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Use UBM to detect potential malignancies in your office
A case report illustrates how this new technology can differentiate lesions in the ciliary body.
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As eye care technology continues to advance, high-resolution imaging remains on the front lines of diagnosing and treating patients suffering from a vast array of diseases and conditions. Light instruments still have tremendous imaging value; however, they fall short in certain areas where ultrasound biomicroscopy (UBM) excels.
The ciliary body cannot be seen with light instruments; as a result, many eye clinicians unconsciously ignore the ciliary body during anterior segment work-ups. Anterior segment UBM imaging bridges the gap between light instrumentation and the ciliary body, providing the fullest, most comprehensive picture possible.
Jerome
Sherman
In a recent case, a patient who presented to my practice with a common complaint was discovered to have a ciliary body malignant melanoma after a routine imaging session. This case illustrates the importance of having a full range of imaging technologies at your disposal.
Case report
A 45-year-old Caucasian female was referred by a contact lens specialist to the Eye Institute and Laser Center in New York. She was nearsighted and had been wearing contact lenses for years. The contact lens specialist happened to notice a small, pigmented nevus on the patient’s iris. It seemed to be extending slightly into the anterior chamber angle. It was visible on gonioscopy and looked nonthreatening. The patient was asymptomatic. She was then referred to me for an evaluation of the nevus.
I recommended that the patient return for UBM imaging (Aviso, Quantel) of the anterior segment, as her referring practice did not have access to UBM. The patient, however, did not keep her appointment and was lost to follow-up. She resurfaced 2 years later, stating that her sister was sick and she had been caring for her in a different state. She had returned home and wanted to resume care.
She still had no symptoms, with 20/20 visual acuity. Her conjunctiva was a little hyperemic in the area where the nevus was before. At this visit, the nevus, which was dark initially, looked fleshy colored, had vascularized and was certainly larger.
I performed the UBM, and the pigmented nevus had transformed into a vascular amelanotic malignant melanoma. She was then referred to specialists at Wills Eye Hospital in Philadelphia, who confirmed the vascular amelanotic malignant melanoma and recommended treatment with an iodine plaque, or I-125, a radioactive plaque administered directly on the eye, near the tumor.
With treatment, the tumor began to regress. She had a 3-month follow-up visit, during which time I confirmed that the tumor was regressing. She did not return for any additional follow-up visits. We exhausted every effort to contact the patient, and were never able to reach her. Her phone was disconnected and all mailings were returned. We do not know for certain, but under these circumstances, one of the obvious possibilities is that the patient had passed away. Studies have shown that patients with malignant melanomas have high mortality rates, which is why we must be extremely careful and make an early diagnosis whenever possible.
Note the presence of a cystic lesion under the peripheral iris contiguous with the ciliary body.
Images: Sherman J
In contrast to the first UBM, here the lesion is in a similar location and of a similar size but is
solid rather than cystic. Melanoma of the ciliary body is the most likely diagnosis.
Benefits of UBM
The ciliary body is largely ignored in eye examinations and, in fact, is not mentioned on patient records. This may have been unavoidable before technology allowed for viewing behind the iris. Many early retinal diseases and most optic nerve diseases are also invisible to ophthalmoscopy and slit-lamp examinations but can be detected with optical coherence tomography. One could argue that both procedures should be routine.
Another benefit of UBM is that it easily demonstrates the difference between a solid lesion and a cystic lesion. Our experience with UBM at the Eye Institute and Laser Center reveals that ciliary body cysts occur in about 15% of the population. Malignant melanoma is significantly rarer, occurring in five to seven cases per year per million population in Caucasians (Seregard et al., Damato, Mellen et al.). UBM helps differentiate between the cystic lesion and the solid lesion, making it easier to identify the more serious, life-threatening cases.
At our private office, we believe that we have an obligation to offer our patients the most advanced technology in an effort to make diagnoses that may not be as obvious when using standard imaging devices.