Grand Rounds Eddie Apenbrinck MD University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 3/18/16

Subjective CC: “Decreased vision” CC: “Decreased vision” HPI: 84 year old white male presented to the VA eye clinic for cataract evaluation. Patient with poor vision OU (OD>OS). Patient was told he had cataracts several years ago. HPI: 84 year old white male presented to the VA eye clinic for cataract evaluation. Patient with poor vision OU (OD>OS). Patient was told he had cataracts several years ago.

POHx: Myopia, Presbyopia PMHx: Stroke (1984) with residual dysphasia and right hemiparesis, benign prostatic hypertrophy Medications: tamsulosin, artificial tears, cetirizine, clopidogrel, carbamazepine, sertraline Allergies: none Social: denies cigarettes, alcohol, and illicit drugs

Exam OD OS BCVA LP 20/200 ( x165)( x005) Pupils: unable to assess APD (lack of patient co-operation) IOP: 11 mm Hg 14 mm Hg EOM: Full OU CVF: Unable OU

Exam OD OS L/L: WNL WNL C/S:WNL WNL K:WNL WNL AC: deep and quiet deep and quiet I/L: 4+ NS cataract3+ NS cataract DFE:no viewC/D: 0.1 MVP:WNL

Assessment and Plan 84 year old male with PMHx significant for dysphasia secondary to remote stroke with visually significant cataracts OU (OD>OS). 84 year old male with PMHx significant for dysphasia secondary to remote stroke with visually significant cataracts OU (OD>OS). Plan Plan Obtain B-scan, IOL master/A-Scan Obtain B-scan, IOL master/A-Scan Schedule for cataract extraction and IOL implant OD Schedule for cataract extraction and IOL implant OD

Clinical Course Unable to obtain IOL master (dense cataract) or A-scan/B-scan (machine out for repair) Unable to obtain IOL master (dense cataract) or A-scan/B-scan (machine out for repair) Planned to obtain measurements for IOL selection on day of surgery Planned to obtain measurements for IOL selection on day of surgery

IOL Master: Day of Surgery

Pre-op Exam OD OS BCVA LP 2 feet Pupils: dilated 7mm 4 2 +APD OD by reverse technique DFE:Poor view; WNL multilobulated elevated yellow retinal mass

Pre-op Ultrasound OD OD OD

Assessment and Plan 84 year old male with intraocular mass OD seen on B-scan prior to cataract surgery 84 year old male with intraocular mass OD seen on B-scan prior to cataract surgery Plan Plan Surgery cancelled Surgery cancelled Referred to Oncology at VA hospital and Dr. Ramasubramanian for evaluation Referred to Oncology at VA hospital and Dr. Ramasubramanian for evaluation Scheduled for PET scan after being seen by Oncology Scheduled for PET scan after being seen by Oncology

Clinical Course Seen by Dr.Ramasubramanian the next day Seen by Dr.Ramasubramanian the next day Appearance of intraocular tumor OD similar to choroidal metastasis. OS WNL Appearance of intraocular tumor OD similar to choroidal metastasis. OS WNL Management options dependent on PET scan results Management options dependent on PET scan results

PET Scan Standard Uptake Value: 3.0

PET Scan Standard Uptake Value: 8.9

Clinical Course PET scan showed intraocular tumor and likely rectal tumor PET scan showed intraocular tumor and likely rectal tumor Per Oncology, tumors likely unrelated given significantly different SUV Per Oncology, tumors likely unrelated given significantly different SUV Referred to GI clinic for evaluation of rectal tumor with possibly biopsy Referred to GI clinic for evaluation of rectal tumor with possibly biopsy Patient refused examination Patient refused examination Patient elected for Palliative care with Hospice and Home Health Patient elected for Palliative care with Hospice and Home Health

Metastatic Cancer to the Eye Most intraocular metastatic tumors involve the choroid, but similar lesions also affect the iris, ciliary body, optic nerve, and retina Most intraocular metastatic tumors involve the choroid, but similar lesions also affect the iris, ciliary body, optic nerve, and retina Unifocal-monocular involvement in 80% of cases; multifocal and/or binocular involvement in 20% of cases Unifocal-monocular involvement in 80% of cases; multifocal and/or binocular involvement in 20% of cases Metastatic cancer to the eye is regarded as the most common intraocular malignant neoplasm. Metastatic cancer to the eye is regarded as the most common intraocular malignant neoplasm.

Epidemiology The cumulative lifetime incidence of clinically detected metastatic intraocular tumors is approximately 0.1% (1 in 1,000) to 0.25% (1 in 400) The cumulative lifetime incidence of clinically detected metastatic intraocular tumors is approximately 0.1% (1 in 1,000) to 0.25% (1 in 400) Most common malignancy to have ocular metastasis Most common malignancy to have ocular metastasis Men: Lung, Prostate, Colorectal Men: Lung, Prostate, Colorectal Women: Breast, Lung, Colorectal Women: Breast, Lung, Colorectal

Appearance Metastatic tumors involving the choroid from breast, lung, or gastrointestinal tract appear as golden yellow to yellowish white round to oval lesion Metastatic tumors involving the choroid from breast, lung, or gastrointestinal tract appear as golden yellow to yellowish white round to oval lesion

Ancillary Testing Fluorescein Angiogram Fluorescein Angiogram Typically shows few or no large-caliber intralesional vessels, relative hypofluorescence of the lesion in the early frames, and late diffuse hyperfluorescence of the lesion Typically shows few or no large-caliber intralesional vessels, relative hypofluorescence of the lesion in the early frames, and late diffuse hyperfluorescence of the lesion Indocyanine green angiography Indocyanine green angiography Most metastatic tumors appear hypofluorescent Most metastatic tumors appear hypofluorescent B scan B scan CT and MRI CT and MRI Fine-needle aspiration biopsy Fine-needle aspiration biopsy

Treatment Options Treatment depends on tumor type but options include: Treatment depends on tumor type but options include: Systemic chemotherapy Systemic chemotherapy Hormonal therapy Hormonal therapy Radiation therapy Radiation therapy External beam radiation therapy External beam radiation therapy Plaque radiotherapy (iodine-125, ruthenium-106, palladium-103) Plaque radiotherapy (iodine-125, ruthenium-106, palladium-103) Enucleation Enucleation

A retrospective, nonrandomized, interventional case series of 8100 patients with uveal melanoma were evaluated for melanoma-related metastasis based on patient race On the basis of race (Caucasian, Hispanic, Asian, and African American) significant differences were noted in: mean age at presentation distance of posterior tumor margin to foveola distance of posterior tumor margin to optic disc tumor base tumor thickness Intraocular hemorrhage rupture of Bruch’s membrane C L Shields, S Kaliki, et al Eye (2015) 29, 1027–1035

Compared with Caucasians, despite relative risk for metastasis of 0.31 for African Americans, 0.73 for Hispanics, and 1.42 for Asians, there was no statistical difference in metastasis, or death from uveal melanoma based on race. Uveal melanoma showed similar prognosis for all races. Eye (2015) 29, 1027–1035 C L Shields, S Kaliki, et al

References Shields JA, Shields CL, Kiratli H, et al. Metastatic tumors to the iris in 40 patients. Am J Ophthalmol 1995;119:422–30. Shields JA, Shields CL, Kiratli H, et al. Metastatic tumors to the iris in 40 patients. Am J Ophthalmol 1995;119:422–30. Shakin EP, Shields JA, Augsburger JJ. Metastatic cancer to the uvea and optic disc: analysis of 200 patients. In: Bornfeld N, Gragoudas ES, Ho ̈ pping W, et al. editors. Tumors of the eye. Amsterdam: Kugler; p. 623–31. Shakin EP, Shields JA, Augsburger JJ. Metastatic cancer to the uvea and optic disc: analysis of 200 patients. In: Bornfeld N, Gragoudas ES, Ho ̈ pping W, et al. editors. Tumors of the eye. Amsterdam: Kugler; p. 623–31. Shields CL, Shields JA, De Potter P, et al. Plaque radiotherapy for the management of uveal metas- tasis. Arch Ophthalmol 1997;115:203–9. Shields CL, Shields JA, De Potter P, et al. Plaque radiotherapy for the management of uveal metas- tasis. Arch Ophthalmol 1997;115:203–9. Parker SL, Tong T, Bolden S, et al. Cancer statistics, CA Cancer J Clin 1997;47:5–27. Parker SL, Tong T, Bolden S, et al. Cancer statistics, CA Cancer J Clin 1997;47:5–27. Shields CL, Kaliki S, Cohen MN et al. Prognosis of uveal melanoma based on race in 8100 patients: the 2015 doyne lecture. Eye (2015) 29, 1027–1035 Shields CL, Kaliki S, Cohen MN et al. Prognosis of uveal melanoma based on race in 8100 patients: the 2015 doyne lecture. Eye (2015) 29, 1027–1035 James J. Augsburger, Rudolf Guthoff, Zelia M. Corre ̂ a. Metastatic Cancer to the Eye. Ophthalmolgy pgs , James J. Augsburger, Rudolf Guthoff, Zelia M. Corre ̂ a. Metastatic Cancer to the Eye. Ophthalmolgy pgs , 2015.