Letters
veloped proptosis 12 days after trauma, with the accumulation of CSF in the upper eyelid thus being of delayed onset. This corresponds with cases reported by Rha et al3 and Sibony et al.4 No signs of increased intracranial pressure were documented by the neurosurgical team. The case reported by Sibony and colleagues had associated orbital roof fractures and developed temperature spikes and pulsatile proptosis without a bruit but with limited eye movements. Rha and colleagues stated that the most common cause of CSF leakage is a meningeal fistula, which is the postulated mechanism in our case. We decided to aspirate fluid in the upper eyelid primarily to exclude abscess formation and to perform incision and drainage if indicated. Because no more fluid collected after the second drainage procedure, no surgery was performed. Rha and colleagues postulated that the drainage of a CSF collection is sufficient to prevent further CSF leakage. Wu et al5 confirmed this, stating that small CSF leaks may often self-seal because of the tamponade effect of orbital fat. Although the patient was pyrexial, a pulsatile swelling and the absence of a bruit favored CSF instead of pus. Twaij et al6 stated that β-2 transferrin is specific for CSF. Aspiration of CSF and a conservative approach in our patient led to the spontaneous closure of his fistula. To our knowledge, this is the first case in the literature demonstrating a large volume of clear CSF being aspirated through the upper eyelid. Leonard Goussard Heydenrych, FCOphth (SA), FRCOphth Colleen Michelle Aldous, PhD Roy Giles, FCRad (SA) Grant Andre du Plessis, MMED Neurosurg (Stell) Burnet Meyer, MMED Ophth (Stell), FCS (SA) Author Affiliations: Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, Durban, South Africa (Heydenrych); Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa (Aldous); Panorama Mediclinic, Cape Town, South Africa (Giles, du Plessis); Cape Eye Hospital, Cape Town, South Africa (Meyer). Corresponding Author: Colleen Michelle Aldous, PhD, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, 719 Umbilo Rd, Durban, South Africa ([email protected]). Published Online: August 21, 2014. doi:10.1001/jamaophthalmol.2014.2866. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Bagolini B. Leakage of spinal fluid into upper lid following trauma. AMA Arch Ophthalmol. 1957;57(3):454-456. 2. Ide T, Yano C. A case of spinal fluid accumulation under the right upper lid following a traffic accident [in Japanese]. Nihon Ganka Kiyo. 1967;18(2):180-182. 3. Rha EY, Kim JH, Byeon JH. Posttraumatic delayed cranio-orbital cerebrospinal fluid leakage: case report. J Plast Reconstr Aesthet Surg. 2013;66 (4):563-565. 4. Sibony PA, Anand AK, Keuskamp PA, Zippen AG. Posttraumatic cerebrospinal fluid cyst of the orbit: case report. J Neurosurg. 1985;62(6):922924. 5. Wu W, Cannon PS, Selva D, Tu Y, Wu Q. Endoscopic transorbital approach for repair of cerebrospinal fluid leakage following removal of an orbito-cranial foreign body. Clin Experiment Ophthalmol. 2011;39(4):375-377. 6. Twaij S, Viswanathan P, Page AB. Acute traumatic orbital cerebrospinal fluid cystocele mimicking orbital abscess. J AAPOS. 2009;13(5):491-493. 1486
Eye-Preserving Treatment for Invasive Conjunctival Melanoma Although orbital exenteration has been recommended for extensive malignant conjunctival neoplasms, including those invading the palpebral margin, fornices, or caruncle, it has not been demonstrated to improve survival of patients with melanomas greater than 2.0 mm thick.1 We describe a patient with extensive conjunctival melanoma (CM) managed by eyepreserving therapies. Report of a Case | A woman in her early 70s reported foreignbody sensation in the left eye for 6 months. Corrected visual acuity was 20/20 OD and 20/30 OS. Ophthalmic examination revealed a dark brown superonasal forniceal tumor measuring 5.5 × 5 × 3 mm in the left eye (Figure 1A). Superior fornix fullness precluded eversion of the eyelid. Our diagnosis was nodular CM. Surgical excision was advised. Intraoperative eversion of the left upper eyelid revealed a ridge-like superonasal forniceal mass extending to the superotemporal palpebral and bulbar conjunctiva (Figure 1B). Subtotal incisional biopsy yielded a specimen measuring 27 × 11 × 5 mm. Histopathological analysis confirmed invasive CM without primary acquired melanosis. Tumor cells extended to the epithelial but not deep margins (Figure 1C and D). The patient refused exenteration after acknowledging her diagnosis, prognosis for tumor control, survival, and potential benefits and risks of wider tumor excision vs exenteration. One week later, wider excision 4 mm around the clinical margins but sparing the eyelid margin and tarsal plate was performed. Double freeze-thaw cryotherapy was applied over the resected area and margins. A 30 × 25-mm amniotic membrane graft sutured with running 7-0 Vicryl covered the conjunctival defect. Three full-thickness sutures were passed through the eyelid to reconstruct the fornix. Simultaneous lymph node biopsy was performed.2 Map biopsy was deferred because the tumor was confluent without primary acquired melanosis. Specimen margins and lymph nodes were tumor free. A symblepharon ring was fitted postoperatively (Figure 2A). Subsequently, an amelanotic forniceal nodule inferotemporally in the left eye was excised and found to be CM (Figure 2B). Such occurrence was attributed to surgical tumor seeding or multifocal melanoma. The patient was given two 14-day cycles of topical mitomycin C, 0.02%, 4 times daily with a 2-week pause between the cycles. Ten days into the second cycle, the patient experienced severe dermatitis (Figure 2C) and treatment was interrupted. Treatment shifted to topical interferon alfa-2b (1 000 000 IU/mL) 4 times daily continuous for 4 months. Fifteen months after wide excision, visual acuity remains 20/30 OS. The patient has full ocular motility with minimal fornix and conjunctival scarring (Figure 2D). She is being monitored periodically. Discussion | Because patients with extensive invasive CM managed by exenteration have shown no survival benefit, we agreed to preserve our patient’s eye.1,3 Current standard for CM includes “no-touch” wide excision followed by cryotherapy of exposed edges and primary surface repair. However, the size of
JAMA Ophthalmology December 2014 Volume 132, Number 12
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Letters
Figure 1. Initial Clinical Presentation and Histopathological Findings A
B
C
D
A, Pigmented conjunctival mass in the left eye measuring 5.5 × 5 × 3 mm was visible superonasally when the patient looked left and down while retracting the upper eyelid. B, Intraoperative examination with eversion of the left upper eyelid revealed a more extensive nodular, darkly melanotic tumor arising from the forniceal conjunctiva superonasally and involving most of the forniceal and tarsal conjunctiva from the 10-o’clock to 2-o’clock meridians. C, Histopathological analysis revealed an invasive melanocytic tumor surrounded by a dense inflammatory infiltrate (hematoxylin-eosin, original magnification ×30). D, High-magnification photomicrograph revealed pronounced large, pleomorphic melanocytes with prominent nuclei, irregular chromatin, and well-defined nucleoli (hematoxylin-eosin, original magnification ×90).
Figure 2. Clinical Outcome A
C
B
D
the surgical defect may preclude primary closure, increasing the risk of long-term fibrosis and symblepharon as described herein.1,4,5 Although used extensively, oral mucosa seems prone to scarring and tends to obscure tumor recurrence.3,5 Conversely, amniotic membrane has been used widely in ocular surface repair owing to its unique healing properties and ability to preserve the fornix with minimal scarring,4,5 providing a viable therapeutic alternative for our patient. Lymph node biopsy was performed because our patient had an extensive tumor without clinical or histopathological feajamaophthalmology.com
A, Three weeks following wider conjunctival excision, a symblepharon ring was fitted over the left ocular surface without difficulty. B, Three months after wide excision with amniotic membrane graft, the patient presented with a new amelanotic nodule located on the inferior temporal fornix in the left eye away from the initially resected tumor; it was found to be a conjunctival melanoma (epithelioid cell type). C, Ten days into the second cycle of treatment with topical mitomycin C, 0.02%, the patient presented with severe contact dermatitis and treatment was interrupted. D, At recent follow-up 15 months after wide excision of conjunctival melanoma and 5 months after completion of adjuvant topical chemotherapy, the patient has full ocular motility with minimal forniceal and conjunctival scarring.
tures consistent with CM de novo, which reportedly has higher rates of metastasis and death than those arising from primary acquired melanosis or nevus.3 Adjuvant treatments for CM include topical mitomycin C, interferon alfa-2b, 5-fluorouracil, and plaque brachytherapy.3,6 Most patients using topical mitomycin C for CM experience at least 1 long-term complication.3,6 Interferon alfa-2b has been shown to be effective for CM and less toxic, but nearly all patients require long-term continuous treatment as our patient did.6 JAMA Ophthalmology December 2014 Volume 132, Number 12
Copyright 2014 American Medical Association. All rights reserved.
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1487
Letters
In summary, our patient is tumor free 15 months after wide excision and topical chemotherapy to treat an extensive CM. Periodic follow-up is warranted to monitor local recurrence. Alison M. Dzwonczyk, MD Zélia M. Corrêa, MD, PhD James J. Augsburger, MD Dwight Kulwin, MD
2. Nijhawan N, Ross MI, Diba R, Ahmadi MA, Esmaeli B. Experience with sentinel lymph node biopsy for eyelid and conjunctival malignancies at a cancer center. Ophthal Plast Reconstr Surg. 2004;20(4):291-295. 3. Oellers P, Karp CL. Management of pigmented conjunctival lesions. Ocul Surf. 2012;10(4):251-263. 4. Dua HS, Gomes JA, King AJ, Maharajan VS. The amniotic membrane in ophthalmology. Surv Ophthalmol. 2004;49(1):51-77. 5. Solomon A, Espana EM, Tseng SC. Amniotic membrane transplantation for reconstruction of the conjunctival fornices. Ophthalmology. 2003;110(1):93-100.
Author Affiliations: University of Cincinnati College of Medicine, Cincinnati, Ohio (Dzwonczyk, Corrêa, Augsburger); Department of Ophthalmology, University of Cincinnati College of Medicine, Cincinnati, Ohio (Corrêa, Augsburger, Kulwin). Corresponding Author: Zélia M. Corrêa, MD, PhD, Department of Ophthalmology, University of Cincinnati College of Medicine, 260 Stetson St, Ste 5300, Cincinnati, OH 45267 ([email protected]). Published Online: August 28, 2014. doi:10.1001/jamaophthalmol.2014.2871. Conflict of Interest Disclosures: None reported. Funding/Support: This work was supported in part by an unrestricted grant from Research to Prevent Blindness (Dr Augsburger). Role of the Funder/Sponsor: Research to Prevent Blindness had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. 1. Shields CL, Shields JA, Gündüz K, et al. Conjunctival melanoma: risk factors for recurrence, exenteration, metastasis, and death in 150 consecutive patients. Arch Ophthalmol. 2000;118(11):1497-1507.
6. Poothullil AM, Colby KA. Topical medical therapies for ocular surface tumors. Semin Ophthalmol. 2006;21(3):161-169.
Choroidal Neovascularization and Chorioretinal Anastomoses Following Laser Treatment of a Secondary Vasoproliferative Tumor Laser photocoagulation–induced choroidal neovascularization (CNV) is an uncommon iatrogenic complication following thermal laser treatment for diabetic macular edema and proliferative diabetic retinopathy.1 Disruption of the retinal pigment epithelium–Bruch membrane complex due to intense laser energy presumably leads to the development of CNV.1,2 We report a dramatic case of laser-induced CNV initially associated with a chorioretinal mass lesion that displayed characteristics of an atypical secondary vasoproliferative tumor. The
Figure 1. Multimodal Imaging of the Chorioretinal Lesion A
C
B
D
Video at jamaophthalmology.com
E
1488
JAMA Ophthalmology December 2014 Volume 132, Number 12
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 05/27/2015
A, Ultra–wide-field retinal color fundus photograph reveals dense and heavy laser scars with a raised pale vascular mass located along the infratemporal arcade with lipid exudate (Optos 200TX). B, Close-up view of the vascular lesion shows that it originated at the edge of laser scars with telangiectatic capillary on the surface (Topcon TRC-50DX). Green arrow indicates the optical coherence tomography section for D; yellow arrow, optical coherence tomography section for E. C, This lesion is hyperfluorescent on fluorescein angiography without an identifiable feeder vessel and appears to arise from the subretinal space or the retinal pigment epithelium. D, The lesion shows heterogeneity, loss of normal retinal architecture, and an epiretinal membrane on spectral-domain enhanced depth imaging optical coherent tomography (Heidelberg Spectralis HRA+OCT). E, Secondary cystoid macular edema is also present on spectral-domain enhanced depth imaging optical coherent tomography (Heidelberg Spectralis HRA+OCT). jamaophthalmology.com
veloped proptosis 12 days after trauma, with the accumulation of CSF in the upper eyelid thus being of delayed onset. This corresponds with cases reported by Rha et al3 and Sibony et al.4 No signs of increased intracranial pressure were documented by the neurosurgical team. The case reported by Sibony and colleagues had associated orbital roof fractures and developed temperature spikes and pulsatile proptosis without a bruit but with limited eye movements. Rha and colleagues stated that the most common cause of CSF leakage is a meningeal fistula, which is the postulated mechanism in our case. We decided to aspirate fluid in the upper eyelid primarily to exclude abscess formation and to perform incision and drainage if indicated. Because no more fluid collected after the second drainage procedure, no surgery was performed. Rha and colleagues postulated that the drainage of a CSF collection is sufficient to prevent further CSF leakage. Wu et al5 confirmed this, stating that small CSF leaks may often self-seal because of the tamponade effect of orbital fat. Although the patient was pyrexial, a pulsatile swelling and the absence of a bruit favored CSF instead of pus. Twaij et al6 stated that β-2 transferrin is specific for CSF. Aspiration of CSF and a conservative approach in our patient led to the spontaneous closure of his fistula. To our knowledge, this is the first case in the literature demonstrating a large volume of clear CSF being aspirated through the upper eyelid. Leonard Goussard Heydenrych, FCOphth (SA), FRCOphth Colleen Michelle Aldous, PhD Roy Giles, FCRad (SA) Grant Andre du Plessis, MMED Neurosurg (Stell) Burnet Meyer, MMED Ophth (Stell), FCS (SA) Author Affiliations: Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, Durban, South Africa (Heydenrych); Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa (Aldous); Panorama Mediclinic, Cape Town, South Africa (Giles, du Plessis); Cape Eye Hospital, Cape Town, South Africa (Meyer). Corresponding Author: Colleen Michelle Aldous, PhD, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, 719 Umbilo Rd, Durban, South Africa ([email protected]). Published Online: August 21, 2014. doi:10.1001/jamaophthalmol.2014.2866. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Bagolini B. Leakage of spinal fluid into upper lid following trauma. AMA Arch Ophthalmol. 1957;57(3):454-456. 2. Ide T, Yano C. A case of spinal fluid accumulation under the right upper lid following a traffic accident [in Japanese]. Nihon Ganka Kiyo. 1967;18(2):180-182. 3. Rha EY, Kim JH, Byeon JH. Posttraumatic delayed cranio-orbital cerebrospinal fluid leakage: case report. J Plast Reconstr Aesthet Surg. 2013;66 (4):563-565. 4. Sibony PA, Anand AK, Keuskamp PA, Zippen AG. Posttraumatic cerebrospinal fluid cyst of the orbit: case report. J Neurosurg. 1985;62(6):922924. 5. Wu W, Cannon PS, Selva D, Tu Y, Wu Q. Endoscopic transorbital approach for repair of cerebrospinal fluid leakage following removal of an orbito-cranial foreign body. Clin Experiment Ophthalmol. 2011;39(4):375-377. 6. Twaij S, Viswanathan P, Page AB. Acute traumatic orbital cerebrospinal fluid cystocele mimicking orbital abscess. J AAPOS. 2009;13(5):491-493. 1486
Eye-Preserving Treatment for Invasive Conjunctival Melanoma Although orbital exenteration has been recommended for extensive malignant conjunctival neoplasms, including those invading the palpebral margin, fornices, or caruncle, it has not been demonstrated to improve survival of patients with melanomas greater than 2.0 mm thick.1 We describe a patient with extensive conjunctival melanoma (CM) managed by eyepreserving therapies. Report of a Case | A woman in her early 70s reported foreignbody sensation in the left eye for 6 months. Corrected visual acuity was 20/20 OD and 20/30 OS. Ophthalmic examination revealed a dark brown superonasal forniceal tumor measuring 5.5 × 5 × 3 mm in the left eye (Figure 1A). Superior fornix fullness precluded eversion of the eyelid. Our diagnosis was nodular CM. Surgical excision was advised. Intraoperative eversion of the left upper eyelid revealed a ridge-like superonasal forniceal mass extending to the superotemporal palpebral and bulbar conjunctiva (Figure 1B). Subtotal incisional biopsy yielded a specimen measuring 27 × 11 × 5 mm. Histopathological analysis confirmed invasive CM without primary acquired melanosis. Tumor cells extended to the epithelial but not deep margins (Figure 1C and D). The patient refused exenteration after acknowledging her diagnosis, prognosis for tumor control, survival, and potential benefits and risks of wider tumor excision vs exenteration. One week later, wider excision 4 mm around the clinical margins but sparing the eyelid margin and tarsal plate was performed. Double freeze-thaw cryotherapy was applied over the resected area and margins. A 30 × 25-mm amniotic membrane graft sutured with running 7-0 Vicryl covered the conjunctival defect. Three full-thickness sutures were passed through the eyelid to reconstruct the fornix. Simultaneous lymph node biopsy was performed.2 Map biopsy was deferred because the tumor was confluent without primary acquired melanosis. Specimen margins and lymph nodes were tumor free. A symblepharon ring was fitted postoperatively (Figure 2A). Subsequently, an amelanotic forniceal nodule inferotemporally in the left eye was excised and found to be CM (Figure 2B). Such occurrence was attributed to surgical tumor seeding or multifocal melanoma. The patient was given two 14-day cycles of topical mitomycin C, 0.02%, 4 times daily with a 2-week pause between the cycles. Ten days into the second cycle, the patient experienced severe dermatitis (Figure 2C) and treatment was interrupted. Treatment shifted to topical interferon alfa-2b (1 000 000 IU/mL) 4 times daily continuous for 4 months. Fifteen months after wide excision, visual acuity remains 20/30 OS. The patient has full ocular motility with minimal fornix and conjunctival scarring (Figure 2D). She is being monitored periodically. Discussion | Because patients with extensive invasive CM managed by exenteration have shown no survival benefit, we agreed to preserve our patient’s eye.1,3 Current standard for CM includes “no-touch” wide excision followed by cryotherapy of exposed edges and primary surface repair. However, the size of
JAMA Ophthalmology December 2014 Volume 132, Number 12
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 05/27/2015
jamaophthalmology.com
Letters
Figure 1. Initial Clinical Presentation and Histopathological Findings A
B
C
D
A, Pigmented conjunctival mass in the left eye measuring 5.5 × 5 × 3 mm was visible superonasally when the patient looked left and down while retracting the upper eyelid. B, Intraoperative examination with eversion of the left upper eyelid revealed a more extensive nodular, darkly melanotic tumor arising from the forniceal conjunctiva superonasally and involving most of the forniceal and tarsal conjunctiva from the 10-o’clock to 2-o’clock meridians. C, Histopathological analysis revealed an invasive melanocytic tumor surrounded by a dense inflammatory infiltrate (hematoxylin-eosin, original magnification ×30). D, High-magnification photomicrograph revealed pronounced large, pleomorphic melanocytes with prominent nuclei, irregular chromatin, and well-defined nucleoli (hematoxylin-eosin, original magnification ×90).
Figure 2. Clinical Outcome A
C
B
D
the surgical defect may preclude primary closure, increasing the risk of long-term fibrosis and symblepharon as described herein.1,4,5 Although used extensively, oral mucosa seems prone to scarring and tends to obscure tumor recurrence.3,5 Conversely, amniotic membrane has been used widely in ocular surface repair owing to its unique healing properties and ability to preserve the fornix with minimal scarring,4,5 providing a viable therapeutic alternative for our patient. Lymph node biopsy was performed because our patient had an extensive tumor without clinical or histopathological feajamaophthalmology.com
A, Three weeks following wider conjunctival excision, a symblepharon ring was fitted over the left ocular surface without difficulty. B, Three months after wide excision with amniotic membrane graft, the patient presented with a new amelanotic nodule located on the inferior temporal fornix in the left eye away from the initially resected tumor; it was found to be a conjunctival melanoma (epithelioid cell type). C, Ten days into the second cycle of treatment with topical mitomycin C, 0.02%, the patient presented with severe contact dermatitis and treatment was interrupted. D, At recent follow-up 15 months after wide excision of conjunctival melanoma and 5 months after completion of adjuvant topical chemotherapy, the patient has full ocular motility with minimal forniceal and conjunctival scarring.
tures consistent with CM de novo, which reportedly has higher rates of metastasis and death than those arising from primary acquired melanosis or nevus.3 Adjuvant treatments for CM include topical mitomycin C, interferon alfa-2b, 5-fluorouracil, and plaque brachytherapy.3,6 Most patients using topical mitomycin C for CM experience at least 1 long-term complication.3,6 Interferon alfa-2b has been shown to be effective for CM and less toxic, but nearly all patients require long-term continuous treatment as our patient did.6 JAMA Ophthalmology December 2014 Volume 132, Number 12
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 05/27/2015
1487
Letters
In summary, our patient is tumor free 15 months after wide excision and topical chemotherapy to treat an extensive CM. Periodic follow-up is warranted to monitor local recurrence. Alison M. Dzwonczyk, MD Zélia M. Corrêa, MD, PhD James J. Augsburger, MD Dwight Kulwin, MD
2. Nijhawan N, Ross MI, Diba R, Ahmadi MA, Esmaeli B. Experience with sentinel lymph node biopsy for eyelid and conjunctival malignancies at a cancer center. Ophthal Plast Reconstr Surg. 2004;20(4):291-295. 3. Oellers P, Karp CL. Management of pigmented conjunctival lesions. Ocul Surf. 2012;10(4):251-263. 4. Dua HS, Gomes JA, King AJ, Maharajan VS. The amniotic membrane in ophthalmology. Surv Ophthalmol. 2004;49(1):51-77. 5. Solomon A, Espana EM, Tseng SC. Amniotic membrane transplantation for reconstruction of the conjunctival fornices. Ophthalmology. 2003;110(1):93-100.
Author Affiliations: University of Cincinnati College of Medicine, Cincinnati, Ohio (Dzwonczyk, Corrêa, Augsburger); Department of Ophthalmology, University of Cincinnati College of Medicine, Cincinnati, Ohio (Corrêa, Augsburger, Kulwin). Corresponding Author: Zélia M. Corrêa, MD, PhD, Department of Ophthalmology, University of Cincinnati College of Medicine, 260 Stetson St, Ste 5300, Cincinnati, OH 45267 ([email protected]). Published Online: August 28, 2014. doi:10.1001/jamaophthalmol.2014.2871. Conflict of Interest Disclosures: None reported. Funding/Support: This work was supported in part by an unrestricted grant from Research to Prevent Blindness (Dr Augsburger). Role of the Funder/Sponsor: Research to Prevent Blindness had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. 1. Shields CL, Shields JA, Gündüz K, et al. Conjunctival melanoma: risk factors for recurrence, exenteration, metastasis, and death in 150 consecutive patients. Arch Ophthalmol. 2000;118(11):1497-1507.
6. Poothullil AM, Colby KA. Topical medical therapies for ocular surface tumors. Semin Ophthalmol. 2006;21(3):161-169.
Choroidal Neovascularization and Chorioretinal Anastomoses Following Laser Treatment of a Secondary Vasoproliferative Tumor Laser photocoagulation–induced choroidal neovascularization (CNV) is an uncommon iatrogenic complication following thermal laser treatment for diabetic macular edema and proliferative diabetic retinopathy.1 Disruption of the retinal pigment epithelium–Bruch membrane complex due to intense laser energy presumably leads to the development of CNV.1,2 We report a dramatic case of laser-induced CNV initially associated with a chorioretinal mass lesion that displayed characteristics of an atypical secondary vasoproliferative tumor. The
Figure 1. Multimodal Imaging of the Chorioretinal Lesion A
C
B
D
Video at jamaophthalmology.com
E
1488
JAMA Ophthalmology December 2014 Volume 132, Number 12
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 05/27/2015
A, Ultra–wide-field retinal color fundus photograph reveals dense and heavy laser scars with a raised pale vascular mass located along the infratemporal arcade with lipid exudate (Optos 200TX). B, Close-up view of the vascular lesion shows that it originated at the edge of laser scars with telangiectatic capillary on the surface (Topcon TRC-50DX). Green arrow indicates the optical coherence tomography section for D; yellow arrow, optical coherence tomography section for E. C, This lesion is hyperfluorescent on fluorescein angiography without an identifiable feeder vessel and appears to arise from the subretinal space or the retinal pigment epithelium. D, The lesion shows heterogeneity, loss of normal retinal architecture, and an epiretinal membrane on spectral-domain enhanced depth imaging optical coherent tomography (Heidelberg Spectralis HRA+OCT). E, Secondary cystoid macular edema is also present on spectral-domain enhanced depth imaging optical coherent tomography (Heidelberg Spectralis HRA+OCT). jamaophthalmology.com
