Eyeworld

EW NEWS & OPINION 22 A lthough cutaneous metastatic melanoma rarely affects the eye, a recent unusual initial manifestation—specifi- cally, appearing as posterior capsule opacification (PCO)—might cause the condition to get more attention from ophthalmologists. "The differential diagnosis of capsular opacification generally in- volves migration and proliferation of residual lens-epithelial cells, creat- ing a hazy or granular translucent opacity," according to lead study au- thor Jonathan D. Solomon, M.D., Solomon Eye Physicians & Surgeons, Bowie, Md. "In our case, the lens capsule was completely opaque and brown from multilayered melanoma cells." The condition was found after a 71-year-old Caucasian woman pre- sented to a clinic with painless vi- sion loss in the right eye. She had cataract surgery 10 years earlier and a history of ulcerative cutaneous melanoma of the upper arm. The study was published online in July 2010 in Graefe's Archive for Clinical and Experimental Ophthalmology. "To our knowledge this is the first report of posterior capsular opacification serving as the initial manifestation of cutaneous metasta- tic melanoma," Dr. Solomon re- ported. "With the incidence of cutaneous melanoma on the rise, and an increasing number of cataract procedures performed annu- ally, clinicians should be aware of the different ways cutaneous metastatic melanoma may involve the intraocular structures of the eye." PCO at its strangest In 1996, the woman was found to have a basal cell carcinoma. "Exci- sional biopsy of a 1.0-mm ulcerative cutaneous melanoma (Clark Level III, Mitotic rate of 19 per HPF) of the upper arm with significant focal sen- tinel lymph node extension in 2007," Dr. Solomon reported. "Sub- sequent axillary node dissection was performed and level III and IV nodes were found to be free of metastasis at the time of initial staging. Follow- up computed tomography and se- quential positron emission tomography were negative for recur- rence 4 months prior to her presen- tation." When the patient presented with visual complaints, best cor- rected visual acuity was hand mo- tion in the right eye, although it remained 20/20 in the left. "Slit-lamp examination of the right eye revealed fine pigmented cells floating in the anterior cham- ber, multiple pigmented clumps on the anterior capsular surface with nodules extending beneath the cap- sulorrhexis onto the lens optic," Dr. Solomon reported. "Multinodular, confluent pigment was found on the posterior capsule." Further examination confirmed the existence of metastatic cuta- neous melanoma to the lens capsule and nearby structures. "As this represented the only metastatic foci and prognosis for vi- sion was poor, enucleation was per- formed," Dr. Solomon reported. "Gross examination of the eye re- vealed an abundance of pigment in the anterior chamber, on the ante- rior and posteriors of the optic of the IOL, in the posterior chamber on the surface of the ciliary processes, and in the vitreous humor." The retina was also found to have been affected. "A pigmented membrane was noted focally on the inner surface of the retina posteri- orly," Dr. Solomon noted. "Histopathologic examination showed that the pigmentation com- prised a mixture of melanophages and malignant melanoma cells." Other observations included iris neovascularization, an occluded angle, and macrophages infiltrating the trabecular meshwork. "Furthermore, a malignant membrane composed of melanoma cells simulated an epiretinal mem- brane in the macula," Dr. Solomon reported. A rarity indeed Metastatic cutaneous melanoma typ- ically spreads "locoregionally, in- volving adjacent lymph nodes, skin, and subcutaneous tissue," Dr. Solomon noted. With less frequency, it can also spread to the lung, liver, and central nervous system. Less than 5% of malignancies found to metastasize to the eye and orbit are reported to involve cuta- neous metastatic melanoma. "This case represents the rare finding of cutaneous melanoma pre- senting with lens capsular nodular metastasis," Dr. Solomon acknowl- edged. "Our case is unique as this patient was pseudophakic and the metastasis was completely confluent on the capsule, imparting a dark brown melanomatous membrane." How did the melanoma cells come to affect the capsule? Dr. Solomon believes it resulted from "dissemination emerging from the adjoining iris root vasculature and ciliary body." Dr. Solomon chose an uncom- mon intervention in this case. "The management of intraocular metasta- sis includes external beam radiother- apy, plaque brachytherapy, chemotherapy, and enucleation," Dr. Solomon reported. "It is esti- mated that less than 1% of uveal metastases are treated with enucle- ation. In our case, the poor visual prognosis, ocular hypertension, poor anticipated response to radiotherapy or chemotherapy, and the lack of other systemic metastases were fac- tors in the decision for enucleation." John D. Sheppard, M.D., pro- fessor of ophthalmology, microbiol- ogy, and immunology, Eastern Virginia Medical School, Norfolk, Va., found this case to be fascinating and one providing a few lessons. "This is a great case and reminds us that when performing an annual exam, one of the things we're look- ing for is the very unusual but dev- astating complication of choroidal melanoma," Dr. Sheppard said. "When a patient has had cancer, that can metastasize to the eye." Still, this kind of case is so rare, "I doubt many of us will see it in our careers," Dr. Sheppard said. EW Editors' note: Dr. Sheppard has no fi- nancial interests related to his com- ments. Dr. Solomon has no financial interests related to this study. Contact information Sheppard: 757-622-2200, docshep@hotmail.com Solomon: jdsolomon@hotmail.com February 2011 by Matt Young EyeWorld Contributing Editor An unusual case of PCO I n a r a r e c a s e , c u t a n e o u s m e t a s t a t i c m e l a n o m a p r e s e n t e d a s P C O , s i m i l a r t o t h a t p i c t u r e d a b o v e Source: Mostafa A. Elgohary, M.D.

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