André Jastrzebski

RE: Bilateral subconjunctival masses due to orbital fat prolapse

A 41-year-old male presented with 6 months of bilateral symmetrical subconjunctival lesions that appeared after a motor vehicle collision (Fig. 1). Injuries included a unilateral zygomatic fracture repaired without incision around the orbit. Ocular examination revealed a visual acuity of 20/20 OU and bilateral, soft, yellow masses in the temporal bulbar conjunctiva which were easily displaced posteriorly with a cotton-tipped swab. Computed tomography disclosed continuity of both subconjunctival lesions with the intraconal space. Both masses were excised without complication. Both masses had a similar histologic appearance of uniform hypovascular lobules containing mature adipocytes separated by fibrovascular septa (Fig. 2). Focal areas showed increased cellularity, including inflammatory cells and frequent multinucleated giant cells within fibrous septa with their nuclei arranged in a “floretlike” pattern (Fig. 2, inset). Orbital fat is divided into 2 compartments: extraconal fat lies outside the extraocular muscles and Tenon’s capsule, whereas intraconal fat lies within the extraocular muscle cone. Various mechanisms (e.g., trauma, surgery, degeneration) can lead to disruption of the connective tissue support of orbital fat leading to herniation. Unlike the more common extraconal fat prolapse frequently seen as an aging change, intraconal fat prolapse is rarely reported. Intraconal fat prolapse may be unilateral, or bilateral in one-third of cases, and generally is located superiorly and temporally, as in our case, secondary to the thin intermuscular septum and abundant fat in this region. Intraconal fat prolapse may be confused clinically with dermolipoma, conjunctival lymphoma, and lacrimal gland prolapse. However, it can be distinguished by the ease with which it can be pushed posteriorly, and also histopathologically. CT and MRI may identify fat prolapse by demonstrating continuity with the intraconal space, as in our case. Recently, there has been confusion and debate concerning the differentiation between intraconal fat prolapse and pleomorphic lipoma. Pleomorphic lipoma is a rare subtype of lipoma most often seen in the soft tissues of the head and neck, on a morphologic continuum with spindle cell lipoma. In 2003, Daniel et al. published a series of 6 cases believed to represent pleomorphic lipoma of the orbit. Histopathological features of these cases included large multinucleated cells often arranged in a “floretlike” pattern. Although thought to represent a distinguishing feature of pleomorphic lipoma and other neoplasms, similar cells, but usually with small normochromatic nuclei, have been recently identified in both prolapsed and in situ intraconal orbital fat, suggesting they also may result from a reactive or degenerative process. As immunohistoFig. 2—Subconjunctival mass shows typical prolapsed orbital fat, with uniform hypovascular lobules, and fibrous septa (H&E 100 ). Inset: high power view of a multinucleated, “floretlike” giant cell in the fibrous septum of the prolapsed orbital fat (H&E 640 ).

Dacryops of Krause Gland in the Inferior Fornix in a Child

Results. Abnormalities in collagen organization were seen in both the anterior and posterior stroma of the keratoconus cornea (Figure 2), with the most drastic disruption occurring within the region of greatest corneal steepening (Figure 1). In the posterior stroma, the normal orthogonal predominant orientation of collagen was absent; in the anterior stroma, the usual isotropic arrangement of collagen was replaced with more highly aligned unidirectional collagen.

Dacryops: A Series of 5 Cases and a Proposed Pathogenesis

IMPORTANCE Lacrimal gland ductal cysts (dacryops) are uncommon, occurring anywhere that lacrimal gland tissue is present. While dacryops has long been recognized, its pathogenesis has not been well established. OBSERVATIONS Five cases of dacryops were identified at the Ottawa Hospital over a 3-year period (2009-2012). Histopathological examination showed immunoreactivity to IgA on the luminal surface of the epithelial ductal cyst and mild chronic inflammation in the underlying stroma or lacrimal gland. CONCLUSIONS AND RELEVANCE Our results suggest that a multifactorial mechanism leads to dacryops including chronic inflammation, an immune response, and IgA hypersecretion with an osmotic effect, all contributing to the cyst formation. Further research on the pathogenesis is recommended.

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.

Isolated conjunctival lymphangioma

lated within fibrous tissue over a period of time. Delayed hemorrhage inside the capsule can occur up to 23 years after surgery secondary to implant shift or migration. Most of the time, these cysts are actually pseudocysts because they lack epithelial lining. Real cysts around the implant arise from migration of the conjunctival squamous epithelium along the surgical wound or of sinus columnar respiratory epithelium through the orbital floor fracture. In our case, the mucus content of the cyst was probably formed by a secretory epithelium. Removal of the implant via a surgical approach is the treatment of choice, but excision of all or part of the fibrous capsule is still controversial. Some authors advocate surgical excision of enough of the cyst wall to minimize the risk of cyst recurrence while being careful not to create a large communication with the maxillary sinus. To our knowledge, only 2 cases of cyst recurrence after Fig. 2—Axial computed tomography scan shows anteroinferior cystic mass with hyperdensity corresponding to the silastic implant (top left, top right). Coronal view (bottom left). Sagittal view shows marked scleral indentation (bottom right).

Bilateral benign reactive lymphoid hyperplasia of the conjunctiva in a pediatric patient.

A 13-year-old boy presented with asymptomatic, bilateral, nasal bulbar conjunctival lesions. Excisional biopsy of the larger lesion showed a mature, mixed lymphocytic infiltrate with germinal centers, consistent with a diagnosis of benign reactive lymphoid hyperplasia, a rare condition in children.

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.

An unusual corneal limbal foreign body: Ostracoda shell

A 7-year-old boy was referred by the emergency department for a corneal limbal foreign body in his right eye. The patient’s parents had first noted the lesion 3 days earlier, after he had been swimming in Lake Manitoba while on vacation. He was asymptomatic other than some mild ocular irritation. The ocular and medical histories were unremarkable. On examination, the visual acuity was 20/25 OD and 20/20 OS. Slit-lamp biomicroscopy revealed a smooth, brown-black, semitransparent, dome-shaped foreign body measuring 2.5 0.7 mm superficially embedded in the inferotemporal corneal limbus OD (Fig. 1). The surrounding conjunctiva was injected. Trace fluorescein uptake was noted around the lesion. The remainder of the ocular examination was unremarkable. Because of limited patient cooperation, removal of the lesion under slit-lamp visualization was unsuccessful. Under general anesthesia, the lesion was found to be firmly adherent to the underlying cornea. The lesion was suspected to be biologic in origin, so hypertonic (5% NaCl) saline solution was applied to the cornea. The foreign body was then readily removed, leaving only a small epithelial defect. Three days later, the signs and symptoms had resolved completely, and the visual acuity was 20/20 OU. Histopathologic examination of the formalin-fixed, paraffin-embedded specimen disclosed an intact pigmented, birefringent, acellular shell with a hollow core containing scattered, predominantly acute inflammatory cells, some of which were adherent to its outer surface (Fig. 2). Further analysis of the specimen by a biologist (LG) at the University of Manitoba revealed it tobe the shellofanOstracodaofeither theDarwinulidaeor the Cypridae family, both of which inhabit Lake Manitoba. The Ostracoda are a class of the Crustacea ranging in size from 0.2 to 30 millimeters. They inhabit virtually all aquatic habitats, with some species living terrestrially in moss. Their