Whole-body 18 FDG PET/CT imaging for lymph node and metastatic staging of conjunctival melanoma.

AIM: To evaluate 18-fluoro-2-deoxyglucose (FDG) whole-body positron emission tomography/computed radiographic tomography (PET/CT) for lymph node and metastatic staging of patients with conjunctival melanoma. METHODS: Fourteen patients with T3 (n = 13) and T4 (n = 1) conjunctival melanoma (as defined in Chapter 42 of the AJCC staging manual) were staged for metastatic disease with PET/CT imaging with fusion. The patients had lymph node and clinical staging evaluations before PET/CT imaging. PET/CT images were studied for the presence and distribution of metastatic conjunctival melanoma (determined by standardised uptake values) and later confirmed by biopsy. MRI imaging was performed if abnormalities were noted on PET/CT images. RESULTS: Fourteen patients with conjunctival melanoma underwent PET/CT imaging. Seven were newly diagnosed (presurgical screening), and seven had undergone prior treatment (follow-up group). Only one patient with conjunctival melanoma (7.1%) was found to have metastatic disease on PET/CT imaging. Abnormal foci were found in the liver, lung, peritoneal cavity, lumbar spine as well as a supraclavicular node (T4N1M4). All liver function tests were normal. The mean length of follow-up after PET/CT imaging was 13 months (range 4-30 months). CONCLUSIONS: PET/CT imaging did not reveal any regional or systemic metastasis among 14 patients with advanced, diffuse and multifocal disease.

Anterior chamber paracentesis cytology (cytospin technique) for the diagnosis of intraocular lymphoma.

AIM: To report on the diagnosis of intraocular lymphoma by aqueous cytology. METHODS: Four patients suspected of having intraocular lymphoma were evaluated by anterior chamber (AC) paracentesis with cytology (cytospin technique). All had a history of non-ocular lymphoma and presented with at least one plus anterior chamber cells despite intensive glucocorticoid therapy. A 25 gauge needle was inserted through clear cornea (bevel up), over the iris stroma, so as to drain the AC. The aqueous humour was sent for cytopathology (cytospin technique), culture, and sensitivity tests. RESULTS: All procedures were diagnostic. Three were lymphoma and the fourth was culture positive for Propionibacterium endophthalmitis. No secondary glaucoma, hyphaema, cataract or infections were related to AC paracentesis. CONCLUSIONS: In this series, AC aspiration cytology enhanced by the cytospin technique was an effective, minimally invasive alternative to vitrectomy based biopsy. This technique should be considered to rule in the diagnosis of intraocular lymphoma in selected cases with cells in the anterior chamber.

PET/CT imaging: detection of choroidal melanoma.

AIM: To determine the size of untreated choroidal melanomas resolved by whole body positron emission tomography fused with computed tomography (PET/CT). METHODS: 50 consecutive patients with untreated choroidal melanomas underwent whole body PET/CT. A functionally fused helical CT scan and 18-fluoro-2-deoxyglucose (FDG) PET scans were employed. The tumours were identified (both quantitatively and qualitatively) and compared with clinical measurements derived from ophthalmoscopic, angiographic, and ultrasonographic imaging. Standardised uptake values (SUV) of more than 2.5 were considered positive. RESULTS: Among the 50 patients with choroidal melanoma, PET/CT scan SUVs of more than 2.5 were noted in 14 (28%) tumours. No AJCC T1 class tumours, 33.3% of T2 melanomas, and 75% of T3 melanomas were physiologically identifiable on PET/CT. With respect to COMS group classifications, no small choroidal tumours, 33% of medium, and 75% of large melanomas were physiologically identifiable. The sole ring melanoma was identifiable on PET/CT imaging. The smallest tumour physiologically identifiable by PET/CT had basal dimensions of 3x5.9 and an apical height of 2.9 mm. CONCLUSION: Though PET/CT was found to be capable of physiologically identifying certain medium (T2) and most large sized (T3) choroidal melanomas, physiological imaging was not completely dependent upon tumour size. Functionally fused PET/CT localised the tumours within the eye and assessed their physiological activity.

Whole body PET/CT for initial staging of choroidal melanoma.

AIM: To investigate the value of whole body positron emission tomography/computed tomography (PET/CT) in screening for metastatic choroidal melanoma in patients initially diagnosed with choroidal melanoma. METHODS: 52 patients with choroidal melanoma underwent whole body PET/CT as part of their metastatic investigation. PET/CT scans were used as a screening tool at the time of their initial diagnosis. A physical examination, liver function tests, and a baseline chest x ray were also obtained. PET/CT images (utilising intravenous18-fluoro-2-deoxyglucose (FDG)) were studied for the presence of metastatic melanoma. The standards for reference were further imaging and/or subsequent biopsies. RESULTS: Two of 52 (3.8%) patients were found to have metastatic melanoma before treatment. The most common sites for metastases were the liver (100%), bone (50%), and lymph nodes (50%). Brain involvement was also present in one patient. One patient (50%) had involvement of multiple sites. Haematological liver enzyme assays were normal in both patients. PET/CT showed false positive results in three patients (5.7%) when further evaluated by histopathology and/or additional imaging. In seven patients (13.4%) PET/CT imaging detected benign lesions in the bone, lung, lymph nodes, colon, and rectum. CONCLUSION: PET/CT imaging can be used as a screening tool for the detection and localisation of metastatic choroidal melanoma. Liver enzyme assays did not identify liver metastases, while PET/CT revealed both hepatic and extrahepatic metastatic melanoma. PET/CT imaging may improve upon the conventional methods of screening for detection of metastatic disease in patients initially diagnosed with choroidal melanoma.

The Finger iridectomy technique: small incision biopsy of anterior segment tumours.

AIMS: To develop a minimally invasive, maximally effective method to biopsy anterior segment tumours. METHODS: A 25 gauge aspiration cutter (vitrector) was used to biopsy anterior segment tumours. The probe was introduced under sodium hyaluronate 1% and through a 1 mm incision. Aspiration (600 mm Hg) cutting (300 cpm) was performed to obtain specimens for cytology and histopathology. RESULTS: Diagnostic material was obtained in nine of 10 (90%) cases. Diagnoses included iris naevus, iris stroma, malignant melanoma, melanocytoma, epithelial inclusion cyst, and sarcoid granuloma. All corneal wounds were self sealing. One patient developed a transient postoperative increase in intraocular pressure. Within the follow up of this study, no patients suffered intraocular haemorrhage, infection, cataract or vision loss. CONCLUSION: The Finger iridectomy technique was a minimally invasive and very effective biopsy technique. Aspiration cutting yielded relatively large pieces of tissue (and cells) used for cytopathological and histopathological evaluation. Small incision surgery allowed for rapid rehabilitation and no significant complications.

Laser photocoagulation for radiation retinopathy after ophthalmic plaque radiation therapy.

AIM: To evaluate the use of scatter laser photocoagulation to prevent radiation related retinopathy, maculopathy, and loss of vision. METHODS: This was an interventional case series. 66 eyes with posterior choroidal melanomas treated by ophthalmic plaque radiation therapy were reported. Of these patients, 50 were selected because they developed radiation retinopathy; 45 of these were treated with sector scatter laser photocoagulation to regress clinically evident radiation retinopathy. 16 additional patients (considered to be "high risk" to develop radiation retinopathy) were also treated. RESULTS: Radiation retinopathy was noted to appear at a mean interval of 26 months following plaque treatment. Laser photocoagulation regressed radiation retinopathy in 29 (64.4%) of the 45 patients treated after the onset of radiation retinopathy (17 with only retinopathy, 10 with a combination of retinopathy and maculopathy, and two with only maculopathy). Of the 16 patients who received laser treatment before clinical evidence of retinopathy, one developed radiation maculopathy and two retinopathy without maculopathy (all three responded to additional laser photocoagulation). In the 45 patient group, vision loss of more than three lines was attributable to radiation maculopathy in seven (15.5%). None of the patients in the prophylactic laser group lost more than three lines of vision as a result of maculopathy. CONCLUSION: Sector scatter argon laser photocoagulation induced regression of radiation retinopathy. Though early treatment of radiation retinopathy appears to be more effective, a more long term and prospective randomised study will be needed to prove efficacy.

Indications and outcome of carotid Doppler ultrasound: an ophthalmic perspective.

PURPOSE: The purpose of this study was to assess indications and outcome of carotid Doppler ultrasound requested by ophthalmologists from an eye hospital over a period of three years. METHODS: This retrospective study was designed to analyse data for all patients referred to have carotid Doppler ultrasound from 1999 to 2001. Colour fundus photograph was used to ascertain diagnosis of ocular condition. Detailed case note analysis was done to correlate patient details, indication, results of carotid Doppler, and status of anti-platelet treatment as well as presence of other risk factors. RESULTS: 107 patients were included in the study. 46.7% had normal internal carotid on Doppler while 53.3% patients had stenosis, 22.8% of which were significant. 15 out of 24 patients with retinal artery occlusion had internal carotid artery (ICA) stenosis. 2 out of 6 patients with migraine had significant stenosis. 12 patients had retinal vein occlusion (5 were bilateral), 9 of whom showed ICA stenosis. 14 of 15 patients with retinal emboli had stenosis of ICA. Other diagnoses included anterior ischaemic optic neuropathy, cranial nerve palsy, etc. 42 patients had 1 to 3 risk factors, and 11 patients had more than 3 risk factors. Ophthalmologists started anti-platelet management in 24 patients (42.1%) with some degree of ICA stenosis. CONCLUSIONS: Approximately 55% of our patients referred for carotid Doppler were positive for ICA stenosis with nearly a fifth of such referrals having more than 70% stenosis, which is considered to be clinically significant. Our results highlight the importance of such referrals for carotid Doppler for various ophthalmic conditions by the ophthalmologists.

Indications and Outcome of Carotid Doppler Ultrasound An Ophthalmic Perspective.

PURPOSE: The purpose of this study was to assess indications and outcome of carotid Doppler ultrasound requested by ophthalmologists from an eye hospital over a period of three years. METHODS: This retrospective study was designed to analyse data for all patients referred to have carotid Doppler ultrasound from 1999 to 2001. Colour fundus photograph was used to ascertain diagnosis of ocular condition. Detailed case note analysis was done to correlate patient details, indication, results of carotid Doppler, and status of anti-platelet treatment as well as presence of other risk factors. RESULTS: 107 patients were included in the study. 46.7% had normal internal carotid on Doppler while 53.3% patients had stenosis, 22.8% of which were significant. 15 out of 24 patients with retinal artery occlusion had internal carotid artery (ICA) stenosis. 2 out of 6 patients with migraine had significant stenosis. 12 patients had retinal vein occlusion (5 were bilateral), 9 of whom showed ICA stenosis. 14 of 15 patients with retinal emboli had stenosis of ICA. Other diagnoses included anterior ischaemic optic neuropathy, cranial nerve palsy, etc. 42 patients had 1 to 3 risk factors, and 11 patients had more than 3 risk factors. Ophthalmologists started anti-platelet management in 24 patients (42.1%) with some degree of ICA stenosis. CONCLUSIONS: Approximately 55% of our patients referred for carotid Doppler were positive for ICA stenosis with nearly a fifth of such referrals having more than 70% stenosis, which is considered to be clinically significant. Our results highlight the importance of such referrals for carotid Doppler for various ophthalmic conditions by the ophthalmologists. (Eur J Ophthalmol 2004; 14: 240-4).

Use of inhaled nitrous oxide for minor eyelid surgery: a placebo-controlled study.

BACKGROUND: Pain from local anaesthetic injection for minor eyelid surgery can often be severe enough to be the most unpleasant part of the procedure. This study was aimed at assessing the efficacy of 50 : 50 N(2)O/O( 2) (Entonox) in relieving such pain. METHODS: In this randomised placebo-controlled double blind trial, 100 patients were randomised to receive either Entonox or air. Questions regarding pain during the administration of local anaesthetic, discomfort during the procedure and side effects experienced were asked by an investigator who was blinded to the type of gas inhaled. RESULTS: The difference in pain score between the Entonox and control groups was not statistically significant (p = 0.474). The difference in discomfort score between the two groups was also not statistically significant (p = 0.948). More side effects were noted with Entonox than with air (p = 0.003, statistically significant). However, this was not clinically significant. CONCLUSION: Entonox has been used effectively in different specialties for pain relief. However, our study was unable to show this beneficial effect in relieving pain from local anaesthetic injections for minor eyelid surgery.