David S. George, MD

The Eye MDs

63 y/o female referred from OD for cataract evaluation

C/O gradual decrease vision over 12 months

Glare form headlights when driving

Episodes of temporal flashes on occasion

Trauma OS as child

OS always “weaker” than OD

Arthritis

BCVA 20/30 OD, 20/60 OS

SLE – NSC OS > OD

BAT 20/60 OD, 20/400 OS

Amsler grid wnl OD, temporal grid blurred OS

No APD

RBAs of CE discussed

During discussion, patient mentioned she had had a blind post on visual field testing for years

I discussed a scotoma is not necessarily consistent with a cataract

Patient was very reluctant to have another VF as these have been done yearly by OD “without change” per patient

MRI :

Tumor in Sella measuring 2.5 X 3.2 cm is displacing optic chiasm

Compression of crossing fibers leads to classic bitemporal hemianopsia

Disc edema due to increased intracranial pressure uncommon (papilledema not seen)

Disc pallor sometimes seen and later increased cupping

“Bow Tie” atrophy possible but not always present early in course

Chiasmal Syndrome (compression)

Pituitary Adenoma (most common)

Craniopharyngioma

Parasellar Internal Carotid Artery Aneurysm

Chiasmal Glioma

Bitemporal Hemianopsia Tumors can reach relatively large size without

symptoms unless hormonally active Prolactin production decreases male libido May enlarge during pregnancy Diplopia possible if involvement of cavernous

sinus due to involvement of other cranial nerves (CN III most common).

Occasional hemorrhage into tumor produces sudden enlargement, headache, and sudden vision loss (Pituitary Apoplexy). Diplopia may be present.

Goals of treatment Control of tumor growth

Normalization of pituitary function

Restoration of vision

Treatment Trans-sphenoidal removal

Pre-op acuity correlates with results

BVA < 20/100 only 62% improved

BVA > 20/100 , 89% showed improvement

Non-surgical Treatment

Bromocriptine for prolactin-secreting tumors

Irradiation as primary therapy or adjunctive therapy for incompletely resectable tumors

Patient returned 6 weeks later, after trans-sphenoidal resection of tumor

“Everything is so much brighter”

BVA now 20/25 OU

(pre-op BVA was 20/30 OD and 20/60 OS)

VF – bitemporal hemianopsia now resolved

20/30

20/25

20/60

20/25

79 yo diabetic male presents with 3 week history of a red, painful left eye

Current treatment is Tobradex drops hourly provided by referring OD

No improvement of symptoms despite use of Tobradex drops

BVA 20/20 OD 20/25 OS

IOP 12 OD 14 OS

SLE Conj 2+ Injection

Mild, Diffuse Corneal Edema

Sub-epi haze /No corneal staining

Rare Cell in A/C / Fine KP

Sectoral Iris Atrophy (9 to 10:00)

Posterior synechia

Mild NSC / No vit cell

Unilateral iritis with mild cells, KP and posterior synechia

Corneal edema and folds with mild sub-epi haze suggests corneal involvement in the dz process

Iris atrophy was sectoral, suggesting viral etiology such as HSV or HZV

Iritis not responding well to Tobradex

No vit cell or pigment

C/D 0.4 OU

No DR

Inferior RD OS!

No break seen in retina

Amelanotic mass under the retina detachment noted from 5 to 7:00 !!!

Incidence 6 cases per million population

Mean age at diagnosis 50 y/o

Choroidal Melanomas rare among non-white individuals

Occurrance is sporadic, not genetic

Role of sunlight and environmental factors remains unknown

Large Tumors (>8mm thick or 16mm longest base diameter)

Enucleation or

External-beam Irradiation then Enucleation

Medium Sized Tumors (3.1 to 8mm thick and < 16 mm)

Enucleation

Brachytherapy with Iodine-125 (local irradiation)

Small Tumors (1 to 3 mm apical thickness, < 5mm dia)

Followed clinically

Large tumors

Pre-op irradiation did not improve survival

5 yr survival 40% (27% mortality due to melanoma)

Medium tumors (N=1317, 12 yrs of data)

Mortality rates same for enucleation or brachytherapy (5yr rate 28% vs 27% respectively)

Small tumors

Tumor related deaths 1% at 5 yrs and 3.7% at 8 yrs

Represent only 1/10th of all ocular melanomas

Overall mortality at 10 years 30-50%, often due to distant metastasis of tumor

Ciliary body and anterior choroidal melanomas carry higher mortality rates than posterior melanomas (likely related to delayed diagnosis)

Can cause local problems as it infiltrates and takes up space

CB melanomas can grow like a ring around the circumference of the ciliary body (up to 360 degrees) – transillumiantion may reveal tumor but ultrasound best (B scan and Ultrasound biomicroscopy)

Hypotension if tumor disrupts overlying ciliary epithelium (often 5 mm Hg lower than other eye)

Angle closure and vascularization of iris possible May find large “sentinel vessel” in conjunctiva (one or

more large episcleral vessels feeding the metabolically active tumor)

Trabecular meshwork can be blocked by melanin laden macrophages or secondary Pigment dispersion syndrome

Lens dislocation and cataract Hyphema or vitreous hemorrhage due to infiltration

into vessels

Metastatic potential depends on the phenotype

of the cells No lymphatic system in the eye thus the only

route of dissemination is hematological Tendency to metastasize to liver Other locations for metastasis include lung,

bone, skin and CNS Check Liver Enzymes and if abnormal then

obtain ultrasound and/or CT studies of the liver (still can miss micrometastasis)