Mesectodermal leiomyoma of the ciliary body: case report.

The clinical, light microscopical, and electron microscopical features of a mesectodermal leiomyoma of the ciliary body are presented. This exceptionally rare and apparently benign tumour is considered to be of neural crest origin. In the case described the tumour cells were seen to contain thin filaments with focal densities and conspicuous numbers of mitochondria, and smooth muscle protein was demonstrated by immunohistochemical means.     

Mesectodermal leiomyoma of the ciliary body extending into the anterior chamber

A neoplasm of the ciliary body extending from the equator to the iris and the anterior chamber was observed in an 18-year old girl. Because the visual acuity was lost and the clinical diagnosis was uncertain the eye was enucleated. Both optic and electron microscopic investigations allowed the diagnosis of the mesectodermal type of leiomyoma of the ciliary body.     

Mesectodermal leiomyoma of the ciliary body managed by partial lamellar iridocyclochoroidectomy

In the right eye of an 11-year-old girl, a large iridociliochoroidal mass developed that measured approximately 14 x 12 x 9 mm in size. The tumor initially resembled a uveal melanoma on the basis of clinical appearance and ancillary studies. Enucleation was not done, however, because of the patient's age and the unusual transillumination properties of the lesion. Instead the tumor was resected by a partial lamellar iridocyclochoroidectomy with an excellent visual outcome. Light and electron microscopy and immunohistochemistry established that the tumor was a leiomyoma. A literature review showed that all but one of the 15 previously reported cases of ciliary body leiomyoma that the authors were able to verify were found in women with an average age of 30 years. The possible significance of this apparent age and sex predilection for this unusual tumor is discussed, and the clinical features which may help differentiate leiomyoma from uveal melanoma are presented.     

Main posterior watershed zone of the choroid

The main posterior watershed zone of the choroid is located between the nasal edge of the optic disc and the fovea and represents the area situated between the territories supplied by the temporal and nasal posterior ciliary arteries. In the fluorescein angiographies of 800 normal subjects a watershed zone was not observed in 33.1% due to technical reasons and in 22.3% due to the simultaneous filling of the peripapillar and macular choriocapillaris. In the remaining 44.6% the watershed zone was well outlined: it was straddling the optic disc in about half of these cases and involved the temporal half of the optic disc and the close choroid in the other half. Very rarely the watershed zone involved the nasal half of the optic disc or the papillo-macular area. The position of the watershed zone could be important to explain the visual field defect in anterior ischemic optic neuropathy and glaucoma.     

The dark choroid in posterior retinal dystrophies

Fourteen families with genetically determined posterior retinal dystrophies were studied by fluorescein angiography. With one exception, the families could be segregated into two clearly defined categories, one in which every member had a dark choroid, and one where each had a light choroid. This implies that the fluorescein angiography provides a means of subdividing certain of these disorders into more specific disease groups.     

The dark choroid in posterior retinal dystrophies.

Many patients with heredomacular degeneration exhibit a peculiar fluorescein angiographic finding of absence of the normal background fluorescence (a dark choroid). The cause of this is unknown but may relate to the deposition of an abnormal material in the retinal pigment epithelial cells. The finding does not correlate with severity or duration of disease but is more frequent in patients with flecks. The finding may be useful in subdividing heredomacular degenerations into more specific disease groups.     

Mesectodermal leiomyosarcoma of the antrum and orbit.

A 39-year-old black man developed a left antral leiomyosarcoma that subsequently extended into the ipsilateral orbit. On light microscopic appearance of the antral tumor the presence of a distinctive myxoid and fibrillar cytoplasmic background suggested the diagnosis of a malignant Schwann's cell tumor. A second biopsy of the orbital extension displayed the same fibrillar character, but the emergence of tumor giant cells with cytoplasmic trichrome positivity also raised the possibility of a rhabdomyosarcoma. Electron microscopy demonstrated the smooth muscle derivation of the tumor, which probably originated from vascular smooth muscle elements. The atypical neural appearance of this myogenous tumor may have been caused by the extensive neural crest contribution to the cephalic connective tissues (mesectoderm). Radiation therapy and chemotherapy were ineffective.     

Primary scleral buckling in open-globe injury involving the posterior segment

PURPOSE: To determine whether scleral buckle placement at the time of primary repair of open-globe injury of the posterior segment is beneficial. DESIGN: Retrospective, comparative, nonrandomized interventional study. PARTICIPANTS: One hundred twenty-five open-globe injuries treated at the Duke University Medical Center from June 1980 to May 1997. METHODS: Open-globe injuries were classified with the Open-globe Injury Classification. Eyes that had zone 2 and 3 injuries that had a primary buckle placed were compared with those that did not. MAIN OUTCOME MEASURES: Subsequent retinal detachment, visual outcome, and need for subsequent scleral buckling. RESULTS: The rate of retinal detachment and the visual outcome were similar in the two groups. More than half of those who did not have a primary buckle placed had subsequent scleral buckling surgery. CONCLUSIONS: Many open-globe injuries of the posterior segment require eventual scleral buckle. There may be a role for placement of a scleral buckle at the time of primary repair.     

Open-globe injuries and intraocular foreign bodies involving the posterior segment

Open globe injuries involving the posterior segment remain a major cause of visual loss in young adults. They occur more frequently in male than in female populations. The majority is due to domestic accidents, since work-related injuries have been decreasing due to proper education and use of safety equipment. However, leisure-related open globe injuries are on the increase. Prompt recognition and treatment of open globe injuries are essential. At presentation, it is necessary to collect etiological data such as cause, nature, time and place of injury. Anti-tetanus immunization must be confirmed. The presenting visual acuity and clinical examination data must be recorded. The lesion type is classified in accordance with the Birmingham Eye Trauma Terminology. Ocular ultrasound or computed tomography is performed for patients suspected of having an intra- or periocular foreign body. Functional prognosis is negatively influenced by a posterior or large rupture, the presence of an intraocular foreign body, the presence of retinal lacerations or retinal detachment, or the occurrence of posttraumatic infectious endophthalmitis. Recent advances in microsurgical techniques such as pars plana vitrectomy and new visualization techniques may improve the anatomical and functional prognosis for these patients. However, postoperative proliferative vitreoretinopathy remains a major concern: it is responsible for a significant rate of secondary retinal detachment with negative consequences for visual prognosis.     

Controversies in the management of open-globe injuries involving the posterior segment

There are numerous unresolved issues and controversies regarding the management of open-globe injuries involving the posterior segment. These areas include, but are not limited to, the following issues. Although vitrectomy has been shown to improve visual outcomes and allow retention of the eye in many cases, the extent of visual improvement is often limited because of the nature of the injury. Timing of vitrectomy surgery has been and will continue to be debated by proponents of early versus delayed intervention. The multiple features of acute ocular injury make it very difficult to interpret retrospective data regarding the most appropriate timing for surgical intervention. The use of prophylactic cryotherapy, in the setting of a scleral laceration with possible retinal damage, is not as controversial at present, as there is now sufficient data indicating that cryotherapy may actually exacerbate intraocular proliferation and worsen the situation. The role and benefit of a prophylactic scleral buckle is very widely contested, and it is not known if it truly decreases the risk of subsequent retinal detachment. Another area of debate centers on the use of antibiotics. When there is a known clinical infection, intravitreal antibiotics are the mainstays of therapy. However, in the absence of clinical infection, the use of prophylactic antibiotics and their routes of administration are quite controversial. Although there are significant data regarding the use of antibiotics in the postoperative setting, this information cannot be extrapolated into the setting of open-globe injuries, as organisms and virulence factors differ. Similarly, the use of vitrectomy versus vitreous tap in the setting of traumatic endophthalmitis is not fully resolved, although vitrectomy is used in most cases to repair concurrent damage from the injury itself. Finally, the placement of intraocular lenses in the acute trauma setting is controversial, as the risk of complications is quite high. Prospective, controlled clinical studies have not been done. This article reviews pertinent data regarding these management issues and controversies, and provides recommendations for treatment based on the available published data and the authors' personal experience.     

Prophylactic scleral buckling in perforating ocular injuries involving the posterior segment

Twenty patients suffering from perforating injury involving the posterior segment of the eye without retinal tear or detachment underwent posterior vitrectomy. In 12 of these where traction of the retina was suspected, prophylactic scleral buckling was performed as well. Only two of these patients developed delayed retinal detachment. Six of the eight patients who did not undergo scleral buckling at the time of the vitrectomy developed this complication. This finding was statistically significant (P = .015) and supports the use of prophylactic scleral buckling in the treatment of eyes with perforating injuries involving the posterior segment to prevent delayed retinal detachment.