Population-based incidence of intraocular tumours in Olmsted County, Minnesota

BACKGROUND/AIMS

To determine population-based incidence of intraocular tumours in Olmsted County, Minnesota.

METHODS

Record review of the Rochester Epidemiology Project medical record linkage system from 1 January 2006 to 31 December 2015 for patient demographics, tumour type by clinical diagnosis and presence or absence of confirmation by histopathology. The incidence rate of any intraocular tumour and of each tumour type was calculated per million person-years. Poisson regression analysis was used to analyse changes in incidence over time.

RESULTS

There were 948 patients diagnosed with intraocular tumours resulting in an age-adjusted and sex-adjusted incidence rate of 727.5 per million (95% CI: 680.8 to 774.2, p<0.05). Most tumours were benign (953, 98%). Of the benign lesions, melanocytic lesions were the majority (942, 97%), with adjusted incidence rates of 646.9 (95% CI: 602.8 to 691.1) for choroidal nevus and 55.8 (95% CI: 43.2 to 64.8) for iris nevus. Malignant lesions were rare (16, 2%) with 13 cases of choroidal melanoma and 1 case each of iris melanoma, retinal leukaemic infiltration and metastasis. The adjusted incidence rate for choroidal melanoma was 7.1 (95% CI: 2.5 to 11.8).

CONCLUSION

In a population-based setting, most intraocular tumours are benign and melanocytic. Although malignant lesions are less common, it is important to remain vigilant with appropriate monitoring given the potential for vision loss and life-threatening malignancy.

Choroidal nevi in children: prevalence, age of onset, and progression

PURPOSE

To determine the age of onset and prevalence of choroidal nevi in children.

METHODS

In this cross-sectional study, the fundus photographs of a pooled sample of children 6 months to 18 years of age with 6-year longitudinal follow-up who participated in the Sydney Paediatric Eye Disease Study, Sydney Myopia Study, and the Sydney Adolescent Vascular Eye Disease Study were reviewed. Prevalence by age, clinical features, and longitudinal follow-up assessment was undertaken.

RESULTS

Of 5,533 children (7,059 examinations), 48 children with a choroidal nevus were identified. Prevalence increased with age: <6 years, 0.47%; 6 years, 0.63%; 12 years, 1.06%; 18 years, 1.79%. Nevus was unilateral in all cases (100%), and the majority were melanotic (46, 96%). Most (36 [75%]) were irregular in shape, with ill-defined margins (45 [94%]). All identified nevi were posterior to the equator. All nevi were small, with the average largest basal diameter of 1.6 mm (range, 0.5-3.2) and were not associated with secondary changes (drusen, orange pigment, subretinal fluid). The majority (18/31 [58%]) of nevi remained stable, with 5 of 31 (16%) demonstrating subtle growth (minimum of 600 μm). Four new-onset nevi were documented. Malignant transformation was not observed in any of the nevi.

CONCLUSIONS

In our study cohort, the prevalence of choroidal nevi increased with age up to 18 years. The distribution and prevalence of choroidal melanocytic lesions reported herein can be used for designing population-based studies in children that incorporate emerging imaging technologies.

Clinical Spectrum of Uveal Metastasis in Korean Patients Based on Primary Tumor Origin

PURPOSE

To describe the clinical features and prognosis of patients with uveal metastasis in Korea.

DESIGN

Retrospective, observational case series.

PARTICIPANTS

Patients diagnosed at 2 tertiary high-volume centers between November 2005 and November 2019.

METHODS

Evaluation of multimodal imaging and electronic medical records.

MAIN OUTCOME MEASURES

The clinical features and outcomes were assessed based on the primary cancer site.

RESULTS

A total of 134 uveal metastases (128 choroidal, 3 iris, and 3 ciliary body tumors) were diagnosed in 95 eyes of 80 patients. Mean age at diagnosis was 56 years (median, 55 years; range, 24-86 years), with a minor preponderance of women (61%). Tumors were bilateral in 15 patients (19%) and the primary origin was established in 49 patients (61%) before ocular detection. The primary tumor originated in the lung (48%), breast (24%), gastrointestinal tract (10%), liver (3%), pancreas (3%), kidney (1%), cervix (1%), and nasopharynx (1%), with some remaining unknown (10%). The overall 5-year survival rate was 21%. Kaplan-Meier analysis revealed that the worst survival was found in pancreatic cancers (mean survival, 5.9 months; P = 0.045), and the best survival was found in gastrointestinal tract cancers (mean survival, 44.5 months).

CONCLUSIONS

The primary tumor origins in Korean patients with uveal metastases differed from those reported in primarily population-based studies of White patients, with a higher prevalence of lung and gastrointestinal tract cancers.

Choroidal and orbital metastases from thyroid cancer

BACKGROUND

Metastases of thyroid carcinomas to the choroid and/or orbit are infrequent. PubMed was searched for English-language articles and case reports published from 1977 to 2012. In our survey, we looked for reports of orbital and/or ocular metastases from the thyroid and found 31 reported cases from 1979 to 2012.

SUMMARY

At the time of onset of ocular symptoms, the vast majority of patients had a long history of thyroid malignancy and evidence of widely disseminated metastatic disease. The age of the reported patients ranged from 29 to 83 years. Among the 22 reported cases of thyroid carcinomas with metastases to the choroid from 1979 to 2012, the most common primary tumor was papillary thyroid carcinoma (PTC); this occurred in seven patients. This was followed by medullary thyroid carcinoma in six cases and follicular thyroid carcinoma (FTC) in five cases. Orbital metastases were reported in nine patients with thyroid carcinomas (PTC=4, FTC=3, Hürthle cell=1, not specified=1). Patients with choroidal metastases presented with decreased or blurred vision, eye pain, and flashes in 81%, 5%, and 5% of cases, respectively. The diagnosis of a choroidal tumor was usually based on noninvasive diagnostic techniques such as ultrasonography, transillumination, computer tomography (CT), and/or magnetic resonance imaging (MRI) scanning. ¹³¹I scanning revealed uptake in the orbit in 26% of cases with choroidal and/or orbital PTC or FTC. For a metastasis that causes a definitive loss of vision and/or persistent pain, the treatment of choice was enucleation. The other treatment options were brachyradiotherapy using ¹²⁵I episcleral radioactive plaque insertion, external beam radiation, ¹³¹I therapy, chemotherapy, and/or targeted therapy with small molecules.

CONCLUSIONS

The orbit and globe are not common sites for metastatic thyroid carcinomas. Diagnosis of a choroidal tumor is usually based on clinical judgment and results of noninvasive diagnostic techniques such as ultrasonography, transillumination, CT, and/or MRI scanning. Fundoscopic examination and ocular ultrasonography by an ophthalmologist are recommended for identification and monitoring of choroidal metastatic deposits.

[Clinico-epidemiological analysis of choroidal melanoma in Split Area, Croatia]

Choroidal melanoma is the most common primary intraocular malignant tumour in adults. The aim of the study was to examine epidemiological characteristics of choroidal melanoma in Split-Dalmatia County from 1990 to 2009. In this retrospective study, data on 46 patients from medical documentation of the University Department of Ophthalmology, Split University Hospital Center, were analyzed. According to 2001 census, the Split-Dalmatia County population was 467,676 inhabitants. The incidence of choroidal melanoma was 0.49 per 100,000 inhabitants, which is somewhere in the middle of the incidence between south and north Europe. Choroidal melanoma most commonly appeared in the 7th decade of life. The average dimensions of choroidal melanoma (basis x height) were 13.4 x 8.0 mm. Histopathologic findings according to Callender classification showed the following types of melanoma: epithelioid cell type 8%, spindle cell type 40%, and mixed type 52%. The most common forms of therapy were enucleation 47.8% and brachytherapy 28.3%, which means that patients presented relatively late when choroidal melanoma advanced in size. The Split-Dalmatia County has 1/10 of the Croatian population, so it could be supposed that approximately 25 new cases of malignant melanoma of the choroid are discovered annually in Croatia. For early detection of the disease, regular and complete checkups are necessary, especially in presbyopic population. Study results enabled better evaluation of the disease and better planning of ophthalmologic service in the treatment of this serious eye disease.

Clinico-pathologic study of 70 enucleations

OBJECTIVE

To assess patients' history, demographic charactertics, cause for enucleation and orbital implant trends.

METHODS

A cross-sectional descriptive case study of 70 patients who underwent enucleation for various reasons between January 2004 to June 2007 at Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar were reviewed. The patients' history, demographic characteristics, cause for enucleation after histopathology and the type of orbital implant were analyzed.

RESULTS

Seventy eyes of patients who underwent enucleation were reviewed. The male patients were 62.85% and female 37.14%. The most common age group involved was paediatric in 51.42%. Retinoblastoma was the most common indication for enucleation in 42.85% of children followed by choroidal melanoma in 17.14%, painful blind eye in 11.42% and phthisis bulbi in 8.57% in adults. Enucleation with orbital implant was done in 45.71%, with dermofat graft in 34.28% and no implant in 20%. The most common complication being erosion in 21.87% and excessive discharge in 15.62%.

CONCLUSIONS

Males were the usual victims. Majority of patients were of paediatric age group. The most common indications for enucleation was retinoblastoma in children and choroidal melanoma and painful blind eye in adults.

Incidence and clinical characteristics of symptomatic choroidal metastasis from lung cancer

PURPOSE

To determine the clinical characteristics of symptomatic choroidal metastasis (CM) resulting from metastatic lung cancer.

METHODS

Twenty-two consecutive patients with symptomatic CM resulting from lung cancer were retrospectively reviewed for ocular findings, medical history and systemic disease. All patients underwent a complete screening for further organ metastasis by computed tomography (CT) and bone scintigraphy. Annual frequency of CM was determined and compared with the incidence predicted from ocular screening studies.

RESULTS

In eight of 22 (36%; 95% confidence interval [CI] 17-59) patients, lung cancer had been diagnosed before occurrence of CM, with a median interval of 13 months. In 14 patients lung cancer was detected after diagnosis of CM, with a median interval of 1 month. Choroidal metastasis was unilateral, solitary and located close to or at the posterior pole in the majority of patients. Further organ metastasis with a median number of three affected organ systems was present in 19 (86%; 95% CI 65-97) patients. Median survival after diagnosis of symptomatic CM was 13 months, by contrast with 2 months in lung cancer patients with CM identified in an ocular screening study. The mean number of patients in Berlin diagnosed with symptomatic CM was 1.4 per year, which was two orders of magnitude less than predicted from screening studies.

CONCLUSIONS

Symptomatic choroidal lung cancer metastasis in the majority of patients presents as a solitary tumour before diagnosis of lung cancer in patients with multiple organ systems affected by metastatic disease. Contrary to predictions from ocular screening studies, it is a rare clinical entity.

[Choroidal metastases]

Uveal metastases are the most frequent malign intraocular tumour, of which more than 80% are localized in the choroids. This, together with the progressive increase in its incidence, makes its study and review necessary for a correct diagnosis and treatment in current clinical practice. Etiology varies according to the sex of the patient: lung carcinoma metastasises most frequently in men and breast carcinoma in women. These tend to multifocality and are generally localized in the posterior pole. Fifty percent of cases follow an asymptomatic development, but they can cause loss of vision, scotomas, metamorphopsias and photopsias. Charactersitic ophthamoscopic examination shows a placoid, homogenous choroidal lesion with a creamy appearance. The differential diagnosis must consider the amelanotic nevus, choroidal amelanotic melanoma, choroidal haemangioma, rear scleritis, choroidal osteoma, chorioretinitis, Harada's disease, rhegmatogenous retina detachment, uveal effusion syndrome, and serous central chorioretinopathy. An exhaustive history and complete ophthalmological examination are essential to the diagnosis, to which fluorescein angiography, ocular echography, fine needle puncture aspiration (FNPA), computerized tomography and magnetic resonance can be added as complementary tests. Treatment of these tumours is usually the systemic treatment of the primary tumour; the possibilities of local treatment are observation, external radiotherapy, transpupillary thermotherapy and enucleation.

Digital imaging in differential diagnosis of small choroidal melanoma

BACKGROUND

To assess the role of digital imaging and a new subtraction method for differential diagnosis of choroidal nevus and small choroidal melanoma.

METHODS

Of 241 consecutive patients referred to a tertiary referral center for suspected choroidal melanoma, 110 who underwent digital imaging of the ocular fundus were eligible for this study. Digital color, red-free and red light retinal images were evaluated in a randomized and masked manner and by the subtraction method for diagnosis of the fundus lesion. The reference standard was based on the combined results of ophthalmological examination, including mydriatic ophthalmoscopy, B scan ultrasonography, digital imaging and fluorescein angiography of the ocular fundus.

RESULTS

Comparative use of digital color, red-free and red light imaging had 85.7% (95%CI 42.1-99.6) sensitivity, 99.0% (95%CI 94.7-99.9) specificity and 98.2% (95%CI 93.6-99.8) exact agreement versus reference standard in differentiation of small choroidal melanoma from pseudomelanoma. Direct comparison between use of digital images and the reference standard showed excellent agreement in detecting small choroidal melanoma from suspected choroidal lesions (K 0.847; 95%CI 0.639-1.0). The subtraction method was useful to show growth in four of 94 melanocytic choroidal tumors. The mean annual incidence of choroidal melanoma in Southwest Finland was 0.80 per 100.000 population. The most frequent choroidal pseudomelanomas were choroidal melanotic and amelanotic nevi, disciform lesions, congenital hypertrophy of the retinal pigment epithelium, and circumscribed choroidal hemangioma.

CONCLUSIONS

Combined use of digital color, red-free and red light imaging was a suitable adjunct in differentiation of small choroidal melanoma from different pseudomelanomas. The subtraction method may reveal early growth of the melanotic choroidal tumors.

[Pseudomelanomas of the choroid]

BACKGROUND

The aim of this study was to evaluate what are the most frequent ocular diseases that were suspected for choroidal melanoma ("pseudo melanoma").

PATIENTS AND METHODS

The data of all patients who were seen in the University Hospital of Mainz under the suspicion of choroidal melanoma between 1.1.1994 and 1.1.2004 and underwent ultrasound examination, fluorescein angiography or fundus photography, were analysed retrospectively. Among 458 examined eyes a choroidal melanoma was diagnosed in 212 cases. In 246 cases the diagnosis was "pseudomelanoma".

RESULTS

The most frequent ocular diseases suspected for choroidal melanoma were "suspicious nevi" in 31 % of the cases and "disciforme macula degeneration" in 34 %. Less frequently we found hyperplasty of pigment epithelium (5 %), melanocytoma (10 %), choroidal haemangioma (6 %), choroidal detachment (7 %) and retinal macroaneurysma with epi-/subretinal haemorrhages (3 %). Rare diagnoses were orbital tumour, scleritis posterior and a combined hamartoma of retina and pigment epithelium (4 % at all). In 58 eyes without a fundus view, ultrasound revealed an intraocular tumour. In these cases vitrectomy/cataract extraction was performed and we found a choroidal melanoma in 5 eyes, a disciforme macula degeneration in 48 eyes and in 5 eyes a retinal macroaneurysma.

CONCLUSIONS

Age-related macula degeneration (AMD) is the cause for one third of all pseudomelanomas. Because of its increasing incidence in the future, more attention must be paid to AMD in the differential diagnosis of chorioretinal lesions suspicious of melanoma.

Incidence and clinical characteristics of symptomatic choroidal metastasis from breast cancer

PURPOSE

To determine the clinical incidence and characteristics of symptomatic choroidal metastasis (CM) in breast cancer.

METHODS

Forty-six consecutive patients with CM from breast cancer were retrospectively reviewed in respect of ocular findings, medical history and systemic disease. Clinical incidence of CM was determined and compared with the incidence predicted from prevalence data obtained in ocular screening studies.

RESULTS

Choroidal metastasis occurred with a median interval of 42.4 months after diagnosis of breast cancer and was predominantly unilateral (63% patients) and solitary (57% affected eyes). A total of 32% of patients had no history of metastatic tumour disease, but systemic screening with CT and scintigraphy revealed metastatic disease in 100% of patients. A median number of three other organs were affected by metastasis. Median survival from diagnosis of CM was 13.1 months. The mean number of local patients diagnosed with CM was 2.9 per year, which was one order of magnitude less than predicted from clinical screening studies.

CONCLUSIONS

Choroidal metastasis occurs in advanced metastatic breast cancer, indicating a grave vital prognosis. In a minority of patients (32%) it is the first sign of metastatic disease. The clinical incidence of CM is far smaller than predicted from prevalence data obtained from ocular screening studies.

Bruch's membrane abnormalities in dome-shaped and mushroom-shaped choroidal melanomas

INTRODUCTION

Mushroom-shaped choroidal melanoma is known to be associated with breaks in Bruch's membrane and is more likely to develop when Bruch's membrane is diseased. The study's goal is to determine if diseases causing breaks in Bruch's membrane predispose a choroidal melanoma to develop into a mushroom-shaped melanoma.

MATERIALS AND METHODS

A retrospective review of cases of choroidal melanoma seen at our institution was carried out to determine if mushroom-shaped melanomas are more common than dome-shaped tumours in patients with macular abnormalities involving a loss of Bruch's membrane integrity. Forty-nine eyes of 48 patients were included in this retrospective study. A dome-shaped or mushroom-shaped configuration was assigned to each tumour. Macular degeneration, macular drusen, retinal pigment epithelial (RPE) stippling, macular oedema, choroidal neovascularisation (CNV), angioid streaks, disciform scars, lacquer cracks, and myopia greater than -3.00 D, were considered to constitute evidence of potential Bruch's membrane breaks and were determined in both eyes. A chi-square evaluation was used to compare the proportion of eyes with macular abnormalities in the 2 tumour configuration groups.

RESULTS

The tumour was dome-shaped in 40 eyes (82%) and mushroom-shaped in 9 eyes (18%). Macular abnormalities, indicative of loss of Bruch's membrane integrity, were seen in 21 (53%) of 40 eyes with dome-shaped melanomas and 5 (56%) of 9 eyes with mushroom-shaped melanomas. The proportion of eyes with macular abnormalities was not statistically different between the dome-shaped and mushroom-shaped tumours, as assessed by chi-square analysis (P = 0.87).

CONCLUSIONS

Bruch's membrane disease does not influence the differentiation of choroidal melanoma into mushroom-shaped or dome-shaped tumour growth patterns.

Estimating the risk of malignant transformation of a choroidal nevus

PURPOSE

To estimate the risk of malignant transformation of a choroidal nevus in the white population.

DESIGN

Systematic literature review.

METHODS

A literature review was performed to obtain data on the prevalence of choroidal nevi in the white population. Data from studies that used indirect ophthalmoscopy or otherwise corrected data to include the entire fundus were selected. Only studies reporting on the United States population were included. The number of affected individuals was estimated using 2000 U.S. census data. The estimate of annual incident choroidal melanoma cases in the corresponding age- and race-matched population was calculated using the Surveillance, Epidemiology, and End Result database (1973-2000). Average annual age-specific incidence rates for 1973 to 2000 for each of the 5-year age groups (adjusted for the U.S. 2000 population) were calculated and applied to the corresponding census data. The ratio of numbers of affected individuals with choroidal melanoma and choroidal nevi gave the annual rate of malignant transformation of a choroidal nevus.

MAIN OUTCOME MEASURES

Annual rate of malignant transformation of a choroidal nevus in the white population of the U.S.

RESULTS

The prevalence of choroidal nevus in the white U.S. population ranged from 4.6% to 7.9%. It was estimated that, on average, 8864625 individuals in the U.S. had a choroidal nevus. The number of individuals with choroidal melanoma in the corresponding age- and race-matched population ranged from 989 to 1008 (mean, 1002). The annual rate of malignant transformation of a choroidal nevus was estimated to be 1 in 8845.

CONCLUSIONS

If it is assumed that all choroidal melanomas arise from preexisting nevi, then the published data suggest a low rate (1/8845) of malignant transformation of a choroidal nevus in the U.S. white population.

Metastatic choroidal tumors in Taiwan: an 11-year experience

PURPOSE

To report the clinical features, the primary sites, and overall prognosis of choroidal metastasis.

DESIGN

Observational case series.

METHODS

Included were all cases of choroidal metastases evaluated at National Taiwan University Hospital over an 11-year period. Patients with blood or lymphoproliferative diseases were excluded. Clinical features were correlated with disease entity and prognosis.

RESULTS

A total of 36 patients with choroidal metastases were identified. The mean age was 53.9 +/- 12.8 years. The mean follow-up period was 5.1 +/- 4.2 months. The primary sites of tumors were lung in 18 (50%), breast in eight (22.2%), gastrointestinal tract in three (8.3%), pancreas in two (5.6%), ovary in two (5.6%), kidney in one (2.8%), liver in one (2.8%), and unknown in one (2.8%). Twenty-two patients (61%) died during follow-up. Mean life span after diagnosis was 4.3 months in these 22 patients.

CONCLUSIONS

Lung and breast cancers represent more than two thirds of primary tumor sites. Choroidal metastases may indicate terminal status of the underlying malignancy and short survival time.

Choroidal metastasis: case reports and review of the literature

BACKGROUND

Choroidal metastases are recognized as the most common intraocular malignancy. Their diagnosis has become more common due to increased emphasis on comprehensive eye examinations for cancer patients and the improved life expectancy of patients with metastatic disease. They are most prevalent in female patients with breast cancer and male patients with lung cancer.

METHODS

A thorough fundus examination, coupled with the use of A-scan and B-scan ultrasonography, will aid in their diagnosis. There are many ways of treating these tumors, including radiation therapy, chemotherapy, and monitoring.

CASE REPORTS

Two case reports of patients diagnosed with choroidal metastases are discussed. Case 1 involved a patient with lung cancer who manifested a large bullous exudative retinal detachment due to an underlying choroidal metastasis. Case 2 dealt with treatment of a patient with metastatic transitional cell cancer who manifested a shallow exudative retinal detachment caused by a choroidal metastasis.

CONCLUSIONS

Due to progress of chemotherapeutic medications, the number of patients who manifest choroidal metastases will continue to increase. It is essential for the practitioner to be able to recognize this disease process to prevent visual loss and institute referral for proper treatment for metastatic disease.

Absence of Change in Choroidal Nevi Across 5 Years in an Older Population

OBJECTIVE

To determine the proportion of choroidal nevi that were previously identified in a population cross section and that showed evidence of growth or progression during a 5-year period.

METHODS

The Blue Mountains Eye Study was a cohort study of residents 49 years and older living in an area west of Sydney, Australia. Retinal photographs were used to identify choroidal nevi. Repeat photographs were obtained 5 years later and graded side-by-side to ascertain clinical growth or progression of all identified nevi. The greatest diameter and surface area of each nevus were measured. Nevus growth was defined as an increase in size of at least 33%.

RESULTS

There were 160 choroidal nevi identified in the 128 subjects with nevi who participated in both eye examinations. Only 1 nevus (0.6%) exhibited clinical growth during the 5 years. No nevi developed other indicators of progression, such as subretinal fluid or orange pigment accumulation.

CONCLUSIONS

Findings from this study indicate that benign nevi in older persons rarely progress. Regular eye examinations may be unnecessary for clearly defined small nonsuspicious choroidal nevi. This information could relieve patient anxiety and reduce costs associated with regular monitoring of nevi.

[Epidemiology of choroidal melanoma in the material of the Department of Ophthalmology CM UJ in Cracow]

PURPOSE

Epidemiological analysis of the choroidal melanoma cases-sent from all over the Poland and treated in our clinic between January 1998 and December 2002.

MATERIAL AND METHODS

The study included 687 patients with choroidal melanoma 348 women and 339 men.

RESULTS

The age of patients was 14-97 years (mean 56 years). The most numerous group consisted of patients between 60-70 years of age (22.7%). Most of the cases came from the regions of Malopolska, Silesia, Lower-Silesia and Mazovia. The time between first symptoms and the first visit in our clinic was between 1 week to 2 years. According to the COMS classification we found small melanoma in 13% of cases, medium in 51% and large in 36% of cases. We found the presence of other malignancies besides the choroidal melanoma in 4.3% patients. We analyzed the demography and positive family history of ocular and general malignancies in the patients.

[Circumstances of choroid and ciliary body melanoma detection]

PURPOSE

To report and analyze the circumstances of uveal melanoma detection.

METHODS

The records of 143 consecutive patients diagnosed in the Ophthalmology Department of Gustave Roussy Institute between September 1994 and September 2001 were analyzed. The study included 66 females and 77 males, aged from 21 to 91 years (mean, 62.75 years).

RESULTS

The first symptom was decreased visual acuity in 37% of cases. In 34.9%, there was no functional sign and a systematic fundus exam provided the diagnosis. Of the 143 patients, 18.8% presented alteration of the visual field or scotoma, 9.9% complained of phosphenes, 9% complained of metamorphopsia, and 6.5% complained of floaters. In 5.5% of cases, there was documented tumor growth. In 2%, the presence of extrascleral exteriorization was the first sign. At the time of diagnosis, anterior tumors tended to be significantly larger than posterior tumors (p<0.007). Smaller lesions were significantly associated with a systematic detection of the tumor (p<0.005). Liver metastasis occurred more frequently with ciliary body melanomas (p<0.001), which were more frequently the largest lesions.

CONCLUSION

These results emphasize the importance of early detection of uveal melanoma. We recommended frequent fundus examination after pupil dilatation.

Comparison of clinical, echographic, and histopathological measurements from eyes with medium-sized choroidal melanoma in the collaborative ocular melanoma study: COMS report no. 21

OBJECTIVE

To compare pre-enucleation clinical and echographic measurements with postenucleation histopathological measurements of choroidal melanoma of a size and in a location suitable for iodine 125 brachytherapy.

DESIGN

Cross-sectional study of patients with melanoma classified as medium-sized who were assigned to the enucleation arm of the randomized trial of 125I brachytherapy vs enucleation conducted by the Collaborative Ocular Melanoma Study (COMS) Group.

METHODS

Measurements of melanoma dimensions by clinical, echographic, and histopathological examinations were compared for 644 eyes. Outcomes Tumor longest basal diameter and apical height.

RESULTS

Tumor dimensions were available for 644 (98%) of 660 patients who had unilateral medium-sized choroidal melanoma and were randomly assigned to enucleation. The clinical and histopathological measurements of the longest basal diameter agreed within +/-2 mm for 371 eyes (58%). The clinical measurement was less than the histopathological measurement by more than 2 mm in 32 eyes (5%), which occurred more frequently when the tumor was within 2 mm of the optic disc. The echographic and histopathological measurements of apical height agreed within +/-2 mm in 579 eyes (90%); the echographic measurement was less than the histopathological measurement in only 2 cases. Features associated with echographic estimates larger than histopathological measurements were greater tumor height and anterior tumor apex location.

CONCLUSIONS

Our results suggest that tumor measurements made according to COMS protocol were highly reliable in planning radioactive plaque therapy and monitoring changes in tumor size after such treatment.

Trends in size and treatment of recently diagnosed choroidal melanoma, 1987-1997: findings from patients examined at collaborative ocular melanoma study (COMS) centers: COMS report no. 20

OBJECTIVE

To describe time trends, from 1987 through 1997, (1) in size of choroidal melanoma among patients with recent diagnosis confirmed at a clinical center that participated in the Collaborative Ocular Melanoma Study (COMS) and (2) in choice of treatment by patients who did not enroll in one of the COMS randomized trials.

METHODS

Investigators at all COMS clinical centers (41 in the United States and 2 in Canada) agreed to report, in a masked fashion that did not include personal identifiers, all patients diagnosed as having choroidal melanoma during the accrual period for COMS randomized trials of radiotherapy. Information reported for patients who did not enroll in a COMS randomized trial included tumor dimensions, date of diagnosis, and initial treatment selected. Patients reported by centers that continued to report cases until 1997 and diagnosed as having choroidal melanoma no more than 1 year before evaluation at a participating COMS center contributed the data analyzed.

OUTCOME MEASURES

Time trends in tumor size among patients reported and in elective treatment of patients not enrolled in COMS randomized trials.

RESULTS

Of 8712 patients with choroidal melanoma examined, 6703 met criteria for analysis of time trend in tumor size and 4077 were analyzed for treatment trends over time. The number of cases with longest tumor basal diameter greater than 15.0 mm declined over time from 393 (30%) of 1330 cases reported in 1987 through 1989 to 345 (25%) of 1397 cases reported in 1996 or 1997. The proportion of patients eligible for COMS randomized trials who did not enroll and who elected enucleation remained stable over time for tumors of all sizes; the proportion of these patients who elected eye-conserving radiotherapy increased over time. Juxtapapillary tumors accounted for nearly half of the enucleations among ineligible patients who had tumors no larger than 15.0 mm in longest basal diameter.

CONCLUSIONS

Among patients examined at COMS centers during 1987 through 1997, the trends observed for patients with recently diagnosed choroidal melanoma included increasing presentation with tumors of smaller size, decreasing use of enucleation for choroidal melanoma 15.0 mm or less in longest basal diameter, and increasing use of such strategies for larger tumors.

Choroidal osteoma in Oriental patients

BACKGROUND

Choroidal osteoma is a rare tumour of the choroid. This is the first report of cases of choroidal osteoma in Thai patients.

OBJECTIVE

To report the clinical characteristics, imaging findings and long-term follow-up of choroidal osteoma in four Oriental patients.

METHOD

Four cases of choroidal osteoma were observed for 5 years or more.

RESULTS

All patients were young female patients whose ages ranged from 24 to 37 years. Three were unilateral and one was bilateral. The tumors were located at the juxtapapillary and macular area with overlying serous retinal detachment. Two patients had previous thyroid diseases and one was pregnant when the tumors were diagnosed. Osteoma did not develop in the vicinity of posterior staphyloma of high myopic eyes. Echography showed acoustic features of a plano-convex sonically dense lesion with high reflectivity echoes which persisted despite lower system sensitivity. None had subretinal neovascularization. Subretinal fluid disappeared spontaneously within one to 14 months in three patients. Gradual growth of the tumor in a pseudopodium manner developed from two to six years after initial examination. Decalcification occurred spontaneously or after laser ablation.

CONCLUSIONS

The authors presented four Oriental patients with choroidal osteoma who were observed for at least 5 years. Echography is the best method for identifying this lesion and has unique acoustic features. Subretinal fluid can be seen in the absence of subretinal neovascularization and resorbs spontaneously. Decalcification occurred as a natural process or after laser ablative treatment. Hormonal changes may implicate the development of this tumor.

Choroidal masses: a fourteen-year analysis

BACKGROUND

Choroidal masses present much diversification in clinical features and incidence. The purpose of this study is to investigate the epidemiological and clinicopathological manifestations of different choroidal tumors in order to tabulate appropriate diagnostic approaches.

METHODS

A retrospective analysis of patients with choroidal masses was conducted, the analysis being based upon the review of our medical records from January 1986 to December 1999 inclusively. A definite diagnosis of choroidal mass was confirmed by at least two experienced ophthalmologists. For patients who were enrolled in this study, an ophthalmic examination was conducted and medical history was recorded. Some ancillary tests, such as indirect ophthalmoscopy, ultrasonography, fluorescein angiography, computed tomography, and magnetic resonance imaging, were used to support the accuracy of our diagnoses.

RESULTS

A total of 149 patients were enrolled in this study, of which 103 cases were excluded due to a loss of follow-up or incomplete medical records. Forty-six patients (51 eyes) included 12 cases (26%) of malignant metastases, 10 cases (22%) of hemangiomas, 2 cases (4%) of osteomas, 5 cases (11%) of melanocytomas, 8 cases (17%) of melanomas, and 9 cases (20%) of other melanocytic lesions. The male to female ratio was 21:25. The average length of follow-up was 20.5 months, and the average age of these patients was 42.8 years. Presenting with varied clinical incidence and pictures, each category of choroidal mass was investigated thoroughly.

CONCLUSION

With more clinical experience and a better understanding of choroidal masses, we are able to propose an early differential diagnosis and therapeutic approach to the effective management of them in order to minimize ocular morbidity and improve patients' survival and quality of life.

Ocular metastases from breast carcinoma: A multicentric retrospective study

Breast cancer may affect the eye and orbit by metastatic neoplastic infiltration, uvea being the most common site of presentation. Management of these cases with radiotherapy is usually gratifying with reported response rate of approximately 75%. A retrospective evaluation of cases treated in five Institutions participating in a collaborative radiation therapy group of north-Italy is reported. Fifty-four cases of metastases to the eye or orbit were referred for radiation therapy to the Departments participating in the survey in the period 1977-1995. There were 49 female patients aged between 28 and 75 years (median, 44 years) at presentation of orbital metastasis. Thirty-eight lesions (70%) were metastases to the choroid, 9 involved other parts of the eye, and 7 patients had orbital metastases. Five of the 49 patients had bilateral choroidal metastases. Radiotherapy was employed with megavoltage equipment. The median total dose delivered was 40 Gy (range, 16-60 Gy). All the patients were treated 5 times per week with fraction sizes ranging from 1.8 to 3.0 Gy (median, 2.0 Gy). Of the 43 evaluable eyes, 34 (79%) showed a definite improvement after radiotherapy. There was a stabilization of the process in 4 patients. The rest (11 lesions) were lost to detailed follow-up of the response of the eye metastases. Twelve patients experienced acute transient cheratoconjunctivitis and in a case a subconjunctival haemorrhage was observed; as late side effects, two cases of chataract were observed during a period of observation of 37 and 117 months. A median survival time of 17 months was observed. The goal of irradiation was to improve vision or at least prevent blindness and enucleation. The palliative effect of irradiation was confirmed with a response rate consistent with the data of the literature on this subject.

[Clinical and histopathological aspects of 113 necrotizing malignant melanomas of the choroid. 1. Clinical and histological features of necrotizing choroidal melanomas]

BACKGROUND

Tumor necrosis may reflect a destructive immune reaction. Systematic and statistically significant comparative clinico-histopathologic studies have not yet been reported.

PATIENTS AND METHODS

113 necrotizing choroidal melanomas (NCM) recruited from 701 enucleated globes 1967-1988 were resectioned, stained and compared to 100 choroidal melanomas without necrosis (CM), and data of 74 patients with a follow-up of more than 10 years were evaluated.

RESULTS

Statistically significant characteristics of NCM were: patient age < 60 yrs. for NCM 27.4%, CM 46%; patient age in men for NCM was 64 yrs on average (CM: 58 yrs.), in women for NCM 67 yrs. (CM: 59 yrs.). Time elapsed between first symptoms and enucleation was < 12 months in 15.9% of NCM (89% for CM), and > 12 months in 23.9% of NCM (11% in CM). Mixed or epitheloid cell tumors was seen in 54.9% of NCM and 49% of CM, spindle cell tumors in 36.3% of NCM and 51% in CM. Advanced tumor stages T3 and T4 were present in 45.1% resp. 36.3% of NCM compared to 37% resp. 16% in CM. Scleral invasion was documented in 67.3% of NCM and 37% of CM, extrascleral dissemination in 43% of NCM and 16% of CM. Secondary glaucomas were seen in 62.2% of NCM and 6% CM, a penetration through Bruch's membrane in 61.0% of NCM and 46% of CM. Intratumoral hemorrhage was noted in 68.14% of NCM and 24% of CM, extratumoral bleeding in 23.9% of NCM and 0% CM. Inflammatory reactions in tumors were observed in 96.7% of NCM harboring > 30% necrosis compared to 5% in CM, and extratumoral in 94.5% of NCM and 0% of CM. Intraocular extratumoral necrosis was seen in 23.9% of NCM and 0% of CM. There were no significant differences in the degree of pigmentation of the 90.3% pigmented NCM or of the 94% pigmented CM, neither in the tumor localization, being constantly behind the equator in 87% of cases. Survival of patients with NCM patients was 5 years and 9 months on average (5-year mortality rate 41.9%), and 74.3% were deceased from metastatic spread.

CONCLUSIONS

Significant clinical and histopathological differences between necrotizing and non-necrotizing malignant melanomas of the choroid can be identified. The inflammatory reaction of NCM must be further elucidated, particularly with respect to the nature of tumor-infiltrating lymphocytes.

Frequency of asymptomatic choroidal metastasis in patients with disseminated breast cancer: results of a prospective screening programme

AIM

To determine the frequency of visually asymptomatic choroidal metastasis in patients with disseminated breast cancer and its dependence on the incidence of metastasis by number and site of other organ metastases.

METHODS

From January 1995 until April 1997 120 patients irradiated for disseminated breast cancer underwent ophthalmological screening for choroidal metastasis. No patient was symptomatic for ocular disease. 68 out of 120 patients were found to have metastases in one organ and 52 patients had metastases in more than one organ. 80% of the patients had bone metastases, 25% lung metastases, 22% liver metastases, 15% brain metastases, and 22% had metastases in other organs.

RESULTS

Six patients (5%) were found to have asymptomatic choroidal metastases. Five patients had unilateral and one patient bilateral metastases. 52 patients with more than one involved organ had a significantly higher risk for asymptomatic choroidal metastasis (6/52, 11%) than 68 patients with metastases in only one organ (0/68) (p = 0.006). In univariate analysis a significantly higher risk was seen for patients with lung metastases (14% choroidal metastases versus 2% in patients without lung metastases, p = 0.03) and for patients with brain metastases (17% choroidal metastases versus 3% in those without brain metastases, p = 0.04).

CONCLUSION

In disseminated breast cancer the incidence of asymptomatic choroidal metastases was 5% and increased to 11% when more than one organ was involved in metastatic spread. Risk factors for choroidal metastases were dissemination of disease in more than one organ and the presence of lung and brain metastases.

[Initial results of proton therapy in choroidal melanoma at the d'Orsey Center for Proton Therapy; the first 464 cases]

PURPOSE

Retrospective analysis of the treatment of choroidal melanoma with protontherapy at the Centre de protonthérapie d'Orsay, France.

PATIENTS AND METHODS

Between September 1991 and September 1995, 612 patients presenting with choroidal melanoma were treated by protontherapy in Orsay. Following initial management of the first 464 patients, results were analyzed, as were results after a 1-year follow-up for 305 patients, a 2-year follow-up for 169 patients, and a 3-year follow-up for 59 patients.

RESULTS

Univariate analysis showed that the actuarial local recurrence rate was 5%, the 3-year survival rate 88%, and the overall metastasic rate 5%. The initial tumor volume was the most significant predictive factor for visual results and metastases. Multivariate analysis revealed that visual results were significantly related to the initial tumor volume, initial retinal detachment, and total dose delivered to the optic nerve and macula.

CONCLUSION

Protontherapy of choroidal melanoma allows in most cases conservation of the eye without modification of survival. Visual results mainly depend on the site and size of the tumor.

Epidemiologic study of time and space clustering of 4 cases of choroidal malignant melanoma

OBJECTIVE

To identify common risk factors that might be associated with a cluster of 4 cases of choroidal malignant melanoma that occurred in a manufacturing plant between 1982 and 1985.

DESIGN

Survey of choroidal malignant melanoma cases in Caddo and Bossier parishes during the same time frame.

METHODS

We identified 4 additional individuals with choroidal malignant melanoma first diagnosed during the study period. Characteristics of the workplace were examined and a questionnaire was administered to all subjects to ascertain exposures to putative carcinogens and to putative risk factors for intraocular malignant melanoma. Observed and expected incidence rates were calculated.

RESULTS

The overall incidence of intraocular malignant melanoma for the 2 parishes during the 4-year period was 0.56 cases per 100,000 population per year, similar to the expected rates for this population. The incidence rate for the manufacturing plant employees was 16.5 cases per 100,000 per year. The mean age at diagnosis for workers at the plant was 38.7 years compared with 69.2 years for nonplant employees.

CONCLUSIONS

The close occurrence of manufacturing plant cases in time and space and the younger age of the people are consistent with a cluster of intraocular melanoma cases. No specific risk factors were found in the workplace environment to impute a causal association.

Lack of correlation between the location of choroidal melanoma and ultraviolet-radiation dose distribution

Ocular melanomas arise from the choroid. The results of our study of a total of 92 ocular melanomas would indicate that there is no preferential location for tumors on the eye. We estimated the ultraviolet (UV) radiation dose distribution using data available in the literature. We then compared tumor location and UV-radiation dose distribution. UVC and UVB do not reach the choroid, and UVA is filtered by the cornea and the lens. Only a small percentage of the incoming rays reach the posterior and inferior part of the retina, but none reach the superior and anterior part of the eye. We concluded that it is therefore very unlikely that UV-radiation exposure is responsible for choroidal melanoma.

Functional vision is improved in the majority of patients treated with external-beam radiotherapy for choroid metastases: a multivariate analysis of 188 patients

PURPOSE

Metastatic deposits are the most common intraocular malignancies. We evaluated the efficacy of external-beam radiotherapy (EBRT) in the palliation of posterior uveal metastases in terms of clinically relevant outcomes: functional vision, tumor control, and globe preservation.

PATIENTS AND METHODS

Four hundred eighty-three consecutive patients (578 eyes) were diagnosed with intraocular metastatic disease from solid tumors between 1972 and 1995. Of these, 233 eyes (188 patients) had lesions of the posterior uveal tract and received EBRT. Best-corrected visual acuity (VA) was documented pre- and post-EBRT. Visual function was considered excellent if VA < or = 20/50, navigational if 20/60 to 20/200, and legally blind if > or = 20/400. Most patients received 30 to 40 Gy in 2- to 3-Gy fractions to the posterior or entire globe.

RESULTS

Fifty-seven percent of all assessable eyes had improved visual function or maintained at least navigational vision following EBRT. Thirty-six percent of legally blind eyes regained useful vision. Ninety-three percent experienced no clinical evidence of tumor progression and the globe preservation rate was 98%. The following characteristics independently predicted improvement to or maintenance of excellent vision on multivariate analysis: excellent vision pre-EBRT (P = .001), age less than 55 years (P = .004), white race (v black/Hispanic) (P = .003), and tumor base diameter less than 15 mm (P < .001).

CONCLUSION

EBRT effectively restores and maintains useful vision in patients with choroid metastases, with a globe preservation rate of 98%. Patients less than 55 years with pretreatment VA better than 20/60 and tumor diameter less than 15 mm are most likely to benefit from this therapeutic intervention.

Risk factors for growth and metastasis of small choroidal melanocytic lesions

PURPOSE

To investigate the clinical features that predict growth and metastasis of an unselected group of small melanocytic choroidal tumors.

METHODS

A retrospective review was performed on 1329 patients with small melanocytic choroidal tumors measuring 3 mm in thickness or less. Clinical parameters of the patient and tumor were extracted and analyzed for their relationship to eventual tumor growth and metastasis using a Cox proportional hazards regression model.

RESULTS

Tumor growth was documented in 18% of patients. The factors predictive of tumor growth (multivariate analysis) included greater tumor thickness, posterior tumor margin touching optic disc, symptoms of flashes, floaters, and blurred vision, orange pigment on the tumor surface, and the presence of subretinal fluid. The relative risk (rr) was greatest for initial tumor thickness > 2.0 mm (rr 5.2) and posterior margin touching the optic disc (rr 2.6). After adjusting for significant tumor variables, the effect of interventional tumor treatment showed a decreasing risk for tumor growth as compared to continued observation without treatment. Of 1329 patients, 35 (3%) developed metastases. The factors predictive of metastases (multivariate analysis) included: posterior tumor margin touching the optic disc, documented growth, and greater tumor thickness. The relative risk for metastases was greatest for tumor thickness 1.1-3.0 mm (rr 8.8) and growth (rr 3.2).

CONCLUSION

Of small choroidal melanocytic tumors measuring 3 mm or less in thickness at the time of initial examination, 18% demonstrate growth and 3% metastasize during the period of followup. Based on this analysis, the clinical features of these tumors can be used to estimate the risk for tumor growth and metastases and assist the clinician with patient management.

Treatment of choroidal melanoma with I-125 plaque

PURPOSES

To evaluate efficacy of I-125 episcleral plaque therapy in patients with ocular melanoma and determine survival, eventual visual acuity, and complications.

METHODS AND MATERIALS

Between July 1, 1984 and January 1, 1991, 144 patients with diagnosis of ocular melanoma were treated with high activity I-125 episcleral plaques. Tumor volumes ranged from 14 to 3449 mm3. Lesion size included small (n = 15; height < 5 mm, and/or largest basal diameter of 8-16 mm) and large (n = 45; height > 8 mm, and/or largest basal diameter > 16 mm). Apical doses ranged from 74.25 to 83.66 Gy with scleral doses ranging from 41 and 160 Gy. Follow-up has ranged from 25 to 90 months (Med = 46 months).

RESULTS

Ocular survival was noted in 130/144. Reasons for enucleation included progressive tumor growth (n = 4), extrascleral extension (n = 4), or blind/painful eye (n = 6), 94 patients developed complications which included cataract (n = 43), optic neuropathy (n = 12), neovascular glaucoma (n = 8) and retinopathies (n = 31). Visual acuity testing pre-episcleral plaque therapy revealed 102 patients with 20/200 vision; at last follow-up 59 patients demonstrated visual acuity testing of 20/200 or better.

CONCLUSION

The use of episcleral I-125 plaque therapy allows for safe and effective therapy in patients with ocular melanoma of various size depending on location and probable visual acuity outcome. A total apical dose of 75 Gy given at 60-65 cGy/hour provides durable local control with acceptable complication rates.

Uveal metastasis from prostate carcinoma

BACKGROUND

Although breast and lung cancers account for most metastatic tumors to the uvea, prostate carcinoma metastatic to the uvea is relatively rare.

METHODS

The authors reviewed 379 consecutive patients with uveal metastasis referred to the Ocular Oncology Service at the Wills Eye Hospital to determine the frequency of prostate carcinoma as the primary neoplasm.

RESULTS

Of 379 consecutive patients with uveal metastasis, the primary tumor was prostate carcinoma in 7 (2% of all patients, 5% of male patients). The mean age at ocular diagnosis was 66 years. In six patients (85%) a prior history of prostate carcinoma was known and the prior history of prostate carcinoma was known and the mean time interval between the diagnosis of the primary tumor and the uveal metastasis was 28 months. All seven patients were found to have active or regressed metastases elsewhere. The choroid was involved in six patients (85%) and the iris in one (15%). Ocular treatment included external-beam radiation therapy in five patients (70%) and episcleral radioactive plaque in two (30%). After a total mean follow-up of 84 months (range, 44-140 months) from the diagnosis of prostate carcinoma, two patients were still alive and five patients have died (mean, 6 months after diagnosis of uveal metastasis).

CONCLUSIONS

Prostate carcinoma can metastasize to the uvea and the presence of uveal metastasis is associated with a shorter survival time compared with metastasis to other sites.

Choroidal metastasis from primary mucinous cystadenocarcinoma of the ovary

Central nervous system metastases are uncommon in epithelial carcinoma of the ovary; and metastases to the eye are even more rare. This article describes what is believed to be only the third case reported of epithelial carcinoma of the ovary metastatic to the eye.

Episcleral plaque radiotherapy in the treatment of uveal melanomas

During an 8-year period, 85 patients with uveal melanomas were treated with episcleral plaque radiotherapy (EPRT). The T-stage was: T1-3 (4%), T2-29 (34%) and T3-53 (62%). The mean tumor elevation was 6.1 mm. Radiation dose was prescribed at the tumor apex and at D5mm. The mean D5mm dose was 150.1 Gy (range 70.5-430 Gy) and the mean dose at the apex was 102.6 Gy (range 29.8-200 Gy). Useful vision (greater than 5/200) was maintained in 73% of patients. The 5-year actuarial survival was 88%. Metastatic disease developed in 9 (11%) patients, 6 of whom died of their disease. Basal tumor dimensions were important factors predicting metastatic disease, p = 0.002. A decrease in tumor evaluation was seen in 82%. There was a much lower incidence of decrease in tumor radial and circumferential dimensions, 47.5 and 46%, respectively, p less than 0.001. Treatment complications were common (56%), particularly in patients with large tumors (72%), p = 0.04. The incidence of complications was higher in patients treated prior to 1988 as compared to those who were treated more recently (67 vs 35%, p = 0.010). There were 13 (15%) patients who had enucleation. This included 12 treated before 1986 and 1 patient treated subsequently (46 vs 2%, p less than 0.001). In a univariate analysis, tumor height and radiation dose at D5mm were important factors predicting enucleation, p = 0.004. In a multivariate analysis, however, the most important factor predicting enucleation was treatment administration prior to 1986, p less than 0.001). A sharp decrease in the incidence of severe complications, including enucleation, as seen after 1985, is likely due to a major effort in treatment optimization.

The electro-oculogram as an aid in the diagnosis of uveal melanoma

The electro-oculogram (EOG) in the 64 patients with a melanoma of the choroid or ciliary body was compared to the EOG in 11 patients with choroidal metastasis, 11 patients with choroidal naevi and 27 patients with a rhegmatogenous retinal detachment. Using the Dt and the Lp/Dt-ratio, 87.5% of the melanomas could be diagnosed correctly whereas choroidal naevus and retinal detachment were diagnosed correctly in 72.7% and 70.4% of the cases respectively. Choroidal metastases never were classified correctly. Accompanying retinal detachment, tumour volume or a break through Bruch's membrane had no influence on the EOG in the melanoma patients. An important advantage of the method is that it can be used irrespective of the condition of the other eye. Combined with ophthalmoscopy, ultrasonography and fluorescein-angiography the EOG can be an additional aid in the differential diagnosis of malignant melanoma of the choroid and ciliary body.

Simultaneous bilateral primary choroidal melanoma

The first published case from Norway of primary bilateral malignant melanoma of the choroid is presented. On the admission of a 73-year-old woman for a choroidal melanoma of the left eye, an asymptomatic tumour was detected in the periphery of her right eye. The left eye was enucleated. Histology confirmed the presence of a choroidal melanoma of the mixed type. After 3 1/2 years with regular follow-ups growth of the asymptomatic tumour was noticed. The fast growth was accompanied by a haemorrhage in the vitreous and a secondary retinal detachment. External radiation with a dose of 33.6 Gy resulted in a regression of the tumour, improvement of visual acuity to 0.5 and re-attachment of the retina, lasting the remaining 8 months of life. Multiple metastasis to the liver caused her death.

Changing clinicopathological concepts of choroidal malignant melanoma

Choroidal malignant melanoma is diagnosed in about 100 Australians annually. It is the most common primary malignant tumour that occurs in the adult eye. The disease is briefly discussed in terms of its epidemiology, histogenesis, histology, diagnosis, management and current research effort. The controversy surrounding the status of enucleation in management is reviewed.

Incidence of choroidal malignant melanoma in Finland in the years 1973-1980

Recent reports concerning the incidence of choroidal and ciliary body melanomas have raised a suspicion of an increase of this malignancy in the developed countries. The rapid rise in the incidence of melanoma of the skin is well known. This study covers the incidence of choroidal and ciliary body melanomas in Finland over the years 1973-1980. A total of 382 cases of intraocular malignant tumours were reported to the Finnish Cancer Registry. 285 choroidal and ciliary body melanomas were found. The age-specific incidences showed a steep rise from the age of 30 to the age of 70. The peak incidence was in the age-group 70 and over. There was only one case, a girl 12 of age, in the age-group 15 years and younger. The age adjusted incidences showed no significant increase during the study period. The age-specific incidence showed no significant difference compared to a previous study. Sex, laterality or latitude were not found to be risk factors.

Malignant melanoma of the uvea in Iceland 1955-1979

During the 25-year period 1955 to 1979, 29 cases of malignant melanoma of the choroid and ciliary body, and 4 cases of melanoma of the iris, were diagnosed in Iceland. Excluding the iris melanomas, the annual incidence rate per 100 000, adjusted to standardized Icelandic population, was 0.7 in males and 0.5 in females. No change in the incidence rate was noted over the period. There was no significant difference in incidence rates between urban and rural regions. At the time of 31st December, 1982, 19 patients with melanoma of the choroid and ciliary body had died. In 10 cases the cause of death was melanoma metastases. All deaths with metastases occurred within 5 years from the day of enucleation. In no case were metastases found before enucleation. Five year survival rates for all patients were 51%, 64% in males and 30% in females. This difference between the sexes was significant.

Malignant melanoma of the choroid and the ciliary body 1956-1975 in Halland and Gothenburg. Incidence, histopathology and prognosis

All the 91 cases of enucleated malignant melanoma of the choroid and ciliary body in an area of the Swedish west coast (630 000 inhabitants) during the period 1956-1975 are analysed. The incidence was 0.72/100 000 inhabitants and year, which means that there was no increase lately corresponding to the increase described for cutaneous melanoma. Distribution according to age, sex and cell-type corresponded to other materials. 86 tumours were choroidal, 5 were located in the ciliary body. The mortality after 15 years was 50%. Tumours of the epitheloid type showed a surprisingly low mortality (29%). In only one case, with a 10 years survival, metastases were found at the time of primary diagnosis. The possibilities for early detection of metastases were, however, small. In 11 cases a period of delay and/or other treatment had preceded enucleation. The prognosis for these cases was not worse than for those who underwent immediate enucleation.

A histopathologic study of 716 unselected eyes in patients with cancer at the time of death

To determine the frequency of ocular metastases in the general population, we conducted a prospective histopathologic study of 716 eyes obtained from patients who had malignant neoplasms at the time of death. Fifty-two patients had ocular metastases; all of these individuals had widespread metastases that contributed to their deaths. The overall incidence of ocular metastases among all fatal cases of cancer was 9.3%. Thirty-three of the 117 patients with various types of leukemia and four of the 60 patients dying with lymphoma had ocular involvement. The total incidence of ocular metastases in patients dying of all types of carcinoma was 4.0%. In the nine patients dying of sarcoma, no ocular metastases were detected. We estimate that about 22,000 patients who will die of cancer in the United States during 1983 will have ocular metastases.

Ocular tumors in Africa

This paper is an analysis of 470 cases of oculo-orbital tumors in Kenya. The present series is compared with the major works conducted in other African and Western countries. We refer to age, sex and geographic characteristics and prevalence of tumors in different populations and stress the differences found. The major emphasis is on retinoblastoma, Burkitt's lymphoma and nasopharyngeal carcinoma. Orbital Hydatidosis is included as a differential diagnosis of unilateral propotosis. Considering all the reviews, retinoblastoma is reported in high numbers in African countries whereas uveal melanoma is extremely rare. Among the tumors of the lids and conjunctiva, squamous cell carcinoma occurs more frequently than in Caucasians. Besides retinoblastoma infiltracting the orbit, Burkitt's lymphoma is the most common orbital tumor, nasopharyngeal carcinoma in Kenya has the third highest incidence in the world. Proptosis is the hallmark of orbital disease and is the commonest manifestation sign at first attendance, a fact which validates the late presentation of most of our patients. The difficulties encountered in early diagnosis and hence the appropriate management are discussed and in concluding remarks some recommendation are made.

An apparent small cluster of choroidal melanoma cases

Three choroidal melanomas were detected in a 2.5-year period in a small community of 3,592 persons. This small cluster represented an incidence about 20 times that expected (P = .0006). The community has an isolated water supply and very little industry. We determined the incidence of cancer in this and two adjacent communities and found no other unexpectedly high incidence. The three patients had no common exposures. Analyses of air and water from the involved community by mass spectroscopy, chromatography, and Ames (mutagenicity) tests were noncontributory. Nine of 60 mice given community water after weaning developed lens opacities eight to 16 months later; electron microscopy showed an abnormal monolayer of cells on the outer surface of the anterior lens capsule. The genesis of this monolayer was not clear. None of the 30 controls showed such lesions.