Faculty Bibliography

PURPOSE: This study was conducted to investigate a case of reactive lymphoid hyperplasia following laser assisted in situ keratomileusis (LASIK). METHODS: A 31-year-old man who underwent LASIK presented 1 month later with a fleshy conjunctival (plical) tumor in the left eye. An excision biopsy of the tumor was performed. RESULTS: Histopathology of the excised tumor revealed reactive lymphoid hyperplasia. DISCUSSION: Conjunctival lymphomas can masquerade as chronic conjunctivitis and can be preceded by reactive lymphoid hyperplasia. It is important to identify and differentiate these tumors. This report describes the unusual occurrence of a lymphoid conjunctival tumor after LASIK eye surgery

PURPOSE: To describe the use of debulking surgery with adjuvant external beam irradiation as an eyelid-sparing treatment for renal cell carcinoma. DESIGN: Interventional case report. METHODS: A 63-year-old male presented with a right upper lid tumor. He had a history of renal cell carcinoma and pulmonary metastasis treated with surgery and systemic chemotherapy. The eyelid tumor was biopsied, followed by debulking surgery and external beam radiation therapy to treat this metastatic tumor. RESULTS: Histopathological evaluation of the excised tumor revealed a metastatic renal cell carcinoma, clear cell type. At 4 months' follow-up, he had no evidence of recurrence or radiation oculopathy. He was pleased with his cosmetic result. CONCLUSIONS: Meta static renal cell carcinoma presenting in the eye and orbit can be the initial manifestation of the primary tumor. It is important to include this tumor in the differential diagnosis of recurrent eyelid lesions. Debulking surgery followed by external beam radiation therapy can be used to control the tumor with an eyelid-sparing cosmetic result

Herein, we review the associations between the kidney, renal cancers, and the eye. Renal cancers have been reported to metastasize to the eye and the orbit. As these tumors can be confused with other amelanotic or vascular tumors, a high index of suspicion is required for early detection and management of the primary tumor. We discuss the physiology of metastases, clinical features and management of metastatic disease. A variety of ocular anomalies have been associated with renal disease. Wilms tumor, a renal tumor of childhood, can present with aniridia, which may be the first clue leading to the diagnosis of the primary tumor. Paraneoplastic syndromes are common manifestations of renal cancers and can present as retinopathies and neuro-ophthalmic disorders. Multiple cancer syndromes involve both the eye and the kidney. For example, the diagnosis of von Hippel retinal tumors can lead to a systemic evaluation and discovery of associated visceral tumors. The prognosis, screening, and counseling of such patients is discussed. Newer systemic treatments available for renal tumors, such as interferon alfa, may lead to ocular side effects including retinopathy. These patients require periodic ophthalmic examinations. This review demonstrates the essential role of the ophthalmologist, for early diagnosis and treatment that can help reduce the morbidity and mortality associated with kidney tumors and renal-associated disease

PURPOSE: To report 12-year follow-up experience with topical mitomycin chemotherapy for diffuse and multifocal primary acquired melanosis (PAM) with atypia and conjunctival melanoma. METHODS: Interventional case series of 16 patients. Mitomycin was a primary treatment for residual epithelial disease in ten patients (eight with PAM with atypia and two with conjunctival melanoma) and as an adjuvant to excision and cryotherapy in six with conjunctival malignant melanoma. Primary treatments consisted of mitomycin 0.04% qid for 28 days (two 14-day cycles) and for 7 consecutive days as adjuvant therapy. Patients were followed for both local recurrence and metastatic disease. RESULTS: Sixteen patients were followed for a mean 81 months (range 13-144 months) after treatment. All tumors responded to chemotherapy. Recurrence was noted in eight (three adjuvant and five primary treatment patients). Three underwent orbital exenteration. The remaining five were treated conservatively. The mean time to recurrence was 36.9 months. The short-term mitomycin-related complications included transient keratoconjunctivitis (n=14), severe keratoconjunctivitis (n=1) and one corneal abrasion with scar formation. The long-term complications included pannus (n=2) and corneal haze (n=1). Visual acuity was maintained within two lines in 14 patients (including measurements just prior to exenteration). Three patients died, one of metastatic conjunctival melanoma. CONCLUSIONS: Conjunctival melanoma and PAM responded to mitomycin 0.04% topical chemotherapy; subepithelial nests appeared resistant to treatment. Treatment-related complications were acceptable. In this series, as primary and adjuvant therapy, topical mitomycin yielded an overall recurrence rate of 50%

PURPOSE: To investigate racial/ethnic differences in the development of uveal malignant melanoma in a large population-based study. DESIGN: Observational cross-sectional study. METHODS: With the 1992 to 2000 data that was provided by the National Cancer Institute's Surveillance, Epidemiology, and End Results Program, we calculated age-adjusted incidence rates of uveal melanoma in various racial/ethnic groups (black, Asian and Pacific Islander, Hispanic, and non-Hispanic white). In addition, we calculated the standard incidence ratio (risk ratio) and 95% confidence interval to describe the differences within these racial/ethnic groups. RESULTS: From 1992 to 2000, there were a total of 1352 uveal melanomas that were diagnosed in 11 Surveillance, Epidemiology, and End Results registries with known racial/ethnic groups. The annual age-adjusted incidence (per million population) of uveal melanoma was 0.31 (black), 0.38 (Asian), 1.67 (Hispanic), and 6.02 (non-Hispanic white). The difference in the incidence of uveal melanoma between each racial/ethnic group was highly statistically significant, with the exception of the black versus the Asian population in which there was no statistically significant difference. CONCLUSION: The relative risk of uveal melanoma was 1.2 for Asian and Pacific Islander patients, 5.4 for Hispanic patients, and 19.2 for non-Hispanic white patients as compared with the black patients. If the non-Hispanic white population and the Hispanic population were combined, then the overall white:black ratio was 18:1

AIM: To determine the size of untreated choroidal melanomas resolved by whole body positron emission tomography fused with computed tomography (PET/CT). METHODS: 50 consecutive patients with untreated choroidal melanomas underwent whole body PET/CT. A functionally fused helical CT scan and 18-fluoro-2-deoxyglucose (FDG) PET scans were employed. The tumours were identified (both quantitatively and qualitatively) and compared with clinical measurements derived from ophthalmoscopic, angiographic, and ultrasonographic imaging. Standardised uptake values (SUV) of more than 2.5 were considered positive. RESULTS: Among the 50 patients with choroidal melanoma, PET/CT scan SUVs of more than 2.5 were noted in 14 (28%) tumours. No AJCC T1 class tumours, 33.3% of T2 melanomas, and 75% of T3 melanomas were physiologically identifiable on PET/CT. With respect to COMS group classifications, no small choroidal tumours, 33% of medium, and 75% of large melanomas were physiologically identifiable. The sole ring melanoma was identifiable on PET/CT imaging. The smallest tumour physiologically identifiable by PET/CT had basal dimensions of 3x5.9 and an apical height of 2.9 mm. CONCLUSION: Though PET/CT was found to be capable of physiologically identifying certain medium (T2) and most large sized (T3) choroidal melanomas, physiological imaging was not completely dependent upon tumour size. Functionally fused PET/CT localised the tumours within the eye and assessed their physiological activity

AIM: To investigate the value of whole body positron emission tomography/computed tomography (PET/CT) in screening for metastatic choroidal melanoma in patients initially diagnosed with choroidal melanoma. METHODS: 52 patients with choroidal melanoma underwent whole body PET/CT as part of their metastatic investigation. PET/CT scans were used as a screening tool at the time of their initial diagnosis. A physical examination, liver function tests, and a baseline chest x ray were also obtained. PET/CT images (utilising intravenous18-fluoro-2-deoxyglucose (FDG)) were studied for the presence of metastatic melanoma. The standards for reference were further imaging and/or subsequent biopsies. RESULTS: Two of 52 (3.8%) patients were found to have metastatic melanoma before treatment. The most common sites for metastases were the liver (100%), bone (50%), and lymph nodes (50%). Brain involvement was also present in one patient. One patient (50%) had involvement of multiple sites. Haematological liver enzyme assays were normal in both patients. PET/CT showed false positive results in three patients (5.7%) when further evaluated by histopathology and/or additional imaging. In seven patients (13.4%) PET/CT imaging detected benign lesions in the bone, lung, lymph nodes, colon, and rectum. CONCLUSION: PET/CT imaging can be used as a screening tool for the detection and localisation of metastatic choroidal melanoma. Liver enzyme assays did not identify liver metastases, while PET/CT revealed both hepatic and extrahepatic metastatic melanoma. PET/CT imaging may improve upon the conventional methods of screening for detection of metastatic disease in patients initially diagnosed with choroidal melanoma.

The Collaborative Ocular Melanoma Study (COMS) developed a standardized set of eye plaques that consist of a 0.5 mm thick bowl-like gold alloy backing with a cylindrical collimating lip. A Silastic seed carrier into which 125I seeds are loaded was designed to fit within the backing. The carrier provides a standardized seed pattern and functions to offset the seeds by 1.0 mm from the concave (front) surface of the carrier. These Silastic carriers have been found to be difficult to load, preclude flash sterilization, and are a source of dosimetric uncertainty because the effective atomic number of Silastic is significantly higher than that of water. The main dosimetric effect of the Silastic carrier is a dose-reduction (compared to homogeneous water) of approximately 10%-15% for 125I radiation. The dose reduction is expected to be even greater for 103Pd radiation. In an attempt to improve upon, yet retain as much of the familiar COMS design as possible, we have developed a thin 'seed-guide' insert made of gold alloy. This new insert has cutouts which match the seed pattern of the Silastic carrier, but allows the seeds to be glued directly to the inner surface of the gold backing using either dental acrylic or a cyanoacrylate adhesive. When glued directly to the gold backing the seeds are offset a few tenths of a millimeter further away from the scleral surface compared to using the Silastic carrier. From a dosimetric perspective, the space formerly occupied by the Silastic carrier is now assumed to be water equivalent. Water equivalency is a desirable attribute for this space because it eliminates the dosimetric uncertainties related to the atomic composition of Silastic and thereby facilitates the use of either 125I and/or 103Pd seeds. The caveat is that a new source of dosimetric uncertainty would be introduced were an air bubble to become trapped in this space during or after the surgical insertion. The presence of air in this space is modeled and the dosimetric impact discussed. Another unintended consequence of water equivalency is that some fluorescent x rays emitted from the gold backing can now reach the eye. These very low energy x rays were virtually eliminated by absorption in Silastic. When loaded with 125I seeds the modified plaque appears to produce dose distributions that are almost the same as those of the original COMS plaque and the maximum dosimetric uncertainty introduced by an air bubble is about 2%. Dose distributions calculated for a modified plaque loaded with 103Pd seeds show that dose to healthy ocular structures distal to the tumor apex can be reduced compared to 125I. Clearly, it is faster and easier to glue seeds into the reusable gold seed-guide insert than it is to load the COMS-Silastic carrier