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Role of muscarinic cholinergic transmission in Edinger-Westphal nucleus-induced choroidal vasodilation in pigeon.

Activation of the parasympathetic ciliary ganglion input to the choroid causes increases in choroidal blood flow. We examined the role and the type of muscarinic receptors within the choroid that are involved in these increases in choroidal blood flow, using electrical stimulation of the nucleus of Edinger-Westphal (EW) to activate the ciliary ganglion input to choroid in ketamine anesthetized pigeons. Baseline choroidal blood flow and its EW-evoked increases measured as peak and total (area under the curve) responses were determined using laser Doppler flowmetry. The EW-evoked responses were reduced dose-dependently after administration of 4-diphenyl-acetoxy-N-methylpiperedine (4-DAMP), a relatively selective antagonist of M3 type muscarinic receptors, with a maximal mean decrease of 86% (peak response) and 93% (total response) at a dose of 10 microg kg(-1)i.v. without a significant effect on baseline choroidal blood flow, heart rate or systemic arterial blood pressure. Atropine, a non-selective antagonist of muscarinic receptors, decreased the EW-evoked responses to a lesser extent than 4-DAMP after intravenous administration of 1 mg kg(-1)(by 67% for peak response and by 53% for total response) or topical administration of a 5% solution (by 41% for peak response and by 62% for total response), both of which increased heart rate and systemic arterial blood pressure without a consistent effect on baseline choroidal blood flow. In contrast, himbacine (i.p. 10 microg kg(-1)), a relatively selective antagonist of M2 type muscarinic receptors, increased the EW-evoked parasympathetic cholinergic vasodilation (by 93% for the peak response and by 142% for the total response) without a significant effect on heart rate, systemic arterial blood pressure or baseline choroidal blood flow. The results of our study suggest a major role of M3 type muscarinic receptors in the EW-evoked increases in choroidal blood flow. Based on findings that the ciliary ganglion input to choroid does not synthesize nitric oxide but inhibitors of NO production do block EW-evoked choroidal vasodilation, it seems likely that the M3 receptors acted on by 4-DAMP are present on choroidal endothelial cells and mediate choroidal vasodilation via stimulation of endothelial release of nitric oxide. In contrast, M2 muscarinic receptors may play a presynaptic role in downregulating EW-evoked parasympathetic cholinergic vasodilation in avian choroid.

Alkaloids↗

Indocyanine green angiographic features of idiopathic submacular choroidal neovascularization.

PURPOSE: To clarify the indocyanine green angiographic features of idiopathic submacular choroidal neovascularization. METHODS: We performed fluorescein and indocyanine green angiography in 16 eyes of 16 patients (nine men, seven women; mean age +/- SD, 35.6 +/- 6.9 years; range, 24 to 48 years) with idiopathic submacular choroidal neovascularization. During the mean follow-up of 11.4 +/- 7.9 months (range, 1 to 28 months), angiography was repeated (mean, 2.6 +/- 0.5 times; range, 2 to 3 times) in 12 eyes and performed only once in four eyes. RESULTS: In the early phase of indocyanine green angiography, a network of choroidal neovascularization was observed in 11 of the 16 eyes with well-defined choroidal neovascularization seen by fluorescein angiography. Choroidal hyperfluorescent areas were noted in 10 of the 16 eyes in the late-phase angiography. Three of the 10 eyes showed focal dilatation of choroidal veins within the hyperfluorescent areas. Choroidal neovascular membrane was located within the hyperfluorescent areas in eight of the 10 eyes with choroidal hyperfluorescent areas. A dark rim surrounding choroidal neovascularization was observed in 13 of the 16 eyes at the initial examination. Indocyanine green angiography was repeated in nine of the 13 eyes and in the other three eyes without dark rim initially. During the follow-up period, the dark rim became prominent in eight of the nine eyes and developed in one eye without dark rim initially. Choroidal neovascular membrane regressed in these nine eyes. Choroidal neovascularization remained active or enlarged in three eyes in which the dark rim was stationary or invisible. CONCLUSIONS: The dark rim surrounding the choroidal neovascularization in indocyanine green angiograms appeared to reflect regression of idiopathic choroidal neovascularization. Choroidal vascular abnormalities such as hyperfluorescent areas or focal venous dilatation seem to be the background lesion predisposing to the choroidal neovascularization.

Adult↗

[Rupture of the choroid after eyeball contusion--an analysis based on the Erlangen Ocular Contusion Registry (EOCR)].

BACKGROUND: Ocular injuries may lead to severe damage of the posterior segment with manifest visual impairment. Choroidal ruptures are frequently masked by acute subretinal haemorrhage. We analysed possible predictive factors and functional results of eyeballs with rupture of the choroid after ocular contusion. PATIENTS AND METHODS: We performed a retrospective study of 376 consecutive inpatients (Erlangen Ocular Contusion Registry - EOCR, over a 10-year period), who were treated because of a blunt eye injury at our eye hospital (86 % males). Detailed notes regarding the anterior and posterior segments were extracted from the standardised charts. Mean age was 28.8 +/- 16.1 years (4 to 84 years). Eyes with previous trauma or globe ruptures were excluded. RESULTS: Twenty-six of 376 patients developed choroidal rupture due to ocular contusion (6.9 %). A choroidal rupture was more frequent in females (9.4 %) than in males (6.5 %). Patients with choroidal rupture were treated as inpatients 5 days longer than patients without (10.7 vs. 5.5 days; p < 0.001). Twenty-two percent of the injuries occurred during work time. Main causes of choroidal ruptures were water jet (19 %), fireworks (12 %), elastic cords (12 %), metal pieces (12 %), gotcha (8 %) and champagne corks (8 %). The risk for developing a choroidal rupture due to water jet or fireworks injuries was increased 9 or 4 times. Ninety-two percent of choroidal ruptures were located at the posterior pole and concentric, 40 % were submacular, 12 % outside the large temporal vessels (4 % were located both centrally and peripherally). Initial visual acuity (VA) and VA at discharge were decreased significantly in eyes with rupture of the choroid (20/200 and 20/60) in contrast to eyes without (20/40 and 20/25; p < 0.001). Choroidal ruptures were often associated with iridodialysis, lens dislocation and contusion cataract (3 x ), vitreous haemorrhage (4 x ), complete retinal defects (6 x ), ciliary body clefts (7 x ) or hyphema rebleeding (4 x ). No association between the height of hyphema and choroidal ruptures was found. The predictive level of choroidal ruptures was 40 % in eyes with a combination of lens dislocation, traumatic cataract and vitreous bleeding. The final VA was 20/200 or less in 11 eyes associated with a prevalence of 55 % of ruptures submacularly. In contrast to this, eyes with VA > 20/200 developed 26 % submacular choroidal ruptures. CONCLUSIONS: Additional severe traumatic changes of the anterior and posterior segment were found 2 - 7 times more frequently in eyes with choroidal ruptures compared to eyes without those ruptures. The visual improvement was limited due to submacular ruptures. Frequent ophthalmological controls are recommended to minimise the risk of choroidal neovascularisation in a submacular location.

Age Distribution↗

Chromosomal imbalances in choroid plexus tumors.

We studied 49 choroid plexus tumors by comparative genomic hybridization. Chromosomal imbalances were found in 32 of 34 choroid plexus papillomas and 15 of 15 choroid plexus carcinomas. Choroid plexus papillomas frequently showed +7q (65%), +5q (62%), +7p (59%), +5p (56%), +9p (50%), +9q (41%), +12p, +12q (38%), and +8q (35%) as well as -10q (56%), -10p, and -22q (47%); choroid plexus carcinomas mainly showed +12p, +12q, +20p (60%), +1, +4q, +20q (53%), +4p (47%), +8q, +14q (40%), +7q, +9p, +21 (33%) as well as -22q (73%), -5q (40%), -5p, and -18q (33%). Several chromosomal imbalance differences could be found that were characteristic for a tumor entity or age group. In choroid plexus papillomas +5q, +6q, +7q, +9q, +15q, +18q, and -21q were significantly more common whereas choroid plexus carcinomas were characterized by +1, +4q, +10, +14q, +20q, +21q, -5q, -9p, -11, -15q, and -18q. Among choroid plexus papillomas, children more often showed +8q, +14q, +12, and +20q; adults mainly presented with +5q, +6q, +15q, +18q, and -22q. Although the number of aberrations overall as well as of gains and losses on their own bore no significance on survival among choroid plexus tumors, a significantly longer survival among patients with choroid plexus carcinomas was associated with +9p and -10q. Our results show that aberrations differ between choroid plexus papillomas and choroid plexus carcinomas as well as between pediatric and adult choroid plexus papillomas, supporting the notion of different genetic pathways. Furthermore, gain of 9p and loss of 10q seem to be correlated with a more favorable prognosis in choroid plexus carcinomas.

Adult↗

The AgNOR technique, PCNA immunohistochemistry, and DNA ploidy in the evaluation of choroid plexus biopsy specimens.

The histologic distinctions between normal choroid plexus and choroid plexus papilloma and between choroid plexus papilloma and choroid plexus carcinoma are sometimes difficult. The authors performed the silver nucleolar organizer region (AgNOR) technique, immunohistochemistry for proliferating cell nuclear antigen (PCNA), and DNA ploidy analysis by flow cytometry on 9 samples of normal choroid plexus, 8 papillomas, and 13 carcinomas to evaluate whether these techniques can aid in these differential diagnoses. Significant differences were found in the mean AgNOR count between normal choroid plexus (1.35 +/- 0.11) and choroid plexus papillomas (2.42 +/- 0.81) (P < 0.001), but not between choroid plexus papillomas and carcinomas. In the normal choroid plexus, AgNORs were smooth and round; in the papillomas and carcinomas, however, they varied in size and shape. Compound AgNORs were commonly present in the tumors but were essentially absent in controls. Antibody to PCNA did not stain normal choroid plexus cells (except for focal staining in one sample of normal choroid plexus adjacent to a carcinoma) but stained many papilloma and carcinoma cells. DNA ploidy analysis demonstrated aneuploidy in some papillomas and carcinomas but could not be used for the distinction of normal choroid plexus from papillomas. These results suggested that the AgNOR technique and PCNA immunohistochemistry could be used to distinguish normal choroid plexus from choroid plexus papilloma in small, diagnostically difficult biopsy specimens.

Antigens, Neoplasm↗

Evaluation of the human choroidal melanoma rabbit model for studying microcirculation patterns with confocal ICG and histology.

The aim of this study was to develop consistently focal elevated choroidal masses of human choroidal melanoma in immunosuppressed rabbits and to correlate the visualization of prognostically significant microcirculation patterns from confocal indocyanine green angiography with histologic microcirculation patterns. A human choroidal melanoma cell line (OCM1) was implanted in the choroid of 40 rabbit eyes using three different techniques: transscleral choroidal injection of a cell suspension, injection of a cell suspension in a surgically induced cyclodialysis cleft, and implantation of solid tumor fragments in a surgically induced cyclodialysis cleft. The rabbits were immunosuppressed with daily injections of Cyclosporin A to prevent host versus graft reaction. The eyes were studied weekly with indirect ophthalmoscopy and fundus photography to monitor tumor growth and indocyanine green angiography using a confocal scanning laser ophthalmoscope to identify microcirculation patterns in vivo and correlate these findings with the histologic demonstration of tumor microcirculation patterns. A tumor mass was identified by indirect ophthalmoscopy in 16 of the 40 implanted rabbit eyes (40%). Each of these tumors was confirmed histologically to represent a focal elevated choroidal mass. All 16 elevated choroidal masses grow in eyes in which solid tumor fragments were implanted. In total, a melanoma was identified histologically in 28 of the implanted 40 eyes (70%). In addition to the 16 eyes where the melanoma appeared as a focal elevated choroidal mass, 4 eyes contained a focal elevated mass in the sclera and 8 eyes contained a flat choroidal tumor. Histologically, microcirculation patterns were identified only in the 16 eyes with focal elevated choroidal masses. Confocal indocyanine green angiography imaged microcirculation patterns in 13 of these 16 eyes (81%). The surgical implantation of small solid fragments of human choroidal melanoma in immunosuppressed rabbit eyes provides the best method to consistently obtain focal elevated choroidal masses. These focal elevated choroidal masses resemble booth the localization and the growth pattern of choroidal melanomas in humans. In addition, they also contain microcirculation patterns similar to those seen in humans that are detectable with confocal indocyanine green angiography. The use of indocyanine green angiography with this animal model may be especially useful in designing and evaluating anti-microcirculation treatments directed at uveal melanoma.

Angiography↗

Presumed tubercular serpiginouslike choroiditis: clinical presentations and management.

PURPOSE: Choroiditis, choroidal tubercles, and tuberculomas are well known ocular manifestations of systemic tuberculosis. The present series aimed to report the occurrence of serpiginouslike choroiditis of presumed tubercular origin. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Eleven eyes in seven consecutive patients with a diagnosis of choroidal tuberculosis simulating serpiginous choroiditis were studied between 1997 and 2000. TESTING AND INTERVENTION: All patients had their fundus photographs taken at the time of initial presentation as well as during follow-up. All patients underwent a Mantoux skin test and chest radiography. In addition, five patients had their aqueous or vitreous humor subjected to polymerase chain reaction (PCR) for Mycobacterium tuberculosis. Sputum examination, biopsy, or both were carried out whenever recommended by the pulmonologist. Systemic antituberculosis chemotherapy was instituted in combination with treatment for ocular inflammation. MAIN OUTCOME MEASURE: Therapeutic response and visual improvement. RESULTS: There were five men and two women ranging in age from 17 to 32 years. Clinical presentations included three morphologic variants; multifocal progressive choroiditis showing wavelike progression to confluent, diffuse lesions resembling serpiginous choroiditis (three eyes); diffuse choroiditis characterized by diffuse plaquelike choroiditis with an amoeboid pattern suggestive of serpiginous choroiditis at initial presentation (four eyes); and mixed variety where opposite eyes had mixed features (four eyes). All patients had strongly positive Mantoux skin test results and positive chest radiograph results. The PCR results from aqueous and vitreous humor in four samples was positive for Mycobacterium tuberculosis; one had sputum positive for acid-fast bacilli, whereas two had histopathologic evidence of tuberculosis from cervical or parahilar lymph nodes. Treatment was associated with resolution of choroidal lesions and visual improvement. Final visual acuity of 20/30 or better was achieved in five eyes. CONCLUSIONS: Choroidal tuberculosis may present as multifocal progressive or diffuse choroiditis resembling serpiginous choroiditis. It is important to recognize these presentations because these eyes show good response to systemic antituberculosis chemotherapy.

Adolescent↗

Latanoprost and matrix metalloproteinase-1 in human choroid organ cultures.

PURPOSE: Latanoprost, a prostaglandin F2a analogue and ocular hypotensive agent, alters extracellular matrix and matrix metalloproteinases (MMPs), including MMP-1, within tissues of the uveoscleral outflow pathway. In addition to these tissues, the anterior choroid also is exposed to fluid within the uveoscleral outflow pathway. The present study was undertaken to compare MMP-1 expression in the choroid with other uveoscleral pathway tissues and to determine the effect of latanoprost on MMP-1 expression in human choroid organ cultures. METHODS: Choroid tissue explant cultures were generated and incubated with PhXA85, the biologically active form of latanoprost, or vehicle for 12 or 18 hours. Explant cultures from iris and ciliary body also were generated and exposed to PhXA85. Protein extracts of theses cultures, as well as from fresh tissues, were then probed for MMP-1 by Western blotting. All samples were normalized for protein content and reletive expression was evaluated by densitometry. Also, total RNA was harvested from fresh tissues or from cultures treated with PhXA85. The amount of MMP-1 mRNA in these samples was measured using real time polymerase chain reaction. These results were normalized according to simultaneous measurements of glyceraldehyde-3-phosphate dehydrogenase mRNA within the same samples. RESULTS: Compared to the ciliary body, in which specific MMP-1 concentration (/total mg protein) was greatest, the specific MMP-1 concentrations within iris, anterior choroid, and posterior choroid were less by 24.7 +/- 0.69%, 40.7 +/- 1.04%, and 64.5 +/- 0.52%, respectively (mean +/- SD). The order of MMP-1 mRNA expression among these tissues from fresh eyes was ciliary body < anterior choroid < posterior choroid < iris. Treatment of ciliary body explant cultures with 200 nM PhXA85 for 12 hours increased MMP-1 protein content by 154 +/- 34% (P = 0.004, students t test, N = 3). In contrast, similar treatment of anterior choroid, posterior choroid, or iris explant cultures minimally changed MMP-1 protein content (23 +/- 22+/-, P = 0.124; 14 +/- 8%, P = 0.462; 27 +/- 16%, P = 0.037, respectively). Increased MMP-1 was observed in choroid cultures incubated for 18 hrs with 200 nM or 500 nM PhXA85. MMP-1 mRNA in 12 hour PhXA85-treated choroid cultures was the same or less than vehicle-treated cultures from 7 of 9 donors. In contrast, MMP-1 mRNA was increased in PhXA85-treated ciliary body cultures from 2 of 2 donors. CONCLUSIONS: These results suggest that the capacity for latanoprost-mediated induction of MMP-1 within the choroid is less than within the ciliary muscle. Hence, it is unlikely that induction of MMP-1 in choroid plays as important a role in uveoscleral outflow modulation as induction of MMP-1 in the ciliary muscle.

Adult↗

Theoretical investigation of the role of choriocapillaris blood flow in treatment of subfoveal choroidal neovascularization associated with age-related macular degeneration.

PURPOSE: To investigate the relationship between choriocapillaris blood flow and blood flow through an overlying choroidal neovascularization, as it relates to photocoagulation-induced changes in the choriocapillaris circulation. METHODS: A theoretical model that simulates the blood flow in the choriocapillaris and choroidal neovascularization of the human eye was developed, based on histologically determined vascular geometry and experimentally measured blood pressure gradients. The choriocapillaris blood pressure and blood flow were examined before and after simulated photocoagulation of various Sattler layer vessels entering the choriocapillaris in the vicinity of the choroidal neovascularization. (The Sattler layer is the inner layer of medium-sized choroidal vessels that includes both arterioles and venules that supply the choriocapillaris.) RESULTS: The theoretical model showed that both partial and complete occlusion of either Sattler arteriole or venous vessels in the vicinity of the capillary-like vessels connecting a choroidal neovascularization to the underlying choriocapillaris results in significant choroidal neovascularization blood flow reduction. These theoretical results are similar to clinically observed changes induced by laser photocoagulation of feeder vessels. (In this discussion, the term "feeder vessels" refers to those vessels in an indocyanine green angiogram image that appear to supply blood to a choroidal neovascularization; these vessels appear to be Sattler layer vessels, rather than the histologically demonstrated short, capillary-like vessels that form choriocapillaris-choroidal neovascularization communications.) CONCLUSIONS: Reduction of choriocapillaris blood flow underlying a choroidal neovascularization may be sufficient to reduce the blood flow rate in the choroidal neovascularization and thereby reduce the associated retinal edema. The results also suggest that reduction of choriocapillaris blood flow may be the common hemodynamic event associated with the successful application of several currently practiced methods of choroidal neovascularization treatment, including feeder vessel photocoagulation, photodynamic therapy, transpupillary thermotherapy, and prophylactic drusen photocoagulation. Ultimately, this model may be useful in determining optimal placement of laser photocoagulation burns to achieve a desirable perturbation in choroidal blood flow distribution and thereby reduce choroidal neovascularization blood flow to the extent necessary to obliterate associated retinal edema.

Blood Flow Velocity↗

Human choroid plexus growth factors: What are the implications for CSF dynamics in Alzheimer's disease?

The choroid plexus plays a key role in supporting neuronal function by secreting cerebrospinal fluid (CSF) and may be involved in the regulation of various soluble factors. Because the choroid plexus is involved in growth factor secretion as well as CSF dynamics, it is important to understand how growth factors in CSF interact with the brain parenchyma as well as with cells in direct contact with the flowing CSF, i.e., choroid plexus and arachnoid villi. While the existence of growth factors in the choroid plexus has been documented in several animal models, the presence and distribution of growth factors in the human choroid plexus has not been extensively examined. This study describes the general distribution and possible functions of a number of key proteins in the human choroid plexus and arachnoid villi, including basic fibroblast growth factor, FGF receptor, and vascular endothelial growth factor. FGF and VEGF could both be readily demonstrated in choroid plexus epithelial cells. The presence of FGF and VEGF within the choroid plexus was also confirmed by ELISA analysis. Since Alzheimer's disease (AD) is known to be associated with a number of growth factor abnormalities, we examined the choroid plexus and arachnoid villi from AD patients. Immunohistochemical studies revealed the presence of FGF and VEGF within the AD choroid plexus and an increased density of FGFr in both the choroid plexus and the arachnoid villi of AD patients. No qualitative changes in the distribution of FGF and VEGF were observed in the AD choroid plexus. The appearance of FGFr in AD arachnoid was associated with robust amyloid and vimentin immunoreactivity. These findings confirm the presence of FGF and VEGF within the normal and AD choroid plexus and suggest that the alteration of growth factors and their receptors may contribute to the pathogenesis of the hydrocephalus ex vacuo that is characteristically seen in AD.

Alzheimer Disease↗

Digital imaging in differential diagnosis of small choroidal melanoma.

BACKGROUND: To assess the role of digital imaging and a new subtraction method for differential diagnosis of choroidal nevus and small choroidal melanoma. METHODS: Of 241 consecutive patients referred to a tertiary referral center for suspected choroidal melanoma, 110 who underwent digital imaging of the ocular fundus were eligible for this study. Digital color, red-free and red light retinal images were evaluated in a randomized and masked manner and by the subtraction method for diagnosis of the fundus lesion. The reference standard was based on the combined results of ophthalmological examination, including mydriatic ophthalmoscopy, B scan ultrasonography, digital imaging and fluorescein angiography of the ocular fundus. RESULTS: Comparative use of digital color, red-free and red light imaging had 85.7% (95%CI 42.1-99.6) sensitivity, 99.0% (95%CI 94.7-99.9) specificity and 98.2% (95%CI 93.6-99.8) exact agreement versus reference standard in differentiation of small choroidal melanoma from pseudomelanoma. Direct comparison between use of digital images and the reference standard showed excellent agreement in detecting small choroidal melanoma from suspected choroidal lesions (K 0.847; 95%CI 0.639-1.0). The subtraction method was useful to show growth in four of 94 melanocytic choroidal tumors. The mean annual incidence of choroidal melanoma in Southwest Finland was 0.80 per 100.000 population. The most frequent choroidal pseudomelanomas were choroidal melanotic and amelanotic nevi, disciform lesions, congenital hypertrophy of the retinal pigment epithelium, and circumscribed choroidal hemangioma. CONCLUSIONS: Combined use of digital color, red-free and red light imaging was a suitable adjunct in differentiation of small choroidal melanoma from different pseudomelanomas. The subtraction method may reveal early growth of the melanotic choroidal tumors.

Adolescent↗

Alteration in choroidal blood flow produced by local pressure.

BACKGROUND: To investigate how transient pressure applied to the retinal pigment epithelium (RPE) layer and choroid affects choroidal blood flow in rabbits. METHODS: Twelve rabbits underwent vitrectomy and local retinectomy. In nine of the rabbits a glass rod was used to exert brief pressure on the RPE layer and choroid. Three of the rabbits had no pressure indentation and were considered to be controls. The choroidal circulation was studied by indocyanine green (ICG) angiography. The retina and choroid were studied by postmortem histology. RESULTS: Pressure on the RPE layer and choroid caused nonfluorescence in segments of retinal arteries and veins and reduced fluorescence in adjacent choroidal capillaries, producing a black region at the pressure site in the angiograms. The size of this region decreased during the angiogram, often accompanied by the appearance of fine channels considered to be flow through the partially blocked vessels; the obstructed ends of the vessels became increasingly hyperfluorescent. These changes lasted for about 24 h before the choroidal circulation recovered. Histology showed evidence of thrombotic-like material in choroidal arteries and veins at the areas of absent perfusion. After local retinectomies, there was no evidence of thrombosis in control eyes where no pressure had been applied. CONCLUSION: Brief pressure on the RPE and choroid causes immediate reduction in flow through choroidal vessels, which appears to be due to local thrombosis in small segments of these vessels that resolves slowly. This may reflect a tendency for thrombi to form rapidly in choroidal vessels; it may also depend on neural reflexes causing vasoconstriction. The long time course of recovery could result in retinal ischemia and may underlie the pathophysiology of other pressure insults to the choroid.

Animals↗

Isolated fetal choroid plexus cysts and trisomy 18: a review and meta-analysis.

OBJECTIVE: Risk of trisomy 18 in a fetus with ultrasonographic diagnosis of choroid plexus cysts and no other anomalies is controversial. Using our data and current literature, we performed a meta-analysis and estimated the positive predictive value of isolated choroid plexus cysts for trisomy 18. STUDY DESIGN: Between Jan. 1, 1989, and Dec. 31, 1992, all women undergoing ultrasonographic examination at our institution were prospectively evaluated for fetal choroid plexus cysts and cytogenetic outcome. In addition, all reports dealing with fetal choroid plexus cysts obtained from MEDLINE (1983 through 1992) were assessed. Only prospective studies with > 10 cases of choroid plexus cysts were further evaluated to determine the total number of fetuses with choroid plexus cysts and otherwise normal sonograms. Frequency of aneuploidy was determined by analysis of our data and the included studies. To estimate the positive predictive value of choroid plexus cysts from trisomy 18, a theoretic 2 x 2 table was constructed with values available from the literature. RESULTS: Eighty fetuses with choroid plexus cysts were identified in our unit. Of 74 fetuses with isolated choroid plexus cysts, there were no cases of trisomy 18. Meta-analysis identified 2 cases of trisomy 18 among 748 fetuses with isolated cysts (1/374). To derive a positive predictive value of isolated choroid plexus cysts for trisomy 18, we reviewed the literature and found a total of 50 fetuses with trisomy 18 who underwent ultrasonographic examination in the midtrimester. There were 3 cases of isolated choroid plexus cysts, and 12 of 50 (24%) had otherwise normal ultrasonographic results. Using a midtrimester incidence of 1 in 2461 for trisomy 18 (Hsu LYF. In: Milunsky A, ed. Genetic disorders of the fetus. 3rd ed. Baltimore: Johns Hopkins University Press, 1992: 155-210; Hook et al. Am J Hum Genet 1989; 45:855-61) and a prenatal prevalence of 0.95% for choroid plexus cysts (based on a review of the literature), we obtained a positive predictive value of 1 in 390. CONCLUSION: On the basis of the risk for trisomy 18 obtained from our meta-analysis (1/374) and its close approximation to the estimated positive predictive value (1/390), our data do not support the routine offering of invasive prenatal cytogenetic testing in cases of isolated choroid plexus cysts.

Brain Diseases↗

Estimating the risk of malignant transformation of a choroidal nevus.

PURPOSE: To estimate the risk of malignant transformation of a choroidal nevus in the white population. DESIGN: Systematic literature review. METHODS: A literature review was performed to obtain data on the prevalence of choroidal nevi in the white population. Data from studies that used indirect ophthalmoscopy or otherwise corrected data to include the entire fundus were selected. Only studies reporting on the United States population were included. The number of affected individuals was estimated using 2000 U.S. census data. The estimate of annual incident choroidal melanoma cases in the corresponding age- and race-matched population was calculated using the Surveillance, Epidemiology, and End Result database (1973-2000). Average annual age-specific incidence rates for 1973 to 2000 for each of the 5-year age groups (adjusted for the U.S. 2000 population) were calculated and applied to the corresponding census data. The ratio of numbers of affected individuals with choroidal melanoma and choroidal nevi gave the annual rate of malignant transformation of a choroidal nevus. MAIN OUTCOME MEASURES: Annual rate of malignant transformation of a choroidal nevus in the white population of the U.S. RESULTS: The prevalence of choroidal nevus in the white U.S. population ranged from 4.6% to 7.9%. It was estimated that, on average, 8864625 individuals in the U.S. had a choroidal nevus. The number of individuals with choroidal melanoma in the corresponding age- and race-matched population ranged from 989 to 1008 (mean, 1002). The annual rate of malignant transformation of a choroidal nevus was estimated to be 1 in 8845. CONCLUSIONS: If it is assumed that all choroidal melanomas arise from preexisting nevi, then the published data suggest a low rate (1/8845) of malignant transformation of a choroidal nevus in the U.S. white population.

Adolescent↗

Clinical factors in the identification of small choroidal melanoma.

The detection and treatment of choroidal melanoma early in its natural course is critical to providing the patient with the best prognosis. Studies of tumour doubling time have indicated that metastasis from choroidal melanoma can occur quite early in the course of the disease, when the tumour is about 3.0 mm in basal dimension and 1.5 mm in thickness. Clinical studies have shown that, at 5 years, metastasis occurs in 16% of patients with small choroidal melanomas (less than 4 mm thick), compared with 32% of those with medium-sized (4-8 mm thick) choroidal melanomas and 53% of those with large (more than 8 mm thick) choroidal melanomas. The difficulty with early detection of choroidal melanoma relates to its clinical similarity to benign choroidal nevus. Factors that assist in differentiating small choroidal melanoma from choroidal nevus can be remembered using the mnemonic "TFSOM" (to find small ocular melanoma), where T = thickness greater than 2 mm, F = subretinal fluid, S = symptoms, O = orange pigment and M = margin touching optic disc. Choroidal melanocytic tumours that display none of these factors have a 3% risk of growth into melanoma at 5 years and most likely represent choroidal nevi. Tumours that display one factor have a 38% risk of growth, and those with two or more factors show growth in over 50% of cases. Most tumours with two or more risk factors probably represent small choroidal melanomas, and early treatment is generally indicated. Therefore, ophthalmologists should be aware of the clinical factors that identify small choroidal melanoma so that early treatment and better prognosis can be achieved for their patients.

Choroid Neoplasms↗

Morphometric changes of the choriocapillaris and the choroidal vasculature in eyes with advanced glaucomatous changes.

PURPOSE: In addition to an elevated intraocular pressure a compromise of the ocular blood supply have been implicated in the pathogenesis of primary open-angle glaucoma. The purpose of this study was to quantify morphologic changes in the choroid including choriocapillaris thickness and density and diameter of large choroidal vessels in post mortem eyes with advanced primary open-angle glaucoma. METHODS: We analyzed 20 eye bank eyes (provided from the Georgia Eye Bank in Atlanta) with end stage primary open-angle glaucoma and compared them with 20 age-matched control eye bank eyes. The eyes were processed for light microscopy and following variables were measured with a digital filar micrometer: density and diameter of large choroidal vessels in the macular and equatorial choroid; thickness of the choroid in the macular and equatorial region; density and thickness of choriocapillaris in the macular, peripapillary, and equatorial choroid; and peripapillary capillary-free area nasal and temporal to the optic disk. RESULTS: Eyes with glaucoma displayed a lower density of the capillaries of the choriocapillaris as compared to control eyes in the macular, temporal peripapillary, and equatorial choroid with 0.50-0.55 (p=0.018), 0.46-0.51 (p=0.016), and 0.50-0.55 (p=0.038), respectively. There was no significant difference for the choriocapillaris density in the nasal peripapillary choroid, the thickness of the capillaries of the choriocapillaris in all assessed locations, and the nasal and temporal peripapillary capillary-free zone of the choriocapillaris between eyes with glaucomatous damage and controls. Assessment of large choroidal vessels in the macular choroid showed that eyes with glaucoma had a decreased density of veins (11.7-38.9 mm(-2); p<0.001) and arteries (7.7-12.4 mm(-2); p=0.005) and arteries with a higher diameter (45.6-28.2 microm; p<0.001) as compared to control eyes. The large vessels in the equatorial choroid displayed no significant difference in diameter but a lower density (21.2-44.1 mm(-2); p=0.017) in eyes with glaucomatous damage as compared to controls. CONCLUSION: Eyes with advanced glaucomatous damage after long standing primary open-angle glaucoma exhibit several changes including decreased density of capillaries of the choriocapillaris and decreased density of large choroidal vessels. We cannot conclude from our study whether the observed vascular changes in the choroid are primary pathogenic factors or secondary phenomena.

Aged↗

Expression of two membrane fusion proteins, synaptosome-associated protein of 25 kDa and vesicle-associated membrane protein, in choroid plexus epithelium.

In addition to being the major site of cerebrospinal fluid formation, the choroid plexus epithelium emerges as an important source of polypeptides in the brain. Physiologically regulated release of some polypeptides synthesized by the choroid plexus has been shown. The molecular mechanisms underlying this polypeptide secretion have not been characterized, however. In the present study, synaptosome-associated protein of 25 kDa and vesicle-associated membrane protein, two membrane fusion proteins playing a critical role in exocytosis in neurons and endocrine cells, were found to be expressed in the choroid plexus epithelium. It was also shown that in choroidal epithelium, synaptosome-associated protein of 25 kDa and vesicle-associated membrane protein stably interact. Two members of the vesicle-associated membrane protein family, vesicle-associated membrane protein-1 and vesicle-associated membrane protein-2, were expressed in the rat choroid plexus at the messenger RNA and protein level. However, their newly discovered isoforms, vesicle-associated membrane protein-1b and vesicle-associated membrane protein-2b, produced by alternative RNA splicing, were not detected in choroidal tissue. Immunohistochemistry demonstrated that vesicle-associated membrane protein is confined to the cytoplasm of choroidal epithelium, whereas synaptosome-associated protein of 25 kDa is associated with plasma membranes, albeit with a varied cellular distribution among species studied. Specifically, in the rat choroid plexus, synaptosome-associated protein of 25 kDa was localized to the basolateral membrane domain of choroidal epithelium and was expressed in small groups of cells. In comparison, in ovine and human choroidal tissues, apical staining for synaptosome-associated protein of 25 kDa was found in the majority of epithelial cells. These species-related differences in cellular synaptosome-associated protein of 25 kDa distribution suggested that the synaptosome-associated protein of 25 kDa homologue, synaptosome-associated protein of 23 kDa, is also expressed in the rat choroid plexus, which was confirmed by reverse-transcriptase polymerase chain reaction. Our findings suggest that synaptosome-associated protein of 25 kDa and vesicle-associated membrane protein are involved in secretion of polypeptides from the choroid plexus epithelium. The presence of synaptosome-associated protein of 25 kDa and its homologue as well as multiple isoforms of vesicle-associated membrane protein in choroidal epithelium may play a role in the apical versus basolateral targeting of secretory vesicles.

Animals↗

Choroid plexus tumours.

Choroid plexus tumours are rare epithelial brain tumours and limited information is available regarding their biology and the best treatment. A meta-analysis was done to determine prognostic factors and the influence of various treatment modalities. A thorough review of the medical literature (1966-1998) revealed 566 well-documented choroid plexus tumours. These were entered into a database, which was analysed to determine prognostic factors and treatment modalities. Most patients with a supratentorial tumour were children, while the most common sites in adults were the fourth ventricle and the cerebellar pontine angle. Cerebellar pontine angle tumours were more frequently benign. Histology was the most important prognostic factor, as one, five, and 10-year projected survival rates were 90, 81, and 77% in choroid plexus-papilloma (n=353) compared to only 71, 41, and 35% in choroid plexus-carcinoma respectively (P<0.0005). Surgery was prognostically relevant for both choroid plexus-papilloma (P=0.0005) and choroid plexus-carcinoma (P=0.0001). Radiotherapy was associated with significantly better survival in choroid plexus-carcinomas. Eight of 22 documented choroid plexus-carcinomas responded to chemotherapy. Relapse after primary treatment was a poor prognostic factor in choroid plexus-carcinoma patients but not in choroid plexus-papilloma patients. Treatment of choroid plexus tumours should start with radical surgical resection. This should be followed by adjuvant treatment in case of choroid plexus-carcinoma, and a "wait and see" approach in choroid plexus-papilloma.

Adolescent↗