Iris mammillations as the only sign of ocular melanocytosis in a child with choroidal melanoma

An 8-year-old girl had visual loss in her left eye over 2 months. Ocular examination showed that visual acuity was counting fingers in the left eye. The left iris was moderately pigmented and thickened with numerous confluent, dome-shaped elevations on its surface, consistent with iris mammillations arising from ocular melanocytosis. There was total retinal detachment and an inferiorly located large amelanotic choroidal mass compressing the optic nerve. A specimen from a fine-needle aspiration biopsy showed spindle and epithelioid melanoma cells. The eye was enucleated. Pathologic examination showed that the bland melanocytes comprising the anterior border layer of iris formed focal aggregates, corresponding to the iris mammillations observed clinically. The uvea was diffusely thickened. Arising from the posterior choroid and obscuring the optic nerve head was a moderately pigmented spindle and epithelioid cell choroidal melanoma with diffuse lymphocytic infiltration and high mitotic activity. This case demonstrates that iris mammillations can be the initial manifestation of ocular melanocytosis in the absence of scleral pigmentation.

Acquired tumors arising from congenital hypertrophy of the retinal pigment epithelium

BACKGROUND

Congenital hypertrophy of the retinal pigment epithelium (CHRPE) is widely recognized to be a flat, stationary condition. Although it can show minimal increase in diameter, it has not been known to spawn nodular tumor that is evident ophthalmoscopically.

OBJECTIVES

To report 5 cases of CHRPE that gave rise to an elevated lesion and to describe the clinical features of these unusual nodules.

METHODS

Retrospective medical record review.

RESULTS

Of 5 patients with a nodular lesion arising from CHRPE, there were 4 women and 1 man, 4 whites and 1 black. Three patients were followed up for typical CHRPE for longer than 10 years before the tumor developed; 2 patients were recognized to have CHRPE and the elevated tumor concurrently. Visual acuity was decreased in 3 patients, mainly due to cystoid macular edema. The tumor was located between the equator and ora serrata in all 5 patients. There was no predilection for quadrant of the fundus. The flat part of the lesion was black and had visible lacunae in all 5 patients. The CHRPE ranged in basal diameter from 3 x 3 mm to 13 x 11 mm. The size of the elevated lesion ranged from 2 x 2 x 2 mm to 8 x 8 x 4 mm. The nodular component in all cases was supplied and drained by slightly prominent, nontortuous retinal blood vessels. Yellow retinal exudation occurred adjacent to the nodule in all 5 patients and 1 patient developed a secondary retinal detachment. Two tumors that showed progressive enlargement, increasing exudation, and progressive visual loss were treated with iodine 125-labeled plaque brachytherapy, resulting in deceased tumor size but no improvement in the visual acuity.

CONCLUSIONS

Congenital hypertrophy of the retinal pigment epithelium can spawn a nodular growth that slowly enlarges, attains a retinal blood supply, and causes exudative retinopathy and chronic cystoid macular edema. Although no histopathologic evidence is yet available, we believe that the tumor probably represents either an acquired adenoma or a reactive proliferation of the retinal pigment epithelium. The best treatment of these lesions is not yet established.

Intraocular lacrimal gland choristoma involving iris and ciliary body

PURPOSE

To describe clinical and pathologic features of an iridociliary lacrimal gland choristoma in which the diagnosis was made clinically and confirmed histopathologically.

METHODS

Case report with clinical, ultrasound biomicroscopic, and histopathologic observations.

RESULTS

We examined a 12-month-old male for a large iris mass that had been present since birth. We suspected it to be a lacrimal gland choristoma based on characteristic clinical features. The lesion was removed by iridocyclectomy, and the diagnosis of lacrimal gland choristoma was confirmed.

CONCLUSION

Intraocular lacrimal gland choristoma has unique clinical features that should suggest the diagnosis.

Temperature changes associated with radiofrequency energy-induced heating of bovine capsular tissue: evaluation of bipolar RF electrodes

SUMMARY

This in vitro study determined the temperature changes associated with radiofrequency (RF) energy-induced heating of bovine capsular tissue using bipolar RF electrodes. Tissue samples were placed in a saline bath (37 degrees C) and RF energy was applied using 2 different types of bipolar electrodes (VAPR T End Effect and Vapor T Side Effect; Mitek, Westwood, MA). Each electrode was activated for 3 seconds at 10 W, 16 W, and 20 W, for 6 separate data acquisitions. Fluoroptic thermometry designed to be unperturbed by RF fields was used to record temperatures on the tissue surface and at depths of 2 mm, 4 mm, and 5 mm, at 1-second intervals before (5 seconds), during (3 seconds), and after (7 seconds) the application of RF energy. The highest mean temperatures were recorded at the tissue surfaces for the different power settings for each RF electrode type, as follows: End Effect: 48.9 degrees C (10 W), 57.0 degrees C (16 W), and 67.3 degrees C (20 W). Side Effect: 51.5 degrees C (10 W), 62.1 degrees C (16 W), and 71.2 degrees C (20 W). All recorded surface temperatures were within the range known to be acceptable for tissue shrinkage. Gradient effects (i.e., higher-to-lower) were observed for the tissue temperatures measured at the different depth positions. None of the temperatures recorded at the different depths were excessive, suggesting that sensitive anatomic structures should not be damaged by RF energy-induced heating under the conditions described above.

Congenital orbital varices causing extreme neonatal proptosis

PURPOSE

To report a 6-week-old male with extreme proptosis caused by thrombosed orbital varices.

METHODS

A 6-week-old male presented with advanced proptosis of his left eye. Computed tomography and magnetic resonance imaging studies of the orbits revealed a heterogeneous cystic mass that filled the entire left orbit. Extreme proptosis and corneal exposure prompted urgent surgical excision of the mass. Histopathologic review of the lesion was consistent with orbital varices.

CONCLUSIONS

Although orbital varices usually are found in adults, they should be considered in the differential diagnosis of orbital lesions in children. Observation is usually warranted, but surgical intervention may be necessary in advanced cases.

Iris varix simulating an iris melanoma

Iris varix is rare and little is known about its clinical characteristics. We treated a thrombosed iris varix that simulated an iris melanoma. A 53-year-old man developed a dark brown iris mass and hyphema in his left eye. Ultrasound biomicroscopy revealed a circumscribed mass of the iris stroma. Because of suspicion for melanoma, it was removed by sector iridectomy. Histopathologic examination disclosed an extensive focus of stromal hemorrhage, partially surrounded by endothelial cells that showed immunoreactivity to vascular markers. The histopathologic diagnosis was thrombosed iris varix. Iris varix is a rare condition that should be included in the differential diagnosis of iris melanoma.

Clinical features predictive of orbital exenteration for conjunctival melanoma

PURPOSE

Conjunctival malignant melanoma can sometimes be difficult to control locally, and orbital exenteration may be necessary. To our knowledge, the risk factors that portend exenteration have not been previously identified. The purpose of this study was to review patients who underwent orbital exenteration for advanced disease and to identify retrospectively the clinical factors predictive of ultimate exenteration.

METHODS

The records of patients with conjunctival melanoma who were managed on the Oncology Service at Wills Eye Hospital from 1974 to 1997 were reviewed. Factors predictive of orbital exenteration were analyzed using Cox proportional hazards regression models.

RESULTS

Of 151 consecutive patients with conjunctival melanoma, 20 (13%) required orbital exenteration for advanced disease. The number of melanoma excisions performed before referral ranged from 0 to 11, with a mean of 2. The clinical factors predictive of orbital exenteration on multivariable analysis were visual acuity of 20/200 or worse, lack of tumor pigmentation, and extralimbal tumor location. All exenterations were performed using an eyelid-sparing technique. At mean follow-up of 51 months after exenteration, 4 patients (20%) had died of metastasis, 3 (15%) were alive with metastasis, and 13 (65%) had not developed metastasis.

CONCLUSIONS

Conjunctival melanoma can show aggressive local behavior, and orbital exenteration is necessary in up to 13% of cases at a tertiary referral center. Patients with risk factors such as poor visual acuity, amelanotic tumor, and extralimbal tumor location may require wider excision and radiation therapy to control the tumor and avoid orbital exenteration. It is hoped that modern surgical approaches will decrease the need for orbital exenteration.

Hamartomas of the iris and ciliary epithelium in tuberous sclerosis complex

Astrocytic hamartomas of the retina are the principal ocular manifestation of tuberous sclerosis complex. Iris abnormalities are rare in tuberous sclerosis complex and include focal areas of stromal depigmentation and atypical colobomata. We describe 2 patients who were found on histopathological examination to have lesions consistent with hamartomas of the iris pigment epithelium and ciliary body epithelium. Iris abnormalities, including pupillary irregularities, were noted on clinical examination prior to the development of iris neovascularization in both patients. These observations suggest that iris abnormalities, including atypical colobomas, may be caused by hamartomas of the iris pigment epithelium and ciliary epithelium in some patients with tuberous sclerosis complex. To our knowledge, hamartomas of tissues derived from the anterior part of the neuroectodermal optic cup have not been reported in cases of tuberous sclerosis complex.

Cutaneous capillary hemangiomas of the eyelid, scalp, and digits in premature triplets

PURPOSE

To document the unique occurrence of multiple cutaneous capillary hemangiomas in healthy triplets.

METHODS

Case reports.

RESULTS

Triplets born 6 weeks prematurely were noted at birth to have classic cutaneous capillary hemangiomas that enlarged in the first few months of life. At 3 months of age, triplet #1 manifested a small capillary hemangioma on the left index finger and a large hemangioma that involved the entire left upper eyelid and completely occluded the visual axis. Triplet #2 had a small hemangioma on the thumb and a large hemangioma on the scalp of the forehead. Triplet #3 displayed only a minor hemangioma of the right upper eyelid that did not threaten her vision. The parents of the triplets admitted having a history of periocular capillary hemangioma that spontaneously resolved. Triplet #1 was managed with oral corticosteroids, with dramatic regression of the mass and exposure of the visual axis.

CONCLUSIONS

Cutaneous capillary hemangioma is usually a sporadic condition. We found this tumor in premature triplets whose parents had a history of a similar tumor. This suggests that hereditary and environmental factors may play a role in the development of this tumor. We advise that medical and family histories be obtained in all children with cutaneous capillary hemangioma.

Combination of clinical factors predictive of growth of small choroidal melanocytic tumors

OBJECTIVE

To better define the effect of individual risk factors and combinations thereof on the growth of small choroidal melanocytic tumors.

DESIGN

Retrospective analysis.

SETTING

Clinical practice of ocular oncology.

PATIENTS

The study included 1287 patients with small suspicious choroidal melanocytic tumors, measuring 3 mm or less in thickness, managed with observation.

RESULTS

On multivariate analysis, the clinical risk factors predictive of growth of small choroidal melanocytic tumors include tumor thickness greater than 2.0 mm, posterior tumor margin touching the disc, visual symptoms, orange pigment, and subretinal fluid. Tumor growth was detected in 4% of those patients with no risk factors. Growth was detected in approximately 36% of patients with 1 risk factor, 45% of patients with 2 risk factors, 50% of patients with 3 risk factors, 51% of patients with 4 risk factors, and 56% of patients with all 5 risk factors. The combination of risk factors offering the greatest risk for growth was tumor thickness greater than 2.0 mm, tumor margin touching disc, and subretinal fluid that was associated with tumor growth in 63% of the affected patients. The relative risk for growth was 1.9 for 1 factor, 3.8 for 2 factors, 7.4 for 3 factors, 14.1 for 4 factors, and 27.1 for all 5 risk factors combined.

CONCLUSIONS

Five risk factors for growth of small choroidal melanocytic tumors have been identified. The combinations of various factors increase the risk for tumor growth from 4% if no factors are present to more than 50% if 3 or more risk factors are present. These factors may be important when counseling patients with small suspicious choroidal melanocytic tumors.

Circumscribed choroidal hemangioma: characteristic features with indocyanine green videoangiography

OBJECTIVE

To determine the characteristic features of indocyanine green videoangiography (ICG-V) of circumscribed choroidal hemangioma.

DESIGN

Prospective, observational case series.

PARTICIPANTS

Twenty-five eyes of 25 consecutive patients with circumscribed choroidal hemangioma.

INTERVENTION

Indocyanine green videoangiography and intravenous fluorescein angiography (IVFA) were prospectively performed and reviewed. The specific features on ICG-V were compared with features of IVFA.

MAIN OUTCOME MEASURES

The behavior of circumscribed choroidal hemangioma cases was observed with ICG-V and IVFA.

RESULTS

On ICG-V, earliest hyperfluorescence of circumscribed choroidal hemangioma was achieved at a mean of 27.6 seconds (range, 13-62 seconds), whereas maximum hyperfluorescence occurred at 222 seconds (range, 33-707 seconds). In the late frames, all eyes demonstrated a relative decrease in fluorescence, including 18 eyes (72%) that demonstrated "washout" of the dye. Other findings on ICG-V included intrinsic vessels in 19 eyes (76%), a late hyperfluorescent rim in 19 eyes (76%), and late frame hot spots in 14 eyes (56%). On IVFA, the earliest hyperfluorescence was achieved at a mean of 24 seconds (range, 10-66 seconds), whereas maximum hyperfluorescence occurred at a mean of 76.3 seconds (range, 21-720 seconds). Increasing hyperfluorescence in the late frames was found in all cases. Other findings included intrinsic vessels in 12 eyes (48%) and hot spots in the late frames in 9 eyes (36%).

CONCLUSIONS

Circumscribed choroidal hemangioma have specific characteristics on ICG-V that are not visualized with IVFA. We believe that ICG-V may become an important noninvasive tool for the diagnosis of choroidal hemangioma.

Localized infection by Serratia marcescens simulating a conjunctival neoplasm

PURPOSE

To report a Serratia marcescens infection that clinically simulated a conjunctival neoplasm.

METHOD

Case report.

RESULTS

A healthy 80-year-old man without contact lenses presented with a pink-yellow conjunctival mass that resembled a solid neoplasm. Stains and cultures of material that exuded from the mass during surgery revealed S. marcescens. Histopathology disclosed an epithelial-lined cyst with macrophages containing S. marcescens.

CONCLUSION

Although S. marcescens usually affects the eye as a keratoconjunctivitis in patients with contact lenses, it can also present as a mass simulating a neoplasm in a patient who does not wear contact lenses.

Metastatic neoplasms in the optic disc: the 1999 Bjerrum Lecture: part 2

BACKGROUND

Little information is available on metastatic tumors to the optic disc.

OBJECTIVE

To determine the clinical features and prognosis of patients with optic disc metastasis.

DESIGN

Retrospective chart review.

RESULTS

Of 660 consecutively evaluated patients with intraocular metastasis, 30 (4.5%) (31 eyes) had metastatic cancer to the optic disc; 24 (80%) were women and 6 (20%) were men. Mean age at the time of ocular diagnosis was 55 years. The primary neoplasm was in the breast in 13 patients (43%), in the lung in 8 (27%), in the intestine in 1 (3%), in the kidney in 1 (3%), and in the prostate in 1 (3%); the primary neoplasm was never determined in 6 patients (20%). The optic disc metastasis was unilateral in 29 patients (97%) and bilateral in 1 (3%). Ophthalmoscopically, the disc metastasis appeared as a diffuse enlargement of the optic disc in 26 eyes (84%) and as a distinct nodule in 5 (16%). There was an adjacent juxtapapillary choroidal component to the metastatic disc lesion in 23 eyes (74%), and the optic disc was involved without a retinal or choroidal component in 8 (26%). Other associated findings included some degree of secondary disc edema in all eyes, buried disc blood vessels in 23 (74%), and splinter hemorrhages in 13 (42%). Fine needle aspiration biopsy was useful in establishing the diagnosis in all 5 eyes in which it was performed. Mean survival was 13 months after diagnosis of the disc metastasis.

CONCLUSIONS

Metastasis to the optic disc accounts for 5% of all intraocular metastases. It can occur as invasion from a juxtapapillary choroidal metastasis or as isolated optic disc metastasis. Breast and lung cancers are the most common primary neoplasms that account for metastasis to the optic disc. The primary site is never determined in 20% of patients. The characteristic clinical features of optic disc metastasis should help differentiate it from other causes of swollen optic disc. Patient prognosis is poor.

Observations on 17 patients with retinocytoma

OBJECTIVE

To study the clinical features and natural history of 17 patients with retinocytoma.

DESIGN

A retrospective case series.

SETTING

Tertiary referral center.

PATIENTS

Data on 17 patients with retinocytoma were reviewed for clinical features. The natural history of retinocytoma and its risk for malignant transformation were also evaluated.

RESULTS

Among 920 consecutive patients who had retinoblastoma, retinocytoma, or both, we identified 24 tumors in 17 patients (1.8%) with clinical features compatible with retinocytoma. The median age at diagnosis was 15 years (range, 4-45 years). Of the 24 tumors, the retinocytoma was bilateral in 3 cases (13%) and the family history of retinoblastoma was positive in 3 cases (13%). Seventeen (71%) of the tumors were extramacular in location, and 7 (29%) were located in the macular area. Ophthalmoscopic features characteristic of retinocytoma included the presence of a translucent retinal mass in 21 (88%), calcification in 15 (63%), and retinal pigment epithelial alteration in 13 (54%) of the 24 tumors. A combination of all 3 features was observed in 8 (33%) of the 24 tumors. In 13 (54%) of the tumors, a zone of chorioretinal atrophy could be observed. In 1 patient, subtle tumor regression was documented photographically. Only 1 retinocytoma (4%) underwent malignant transformation into retinoblastoma. At the last follow-up visit, none of the patients had developed a pineoblastoma or another second malignant neoplasm.

CONCLUSIONS

Retinocytoma is a rare benign retinal tumor that has characteristic clinical features. The areas of chorioretinal atrophy were suggestive of tumor regression. In our series, the risk for malignant transformation of retinocytoma into retinoblastoma was 4%; therefore, patients with a presumed diagnosis of retinocytoma should be closely observed.

Conjunctival melanoma: risk factors for recurrence, exenteration, metastasis, and death in 150 consecutive patients

OBJECTIVE

To identify the risk factors of conjunctival malignant melanoma that predict local tumor recurrence, orbital exenteration, distant metastasis, and tumor-related mortality.

DESIGN

The study group consisted of 150 consecutive patients with a diagnosis of conjunctival melanoma. The clinical parameters of the patient, tumor, and treatment were analyzed in a nonrandomized fashion for their relation to 4 main outcome measures using Cox proportional hazards regression models.

RESULTS

The Kaplan-Meier estimate of local tumor recurrence was 26% at 5 years, 51% at 10 years, and 65% at 15 years. The mean number of recurrences per patient was 1 (median, 0). Ninety-eight patients (65%) had no recurrences, 28 patients (19%) had 1, 11 patients (7%) had 2, 5 patients (3%) had 3, and 8 patients (5%) had 4 or more recurrences. According to multivariate analysis, the factors that predicted local tumor recurrence were the location of the melanoma (not touching the limbus) (P = .01) and tumor-margin pathology (lateral margin involved) (P = .02). Multivariate analysis for features predictive of ultimate exenteration included initial visual acuity (20/40 or worse) (P = .0007), melanoma color (red) (P = .01), and melanoma location (not touching the limbus) (P = .02). Tumor metastasis occurred in 16% of patients at 5 years, 26% at 10 years, and 32% at 15 years. Metastasis was initially in the regional lymph nodes in 17 cases, brain in 4, liver in 3, lung in 2, and disseminated in 1 case. Risks for metastases with use of multivariate analysis included tumor-margin pathology (lateral margin involved) (P = .002) and melanoma location (not touching limbus) (P = .04). Tumor-related death occurred in 7% of patients at 5 years and 13% at 8 years. Risk factors for death with use of multivariate analysis included initial symptoms (lump) (P = .004) and pathologic findings (de novo melanoma without primary acquired melanosis) (P = .05). In a series of univariate analyses, the technique of initial surgery was shown to be an important factor in preventing eventual tumor recurrence (P = .07), metastasis (P = .03), and death (P = .006). Patients who were managed with excisional biopsy using the "no-touch technique" plus alcohol corneal epitheliectomy and supplemental cryotherapy fared far better than those treated with excisional biopsy alone. In addition, the surgical technique used before referral to us was critical. Those patients who had an incisional diagnostic biopsy prior to referral were at risk for more than 1 recurrence (P = .04), and those who had excisional biopsy alone without supplemental cryotherapy were at risk for eventual exenteration (P = .0006) and death (P = .04).

CONCLUSIONS

Conjunctival malignant melanoma is a potentially deadly tumor. In this study, metastasis was detected in 26% of patients and death occurs in 13% at 10 years. The surgical technique of tumor management was found to be possibly related to tumor metastases and death. Meticulous surgical planning, use of wide microsurgical excisional biopsy with the no-touch technique, and supplemental alcohol corneal epitheliectomy and conjunctival cryotherapy performed by experienced surgeons are advised. Incisional biopsy should be avoided.

Chemoreduction and local ophthalmic therapy for intraocular retinoblastoma

PURPOSE

To study the effectiveness of combined systemic chemotherapy and local ophthalmic therapy for retinoblastoma with the goal of avoiding enucleation and external-beam radiation therapy (EBRT).

PATIENTS AND METHODS

This was a prospective, nonrandomized, single-arm clinical trial. Seventy-five eyes were followed in 47 children. Patients were treated with a six-cycle protocol of vincristine, etoposide, and carboplatin. Most (83%) also received ophthalmic treatment (cryotherapy, laser photocoagulation, thermotherapy, or plaque radiation therapy) during and/or after the chemotherapy.

RESULTS

With a median follow-up of 13 months, event-free survival was 74%, with an event defined as enucleation and/or EBRT. Six children required EBRT in seven eyes (9%); five required enucleation of one eye (7%); five required a combination of EBRT and enucleation in six eyes (8%). Reese-Ellsworth groups 1, 2, and 3 eyes had excellent results, with avoidance of EBRT or enucleation in all 39. Treatment of groups 4 and 5 was less successful, with 33% of six eyes and 53% of 30 eyes, respectively, requiring EBRT and/or enucleation. Toxicities from chemotherapy were mild and included cytopenias (89%), fever and neutropenia (28%), infection (9%), and gastrointestinal symptoms, dehydration, and vincristine neurotoxicity (40%). No patients developed a second malignancy, metastatic disease, renal disease, or ototoxicity.

CONCLUSION

In retinoblastoma patients with Reese-Ellsworth eye groups 1, 2, or 3, systemic chemotherapy used with local ophthalmic therapies can eliminate the need for enucleation or EBRT without significant systemic toxicity. More effective therapy is required for Reese-Ellsworth eye groups 4 and 5.

Surgical excision of selected amblyogenic periorbital capillary hemangiomas

To report the successful surgical excision of well-circumscribed capillary hemangiomas of the eyelid and orbit inducing occlusion amblyopia in 2 cases with immediate improvement of the patient's symptoms. A 2-month-old girl was diagnosed with a massive, amblyogenic orbital tumor which was removed intact via an inferior transconjunctival orbitotomy after magnetic resonance imaging (MRI) revealed a well-defined mass filling the entire inferior orbit. Histopathologic examination confirmed the diagnosis of orbital capillary hemangioma. A 1-month-old girl developed occlusion amblyopia due to an enlarging subcutaneous tumor of the left upper eyelid. The discrete mass was excised via an eyelid crease approach and confirmed to be an eyelid capillary hemangioma. There were no short-term or long-term complications in either case. In both cases, immediate resolution of occlusion amblyopia and cosmetic disfiguration was achieved. The final visual acuities were 20/20 at 5 years in the first patient and 20/30 at 4 years follow-up in the second patient. Orbital and eyelid capillary hemangiomas can induce profound permanent amblyopia. If the tumor is well-circumscribed, confirmed with orbital imaging, then surgical excision, with immediate resolution of amblyogenic factors, can be considered as a treatment option.

Oral cimetidine (Tagamet) for recalcitrant, diffuse conjunctival papillomatosis

PURPOSE

To report the efficacy of cimetidine for treatment of conjunctival papillomatosis.

METHODS

An 11-year-old boy had an 8-year history of diffuse conjunctival papillomas, treated previously with standard measures of excisional biopsy and cryotherapy. He developed spontaneous conjunctival bleeding and diffuse tumor recurrence over the entire conjunctival surface. Oral cimetidine liquid (30 mg/kg/day) was prescribed.

RESULTS

Within 2 months, dramatic tumor regression was noted, with nearly complete resolution by 4 months. The patient had no local or systemic side effects from the medication.

CONCLUSIONS

Oral cimetidine possesses immune modulation properties and may be useful in some cases of virus-induced conjunctival papillomatosis.