[Chronic blepharitis. Pathogenesis, clinical features, and therapy]. / Chronische Blepharitis. Pathogenese, klinischer Verlauf und therapeutische Ansätze.

Chronic blepharitis is one of the most common diseases of the eyelids, but surprisingly, it is not often recognized. Frequently, a skin disease such as seborrheic dermatitis, atopic dermatitis, or acne rosacea is the underlying cause of chronic blepharitis. Bacterial pathological lipase, cholesterylesterase production, and bacterial lipopolysaccharides are pathogenetically relevant. Only rarely do genuine bacterial infections play a role. Collarettes occur at the base of the eye lashes, and the Meibomian glands show either abundant fluid secretion or inspissated secretion with obstruction of the orifices. Chronic blepharitis can include sequelae including dry eye and corneal and lid contour changes. The basic treatment comprises attendance of the underlying dermatological disease and lid hygiene. In addition, preservative-free tear film substitutes, antibiotics, immunomodulatory agents, or even surgical intervention may become necessary.

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.

Plasmacellular differentiation in extranodal marginal zone B cell lymphomas of the ocular adnexa: an analysis of the neoplastic plasma cell phenotype and its prognostic significance in 136 cases.

AIM: To determine (a) the expression of plasma cell related antigens in extranodal marginal zone B cell lymphomas (EMZL) of the ocular adnexa; and (b) the prognostic value of plasmacellular differentiation in these tumours. METHODS: A consecutive case series of 136 ocular adnexal EMZL obtained from three ocular pathology centres over 20 years was analysed retrospectively. An extensive immunohistochemical panel, including the plasma cell related antigens VS38c, CD38, CD138, multiple myeloma oncogene-1-protein (MUM1/IRF4), and CREB binding protein (CBP) was performed. EMZL were defined as "plasmacellular differentiated" on the basis of morphological features, evidence of cytoplasmic immunoglobulin, negativity for BSAP/PAX5, and expression of at least one of the investigated plasma cell related antigens. Controls included normal or hyperplastic lymphatic tissues. Detailed clinical data were collected for most patients, and compared with the results of immunohistochemistry. The end points considered for statistical analysis were development of local tumour recurrence, development of systemic disease, and lymphoma related death. RESULTS: 57 (42%) of the 136 ocular adnexal EMZL showed a plasmacellular differentiation; 45 of these plasmacytoid cases were primary tumours. In contrast with most admixed normal plasma cells, which displayed co-expression of MUM1/IRF4, Vs38c, CD38, CD138, and CBP, the plasmacellular differentiated EMZL tumour cells demonstrated co-expression of all five plasma cell related antigens in only six of 57 (11%) plasmacellular differentiated ocular adnexal EMZL. The most commonly expressed plasma cell related antigen was MUM1/IRF4, immunoreactivity being seen in 56/57 (98%) plasmacellular differentiated EMZL examined. Although the association of plasmacellular differentiation in primary ocular adnexal EMZL and disseminated disease was statistically significant on univariate analysis (p = 0.042), this was weaker on multivariate analysis. CONCLUSION: Plasmacellular differentiated tumour cells in EMZL demonstrate an aberrant immune profile for plasma cell related antigens when compared with normal plasma cells. On multivariate analysis, plasmacellular differentiation in ocular adnexal EMZL was not significantly associated with local recurrence, the development of systemic disease, or with lymphoma related death.

Long term outcome of ocular adnexal lymphoma subtyped according to the REAL classification. Revised European and American Lymphoma.

AIM: To classify ocular adnexal lymphomas according to the Revised European and American Lymphoma (REAL) classification and to determine any correlation between clinical features or histomorphological variables with the patients' outcome. METHODS: Conventional and immunohistology were performed on representative sections of 53 specimens of 46 patients with ocular adnexal lymphoma. The antibodies used were CD20, BCL-2, CD21, CD23, CD43, CD3, CD5, p53, cyclin D1, pan-cytokeratin, kappa, lambda, IgD, and IgM. The growth fraction of the tumours was determined using the MIB-1 antibody directed against the Ki-67 antigen. Clinical follow up data regarding the outcome were obtained from the treating physicians and/or hospital files. The Student's t test and log rank test were used for statistical analysis. RESULTS: The patient collective consisted of 29 females and 17 males with an age range of 32-89.7 years (average 63 years). Almost all specimens represented B cell non-Hodgkin's lymphomas: extranodal marginal zone lymphoma (EMZL) (n=38), diffuse large cell B cell lymphoma (n=8), lymphoplasmocytic lymphoma/immunocytoma (n=2), mantle cell lymphoma (n=2), follicle centre lymphoma (n=1), and plasmacytoma (n=1). One case of a secondary anaplastic large cell lymphoma of T cell type (T-ALCL) was diagnosed. The majority of the patients had stage I disease. A variety of therapeutic regimens was administered, the main form of treatment being radiotherapy. The average follow up time was 85 months. Complete remission was achieved in 24 patients (10 after excision alone, eight after radiotherapy alone, three after combined excision and radiotherapy, one after chemotherapy alone, and two after combined radiotherapy and chemotherapy). 12 patients died of causes related to lymphoma; in one patient the cause of death was unknown. Six patients had persistent tumour at final follow up and two patients were lost to follow up. The stage at presentation, as well as the lymphoma malignancy category, had a significant correlation with the final course of the disease (p=0.0001 and p=0.03, respectively). A significant correlation was also noted between the final outcome (p<0.05) and tumour cell expression for Ki-67 antigen and p53 protein. CONCLUSION: 67% of patients with ocular adnexal lymphoma had EMZL. The stage at presentation had a significant influence on the final outcome. MIB-1 and p53 expression by the tumour cells proved to be important immunohistochemical markers concerning the prognosis. It is suggested that, following thorough staging investigations, primary EMZL (stage I) (if accessible) should be treated with excisional biopsy and subsequent low dose radiotherapy. Primary diffuse large cell B cell lymphoma of the ocular adnexa requires at least similar therapeutic measures and regular intensive follow up.

Comparison between color duplex ultrasonography and histology of the temporal artery in cranial arteritis (giant cell arteritis).

BACKGROUND: Duplex sonography of the temporal artery may be helpful in the diagnosis of cranial arteritis. PATIENTS AND METHODS: The superficial temporal arteries of 36 patients with cranial arteritis or suspected arteritis were examined using both duplex ultrasonography (US) and biopsy. The data of these patients were divided into two groups. Group A consisted of 24 patients (66.7%) with definite positive results using duplex (US) and Group B of 12 patients (33.3%) who showed a suspicious or negative ultrasonographic result. RESULT: In all patients of Group A, the histological findings corresponded with the ultrasonographic changes in the inflamed artery. - The characteristic ultrasonographic sign was a dark halo around the lumen of the temporal arteries. There was a high correlation between a bilateral halo found by US with an ocular involvement. Ten out of 14 patients with a bilateral halo (71.4%) showed a distinct involvement of the optic nerve or retina. - The characteristic histological signs were infiltration of the vessel wall by inflammatory cells, mainly lymphocytes. Group B: The biopsies of the superficial temporal arteries were positive in 8 patients (66.7 %), negative in 4 other patients (33.3%). CONCLUSION: Patients with a distinct halo, demonstrated by US, also showed corresponding pronounced inflammatory cell infiltration of the vessel wall. Patients with no ultrasonographic changes presented histological signs of initial inflammation such as isolated inflammatory cells around the vasa vasorum and/or in the adventitial layer.

Long-term results after filtering surgery with limbal-based and fornix-based conjunctival flaps.

BACKGROUND AND OBJECTIVE: To compare the long-term results of filtering surgery using either a limbal-based or fornix-based flap. PATIENTS AND METHODS: From 1985 to 1988, 90 eyes of 81 glaucoma patients undergoing filtering surgery were included in a prospective randomized clinical trial. They were alternately operated on with either a limbal-based or fornix-based conjunctival flap. The authors evaluated the functional and morphologic long-term results of 34 eyes (18 fornix based, 16 limbal based) after a minimum follow-up of 6 years. Intraocular pressure (IOP), visual acuity, visual field, intensity of symptoms due to dry eyes, and corneal overlap of the filtering bleb using planimetry were reexamined. RESULTS: No statistically significant difference of IOP reduction, deterioration of visual acuity, deterioration of visual field, sicca score, or corneal overlap of the filtering bleb was found between the limbal-based and fornix-based groups. There was no correlation between corneal overlap of the filtering bleb and the sicca score. CONCLUSION: The long-term results of fornix-based and limbal-based filtering surgery did not show a statistically significant difference.

[Intensive intracorneal keloid formation in a case of Peters plus syndrome and in Peters anomaly with maximum manifestation]. / Ausgeprägte intrakorneale Keloidbildung bei Peters-Plus-Syndrom und bei einer Maximalvariante der Peters-Anomalie.

We present two cases of Peters anomaly (Peters plus syndrome and a maximum manifestation variant) with abnormally thickened cornea and corneal staphyloma. Both patients presented to our hospital shortly after birth and were treated with perforating keratoplasty and lensectomy. Histological analysis showed marked thickening of the corneal stroma due to abnormal stromal connective tissue deposition. Additionally, both eyes showed the characteristic changes of Peters anomaly with corneal opacity, adherence of the iris stroma and anterior lens surface to the posterior corneal surface, absence of the corneal endothelium, Descemet and Bowmans layers. Peters anomaly with abnormally thick intracorneal fibrosis with or without congenital corneal staphyloma is a very rare manifestation.

[Isolated corneal intraepithelial dysplasia]. / Isoliertes Carcinoma in situ der Kornea.

We present the case of an 83-year-old patient with an isolated epithelial dysplasia of the cornea. After corneal abrasion the lesion reoccurred 14 days later. The abrasion was then increased to cover the whole corneal epithelium and adjacent limbal and conjunctival areas were also biopsied. Histology revealed a corneal epithelial dysplasia stage 3, whereas the limbal and conjunctival biopsies showed normal epithelium. After resection two cycles of local mitomycin C application (2 cycles of 14 days each) were administered and 9 months after the second intervention the cornea remained clear with good vision. The investigation for human papillomavirus showed a type 6, which is not associated with an increased risk of malignancy.

TGFBI (BIGH3) gene mutations in German families: two novel mutations associated with unique clinical and histopathological findings.

BACKGROUND: To report the clinical, histopathological and immunohistochemical findings of two novel mutations within the TGFBI gene. METHODS: The genotype of 41 affected members of 16 families and nine sporadic cases was investigated by direct sequencing of the TGFBI gene. Clinical, histological and immunohistochemical characteristics of corneal opacification were reported and compared with the coding region changes in the TGFBI gene. RESULTS: A novel mutation Leu509Pro was detected in one family with a geographic pattern-like clinical phenotype. Histopathologically we found amyloid together with non-amyloid deposits and immunohistochemical staining of Keratoepithelin (KE) KE2 and KE15 antibodies. In two families and one sporadic case the novel mutation Gly623Arg with a late-onset, map-like corneal dystrophy was identified. Here amyloid and immunohistochemical staining of only KE2 antibodies occurred. Further, five already known mutations are reported: Arg124Cys Arg555Trp Arg124His His626Arg, Ala546Asp in 13 families and five sporadic cases of German origin. The underlying gene defect within the TBFBI gene was not identified in any of the four probands with Thiel-Behnke corneal dystrophy. CONCLUSIONS: The two novel mutations within the TGFBI gene add another two phenotypes with atypical immunohistochemical and histopathological features to those so far reported.

Keratoepithelin in secondary corneal amyloidosis.

BACKGROUND: Amyloid is found in several corneal dystrophies, including distinct lattice corneal dystrophies (LCD) and Avellino corneal dystrophy. Recently, point mutations in the transforming growth factor-beta-induced gene (TGFBI) encoding for keratoepithelin (KE) have been demonstrated in these corneal disease entities. We intended to investigate if KE was also a component of the rarely seen secondary corneal amyloid deposits. METHODS: Immunohistochemical staining with a polyclonal antibody against KE was performed on formalin-fixed paraffin-embedded tissue of five corneal buttons with secondary amyloid obtained after keratoplasty. Secondary amyloidosis was due to Fuchs endothelial dystrophy (FED) with bullous keratopathy and/or recurrent erosions in all cases. The diagnosis had been established by light microscopy using Congo red staining. Two cases of LCD type I served as positive controls and three corneas with FED and one with keratoconus without amyloid served as negative controls. RESULTS: All corneas with secondary amyloidosis as well as LCD type I revealed positive staining in the respective amyloid deposits. KE was localized in the subepithelial pannus and in the anterior stroma in the corneas with secondary amyloidosis. In the specimens with LCD type I it was distributed in the amyloid deposits located in the anterior and mid-stroma. Staining for KE showed a granular appearance in all cases. The intensity of staining was variable among the specimens. CONCLUSIONS: KE is found not only in primary amyloid deposits of hereditary corneal dystrophies, but also in secondary amyloidosis of the cornea of diverse ethiologies.

[Molecular genetic and histopathological examinations for genotype-phenotype analysis in patients with TGFBI-linked corneal dystrophy]. / Molekulargenetische und histopathologische Untersuchungen zur Genotyp-Phänotyp-Analyse bei Patienten mit TGFBI-gekoppelten Hornhautdystrophien.

PURPOSE: Different missense mutations in the TGFBI gene cause granular (Groenouw CDGG1, Avellino CDA, Reis-Bücklers CDB1) and lattice (Type I; Biber-Haab-Dimmer; CDL1) corneal dystrophies and, in some reports, corneal dystrophy Thiel-Behnke (CDB2). We report on the mutation spectrum and the genotype-phenotype correlations on the basis of clinical and histopathological examinations of 13 German families with TGFBI-linked corneal dystrophies. METHODS: In 31 patients with different corneal dystrophies, DNA was extracted from leukocytes of the peripheral blood and mutation analysis was performed by direct sequencing of the TGFBI gene. Clinical and histopathological findings were compared with the molecular genetic findings for genotype-phenotype correlations. RESULTS: In 6 patients (2 families/one single person) with clinical and histopathological CDL1 we found a Missense mutation Arg124Cys and in 7 patients (3 families/one single person) with clinical and histopathological CDA we found a Missense mutation Arg124His in the exon 4 of the TGFBI gene. In 12 patients (4 families/2 single persons) with clinical and histopathological CDGG1 we found a Missense mutation Arg555Trypt in the codon 12 of the TGFBI gene. In all five patients (1 family/4 single persons) with clinical and histopathological CDB2 we could not find any mutation in the TGFBI gene. In one patient with exceptional clinical and histopathological findings we found a Missense mutation Ala546Asp, which was reported before only twice in connection with polymorphous corneal amyloidosis. CONCLUSIONS: In comparison of our clinical and histopathological findings and the molecular genetic results we found a strong genotype-phenotype correlation in patients with TGFBI-linked corneal dystrophies. Rare mutations can lead to exceptional clinical and histopathological findings which cannot be classified into the different groups of corneal dystrophies. In our patients with CDB2 we could not find any molecular genetic correlation to the TGFBI gene.

Sympathetic ophthalmia: an immunohistochemistry study of four cases.

We present histological and immunohistochemical data on four cases of sympathetic ophthalmia, a disease that is believed to occur predominantly after perforating injury to the eye. Only a few cases without previous perforation have been reported. Nevertheless, sympathetic ophthalmia should be taken into consideration if there is a bilateral intraocular inflammation, even without trauma, as in two of our cases (cases 1 and 2). An unusual case after uneventful intracapsular cataract extraction and a posttraumatic "classic" case are also presented (cases 3 and 4). We found a granulomatous infiltration of the uveal tract by lymphocytes, plasma cells, and epithelioid cells, particularly of the choroid. Dalen-Fuchs nodules were found in all cases, the second case also being associated with phacoanaphylaxis. Case 1 and 4 showed immunohistochemically a predominance of CD3-positive cells (T-lymphocytes), whereas in cases 2 and 3, many cells surprisingly stained positively for L26 (B-lymphocytes). In case 2 the immune response may have been altered by the additional phacoanaphylaxis. In all four cases, scattered epithelioid cells stained positively for CD 68. We conclude that in cases of bilateral uveitis, even without previous penetrating injury or after common intraocular surgery, sympathetic ophthalmia as a possible cause should be taken into consideration because an early diagnosis with subsequent enucleation of the exciting eye is of decisive influence on the course of the disease.