Download Light Perception Cataract - University of Louisville Ophthalmology

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.