By Paul T. Finger, MD

History

This patient was noted to have a pigmented tumor on his right iris.

The digital images below will show a rounded pigmented tumor extending from the anterior chamber angle. Gonioscopy revealed no evidence of pigment dusting around the tumor or tumor in the adjacent ciliary body. It was also significant that there was no evidence of distortion of the iris stroma, ectropion uveae, sector cataract or abnormal vascularity (as might be seen with iris melanoma).

Impression

Iris Pigment Epithelial (IPE) Cyst

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By Paul T. Finger, MD

History

A 63 year old male was referred to The New York Eye Cancer Center with a 6 month history of progressive painless proptosis of the right eye.

These magnetic resonance imaging (MRI) studies demonstrate displacement of the optic nerve, a bright T1 tumor image, and a variably bright T2 tumor image. The tumor is noted to involve the orbit, the ethmoid and frontal sinuses.

Despite this large orbital tumor with optic nerve displacement, the patient was 20/20 OU, he had no visual field defect, and no signs of optic neuropathy. A complete medical survey was initiated and the patient was cleared for surgery. A combination of anterior orbitotomy and transnasal ethmoidectomy were performed to evacuate the mucus and allow for future drainage.

Though recurrence is possible, this surgery is typically curative. We recommend sending the mucoid contents for culture and sensitivity and cytopathology.

Impression:

Orbital Mucocele

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By Paul T. Finger, MD

History

A 67 year old male was referred to The New York Eye Cancer Center with a 18 x 18 mm base, and 9.3 mm high dome-shaped tumor in his left eye.

Note

This is a large file which may take up to 5 minutes to download (at 56K). If you are using dial-up Internet access, you will see a static image for 5 minutes.

Note the “twinkling” within the tumor.

This is caused by blood circulating within the melanoma. You can use this observation to differentiate between benign and malignant tumors. In general, malignant tumors have an active circulation as compared to “pseudo-melanomas” like a choroidal hemorrhage. The “twinkling” represents intrinsic vascularity or blood flow. Blood flow and vascularity will be found to diminish after radiation therapy.

Impression

Large Choroidal Melanoma

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By Paul T. Finger, MD

History

A 64-year-old female was referred to The New York Eye Cancer Center with a small iris tumor visible at the pupillary margin

Impression

Iris Pigment Epithelial Cyst

Iris pigment epithelial cysts are commonly located at the iridociliary junction and are round or oval. When observed by slit-lamp examination, they have a smooth brown surface. Visualization of the tumor can be improved by dilation of the pupil.

Iris pigment epithelial cysts have thin walls and sonolucent contents (as imaged by UBM). It is generally accepted that the high reflectivity of the cyst wall is caused by its epithelial cell lining and that its sonolucent core is consistent with a liquid content.

Iridociliary cysts typically displace the iris root anteriorly. This can induce a focal plateau-iris configuration with or without angle-closure. Though single cysts are more common, multiple cysts are found in at least one third of cases. When multiple cysts involve more than 180 degrees of the iris, as it does in 10% of patients, angle-closure glaucoma may develop.

The natural history of iris pigment epithelial cysts is poorly understood. Therefore serial observation is warranted.

Recommendation:

1. Observation
2.  Laser cystotomy for progressive angle closure, threatening acute glaucoma

References

1. Differential Diagnosis of Anterior Segment Cysts by Ultrasound Biomicroscopy. Authors: Marigo FA, Esaki K, Finger PT, Greenfield DS, Liebmann JM, Ritch R. Ophthalmology 1999;106:2131-35
2. Anterior Segment Tumors: Current Concepts and Innovations. Marigo FA, Finger PT. Survey of Ophthalmology 2003;48:569-593.
3. Transpupillary Nd:YAG laser cystotomy for iris pigment epithelial cysts with secondary progressive angle closure. Ophthalmic surgery, lasers & imaging [1542-8877] Kathil, Pratima. yr:2011 vol:42 Online pg:e40 -e43

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By Paul T. Finger, MD

History

A 71-year-old white female presented with a growth which appeared on her left eye 3 months prior to examination. Slit lamp examination revealed a gray, gelatinous, slightly elevated neovascular mass measuring 2.4 x 3.6 mm at the limbus centered in the 8 o’clock meridian.

An exfoliative biopsy was performed and a plug was placed in the lower punctum. Histopathology confirmed the diagnosis of CIN (corneal and conjunctival intraepithelial neoplasia).

The known risks and potential benefits of topical Interferon Alfa-2b (IFNa2b) and traditional forms of treatment (including but not limited to surgical excision and cryotherapy) were extensively discussed. After informed consent was obtained, treatment was given with topical IFNa2b (Schering Plough, Kenilworth, NJ).

Treatment of CIN has traditionally involved wide excision of the tumor with application of cryotherapy, topical Mitomycin-C, or radiation.

At The New York Eye Cancer Center, currently almost all patients with squamous conjunctival neoplasia can be treated without surgery, using topical chemotherapy eye drops. Depending on the type of chemotherapy eye drops, there may be local side effects (conjunctival hyperemia, follicular conjunctivitis) which generally resolve within 1 month of therapy.

This patient has done well, with no apparent side effects. It is my impression that topical interferon should the primary treatment for most cases of ocular surface squamous carcinoma and moderate to severe dysplasia.

Impression:

Topical Interferon Chemotherapy for Squamous Conjunctival Intraepithelial Neoplasia

References

1. Schechter BA, Schrier A, Nagler RS, Smith EF, Velazquez GE. Regression of Primary Conjunctival and Corneal Intraepithelial Neoplasia with Topical Interferon Alfa-2b. Cornea 2002; 21(1):6-11.
2. Wilson MW, Czechonska G, Finger PT, Rausen A, Hooper ME, Haik BG. Chemotherapy for eye cancer. Survey of Ophthalmology 45(5):416-444, 2001.

Related Links

• Survey of Ophthalmology 45(5):416-444, 2001.
• Topical Interferon Literature
• Search PubMed for Topical Interferon for Squamous Conjunctival Neoplasia
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By Paul T. Finger, MD

History

This 45 year old HIV positive patient was noted decreased vision in his left eye for 3 weeks duration. He had a past medical history of renal cell carcinoma with lung metastasis.

Impression

Choroidal Metastasis: of Renal Cell Carcinoma Origin

Treatment

This risks and benefits of chemotherapy and external beam radiation therapy were discussed in detail. Though he was to receive systemic chemotherapy, external beam irradiation was initiated due to the severity of his disease.

Comment

This case presents multiple findings consistent with metastatic choroidal tumors: uveal mass and secondary retinal detachment. Multifocality and bilaterality can also be noted.

The presence of metastatic tumor in his lungs was a risk factor for uveal extension. All patients with intraocular metastasis should undergo radiographic imaging of their head, chest, and abdomen or total body PET/CT.

This case is unusual in that the most common primary cancers are breast in women and lung in men. Choroidal metastasis of renal cell origin are relatively rare.

In this case, our patient presented with a known primary cancer. Eighteen percent of patients will present with no known primary, most will have their primary discovered by subsequent systemic evaluations, and a few will have to undergo ocular fine-needle aspiration biopsy to help determine its source

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By Paul T. Finger, MD

History

This 16-month old patient was referred for bilateral leukocoria (white pupil), acute glaucoma OS, with evidence of anterior chamber seeding and possible optic nerve/orbital invasion. The left pupil was nonreactive.

Impression

Retinoblastoma

Note

This risks and benefits of observation, enucleation, chemotherapy and external beam radiation therapy were discussed in detail. Single agent cisplatinum chemotherapy (3 cycles due to definite choroidal and possible orbital and optic nerve involvement) and enucleation of the left eye was performed. Histopathologic evaluation of the left eye revealed retinoblastoma without optic nerve or orbital extension. The right eye was enucleated after failure of systemic chemoreduction to produce a treatable tumor.

Comment

This case presents multiple classic findings of retinoblastoma: leukocoria (white pupil), secondary glaucoma, orbital inflammation, anterior segment seeding, strabismus, and intraocular calcification. Other findings of retinoblastoma (not found in this case) can include pinealoma, and extraocular tumor extension. In North America today, when the tumor is confined to the eye more than 95% of children survive their retinoblastoma.

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• Retinoblastoma
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By Paul T. Finger, MD

Impression

PAM with Atypia with Eyelid Extension.

*Note* This risks and benefits of observation, exenteration, excision with and without cryotherapy and/or topical mitomycin, as well as radiation were discussed with this patient in detail. Primary excision with subsequent topical mitomycin therapy was recommended and performed. The nodular and resectable areas were removed. Topical mitomycin was employed to address the residual diseased epithelium.

Comment

This case presents several classic findings of PAM as well as the unusual finding of extension onto the lower eyelid. Other findings of conjunctival melanomas and primary acquired melanosis include thickness, neovascularization, and corneal epithelial extension. Intraocular extension is very rare, but should this tumor recur, orbital invasion is not uncommon.

Your Questions or Comments

Melanie Kazlas, M.D.
Director of Pediatric Ophthalmology
Boston Medical Center

Question: Yesterday I saw a 10 year old Hispanic/African American child for a routine visit. He had salt and pepper melanosis in the inferior fornix OS>OD as well as a flat pigmented lesion of the nasal inferior tarsal conjunctiva (2x2mm). I often see perilimbal melanosis in my darkly pigmented patients. Can my patient also be classified as having “racial” melanosis?

Answer: I too see a lot of racial melanosis. As a general rule, if it is bilateral, it is probably racial melanosis. As you have noted (unlike your case) racial melanosis primarily involves the bulbar conjunctiva. It is also important to know that nevi can grow during puberty.

In general, I photograph and follow most of these patients. Photography has been made relatively inexpensive and easier by digital technology. My threshold for biopsy of suspicious or growing lesions is low. Make sure an ophthalmic pathologist sees the specimen.

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By Paul T. Finger, MD

History

3D ultrasound is particularly helpful in evaluation of the disorganized eye. This case of retinal detachment with hemorrhagic choroidals illustrates this advantages of 3D ophthalmic ultrasonography. This 60 year old male hypertensive patient was referred with neovascular glaucoma. Both 2D and 3D ultrasonography were performed.

Unlike static 2D images, a 3D volume can be rotated, oriented, and sectioned. This movie allows the viewer to review 5 (out of hundreds of possible) sections of this 3D ocular volume.

The original 3D block was composed of 90 sequentially acquired 2D images reconstructed into a 9.5 megabyte file. Due to limitations of the Internet, the entire file (volume) is not displayed. While evaluating this animation, you are experiencing a retrospective review of the ultrasound examination and realizing the potential of telemedicine.

Impression

Open Funnel Detachment and Hemorrhagic Choroidals

Comment

This case presents two of the many unique capabilities of 3D ultrasonography:

1. The ability to quarter the acquired volume and thereby image 3 planes (3 dimensions) simultaneously.
2. The ability to replay the examination in a remote location (as you are doing in limited form). This capability will allow ultrasound specialists to review and comment on examinations performed in remote locations.

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