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Infrared
autofluorescence, short-wave autofluorescence and spectral-domain optical
coherence tomography of optic disk melanocytomas
Peng Zhang, Yan-Nian Hui, Wen-Qin Xu, Zi-Feng Zhang,
Hai-Yan Wang, Dong-Jie Sun, Yu-Sheng Wang
Department of
Ophthalmology, Eye Institute of Chinese PLA, Xijing Hospital, the Fourth
Military Medical University, Xi’an 710032, Shaanxi Province, China
Correspondence to: Yu-Sheng
Wang. Department of Ophthalmology, Eye Institute of Chinese PLA, Xijing
Hospital, the Fourth Military Medical University, Xi’an 710032, Shaanxi
Province, China. wangys003@126.com
Received: 2014-04-24
Accepted: 2015-10-13
Abstract
AIM: To investigate the findings of infrared
fundus autofluorescence (IR-AF) and spectral-domain optical
coherence tomography (SD-OCT) in eyes with optic disc melanocytoma (ODM).
RESULTS: The ODMs in all cases
(100%) presented similar IR-AF, SW-AF, and FA findings. On IR-AF images, ODMs
showed outstanding hyper-AF with well-defined outline. On SW-AF images, the
area of ODMs presented as hypo-AF. FA images revealed the leaking retinal
telangiectasia on the surface of the ODMs. On SD-OCT images in 8 cases (100%),
the ODMs were sloped with highly reflective surface, which were disorganized retina and optic nerve layers. In 7 cases (87.5%), peripapillary
choroids were involved. The melanocytomas of
8 cases (100%) presented as optically empty spaces. Vitreous seeds were found
in one case (12.5%).
CONCLUSION: IR-AF imaging may
provide a new modality to evaluate the pathologic features of ODMs, and together
with SW-AF imaging, offers a new tool to study biological characteristics
associated with ODMs. SD-OCT is a valuable tool in delimitating the tumor
extension and providing morphological information about the adjacent retinal
tissue.
KEYWORDS: melanocytoma; angiography; autofluorescence;
optical coherence tomography
DOI:10.18240/ijo.2016.05.13
Citation:
Zhang P, Hui YN, Xu WQ, Zhang ZF, Wang HY, Sun DJ, Wang YS. Infrared
autofluorescence, short-wave autofluorescence and spectral-domain optical
coherence tomography of optic disk melanocytomas. Int J Ophthalmol 2016;9(5):713-716
INTRODUCTION
In most cases, ODMs are seemed to be a stable lesion
with no tendency to grow[2].
However, 10%-15% of them show subtle enlargement over several years. The
larger, growing tumor can cause compressive optic neuropathy, visual field
defect, vascular occlusion, and loss of vision[2-4]. Moreover, malignant change is estimated to occur
in about 5% of cases[5].
ODM is usually diagnosed by ophthalmoscopic
examination due to the characteristic appearance of the tumor. Ancillary
imaging procedures, such as fundus photography, fluorescein angiography (FA),
and optical coherence tomography (OCT), are useful for diagnosis and follow-up
evaluations of ODM.
In addition, short-wave autofluorescence (SW-AF), a
non-invisive examination based on the endogenous lipofuscin in retinal pigment
epithelium (RPE) excited by an external blue light, is described to be helpful
for diagnosing ODM[6]. In
our view, another type of AF, infrared fundus autofluorescence (IR-AF) should
be more valuable in diagnosing ODM. IR-AF could be derived from melanin excited
by infrared light[7]. The
melanosome is melanin-containing organelle in melanocyte. Melanocytoma is
mainly composed of melanocytes, theoretically, which should be responsible for
the exogenous exciting light to originate IR-AF. Recent years, IR-AF has been
used in the assessment of RPE related diseases, such as central serous
chorioretinopathy, macular dystrophy and macular choroidal neovascularization[8-10], but not yet in
melanocytoma.
OCT is the optical analog of ultrasound imaging and is
emerging as a powerful imaging technique that enables non-invasive, in vivo, high resolution and speed,
achieving the visualization of tissue architectural morphology in situ and in real time in vivo[11].
Our purpose in the present study was to compare
abnormal AF images, including IR-AF and SW-AF images, with spectral-domain OCT
(SD-OCT) and FA images to investigate the utility of IR-AF, SW-AF and SD-OCT at
diagnosis and detection of ODMs.
SUBJECTS AND METHODS
The
study was a retrospective review of 8 consecutive cases with ODM (Table 1)
imaged with fundus color photography, IR-AF, SW-AF, FA, and SD-OCT in the
Department of Ophthalmology of Xijing Hospital. The Ethics Committee of the
Xijing Hospital approved this study. The written informed consents related to
use data, and publish images were obtained from all cases. This study, data
collection, analysis, and presentation conformed to the tenets of the
Declaration of Helsinki.
Table 1 Patient demographic and optic disk melanocytomas data
|
Case no. |
Gender |
Age (a) |
Eye |
BCVA |
Site and extent of tumor |
Optic disc involvement (clock hours) |
|
1 |
M |
42 |
Right |
0.8 |
Optic disk and subretina |
8 |
|
2 |
F |
60 |
Left |
1.0 |
Optic disk |
6 |
|
3 |
F |
38 |
Left |
1.0 |
Optic disk and subretina |
3 |
|
4 |
F |
46 |
Right |
0.8 |
Optic disk and subretina |
6 |
|
5 |
F |
55 |
Right |
0.6 |
Optic disk and subretina |
5 |
|
6 |
F |
62 |
Right |
0.4 |
Optic disk and subretina |
10 |
|
7 |
F |
49 |
Left |
0.6 |
Optic disk and subretina |
5 |
|
8 |
M |
57 |
Right |
0.5 |
Optic disk and subretina |
8 |
F: Female; M: Male; BCVA: Best-corrected
visual acuity (LogMAR).
IR-AF, SW-AF and FA were
performed using the Heidelberg spectralis HRA (Heidelberg Retina Angiograph;
Heidelberg Engineering, Heidelberg, Germany). AF images were obtained after
maximum pupillary dilation was achieved with instillation of 0.5% tropicamide
and 0.5% phenylephrine. After the acquisition of AF, FA was performed after
fluorescein sodium injection.
SD-OCT (3D-OCTTM system,
Topcon, Tokyo, Japan) with single scan through the center of the optic disc,
routinely.
RESULTS
This
series consists of 8 cases（6 females and 2 males）with a mean age of 51.13y
(range: 38 to 62y). All the cases were Chinese.
Dilated funduscopic
examination revealed the pigmented ODMs appearing as dark brown or black
elevated masses covering the optic disk and adjacent retina (Figure 1A) in 8
cases (100%). ODMs in all cases (100%) presented similar IR-AF, SW-AF, and FA
features. On IR-AF images, ODMs showed outstanding hyper-AF with well-defined
outline (Figure 1B) corresponding to the area of pigmented masses in images of fundus color photography. On SW-AF
images, hypo-AF corrsponding to the pigmented masses combined with uninvolved
optic discs (Figure 1C). FFA images of all cases (100%) revealed the leaking
retinal telangiectasia on the surface of the tumors, and melanocytomas themselves demonstrated hypofluorescence
throughout the angiogram due to the absence of blood vessels (Figure 1D, 1E). On SD-OCT images of 8 cases
(100%), nerve fiber layers and retinas above the ODMs presented as disorgnized
hyperreflectivity. All the melanocytomas presented as optically empty cavities
due to anterior aspects of the melanocytomas with abrupt and complete shadowing
(Figure 1F, 1G). Choroidal involvements were found in 7 cases (87.5%), on
SD-OCT images, the peripapillary choroidal tumor invasion defined as
thickening, hyperreflectivity or hyporeflectivity of the choroid (Figure 1F).
No patients had OCT evidence of subretinal fluid or cystoid macular edema in
this series. Hi-reflective spots in the vitreous cavity near by the tumor and
corresponding to vitreous seeding were found in one case (12.5%) (Figure 1G).
Figure 1 Images of optic disc
melanocytomas A: Color fundus photograph shows optic
disc melanocytoma presenting as a pigmented mass, involving part of optic disc
and retina in left eye; B: IR-AF
image, the optic disc melanocytoma shows hyper-AF with well-defined outline; C: SW-AF image, the optic disc
melanocytoma and adjacent tissues including optic disc appear as hypo-AF; D: Early phase of FFA demonstrates the
retinal telangiectasia on the surface of optic disc melanocytoma in left eye; E: Late phase of FFA shows the leaking
retinal telangiectasia on the surface of optic disc melanocytoma; F: SD-OCT image reveals the
hyperreflective retina and optic nerve fiber layers, followed by optically
empty mass. Involved choroid presents as local thickening and hyporeflection in
left eye (see arrow); G: SD-OCT
image reveals the hyperreflective retina and optic nerve fiber layers, followed
by optically empty mass. Some hyperreflective vitreous seeds can be found
within the posterior vitreous in right eye (see arrow).
DISCUSSION
ODMs are
slow growing, relatively common and benign tumors that generally do not affect
visual acuity. This tumor appears to have a slight predominance for females, and
have an equal incidence in all races[3].
In the past, these tumors were often confused with melanomas and the patients
were treated by enucleation[3,12].
However, ODMs may cause a various degrees of visual field defects,
including enlargement of the blind spot or major visual field defects.
Moreover, some of the tumors can produce several complications, such as retinal
vein occlusion, papilledema or optic nerve atrophy inducing visual loss due to
local compression[1,13-14].
Some ODMs can induce ischemic optic neuropathy associated with tumor
necrosison, rare occasions, can undergo malignant transformation into melanomas[15-17]. Hence, patients
with ODM should be emphasized the need for experiencing carefully periodic
ocular examination[18].
The diagnosis of a ODM
usually can be made by its characteristic features of dark brown or black mass
in the optic disk ophthalmoscopically. Because the melanocytes are deeply
pigmented and closely compact with relatively little vascularity, FA and
indocyanine green angiography (ICGA) are helpful ancillary examinations to
diagnosis and follow-up evaluation of ODM for the reason of hypofluorescence
inside of the tumor throughout the angiogram. In addition, trichangiectasia on
the tumor can be verified by FFA[12].
To perform FFA or ICGA, fluorescein sodium or indocyanine green must be used
intravenously, therefore, adverse reactions including nausea, vomiting, hives,
acute hypotension, even cardiac arrest or anaphylactic shock may happen[19-20].
SW-AF and IR-AF are two
types of non-invasive, dye-free endogenous fluorescence examinations. Guerra et al[6] reported that ODM appeared as an outstanding
hypo-SW-AF lesion and the remaining retina was isoautofluorescent. SW-AF is
useful in differential diagnoses of choroidal nevus and choroidal melanoma. Suspicious
choroidal nevi appears as very bright hyper-SW-AF areas[21-22]. Choroidal melanoma shows discrete and bright
hyper-SW-AF for the existence of overlying intracellular lipofuscin[23].
In this clinical study, we
found the presence of hypo-SW-AF in ODMs, secondary to the absence of
lipofuscin over or inside the tumor, and the association with the highly
pigmented mass blocking the posterior RPE. Except for the melanocytomas, optic
disc and retinal vascular structures are hypo-SW-AF. On the image of SW-AF, it
is difficult to distinguish ODM from neighbouring tissues with hypo-SW-AF. In
contrast, IR-AF is more sensitive in evaluating ODM.
To evaluate the extension of the tumor into the retrolaminar
portion of the optic nerve and surrounding retina, choroid. ODM with diameter
greater than 0.5 mm could be demonstrated with ultrasonography, computed
tomography (CT) or magnetic resonance imaging (MRI). But these imaging
examination techniques cannot easily differentiate melanocytoma from other
elevated lesions of the optic disk. Furthermore, microscopic extension of the
tumor is unlikely to be determined by above mentioned examinations[3,5].
SD-OCT is another valuable
tool for correlating directly with morphological changes on and around ODM.
Specific features of OCT findings with ODMs include the overlying retinal and
peripapillary nerve fiber layer are disorganized, and relatively
hyperreflective, followed by a abrupt posterior optical shadowing. Moreover,
this study revealed that tumor invasion, namely the choroidal involvement could
be verified by SD-OCT[27].
Choroidal involvement is
suggested by upward displacement of the normal RPE architecture or
hyperreflectivity of the choroid, because the normal choroid is hyporeflective.
Besides, SD-OCT can be used to document some complications secondary to ODMs,
such as cystoid retinal edema, subretinal fluid, hemorrhage and disk edema[28]. Vitreous seeds are
evident in one patient in this study, this phenomena supposed to be due to
disruption of the internal limit membrane, melanocyte cells disseminated into
the vitreous cavity[29].
In conclusion, ODMs are
benign, slow growing tumors that generally do not affect visual acuity. Based
on our personal experience and on review of the literatures, serious
complications, such as retinal vascular obstruction, malignant transformation
are very possibility. It is very important to emphasize the need for long-term
surveillance of these tumors. ODMs have unique imaging characteristics of
SW-AF, IR-AF and SD-OCT, except for traditional ophthalmoscopic examination,
this new generation of ancillary imaging procedures may be helpful for
confirming suspicious melanocytic lesions.
ACKNOWLEDGEMENTS
Conflicts of Interest: Zhang P, None; Hui YN,
None; Xu WQ, None; Zhang ZF, None; Wang HY, None; Sun DJ,
None; Wang YS, None.
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