Conjunctival cytologic features in anophthalmic patients wearing an ocular prosthesis

PURPOSE: To evaluate the cytologic features of conjunctival epithelium in anophthalmic sockets with an ocular prosthesis, using an impression cytology technique and to determine the clinical factors associated with these changes. METHODS: In a prospective case-controlled study, 40 consecutive unilateral anophthalmic patients who wore an ocular prosthesis were recruited. A questionnaire on the care of the prosthesis included total wearing period, frequency of cleaning, frequency of polishing, cleaning solution, and eye drop use. The degree of inflammation of the anophthalmic conjunctival socket was evaluated. Impression cytology specimens were taken from the upper tarsal conjunctiva, the bulbar conjunctiva, and the lower tarsal conjunctiva of each socket, and from the contralateral eye (to serve as an internal matched control). The goblet cell density and the nucleus-to-cytoplasm ratio of the epithelial cells were measured. The relevance of these conjunctival cytologic features to the various factors of prosthesis care or conjunctival inflammation was analyzed. RESULTS: In the anophthalmic sockets, the conjunctiva showed squamous metaplasia at all 3 areas sampled. The goblet cell density was significantly decreased and the nucleus-to-cytoplasm ratio of the epithelial cells was significantly increased compared with the control eyes (p<0.05, on all 3 areas sampled, Wilcoxon signed rank test). These conjunctival cytologic changes were not significantly associated with total wearing time, frequency of polishing, cleaning solution, or eye drops use (p>0.05, Spearman's correlation test). CONCLUSIONS: Squamous metaplasia with decreased goblet cell density and increased nucleus-to-cytoplasm ratio occurred in anophthalmic conjunctival sockets but was not associated with particular aspects of prosthesis care.     

Ocular surface squamous neoplasia in an anophthalmic socket 60 years after enucleation

Ocular surface squamous cell neoplasia in an anophthalmic socket is an exceptionally rare occurrence. We report a 62-year-old white man who had his left eye enucleated at age 2 and developed an invasive squamous cell carcinoma 60 years later. He received multiple treatments, including excisional biopsy, topical mitomycin C chemotherapy, cryotherapy, and finally exenteration. We review the literature to evaluate the clinical characteristics, time of onset following enucleation, treatment, and outcome of previously reported cases. Our case emphasizes the importance of a thorough examination of the anophthalmic socket, including upper and lower lid eversion.     

Induction of bilateral ligneous conjunctivitis with the use of a prosthetic eye

The purpose of this article to report a case of ligneous conjunctivitis in an anophthalmic socket, in respect of a 20-year-old woman. The subject woman had a history of left enucleation surgery presented with bilateral palpebral ligneous conjunctivitis and ligneous gingivitis. The hematologic study revealed a severe plasma plasminogen deficiency. The eyelid lesions were successfully treated with surgical excision, topical heparin and corticosteroid eyedrops. However, the ligneous lesions recurred bilaterally after she was fitted with a prosthetic eye and were refractory to intensive topical treatment with heparin and cyclosporin A eye drops. This case shows that the use of a prosthetic eye may induce ligneous conjunctivitis in an anophthalmic socket and normal eye which is refractory to topical treatment.     

Role of Trichloroacetic Acid in Treating Posterior Conjunctival Cyst in an Anopthalmic Socket

Orbital cysts in anophthalmic socket are infrequent. Most of the cysts reported are anterior and the inability to retain a formerly well-fitted prosthesis is the most common symptom. We present a posterior conjunctival cyst developed after a dermo-fat graft reconstruction in an eviscerated socket. Eleven years after evisceration surgery due to irreparable ocular trauma an extrusion of the orbital implant occurred. Removal of the orbital implant and a socket reconstruction with dermis fat graft was done. Three years later, the patient again returned back to the treating ophthalmologist with complaint of an inability to retain the formerly well-fitted artificial prosthesis. A detailed ophthalmic examination failed to reveal any abnormality. The CT scan showed a posteriorly located conjunctival cyst in the right orbit. Tricholoroacetic acid (TCA) was injected intracystically into the conjunctival cyst. Ten months of follow-up did not show any recurrence of the conjunctival cyst and allowed complete tolerance of the prosthesis. This case report highlights the role of tricholoacetic acid in treating a posteriorly located conjunctival cyst in an anophthalmic socket.     

Conjunctival flora in anophthalmic patients: microbiological spectrum and antibiotic sensitivity

AIM: To identify the spectrum and susceptibility pattern of isolated microorganisms from conjunctival flora of anophthalmic patients. METHODS: A cross-sectional clinical study including 60 patients with unilateral anophthalmia. Patients with use of antibiotic drops in their socket during the last month were also included. From each patient, three microbiological samples were taken from the lower conjunctival sac (healthy eye, pre-prosthesis, and retro-prosthesis space of socket). The 180 samples obtained were cultured. Isolates were identified and their antibiotic sensitivities were determined. RESULTS: A total of 251 isolates were recovered (62 isolates from healthy eye, 93 from pre-prosthesis, and 96 from retro-prosthesis space). The most common organism was Staphylococcus epidermidis, in both healthy eyes (64.5%) and sockets (45.5%). Altogether, coagulase-positive Staphylococci, Streptococci, and Gram-negative bacteria accounted for less than 15% of isolates in healthy eyes and more than 35% in sockets. Regarding the antibiotic sensitivities, there were no significant differences between isolates from sockets and healthy eyes. Nine patients recognized the use of self-prescribed antibiotic drops in their socket. In the healthy eyes of these subjects, Gram-positive microorganisms showed significantly greater resistance to aminoglycosides and tetracycline. CONCLUSION: Sockets of anophthalmic patients show a greater number of pathogens compared to healthy eyes. The use of antibiotic drops in the socket promotes a resistant flora not only in the socket but also in the healthy eye. Quinolones and macrolides may be better therapeutic options than aminoglycosides for treating conjunctivitis of anophthalmic sockets, since these antibiotics are less active against Staphylococcus epidermidis.     

Orbital dermoid cysts presenting as subconjunctival fat droplets

The authors report 3 cases of orbital dermoid cysts presenting with subconjunctival fat droplets. Three female patients were evaluated for conjunctival injection and yellowish granular material lying under the bulbar conjunctiva in the left eye. Slit-lamp examination showed a number of subconjunctival fat droplets in the involved eyes. Orbital CT and MRI in each case revealed a cystic mass located in the superotemporal aspect of the left orbit. The masses were excised via lateral orbitotomy in 2 patients, and a conjunctival biopsy of the granular material was performed in 1 patient. The cystic masses were histopathologically diagnosed as dermoid cysts with findings of lipogranuloma that suggested a previous rupture of the cyst itself. Examination of the conjunctival specimen also suggested lipogranuloma. Orbital dermoid cysts should be considered in patients presenting with subconjunctival fat droplets.     

Painful orbital inflammatory lesions and mastocytosis

A 15-year-old female patient developed painful nodules in an anophthalmic socket that were exacerbated by treatment with steroids and narcotics. Although orbit biopsy showed chronic inflammation, the diagnosis of mastocytosis was confirmed with skin biopsy and urinary levels of histamine. The patient responded to excision of nodules and treatment for mastocytosis. Painful orbital lesions associated with mastocytosis have not been reported previously.     

Dry anophthalmic socket syndrome – Standardized clinical evaluation of symptoms and signs

ObjectivesTo assess symptoms and signs of the dry anophthalmic socket syndrome (DASS) in a standardized manner.Methods87 unilateral anophthalmic patients were evaluated using the Ocular Surface Disease Index (OSDI), the 5-Item Dry Eye Questionnaire (DEQ-5), and a modified version of Symptom Assessment iN Dry Eye (SANDE) questionnaire separately for the anophthalmic socket and for the healthy fellow eye. Conjunctival inflammation was semi-quantitatively graded and Schirmer I test with topical anesthesia was performed bilaterally. The correlations between scores of the dry eye questionnaires and the results of the Schirmer tests, conjunctival inflammation, and demographic data were examined.ResultsPatients had significantly higher OSDI, DEQ-5 and SANDE scores at the anophthalmic side compared to the healthy eye (p ≤ 0.019, respectively). 63% of patients complained of anophthalmic socket dryness in at least one of the three questionnaires. Patients had higher inflammation (p < 0.001) and more tear volume in the Schirmer I test with topical anesthesia (p ≤ 0.024) on the anophthalmic side compared to the fellow eye.ConclusionsMost anophthalmic patients have significantly more subjective dryness complaints on their anophthalmic side compared to the healthy fellow eye, even in absence of tear deficiency and clinical blepharitis. Eye care practitioners should consider the diagnosis criteria and the definition for DASS proposed in this study, when counseling anophthalmic patients. However, research should be undertaken to investigate the role and the interactions of causative etiological causes for DASS. Furthermore, there is a high priority to establish a standardized examination protocol and to develop an evidence-based treatment algorithm for DASS.     

Traumatic globe luxation and enucleation caused by a human bite injury

A 55-year-old woman presented to the emergency room with complete loss of vision in the left eye after being bit in the face by her autistic grandson. She had a small upper eyelid laceration and an anophthalmic socket on the left side. A thorough history revealed that the bite had caused traumatic luxation of her globe, which had allowed the child to transect the optic nerve with his teeth. Careful attention was directed toward the prevention of retrograde infection in this unusual case of traumatic enucleation.     

Autologous serum eye drops used to treat an ulcerated dermis-fat graft

A 49-year-old woman with a contracted and keratinized anophthalmic socket underwent a dermis-fat graft for orbital augmentation. She presented with an early ulcer on the surface of the dermis, with inhibited conjunctival growth. There was no improvement after 1 month of conservative treatment. The authors applied autologous serum eye drops to accelerate epithelial repair, with resolution of the ulcer and reduction of surface keratin within 3 weeks. This is the first report of dermis-fat graft ulcer treated with autologous serum.     

A patient with sarcoidosis diagnosed by a biopsy of scleral nodules

Purpose To report the case of a patient with nodular scleritis who was diagnosed as having sarcoidosis by a biopsy of scleral nodules.Methods Case report.Results A 26-year-old man with nodular scleritis underwent a biopsy of scleral nodules. The year before, he had been diagnosed with granulomatous iridocyclitis of the right eye. Although sarcoidosis had been suspected, extensive systemic examinations resulted in no positive findings of sarcoidosis. Histopathological specimens revealed non-caseating epithelioid granuloma with giant cells. The nodular scleritis was resolved by topical corticosteroids.Conclusions A scleral biopsy is useful for the diagnosis of sarcoidosis when the patient has nodular scleritis with no systemic signs.     

Large subconjunctival emphysema causing diplopia and lagophthalmos

PURPOSE: To describe a patient who developed diplopia, lagophthalmos and exposure keratopathy due to a large subconjunctival emphysema. METHODS: A 24-year-old man sustained an injury in his left eye from a compressed air hose. The patient complained of pain and diplopia. He underwent slit-lamp examination, funduscopy and computed tomography. RESULTS: Ophthalmic examination revealed a decrease in vision in the left eye to 0.5, a conjunctival laceration adjacent to the medial limbus, subconjunctival hemorrhage, a large subconjunctival emphysema, lagophthalmos, hypertropia and superficial punctate keratopathy. The posterior pole was intact as were the orbital bones. Two weeks after the injury the conjunctival emphysema, diplopia, lagophthalmos and superficial keratopathy resolved, and visual acuity improved to 1. CONCLUSIONS: Large subconjunctival emphysema can result in diplopia, lagophthalmos and exposure keratopathy.     

Management of subconjunctival haematoma by tissue plasminogen activator

A patient with subconjunctival haematoma related to enterovirus 70 who was treated with tissue plasminogen activator (tPA) is reported. A 46-year-old man developed a severe subconjunctival haematoma and discharge in the left eye. Investigations, including coagulation tests, showed no abnormalities apart from a high-serum antibody titre for enterovirus 70. The polymerase chain reaction demonstrated enterovirus 70 DNA in resected conjunctival tissue, leading to a diagnosis of acute haemorrhagic conjunctivitis. The left eye was treated with a single subconjunctival injection of tPA (16 000 IU) and the subconjunctival haematoma resolved completely after 3 days. Severe subconjunctival haematoma can occur in patients with acute haemorrhagic conjunctivitis due to enterovirus 70. Subconjunctival injection of tPA may be useful for the treatment of severe subconjunctival haematoma.     

前臂游离皮瓣眶内移植矫正眶内容缺失和眼窝闭锁

目的 评价前臂游离皮瓣整复眶内容摘除术后及视网膜母细胞瘤术后继发严重眶内容缺失和眼窝闭锁畸形的效果。方法 眼窝或眶窝严重畸形患者16例,其中眶内容摘除术后7例,因视网膜母细胞瘤幼年行眼球摘除和放疗者9例。采用带有桡动脉和头静脉的前臂游离皮瓣,应用显微外科技术将桡动脉与面动脉吻合,头静脉与颈外静脉吻合,行游离皮瓣眼窝成形,同时联合眶内羟基磷灰石材料充填,以矫正眶内容缺失和眼窝闭锁畸形。结果 16例前臂游离皮瓣眼窝成形者,所有患者皮瓣均成活,术后随访0．5-5．0年,患者外观满意,义眼配戴良好。结论 前臂游离皮瓣眶内移植是修复重度眶窝畸形的良好方法之一。（中华眼科杂志,2004,40：373-376)     

Conjunctival squamous cell carcinoma in the anophthalmic socket

PURPOSE: To describe 2 patients in whom squamous cell carcinoma of the conjunctiva developed in the anophthalmic socket more than 44 years after enucleation and chronic use of an ocular prosthesis. METHODS: Retrospective case reports. RESULTS: These 2 patients did not have known risk factors for squamous cell carcinoma, including solar ultraviolet radiation or exposure (since they wore their prosthesis full-time), HIV infection, chronic orbital inflammatory disease, or immune-compromising systemic disease. Both patients had an orbital exenteration and underwent a full work-up including evaluation of the regional lymph nodes and systemic work-up to rule out distant metastasis. CONCLUSIONS: Squamous cell carcinoma of the anophthalmic socket can develop many years after enucleation. Regular inspection of the anophthalmic socket containing a prosthesis to rule out conjunctival squamous cell carcinoma is prudent.     

Conjunctival necrosis due to subconjunctival injection of betamethasone in treatment of graft rejection after penetrating keratoplasty.

A rare side effect of betamethasone applied subconjunctivally is described. A 51-year-old man who had undergone penetrating keratoplasty in his left eye 2 months previously developed graft rejection and was treated by subconjunctival injection of betamethasone. Within 2 weeks, the patient complained of conjunctival hyperemia and irritation. Biomicroscopic examination revealed conjunctival and subconjunctival necrosis with white necrotic tissue at the subconjunctival corticosteroid injection site. Simple debridement and primary wound closure of the involved area resulted in complete healing. Ophthalmologists should be aware that subconjunctival injection of betamethasone may cause conjunctival necrosis.     

Conjunctival non-caseating granulomas in a human immunodeficiency virus (HIV) positive patient attributed to sarcoidosis

PURPOSE: To report a rare case of isolated ocular sarcoidosis in an HIV positive patient. DESIGN: Case report. METHODS: A 47-year-old HIV+ Caucasian male was referred for chronic bilateral follicular conjunctivitis. RESULTS: A conjunctival biopsy that was performed on the right eye showed sarcoidosis. General medical evaluation including a spiral thin cut chest CT scan revealed no systemic involvement. The ocular signs and symptoms resolved completely with topical corticosteroid treatment. CONCLUSIONS: HIV infection and sarcoidosis rarely coexist, presumably because their immunopathogenesis mechanisms diverge. In the absence of systemic involvement, a definite diagnosis can only be made by biopsy of the ocular tissues.     

Asymptomatic subconjunctival entrapment of a cilium

We report an unusual case of asymptomatic subconjunctival entrapment of a cilium. A 64-year-old man presented with a 3?month history of a painless black line in the conjunctiva of the left eye, and slit-lamp examination revealed a cilium under the conjunctiva. The patient remained asymptomatic without conjunctival edema or hyperemia during a 2?week follow-up. To the best of our knowledge, this is the first report of an asymptomatic cilium inside the subconjunctival space.     

Tungiasis infestation of dermis fat graft in an anophthalmic socket

A patient with an anophthalmic socket with a dermis-fat graft (DFG) developed inflammation and a foul odour in the right socket. The DFG was surgically removed and Tungiasis infestation was detected. This is the first case to report Tungiasis infestation in a DFG in an anophthalmic socket.     

Ocular relapse in acute myeloid leukemia (M4) with normal bone marrow

A patient with the rare occurrence of ocular relapse of acute myeloid leukemia (AML) M4 while the bone marrow was normal is reported in this paper. A 47-year-old woman with AML was treated with chemotherapy and went successfully into remission. Four months later, she presented with pain, redness, and a mass over the left eye. The ocular relapse involved the subconjunctival space and anterior chamber of the left eye and, presumably, the left lacrimal gland. There were also multiple subcutaneous nodules on both of her forearms. Incisional biopsy from the subconjunctival lesion was performed. Histopathological examination of the specimen showed diffuse blast cell infiltration. Her bone marrow was still in remission. Although exceedingly rare, ocular extramedullary relapse in AML M4 heralds bone marrow recurrence and, despite intensive chemotherapy, the prognosis is dismal. The authors have no financial interests in any of the drugs used in the management of the patient subject in this report.