Orbital solitary fibrous tumor: radiographic and histopathologic correlations.

OBJECTIVE: To correlate the clinicopathologic and radiographic features characteristic of orbital solitary fibrous tumor (SFT). METHODS: The diagnostic features and clinical outcome of seven adults with orbital SFT are retrospectively outlined. Orbital imaging was performed by ultrasonography, computed tomography, or magnetic resonance imaging. Some cases were imaged by multiple modalities. Histopathologic examination of each tumor specimen included standard light and immunohistochemical stains. RESULTS: Heterogeneous internal composition was better appreciated on magnetic resonance imaging than on computed tomography. All cases undergoing magnetic resonance imaging showed T1 isointensity and T2 hypointensity relative to gray matter. Strong, generalized immunohistochemical reactivity to vimentin and CD34 validated the diagnosis of SFT and differentiated the specimens from other spindle cell neoplasms. After complete tumor resection, our patients remain tumor free with postoperative intervals of 15 to 45 months. CONCLUSIONS: Solitary fibrous tumor has now been reported in 26 orbits. No physical finding is pathognomonic, but several imaging traits are highly characteristic. Intralesional image heterogeneity and a predominantly low T2 signal intensity are distinctive of SFT. Complete tumor resection and immunohistologic specimen evaluation are emphasized. Clinicians should consider the diagnosis of SFT when confronted with an adult patient having an orbital soft tissue mass demonstrating the distinctive magnetic resonance imaging findings.

Ultrasonographic evidence of a mushroom-shaped choroidal metastasis.

PURPOSE: To describe the evolution of a "collar-button" or mushroom-shaped choroidal metastasis. METHODS: Case report. RESULTS: A 52-year-old woman with known primary colon cancer and widespread extraocular metastases developed bilateral choroidal masses with neurosensory retinal detachments. Clinical and ultrasound evaluation demonstrated evolution of a choroidal metastasis with a "collar-button" configuration in the right eye. CONCLUSION: A choroidal metastasis may develop a mushroom-shaped configuration. This "collar-button" configuration is not pathognomonic for choroidal melanoma.

Choroidal neovascularization with granulomatous inflammation in ocular histoplasmosis syndrome.

PURPOSE: To report pathologic examination of an excised choroidal neovascular membrane in a patient with ocular histoplasmosis syndrome that demonstrated granulomatous inflammation. METHOD: Case report. A 50-year-old woman with sudden vision loss in her left eye demonstrated clinical and fluorescein angiographic findings characteristic of choroidal neovascularization secondary to ocular histoplasmosis syndrome. RESULTS: Histopathologic examination of the surgically excised choroidal neovascular membrane disclosed granulomatous inflammation. CONCLUSIONS: This case suggests an important role of mononuclear phagocytic cells as primary mediators of angiogenesis or modifiers of choroidal neovascularization. This association of choroidal neovascularization with granulomatous inflammation did not respond to treatment with systemic corticosteroids.

Localized neurofibroma of the orbit: a radiographic and histopathologic study.

PURPOSE: To demonstrate the clinical, radiographic, intraoperative and histopathologic presentation of a localized neurofibroma of the orbit. METHODS: Clinicopathologic case report. RESULTS: A 25-year-old man was examined for inferior displacement of the right globe. Physical examination and neuro-imaging identified a localized solid tissue mass of the superior orbit. Histopathologic evaluation after complete surgical resection proved the lesion to be a localized neurofibroma. CONCLUSIONS: The patient's history, clinical presentation, and imaging studies were strongly characteristic for this infrequently encountered orbital lesion. Several imaging features, including multilobulation, multiplicity, ring-configured contrast enhancement, and magnetic resonance imaging (MRI) signal intensity heterogeneity, when present in combination, may be reasonably diagnostic of this tumor.

Ocular disease in the diabetic elderly.

Diabetic retinopathy is a significant complication for the older diabetic patient. Visual loss often can be prevented, ameliorated, or delayed, but timely referral is key. Even those who cannot be helped medically or surgically can be assisted in making use of remaining visual function and other remaining senses. Many patients are not screened or referred according to American College of Physicians/American Academy of Ophthalmology guidelines and thus are not receiving the best possible care.

Cutaneous malignant melanoma metastatic to the eyelid.

Cutaneous malignant melanoma metastatic to the choroid, orbit, or vitreous is rare. Metastatic lesions to the eyelid are rare as well. The authors report a case of malignant melanoma metastatic to the eyelid. This was the first sign of tumor recurrence in a patient who was thought to have been successfully treated for a melanoma of the back 3 years previously. The patient died 6 weeks after diagnosis of the eyelid lesion. In the presence of known malignancy, metastasis must be suspected in new eyelid lesions.

Transconjunctival mitomycin C as an adjunct to conventional glaucoma filtration surgery in rabbits.

PURPOSE: Subconjunctival mitomycin C has been used in glaucoma filtration surgery with success. A prospective, randomized, masked, placebo-controlled study was performed to evaluate whether single transconjunctival mitomycin C applied either preoperatively or postoperatively would enhance the success of filtration surgery in rabbits. METHODS: Two groups of 5 rabbits were studied. In Group I, a Weck-Cel sponge soaked in 0.5 mg/ml mitomycin C was applied transconjunctively for 7 minutes immediately before a full thickness filtering procedure. The other eye was treated similarly with a sponge soaked in balanced salt solution. Group II first underwent filtration surgery followed by treatment with either mitomycin-c or balanced salt solution 3 days later. Postoperative intraocular pressure, bleb status, and complications were evaluated. Treatment failure was defined as postoperative pressure within 4 mmHg of that determined preoperatively or the absence of bleb formation. RESULTS: In Group I, mean time to failure (+/- SD) was significantly longer (p = 0.03) in experimental eyes (30 +/- 15.1 days) than control eyes (8.6 +/- 0.8 days). In Group II, the time to failure was 12.4 (+/- 2.6) days versus 9.6 (+/- 2.5) days in the experimental and control eyes respectively, but this was not statistically significant (p = 0.10). Transient limbal vascularization and corneal haze were seen in all experimental eyes. Serious complications included late bleb rupture in eyes pretreated with mitomycin C (all eyes in Group I) and corneal decompensation (one mitomycin-c eye). CONCLUSIONS: This study demonstrates that a single preoperative tranconjunctival application of mitomycin-c is more effective at the time of surgery than an application applied in the intermediate postoperative period. Additional studies are needed, however, to further refine both the dose and timing of mitomycin-c application during filtration surgery.

Osteogenin-enhanced bone-specific differentiation in hydroxyapatite orbital implants.

Hydroxyapatite orbital implants undergo early ingrowth of fibrovascular tissue after enucleation. This animal study determined whether control and osteogenin-impregnated hydroxyapatite orbital implants vary in their osteogenic response at 6 and 52 weeks. Rabbits underwent enucleation with implantation of control or osteogenin-impregnated hydroxyapatite spheres. Light microscopy determined fibrovascular ingrowth, and histomorphometry quantitated the amount of bone produced. Osteogenin implants vascularized at a faster rate and contained bony foci by 6 weeks that became confluent at 1 year. Spontaneous osteogenesis was not seen in control animals at 6 weeks. After 1 year they contained bone, although less than in the osteogenin implants. Mixed cell inflammation was observed at the hydroxyapatite-tissue interface in both groups. No inflammation was noted at the interface of hydroxyapatite and bone. These are the first controlled observations that bone-specific differentiation occurs in the pores of spherical hydroxyapatite implants within the soft tissues of the socket. This vascularized process can be enhanced with osteogenin to occur earlier and more uniformly in the implants at one year.

Characterization of a central corneal cloudiness sharing features of posterior crocodile shagreen and central cloud dystrophy of François.

A 56-year-old black woman with full-thickness mosaic pattern central corneal cloudiness, similar in appearance to central cloudy dystrophy and posterior crocodile shagreen, underwent corneal transplantation. Atypical features included decreased vision, photophobia, and epithelial involvement, with occasional foreign body sensation. Numerous 0.5-2.0-micron-diameter lacunae were present in the corneal stroma and Bowman's layer, and a saw-toothed lamellar pattern was often evident in the corneal stroma. Soybean agglutinin (SBA), a lectin that binds N-acetyl-galactosamine residues, bound diffusely to stromal foci exhibiting similar size and distribution to the lacunae observed by electron microscopy. An absence of histochemically detectable lipid associated with these lacunae suggests that SBA reacted with glycoconjugates other than glycolipids. Biochemical analyses revealed similar contents of keratan sulfate, chondroitin/dermatan sulfate, and collagen as in normal controls, suggesting that the SBA binding moieties are associated with a glycoprotein or proteoglycan that is structurally or compositionally different from those found in normal cornea. This patient may represent an extreme variant of Vogt's or François central corneal clouding or a previously undescribed corneal dystrophy.

Histological and radiological analyses of hydroxyapatite orbital implants in rabbits.

To date, only anectodal clinical data exist pertaining to the histological changes of hydroxyapatite within an enucleated socket. This study was conducted to determine the histological and radiological changes in a coralline hydroxyapatite sphere placed into the central socket, in a controlled fashion. Rabbits underwent simple enucleation with implantation of an autologous sclera-wrapped hydroxyapatite spheres with extraocular muscle reattachment. Preoperatively, the mineral density of each sphere was determined using quantitative computed tomography (CT) that was repeated 2- and 6 weeks postoperatively. The implants were harvested at 2- and 6 weeks and submitted for light and electron microscopic analysis. The results demonstrated a uniform influx of fibrovascular tissue that did not reach the center of the implant, even at 6 weeks. A marked mixed-cell inflammatory response was noted at the interface between the fibrovascular tissue and the hydroxyapatite. Giant cells were noted only at the scleral windows. This study demonstrated that the early response to hydroxyapatite implants was fibrovascular ingrowth with mixed-cell inflammation. These histological observations correlated with findings observed with quantitative CT. Quantitative CT appears to be an ideal modality for observing the early temporal tissue density changes in hydroxyapatite implants.

Sebaceous gland hyperplasia of the caruncle.

The caruncle is an ocular adnexal structure composed of both mucosal and epidermal elements. Consequently, a number of benign and malignant lesions of epithelial and supportive tissues may arise in this area. Lesions of the caruncle are rarely reported, and their appropriate diagnosis and management may be uncertain. One such lesion is sebaceous gland hyperplasia. Of all caruncular lesions that undergo excision, sebaceous gland hyperplasia is infrequently encountered. We have observed four cases of sebaceous gland hyperplasia of the caruncle over the last 2 years. Our observations suggest that this lesion has a characteristic onset, progression, and appearance, enabling diagnosis to be made on clinical examination alone. Excision is indicated only if there is an atypical presentation, a carcinoma is suspected, if mass effect causes discomfort or epiphora, or if cosmesis is an issue.

Stromal healing following explantation of an ICR (intrastromal corneal ring) from a nonfunctional human eye.

We examined the cornea of the nonfunctional left eye of a 46-year-old man, which was enucleated 8 months following explantation of an ICR (Intrastromal Corneal Ring). Corneal haze was confined to the midstroma, in the region of the tissue from which the ICR had been removed. Stromal tissue in this area was subtly compressed and irregular. Electron microscopy in conjunction with cuprolinic blue staining demonstrated an unremarkable proteoglycan population and several areas of slight collagen disruption at midstromal depth at the site of the previously implanted ICR. We conclude that disruptions of the corneal stroma that remain 8 months following explantation of an ICR are minimal.

Comparative Efficacy of the SLT versus LASAG Nd: YAG Delivery Systems in Rabbits.

PURPOSE: The efficacy of two types of contact transscleral Nd:YAG laser delivery systems, a synthetic sapphire-tipped laser probe connected to a Surgical Laser Technologies (SLT) laser and a quartz fiberoptic tip connected to a LASAG Microrupter III, was compared. METHOD: A total of nine pigmented rabbits underwent transscleral LASAG cycloablation in one eye (3.2 W, 0.5 s); an additional eight rabbits underwent Surgical Laser Technologies cycloablation (3.0 W, 0.5 s). RESULTS: The maximum difference in intraocular pressure between the experimental versus fellow eyes was - 15.09 mm Hg (+/-0.25) with the LASAG and -13.16 mm Hg (+/-3.12) with the SLT laser; in both delivery systems, this difference was achieved 4 days postoperatively. The differences between the two groups in duration of pressure reduction was not statistically significant (p = 0.83). CONCLUSION: These data suggest that these delivery systems are equally effective in lowering intraocular pressure in rabbits. Histological changes of the ciliary processes and adjacent ocular tissue are presented.

Invasive squamous cell carcinoma arising from asymptomatic choristomatous cysts of the orbit. Two cases and a review of the literature.

BACKGROUND: Epithelial choristomatous cysts are common orbital lesions, the most frequent of which are dermoid or epidermoid tumors. Massive enlargement or extraorbital extension of these benign lesions may occur. Malignant transformation of the epithelial lining of epidermoid cysts is rarely reported. METHODS: Two patients are presented in whom the epithelial lining of a previously asymptomatic choristomatous cyst of the orbit underwent malignant transformation to produce invasive squamous cell carcinoma. The unusual origin and clinical presentation of the lesions caused a delay in the diagnosis and therapy in both patients. Metastatic workup was negative in both patients, who underwent resection of their tumors via orbital exenteration with craniofacial resection. Reported cases of malignant transformation in analogous choristomatous cysts elsewhere in the cranium are reviewed. RESULTS: One patient is alive and well without recurrent disease 40 months postoperatively. The second patient died of a pulmonary embolus 2 months postoperatively. Autopsy showed no residual tumor. Overall, only 3 of 18 reported patients with epidermoid choristoma of the head and orbit with malignant transformation were alive when reported. CONCLUSIONS: Malignant squamous metaplasia is believed to be a rare complication of orbital dermoid or epidermoid cysts, with only two previously reported cases. However, malignant transformation is relatively frequent in analogous epidermoid cysts found elsewhere in the cranial vault, especially after incomplete excision. These reports encourage the complete removal of epithelial choristomas of the orbit.

Extrascleral malignant melanoma.

We present two cases of anterior extrascleral extension of malignant melanoma in eyes previously blind from other causes. In both cases, the tumor was not detected by the physician but rather by the patient himself (case 1) or his wife (case 2). In one case, the tumor became manifest more than 60 years after the eye became blind from trauma. Although blind eyes may harbor lethal tumors and, therefore, need regular examinations, this simple part of the physical examination frequently remains neglected by ophthalmologists as well as by primary care physicians. We wish to emphasize the potential life-saving importance of regular examinations of blind eyes.

Mascara pigmentation of the bulbar conjunctiva associated with rigid gas permeable lens wear.

We present three patients who were found to have unusual pigmentation of the bulbar conjunctiva. The areas, 1 to 2 mm in size, were translucent with dark black dust-like particles randomly placed within well defined borders. These specks were usually elevated, had a granular texture, and appeared to be overlying pingueculae. All three patients wore rigid gas permeable contact lenses, were found to have either a short tear break-up time or deficient tear aqueous layer, had associated 3:00 and 9:00 o'clock staining, and routinely used heavy mascara and/or eyeliner. In one patient, the areas resolved on discontinuing contact lens wear. The elevated areas may be associated with minor discomfort. We propose that a deficient tear layer and drying adjacent to the lens edge may compromise the conjunctival epithelium and prevent efficient washing of the pigment particles from the conjunctiva, allowing these granules to become embedded in the epithelium. Additional causes of conjunctival pigmentation are discussed.

Recurrent corneal erosion: pathology of corneal puncture.

Recurrent corneal erosion is a difficult disorder to treat. Despite conventional therapy, some patients continue to have episodes of erosion. Recent literature suggests the efficacy of corneal puncture, which is thought to induce adherence of the epithelium and basement membrane to the anterior stroma. We performed multiple corneal punctures with 23-, 25-, 27-, and 30-gauge needles on one patient who underwent penetrating keratoplasty 7 weeks later. We found that an insertion depth of 0.1 mm was sufficient to cause the production of new basement membrane and fibrocytic reaction in the anterior stroma. Analysis of the pathologic specimen supports the use of the larger 23- and 25-gauge needles, and cautions against the use of small gauge needles, especially 30-gauge, for this procedure.