[Long-term progression in a case of transvitreal endoresection of a posterior choroidal malignant melanoma].

BACKGROUND: In Japan, there are few reports of the prognosis of the endoresection of malignant choroidal melanoma. We previously reported this case of transvitreal endoresection of a posterior choroidal malignant melanoma. The tumor recurred and enucleation was carried out. Here we report the subsequent long-term clinical course. CASE: A choroidal tumor temporal to the macula was noted in the right eye of a 47-year-old male patient. The tumor size increased within the 1 year of observation and was suspected to be a malignant choroidal melanoma. Since the patient strongly wished to preserve his eyeball, he underwent infrared diode laser photocoagulation, resulting in further progress of the tumor. Three months later a transvitreal piecemeal endoresection was carried out. Four years after endoresection, the tumor recurred, and then the eyeball was enucleated. A pathological examination identified a spindle-cell type malignant melanoma located in the posterior part of the eyeball. No invasion was observed within the sclera or optic nerve. Neither local recurrence nor metastasis has been observed for 5 years after the enucleation. CONCLUSION: In this case, in spite of our utmost efforts, the eyeball could not be preserved. This case can provide useful information for considering endoresection as a management tool for choroidal melanoma.

Endophthalmitis caused by Enterococcus mundtii.

Enterococcus mundtii has rarely been isolated from environmental or human sources. We report the identification of E. mundtii as a pathogen of human infectious disease by DNA sequencing of 16S rRNA and sodA genes in a case of endophthalmitis developed in a 66-year-old immunocompetent gardener.

Bilaterally identical monoclonality in a case of primary intraocular lymphoma.

PURPOSE: To report a case of primary intraocular lymphoma possessing bilaterally identical monoclonal rearrangements of the immunoglobulin heavy chain (IgH) gene. DESIGN: Observational case report. METHODS: A 78-year-old woman with bilateral vitritis, subretinal infiltrates in the right eye, and no involvement of the central nervous system (CNS) was diagnosed histologically with diffuse large B-cell lymphoma by a transvitreal subretinal biopsy of the right eye. One month later, vitrectomy was performed on the left eye due to increased vitreous opacity. DNA was extracted from a vitrectomy specimen from each eye, and the third complementarity-determining region of IgH gene was analyzed by polymerase chain reaction and direct sequencing. RESULTS: Monoclonal rearrangements of IgH gene with identical DNA sequence were detected in both eyes. CONCLUSIONS: Bilaterally identical monoclonality was detected in a case of primary intraocular lymphoma with no CNS involvement.

Indocyanine green staining for the triple corneal procedure.

BACKGROUND AND OBJECTIVE: In the triple corneal procedure, successful completion of capsulorhexis is of the utmost importance. Another use of indocyanine green dye for better visualization of the anterior lens capsule of mature cataract during the triple corneal procedure is described. PATIENTS AND METHODS: Four consecutive patients (mean age, 69.5 years) with both mature cataracts and corneal opacity underwent the triple corneal procedure. After trephination of the recipient cornea, the anterior capsule of the lens was stained with indocyanine green. A continuous curvilinear capsulorhexis (CCC) was performed, after which conventional triple corneal procedures were followed. RESULTS: In all four cases, this technique markedly improved visualization of the lens capsule and resulted in successful and easy manipulation of the CCC and subsequent removal of residual lens cortex. CONCLUSIONS: Staining of the anterior capsule of mature cataract in the triple corneal procedure clearly defines the border of the capsule, thus allowing easy and complete execution of CCC.

Optical coherence tomographic and angiographic findings of a case with subretinal toxocara granuloma.

PURPOSE: To study a case with a subretinal Toxocara granuloma. DESIGN: Interventional case report. METHODS: A patient with a exudative macular lesion, diagnosed as ocular toxocariasis, was examined with optical coherence tomography (OCT) and angiography before and after systemic corticosteroid and anthelminthic therapy. RESULTS: In OCT images, the macular granuloma initially appeared as a highly reflective mass protruding above the retinal pigment epithelium and showed dye leakage by angiography. Posttherapy, the lesion was no longer exudative, was less elevated, and was covered by the retinal pigment epithelium. There was reticular hyperfluorescence surrounded by a hypofluorescent rim in the angiograms. CONCLUSIONS: Subretinal Toxocara granuloma may have a presentation similar to idiopathic choroidal neovascularization (CNV) and should be included in the differential diagnosis of the idiopathic CNV.

Immunohistochemical and molecular genetic evidence for type IV collagen alpha5 chain abnormality in the anterior lenticonus associated with Alport syndrome.

OBJECTIVE: To present evidence for a type IV collagen alpha5 chain (alpha5[IV]) abnormality in the anterior lens capsule of a patient with anterior lenticonus associated with Alport syndrome. METHODS: The anterior lens capsule obtained from a 54-year-old man with anterior lenticonus associated with Alport syndrome was examined ultrastructurally and stained immunohistochemically for the alpha chains of type IV collagen, alpha1(IV) to alpha6(IV). A search was also made for a mutation in the COL4A5 complementary DNA encoding the alpha5(IV) chain by reverse transcription-polymerase chain reaction of illegitimate transcripts. RESULTS: The anterior lens capsule of the patient was much thinner than that of normal subjects and lacked the alpha3(IV) to alpha6(IV) chains immunohistochemically, while control specimens stained positively for all of the alpha(IV) chains. The patient had a C-to-T transition at nucleotide 5231 causing a nonsense mutation, R1677X, in the COL4A5 complementary DNA. CONCLUSION: Our findings demonstrated that normal anterior lens capsules express all of the alpha(IV) chains and that a patient with anterior lenticonus associated with Alport syndrome had a mutation in the COL4A5 gene resulting in the lack of immunoreactivity to alpha3(IV) to alpha6(IV) chains in the anterior lens capsule. Clinical Relevance This study showed abnormal composition of alpha(IV) chains in the anterior lens capsule of a patient with anterior lenticonus caused by a nonsense mutation in the COL4A5 gene. Further investigation of the phenotype-genotype relationship will provide a better understanding of the molecular pathogenesis of anterior lenticonus.

Temporary use of a customized, glued-on hard contact lens before penetrating keratoplasty for descemetocele or corneal perforation.

Descemetocele or corneal perforation makes it difficult to perform penetrating keratoplasty (PKP). To circumvent this difficulty, a polymethylmethacrylate hard contact lens with a diameter of 4.0 mm was customized and applied to the cornea with tissue adhesive prior to PKP in three patients, one with corneal perforation and two with descemetoceles. The results showed that this modified method facilitated trephination during PKP without complications in all three patients, suggesting that it may be applicable to other similar clinical situations.

Accuracy of intraocular pressure by Tono-Pen XL over amniotic membrane patching in rabbits.

PURPOSE: To report an accuracy of intraocular pressure (IOP) by Tono-Pen XL over amniotic membrane patching in rabbits. DESIGN: Experimental study. METHODS: Seven male albino rabbits were used in this study. After general anesthesia, IOP was measured in both eyes using the Tono-Pen without amniotic membrane. A single layer amniotic membrane was then immediately placed over the rabbit eye, and the IOP measurement was repeated. RESULTS: The average IOP without amniotic membrane was 5.8 +/- 0.6 mm Hg (mean +/- SD). The average IOP through amniotic membrane was 6.0 +/- 0.4 mm Hg (mean +/- SD). There was no statistical difference in IOP measured on corneas with or without the amniotic membrane (P =.34). CONCLUSIONS: The accuracy of IOP measurement by Tono-Pen XL over a single layer of amniotic membrane patching was demonstrated using rabbit eyes. Further studies in human eyes may verify our findings in actual clinical settings.

Does precipitation reduce tissue staining by indocyanine green dye solutions?

PURPOSE: Indocyanine green (ICG) dye precipitates when mixed with certain ophthalmic irrigation solutions. The purpose of this study is to investigate whether this precipitation reduces ICG staining of the anterior lens capsule. METHODS: ICG was diluted with each of the following solutions: BSS Plus, physiological saline, or Opeguard Neo. The products were then examined for green precipitate by light microscopy. The tissue staining capability of each ICG solution was tested at two different concentrations (0.5% and 0.0625%) in porcine lenses, regardless of whether the solution contained precipitate. RESULTS: Green precipitate was observed in both concentrations of ICG solutions diluted with BSS Plus, but not in the solutions diluted with either physiological saline or Opeguard Neo. As assessed with light microscopy, staining of the anterior lens capsule appeared weaker for all 0.0625% ICG solutions compared to the corresponding 0.5% ICG solutions. The precipitate that formed in the 0.5% ICG solution diluted with BSS Plus had little effect on the staining quality of the anterior lens capsule. In contrast, the 0.0625% ICG solution diluted with BSS Plus (w/precipitate) showed weaker staining in the lens capsule compared to the other two 0.0625% ICG solutions (w/o precipitate). CONCLUSION: These results suggest that precipitation of ICG may weaken its capability to stain the anterior lens capsule or other transparent ocular tissues. Therefore, ICG solutions that do not form a precipitate may be more capable of staining tissues at lower concentrations. As for other possibilities to explain the deterioration in staining, the effect of the composition of BSS Plus should also be considered.

Characterization and diabetes-induced impairment of nitric oxide synthase in rat choroid.

PURPOSE: To examine the nitric oxide (NO) system in the choroid of normal rats and rats with streptozotocin (STZ)-induced diabetes. METHODS: We assayed NO synthase (NOS) activity by monitoring the conversion of L-[(14)C] arginine to L-[(14 )C] citrulline, identified the NOS isoforms by immunoblotting, and examined the effects of STZ-induced diabetes on NOS in the rat choroid. RESULTS: Calcium-independent NOS activity was insignificant in the choroid of normal and diabetic rats. Choroidal calcium-dependent NOS activity was high and comparable to that in the cerebellum. Neuronal (n) NOS protein in the choroid was found in both the membrane and cytosolic fractions and showed similar subcellular distribution as NOS activity, while endothelial (e) NOS protein in the choroid was present almost solely in the membrane fraction. Total NOS activity (nNOS + eNOS) and protein levels of nNOS and eNOS in the choroid were significantly reduced 6 weeks after the induction of diabetes. CONCLUSIONS: The high NOS activity in the choroid measured in vitro appears to come mostly from nNOS. Because choroidal nNOS exists in the parasympathetic perivascular nerve fibers, the decrease in choroidal nNOS in diabetic eyes suggests that the choroid undergoes a diabetes-induced neuronal disorder. Thus, diabetic choroidopathy encompasses diabetic neuropathy and microangiopathy.

Detection of measles virus genomic RNA in tear samples from a patient with measles keratitis.

PURPOSE: To report a case of measles keratitis, in which measles virus genomic RNA was detected in tear samples. METHODS: Samples of tears and pharyngeal mucus were obtained from a 19-year-old man with active systemic measles on day 7 after illness onset. These specimens were then subjected to reverse-transcriptase polymerase chain reaction (RT-PCR), using measles-specific primers. RESULTS: One week after systemic measles outbreak, the patient presented with a chief complaint of irritation in both eyes. Slit-lamp examination revealed bilateral superficial punctate keratopathy in the central cornea with small diffuse subepithelial infiltrations, and RT-PCR detected measles virus genomic RNA in tears and pharyngeal mucus. The patient was treated with topical 0.1% fluorometholone and 0.5% levofloxacin three times a day for 1 week, and the keratopathy resolved without sequelae. CONCLUSION: This report demonstrates for the first time the presence of measles virus genomic RNA in the tears of a patient with measles keratitis. It also highlights the utility of RT-PCR for rapid detection of measles RNA in tear or mucus samples. Furthermore, the presence of virus in bodily fluids and secretions signifies the potential contagiousness of this type of keratopathy.

Fornix and conjunctiva reconstruction by amniotic membrane in a patient with conjunctival mucosa-associated lymphoid tissue lymphoma.

BACKGROUND: Conjunctival mucosa-associated lymphoid tissue (MALT) lymphoma is a rare, low-grade, non-Hodgkin's B-cell lymphoma. Herein, we report our successful management of the large conjunctival defect caused by resection of conjunctival MALT lymphoma by covering it with transplanted amniotic membrane. CASE: A 28-year-old Japanese man, who had been diagnosed histologically as having conjunctival MALT lymphoma in his left eye, was referred to us for treatment. The tumor was located on the lower bulbar and palpebral conjunctiva, and involved the fornix. Extensive resection of the conjunctival lesion was performed. Two pieces of amniotic membrane were used to reconstruct the fornix, bulbar, and palpebral conjunctival defect. OBSERVATIONS: Epithelialization over the transplantation was completed within 3 weeks when all sutures were removed. During the 6 months of follow-up, there was no recurrence or any postoperative complication, such as graft rejection, symblepharon, or chronic inflammation. CONCLUSIONS: We demonstrated for the first time that amniotic membrane can be used to cover a large defect on both bulbar and palpebral conjunctiva when such a low-grade malignancy as MALT lymphoma is extensively excised. Amniotic membrane transplantation was quite effective for the fornix and conjunctival reconstruction.

Successful management of conjunctival intraepithelial neoplasia by interferon alpha-2b.

BACKGROUND: Interferon alpha-2b (IFN alpha 2b) was recently shown to be effective as an alternative therapy for conjunctival intraepithelial neoplasia (CIN). Herein, we report our successful management of CIN by the use of IFN alpha 2b. CASE: A 73-year-old woman presented with a complaint of irritation due to a tumorous lesion in her left eye. Slit-lamp microscope examination revealed a tumorous lesion involving the bulbar and palpebral conjunctiva as well as the limbus, from the 3-o'clock position to the 8-o'clock position. She had already undergone cryotherapy in the same eye in another hospital, twice for a lesion on the lower tarsal conjunctiva and once for a lesion on the upper tarsal conjunctiva. The histological diagnosis had been CIN. OBSERVATIONS: In treating this patient, IFN alpha 2b was injected subconjunctivally twice and also applied as eye drops for 12 weeks. Two weeks after the initial treatment, the tumorous lesion disappeared. During a 1-year follow-up period, no recurrence was noted. CONCLUSION: Topical and subconjunctival IFN alpha 2b is a valuable treatment option for CIN.

Visualization of conjunctival cyst by indocyanine green.

PURPOSE: To report complete removal of conjunctival cyst using indocyanine green solution to facilitate visualization. DESIGN: Interventional case report. METHODS: A 71-year-old woman referred with the diagnosis of severe conjunctival chemosis of her right eye of several months' duration was found to have a large conjunctival cyst. After informed consent was obtained, surgical resection of the cyst was performed. RESULTS: Under topical anesthesia, indocyanine green solution was injected through a 27-gauge needle into the conjunctival cyst. This achieved excellent visualization of the cyst outline and facilitated complete resection. During the resection, staining of the cyst wall remained despite a small perforation in the capsule, and complete resection was achieved without difficulty. CONCLUSION: Injection of indocyanine green solution into a conjunctival cyst may be used to facilitate visualization and aid in complete resection of the cyst wall.

Perfluorocarbon liquid assists in stripping the ILM to treat detached retina caused by macular hole.

Stripping the internal limiting membrane (ILM) is supposed to be beneficial in attaching the retina in retinal detachment because of macular hole. However, it is difficult to lift up and strip the ILM over extensively detached retinas because such retinas are very mobile. To evade this difficulty, we flattened the detached retina with perfluorocarbon liquid (PFCL) and peeled the ILM in the presence of PFCL. The ILM flap was easily turned up and enlarged with the posterior counter traction by PFCL. Intraoperative flattening of the retina with PFCL is useful in peeling the ILM from detached retinas.

Surgical treatment of limbal vernal keratoconjunctivitis by resection of a limbal lesion.

PURPOSE: To report our experience managing a limbal mass associated with limbal vernal keratoconjunctivitis (VKC) by surgical excision. METHODS: A 16-year-old girl was referred to our hospital with the chief complaints of itching and photophobia in both eyes. She had a 2-year history of gradually enlarging limbal gelatinous masses on the temporal limbus in both eyes, which were diagnosed as limbal papillae of VKC. As the symptoms in her left eye were more severe, surgical resection of the limbal mass in her left eye was performed to relieve mechanical stress on the eyelid, followed by a free conjunctival autograft taken from the supranasal bulbar conjunctiva. RESULTS: After excision of the mass, ocular inflammation and other symptoms gradually disappeared. At 12-month follow-up, there was no recurrence of the mass. Findings in a histological examination of the excised limbal lesion were consistent with those of limbal papilla of VKC. CONCLUSION: In recalcitrant cases of limbal VKC, in which the symptoms are apparently caused by an elevated limbal mass, surgical excision of the limbal mass can be one of the therapeutic modalities, and it may facilitate resolution of the symptoms caused by chronic limbal VKC.