- Email: [email protected]
Optical coherence tomography of melanocytoma
report also brings forward the fact that tuberculosis can present with dystrophic intraocular calcification. REFERENCES
1. Shields JA, Shields CL, Eagle RC Jr, et al. Endogenous endophthalmitis simulating retinoblastoma. Retina 1995;15: 213–219. 2. Stafford WR, Yanoff M, Parnell BS. Retinoblastomas initially misdiagnosed as primary ocular inflammations. Arch Ophthalmol 1969;82:771–773. 3. Shields JA, Parsons HM, Shields CL, et al. Lesions simulating retinoblastoma. J Pediatr Ophthalmol Strabismus 1991;28: 338 –340. 4. Shields CL, Shields JA, Shah P. Retinoblastoma in older children. Ophthalmology 1991;98:395–399.
Optical Coherence Tomography of Melanocytoma Richard J. Antcliff, FRCOphth, Timothy J ffytche, FRCS, FRCOphth, John S. Shilling, FRCS, FRCOphth, John Marshall, PhD To evaluate the use of optical coherence tomography in differentiating between melanocytoma and choroidal melanoma. METHODS: Case reports. Three consecutive patients with melanocytoma were scanned using optical coherence tomography. RESULTS: Optical coherence tomography showed lesions with a high reflectance signal anteriorly and optical shadowing behind, corresponding to the melanocytomas. The high signal was continuous with the retinal nerve fiber layer, consistent with known growth patterns of melanocytoma. CONCLUSION: Optical coherence tomography may be useful in differentiating melanocytoma from choroidal melanocytic lesions. (Am J Ophthalmol 2000;130: 845– 847. © 2000 by Elsevier Science Inc. All rights reserved.)
characteristic growth patterns, including growth deep in the optic nerve parenchyma, in the juxtapapillary choroid, and in the retinal nerve fiber layer.1 Differentiation of melanocytoma from malignant melanoma can be difficult and is based largely on race, position, and chronicity or benign growth pattern, and ultrasound examination is not usually helpful.1 Optical coherence tomography is a new method for high-resolution cross-sectional imaging of the retina. It uses light to detect relative changes in reflection at optical interfaces using the method of low-coherence interferometry. It may be thought of as being analogous to B-scan ultrasonography, although it measures optical instead of acoustic reflection.2 The typical picture of an optical coherence tomography scan of the retina consists of a posterior high reflectance peak usually considered to be the retinal pigment epithelium and choriocapillaris, a lesser peak anteriorly at the vitreoretinal interface, and layers of varied reflectance in between representing the layered arrangement of the retina.3,4 We present three consecutive patients with melanocytoma scanned with optical coherence tomography.
CASE REPORTS
PURPOSE:
M
ELANOCYTOMA IS A BENIGN PIGMENTED TUMOR. ITS
most common position is on or adjacent to the optic nerve head, and it is thought to develop from dendritic uveal melanocytes present in the lamina cribrosa.1 Melanocytomas are relatively more common in darkly pigmented races than uveal melanomas. They have several Accepted for publication June 16, 2000. From the GKT Department of Ophthalmology (R.J.A., J.M.), and the Department of Ophthalmology (T.J.F., J.S.S.), Rayne Institute, St Thomas’ Hospital, London, England. Richard J. Antcliff was supported by the Allerton Fund. Inquiries to Richard J. Antcliff, FRCOphth, GKT Department of Ophthalmology, Rayne Institute, St Thomas’ Hospital, Lambeth Palace Rd, London SE1 7EH, England; fax: (⫹44) 20 7401 9062.
VOL. 130, NO. 6
PATIENT 1 WAS A 35-YEAR-OLD WOMAN OF AFRO-CARIB-
bean origin who presented on July 29, 1999, with decreased vision in her right eye. Her visual acuities were RE: 20/200 and LE: 20/20. Examination of her fundus revealed a large pigmented lesion adjacent to her right optic disk with subretinal fluid extending under the fovea. The appearance was suggestive of a melanocytoma. Optical coherence tomography scanning of her right eye showed a large lesion extending anteriorly with a single high reflectance line and optical shadowing behind this. The high reflectance layer overlying the optical shadowing produced by the melanocytoma was continuous with the high reflectance signal produced by the adjacent retinal nerve fiber layer (Figure 1, top). Her subretinal fluid resolved spontaneously, and her right visual acuity improved to 20/80 in three months. Patient 2 was a 63-year-old Caucasian woman with a pigmented lesion in her right eye found incidentally on routine examination 40 years ago. It was found that she probably had a melanocytoma and was advised conservative management. Regular follow-up over the period revealed no change in the lesion, and her visual acuity remained 20/40. Optical coherence tomography scanning of the lesion showed a high reflectance band anteriorly with optical shadowing behind. The high reflectance band produced by the melanocytoma was continuous with the high reflectance signal produced by the adjacent retinal nerve fiber layer (Figure 1, bottom). Patient 3 was a 75-year-old woman who had been noted to have a pigmented lesion at her right optic disk on routine
BRIEF REPORTS
845
FIGURE 1. (A) Right eye of patient 1, and (B) right eye of patient 2. Color photographs on the right and optical coherence tomography scans on the left. Color photographs show melanocytomas of the right optic disks. The optical coherence tomography scans show high reflectance layer (white) with optical shadowing behind, representing the melanocytomas. The high reflectance layer produced by the melanocytomas is continuous with the high reflectance layer produced by the retinal nerve fiber layer in the adjacent retina (solid arrows). The optical coherence tomography scans are 2 mm deep, and the horizontal bars represent 200 m. Dashed arrows in the color photographs show the orientation of the scans.
FIGURE 2. Right eye of patient 3. Color photograph on the right and optical coherence tomography scan on the left. Color photograph shows a small melanocytoma of the right optic disk. The optical coherence tomography scan shows a thick high reflectance layer (white) with optical shadowing behind, representing the melanocytoma. The high reflectance layer produced by the melanocytoma is continuous with the high reflectance layer produced by the retinal nerve fiber layer in the adjacent retina (solid arrow). The optical coherence tomography scan is 2 mm deep, and the horizontal bar represents 200 m. Dashed arrow in the color photograph shows the orientation of the scan.
examination 26 years ago. She was found to have a melanocytoma and was advised conservative management. Regular follow-up had revealed no change in the lesion, and her visual 846
AMERICAN JOURNAL
acuity remained 20/30. Optical coherence tomography scanning of the lesion showed a thick band of a high signal anteriorly with optical shadowing behind this. The high OF
OPHTHALMOLOGY
DECEMBER 2000
reflectance band produced by the melanocytoma was continuous with the high reflectance signal produced by the adjacent retinal nerve fiber layer (Figure 2).
COMMENT OPTICAL COHERENCE TOMOGRAPHY IN ALL THREE EYES
with melanocytoma showed a high reflectance signal overlying optical shadowing, which corresponded with the melanocytoma. This high reflectance signal was continuous with the retinal nerve fiber layer in the adjacent retina and not with the posterior high reflectance signal generated by the retinal pigment epithelium and choriocapillaris. This corresponds with the known growth pattern of melanocytomas.1 By contrast, because the retinal pigment epithelium and choriocapillaris form a highly reflective layer attenuating the underlying choroidal signal, optical coherence tomography shows the signal from a choroidal melanoma to be only a little different than that of a normal choroid.5 This is only altered when overlying retinal changes, such as neurosensory detachment or edema, which are well visualized by optical coherence tomography, lead to further attenuation of the choroidal signal. The three patients illustrated here would suggest that optical coherence tomography can be used to differentiate melanocytomas from choroidal melanomas. REFERENCES
1. Reidy JJ, Apple DJ, Steinmetz RL, et al. Melanocytoms: nomenclature, pathogenesis natural history and treatment. Surv Ophthalmol 1985;29:319 –327. 2. Hee MR, Izatt JA, Swanson EA, et al. Optical coherence tomography of the human retina. Arch Ophthalmol 1995;113: 325–332. 3. Toth CA, Narayan DG, Boppart SA, et al. A comparison of retinal morphology viewed by optical coherence tomography and by light microscopy. Arch Ophthalmol 1997;115:1425– 1428. 4. Chauhan DS, Marshall J. The interpretation of optical coherence tomography images of the retina. Invest Ophthalmol Vis Sci 1999;40:2332–2342. 5. Schaudig U, Hassenstein A, Bernd A, Walter A, Richard G. Limitations of imaging choroidal tumours in vivo by optical coherence tomography. Graefe’s Arch Clin Exp Ophthalmol 1998;236:588 –592.
Axonal Loss in a Patient with Anterior Ischemic Optic Neuropathy as Measured with Scanning Laser Polarimetry T. P. Colen, MD, J. A. M. van Everdingen, MD, and H. G. Lemij, MD, PhD VOL. 130, NO. 6
PURPOSE:
To report Nerve Fiber Analyzer (NFA/GDx; Laser Diagnostic Technologies, San Diego, California) measurements in a patient during the early phase of an anterior ischemic optic neuropathy. METHODS: Case report. A 58-year old man with acute anterior ischemic optic neuropathy had repeated NFA/ GDx scans of the nerve fiber layer adjacent to the optic nerve head of the involved eye, as well as repeated HFA 30.2 (Humphrey Field Analyzer; Humphrey Systems, San Leandro, California) visual field examinations. RESULTS: At presentation (day 0), he had a normal superior nerve fiber bundle on the NFA/GDx, with a deep inferior hemifield scotoma. By day 21 and day 36, the superior nerve fiber bundle thinned on the NFA/GDx, whereas the scotoma remained practically unchanged. CONCLUSION: These findings suggest that after the onset of an anterior ischemic optic neuropathy, acute loss of axonal function results in scotoma, presumably from ischemia. This is followed by a gradual disappearance of nerve fiber tissue, as measured with the NFA/GDx, within several weeks. (Am J Ophthalmol 2000;130: 847– 850. © 2000 by Elsevier Science Inc. All rights reserved.)
A
NTERIOR ISCHEMIC OPTIC NEUROPATHY IS THOUGHT
to result from insufficiency in perfusion of the short posterior ciliary arteries1 and leads to infarction of axons in the retinal nerve fiber layer. The Nerve Fiber Analyzer (NFA; Laser Diagnostic Technologies, San Diego, California) is a scanning laser polarimeter, designed for the detection and follow-up of glaucoma. It uses a polarized laserbeam to assess nerve fiber layer thickness in the peripapillary retina, and it discriminates well between normals and glaucoma patients.2,3 The current standard in scanning laser polarimetry is the GDx, a third-generation NFA. A 58-year-old white man presented with blurred vision in the inferior visual field of his right eye (day 0). His symptoms had gradually worsened in the previous 10 days. He did not have any headaches, scalp tenderness, or jaw claudication. He had no ocular history. His visual acuity was RE: 20/40 and LE: 20/15. His sign was a swollen optic disk in the right eye. Erythrocyte sedimentation rate (Westegren) was 4 mm, and the C reactive protein was less than 1 mm (normal less than 8 mm). The right eye showed a deep scotoma in the inferior visual field (HFA 30.2, Humphrey Field Analyzer; Humphrey Systems, San Leandro, CA) and a normal superior nerve fiber bundle on the NFA/GDx (Figure 1). The left eye was unremarkable. A diagnosis of nonarteritic anterior ischemic optic Accepted for publication June 14, 2000. From the Rotterdam Eye Hospital, Rotterdam, The Netherlands. Inquiries to Thomas P. Colen, MD, Glaucoma Service, Rotterdam Eye Hospital, P.O. Box 70030, NL-3000 LM Rotterdam, The Netherlands; fax: ⫹31 10 4017655; e-mail: [email protected]
BRIEF REPORTS
847
1. Shields JA, Shields CL, Eagle RC Jr, et al. Endogenous endophthalmitis simulating retinoblastoma. Retina 1995;15: 213–219. 2. Stafford WR, Yanoff M, Parnell BS. Retinoblastomas initially misdiagnosed as primary ocular inflammations. Arch Ophthalmol 1969;82:771–773. 3. Shields JA, Parsons HM, Shields CL, et al. Lesions simulating retinoblastoma. J Pediatr Ophthalmol Strabismus 1991;28: 338 –340. 4. Shields CL, Shields JA, Shah P. Retinoblastoma in older children. Ophthalmology 1991;98:395–399.
Optical Coherence Tomography of Melanocytoma Richard J. Antcliff, FRCOphth, Timothy J ffytche, FRCS, FRCOphth, John S. Shilling, FRCS, FRCOphth, John Marshall, PhD To evaluate the use of optical coherence tomography in differentiating between melanocytoma and choroidal melanoma. METHODS: Case reports. Three consecutive patients with melanocytoma were scanned using optical coherence tomography. RESULTS: Optical coherence tomography showed lesions with a high reflectance signal anteriorly and optical shadowing behind, corresponding to the melanocytomas. The high signal was continuous with the retinal nerve fiber layer, consistent with known growth patterns of melanocytoma. CONCLUSION: Optical coherence tomography may be useful in differentiating melanocytoma from choroidal melanocytic lesions. (Am J Ophthalmol 2000;130: 845– 847. © 2000 by Elsevier Science Inc. All rights reserved.)
characteristic growth patterns, including growth deep in the optic nerve parenchyma, in the juxtapapillary choroid, and in the retinal nerve fiber layer.1 Differentiation of melanocytoma from malignant melanoma can be difficult and is based largely on race, position, and chronicity or benign growth pattern, and ultrasound examination is not usually helpful.1 Optical coherence tomography is a new method for high-resolution cross-sectional imaging of the retina. It uses light to detect relative changes in reflection at optical interfaces using the method of low-coherence interferometry. It may be thought of as being analogous to B-scan ultrasonography, although it measures optical instead of acoustic reflection.2 The typical picture of an optical coherence tomography scan of the retina consists of a posterior high reflectance peak usually considered to be the retinal pigment epithelium and choriocapillaris, a lesser peak anteriorly at the vitreoretinal interface, and layers of varied reflectance in between representing the layered arrangement of the retina.3,4 We present three consecutive patients with melanocytoma scanned with optical coherence tomography.
CASE REPORTS
PURPOSE:
M
ELANOCYTOMA IS A BENIGN PIGMENTED TUMOR. ITS
most common position is on or adjacent to the optic nerve head, and it is thought to develop from dendritic uveal melanocytes present in the lamina cribrosa.1 Melanocytomas are relatively more common in darkly pigmented races than uveal melanomas. They have several Accepted for publication June 16, 2000. From the GKT Department of Ophthalmology (R.J.A., J.M.), and the Department of Ophthalmology (T.J.F., J.S.S.), Rayne Institute, St Thomas’ Hospital, London, England. Richard J. Antcliff was supported by the Allerton Fund. Inquiries to Richard J. Antcliff, FRCOphth, GKT Department of Ophthalmology, Rayne Institute, St Thomas’ Hospital, Lambeth Palace Rd, London SE1 7EH, England; fax: (⫹44) 20 7401 9062.
VOL. 130, NO. 6
PATIENT 1 WAS A 35-YEAR-OLD WOMAN OF AFRO-CARIB-
bean origin who presented on July 29, 1999, with decreased vision in her right eye. Her visual acuities were RE: 20/200 and LE: 20/20. Examination of her fundus revealed a large pigmented lesion adjacent to her right optic disk with subretinal fluid extending under the fovea. The appearance was suggestive of a melanocytoma. Optical coherence tomography scanning of her right eye showed a large lesion extending anteriorly with a single high reflectance line and optical shadowing behind this. The high reflectance layer overlying the optical shadowing produced by the melanocytoma was continuous with the high reflectance signal produced by the adjacent retinal nerve fiber layer (Figure 1, top). Her subretinal fluid resolved spontaneously, and her right visual acuity improved to 20/80 in three months. Patient 2 was a 63-year-old Caucasian woman with a pigmented lesion in her right eye found incidentally on routine examination 40 years ago. It was found that she probably had a melanocytoma and was advised conservative management. Regular follow-up over the period revealed no change in the lesion, and her visual acuity remained 20/40. Optical coherence tomography scanning of the lesion showed a high reflectance band anteriorly with optical shadowing behind. The high reflectance band produced by the melanocytoma was continuous with the high reflectance signal produced by the adjacent retinal nerve fiber layer (Figure 1, bottom). Patient 3 was a 75-year-old woman who had been noted to have a pigmented lesion at her right optic disk on routine
BRIEF REPORTS
845
FIGURE 1. (A) Right eye of patient 1, and (B) right eye of patient 2. Color photographs on the right and optical coherence tomography scans on the left. Color photographs show melanocytomas of the right optic disks. The optical coherence tomography scans show high reflectance layer (white) with optical shadowing behind, representing the melanocytomas. The high reflectance layer produced by the melanocytomas is continuous with the high reflectance layer produced by the retinal nerve fiber layer in the adjacent retina (solid arrows). The optical coherence tomography scans are 2 mm deep, and the horizontal bars represent 200 m. Dashed arrows in the color photographs show the orientation of the scans.
FIGURE 2. Right eye of patient 3. Color photograph on the right and optical coherence tomography scan on the left. Color photograph shows a small melanocytoma of the right optic disk. The optical coherence tomography scan shows a thick high reflectance layer (white) with optical shadowing behind, representing the melanocytoma. The high reflectance layer produced by the melanocytoma is continuous with the high reflectance layer produced by the retinal nerve fiber layer in the adjacent retina (solid arrow). The optical coherence tomography scan is 2 mm deep, and the horizontal bar represents 200 m. Dashed arrow in the color photograph shows the orientation of the scan.
examination 26 years ago. She was found to have a melanocytoma and was advised conservative management. Regular follow-up had revealed no change in the lesion, and her visual 846
AMERICAN JOURNAL
acuity remained 20/30. Optical coherence tomography scanning of the lesion showed a thick band of a high signal anteriorly with optical shadowing behind this. The high OF
OPHTHALMOLOGY
DECEMBER 2000
reflectance band produced by the melanocytoma was continuous with the high reflectance signal produced by the adjacent retinal nerve fiber layer (Figure 2).
COMMENT OPTICAL COHERENCE TOMOGRAPHY IN ALL THREE EYES
with melanocytoma showed a high reflectance signal overlying optical shadowing, which corresponded with the melanocytoma. This high reflectance signal was continuous with the retinal nerve fiber layer in the adjacent retina and not with the posterior high reflectance signal generated by the retinal pigment epithelium and choriocapillaris. This corresponds with the known growth pattern of melanocytomas.1 By contrast, because the retinal pigment epithelium and choriocapillaris form a highly reflective layer attenuating the underlying choroidal signal, optical coherence tomography shows the signal from a choroidal melanoma to be only a little different than that of a normal choroid.5 This is only altered when overlying retinal changes, such as neurosensory detachment or edema, which are well visualized by optical coherence tomography, lead to further attenuation of the choroidal signal. The three patients illustrated here would suggest that optical coherence tomography can be used to differentiate melanocytomas from choroidal melanomas. REFERENCES
1. Reidy JJ, Apple DJ, Steinmetz RL, et al. Melanocytoms: nomenclature, pathogenesis natural history and treatment. Surv Ophthalmol 1985;29:319 –327. 2. Hee MR, Izatt JA, Swanson EA, et al. Optical coherence tomography of the human retina. Arch Ophthalmol 1995;113: 325–332. 3. Toth CA, Narayan DG, Boppart SA, et al. A comparison of retinal morphology viewed by optical coherence tomography and by light microscopy. Arch Ophthalmol 1997;115:1425– 1428. 4. Chauhan DS, Marshall J. The interpretation of optical coherence tomography images of the retina. Invest Ophthalmol Vis Sci 1999;40:2332–2342. 5. Schaudig U, Hassenstein A, Bernd A, Walter A, Richard G. Limitations of imaging choroidal tumours in vivo by optical coherence tomography. Graefe’s Arch Clin Exp Ophthalmol 1998;236:588 –592.
Axonal Loss in a Patient with Anterior Ischemic Optic Neuropathy as Measured with Scanning Laser Polarimetry T. P. Colen, MD, J. A. M. van Everdingen, MD, and H. G. Lemij, MD, PhD VOL. 130, NO. 6
PURPOSE:
To report Nerve Fiber Analyzer (NFA/GDx; Laser Diagnostic Technologies, San Diego, California) measurements in a patient during the early phase of an anterior ischemic optic neuropathy. METHODS: Case report. A 58-year old man with acute anterior ischemic optic neuropathy had repeated NFA/ GDx scans of the nerve fiber layer adjacent to the optic nerve head of the involved eye, as well as repeated HFA 30.2 (Humphrey Field Analyzer; Humphrey Systems, San Leandro, California) visual field examinations. RESULTS: At presentation (day 0), he had a normal superior nerve fiber bundle on the NFA/GDx, with a deep inferior hemifield scotoma. By day 21 and day 36, the superior nerve fiber bundle thinned on the NFA/GDx, whereas the scotoma remained practically unchanged. CONCLUSION: These findings suggest that after the onset of an anterior ischemic optic neuropathy, acute loss of axonal function results in scotoma, presumably from ischemia. This is followed by a gradual disappearance of nerve fiber tissue, as measured with the NFA/GDx, within several weeks. (Am J Ophthalmol 2000;130: 847– 850. © 2000 by Elsevier Science Inc. All rights reserved.)
A
NTERIOR ISCHEMIC OPTIC NEUROPATHY IS THOUGHT
to result from insufficiency in perfusion of the short posterior ciliary arteries1 and leads to infarction of axons in the retinal nerve fiber layer. The Nerve Fiber Analyzer (NFA; Laser Diagnostic Technologies, San Diego, California) is a scanning laser polarimeter, designed for the detection and follow-up of glaucoma. It uses a polarized laserbeam to assess nerve fiber layer thickness in the peripapillary retina, and it discriminates well between normals and glaucoma patients.2,3 The current standard in scanning laser polarimetry is the GDx, a third-generation NFA. A 58-year-old white man presented with blurred vision in the inferior visual field of his right eye (day 0). His symptoms had gradually worsened in the previous 10 days. He did not have any headaches, scalp tenderness, or jaw claudication. He had no ocular history. His visual acuity was RE: 20/40 and LE: 20/15. His sign was a swollen optic disk in the right eye. Erythrocyte sedimentation rate (Westegren) was 4 mm, and the C reactive protein was less than 1 mm (normal less than 8 mm). The right eye showed a deep scotoma in the inferior visual field (HFA 30.2, Humphrey Field Analyzer; Humphrey Systems, San Leandro, CA) and a normal superior nerve fiber bundle on the NFA/GDx (Figure 1). The left eye was unremarkable. A diagnosis of nonarteritic anterior ischemic optic Accepted for publication June 14, 2000. From the Rotterdam Eye Hospital, Rotterdam, The Netherlands. Inquiries to Thomas P. Colen, MD, Glaucoma Service, Rotterdam Eye Hospital, P.O. Box 70030, NL-3000 LM Rotterdam, The Netherlands; fax: ⫹31 10 4017655; e-mail: [email protected]
BRIEF REPORTS
847