Sentinel Node Biopsy for Conjunctival Melanoma; Single Centre Experience and Review of Current Literature.

PURPOSE: To evaluate the role of sentinel lymph node (SLN) biopsy in patients with conjuctival melanoma (CjM). STUDY DESIGN: Retrospective observational cohort study and literature review. SUBJECTS: Slovenian patients with CjM are included in the study. METHODS: Prospectively collected data of CjM patients treated from June 2005 to December 2016 were retrospectively analyzed. MAIN OUTCOME MEASURES: The numbers of SLN biopsy procedures, positive and false positive SLN, and local and regional relapses have been described together with overall survival. RESULTS: From June 2005 until December 2016, 24 patients with CjM were treated. The median follow-up time was 65.3 months. The mean Breslow thickness was 1.5 mm (sd = 1.8 mm), and ulceration was present in 29% of cases. Altogether, 14/24 (58%) SLN biopsy procedures were performed. SLN was positive in 2/14 (14%) cases. The estimated 5-year overall survival (OS) of the group was 72.5%, with a median survival of 151 months (95% CI 77-224). From January 2013 to January 2020, five (5/140, 3%) authors reported results comparable to our study. CONCLUSION: Our results confirm that CjM is a rare disease with approximately 14% of positive SLN. At the moment, there are no firm conclusions regarding who would benefit most from SLN biopsy or whether or not CLND should be offered. Data from literature emphasize the need for consistent and uniform staging and future multicentric studies.

PRAME expression in melanocytic lesions of the conjunctiva.

AIMS: PRAME (PReferentially expressed Antigen in MElanoma) is a tumour-associated antigen that is preferentially strongly expressed in most cutaneous melanomas but not or only focally in naevi. Our aim was to evaluate PRAME expression in melanocytic lesions of the conjunctiva. METHODS AND RESULTS: Surgical specimens of 114 conjunctival melanocytic naevi of different types (including 67 common, 25 combined deep penetrating and 21 inflamed juvenile naevi), 30 invasive melanomas, 10 in-situ melanomas, 23 primary acquired melanoses (PAM) without atypia and 11 PAM with atypia were analysed for PRAME expression by immunohistochemistry. Nuclear positivity for PRAME in melanocytes was assessed as the percentage of positive nuclei: negative (0%), 1+ (1-25%), 2+ (26-50%), 3+ (51-75%) and 4+ (> 75%). In 113 of 114 conjunctival melanocytic naevi, PRAME was either completely negative or focally 1+ positive. Diffuse 4+ PRAME expression was identified in 17 of 30 (57%) invasive melanomas, seven of 10 (70%) in-situ melanomas, four of five (80%) PAM with severe atypia, none of three PAM with moderate atypia, none of three PAM with mild atypia, one of 23 (4%) PAM without atypia and none of 114 naevi. Diffuse 4+ PRAME expression in invasive melanomas correlated with a higher mitotic count but was not related to age and gender of the patients, Breslow thickness, location or mutational status. CONCLUSION: Diffuse 4+ PRAME positivity is highly specific for malignant conjunctival melanocytic lesions. PRAME is therefore a useful ancillary marker to support the diagnosis of a suspected conjunctival melanoma.

Combined deep penetrating nevi of the conjunctiva are relatively common lesions characterised by BRAFV600E mutation and activation of the beta catenin pathway: a clinicopathological analysis of 34 lesions.

BACKGROUND: Deep penetrating nevus (DPN) is not a widely recognised lesion on the conjunctiva and only a few cases consistent with combined DPN have been reported. METHODS: A review of all excised and histopathologically diagnosed conjunctival melanocytic lesions between 2003 and 2018 was performed in order to identify melanocytic nevi morphologically consistent with DPN. RESULTS: Thirty-four DPN were identified among 361 histopathologically examined conjunctival nevi (9.4%), including 33 (97%) combined with a common nevus and 1 (3%) pure DPN. The patients' age ranged from 7 to 51 years (median, 22 years). Clinically, 21 of 29 (72%) lesions with available data were darkly pigmented, and an increase in size and/or pigmentation was noted in 13 of 18 (72%) lesions with known history. All 24 lesions in which an immunohistochemical analysis was possible were diffusely positive for BRAFV600E (in DPN and common nevus components) and showed a diffuse nuclear positivity for beta catenin and cyclin D1 in the DPN component. None of the 21 lesions with available follow-up data recurred during a follow-up period from 0.3 to 16.3 years (median, 7.5 years). CONCLUSIONS: DPN of the conjunctiva is a relatively common lesion and usually presents as a combined nevus. Genetically, DPN of the conjunctiva are characterised by a combination of BRAFV600E mutation and activation of the beta catenin pathway. Recognition of DPN of the conjunctiva is important in order not to overdiagnose it as a melanoma, and to explain its potential atypical clinical features. DPN of the conjunctiva seems to be a benign lesion.

Management of Traumatic Lower-Eyelid Avulsion and Complete Loss of the Lacrimal Canaliculus: A Case Report.

Eyelid injuries commonly occur as a result of blunt or sharp periocular trauma. When the medial canthal region is affected, injury can be associated with canalicular laceration or avulsion. Complete loss of the lacrimal canaliculus associated with epiphora is a challenging condition, and reconstruction often leads to poor and disappointing results. Surgical treatment of a patient following blunt facial trauma that resulted in medial avulsion of the lower eyelid with tissue loss is presented. A 72-year-old male patient presented with avulsion of the medial 2/3 of the left lower eyelid together with complete loss of the inferior canaliculus. Eyelid tissue was not preserved. The inferior canaliculus was reconstructed using a Mini Monoka (FCI Ophthalmics), which was sutured under the caruncle and was enveloped with surrounding tissue. Loss of the lower eyelid tissue was substituted with a medially shifted Hughes flap and free skin transplant from the ipsilateral upper eyelid. The Hughes flap was divided after 2 weeks, while the Mini Monoka extruded spontaneously approximately 3 months after the injury. Ten months after the injury, the opening of the reconstructed lower canaliculus was positioned under the caruncle and was patent on probing and syringing. The patient is without epiphora and is satisfied with the functional and aesthetic result. In eyelid injuries we follow certain rules of reconstruction, but each case is unique and requires some inventiveness. The idea of inferior canalicular reconstruction following lower-eyelid avulsion with tissue loss is presented.

Optical coherence tomography for an in-vivo study of posterior-capsule-opacification types and their influence on the total-pulse energy required for Nd:YAG capsulotomy: a case series.

BACKGROUND: Posterior capsule opacification (PCO) is the most common post-operative complication associated with cataract surgery and is mostly treated with Nd:YAG laser capsulotomy. Here, we demonstrate the use of high-resolution spectral-domain optical coherence tomography (OCT) as a technique for PCO analysis. Additionally, we evaluate the influence of PCO types and the distance between the intraocular lens (IOL) and the posterior capsule (PC), i.e., the IOL/PC distance, on the total-pulse energy required for the Nd:YAG laser posterior capsulotomy. METHODS: 47 eyes with PCO scheduled for the Nd:YAG procedure were examined and divided into four categories: fibrosis, pearl, mixed type and late-postoperative capsular bag distension syndrome. Using custom-made computer software for OCT image analysis, the IOL/PC distances in two dimensions were measured. The IOL/PC distances were compared with those of a control group of 15 eyes without PCO. The influence of the different PCO types and the IOL/PC distance on the total-pulse energy required for the Nd:YAG procedure was analyzed. RESULTS: The total-pulse energy required for a laser capsulotomy differs significantly between PCO types (p = 0.005, Kruskal-Wallis test). The highest energy was required for the fibrosis PCO type, followed by mixed, pearl and late-postoperative capsular bag distension syndrome. The IOL/PC distance also significantly influenced the total-pulse energy required for laser capsulotomy (p = 0.028, linear regression). Lower total-pulse energy was expected for a larger IOL/PC distance. CONCLUSIONS: Our study indicates that the PCO types and the IOL/PC distance influence the total-pulse energy required for Nd:YAG capsulotomy. The presented OCT method has the potential to become an additional tool for PCO characterization. Our results are important for a better understanding of the photodisruptive mechanisms in Nd:YAG capsulotomy.