Eye Diseases and Tumors PDF

Choroidal Osteoma DDx Sclerochoroidal calcification – Deposition of calcium salts in sclera/choroid – Idiopathic, hypercalcemia, other syndromes – Bilateral, multifocal – S/T location along arcades Dr. Yang, 2024...

Choroidal Osteoma DDx Sclerochoroidal calcification – Deposition of calcium salts in sclera/choroid – Idiopathic, hypercalcemia, other syndromes – Bilateral, multifocal – S/T location along arcades Dr. Yang, 2024 117  § Astrocytoma Tumors of Optic Nerve § Melanocytoma Dr. Yang, 2024 118 Optic Nerve Melanocytoma Clinical Features – Benign, deeply pigmented tumor located over the optic disc – Usually stable but slow subtle growth noted in 15% – Probably congenital – Unilateral – Mostly asymptomatic Dr. Yang, 2024 119 Optic Nerve Melanocytoma Dr. Yang, 2024 -maybe young children have this but not detected well until adulthood when there is more pigmentation -invades the adjacent RNFL 120 Optic Nerve Melanocytoma Ancillary tests – Fluorescein angiography – OCT – Visual field test à can show an enlarged blind spot or arcuate scatoma Dr. Yang, 2024 121 Optic Nerve Melanocytoma Dr. Yang, 2024 122 Optic Nerve Melanocytoma Complications – Growth Optic nerve /N F L compression Retinal vein/artery occlusion, ischemic optic neuropathy Exudates, subretinal fluid accumulation APD, VA reduction, VF defects – 1-2% malignant transformation Dr. Yang, 2024 -biggest problem with this condition is growth 123 M etastatic § Uveal metastasis Tumor § Optic nerve metastasis Dr. Yang, 2024 124 Metastatic Tumors General Considerations – Up to 10% of patients with metastatic cancer may have ocular metastasis – ~30% have no history of primary cancer at the time of ocular diagnosis – Most common primary cancers: breast, lung – The posterior choroid is the most common location for ocular metastasis – Lesions may be multifocal and bilateral Dr. Yang, 2024 125 Location of primary cancer in 1111 patients with uveal metastasis 37% 26% 16% 4% 4% 3% 2% 2% 2% 1% 1% Breast Lung Kidney GI tract Skin Lung Prostate Thyroid Pancreas Others Unknown carcinoid M EA J O , 2018, Volume 25 (2), Shields, C L , et al. Dr. Yang, 2024 126 Metastatic Tumors Mechanisms of metastasis – Seeding à spread of cancer cells adjacent neighboring tissue – Blood circulation – Lymphatic drainage Dr. Yang, 2024 -vascular supply is most likely to be affected which would be the choroid 127 Metastatic Tumors Intraocular locations for metastasis – ~ 88% choroid – ~ 9%iris – ~ 2%ciliary body – Very rare retinal metastasis Dr. Yang, 2024 128 Metastatic Tumors Symptoms – Can be asymptomatic – Decreased and/or distorted vision – Flashes of light, floating spots – Diplopia, photophobia, pain Dr. Yang, 2024 129 Metastatic Tumors Iris and ciliary body metastases à Less common – Rare – Usually a loosely-cohesive creamy pale or pink iris mass – Ciliary body metastasis may be difficult to visualize – Simulate iridocyclitis, endophthalmitis – Pseudohypopyon, hyphema – Secondary glaucoma Dr. Yang, 2024 130 Metastatic Tumors Choroidal metastasis – The most common eye site for metastasis: posterior choroid – Usually diffuse, plateau configuration – Creamy yellow mass (exceptions: metastatic skin melanoma, renal, thyroid cancers) – May be multifocal, bilateral – Subretinal fluid – May cause extensive RD – Can grow quickly Dr. Yang, 2024 131 Metastatic Tumors Dr. Yang, 2024 -asymptomatic unless macula is involved -can appreciate pale characteristics and RPE spicules -metastatic tumor from breast cancer so left eye would be more symptomatic than right eye bc of the location of lesion 132 Metastatic Tumors Dr. Yang, 2024 -choroidal metastasis from lung cancer 133 Metastatic Tumors Optic disc metastasis – Usually extension from choroidal metastasis – Can be confined to optic disc without choroidal component – Appears as a swollen, infiltrated disc Retinal metastasis – Very rare Dr. Yang, 2024 134 Metastatic Tumors Diagnostic tests – Fluorescein angiography – Indocyanine green angiography – Ultrasonography – OCT – CT and MRI à not really used for ocular purposes – Fine needle aspiration biopsy – Systemic investigation: blood tests, imaging Dr. Yang, 2024 135 Metastatic Tumors Fluorescein angiography Dr. Yang, 2024 -metastatic tumors are not really much vascularized whereas melanomas are vascularized 136 Metastatic Tumors ICG angiography Dr. Yang, 2024 -doesn’t show too significant hyper or hyperfluorescent 137 Metastatic Tumors Dr. Yang, 2024 -oct shows affecting all photoreceptors, RPE and subretinal fluid 138 Metastatic Tumors Dr. Yang, 2024 -in contrast to melanoma, the choroidal melanoma the mass needs to be of significant size before serous retinal detachment occurs 139 Metastatic Tumors Ultrasonography Dr. Yang, 2024 -elevated lesion, no hollowness -A-scan is very irregular 140 Metastatic Tumors Management – Chemotherapy for systemic disease – Observation if vision not threatened – External beam irradiation – Photodynamic therapy – Intravitreal anti-VEGF injection Dr. Yang, 2024 141 Lymphoma and Leukemia Dr. Yang, 2024 142 Lymphoma and Leukemia Lymphoma Leukemia Hodgkin’s lymphoma A group of cancers that usually begin in the bone marrow Non-Hodgkin’s lymphoma (NHL) Result in high numbers of abnormal white blood cells – Primary Intraocular Lymphoma Dr. Yang, 2024 -lymphoma produces intraocular tumors more commonly than leukemia -both hodgkins and non-hodgkins are malignant but are relatively rare -non is more common in the US 143 Primary Intraocular Lymphoma General Considerations Two forms Rare, highly malignant Vitreoretinal form (more common) Usually non-Hodgkin’s B-cell lymphoma Uveal form (less aggressive) Highly associated with primary C N S lymphoma Higher incidence in the 5th ~8th decades of life Higher incidence in the immunocompromised Often bilateral, asymmetric Great masquerader – DDx: uveitis, white dot syndromes, metastatic cancers, posterior scleritis Dr. Yang, 2024 144 Primary Intraocular Lymphoma Vitreoretinal form More common, more fatal than uveal form Usually associated with C N S lymphoma à fatal Yellowish white sub-RPE infiltrative mass with clumping of overlying RPE Signs of uveitis and vitritis Mostly bilateral and asymmetric Dr. Yang, 2024 145 Primary Intraocular Lymphoma Uveal form Less common Usually associated with visceral NHL Creamy yellow choroidal infiltrates May be solitary, multifocal, or confluent Unilateral or bilateral Relatively stable Minimal symptoms Overall, better prognosis than vitreoretinal form Dr. Yang, 2024 146 Primary Intraocular Lymphoma Ancillary tests Fluorescein angiography – Vitreal/retinal/uveal biopsy – Evaluation for C N S lymphoma Lumber puncture, MRI – Blood tests to rule out DDx’s – Fluorescein angiography Dr. Yang, 2024 147 Primary Intraocular Lymphoma Management – Vitreoretinal form – Uveal form Ocular irradiation Chemotherapy if systemic involvement present C N S irradiation if brain involvement detected Ocular radiotherapy if no systemic involvement C hemotherapy Complete regression Possible relapses Dr. Yang, 2024 148 Primary Intraocular Lymphoma Outcome – Highly variable Indolent waxing and waning Aggressive progression that results in a completely blind eye – Extremely virulent and rapidly progressive if associated with AIDS – Poor prognosis for long-term survival if C N S lymphoma develops Dr. Yang, 2024 149 Intraocular Leukemia General consideration – Likely to occur during relapse – A sign of severe disease – Can involve iris, CB, choroid, retina, vitreous, or optic nerve – Occurs most often in children with acute lymphoblastic leukemia – Adult T-cell leukemia and other types can also involve the intraocular structures Dr. Yang, 2024 150 Intraocular Leukemia Clinical features – A solitary mass or a diffuse iris thickening – A neoplastic pseudohypopyon – Spontaneous hyphema – A diffuse or patchy thickening of the retina and choroid – Extensive retinal hemorrhage – Infiltration of the optic disc – Tumor cells in the vitreous Dr. Yang, 2024 151 Intraocular Leukemia Pathology – Leukemic blast cells with extensive hemorrhage – The tumor cells often fill the retinal/uveal blood vessels – The tumor cells may invade deep into the optic nerve Dr. Yang, 2024 152 Intraocular Leukemia Dr. Yang, 2024 -shows pesudohypopion 153 Intraocular Leukemia Dr. Yang, 2024 154 Intraocular Leukemia Diagnostic approaches – Clinical presentations with known hx of leukemia – Fine needle aspiration biopsy – FA and ultrasonography show no specific diagnostic features Dr. Yang, 2024 155 Intraocular Leukemia Management Outcome – Systemic chemotherapy – Most retinal lesions respond to radiation/chemotherapies – Ocular irradiation – If untreated, results in profound visual loss – Intraocular infiltrative tumors indicate poor prognosis Dr. Yang, 2024 156