Malignant melanoma of the conjunctiva with intraocular extension.

Intraocular extension of a malignant melanoma of the conjunctiva is a rare entity. A 75-year-old woman underwent repeated surgery after receiving the diagnosis of a multilocular recurrent malignant melanoma arising from a primary acquired melanosis. Treatment included 2 lamellar sclerokeratectomies and percutaneous radiotherapy. Five years after initial surgery, intraocular extension of the melanoma was observed, and enucleation was performed. Findings from histopathological examination revealed a malignant melanoma occupying part of the ciliary body, the trabecular meshwork, and the iris. Eyes with recurrent malignant melanoma of the conjunctiva should be carefully monitored for intraocular extension. Deep excision of conjunctival melanoma, including lamellar sclerokeratectomy, may abolish the natural barrier against intraocular extension of malignant melanomas of the conjunctiva.

Long term results after autologous nasal mucosal transplantation in severe mucus deficiency syndromes.

AIM: Severe mucus deficiency syndromes may require substitution of mucous membrane for re-establishment of the ocular surfaces. The long term results after autologous nasal mucosal transplantation were investigated. METHODS: 55 eyes of 50 patients with severe mucus deficiency syndromes were followed retrospectively after free autologous nasal mucosal transplantation-group A: patients after severe lye, acid, heat burns, or radiation (n=38 eyes), group B: patients with systemic mucosal disease (n=17 eyes). The results of routine clinical examination were recorded and patients were followed for a median of 37 months. 17 biopsies of transplanted nasal mucosa were studied by light microscopy and 22 patients by impression cytology before and at several intervals after mucosal transplantation. RESULTS: All nasal mucosal grafts healed well and no intraoperative complications occurred. During follow up 107 additional surgical procedures were performed including 16 lamellar and 21 penetrating keratoplasties. Subjective complaints improved in 44/47 patients with preoperative symptoms. Best corrected visual acuity at the end of follow up was increased in 23 eyes, 10 eyes (18. 2%) reached a final visual acuity equal to or greater than 20/200. Histopathologically, all (n=17) biopsies showed vital intraepithelial mucin producing goblet cells in the nasal mucosal graft (median 25 cells/field (400x magnification)). The mean density of goblet cells before transplantation was 48/mm(2) and after nasal mucosal grafting 432/mm(2) measured by impression cytology (p<0. 0001). CONCLUSIONS: Functional goblet cells persist in autologous nasal mucosa for up to 10 years after transplantation. In patients with severe mucus deficiency syndromes of different origin nasal mucosal transplantation can re-establish the ocular surface, substitute the mucus components of the tear film, improve symptoms of the patients, and facilitate a moderate increase in visual acuity.

Rhegmatogenous retinal detachment after block excision of epithelial implantation cysts and tumors of the anterior uvea.

OBJECTIVE: To report on frequency, time of occurrence, treatment, and final outcome of rhegmatogenous retinal detachment after block excision, combined with corneoscleral tectonic grafts, of intraocular epithelial implantation cysts and tumors of the anterior uvea involving the anterior chamber angle. DESIGN: Noncomparative case series. PARTICIPANTS: The study included 144 patients who had consecutively undergone scleral full-thickness block excision of tumors of the anterior uvea (n = 87) or intraocular epithelial implantation cysts (n = 57). Diameter of the block excision ranged between 5.5 and 20 mm. In 39 patients, the tumor extended posterior to the ora serrata. INTERVENTIONS: Retinal detachment surgery. MAIN OUTCOME MEASURES: Retinal detachment rate, visual acuity, risk factors. RESULTS: Retinal detachment occurred in 10 (6.9%) of 144 patients (2 of 57, or 3.5% of patients with cysts; 8 of 87 or 9.2% of patients with tumors) 3 to 12 months after block excision. Six patients underwent primary pars plana vitrectomy with temporary endotamponade by silicone oil, which was removed 3 to 9 months later. In four patients, a scleral buckling procedure only was performed. After a mean follow-up of 31 months after silicone oil removal or the buckling procedure (median, 30 months; range, 13-42 months), the retina has remained attached in all patients operated on. Visual acuity increased from 2/20 (median; range, light perception-6/20) to 8/20 (median; range, 2/20-12/20). In the eyes with retinal detachment compared to the eyes without retinal detachment, the block excision was significantly larger (13.75+/-4.86 mm vs. 9.41+/-3.02; P = 0.01) and was located significantly more posteriorly (limbus distance of posterior excision margin: 6.75+/-2.87 vs. 4.35+/-3.24 mm; P = 0.01). CONCLUSIONS: Scleral buckling procedures and primary pars plana vitrectomy with temporary ocular endotamponade can give acceptable results in eyes with rhegmatogenous retinal detachment occurring after block excision of epithelial implantation cysts or tumors of the anterior uvea. Despite intraoperative vitreous prolapse or tumor extension posterior to the ciliary body, rhegmatogenous retinal detachment occurs in fewer than 10% of patients undergoing block excision of cysts or tumors of the anterior uvea. Size and posterior location of the block excision are the main risk factors for rhegmatogenous retinal detachment, which becomes unlikely later than 12 months after surgery.

Microcirculation architecture of metastases from primary ciliary body and choroidal melanomas.

PURPOSE: To describe the microcirculation architecture of metastatic choroidal and ciliary body melanoma. METHOD: Histologic sections of 35 metastases from 19 primary melanomas were stained to demonstrate microcirculation. RESULT: The appearance of microcirculatory networks in metastases is independent of the target organ but associated with the size of the metastatic deposit (estimated coefficient = 0.5959; SE = 0.3024; P = .0488). CONCLUSION: The microcirculatory patterns of primary uveal melanomas that are associated with metastatic behavior appear in foci of metastasis, regardless of the site of dissemination.

Detection of varicella zoster virus DNA and viral antigen in human eyes after herpes zoster ophthalmicus.

OBJECTIVE: The purpose of the study was to identify varicella zoster virus (VZV) DNA and viral antigen in human eyes at various intervals after clinical onset of herpes zoster ophthalmicus (HZO). DESIGN: A retrospective case series. PARTICIPANTS: There were 9 eyes and 4 corneal buttons surgically obtained from 13 patients with HZO at the University Eye Hospital of Erlangen-Nürnberg between 1984 and 1994. Specimens were examined at different timepoints after clinical onset of HZO (range, 1 day-19 years; median, 36 months). METHODS: Histopathologic evaluation was performed on formalin-fixed and paraffin-embedded tissue by routine histology, immunohistochemistry (5-B-7 murine monoclonal antibody to VZV; peroxidase-antiperoxidase method), and DNA-in situ hybridization (35S deoxyadenosine triphosphate-labeled HindIII fragments [A and C] of VZV). RESULTS: Typical histopathologic changes associated with HZO were identified: vascularization of the corneal stroma (11 of 13), granulomatous reaction to Descemet's membrane (8 of 13), fusiform-shaped ciliary scarring (5 of 9), optic neuritis (4 of 9), and perineuritis (8 of 9) and perivasculitis (8 of 9) of the long posterior ciliary nerves and arteries. VZV antigen was detected in two patients with acute infection 1 and 7 days after onset of HZO, respectively. VZV-DNA was identified in seven patients up to 10 years after onset of HZO in corneal epithelial cells (2 of 13), corneal stroma (5 of 13), inflammatory infiltrate of the anterior chamber (1 of 9), episclera (2 of 9), posterior ciliary nerves (1 of 9) and arteries (5 of 9), optic nerve (5 of 9), and adjacent leptomeninges (2 of 9). CONCLUSION: Persistence of viral genomes, most likely accompanied by gene expression or slow viral replication, appears to be responsible for the often smoldering panophthalmitis and the chronic recurrent keratouveitis in patients with HZO. Localization of viral DNA in vascular structures suggests a role for vasculitis in the pathogenesis of some ocular findings associated with HZO.

[Diffuse malignant melanoma of the uvea. A clinico-histopathologic study of 39 patients]. / Diffuse maligne Melanome der Uvea. Eine klinisch-histopathologische Studie über 39 Patienten.

BACKGROUND: Focal malignant melanomas involving only the iris have a very good prognosis. Involvement of the iris and/or diffuse growth makes the prognosis worse. The prognostic parameters of diffusely growing malignant anterior uveal melanomas are analysed. PATIENTS AND METHODS: From 1981-1995 serial sections of 39 eyes, 23 women and 16 men, of diffusely growing malignant anterior uveal melanomas were histologically examined. Patients were between 9 and 80 years old (median 56 years). Follow-up was between 2 months and 15 years. At the end of the study, 13 patients had died from metastasis, all showed involvement beyond the iris. Four patients died from other causes. RESULTS: The 39 diffuse malignant melanomas were categorized into 10 affecting only the iris, 18 iris and ciliary body and 11 involving iris, ciliary body and choroid. 14 spindle-cell, 23 mixed-cell and 2 epithelioid-cell tumors were identified. We observed between 0 and 4 mitoses in 40 high-power fields. Only 4 melanomas showed more than 100 tumor-infiltrating lymphocytes in 20 high-power fields. Nine tumors showed extra-scleral spread, nine displayed vascular networks. Univariate Kaplan-Meier survival curves showed as significant prognostic factors: localization in the iris only (p = 0.0008), spindle cell type (p = 0.0002) and absence of vascular networks (p = 0.01). This was confirmed by multivariate Cox analysis. CONCLUSION: Patients with diffuse malignant melanoma confined to the iris alone have a good prognosis for survival. Diffuse tumor cell spread can be diagnosed at the slitlamp with high magnification. Conservative follow-up is acceptable, as long as ciliary body involvement is ruled out. Eye with medically uncontrollable secondary glaucoma should be enucleated. Anti-glaucoma filtering procedures are contraindicated because of the danger of extraocular spreading malignant cells.

[Autologous early transplantation of nasal mucosa after the most severe eye chemical burns]. / Autologe Nasenschleimhauttransplantation frühzeitig nach schwersten okularen Verätzungen.

UNLABELLED: The treatment of severe eye burns is still complicated. Since 1984 we have performed autologous nasal mucosa transplantation for the severe mucus deficiency syndromes often occurring during follow-up. Now we report on our initial experience using nasal mucosa transplantation shortly after severe burns. PATIENTS: Prospectively, nine patients (eight male, one female) were examined after autologous nasal mucosa grafting within 14 days after eye burns. In all patients there was an almost complete defect of limbal vascularization, large areas of necrotic conjunctiva and prolonged epithelialization problems. The patients were followed for an average of 38 months. RESULTS: In all patients the subjective complaints lessened and sufficient ocular wetting led to rapid reepithelialization. During the follow-up period two patients showed light symblephara. In five patients visual acuity improved to > or = 20/200. CONCLUSION: Early nasal mucosa transplantation is an additional tool in the treatment of severe ocular burns.

The microcirculation of choroidal and ciliary body melanomas.

The microcirculation of ciliary body and choroidal melanomas is remodelled into patterns. The presence of microvascular networks, composed of back-to-back loops that encircle microdomains of tumour, and parallel vessels with cross-linking, are associated with death from metastatic melanoma. The formation of these complex vascular patterns may result from reciprocal interactions between the tumour cell and the extracellular matrix, and pattern formation may reflect an invasive tumour cell phenotype. Ciliary body and choroidal melanomas are among the few forms of cancer treated before a pathologist assigns a grade to indicate whether tumour is likely to follow a benign or aggressive course. There is evidence to suggest that prognostically significant microcirculatory patterns may be detectable by non-invasive imaging techniques that may provide a substitute for biopsy to guide the clinical management of patients with these sight- and life-threatening tumours.

Cystic epithelial ingrowth after goniotomy for congenital glaucoma. A clinicopathologic report.

PURPOSE: To describe the clinical and histopathologic findings of a child with congenital glaucoma who developed cystic epithelial ingrowth after goniotomy. METHODS: A five-month-old boy was diagnosed with congenital glaucoma due to Axenfeld syndrome. Goniotomy was performed immediately after the clinical diagnosis in his left eye. Cystic epithelial ingrowth was noted two years postoperatively. The cyst was incompletely excised elsewhere, and recurred two years later. RESULTS: Cystic epithelial ingrowth expanded from the 2 o'clock to the 4 o'clock position involving the chamber angle. Best corrected preoperative visual acuity was 20/600 in his left eye. Cystic epithelial ingrowth was treated by block excision (8.0 mm) and tectonic corneoscleral grafting (8.1 mm). Best corrected postoperative visual acuity was 20/200 and the intraocular pressure was 8 mmHg without antiglaucomatous medication. There was no recurrence of the cyst during the 31 months of follow-up. Histopathologic results found that cystic epithelial ingrowth consisted of nonkeratinizing squamous epithelium with goblet cells covering Descemet's membrane, the chamber angle structures, the anterior face of the ciliary body, and the iris. CONCLUSIONS: Cystic epithelial ingrowth is a rare complication after goniotomy. Block excision with tectonic corneoscleral grafting is the treatment of choice for cystic and diffuse sheet-like epithelial ingrowth.

[Block excision with tectonic corneoscleroplasty for cystic and/or diffuse epithelial invasion of the anterior eye segment. Report of 51 consecutive patients (1980-1996)]. / Blockexzision mit tektonischer Korneoskleralplastik wegen zystischer und/oder diffuser Epithelinvasion des vorderen Augenabschnitts. Bericht über 51 konsekutive Patienten (1980-1996).

PURPOSE: Many surgical and nonsurgical techniques for the treatment of cystic and/or diffuse sheet-like epithelial ingrowth of the anterior chamber led to recurrences or even enucleation of the eye. PATIENTS AND METHODS: There were 32 (62.7%) men and 19 (37.3%) women ranging in age from 1 month to 80 years (median, 55.5 years). Cystic epithelial ingrowth occurred in 45 patients, and diffuse sheet-like epithelial downgrowth in 6 patients. Block excision consisted of simultaneous en bloc removal of epithelial ingrowth together with adjacent iris, pars plicata of the ciliary body, and cornea and sclera in full-thickness. The resulting defect was covered with a tectonic corneoscleral graft. The median follow-up was 7.9 years. RESULTS: The main causes for epithelial ingrowth were trauma (41.2%) and complicated cataract extractions (27.5%). Eleven patients had undergone surgery of epithelial ingrowth before block excision, elsewhere. Epithelial ingrowth involved up to 5 clock hours of the circumference of the chamber angle (median, 3 clock hours). The median preoperative visual acuity was 0.3 (range, hand motions -1.0). The median diameter of the block excision was 8.0 mm (range, 5.5-12.0 mm). The main postoperative complications were vitreous hemorrhage (27.5%) and corneal endothelial decompensation (21.6%). The median postoperative visual acuity was 0.2. Visual acuity was > or = 0.3 in 43.1% of patients and < 0.1 in 35.3% of patients. Visual results were significantly better after simultaneous cataract extraction with intraocular lens implantation (n = 5). Histopathologically, the invading epithelium mainly consisted of nonkeratinizing squamous epithelium with goblet cells (64.7%). There was a secondary proliferation of corneal endothelium on the cyst's surface in 82.4% of patients. There was no clinical evidence of recurrence of epithelial ingrowth, and no enucleation had to be performed during follow-up. CONCLUSION: Block excision with tectonic corneoscleral grafting is the treatment of choice for cystic and/or diffuse sheet-like epithelial ingrowth of the anterior chamber or anterior uvea, retrospectively.

Block excision of tumors of the anterior uvea. Report on 68 consecutive patients.

PURPOSE: This study describes the authors' surgical technique and the results in 68 consecutive patients with tumors of the iris and ciliary body involving the angle removed by block excision and tectonic corneoscleral grafting between 1980 and 1995. PATIENTS AND METHODS: There were 41 (60.3%) women and 27 (39.7%) men whose ages ranged from 14 to 85 years (median, 41 years). Follow-up ranged from 0.5 to 15.2 years (median, 6.3 years). Tumors of the iris and ciliary body with chamber angle involvement were removed with a modified block excision consisting of simultaneous en bloc removal of the tumor with adjacent iris and cornea and sclera in full-thickness. The resulting defect of 6 to 20 mm (median, 9.0 mm) diameter is covered with a tectonic corneoscleral graft. RESULTS: Forty-nine tumors (72.1%) were classified as malignant tumors of the iris and ciliary body. Twenty-one (44.7%) of 47 malignant melanomas showed histologic evidence of scleral invasion of more than one third of scleral thickness. Extrascleral extension of the tumor was present in seven (14.9%) patients with malignant melanomas and in four (21.1%) patients with benign tumors of the iris and ciliary body. The 10-year survival probability of patients with malignant melanomas was 91.4%. The main intraoperative complication was vitreous hemorrhage in 24 (35.3%) patients, and the main postoperative complication was complicated cataract, occurring in 22 (32.3%) patients. Two local tumor recurrences (2.9%) were observed. Four eyes (5.8%) had to be enucleated after block excision. Best-corrected postoperative visual acuity was better than 20/60 in 36 (52.9%) patients. CONCLUSIONS: The authors' results indicate that block excision with tectonic corneoscleral grafting may be the treatment of choice for progressive circumscribed tumors of the iris and ciliary body involving the anterior chamber angle up to 150 degrees of its circumference.

[Hormonally inactive hypophyseal adenomas: the results and late sequelae after surgery and radiotherapy]. / Hormoninaktive Hypophysenadenome: Resultate und Spätfolgen nach Operation und Radiotherapie.

PURPOSE: External radiation therapy for non functioning pituitary adenomas is clearly indicated in inoperable patients, after incomplete transsphenoidal microsurgery and in case of tumor progression. This retrospective analysis gives results and toxicity following surgery and postoperative radiotherapy of non-functioning pituitary adenomas. PATIENTS AND METHODS: Between 1983 and 1990, 50 patients with non-functioning pituitary adenomas received combined treatment at our institutions. Surgical approaches were transsphenoidal (61%), transcranial (24%) or a combination of both (15%) in short intervals. All 50 patients received a full-dose radiotherapy with single fractions between 1.9 and 2.1 Gy (median 1.9 Gy) and total doses between 46 and 63 Gy (median 48 Gy). Field sizes ranged between 20 and 72 cm2 (median 30 cm2). Endpoints of this study were: progression-free survival, late effects of brain, optic nerve and intracranial vessels, visual impairment and hypothalamic-pituitary dysfunction. Median follow-up was 54 months. RESULTS: Forty-seven of the 50 patients remained progression-free. Patients over age 60 years progressed more frequently (3/17) as compared to younger patients (0/33, p = 0.034). Following radiotherapy vision improved in 8 patients (16%), 14 patients (28%) experienced a visual impairment between 10% and 60% (according to the grading system of the German Ophthalmologic Society). In multivariate analysis no influence of age (p = 0.097) or biologically effective dose (BED) (p = 0.11) was seen on visual impairment. Three patients (6%) experienced late effects with optic neuropathy in 2 cases and temporal lobe necrosis in 1 case. Only the BED had a significant impact on late effects (p = 0.0094). Adrenal, thyroid and gonadal function abnormalities were present in 58%, 66% and 96% of the patients at last follow-up, respectively. CONCLUSIONS: Radiotherapy after incomplete transsphenoidal or transcranial surgery of non-functioning pituitary adenoma is an effective treatment. Future perspectives must include the better defining of high-risk patients and the reduction of late morbidity.

Relation between the microcirculation architecture and the aggressive behavior of ciliary body melanomas.

PURPOSE: To study the relation between vascular patterns and the biologically aggressive behavior of ciliary body melanomas. METHODS: The authors compared the frequency distribution of vascular patterns by location for 234 uveal melanomas (54 tumors involving the ciliary body, and 180 without ciliary body involvement). Stepwise Cox regressions (for the endpoint of time-to-death due to melanoma), performed separately for melanomas with and without ciliary body involvement, included the following variables: size, vascular patterns, cell type, mean of the largest nucleoli, mitoses, tumor infiltrating lymphocytes, age, and sex. A separate Cox regression procedure included the variable of tumor location. Kaplan-Meier survival curves were generated for time to melanoma death with ciliary body involvement and melanomas without ciliary body involvement for tumors containing or lacking vascular networks. RESULTS: These vascular patterns appear more often in the ciliary body than in the choroid: parallel vessels (P = 0.022), arcs (P = 0.003), and parallel with cross-linking, arcs with branching, and loops and networks (all P = 0.0001). Stepwise regression for tumors confined to the choroid indicated that the presence of networks was the most significant variable (P = 0.0001); stepwise regression for tumors with ciliary body involvement suggested that only one variable, networks, was significant (P = 0.0066). Kaplan-Meier survival estimates indicated that the survival of patients with tumors containing networks in the ciliary body was comparable to those containing networks in the choroid. CONCLUSION: Regardless of location, ciliary body or choroid, the presence of vascular networks shortens survival. The tumor location does not enter a stepwise Cox regression model when vascular patterns are included as variables. Therefore, the aggressive behavior of ciliary body melanomas appears to be related to the tendency for vascular networks to develop in this location.

Correlation of microcirculation architecture with ultrasound backscatter parameters of uveal melanoma.

Ultrasound tissue characterization parameters of size and acoustic concentration can be used to sub-classify uveal melanoma and estimate the patient's risk of death. Histologically determined microcirculation patterns have also been found to sub-classify uveal melanoma and predict patient's risk of death. This study examines the spatial relationship between tumor features detected by the two techniques. Three dimensional ultrasound images that depict the size and relative concentration of scattering elements in uveal melanoma within a range of approximately 50-120 microns were compared with PAS (without hematoxylin) stained histological sections graded and localized according to tumor microvascular patterns. Both ultrasound parameter imaging and histopathology were accomplished by workers masked to the other procedure. In three of five patients vascular networks were identified histopathologically. The predominant ultrasound feature seen in the regions of the histologically identified networks were clusters of scatterers in the range of approximately 50-80 microns. In the two cases without a network vascular pattern, lower range scatterers dominated the tumor volume. All the cases could be distinguished by the size and distribution of contiguous spatial clusters of acoustic scatterers. Scatterer size features detected in three dimensional ultrasound parameter images can identify tumor regions containing a specific microvascular pattern. Ultrasound tissue characterization features used to sub-classify uveal melanoma may have a biophysical basis related to patterns of tumor microcirculation.

Bilateral herpes simplex virus type 2 keratitis: a clinicopathologic report with immunohistochemical and ultrastructural observations.

This report describes the clinical, histopathologic, ultrastructural, and immunohistochemical findings in two corneal buttons from a 13-year-old girl who developed bilateral progressive corneal stromal opacification during childhood. As determined by light microscopy, both corneal buttons were edematous with a chronic inflammatory infiltrate confined to the deep layers of the stroma. We detected intranuclear eosinophilic inclusions in some epithelial cells. We detected herpesvirus particles in stromal keratocytes and endothelial cells by transmission electron microscopy. Immunohistochemistry studies identified concurrent expression of specific herpes simplex virus type 2 antigen in corneal epithelial cells, in keratocytes in the deep layers of the stroma, and in endothelial cells. The cause of progressive bilateral stromal corneal opacification in this child was herpes simplex virus type 2 keratitis. This condition should be considered in the differential diagnosis of progressive, bilateral corneal opacification in children.

Mean of the ten largest nucleoli, microcirculation architecture, and prognosis of ciliochoroidal melanomas.

BACKGROUND: Cytomorphometric measurements and the architecture of the microcirculation in tissue sections of eyes removed for ciliary body or choroidal melanomas have been identified independently as prognostically significant factors for survival. The relative significance of these two histologic features is addressed in this study. METHODS: The same 234 cases used to assess the prognostic significance of the microcirculatory patterns of choroidal and ciliary body melanomas were examined by two independent observers who measured the largest diameter of melanoma cell nucleoli from digitized images at a high magnification (x 3000) using the laser scanning confocal microscope. The mean of the ten largest nucleoli was calculated for each tumor according to previously published methods. Intraobserver and interobserver reproducibility was assessed for these measurements. Several Cox multiple regression models were constructed which included this cytomorphometric variable with and without the inclusion of the microcirculatory patterns. RESULTS: There is a high degree of intraobserver reproducibility but only a weak degree of interobserver reproducibility in measuring the mean of the ten largest nucleoli. Using multiple Cox regression models, the mean of the ten largest nucleoli from each observer failed to exert any effect on outcome after enucleation, regardless of whether the presence of networks of closed vascular loops was considered in the statistical formulation. The presence of networks of closed vascular loops was found to be the most statistically dominant histologic prognostic characteristic. CONCLUSION: The authors have not been able to confirm the use of the mean of the ten largest nucleoli as a significant prognostic factor in the outcome of patients whose eyes have been removed for ciliary body or choroidal melanomas. Further investigation of this cytomorphometric technique by other laboratories is warranted.

Three-dimensional relationships between tumor cells and microcirculation with double cyanine immunolabeling, laser scanning confocal microscopy, and computer-assisted reconstruction: an alternative to cast corrosion preparations.

The morphology of the microcirculation of uveal melanomas is a reliable market of tumor progression. Scanning electron microscopy of cast corrosion preparations can generate three-dimensional views of these vascular patterns, but this technique sacrifices the tumor parenchyma. Formalin-fixed wet tissue sections 100-150 microns thick from uveal melanomas were stained with the lectin Ulex europaeus agglutinin I (UEAI) and proliferating cell nuclear antigen (PCNA) to demonstrate simultaneously the tumor blood vessels and proliferating tumor cells. Indocarbocyanine (Cy3) was used as a fluorophore for UEAI and indodicarbocyanine (Cy5) was used for PCNA. Double labeled sections were examined with a laser scanning confocal microscope. Images of both stains were digitized at the same 5-microns intervals and each of the two images per interval was combined digitally to form one image. These combined images were visualized through voxel processing to study the relationship between melanoma cells expressing PCNA and various microcirculatory patterns. This technique produces images comparable to scanning electron microscopy of cast corrosion preparations while permitting simultaneous localization of melanoma cells expressing PCNA. The microcirculatory tree can be viewed from any perspective and the relationship between tumor cells and the tumor blood vessels can be studied concurrently in three dimensions. This technique is an alternative to cast corrosion preparations.

Microcirculation architecture of melanocytic nevi and malignant melanomas of the ciliary body and choroid. A comparative histopathologic and ultrastructural study.

PURPOSE: This study was designed to (1) describe the vascular patterns of ciliary body and choroidal nevi by light microscopy, (2) compare the vascular ultrastructure of nevi with vessels of the normal uvea and uveal melanomas, and (3) compare the behavior of ciliochoroidal melanomas with and without a nevus-like vascular architecture. METHODS: After delineating the vascular patterns of 23 choroidal and ciliary body nevi by light microscopy, the authors identified 49 melanomas that had the same vascular patterns as nevi from a previously published series of 234 uveal melanomas. The survival of these 49 patients who had melanomas with a nevus-like vascular architecture was compared with the 185 patients who had melanomas that lacked this vascular profile. RESULTS: By light microscopy, the only vascular patterns identified in nevi are "normal" vessels, zones of avascularity ("silent" pattern), straight, and parallel vessels; closed vascular loops and networks were not detected in nevi. By transmission electron microscopy, the vascular basement membrane of malignant melanomas was multilaminar, fragmented, and significantly thicker than in normal eyes or nevi. None of the patients with nevi died of metastatic disease. Fourteen percent of patients whose melanomas had the same vascular profile as nevi died of metastatic disease, whereas 32% of patients whose melanomas had vascular patterns other than those seen in nevi died of metastatic melanoma (P = 0.012). CONCLUSIONS: The microcirculation architecture marks tumor progression in uveal melanocytic lesions by light and electron microscopy. In the spectrum of these lesions, nevi are benign, melanomas that have the same vascular profile as nevi have an intermediate biologic behavior, and melanomas with vascular networks are strongly associated with death due to metastatic disease.