Zipper cell endotheliopathy: a new subset of idiopathic corneal edema.

PURPOSE: To report the clinical and histologic findings of a new subset of idiopathic corneal edema: zipper cell endotheliopathy. DESIGN: Observational case report. PARTICIPANT: A 55-year-old woman with unilateral bullous keratopathy. METHODS: Clinical observation consisted of slit-lamp examination and in vivo confocal microscopy (IVCM). Aqueous humor samples and the excised corneal button were analyzed for the presence of herpes viruses. The excised cornea was subjected to detailed immunohistochemistry (IHC) and scanning and transmission electron microscopy. MAIN OUTCOME MEASURES: Clinical and pathologic characteristics of zipper cell endotheliopathy. RESULTS: In vivo confocal microscopy revealed unique morphologic alterations of the corneal endothelial layer. Focal areas of denudation were surrounded by endothelial cells with zipper-like cell borders and intercellular structures. Besides central corneal edema, no other signs of corneal inflammation were detected. A herpes virus origin for the bullous keratopathy was excluded. The IHC analysis disclosed positive staining for cytokeratin (CK) 7, CK8/18, and CK19, suggesting epithelial metaplasia of the endothelial cells. Ultrastructural examination confirmed the IVCM findings by showing large areas of endothelial denudation and vacuolated endothelial cells with large, broad-based extensions that partially overlapped neighboring cells. Despite extensive complementary research and review of the literature, the endothelial alterations could not be attributed to any known corneal disorder. CONCLUSIONS: To the authors' knowledge, zipper cell endotheliopathy is a new subset of idiopathic corneal edema. The case report presented illustrates the potential use of IVCM to differentiate the spectrum of corneal disorders and to discover new corneal diseases.

Clinical and cytogenetic analyses in uveal melanoma.

PURPOSE: Uveal melanoma is one of the most frequently occurring primary intraocular malignancies in the Western world. Cytogenetically these tumors are characterized by typical chromosomal losses and gains, such as loss of 1p, 3, and 6q and gain of 6p and 8q. Whereas most studies focus on known aberrations, in this one, cytogenetic changes were characterized and correlated with clinical and histopathologic parameters. METHODS: Karyotypes of 74 primary uveal melanomas were analyzed with respect to the presence or absence of chromosomal gains and losses. In the analysis, classic clinical and histopathologic parameters were analyzed together with the chromosomal aberrations. RESULTS: At a median follow-up of 43 months, 34 patients had died or had metastatic disease. Clonal chromosomal abnormalities were present in 59 tumors. The most frequent chromosomal abnormalities involved chromosome 8 (53%); loss of chromosome 3, p-arm (41%) and q-arm (42%); partial loss of chromosome 1, p-arm (24%); and abnormalities in chromosome 6 that resulted in gain of 6p (18%) and/or loss of 6q (28%). Less-frequent aberrations were abnormalities in chromosome 16, in particular loss of chromosome 16 q-arm (16%). In the univariate analysis, loss of chromosome 3, largest tumor diameter, gain in 8q, and mixed/epithelioid cell type in the tumor compared with tumors without these chromosomal changes or with a spindle cell type was associated with decreased disease-free survival. When corrected for confounding variables, significance of gain of 8q and cell type was decreased, whereas the significance of loss of chromosome 3p or 3q and largest tumor diameter remained the same. CONCLUSIONS: Monosomy 3 and largest tumor diameter are the most significant in determining survival of patients with uveal melanoma. Abnormalities in the q-arm of chromosome 16 are relatively common in uveal melanoma, but are not associated with survival or other cytogenetic or histopathologic parameters.

Late-onset retinoblastoma in a well-functioning fellow eye.

PURPOSE: To describe the documented growth, clinical course, and histopathology of retinoblastomas in an untreated and otherwise normal right eye of a 27-year-old white male with a g.153211T>A (p.Tyr606X) mutation in the retinoblastoma 1 gene, whose left eye was enucleated at age 2 years for 2 retinoblastomas. DESIGN AND PARTICIPANTS: Retrospective interventional case report. INTERVENTIONS: Over the years, the right eye was irradiated twice and underwent trans-pars plana vitrectomy, transscleral cryocoagulation, argon laser photocoagulation of tumors and their feeder vessels, extracapsular cataract extraction with posterior chamber lens implantation, and neodymium:yttrium-aluminum-garnet laser treatment of after-cataract in the form of Elschnig's pearls. Finally, the patient received combination chemotherapy with etoposide, methotrexate, actinomycin D, cisplatin, and vincristine. RESULTS: The eye finally had to be removed 12 years later due to tumor recurrences and seeding, pseudohypopyon, and elevated intraocular pressure. Histopathology showed microcellular retinoblastoma cells in the anterior chamber angle and trabecular meshwork without subconjunctival extension and in the nasal ciliary body, pars plana, internal limiting membrane, and optic nerve head anterior to the cribriform plate. The patient is without local or systemic recurrences at age 50, 11 years after the last eye was enucleated. CONCLUSIONS: This report shows that retinoblastoma patients may have tumor growth in their fellow eye 25 years after the first eye and also that Elschnig's after-cataract pearls still can arise after irradiation of a lens with 45 Gy.

Concurrent loss of chromosome arm 1p and chromosome 3 predicts a decreased disease-free survival in uveal melanoma patients.

PURPOSE: Uveal melanoma is a highly malignant disease with a mortality rate of 50% at 10 to 15 years. Previous studies have shown that chromosomal changes are associated with decreased survival of the patient. However, in these studies the small number of tumors analyzed did not allow robust statistical analysis. In the present study, the independent numerical changes in chromosomes 1, 3, 6, and 8 on disease-free survival (DFS) was assessed in a large series of patients with uveal melanoma. METHODS: One hundred twenty tumors from patients with uveal melanoma were analyzed for numerical changes in chromosomes 1, 3, 6, and 8, with cytogenetic analysis, fluorescent in situ hybridization, and/or comparative genomic hybridization. Data were correlated with disease outcome in univariate and multivariate analyses, by Kaplan-Meier and Cox regression analyses. RESULTS: At a mean follow-up time of 45 months, 42 patients had died or had metastatic disease. In the univariate analysis, loss of chromosome 3, gain of 8q, largest tumor diameter, or the presence of epithelioid cells was associated with a decreased DFS. In the multivariate analysis, the effect of monosomy 3 on survival was largely modified by changes in 1p36. Regarding all chromosomal changes, only the concurrent loss of the short arm of chromosome 1 and all of chromosome 3 was an independent prognostic parameter for disease-free survival (P < 0.001). CONCLUSIONS: In uveal melanoma, concurrent loss of the short arm of chromosome 1 and all of chromosome 3 is an independent predictor of decreased DFS.

Reduced melanoma-related mortality in uveal melanoma by preenucleation radiotherapy.

BACKGROUND: Radiotherapy of an eye before enucleation, so called preenucleation radiotherapy (PER), of patients with uveal melanoma was initiated to reduce enucleation-induced systemic metastasis. Earlier studies with a short follow-up period have not demonstrated a significant effect on survival. OBJECTIVE: To study the effect of PER on melanoma-related mortality after more than 9 years of follow-up. DESIGN: In a prospective study, 167 patients with uveal melanoma were treated between 1978 and 1992 by irradiation with 800 rad (8 Gy) given in 2 fractions 2 days before enucleation. A group of 108 patients with uveal melanoma treated between 1971 and 1992 by enucleation only in the same hospital served as a historical control group. Patients were followed up until December 2002 or death. RESULTS: Melanoma-related death occurred in 32.3% of the PER-treated group and in 40.7% of the enucleation only group. Mean follow-up was 9.25 years. After 48 months of follow-up, a significant difference in survival became evident in favor of the PER group. The estimated 15-year survival rates for patients with melanoma in the PER group and enucleation only group were 63.7% and 51.0%, respectively. For patients dying of all causes, these percentages were 47.5% and 25.2%, respectively. In both groups, women had a better prognostic outcome than men. CONCLUSION: This study suggests that PER improves long-term survival in patients with uveal melanoma.

Blepharoptosis and upper eyelid swelling due to lipogranulomatous inflammation caused by silicone oil.

PURPOSE: Report of two patients who presented with unilateral upper eyelid swelling and ptosis 1 and 8 years, respectively, after vitreoretinal surgery with intraocular silicone oil. DESIGN: Report of two cases. METHODS: In the first case, the oil was still present in the eye. In the second case, the intraocular oil and an epibulbar buckle had been removed 7 years earlier. RESULTS: Histopathology of upper eyelid skin and preaponeurotic fat revealed lipogranulomatous inflammation. CONCLUSIONS: Leakage of intraocular silicone oil into the eyelid tissues may cause an inflammatory reaction resulting in eyelid swelling and ptosis. We presume that in the first patient, silicone oil had leaked from the eye during or after surgery; in the second patient, silicone oil had probably been left behind in the space previously occupied by the epibulbar buckle.

Immunohistochemical analysis of the internal limiting membrane peeled with infracyanine green.

PURPOSE: To investigate whether the peeled internal limiting membrane (ILM) contains cellular retinal cell fragments, and to learn more about their possible origin. DESIGN: Experimental study. METHODS: ILM peeled from ten eyes during vitrectomy by infracyanine green (ICG) was studied immunohistochemically using the markers: GFAP, S-100, and vimentin. Five ILM specimens were from eyes with diabetic macular edema (DME), two from eyes with a macular hole, and three from eyes with persisting macular edema after retinal detachment surgery. RESULTS: In eight of the ten ILM specimens, we found GFAP-positive staining, indicating the presence of remnants of footplates from Müller cells or glial cells. Two ILM specimens were positive for S-100, indicating the presence of neural cells or ganglion cells. CONCLUSIONS: ILM peeled from the retina during vitrectomy using ICG may contain remnants of Müller cell footplates, neural cells, and ganglion cells.

Detection of genetic prognostic markers in uveal melanoma biopsies using fluorescence in situ hybridization.

PURPOSE: In uveal melanoma, specific chromosomal abnormalities are known to correlate with the risk of metastases; changes in chromosomes 3 and 8q correlate strongly with a decreased survival of the patient, whereas chromosome 6 abnormalities are associated with a better prognosis. Usually, karyotyping and fluorescence in situ hybridization (FISH) analysis are used to detect these abnormalities in resected tumor tissues. However, the evaluation of these chromosomal changes is compromised in patients treated with eye-retaining treatment protocols because of the lack of tumor material. The purpose of this study was to validate the use of FISH for the analysis of genetic prognostic markers. EXPERIMENTAL DESIGN: We analyzed 40 uveal melanoma fine needle aspiration biopsies (FNABs) and the corresponding main tumor with FISH. RESULTS: All biopsies were found to contain tumor cells, and FISH analyses of the samples were successful in all cases. Statistical analysis showed very good agreement between the FISH results from the biopsies and those from the main tumor. In only 2 of 249 hybridizations did we find a small variation that could have led to a misclassification. CONCLUSIONS: Our results indicate that the application of FISH to FNABs is a reliable method for assaying genetic prognostic parameters such as chromosome 3 loss and/or chromosome 8q gain. Implementation of this method in a diagnostic setting means that we are able to identify patients at risk of developing metastatic disease, not only in enucleated patients but also in cases treated with conservative treatment modalities such as radiotherapy.

Somatostatin receptors in malignant lymphomas: targets for radiotherapy?

UNLABELLED: Somatostatin (SS) receptor (sst) scintigraphy is widely used in the visualization of neuroendocrine tumors expressing sst, and radiotherapy using radionuclide-labeled SS analogs has been introduced for treatment of patients with neuroendocrine tumors. Previous sst scintigraphy studies revealed that malignant lymphomas can also be visualized using this technique. The question has been addressed whether lymphomas might also be possible targets for radiotherapy using radionuclide-labeled SS analogs. Therefore, we investigated in vitro the characteristics of lymphoma tissues and lymphoid cell lines to evaluate whether lymphomas can be targets for radiotherapy. METHODS: Six orbital lymphomas, 2 Hodgkin's lymphomas, and 2 non-Hodgkin's lymphomas from the neck region were collected. Reverse transcriptase polymerase chain reaction (RT-PCR) and quantitative RT-PCR were performed to detect and quantify the expression of sst(1-5) mRNA. Receptor autoradiography studies using [(125)I-Tyr(3)]octreotide were performed to evaluate binding to sst on cryostat sections of lymphomas. Immunohistochemistry was used to investigate expression of sst(2) and sst(3). Membrane binding studies and in vitro internalization experiments using [(125)I-Tyr(3)]octreotide were performed to study binding and uptake of [(125)I-Tyr(3)]octreotide by lymphoid cell lines (JY, TMM, APD) and primary cells derived from a B-cell-derived chronic lymphatic leukemia. RESULTS: A selective expression of sst(2) and sst(3) messenger RNA (mRNA) was demonstrated. By quantitative RT-PCR, expression levels of sst(2) and sst(3) mRNA were relatively low. Autoradiography studies revealed low binding of [(125)I-Tyr(3)]octreotide, whereas immunoreactivity could not be detected for sst(2) and sst(3) by immunohistochemistry. On the lymphoid cell lines only low numbers of high-affinity SS binding sites were found. In vitro, uptake of [(125)I-Tyr(3)]octreotide by these cells was also very low. CONCLUSION: On the basis of our findings, we conclude that lymphomas do not appear to be candidates for radiotherapy using radionuclide-labeled SS analogs. However, lymphomas are highly radiosensitive tumors and further clinical studies should be performed to evaluate whether the low receptor density is sufficient for targeting treatment in these tumors.

Insulin-like growth factor-I and its receptor in neovascular age-related macular degeneration.

PURPOSE: The insulin-like growth factor (IGF)-I protein is a growth-promoting polypeptide that can act as an angiogenic agent in the eye. The purpose of the current study was to localize the expression of IGF-I and its receptor (IGF-IR) mRNA and IGF-IR protein in situ in the normal human eye and to examine the presence of expression in eyes with neovascular age-related macular degeneration (AMD). METHODS: Formalin-fixed, paraffin-embedded slides of 4 normal control eyes and 14 eyes with choroidal neovascularization (CNV) secondary to AMD were examined. Three eyes with proliferative diabetic retinopathy were studied as the positive control. IGF-I and IGF-IR mRNA was detected by in situ hybridization with digoxigenin-labeled RNA probes. IGF-IR protein was studied by immunohistochemistry. RESULTS: In the normal retina, IGF-I and IGF-IR mRNA expression was found throughout the neuroretinal layers, in the retinal pigment epithelium (RPE), and in some choriocapillary and retinal capillary endothelial cells. In eyes with CNV we found IGF and IGF-IR mRNA in capillary endothelial cells, some transdifferentiated RPE, and fibroblast-like cells. IGF-IR protein was found in normal eyes in all neuroretinal layers, in the RPE, and in the choroidal vessels. In eyes with CNV, IGF-IR protein was present in the RPE monolayer, in transdifferentiated RPE, and in newly formed vessels. CONCLUSIONS: The colocalization of protein and receptor indicates an autocrine function of IGF-I in the normal human retina. Because IGF-I participates in ocular neovascularization, synthesis of IGF-IR and IGF-I in endothelial cells, RPE cells, and fibroblast-like cells in CNV may point toward a role for this growth factor in the pathogenesis of neovascular AMD.

In vivo and in vitro detection of dopamine d2 receptors in uveal melanomas.

Scintigraphy with radiolabeled benzamides was used in melanoma patients. Studies with a newer benzamide called 123I-epidepride, a high-affinity D2 receptor (D2R) antagonist, showed high sensitivity in D2R-positive pituitary adenomas. We evaluated the presence of D2R in patients with uveal melanomas in vivo with 123I-epidepride, and in vitro in melanomas, using immunohistochemistry (IHC) and 125I-epidepride autoradiography. We studied the in vivo tumor-to-background (TB) ratios in six patients with posterior uveal melanoma (one previously enucleated). IHC was performed in 3 of 6 tumors after enucleation and in another 20 uveal melanomas, 7 metastatic lymph nodes from skin melanoma, and 2 normal specimens. 125I-epidepride autoradiography was performed in 10 uveal melanomas (3 of which were studied in vivo), 7 metastases, and 2 normal samples. Radioligand uptake was present in the affected eye of 5 patients with uveal melanoma (TB = 3.1-6.1) and absent in the operated one (TB = 1). Eight uveal tumors were positive at IHC (35%), 14 weakly positive (61%), and 1 negative (4%). Two metastases were positive (29%), 2 weakly positive (29%), and 3 negative (42%). Two uveal tumors were positive at autoradiography (20%), 7 had nonspecific binding (70%), and 1 was negative (10%). One metastasis was positive (14%), while 6 were negative (86%). 123I-epidepride scintigraphy in uveal melanomas seems promising for sensitivity and image quality. D2R was demonstrated in a significant proportion of the melanomas, although 123I-epidepride uptake might also be nonspecific and unrelated to D2R binding. Although further studies on larger series are needed, 123I-epidepride could represent a future tool to study the expression of D2R in other classes of neuroendocrine tumors.