Ted H. Wojno

Clinicopathologic findings from lacrimal sac biopsy specimens obtained during dacryocystorhinostomy.

Purpose To retrospectively review the pathologic diagnoses and clinical characteristics of patients undergoing dacryocystorhinostomy (DCR). Methods Specimens accessioned between 1991 and 2001 in a single ophthalmic pathology laboratory were reviewed. All of the specimens included a lacrimal sac biopsy specimen. The pathologic diagnoses were recorded. The clinical features of the patients with significant pathologic abnormalities were reviewed to determine if the pathology was suspected before or at the time of the DCR. Results There were 377 DCR specimens from 316 patients representing 1.8% of 21,018 ophthalmic pathology specimens accessioned between 1991 and 2001. Diagnoses, in decreasing order of frequency, were nongranulomatous inflammation (321, 85.1%), granulomatous inflammation consistent with sarcoidosis (8, 2.1%), lymphoma (7, 1.9%), papilloma (4, 1.1%), lymphoplasmacytic infiltrate (4, 1.1%), transitional cell carcinoma (2, 0.5%), and single cases of adenocarcinoma, undifferentiated carcinoma, granular cell tumor, plasmacytoma, and leukemic infiltrate. A total of 31 (8.2%) specimens from 25 (7.9%) of patients demonstrated significant pathology. Among 17 specimens (4.5%) from 14 patients with neoplasms whose clinical histories were available, 8 (2.1%) were not suspected before surgery. Conclusions Nongranulomatous inflammation consistent with chronic dacryocystitis is the most common diagnosis in lacrimal sac specimens obtained at DCR. Neoplasms resulting in chronic nasolacrimal duct obstruction occurred in 4.6% of cases and were unsuspected before surgery in 2.1% of patients. We recommend pathologic examination of DCR specimens.

Ocular adnexal lymphoid proliferations: Clinical, histologic, flow cytometric, and molecular analysis of forty-three cases

PURPOSE To describe the clinical features, histologic findings, flow cytometric immunophenotypes, and molecular profiles of ocular adnexal lymphoid proliferations. STUDY DESIGN Prospective noncomparative case series. PARTICIPANTS Forty-three patients suspected of having ocular adnexal lymphoid proliferations were biopsied and prospectively evaluated. METHODS Provisional diagnoses were made on the basis of routine histology and immunohistochemistry for B and T cells. Results of flow cytometric immunophenotyping (FCI) and molecular assessment using polymerase chain reaction for immunoglobulin heavy chain (IgH) and TCR gamma chain gene rearrangement and bcl-2/IgH translocation were then incorporated into a final diagnosis. Demographic and clinical outcome data were collected. MAIN OUTCOME MEASURES Final diagnosis based on histology, flow cytometry, and polymerase chain reaction. RESULTS Forty-three cases were studied. Final diagnoses included 17 lymphomas, 18 chronic inflammations, 4 reactive lymphoid hyperplasias, and 4 atypical lymphoid infiltrates. Preliminary evaluation accurately categorized all 43 cases as either lymphoma or nonlymphoma. FCI permitted more precise subclassification of the lymphomas according to the Revised European American Lymphoma (REAL) system of nomenclature as follows: eight marginal zone B cell (mucosa-associated lymphoid tissue type), three mantle cell, two follicular, three large cell, and one lymphoplasmacytoid lymphoma. FCI showed a clonal B cell proliferation in 94% (16 of 17) of the lymphomas; FCI identified a clonal B cell population in 4% (1 of 25) of cases of nonlymphomas. Molecular evidence of clonality was identified in 88% (15 of 17) of lymphomas, 39% (7 of 18) of chronic inflammations, and 50% (4 of 8) of reactive lymphoid hyperplasias and atypical lymphoid infiltrates. CONCLUSIONS The histologic diagnosis of ocular adnexal lymphoid lesions is highly accurate when determined by an experienced pathologist. FCI refines the histologic diagnosis and classification. Results of molecular studies should be interpreted in conjunction with clinical, histologic, and immunophenotyping findings.

Kimura disease of the orbit and ocular adnexa.

Kimura disease (KD) is a distinct clinicopathologic entity that has been the subject of considerable confusion and debate. Although common in Asia, KD rarely occurs in non-Asian patients. Kimura disease shares both clinical and histopathologic features with angiolymphoid hyperplasia with eosinophilia (ALHE). Because of this overlap and the rarity of KD in Europe and the United States, KD and ALHE have been used synonymously in the Western medical literature, as they were thought to represent variations of the same disease. Some pathologic reports have called for distinguishing KD and ALHE as two separate entities, based on their histologic features. Kimura disease occurs most commonly in the head and neck region and has been described in the orbit, eyelids, and lacrimal gland more frequently than ALHE. Because both diseases can cause proptosis, lid swelling, ocular dysmotility, or a palpable mass, they should be considered in the differential diagnosis of orbital lesions occurring in adults. We report two cases of KD involving the orbit and ocular adnexa, and review additional cases reported in the literature. The ophthalmic literature does not clearly reflect the current understanding that KD and ALHE are best considered two separate clinicopathologic entities.

The Incidence of Extraocular Muscle and Cranial Nerve Palsy in Orbital Floor Blow-out Fractures

The frequency of extraocular muscle (EOM) or cranial nerve (CN) palsy as the sole cause of diplopia in orbital floor blow-out fractures has not been previously determined. Of 40 blow-out fracture patients studied prospectively, seven had motility disturbances consistent with palsy of one EOM or CN. All seven patients had negative forced ductions, making entrapment, edema, or orbital hemorrhage unlikely causes of diplopia. The diplopia resolved in four patients in 1 year. Persistent diplopia is a common indication for repair of such fractures. If, however, diplopia is due only to EOM or CN palsy, orbital surgery should be deferred (in the absence of significant enophthalmos) in favor of observation and/or later strabismus surgery.

Invasive Keratoacanthoma of the Eyelid and Ocular Adnexa

PURPOSE To report three patients with superficially invasive crateriform squamous proliferations of periocular tissue. METHODS The authors identified three patients with superficially invasive periocular tumors that had clinical features of keratoacanthoma. Clinical histories, radiographs, and surgical pathologic specimens were reviewed. RESULTS All three tumors arose over several weeks, had a crateriform configuration, and exhibited superficial invasion of underlying tissues, including perineural invasion and infiltration into skeletal muscle. All three tumors were classified as invasive keratoacanthoma. One tumor exhibited late perineural extension into the cavernous sinus and convincing histologic features consistent with squamous cell carcinoma. CONCLUSION The clinical importance of recognizing invasive keratoacanthoma is that although the tumor has the potential for spontaneous involution, locally aggressive behavior with deep perineural invasion is possible. This tumor is considered to represent a variant of squamous cell carcinoma. The authors recommend complete surgical excision of crateriform squamous proliferations with frozen section control of margins of resection.

Lid splitting with lash resection for cicatricial entropion and trichiasis

Lid margin splitting at the gray line with resection of the lash-bearing anterior lamella of the eyelid is a simple and effective treatment for cicatricial entropion and trichiasis. Twenty-six patients underwent this procedure with good results.

Sotradecol (sodium tetradecyl sulfate) injection of orbital lymphangioma.

PURPOSE To describe the results of intralesional injection of the sclerosing agent sodium tetradecyl sulfate in patients with lymphangioma. METHODS Three patients (one child and two adults) were treated. RESULTS Two patients had improvement in the size of the lymphangioma, although the result was short-lived in one instance. Minimal change was noted in the third patient. Two patients had transient edema and ecchymosis, and one patient had a mild allergic reaction to the injected solution. CONCLUSIONS Sodium tetradecyl sulfate may be a useful therapeutic option for some patients with eyelid or orbital lymphangioma, particularly if a previous operation has not been performed.

The Association Between Cigarette Smoking and Basal Cell Carcinoma of the Eyelids in Women

PURPOSE To determine if there is an association between basal cell carcinoma of the eyelid and cigarette smoking. METHODS A cross-sectional, retrospective, case-controlled study was done comparing the prevalence of cigarette smoking in 112 patients with biopsy-proven basal cell carcinoma of the eyelid to age and sex-matched controls with other eyelid disorders. Exposure-odds ratios were computed for each group. RESULTS Patients with basal cell carcinoma of the eyelid were no more likely to be smokers than controls (odds ratio [OR] 1.78, not statistically significant at the 95% confidence interval [CI]). When divided by sex however, there was an association between cigarette smoking and basal cell carcinoma in women (OR 2.87, statistically significant at the 95% CI) but not in men (OR 1.30, not statistically significant at the 95% CI). CONCLUSION Basal cell carcinoma of the eyelid is associated with cigarette smoking in women but not in men.

Langerhans Cell Histiocytosis of the Orbit: Five Clinicopathologic Cases and Review of the Literature

Langerhans cell histiocytosis (LCH) is a proliferation of Langerhans cells intermixed with inflammatory cells, in particular eosinophils, that may manifest as unisystem (unifocal or multifocal) or multisystem disease. Orbital involvement typically manifests as a solitary lesion that carries a favorable prognosis. We describe the clinical and histologic spectrum of LCH of the orbit in our five cases. One patient exhibited multifocal unisystem disease; the other four had a localized process. Typical histologic features included numerous histiocytes with varying degrees of giant cell formation and scattered eosinophilic granulocytes. The presence of Langerhans cells was confirmed by CD1a and S100 immunohistochemistry. Transmission electron microscopy demonstrated characteristic intracytoplasmic Birbeck granules. We review the different ophthalmic manifestations of LCH and treatment strategies. As LCH may solely involve the orbit, treatment is based on the degree of organ involvement. LCH should included in the differential diagnosis in tumors of the ocular adnexae, especially in young children.

Bone Formation in Hydroxyapatite Orbital Implants

PURPOSE We examined the histopathologic features of two hydroxyapatite orbital implants that were removed from two patients. METHODS Two surgically removed hydroxyapatite orbital implants were decalcified and processed for routine light microscopic examination. RESULTS Both implants demonstrated fibrovascular ingrowth and foci of bone formation. CONCLUSION Bone may form in hydroxyapatite orbital implants.