UNILATERAL DIFFUSE UVEAL MELANOCYTIC PROLIFERATION

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.

UNILATERAL DIFFUSE UVEAL MELANOCYTIC PROLIFERATION: CASE REPORT AND BRIEF REVIEW

PURPOSE

To report a case of unilateral diffuse uveal melanocytic proliferation, in a patient with history of breast cancer, with bone and hepatic metastasis.

METHODS

Case report with funduscopic examination, fundus autofluorescence, and spectral-domain optical coherence tomography.

RESULTS

A 57-year-old female patient attended at our clinic for a routine glaucoma follow-up. Fundoscopy was normal on the right eye and showed multiple red patches in the posterior pole and inferior arcade. Multimodal examination was performed, compatible to diffuse uveal melanocytic proliferation on her left eye, and excluding other conditions, such as choroidal metastasis.

CONCLUSION

Diffuse uveal melanocytic proliferation is a rare paraneoplastic condition, which usually is presented bilaterally. Unilateral cases of diffuse uveal melanocytic proliferation have been previously described only 5 times on the literature and are usually associated with breast cancer.

LONG-TERM FOLLOW-UP OF ASYMMETRIC BILATERAL DIFFUSE UVEAL MELANOCYTIC PROLIFERATION IN A PATIENT WITH METASTASIZED UROTHELIAL CARCINOMA

PURPOSE

To report a case of bilateral diffuse uveal melanocytic proliferation over 30 months follow-up.

METHODS

Multimodal imaging including ultra-wide-field color fundus photography, blue light fundus autofluorescence, swept-source optical coherence tomography, fluorescein angiography, and indocyanine green angiography.

RESULTS

A 49-year-old woman presented with decreased vision 2 months after bladder cancer surgery. Exudative retinal detachment and leopard spot pattern chorioretinopathy were observed in the right eye. Chemotherapy and cystectomy were initiated. Progressive bilateral vision loss occurred with melanocytic proliferation, choroidal thickening, subretinal fibrosis, fluid extravasation, rapid development of mature cataract, multiple iris cysts, and rubeosis, despite plasmapheresis and IV immunoglobulins. After cataract surgery, massive fibrin reaction resulted in a ciliolenticular block. One year later, positron emission tomography-computed tomography revealed absence of metastases. At Month 23, choroidal thickness increased in line with tumor progression. Palliative systemic therapy was initiated. Secondary macular neovascularization was treated with intravitreal antivascular endothelial growth factor injections. Visual acuity was light perception in the right eye and 20/200 in the left eye at last follow-up.

CONCLUSION

Bilateral diffuse uveal melanocytic proliferation results in progressive melanocyte proliferation and exudation, leading to severe visual loss. In our case, visual acuity was preserved at a low level in one eye under continuous systemic treatment. Systemic corticosteroids are recommended for cataract surgery in the setting of bilateral diffuse uveal melanocytic proliferation to prevent massive fibrin reaction. Intravitreal antivascular endothelial growth factor injections may be indicated if secondary macular neovascularization develops.

Ocular Paraneoplastic Syndromes: A Critical Review of Diffuse Uveal Melanocytic Proliferation and Autoimmune Retinopathy

Background: Dozens of paraneoplastic syndromes affect the visual system ranging from conjunctival pemphigoid to encephalopathy of the occipital cortex. The most profiled ocular syndromes are bilateral diffuse uveal melanocytic proliferation (BDUMP) and the autoimmune retinopathies.Purpose: To review the critical features of these 2 entities then concentrate on advancements in treatment made within the last 10 years.Study Design: Literature review with structured data abstraction.Results: Major insights into pathogenesis have been wanting. Plasmapheresis appears to improve vision in a substantial proportion of patients with BDUMP. The number of clinical variables that influence visual outcome in paraneoplastic retinopathies combined with the variety of local and systemic treatment options makes interpretation of clinical effectiveness difficult.Conclusions: The rarity of these disorders makes randomized clinical trials unlikely. It may be time for a clinical professional organization to use a modified Delphi method to establish a consensus algorithm for the diagnosis and management of retinal paraneoplastic syndromes to augment clinical communications and clinical trials.

Ocular Paraneoplastic Syndromes

Ocular-involving paraneoplastic syndromes present a wide variety of clinical symptoms. Understanding the background pathophysiological and immunopathological factors can help make a more refined differential diagnosis consistent with the signs and symptoms presented by patients. There are two main pathophysiology arms: (1) autoimmune pathomechanism, which is presented with cancer-associated retinopathy (CAR), melanoma-associated retinopathy (MAR), cancer-associated cone dysfunction (CACD), paraneoplastic vitelliform maculopathy (PVM), and paraneoplastic optic neuritis (PON), and (2) ectopic peptides, which is often caused by tumor-expressed growth factors (T-exGF) and presented with bilateral diffuse uveal melanocytic proliferation (BDUMP). Meticulous systematic analysis of patient symptoms is a critical diagnostic step, complemented by multimodal imaging, which includes fundus photography, optical coherent tomography, fundus autofluorescence, fundus fluorescein angiography, electrophysiological examination, and sometimes fundus indocyjanin green angiography if prescribed by the clinician. Assessment of the presence of circulating antibodies is required for diagnosis. Antiretinal autoantibodies are highly associated with visual paraneoplastic syndromes and may guide diagnosis by classifying clinical manifestations in addition to monitoring treatment.

Diffuse Uveal Melanocytic Proliferation With Primary Vitreoretinal Lymphoma

Importance

Bilateral diffuse uveal melanocytic proliferation is a rare sign of several systemic malignant neoplasms.

Observations

A patient presenting with uveal melanocytic proliferation underwent a detailed physical examination and extensive imaging. No systemic malignant neoplasm was found. Chorioretinal biopsy was performed, and its immunohistochemical results revealed the presence of primary vitreoretinal lymphoma.

Conclusions and Relevance

This patient's results suggest that diffuse uveal melanocytic proliferation may be associated not just with systemic malignant disease, but also with primary intraocular tumors, in this case a primary vitreoretinal lymphoma.

Lymphoma and unilateral diffuse uveal melanocytic proliferation: when both conditions co-exist in the eye

The case is presented of a 60 year-old male with decreased visual acuity in his left eye (LE). In the funduscopic examination, pigmentary alterations associated with sub-retinal orange plaques could be observed that, in autofluorescence, manifested as hypoautofluorescent spots. Subsequently, the patient subsequently developed significant vitritis with large white sub-retinal plaques on the posterior pole of his LE, with no alterations in the right eye. The IL-10/IL-6 coefficient was 0.87, and a lesion suggestive of a lymphoma in the frontal lobe could be seen on brain magnetic resonance scan. The patient was diagnosed with primary lymphoma of the central nervous system with ocular involvement of the LE and associated unilateral diffuse uveal melanocytic proliferation of the same eye. Diffuse uveal melanocytic proliferation is a bilateral para-neoplastic process that occurs as a consequence of carcinomatous tumour processes, although it does not always meet these characteristics.

A rare case of unilateral diffuse melanocytic proliferation

A 67-year-old woman presented with metamorphopsia in the right eye. Leopard mottling was seen temporal to the fovea oculus dexter with corresponding hyper- and hypo-autofluorescent lesions on fundus autofluorescence. Spectral domain-optical coherence tomography revealed hyperreflective dots in the retinal pigment epithelium and choroid with subretinal fluid (SRF). Intravitreal bevacizumab was administered with which SRF resolved, albeit with increase in the areas of mottling. The patient was diagnosed to have metastatic ductal carcinoma of the right breast. It is important to bear in mind that the well-known entity of bilateral diffuse uveal melanocytic proliferation can rarely present unilaterally.