- Email: [email protected]
Poster 29: Ciliary Body Melanoma: Clinical Diagnosis and Management
312 scattered dot and blot hemorrhages in both eyes. B-scan ultrasonography showed possible underlying drusen in the right optic nerve head and significant elevation of the left optic nerve head without underlying drusen. Visual field testing showed an enlarged blind spot OU. Immediate CT scan revealed no space-occupying lesion. Laboratory test results revealed an elevated ESR of 42, low platelet count and hematocrit, and an elevated HgbA1c of 9.0%. The RPR was negative. MRI of the head and optic nerves revealed no space-occupying lesion or hemorrhages, no optic nerve infiltration, and normal cavernous sinuses. Magnetic resonance angiography and magnetic resonance venogram were both normal and showed no thrombosis. Lumbar puncture revealed an equal and normal opening and closing pressure; however, cultures of the cerebrospinal fluid were not performed. Carotid Doppler showed no radiographic evidence of significant carotid stenosis. Conclusion: Currently, the primary differentials include diabetic papillopathy and papilledema. This poster will evaluate various differentials of elevated optic nerve edema with a focus on papilledema and diabetic papillopathy. Management and treatment of our patient will also be discussed. Poster 28 Trouble in the Tropics Zoeanne Schinas, O.D., and Julie A. Tyler, O.D., Nova Southeastern University, College of Optometry, 3200 South University Drive, Ft. Lauderdale, Florida 33328 Background: The term tropical spastic paraparesis (TSP) was first used in 1969 in reference to a chronic and progressive neurologic disorder that affects individuals within the equatorial regions of the world. Originally the condition was believed to be associated with exposure to various agents that resulted in an immune dysfunction. The precipitating agents included infectious pathogens, longstanding nutritional deficiencies, and exposure to toxic foods. In the 1980s, a new association was identified between TSP and HTLV-1, a type C retrovirus. Since this association was recognized, the condition has also been described as HTLV1–associated myelopathy/tropical spastic paraparesis or HAM/TSP. Case Report: A 31-year-old black woman presented to the clinic with complaints of floating spots and flashes of light O.S. Her ocular history was significant for recurrent uveitis OU successfully treated with topical ocular medications. The patient’s medical history was significant for TSP that restricted her mobility to a wheelchair. Bestcorrected visual acuity was 20/20 O.D. and 20/25 O.S. Preliminary testing was without defect. Biomicroscopy was unremarkable O.D.; however, the O.S. revealed cells without flare, mutton fat KP, and Arlt’s triangle with a clear cornea. No synechiae were present. Intraocular pressure was 18 mmHg and 22 mmHg, O.D. and O.S.
Optometry, Vol 79, No 6, June 2008 respectively. Dilated fundus and vitreous examinations were performed. A vitritis was noted, resulting in a hazy retinal view O.S. The retina was without pathology or scarring in both eyes. The optic nerves were pink and distinct OU with C/D ratio asymmetry, O.S. greater than O.D. Because of presumed systemic association and the unusual nature of the patient’s condition, she was referred for an ophthalmologic consult. Conclusion: TSP is a rare systemic condition with ocular manifestations including keratoconjunctivitis sicca and uveitis. Differential diagnosis for atypical uveitis will be discussed, as well as a review of the various systemic manifestations for this interesting neurologic condition. Poster 29 Ciliary Body Melanoma: Clinical Diagnosis and Management Ryan K. Patel, O.D., and Sanjeet K. Shahi, O.D., Lake City VAMC, 619 South Marion Avenue, Lake City, Florida 32025 Background: Uveal melanomas are the most common primary intraocular malignancies that are located in the choroid (70%), ciliary body (25%), and iris (5%). The annual incidence of uveal melanoma is 6 to 8 cases per 1 million with approximately 1,500 new diagnoses each year in the United States. While ciliary body tumors are rare, malignant melanomas usually display the following characteristics: a sectoral cataract, lenticular astigmatism, extrascleral extension, or a visual field defect. The composition of primary ciliary body melanomas is usually melanocytes from the uveal tract. There are 3 distinct cell types that are used to describe uveal melanomas; spindle A, spindle B, and epithelioid. The epithelioid cell types predict a poorer prognosis because of the aggressive behavior of these neoplasms. Prompt treatment is necessary after the initial diagnosis because of the association of distant metastasis resulting in an overall mortality rate of 30% to 50%. Treatment options include I-125 plaque brachytherapy, external beam irradiation, sclerouvectomy, enucleation, and in widespread cases orbital exenteration. Case Summary: A 65-year-old white man presented to the clinic for an annual eye examination. His medical history was positive for hypertension, gastroesophageal reflux disease, dyslipidemia, and actinic keratosis. Examination revealed best-corrected visual acuities of 20/50 in each eye. The right pupil appeared irregularly shaped with normal reaction to light, and the left pupil showed a brisk reaction to light. Slit lamp examination of the right eye revealed a focal elevation of the iris superonasally with a dark brown mass extending posteriorly and inferiorly onto the posterior chamber intraocular lens. Gonioscopic examination revealed extension into the anterior chamber with black pigmentary changes. Examination of the posterior segment of both eyes was unremarkable with no masses or elevations. Approximate dimensions of the mass on magnetic reso-
Poster Presentations nance imaging were 7x5 mm. A full metastatic workup was performed, which included CT scans of the chest, abdomen, and thorax. The results revealed 2 small lesions in the lung of approximately 1.8 mm and 8 mm in length. Oncology results revealed the lesions were not of significance for a primary site of metastasis and will be monitored quarterly by a series of CT scans. Based on the clinical characteristics of the lesion, a final diagnosis of a ciliary body melanoma was made, and prompt treatment was initiated by an ocular oncologist. Treatment with I-125 plaque radiotherapy was performed successfully for 4 days, and surgical removal of the plaque was completed with no complications on the fifth day. After treatment, the patient will be monitored frequently by oncology, hematology, and his eye care team for recurrences of this disease process. Conclusion: Ciliary body melanomas with metastatic involvement are rare and need to be managed carefully with systemic considerations. Recognizing the signs of uveal tumors that need immediate attention can be life saving for those individuals with or without metastatic disease. Because these uveal tumors carry a high mortality rate and a potential for life-threatening visual loss from treatment, they require prompt referral. Poster 30 Ocular Complications From Consensus Interferon Therapy for Hepatitis C Virus: A Case Report Jeanine Morasch, O.D., Sarah Singleton, O.D., Deanna Lum, O.D., Alyon Wasik, O.D., and Richard Ober, M.D., Southern AZ VA Healthcare System, Eye Clinic, 3601 S. 6th Avenue (2-112A), Tucson, Arizona 85723 Background: Chronic hepatitis C virus (HCV) is a leading cause of liver cirrhosis in the United States. Interferon (IFN) therapy, the most common treatment for HCV, is administered once per week in the pegylated form. Consensus interferon (interferon alphacon-1) is a new, recombinant, non-naturally occurring interferon consisting of a 166-protein sequence. Dosing is daily for 48 weeks, and it is used in cases of relapse or poor response to traditional IFN. Ocular side effects of IFN include retinal hemorrhages, cotton wool spots (CWS), and optic neuropathy. This poster presents a case of consensus interferon (CIFN) retinopathy and optic neuropathy. Case report: A 57-year-old white man reported 2 episodes of “swirling” temporal field O.D. lasting 1 hour and mild blurry vision OU for 1 month. He started CIFN daily for HCV 1 month ago. Last complete blood counts revealed an absolute neutrophil count of 900/uL. Ocular history was noncontributory. Medical history revealed HTN controlled with medication, no DM. BCVA was 20/20 O.D., O.S. Pupils, confrontation visual fields, and IOP were unremarkable. Dilated fundus exam showed mild venous dilation OU and 1 CWS nasal to the optic nerve O.D. Both discs had a congested, hyperemic appearance temporally O.D. greater
313 than O.S. and dilated, tortuous disc vessels inferonasal O.D. Humphrey visual fields showed generally reduced sensitivity O.D., mild inferior defects O.S. Stratus OCT 4.0 fast RNFL showed greater-than-normal average thickness O.D. compared with O.S. in superior and temporal quadrants. Fast optic disc showed mild rim and peripapillary thickening O.D. Intravenous fluorescein angiography showed extensive disc dilations, mild nasal leakage without filling defects O.D. CIFN was discontinued the next day by the prescribing gastroenterologist because of ocular findings and neutropenia. Signs and symptoms gradually resolved over 3 months. After 5 months, OCT fast RNFL and fast optic disc were stable O.D., O.S. Conclusion: Ocular side effects of IFN are well-documented in the literature, but little is known about adverse effects of CIFN. This case demonstrates that ocular side effects seen with traditional IFN can occur with CIFN, but may be more frequent and severe because of increased dosing. CIFN is an important differential diagnosis for retinopathy or optic neuropathy. Poster 31 Restasis® Can Trigger Ocular Infections in Populations at Risk Valerie Lefebvre, O.D., and Greg Black, O.D., Nova Southeastern University, College of Optometry, 3200 South University Drive, Ft. Lauderdale, Florida 33328 Case Report: A 52-year-old white man with a positive history for human immunodeficiency virus (HIV) presented for a comprehensive examination. The patient had a longstanding history of dry eyes secondary to aqueous deficiency, ineffectively controlled with artificial tears. Restasis® (Cyclosporine Ophthalmic Emulsion 0.05%) therapy was initiated. Two weeks later, the patient returned to the clinic complaining of burning in his right eye. The slit lamp examination found 2 dendrites, and the patient was diagnosed with herpes simplex virus (HSV) keratitis. Discussion: Restasis® is a topical immunomodulator indicated to treat keratoconjunctivitis sicca of inflammatory etiology. Because of its anti-inflammatory effects, it is contraindicated in patients with active ocular infection. This case report suggests that it should be used with caution in immunocompromised patients at risk for secondary infections. Poster 32 Delayed Treatment of Orbital Meningioma in a Pregnant Chinese Woman: A Case Report Larry Hou-Yan Ng, O.D., Jimmy Tse, BSc (Hons) Optom, The Hong Kong Polytechnic University Background: To report a case of orbital meningioma in a 16-weeks pregnant Chinese woman. Case history: A 37-year-old pregnant Chinese female myope, GK, presented to our optometry clinic to have a
Optometry, Vol 79, No 6, June 2008 respectively. Dilated fundus and vitreous examinations were performed. A vitritis was noted, resulting in a hazy retinal view O.S. The retina was without pathology or scarring in both eyes. The optic nerves were pink and distinct OU with C/D ratio asymmetry, O.S. greater than O.D. Because of presumed systemic association and the unusual nature of the patient’s condition, she was referred for an ophthalmologic consult. Conclusion: TSP is a rare systemic condition with ocular manifestations including keratoconjunctivitis sicca and uveitis. Differential diagnosis for atypical uveitis will be discussed, as well as a review of the various systemic manifestations for this interesting neurologic condition. Poster 29 Ciliary Body Melanoma: Clinical Diagnosis and Management Ryan K. Patel, O.D., and Sanjeet K. Shahi, O.D., Lake City VAMC, 619 South Marion Avenue, Lake City, Florida 32025 Background: Uveal melanomas are the most common primary intraocular malignancies that are located in the choroid (70%), ciliary body (25%), and iris (5%). The annual incidence of uveal melanoma is 6 to 8 cases per 1 million with approximately 1,500 new diagnoses each year in the United States. While ciliary body tumors are rare, malignant melanomas usually display the following characteristics: a sectoral cataract, lenticular astigmatism, extrascleral extension, or a visual field defect. The composition of primary ciliary body melanomas is usually melanocytes from the uveal tract. There are 3 distinct cell types that are used to describe uveal melanomas; spindle A, spindle B, and epithelioid. The epithelioid cell types predict a poorer prognosis because of the aggressive behavior of these neoplasms. Prompt treatment is necessary after the initial diagnosis because of the association of distant metastasis resulting in an overall mortality rate of 30% to 50%. Treatment options include I-125 plaque brachytherapy, external beam irradiation, sclerouvectomy, enucleation, and in widespread cases orbital exenteration. Case Summary: A 65-year-old white man presented to the clinic for an annual eye examination. His medical history was positive for hypertension, gastroesophageal reflux disease, dyslipidemia, and actinic keratosis. Examination revealed best-corrected visual acuities of 20/50 in each eye. The right pupil appeared irregularly shaped with normal reaction to light, and the left pupil showed a brisk reaction to light. Slit lamp examination of the right eye revealed a focal elevation of the iris superonasally with a dark brown mass extending posteriorly and inferiorly onto the posterior chamber intraocular lens. Gonioscopic examination revealed extension into the anterior chamber with black pigmentary changes. Examination of the posterior segment of both eyes was unremarkable with no masses or elevations. Approximate dimensions of the mass on magnetic reso-
Poster Presentations nance imaging were 7x5 mm. A full metastatic workup was performed, which included CT scans of the chest, abdomen, and thorax. The results revealed 2 small lesions in the lung of approximately 1.8 mm and 8 mm in length. Oncology results revealed the lesions were not of significance for a primary site of metastasis and will be monitored quarterly by a series of CT scans. Based on the clinical characteristics of the lesion, a final diagnosis of a ciliary body melanoma was made, and prompt treatment was initiated by an ocular oncologist. Treatment with I-125 plaque radiotherapy was performed successfully for 4 days, and surgical removal of the plaque was completed with no complications on the fifth day. After treatment, the patient will be monitored frequently by oncology, hematology, and his eye care team for recurrences of this disease process. Conclusion: Ciliary body melanomas with metastatic involvement are rare and need to be managed carefully with systemic considerations. Recognizing the signs of uveal tumors that need immediate attention can be life saving for those individuals with or without metastatic disease. Because these uveal tumors carry a high mortality rate and a potential for life-threatening visual loss from treatment, they require prompt referral. Poster 30 Ocular Complications From Consensus Interferon Therapy for Hepatitis C Virus: A Case Report Jeanine Morasch, O.D., Sarah Singleton, O.D., Deanna Lum, O.D., Alyon Wasik, O.D., and Richard Ober, M.D., Southern AZ VA Healthcare System, Eye Clinic, 3601 S. 6th Avenue (2-112A), Tucson, Arizona 85723 Background: Chronic hepatitis C virus (HCV) is a leading cause of liver cirrhosis in the United States. Interferon (IFN) therapy, the most common treatment for HCV, is administered once per week in the pegylated form. Consensus interferon (interferon alphacon-1) is a new, recombinant, non-naturally occurring interferon consisting of a 166-protein sequence. Dosing is daily for 48 weeks, and it is used in cases of relapse or poor response to traditional IFN. Ocular side effects of IFN include retinal hemorrhages, cotton wool spots (CWS), and optic neuropathy. This poster presents a case of consensus interferon (CIFN) retinopathy and optic neuropathy. Case report: A 57-year-old white man reported 2 episodes of “swirling” temporal field O.D. lasting 1 hour and mild blurry vision OU for 1 month. He started CIFN daily for HCV 1 month ago. Last complete blood counts revealed an absolute neutrophil count of 900/uL. Ocular history was noncontributory. Medical history revealed HTN controlled with medication, no DM. BCVA was 20/20 O.D., O.S. Pupils, confrontation visual fields, and IOP were unremarkable. Dilated fundus exam showed mild venous dilation OU and 1 CWS nasal to the optic nerve O.D. Both discs had a congested, hyperemic appearance temporally O.D. greater
313 than O.S. and dilated, tortuous disc vessels inferonasal O.D. Humphrey visual fields showed generally reduced sensitivity O.D., mild inferior defects O.S. Stratus OCT 4.0 fast RNFL showed greater-than-normal average thickness O.D. compared with O.S. in superior and temporal quadrants. Fast optic disc showed mild rim and peripapillary thickening O.D. Intravenous fluorescein angiography showed extensive disc dilations, mild nasal leakage without filling defects O.D. CIFN was discontinued the next day by the prescribing gastroenterologist because of ocular findings and neutropenia. Signs and symptoms gradually resolved over 3 months. After 5 months, OCT fast RNFL and fast optic disc were stable O.D., O.S. Conclusion: Ocular side effects of IFN are well-documented in the literature, but little is known about adverse effects of CIFN. This case demonstrates that ocular side effects seen with traditional IFN can occur with CIFN, but may be more frequent and severe because of increased dosing. CIFN is an important differential diagnosis for retinopathy or optic neuropathy. Poster 31 Restasis® Can Trigger Ocular Infections in Populations at Risk Valerie Lefebvre, O.D., and Greg Black, O.D., Nova Southeastern University, College of Optometry, 3200 South University Drive, Ft. Lauderdale, Florida 33328 Case Report: A 52-year-old white man with a positive history for human immunodeficiency virus (HIV) presented for a comprehensive examination. The patient had a longstanding history of dry eyes secondary to aqueous deficiency, ineffectively controlled with artificial tears. Restasis® (Cyclosporine Ophthalmic Emulsion 0.05%) therapy was initiated. Two weeks later, the patient returned to the clinic complaining of burning in his right eye. The slit lamp examination found 2 dendrites, and the patient was diagnosed with herpes simplex virus (HSV) keratitis. Discussion: Restasis® is a topical immunomodulator indicated to treat keratoconjunctivitis sicca of inflammatory etiology. Because of its anti-inflammatory effects, it is contraindicated in patients with active ocular infection. This case report suggests that it should be used with caution in immunocompromised patients at risk for secondary infections. Poster 32 Delayed Treatment of Orbital Meningioma in a Pregnant Chinese Woman: A Case Report Larry Hou-Yan Ng, O.D., Jimmy Tse, BSc (Hons) Optom, The Hong Kong Polytechnic University Background: To report a case of orbital meningioma in a 16-weeks pregnant Chinese woman. Case history: A 37-year-old pregnant Chinese female myope, GK, presented to our optometry clinic to have a