Fresh frozen amniotic membrane for conjunctival reconstruction after excision of neoplastic and presumed neoplastic conjunctival lesions.

PurposeSuspicious neoplastic conjunctival lesions often require wide excision with tumour-free margins, leaving significant conjunctival defects requiring reconstruction. In this study we report the results of using fresh frozen amniotic membrane grafts (AMG) after wide excision of potentially malignant lesions.MethodsRetrospective review of 53 patients; between January 2011 and April 2014. Conjunctival lesions were excised with a non-touch technique (2 mm margin) and sent for histopathological analysis. The surgical margins were treated with cryotherapy and a fresh frozen AMG was used to cover the defect. The main features examined were for any signs of recurrence, the conjunctivalisation of the AMG, complications and cosmetic appearance.ResultsFifty-three patients; 35 males and 18 females. Mean age was 54.9 (range 19-88). The mean follow up to January 2015 for all lesions was 21.4 months (range 8-48 months). The most common lesions were invasive malignant melanoma. There were no local surgical complications in 77.3% of patients; minimal scarring (11.3%), symblepharon (11.3%), and granuloma (7.5%). Five patients with conjunctival melanoma developed in-transit metastasis and orbital extension, none of it was at the site of the AMG.ConclusionOur case series is the largest reported to date, with the largest number of melanomas. The use of fresh frozen AMG has improved the local surgical outcomes by improving healing and reducing scarring as well as allowing for a wider surgical margin.

Outcomes of treatment with stereotactic radiosurgery or proton beam therapy for choroidal melanoma.

AIM: To present our experience of the use of stereotactic radiosurgery and proton beam therapy to treat posterior uveal melanoma over a 10 year period. METHODS AND MATERIALS: Case notes of patients treated with stereotactic radiosurgery (SRS), or Proton beam therapy (PBT) for posterior uveal melanoma were reviewed. Data collected included visual acuity at presentation and final review, local control rates, globe retention and complications. We analysed post-operative visual outcomes and if visual outcomes varied with proximity to the optic nerve or fovea. RESULTS: 191 patients were included in the study; 85 and 106 patients received Stereotactic radiosurgery and Proton beam therapy, respectively. Mean follow up period was 39 months in the SRS group and 34 months in the PBT group. Both treatments achieved excellent local control rates with eye retention in 98% of the SRS group and 95% in the PBT group. The stereotactic radiosurgery group showed a poorer visual prognosis with 65% losing more than 3 lines of Snellen acuity compared to 45% in the PBT group. 33% of the SRS group and 54% of proton beam patients had a visual acuity of 6/60 or better. CONCLUSIONS: Stereotactic radiosurgery and proton beam therapy are effective treatments for larger choroidal melanomas or tumours unsuitable for plaque radiotherapy. Our results suggest that patients treated with proton beam therapy retain better vision post-operatively; however, possible confounding factors include age, tumour location and systemic co-morbidities. These factors as well as the patient's preference should be considered when deciding between these two therapies.

Failure of intravitreal bevacizumab in the treatment of choroidal metastasis.

BACKGROUND: Metastasis to choroid is the most common intraocular malignancy, arising most frequently from carcinoma of breast in women and lung in men. Recent case reports have described successful use of intravitreal bevacizumab to achieve local control of such tumours. MATERIALS AND METHODS: Five cases of choroidal metastases from varying primaries: breast, lung, and colon were treated with intravitreal bevacizumab, and tumour response observed and documented with serial photographs and B-scans. RESULTS: Four of the five tumours were seen to progress despite intravitreal bevacizumab treatment. CONCLUSIONS: Intravitreal bevacizumab as the primary treatment of choroidal metastases is not recommended and should not delay more effective alternative treatments.

Ocular surface foreign bodies: novel findings mimicking ocular malignant melanoma.

PURPOSE: Malignant melanoma of the eye is an uncommon condition that is important to recognise. We describe three cases in which ocular foreign bodies have masqueraded as ocular malignant melanoma. METHODS: Interventional case reports. RESULTS: Case 1 describes diathermy-induced carbon particle implantation, during plaque therapy for the treatment of uveal melanoma, mimicking recurrence with extra-scleral invasion. Case 2 shows a foreign body called 'mullite' mimicking conjunctival melanoma. Case 3 demonstrates a conjunctival foreign body called 'illite' that mimicked a limbal melanocytic lesion, clinically thought to be either melanocytoma or melanoma. CONCLUSION: This report highlights the importance of careful history taking, examination, and appropriate biopsy in cases of suspected malignant melanoma, to prevent unnecessary and potentially radical treatment.

Three cases of intraocular mesectodermal leiomyoma expressing progesterone and androgen receptors.

BACKGROUND/AIMS: A prospective study identified three patients between 2004 and 2010 with mesectodermal leiomyoma. The study was conducted to analyse the presence or absence of sex steroid hormone receptors in mesectodermal leiomyomas. METHODS: The clinical features were collated. All three patients had operative procedures to either remove or sample the mesectodermal leiomyomas. The tissue was fixed in formalin and exposed to conventional histological processing. Immunohistochemistry using antibodies to androgen (AR), oestrogen (ER), and progesterone (PR) receptors was performed, followed by stain scoring to assess for expression status. RESULTS: All three cases were confirmed by histology to be examples of mesectodermal leiomyomas. All three expressed sex steroid hormone receptors. One case expressed both PR and AR, one case PR only and another case AR only. None of the cases expressed ER receptors. CONCLUSION: All three cases displayed some sex steroid hormone receptor expression. This is supportive evidence that sex steroid hormones may have a role in the pathogenesis of this tumour and suggest that it may be amenable to hormonal manipulation therapy, in a manner similar to conventional uterine leiomyomas.

Reduced FANCD2 influences spontaneous SCE and RAD51 foci formation in uveal melanoma and Fanconi anaemia.

Uveal melanoma (UM) is unique among cancers in displaying reduced endogenous levels of sister chromatid exchange (SCE). Here we demonstrate that FANCD2 expression is reduced in UM and that ectopic expression of FANCD2 increased SCE. Similarly, FANCD2-deficient fibroblasts (PD20) derived from Fanconi anaemia patients displayed reduced spontaneous SCE formation relative to their FANCD2-complemented counterparts, suggesting that this observation is not specific to UM. In addition, spontaneous RAD51 foci were reduced in UM and PD20 cells compared with FANCD2-proficient cells. This is consistent with a model where spontaneous SCEs are the end product of endogenous recombination events and implicates FANCD2 in the promotion of recombination-mediated repair of endogenous DNA damage and in SCE formation during normal DNA replication. In both UM and PD20 cells, low SCE was reversed by inhibiting DNA-PKcs (DNA-dependent protein kinase, catalytic subunit). Finally, we demonstrate that both PD20 and UM are sensitive to acetaldehyde, supporting a role for FANCD2 in repair of lesions induced by such endogenous metabolites. Together, these data suggest FANCD2 may promote spontaneous SCE by influencing which double-strand break repair pathway predominates during normal S-phase progression.

Don't it make my blue eyes brown: heterochromia and other abnormalities of the iris.

Eye colour is one of the most important characteristics in determining facial appearance. In this paper I shall discuss the anatomy and genetics of normal eye colour, together with a wide and diverse range of conditions that may produce an alteration in normal iris pigmentation or form.

Resistance of uveal melanoma to the interstrand cross-linking agent mitomycin C is associated with reduced expression of CYP450R.

BACKGROUND: Uveal melanoma (UM) is the most common primary intraocular tumour of adults, frequently metastasising to the liver. Hepatic metastases are difficult to treat and are mainly unresponsive to chemotherapy. To investigate why UM are so chemo-resistant we explored the effect of interstrand cross-linking agents mitomycin C (MMC) and cisplatin in comparison with hydroxyurea (HU). METHODS: Sensitivity to MMC, cisplatin and HU was tested in established UM cell lines using clonogenic assays. The response of UM to MMC was confirmed in MTT assays using short-term cultures of primary UM. The expression of cytochrome P450 reductase (CYP450R) was analysed by western blotting, and DNA cross-linking was assessed using COMET analysis supported by γ-H2AX foci formation. RESULTS: Both established cell lines and primary cultures of UM were resistant to the cross-linking agent MMC (in each case P<0.001 in Student's t-test compared with controls). In two established UM cell lines, DNA cross-link damage was not induced by MMC (in both cases P<0.05 in Students's t-test compared with damage induced in controls). In all, 6 out of 6 UMs tested displayed reduced expression of the metabolising enzyme CYP450R and transient expression of CYP450R increased MMC sensitivity of UM. CONCLUSION: We suggest that reduced expression of CYP450R is responsible for MMC resistance of UM, through a lack of bioactivation, which can be reversed by complementing UM cell lines with CYP450R.

Retinal vasoproliferative tumours.

Vasoproliferative tumours are uncommon retinal lesions that may occur in isolation (primary) or in association with another ocular condition (secondary). They may be unilateral or bilateral and have a predilection for the peripheral inferior temporal quadrant of the retina. Vasoproliferative tumours can be associated with abnormalities of the macular, including epiretinal membrane formation and cystoid macular edema. A number of modalities have been used to treat these tumours including cryotherapy and radiotherapy.

The in vivo modulatory effects of an anterior-chamber microenvironment on uveal melanoma.

BACKGROUND: Primary melanoma of the iris, for reasons unknown has a lower metastatic rate compared with primary ciliary-body melanoma. Six histology cases of ciliary-body melanoma were identified that had spread onto the iris surface and into the stroma, representing a change in tumour microenvironment from aqueous humour non-exposure (ciliary-body component) to aqueous humour exposure (iris surface component). This provided an ideal paradigm for investigating the effects of different environments on melanoma. METHOD: Conventional light microscopy was performed on stained paraffin sections of the identified cases, followed by immunohistochemistry to cell cycle proteins p27 and Cyclin D1. Fluorescence in situ hybridisation (FISH) analysis was conducted on the paraffin sections for changes of chromosomes 3 and 8, associated with poor uveal melanoma prognosis. RESULTS: Iris surface melanoma cells were smaller compared with the adjacent deeper iris stromal melanoma cells and with those in the ciliary body. Fewer iris surface melanoma cells expressed Cyclin D1 protein, but more expressed p27 protein, compared with the larger iris stromal melanoma cells (paired Wilcoxon signed ranks test: Cyclin D1 p = 0.028; p27 p = 0.046) and with the ciliary-body melanoma cells (paired Wilcoxon signed ranks test: Cyclin D1 p = 0.028; p27 p = 0.028). With FISH, chromosome 3 and 8 alterations were less common among the iris surface melanoma cells than the deeper iris stromal melanoma cells and the ciliary-body melanoma cells, which were consistently characterised by a relative genetic imbalance for chromosomes 3 and 8. CONCLUSIONS: These data suggest that there are tumour-modulatory factors within the anterior chamber environment that probably select populations of ciliary-body melanoma cells, with a less aggressive, better-differentiated status. Furthermore, it may help explain why iris melanomas generally have a less aggressive course than ciliary-body and choroidal melanomas.

What is the significance of vortex vein invasion in uveal melanoma?

PURPOSE: To correlate vortex vein invasion with established prognostic factors for uveal melanoma. METHODS: Enucleated eyes with a confirmed histopathological diagnosis of uveal melanoma with vortex vein invasion were identified, over a 10-year period. Established uveal melanoma prognostic factors, with tumour genetics were correlated with vortex vein invasion and patient survival. RESULTS: Microscopic vortex vein involvement was present in 29 of 244 (11.9%) uveal melanomas. Of 29, 6 (20.7%) tumours had macroscopic evidence of vortex vein invasion. Of 29, 14 (48.3%) tumours also showed evidence of non-vortex vein, 'direct' scleral invasion. 23 (79.3%) of 29 melanomas involved only the choroid. The mean maximum diameter of tumours with vortex vein invasion was 15.8 mm and the mean thickness was 9.7 mm. The uveal melanoma was a discrete nodule in 27 of 29 (93.1%) cases. Histologically, 8 of 29 tumours (27.6%) were spindle cell, 19 of 29 (65.5%) were mixed cell, and 2 of 29 (6.9%) were epithelioid cell type. Of 29, 22 (75.9%) uveal melanomas with vortex vein invasion contained extracellular matrix networks and loops. Genetic abnormalities correlated with poor prognosis were seen in 25 of 29 (86.2%) tumours with vortex vein invasion. Liver metastasis was confirmed in 19 of 29 (65.5%) patients with vortex vein invasion. No patients with uveal melanomas showing vortex vein invasion suffered orbital recurrence of disease following enucleation. CONCLUSIONS: The trends show that vortex vein invasion is associated with a choroidal location, large tumour size, spindle cell bias, presence of extracellular matrix loops/networks and genetic markers. A higher proportion of patients with vortex vein invasion progress to develop liver metastasis compared with the general uveal melanoma population.

Bovine pericardium (Tutopatch) wrap for hydroxyapatite implants.

PURPOSE: To evaluate bovine pericardium (Tutopatch) as a wrapping material for hydroxyapatite implants in patients undergoing enucleation for uveal melanoma. METHOD: Prospective cohort study of patients who had enucleation for uveal melanoma between January 2003 and August 2003 were included in the study. Any patient with less than 3 months follow-up was excluded. Enucleation was performed under general anaesthesia followed by insertion of hydroxyapatite implants wrapped in bovine pericardium (Tutopatch). The recti muscles were sutured directly to the wrap. The tenon's capsule and conjunctiva were closed in two layers. A conformer was inserted at 1 week and artificial eye at 2-3 months. The patients were followed up regularly and were assessed for cosmetic result, exposure of implant, and the need for any further surgical procedures. RESULTS: A total of 19 patients (seven male and 12 female) were included in the study. Median age at diagnosis was 63 years (range 38-80 years). Median follow-up was 26 months (range 22-30 months). No patient developed postoperative complications of wound dehiscence. The overall cosmetic result was excellent in all the patients. The rate of postoperative complications compared favourably with published data using other wrapping materials/implants. CONCLUSION: Tutopatch is a safe wrapping material for hydroxyapatite orbital implants in patients undergoing enucleation for uveal melanoma.

False diagnosis of papilloedema and idiopathic intracranial hypertension.

The diagnosis of idiopathic intracranial hypertension (IIH) relies heavily on the appearance of the optic disc. We report eighteen children referred to us over a 3 year period with disc swelling and suspected IIH. Following a tertiary ophthalmological review, papilloedema was excluded in ten with buried drusen, disc crowding, pseudopapilloedema, or misinterpretation of normal appearances. In these ten children, five had a mean opening pressure on lumbar puncture of 27.2 cm H2O, range 19-32, which was significantly lower than those with IIH (37.5 cm H2O, range 29-47; p<0.01). We conclude that diagnosis of IIH is difficult, and that more precisely defined criteria for assessment and diagnosis are needed.

Multiple locations on chromosome 3 are the targets of specific deletions in uveal melanoma.

PURPOSE: Loss of chromosome 3 is a frequent event in uveal melanomas, which is associated with hepatic metastases and a poor prognosis. The entire copy of chromosome 3 is usually lost (monosomy 3); however, a small subset of tumours demonstrate partial deletions of chromosome 3. Analysis of these tumours may allow the identification of tumour suppressor genes (TSGs) that are the molecular target of monosomy 3. Therefore, the purpose of this investigation was to determine the location of these partial deletions of chromosome 3 in uveal melanomas. METHODS: Microsatellite analysis and restriction fragment-length polymorphism analysis were performed on 52 primary uveal melanomas using 19 markers located on both arms of chromosome 3. Cytogenetic analysis and fluorescence in situ hybridisation were performed, where possible, to confirm molecular findings. RESULTS: Of 52 tumours studied, five tumours (10%) demonstrated LOH at one or more informative markers, but retention of heterozygosity was observed at other loci on chromosome 3, consistent with the presence of structural abnormalities to chromosome 3. Consistent with previous findings, the pattern of LOH in these tumours indicates the presence of deletions around 3p25-26 and on 3q, and that a new target region at 3p11-14 is preferentially deleted. CONCLUSIONS: These results indicate the presence of several tumour suppressor loci on chromosome 3 and support the notion that the high rate of monosomy 3 in uveal melanoma is driven by disruption of several TSGs located on both arms of chromosome 3.