Helmut Buettner

Tissue breakdown and exposure associated with orbital hydroxyapatite implants.

Tissue breakdown and exposure of a hydroxyapatite implant were observed in eight patients: in four of six patients after evisceration and in four of 31 after enucleation. The reasons for evisceration were a blind, painful eye and endophthalmitis in two patients each. The reasons for enucleation were a choroidal melanoma in two patients and endophthalmitis and irreparable traumatic damage in one patient each. The patients with endophthalmitis received the implant in a second surgical procedure after intensive antibiotic treatment. Small tissue defects healed spontaneously, whereas large defects showed little tendency to heal by secondary intention. Tissue breakdown over a hydroxyapatite implant may be related to delayed ingrowth of fibrovascular tissue, and possibly related to an inflammatory reaction incited by the hydroxyapatite. Careful case selection, facilitation of tissue penetration by drilling holes into the hydroxyapatite sphere, delayed fitting of the prosthesis, and vaulting of the posterior surface of the initial prosthesis to reduce pressure on the tissues covering the anterior pole of the implant may alleviate the problems of tissue breakdown and exposure.

Clinical Features and Treatment of Seven Patients With Carcinoid Tumor Metastatic to the Eye and Orbit

PURPOSE To understand better the clinical features, treatment, and outcome of patients with carcinoid tumors metastatic to the eye and orbit. METHODS We studied seven patients with carcinoid tumors metastatic to the eye and orbit who were initially examined at the Mayo Clinic between 1974 and 1992. Carcinoid tumors metastasized to the choroid of six eyes of four patients and unilaterally to the orbit in three additional patients. RESULTS Decreased vision was the most frequent initial symptom with choroidal metastases. Choroidal metastases were treated with brachytherapy only, with brachytherapy and chemotherapy, with external beam irradiation and chemotherapy, or with chemotherapy only. The duration of follow-up of these four patients ranged from seven to eight years after the diagnosis of choroidal metastases. Two of the four patients died from tumor complications 7 1/2 and seven years after the diagnosis of choroidal metastases. Proptosis and limitation of ocular motility were the most common initial signs with orbital metastases. Orbital metastases were treated with external beam irradiation and chemotherapy, with chemotherapy only, or with external beam irradiation only. Duration of follow-up of these three patients ranged from one-half to two years after the diagnosis of orbital metastases. All three patients died from tumor complications during the follow-up period. CONCLUSIONS Because of the relatively good prospects for long-term survival in patients with carcinoid tumors metastatic to the choroid, early detection and treatment of the metastases are important.

Pans Plans Vitrectomy for Vitreous Amyloidosis

Thirty-six pars plana vitrectomies were performed on 30 eyes of 17 patients with biopsy-proven vitreous amyloidosis. Reopacification of the retrolental vitreous was the most common reason for vitrectomy revision, required in 24% of patients. Complications of amyloid or vitrectomy included retinal detachment requiring scleral buckling in 17% of eyes and glaucoma requiring filtering surgery in 17% of eyes. After a mean 35-month post-vitrectomy follow-up, 48% of eyes had visual acuities of 20/40 or better, and 32% of eyes had visual acuities between 20/50 and 20/100. Twenty percent of eyes had visual acuities of 20/200 or worse due either to persistent retinal detachment, open angle glaucoma, or residual opacification of the vitreous.

Massive Vitreous Hemorrhage and Senile Macular Choroidal Degeneration

In the elderly patient with a massive vitreous hemorrhage in one eye and senile macular choroidal degenerative changes in the fellow eye, a hemorrhagic disciform detachment causing this massive vitreous hemorrhage must be considered in the differential diagnosis. Ultrasonography selectively combined with radioactive phosphorus (32P) testing differentiates between a hemorrhagic disciform detachment or disciform scar and a malignant melanoma of the choroid. The ultrasonographic findings of a hemorrhagic disciform detachment may vary, but usually the posterior pole lesion is relatively flat and broad-based with a fairly homogeneous pattern without choroidal excavation. Posterior polar lesions secondary to senile macular choroidal degeneration do not grow. The vitreous hemorrhage clears in about three fourths of the patients, eventually allowing visualization of the posterior pole and ophthalmoscopic confirmation of a disciform scar. Almost one half of the eyes may be expected to lose all light perception because of the development of an initially hemorrhagic retinal detachment.

Intravitreal Large-Cell Lymphoma

Large-cell (non-Hodgkins) lymphoma may occur in the eye as a cellular infiltrate in the vitreous, uveal tract (choroid), retina, or optic nerve. Lymphomatous involvement may be limited to the eye but also is frequently associated with lesions of the central nervous system. Ocular involvement may precede involvement of the central nervous system by months or, in some cases, years. Ocular large-cell lymphoma is bilateral in approximately 80% of cases but often is asymmetric. The mean age of patients with ocular large-cell lymphoma is 60 years, and women are affected almost twice as often as men. Intravitreal large-cell lymphoma may manifest as an infiltrate of large glassy-gray cells or clusters of cells, and it may mimic uveitis or other inflammatory and infectious conditions of the eye. The diagnosis is based on cytologic and immunocytochemical studies of a vitreous biopsy specimen obtained by aspiration or by vitrectomy through the pars plana. Advances in irradiation of the eyes and the central nervous system, supplemented with corticosteroids and intrathecally and intravenously administered chemotherapeutic agents, have resulted in improvement of the dismal prognosis for patients with large-cell lymphoma.

Scleritis as an Initial Manifestation of Choroidal Malignant Melanoma

PURPOSE The purpose of this article is to present the unusual circumstances in which malignant melanoma of the choroid can masquerade as scleritis, thus confounding its diagnosis. METHODS Three cases of plaque-like malignant melanomas of the choroid are reported that, on initial examination, had features of scleritis. The events leading to their eventual correct diagnosis also are presented. RESULTS In each case, there was ocular pain, blurred vision, anterior chamber and/or vitreous cavity cellular reaction, and an exudative retinal detachment associated with an ill-defined, relatively flat variably pigmented choroidal mass. In all three cases, the inflammatory component responded promptly to corticosteroid treatment and was accompanied by visual improvement. In two eyes, shrinkage of the choroidal mass accompanied the corticosteroid treatment, lending support to a working diagnosis of scleritis. By demonstrating expansion of the choroidal masses, examination of sequential fundus photographs influenced the decision to enucleate the eyes for presumed malignant choroidal melanoma. CONCLUSION Clinicians should be alert to the circumstances in which malignant melanomas of the choroid can masquerade as scleritis. Careful evaluation by ophthalmoscopy, ultrasonography, fundus photography, and subsequent sequential examination is necessary to arrive at the correct diagnosis.

Isolated Neurofibromas of the Conjunctiva

We studied four histologically verified cases of isolated neurofibromas of the conjunctiva. The histologic pattern was diffuse in two patients, plexiform in one patient, and solitary in one patient. Simple excision was curative in all cases. We emphasize the importance of distinguishing neuromas (which may be associated with multiple endocrine neoplasia) from neurofibromas.

ocular Complications Of Disseminated Intravascular Coagulation (dic) In Abruptio Placentae

A 30 year old white woman presented at term with vaginal bleeding, dizziness and blurred vision due to bilateral serous retinal detachments. Extensive areas of choroidal occlusion with focal leakage of dye from the posterior retinal pigment epithelium and choroid were demonstrated by fluorescein angiography. With the diagnosis of abruptio placentae, a dead fetus and disseminated intravascular coagulation (DIC) the patient underwent removal of the uterine contents by cesarean section. DIC and retinal detachments resolved with improvement of vision, DIC, frequently observed in obstetric complications, has a tendency to occlude the posterior choroidal vessels, which often results in serous retinal detachments. In the setting of pregnancy, especially complicated late pregnancy, the occurrence of serous retinal detachments may be an early ocular sign of DIC.

VISUAL LOSS ASSOCIATED WITH PSEUDOXANTHOMA ELASTICUM

An 18-year-old woman with pseudoxanthoma elasticum had sudden profound bilateral visual loss, presumably as a result of optic nerve infarction caused by anemia and hypotension from massive gastrointestinal bleeding. Her central visual acuity largely recovered in her right eye, but her left eye had only hand motions acuity. During the subsequent 24 years, she underwent three separate surgical procedures for gastrointestinal bleeding. Abdominal arterial angiography showed numerous aneurysms of the gastric arteries. A subtotal gastrectomy was done, and histopathologic examination found advanced degenerative changes of the elastic lamina of the gastric arteries. At age 42 years, the patient lost residual vision in her right eye. This was caused by an extrafoveal subretinal choroidal neovascular membrane, which was obliterated with laser photocoagulation. Degeneration of elastic tissue, the primary defect in this syndrome, may cause cardiovascular complications and formation of breaks in the Bruch membrane, which are visible as angioid streaks. Ingrowth of fibrovascular tissue through angioid streaks may cause disturbances of macular function. The optic nerve ischemia and infarction associated with the profound visual loss in this patient reminds the ophthalmologist of the systemic nature of this disorder and the possibility that systemic vascular complications with massive blood loss may occur.

Clinicopathologic correlations in 646 consecutive surgical eye specimens, 1990-2000

All surgical eye specimens examined in our pathology laboratory between January 1, 1990, and July 31, 2000 (N = 646), were classified by surgical procedure (enucleation, evisceration, or exenteration) and pathologic diagnosis. Among 523 enucleated globes (81.0%), 252 (48.2%) contained tumors, of which 208 were intraocular malignant melanomas. Nonneoplastic causes for enucleation included glaucoma (67/523 [12.8%]), phthisis bulbi (61/523 [11.7%]), and recent trauma (59/523 [11.3%]). Sixty-seven specimens (10.4%) had been eviscerated. Fifty-six specimens (8.7%) were obtained by exenteration performed to manage malignant tumors originating in or invading the orbit. Between 1990 and 2000, the percentage of procedures performed to remove neoplasms decreased from 65% to 38%, procedures performed to treat glaucoma increased from 4% to 29%, and those to treat phthisis bulbi increased from 8% to 13%. The numbers of procedures remained relatively constant for trauma and for infectious and inflammatory diseases.