Letters
Figure. Iris Lymphoma of the Right Eye Before and After Therapy A
B
C
D
E
F
G
H
A, Well-delineated, bilobed, vascularized, tan iris lesion. B, Anterior chamber angle involvement on gonioscopy. C, Ciliary body involvement on ultrasonographic biomicroscopy. D, Aspiration biopsy showing neoplastic medium-sized lymphocytes with hyperchromatic nuclei containing prominent nucleoli that contrast with small, reactive lymphocytes (hematoxylin-eosin, original magnification ×60). E, Numerous cells are CD20+ neoplastic B lymphocytes (immunohistochemistry, original magnification ×60). F, Few cells are reactive CD3+ T lymphocytes (immunohistochemistry, original magnification ×60). G, After 3 monthly intralesional rituximab injections, the tumor disappeared completely. H, The anterior chamber angle was free of tumor. I, No tumor was found on ultrasonographic biomicroscopy.
I
preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Conjunctival Pseudotumor Caused by Herpes Simplex Virus Infection
1. Mashayekhi A, Shields CL, Shields JA. Iris involvement by lymphoma: a review of 13 cases. Clin Experiment Ophthalmol. 2013;41(1): 19-26.
A conjunctival mass in a patient with human immunodeficiency virus (HIV) can have a long differential diagnosis, ranging from opportunistic infections to malignant neoplasms. Given that patients in this population may have atypical presentations, the benefit of invasive biopsy often outweighs surgical risk and can help guide treatment. We report 2 cases of patients referred to our ocular oncology services with herpetic conjunctivitis that masqueraded as conjunctival tumors.
2. Larkin KL, Saboo US, Comer GM, et al. Use of intravitreal rituximab for treatment of vitreoretinal lymphoma. Br J Ophthalmol. 2014;98(1): 99-103. 3. Laurenti L, De Padua L, Battendieri R, et al. Intralesional administration of rituximab for treatment of CD20 positive orbital lymphoma: safety and efficacy evaluation. Leuk Res. 2011;35(5):682-684. 4. Savino G, Battendieri R, Gari M, Caputo CG, Laurenti L, Blasi MA. Long-term outcomes of primary ocular adnexal lymphoma treatment with intraorbital rituximab injections. J Cancer Res Clin Oncol. 2013;139(7): 1251-1255. 5. Ferreri AJ, Govi S, Colucci A, Crocchiolo R, Modorati G. Intralesional rituximab: a new therapeutic approach for patients with conjunctival lymphomas. Ophthalmology. 2011;118(1):24-28. 6. Kim H, Csaky KG, Chan CC, et al. The pharmacokinetics of rituximab following an intravitreal injection. Exp Eye Res. 2006;82(5): 760-766.
Report of Cases | Case 1. A man in his early 50s with a history of herpes simplex virus (HSV) keratouveitis presented with increasing left eye pain for 2 months. His medical history was significant for HIV (CD4 lymphocyte count, 525/μL [to convert to ×109 per liter, multiply by 0.001]; viral load undetectable) and hepatitis C. On examination, a fleshy yellow conjunctival lesion with subconjunctival hemorrhage was noted (Figure 1A), with a follicular reaction
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Figure 1. Case 1 A
B
C
D
A, Appearance of the conjunctival mass on presentation. B, Hematoxylin-eosin staining of the mass showing multinucleated giant cells and plasma cell infiltrate (original magnification ×20). C, Positive immunostaining for herpes simplex virus antigen in areas of multinucleated giant cells (original magnification ×20). D, Appearance of the eye 1 month after lesion excision.
on the tarsal conjunctiva. Given the patient’s complex medical history and presentation, an incisional biopsy was performed. Intraoperatively, the lesion was noted to be gelatinous, with a keratinized superficial layer firmly adherent to the conjunctiva. Hematoxylin-eosin staining revealed a dense polyclonal plasma cell infiltrate. Immunohistological staining results were negative for viral and bacterial markers. Rare cells appeared to have viral infection with HSV immunoreactivity. Therapeutic excisional debulking was then performed, which confirmed the diagnosis of HSV conjunctival infection and reactive lymphoplasmacytic inflammation (Figure 1B and C). Given the patient’s previous acyclovir-resistant HSV infections, the patient was treated with intravenous foscarnet sodium for 6 weeks. His ocular surface healed and his discomfort resolved within 1 month (Figure 1D). Case 2. A woman in her late 40s with a history of HIV that was well controlled with antiretroviral therapy (CD4 lymphocyte count, 750/μL; viral load
Figure. Iris Lymphoma of the Right Eye Before and After Therapy A
B
C
D
E
F
G
H
A, Well-delineated, bilobed, vascularized, tan iris lesion. B, Anterior chamber angle involvement on gonioscopy. C, Ciliary body involvement on ultrasonographic biomicroscopy. D, Aspiration biopsy showing neoplastic medium-sized lymphocytes with hyperchromatic nuclei containing prominent nucleoli that contrast with small, reactive lymphocytes (hematoxylin-eosin, original magnification ×60). E, Numerous cells are CD20+ neoplastic B lymphocytes (immunohistochemistry, original magnification ×60). F, Few cells are reactive CD3+ T lymphocytes (immunohistochemistry, original magnification ×60). G, After 3 monthly intralesional rituximab injections, the tumor disappeared completely. H, The anterior chamber angle was free of tumor. I, No tumor was found on ultrasonographic biomicroscopy.
I
preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Conjunctival Pseudotumor Caused by Herpes Simplex Virus Infection
1. Mashayekhi A, Shields CL, Shields JA. Iris involvement by lymphoma: a review of 13 cases. Clin Experiment Ophthalmol. 2013;41(1): 19-26.
A conjunctival mass in a patient with human immunodeficiency virus (HIV) can have a long differential diagnosis, ranging from opportunistic infections to malignant neoplasms. Given that patients in this population may have atypical presentations, the benefit of invasive biopsy often outweighs surgical risk and can help guide treatment. We report 2 cases of patients referred to our ocular oncology services with herpetic conjunctivitis that masqueraded as conjunctival tumors.
2. Larkin KL, Saboo US, Comer GM, et al. Use of intravitreal rituximab for treatment of vitreoretinal lymphoma. Br J Ophthalmol. 2014;98(1): 99-103. 3. Laurenti L, De Padua L, Battendieri R, et al. Intralesional administration of rituximab for treatment of CD20 positive orbital lymphoma: safety and efficacy evaluation. Leuk Res. 2011;35(5):682-684. 4. Savino G, Battendieri R, Gari M, Caputo CG, Laurenti L, Blasi MA. Long-term outcomes of primary ocular adnexal lymphoma treatment with intraorbital rituximab injections. J Cancer Res Clin Oncol. 2013;139(7): 1251-1255. 5. Ferreri AJ, Govi S, Colucci A, Crocchiolo R, Modorati G. Intralesional rituximab: a new therapeutic approach for patients with conjunctival lymphomas. Ophthalmology. 2011;118(1):24-28. 6. Kim H, Csaky KG, Chan CC, et al. The pharmacokinetics of rituximab following an intravitreal injection. Exp Eye Res. 2006;82(5): 760-766.
Report of Cases | Case 1. A man in his early 50s with a history of herpes simplex virus (HSV) keratouveitis presented with increasing left eye pain for 2 months. His medical history was significant for HIV (CD4 lymphocyte count, 525/μL [to convert to ×109 per liter, multiply by 0.001]; viral load undetectable) and hepatitis C. On examination, a fleshy yellow conjunctival lesion with subconjunctival hemorrhage was noted (Figure 1A), with a follicular reaction
jamaophthalmology.com
JAMA Ophthalmology January 2015 Volume 133, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 05/28/2015
105
Letters
Figure 1. Case 1 A
B
C
D
A, Appearance of the conjunctival mass on presentation. B, Hematoxylin-eosin staining of the mass showing multinucleated giant cells and plasma cell infiltrate (original magnification ×20). C, Positive immunostaining for herpes simplex virus antigen in areas of multinucleated giant cells (original magnification ×20). D, Appearance of the eye 1 month after lesion excision.
on the tarsal conjunctiva. Given the patient’s complex medical history and presentation, an incisional biopsy was performed. Intraoperatively, the lesion was noted to be gelatinous, with a keratinized superficial layer firmly adherent to the conjunctiva. Hematoxylin-eosin staining revealed a dense polyclonal plasma cell infiltrate. Immunohistological staining results were negative for viral and bacterial markers. Rare cells appeared to have viral infection with HSV immunoreactivity. Therapeutic excisional debulking was then performed, which confirmed the diagnosis of HSV conjunctival infection and reactive lymphoplasmacytic inflammation (Figure 1B and C). Given the patient’s previous acyclovir-resistant HSV infections, the patient was treated with intravenous foscarnet sodium for 6 weeks. His ocular surface healed and his discomfort resolved within 1 month (Figure 1D). Case 2. A woman in her late 40s with a history of HIV that was well controlled with antiretroviral therapy (CD4 lymphocyte count, 750/μL; viral load
