Nils Eide

Fine-needle aspiration biopsy and other biopsies in suspected intraocular malignant disease: a review.

Ocular oncologists require a strong indication for intraocular biopsy before the procedure can be performed because it carries a risk for serious eye complications and the dissemination of malignant cells. The purpose of this review is to evaluate the extent to which this restricted practice is supported by evidence from previous reports and to outline our main indications and contraindications. The different intraocular biopsy techniques in the anterior and posterior segment are discussed with a focus on our preferred method, fine‐needle aspiration biopsy (FNAB). In the literature, complications are typically under‐reported, which reduces the possibilities of evaluating the risks correctly and of making fair comparisons with other biopsy methods. In FNAB, the exact placement of the needle is critical, as is an accurate assessment of the size of the lesion. Fine‐needle aspiration biopsy is usually not a reliable diagnostic tool in lesions < 2 mm in thickness. It is very advantageous to have a cytopathologist present in the operating theatre or close by. This ensures adequate sampling and encourages repeated biopsy attempts if necessary. This approach reduces false negative results to < 3%. Adjunct immunocytochemistry is documented to increase specificity and is essential for diagnosis and management in about 10% of cases. In some rare pathological processes the diagnosis depends ultimately on the identification of specific cell markers. An accurate diagnosis may have a decisive influence on prognosis. The cytogenetic prognostications made possible after FNAB are reliable. Biopsy by FNA has a low complication rate. The calculated risk for retinal detachment is < 4%. Intraocular haemorrhage is frequently observed, but clears spontaneously in nearly all cases. Only a single case of epibulbar seeding of malignant cells at the scleral pars plana puncture site of transvitreal FNAB has been documented. Endophthalmitis has been reported and adequate standard preoperative preparation is obligatory. An open biopsy is still an option in the anterior segment, but has been abandoned in the posterior segment. Although vitrectomy‐based procedures are becoming increasingly popular, we recommend using FNAB as part of a stepwise approach. A vitrectomy‐assisted biopsy should be considered in cases where FNAB fails. In any adult patient with suspected intraocular malignancy in which enucleation is not the obvious treatment, the clinician should strive for a diagnosis based on biopsy. When the lesion is too small for biopsy or the risks related to the procedure are too great, it is reasonable to be reluctant to biopsy. The standards applied in the treatment of intraocular malignant diseases should be equivalent to those in other fields of oncology. Our view is controversial and contrary to opinion that supports current standards of care for this group of patients.

Intraocular metastasis from cutaneous malignant melanoma

Abstract. Metastatic melanoma to the eye can show a number of unusual features. Two cases with intraocular metastases from primary cutaneous malignant melanoma, with a latency of 5 and 16 years, respectively, from excision to debut of ocular symptoms are reported. In the first case, tumour cell invasion of the chamber angle caused an advanced secondary glaucoma. This eye was enucleated some months later when the tumour extended through the sclera despite palliative external radiation therapy. In the other seeing eye, small melanoma metastases were treated with laser. The patient died of systemic involvement. In the second case, a probable melanoma metastasis was revealed by a vitrectomy of a thickened posterior vitreous membrane. Ophthalmoscopy and B‐scan ultrasonography 8 months later showed growths projecting 2 mm into the vitreous cavity. Metastases from a malignant melanoma with infiltration of the retina forming nodules, but also affecting adjacent choroid and optic nerve, was disclosed by histology. The patient died of metastasis to the brain.

Retinal detachment after YAG‐laser capsulotomy

Abstract Preoperative findings and postoperative results in 8 patients with retinal detachment after YAG‐laser capsulotomy are described. In this period the overall incidence of clinical retinal detachment in pseudophakic eyes after YAG capsulotomy in our hospital was 1.0% (2 of 193). Possible relationships between YAG‐laser capsulotomy and retinal detachment are discussed. Two risk factors for developing retinal detachment were found in 6 of 8 patients. After surgical repair 7 retinas were re‐attached. The final visual acuity was better than 0.5 in 5 patients.

Immunomagnetic detection of micrometastatic cells in bone marrow in uveal melanoma patients

Purpose:  Our objective was to introduce immunomagnetic separation (IMS) in ocular research by evaluating the possibility of detecting tumour cells in bone marrow (BM) and peripheral blood (PB) samples and validating the captured cells as melanocytic cells.

Simultaneous bilateral primary choroidal melanoma

Abstract. The first published case from Norway of primary bilateral malignant melanoma of the choroid is presented. On the admission of a 73‐year‐old woman for a choroidal melanoma of the left eye, an asymptomatic tumour was detected in the periphery of her right eye. The left eye was enucleated. Histology confirmed the presence of a choroidal melanoma of the mixed type. After 3 1/2 years with regular follow‐ups growth of the asymptomatic tumour was noticed. The fast growth was accompanied by a haemorrhage in the vitreous and a secondary retinal detachment. External radiation with a dose of 33.6 Gy resulted in a regression of the tumour, improvement of visual acuity to 0.5 and re‐attachment of the retina, lasting the remaining 8 months of life. Multiple metastasis to the liver caused her death.

Primary malignant melanoma of the lacrimal sac

Abstract A case report of a primary malignant melanoma of the lacrimal sac is presented. After excision a local recurrence appeared one year later. Wide, but incomplete excision and postoperative irradiation resulted in local tumour control for 4 years. The patient succumbed to a uremic death caused by a rectal cancer removed 3 years before the occurrence of the malignant melanoma.

Contusion rupture of the globe.

Abstract. Severe contusion‐injuries caused rupture of the globe in 20 eyes in 18 patients. 14 eyes had an open rupture (OR) and primary closure was performed in 13 eyes and one eye was enucleated. Six eyes with closed rupture (CR) had no emergency exploration. In both types of rupture, we intended to do vitrectomy within 14 days. In 12 cases vitrectomy was combined with retinal detachment surgery, lens extraction and gas injection. The upper‐lateral quadrant close to the limbus was the most common site of rupture (12 eyes). In 8 eyes the length of the rupture exceeded one quadrant. The lens was extruded in 9 of 14 eyes with OR. Vision preoperatively was in all eyes only light perception. Useful vision (counting fingers or better) was obtained in 7 of 13 eyes with OR and 2 of 5 eyes with CR, excluding 2 totally blind eyes upon admission, one eye in each group. Three patients became totally blind, one patient was hit in her last eye and two patients had bilateral ruptures and these eyes could not be saved.

Chronic ocular ischaemia

Abstract. Patients with carotid artery occlusive disease may develop ocular changes in both the anterior and posterior segments of the eye caused by chronic ischaemia. Four cases are reported with a wide variety of the characteristic ocular ischaemic symptoms and signs. Pulsed Doppler spectral analysis of the precerebral carotid arteries was used to detect the presence of relevant carotid occlusive disease. Diagnosis and therapy require an interdisciplinary approach, to prevent cerebral stroke and to preserve ocular function.

Bilateral uveal melanomas with different gene expression detected with 7 years interval.

To report a bilateral uveal melanoma detected in a micrometastasis study.

Disseminated tumour cells in bone marrow of patients with uveal melanoma

Purpose:  Approximately 50% of patients with uveal melanomas develop metastases. Thus, it is important to improve our understanding of how melanoma metastases develop.