Fall 2017 Newsletter

Follow our latest updates in our Summer 2019 Newsletter

Fall 2017 Newsletter
7th Residency Announcement

Exciting Residency Announcement!

ACGME approves seventh resident complement; first increase in over 30 years!

Grand Rounds

Grand Rounds and Case Studies

Check out our weekly presentations

OTEP

OTEP

Ophthalmic Technician Education Program

LARGEST STUDY ON CHINESE AMERICANS PUBLISHED

LARGEST STUDY ON CHINESE
AMERICANS PUBLISHED

USC Ophthalmology Researchers Find More
Effective Treatments For Blinding Eye Diseases

EDUCATION

Case Study: Does Size Matter?

Berry
Presenter: Jonathan Lu, MD Discussant: Jesse Berry, MD
 

History

  • Patient #1 51 y/o female without significant medical or ocular history Referred for retinal lesion found after routine eye exam
  • Patient #2 69 y/o male without significant medical or ocular history Referred for retinal lesion noted during DFE for flashes/floaters

Exam Findings

  • Patient #1: Vision: 20/25 || 20/20. IOP: 15 || 19. Pupils: WNL OU. DFE 3Hx4V DD hyperpigmented lesion with minimal to moderate elevation with overlying orange pigment overlying superotemporal arcade, peripheral retinal cyst at 2 o’clock
  • Patient #2: Vision: 20/20 OU. IOP: 17 OU. Pupils: WNL OU DFE 5 x5 DD hyperpigmented lesion with minimal to moderate elevation with overlying drusen. Ultrasound measurement 6.30 mm LBD 2.22 thickness lesion. OCT with choriocapillaris compression over choroidal mass

Differential Diagnosis

  • Choroidal nevus
  • Choroidal melanoma
  • Pigmented metastasis
  • RPE adenoma
  • Melanocytoma
  • Peripheral exudative hemorrhagic chorioretinopathy (PEHCR)
  • Congenital hypertrophy of the retinal pigment epithelium (CHRPE)
  • Choroidal hemangioma

Additional Investigations

  • Patient #1: Ultrasound dome shaped medium reflectivity 6.69 mm LBD 1.47 thickness lesion. OCT with SRF and shaggy photoreceptors, elevated choroidal mass
  • Patient #2: Ultrasound measurement 6.30 mm LBD 2.22 thickness lesion. OCT with choriocapillaris compression over choroidal mass

Diagnosis

  • Patient #1: Choroidal melanoma
  • Patient #2: Choroidal nevus

Pathophysiology

  • Nevi:
    • Benign melanocytic lesions of posterior uvea
    • 4.6-7.9% in Caucasians (Singh 2005)
    • Malignant transformation rare but increases with age
      • 1 in ~5000-8000 nevi become malignant (Ganley 1973, Singh 2005)
    • Typically asymptomatic
    • Wide variation in dimensions
    • Management typically with just monitoring
  • Melanoma:
    • Malignancy of melanocytes
      • Part of uveal melanoma more broadly
    • Mean age-adjusted incidence of uveal melanoma is ~4 per million
      • Higher rate in those with preexisting choroidal nevus and congenital ocular/oculodermal melanocytosis (1/400 risk)
    • Middle aged men and women
    • Can be asymptomatic or symptomatic (photopsia, floaters, visual field loss, secondary glaucoma)
  • Significant size overlap

Treatment

  • Nevi: monitor
  • Melanoma
    • Depends on tumor size, location, symptoms general medical condition
    • Options
    • Monitor
    • Enucleation
    • Plaque radiotherapy
    • Charged particle irradiation
    • Transpupillary thermotherapy

Prognosis and Future Directions

  • ED-OCT
  • Nevi findings:
    • choriocapillaris thinning (and shadowing) (94% of cases)
    • RPE changes(43%)
    • photoreceptor loss (43%)
    • IS/OS irregularity (37%)
    • ELM irregularity (18%)
    • overlying SRF (16%)
  • Melanoma with fresh SRF and shaggy photoreceptors
  • (Shields et al for above figures)
Figure 1: Patient #1, 51 y/o female. Likely melanoma clinically, close monitoring for growth and possible brachytherapy.
Figure 2: LBD: 6.69, Thickness: 1.49
Figure 3: Patient #2, 69 y/o male. Nevus, monitor. Initial vision symptoms from a schisis/RD
Figure 4: LBD: 6.30, Thickness: 2.22

Conclusions

  • Differentiating choroidal nevi and small choroidal melanomas is a clinical diagnosis
    • Benefits significantly from ancillary imaging: ultrasound B-scan and A-scan, OCT-EDI, fluorescein angiography, serial fundus photography
  • Caution as there is overlap within diagnostic criteria
    • Including key differentiators of size (thickness, longest basal diameter) and OCT characteristics
  • To answer title slide: Size of melanocytic lesions does matter, but doesn’t tell the whole picture
    • Get an ophthalmic oncology expert involved

References

  • Augsburger JJ, Correa ZM, Trichopoulos N, Shaikh A. Size Overlap between Benign Melanocytic Choroidal Nevi and Choroidal Malignant Melanomas. Invest Ophthalmol Vis Sci. 2008;49(7):2823. doi:10.1167/iovs.07-1603
  • Augsburger JJ, Schroeder RP, Territo C, Gamel JW, Shields JA. Clinical parameters predictive of enlargement of melanocytic choroidal lesions. British Journal of Ophthalmology. 1989;73(11):911-917. doi:10.1136/bjo.73.11.911
  • Ganley JP, Comstock GW. Benign Nevi and Malignant Melanomas of the Choroid. American Journal of Ophthalmology. 1973;76(1):19-25. doi:10.1016/0002-9394(73)90003-2
  • Gass JD. Problems in the differential diagnosis of choroidal nevi and malignant melanomas. The XXXIII Edward Jackson Memorial Lecture. Am J Ophthalmol. 1977;83(3):299-323. doi:10.1089/ten.2005.11.1254
  • Li HK, Shields CL, Mashayekhi A, et al. Giant Choroidal Nevus. Ophthalmology. 2010;117(2):324-333. doi:10.1016/j.ophtha.2009.07.006
  • McLean IW, Zimmerman LE, Evans RM. Reappraisal of Callender’S Spindle a Type of Malignant Melanoma of Choroid and Ciliary Body. American Journal of Ophthalmology. 1978;86(4):557-564. doi:10.1016/0002-9394(78)90307-0
  • Shah SU, Kaliki S, Shields CL, Ferenczy SR, Harmon SA, Shields JA. Enhanced Depth Imaging Optical Coherence Tomography of Choroidal Nevus in 104 Cases. Ophthalmology. 2012;119(5):1066-1072. doi:10.1016/j.ophtha.2011.11.001
  • Shields CL. Combination of Clinical Factors Predictive of Growth of Small Choroidal Melanocytic Tumors. Arch Ophthalmol. 2000;118(3):360. doi:10.1001/archopht.118.3.360
  • Shields CL, Kaliki S, Rojanaporn D, Ferenczy SR, Shields JA. Enhanced Depth Imaging Optical Coherence Tomography of Small Choroidal Melanoma: Comparison With Choroidal Nevus. Arch Ophthalmol. 2012;130(7):850. doi:10.1001/archophthalmol.2012.1135
  • Shields C, Manalac J, Saktanasate J, Shields J, Das C. Review of spectral domain enhanced depth imaging optical coherence tomography of tumors of the choroid. Indian J Ophthalmol. 2015;63(2):117. doi:10.4103/0301-4738.154377
  • Shields CL, Manalac J, Das C, Ferguson K, Shields JA. Choroidal melanoma: clinical features, classification, and top 10 pseudomelanomas. Current Opinion in Ophthalmology. 2014;25(3):177-185. doi:10.1097/ICU.0000000000000041
  • Singh AD, Kalyani P, Topham A. Estimating the Risk of Malignant Transformation of a Choroidal Nevus. Ophthalmology. 2005;112(10):1784-1789. doi:10.1016/j.ophtha.2005.06.011
  • Thiagalingam S. Absence of Change in Choroidal Nevi Across 5 Years in an Older Population. Arch Ophthalmol. 2004;122(1):89. doi:10.1001/archopht.122.1.89
  • You QS, Xu L, Jonas JB, Wang S, Yang H. Change in choroidal nevi during a 5-year follow-up study: the Beijing Eye Study. British Journal of Ophthalmology. 2010;94(5):575-578. doi:10.1136/bjo.2009.165720

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