Nicole E. Gross

Survey of 520 eyes with uveal metastases.

OBJECTIVE The purpose of this investigation is to report the clinical features of patients with uveal metastases seen at a major ocular oncology center. DESIGN/PARTICIPANTS A retrospective chart review was performed on all patients with uveal metastases evaluated at an ocular oncology outpatient facility over a 20-year period. MAIN OUTCOME MEASURE To assess the systemic and ophthalmic features of uveal metastases. RESULTS A total of 950 uveal metastases were diagnosed in 520 eyes of 420 consecutive patients. Of the 950 metastatic foci, the uveal involvement included iris in 90 (9%), ciliary body in 22 (2%), and choroid in 838 (88%). The total number of uveal metastases per eye was 1 (71%) in 370 eyes, 2 (12%) in 63 eyes, and 3 or more (17%) in 87 eyes. The mean number of uveal metastases per eye was two (median, one). Iris metastases presented most often as a yellow-to-white solitary nodule in the inferior quadrant. Ciliary body metastases typically presented as a solitary, sessile, or dome-shaped yellow mass in the inferior quadrant, but were difficult to visualize directly. The choroidal metastases typically were yellow in color, plateau shaped, and associated with subretinal fluid. In the 479 eyes with choroidal metastases, the epicenter of the main tumor was found in the macular area in 59 eyes (12%), between the macula and equator in 383 eyes (80%), and anterior to the equator in 37 eyes (8%). The mean size of the main (largest) choroidal tumor in each eye was 9 mm in base and 3 mm in thickness. At the time of ocular diagnosis, 278 patients (66%) reported a history of a primary cancer and 142 patients (34%) had no history of a cancer. Subsequent evaluation of these 142 patients after the ocular diagnosis of uveal metastasis showed a primary tumor in the lung in 50 patients (35%), breast in 10 (7%), others in 9 (6%), and no primary site was found in 73 patients (51%). Nearly half of the patients with no known primary site eventually died of diffuse metastatic disease. In the entire group of 420 patients, the uveal metastasis came from a primary cancer of the breast in 196 (47%), lung in 90 (21%), gastrointestinal tract in 18 (4%), kidney in 9 (2%), skin in 9 (2%), prostate in 9 (2%), and other cancers in 16 (4%). In 73 cases (17%), the primary site was never established despite systemic evaluation by medical oncologists. CONCLUSIONS Iris, ciliary body, and choroidal metastases have typical clinical features that should suggest the diagnosis. The choroid is the most common site for uveal metastases, and the tumors occur most often in the posterior pole of the eye with an average of two tumors per eye. Approximately one third of patients have no history of primary cancer at the time of ocular diagnosis. Breast and lung cancers represent more than two thirds of the primary tumor sites.

Indocyanine green angiography-guided photodynamic therapy for treatment of chronic central serous chorioretinopathy: a pilot study.

BACKGROUND Most patients with central serous chorioretinopathy (CSC) have spontaneous resolution of exudative macular detachments and a good visual prognosis. Patients with CSC have a primary choroidal hyperpermeability problem evident as multifocal areas of hyperpermeability during indocyanine green (ICG) angiography. A small percentage of patients develop chronic or progressive disease with widespread decompensation of the retinal pigment epithelium and severe vision loss. There is no known treatment for this variant of the disorder. PURPOSE To study ICG-guided photodynamic therapy (PDT) with verteporfin as a potential treatment for patients with chronic CSC. METHODS Twenty eyes of 15 patients were studied with fluorescein angiography, optical coherence tomography, and ICG angiography to diagnose the maculopathy, monitor the detachments, and localize the choroidal hyperpermeability of the disorder. PDT with ICG guidance was applied to areas of choroidal hyperpermeability, and the patients were observed to determine the anatomic and functional outcomes. RESULTS Photodynamic therapy guided by ICG was associated with complete resolution of exudative macular detachments in 12 patients and incomplete resolution in the remaining eight eyes. The vision improved in six eyes and remained unchanged in 14 eyes during a mean follow-up of 6.8 months. Six weeks after treatment, the mean visual acuity improved by 0.55 lines, an amount that was marginally significant. There was a significant inverse correlation between the baseline visual acuity and the amount of improvement in acuity at 6 weeks. No patient had any treatment-related side effects. CONCLUSIONS Indocyanine green angiography-guided PDT with verteporfin seems to aid in the resolution of exudative detachments in patients with chronic CSC. This treatment was associated with a rapid reduction in subretinal fluid and improvement in visual acuity. Although the follow-up time and number of patients in this pilot study were limited, the encouraging results and lack of complications suggest that further study is indicated.

Optical coherence tomography of branch retinal vein occlusion.

Purpose: To evaluate the incidence of serous retinal detachment (SRD) secondary to a branch retinal vein occlusion (BRVO) by using optical coherence tomography (OCT). Methods: Fourteen eyes of 14 patients with a BRVO underwent a detailed history, ophthalmoscopic examination, and fluorescein angiographic evaluation. They were also studied with OCT. Results: The 14 patients included eight women and six men with a mean age of 73.6 ± 10.5 years (range, 55‐90 years). Four eyes were found to have cystoid macular edema by fluorescein angiography, whereas 10 cases were detected by OCT. SRD involving any portion of the macula was found in 10 (71.4%) of the 14 eyes, and SRD extending into the fovea was found in six (42.9%) eyes. Two (14.3%) of the 14 patients also showed a subfoveal hemorrhage that appeared to have gravitated inferiorly through the SRD to the dependent portion of the detachment. Conclusions: That few patients with SRD secondary to a BRVO discovered by ophthalmoscopy have been reported in the literature would suggest that this is an uncommon complication. The authors found with OCT that SRD commonly occurs in BRVO. In addition, subretinal hemorrhage may occur in the context of BRVO, and the authors propose that blood gravitates through the subretinal fluid to settle behind the retina.

Nature and risk of neovascularization in the fellow eye of patients with unilateral retinal angiomatous proliferation.

Purpose: To determine the nature and risk of neovascularization in the fellow eyes of patients with unilateral retinal angiomatous proliferation (RAP), a neovascular form of age-related macular degeneration (AMD). Methods: A consecutive series of 52 patients diagnosed with unilateral RAP were studied retrospectively. Clinical biomicroscopic examination, fluorescein angiography, and indocyanine green angiography were used to evaluate all patients for the development of neovascular manifestations in the fellow eye. Results: Neovascularization developed in the fellow eye in 52 patients over the follow-up period (range, 2–36 months). All patients developed neovascular manifestations of RAP in the fellow eye. Twenty-one patients (40%) developed a RAP lesion within 1 year; 29 (56%), within 2 years; and 52 (100%), within 3 years. At the time of diagnosis of neovascularization in the fellow eye, 8 patients (15%) had a stage I RAP lesion, 36 (70%) had a stage II RAP lesion, and 8 (15%) had a stage III RAP lesion. Other characteristic findings in these patients included the presence of preretinal, intraretinal, and subretinal hemorrhages in 49 patients (94%) and pigment epithelial detachments in 41 patients (79%). Conclusions: In patients diagnosed with unilateral RAP lesions, the form of neovascularization that develops in the fellow eye is virtually always RAP. The annual and accumulative risk of neovascularization in the fellow eye is higher in patients with RAP than in those with other forms of neovascular AMD. These new findings enhance our understanding of the clinical spectrum of RAP in terms of its natural course and visual prognosis and may possibly offer useful information to establish future treatment options.

Retinal choroidal collateral circulation after radial optic neurotomy correlated with the lessening of macular edema.

Purpose: To evaluate patients who had undergone radial optic neurotomy for central retinal vein occlusion for the presence of retinal choroidal collateral circulation and to correlate these collaterals with changes in macular thickness during follow-up. Radial optic neurotomy is designed to release proposed pressure within the scleral canal. Methods: Retrospective review of patients undergoing radial optic neurotomy. The patients had a baseline examination including ophthalmoscopy, fluorescein angiography, and optical coherence tomography. At an interval follow-up at approximately 3 months the patients were reevaluated with ophthalmoscopy, optical coherence tomography, and indocyanine green angiography. Results: There were 6 patients, and the mean age was 68.3 years. The mean time from onset of the central retinal vein occlusion to the radial optic neurotomy was 2.3 months. One patient had no collateral vessels, three patients had significant collaterals, and two patients had moderate-caliber collaterals. The mean central macular thickness preoperatively was 1,021 μm and the mean central macular thickness postoperatively was 733 μm. The change in macular thickness was highly correlated with the degree of development of collaterals from the retinal to the choroidal circulation (P = 0.008, Spearman’s rho = 0.93). Conclusion: Although all patients had a radial optic neurotomy a significant determinant in reduction of macular edema was the presence of retinal-choroidal collateral circulation. This suggests that there may be additional mechanisms, other than simple release of alleged pressure in the scleral canal, for any observed effects from radial optic neurotomy.

Retinal-choroidal indocyanine green dye clearance and liver dysfunction.

toms (mean, 18 months; range, 0–48 months). In fact, the authors go on to state that the finding of capillary nonperfusion along with exudative retinopathy are the “ two most visually threatening manifestations of this condition.” 5 Moreover, Gass7 describes capillary nonperfusion as one of the main features of this syndrome. We present an adult patient with IRVAN with unusual features. First, the patient is male, and 11 of the 16 previously described patients were female.1–6 Second, he is older, presenting first at 61 years of age, while the average age reported by Chang et al was 32 years. Third, he has had retention of good vision. Although most patients present with good vision, five of seven patients that were followed by Chang et al eventually lost vision in one or both eyes within an average of 3 years after the onset of symptoms. Lastly, although our patient’s symptoms have persisted for more than 4 years and while all other criteria for the diagnosis of IRVAN are present, he still does not have evidence of capillary nonperfusion. The most likely explanation for the lack of capillary nonperfusion is that the course of the disease in our patient is relatively early. However, compared to patients followed by Chang et al, patients with IRVAN usually manifest this feature of the disease by this time in the process. We believe that while patients with IRVAN suffer in part from a retinal microvascular disease process, similar to other clinical entities that progress to retinal neovascularization, such as diabetic retinopathy, some time is required before sufficient nonperfusion develops and leads to the onset of retinal neovascularization. Indeed, it is likely that the patient described herein will also develop such a problem in the future. Therefore, careful follow-up is still warranted. Nonetheless, the absence of capillary nonperfusion in an adult patient with IRVAN has not been previously reported and this case is unique in this regard.

Fundus autofluorescence in retinopathy caused by deferoxamine toxicity.

PURPOSE To describe the fundus autofluorescence photographic pattern in a case of deferoxamine retinopathy. METHODS Observational case report. RESULTS A 91-year-old woman receiving intravenous deferoxamine treatment presented with a history of deteriorating vision in both eyes. Autofluorescence photography revealed well circumscribed areas of hyperautofluorescence that correlated with areas of pigmentation shown by color photography. Deferoxamine retinopathy was diagnosed. CONCLUSION Fundus autofluorescence photography is a noninvasive imaging method for early detection of deferoxamine retinopathy and can be used to monitor the status of the macula in patients at risk for this toxicity.