Baseline and Post-NACT Imaging in Retinoblastoma With Optic Nerve Involvement: Can MRI Predict Prognosis?

PURPOSE

To describe a staging system for optic nerve invasion using magnetic resonance imaging (MRI) and report any correlation with survival outcome.

METHODS

This was a ambispective study. Twenty-one patients with retinoblastoma who had optic nerve involvement on MRI were staged at baseline based on contrast enhancement and/or thickening and length of involvement. Response to neoadjuvant chemotherapy (NACT) was noted according to proposed response evaluation criteria and results were correlated with survival outcome.

RESULTS

Baseline MRI staging was able to predict event-free survival (EFS) (P = .0015) using the log-rank test for trends. Patients with optic nerve enhancement alone showed 100% survival prognosis. Optic nerve thickening cases with complete or partial response to NACT showed better EFS (P > .90) than those with stable disease according to response evaluation criteria.

CONCLUSIONS

The modified staging system for optic nerve invasion used in the current study significantly predicted EFS. The study also showed that response to NACT may be affected by baseline staging. The authors recommend that cases with optic nerve enhancement only, irrespective of the length of involvement (stage 0), may be treated with upfront enucleation. Cases with optic nerve thickening may be staged to evaluate the correlation with survival outcome in a larger cohort in future studies. [J Pediatr Ophthalmol Strabismus. 2024;61(2):98-105.].

Cavernous Malformation of the Optic Nerve and Chiasm: Prompt Suspicion and Surgery Matter

BACKGROUND

Cavernous malformations (CMs) of the optic nerve and chiasm are extremely rare, accounting for less than 1% of all intracranial CMs. Acute, subacute, or progressive visual loss from CM may occur with or without hemorrhage. Prompt surgical excision of the CM offers the best hope to improve or stabilize vision. Given its rarity, optic nerve and chiasm CMs may not be readily suspected. We provide 3 cases of optic nerve and chiasm CM, highlighting key neuroimaging features and the importance of expedited intervention.

METHODS

Case records of the neuro-ophthalmology clinics of the Bascom Palmer Eye Institute and the University of Colorado, and literature review of reported cases of optic CM.

RESULTS

A 49-year-old woman reported acute progressive painless vision loss in the right eye. MRI showed a suprasellar mass with heterogeneity in signal involving the right prechiasmatic optic nerve. Surgical excision of the CM 5 days after onset of visual loss improved vision from 20/300 to 20/30. A 29-year-old woman with acute painless blurred vision in the right eye had anterior chiasmal junctional visual field defects corresponding to a heterogeneously minimally enhancing mass with blood products enlarging the optic chiasm and proximal right optic nerve. Surgical excision of the CM 8 weeks after onset of visual loss improved vision from 20/40 to 20/15 with improved visual fields. A 33-year-old woman with a history of familial multiple CMs, diagnosed at age 18, reported new-onset severe headache followed by blurred vision. MRI showed a hemorrhagic lesion of the optic chiasm and right optic tract. She was 20/20 in each eye with a reported left superior homonymous hemianopia. No intervention was recommended. Vision of the right eye worsened to 20/400 2 months later. The patient was followed over 13 years, and the MRI and visual function remained unchanged. Literature review yielded 87 optic CM cases occurring across gender and nearly all ages with visual loss and headache as the most common presenting symptoms. Optic chiasm is the most common site of involvement (79%). Nearly 95% of reported CM cases were treated with surgery with 81% with improved vision and 1% with worsened vision.

CONCLUSION

MRI features are critical to the diagnosis of optic nerve and chiasm CM and may mimic other lesions. A high index of suspicion by the neuro-ophthalmologist and neuroradiologist leads to early recognition and intervention. Given optic CM displaces and does not infiltrate neural tissue, expedited surgical resection by a neurosurgeon after consideration of other diagnostic possibilities improves visual function in most cases.

[Results of radiation therapy for optic nerve sheath meningioma]

Optic nerve sheath meningioma (ONSM) is a slow-growing benign tumor that tends to extend intracranially. The tumor is characterized by vision disturbance, optic nerve atrophy and edema. At present, radiotherapy is recommended as the treatment of choice for ONSM.

PURPOSE

To assess the neuro-ophthalmic symptomatology of ONSM and how it changes in response to radiotherapy.

MATERIAL AND METHODS

In the period from 2004 to 2018, 112 patients with ONSM aged 17 to 76 years underwent stereotactic radiotherapy. In 91 patients, visual functions varied from light perception to 1.0; in 21 patients the affected eye was blind. The prospective follow-up of 103 patients lasted 6 months to 10 years (mean follow-up duration was 57 months). Studied patients underwent either conventional fractionated radiotherapy with Novalis (n=88) or hypofractionation radiotherapy with CyberKnife (n=24).

RESULTS

According to ophthalmological examination, in 60.5% of cases an improvement of visual functions was observed, 39.5% of patients had visual functions remain stable at the initial level. No vision impairment during irradiation was detected. Vision deterioration in the long-term follow-up was observed in 2 patients: extended tumor growth in one case and radio-induced retinopathy in the other.

CONCLUSION

The study showed that this method of treatment for ONSM is effective and safe, allowing preservation of visual functions and in some cases - its improvement, while tumor growth remains under control.

OPTIC DISK ASTROCYTOMA UNASSOCIATED WITH TUBEROUS SCLEROSIS COMPLEX MANAGED WITH SURGICAL EXCISION AND A 7-YEAR FOLLOW-UP

PURPOSE

Optic disk astrocytoma is a rare variant of congenital hamartoma, which is usually associated with tuberous sclerosis complex. Generally, it is stationary but in rare cases, it can show progressive growth and cause severe local complications.

METHODS

Clinical-pathologic correlation.

RESULTS

A 10-year-old boy presented a unilateral optic disk mass with vitreous hemorrhage that eventually necessitated vitrectomy of the affected eye. Visual acuity was hand movements at presentation. Pars plana vitrectomy was performed because of sudden loss of vision. At the time of vitrectomy, a yellow tumor that measured 1.5 mm in basal diameter and 6 mm in thickness was surgically removed. Cytological analysis revealed benign giant cells. The cells were negative for HMB-45 but stained positively for glial fibrillary acidic protein and neuron-specific enolase compatible with an astrocytic lesion. At the follow-up of 7 years, his vision was 20/80 and there has been no recurrence of the tumor.

CONCLUSION

Optic disk astrocytoma can be managed with local surgical excision and vision can be preserved if treated timely. Histopathologic features can help evaluate the degree of nuclear pleomorphism and cell morphology. Special immunohistochemical studies of the tumor's coexpressed neuronal markers will help differentiate astrocytoma from other neoplasms.

Optic nerve sheath meningioma

PURPOSE OF REVIEW

Optic nerve sheath meningiomas (ONSMs) are rare benign tumors of the anterior visual pathway which present with slowly progressive and painless vision loss and account for approximately 2% of all orbital tumors. This article provides an overview as well as an update on the ONSMs with regards to cause, epidemiology, clinical presentation, diagnosis, and management in adults and pediatric population.

RECENT FINDINGS

The clinical presentation and prognosis of ONSMs can vary and largely depend on the location of tumor as well as the histologic type. Overall, the diagnosis is based on clinical presentation, examination, and neuroimaging findings. Nevertheless, delays in diagnosis or misdiagnosis are not uncommon and can result in higher morbidity rates. Recent advances in diagnostic as well as more effective and less-invasive treatment options are discussed in this review.

SUMMARY

ONSMs are a rare cause of slowly progressive and inexorable visual loss. Although ONSM diagnosis depends on the characteristic clinical and radiologic findings, prompt diagnosis, and appropriate management is critical for favorable visual outcomes. Thus, current focus is optimizing diagnostic as well-treatment methods for patients with ONSMs.

Prevalence of Strabismus Among Children With Neurofibromatosis Type 1 Disease With and Without Optic Pathway Glioma

PURPOSE

To evaluate the prevalence of strabismus in neurofibromatosis type 1 (NF-1) by comparing children with normal neuroimaging to those with optic pathway glioma.

METHODS

A retrospective data collection of all children with NF-1 with neuroimaging studies examined at a single medical center between 2000 and 2016.

RESULTS

Of the 198 children with NF-1 reviewed, 109 (55%) were male, 121 (61%) had normal neuroimaging, and 77 (39%) had an optic pathway glioma. Mean age at presentation was 6.3 ± 4.7 years and mean follow-up was 4.8 ± 3.1 years. Strabismus was present in 29 (15%) children and was significantly more prevalent in children with NF-1 with optic pathway glioma (21 of 77 [27%]) than in those with normal neuroimaging (8 of 121 [7%], P < .001). Sensory strabismus was only found in children with optic pathway glioma, accounting for most cases (12 of 21 [57%]). A strong association between strabismus and optic pathway glioma is demonstrated by an odds ratio of 5.29 (P < .001). Children with NF-1 with optic pathway glioma have a 4.13 times higher relative risk of developing strabismus than children with NF-1 without it (P = .001). The direction of ocular misalignment in children with NF-1 with optic pathway glioma was not significantly different than that observed in children without optic pathway glioma (P = .197, Fisher's exact test). Only 5 (17%) children with NF-1 with strabismus (3 with optic pathway glioma) underwent corrective surgery to align their eyes.

CONCLUSIONS

Optic pathway glioma in children with NF-1 is associated with an increased risk of strabismus that is often sensory. Although exotropia is the most common ocular misalignment associated with optic pathway glioma, the direction of strabismus cannot be used as an accurate predictor for its presence. [J Pediatr Ophthalmol Strabismus. 2019;56(1):19-22.].

Diagnosis and Treatment of Orbital Optic Nerve Sheath Meningioma

BACKGROUND

Primary and secondary optic nerve sheath meningiomas (ONSMs) are neoplasms that account for a large proportion of optic nerve and orbital tumors. The diagnosis is not always straightforward and is based on the appropriate clinical findings and neuroimaging. Biopsy or surgical intervention may occasionally be necessary but is associated with significant morbidity.

METHODS

Issues related to clinical signs and symptoms, diagnosis, natural history, and treatment strategies are reviewed based on a review of published literature.

RESULTS

Diagnosis is usually based on radiographic and clinical findings. Biopsies are not obtained in most cases, thus adding further to the bias of possible misdiagnosis in all reported case series that do not have the benefit of histopathologic confirmation. Natural history typically shows inexorable progression in most cases, although long periods of stability are occasionally reported. Treatment options include observation, radiation alone, surgery alone, and combined radiation and surgery. The optimum timing of interventional therapy and radiation are evolving.

CONCLUSIONS

After serial examination documents new decline in acuity and/or visual field, fractionated radiotherapy appears most likely to preserve visual function and is a valid treatment approach for primary orbital ONSM. Tumor enlargement, as determined by serial imaging, may also provide an indication to begin radiotherapy.

Optic Gliomas in Neurofibromatosis Type 1

PURPOSE

To examine the incidence, presentation, and outcome of optic gliomas in children with neurofibromatosis type 1 (NF1) in Southern California Kaiser Permanente.

METHODS

The authors queried the Southern California Kaiser Permanente electronic medical record database to find patients diagnosed as having NF1. Genetics, ophthalmology, and imaging medical records of patients with optic glioma were reviewed.

RESULTS

A total of 708 patients younger than 21 years had a diagnosis of NF1 in Southern California Kaiser Permanente and 30 (4.2%) had a diagnosis of optic glioma. The average age of diagnosis was 5 years, with a range of 18 months to 12 years. Half (15 of 30) of the patients diagnosed as having optic glioma presented with symptoms (eg, vision loss, proptosis, and precocious puberty). Eight of 15 of the symptomatic patients were treated with surgery and/or chemotherapy. Symptomatic children were diagnosed later than those diagnosed through routine screening (5.7 vs 3.9 years old). The oldest child presented with symptoms at age 12 years. One asymptomatic patient had prophylactic chemotherapy. Sixty-three percent (19 of 30) of the gliomas were bilateral, 23% (7 of 30) were right-sided, and 13% (4 of 30) were left-sided. Fifty-three percent (17 of 30) of the gliomas involved the optic chiasm.

CONCLUSIONS

Screening practices for optic glioma are inconsistent. Most children with NF1 at risk for optic glioma do not have even one visit with an ophthalmologist. Children with NF1 can develop asymptomatic optic glioma as early as age 1 year. Annual ophthalmologic examination and screening for precocious puberty in children with NF1 is important for early diagnosis of optic gliomas and may reduce morbidity. [J Pediatr Ophthalmol Strabismus. 2016;53(6):334-338.].

[Enlarged blind spot and reduced visual evoked potentials due to melanocytoma of the optic disc]

A 59-year-old male patient presented with clinical characteristics of a melanocytoma of the optic disc in the right eye. Using functional tests, such as visual acuity, visual fields, visual evoked potentials (VEP) and imaging procedures (e.g., fundus photography and spectral domain optical coherence tomography) the findings were documented. Best corrected visual acuity was 25/20 in both eyes. Ophthalmoscopy showed a slightly prominent and pigmented tumor in the upper third of the optic disc. Comparing both eyes, an enlarged blind spot and a reduction of VEP were detectable.

Unusual case of traumatic neuroma of the orbit

Traumatic or amputation neuromas are neoformations developing after damage to a peripheral nerve. They are not proper tumors but rather a reactive process or a frustrated attempt of nerve regeneration. Traumatic neuromas are potentially found in every sensory peripheral nerve and often at the site of past surgical intervention, including orbital surgery. A 29-year-old Northern African migrant presented progressive exophthalmos and progressive loss of acuity in left eye, which had started about 6 months before after a cranio-facial trauma caused by a violent assault. MRI of the orbits showed a massive intra-orbital, intra-conical lesion, clearly compressing and dislocating the optic nerve and extending posteriorly to the orbital apex. Surgery was performed through lateral approach of Kroenlein and led to complete excision of the lesion. Histology revealed fibrotic, adipose and striated muscle tissues, a disordered, non-neoplastic overgrowth of small and large fascicles of nerves, inflammatory infiltrates, and fibrosis with sparse calcifications were diffusely observed in a background of fat, scar and striated muscle tissued. Patient was discharged on the fifth day in good health condition, without deficit of eye motion but without recovery of visual acuity. In conclusion, this case demonstrates that traumatic neuromas may arise in the orbit in patients with minor direct trauma to nerves and without previous surgical treatment.

[Eight cases of cavernous hemangioma of the optic chiasm]

OBJECTIVE

To report the clinical characteristics, neuto-imaging and prognosis of cavernous hemangioma of the optic chiasm.

METHODS

Retrospective data analysis was conducted in 8 patients from Beijing Tongren Hospital and Beijing Tiantan Hospital. Patients' clinical characteristics, neuroimaging and prognosis were assessed.

RESULTS

There were eight patients aging from 16-58 years old including 3 females and 5 males. The median age was 39.5 years. From the time of onset to diagnosis, the shortest time was 25 days and the longest was 2 years and 4 months. Clinical characteristics of 8 cases were analyzed. Among 8 cases, 3 patients had acute course, 3 patient had chronic course with acute exacerbation and 2 patients had chronic course. All patients presented with decreased visual acuity and/or visual field defect and 3 cases had headache. The most common initial manifestation was decreased visual acuity and/or visual field defect (4 cases). Only 4 cases were diagnosed cavernous hemangioma of the optic chiasm before surgery. The hemangioma was total resected in 6 patients and other two got partly removed. Visual function was improved in 4 cases after surgery. MRI showed mixed signal.

CONCLUSIONS

All patients presented decreased visual acuity and/or visual field defect, often accompanied with headache. It can be misdiagnosed at early stage. MRI may be helpful to the diagnosis. Complete resection at early stage may improve the visual function.

Clinical protocols for ³¹P MRS of the brain and their use in evaluating optic pathway gliomas in children

INTRODUCTION

In vivo (31)P Magnetic Resonance Spectroscopy (MRS) measures phosphorus-containing metabolites that play an essential role in many disease processes. An advantage over (1)H MRS is that total choline can be separated into phosphocholine and glycerophosphocholine which have opposite associations with tumour grade. We demonstrate (31)P MRS can provide robust metabolic information on an acceptable timescale to yield information of clinical importance.

METHODS

All MRI examinations were carried out on a 3T whole body scanner with all (31)P MRS scans conducted using a dual-tuned (1)H/(31)P head coil. Once optimised on phantoms, the protocol was tested in six healthy volunteers (four male and two female, mean age: 25±2.7). (31)P MRS was then implemented on three children with optic pathway gliomas.

RESULTS

(31)P MRS on volunteers showed that a number of metabolite ratios varied significantly (p<0.05 ANOVA) across different structures of the brain, whereas PC/GPC did not. Standard imaging showed the optic pathway gliomas were enhancing on T1-weighted imaging after contrast injection and have high tCho on (1)H MRS, both of which are associated with high grade lesions. (31)P MRS showed the phosphocholine/glycerophosphocholine ratio to be low (<0.6) which suggests low grade tumours in keeping with their clinical behaviour and the histology of most biopsied optic pathway gliomas.

CONCLUSION

(31)P MRS can be implemented in the brain as part of a clinical protocol to provide robust measurement of important metabolites, in particular providing a greater understanding of cases where tCho is raised on (1)H MRS.

[Meningiomas. Clinical case examples]

Using four case reports as examples the best treatment is discussed by considering the specific history and magnetic resonance imaging (MRI) findings. In many cases different therapeutic alternatives are possible for treatment of meningiomas.

Optic pathway gliomas: a review

Optic pathway gliomas account for 3-5% of all pediatric CNS tumors and represent the most common intrinsic optic nerve tumors. These tumors occur preferentially during the first decade of life and are particularly frequent in children with neurofibromatosis type 1. Although optic pathway gliomas are low-grade tumors, their behavior can be aggressive, and their management is often challenging. Their management includes observation, surgery, chemotherapy and radiation. The role of each modality is discussed as well as current and future developments in treatment, in particular targeted therapies that are currently being investigated.

[Delay in diagnosis of meningiomas involving the optic apparatus: conclusions and guidelines for early imaging based on our experience in 100 patients]

INTRODUCTION

Early diagnosis of tumors which compress the anterior optic apparatus is important in order to prevent visual functional damage. Pre-operative visual function is correlated with post operative visuaL results, therefore, delay in diagnosis leading to deterioration in vision may cause irreversible damage.

OBJECTIVES

Reviewing our experience with 100 patients with meningiomas involving the optic apparatus and establishing guidelines for early imaging in patients with visual impairment to prevent delays in diagnosis.

METHODS

Data was retrospectively collected for 100 patients with a meningioma involving the anterior optic apparatus, who underwent surgery between the years 2003-2011. Data was collected from hospital inpatient and outpatient files, as well as eye exams from the outset of the patient's symptoms and other exams that were carried out in the community.

RESULTS

In 14 patients there was a delay of one year or more in the diagnosis of meningioma. Of these, 3 were initially diagnosed with glaucoma, 3 with cataracts, 2 with migraines, in 5 patients no further investigation was conducted in spite of their ongoing complaints and in 1 patient, brain imaging was reported as normal.

CONCLUSIONS

In a distinct number of patients there was a delay in diagnosis of over a year. A patient with complaints of deterioration in visual acuity which is not corrected by glasses, with examination findings of an afferent pupil and visual field defects, should undergo neuro-imaging in order to rule out a space-occupying lesion. This should be the case even if the patient has findings of a cataract which may partially explain deterioration in visual acuity.

Fractionated stereotactic radiation therapy for orbital optic nerve sheath meningioma - a single institution experience and a short review of the literature

Optic nerve sheath meningioma (ONSM) is a rare orbital tumor that generally induces a slow progressive visual loss in affected patients. Radiotherapy (RT) has currently become the first choice to treat ONSM. In this study our experience in ONSM treatment with fractionated stereotactic radiotherapy (FSRT) is reported. Five patients with diagnosis of orbital ONSM were treated between April 2007 and December 2009 at the Radiation Oncology department of our institution. All patients underwent history and physical, and ophthalmic examinations. Orbital MRI was performed before and 6 weeks after treatment; thereafter every 6 months for the first 2 years. By previous stereotactic localization of the target, RT was delivered with 28 daily fraction of 1.8 Gy by multiple non coplanar arcs dynamically conformed by a micro multileaf-collimator. At diagnosis, in all 5 patients, visual acuity limitations of different degrees were found, while exophthalmos was present in 2, diplopy in 2, orbital pain in 1, and proptosis in 1. In all patients pre-treatment MRI showed an orbital mass involving the optic nerve. After radiotherapy, previous symptoms improved in all patients. However, after RT the MRI consistently showed a stationary status compared to the MRI before RT. At a median follow up of 26 months (range 9-37) all patients had a subjective and/or objective better visual performance than before RT without any evidence of disease progression. No late side effects were recorded. Accordingly to the current literature, our experience confirms the efficacy and the safety of FSRT in patients with orbital ONSM.

[Optical coherence tomography for surveillance of optic disc melanocytoma]

INTRODUCTION

Melanocytoma of the optic disc is a stable condition that unfrequently undergoes malignant transformation.

CASE REPORT

We reported the case of a 42-year-old woman who presented with a pigmented tumoral lesion of the optic disc in her left eye. We described its characteristics in optical coherence tomography (OCT).

CONCLUSION

Patients with pigmented tumors of the optic disc should have a periodic monitoring. OCT may be helpful in the difficult differential diagnosis between malignant and benign tumor and the monitoring of this lesion.

[Usefulness of systematic brain magnetic resonance imaging in children with neurofibromatosis type 1]

BACKGROUND AND AIM

The aim of this study was to evaluate the usefulness of systematic screening of asymptomatic neurofibromatosis type 1 (NF1) children with magnetic resonance imaging (MRI).

PATIENTS AND METHODS

We retrospectively reviewed the MRIs of children diagnosed with NF1 disease according to the National Institutes of Health criteria, who had been followed for at least 1 year by the department of pediatric neurology (Lyon, France). Brain MRI was systematically performed in asymptomatic patients under 6 years of age.

RESULTS

One hundred patients with a median follow-up of 3.7 years (range, 1-8.6 years) were reviewed. Brain MRI was performed in a total of 94 children. Nine optic pathway gliomas were detected in symptomatic patients. Six children had symptoms caused by the tumor. Gliomas remained stable in 10 patients; 1 symptomatic glioma in an 8-year-old girl required treatment. Spontaneous regression was seen in 1 patient.

CONCLUSION

Our results suggest that MRI screening of asymptomatic children to detect optic pathway gliomas does not improve the therapeutic decision and should not be performed systematically. We suggest further investigation in collaboration with the French NF Network.

Multiple gangliogliomas of the optic pathway

We report a case of multiple gangliogliomas of the optic pathway in an 18-year-old boy. He presented with visual disturbance mainly in his left eye, non-specific headaches, and episodes of sensory disturbance in his left arm. Visual acuity was 6/9 and 6/24 in his right and left eye respectively. He did not have any Lisch nodules. Optic atrophy was noted in his left eye. MRI scan revealed multiple enhancing lesions involving the optic chiasm, left optic tract, right lateral geniculate body, and right optic radiation in the temporal lobe. Stereotactic biopsy of the temporal tumour confirmed ganglioglioma. Multiple gangliogliomas of the optic pathway has not been hitherto described.

Optic Disc Melanocytoma and Glaucoma

An 82-year-old man presented with optic disc melanocytoma and glaucomatous optic neuropathy. The coexistence of these findings is particularly challenging, as there is no specific means for differentiating whether the optic nerve damage is glaucoma- or melanocytoma-related.

[Clinical manifestation and follow-up of melanocytoma of the optic disc]

OBJECTIVE

To investigate the clinical manifestation and follow-up of melanocytoma of the optic disc.

METHODS

Retrospective case series study was taken to study the clinical data of the cases with melanocytoma of the optic disc at Peking Union Medical College Hospital from 1978 to 2007. The examination included direct and indirect ophthalmoscopy, fundus photography, fundus fluorescein angiography (FFA), fundus indocyanine green angiography (ICGA), optical coherence tomography (OCT) and B-scan. The clinical manifestation and the outcome in follow-up period were analyzed.

RESULTS

Ten cases aged 31-58 years (mean 43 years) were included in this study. Among them, 9 cases were male, 1 case was female. All cases were unilateral involved, 5 cases were right eye, 5 cases were left eye. The distribution of the visual acuity was follows: light perception in 2 eyes, 20/200 in one eye, 20/20 or above in 7 eyes. The tumor mass at the optic disc with extensive serous detachment of retina was detected on B-scan in one eye. The benign melanocytoma was diagnosed by vitreous fine needle biopsy for this eye. In other case, the tumor was found to be enlarged, visual field defect deteriorated, pigment granules appeared in the vitreous adjacent to the tumor during on year follow-up period. On the patient request, enucleation was performed to rule out the malignancy of the tumor. Pathologic study showed that the tumor cells were active, but benign state. The tumor size and visual acuity in other eight eyes remained stable in the follow-up period with one to 18 years (mean 3.5 years). On FFA and ICGA, bilateral choroidal nevi were found in one eye.

CONCLUSIONS

Melanocytoma of the optic disc is a benign tumor that rarely causes visual impairment. However, visual acuity may be impaired due to enlargement of the tumor or necrosis in tumor. It is important to follow-up every case with melanocytoma of the optic disc as long as possible.

60-year old woman with extra-axial frontal mass

We describe a 60 year-old woman presenting with visual loss of her left eye. No lymphadenopathies, fever, or weight loss were detected. Neuroimaging studies revealed an extra-axial mass along the posterior aspect of the left optic nerve. The mass was resected and showed xanthomatous histiocytes that were positive for CD-68, occasionally positive for S-100, and negative for CD-1. The lesion was diagnosed as Erdheim-Chester disease (ECD) affecting the CNS. The patient is under systemic evaluation in order to discover other ECD lesions. Microscopic findings and differential diagnoses are discussed.

[Pathogenesis and the most frequent symptoms of neurofibromatosis type 1]

This study was to evaluate pathogenesis, symptoms, clinical course and possible treatment of neurofibromatosis type 1. Neurofibromatosis type 1, von Recklinghausen's disease, is one of the phacomatoses. It belongs to the most frequent inherited diseases in human population. This disease is autosomal dominant, but new spontaneous mutation are also common. The symptoms are caused by disorders in the melanocytes and gliocytes. In ophthalmological examination Lisch nodules, café-au lait spots, neurofibromas of the lids, optic pathway gliomas and deformation of the orbit bones, can be observed. The symptoms are different, depend upon the age and demonstrate charateristic evolution through the lifetime.

[Optic nerve melanocytoma--associated with age related macular degeneration]

We report the case of a 73 year old patient who presented for decreased vision in his right eye, ocular examination revealed a pigmented tumour in the left optic disc (optic nerve melanocytoma). We briefly mention another case of optic nerve melanocytoma in a 6 year old, Caucasian patient.

Cytologic diagnosis of ocular melanocytoma: a case report

BACKGROUND

Pigmented lesions of the eye represent a challenging field from both clinical and pathologic approaches. The importance of a correct diagnosis in this case is enhanced by the delicate structures involved and their difficult accessibility.

CASE

We report a case of a 51-year-old man with acute vision loss and the feeling of a foreign body in the left eye diagnosed with vitreous hemorrhage. A small, pigmented lesion in the proximity of optic nerve head was detected. After a 9-year follow-up, a definitive diagnosis of melanocytoma was achieved in vitrectomy cytology. Smears showed a population of plump, cohesive melanocytes and elongated cells with cytoplasmic melanin and uniform rounded nuclei. No change in the lesion has occurred 3 years after vitrectomy.

CONCLUSION

Fine needle aspiration proved to be helpful and reliable for the correct diagnosis of melanocytoma, which does not require additional treatment.

Ophthalmic Ultrasound: A Diagnostic Atlas, 2nd Edition

BACKGROUND

Treatment of primary optic nerve sheath meningiomas (ONSMs) remains controversial. Although recent studies have suggested a favorable outcome of radiotherapy, controlled data on the efficacy of fractionated stereotactic conformal radiotherapy (SCRT) in primary ONSMs are still lacking.

METHODS

Seven eyes treated with SCRT (total dose: 54 Gy) were compared with six eyes that were not treated because of patient or physician preference. The indication for intervention was deterioration of visual function with or without imaging evidence of tumor progression. Patients with secondary ONSMs and those with neurofibromatosis type 2 were excluded. The mean follow-up period was 57 months for the treated eyes and 61 months for the untreated eyes.

RESULTS

Among the seven treated eyes, visual acuity improved in six, five of which sustained improvement of three or more Snellen lines. One eye deteriorated by two lines. Visual field improved in four eyes, remained stable in two, and deteriorated in one. Four untreated eyes showed worsening of visual acuity and two remained stable. Visual field deteriorated in three eyes and was stable in three. None of the untreated eyes experienced improvement in visual acuity or visual field. No complications of treatment were documented.

CONCLUSIONS

In agreement with previous reports, these results indicate that SCRT is superior to observation in its impact on visual function in eyes with primary ONSMs.

Involution of endophytic optic disc hemangioma with a single session of photodynamic treatment

We report a 58-year-old otherwise healthy woman with unilateral endophytic optic disc hemangioma and associated serous retinal detachment and exudation. A standard verteporfin dose was given and a photodynamic treatment (PDT) protocol was followed. A moderate vitreous hemorrhage occurred four days after PDT. The hemangioma regressed markedly 6 weeks after the procedure and serous retinal detachment showed marked resolution.

Radiothérapie stéréotaxique fractionnée des méningiomes de la gaine du nerf optique: à propos de huit cas

Optic nerve sheath meningioma (ONSM) accounts for one-third of primary optic nerve tumors, and 2% of all meningiomas. ONSM must be distinguished from other meningiomas, in particular from cavernous meningiomas because of the different prognosis and treatment. The most frequent clinical sign is a progressive or sudden unilateral visual loss. Treatment of ONSM is still subject to discussion. This report covers a series of eight ONSM patients treated with fractionated stereotactic radiotherapy.

MATERIAL AND METHODS

Between 2000 and 2006, we managed eight patients with ONSM. The average patient age was 47 years. There were five women and three men. The most frequent clinical signs were visual loss (100%), proptosis (35%), diplopia (25%). One patient was initially treated with surgery. All patient have been treated by fractionated stereotactic radiotherapy. 45 Gy in 25 fractions were delivered on the meningioma area at a rate of 5 fractions of 1.8 Gy per week. We used a Brainlab framework associated with a thermo-formed mask. A computed tomography then magnetic resonance imaging was obtained for each patient. The data was merged and planning took place on a Brainlab dosimetric console. The treatment was performed with a head-only Varion linear accelerator, with a Brainlab multi-blade collimator.

RESULTS

The average follow-up was 27 months. Each patient had a complete radiological and ophthalmologic exam every 3 months during the first year, then every 6 months thereafter. Tumor control rate was 100%. Vision was re-established in five patients and three patients had improvement, including one patient during treatment. 100% of proptosis and diplopias regressed. No side effect was reported.

CONCLUSION

This is still a preliminary study, but the results suggest that fractionated stereotactic radiotherapy may emerge as a primary treatment for ONSM, delaying surgery, which has proven functionally disappointing.

From the archives of the AFIP: Pediatric orbit tumors and tumorlike lesions: neuroepithelial lesions of the ocular globe and optic nerve

Tumors and tumorlike lesions of the globe and optic nerve in children represent a different histologic spectrum than in adults; the imaging appearances of these lesions reflect their pathologic features. Retinoblastoma is a tumor of infancy and the most common intraocular tumor in children. There are heritable and nonheritable forms. The most common clinical finding is leukocoria. The differential diagnoses of this sign include several nonneoplastic lesions: Persistent hyperplastic primary vitreous is a congenital persistence of an embryonic structure causing a retrolental mass. The primitive vasculature may produce a septum in the posterior chamber. Coats disease is a vascular malformation of the retina that produces a lipoproteinaceous subretinal exudate. The vascular malformation enhances with intravenous contrast material, and the fat-containing subretinal exudate does not. Larval endophthalmitis is a granulomatous reaction to the dead or dying larvae of Toxocara canis or T. cati. The most important feature that allows differentiation of retinoblastoma from these so-called pseudoretinoblastomas is the presence of calcification in the former. Medulloepithelioma has two histologic forms; the teratoid type may contain calcifications, but it usually arises anteriorly from the ciliary body rather than posteriorly from the retina. Optic nerve glioma is the most common tumor of the optic nerve in children and is frequently associated with neurofibromatosis type 1. These gliomas are usually pilocytic astrocytomas and cause fusiform enlargement of the nerve.

Choroidal metastasis as a first sign of recurrence in a patient with gastric adenocarcinoma

CASE REPORT

A 40-year-old man with a history of gastric adenocarcinoma presented with progressive visual loss in his right eye. A solitary choroidal tumour was found, but no clinically detectable metastasis initially.

COMMENTS

This patient represents a rare occurrence of metastatic gastric adenocarcinoma to the choroid and optic nerve, developing as a first sign of systemic recurrence.

[Aqueductal stenosis in the neurofibromatosis type 1. Presentation of 19 infantile patients]

AIM

To present a series of infantile patients with aqueductal stenosis associated with neurofibromatosis type 1 (NF1).

PATIENTS AND METHODS

Nineteen patients with ages below 16 years, 11 girls and 8 boys, with NF1 presented hydrocephalus due to aqueductal stenosis. All patients, except one who died before the imaging study was performed and was diagnosed by autopsy, were studied by pneumoencephalography (since 1965 to 1974), computerized tomography (CT) (since 1975 to 1984), magnetic resonance (MR) or MR and CT (since 1985 to 2004) (two children had been studied by pneumoencephalography some years before) most times to discard optic pathway tumor and, in few patients, because of intracranial hypertension.

RESULTS

All patients showed three ventricular hydrocephalus with aqueductal stenosis. Eleven patients showed optic pathway tumor. One patient had a benign aqueductal tumor that impaired the normal flow of cerebrospinal fluid. Neurological features of hydrocephalus occurred very rapidly in some patients and after several years of evolution in others. Two boys showed precocious puberty. All patients were treated with shunt.

CONCLUSIONS

In our series, aqueductal stenosis occurred in about 5% of children with NF1. Aqueductal stenosis and hydrocephalus were identified at a short age because many patients were studied suspecting optic pathway tumor. Eleven patients (about 60%) associated optic pathway tumor and aqueductal stenosis.