Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Grand Rounds Eddie Apenbrinck MD University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 3/18/16 Subjective CC: “Decreased vision” HPI: 84 year old white male presented to the VA eye clinic for cataract evaluation. Patient with poor vision OU (OD>OS). Patient was told he had cataracts several years ago. POHx: Myopia, Presbyopia PMHx: Stroke (1984) with residual dysphasia and right hemiparesis, benign prostatic hypertrophy Medications: tamsulosin, artificial tears, cetirizine, clopidogrel, carbamazepine, sertraline Allergies: none Social: denies cigarettes, alcohol, and illicit drugs Exam BCVA Pupils: IOP: EOM: CVF: OD LP (-5.25+1.25x165) OS 20/200 (-6.25+1.50x005) 3 2 4 2 unable to assess APD (lack of patient co-operation) 11 mm Hg 14 mm Hg Full OU Unable OU Exam L/L: OD WNL OS WNL C/S: WNL WNL K: WNL WNL AC: deep and quiet deep and quiet I/L: 4+ NS cataract 3+ NS cataract DFE: no view C/D: 0.1 MVP:WNL Assessment and Plan 84 year old male with PMHx significant for dysphasia secondary to remote stroke with visually significant cataracts OU (OD>OS). Plan Obtain B-scan, IOL master/A-Scan Schedule for cataract extraction and IOL implant OD Clinical Course Unable to obtain IOL master (dense cataract) or A-scan/B-scan (machine out for repair) Planned to obtain measurements for IOL selection on day of surgery IOL Master: Day of Surgery Pre-op Exam BCVA Pupils: DFE: OD LP OS CF @ 2 feet dilated 7mm 4 2 +APD OD by reverse technique Poor view; multilobulated elevated yellow retinal mass WNL Pre-op Ultrasound OD OD OD Assessment and Plan 84 year old male with intraocular mass OD seen on B-scan prior to cataract surgery Plan Surgery cancelled Referred to Oncology at VA hospital and Dr. Ramasubramanian for evaluation Scheduled for PET scan after being seen by Oncology Clinical Course Seen by Dr.Ramasubramanian the next day Appearance of intraocular tumor OD similar to choroidal metastasis. OS WNL Management options dependent on PET scan results PET Scan Standard Uptake Value: 3.0 PET Scan Standard Uptake Value: 8.9 Clinical Course PET scan showed intraocular tumor and likely rectal tumor Referred to GI clinic for evaluation of rectal tumor with possibly biopsy Per Oncology, tumors likely unrelated given significantly different SUV Patient refused examination Patient elected for Palliative care with Hospice and Home Health Metastatic Cancer to the Eye Most intraocular metastatic tumors involve the choroid, but similar lesions also affect the iris, ciliary body, optic nerve, and retina Unifocal-monocular involvement in 80% of cases; multifocal and/or binocular involvement in 20% of cases Metastatic cancer to the eye is regarded as the most common intraocular malignant neoplasm. Epidemiology The cumulative lifetime incidence of clinically detected metastatic intraocular tumors is approximately 0.1% (1 in 1,000) to 0.25% (1 in 400) Most common malignancy to have ocular metastasis Men: Lung, Prostate, Colorectal Women: Breast, Lung, Colorectal Appearance Metastatic tumors involving the choroid from breast, lung, or gastrointestinal tract appear as golden yellow to yellowish white round to oval lesion Ancillary Testing Fluorescein Angiogram Indocyanine green angiography Typically shows few or no large-caliber intralesional vessels, relative hypofluorescence of the lesion in the early frames, and late diffuse hyperfluorescence of the lesion Most metastatic tumors appear hypofluorescent B scan CT and MRI Fine-needle aspiration biopsy Treatment Options Treatment depends on tumor type but options include: Systemic chemotherapy Hormonal therapy Radiation therapy External beam radiation therapy Plaque radiotherapy (iodine-125, ruthenium-106, palladium-103) Enucleation Eye (2015) 29, 1027–1035 C L Shields, S Kaliki, et al A retrospective, nonrandomized, interventional case series of 8100 patients with uveal melanoma were evaluated for melanoma-related metastasis based on patient race On the basis of race (Caucasian, Hispanic, Asian, and African American) significant differences were noted in: mean age at presentation distance of posterior tumor margin to foveola distance of posterior tumor margin to optic disc tumor base tumor thickness Intraocular hemorrhage rupture of Bruch’s membrane Eye (2015) 29, 1027–1035 C L Shields, S Kaliki, et al Compared with Caucasians, despite relative risk for metastasis of 0.31 for African Americans, 0.73 for Hispanics, and 1.42 for Asians, there was no statistical difference in metastasis, or death from uveal melanoma based on race. Uveal melanoma showed similar prognosis for all races. References Shields JA, Shields CL, Kiratli H, et al. Metastatic tumors to the iris in 40 patients. Am J Ophthalmol 1995;119:422–30. Shakin EP, Shields JA, Augsburger JJ. Metastatic cancer to the uvea and optic disc: analysis of 200 patients. In: Bornfeld N, Gragoudas ES, Höpping W, et al. editors. Tumors of the eye. Amsterdam: Kugler; 1991. p. 623–31. Shields CL, Shields JA, De Potter P, et al. Plaque radiotherapy for the management of uveal metas- tasis. Arch Ophthalmol 1997;115:203–9. Parker SL, Tong T, Bolden S, et al. Cancer statistics, 1997. CA Cancer J Clin 1997;47:5–27. Shields CL, Kaliki S, Cohen MN et al. Prognosis of uveal melanoma based on race in 8100 patients: the 2015 doyne lecture. Eye (2015) 29, 1027–1035 James J. Augsburger, Rudolf Guthoff, Zélia M. Corrêa. Metastatic Cancer to the Eye. Ophthalmolgy pgs 810-814, 2015.