Cytology of metastatic cutaneous melanoma to the vitreous and retina.

PURPOSE: The authors report one patient with definitive and one patient with presumed metastatic cutaneous malignant melanoma to the vitreous and retina diagnosed by cytologic evaluation of the vitreous and subretinal fluid. METHODS: A diagnostic vitrectomy was performed on two patients with atypical vitreous and retinal infiltrates. Additionally, subretinal fluid was obtained from the second patient. The specimens were processed for cytologic examination. The cytology specimens were compared with previously excised cutaneous melanomas from the patients. RESULTS: Examination results showed cells in the vitreous with high nuclear-to-cytoplasm ratios, coarse chromatin, and intracytoplasmic melanin pigment granules. The cytologic features were compared with the cutaneous malignant melanoma, and a diagnosis of metastatic melanoma was made. One patient eventually required enucleation, and the metastatic tumor in the other patient was controlled by local irradiation. CONCLUSIONS: Cytologic evaluation of the vitreous and subretinal fluid is helpful in establishing a diagnosis in patients with metastatic cutaneous melanoma to the vitreous and retina.

Toxoplasma gondii retinochoroiditis after liver transplantation.

A 48-year-old woman with a previous a liver transplant and a cataract extraction developed a necrotizing retinochoroiditis in her right eye. Vitreous and serum cultures failed to yield a causative organism. As the retinochoroiditis progressed, visual acuity worsened to the point of no light perception, and the eye became blind and painful. An enucleation was performed and histologic examination showed Toxoplasma gondii necrotizing retinochoroiditis. This is the first histologically documented case of T. gondii retinochoroiditis after liver transplantation. The fulminant clinicopathologic appearance of the retinochoroiditis is similar to that previously reported to occur in acquired immune deficiency syndrome (AIDS) and other forms of immunosuppression, unlike the reactivated congenital retinochoroiditis that occurs in immunocompetent patients.

Choroidal melanoma with pigment dispersion in vitreous and melanomalytic glaucoma.

A 39-year-old black man underwent enucleation of the left eye because of poor vision, ocular pain, and intractable glaucoma secondary to a choroidal tumor. Two diagnostic vitrectomies, performed 11 and 7 months before enucleation, had failed to disclose the proper diagnosis. Histologic diagnosis was necrotic malignant melanoma of the choroid with melanocytoma cells, extensive pigment dispersion throughout the eye, and melanomalytic glaucoma. Possible mechanisms of tumor necrosis are reviewed.

Ophthalmomyiasis interna causing visual loss.

Ophthalmomyiasis interna caused severe intraocular inflammation and loss of vision in two eyes. In the first eye, the organism was found in the vitreous and created a severe uveitis; a second-stage larva of Hypoderma lineatum was later removed from the anterior chamber. Phthisis bulbi ensued with loss of all vision. In a second eye, a subretinal maggot was observed to produce tracks in the pigment epithelium, with subretinal and vitreous hemorrhage. Severe uveitis and traction retinal detachment later developed. Despite successful reattachment of the retina, visual acuity remained only light perception. These cases demonstrate that ophthalmomyiasis interna is not always a benign condition.

Results of surgery for ocular Toxocara canis.

It has been shown that the diagnosis of ocular Toxocara canis is highly accurate when the typical clinical findings are associated with a positive ELISA titer in the serum of 1:8 or greater. The inflammatory reaction in this disorder can be devastating and not infrequently leads to a tractional detachment of the posterior pole or a rhegmatogenous detachment and/or a progressive cyclitic membrane leading to phthisis bulbi. We have recently performed vitreoretinal surgery on 17 patients with complications secondary to ocular T canis. Fifteen patients had stability or improvement in visual acuity, and one patient had a decrease in visual acuity. There were no surgical complications present. The clinical features, operative techniques used, and postoperative course are summarized, and the indications for the used of various surgical procedures are presented.

Applanation-Schiøtz disparity after retinal detachment surgery utilizing cryopexy.

Previous reports of applanation-Schiøtz disparity following retinal detachment surgery involved patients whose detachments were treated with diathermy and scleral buckling. In 73 patients with retinal detachments treated by cryopexy and scleral buckling, applanation and Schiøtz pressures were measured before and after surgery. In the postoperative period, applanation tension values were significantly higher than Schiøtz values in the operated eyes only; the mean disparity was 6 mm Hg, with a range of 0 to 14 mm Hg. Sex, age, surgical aphakia, and length of time after surgery did not influence the data. Placement of the buckle, rather than extent of cryopexy, appeared to be the main factor in producing this disparity. Ophthalmologists who utilize the Schiøtz tonometer should be aware of the various conditions, including retinal detachment surgery, which produce low ocular rigidity.

ELISA for diagnosis of ocular toxocariasis.

The enzyme-linked immunosorbed assay test was positive in 37 of 41 patients (90%) suspected of having clinical Toxocara infections. The antigen used in this test is prepared from the Toxocara egg and is felt to be extremely specific in making the diagnosis. The prevalence of Toxocara infection is much greater than previously believed. It is hoped that this test will help the surgeon fell more secure in not enucleating eyes containing masses suggestive of Toxocara infection.

Rhegmatogenous retinal detachment following chorioretinal inflammatory disease.

Preexisting ocular inflammatory disease was responsible for 44 cases (1.7%) of rhegmatogenous retinal detachment in a large series of consecutive retinal detachments. Characteristics of retinal detachments following ocular inflammatory disease include a longer duration of the detachment, fewer observable retinal breaks, a higher incidence of visible vitreous membranes and preoperative macular puckers, a younger age distribution, and a higher incidence of phakic patients. In comparing the group of postinflammatory rhegmatogenous retinal detachments with detachments not associated with inflammation, the following characteristics did not show any statistically significant difference: sex, the eye involved, the status of the ciliary epithelium, the presence or types of retinal folds, the rate of operative complications, or the rate of reattachment at six months.

The use of the 32P test in the management of malignant melanoma of the choroid: a five-year follow-up study.

We have presented mortality, clinical, and histopathologic data on a consecutive group of patients with malignant choroidal melanoma studied by a radioactive phosphorus uptake test. The mortality of 14% is the lowest reported in the literature (Table 11) and suggests that early diagnosis followed by prompt enucleation affords the patient a favorable prognosis. There is no evidence to suggest that the surgical manipulations involved expose the patient to added risks. Factors of importance regarding prognosis of malignant melanoma include tumor size, cell type, and presence or absence of extrascleral extension. Of these, we believe that cell type is the most important factor. Our data to date do not permit us to predict from the 32P tests the prognosis for patient survival.

Clinical experience with presumed hemangioma of the choroid: radioactive phosphorus uptake studies as an aid in differential diagnosis.

A total of 27 cases of choroidal hemangioma was evaluated with radioactive phosphorus uptake studies. In each case the diagnosis of malignant melanoma was initially entertained, but the 32P test was unequivocally negative in every instance. Follow-up studies in every case have supported the clinical diagnosis. In 22 patients, the lesion was treated with photocoagulation, and in every treated case the serous macular detachment disappeared. The importance of early and correct clinical diagnosis is stressed, since these are salvageable and potentially useful seeing eyes.

Infections after retinal detachment surgery.

The signs and symptoms of infection after retinal detachment surgery may be subtle and frequently are overlooked during early stages. A retrospective analysis of 3,334 consecutive procedures for retinal detachment revealed 37 cases (1.1%) with postoperative infection. In 13 of these a scleral abscess and a form of endophthalmitis developed, whereas 24 had no evidence of vitreous involvement and were classified as the granuloma type. Only 43% of infected patients had positive cultures. Analysis of changes in infection rate involved comparison with changes over the years in suture material, implant material, performance of scleral undermining, drainage of subretinal fluid, number of previous surgical procedures, age of patient, use of diathermy or cryotherapy, and type of prophylactic antibiotic therapy. During the 13 years studied the rate of infection decreased from 2.2% to 0.7%. Treatment requires surgical removal of all foreign material before the inflammatory signs can be cleared. Concurrent appropriate antibiotic therapy also is recommended. With this form of treatment, all but one patient showed a satisfactory response, although 4 patients still have mild conjunctival congestion.

The significance of the 32-P uptake test in the diagnosis of posterior uveal melanomas.

One hundred consecutive histologically confirmed malignant melanomas of the posterior uvea; on which the 32-P test was performed prior to enucleation, were classified according to cell type. The 32-P uptake results of the pure spindle cell melanomas were compared with the results in the mixed and epithelioid cell tumors. There appears to be no relationship between 32-P uptake and cell type using the Callender classification. The 32-P uptake results in the 100 melanomas were then compared with the results in teh 30 benign lesions which are known to simulate melanoma occasionally. There was a significant difference in 32-P uptake between the benign and malignant lesions, and no false-positive results were encountered. The importance of the 32-P test as a diagnostic adjunct for malignant intraocular tumors is emphasized.