Oman Journal of Ophthalmology

CLINICAL QUIZ
Year
: 2018  |  Volume : 11  |  Issue : 1  |  Page : 97--99

A rare case of superior hypopyon with iris neovascularization


Deepti Mahajan, Ravinder Kumar Gupta, Kulbhushan Prakash Chaudhary 
 Department of Ophthalmology, I.G.M.C., Shimla, Himachal Pradesh, India

Correspondence Address:
Deepti Mahajan
Arunodaya, Cemetery Road, Sanjauli, Shimla - 171 006 Himachal Pradesh
India




How to cite this article:
Mahajan D, Gupta RK, Chaudhary KP. A rare case of superior hypopyon with iris neovascularization.Oman J Ophthalmol 2018;11:97-99


How to cite this URL:
Mahajan D, Gupta RK, Chaudhary KP. A rare case of superior hypopyon with iris neovascularization. Oman J Ophthalmol [serial online] 2018 [cited 2022 Aug 20 ];11:97-99
Available from: https://www.ojoonline.org/text.asp?2018/11/1/97/226351


Full Text



A 70-year-old female presented to the eye outpatient department with the chief complaint of blurred vision, pain, and redness in the left eye for 2 days. Visual acuity in the right eye was 6/6 and hand movement close to face in the left eye. Slit lamp examination left eye revealed a superior hypopyon, +3 cells in the anterior chamber, and iris neovascularization [Figure 1] and [Figure 2]. Intraocular pressure by noncontact tonometer was 10 and 22 mm in the right and left eye, respectively. B-scan [Figure 3] and magnetic resonance imaging (MRI) brain and orbit [Figure 4] were ordered.{Figure 1}{Figure 2}{Figure 3}{Figure 4}

 Questions



What is the likely diagnosis?What is the differential diagnosis?What could be the cause of raised intraocular pressure in the left eye?What are findings on ultrasound and MRI?What is the line of management and workup for the patient?

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 Answers for Clinical Quiz



Answers

Based on the clinical appearance and echographic findings, the patient was diagnosed ciliary body melanoma, with metastasis to the irisDifferential diagnosis are:

Posttraumatic fungal exudatesMetastasisLymphoma.

The mechanisms that can lead to glaucoma are the direct extension of the tumor into the trabecular meshwork, the seeding of tumor cells into outflow channels, pigment dispersion, inflammation, hemorrhage inducing hemolytic glaucoma, and melanomalytic glaucomaB-scan revealed a mass in the ciliary region of the left eye [Figure 3]. MRI brain with bilateral optic nerves was ordered which revealed altered signal intensity area in the ciliary body region, hyperintense on T2 and flair [Figure 4]Prednisolone Acetate 1% (G. Predforte) 4 times a day, Atropine 1% (G. Atro) three times a day, Timolol 0.5% and Brimonidine 0.2% (G. Brimocom) twice a day was given. A complete metastatic workup for tumor staging-complete blood count, basic metabolic panel, liver function tests (LFTs), chest X-ray, and abdominal ultrasound was done which were negative for evidence of metastasis. As it was an advanced and complicated tumor with metastasis to the iris, compromising the visual function, an elective enucleation surgery was planned. Size of the eyeball on gross examination was 2.5 cm × 2.5 cm × 1.3 cm. Outer surface of the eyeball was gray-white with prominent vascular markings [Figure 5]. On cut section, posterior chamber showed a gray-brown growth attached on the scleral surface. Posterior half of the eyeball and optic nerve were not involved. Tumor in the choroid layer of the eyeball was seen on microscopic examination. Due to the clear margins and lack of evidence indicating distant metastasis, no further treatment was necessary and was counseled to undergo yearly eye exams with annual tumor surveillance, consisting of a physical examination, LFTs, and imaging of the liver with ultrasonography or MRI with contrast.{Figure 5}

 Discussion



Uveal melanoma is the most common primary intraocular malignancy in white adults. Melanoma of ciliary body is reported 1 of 10 cases of all intraocular melanomas.[1],[2] Only two reports have been documented in India and none presented with glaucoma. This is a case from the Indian subcontinent of the primary ciliary body and choroidal melanoma presenting with secondary glaucoma and uveitis.

The most frequent symptoms are represented by local signs as blurry vision due to astigmatism or lens dislocations, floaters, painless visual field loss, or pain as a result of acute glaucoma.[1]

Patient with iris involvement most commonly presents with a unilateral metastatic nodule.[3] The liberation of friable cells often leads to a secondary iritis, episcleral injection, and occasionally, pseudohypopyon.[4]

The ciliary body and anterior choroidal melanomas have the worst prognosis of all intraocular melanomas because (a) hematogenous metastasis is faster in ciliary body melanoma[1] (b) late diagnosis of the tumor due to the absence of clinical signs in the early stages and anatomical localization, making it harder to identify.

External beam therapy or brachytherapy can be used for medium-sized tumor (<15 mm in diameter).[5] In advanced cases, depending on the size, local extension and cellular type of the melanoma, the treatment is surgical, with enucleation of the eye, block excision, or sclerouvectomy consisting in an in-block removal of ciliary body, cornea, iris, and sclera following by grafting to close the defect.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Costache M, Patrascu O, Adrian D, Costache D, Sajin M, Ungureanu E, Simionescu O. Ciliary Body Melanoma - A Particularly Rare Type of Ocular Tumor. Case Report and General Considerations. Maedica 2013;8:360-4.
2Oittinen HA, O'Shaughnessy M, Cullinane AB, Keohane C. Malignant melanoma of the ciliary body presenting as extraocular metastasis in the temporalis muscle. J Clin Pathol 2007;60:834-5.
3Shields CL, Shields JA, Gross NE, Schwartz GP, Lally SE. Survey of 520 eyes with uveal metastases. Ophthalmology 1997;104:1265-76.
4Shields JA, Shields CL, Kiratli H, de Potter P. Metastatic tumors to the iris in 40 patients. Am J Ophthalmol 1995;119:422-30.
5Demirci H, Shields CL, Shields JA, Honavar SG, Eagle RC Jr. Ring melanoma of the ciliary body: Report on twenty-three patients. Retina 2002;22:698-706.