Fine-needle aspiration biopsy of iris tumors in 100 consecutive cases: technique and complications

Cysts and tumours of the iris: Diagnostic tools and key management considerations-A review

The iris is a unique structure, with exquisite variations in colour and form. Pathological changes, specifically including iris cysts and tumours are relatively uncommon, difficult to diagnose, and yet potentially blinding or life-threatening. Based on a comprehensive literature review, with highly illustrated key case examples, this report aims to guide the clinician in filtering the differential diagnoses of iris cysts and tumours. Evaluation is in the context of key diagnostic clinical tools and management considerations. Diagnostic imaging techniques include serial anterior segment photography, ultrasound, anterior segment optical coherence tomography, and iris fluorescein angiography, however, the roles of computerised topography and magnetic resonance imaging are also considered in this review. Management includes categorisation in terms of solid iris tumours (melanocytic vs. non-melanocytic), or iris cysts (primary vs. secondary) that may be usefully differentiated by clinical assessment, avoiding more invasive interventions. Cystic lesions are generally benign, although implantation cysts in particular cause significant complications and surgical challenges. Most solid tumours are melanocytic and also typically benign. However, in larger lesions, rapid growth, symptoms and complications more likely indicate malignancy, requiring further investigation.

Iris melanoma: Review of clinical features, risks, management, and outcomes

Primary uveal melanoma is rare and affects approximately 8,000 persons per year worldwide. This malignancy can involve the iris, ciliary body, and choroid. Of these three structures, the iris is the least commonly affected site, representing only 4% of all uveal melanomas. Iris melanoma can arise from iris melanocytic nevus, iris melanocytosis, or de novo. In a longitudinal study of 1,611 patients with iris nevus, transformation into melanoma, using Kaplan-Meier estimates, was found in 2.6% by five years and in 4.1% by 10 years. The factors that predicted growth of iris melanocytic nevus into melanoma are denoted by a letter (ABCDEF) guide: A for age ≤40 years old at presentation (hazard ratio [HR] = 3, P = .01), B for blood (hyphema) (HR = 9, P < .0004), C for clock hour of tumor inferiorly (tumor location) (HR = 9, P = .03), D for diffuse flat tumor configuration (HR = 14, P = .02), E for ectropion uveae (HR = 4, P = .002), and F for feathery ill-defined margins (HR = 3, P = .02). At diagnosis, iris melanoma has a mean cross-sectional diameter of 5.5 mm and thickness of 2.1 mm, often with tumor seeding (28%) and secondary glaucoma (35%). We provide a comprehensive review of iris nevus and melanoma to explore relevant demographic and clinical data, risk factors for tumor growth, management, and prognosis, with the hope that clinicians will be more comfortable in understanding this rare malignant condition.

Detection of Circulating Tumor Cells in Patients with Small Choroidal Melanocytic Lesions

PURPOSE

To determine the presence of circulating tumor cells (CTCs) in patients with indeterminate small choroidal melanocytic lesions (SCMLs).

DESIGN

Retrospective case series.

PARTICIPANTS

Forty-seven patients with choroidal melanocytic lesions 2.5 mm or less in tumor thickness and ≤ 10 mm in largest basal diameter (LBD).

METHODS

Blood samples were analyzed for CTCs and the presence of monosomy-3 (M3) in CTCs. Tissue biopsy was performed in the patients who were CTC-positive (pCTC).

MAIN OUTCOME MEASURES

Presence and M3 status of the CTCs with regard to the clinical characteristics and results from tissue biopsy.

RESULTS

Median thickness of all (n = 47) lesions was 1.1 mm (range: 0.2-2.5 mm), and LBD was 5.6 mm (range: 2.0-10.0 mm). Circulating tumor cells were found in 25 patients (n = 25). This group was classified as pCTC and compared with the CTC-negative (nCTC) group consisting of 22 patients (n = 22). Median tumor dimensions in the pCTC versus the nCTC group were 1.6 mm (range: 0.6-2.5 mm) versus 0.5 mm (range: 0.2-2.5 mm) for thickness and 6.6 mm (range: 4.1-10.0 mm) versus 4.0 mm (range: 2.0-8.0 mm) for LBD, respectively. Both LBD and thickness were positively associated (P < 0.001) with the presence of CTC. Compared with the nCTC group, a higher percentage of the pCTC group exhibited LBD > 5 mm (36% vs. 88%), subretinal fluid (9.1% vs. 56%), orange pigment (4.5% vs. 60%), sonographic hollowness (9.1% vs. 60%), and the presence of multiple risk factors (0% vs. 68% for ≥3 factors) with P < 0.001 for all parameters. No significant difference was detected in the clinical parameters of the patients who had disomy-3 (D3) (n = 7) versus M3 (n = 17) in their CTC. The tissue biopsy confirmed the uveal melanoma (UM) in 22 of the 25 pCTC patients (88%), whereas no conclusive diagnosis could be determined in the remaining 3 cases because of insufficient or invalid material.

CONCLUSIONS

We report compelling evidence for the potential of liquid biopsy as an additional tool to screen SCMLs for malignancy. These findings pave the way toward the implementation of liquid biopsy to detect small UM and monitor melanocytic lesions.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Significant improvement of ocular clinical pictures of iris metastasis from small-cell lung cancer after systemic chemotherapy

The uveal tract is the most common ophthalmic site of ocular metastasis from systemic tumors due to the luxurious blood flow within the choroidal tissue. However, iris metastasis from systemic cancer is uncommon, accounting for only 8% of cases of uveal metastasis. There are several methods for the treatment of iris tumor. Here, we reported a case of iris metastasis from small-cell lung cancer. The tumor shrunk after systemic treatment for lung cancer and showed no recurrence after a 4-month follow-up.

Iris metastasis as the initial presentation of metastatic esophageal cancer diagnosed by fine needle aspiration biopsy: A case report

RATIONALE

Metastasis of neoplasms to the eye is quite uncommon. In this case report, we describe a patient where primary esophageal cancer was diagnosed by fine needle aspiration biopsy (FNAB) of an iris tumor.

PATIENT CONCERNS

A 70-year-old male complained of redness and discomfort in the right eye.

DIAGNOSIS AND INTERVENTIONS

The patient's right eye was diagnosed as idiopathic uveitis, and a topical steroid was administered. As vitreous opacities were observed even after topical therapy, oral prednisolone was administered. On slit-lamp examination of the right eye, an iris mass with neovascularization was seen in the anterior chamber. A metastatic tumor was suspected, and FNAB was performed. Histology revealed squamous cell carcinoma. Systemic workup revealed esophageal cancer with several metastases. Best-corrected visual acuity decreased to 20/400, and intraocular pressure was 40 mmHg in the right eye. Two iris tumors with neovascularization were present extending into the anterior chamber with posterior iris synechiae and 360 degree peripheral anterior synechiae. Intraocular pressure in the right eye was medically managed with hypotensive eye drops and oral acetazolamide. Iris metastases were treated with 40 Gray of radiation therapy and concurrent chemotherapy.

OUTCOMES

The tumor regressed, but intraocular pressure was refractory to treatment because of 360 degree goniosynechial closure. The right eye lost light perception six months after treatment commenced, and the patient died 9 months after the onset of therapy due to multiple systemic metastases.

LESSONS

This is a rare case of masquerade syndrome without systemic symptoms in which FNAB of an iris tumor led to a diagnosis of metastatic esophageal squamous cell carcinoma. Although the patient lost his sight due to uncontrollable ocular hypertension, systemic chemotherapy, and radiation therapy were initially effective in the treatment of the metastatic iris tumor. As the prognosis of patients with metastatic iris tumors is poor, it is important for ophthalmologists to consider such diagnoses and conduct systemic investigations when necessary.

Relief of symptomatic pseudo-polycoria due to iris biopsy using a daily contact lens

Purpose

To report a case of pseudo-polycoria from iris biopsy managed by a daily disposable prosthetic colored hydrogel lens.

Observations

A 55-year-old- Caucasian female presented with complaints of photophobia in her right eye, that was exacerbated when going from a dark to light environment. Her past ocular history included a diagnosis by another outside physician of presumed multifocal iris melanoma in the right eye, followed by an iris biopsy performed one month later. Upon presentation to our clinic two months later, best corrected visual acuity was 20/20- in the right eye and 20/25 in the left eye. Slit lamp exam of the right eye revealed iris abnormalities, full-thickness biopsy defects at 2, 3 and 6 o'clock and a 0.8 × 0.7mm area of iris hyperpigmentation at 8 o'clock (Fig A,B,C, and D). The patient was provided with three non-surgical options to manage her symptoms: a commercially available soft daily replacement printed prosthetic hydrogel lens, a commercially available soft monthly replacement silicone printed prosthetic hydrogel lens, or a custom soft yearly replacement prosthetic hydrogel lens with dark inlay. The soft daily printed prosthetic hydrogel lens was chosen because of its ease in hygiene regimen and did not limit peripheral vision as the yearly dark inlay lens would.

Results

The patient now wears Alcon Dailies® Color, Base curvature 8.6, Diameter 13.8, color mystic green in the right eye and her symptoms of photophobia have been resolved (Figure F).

Conclusion

There are limited options to manage photophobia in patients with polycoria or pseudo-polycoria. Surgical intervention is dictated by how many quadrants of iris are involved and therefore how symptomatic a patient may be. A less invasive alternative to surgical intervention is the use of a contact lens. In this case, traditional hand painted or printed yearly or monthly replacement hydrogel contact lenses were not used. Instead, a daily disposable hydrogel was successfully fit, highlighting that there is often a simple solution to a seemingly complicated issue.

Current molecular and clinical insights into uveal melanoma (Review)

Uveal melanoma (UM) represents the most prominent primary eye cancer in adults. With an incidence of approximately 5 cases per million individuals annually in the United States, UM could be considered a relatively rare cancer. The 90-95% of UM cases arise from the choroid. Diagnosis is based mainly on a clinical examination and ancillary tests, with ocular ultrasonography being of greatest value. Differential diagnosis can prove challenging in the case of indeterminate choroidal lesions and, sometimes, monitoring for documented growth may be the proper approach. Fine needle aspiration biopsy tends to be performed with a prognostic purpose, often in combination with radiotherapy. Gene expression profiling has allowed for the grading of UMs into two classes, which feature different metastatic risks. Patients with UM require a specialized multidisciplinary management. Primary tumor treatment can be either enucleation or globe preserving. Usually, enucleation is reserved for larger tumors, while radiotherapy is preferred for small/medium melanomas. The prognosis is unfavorable due to the high mortality rate and high tendency to metastasize. Following the development of metastatic disease, the mortality rate increases to 80% within one year, due to both the absence of an effective treatment and the aggressiveness of the condition. Novel molecular studies have allowed for a better understanding of the genetic and epigenetic mechanisms involved in UM biological activity, which differs compared to skin melanomas. The most commonly mutated genes are GNAQ, GNA11 and BAP1. Research in this field could help to identify effective diagnostic and prognostic biomarkers, as well as novel therapeutic targets.

UVEAL MELANOMA BIOPSY A REVIEW

In intraocular tumors, diagnosis is usually based on clinical examination and imaging without the need for invasive surgery or tissue sampling. The diagnosis can be confirmed by biopsy, however, in the case of intraocular malignancy, the biopsy is considered controversial. Due to the development of uveal melanoma cytogenetic prognostics and the progression in generalised uveal melanoma treatment, intraocular melanoma biopsy is becoming increasingly important. Diagnostic biopsy of intraocular tumors is indicated in cases of diagnostic uncertainty for findings with conflicting non-invasive test results and for small melanocyte lesions. Tumor prognostic biopsy is performed to obtain a tissue sample for tumor cytogenetic testing, which can help to determine the prognosis and specific metastatic risk of the patient. For anterior segment tumors, anterior chamber fluid sampling, thin-needle iris biopsy, punch biopsy, surgical biopsy or biopsy using vitrectomy may be used. For posterior segment tumors, procedures include transscleral or transretinal thin-needle biopsy, vitrectomy-assisted biopsy, punch biopsy, endoresection or transscleral exoresection. Complications of intraocular melanoma biopsy include too small or non-valuable sample collection, intra-tumoral heterogeneity, intra-ocular trauma and induction of intraocular or extraocular tumor dissemination.

Micro-incision, trans-iridal aspiration cutter biopsy for ciliary body tumours

OBJECTIVE

To perform micro-incision, trans-iridal, aspiration-cutter-assisted biopsy for ciliary body tumours.

DESIGN

Retrospective, nonrandomized, observational, interventional case series.

METHODS

Five consecutive patients undergoing ciliary body tumour biopsy were clinically diagnosed using slit-lamp photography, gonioscopy, high-frequency ultrasound imaging, and systemic radiographic staging. A 1-2 mm clear cornea incision was placed opposite to the central clock hour of the ciliary body tumour. Viscoelastic was infused into the anterior chamber for stabilization and endothelial protection. Then, a 27-gauge aspiration cutter was used to make an iridotomy at the iris root and then extend through the iris into the tumour. Biopsy was performed using mechanical cutting starting at 300 cuts per minute and aspiration at 600 mm Hg. After withdrawal of the cutter from the eye, the effluent tube was flushed into a 3 cc syringe, inspected for specimen under the operating microscope and sent for pathology. Multiple biopsies were performed on each patient. Viscoelastic was removed and Seidel examination of the corneal wound performed.

RESULTS

Five eyes were biopsied. A mean 3.6 passes were used to obtain tumour tissue. Tumour cells and tissue were obtained in all cases. Cytologic, histopathologic, and immuno-histochemical analysis were performed (100%, n = 5/5). Diagnoses included melanoma (60%, n = 3/5), melanocytoma (20%, n = 1/5), and leiomyoma (20%, n = 1/5). Transient postoperative hyphemas cleared within 1 week (80%, n = 4/5). No secondary glaucoma, infection, or cataracts were noted.

CONCLUSION

Aspiration-cutter biopsy through the iris root provided a minimally invasive, safe method for obtaining ciliary body tissue for cytology, histopathology, and immunohistochemical analysis.

Fine-needle aspiration biopsy for suspected uveal metastases

OBJECTIVE

One indication of fine-needle aspiration biopsy (FNAB) is the diagnostic confirmatory of a clinical suspicion of uveal metastasis. We analyzed our experience in this clinical setting to assess the effectiveness of FNAB technique.

DESIGN

Retrospective study.

PARTICIPANTS

28 patients (28 eyes) underwent FNAB biopsy.

METHODS

Aspirates were performed using 25-gauge needle and were classified into the following categories: positive, atypical, negative, or nondiagnostic. The electronic medical records provided all clinical data. Subsequent clinical course was considered as the diagnostic standard.

RESULTS

Subsequent clinical course was metastatic tumour in 19 cases (68%) and nonmetastatic tumour in other 9 cases, considered as the diagnostic standard. Cytological interpretations for metastases were positive in 19 cases (68%), atypical in 2 cases (7%), negative in 4 cases (14%), and nondiagnostic in 3 cases (11%). The metastasis-positive cases included 9 adenocarcinoma, 3 uveal lymphoma, 3 small cell carcinomas, 3 non-small cell carcinomas, and 1 metastatic paraganglioma. Both of the atypical cases were suggestive for non-Hodgkin lymphoma. The 4 negative cases for metastases included 2 true negative cases, and 2 false negative aspirates that subsequently proved to be metastatic adenocarcinoma. The 3 nondiagnostic cases included 1 schwannoma, 1 low-grade uveal non-Hodgkin lymphoma, and 1 metastatic adenocarcinoma. The overall sensitivity for FNAB was 87.5%, with a specificity of 100%.

CONCLUSIONS

FNAB of suspected uveal metastases is a reliable diagnostic technique.

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.

Uveal Melanoma Biopsy: A Review

Intraocular tumor diagnosis is based on clinical findings supported by additional imaging tools, such as ultrasound, optical coherence tomography and angiographic techniques, usually without the need for invasive procedures or tissue sampling. Despite improvements in the local treatment of uveal melanoma (UM), the prevention and treatment of the metastatic disease remain unsolved, and nearly 50% of patients develop liver metastasis. The current model suggests that tumor cells have already spread by the time of diagnosis, remaining dormant until there are favorable conditions. Tumor sampling procedures at the time of primary tumor diagnosis/treatment are therefore now commonly performed, usually not to confirm the diagnosis of UM, but to obtain a tissue sample for prognostication, to assess patient's specific metastatic risk. Moreover, several studies are ongoing to identify genes specific to UM tumorigenesis, leading to several potential targeted therapeutic strategies. Genetic information can also influence the surveillance timing and metastatic screening type of patients affected by UM. In spite of the widespread use of biopsies in general surgical practice, in ophthalmic oncology the indications and contraindications for tumor biopsy continue to be under debate. The purpose of this review paper is to critically evaluate the role of uveal melanoma biopsy in ophthalmic oncology.

Iris melanoma presenting as childhood glaucoma

Purpose

To describe the natural history and management of a rare case of iris melanoma in a pediatric patient.

Observations

A Caucasian female presented with left pupillary abnormalities at age 7, progressive iris changes at age 9, and markedly elevated intraocular pressure with advanced optic nerve cupping at 11 years of age. She was found to have a pigmented lesion overlying her iris and invading her angle. Trans-corneal fine needle aspirate biopsy demonstrated malignant melanoma of the iris. The patient subsequently underwent Iodine-125 plaque brachytherapy for the tumor.

Conclusions

and Importance: Early identification and treatment of iris melanoma may be associated with decreased risk of local progression and metastatic disease. Treatment of glaucoma in conjunction with uveal melanoma is complicated by tumor specific considerations, including treatment of the tumor and prevention of metastasis.

Iris metastasis as a first manifestation of lung adenocarcinoma

OBJECTIVE

To describe a case of lung adenocarcinoma for which the first clinical manifestation was an iris metastasis.

CASE REPORT

A 76-year-old male patient came for consultation referring a «pinkish speck» on his right eye. On biomicroscopy examination, a mass was found on the iris of the right eye. Subsequent systemic work-up of the patient revealed a left lung adenocarcinoma.

DISCUSSION

Although uncommon, iris metastasis secondary to lung cancer should be part of differential diagnosis in iris tumours.

Iris Melanoma in a Child Simulating Juvenile Xanthogranuloma

An 8-year-old girl was referred for an amelanotic iris tumor believed to have enlarged slightly over 3 months, suspicious for juvenile xanthogranuloma (JXG). The affected right eye had a lightly pigmented, vascular iris mass measuring 6 mm in basal dimension and 2 mm in thickness. There were no feeder vessels, seeding, inflammatory cells, or cutaneous abnormalities. Diagnostic fine needle aspiration biopsy (FNAB) was performed, revealing spindle B melanoma cells that were immunoreactive for melanocytic markers HMB45 and Melan-A. Complete tumor resection by basal sector iridectomy was performed. Histopathology confirmed spindle B melanoma. At 14-years follow up, there has been no recurrence or metastasis and visual acuity remains 20/25. Iris melanoma can develop in children and clinically resemble nodular JXG.

Optical coherence tomography angiography of a pigmented Fuchs' adenoma (age-related hyperplasia of the nonpigmented ciliary body epithelium) masquerading as a ciliary body melanoma

Purpose

To report a case of age-related hypertrophy of the nonpigmented ciliary epithelium (ARH-NPCE) clinically resembling a ciliary body melanoma and report the optical coherence tomography angiography (OCTA) findings associated with this lesion.

Observations

A 51-year-old male was referred for evaluation of a deeply pigmented ciliary body mass with extension through the iris root. Iridocyclectomy was performed due to concern for ciliary body melanoma. Histopathologic analysis was instead consistent with ARH-NPCE, also known as Fuchs' adenoma. Prior to surgery, OCTA images revealed abnormal vasculature in the area of the lesion. Vessels in the peripheral iris approaching the lesion appeared more tortuous and were non-radial as compared with normal iris vessels. The ciliary body mass itself could not be penetrated using an OCTA system operating at 1050 nm.

Conclusions and importance

ARH-NPCE may clinically resemble a pigmented ciliary body melanoma. This is the second case describing this clinical scenario, which may be more common than previously thought. Non-invasive imaging with OCTA revealed an abnormal peripheral iris vasculature pattern in the area of the iridociliary mass characterized by disorganized, tortuous, and non-radial vessels. Despite advances in longer wavelength OCTA systems, poor penetration of the ciliary body lesion precluded imaging of the intratumoral vessels in this location.

Evaluation of Iris Melanoma with Anterior Segment Optical Coherence Tomography

Anterior segment optical coherence tomography (AS-OCT) is a relatively new imaging modality that allows assessment of anterior segment structures. AS-OCT enables the differentiation of benign and malignant tumors through the evaluation of lesion size, internal structure, degree of vascularity, and anterior and posterior surfaces. Herein, we discuss the AS-OCT findings of a patient with spindle type iridociliary melanoma diagnosed in pathologic examination.

Biopsy techniques for intraocular tumors

Biopsy involves the surgical removal of a tissue specimen for histopathologic evaluation. Most intraocular tumors are reliably diagnosed based on the clinical evaluation or with noninvasive diagnostic techniques. However, accurately diagnosing a small percentage of tumors can be challenging. A tissue biopsy is thus needed to establish a definitive diagnosis and plan the requisite treatment. From fine-needle aspiration biopsy (FNAB) to surgical excision, all tissue collection techniques have been studied in the literature. Each technique has its indications and limitations. FNAB has been reported to provide for 88–95% reliable and safe ophthalmic tumor diagnosis and has gained popularity for prognostic purposes and providing eye conserving treatment surgeries. The technique and instrumentation for biopsy vary depending upon the tissue involved (retina, choroid, subretinal space, vitreous, and aqueous), suspected diagnosis, size, location, associated retinal detachment, and clarity of the media. The cytopathologist confers a very important role in diagnosis and their assistance plays a key role in managing and planning the treatment for malignancies.

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.

Uveal melanoma: relatively rare but deadly cancer

Although it is a relatively rare disease, primarily found in the Caucasian population, uveal melanoma is the most common primary intraocular tumor in adults with a mean age-adjusted incidence of 5.1 cases per million per year. Tumors are located either in iris (4%), ciliary body (6%), or choroid (90%). The host susceptibility factors for uveal melanoma include fair skin, light eye color, inability to tan, ocular or oculodermal melanocytosis, cutaneous or iris or choroidal nevus, and BRCA1-associated protein 1 mutation. Currently, the most widely used first-line treatment options for this malignancy are resection, radiation therapy, and enucleation. There are two main types of radiation therapy: plaque brachytherapy (iodine-125, ruthenium-106, or palladium-103, or cobalt-60) and teletherapy (proton beam, helium ion, or stereotactic radiosurgery using cyber knife, gamma knife, or linear accelerator). The alternative to radiation is enucleation. Although these therapies achieve satisfactory local disease control, long-term survival rate for patients with uveal melanoma remains guarded, with risk for liver metastasis. There have been advances in early diagnosis over the past few years, and with the hope survival rates could improve as smaller tumors are treated. As in many other cancer indications, both early detection and early treatment could be critical for a positive long-term survival outcome in uveal melanoma. These observations call attention to an unmet medical need for the early treatment of small melanocytic lesions or small melanomas in the eye to achieve local disease control and vision preservation with the possibility to prevent metastases and improve overall patient survival.

Vascularized solid iris lesion in a 3 year old child: 5 years of follow up

Background

Iris tumors are rare in young patients. When an iris lesion occurs in a pediatric patient, it can be difficult to classify because of the wide spectrum of iris proliferations.

Case presentation

We report on an unusual case of a vascularized iris lesion in a three year old Caucasian patient, with no symptoms and no visual impairment. We evaluated in a 50-month follow up with non-invasive diagnostic tools in order to avoid eye biopsy.

Conclusion

We focused attention on the differential diagnoses and underlined the role of non-invasive diagnostic tools in a child to avoid or postpone the eye biopsy. We performed a review of the literature to identify the best medical practice in pediatric iris lesions with atypical characteristics.

Microincision, Aspiration Cutter-Assisted Multifocal Iris Biopsy for Melanoma

Purpose

To describe a minimally invasive method to create multifocal full-thickness surgical iridectomy biopsies.

Methods

Seven patients suspected to have diffuse iris melanoma underwent multifocal surgical iridectomy biopsy through a single 1.0-mm clear corneal incision. A 25-G inked trocar was used to create one visible corneal portal, through which the anterior chamber was filled with sodium hyaluronate 1%. Then, a 25-G aspiration cutter probe was introduced through the corneal incision such that the aspiration portal was occluded by the iris biopsy sites. Then aspiration (600 mm Hg) cutting (300 cuts per minute) was used to create full- and partial-thickness surgical iridectomy biopsies at multiple locations. After each biopsy the probe was removed, and its contents aspirated into a separate 3-mL syringe (marked by clock hour location). The sodium hyaluronate 1% was removed and wound checked for leakage.

Results

Diagnostic specimens were obtained in all cases. Five were found to be diffuse iris melanomas and 2 were indeterminate iris melanocytic proliferations. No patients developed a secondary increase in intraocular pressure, hyphema, infection, cataract, or vision loss. No cases of intraocular tumor dissemination were observed. No patient complained of glare or monocular diplopia. Three of 7 corneal wounds were self-sealing.

Conclusions

Multifocal surgical iridectomy biopsy can be minimally invasive and effective allowing for partial- and full-thickness iris biopsy. Use of a 25-G aspiration cutting probe allowed for small incision surgery, rapid rehabilitation, and no significant complications.

Diffuse Anterior Retinoblastoma with Sarcoidosis-Like Nodule

Background

Retinoblastomas account for 4% of malignancies in children, 1-2% of which are diffuse infiltrating retinoblastomas. Diffuse anterior retinoblastoma is rare and does not involve the retina. Here, we report on a diffuse anterior retinoblastoma with large sarcoidosis-like nodules on the iris that were responsive to anti-inflammatory therapy.

Case

We present a 6-year-old girl who had anterior uveitis with white nodules on the iris and posterior surface of the cornea in her right eye. The nodules initially responded well to anti-inflammatory treatment. However, anterior segment optical coherence tomography (AS-OCT) showed that the nodules gradually grew, shrinking the iris. We then collected the aqueous humor for diagnosis. A biopsy revealed clusters of small cells with a high nuclear-to-cytoplasm ratio with partial rosette formation. Therefore, we diagnosed diffuse anterior retinoblastoma without retinal involvement and performed enucleation of the right eye. The histopathology demonstrated undifferentiated cells similar to those seen on the biopsy, and tumor cells invaded the iris stroma, posterior surface of the cornea, ciliary body, and sclera. After the enucleation, she underwent chemotherapy and remains alive.

Conclusion

A differential diagnosis of retinoblastoma should be considered when white nodules refractory to anti-inflammatory therapy occur in the eye, even in the absence of obvious retinal masses. AS-OCT findings are useful in assessing retinoblastoma.

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.

Management of posterior uveal melanoma: past, present, and future: the 2014 Charles L. Schepens lecture

PURPOSE

To review the management of ciliary body and choroidal melanoma (posterior uveal melanoma [PUM]) over the last century with an emphasis on changing concepts.

DESIGN

Retrospective review.

PARTICIPANTS

Review of personal experience over 40 years and pertinent literature on management of PUM.

METHODS

Diagnosis and therapy for PUM.

MAIN OUTCOME MEASURES

Patient survival.

RESULTS

In the early 1900s, most patients presented with a large symptomatic melanoma that necessitated enucleation, and the systemic prognosis was poor. In the 1970s, controversy erupted regarding the role of enucleation for PUM. Some authorities advocated prompt enucleation, and others proposed that enucleation promoted metastasis, known as the "Zimmerman hypothesis." Others recommended observation, withholding treatment until tumor growth was documented. During the 1970s, there was a trend toward eye-saving procedures, including laser photocoagulation, surgical removal of tumor, and techniques of radiotherapy. Despite local treatment success, systemic prognosis remained guarded with approximately 40% mortality overall. However, there was convincing evidence that smaller tumors offered a significantly better prognosis. Currently, there is a movement toward earlier identification and treatment of small melanomas using clinical factors predictive of malignant potential, in keeping with similar philosophy regarding other cancers. Further understanding of melanoma cytogenetics and molecular pathways have helped to recognize patients at risk for metastasis. At-risk patients are offered systemic therapeutic trials to prevent metastasis. We anticipate that the future management of PUM will focus on detection of clinical and imaging clues for earliest diagnosis, prompt local tumor treatment, and systemic targeted therapies for microscopic metastasis or prevention of metastasis. Personalized evaluation of patient-specific melanoma molecular pathway signature could allow for therapeutic intervention at a site specific to the pathway abnormality that leads to the development of melanoma.

CONCLUSIONS

Management of PUM has made major strides over the past century from the days of enucleation for massive, fatal tumor to early detection of smallest tumors with a more favorable prognosis. Current and future targeted specific tumor pathway interruption using systemic agents could improve survival.

Melanoma of the eye: revealing hidden secrets, one at a time

Melanoma of the eye can involve the uveal tract with iris, ciliary body, or choroid involvement or it can involve the conjunctiva, eyelid, or orbit. Uveal involvement with choroidal melanoma is the most common, found in light complexion Caucasians with an age-adjusted incidence of 4.3 per million persons. Early detection of uveal melanoma is critical. The ABCDEF guide helps to differentiate iris nevus from iris melanoma. The letters represent: A, age young (≤40 years); B, blood in anterior chamber; C, clock hour of mass inferiorly; D, diffuse configuration; E, ectropion; and F, feathery margins. The mnemonic of TFSOM-UHHD (To Find Small Ocular Melanoma-Using Helpful Hints Daily) helps to differentiate choroidal nevus from small melanoma and represents: T, thickness over 2 mm; F, fluid; S, symptoms; O, orange pigment; M, margin within 3 mm of the optic disc; UH, ultrasound hollow; H, halo absent; and D, drusen absent. Patients with 3 or more of these factors are likely to have melanoma. These key clinical features help to identify small melanoma at a time when therapy could be life-saving. Conjunctival melanoma usually arises from primary acquired melanosis, a flat pigmentation that can lead to melanoma. Wide excision using no touch strategy is important to tumor control. Ocular examination is advised annually for all persons for detection of refractive error, cataract, glaucoma, and other conditions, but also for the detection of asymptomatic malignancies like melanoma. One at a time, we have uncovered the secrets of ocular melanoma and we forge ahead with the goal to solve the riddle of this challenging disease.

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.

Iris nevus growth into melanoma: analysis of 1611 consecutive eyes: the ABCDEF guide

PURPOSE

To determine clinical features predictive of growth of iris nevus into melanoma.

DESIGN

Retrospective, comparative case series.

PARTICIPANTS

A total of 1611 consecutive patients referred to an ocular oncology center with iris nevus.

INTERVENTION

Observation and photographic documentation.

MAIN OUTCOME MEASURES

Growth into melanoma.

RESULTS

The mean age at referral for iris nevus was 51 years (median, 54; range, <1-94 years). At presentation, the mean tumor basal diameter was 3 mm (median, 3 mm; range, <1-12 mm) and mean tumor thickness was 0.8 mm (median, 0.5 mm; range, 0-5 mm). All patients were initially diagnosed with benign iris nevus. Growth of iris nevus to melanoma was confirmed in 2% of eyes (n = 27) over a mean follow-up of 68 months (median, 46 months; range, 3-465 months). By Kaplan-Meier estimates, iris nevus growth to melanoma occurred in <1%, 3%, 4%, 8%, and 11% at 1, 5, 10, 15, and 20 years, respectively. Factors predictive of iris nevus growth to melanoma by multivariable analysis included age ≤ 40 years at presentation (hazard ratio [HR], 3), episode of hyphema (HR, 9), 4:00 to 9:00 clock hour location of tumor (HR, 9), diffuse tumor (involving entire iris surface) (HR, 14), ectropion uveae (HR, 4), and feathery tumor margins (HR, 3). Additional important factors by univariable analysis included tumor seeding on the iris or in the anterior chamber angle, feeder vessels, and nodule formation. These factors can be remembered using the mnemonic ABCDEF, representing A = age young, B = blood, C = clock hour inferior, D = diffuse, E = ectropion, and F = feathery margin.

CONCLUSIONS

In an analysis of 1611 cases of iris nevus referred for evaluation at an ocular oncology center, growth into melanoma occurred in 8% by 15 years. Risk factors for growth, identified by ABCDEF included Age young, Blood (hyphema), Clock hour inferior, Diffuse configuration, Ectropion uveae, and Feathery tumor margin.

Don't it make my blue eyes brown: heterochromia and other abnormalities of the iris

Eye colour is one of the most important characteristics in determining facial appearance. In this paper I shall discuss the anatomy and genetics of normal eye colour, together with a wide and diverse range of conditions that may produce an alteration in normal iris pigmentation or form.

Anterior segment tumor aspiration cutter-assisted biopsy: experience with pathology

PURPOSE

To report pathologic evaluation and diagnostic yield of an aspiration cutter-assisted biopsy of anterior segment tumors.

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

Fifty-five eyes of 55 patients with iris and iridociliary tumors underwent an aspiration cutter-assisted biopsy at a single institution. Cytospin and cell-block preparations were performed on all biopsy samples. Bleached preparations and a panel of immunohistochemical stains were performed in selected cases. Cytologic diagnosis was correlated with clinical diagnosis and with histopathologic diagnosis, when available. Main outcome measures were (1) specimen cellularity, (2) diagnostic studies performed, (3) cytopathologic diagnosis, and (4) concordance with histopathologic diagnosis.

RESULTS

Specimen cellularity was adequate for cytopathologic interpretation of cytospin preparations in 55 (98.2%) of 56 biopsies. Twenty-three (41%) of 56 biopsy samples had diagnostic material in cell-block preparations. The most common cytopathologic diagnoses were melanoma (n = 39/56; 69.6%), melanocytoma (n = 4/56; 7.1%), nevus (n = 4/56; 7.1%), lymphoma (n = 2/56; 3.6%), and epithelial implantation cyst (n = 2/56; 3.6%). One biopsy sample (1.8%) yielded nondiagnostic material. Wide incisional or excisional biopsy confirmation was available in 13 (23.2%) of 56 aspiration cutter-assisted biopsy cases. Cytopathologic diagnoses were consistent with histopathologic diagnosis in 12 (92.3%) of 13 cases.

CONCLUSIONS

Although specialized pathologic techniques were necessary to maximize material available for diagnosis, all biopsies yielded cellular material and 41% yielded diagnostic tissue in cell block preparation. Although lower than the yield of wide incisional or excisional biopsy, aspiration cutter-assisted biopsy of anterior segment tumors achieved a diagnostic yield of 98.2%.

Anterior segment tumor biopsy using an aspiration cutter technique: clinical experience

PURPOSE

To report the results and complications of an aspiration cutter-assisted anterior segment tumor biopsy performed under viscoelastic.

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

Fifty-five patients with anterior segment tumors underwent aspiration cutter-assisted biopsy at a single center. Fifty-six biopsies were performed, because 1 eye underwent biopsy twice. Indications for biopsy included: suspected anterior segment malignancy, patient's desire for pathologic confirmation before treatment, atypical tumor, and genetic tumor analysis. The main evaluated outcomes were the perioperative visual acuity, the biopsy technique, and related complications.

RESULTS

The initial sample comprised 55 consecutively biopsied patients, from which a minimum 1-month follow-up existed for 52 biopsy samples. The median total follow-up was 30.4 months (range, 1 to 190 months). The mean initial visual acuity was 20/50 before and 20/50 1 month after biopsy. No patient lost vision. Most cases were suspected iris melanoma (n = 39/56; 69.6%), followed by suspicious iris nevi (n = 4/56; 7.1%) and melanocytoma (n = 4/56; 7.1%). Seven (n = 7/52; 13.4%) wounds required a single 10-0 nylon suture to achieve negative Seidel test results at the corneal entry site. Postoperative surgical findings included transiently increased intraocular pressure (n = 6/52; 11.5%), 1 hyphema, 1 flare, and 1 persistent pupillary defect. All but the pupillary defect resolved within 4 weeks of the biopsy procedure. There were no secondary infections or cataracts.

CONCLUSIONS

This study suggests that small-incision, aspiration cutter-assisted anterior segment biopsy seems to be a safe and effective procedure. No short- or long-term complications that would prevent its use were noted.

Exoresection and endoresection for uveal melanoma

Surgical resection of uveal melanomas is an alternative eye-salvaging approach to the more commonly used irradiation techniques. There are two surgical resection techniques: Transscleral resection or “Exoresection” via a partial lamellar sclerouvectomy and “Endoresection” via a pars plana vitrectomy. While exoresection is more applicable to anteriorly located tumors with ciliary body and/or iris involvement, endoresection is more suitable for posteriorly located tumor without ciliary body involvement. Both approaches are suitable for large tumors with >8 mm in thickness. In general, eyes containing these large tumors have a very dismal prognosis regarding long-term visual function, eye retention, and irradiation-induced side effects. By removing the tumor burden from the eye, histopathologic and cytogenetic information of the tumor is available and complications associated with the so-called toxic tumor syndrome are avoided. However, both types of surgical resection are challenging surgical procedures, bearing the risk of early and late postoperative complications.

Does the taking of biopsies affect the metastatic potential of tumours? A systematic review of reports on veterinary and human cases and animal models

Clinicians and pathologists are sporadically asked by owners whether the taking of tumour biopsies may affect the behaviour of the tumour, including its potential to metastasise. Unfortunately, systematic studies on this subject are unavailable in veterinary medicine, and the aim of this study was to estimate the risk of adverse effects of biopsy taking on tumour progression in animals. A systematic review of veterinary and human case reports and clinical studies as well as experimental animal models of biopsy-induced tumour metastasis was undertaken. There were only two veterinary case reports of needle tract metastases (NTM) following the taking of needle biopsies from urogenital and pulmonary tumours. Seventeen experimental studies found a high incidence of NTM but only a rat osteosarcoma and a hamster squamous carcinoma model showed an increased incidence of distant or regional metastases after incision or excision biopsy. In human medicine, the occurrence of NTM has been reported after the taking of biopsies from mesotheliomas (15%), melanomas (11%) and gall bladder tumours (11%), liver metastases of colon carcinomas (4%) and mammary carcinomas (4%) but an incidence of only <1% for all other tumours. Circulating tumour cells increased immediately after the taking of biopsies from human squamous cell, prostate, breast and hepatocellular carcinomas. Although no increased risk of biopsy-induced distant metastasis has been reported for any type of tumour, this is inconclusive due to a lack of non-biopsied control groups in human studies. Reports of biopsy-induced metastasis in animal tumours indicate that the taking of transcutaneous biopsies from urogenital tumours may be associated with a risk of NTM. However, there is no evidence of a general increase in risk of distant metastases in any tumour type in people or animals. The overall risk therefore appears to be negligible when compared to the valuable information obtained from biopsies in veterinary practice.

Choroidal metastasis from hepatocellular carcinoma, diagnosed by fine needle aspiration biopsy and treated by iodine-125 brachytherapy

PURPOSE

To report a rare case of choroidal metastasis from hepatocellular carcinoma.

METHODS

A 63-year-old man with known hepatocellular carcinoma (HCC) and treated clavicular metastasis noted reduced visual acuity in the right eye. He was found to have an amelanotic choroidal tumor measuring 18 × 14 × 9.3 mm and with retinal detachment. Fine needle aspiration biopsy confirmed metastatic HCC.

RESULTS

The choroidal metastasis was treated with 5 days of iodine-125 plaque brachytherapy (3500 cGy to apex). Tumor regression to 2.6 mm thickness with resolution of retinal detachment and preservation of visual acuity at 20/40 at the 4-month follow-up was documented.

CONCLUSIONS

HCC metastasis to the choroid can be treated with focal plaque brachytherapy, with preservation of vision and quality of life.

A systematic review of cases reporting needle tract seeding following thyroid fine needle biopsy

BACKGROUND

Because of its accuracy and cost-effectiveness, thyroid fine needle biopsy (FNB) is the procedure of choice in the preoperative management of thyroid nodules. Needle tract seeding (NTS) has been a concern since the earliest days of FNB, contributing to the delayed acceptance of FNB as a safe procedure. In this review we tried to systematically record all reports of NTS after diagnostic thyroid FNB and provide useful hints to minimize the risk of NTS.

METHODS

Computerized advanced search for primary evidence was performed in the PubMed (Public/Publisher Medline) electronic database. The search was not limited by publication time or English language.

RESULTS

Ten relevant articles were found: eight case reports, one case in a surgical series, and one retrospective observational study.

CONCLUSIONS

Despite initial concerns about the risk of NTS, FNB is now considered to be a safe procedure. Although proper FNB technique can reduce its risk, NTS is an unavoidable complication of FNB, which clinicians should be aware of. However, the incidence of NTS is low and it doesn't seem to affect the prognosis because the seedings can be surgically removed without recurrence. The management of the thyroid nodules is to-date based on FNB, and the benefits from FNB (elimination of needless imaging and surgery) far outweigh the potential risk for NTS.

Exoresection via partial lamellar sclerouvectomy approach for uveal tumors: A successful performance by a novice surgeon

PURPOSE

To evaluate the results and complications of exoresection via a partial lamellar sclerouvectomy (PLSU) procedure for uveal tumors performed by a novice surgeon without help from an experienced surgeon.

METHODS

Medical records of 22 patients who underwent exoresection for uveal tumors between February 1999 and January 2009 were evaluated retrospectively. Exoresection was considered for tumors with their epicenter in the iris or in the ciliary body.

RESULTS

Twenty-two patients with a mean age of 45.9 years (range: 19-72 years) were included in this study. The histopathologic diagnosis was uveal malignant melanoma in 16 patients, iridociliary nevus in 2 patients, iris nevus in 2 patients, and iridociliary melanocytoma in 2 patients. Postoperative complications included cataract in 11 patients (50%), scleral thinning in 4 patients (18%), vitreous hemorrhage in 2 patients (9%), hyphema in 2 patients (9%), secondary glaucoma in 2 patients (9%), iridodialysis in 1 patient (4.5%), bullous keratopathy in 1 patient (4.5%), and posterior synechiae in 1 patient (4.5%). At a mean follow-up of 40.1 months (range: 1-98 months), there were no recurrences or metastatic events.

CONCLUSIONS

Exoresection seems to be an effective treatment option in selected cases of iridociliary and ciliary body tumors. Novice surgeons with limited training in PLSU should not discourage themselves from doing this type of surgery. Several postoperative complications inevitably occur and require frequent patient monitoring.

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.

Clinical spectrum of diffuse infiltrating retinoblastoma in 34 consecutive eyes

PURPOSE

To evaluate the clinical features and management of diffuse infiltrating retinoblastoma.

DESIGN

Retrospective case series.

PARTICIPANTS

Thirty-four eyes in 32 patients.

METHODS

The patients' records were reviewed for patient and tumor features, ocular management, histopathologic findings, and patient survival.

MAIN OUTCOME MEASURES

Clinical features, tumor management, and patient survival.

RESULTS

Of 1507 patients with retinoblastoma, only 32 (2%) were classified with diffuse infiltrating retinoblastoma. The mean age at diagnosis was 4 years (range 1.5-16 years). The referring diagnoses included retinoblastoma (26 eyes, 76%), uveitis (3, 9%), Coats disease (1, 3%), trauma (1, 3%), and unspecified retinal problem (3, 9%). The anterior segment displayed tumor seeds on the corneal endothelium (8, 24%), cornea stromal edema (3, 9%), pseudohypopyon (11, 32%), hyphema (3, 9%), iris neovascularization (17, 50%), and iris tumor nodules (6, 18%). The posterior segment revealed extensive ill-defined retinoblastoma infiltrating the retina for a mean basal diameter of 20 mm and overall flat growth, sometimes with undulating retinal thickening. Overlying extensive vitreous tumor seeds (31, 91%) and vitreous hemorrhage (8, 24%) were noted. Calcification was present on ultrasonography (27/34, 79%) and computed tomography (8/9, 89%). Enucleation was performed for all 34 eyes, and there were no cases of metastases at 47 months follow-up.

CONCLUSIONS

Diffuse infiltrating retinoblastoma can masquerade as uveitis or unexplained hyphema or keratic precipitates. Suspicion for retinoblastoma is important.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Iris melanoma

The iris is the least common site of primary uveal melanoma. The prognosis of iris melanoma is better than that of melanoma of the ciliary body and choroid, but the reason for this difference is unclear. One possible explanation is that iris melanoma is smaller than its posterior segment counterparts at the time of diagnosis. Most iris melanomas are spindle cell types, according to a modified Callender classification system. There is evidence that the proliferation of melanocytes of the anterior iris surface (iris plaque) and diffuse stromal invasion may be risk factors for local recurrence and metastasis, respectively.

Iris metastasis in small-cell lung carcinoma

Small-cell lung cancer (SCLC) is characterized by rapid growth and early metastasis. Despite its sensitivity to cytotoxic treatment, until now treatments have failed to control or cure this disease in most patients. Here, we describe a patient with SCLC in which symptoms caused by iris metastasis were the only sign of relapse after multimodality treatment.