1. بسم الله الرحمن الرحيم Case presentation By SAAD ALDAHMASH,MD

2. 53 years old gentleman K/C: 1) HCV on ribavirin 600 mg bid & Interferon –alpha 125ug once a week for almost 8/12. 2)Ulcerative colitis on mesalazine for long time. No other medical illness.

3. C/O scotoma in the Right eye for the last one year. No Hx of decrease VA. No Hx of other ocular symptoms. No Hx of previous ocular disease or surgery.

4. Ocular examination VA OD 20/20 OS 20/20 IOP OD 17 mmhg OS 19 mmhg A/S OD WNL OS WNL

5. Fundus Exam OD

7. OD

9. FFA (red free)

10. 28 sec

11. 41 sec

12. 3min 11sec

13. 5min 33 sec

14. B-Scan 3.48 mm H.T 8.21 mm Transverse 9.02 mm vertical

17. A-Scan

20. Doppler Solid & high vascular lesion

22. DDx Choroidal melanoma. Choroidal nevus. Metastasis. Osteoma. Circumscribed choroidal haemangioma.

23. Diagnosis Medium size Choroidal melanoma with retinal invasion OD. Interferon-Alpha related CWS OU.

24. Ocular side effects of interferon Decrease or loss of vision, retinopathy including macular edema, retinal artery or vein thrombosis, retinal hemorrhages and cotton wool spots, optic neuritis, and papilledema are induced or aggregated by treatment with alpha interferons.

25. Overview of management of CM Several factors affecting choosing treatment modalities including : Size & location & extent of the tumor. Visual status of the affected eye and fellow eye as well. Age & general health of the patient.

26. Standard treatment options *) observation : may be appropriate for elderly,systemically ill patient where other modalities are not applicable ; It may be indicated for small size tumors for close observation especialy if signs of chronicity present (e.g drusen).

27. Standard treatment options *)Radioactive plaque therapy(brachtherapy): It is the 1 st choice Rx for most medium sized & small tumors. It has the advantage of it is globe preserving procedure ( with some vision).

28. Standard treatment options By applying radioactive plaque over the sclera overlying the tumor allows delivery of high dose of radiation to the tumor & relatively low dose to surrounding retina. Various isotopes used most commonly used are : cobalt 60, Iodine 125,ruthenium106. Local tumor control rate as high as 96%.

29. Standard treatment options Main side effects are mainly to the surrounding tissue & they include : Optic Neuropathy. Retinopathy. Vit. Hge. Cataract. All these side effects are dose dependent.

30. Standard treatment options *)Charged particle Radiation : Main indication are those tumors unsuitable for brachytherapy because of the size of tumor or posterior location near ON or fovea (<= 4 mm distance ). It delivers more homogeneous dose of radiation to the tumor than does brachy therapy.

31. Standard treatment options It gives local tumor control rate up to98%. It deliver high energy dose to anterior segment structures. Main S/E : NVG. Cataract. ERD. Retinopathy.

32. Standard treatment options *)Enucleation : Historically was the gold standard of treatment ; it is now still the appropriate option for a) all large size tumors. b) some medium size tumors especially if all useful vision is irreversibly lost.

33. Standard treatment options The Hypothesis of Enucleation is increasing chance of cellular spreading intraoperatively ;increasing mortality no longer acceptable nowadays.

34. Standard treatment options *)External beam radiation therapy : Is ineffective as a monotherapy ; but may be effective in limiting orbital recurrences in large melanomas. It could be also alternative to exentration if combined with enucleation. It is not statistically significant in reducing 5 years mortality.

35. Investigational treatment modalities *)TTT (transpupillary thermotherapy ): By using diode laser ; it may lead to rupturing Bruch`s membrane, acceleration of tumor growth, increasing recurrence. If combined with either brachytherapy or charged particle radiotherapy may lead to better local control of tumor.

36. Investigational treatment modalities *) cryotherapy : Many personal experience for small size tumors. *) transscleral diathermy: is contraindicated for all malignant intraocular tumors ; because it leads to scleral damage & providing a rout for extrascleral extension.

37. Investigational treatment modalities *) PDT : Many case reports for small subfoveal amelanotic melanoma : but they lack the long period follow up, small no. *) Exentration : For extrascleral extension ; but rarely done nowadays because combined enucleation +local external radiotherapy achieved survival outcomes similar to Exentration.

38. Investigational treatment modalities *) Surgical excision of the tumor : A) transsclera. B) transretinal. There are many personal experiences for small & medium size tumors which were excised successfully ; but they lack nature of evidence based practice until metaanalysis or at least strong double blinded clinical trials with long follow up are available.

39. Investigational treatment modalities The disadvantages of surgical approach: Difficult surgically. Inability to evaluate tumor margins for residual disease. High incidence of pathologically recognized scleral & retinal & vitreous involvement. risk of malignant cells spread intraoperatively.

40. Prognosis Poor prognostic factors are : 1) Large tumor size: 5 years mortality for a) small tumors ( B.D 4-8 mm & thickness 1- 2.4 mm ) is 12%. b) medium tumors ( B.D 6-<16 mm& thickness 2.5-,10 mm ) is 30%. c) large tumors ( B.D >16 mm & thickness >10 mm ) is 50%.

41. Prognosis 2) anterior location of tumor. 3) extraocular extension. 4) tumor regrowth after local treatment. 5) histopathological e.g dominant epitheloid cells 6) presence of metastasis e.g life expectancy in case of liver metastasis is <3/12.

42. Summary Standard treatment for choroidal melanoma : 1) observation. 2) globe preserving : a) Brachytherapy ; for medium and small tumors. b) charged-particle therapy; for cases not suitable for brachytherapy ( size or location ) 3) Enucleation : for large tumors & eyes lost their vision irreversibly;.( +/- external local radiation). What you will choose for our case?