Systemic amyloidosis presenting as a mass of the conjunctival semilunar fold

PURPOSE: To report a case of systemic amyloidosis that presented as a mass of the plica semilunaris (semilunar fold) of the conjunctiva. METHODS: Case report. RESULTS: A healthy 56-year-old man developed a fleshy, hemorrhagic lesion of the semilunar fold of the left conjunctiva. Excisional biopsy revealed an acellular lesion of the conjunctival stroma that stained positively for Congo red and showed apple-green birefringence and dichroism with polarization microscopy. The diagnosis was amyloidosis of the semilunar fold of the conjunctiva. Subsequent evaluation disclosed systemic amyloidosis. The patient remains asymptomatic. CONCLUSIONS: Although conjunctival amyloidosis usually occurs as a localized lesion without systemic involvement, it can be the initial sign of systemic amyloidosis.     

American College of Cardiology/American Heart Association preoperative assessment guidelines reduce resource utilization before aortic surgery

BACKGROUND: Methods used for evaluation of cardiac risk before noncardiac surgery vary widely. We evaluated the effect over time on practice and resource utilization of implementing the American College of Cardiology/American Heart Association Guidelines on Preoperative Risk Assessment. METHODS: We compared 102 historical control patients who underwent elective abdominal aortic surgery (from January 1993 to December 1994) with 94 consecutive patients after guideline implementation (from July 1995 to December 1996) and 104 patients in a late after guideline implementation (from July 1, 1997, to September 30, 1998). Resource use (testing, revascularization, and costs) and outcomes (perioperative death and myocardial infarction) were examined. Patients with and without clinical markers of risk for perioperative cardiac complications were compared. RESULTS: The use of preoperative stress testing (88% to 47%; P <.00001), cardiac catheterization (24% to 11%; P <.05), and coronary revascularization (25% to 2%; P <.00001) decreased between control and postguideline groups, respectively. These changes persisted in the late postguideline group. Mean preoperative evaluation costs also fell ($1087 versus $171; P <.0001). Outcomes of death (4% versus 3% versus 2%) and myocardial infarction (7% versus 3% versus 5%) were not significantly different between control, postguideline, and late postguideline groups, respectively. Stress test rates were similar for patients at low risk versus high risk in the historical control group (84% versus 91%; P =.29) but lower for patients at low risk after guideline implementation (31% versus 61%; P =.003). CONCLUSION: Implementation of the American College of Cardiology/American Heart Association cardiac risk assessment guidelines appropriately reduced resource use and costs in patients who underwent elective aortic surgery without affecting outcomes. This effect was sustained 2 years after guideline implementation.     

Ring melanoma of the ciliary body: report on twenty-three patients

BACKGROUND: Ring melanoma of the ciliary body is a rare variant of uveal melanoma that has a poor prognosis. Only isolated cases have been reported in the literature. METHODS: A retrospective review of the clinical features, management, histopathology, and prognosis of 23 consecutive patients with ring melanoma of the ciliary body was performed. RESULTS: Of 8,800 patients with uveal melanoma treated on the Oncology Service at Wills Eye Hospital over a 25-year period, only 23 patients (0.3%) were found to have ring melanoma of the ciliary body. The mean patient age was 59 years (median, 63 years; range, 8-81 years). The only visual symptom was blurred vision in 17 patients (74%), and the other six patients (26%) were asymptomatic. At the initial presentation elsewhere, melanoma was recognized in 13 cases (57%). In the remaining 10 cases (43%), the initial clinical diagnosis was glaucoma in three (13%), iris nevus in three (13%), cataract in two (9%), ciliary body detachment in one (4%), and iridocyclitis in one (4%). The patients were observed elsewhere for a mean of 3 months before the diagnosis of melanoma was suspected and referral to Oncology Service was made. On examination, the tumor involved a mean of eight clock hours of the ciliary body. Seven patients (30%) had complete circumferential (360 degrees) involvement of the ciliary body, and 16 (70%) had incomplete (180-360 degrees) ring involvement. The mean tumor thickness was 8 mm. Associated findings included neovascularization of the iris in one case (4%), shallow anterior chamber in 11 (48%), anterior chamber inflammation in five (22%), cataract in nine (39%), lens indentation in eight (35%), and lens subluxation in three (13%). A prominent episcleral (sentinel) vessel (17 cases, 74%), multilobulation of the mass (19 cases, 83%), blockage of light on transillumination (23 cases, 100%), and ultrasonographic hollowness with intrinsic pulsations (23 cases, 100%) were important features differentiating this tumor from simulating conditions. The tumor was managed with enucleation in all 23 patients. Histopathologic studies revealed epithelioid cell-type melanoma in two patients (9%), mixed cell-type in 17 (74%), and spindle cell-type in four (17%). Extraocular extension was present in eight patients (35%). Metastasis developed in 12 of 23 patients (52%) after a mean follow-up of 55 months. CONCLUSIONS: Ring melanoma of the ciliary body is a rare tumor that can remain hidden from ophthalmoscopic examination. Certain features, such as prominent episcleral sentinel vessels, multilobulation of the mass, light blockage on transillumination, and ultrasonographic hollowness with intrinsic vascular pulsations, suggest the diagnosis. The life prognosis is poor.     

Tube occlusion from the external ostium after implantation of an aqueous shunt

Two patients had undergone double-plate Molteno shunt implantation. Both patients required surgical revision, the first at 41 months and the second at 8 months postoperatively, because of a failure of previously functioning tube shunts caused by blockage of the external ostium and intraluminal invasion of the tube by fibrous tissue. At the time of surgical revision, fibrous tissue extended down the lumen of the tube, occluding its external ostium. After excision of this tissue, both shunts became fully functional. When functioning aqueous shunts fail and there is no evidence of a bleb over the shunt reservoir or blockage of the internal ostium, ingrowth of fibrous tissue into the external ostium should be considered as a potential cause, especially if a ripcord or Latina suture has been left in place.     

Benign lymphoid infiltrate of the iris simulating a malignant melanoma

PURPOSE: To report a clinicopathologic correlation of an unusual benign lymphocytic iris mass in a patient who had no systemic lymphoproliferative disease. METHODS: Case report. RESULTS: A 49-year-old man developed a circumscribed, tan lesion in his left iris. The lesion was suspected clinically to be an atypical iris melanoma. Histopathologic studies of the resected mass revealed a solid tumor that was comprised of lymphocytes and histiocytes. Immunohistochemical studies identified that most of the cells were T lymphocytes. The histopathologic diagnosis was atypical lymphoid infiltrate. Workup for systemic lymphoma and Epstein-Barr virus infection was negative. CONCLUSION: Lymphoid infiltrate can manifest as a solitary mass that can simulate an iris melanoma.     

Health-related quality of life in patients 7 months after a myocardial infarction: factors affecting the Short Form-12

We assessed patients' health-related quality of life after myocardial infarction and identified related variables. Clinical data were obtained retrospectively from medical records of consecutive patients admitted to a Midwestern university-affiliated medical center with diagnosis of myocardial infarction from July 1999-July 2000. Telephone interviews 7 months after discharge were made to administer the Short Form-12 (SF-12) and obtain patient, disease, drug, and intervention data. Complete information was obtained from 200 patients (mean age 63.4 +/- 13.1 yrs, 68% men). The mean Physical Component Summary (PCS)-12 score was 40.6 +/- 12.0, and the mean Mental Component Summary (MCS)-12 score was 52.1 +/- 10.0. Based on univariate analyses, low PCS-12 scores were associated with women; non-Q-wave infarctions; greater number of illnesses; history of myocardial infarction, chronic heart failure (CHF), transient ischemic attack (TIA), renal disease, peripheral vascular disease, or percutaneous coronary intervention (PCI); rehospitalization during the interim period; and unscheduled PCI since index myocardial infarction. Low MCS-12 scores were associated with age below 65 years, low overall self-reported drug therapy compliance, low self-reported compliance with angiotensin-converting enzyme inhibitor and lipid-lowering therapy, no history of coronary artery bypass graft, and no stress test since index myocardial infarction. A multivariate regression model for PCS-12 kept the following variables: greater number of illnesses, history of CHF or TIA, and rehospitalization since index myocardial infarction. The MCS-12 model contained age below 65 years, low overall compliance, and low compliance with lipid-lowering therapy. Further work is necessary to determine noncardiovascular predictors of quality of life and whether interventions for these patients will result in improved quality of life.