P A Rundle

Conjunctival Lymphoid tumors: clinical analysis of 117 cases and relationship to systemic lymphoma

OBJECTIVE To investigate the clinical features of conjunctival lymphoid tumors and factors predictive of systemic lymphoma. DESIGN Retrospective, observational case series. SETTING Clinical practice of ocular oncology. PARTICIPANTS The participants included 117 consecutive patients with lymphoid tumors of the conjunctiva treated at the Oncology Service of Wills Eye Hospital between 1974 and 1999. MAIN OUTCOME MEASURE The main outcome measure was the development of systemic lymphoma. Cox proportional regression models were used to calculate the risk of eventual systemic lymphoma. Kaplan-Meier survival estimates were used to analyze the development of systemic lymphoma as a function of time. RESULTS There were 55 males (47%) and 62 females (53%); 110 patients (94%) were white and 7 patients (6%) were African AMERICAN: The mean age at ocular presentation was 61 years, and the conjunctival lymphoid infiltrate was unilateral in 72 patients (62%) and bilateral in 45 patients (38%). In 8 patients (7%), initial unilateral conjunctival disease evolved into bilateral involvement over a mean of 32 months. Additional sites of ocular involvement were found in 27 patients (23%) and included lymphoid tumor in the eyelid in 3 cases, orbit in 18, choroid in 5, and vitreous in 1. Systemic lymphoma was known to exist before ocular diagnosis in 16 patients; (14%; for a mean of 51 months) and was found subsequent to ocular diagnosis in 20 patients (17; at a mean of 21 months). Therefore, of 117 patients with conjunctival lymphoid infiltration, 36 (31%) had or eventually developed systemic lymphoma, and 81 (69%) did not manifest systemic lymphoma during the mean follow-up of 38 months. Of the 64 patients with unilateral conjunctival involvement, 11 (17%) manifested systemic lymphoma, and of the 53 patients with bilateral involvement, 25 (47%) manifested systemic lymphoma. By univariate analysis, the clinical factors at date first seen predictive of the presence or development of systemic lymphoma included location of the tumor at an extralimbal site (fornix or midbulbar conjunctiva; P = 0.02) and increasing number of conjunctival tumors (P = 0.02). Using Kaplan-Meier life table analysis of those 101 patients who had conjunctival lymphoid tumor(s) and no evident systemic lymphoma at presentation, systemic lymphoma was eventually discovered in 7% of patients at 1 year, 12% at 2 years, 15% at 5 years, and 28% at 10 years. Overall, only one patient (<1%) died of systemic lymphoma, at 28 months after the diagnosis of the ocular disease. CONCLUSIONS Lymphoid tumors of the conjunctiva are associated with systemic lymphoma in 31% of patients. Systemic lymphoma is found more often in those patients with forniceal or midbulbar conjunctival involvement and in those with multiple conjunctival tumors. Long-term systemic follow-up is advised, because related systemic lymphoma can manifest many years later.

Efficacy of photodynamic therapy in circumscribed choroidal haemangioma

AbstractPurpose To report efficacy of photodynamic therapy (PDT) in the treatment of three cases of juxtafoveal circumscribed choroidal haemangioma.Methods Data on three patients (two primary, and one failed TTT) treated with verteporfin, 6 mg/m2 given as i.v. infusion over 10 min. Diode laser (690 nm) with an intensity of 600 mW/cm2 for 83 s (50 mJ/cm2) was applied 5 min after completion of infusion. Overlapping multiple spots (2500 μm) were applied to cover the entire surface of the tumour. The mean pretreatment tumour size was 7 mm (base) × 2.2 (thickness) mm. Periodic follow-up with ophthalmoscopy, ultrasonography, and angiographic studies was performed.Results All three cases showed complete regression of the tumour with resolution of subretinal fluid, flattening of tumour, and absence of choroidal vasculature on ICG. The visual acuity either improved or remained stable in all three cases. The overlying retinal vessels remained unaffected. There were no ocular or systemic complications.Conclusions PDT is an effective treatment for management of juxtafoveal circumscribed choroidal haemangioma.

Proton beam therapy for iris melanoma: a review of 15 cases

AimTo report results of proton beam therapy for iris melanoma.MethodsA retrospective case series of 15 patients with nonresectable iris melanomas treated with proton beam therapy between August 1998 and August 2004. The main outcome measures were (1) local tumour control, (2) complications, and (3) eye retention.ResultsOf the 15 cases, 11 patients showed documented growth (including two cases of local recurrence following iridocyclectomy) while a further three cases were biopsy-proven melanoma. One patient presented with a newly acquired vascular nodule of the iris associated with angle seeding and glaucoma. Tumour control at mean follow-up of 34 months was 93% (14 of 15 eyes). Common complications included glaucoma in 53% (five patients had glaucoma prior to irradiation), dry eye (27%) and cataract in three patients (20%). Eye retention was possible in 80% (12 cases).ConclusionProton beam therapy is an effective treatment for cases of nonresectable iris melanoma. The major complications are cataract and glaucoma.

Photodynamic therapy of choroidal haemangioma associated with Sturge-Weber syndrome.

1 Kaufman AH, Niles JL, Foster CS. ANCA test in ophthalmic inflammatory disease. Int Ophthalmol Clinics 1994; 34(3): 215–227. 2 Ara J. Relationship between ANCA and disease activity in small vessel vasculitis patients with anti MPO ANCA. Nephrol Dial Transplant 1999; 14(7): 1667–1672. 3 Bakkaloglu A, Ozen S, Baskin E, Tinazetepel BN. The significance of antineutrophil cytoplasmic antibody in microscopic polyangitis and classic polyarteritis nodosa. Arch Dis Childhood 2001; 85(5): 427–430. 4 Throne JE, Jabs DA. Ocular manifestation of vasculitis. Rheum Dis Clin North Am 2001; 27(4): 1–12. 5 Pulido JS, Goeken JA, Nerad JA, Sobol WM, Folberg R. Ocular manifestations of patients with circulating antineutrophil cytoplasmic antibodies. Arch Ophthalmol 1990; 108: 845–850.

Choroidal neovascularization secondary to choroidal osteoma: successful treatment with photodynamic therapy

Choroidal neovascularization secondary to choroidal osteoma: successful treatment with photodynamic therapy

Extrascleral extension of choroidal malignant melanoma following transpupillary thermotherapy

retinal detachment of both eyes is a rare finding. An annual incidence of 0.35 patients with bilateral simultaneous retinal detachment per 100 000 populations was estimated recently in Norway. These patients were significantly younger. They are usually myopic with multiple round retinal holes. Unilateral and bilateral retinal or vitreous haemorrhages are common features secondary to subarachnoid haemorrhage. They occur in 3–5% of cases of subarachnoid haemorrhages and usually come to the attention of an ophthalmologist during recovery after the patient regains consciousness. Any patient presenting with retinal or vitreous haemorrhages associated with neurological symptoms such as headache, nausea, or altered consciousness should be investigated to exclude intracranial haemorrhages; however, bilateral vitreous haemorrhages and headache are not pathognomonic of Terson’s syndrome. A non-diabetic vitreous haemorrhage most frequently arises as a result of vitreous separation. Our case demonstrates the importance of careful inspection as vitreous haemorrhage clears together with ultrasound B-scan to exclude rhegmatogenous retinal detachment even when the cause of vitreous haemorrhage is not considered to be related to vitreous separation.

Outcomes of treatment with stereotactic radiosurgery or proton beam therapy for choroidal melanoma.

AimTo present our experience of the use of stereotactic radiosurgery and proton beam therapy to treat posterior uveal melanoma over a 10 year period.Methods and materialsCase notes of patients treated with stereotactic radiosurgery (SRS), or Proton beam therapy (PBT) for posterior uveal melanoma were reviewed. Data collected included visual acuity at presentation and final review, local control rates, globe retention and complications. We analysed post-operative visual outcomes and if visual outcomes varied with proximity to the optic nerve or fovea.Results191 patients were included in the study; 85 and 106 patients received Stereotactic radiosurgery and Proton beam therapy, respectively. Mean follow up period was 39 months in the SRS group and 34 months in the PBT group. Both treatments achieved excellent local control rates with eye retention in 98% of the SRS group and 95% in the PBT group. The stereotactic radiosurgery group showed a poorer visual prognosis with 65% losing more than 3 lines of Snellen acuity compared to 45% in the PBT group. 33% of the SRS group and 54% of proton beam patients had a visual acuity of 6/60 or better.ConclusionsStereotactic radiosurgery and proton beam therapy are effective treatments for larger choroidal melanomas or tumours unsuitable for plaque radiotherapy. Our results suggest that patients treated with proton beam therapy retain better vision post-operatively; however, possible confounding factors include age, tumour location and systemic co-morbidities. These factors as well as the patient’s preference should be considered when deciding between these two therapies.

Bovine pericardium (Tutopatch) wrap for hydroxyapatite implants

PurposeTo evaluate bovine pericardium (Tutopatch®) as a wrapping material for hydroxyapatite implants in patients undergoing enucleation for uveal melanoma.MethodProspective cohort study of patients who had enucleation for uveal melanoma between January 2003 and August 2003 were included in the study. Any patient with less than 3 months follow-up was excluded. Enucleation was performed under general anaesthesia followed by insertion of hydroxyapatite implants wrapped in bovine pericardium (Tutopatch). The recti muscles were sutured directly to the wrap. The tenons capsule and conjunctiva were closed in two layers. A conformer was inserted at 1 week and artificial eye at 2–3 months. The patients were followed up regularly and were assessed for cosmetic result, exposure of implant, and the need for any further surgical procedures.ResultsA total of 19 patients (seven male and 12 female) were included in the study. Median age at diagnosis was 63 years (range 38–80 years). Median follow-up was 26 months (range 22–30 months). No patient developed postoperative complications of wound dehiscence. The overall cosmetic result was excellent in all the patients. The rate of postoperative complications compared favourably with published data using other wrapping materials/implants.ConclusionTutopatch® is a safe wrapping material for hydroxyapatite orbital implants in patients undergoing enucleation for uveal melanoma.

Conjunctival intra-epithelial neoplasia occurring in young patients with asthma

BackgroundConjunctival intra-epithelial neoplasia (CIN) typically occurs in elderly individuals. A number of aetiological factors are implicated in CIN, including life-long exposure to ultra-violet light and immunodeficiency states, particularly HIV infection. Asthma is a common condition affecting more than 3.5 million individuals in the UK, and is associated with atopy in approximately 70% of cases. In this paper we describe CIN occurring in young patients with asthma.MethodsRetrospective case series: A review of our ocular oncology database helped to identify 11 patients <55 years of age and presenting with CIN. Of these, seven (64%) were noted to have co-existent asthma.ResultsSeven patients were included in the study (six male and one female). Mean age at presentation was 44 years (range 36–54 years). Five patients showed unilateral disease, whereas two showed bilateral. Five patients showed local recurrence; however, there were no cases of metastasis.ConclusionThe occurrence of CIN, particularly bilateral CIN, in younger immunocompetent individuals is very unusual, and the presence of asthma in 64% of our patient cohort suggests that atopic asthma may be a further aetiological factor involved in the development of this rare neoplasm.

Treatment of invasive ocular surface squamous neoplasia with proton beam therapy

Sir, Ocular surface squamous neoplasia (OSSN) has the potential for causing significant ocular and systemic morbidity and mortality. We present two cases of invasive OSSN successfully treated with proton beam therapy (PBT). Both were non-resectable due to deeper scleral invasion.