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Arteriovenous Dissection in a Living Human Vienna, Austria, 1990. Dordrecht, Holland: Klu- Table 2. Ultrasonographic Findings of 25 Well-Documented Patients wer Academic Publishers; 1993:307-311. With Cavitary Melanoma of the Uvea in English Literature 9. Frazier-Byrne S, Green RL. Intraocular tumors. In: Frazier-Byrne S, Green RL, eds. Ultrasound of the Eye and Orbit. 2nd ed. St Louis, Mo: Ultrasonographic Findings Mosby; 2002:115-190. 10. Scott CT, Holland GN, Glasgow BJ. Cavita- Solid % Mass tion in ciliary body melanoma. Am J Ophthalmol. Component Loculation Echoes in Septa in Thickness Occupied 1997;123:269-271. Source Present on USG Cavitation Cavitation by Cavity 11. Cohen PR, Rapini RP. Nevus with cyst: a re- port of 93 cases. Am J Dermatopathol. 1993; Kennedy5 NA NA NA NA NA 15:229-234. NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA Reese6 NA NA NA NA NA Arteriovenous Dissection Zakka et al7 ϩ Unilocular ϩ −NA in a Living Human Eye: Stone and Shapiro4 ϩ Unilocular ϩ −65 ϩ Unilocular ϩ −75 Clinicopathologic − Unilocular ϩ −60 Correlation ϩ Unilocular − − 30 ϩ Multilocular ϩϩ 40 Fledelius et al8 − Unilocular − − 75 Although the visual results after ar- Scott et al10 − Multilocular ϩϩ NA teriovenous dissection (AVD) seem 1,2 Lois et al2 − Unilocular ϩ −79 encouraging, its effectiveness has ϩ Unilocular − − 59 not been proved in a controlled, pro- ϩ Multilocular − ϩ 31 spective clinical trial. The role of sur- ϩ Multilocular ϩϩ 59 gical decompression itself remains ϩ − Unilocular −64 unclear,3 and little is known about − Multilocular ϩϩ 62 ϩ Unilocular ϩ −55 surgically induced nerve fiber de- ϩ Multilocular ϩϩ 38 fects. The goal of this study was to Rebolleda et al3 ϩ Multilocular ϩϩ 50 observe the effects of an AVD on un- Frazier Byrne ϩ Unilocular ϩ −30 affected human retinal tissue. and Green9 ϩ Multilocular ϩϩ 35 Report of a Case. We treated an 80- ϩ Abbreviations: NA, not available; USG, ultrasonography; −, absent; , present. year-old woman with an advanced sebaceous carcinoma of her right up- ratory, 93 (.9%) nevi were found to ogy; November 15, 2003; Ana- per eyelid. To achieve complete tu- have cavities.11 heim, Calif; and at the Eastern mor removal, we had to exenterate Ophthalmic Pathology Meeting; Oc- the orbit. After receiving approval by Junjun Zhang, MD tober 3, 2003; Durham, NC. our local ethics committee, we tried Hakan Demirci, MD to perform an AVD before remov- Carol L. Shields, MD 1. Shields JA, Shields CL. Clinical features of pos- ing the eye. John A. Leon, MD terior uveal melanoma. In: Shields JA, Shields After a standard vitrectomy, the CL, eds. Atlas of Intraocular Tumors. Philadel- Jerry A. Shields, MD phia, Pa: Lippincott Williams & Williams; 1999: internal limiting membrane was re- Ralph C. Eagle, Jr, MD 73-94. moved from its position over an ar- 2. Lois N, Shields CL, Shields JA, Eagle RC Jr, De Potter P. Cavitary melanoma of the ciliary body: teriovenous crossing. The common Financial Disclosure: None. a study of eight cases. Ophthalmology. 1998; adventitial sheath over the arterio- Correspondence: Dr Shields, 105:1091-1098. venous crossing was opened with a 3. Rebolleda G, Suarez Figueroa M, Munoz- Ocular Oncology Service, Wills Negrete FJ, Rocamora A. Magnetic resonance bent blade. We then tried to sepa- Eye Hospital, 840 Walnut St, imaging in cavitary choroidal melanoma. Eur rate the overlying artery by using a Philadelphia, PA 19107 (mvenditto J Ophthalmol. 2000;10:335-337. blunt hook and a sharp blade. With 4. Stone RD, Shapiro DR. Ultrasonically diag- @shieldsoncology.com). nosed cystic ciliary body melanomas. In: Thi- these techniques, we could remove Funding/Support: Support pro- jssen JM, Hilman JS, Gallenga PE, Cennamo G, the artery from the vein except for the eds. Ultrasonography in Ophthalmology 11, Pro- vided by the Paul Kayser Interna- ceedings of the 11th SIDUO Congress. Capri, Italy: common juncture right at the cross- tional Award of Merit in Retina Re- 1986. Dordrecht, Holland: Kluwer Academic ing. The entire specimen was im- search, Houston, Tex (Dr J. Shields), Publishers; 1988:171-184. mersed for light microscopy. 5. Kennedy RE. Cystic malignant melanomas of Macula Foundation, New York, NY the uveal tract. Am J Ophthalmol. 1948;31: Results of histological examina- (Dr C. Shields), the Noel T. and 159-167. tion confirmed the diagnosis of a se- Sara L. Simmonds Endowment for 6. Reese AB. Pigment tumor. In: Reese AB, ed. Tu- baceous carcinoma. In the surgi- mors of the Eye. New York, NY: Paul B Hoeber Ophthalmic Pathology, Wills Eye Inc; 1951:198-349. cally treated areas of the retina, the Hospital (Dr Eagle) and the Eye 7. Zakka KA, Foos RY, Spencer WH, Kerman BM, nerve fiber layer was remarkably Newman NM, Pettit TH. Cavitation in intra- Tumor Research Foundation, Phila- ocular malignant melanoma. Arch Ophthalmol. damaged and the internal limiting delphia, PA (Dr C. Shields). 1982;100:112-114. membrane was absent (Figure 1). Previous Presentation: This report 8. Fledelius HC, Prause JU, Scherfig E. Tumors Deeper retinal layers were relaxed of the choroid, three unusual cases examined by was presented at the American As- ultrasound. In: Till P, ed. Ophthalmic Echogra- and edematous. The connection be- sociation of Ophthalmic Pathol- phy 13, Proceedings of the 13th SIDUO Congress, tween the artery and vein was very (REPRINTED) ARCH OPHTHALMOL / VOL 123, APR 2005 WWW.ARCHOPHTHALMOL.COM 571 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Furthermore, our study strength- ens the clinical and histological cor- relations regarding the previously described tight connection of the crossing vessels by documenting these precisely in the living eye and pro- 4,5 V viding histological correlation. We therefore tend to doubt reports of suc- A cessful and simple separation with the technique described herein. Some groups reported the successful use of scissors.1,2 However, having the nerve fiber layer damage in mind, the use of scissor may lead to greater retinal damage compared with the use of blades. Our experience leads us to main- tain that it is not feasible to cut such thin tissue with a blade or scissors, al- though our results reflect the find- ings in only 1 eye. We recommend Figure 1. Surgically damaged retina with a gap beside (arrows) and between the vessels. A indicates that future studies concentrate on retinal artery; V, retinal vein (hematoxylin-eosin; original magnification ϫ200). whether successful vessel separation correlates to visual improvement. Nicolas Feltgen, MD Claudia Auw-Haedrich, MD Renate Buchen, MT Lutz L. Hansen, MD A Financial Disclosure: None. Correspondence: Dr Feltgen, De- partment of Ophthalmology, Uni- versity of Freiburg, Killlianstrasse 5, 79106 Freiburg, Germany (feltgen @aug.ukl.uni-freiburg.de). 1. Mester U, Dillinger P. Vitrectomy with arterio- venous decompression and internal limiting membrane dissection in branch retinal vein occlusion. Retina. 2002;22:740-746. V 2. Osterloh M. Surgical decompression of branch retinal vein occlusions. Arch Ophthalmol. 1988; 106:1469-1471. 3. Han D, Benett S, Williams D, Dev S. Arteriove- nous crossing dissection without separation of the retina vessels for treatment of branch reti- nal vein occlusion. Retina. 2003;23:145-151. 4. Tang W, Han D. A study of surgical approaches 20 µm on retinal vascular occlusions. Arch Ophthalmol. Figure 2. At the crossing, the vessels are clearly not dissected (arrows). The distance between both lumina 2000;118:138-143. is 4.48 µm. A indicates retinal artery; V, retinal vein (hematoxylin-eosin; original magnification ϫ600). 5. Seitz R. Die Netzhautgefäße. Stuttgart, Ger- many: Georg Thieme Verlag; 1962. tight at the arteriovenous crossing study—are of 6 enucleated human itself, where the vessels obviously eyes from an eye bank.4 To date, the could not be dissected (Figure 2). complication rate of AVD has been Cytomegalovirus Retinitis Serial sections showed that the dis- low, but little is known about nerve in an Immunocompetent tance across the adjoining vascular fiber layer damage. Patient walls separating the lumina of the 2 Our histological findings have vessels was as little as 4.48 µm. confirmed our assumption of a pro- Cytomegalovirus (CMV) retinitis is nounced nerve fiber layer defect. We typically seen in immunocompro- Comment. In the present study, we are concerned about this issue, as we mised patients. Groups at risk for tried to focus on the histological dam- would anticipate visual field de- CMV retinitis include patients with age after AVD in a living human eye. fects. However, the effects of AVD AIDS with a CD4 cell count less than The only histological results pre- on the visual field remain un- 50/µL,1 kidney transplant patients un- sented in the literature—by a single known and deserve investigation. dergoing long-term immunosuppres- (REPRINTED) ARCH OPHTHALMOL / VOL 123, APR 2005 WWW.ARCHOPHTHALMOL.COM 572 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021.
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