[A case of ring melanoma found while treating traumatic glaucoma].

BACKGROUND: Ring melanoma, a malignant melanoma which infiltrates over 180 degrees degrees of the ciliary body is very rare in Japan. We report a case of ring melanoma found while treating treatment of traumatic glaucoma with an ultrasound biomicroscope (UBM). CASE: A 44-year old woman presented with high intraocular pressure after blunt trauma in her left eye. CLINICAL FINDINGS: Best-corrected visual acuity OS was 1.2, and intraocular pressure was 30 mmHg. Gonioscopy showed about 180 degrees of the angle recession. Intraocular pressure was difficult to control in spite of anti-glaucoma drug treatment. Rapid progression of iris elevation and 360 degrees thickening of the ciliary body were detected by UBM. We detected atypical cells with melanine granules in the aqueous fluid and positive findings in PET-CT, leading to a diagnosis of ciliary body malignant melanoma. Consequently we enucleated the left eye. The histopathological diagnosis was ring melanoma. CONCLUSION: Ring melanoma is an important element in the differential diagnosis for untreatable secondary glaucoma.

A Case of Cardiac Amyloidosis Presenting with Mid- to Late Diastolic Retrograde Flow from the Left Atrium to the Pulmonary Vein: Transesophageal Pulsed Doppler Echocardiographic Observations.

A patient of cardiac amyloidosis was found to have mid- to late diastolic retrograde flow from the left atrium (LA) to the pulmonary vein. Congo-red staining was positive for amyloid in the rectal tissue. M-mode and two-dimensional echocardiograms revealed symmetric hypertrophy and typical speckled pattern of the left ventricle (LV). The LV pressure curve showed a dip and plateau configuration during diastole, and end-diastolic pressure was 28 mmHg. In addition, the LV pressure was high at mid-diastole, surpassing the pulmonary capillary wedge pressure from mid- to late diastole. The transmitral flow velocity revealed "restrictive" pattern, and the pulmonary venous flow velocity showed retrograde flow from the LA to the pulmonary vein during mid-diastole and atrial systole. It is suggested that recording of the pulmonary venous flow velocity by transesophageal pulsed Doppler echocardiography is useful for understanding the mechanism of the development of pulmonary congestion or edema. (ECHOCARDIOGRAPHY, Volume 13, November 1996)

Left Atrial Contribution to Left Ventricular Filling in Patients with Mitral Stenosis: Combined Analysis of Transmitral and Pulmonary Venous Flow Velocities.

We recorded transmitral and pulmonary venous flow velocities using transthoracic continuous-wave and transesophageal pulsed Doppler echocardiography, respectively, in 36 patients with mitral stenosis who were in sinus rhythm to investigate the left atrial contribution to left ventricular filling in mitral stenosis. The mitral valve area was determined by transthoracic two-dimensional short-axis echocardiography. Patients were classified as having mild stenosis (>/=1.5 cm(2), n = 17) or moderate stenosis (<1.5 cm(2), n = 19). The mean pulmonary capillary wedge pressure and left atrial maximal diameter were significantly larger, and left atrial volume change during atrial contraction was significantly smaller in the moderate group than in the mild group. The percent left atrial contribution to left ventricular filling, estimated from the transmitral flow velocity, the peak atrial systolic velocity, and the percent ratio of left atrial systolic regurgitation to left atrial filling, estimated from the pulmonary venous flow velocity, were significantly lower in the moderate group than in the mild group. The percent left atrial contribution to left ventricular filling, the peak atrial systolic velocity, and the percent ratio of left atrial systolic regurgitation to left atrial filling were positively correlated with the mitral valve area and negatively correlated with the mean pulmonary capillary wedge pressure. These results suggest that the left atrial contribution to left ventricular filling in patients with mitral stenosis in sinus rhythm decreases as the severity of valve stenosis increases, and that analysis of the atrial systolic waves of the transmitral and pulmonary venous flow velocities provides important information for evaluation of left atrial systolic performance in patients with mitral stenosis.

Transesophageal Pulsed Doppler Echocardiographic Study of Systolic Flow Velocity Patterns of the Pulmonary Vein in Patients with Atrial Fibrillation.

We recorded pulmonary venous flow velocity in 27 patients with atrial fibrillation using transesophageal pulsed Doppler echocardiography to investigate the cycle length-dependent characteristics and background of early systolic reversal and second systolic forward waves. The study group consisted of 15 patients with mitral stenosis, 5 patients with left atrial myxoma, and 7 patients without underlying organic heart disease; they were compared with 20 normal controls in sinus rhythm. The mean pulmonary capillary wedge pressure was significantly greater in patients with mitral stenosis and left atrial myxoma than in normal controls and in patients with isolated atrial fibrillation. The mean peak velocity of the early systolic reversal wave was also significantly greater in patients with mitral stenosis and left atrial myxoma than in patients with isolated atrial fibrillation. The mean peak velocity of the second systolic forward wave was significantly lower in patients with mitral stenosis and left atrial myxoma than in controls and in patients with isolated atrial fibrillation. The preceding RR interval had significant negative correlations with the peak early systolic reversal velocity, left atrial pressure during closure of the mitral valve, and peak V wave height of the pulmonary capillary wedge pressure in patients with mitral stenosis and left atrial myxoma. In the same patient groups, the preceding RR interval had significant positive correlations with the peak second systolic forward velocity and amplitudes of the mitral annular and interatrial septal motions during ventricular systole. The variations in the peak velocities of the early systolic reversal and second systolic forward waves with the preceding RR interval were smaller in patients with more severe mitral stenosis. In conclusion, early systolic reversal waves of the pulmonary venous flow velocity reflect left atrial pressure, and the second systolic forward waves reflect left atrial filling. Both velocities vary with disease conditions or preceding RR intervals in atrial fibrillation.

Left Atrial Systolic Performance in the Presence of Elevated Left Ventricular End-Diastolic Pressure: Evaluation by Transesophageal Pulsed Doppler Echocardiography of Left Ventricular Inflow and Pulmonary Venous Flow Velocities.

We recorded left ventricular inflow (LVIF) and pulmonary venous flow (PVF) velocities by transesophageal pulsed Doppler echocardiography in 25 patients with a ratio of peak atrial systolic to early diastolic LVIF velocity of <1 and a left ventricular end-diastolic pressure (LVEDP) of 15 mmHg or greater, as well as in 30 normal subjects. The group consisted of 14 patients with prior myocardial infarction, 7 with dilated cardiomyopathy, and 4 with cardiac amyloidosis, and were divided into: (1) group A (n = 7): peak atrial systolic LVIF velocity of 40 cm/sec or greater; (2) group B (n = 7): peak atrial systolic LVIF velocity of <40 cm/sec and peak atrial systolic PVF velocity of 30 cm/sec or greater; and (3) group C (n = 11): peak atrial systolic LVIF velocity of <40 cm/sec and peak atrial systolic PVF velocity of <30 cm/sec. Although LVEDPs in groups B and C were significantly greater than in group A, there was no difference between groups B and C. The mean pulmonary capillary wedge pressure (mPCWP) in group C was significantly greater than in groups A and B, but there was no difference between groups A and B. The difference between LVEDP and mPCWP (LVEDP - mPCWP) in group B was significantly higher than in groups A and C. Dilatation of the left atrium (LA) was seen in all three groups, particularly in groups B and C. There were no differences in peak atrial systolic LVIF velocity and LA volume change during atrial contraction between group A and the control group, and there were no differences in LA volume change and peak second systolic PVF velocity between groups A and B. LA volume change and peak second systolic PVF velocity were significantly less in group C than in groups A and B. Among the four patients whose courses could be observed after medical treatment with diuretic and vasodilator, one changed from group B to A, one from group B to C, one from group C to A, and one remained in group C. Thus, recording of peak atrial systolic LVIF and PVF by transesophageal pulsed Doppler echocardiography permits detailed evaluation of LA systolic performance in the presence of elevated LVEDP. These two variables provide important information for less invasive differentiation of LA afterload mismatch from LA myocardial failure.