Simultaneous bilateral diffuse melanocytic uveal hyperplasia

Diagnostic and therapeutic considerations in patients with bilateral diffuse uveal melanocytic proliferation

PURPOSE

This review aims to summarize the current knowledge concerning the clinical features, diagnostic work-up, and therapeutic approach of bilateral diffuse uveal melanocytic proliferation (BDUMP).

METHODS

A meticulous literature search was performed in the PubMed database. A supplementary search was made in Google Scholar to complete the collected items. Our search strategy utilized the following keywords: "bilateral diffuse uveal melanocytic proliferation", "BDUMP", and "Paraneoplastic Syndrome". Articles were considered based on their relevance, with the search spanning publications up to 2023. Studies were excluded if they did not contribute pertinent information or lacked methodological rigor. A critical appraisal of included studies was conducted, assessing study design, sample size, methodology, and potential bias, ensuring a thorough and transparent review process.

RESULTS

BDUMP is a rare and potentially sight-threatening condition characterized by the bilateral proliferation of melanocytes within the uvea. BDUMP is typically observed in middle-aged or elderly individuals and is often associated with an underlying malignancy, most commonly of gastrointestinal origin. BDUMP is frequently misdiagnosed as a benign nevus or choroidal metastasis, leading to delayed diagnosis and treatment. The ophthalmic symptoms and signs typically precede the diagnosis of a systemic malignancy, emphasizing the crucial role of ophthalmologists in the recognition of BDUMP. Several diagnostic modalities can aid in the diagnosis of BDUMP, including ophthalmic examination, imaging studies such as optical coherence tomography, fluorescein angiography, and indocyanine green angiography, and biopsy of the uveal tissue. Treatment of BDUMP is directed towards the underlying malignancy and may include chemotherapy, radiotherapy, or surgical resection. Additionally, strict monitoring with regular follow-ups may contribute to the detection of new lesions and the reduction in the size of existing ones.

CONCLUSIONS

BDUMP can be considered a potential biomarker in the management of malignancies, especially when the primary underlying tumor has not been detected. Further research is needed to better understand the pathogenesis of BDUMP and its association with malignancy.

Seeing is believing: A review of apheresis therapy in the treatment of ophthalmologic disease

Apheresis procedures have a role in treatment of disparate diseases involving many different organ systems. Often the disease processes where apheresis plays a role in treatment are considered "orphan diseases"-relatively rare disease processes that lack specific pharmaceutical agents or established treatment protocols. Many of these disease processes can affect the eye with devastating results for the eyesight of these patients. The unique ability of apheresis to affect disease by modifying blood plasma and modulating disease-causing agents therein renders apheresis procedures valuable tools in the treatment of certain ophthalmologic diseases. This review comprehensively evaluates the role of apheresis in the treatment of ophthalmologic diseases of the eye and surrounding orbit including age-related macular degeneration, bilateral diffuse uveal melanocytic proliferation, paraneoplastic retinopathy, atopic keratoconjunctivitis, sympathetic ophthalmia, and endocrine-associated ophthalmopathy. Apheresis procedure parameters are provided for the apheresis practitioner based on review of the relevant literature.

Iris cysts: A comprehensive review on diagnosis and treatment

Iris cysts, both primary and secondary, are a diagnostic and treatment challenge. Primary cysts arise either from the iris pigment epithelium or the iris stroma. Posterior pigment epithelial cysts are subdivided according to their location as central, midzonal, and peripheral. Iris stromal cysts are classified either as congenital or acquired. Free-floating cysts are usually dislodged pigment epithelial cysts. Secondary cysts are classified according to the underlying cause as implantation cysts, drug-induced, uveitic, tumor-induced, parasitic, or as cysts associated with systemic disorders. Differential diagnosis is based on the clinical presentation and imaging. Ultrasound biomicroscopy is the gold standard for the imaging of iris cysts, combining excellent resolution with sufficient tissue penetration. Treatment of iris cysts depends largely on whether they become symptomatic or not. Symptoms include obstruction of the visual axis, corneal decompensation, secondary uveitis, and secondary glaucoma. Treatment options cover a range from simple observation to fine-needle aspiration (with or without intracystic injection of absolute alcohol or antimitotic agents), laser (argon, Nd:YAG), or surgical excision. In the past, the prevailing notion was that of a radical surgical intervention in the form of iridectomy or iridocyclectomy. Given the high rate of recurrence, a stepwise conservative approach is currently favored by most clinicians.

Bilateral diffuse uveal melanocytic proliferation: Case report and literature review

Bilateral diffuse uveal melanocytic proliferation (BDUMP) is a rare paraneoplastic intraocular disease that causes progressive visual loss in patients driven by an IgG factor associated with an underlying malignancy. Characteristic ocular findings include exudative retinal detachment, rapid cataract formation and uveal melanocytic tumours. The awareness and documentation of BDUMP has increased during the past decade, and the increasing amount of data collected demonstrates the effect of treatment with plasmapheresis and the value of diagnostic tools in BDUMP such as genetic and immunologic investigations. The literature of BDUMP has not been reviewed since 2003, and there is a growing need for an updated review on diagnosis and management of BDUMP. We review the literature and report a case of BDUMP with a white ciliary body tumour, iris rubeosis, increased iris pigmentation and cataract.

Multimodal imaging of bilateral diffuse uveal melanocytic proliferation associated with an iris mass lesion

Background

Bilateral diffuse uveal melanocytic proliferation (BDUMP) is a rare, paraneoplastic syndrome characterized by bilateral painless visual loss and proliferation of choroidal melanocytes in association with an underlying systemic malignancy. We report a case of bilateral diffuse uveal melanocytic proliferation associated with an underlying gynecological malignancy that also features the infrequent finding of an iris mass lesion, using multimodal imaging including ultra-widefield imaging, spectral domain and swept-source optical coherence tomography.

Case presentation

A 59-year-old white female with a prior history of gynecological malignancy in remission presented with progressive bilateral visual loss over several weeks. The patient was noted to have a focal iris mass lesion in her right eye. Ultra-widefield color fundus photography showed a characteristic bilateral ‘giraffe pattern’ of pigmentary changes extending into the periphery as well as multiple discrete deeply pigmented lesions. Ultra-widefield autofluorescence was useful for visualizing the full extent of involvement. Indocyanine green angiography helped to demarcate the discrete pigmented choroidal lesions. Swept-source OCT clearly delineated the alternating zones of retinal pigment epithelium (RPE) thickening and RPE loss, as well as the prominent choroidal infiltration and thickening.

Conclusions

BDUMP is an important diagnosis to consider in the presence of multiple discrete melanocytic choroidal lesions, diffuse choroidal thickening, characteristic RPE changes, iris mass lesions and exudative retinal detachment. Ultra-widefield imaging may demonstrate more extensive lesions than that detected on clinical examination or standard field imaging. Imaging with SS-OCT shows choroidal and RPE characteristics that correlate well with known histopathology of this entity.

Bilateral diffuse uveal melanocytic proliferation as a precursor to multiple systemic malignancies

Bilateral diffuse uveal melanocytic proliferation (BDUMP) is a rare, intraocular paraneoplastic syndrome characterized by multiple, elevated, pigmented uveal lesions, diffuse thickening of the uveal tract, and rapidly progressive cataracts. We report a 70-year-old Caucasian male with an inferotemporal conjunctival-scleral pigmented lesion of the right eye. Funduscopy and ultrasonography revealed multiple elevated pigmented choroidal lesions in both eyes. Genome-wide single nucleotide polymorphism (SNP) analysis of intraoperative transscleral fine-needle aspiration biopsies from both eyes revealed a whole gain on chromosome 5. BDUMP was diagnosed, and the patient underwent a thorough systemic investigation, which was negative for an underlying malignancy; however, by maintaining a high index of suspicion, multiple malignancies were uncovered and appropriately treated over the ensuing years. This report presents the clinical, cytologic, and cytogenetic features of BDUMP, and is the first to demonstrate a novel finding of a whole gain in chromosome 5 by SNP analysis of the choroidal lesions. Additionally, this is the first case to potentially associate BDUMP and both transitional cell carcinoma of the bladder as well as renal clear cell carcinoma.

The potential role of plasma exchange as a treatment for bilateral diffuse uveal melanocytic proliferation: a report of two cases

Bilateral diffuse uveal melanocytic proliferation (BDUMP) is a rare paraneoplastic syndrome associated with gynecologic malignancies in women and pancreatic or lung carcinomas in men. The clinical presentation consists of the rapid onset of decreased visual acuity due to bilateral serous retinal detachment and cataracts. Pathologically, there is diffuse uveal thickening and proliferation of uveal melanocytes. The onset of blindness is often rapid, with some patients presenting with blindness. We describe the cases of two women with gynecologic malignancies who were treated with plasma exchange (PE) for BDUMP. After a course of five to seven procedures, their ocular disease stabilized. One patient has maintained her vision more than 1 year following the completion of the course of PE. The other patient, who also received treatment with corticosteroids, in addition to the PE, reported stable vision on telephone follow-up 9 months after presentation. These cases suggest that PE may be a treatment option in this rare paraneoplastic syndrome which has otherwise been reported to invariably result in vision loss.

High-resolution OCT imaging of RPE degeneration in bilateral diffuse uveal melanocytic proliferation

Bilateral diffuse uveal melanocytic proliferation is a rare paraneoplastic syndrome that presents with bilateral progressive loss of vision. A 70-year-old woman presented with a 3-month history of progressive, bilateral vision loss. The patient had bilateral, diffuse, shallow, subretinal fluid with patchy, reddish-brown lesions at the level of the retinal pigment epithelium (RPE) that showed significant early hyperfluorescence on fluorescein angiography and a corresponding loss of autofluorescence. Optical coherence tomography of both eyes revealed complete RPE and inner segment/outer segment junction loss with adjacent areas of thickening at the level of the RPE. Bilateral diffuse uveal melanocytic proliferation was diagnosed based on these clinical findings, and a systemic evaluation for malignancy revealed metastatic endometrial adenocarcinoma. Both autofluorescence and optical coherence tomography demonstrated unique imaging characteristics that correlated with the reported histopathology of bilateral diffuse uveal melanocytic proliferation. These imaging modalities can contribute to the rapid and accurate diagnosis of bilateral diffuse uveal melanocytic proliferation.

Fundus Autofluorescence Imaging of Diffuse Uveal Melanocytic Proliferation

Fundus autofluorescence imaging (FAF) in a case of diffuse uveal melanocytic proliferation is described in this study. It is a rare chorioretinopathy associated with systemic cancer, for which the exact pathological mechanisms are poorly understood. FAF-imaging revealed a diffuse background of hyper-autofluorescence associated with diffuse orange pigment deposition and islands of persistent hypo-fluorescence corresponding to loss of retinal pigment epithelium (RPE). In this disorder, increasingly smaller spots of FAF hypo-fluorescence were found from the center to the periphery of the affected retina. Fluorescein angiography demonstrated a negative of the FAF-images. FAF hypo-autofluorescence corresponded to optical coherence tomography (OCT) thinning or absence of the RPE-layer. Conversely, FAF hyper-autofluorescence correlated to thickening of the RPE-layer on OCT. The case demonstrates that FAF can be useful for the diagnosis of diffuse uveal melanocytic proliferation and offers greater insight into the pathophysiology of this disease.

Paraneoplastic syndromes in neuro-ophthalmology

PURPOSE OF REVIEW

The aim of this review is to discuss and highlight the recent advances in our understanding of paraneoplastic syndromes in neuro-ophthalmology and their significance.

RECENT FINDINGS

The pathophysiologic mechanism in neuro-ophthalmic paraneoplastic syndromes involves an immune response triggered by aberrant expression of onconeuronal antigens that cross-react with antigens in the visual system. Recently, 18-fluoro-deoxy-glucose/positron emission tomography with computed tomography scanning has emerged as a useful modality in diagnosing occult tumors responsible for paraneoplastic syndromes. Paraneoplastic optic neuropathy has been recently associated with the anti-CV2/CRMP-5 antibody. The use of serologic analysis of recombinantly expressed clones (SEREX) has led to the identification of new antigens associated with melanoma-associated retinopathy, such as visual arrestin, rhodopsin, titin, and mitofilin. Calcium-channel blockers and alemtuzumab have been found to improve visual function in cancer-associated retinopathy. Rituximab has been found to be effective in childhood opsoclonus-myoclonus syndrome.

SUMMARY

A high index of suspicion is needed to diagnose neuro-ophthalmic paraneoplastic syndromes. There have been recent advances in our understanding of the pathophysiology and treatment of these disorders. This will facilitate early treatment of causative occult tumors and improves the prognosis.

Bilateral diffuse melanocytic proliferation associated with ovarian carcinoma and metastatic malignant amelanotic melanoma

PURPOSE

To report a case of metastatic malignant amelanotic melanoma to the skin from a patient diagnosed with bilateral diffuse uveal melanocytic proliferation (BDUMP). This dermatological finding is a unique phenomenon associated with BDUMP.

DESIGN

Retrospective case report.

METHODS

We studied the case of a 66-year-old Caucasian woman with gradual onset of blurred vision in her right eye followed by her left eye. She had previously been diagnosed with ovarian carcinoma, and findings of funduscopic examinations were consistent with BDUMP. Metastatic examination revealed no evidence of liver involvement. Clinical and histopathological examinations of both enucleated eyes were consistent with BDUMP.

RESULTS

The hematoxylin and eosin, S-100, and HMB-45 stains were consistent with metastatic malignant amelanotic melanoma to the skin.

CONCLUSIONS

Although believed to have a low potential for metastasis, patients should be monitored and evaluated regularly to detect any new lesions not associated with their primary inciting carcinoma.

Presymptomatic diagnosis of bronchogenic carcinoma associated with bilateral diffuse uveal melanocytic proliferation

A 62-year-old man presented with bilateral diffuse uveal melanocytic proliferations (BDUMP) and painful flexor contractures of the fingers of both hands. All these features were considered paraneoplastic but extensive and repeated investigations revealed no underlying malignancy. Oral steroids and orbital radiotherapy were ineffective. The diagnosis was confirmed by trans-scleral biopsy of the right choroid. Rapidly progressive cataracts were treated by phacoemulsification. Severe exudative retinal detachment with rubeosis and neovascular glaucoma in the left eye were treated successfully by partial choroidectomy. Fifteen months after presentation, investigations detected a 22 mm, poorly differentiated adenocarcinoma, which was resected without complication. The ocular tumours in both eyes regressed, without improvement in vision of Light Perception, and the palmar fasciitis also improved. The patient remained free of tumour recurrence until sudden death from myocardial infarction five years after he first presented.

Bilateral diffuse uveal melanocytic proliferation associated with pancreatic carcinoma: a case report and literature review of this paraneoplastic syndrome

A case of a 64-year-old man with bilateral diffuse uveal melanocytic proliferation is presented. Bilateral diffuse uveal melanocytic proliferation is a rare paraneoplastic disorder where an underlying malignancy causes bilateral blindness by uveal thickening, serous retinal detachment, and rapid cataract formation. The ocular symptoms and signs herald the onset of this disease, which leads to death in most cases within about 1 year. Including the present case, our literature review reveals that a total of 28 cases of bilateral diffuse uveal melanocytic proliferation have now been reported. Several different malignancies have been associated with bilateral diffuse uveal melanocytic proliferation, but ovarian carcinoma in women and lung and suspected pancreatic carcinoma in men are the most common. Our case is the first to be proven at autopsy to be associated with pancreatic carcinoma. The underlying mechanism remains to be identified, as numerous endogenous factors may regulate the proliferation of uveal melanocytes. Consideration of this entity during clinical examination may lead to an earlier diagnosis of malignancy and an improved prognosis.

Bilateral diffuse uveal melanocytic proliferation associated with extraocular cancers: review of a process particularly associated with gynecologic cancers

We reviewed cases of a paraneoplastic syndrome in which uveal melanocytes proliferated and led to blindness. Eighteen cases were derived from the literature, and two were taken from our institution. The average patient age at the time of the diagnosis was 63 years (range, 34-89 years). There were 13 women and 7 men. In approximately half of the cases, the ocular symptoms antedated those of the inciting tumor. Most of the inciting tumors were poorly differentiated carcinomas. The most common tumors were from the female genital tract (ovary and uterus) among the women patients and from the lung among the men. Tumors from the breast were rare (one possible case), and tumors of the prostate were conspicuously absent. All five inciting tumors whose histopathology was reviewed expressed neuron-specific enolase, but none prominently expressed antigens more specific for neuroendocrine carcinomas such as chromogranin or synaptophysin. It is our experience that many general pathologists are not aware of this unique paraneoplastic syndrome. Our report is the first to document a statistically significant association between this syndrome and gynecologic cancers.

Blindness as a consequence of a paraneoplastic syndrome in a woman with clear cell carcinoma of the ovary

BACKGROUND

Paraneoplastic syndromes are rare conditions associated with cancer that result in serious disease states at unique sites. In 1982, a report of bilateral diffuse uveal melanocytic proliferation associated with nonocular cancers which resulted in blindness was reported. We present a case of a woman with recurrent ovarian cancer who developed this paraneoplastic syndrome.

CASE

A 55-year-old woman had been diagnosed in 1990 with an ocular melanoma of her right eye and in 1994 with clear cell carcinoma of the ovary. With recurrence of ovarian cancer, new eye lesions were identified in both eyes. After enulcleation of her right eye, an ocular melanoma and diffuse bilateral melanocytic proliferation (BDUMP) were found. The sight in her left eye continued to deteriorate as other signs of BDUMP occurred in the eye. Within 1 month of diagnosis, the patient was blind. She subsequently succumbed to progression of ovarian cancer.

CONCLUSION

Recurrent ovarian cancer is usually an intraabdominal disease that results in gastrointestinal dysfunction. This case illustrates a rare paraneoplastic syndrome associated with ovarian cancer that mimics metastatic disease to the eye, but has a different pathophysiology.

Posterior uveal melanoma. The Swedish perspective

Posterior uveal melanoma is the most common primary intraocular malignant tumour and in Sweden some 70-80 new cases present each year. While uveal melanoma is more prevalent in the setting of ocular melanocytosis and neurofibromatosis, there is little conclusive data on the aetiology. Most patients experience a progressive visual field defect and present with a grey or greyish-brown mass of the posterior choroid. Diagnostic procedures include fluorescein angiography, ultrasound and magnetic resonance imaging. In some cases, intraocular biopsy may be required to make a correct diagnosis. Posterior uveal melanomas can usually be managed by any of a number of eye-preserving options like plaque radiotherapy and charged particle irradiation, but eyes containing large tumours are often enucleated. Nearly half of patients with posterior uveal melanoma, and in particular those with large tumours, ultimately succumb to metastatic disease. While most patients with tumour dissemination are treated with systemic chemotherapy possibly combined with interferon, metastatic spread confined to the liver may potentially be managed by intraarterial perfusion chemotherapy or liver resection. However, outcome of patients with systemic disease remains extremely poor with a median survival following detectable tumour dissemination of only two to five months. There are still insufficient data on the impact of various treatments on survival, but a large prospective trial addressing this issue is in progress. The present review summarizes the state-of-the-art knowledge and current management of posterior uveal melanoma from a Swedish perspective.

Vogt-Koyanagi-Harada syndrome

The Vogt-Koyanagi-Harada syndrome (VKH) is a bilateral, diffuse granulomatous uveitis associated with poliosis, vitiligo, alopecia, and central nervous system and auditory signs. These manifestations are variable and race dependent. This inflammatory syndrome is probably the result of an autoimmune mechanism, influenced by genetic factors, and appears to be directed against melanocytes. On histopathologic examination typical cases show nonnecrotizing diffuse granulomatous panuveitis with initial sparing and late involvement of the choriocapillaris and formation of Dalen-Fuchs' nodules. Fluorescein angiography, lumbar puncture, and echography are useful adjuncts in the diagnosis and management of VKH syndrome. Patients with this syndrome are treated generally with high dose systemic corticosteroids or, when necessary, with cyclosporine or cytotoxic agents. The prognosis of patients with VKH syndrome is fair, with nearly 60% of patients retaining vision of 20/30 or better. The complications of VKH syndrome that lead to visual loss include cataracts in about 25% of patients, glaucoma in 33%, and subretinal neovascular membranes (SRNVMs) in about 10%; the latter, however, are an important cause of late visual loss. These complications usually require medical and/or surgical intervention, including photocoagulation. The major risk factor for the development of cataracts, SRNVMs, and, to some extent, glaucoma, is chronic recurrent intraocular inflammation that may be resistant to corticosteroid therapy. It appears that initial treatment with high dose corticosteroids, combined with prolonged corticosteroid therapy at appropriate dosage, may minimize these complications and may improve visual prognosis.

Natural history of diffuse uveal melanocytic proliferation. Case report

BACKGROUND

Diffuse uveal melanocytic proliferation is a rare paraneoplastic syndrome resulting in rapid bilateral visual loss due to proliferation of benign melanocytes within the choroid and ciliary body. Most of the previously reported cases have been seen with bilateral involvement and typical ocular features.

PATIENT

The authors report the case of a 61-year-old man who presented with uniocular posterior pole lesions at the level of the retinal pigment epithelium and subsequently developed the typical bilateral lesions of diffuse uveal melanocytic proliferation. His clinical course was typical, with visual disturbance preceding signs and symptoms of malignancy by 5 months. Rapid decline ensued, and he eventually died 10 months after the onset of visual symptoms.

RESULTS

Results of ocular pathologic examination showed the typical choroidal thickening due to the proliferation of melanocytes and the primary tumor was found to be an undifferentiated adenocarcinoma originating in either the pancreas or the esophagus.

CONCLUSIONS

The very early funduscopic and fluorescein angiographic findings of diffuse uveal melanocytic proliferation are presented as well as the evolution, ocular pathology, and possible mechanisms for its development.