[Experimental study of hyaluronic acid gel fillers biodegradation in orbit]. / Eksperimental'noe issledovanie biodegradatsii fillerov na osnove gelya gialuronovoi kisloty v orbite.

INTRODUCTION: Recently, hyaluronic acid gel (HAG) fillers were proposed as an effective alternative treatment option for surgical orbital volume augmentation. Several authors reported about long-standing effect of the filler. PURPOSE: To assess the features of HAG biodegradation after intraorbital injection in experimental environment. MATERIAL AND METHODS: In the course of the experiment, 7 chinchilla rabbits (14 eyes) received a single 1ml intraorbital HAG injection (Restylane SubQ, Galderma, Sweden) using a cannula. The animals' orbits were examined by ultrasound scan after the injection and at 1, 3, 6, 9, 12 and 18 months. The animals were subsequently sacrificed for morphological study of orbital tissue containing the HAG filler. RESULTS: The HAG filler persisted in the orbit of experimental animals during the whole follow-up period. The volume of HAG depot and its density diminished gradually till the 18th month, after which the particles of HAG could still be detected with the morphological study and ultrasound. CONCLUSION: The HAG filler persisted in the orbit of experimental animals up to 18 months. Incomplete biodegradation explains the longstanding duration of the injection effect.

[Hyaluronic acid gel implants for correction of pathological conditions of the orbit and eyelids]. / Primenenie in''ektsionnykh implantatov na osnove gelia gialuronovoi kisloty pri patologii vek i orbity.

PURPOSE: To evaluate the effectiveness of injectable implants made of hyaluronic acid gel (HAG) in ophthalmoplastics. MATERIAL AND METHODS: The study included 57 patients (37 patients with lagophthalmos related to acute or chronic facial nerve palsy, endocrine ophthalmopathy; 20 patients with enophthalmos, anophthalmic syndrome). Depending on filler particle size, the patients received either intrapalpebral or intraorbital HAG injection. The biometric measures of palpebral fissure, the position of the eye/implant, and the condition of the cornea were evaluated during the follow-up period (12 months for eyelid and 18 for orbital injection). RESULTS: In the course of the follow-up, all patients showed reliable reduction of lagophthalmos; additionally, improvement of the condition of the cornea was observed in patients after intrapalpebral injection; patients after intraorbital injection exhibited reduction in enophthalmos, upper orbital palpebral fold retraction and upper eyelid excursion. No serious complications have occurred after the injection. CONCLUSION: As minimally invasive method of treating various pathologies of the orbit and eyelids, HAG fillers showed good clinical effectiveness and safety.

[Histopathological study of experimental intrapalpebral injection of hyaluronic acid gel].

UNLABELLED: Hyaluronic acid gel (HAG) fillers are successfully used in the treatment of many eyelid disorders. It is considered that the effect of HAG injection lasts for 6 months on average. However, in our experience volume augmentation persists longer, suggesting that the presence of the filler in the eyelid may be associated with certain tissue reactions. The objective of the study was to investigate morphological features of HAG biodegradation. MATERIAL AND METHODS: Seven adult Chinchilla rabbits (14 eyes) received a single 0.1 ml HAG (Restylane, Q-Med AB, Sweden) subcutaneous upper eyelid injection followed by contouring of the skin for 1.5 mm on average. Tissue samples containing HAG were collected for histopathological examination with morphometric analysis on day 0, week 2, months 1, 2, 4, 6, and 9. RESULTS: HAG persisted subcutaneously in the eyelid during the 9 months of the study in the form of a sponge-like structure with compartments of varying shape and size. Its total volume diminished gradually, nevertheless at the end of the study the filler could still be found in some compartments, mainly peripheral. In the central area of the depot residual HAG was surrounded by optically transparent spaces. CONCLUSION: After being injected subcutaneously into the eyelids of experimental animals HAG formed a sponge-like structure causing a significant increase in eyelids volume. Gradual biodegradation of HAG was accompanied by neocollagenogenesis and 9 months later the process was still ongoing.

[Rare case of primary orbital osteoma]. / Redkii sluchai pervichnoi osteomy orbity.

We report a case of primary orbital osteoma originated from the sphenoid and notable for a mismatch between its giant size and mild clinical presentation. A lot of attention has been paid to the choice of surgical technique.

Fungal keratitis - improving diagnostics by confocal microscopy.

PURPOSE: Introducing a simple image grading system to support the interpretation of in vivo confocal microscopy (IVCM) images in filamentous fungal keratitis. SETTING: Clinical and confocal studies took place at the Department of Ophthalmology, Aarhus University Hospital, Denmark. Histopathological analysis was performed at the Eye Pathology Institute, Department of Neuroscience and Pharmacology, University of Copenhagen, Denmark. METHODS: A recent series of consecutive patients with filamentous fungal keratitis is presented to demonstrate the results from in-house IVCM. Based upon our experience with IVCM and previously published images, we composed a grading system for interpreting IVCM images of filamentous fungal keratitis. RESULTS: A recent case series of filamentous fungal keratitis from 2011 to 2012 was examined. There were 3 male and 3 female patients. Mean age was 44.5 years (range 12-69), 6 out of 17 (35%) cultures were positive and a total of 6/7 (86%) IVCM scans were positive. Three different categories of IVCM results for the grading of diagnostic certainty were formed. CONCLUSION: IVCM is a valuable tool for diagnosing filamentous fungal keratitis. In order to improve the reliability of IVCM, we suggest implementing a simple and clinically applicable grading system for aiding the interpretation of IVCM images of filamentous fungal keratitis.

The influence of brightness on functional assessment by mferg: a study on scaffolds used in retinal cell transplantation in pigs.

To determine the effect of membrane brightness on multifocal electroretinograms (mfERGs), we implanted poly lactic-co-glycolic acid (PLGA) membranes in the subretinal space of 11 porcine eyes. We compared membranes with their native shiny white color with membranes that were stained with a blue dye (Brilliant Blue). Histological and electrophysiological evaluation of the overlying retina was carried out 6 weeks after implantation. Histologically, both white and blue membranes degraded in a spongiform manner leaving a disrupted outer retina with no preserved photoreceptor segments. Multifocal ERG revealed the white membranes to have a significantly higher P1-amplitude ratio than the blue (P = 0.027), and a correlation between brightness ratio and P1-amplitude ratio was found (r = 0.762). Based on our findings, we conclude that bright subretinal objects can produce normal mfERG amplitude ratios even when the adjacent photoreceptors are missing. Functional assessment with mfERG in scaffold implant studies should therefore be evaluated with care.

Subretinal implantation of electrospun, short nanowire, and smooth poly(ε-caprolactone) scaffolds to the subretinal space of porcine eyes.

Biodegradable scaffolds play an important adjunct role in transplantation of retinal progenitor cells (RPCs) to the subretinal space. Poly(ε-Caprolactone) (PCL) scaffolds with different modifications were subretinally implanted in 28 porcine eyes and evaluated by multifocal electroretinography (mfERG) and histology after 6 weeks of observation. PCL Short Nanowire, PCL Electrospun, and PCL Smooth scaffolds were well tolerated in the subretinal space in pigs and caused no inflammation and limited tissue disruption. PCL Short Nanowire had an average rate of preserved overlying outer retina 17% higher than PCL Electrospun and 25% higher than PCL Smooth. Furthermore, PCL Short Nanowire was found to have the most suitable degree of stiffness for surgical delivery to the subretinal space. The membrane-induced photoreceptor damage could be shown on mfERG, but the reductions in P1 amplitude were only significant for the PCL Smooth. We conclude that of the tested scaffolds, PCL Short Nanowire is the best candidate for subretinal implantation.

Mantle cell lymphoma in the orbital and adnexal region.

AIMS: To characterise clinicopathological features of mantle cell lymphoma (MCL) in the orbital and adnexal region. METHODS: Data on lymphoid lesions were retrieved searching the Danish Ocular Lymphoma Database 1980-2005. Specimens were collected from Danish pathological departments and re-evaluated with a panel of monoclonal antibodies. For all patients with confirmed MCL the complete clinical files were collected and reviewed. RESULTS: Twenty-one patients with MCL in the orbital and adnexal region were identified comprising 9% (21/230) of all lymphoma in the ocular region. There were 18 male patients and three female patients with an age range from 60 to 90 years (median 75 years). Orbital and adnexal region MCL as first presenting symptom comprised 67% of the patients. Of these, 71% had bilateral involvement. The orbit (71%) and eyelids (64%) were the most commonly affected sites. All but two presented in stage III/IV. Secondary MCL comprised 33% of the patients. Bilateral affection (29%) was less common in this patient group. The median survival was not different between the two presentation groups. Patients receiving anti-CD20 (rituximab)-containing chemotherapy had a significantly better 5-year overall survival (OS) rate (83%) than patients in treatment regimes without rituximab (5-year OS rate, 8%). CONCLUSIONS: Orbital and adnexal region MCL presents in elderly males. The orbit and eyelid are frequently involved. There is a very high proportion of systemic involvement in general with MCL of the orbital and adnexal region. Most patients presented with stage IV disease and had multiple relapses and short survival time. Treatment with rituximab-containing chemotherapy improved survival significantly compared with combination chemotherapy without rituximab.

Calcium-independent phospholipase A2 regulates retinal pigment epithelium proliferation and may be important in the pathogenesis of retinal diseases.

Calcium-independent phospholipase A2, group VIA (iPLA2-VIA) is involved in cell proliferation. This study aimed to evaluate the role of iPLA2-VIA in retinal pigment epithelium (RPE) cell proliferation and in retinal diseases involving RPE proliferation. A human RPE cell line (ARPE-19) was used to explore this role in vitro. Proliferating ARPE-19 cells had increased expression and activity of iPLA2-VIA. iPLA2-VIA was found in the nuclei of proliferating ARPE-19 cells, whereas in confluent ARPE-19 cells, with limited proliferation, iPLA2-VIA was primarily found in the cytosol. Inhibition of iPLA2-VIA decreased the rate of proliferation, whereas over expression of iPLA2-VIA increased the rate of proliferation. Using an experimental porcine model of RPE proliferation we demonstrated significant nuclear upregulation of iPLA2-VIA in proliferating RPE cells in vivo. We furthermore evaluated the expression of iPLA2-VIA in proliferative vitreoretinopathy (PVR). PVR membranes revealed nuclear expression of iPLA2-VIA in the RPE cells which had migrated and participated in the formation of the membranes. Overall, the present results point to an important role of iPLA2-VIA in the regulation of RPE proliferation suggesting that iPLA2-VIA may be considered as a possible pharmaceutical target in retinal diseases involving RPE proliferation and migration.

CNS metastasis from malignant uveal melanoma: a clinical and histopathological characterisation.

AIM: To characterise uveal melanoma that has metastasised to the central nervous system (CNS). METHODS: Review of 2365 patients constituting all patients diagnosed as having primary uveal melanoma in Denmark during the period 1943-1997. All patients with malignant uveal melanoma and metastasis to the CNS were identified. For each patient, clinical and histopathological data were gathered. RESULTS: Sixteen patients with CNS metastasis were identified. The median age was 58 years. The majority of CNS metastases were located in the frontal and parietal lobes. Eleven patients had widespread metastases. Five patients had exclusively metastasis to the CNS. The average time from diagnosis of primary tumour to symptoms of CNS metastasis was 91 months. The average time from the initial CNS symptoms to death was 20 months. All tumours were composed of either mixed or spindle cells. The average largest basal diameter of the primary tumours was 12 mm. One tumour was a ring melanoma. The majority of tumours had a ruptured Bruch membrane. Retinal invasion was observed in 36% of tumours. No specimen had optic nerve invasion. Scleral invasion was pronounced in 36% of cases, and extrascleral extension was observed in two cases (14%). The amount of tumour infiltrating lymphocytes was pronounced in three cases (23%). CONCLUSION: The proportion of uveal melanoma patients having CNS metastasis was 0.7%. Eleven patients had multiple organ metastases, and the average time from the initial CNS symptoms to death was 8 months. Five patients had metastasis to the CNS solely, and the average time from the initial CNS symptoms to death was 57 months.

Primary lymphoma of the lacrimal sac: an EORTC ophthalmic oncology task force study.

AIM: To define the clinical and histopathological characteristics of primary lacrimal sac lymphoma in a predominantly white population. METHODS: Specimens of lacrimal sac lymphoma and follow up data were solicited from members of the Ophthalmic Oncology Task Force of the European Organization for Research and Treatment of Cancer (EORTC) and the European Ophthalmic Pathology Society (EOPS). Specimens were stained with haematoxylin and eosin and an immunohistochemical panel against leucocyte antigens was applied. Diagnosis was reached by consensus of five experienced pathologists according to the World Health Organization classification system. The histopathological findings were correlated with the clinical data. RESULTS: Of 15 primary lacrimal sac lymphomas, five (33%) were diffuse large B cell lymphoma (DLBCL), five (33%) were extranodal marginal zone B cell lymphoma of mucosa associated lymphoid tissue (MALT lymphoma), three were classified as "transitional MALT lymphoma," being in transition from MALT lymphoma to DLBCL, and two were unclassified B cell lymphomas. Nine of the patients were female, and the median age at the time of diagnosis was 71 years (range 45-95 years). The most frequent presenting symptoms were epiphora (85%), swelling in the region of the lacrimal sac (79%), and dacryocystitis (21%). All but one patient presented in stage I. Systemic spread occurred in three of nine patients (33%). The 5 year overall survival was 65%. CONCLUSIONS: DLBCL and MALT lymphoma are equally common in the lacrimal sac in contrast with the remaining periorbital and/or orbital region where MALT lymphoma predominates.

Sinonasal schwannoma--a clinicopathological analysis of five rare cases.

Schwannoma of the nasal cavity or the sinuses is a rare condition. We report a small series of five consecutive patients; three males and two females, age range 22-81 years, all Caucasian. Symptoms were typically non-specific, and the tumours were often quite large when diagnosed, being locally infiltrating and even destructive. Histologically, the tumours were remarkable by sparse occurrence of Antoni type B areas and lack of encapsulation. Four cases were benign; however, one case of melanotic schwannoma, exhibited malignant transformation. Two of the patients had intracranial involvement, but with an intact dura. All tumours were treated surgically; only the malignant case received adjuvant radiotherapy. Patients were followed from five months to 15 years, with a median of 57 months. The benign cases have so far shown good prognosis without recurrences; however, in the case of the melanotic schwannoma a fatal malignant transformation was seen 13 years after initial diagnosis. On the basis of our review early detection and complete surgical removal is recommended.

Epstein-Barr positive T-cell lymphoma in the ocular region.

PURPOSE: To present two cases of rapidly growing tumors in the ocular adnexa. Both tumors were Epstein-Barr virus (EBV) positive peripheral T-cell lymphoma. METHODS: Case 1 was a 60-year-old man with a non-tender ulcerating tumor involving the lateral third of both upper and lower right eyelid. Case 2 was a 55-year-old man with a swelling of the left eyelid expanding cranially and dislocating the left eye, resulting in proptosis and diplopia. Both patients underwent incisional biopsy that did not disclose the malignant nature of the tumors. Clinical evaluation resulted in suspicion of malignancy and surgical excision was performed. RESULTS: The tumors were found to be consistent with EBV-positive peripheral T-cell lymphoma. CONCLUSIONS: Peripheral T-cell lymphoma is uncommon but a diagnosis to be considered in a patient with a tumorous lesion in the eye region. Furthermore, peripheral T-cell lymphoma may be EBV-positive.

An unusual retinal vascular morphology in connection with a novel AIPL1 mutation in Leber's congenital amaurosis.

AIMS: To report a case of an unusual retinal vascular morphology in connection with a novel AIPL1 mutation in a patient with Leber's congenital amaurosis (LCA). METHODS: A patient with LCA and no light perception from birth had both eyes enucleated at the age of 22 years because of excruciating pain. Mutation analysis was performed on known LCA genes. The eyes were processed for casts of the vascular tree, routine histopathology, and electron microscopy. RESULTS: A novel H82Y (244C-->T) mutation and a H90D (286G-->C) polymorphism were detected in exon 2 of the AIPL1 gene. Both the cast and the histopathological examination showed dilated retinal vessels, mainly venules, primarily localised in the posterior pole. In the mid-peripheral retina the density of capillaries on the arteriolar side of the microcirculatory units was significantly decreased. The vascular system was seen to gradually attenuate towards the retinal periphery, and to stop at a zone located approximately 4 mm from the ora serrata along the whole circumference. In this zone pigmented aggregates characteristic of retinitis pigmentosa were seen to ensheath the retinal vessels. The photoreceptors were almost totally absent and retinal gliosis was present. A decreased number of ganglion cells and an increased vacuolisation of the nerve fibre layer were observed. The retinal pigment cells and Bruch's membrane appeared normal in all regions. CONCLUSION: An unusual retinal vascular morphology in an LCA patient is presented and possible pathogenic mechanisms of the findings are discussed.

Establishment and characterization of human uveal malignant melanoma xenografts in nude mice.

The purpose of this study was to develop a suitable animal model for the investigation of the pathogenesis and therapy of uveal malignant melanoma. Eight choroidal malignant melanomas from eight patients were transplanted into nude mice in an attempt to establish a serially transplantable tumour model. Tumour tissue blocks (2 x 2 x 2 mm) from enucleated eyes with choroidal malignant melanoma were transplanted subcutaneously into the flanks of nude mice. The growing tumours were measured and serially transplanted. The tumour samples were investigated by histology, immunohistochemistry and electron microscopy. Only one of the eight transplanted primary tumours (13%) was established as a xenograft in nude mice. Furthermore, the take rate of the transplantable tumour was low (13%). The growth of the tumour fitted a Gompertz function, and the calculated tumour volume doubling time was 54 days. The transplanted tumour cells were epithelioid and slightly larger than the primary tumour cells and had prominent nucleoli. However, the transplanted tumour retained a morphological appearance similar to that of the primary tumour. Immunohistochemical examinations demonstrated that the cells preserved the characteristic properties of malignant melanoma. However, the transplanted cells demonstrated vimentin reactivity, whereas the primary tumour cells were negative for vimentin. It can be concluded that a new experimental model of malignant uveal melanoma with tumours that were easy to observe and access was established in nude mice.

Liposarcoma metastatic to the orbit.

PURPOSE: To describe a patient with liposarcoma metastatic to the left orbit. METHODS: A 72-year-old man was admitted with diplopia and proptosis of the left eye. Previously, a retroperitoneal liposarcoma had been surgically removed followed by postoperative radiation. Visual acuity was normal. There was proptosis of the left eye, increased retrobulbar resistance and reduced mobility. Trans-septal orbital biopsies showed liposarcoma. The patient was initially treated with prednisolone and later received radio- and chemotherapy. Despite treatment he lost vision of the left eye and died a few months later. RESULTS: Histological examination of the orbital tumor revealed a spindle-cell liposarcoma similar to the primary tumor of the retroperitoneum. CONCLUSIONS: Liposarcoma metastatic to the orbit is rare, but should be suspected in a patient with proptosis caused by a space-occupying lesion and a history of liposarcoma.

Cell proliferation activity in posterior uveal melanoma after Ru-106 brachytherapy: an EORTC ocular oncology group study.

AIM: To evaluate the cell proliferation activity in posterior uveal melanomas after Ru-106 brachytherapy. METHODS: Eyes containing choroidal or ciliary body melanoma from seven ocular oncology centres, which were enucleated after first being treated by Ru-106 brachytherapy and which had enough melanoma tissue to enable histological assessment, were included. The 57 eligible specimens were divided into a group of 44 eyes that were enucleated because of tumour regrowth, and a non-recurrent group of 13 eyes that were enucleated because of complications such as neovascular glaucoma. 46 non-irradiated eyes harbouring uveal melanoma served as a control group. All specimens underwent routine processing. They were cut into 5 microm sections, and were stained with two main cell proliferation markers: PC-10 for PCNA and MIB-1 for Ki-67. The stained sections were assessed, and the cells that were positive in the immunostaining were counted in each section. The results were evaluated by various statistical methods. RESULTS: The PC-10 score showed a statistically significant difference across the three groups (p = 0.002). The control group showed the highest PC-10 score (median 31.0 PCC/HPF) followed by the tumour regrowth group (median 4.9 PCC/HPF). The lowest PC-10 scores were found in the non-recurrent tumours (median 0.05 PCC/HPF). The MIB-1 score in the control group (median 5.77 PCC/HPF) was similar to the regrowth group (median 5.4 PCC/HPF). In contrast, the MIB-1 score in the non-recurrent tumours was statistically significantly lower (median 0.42 PCC/HPF). The PC-10 and MIB-1 scores were similar in tumours composed of either spindle cells or epithelioid cells in all groups. CONCLUSIONS: The non-recurrent melanomas demonstrate significantly lower cellular proliferation activity than melanomas that showed regrowth or that were not irradiated at all. In our hands, PCNA gave more meaningful information than Ki-67. Our findings strongly support the need for treating regrowing posterior uveal melanoma either by enucleation or re-treatment by brachytherapy. On the other hand, also in the non-recurrent uveal melanomas there are viable cells with potential for proliferation, although fewer in number, with unknown capacity for metastatic spread. Therefore, the irradiated tumours should be followed for many years, probably for life.

Interferon-alfa treatment of facial infantile haemangiomas: with emphasis on the sight-threatening varieties. A clinical series.

PURPOSE: To report on the efficacy of systemic Interferon-alfa therapy in controlling the endothelial proliferation in expanding facial haemangiomas of infancy threatening the eye. METHODS: The series comprised 9 subjects with facial haemangiomas of rapid growth within the first few months of life. All haemangiomas had relation to an eyelid and affected the visual access to the eye. At least three tumours were also intraorbital, and in one case the glottis was affected. Interferon-alfa was given subcutaneously in daily doses of 3 mio units/m2. Ophthalmic follow-up including ultrasound evaluation was done, initially with intervals of 4-8 weeks. RESULTS: Interferon-alfa was given over 9-41 weeks (median duration 22 weeks) in cumulated doses of 63-287 million units. Progression was arrested in all and with a subsequent tumour regression considered accelerated as judged from earlier clinical giant haemangioma experience. A control series was not possible. One patient had systemic prednisone added over some weeks. Two infants reacted with a flu-like malaise. A premature infant developed a slight spastic diplegia. CONCLUSIONS: In the 9 infants with growing ophthalmic haemangiomas we recorded a good response to systemic Interferon-alfa administered as daily doses by subcutaneous injection. In general the treatment appeared well tolerated. During clinical follow-up diagnostic ultrasound evaluation (the depth dimension) proved helpful; in particular there was a sparing effect on CT and MRI scans which require general anaesthesia.

Human papillomavirus in conjunctival papilloma.

AIM: To examine conjunctival papillomas for the presence of human papillomavirus (HPV) and koilocytosis. METHODS: Archival paraffin embedded tissue from 55 conjunctival papillomas was analysed for the presence of HPV by polymerase chain reaction and subsequent filter hybridisation. Histological sections of the 55 papillomas were evaluated for the presence of koilocytosis. RESULTS: HPV was present in 48 of 52 (92%) beta globin positive papillomas. HPV type 6/11 were found in 40 of 47 investigated papillomas and a double infection with HPV 6/11 and 16 was identified in a single papilloma. In six papillomas the HPV type could not be identified. Koilocytosis was present in 22 of 55 papillomas (40%). CONCLUSION: There is a strong association between HPV and conjunctival papillomas. HPV type 6/11 is the most common HPV type in conjunctival papilloma. The sensitivity of koilocytosis as an indicator of HPV in conjunctival papilloma is low.

Lack of FasL expression in cultured human retinal pigment epithelial cells.

Retinal pigment epithelial (RPE) cells have been proposed to play a part in maintaining the eye as an immune privileged organ. However, our knowledge of the implicated mechanism is still sparse. Fas ligand (FasL) expression of RPE cells is generally recognized to be essential for the immune privilege of the eye, but due to contradictory published results, it is unclear whether RPE cells express this molecule. The purpose of this study was to investigate the expression of FasL in RPE cells in vitro and in vivo. Cultured human fetal and adult RPE cells were examined by flow cytometry, Western blotting, RT-PCR and RNase Protection assay for FasL expression. Additionally, sections of ocular tissue were stained for FasL by immunohistochemistry. None of the used methods indicated FasL expression in cultured fetal or adult RPE cells of various passages. However, RPE cells in vivo, as judged from tissue sections, were positive for FasL, indicating a discrepancy between RPE cells in vitro and in vivo with regard to this molecule.