BACKGROUND: Magnetic resonance imaging (MRI) has demonstrated high levels of tissue contrast, accuracy and reproducibility in evaluating posterior uveal melanoma. Owing to smaller size, the role of MRI in detecting and characterising iris melanoma has not yet been explored.
OBJECTIVE: To develop a protocol to image iris melanoma and describe the MRI characteristics of histopathological-confirmed iris melanoma.
METHODS: An optimised MRI protocol, using a 3T MRI scanner and a 32-channel head coil, was developed to image iris tumours. A prospective, single-centre, 12-month study was conducted on all patients with lesions suspicious for iris melanoma. All patients were offered an MRI scan in addition to the standardised clinical procedures. Image quality comparison was made with existing clinical investigations. Iris melanoma characteristics on MRI are described.
RESULTS: A successful optimised MRI scan protocol was developed that was able to detect and characterise iris melanoma. One normal participant and five patients with subsequent histopathological-confirmed iris melanoma (n = 6) were recruited. Four patients completed the full MRI sequence. All iris melanoma were detected on at least one T1- or T2-weighted images. When compared to the vitreous, all iris melanomas demonstrated hyper-intensity on T1-weighted images and hypo-intensity on T2-weighted images. On T1-mapping, T1-values of iris melanoma demonstrated an inverse relationship with the degree of tumour pigmentation.
CONCLUSIONS: This study highlights an optimised, easily reproducible MRI scan protocol to image iris melanoma. Numerous MR imaging characteristics of iris melanoma are reported for the first time and a potential non-invasive tumour biomarker is described.

To report clinical outcomes of modified Collaborative Ocular Melanoma Study IRIS (COMS IRIS) plaques for treatment of iris, iridociliary, and ciliary body melanoma.
Retrospective, single-centre cohort study of iris melanoma treated with COMS IRIS plaque radiotherapy from July 26, 2010 to October 15, 2018. Medical records were reviewed for demographics, tumour features, treatment parameters, and clinical outcomes.
There were 22 cases, diagnosed at mean age of 59 years (median 65, range 21-85 years) with female sex in 14 (64%). Presenting tumour features included Snellen visual acuity (VA) ≥ 20/40 in 18 (82%) cases, mean largest tumour basal diameter 4.7 mm (median 3.9, range 2.3-13.8 mm) and thickness 1.7 mm (median 1.6 mm, range 0.8-3.9 mm), iris stromal seeding in 3 (14%) cases, angle seeding in 16 (73%), and ciliary body involvement in 13 (59%). After mean follow-up of 51 months (median 44, range 4-113 months), Snellen VA was ≥20/40 in 14 (64%) cases, with local tumour recurrence in 2 (9%), and enucleation in 2 (9%). The 3-year Kaplan-Meier estimated risk of local tumour recurrence was 7%. The most common radiation side effects were cataract in 17 (77%) patients and dry eye in 5 (23%). Systemic metastasis occurred in no cases, and 1 (5%) non-melanoma-related death due to natural causes was observed at last follow-up.
COMS IRIS plaques are effective for treatment of iris, iridociliary, and ciliary body melanoma with modest VA outcomes and low frequency of local tumour recurrence, enucleation, radiation side effects, and systemic metastasis.

To investigate the validity and safety of tele-ophthalmology evaluations as a clinical assessment tool when performed by an ophthalmologist to detect lesion growth in patients with low-, medium-, and high-risk choroidal and iris nevi.
Retrospective observational pilot study.
Consecutive patients with low-/medium-/high-risk choroidal or iris nevi who underwent tele-oncology examinations over 5 months. All patients had a dilated fundus or anterior segment photography, A- and B-scan ultrasonography or ultrasound biomicroscopy (UBM), and spectral domain optical coherence tomography (SD-OCT) depending on the nature of their lesion. Patients who followed up with in-person examinations had an additional ophthalmoscopic examination.
Seventy-one eyes of 71 patients were included. The diagnoses were 47 low-risk choroidal nevi, 10 medium-risk choroidal nevi, 5 high-risk choroidal nevi, and 9 iris nevi. The tele-ophthalmology examinations found a sensitivity of 100%, specificity of 92%, positive predictive value of 57%, and negative predictive value of 100% to detect growth of a lesion.
Tele-ophthalmology assessment for choroidal and iris nevi is a sensitive clinical tool to evaluate growth with 100% sensitivity and negative predictive value when performed by trained ultrasound technicians and reviewed by an ophthalmologist with expertise in ocular oncology. It has the potential to alleviate patient- and physician-related treatment burden.

Iris naevi and iris freckles have a frequency of 4% and 50% in the European population, respectively. They are associated with dysplastic naevi, but few studies have examined their link to cutaneous melanoma.
To assess whether iris pigmented lesions are a predictive indicator for cutaneous melanoma.
This is a melanoma case-control study of 1254 European-background Australians. Sun exposure and melanoma history, a saliva sample for DNA analysis and eye photographs taken with a digital camera were collected from 1117 participants. Iris images were assessed by up to four trained observers for the number of iris pigmented lesions. The data were analysed for correlations between iris pigmented lesions and melanoma history.
Case participants over the age of 40 had similar numbers of iris pigmented lesions to age matched controls (mean 5·7 vs. 5·2, P = 0·02), but in younger case and control participants there was a greater difference (mean 3·96 vs. 2·19, P = 0·004). A logistic regression adjusted for age, sex, skin, hair and eye colour, skin freckling and naevus count found that the presence of three or more iris pigmented lesions increases the melanoma risk 1·45-fold [95% confidence interval (CI) 1·07-1·95]. HERC2/OCA2 rs12913832 and IRF4 rs12203592 influenced both eye colour and the number of iris pigmented lesions. On the HERC2/OCA2 A/A and A/G genotype background there was an increasing proportion of blue eye colour when carrying the IRF4 T allele (P = 3 × 10-4 ) and a higher number of iris pigmented lesions with the IRF4 T/T homozygote (P = 3 × 10-9 ).
Iris pigmented lesion count provides additional predictive information for melanoma risk above that from conventional risk factors.

To evaluate the outcome of eyes with a confirmed iridociliary epithelial tumour (ICET) following biopsy. Forty-two specimens were selected from the Comparative Ocular Pathology Laboratory of Wisconsin database, including 11 globes enucleated following ICET biopsy and 31 iridociliary biopsies with a confirmed ICET. Histopathology was performed for all specimens. When identified, the corneal surgical wound was examined in enucleated globes. Tumour type and margins were determined for biopsy specimens and follow-up was obtained when possible. Biopsies were performed for diagnosis, debulking or excision. 30/31 biopsies had dirty margins, and iridociliary adenomas were indistinguishable from adenocarcinomas by biopsy. Upon biopsy submission 5/23 biopsies were reported as incisional and 18/23 as excisional. Follow-up information was obtained for 14/18 of those reported as excisional. 8/14 had documented recurrence within 5.0±5.6 months and 6/14 had no recurrence at 21.5±13.6 months postoperatively. Three enucleated globes were diagnosed with iridociliary adenocarcinomas and eight with iridociliary adenomas. The corneal surgical wound was sampled in 8/11 globes. There was a synechia to the surgical wound in 3/8 globes, and in 3/8 globes there were neoplastic cells within or adjacent to the surgical wound. The postoperative success of ICET excision is highly variable; complete excision is rarely achieved and recurrence is common. Biopsy effects on ocular tissues may result in synechia and other surgical complications. ICET can be diagnosed by biopsy, but adenomas are indistinguishable from adenocarcinomas.

This is a case of anterior uveitis in a 50 year-old man caused by lung adenocarcinoma metastasis to the iris. The patient was initially worked up for pneumonia and was discovered to have multiple lung lesions on computed tomography scan. Prior to discharge, the patient began complaining of ocular redness, pain, photophobia and decreased visual acuity. The patient was given an initial diagnosis of anterior uveitis with uveitic glaucoma, which was later confirmed to be secondary to lung adenocarcinoma metastasis to the iris. Metastasis to the iris is a particularly rare cause of anterior uveitis and may inadvertently be left out of a physician\'s differential diagnosis. This case illustrates a rare, but clinically important cause of anterior uveitis with intraocular hypertension, which should be considered in all cases of ocular redness and pain.

OBJECTIVE: To determine the influence of patient age on life prognosis in patients with uveal melanoma.
METHODS: Matched retrospective cohort study of 122 patients in each age category (young [≤20 years], mid-adults [21-60 years], older adults [>60 years]).
RESULTS: Kaplan-Meier estimates of tumor-related metastasis at 3, 5, and 10 years were 1%, 8%, and 8% in young; 8%, 11%, and 26% in mid-adults; and 13%, 16%, and 24% in older adults. After exclusion of iris melanoma, Kaplan-Meier estimates of tumor-related metastasis at 3, 5, and 10 years were 2%, 11%, and 18% in young; 9%, 14%, and 21% in mid-adults; and 9%, 34%, and 33% in older adults. Risk factors for metastasis based on multivariate analysis included increasing age in young (p=0.05, hazard ratio [HR] 1.33), male gender in mid-adults (p=0.046, HR 4.23), and larger tumor basal diameter in mid-adults (p=0.002, HR 1.37) and older adults (p=0.001, HR 1.30). After adjusting for tumor diameter, the metastatic rate was lower in young patients compared to mid-adults (0=0.042, HR 3.00) and older adults (p=0.007, HR 4.20).
CONCLUSIONS: Younger patient age at the time of diagnosis of uveal melanoma is associated with lower rate of metastasis compared to mid-adults and older adults.

OBJECTIVE: To collaborate with multiple centers to identify representative epidemiological, clinical, and pathologic characteristics of melanoma of the iris. This international, multicenter, Internet-assisted study in ophthalmic oncology demonstrates the collaboration among eye cancer specialists to stage and describe the clinical and pathologic characteristics of biopsy-proven melanoma of the iris.
METHODS: A computer program was created to allow for Internet-assisted multicenter, privacy-protected, online data entry. Eight eye cancer centers in 6 countries performed retrospective chart reviews. Statistical analysis included patient and tumor characteristics, ocular and angle abnormalities, management, histopathology, and outcomes.
RESULTS: A total of 131 patients with iris melanoma (mean age, 64 years [range, 20-100 years]) were found to have blue-gray (62.2%), green-hazel (29.1%), or brown (8.7%) irides. Iris melanoma color was brown (65.6%), amelanotic (9.9%), and multicolored (6.9%). A mean of 2.5 clock hours of iris was visibly involved with melanoma, typically centered at the 6-o\'clock meridian. Presentations included iritis, glaucoma, hyphema, and sector cataract. High-frequency ultrasonography revealed a largest mean tumor diameter of 4.9 mm, a mean maximum tumor thickness of 1.9 mm, angle blunting (52%), iris root disinsertion (9%), and posterior iris pigment epithelium displacement (9%). Using the American Joint Commission on Cancer-International Union Against Cancer classification, we identified 56% of tumors as T1, 34% of tumors as T2, 2% of tumors as T3, and 1% of tumors as T4. Histopathologic grades were G1-spindle (54%), G2-mixed (28%), G3-epithelioid (5%), and undetermined (13%) cell types. Primary treatment involved radiation (26%) and surgery (64%). Kaplan-Meier analysis found a 10.7% risk of metastatic melanoma at 5 years.
CONCLUSIONS: Iris melanomas were most likely to be brown and found in the inferior quadrants of patients with light irides. Typically small and unifocal, melanomas are commonly associated with angle blunting and spindle cell histopathology. This multicenter, Internet-based, international study successfully pooled data and extracted information on biopsy-proven melanoma of the iris.

OBJECTIVE: To demonstrate the correlation of ultrasound biomicroscopy (UBM) features of iris melanoma with histopathology.
METHODS: Retrospective analysis of medical records.
METHODS: The medical records of patients that underwent surgery for iris melanoma at the Princess Margaret Hospital, University of Toronto, from June 1990 to October 1998 were reviewed. The clinical features, as well as the UBM findings prior to surgical intervention, were evaluated. The anatomic features noted on UBM were correlated with histopathologic features seen in the surgical specimens.
RESULTS: Fourteen cases met the inclusion criteria and were included in the final analysis. The ultrasound acoustic characteristics showed a broad spectrum of findings among iris melanomas. Tumor acoustic parameters correlated well with histologic features, including tumor vascularity, surface plaque, extrascleral extension, ciliary body involvement, and integrity of iris pigment epithelium.
CONCLUSIONS: UBM is a useful imaging technique for the in vivo assessment of primary iris melanoma and can provide detailed imaging of the tumor\'s interface with the angle structures. The preoperative assessment of these tumors by UBM may aid the surgeon in choosing the most appropriate technique to ensure total removal.

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