Diagnosis and management of malignant melanoma.

The incidence of malignant melanoma has increased in recent years more than that of any other cancer in the United States. About one in 70 people will develop melanoma during their lifetime. Family physicians should be aware that a patient with a changing mole, an atypical mole or multiple nevi is at considerable risk for developing melanoma. Any mole that is suggestive of melanoma requires an excisional biopsy, primarily because prognosis and treatment are based on tumor thickness. Staging is based on tumor thickness (Breslow's measurement) and histologic level of invasion (Clark level). The current recommendations for excisional removal of confirmed melanomas include 1-cm margins for lesions measuring 1.0 mm or less in thickness and 2-cm margins for lesions from 1.0 mm to 4.0 mm in thickness or Clark's level IV of any thickness. No evidence currently shows that wider margins improve survival in patients with lesions more than 4.0 mm thick. Clinically positive nodes are typically managed by completely removing lymph nodes in the area. Elective lymph node dissection is recommended only for patients who are younger than 60 years with lesions between 1.5 mm and 4.0 mm in thickness. In the Eastern Cooperative Oncology Group Trial, interferon alfa-2b was shown to improve disease-free and overall survival, but in many other trials it has not been shown to be effective at prolonging overall survival. Vaccine therapy is currently being used to stimulate the immune system of melanoma patients with metastatic disease.

Periumbilical pseudoxanthoma elasticum with systemic manifestations.

We have reviewed the typical clinical manifestations of pseudoxanthoma elasticum and presented the case of a patient with involvement of the skin, eyes, and cardiovascular system. We suggest that patients with periumbilical lesions that might indicate pseudoxanthoma elasticum have, at minimum, a full physical examination with emphasis on the cardiovascular system and a complete ophthalmologic evaluation.

The use of live pigs in the surgical training of dermatology residents.

Refining of surgical skills requires instruction, manual repetition, and observation of results. This study demonstrates that while many dermatology residents use pig's feet or synthetic models of skin for practice, few use live animals. We describe the benefits and mechanics of utilizing anesthetized pigs for cutaneous surgical training.

'Blow-outs' in the retinal pigment epithelium.

A hole was detected in the epithelium of a retinal pigment epithelium (RPE) detachment in two patients. Leakage through the hole led to an elevation of the overlying neurosensory retina in each case. The resulting vision was 20/70 in one eye and 20/30 in the other. The defects in the RPE occurred in a setting different from that usually seen with tears in the pigment epithelium and had a different clinical appearance.

Rhegmatogenous retinal detachment with subretinal exudates.

Two young patients with probable longstanding traumatic retinal detachments underwent successful surgical repair. Dramatic subretinal exudates and crystalline material gradually resorbed; however, poor final vision resulted. No predisposing condition other than the longstanding retinal detachments was noted in these patients.

Retinal infiltrates in six patients with an associated viral syndrome.

This report documents the fundus findings in ten eyes of six patients who had retinal infiltrates develop during or shortly after a viral-like illness. The whitish infiltrates varied in size from 150 to 1700 micron. They occurred in both the posterior pole and periphery, and were located in the superficial as well as deep retinal layers. There was minimal or no vitritis. The infiltrates resolved over a period of months with and without chorioretinal scarring. The optic nerve was involved in two patients, causing a temporary decrease in acuity. However, the only eye left with visual acuity less than 20/40 had a paracentral macular lesion that scarred.

Intrastromal iris hemorrhage in a patient with hemoglobin C trait.

A 67-year-old man had a spontaneous intrastromal iris hemorrhage which resolved without complications. A thorough evaluation revealed no underlying abnormality except for the presence of hemoglobin C trait.

Histoplasmic endophthalmitis. A clinicopathologic correlation.

A patient had a 12-year history of relapsing disseminated histoplasmosis. None of the characteristic lesions of the presumed ocular histoplasmosis syndrome were present in either eye. Ocular involvement began as a peripheral focal retinitis associated with vitreitis and iritis. Histoplasma capsulatum organisms grew in cultures from aqueous and vitreous and were demonstrated histologically in an iridectomy specimen. Despite intraocular and subconjunctival administration of amphotericin B, intractable pain associated with progressive necrotizing granulomatous iridocyclitis necessitated enucleation. Histoplasma capsulatum organisms were seen extracellularly in the vitreous cavity and both intracellularly and extracellularly in areas of granulomatous inflammation involving the iris, ciliary body (diffusely), and the retina (focally). The choroid was not involved.

Macroaneurysms of the retinal arteries.

In a study of the natural course and risk factors leading to visual impairment from retinal arterial macroaneurysms in 40 eyes (35 patients), we used a simple classification based on the anatomic location of the macroaneurysm and complicating factors. Group A included 17 eyes in which the exudate, edema, hemorrhage, or aneurysm (or a combination of these) was located within the vascular arcades and caused a decrease in central visual acuity. Group B included eight eyes in which the exudate, edema, hemorrhage, or aneurysm (or a combination of these) was located within the vascular arcades but did not cause a decrease in central visual acuity. Group C included 15 eyes in which the exudate, edema, hemorrhage, or aneurysm (or a combination of these) was located peripheral to the vascular arcades. Eyes in Group A with recent visual symptom had an uncertain prognosis and some were treated; eyes in Group B had a more favorable prognosis but required careful periodic examinations; and eyes in Group C had a favorable prognosis and almost always did well without treatment. Eyes with macroaneurysms hemorrhaging into the vitreous or under the inner limiting lamina also tended to recover.

Metastatic calcification of the choroid in a patient with primary hyperparathyroidism.

This case report documents for the first time the funduscopic appearance and the fluorescein angiographic and ultrasonographic findings of what probably represents sclerouveal metastatic calcification in a patient with a past history of hyperparathyroidism. Fluorescein angiography revealed window defects centrally and mild staining of the more prominent periphery of the lesions. B-scan ultrasonography revealed marked sonoreflectivity characteristic of calcium.

Radioactive phosphorus-uptake-testing variables before and after enucleation.

Values for radioactive phosphorus uptake from 23 eyes with malignant melanomas of the choroid were compared before and after enucleation. In all but two eyes, the percentage increase in 32P uptake was higher immediately after enucleation than before enucleation. In 11 eyes, the variation was more than 100%. In one eye, the percentage increase of 32P uptake was 68% before enucleation and 137% after enucleation. The clinical importance of our findings is that pressure on the globe by the detector probe before enucleation may locally decrease choroidal blood volume thereby causing an increase in the calculated 32P uptake.

Infection prophylaxis with silastic sponge explants in retinal detachment surgery.

In our animal model, silastic scleral sponges retained bactericidal levels of neomycin sulfate for at least 1 week, when thoroughly infiltrated prior to episcleral placement. This would provide an effective protection against acute buckle infections caused by bacteria contaminating the surgical field. Our clinical experience in 1,081 consecutive scleral buckling procedures substantiates the validity of this conclusion.