C. Auw-Hädrich

[Corneal melting after cross-linking and deep lamellar keratoplasty in a keratoconus patient].

We present the case of a 45-year-old patient with severe atopic disease and keratoconus who suffered from corneal melting following cross-linking and deep anterior lamellar keratoplasty (DALK) due to subclinical infection with Herpes simplex virus (HSV). Penetrating keratoplasty and intensive antiviral and immunosuppressive medical treatment were necessary to control the infection. The case demonstrates the difficulties in the treatment of keratoconus in patients with severe atopic disease.

Ulzerierte Lidtumoren beidseits bei Atopie

Rechtes Auge:An einer Stelle,an der 7 Jahre zuvor eine hyperkeratotische seborrhoische Warze entfernt worden war (⊡ Abb. 1), zeigte sich ein rasch wachsender ca. 8×10 mm großer Unterlidtumor mit unregelmäßigem Randwall und tiefem Krater,der mit dicht gepackten Hornschuppen gefüllt war (⊡ Abb.2).Innerhalb von nur 3 Monaten infiltrierte der Tumor das gesamte Unterlid und drängte in die vordere Orbita (⊡ Abb.3).Der Tumor war gegenüber der Periorbita verschieblich, die Lymphknotenstationen waren klinisch unauffällig. Schnelles Tumorwachstum und das histologische Bild einer großen Gewebeprobe aus dem Tumorrand, die gute Abgrenzbarkeit des Tumors gegenüber der Umgebung,die nur mäßige Zellpolymorphie sowie der tiefe,dicht mit nekrotischen Hornmassen und Hornperlen gefüllte Krater sprachen eher für ein Keratoakanthom.Eine anamnestisch fragliche Blutung deutete allerdings auf ein Plattenepithelkarzinom.Die zunächst gestellte Verdachtsdiagnose eines Keratoakanthoms musste nachträglich anhand der durch die gesamte Breite des Tumors reichenden Schnitte revidiert und der Tumor als Plattenepithelkarzinom eingeordnet werden (T2N0M0). Die immunhistologische Untersuchung zeigte eine Infektion der Tumorzellen mit Human-Papilloma-Viren (HPV). Linkes Auge: 10 Jahre nach Entfernung des Plattenepithelkarzinoms des rechten Unterlides stellte sich der Patient mit einem großen, rasch progredienten, ulzerierenden Oberlidund Brauentumor des linken Auges vor (⊡ Abb. 4). Der 50×30 mm große Tumor war am Knochen fixiert. Das Lid konnte nicht geöffnet werden. In der linken Glandula parotis und in der Halsgefäßscheide fanden sich bei den Ultraschallund CT-Untersuchungen zahlreiche bis zu 1,5 cm große Knoten (T4N1M0) (⊡ Abb.5).Das Tumorgewebe war mit Human-Papilloma-Viren infiziert. Am rechten Auge bestand kein Anhalt für ein Tumorrezidiv.Der Visus des rechten Auges war 1,0. Liebe Kolleginnen und Kollegen

Severe bleeding eyelid after trivial trauma: conjunctival metastasis of a renal cell carcinoma

Dear Editor, A 70-year-old woman was referred to our clinic with a persistent bleeding of the eye following a minor injury, having slipped and bumped her head against a bedside table that morning. The right upper eyelid contained a subtarsal lesion and a hyposphagma in the temporal superior quadrant of her right eye. There was no evidence of a penetrating eye injury. Due to a permanent conjunctival hemorrhage, inspection of the wound was difficult. As the source of bleeding could not be identified using the slit-lamp, surgical exploration and wound care were planned. The wound exploration and haemostasis were performed as an emergency procedure. Next to the wound, a whitish gelatinous nodule could be identified as the source of the bleeding (Fig. 1a). An excisional biopsy of this nodule was taken and the bleeding was stopped with an electrosurgical cauter. The patient’s medical history revealed a renal cell carcinoma (initial pT3, pNx cM0 G2 R0 L0 V1). A nephrectomy on the left side had been performed in July 2006 as well as consecutive resections of metastases of the diaphragm, the right lung, and the right breast in November 2007. In September 2008, partial resection of the 6th rib was performed, as well as a resection of a second metastasis of the right lung. Since January 2009, a further 20 smaller metastases of the lungs had been removed, and in February 2009 the patient presented with cerebral metastases. These were treated with a radiosurgical procedure in April 2009. The patient is still alive and in moderate condition. Histology of the conjunctival specimen showed a low differentiated malignant epithelial tumor (Fig. 1b). There were only a few small vessels supplying the tumor. Immunohistochemistry was positive for pancytokeratine AE1/AE3 (Fig. 1c) and CD10 (Fig. 1d). Examination of the primary tumor showed identical histological and immunohistochemical findings. In summary, the histopathological findings confirmed the nodule as a conjunctival metastasis of the known renal cell carcinoma. In 2004, Shields and co-worker analyzed a series of 1,643 conjunctival tumors [1]. In this large cohort they found only 13 metastases, i.e., metastases accounted for less than 1% of all conjunctival tumors. Five of these 13 metastases were associated with breast cancer, three with pulmonary cancer, two with a malignant melanoma of the skin, one with a carcinoid, one with a laryngeal carcinoma, and one metastasis of unknown origin. These data illustrate the rarity of conjunctival metastases in comparison to primary conjunctival tumors. However, renal cell carcinomas (RCC) represent approximately only 1–3% of all adult visceral cancers [2]. One of the common characteristics of RCCs is their tendency to metastasize without showing early clinical symptoms. The most common locations of metastases are the lungs (>50%) and the bones (up to 30%), followed by regional lymph nodes, the liver, and the brain [3]. Only in very rare cases do RCCs affect the eye. In a T. Lapp (*) Division of Infection and Immunity, University College London, The Cruciform Building, Gower Street, London WC1E 6BT, UK e-mail: T.Lapp@ucl.ac.uk

Collagen Characteristics and Refractive Outcomes

High satisfaction after refractive surgery fundamentally depends on the long-term refractive stability. Several factors have an influence on postoperative refractive results, i.e. long-term stability of preoperative refraction, preoperative difference between subjective and objective refractive measurements. Individual tissue characteristics might have an influence on postoperative results as well. However, there are no options up to now to evaluate tissue parameters preoperatively.

Rostfarbene konjunktivale und subkonjunktivale Verfärbungen

Abb. 18 RechtesAuge (OD)und linkesAuge (OS) imGeradeausblick (Mitte) sowiesichtbareBindehautanteile inden4Hauptblickrichtungen. Größtenteils homogene oberflächliche orange-bräunliche Verfärbungenmit Aussparung der superioren Bulbusanteile,dabei imBereichdesnasalenPingueculumdes linkenAugesmitheterogenemVerteilungsmuster.Erläuterung s. Text renzbereich des Labors 176–391.000/μl) und therapierefraktären Hypertonien (max. 160/90mmHg) im Rahmen einer fremd-allogenen Blutstammzelltransplantation (PBSCT) bei akuter myeloischer Leukämie aufgetreten. Es erfolgte im Rahmen der hämatologisch-onkologischenBehandlung u. a. die Transfusion von 43 Erythrozytenkonzentraten und 154 Thrombozytenkonzentraten (davon 151 Thrombozytenapheresekonzentrate). Dabei wurde einmaximales Gesamtbilirubin von 7,8mg/dl (Referenzbereich <0,9mg/dl) und ein maximales Ferritin von 4917 ng/ml (Referenzbereich 15–150 ng/ml) erreicht. Die Laborwerte zeigten zuletzt ein normwertiges Bilirubin und ein persistierend erhöhtes Ferritin bei 1805–2098 ng/ml bei einer Transferrinsättigung von 66% (Referenzbereich 16–45%). Anamnestisch handelte es sich bei der Verfärbung der Augenoberfläche um einen größenstabilen Befund, der sich im Rahmen der PBSCT entwickelt habe und in der Kindheit nicht bestanden hätte.

Epithelinvasion nach traumatischer Flap-Dislokation

Eine traumatische Flap-Dislokation gehört zu den seltenen und späten Komplikationen nach LASIK [1]. Nach einer FlapDislokation kann es zu Irregularitäten der Hornhaut, Infektionen oder auch einer Epithelinvasion kommen [2,3]. Auch Fremdkörper sind im Interface beschrieben. Die Behandlung einer Epithelinvasion erfordert ein Anheben des Flaps, das Entfernen des eingewachsenen Epithels und ggf. die Behandlung mit proliferationshemmenden Medikamenten [2,4]. Wir präsentieren den Fall einer Patientin mit Epithelinvasion nach traumatischer Flap-Dislokation mit Foto-, OCTund histologischer Dokumentation.

Ultrastrukturelle Analyse von Hornhautlentikeln nach fs-Lentikelextraktion gibt es einen Zusammenhang mit den refraktiven Ergebnissen?

BACKGROUND ReLEx®flex is a corneal refractive procedure performed by removing corneal lenticules with a femtosecond (fs) laser system. Using electron microscopy, tissue parameters of extracted lenticules were analysed for potential correlations to the refractive results. Furthermore, the effect of previous contact lens (CL) wear on refractive stability (regression) was tested. PATIENTS AND METHODS 19 lenticules from 11 patients (age 24-56 years, 8 f, 3 m) were prepared for EM. The central areas of the samples were photographed and the distance between the collagen fibres and their diameters were digitally measured. ANOVA analysis was used to correlate postoperative refractional stability with time of preoperative CL use, fibre diameter and the coefficient of variation (CV) of fibre distance. RESULTS 14 of 19 lenticules were from patients who had worn CL preoperatively. The cumulative duration of CL wear averaged around 31.2 ± 35.5 thousand hours. Preoperative CL use significantly influenced the postoperative regression: the longer time patients had worn CL, the greater was the regression towards myopia (p = 0.01). Additionally, the morphological parameters collagen fibre diameter (p = 0.09) and CV of fibre distance (p = 0.07) had an impact on regression. CONCLUSIONS Prolonged CL use and alterations in ultrastructural patterns affected the refractive stability after ReLExflex. Although the pathophysiological relationships between CL use, corneal morphological parameters, and refractive stability are still poorly understood, these findings could potentially be used as prognostic markers for postoperative refraction after ReLExflex.

Orbitale Sarkoidose - ein Fall mit ungewöhnlichem Verlauf

Background Most cases of orbital sarcoidosis are associated with a systemic sarcoidosis. Patients and methods A 67-year-old woman suffered from an orbital mass on the right side, which led to disturbance of the ocular motility. Slight improvement was achieved by the administration of systemic steroids Results Histologically a chronic granulomatous inflammation was revealed in the biopsy of the orbital mass. The suspected diagnosis was sarcoidosis, but three conventional chest X-rays within 10 months and the serum angiotensin-converting-enzyme were normal. Suprisingly a computertomography of the chest showed mediastinal lymphomas. Conclusion Granulomatous orbital inflammation without any local cause or other systemic granulomatous disease strongly suggests a systemic sarcoidosis. In case of missing lymph node enlargement in conventional chest X-ray computertomography should be performed.