‫بسم هللا الرحمن الرحيم‬
Case presentation
By
SAAD ALDAHMASH,MD
• 53 years old gentleman K/C:
•
1) HCV on ribavirin 600 mg bid &
Interferon –alpha 125ug once a week for
almost 8/12 .
•
2)Ulcerative colitis on mesalazine for
long time .
• No other medical illness .
• C/O scotoma in the Right eye for the last
one year.
• No Hx of decrease VA.
• No Hx of other ocular symptoms .
• No Hx of previous ocular disease or
surgery.
Ocular examination
• VA OD 20/20
OS 20/20
• IOP OD 17 mmhg
OS 19 mmhg
• A/S OD WNL
OS WNL
Fundus Exam OD
OD
OD
FFA (red free)
28 sec
41 sec
3min 11sec
5min 33 sec
B-Scan
•
•
•
3.48 mm H.T
8.21 mm Transverse
9.02 mm vertical
A-Scan
Doppler
Solid & high vascular lesion
DDx
•
•
•
•
•
Choroidal melanoma.
Choroidal nevus.
Metastasis.
Osteoma.
Circumscribed choroidal haemangioma.
Diagnosis
• Medium size Choroidal
melanoma with retinal invasion
OD.
• Interferon-Alpha related CWS
OU .
Ocular side effects of interferon
• Decrease or loss of vision,
retinopathy including macular edema,
retinal artery or vein thrombosis,
retinal hemorrhages and cotton wool
spots, optic neuritis, and papilledema
are induced or aggregated by
treatment with alpha interferons.
Overview of management of CM
• Several factors affecting choosing
treatment modalities including :
• Size & location & extent of the tumor .
• Visual status of the affected eye and
fellow eye as well .
• Age & general health of the patient .
Standard treatment options
• *) observation :
• may be appropriate for elderly
,systemically ill patient where other
modalities are not applicable ;
• It may be indicated for small size tumors
for close observation especialy if signs of
chronicity present (e.g drusen) .
Standard treatment options
• *)Radioactive plaque
therapy(brachtherapy):
• It is the 1st choice Rx for most medium
sized & small tumors .
• It has the advantage of it is globe
preserving procedure ( with some vision) .
Standard treatment options
• By applying radioactive plaque over the
sclera overlying the tumor allows delivery
of high dose of radiation to the tumor &
relatively low dose to surrounding retina.
• Various isotopes used most commonly
used are : cobalt 60 , Iodine
125,ruthenium106.
• Local tumor control rate as high as 96%.
Standard treatment options
• Main side effects are mainly to the
surrounding tissue & they include :
•
•
•
•
•
Optic Neuropathy .
Retinopathy .
Vit. Hge .
Cataract .
All these side effects are dose dependent .
Standard treatment options
• *)Charged particle Radiation :
• Main indication are those tumors
unsuitable for brachytherapy because of
the size of tumor or posterior location near
ON or fovea (<= 4 mm distance ) .
• It delivers more homogeneous dose of
radiation to the tumor than does brachy
therapy .
Standard treatment options
• It gives local tumor control rate up to98%.
• It deliver high energy dose to anterior
segment structures .
• Main S/E :
•
•
•
•
NVG .
Cataract.
ERD .
Retinopathy.
Standard treatment options
• *)Enucleation :
• Historically was the gold standard of
treatment ; it is now still the appropriate
option for a) all large size tumors .
b) some medium size tumors
especially if all useful vision is irreversibly
lost.
Standard treatment options
• The Hypothesis of Enucleation is
increasing chance of cellular
spreading intraoperatively ;increasing
mortality no longer acceptable
nowadays.
Standard treatment options
• *)External beam radiation therapy :
• Is ineffective as a monotherapy ; but may
be effective in limiting orbital recurrences
in large melanomas .
• It could be also alternative to exentration if
combined with enucleation.
• It is not statistically significant in reducing
5 years mortality .
Investigational treatment modalities
• *)TTT (transpupillary thermotherapy ):
• By using diode laser ; it may lead to
rupturing Bruch`s membrane , acceleration
of tumor growth , increasing recurrence .
• If combined with either brachytherapy or
charged particle radiotherapy may lead to
better local control of tumor .
Investigational treatment modalities
• *) cryotherapy :
• Many personal experience for small size
tumors .
• *) transscleral diathermy: is
contraindicated for all malignant
intraocular tumors ; because it leads to
scleral damage & providing a rout for
extrascleral extension .
Investigational treatment modalities
• *) PDT :
• Many case reports for small subfoveal
amelanotic melanoma : but they lack the
long period follow up , small no.
• *) Exentration :
• For extrascleral extension ; but rarely done
nowadays because combined enucleation
+local external radiotherapy achieved
survival outcomes similar to Exentration.
Investigational treatment modalities
• *) Surgical excision of the tumor :
• A) transsclera .
• B) transretinal .
• There are many personal experiences for small
& medium size tumors which were excised
successfully ; but they lack nature of evidence
based practice until metaanalysis or at least
strong double blinded clinical trials with long
follow up are available .
Investigational treatment modalities
• The disadvantages of surgical approach:
• Difficult surgically .
• Inability to evaluate tumor margins for residual
disease .
• High incidence of pathologically recognized
scleral & retinal & vitreous involvement .
• risk of malignant cells spread intraoperatively .
Prognosis
• Poor prognostic factors are :
• 1) Large tumor size:
5 years mortality for
a) small tumors ( B.D 4-8 mm & thickness 12.4 mm ) is 12% .
b) medium tumors ( B.D 6-<16 mm&
thickness 2.5- ,10 mm ) is 30% .
c) large tumors ( B.D >16 mm & thickness
>10 mm ) is 50% .
Prognosis
2) anterior location of tumor .
3) extraocular extension .
4) tumor regrowth after local treatment .
5) histopathological e.g dominant epitheloid
cells
6) presence of metastasis e.g
life expectancy in case of liver metastasis
is <3/12.
Summary
• Standard treatment for choroidal melanoma :
1) observation.
2) globe preserving :
a) Brachytherapy ; for medium and small
tumors.
b) charged-particle therapy; for cases not
suitable for brachytherapy ( size or location )
3) Enucleation : for large tumors & eyes lost their
vision irreversibly;.( +/- external local radiation).
What you will choose for our case?