Evan Sacks

Multifocal Static Creamy Choroidal Infiltrates: An Early Sign of Lymphoid Neoplasia

Three patients, each more than 60 years of age at initial presentation, had early stage lymphoid infiltrates (formerly called reactive lymphoid hyperplasia) of the choroid and contiguous extraocular tissues. There were multifocal, confluent, and nonconfluent creamy patches in the choroid. These lesions changed very little over periods of observation ranging from 1 to 4 years and failed to produce ophthalmoscopically visible disturbances of the retinal pigment epithelium (RPE). Fluorescein angiography demonstrated dye collection within the lesions without leakage into the subretinal or subpigment epithelial spaces. Both ultrasonography and computed tomography (CT) showed thickening of the choroid with either anterior or posterior episcleral extensions of lymphoid tissue. Pathologic evaluation of biopsy specimens of extraocular portions of the lesions showed low-grade tumors that were diffuse infiltrates of mature lymphocytes, which exhibited lymphoplasmacytoid features, Dutcher bodies, or small residual germinal centers (so-called borderline lesions). Two patients had uniocular localized disease, whereas the third had bilateral ocular lesions, hypogammaglobulinemia, and another extranodal chest wall lymphoid tumor. Therapy for the localized ocular condition consisted either of oral administration of corticosteroids or low doses of radiotherapy.

Endonasal laser-assisted dacryocystorhinostomy.

Dacryocystorhinostomy is a procedure that is performed to allow drainage of tears from the lacrimal sac directly into the nasal cavity. Endonasal telescopes facilitate performance of this operation with better visualization and decreased morbidity. We present our experience with endoscopic laser-assisted DCR. In the last 31 months, we have performed 31 procedures on 23 patients with either the holmium: YAG laser or the argon: HGM laser. We have a 97% overall success rate with a mean follow-up of 16 months. Our series includes both adult and pediatric patients as well as five revision procedures after failed external DCR. We present our technique, results, and the reasons for our change in laser delivery systems. Most importantly, we discuss the technical factors that contribute to our overall success. These include a large rhinostomy size, simultaneous correction of intranasal and/or sinus pathology, the avoidance of laser use within the lacrimal sac, and close postoperative monitoring with intranasal debridement. We conclude that endoscopic laser-assisted DCR is a better alternative to standard external DCR because it avoids a cutaneous scar, excessive tissue injury, and postoperative morbidity.

A comparison of conjunctival and nonocular dendritic cells utilizing new monoclonal antibodies.

Langerhans cells belong to the dendritic cell family. Their presence in the conjunctiva and cornea has been demonstrated by means of various membrane and cytoplasmic markers. Utilizing OKT6, a monoclonal antibody that specifically binds to Langerhans cells in conjunction with la histocompatibility antigens (HLA-DR), and a new panel of monoclonal antibodies, we compared the population density and characteristic phenotypes of Langerhans cells in normal conjunctiva with those in normal epidermis. A greater density of Langerhans cells was noted in epidermis in comparison with conjunctiva. Various areas of the conjunctiva and cornea were mapped for Langerhans cell distribution. The T6/la ratio of Langerhans cells in conjunctiva was notably different from that in skin. Utilizing the Prolm2 marker, we identified non-Langerhans dendritic cells in the substantia propria and in the basilar epithelium of the conjunctiva, antigen-processing cells probably identical to the interdigitating dendritic cells of lymph nodes.

The Immunoarchitecture of the Normal Human Lacrimal Gland

To delineate the immunoarchitecture of the normal human lacrimal gland, monoclonal antibodies that detect B- and T-lymphocyte, macrophage, and dendritic cell lineage, subset, and differentiation-associated antigens were used in combination with highly sensitive tissue-section immunoperoxidase techniques. Plasma cells, identified with monoclonal antibody OKT10, represented the predominant mononuclear cell population, accounting for 53.9% of all mononuclear cells present. A qualitative study of plasma cell cytoplasmic immunoglobulin heavy-chain expression in deparaffinized, formalin-fixed tissue sections showed that the vast majority of these plasma cells contained IgA. Rare plasma cells contained IgG, IgM, or IgD. T-cells, identified with monoclonal antibody OKT3, represented the second most common cell type in the normal human lacrimal gland, accounting for 40.3% of all mononuclear cells present. T cells were located predominantly in lymphocytic foci and singly in the interstitium. T8 antigen-positive (suppressor/cytotoxic) T cells predominated over T4 antigen-positive (helper) T cells, averaging 25.2 and 14.7%, respectively. The overall mean T4/T8 ratio was 0.56. T8 antigen-positive T cells were the most numerous cell population outside aggregates and follicles, being distributed almost equally between the acini and the ducts (49%) and the interstitium (51%). Only 16% of T4 antigen-positive cells preferred glands or ducts to the interstitium. B cells, identified with monoclonal antibody BL9, represented only 5.7% of all mononuclear cells present. B cells were exclusively found in the centers of primary and secondary follicles. The majority of the surface immunoglobulin-positive B cells expressed IgM, fewer expressed IgD, and still fewer expressed IgG or IgA. Rare LeuM1+ OKM1+ macrophages were present in the center of B-cell follicles, where rare OKT6+ dendritic cells and activated T cells (IL-2+) were also discovered. These results support the concept that the lacrimal gland belongs to the mucosa-associated lymphoid system.

Immunophenotypic Analysis of the Inflammatory Infiltrate in Ocular Cicatricial Pemphigoid

Ocular cicatricial pemphigoid (OCP) is characterized by the deposition of immunoglobulin and complement along the conjunctival epithelial basement membrane zone (BMZ). In order to further elucidate the cellular populations of the local inflammatory infiltrates, the authors used a panel of monoclonal antibodies in cryostat tissue sections to delineate T cell subsets, B lymphocytes, dendritic cells, and macrophages in six patients with OCP. In comparison with matched controls of the epibulbar conjunctiva, the authors discovered a threefold increase in T lymphocytes within the epithelium and a 20-fold increase within the substantia propria. In contrast with the normal-standing population of conjunctival T lymphocytes, there were activated interleukin 2 receptor (IL-2R)-positive lymphocytes in both the epithelium and the substantia propria. Macrophages were the second most common cells in the substantia propria, accounting for 12.7% of the mononuclear population--a threefold increase over the normal percentage. B cells and plasma cells, normally absent from epibulbar conjunctiva, were the next most prominent populations, constituting 6.9 and 4.6%, respectively, of all mononuclear cells. Dendritic cells which process antigen locally constituted only 1.2% of the mononuclear cell population, but were increased 25-fold over normal controls. By elaborating cytokines that promote fibroplasia, the T cells in OCP may be effector cells along with macrophages and other inflammatory cells in bringing about scarification of the substantia propria, and may furthermore be responsible for an immunoregulatory defect that allows local B lymphocytes to produce autoantibodies to the BMZ.