Adjuvant External Beam Radiotherapy Following Enucleation of Eyes With Extraocular Extension From Uveal Melanoma

Surgical outcomes of unwrapped acrylic orbital implants: A review of 192 patients

PURPOSE

The purpose of this study is to report the results in a series of acrylic orbital implant placements without the use of wrapping material.

METHODS

We retrospectively reviewed the records of the patients who underwent enucleation with acrylic orbital implant insertion without scleral wrapping at the Department of Ophthalmology, Poznań University of Medical Sciences, Poland, between 2013 and 2020.

RESULTS

There were 192 patients: 102 women and 90 men, mean age: 60 years (range: 13-90 years). In the majority of cases, the reason for enucleation was uveal melanoma (148 patients-77.1%), followed by secondary glaucoma in 22 patients (11.5%) and painful, phthisical eye in 16 (8.3%). The median follow-up was 23 months (range: 1-96 months). The stability of the implants was satisfactory in the majority of cases, and there were no cases of implant migration identified during the study period. We noted a total of 4 (2%) implant exposures. Other postoperative complaints included eyelid malposition-21 patients (11%), Tenon's capsule thinning (15 patients-7.8%) and post-enucleation eye socket syndrome (PEES)-7 patients (3.6%). The rate of postoperative complications was associated only with a history of previous ocular surgery (P=0.006).

CONCLUSIONS

The stability and functional outcomes of unwrapped acrylic orbital implants in this group of patients were satisfactory during the follow-up period.

Large extraocular extension of a choroidal melanoma with orbital inflammation

Purpose

To describe an atypical case of a choroidal melanoma presenting with eyelid edema, chemosis, pain and diplopia and demonstrating significant extraocular extension on ultrasonography and neuroimaging.

Observations

A 69-year-old woman presented with a headache, eyelid edema, chemosis and pain in the right eye. Upon subsequent onset of diplopia, MRI of the orbits was performed and demonstrated a predominantly extraocular, intraconal mass with a small intraocular component. She was started on corticosteroids and referred to the ocular oncology service for evaluation. On fundus examination, she was noted to have a pigmented choroidal lesion consistent with melanoma, and ultrasound showed a large area of extraocular extension. Enucleation, enucleation with subsequent radiation and exenteration were discussed, and the patient requested an opinion from radiation oncology. A repeat MRI obtained by radiation oncology demonstrated a decrease in the extraocular component after corticosteroid treatment. The improvement was interpreted as suggestive of lymphoma by the radiation oncologist who recommended external beam radiation (EBRT). Fine needle aspiration biopsy was insufficient for cytopathologic diagnosis, and the patient elected to proceed with EBRT in the absence of a definitive diagnosis. Next generation sequencing revealed GNA11 and SF3B1 mutations, which supported the diagnosis of uveal melanoma and led to enucleation.

Conclusion and Importance

Choroidal melanoma may present with pain and orbital inflammation secondary to tumor necrosis, which may delay diagnosis and decrease the diagnostic yield of fine-needle aspiration biopsy. Next generation sequencing may aid the diagnosis of choroidal melanoma when there is clinical uncertainty and cytopathology is unavailable.

Very late orbital recurrence of choroidal melanoma four decades post enucleation

Orbital recurrence of malignant choroidal melanoma is quite uncommon, occurring in about 3% of patients undergoing enucleation for large tumors. Orbital recurrences after more than 10 years from enucleation are even rarer. In literature, only few reports described orbital recurrence that occurred between 10 and 40 years after primary diagnosis. Herein we report a very late choroidal melanoma recurrence, 40 years post enucleation, of a 52 year-old female who had undergone left enucleation at the age of 12. She presented to our clinic for consultation in 2017, complaining of difficulty to contain the prosthesis, as well as, presence of small pigmented palpable nodules inferiorly in her anophthalmic socket. The patient was not aware of the medical condition which had lead to the enucleation. We requested her medical reports and detailed history through her family. We realized after reviewing her charts 40 years back, that her enucleation was due to malignant choroidal melanoma (CMM). Full screening was performed. After magnetic resonance imaging (MRI), that showed the presence of nodular masses in the anophthalmic socket, an excisional biopsy was performed. Histopathology confirmed the diagnosis of CMM (epithelioid and spindle cell type), supporting the hypothesis that residual melanoma cells may remain clinically dormant for long periods, even for decades. A literature review was performed in order to review similar cases and to understand and discuss multiple factors, which may explain this extremely delayed recurrence. To the best of our knowledge, this is the third case to be reported in the literature.