Lower eyelid reconstruction with a cheek flap supported by fascia lata.

The use of a cheek rotation flap is a well-known method for reconstruction of a large defect of the lower eyelid. In this technique, a separate lining tissue supporting the cheek flap is required for full-thickness reconstruction. Previously, a chondromucosal graft or conchal cartilage has been used to support this flap. Recently, we have used a homologous or autologous fascia lata as support for the cheek flap instead of rigid tissues like cartilages. A fascia lata strip is fixed with tolerable tension to the medial canthal tendon and lateral orbital rim. The inner surface of the fascia and the cheek flap is lined with a buccal mucosa graft to decrease irritation of the conjunctiva and cornea. We present here seven patients in whom this procedure was used for lower eyelid reconstruction following resection of a malignant skin tumor. Based on follow-ups of 7 to 22 months, the functional and aesthetic results have been good in all cases. This procedure may be applicable for total or subtotal reconstruction of the lower eyelid.     

Paracoccidioidomycosis: Study of six cases with ocular involvement

We present 6 patients with ocular involvement due to paracoccidioidomycosis. All cases were confirmed by the finding of Paracoccidioides brasiliensis in histopathological or direct mycologic examination of material from the lesion in the eyelid or conjunctiva. In two cases the bulbar conjunctiva was also involved, in another the cornea, and still another patient developed endophthalmitis. The presence of this mutilating disease which may lead to blindness should be suspected when chronic blepharitis or palpebral ulcerated papular lesions are detected in patients from endemic areas of paracoccidioidomycosis. This etiology should also be suspected in patients with anterior and posterior uveitis after discarding the most frequent causes of this condition.     

Fine needle aspiration cytology in recurrent amelanotic melanoma: a case report

BACKGROUND: Amelanotic melanoma can mimic a wide variety of epithelial and nonepithelial malignant tumors. Varied cytomorphology of melanoma has been described on exfoliative and fine needle aspiration cytology (FNAC). We report a case of recurrent amelanotic melanoma to highlight its varied cytomorphologic features, which may cause diagnostic problems on cytologic and on histologic examinations. CASE: A 63-year-old male presented with nodular swellings in the right anterior chest wall, right axilla and back. A nodule in the chest had been excised 6 months earlier. Clinically, the lesion was interpreted as recurrent soft tissue sarcoma. FNAC revealed malignant cells with highly varied morphology with plasmacytoid and pleomorphic malignant cells with occasional fibrocollagenous tissue strands showing adherent neoplastic cells. A cytologic diagnosis of pleomorphic malignant tumor was suggested, and the original histologic slides were reviewed; they showed a striking alveolar pattern that vaguely resembled an alveolar rhabdomyosarcoma. However, on immunohistochemistry, the tumor cells were S-100 and melan-A positive and desmin negative. A final diagnosis of amelanotic melanoma was made. CONCLUSION: Awareness of the highly varied cytomorphology of amelanotic melanoma minimizes the diagnostic difficulty on fine needle aspiration smears. Suitable immunohistochemical markers are of great value in difficult situations.     

Malignant melanomas of eyelid skin

Four cases of malignant melanoma of eyelid skin are reported. Management of the condition is discussed, with a review of the literature. The conclusions lead us to recommend wide surgical excision for those melanomas arising on the lash margins. If the melanoma is clear of the eyelid margin, smaller margins may be adequate.     

Prefabricated (expander) capsule-lined transposition and advancement flaps in reconstruction of lower eyelid and oral defects: an experimental study

In six pigs with prefabricated transposition flaps and six pigs with prefabricated advancement flaps, both flap types (lined with an expander capsule) were used to reconstruct wedge excisions of the lower eyelid or defects in the cheek/oral mucosa. The capsules replaced the conjunctiva in eyelid defects and the oral mucosa in cheek defects. Histopathologic studies were performed at 5 to 7 days, 9 to 10 days, 2 weeks, 3 to 4 weeks, and 2 and 3 months after flap reconstructions. Healing was rapid and uneventful, leading to restoration of the conjunctiva/eyelid and oral mucosa between 9 days and 2 weeks. The healing of the eyelid conjunctiva was somewhat faster than of the oral mucosa. The expander capsule acted as a conjunctival/ mucosal substitute, providing a temporary physical shield, an infectious barrier, and a matrix for epithelial regeneration. All reconstructions were successful except one oral reconstruction with early flap necrosis. Flaps lined with an expander capsule could improve and facilitate clinical reconstructions in the eyelid and oral cavity.     

Histological and Ultrastructural Studies on the Conjunctiva of the Barred Owl (Strix varia)

This report is the first characterization of the histology and ultrastructure of the barred owl conjunctiva. The inferior eyelid was dominated by a large disk-shaped plate covered by a non-keratinized stratified squamous or cuboidal epithelium of variable thickness. The apical surface of the plate epithelium varied from flat to long microvilli or even short cytoplasmic extensions similar to those seen in the third eyelid. All specimens had a few goblet cells filled with mucous secretory granules in the plate region. The underlying connective tissue was a dense fibroelastic stroma. Eosinophils were surprisingly common in the epithelial layer and underlying connective tissue in the plate and more distal orbital mucosal region. The orbital mucosa contained goblet cells with heterogeneous glycosylation patterns. The leading edge and marginal plait of the third eyelid are designed to collect fluid and particulate matter as they sweep across the surface of the eye. The palpebral conjunctival surface of the third eyelid was covered by an approximately five-cell-deep stratified squamous epithelium without goblet cells. The bulbar surface of the third eyelid was a bilayer of epithelial cells whose superficial cells have elaborate cytoplasmic tapering extensions reaching out 25 μm. Narrow cytofilia radiated outwards up to an additional 15–20 μm from the cytoplasmic extensions. Lectin labeling demonstrated heterogeneous glycosylation of the apical membrane specializations but only small amounts of glycoprotein-filled secretory granules in the third eyelid.     

Fine needle capillary sampling of eyelid masses. A study of 70 cases

OBJECTIVE: To study the cytomorphology of eyelid tumors, correlate it with histopathology and determine the diagnostic accuracy of fine needle capillary (FNC) sampling (nonaspiration) in the evaluation of lid tumors. STUDY DESIGN: A prospective study of 70 cases of eyelid masses carried out using FNC, with confirmation by histology in 66 cases and peripheral blood smear and bone marrow examination in 3. Histology was not done in 1 case, and 11 cases were inadequate on cytology. The diagnostic accuracy of cytology was 94.73%, and false negativity was 5.17%. RESULTS: The ages of the patients ranged from 3 to 75 years, with a mean of 40.4. The male/female ratio was nearly equal (37:33). The upper eyelid was affected in 45 cases and lower lid in 25 cases. The right eye was affected in 35 cases, left eye in 34 cases and both eyes in 1 case. Fifteen benign, 35 malignant and 9 infectious/inflammatory lesions were encountered, with 11 inadequate smears. CONCLUSION: FNC sampling is an effective method of sampling eyelid tumors because it causes little discomfort to the patient and allows the operator to maintain better control over the procedure. A distinction between inflammatory, benign and malignant lesions and between the types of malignant tumors can be made.     

Spontaneous regression of primary malignant melanoma with metastases

This report describes a case of metastatic malignant melanoma in which the presumed primary tumor fulfilled the criteria of spontaneous regression of malignant melanoma.     

Fine needle aspiration cytology of eyelid tumors

Fine needle aspiration (FNA) biopsy was performed on 19 patients with eyelid masses. Six of the patients also had preauricular/submandibular nodal enlargements aspirated. Histopathologic study was performed in ten of the cases. FNA cytology made the diagnosis of an epithelial malignancy in 17 cases (10 sebaceous carcinomas, 4 poorly differentiated carcinomas, 2 squamous cell carcinomas and 1 malignant melanoma). The diagnostic accuracy of FNA cytology in evaluating eyelid masses was thus 89.4%; there were two false-negative cases. All nodal FNA smears revealed metastases of the respective primary tumors. This study indicated that FNA cytology is a simple and efficient method for making the diagnosis of malignancy in eyelid masses, especially in those patients who are not suitable candidates for surgery. Subsequent nodal metastases and tumor recurrence were detected without difficulty using FNA smears.     

Amelanotic malignant melanoma arising in an ovarian cystic teratoma: a case report

BACKGROUND: Malignant melanoma arising in a cystic teratoma is extremely rare. We report the clinicopathologic and cytopathologic features of an amelanotic malignant melanoma arising in an ovarian cystic teratoma. CASE: A 55-year-old woman presented with an asymptomatic right ovarian mass, showing features of cystic teratoma according to preoperative computed tomography and magnetic resonance imaging. The resected teratoma was suspected to include a nonepithelial malignancy in a touch preparation from a solid component. The tumor showed immunoreactivity for Melan-A, S-100 and HMB-45 in the absence of melanin granules, which established the diagnosis of amelanotic malignant melanoma arising in an ovarian cystic teratoma. CONCLUSION: Cytopathologic findings from touch preparations and immunohistochemical staining are useful for the diagnosis of amelanotic malignant melanoma arising in an ovarian cystic teratoma.     

Oncological principles of surgery in the periorbital region

The aim of this study is to describe the most common malignant periorbital tumours and principles of their surgical treatment. The most common malignant tumours of the eyelids are: basocellular carcinoma, squamocellular carcinoma, sebaceous carcinoma and malignant melanoma. The primary treatment of periorbital tumours is surgery, other methods are cryotherapy or radiotherapy. Malignant tumours of the eyelids are fairly rare. Diagnosis in some of the cases is difficult, since the first signs of the tumours are small changes on the eyelid margin or eyelid skin. Focal loss of the eyelashes could be the first sign of a malignant tumour. General oncological principles are valid also in the surgery of periorbital region. Eyelids have special anatomical structure and their main role is protection of the eyeball. Therefore, early diagnosis and total tumour removal--regardless of the anatomical borders--as well as immediate reconstruction are important in the treatment of eyelid tumours.     

Diagnostic assessment of cutaneous melanoma and common nevi using tissue counter analysis

OBJECTIVE: To test the applicability of tissue counter analysis to the diagnostic discrimination of cutaneous malignant melanoma and benign common melanocytic nevi. STUDY DESIGN: Forty cases each of melanoma and nevi were consecutively sampled. After creation of a learning set based on 20 cases each, discriminant analysis of background versus tissue elements, tumor versus other tissue elements and benign versus malignant tumor elements was performed. The discriminant functions were used to assess the amount of benign and malignant tumor elements in each case. RESULTS: In the learning set, discriminant analysis facilitated recognition of 99.6% of tissue versus background, 90.7% of tumor versus other tissue components and 85.6% of malignant versus benign tumor elements. In the whole set, the percentage of malignant tumor elements was 8.7 +/- 7.7 (range, 0.1-29.6) for benign nevi and 77.4 +/- 16.2 (43.6-99.4) for malignant melanoma. Based on these measurements, the correct diagnosis could be established in all cases (chi 2 > .0001). CONCLUSION: Tissue counter analysis may be a useful method for diagnostic purposes in histopathology.     

Persistence of Herpes Simplex Virus Type 1 DNA in Chronic Conjunctival and Eyelid Lesions of Mice

Herpes simplex virus type 1 (HSV-1) causes chronic blepharitis and conjunctivitis as well as keratitis in humans. The pathogenesis of these inflammatory ocular and dermal lesions is not well understood. We have examined the persistence of HSV-1 DNA and its relationship to inflammatory lesions in the conjunctiva and eyelid skin of mice which were inoculated with HSV-1 by the corneal route. Viral DNA was detected by in situ PCR in the conjunctiva and eyelid tissue of infected mice at 5, 11, 23, and 37 days postinfection (p.i.). This DNA was localized in the epithelial cells of the conjunctiva and hair follicles and in the epidermal cells of the eyelid skin. Viral proteins were not detected in the conjunctiva or the eyelid skin after 5 days p.i., even though histopathological lesions were found at 23 and 37 days p.i. in both tissues. The DNA-containing cells were adjacent to sites of inflammation in the chronic lesions in both the conjunctiva and the eyelid skin. A similar temporal and spatial relationship between HSV-1 DNA and inflammatory lesions has been previously reported for the cornea. Our data suggest that the lesions in the cornea, conjunctiva, and eyelid skin progress similarly. Further studies are required to determine whether the long-term presence of HSV-1 is involved in the mechanism by which these chronic inflammatory lesions develop. The presence of HSV-1 DNA in these extraocular tissues for extended periods may constitute persistent viral infection of nonneuronal cells.     

The evaluation and management of lower eyelid retraction following cosmetic surgery

Lower eyelid retraction is a common complication after cosmetic surgery of the lower eyelids, midface, and the adjacent face. Lower eyelid retraction is defined as the inferior malposition of the lower eyelid margin without eyelid eversion. Lower eyelid retraction presents clinically with scleral show; round, sad-looking eyes; lateral canthal tendon laxity; and symptoms of ocular irritation, including photophobia, excessive tearing, and nocturnal lagophthalmos. These patients frequently require ocular lubricants, including artificial tears and ointments, which often provide only minimal alleviation of their symptoms. The author has observed that lower eyelid retraction is usually accompanied by midface descent. On the basis of surgical observations, the causes of lower eyelid retraction seem to be multifactorial and include scarring between the orbital septum and capsulopalpebral fascia (or lower eyelid retractors), lateral canthal tendon laxity, and midface descent. After describing the causes of lower eyelid retraction, the author presents a system for evaluating patients that can assist the surgeon in choosing the surgical procedure(s) required to correct the lower eyelid malposition. The surgeon must know how to tighten a lax lateral canthal tendon, be familiar with the anatomy of the lower eyelid from conjunctiva to skin side, and know how to surgically elevate the midface. The techniques for correcting lower eyelid retraction are also presented. Appropriate surgery, which is determined on the basis of the preoperative evaluation, has allowed for the correction of these previously difficult-to-treat lower eyelid malpositions with minimal complications.     

Double primary lung cancers: with special reference to their exfoliative cytology and to the rare, malignant "mixed" tumor of the salivary-gland type

Two autopsy cases are reported in which double primary cancers of the lung had been strongly or definitely suspected before death by demonstration of two different types of malignant cells in the sputum as well as in smears of aspirates from pleural fluid and/or mediastinal tumor. By exfoliative cytology, one case was characterized by carcinoma cells of the small-cell type plus the large-cell and/or adenocarcinoma type; the other displayed small-cell-type and squamous-cell-type malignant cells. The autopsies definitely revealed in the first case an anaplastic carcinoma of the small-cell type in the left bronchus and a salivary-gland-type malignant "mixed" tumor in the right lower lobe and in the second case an anaplastic carcinoma of the small-cell type in the right upper lobe and a squamous-cell carcinoma in the left upper lobe. The frequence of occurrence and pathologic diagnosis of double primary lung cancers are reviewed and discussed. A rare type of lung cancer, salivary-gland-type malignant "mixed" tumor, is given special reference.     

The evaluation of human papillomavirus and p53 gene mutation in benign and malignant conjunctiva and eyelid lesions

Papillomas and squamous cell carcinomas are the most common conjunctival and eyelid lesions. The etiology is still unclear and recently human papillomavirus infection and p53 gene mutation have been taken into consideration. The aim of our study was the evaluation of HPV DNApresence and p53 gene mutation in 45 benign and 38 malignant squamous lesions of the conjunctiva and eyelid. For HPV detection PCR-RFLP and immunohistochemical reaction were used; for p53 gene mutation PCR-SSCP was used. Only 8.8% papillomas, 9.1% squamous cell cancers and 3.7% basal cell cancers (using PCR-RFLP method) and 26.6% papillomas, 7.4% squamous cell cancers and 9.1% basal cell cancers (using immunohisto-chemical reaction) were HPV positive. p53 gene mutation was evaluated in 24.4% papillomas, 54.5% squamous cell cancers and 22.2% basal cell cancers; most commonly in 6 and 7 exon. Human papillomavirus infection, opposite to p53 gene mutation, is not a significant etiological factor of the benign and malignant conjunctival and eyelid lesions development.     

A report of the first case of Dirofilaria infection in the eyelid region in Japan

Dirofilaria worms were recovered from a painless hard tumor in the right eyelid of a 19-year-old Japanese male who had lived in Kagoshima and Kumamoto Prefectures, Japan. In the worms, the cuticle had a smooth surface, the inner cuticular layer had internal lateral longitudinal ridges, and the musculature of the body wall was the polymyarian type. On the basis of all morphological characteristics observed, this worm was identified as an immature female Dirofilaria immitis. This is the first human case of nematode infection in the eyelid in Japan. Surgical removal of the mass with worms resulted in complete recovery from swelling of his right eyelid.     

Fine needle aspiration cytology of malignant melanoma of soft parts. Report of two cases

Two cases of malignant melanoma of soft parts were diagnosed by fine needle aspiration (FNA) biopsy. One case involved the right thumb of a 22-year-old woman; the other involved a submental mass in a 36-year-old man who had been previously diagnosed as having malignant melanoma of soft parts. The FNA smears showed discohesive polygonal or oval and fusiform cells with eccentric nuclei, irregular nuclear chromatin and prominent nucleoli. FNA cell block sections contained polygonal or fusiform cells with clear cytoplasm, eccentrically placed nuclei and prominent nucleoli. Ultrastructural and immunocytochemical studies on aspirated material supported the diagnosis of malignant melanoma.     

Non-Invasive Detection of Anaemia Using Digital Photographs of the Conjunctiva

ResultsConjunctival EI was reproducible between images (average coefficient of variation 2.96%). EI of the palpebral conjunctiva correlated more strongly with haemoglobin concentration than that of the forniceal conjunctiva. Using the compact camera, palpebral conjunctival EI had a sensitivity of 93% and 57% and specificity of 78% and 83% for detection of anaemia (haemoglobin < 110 g/L) in training and internal validation sets, respectively. Similar results were found using the iPhone camera, though the EI cut-off value differed. Conjunctival EI analysis compared favourably with clinician assessment, with a higher positive likelihood ratio for prediction of anaemia.ConclusionsErythema index of the palpebral conjunctiva calculated from images taken with a compact camera or mobile phone correlates with haemoglobin and compares favourably to clinician assessment for prediction of anaemia. If confirmed in further series, this technique may be useful for the non-invasive screening for anaemia.