[Metastatic clear cell renal cell carcinoma: a potential mimicker of choroidal melanoma]. / Világossejtes vesesejtes karcinóma koroideális melanómát utánzó áttéte.

While metastases are the most common intraocular malignancies, ocular metastases of renal cell carcinoma are rare. The most frequent primary malignancy of the eye is uveal melanoma. The common ocular localization is the choroid in both cases. The clinical differentiation of choroidal metastasis from renal cell carcinoma and choroidal melanoma malignum is a diagnostic challenge for the ophthalmologist. We present two cases where renal cell carcinoma had metastasized to the choroid. Enucleation was performed in a 61- and a 71-year-old male patient with suspected advanced choroidal malignant melanoma following biomicroscopic and B-scan ultrasonography examination. Histopathological examination confirmed clear-cell renal cell carcinoma in both cases. The clinical and ultrasonographic appearance of clear-cell renal cell carcinoma metastasis may mimic choroidal malignant melanoma, and may only be suspected if a primary renal cell carcinoma is already established.

Clinical Review of Ocular Traumas Resulting in Enucleation or Evisceration in a Tertiary Eye Care Center in Hungary.

PURPOSE: To analyse the demographic and clinical characteristics of ocular traumas resulting in enucleation/evisceration in a large tertiary referral center in a developed country (Hungary) over a period of 15 years. Patients and Methods. A retrospective review of enucleated/eviscerated eyes that underwent surgery between 2006 and 2020 at the Department of Ophthalmology of Semmelweis University, Budapest, Hungary, due to ocular trauma as the primary indication for enucleation/evisceration. For each subject, clinical history, B-scan ultrasound report, and histopathology results were reviewed. RESULTS: There were 124 enucleated/eviscerated eyes from 124 patients (91 males (73.4%)). The mean age at the time of trauma was 37.3 ± 26.0 years while the mean age at the time of enucleation/evisceration was 46.9 ± 20.3 years. The main clinical diagnoses after ocular trauma were open globe injury (n = 96; 77.4%), ocular burns (n = 6; 4.8%), traumatic optic neuropathy (n = 4; 3.2%), bulbar avulsion (n = 3; 2.4%), traumatic cataract (n = 2; 1.6%), retinal ablation (n = 1; 0.8%), and traumatic carotid-cavernous fistula (n = 1; 0.8%). Among the 124 patients, 98 (79.0%) underwent enucleation and 26 (21.0%) evisceration. Patients who underwent primary enucleation/evisceration (n = 24 19.4%) were significantly older at the time of the injury (57.7 ± 22.7 years) than people who underwent secondary eye removal (32.4 ± 24.4 years) (p < 0.0001). The mean time interval between trauma and enucleation/evisceration was 114.9 ± 163.5 months. The main clinical indications for anophthalmic surgery were atrophia/phthisis bulbi (n = 56, 45.2%), acute trauma (n = 25, 20.2%), painful blind eye due to glaucoma (n = 17, 13.7%), endophthalmitis (n = 10, 8.1%), and cosmetic reasons (n = 7, 5.6%). One patient (0.8%) had sympathetic ophthalmia. CONCLUSIONS: Primary enucleation/evisceration was performed in one-fifth of all ocular trauma-related anophthalmic surgeries in our tertiary eye care center with enucleation being the most common procedure. Atrophia/phthisis bulbi was the most frequent immediate clinical indication for enucleation/evisceration.

Congenital ptosis repair using posterior approach levator plication / Veleszületett szemhéjcsüngés mutéti megoldása a szemhéjemelo izom kötohártya feloli redozésével.

Összefoglaló. Bevezetés: Szemhéjcsüngésnek (ptosis vagy blepharoptosis) nevezzük azt az állapotot, amikor a felso szemhéj abnormálisan alacsony pozícióban van. A szemhéjcsüngésnek lehetnek veleszületett és szerzett formái. Célkituzés: Célunk volt bemutatni a szemhéjemelo izom (levator) - veleszületett szemhéjcsüngés korrekciója céljából végzett - kötohártya feloli redozésének eredményeit retrospektív módszerrel. Módszer: 20 beteg 22 szemhéján végeztük el a mutétet (átlagéletkor: 19,4 ± 9,9 év, férfi: 12 [60%], no: 8 [40%]). Beválasztási kritérium volt a közepes (5-8 mm) vagy jó (9 mm felett) levatorfunkció. Kizártuk a korábban szemhéjkorrekciós mutéten átesett és a 3 hónapnál rövidebb követési idovel rendelkezo betegeket. A mutét elott megmértük a levatorfunkciót és a margó-reflex-távolságot. A mutét után megmértük a margó-reflex-távolságot, a szemhéjak magassága közti aszimmetria mértékét, és elemeztük a szemhéj posztoperatív kontúrját. Eredmények: A preoperatív levatorfunkció 10,6 ± 3,0 mm, a preoperatív margó-reflex-távolság 1,8 ± 0,8 mm volt. A 7,8 ± 7,2 hónap átlagos követési ido alatt a posztoperatív margó-reflex-távolság 3,2 ± 0,8 mm volt. A preoperatív és a posztoperatív margó-reflex-távolság különbsége nem tért el szignifikánsan a sikeres és a sikertelen mutétek között (p = 0,523). A szemhéjak magassága közti aszimmetria mértéke 3 betegnél haladta meg az 1 mm-t. A szemhéj posztoperatív kontúrja minden esetben megfelelo volt. A mutét összességében 86,4%-ban (19/22) volt sikeres. A helyi érzéstelenítésben és altatásban végzett mutétek közt nem találtunk szignifikáns különbséget a sikeresség tekintetében (p = 0,227). Következtetés: Tanulmányunk alapján az elvégzett mutéteink eredményessége a nemzetközi irodalomban közöltekhez hasonló volt. A veleszületett szemhéjcsüngés korrekciójára a kötohártya feloli levatorredozés megfelelo kezelési mód közepes vagy annál jobb levatorfunkció esetén. Orv Hetil. 2021; 162(18): 705-711. INTRODUCTION: Droopy eyelid (ptosis or blepharoptosis) is defined through abnormally low upper eyelid position. Ptosis can be classified as congenital or acquired. OBJECTIVE: Our purpose was to report the results of posterior approach levator plication for congenital ptosis in a retrospective review. METHOD: 22 eyelids of 20 patients were included in this study (age: 19.4 ± 9.9 years, male: 12 [60%], female: 8 [40%]). The inclusion criteria were moderate (5-8 mm) or good (more than 9 mm) levator function. Patients with postoperative follow-up time shorter than 3 months and those who underwent previous eyelid surgery were excluded. The data collected included preoperative levator function and margin reflex distance, postoperative margin reflex distance, inter-eyelid height asymmetry and postoperative eyelid contour. RESULTS: Preoperative levator function was 10.6 ± 3.0 mm, preoperative margin reflex distance was 1.8 ± 0.8 mm. During 7.8 ± 7.2 months postoperative follow-up, postoperative margin reflex distance was 3.2 ± 0.8 mm. The difference between preoperative and postoperative margin reflex distance was not significant (p = 0.523) in the group of successful operations compared with unsuccessful operations. Inter-eyelid height asymmetry was more than 1 mm in 3 cases. Satisfactory postoperative eyelid contour was achieved in all cases. Overall success rate was 86.4% (19/22). Surgical success did not differ significantly between surgeries in local or general anaesthesia (p = 0.227). CONCLUSION: Our study shows an overall success rate of the procedures comparable to those in international publications. Posterior approach levator plication for congenital ptosis with moderate or better levator function seems to be a suitable treatment method. Orv Hetil. 2021; 162(18): 705-711.

Clinical Review of Microbial Corneal Ulcers Resulting in Enucleation and Evisceration in a Tertiary Eye Care Center in Hungary.

PURPOSE: To analyse the clinical and microbiological characteristics and preexisting ophthalmic and systemic conditions of infectious keratitis resulting in enucleation/evisceration in a large tertiary referral center in a developed country (Hungary) over a period of 12 years. Patients and Methods. A retrospective review of enucleated/eviscerated eyes undergoing surgery between 2007 and 2018 at the Department of Ophthalmology of Semmelweis University, Budapest, Hungary, with infectious keratitis as the primary indication for enucleation or evisceration. For each subject, clinical history, B-scan ultrasound report, and microbiological analyses were reviewed. RESULTS: There were 48 enucleated/eviscerated eyes from 47 patients (29 females (61.7%), age at the time of surgery 66.4 ± 18.5 years). Indication for surgery was hopeless, unmanageable keratitis (62.5%), and keratitis with endophthalmitis (37.5%). The most common preexisting ophthalmic conditions were previous cataract surgery (60.4%), previous therapeutic penetrating keratoplasty (PKP) (56.3%), corneal perforation (52.1%), glaucoma (41.7%), and long-term topical steroid usage (31.3%). In order to treat keratitis, before enucleation or evisceration, 20 eyes (41.7%) underwent PKP, 12 eyes (25.0%) amniotic membrane transplantation, 8 eyes (16.7%) conjunctival autograft transplantation, 6 eyes (12.5%) tarsorrhaphy, and 4 eyes (8.3%) vitrectomy to salvage the eye prior to the final treatment of enucleation or evisceration. The most frequent preexisting systemic diseases were hypertension (62.5%), cardiac disease (20.8%), diabetes mellitus (20.8%), and rheumatoid arthritis (14.6%). Staphylococcus aureus (17.0%) and Propionibacterium acnes (12.8%) were the most commonly isolated gram-positive bacteria, and Pseudomonas aeruginosa was the most frequently isolated gram-negative pathogen bacterium (10.6%). Six globes (12.5%) had positive fungal cultures (1 case of Candida albicans, Candida parapsilosis, Trichosporon inkin, Acremonium sp., Fusarium sp., and Penicillium sp.). CONCLUSIONS: Staphylococcus aureus, Propionibacterium acnes, and Pseudomonas aeruginosa keratitis with or without endophthalmitis represent the most common indication for ocular enucleation/evisceration in patients with microbial keratitis in a tertiary referral center in Hungary. The incidence of enucleation and evisceration related to mycotic keratitis does not seem to have increased within the last decade. Most frequent preexisting systemic diseases in cases of enucleation and evisceration are hypertension, cardiac disease, diabetes mellitus, and rheumatoid arthritis.

Differential diagnosis and management of melanocytic lesions of the ocular surface / [Pigmentsejt-eredetu szemfelszíni elváltozások differenciáldiagnózisa és kezelése]

Our purpose is to summarize the actual knowledge about melanocytic lesions of the ocular surface (conjunctival nevus, primary acquired melanosis and conjunctival melanoma),especially their clinical appearance, differential diagnosis and treatment. Conjunctival nevus is the most common benign, conjunctival melanocytic lesion. Primary acquired melanosis mainly presents in middle-aged or elderly individuals, characterized by proliferation of melanocytes of the conjunctival epithelial layer. Conjunctival melanoma is a rare tumor, it is the second most common malignant ocular surface tumor after ocular surface squamous neoplasia and the third most common ocular malignancy following choroideal malignant melanoma and ocular surface squamous neoplasia. Early recognition and proper management of conjunctival melanoma is indispensable due to its high malignant and metastatic potential. Due to frequent recurrences, the knowledge and use of intra- and postoperative adjuvant treatment modalities, and regular follow-up are necessary. Orv Hetil. 2020; 161(15): 563­574.

Clinicopathological Review of 547 Bulbar Enucleations in Hungary (2006-2017).

PURPOSE: To analyse current clinicopathological enucleation indications in a large third-referral centre in a developed country (Hungary) over a period of 12 years. METHODS: Retrospective review was performed on 547 enucleated eyes of 543 patients (48.6% males, age 52.7 ± 24.5 years) who were operated on between 2006 and 2017 at the Department of Ophthalmology of Semmelweis University, in Budapest, Hungary. For each subject, clinicopathological data, including patient demographics, indications for enucleation, B-scan ultrasound reports, operative details, and histopathological analyses, were reviewed. Primary enucleation indications were classified into trauma, tumours, systemic diseases, surgical diseases, infections or inflammations, miscellaneous diseases, and unclassifiable groups. Clinical immediate enucleation indications were classified as tumours, atrophia or phthisis bulbi, infection or inflammation, painful blind eye due to glaucoma, acute trauma, threatening or spontaneous perforation, cosmetic causes, and expulsive bleeding. RESULTS: The most common primary enucleation indications were tumours (47.3%), trauma (16.8%), surgical diseases (15.7%), infection or inflammation (11.6%), systemic diseases (5.1%), miscellaneous diseases (2.0%), and unclassifiable diseases (1.5%). Clinical immediate enucleation indications were tumours (46.1%), atrophia or phthisis bulbi (18.5%), infection or inflammation (18.5%), painful blind eye due to glaucoma (11.2%), acute trauma (3.7%), threatening or spontaneous perforation (1.3%), cosmetic reasons (0.5%), and expulsive bleeding (0.4%). CONCLUSIONS: Intraocular tumours represent the most common clinicopathological indication for ocular enucleation in our study population. Following ocular trauma and systemic diseases, the rate of enucleation decreased in the last decade, compared to those previously reported in other developed countries. However, changes were not observed for surgical diseases, infectious and inflammatory causes, or for miscellaneous and unclassified diseases. Orbital implant financing should be increased to ensure better postoperative aesthetic rehabilitation, following enucleation in Hungary.

Measurements of orbital volume using cone-beam computed tomography in eye movement abnormalities.

PURPOSE: To measure the orbital volume in adult patients with unilateral eye movement abnormalities originating in childhood. METHODS: Cone-beam computed tomography was performed in 2 patients with eye movement abnormalities. A 28-year-old woman was treated because of right divergent squint originating at 8 years of age after penetrating corneal trauma. A 38-year-old man was examined because of abnormal head posture caused by left superior oblique underaction originating at 6 years of age. Orbital scans were analyzed with Cranioviewer 3D craniofacial cephalometric program. We measured bony orbital area in 6 slices (in ventro-dorsal direction per 4.8 mm) in every orbit on coronal scans. RESULTS: The volume was more in the orbit with unilateral divergent squint and less in the orbit with unilateral superior oblique underaction compared to the contralateral orbital volume measurements. CONCLUSION: Cranioviewer 3D craniofacial cephalometric program is suitable for volumetric analysis of the bony orbit on cone-beam computed tomography files. The development of the orbit can be influenced by extraocular muscle movements.

Measurement of orbital volume after enucleation and orbital implantation.

INTRODUCTION: This article reports experience relating to the measurement of orbital volume by means of cone beam computed tomography (CBCT) and Cranioviewer program software in patients who have undergone enucleation and orbital implantation. PATIENTS AND METHODS: CBCT scans were made in 30 cases, 10 of which were later excluded because of various technical problems. The study group therefore consisted of 20 patients (8 men and 12 women). The longest follow-up time was 7 years, and the shortest was 1 year. In all 20 cases, the orbital volume was measured with Cranioviewer orbital program software. Slices were made in the ventrodorsal direction at 4.8 mm intervals in the frontal plane, in both bony orbits (both that containing the orbital implant and the healthy one). Similar measurements were made in 20 patients with various dental problems. CBCT scans were recorded for the facial region of the skull, containing the orbital region. The Cranioviewer program can colour the area of the slices red, and it automatically measures the area in mm. RESULTS: In 5 of the 20 cases, the first 4 or all 5 slices revealed that the volume of the operated orbit was significantly smaller than that of the healthy orbit, in 12 cases only from 1 to 3 of the slices indicated such a significant difference, and in 3 cases no differences were observed between the orbits. In the control group of patients with various dental problems, there was no significant difference between the two healthy orbits. The accuracy of the volume measurements was assessed statistically by means of the paired samples t-test. SUMMARY: To date, no appropriate method is avaliable for exact measurement of the bony orbital volume, which would be of particular importance in orbital injury reconstruction. However, the use of CBCT scans and Cranioviewer orbital program software appears to offer a reliable method for the measurement of changes in orbital volume.

Porous Hydroxyapatite and Aluminium-Oxide Ceramic Orbital Implant Evaluation Using CBCT Scanning: A Method for In Vivo Porous Structure Evaluation and Monitoring.

Objective. This study aimed to define CBCT as a technique for postimplantation in vivo examination of porous hydroxyapatite and aluminium-oxide orbital implant shape, volume and density changes. Methods and Materials. CBCT was used to evaluate 30 enucleated patients treated with spherical polyglactin 910 wrapped hydroxyapatite and aluminum-oxide orbital implants. The mean duration of patient followup was 3.2 years or 1338 days with a range of 0.2 to 7.2 years or 79 to 2636 days in a population with an average age of 40.8 years. Results. The resolution of currently clinically used CBCT equipment allowed detailed structural observation of the orbital hydroxyapatite implants with some modifications. Volume and shape estimations were possible while density evaluation was more complicated compared to medical source computed tomography. The mean densities of the orbital implants were followed and a consistent gradual decrease identified from the beginning of implantation which was better defined after the applied correction procedure. Conclusion. CBCT with lower dosages of radiation exposure can be used to follow changes in implanted high-density porous structures. The density evaluation is possible with calibration modifications. Changes in orbital implant densities identified in this study may correspond to healing and maturation of soft tissues surrounding and penetrating the implants.

Cbfa1/Runx2 expression in an ossifying basal cell carcinoma of the eyelid.

A case of basal cell carcinoma (BCC) with intratumoural bone formation affecting the eyelid of a 77-year-old lady is described. Bone formation in BCCs is an uncommon event. We revised the 23 cases described in the literature: most of them occurred on the face. The pathophysiological mechanism responsible for ossification in cutaneous lesions remains unclear. The bone often develops adjacent to, or within hair follicles. We evaluated the immunohistochemical expression in the present case of Cbfa1/Runx2, an early marker for osteoblastic progenitor cells. A well-developed lamellar bone with adipose bone marrow was observed both in the superficial stroma and intratumourally. Cbfa1/Runx2 was localised in the osteocytes of the heterotopic bone and in the keratin cysts of the BCC. The expression of Cbfa1/Runx2 in the present BCC suggests a possible role of this protein in the induction of the heterotopic bone.

Recently recognized cases of ophthalmofilariasis in Hungary.

PURPOSE: To report four cases of zoonotic ophthalmodirofilariasis infection caused by Dirofilaria repens in Hungary. METHODS: Four cases of ophthalmofilariasis have been treated at our department during the last 14 months. A subconjunctival moving worm was observed by slit lamp biomicroscopy in two cases. In one of these a living filaria was surgically removed, but the other disappeared. Red eye and migrating edema were the presenting signs in two cases. A biopsy taken from the subcutaneous masses disclosed D repens. RESULTS: Histopathologic or parasitologic examination identified a female D repens in every case. Laboratory alterations were not found. Symptoms subsided after treatment. CONCLUSION: The clinical presentation of filariasis is not always straightforward, and a high index of suspicion is necessary in cases presenting with orbital or periorbital inflammation. During the past 10 years the identification of locally acquired infections by D repens has increased in Hungary.

Orbital tumour as initial manifestation of acute myeloid leukemia: granulocytic sarcoma: case report.

We report orbital involvement as an initial manifestation of acute myeloid leukemia in a 57-year-old woman. The patient presented with painful proptosis and limited ocular motility. Orbital computed tomography revealed bilateral homogeneous masses. Orbital biopsy was performed on the right side; and histopathology disclosed a myelocytic tumour. Despite treatment using irradiation and chemotherapy, the patient died eleven months after presentation. There appear to be only a few previous reports of acute myeloid leukemia cases presenting with orbital involvement, and most cases occurred in children. This very rare condition has a poor survival prognosis, even with radiation treatment and chemotherapy.

Modified procedure for secondary facial rehabilitation following total bilateral irreversible peripheral facial palsy.

We present the case of a middle-aged gentleman who developed total bilateral irreversible peripheral facial palsy over a period of 10 years, starting with palsy of the marginal mandibular and buccal branches of the facial nerve and progressing to the zygomatic and temporal branches. The patient did not develop any other neurological symptoms, and all neurological and other tests have remained negative over the last 10 years. Dripping of saliva and inability to close the mouth necessitated reanimation of the perioral region with the help of a fascia lata graft fixed to the fascia of the masseter muscles. The increasing lagophthalmos and associated eye problems were alleviated with a temporal muscle transposition combined with a lengthening procedure using the temporal fascia, passed through the upper and lower eyelids and hooked around the medial canthal ligament. The fascia strips were sutured not to the canthal ligament itself, but to each other, thereby placing equal self-adjusted tension on the upper and lower eyelids. Both operations were successful and improved eating and eye closure functions, allowing resolution of the eye symptoms.

[Parotid gland Warthin's tumor combined with actinomycosis]. / Actinomycosissal kombinált, parotisban elhelyezkedo Warthin-tumor ritka esete.

The authors describe the diagnostic problems and difficulties of treatment of Warthin's tumor combined with actinomycosis. A 48-year-old woman was presented with a mass in the left parotid region and paresis of the lower left palpebra. The CT, echography, parotid X-ray findings supposed a neoplasm of the left parotid gland which was proved by intraoperative freezing histology. The ramus of the mandible was involved in the process. Total parotidectomy and partial mandiblectomy were performed, with sacrifice of the facial nerve, followed by nerve reconstruction. The final histological evaluation was Warthin's tumor with actinomycosis. Eight years after treatment the patient is free of disease.

[Oncological principles of surgery in the periorbital region]. / Onkosebészeti alapelvek a periorbitalis régióban.

The aim of this study is to describe the most common malignant periorbital tumours and principles of their surgical treatment. The most common malignant tumours of the eyelids are: basocellular carcinoma, squamocellular carcinoma, sebaceous carcinoma and malignant melanoma. The primary treatment of periorbital tumours is surgery, other methods are cryotherapy or radiotherapy. Malignant tumours of the eyelids are fairly rare. Diagnosis in some of the cases is difficult, since the first signs of the tumours are small changes on the eyelid margin or eyelid skin. Focal loss of the eyelashes could be the first sign of a malignant tumour. General oncological principles are valid also in the surgery of periorbital region. Eyelids have special anatomical structure and their main role is protection of the eyeball. Therefore, early diagnosis and total tumour removal--regardless of the anatomical borders--as well as immediate reconstruction are important in the treatment of eyelid tumours.

Contracted anophthalmic socket repair.

PURPOSE: The aim of this paper is to describe a simple method for severely contracted anophthalmic socket repair in which a silicone sphere is used as an expander for widening and deepening severely contracted conjunctival sacs. PATIENTS AND METHOD: This method was used in five patients. Each patient had undergone previous operations but they could not wear artificial eyes and there was no hope of performing any other type of surgical procedure successfully. In our surgical method, the severely contracted conjunctiva is cut deeply at the desired level of the upper and lower eyelid fornix. A certain amount of scar tissue is excised and a silicone sphere is placed under the eyelids. The eyelid margins are sutured to each other with a double-running nylon suture. After four months, the eyelid fissure is opened and a special round-shaped artificial eye is inserted. The original silicone sphere is used as an expander in the evenings during the next two or three months. RESULTS: This procedure was used successfully in four of the five cases. In one case the silicone sphere was lost and cicatrization reoccurred. The longest follow-up time is now five years, the shortest, one year. CONCLUSION: Using a silicone sphere as an expander can be an alternative surgical method for contracted anophthalmic socket repair. The main advantage of this method is its simplicity. In order to use this procedure, good cooperation between doctor and patient is essential.