Ocular Oncology Basics: Diagnosis of Intraocular Malignancies

Bikramjit P Pal


“Declare the past, diagnose the present, foretell the future.” ― Hippocrates

In this section I will deal with various diagnostic methods which are commonly in practice for the diagnosis of mainly intra ocular malignancies. Diagnostic modalities used for extraocular malignancies will be considered in the respective chapters.


1.History


Even though twenty first century has seen a boom in the diagnostic armamentarium available to the ophthalmologist, art of good history taking can never be out of fashion.

   In the sick room, ten cents' worth of human understanding equals ten dollars' worth of medical science. - Martin H. Fischer

2. Visual Acuity


Its a good habit to check the current refraction and comparing with previous spectacles. This will not only detect changes but also show a sudden hyperopic shift providing a diagnostic clue.

3. External local examination


This step is accomplished while having a interaction with the patient. Any strabismus, lid abnormalities, pigmentary changes in the ocular/peri-ocular region can be diagnosed. Examination of the regional lymph nodes is an important but often missed step.

4. Slit Lamp Biomicroscopy.[ 1],[2]


One of the most important investigative modalities not only provides us with details about the primary tumour but also presence of any associated anomalies and secondary effects.

 
5.  Indirect Ophthalmoscopy (IDO)



IDO is an art  perfected only with practice and patience. Once perfected it can reveal plethora of findings.

DIAGNOSTICS MODALITIES

1. B scan Ultrasound:


Bscan ultrasound should ideally be done by the treating ocular oncologist.

B scan features in Chroroidal Melanoma( useful only when lesion is greater than 1 mm). The various features on B scan is due to homogenous nature of melanoma cells with minimal fibrous tissue.

    1. Low internal reflectivity
    2. A acoustic quiet area at the base of the tumor called acoustic hollowness.
    3. Choroidal excavation
    4. Orbital shadowing: the reflectivity posterior to the tumour is low.
    5. On A scan low to medium reflectivity is seen with characteristic "positive angle kappa": the reflectivity decreases after a high spike.
    6. Tumor diameter and thickness on B scan are the basis of a treatment plan. B scan post treatment judges the activity on the basis of thickness and clinical characteristics.
    7. B scan is also used in judging the placement of a plaque.
    8. B scan is also helpful in judging extra ocular spread.

 2. Ultrasound Biomicroscopy ( UBM)


3 Fundus Imaging ( with WIDE FIELD IMAGING) [ 5,6,]


Uses

Imaging systems

Standard Fundus Photograph

Retcam

Panoret 100

Optos

4. Fundus Autofluorescence (FAF) [7]


5. Optical Coherence Tomography ( OCT & EDI OCT ) [8]


6. Fundus Fluorescein Angiography ( FFA) , Indocyanine Green Angiography (ICG) [1]


7. Transillumination:


Transillumination is useful in pigmented tumours in assessing the margins.  It is a useful method of localizing tumour margins during plaque placement. Its usefulness decreases in pigmented fundus ( a inhibiting factor in dark complexioned persons).
a) Transpupillary: when the light source is placed over the cornea .
b) Transocular: when light source is placed over the globe opposite to the tumour.
c) Transscleral: when the light source is placed under the tumour to determine its transillumination property.

 

8. Fine Needle Aspiration Biopsy (FNAB)


 
9.  Neuroimaging ( CT , MRI, PET) [1,2]


 

References
1)  Singh AD, Damato BE, Pe'er J, Murphee AL, Perry JD. Clinical Ophthalmic Oncology .Philadelphia: Saunders, Elsevier 2007
2) Damato BE. Ocular Tumours. Diagnosis and treatment. Butterworth-Heinemann 2000
3) De Jong MC, Van der Meer FJ, Göricke SL, Brisse HJ, Galluzzi P et al.  Diagnostic  Accuracy  of  Intraocular Tumor Size Measured with MR Imaging in the Prediction of Postlaminar Optic Nerve Invasion and Massive Choroidal Invasion of Retinoblastoma. Radiology. 2015 Dec 19:151213. [Epub ahead of print]
4)Vasquez LM, Giuliari GP, Halliday W, Pavlin CJ, Gallie BL et al. Ultrasound biomicroscopy in the management of retinoblastoma. Eye (Lond). 2011 Feb;25(2):141-7
5) Heimann H, Jmor F, Damato B. Imaging of retinal and choroidal vascular tumours. Eye (Lond). 2013 Feb;27(2):208-16
6) Schalenbourg A, Zografos L. Pitfalls in colour photography of choroidal tumours. Eye (Lond). 2013 Feb;27(2):224-9
7) Almeida A, Kaliki S, Shields CL. Autofluorescence of intraocular tumours. Curr Opin Ophthalmol. 2013 May;24(3):222-32
8) Shields CL, Pellegrini M, Ferenczy SR, Shields JA. Enhanced depth imaging optical coherence tomography of intraocular tumors: from placid to seasick to rock and rolling topography--the 2013 Francesco Orzalesi Lecture. Retina. 2014 Aug;34(8):1495-512.