[Ocular retention in patients with uveal melanoma managed by a multimodality approach]. / Estudio de la conservación del globo ocular con un abordaje multiterapéutico en el melanoma uveal.

OBJECTIVE: to analyze ocular survival in eyes with uveal melanoma treated with conservative therapies, in a centre that applies all treatment modalities. METHODS: Patients diagnosed with uveal melanoma and treated between September 1990 and April 2007 were included in an historical cohorts study. RESULTS: 273 patients were included. 193 were treated with conservative treatments (70.69%) and 80 were enucleated as primary treatment. 14 patients were enucleated after conservative treatment (7.2%). Kaplan-Meier survival analysis showed an 88% survival probability of the eye in the first 5 years after conservative treatment and 83% at 10 years. CONCLUSIONS: Conservative treatments for uveal melanoma, especially brachitherapy, are safe and effective in relation to tumor control and rate of secondary effects.

A retrospective review of conjunctival melanoma: Presentation, treatment and evolution. / Revisión retrospectiva del melanoma conjuntival: presentación, tratamiento y evolución.

OBJECTIVE: The purpose of the present study is to describe the clinical characteristics and outcomes of patients diagnosed and treated for conjunctival melanoma in the Ocular Oncology Unit of the University Hospital Clinic of Valladolid. METHODS: A retrospective observational case series study was conducted on patients diagnosed with conjunctival melanoma in the Ocular Oncology Unit of University Hospital Clinic of Valladolid, from January 1992 to December 2017. Demographic information and tumour features were recorded in a Microsoft Access database. RESULTS: Among a total of 462 consecutive patients, the tumour was classified as melanocytic in 252 cases (54.5%), with 27 patients having the pathological diagnosis of conjunctival melanoma. The mean age at diagnosis was 59.2years (16-88), and there were 41% males and 59% females, with a mean follow-up of 6.1±6.8years. As regards the origin of conjunctival melanoma, 16 cases (59%) arose from primary acquired melanosis, 26% from nevus, and 15% developed de novo. The treatment performed was incisional or excisional biopsy in all patients, local adjuvant chemotherapy in 15 cases (56%) and brachytherapy in 5 patients (18%). The median survival was 18years and the probability of survival at 5 and 10years was 89% and 69%, respectively. CONCLUSIONS: Conjunctival melanoma is a rare disease, usually undervalued by the patient as well as being underdiagnosed, leading to insufficient and delayed treatment. Early diagnosis and treatment are essential to prevent recurrences and systemic extension, as well as to preserve vision and life.

Intraocular metastasis: comparison of clinical presentation with a known and unknown primary tumour. / Metástasis intraoculares: comparación entre las formas de presentación clínica con tumor primario conocido y desconocido.

OBJECTIVE: The purpose of the present study is to review the frequency of intraocular metastases as first presentation of systemic disease, and to identify clinical and tumour characteristics. METHODS: Retrospective study of consecutive cases diagnosed of intraocular metástasis at a referral intraocular tumours unit between 1993 and 2014. General, epidemiological and ophthalmological characteristics were recorded. RESULTS: A total of 21 patients, with a mean age 62.7 years (31-89) were diagnosed with intraocular metástasis between 1993 and 2014. Both eyes were affected in 4 cases. Location was choroid in 20 cases. The intraocular tumour was the first manifestation of the systemic disease in 13 patients (61.9%). Primary tumour was breast in 47.6% and lung in 23.8%. Diagnosis of the primary tumour was performed by systemic studies, and only 1 patient required intraocular biopsy. Regarding the treatment, the majority of cases were controlled with systemic therapy, with 4 cases requiring additional external beam radiotherapy, and only one enucleation. No clinical differences were found between the cases with known and unknown systemic neoplasia, except in exudative retinal detachment, which was more frequent in the second group. CONCLUSIONS: Although intraocular metastases are the most frequent intraocular tumour, they are not a frequent cause of consultation. In more than half of the cases it is the first presentation of unknown systemic neoplasia as a solitary non-pigmented intraocular mass. Early diagnosis is crucial to establish the appropriate treatment, preserve visual function, and improve the prognosis of the patient.

Primary conjunctival follicular lymphoma mimicking chronic conjunctivitis.

CLINICAL CASE: The case is presented of a 43 year-old male patient with chronic follicular conjunctivitis, negative bacterial serology, and refractory to local treatment. The incisional biopsy performed showed to be consistent with reactive lymphoid hyperplasia. A year later, a new incisional biopsy showed follicular lymphoma, with no systemic involvement, and he was treated with local radiotherapy. DISCUSSION: When a chronic follicular conjunctivitis is refractory to treatment, it is essential to perform an incisional biopsy to establish the histopathological diagnosis that can range from chronic inflammation, reactive lymphoid hyperplasia to lymphoma. Follicular lymphoma is rare among conjunctival lymphomas, and the staging is indispensable for the correct therapeutic approach.

[Ocular hypertension as the principal indicator of onset of uveal melanoma]. / Hipertensión ocular como principal forma de presentación del melanoma uveal.

PURPOSE: To present a series of patients with uveal melanoma masquerading as ocular hypertension. METHODS: Patients diagnosed with uveal melanoma were reviewed, selecting those cases with initial presentation as secondary unilateral glaucoma. Clinical and histopathological information useful for prognosis was examined, such as anterior border localization, size and shape of the tumor, associated ocular pathology, cell type and degree of extraocular extension. RESULTS: Seven patients out of a total of 160 diagnosed with melanoma presented with ocular hypertension (4.3% of the total). Six tumors were large, with only one of them being middle-size. All cases had an associated asymmetric cataract on the affected side. Four cases had neovascular glaucoma, two pseudo-phacolytic glaucoma and the remaining case had invasion of the anterior chamber angle. All cases were unresponsive to medical treatment for glaucoma, due to the unsuspected tumor they harbored. Visual acuity was lower than 0.1 in the affected eye in all patients. Only one case had extraocular extension. A histopathologic examination performed in six cases showed that 3 tumors had epithelioid cellularity and also 3 had varying degrees of extrascleral extension. CONCLUSIONS: In patients presenting with the association of unilateral glaucoma and asymmetric cataract, it is crucial to perform imaging studies, such as ultrasound, in order to rule out the presence of an intraocular tumor, and to achieve an early diagnosis, improving the patient's prognosis and the morbidity of treatments.

Vitamin D inhibits angiogenesis in transgenic murine retinoblastoma.

PURPOSE: Vitamin D compounds have been shown to inhibit tumor growth in a transgenic retinoblastoma murine model. The mechanism of action has not been defined clearly, although an antiangiogenic action has been proposed. METHODS: Transgenic retinoblastoma mice received high (0.05 microgram) and low (0.025 microgram) doses of vitamin D3 by intraperitoneal injection 5 times per week for 5 weeks. Control animals were injected with mineral oil vehicle alone. At 5 months of age, the animals were killed and eyes were enucleated and processed for light microscopy. Paraffin-embedded sections were stained with an immunoperoxidase stain (GS-1) specific for mammalian vascular endothelium. Sections were graded by a single masked reviewer, and intraobserver reliability was assessed. Mean vessel counts were made for each group. RESULTS: The high-dose group had the lowest mean vessel count (8.5), followed by the low-dose group (10.1). The control group had the highest mean vessel count (14.1). Vitamin D-treated animals (high- and low-dose groups combined) had significantly fewer vessels P = 0.001) than untreated controls. CONCLUSIONS: These results support the hypothesis that inhibition of angiogenesis is a mechanism of action for vitamin D in the transgenic retinoblastoma mouse model.

Orbital intradiploic giant epidermoid cyst.

We report a case of an intradiploic epidermoid cyst of the lateral orbital wall that resulted in proptosis and downward displacement of the left eye. Computed tomography and magnetic resonance imaging revealed a bone-destroying mass involving the frontal, sphenoid, and zygomatic bones that extended into the orbit, temporalis, and anterior cranial fossa. Complete surgical removal was performed through a lateral orbitotomy. The lateral wall was reconstructed with a porous polyethylene sheet. The cyst has not recurred after 18 months of follow-up.

Histopathology of proton beam-irradiated vs enucleated uveal melanomas.

The histopathology of eyes with uveal melanoma was compared in a masked fashion in 47 eyes whose primary treatment was enucleation and a matched series of 47 eyes enucleated after proton beam irradiation. Irradiated tumors were more likely to show signs of necrosis (P less than .001) and fibrosis (P = .005) and to have balloon cells present (P = .002). In the irradiated group, mitotic figures were fewer in 40 high-power fields (P = .020), and the prevalence of tumor blood vessel damage (P less than .001) was higher. Changes in the retina were more common in the irradiated series, but damage was usually overlying or in close proximity to the tumor. Based on characteristic changes, the pathologist distinguished irradiated from nonirradiated eyes in 85% of the cases. These findings suggest that irradiation damages tumor cells and blood vessels, and alters the tumor's capacity for cellular reproduction.

Histopathologic study of eyes after iodine I 125 episcleral plaque irradiation for uveal melanoma.

OBJECTIVES: To describe the histopathologic findings attributable to irradiation in eyes with uveal malignant melanoma treated with iodine I 125 brachytherapy and to compare these findings with those reviewed in a previous study that compared histopathologic findings in eyes enucleated after proton beam teletherapy with those seen in eyes in a nonirradiated control group. METHODS: The slides from 22 eyes with uveal melanoma that had undergone enucleation after the administration of 125I brachytherapy were studied. The histopathologic features of the tumor and the retina were graded. Results were compared with findings from a previously reported group of 47 proton beam-treated eyes and its control group. RESULTS: Patient age, time between irradiation and enucleation, and ciliary body involvement were similar for the 125I brachytherapy-treated group and the proton beam-treated group and its control group. This allows comparison of the histopathologic findings. Comparing the 125I brachytherapy- and proton beam-treated groups, most histopathologic features were similar with nominally statistically significant differences only for cell type, number of mitotic figures, and fibrous metaplasia of the retinal pigment epithelium adjacent to the tumor. CONCLUSIONS: Irradiation of uveal melanoma induces changes in the tumor and in the surrounding retina. Brachytherapy and charged particle therapy are the 2 principal methods of irradiation. This study demonstrates that similar changes are produced by 125I plaque irradiation and proton beam irradiation.

Nucleolar organizer regions in determining malignancy of pigmented conjunctival lesions.

We assessed the usefulness of silver staining of nucleolar organizer regions in the diagnosis of pigmented conjunctival tumors. Fifty-one biopsy specimens were silver stained to identify the nucleolar organizer regions. Nineteen nevi without atypia, three nevi with atypia, eight primary acquired melanosis lesions, and 14 melanomas were studied. In each specimen, silver staining of the nucleolar organizer regions was counted in 100 cells to yield an average of the silver staining of the nucleolar organizer region count. The mean silver staining of the nucleolar organizer region counts per cell was correlated with the degree of malignancy of pigmented conjunctival lesions as follows: nevi, 3.0; primary acquired melanosis, 3.2; nevi with atypia, 3.9; primary acquired melanosis with atypia, 5.0; and melanoma, 5.7 (Spearman correlation [rS] = .83, P = .0001; analysis of variance [ANOVA] F test = 20.9, P = .0001). A cutoff value of 4.0 (mean silver staining of nucleolar organizer regions per cell) will differentiate melanoma and primary acquired melanosis with atypia from other lesions (sensitivity, 100%; specificity, 96%). The silver staining of nucleolar organizer regions is a useful adjunct in determining the malignancy of pigmented conjunctival tumors.

Orbital granulocytic sarcoma.

AIM: Orbital granulocytic sarcoma is a localised tumour composed of cells of myeloid origin. Histological diagnosis can be difficult in patients with poorly differentiated orbital tumours and no evidence of systemic leukaemia. The naphthol AS-D chloracetate esterase (Leder stain) and immunohistochemical stains for lysozyme and MAC387 were used to determine the staining characteristics of these tumours. A case series of seven patients with orbital granulocytic sarcoma is presented. METHODS: Seven patients with orbital granulocytic sarcoma were studied. Haematoxylin and eosin, Leder, and lysozyme stained sections were available in seven cases. Unstained formalin fixed paraffin embedded sections of seven cases were available for immunohistochemical evaluation using the avidin-biotin-complex technique for MAC387. RESULTS: The mean age of presentation of the orbital tumour was 8.8 years. Four patients presented with an orbital tumour before any systemic manifestations of leukaemia. In two cases the diagnosis of the orbital tumour and systemic leukaemia was made simultaneously. There was one case of established systemic myeloid leukaemia in remission with the subsequent development of orbital granulocytic sarcoma. Six of seven cases (86%) were positive for the Leder stain. Five of seven cases (71%) showed positive immunoreactivity with lysozyme. The immunohistochemical stain for MAC387 was positive in all seven cases (100%) including one case that was negative for both lysozyme and Leder stains. CONCLUSIONS: Orbital granulocytic sarcoma is a tumour that affects children and can present with rapidly progressive proptosis. This tumour may develop before, during, or after the occurrence of systemic leukaemia. The combination of Leder and lysozyme stains is useful in the diagnosis of orbital granulocytic sarcoma. MAC387 may be a more reliable marker for orbital granulocytic sarcoma.

The need for continuous immunosuppression with cyclosporin A to maintain an experimental model of uveal melanoma.

We investigated the need for continuous immunosuppression to maintain experimental tumours derived from human uveal melanoma cells implanted in the choroid of pigmented rabbits. Two groups of pigmented rabbits immunosuppressed with cyclosporin A (CsA) were implanted with human uveal melanoma cells in the suprachoroidal space. After 5 weeks, CsA was discontinued in group 2. Animals were treated with prophylactic antibiotics and examined weekly for tumour growth, weight and secondary effects; blood urea nitrogen levels were measured every two weeks. Autopsies and histopathological studies were performed after death or euthanasia at the end of week 12. The difference between the groups in the development of ophthalmoscopic tumours was not statistically significant 5 weeks after implantation. Tumours in group 1 grew progressively throughout the experiment, whereas group 2 tumours showed marked regression 3-4 weeks after discontinuing CsA. Tumours in group 1 were significantly larger and had greater mitotic activity and showed more ciliary body, optic nerve and extrascleral invasion than tumours in group 2, which showed massive fibrosis, minimal mitotic activity and marked inflammatory cell infiltration. Continuous immunosuppression with CsA seems to be necessary to maintain tumour growth in this experimental model of uveal melanoma.

An evaluation of tumour vascularity as a prognostic indicator in uveal melanoma.

Experimental and clinical evidence suggests that tumour angiogenesis plays a role in the tendency for certain neoplasms, including cutaneous melanomas, to metastasize. We evaluated whether tumour vasculature is associated with the rate of metastases in patients with melanoma of the choroid or ciliary body. The study was based on a group of 63 patients enucleated between 1976 and 1984 with paraffin-embedded tissue blocks available for sectioning and with known survival status as of December 1988. Vessel endothelial cells were highlighted with Ulex europaeus agglutinin I (UEA-I) conjugated with peroxidase. UEA-I-stained microvessels were counted at varying levels in the tumour (apex, centre and base) without knowledge of patient outcome. Patients with (n = 30) and without (n = 33) metastases had similar total vessel counts (P = 0.31). There was no evidence of greater vessel density in tumours that had metastasized, by level within the tumour. Similar results were obtained in multivariate analyses. Findings of this study suggest that tumour microvessel density is unrelated to patient survival in uveal melanoma.

Calcareous corneal degeneration: report of two cases.

Band keratopathy, calcium salts in Bowman's membrane, is the most classic form of corneal calcification seen in clinical practice. However, calcareous degeneration, calcium deposition involving the full corneal thickness, is rare. We reviewed the clinical and histopathological records of two patients with severe dry eyes and calcareous corneal degeneration. In each case, complete ophthalmic examination and histopathological study were performed. Both patients had severe dry eyes, case 1 secondary to graft-versus-host disease and case 2 secondary to rheumatoid arthritis, and a persistent epithelial defect and anterior segment chronic inflammation. Both patients underwent repeated penetrating keratoplasties. Histological examination of the corneal buttons showed that calcareous corneal degeneration and band keratopathy were coincident in both cases. Both patients received postoperative medications for high-risk grafting. The mechanisms of corneal calcification may be the same in calcific band keratopathy and calcareous corneal degeneration.

Porcine model of proliferative vitreoretinopathy with platelets.

PURPOSE: To develop an experimental model of proliferative vitreoretinopathy (PVR) in the pig, and determine the efficacy of platelet-derived growth factor (PDGF) compared with different platelet plasma concentrates in its development. METHODS: Animals were divided into four groups of 12 pigs each. Group 1, 2, and 3 underwent four 3-mm-long retinotomies, a partial mechanical vitrectomy, and six transconjunctival retinal cryoapplications and were injected intravitreally with, respectively, 0.2 ml of platelet rich plasma, 0.2 ml of a solution containing 200 ng of porcine PDGF, and 0.2 ml of platelet concentrated plasma. Group 4 received only an intravitreal injection of 0.2 ml of porcine PDGF. RESULTS: In Group 1, retinal detachments (RDs) developed in six eyes (50%) (two eyes, total RDs; four, extensive RDs). In Group 2, focal RDs developed in six eyes (50%). In Group 3, 11 eyes (92%) developed Rds (six eyes, total RDs; three, extensive RDs, two, focal RDs). Group 4, did not develop lesions. Statistically significant differences were found between Group 3 and the other groups. Group 2 RDs were associated with the presence of vitreoretinal membranes but there were no signs of PVR. In Groups 1 and 3, signs of anterior PVR, posterior PVR, and retinal holes with rolled edges were observed. CONCLUSIONS: We have developed a model of PVR in the pig, the retina of which more closely resembles that of humans. Platelet plasma more effectively contributed to the development of an experimental model of porcine PVR than 200 ng of PDGF. The efficacy depends on the platelet concentration of the plasma. These results suggest that other growth factors and plasma components may interact synergistically with PDGF in the pathogenesis of PVR.

Morphologic and immunocytochemical characterization of four human uveal cell lines (melanoma- and melanocytes-derived).

PURPOSE: To characterize three cell lines from human uveal melanomas and one ocular melanocyte cell line to study the specificity of several antigens in the malignant transformation of melanocytic uveal cells. METHODS: Light microscopy (LM), transmission electron microscopy (TEM), and immunocytochemical techniques were used in the characterization of OCM-1, SP 6.5, and MKT-BR human uveal melanoma cell lines and UW-1 normal melanocyte cell line from human uvea. Several monoclonal antibodies (MoAbs) S-100, HMB-45, MNF-116, PAL-M1, NK1/C-3, IND-1, and MAAMA were used. RESULTS: All cell lines showed an epithelioid/spindle morphology with occasional multinucleated cells, and nuclear pleomorphism. TEM showed intracytoplasmatic premelanosomes. Incubation with HMB-45 MoAb was positive in all cell lines. PAL-M2, NK1/C-3, MAAMA, and IND-1 MoAbs stainings were positive with variable intensity. MNF-116 MoAb showed negative staining in the four lines, and S-100 MoAb was also negative except for the UW-1 cell line. CONCLUSIONS: Human uveal melanoma cell lines OCM-1, SP 6.5, and MKT-BR and the ocular melanocyte cell line UW-1 exhibited maintenance of some structural and ultrastructural characteristics of melanocytic cells. All four MoAbs, PAL-M2, NK1/C3, IND-1, and MAAMA against cutaneous melanoma-associated antigens stained positively all melanoma cell lines as well as the melanocytic cell line, suggesting that in vitro proliferation of melanocytes could modify their antigenic expression.

The role of retinotomy in an experimental rabbit model of proliferative vitreoretinopathy.

PURPOSE: To create a model of proliferative vitreoretinopathy (PVR) using retinotomy with vitrectomy, cryotherapy, and platelet-rich plasma (PRP) injection, which more closely resembles the human pathophysiologic condition. METHODS: One hundred and twenty albino rabbits were divided into 10 groups of 12 rabbits each and underwent the following procedures: group 1, vitrectomy; group 2, cryotherapy; group 3, PRP intravitreous injection; group 4, retinotomy; group 5, retinotomy and vitrectomy; group 6, retinotomy and cryotherapy; group 7, retinotomy and PRP injection; group 8, retinotomy, vitrectomy, and cryotherapy; group 9, vitrectomy, cryotherapy, and PRP injection and group 10, retinotomy, vitrectomy, cryotherapy, and PRP injection. All animals underwent follow-up examinations with indirect ophthalmoscopy and fundus photography on days 1, 3, 7, 10, 14, 21, and 28 after the procedure(s). Retinal changes were categorized according to the classification of Fastenberg et al. At the end of the experiments, the eyes were enucleated, and examined under light and electron microscopy. RESULTS: No retinal detachments (RDs) were observed in groups 1, 2, 4, 5, 6, and 8. RDs of varying severity were observed in group 3 (n = 1), group 7 (n = 2), group 9 (n = 6), and group 10 (n = 12). Light and transmission electron microscopy confirmed the findings. CONCLUSIONS: Combining retinotomy with vitreous removal, cryotherapy, and PRP injection creates an efficient and different model of PVR that produced RD in 100% of rabbit eyes.

Intravitreal and subretinal proliferation induced by platelet-rich plasma injection in rabbits.

We developed an experimental model of proliferative vitreoretinopathy (PVR) in albino rabbits by combining some factors suspected of causing the disease. Sixty nine eyes divided into six groups served as controls (Groups C 1-6). Forty nine eyes were divided into four experimental groups (Groups E 1-4). Group E1 (n = 12) was injected with 0.15 ml of platelet-rich plasma. In addition, Groups E2 (n = 12) and E3 (n = 12) underwent cryotherapy or vitrectomy. Group E4 (n = 13) underwent both procedures. Seven of the 13 Group 4 experimental eyes developed total retinal detachment and giant holes. None of the other groups developed more than two total retinal detachments or giant holes (P < 0.05). Light and electron microscopy showed intravitreal or preretinal proliferation composed of fibroblast-like cells. Retroretinal membranes appeared only in Group E4 eyes, composed of elongated cells with oval nuclei and abundant organelles in the cytoplasm. We believe these lesions mimic human PVR more closely than other models previously developed.

Conjunctival biopsy in the diagnosis of ocular sarcoidosis.

Sarcoidosis is a multisystem granulomatous disease of unknown etiology that can affect almost every organ in the body, particularly the lungs, skin, eyes, and thoracic lymph nodes. A definitive diagnosis of sarcoidosis requires that a biopsy be performed. A specimen can be obtained from any affected ocular structure, including conjunctiva, lacrimal gland, eyelid skin, and orbit. Among them, conjunctival biopsy has been suggested as a sensible and safe procedure for confirming suspected sarcoidosis. We describe three patients in whom ocular symptoms were the sole initial manifestations of sarcoidosis and who were diagnosed based on the results of a conjunctival biopsy. We also discuss the efficacy of and indications for conjunctival biopsy.

Corneal perforation due to late radiation therapy-induced corneal necrosis--clinicopathological correlation.

A clinicopathological correlation is made between corneal perforation and late radiation therapy-induced corneal necrosis in a male adolescent treated for orbital rhabdomyosarcoma.