The Effectiveness of Ultrasound Biomicroscopic and Anterior Segment Optical Coherence Tomography in the Assessment of Anterior Segment Tumors: Long-Term Follow-Up

Intraocular Pressure and Cup-to-Disc Ratio Asymmetry in Diagnosing Iris Melanoma

Purpose

Distinguishing an iris melanoma from an iris nevus can be challenging as few clinical features other than documented growth are helpful in making the diagnosis. In this study, we compared the presenting intraocular pressure (IOP) and cup-to-disc ratio (CDR) between affected and unaffected eyes in patients with iris melanoma and iris nevus.

Patients and methods

This was a single-institution retrospective case series of patients treated for iris melanoma and iris nevus from January 2013 to October 2022. Thirty-nine subjects with iris melanoma and forty age-matched patients with iris nevus were included. We analyzed the difference in IOP, CDR, and diagnosis of glaucoma between affected and unaffected eyes in patients with iris melanoma and control iris nevus cohort.

Results

The average IOP for eyes with iris melanoma and iris nevus was 18.8±6.1 mmHg and 14.6±3.5 mmHg (P<0.001), respectively. The average CDR was 0.36±0.27 and 0.24±0.14 (P=0.02), respectively. The average IOP of the contralateral unaffected eye in iris melanoma patients was 16.3±3.5 mmHg, significantly less than the affected eye (P=0.03). The average CDR of the contralateral unaffected eye in iris melanoma was 0.25±0.15, which was trending towards being less than the affected eye (P=0.05). There was no difference in the average IOP (P=0.89) or average CDR (P=0.49) between the affected and unaffected eye in patients with iris nevus.

Conclusion

We demonstrate that patients with iris melanoma are more likely to have greater IOP and CDR in the affected eye compared to the unaffected eye, and a diagnosis of unilateral glaucoma than eyes with iris nevus. Patients with iris melanoma had greater IOP asymmetry between the affected and unaffected eye. Therefore, IOP and CDR asymmetry may suggest a diagnosis of iris melanoma.

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.

Anterior segment swept-source optical coherence tomography and ultrasound biomicroscopy in iris and ciliary body lesions

OBJECTIVES

Differentiation of iris and ciliary body lesions as benign or malignant and cystic or solid is important. The aim of this study was to compare anterior segment swept-source optical coherence tomography (AS SS-OCT) and ultrasound biomicroscopy (UBM) findings in iris and ciliary body tumors.

RESEARCH DESIGN AND METHODS

Forty-two eyes of 38 cases with iris and ciliary body tumors imaged with UBM and AS SS-OCT between September 2018 and September 2023 were evaluated retrospectively.

RESULTS

Of 42 eyes, 14 had melanoma, 14 iris pigment epithelial (IPE) cysts, 7 nevi, 3 Lisch nodules, 2 iris stromal cysts, 1 pars plana cysts, and 1 iris mammillations. An equivalent (100%) visualization of the anterior tumor margin was obtained with both techniques. Compared to AS SS-OCT, UBM was superior for posterior margin visualization in melanocytic tumors and IPE cysts. Bland-Altman plots demonstrated good agreement between UBM and AS SS-OCT for melanocytic tumors < 2.5 mm in base diameter and < 2 mm in thickness.

CONCLUSIONS

Although, UBM is the gold standard for ciliary body and iridociliary tumors. AS SS-OCT should be considered as an excellent alternative to UBM, especially in minimally elevated iris lesions.

Imaging of Anterior Segment Tumours: A Comparison of Ultrasound Biomicroscopy Versus Anterior Segment Optical Coherence Tomography

Anterior segment tumours of the eye are relatively rare but can pose significant morbidity and mortality. We conducted a literature review to compare the performance of ultrasound biomicroscopy to anterior segment optical coherence tomography in the imaging of these tumours. A total of seven studies were included accounting for a cumulative 1,114 eyes. Ultrasound biomicroscopy has traditionally formed, and remains, the mainstay of tumour imaging due to its ability to penetrate pigmented lesions and delineate the posterior border of tumours, and the current evidence supports this.

Symptomatic familial primary iris cysts at the pupillary margin in three consecutive generations: A case series

Case series purpose

Iris cysts are uncommon lesions, most of them are iris pigment epithelial (IPE) cysts which typically manifest in adults as unilateral single cysts, are typically asymptomatic and rarely require treatment. The most frequent location of IPE cysts is the iris periphery and the iridociliary sulcus, whereas pupillary cysts are rare. This observational case series aims to describe a unique occurrence of bilateral pupillary IPE cysts in three consecutive generations of a single family.

Observations

The series describes eight patients of a single family with no consanguineous marriage. All patients have IPE cysts with remarkable abnormally-shaped pupils. The patients were examined at the slit-lamp and imaged with anterior segment optical coherence tomography. Three brothers (14, 19 and 28 years old) were symptomatic and suffered from hemeralopia and reduced visual acuity. ND-YAG laser was successful in relieving the symptoms in the two younger brothers. No recurrence or refill of the cysts occurred after laser application and no intra- or ppostoperative complications were observed during a 9-month follow-up. The older family members showed spontaneously shrunken IPE cysts.

Conclusions and Importance

IPE cysts are considered idiopathic with an unclear origin. The rare familial incidence of the cysts suggests an autosomal dominant heredity pattern. Many theories were proposed to explain the origin of cysts and none is conclusive. Their principal clinical significance is their similarity to pigmented iris tumors, but they might also cause visual symptoms. Treatment modalities vary from less invasive chemical compounds and ND: YAG laser application to more invasive surgical procedures with disparate efficacy and safety. In the case of multiple cysts, examination of other family members is worthy even when asymptomatic and cardiac consultation of affected patients is warranted as IPE cysts may proclaim a coexisting cardiovascular abnormality, such as familial aortic dissection.

Ultrasound in ocular oncology: Technical advances, clinical applications, and limitations

Due to its accessibility and ability for real-time image acquisition of ocular structures, ultrasound has high utility in the visualization of the eye, especially in ocular oncology. In this minireview, we summarize the technical rationale and applications of ultrasound modalities, A-scan, B-scan, high-frequency ultrasound biomicroscopy (UBM), and Doppler measurement. A-scan ultrasound uses a transducer of 7-11 MHz, making it useful for determining the echogenicity of ocular tumors (7-8 MHz) and measuring the axial length of the eye (10-11 MHz). B-scan ultrasound operates at 10-20 MHz, which can be used for measuring posterior ocular tumors while UBM operates at 40-100 MHz to evaluate anterior ocular structures. Doppler ultrasonography allows for the detection of tumor vascularization. While ultrasonography has numerous clinical applications due to its favorable penetration compared with optical coherence tomography, it is still limited by its relatively lower resolution. Ultrasound also requires an experienced sonographer due to the need for accurate probe localization to areas of interest.

Spectrum of AS-OCT features of ocular surface tumors and correlation of clinico-tomographic features with histopathology: a study of 70 lesions

PURPOSE

To assess the correlation between clinical and anterior segment optical coherence tomographic (AS-OCT) details and histopathological changes in various ocular surface lesions.

METHODS

Prospective case series of 70 lesions in 65 patients.

RESULTS

AS-OCT revealed epithelial changes in OSSN (n = 19; 44%), squamous papilloma (n = 3; 60%), nevus (n = 1; 33%), epithelial hyperplasia (n = 1; 33%), granular dystrophy (n = 1; 100%) and granulation tissue (n = 1; 100%); subepithelial changes in chronic inflammation (n = 4, 100%), lymphoma (n = 3; 100%) and arteriovenous malformation (n = 1; 100%); combined epithelial and subepithelial changes in OSSN (n = 24; 56%), squamous papilloma (n = 2; 40%), PEH (n = 3; 100%), nevus (n = 2; 67%), epithelial hyperplasia (n = 2; 67%), solar elastosis (n = 1; 100%), lobular capillary hemangioma (n = 1; 100%) and sebaceous carcinoma (n = 1; 100%). Epithelial involvement on AS-OCT paralleled the histopathological findings in 98% (n = 69) and subepithelial involvement in 83% (n = 58). The correlation of clinico-tomographic diagnosis with histopathology diagnosis was seen in 77% (n = 54) lesions. Sensitivity and specificity of AS-OCT as a diagnostic tool for detection of epithelial involvement were 100% and 92% and for subepithelial involvement was 98% and 100%, respectively.

CONCLUSION

The correlation between AS-OCT and histopathology features determining epithelial and subepithelial involvement is excellent. It is a useful adjunctive tool for the diagnosis of ocular surface lesions.

Clinical Features of Iris Cysts in Long-Term Follow-Up

This study evaluated the characteristics and clinical course of patients with iris cysts in the long-term follow-up (24–48 months). We retrospectively analyzed the medical records of 39 patients with iris cysts (27 women and 12 men). Age, visual acuity, intraocular pressure (IOP), slit-lamp evaluation, and ultrasound biomicroscopy images were assessed. The mean age at diagnosis was 40.6 ± 17.48 years. Thirty (76.9%) cysts were peripheral, five (12.8%) were located at the pupillary margin, two (5.1%) were midzonal, and two (5.1%) were multichamber cysts extending from the periphery to the pupillary margin. A total of 23 (59%) cysts were in the lower temporal quadrant, 11 (28.2%) were in the lower nasal quadrant, and 5 (12.8%) were in the upper nasal quadrant. Cyst size was positively correlated with patient age (rs = 0.38, p = 0.003) and negatively correlated with visual acuity (rs = −0.42, p = 0.014). Cyst growth was not observed. The only complication was an increase in IOP in three (7.7%) patients with multiple cysts. The anatomical location of the cysts cannot differentiate them from solid tumors. The vast majority of cysts are asymptomatic, do not increase in size, and do not require treatment during long-term follow-up.