Unsuspected and misdiagnosed posterior uveal melanoma following enucleation and evisceration in Ottawa-Gatineau.

OBJECTIVE: There is a gap in the recent literature on the topic of clinically misdiagnosed and unsuspected posterior uveal melanomas (PUM) with a calculation of the frequency of these events for a specific geographical area. As the only ophthalmic pathology laboratory in our region, we determined the rate of these outcomes over a 16-year period. METHODS: We retrospectively reviewed 2558 consecutive ophthalmic pathologic specimens in the Ottawa-Gatineau region, of which 334 were eviscerations and 227 were enucleations. We calculated the frequency of clinically misdiagnosed PUM and of clinically unsuspected PUM. We also determined the rate of uveal melanoma undergoing enucleation. RESULTS: From 100 diagnoses of PUM, 2 (2.0%) cases were clinically unsuspected and 2 (2.0%) cases were clinically misdiagnosed. The rate of uveal melanoma undergoing enucleation was 5.6 cases per 1 000 000 of population per annum. From 2009 to 2012, the incidence of this event was 3.8 cases per 1 000 000 per annum, which was lower than the previous three 4-year increments. CONCLUSIONS: We present the first and only single-centred, population-based data on the rates of unsuspected PUM and of clinical misdiagnosis of PUM in the era of modern diagnostic imaging. Our rate of clinical misdiagnosis is within the range of recent reports of this event. Unsuspected PUM occurred at a rate substantially lower than previously published. The incidence of uveal melanoma undergoing enucleation has decreased despite an increase in population, which reflects a shift in management from enucleation to radiation therapy.

Secondary corneal amyloidosis after perforating corneal trauma: A series of 5 cases and review of the literature.

We retrospectively reviewed the clinical and surgical histories of 5 patients with traumatic secondary corneal amyloidosis, a relatively rare sequela of nonsurgical and surgical perforating corneal trauma. Four had history of nonsurgical trauma, and 1 had surgical trauma to the cornea. Three specimens were obtained by penetrating keratoplasties and 2 by excision of the cornea during evisceration of the ocular contents. All the corneal specimens showed full-thickness scars of a prior perforating wound with congophilic amyloid deposits that exhibited apple-green birefringence under polarized light and dichroism. All cases had variable degrees of predominantly chronic nongranulomatous inflammation. Ultrastructural examination in 1 patient disclosed 8-nm diameter fibrils in disarray, consistent with amyloid. Amyloid P immunostaining was positive in all 3 patients tested for this protein.

Conjunctival malignant melanoma: A rare variant and review of important diagnostic and therapeutic considerations.

Malignant melanoma of the conjunctiva is a relatively infrequent neoplasm that can be associated with significant morbidity and cause diagnostic difficulty to both the ophthalmologist and pathologist. We herein describe the first reported case in North American and European databases of a rare variant-signet ring cell melanoma - arising in the background of primary acquired melanosis (PAM) and use this case as a review of important diagnostic and therapeutic considerations when faced with this condition.

Histochemical analysis and immunohistochemical profile of mucoepidermoid carcinoma of the conjunctiva.

PURPOSE: To elucidate the distinct histochemical and immunohistochemical profile of mucoepidermoid carcinoma of the conjunctiva (MECC) and to determine which combination of stains is most useful in diagnosing MECC and differentiating it from squamous cell carcinoma of the conjunctiva (SCC) in cases where the clinical or cytological findings are not definitive. METHODS: Eight specimen of MECC from 4 patients and 4 specimens of SCC from 4 patients were examined using a variety of special stains and immunohistochemical markers. The results were then analyzed for usefulness in diagnosing MECC. RESULTS: The most useful markers in diagnosing MECC and differentiating it from SCC are mucicarmine, colloidal iron, and alcian blue all with sensitivities of 88%, and a specificity of 100%; CEA with a sensitivity of 83% and a specificity of 75%; and, mucin-1 with a sensitivity of 100% and a specificity of 25%, but which showed a distinct pattern of staining of MECC when compared to SCC. In our series, the sensitivity of the CK7+/CK20- combination for MECC was only 38%. CONCLUSIONS: The most useful stains in ruling out SCC in a suspected case of MECC were shown to be mucicarmine and the glycosaminoglycan (GAG) stains. However, in cases where mucicarmine and the GAG stains are negative or difficult to interpret and there is suspicion of a diagnosis of MECC, CEA and mucin-1 may be helpful for this diagnosis. The findings of CK7+/CK20- also may be of assistance, but are not as sensitive when compared to analogous salivary gland lesions, when differentiating MECC from SCC.

The bioceramic implant: evaluation of implant exposures in 419 implants.

PURPOSE: To compare the rate of exposure in the immediate 3-month postoperative follow-up period with the rate of exposure after the immediate postoperative period in 419 anophthalmic patients with a bioceramic (aluminum oxide) orbital implant. METHODS: This is a retrospective, clinical case series of 419 patients who received a bioceramic orbital implant. All patients who presented to five oculofacial surgeons (D.J., S.G., J.D., S.K., L.M.) from January 1, 2000, to June 1, 2007, who received a bioceramic orbital implant and had a minimum of 3 months of follow-up were included in this study. The authors analyzed age, gender, type of surgery, implant size, peg system, follow-up duration, time of pegging, and problems encountered. The data from the patients with greater than 3 months of follow-up with exposure of the bioceramic implant are detailed in this report. RESULTS: There were 353 patients followed for 3 to 96 months with an average of 30 months of follow-up (median 23 months). Implant exposure occurred in 32/353 bioceramic implants (9.1%). Six of the 32 (19%) exposures occurred during the 90-day postoperative period (average 2.1 months). Twenty-six (81%) exposures occurred outside of the 90-day postoperative period (average 27.5 months, range 4-82 months). CONCLUSIONS: Implant exposures can occur anytime postimplant placement. This review discovered an implant exposure rate of 9.1%, with the majority of the exposures occurring after the postoperative follow-up period. Patients with porous orbital implants should be followed on a long-term basis to detect this complication.

Pathogenesis of canalicular lacerations.

PURPOSE: To assess the pathogenesis of canalicular lacerations. METHODS: This is a retrospective, clinical case series of 236 patients who sustained a canalicular laceration. All patients who presented to the oculoplastic service of 3 individuals (D.R.J., S.M.G., L.A.M.) from May 1, 1998 to September 30, 2007, with a canalicular laceration were included in the study. Case histories were carefully reviewed in an attempt to classify the mechanism of injury as: "direct (penetrating) injury," "indirect (avulsive)," or "diffuse (avulsive)." Associated injuries (floor fractures, soft tissue lacerations, etc.) were also recorded. RESULTS: Of the 236 patients reviewed, direct canalicular injuries were detected in 128 (54.2%), indirect injuries were detected in 60 (25.4%), and diffuse injuries were detected in 48 (20.3%). Avulsive blunt injuries (due to indirect or diffuse trauma) therefore accounted for 45.7% of the lacerations whereas direct penetrating injuries accounted for 55.2% of the canalicular lacerations. Other injuries associated with the trauma occurred in 152 of the 236 patients (64%). Lacerations involving other portions of the eyelids, periocular area, and face made up the greatest number of associated injuries, and occurred with equal frequency in the direct penetrating group and the indirect/diffuse (avulsive injury) group. Associated injuries more serious in nature including orbital fractures, globe rupture, other body injuries, and head trauma were more commonly seen when diffuse trauma was involved. CONCLUSIONS: Direct, indirect, or diffuse forces may injure canaliculi but direct penetrating injuries were more common than avulsive injuries. More serious injuries (orbital fractures, globe rupture, other body injuries, and head trauma) were more commonly seen when diffuse trauma was involved.

Orbital cholesterol granuloma and cholesteatoma: significance of differentiating the two.

Cholesteatoma and cholesterol granuloma are relatively rare lesions of the orbit. Both may involve the superior orbit and present with globe ptosis, proptosis, and double vision developing over weeks to years. In addition to their etiology being unknown, the nomenclature regarding these tumors historically has been confusing, with a variety of names being used to describe them. Their histopathology shares numerous similarities but has one key distinguishing feature: The cholesterol granulomas lack an epithelial lining, whereas the cholesteatomas have an epithelial lining. Surgical removal is the treatment of choice for both tumors. It is important to differentiate the two as the prognosis with recurrence differs. Cholesteatoma may recur with the possibility of malignancy found at the time of re-exploration. We present a case of each tumor type, illustrating their similarities and highlighting the histopathologic findings and treatment recommendations.

The use of vicryl mesh in 200 porous orbital implants: a technique with few exposures.

PURPOSE: To report the results of a wrapping technique for porous orbital implants by using polyglactin 910 (Vicryl) mesh (Ethicon Inc., Somerville, NJ, U.S.A.). METHODS: We retrospectively reviewed the records of 200 consecutive patients from one author's practice who received a polyglactin 910 mesh-wrapped porous orbital implant after enucleation or as a secondary implant between October 1, 1996, and April 15, 2001. We recorded potential problems that might be attributed to polyglactin 910 mesh both before pegging (excessive inflammatory response to the material, conjunctival thinning, and implant exposure) and after pegging (exposure of the implant around the sleeve, conjunctival thinning, and implant exposure other than adjacent to the peg). RESULTS: One hundred twenty-two men and 78 women underwent placement of a polyglactin 910 mesh-wrapped porous orbital implant. The average age at the time of implantation was 48.9 years (range, 11 to 85 years). The average follow-up interval in the 200 patients was 19.4 months (range, 2 to 80 months). Thirteen of the 200 patients had less than 6 months of follow-up, leaving 187 patients with an average follow-up of 20.5 months (range, 6 to 80 months). There were 76 primary enucleations and 124 secondary orbital implants. Thirty-seven patients received a Bio-Eye hydroxyapatite implant (HA) (Integrated Orbital Implants, San Diego, Calif), 97 received a synthetic FCI hydroxyapatite implant (FCI, Issy-Les-Moulineaux, France), and 66 received a Bioceramic implant (aluminum oxide-Al2O3) (FCI, Issy-Les-Moulineaux, France). One hundred fourteen patients (57%) underwent peg placement. The average time to pegging was 9.9 months (range, 6 to 16 months). Before pegging, 4 of 187 patients (2.1%) had implant exposure. Three of these exposures followed secondary orbital implant placement (2 Bio-Eye HA, 1 synthetic FCI3 HA) and one followed an enucleation (synthetic FCI3 HA). Two patients required a temporalis fascia graft and one required a scleral patch; the remaining defect closed spontaneously. One patient had conjunctival thinning 6 months after orbital implantation, which remained stable with no frank exposure for 36 months. No patient had excess socket inflammation. After peg placement, 3 additional patients had exposure of the implant around the peg site. There were no cases of conjunctival thinning or exposure of the implant other than adjacent to the peg site. CONCLUSIONS: Polyglactin 910 mesh is an excellent option as a wrapping material for porous orbital implants. It is simple to use, readily available, eliminates the need for donor tissue, does not require a second operative site, and it is less expensive than other currently available wrapping materials. We attribute our high success rate to our technique, which emphasizes proper placement of the implant within the Tenon space, suturing the extraocular muscles anterior to their normal anatomic sites, and meticulous closure of the Tenon capsule and conjunctiva in separate layers.