Periocular Skin Lesions Research Articles

Optical Coherence Tomography of Peri-Ocular Skin Cancers: An Optical Biopsy

Introduction: Optical coherence tomography (OCT) imaging has been used as a diagnostic tool for retinal disease for several years, and OCT apparatuses are becoming increasingly powerful. However, OCT has yet to reach its full potential in ophthalmology clinics. Alike retinal layers, it has been shown that OCT is able to generate cross-sectional images of the skin and allows visualization of skin lesions in a histopathology-like manner. Objective: We aim to validate OCT as an imaging modality for peri-ocular skin cancer. Through a series of cases, we highlight findings for 3 common eyelid malignancies: basal cell carcinoma, squamous cell carcinoma and sebaceous carcinoma. We propose an OCT image-based signature for basal cell carcinoma. Methods: This is a prospective study. Fifty-eight lesions suspicious of malignancy from 57 patients were subjected to OCT imaging prior to the surgical excision of the lesion. OCT images were analysed and scored according to previously identified OCT features. Eight representative examples are presented, highlighting the OCT patterns for each malignancy side by side to its corresponding histopathological sections. Results: Out of the 58 lesions analysed, 53 were malignant. A loss of the dermal-epidermal junction is observed in all malignant lesions. A strong link is observed between the presence of subepithelial hyporeflective nests on OCT and the diagnosis of basal cell carcinoma (present in 83% of cases). Conversely, lesions of epithelial origin such as squamous cell carcinoma are most often represented on OCT by acanthosis. Two supplementary cases, one basal cell carcinoma and one sebaceous carcinoma, are provided to illustrate how OCT imaging is a valuable tool in cases where clinical observations may be unusual. Conclusions: We provide evidence supporting the use of OCT for the evaluation of peri-ocular cancers. OCT enables visualization of the skin layers in vivo, before biopsy. Our results show that certain OCT features can contribute to include or exclude a diagnosis of basal cell carcinoma. By integrating this non-invasive imaging methodology into the routine assessment of peri-ocular skin lesions, especially in health care centres where access to specialists is limited, OCT imaging can increase clinical precision, reduce delays in patient referral and enhance patient care.

Novel application of anterior segment optical coherence tomography for periocular imaging

This study aims to assess the use of optical coherence tomography (OCT) imaging for periocular skin lesions and to determine which characteristic features of these images can be correlated to histopathology. This is an ongoing prospective study with Research Ethics Board approval. Fifty patients over 18 years old with lesions clinically suspicious of nonmelanoma skin cancer on the periocular region were included in this study. After consent was obtained, clinical photographs and dermatoscopic images were obtained (DermLite II Hybrid M) from the lesion and its contralateral side. Subsequently, the patient was subjected to OCT imaging using the anterior segment module of a spectral domain OCT (Optovue Avanti) and images of the contralateral skin were also obtained. Surgical excision of the lesion was performed and sent for histopathological examination as per routine treatment. OCT images were then correlated to their matching digitalized histopathology section (Philips Ultra Fast Scanner 1.6 RA). Based on the OCT images acquired from 50 patients, 8 predominant architectural features have been correlated to histopathology: hyperkeratosis, acanthosis, loss of dermal-epidermal junction delineation, hyporeflective tumour nests, cystic structures, "bunch of grapes" nodules, hyperreflective nests, and ulcerations. Results observed from 45 malignant lesions (basal cell carcinoma, squamous cell carcinoma, and sebaceous gland carcinoma) suggest that groups of features and their layout within the same OCT image may be associated to specific tumour characteristics. Current data suggest that anterior-segment OCT imaging is a noninvasive imaging modality for periocular lesions and may be a valuable tool to help differentiate between some tumour types before a biopsy is performed.

Surgical treatment of eyelid tumors

Eyelid tumors are often periocular skin lesions but can also be derived from adnexal structures or the conjunctiva. Treatment is primarily surgical, especially for malignant tumors, whereby complete excision is strived for to minimize the local rate of recurrence. Adjuvant therapy and conservative alternative methods (e.g. radiotherapy, cryotherapy and immunomodulation) are reserved for specific cases. The main goal for reconstruction of the eyelids is the functional and aesthetic rehabilitation. This article focuses on the principles and underlying techniques for the reconstruction of the periocular region.

Clinical efficacy of autogenous septal cartilage on cleft lip nasal deformity

Objective To explore the application of kite flap in soft tissue defect of eyelid and periocular skin. Methods A triangular ( kite ) flap was designed in close proximity to the defect after eyelid and periocular skin lesions. Under orbicular muscle or fascia, the flap with muscle or fascia was removed. Since 2011, we have selected 50 patients aged 16-70 years. Results All incisions were primary healing, no recurrence of the lesion and all flaps survived, Follow up for 1 to 5 years showed that the scar of the incision was not obvious, no tissue organ was displaced, and the form of the eyelid and eyebrow on both sides was naturally smooth and symmetrical. Conclusions For the soft tissue defect of the eyelid and periocular skin, not suitable for direct suture, the kite flap can be used for the repair, which is simple and easy, with ideal results. Key words: Eyelids; Skin diseases; Reconstructive surgical procedures; Soft tissue; Defects; Kites flap

Butcherbird polyomavirus isolated from a grey butcherbird (Cracticus torquatus) in Queensland, Australia

A novel avian polyomavirus was detected in peri-ocular skin lesions collected from a grey butcherbird (Cracticus torquatus), using a combination of multiply primed rolling circle amplification, nested PCR and long range PCR. The sequence of Butcherbird polyomavirus was determined by combining next generation sequencing and primer walking techniques. The circular double-stranded DNA genome of Butcherbird polyomavirus consisted of 5084bp, and encoded six open reading frames (ORF-X, VP2, VP3, VP1, small T-antigen and large T-antigen). Phylogenetic analysis placed it amongst other members of the genus Avipolyomavirus, most closely related to Crow polyomavirus. Next generation sequencing enabled the detection of DNA fragments similar to, but distinct from, Canarypox virus within the same lesion from which Butcherbird polyomavirus was amplified, thus confirming an avipolyomavirus-avipoxvirus co-infection in the peri-ocular skin lesions of this grey butcherbird.

The ophthalmic side-effects of imiquimod therapy in the management of periocular skin lesions

AimTo describe the ophthalmic side-effects of topical imiquimod for periocular actinic keratoses, squamous cell carcinoma in situ and basal cell carcinoma.MethodA retrospective study was carried out in two centres of...

Periorbital dermatitis: Causes, differential diagnoses and therapy

Periorbital dermatitis is common and frequently difficult to treat. Patients with periorbital dermatitis often suffer severely because their disease is in such a visible location. Because of the variety of clinical appearance, the differential diagnostic considerations are often difficult. We examined the causes of periorbital dermatitis and compared the data of 88 patients from the Department of Dermatology, University Hospital Erlangen to those of the German IVDK (Information Network of the Departments of Dermatology). Between 1999 and 2004, predominant causes of periorbital dermatitis were allergic contact dermatitis (Erlangen 44%, IVDK 32%), atopic eczema (Erlangen 25%, IVDK 14%), airborne contact dermatitis (Erlangen 10%, IVDK 2%) and irritant contact dermatitis (Erlangen 9%, IVDK 8%). Less frequent causes for secondary eczematous periocular skin lesions were periorbital rosacea, allergic conjunctivitis or psoriasis vulgaris. Female gender, atopic skin diathesis and age of 40 years and older were identified as risk factors for periocular dermatitis. Common elicitors of periorbital allergic contact dermatitis were leave-on cosmetic products (face cream, eye shadow) and eye drops with the usual allergens being fragrances, preservatives and drugs. Exact identification of relevant contact allergens and allergen elimination are essential for successful treatment. Calcineurin inhibitors are the first-line therapy for facial atopic eczema. They may be also effective in periocular eczematous lesions of other origins although they are not approved for such use.

CD154 signaling regulates the Th1 response to herpes simplex virus-1 and inflammation in infected corneas.

Approximately 7 days after HSV-1 corneal infection, BALB/c mice develop tissue-destructive inflammation in the cornea termed herpes stromal keratitis (HSK), as well as periocular skin lesions that are characterized by vesicles, edema, and fur loss. CD4(+) T cells and Th1 cytokines contribute to both the immunopathology in the cornea and the eradication of viral replication in the skin. We demonstrate that disruption of CD40/CD154 signaling does not impact the initial expansion of CD4(+) T cells in the draining lymph nodes, but dramatically reduces the persistence and Th1 polarization of these cells. Despite the reduced Th1 response, CD154(-/-) mice developed HSK and periocular skin disease with similar kinetics and severity (as assessed by clinical examination) as wild-type (WT) mice. However, when the composition of the inflammatory infiltrate was examined by flow cytometric analysis, CD154(-/-) mice exhibited significantly fewer CD4(+) and CD8(+) T cells and neutrophils than WT mice at the peak of HSK. Moreover, CD4(+) T cells from infected corneas of CD154(-/-) mice produced significantly less IFN-gamma than those of WT mice when stimulated with viral Ags in vitro. The IFN-gamma production of cells from infected corneas of WT mice was not affected by addition of anti-CD154 mAb to the stimulation cultures. This suggests that CD154 signaling is required at the inductive phase, but not at the effector phase, of the Th1 response within the infected cornea. We conclude that local disruption of CD40/CD154 signaling is not likely to be a useful therapy for HSK.

On the essential involvement of neutrophils in the immunopathologic disease: herpetic stromal keratitis.

Corneal infection with herpes simplex virus-1 in immunocompetent mice induces an immunopathologic response termed herpetic stromal keratitis (HSK). The earliest sign of disease is neutrophil infiltration, which lasts for 48 to 72 h and then disappears. However, a secondary neutrophil infiltration, this time more massive, occurs, beginning 8 to 9 days postinfection, a time in which HSK becomes clinically evident. The role of neutrophils in HSK expression was investigated by eliminating such cells using a specific mAb (RB6-8C5). In neutrophil-depleted immunocompetent mice, virus replicated more abundantly, but no effects on HSK expression were observed, possibly because sustained neutropenia could not be maintained. However, using a severe combined immunodeficient mouse model, in which HSK does not occur unless given adoptive transfer of CD4+ T cells, the effects of neutrophil depletion were more pronounced. There were significantly less incidence and severity of HSK in CD4+ T cell-reconstituted severe combined immunodeficient mice that were depleted of neutrophils as compared with controls. Neutrophil-depleted mice displayed moderate to severe periocular skin lesions, progressively became cachetic, and developed signs of encephalitis. Virus was recovered at higher titers and for longer periods from eyes of neutrophil-depleted animals. Brain virus titers were also significantly higher on day 12 postinfection as compared with control animals. These results suggest that herpes simplex virus infection of the cornea rapidly invokes recruitment of neutrophils that may aid in viral clearance, and that neutrophils directly or indirectly serve as agonists in perpetuating a CD4+ T cell-mediated inflammatory reaction.

Characterization of herpes simplex virus type-1 infection and herpetic stromal keratitis development in IFN-gamma knockout mice.

Herpetic stromal keratitis (HSK) has an immune-mediated pathogenesis that involves T cells that have a type 1 cytokine profile. IFN-gamma is suspected to be the type 1 cytokine involved in ocular pathology, and to test this notion more directly the pathogenesis of HSK was compared in mice deficient in the IFN-gamma gene (gamma knockout or gko) and control mice (wild-type littermates or BALB/c mice). The clinical course of HSK in gko mice closely paralleled that in control mice, yet virus persisted in the corneas of gko mice for an extended period of time, severe periocular skin lesions developed, and gko mice were far more susceptible to encephalitis. Delayed-type hypersensitivity to viral Ag was present, though diminished, in knockout mice, and serum herpes simplex virus-specific IgG isotypes indicated a Th2 shift. No differences existed in proliferative responses to in vitro Ag stimulation in gko vs control mice nor in T cell or proinflammatory cytokine mRNA levels in the corneas of infected mice. However, up-regulation of Th2 cytokine mRNA did occur in in vitro Ag-stimulated gko immune splenocytes. Histopathologic lesions were not statistically different between any of the groups of mice analyzed. These observations indicate that although IFN-gamma plays an important role in the clearance of virus from the eye, the pathogenesis of HSK lesions most likely involves additional cytokines, inflammatory mechanisms, or immune responses to nonviral Ags.

IFN-gamma and IL-2 are protective in the skin but pathologic in the corneas of HSV-1-infected mice.

HSV type 1 (HSV-1) infection of the mouse cornea results in a tissue-destructive inflammatory reaction in the cornea, but little or no disease in the skin surrounding the eye. Depleting T lymphocytes from mice before HSV-1 corneal infection prevents the corneal inflammation but severely exacerbates the periocular skin lesions. Studies described in this communication investigated the role of T cell cytokines in the corneal and periocular skin disease induced by HSV-1 corneal infection. Mice received weekly i.p. injections of rat mAb specific for IL-2, IL-4, or IFN-gamma beginning 1 day before (day -1) or 6 days after (day +6) corneal infection with the RE strain of HSV-1. The severity of corneal inflammation and the area of periocular skin involvement were measured. Treatment with anti-IFN-gamma or anti-IL-2 significantly reduced the incidence and severity of corneal inflammation. Treatment was equally effective when initiated on day -1 (before T cell activation) or day +6 (after T cell activation but before the initiation of corneal inflammation). Treatment with anti-IL-4 had no effect. The histologic features of corneal inflammation in mock-treated mice included neovascularization, corneal edema, and cellular infiltration. Corneas of anti-IL-2-treated mice that developed inflammation had similar but less severe histologic features. Corneas of anti-IFN-gamma-treated mice that developed inflammation had neovascularization and edema but minimal cellular infiltration. Treatment with anti-IFN-gamma or anti-IL-2 significantly exacerbated periocular skin lesions when initiated at day -1, but not when initiated at day +6. Anti-IL-4 treatment had no effect on skin lesions. Treatment with either anti-IFN-gamma or anti-IL-2, when initiated at day -1, significantly inhibited the delayed-type hypersensitivity response to HSV Ag, but when treatment was begun at day +6 only anti-IFN-gamma significantly inhibited the delayed-type hypersensitivity response. Our findings suggest that IFN-gamma and IL-2 are important elements in both an immunopathologic T-lymphocyte response to HSV-1 Ag in the cornea and a protective T lymphocyte response in the skin.

Varied Clinical Spectrum of Necrobiotic Xanthogranuloma

Four cases are presented that illustrate a wide spectrum of ophthalmologic and systemic features of necrobiotic xanthogranuloma (NXG). Case 1 initially had signs of Cogan syndrome, and then developed chronic lymphocytic leukemia. Case 2, the first case of NXG to undergo autopsy, had progressive cicatricial lid retraction and corneal perforation. Case 3 had a more typical presentation of diplopia and blepharoptosis caused by orbital and periorbital infiltrative masses. Case 4 had nondeforming periocular skin lesions over a 6-year period. In all four cases, the diagnosis was made on the basis of characteristic histopathologic and laboratory findings. Although the cause of NXG is still obscure, in many cases it appears to be a forerunner of lymphoproliferative diseases.

Concurrent regeneration of T lymphocytes and susceptibility to HSV-1 corneal stromal disease

In these studies, mice were simultaneously depleted of CD4 and CD8 T lymphocytes (T cell-depleted) by weekly intraperitoneal injections of rat monoclonal antibodies specific for L3T4 and Lyt-2 respectively, beginning 1 day before topical corneal infection with KOS herpes simplex virus type 1 (HSV-1). Control mice were mock-depleted by weekly injections of saline. All mice developed dendritic epithelial lesions 2-3 days after infection, which healed within 2 days. Fifty percent of the mock-depleted mice developed severe HSV-1 stromal disease, which began 9-14 days after infection. No skin lesions were observed in mock-depleted mice. In contrast, none of the T cell-depleted mice developed HSV-1 corneal stromal disease through an initial 30 day observation period. These mice did develop severe periocular skin lesions. After 30 days, the T cell-depleted mice were subdivided into two groups. In one group, T cell depletion was continued and the mice remained largely free of stromal disease for an additional 30 days (one of 30 mice developed a mild stromal haze). T cell depletion was discontinued in the second group. During the subsequent 30 days the CD4 and CD8 T cells in their lymph nodes and spleens recovered to approximately 50% of normal, and 43% (13 of 30) of the mice developed severe HSV-1 stromal disease. The skin lesions healed in all T cell-depleted mice between days 30 and 60, even when T cell depletion was maintained. Our findings demonstrate that T cells are both protective (preventing the spread of HSV-1 in the skin) and detrimental (inducing the destruction of the corneal stroma).(ABSTRACT TRUNCATED AT 250 WORDS)