Systemic and ocular findings in 169 prospectively studied child deaths: retinal hemorrhages usually mean child abuse.

The presence and location of ocular hemorrhages were prospectively studied in 169 randomly selected child deaths referred to a medical examiner. Causes of death in the study group included natural diseases and various injuries involving the head, trunk, and asphyxia. Retinal hemorrhages were identified in 70 cases: 62 head injuries, four central nervous system diseases (but not other natural diseases), and four deaths of undetermined cause. The presence of retinal, peripheral retinal, optic nerve sheath, and intrascleral hemorrhages were strongly associated with head injury as compared to other injuries and natural diseases (Yates corrected P-values < 0.001). Among the head-injured with retinal hemorrhages, nine had a history of severe traumatic event (e.g., an unrestrained rear-seat passenger in high-speed collision) and 53 were victims of inflicted injury (e.g. violent shaking). In the absence of a verifiable history of a severe head injury or life-threatening central nervous system disease, retinal and ocular hemorrhages were diagnostic of child abuse.

Are retinal hemorrhages found after resuscitation attempts? A study of the eyes of 169 children.

Resuscitation attempts have been hypothecated to explain retinal hemorrhages in infants who are suspected victims of child abuse. This study was undertaken to test that hypothesis by postmortem ocular examinations following unsuccessful resuscitation attempts on a sample of 169 children selected by 19 prosectors willing to contribute to the study. Cardiopulmonary resuscitation had been attempted for a minimum of 30 min in 131 of the children, whereas 38 controls did not have such protracted attempts; 70 children with prolonged resuscitation attempts had no retinal hemorrhages, including eight children whose fatal blunt force injuries of the trunk represented extremes of the forces used in resuscitation attempts. Children who died of asphyxia, respiratory illnesses, sudden infant death syndrome, and various other causes had no hemorrhages; neither did 21 children who died of head injury or central nervous system (CNS) diseases, nor did 29 controls. Retinal hemorrhages were present in 70 children, 61 with prolonged resuscitation attempts and nine controls. Among those with attempted resuscitation, 56 had head injuries, and four had CNS diseases and sepsis, all recognized causes of retinal hemorrhages. The other death that involved a resuscitation attempt and retinal hemorrhages was an officially "undetermined" death. The child had come from a household with two prior child deaths and documented abuse. No case is found in this study to support the hypothesis that retinal hemorrhages are caused by resuscitation attempts.

Vitreoretinal traction and perimacular retinal folds in the eyes of deliberately traumatized children.

The pathophysiology of perimacular folds in eyes of deliberately traumatized children is disputed. The authors reviewed the clinical and forensic records and systemic and ocular findings at autopsy of three children with perimacular retinal folds who died after being violently shaken. Two of the children suffered direct head trauma in addition to being shaken; one patient was violently shaken without any physical or forensic evidence of direct head trauma. No direct ocular trauma was detected. In each case, the vitreous had partially separated from the retina but remained attached to the internal limiting membrane at the apices of the folds and the vitreous base, implicating traction in the pathogenesis of these folds. Although some intraocular findings in deliberately traumatized children may be explained by direct head injury, the possibility of both direct head trauma and shaking must be considered. Perimacular folds may develop without direct ocular or head trauma and may constitute evidence supporting violent shaking.

Histopathology of rejected orthotopic corneal grafts in the rat.

We have used an orthotopic graft model in the rat to study the histologic characteristics of corneal allograft rejection. Unrejected allogeneic grafts could not be distinguished from clear syngeneic grafts. Although donor Langerhans cells are necessary for the development of delayed-type hypersensitivity (DTH), the histopathological characteristics of rejecting corneal allografts in immunologically naive hosts were identical regardless of the presence or absence of donor Langerhans cells. By contrast, preimmunization had a dramatic effect on the histology of graft rejection. Untreated allografts placed onto pre-immunized recipients underwent a marked cellular necrosis accompanied by minimal inflammation that easily distinguished these grafts from the previous groups. These results suggest that neither the presence nor absence of DTH responsiveness correlates with the histopathological events that accompany corneal graft rejection. However, preimmunization leads to a different histologic pattern of rejection that is characterized by an intense cellular necrosis.

ELISA HIV testing and viral culture in the screening of corneal tissue for transplant from medical examiner cases.

The spread of AIDS and its association with a retrovirus, commonly called T-lymphotropic virus type III (HIV) has produced great concern among those involved in transplantation about the possibility for transmission of this disease through tissue and organ transplant. Isolation of the virus from conjunctiva and tears further heightened this concern for corneal transplants. This review of medical examiner (ME) cases, a population in which high numbers of transplant corneas are retrieved, has revealed positive serologic tests for HIV in serum from 5 cases in 205 screens. These represent potential donors based on other standard medical criteria available at the time of collection. This tissue was also submitted for viral culture, and virus was recovered from the corneal tissue in McCarey-Kaufman (MK) media. These findings and case reviews are discussed.

Presentation of the H-Y antigen on Langerhans' cell-negative corneal grafts downregulates the cytotoxic T cell response and converts responder strain mice into phenotypic nonresponders.

We have used the murine cornea is an allograft model to investigate the relative roles of graft-derived IA+ APC (Langerhans' cells) and host-derived APC during the induction of CTL responses to H-Y. The natural exclusion of LC from the immunizing corneal graft led to a specific state of unresponsiveness to H-Y in responder strain mice, while inclusion of LC resulted in responsiveness. Failure to respond to H-Y could not be attributed to the absence of H-Y or IA antigen expression on the surface of LC-deficient grafts but instead, appeared to be due to active suppression of the T helper cell response during in vivo priming. Reprocessing of the H-Y antigen by host APC did not occur after immunization with H-Y presented on H-2-incompatible grafts unless presented initially by graft-derived LC. H-2 as well as some non-H-2 alloantigens were presented to the host without a requirement for donor-derived LC. Thus there appear to be differential requirements for the processing and presentation of alloantigens.

The rapid detection of Acanthamoeba in paraffin-embedded sections of corneal tissue with calcofluor white.

Acanthamoeba keratitis is a difficult diagnosis to make with routine stains and cultures. Gram's, Giemsa, and hematoxylin-eosin stains do not differentially stain Acanthamoeba, making the detection of organisms difficult. Trophozoite and cyst forms in paraffin-embedded corneal tissue sections can be rapidly and differentially stained with calcofluor white. Under the fluorescence microscope, the trophozoites are bright red-orange, and cyst cell walls fluoresce bright apple-green with red-orange cytoplasm. Retrospective identification can be made by destaining hematoxylin-eosin-stained sections. Digesting background corneal tissue with trypsin or collagenase and hyaluronidase solutions helps to more readily identify trophozoites.

Destructive and nondestructive patterns of immune rejection of syngeneic intraocular tumors.

Two immunogenic, syngeneic murine tumors were used to analyze the immunopathological processes associated with the immune rejection of primary intraocular tumors. Intracameral inoculation of P91 mastocytoma, an immunogenic variant of P815 mastocytoma, into DBA/2 mice resulted in progressive tumor growth for several weeks before immune rejection eradicated the intraocular neoplasm. The histopathologic characteristics of the tumor rejection included: a) destruction of the vascular endothelium of the microvasculature feeding the tumor; b) ischemic bulk necrosis; c) extensive innocent bystander damage to normal ocular structures; and d) absence of direct inflammatory cell-to-tumor cell contact. Thus, the immunopathological features resembled a delayed-type hypersensitivity (DTH) lesion. A second intraocular tumor model was similarly studied. UV5C25 fibrosarcoma grew slowly in the eyes of syngeneic BALB/c hosts. In sharp contrast to P91 tumors, a mononuclear cellular infiltrate was prominent within the tumor. After 5 wk, the intraocular tumors were completely rejected without detectable damage to normal ocular structures. The rejection of UV5C25 tumors did not produce scar tissue, damage to vascular endothelium, bulk necrosis, or atrophy of the globe. Although tumor-specific cytotoxic T lymphocytes (CTL) and DTH responses were readily detected, there was no histological evidence for DTH-mediated tumor rejection. Moreover, in situ immunoperoxidase staining indicated that the majority of the infiltrating lymphocytes were CTL, based on their characteristic phenotype: Thy-1+, Lyt-2+. Furthermore, the growth of UV5C25 fibrosarcoma in athymic, natural killer (NK) cell competent BALB/c nude mice demonstrated progressive tumor growth without infiltrating host cells. Collectively, the results indicate that immunogenic intraocular tumors can undergo strikingly different patterns of immune rejection with profoundly different pathological consequences. In one case (P91), tumor rejection occurs by a process that strongly resembles DTH and produces extensive nonspecific damage to normal tissues, resulting in irrevocable loss of vision. In contrast, the second intraocular tumor undergoes an immune rejection that is characterized by precision and a notable absence of damage to normal ocular tissues. The weight of evidence presented here strongly supports the hypothesis that the latter form of tumor rejection is mediated by CTL. Thus, the immunologic pathway invoked for tumor rejection in the eye has a profound effect on the fate of this delicate organ and the preservation of vision.

Neuronal ceroid lipofuscinosis. Ocular histopathologic and electron microscopic studies in the late infantile, juvenile, and adult forms.

Diagnosis of the neuronal ceroid lipofuscinoses (NCLF), a group of recessively inherited neurolipidoses, must rely on clinical as well as light and electron microscopic histopathologic findings, as a precise biochemical defect has not yet been identified. We have studied the eyes from two patients with the late infantile and juvenile forms of the disease. On electron microscopy, we observed, almost exclusively, inclusions with curvilinear profiles in the late infantile type, while multimembranous and curvilinear bodies were seen in juvenile NCLF. In both forms of the disease, retinal destruction seems to start at the photoreceptor and outer retinal levels and progresses from the macular area to the periphery. Conjunctival biopsy is helpful in the diagnosis of these disorders, as demonstrated in the adult case presented here.

Conjunctival lesions in adults. A clinical and histopathologic review.

A total of 2,455 conjunctival lesions in adults (over 15 years old) obtained during a 61-year period were reviewed and histopathologically classified as congenital, acquired epithelial, acquired subepithelial, pigmented, inflammatory/degenerative, and miscellaneous. The most common lesions in decreasing order of frequency were: pterygium, nevus, dysplasia, nonspecific nongranulomatous inflammation, and epithelial inclusion cyst. The most common conjunctival malignancy in adults was squamous cell carcinoma, followed by melanoma, and pagetoid change associated with sebaceous gland carcinoma. Squamous cell carcinomas arise from progressive stages of mild, moderate, and severe dysplasia. These tumors have a low malignant potential but may behave more aggressively in the spindle cell and mucoepidermoid variants. Melanomas arise de novo, from nevi or, most commonly, from acquired melanosis and have an associated 14-32% mortality rate by metastatic spread. Sebaceous carcinomas are often initially clinically misdiagnosed, involve the conjunctiva by pagetoid spread, and can have a low rate of metastasis and death if diagnosed early and excised with frozen-section monitoring of the surgical margins.

Sympathetic ophthalmia. Immunopathological findings.

Ocular tissue from six patients with a clinical diagnosis of sympathetic ophthalmia (SO) was examined using immunohistochemical techniques. All patients presented with a history of bilateral panuveitis after penetrating ocular injury or multiple intraocular surgeries and clinical features of SO. In four cases, classic histopathological features of SO were observed, including granulomatous uveal tract infiltration and subretinal pigment epithelium (RPE) collections of inflammatory cells (Dalen-Fuchs nodules). Bone marrow derived monocytes were the major cellular components in these granulomas. In two cases, histopathology failed to demonstrate typical Dalen-Fuchs nodules or granulomas in the choroid. However, the choroidal infiltrates were composed primarily of T-helper and B lymphocytes, without macrophages or epithelioid cells. The eyes examined in this report indicate that a varied spectrum of immunopathological and histopathological findings may occur in clinically diagnosed SO.

Isolation of the human T-cell leukemia/lymphotropic virus type III from the cornea.

Corneoscleral donor tissue from a donor with a positive serum antibody to HTLV-III but without the overt clinical signs of the acquired immune deficiency syndrome (AIDS) was cultured for the presence of the human T-cell leukemia/lymphotropic virus type III (HTLV-III). The virus was isolated from the two corneal specimens in this patient after the tissue had been stored for four days in McCarey-Kaufman medium. The presence of HTLV-III was confirmed by the detection of viral core proteins (approximately 24,000 protein, termed P24 gag), by immunofluorescence of a touch preparation of the corneal epithelium as well as in cells cultured in vitro. The percentage of immunofluorescent cells detected by HTLV-III anti-P24 antibody ranged between 2% and 3%. These findings emphasize the possibility of transmission of this virus via corneal transplantation surgery. Although no documented cases of AIDS have occurred in corneal transplant recipients, serologic screening of donors before the use of the tissue for transplantation is advisable.

Histopathologic analysis of intraocular allogeneic tumors in mice.

The authors have studied histopathologically the growth, invasion, and regression of allogeneic P815 mastocytoma cells placed in the anterior chambers of eyes of three different strains of inbred mice. Previous clinical observations had suggested that the degree of immunogenetic disparity between tumor and recipient governed the intensity and specificity of the host's immune response to the intraocular neoplasm. Our histopathologic studies confirm this conclusion. BALB/c mice, which are H-2 syngeneic with P815 cells, develop progressively growing tumors around which no evidence of host immune or inflammatory response can be found. P815 cells confront A/J mice with a single class I MHC disparity; early intraocular tumor growth is vigorous in this strain, and when the tumor rejection takes place, it is followed by marked fibrovascular scar tissue formation which destroys intraocular structures, resulting in atrophia bulbi. C57BL/6 mice recognize immunologically three categories of allogeneic class I antigens on P815 cells. In these hosts, early tumor growth within the anterior chamber is feeble and rejection is attended by only minimal inflammation; as a consequence, scar formation is trivial and the eye remains anatomically intact. Based on certain histopathologic features, the authors suggest that two distinctly different immune effector mechanisms are involved in intraocular tumor rejection in A/J and C57BL/6 hosts. One immune rejection process results in extensive innocent bystander destruction of normal host tissues (A/J mice) while the other immune mechanism is more precise and does not damage host ocular structures (C57BL/6 mice).

Acanthamoeba keratitis associated with soft contact lenses.

Three patients (a 13-year-old girl, a 25-year-old man, and a 22-year-old woman) who used daily-wear soft contact lenses, sterilized with saline made from distilled water and salt tablets, developed Acanthamoeba keratitis. Acanthamoeba was cultured from the contact lens solution of one patient. This patient, in whom the diagnosis was made by corneal biopsy early in the clinical course, was successfully treated with topical neomycin-polymyxin, miconazole, and propamidine isethionate. The other two patients underwent penetrating keratoplasty. One of these patients, who received a graft early in the clinical course, developed a recurrence of disease in the graft, whereas the other, who received the graft 18 months after the initial symptoms, has maintained a clear corneal transplant with useful vision.

Ocular histopathology and ultrastructure of Sanfilippo's syndrome, type III-B.

The ocular histopathology of systemic mucopolysaccharidosis, type III-B (Sanfilippo's syndrome) was studied using histochemical and ultrastructural techniques. Cytoplasmic, single-membrane-bound vacuoles containing the major storage product, acid mucopolysaccharide, were found in virtually every ocular tissue. Lamellar cytoplasmic membranous bodies of complex lipid were found mainly in the retinal ganglion cells and the lens epithelium. Many tissues had inclusions that were of an intermediate type and were composed of combined fibrillogranular and lamellar membranous material. Hypopigmentation of the neuroepithelial pigment layers (ie, iris, ciliary, and retinal) seems to be the result of autophagocytosis with melanolysis. Photoreceptor cell degeneration was similar to that seen in some forms of retinitis pigmentosa. The mechanism of photoreceptor cell degeneration is unknown. It may be the result of metabolic dysfunction due to accumulation of mucopolysaccharide in the retinal pigment epithelium.

Epithelial characteristics of the endothelium in Chandler's syndrome.

The cells lining the posterior surface of a corneal button obtained from a patient with Chandler's syndrome were examined by transmission and scanning electron microscopy, and by keratin staining. The ultrastructural appearance with intracytoplasmic 8 nm filaments, desmosomes, microvillous projections, and positive keratin staining suggests that these may be epithelial cells. Clinical specular microscopy of this cornea prior to transplantation revealed characteristic changes that were seen to be related to the density of microvillous projections on the cell membrane.

Ultrastructure of epiretinal membrane causing retinal starfold.

A prominent posterior retinal "starfold" was seen in an eye with an extensive rhegmatogenous retinal detachment. The retina was reattached with a scleral buckling operation. The epiretinal membrane causing the starfold was later removed by vitreous surgery and was studied by electron microscopy, permitting the first such clinicopathologic correlation in a human eye. The membrane was composed of vitreous collagen, newly formed collagen, and cells. The cell types included retinal pigment epithelial (RPE) cells, fibrous astrocytes, and macrophages. The fibrous astrocytes and some of the RPE cells contained intracytoplasmic microfilaments of the type thought to be myofibrils. These may account for contraction of the membrane, causing the starfold configuration of the underlying and adjacent retina.

Retrocorneal smooth-muscle proliferation on rejected corneal graft.

Light microscopy and transmission electron microscopy were used to study an unusual case of retrocorneal proliferation of smooth muscle from an area of iridocorneal synechia in a rejected corneal graft. This membrane was composed of cells with many characteristics of smooth-muscle cells, especially the typical shape, production of a single-layered basal lamina on all sides, and massive intracytoplasmic accumulation of filaments of the typical size.

Ocular clinicopathologic correlation of Hallervorden-Spatz syndrome with acanthocytosis and pigmentary retinopathy.

We studied the eyes of a 10-year-old girl with retinal degeneration, acanthocytosis, and normal betalipoprotein levels. The ophthalmoscopic pattern was characterized initially by a flecked retina and later by bone-spicule formation and "bull's-eye" annular maculopathy. On ultrastructural study, the retinal pigment epithelium varied in size and contained large, round single-membrane-bound aggregates composed of complex melanolipofuscin granules. Cells that had migrated into the outer retinal layers contained similar melanolipofuscin aggregates; these cells were identified as macrophages and correlated with the flecks and macular annulus seen on ophthalmoscopy. The cells around the retinal blood vessels contained normal melanin pigment, were identified as retinal pigment epithelial cells, and correlated with the bone spicule pigmentation found on ophthalmoscopic examination.