Choroidal biopsies for intraocular tumors of indeterminate origin

INFUSION PORT SITE TUMOR SEEDING AFTER PARS PLANA VITRECTOMY-ASSISTED BIOPSY OF CHOROIDAL MELANOMA

PURPOSE

To report a rare case of infusion port site tumor seeding of choroidal melanoma after pars plana vitrectomy-assisted biopsy and successful treatment with second plaque brachytherapy.

METHODS

Observational case report with clinical data and diagnostic images.

RESULTS

A 55-year-old White woman diagnosed with choroidal melanoma of the left eye was found to have a second intraocular tumor 30 months after plaque brachytherapy and pars plana vitrectomy-assisted tumor biopsy. The second melanoma developed at the 5 o'clock vitrectomy infusion port site. The tumor regressed after plaque brachytherapy, and the patient has not developed systemic metastasis 5 years after diagnosis of intraocular seeding.

CONCLUSION

Intraocular seeding into the infusion port site, although rare, may be encountered after pars plana vitrectomy-assisted biopsy of choroidal melanoma.

Predicting Malignant Transformation of Choroidal Nevi Using Machine Learning

Objective

This study aims to assess a machine learning (ML) algorithm using multimodal imaging to accurately identify risk factors for uveal melanoma (UM) and aid in the diagnosis of melanocytic choroidal tumors.

Subjects and Methods

This study included 223 eyes from 221 patients with melanocytic choroidal lesions seen at the eye clinic of the University of Illinois at Chicago between 01/2010 and 07/2022. An ML algorithm was developed and trained on ultra-widefield fundus imaging and B-scan ultrasonography to detect risk factors of malignant transformation of choroidal lesions into UM. The risk factors were verified using all multimodal imaging available from the time of diagnosis. We also explore classification of lesions into UM and choroidal nevi using the ML algorithm.

Results

The ML algorithm assessed features of ultra-widefield fundus imaging and B-scan ultrasonography to determine the presence of the following risk factors for malignant transformation: lesion thickness, subretinal fluid, orange pigment, proximity to optic nerve, ultrasound hollowness, and drusen. The algorithm also provided classification of lesions into UM and choroidal nevi. A total of 115 patients with choroidal nevi and 108 patients with UM were included. The mean lesion thickness for choroidal nevi was 1.6 mm and for UM was 5.9 mm. Eleven ML models were implemented and achieved high accuracy, with an area under the curve of 0.982 for thickness prediction and 0.964 for subretinal fluid prediction. Sensitivity/specificity values ranged from 0.900/0.818 to 1.000/0.727 for different features. The ML algorithm demonstrated high accuracy in identifying risk factors and differentiating lesions based on the analyzed imaging data.

Conclusions

This study provides proof of concept that ML can accurately identify risk factors for malignant transformation in melanocytic choroidal tumors based on a single ultra-widefield fundus image or B-scan ultrasound at the time of initial presentation. By leveraging the efficiency and availability of ML, this study has the potential to provide a non-invasive tool that helps to prevent unnecessary treatment, improve our ability to predict malignant transformation, reduce the risk of metastasis, and potentially save patient lives.

Overrepresentation of human epidermal growth factor receptor 2 positive- and Luminal B breast cancer metastases in the eyes and orbit

BACKGROUND

Breast cancer is the most common cancer to spread to the choroid and orbit. Depending on a set of prognostic and predictive biomarkers, breast cancer can be divided into at least four distinct subtypes with separate treatment and clinical course.

SUBJECTS

Thirty-two patients with metastases to the eye and periocular area diagnosed between 2005 and 2020, of which 11 also had primary tumour tissue available. Expression levels of oestrogen- (ER) and progesterone receptors (PR), Human epidermal growth factor receptor 2 (HER2) and the proliferation marker Ki67 were analysed.

RESULTS

Twenty-five of 32 patients (78%) had a history of primary breast cancer, whereas the remaining 7 (22%) presented with metastatic disease. Of available metastases, 83% were positive for ER, 37% for PR, 54% for HER2, and 50% for Ki67. Metastases had significantly lower proportions of PR-positive cells than primary tumours, and the distribution of the Luminal A, Luminal B, HER2 enriched and triple-negative subtypes differed between primary tumours and metastases (P = 0.012): Six of 9 patients with a full set of biomarkers on both primary tumours and metastases switched subtype (67%), and 23 of 32 metastases (77%) were of the Luminal B subtype.

CONCLUSIONS

Nearly 4 in 5 breast cancer metastases in the eyes and orbit are of the Luminal B subtype, and a majority are HER2 positive. The breast cancer subtype frequently switches between primary tumours and metastases. Future studies should evaluate these results in larger cohorts.

Vitreoretinal Surgery in Uveitis: From Old to New Concepts - A Review

PURPOSE

The aim of this article is to do a comprehensive literature review about the current role of pars plana vitrectomy in uveitis and in its different structural complications such as cystoid macular edema, epiretinal membrane, macular hole, and retinal detachment.

METHODS

This comprehensive literature review was performed based on a search on PubMed, BioMed Central, Science Open, and CORE databases, of relevant articles abording pars plana vitrectomy in uveitis.

DISCUSSION

Uveitis is a complex disease with multiple etiologies and pathogenic mechanisms. Therapeutic pars plana vitrectomy (PPV) may aid in uveitic structural complications such as cystoid macular edema, epiretinal membranes, macular hole, and retinal detachments even though some cases may present unpredictable visual outcomes. Diagnostic PPV with appropriate ancillary testing is also a valuable tool for the assessment and diagnosis of uveitis in a large proportion of patients.

CONCLUSION

Over the years, pars plana vitrectomy has undergone significant transformations since its invention nearly 5 decades ago, however, the quality of evidence in the literature regarding its use for uveitis has not improved in the same way. Even though some structural uveitis complications (as previously mentioned) may respond well to surgery, there is still a certain unpredictability regarding its visual outcomes. On the other hand, diagnostic vitrectomy with appropriate ancillary testing is also a valuable tool for the assessment and diagnosis of uveitis in a large proportion of patients.

Surgical Approach in Intraocular Tumors

Surgery in intraocular tumors is done for excision/biopsy and the management of complications secondary to the treatment of these tumors. Excision/biopsy of intraocular tumors can be done via fine-needle aspiration biopsy (FNAB), transretinal biopsy (TRB), partial lamellar sclerouvectomy (PLSU), and endoresection. FNAB, TRB, and PLSU can be used in tumors that cannot be diagnosed by clinical examination and other ancillary testing methods. PLSU is employed in tumors involving the iridociliary region and choroid anterior to the equator. Excisional PLSU is performed for iridociliary and ciliary body tumors with less than 3 clock hours of iris and ciliary body involvement and choroidal tumors with a base diameter less than 15 mm. However, for biopsy, PLSU can be employed with any size tumor. Endoresection is a procedure whereby the intraocular tumor is excised using vitrectomy techniques. The rationale for performing endoresection is based on the fact that irradiated uveal melanomas may cause complications such as exudation, neovascular glaucoma, and intraocular pigment and tumor dissemination (toxic tumor syndrome), and removing the dead tumor tissue may contribute to better visual outcome. Endoresection is recommended 1-2 weeks after external radiotherapy. Pars plana vitrectomy is also used in the management of complications including vitreous hemorrhage, retinal detachment, and epiretinal membrane that can occur after treatment of posterior segment tumors using radiotherapy and transpupillary thermotherapy. It is important to make sure the intraocular tumor has been eradicated before embarking on such treatment.

Transretinal biopsy via 23-gauge pars plana vitrectomy for retinal and choroidal tumors: cytopathological results, surgical complications, and patient outcomes

PURPOSE

To evaluate the cytopathological results, surgical complications, and patient outcomes after transretinal biopsy (TRB) for diagnosis of retinal/choroidal tumors METHODS: Records of 40 cases who underwent TRB via 23-gauge (23 G) pars plana vitrectomy between March 2011 and March 2020 were reviewed.

STUDY DESIGN

Retrospective.

RESULTS

Twenty-six (65.0%) cases were women and 14 (35.0%) were men. The mean age at diagnosis was 57.2 (range: 18-83) years. The mean tumor base diameter was 12.0×9.8 mm and the mean tumor thickness was 4.9 mm. According to cytopathological examination, 29 (72.5%) cases had choroidal melanoma, 2 (5.0%) had non-small cell lung cancer metastasis, 1 (2.5%) had adenoma of retinal pigment epithelium, 1 (2.5%) had small cell lung cancer metastasis, 1 (2.5%) had invasive breast cancer metastasis, 1 (2.5%) had retinal astrocytic hamartoma, and 1 (2.5%) had pseudoneoplastic gliosis. Cytopathological examination of 4 (10.0%) cases revealed findings consistent with macular and extramacular degeneration. Postoperative complications were mild vitreous hemorrhage in 16 (40.0%) cases, gradually worsening cataract in 4 (11.8%), retinal detachment in 1 (2.5%), hyphema in 1 (2.5%), glaucoma in 1 (2.5%), and macular hole in 1 (2.5%). During the mean 11.1 (range: 1-55) months follow-up, 1 (3.4%) patient with choroidal melanoma developed liver metastasis. All patients were alive at the end of follow-up.

CONCLUSIONS

TRB using 23 G pars plana vitrectomy can be used to make the cytopathologic diagnosis of retinal/choroidal tumors whenever the clinical diagnosis is not certain or in cases with known diagnosis to obtain information on cell type/cytogenetics. In our series, the most common diagnosis after cytopathologic examination was choroidal melanoma.

Nuclear expression of BAP-1 in transvitreal incisional biopsies and subsequent enucleation of eyes with posterior choroidal melanoma

BACKGROUND

As a majority of patients with choroidal melanoma do not undergo enucleation, tumour tissue for prognostic testing has to be obtained with alternate methods. Transvitreal incisional biopsies enable histological examination as well as immunohistochemical staining of BRCA1-associated protein-1 (BAP-1).

METHODS

Fifty-nine patients diagnosed with choroidal melanoma in transvitreal biopsies between years 2003 and 2019 were included. Twenty-one of these patients subsequently underwent enucleation. The level of nuclear expression of BAP-1 in transvitreal biopsies and enucleations was evaluated and the concordance calculated. Metastasis-free survival and HR for metastasis were analysed.

RESULTS

The mean tumour thickness and diameter at biopsy was 3.8 mm (SD 2.1) and 9.3 mm (SD 4.8), respectively. For biopsies, 37 of 59 tumours (63%) were classified as having high nuclear BAP-1 expression, and 22 (37%) as low. For enucleations, 13 of 21 tumours (62%) were classified as having high nuclear BAP-1 expression, and 8 (38%) as low. Eighty-six per cent of biopsies had an identical BAP-1 classification as the subsequent enucleation, yielding a Cohen's kappa coefficient of 0.70. Patients with low nuclear BAP-1 expression in transvitreal biopsies had a significantly shorter metastasis-free survival (p=0.001), with a size-adjusted Cox regression HR for metastasis of 13.0 (95% CI 3.1 to 54.4, p=0.0004).

CONCLUSION

Loss of nuclear BAP-1 expression occurred in a large proportion of the small tumours included in this study. BAP-1 immunoreactivity in transvitreal incisional biopsies of choroidal melanoma is substantially concordant with immunoreactivity in enucleated specimens and identifies patients with poor metastasis-free survival.

Intraocular Biopsy and ImmunoMolecular Pathology for "Unmasking" Intraocular Inflammatory Diseases

Intraocular inflammation can hide a variety of eye pathologies. In 33% of cases, to obtain a correct diagnosis, investigation of the intraocular sample is necessary. The combined analyses of the intraocular biopsy, using immuno-pathology and molecular biology, point to resolve the diagnostic dilemmas in those cases where history, clinical tests, and ophthalmic and systemic examinations are inconclusive. In such situations, the teamwork between the ophthalmologist and the molecular pathologist is critically important to discriminate between autoimmune diseases, infections, and intraocular tumors, including lymphoma and metastases, especially in those clinical settings known as masquerade syndromes. This comprehensive review focuses on the diagnostic use of intraocular biopsy and highlights its potential to enhance research in the field. It describes the different surgical techniques of obtaining the biopsy, risks, and complication rates. The review is organized according to the anatomical site of the sample: I. anterior chamber containing aqueous humor, II. iris and ciliary body, III. vitreous, and IV. choroid and retina. We have excluded the literature concerning biopsy for choroidal melanoma and retinoblastoma, as this is a specialized area more relevant to ocular oncology.

Outcomes of 27-Gauge Vitrectomy-Assisted Choroidal and Subretinal Biopsy

BACKGROUND AND OBJECTIVE

To report the initial experience of 27-gauge vitrectomy-assisted choroidal and subretinal biopsy PATIENTS AND METHODS: Retrospective, interventional case series. Eighteen eyes of 18 patients undergoing 27-gauge vitrectomy-assisted choroidal (n = 16) or subretinal biopsy (n = 2). Clinical and lesion characteristics, cytopathology, histology, gene expression profiling (GEP), visual acuity (VA), complications including vitreous hemorrhage (VH), development of rhegmatogenous retinal detachment (RD), and need for additional surgeries were analyzed.

RESULTS

Indications were choroidal melanoma (n = 10), indeterminate choroidal (n = 5), and subretinal lesions (n = 3). Mean lesion height was 3.33 mm ± 1.55 mm (range: 0.80 mm to 6.75 mm) and largest diameter was 8.63 mm ± 4.14 mm (range: 3 mm to 15.5 mm). Mean number of intralesional biopsy passes required was 1.76 ± 0.83 (range: one to four). During a mean follow-up of 7.4 months ± 2.7 months (range: 4 months to 14 months), VA was unchanged (0.5 logMAR ± 0.6 logMAR vs. 0.7 logMAR ± 0.84 logMAR; P = .07). Pathologic diagnosis was obtained in 16 of 18 eyes (88.9%), and GEP data were collected for all 11 choroidal melanomas. Post-biopsy VH occurred in 13 of 18 eyes (72.2%) and was severe enough to require a concurrent limited vitrectomy in six eyes (33.3%). These eyes had a greater lesion height compared to eyes not requiring a vitrectomy (4.08 mm ± 1.68 mm vs. 2.76 mm ± 1.43 mm; P = .04). A rhegmatogenous RD requiring repeat surgery developed in two of 18 eyes (11.1%).

CONCLUSION

The authors concluded that 27-gauge vitrectomy-assisted choroidal and subretinal biopsy established a diagnosis in 88.9% of eyes in lesions 0.8 mm or larger. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:406-415.].

The Histopathological Finding of the Surgically Extracted Atypical Dome-Shaped Choroidal Osteoma

Purpose. To report a case of atypical dome-shaped choroidal osteoma, which was diagnosed by histopathological finding of surgically extracted tumor. Case Report. A 35-year-old woman presented with visual field abnormality in the left eye (OS). Her best-corrected visual acuity with Landolt ring chart was 1.0 OS. The funduscopic examination revealed a yellowish dome-shaped choroidal tumor located in the temporal side of the macula with exudative retinal detachment. 25-gauge pars plana vitrectomy and the extraction of the tumor were performed for the definitive diagnosis. Results. As a result of histopathological finding from the extracted tumor, she was diagnosed with choroidal osteoma. 10 months after the last surgery, the BCVA is 0.7 OS. The tumor is not relapsed. Conclusions. We must keep in mind that choroidal osteoma can be one of the differential diagnoses for the dome-shaped choroidal tumor.

NODULAR POSTERIOR SCLERITIS: Clinico-Sonographic Characteristics and Proposed Diagnostic Criteria

PURPOSE

To report the clinical and ultrasound features and outcomes of a series of nodular posterior scleritis.

METHODS

Retrospective medical record review of 11 consecutive patients with nodular posterior scleritis. Patient demographics, ocular and systemic findings, ultrasound features, and final anatomical and visual outcomes were recorded.

RESULTS

There were 9 females and 2 males (11 eyes) with mean age at presentation of 57 years (range, 30-84 years). Underlying systemic inflammatory disease was present in 73%. Symptoms included pain in 73% and blurred vision in 45%. A solitary amelanotic mass without the presence of lipofuscin was found in all cases. Associated ocular features included retinal pigment epithelial changes (67%), intraocular inflammation (55%), subretinal fluid (50%), macular edema (50%), and choroidal folds (30%). B-mode ultrasound showed a sclerochoroidal mass with high internal reflectivity (100%) of mean elevation of 4.1 mm. There was nodular thickening of the sclera (100%) and fluid in Tenon space or "T" sign (36%). A complete regression of the nodule after the treatment was observed only in 1 patient (11%) and partial regression in 4 patients (44%).

CONCLUSION

Nodular posterior scleritis should be considered in the differential diagnosis of a single amelanotic choroidal mass showing high internal reflectivity on ultrasound B-scan. It can produce intraocular inflammation in 50% of the cases and may be painless in 25%. It has a high association with a systemic underlying disease.

Management of uveal tract melanoma: A comprehensive review

Uveal tract melanoma is the most common primary intraocular malignancy in adults, accounting for about 5-10% of all the melanomas. Since there are no lymphatic vessels in the eye, uveal melanoma can only spread hematogenously leading to liver metastasis. A wide variety of treatment modalities are available for its management, leading to dilemma in selecting the appropriate therapy. This article reviews the diagnostic and therapeutic modalities available and thus, can help to individualize the treatment plan for each patient.

The Role of Chorioretinal Biopsy in the Diagnosis of Intraocular Lymphoma

PURPOSE

To assess the clinical usefulness of chorioretinal biopsy in establishing a definitive diagnosis in intraocular lymphomas.

DESIGN

Retrospective, noncomparative, consecutive diagnostic case series.

METHODS

setting: Moorfields Eye Hospital, London, United Kingdom.

PATIENTS

Twenty-nine consecutive patients presenting with severe uveitis that required an intraocular biopsy where underlying lymphoma was suspected.

OBSERVATION PROCEDURE

A retrospective review of a 15-year period (1999-2014) was undertaken of all patients that have undergone chorioretinal biopsy for suspected lymphoma at Moorfields Eye Hospital, London, United Kingdom. Patients were identified on the hospital's computerized database.

MAIN OUTCOME MEASURES

Effectiveness of chorioretinal biopsy in establishing a definitive diagnosis or in excluding malignancy.

RESULTS

A specific histologic diagnosis was made in 17 cases (59%) while in 9 cases the biopsy combined with clinical data was effective in excluding malignancy. In the 3 remaining cases, no specific diagnosis was made. No intraoperative complications were reported. Postoperative complications other than cataract included 2 vitreous hemorrhages and 2 retinal detachments. Of the 17 cases with a histologic diagnosis, 15 were obtained in eyes with marked vitritis, as opposed to 2 with minimal vitritis.

CONCLUSIONS

Chorioretinal biopsy provided a definitive diagnosis of lymphoma in 59% of cases and assisted in exclusion of a further 31% in this series. The level of vitritis appears to act as a strong index of likelihood in achieving a definitive histologic diagnosis.

Diagnostic Fine-Needle Aspiration Biopsy for Iris Melanoma

PURPOSE

The aim of this study was to describe a case of iris melanoma diagnosed by fine-needle aspiration biopsy (FNAB) with review of the literature.

DESIGN

This study presents a case report and review of the literature.

METHODS

A 76-year-old white man presented with iris melanoma arising from preexisting iris nevus that was confirmed cytologically by a transcorneal FNAB.

RESULTS

A pigmented lesion on the left iris extending from 3 to 8:30 o'clock, from the iris root to the pupillary margin without ectropion uveae, was biopsied through 1-mm clear corneal incision. A short 25-gauge needle was inserted into the tumor while applying aspiration, and 10-0 suture was used to close the wound. Cytopathology confirmed the presence of spindle-shaped cells with conspicuous cytoplasmic melanin and nuclear atypia consistent with the diagnosis of melanoma. There were no intraoperative or postoperative complications. The patient was subsequently treated with radiation plaque brachytherapy.

CONCLUSIONS

Although indicated only in minority of cases, it is important to consider FNAB for the diagnosis and management of iris lesions.

[Combined choroidal biopsy and cytology for diagnosis of intraocular tumour]

CLINICAL CASE

No intraocular biopsy technique is free of risk and all have the possibility of giving false negatives due to the difficulty in obtaining a sufficient sample. A modified chorioretinal biopsy was performed on a patient with suspected choroidal melanoma after negative biopsy with 25G vitrectomy. In addition to removing a solid fragment of tumor material using bimanual surgery, material from the lesion was obtained with the vitreotome to perform cytology, which confirmed the diagnosis of melanoma.

DISCUSSION

Cytology obtained through the vitreotome in association with removing a solid sample of the choroidal lesion may improve the efficiency of intraocular biopsy.

Fine needle aspiration biopsy of ophthalmic tumors

A majority of intraocular tumors can be diagnosed based on clinical examination and ocular imaging studies, which obviate the need for diagnostic ophthalmic fine needle aspiration biopsy (FNAB). Overall, diagnostic accuracy of ophthalmic FNAB is high but limited cellularity can compromise the diagnostic potential of ophthalmic aspirate samples. The role of ophthalmic FNAB is limited in retinal tumors. Orbital FNAB should be considered in the evaluation of lacrimal gland tumors, orbital metastasis, and lymphoproliferative lesions. Negative cytologic diagnosis of malignancy should not be considered unequivocal proof that an intraocular malignancy does not exist. With improved understanding of genetic prognostic factors of uveal melanoma, ophthalmic FNAB is gaining popularity for prognostic purposes in combination with eye conserving treatment of the primary tumor. In special clinical indications, ancillary studies such as immunohistochemistry and FISH can be performed on ophthalmic FNAB samples. Assistance of an experienced cytopathologist cannot be overemphasized.

Transretinal uveal melanoma biopsy with 25-gauge vitrectomy system

PURPOSE

To evaluate the efficacy and the safety of uveal melanoma transretinal biopsy using 25-gauge vitrectomy system.

METHODS

At the patient's request of a tissue diagnosis, nine posterior uveal melanomas treated by proton-beam therapy were biopsied during the insertion of tantalium markers.

RESULTS

The diagnosis was uveal melanoma, confirmed in all cases using cytological (7 of 9) and histological analysis (2 of 9). Immunocytochemistry was performed on all samples (9 of 9). In eight of nine patients, minor postoperative vitreous haemorrhages were seen, which resolved in 1 day. No other ocular complications were noticed.

CONCLUSION

Uveal melanoma biopsy using 25-gauge vitrectomy system is a valuable procedure to confirm the diagnosis, with adequate sample and low ocular morbidity.

Diagnostic incisional biopsies in clinically indeterminate choroidal tumours

Most intraocular tumours are reliably diagnosed by a careful clinical examination combined with one or more non-invasive diagnostic techniques. However, in a small percentage of tumours, typically small and clinically amelanotic, the features are insufficiently distinct for a confident clinical diagnosis and tissue is required for diagnosis. We used a 23-G vitreous cutter to access the biopsy site in 43 patients with clinically indeterminate tumours. After retinotomy, an incisional choroidal biopsy yielded a specimen of ∼1 mm(3). Obtained tissue was routinely processed for light microscopy including an immunohistochemical panel of monoclonal antibodies. Adequate tissue for diagnosis was provided in 41/43 (95%) patients. The sensitivity and specificity to detect malignant disease were 0.97 and 1.00, respectively. The positive predictive value was 1.00. Complications included progression of pre-existing retinal detachment in 5/43 (12%) patients and transient rise in intraocular pressure to >40 mm Hg in 6/43 (14%) patients; 4 of these 6 patients had a pre-existing retinal detachment. No patient with a pre-operatively attached retina had a retinal detachment. We conclude that an incisional transretinal choroidal biopsy yields abundant material and may adequately confirm or exclude malignancy in patients with clinically indeterminate tumours. The complication rate can be minimised when patients with pre-existing retinal detachment are excluded from biopsy.

Two cases of ocular sarcoidosis in which vitreous cytology was useful for supporting the diagnosis

The purpose of this paper is to report two cases of sarcoidosis with conflicting signs in which vitreous cytology was useful for supporting the diagnosis. Case 1 was a 56-year-old man who was referred with blurred vision, and was found to have iridocyclitis, vitreous opacities, and optic neuritis bilaterally. He also had a swelling of both mandibular glands. He received pulsed corticosteroid therapy, but the vitreous opacities and papilledema did not resolve. The second case was a 77-year-old man referred with blurred vision, and both eyes had snowball-like vitreous opacities and optic neuritis. The ocular findings in both cases strongly suggested sarcoidosis, but the systemic findings did not meet the diagnostic criteria for sarcoidosis. We performed pars plana vitrectomy to remove the vitreous opacities, and the collected vitreous samples were sent for cytological analyses. Epithelioid and multinucleated giant cells pathognomonic of sarcoidosis were found in the vitreous samples which enabled us to make a diagnosis of sarcoidosis. Vitreous cytology can help in supporting a diagnosis of sarcoidosis, especially in cases of ocular inflammation suggesting sarcoidosis but systemic findings that do not satisfy the diagnostic criteria for this disease.

Rapid cytologic diagnosis of choroidal malignant melanoma by vitreous smear

The eye is an uncommon subject of cytopathological examination. However, cytopathologic examination may be required for definitive diagnosis in some cases, as malignant tumors of the eye may sometimes be difficult to distinguish clinically from benign disorders. We report a case of malignant melanoma (MM) of the choroid, in which vitrectomy was performed for the initial clinical diagnosis of vitreous hemorrhage. As the dense vitreous hemorrhage was gradually cleared during the vitrectomy, a choroidal mass was discovered and the vitreous fluid was procured for rapid cytologic diagnosis. We used a modified Shorr's stain that can be completed within several minutes. With this method, highly atypical, pleomorphic cancer cells, occasionally associated with melanin pigment granules, were demonstrated. These cytologic findings indicated a diagnosis of MM arising from the choroid. Histologic examination of the enucleated eye confirmed MM of epithelioid type. The advantage and indication of the rapid cytologic diagnosis is discussed.

Case of metastatic pulmonary carcinoma in optic disc diagnosed from results of biopsy performed during vitrectomy surgery

BACKGROUND

Most intraocular metastatic tumors occur in the uveal tract, while isolated metastasis to the optic nerve is rarely found. We report a case of metastasis to the optic disc from primary lung cancer, diagnosed from biopsy findings obtained during a vitrectomy.

PATIENT AND METHODS

A 69-year-old male presented with gradual visual impairment due to a milky white tumour that extended from the optic disc into the vitreous cavity. A systemic examination revealed primary squamous cell lung cancer.

RESULTS

A biopsy specimen was obtained from the optic disc tumor during a vitrectomy, which led to a diagnosis of metastasis from lung cancer. Despite courses of chemotherapy and radiotherapy, the patient died of brain metastasis.

DISCUSSION

There are few reports of secondary optic disc tumors and pathological biopsy findings are rare. When a milky white tumor is observed extending from the optic disc, a possible differential diagnosis is metastatic neoplasm.

Neuro-ophthalmic sarcoidosis

PURPOSE OF REVIEW

Almost 100 years after its original description, sarcoidosis remains an enigmatic disease with unclear etiology and capricious symptomology, as well as a diagnostic challenge. This review coalesces current literature on the neuro-ophthalmic manifestations of sarcoidosis and discusses the epidemiology, etiology, clinical presentation, diagnosis, and management of this disease.

RECENT FINDINGS

Recent investigations strongly identify a genetic component as well as a host of candidate antigenic triggers. Certain human leukocyte antigen polymorphisms may influence not only the susceptibility of individuals to sarcoidosis but also the course of the disease. Diagnostic advances include the finding of two additional potential biomarkers of sarcoidosis as well as the use of positron emission tomography technology in localization of disease sites for biopsy. In addition to the concomitant and alternative use of immunosuppressive agents to steroid therapy, disease remission in refractory neuro-ophthalmic sarcoidosis with tumor necrosis factor alpha inhibitors has also been reported.

SUMMARY

Sarcoidosis can affect any part of the visual system; the most common neuro-ophthalmic presentation is optic neuropathy. Diagnosing the disease is problematic as the clinical presentation is nonspecific which may be associated with many other pathologies and no diagnostic finding is pathognomonic. In recent years, progress has been made in identifying new biomarkers and developing imaging techniques. Although corticosteroids remain the mainstay of therapy, many new pharmacological agents have been added to the treatment arsenal.

Intraocular lymphoma diagnosed by fine-needle aspiration biopsy

PURPOSE

To describe clinical experience in the diagnosis of intraocular lymphoma by fine-needle aspiration biopsy (FNAB) in patients with one or more discrete intraocular infiltrative lesions and limited or absent intravitreal tumour cells.

METHODS

 Retrospective descriptive analysis of patients who underwent intraocular FNAB of a solid retinal, subretinal pigment epithelial or uveal tumour that proved to be a malignant lymphoma.

RESULTS

After exclusions, our study group consisted of seven patients, each of whom had one or more discrete intraocular infiltrative lesions and limited or absent intravitreal tumour cells and underwent a diagnostic intraocular FNAB that confirmed malignant intraocular lymphoma cytopathologically. These included three patients with one or more geographic yellow subretinal pigment epithelial infiltrates and one patient each with a prominent nodular white subretinal pigment epithelial tumour, a rapidly developing solid placoid choroidal mass, a haemorrhagic retinal infiltrative lesion and an infiltrative iris tumour, respectively. A prominent feature of virtually all aspirates was a large proportion of degenerated lymphoid cells in the background. Cytologically intact tumour cells ranged from relatively homogeneous small round cells with large nucleus to cytoplasm ratio to pleomorphic large cells with irregular knob-like nuclear protrusions. Immunocytochemical stains for lymphoid markers were helpful in confirming the pathological diagnosis of lymphoma in the five patients in whom this testing was performed.

CONCLUSION

FNAB was a useful diagnostic tool in the described subgroup of patients with suspected intraocular lymphoma. FNAB should be considered as a diagnostic option in selected patients with suspected intraocular lymphoma, especially if there are few or no vitreous cells.

Fine-needle aspiration biopsy and other biopsies in suspected intraocular malignant disease: a review

Ocular oncologists require a strong indication for intraocular biopsy before the procedure can be performed because it carries a risk for serious eye complications and the dissemination of malignant cells. The purpose of this review is to evaluate the extent to which this restricted practice is supported by evidence from previous reports and to outline our main indications and contraindications. The different intraocular biopsy techniques in the anterior and posterior segment are discussed with a focus on our preferred method, fine-needle aspiration biopsy (FNAB). In the literature, complications are typically under-reported, which reduces the possibilities of evaluating the risks correctly and of making fair comparisons with other biopsy methods. In FNAB, the exact placement of the needle is critical, as is an accurate assessment of the size of the lesion. Fine-needle aspiration biopsy is usually not a reliable diagnostic tool in lesions < 2 mm in thickness. It is very advantageous to have a cytopathologist present in the operating theatre or close by. This ensures adequate sampling and encourages repeated biopsy attempts if necessary. This approach reduces false negative results to < 3%. Adjunct immunocytochemistry is documented to increase specificity and is essential for diagnosis and management in about 10% of cases. In some rare pathological processes the diagnosis depends ultimately on the identification of specific cell markers. An accurate diagnosis may have a decisive influence on prognosis. The cytogenetic prognostications made possible after FNAB are reliable. Biopsy by FNA has a low complication rate. The calculated risk for retinal detachment is < 4%. Intraocular haemorrhage is frequently observed, but clears spontaneously in nearly all cases. Only a single case of epibulbar seeding of malignant cells at the scleral pars plana puncture site of transvitreal FNAB has been documented. Endophthalmitis has been reported and adequate standard preoperative preparation is obligatory. An open biopsy is still an option in the anterior segment, but has been abandoned in the posterior segment. Although vitrectomy-based procedures are becoming increasingly popular, we recommend using FNAB as part of a stepwise approach. A vitrectomy-assisted biopsy should be considered in cases where FNAB fails. In any adult patient with suspected intraocular malignancy in which enucleation is not the obvious treatment, the clinician should strive for a diagnosis based on biopsy. When the lesion is too small for biopsy or the risks related to the procedure are too great, it is reasonable to be reluctant to biopsy. The standards applied in the treatment of intraocular malignant diseases should be equivalent to those in other fields of oncology. Our view is controversial and contrary to opinion that supports current standards of care for this group of patients.

Expression of the SST receptor 2 in uveal melanoma is not a prognostic marker

INTRODUCTION

Uveal melanoma (UM) cells and neurohormone-producing cells both originate from the neural crest. Somatostatin receptors subtype 2 (SSTR2) are over-expressed in several tumors, often from neuroendocrine origin, and synthetic antagonists like octreotide and octreotate are being used as diagnostic or therapeutic agents. We investigated the SSTR2 expression in UM, and determined whether this expression was related to prognosis of the disease.

MATERIALS AND METHODS

UM cell lines and fresh primary UM samples were tested for SSTR2 expression by autoradiography (AR) using 125I-Tyr3-octreotate. Furthermore, UM cell lines were analyzed for SSTR2 mRNA expression with quantitative real-time RT-PCR.

RESULTS

Using AR, cell-surface SSTR2 expression was demonstrated in two UM metastatic cell lines, but no expression was detected in three cell lines derived from primary UM. However, all primary and metastatic UM cell lines showed mRNA expression levels for SSTR2 using quantitative real-time RT-PCR. Only three of 14 primary UM demonstrated moderate SSTR2 expression, and this expression was not significantly associated with tumor-free survival or any tested prognostic factor.

CONCLUSIONS

Based on the rare and low expression of SSTR2 found in primary UM specimens and in UM cell lines, we conclude that SSTR2 is not widely expressed in UM. Furthermore, SSTR2 expression was not associated with tumor-free survival and prognostic factors. Therefore SSTR2 is not suited as prognostic marker or therapeutic target in UM.

In vivo monosomy 3 detection of posterior uveal melanoma: 3-year follow-up

BACKGROUND

Monosomy 3 is a highly specific marker for poor prognosis in posterior uveal melanoma. Unfortunately, cytogenetic prognostication is limited to enucleated eyes or resected tumors. The aim of this study was to evaluate mid-term natural history and safety of in vivo detection of chromosome 3 status in posterior uveal melanomas undergoing plaque brachytherapy.

METHODS

A 25-gauge transscleral fine needle aspiration biopsy (FNAB) was performed in 32 eyes affected by posterior uveal melanoma undergoing plaque brachytherapy, just before applying the radioactive plaque. Sampled material underwent fluorescence in situ hybridization (FISH) with centromeric probes for chromosome 3. All patients had a follow-up of at least 36 months.

RESULTS

Mean follow-up was 47.1 +/- 8.5 months. Mean largest basal diameter and mean thickness of the tumors were 12.5 +/- 2.7 mm and 8 +/- 2.3 mm respectively. FNAB yielded sufficient material in 26 of 32 cases (81.2%). Adequacy of the sample ranged from 91.1% (ciliary body tumors) to 76.8% (choroidal tumors). Seventeen cases had monosomy 3 (65.3%). No correlation was found between monosomy 3 and tumor dimensions or location (ciliary body vs choroidal tumors). No early and mid-term local complications were documented. Seven patients (21.8%) died during follow-up: five (15.6%) of them died due to metastatic disease (all had monosomy 3 tumors).

CONCLUSIONS

Posterior uveal melanomas may be adequately and safely sampled, by intra-operative transscleral FNAB, to detect in vivo monosomy 3.

Evaluation of Characteristic Ocular Signs and Systemic Investigations in Ocular Sarcoidosis Patients

PURPOSE

To evaluate the diagnostic values of ocular signs and systemic investigations in ocular sarcoidosis, in a retrospective case-control study.

METHODS

Subjects were 67 consecutive uveitis patients with biopsy-proven sarcoidosis and 111 control patients with other clinical uveitis entities. The predictive values analyzed were sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The five ocular signs for ocular sarcoidosis are (1) mutton fat keratic precipitates and iris nodules; (2) nodules at the trabecular meshwork and tent-shaped peripheral anterior synechia; (3) snowball vitreous opacities; (4) nodular periphlebitis, and (5) multiple chorioretinal lesions (active or atrophic) in the peripheral fundus. In addition, the results of the following five systemic investigations were considered: (1) negative tuberculin skin test; (2) elevated serum angiotensin-converting enzyme; (3) elevated serum lysozyme; (4) elevated serum gamma-globulin; and (5) bilateral hilar lymphadenopathy on chest X-ray.

RESULTS

The incidence of all ocular signs and positive results for the systemic investigations were significantly higher in sarcoidosis patients than in controls (P < 0.001). The presence of two or three of the five ocular signs were indicative of a positive finding in the diagnostic parameters. The presence of two positive results among the five systemic investigations showed values higher than 0.800 for all diagnostic parameters.

CONCLUSIONS

Combinations of the specified ocular signs and the results of systemic investigations can be used for the diagnosis of ocular sarcoidosis.