Faculty Bibliography

OBJECTIVES: To report the use of whole-body positron emission tomography fused with computed tomography (PET/CT) for the diagnosis and staging of orbital lymphoma. DESIGN: Retrospective observational case series. PARTICIPANTS: Four patients with biopsy-proven orbital lymphoma were evaluated by 18-fluoro-2-deoxyglucose whole-body PET/CT imaging. METHODS: Positron emission tomography/CT images were studied for the presence of glucose uptake. Foci were considered suspicious based on their standardized uptake values (SUVs). Physiologic images (PET) and their anatomic counterparts (CT) were fused to allow form and function to be evaluated on the same diagnostic page. MAIN OUTCOME MEASURES: Positron emission tomography/CT images were assessed for foci with abnormally high SUVs that correlated with biopsy-proven lymphoma. RESULTS: Positron emission tomography/CT detected orbital lymphoma in 3 patients (75%). It also revealed systemic lymphoma in 2 of the 4 patients. The 2 patients found to have systemic lymphoma were diagnosed to have extranodal marginal zone B-cell orbital lymphoma of the mucosa-associated lymphoid tissue (MALT) type. Similarly, the 2 with negative PET/CT results also had orbital MALT-type lymphoma. We found that PET/CT imaging helped guide further management in all 4 patients. CONCLUSIONS: Positron emission tomography/CT should be considered as a new method of diagnosing, staging, and restaging patients with orbital lymphomas

AIMS: To correlate the clinical, ultrasound and pathological features of the eyes first evaluated by 18-fluorine-labelled 2-deoxy-2-fluoro-d-glucose (FDG) positron emission tomography (PET)/computed tomography and then enucleated for choroidal melanoma. METHODS: 14 consecutive patients enucleated for choroidal melanoma were examined. At presentation, clinical, ultrasound and PET/computed tomography imaging were carried out. Ultrasound was used to measure the tumour size and evaluate the tumour shape and intrinsic vascularity (blood flow). Histopathological and immunohistochemical evaluations included tumour cell type, necrosis, glycogen content, vascularity and extrascleral extension. RESULTS: 13 tumours were T3 and one T2 (American Joint Committee on Cancer - International Union against Cancer). The mean tumour height was 10.6 (range 3.5-17.7) mm with a largest basal dimension of 19.3 (range 14.5-30) mm. Patients having melanoma with the highest six standardised uptake values ((SUV) > or =4.0) were (on average) >10 years older, their melanomas had larger basal dimensions and were epithelioid-cell type; three melanomas were centred anterior to the equator; three contained enlarged blood vessels (>150 mum in diameter); and three formed extrascleral extension. Patients with the two highest SUV tumours died due to metastatic melanoma. CONCLUSION: PET/computed tomography imaging offers a physiological assessment of glucose metabolism in primary choroidal melanomas. Increased FDG PET/computed tomography SUV was positively correlated with known clinical, pathological and ultrasound features linked to metastatic potential of choroidal melanoma.

PURPOSE: To present giant conjunctival inclusion cysts as a late complication of strabismus surgery. DESIGN: Retrospective case series of selected patients. PARTICIPANTS: Four patients with a history of strabismus surgery who had developed giant conjunctival inclusion cysts. METHODS: A chart review was performed. The patient's ocular history, ophthalmic examinations, and imaging (ultrasound/ultrasound biomicroscopy and/or computed tomography) were recorded. Surgical excision with subsequent histopathologic correlation was obtained in 3 cases. MAIN OUTCOME MEASURES: Clinical and imaging characteristics with histopathologic correlation. RESULTS: Four patients with giant conjunctival inclusion cysts had a history of strabismus surgery. Ultrasound biomicroscopy was performed in 3 cases and revealed large, cystic, well-circumscribed tumors with low internal reflectivity and hyperechoic components. Computed tomography of the orbits was used to evaluate posterior extension. Their size induced limitation in motility, strabismus, and problems related to chronic exposure. Histopathologic evaluations were consistent with benign inclusion cysts of the conjunctiva. CONCLUSIONS: Giant conjunctival inclusion cysts may appear decades after strabismus surgery. Tumor size, cystic nature, and involvement of underlying structures can be determined by ultrasonography and radiographic imaging. Complete surgical removal can be curative

PURPOSE: To report on the diagnosis of intraocular lymphoma by aqueous-cytology. METHODS: Four patients suspected to have intraocular lymphoma were evaluated by anterior chamber paracentesis with cytology (cytospin-technique). All had a history of non-ocular lymphoma and presented with at least one-plus anterior-chamber cells despite intensive glucocorticoid therapy. A 25-gauge needle was inserted through clear-cornea (bevel-up), over the iris stroma, as to drain the anterior chamber. The aqueous humor was sent for cytopathology (cytospin technique), culture and sensitivity. RESULTS: All procedures were diagnostic. Three were lymphoma and the fourth was culture-positive for propionibacterium endophthalmitis. No secondary glaucoma, hyphema, cataract or infections were related to anterior chamber paracentesis. CONCLUSIONS: In this series, anterior chamber aspiration cytology enhanced by the cytospin-technique was an effective, minimally invasive alternative to vitrectomy-based biopsy. This technique should be considered to rule in the diagnosis of intraocular lymphoma in selected cases with cells in the anterior chamber

PURPOSE: To report the onset of bilateral angle closure glaucoma resulting from ciliochoroidal effusions noted after taking escitalopram. DESIGN: Case report. METHODS: A 41-year-old woman with a medical history of depression was placed on escitalopram and presented with acute bilateral angle closure glaucoma. A medical history and ophthalmic examination (including slit-lamp photography and high-frequency ultrasonography) were performed at the time of diagnosis and at resolution of her symptoms. RESULTS: High-frequency ultrasonography revealed bilateral choroidal effusions with ciliary body detachments and angle closure. Attempts to reduce intraocular pressure with topical ocular antihypertensive drugs and subsequent laser peripheral iridotomy were unsuccessful. Over the course of four days, the use of topical cycloplegics, corticosteroids, and discontinuation of escitalopram resulted in normalization of intraocular pressures, deepening of anterior chamber depths, and resolution of her uveal effusions. CONCLUSIONS: The use of escitalopram resulted in uveal effusions, angle rotation, and acute bilateral angle closure glaucoma. Discontinuation of escitalopram and corticosteroid therapy resulted in normalization of the patient's eyes

BACKGROUND: To describe a case of reactive lymphoid hyperplasia following laser assisted in situ keratomileusis (LASIK). METHODS: This observational case report describes a 31-year-old man who underwent LASIK and presented 1 month later with a fleshy, conjunctival (plical) tumour in the left eye. An excisional biopsy of the tumour was performed. RESULTS: Histopathology of the excised tumour revealed reactive lymphoid hyperplasia involving the left conjunctiva. DISCUSSION: Conjunctival lymphomas can masquerade as chronic conjunctivitis and can be preceded by reactive lymphoid hyperplasia. It is important to identify and differentiate these tumours. This report describes the unusual occurrence of a lymphoid conjunctival tumour after LASIK eye surgery

PURPOSE: To describe a minimally invasive method to create a full-thickness surgical iridectomy. DESIGN: An interventional case series. METHODS: Surgical iridectomies were performed through a 1-mm clear corneal incision. The anterior chamber was prepared with acetylcholine chloride 10 mg/ml and sodium hyaluronate 1%. A 25-gauge aspiration-cutter 'probe' was introduced through the corneal incision such that the aspiration portal was occluded by the iris stroma. Then aspiration (600 mm/Hg) cutting (300 cpm) was used to create a surgical iridotomy in 2 cases. Then the probe was removed. RESULTS: Full-thickness iridotomies were created. None of the patients were noted to have a secondary increase in intraocular pressure, hyphema, infection, cataract or vision loss. The clear-corneal wounds were self-sealing. CONCLUSIONS: Small incision surgical iridectomy can be minimally invasive and effective. Use of a 25-gauge aspiration-cutting probe allowed for small incision surgery, rapid rehabilitation and no significant complications

The clinical, ultrasonographic, and histopathologic characteristics of an oncocytoma of the conjunctiva are described. A 49-year-old woman presented with a red-orange lesion adjacent to the caruncle in her left eye. A clinical examination including high-frequency ultrasound was performed prior to excisional biopsy of her tumor. High-frequency ultrasound demonstrated an epibulbar tumor with low internal reflectivity and a cystic component. There was no involvement of the underlying sclera. Multiple hypoechoic components of the tumor stroma were correlated to multiple cystic glandular structures on histopathologic evaluation. The excised tumor was diagnosed to be an oncocytoma

BACKGROUND: The aim of this study was to evaluate early insertion of ocular prostheses for aesthetic rehabilitation after enucleation and review current methods of enucleation surgery. METHODS: Twelve patients with large intraocular malignancies were treated by enucleation with implant. At the end of surgery, a medium-size conformer was inserted onto the closed conjunctival wound (just before applying a pressure dressing). The pressure dressing was removed 3 to 5 days after surgery. Immediately after bandage removal, the patients saw themselves in a mirror and were offered placement of a relatively small ocular prosthesis. Patients were asked if they preferred their aesthetic appearance with or without the prosthesis. RESULTS: Eight patients (67%) tolerated introduction of the prosthesis at the time of removal of their pressure dressing (3 to 5 days after enucleation surgery). Because of discomfort, 4 were able to receive their prostheses at their second postoperative visit (day 12 or 13). The manipulation at prosthesis insertion and subsequent wearing was found to have no effect on wound closure, final prosthetic fittings, or movement of the permanent prosthesis. All patients were pleased with the cosmetic benefit afforded by early introduction of the prosthesis and preferred their appearance to that of their eye with the conformer. CONCLUSIONS: Early replacement of the conformer by an ocular prosthesis allows for cosmetic rehabilitation and improved quality of life