Faculty Bibliography

The current World Health Organization classification of conjunctival melanocytic proliferations divides them into conjunctival nevi and invasive melanoma but, in contrast to other anatomic sites, does not recognize melanoma in situ. All atypical intraepithelial conjunctival proliferations are included in a heterogeneous category designated as primary acquired melanosis (PAM) with atypia. We performed clinicopathologic analysis of 29 cases of PAM with atypia. On the basis of histologic features and frequency of association with invasive melanoma and metastases, we were able to divide our cases into 2 histologic groups. The low-risk group (13 cases) included lesions composed of small to medium size melanocytes with high nuclear to cytoplasmic ratio and small to medium size hyperchromatic nuclei devoid of nucleoli showing predominantly single cell lentiginous growth pattern. Invasive melanoma occurred in only 2 cases from this group. None of these lesions metastasized. The second, high-risk group (16 cases), showed increased frequency of association with invasive melanoma (15/16 cases, 94%) and metastases (4/16 cases, 25%). These lesions were more heterogeneous architecturally but were all composed of melanocytes showing various degrees of epithelioid features such as abundant cytoplasm, vesicular nuclei, or prominent nucleoli. In 4 cases discrete areas showing high-risk and low-risk features were identified. All 4 lesions were associated with invasion. Our findings offer a practical approach for prognostically useful subclassification of PAM with atypia, which emphasizes cytologic features of intraepithelial conjunctival melanocytic proliferation.

We review the use of three topical medications for the therapy of ocular surface tumors: mitomycin C, 5-fluorouracil, and interferon alpha-2B. One hundred sixty patients with histologically or cytologically proven epithelial and melanocytic tumors were identified in the literature. Side effects occurred most often with mitomycin C, followed by 5-fluorouracil, and interferon alpha-2B. Patients most frequently experienced transient keratitis, redness, and irritation. Topical agents were used as both primary and adjuvant therapy. Rates of tumor regression for CIN and squamous cell carcinoma ranged from 80 to 96%, and 70% of pigmented tumors regressed after an average follow-up of 27 months.

Due to their indolent nature, conjunctival lymphomas have different treatment options compared to other adnexal lymphomas. Therapeutic options directed towards conjunctival lymphomas include radiotherapy (external beam radiation), brachytherapy, cryotherapy, intralesional interferon injections, systemic rituximab, and observation. Radiotherapy that has been demonstrated to be highly effective for both low and high-grade tumors, however, can be associated with a high percentage of short-term side effects and long-term complications. Brachytherapy can provide local tumor control, but can also cause many complications. Cryotherapy may be used for certain tumor locations, but has a high recurrence rate. Both interferon and rituximab show promising results for treating low-grade tumors while avoiding the complications associated with radiotherapy. Finally, reports of spontaneous regression of low-grade conjunctival lymphomas have led some investigators to advocate a course of careful observation following biopsy.

PURPOSE/OBJECTIVE:To report a case of conjunctival melanoma arising from diffuse primary acquired melanosis (PAM) with atypia in a young black woman in the context of previously published cases of this lesion in blacks. METHODS:Retrospective case report with literature review. The number and percentage of conjunctival melanomas occurring in black patients were determined from case series in which race was specified, published from 1950 to the present. RESULTS:Nodular multifocal conjunctival melanoma in a 30-year-old black woman was treated using surgical excision and adjuvant cryotherapy. Extensive PAM with severe atypia, including areas of microinvasive melanoma, was treated using topical mitomycin C. Literature review revealed 35 cases of conjunctival melanoma occurring in black patients. No previous reports of mitomycin C use in black patients with melanoma or PAM were identified. CONCLUSIONS:Conjunctival melanoma is an exceedingly rare tumor in black patients. The current case brings the total of reported cases to 36. We successfully treated nodular melanoma and diffuse PAM in a young black woman using a combination of excision with cryotherapy and topical mitomycin C, suggesting that these lesions are amenable to the same types of therapy previously described for white patients.

A 79-year-old woman with pseudophakic bullous keratopathy had microkeratome-assisted posterior keratoplasty for the treatment of clinically significant corneal edema. An island of epithelial ingrowth was noted in the flap-graft interface that was not communicating with the flap periphery. Partial lifting of the anterior corneal flap and removal and irrigation of the epithelial cells were successfully performed. A review of reports of microkeratome-assisted posterior penetrating keratoplasty shows epithelial ingrowth is common after this procedure. The presence of posterior sutures, a central location of the epithelial cells, communication with the periphery, and evidence of stromal melting should prompt immediate surgical intervention.

Fuchs' endothelial dystrophy is a common disease that has been widely studied since its initial report in 1910 by Ernst Fuchs. Although its clinical course and pathologic characteristics are well described, the etiology and inheritance pattern are still ambiguous. Ongoing work is evaluating the role of mitochondrial DNA in the pathogenesis of FED. Significant advances in the surgical treatment of FED, in part utilizing some of the techniques of refractive surgery, are promising thus far. Larger case series are needed to fully assess the safety, efficacy and indications of these techniques. Indeed, the time is right to take "a fresh look at an aging disease" [9].

Dramatic advances in our understanding of the molecular genetic basis of Leber's hereditary optic neuropathy (LHON) have revolutionized our ability to diagnose and prognosticate this disease. Unfortunately no corresponding advances in the treatment of LHON have emerged. Glaucoma is a prevalent form of optic neuropathy that has been studied extensively. Lessons learned from treatment of LHON and glaucoma may have important implications for both diseases. LHON presents formidable challenges to the design and conduct of clinical trials. The acutely symptomatic LHON patient with monocular vision loss provides a unique clinical situation in which to test an agent during a critical therapeutic window. Advances in neuroprotection, apoptosis, and neurodegenerative diseases may provide important clues for potential therapeutic agents for LHON. Antioxidants and agents that interfere with the critical steps of mitochondrial-dependent, oxidative stress-induced apoptosis are candidates for future LHON therapy. A variety of neuroprotective agents, under active investigation in other diseases, may be useful in LHON therapy. Effective pharmacotherapy will complement the current management approach that has changed little in the 130 years since LHON was originally described.