Primary iris melanoma: diagnostic features and outcome of conservative surgical treatment

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 in an Australian cohort

BACKGROUND

To report the clinicopathological features and epidemiology of iris melanoma in Queensland, Australia.

METHODS

This was a retrospective study of 86 patients with iris melanoma treated between 2001 and 2022 at the Queensland Ocular Oncology Service, Brisbane, Australia. Main outcome measures included demographics, clinical and phenotypic features, age-adjusted incidence and relative survival.

RESULTS

Eighty-six patients (63% female) were included. Mean age was 54 years (range 17-82 years). The majority of patients (97%) were Caucasian, with blue eyes, fair skin and Fitzpatrick Skin Type I or II. Demographic features and clinical history showed a tendency for high ultraviolet radiation (UVR) exposure in the cohort. Histopathology was available in 69 cases (82%), and of these, 77% tumours were of spindle cell origin, with low-risk genetic profiles. Patients were followed for a mean of 8 years (median 7, range 1-21 years) after diagnosis, and only one case of metastasis was documented.

CONCLUSIONS

The association of iris freckles, history of UVR exposure and dermatologic findings supports the role of UVR in iris melanoma. Occupation and avocation history, as well as evaluation of iris freckles may offer an easily accessible way of stratifying the risk of an individual for development of UVR-related uveal melanoma.

Predictive model for iris melanoma

AimTo develop a predictive model for the diagnosis of iris melanoma.

METHODS

Retrospective consecutive case series that included 100 cases of pathologically confirmed iris melanoma and 112 cases of Iris naevus, either pathological confirmation or documented stability of >1 year. Patient demographic data, features of clinical presentation, tumour characteristics and follow-up were collected. Iris melanoma with ciliary body extension was excluded. Lasso logistic regression with 10-fold cross-validation was used to select the tuning parameter. Discrimination was assessed with the area under the curve (AUC) and calibration by a plot.

RESULTS

There was a significant asymmetry in the location of both nevi and melanoma with preference for inferior iris quadrants (83, 74%) and (79, 79%), respectively (p=0.50). Tumour seeding, glaucoma and hyphaema were present only in melanoma. The features that favoured the diagnosis of melanoma were size (increased height (OR 3.35); increased the largest basal diameter (OR 1.64)), pupillary distortion (ectropion uvea or corectopia (OR 2.55)), peripheral extension (angle or iris root involvement (OR 2.83)), secondary effects (pigment dispersion (OR 1.12)) and vascularity (OR 6.79). The optimism-corrected AUC was 0.865. The calibration plot indicated good calibration with most of the points falling near the identity line and the confidence band containing the identity line through most of the range of probabilities.

CONCLUSIONS

The predictive model provides direct diagnostic prediction of the lesion being iris melanoma expressed as probability (%). Use of a prediction calculator (app) can enhance decision-making and patient counselling. Further refinements can be undertaken with additional datasets, forming the basis for automated diagnosis.

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.

Side Effects of Proton Beam Radiotherapy Treatment on Iris Melanoma

PURPOSE

This study evaluated the functional outcome and ocular side effects of patients receiving proton beam radiotherapy (PBR) for the treatment of iris melanoma (IM).

DESIGN

This retrospective study analyzed prospectively collected data.

PARTICIPANTS

Patients with IM who underwent PBR as a primary treatment.

METHODS

Treatment was given in the form of whole PBR (wPBR: n = 51) or segmental PBR (sPBR: n = 98).

MAIN OUTCOME MEASURES

Visual acuity (VA) and side effects were divided into ocular surface disease (OSD), secondary glaucoma, or cataract development.

RESULTS

A total of 149 eyes of 149 patients with a mean age of 53.9 ± 16.0 years were included. Tumor recurrence developed in 3 patients (wPBR: 1/51; sPBR: 2/98). Ocular surface disease was observed in 78.4% of the wPBR group (40/51) and 25.5% of the sPBR group (25/98) (P < 0.001) after 0.7 ± 1.2 years and 1.1 ± 0.9 years, respectively. The main side effect was dry eye syndrome in both groups, but severe side effects such as limbal stem cell failure were found only in the wPBR group (4/51; 7.8%). Secondary glaucoma developed in 31.4% of the wPBR group (16/51) compared with 1.0% in the sPBR group (1/98; P < 0.001). Glaucoma control was generally achieved with eye drops, whereas surgery was necessary in 5 patients (wPBR: 4/51, 7.8%; sPBR: 1/98, 1%). Cataract surgery was performed in 47.9% of the wPBR group (23/48) and 19.8% of the sPBR group (19/96) (P < 0.001). Before treatment, VA was 0.14 ± 0.27 logarithm of the minimum angle of resolution (logMAR) in the wPBR group and 0.04 ± 0.19 logMAR in the sPBR group. A worsening was seen in the wPBR group (0.55 ± 0.16 logMAR; P < 0.001) 6 months after radiotherapy, which normalized after 12 months (0.15 ± 0.30 logMAR; P = 0.17). In the sPBR group, no such decrease in VA was observed (6 months: 0.03 ± 0.22 logMAR, P = 0.54; 12 months: 0.04 ± 0.21 logMAR, P = 0.98).

CONCLUSIONS

Our results demonstrate that PBR is a very successful treatment option for patients with IM, showing a high tumor control rate and relatively low complication profile. Tumor recurrence was a rare event, and secondary enucleation was not necessary in any patient. Side effects are commonly seen, but severe side effects such as limbal stem cell failure or secondary glaucoma mainly developed after wPBR. These results are important for clinical decision making and discussion with the patient regarding this form of radiotherapy.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Angiographic Features of Iris Melanocytic Tumors: Nevus versus Melanoma

Introduction

Determining the nature of iris melanocytic tumors based on clinical exam alone remains challenging. Tumor-associated vasculature of iris melanocytic lesions may facilitate the ability to discern between iris nevus and melanoma.

Methods

In a single-institution, retrospective, observational study of 45 patients with pathologically confirmed iris melanoma and 15 patients with iris nevi that were either clinically stable or pathologically confirmed were included. Tumor characteristics and associated vasculature were identified on clinical exam and slit-lamp photographs. Fluorescein angiographic parameters including feeder vessels, intrinsic vessels, leakage, masking, and angiographic silence were assessed.

Results

Feeder vessels were present in 17 (43%) melanomas and were absent in the nevus group (p = 0.002). Thirty-three (83%) iris melanomas and 5 (33%) iris nevi were observed to have intrinsic vessels, and a statistically significant association of intrinsic vessels with malignancy (p = 0.001) was noted. Fluorescein leakage was also observed more frequently in iris melanoma 39 (98%) than in nevi 9 (60) with a significant difference (p = 0.001). Angiographic silence occurred in 3 nevi (20%) and was not observed in any melanoma (p = 0.017). Overall, the presence of intrinsic vessels +/- feeder vessels had high sensitivity (0.85) and high positive predictive value (0.87) for diagnosis of iris melanoma.

Conclusions

Anterior segment fluorescein angiography allows for the assessment of tumor-associated vascular patterns and demonstrates utility in differentiating iris nevi from melanoma. Feeder vessels were only observed in iris melanoma and were absent in iris nevi. The intrinsic vessels were present more frequently in melanomas and are thus associated with malignancy. Angiographic silence is indicative of iris nevi.

Proton Therapy for 166 Patients with Iris Melanoma: Side Effects and Oncologic Outcomes

OBJECTIVE

To investigate the oncologic and functional outcomes of a large cohort of patients with a favorable stage of circumscribed and diffuse iris melanoma who underwent primary proton treatment and the risk factors related to initial tumor characteristics and the treatment field architecture.

DESIGN

Retrospective, single-center, case study.

PARTICIPANTS

We reviewed 225 patients with iris melanoma who were consecutively treated with proton beam therapy at our institution between 1998 and 2020.

METHODS

We performed Kaplan-Meier time-to-event analyses and multivariate Cox proportional hazard analyses to identify the impacts of tumor characteristics and target volumes on oncologic and functional outcomes.

MAIN OUTCOME MEASURES

We measured local tumor control, eye preservation rates, metastasis-free survival, cataract and glaucoma-directed surgery, intraocular pressure, and changes in visual acuity.

RESULTS

Of the 192 patients with tumors confined to the iris (T1a-c) who underwent proton therapy as primary treatment, a total of 166 patients (mean age, 58.4 years; 88 women) with a minimum follow-up of 6 months were included. Multifocal or diffuse tumor spread was present in 77 (46.4%) patients. The median follow-up time was 54.0 (interquartile range, 27.4-91.8 months) months. Local recurrence occurred in 2 patients (1.2%) with circumscribed iris melanoma. Enucleation was a rare event (n = 5, 3%) and no patient developed metastatic disease. A large-treatment field (full aperture, involving > 10 clock hours) was identified as a risk factor for the development of secondary glaucoma (hazard ratio [HR], 6.3; P < 0.001) and subsequent surgical interventions (HR, 10.85; P < 0.001). The large-treatment field group showed a significant decline in visual acuity (logarithm of the minimum angle of resolution > 0.3; log-rank P < 0.0001), which was associated with secondary glaucoma (HR, 3.40; P = 0.002).

CONCLUSIONS

Proton therapy provides an effective, noninvasive treatment option for patients with a favorable stage of iris melanoma. Irradiation of the anterior segment for up to 10 clock hours is associated with a low risk of the development of secondary glaucoma and vision loss.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Iris melanocytic tumours in New Zealand/Aotearoa: presentation, management and outcome in a high UV exposure environment

BACKGROUND/OBJECTIVES

Iris melanoma, a rare intraocular malignancy, represents the smallest subgroup of uveal melanoma. This first, comprehensive study of iris melanocytic lesions in the high ultraviolet environment in New Zealand/ Aotearoa (NZ) examines diagnosis, management and outcomes.

SUBJECTS/METHODS

Retrospective study of iris melanocytic tumours referred to tertiary referral centres in Auckland, NZ, over 20 years (1999-2018). Data analysed include demographics, tumour characteristics, histology, genetic analyses, treatment modalities, recurrence, metastasis, 5-year and overall survival.

RESULTS

Cohort (N = 51) was predominantly NZ European (98.0%) with no indigenous Māori, or Pasifika. Median age at presentation was 58 years. Tumours involved a median of two clock hours of iris. The posterior tumour margin extended to the anterior chamber angle in 22 patients (45.8%). Management included initial observation 54.9%, iridectomy/excision biopsy 29.4%, irido-cyclectomy 7.8%, plaque radiotherapy 7.8%, proton beam radiotherapy 7.8%, and ultimately enucleation 17.6%. Histology was performed in 19 cases (37%) with 16 confirmed melanomas (84%). Mean follow-up 4.2 years with median visual acuity of 6/7.5 two years post intervention. Melanoma-related metastasis and mortality occurred in two cases with five-year melanoma-related mortality of 2.0%.

CONCLUSION

In a climate with high ultraviolet exposure iris melanocytic tumours occurred almost exclusively in NZ Europeans, however, the majority of cases were category T1, possibly reflecting early diagnosis in the NZ health system. Nonetheless, >50% underwent surgery or radiotherapy, often utilising more than one modality. A high index of suspicion and early referral of iris melanocytic lesions should be considered in regions with high UV exposure.

An unusual case of a pigment epithelial cyst masquerading as a uveal melanoma after zoster ophthalmicus-related iris atrophy

Purpose

To report the case of a 69-year-old male who was referred for a previously unidentified pigmented iris lesion with surrounding iris atrophy masquerading as an iris melanoma.

Observations

A sharply demarcated pigmented lesion extending from the trabecular meshwork to the pupillary margin was identified in the left eye. There was adjacent iris stromal atrophy. Testing was consistent with a cyst-like lesion. The patient later described a prior episode of ipsilateral herpes zoster involving the ophthalmic division of cranial nerve five.

Conclusions and Importance

Iris cysts present an uncommon iris tumor, often going unrecognized especially if located on the posterior iris surface. When they present acutely, as in this case where a previously unidentified cyst was revealed following zoster-induced sectoral iris atrophy, these pigmented lesions can be concerning for malignancy. Accurately identifying iris melanomas and differentiating them from benign iris lesions is imperative.

Intraocular Lens and Lens Capsule Spread of Iridociliary Melanoma: Clinical and Histopathologic Features of 2 Cases

Purpose: To describe two patients with intraocular lens (IOL) and lens capsule spread of iridociliary melanoma. Methods: Two pseudophakic patients with iridociliary body melanoma that spread onto the surface of their IOL and remaining lens capsule were included. Their eyes were enucleated and the histopathologic features were evaluated. Results: Case 1 was an 82-year-old woman with diffuse primary iridociliary melanoma affecting the iris, lens capsule, IOL surface, and ciliary body. Case 2 was a 68-year-old female who developed melanoma recurrence in the anterior segment after plaque brachytherapy for iridociliary melanoma. The melanoma in both cases grew as a pigmented membrane onto the surface of the IOL. Conclusions: Intraocular lens and lens capsule spread of iridociliary melanoma can occur primarily or develop secondarily after plaque brachytherapy of a pseudophakic eye. Since the extent of the melanoma may be uncertain and there is a high likelihood of glaucoma, enucleation is a reasonable option.

Proton beam radiation for iris melanoma: case series and review of literature

Objective

Purpose of this study is to analyse the visual outcomes, the complication and eye retention rate as well as tumour control data of patients treated with proton beam radiation therapy (PBRT) for iris melanoma.

Methods

Retrospective case series and review based on patients’ records. All tumours were categorised according to the American Joint Committee of Cancer staging criteria for primary iris melanoma und underwent either sectorial or whole anterior segment PBRT.

Results

Thirteen cases were identified of which five received PBRT of the whole anterior segment and eight received sectorial PBRT. Local tumour control after a mean follow-up of 25 months was 92%. Complications after PBRT included cataract (46%), secondary glaucoma (31%), superficial keratitis (15%) and madarosis (8%). Complications were more common in patients necessitating irradiation of the entire anterior segment than in patients which received sectorial irradiation. Eye retention was achieved in all cases. No statistically significant difference in the mean best corrected visual acuity (BCVA) and intraocular pressure (IOP) was found before and after treatment. Comparison of mean BCVA and IOP between different treatment groups (complete anterior segment vs sectorial irradiation) at the last follow-up visit were also not significantly different. No patient developed metastatic disease during follow-up.

Conclusion

PBRT is a safe and vision preserving therapeutic modality for iris melanoma. Complete irradiation of the anterior segment is associated with higher complication rates.

Topography and clinical features of iris melanoma

BACKGROUND

To characterise the topographical and clinical features of primary iris melanoma and to visualise the patterns of tumour extent in the iris.

METHODS

Clinical characteristics of iris melanomas were analysed, and data on their size, shape, and location were converted into a database of two-dimensional iris charts by means of computer-drawing software. The geometric centre of each tumour was entered into corresponding sectors of the chart. The extent of the melanomas was computationally visualised by merging the iris drawings and displaying the number of overlapping tumours on colour-coded iris maps.

RESULTS

Twenty-nine patients (18 females and 11 males) with a mean age of 52 years met the inclusion criteria. The mean largest tumour diameter was 6.1 mm (range, 1.8-11.0 mm). Five tumours (17%) involved the pupillary margin, 10 (34%) involved the iris root, and 10 (34%) involved both sites. The hemispheric location of the tumour centroid was superior in 3 eyes (11%) and inferior in 25 (89%) (p < 0.0001), and the distribution between the temporal and nasal hemispheres was 17 (61%) and 11 (39%), respectively (p = 0.26). In females, the iris melanomas were located more temporally (p  =  0.02) and had more often originated from a pre-existing naevus (p = 0.03), than in males. There was also shift towards more temporally located melanomas in younger patients.

CONCLUSIONS

The lower temporal iris quadrant is the preferential area of melanoma occurrence and growth. Iris melanoma tends to be more temporally located in females, who compared with males also have a higher proportion of melanomas arising from a pre-existing naevus.

Uveal melanoma diagnosis and current treatment options (Review)

Uveal melanoma is a rare condition accounting for only 5% of all primary melanoma cases. Still, it is the most frequently diagnosed primary intraocular malignant tumor in adults. Almost 90% of the tumors involve the choroid and only a small percentage affects the ciliary body or the iris. There is a consistent difference in incidence between different regions with individuals of northern European descent having a significantly higher risk as compared to Hispanics, Asians, and Blacks. Among the many risk factors, mutations in the G protein subunit alpha Q (GNAQ) or G protein subunit alpha 11 (GNA11) genes and different receptors are highly suggestive. While iris melanoma can easily be noticed by the patient itself or diagnosed at a routine slit-lamp evaluation, a consistent percentage of posterior uveal tumors are incidentally diagnosed at funduscopic evaluation as they can evolve silently for years, especially if located in the periphery. Uveal melanoma classifications rely on the tumor size (thickness and basal diameter) and also on intraocular and extraocular extension. The differential diagnosis with pseudomelanomas is carried out according to the tumor aspect and position. Iris melanoma has a better prognosis and a lower mortality rate as compared to choroidal melanoma that has a much higher rate of metastasis (50% of the patients) and a subsequent limited life expectancy from 6 to 12 months. While conservative therapeutic options for the primary tumor, relying on different surgical excision techniques and/or irradiation therapies, offer good local tumor control, the treatment options for metastatic disease, although numerous, are still inadequate in preventing a fatal outcome.

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.

Anterior Segment OCTA of Melanocytic Lesions of the Conjunctiva and Iris

PURPOSE

To study the feasibility and diagnostic value of vascular imaging using optical coherence tomography (OCT)-angiography (OCTA) of melanocytic lesions of the conjunctiva and iris.

DESIGN

Cross-sectional study.

METHODS

Twenty-five patients with an untreated conjunctival lesion (5 melanoma, 13 nevus, 7 primary acquired melanosis [PAM]) and 52 patients with an untreated iris lesion (10 melanoma, 42 nevus) were included. Patients were imaged using a commercially available OCTA device, with the addition of an anterior segment lens and manual focussing. Tumor vessel presence, vascular patterns and vascular density were assessed.

RESULTS

Good OCTA images were obtained in 18 of 25 conjunctival lesions and 42 of 52 iris lesions. Failure was caused by lack of patient cooperation, an unfavorable location, or mydriasis. In all imaged conjunctival lesions and 77% of iris lesions, vascular structures were detected. Conjunctival melanoma and nevi demonstrated the same intralesional tortuous patterns, whereas vasculature in eyes with PAM was similar to normal conjunctiva. Both iris melanoma and nevi demonstrated tortuous patterns, distinct from the radially oriented normal iris vasculature.

CONCLUSIONS

Optical coherence tomography angiography (OCTA) allows for noninvasive imaging of the vasculature in melanocytic lesions of the conjunctiva and iris. Good image quality depends highly on patient cooperation and lesion characteristics. Differentiation of benign and malignant lesions was not possible. New software is called for to improve image acquisition and analysis.

Iris Melanoma: Management and Prognosis

Iris melanomas represent 2–5% of uveal melanomas. Iris melanomas vary in their size, shape, degree of pigmentation and clinical behavior. The main local clinical complications of iris melanomas are tumor vascularization, ectropion uvea, pupillary distortion, pigment dispersion, sector cataract, chronic uveitis, hyphema and glaucoma with irreversible optic nerve damage. The most effective treatment for iris nevus and melanoma remains debatable; treatment modalities have been proposed depending on the local status as well as the age and general condition of the patient. A melanocytic iris nevus is usually observed until documented progression is identified. In this case, radiotherapy or surgical resection is generally performed. Cataract, glaucoma and limbal stem cell deficiency are usually secondary to radiotherapy, while incomplete tumor excisions, which could lead to recurrence, hemorrhage, vitreous loss, dislocated lens, iridocyclitis, macular edema, retinal detachment, glaucoma and cataract, are related to surgical resection. In some cases, a combination of radiotherapy and surgery is used. Conservative treatment is an efficient alternative to enucleation and allows good local tumor control.

Angle Closure Glaucoma Secondary to Enlarged Soemmering Ring That is Clinically Similar to Iris Tumour

Purpose

To report a case of a grown Soemmering ring that manifested as an iris tumour 24 years after cataract surgery.

Methods

A case report.

Results

A 27-year-old white man was presented with a suspected iris tumour in his left eye. He had undergone lensectomy in both eyes without intraocular lens implantation 24 years ago. Last year, he was treated by topical anti-glaucoma medication for left eye intraocular pressure (IOP) rising. Six months later, his ophthalmologist found two separate iris bumps. The patient was referred to an ocular oncologist and was to be treated with plaque brachytherapy as iris melanoma, but he denied. Ultrasound biomicroscopy (UBM) of the left eye showed significant angle narrowing due to separate ovoid hyper echoic masses behind the iris, which was clearly separated from the ciliary body. Retained and growth lens material caused a Soemmering ring to enlarge, which was the reason for glaucoma and iris bumping. The patient has been followed for more than one year without any changes being observed.

Conclusion

An enlarged and grown Soemmering ring should be considered in the differential diagnosis of any iris and ciliary body tumour, especially in patients who have had cataract surgery.

[New treatment options for iridociliary tumors]

BACKGROUND

Benign iridal tumors rarely necessitate a therapeutic intervention. In contrast, malignant tumors of the iris can threaten the patient's life and eyesight and require early treatment to prevent the development of metastases.

OBJECTIVE

Presentation of current treatment options for iridal tumors with special emphasis on iridal melanoma.

METHODS

This article gives an overview of the current literature based on a PubMed search as well as own clinical experience.

RESULTS

Treatment options for iridal and ciliary body melanomas comprise radiotherapeutic and surgical (eyeball-sparing and non-sparing) approaches. The eyeball-sparing surgical procedure of choice is block excision. While local tumor control rates and metastasis rates of block excision and radiotherapy are comparable, there are distinct differences especially between the spectra of complications. New treatment procedures include immunomodulatory approaches and targeted therapies. Using checkpoint inhibitors, no convincing enhancement of overall survival could be demonstrated for metastatic iridal melanoma, as is the case for cutaneous melanoma. In contrast, tumor vaccination with the help of tumor RNA-laden patient-derived dendritic cells seems to be a promising option for a subgroup of high-risk patients. Targeted therapies aiming to suppress the MAPK and PI3K/Akt pathways could not achieve any improvement in patient survival.

CONCLUSION

For the primary treatment of iridal melanoma a surgical, eyeball-sparing approach and also when appropriate, radiotherapy can be recommended. In the future, eligible high-risk patients could profit from a tumor vaccination. To date, there is no effective systemic treatment for metastatic iridal melanoma.

Proton Beam Therapy for Iris Melanomas in 107 Patients

PURPOSE

To report on the clinical characteristics and outcomes for patients with iris melanoma using proton therapy.

DESIGN

Retrospective study.

PARTICIPANTS

One hundred seven patients with iris melanoma from 3 regional ophthalmologic centers.

METHODS

A retrospective study was conducted for iris melanoma patients from 3 regional ophthalmologic centers referred to and treated at a single proton therapy facility between 1996 and 2015.

MAIN OUTCOME MEASURES

At each follow-up visit, examinations included measurement of best-corrected VA, slit-lamp, examination, indirect ophthalmoscopy, and ultrasound biomicroscopy.

RESULTS

With a median follow-up of 49.5 months, 5 of 107 patients experienced a local relapse within a median of 36.3 months. The cumulative incidence of relapse was 7.5% at 5 years. All 5 patients showed involvement of the iridocorneal angle (P = 0.056). Diffuse iris melanoma showed a higher risk of relapse (P = 0.044). Four patients showed out-of-field relapse and 1 showed angular relapse. Three patients were retreated with proton therapy, whereas 2 other patients, one with T1b disease and another with diffuse T3 disease, underwent secondary enucleation. None of the patients experienced metastases nor died of iris melanoma. Vision improved in 59.4% of patients (n = 60/101). However, cataracts occurred in 57.4% of the 54 patients (n = 31) without cataract or implant at diagnosis. Secondary glaucoma was reported in 7.6% of the patients (n = 8), uveitis in 4.7% (n = 5), and hyphema in 3.7% (n = 4). All but 5 cases of complications were mild, transient, and not sight limiting after treatment. Five cases of glaucoma, including 1 with uveitis, were severe and associated with visual deterioration.

CONCLUSIONS

Proton therapy showed efficacy and limited morbidity in iris melanomas.

Late Solitary Extraocular Recurrence From Previously Resected Iris Melanoma

PURPOSE

To report on cases of late extraocular relapse of previously resected iris melanoma, without concurrent intraocular recurrence.

DESIGN

Retrospective case series.

METHODS

A retrospective chart review of 4 patients diagnosed with late subconjunctival relapse of previously resected iris melanoma.

RESULTS

Three female patients and 1 male patient underwent iris tumor resection and presented to our service with suspicious conjunctival lesions at a median of 22 years later (mean: 21 years). None showed intraocular relapse. Treatment of the conjunctival tumors included excisional biopsy (n = 4), followed by cryotherapy (n = 3) and/or brachytherapy (n = 3). In all cases, histopathology confirmed malignant melanoma, with no intraepithelial component or associated melanosis. Genetic sequencing (n = 3) showed wild-type BRAF and NRAS in all. GNA11 mutation was found in 1 case. On array-based comparative genomic hybridization (n = 3), gain of 6p was found in 2 cases and gain of 8 in 2. Overall, findings were strongly suggestive of a diagnosis of late extraocular relapse from previously resected iris melanoma. In a median of 2.5 years (mean: 7.7 years) from the subconjunctival relapse, no further episodes of intraocular/extraocular recurrence were recorded, and all patients were free from distant metastasis.

CONCLUSIONS

Patients undergoing iris melanoma resection are at risk of developing late solitary extraocular relapse even more than 30 years after surgery. In the absence of an intraocular component, diagnosis may be challenging, as tumors mimic a primary conjunctival lesion. Management by excisional biopsy followed by adjuvant therapy was successful, and histopathology and genetic analysis supported a diagnosis of extraocular uveal tumor spread rather than a primary conjunctival tumor.

Fully automated blink detection for uveal melanoma radiotherapy

Uveal melanoma is a widespread neoplasm in the eye that cause vision defects. The disease may result in loss of eye, even loss of life with a risk of metastasis to other tissues. There have been proposed various treatment methods to overcome the disease including enucleation and radiotherapy. Radiotherapy treatment is certainly preferable since it avoids the loss of eye. The treatment is applied with radioactive beam directed to the tumor, and thus the eye must be kept steady usually with local anesthesia. However, anesthesia has many health risks; therefore it is preferable to perform this operation without it. This paper presents an approach where a camera will be recording the eye and the radiotherapy will immediately be halted when the eye is closed to avoid unnecessary beams directed to healthy regions of the eye. System is based on the classification of the acquired image frames as "eye open" and "eye closed". The speed of the algorithm is aimed as close as possible to real time so that it can respond instantly to any change in present eye state. A total of 480 video frames, 120 frames for each open and closed eyes in bright and dark lighting conditions separately, were used for experimentation. Test results indicate that developed features are successful in terms of being very fast providing no classification error.

Proton therapy of iris melanoma with 50 CGE : Influence of target volume on clinical outcome

PURPOSE

The aim of this study was to evaluate local tumour control, incidence of radiation-induced glaucoma and associated interventions of sector-based and whole anterior segment proton beam therapy (PBT) for the treatment of iris melanoma.

PATIENTS AND METHODS

We retrospectively analysed the data of 77 patients with iris melanoma who underwent PBT applied as 50 CGE in four daily fractions. Of the patients, 47 received PBT with a circular-shaped collimator and 30 with a conformal sector-shaped target volume. Local control, eye preservation and secondary glaucoma were evaluated.

RESULTS

Median follow-up time was 54.9 months. Local tumour control was 100% in patients receiving whole anterior segment irradiation. Two patients developed pigment dispersion in the non-irradiated area after sector-based PBT and received whole anterior segment salvage PBT. The mean volume of ciliary body irradiated was 89.0% and 34.9% for whole anterior segment and lesion-based irradiation, respectively. At the end of follow-up, secondary glaucoma was found in 74.3% of the patients with whole anterior segment irradiation and in 19.2% with sector-based irradiation. Patients with sector-based PBT had a stable visual acuity of logMAR 0.1, while it declined from logMAR 0.1 to 0.4 after whole anterior segment irradiation.

CONCLUSION

We found a significant reduction in radiation-induced secondary glaucoma and glaucoma-associated surgical interventions and stable visual acuity after sector-based irradiation compared with whole anterior segment irradiation. Sector-based irradiation revealed a higher risk for local recurrence, but selected patients with well-circumscribed iris melanoma benefit from applying a lesion-based target volume when treated with sector-based PBT.

Use of Ruthenium-106 Brachytherapy for Iris Melanoma: The Scottish Experience

PURPOSE

To analyse long-term outcomes of ruthenium-106 (¹⁰⁶Ru) plaque brachytherapy for the treatment of iris melanoma.

METHODS

We retrospectively reviewed medical records of 19 consecutive patients with pure iris melanoma treated with ¹⁰⁶Ru plaque brachytherapy between 1998 and 2016 at the Scottish Ophthalmic Oncology Service, Glasgow. The iris melanoma was treated with a ruthenium plaque placed on the corneal surface to deliver a surface dose of 555 Gy. We analysed vision preservation, local tumour control, radiation-related complications, eye retention rates, symptomatic metastasis and melanoma-related mortality.

RESULTS

The mean largest basal diameter of the lesions was 3.50±1.42 mm (range 1.6-6.5 mm), and the mean maximum height was 1.47±0.65 mm (range 0.7-2.8 mm). The tumour control and eye retention were 100% at a mean follow-up of 62 months (range 6-195 months). A 62% reduction in tumour height was observed on ultrasonography. Complications included cataract (68%), dry eye (47%), uveitis (37%) and scleral thinning (5%). At the final follow-up visit, the mean loss of Snellen visual acuity was 1.11±2.90 lines and vision of 6/9 or better was maintained in 53% of patients. None of the patients had evidence of symptomatic metastasis (non-imaged) or melanoma-related mortality.

CONCLUSIONS

¹⁰⁶Ru plaque treatment for iris melanoma was highly effective a high tumour control, no tumour recurrences and a relatively a low complication rate.

Results in Combined Cataract Surgery With Prosthetic Iris Implantation in Patients With Previous Iridocyclectomy for Iris Melanoma

PURPOSE

To present visual and functional results following implantation of iris prosthesis combined with cataract surgery in eyes with previous iridocyclectomy for iris melanoma or presumed iris melanoma.

DESIGN

Retrospective noncomparative case series.

METHODS

Sixteen patients (16 eyes) with iris defects after iridocyclectomy for iris melanoma in 15 cases and iris adenoma in 1 case underwent prosthetic iris device implantation surgery. Prosthetic iris implantation was combined with phacoemulsification and intraocular lens (IOL) implantation. The visual acuity, subjective glare and photophobia reduction, anatomic outcome, and complications were reviewed.

RESULTS

Best-corrected visual acuity was improved in 13 eyes (81.25%), remained stable in 2 eyes (12.25%), and decreased in 1 eye (6.25%). Photophobia and glare improved in every case except for 1 (93.75%). Notably, after surgery 12 patients (75.00%) reported no photophobia and 10 patients (62.50%) reported no glare. The median postoperative follow-up was 29.5 months, with a minimum of 5 months and a maximum of 189 months. All iris devices were in the correct position, and all eyes achieved the desired anatomic result. The IOL optic edges were covered in all areas by either residual iris or opaque portions of a prosthetic iris device.

CONCLUSIONS

In patients who have undergone previous iridocyclectomy for presumed iris melanoma, combined cataract surgery and iris prosthesis placement, with or without iris reconstruction, can lead to visual improvement as well as reduction of both glare and photophobia.

Nevoid iris melanoma, case report

CASE REPORT

The case is presented of a patient with diagnosis of iris nevus in the left eye in youth with a poor follow-up, who referred a decreased visual acuity in that eye. A hyphaema and a 3×4×3mm nodule with irregular pigmentation was observed. Excision of the tumour and histological analysis confirmed the suspicion of iris melanoma in stage Ia.

DISCUSSION

Despite the low grade malignancy of iris melanoma and the low frequency of transformation of iris nevus into melanoma, a follow-up is required for its early diagnosis and treatment.

UNTREATED IRIS MELANOMA COMPLICATED BY HYPHEMA AND UNCONTROLLED GLAUCOMA RESPONSIVE TO IODINE-125 BRACHYTHERAPY

PURPOSE

To describe a case of iris melanoma for which a patient refused treatment for 15 years, and the complications that resulted.

METHODS

Single case report.

RESULTS

A 52-year-old white man was evaluated for a suspicious pigmented lesion of the left iris. He was followed closely with serial examinations and ultrasound biomicroscopy, and he refused therapy when the lesion showed growth 15 years after presentation. The patient subsequently developed recurrent hyphema, intraocular pressure up to 55 mmHg, and glaucomatous optic neuropathy. He eventually underwent iodine-125 brachytherapy resulting in tumor regression and improvement of intraocular pressure.

CONCLUSION

Untreated iris melanoma can develop complications such as recurrent hyphema and glaucoma with irreversible optic nerve damage. Treatment of slow-growing iris melanoma must be considered to prevent complications.

Rare presentations of primary melanoma and special populations: a systematic review

A subset of patients with melanoma present in rare and unique clinical circumstances requiring specific considerations with respect to diagnostic and therapeutic interventions. Herein, we present our review of patients with: (1) primary mucosal melanoma of the head and neck, gastrointestinal, and genitourinary tracts; (2) primary melanoma of the eye; (3) desmoplastic melanoma; (4) subungual melanoma; (5) melanoma in special populations: children, nonwhites, as well as a discussion of familial melanoma.

Proton beam therapy for presumed and confirmed iris melanomas: a review of 36 cases

BACKGROUND

To report the clinical features and outcomes of iris melanomas treated by proton beam therapy.

MATERIALS AND METHODS

A retrospective study was conducted at the Croix-Rousse University Hospital of Lyon, Department of Ophthalmology, in 36 patients treated by proton beam therapy for presumed (n = 29) and confirmed (n = 7) iris melanomas between July 1997 and October 2010. Ciliary body melanomas with iris involvement were excluded. The patients' mean age was 54.4 years (range, 22-82 years). The average tumor diameter was 3.8 mm (range, 2.5-8.0). The iridocorneal angle was invaded by the tumor in 47% of cases (n = 17), the ciliary body in 17% of cases (n = 6), and the sclera in 3% (n = 1). Raised intraocular pressure was present before treatment in 11.1 % of cases (n = 4). Tumor biopsy was performed in 19% of cases (n = 7). Four patients had undergone an initial incomplete surgical excision of tumor before radiotherapy. Surgical preparation of the eye with tantalum ring positioning had been performed in all cases 3-4 weeks before irradiation. The prescribed dose was 60 Cobalt Gray Equivalent (CGE) of proton beam radiotherapy delivered in four fractions on four consecutive days.

RESULTS

The median follow-up was 50 months (mean 60.5, range 15-136). One patient (2.7%) was lost to follow-up. None of the patients showed tumor progression, local recurrence, or metastasis. None of the patients required secondary enucleation. Cataract was developed in 62% of patients, glaucoma in two cases (6%) after irradiation, and hyphema with the aggravation of pre-existing glaucoma in one patient. No patients developed neovascular glaucoma.

CONCLUSIONS

Proton beam therapy appears to be the treatment of choice for the conservative treatment of iris melanomas with excellent tumor control and an acceptable rate of complications. Longer follow-up studies on a larger series is necessary to consolidate these results.

Ocular melanoma: an overview of the current status

Ocular melanoma is the second most common type of melanoma after cutaneous and the most common primary intraocular malignant tumor in adults. Large majority of ocular melanomas originate from uvea, while conjunctival melanomas are far less frequent. Incidence of uveal melanoma has remained stable over last three decades. Diagnosis is in most cases established by clinical examination with great accuracy. Local treatment of uveal melanoma has improved, with increased use of conservative methods and preservation of the eye, but survival rates have remained unchanged. Recent advances in cytogenetics and genetics enhanced prognostication and enabled to determine tumors with high metastatic potential. However, due to lack of effective systemic therapy, prognosis of patients with metastasis remains poor and metastatic disease remains the leading cause of death among patients with uveal melanoma. Conjunctival melanoma is rare, but its incidence is increasing. It mostly occurs among white adults. In majority of cases it originates from preceding primary acquired melanosis. Current standard treatment for conjunctival melanoma is wide local excision with adjuvant therapy, including brachytherapy, cryotherapy and topical application of chemotherapeutic agent. Rarity of this tumor limits conduction of controlled trials to define the best treatment modality. As well as for uveal melanoma, prognosis of patients with metastasis is poor because there is no effective systemic therapy. Better understanding of underlying genetic and molecular abnormalities implicated in development and progression of ocular melanomas provides a great opportunity for development of targeted therapy, which will hopefully improve prognosis of patients with metastatic disease.

Surgical treatment of iris and ciliary body melanoma: follow-up of a 25-year series of patients

PURPOSE

To evaluate outcome of surgical resection of iris and irido-ciliary melanomas.

METHOD

Retrospective analysis of all cases treated in Denmark 1975-1999 with clinical follow-up in 2002 and death certificate analysis in 2008. A quality of life questionnaire was completed at follow-up.

RESULTS

A total of 53 patients were identified. Of these, 47 were examined at follow-up. Median observation time was 7.15 years (range 0.3-27.4 years). Five patients had died of nonmelanoma causes, and one could not be reached because of immigration. None of the patient had melanoma metastases, and none had died of melanoma-related causes. Only one patient had a local recurrence, which was successfully treated by cryotherapy. The quality of life-related questions demonstrated that most patients (40) suffered from photophobia, and eight patients had changed their driving habits, not driving at night time. However, none had changed job as a consequence of the surgical treatment. Only two patients were emotionally affected by the diagnosis of iris melanoma.

CONCLUSION

Resection of small iris and irido-ciliary melanomas is a safe and efficient procedure, provided that strict diagnostic and surgical procedures are followed and the preoperative intraocular pressure is normal.

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.

Plaque radiotherapy for residual or recurrent iris melanoma after surgical resection in 32 cases

PURPOSE

To evaluate plaque radiotherapy for management of residual or recurrent iris melanoma after surgical resection.

DESIGN

Retrospective, nonrandomized interventional case series.

PARTICIPANTS

We included 32 patients with residual or recurrent iris melanoma after surgical resection.

INTERVENTION

Custom designed iodine-125 plaque radiotherapy.

MAIN OUTCOME MEASURES

Tumor control, recurrence, poor visual acuity, enucleation, metastasis, and radiation complications.

RESULTS

There were 32 eyes with residual (n = 12) or recurrent (n = 20) iris melanoma after surgical resection that were treated with iodine-125 plaque radiotherapy. The residual melanoma was evident clinically in 3 cases and histopathologically in 9; plaque radiotherapy was delivered at a mean interval of 2 months after resection. For the recurrent cases, the mean interval from initial tumor resection to detection of recurrence was 58 months, at which time plaque radiotherapy was applied. For all cases, the mean tumor basal diameter was 6 mm (range, 1-13) and thickness was 2 mm (range, 0.8-4.0) at the time of radiotherapy. Anterior chamber seeding was present in 26 (81%) eyes and glaucoma in 11 (34%) eyes. Visual acuity at presentation was good (20/20-20/50) in 27 (84%), intermediate (20/60-20/150) in 3 (9%), and poor (≤20/200) in 2 eyes (6%). At 6 years after plaque radiotherapy, outcomes included complete tumor control in 87%, poor visual acuity in 9%, enucleation in 13% (for reasons of tumor recurrence [n = 3] and severe glaucoma [n = 1]), and metastasis in 3%. At 6 years, radiation complications included corneal epitheliopathy in 6%, scleral necrosis in 3%, cataract in 53%, elevated intraocular pressure (from tumor or radiotherapy) in 19%, and macular edema in 6%.

CONCLUSIONS

Iodine-125 plaque radiotherapy is effective in the management of residual or recurrent iris melanoma after surgical resection, providing tumor control in 87% of patients at 6 years and avoiding enucleation in most cases.

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.

Plaque radiotherapy treatment with ruthenium-106 for iris malignant melanoma

PURPOSE

To report the results of ruthenium-106 plaque radiotherapy for iris malignant melanoma.

METHODS

A retrospective study of 15 patients with pure iris melanoma treated with ruthenium-106 plaque radiotherapy from June 1998 to June 2006. The main outcome measures were tumour control and ocular complications.

RESULTS

Of the 15 patients, 8 had biopsy-proven melanoma (6 incisional and 2 excisional biopsies). In the remaining seven patients enlargement of the lesion was documented. The median follow-up was 96 months (ranging from 14 months to 12 years). Common radiation-related complications included cataract in 9 (60%) patients, dry eyes in 3 (20%) patients and elevated intraocular pressure in 4 (27%) patients. Vision was preserved in 80% of patients. Local tumour control was obtained in all patients.

CONCLUSIONS

Ruthenium-106 plaque radiotherapy is an effective treatment for primary malignant iris melanoma, resulting in excellent local control with preservation of vision. Main complications included cataract, dry eyes, and glaucoma.

Management of iris melanomas with 125Iodine plaque radiotherapy

PURPOSE

To report the experience of the Princess Margaret Hospital/University Health Network with the treatment of iris melanoma (IM) with (125)Iodine plaque brachytherapy.

DESIGN

Retrospective noncomparative case series.

METHODS

All cases of IM submitted to (125)Iodine plaque radiotherapy were included. Patients' demographic, clinical, management, and follow-up data were reviewed. Outcome measures included rates of tumor control, eye preservation, systemic metastases, and brachytherapy-related complications.

RESULTS

Fourteen IMs were included in the study. All patients had blue/green irises. Mean largest basal dimension and thickness were 7.1 +/- 2.1 mm (range, 4.0 to 11.5 mm) and 2.2 +/- 0.8 mm (range, 1.0 to 3.5 mm), respectively. Ten patients (71%) had seeding and 2 (14%) had glaucoma at presentation. Median follow-up was 26.6 +/- 19.5 months (range, 6 to 72 months). Tumor control was achieved in 100% of the cases and no eye was enucleated because of radiation-induced complications. At last visit, all patients were alive and free of metastasis. Final visual acuity was the same as or better than before treatment in 9 patients (75%). Cataract was the most common complication (8; 75%), followed by persistent glaucoma (2; 17%) and anterior uveitis (1; 8%). No other significant complication was seen during the follow-up period.

CONCLUSIONS

Plaque radiotherapy is a safe and effective conservative treatment option for IM, although cataract is a common, yet treatable, complication. This treatment scheme circumvents an intraocular procedure and may avoid the dissemination of malignant cells, and provides a margin of safety in the treatment of clinically undetectable disease.

Local environmental influences on uveal melanoma: vitreous humor promotes uveal melanoma invasion, whereas the aqueous can be inhibitory

BACKGROUND

Uveal melanomas of the choroid and ciliary body are aggressive tumors causing the death of approximately 50% of patients. In contrast, iris melanomas only infrequently metastasize; why these differences exist is not known. The local environment can regulate cancer growth and development, and it is probable the aqueous and vitreous humors have an important role in regulating uveal melanoma behavior.

METHODS

To explore this possibility cultures of uveal melanoma were exposed to aqueous and vitreous and the effects investigated using invasion and proliferation assays. ChemiArrays (Chemicon International, Temecula, Calif) were performed to determine which regulatory factors might influence the process.

RESULTS

The vitreous universally promoted uveal melanoma invasion, whereas the aqueous mainly had no effect or was inhibitory. Tumor location, and the baseline invasion of the melanoma, affected the ability of aqueous and vitreous from different patients to regulate invasive behavior. Proliferation was not significantly altered as a result of exposure to the aqueous or vitreous. The ability of the humors to regulate uveal melanomas may involve TIMP-2, TIMP-3, and TGF-beta2, as high expression was found by ChemiArray analysis and there were differences in the levels of the regulators in the aqueous compared with the vitreous.

CONCLUSIONS

The findings suggest that in situ uveal melanoma development reflects an interaction between the tumor and the environment of the eye. Exposure to the aqueous would therefore contribute to the benign nature of iris melanomas, whereas potential interaction with the vitreous appears to promote the aggressive behavior of posterior uveal melanomas.

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.

Diffuse iris melanoma: Report of a case with review of the literature

Diffuse iris melanoma is an uncommon variant of anterior uveal melanoma. It is characterized by heterochromia and unilateral glaucoma secondary to angle invasion, and can be difficult to diagnose. We present a patient who had been managed for left-sided raised intraocular pressure with latanoprost eye drops for 12-months and pigmentary changes were subsequently noted. On referral to the Ocular Oncology Unit, Sydney, iris melanoma was suspected and confirmed on iridectomy, and the eye was eventually enucleated.

Malignant melanoma in the 21st century, part 2: staging, prognosis, and treatment

Critical to the clinical management of a patient with malignant melanoma is an understanding of its natural history. As with most malignant disorders, prognosis is highly dependent on the clinical stage (extent of tumor burden) at the time of diagnosis. The patient's clinical stage at diagnosis dictates selection of therapy. We review the state of the art in melanoma staging, prognosis, and therapy. Substantial progress has been made in this regard during the past 2 decades. This progress is primarily reflected in the development of sentinel lymph node biopsies as a means of reducing the morbidity associated with regional lymph node dissection, increased understanding of the role of neoangiogenesis in the natural history of melanoma and its potential as a treatment target, and emergence of innovative multimodal therapeutic strategies, resulting in significant objective response rates in a disease commonly believed to be drug resistant. Although much work remains to be done to improve the survival of patients with melanoma, clinically meaningful results seem within reach.

Proton beam therapy for iris melanomas

AIMS

To describe the results in terms of local control, eye preservation and systemic evolution of iris melanomas treated by proton beam irradiation.

METHODS

Retrospective review of the charts of patients with iris melanoma treated by proton beam therapy between April 1998 and September 2002. Ciliary body melanomas with iris involvement or tumours with extrascleral invasion were excluded. Treatment consisted of 60 Gy of proton beam irradiation delivered in four fractions to the tumour volume.

RESULTS

A total of 21 patients were treated, median follow-up of 33 months (8-72 months). 15 patients presented a lesion with documented growth. The median clinical diameter was 5 mm (2-8 mm), the median ultrasound diameter 4.8 mm (2-7.7 mm) The patients were 6% T1, 57.1% T2, and 14.3% T3 all N0M0. The iridocorneal angle was invaded by the tumour in 71.4% of patients. At the end of follow-up, all patients were alive with no proven metastatic disease except one patient with suspicious liver lesions. None of the patients showed tumour progression or ocular relapse. The tumour response at 2 years was a flat lesion for 6.3% of cases, partial regression in 75% and stable in 18.8%. None of the patients required secondary enucleation. The main complication was cataract (45% within 24 months of treatment). Raised intraocular pressure was observed in 15% of patients but no neovascular glaucoma.

CONCLUSIONS

Proton beam therapy shows potential utility for selected cases of localised iris melanomas allowing excellent local tumour control and eye preservation. Further follow-up on larger series is needed to confirm these results.

Sympathetic ophthalmia after surgical resection of iridociliary melanoma. A case report

BACKGROUND

We report a case of sympathetic ophthalmia with systemic findings following resection of a malignant melanoma of the iris and ciliary body, and describe the treatment and clinical outcome.

METHODS

A 49-year-old man underwent sector iridocyclectomy of a malignant iridociliary melanoma of the right eye. Five weeks later, he was diagnosed with sympathetic ophthalmia. Snellen's best-corrected visual acuity, fluorescein angiography, electroretinography, cerebrospinal fluid analysis and audiometry were performed. High-dose systemic steroid and immunosuppressive (cyclosporine and azathioprine) therapy was prescribed. Two months later chorioretinitis and macular edema persisted, and intravitreous triamcinolone was injected into the right eye.

RESULTS

Five weeks after resection of an iridociliary melanoma, our patient had reported acute bilateral vision loss. Visual acuity was hand motion in both eyes. Examination showed bilateral granulomatous uveitis, diffuse choroiditis with Dalen-Fuchs nodules, papillitis and vitritis. On fluorescein angiography multiple hyperfluorescent dots, which coalesced in areas of exudative retinal detachment, were evident. The patient presented meningismus with pleocytosis on cerebrospinal fluid analysis, and sensorineural deafness. Sympathetic ophthalmia was diagnosed. High-dose intravenous steroids followed by oral prednisone at a tapering dose and immunosuppressive agents (cyclosporine and azathioprine), topical steroids in both eyes and intravitreal steroids in the right eye were administered. Phacoemulsification and intraocular lens implantation were performed to treat a dense cataract of the right eye. After 24 months of follow-up, best-corrected visual acuity was 20/200 in the right eye and 20/25 in the left; no signs of intraocular inflammation were observed and neurological signs had resolved. Low maintenance doses of systemic steroids and immunosuppressive agents were administered up to month 18 of follow-up to avoid recurrence.

CONCLUSIONS

Sympathetic ophthalmia is a rare, but severe disease that can occur after resection of iridociliary melanoma. High-dose steroid therapy and supplementation with immunosuppressive agents early in the course of the disease was effective in resolving the condition.

Proton beam therapy for iris melanoma: a review of 15 cases

AIM

To report results of proton beam therapy for iris melanoma.

METHODS

A retrospective case series of 15 patients with nonresectable iris melanomas treated with proton beam therapy between August 1998 and August 2004. The main outcome measures were (1) local tumour control, (2) complications, and (3) eye retention.

RESULTS

Of the 15 cases, 11 patients showed documented growth (including two cases of local recurrence following iridocyclectomy) while a further three cases were biopsy-proven melanoma. One patient presented with a newly acquired vascular nodule of the iris associated with angle seeding and glaucoma. Tumour control at mean follow-up of 34 months was 93% (14 of 15 eyes). Common complications included glaucoma in 53% (five patients had glaucoma prior to irradiation), dry eye (27%) and cataract in three patients (20%). Eye retention was possible in 80% (12 cases).

CONCLUSION

Proton beam therapy is an effective treatment for cases of nonresectable iris melanoma. The major complications are cataract and glaucoma.

Iris melanoma: a case report and review

Iris melanoma is a rare ocular tumour, which can be detected early in its development. This tumour is almost always unilateral and arises usually from a pre-existing naevus. Failure to detect it may be associated with morbid ocular and systemic complications, yet there are successful therapies to treat this condition, if detected early. The patient presented to the eye clinic with symptoms of occasional, brief loss of vision in his left eye for a few weeks prior to his visit. Slit-lamp examination revealed a mass on the inferior part of the iris of the left eye. Intra-ocular pressure measurements were RE 15 mmHg and LE 38 mmHg. It was found that a tumour had spread throughout the iris stroma and invaded the anterior chamber angle. Although enucleation would have been the treatment of choice in the past, the trend today in the treatment of a growing, large circumscribed iris tumour is to excise it. It was successfully excised by irido-cyclo-trabeculectomy.