Education in cultural competency in Japan.

Cultural competency can help radiologists and other radiology personnel provide better care to patients. This article illustrates this point with reference to Japanese culture.

Effect of fibrin bandage fibrinogen concentration on blood loss after grade V liver injury in swine.

OBJECTIVE: To determine the effect of fibrinogen concentration of dry fibrin bandages on blood loss after grade V liver injury. METHODS: Twenty-four pigs were used. Grade V liver injuries were induced and treated with dry fibrin bandages containing 0, 4, 8, or 15 mg fibrinogen/cm2. Animals were monitored for 60 minutes. Blood loss, fluid use, hematological data, and hemostasis were assessed. RESULTS: Post-treatment blood losses (mean and 95% confidence interval [CI]) were 1,560 mL (356-6,844), 372 mL (65-2,134), 225 mL (51-992), and 127 mL (22-732) in the 0-, 4-, 8-, and 15-mg groups, respectively. Only the 15-mg group had results significantly lower than the 0-mg group (p < 0.05). Blood loss was negatively related to fibrinogen concentration (p < 0.05). CONCLUSION: Fibrinogen concentration was inversely related to blood loss after grade V liver injury. The 15-mg formulation was the only one that significantly reduced blood loss.

Different hypotensive responses to intravenous bovine and human thrombin preparations in swine.

BACKGROUND: Accidental intravenous introduction of commercial bovine thrombin (BT) during use of fibrin glue may result in profound hypotension. Commercial human thrombin (HT) is now available. This study compared the effects of intravenous BT versus HT in swine. METHODS: Swine received 30 U/kg BT, 60 U/kg BT, 30 U/kg HT, or 60 U/kg HT intravenously. Mean arterial pressure (MAP) and survival were monitored for 30 minutes. Thrombin purities and in vitro activities were examined. RESULTS: MAP nadir was lower (p < 0.05) after BT, 27.7 +/- 3.3% (mean +/- SEM) of pretreatment MAP, compared with 41.1 +/- 3.7% after HT. Five of six animals died after 60 U/kg BT, whereas all others survived (p < 0.05). Histology suggested more severe disseminated intravascular coagulation after BT. HT was purer than BT. In vitro activities were similar. CONCLUSION: Both BT and HT produced hypotension. HT appeared safer, because of higher purity. Regardless of source and purity, thrombin must be used with caution.

Band-shaped and whorled microcystic dystrophy of the corneal epithelium.

OBJECTIVE: To report the clinical, histopathologic, and electron microscopic features of band-shaped and whorled microcystic corneal epithelial dystrophy. DESIGN: Two interventional case reports. PARTICIPANTS: Two patients, two eyes. INTERVENTION: The involved area of corneal epithelium was scraped from each cornea. RESULTS: Histopathologic examination showed microscopic vacuoles in the epithelial cytoplasm in both cases. Electron microscopic examination revealed mainly empty cytoplasmic vacuoles with scant nonspecific osmophilic material. The process recurred clinically in one patient. Changes in corneal topography are documented in one patient. CONCLUSION: Clinical findings and pathologic studies seem nearly identical to those in the original report. No pattern of systemic disorder or medication use was found. The cause of this condition remains unknown.

Intramuscular lipoma of the eyelid.

To report a unique case of intramuscular lipoma of the eyelid and to alert surgeons to this entity that simulates a common dermoid cyst. A slowly-growing mass of the upper eyelid was excised from a 62-year-old man. Histology showed mature lipocytes interspersed with skeletal muscle. To our knowledge, this case represents the first report of intramuscular lipoma of the eyelid. Lipomas, including the intramuscular variety, are common tumors elsewhere in the body. The differential diagnosis of eyelid masses should include this entity.

Effect of dry fibrin sealant dressings versus gauze packing on blood loss in grade V liver injuries in resuscitated swine.

BACKGROUND: We conducted this study to determine whether the dry fibrin sealant dressing (DFSD) would stop bleeding from a grade V liver injury and to evaluate the effects of leaving the absorbable DFSD in survival animals. METHODS: Twenty-four swine (40+/-3.0 kg) received a uniform grade V liver injury and were randomized to one of four 1-hour treatment groups: (1) gauze packing, (2) DFSD, (3) immunoglobulin G placebo dressing, and (4) no treatment. All animals were resuscitated with lactated Ringer's solution. Total blood loss (TBL), mean arterial pressure, resuscitation volume, and laboratory data were monitored for 1 hour after injury. Four swine were treated with the DFSD after grade V injury and allowed to survive for 7 or 14 days. RESULTS: The TBL was 1,104+/-264 mL (mean +/- SEM), 544+/-104 mL, 4,223+/-1,555 mL, and 6,026+/-1,020 mL for groups 1, 2, 3, and 4 respectively. TBL in DFSD animals was less than that in animals treated with gauze packing (p = 0.06). Grade V injuries were uniform among the 1-hour groups, and no evidence of intrahepatic abscess, unusual adhesions, or hepatic vein, vena caval, or pulmonary thromboses were noted in the long-term survival animals. CONCLUSION: In this model of grade V liver injury, blood loss with the DFSD was 51% of that observed with standard gauze packing (not statistically different). Initial survival data revealed no complications attributable to the fibrin dressing. DFSD may provide simple, rapid, and definitive hemorrhage control in life-threatening liver injuries without the need for reoperation.

Hemangiopericytoma of the lacrimal sac.

Hemangiopericytoma (HPCT) rarely originates in the lacrimal sac; 7 cases have been reported previously and only 1 contained an ultrastructural study. In this article we report an additional case and review the previous reports. While the initial biopsy specimen showed nonspecific cytologic abnormalities, light and electron microscopic studies on the subsequently excised tumor demonstrated that it had a structure characteristic of HPCT. The onset of lacrimal sac HPCT occurs in a younger age group than that of HPCT of other orbital locations. The tumor may recur locally but, to our knowledge, never has been reported to metastasize from a sac location. The treatment goal is complete surgical excision.

Epibulbar granular cell tumor. Report of a case and review of the literature.

BACKGROUND: The granular cell tumor (GCT) is a common, usually benign, neoplasm of uncertain histogenesis that may affect any organ in the body. It occurs rarely in ophthalmic sites, where orbital location is most frequent. The purpose of this report is to describe a unique case of an epibulbar, subconjunctival GCT in a child. METHOD: Histopathologic examination of the excised tumor included standard and immunohistochemical staining of formaldehyde-fixed, paraffin-embedded tissue. RESULTS: Histopathologic study showed the characteristic morphology of GCT. Immunohistochemistry was strongly positive for vimentin, weakly and partly positive for neuron-specific enolase, and negative for S-100 and HAM-56. CONCLUSIONS: Granular cell tumor must be added to the differential diagnosis of epibulbar masses. Immunohistochemistry of the tumor in this case suggests an uncommitted mesenchymal cell origin.

Conjunctival neurilemoma. Report of 3 cases.

Neurilemoma (schwannoma) of the conjunctiva is a rare ocular tumor. We report 3 cases of benign conjunctival neurilemoma occurring in women without other ocular or systemic disease. Two of these tumors arose from the bulbar conjunctiva and 1 from the tarsal conjunctiva. Immunoperoxidase staining for S-100 protein was positive in each case.

Ganciclovir intraocular implant. A clinicopathologic study.

BACKGROUND: Surgical implantation of the intraocular sustained-release ganciclovir device is a safe and effective treatment for cytomegalovirus (CMV) retinitis. Previous histopathologic studies on eyes containing such implants have been limited by the necessity of removing the device before processing. Microtome sectioning of hard plastics within paraffin-embedded blocks is infeasible, and the anatomic relations of implant to eye are destroyed. METHODS: The authors studied four eyes from three patients who had undergone implant insertion. Globes with implants in place were fixed in neutral 10% formation, embedded in methylmethacrylate, sectioned on a special microtome, and stained with hematoxylin-eosin. RESULTS: After methacrylate embedding, the precise anatomic relations of the implant to the neighboring uveoscleral coats were preserved. In two eyes, the suture tab of the implant protruded through the sclera, exiting subconjunctivally. In two eyes, the implant was totally intravitreal. In all patients, the device was supported by fibrous tissue which emanated from a surgical coloboma of the pars plana ciliaris. Focal granulomatous inflammation adjoined suture and implant materials but no other inflammation or deleterious effects on the ocular structures were noted. CONCLUSION: This report is the first to document the intraocular histopathology of the ganciclovir implant. The subconjunctival location, enhancing the potential for endophthalmitis, may be avoided by trimming of the suture tab close to the anchoring suture and not tying it too tightly. Methylmethacrylate embedding is a useful technique for preserving the microanatomy of intraocular implants.

Calcific phacolysis. Salvageable vision following treatment.

Calcific phacolysis has been previously described histopathologically in the enucleated eyes of three patients with unilateral posttraumatic total blindness. Each eye showed dissolution of a mature cataractous lens with dispersion of calcific lens material throughout the globe. We studied a patient in whom the signs of calcific phacolysis developed 19 months following intraoperative dislocation of a cataract into the vitreous. Partial removal of calcific particles was achieved by subtotal vitrectomy and lensectomy, with subsequent penetrating keratoplasty. Corneal histopathological findings showed a deposition of calcified lens particles between Descemet's membrane and retrocorneal fibrous membrane. Despite diffuse retinal calcification, the patient's visual acuity was 20/400. To our knowledge, this is the first report of calcific phacolysis occurring after surgical dislocation of a cataract into the vitreous and wherein treatment resulted in some preservation of vision. Early diagnosis and aggressive therapy may improve the visual prognosis in this condition.

Pyogenic granuloma after transconjunctival blepharoplasty: a case report.

This is the first known report of a relatively large postoperative pyogenic granuloma developing after a nonsutured transconjunctival blepharoplasty. Inflammation and separation or malapposition of the conjunctival wound edges probably permitted the lesion to proliferate in the inferior fornix. No foreign material could be implicated because no suture was used to close this incision. Additionally, Polydek suture material (braided polyester fiber) was associated with the complication of a suture tract and granuloma when used for a tarsal suspension procedure for ectropion repair in this patient.

Calcific phacolysis.

BACKGROUND AND METHODS: The authors report the clinical and ocular histopathologic findings in three patients with longstanding unilateral post-traumatic blindness. After one or more decades, acute pain associated with conjunctival hyperemia and apparent keratoprecipitates or a hypopyon developed in the affected eye of each individual. Phacoanaphylaxis was diagnosed preoperatively in two patients. RESULTS: Calcified granular lens fragments were dispersed throughout all three eyes. The anterior chamber in all patients contained extracellular calcified lens particles, but only one eye contained conspicuous macrophages. Two eyes showed elevated intraocular pressure (IOP), and in one patient calcified particles extended into a glaucomatous optic nerve head. CONCLUSION: To the authors' knowledge, this is the first report describing a rare condition involving the intraocular dispersal of calcified lens particles after disruption of the lens capsule. The authors have designated this entity as calcific phacolysis.

Periocular xanthogranulomas associated with severe adult-onset asthma.

This article describes six patients who presented, usually bilaterally, with yellow-orange, elevated, indurated, and nonulcerated xanthomatous eyelid lesions, typically extending into the anterior orbital fat, and sometimes involving the extraocular muscles and the lacrimal gland. Because the eyelids remained intact and because the process did not reach the deep orbital and perioptic connective tissues, visual acuity was well preserved. There is cosmetic morbidity and occasionally motility restriction with advancing involvement of the extraocular muscles. All patients had variably severe adult-onset asthma that required treatment with systemic prednisone and inhalants. No evidence of Erdheim-Chester disease was found in any patient, but the appearance in one patient, after 25 years of follow-up, of a separate subcutaneous necrobiotic xanthogranulomatous lesion in the mandibular region with an associated paraproteinemia, suggests that at least some of our cases might be a mild form of necrobiotic xanthogranuloma. For this reason, we would suggest repeated periodic serum protein immunoelectrophoretic studies as well as evaluation for lymphoma. Therapy probably should consist of low doses of periorbital radiotherapy coupled with high doses of corticosteroids. Should this not be successful, then systemic administration of corticosteroids with chemotherapeutic agents might be efficacious, as in necrobiotic xanthogranuloma.

Epibulbar molluscum contagiosum in acquired immune deficiency syndrome. Case report and review of the literature.

BACKGROUND: While molluscum contagiosum of the eyelid skin is commonly complicated by conjunctivitis, primary involvement of the conjunctiva or cornea by molluscum lesions is exceedingly rare. The authors studied a 34-year-old man with acquired immune deficiency syndrome (AIDS) in whom multiple molluscum lesions of the lids and a single nodule of the limbus developed. METHODS: The nodular lesion was excised from the limbus and processed for histologic examination by light microscopy. Pertinent literature concerning epibulbar molluscum contagiosum was reviewed. RESULTS: Histopathology of the excised lesion showed molluscum bodies within the acanthotic, hyperkeratotic conjunctival epithelium with surrounding chronic, nongranulomatous inflammation. Only 10 previous cases of conjunctival or corneal primary lesions have been reported, half of which showed associated cutaneous involvement. Lesions tended to be single, noninflamed, dome-shaped, and umbilicated, often with a yellowish central core. Patients were otherwise well and ranged in age from 3 to 55 years. Simple excision was effective in eradicating the lesions. CONCLUSION: Primary epibulbar molluscum contagiosum is rare. Although cutaneous molluscum is common in AIDS, this report is the first to document conjunctival molluscum in a patient with AIDS.

Cryptococcosis of the anterior segment in acquired immune deficiency syndrome.

Cryptococcosis is a rare form of human ocular infection, usually occurring in immunocompromised patients. Unilateral or bilateral posterior segment involvement is the rule. The authors describe a unique case of intraocular cryptococcosis presenting as an iris inflammatory mass in a patient with acquired immune deficiency syndrome. Diagnosis was established by anterior chamber paracentesis and confirmed by histopathologic examination of the enucleated eye.

Microsporidial keratoconjunctivitis in acquired immunodeficiency syndrome.

We describe three patients with acquired immunodeficiency syndrome who presented with a bilateral coarse superficial epithelial keratitis due to infection with the protozoal parasite Microspora, Encephalitozoon cuniculi. Despite the extent of the corneal surface disease, conjunctival inflammation was minimal. Visual acuity ranged from 20/20 to 20/200. In one patient, the keratitis was complicated by the development of a surface defect with secondary Pseudomonas species infection. All patients had a history of exposure to household pets. Standard cultures were negative. Diagnosis was established in two of the three cases based on characteristic appearance of the protozoan in conjunctival scrapings. Electron microscopy of a conjunctival biopsy specimen in one patient confirmed the species. No recognized effective treatment is available for this infection.

Congenital idiopathic corneal endotheliopathy.

Two unrelated boys had a history of bilateral corneal clouding at birth following uncomplicated full-term gestations and spontaneous vaginal deliveries (without forceps). Clinical examinations disclosed bilateral corneal edema, no inflammation, and normal intraocular pressures. There was no history of similarly affected family members. The patients underwent penetrating keratoplasty at ages 4 months (patient 1) and 12 years (patient 2). Light and electron microscopic studies of the corneal buttons from both patients revealed areas of degeneration of the endothelium and separation of rounded endothelial cells. The morphologic features were strikingly similar to those in two acquired forms of corneal disorders--autoimmune endotheliopathy and "acute endotheliitis." Immunocytologic and in situ hybridization studies for herpes simplex virus were not consistent with either productive or latent corneal infection. Ultrastructural changes in Descemet's membrane reflect delayed or abnormal development of the postnatal nonbanded layer in patients 1 and 2, respectively. These suggest an intrauterine insult that resulted in endothelial dysfunction. The histologic and ultrastructural features of these two congenital cases are not typical of those seen in any of the recognized causes of congenital corneal clouding. We propose that these cases represent a unique congenital corneal endotheliopathy of undetermined origin.

Sympathetic ophthalmia.

Sympathetic ophthalmia is a bilateral diffuse granulomatous panuveitis occurring after accidental or surgical penetrating injury to one eye. Onset of sympathetic ophthalmia may occur as early as 5 days or as late as 42 years following the injury.