- Email: [email protected]
Melanoma-associated retinopathy and recurrent exudative retinal detachments in a patient with choroidal melanoma
membrane for allograft replacement of severely scarred conjunctiva,4 we have employed this tissue for the replacement of large conjunctival defects after tumor resection. In our case, the extensive area of flat melanosis, a known precursor to melanoma, was treated with cryotherapy for the conjunctival portion and topical mitomycin C chemotherapy for the corneal portion. Mitomycin C averts the visually disabling postoperative scarring and tissue overgrowth that had been seen with previously employed measures of alcohol-induced corneal epitheliectomy.3 We usually delay the application of mitomycin C in these cases for several weeks after surgery when the conjunctiva is completely healed so that transcleral penetration and intraocular complications are avoided. In summary, newer techniques are available for conjunctival tumor management. These techniques may possibly allow improved tissue healing after surgery. Additionally, the flexibility for mucous membrane reconstruction may permit more generous margins to be obtained at the time of excision, hopefully avoiding the problem of margin involvement with melanoma and subsequent tumor recurrence. However, longer follow-up is warranted.
METHODS:
Assessment of fundus findings, fluorescein angiograms, and electroretinograms. RESULTS: The patient had recurrent exudative detachments of the macula in her right eye and electroretinogram responses consistent with the diagnosis of melanoma-associated retinopathy. The abdominal computed tomography (CT) scan was negative, but 13 months later, CT scanning revealed many masses in her liver. Fine-needle biopsy confirmed the diagnosis of metastatic melanoma. CONCLUSION: To our knowledge, this is the first report of melanoma-associated retinopathy in a patient with a previous choroidal melanoma. (Am J Ophthalmol 2001;132:578 –581. © 2001 by Elsevier Science Inc. All rights reserved.)
P
REFERENCES
1. Shields CL, Shields JA, Cater J, et al. Conjunctival malignant melanoma: risks for recurrence, exenteration, metastasis, and death in 150 cases. Arch Ophthalmol 2000;1497–507. 2. Shields JA, Shields CL. Melanocytic tumors. In: Shields JA, Shields CL, editors. Atlas of conjunctival and eyelid tumors. Philadelphia: Lippincott Williams & Wilkins; 1999:243–262. 3. Shields JA, Shields CL, DePotter P. Surgical management of conjunctival tumors: the 1994 Lynn B. McMahan Lecture. Arch Ophthalmol 1997;115:808 – 815. 4. Tseng SC, Prabhasawat P, Lee SH. Amniotic membrane transplantation for conjunctival surface reconstruction. Am J Ophthalmol 1997;124:765–774. 5. Demirci H, McCormick SA, Finger PT. Topical Mitomycin C chemotherapy for conjunctival malignant melanoma and primary acquired melanosis with atypia. Arch Ophthalmol 2000;118:885– 891.
● CASE:
A 69-year-old woman presented with a 2-week history of blurred vision and night blindness. Her ophthalmic history was significant for a choroidal melanoma in the left eye that was treated by enucleation 23 years previously. The patient had no other medical problems and was not taking any medications. She had no family history of night blindness. Best-corrected visual acuity was 20/100 in the right eye. Fundus examination of the right eye showed two small serous retinal detachments, one in the center of the macula
Melanoma-associated Retinopathy and Recurrent Exudative Retinal Detachments in a Patient With Choroidal Melanoma David N. Zacks, MD, PhD, Michael K. Pinnolis, MD, Eliot L. Berson, MD, and Evangelos S. Gragoudas, MD
Accepted for publication May 8, 2001. From the Retina Service and the Berman-Gund Laboratory for the Study of Retinal Degenerations, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston. Supported in part by a Heed Fellowship (D.N.Z.), the Foundation Fighting Blindness (E.L.B.), the Melanoma Research Fund (E.S.G.), and a Senior Investigator Award from Research to Prevent Blindness, New York (E.S.G.). Inquiries to David N. Zacks, MD, PHD, Retina Service, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA, 02114; fax: 617-573-3698; e-mail: [email protected]
PURPOSE:
To report a patient who presented with photopsias, night blindness, exudative retinal detachments, and melanoma-associated retinopathy in her right eye 23 years after the left eye was enucleated for a choroidal melanoma.
578
AMERICAN JOURNAL
ARANEOPLASTIC RETINOPATHIES ARE A SET OF RETI-
nal disorders in which tumors stimulate the production of antibodies against various cells in the retina. Two main types of paraneoplastic retinopathies have been recognized: cancer-associated retinopathy and melanoma-associated retinopathy. Cancer-associated retinopathy is associated with the production of an antibody targeted against the photoreceptor cells and usually occurs in patients with small-cell carcinoma of the lung but has been described with numerous other types of cancers.1 In contrast, melanoma-associated retinopathy occurs in patients with cutaneous melanomas and is caused by an antibody targeted against the retinal bipolar cells.1–3 In this report, we present a patient with the melanoma-associated retinopathy syndrome in whom the primary tumor was a choroidal melanoma in the fellow eye. To our knowledge, this is the first report of such a case.
OF
OPHTHALMOLOGY
OCTOBER 2001
FIGURE 1. (Top) Color photograph of the fundus of the right eye shows the two areas of exudative detachments, one in the center of the macula and one along the superior temporal arcade. Note the pseudohypopyon appearance of the central macular detachment. (Bottom) Late-phase photograph of the fluorescein angiogram shows minimal fluorescein leakage and accumulation in the areas of the detachment.
VOL. 132, NO. 4
BRIEF REPORTS
579
FIGURE 2. Full-field electroretinograms to single (0.5 Hz) flashes of blue or white light and to a 30-Hz white flicker from a normal subject and the patient with melanoma-associated retinopathy. Three consecutive responses are illustrated. Cornea positivity is an upward deflection. Stimulus onset is designated by vertical hatched lines in columns one and two and by vertical shock artifacts in column three. Horizontal arrows designate cone implicit times in column three. Lower normal values are: 0.5 Hz blue, 100 uV; 0.5 Hz white, 350 uV; and 30 Hz flicker, 50 uV. The lower norm for 30 Hz implicit time is 32 msecs.
and a second along the superior temporal arcade (Figure 1, left). No other lesions or masses were found. Fluorescein angiography revealed blockage of the choroidal fluorescence in these areas, with only minimal pooling of dye within the subretinal fluid (Figure 1, right). The enucleated socket on the left side contained no visible or palpable lesions. A full-field electroretinogram showed a nondetectable rod response to a 0.5-Hz blue stimulus and a corneanegative mixed cone-rod response to a 0.5-Hz white stimulus. The cone response to a 30-Hz white flicker was normal in both amplitude and implicit time (Figure 2). Sections of both normal human and rat retinas showed labeling of the rod bipolar cells with the serum IgG fraction of the patient by indirect immunofluorescence (data not shown). Examination for the presence of metastases from her choroidal melanoma was negative, but 13 months later, computed tomography (CT) scanning detected the presence of liver masses. Fine580
AMERICAN JOURNAL
needle biopsy of these masses found clusters of melanoma cells suspicious for metastasis from her previously treated choroidal melanoma. The patient was treated with chemotherapy but died 11 months after the biopsy was performed. Our patient had two findings not previously associated with melanoma-associated retinopathy. First, her retinopathy was presumably secondary to metastases from a choroidal melanoma. All previously described cases of melanoma-associated retinopathy occurred in patients with cutaneous melanoma. Secondly, and for unknown reasons, the retinopathy of our patient was associated with exudative retinal detachments. Clinicians should be alert to the possibility that development of photopsias and night-blindness in the normal fellow eye of a patient with a choroidal melanoma may be caused by melanoma-associated retinopathy, and that these symptoms may predate clinically detectable metastatic disease. OF
OPHTHALMOLOGY
OCTOBER 2001
REFERENCES
1. Solomon SD, Smith JH, O’Brien J. Ocular manifestations of systemic malignancies. Curr Opinion Ophthalmol 1999;10: 447– 451. 2. Berson EL, Lessell S. Paraneoplastic night blindness with malignant melanoma. Am J Ophthalmol 1988;106:307–311. 3. Milam AH, Saari JC, Jacobson SG, et al. Autoantibodies against retinal bipolar cells in cutaneous melanoma-associated retinopathy. Invest Ophthalmol Vis Sci 1993;34:91–100.
Evaluation of the Peripheral Visual Field After Foveal Translocation Akira Kubota, MD, Masahito Ohji, MD, Shunji Kusaka, MD, Atsushi Hayashi, MD, Jun Hosohata, MD, Takashi Fujikado, MD, and Yasuo Tano, MD PURPOSE:
To evaluate the peripheral visual field after foveal translocation with scleral imbrication or 360degree retinotomy. METHODS: Retrospective, single-center, nonrandomized study. We calculated the rate of preservation of the peripheral visual field using Goldmann perimetry by dividing the width of the postoperative V-4 isopter by the preoperative width and expressing the result as a percentage. RESULTS: In nine eyes that underwent scleral imbrication, the rate of preservation was 100.0% superiorly, 102.6% superotemporally, 99.9% temporally, 97.9% inferotemporally, 96.9% inferiorly, 82.3% inferonasally, 93.7% nasally, and 87.3% superonasally. In 33 eyes that underwent 360-degree retinotomy, it was 89.1%, 87.0%, 81.9%, 78.1%, 86.6%, 90.0%, 89.9%, and 86.8%, respectively. CONCLUSION: After foveal translocation with scleral imbrication, the peripheral visual field was preserved except for slight narrowing nasally; 360-degree retinotomy resulted in preservation of the visual field, except for slight narrowing in all meridians. (Am J Ophthalmol 2001;132:581–584. © 2001 by Elsevier Science Inc. All rights reserved.)
F
OVEAL TRANSLOCATION HAS THE POTENTIAL TO IM-
prove visual function. However, postoperative complications are concerns. Several surgical techniques achieve foveal translocation; foveal translocation with 360-degree retinotomy and foveal translocation with scleral imbrication1,2 are the most Accepted for publication May 2, 2001. From the Department of Ophthalmology, Osaka University Medical School, Suita, Japan. Inquiries to Akira Kubota, MD, Department of Ophthalmology, Osaka University Medical School, 2-2 Yamadaoka, Suita 565-0871, Japan; fax: ⫹81-6-6879-3458; e-mail: [email protected]
VOL. 132, NO. 4
commonly used. A total retinal detachment is created in foveal translocation with 360-degree retinotomy, whereas a retinal detachment temporal to the disk is created in foveal translocation with scleral imbrication. Because visual field narrowing resulting from creation of the retinal detachment is of great concern, we retrospectively evaluated the peripheral visual fields before and after translocation surgery. All patients underwent foveal translocation with 360degree retinotomy or foveal translocation with scleral imbrication at Osaka University Hospital. The charts were retrospectively reviewed. The visual field was measured preoperatively and postoperatively using Goldmann perimetry in nine eyes of nine patients who underwent foveal translocation with scleral imbrication and in 33 eyes of 33 patients who underwent foveal translocation with 360-degree retinotomy. The median patient ages were 59.4 years (range, 46 to 71) and 69.8 years (range, 47 to 82), respectively. The median follow-up period was 18.9 months (range, 4 to 38) and 5.7 months (range, 1 to 12.5), respectively. We evaluated the rate of preservation of the peripheral visual field in eight meridians by dividing the postoperative V-4 isopter with the preoperative width and expressing the result as a percentage. ● CASE 1:
A 57-year-old woman with myopic choroidal neovascularization in her left eye underwent foveal translocation with scleral imbrication on August 5, 1999. Her preoperative visual acuity was 20/100; 9 months postoperatively, it was 20/60. The peripheral visual field was maintained postoperatively (Figure 1). ● CASE 2:
A 75-year-old man with age-related macular degeneration in his left eye underwent foveal translocation with 360-degree retinotomy on August 17, 1999. His visual acuity improved from 20/40 to 20/30 9 months postoperatively. The peripheral visual field was slightly narrowed postoperatively (Figure 2). After foveal translocation with scleral imbrication, the average rate preservation of the visual field was 100.0% superiorly, 102.6% superotemporally, 99.9% temporally, 97.9% inferotemporally, 96.9% inferiorly, 82.3% inferonasally, 93.7% nasally, and 87.3% superonasally. After foveal translocation with 360-degree retinotomy, the average rate of preservation of the visual field was 89.1% superiorly, 87.0% superotemporally, 81.9% temporally, 78.1% inferotemporally, 86.6% inferiorly, 90.0% inferonasally, 89.9% nasally, and 86.8% superonasally. After foveal translocation with scleral imbrication, the V-4 isopter was narrowed nasally. The temporal peripheral visual field was unaffected. Therefore, the major factor narrowing the visual field is the creation of a retinal detachment temporal to the disk. After foveal translocation with 360-degree retinotomy, the size of the V-4 isopter was slightly narrowed in all
BRIEF REPORTS
581
METHODS:
Assessment of fundus findings, fluorescein angiograms, and electroretinograms. RESULTS: The patient had recurrent exudative detachments of the macula in her right eye and electroretinogram responses consistent with the diagnosis of melanoma-associated retinopathy. The abdominal computed tomography (CT) scan was negative, but 13 months later, CT scanning revealed many masses in her liver. Fine-needle biopsy confirmed the diagnosis of metastatic melanoma. CONCLUSION: To our knowledge, this is the first report of melanoma-associated retinopathy in a patient with a previous choroidal melanoma. (Am J Ophthalmol 2001;132:578 –581. © 2001 by Elsevier Science Inc. All rights reserved.)
P
REFERENCES
1. Shields CL, Shields JA, Cater J, et al. Conjunctival malignant melanoma: risks for recurrence, exenteration, metastasis, and death in 150 cases. Arch Ophthalmol 2000;1497–507. 2. Shields JA, Shields CL. Melanocytic tumors. In: Shields JA, Shields CL, editors. Atlas of conjunctival and eyelid tumors. Philadelphia: Lippincott Williams & Wilkins; 1999:243–262. 3. Shields JA, Shields CL, DePotter P. Surgical management of conjunctival tumors: the 1994 Lynn B. McMahan Lecture. Arch Ophthalmol 1997;115:808 – 815. 4. Tseng SC, Prabhasawat P, Lee SH. Amniotic membrane transplantation for conjunctival surface reconstruction. Am J Ophthalmol 1997;124:765–774. 5. Demirci H, McCormick SA, Finger PT. Topical Mitomycin C chemotherapy for conjunctival malignant melanoma and primary acquired melanosis with atypia. Arch Ophthalmol 2000;118:885– 891.
● CASE:
A 69-year-old woman presented with a 2-week history of blurred vision and night blindness. Her ophthalmic history was significant for a choroidal melanoma in the left eye that was treated by enucleation 23 years previously. The patient had no other medical problems and was not taking any medications. She had no family history of night blindness. Best-corrected visual acuity was 20/100 in the right eye. Fundus examination of the right eye showed two small serous retinal detachments, one in the center of the macula
Melanoma-associated Retinopathy and Recurrent Exudative Retinal Detachments in a Patient With Choroidal Melanoma David N. Zacks, MD, PhD, Michael K. Pinnolis, MD, Eliot L. Berson, MD, and Evangelos S. Gragoudas, MD
Accepted for publication May 8, 2001. From the Retina Service and the Berman-Gund Laboratory for the Study of Retinal Degenerations, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston. Supported in part by a Heed Fellowship (D.N.Z.), the Foundation Fighting Blindness (E.L.B.), the Melanoma Research Fund (E.S.G.), and a Senior Investigator Award from Research to Prevent Blindness, New York (E.S.G.). Inquiries to David N. Zacks, MD, PHD, Retina Service, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA, 02114; fax: 617-573-3698; e-mail: [email protected]
PURPOSE:
To report a patient who presented with photopsias, night blindness, exudative retinal detachments, and melanoma-associated retinopathy in her right eye 23 years after the left eye was enucleated for a choroidal melanoma.
578
AMERICAN JOURNAL
ARANEOPLASTIC RETINOPATHIES ARE A SET OF RETI-
nal disorders in which tumors stimulate the production of antibodies against various cells in the retina. Two main types of paraneoplastic retinopathies have been recognized: cancer-associated retinopathy and melanoma-associated retinopathy. Cancer-associated retinopathy is associated with the production of an antibody targeted against the photoreceptor cells and usually occurs in patients with small-cell carcinoma of the lung but has been described with numerous other types of cancers.1 In contrast, melanoma-associated retinopathy occurs in patients with cutaneous melanomas and is caused by an antibody targeted against the retinal bipolar cells.1–3 In this report, we present a patient with the melanoma-associated retinopathy syndrome in whom the primary tumor was a choroidal melanoma in the fellow eye. To our knowledge, this is the first report of such a case.
OF
OPHTHALMOLOGY
OCTOBER 2001
FIGURE 1. (Top) Color photograph of the fundus of the right eye shows the two areas of exudative detachments, one in the center of the macula and one along the superior temporal arcade. Note the pseudohypopyon appearance of the central macular detachment. (Bottom) Late-phase photograph of the fluorescein angiogram shows minimal fluorescein leakage and accumulation in the areas of the detachment.
VOL. 132, NO. 4
BRIEF REPORTS
579
FIGURE 2. Full-field electroretinograms to single (0.5 Hz) flashes of blue or white light and to a 30-Hz white flicker from a normal subject and the patient with melanoma-associated retinopathy. Three consecutive responses are illustrated. Cornea positivity is an upward deflection. Stimulus onset is designated by vertical hatched lines in columns one and two and by vertical shock artifacts in column three. Horizontal arrows designate cone implicit times in column three. Lower normal values are: 0.5 Hz blue, 100 uV; 0.5 Hz white, 350 uV; and 30 Hz flicker, 50 uV. The lower norm for 30 Hz implicit time is 32 msecs.
and a second along the superior temporal arcade (Figure 1, left). No other lesions or masses were found. Fluorescein angiography revealed blockage of the choroidal fluorescence in these areas, with only minimal pooling of dye within the subretinal fluid (Figure 1, right). The enucleated socket on the left side contained no visible or palpable lesions. A full-field electroretinogram showed a nondetectable rod response to a 0.5-Hz blue stimulus and a corneanegative mixed cone-rod response to a 0.5-Hz white stimulus. The cone response to a 30-Hz white flicker was normal in both amplitude and implicit time (Figure 2). Sections of both normal human and rat retinas showed labeling of the rod bipolar cells with the serum IgG fraction of the patient by indirect immunofluorescence (data not shown). Examination for the presence of metastases from her choroidal melanoma was negative, but 13 months later, computed tomography (CT) scanning detected the presence of liver masses. Fine580
AMERICAN JOURNAL
needle biopsy of these masses found clusters of melanoma cells suspicious for metastasis from her previously treated choroidal melanoma. The patient was treated with chemotherapy but died 11 months after the biopsy was performed. Our patient had two findings not previously associated with melanoma-associated retinopathy. First, her retinopathy was presumably secondary to metastases from a choroidal melanoma. All previously described cases of melanoma-associated retinopathy occurred in patients with cutaneous melanoma. Secondly, and for unknown reasons, the retinopathy of our patient was associated with exudative retinal detachments. Clinicians should be alert to the possibility that development of photopsias and night-blindness in the normal fellow eye of a patient with a choroidal melanoma may be caused by melanoma-associated retinopathy, and that these symptoms may predate clinically detectable metastatic disease. OF
OPHTHALMOLOGY
OCTOBER 2001
REFERENCES
1. Solomon SD, Smith JH, O’Brien J. Ocular manifestations of systemic malignancies. Curr Opinion Ophthalmol 1999;10: 447– 451. 2. Berson EL, Lessell S. Paraneoplastic night blindness with malignant melanoma. Am J Ophthalmol 1988;106:307–311. 3. Milam AH, Saari JC, Jacobson SG, et al. Autoantibodies against retinal bipolar cells in cutaneous melanoma-associated retinopathy. Invest Ophthalmol Vis Sci 1993;34:91–100.
Evaluation of the Peripheral Visual Field After Foveal Translocation Akira Kubota, MD, Masahito Ohji, MD, Shunji Kusaka, MD, Atsushi Hayashi, MD, Jun Hosohata, MD, Takashi Fujikado, MD, and Yasuo Tano, MD PURPOSE:
To evaluate the peripheral visual field after foveal translocation with scleral imbrication or 360degree retinotomy. METHODS: Retrospective, single-center, nonrandomized study. We calculated the rate of preservation of the peripheral visual field using Goldmann perimetry by dividing the width of the postoperative V-4 isopter by the preoperative width and expressing the result as a percentage. RESULTS: In nine eyes that underwent scleral imbrication, the rate of preservation was 100.0% superiorly, 102.6% superotemporally, 99.9% temporally, 97.9% inferotemporally, 96.9% inferiorly, 82.3% inferonasally, 93.7% nasally, and 87.3% superonasally. In 33 eyes that underwent 360-degree retinotomy, it was 89.1%, 87.0%, 81.9%, 78.1%, 86.6%, 90.0%, 89.9%, and 86.8%, respectively. CONCLUSION: After foveal translocation with scleral imbrication, the peripheral visual field was preserved except for slight narrowing nasally; 360-degree retinotomy resulted in preservation of the visual field, except for slight narrowing in all meridians. (Am J Ophthalmol 2001;132:581–584. © 2001 by Elsevier Science Inc. All rights reserved.)
F
OVEAL TRANSLOCATION HAS THE POTENTIAL TO IM-
prove visual function. However, postoperative complications are concerns. Several surgical techniques achieve foveal translocation; foveal translocation with 360-degree retinotomy and foveal translocation with scleral imbrication1,2 are the most Accepted for publication May 2, 2001. From the Department of Ophthalmology, Osaka University Medical School, Suita, Japan. Inquiries to Akira Kubota, MD, Department of Ophthalmology, Osaka University Medical School, 2-2 Yamadaoka, Suita 565-0871, Japan; fax: ⫹81-6-6879-3458; e-mail: [email protected]
VOL. 132, NO. 4
commonly used. A total retinal detachment is created in foveal translocation with 360-degree retinotomy, whereas a retinal detachment temporal to the disk is created in foveal translocation with scleral imbrication. Because visual field narrowing resulting from creation of the retinal detachment is of great concern, we retrospectively evaluated the peripheral visual fields before and after translocation surgery. All patients underwent foveal translocation with 360degree retinotomy or foveal translocation with scleral imbrication at Osaka University Hospital. The charts were retrospectively reviewed. The visual field was measured preoperatively and postoperatively using Goldmann perimetry in nine eyes of nine patients who underwent foveal translocation with scleral imbrication and in 33 eyes of 33 patients who underwent foveal translocation with 360-degree retinotomy. The median patient ages were 59.4 years (range, 46 to 71) and 69.8 years (range, 47 to 82), respectively. The median follow-up period was 18.9 months (range, 4 to 38) and 5.7 months (range, 1 to 12.5), respectively. We evaluated the rate of preservation of the peripheral visual field in eight meridians by dividing the postoperative V-4 isopter with the preoperative width and expressing the result as a percentage. ● CASE 1:
A 57-year-old woman with myopic choroidal neovascularization in her left eye underwent foveal translocation with scleral imbrication on August 5, 1999. Her preoperative visual acuity was 20/100; 9 months postoperatively, it was 20/60. The peripheral visual field was maintained postoperatively (Figure 1). ● CASE 2:
A 75-year-old man with age-related macular degeneration in his left eye underwent foveal translocation with 360-degree retinotomy on August 17, 1999. His visual acuity improved from 20/40 to 20/30 9 months postoperatively. The peripheral visual field was slightly narrowed postoperatively (Figure 2). After foveal translocation with scleral imbrication, the average rate preservation of the visual field was 100.0% superiorly, 102.6% superotemporally, 99.9% temporally, 97.9% inferotemporally, 96.9% inferiorly, 82.3% inferonasally, 93.7% nasally, and 87.3% superonasally. After foveal translocation with 360-degree retinotomy, the average rate of preservation of the visual field was 89.1% superiorly, 87.0% superotemporally, 81.9% temporally, 78.1% inferotemporally, 86.6% inferiorly, 90.0% inferonasally, 89.9% nasally, and 86.8% superonasally. After foveal translocation with scleral imbrication, the V-4 isopter was narrowed nasally. The temporal peripheral visual field was unaffected. Therefore, the major factor narrowing the visual field is the creation of a retinal detachment temporal to the disk. After foveal translocation with 360-degree retinotomy, the size of the V-4 isopter was slightly narrowed in all
BRIEF REPORTS
581