Bilateral diffuse uveal melanocytic proliferation: Case report and literature review

Central serous chorioretinopathy: An evidence-based treatment guideline

Central serous chorioretinopathy (CSC) is a relatively common disease that causes vision loss due to macular subretinal fluid leakage and it is often associated with reduced vision-related quality of life. In CSC, the leakage of subretinal fluid through defects in the retinal pigment epithelial layer's outer blood-retina barrier appears to occur secondary to choroidal abnormalities and dysfunction. The treatment of CSC is currently the subject of controversy, although recent data obtained from several large randomized controlled trials provide a wealth of new information that can be used to establish a treatment algorithm. Here, we provide a comprehensive overview of our current understanding regarding the pathogenesis of CSC, current therapeutic strategies, and an evidence-based treatment guideline for CSC. In acute CSC, treatment can often be deferred for up to 3-4 months after diagnosis; however, early treatment with either half-dose or half-fluence photodynamic therapy (PDT) with the photosensitive dye verteporfin may be beneficial in selected cases. In chronic CSC, half-dose or half-fluence PDT, which targets the abnormal choroid, should be considered the preferred treatment. If PDT is unavailable, chronic CSC with focal, non-central leakage on angiography may be treated using conventional laser photocoagulation. CSC with concurrent macular neovascularization should be treated with half-dose/half-fluence PDT and/or intravitreal injections of an anti-vascular endothelial growth factor compound. Given the current shortage of verteporfin and the paucity of evidence supporting the efficacy of other treatment options, future studies-ideally, well-designed randomized controlled trials-are needed in order to evaluate new treatment options for CSC.

A Case of Bilateral Diffuse Uveal Melanocytic Proliferation Followed by Massive Unilateral Uveal Proliferation

OBJECTIVE

To report a case of bilateral diffuse uveal melanocytic proliferation (BDUMP) followed by massive unilateral uveal proliferation.

METHODS

Retrospective case report.

RESULTS

A 47-year-old female with history of metastatic ovarian carcinoma initially presented with bilateral vision loss and multifocal red patches on posterior poles consistent with BDUMP. Five years later, she presented with bilateral neovascular glaucoma and unilateral iris and ciliary body mass concerning for malignancy. Enucleation revealed diffuse uveal growth involving almost the entirety of the uveal tract.

CONCLUSIONS

BDUMP can rarely be associated with uveal proliferation. Routine examinations are recommended to monitor for any changes concerning malignancy.

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.

Management of Bilateral Diffuse Uveal Melanocytic Proliferation (BDUMP)-A Case Report

Background and Objectives: This study reports a case of a 62-year-old patient experiencing a significant decline in vision over the past three months. The initial best-corrected visual acuity (BCVA) of 20/20 in both eyes diminished to 20/200 in the right eye (RE) and counting fingers (CF) in the left eye (LE) within this timeframe. The patient was diagnosed with stage 4 ovarian cancer just one month before the significant vision deterioration. Materials and Methods: A thorough ophthalmologic examination revealed a notable progression of cataracts and the presence of subretinal fluid on the posterior pole, accompanied by choroidal thickening. The right eye exhibited multifocal, orange-pigmented, and elevated choroidal lesions, while the left eye's fundus examination was impeded by dense cataracts. Optical coherence tomography (OCT) revealed bilateral choroidal thickening with overlying folds and subretinal fluid, and ultrasound imaging of the choroidal lesions indicated moderate homogenous internal reflectivity. Results: The patient received a diagnosis of BDUMP (bilateral diffuse uveal melanocytic proliferation), a paraneoplastic syndrome marked by simultaneous, bilateral, painless vision loss and the rapid onset of bilateral cataracts with serous retinal detachments. Despite cataract extraction, the expected visual recovery was not achieved (RE: CF; LE: 2/200, respectively). Plasmapheresis showed some success in stabilizing vision loss attributed to serous retinal detachments. Conclusions: BDUMP necessitates addressing the underlying malignancy for effective treatment. Left untreated, it can lead to near blindness within a year. The prognosis remains grim, with an average survival time ranging from 12 to 15.7 months from the time of diagnosis. Considering this case report, it is crucial to establish effective management plans and further investigate potential treatment methods and predictive markers centered around BDUMP. Collaboration between healthcare professionals and researchers is crucial in addressing the complexities of BDUMP, as the timely diagnosis and treatment of the disease remains a top priority.

Bilateral Diffuse Uveal Melanocytic Proliferation Initially Presented as Glaucoma

PURPOSE

To report a bilateral diffuse uveal melanocytic proliferation (BDUMP) patient whose initial presentation was glaucoma.

METHODS

Clinical review of a BDUMP case.

RESULTS

A 65-year-old woman presented with ocular pain of the left eye for 1 day and vision loss of the right eye for 1 week. An ophthalmological examination revealed increased intraocularr pressure in the left eye and shallow anterior chamber in both eyes. BDUMP was diagnosed following a series of auxiliary examinations. After 1.5 years of follow-up, progressive cataracts appeared, and the patient accepted cataract surgery in both eyes. Visual acuity improved from light perception to 20/100 in both eyes 1.5 years after cataract surgery, but declined to light perception again at the last follow-up.

CONCLUSION

BDUMP can be initially presented as glaucoma, and cataract surgery can be considered in BDUMP patients in order to improve the patients' quality of life, even if exudative retinal detachment exists.

A case of bilateral diffuse uveal melanocytic proliferation with secondary angle closure caused by ciliary body thickening

Purpose

To describe a case of bilateral diffuse uveal melanocytic proliferation (BDUMP) with secondary angle closure caused by ciliary body thickening accompanied by intraocular pressure (IOP) elevation after mydriasis.

Observations

A 55-year-old woman with a history of ovarian cancer had blurred vision in both eyes. Fundus examination revealed multiple patchy lesions in both eyes and a nevus-like elevated lesion in the right eye. Anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM) demonstrated angle closure resulting from ciliary body thickening. After mydriasis, the IOP was elevated in both eyes. Instillation of a miotic drug successfully reversed the IOP to normal levels.

Conclusions and Importance

BDUMP caused secondary angle closure in both eyes, presumably due to thickening of the entire ciliary body. AS-OCT and UBM were advantageous for analyzing the morphology of the anterior eye segment in BDUMP. Clinicians should be aware of the possibility of angle closure during the management of patients with BDUMP.

Bilateral diffuse uveal melanocytic proliferation

Learning Point for Clinicians Bilateral diffuse uveal melanocytic proliferation (BDUMP) can occur not only in patients with cancer, but also as the first sign of subclinical malignancies. Clinicians should be aware of BDUMP when a patient presents with rapid vision loss with fundus changes.

TREATMENT OF BILATERAL DIFFUSE UVEAL MELANOCYTIC PROLIFERATION WITH INTRAVITREAL STEROID IMPLANTS

BACKGROUND/PURPOSE

To report a case of bilateral diffuse uveal melanocytic proliferation (BDUMP) treated with intravitreal steroid implants.

METHOD

Bilateral diffuse uveal melanocytic proliferation was diagnosed and treated with intravitreal steroid implants (both dexamethasone 0.7 mg [intravitreal dexamethasone implants] and fluocinolone acetonide 0.18 mg [intravitreal fluocinolone acetonide implants]) and monitored every 2 weeks to 4 weeks with optical coherence tomography.

RESULTS

Intravitreal dexamethasone implants improved visual acuity and central retinal thickness for 10 weeks, was best from 4 to 6 weeks, and recurred by 14 weeks after treatment. Intravitreal fluocinolone acetonide implants improved visual acuity and central retinal thickness for 20 weeks after treatment without edema recurrence. No retinal detachments were observed over 1 year of treatment.

CONCLUSION

Intravitreal steroid implants resulted in visual acuity improvement and central retinal thickness reduction for up to 20 weeks and may protect against retinal detachments in patients with bilateral diffuse uveal melanocytic proliferation.

Bilateral diffuse uveal melanocytic proliferation: Report of a novel optical coherence tomography finding and clinical response to plasmapheresis

Purpose

To describe a novel optical coherence tomography (OCT) finding in a case of bilateral diffuse uveal melanocytic proliferation (BDUMP) and to report the clinical response to plasmapheresis.

Observations

We report the case of a 54-year-old man who was being treated with adjuvant immune checkpoint inhibitors for metastatic renal cell carcinoma. He had suffered from bilateral progressive vision loss without ocular pain. At presentation in the retina clinic, visual acuity was counting fingers bilaterally. Examination revealed characteristic findings suggestive of a peculiar paraneoplastic intraocular syndrome called BDUMP. Multiple choroidal nevi-like melanocytic tumors were noted bilaterally. The diagnosis was confirmed using multimodal imaging with fluorescein angiography and fundus autofluorescence, which revealed a typical leopard pattern. Ultrasonography revealed choroidal thickening extending to the ciliary body. OCT showed multiple pockets of serous retinal detachment (SRD) and bacillary layer detachment (BALAD), a newly recognized and rarely described manifestation of the disease. The clinical response to plasmapheresis was robust with resolution of the BALAD and SRD and improvement of the vision to 20/30 in both eyes at the seven-month follow-up.

Conclusions and importance

BALAD is a newly recognized manifestation of BDUMP. Early recognition of this paraneoplastic syndrome and prompt initiation of plasmapheresis has the potential to improve and stabilize vision.

Rare Case of Bilateral Diffuse Uveal Melanocytic Proliferation with Dermal and Mucosal Hyperpigmentations

Purpose: The demonstration of a rare case of bilateral diffuse uveal melanocytic proliferation (BDUMP) due to a lung carcinoma with unusual dermal lesions. Case description: A 76-year-old man with painless bilateral vision loss revealed leopard or giraffe spot chorioretinopathy and bilateral serous retinal detachment. Ultrasound biomicroscopy revealed uveal swelling expanding into the anterior chamber angle. Dermal and mucosal lesions were present on the lip, breast, groin, scrotum, and penis. Screening analyses revealed a non-small cell lung carcinoma. Conclusions: The diagnosis of BDUMP, a rare paraneoplastic syndrome, was made. The ophthalmological diagnosis led to screening investigations and revealed the underlying malignant disease. Uncommonly, multiple dermal and mucosal lesions could be detected and were analyzed histopathologically.

Efficacy of combined anti-VEGF and photodynamic therapy for bilateral diffuse uveal melanocytic proliferation: Case series

RATIONALE

Bilateral diffuse uveal melanocytic proliferation (BDUMP) is an extremely rare retinal exudative disease with physical disorders and no established treatment standard. We describe treatment courses in 3 cases of BDUMP.

PATIENTS CONCERNS

Three male patients complained active vision loss. One male patient in his 70s (patient 1) was treated with prednisolone, mesalazine, and ciclosporin for hypoplastic anemia and ulcerous colitis. One male patient in his 60s (patient 2) was on prednisolone therapy for adult Still disease. Another male patient in his 70s (patient 3) was on prednisolone therapy for polymyalgia rheumatica, giant cell arteritis, and pancreatic body tumor.

DIAGNOSES

Retinal specialists diagnosed these patients with BDUMP based on characteristic fundus findings of multiple red patches and retinal exudate.

INTERVENTIONS

Two patients (patients 1 and 2) with poor response to anti-vascular endothelial growth factor (VEGF) monotherapy and/or triamcinolone acetonide sub-Tenon injection were treated with combined anti-VEGF therapy and photodynamic therapy. One patient (patient 3) was treated with 3 rounds of monthly anti-VEGF monotherapy.

OUTCOMES

Retinal exudates were resolved in all patients. No recurrence of retinal exudates was observed for at least 10 months, 2 years, or 4 months after the therapy in patients 1, 2, and 3, respectively. However, best-corrected visual acuity of the right eye was low (20/200) compared with that of the left eye (20/22) in patient 2 despite exudate resolution, due to permanent outer retinal damage secondary to long-term retinal exudate.

LESSONS SUBSECTIONS

Combined anti-VEGF therapy and photodynamic therapy may be a feasible therapeutic option for treatment-resistant exudate in patients with BDUMP. Early diagnosis of BDUMP and prompt administration of combination therapy are crucial.

Bilateral Diffuse Uveal Melanocytic Proliferation in a Patient with Recurrent Frontal Lobe Meningioma

Background: Bilateral diffuse uveal melanocytic proliferation (B-DUMP) is a paraneoplastic disorder that may be seen in patients with a known malignancy but more commonly is seen in those without any history of cancer. It leads to multiple uveal tumors with exudative retinal detachment along with thickening of the choroid and generally carries a poor prognosis. Its etio-pathogenesis is poorly understood but is said to involve factors secreted by the systemic malignancy that lead to proliferation of melanocytes in the uvea.Methods: We report the presentation and management of a female with history of treated frontal lobe meningioma who presented with neovascular glaucoma along with B-DUMP and was found to have recurrence of the meningioma on neuro-imaging.Conclusions: Central nervous system meningiomas can cause B-DUMP and management of the malignancy may lead to partial resolution of posterior segment manifestations of B-DUMP.

Bacillary Layer Detachment in Bilateral Diffuse Uveal Melanocytic Proliferation Masquerading as Neovascular AMD

Bilateral diffuse uveal melanocytic proliferation (BDUMP) is a rare and unusual paraneoplastic ocular syndrome with generally poor prognosis. The authors present a case of BDUMP in a patient with bladder cancer, examined with current multimodal imaging. In the clinical setting with drusen and exudative macular detachments, the fundus simulated neovascular age-related macular degeneration, warranting standard-of-care therapy. The imaging actually showed the typical manifestations of BDUMP, but also newly recognized, associated manifestations, including the bacillary layer detachment, a gravitating retinal detachment, and multifocal choroidal hyperpermeability, but no evidence of neovascularization. Recognition of these associated manifestations is of value in appreciating the pathophysiology of this paraneoplastic disorder. Based on the imaging, the correct diagnosis was possible along with a better understanding of the nature of the clinical features in the posterior fundus. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:413-417.].

Bilateral Diffuse Uveal Melanocytic Proliferation Secondary to Rectal Adenocarcinoma: A Case Report and Literature Review

Background: Bilateral diffuse uveal melanocytic proliferation (BDUMP) is a rare paraneoplastic intraocular syndrome that causes progressive visual loss in patients, and is associated with an underlying malignancy. Recently, the incidence of BDUMP has increased with the prolonged life expectancy of oncology patients.

Case Presentation: We report a case of a 68-year-old man with significant visual loss in both eyes. The patient presented with a diffusely thickened choroid and ciliary body, extremely shallow anterior chamber, increased intraocular pressure, and cataract formation, accompanied by exudative retinal detachment in both eyes. He underwent a pars plana vitrectomy and choroidal biopsy, which revealed benign proliferation of melanocytes. A small amount of subretinal fluid persisted, and uveal thickness persisted in the early postoperative period. During the 1-year follow-up assessment, he underwent rectal tumor resection, and was pathologically diagnosed with rectal adenocarcinoma. Six months after the rectal tumor resection, the subretinal fluid was completely absorbed and the retina had reattached. The thickness of both the ciliary body and choroid had significantly decreased.

Conclusion: This case report describes a rare paraneoplastic intraocular syndrome, BDUMP, which was associated with rectal adenocarcinoma. Treatment for the primary malignancy gradually improved the visual symptoms and signs.

Bilateral diffuse uveal melanocytic proliferation with multifocal diffuse integumentary melanocytic proliferation paraneoplastic syndrome: A case report

Bilateral diffuse uveal melanocytic proliferation (B-DUMP) is a rare paraneoplastic syndrome typically presenting with bilateral visual loss. B-DUMP is associated with extraocular systemic malignancies with the most common being lung cancer in males and uro-gynaecological cancer in females (mainly ovarian cancer). Cutaneous and/or mucosal involvement in patients with B-DUMP has been reported but it is not well characterised. Herein, we present a female in her 70s with diagnosis of stage IV vaginal clear-cell carcinoma and metastatic melanoma of unknown primary that developed progressive bilateral loss of visual acuity compatible with 'B-DUMP'. Simultaneously, she developed multifocal bilateral bluish-greyish patches on the skin that were shown to have a proliferation of dermal melanocytes. We propose that the clinical and histopathologic cutaneous findings seen in patients with B-DUMP be termed 'diffuse integumentary melanocytic proliferation (DIMP)'.

Case Report: Blurred Vision and Eruptive Nevi - Bilateral Diffuse Uveal Melanocytic Proliferation With Mucocutaneous Involvement in a Lung Cancer Patient

We describe a case of a 65-year old patient presenting with unusual mucocutaneous melanocytic proliferations of a Bilateral Diffuse Uveal Melanocytic Proliferation (BDUMP) imitating a multifocal melanoma in situ, which improved dramatically after plasmapheresis. The patient first presented at the dermatology department due to rapidly evolving brown and black macules on the glans penis. Further skin involvement of the perineal and perianal region, mamillae and oral mucosa was stated. Histology from a penile biopsy was compatible with a melanoma in situ. Due to the distribution pattern and elevated serum tumor marker S100B, metastatic melanoma was considered. Staging examinations using PET-CT scan however, revealed a lung tumor, later confirmed as a Non-small-cell lung cancer (NSCLC). Primary radio chemotherapy was initiated to treat NSCLC. Shortly after initiation of radio chemotherapy the patient developed massive vision impairment and a NSCLC-associated BDUMP was diagnosed which led to the correct classification of melanocytic skin lesions as mucocutaneous BDUMP manifestation. Plasmapheresis was started resulting in a rapid improvement of vision starting ten days after the first plasmapheresis. In contrast skin manifestations started to disappear with a marked delay 4 months after the last plasmapheresis cycle. This case highlights the importance of memorizing multiple rapidly progressing melanocytic skin and/or mucous membrane spots together with visual impairment as a possible paraneoplastic BDUMP that needs a fundamentally different therapeutic approach compared to multifocal melanoma in situ. What is already known about this topic? Bilateral Diffuse Uveal Melanocytic Proliferation (BDUMP) is a paraneoplastic syndrome with melanocytic uveal proliferation leading to vision impairment. Extraocular manifestation is rare, mainly affect the subepidermal compartment and is hard to treat. Plasmapheresis has been shown to be an effective treatment mainly for vision improvement in some but not all cases. What does this study add? Our BDUMP case with widespread skin and mucosal involvement initially mimicked a multifocal melanoma in situ and showed an excellent treatment response to plasmapheresis. Improvement of mucocutaneous lesions has not been documented well in the literature so far. We show a more than one year lasting follow up still underlining the beneficial effect of plasmapheresis in this case. In-vitro data supports the hypothesis that plasma exchange eliminates a "Cultured melanocyte elongation and proliferation (CMEP)" factor out of patient blood leading to decreased melanocyte proliferation shown numerically in-vitro and clinically in-vivo. Our case clearly indicates that before establishing a definite diagnosis and therapy in patients with rapidly evolving melanocytic skin and/or mucosal lesions BDUMP mimicking multifocal melanoma in situ should be considered making a thorough diagnostic workup mandatory.

Serous business: Delineating the broad spectrum of diseases with subretinal fluid in the macula

A wide range of ocular diseases can present with serous subretinal fluid in the macula and therefore clinically mimic central serous chorioretinopathy (CSC). In this manuscript, we categorise the diseases and conditions that are part of the differential diagnosis into 12 main pathogenic subgroups: neovascular diseases, vitelliform lesions, inflammatory diseases, ocular tumours, haematological malignancies, paraneoplastic syndromes, genetic diseases, ocular developmental anomalies, medication-related conditions and toxicity-related diseases, rhegmatogenous retinal detachment and tractional retinal detachment, retinal vascular diseases, and miscellaneous diseases. In addition, we describe 2 new clinical pictures associated with macular subretinal fluid accumulation, namely serous maculopathy with absence of retinal pigment epithelium (SMARPE) and serous maculopathy due to aspecific choroidopathy (SMACH). Differentiating between these various diseases and CSC can be challenging, and obtaining the correct diagnosis can have immediate therapeutic and prognostic consequences. Here, we describe the key differential diagnostic features of each disease within this clinical spectrum, including representative case examples. Moreover, we discuss the pathogenesis of each disease in order to facilitate the differentiation from typical CSC.

Diffuse Pigmented Lesions in the Outer Retina: An Unusual Fundus Appearance

Purpose:

This report describes and provides a differential diagnosis for a patient with unusual bilateral retinal pigmented lesions.

Methods:

A 40-year-old woman was found to have multiple flat, gray lesions scattered across her fundi, becoming larger and more confluent toward the periphery. There were small drusenlike deposits in her foveae. The hyperpigmented lesions demonstrated hypoautofluorescence with thickening of the retinal pigment epithelium and disruption of the overlying layers on optical coherence tomography (OCT). Full-field electroretinography revealed generalized reduced a- and b-wave amplitudes.

Results:

Chest x-ray, breast ultrasound, mammography, and pelvic ultrasound findings were negative for malignant etiologic factors. Panel testing results for hereditary retinal dystrophy were negative.

Conclusions:

Although the clinical and OCT appearance of the lesions is similar to congenital grouped pigmentation, the symmetric and bilateral nature of ocular findings coupled with electroretinographic changes suggest a possible retinal dystrophy. This case adds to the phenotypic diversity of pigmented fundus lesions.

Diagnosis of bilateral diffuse uveal melanocytic proliferation unveils primary gastric adenocarcinoma: a case report

Background

Bilateral diffuse uveal melanocytic proliferation (BDUMP) is an extremely rare paraneoplastic syndrome, with most cases reported as secondary to female urogenital and male lung malignancies. We reported this case of BDUMP patient whose primary malignancy was gastric adenocarcinoma verified with gastroscopy and subsequent pathological test.

Case presentation

A patient complaining blurred vision was suspected of bilateral diffuse uveal melanocytic proliferation (BDUMP), due to bilateral round oval patches at the posterior pole and cardinal signs in retinal angiography. Malignancy screening was suggested, and pathological report from gastroscopy confirmed the primary lesion as gastric adenocarcinoma. The patient chose palliative care due to late stage and unresectable nature of the malignancy.

Conclusions

Identifying BDUMP warrants further investigation of a primary malignancy. Our case provided evidence for the link between gastric adenocarcinoma and BDUMP.

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.

Bilateral diffuse uveal melanocytic proliferation secondary to thyroid carcinoma

We present a rare case of a bilateral diffuse uveal melanocytic proliferation (BDUMP), which occurred secondary to recurrence of carcinoma of thyroid in a 79-year-old gentleman who was initially misdiagnosed to have age related macular degeneration and/or chronic central serous chorioretinopathy. In spite of being treated with anti-VEGF injection and photodynamic therapy there was progressive loss of vision. Multimodal imaging like autoflourescence, infrared imaging, fluorescein angiography, indocyanine angiography, and OCT angiography helped us in clinching the final diagnosis.

Bilateral diffuse retinal pigment epithelium proliferation induced by choroidal inflammation: A case report

RATIONALE

Proliferation of retinal pigment epithelium (RPE) is typically observed in limited ocular disorders, in connection with the local mechanism of RPE proliferation-mediated wound repair. Bilateral and diffuse type RPE proliferation is considered to be associated with paraneoplastic syndromes, such as a bilateral diffuse uveal melanocytic proliferation. However, other reported diseases that induce bilateral diffuse RPE proliferation are quite rare, especially for patients who are considered to have a non-malignant status.

PATIENT CONCERNS

The bilateral eyes of a 47-year-old woman with bilateral ocular inflammation, presented united multiple small to medium white retinal lesions during the disease progress.

DIAGNOSES

Optical coherence tomography showed scattered serous retinal detachments, choroidal folds, choroidal thickening and diffuse RPE proliferation. As autofluorescence and angiography showed a "giraffe pattern", bilateral diffuse uveal melanocytic proliferation was suspected. However, systemic investigations identified no malignancy. In consideration of the above findings, choroidal inflammation was thought to be the major cause of this condition.

INTERVENTIONS

The patient was administered intensive systemic steroids. Over the next 2 months, the amount of steroid was tapered off.

OUTCOMES

After administration, the bilateral diffuse RPE proliferation settled down. During the 2-year follow-up, there was no recurrence of ocular inflammation and diffuse RPE proliferation, or any other malignancy found.

LESSONS

This finding demonstrates that bilateral diffuse RPE proliferation can be generated as a secondary phenomenon of choroidal inflammation in patients with a non-malignant status.

Paraneoplastic Syndromes in Neuro-ophthalmology

PURPOSE OF REVIEW

This article discusses the varied types of paraneoplastic syndromes that commonly have neuro-ophthalmologic manifestations. Diagnostic considerations and therapeutic options for individual diseases are also discussed.

RECENT FINDINGS

Paraneoplastic syndromes can affect the afferent and efferent visual systems. Paraneoplastic syndromes may result in reduced visual acuity from retinal degeneration, alterations in melanocyte proliferation and uveal thickening, or acquired nystagmus. Ocular motor abnormalities related to paraneoplastic syndromes may present with symptoms from opsoclonus or from neuromuscular junction disease. Diagnosis remains challenging, but serologic identification of some specific antibodies may be helpful or confirmatory. Treatment, in addition to directed therapies against the underlying cancer, often requires systemic corticosteroids, plasma exchange, or immunosuppression, but some specific syndromes improve with use of targeted pharmacologic therapy.

SUMMARY

Diagnosis and therapy of paraneoplastic syndromes presenting with neuro-ophthalmic symptoms remain a challenge, but strategies are evolving and new approaches are on the horizon.

Heterogeneity of cultured melanocyte elongation and proliferation factor in bilateral diffuse uveal melanocytic proliferation

A patient with bilateral diffuse uveal melanocytic proliferation (BDUMP) associated with endometrial cancer was treated with plasmapheresis, but failed therapy with progressive serous retinal detachment. We collected plasma before and after plasmapheresis therapy. Our goal was to determine if the cultured melanocyte elongation and proliferation (CMEP) factor and hepatocyte growth factor (HGF) was present in the IgG enriched fraction and understand why our patient failed plasmapheresis therapy. Melanocytes were cultured for 3-5 days in the presence of control medium, unfractionated pre-plasmapheresis BDUMP medium, IgG enriched or IgG depleted BDUMP medium, or unfractionated post-plasmapheresis BDUMP medium. Subretinal fluid was collected from patients with BDUMP and control retinal detachments and analyzed by electropheresis with immunoblotting. Medium with unfractionated BDUMP plasma stimulated melanocyte growth 1.4-1.5 fold compared to control medium on days 3-5 (p < 0.001 for all). Both IgG enriched and IgG depleted BDUMP medium mildly increased melanocyte growth 1.3 fold (p < 0.05 for enriched, p < 0.01 for depleted) compared to control. In comparison, unfractionated BDUMP medium caused a 1.7-fold increase in melanocyte growth, which was significantly more than the enriched (p < 0.01) and depleted (p < 0.05) fractions. Pre-plasmapheresis and post-plasmapheresis unfractionated BDUMP medium equally stimulated melanocyte growth 1.7-fold (p < 0.05) compared to control. HGF was present in IgG depleted, pre-plasmapheresis, and post-plasmapheresis samples, but absent in the IgG enriched fraction. There was no enrichment of IgG in the subretinal fluid from eyes with BDUMP. In conclusion, CMEP factor is not concentrated in the IgG enriched plasma fraction in our patient who failed plasmapheresis therapy. HGF levels have no correlation with melanocyte growth. Because plasmapheresis preferentially removes immunoglobulins from the plasma, our patient responded poorly to plasmapheresis treatment with worsening retinal detachment.

Prevalence of Hepatocyte Growth Factor and Autoantibodies to α-HGF as a New Etiology for Bilateral Diffuse Uveal Melanocytic Proliferation Masquerading as Neovascular Age-Related Macular Degeneration

Objective

The goal was to test the hypothesis that high serum hepatocyte growth factor (HGF) and retinal autoantibodies against α-HGF contribute to the pathology of bilateral diffuse melanocytic proliferation (BDUMP).

Methods

Case report of an elderly diagnosed with neovascular age-related macular degeneration (n-AMD) treated with bilateral Bevacizumab injections. Examination included comprehensive ophthalmic examination and images obtained by fundus photography, fundus autofluorescence, fluorescein angiography, spectral-domain optical coherence tomography (OCT), and B-scan ultrasonography. The levels of HGF and circulating HGF receptor (c-MET) were measured in the serum by ELISA and anti-retinal autoantibodies by western blotting.

Results

Patient received Bevacizumab injections for presumed n-AMD and had a history of papillary renal cell carcinoma stage 4 with a tumor containing gene mutation Y1230C in the mesenchymal-epithelial transition factor (MET). Visual acuity was 20/200 OD and CF OS. Multimodal imaging was consistent with BDUMP. Plasma exchange therapy was recommended but could not be started until 10 months later due to deterioration in his medical condition. Pre- and post-plasma exchange sera demonstrated anti-retinal autoantibodies against 69-kDa protein of the same molecular weight as the α-HGF. Serum autoantibodies reacted with purified recombinant α-HGF on the blot.

Conclusions

BDUMP can mimic n-AMD, which can delay treatment. Plasma exchange resulted in resolved inflammation, resolution of exudative detachments and improved vision after cataract surgery. Consideration of the tumor genetics led to the recognition of elevated HGF levels and autoantibodies to α-HGF (anti-69-kDa), which suggested a new pathogenic mechanism of BDUMP. We believe that therapy with tyrosine kinase inhibitors and a checkpoint inhibitor may contribute to the high HGF levels and subsequent immune response.