Advances in Ocular Imaging

Transcription

1 Wide angle fundus imaging and Fuorescein angiography in evaluation and management of intraocular tumors Ihab Saad Othman, MD, FRCS Professor of Ophthalmology Cairo University Cairo, Egypt Advances in Ocular Imaging Kowa Topcon Retcam 1

2 Wide-Field (Digital) Imaging. Field-of-view: The instantaneous field-of -view (FOV). Field-of-regard (FOR): Total field of imaging available with camera. Ora serrata Equator ORA SERRATA EQUATOR Standard fundus camera field-of-view (FOV) What would we do differently if we could remotely image the entire eye? Wide Angle Imaging Retcam Panoret Optos 2

3 Wide angle viewing: Staging of Retinoblastoma Reese-Ellsworth Staging system (1963): Predicts visual prognosis with external beam radiotherapy Group I: Very favorable prognosis: Single tumor, 4 DD at or behind the equator. Multiple tumors, 4 DD at or behind the equator Group II: favorable prognosis: Solitary tumor, 4-10 DD at or behind the equator. Multiple tumors, 4-10 DD at or behind the equator. Reese-Ellsworth Staging system Group III: doubtful prognosis: Any lesion anterior to the equator Solitary tumors larger than 10 disc diameters behind the equator Group IV: unfavorable prognosis: Multiple tumors, some >10 DD Any lesion extending anteriorly to ora serrata. 3

4 Reese-Ellsworth Staging system Group V: very unfavorable prognosis: Massive tumor involving over half the retina. Vitreous seeding. Retinoblastoma Staging: International classification of retinoblastoma (2003) is based on the rate of ocular salvage with systemic chemotherapy A B Very favorable. Tumor confined to C the retina D Unfavorable. Tumor dispersed to adjacent spaces E Unsalvageable 4

5 Retinoblastoma Staging: International classification of retinoblastoma Group A: Tumor Not more than 3mm Located more than 1.5 mm from optic disc and 3 mm from fovea Retinoblastoma International classification of retinoblastoma Group B: Tumors confined to the retina 10mm Any location No subretinal fluid beyond 3 mm from the base of the tumor 5

6 Retinoblastoma Group C: Any size tumor < ½ the eye Subtle dispersion Fine vitreous seeds No dispersed tumor masses Subretinal seeds less than 3 mm from the tumor Retinoblastoma Group D: Diffuse disease with significant vitreous or subretinal seeding Subretinal fluid in more than one quadrant of the retina Subretinal fluid, present or past, without seeding, involving up to total retinal detachment 6

7 Group D: Tumor(s) may be massive or diffuse Diffuse subretinal seeding, present or past, may include subretinal plaques or tumor nodules Diffuse or massive vitreous disease may include "greasy" seeds or avascular tumor masses Wide Angle Viewing Extremely valuable in: Treatment monitoring 7

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9 Documents Plaque Centration IOAM, 3 cycles 9

10 IOAM, 3 cycles 10

11 5 months follow up: Subretinal seeds recurrence/ Enucleation Direct Gonioscopy: Case: 1.5 year-old male Ciliochoroidal mass: PLSU 11

12 Case: 1.5 year-old male Ciliochoroidal mass: PLSU Pathology: Ectopic lacrimal gland Direct Gonioscopy: Medulloepithelioma 12

13 CB masses 18 YOM CB mass followed for the last 4 years Growing on UBM UBM: AP UBM: Transverse 13

14 Differential Diagnosis Adenoma (non-pigmented ciliary epithelium) Medulloepithelioma Metastasis Melanoma Transcleral Resection 14

15 Specimen Specimen 15

16 Granulaomatous inflammation Non-caseating ZN-negative?? Sarcoidosis, chest X-ray normal, ACE normal Opto Tx

17 Follow up of Pediatric age group > 3 years vs GA 8 YOF VA: 6/24 17

18 4 YOF VA: 6/6 10 YOF VA: 6/24 18

19 5 YOM Monophthalmic VA: 6/36 32 YOF Mom 19

20 Choroidal Tumors Diagnosis and Management Choroidal Melanoma: Most common primary intraocular malignancy in adults Dendritic melanocytes (neural crest origin) 20

21 Opaque media Initial evaluation of thickness Follow up of treatment response A-scan: Low to medium reflectivity B-scan: Acoustic hollowness, choroidal excavation, + angle kappa 21

22 45 year-old-female with choroidal melanoma 16 YOF Peripheral choroidal mass Wide Angle FF/A 22

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24 63 YOF: Melanoma Post-Ru 106 / TTT 24

25 Tumor Extent 55 YOF Enucleation Autofluorescence 25

26 48 YOM Tumor control post PLSU/TTT 2 months VA: 6/36 26

27 18 month VA: 6/9 28 YOF PLSU/TTT 3 months VA: 6/36 27

28 1 year VA: 6/9 28

29 Choroidal Metastases 4 7 year-old female with multiple breast metastases FNAB: Highly reliable Uncertain diagnosis Difficult technique Experienced cytopathologist 29

30 72 year-old female with choroidal mass: unknown primary Classically: FNAB: indirect ophthalmoscopy: Inverted image Laterally rotated image Mastering and meticulous manipulations Hundreds of cases with a steep learning curve 30

31 Interventional Photo-guided choroidal biopsy Retcam Interventional Photo-guided choroidal biopsy Adenocarcinoma 31

32 57 YOF DVA OS for 3 months 32

33 Lymphoma: 60 YOF FNAB Plasmacytoma in a 65 YOF 33

34 Hemorrhagic Lesions Simulating Melanoma 58 year-old female Choroidal Mass OS x 1 month VA: 6/18 34

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38 Vertical Transverse 38

39 Revise History: Discussion New Investigative tools: Wide Angle FF/A is a primordial tool in management of intraocular tumors Paradigm shift with a whole chapter in panoramic view and peripheral fundus changes In tumors: Early diagnosis and timely intervention is imperative in SURVIVAL 39

40 Remember: WHEN DEALING WITH CANCER YOU ARE DELAING WITH LETHAL DISEASE YOU ARE DELAING WITH HUMAN LIFE NO ROOM FOR TRIAL AND ERROR EYE SALVAGE WILL DEPEND ON PROPER DIAGNOSIS AND SOUND MANAGEMENT EVERY EFFORT IS JUSTIFIED TO SAVE AN EYE WITHOUT COMPROMISING LIFE Wide angle fundus Digital Screening: Retcam Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon 40

41 Opto Tx 200 Opto Tx

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