Hüseyin Üstün

Paraneoplastic acrokeratosis of Bazex (Bazex's syndrome): Report of a female case associated with cholangiocarcinoma and review of the published work

Paraneoplastic acrokeratosis of Bazex (PAB) or Bazexs syndrome is a rare, paraneoplastic syndrome that mostly affects men over 40 years old, and generally associates with squamous cell carcinoma of the upper aerodigestive tract. We describe a 57‐year‐old woman with the characteristic features of PAB, including violaceous erythematous, scaling eruption, palmoplantar keratoderma and nail dystrophy. Further analysis revealed the underlying neoplasm to be cholangiocarcinoma. The clinical aspects of PAB and associated neoplasms are reviewed.

The effect of topical cyclosporine A on clinical findings and cytological grade of the disease in patients with dry eye.

Purpose: To compare the clinical findings and the cytological grade of the disease before and after 6 months of topical cyclosporine A treatment in patients with dry eye. Setting: This single-center prospective study was performed at the Department of Ophthalmology, Ankara University School of Medicine, between January 2007 and June 2008. Method: Forty-five patients with dry eye (with 5 mm/5 minutes or less Schirmer test) were included in the study. Patients were treated with cyclosporine A 0.005% ophthalmic emulsion (RESTASIS) twice daily in addition to lubricant eyedrops 5 times a day. Schirmer test values, tear breakup time (BUT), and impression cytology (goblet cell density, nucleus to cytoplasmic ratio, and epithelial cell morphology) were evaluated at baseline and after 6 months. Results: Before and after 6 months of the treatment with topical cyclosporine A, the median Schirmer test scores were found as 3.00 and 4.00 mm, respectively. The median BUT score at baseline was 4.00 seconds, and after treatment, the median score was 5.00 seconds. There were statistically significant differences in the median Schirmer and BUT values between, before, and after 6 months of treatment (P < 0.05). The mean cytological grade according to Nelson grading system was 1.84 at baseline and 1.51 after treatment with topical cyclosporine A for 6 months. Statistically significant improvement in cytological grades after treatment was observed (P < 0.05). Conclusion: Treatment of patients with dry eye for 6 months with topical cyclosporine A resulted in an increase in Schirmer test results, an increase in BUT scores, and an improvement in cytological grade of the disease.

Topical cyclosporine A for the dry eye findings of thyroid orbitopathy patients

The study was approved by the local ethics committee of Ministry of Health, Ankara Research and Training Hospital (14 February 2008, Number 00155) and patient recruitment began. The authors declared that they have no conflict of interest. A total of 90 eyes of 45 patients with TO were prospectively evaluated for this study between 1 April 2008 and 1 December 2008. The diagnosis of TO was made, when two of the following three signs of the disease were present: 2 (1) Concurrent or recently treated immune-related thyroid dysfunction: Graves hyperthyroidism, Hashimoto’s thyroiditis, and the presence of circulating thyroid antibodies without a coexisting dysthyroid state; (2) typical orbital signs (one or more of the following): unilateral or bilateral eyelid retraction with typical temporal flare (with/or without lagophthalmos), bilateral proptosis (as evidenced by comparison with patient’s old photos), restrictive strabismus in a typical pattern compressive optic neuropathy, fluctuating eyelid oedema/erythema, chemosis/caruncular oedema; and (3) radiographic evidence of TO including unilateral/bilateral fusiform enlargement of one or more of the following: medial rectus muscle, inferior rectus muscle, superior rectus–levator complex. In all patients, assessment of activity of TO was carried out using Clinical Activity Score (CAS) based on the classification system proposed by Mourits et al. 3

Expression of p53 in lesions and unaffected skin of patients with plaque-type and guttate psoriasis: A quantitative comparative study

Psoriasis is a common inflammatory and hyperproliferative skin disease characterized by hyperproliferation of keratinocytes. The pathogenesis of psoriasis has yet to be determined. The control of cell growth is a delicately balanced process, regulated by external signals or the internal genetic program of an individual cell. In psoriasis, these processes are disturbed and some candidate genes like p53 are suspected of being involved in the pathogenesis of the disease. The p53 protein is essential for the regulation of cell proliferation. The study was performed on 32 patients with psoriasis (24 plaque type, eight guttate type). Biopsy specimens for immunohistochemical determination of p53 protein expression were collected from both the lesional and the nonlesional skin sites that were not exposed to sun in all of the patients (n = 32). Taking the ultraviolet (UV) exposure of the skin into consideration, a third skin sample was taken from each patient (n = 7) who had lesions on the sun‐exposed areas. Immunohistochemical assessment of p53 expression in skin was determined as p53 protein expression per 1000 cells (keratinocytes). The statistical analysis revealed that the expressions of p53 per 1000 cells were higher in non‐sun‐exposed lesional skin than the non‐sun‐exposed nonlesional skin, also in plaque‐type psoriasis than guttate‐type psoriasis (P = 0.000, P = 0.046, P = 0.037, respectively). There was a positive correlation between the p53 expression in non‐sun‐exposed lesional skin versus expression in sun‐exposed lesional skin (cubic centimeters = 0.811, P = 0.027). Our results show a stronger association of elevated p53 expression with chronic rather than acute inflammatory psoriasis. This may indicate a mechanistic difference between plaque‐type and guttate psoriasis. Alternatively, this could reflect a chronological course as the disease transitions from an acute to a chronic phase.

Squamous cell carcinoma of the lacrimal sac.

The clinical and histopathological findings in a 40-year-old man with a lacrimal sac tumor are reported. Although the clinical history indicated a lacrimal sac obstruction and recurrent dacryocystitis, the lesion was diagnosed by light microscopy as a squamous cell carcinoma.

Confetti‐like macular atrophy: A new entity?

Anetoderma, is characterized by herniated atrophic macules clinically and by decreased to absent dermal elastic fibers histopathologically. Atrophoderma is characterized by depressed, atrophic, pigmented patches clinically and by thickened and homogenized dermal collagen bundles with absence of elastolysis histopathologically. Atrophoderma elastolyticum discretum describes lesions that are reminiscent of atrophoderma clinically but they are compatible with anetoderma histopathologically. A 34‐year‐old female patient presented with diffuse, hypopigmented, atrophic, shiny macules on the upper limbs and upper trunk. Histopathological examination revealed an atrophic epidermis with disorganized, hyalinized and coarse collagen bundles in the middle and lower dermis. Elastic fiber loss and fragmentation were detected in the upper dermis. The other patient was a 42‐year‐old female patient. She applied with diffuse, hypopigmented, shiny, atrophic macules on the upper limbs and upper trunk. Histopathological examination revealed findings that were similar to those of the first case but there was near complete loss of elastic fibers throughout the whole thickness of dermis. Our cases did not show depressed or herniated atrophic macules clinically but the macules were at the same level with the surrounding healthy skin. Histopathological findings in these cases showed the histopathological features of both atrophoderma and anetoderma. These two cases are interesting because they may represent a clinicopathological entity which has not been described before.

Duration of renal failure as risk factor for conjunctival squamous metaplasia.

OBJECTIVE To assess ocular surface changes in patients with chronic renal failure (CRF), to compare the results with the duration of illness. STUDY DESIGN Impression cytology from 48 patients with CRF on regular hemodialysis and 16 age- and sex-matched control subjects were studied. Specimens were taken from the temporal bulbar conjunctiva using cellulose acetate filter paper. RESULTS Among the patients with CRF who were ill for 0-10 years, 25 patients (78.1%) disclosed grade 0-1, and 7 patients (21.9%) disclosed grade 2-3 cytologic changes, whereas in those with the duration of CRF > 10 years, 9 patients (56.2%) had grade 0-1 and 7 patients (43.8%) had grade 2-3 changes. Specimens from the control group revealed 93.8% grade 0-1 and 6.2% grade 2-3 changes (p < 0.05). CONCLUSION The ocular surfaces of patients with CRF differ significantly from those of normal individuals, and the severity of conjunctival changes is related to the duration of CRF.

Keratoconus in a case of lipoid proteinosis.

Purpose: To report a patient of lipoid proteinosis (LP) with bilateral keratoconus. Methods: A 16-year-old boy presented to our institution with a complaint of gradual decrease in vision over the past 4 years in both eyes and a contact lens intolerance. He had a hoarse voice and multiple areas of hyperpigmented lesions over the head and neck region. Slit lamp biomicroscopy of the both eyes showed multiple round solid pearly lesions along the upper and lower lid margins and a mild central corneal ectasia in both eyes. Central corneal thickness and the keratometric values were measured by using Scheimpflug imaging (Pentacam), and the results were compatible with keratoconus. The histopathologic examination of the lesions taken from bilateral eyelid margins showed hyalinosis, papillomatosis, and depositions of eosinophilic material around the blood vessels, which were compatible with LP. Conclusions: With this report, we describe a case of LP with keratoconus. As seen in our case, LP and its characteristic eyelid margin lesions in keratoconus patients can be associated with a contact lens intolerance.

Ocular surface changes in patients treated with oral antidiabetic drugs or insulin.

Purpose To describe and compare ocular surface changes in patients with type 2 diabetes treated with either oral antidiabetic drugs (OAD) or insulin. Methods Forty eyes of 20 patients treated with OAD, 40 eyes of 20 patients treated with insulin, and 10 nondiabetic controls seen at Ministry of Health Ankara Educational and Research Hospital, 1st Eye Clinic, were studied. All subjects underwent routine ophthalmic examinations, Schirmer test, tear film break-up time analysis, and conjunctival impression cytologic analysis. Patients treated with OAD or insulin and a control group were compared for tear function parameters, goblet cell density, and squamous metaplasia grade. The relation between status of retinopathy and ocular surface disorder and serum HbA1c levels of diabetic patients were also noted. Results The tear film break-up time values were significantly lower in patients treated with OAD (p<0.05). There was no statistically significant difference in Schirmer test results of the 3 groups. Goblet cell density and squamous metaplasia grade were similar in all groups. The median grade was grade 1, in which epithelial cells are slightly larger, more polygonal, have eosinophilic staining cytoplasm, and goblet cells are decreased in number. Status of retinopathy did not seem to relate to ocular surface disorder. The serum HbA1c level of diabetic patients treated with insulin or OAD was similar (p>0.05). Conclusions Precorneal tear film stability was worse in patients treated with OAD; however, impression cytology analysis and Schirmer test results were similar in all groups.