page 14] correspondence: conflict of interest: the authors report no conflicts of interest. havva serap toru, md contributions: all authors contributed equally. department of pathology accepted for publication: february, 2018 akdeniz university school of medicine this work is licensed under a creative commons attribution 07058 antalya, turkey non-commercial 3.0 license (cc by-nc 3.0). email: serap_toru@yahoo.com ©copyright toru, et al., 2018. licensee ophthoscience publishers, usa [page 15] [page 16] [page 11] correspondence: conflict of interest: the authors report no conflicts of interest. mansooreh bagheri, md contributions: all authors contributed equally. department of ophthalmology accepted for publication: february, 2018 pootschi opthalmology research center this work is licensed under a creative commons attribution zand avenue, shiraz, iran non-commercial 3.0 license (cc by-nc 3.0). email: mansooreh_bagheri@yahoo.com ©copyright bagheri, et al., 2018. phone: 00989173201260 licensee ophthoscience publishers, usa [page 12] [page 13] ń correspondence: conflict of interest: the authors report no conflicts of interest. juan ibáñez alperte, md, phd contributions: all authors contributed equally. department of ophthalmology accepted for publication: april 1, 2014 “lozano blesa” university clinic hospital this work is licensed under a creative commons attribution san juan bosco 15, es-50009 zaragoza, spain non-commercial 3.0 license (cc by-nc 3.0). email: juanibanezalperte@msn.com ©copyright jimenez et al., 2014. phone: +34 665802084 licensee ophthoscience publishers, usa hrev_master [eye reports 2011; 1:e2] [page 3] enucleation assisted with filler for open-globe injury ayako takahashi,1 masayuki akimoto,1,4 sachiyo hama,1 yoko shirai,2 sachiko minamiguchi3 departments of 1ophthalmology, 2dentistry, 3pathology, 4clinical research institute, kyoto medical center, national hospital organization, kyoto medical center, japan abstract in cases of severe open-globe injury, it is often difficult to reconstruct the globe and maintain visual acuity. ocular globe enucleation may decrease the risk of sympathetic ophthalmia in the fellow eye. however, the surgical procedure is difficult to perform with an open globe, because the injured globe is inclined to collapse. we report the case of an enucleation for an open-globe injury in which we used alginate, which is often used for dental impressions, as filler for the collapsed globe. we were able to maintain the resistance of the globe sufficiently well enough to perform the procedure easily and without complication. thus, alginate may be a novel aid to assist in enucleation by preserving globe resistance. introduction ocular globe enucleation is often a necessary procedure following open-globe injury when the eye is diagnosed as being incapable of reconstruction. however, enucleation is often difficult to perform in open globe injuries, because the injured globe is inclined to collapse, despite filling it up with air or liquid. here, we report a case in which enucleation was performed easily and without complication, using alginate as the filler. alginate is often used for dental impressions because it is a soft gel that rapidly turns into a solid. case report a 74-year-old man who was hit by a car and suffered an open globe injury deemed incapable of being reconstructed. his left eye was perforated at the upper temporal corneal limbus, from the 11 o'clock to the 5 o'clock position, and totally collapsed (figure 1a). in order to prevent sympathetic ophthalmia (so) of the right eye, enucleation was deemed inevitable. a decision was made to enucleate the left eye, on the tenth day after the injury. informed consent was obtained; the operation was performed in conformity with the declaration of helsinki and was approved by our ethical committee. the operation was performed under general anesthesia. following standard sterile technique, the conjunctiva was incised at the fornix base and the sclera was exposed. the scleral wound was closed using interrupted 8-0 silk suture. physiologic saline was injected into the globe through the wound. an attempt was made to aspirate the content of the globe; however, only little amount was aspirated. then, alginate was prepared, just before its use, because it begins to harden within 1 minute. a spoonful (8.4 g) of alginate powder (aroma fine plus® normal set, gc international corp., tokyo, japan), sterilized by ethylene oxide gas and 20 ml of cold water were vigorously mixed together with a spatula and poured into a 10 ml syringe; cooler water allows for a longer working time. two 18 gauge needles were inserted into the globe through the corneal limbus. carbon dioxide gas was injected by insufflator (alpha duolap, gimmi, tuttlingen, germany) through one of the needles to inflate the collapsed globe, and then alginate was injected, up to approximately 3 ml through the second needle until the globe had sufficiently recovered its resistance. excessive alginate that leaked out of the globe was easily removed after it had solidified. the globe was subluxated by tenotomy of the 4 recti and 2 oblique muscles, and the optic nerve was cut. these procedures were much easier following injection of the alginate, because of the adequate resistance of the globe. the globe was completely enucleated without any further damage (figures 1b-d). discussion open-globe injury can induce so in the fellow eye, which is believed to be an autoimmune inflammatory response. the incidence of so after open-globe injury has been reported to be 0.1-0.3%.1-4 the time for so to develop varies from 2 weeks to 50 years, with approximately 90% of patients developing the disease within 1 year of injury.5 so is in itself a sightthreatening disease. definitive prevention of so requires prompt (within 2 weeks following the injury) enucleation or evisceration of the injured eye, especially when there is little possibility for the injured eye to regain any function.5 enucleation is also performed for other reasons such as painful or disfiguring blind eye, neoplasm, and infection.6 in cases where the globe is collapsed, often following open-globe injury, enucleation may be a technically difficult procedure. acquiring sufficient resistance of the globe can make enucleation easier and decrease the risk of trauma to the remaining orbital structures. several innovative methods for enucleation have been reported. torres et al. invented a new device which consists of surgical scissors custom made to have two connectable arms adapted to modified spoons and blades.7 finger et al. used an original cryotherapy probe to induce proptosis during optic nerve transection.8 however, these ideas do not address the issue of the collapsed globe. alginate is an anionic polysaccharide distributed widely in the cell walls of brown algae. by binding with water, it forms a viscous gum, which is universally used for dental impressions. alginate is also used in a variety of other applications, including the treatment of peptic ulcers and gastroesophageal reflux disease9 and as a substance for endoscopic hemostasis. further, calcium alginate is used in dressings for traumatic wounds in order to promote healing and prevent infection. tane et al. reported that calcium alginate sheets were effective for use in wound dressing in a case after ocular evisceration.10 alginate is also used in biologic experiments for the immobilization of cells. this wide use of alginate suggests its physiologic safety. in a manner similar to dental application, ophthalmologists use alginate for the fabrication of ocular prostheses before and after enucleation.11 tanaka et al. demonstrated that alginate eye reports 2011; volume 1:e2 correspondence: masayuki akimoto, department of ophthalmology, national hospital organization, kyoto medical center, 1-1 fukakusa-mukaihatacho, fushimiku, kyoto 6128555, japan. tel: +81.75.641.9161 fax: +81.75-643.4325. e-mail: masayuki@akimoto3.com key words: trauma, enucleation, filler, sympathetic ophthalmia. contributions: at, ma, sh original idea and discussions; at, ma, surgical procedure; at, manuscript writing; ys, assisting in the use of the alginate; sm, specimen sectioning and imaging. conflict of interest: the authors report no conflicts of interest. received for publication: 27 april 2011. accepted for publication: 3 june 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright a. takahashi et al., 2011 licensee pagepress, italy eye reports 2011; 1:e2 doi:10.4081/eye.2011.e2 non -co mmerc ial us e o nly [page 4] [eye reports 2011; 1:e2] impression materials were sterilized by ethylene oxide gas and useful as filler for removing mucous retention cysts.12 this report encouraged us to use alginate as filler for the open globe during enucleation to preserve the resistance of the globe, which may be applicable even if the globe is ruptured. alginate is inexpensive and easily commercially available. its preparation for use as filler and its injection do not require any special technique. thus, except in cases in which a pathologic diagnosis of the enucleated tissue is necessary, alginate may be a novel aid to assist in enucleation by preserving the resistance of the globe. references 1. kilmartin dj, dick ad, forrester jv. prospective surveillance of sympathetic ophthalmia in the uk and republic of ireland. br j ophthalmol 2000;84:259-63. 2. zhang y, zhang mn, jiang ch, yao y. development of sympathetic ophthalmia following globe injury. chin med j (engl) 2009;122:2961-6. 3. savar a, andreoli mt, kloek ce, andreoli cm. enucleation for open globe injury. am j ophthalmol 2009;147:595-600.e1. 4. mansouri m, faghihi h, hajizadeh f, et al. epidemiology of open-globe injuries in iran: analysis of 2,340 cases in 5 years (report no. 1). retina 2009;29:1141-9. 5. sen hn, nussenblatt rb. sympathetic ophthalmia: what have we learned? am j ophthalmol 2009;148:632-3. 6. rasmussen ml, prause ju, johnson m, kamper-jørgensen f, toft pb. review of 345 eye amputations carried out in the period 1996-2003, at rigshospitalet, denmark. acta ophthalmol 2010;88:21821. 7. torres vl, schor p, erwenne cm. a new device for ocular globe enucleation. ophthalmic surg lasers imaging 2008;39:524-7. 8. finger pt. “finger-tip” cryoprobe assisted enucleation. am j ophthalmol 2005;139: 559-61. 9. tytgat gn, mccoll k, tack j, et al. new algorithm for the treatment of gastrooesophageal reflux disease. aliment pharmacol ther 2008;27:249-56. 10. tane n, ohira a, aihara m. use of calcium alginate for the eye socket wound dressing. jpn j clin ophthalmol 2009;63:1175-9. 11. mathews mf, smith rm, sutton aj, hudson r. the ocular impression: a review of the literature and presentation of an alternate technique. j prosthodont 2000;9:210-6. 12. tanaka y, harada t, naito s, yoshimura y. usefulness of therapeutic method for mucous retention cysts of oral floor using alginate impression material. j jpn stomatol soc 1999;48:134-7. case report figure 1. (a) t2-weighted magnetic resonance image before enucleation, demonstrating that the patient’s left globe had totally collapsed; (b) injected alginate preserved the resistance of the globe, which assisted with enucleation; (c) good transection of the optic nerve was observed, suggesting that enucleation was performed completely without unnecessary trauma. arrow indicates the stump of the optic nerve; (d) alginate was evenly distributed in the cavity of the globe. non -co mmerc ial us e o nly hrev_master [eye reports 2011; 1:e7] [page 17] oncocytoma of the upper conjunctival fornix zaina al-mohtaseb, seongmu lee, michael t. yen cullen eye institute, department of ophthalmology, baylor college of medicine, houston, texas, usa abstract oncocytomas are tumors characterized by large, eosinophilic epithelial cells with abundant mitochondria that form ductular or glandular spaces. while these tumors have been described in other organs, those of the ocular adnexa occur infrequently, with the caruncle being the most common site of involvement. conjunctival oncocytomas are extremely rare and are believed to arise from the ductal elements of the lacrimal gland proper and the accessory lacrimal glands of the conjunctiva. we describe the clinical and histological features of a case of an oncocytoma presenting as an atypically located superior fornix mass in a 78-yearold female, with a review of the literature. case report oncocytomas are tumors characterized by large, eosinophilic epithelial cells with abundant mitochondria that form ductular or glandular spaces. while these tumors have been described in many organs including the salivary, thyroid, adrenal glands, and kidneys, those of the ocular adnexa are uncommon and are believed to arise from metaplasia of the ducts of the lacrimal gland epithelium. the caruncle is the most common site of involvement, representing approximately 3% of tumors in this region.1-3 oncocytomas of the conjunctiva, however, are extremely rare.1-6 we report a case of an atypically located conjunctival oncocytoma and review the literature. a 78-year-old female was referred for evaluation of fornix lesion. examination revealed a round, well-circumscribed, mobile, elevated red lesion measuring 3.0¥3.0¥3.0 mm in the bulbar conjunctiva of the superior fornix near the right medial canthus, concealed under the eyelid (figure 1). histological examination showed a well-demarcated mass composed of tubular epithelial structures with a central lumen (figure 2). the cells showed uniform round/oval nuclei surrounding central lumina and prominent basement membrane. the cytoplasm of the epithelial cells contained prominent eosinophilic granules that stained with masson trichrome. the luminal border of the tubules also stained with pas and colloidal iron. a diagnosis of oncocytoma was made. discussion oncocytomas of the ocular adnexa are uncommon and have been described in the eye reports 2011; volume 1:e7 correspondence: seongmu lee, cullen eye institute, department of ophthalmology, baylor college of medicine, 6565 fannin nc-205, houston, texas 77030, usa. tel. +1.713.798-3231 fax: +1.713.798.8739. e-mail: seongl@bcm.edu key words: oncocytoma, oxyphil adenoma, conjunctival, lacrimal, caruncle. contributions: the authors contributed equally. conflict of interest: the authors report no conflicts of interest. funding: supported in part by an unrestricted educational grant from research to prevent blindness, inc. (new york, ny). received for publication: 22 june 2011. accepted for publication: 22 august 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright z. al-mohtaseb et al., 2011 licensee pagepress, italy eye reports 2011; 1:e doi:10.4081/eye.2011.e7 figure 1. anterior segment image revealing a round, well-circumscribed, mobile, elevated red lesion measuring 3.0¥3.0¥3.0 mm in the bulbar conjunctiva of the superior fornix concealed under the eyelid. figure 2. a) histological examination showed a well-demarcated mass composed of tubular epithelial structures with a central lumen consistent with oncocytoma. b) the cytoplasm of the epithelial cells contained prominent eosinophilic granules that stained with masson trichrome. the luminal border of the tubules also stained with c) pas and d) colloidal iron. [page 18] [eye reports 2011; 1:e7] caruncle, lacrimal sac, lacrimal gland, and accessory glands of krause.3,4 conjunctival oncocytomas are extremely rare.1-5 the tumor location in the conjunctival fornix in this case is particularly atypical. of the reported cases in the published english literature, the average age was 68-years, and 60% were female. the duration of symptoms ranged from two months to five years, with no evidence of recurrence reported after excision (table 1).1-5,7-8 clinically, oncocytomas have been described as red-brown or yellow-tan lesions that are elevated and at times lobulated or cystic. histopathologically, these tumors are characterized by a proliferation of large, uniform, polygonal epithelial cells that exhibit abundant, fine granular eosinophilic cytoplasm and contain dark round to ovoid paracentral nuclei. the cytoplasm contains dark granules that are positive for modified phosphotungstic acidhaematoxylin and immunostain with monoclonal antimitochondrial antibodies due to the high density of mitochondria.1 the oncocytes form solid cords and tubular structures that occasionally display papillary infoldings and have a characteristic absence of inflammatory cells. in some areas, the tubules form large cystic spaces, which contain a seromucinous material that is periodic acid schiff and alcianblue positive.3,6 many authors believe that oncocytomas arise from age-related oncocytic metaplasia of ducts and acinar cells of the accessory lacrimal glands of the ocular adnexa, while others suggest oncocytic transformation of the caruncular surface and conjunctival epithelium as the site of origin.1,3,6 in a more recent study, ostergaard et al. examined the cytokeratin profile of oncocytic lesions of the ophthalmic region to investigate the origin of these tumors. the authors reported that oncocytomas of the ocular adnexa demonstrated a profile similar to that of the lacrimal gland proper and the accessory lacrimal gland duct elements, and that all lesions showed a similar expression pattern irrespective of histological differentiation, suggesting that oncocytic metaplasia, hyperplasia, and oncocytoma may represent the same type of lesion in different stages of development.1 in summary, oncocytomas of the conjunctiva are benign epithelial tumors most likely arising from ductal elements of the lacrimal gland proper and accessory lacrimal glands of the conjunctiva and may present in the conjunctival fornix. references 1. ostergaard j, prause ju, heegaard s. oncocytic lesions of the ophthalmic region: a clinicopathological study with articlecase report ta bl e 1. s um m ar y of r ep or te d ca se s of c on ju nc tiv al o nc oc yt om a: c lin ic al fe at ur es a nd o ut co m es ca se st ud y ag e ge nd er d ur at io n d ia gn os is cl in ic al lo ca tio n si ze ( m m ) tr ea tm en t re cu rr en ce ye ar o f s tu dy of le si on de sc rip tio n 1 bi gg s 65 f 3 m on th s on co cy to m a c om bi ne d wi th pe du nc ul at ed m as s bu lb ar co nj un ct iva , n ea r p lic a s em ilu na ris * ex cis io n no 19 77 sq ua m ou s ce ll p ap ill om a 2 bi gg s 72 f * on co cy to m a * bu lb ar co nj un ct iva , 1 m m fr om p lic a s em ilu na ris 1 ex cis io n no 19 77 3 bi gg s 55 m 2 m on th s on co cy to m a * co nj un ct iva at lo we r f or ni x * ex cis io n no 19 77 4 bi gg s 80 m * on co cy to m a lo bu lat ed ch er ry -re d m as s co nj un ct iva at lo we r f or ni x 15 x 12 ex cis io n no 19 77 5 re id el * * * on co cy to m a * co nj un ct iva * ex cis io n no 19 83 6 gr os sn ikl au s 87 m * on co cy to m a * bu lb ar co nj un ct iva * ex cis io n no 19 87 7 sp ra ul 72 f 2 y ea rs on co cy to m a ch er ry re d le sio n bu lb ar co nj un ct iva n ea r p lic a s em ilu na ris * ex cis io n no 19 96 8 pe rc or el la 55 m 2 m on th s on co cy to m a sw el lin g co nj un ct iva at lo we r f or ni x * ex cis io n no 19 97 9 pe rc or el la 68 f * on co cy to m a pa pi llo m a co nj un ct iva at m ed ial ca nt hu s * ex cis io n no 19 97 10 ku rli 49 f 5 y ea rs on co cy to m a el ev at ed re dor an ge tu m or co nj un ct iva ad jac en t t o ca ru nc le * ex cis io n no 20 06 11 os te rg aa rd * * * on co cy to m a * co nj un ct iva * ex cis io n no 20 09 12 al -m oh ta se b 78 f un kn ow n on co cy to m a m ob ile , e le va te d re d tu m or co nj un ct iva at su pe rio r f or ni x 3 x 3 x 3 ex cis io n no 20 10 *i nf or m at io n un av ail ab le [eye reports 2011; 1:e7] [page 19] emphasis on cytokeratin expression. acta ophthalmol 2011;89:263-7. 2. kurli m, finger pt, garcia jp jr, schneider s. peribulbar oncocytoma: high-frequency ultrasound with histopathologic correlation. ophthalmic surg lasers imaging 2006;37:154-6. 3. biggs sl, font rl. oncocytic lesions of the caruncle and other ocular adnexa. arch ophthalmol 1977;95:474-8. 4. pecorella i, garner a. ostensible oncocytoma of accessory lacrimal glands. histopathology 1997;30:264-70. 5. grossniklaus he, green wr, luckenbach m, chan cc. conjunctival lesions in adults: a clinical and histopathologic review. cornea 1987;6:78-116. 6. rennie ig. oncocytomas (oxyphil adenomas) of the lacrimal caruncle. br j ophthalmol 1980;64:935-9. 7. reidel k, stefani fh, kampik a. oncocytoma of the ocular adnexa. klin monatsbl augenheilkd 1983;182:544-8. 8. spraul cw, lang gk. oncocytoma of the conjunctiva. klin monbl augenheilkd 1996;209:176-7. case report hrev_master [page 32] [eye reports 2011; 1:e10] conjunctival blue nevus joseph j. chen, seongmu lee, michael t. yen cullen eye institute, department of ophthalmology, baylor college of medicine, houston, tx, usa abstract the authors report a case of a conjunctival blue nevus and review the literature pertaining to these pigmented lesions in this location, describing clinical and histological report of a patient with a blue nevus of the palpebral conjunctiva with a literature review. a 64-year-old white female was evaluated for a darkening pigmented lesion of the left lower palpebral conjunctiva. examination revealed a 3 mm x 6mm blue-black lesion with sharply demarcated edges and an irregular border. histopa thology showed plump spindle-shaped, pigmented melanocytic cells revealing a branching network of dendritic processes with small, elongated, and hyperchromatic nuclei consistent with a common blue nevus. no recurrence was noted at 9-month follow-up. blue nevi of the conjunctiva are lesions that have a low risk for malignant transformation but can appear clinically similar to primary acquired melanosis or melanoma. blue nevi of the conjunctiva are rare and represent 0.5%-3.0% of pigmented conjunctival lesions. there was one reported case in a literature search of a malignant melanoma arising from a conjunctival cellular blue nevus. treatment is complete wide excisional biopsy. introduction blue nevi are skin lesions containing melanocytic proliferations which can present in a variety of locations, most commonly in the dorsum of the hands and feet, the scalp, and the sacrococcygeal regions.1 blue nevi also rarely present in mucosal membranes, such as the mouth, nose, uterus, vagina, endometrium, prostate, bronchus, and esophagus.2 we present a case of a rare presentation of a common blue nevus in the palpebral conjunctiva. case report a 64-year-old white female was referred for a darkening pigmented lesion noted on her left lower palpebral conjunctiva. the patient reported that the lesion had been present for more than 10 years and while she had not noticed any growth in the size of the lesion, it had become darker in appearance. she denied any family history of skin malignancies or ocular lesions. she had no history of previous pigmented lesions or history of malignancy, and review of systems was noncontributory. on slit lamp exam, a flat hyperpigmented lesion with irregular borders was noted in the inferior palpebral conjunctiva on the right eye measuring 3.1 mm vertically and 6.2 mm horizontally (figure 1). the remainder of the ocular exam was unremarkable. the lesion was fully excised and sent for histopathologic analysis. histologically, there was mid to deep dermal proliferation of pigmented dermal melanocytes with no junctional component and no involvement of the epidermal layers (figure 2). on higher magnification, there were pigmented spindle-shaped dendritic melanocytes revealing a branching network of dendritic processes with small, elongated, and hyperchromatic nuclei (figure 3). the dendritic cells did not display any cytologic atypia or mitotic figures. a diagnosis of common blue nevus was made. at 9 month follow-up, the patient displayed no evidence of recurrence. discussion blue nevi were first described by jadassohntieche in 1906 with a distinction made by allen and spitz in 1953 dividing blue nevi into the classically described categories of common blue nevus and cellular blue nevus.1-3 in current literature, the common blue nevus type has been further subtyped to include common blue nevus, combined blue nevus, sclerosing (desmoplastic) blue nevus, hypomelanotic/ amelanotic blue nevus, and epithelioid blue nevus of carney complex/pigmented epithelioid melanocytoma. the cellular blue nevus has been further subtyped into cellular blue nevus, amelanotic cellular blue nevus, atypical cellular blue nevus, and malignant blue nevus.2 common blue nevi are distinguished histologically by characteristic variably pigmented spindle-shaped dendritic melanocytes in the mid to deep dermis which do not have a junctional component and which do not display any significant cytologic atypia. cellular blue nevi are distinguished from common blue nevi in that they usually present as a pigmented biphasic tumor with a classic blue nevus component and a component of distinct cellular areas of spindled to oval melanocytes with clear cytoplasm. both common and cellular blue nevi can present at any age, although typically present in the third or fourth decade and most commonly are found in the sacrococcygeal region, scalp, face, and dorsal areas of the extremities.1 a subtype of cellular blue nevus has been described as malignant blue nevus, which has features of cellular blue nevus but can metastasize and result in death. malignant blue nevi can arise from prior biopsy or excision sites of blue nevi or can arise de novo.2 histopa thologically, malignant blue nevi appear similar to cellular blue nevi with a biphasic architecture but have severely atypical cytologic features.4 malignant blue nevi have a poor prognosis, with a high rate of recurrence and metastasis. in a case series of 12 patients with melanoma arising from blue nevus in the skin, 10 of 12 (83%) patients developed metastases over a mean period of 40 months.5 some studies have shown that immunohistochemistry may be of benefit, showing that malignant blue nevi show increased ki-67 expression and may lose hmb45 labeling.6 recently, zembowicz et al. have suggested that the gnaq and gna11 proteins of the g-protein alpha subunits involved in signaling by g-protein coupled receptors are important for controlling early dermal melanoblast proliferation, citing that there is a permanent increase in dermal melanoblast numbers with activating mutations in gnaq and gna11, and also that somatic mutations in the gnaq gene have been identified in 83% of cases of blue nevi, 50% of malignant blue nevi, and 46% of uveal melanoma.2 the pathogenesis of blue nevi has not been well established, but most currently, the prevailing theory postulates that dermal melanocytes are arrested during embryologic migration from the neural crest to the epidereye reports 2011; volume 1:e10 correspondence: michael t. yen, cullen eye institute, department of ophthalmology, baylor college of medicine, 6565 fannin nc-205, houston, tx 77030, usa. tel: +1.713.798-3231 fax: +1.713.798.8739. e-mail: myen@bcm.tmc.edu key words: conjunctiva, blue nevus, melanocytic proliferation. acknowledgements: supported in part by an unrestricted educational grant from research to prevent blindness, inc. (new york, ny). conflict of interest: the authors report no conflicts of interest. received for publication: 29 june 2011. accepted for publication: 11 september 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright j.j. chen et al., 2011 licensee pagepress, italy eye reports 2011; 1:e10 doi:10.4081/eye.2011.e10 non -co mmerc ial us e o nly [eye reports 2011; 1:e10] [page 33] mis.2 this theory is supported by the fact that melanocytes, after population of the dermis from 10 weeks of gestation, will disappear at the end of gestation except in the presacral area, head and neck area, and dorsal areas of the distal extremities, which are also the most common sites of presentation for blue nevi in the skin.1 blue nevi rarely occur in the conjunctiva, with only 22 reported cases of conjunctival blue nevi in the literature to date. there have been four large case series of pigmented conjunctival lesions, which noted blue nevi. in the largest series of 418 conjunctival nevi, shields, et al. reported that 4 of the cases conjunctival nevi were histologically confirmed as blue nevi. of these 4 cases, 2 were located in the bulbar conjunctiva, one in the tarsal conjunctiva, and one in the fornix. all were brown in color, none had cysts, none had feeder vessels, and one has intrinsic vessels. one of the cases of blue nevus developed malignant melanoma; this case was one of the only 3 patients out of 410 patients in the series who developed malignant melanoma.7 grossniklaus, et al. reported five out of 317 (1.5%) pigmented conjunctival lesions to be blue nevi in adults.8 out of a series of 71 pigmented conjunctival lesions in children reported by mcdonnell, et al., only one (1.6%) was found to be a blue nevus.9 of the conjunctival blue nevi which report histopathologic analysis, there were 6 common blue nevi, including the blue nevus in this report, and 5 cellular blue nevi.10-12 in addition to the one case from the shield, et al. series in which malignant melanoma developed,7 there was only one case of malignant transformation of a blue nevus reported, which was described histologically as a cellular blue nevus that appeared on exam as primary acquired melanosis and reported no recurrence after excision at 7 year follow-up.11 it is uncertain whether these two reports represent the same patient or two different patients, as the two reports are from the same institution and share some authors. in summary, blue nevi are distinct melanocytic neoplasms that are commonly found in the skin but rarely occur in mucosal membranes, including the conjunctiva. conjunctival blue nevi, particularly the cellular blue nevus subtype, have a rare potential for malignant transformation and have the potential to recur after excision. because of this low potential for malignant transformation, treatment is wide local excisional biopsy with surveillance. references 1. rodriguez ha, ackerman lv. cellular blue nevus: clinicopathologic study of forty-five cases. cancer 1968;21:393-405. 2. zembowicz a, pushkar ad. blue nevi and variants: an update. arch pathol lab med 2011;135:327-36. 3. allen ac, spitz s. malignant melanoma; a clinicopathological analysis of the criteria for diagnosis and prognosis. cancer 1953; 6:1-45. 4. duteille f, duport g, larregue m, et al. malignant blue nevus: three new cases and a review of the literature. ann plast surg 1998;41:674-8. 5. connelly j. smith jl jr. malignant blue nevus. cancer 1991;67:2653-7. 6. prieto vg, shea cr. use of immunohistochemistry in melanocytic lesions. j cutan pathol 2008;35 suppl 2:1-10. 7. shields cl, fasiuddin af, mashayekhi a, shields ja. conjunctival nevi: clinical features and natural course in 410 consecutive patients. arch ophthalmol 2004;122: 167-75. 8. grossniklaus he, green wr, luckenbach m, chan cc. conjunctival lesions in adults: a clinical and histopathologic review. cornea 1987;6:78-116. 9. mcdonnell jm, carpenter jd, jacobs p, et al. conjunctival melanocytic lesions in children. ophthalmology 1989;96:986-93. 10. alkatan hm, arfaj km, maktabi a. conjunctival nevi: clinical and histopathologic features in a saudi population. ann saudi med 2010;30:306-12. 11. demirci h, shields cl, shields ja, eagle rc jr. malignant melanoma arising from unusual conjunctival blue nevus. arch ophthalmol 2000;118:1581-4. 12. leopold jg, richards db. the interrelationship of blue and common naevi. j pathol bacteriol 1968;95:37-46. case report figure 1. external photograph shows a flat, hyperpigmented blue-black lesion with irregular borders deep in the stroma with no apparent vascularity. figure 2. conjunctival blue nevus. heavily pigmented dendritic melanocytes located in the substantia propria with normal conjunctival epithelium and no evidence of acquired melanosis (hematoxylin-eosin, original magnification x 40). figure 3. plump, heavily pigmented spindle-shaped melanocytes with no junctional activity and no involvement of the conjunctival epithelium with small, elongated, and hyperchromatic nuclei (hematoxylin-eosin, original magnification x 200). non -co mmerc ial us e o nly hrev_master [eye reports 2011; 1:e1] [page 1] bilateral pterygium in the two siblings suleyman ciftci,1 leyla ciftci2 1department of ophthalmology, diyarbakir training and research hospital; 2department of cardiology, faculty of medicine, dicle university, diyarbakir, turkey abstract pterygia are fibrovascular connective tissue overgrowths of bulbar conjunctiva onto the cornea. there is a worldwide distribution of pterygium, but it occurs more commonly in warm, dry climates. patients younger than the age of 15 rarely acquire a pterygium. we report a case of bilateral nasal pterygium in two siblings. a 10-year-old boy and a 12-year-old girl who are siblings presented with bilateral nasal pterygium. while pterygium is a common disorder, its bilaterality in young people is not a common condition. this report is the first known report in the peer-reviewed medical literature of patients with bilateral nasal pterygium in siblings younger than the age of 15. introduction pterygia are fibrovascular connective tissue overgrowths of bulbar conjunctiva onto the cornea. they are horizontally located in the interpalpebral fissure on either the nasal or temporal side of the cornea. histopathologic examination reveals that the subepithelial tissue exhibits elastotic degeneration of collagen, resulting from breakdown of the collagen and destruction of bowman’s membrane. patients younger than the age of 15 rarely acquire a pterygium.1 case report a 10-year-old boy and a 12-year-old girl who are siblings presented with bilateral nasal pterygium. on examination, the anterior segments in both eyes of both patients were otherwise normal, as were the posterior segments as well as the intraocular pressures (figures 1 and 2). the visual acuity of the boy was 8/10 in the right eye and 9/10 in the left eye without correction. the visual acuity of the girl was 9/10 in each eye without correction. there was no evidence of other functional impairments in either of the two siblings. none of their parents or their first-degree relatives, who live under the same environmental and geographical conditions, had any pterygia. discussion there is a worldwide distribution of pterygium, but it is more common in warm, dry climates. the association between ultraviolet radiation and formation of pterygia is strong. in addition, local drying of the cornea and conjunctiva in the interpalpebral fissure from tear film abnormalities may lead to fibroblastic growth.1 there is also some evidence that hereditary factors play a role in the development of pterygium. several case reports suggest a possible autosomal dominant pattern of occurrence.2-4 our knowledge of the pathogenesis of pterygium has increased in recent years. recently, jaworski et al.5 studied some of the genes that play a role in cell migration. these gene products include spermidine/spermine n1-acetyltransferase 1, clusterin, s100 protein, and keratins. among migration-related genes present in pterygia is the gene sat1, which encodes for the enzyme spermidine/ spermine n1-acetyltransferase 1. sat1 is abundant particularly at the body of the pterygium. one polyamine analogue, ipenspm, a potential inhibitor of sat1, significantly reduces migration in primary cultures of pterygium.5 another of the more abundantly expressed gene products in pterygia is clusterin. clusterin has many functions and is known by several synonyms: apolipoprotein j, testosterone-repressed prostate message 2, sulfated glycoprotein 2, and complement-associated protein sp-40. clusterin is abundant particularly at the fibrovascular body of the pterygium.5 s100 proteins comprise a multitude of low molecular weight, calcium-binding proteins that interact with other proteins to modulate biological processes.6,7 s100a8 and s100a9 are present at higher levels in pterygia than in uninvolved conjunctiva, and present in tear fluids of patients with pterygia. s100a9 (also known as calgranulin b) is abundant particularly at the leading edge of the pterygium body. s100a9 may be a pterygium and/or conjunctiva marker5,6 and may also serve as an especially useful indicator for predicting recurrent pterygium.8 kerkhoff et al. have showed that s100a8 and s100a9 are released from neutrophils by a eye reports 2011; volume 1:e1 correspondence: suleyman ciftci, diyarbakir eğitim ve araştirma hastanesi göz hastalikları polikliniği, 21000 diyarbakir, turkey. tel: +90.412.2570206 fax: +90.0412.2245267. e-mail: ciftci1977@hotmail.com key words: bilaterality, pterygium, sibling, young patients. conflict of interest: the authors report no conflicts of interest. received for publication: 6 april 2011. accepted for publication: 30 may 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright s. ciftci and l. ciftci, 2011 licensee pagepress, italy eye reports 2011; 1:e1 doi:10.4081/eye.2011.e1 figure 2. nasal pterygia (arrows) in the right and left eyes of the 12-year-old girl. figure 1. nasal pterygia (arrows) in the right and left eyes of the 10-year-old boy. non -co mmerc ial us e o nly [page 2] [eye reports 2011; 1:e1] microtubule-dependent mechanism and may induce inflammation by influencing leukocyte trafficking.9 jaworski et al. suggested the hypothesis that a pterygium may spread across the corneal surface by migration of cells bearing conjunctival and limbal markers into the corneal epithelium.5 they observed migration-related transcripts of the following proteins: keratin 19, found in limbal stem cells; keratins 4 and 13, found in conjunctiva and limbal cells; and aldehyde dehydrogenase, found in corneal epithelial cells.5 matrix metalloproteinases (mmps) also play a role in the development of pterygium. the pterygial cells which invade over bowman’s layer were found to have produced increased matrix metalloproteinases. mmp-1, mmp-2, and mmp-9 are likely the main mmps responsible for dissolution of bowman’s layer, by activating fibroblasts at the head of the pterygium, nearest to intact bowman’s layer.10 the finding of increased mmps at the leading edge of a pterygium led to a more recent study on the effect of doxycycline, an mmp inhibitor on pterygium growth. doxycycline was shown to reduce migration of pterygial epithelial cells in culture.11 tong et al. concluded that aberrant wound healing processes play a role in pterygium pathogenesis. they compared expression of primary pterygia, recurrent pterygia, and uninvolved conjunctiva, and observed increased expression of adhesion molecules and extracellular matrix and structural proteins (fibronectin; collagen and keratin family members). expression of epithelial-mesenchymal transition (emt), with down-regulation of ecadherin and up-regulation of β-catenin and lymphoid-enhancer-factor-1, has also been proposed as a mechanism for the origin of pterygial fibroblasts.16 vascular endothelial growth factor (vegf) plays an important role in fibrovascular component of pterygia. recently tsai et al. evaluated potential associations between pterygium formation and the vegf gene-460 polymorphism. they observed no significant differences seen between pterygium and control groups in age and sex, but found that vegf-460c polymorphism is associated with pterygium formation in young female patients.17 dushku and reid found that there is increased expression of p53 in all pterygia they studied. the increased amount of p53 protein in pterygial cells does not cause apoptosis or block cell proliferation, suggesting that the normal p53 functions are inactivated in pterygia.10 despite the increased amount of p53 protein in pterygial cells, pterygium has been described by some as a benign neoplastic lesion.13-15 conversely, the small leucine-rich proteoglycan (slrp) family is highly expressed in the cornea and is believed to contribute to corneal transparency. members of this family include decorin, keratocan, lumican, and mimecan (also called osteoglycin). slrps are collectively down-regulated in pterygium. furthermore, there are no transcripts for any of these slrps in the pterygium library.5,12 conclusions pterygium is a common disorder; however, it is not common in childhood.4 few cases of pterygia in childhood have been reported. in a series of 95 patients with pterygia, ajayi and bekibele18 reported the youngest was a 10year-old child with a pterygium. islam and wagoner2 reported a family with pterygia. one member of the family was a 4-year-old child. belliveau and ali19 reported a 3-year-old child with a pterygium due to xeroderma pigmentosum; pterygia are a common finding in xeroderma pigmentosa. in the cases in children reported, all except one patient, which reported by islam and wagoner, were unilateral. in none of the cases reported was there a history of a sibling with a pterygium. our case is unique in that it is a sibling pair with pterygia, that are also bilateral. i have previously reported a boy with bilateral nasal pterygium.20 this report is the first known report in the peerreviewed medical literature of patients with bilateral nasal pterygium in siblings younger than the age of 15. references 1. stephen g. waller, anthony p. adamis. pterygium. chapter 35. in: william tasman, eds. duane's clinical ophthalmology on cd-rom. 1st ed. philadelphia: lippincott williams & wilkins, 2006. 2. islam si, wagoner md. pterygium in young members of one family. cornea 2001;20:708-10. 3. zhang jd. an investigation of aetiology and heredity of pterygium. report of 11 cases in a family. acta ophthalmol 1987;65:413-6. 4. saw sm, tan d. pterygium: prevalence, demography and risk factors. ophthalmic epidemiol 1999;6:219-28. 5. jaworski cj, aryankalayil-john m, campos mm, et al. expression analysis of human pterygium shows a predominance of conjunctival and limbal markers and genes associated with cell migration. mol vis 2009;15:2421-34. 6. riau ak, wong tt, beuerman rw, tong l. calcium-binding s100 protein expression in pterygium. mol vis 2009;15:335-42. 7. tu cl, chang w, bikle dd. the extracellular calcium-sensing receptor is required for calcium-induced differentiation in human keratinocytes. j biol chem 2001;276:41079-85. 8 zhou l, beuerman rw, ang lp, et al. elevation of human alpha-defensins and s100 calcium-binding proteins a8 and a9 in tear fluid of patients with pterygium. invest ophthalmol vis sci 2009;50:207786. 9. kerkhoff c, klempt m, kaever v, sorg c. the two calcium-binding proteins, s100a8 and s100a9, are involved in the metabolism of arachidonic acid in human neutrophils. j biol chem 1999;274:32672-9. 10. reid tw, dushku n. what a study of pterygia teaches us about the cornea? molecular mechanisms of formation. eye contact lens 2010;36:290-5. 11. cox ca, amaral j, salloum r, et al. doxycycline's effect on ocular angiogenesis: an in vivo analysis. ophthalmology 2010;117:1782-91. 12. kao ww, liu cy. roles of lumican and keratocan on corneal transparency. glycoconj j 2002;19:275-85. 13. dushku n, reid tw. immunohisto chemical evidence that human pterygia originate from an invasion of vimentinexpressing altered limbal epithelial basal cells. curr eye res 1994;13:473-81. 14. weinstein o, rosenthal g, zirkin h, et al. overexpression of p53 tumor suppressor gene in pterygia. eye 2002;16:619-21. 15. tan dt, tang wy, liu yp, et al. apoptosis and apoptosis related gene expression in normal conjunctiva and pterygium. br j ophthalmol 2000;84:212-6. 16. tong l, chew j, yang h, et al. distinct gene subsets in pterygia formation and recurrence: dissecting complex biological phenomenon using genome wide expression data. bmc med genomics 2009;2:14. 17. tsai yy, chiang cc, bau dt, et al. vascular endothelial growth factor gene 460 polymorphism is associated with pterygium formation in female patients. cornea 2008;27:476-9. 18. ajayi bg, bekibele co. evaluation of the effectiveness of post-operative beta-irradiation in the management of pterygium. afr j med med sci 2002;31:9-11. 19. belliveau mj, ali a. pterygium resection with conjunctival autograft in a young child with xeroderma pigmentosum. cornea 2008;27:1174-5. 20. ciftci s. bilateral pterygium, symmetrical nodosity of the auricle, and free iris cyst. can j ophthalmol 2009;44:713. case report non -co mmerc ial us e o nly hrev_master [eye reports 2011; 1:e6] [page 15] spontaneous ipsilateral subconjunctival hemorrhage and the related risk factors evgenia kanonidou,1 vasileios konidaris,2 christina kanonidou,3 nikolas ziakas2 1department of ophthalmology, general hospital of veria, veria; 2department of ophthalmology, aristotle university of thessaloniki, ahepa university hospital; 3postgraduate student, aristotle university of thessaloniki, thessaloniki, greece abstract the aim of the report is to assess the risk factors among patients with spontaneous ipsilateral subconjunctival hemorrhage (sch) who presented to the outpatients’ department in general hospital of veria, veria, greece. thirty-five patients with sch participated in the study. a thorough case history was taken and a full ophthalmic examination was performed to identify the risk factors related to the clinical finding. the common hematological parameters associated with the coagulation profile of each patient were evaluated. with the exception of sch, the ophthalmic examination was normal in all patients. identified risk factors include history of systemic hypertension (21 patients [60%], mean systolic value: 170 mmhg±15 mmhg), strenuous exercise [19 patients (54%)] and minor ocular trauma [5 patients (14%)]. other risk factors [each in 2 patients (6%)] included: diabetes mellitus, smoking, severe cough, straining at stool, and weight lifting. seven patients (20%) were under medication related to bleeding diathesis. the values of the blood coagulation parameters were within the normal limits in all patients. twenty-nine patients (83%) had elevated blood pressure during the ophthalmological examination. our study provides documentation regarding the potential risk factors associated with sch. it is interesting to observe the high incidence of hypertension among the patients with sch. therefore, it is highly recommended that the blood pressure be checked in all patients with sch and that the patients be referred to a general practitioner for further management if indicated. introduction subconjunctival hemorrhage (sch) is a commonly presenting clinical problem for an ophthalmologist.1,2 in several studies in general ophthalmologic studies, schs were seen in 0.35-0.8% of patients.3,4 the clinical sign of sch is the presence of blood underneath the conjunctiva, often in one sector of the eye, to the extent in some cases that the entire view of the sclera is obstructed.1 the purpose of this study was to assess the risk factors among patients with spontaneous ipsilateral sch who presented to the outpatient department of our referral centre. materials and methods participants in the study were 35 patients (21 male and 14 female), mean age 57 years old (sd±16), who presented to the ophthalmology outpatient department with spontaneous ipsilateral sch. a thorough case history was taken from each individual and a full ophthalmic examination (slitlamp and non-contact lens fundus examination) was performed to identify the potential risk factors related to the clinical finding of sch. the patients’ blood pressure was measured at the time of presentation. the common hematological parameters associated with the coagulation profile of each patient [i.e. platelet count (plt) prothrobin time (pt), activated partial thromboplastin time (aptt), and international normalized ratio (inr)] were also evaluated. the study followed the tenets of the declaration of helsinki and was approved by the local ethical committee. written informed consent was obtained from all subjects prior to their participation. results the ophthalmic examination was normal in all the patients, with the exception of sch. twenty-one patients (60%) had a history of systemic hypertension, 2 (6%) had a history of diabetes and 2 (6%) were smokers. nineteen patients (54%) had a history of recent heavy exercise; 5 patients (14%), possible minor local trauma during sleep; 2 patients (6%), severe coughing prior to the subconjunctival bleeding; 2 patients (6%), straining at stool; and, 2 patients (6%), lifting of weights. seven patients (20%) were under medication related to bleeding diathesis (5 with acetylsalicylic acid and 2 with clopidogrel bisulfate) (figure 1). in some of the patients there was a co-existence of two or more of the risk factors under investigation. in 19 of the patients there was only one identified risk factor for sch. in 8 of the patients, there were 2 risk factors (in 5 of the patients, the 2 were hypertension and heavy exercise, in 1 patient, the 2 were hypertension and diabetes, in 1 patient, the 2 were smoking and minor local trauma, in 1 patient, the 2 were smoking and medication related to bleeding diathesis, and in 1 patient, the 2 were severe coughing and heavy exercise). in 6 of the patients, there were 3 risk factors (in 1 of the patients, the 3 were hypertension, medication related to bleeding diathesis, and lift of weight, in 1 patient, the 3 were hypertension, severe coughing and heavy exercise, in 1 patient, the 3 were hypertension, heavy exercise and minor local trauma, in patient, the 3 were hypertension, straining at stool and heavy exercise, in 1 patient, the 3 were hypertension, heavy exercise and medication related to bleeding diathesis, and in 1 patient, the 3 were heavy exercise, lift of weight and minor local trauma). in one patient, there were 4 risk factors: hypertension, severe coughing, heavy exercise and medication related to bleeding diathesis. in another one patient, there were 5 risk factors: hypertension, diabetes, straining at stool, medication related to bleeding diathesis and lift of weight. the values of the blood coagulation parameters were between the normal limits [plt: 256,866 (sd 51,709), pt: 11.38 (sd 0.85), aptt: 26.02 (sd 2.45), inr:1.02 (0.63)]. it was interesting to observe that 29 patients (83%) had elevated blood pressure during the ophthalmological examination (mean systolic value: 170 mmhg±15 mmhg) while 30 patients (87%) mentioned that they considered that their condition should be medically treated despite the doctor’s reassurance that sch is a self-limiting condition. it is also worthy to mention that 2 patients (6%) visited again the outpatients’ department in a week’s eye reports 2011; volume 1:e6 correspondence: kanonidou, evgenia, department of ophthalmology, general hospital of veria/ 97 vlasi gavriilidi street, gr 55131, thessaloniki, greece. tel: +30.6974416953. e-mail: evkanon@hotmail.com key words: subconjunctival, hemorrhage, risk factors, hypertension, bleeding diathesis. conflict of interest: the authors report no conflicts of interest. contributions: all the authors contributed equally. received for publication: 7 april 2011. accepted for publication: 8 august 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright e. kanonidou et al., 2011 licensee pagepress, italy eye reports 2011; 1:e6 doi:10.4081/eye.2011.e6 non -co mmerc ial us e o nly [page 16] [eye reports 2011; 1:e6] time, even though the sch was partially absorbed, as they were still anxious regarding their condition. discussion though it is a non-vision threatening condition in most of the cases, sch may reflect blood coagulation or underlying systemic disorders. a study by pitts, et al. confirms that blood pressure is higher in sch than in a control group. according to this study, there is also a high incidence of hypertension in patients with sch referring themselves to the ophthalmologists, which persists on subsequent assessment. this finding was found true even when the patient attributed the sch to eye rubbing or to a straining manoeuvre and whether or not the fundus shows early hypertensive changes.5 the high incidence of hypertension by established criteria suggests that hypertension may be an important aetiological factor in sch and it is recommended that all patients with this condition have their blood pressure checked and be referred to the general practitioner.5 a further study by mimura, et al. suggested that the cause of sch in hypertensive patients is microvascular damage, which is more common in hypertensive patients than in otherwise healthy patients.2 in our investigation, it was interesting to observe that blood pressure was elevated in the vast majority of the patients with spontaneous ipsilateral sch, a fact that might possibly be related to their concerns about their condition. sch develops in patients with local trauma, or a trauma associated with retrobulbar hemorrhage or ruptured globe.6 sch is also recognized in whooping cough, sneezing, constipation or other forms of straining (valsalva) and even strangulation, where the mechanism is thought to be raised venous pressure.2,3,6 recurrent, bilateral and severe subconjunctival hemorrhages mandate the search for an underlying etiology, such as a blood dyscrasia, blood clotting disorder, or recurrent increased intrathoracic pressure caused by repetitive vomiting or coughing spells.7 these risk factors were also assessed in our investigation. it has also been reported that sch can be a feature of diabetes.8 patients with a bleeding disorder, such as haemophilia, or others under anti-platelet or anticoagulant medication may be more prone to having a sch. in our study, the coagulation blood tests were normal in all the patients. sch presents more commonly as a spontaneous event without these etiological factors, especially in the elderly or arteriosclerotic patients.9 a recent study by mimura, et al. reported that the peak age of occurrence of sch was between 61 and 70 years. fourteen patients (77.7%) in that study had trauma or contact-lens-induced injury, and 4 patients (22.3%) among the younger patients aged 0-40 years had an unknown etiology. among the older patients aged 61-94 years, the chief risk factor for sch was hypertension (47.5%), followed by unknown etiology (39.4%) and then diabetes (13.1%).2 sch is self-limiting and typically resolves in two to three weeks, without any treatment required. artificial teardrops can be given if a mild ocular irritation related to corneal dryness or dellen formation from an elevation of conjunctiva adjacent to the cornea is present. some authors recommend further investigation of patients having sch while others suggest that reassurance alone is required.10 in our investigation it was interesting to observe the high percentage of patients requesting prescribed medication for the treatment of their condition as well as the fact that a proportion of patients visited again the outpatient department for further consultation despite the doctor’s reassurance at their initial visit. the reason for the patients' anxiety can be contributed to the fact that sch can be a source of worry and an embarrassment to the patients, mainly due to its impressive appearance, but also to the mistaken belief that sch is related to elevated intraocular pressure, strokes, or other serious circulatory system disorders. our study provides documentation regarding the potential risk factors associated with sch. it is interesting to observe the high incidence of hypertension among the patients with sch. it is possible that the high incidence of hypertension is related to patients’ concerns about their condition. nevertheless, it is highly recommended that the blood pressure be checked in all patients with sch at the ophthalmic exam visit and that the patients should be referred to a general practitioner for further management if indicated. references 1. kanski jj. clinical ophthalmology. a systematic approach. 2nd ed. boston, massachusetts: butterworth-heinemann; 2007. p. 629. 2. mimura t, usui t, yamagami s, et al. recent causes of subconjunctival hemorrhage. ophthalmologica 2010;224:133-7. 3. kaimbo wa kaimbo d. epidemiology of traumatic and spontaneous subconjunctival haemorrhages in congo. bull soc belge ophtalmol 2009;311:31-6. 4. leiker ll, mehta bh, pruchnicki mc, rodis jl. risk factors and complications of subconjunctival hemorrhages in patients taking warfarin. optometry 2009; 80:227-31. 5. pitts jf, jardine ag, murray sb, barker nh. spontaneous subconjunctival haemorrhage-a sign of hypertension? br j ophthalmol 1992;76:297-9. 6. op de coul me, budde jh. diagnostic image (136). a boy with coughing fits and subconjunctival hemorrhage. subconjunctival hemorrhage secondary to whooping cough. ned tijdschr geneeskd 2003;147:805. 7. trevor-roper pd, curran pv. the eye and its disorders. 2nd ed. oxford: blackwell scientific; 1984. pp. 341-367. 8. fukuyama j, hayasaka s, yamada k, setogawa t. causes of subconjunctival hemorrhage.ophthalmologica 1990;200:637. 9. groomer ae, terry je, westblom tu. subconjunctival and external hemorrhage secondary to oral anticoagulation. j am optom assoc 1990;61:770-5. 10. alder fh. gifford’s textbook of ophthalmology. 4th ed. philadelphia: saunders; 1949. pp. 196-219. article figure 1. risk factors related to spontaneous ipsilateral subconjunctival hemorrhage in the participants in our investigation (% percentage). non -co mmerc ial us e o nly hrev_master [page 12] [eye reports 2011; 1:e5] what are the half-lives of ranibizumab and aflibercept (vegf trap-eye) in human eyes? calculations with a mathematical model michael w. stewart mayo clinic school of medicine, jacksonville, fl, usa abstract the aim of the article is to estimate the intravitreal half-lives of ranibizumab and aflibercept (vegf trap-eye; vte) in human eyes. using a published mathematical model for rabbits, the intravitreal half-lives of ranibizumab and bevacizumab were calculated and compared to empirical data. the slope coefficient within the model was changed to set the bevacizumab output equal to experimental values to meet 3 goals: firstly, to validate the model in rabbit eyes; secondly, to test the mutability of the model to monkey eyes; thirdly, to calculate the half-lives of ranibizumab and the vte in human eyes. the half-life calculations for ranibizumab deviate from published rabbit and monkey values by only 8.3% and 4.2%. using the experimentally determined half-life of bevacizumab in human eyes (8.25 days) to set the equation, the half-lives of ranibizumab and the vte are calculated to be 4.75 days and 7.13 days in human eyes. the intraocular half-lives of ranibizumab and the vte are estimated using existing published animal and human data and a mathematical model. the validity of these half-lives and binding activities, however, awaits clinical correlation. introduction antibody based anti-vegf drugs have become standard of care for the treatment of exudative age-related macular degeneration and are frequently administered for diabetic retinopathy and retinal vein occlusions. the view studies showed that ranibizumab and the aflibercept (vegf trap-eye; vte) had comparable peak clinical effects (heier j, presen tation, angiogenesis, miami, fl, february 11, 2011; smith urfurth u, presentation, angiogenesis, miami, fl, february 11, 2011) suggesting that the maximum clinical response achievable with anti-vegf monotherapy in a study population may have been reached by the currently available drugs. new anti-vegf agents may need to be differentiated more by their duration of action than by their peak clinical effect.the duration of clinical action of anti-vegf drugs is determined by a combination of binding strength and intraocular half-life.1,2 the intravitreal half-life of most drugs is first determined in animal models, usually rabbit and/or monkey, and then in humans during phase i-iii trials or postapproval. pharmacokinetic studies in human eyes usually consist of intravitreal drug injections followed several days to weeks later by sampling of the vitreous or aqueous during a surgical procedure. for most drugs, pharmacokinetic data in at least 1 animal model has been determined and some, such as ranibizu mab, receive regulatory approval without human pharmacokinetic studies.3,4 the goal of this study is to estimate the as yet undetermined intravitreal half-lives of ranibizumab and the vte in humans by using experimental animal and human data combined with a previously published mathematical model.5 materials and methods a medline search for studies reporting pharmacokinetic data on ranibizumab, bevacizumab, the vte and similar macromolecules in both animals and humans was performed. unique animal models rabbit and monkey that tested both ranibizumab and bevacizumab or structurally similar molecules were identified.6-8 the intravitreal half-life of bevacizumab in humans was calculated by averaging values from published studies.9-10 a previously published mathematical model that calculated intravitreal drug half-lives in rabbits was employed.5 the model predicts the half-life of a drug according to the following equation: log t1/2 = -0.32+0.432* (log mw)-0.157* (log p)+0.003* (dose / solubility) at ph 7.4 where: t1/2 is the half-life of the compound. mw is the molecular weight of the compound. log p is the logarithm of p, the partition coefficient or the ratio of the concentrations of an un-ionized compound in two immiscible phases at equilibrium. as such, log p is the lipophilicity of the compound and p=-0.51 for macromolecules. the ratio of dose/solubility is assumed to be 1 for this data set. to test the validity of the model, the halflives of ranibizumab and bevacizumab were calculated. the slope coefficient (0.432) was changed slightly to set the half-life of bevacizumab equal to the published value, the expected half-life of ranibizumab was re-calculated, and the deviation, as a percentage from the published value, was calculated. the mutability of the model to monkey eyes was then tested. the slope coefficient was changed to set the bevacizumab half-life equal to the published value, the expected ranibizumab halflife was calculated, and the deviation, as a percentage from the published value, was calculated. finally the model was used to calculate the drug half-lives in human eyes. the slope coefficient was changed to set the bevacizumab half-life equal to the average of the published values (8.25 days) and the half-lives of ranibizumab (mw-48 kd) and the vte (mw110kd) were calculated. to determine the possible relationship between the size of the eye and the mutability of the equation, the slope coefficients were graphed against the intravitreal volumes and subjected to a regression analysis. results based upon a review of the literature (table 1),3,4,6-14 the following animal models were selected against which to test the validity and mutability of the modified half-life equation: i) for rabbits, bakri et al. determined ranibizumab and bevacizumab half-lives of 2.88 days and 4.32 days respectively;7,8 ii) for monkeys, mordenti et al. determined fab and her2 (macromolecules structurally similar to ranibizumab and bevacizumab, respectively) half-lives of 3.2 days and 5.6 days respectively.6 using the published half-life equation, the initially calculated half-lives of ranibizumab and bevacizumab in rabbit eyes were 2.54 days and 4.17 days. the slope coefficient was increased from 0.43200 to 0.43564 to set the output for bevacizumab to equal 4.32 days. the re-calculated half-life of ranibizumab was 2.64 days, only 8.3% shorter than the experimental eye reports 2011; volume 1:e5 correspondence: michael w. stewart, 4500 san pablo rd., jacksonville, fl 32224, usa. tel. +1.904.953.2232 fax: +1.904.953.7040. e-mail: stewart.michael@mayo.edu key words: age-related macular degeneration, ranibizumab, bevacizumab, vegf trap, aflibercept, half-lives, pharmacokinetics. received for publication: 11 june 2011. accepted for publication: 31 july 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright m.w. stewart, 2011 licensee pagepress, italy eye reports 2011; 1:e5 doi:10.4081/eye.2011.e5 non -co mmerc ial us e o nly [eye reports 2011; 1:e5] [page 13] value (2.88 days). to establish the mutability of the half-life equation to monkey eyes, the slope coefficient was increased to 0.45720 to set the bevacizumab output to 5.6 days. the calculated half-life of ranibizumab was 3.34 days, only 4.2% above the experimental value (3.2 days). to calculate the half-lives of ranibizumab and the vte in human eyes the slope coefficient was changed a third time. increasing the coefficient to 0.49000 calculates the bevacizumab half-life to be 8.25 days, the average value reported in the literature. by inputting the molecular weights of ranibizumab and the vte, their half-lives are calculated to be 4.75 days and 7.13 days. to determine a possible relationship between eye size and mutability of the equation between species, the 3 slope coefficients used in the previous calculations were graphed against eye volumes (figure 1). a linear relationship with a high correlation coefficient (r2 = 0.9956) was determined. discussion accurate intraocular drug half-lives allow physicians to create efficacy models to predict the results of untested clinical situations and to more accurately predict drug washout periods when patients change medications or enter controlled clinical trials. a reliable mathematical model would enable physicians to design better clinical studies and provide improved patient care. experimental pharmacokinetic data from rabbits, monkeys and humans has been published for the 3 antibody based anti-vegf drugs but only bevacizumab has been studied in all 3 species.3,4,6-13 until human data for ranibizumab and the vte become available, half-life calculations based upon a methodically derived mathematical model may provide the most accurate values. published reports show that intravitreal halflife differences exist even for the same drug within a single species. these differences may be due to several factors including vitreous and aqueous sampling techniques, drug reflux at the time of injection, and drug assay technique and performance. when choosing experimental models with which to make half-life comparisons between different drugs, models that test at least 2 drugs – bakri et al.’s rabbit model and mordenti et al.’s monkey model – would minimize artifactual differences. a mathematical model derived from experimental rabbit data5 provides the best starting point for predicting drug half-lives in other species. this model was created from half-life data of over 60 drugs, including bevacizumab. according to the model the most important determinant of drug half-life is molecular size; less important factors include lipophilicity, drug solubility, dose, salt form factor, and eye pigmentation. the model predicts that macromolecules with similar structure (e.g. fab antibody fragments or full length antibodies) should have similar half-lives within a given species. experimental data with rituximab (mw 145 kd) – intravitreal half-life of 4.7 days in rabbits suggests this to be true.14 since lipophilicity, drug solubility, and salt form factor are independent of the vitreous volume, the model was altered by changing only the slope coefficient. bevacizumab data exists for all 3 species so its half-lives were used to guide changes of the slope coefficient within the mathematical model. these changes were made with 3 goals in mind: i) to establish validity of the model in rabbits; ii) to establish mutability of the model to monkeys; iii) to calculate half-lives of ranibizumab and vte in humans. the bevacizumab guided changes in the model produced ranibizumab values of 2.64 days in the rabbit and 3.34 days the monkey, differing from the experimental values by only 8.3% and 4.2%. this finding suggested that the model was accurate for macromolecule halflives in rabbit eyes and mutable to monkey eyes. given these findings, the model was used to calculate the half-lives of ranibizumab (4.75 days) and the vte (7.13 days) in humans. both published experimental results and the halflife calculations obtained with this adapted model are consistent with 2 commonly held principles of intraocular drug pharmacokinetics. firstly, the intravitreal half-life of a given drug increases with the size of the eye. when the slope coefficient is graphed against the size of the eye a highly correlated (r2=0.9956) linear relationship is seen. this limited experimental data suggests that the half-life of a drug in one species may be predicted based upon experimental data in other species. more work, however, needs to be done to determine the validity of such a mathematical relationship. secondly, the half-lives of drugs with similar structures increase according to the logarithm of molecular weight. this suggests that for the anti-vegf drugs the intravitreal halflives should rank as follows: bevacizumab > vte > ranibizumab. the major weakness of this model concerns the mutability of the rabbit-determined model between species. though changing the slope coefficient seems a logical transformation, the validity of this strategy must await confirmation with experimental data. references 1. stewart mw. predicted biologic activity of intravitreal bevacizumab. retina 2007;27: 1196-200. 2. stewart mw, rosenfeld p. predicted biological activity of intravitreal vegf trap. br j ophthalmol 2008;92:667-8. 3. gaudreault j, webb w, van hoy m, et al. pharmacokinetics and retinal distribution of amd rhufab v2 after intravitreal administration in rabbits. aaps pharm sci 1999;suppl 1:2142. article figure 1. intravitreal volume is graphed against the slope coefficient of the mathematical model, as determined by bevacizumab half-lives. table 1. intraocular half-lives of ranibizumab, vte, bevacizumab and similar macromolecules are listed. authors drug species half-life bakri8 ranibizumab rabbit 2.88 days gaudreault11 ranibizumab rabbit 2.89 days regeneron vte rabbit 4.79 days bakri7 bevacizumab rabbit 4.32 days nomoto12 bevacizumab rabbit 5.95 days miyake13 bevacizumab rabbit 2.8 days (aqueous) kim14 infliximab rabbit 4.7 days gaudreault4 ranibizumab monkey 2.63 days (0.5 mg)0 gaudreault4 ranibizumab monkey 3.9 days (2.0 mg) mordenti6 fab monkey 3.2 days mordenti6 her2 monkey 5.6 days zhu10 bevacizumab human 6.7 days krohne9 bevacizumab human 9.82 days (aqueous) intravitreal volume (ml) s lo p e c o e ff ic ie n t 0.5 0.49 0.48 0.47 0.46 0.45 0.44 0.43 0 0.5 1 1.5 2 2.5 3 .3.5 4 4.5 5 y= 0.0178x+0.4107 r2=0.9956 non -co mmerc ial us e o nly [page 14] [eye reports 2011; 1:e5] 4. gaudreault j, fei d, rusit j, et al. preclinical pharmacokinetics of ranibizu mab (rhufabv2) after a single intravitreal administration. invest ophthalmol vis sci 2005;46:726-33. 5. durairaj c, shah jc, senapati s, kompella ub. prediction of vitreal half-life based on drug physiochemical properties: quantitative structure-pharmacokinetic relationships (qspkr). pharm res 2009;26:123660. 6. mordenti j, cuthbertson ra, ferrara n, et al. comparisons of the intraocular tissue distribution, pharmacokinetics, and safety of 125i-labeled full-length and fab antibodies in rhesus monkeys following intravitreal administration. toxicol pathol 1999; 27:536-44. 7. bakri sj, snyder mr, reid jm, et al. pharmacokinetics of intravitreal bevacizumab (avastin). ophthalmology 2007; 114;855-9. 8. bakri sj, snyder mr, reid jm, et al. pharmacokinetics of intravitreal ranibizu mab (lucentis). ophthalmology 2007;114: 2179-82. 9. krohne tu, eter n, holz fg, meyer ch. intraocular pharmacokinetics of bevacizumab after a single intravitreal injection in humans. am j ophthalmol 2008; 146:508-12. 10. zhu q, zeimssen f, henke-fahle s, et al. vitreous levels of bevacizumab and vascular endothelial growth factor-a in patients with choroidal neovascularization. oph thalmology 2008;115:1750-5. 11. gaudreault j, fei d, beyer jc, et al. pharmacokinetics and distribution of ranibizumab, a humanized antibody fragment directed against vegf-a, following intravitreal administration in rabbits. retina 2007;27:1260-6. 12. nomoto h, shiraga f, kuno n, et al. phar macokinetics of bevacizumab after topical, subconjunctival, and intravitreal administration in rabbits. invest ophthal mol vis sci 2009;50:4807-13. 13. miyaki t, sawada o, kakinoki m, et al. pharmacokinetics of bevacizumab and its effect on vascular endothelial growth factor after intravitreal injection of bevacizumab in macaque eyes. invest ophthal mol vis sci 2010;51:1606-8. 14. kim h, csaky kg, chan cc, et al. the pharmacokinetics of rituximab following an intravitreal injection. exp eye res 2006; 82:760-6. article non -co mmerc ial us e o nly hrev_master [eye reports 2011; 1:e14] [page 45] detection of helicobacter pylori in the lacrimal sac mucosa of the patients with primary acquired nasolacrimal duct obstruction naser owji,1 seyed mohammad bagher abtahi,2 negar azarpira3 1poostchi eye research center; 2department of ophthalmology, khallili hospital; 3organ transplant research center, shiraz university of medical sciences, shiraz, iran abstract helicobacter pylori have been detected in sinonasal mucosa in both normal and pathologic condition. the nasolacrimal duct is within the medial wall of maxillary sinus and open into the nasal cavity, so ascending colonization of nasolacrimal duct and lacrimal sac is possible. the aim of this study is to investigate the presence of h. pylori by polymerase chain (pcr) reaction in the nasal and lacrimal sac mucosa of the patients with primary acquired nasolacrimal duct obstruction. eighty patients with primary acquired nasolacrimal duct obstruction who were scheduled for dacryocystorhinostomy enrolled in the study. the patients were asked if they suffered from the classic symptoms of gastroesophageal reflux disease (heart burn, regurgitation, and acid taste). tissue samples from the lacrimal sac mucosa and nasal mucosa were obtained during dacryocystorhinostomy surgery. the tissues were analyzed for detection of h. pylori dna by pcr. the mean age of patients was 41.96±14.7 years (age range, 17-84 years). pcr for h. pylori dna was positive in the nasal mucosa in 3 patients, in the lacrimal sac mucosa in 2 patients and in both nasal mucosa and lacrimal sac mucosa in 1 patient. classic symptoms of gastroesophageal reflux disease were found in 16 patients (20%). it is possible to detect h. pylori in the lacrimal sac mucosa of some patients with primary acquired nasolacrimal duct obstruction. more comprehensive studies are needed to determine whether h. pylori plays an etiopathologic role in the development of primary acquired nasolacrimal duct obstruction. introduction helicobacter pylori is a microaerophilic gram-negative spiral organism that normally inhabits the gastric mucus layer. h. pylori is a major cause of gastritis and peptic ulcer disease and has been implicated in the development of gastric malignancy.1 colonization of h. pylori has been found in dental plaques, saliva, tonsils and adenoids.2,3 recently this organism was also detected in the nasal and maxillary sinus specimens of patients with chronic sinusitis.4-6 some believe that the sinonasal mucosa serves as reservoir for h. pylori infections.5,6 the nasolacrimal duct is within the medial wall of the maxillary sinus and opens into the nasal cavity, so ascending colonization of nasolacrimal duct and lacrimal sac is possible. the present investigation was planned to determine the presence of h. pylori by polymerase chain reaction (pcr) in the nasal and lacrimal sac mucosa in patients with primary acquired nasolacrimal duct obstruction who underwent dacryocystorhinostomy. materials and methods eighty consecutive patients with primary acquired nasolacrimal duct obstruction were enrolled. they were scheduled for dacryocystorhinostomy (dcr) in khallili teaching hospital (shiraz, iran). the study was approved by the local ethics committee (poostchi eye research center). all patients gave their informed consent before enrolling in the study. all patients were examined by an otolaryngologist to rule out possible secondary causes of nasolacrimal duct obstruction. the patients were asked whether they had classic symptoms of gastroesophageal reflux disease (heart burn, regurgitation, and acid taste) and whether they had used antibiotics, bismuth compounds, h2 receptor blockers, antacid drugs, and proton pump inhibitors before the surgery. those who used the above systemic medications four weeks before the surgery were excluded from the study. classic external dcr was carried out under general anesthesia. tissue samples from lacrimal sac mucosa and nasal mucosa were prepared at the time of lacrimal sac and nasal mucosal flap preparation. biopsy specimens were fixed in 10% buffered formalin, embedded in paraffin, sectioned and stained with hematoxylin-eosin to evaluate the pathological findings. dna was extracted from the sample tissues (containing approximately 10 mg of specimen) by using a tissue dna extraction kit (cinnagen, tehran, iran), following the manufacturer’s instructions. great care was taken to avoid contamination both during the sample collection step and preparation step. a polymerase chain reaction assay with the h. pylori pcr detection kit was performed according to the manufacturer's protocol. pcr primers were targeted to an urec gene segment of h. pylori. all samples were positive for b-globin as an internal control. in each run, positive and negative controls were included. culturing of microorganisms and pcr for other microorganisms was not performed in this investigation. the chi-square test and independent t-test were used for statistical analysis. a p value of less than 0.05 was considered to be significant. results the present investigation was performed on 80 patients. there were 21 male (26.25%) and 59 female (73.75%) patients. the mean age of patients was 41.96±14.7 years (age range, 1784 years). the pcr for h. pylori dna was positive in the nasal mucosa in 3 patients, in the lacrimal sac mucosa in 2 patients and in both eye reports 2011; volume 1:e14 correspondence: naser owji, department of ophthalmology, khallili hospital, oculoplasty service, shiraz university of medical sciences, shiraz, fars, iran. tel./fax: +98.711.647.1479. e-mail: dr_oji@yahoo.com key words: helicobacter pylori, acquired nasolacrimal duct obstruction, polymerase chain reaction, nasal mucosa, lacrimal sac mucosa. acknowledgements: the authors would like to thank soraya saky, md for assistance in data collection, and mohammad javad ashraf, md for review of pathology specimens. contributions: no, manuscript conception and design, revision and final approval; smba, na, data acquisition, manuscript drafting and final approval. funding: financially, this study is partially supported by organ transplant research center, shiraz university of medical sciences. there is no proprietary interest. received for publication: 10 april 2011. revision received: 5 december 2011. accepted for publication: 6 december 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright n. owji et al., 2011 licensee pagepress, italy eye reports 2011; 1:e14 doi:10.4081/eye.2011.e14 non -co mmerc ial us e o nly [page 46] [eye reports 2011; 1:e14] nasal mucosa and lacrimal sac in 1 patient. statistically, there was no significant difference (p=0.63) between the mean age of patient with positive pcr (39.16 years) and that of the patients with negative pcr (42.18 years). classic symptoms of gastroesophageal reflux disease (gerd) were found in 16 patients (20%). classic symptoms of gerd were present in 1 pcr positive patient and in 15 pcr negative patients. there was no statistically significant difference between the two groups (p=0.65). there was, however, a statistically significant difference between the mean ages of the patients with and without classic symptoms of gerd, which were 50.81 years, and 39.75 years, respectively (p=0.007). discussion h. pylori normally inhabits the gastric mucosa. h. pylori has been detected in dental plaque, saliva, tonsils, and adenoids.2,3 the oral cavity might be considered a reservoir for h. pylori.7 h. pylori has been found in nasal polyp, nasal mucosa and maxillary sinus mucosa in some patients with chronic sinusitis.4-6 the role of h. pylori infection in ophthalmic diseases such as chronic ocular inflammation, glaucoma,8 rosacea, and chronic blepharitis9 has been postulated. the complex interaction between h. pylori and ocular disease is a field of ongoing research. gastric colonization by h. pylori infection is associated with release of variable proinflammatory and vasoactive substances such as interleukins, tumor necrosis factor α, interferon g, prostaglandins, and creactive protein. in addition, in peptic ulcer disease associated with h. pylori infection, nitric oxide and endothelin-1 (constrictor of arterioles and venules) are increased. these substances may influence, for example, the pathophysiology of glaucoma by microvascular disturbance of anterior optic nerve vessels and the ophthalmic artery.10 production of oxidative stress and circulating lipid peroxides by h. pylori infection could affect pathophysiology of glaucoma as well.11 similar mechanisms have been proposed for a possible association between h. pylori infection and choroido retinopathy.12 gastrin (a potent vasodilator) level in the serum is elevated in patients with h. pylori associated gastric disease. circulating gastrin may cause vasodilation of the skin and ocular surface vessels leads to rosacea manifestations.13 to the best of our knowledge, this is the first study reporting the presence of h. pylori in the lacrimal sac mucosa. the detection of h. pylori in the lacrimal sac mucosa shows that colonization is not restricted to the nasal cavity, but ascending colonization via nasolacrimal duct is possible. the postulated mechanisms by which h. pylori reaches the nasal cavity are as follows. first, h. pylori may come from the stomach by gastroesophageal reflux (ger). second, the oral cavity may act as a reservoir of h. pylori, and the microorganism may come to the nasal cavity directly through oronasal reflux.4,6 in our study, the prevalence of subjective signs of gerd was similar in both pcr positive and negative patients. we did not investigate ger objectively. in addition, we did not investigate the presence of h. pylori in the stomach or oral cavity, so we do not know about the source of infection in these cases. the role of h. pylori infection in the pathogenesis of upper respiratory system diseases has been evaluated by some investigators.14 it is speculated that there is a relationship between gerd and chronic rhinopharyngitis and rhinosinusitis in both children and adult.15-17 it is suggested that direct reflux of gastric juice into nasopharynx may cause mucosal edema and inflammation, leading to obstruction of sinus ostia.18 recently focus has been on the possible direct role of h. pylori in tissue injury of the sinonasal mucosa and development of chronic rhinosinusitis.4,6 however, the causality has not been established yet. primary acquired nasolacrimal duct obstruction (pando) occurs in the absence of an obvious precipitating cause.19 pathologic studies of lacrimal passages have indicated that pando results from fibrous obstruction secondary to chronic inflammation. the first event in nasolacrimal duct obstruction is unknown but dacryostenosis develop as a result of inflammation and fibrosis. dacryostenosis with stasis and secondary infection may lead to complete nasolacrimal duct obstruction.20,21 descending infection from the conjunctiva has been considered a causative factor in dacryostenosis. in addition to the descending infection from the eye, ascending infection from nasal mucosa could be the starting point of dacryostenosis.22 bacteria, fungi, and parasites have been implicated as underlying causes of lacrimal drainage obstruction.19 in our series, those who used systemic antibiotics or bismuth during the four weeks before the surgery were excluded, as the treatment may eradicate or decrease h. pylori presence. the lacrimal sac mucosa of three patients was positive for h. pylori. retrograde colonization of nasolacrimal duct and hence lacrimal sac mucosa from the nasal cavity is possible. it may be transient colonization but infection of the nasolacrimal duct and lacrimal sac could not be ruled out. it is highly speculative, but in some patients with pando, h. pylori may cause direct nasolacrimal duct mucosa injury and chronic inflammation, leading to nasolacrimal duct stenosis. if it is true, treatment of h. pylori in these patients is warranted to prevent complete nasolacrimal duct obstruction. limitations of the present case series suggest several areas for further research. one of the drawbacks of our study is the lack of control group. secondly, the small group of participants limits the ability to make generalizations and requires one to view the results with caution. hence, there is a need for further research to evaluate the presence of h. pylori in larger series with a control group and to evaluate the effect of treatment for h. pylori in patients with positive pcr. references 1. hashemi mr, rahnavardi m, bikdeli b, dehghani zahedani m. h. pylori infection among 1000 southern iranian dyspeptic patients. world j gastroenterol 2006;12: 5479-82. 2. unver s, kubilay u, sezen os, coskuner t. investigation of helicobacter pylori colonization in adenotonsillectomy specimens by means of the clo test. laryngoscope 2001;111:2183-6. 3. nabwera hm, logan rph. epidemiology of helicobacter pylori: transmission, translocation and extragastric reservoirs. j physiol pharmacol 1999;50:711-22. 4. morinaka s, ichimiya m, nakamura h. detection of helicobacter pylori in nasal and maxillary sinus specimens from patients with chronic sinusitis. laryngoscope 2003;113:1557-63. 5. dinis pb, subtil j. helicobacter pylori and laryngopharyngeal reflux in chronic rhinosinusitis. otolaryngol head neck surg 2006;134:67-72. 6. ozdek a, cirak my, samim e, et al. a possible role of helicobacter pylori in chronic rhinosinusitis: a preliminary report. laryn-goscope 2003;113:679-82. 7. nguyen am, el-zaatari fa, graham dy. helicobacter pylori in the oral cavity. oral surg oral med oral pathol oral radiol endod 1995;79:705-9. 8. galloway ph, warner sj, morsherd mg, mikelberg fs. helicobacter pylori infection and the risk of open-angle glaucoma. ophthalmology 2003;110:922-26. 9. sacca sc, pascotto a, venturino gm, et al. prevalence and treatment of helicobacter pylori in patients with blepharitis. invest ophtalmol vis sci 2006;47:501-8. 10. kountouras j, zavos c, chatzopoulos d. induction of apoptosis as a proposed pathophysiological link between glaucoma and helicobacter pylori infection. med hypo-theses 2004;62:378-81. 11. kountouras j, mylpoulos n, chatzopoulos d, et al. eradication of helicobacter pylori article non -co mmerc ial us e o nly [eye reports 2011; 1:e14] [page 47] may beneficial in themanagement of chronic open angle glaucoma. arch intern med 2002;162:1237-44 12. giusti c,mauget-faysse m. helicobacter pylori and idiopathic central serous chorioretinopathy. swiss med wkly 2004;134: 395-8. 13. mindel js, rosenberg ew. is helicobacter pylori of interest to ophthalmologist? ophthalmology 1997;104:1729-30. 14. kurtaran h, uyar me, kasapoglu b, et al. role of helicobacter pylori in pathogenesis of upper respiratory system diseases. j natl med assoc 2008;100:1224-32. 15. dibaise jk, olusola bf, huerter jv, quigley em. role of gerd in chronic resistant sinusitis: a prospective, open label, pilot trial. am j gastroenterol 2002;97:843-50. 16. bothwell mr, parsons ds, talbot a, et al. outcome of reflux therapy on pediatric chronic sinusitis. otolaryngol head neck surg 1999;121:255-62. 17. ozmen s, yücel ot, sinici i, et al. nasal pepsin assay and ph monitoring in chronic rhinosinusitis. laryngoscope 2008;118: 890-4. 18. dibaise jk, sharma vk. does gastroesophageal reflux contribute to the development of chronic sinusitis? a review of the evidence. dis esophagus 2006;19:419-24. 19. bartley gb. acquired lacrimal drainage obstruction: an etiologic classification system, case reports, and a review of the literature. part 1. ophthal plast reconstr surg 1992;8:243-2. 20. linberg jv, mccormick sa. primary acquired nasolacrimal duct obstruction: a clinicopathologic report and biopsy technique. ophthalmology 1986;93:1055-63. 21. mauriello ja, palydowycz s, deluca j. clinicopathologic study of lacrimal sac and nasal mucosa in 44 patients with complete acquired nasolacrimal duct obstruction. ophthal plast reconstr surg 1992;8:13-21. 22. paulsen fp, thale ab, maune s, tillman bn. new insights into the pathophysiology of primary acquired dacryostenosis. ophthalmology 2001;108:2329-35 article non -co mmerc ial us e o nly hrev_master [page 42] [eye reports 2011; 1:e13] idiopathic intracranial hypertension: a possible association with imatinib anja m. palmowski-wolfe,1 eva pape,2 thomas baumann,3 margarita g. todorova1 1university of basel, department of ophthalmology; 2university basel, department of neurology, basel; 3neurozentrum bern, bern, switzerland abstract idiopathic intracranial hypertension (iih) is characterized by an increased intracranial pressure in the absence of a tumor and in the absence of a venous thrombosis. associated risk factors include obesity and several medications such as tetracyclines. we report a 60-year-old patient who developed iih under treatment with imatinib. to our knowledge such a possible connection has not been reported in the literature, even though intracranial hypertension is now listed as a rare possible side effect of treatment with imatinib in the swiss list of medications arzneimittelkompendium. it remains to be seen, if further case reports will support this observation. introduction imatinib inhibits particular tyrosine kinases that are expressed excessively in certain carcinomatous diseases and also inhibits plateletderived growth factor. it was introduced approximately a decade-and-a-half ago to treat chronic myeloid leukaemia (cml). in this disease a certain tyrosine kinase, encoded by the bcr-abl gene transcript, is expressed and causes uncontrolled cell divisions through its excess activity. this process can be blocked with imatinib which results in a reduction of the number of pathologic tumor cells.1 meanwhile imatinib is also applied to treat patients with gastrointestinal stromal tumors.1 imatinib is the only fda approved tyrosine kinase inhibitor for the treatment of patients with systemic mastocytosis, where a majority of patients excessively express the mast and stem cell growth factor receptor, scfr or cd117, encoded by the kit gene, and which has tyrosine kinase activity.2 as imatinib has only been on the market for a relatively short time, with time, new side effects are being described.1 we report a possible association between imatinib and idiopathic intracranial hypertension (iih). case report a 60-year-old caucasian female presented with blurred vision at our department of neurology. her past medical history was remarkable for a systemic mastocytosis of more than 35 years, with possible gastrointestinal involvement, and with bone marrow involvement proven by histology. for the last 3 years, the mastocytosis was treated with imatinib, which is marketed by novartis under the name of glivec (imatinib ut imatinib mesilate) in europe and under the name of gleevec (imatinib mesilate) in the us. the patient also had obesity of more than 30 kg excess body weight (who iii) and arterial hypertension. on examination, her snellen visual acuity in decimal equivalents was 0.7 in each eye. chronic papilledema was present in both eyes, and as a consequence, there were already signs of chronic nerve fibre damage, notably disc atrophy (figure 1). the optical coherence tomography demonstrated a superior temporal nerve fibre layer defect (figure 2). this nerve fiber layer defect correlated with a bilateral caudal nasal visual field defect (figure 3). magnetic resonance imaging revealed enlarged optic nerve sheaths with increased filling on both sides and a partial empty sella, which had already been described 4 years previously (figure 4). a thrombosis of the sinus veins was ruled out with magnetic resonance venography (figure 5). on lumbar puncture an increased intracranial pressure (icp) of 38.5 cmh2o was measured. the number of cells in the cerebrospinal fluid was normal (0.3¥106/l), and total protein was 349 mg/l. in order to reduce icp, the patient was started on oral acetazolamide 250 mg four times per day. weight reduction was recommended and dietary training was provided, albeit with limited success. under the hypothesis that imatinib might be associated with the increased icp, the manufacturer of the imatinib was contacted. a closer association to imatinib could not be proven at the time. nevertheless the patient was switched to nilotinib (tasigna, novartis), a second-generation tyrosine kinase inhibitor. under these measures, the blurred vision went away and the visual acuity improved to 0.8 in the right eye and 1.0 in the left eye. over a time period of one-and-a-half years, the visual fields showed no significant changes. when an attempt was made to discontinue diamox, blurred vision recommenced but then resolved again with oral acetazolamide. acetazolamide was then switched to topiramate, an anticonvulsant that, among other presumed actions, inhibits the carbonic anhydrase enzyme and has an anorectic side effect. under this treatment, the patient became free of symptoms and lost 3 kg over the course of 2 months. discussion iih is a disease of unknown etiology. obesity, especially of the lower body half, increases the risk of developing iih. medications such as tetracyclines have also been associated with this disease.3 in rare cases, iih has been described as a presenting symptom in cml, a myeloproliferative eye reports 2011; volume 1:e13 correspondence: prof. dr. anja palmowski-wolfe, universität basel, augenklinik, mittlere strasse 91, ch 4031 basel, switzerland. tel. +41.61.265.8722 fax: +41.61.265.8744. e-mail: palmowskia@uhbs.ch key words: idiopathic intracranial hypertension, glivec, imatinib. received for publication: 30 may 2011. revision received: 30 september 2011. accepted for publication: 30 october 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright a.m. palmowski-wolfe et al., 2011 licensee pagepress, italy eye reports 2011; 1:e13 doi:10.4081/eye.2011.e13 figure 1. fundus photographs of the right and left optic nerve heads show the patient’s chronic papilledema with a resulting slight disc pallor as a sign of beginning optic atrophy. non -co mmerc ial us e o nly [eye reports 2011; 1:e13] [page 43] disorder that results in an increase of leucocytes present in the bone marrow and blood. it has been postulated, that the very high white blood cell count in cml reduces the absorption of cerebrospinal fluid (csf) into the sinuses, thus leading to iih.4,5 mastocytosis is a rare disease that also leads to an increased production of cells, in this instance mast cells and their precursors. in our patient, her mastocytosis was well controlled and, at the time where she developed iih, there was no increased number of cells in her blood. therefore, an increased hyperviscosity of the peripheral blood preventing resorption of csf into the sinuses seems an unlikely cause of iih in our patient. in addition, we have not found any reports in the peer-reviewed medical literature (using medline) that describe iih in mastocytosis. imatinib is a recent drug which means, that with time, new side effects are being described.1 in a search of the peer-reviewed medical literature (using medline), we have not found a reported association of imatinib and iih. however, a non peer-reviewed anecdotal report revealed a possible connection in one individual who was on imatinib for 10 months and ended up with pseudo tumor cerebri.6 in another non peer-reviewed literature document iih is claimed as a potential rare side effect of imatinib, though no clinical case report, reference, or substantiation is provided.7 the pathomechnism by which imatinib might cause iih is not clear. weight gain from fluid retention has been reported as a frequent side effect of imatinib.1 in fact, this fluid retencase report figure 2. the optical coherence tomography reveals superior temporal nerve fibre layer (nfl) loss. the black line demarcates the patient’s nfl thickness for the right eye (top) and for the left eye (below). reduced nfl thickness (marked by the black arrows) is indicated when this line deviates from the green area of normative values in to the red area. figure 3. the nerve fibre layer loss seen in figure 2 correlates well with the visual fields obtained at that time. these show a nasal, more caudal field loss (black arrows) in the right eye more than the left eye. figure 4. magnetic resonance imaging demonstrates enlarged optic nerve sheaths (red arrows) as well as a partial empty sella (asterisk). figure 5. the sinus veins are shown with contrast medium (asterisk). with this magnetic resonance venography a thrombosis of the sinus veins could be ruled out. non -co mmerc ial us e o nly [page 44] [eye reports 2011; 1:e13] case report tion can also occur in the brain. in 2002, ebnöether, et al. reported 2 patients who developed cerebral edema under imatinib; in one of these patients, this cerebral edema occurred 6 months after the treatment was started. the authors explained the underlying pathomechanism as follows: imatinib inhibits platelet derived growth factor which may result in a decrease in interstitial fluid pressure and increase in capillary-to-interstitium transport.8 in addition, imatinib may increase appetite and lead to weight gain from increased food intake, as in our patient who had gained 30 kg when started on imatinib. an association between imatinib and iih may thus exist either as a direct association or as an indirect association through induction of a weight increase. as such an association could not be ruled out, the patient was switched to nilotinib. nilotinib is a second generation tyrosine kinase inhibitor that has a target profile similar to imatinib.2 even though it is not quite as successful as imatinib in the treatment of systemic masocytosis,2 to our knowledge, iih has so far not been associated with nilotinib. in the meantime, iih has been included in the swiss medical compendium as a possible side effect of imatinib. however, the swiss medical compendium does not suggest a pathomechanism and also does not provide additional reasoning for this listing. references 1. mughal ti, schrieber a. principal long-term adverse effects of imatinib in patients with chronic myeloid leukemia in chronic phase. biologics 2010;4:315-23. 2. ustun c, deremer dl, akin c. tyrosine kinase inhibitors in the treatment of systemic mastocytosis leuk res 2001;35: 1143-52. 3. kapoor kg. more than meets the eye? redefining idiopathic intracranial hypertension. int j neurosci 2010;120:471-82. 4. abbot l, mioneau g, johnston d. an unusual cause of headaches and priapism in a teenager. paediatr child health 2008;13: 299-301. 5. falardeau j, lee a. chronic myeloid leukemia mimicking idiopathic intracranial hypertension. neuro-ophthalmology 2001;26:229-34. 6. side effects with glivec. cmlsupport chronic myeloid leukaemia support group. available from: http://www.cmlsupport.org.uk/node/5984 7. imatinib side effects. drugs.com, drug information online. available from: http://www.drugs.com/sfx/imatinib-sideeffects.html 8. ebnöether m, stentoft j, ford j, et al. cerebral oedema as a possible complication of treatment with imatinib. lancet 2002; 359:1751-52. non -co mmerc ial us e o nly hrev_master [page 10] [eye reports 2012; 2:e3] orbital metastatic primary mediastinal neuroendocrine tumor: a histopathological case report hind alkatan,1 ayman ayoubi2 1pathology and laboratory medicine department; 2oculoplastic and orbit division, king khaled eye specialist hospital, riyadh, saudi arabia abstract neuroendocrine tumors most frequently involve the gastrointestinal tract and bronchopulmonary system. few cases of presumed primary neuroendocrine tumors in the orbit have been reported so far and most of the orbital cases are actually metastatic. we describe the unusual occurrence of this tumor in the orbit of a 16-year-old boy. the lesion was initially thought to be primary; however, the diagnosis of a metastatic orbital lesion was later supported by the histopathological appearance of his orbital biopsy, characteristic immunohistochemical profile and the presence of a primary mediastinal tumor. the patient did not have any symptoms suggestive of a carcinoid syndrome during the course of his disease. unfortunately, tests showed lymph node involvement and distant metastatic lesions and he died from these a few months later while on palliative therapy. introduction carcinoid tumors are neoplasms that are believed to arise from neuroendocrine cells of the gastrointestinal mucosa and in other anatomical locations such as lungs, ovaries, thyroid and breasts.1 neuroendocrine tumors (net) are often referred to using the term carcinoid, but the newer who classification uses the term net. the classification of lesions is based on size, localization, proliferation rate, differentiation and hormone production. metastatic spread to the eye and ocular adnexae is relatively uncommon and primary orbital cases are also rare.2 we report a patient who presented with an orbital neuroendocrine tumor that was finally concluded to be metastatic. his systemic workup before his death revealed a primary chest lesion. case report a 16-year-old male presented with rapidly progressing right side painless proptosis and diplopia over the previous month. the patient was healthy prior to his presentation. there was no history of preceding trauma and no other symptoms such as fever, night sweats, loss of weight or appetite; there was no history of skin lesions. visual acuity was 20/30 (uncorrected) on the affected side. external examination showed 8 mm of proptosis on the right side using hertel exophthalmometer at base 102. there was limitation of right eye abduction, dilated conjunctival blood vessels temporally, mild superficial exposure keratopathy and optic disc swelling on the same side (figure 1a). initial systemic examination revealed cervical lympadenopathy on the right side. lymph nodes were soft, rubbery and non-tender with no overlying skin changes. initial clinical diagnosis was rhabdomyosarcoma in view of his age and the rapidly progressing tumor or lymphoma, also taking into consideration his lymphadenopathy and the painless proptosis. magnetic resonance imaging of the orbits showed a large right temporally located extraconal orbital mass (3¥2.5 cm) abutting the lateral rectus muscle and extending to the orbital apex. the mass was isodense to the adjacent muscles with faint marginal contrast enhancement (figure 1b). the radiology report suggested the possibility of a neurogenic tumor or rhabdomyosarcoma. orbital incisional biopsy through right lateral orbitotomy showed tumor lobules separated by fibrous stroma in the hematoxylin and eosin stained histopathology slides. the lobules consist of poorly differentiated cells with small round to cuboidal nuclei and abundant cytoplasm (figure 2a). mitotic figures were frequent (figure 2b). the tumor cells expressed cytokeratin ck8/18, chromogranin (figure 3a) and synaptophysin (figure 3b). negative markers included desmin, myogenin, cd99, s-100, smooth muscle actin (sma) and epithelial membrane antigen (ema). proliferation rate was 20% by ki67. the final diagnosis was neuroendocrine tumor with histological grading grade 2. the patient was referred to a general tertiary care center for tests and management. his further systemic workup did not reveal any gastrointestinal primary tumor, but a computerized tomography (ct) scan of his chest showed a heterogenous lobulated mediastinal mass measuring 11.6¥9¥6 cm compressing the bronchial branches in addition to multiple nodules involving the lung parenchyma bilaterally. his total body ct scan also showed metastatic bone lesions involving lumbar vertebrae, left side of the sacrum and right iliac bone. bilateral multiple enlarged supraclavicular lymph nodes were also evident by magnetic resonance imaging in addition to pararenal soft tissue lesions adjacent to the left kidney and dorsolateral to the right iliopsoas muscle. the patient was considered to have stage 4 disease because of his distant metastasis with the primary lesion being in the chest. no tissue diagnosis was considered. because of the wide-spread disease, exenteration was not performed and he was started on chemotherapy consisting of cisplatin and etoposide. response to the 1st cycle of treatment was poor, as documented in his medical records. he also received palliative radiotherapy to the supraclavicular lymph nodes and his enlarging right orbital lesion. he was given a total dose of 2030 gy in 5-10 fractions. he was then transferred to another local health care facility in his family’s home town for supportive care. his condition deteriorated over the next few months and he died from his metastatic disease. discussion net originates from the chromaffin cells of eye reports 2012; volume 2:e3 correspondence: hind alkatan, king khaled eye specialist hospital, riyadh, saudi arabia. tel: +966.1.4821234 ext 3131; mobile: +966504492399. e-mail: hkatan@kkesh.med.sa key words: neuroendocrine, carcinoid, orbit. acknowledgements: this paper was presented at the eastern ophthalmic pathology society (eops) meeting, cleveland, ohio, usa, september 2010. irb/ec: this case study was not registered with the irb but followed the guidelines stipulated by the ethics committee of the institution. contributions: ha is fully responsible for the accuracy of the information and for preparation of the manuscript; aa has provided clinical data and is the treating physician responsible for the case. conflict of interests: the authors declare no potential conflict of interests. received for publication: 31 may 2011. revision received: 6 february 2012. accepted for publication: 13 february 2012. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright h. alkatan and a. ayoubi, 2012 licensee pagepress, italy eye reports 2012; 2:e3 doi:10.4081/eye.2012.e3 non -co mmerc ial us e o nly [eye reports 2012; 2:e3] [page 11] the gastrointestinal and bronchial tract.1,3 carcinoid syndrome may develop in a small number of patients, usually in association with metastatic disease, and it manifests as cutaneous flushing, cyanosis, diarrhea, asthma and endocardial fibrosis.4 ophthalmic manifestations of this syndrome include conjunctival injection, intravascular sludging, perivascular pigment clumping and a decrease in the ophthalmic artery pressure that are believed to be attributed to serotonin and vasoactive peptides secreted by a functioning net.5 several cases of non-ocular net in various anatomic locations have been reported; however, primary orbital net is rare.1,2 orbital involvement by net accounts for only 4-5% of all orbital metastatic disease and it is usually from a gastrointestinal primary tumor, while ocular uveal involvement is often from primary bronchopulmonary nets.2,6 bilateral orbital metastasis has been also reported.7,8 an overall high proportion of net cases (15%) metastasize to the orbit, although it is considered a relatively rare site for metastatic disease.9 of these cases of orbital involvement by net, the majority of the metastases are from primary gastrointestinal tumors or tumors of unknown primary origin. mititelu et al. reported a presumed primary left orbital net progressing to neoplastic meningitis while the original tumor site was never identified.10 riddle et al. reported 15 cases of eye and orbit net metastases. of the 12 cases in whom the primary site was known: 7 cases were bronchial, 4 from the ileum and one case only was from trachea. however, if we isolate these 7 orbital cases, the primary site was unknown in 3, was ileum in 3 and trachea in one case only.11 in a review by shetlar et al. of 18 cases of orbital metastases, including 3 cases reported by the authors and an additional 15 cases reported by others, 11 were of gastrointestinal origin, the primary site was unknown in 5, mediastinal in one and trachea in one.4 mehta et al. reported their 13 cases of orbital metastatic net among whom 11 were of gastrointestinal origin (ileal in 7 and colonic in 4), and only one each from breast and bronchus. mehta et al. also reviewed the literature of net metastasis to the orbit and out of 23 cases reported by others (in which the primary tumor was known), 16 were of gastrointestinal origin, 5 of bronchopulmonary origin, one was of renal origin and one was of mediastinal origin.12 on the other hand, only a few cases of metastatic ocular uveal net have been reported.11 metastatic spread to the eye itself is more likely to arise from bronchial tumors, and it involves primarily the uveal tract where it can be misdiagnosed as uveal melanoma.4,13 the primary tumor in almost all uveal metastasis has been shown to arise from the bronchus. the reasons behind this predilection are not understood. riddle et al. reported that out of 8 cases of metastasis to the ocular uveal tissue from net, 7 were of bronchial origin and the remaining single case was of ileal origin.11 out of 12 uveal metastatic net reviewed by shetlar et al., in contrast to the orbital cases in the same review discussed above, the primary site was bronchial in 11 cases and the ileum in one case only.4 in their review, mehta et al. commented that this might be due to intrinsic properties of the tumors affecting their ability to develop a metastasis.12 metastases are uncommon in typical bronchopulmonary net, but regional lymph node secondary tumors occur more commonly in atypical settings; although distant metastasis occurs less frequently. usual metastases are to lymph nodes, contralateral lung, liver, bone, ovaries, brain and skin.14 metastatic intraocular or orbital net usually presents after the primary neoplasm is diagnosed.2,11 symptoms of the carcinoid syndrome are commonly observed in cases of metastatic disease in general, as functioning net metastases (usually hepatic) may secrete vasoactive substances, detected as raised urinary 5-hiaa, and manifest clinically as symptoms of carcinoid syndrome, such as facial flushing, diarrhea, abdominal cramps, asthma and tachycardia.11,12 however, carcinoid syndrome is rare in bronchpulmonary net without metastasis; therefore, symptoms are usually absent.15 case report figure 1. (a) clinical appearance of the proptotic right globe in our 16-year-old patient. (b) axial t1-magnetic resonance imaging showing the right isodense mass pushing the optic nerve, with ring of contrast enhancement. figure 2. (a) histopathology picture of the tumor lobules (hematoxylin and eosin, original magnification x 200). (b) mitotic figure (white arrow) (hematoxylin and eosin, original magnification x 1000). figure 3. (a) positivity of the tumor cells as indicated by dark brown staining to chromogranin a (original magnification x 400). (b) positive islands of tumor cells to synaptophysin stained brown within light colored stroma (original magnification x 200). non -co mmerc ial us e o nly [page 12] [eye reports 2012; 2:e3] zimmerman and his co-authors reviewed 15 cases of orbital/ocular metastatic net and only 4 of these patients had elevated 5-hiaa and/or symptoms of the carcinoid syndrome.2 even with metastasis to the orbit, symptoms of carcinoid syndrome are often absent. only 2 patients out of the 13 cases of orbital metastatic net reported by mehta et al. had elevated urinary 5-hiaa without hepatic metastasis, thus suggesting a significant production of the vasoactive substances by the orbital metastatic tumor itself.12 the location of his ocular metastatic lesion makes our patient unique. his primary mediastinal net was asymptomatic and he presented first with the orbital metastatic lesion before the primary lesion was discovered. this is considered unusual since the metastatic disease was orbital instead of being intraocular (uveal). sira and co-authors similarly reported the first case of net metastasizing from the larynx to the orbit; however, in their case the involvement was bilateral.8 our patient also did not have symptoms suggestive of a carcinoid syndrome to attract attention to his primary disease. the absence of carcinoid syndrome manifestations delayed his diagnosis. another interesting but rare finding in metastatic net is their presentation as orbital inflammation that must be carefully distinguished from the systemic carcinoid syndrome. this presentation is thought to be related to spontaneous release of intrinsic inflammatory mediators.8,16 the histological differential diagnosis suggested by zimmerman et al. includes amelanotic melanoma, paraganglioma and metastasis from oat cell carcinoma, retinoblastoma, neuroblastoma, since they all share the histological cellular appearance of small dark cells, but can otherwise be eliminated according to clinical, immunohistochemical and ultrastructural criteria. the differential diagnosis also includes non-orbital net; this is more problematic.2 therefore, immunohistochemical methods are important for proper diagnosis with frequent reactivity to chromogranin a and synaptophysin. chromogranin a is one of the acidic proteins present in the secretory granules of neuroendocrine cells and is seen in most net, while synaptophysin is another broad-spectrum neuroendocrine marker localized in cytoplasmic vesicles in neurons, neuroendocrine cells and their neoplasms. other useful markers for net include neuron-specific enolase that is a highly sensitive, but not specific, marker for net, in addition to serotonin and calcitonin for metastatic net, depending on the characteristic hormone or marker related to the primary site. it has been suggested to use a selective panel of antibodies to obtain the greatest diagnostic accuracy.4 the differential diagnosis in our case, based on the histopathological appearance of the tumor and the clinical suspicion, included desmoplastic round cell tumor. this was ruled out by the lack of prominent desmoplastic stroma and muscular differentiation (negative desmin, sma and myogenin). our patient had positive staining to chromogranin a (polyclonal rabbit anti-human) and synaptophysin (monoclonal mouse antibody). magnetic resonance imaging is helpful in localizing the tumor which may demonstrate the same density as the extraocular muscles in both t1and t2-weighted images.3 this was also seen in our case. no exact data is available for long-term survival of ocular metastatic net. the overall median survival of 227 cases of ocular metastatic disease reported by ferry and font was 7.4 months and only 2 out of these were net.17 in general, a relatively good prospect for longterm survival in net cases is expected, thus excision of small solitary metastatic lesions in the orbit is recommended to achieve local control of the disease. enucleation or exenteration might also be ultimately required to ensure total surgical excision and local control of the disease that is believed to prolong survival time.3,4 the role of chemotherapy and external beam irradiation for orbital net has not been well defined. however, some have reported an effective response to chemotherapy with cisplatin and etoposide.3 our patient had incisional biopsy aimed at reaching the proper diagnosis before definitive surgical treatment was planned. however, he was found to have a late stage disease and only palliative therapy was offered to him in the referral hospital. in conclusion, we report an unexpected metastatic net in a patient with absent carcinoid syndrome manifestations. these factors helped a proper diagnosis to be made but also led to an unfavorable outcome. periodic ophthalmological examination of patients with net is recommended for early detection of any ocular involvement and to guide treatment. on the other hand, ophthalmologists should also be aware of the rare occurrence of these tumors in the orbit and eye in order to avoid any delay in management. references 1. godwin jd ii. carcinoid tumors: an analysis of 2837 cases. cancer 1975;36:560-9. 2. zimmerman le, stangl r, riddle pj. primary carcinoid tumor of the orbit: a clinicopathologic study with histochemical and electron microscopic observations. arch ophthalmol 1983;101:1395-8. 3. fan jt, buettner h, bartley gb, bolling jp. clinical features and treatment of seven patients with carcinoid tumor metastatic to the eye and orbit. am j opthalmol 1995; 119:211-8. 4. shetlar dj, font rl, ordonez n, et al. a clinicopathologic study of three carcinoid tumors metastatic to the orbit: immunohi stochemical, ultrastructural, and dna flow cytometric studies. ophthalmology 1990; 97:257-64. 5. wong vg, melmon kl. ophthalmic manifestations of the carcinoid flush. n engl j med 1967;277:406-9. 6. goldberg ra, rootman j, cline ra. tumors metastatic to the orbit: a changing picture. surv ophthalmol 1990;35:1-24. 7. sivagnanavel v, riodan-eva p, jarosz j, et al. bilateral orbital metastases from a neuroendocrine tumor. j neuroophthalmol 2004;24:240-2. 8. sira m, clauss rp, maclean c, rose ge. orbital metastases from neuroendocrine carcinoma, masquerading as graves orbitopathy. orbit 2010;29:94-6. 9. isidori am, kaltsas g, frajese v, et al. ocular metastases secondary to carcinoid tumors: the utility of imaging with [(123)i]meta-iodobenzylguanidine and [(111)in]dtpa pentetreotide. j clin endocrinol metab 2002;87:1627-33. 10. mititelu m, stanton ca, yeatts rp. primary neuroendocrine tumor of the orbit progressing to neoplastic meningitis. ophthal plast reconstr surg 2008;24:231-3. 11. riddle pj, font ri, zimmerman le. carcinoid tumors of the eye and orbit: a clinicopathologic study of 15 cases, with histochemical and electron microscopic observations. hum pathol 1982;13:459-69. 12. mehta js, abou-rayyah y, rose ge. orbital carcinoid metastasis. ophthalmology 2006;113:466-72 13. bardenstein ds, char dh, jones c, et al. metastatic ciliary body carcinoid tumor. arch ophthalmol 1990;108:1590-4. 14. aburn ns, whitehead k, sullivan tj. bronchpulmonary atypical carcinoid tumor metastatic to the orbit. aust n z j ophthal mol 1995;23:241-4. 15. conley yd, cafoncelli ar, khan jh, et al. bronchial carcinoid tumor, experience over 20 years. am j surg 1992;58:670-2. 16. knox rj, gigantelli jw, arthurs bp. recurrent orbital inflammation from metastatic orbital carcinoid tumor. oph thalmic plast reconstr surg 2001;17: 1379. 17. ferry ap, font r. carcinoma metastatic to the eye and orbit. i. a clinicopathologic study of 227 cases. arch ophthalmol 1974;92:276-86. case report non -co mmerc ial us e o nly [page 23] correspondence: conflict of interest: the authors report no conflicts of interest. choi mun chan, mbbs contributions: all authors contributed equally. singapore national eye centre accepted for publication: may, 2018 11 third hospital avenue this work is licensed under a creative commons attribution singapore 168751 non-commercial 3.0 license (cc by-nc 3.0). e-mail: chan.choi.mun@snec.com.sg ©copyright chan et al., 2018. phone: (65) 6322-8330 licensee ophthoscience publishers, usa [page 24] [page 25] hrev_master [page 38] [eye reports 2011; 1:e12] optic disc parameters in manifest and suspected glaucoma peter wanger,1 lucian vancea,2 lene martin1,3 1department of clinical neuroscience, ophthalmology & vision, karolinska institutet, stockholm; 2eye clinic, sundsvalls hospital, sundsvall; 3academy of health and welfare, mälardalen university, eskilstuna, sweden abstract structure and function measurements are important in glaucoma management. digital fundus photography has become a standard procedure and the heidelberg retina tomograph (hrt), commonly used by glaucoma specialists, provides a glaucoma probability score (gps). the visual field index (vfi) is a novel statistic, aiming to facilitate follow-up of glaucoma patients. the aim of this study was to compare the results from the digital analysis of fundus photographs with hrt measurements including gps and vfi in patients with ocular hypertension, suspect glaucoma or glaucoma, and if possible define an optic disc index, useful in glaucoma diagnosis. fifty-eight consecutive patients from a glaucoma service were included. optic disc parameters (disc and cup areas) were measured on digital fundus photographs, using a semi-automatic method, and compared with the gps from the hrt and the vfi from standard automated perimetry. a significant relationship was observed between the gps group classification (normal, borderline, or abnormal) and vfi classification (normal or abnormal), both when the gps borderline group was regarded as normal (p = 0.0038 fisher test) and as abnormal (p=0.0179, kappa = 0.33). no significant relationship was observed between vfi and optic disc parameters. the threedimensional information in the gps appears to be more related to visual function, as measured by vfi, than the planimetric measures of the optic disc. introduction digital fundus cameras are a standard part of the ophthalmologic equipment, commonly used in screening for retinal disorders, such as age-related macular degeneration.1 evaluation of the optic disc parameters on fundus photographs is clinically relevant in glaucoma diagnosis and follow-up2 and several algorithms have been evaluated for planimetric calculation of optic nerve head parameters.3 optic disc analysis can also be automatically performed with confocal scanning laser ophthalmoscopy4 using the heidelberg retinal tomography, hrt (heidelberg engineering gmbh, heidelberg, germany). recently, we developed a program which was designed to provide clinically relevant measures of optic disc parameters with a minimum of user input.5 the program can be used directly on the acquired images, with the examined subject still available for re-examination. in topographic analyses of the optic nerve the effect of disc size has to be taken into account.6 when calculating linear or area cupto-disc ratios, small discs may be classified normal despite the presence of glaucoma and, vice versa, large discs may be falsely labelled as glaucomatous.7 recently, a scoring system for evaluation of the optic disc in glaucoma was presented by the rand study group8, which relied on estimation of both the cup-todisc ratio and the disc size in order to overcome this drawback. the aim of this study was to compare the results from the digital analysis of fundus photographs with hrt measurements including glaucoma probability score (gps) and visual field index (vfi) in patients with ocular hypertension, suspect glaucoma, or glaucoma, and, if possible, define an optic disc index, useful in glaucoma diagnosis. materials and methods subjects the patients were recruited from a glaucoma service at a regional hospital. inclusion criteria were as follows: primary open angle glaucoma (poag), defined as intraocular pressure (iop) >21 mmhg at two or more occasions and either retinal nerve fiber layer (rnfl) defect or visual field (vf) defect, without other explanation, or both; suspected glaucoma, defined as either iop >21 mmhg at two or more occasions or either retinal rnfl defect or vf defect, without other explanation; ocular hypertension (oht), defined as iop >21 mmhg at two or more occasions with normal vf and no rnfl defect; and, normal tension glaucoma (ntg), defined as iop <22 mmhg at two or more occasions and either rnfl defect or vf defect, without other explanation, or both. exclusion criteria were other disorders (such as optic nerve hypoplasia) that could influence the eye or vision and subjects with unreliable visual field results, defined according to the manufacturer’s manual. all patients had been examined at least twice at the glaucoma service and were scheduled for follow-up. one eye from each of the 58 patients was randomly selected for analysis (tables 1 and 2). all but 16 of the subjects had refraction within ± 3d (all refraction is expressed in spherical equivalent). one subject had a hyperopia of +3.75d. the remaining subjects had moderate myopia (-3.5d to -6d; n=7) or high myopia (-6.75d to -14.75d; n=8). methods all subjects underwent a standard clinical examination and visual field examination, using the humphrey visual field analyser (hfa), 24-2 threshold test, sita fast (carl zeiss meditec, dublin, california, usa). digital images of the optic nerve head (onh) were obtained using the heidelberg retinal tomography 3 (hrt3) (heidelberg engineering gmbh) and the zeiss visupac and ff 450plus telecentric fundus camera system (carl zeiss meditec). measurements of optic disc parameters were performed using the gps calculations in the hrt. gps makes a global assessment of the onh by comparing the measured shape of the optic disc and the surrounding retina to a model for normal and glaucomatous optic nerves. the output of the program is a number between 0.00 and 1.00, which is classified as within normal limits (below 0.28), borderline (0.28 to 0.64) or outside normal limits (above 0.64).9 the quality of the images is evaluated by the hrt software and classified as excellent, very good, good, acceptable, poor or not usable (manufacturer’s manual). only recordings with quality grade acceptable or better were used. the global gps measure and the cup area (ca) measure were used. the retinal size tool (rst) was used for measurements on the digital fundus photographs.5 rst is a computer program developed in-house, that can be used on any digital funeye reports 2011; volume 1:e12 correspondence: lene martin, academy of health and welfare, mälardalen university, po box 325, se-631 05 eskilstuna, sweden. tel. +46.161.532.02 e-mail: lene.martin@mdh.se key words: digital fundus photography, optic disc, heidelberg retina tomograph, glaucoma probability score, visual field index. received for publication: 13 april 2011. accepted for publication: 18 october 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright p. wanger et al., 2011 licensee pagepress, italy eye reports 2011; 1:e12 doi:10.4081/eye.2011.e12 non -co mmerc ial us e o nly [eye reports 2011; 1:e12] [page 39] dus photograph where both the macula and the onh are visible. optic disc parameters, i.e. optic disc and cup, are assumed to be elliptical,10 and the user marks the endpoints of their long and short diameters by mouse clicks. in order to compensate for differences in magnification due to camera and eye optics, the macula-optic disc centre distance is used as reference measure10-12 when converting pixel units to metric distance.5 this measure is reported to be quite constant among adults.13 the interoperator agreement has been shown to be very good, both regarding disc and cup area (r=0.92 and 0.93, respectively).5 in the current study the cup area (ca), disc area (da), and the quotient cup/disc area (cada) were evaluated. the vfi14 in the hfa was used for comparison with the structural measures. an hfa vfi >98% was regarded as a normal (bengtsson, personal communication). the study was performed according to the helsinki declaration and approved by the local ethical committee. written informed consent was obtained from all patients prior to enrolment. statistics for comparisons and correlations, the fisher test, the kruskall-wallis non-parametric anova-test and the spearman correlation test were used. binary logistic regression was used in an attempt to define a diagnostic index based on the measurement on the fundus photographs. results optic disc parameters in heidelberg retina tomograph 3 and retinal size tool table 3 show the disc parameters in all subjects measured both with the rst (ca, da, cada) and the hrt gps (ca). there was a strong correlation in the total group (r2=0.63; p<0.0001) between the ca measurements performed by the gps and the rst, and no difference in median value (0.46 in both measures). the ca’s were significantly smaller in the high myopes, measured both with rst (median 0.33; p<0.0001) and gps (median 0.32; p=0.004). nineteen patients out of 58 (33%) had normal optic discs according to the gps program; 12 were judged as borderline, and 27 as abnormal (example discs shown in figure 1). in the 8 patients with high myopia, 7 were classified as normal and 1 as borderline. table 4 shows the disc parameters, measured by rst, in the three gps groups. a significant difference was found in ca and cada between the normal group and both the borderline and the abnormal group and in da between the normal and the abnormal group (table 5). cada correlated significantly, but weakly with gps (r2=0.19, p<0.001). optic disc parameters and humphrey visual field analyzer visual field index eighteen patients out of 58 (31%) had normal visual fields according to the vfi, and 40 had subnormal vfi values. in the 8 patients with high myopia, 5 had normal vfi values. table 6 shows the relationship between hfa vfi and disc parameters in all patients. there article table 3. median values for disc parameters in relation to the degree of myopia. all (n=58) high myopes (n=8) non high myopes (n=50) median rst da (mm2) 2.17 (1.19-3.23) 1.64 (1.42-2.14) 2.22 (1.19-3.23) median rst ca (mm2) 0.46 (0.12-1.89) 0.33 (0.12-0.41) 0.56 (0.12-1.89) median rst cada (mm2) 0.11 (0.04-0.20) 0.1 (0.05-0.19) 0.11 (0.04-0.20) median hrt gps ca (mm2) 0.46 (0.09-1.11) 0.32 (0.15-0.30) 0.48 (0.091.11) rst, retinal size tool; da, disc area; ca, cup area; cada, cup/disc area quotient; hrt, heidelberg retinal tomography; gps, glaucoma probability score. values in parentheses represent the range of values. table 4. median values for retinal size tool disc parameters and humphrey visual field analyzer visual field index in the three glaucoma probability score classification groups. gps normal gps borderline gps abnormal number of subjects 19 12 27 median rst da (mm2) 1.67 (1.19-3.02) 2.15 (1.31-2.68) 2.32 (1.38-3.23) median rst ca (mm2) 0.31 (0.12-0.65) 0.59 (0.13-1.04) 0.63 (0.17-1.89) median rst cada (mm2) 0.16 (0.07-0.32) 0.28 (0.1-0.41) 0.28 (0.08-0.59) median hfa vfi (%) 99 (65-100) 97.5 (80-100) 97 (65-99) rst, retinal size tool; gps, glaucoma probability score; da, disc area; ca, cup area; cada, cup/disc area quotient; hfa, humphrey visual field analyzer; vfi, visual field index. values in parentheses represent the range of values. table 2. diagnoses in the studied group. oht poag ntg glaucoma glaucoma suspect secondary to secondary to glaucoma pseudoexfoliation pigmentary dispersion number of subjects 7 13 10 15 3 10 suspected glaucoma consisted of poag, ntg, and pseudoexfoliative glaucoma. table 1. age, gender and refraction (spherical equivalent). median age (range) 64 (30-85) gender (female/male) 31/27 median refraction (range) -0.63 (-14.5 to +3.75) refraction expressed as spherical equivalent. table 5. anova p-values of comparisons between gps classifications for cup area, disc area, and cup/disc area quotient. ca da cada gps classification normal vs borderline <0.05 >0.05 <0.05 normal vs abnormal <0.001 <0.001 <0.01 borderline vs abnormal >0.05 >0.05 >0.05 ca, cup area; da, disc area; cada, cup/disc area quotient; gps, glaucoma probability score; vfi, visual field index. table 6. relationship between humphrey visual field analyzer visual field index and median disc parameters. vfi normal (>98%) vfi abnormal (<=98%) number of subjects 18 40 median da (mm2) 2.01 (1.19-3.02) 2.21 (1.23-3.23) median ca (mm2) 0.43 (0.12-0.96) 0.5 (0.12-1.89) median cada (mm2) 0.22 (0.07-0.4) 0.23 (0.07-0.59) median hrt gps ca (mm2) 0.17 (0.02-0.7) 0.64 (0.08-0.92)* vfi, visual field index; da, disc area; ca, cup area; cada, cup/disc area quotient; hrt, heidelberg retinal tomography; gps, glaucoma probability score; *p=0.001. values in parentheses represent the range of values. non -co mmerc ial us e o nly [page 40] [eye reports 2011; 1:e12] was a significant difference between vfi in the gps normal group compared with the gps abnormal group (<0.05) (table 7). the correlation between vfi and gps score was weak (r2=0.083, p=0.027). regarding classification, a significant relationship was observed between the gps group classification (normal, borderline, or abnormal) and vfi classification (normal or abnormal), both when the gps borderline group was regarded as normal and as abnormal (tables 7 and 8). there was no correlation between cada and vfi (r2=0.006, p = 0.56). a logistic regression equation based on da and cada did not discriminate between subjects with normal and abnormal vfi. discussion optic disc parameters in heidelberg retina tomograph 3 and retinal size tool and gps classifications in a previous study, comparing disc measurements from rst and hrt3 in non-glaucomatous subjects, no significant difference between the measurements were found either in da or in ca.5 this observation was confirmed regarding ca in the current study of glaucoma subjects, but could not be confirmed regarding the da, since the gps program does not report this measure. it is well known that disc size influences the ability to classify the optic disc as normal or glaucomatous.6,8,9 this influence is true also for the hrt3 gps classification.9 in the current study, the largest discs, median disc area of 2.32 mm2, were found in the gps abnormal group, compared to median disc area of 2.15 mm2 in the gps borderline group, and median disc area of 1.67 mm2 in the gps normal group. for use in glaucoma management, the rand system8 defines a score for the linear cup to disc ratio (cdr): score of 0 is cdr < 0.5, score 1 is cdr 0.5 to < 0.7, score 2 is cdr 0.7 to 0.9, and score 4 is cdr > 0.9, and the rand system adjusts this score by subtracting one unit if the da is ophthalmoscopically judged to be large and adding one unit if the da is judged to be small. in the current study, which included patients with no or low degree of glaucomatous on damage, binary logistic regression showed no significant effects of combining optic disc parameters for the identification of eyes with abnormal vfi. thus, the significant relationship between gps and vfi appears to depend on the three-dimensional analysis of the neuro-retinal rim area performed by the hrt. a weakness in the rst method is that notching of the rim area is not visible in the measurement values. however, visual evaluation of the fundus photographs revealed notching in one eye only. the concordance between gps and vfi in classification as normal and abnormal was moderate. alencar, et al.15 reported that gps values were predictive of conversion in a population of patients with suspected glaucoma. thus, the combination of gps and vfi data may provide an easily analyzed basis for decision-making in glaucoma management. conclusions a statistically significant relationship was found between hrt gps and hfa vfi, but not between optic disc parameters, obtained by planimetric measurements on digital fundus photographs. the three-dimensional information in the gps appears to be more related to visual function, as measured by vfi, than the planimetric measures of the optic disc. references 1. sheidow pt, hooper p. prospective evaluation of digital non-stereo color fundus photography as a screening tool in age-related macular degeneration. am j ophthalmol 2005;139:455-61. 2. o'leary n, crabb dp, mansberger sl, et al. glaucomatous progression in series of stereoscopic photographs and heidelberg retina tomograph images. arch ophthalmol 2010;128:560-8. 3. laemmer r, schroeder s, martus p, et al. quantification of neuroretinal rim loss using digital planimetry in long-term follow-up of normals and patients with ocular hypertension. j glaucoma 2007;16:430-6. 4. chauhan bc, hutchison dm, artes ph, et al. optic disc progression in glaucoma: comparison of confocal scanning laser tomography to optic disc photographs in a prospective study. invest ophthalmol vis sci 2009;50:1682-91. 5. bartling h, wanger p, martin l. measurement of optic disc parameters on digital fundus photographs – algorithm development and evaluation. acta ophthalmol scand 2008;86:837-41. 6. heijl a, mölder h. optic disc diameter influences the ability to detect glaucomatous disc damage. acta ophthalmol (copenh) 1993;71:122-9. 7. hoesl lm, mardin cy, horn fk, et al. influence of glaucomatous damage and optic disc size on glaucoma detection by scanning laser tomography. j glaucoma 2009;18:385-9. 8. rand study group. for which glaucoma suspects is it appropriate to initiate treatarticle figure 1. examples of optic discs with different glaucoma probability score classifications and visual field index findings. (a) female born 1944, with oht, gps normal, rst ca/da 0.19,vfi 99%; (b) male born 1938, with pseudoexfoliation, gps borderline, rst ca/da 0.22, vfi 93%; and (c) male born 1948, with ntg, gps abnormal, rst ca/da 0.64, vfi 83%.oht, ocular hypertension; gps, glaucoma probability score; rst, retinal size tool; cada, cup/disc area quotient in mm2; vfi, visual field index; ntg, normal tension glaucoma. table 8. relationship between glaucoma probability score (gps) grouping and normal/ abnormal visual field index, when the gps borderline group was regarded as abnormal. gps normal gps borderline or abnormal vfi >98 10 8 vfi <=98 9 31 gps, glaucoma probability score; vfi, visual field index; p=0.0179 fischer test; kappa = 0.33. a b c table 7. relationship between glaucoma probability score (gps) grouping and normal/ abnormal visual field index, when the gps borderline group was regarded as normal. gps normal or gps abnormal borderline vfi > 98 15 3 vfi ≤=98 16 24 gps, glaucoma probability score; vfi, visual field index; p, 0.0038 fisher test; kappa = 0.36. non -co mmerc ial us e o nly [eye reports 2011; 1:e12] [page 41] ment? ophthalmology 2009;116:710-16. 9. strouthidis ng, garway-heath df. new developments in heidelberg retina tomograph for glaucoma. curr opin ophthalmol 2008;19:141-8. 10. williams td. elliptical features of the human optic nerve head. am j optom physiol opt 1987;64:172-8. 11. wakakura m, alvarez e. a simple clinical method of assessing patients with optic nerve hypoplasia. the disc-macula distance to disc diameter ratio (dm/dd). acta ophthalmol (copenh) 1987;65:612-7. 12. williams td, wilkingson jm. position of the fovea centralis with respect to the optic nerve head. optom vis sci 1992;69;369-77. 13. mok kh, lee vw. disk-to-macula distance to disc-diameter ratio for optic disc size estimation. j glaucoma 2002;11:392-5. 14. bengtsson b, heijl a. a visual field index for calculation of glaucoma rate of progression. am j ophthalmol 2008;145:343-53. 15. alencar lm, bowd c, weinreb rn, et al. comparison of hrt-3 glaucoma probability score and subjective stereophotograph assessment for prediction of progression article non -co mmerc ial us e o nly hrev_master [page 10] [eye reports 2011; 1:e4] a rare case of wagr syndrome with peter anomaly rohit s. adyanthaya, michael x. repka wilmer ophthalmological institute, the johns hopkins university school of medicine, baltimore, maryland, usa abstract we report a case of the wagr syndrome associated with the peter anomaly. a 6-day-old baby boy was found to have bilateral corneal opacities, 360 degrees of iris hypoplasia and cataracts. physical examination revealed bilateral undescended testicles. family history was unremarkable and genetic testing revealed a deletion 11p11.2-13 indicating wagr syndrome. a wilms tumor developed and was removed at age 2 years. there was moderate developmental delay. the occurrence of wagr syndrome with peter anomaly has been reported in three other patients to our knowledge. introduction wagr syndrome is a disorder characterized by microdeletions of the short arm of chromosome 11 at band p13 and is clinically associated with wilms tumor, aniridia, genitourinary anomalies and mental retardation (w-a-g-r). deletions of neighboring genes, the pax6 ocular development gene and the wilms tumor gene (wt1), result in aniridia and wilms tumor, respectively. peter anomaly is an anterior segment dysgenesis in which there is abnormal development of the anterior chamber. case report a 6-day-old infant boy was evaluated for bilateral corneal opacities. his prenatal history was uneventful with spontaneous vaginal delivery at 36 weeks gestation. the right eye had a central white corneal opacity, which extended to the limbus from 4 o'clock to 7 o'clock. there were 360 degrees of iris hypoplasia with iris vessels visible. there was an area of iridocorneal adhesion inferiorly. the anterior chamber was shallow. the horizontal and vertical corneal diameters were 8.8 mm. there was a nuclear cataract visible behind the corneal opacification. the left eye had denser central corneal opacification. there were 360 degrees of iris hypoplasia with a vascular ring at the poorly formed pupillary margin. the anterior chamber was noted to be shallow, especially inferiorly with an area of irido-corneal adhesions. a dense nuclear and cortical cataract was noted. the corneal diameters were 9.0 mm vertical and 10.5 mm horizontal. the intraocular pressure measured with a handheld applanation tonometer (tono-pen: bio-rad, santa ana, ca, usa) varied from 18 to 22 mm of hg in both eyes. b-scan ocular echography found bilateral lenticular opacities and attached retinas. systemic examination revealed bilateral undescended testicles. abdominal sonography showed normal kidneys. family history was unremarkable. genetic testing revealed a deletion on chromosome 11p11.2-13. bilateral (non-simultaneous) penetrating keratoplasties with lensectomy were performed. a second corneal graft was performed in each eye after about one year. glaucoma developed in the right eye, with subsequent retinal detachment, and corneal graft failure. the graft in the left eye remained clear at 6 years of age. in addition, quarterly sonograms of the abdomen were conducted. a computed tomography (ct) scan of the abdomen and pelvis at age 2 years demonstrated a 2.0¥1.8¥2.4 cm mass in the mid pole of the left kidney leading to the diagnosis of wilms tumor, which was successfully excised. the pathology was consistent with a stage i wilms tumor, and was negative for tumor-specific loss of heterozygosity. furthermore, over time, he was noted to have moderate developmental delay with learning disability and attention deficit hyperactivity disorder (adhd). discussion the occurrence of wagr syndrome with peter anomaly has been reported in three other patients to our knowledge. these were a 2-month-old boy with the peter anomaly and deletion of 11p13 who did not have wilms tumor,1 a 6-day-old boy with the peter anomaly and a wilms tumor (chromosomal analysis was not performed)2 and a 1-month-old boy with deletion on chromosome 11p13-15.1 with an anomalous anterior segment and microphthalmos with bilateral wilms tumors developing at the age of 3 years.3 our case of peters anomaly plus wilms tumor presents further evidence of an association of wagr syndrome and peter anomaly. wagr syndrome (omim 194072) was first described by miller, et al.4 and is an extensively studied contiguous gene syndrome. children with wagr syndrome invariably have a germline chromosomal deletion at 11p of variable size, but always affecting wt1 and pax6 genes, both on band 13 (11p13).5 aniridia occurs sporadically or as an autosomal dominant inherited condition. one-third of patients with sporadic aniridia will be found to have wagr syndrome.6 the pax6 gene, involved in ocular embryogenesis, has been identified as a candidate gene for aniridia. therefore, it is reasonable that ocular anomalies other than aniridia might result from a deletion in the pax6 gene. the second gene in this region is the wt1 gene (wilms tumor gene). individuals who have a deletion in this gene have an increased risk for developing wilms tumor as well as having abnormal genitalia. their risk of having wilms tumor is around 45-57%.7,8 90% of wilms tumors present by the age of 4 years and 98% by the age of 7 years. screening for wilms tumor includes ultrasound every three months during this period. there is also approximately a 40% chance of renal problems, including renal failure in late adolescence in children with wagr and wilms tumor.9 the associated genitourinary findings include cryptorchidism present in nearly 60% of the cases,8 hypospadias, micropenis and other urinary tract abnormalities (also caused by wt1 gene deletions). peter anomaly is an anterior segment dysgenesis in which abnormal cleavage of the anterior chamber occurs. mutations may involve the pax6 gene.9,10 with reported cases of peter anomaly and aniridia.11,12 though churchill, et al. found no such association.13 peter plus syndrome is characterized by genitourinary abnormalities, syndactyly, brachycephaly, and cardiac, neural, and hearing abnormalities. since the pax6 gene is also involved in the development of the central nervous system, a wide variety of neurological, behavioral, and psychiatric abnormalities can also be present.8 references 1. hanson im, fletcher jm, jordan t, et al. mutations at the pax6 locus are found in eye reports 2011; volume 1:e4 correspondence: rohit adyanthaya, stony brook university, hsc l-2, rm 152, stony brook, new york 11768, usa. e-mail: rohiteyedoctor@gmail.com key words: wagr syndrome, peter anomaly. received for publication: 9 april 2011. accepted for publication: 31 july 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright r.s. adyanthaya and m.x. repka., 2011 licensee pagepress, italy eye reports 2011; 1:e4 doi:10.4081/eye.2011.e4 non -co mmerc ial us e o nly [eye reports 2011; 1:e4] [page 11] heterogeneous anterior segment malformations including peters' anomaly. nat genet 1994;6:168-73. 2. eiferman ra. association of wilms' tumor with peters' anomaly. ann ophthalmol 1984;16:933-4. 3. kawase e, tanaka k, honna t, azuma n. a case of atypical wagr syndrome with anterior segment anomaly and microphthalmos. arch ophthalmol 2001;119:18556. 4. miller rw, fraumeni jf jr, manning md. association of wilms tumor with aniridia, hemihypertophy and other congenital malformations. n engl j med 1964;270:922-7. 5. crolla ja, cawdery je, oley ca, et al. a fish approach to defining the extent and possible clinical significance of deletions at the wagr locus. j med genet 1997;34: 207-12. 6. ivanov i, shuper a, shohad m, et al. aniridia: recent achievements in clinical practice. eur j pediatr 1995;154:795-800. 7. muto r, yamamori s, ohashi h, osawa m. prediction by fish analysis of the occurrence of wilms tumor in aniridia patients. am j med genet 2002;108:285-9. 8. fischbach bv, trout kl, lewis j, et al. wagr syndrome: a clinical review of 54 cases. pediatrics 2005;116:984-8. 9. breslow ne, collins aj, ritchey ml, et al. end stage renal disease in patients with wilms tumor: results from the national wilms tumor study group and the united states renal data system. j urol 2005; 174:1972-5. 9. azuma n, yamaguchi y, handa h, et al. missense mutation in the alternative splice region of the pax6 gene in eye anomalies. am j hum genet 1999;65:65663. 10. sawada m, sato m, hikoya a, et al. a case of aniridia with unilateral peters anomaly. j aapos 2011;15:104-6. 11. mayer um. peters' anomaly and combination with other malformations (series of 16 patients). ophthalmic paediatr genet 1992;13:131-5. 12. koster r, van balen at. congenital corneal opacity (peters' anomaly) combined with buphthalmos and aniridia. ophthalmic paediatr genet 1985;6:241-6. 13. churchill aj, booth ap, anwar r, markham af. pax 6 is normal in most cases of peters' anomaly. eye (lond) 1998;12:299303. case reports non -co mmerc ial us e o nly [page 1] correspondence: conflict of interest: the authors report no conflicts of interest. olya pokrovskaya, mbbchbao contributions: all authors contributed equally. department of ophthalmology accepted for publication: february, 2018 mater miscericordiae university hospital this work is licensed under a creative commons attribution dublin, ireland non-commercial 3.0 license (cc by-nc 3.0). e-mail: olya.pokrovskaya@gmail.com ©copyright pokrovskaya et al., 2018. phone: 353-87-6149912 licensee ophthoscience publishers, usa [page 2] [page 3] [page 4] [page 5] [page 6] correspondence: conflict of interest: the authors report no conflicts of interest. mete güler, md contributions: all authors contributed equally. department of ophthalmology accepted for publication: april 1, 2014 adiyaman university school of medicine this work is licensed under a creative commons attribution 02040 adiyaman, turkey non-commercial 3.0 license (cc by-nc 3.0). email: meteglr@yahoo.com ©copyright jimenez et al., 2014. phone: +90 04162233800 licensee ophthoscience publishers, usa fax: +90 04162231690 hrev_master [page 34] [eye reports 2011; 1:e11] the use of ocular coherence tomography in evaluating optic nerve health in eyes with large disc size guy a. weiss,1 gadi wollstein,2 lilly naveh,3 maya landoy-kalev,3 dan ga’aton,4 zvia burgansky-eliash3 1department of medicine, university at buffalo, buffalo, ny; 2university of pittsburgh medical center eye center, eye and ear institute, ophthalmology and visual science research center, department of ophthalmology, university of pittsburgh school of medicine, pittsburgh, pennsylvania, usa; 3edith wolfson medical center; 4rabin center, department of ophthalmology, sackler faculty of medicine, tel aviv university, tel aviv, israel abstract large discs are often associated with large cups; in order to exclude glaucomatous cupping a good objective tool is needed. the purpose of this study is to evaluate ocular coherence tomography (oct) optic nerve head (onh) parameters as indicators of ocular health in subjects with large discs. eighty-one eyes of 53 healthy patients were evaluated; 46 eyes had large discs (disc area ≥2.6 mm2) and 35 eyes had regular size discs (disc area <2.6 mm2). all subjects underwent oct. all onh parameters were documented, including vertical integrated rim area (vira), horizontal integrated rim width (hirw), rim area, cup area, cup-to-disc (cd) area ratio, horizontal cup to disc ratio (hcdr), vertical cup to disc ratio (vcdr), cup area topography, and cup volume. in addition, oct retinal nerve fiber layer (rnfl) global mean thickness and four quadrants mean thicknesses were analyzed. all cup parameters were significantly higher in the large disc group compared to the normal disc group. the parameters estimating the rim varied between the groups: in the large disc group vira was significantly lower while hirw was significantly higher, compared to the control group. rim area was the only parameter with similar values in both groups (1.52±0.24 mm2 and 1.6±0.3 mm2 in the large and regular disc groups, respectively). correlation analysis revealed significant positive association between disc area and cup parameters in the large disc group. in contrast, in the regular disc group, disc area was positively associated with rim parameters. rim area might serve as an indicator for ocular health in large discs with large cups. introduction ocular coherence tomography (oct) is a reliable tool for diagnosing and following patients with glaucoma.1-3 glaucoma is characterized by a gradual loss of retinal ganglion cells and thinning of the retinal nerve fiber layer4,5 leading to a typical increase in the cupto-disc (cd) ratio. peripapillary circumferential retinal nerve fiber layer (rnfl) scans and radial optic nerve head (onh) scans have similar accuracy for glaucoma detection. the best onh parameters for discriminating between healthy and glaucomatous discs in different studies were: rim area,3 vertical cup to disc ratio (vcdr),1 and cd area ratio (please see appendix for definitions of cup and disc measurement terminology).2 unfortunately, there is no available normative database for the onh scans in the commonly used stratusoct instrument (carl zeiss meditec, inc. dublin, ca, usa); therefore it is not possible to assess individual patients’ values. large discs might have large cups and increased cd area ratio without an accompanying thinning in rnfl. moreover, histological studies in primates and humans demonstrated an increase in the number of nerve fibers with the increase in disc area.6,7 yet in humans, the larger disc size was associated with a decrease in nerve fiber density per disc area, since the fibers have a larger area through which to cross.7 the effect of large onh on rnfl thickness is controversial. it has been suggested that the peripapillary rnfl thickness is greater closer to the onh.8 when measuring rnfl around a large disc with fixed-diameter oct protocol, the rnfl thickness is overestimated and pathological thinning might be overlooked. savini, et al. demonstrated that an increase in disc size is associated with an increase in rnfl measurements using a fixed-diameter oct protocol scan.9 rnfl thickness decrease with increasing scan radii was also demonstrated by carpineto, et al.10 another study using rnfl in a constant distance from the onh rim, and not the standard fixed-diameter scan, found thinner rnfl in larger discs.11 other studies did not find such a correlation between the circumpapillary rnfl measurement placement and disc size.12 in this study we aim to evaluate oct onh parameters as indicators of eye health in subjects with large discs. materials and methods eighty-one eyes of 54 healthy subjects were evaluated in this retrospective crosssectional study in two separate cohorts. forty-six eyes of consecutive eligible subjects with large discs imaged at the edith wolfson medical center (holon, israel) were recruited to the large disc size group. thirty-five eyes of consecutive eligible subjects with normal disc size imaged at the university of pittsburgh medical eye center (pittsburgh, pa, usa) were recruited to the control group. the definition of a large disc was established by the disc area measurement obtained by oct according to previously published data in healthy subjects.13-15 all discs with area larger than 2.6 mm2 (mean area +1 standard deviation) were considered to be large discs, while the control group had disc areas under 2.6 mm2 this study was approved by the institutional review board (irb) / ethics committee at both institutions and adhered to the declaration of helsinki and health insurance portability and accountability act (hipaa) regulations. informed consent was obtained from all participants. in both groups, all subjects denied ocular complaints or diseases, had intraocular pressure of less than 22 mmhg, normal anterior segments on slit lamp exam, normal discs and maculae, reliable normal visual fields in both eyes, and normal mean rnfl thicknesses in both eyes. exclusion criteria were refractive error > ± 6 d (spherical equivalent), peripapillary atrophy, and any eye pathology or previous eye surgery except for uncomplicated cataract extraction. all subjects were scanned after pupillary dilatation with the time-domain oct, the stratusoct (software version 4.0; carl zeiss meditec, inc. dublin, ca, usa), by experienced operators. oct measurements of the onh were generated with the fast optic disc acquisition protocol of six total radial scans 6 mm in length in a spoke pattern configuration ceneye reports 2011; volume 1:e11 correspondence: zvia burgansky eliash, department of ophthalmology, wolfson medical center, p.o. box 5, holon 58100, israel. tel. +972.3.5028469 fax: +972.3.5028133. e-mail: zviaeb@gmail.com key words: ocular coherence tomography, optic nerve head, large discs. received for publication: 11 may 2011. revision received: 5 october 2011. accepted for publication: 18 october 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright g.a. weiss et al., 2011 licensee pagepress, italy eye reports 2011; 1:e11 doi:10.4081/eye.2011.e11 non -co mmerc ial us e o nly [eye reports 2011; 1:e11] [page 35] tered on the onh, evenly spaced 30 degrees apart. each radial scan included 128 a-scans. qualified scans had signal strength of at least 6. the oct defined the onh margin automatically as the end of the retinal pigment epithelium. the generated image was manually corrected in case the oct did not recognize accurately the onh margin. the rate of images that were manually adjusted was not recorded; previous studies reported manual adjustment of disc margin in 50-60% of cases.9,16 all onh parameters were documented, including vira, hirw, rim area, cup area, cd area ratio, hcdr, vcdr, cup area topography (using an offset of 150 microns), and cup volume (using an offset of 150 microns). in addition, oct rnfl global mean thickness and four quadrant mean thicknesses were analyzed. statistical analysis was performed to determine the differences in mean values of onh parameters between the two groups, using the general linear model (glm). the number of eyes was included in the linear model in order to control for the use of both eyes in some patients. in each model, diagnosis and sex were included as fixed factors. correlation analysis was used to determine the association between rim and cup parameters to disc area, in both groups. significance was set as a p value of less than 0.05. results the study population characteristics are summarized in table 1. there were no age differences between the two study groups. all subjects were caucasians. there were more female subjects in the large disc group than in the control group (p=0.03). the average disc area in the large disc group was 3.01 mm2 (range 2.6-3.7) while the average disc area in the control group was 2.05 mm2 (range 1.5-2.5, p<0.01). the various average onh parameters provided by the oct in the two groups are shown in table 2. all cup parameters were significantly higher in the large disc group compared to the control group. the parameters estimating the rim varied between the groups: in the large disc group, vira was significantly lower while hirw was significantly higher, compared to the control group. the only parameter that did not vary between the groups was the rim area, with a value of 1.52 ± 0.24 mm2 in the large disc group and 1.6 ± 0.3 mm2 in the control group (p=0.15). in the large disc group, a significant correlation was demonstrated between all cup parameters and disc area (cup area: r=0.75, p<0.01, cd area ratio: r=0.48, p=0.001, hcdr: r=0.34, p=0.02, vcdr: r=0.495, p<0.01, cup area topography: r=0.56, p<0.01, and cup volume: r=0.36, p=0.001, figure 1). on the other hand, in this group, no significant correlation was demonstrated between any of the rim parameters and the disc area (figure 2). in the regular disc size group, a significant association with disc area was evident only in cup area (r=0.34, p=0.04) and cup volume (r=0.35, p=0.04) but not in the other cup parameters (figure 3). in this group, 2 of 3 rim parameters were significantly correlated with disc area: hirw (r=0.57, p<0.01) and rim area r=0.54, p=0.001 (figure 4). we found a trend of correlation (p=0.07, r=0.3) between the disc area and the mean rnfl in the control group but not in the large disc group or the two groups combined. the quadrant rnfl data did not correlate to the disc area in any of the groups. discussion disc size varies significantly in healthy subjects with ophthalmoscopically-measured disc area ranging between 0.8 and 6 mm2.17 subjects with large discs and large cups are often referred to glaucoma clinics with suspected glaucoma by optic nerve appearance. it is known that in a large disc, a large cup is also expected.6,18 nevertheless, a good objective tool is needed to differentiate between physiological large cups in large discs and glaucomatous large optic nerves. measuring circumferential rnfl with fixed-diameter oct protocol may be misleading in these cases because of closer approximation to the onh edge, which gives artificially higher values.8 in this study we found that while all onh parameters varied between subjects with regular disc size and those with large disc and large cups, rim area had similar values in both groups. there are three different rim parameters derived from the onh scan: vira, hirw and rim area, each behaved differently when the two study groups were compared. vira estimates the total volume of rim tissue, as defined previously. in this study we found a significantly lower value in the large disc group, suggesting the discs in this group were shallower. hirw estimates the total area of rim tissue, as defined previously. interestingly, the value of hirw was significantly higher in the large disc group compared to the controls, implying that the rim in this group is thicker, as was found in histology studies.7,18 in contrast to the vira and hirw, the rim area parameter, as defined previously, had similar values in both groups. we did find that in the large discs, all 6 parameters describing the cup and cd area ratio are larger, as described by previous histology studies that found larger article table 2. optic nerve head mean parameters. large disc regular disc p* (mean ± sd) (mean ± sd) vertical integrated rim area (vira, mm3) 0.25±0.01 0.41±0.18 <0.0001 horizontal integrated rim width (hirw, mm2) 1.76±0.16 1.64±0.19 0.003 rim area (mm2) 1.52±0.24 1.60±0.30 0.15 cup area (mm2) 1.49±0.37 0.45±0.27 <0.0001 cd area ratio 0.49±0.01 0.21±0.12 <0.0001 horizontal cd ratio (hcdr) 0.72±0.008 0.46±0.14 <0.0001 vertical cd ratio (vcdr) 0.66±0.01 0.43±0.13 <0.0001 cup area topography (mm2) 1.32±0.37 0.76±0.62 <0.0001 cup volume (mm3) 0.33±0.14 0.009±0.01 <0.0001 the mean value of the onh parameters in each group and the p value of comparison. onh, optic nerve head; cd, cup to disc; *independentsample two-tailed t-test. table 1. demographic and clinical characteristics of the study population. large disc regular disc p n eyes (pts) 46 (25) 35 (28) age (yrs) 55.1±12.6 54.4±19.4 0.86* female / male 31/15 15/20 0.03° disc area (mm2) 3.02±0.26 2.05±0.26 <0.0001* rnfl (µm) 99.09±9.1 96.24±9.73 0.18* superior rnfl (mm) 121±11.8 117±17.3 0.26* nasal rnfl (mm) 80±13.2 79±14.5 0.89* inferior rnfl (mm) 126±16.8 120±16.1 0.11* temporal rnfl (mm) 70±12.3 69±11.5 0.62* a comparison of patients’ characteristics between the study groups. rnfl, retinal nerve fiber layer; *independent-sample two-tailed t-test; °chi-square tests. non -co mmerc ial us e o nly [page 36] [eye reports 2011; 1:e11] cup area in larger discs.6,18 moreover, in large discs, we found a positive correlation between the cup parameters and disc area, while such association was not found with rim parameters. thus, when passing a certain threshold of disc size, further enlargement of the disc directly influences the cup size while rim magnitude does not increase. on the other hand, in disc area range under 2.6 mm2, as the disc is getting bigger, rim size increases while most cup dimensions are not influenced. indeed, a recent large scale study with subjects who had a wide range of disc sizes (average 2.27 mm2) found correlations between disc area and the same parameters as seen in the regular disc group in our study.14 rim area was found to be similar in the entire cohort of healthy discs in our study, whether large or normal in size (1.52±0.24 mm2 and 1.6±0.3 mm2, respectively) as was previously demonstrated using the heidelberg retinal tomography, hrt (heidelberg engineering, inc., carlsbad, ca, usa).19 this parameter was also found to be a reliable indicator of glaucomatous optic neuropathy. the area under the receiver operating curve (aroc) for discrimination between healthy and glaucomatous eye in different publications was 0.92 to 0.97 with average values of 0.84±0.31 mm2 in wollstein, et al.3 and 0.89±0.34 mm2 in naithani, et al.13 in the glaucomatous population. this data from the literature further supports the role of rim area parameter as an important indicator for disc health. the lack of correlation between rnfl measurements and disc size in the large disc group may have resulted from inhomogeneity of the discs characteristics. two possible and contradicting factors may influence the rnfl thickness measurement with a fixed-diameter scan circle in large discs. the first factor is the shorter distance from the onh rim which increases the thickness,9,10 and the second factor is the thinner overall rnfl thickness in these discs.7,11 as these factors are opposed, the net correlation in a group may vary. one potential limitation of this study is the exclusive inclusion of caucasian subjects. subjects from african ancestry present higher prevalence of large discs, when compared with caucasian patients,14 therefore further investigation is warranted in this population. another possible limitation results from a higher prevalence of female participants in the large disc group, although we controlled for sex bias in the statistical analysis we conducted. we did not perform sample size calculations, thus the lack of difference in rim area could result from insufficient study cohort, although differences in other onh parameters were highly significant. another limitation is the lack of axial length comparison between the groups, article figure 1. correlation of cup parameters with disc area in the large disc group. in the large disc group, a significant correlation was demonstrated between all cup parameters and disc area. figure 2. correlation of rim parameters with disc area in the large disc group. in the large disc group, no significant correlation was demonstrated between any of the rim parameters and the disc area. figure 3. correlation of cup parameters with disc area in the control group. in the regular disc group, a significant association with disc area was not evident in most cup parameters except for the cup area and cup volume. figure 4. correlation of rim parameters with disc area in the control group. in the regular disc group, 2 of 3 rim parameters were significantly correlated with disc area (hirw and rim area). non -co mmerc ial us e o nly [eye reports 2011; 1:e11] [page 37] despite exclusion of subjects with high refractive errors. the axial length was found to be inversely correlated to the disc size20 and should be included in future studies. a possible bias is a selection bias of large cups among the large disc cohort, since these subjects were referred to the clinic with suspicious discs, yet this served to answer the clinical question. our findings may have significant implications on the clinical use of oct. rim area might serve as an indicator for disc health in large discs. these findings need to be further explored in subjects with large discs who have glaucoma. appendix the stratusoct provides several calculated values. the vertical integrated rim area (vira) is a measure of the total volume of the retinal nerve fiber layer within the rim that is calculated by the stratusoct using the product of the disc circumference and average of 6 individually-calculated sectional rim areas (in each of the 6 spokes). the horizontal integrated rim width (hirw) is a measure of the total rim area that is calculated by the stratusoct using the product of the disc circumference and average of 6 individually-calculated sectional rim widths (in each of the 6 spokes) rather than rim areas. the rim area is the area of the cup subtracted from the area of the disc, calculated from a flattened planimetric image of the disc in axis with the pupil. the cup area also is calculated from a flattened planimetric image of the disc in axis with the pupil. the horizontal cup to disc ratio (hcdr) is the ratio of longest horizontal line across the flattened planimetric ring image of the cup calculated from cross-sectional 3-dimentional data along 6 axes (in each of the 6 spokes) to the longest horizontal line across the flattened planimetric image of the disc calculated from cross-sectional 3-dimentional data along 6 axes (in each of the 6 spokes), whether or not these two horizontal lines overlap. the vertical cup to disc ratio (vcdr) is the ratio of longest vertical line across the flattened planimetric image of the cup calculated from cross-sectional 3dimentional data along 6 axes (in each of the 6 spokes) to the longest vertical line across the flattened planimetric image of the disc calculated from cross-sectional 3-dimentional data along 6 axes (in each of the 6 spokes), whether or not these two vertical lines overlap. the cup area topography is the calculated cup area based on the 3-dimentional topography of the cup obtained along 6 axes (in each of the 6 spokes) using a fixed standard offset which is often 150 microns. the cup volume is the calculated cup area based on the 3-dimentional topography of the cup obtained along 6 axes (in each of the 6 spokes) using a fixed standard offset, which is often 150 microns. references 1. manassakorn a, nouri-mahdavi k, caprioli j. comparison of retinal nerve fiber layer thickness and optic disk algorithms with optical coherence tomography to detect glaucoma. am j ophthalmol 2006;141:105-15. 2. medeiros fa, zangwill lm, bowd c, et al. use of progressive glaucomatous optic disk change as the reference standard for evaluation of diagnostic tests in glaucoma. am j ophthalmol 2005;139:1010-8. 3. wollstein g, ishikawa h, wang j, et al. comparison of three optical coherence tomography scanning areas for detection of glaucomatous damage. am j ophthalmol 2005;139:39-43. 4. sommer a, miller nr, pollack i, et al. the nerve fiber layer in the diagnosis of glaucoma. arch ophthalmol 1977;95:2149-56. 5. harwerth rs, carter-dawson l, shen f, et al. ganglion cell losses underlying visual field defects from experimental glaucoma. invest ophthalmol vis sci 1999;40:224250. 6. quigley ha, coleman al, dormanpease me. larger optic-nerve heads have more nerve-fibers in normal monkey eyes. arch ophthalmol 1991;109:1441-3. 7. jonas jb, schmidt am, muller-bergh ja, et al. human optic nerve fiber count and optic disc size. invest ophthalmol vis sci 1992;33:2012-8. 8. gabriele ml, ishikawa h, wollstein g, et al. peripapillary nerve fiber layer thickness profile determined with high speed, ultrahigh resolution optical coherence tomography high-density scanning. invest ophthalmol vis sci 2007;48:3154-60. 9. savini g, zanini m, carelli v, et al. correlation between retinal nerve fibre layer thickness and optic nerve head size: an optical coherence tomography study. br j ophthalmol 2005;89:489-92. 10. carpineto p, ciancaglini m, aharrh-gnama a, et al. custom measurement of retinal nerve fiber layer thickness using stratus oct in normal eyes. eur j ophthalmol 2005;15:360-6. 11. savini g, barboni p, carbonelli m, zanini m. the effect of scan diameter on retinal nerve fiber layer thickness measurement using stratus optic coherence tomography. arch ophthalmol 2007;125:901-5. 12. kaushik s, pandav ss, ichhpujani p, gupta a. fixed-diameter scan protocol preferable for retinal nerve fibre layer measurement by optical coherence tomography in all sizes of optic discs. br j ophthalmol 2009;93:895-900. 13. naithani p, sihota r, sony p, et al. evaluation of optical coherence tomography and heidelberg retinal tomography parameters in detecting early and moderate glaucoma. invest ophthalmol vis sci 2007;48:3138-45. 14. marsh bc, cantor lb, wudunn d, et al. optic nerve head (onh) topographic analysis by stratus oct in normal subjects: correlation to disc size, age, and ethnicity. j glaucoma 2010;19:310-8. 15. schuman js, wollstein g, farra t, et al. comparison of optic nerve head measurements obtained by optical coherence tomography and confocal scanning laser ophthalmoscopy. am j ophthalmol 2003; 135:504-12. 16. iliev me, meyenberg a, garweg jg. morphometric assessment of normal, suspect and glaucomatous optic discs with stratus oct and hrt ii. eye (lond) 2006;20:1288-99. 17. jonas jb, budde wm, panda-jonas s. ophthalmoscopic evaluation of the optic nerve head. surv ophthalmol 1999;43:293320. 18. jonas jb, gusek gc, naumann go. optic disc, cup and neuroretinal rim size, configuration and correlations in normal eyes. invest ophthalmol vis sci 1988;29:1151-8. 19. min kh, seong gj, hong yj, kim cy. optic nerve head topographic measurements and retinal nerve fiber layer thickness in physiologic large cups. korean j ophthalmol 2005;19:189-94. 20. savini g, barboni p, parisi v, carbonelli m. the influence of axial length on retinal nerve fibre layer thickness and optic-disc size measurements by spectral-domain oct. br j ophthalmol 2011. [epub ahead of print]. article non -co mmerc ial us e o nly correspondence: conflict of interest: the authors report no conflicts of interest. logandran vijaya kuma contributions: lvk prepared the case report and vghm supervised, department of ophthalmology edited the manuscript, and provided interpretation. raja permaisuri bainun hospital accepted for publication: april 1, 2014 30990, ipoh, perak, malaysia this work is licensed under a creative commons attribution email: drlogan2008@hotmail.com non-commercial 3.0 license (cc by-nc 3.0). phone: +60124205582 ©copyright kumar, et al., 2014. fax: +6052531541 licensee ophthoscience publishers, usa hrev_master [eye reports 2012; 2:e2] [page 7] eye reports 2012; volume 2:e2 late onset post-lasik keratectasia with reversal and stabilization after use of latanoprost and corneal collagen cross-linking aleksandar stojanovic,1,2 xiangjun chen,2 linyan zheng,3 yile xu,3 filip stojanovic,2 tor paaske utheim2 1eye department, university hospital of north norway, tromsø, norway; 2synslaser kirurgi as, tromsø/oslo, norway; 3school of ophthalmology and optometry and eye hospital, wenzhou medical college, wenzhou, zhejiang, china abstract we report a case of late onset keratectasia after laser in situ keratomileusis (lasik) and its quick reversal and stabilization after use of latanoprost and riboflavin/ultraviolet-a corneal collagen cross-linking (cxl). a 39-year-old man with normal intraocular pressure developed a rapid deterioration of vision in his left eye 6 years after lasik-retreatment for high myopic astigmatism. keratectasia was diagnosed by corneal topography and ultrasound pachymetry. after two months of treatment with latanoprost and a minor intraocular pressure reduction, uncorrected distance visual acuity improved from 20/100 to 20/20 and corneal topography showed reversal of keratectasia. cxl was performed after the reversal to achieve long-term stabilization. at 1, 3, 6, 13 and 39 months followup exams after the cxl, stable vision, refraction, and topography were registered. this case shows that keratectasia may rapidly occur several years after lasik and that a quick reversal and stabilization may be achieved by use of latanoprost followed by cxl. introduction although several risk factors for keratectasia after laser in situ keratomileusis (lasik) have been identified and screening techniques continue to improve, post-lasik keratectasia still occurs.1 a case of transient post-lasik keratectasia associated with a marked elevation of intraocular pressure (iop), where the keratectasia subsided promptly after iop normalization, has previously been reported.2 the current study reports a case of late onset postlasik-keratectasia associated with normal iop, where reversal of keratectasia occurred after only minor iop reduction after use of latanoprost. collagen cross-linking (cxl) was subsequently used to successfully stabilize the result. case report a 39-year-old male truck driver underwent uneventful bilateral lasik in october 2001. the patient had no previous history of eye rubbing, trauma, atopy, or any eye disease. no family history of keratoconus was reported. his corrected distance visual acuity (cdva) before lasik was 20/16 in both eyes. for the right and the left eye the preoperative manifest refraction was -6.75-3.50¥156 and -6.75-5.00¥4, keratometry at orthogonal meridians within the central 3 mm was 44.40d /41.90d¥165° and 44.60d /41.20d¥7°. preoperative iop (measured by goldmann applanation tonometry, corrected for pachymetry) was 14 mmhg in both eyes. orbscan ii (b&l, rochester, ny, usa) corneal topography showed no morphological signs of increased risk for ectasia. the orthogonal asymmetry within the central 3 mm was 1.3d and 1.4 d and the highest point on posterior floating elevation map was 35 and 37 microns for the right and left eye, respectively. central corneal thickness measured by ultrasonic pachymetry (corneo-gage plus, sonogage inc., cleveland, oh, usa) was 586 microns and 593 microns, and the planned ablation depth was 128 microns and 135 microns, for the right and the left eye respectively. emmetropia within the optical zone of 5.5 mm, and transition zone of 6.5 mm was attempted. the planned flap thickness was 160 microns, leaving the minimal planned residual stroma at 298 microns in both eyes. hansatome (b&l, rochester, ny, usa) microkeratome with a 160-micron head and an 8.5 mm ring was used on both eyes. intraoperative flap thickness, as measured by subtraction pachymetry, was 146 and 158 microns in the right and the left eye, respectively. lasersight, astrascan (lasersight, orlando, fl, usa), 200 hz, 1 mm flying-spot laser was used for the ablation. correspondence: aleksandar stojanovic, fløyvn. 32, 9020 tromsdalen, norway. tel. + 47.9069.3319 fax: + 47.7764.7929. e-mail: aleks@online.no key words: keratectasia, lasik complication, cxl. contributions: the authors contributed equally. conflicts of interests: the authors have no potential conflicts of interests. received for publication: 1 january 2012. revision received: 1 january 2012. accepted for publication: 14 january 2012. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright a. stojanovic et al., 2012 licensee pagepress, italy eye reports 2012; 2:e2 doi:10.4081/eye.2012.e2 figure 1. anterior surface elevation map after the lasik-retreatment in 2002 (left), after the acute visual deterioration in 2007 (center) and the difference between the two, showing the anterior surface protrusion (right). non -co mmerc ial us e o nly after the initial surgery, the patient’s uncorrected distance visual acuity (udva) was 20/65 in both eyes, with cdva of 20/20 in both eyes, corrected with -2.00-1.25¥175 and -1.501.00¥170. the central ultrasound pachymetry was 505 and 502 microns for the right and the left eye, respectively. retreatment using the flap re-lift technique aiming at emmetropia was performed in january 2002. the ablation depth of the retreatment was 49 and 39 microns and the calculated minimal residual stromal thickness was 296 and 303 microns for the right and the left eye, respectively. after the retreatment, the patient achieved udva of 20/20 in both eyes and there were no signs of keratectasia on orbscan ii topography at the follow-up exam 3 months after the surgery. at that point the ultrasound central corneal pachymetry was 463 and 470 microns, and the highest point on the posterior floating elevation map was 43 and 45 microns for the right and left eye, respectively. the patient reported five years of stable and good vision until november 2007, at which point he experienced an acute and progressive worsening in his left eye, which could not be corrected with spectacle glasses or soft contact lenses. on examination performed on december 12, 2007, udva was 20/25 and 20/100, with cdva 20/20 and 20/60, corrected with -0.25-0.50¥180 and -1.00-1.50¥145, for the right and the left eye respectively. right eye showed unremarkable clinical and topography findings. orbscan ii topography analysis of the left eye revealed signs of keratectasia, showing protrusion on the anterior elevation map (figure 1), as well as the maximum height on the posterior floating elevation map of 85 microns (figure 2, center), coinciding with the point of the minimal corneal thickness of 410 microns. keratometric map showed an irregular astigmatism with 3.1 d of asymmetry within the central 3 mm. iop (corrected for pachymetry) was 14 mmhg. central ultrasound pachymetry was 435 microns. treatment with latanoprost (xalatan®, pfizer inc, new york, ny, usa) once daily was initiated at this time. according to the patient and the local optometrist, his udva improved dramatically within the following two weeks. at the followup examination 2 months after the onset of treatment with latanoprost (february 11, 2008), udva and cdva of the left eye improved to 20/20 and only a minor manifest refractive error remained. orbscan ii anterior surface analysis showed the regression of the protrusion (figure 3), while the posterior elevation decreased to 55 microns (figure 2, right). keratometric map showed a decrease of the irregular astigmatism within the central 3 mm to 1.5 d. the iop showed a slight decrease to 11 mmhg. on the same day, latanoprost was discontinued and cxl, with 0.1% riboflavin/dextran solution and 365 nm ultraviolet-a (uva) irradiation with uva-illuminator (uv-x, iroc, zurich, switzerland), was performed according to the standard protocol.3 the 1-, 3-, 6-, 13and 39-months follow-up exams after cxl showed consistently stable udva of 20/20, stable refraction and no topographic signs of ectasia. discussion high-grade myopia and astigmatism as well as a history of retreatment are identified risk factors for post lasik keratectasia.4 in the current case keratectasia was topographically diagnosed by moderate protrusion of the anterior surface, marked increase of the height of the posterior elevation and increased asymmetry. the concurrent corneal thinning on ultrasound pachymetry followed the finding. guirao and colleagues explained the mechanism of keratectasia as the action of the iop on the weakened cornea.4,5 in our case, in contrast with the previously published case report where the keratectasia reversal occurred with reduction of elevated iop,2 the reversal coincided with only a minor reduction of normal case report [page 8] [eye reports 2012; 2:e2] figure 2. posterior floating elevation after the lasik-retreatment in 2002 (left) (45 microns), after the acute visual deterioration in 2007 (center) (85 microns) and after the treatment with latanoprost and collagen cross-linking (right) (55 microns). figure 3. anterior surface elevation map at the acute visual deterioration (left), after the treatment with latanoprost (center) and the difference between the two, showing the regression of the anterior surface protrusion (right). non -co mmerc ial us e o nly [eye reports 2012; 2:e2] [page 9] iop after use of latanoprost. atmospheric pressure, iop, and corneal biomechanical strength are factors known to affect the corneal shape and optics. the dynamic balance between these factors seems to be robust in healthy virgin corneas, unaffected by iop fluctuation in a relatively wide range.2 however, one may speculate that a sudden occurrence of keratectasia in the current case, followed by its reversal coinciding with use of latanoprost and a minor decrease of iop, may imply that the factors keeping the postlasik cornea stable may not be in a robustly balanced continuum, but rather in a fragile balance. hiatt and colleagues6 reported a case where iop reduction was used for reversal of lasikinduced keratectasia, but the ectasia recurred 3 months after discontinuation of the iopreducing medication. we chose to treat our patient with cxl rather than continuing the latanoprost, primarily to avoid the need for long-term medication. although a certain causality between the use of latanoprost and reversal of post-lasik keratectasia in the current case cannot be established, and the iop reduction may not always be effective, it shows that latanoprost may be used in an initial attempt to reverse keratectasia even in normotensive eyes, and that the reversal can be stabilized by use of cxl. references 1. binder ps, lindstrom rl, stulting rd, et al. keratoconus and corneal ectasia after lasik. j cataract refract surg 2005;31: 2035-8. 2. toshino a, uno t, ohashi y, et al. transient keratectasia caused by intraocular pressure elevation after laser in situ keratomileusis. j cataract refract surg 2005;31: 202-4. 3. wollensak g, spoerl e, seiler t. riboflavin/ultraviolet-a-induced collagen crosslinking for the treatment of keratoconus. am j ophthalmol 2003;135:620-7. 4. guirao a. theoretical elastic response of the cornea to refractive surgery: risk factors for keratectasia. j refract surg 2005; 21:176-85. 5. comaish if, lawless ma. progressive postlasik keratectasia; biomechanical instability or chronic disease process? j cataract refract surg 2002;28:2206-13. 6. hiatt ja, wachler bs, grant c. reversal of laser in situ keratomileusis-induced ectasia with intraocular pressure reduction. j cataract refract surg 2005;31:1652-5. case report non -co mmerc ial us e o nly [page 9] correspondence: conflict of interest: the authors report no conflicts of interest. benjamin d. aronson, parmd contributions: all authors contributed equally. department of pharmacy practice and pharm. sci. accepted for publication: april, 2019 university of minnesota college of pharmacy this work is licensed under a creative commons attribution 1100 kirby drive, duluth, mn 55812 non-commercial 3.0 license (cc by-nc 3.0). e-mail: arons071@d.umn.edu ©copyright aronson et al., 2019. phone: (218) 726-6067 licensee ophthoscience publishers, usa [page 10] [page 11] [page 12] [page 13] [page 14] [page 20] correspondence: conflict of interest: the authors report no conflicts of interest. ilaria biagini, co contributions: all authors contributed equally. neuromuscoskeletal department, eye clinic accepted for publication: may, 2018 university of florence this work is licensed under a creative commons attribution florence, italy non-commercial 3.0 license (cc by-nc 3.0). e-mail: ilaria.biagini55@gmail.com ©copyright biagini et al., 2018. phone: 39-339-60529 licensee ophthoscience publishers, usa [page 21] [page 22] hrev_master [eye reports 2012; 2:e1] [page 1] rhabdomyosarcoma mimicking lymphangioma: report of three cases silvana guerriero,1 lorenza ciracì,1 ermete giancipoli,1 maria grazia fiore,2 domenico piscitelli2 1department of ophthalmology; 2department of pathology, university of bari, italy abstract we report three cases of proptosis, in children aged 6, 10 and 12, whereby in all cases the first clinical, radiologic and ultrasonographic diagnosis was lymphangioma, while the final anatomopathological diagnosis was rhabdomyosarcoma. in presence of a rapidly worsening exophthalmos or eyelid swelling in a child, an early correct diagnosis is very important. imaging techniques play a very important role in the diagnosis, but are often inconclusive and an excisional biopsy (if feasible) must always be considered. introduction in presence of a rapidly worsening exophthalmos or eyelid swelling in a child, an early correct diagnosis is very important. differential diagnosis must include many orbital pathologies: inflammatory lesions such as orbital cellulitis, idiopathic inflammatory orbital pseudotumor, conjunctivitis, and allergic edema, and tumors such as orbital capillary hemangioma, lymphangioma, neuroblastoma, langerhan’s cell histiocytosis and rhabdomyosarcoma. the severity of these diseases is different, as well as the therapeutic intervention and course of the disease imaging techniques like computed tomography (ct), magnetic resonance imaging (mri) and ultrasonography play a very important role in the diagnosis, but are often inconclusive. between march 2007 and april 2008, three pediatric patients were admitted to our unit. in all three cases imaging findings suggested the diagnosis of a lymphangioma, but only an excisional biopsy led to a definitive diagnosis of rhabdomyosarcoma in all cases. case reports case #1 an otherwise healthy 6-year-old caucasian boy was referred to our unit for surgical removal of a presumed chalazion in the inferior right eyelid (figure 1a). due to rapid worsening of the eyelid swelling, we performed b-scan ultrasonography, which revealed a solid, well-defined mass with a medium-low internal reflectivity, low ultrasound attenuation and signs of internal vascularization (figure 1b). ct of the orbit showed a solid mass in the medial-inferior part of the orbit, that appeared homogeneous and hyperdense after contrast enhancement. the lesion infiltrated the orbital soft tissues but spared the orbital bones (figure 1c and 1d). a new diagnosis of orbital lymphangioma was suggested by radiologist. the patient underwent trans-eyelid excision of the mass (figure 2) under general anesthesia. the pathologic result was a solid variant of embryonal rhabdomyosarcoma; striated muscle fibers were evident between sheets of poorly differentiated round tumoral cells that showed hyperchromic nuclei and scarce cytoplasm (figure 3). chemotherapy with cyclophosphamide, actinomycin d and vincristine sulfate and successive radiotherapy (40 gy) were instituted. the child continued to demonstrate complete tumor regression at two years follow-up. he developed cataract as a late effect of the radiotherapy, and was successfully operated. his final visual acuity was 20/20. case #2 an otherwise healthy 10-year-old caucasian boy was referred to our unit with a one month history of exophthalmos in his left eye (figure 4a). orbital b-scan ultrasonography revealed a solid extraconic neoformation involving the medial segment of the left orbit, 2 cm across and 3.5 cm long, well-defined against the surrounding tissues, with a hyporeflective, dyshomogeneous internal reflectivity owing to the presence of septa (figure 4b). orbital ct scans revealed a well-defined lesion with clear margins in the medial segment of the left orbit, causing lateral displacement of the optic nerve and eye. the lesion showed several chambers, which were more evident after contrast enhancement (figure 4c). t2-weighted mri images disclosed irregular isointense tissue with an isointense peripheral rim and some central areas with hyperintense signal. on t1-weighted gadolinium-enhanced images the central area of the mass was hypointense. a peripheral hyperintense rim was evident, as well as thin septi dividing the central cystic area, but no fluid levels were present (figure 4d) these findings were suggestive of lymphangioma containing proteinaceus fluid or hemorrhage. since these findings were suggestive of lymphangioma containing proteinaceous fluid, watchful waiting seemed advisable but 15 days later, worsening of the proptosis made it necessary to perform an excisional biopsy (figure 5). we performed an anterior trans-eyelid excisional biopsy of the mass under general anesthesia. intraoperatively, a multicystic encapsulated pink mass with a whitish internal fluid was found. near-total excision of the mass was performed (figure 5). total excision of the mass was not possible because the mass extended posteriorly toward the orbital apex. these findings continued to suggest the diagnosis of a lymphangioma. however, the pathologic result was a solid alveolar rhabdomyosarcoma. histology showed sheets of poorly differentiated round tumoral cells with hyperchromic nuclei and scarce cytoplasm. several atypical mitoses were present (figure 6). chemotherapy with cyclophosphamide, actinomycin d and vincristine sulfate and successive radiotherapy (40 gy) were instituted. the child continued to demonstrate complete tumor regression at two years follow-up. he developed cataract as a late effect of the radiotherapy. his visual acuity is now 10/20. case #3 an otherwise healthy 12-year-old caucasian boy was referred to our unit with a 20-day history of eyelid edema (figure 7a). we performed b-scan ultrasonography, which revealed a poorly-defined extra-conic solid mass located in the anterior upper segment of the right orbit, 3.0 cm across, with minor alterations at ultrasound, and a medieye reports 2012; volume 2:e1 correspondence: silvana guerriero, università degli studi di bari, piazza g. cesare, 11, 70124 bari, italy. tel. +39.080.5478.7916 fax: +39.080.5478.918. e-mail: silvanaguerriero@gmail.com key words: rhabdomyosarcoma, lymphangioma, magnetic resonance imaging, computed tomography, sonography. conflict of interest: the authors declare no potential conflicts of interests. received for publication: 9 april 2011. revision received: 21 december 2011. accepted for publication: 22 december 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright s. guerriero et al., 2012 licensee pagepress, italy eye reports 2012; 2:e1 doi:10.4081/eye.2012.e1 non -co mmerc ial us e o nly [page 2] [eye reports 2012; 2:e1] um-low internal reflectivity (figure 7b). ct scans demonstrated a lobular non-encapsulated mass, featuring the same density as the extra-ocular muscles, well-defined against the surrounding soft tissues, with diffuse contrast enhancement (figure 7c and 7d). we performed an anterior trans-eyelid excisional biopsy of the mass under general anesthesia (figure 8). histology showed a cell population consisting of small, round tumor cells with hyperchromatic nuclei and of large, polygonal-shaped tumor cells with abundant eosinophilic cytoplasm, which often contained cross striations, alternating with areas of clubshaped tumor cells arranged in clumps and outlined by fibrous septa. in the center, the clusters were arranged loosely, and therefore, they appear in an alveolar pattern. these cells stained intensely with eosinophilic stain. cross-striated malignant rhabdomyoblasts were observed. the pathologic result was mixed embryonal and alveolar rhabdomyosarcoma (figure 9). chemotherapy with cyclophosphamide, actinomycin d and vincristine sulfate and successive radiotherapy (40 gy) was instituted. the child continued to demonstrate complete tumor regression at two years follow-up. he developed cataract as a late effect of the radiotherapy, and his visual acuity is now 10/20. in all three cases the subsequent histopathologic examination disclosed undifferentiated small round cells with hyperchromatic nuclei, a high nuclear-to-cytoplasmic ratio, and a brisk mitotic activity. immunohistochemistry demonstrated intense immunoreactivity to smooth muscle actin and desmin. these findings led to a definitive diagnosis of rhabdomyosarcoma in all three cases: a solid alveolar rhabdomyosarcoma in the first case, an embryonal rhabdomyosarcoma in the second, and a mixed embryonal and alveolar rhabdomyosarcoma in the last case. discussion in the presence of exophthalmos during examination in a child, the examiner must be extremely careful to differentiate between various pathologies with a different severity: inflammatory lesions such as orbital cellulitis, idiopathic inflammatory orbital pseudotumor, conjunctivitis, and allergic edema, and tumors such as orbital capillary hemangioma, lymphangioma, neuroblastoma, langerhan’s cell histiocytosis and rhabdomyosarcoma. most of these conditions can be differentiated by clinical history taking and examination, but orbital lymphangioma may prove to be more challenging to differentiate from rhabdomyosarcoma. important elements of differential diagnosis to consider during the orbital exam are: uni or bilateral exophthalmos, the type of progression, slow or rapid, the reducibility, and whether there is pulsatility. the orbital edge must be palpated to look for a mass; the presence of a palpebral redness or thickness orientates towards an orbital cellulitis or a rhabdomyosarcoma, modification of the eyelid colour when the child cries orientates towards a capillary haemangioma. a rapidly worsening bilateral exophthalmus, if associated with periorbital ecchymosis, is suggestive of a metastatic neuroblastoma, the most common malignant tumor in a child under the age of five. an orbital mass may be a metastasis of a primitive tumor (10% of cases) located in the retroperitoneal space or in the mediastinum or else a primitive adrenal tumor. a history of orbital pain or headache is more suggestive of an orbital cellulitis. the fundus oculi must be systematically inspected, looking for an optic oedema, optic atrophy, or choroid folds. other functional restrictions, in particular a reduction of visual acuity and a visual fields deficit, are quite difficult to determine, especially in a child. the physical examination is also very important: coffee and milk spots suggest recklinghausen’s disease. coloured lesions of the skin could also be present in other diseases, such as histiocytosis and capillary haemangioma. however, in presence of a rapidly worsening and painless exophthalmos, we must always suspect a rhabdomyosarcoma. rhabdomyosarcoma is a rare childhood tumor, with an annual incidence of 4.3 cases per million children.1 the orbit is the primary site in approximately 10% of these tumors.2 the most frequent clinical findings in patients with ophthalmic rhabdomyosarcoma are proptosis (79%), globe displacement (79%), eyelid edema (64%), and conjunctival congestion (61%).3 orbital lymphangioma is an uncommon benign cystic lesion generally manifesting in childhood. it accounts for about 1% of orbital tumors, with no gender preference.3 it usually presents with a slowly progressive proptosis, displacement of the globe, ptosis and restriction of eye movements. occasionally, focal lesions may remain asymptomatic. spontaneous intraorbital hemorrhage may cause acute proptosis, compressive optic neubrief report figure 1. a) swelling of the right inferior eyelid (arrow). b) b-scan ultrasonography revealed a solid, well defined mass, with low-medium internal reflectivity (arrow). c) and d) ct scans showed a solid mass in the medial-inferior part of the orbit (arrow). figure 2. excisional biopsy (arrow showing the mass). non -co mmerc ial us e o nly [eye reports 2012; 2:e1] [page 3] ropathy and loss of vision.4 rhabdomyosarcoma occurs in patients of the same age group as those with lymphangioma, and both diseases cause painless, noninflammatory proptosis, developing over a short time. differentiation by orbital imaging is usually helpful and shows a solid enhanced mass with rhabdomyosarcoma versus a multicystic non-enhanced mass with lymphangioma. however, in rare cases, rhabdomyosarcoma can display cavitation, appearing similar to lymphangioma.3 the differentiation between rhabdomyosarcoma and lymphangioma seems to be quite challenging because of the frequent overlap of both clinical and radiological aspects of these pathologies. only the histopathologic examination can confirm the diagnosis. many other similar cases have been reported in the literature (table 1): seedat et al. presented a patient with acute sinusitis whose ct scan showed a ringenhancing lesion within the orbit typical of an orbital subperiosteal abscess. on exploration of the orbit, there was no pus present but a tumour was found, which on histological examination was found to be a rhabdomyosarcoma.5 fetkenhour et al. described a healthy 4year-old girl who presented with an abruptonset proptosis of her right eye with a mild painless swelling of the right upper eyelid during the previous 3 weeks. mri showed a superonasal heterogeneous soft tissue mass with no bone erosion. on t1-weighted gadoliniumenhanced images, the central area of the mass was hypointense, suggestive of proteinaceous material. a peripheral hyperintense rim indicated vascularized tissue. there was a thin septum dividing the central cystic area, but fluid-fluid levels were not seen. diagnosis of lymphangioma was favored in light of the rapid development of proptosis, dilated conjunctival lymphatics, subcutaneous ecchymosis, and the presence of presumed cystic, rather than solid, structures on mri. but histopathologic examination disclosed undifferentiated small round cells with hyperchromatic nuclei, high nuclearto-cytoplasmic ratio, and brisk mitotic activity. brief report figure 3. histology (x100, with hematoxylin and eosin staining, scale bar: 100 μm) showed a solid variant of embryonal rhabdomyosarcoma; striated muscle fibers (arrow) are evident between sheets of poorly differentiated round tumoral cells, that show hyperchromic nuclei and scarce cytoplasm. figure 4. a) left exophthalmos (arrow). b) b-scan ultrasonography of the mass (arrow). c) ct scans revealed a well-defined lesion with clear margins in the medial segment of the left orbit (arrow). d) mri revealed a homogeneous aspect of the mass, isointense with the extraocular muscles, and a multitude of internal micro-chambers; a strong enhancement of the lesion was observed after intravenous gadolinium administration (arrow). figure 5. anterior trans-eyelid excisional biopsy of the mass (the arrow shows the mass). non -co mmerc ial us e o nly [page 4] [eye reports 2012; 2:e1] immunohistochemistry demonstrated intense immunoreactivity for smooth muscle actin and desmin. these findings confirmed the diagnosis of rhabdomyosarcoma.6 burkat et al. described a case of a rhabdomyosarcoma masquerading as heterogeneous soft tissue mass with no bone erosion. on t1-weighted gadolinium-enhanced images, the central area of the mass was hypointense, suggestive of proteinaceous material. a peripheral hyperintense rim indicated vascularized tissue, presenting with right medial canthal swelling. the patient was initially diagnosed with dacryocystitis and treated with oral antibiotics, followed by incision and drainage of a presumed lacrimal sac abscess. rapid recurrence of the swelling led to further clinical evaluation, including a maxillofacial ct, which revealed an extensive nasal and orbital mass that was consistent with embryonal rhabdomyosarcoma on histopathologic analysis.7 lazaridou et al. described a case of orbital rhabdomyosarcoma masquerading as a lacrimal mucocele in a newborn infant.8 on the other hand, cota et al. described an orbital abscess in a 6-year-old boy masquerading as a rhabdomyosarcoma9 in our case series, an expert sonographer and three different expert radiologists made an initially incorrect diagnosis in all cases. usually, on ultrasonographical examinations, rhabdomyosarcoma appears as a solid homogeneous mass, with moderate reflectivity and mild sound attenuation.10 sometimes septa can be seen separating different reflectivity structures. blood flow is often detectable, and bone erosion is sometimes present. on ct scans, rhabdomyosarcoma appears as a solid, defined, homogeneous formation, isodense to the skeletal muscles, with a regular internal structure, and moderate enhancement after contrast administration. in most cases the bone is spared, and only in more evolved forms is bone thinning or erosion present. sometimes ct scan shows micro internal vaults.11 on t1-weighted mri, rhabdomyosarcoma may appear hypointense with respect to the orbital fat. on proton density and t2weighted mri, hypointensity, isointensity, and even hyperintensity may be appreciable with respect to both the extraocular muscles and the orbital fat.12 imaging of lymphangioma often shows a multicystic mass with lobular margins. inside the cyst an air-fluid level is often present. on mri, lymphangioma shows hypointensity to the vitreous in t1 weighted images and hyperintensity in t2. the lymphangioma rim may be brief report figure 8. excisional biopsy. figure 7. a) left eyelid edema (arrow). b) b-scan ultrasonography: peribulbar section showing a poorly-defined extra-conic solid mass (arrow) located in the anterior upper segment of the right orbit-the eye is not visible. c) and d) ct scans showed a lobular non-encapsulated mass (arrow), featuring the same density as the extra-ocular muscles. figure 6. histology (x400, with hematoxylin and eosin staining, scale bar: 50 μm) showed a solid variant of alveolar rhabdomyosarcoma, with sheets of poorly differentiated round tumoral cells that show hyperchromic nuclei and scarce cytoplasm (big arrow). several atypical mitoses are present (small arrow). non -co mmerc ial us e o nly [eye reports 2012; 2:e1] [page 5] minimally enhanced.13 in all three of our cases, the lesion presented as an oval mass with clear margins, without any evidence of bone erosion. orbital structures adjacent to the lesion were compressed and displaced but not infiltrated. enhancement after contrast medium on ct in all cases showed a diffuse and patchy impregnation, more accentuated at the periphery of the lesion. in all lesions, imaging showed the presence of internal vaults that were particularly evident after the injection of contrast medium. these findings led to a diagnosis of lymphangioma, but this was not confirmed by histology. diagnostic imaging is useful to determine the location, size, and relationship with other orbital structures, as well as bone erosion and intracranial extension, but often ultrasonographic13 and radiological4-10 characteristics of different pathologies overlap and thus do not allow a clear diagnosis. imaging techniques are an important aid in the diagnosis of orbital pathologies, but are often inconclusive. management should be based first of all on clinical findings, and imaging findings should be treated with some care. the appropriate diagnosis of orbital rhabdomyosarcoma requires close cooperation and communication between the radiologist and the ophthalmologist. rhabdomyosarcoma should be suspected brief report figure 9. histology (x100, with hematoxylin and eosin staining, scale bar: 100 μm) showed large and poorly differentiated cells infiltrating orbital fat (arrow). table 1. comparison of suspected diagnosis and imaging with the final histological diagnosis, of cases reported in the literature and the cases described in this paper. author suspected diagnosis imaging final diagnosis seedat et al.5 suspected subperiosteal abscess in a ct scan: ring-enhancing lesion within the orbit typical rhabdomyosarcoma patient with acute sinusitis of an orbital subperiosteal abscess. fetkenhour et al.6 suspected lymphangioma in a patient with mri: heterogeneous soft tissue mass with no bone rhabdomyosarcoma proptosis of her right eye and painless erosion and internal septa swelling of the right upper eyelid mri t1images: the central area of the mass was hypointense, suggestive of proteinaceous material and a peripheral hyperintense rim indicated vascularized tissue burkat et al.7 suspected dacryocystitis in a patient with mr-enhanced images: the central area of the mass rhabdomyosarcoma swelling in the right medial canthus was hypointense, suggestive of proteinaceous material, and a peripheral hyperintense rim indicated vascularized tissue lazaridou et al.8 suspected lacrimal mucocele in a newborn ct: homogenously hypodense mass rhabdomyosarcoma patient with epiphora and swelling below the left medial canthus our case #1 suspected chalazion or lymphangioma in ct: solid mass in the medial-inferior part of the orbit, rhabdomyosarcoma a patient with left inferior eyelid swelling homogeneous and hyperdense after contrast enhancement our case #2 suspected lymphangioma in a patient with ct: well-defined lesion with clear margins in the medial rhabdomyosarcoma left eye exophthalmus segment of the left orbit, with several chambers, which were more evident after contrast enhancement mri: irregular isointense tissue with an isointense peripheral rim and some central areas with a hyperintense signal our case #3 suspected lymphangioma in a patient with ct: lobular non-encapsulated mass, featuring the same rhabdomyosarcoma superior left eyelid edema density as the extra-ocular muscles, well-defined against the surrounding soft tissues, with diffuse contrast enhancement non -co mmerc ial us e o nly [page 6] [eye reports 2012; 2:e1] whenever the clinical presentation of a rapidly progressive unilateral exophthalmos or eyelid swelling is observed in a child, and an exicional biopsy must always be considered. a prompt, correct diagnosis can be lifesaving. references 1. gurney jg, young jr jl, roffers sd, et al. soft tissue sarcomas. in: ries lag, smith ma, gurney jg, et al., eds. cancer incidence and survival among children and adolescents: united states seer program 1975-1995. bethesda, md: national cancer institute; 1999. national institutes of health publication nih 99-4649. 2. ducrey n, nenadov-beck m, spahn b. update of orbital rhabdomyosarcoma therapy in children. j fr ophthalmol 2002; 25:298-302. 3. shields cl, shields ja, honaver sg, demirci h. clinical spectrum of primary ophthalmic rhabdomyosarcoma. ophthalmology 2001;108: 2284-92. 4. mishra a, abuhajer r, alsawidi k, et al. congenital orbital lymphangioma in a 20years old girl. a case report and review of literature. libyan j med 2009;4:162-3. 5. seedat ry, hamilton pd, de jager lp. orbital rhabdomyosarcoma presenting as an apparent orbital subperiosteal abscess. int j pediatr otorhinolaryngol 2000;52: 177-81. 6. frtkenhour ds, shields cl, chao an, et al. orbital cavitary rhabdomyosarcoma masquerading as lymphangioma. arch ophthalmol 2001;119:1208-10. 7. burkat cn, lucarelli mj. rhabdomyo-sarcoma masquerading as acute dacryocystitis. ophthal plast reconstr surg 2005;21: 456-8. 8. lazzaridou, nabili s, lavv t. orbital rhabdomyosarcoma masquerading as a mucocele. j pediatr ophthalmol strabismus 2008;45:306-8. 9. cota n, chandna a, abernethy lj. orbital abscess masquerading as a rhabdomyosarcoma. j aapos 2000;4(5):318-20. 10. sartor k, ed. mr imaging of the skull and brain: a correlative text-atlas. berlin, new york, ny: springer-verlag; 1992. 11. cooper s, munk pl, downey db, et al. findings of magnetic resonance and colour-flow doppler imagining of orbital embryonal rhabdomyosarcoma. can assoc radiol j 1994;45:217-220. 12. karcioglu za, hadjistilianou d, rozans m, defrancesco s. orbital rhabdomyosarcoma. cancer control 2004;11:328-33. 13. neudorfer m, leibovitch i, stolovitch c, et al. intraorbital and periorbital tumors in children-value of ultrasound and color doppler imaging in the differential diagnosis. am j ophthalmol 2004;137:1065-72. brief report non -co mmerc ial us e o nly hrev_master [eye reports 2012; 2:e4] [page 13] orbital metastasis from cutaneous melanoma loukia tsierkezou, peter cikatricis, parveen abdullah, samer elsherbiny birmingham midland eye centre, city hospital, birmingham, uk abstract we report a case of a metastatic cutaneous melanoma to the orbit. a 60-year-old caucasian male presented with a 2-day history of left-sided ocular pain, lid swelling and chemosis. initially, this was treated as conjunctivitis with no signs of improvement. four days later, the patient developed left proptosis, mechanical ptosis, left esotropia and diplopia. computed tomography scan of the orbit demonstrated marked thickening of the lateral rectus muscle. the patient was treated as pseudotumor. subsequent biopsy revealed malignant cutaneous melanoma. the patient had a history of cutaneous melanoma excised 15 years previously. further imaging showed advanced metastatic disease in the brain, the lung and the liver. the patient passed away five months after initial presentation. cutaneous melanoma metastasizing to the orbit has poor prognosis. patients often have advanced disease at the time of presentation and orbital metastases may be the initial sign. a detailed history is paramount in making timely diagnosis. introduction metastatic cutaneous melanoma to the eye and the orbit is very rare.1-4 in autopsy series of metastatic cutaneous melanoma patients, the numbers of orbital metastases are reported ranging from 1-33%.5 orbital metastases from cutaneous melanoma account for 5.3-15% from all metastatic tumors to the orbit.6 the most common primary source of metastatic tumors to the orbit is breast cancer (42%), followed by lung cancer (11%).3,5,7,8 cutaneous malignant melanoma is reported to be the fourth most common.4 the predominant site of orbital metastases in breast cancer and melanoma tends to be the orbital fat and extra-ocular muscles, whereas in the case of lung cancer it is the bony orbit.9 frequently, the orbital involvement presents long after the primary disease and sometimes it represents the first sign of a metastatic disease before the primary tumor is found. therefore, a thorough history and physical examination (by the appropriate specialist) is very important.10 orbital melanomas derive from melanocytes of the uveal tissues or characterize distant metastasis of cutaneous melanomas to the orbit. they can be classified into primary and secondary orbital melanomas. primary orbital melanomas are extremely rare whereas secondary orbital melanomas are more common. orbital melanomas usually represent massive extra-scleral extensions of uveal melanomas.11 case report a 60-year-old caucasian male presented with a 2-day history of unilateral, left-sided ocular pain, lid swelling and chemosis. at first, this was treated as conjunctivitis with topical antibiotics by his general practitioner with no signs of improvement. left eyelid swelling, chemosis and limited ocular movements on abduction and adduction were noted. the visual acuity in the right eye was 6/6 and in the left was 6/9. intraocular pressures were 13 mmhg in the right eye and 19 mmhg in the left eye. fundal examination was normal. optic nerve function was preserved with normal color vision and pupils equal and reactive to light without afferent pupillary defect. the first impression of the casualty officer was allergic reaction and the patient was discharged home with oral antihistamines and steroid eye drops. four days later the patient was reviewed. on examination, there was marked left proptosis, mechanical ptosis, left esotropia and diplopia. the patient was otherwise systemically well with a history of atopy. a computed tomography (ct) scan of the orbit demonstrated markedly thickened belly of the left lateral rectus muscle with musculo-tendon junction involvement in keeping with pseudotumor (figure 1a). a ct scan of the head revealed 2¥2 cm low attenuation area in the left parietal area, which required further imaging. blood tests showed raised c-reactive protein (crp) (160 mg/l), erythrocyte sedimentation rate (esr) (83 mm/hr) and slightly deranged liver function tests. thyroid function was normal. the patient was initially treated as a pseudotumor with suspected myositis. oral prednisolone, oral ibuprofen and topical treatment with prednisolone eye drops were prescribed, again, with no signs of improvement. the patient subsequently gave a history of previously excised skin melanoma 15 years ago. a biopsy of the left orbital and lateral rectus muscle mass subsequently revealed malignant melanoma. sections of the biopsy from the left orbital mass showed fibrovascular tissue, which was infiltrated by lymphocytes, plasma cells and macrophages. there were scattered groups and clusters of atypical cells with hyperchromatic and pleomorphic nuclei. the nuclei were oval, round to elongated and there was melanin pigment in the background. immunohistochemistry was performed and the cells were positive for s100, melan-a and hmb45. cd68 was positive in the background macrophages but the tumor cells were negative for it (figure 2). a diagnosis of metastatic orbital melanoma was made based on patient’s history of cutaneous melanoma. further investigations including a whole body ct-scan revealed metastases in the lungs, the liver with possible peritoneal and serosal deposits (figure 1b and c). magnetic resonance imaging of the brain and orbit showed metastases in the brain and left lateral rectus (figure 3). the patient was referred to the oncologists for further management. exenteration of the orbit was not recommended in the first instance due to poor life expectancy. two months later bscan ultrasonographic examination revealed an intraconal mass of 14 mm in diameter. repeat ct demonstrated increased number of metastases in the lungs and the liver with new pelvic and peritoneal lesions. the oncologists recommended evisceration and a month later debulking of the orbit. removal of the orbital and brain masses was carried out by the neurosurgeons. the patient passed away shortly afterwards, five months after orbital presentation. eye reports 2012; volume 2:e4 correspondence: loukia tsierkezou, birmingham midland eye centre, city hospital, dudley road, b18 7qh, birmingham, uk. tel. +44 121 5076799. e-mail: ltsier@hotmail.com key words: cutaneous melanoma, metastases, orbit. contributions: lt, data collection, analysis and interpretation, manuscript preparing, revising and editing of the final version submitted for publication; pc, images, histopathology report and slides selection and editing, manuscript critical review and final approval; pa, histopathology report and slides providing; se-s, clinical data providing, manuscript critical review and approval of the final version submitted for publication. conflict of interests: the authors declare no potential conflict of interests. received for publication: 9 march 2012. revision received: 11 june 2012. accepted for publication: 15 june 2012. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright l. tsierkezou et al., 2012 licensee pagepress, italy eye reports 2012; 2:e4 doi:10.4081/eye.2012.e4 non -co mmerc ial us e o nly [page 14] [eye reports 2012; 2:e4] discussion differentiation between primary and secondary orbital melanomas is difficult. fine needle aspiration biopsy can help provide information about the origin of any orbital tumor.12 de bustros et al.1 based their diagnosis of metastatic disease in accordance with the history or presentation of other metastatic lesions at the time of diagnosis. in their series they emphasize that the eye can be the initial site of recurrence of cutaneous melanoma. even in cases where there is no known history of skin lesion excisions and a metastatic orbital melanoma is suspected, the dermatologists should search for a cutaneous or mucosal melanoma.2 many patients (like our patient) may not remember to mention a history of previously excised skin lesion. therefore, it is very important to actively seek information in every case with intraocular or orbital tumor.1 ramesh et al.12 reviewed literature regarding intraocular sites of cutaneous melanoma metastases. in total, 75% involved the uvea. de bustros et al.1 in their series of 12 eyes report the eye as a potential initial site of a clinically identifiable recurrence of cutaneous malignant melanoma. valenzuela et al.9 in a chart review of 80 patients established that the orbit was the first site of presentation of a metastatic tumor in 15% of the cases. generally, a metastatic tumor may present with ophthalmic symptoms before the diagnosis of the primary source of tumor has been established.4,5,13 orbital metastases in some cases occur after long, disease-free intervals.6,10 in our case ocular metastases presented 15 years following the excision of skin melanoma with widespread metastases. the mean survival of patients with intraocular metastasis of melanoma is generally poor. zografos et al.3 in case report figure 3. a and b) magnetic resonance imaging scan of the orbit shows focal and globular swelling of the lateral rectus muscle representing metastasis. c) a t1 weighted coronal magnetic resonance imaging scan of the brain with contrast enhancement demonstrates lesion in the parietal region and surrounding oedema (white arrow). figure 1. a) an axial computed tomography (ct) scan of brain and orbit showing markedly thickened lateral rectus at the muscle belly, which is involving the musculo-tendon junction (white arrow). b) axial ct scan of the lungs showing multiple deposits (white arrows). c) axial ct scan showing metastasis in the liver (white arrow). figure 2. (a) histopathology slides showing melan-a immuno stain for melanoma. (b) hematoxylin and eosin stain (see text). non -co mmerc ial us e o nly [eye reports 2012; 2:e4] [page 15] a retrospective clinical study of 15 eyes have reached similar figures of mean survival to those reported in other literature. this corresponds to a mean survival time of patients with intraocular metastasis between 2.5 and 9.0 months. the mean survival for orbital metastatic melanoma was 19.7 months. ferry and fond7 carried out a clinical-pathological study of 227 patients with carcinoma metastatic to the eye or the orbit and the mean survival was 7.4 months from the time of ocular/orbital involvement. holland et al.14 reported the mean survival to be at 14.7 months (table 1). patients who present with ocular metastases from cutaneous melanoma have usually widespread systemic disease at the time of ocular manifestation.3,4,15 at presentation, our patient had widespread systemic metastases and 5 months survival. melanoma in the orbit preferentially involves extra-ocular muscles.3,5 ct scanning demonstrates smooth enlargement of the muscle.6 as described previously, the ct of the orbit in this case revealed a markedly thickened lateral rectus at the muscle belly. therefore, diplopia and extraocular muscles limitations are common presenting signs.6,8,15 proptosis and pain usually present in the early clinical course of the disease as well.9 in certain cases, debulking of the mass may be a palliative measure.3,6,16 orbital exenteration and surgical treatment of brain metastasis represent in some options too aggressive of a management of patient with poor prognosis and short life expectancy. among the various possible treatment options gamma knife radiosurgery maybe an effective treatment option for orbital tumors as well as intracranial tumors. kim et al.17 in a study of 15 patients with orbital tumors (2 of which were metastatic tumors) showed that in the 13 patients whose vision was preserved preoperatively, 6 patients showed improvement in visual acuity, 4 patients showed no change in vision, and 3 patients showed deterioration. however, three patients with malignant lesions had to undergo another operation due to tumor progression. circumscribed proton beam radiotherapy or global photon beam radiotherapy at relatively high irradiation doses, seem to achieve some favorable results.3 conclusions in patients with a known history of cutaneous melanoma presenting with ocular inflammation, a high index of suspicion for metastatic disease should be maintained. orbital metastases of malignant cutaneous melanoma are very rare but they may be the first sign of manifestation of advanced metastatic disease. the diagnosis is based on a previous history of cancer. most frequently it involves the extra-ocular muscles. imaging is an important tool in detecting and localising the tumour, defining its characteristics and extent within the orbit, as well as in establishing the systemic spread of the disease. the life expectancy is short. thus, in the majority of cases any treatment may only be palliative. the diagnosis of orbital metastases is very important as it can lead to early diagnosis and it can establish the extent of the primary disease, in order to improve the patient’s quality of life with palliative management. references 1. de bustros s, augsburger jj, shields ja, et al. intraocular metastases from cutaneous malignant melanoma. arch ophthalmol 1985;103:937-40. 2. fujii k, komurasaki y, kanno y, ohgou n. unilateral exophthalmos due to orbital metastasis from a contralateral intraocular melanoma. eur j dermatol 1998;8:343-6. 3. zografos l, ducrey n, beati d, et al. metastatic melanoma in the eye and orbit. ophthalmology 2003;110:2245-56. 4. ullah t, gurwood as, myers md. ocular metastasis of cutaneous malignant melanoma. optometry 2009;80:572-8. 5. rosenberg c, finger pt. cutaneous malignant melanoma metastatic to the eye, lids and orbit. surv ophthalmol 2008;53:187202. 6. ahmad sm, esmaeli b. metastatic tumors of the orbit and ocular adnexa. curr opin ophthalmol 2007;18:405-13. 7. ferry ap, fond rl. metastatic carcinoma to eye and orbit. arch ophthalmol 1974;92: 276-86. 8. pedroli gl, hamedani m, barraco p, et al. orbital metastasis in malignant melano ma. j fr ophthalmol 2001;24 286-90. 9. valenzuela aa, archibald cw, fleming b, et al. orbital metastasis: clinical feaures, management and outcome. orbit 2009;28: 153-9. 10. bond jb, wesley re, reynolds vh, et al. orbital metastasis from cutaneous melanoma. south med j 1985;79:1439-42. 11. liarikos s, rapidis ad, roumeliotis a, angelopoulos ap. secondary orbital melanomas: analysis of 15 cases. j craniomaxillofac surg 2000;28:148-52. 12. ramesh k, marshall jwv, wharton sb, dhillon b. intraocular metastases of cutaneous melanoma: a case report and review of the literature. eye 1999;13:247-50. 13. char dh, miller t, kroll s. orbital metastases: diagnosis and course. br j ophthalmol 1997;81:386-90. 14. holland d, maune s, kovács g, behrendt s. metastatic tumors of the orbit: a retrospective study. orbit 2003;22:15-24. 15. drummond sr, fenton s, pantilidis ep, et al. a case of cutaneous melanoma metastatic to the right eye and left orbit. eye 2003;17:420-2. 16. orcutt jc, char dh. melanoma metastatic to the orbit. ophthalmology 1988;95:1033-7. 17. kim ms, park k, kim jh, et al. gamma knife radiosurgery for orbital tumors. clin neurol neurosurg 2008;110:1003-7. case report table 1. relative incidence of cutaneous melanoma metastatic to the orbit and mean survival. authors and type of no. of orbital metastatic orbital mean timing of mean survival references study patients metastasisfrom cutaneous ocular all causes melanoma presentation ferry & fond7 clinical 227 28 1 7.4 months bond et al.10 case reports 2 2 2 7.5 years 8 months de bustros et al.1 clinical 12 0 0 3.25 years 2.4 months char et al.13 clinical 31 31 5 16 months liarikos et al.11 clinical 15 15 1 16.6 months zografos et al.3 clinical 20 7 5 5.5 years 19.7 months holland et al.14 clinical 20 20 0 5.3 years 14.7 months rosenberg and review 93 29 29 5.5 years 7.5 months finger5 patients in case reports ullah et al.4 case report 1 1 1 6 months valenzuela et al.9 clinical 80 80 16 3.6 years 18 months non -co mmerc ial us e o nly [page 22] ⁴ correspondence: conflict of interest: the authors report no conflicts of interest. avi rubinov, md contributions: all authors contributed equally. university of calgary accepted for publication: april, 2019 7007 14th street sw this work is licensed under a creative commons attribution calgary, ab t2v1p9 canada non-commercial 3.0 license (cc by-nc 3.0). e-mail: avi@rubinovl.com ©copyright rubinov et al., 2019. phone: (587) 435-6430 licensee ophthoscience publishers, usa [page 23] [page 24] [page 25] [page 6] correspondence: conflict of interest: the authors report no conflicts of interest. erbil seven, md contributions: all authors contributed equally. department of ophthalmology accepted for publication: april, 2019 yuzuncu yil univeristy this work is licensed under a creative commons attribution 65080, tusba, van, turkey non-commercial 3.0 license (cc by-nc 3.0). e-mail: erbilseven@gmail.com ©copyright seven et al., 2019. phone: (90) 5059295628 licensee ophthoscience publishers, usa [page 7] [page 8] [page 5] correspondence: conflict of interest: the authors report no conflicts of interest. aine ni mhealoid, mbbch, bao, mrcsi contributions: all authors contributed equally. eye department, mater misericordiae hospital accepted for publication: march 4, 2020 3 tudor grove this work is licensed under a creative commons attribution ashbourne, co meath, ireland non-commercial 3.0 license (cc by-nc 3.0). e-mail: ainenimhealoid@rcsi.ie ©copyright mhealoid et al., 2020. phone: (353) 86-360-1361 licensee ophthoscience publishers, usa [page 6] [page 7] [page 8] [page 18] in a search of the peer-reviewed medical literature (using medline and cross-referenced literature), this study may be the first to correspondence: conflict of interest: the authors report no conflicts of interest. lott pooi wah contributions: all authors contributed equally. ophthalmology department accepted for publication: october, 2020 university of malaya this work is licensed under a creative commons attribution kuala lumpur, malaysia non-commercial 3.0 license (cc by-nc 3.0). email: lottpw@yahoo.com ©copyright krishna, et al., 2020. phone: + 60 17 982 5096 license ophthoscience publishers, usa [page 19] ῠ [page 20] [page 18] ş ğ i̇ μ μ μ μ correspondence: conflict of interest: the authors report no conflicts of interest. cagri ilhan, md contributions: all authors contributed equally. ulucanlar eye training and research hospital accepted for publication: march 25, 2020 university of health sciences this work is licensed under a creative commons attribution ulucanlar cd no 59, 06230, altindag, ankara, turkey non-commercial 3.0 license (cc by-nc 3.0). e-mail: cagriilhan@yahoo.com ©copyright keles et al., 2020. phone: (90) 533-133-9709 licensee ophthoscience publishers, usa [page 19] μ [page 20] [page 21] μ μ μ μ μ μ μ μ μ μ [page 22] [page 23] hrev_master [eye reports 2011; 1:e3] [page 5] outcomes of 23-gauge pars plana vitrectomy in combined scleral buckling and vitrectomy for complex rhegmatogenous retinal detachments scott d. schoenberger,1 daniel m. miller,1,2 christopher d. riemann,1,2 robert e. foster,2 michael r. petersen2 1department of ophthalmology, university of cincinnati; 2cincinnati eye institute, cincinnati, ohio, usa abstract rhegmatogenous retinal detachments associated with proliferative vitreoretinopathy, giant retinal tears, ocular trauma, proliferative diabetic retinopathy, or necrotizing retinitis are considered more complex than those without these factors. the aim of the current review is to address the surgical outcomes and complications of 23-gauge pars plana vitrectomy with scleral buckling (23gppv/sb) for repair of these complex retinal detachments. this retrospective study involved 54 eyes of 53 patients who underwent 23gppv/sb between july 2007 and september 2009. preoperative diagnosis, surgical technique, preoperative and postoperative visual acuities, intraoperative and postoperative complications, and anatomic reattachment rates were examined. fifty-four eyes of 53 patients were reviewed in this study and indications for surgery varied. mean logarithm of the minimal angle of resolution�(logmar) preand post-operative visual�acuities were 1.166 (20/293) and 0.780 (20/120), respectively, which led to a statistically significant improvement in logmar (p=0.0165). single operation and final reattachment rates were 87% (47 of 54 eyes) and 100%, respectively. postoperative complications included choroidal effusion/hemorrhage (14.8%, 8 of 54 eyes) and vitreous hemorrhage (11.1%, 6 of 54 eyes). other more infrequent complications included hyphema (9.3%, 5 of 54 eyes), hypotony (5.6%, 3 of 54 eyes) and ocular hypertension > 35 mmhg (3.7%, 2 of 54 eyes). a total of 31.5% (17 of 54 eyes) of patients had a complication in the postoperative time period, but 58.8% of these resolved spontaneously without requiring an intervention. 23gppv/sb may be considered for complex retinal detachment repair with good anatomic reattachment rates, but with relatively high complication rates. introduction advancements in surgical instrumentation have led to changes in the surgical repair of rhegmatogenous retinal detachments (rrds). key components of rrd repair include pars plana vitrectomy (ppv), scleral buckling procedure (sbp), intraocular gas and silicone oil (so) infusion, endolaser photocoagulation, perfluorocarbon liquids, and wide-angle viewing systems.1-4 the evolution of smaller gauge vitrectomy instruments has been a significant technological advance in vitreoretinal surgery. there has been a trend towards the use of smaller gauge vitrectomy instruments to treat increasing complex posterior segment pathology.5-7 twenty threeand 25-gauge instruments have been used in primary pseudophakic retinal detachment repair.8 there have also been reports of their use in more complex retinal detachments requiring silicone oil.9,10 there is a spectrum of pathology in the treatment of rrds. generally, rrds associated with proliferative vitreoretinopathy (pvr), giant retinal tears (grt), ocular trauma, proliferative diabetic retinopathy (pdr), or necrotizing retinitis are considered more complex than rrds without these factors.11 many vitreoretinal surgeons would manage these more complex cases utilizing 20-gauge pars plana vitrectomy, and in many instances, with combined scleral buckling.12-18 however, the management of complex rrds varies by surgeon preference and experience. the aim of this retrospective study was to examine the anatomic success, visual outcomes, and complications of patients with complex rrds treated with 23-gauge pars plana vitrectomy with scleral buckling (23gppv/sb). indications for surgery in this review included rrds associated with pvr (any grade), grt, ocular trauma, high myopia and multiple tears. materials and methods patients who underwent 23-gauge ppv with sbp between july 2007 and september of 2009 by one of four surgeons at the cincinnati eye institute were retrospectively identified. all patients provided preoperative informed consent for surgery. after the final follow up visit for each patient, data were retrospectively reviewed and were collected in accordance with compliance guidelines set forth by the health insurance portability and accounta bility act of 1996. institutional review board (irb) approval was obtained from the university of cincinnati irb prior to data collection. all patients undergoing 23gppv/sb between the time frames mentioned above with at least one month of follow-up were included in the study. all patients underwent either local anesthesia with monitored anesthesia care and retrobulbar anesthesia or general anesthesia. the periocular skin was prepared with 5% povidone-iodine followed by a drop of povidone-iodine in the inferior fornix. the eye was prepared and draped in standard fashion and a lid speculum was placed. a 360-degree encircling scleral buckle was placed using standard techniques. the site of all breaks was identified with indirect ophthalmoscopy and scleral depression. the buckle was positioned to support the identified breaks and/or vitreous base. a #42 band or #41 band (labtician, oakville, ontario, canada) was sutured into position utilizing 5-0 nylon horizontal mattress sutures and the buckle was opposed with a watzke sleeve (labtician). the buckle was raised to a moderate height prior to proceeding with vitrectomy. simultaneous clear corneal cataract surgery was performed by the vitreoretinal surgeon using standard phacoemulsification techniques in three of the cases. a 10-0 nylon suture was placed in the corneal incision at the conclusion of the cataract surgery. all ppv and cataract surgery was performed utilizing the accurus® vitreoretinal surgical system (alcon laboratories fort worth, tx, usa) and either xenon (alcon) or photon (synergetics, o’fallon, mo, usa) light sources. the trocar/cannula system (alcon) was used to place 23-gauge cannulas in the superonasal, superotemporal and inferotemporal quadrants. the trocar/cannula incisions were made in a beveled fashion through bare eye reports 2011; volume 1:e3 correspondence: daniel m. miller, 1945 cei drive, cincinnati, oh 45242, usa. tel. +1.513.984.5133 fax: +1.513.984.2390. email: dmiller@cincinnatieye.com key words: pars plana vitrectomy, scleral buckling, complex rhegmatogenous retinal detachment. conflict of interest: the authors report no conflicts of interest. contributions: all the authors contributed equally. received for publication: 17 april 2011. accepted for publication: 24 june 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright s.d. schoenberger et al., 2011 licensee pagepress, italy eye reports 2011; 1:e3 doi:10.4081/eye.2011.e3 non -co mmerc ial us e o nly [page 6] [eye reports 2011; 1:e3] sclera. the conjunctiva had been previously recessed during the peritomy for scleral buckling. cannulas were placed inferotemporally, superotemporally, and superonasally 3 mm posterior to the limbus for pseudophakic eyes and 4 mm for phakic eyes. the infusion line was connected to the inferotemporal cannula. wide-angle fundus visualization was achieved using either the biom noncontact wide field imaging system (oculus, munich, germany) or the avi contact panoramic viewing system (advanced visual systems inc., ny, ny, usa). the surgical procedures varied slightly depending upon the location and extent of the retinal detachment and the individual preferences of the four surgeons. generally, a core vitrectomy was performed followed by meticulous peripheral vitreous dissection with particular attention to relieving all traction at the sites of retinal breaks and along detached retina. scleral depression was performed when necessary. in many cases, perfluoron (alcon) was utilized to stabilize detached retina and facilitate egress of subretinal fluid through peripheral retinal breaks. membrane peeling was performed using end-grasping forceps. retinectomy was performed in some cases utilizing either the vitreous cutter or intraocular scissors. a fluid-air exchange with a soft tip extrusion needle with active suction or the vitreous cutter itself was used to drain subretinal and posterior pole fluid. a directional endolaser (synergetics) and/or laser indirect ophthalmoscope was utilized to demarcate retinal breaks and in some cases to perform 360 degree laser or demarcate a retinectomy border. nonexpansile mixtures of either perfluoropropane (c3f8) or sulfur hexafluoride (sf6) were used, and in many cases, 5000 centistoke silicone oil (bausch and lomb, san dimas, ca, usa) was utilized for tamponade. at the conclusion of each procedure, the sclerotomies were closed with 7-0 vicryl sutures for many of the patients. the overlying conjunctiva was closed with 6-0 plain gut suture. subconjunctival antibiotic and dexamethasone was administered. ciloxan ophthalmic ointment was placed on the surface of the eye followed by a patch and shield. patients were instructed to position either face down or one side down for on average 7 days. patient medical records were reviewed. age, gender, eye, ophthalmic history, preand post-operative snellen visual acuities, surgery data, intraand post-operative complications, final attachment rates and need for subsequent retinal detachment repair were obtained. length of follow up was also recorded. a total of 54 eyes in 53 patients were identified. one male patient underwent surgery on both eyes during the course of the study; one eye had a rrd with high myopia and the other eye had a grt. with the exception of patient gender, all statistical analysis and percentages were in reference to the number of eyes. snellen visual acuities were converted to logmar values for statistical analysis using the following equation: logmar = log (visual fraction). logmar acuities were converted back to snellen visual acuities for reporting mean preoperative and postoperative visual acuities. for visual acuities worse than 20/400, visual function was recorded as count fingers (cf), hand motion (hm) or light perception (lp). no patients had no light perception vision pre or postoperatively. logmar values were assigned as 2.0 (cf vision), 2.3 (hm vision) or 2.6 (lp vision), as has been used in other studies.19-20 a student’s t-test with a 5% level of significance was used to determine if there was a statistical difference in the pre and postoperative logmar visual acuities, and to compare postoperative complication rates among those with silicone filled eyes versus gas filled eyes. results patient demographics are summarized in table 1. there were 54 eyes of 53 patients who underwent 23gppv/sb. mean age of the 54 eyes was 53.96 years (range of 18-88 years, standard deviation of 15.33). right eyes were affected in 48.1% (26 of 54 eyes), while left eyes were affected in 51.9% (28 of 54 eyes). 41 of 53 patients (77.4%) were males, while the remaining 12 patients (22.6%) were females. one male patient underwent surgery on both eyes during the study. the mean follow up time for each eye was 8.96 months (standard deviation 5.61, range 1 to 23 months). the indications for surgery included the following: rrd with any grade of pvr (15 of 54 eyes, 27.8%), multiple breaks associated with rrd (13 of 54 eyes, 24.1%), grt (9 of 54 eyes 16.7%), high myopia (8 of 54 eyes, 14.8%), trauma (4 of 54 eyes, 7.4%), and other (5 of 54 eyes, 4.8%). lens status was as follows: 37.0% of eyes were phakic (20 of 54 eyes), 59.3% were pseudophakic (32 of 54 eyes), one was aphakic (1.9%) and one had an anterior chamber intraocular lens (1.9%). fifteen of 54 eyes (27.8%) had undergone a prior pars plana vitrectomy. table 2 summarizes surgical techniques and intraoperative variables. a 360-degree encircling scleral buckle was placed in all eyes. the number of eyes with simultaneous cataract extraction was three of 54 (5.6%) and one eye underwent a retinectomy at the time of surgery. the most commonly used tamponading agent was sf6 (61.1%, 33 of 54 eyes), with silicone oil (24.1%, 13 of 54 eyes) and c3f8 (14.8%, 8 of 54 eyes) used less frequently. the vast majority of eyes had a 42 band placed (88.9%, 48 of 54 eyes) as opposed to a 41 band (11.1%, 6 of 54 eyes). perfluoron-octane (pfo) was used in 66.7% of eyes (36 of 54 eyes). all sclerotomies were left open in three eyes and a portion was left open in four eyes. all 23-gauge sclerotomy incisions were closed with a single interrupted 7-0 vicryl suture in the majority of cases (47 eyes). visual outcomes, anatomic success and article table 1. patient demographics. gender number of patients (%) male 41 (77.4)* female 12 (22.6) age of 54 eyes mean 53.96 years standard deviation 15.33 follow up time of 54 eyes mean 8.96 months standard deviation 5.61 number of eyes (%) eye involved right 26 (48.1) left 28 (51.9) diagnosis rrd with pvr 15 (27.8) multiple tears 13 (24.1) grt 9 (16.7) myopia 8 (14.8) traumatic 4 (7.4) other 5 (4.8) prior ppv yes 15 (27.8) no 39 (72.2) lens status phakic 20 (37.0) pseudophakic 32 (59.3) aciol 1 (1.9) aphakic 1 (1.9) *one male patient had surgery on both eyes. rrd, rhegmatogenous retinal detachment; pvr, proliferative vitreoretinopathy; grt, giant retinal tear; aciol, anterior chamber intraocular lens. table 2. intraoperative features. number of eyes (% of eyes) additional step retinectomy 1 (1.9%) cataract extraction 3 (5.6%) pfo 36 (66.7%) intraocular tamponade sf6 33 (61.1%) c3f8 8 (14.8%) silicone oil 13 (24.1%) band placed 41 6 (11.1%) 42 48 (88.9%) ppv, pars plana vitrectomy; pfo, perfluoro-n-octane. non -co mmerc ial us e o nly [eye reports 2011; 1:e3] [page 7] complications are summarized in table 3. mean logmar preoperative visual acuity was 1.166 (20/293) with a standard deviation of 0.941. mean logmar postoperative visual acuity was 0.780 (20/120) with a standard deviation of 0.685. visual acuity significantly improved by 0.386 logmar units (p=0.0165). the anatomic reattachment rate was 87.0% after one operation (47 of 54 eyes), with all eyes ultimately remaining attached. seven eyes developed recurrent retinal detachment (rhegmatogenous and/or tractional) and required additional surgery. six were due to pvr and one was related to a choroidal hemorrhage. two eyes required a third retinal detachment repair. additional postoperative complications other than recurrent retinal detachment were common in this series reflecting the complexity of the underlying pathology. as listed in table 3, complications were separated based on when they presented clinically: intraoperative/ immediate (postoperative day one) or delayed (postoperative day two or beyond). choroidal effusion or hemorrhage occurred in 8 of 54 eyes (14.8%). five eyes had an intraoperative or immediate choroidal effusion or hemorrhage. only one of the eight eyes with a choroidal effusion or hemorrhage had coexisting hypotony. vitreous hemorrhage occurred in 6 eyes (11.1%), of which two were immediate and resolved spontaneously. three of four eyes with a delayed vitreous hemorrhage occurred in eyes that re-detached and required additional surgery. a hyphema occurred in five eyes (9.3%). delayed hyphemas (three of five eyes) resolved spontaneously, but the two eyes with immediate hyphemas also developed vitreous and suprachoroidal hemorrhages. hypotony occurred in three of 54 eyes (5.6%). it resolved spontaneously in two eyes, but one eye also developed a choroidal hemorrhage, hyphema, vitreous hemorrhage, and ultimately required a second retinal detachment repair. ocular hypertension with an intraocular pressure greater than 35 mmhg occurred on pod1 in 2 of 54 eyes (3.7% of eyes), but resolved by the next postoperative visit. a total of 17 eyes (31.5%) had one of these complications at some point during the intraoperative or postoperative course, but over half of these (59.9%) resolved without any intervention. two patients had at least four complications, including hyphema, vitreous hemorrhage, choroidal hemorrhage and a retinal detachment. they attained final snellen visual acuities of 20/200 and 20/400. there was a nonsignificant trend towards decreased complications in silicone filled eyes (15.4% versus 36.6% in gas filled eyes, p=0.157). discussion prior studies have described complex rhegmatogenous retinal detachments as those that have included pvr, grt, ocular trauma, high/pathologic myopia, pdr, and necrotizing retinitis.11 surgeon preference influences the surgical approach to more complex pathology. many surgeons would consider combined scleral buckling and 20-gauge ppv for these cases.15-18,21-24 a recent trend in vitreoretinal surgery has been the application of smaller gauge vitrectomy instruments for increasing complex retinal pathologies. twenty three-gauge ppv has been shown to be associated with more rapid visual recovery than traditional 20-gauge ppv in epiretinal membrane surgery.25 others have used 23-gauge ppv for a multitude of posterior segment pathology with few complications and improved visual acuity.26-28 given the recent literature supporting the use of smaller vitrectomy instruments with a good visual outcome and safety profile, the goal of the current review was to describe results using 23-gauge pars plana vitrectomy in combination with scleral buckling in these complex retinal detachment repairs. the main outcome measures included preoperative and postoperative visual acuities, postoperative complications, and anatomic success. visual acuities were significantly better postoperatively. preoperative snellen acuities averaged about 20/300 and postoperatively were about 20/120. the role of induced corneal astigmatism by surgery was not addressed in this study, but prior studies have shown this to be less of an issue in those undergoing 23-gauge ppv as compared to 20gauge ppv.25 surgically induced corneal astigmatism is unlikely to be a critical factor in patients with complex rrds and generally poor postoperative visual acuity results. however, a large proportion of patients with complex rhegmatogenous rrd do achieve good visual acuities and ppv-induced astigmatism may be a factor in their visual rehabilitation. immediate and delayed complications were not uncommon, as nearly one third of patients had a hyphema, ocular hypertension or hypotony, choroidal effusion or hemorrhage, vitreous hemorrhage or retinal detachment at some point in the postoperative period. the most common complications were choroidal effusions/hemorrhages and vitreous hemorrhages. one hypothesis is that there may be transient hypotony postoperatively in these cases. this may occur even when 23-gauge sclerotomy sites are closed with 7-0 vicryl sutures. the trocar system used in this series produces an irregular t-shaped sclerotomy site even when made in a beveled fashion and thus may not close completely as with a linear 20gauge incision. several patients also had other risk factors for transient hypotony, including high myopia and prior pars plana vitrectomy. overall, postoperative complications (with the exception of recurrent retinal detachment) were generally self-limited and did not affect final anatomic result or visual acuity results. the complication rates reported in this study are higher than those previously published by others for 20 gauge ppv with scleral buckling. wickham et al.22 and gartry et al.14 reported vitreous hemorrhage in approximately 5-7% and choroidal hemorrhage in 4% of patients undergoing combined 20-gauge ppv with scleral buckling. however, the inclusion and exclusion criteria were different from the current review. in the former,22 patients were excluded if they had prior ppv, had grade c or greater pvr or grts. the latter article14 reviewed cases of relatively uncomplicated rrd, excluding grts and more advanced pvr. albrieux et al. compared 23-gauge ppv to 20 gauge ppv for rrd repair.29 they found a similar rate of postoperative complications and anatomic reattachment among the two groups. while the rate of complications was lower than the current review (one choroidal detachment in the 23 gauge group, no hypotony, no reported vitreous hemorrhage or hyphema), sbp was not performed, and patients were excluded if article table 3. visual outcomes and complications. mean preoperative visual acuity snellen 20/293 logmar 1.166 mean postoperative visual acuity snellen 20/120 logmar 0.780 logmar improvement 0.386 number of eyes (% of eyes) anatomic success after one surgery 47 (87.0) after two surgeries 52 (96.3%) final 54 (100%) immediate or intraoperative complications ocular hypertension 2 (3.7%) hypotony 1 (1.9%) hyphema 2 (3.7%) vitreous hemorrhage 2 (3.7%) choroidal effusion/hemorrhage 5 (9.3%) delayed complications (prestenting pod2 and beyond) ocular hypertension 0 (0.0%) hypotony 2 (3.8%) hyphema 3 (5.6%) vitreous hemorrhage 4 (7.4%) choroidal effusion/hemorrhage 3 (5.6%) number of eyes 17 (31.5%) with any complication va, visual acuity; logmar, logarithm of the minimal angle of resolution; pod2, postoperative day 2. non -co mmerc ial us e o nly [page 8] [eye reports 2011; 1:e3] they had prior ppv, traumatic rd, pvr grade c, grts, among other exclusion criteria. in the current review, patients had an anatomic reattachment rate of 87% after one surgery, but reached final reattachment in all cases. the reattachment rates in this study were similar to those reported by others for more complex retinal detachments.10,12,14,15,22 single operation reattachment rates were lower than those reported by stangos et al. (92.3%) and weichel et al. (94%), but these patients underwent 20 gauge ppv with sbp for pseudophakic rrds without associated pvr or grt.13,28 the anatomic reattachment reported by albrieux et al. for ppv without sbp was 74.3% (20 gauge group) and 80% (23 gauge group).29 the anatomic reattachment rate in the current review was similar to another study comparing 20 (89.3%), 23 (88.9%) and 25 gauge ppv (93.3%) without sbp for pseudophakic rrds in patients without prior ppv.30 there are significant limitations to this retrospective study. first, the sample size is fairly small and indications for surgery were variable. also, there are a large number of confounding variables that were present, including a history of prior ppv, gas or silicone used for intraocular tamponade, use of pfo, closure of sclerotomies and simultaneous cataract extraction or retinectomy. certainly, some of these variables might play a role in the single operation reattachment rates and the development of postoperative complications. the potential advantages of 23gppv/sb surgery versus 20-gauge includes smaller sclerotomy size, cannula based infusion line placement (versus suture fixation), and possibly reduced astigmatism. in the past, smaller gauge surgeries for more complex detachments have been limited due to reduced instrument rigidity and a reduced armamentarium of instruments (e.g. scissors). however, a wider array of ancillary instruments is available and 23-gauge ppv instruments have significant rigidity allowing complete eye rotation/control and dissection of dense fibrovascular tissue. recent studies have shown similar flow rates between 23and 20-gauge instruments thus enabling high vacuum based maneuvers.31,32 eventually, when a 23-gauge fragmotome for lensectomy is produced, the 23-gauge platform may replace 20gauge ppv in most cases. in summary, we conclude that 23-gauge pars plana vitrectomy with scleral buckling is a viable alternative to the traditional 20-gauge pars plana vitrectomy with scleral buckling. our retrospective study shows a significant improvement in visual acuity after surgery, with a high single operation reattachment rate and a final reattachment rate of 100%. however, our study did show that postoperative complications (especially vitreous hemorrhage and choroidal effusion/hemorrhage) are higher than those reported in some prior studies14,22 and that these complications need to be further studied. it is unknown whether the higher complication rate is related to the 23 gauge platform or a difference in patient population, with more complex pvr, ocular trauma, and grts included in the current review. ideally, a study to compare traditional 20-gauge ppv with scleral buckling and 23-gauge ppv with scleral buckling would help elucidate whether or not these complications are related to smaller gauge vitrectomy instruments and incisions, or related to the highly complex nature of retinal detachment repair in these patients. references 1. brazitikos pd, d’amico dj, tsinopoulos it, stangos nt. primary vitrectomy with perfluoro-n-octane use in the treatment of pseudophakic retinal detachment with undetected retinal breaks. retina 1999;19: 103-9. 2. mccuen bw 2nd, landers mb 3rd, machemer r. the use of silicone oil following failed vitrectomy for retinal detachment for advanced proliferative vitreoretinopathy. ophthalmology 1985;92:102934. 3. lesnoni g, billi b, rossi t, stirpe m. the use of panoramic viewing system in relaxing retinotomy and retinectomy. retina 1997;17:186-90. 4. lincoff h, coleman j, kreissig i, et al. the perfluorocarbon gases in the treatment of retinal detachment. ophthalmology 1983;90:546-51. 5. fujii gy, de juan e jr, humayun ms, et al. initial experience using the transconjunctival sutureless vitrectomy system for vitreoretinal surgery. ophthalmology 2002; 109:1814-20. 6. lakhanpal rr, humayun ms, de juan e jr, et al. outcomes of 140 consecutive cases of 25-gauge transconjunctival surgery for posterior segment disease. ophthalmology 2005;112:817-24. 7. ibarra ms, hermel m, prenner jl, hassan ts. long-term outcomes of transconjunctival sutureless 25-gauge vitrectomy. am j ophthalmol 2005;139:831-6. 8. miller dm, riemann cd, foster re, peterson mr. primary repair of retinal detachment with 25-gauge pars plana vitrectomy. retina 2008;28:931-6. 9. shah cp, ho ac, regillo cd, et al. shortterm outcomes of 25-gauge vitrectomy with silicone oil for repair of complicated retinal detachment. retina 2008;28:723-8. 10. misra a, ho-yen g, burton rl. 23-gauge sutureless vitrectomy and 20-gauge vitrectomy: a case series comparison. eye (lond) 2009;23:1187-91. 11. azen sp, scott iu, flynn hw jr, et al. silicone oil in the repair of complex retinal detachments: a prospective observational multicenter study. ophthalmology 1998; 105: 1587-97. 12. sirimaharaj m, balachandran c, chan wc, et al. vitrectomy with short term postoperative tamponade using perfluorocarbon liquid for giant retinal tears. br j ophthal mol 2005;89:1176-9. 13. weichel ed, martidis a, fineman ms, et al. pars plana vitrectomy versus combined pars plana vitrectomy-scleral buckle for primary repair of pseudophakic retinal detachment. ophthalmology 2006;113: 2033-40. 14. gartry ds, chignell ah, franks wa, wong d. pars plana vitrectomy for the treatment of rhegmatogenous retinal detachment uncomplicated by advanced proliferative vitreoretinopathy. br j ophthalmol 1993; 77:199-203. 15. han dp, pulido js, mieler wf, johnson mw. vitrectomy for proliferative diabetic retinopathy with severe equatorial fibrovascular proliferation. am j ophthal mol 2005;119:563-70. 16. sigueira rc, gomes cv, dalloul c, jorge r. vitrectomy with and without scleral buckling for retinal detachment. arq bras oftalmol 2007;70:298-302. 17. boscia f, furino c, recchimurzo n, et al. oxane hd vs silicone oil and scleral buckle in retinal detachment with proliferative vitreoretinopathy and inferior retinal breaks. graefes arch clin exp ophthalmol 2008;246:943-8. 18. goezinne f, la heij ec, berendschot t, et al. low redetachment rate due to encircling scleral buckle in giant retinal tears treated with vitrectomy and silicone oil. retina 2008;28:485-92. 19. arevalo jf, garcia ra, wu l, et al. radial optic neurotomy for central retinal vein occlusion: results of the pan-american collaborative retina study group (pacores). retina 2008;28:1044-52. 20. optic nerve decompression surgery for nonarteritic anterior ischemic optic neuropathy (naion) is not effective and may be harmful. the ischemic optic neuropathy decompression trial research group. jama 1995;273:625-32. 21. alexander p, ang a, poulson a, snead mp. scleral buckling combined with vitrectomy for the management of rhegmatogenous retinal detachment associated with inferior retinal breaks. eye 2008;22:200-3. 22. wickham l, connor m, aylward gw. vitrectomy and gas for inferior break retinal detachments: are the results comparaarticle non -co mmerc ial us e o nly [eye reports 2011; 1:e3] [page 9] ble to vitrectomy, gas and sclera buckle? br j ophthalmol 2004;88:1376-9. 23. sharma a, grigoropoulos v, williamson th. management of primary rhegmatogenous retinal detachments with inferior breaks. br j ophthalmol 2004;88:1372-5. 24. scott iu, murray tg, flynn hw jr, et al. outcomes and complications associated with giant retinal tear management using perfluoro-n-octane. ophthalmology 2002; 109:1828-33. 25. hikichi t, matsumoto n, ohtsuka h, et al. comparison of one-year outcomes between 23and 20-gauge vitrectomy for preretinal membrane. am j ophthalmol 2009;147:639-43.e1. 26. gupta op, ho ac, kaiser pk, et al. shortterm outcomes of 23-gauge pars plana vitrectomy. am j ophthalmol 2008;146:193-7. 27. fine hf, iranmanesh r, iturralde d, spaide rf. outcomes of 77 consecutive cases of 23-gauge transconjunctival vitrectomy surgery for posterior segment disease. ophthalmology 2007;114:1197-200. 28. stangos an, petropoulos ik, brozou cg, et al. pars-plana vitrectomy alone vs vitrectomy with scleral buckling for primary rhegmatogenous pseudophakic retinal detachment. am j ophthalmol 2004;138:952-8. 29. albrieux m, rouberol f, bernheim d, et al. comparative study of 23-gauge vitrectomy versus 20-gauge vitrectomy for the treatment of rhegmatogenous retinal detachment. graefes arch clin exp ophthalmol 2011 apr 16. [epub ahead of print] 30. lewis sa, miller dm, riemann cd, et al. comparison of 20-, 23-, and 25-gauge pars plana vitrectomy in pseudophakic rhegmatogenous retinal detachment repair. ophthalmic surg lasers imaging 2011; 42:107-13. 31. hubschman jp, gupta a, bourla dh, et al. 20-, 23-, and 25-gauge vitreous cutters: performance and characteristics evaluation. retina 2008;28:249-57. 32. magalhaes o jr, chong l, deboer c, et al. vitreous dynamics: vitreous flow analysis in 20-, 23-, and 25-gauge cutters. retina 2008;28:236-41. article non -co mmerc ial us e o nly [page 13] correspondence: conflict of interest: the authors report no conflicts of interest. irina effendi-tenang, mbbs contributions: all authors contributed equally. university of malaya eye research centre accepted for publication: march 5, 2020 university of malaya medical centre this work is licensed under a creative commons attribution 59100 kuala lampur, malaysia non-commercial 3.0 license (cc by-nc 3.0). e-mail: irina@ummc.edu.my ©copyright effendi-tenang, et al., 2020. phone: (353) 86-360-1361 licensee ophthoscience publishers, usa [page 14] [page 15] [page 16] [page 17] correspondence: conflict of interest: the authors report no conflicts of interest. ian dooley, md contributions: all authors contributed equally. department of ophthalmology accepted for publication: april 1, 2014 cork university hospital this work is licensed under a creative commons attribution wilton, cork, ireland non-commercial 3.0 license (cc by-nc 3.0). email : ian.iandooley55@gmail.com ©copyright dooley et al., 2014. phone: + licensee ophthoscience publishers, usa [page 24] correspondence: conflict of interest: the authors report no conflicts of interest. justin t mcdaniel, phd contributions: all authors contributed equally. school of human sciences, southern illinois univ. accepted for publication: march 27, 2020 475 clocktower drive, mailcode 4632 this work is licensed under a creative commons attribution carbondale, il 62901 non-commercial 3.0 license (cc by-nc 3.0). e-mail: jtmcd@siu.edu ©copyright mcdaniel et al., 2020. phone: (618) 453-1832 licensee ophthoscience publishers, usa [page 25] [page 26] [page 27] [page 28] [page 29] hrev_master [page 20] [eye reports 2011; 1:e8] changes in ocular flow induced by hypoand hypercapnia relate to static visual acuity in humans naoyuki hayashi, tsukasa ikemura, nami someya institute of health science and graduate school of human-environment studies, kyushu university, kasuga, japan abstract we investigated whether the change in ocular blood flow, induced by hypoand hypercapnia, is related to static visual acuity. eleven healthy subjects (26±5 years) underwent three treatments. a three-treatment three-period crossover design was used. in the hypocapnia treatment (hypo), the subjects controlled their minute ventilation (ve) to a target of 25 l/min for 6 min. in the hypercapnia treatment (hyper), the subjects inspired high-fraction co2 gas (fico2 = 4%) for 6 min. in the control treatment (con), ve was not manipulated. we measured choroidal and retinal blood flow by laser speckle flowmetry as ocular blood flow, and static visual acuity using the landolt c chart. end-tidal partial pressure of co2 differed significantly among hypo, hyper and con (21±1, 48±1, and 42±1 mmhg, respectively). retinal blood flow decreased significantly from the baseline in hypo (-22±5%), but increased significantly in hyper (+3±9%) compared to con. decimal visual acuity was significantly lower in hypo than in the con (0.21±0.1 vs. 0.24±0.1 p<0.05). these results suggest that changes in ocular blood flow induced by changes in arterial co2 partial pressure influences visual acuity. introduction a continuous blood supply to the retina is essential for the maintenance of eye function because o2 is in high demand and is not stored in the retina and surrounding tissue1. nutrition to the retina comes from the retinal and choroidal vessels.2 loss of ocular blood flow regulation associated with pathological conditions, such as diabetes and glaucoma, is related to impaired visual function.1-4 in extreme cases, loss of myelinated axons in the optic nerve is observed by the pharmacological decrease in ocular blood flow in rabbits;5 however, the effect of acute changes in ocular blood flow on visual function has not been elucidated in healthy humans. on the other hand, increase in choroidal blood flow was observed with improved contrast sensitivity in healthy subjects after sidenafil administration.6 thus we can simply hypothesize that acute change in ocular blood flow alters vision. the main purpose of the present study was to examine the hypothesis that increased ocular blood flow improves visual acuity, and decreased ocular blood flow decreases visual acuity. the present study was designed to observe change in visual acuity and ocular blood flow associated with change in arterial co2 partial pressure (paco2) induced by change in ventilation. for functional relevance, the decrease in ocular blood flow could be attributed to impairment of visual acuity after high intensity exercise,7 which induces hyperventilation and consequent decrease in ocular flow. additionally, we compared the co2 sensitivity in ocular and cerebral blood vessels since it is well known that ocular blood vessels are, like cerebral blood vessels, very sensitive to variations in paco2.2,8,9,10 materials and methods subjects eleven healthy non-smokers (5 males and 6 females, 26±5 years, 171±14 cm, 64±14 kg, mean±sd) participated in this study. all subjects were free of any known autonomic dysfunction, cardiovascular and ocular disease, and were not using medications. the ethics committee of the institution of health science, kyushu university, japan, approved the experimental protocol, and all subjects provided written informed consent to participate prior to the commencement of the study. all protocols conformed to the declaration of helsinki. before the experiments, each subject visited the laboratory for familiarization with the techniques and procedures of the protocol. procedures all experiments were performed at a room temperature at 24ºc, illuminated at 90-100 lx. the subjects arrived at the laboratory after having abstained from caffeinated beverages and exercise for 6 h, and from a light meal for at least 2 h. for instruction and probe setting, the subject rested in a chair. two minutes of baseline data were recorded while the subjects breathed room air. a three-treatment three-period crossover design was used. all subjects performed three 6-min experimental procedures after the baseline period, consisting of eupnea (con), hypocapnia (hypo) and hypercapnia (hyper). washout period was 30 min between treatments. in the con treatment, ventilation was not controlled. in the hypo treatment, the subjects controlled their minute ventilation (ve) at 25 l/min with 1 l tidal volume and 25 times/min respiratory rate with auditory feedback using a metronome and an experimenter. in the hyper treatment, the subjects inspired high-fraction co2 gas (fico2=4%) from a douglas bag. in all treatments, subjects inspired through a y-shaped valve from a douglas bag filled with the gas or air. the expired gas was sent to the outside. the subjects wore a nose clip. the order of the treatments was randomized. for allocation of the participants, a computer-generated list of random numbers was used. subjects who wore glasses or contact lens took these off during the experiment. measurement standard electrocardiogram was recorded continuously (ecg; meg2100; nihon-kohden, tokyo, japan). beat-by-beat blood pressure was monitored with an automatic sphygmomanometer on the left middle finger (finometer; finapres medical system, amsterdam, the netherlands). the mean blood velocity (mcav) of the right middle cerebral artery (mca) was obtained by transcranial doppler ultrasonography (waki; atys medical, soucieu-en-jarrest, france). a 2 mhz doppler probe was placed on the right temporal window eye reports 2011; volume 1:e8 correspondence: naoyuki hayashi, institute of health science, kyushu university, kasuga, fukuoka 816-8580, japan. tel. +81.92.583.7848 fax: +81.92.583-7848. e-mail: naohayashi@ihs.kyushu-u.ac.jp key words: ventilation, co2, vision, ocular circulation. acknowledgement: the authors are grateful for a grant from the yamaha motor foundation for sports to nh. contributions: nh, study design, data acquisition and interpretation, article drafting, revising and final approval; ti, data analysis and article revising; ns, data acquisition and article revising. conflict of interest: the authors report no conflicts of interest. received for publication: 18 may 2011. accepted for publication: 6 september 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright n.i hayashi et al., 2011 licensee pagepress, italy eye reports 2011; 1:e8 doi:10.4081/eye.2011.e8 non -co mmerc ial us e o nly [eye reports 2011; 1:e8] [page 21] and fixed with an adjustable headband. the mcav waveform was obtained 47-51 mm from the skin surface. the signals from the ecg, sphygmomanometer and mcav were sampled and recorded at 1 khz using an a/d converter (powerlab 8/30; adinstruments, co, usa). minute-by-minute heart rate and mean arterial pressure (map) were calculated from ecg and blood pressure recordings. the subjects breathed through a mouthpiece connected to a hot wire flowmeter (rm-300; minato medical sciences, osaka, japan) for the measurement of ve and end-tidal co2 partial pressure (petco2). the flowmeter was calibrated using a 2-l syringe. a small sample of respired gas (1 ml/s) was continuously withdrawn from the mask and analyzed for co2 with a mass spectrometer (wsmr-1400; westron corp., chiba, japan). the mass spectrometer was calibrated with fresh air and precision gas. static visual acuity of the right eye was estimated for the last two minutes of the resting baseline and each gas inspiration using the landolt c chart 1 m from the subjects’ eyes. three different charts were used randomly not to allow subjects to memorize the chart. visual acuity was expressed as decimal acuity (no unit), i.e., 20:20 and 20:200 correspond to 1.0 and 0.1, respectively. laser speckle for four seconds was obtained 3 or 4 times for 0.5-2 min for the baseline and 4-6 min for each treatment (lsfg; softcare-ltd, fukuoka, japan). subjects were asked to open their right eye for more than four seconds during the measurement. no drug administration such as mydriatic was used. lsfg is a non-invasive technique to measure real-time, two-dimensional relative blood flow velocity of ocular microcirculation using the laser speckle phenomenon,11 which is recognized as an interference phenomenon of coherent light sources, such as lasers.12 when tissue is illuminated under laser radiation, a speckle pattern appears, the structure of which changes rapidly according to blood flow velocity.13 a laser beam emitted from a laser diode (wavelength 830 nm) is transmitted into part of the intraocular tissue. the observation field included the optic nerve head and the macular area. the blood flow map is obtained from the mean blur rate (30 frames per second), a quantitative index of relative blood flow velocity. from the data, two-dimensional perfusion maps are determined (figure 1), quantifying blood flow velocity using commercially available software (lsfg analyzer ver. 3.0.33.0 softcare-ltd, fukuoka, japan). the mean velocity of blood flow was calculated from three or more entire cardiac cycles. ocular blood flow velocity was obtained from retinal and choroidal capillary vessels (rcv). rcv was obtained from a given observation field of capillary vessels between the optic nerve head and the macula. this field was the same among subjects. so rcv represents blood flow velocity. this measurement does not separate retinal and choroidal flow. ocular blood flow was obtained from inferior temporal retinal arteriole (itra), and superior temporal retinal arteriole (stra). the cross section of the target arteriole was automatically selected by the software, and the blood flow was calculated from the integral of a cross sectional map of perfusion. the software can identify the arteriole, but not the capillaries. thus, it provides relative blood flow of the arterioles according to the integral of a cross sectional map of perfusion. data analysis paco2 was estimated from ve and petco2.14 ocular blood flow measurements were used for analysis only when clear laser speckle imaging was obtained in two or more consecutive heart beats during a 4-s recording period. these flow data were averaged in each condition and calculated as a relative value to the resting baseline value. data are expressed as the mean±se. the effect of treatments was examined by repeated-measures anova. when a significant f value was detected, this was analyzed further against the con value using dunnett’s post-hoc test. likewise, the relative response from the resting baseline in each vasculature to different ventilations was compared by repeated-measures anova and dunnett’s test to compare with the mcav value. pearson correlation coefficient was calculated for the responses to co2 among vasculatures, and between acuity changes and relative changes in blood flow in various vasculatures. multiple regression analysis was performed to reveal effects of blood flow in rcv and mca on visual acuity. the level of statistical significance was set at p<0.05. these statistical analyses were performed with sas (version 8.2; sas institute, cary, nc, usa) at the computing and communications center, kyushu university, japan. results systemic change hypercapnia increased both map and hr, while hypocapnia decreased map and increased hr (table 1). these changes were slight but significant. hypercapnia significantly increased mcav, while hypocapnia significantly decreased it (table 1). petco2 differed article table 1. map, hr, mcav, paco2 and ve during baseline and treatment. baseline treatment map (mmhg) hyper 87.6±3.6 88.9±3.7* hypo 87.4±3.8 84.5±3.6* con 87.4±3.2 85.8±2.6 hr (bpm) hyper 65.7±3.7 68.0±3.8* hypo 67.1±4.6 78.9±5.5* con 63.9±3.5 65.6±3.6 mcav (cm/s) hyper 76.2±4.4 81.7±4.9* hypo 79.1±3.8 46.1±2.6* con 79.3±4.3 77.1±4.0 paco2 (mmhg) hyper 42.5±1.3 48.4±0.6* hypo 43.2±0.6 23.9±0.3* con 43.1±1.4 43.2±1.0 ve (l/min) hyper 6.8±0.4 12.1±0.9* hypo 7.1±0.5 22.9±1.4* con 7.0±0.4 7.7±0.4 values are the mean±se. all variables during the treatment significantly changed from the resting baseline values, except in the con treatment. *p<0.05 vs. baseline. figure 1. examples of the velocity data obtained in a subject at eupnia (con, upper) and hypocapnia (hypo, bottom). color bars shown in the right side indicates the blood flow velocity. note decrease in blood flow velocity in hypo, compared to con treatment. non -co mmerc ial us e o nly [page 22] [eye reports 2011; 1:e8] significantly among con, hypo, and hyper treatments (42±1, 21±1, and 48±1 mmhg, respectively). accordingly, there were significant differences in estimated paco2 among treatments (table 1). ocular and cerebral blood flow the eupnea (con) did not significantly alter blood flow velocity in mca, and blood flow in rcv, itra and stra from the baseline value (p>0.1). hyperventilation resulting in hypocapnia (hypo) significantly decreased blood flow velocity in mca, blood flow velocity in rcv, and blood flow in itra and stra by 42±4%, 22±15%, 15±8% and 13±18%, respectively (figure 2). the decrease in mcav was significantly greater than in other vasculatures. high-fraction co2 gas inspiration (hyper) slightly but significantly changed blood flow velocity in mca and rcv (8±9 % and 3±9%, respectively), but not blood flow in itra and stra. the increase in mcav was significantly greater than in itra flow. visual acuity visual acuity with hypo, con and hyper treatments was 0.21±0.1, 0.24±0.1 and 0.25±0.1, respectively (figure 3). visual acuity was significantly lower in hypo and tended to be greater in hyper than in the con treatment. the difference in visual acuity in hypo and hyper treatments compared with the con treatment was significantly and positively correlated with the relative changes in blood flow in rcv and mca (r=0.52 and 0.51, respectively, n=22) (figure 4). the correlation was still observed between visual acuity and rcv in hypo treatment (r=0.67, n=11). except for this case, there was no significant correlation in changes between blood flow and visual acuity when hypo and hyper were separately examined. however, when deleting an extreme point in rcv and visual acuity relationship, we lost the significant correlation. on the other hand, in the mca and visual acuity relationship, while even after deleting one to five extreme points, significant correlation was still present between mca and visual acuity relationship. multiple regression revealed the significant effect on a change in visual acuity of changes in blood flow both in mca and rcv: 1,000 v = 0.7 r + 0.4 m + 2.3; where v represents the change in visual acuity from baseline, r and m are the relative changes in rcv blood flow and mcav, respectively. relationship in co2 reactivity among vasculatures the correlation coefficient among relative responses in vasculature to hypo treatment was significant between itra and rcv (r=0.60), but no significant correlations were obtained among other ocular and cerebral blood flow responses (r ranged from -0.04 to 0.50, p>0.1). discussion a main finding in the present study is that hypoand hypercapnia altered rcv with a concomitant change in static visual acuity, supporting our hypothesis that rcv correlates with static visual acuity. another finding was that the magnitude of vessels response to co2 in ocular vessels is less than in cerebral one, supporting a previous study which reported mca blood flow response was greater to hypercapnia than retinal blood flow.15 effect of ocular circulation on visual acuity the present results demonstrate for the first time that both acute increase and decrease of rcv correlate with the improvement and impairment of visual acuity in healthy humans, supporting our hypothesis. there was also a significant positive correlation between rcv and visual acuity. the finding is consistent with previous findings that increased blood flow was related to the improvement of contrast sensitivity.16 concomitant increases in choroid flow and contrast sensitivity were found in healthy subjects after sildenafil administration.6 these findings could be supported by evidence for the relationship between chronic change in ocular blood flow and vision,1-4 though some previous studies have reported no relationship between ocular blood flow and visual function during hypoand hypercapnic, pharmacologic and altitude stimulus.17,18 chronic reduction in ocular blood flow is well known to be related to impaired article figure 2. relative changes in blood flow velocity in middle cerebral artery (mcav), blood flow velocity in retinal and choroidal vessels (rcv), and blood flow in inferior temporal retinal arteriole (itra) and superior temporal retinal arteriole (stra) in response to hypocapnia (hypo), eupnia (con) and hypercapnia (hyper). hypo significantly decreased blood flow in mca, rcv, itra and stra. the decrease in mcav was significantly greater than in the other vasculatures. hyper treatment slightly but significantly changed blood flow in mca and rcv, but not in itra and stra. the increase in mcav was significantly greater than in itra. n=11. *p<0.05 vs con, =p<0.05 vs mca figure 3. visual acuity during hypocapnia (hypo), eupnia (con) and hypercapnia (hyper). this was significantly less in hypo and tended to be greater in hyper than in the con treatment. n=11. *p<0.05 vs con (*)p=0.08 figure 4. relationship between changes in visual acuity and blood flow velocity in the retinal and choroidal vessels (rcv, left panel) and middle cerebral artery (mca, right). the difference in visual acuity from the eupnea (con) treatment was significantly correlated with the relative changes of blood flow velocity in rcv and mca (r=0.52 and 0.51, respectively, n=22, p<0.05). circles show the response to hypocapnea (hypo) and triangles show that to hypercapnea (hyper). non -co mmerc ial us e o nly [eye reports 2011; 1:e8] [page 23] visual function in diseases and animal models.1-5 acute loss of contrast sensitivity in glaucoma patients was improved by hypercapnia.19 these findings could support the relevance of acute change in ocular blood flow on the concomitant change in visual acuity. the relationship between changes in ocular flow and visual acuity could provide an important translational implication, if ocular blood flow is relevant to various visual variables, such as dynamic visual acuity, visual field and contrast sensitivity as well as static visual acuity. for example, the present finding is useful to find how to maintain or improve visual acuity during work. it was reported that high intensity exercise induces temporary impairment of visual acuity.7 high intensity exercise relates to hyperventilation, which induces hypocapnea. thus the relationship of ocular blood flow to visual acuity has implications in preventing the decreased vision. effect of co2 on ocular and cerebral vascular responses blood flow velocity reduced in both ocular capillary and arterioles in response to decreased paco2, and partly increased in response to increased paco2. the response of ocular blood flow or blood flow velocity to hypercapnia has been well documented in retinal capillary, superior temporal peripapillary retina, and ophthalmic and central retinal arteries.18,20,21 the response to hypocapnia was also reported.18 the present study supports that both retinal arteriole and retinal-choroidal vasculatures respond to both hypoand hypercapnia. the response to hypoand hypercapnia was greater in mcav than blood flow velocity in ocular vessels and blood flow in retinal arterioles both in groups and individuals, indicating weaker reactivity in ocular than the cerebral vessels. few previous studies have compared the ocular vessel and cerebral vessel response to co2.15,22,23 a weaker reactivity in ocular vessels to co2 has physiological relevance. the function of the retina is vulnerable to overperfusion.2,9 weak reactivity could serve for the relatively easy stabilization of ocular perfusion. relationship between responses in various vessels retinal vessels are routinely inspected during physical examinations and used to estimate clinical cerebral vessel conditions. a correlation between vascular reactivity to co2 in retinal and cerebral vessels has been reported.24 studies have been performed based on analogy of ocular vessels to the cerebral circulation; however, no published study to our knowledge has investigated the relationship between cerebral and ocular vessel responses to co2. the present result does not show a relationship among these responses. this implies that the magnitude of response to vasoconstrictive and vasodilative mechanisms is not necessarily the same in ocular and cerebral vasculatures in an individual. limited correlation even in ocular flow responses might be due to the effect of this complex flow nature in the retina. rcv is a combination of retinal and choroidal flow velocity; the retinal circulation component is characterized by a low level of flow and is supplied by the central retinal artery, which is connected to the itra and the stra, whereas the choroidal circulation component has relatively higher flow and is supplied by ciliary arteries.9,25 unfortunately, we cannot separate these signals in the present study. limitations the increase in paco2 was limited since increase in inspired co2 stimulates ventilation. hyper treatment did not provide a corresponding change in paco2 to hypo treatment. as a result, the decrease of ocular blood flow was limited and the change of visual acuity did not reach statistical significance. increase in ventilation could increase pao2. in our preliminary measurement in the same experimental setting, we observed 10% increase in peto2 in four of subjects during hypo treatment. an increase of 13% in peto2 has been reported during hypercapnia.26 thus, arterial oxygen tension accompanied by increased ventilation might reduce the ocular blood flow. results obtained during hypocapnia could be mixed with the effect of increased oxygen tension. however the effect of oxygen tension is more limited than previous studies comparing ocular blood flow between air and carbogen. using carbogen leads peto2 up to 400 mmhg,27 while the present study might have roughly increase it by 115 mmhg. in turn, we can conclude that hypercapnea increases ocular blood flow since the effect of hypercapnia overwhelms the effect of increased oxygen, if any. it should be noted that the change of pco2 also alters the oxygen dissociation curve of hemoglobin (hb), i.e., the bohr effect and the converse of the bohr effect. in fact, the possibility of impeding o2 unloading even in human muscle tissues has been reported.28 the present study does not allow us to conclude that the single effect of blood flow alters the visual acuity. in turn, there remains the possibility that the shift of oxygen dissociation curve of hb modified the acuity; any factor modifying visual acuity associated with respiratory manipulation should be carefully interpreted. altered cerebral perfusion could affect visual acuity as shown in the concomitant change and significant correlation in changes of mcav and visual acuity, though mca dynamics may be different in nature than posterior cerebral artery dynamics.29 there is also indirect evidence that altered cerebral perfusion could affect visual acuity: a relationship between mca blood flow and visual acuity and contrast sensitivity in primary open-angle glaucoma in a cross-sectional study.4 it is difficult to obtain direct evidence that cerebral perfusion relates to visual function because the nature of both cerebral and ocular flows are similar to many physiological stimulations. thus there is room for argument as to whether or not cerebral blood flow changes the visual acuity. in summary, we compared the ocular and cerebral blood flow among hyper-, hypo-, and normo-capnia conditions. we demonstrated that the ocular blood flow change induced by both hypoand hyper-capnia are associated with concomitant changes in visual acuity. these findings are useful for further understanding the physiological nature of ocular blood flow and its relation to visual function. references 1. wangsa-wiraman nd, linsenmeier ra. retinal oxygen. fundamental and clinical aspects. arch ophthalmol 2003;121:547-57. 2. bill a. blood circulation and fluid dynamics in the eye. physiol rev 1975;55:383-417. 3. guan k, hudson c, wong t, et al. retinal hemodynamics in early diabetic macular edema. diabetes 2006;55:813-8. 4. harris a, siesky b, zarfati d, et al. relationship of cerebral blood flow and central visual function in primary openangle glaucoma. j glaucoma 2007;16:15963. 5. sasaoka m, taniguchi t, shimazawa m, et al. intravitreal injection of endothelin-1 caused optic nerve damage following to ocular hypoperfusion in rabbits. exp eye res 2006;83:629-37. 6. sponsel we, paris g, sandoval ss, et al. sildenafil and ocular perfusion. n engl j med 2000;342:1680. 7. ishigaki h, miyao m, ishihara s, et al. the deterioration of visual acuity by exercise under a mesopic vision environment. j sports med phys fitness 1991;31:272-6. 8. alm a, bill a. the oxygen supply to the retina. i. effects of changes in intraocular and arterial blood pressures, and in arterial po2 and pco2 on the oxygen tension in the vitreous body of the cat. acta physiol scand 1972;84:261-74. 9. delaey c, van de voorde j. regulatory mechanisms in the retinal and choroidal circulation. opthalmic res 2000;32:249-56. 10. van de borne p, mezzetti s, montano n, et al. hyperventilation alters arterial baroreflex control of heart rate and muscle symarticle non -co mmerc ial us e o nly [page 24] [eye reports 2011; 1:e8] pathetic nerve activity. am j physiol heart circ physiol 2000;279:h536-41. 11. tamaki y, araie m, kawamoto e, et al. non-contact, two-dimensional measurement of retinal microcirculation using laser speckle phenomenon. invest ophthalmol vis sci 1994;35:3825-34. 12. tamaki y, araie m, kawamoto e, et al. non-contact, two-dimensional measurement of tissue circulation in the choroids and optic nerve head using laser speckle phenomenon. exp eye res 1995;60:373-83. 13. fujii h, nohira k, yamamoto y, et al. evaluation of blood flow by laser speckle image sensing. part 1. appl opt 1987;26:5321-5. 14. jones nl, robertson dg, kane jw. difference between end-tidal and arterial pco2 in exercise. j appl physiol 1979;47:954-60. 15. kisilevsky m, mardimae a, slessarev m, et al. retinal arteriolar and middle cerebral artery responses to combined hypercarbic/hyperoxic stimuli. invest ophthalmol vis sci 2008;49:5503-9. 16. huber kk, adams h, remky a, arend ko. retrobulbar haemodynamics and contrast sensitivity improvements after co2 breathing. acta ophthalmol scand 2006;84:481-7. 17. bosch mm, merz tm, barthelmes d, et al. new insights into ocular blood flow at very high altitudes. j appl physiol 2009;106: 454-60. 18. harris a, arend o, wolf s, et al. co2 dependence of retinal arterial and capillary blood velocity. acta ophthalmol scand 1995;73:421-4. 19. hosking sl, evans dw, embleton sj, et al. hypercapnia invokes an acute loss of contrast sensitivity in untreated glaucoma patients. br j ophthalmol 2001;85:1352-6. 20. chung hs, harris a, halter pj, et al. regional differences in retinal vascular reactivity. invest ophthalmol vis sci 1999;40:2448-53. 21. lietz a, hendrickson p, flammer j, et al. effect of carbogen, oxygen and intraocular pressure on heidelberg retina flowmeter parameter ‘flow’ measured at the papilla. ophthalmologica 1998;212:149-52. 22. schmetterer l, findl o, strenn k, et al. role of no in the o2 and co2 responsiveness of cerebral and ocular circulation in humans. am j physiol 1997;273:r2005-12. 23. bayerle-eder m, wolzt m, polska e, et al. hypercapnia-induced cerebral and ocular vasodilation is not altered by glibenclamide in humans. am j physiol regul integr comp physiol 2000;278:r1667-73. 24. hickam jb, schieve jf, wilson wp. the relation between retinal and cerebral vascular reactivity in normal and arteriosclerotic subjects. circulation 1953;7:84-7. 25. netter fh. atlas of human anatomy 4 th ed. philadelphia, pa: saunders; 2006. 26. venkataraman st, hudson c, fisher ja, flanagan jg. the impact of hypercapnia on retinal capillary blood flow assessed by scanning laser doppler flowmetry. microvasc res 2005;69:149-55. 27. luksch a, garhöfer g, imhof a, et al. effect of inhalation of different mixtures of o2 and co2 on retinal blood flow. br j ophthalmol 2002;86:1143-7. 28. hayashi n, ishihara m, tanaka a, yoshida t. impeding o2 unloading in muscle delays oxygen uptake response to exercise onset in humans. am j physiol 1999;277:r127481. 29. haubrich c, wendt a, diehl rr, klötzsch c. dynamic autoregulation testing in the posterior cerebral artery. stroke 2004;35: 848-52. article non -co mmerc ial us e o nly [page 18] correspondence: conflict of interest: the authors report no conflicts of interest. karen allison, md contributions: all authors contributed equally. veterans administration hospital accepted for publication: april, 2019 30 west 60th street, suite 1y this work is licensed under a creative commons attribution new york, ny 10023 non-commercial 3.0 license (cc by-nc 3.0). e-mail: kallisonmdpc@gmail.com ©copyright allison et al., 2019. phone: (212) 459-0001 licensee ophthoscience publishers, usa [page 19] 2.2 3.36 0 2 4 2004 2020n o . o f p e rs o n s (i n m ill io n s ) year historical and projected oag cases in the united states 0% 5% 10% 15% 20% p e rc e n ta g e ethnicity rate of blindness in the united states due to primary oag. african americans caucasians [page 20] [page 21] [page 14] correspondence: conflict of interest: the authors report no conflicts of interest. hsin yi lee contributions: all authors contributed equally. ophthalmology department accepted for publication: october, 2020 hospital selayang this work is licensed under a creative commons attribution selangor, malaysia non-commercial 3.0 license (cc by-nc 3.0). email: adrianne0786@gmail.com ©copyright yi, et al., 2020. phone: +360 122 740 7017 license ophthoscience publishers, usa [page 15] a b [page 16] [page 17] [page 1] correspondence: conflict of interest: the authors report no conflicts of interest. wendy yen nee see, md contributions: all authors contributed equally. eye department, hospital umum sarawak accepted for publication: march 2, 2020 a1-4, the arcadia, jalen stampin timur this work is licensed under a creative commons attribution 93350 kuching, sarawak, malaysia non-commercial 3.0 license (cc by-nc 3.0). e-mail: wendy_choc@hotmail.com ©copyright see et al., 2020. phone: (60) 1-28863662 licensee ophthoscience publishers, usa [page 2] [page 3] [page 4] hrev_master [eye reports 2011; 1:e9] [page 25] diabetes and corneal endothelial cell characteristics: a study based on eye bank data geoffrey brown,1 eric siegel,2 steve staples,1 jennifer doyle,1 jason y. chang3,4 1arkansas lions eye bank and laboratory; 2department of biostatistics; 3department of neurobiology and developmental sciences; 4department of ophthalmology, jones eye institute, university of arkansas for medical sciences, little rock, ar, usa abstract the aim of the article is to determine whether corneal endothelial cell density and other characteristics, such as cell area, pleomorphism and polymegathism, are affected by diabetes. corneal endothelial cell density and other characteristics of donor eyes collected during 2007 and 2008 in a local eye bank were measured by the hai eyebank specular microscope system. adult donors aged 21 or older who consented to research were divided into healthy versus compromised eye-status groups based on eye disease or past eye surgeries. differences in corneal measures between diabetic and non-diabetic subjects were analyzed separately in each group via mixed models ancova, with diabetes as the fixed effect, donor as the random effect, and age as the continuous covariate. a total of 253 subjects met study criteria, of which 81 (32%) had diabetes. in the 180 subjects with healthy eye status, the medians (ranges) of age were 62 (29-78) years among 52 diabetics (29%), versus 57 (21-79) years among non-diabetics (p=0.013). in the 73 subjects with compromised eye status, the medians (ranges) of age were 70 (32-78) years among 29 diabetics (40%), versus 70 (29-79) years among nondiabetics (p=0.77). between diabetics and non-diabetics, eye disease and past eye surgeries were well-balanced in the compromised eye-status group, while race and sex were wellbalanced in both eye-status groups. results from separate analyses on the two groups indicated that diabetes did not affect corneal cell density or other corneal-cell characteristics analyzed. even though diabetics constituted a large percentage of the eye bank donor population, this disease did not have a statistically significant impact on corneal endothelial cell density, cell area, pleomorphism or polymegathism. introduction since the first successful corneal transplant performed in 1905,1 there is a constant need for more donor eyes for this procedure. as such, there were 39,391 corneal transplants performed in the united states in 2007, and the number increased to 41,652 in 2008 according to the record provided by the eye bank association of america (ebaa).2 corneal endothelial cell density is one of the most important criteria that determine whether a donor cornea is eligible for transplant. there is an age-dependent decrease of corneal endothelial cell density, a phenomenon that has been documented in people from various ethnic groups. examples include those from the united states,3,4 japan,4 india,5 philippine,6 pakistan,7 iran,8 and china.9 however, it is important to note that all of the reports above are data derived from normal, healthy volunteers. very often people with a history of diabetes mellitus were excluded. as a result, the data presented in those reports do not necessarily reflect those from donor eyes in a typical eye bank. this is because a typical eye bank does encounter donors with various health conditions, including diabetes, and can be very different from those normal, healthy volunteers reported in those studies. exclusion of people with diabetes in those reports analyzing corneal endothelial cell density implies that diabetes can alter corneal cell density. however, the published literature on this subject contains conflicting results. diabetes is reported to increase,10 decrease11-13 or have no effect14-17 on corneal endothelial cell density. in this study, we used data collected from 253 research-consenting adults who donated their corneas to a local eye bank during 2007 and 2008 to examine whether there was evidence suggesting that diabetes might adversely affect corneal endothelial qualities such as endothelial cell density. to do this, we classified donors into two groups, a healthy group and a group with compromised eye status, based on history of eye disease or past eye surgeries. we then compared the age-adjusted impact of diabetes on four corneal cell parameters: cell density, cell area, pleomorphism, and polymegathism in each group. the percentage of hexagonal cells was used as an indicator of pleomorphism and the coefficient of variation in cell size was used as an indicator of polymegathism. materials and methods data of this report were extracted from the arkansas lions eye bank and laboratory (the eye bank) housed at the university of arkansas for medical sciences, which routinely obtained informed consent from individual donors for use of their eyes in research. the consent included the authorization to share personal health information recorded in the medical/social history questionnaire for research. this eye bank received donor eyes from 154 individuals (113 male, 41 female) in 2007 and 156 individuals (91 male, 65 female) in 2008. for comparison, the total number of donors in 2004, 2005 and 2006 was 181, 183 and 148, respectively. among donors in 2007 and 2008, 275 adults aged 21 years or older allowed the eye bank to use their data for research. specimens from this group were excluded from further processing if they were of poor conditions, if the donors had positive serology for viruses such as hiv or hepatitis, or if the donors had a history of other medical conditions that were deemed to pose a risk to corneal-transplant recipients. a total of 501 corneas from 253 donors were eventually examined on the specular microscope, from which this report was generated. the hai eyebank specular microscope system (hightech american industrial eye reports 2011; volume 1:e9 correspondence: jason y. chang, department of neurobiology and developmental sciences, slot 510, university of arkansas for medical sciences 4301 w. markham st., little rock, ar 72205, usa. tel. +1.501.686.7025 fax: +1.501.686-6382. e-mail: changjasony@uams.edu key words: corneal endothelial cells, diabetes, eye bank. acknowledgements: this work was partially supported by funds from research to prevent blindness. we greatly appreciate eye bank donors who not only donated their corneas but also allowed us to conduct this research. the thoughtful critiques and suggestions provided by dr. michael brown are highly appreciated. contributions: gb, ss, jd, data collection and assistance in manuscript writing; es, data analysis and assistance in manuscript writing; jyc, organizer of the project, data analysis and the main writer of the manuscript. conflict of interest: the authors report no conflicts of interest. received for publication: 14 june 2011. accepted for publication: 12 september 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright g. brown et al., 2011 licensee pagepress, italy eye reports 2011; 1:e9 doi:10.4081/eye.2011.e9 non -co mmerc ial us e o nly [page 26] [eye reports 2011; 1:e9] laboratories, inc., lexington, ma, usa) was used to document corneal characteristics. approximately 100 cells of each cornea were analyzed, and the computer automatically calculated corneal endothelial cell density, polymegathism and pleomorphism for each specimen. the mean cell area (in μm2/cell) of each specimen was calculated as 1,000,000 divided by its corneal-cell density (in cells/mm2). according to the eye bank record, 73 (29%) of the 253 study subjects had various types of eye diseases (e.g., cataract, glaucoma, macular degeneration) or eye operations (e.g., intraocular lens, trauma repair, shunt, corrective surgery). in the past, people with these conditions were excluded from studies analyzing the effect of diabetes on corneal endothelial cell density because these conditions could potentially affect one or more of the parameter studied.12-15,17,18 in our study, a preliminary analysis was conducted for confounding of eye disease and eye surgeries with diabetes and age. because of the results, subjects were classified as having compromised eye status if they had eye disease or a history of eye surgeries, versus having healthy eye status if they had neither, and the two eye-status groups were analyzed separately in parallel analyses, as described in the next section. statistical analyses in the preliminary analysis for confounding, the associations of age with eye disease and eye surgeries were tested using the wilcoxon rank sum (wrs) test, while the associations of diabetes with eye disease and eye surgeries were tested using the pearson chi-square test; the magnitude of all associations were quantified using spearman’s rank-correlation coefficient. within each eye-status group, donor ages were summarized by diabetes status (yes/no) as the median (range), and tested for imbalance via wrs test, while race and sex were summarized by diabetes status as proportions, and tested for imbalance via fisher’s exact test. within the compromised eye-status group, the incidence of eye disease, intra-ocular lens (iol) surgeries, and non-iol surgeries were summarized by diabetes status as proportions, and tested for imbalance using fisher’s exact test. corneal-cell measures were summarized by eye status and decade of age as means and standard deviations (sds). left eyes were compared to right eyes via paired ttest for possible differences in corneal measures. the impact of diabetes on corneal measures was conducted in separate, parallel analyses on the two eye-status groups using mixedmodels analysis of covariance (ancova),19 with diabetes as the fixed effect, donor as the random effect, and age as the continuous covariate. the validity of ancova models were pre-tested via mixed-models regression techniques, specifically by testing for significant age-by-diabetes interactions. following the practice of ray and rosner,21 inter-eye correlations (iecs) were estimated as intra-class correlations (iccs) from the mixed-models variance components, using the following formula: where s2 b denotes the variance between donors, s2 w denotes the variance within donors, and their sum denotes the total variance. to help interpret the diabetes effects biologically, predicted reference means were calculated for a reference age of 60 years in the healthy eye-status group and 70 years in the compromised eye-status group; both reference ages were chosen to be near the medians of their groups. finally, the question was investigated of whether the age trends, age-adjusted diabetes effects, or total variances and iecs differed significantly between subjects with healthy versus compromised eye status. to do this, the data for each corneal-cell measure from the two groups were combined into a single mixed-models analysis that contained an eye-status main effect plus eye-status interactions with age and diabetes. eye-status differences in the age trends and diabetes effects were tested for significance using the type-iii f-statistics for the eye-status interactions with age and diabetes, respectively. eye-status differences in the total variances and iecs were tested for significance via likelihood-ratio chisquare test of the full model (having different variance components between groups) against a reduced model (having equal variance components between groups). an alpha=0.05 significance level was used for all statistical tests. results donor characteristics among a total of 310 donors in 2007 and 2008, a total of 275 adults 21 or older (134 in 2007 and 141 in 2008) gave informed consent to participate in research. of these, 22 had their specimens excluded from processing because of poor condition, positive viral serology, or medical history for conditions that put a transplant recipient at risk. of the remaining 253 subjects, 73 (29%) were classified as having compromised eye status (eye disease or a history of eye surgeries), while 180 (71%) were classified as having healthy eye status (no eye disease and no history of eye surgeries). a total of 81 subjects in the study (32%) had diabetes. the preliminary analysis for confounding showed (i) that eye disease was associated strongly with age (rank correlation 0.40; wrs p<0.0001) and mildly with diabetes (rank correlation 0.12; chi-square p=0.06), (ii) that eyesurgery history was associated strongly with age (rank correlation 0.38; wrs p<0.0001) and moderately with diabetes (rank correlation 0.16; chi-square p=0.01), and (iii) that eye-surgery history had high association with eye disease (rank correlation 0.72; chi-square p<0.0001). because of the evident confounding, we chose to study the two eye-status groups in separate, parallel analyses. table 1 gives breakdowns of donor characteristics by diabetes status within the two eyestatus groups. in adults with healthy eye status, the median age was 62 years for diabetics article table 1. donor characteristics by diabetes status. in adults with in adults with healthy eye status compromised eye status overall diabetic nondiabetic p* diabetic nondiabetic p* donor number 52 128 --29 44 --253 median age (range) 62 (29-78) 57 (21-79) 0.013 70 (32-78) 70 (29-79) 0.77 62 (21-79) non-caucasian 5 (10%) 6 (5%) 0.30 1 (3%) 2 (5%) 1.00 14 (6%) female 13 (25%) 42 (33%) 0.37 12 (41%) 17 (39%) 1.00 84 (33%) any eye disease 0 (0%) 0 (0%) --28 (97%) 40 (91%) 0.64 68 (28%) any non-iol surgery 0 (0%) 0 (0%) --5 (17%) 3 (7%) 0.25 8 (3%) any iol surgery 0 (0%) 0 (0%) --21 (72%) 25 (57%) 0.22 46 (18%) *p values are via wilcoxon rank-sum test on age, and via fisher’s exact test on all other donor characteristics. non -co mmerc ial us e o nly [eye reports 2011; 1:e9] [page 27] versus 57 years for non-diabetics (p=0.013); however, the age distributions still overlapped substantially, with ranges of 29-78 years for diabetics versus 21-79 years for non-diabetics. in adults with compromised eye status, the median age was 70 years for diabetics versus 70 years for non-diabetics (p=0.77). race and sex showed no significant diabetes imbalance in either eye-status group, and the incidences of eye diseases and past eye surgeries showed no significant diabetes imbalance in the compromised eye-status group. corneal endothelial-cell measures of each eye status group left eyes were compared to right eyes via paired t-test for significant differences in corneal epithelial-cell measures; none were found (all p >0.50). table 2 shows descriptively how corneal cell density (cells/mm2), cell area (μm2/cell), pleomorphism (% of cells that are hexagonal), and polymegathism (coefficient of variation in cell size) varies with age and eye status. both eye-status groups show similarly decreasing trends with age in cell density, similarly increasing trends with age in cell area, and similarly unclear trends with age in pleomorphism and polymegathism. age-adjusted diabetes effect in adult donors with healthy eye status the corneal-cell measures of adult donors with healthy eye status were analyzed for ageadjusted diabetes effects using mixed-models regression techniques. none of the age trends had a significant quadratic component, indicating that it was reasonable to fit all corneal measures with linear trends. all age-by-diabetes interactions were non-significant, indicating for each measure (i) that the linear trends had the same slope for diabetics versus non-diabetics, and therefore (ii) that mixedmodels ancova was the appropriate analysis model. table 3 shows the results of the mixedmodels ancovas on subjects with healthy eye status. inter-eye correlations ranged from a low of 26.4% for pleomorphism to a high of 69.7% for cell density. the age effect was highly significant (p<.0001) with positive slope for cell area, highly significant (p<.0001) with negative slope for cell density, but insignificant for pleomorphism (p=0.63) and polymegathism (p=0.24). the age-adjusted diabetes effects were statistically insignificant article table 2. corneal cell measures versus age group and eye status. age group eye status # of eyes* cell density° cell area# pleomorphism§ polymegathism$ 21-30 healthy 30 3019 (258) 333.7 (29.0) 54.47 (7.14) 19.47 (3.31) compromised 2 2918 (74) 342.9 (8.7) 54.50 (0.71) 19.00 (1.41) 31-40 healthy 24 3072 (451) 330.7 (37.8) 55.58 (6.90) 18.50 (3.05) compromised 3 2979 (105) 336.0 (11.6) 60.67 (2.52) 16.67 (0.58) 41-50 healthy 56 2662 (293) 380.2 (42.1) 52.46 (7.19) 19.19 (4.84) compromised 4 2605 (123) 384.5 (18.9) 50.50 (3.87) 16.00 (1.63) 51-60 healthy 94 2706 (319) 375.8 (56.0) 52.91 (7.08) 20.05 (5.68) compromised 18 2791 (279) 361.6 (34.8) 53.33 (6.52) 21.11 (3.20) 61-70 healthy 106 2627 (230) 383.6 (34.7) 52.52 (6.10) 19.83 (3.21) compromised 44 2392 (453) 440.9 (131.) 50.55 (7.24) 21.59 (4.03) 71-80 healthy 50 2530 (404) 406.9 (76.9) 54.32 (6.76) 20.08 (2.58) compromised 70 2413 (452) 429.7 (87.3) 51.30 (6.87) 21.51 (3.59) average of all groups 2639 (389) 388.8 (72.4) 52.76 (6.86) 20.12 (4.12) data from both eyes of the same individual were used to calculate the mean (sd) of the group. *measurements were available on a total of 501 eyes from 253 subjects. °cell density, average density of cells in the corneal specimen, in cells/mm2. #cell area, average area of cells in the corneal specimen, in μm2/cell. §pleomorphism, percentage of cells in the specimen that have a hexagonal shape. $polymegathism, coefficient of variation of cell size in the corneal specimen, in percentage units. table 3. mixed-models ancovas for diabetes effect adjusting for age, conducted on adult donors with healthy eye status. corneal cell measure total variance effect name estimate±se° df t p (units) (iec)* statistic cell area 2512.1 age# +1.36±0.24 179 +5.61 <.0001 (μm2/cell) (62.1%) diabetes§ –7.64±7.60 179 –1.01 0.32 (reference means)$ (384.46±4.26)^ (376.82±6.26)** cell density 101899 age# –9.71±1.58 179 –6.16 <.0001 (cells/mm2) (69.7%) diabetes§ +38.8±49.6 179 +0.78 0.43 (reference means)$ (2650.3±27.7)^ (2689.0±40.8)** pleomorphism (%) 46.355 age# –0.014±0.029 178 –0.48 0.63 (26.4%) diabetes§ –0.402±0.913 178 –0.44 0.66 (reference means)$ (53.287±0.512)^ (52.885±0.751)** polymegathism (%) 17.601 age# +0.022±0.019 179 +1.18 0.24 (37.2%) diabetes§ +0.103±0.586 179 +0.18 0.86 (reference means)$ (19.766±0.328)^ (19.869±0.482)** *inter-eye correlation between left and right eyeballs from the same donor; °standard error of the estimate. #slope of the linear age trend, in units/year, for subjects in the healthy eye-status group. §age-adjusted difference, diabetics minus non-diabetics, for subjects in the healthy eye-status group. $reference means are the predicted means of 60-year-old subjects in the healthy eye-status group, where ^ denotes the predicted mean of the non-diabetic 60-year-old and * denotes the predicted mean of the diabetic 60-year-old. reference means double as y-intercepts in the regression equations y = reference + slope x (age – 60), where y is the corneal-cell measure, age is the subject’s age in years, slope is the slope of the linear age trend, and reference is the reference mean denoted by ^ and **for non-diabetics and diabetics, respectively. non -co mmerc ial us e o nly [page 28] [eye reports 2011; 1:e9] (lowest p=0.32, cell area) on all four cell measures. table 3 also shows the ancova models’ predicted reference means for two 60-year-old individuals with healthy eye status, one with diabetes and one without, in order to facilitate biological interpretation of the diabetes effects. computations from the values in table 3 show that the reference diabetic had 2.0% lower cell area, 1.5% higher cell density, 0.7% lower pleomorphism, and 0.5% higher polymegathism than did the reference non-diabetic. it should be noted that the reference means in table 3 double as y-intercepts in the regression equations y = reference + slope x (age 60), where y is the predicted mean corneal-cell measure, age is the subject’s age in years, slope is the slope of the linear age trend, and reference is the appropriate reference mean for diabetics or non-diabetics with healthy eye status. graphic illustration of the results for cell density is shown in figure 1. age-adjusted diabetes effect in adult donors with compromised eye status the corneal-cell measures of adult donors with compromised eye status were likewise analyzed for age-adjusted diabetes effects using mixed-models regression techniques. again, none of the age trends had a significant quadratic component, indicating that it was reasonable to fit all corneal measures with linear trends. and again, all age-by-diabetes interactions were non-significant, indicating for each measure (i) that the linear trends had the same slope for diabetics versus non-diabetics, and therefore (ii) that mixed-models ancova was the appropriate analysis model. table 4 shows the results of the mixed-models ancovas on subjects with compromised eye status. inter-eye correlations ranged from a low of 24.9% for cell area to a high of 51.7% for cell density. the age effect was statistically significant (p=0.0075) with positive slope for cell area, highly significant (p=0.0017) with negative slope for cell density, insignificant (p=0.10) for pleomorphism, and statistically significant (p=0.010) with positive slope for polymegathism. the age-adjusted diabetes effects were statistically insignificant (lowest p=0.19, pleomorphism) on all four cell measures. table 4 also shows the ancova models’ predicted reference means for two 70-year-old individuals with compromised eye status, one with diabetes and one without, in order to facilitate biological interpretation of the diabetes effects. computations from the values in table 4 show that, compared to the reference non-diabetic, the reference diabetic had 2.1% higher cell area, 3.6% lower cell density, 3.4% lower pleomorphism, and 3.0% higher polymegathism. here, the reference means in table 4 double as y-intercepts in the regresarticle figure 1. corneal endothelial cell density as a function of age in donors with healthy eye status. vertical axis shows cell density in cells/mm2, while horizontal axis shows age in years. solid black circles (dashed black line) represent observed values (predicted means) of cell density in diabetics, while open gray circles (solid line) represent observed values (predicted means) of cell density in non-diabetics. the regression equation for diabetics (dashed black line) is: cell density (in cells/mm2) = 2689.0-9.71 x (age – 60), where age is in years. the regression equation for non-diabetics (solid gray line) is: cell density (in cells/mm2) = 2650.3-9.71 x (age – 60), where age is in years. figure 2. corneal endothelial cell density as a function of age in donors with compromised eye status. vertical axis shows cell density in cells/mm2, while horizontal axis shows age in years. solid black circles (dashed black line) represent observed values (predicted means) of cell density in diabetics, while open gray circles (solid line) represent observed values (predicted means) of cell density in non-diabetics. the regression equation for diabetics (dashed black line) is: cell density (in cells/mm2) = 2392.1-14.05 x (age – 70), where age is in years. the regression equation for non-diabetics (solid gray line) is: cell density (in cells/mm2) = 2482.3-14.05 x (age – 70), where age is in years. non -co mmerc ial us e o nly [eye reports 2011; 1:e9] [page 29] sion equations y = reference + slope x (age 70), where y is the predicted mean corneal-cell measure, age is the subject’s age in years, slope is the slope of the linear age trend, and reference is the appropriate reference mean for diabetics or non-diabetics with compromised eye status. graphic illustration of the results for corneal cell density is shown in figure 2. differences between ancovamodel results for subjects with healthy versus compromised eye status although the focus of this report is on the age-adjusted diabetes effect, it is reasonable to ask whether subjects having compromised eye status (table 4) differed significantly from subjects having healthy eye status (table 3) with respect to the age trend or age-adjusted diabetes effect in any corneal-cell measure. we investigated this question by combining the data for each corneal-cell measure from the two groups into a single mixed-models analysis, as described in the statistical analysis section. for polymegathism, the difference in age trends between tables 3 and 4 was almost significant (interaction p=0.07), but for the other three measures, the differences in age trends between tables was not significant (lowest interaction p=0.18). and none of the four corneal-cell measures showed a statistically significant difference in their diabetes effect between the two tables (lowest interaction p=0.21). however, likelihood-ratio chi-square tests showed that, when compared to subjects with healthy eye status, those with compromised eye status had significantly larger betweendonor and within-donor variances for both cell area and cell density. this finding reinforces the appropriateness of the decision to conduct separate analyses on subjects with healthy versus compromised eye status. for cell area, between-donor variance increased to 1.5-fold and within-donor variance increased to 7.5fold, such that total variance increased to 3.8fold (9565.0 divided by 2512.1) while iec fell by 37.2 percentage points (62.1% versus 24.9%) from table 3 to table 4 (c2=150.9, df=2; p<0.0001). for cell density, a similar analysis indicates that between-donor variance increased to 1.3-fold and within-donor variance increased to 2.8-fold, such that total variance increased to 1.8-fold (180,845 divided by 101,899) while iec fell by 18.0 percentage points (69.7% versus 51.7%) from table 3 to table 4 (c2=36.05, df=2; p<0.0001). on the other hand, the total variance and iec showed very little change between tables for pleomorphism (chi-square=0.14, df=2; p=0.93), and a suggestive, but insignificant change between tables for polymegathism (chi-square=4.81, df=2; p=0.090). discussion corneal endothelial cell density from eye bank donors was previously examined by the cornea donor study using 1101 qualified donor cornea collected from january 10, 2000 to august 2, 2002.22 these investigators noticed a non-linear age-dependent drop of cell density until age 60. beyond this point, the cell density changed little. it should be noted that only corneas qualified for that particular study were used in that analysis, which meant that all corneas analyzed in that report had a cell density between 2300-3300 cells/mm2.22 in contrast, our data included 253 research-consenting adult donors during years 2007 and 2008. consequently, ours reflected the raw data that one would encounter in a typical regional eye bank. results from this study indicated that there was an age-dependent decrease of corneal endothelial cell density in both eye-status groups (tables 3 and 4). it should be noted that, among those donors at >70 years old, ~73% (88 out of 120 eyes) met the standard (≥2,300 cells/mm2) set by the cornea donor study. thus, age alone should not be used as a criterion for donor cornea. in practice, our eye bank uses 2000 cells/mm2 as the cutoff criterion to determine whether the cell density of a donor cornea is qualified for transplant. according to data provided by the nih (year 2007), 10.7% (23.5 million) of the population in the united states age 20 years or older have diabetes. the prevalence of diabetes increased to 23.1% (12.2 million) of the population age 60 years or older.23 our data from 2007 and 2008 indicated that ~32% of our adult donors had diabetes, which was significantly higher than the 18% reported in the cornea donor study that involved 1,101 corneas.22 importantly, ~38% of donors among those 60 years or older in our study population had diabetes. this was much higher than the abovementioned 23.1% in the united state. based on the report from the arkansas department of health and human services,24 an estimated 233,255 adult residents in arkansas had diabetes in 2005. the cost of hospital charges was ~$87 million for arkansas in 2005, which included 651 lower extremity amputations and article table 4. mixed-models ancova of diabetes effect adjusting for age, conducted on adult donors with compromised eye status. corneal cell measure total variance effect name estimate±se° df t p (units) (iec)* statistic cell area 9565.0 age# +2.50±0.91 68 +2.76 0.0075 (μm2/cell) (24.9%) diabetes§ +8.71±18.72 68 +0.47 0.64 (reference means)$ (422.65±12.19)^ (431.36±14.55)** cell density 180845 age# –14.05±4.29 68 –3.27 0.0017 (cells/mm2) (51.7%) diabetes§ –90.2±89.4 68 –1.01 0.32 (reference means)$ (2482.3±58.2)^ (2392.1±69.5)** pleomorphism (%) 46.786 age# –0.108±0.065 68 –1.66 0.10 (31.3%) diabetes§ –1.773±1.341 68 –1.32 0.19 (reference means)$ (52.068±0.874)^ (50.295±1.043)** polymegathism (%) 13.240 age# +0.094±0.036 68 +2.63 0.010 (42.9%) diabetes§ +0.644±0.743 68 +0.87 0.39 (reference means)$ (21.182±0.484)^ (21.827±0.578)** *inter-eye correlation between left and right eyeballs from the same donor; °standard error of the estimate. #slope of the linear age trend, in units/year, for subjects in the compromised eye-status group. §age-adjusted difference, diabetics minus non-diabetics, for subjects in the compromised eye-status group. $reference means are the predicted means of 70-year-old subjects in the compromised eye-status group, where ^ denotes the predicted mean of the non-diabetic 70-year-old and ** denotes the predicted mean of the diabetic 70-year-old. reference means double as y-intercepts in the regression equations y = reference + slope x (age – 70), where y is the corneal-cell measure, age is the subject’s age in years, slope is the slope of the linear age trend, and reference is the reference mean denoted by ^ and ** for non-diabetics and diabetics, respectively. non -co mmerc ial us e o nly [page 30] [eye reports 2011; 1:e9] 1565 hospitalizations for ketoacidosis. this high prevalence of diabetic donors raised an important question, i.e., whether this disease can affect corneal endothelial cell quality, including cell density, thus compromising the number of qualifying corneas. this issue becomes even more important when we consider that the number of qualified corneas received in each eye bank may decrease because more and more refractory corneal procedures are being currently performed.25 the effect of diabetes on corneal endothelial cells was indeed a subject of discussion in several reports. based on a comparison of 30 diabetic patients and 30 non-diabetic subjects using contact specular microscope, siribunkum, et al. reported that the diabetics had statistically significant increase in corneal endothelial cell density and decrease in mean cell area.10 a comparison of 158 type ii diabetic patients and 165 control subjects led mathew, et al. concluded that type ii diabetes caused an increase (~5%) of corneal endothelial cell density.26 the finding of an increased endothelial cell density was not supported by other reports. for example, lee et al. conducted an age-adjusted comparison of 200 diabetics to 100 normal subjects, and found that that diabetics had statistically significantly less (~ 5%) cell density as compared to controls (diabetes: 2577±27, control: 2700±39). they also found that diabetics had more irregular shaped cells and more variation in cell sizes.12 modis, et al.27 recently reported that there was a statistically significant decrease (~3%) in endothelial cell density in type i diabetes relative to healthy subjects (2428±219 versus 2495±191). however, they did not find a statistically significant difference in endothelial cell density between type ii diabetes and age-matched controls. an earlier study by inoue et al. using a multivariate regression analysis comparing 99 diabetics and 97 control subjects also found that diabetics had lower endothelial cell density.11 in contrast to those reports above, other studies found diabetes did not cause statistical differences in corneal endothelial cell density. larsson, et al. analyzed 49 type i diabetics, 60 type ii diabetics and their respective agematched controls and found there was no difference in endothelial cell density between diabetics and control subjects.15 pardos and krachmer studied 52 diabetic patients with long-term (>14 years) proliferative retinopathy also found no evidence that diabetes caused statistically significant difference in endothelial cell density when compared to 32 control subjects.14 finally, inoue, et al. examined a group of 1394 cataract patients before their surgery procedures and found that the presence of type 2 diabetes had no effect on endothelial cell density in this particular group of patients.18 results from this study indicated that diabetes did not cause statistically different endothelial cell density (tables 3,4; figures 1,2), cell area, pleomorphism and polymegathism (tables 3,4), regardless of eye status. given our findings that corneas from diabetic donors are comparable to those from nondiabetic donors and are appropriate for cornea transplant, an important issue is whether corneas from diabetic donors perform as well as those from non-diabetic donors after the transplant surgery. this issue is important because a recent report by mathew, et al. indicated that surgeries that affect cornea, such as manual small incision cataract surgery, could cause a decrease in corneal endothelial cell density, and this decrease appeared to be more pronounced in type ii diabetic patients.26 based on this finding, there is a possibility that corneas from diabetic donors may behave differently compared to those from non-diabetic donors. we currently do not have data to address this issue and will investigate this in future studies. this current study was unique in two ways. while data from live volunteers reported in those above-mentioned reports were valid, they did not necessarily represent the population encountered in an eye bank. in contrast, this study was unique in that it represented the actual data from a regional eye bank where donor corneas were collected and shipped out routinely for corneal transplants. second, while other studies were performed in subjects without eye diseases and eye surgeries, we performed two parallel analyses on those with and those without compromised eye conditions. the same conclusion was achieved in both analyses. there were certainly some limitations to this study. first, it represented a set of 2-year data from an arkansas eye bank. this could be used to compare data from eye banks in other regions (e.g., alaska, maine or florida) or other countries (e.g., france, guatemala or australia) but it was not necessarily a fair representation of what they would encounter in those eye banks. second, this study used a closed pool of donors. instead of a continuous recruitment of volunteers to reach a certain target number (e.g., 100 diabetics and 100 controls), we used data from donors within a 2year period and had no control over how many subjects we would have in each category. also, there was a screening process of the potential donors before we collected their corneas. those did not meet our criteria were rejected, thus their data were not used for this analysis. furthermore, we were limited to use only data from those donors who consented to our research. in this regard, we were fortunate to have ~94% of adult donors who gave informed consent to use their data for research. an additional limitation we encountered in carrying out this project was that we obtained the information regarding diabetes from the medical/social history questionnaire, which gave us a positive identification of diabetic donors but was limited such that it was without detailed disease history for each individual. we do not have a detailed record of type i versus type ii diabetes for each donor. as a result, we grouped both types together in the analysis. consequently, we could not conclude whether type i diabetes was significantly different from type ii diabetes for those parameters we evaluated in this study. in a report analyzing corneal endothelial cells in patients with type i and type ii diabetes, modis, et al. concluded that type i diabetic corneas were more susceptible to environmental changes than type ii corneas.27 based on their findings, there is a possibility that corneas from type i and type ii diabetic donors may perform differently after the transplant. this issue warrants further investigation in the future. in conclusion, we performed a study on data collected from the arkansas lions eye bank and laboratory during 2007 and 2008. in findings similar to those of other studies, we observed among subjects with healthy eye status (table 3) an age-dependent decrease in corneal endothelial cell density and an age-dependent increase in cell area, along with statistically insignificant age trends in percentage of hexagonal cells and coefficient of variation in cell size. among subjects with compromised eye status (table 4), we observed statistically significant age-dependent decrease in cell density as well as increase in cell area and variation in cell size. the age trend for percentage of hexagonal cells was not significant. importantly, subjects with compromised eye status had significantly larger variance components for cell density and cell area; for both measures, the difference was especially pronounced for the component of variance between eyeballs within the same donor. this finding suggests that previous studies12-15,17,18 were prudent to have excluded subjects with eye disease or past eye surgeries. also importantly, there was a large percentage of donors who had diabetes: 32% overall, 29% among subjects with healthy eye status and 40% among subjects with compromised eye status. differences in corneal measures between diabetic and non-diabetic subjects were analyzed in both eye-status groups via separate, parallel mixed-models ancovas. results indicated that, when adjusted for age, diabetes did not have a statistically significant impact on corneal endothelial cell density, cell area, pleomorphism and polymegathism, either in subjects with healthy eye status, or in subjects whose status was compromised by eye disease or history of eye surgeries. based on the parameters analyzed in this study, corneas from diabetic donors were comparable to those from non-diabetic donors for cornea transplants. future analysis is required to determine whether the outcomes of corneal transplant are comparable from corneas article non -co mmerc ial us e o nly [eye reports 2011; 1:e9] [page 31] obtained from diabetic and non-diabetic donors, and whether corneas from type i and type ii diabetic donors perform equally well after the transplant. references 1. moffatt sl, cartwright va, stumpf th. centennial review of corneal transplantation. clin experiment ophthalmol 2005;33: 642-57. 2. ebaa. eye bank association of america press release (april 24, 2009). http://www.restoresight.org/files/2008pres srelease_statreport.pdf accessed: 22 september 2009. 3. yee rw, matsuda m, schultz ro, edelhauser hf. changes in the normal corneal endothelial cellular pattern as a function of age. curr eye res 1985;4:671-8. 4. matsuda m, yee rw, edelhauser hf. comparison of the corneal endothelium in an american and a japanese population. arch ophthalmol 1985;103:68-70. 5. rao sk, ranjan sen p, fogla r, et al. corneal endothelial cell density and morphology in normal indian eyes. cornea 2000;19:820-3. 6. padilla md, sibayan sa, gonzales cs. corneal endothelial cell density and morphology in normal filipino eyes. cornea 2004;23:129-35. 7. ashraf km, saeed mu, zia r. corneal endothelial cell density in a normal pakistani population. eye (lond) 2006;20:116-8. 8. hashemian mn, moghimi s, fard ma, et al. corneal endothelial cell density and morphology in normal iranian eyes. bmc ophthalmol 2006;6:9. 9. yunliang s, yuqiang h, ying-peng l, et al. corneal endothelial cell density and morphology in healthy chinese eyes. cornea 2007;26:130-2. 10. siribunkum j, kosrirukvongs p, singa lavanija a. corneal abnormalities in diabetes. j med assoc thai 2001;84:1075-83. 11. inoue k, kato s, inoue y, et al. the corneal endothelium and thickness in type ii diabetes mellitus. jpn j ophthalmol 2002;46: 65-9. 12. lee js, oum bs, choi hy, et al. differences in corneal thickness and corneal endothelium related to duration in diabetes. eye (lond) 2006;20:315-8. 13. roszkowska am, tringali cg, colosi p, et al. corneal endothelium evaluation in type i and type ii diabetes mellitus. ophthalmologica 1999;213:258-61. 14. pardos gj, krachmer jh. comparison of endothelial cell density in diabetics and a control population. am j ophthalmol 1980; 90:172-4. 15. larsson li, bourne wm, pach jm, brubaker rf. structure and function of the corneal endothelium in diabetes mellitus type i and type ii. arch ophthalmol 1996; 114:9-14. 16. matsuda m, ohguro n, ishimoto i, fukuda m. relationship of corneal endothelial morphology to diabetic retinopathy, duration of diabetes and glycemic control. jpn j ophthalmol 1990;34:53-6. 17. quadrado mj, popper m, morgado am, et al. diabetes and corneal cell densities in humans by in vivo confocal microscopy. cornea 2006;25:761-8. 18. inoue k, tokuda y, inoue y, et al. corneal endothelial cell morphology in patients undergoing cataract surgery. cornea 2002;21:360-3. 19. littell rc, ed. sas system for mixed models. 4th ed. analysis of covariance. cary, nc: sas institute; 1996. pp. 171-227. 20. ray wa, o'day dm. statistical analysis of multi-eye data in ophthalmic research. invest ophthalmol vis sci 1985;26:1186-8. 21. rosner b. statistical methods in ophthalmology: an adjustment for the intraclass correlation between eyes. biometrics 1982;38:105-14. 22. sugar a, gal rl, beck w, et al. baseline donor characteristics in the cornea donor study. cornea 2005;24:389-96. 23. national diabetes statistics, 2007 fact sheet. national institute of diabetes and digestive and kidney diseases. u.s. department of health and human services, national institutes of health. http://diabetes.niddk.nih.gov/dm/pubs/statistics/ accessed: 22 september 2009. 24. seaton d. diabetes: the burden of diabetes in the natural state. 2007. http://www.healthy.arkansas.gov/programs services/epidemiology/chronicdisease/do cuments/publications/diabetes_report200 7.pdf accessed: 22 september 2009. 25. chu w. the past twenty-five years in eye banking. cornea 2000;19:754-65. 26. mathew pt, david s, thomas n. endothelial cell loss and central corneal thickness in patients with and without diabetes after manual small incision cataract surgery. cornea 2011;30:424-8. 27. modis l jr, szalai e, kertesz k, et al. evaluation of the corneal endothelium in patients with diabetes mellitus type i and ii. histol histopathol 2010;25:1531-7. article non -co mmerc ial us e o nly [page 1] correspondence: conflict of interest: the authors report no conflicts of interest. ana ibáñez muñoz, md contributions: all authors contributed equally. department of ophthalmology accepted for publication: april, 2019 san pedro hospital this work is licensed under a creative commons attribution piqueras 98, 26007 logroño, spain non-commercial 3.0 license (cc by-nc 3.0). e-mail: anciban82@hotmail.com ©copyright muñoz et al., 2019. phone: (34) 675613259 licensee ophthoscience publishers, usa [page 2] [page 3] [page 4] [page 5] [page 1] correspondence: conflict of interest: the authors report no conflicts of interest. irune ortego renedo, md contributions: all authors contributed equally. ophthalmology department accepted for publication: october, 2020 san pedro hospital this work is licensed under a creative commons attribution logroño, spain non-commercial 3.0 license (cc by-nc 3.0). email: iruneortega.io@gmail.com ©copyright renedo, et al., 2020. phone: +34 628 649 935 license ophthoscience publishers, usa [page 2] a b [page 3] [page 4] [page 5] β [page 15] correspondence: conflict of interest: the authors report no conflicts of interest. ozgun melike gedar totuk, md contributions: all authors contributed equally. department of ophthalmology accepted for publication: april, 2019 bahecesehir university this work is licensed under a creative commons attribution #66-68 sahrayicedit, kadikoy, istanbul, turkey non-commercial 3.0 license (cc by-nc 3.0). e-mail: melikegedar@gmail.com ©copyright totuk et al., 2019. phone: (90) 5333367986 licensee ophthoscience publishers, usa [page 16] [page 17] [page 21] correspondence: conflict of interest: the authors report no conflicts of interest. erol havuz, md contributions: all authors contributed equally. university of health sciences accepted for publication: october, 2020 suam samsun hospital this work is licensed under a creative commons attribution samsun, turkey non-commercial 3.0 license (cc by-nc 3.0). email: erolhavuz@gmail.com ©copyright havuz, 2020. phone: +90 505 641 99 95 licensee ophthoscience publishers, usa [page 22] [page 23] ń [page 24] [page 17] correspondence: conflict of interest: the authors report no conflicts of interest. emma c. davies, md contributions: all authors contributed equally. massachusetts eye and ear infirmary accepted for publication: may, 2018 harvard university this work is licensed under a creative commons attribution boston, ma non-commercial 3.0 license (cc by-nc 3.0). e-mail: emma_davies@meei.harvard.edu ©copyright davies et al., 2018. phone: (617) 573-4393 licensee ophthoscience publishers, usa [page 18] [page 19] [page 9] correspondence: conflict of interest: the authors report no conflicts of interest. arzu taskiran comez, md contributions: all authors contributed equally. eye department, conakkale onsekiz mart university accepted for publication: march 5, 2020 pamira park su evleri no 2 this work is licensed under a creative commons attribution guzelyali canakkale, turkey non-commercial 3.0 license (cc by-nc 3.0). e-mail: arzucomez@yahoo.com ©copyright comez and yildiz, 2020. phone: (90) 533-420-2430 licensee ophthoscience publishers, usa [page 10] [page 11] [page 12] [page 6] correspondence: conflict of interest: the authors report no conflicts of interest. zeynep eylül ercan contributions: all authors contributed equally. ophthalmology department accepted for publication: october, 2020 hitit university this work is licensed under a creative commons attribution corum, turkey non-commercial 3.0 license (cc by-nc 3.0). email: eylulercan@doctor.com ©copyright ercan, et al., 2020. phone: + 90 532 205 9636 license ophthoscience publishers, usa [page 7] [page 8] ş μ [page 9] [page 10] [page 11] [page 12] [page 13] 