Neoplastic masquerade syndromes

Masquerade syndrome: A review of uveitic imposters

Masquerade syndromes in uveitis are complex clinical conditions where non-inflammatory diseases mimic uveitic manifestations, often leading to diagnostic and therapeutic challenges. This review delves into the diverse spectrum of masquerade syndromes, categorizing them into neoplastic and non-neoplastic entities. We explore the prevalence of primary intraocular lymphoma, leukaemia, retinoblastoma, and other malignancies, as well as conditions like retinitis pigmentosa and endophthalmitis that can present as uveitis. Through detailed analysis of symptoms, diagnostic methods, and treatment approaches, the review emphasizes the importance of considering masquerade syndromes in differential diagnoses to prevent mismanagement. The synthesis of current knowledge aims to enhance clinicians' ability to discern these complex presentations, advocating for a multidisciplinary approach to diagnosis and care, thereby improving patient outcomes in cases of uveitic masquerade syndromes.

Evaluation of choroidal thickness and choroidal vascularity index in patients with Crimean-Congo hemorrhagic fever

PURPOSE

This study aimed to compare choroidal thickness parameters between patients diagnosed with Crimean-Congo hemorrhagic fever (CCHF) and healthy individuals using spectral domain optical coherence tomography.

METHODS

The right eyes of 27 individuals diagnosed with CCHF and 27 healthy subjects were included in this study. CCHF cases were assessed based on a history of tick bites and hospitalization. Choroidal thickness was measured using enhanced depth imaging optical coherence tomography. Measurements of choroidal thickness were taken at 5 different points, including the subfoveal quadrant and the fovea up to 2000 μm with 1000 μm intervals in the temporal and nasal quadrants. Choroidal vascular index (CVI) was calculated as the ratio of luminal area (LA) to total choroidal area (TCA) at the macula's total area and at 1500 μm from the center (CVI and CVI1500).

RESULTS

Choroidal thickness in the CCHF group was found to be thicker in each quadrant compared to the control group, with the subfoveal and nasal quadrants showing significantly greater thickness. TCA, stromal area, and LA were significantly higher in the CCHF group, while no significant difference was observed in CVI and CVI1500.

CONCLUSION

The findings of this study suggest that CCHF disease may have an impact on the choroidal structure.

Challenges in posterior uveitis-tips and tricks for the retina specialist

PURPOSE

Posterior uveitis is a common chorioretinal pathology affecting all ages worldwide and is a frequent reason for referral to the retina clinic. The spectrum of etiologies for uveitis is very broad and includes infectious and auto-immune diseases. Inflammation can be confined to the eye or may be a part of systemic disease. A useful outline is therefore proposed to aid in the correct diagnosis of these challenging entities. The situation is further complicated by the fact that many neoplastic conditions resemble features of posterior uveitis; they are known as "masqueraders of uveitis". Here, we summarize different posterior uveitides that present with rare findings, along with masqueraders that can be difficult to distinguish. These conditions pose a diagnostic dilemma resulting in delay in treatment because of diagnostic uncertainty.

METHODS

An extensive literature search was performed on the MEDLINE/PUBMED, EBSCO and Cochrane CENTRAL databases from January 1985 to January 2022 for original studies and reviews of predetermined diagnoses that include posterior uveitic entities, panuveitis and masquerade syndromes.

RESULTS

We described conditions that can present as mimickers of posterior uveitis (i.e., immune check-points inhibitors and Vogt-Koyanagi-Harada-like uveitis; leukemia and lymphoma associated posterior uveitis), inflammatory conditions that present as mimickers of retinal diseases (i.e., Purtscher-like retinopathy as a presentation of systemic lupus erythematosus; central serous chorioretinopathy masquerading inflammatory exudative retinal detachment), and uveitic conditions with rare and diagnostically challenging etiologies (i.e., paradoxical inflammatory effects of anti-TNF-α; post vaccination uveitis; ocular inflammation after intravitreal injection of antiangiogenic drugs).

CONCLUSION

This review of unique posterior uveitis cases highlights the overlapping features of posterior uveitis (paradoxical inflammatory effects of anti -TNF α and uveitis; Purtscher-like retinopathy as a presentation of systemic lupus erythematosus, …) and the nature of retinal conditions (ischemic ocular syndrome, or central retinal vein occlusion, amyloidosis, inherited conditions like retinitis pigmentosa, autosomal dominant neovascular inflammatory vitreoretinopathy (ADNIV), etc.…) that may mimic them is represented. Careful review of past uveitis history, current medications and recent vaccinations, detailed examination of signs of past or present inflammation, eventually genetic testing and/ or multimodal retinal imaging (like fluorescein angiography, EDI-OCT, OCT-angiography for lupus Purtscher-like retinopathy evaluation, or ICG for central serous retinopathy, or retinal amyloid angiopathy) may aid in correct diagnosis.

Delayed recurrence of an iridociliary malignant melanoma 180° from the primary tumor

Purpose

We report the case of a 66-year-old female who returned with a rare recurrence of iridociliary melanoma 180° from the original lesion.

Observations

Upon initial presentation eleven years prior, a pigmented iris lesion suspicious for primary uveal melanoma was noted in the right eye at 9 o'clock. After one year of observation, inferior growth of the iris lesion prompted treatment via primary iridectomy with excisional biopsy and pupilloplasty. Postoperative biopsy confirmed spindle B type melanoma with epithelial foci, and adjuvant brachytherapy was performed to treat the reported positive anterior ciliary body involvement. Ten years after initial plaque brachytherapy treatment, the patient returned with a pigmented iris lesion in the right eye at 3:30–5 o'clock, which was treated with enucleation. On pathology, the new melanoma was predominantly epithelioid, consistent with a transformed recurrent iridociliary melanoma. The patient remains metastasis free 13 years after initial diagnosis.

Conclusions and importance

This case describes a rare, late recurrence of an iridociliary melanoma 180° away eleven years after initial presentation, emphasizing the importance of lifelong follow-up for patients with iridociliary melanoma. This rare form of recurrence has not been previously reported in the literature. We hypothesize the original lesion contained radiotherapy resistant epithelioid cells which grew superficially on the posterior iris and anterior ciliary body, ultimately breaking back through the anterior iris 180° away.

Vitreous proteomics, a gateway to improved understanding and stratification of diverse uveitis aetiologies

PURPOSE

The vitreous proteome might provide an attractive gateway to discriminate between various uveitis aetiologies and gain novel insights into the underlying pathophysiological processes. Here, we investigated 180 vitreous proteins to discover novel biomarkers and broaden disease insights by comparing (1). primary vitreoretinal lymphoma ((P)VRL) versus other aetiologies, (2). sarcoid uveitis versus tuberculosis (TB)-associated uveitis and (3). granulomatous (sarcoid and TB) uveitis versus other aetiologies.

METHODS

Vitreous protein levels were determined by proximity extension assay in 47 patients with intraocular inflammation and a prestudy diagnosis (cohort 1; training) and 22 patients with a blinded diagnosis (cohort 2; validation). Differentially expressed proteins identified by t-tests on cohort 1 were used to calculate Youden's indices. Pathway and network analysis was performed by ingenuity pathway analysis. A random forest classifier was trained to predict the diagnosis of blinded patients.

RESULTS

For (P)VRL stratification, the previously reported combined diagnostic value of IL-10 and IL-6 was confirmed. Additionally, CD70 was identified as potential novel marker for (P)VRL. However, the classifier trained on the entire cohort (cohort 1 and 2) relied primarily on the interleukin score for intraocular lymphoma diagnosis (ISOLD) or IL-10/IL-6 ratio and only showed a supportive role for CD70. Furthermore, sarcoid uveitis displayed increased levels of vitreous CCL17 as compared to TB-associated uveitis.

CONCLUSION

We underline the previously reported value of the ISOLD and the IL-10/IL-6 ratio for (P)VRL identification and present CD70 as a potentially valuable target for (P)VRL stratification. Finally, we also show that increased CCL17 levels might help to distinguish sarcoid uveitis from TB-associated uveitis.

Evaluation of subclinical ocular involvement in patients with deficiency of adenosine deaminase 2 (DADA2)

PURPOSE

To evaluate changes in the peripapillary, macular, and choroidal microvasculature in the eyes of patients with deficiency of adenosine deaminase 2 (DADA2) and no clinical signs of ocular involvement.

METHODS

The study included 12 eyes of 12 patients with DADA2 and 24 eyes of 24 healthy subjects. The foveal avascular zone (FAZ), macular vessel densities (VDs) in the superficial and deep retinal capillary plexuses, peripapillary VDs, and choroidal thickness were evaluated by optical coherence tomography angiography (OCTA). Measurements were compared between DADA2 patients and healthy controls.

RESULTS

The median age was 17 (8-25) years in DADA2 patients and 17.5 (7-23) years in control group at the OCTA visit (p = 0.934). FAZ area did not differ between the groups (p = 0.224). In the superficial capillary plexus, whole-image, foveal, and parafoveal VD values were slightly lower in DADA2 patients than in controls (p = 0.054, p = 0.052, p = 0.117). In the deep capillary plexus, whole-image and parafoveal VD values were significantly lower in DADA2 patients than controls (p = 0.010, p = 0.001). VD in the radial peripapillary capillary plexus was also lower in DADA2 patients, with significantly lower peripapillary VD (p = 0.002). Subfoveal choroidal thickness was significantly higher in patients with DADA2 (p < 0.001).

CONCLUSIONS

This OCTA study demonstrates that both retinal and choroidal involvement may occur in DADA2 patients before the emergence of evident clinical findings.

Posterior Scleritis as a Paraneoplastic Syndrome in Colon Cancer: A Case Report

This study presents a rare case of unilateral posterior scleritis as an ophthalmic manifestation of a paraneoplastic syndrome. A 61-year-old man presented to our department complaining of gradual worsening of vision in his left eye. Visual acuity was 10/10 and 3/10 in his right and left eye, respectively. He also mentioned that he experienced posterior ocular pain while sleeping at night, but was otherwise asymptomatic. His past ophthalmic and medical history were clear. A thorough clinical, imaging (fundus photography, optical coherence tomography, fluorescein angiography, and B-scan), and laboratory investigation was carried out. A diagnosis of posterior scleritis was made, but no obvious cause or underlying disease was identified even after a thorough systematic assessment. Regular follow-up within the next few months did not reveal any further pathological findings. Finally, 6 months after the initial presentation, the patient was diagnosed with colon cancer. Posterior scleritis can present as an ophthalmic manifestation of a paraneoplastic syndrome in patients with an underlying malignancy, even months before the presentation of systemic symptoms and diagnosis of the underlying disease. In conclusion, in patients (especially older adults) with posterior scleritis, the possibility of a malignant neoplasia must not be ignored or underestimated (paraneoplastic syndrome).

Retinoblastoma associated with orbital pseudocellulitis and high-risk retinoblastoma: a study of 32 eyes

PURPOSE

To study the correlation between retinoblastoma (RB) associated with orbital pseudocellulitis and high-risk histopathology features.

METHODS

Retrospective study of 32 patients who underwent primary enucleation for RB presenting with orbital pseudocellulitis.

RESULTS

All RB patients presented with orbital pseudocellulitis. The mean age at presentation of RB was 30 months (median, 24 months; range, 3-70 months). There were 14 (44%) males and 18 (56%) females. All patients were referred with a diagnosis of RB with orbital pseudocellulitis. Tumor was bilateral in 12 (38%) patients but orbital pseudocellulitis was unilateral in all cases. The pseudocellulitis features included proptosis (n = 9; 28%), eyelid edema (n = 22; 69%), conjunctival congestion (n = 23; 72%), and conjunctival chemosis (n = 15; 47%). Based on clinical features and orbital imaging, all patients were diagnosed to have group E intraocular RB. All patients received intravenous steroids prior to enucleation. On histopathology, tumor necrosis was present in all cases with a mean % necrosis of 60% (median, 60%; range, 10% to 90%). Most tumors (72%) were poorly differentiated. High-risk histopathology features were noted in 23 (72%) cases and adjuvant chemotherapy was advised for all these patients. The most common high-risk histopathology features included post-laminar optic nerve infiltration (34%) and scleral infiltration (22%). Over a mean follow-up period of 34 months (median, 9 months; range, < 1-188 months), there was no event of metastasis or death in any patient.

CONCLUSION

RB presenting with orbital pseudocellulitis is associated with high incidence of high-risk histopathology features.

Orbital Pseudocellulitis: A Retinoblastoma-Associated Masquerade Syndrome

Introduction

A masquerade syndrome is an atypical presentation of a neoplastic process that mimics an inflammatory condition. In this paper, we focus on orbital pseudocellulitis.

Case Series

Our case series includes 5 retinoblastoma patients with orbital pseudocellulitis at presentation. In 3 patients the disease was bilateral, in 1 trilateral, and in 1 unilateral. The eyes with pseudocellulitis were enucleated, while the fellow eyes were treated conservatively, when affected. Four patients responded well to the therapy and showed remission of the tumor. The patient with trilateral retinoblastoma did not respond to therapy and died of disease.

Discussion

Differential diagnosis with infectious orbital cellulitis is extremely important. Patients with orbital cellulitis present with fever, sinusitis, leukocytosis, and raised inflammatory markers, while ophthalmoscopic examination is negative and imaging studies show sinus involvement. On the contrary, patients with retinoblastoma do not show systemic inflammation, while ophthalmoscopic examination reveals leukocoria, buphthalmos, and an intraocular tumor mass associated with retinal detachment. Magnetic resonance imaging shows intralesional calcifications and soft tissue edema without sinus involvement. Histology confirms the diagnosis.

Conclusions

Medical history, physical examination, and imaging studies are crucial in the diagnosis of retinoblastoma-associated orbital pseudocellulitis. Retinoblastoma should be excluded in all patients with signs of pre-septal orbital cellulitis through fundoscopy and/or imaging studies.

Choroidal vascularity index as a biomarker of systemic inflammation in childhood Polyarteritis Nodosa and adenosine deaminase-2 deficiency

BACKGROUND/PURPOSE

To assess EDI-OCT (enhanced depth imaging optical coherence tomography) of choroid for inflammatory signs in children with polyarteritis nodosa (PAN) and adenosine deaminase-2 deficiency (DADA-2).

METHODS

In this cross-sectional study conducted between June 2017 and September 2018, we evaluated children diagnosed with PAN (n = 11) and DADA-2 (n = 4) and an age- and sex-matched control group (n = 15). Demographic and laboratory data were retrospectively analyzed from patient charts. Disease activity was assessed using the pediatric vasculitis activity score (PVAS). Choroidal images were obtained with spectral domain-OCT to measure choroidal thickness (ChT) at 5 points (750 and 1500 μm from the foveal center in the temporal and nasal quadrants and beneath the fovea), and to calculate the total subfoveal choroidal area (TCA), luminal area (LA), stromal area (SA), and the choroidal vascularity index (CVI).

RESULTS

The median (min-max) age was 8 (4-16) years in PAN patients, 6 (5-16) years in DADA-2 patients and 8 (8-10) years in control group at the OCT visit (p = 0.214). The ChT at 3 points and the TCA, LA, and SA were higher in children with both PAN and DADA-2 patients compared to those of the control group (p < 0.0001, p = 0.049, p = 0.007, p = 0.007, p = 0.006, p = 0.033, respectively). The CVI was similar in both groups. No association was observed between the OCT findings, PVAS, and the erythrocyte sedimentation rate, and serum leukocyte and C-reactive protein levels.

CONCLUSION

Similar CVI scores were obtained from PAN and DADA2 patients under treatment and from healthy controls. Increased subfoveal ChT without any other signs of ocular involvement may suggest choroidal thickening as a sign of mild subclinical inflammation.

ROLE OF DIAGNOSTIC PARS PLANA VITRECTOMY IN DETERMINING THE ETIOLOGY OF UVEITIS INITIALLY UNKNOWN

PURPOSE

To estimate the success and safety of diagnostic pars plana vitrectomy (PPV) in determining the etiology of uveitis initially unknown and analyze their characteristics.

METHODS

The PubMed, Embase, and Ovid were searched up to October 2017 to identify relevant studies. The PRISMA guidelines were followed. Statistical analyses were performed with R version 3.3.1. Result in proportion were transformed by the Freeman-Tukey variant of arcsine square to attain symmetry of confidence intervals (CIs). The statistical heterogeneity was assessed by the chi-square test and I statistics. Sensitivity analysis and subgroup analyses were performed to identify the source of heterogeneity. Publication bias was assessed by the Egger test.

RESULTS

Sixteen studies involving 1,195 patients were finally included. The pooling result showed the successful rate of diagnostic PPV was 44% (95% CI [39%∼50%]). Among patients whose diagnostic PPV yielded a definitive diagnosis, 69% were infectious uveitis (95% CI [61%∼77%]), 23% were lymphoma (95% CI [17%∼30%]), and 4% were metastatic carcinoma (95% CI [2%∼10%]). Among patients diagnosed with infectious uveitis, the most frequent pathogens identified were viruses, followed by bacteria, Toxocara canis, Toxoplasma gondii, tuberculosis, and fungus. The incidence of postoperative cataract and postoperative retinal detachment was 19% (95% CI [8%∼29%]) and 5% (95% CI [1%∼10%]), respectively, and the rate of secondary vitrectomy surgery was 10% (95% CI [2%∼22%]). Postoperative visual improvement rate was 46% (95% CI [39%∼52%]), and the postoperative treatment strategy was changed in light of the results of diagnostic PPV in 20% of cases (95% CI [10%∼29%]).

CONCLUSION

For uveitis of unknown cause, diagnostic PPV is an effective, reliable, and relatively safe procedure for establishing the definite diagnosis and guiding further treatment. Positive therapeutic effect could also be achieved.

Diagnostic vitrectomy: a case series in a single referral center

OBJECTIVE

To study the results and safety of diagnostic vitrectomy in patients with unknown etiology panuveitis.

METHODS

A retrospective descriptive observational study was carried out in which a total of 29 patients (37 eyes) were included, who underwent a vitreous biopsy due to acute intraocular inflammatory processes. In all, demographic and clinical data were collected. We studied the specific samples extraction methods and their diagnosic processing.

RESULTS

Of the 29 patients analyzed, 18 were men. Mean of age was 63.11 years old (standard deviation: 14.55). The most frequent initial symptom was visual acuity decrease, with mean initial visual acuity being 20/40, excluding 8 eyes that had vision lower than 20/200. 21 presented unilateral ocular involvement. Vitrectomy was performed in all of them obtaining a dry sample. Vitrectomy was performed in all of the patients obtaining a dry sample. Moreover, the following techniques were done: 5 retinal biopsies, obtaining 5 muestras diluidas, 1 subretinal abscess aspirate and 1 aqueous humor aspirate. The most frequent processing technique that was used was cytology in 25 eyes, followed by PCR (polymerase chain reaction) in 11 eyes and culture in 10 eyes. Diagnosis was achieved in 94.5% of patients. Main diagnosis found was lymphoma, followed by toxoplasmosis.

CONCLUSIONS

Diagnostic vitrectomy is very important in ophthalmic inflammation identification. Different techniques for obtaining and processing can be used.

Evaluation of Choroidal Thickness, Choroidal Vascularity Index and Peripapillary Retinal Nerve Fiber Layer in Patients with Juvenile Systemic Lupus Erythematosus

Objective

The aim of this study was to conduct a detailed ophthalmological examination in children with systemic lupus erythematosus (jSLE), including choroidal thickness (ChT), choroidal vascularity index (CVI) and peripapillary retinal nerve fiber layer (RNFL).

Methods

The study included all jSLE patients ( n = 21) diagnosed according to the Systemic Lupus International Collaborating Clinics classification criteria between January 2017 and April 2017, and an age- and gender-matched control group ( n = 21). The Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) was used to assess disease activity. After routine eye examinations, ChT at five points (750 µ and 1500 µ from the center of the fovea both in the temporal and nasal quadrants and under the fovea), total subfoveal choroidal area (TCA), luminal area (LA), stromal area (SA), CVI and RNFL thickness at the optic disc were evaluated.

Results

One patient had active ocular involvement in the form of episcleritis. Another patient had corticosteroid-induced cataract. The median age of the patients was 16 years (6-19 years). ChT at five points, TCA, LA and SA were found to be higher in patients with jSLE, whereas RNFL thickness and CVI were similar to those of the healthy control individuals. No correlation was determined between optical coherence tomography findings, SLEDAI and the immunological parameters (antinuclear antibodies, anti-double-stranded DNA, complements 3 and 4, extracted nuclear antigen antibody, antiphospholipid antibody). Intraretinal and subretinal fluid was not present in any of the patients.

Conclusion

The choroid was thicker in patients with jSLE than in the control group. The study results suggest that jSLE may affect the choroid. Ophthalmological evaluation is important in SLE patients, even in the absence of relevant complaints.

Diagnostic Vitrectomy (25-Gauge) in a Case with Intraocular Lymphoma Masquerading as Bilateral Granulomatous Panuveitis

Purpose.

To report a case of intraocular lymphoma, masquerading as bilateral granulomatous panuveitis, and diagnosed after harvesting vitreous specimen with a 25-gauge vitrectomy instrument.

Methods.

A 67-year-old woman presented with bilateral granulomatous uveitis. Visual acuity in both eyes was severely impaired because of severe concurrent cataract and vitreous organization. Sutureless phacoemulsification and posterior chamber intraocular lens implantation combined with 25-gauge diagnostic vitrectomy was performed.

Results.

Cytopathology and immunocytochemistry of the vitreous disclosed a non-Hodgkin B-cell lymphoma despite unremarkable brain MRI, lumbar puncture, bone marrow aspiration, and whole body scan. Visual acuity improved to 20/120 in both eyes.

Conclusions.

Sutureless combined 25-gauge diagnostic vitrectomy, phacoemulsification, and posterior chamber intraocular lens implantation during one-stage surgery was effective in obtaining appropriate vitreous material for cytology in a case of intraocular lymphoma.

DELINEATION OF CHOROIDAL AND RETINAL LESIONS IN POSTERIOR UVEITIS BY MULTISPECTRAL WIDE-FIELD SCANNING LASER OPHTHALMOSCOPY

PURPOSE

To investigate whether wide-field multispectral scanning laser ophthalmoscopy could assist in determining depth of chorioretinal pathology in posterior uveitis.

METHODS

Cross-sectional retrospective review of patients with birdshot chorioretinopathy (BCR; 42 eyes of 21 patients) or active primary vitreoretinal lymphoma (PVRL; 18 eyes of 10 patients) who had multispectral wide-field scanning laser ophthalmoscopy (Optos) images. Images acquired with 532 nm and 635 nm lasers were analyzed separately using Optos V Vantage Pro Review software.

RESULTS

All 42 eyes with birdshot chorioretinopathy and 8/18 eyes with active primary vitreoretinal lymphoma had lesions on 635 nm imaging, while 26/42 of the birdshot chorioretinopathy eyes and 18/18 eyes with active primary vitreoretinal lymphoma had lesions on 532 nm imaging. The difference between the 2 groups on both 635 nm and 532 nm was statistically significant (P < 0.05).

CONCLUSION

Retinal and choroidal lesions in patients with posterior uveitis can be differentially visualized with Optos 532 nm and 635 nm lasers, respectively, allowing determination of depth of pathology.

Multimodal Imaging in Masquerade Syndromes

Masquerade syndromes present to uveitis clinics due to the appearance of inflammatory signs and chronic symptoms that are not responsive to conventional treatment. They are frequently misdiagnosed and treated as refractory inflammatory conditions, which delays appropriate diagnosis and management. This review of literature focuses on the commonly encountered masquerade syndromes and discusses the role of multimodal imaging in addressing these complex clinical presentations. We review the conventional imaging techniques for these patients and discuss emerging technological advances that may help in establishing a diagnosis. We present cases highlighting the utility of multimodal imaging in identifying the etiology.

Differentiation of severe bilateral panuveitis following phacoemulsification: a case report

BACKGROUND

Cataract surgery typically offers instant visual rehabilitation with rare postoperative complications. However, if complications occur, these complications may be confusing and threatening. We present a case of severe bilateral panuveitis following phacoemulsification and intraocular lens implantation and discuss the importance of a correct diagnosis and management.

CASE PRESENTATION

A 75-year-old Asian male with bilateral phacoemulsification and intraocular lens implantation developed severe inflammation with sharp vision loss in both eyes after the surgeries. Physical examination indicated bilateral panuveitis. With a presumptive diagnosis of suppurative endophthalmitis and a history of effective treatment with intravenous antibiotics plus ofloxacin and steroid drops, intravenous ceftazidime and vancomycin were administered. However, the effects were minimal. With a supplemental history of recurrent oral, perineal, and gastrointestinal ulcers, a diagnosis of Behcet's disease was made, and systemic immune inhibitors were prescribed instead of invasive treatments, which might exacerbate the condition. After 5 days of medication, the inflammation was markedly relieved, and no recurrence was observed 2 weeks later.

CONCLUSION

Correct differentiation of confusing conditions is crucial to implement appropriate management. Postoperative complications of cataract surgery should be differentiated carefully, and perioperative management in patients with autoimmune uveitis should be provided with caution.

Vitreoretinal lymphomas misdiagnosed as uveitis: Lessons learned from a case series

PURPOSE

To present challenging cases of vitreoretinal lymphoma (VRL) that was misdiagnosed as uveitis because of the apparent intraocular inflammation. At the light of the new classification of intraocular lymphomas, we detail the characteristics that masqueraded the tumors and the clinical aspects that guided us to the correct diagnosis.

MATERIALS AND METHODS

We retrospectively reviewed the patients referred to our uveitis service between January 2006 and December 2014.

RESULTS

Seven patients referred with a presumptive diagnosis of idiopathic uveitis received a final diagnosis of VRL. The median time between the onset of symptoms and definitive diagnosis was 25 months for these complex cases. The median time from presentation at our clinic to final diagnosis was 1 month. The described clinical features including dense vitreous cells and subretinal infiltrates were characteristic and tend to be present in all these chronically ill patients. Vitreous samples were collected, and all demonstrated the pathognomonic tumor cells, the specific immunoglobulin heavy chain gene rearrangements, and an interleukin (IL)-10 to IL-6 ratio >1.

CONCLUSION

VRLs are severe diseases with a poor prognosis that may be misdiagnosed as idiopathic inflammatory conditions of the eye. Treatment with steroids may occult the tumors and delay the correct diagnosis. Appropriate evaluation may prompt to a timely vitreous sampling and therefore to a faster diagnosis in these peculiar cases where the correct diagnosis was delayed by several months.

The Role of Chorioretinal Biopsy in the Diagnosis of Intraocular Lymphoma

PURPOSE

To assess the clinical usefulness of chorioretinal biopsy in establishing a definitive diagnosis in intraocular lymphomas.

DESIGN

Retrospective, noncomparative, consecutive diagnostic case series.

METHODS

setting: Moorfields Eye Hospital, London, United Kingdom.

PATIENTS

Twenty-nine consecutive patients presenting with severe uveitis that required an intraocular biopsy where underlying lymphoma was suspected.

OBSERVATION PROCEDURE

A retrospective review of a 15-year period (1999-2014) was undertaken of all patients that have undergone chorioretinal biopsy for suspected lymphoma at Moorfields Eye Hospital, London, United Kingdom. Patients were identified on the hospital's computerized database.

MAIN OUTCOME MEASURES

Effectiveness of chorioretinal biopsy in establishing a definitive diagnosis or in excluding malignancy.

RESULTS

A specific histologic diagnosis was made in 17 cases (59%) while in 9 cases the biopsy combined with clinical data was effective in excluding malignancy. In the 3 remaining cases, no specific diagnosis was made. No intraoperative complications were reported. Postoperative complications other than cataract included 2 vitreous hemorrhages and 2 retinal detachments. Of the 17 cases with a histologic diagnosis, 15 were obtained in eyes with marked vitritis, as opposed to 2 with minimal vitritis.

CONCLUSIONS

Chorioretinal biopsy provided a definitive diagnosis of lymphoma in 59% of cases and assisted in exclusion of a further 31% in this series. The level of vitritis appears to act as a strong index of likelihood in achieving a definitive histologic diagnosis.

Changes of choroidal structure after treatment for primary intraocular lymphoma: retrospective, observational case series

Background

We report changes of choroidal structure determined by binarization of enhanced depth imaging optical coherence tomographic (EDI-OCT) images after treatment for primary intraocular lymphoma (PIOL).

Methods

Five eyes of four patients with PIOL were examined by EDI-OCT before and 6 months after intravitreal methotrexate injections. In addition, 15 eyes of 15 normal individuals controlled by age and refractive error were examined by EDI-OCT. Binarization of the EDI-OCT images was performed using publicly accessible software (ImageJ). The examined area of the subfoveal choroid was 1,500 μm wide, and the dark areas that represented the luminal areas were traced by the Niblack method. Wilcoxon signed rank test was used to determine the significance of changes in the subfoveal choroidal thickness, interstitial area, and luminal area. Mann–Whitney U test was used to compare the parameters in the eyes with pretreatment PIOL and normal control eyes.

Results

The subfoveal choroidal thickness was significantly decreased after treatment (P = 0.0431). In the binarized images, the interstitial area was significantly decreased after treatment (P = 0.0431), while the luminal area was not significantly changed (P = 0.8927). After delayed onset of PIOL, increased interstitial area, thickened choroid and unchanged luminal area were observed in one eye. The interstitial area and choroidal thickness were significantly increased in the eyes with pretreatment PIOL compared with the normal control eyes (P = 0.0207, P = 0.0495, respectively), while the luminal area was not significantly different (P = 0.2752).

Conclusions

After treatment for PIOL, the EDI-OCT images showed a thinner choroid, and binarization of the EDI-OCT images showed significantly decreased interstitial areas compared with the luminal areas. The binarized EDI-OCT images can provide useful information on choroidal structure in eyes with PIOL, and combining these images with intraocular interleukin levels or fundus autofluorescence images should provide valuable information for determining the PIOL activity.

Two masquerade presentations of retinoblastoma

Masquerade syndromes are disorders occurring with intraocular inflammation misdiagnosed as uveitis. The underlying causes may be benign or malignant conditions, and one of the most important diagnoses to take into consideration in children is retinoblastoma. We present two cases with uncertain early misdiagnosis whose definite diagnosis eventually was retinoblastoma.

Primary extranodal marginal zone B-cell lymphoma with diffuse uveal involvement and focal infiltration of the trabecular meshwork: a case report and review of literature

Background

Primary extranodal marginal zone lymphoma (EMZL) of the uvea is a rare condition and diagnosis may be challenging. We aim to report the clinical, histopathologic and immunohistochemical findings in a case of primary EMZL with diffuse uveal involvement and focal infiltration of the trabecular meshwork.

Case presentation

A 38-year-old male presented with 2-year progressive vision loss in the right eye. Fundus examination showed choroidal thickening with diffuse retinal pigment epithelium (RPE) changes and inferior exudative retinal detachment. Ultrasonography revealed low-reflective masses with diffuse thickening of the choroid involving the optic nerve and orbit. Despite treatment with steroids, his symptoms progressed over time. One year later, visual acuity of the right eye markedly decreased to no light perception and enucleation was performed. Histopathological findings revealed infiltrates of malignant cells in the choroid, iris, ciliary body and trabecular meshwork. Immunohistochemistry confirmed the diagnosis of primary uveal EMZL.

Conclusions

This is the first case reporting primary EMZL diffusely involving the uvea with focal infiltration of the trabecular meshwork.

Transient MEK inhibitor-associated retinopathy in metastatic melanoma

BACKGROUND

Melanoma is one of the most aggressive skin cancers. Recently, selective MEK inhibitors have shown efficacy in patients with advanced BRAF- and NRAS-mutant melanoma. Soon after the initiation of clinical oncology trials with MEK inhibitors, it was observed that some participants developed an eye condition resembling central serous chorioretinopathy. The present article addresses the clinical features and management of these MEK inhibitor-associated retinal syndromes.

PATIENTS AND METHODS

Thirty-two patients with advanced cutaneous melanoma were treated with the selective MEK inhibitor binimetinib (MEK162) in three different Phase 1b or 2 clinical trials. Twenty patients on binimetinib monotherapy and 12 on binimetinib plus RAF inhibitor [pan-kinase RAF inhibitor RAF265 (n = 7) or selective BRAF inhibitor encorafenib (LGX818) (n = 5)] combination therapy underwent ophthalmological examinations at regular intervals, including determination of best corrected visual acuity, perimetry, colour vision testing, dilated fundus examination, and multimodal imaging.

RESULTS

Grade 1-2 bilateral retinopathies with multiple lesions were observed in 13 of 20 patients on binimetinib monotherapy, 4 of 7 patients on binimetinib plus RAF265 combination therapy, and 2 of 5 patients on binimetinib plus encorafenib combination therapy. In this study population, the rate ranged from 40% to 65%. Retinopathy events appeared during the first 4 weeks, and in some cases, during the first few days of treatment. Patients reported mild and only short-lived visual symptoms. Optical coherence tomography revealed neuroretinal elevations. Central retinal thickness and volume showed dose-dependent increases after the start of treatment, followed by a marked decrease despite continued treatment, which was associated with symptom resolution. No vascular abnormalities were found with fluorescein and indocyanine green angiography.

CONCLUSIONS

Treatment with the selective MEK inhibitor binimetinib as a single agent or in combination with RAF inhibitors induced transient retinopathy with multiple bilateral lesions in some patients. Binimetinib-induced retinopathy was usually mild, self-limiting, and tolerable as visual function was not seriously impaired.

Role of autofluorescence in inflammatory/infective diseases of the retina and choroid

Fundus autofluorescence (FAF) has recently emerged as a novel noninvasive imaging technique that uses the fluorescent properties of innate fluorophores accumulated in the retinal pigment epithelium (RPE) to assess the health and viability of the RPE/photoreceptor complex. Recent case reports suggest FAF as a promising tool for monitoring eyes with posterior uveitis helping to predict final visual outcome. In this paper we review the published literature on FAF in these disorders, specifically patterns in infectious and noninfectious uveitis, and illustrate some of these with short case histories.

Neoplastic masquerade syndromes in patients with uveitis

PURPOSE

To identify the demographic and clinical characteristics, along with the frequency, of neoplastic masquerade syndromes in a tertiary uveitis clinic.

DESIGN

A retrospective observational cohort.

METHODS

Demographic and clinical data on all patients presenting to the National Eye Institute (NEI) with uveitis between 2004 and 2012 were used to compare neoplastic masquerade syndromes and uveitis.

RESULTS

A total of 853 patients presenting with uveitis were identified. Of these, 21 (2.5%) were diagnosed with neoplastic masquerade syndromes. The average age at presentation of masquerade syndrome patients was 57 years (median, 55; range, 38-78); for uveitis, 42 years (median, 43; range, 3-98) (P = 0.0003). There were 48% females in the masquerade syndromes group, compared with 59% females in the uveitis group. African American patients represented 9% of the masquerade syndrome patients and 36% of uveitis patients (P = 0.01). Mean worse eye visual acuity was 0.89 (20/160) in neoplastic masquerade syndromes, and 0.66 (20/100) in the uveitis group (P = 0.21). Of masquerade syndrome patients, 90% had posterior inflammation, compared with 63% of uveitis patients (P = 0.006). Of those with masquerade syndromes, 48% of patients had unilateral disease, compared with 27% of the uveitis patients (P = 0.04).

CONCLUSIONS

Patients with neoplastic masquerade syndromes were more likely to be older, male, or non-African American and to have posterior segment inflammation and unilateral disease. Patients with masquerade syndromes also had worse visual acuity than did uveitis patients. These differences in clinical characteristics may help to raise the suspicion for neoplastic masquerade syndromes.

Relationship between suspected reasons of intraocular inflammation and the results of diagnostic vitrectomy: an observational study

BACKGROUND

Intraocular inflammation of the posterior segment may be associated with neoplastic, infectious, and inflammatory diseases. Biopsy of vitreous and additional ocular tissue might be required for a definitive diagnosis. We therefore aimed to investigate the safety and usefulness of diagnostic vitrectomy in intraocular inflammation.

METHOD

We performed an observational retrospective study of patients who underwent vitreous biopsy due to atypical intraocular inflammation, experienced failed resolution to empirical therapy, or for whom there was suspicion of an underlying neoplastic process.

RESULTS

Seventy consecutive patients were included due to idiopathic uveitis of the posterior segment unresponsive to systemic corticosteroids (n = 33, 47%), suspected vitreoretinal or choroidal lymphoma (n = 18, 26%), viral retinitis (n = 17, 24%), and suspected endogenous endophthalmitis (n = 2, 3%). Suspected viral retinitis was most often confirmed (13/17, 76%), followed by lymphoma (6/18, 33%). Remarkably, a proportion of suspected idiopathic uveitis was infectious (7/33, 21%). The most prevalent adverse event following diagnostic vitrectomy was cataract surgery in phakic patients (n = 16/41, 39% of phakic patients). Retinal detachments were observed chiefly in infectious or neoplastic disease (n = 5, 7%) after a median time of 105 days.

CONCLUSION

Diagnostic vitrectomy was helpful in substantiating the clinical suspected diagnosis of posterior segment inflammation. Potential secondary adverse events should be kept in mind.

Primary intraocular lymphoma

Primary intraocular lymphoma (PIOL) is an ocular malignancy that is a subset of primary central system lymphoma (PCNSL). Approximately one-third of PIOL patients will have concurrent PCNSL at presentation, and 42-92% will develop PCNSL within a mean of 8-29 months. Although rare, the incidence has been rising in both immunocompromised and immunocompetent populations. The majority of PIOL is diffuse large B-cell lymphoma, though rare T-cell variants are described. Recently, PIOL has been classified by main site of involvement in the eye, with vitreoretinal lymphoma as the most common type of ocular lymphoma related to PCNSL. Diagnosis remains challenging for ophthalmologists and pathologists. PIOL can masquerade as noninfectious or infectious uveitis, white dot syndromes, or occasionally as other neoplasms such as metastatic cancers. Laboratory diagnosis by cytology has been much aided by the use of immunocytochemistry, flow cytometry, biochemical finding of interleukin changes (IL10:IL6 ratio > 1), and cellular microdissection with polymerase chain reaction amplification for clonality. Use of several tests improves the diagnostic yield. Approaches to treatment have centered on systemic methotrexate-based chemotherapy, often with cytarabine (Ara-C) and radiotherapy. Use of intravitreal chemotherapy with methotrexate (0.4 mg/0.1 mL) is promising in controlling ocular disease, and intravitreal rituximab (anti-CD20 monoclonal antibody) has also been tried. Despite these advances, prognosis remains poor.

A systematic approach to the diagnosis of suspected central nervous system lymphoma

Central nervous system (CNS) lymphoma can present a diagnostic challenge. Currently, there is no consensus regarding what presurgical evaluation is warranted or how to proceed when lesions are not surgically accessible. We conducted a review of the literature on CNS lymphoma diagnosis (1966 to October 2011) to determine whether a common diagnostic algorithm can be generated. We extracted data regarding the usefulness of brain and body imaging, serum and cerebrospinal fluid (CSF) studies, ophthalmologic examination, and tissue biopsy in the diagnosis of CNS lymphoma. Contrast enhancement on imaging is highly sensitive at the time of diagnosis: 98.9% in immunocompetent lymphoma and 96.1% in human immunodeficiency virus-related CNS lymphoma. The sensitivity of CSF cytology is low (2%-32%) but increases when combined with flow cytometry. Cerebrospinal fluid lactate dehydrogenase isozyme 5, β2-microglobulin, and immunoglobulin heavy chain rearrangement studies have improved sensitivity over CSF cytology (58%-85%) but have only moderate specificity (85%). New techniques of proteomics and microRNA analysis have more than 95% specificity in the diagnosis of CNS lymphoma. Positive CSF cytology, vitreous biopsy, or brain/leptomeningeal biopsy remain the current standard for diagnosis. A combined stepwise systematic approach outlined here may facilitate an expeditious, comprehensive presurgical evaluation for cases of suspected CNS lymphoma.

Vitreous diagnosis in neoplastic diseases

Vitreous body is an intraocular structure, origin of diverse pathologies, but is also the place where cells and inflammatory mediators are released coming from several pathologic processes. These inflammatory reactions can happen in any other ocular location like choroid, retina, optic nerve, or ciliary body and vitreous humor constitutes a stagnant reservoir for these resulting substances and debris. Through the recent techniques of vitreous collecting, handling, and analysis, increasingly more sophisticated and with fewer complications, cellularity and molecules in the vitreous of challenging pathologies for the ophthalmologist can now be studied. The most usefulness for vitreous diagnosis would be the masquerade syndromes, and the best exponent in this group is the primary vitreoretinal lymphoma (PVRL), in which cytology and an IL-10/IL-6 ratio more than 1 is fundamental for the diagnosis.

Masquerade syndrome of multicentre primary central nervous system lymphoma

Purpose. In Italy we say that the most unlucky things can happen to physicians when they get sick, despite the attention of colleagues. To confirm this rumor, we report the sad story of a surgeon with bilateral vitreitis and glaucoma unresponsive to traditional therapies. Methods/Design. Case report. Results. After one year of steroidal and immunosuppressive therapy, a vitrectomy, and a trabeculectomy for unresponsive bilateral vitreitis and glaucoma, MRI showed a multicentre primary central nervous system lymphoma, which was the underlying cause of the masquerade syndrome. Conclusions. All ophthalmologists and clinicians must be aware of masquerade syndromes, in order to avoid delays in diagnosis.

Review for disease of the year: differential diagnosis of ocular toxoplasmosis

The diagnosis of ocular toxoplasmosis is mainly clinical, based in the presence of focal necrotizing retinochoroiditis often associated with a preexistent chorioretinal scar, and variable involvement of the vitreous, retinal blood vessels, optic nerve, and anterior segment of the eye. Recognition of this clinical spectrum of toxoplasmic retinochoroiditis is crucial, but other infectious, noninfectious, and neoplastic entities should also be considered in the differential diagnosis. Investigations such as serological tests, polymerase chain reaction of ocular fluids, and assessment of intraocular antibody synthesis are helpful in uncertain cases. This article provides an overview of the differential diagnosis of ocular toxoplasmosis, focusing on the most important entities to be considered and emphasizing distinctive features of each one of them in the clinical setting. Ocular toxoplasmosis has multiple clinical manifestations, which partially overlap with those of other entities and these should be carefully considered when making the differential diagnosis, particularly in less typical cases.

Indolent nonprogressive multifocal choroidal lesions

PURPOSE

We present a case series of four patients with unilateral, nonprogressive, yellow or white choroidal lesions of unknown etiology.

METHODS

Four healthy patients were referred to an academic medical retina practice for unusual fundus findings in one eye only. Both eyes of all four patients underwent clinical examination and retinal imaging, including fluorescein angiography, indocyanine green imaging, and optical coherence tomography. The outcome of this series was based on the clinical course of these patients and the features of the retinal images.

RESULTS

The differential diagnosis based on the clinical appearances for these unknown cases includes birdshot chorioretinopathy, lymphoma or reactive lymphoid hyperplasia, metastases, orbital and intraocular pseudotumor, and bacterial or fungal infection. Extensive workups for these clinical entities including HLA-A29, angiotensin-converting enzyme level and computed tomography of the chest, liver function testing, magnetic resonance imaging of the brain, and orbital ultrasound have remained negative.

CONCLUSION

Clinical and imaging characteristics for the four patients include absence of intraocular inflammation, late staining of lesions on fluorescein angiography, and hypofluorescence of lesions on indocyanine green. Lesions were not visible in the retina or retinal pigment epithelium using time domain optical coherence tomography. However, enhanced depth imaging spectral-domain optical coherence tomography imaging available for one patient suggests that these lesions are localized to the choroid; further interpretation of this advanced imaging technique will likely prove useful in the future. The patients' clinical course has remained nonprogressive with no changes over a prolonged period of observation. These cases could represent atypical manifestations of known retinal disease diagnoses or variations of a new chorioretinal disease process.

[Recurrent uveitis of unknown origin in childhood]

This report describes a 12-year-old girl with diffuse infiltrating retinoblastoma. This inflammatory condition belongs to the uveitis masquerade syndromes, which comprise a group of various ocular diseases such as chronic intraocular inflammation and ocular tumors.

[Acute angle closure glaucoma with unilateral acute loss of vision]

We report the case of a 31-year-old patient who presented with unilateral acute loss of vision, severe headache, and symptoms of an acute angle-closure glaucoma. Surprisingly, a prepapillary uveal melanoma was the underlying reason; that is, a masquerade syndrome was seen. Enucleation and histopathological investigation of that eye were performed within 3 days after first presentation. Acute angle-closure glaucoma as the initial presentation of uveal melanoma is rare. Nevertheless, clinicians should be aware that patients with refractory unilateral angle-closure glaucoma and asymmetrically opaque media may harbor an occult uveal melanoma.

Primary T-cell lymphoma of the retina and cerebellum: immunophenotypic and gene rearrangement confirmation

PURPOSE

To document fully the first credible primary T-cell lymphoma of the retina and central nervous system in a 71-year-old man.

DESIGN

Interventional, retrospective report.

METHODS

Critical analysis of clinical history and findings, which included bilateral vitreitis with anterior chamber reaction, creamy intraretinal infiltrates, and retinal detachment; complete blood counts and other blood studies (anti-neutrophil cytoplasmic antibody [ANCA], angiotensin-converting enzyme levels, and Lyme and fluorescent treponemal antibody absorption titers); magnetic resonance imaging (MRI) scanning of the brain with total body computed tomographic and positron emission tomographic scanning; interleukin (IL) level determinations (IL-10 and IL-6); cytologic and electron microscopic evaluations; immunophenotyping of cells; and polymerase chain reaction studies for viral deoxyribonucleic acid and ribonucleic acid, and immunoglobulin heavy-chain, and T-cell receptor (TCR) gene rearrangements.

RESULTS

The first vitreous specimen was diagnosed mistakenly as cytologically reactive and contained elevated levels of IL-10 and IL-6 in a ratio of 7 to 1. T cells predominated on immunophenotypic analysis. Computed tomographic and positron emission tomographic whole body scanning showed negative results for lymphoma. An MRI scan of the brain eventually revealed a cerebellar lesion. A retinal biopsy harbored cytologically atypical pleomorphic cells that were almost all immunophenotypically T cells; polymerase chain reaction studies demonstrated a clonal TCR gene rearrangement. T-cell lymphocytes in the biopsy specimen of the cerebellum had an identical clonal TCR gene rearrangement.

CONCLUSIONS

This case unequivocally establishes that primary retinal T-cell lymphoma accompanied by central nervous system involvement can occur. Elevation in the IL-10 to IL-6 ratio in the face of inconclusive or confusing vitreous cytologic and immunophenotypic findings (a predominance of "reactive T cells with some atypicality") should lead to gene rearrangement studies on biopsies of involved tissues for the detection of T-cell clonality.

Primary intraocular lymphoma

Primary intraocular lymphoma, recently suggested to be renamed primary retinal lymphoma, is a subset of primary central nervous system lymphoma and is usually an aggressive diffuse large B-cell lymphoma. Between 56% and 85% of patients who initially present with primary intraocular lymphoma alone will develop cerebral lesions. Patients typically complain of decreased vision and floaters, most likely secondary to the chronic vitritis and subretinal lesions. The diagnosis of primary intraocular lymphoma can be difficult to make and requires tissue for diagnosis. The atypical lymphoid cells are large and display a high nuclear to cytoplasmic ratio, prominent nucleoli, and basophilic cytoplasm. Flow cytometry, immunohistochemistry, cytokine analysis, and gene rearrangements also aid in the diagnosis. Local and systemic treatments, such as chemotherapy and radiation, are employed, although the relapse rate remains high.

Glaucoma in Juvenile Xanthogranuloma

Juvenile xanthogranuloma (JXG) is a benign histiocytic skin disorder mainly encountered during infancy. Approximately 10% of cases exhibit ocular manifestations leading to serious complications. Specifically, secondary glaucoma can result in severe and blinding eye disease. We present a case of a two-month-old female with JXG related glaucoma in order to demonstrate the classic presentation and the problems commonly encountered in treating this disease. The natural history, pathogenesis, and treatment of the condition are then discussed and the pertinent literature reviewed. JXG should be considered in any case of unilateral glaucoma that presents in infancy.

Choroidal melanoma masquerading as panuveitis in a patient with multiple myeloma

BACKGROUND

Choroidal melanoma can sometimes present with associated anterior uveitis or panuveitis that can mask the underlying intraocular neoplasm and confound the diagnosis.

METHODS

Retrospective chart review.

RESULTS

A 58-year-old woman presented with recurrent episodes of hypopyon, severe panuveitis, and a choroidal mass lesion in the right eye. Extensive systemic workup led to a diagnosis of multiple myeloma. Despite successful treatment of myeloma, the choroidal mass persisted and increased in size. Transscleral biopsy of the mass lesion revealed primary malignant choroidal melanoma.

CONCLUSION

This case demonstrates that choroidal melanoma can present as masquerade syndrome with significant intraocular inflammation. Such cases pose a significant diagnostic dilemma to the clinician. Transscleral choroidal biopsy can provide critical information that is essential to establishing a definitive diagnosis and treatment plan.