mortality. RESULTS: Relevant clinical information for the diagnosis of malignant melanoma and differentiation from other pigmented conjunctival lesions were accessed. Clinical and pathological features and different modalities of treatment for malignant melanoma have been reviewed. CONCLUSIONS: Patients presenting with a pigmented conjunctival lesion should be evaluated by an experienced ophthalmologist. Ocular history, family history of melanoma, and clinical features of the lesion need careful assessment and malignancy risk evaluation. Digital photo documentation should be performed. Clinical or surgical planning should be done based on the clinical suspicion. Careful histopathology analysis is required for treatment orientation and prognostic factors identification, mainly in cases of malignancy.

Subconjunctival Loa loa worm: first case report in Brazil / Verme subconjuntival da espécie Loa loa: primeiro caso no Brasil

We report the first case of ocular infestation by Loa loa in Brazil. Loiasis is caused by infestation with Loa loa, a filarial parasite originally found in the rainforests of western and central Africa. It is transmitted by the bite of the fly Chrysops and has been recently described in other places other than Africa, in African immigrants or travellers. Our case is a 33 year-old woman from Cameroon who was living in São Paulo, Brazil, for 5 years. She was asymptomatic until one morning she started feeling "something moving" in the left eye. Under topical anesthesia, on the slit lamp, a moving worm was removed from the subconjunctival space, which later was confirmed to be a male Loa loa adult specimen. Blood tests revealed microfilaraemia of 129 mf/mL. The patient was treated with 400 mg oral albendazole for 3 weeks and 60 mg prednisone. This report illustrates an unusual ocular disease, which is extremely rare outside of Africa, but easily diagnosed and treated. Ophthalmologists should be aware of it, in face of an increasingly globalized world.

Este é o primeiro relato na literatura nacional e internacional de infestação ocular por Loa loa no Brasil. A loíase é uma filariose causada pelo parasita Loa loa, encontrado nas florestas tropicais da África equatorial. A transmissão se dá pela picada do mosquito Chrysops e casos têm sido descritos em países não africanos, em imigrantes e viajantes. O presente caso trata-se de uma paciente de 33 anos natural de Camarões e residente em São Paulo, Brasil, há 5 anos. Até então assintomática, uma manhã sentiu algo "se mexendo" em seu olho esquerdo. Sob anestesia tópica, na lâmpada de fenda, um verme altamente móvel foi removido do espaço subconjuntival e enviado para identificação, que confirmou tratar-se de um espécime macho adulto de Loa loa. Testes sanguíneos revelaram microfilaremia de 129 mf/mL. A paciente foi tratada com albendazol 400 mg e prednisona 60 mg esquema regressivo por 3 semanas. Este relato ilustra uma doença excepcionalmente rara no Brasil, e praticamente desconhecida dos oftalmologistas em nosso país.

A historical note on an imported case of loiasis in Rio de Janeiro, Brazil, 1964 / Nota histórica sobre caso importado de loíase no Rio de Janeiro, Brasil, 1964

Loiasis is a filarial disease transmitted by the Chrysops spp. tabanid flies in West and Central Africa. It is most commonly diagnosed by the clinical manifestations of Calabar swellings (transient localized inflammatory edema) or, most dramatically, by the appearance of a migrating worm through the conjunctival tissues or the bridge of the nose. We report the case of a 35-year-old resident in the city of Rio de Janeiro who displayed a moving Loa loa in the bulbar conjunctival tissue two years after returning from a six-month trip to Uganda. Surgical removal of the worm was performed.

A loaíase é uma filaríase transmitida por tabanídeos (mutucas) do gênero Chrysops na África central e ocidental, comumente diagnosticada pela apresentação clínica de edema de Calabar (edema inflamatório transitório e localizado) ou, mais dramaticamente, pela migração de um verme adulto pelo tecido conjuntival ou asa do nariz. Descrevemos o caso clínico de um paciente do sexo masculino, 35 anos, residente no Rio de Janeiro, que se apresentou com um verme adulto de Loa loa migrando sobre o tecido conjuntival bulbar dois anos após retornar de uma viagem de seis meses de duração a Uganda. Procedeu-se a remoção cirúrgica do verme.

Amiloidosis conjuntival: reporte de tres casos / Conjunctival amyloidosis: three case report

La amiloidosis conjuntival es una condición infrecuente en la práctica clínica, que se caracteriza por el depósito de material amiloide de la conjuntiva. Se estima que es la causa del 0,002 por ciento de las lesiones conjuntivales. Dada la baja incidencia de esta patología, existen pocos reportes en la literatura. En este trabajo se presentan los casos clínicos de tres pacientes con amiloidosis conjuntival que fueron atendidos en nuestro centro y se propone una aproximación diagnóstica para evaluar la existencia de amiloidosis sistémica.

Conjunctival amyloidosis is a rare condition characterized by the localized deposition of amyloid material in the conjunctiva. It's supossed to be the cause of 0.002 percent of conjunctival lesions. Given the low incidence of this disease, there are few reports in the literature. In this manuscript we present the cases of three patients with primary conjunctival amyloidosis who were attended at our institution. We also propose a diagnostic algorithm to rule out systemic amyloidosis in patients in whom the finding is conjunctival amyloidosis.

Pleomorphic adenoma of a subconjunctival ectopic lacrimal gland.

This report describes a case of pleomorphic adenoma of an ectopic lacrimal gland arising subconjunctivally in the lateral fornix in a 13-year-old girl. The tumor was removed surgically in toto with the capsule. This is probably the first reported case.

Insect wing tarsal foreign body causing conjunctival granuloma and marginal keratitis.

A 37 year old male was referred to our centre for management of episcleritis with peripheral keratitis in the right eye. He had a history of ocular discomfort in the right eye of 1 week duration. Slitlamp examination revealed marginal keratitis between 12'o clock to 2'o clock positions in the right eye. Lid eversion revealed an insect wing on the tarsal conjunctiva along with an adjacent conjunctival granuloma. The area of the marginal keratitis corresponded to the area of the foreign body and the conjunctival granuloma. The probable mechanism of the development of marginal keratitis and the conjunctiva granuloma is speculated in this case report.

Ocular toxicity by latex of Calotropis procera (Sodom apple).

We report the spectrum of ocular toxicity following accidental inoculation of latex of Calotropis procera (Sodom apple) in 29 eyes between January 2003 and December 2006. All patients presented with sudden painless dimness of vision with photophobia. Twenty-five (86%) patients had initial visual acuity of less than 20/60. All eyes had conjunctival congestion and mild to severe corneal edema with Descemet's folds. Three (10%) eyes had an epithelial defect, nine (31%) had iridocyclitis, and seven (24%) had associated secondary glaucoma. After treatment with topical corticosteroids, antiglaucoma agents, cycloplegics, hypertonic saline and tears supplements, 27 (93%) eyes recovered completely within 3-14 days. After three months, 17 (74%) out of 23 eyes showed a significant low endothelial cell count compared to the normal fellow eye ( P 0.001). The latex of Calotropis procera causes significant ocular morbidity which may be preventable by simple health education. The long-term effect on corneal endothelium has to be studied further.

Seborrheic Keratosis of the Conjunctiva: A Case Report

Seborrheic keratosis is a benign epithelial neoplasia that occurs mainly in the skin of the eyelids and face. We describe a case of seborrheic keratosis of the conjunctiva confirmed by histopathology. A 72-year-old man presented with a recurrent conjunctival mass involving the nasal side of his right eye. Clinically, a diagnosis of conjunctival papilloma was made, and a mass excision was performed. The histopathological analysis evidenced a conjunctival-covering epithelium with papillomatous changes and irregular acanthosis, at the expense of a proliferation of basaloid cells. In addition, the lesion exhibited multiple pseudohorn cysts containing keratin. With the above findings, a diagnosis of conjunctival seborrheic keratosis was established. The occurrence of seborrheic keratosis on the conjunctiva is rare. In this case, seborrheic keratosis was confirmed by pathologic report despite its similar appearance with papilloma. Seborrheic keratosis should be considered in the differential diagnosis of conjunctival lesions.

Epidemiología de las lesiones conjuntivales y su correlación clínico-patológica / Epidemiology of conjunctival lesions and clinical-pathological correlation

Se realizó una revisión de los 1166 casos de lesiones conjuntivales recibidos por el Laboratorio de Patología Ocular del Hospital Clínico de la Universidad de Chile entre los años 1968-2005. En base a ella se describen los distintos diagnósticos histopatológicos según su frecuencia, distribución por sexo, edad, localización y tiempo de evolución. La edad promedio para los casos fue de 36 años con un 51,5 por ciento de hombres afectados y un tiempo de evolución promedio de 68 meses. Las lesiones más frecuentes fueron las pigmentarias (44,2 por ciento), seguidas de las epiteliales (22,7 por ciento) y los cuadros infecciosos (10,9 por ciento). La localización más frecuente para todas las lesiones fue bulbar. Se estableció, además, una correlación entre los diagnósticos clínicos e histopatológicos, la cual resultó ser positiva en un 60,9 por ciento, siendo marcadamente superior para las lesiones pigmentarias e inferior para lesiones degenerativas, cuadros infecciosos y tumores clasificados como pre-malignos o malignos.

We made a retrospective review of 1166 cases of conjuntival lesions, accepted for its study at the Laboratory of Ocular Pathology, University of Chile, from 1968 to 2005. Based on this survey, different histopathologic diagnosis were described, characterized by its frequency, gender distribution, age, location and time of evolution. The average age was 36 years, with a 51,5 percent being male, and an average time of evolution of 68 months. Most frequent lesions were pigmented (44,2 percent), followed by epithelial (22, 7 percent), and infectious diseases (10,9 percent). The most frequent location was bulbar. A clinical - pathologic correlation was established, being positive in 60,9 percent of cases. It was noticeable superior for pigmented lesions, and inferior for degenerative lesions, infectious disease and tumors classified as pre malignants or malignants.

Ocular manifestations of cysticercosis: a case report.

Ocular and extraocular cysticercosis is a commonly encountered manifestation of the disease caused by the cysticercus cellulosae. Any region of the eye may be afflicted including the subconjunctival space. We present the case ofa young female who developed a small mass at the medial canthus of the left eye, which was diagnosed as conjunctival cysticercosis subsequent to excision and histopathological examination.

Ocular sparganosis.

A 50-year-old male attended outpatients department with complaints of irritation, foreign body sensation and mild redness in his right eye. On examination a conjunctival nodule was found with localised inflammation. All investigations were normal. Surgical excision of the nodule was contemplated. During local dressing a live tapeworm about 20 cm in length and 3 mm in breadth emerged. Pathological examination confirmed it to be a tapeworm spirometra. The case was diagnosed to be ocular sparganosis.

Método citológico e histopatológico no diagnóstico das lesões da conjuntiva: estudo comparativo / Cytologic and histologic methods in the diagnosis of conjunctival lesions: comparative study

OBJETIVOS: Avaliar a eficácia e a confiabilidade do método citológico nas lesões da conjuntiva, comparando-o com o exame histopatológico. MÉTODOS: Realizou-se estudo prospectivo em 31 lesões conjuntivais. O material para estudo foi coletado raspando-se as lesões com a ajuda da espátula de Kimura. Posteriormente, procedeu-se à exérese das mesmas que foram encaminhadas para o exame histopatológico. As lâminas do exame citológico foram coradas pela técnica de Papanicolaou. RESULTADOS: O método citológico mostrou alta especificidade (100 por cento) e sensibilidade (92,9 por cento). O valor preditivo positivo foi de 100 por cento e o valor preditivo negativo foi de 94,4 por cento. CONCLUSÕES: O simples método citológico é efetivo e seguro no diagnóstico de lesões tumorais da conjuntiva.