ODs have a role in detecting early cancer

NEW ORLEANS – A number of common ocular conditions seen in the optometrist’s office may be masquerading as melanoma, according to presenters here at the American Academy of Optometry plenary session.

“Keep a high index of suspicion,” Jerry Shields, MD, co-director of the Wills Eye oncology service, told attendees. “Do not overlook a life-threatening condition. You can play a role in diagnosing early cancer.”

Primary Care Optometry News co-sponsored the plenary session.

“In a patient with astigmatism that’s difficult to correct, dilate and look at the ciliary body,” he said. “The patient could have a ciliary body melanoma.”

A patient with esotropia and a peculiar reflex could have retinoblastoma,” Shields continued.

“Most with macular retinoblastoma will have leukocoria,” co-presenter Carol Shields, MD, added. She is also co-director of the Wills Eye oncology service.

“If you catch them at 2 or 3 months of age, they don’t yet have strabismus,” she added.

Jerry Shields, MD, noted: “Parents will say: ‘The doctor said not to worry about it; the baby will outgrow it.’”

Carefully evaluate adults with strabismus, Shields continued. He shared the case of a man, age 57, who had exotropia for 50 years and now has worsening vision.

“He had a choroidal melanoma,” Shields said. “We speculate he may have had a juxtafoveal lesion that grew into a melanoma.”

Carol Shields, MD, noted that most adults come in with blurred vision before they develop strabismus.

Chalazion, another condition commonly seen in the optometric practice, can actually be sebaceous carcinoma if a loss of cilium is noted, Jerry Shields, MD, said.

“Merkel cell carcinoma appears reddish-blue on the upper lid and is sausage shaped,” he said. “Metastasis and death occurs in 25%.”

Carol Shields, MD, offered a clinical pearl: “Merkel cell and sebaceous carcinoma get rid of the lashes; chalazion does not. Always send chalazion to pathology.”

Jerry Shields, MD, continued: “Eyelid metastases are uncommon, but can be the first sign of cancer or the first sign of metastasis for known primary care. Most patients with this chalazion die in a few months.”

Cancers that can simulate chalazion include basal cell, Merkel cell, sebaceous, metastasis and sweat gland neoplasms, he added.

Sebaceous carcinoma can look like severe blepharitis (with lash loss), Shields added.

“Basal cell carcinoma is less common than the nodular type, has diffuse lid thickening, no central crater, is very invasive and can be fatal, but metastasis is very rare,” he said.

Eyelid sebaceous carcinoma has two primary presentations, Shields said. It can resemble an eyelid nodule or it can be diffuse and resemble conjunctivitis or blepharitis.

“Scleritis that does not respond to steroids, sentinel vessels, dilated vessels that overly something in the ciliary body – this can indicate ciliary body melanoma,” he said.

“There will be times when you see a macrovessel, and you look in the eye and won’t find a tumor,” Carol Shields, MD, said. “But when you see these large vessels, check inside the eye for melanoma.”

Neoplasms, squamous cell carcinoma and melanoma can all simulate pinguecula and pterygia, Jerry Shields, MD, said.

“If a lesion is atypical, consider complete removal and send for pathology,” he said.

Shields advised ruling out ciliary body melanoma in patients with unilateral cataract and a poor view of the fundus.

Some are discovered at surgery and some at the first postoperative visit, he said.

“How can the occult ciliary body be detected when you can’t see the fundus?” Shields asked. “Look for sentinel vessels. Do ultrasound, transillumination, B scan. Rule out melanoma as early as possible.

“If you don’t have ultrasound, do transillumination,” he continued. “Take a bright light and topical anesthesia, and put it in the fornix. The light will come through the cataract and the pupil and will cast a shadow into the ciliary body.” – by Nancy Hemphill, ELS, FAAO

Disclosures: Shields and Shields report no relevant financial disclosures.