Malignancy in the blind painful eye--report of two cases and literature review

Prevalence of intraocular tumours detected by ultrasonography in eyes with opaque media

OBJECTIVE

To study the prevalence of intraocular tumours detected by screening ultrasonography in eyes with opaque media.

METHODS

Retrospective review of B-scan ultrasonography in eyes with opaque media and diagnosis of blindness or phthisis between January 1, 1994, and December 31, 2013. Ultrasounds for diagnostic purposes in acute endophthalmitis, retinal detachment, or vitreous hemorrhage were excluded.

RESULTS

There were 119 blind eyes with opaque media examined with B-scan ultrasonography. Mean patient age was 59 years, with visual acuity of hand motions or worse in 89 eyes (74.8%), elevated intraocular pressure in 23 eyes (19.3%), and pain in 30 eyes (25.4%). Follow-up was ≥1 year in 69 eyes (58%) with a mean 64 months (median, 56 months; range, 12-129 months). Of these 69 eyes, ultrasound frequency was more often than annual in 2 eyes (2.9%), annual in 2 eyes (2.9%), every 13-60 months in 43 eyes (62%), every 61-120 months in 19 eyes (27.5%), and less often than every 120 months in 3 eyes (4.3%). Sixteen eyes with opaque media only received ultrasound at presentation, and 6 eyes had screening ultrasonography only prior to evisceration or enucleation. No intraocular tumours were detected in any eye during the study period.

CONCLUSIONS

In this series, no intraocular tumours were detected by screening ultrasonography in eyes with opaque media. Larger studies with long-term follow-up are required to determine the utility and cost-effectiveness of serial ultrasonography monitoring. Ultrasound may have its highest utility in the setting of initial evaluation, clinical change, and preoperative work-up to avoid evisceration in the setting of occult malignancy.

[Secondary open-angle glaucoma: uveitic secondary glaucoma, steroid-induced glaucoma, posttraumatic and postoperative glaucoma, tumor-related glaucoma and glaucoma due to elevated episcleral venous pressure]

Secondary open-angle glaucomas are a heterogeneous group of diseases in which a variety of pathophysiological mechanisms result in an elevation of intraocular pressure (IOP). In contrast to primary open-angle glaucoma in many cases besides IOP reduction a causal treatment is possible. This article is the second part of a review of the more frequently encountered forms of secondary open-angle glaucoma. Uveitic glaucoma, steroid-induced glaucoma, posttraumatic and postoperative glaucoma, glaucoma due to intraocular tumors and caused by elevated episcleral venous pressure are covered. The underlying pathophysiological mechanisms, characteristic clinical findings and treatment options are discussed.

Sekundärglaukome im Rahmen retinaler Erkrankungen

Zusammenfassung: Eine Vielzahl retinaler Erkrankungen kann zur Entwicklung eines Glaukoms führen. Die häufigste Form dieser Sekundärglaukome sind die Neovaskularisationsglaukome, die den Hauptteil dieser Übersicht bilden. Dabei handelt sich um ein schwerwiegendes Krankheitsbild, dass in mehreren Stadien verläuft, wobei die Prognose mit zunehmendem Stadium ungünstiger und die Therapie herausfordernder wird. Neben Pathogenese und Diagnostik wird daher ein Schwerpunkt wird auf die Früherkennung und eine an das jeweilige Krankheitsstadium angepasste Therapie gelegt. Auch seltenere Sekundärglaukome im Rahmen intraokularer Tumore sowie Glaukome assoziiert mit einer Netzhautablösung (Schwartz-Matsuo Syndrom) und Glaukome, die im Spätverlauf nach unkomplizierter Vitrektomie auftreten, werden in dieser Übersicht diskutiert. Abstract: A variety of retinal diseases can lead to the development of glaucoma. The most common type of these secondary glaucomas is neovascular glaucoma (NVG), which constitutes the main subject of this review. NVG is a severe condition with a poor prognosis. Treatment gets increasingly challenging as the disease progresses. Thus emphasis is put on early diagnosis and an stage adjusted therapy. Other less frequent secondary glaucomas, such as glaucomas due to intraocular tumors or associated with retinal detachment (Schwartz-Matsuo syndrome) and late onset open-angle glaucomas after uncomplicated vitrectomy are covered.

Necrotic uveal melanoma presenting as orbital cellulitis with intraocular hemorrhage: A case report

Purpose

To report a case of necrotic uveal melanoma presenting as orbital cellulitis with an intraocular hemorrhage.

Observations

A 61 year-old non-verbal male presented with a two-week history of right eyelid swelling and erythema unresponsive to antibiotics. In addition to these signs of orbital cellulitis, he presented with an opaque media precluding fundus visualization. He was later found to have a collar-button shaped mass consistent with uveal melanoma on B scan ultrasonography during an exam under anesthesia. The patient underwent enucleation with histopathology confirming a necrotic uveal melanoma.

Conclusion and Importance

This case demonstrates how necrotic uveal melanoma can present as orbital cellulitis and the importance of keeping the diagnosis on the differential.

Malignant melanoma of conjunctiva: Diagnosis on fine-needle aspiration cytology

Malignant melanoma of conjunctiva is an uncommon malignancy. The diagnosis is suspected clinically and confirmed on pathological examination. We present a case of a 63-year-old female with previous history of pigmented lesion in the right eye and subsequently diagnosed as malignant melanoma of right conjunctiva and cornea on fine-needle aspiration cytology and histopathology.

Unsuspected and misdiagnosed posterior uveal melanoma following enucleation and evisceration in Ottawa-Gatineau

OBJECTIVE

There is a gap in the recent literature on the topic of clinically misdiagnosed and unsuspected posterior uveal melanomas (PUM) with a calculation of the frequency of these events for a specific geographical area. As the only ophthalmic pathology laboratory in our region, we determined the rate of these outcomes over a 16-year period.

METHODS

We retrospectively reviewed 2558 consecutive ophthalmic pathologic specimens in the Ottawa-Gatineau region, of which 334 were eviscerations and 227 were enucleations. We calculated the frequency of clinically misdiagnosed PUM and of clinically unsuspected PUM. We also determined the rate of uveal melanoma undergoing enucleation.

RESULTS

From 100 diagnoses of PUM, 2 (2.0%) cases were clinically unsuspected and 2 (2.0%) cases were clinically misdiagnosed. The rate of uveal melanoma undergoing enucleation was 5.6 cases per 1 000 000 of population per annum. From 2009 to 2012, the incidence of this event was 3.8 cases per 1 000 000 per annum, which was lower than the previous three 4-year increments.

CONCLUSIONS

We present the first and only single-centred, population-based data on the rates of unsuspected PUM and of clinical misdiagnosis of PUM in the era of modern diagnostic imaging. Our rate of clinical misdiagnosis is within the range of recent reports of this event. Unsuspected PUM occurred at a rate substantially lower than previously published. The incidence of uveal melanoma undergoing enucleation has decreased despite an increase in population, which reflects a shift in management from enucleation to radiation therapy.

UVEAL MELANOMA EXTENSION TO THE OPTIC CHIASM

PURPOSE

Case report describing a patient who developed intracranial extension of a uveal melanoma through the optic nerve.

METHODS

We reviewed the patient's medical history and images. A 41-year-old woman who was blind in one eye had a uveal melanoma that extended through the optic nerve into the optic chiasm and involved the hypophysis. The patient then developed metastasis.

RESULTS

The patient developed uveal melanoma extension into the optic chiasm through the optic nerve resulting in a visual field defect in the fellow eye.

CONCLUSION

Uveal melanoma extension through the optic nerve is a devastating complication, which occurs anywhere from 0.6% to 3.7% in patients with uveal melanoma. If enucleation of the affected eye is performed, a representative portion of the optic nerve should be excised to decrease the risk of extension. Patients with phthisical eyes should undergo appropriate imaging techniques to prevent a missed diagnosis of optic nerve involvement.

Uveal melanoma presenting as cataract and staphyloma

Blind eyes can harbor a choroidal melanoma. We report a case of uveal melanoma presenting as staphyloma and complicated cataract in a 45-year-old female. The left eye was blind for six months. She underwent comprehensive ocular examination but fundus examination was precluded due to total cataract. The ultrasound of the eye showed a large mass filling the superior, nasal and inferonasal vitreous cavity with high surface reflectivity and low to moderate internal reflectivity. Magnetic resonance imaging (MRI) confirmed the diagnosis of choroidal melanoma. The patient underwent extended enucleation and histopathology was consistent with uveal melanoma.