Pseudomelanomas at a referral ocular oncology center in Brazil / Pseudomelanomas em um centro de referência em oncologia ocular no Brasil

ABSTRACT Objective: To evaluate the epidemiological, clinical, and imaging profile of lesions that mimic choroidal melanoma. Methods: Retrospective study of medical records of suspected choroidal melanoma lesions referred to the Ocular Oncology Service from the Universidade Federal de São Paulo, from 2014 to 2020. Demographic data, clinical history, and exams were evaluated. Results: A total of 104 patients (mean age: 65.57 ± 13.18; 49.04% female) were referred to our service with suspected choroidal melanoma. Of these, 32 (30.77%) were classified as pseudomelanoma, while 72 (69.23%) had a confirmed diagnosis of choroidal melanoma. Pseudomelanoma cases manifested in older individuals (p < 0.001), with smaller lesions in height (p < 0.001), anteroposterior diameter (p = 0.008), and lateral diameter (p = 0.003) on ultrasound. Pseudomelanoma cases were associated with higher frequencies of vitreous hemorrhage (p = 0.014) and lower rates of the presence of a mass (p = 0.001) and retinal detachment (p < 0.001). The main diagnoses of pseudomelanoma cases were choroidal nevus (40.63%), subretinal hemorrhage (18.75%) and choroidal neovascular membrane (18.75%). Conclusion: Almost one third of the cases referred with suspected choroidal melanoma were pseudomelanomas, which demonstrates that there is still a considerable path to improve the ability of general ophthalmologists to clinically discriminate melanoma from other conditions that can mimic it.

RESUMO Objetivo: Avaliar a frequência e o perfil epidemiológico, clínico e de imagem das lesões que simulam o melanoma de coroide. Métodos: Trata-se de estudo de revisão retrospectiva de prontuários de suspeita de lesões de melanoma de coroide de 2014 a 2020 no Setor de Oncologia Ocular da Universidade Federal de São Paulo. Foram avaliados dados demográficos, dados clínicos e exames complementares. Resultados: Um total de 104 pacientes (média de idade: 65,57 ± 13,18; 49,04% do sexo feminino) foram encaminhados ao nosso serviço com suspeita de melanoma de coroide. Destes, 32 (30,77%) foram classificados como pseudomelanoma, enquanto 72 (69,23%) tiveram diagnóstico confirmado de melanoma de coroide. Os casos de pseudomelanoma manifestaram-se em indivíduos mais velhos (p < 0,001) e apresentaram lesões menores em altura (p < 0,001), diâmetro anteroposterior (p = 0,008) e diâmetro lateral (p = 0,003) na ultrassonografia. Os casos de pseudomelanoma estão associados a maiores frequências de hemorragia vítrea (p = 0,014) e menores taxas de presença de massa (p = 0,001) e descolamento de retina (p < 0,001). Os principais diagnósticos dos casos de pseudomelanoma foram nevo (40,63%), hemorragia sub-retiniana (18,75%) e membrana neovascular coroidal (18,75%). Conclusão: Quase um terço dos casos encaminhados com suspeita de melanoma de coroide foram pseudomelanomas, o que demonstra que ainda há um caminho considerável para melhorar a habilidade do oftalmologista geral em discriminar clinicamente o melanoma de outras condições que o simulam.

Population-based incidence of intraocular tumours in Olmsted County, Minnesota.

BACKGROUND/AIMS: To determine population-based incidence of intraocular tumours in Olmsted County, Minnesota. METHODS: Record review of the Rochester Epidemiology Project medical record linkage system from 1 January 2006 to 31 December 2015 for patient demographics, tumour type by clinical diagnosis and presence or absence of confirmation by histopathology. The incidence rate of any intraocular tumour and of each tumour type was calculated per million person-years. Poisson regression analysis was used to analyse changes in incidence over time. RESULTS: There were 948 patients diagnosed with intraocular tumours resulting in an age-adjusted and sex-adjusted incidence rate of 727.5 per million (95% CI: 680.8 to 774.2, p<0.05). Most tumours were benign (953, 98%). Of the benign lesions, melanocytic lesions were the majority (942, 97%), with adjusted incidence rates of 646.9 (95% CI: 602.8 to 691.1) for choroidal nevus and 55.8 (95% CI: 43.2 to 64.8) for iris nevus. Malignant lesions were rare (16, 2%) with 13 cases of choroidal melanoma and 1 case each of iris melanoma, retinal leukaemic infiltration and metastasis. The adjusted incidence rate for choroidal melanoma was 7.1 (95% CI: 2.5 to 11.8). CONCLUSION: In a population-based setting, most intraocular tumours are benign and melanocytic. Although malignant lesions are less common, it is important to remain vigilant with appropriate monitoring given the potential for vision loss and life-threatening malignancy.

Choroidal nevi in children: prevalence, age of onset, and progression.

PURPOSE: To determine the age of onset and prevalence of choroidal nevi in children. METHODS: In this cross-sectional study, the fundus photographs of a pooled sample of children 6 months to 18 years of age with 6-year longitudinal follow-up who participated in the Sydney Paediatric Eye Disease Study, Sydney Myopia Study, and the Sydney Adolescent Vascular Eye Disease Study were reviewed. Prevalence by age, clinical features, and longitudinal follow-up assessment was undertaken. RESULTS: Of 5,533 children (7,059 examinations), 48 children with a choroidal nevus were identified. Prevalence increased with age: <6 years, 0.47%; 6 years, 0.63%; 12 years, 1.06%; 18 years, 1.79%. Nevus was unilateral in all cases (100%), and the majority were melanotic (46, 96%). Most (36 [75%]) were irregular in shape, with ill-defined margins (45 [94%]). All identified nevi were posterior to the equator. All nevi were small, with the average largest basal diameter of 1.6 mm (range, 0.5-3.2) and were not associated with secondary changes (drusen, orange pigment, subretinal fluid). The majority (18/31 [58%]) of nevi remained stable, with 5 of 31 (16%) demonstrating subtle growth (minimum of 600 µm). Four new-onset nevi were documented. Malignant transformation was not observed in any of the nevi. CONCLUSIONS: In our study cohort, the prevalence of choroidal nevi increased with age up to 18 years. The distribution and prevalence of choroidal melanocytic lesions reported herein can be used for designing population-based studies in children that incorporate emerging imaging technologies.

Estimating malignancy risk of melanocytic choroidal tumours detected in the Australian National Eye Health Survey.

Clinical relevance: The malignant potential of choroidal melanocytic tumours detected incidentally in the community is thought to be low, but this has not been assessed using a validated screening tool. An accurate characterisation of the malignant potential of these lesions has implications for resource allocation, service provision, education, and training.Background: MOLES (Mushroom shape, Orange Pigment, Large size, Enlargement, and Subretinal fluid) categorises tumours as 'common naevus', 'low-risk naevus', 'high-risk naevus', and 'probable melanoma'. The MOLES system recommends that patients with common naevi (score = 0) undergo review by a community optometrist every two years, ideally with sequential colour photography. For the remaining patients (score ≥ 1), specialist imaging and assessment are recommended, with referral triaged as non-urgent for patients with low-risk (score = 1) or high-risk naevi (score = 2) and urgent for patients with probable melanoma (score > 2).Methods: Lesions flagged as choroidal melanocytic tumours on retinal photographs taken during the Australian National Eye Health Survey were retrospectively analysed by an ocular oncologist. Each lesion was assigned a MOLES score and categorised as common, low-risk, high-risk or probable melanoma.Results: Seventy-seven choroidal naevi were identified. Seventy-five (97%) of the choroidal naevi were categorised as common naevi, with a MOLES score of 0. Two (3%) choroidal naevi had a score of 1 and diagnosed as low-risk naevi due to their size. No naevi had a score of 2 or more.Conclusion: All choroidal naevi detected in this nationally representative population survey were innocuous. This suggests that the vast majority of choroidal melanocytic tumours that are incidentally detected in Australia can be managed in primary eye care settings without the need for specialist referral. MOLES provides a simple evidence-based method for choroidal naevi assessment in primary care.

Clinical Spectrum of Uveal Metastasis in Korean Patients Based on Primary Tumor Origin.

PURPOSE: To describe the clinical features and prognosis of patients with uveal metastasis in Korea. DESIGN: Retrospective, observational case series. PARTICIPANTS: Patients diagnosed at 2 tertiary high-volume centers between November 2005 and November 2019. METHODS: Evaluation of multimodal imaging and electronic medical records. MAIN OUTCOME MEASURES: The clinical features and outcomes were assessed based on the primary cancer site. RESULTS: A total of 134 uveal metastases (128 choroidal, 3 iris, and 3 ciliary body tumors) were diagnosed in 95 eyes of 80 patients. Mean age at diagnosis was 56 years (median, 55 years; range, 24-86 years), with a minor preponderance of women (61%). Tumors were bilateral in 15 patients (19%) and the primary origin was established in 49 patients (61%) before ocular detection. The primary tumor originated in the lung (48%), breast (24%), gastrointestinal tract (10%), liver (3%), pancreas (3%), kidney (1%), cervix (1%), and nasopharynx (1%), with some remaining unknown (10%). The overall 5-year survival rate was 21%. Kaplan-Meier analysis revealed that the worst survival was found in pancreatic cancers (mean survival, 5.9 months; P = 0.045), and the best survival was found in gastrointestinal tract cancers (mean survival, 44.5 months). CONCLUSIONS: The primary tumor origins in Korean patients with uveal metastases differed from those reported in primarily population-based studies of White patients, with a higher prevalence of lung and gastrointestinal tract cancers.

A 10-year review of histopathological findings of enucleated eyes from a tertiary-care center, Pakistan.

OBJECTIVE: To determine the histopathology of enucleated eye specimens. METHODS: The 10-year inventory was conducted at Aga Khan University Hospital, Karachi, and comprised all histopathology reports of enucleated eye specimens received from January 2007 to December 2016 by the Section of Histopathology, Department of Pathology. SPSS 19 was used for data analysis. RESULTS: A total of 232 ocular tissue specimens from 231 patients were evaluated. Ocular tumours were the most common histopathological diagnosis 186(80%). Among tumours, retinoblastoma was the most common 137(59%) followed by malignant melanoma 31(13%) and squamous cell carcinoma 15(6.5%). Overall, 16(6.9%) specimens had degenerative changes secondary to different ocular disorders. Staphyloma and Coat's disease was diagnosed in 3(1.3%) cases each. In 4(1.7%) cases, there was no formal diagnosis. CONCLUSIONS: Early identification of tumours may allow for conservative management and limit the need for enucleations.

Choroidal Melanoma: Our Experience.

BACKGROUND: Choroidal melanomas are diagnosed in approximately 6 out of one million Americans per year, and although their incidence is low, they are the most common primary intraocular tumor in adults. METHODS: Choroidal melanoma is rare tumors and till date no such reports with sclera involvement has been reported from Nepal. It is a prospective case series. The aim of this study is for awareness of the severity of the Choroidal melanoma and it's management. Besides, it is also to study the demography, presentation, histopathological variations and management of cases of choroidal melanoma. All the consecutive cases of Choroidal melanoma presenting between Jan 2017 to May 2018 and those who were within the inclusion criteria were included in this study. RESULTS: There were eight patients, five male and three female, within age range of 18-73, median age was 47. All patients presented with decreased vision ranging from 6/24 to PL of less then three months to 2 years duration. Fund us showed choroidal mass associated with Vitreous hemorrhage (VH), and retinal detachment (RD). Two patients were managed with enucleation with External beam radiotherapy (EBRT). Four underwent only enucleation. One patient with lesion size less then 10mm under went plaque brachy therapy. One patient underwent initially Plaque brachy therapy but later had to undergo Enucleation. Histopathological examination (HPE) of enucleated patient revealed epitheloid cell melanoma grade three in four and Spindle cell melanoma in three patients. Each one patient of epitheloid cell melanoma and spindle cell melanomahad scleral involvement. Indication for radiotherapy was scleral involvement. CONCLUSION: With 8 cases of Choroidal melanoma in a single year in a single hospitalgives us a clue that there may be much more undiagnosed cases of Choroidal melanomain Nepal that should be taken seriously. Going for annual eye examination with routine dilated fund us exams can help in prevention and early diagnosis of this life and sight threatening condition and to reduce the mortality rate.

Clinical spectrum, treatment and outcomes of uveal melanoma in a tertiary centre.

INTRODUCTION: We aimed to describe the clinical characteristics, diagnostic challenges, treatment patterns and outcomes of uveal melanoma (UM) in a tertiary care centre. METHODS: This is a retrospective case series of 11 consecutive patients with UM who were managed in a tertiary referral centre between 2002 and 2017. Epidemiological, clinical, pathological and radiological characteristics were reviewed. Classification of choroidal melanoma as small, medium or large was based on the criteria established by the Collaborative Ocular Melanoma Study. RESULTS: Mean age at presentation was 42.9 (range 27‒67) years. In 7 (64%) patients, a definitive diagnosis of UM was made after a mean follow-up period of 6.4 (range 1‒17) months. There were one, six and four patients with small-, medium- and large-sized choroidal melanomas, respectively. Treatment was enucleation in 5 (45.5%) patients, plaque brachytherapy in 4 (36.4%) patients, transpupillary thermotherapy in 1 (9.1%) patient, and observation in 1 (9.1%) patient. Median follow-up was 29 months. Metastatic disease developed in 5 (45.5%) patients at the mean age of 46.6 (range 38‒56) years, with median overall survival of 20 months. Genetic mutations in three patients were monosomy 3 (n = 2), and gain of 3q and 8q (n = 1). CONCLUSION: Our study supports the finding that UM in Chinese and Asian Indian patients presents at a younger age than in Caucasians. Although it is rare, ophthalmologists should remain mindful of this life-threatening disease. We propose establishing a national and regional registry for ocular tumours with genetic information to characterise the disease spectrum in Southeast Asia.

Prevalence of choroidal nevus and retinal pigment epithelial alterations in vitiligo patients.

PURPOSE: To investigate ocular manifestations in patients with vitiligo by multimodal imaging, including optical coherence tomography (OCT), color fundus photography, and fundus autofluorescence (FAF). METHODS: In this prospective, observational clinical study, vitiligo patients underwent ophthalmologic and dermatologic clinical assessment and imaging by spectral-domain OCT, FAF, and color fundus imaging. Ocular echography was performed as indicated. Statistical analysis was performed using paired T test and Pearson correlation. RESULTS: A total of 61 eyes of 31 vitiligo patients were examined. Ocular findings consisted of choroidal nevi (n = 10, 32%), of which four (40%) were bilateral; two patients (6.5%) had a prominent choroidal pattern, two (6.5%) had hypopigmentary retinal pigment epithelium (RPE) lesions, and one (3.2%) had peripapillary atrophy of the RPE. Choroidal nevi were demonstrated only in eyes of patients with generalized vitiligo and were more common with upper body involvement (p = 0.02) and more prevalent in women (p = 0.02). Hypopigmentary lesions were detected in two patients and demonstrated on OCT as RPE atrophy and as photoreceptor/RPE changes. CONCLUSIONS: In this case series, vitiligo patients had a higher rate of choroidal nevi than previously reported. The hypopigmentary vitiliginous fundus lesions were depicted on OCT as photoreceptor and RPE atrophy. These findings may suggest the advisability of regular ocular monitoring for vitiligo patients.

Metástasis intraoculares: comparación entre las formas de presentación clínica con tumor primario conocido y desconocido / Intraocular metastasis: comparison of clinical presentation with a known and unknown primary tumour

OBJETIVO: El objetivo del presente estudio es revisar la frecuencia de metástasis intraoculares como primera manifestación de enfermedad sistémica e identificar las características clínicas y tumorales. MÉTODOS: Estudio retrospectivo y consecutivo de casos diagnosticados como metástasis intraoculares en una unidad de referencia de tumores intraoculares entre 1993 y 2014. Se registraron las características generales, epidemiológicas y oftalmológicas. RESULTADOS: Entre 1993 y 2014, se diagnosticaron 21 pacientes con metástasis intraoculares. Edad media de 62,7 años (31-89). Se observó bilateralidad en 4 casos y localización coroidea en 20 casos. El tumor intraocular fue la primera manifestación de la enfermedad sistémica en 13 pacientes (61,9%). El tumor primario fue la mama en el 47,5% de los casos y el pulmón en el 23,8%. El diagnóstico del tumor primario se realizó mediante estudios sistémicos y solo un paciente requirió biopsia intraocular. Respecto al tratamiento, la mayoría de los casos se controlaron mediante terapia sistémica; 4 casos precisaron radioterapia externa adicional y solamente un caso, enucleación. No se encontraron diferencias clínicas entre los casos de cáncer sistémico conocido o desconocido, excepto respecto al desprendimiento de retina exudativo, más frecuente en el segundo grupo. CONCLUSIONES: Aunque las metástasis intraoculares son el tumor intraocular más frecuente, no son un motivo frecuente de consulta. En más de la mitad de los casos es la forma de presentación de una neoplasia sistémica desconocida como una masa intraocular solitaria no pigmentada. El diagnóstico precoz es crucial para establecer el tratamiento adecuado, preservar la función visual y mejorar el pronóstico vital del paciente

OBJECTIVE: The purpose of the present study is to review the frequency of intraocular metastases as first presentation of systemic disease, and to identify clinical and tumour characteristics. METHODS: Retrospective study of consecutive cases diagnosed of intraocular metástasis at a referral intraocular tumours unit between 1993 and 2014. General, epidemiological and ophthalmological characteristics were recorded. RESULTS: A total of 21 patients, with a mean age 62.7 years (31-89) were diagnosed with intraocular metástasis between 1993 and 2014. Both eyes were affected in 4 cases. Location was choroid in 20 cases. The intraocular tumour was the first manifestation of the systemic disease in 13 patients (61.9%). Primary tumour was breast in 47.6% and lung in 23.8%. Diagnosis of the primary tumour was performed by systemic studies, and only 1 patient required intraocular biopsy. Regarding the treatment, the majority of cases were controlled with systemic therapy, with 4 cases requiring additional external beam radiotherapy, and only one enucleation. No clinical differences were found between the cases with known and unknown systemic neoplasia, except in exudative retinal detachment, which was more frequent in the second group. CONCLUSIONS: Although intraocular metastases are the most frequent intraocular tumour, they are not a frequent cause of consultation. In more than half of the cases it is the first presentation of unknown systemic neoplasia as a solitary non-pigmented intraocular mass. Early diagnosis is crucial to establish the appropriate treatment, preserve visual function, and improve the prognosis of the patient

Choroidal nevus: a review of prevalence, features, genetics, risks, and outcomes.

PURPOSE OF REVIEW: To review the prevalence, clinical features, imaging findings, cytogenetics, and risks and outcomes of choroidal nevus. RECENT FINDINGS: Choroidal nevus is a benign melanocytic tumor, often discovered incidentally on ophthalmic examination. This lesion is generally well circumscribed and pigmented. The prevalence of choroidal nevus in postequatorial region in United States adults (≥40 years old) is approximately 5%. Choroidal nevus is associated with higher lifetime unopposed estrogen and greater BMI. In population-based evaluation, the mean nevus basal dimension is approximately 1.25 mm. Giant nevus (basal dimension ≥10 mm) carries greater risk for malignant transformation. Imaging modalities for evaluation of choroidal nevus include ultrasonography, fundus autofluorescence, and optical coherence tomography (OCT). Fluorescein angiography is occasionally employed to detect multifocal pinpoint leaks or choroidal neovascular membrane. Recently, OCT angiography demonstrated nevus with minimal overlying macular microvascular changes compared with melanoma. Cytogenetically, GNA11 or GNAQ mutations have been documented in uveal melanoma in 83% and in some cutaneous nevus subtypes. Further mutations lead to the development of melanoma at a rate of one of 8845 cases. Risk factors for transformation of nevus into melanoma are recalled by the mnemonic 'To find small ocular melanoma using helpful hints daily' representing thickness (T) more than 2 mm, subretinal fluid (F), symptoms (S) of flashes/floaters/blurred vision, orange (O) lipofuscin pigment, margin (M) less than 3 mm from optic disk, ultrasonographic hollowness (UH), halo (H) absence, and drusen (D) absence. The presence of three or more risk factors implies more than 50% chance for transformation to melanoma within 5 years. A new, online ocular oncology reading center can help judge nevus risk. SUMMARY: Choroidal nevus is a common intraocular lesion, found predominantly in Whites. This mass carries a small risk (<1%) for malignant transformation. Patients with at least three risk factors should be evaluated for possible melanoma at an experienced ocular oncology center.

The Pediatric Choroidal and Ciliary Body Melanoma Study: A Survey by the European Ophthalmic Oncology Group.

PURPOSE: To collect comprehensive data on choroidal and ciliary body melanoma (CCBM) in children and to validate hypotheses regarding pediatric CCBM: children younger than 18 years, males, and those without ciliary body involvement (CBI) have more favorable survival prognosis than young adults 18 to 24 years of age, females, and those with CBI. DESIGN: Retrospective, multicenter observational study. PARTICIPANTS: Two hundred ninety-nine patients from 24 ocular oncology centers, of whom 114 were children (median age, 15.1 years; range, 2.7-17.9 years) and 185 were young adults. METHODS: Data were entered through a secure website and were reviewed centrally. Survival was analyzed using Kaplan-Meier analysis and Cox proportional hazards regression. MAIN OUTCOME MEASURES: Proportion of females, tumor-node-metastasis (TNM) stage, cell type, and melanoma-related mortality. RESULTS: Cumulative frequency of having CCBM diagnosed increased steadily by 0.8% per year of age between 5 and 10 years of age and, after a 6-year transition period, by 8.8% per year from age 17 years onward. Of children and young adults, 57% and 63% were female, respectively, which exceeded the expected 51% among young adults. Cell type, known for 35% of tumors, and TNM stage (I in 22% and 21%, II in 49% and 52%, III in 30% and 28%, respectively) were comparable for children and young adults. Melanoma-related survival was 97% and 90% at 5 years and 92% and 80% at 10 years for children compared with young adults, respectively (P = 0.013). Males tended to have a more favorable survival than females among children (100% vs. 85% at 10 years; P = 0.058). Increasing TNM stage was associated with poorer survival (stages I, II, and III: 100% vs. 86% vs. 76%, respectively; P = 0.0011). By multivariate analysis, being a young adult (adjusted hazard rate [HR], 2.57), a higher TNM stage (HR, 2.88 and 8.38 for stages II and III, respectively), and female gender (HR, 2.38) independently predicted less favorable survival. Ciliary body involvement and cell type were not associated with survival. CONCLUSIONS: This study confirms that children with CCBM have a more favorable survival than young adults 18 to 25 years of age, adjusting for TNM stage and gender. The association between gender and survival varies between age groups.

Sex Differences in the Relationship Between Obesity and Choroidal Nevus in US Adults.

PURPOSE: To investigate sex differences and the effect of other variables on the association between obesity and choroidal nevus in the US adult population. METHODS: The study population of this cross-sectional study included 5575 subjects aged ≥40 years from the 2005 to 2008 National Health and Nutrition Examination Survey (NHANES) who underwent retinal imaging. Primary predictor variables were body mass index (BMI) when the subject was 25 years old ("former BMI") and BMI at time of NHANES participation ("current BMI"). Body mass index was classified "elevated" (≥25 kg/m2) versus "normal" (<25 kg/m2). The main outcome measure was choroidal nevus in either eye on retinal imaging. Subgroup analysis was stratified by sex and race. RESULTS: The mean age of the study population was 56.4 years, with 47.3% male and 52.7% female subjects. The prevalence of choroidal nevus was 4.7% overall. Former elevated BMI was associated with choroidal nevus in the overall population (odds ratio [OR]: 1.35, 95% confidence interval [CI]: 1.06-1.71, P = 0.01) and males (OR: 1.43, CI: 1.03-1.99, P = 0.03). Current elevated BMI was associated with choroidal nevus in the overall population (OR: 1.37, CI: 1.02-1.85, P = 0.04); females (OR: 1.72, CI: 1.11-2.68, P = 0.02), and postmenopausal females (OR: 1.94, CI: 1.23-3.06, P = 0.006). CONCLUSIONS: Choroidal nevus is associated with former and current obesity. Sex and postmenopausal status differences in this association could provide insight into the demographics of patients at risk for developing choroidal nevus.

Relationship Between Female Reproductive Factors and Choroidal Nevus in US Women: Analysis of Data From the 2005-2008 National Health and Nutrition Examination Survey.

IMPORTANCE: Choroidal nevus is a precursor for uveal melanoma and there are no known risk factors besides white race. Female sex hormones have been hypothesized to play a role in the pathogenesis of uveal melanoma. OBJECTIVE: To explore the association between female reproductive factors and choroidal nevus in the US adult female population. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional, population-based study of 2505 US women aged 40 years or older from the 2005-2008 National Health and Nutrition Examination Survey. The women completed the reproductive health questionnaire and underwent retinal imaging. The analysis was conducted in April 2015. EXPOSURES: Age at menarche, oral contraceptive use, pregnancy, parity, age at first and last births, age at menopause, hysterectomy, oophorectomy, hormone therapy use, and body mass index (calculated as weight in kilograms divided by height in meters squared). MAIN OUTCOMES AND MEASURES: Choroidal nevus on retinal imaging. RESULTS: The mean age of participants was 56.5 years, and the racial/ethnic distribution was 76.9% white, 10.1% African American, 8.4% Hispanic, and 4.8% other. The weighted prevalence of choroidal nevus was 4.5%. Premenopausal women who first gave birth before age 20 years had more than 4 times higher odds of choroidal nevus than those who first gave birth after age 35 years (odds ratio [OR], 4.16; 95% CI, 1.29-13.45; P = .02), and premenopausal women who gave birth to their last child before age 25 years had nearly 5 times higher odds of choroidal nevus than those who gave birth to their last child after age 35 years (OR, 4.89; 95% CI, 1.15-20.74; P = .03). These relationships were independent of total parity and years between the first and last births. The odds of choroidal nevus in postmenopausal women who were overweight and obese were 2 times higher than in postmenopausal women with normal body mass index (OR, 2.11; 95% CI, 1.19-3.76; P = .01 for overweight and OR, 1.92; 95% CI, 1.13-3.25; P = .02 for obese). CONCLUSIONS AND RELEVANCE: The association between choroidal nevus and earlier start and end to childbearing in premenopausal women and obesity in postmenopausal women suggests that this relationship could be partially mediated via increased total lifetime unopposed estrogen. Clinicians should have an increased index of suspicion for choroidal nevus and choroidal melanoma in this population.

Melanoma of the eye: revealing hidden secrets, one at a time.

Melanoma of the eye can involve the uveal tract with iris, ciliary body, or choroid involvement or it can involve the conjunctiva, eyelid, or orbit. Uveal involvement with choroidal melanoma is the most common, found in light complexion Caucasians with an age-adjusted incidence of 4.3 per million persons. Early detection of uveal melanoma is critical. The ABCDEF guide helps to differentiate iris nevus from iris melanoma. The letters represent: A, age young (≤40 years); B, blood in anterior chamber; C, clock hour of mass inferiorly; D, diffuse configuration; E, ectropion; and F, feathery margins. The mnemonic of TFSOM-UHHD (To Find Small Ocular Melanoma-Using Helpful Hints Daily) helps to differentiate choroidal nevus from small melanoma and represents: T, thickness over 2 mm; F, fluid; S, symptoms; O, orange pigment; M, margin within 3 mm of the optic disc; UH, ultrasound hollow; H, halo absent; and D, drusen absent. Patients with 3 or more of these factors are likely to have melanoma. These key clinical features help to identify small melanoma at a time when therapy could be life-saving. Conjunctival melanoma usually arises from primary acquired melanosis, a flat pigmentation that can lead to melanoma. Wide excision using no touch strategy is important to tumor control. Ocular examination is advised annually for all persons for detection of refractive error, cataract, glaucoma, and other conditions, but also for the detection of asymptomatic malignancies like melanoma. One at a time, we have uncovered the secrets of ocular melanoma and we forge ahead with the goal to solve the riddle of this challenging disease.

Management of choroidal metastases.

BACKGROUND: Choroidal metastases (CM) are the most common malignant intraocular lesion observed in up to 4-12% of necropsy series of patients with solid cancer. The spectrum of presentations varies from prevalent CM in disseminated cancer to isolated CM. CM are responsible for visual deterioration. Depending on the primary cancer, estimated life expectancy, overall cancer presentation and ocular symptoms, the management of CM varies widely. We address the multidisciplinary management of CM and technical aspects of radiotherapy. MATERIAL AND METHODS: A systematic review of literature was performed from 1974 to 2014. RESULTS: Choroidal metastases occur preferentially in breast and lung carcinomas but are reported in all cancer types. The standard treatment remains external beam radiotherapy, applying 30Gy in 10 fractions or 40Gy in 20 fractions. The reported complete response and improved visual acuity rates are 80% and 57% to 89%, respectively. Some chemotherapy or new targeted therapy regimens yield promising CM response rates. DISCUSSION: Radiation therapy consistently shows rapid symptom alleviation, yield excellent local control and functional outcomes. However, there are only few reports on late toxicities after 6months given the unfavorable prognostic of CM patients. Selected patients may live more than two years, underlying the need to better assess mean and long term outcomes. Some authors have favored exclusive systemic strategies with omission of irradiation. The current literature suffers from the scarcity of prospective trials. Duration of tumor response following systemic therapy is rarely reported but appears less favorable as compared to radiotherapy. Systemic treatments may be proposed for pauci-symptomatic CM in a polymetastatic context while radiation therapy remains necessary in symptomatic CM either upfront or as an alternating treatment. Focalized radiation like brachytherapy and proton therapy may be proposed for isolated CM with long disease-free interval between primary and CM, as these techniques have the potential to yield better tumor and functional outcomes in patients with long life expectancy.

Prevalence of choroidal naevi using scanning laser ophthalmoscope.

PURPOSE: To determine the prevalence of choroidal naevi in a healthy population using an ultra-wide scanning laser ophthalmoscope which can capture up to a 200° field of view of the retina, without pupil dilation. METHODS: Subjects were recruited from a college population. Each subject underwent an eye examination that included retinal and choroidal imaging using the Optos scanning laser ophthalmoscope and completed a self-administered questionnaire. Univariate and multivariate regression analysis were performed to identify associated factors with choroidal naevi. RESULTS: The Optomap images of 406 participants (mean age 23.5 ± 4.4) were analysed. Thirty-nine subjects (10%) presented with at least one naevus in one eye, and multiple naevi were observed unilaterally in eight subjects. Drusen were noted in only one eye. The mean naevus diameter was 2.38 mm (± 2.07). Prevalence was not associated with either eye colour, time spent outdoors, visual impairment, or ethnic group, but was significantly associated with male gender (OR 2.41, p = 0.009), blond/red hair colour (OR 2.42, p = 0.037), skin that neither burns nor tans (OR 2.8, p = 0.02) and habitual sunglasses use (OR 0.33, p = 0.002). CONCLUSIONS: A higher prevalence of choroidal naevi was detected in this college population compared to other population-based studies. This is likely due to the use of an ultra-wide field scanning laser ophthalmoscope which provides up to 200° of the fundus. The naevi were associated with several factors.

Quality of life and cancer-related needs in patients with choroidal melanoma.

AIMS: To assess quality of life (QoL) indices and their associations with treatment modality, sociodemographics and cancer-related needs in choroidal melanoma patients. METHODS: Patients (N=99) treated at the University of California, Los Angeles, for choroidal melanoma within the prior 5 years (M=2.05) completed questionnaires assessing demographics, cancer-related needs, vision-specific QoL, depressive symptoms and concern about recurrence. Visual acuity, comorbidities, treatment modality (radiotherapy, enucleation) and years since diagnosis were gathered from medical records. Primary analyses were multiple regressions. RESULTS: Although concern about cancer recurrence was elevated, QoL was better than in other oncology samples and comparable with healthy samples on some outcomes. Enucleation was associated with worse vision-specific QoL, and presence of comorbid diseases was associated with worse vision-specific QoL, depressive symptoms and concern about cancer recurring (all p values<0.05). Patients who experienced at least one stressful life event in the past year (vs no events) reported more depressive symptoms (p<0.01). Report of more unmet cancer needs was associated with worse vision-specific QoL, depressive symptoms and more concern about recurrence (all p values<0.05), uniquely explaining 4%-12% of the variance. CONCLUSIONS: For choroidal melanoma patients, an average of 2 years after treatment, the number of physical comorbidities and unmet cancer needs were the strongest correlates of poorer QoL.

[Choroidal melanoma treated by protontherapy: anatomical and functional results at Strasbourg University Medical Center]. / Mélanomes choroïdiens traités par protonthérapie : résultats anatomiques et fonctionnels au CHU de Strasbourg.

PURPOSE: To report anatomical and functional results of choroidal melanoma treated by protontherapy between 2001 and 2011 and to compare these with data reported in the literature. METHODS: The present study is a retrospective review of the charts of patients presenting with choroidal melanoma, managed at Strasbourg University Medical Center between 2001 and 2011, and receiving protontherapy. Visual acuity and a complete ophthalmologic examination, including intraocular pressure, dilated fundus exam, and ultrasonography with measurement of the major diameter of the tumor, were performed prior to treatment and at various follow-up visits (every six months for five years, then once a year for ten years). The rates and timing of local complications (cataract, rubeosis, retinal detachment, neovascular glaucoma and secondary enucleation) and systemic complications (metastasis) are also reported. RESULTS: Seventy charts were included. Mean age of the treated population was 61.4 ± 15.2 years. Male/female ratio was 1.06. Mean visual acuity, 0.55 ± 0.6 (20/67) on presentation, decreased progressively from month 42. Mean tumor thickness was 5.8 ± 2.8mm and major diameter 11.2 ± 2.9 mm. Decreased tumor thickness was noted beginning at month 12 of follow-up (Anova, P<0.0001), while major diameter remained unchanged over time (P>0.05). The risk of complications (retinal detachment, rubeosis, neovascular glaucoma) was greater between the second and third year. Mean 5-year survival was 87.5%. The rate of secondary enucleation was 8.5%. CONCLUSION: Protontherapy most often allows for preservation of the globe. Visual loss, often significant and permanent, is frequent.