Supplementary Material

Chapter 30

Cases from
Iris Cyst: 38-year-old female with iris lesion and gradual decrease in vision

Iris Melanoma: 47-year-old male referred in 1997 for evaluation of iris lesion

Melanocytoma of the Iris and Ciliary Body:  14-year-old male with a pigmented iris lesion of the left eye noticed on routine eye exam approximately two years earlier. Higher power magnification showed elevation of lesion with mildly irregular surface without surface vessels and the iris central to the lesion pushed into folds.

Tumor cases from

Probable Iris Nevus: This patient had always noted “speckles” of brown pigmentation on her blue iris. Her ophthalmologist noticed that one of the nodules on the right iris appeared raised and referred her for evaluation and ultrasound.

Iris Nevus vs. Small Iris Melanoma: This patient presented in 1999 at the age of 27 years old. At that time she said that she had always had a freckle in her right eye that her parents noted when she was a child. This lesion has been followed at the time of this video for 11 years with no change. It is either a thick iris nevus or a melanoma. On echography the lesion is 0.8 mm thick.

Nevus with Ectropion: 30 yo mass present for 10 years. He has noted a recent change in size. An iridocyclectomy was performed. Pathologic examination demonstrated a spindle cell nevus.

Intrastromal Amelanotic Iris Nevus: This 53 year-old white male went to his optometrist complaining of decreased visual acuity in the right eye and was found to have a hyphema and an elevated intraocular pressure to 32 mmHg. When we saw him he had an amelanotic mass as seen here. His visual acuity was equal and normal in both eyes and his intraocular pressures were 16 mmHg OD and 17 mmHg OS. On echography this lesion was 1.9 mm thick and appeared to extend deep into the angle but not into the ciliary body. The lesion was vascular. It was recommended to this patient that he consider excision of this lesion but he refused any surgical management. 26 months later he returned because the lesion was bleeding intermittently. The lesion was resected and was found to be an intrastromal amelanotic iris nevus. Eight weeks after his surgery he had 20/25 vision and an intraocular pressure of 14 mmHg.

Iris Nevus Versus Melanoma: 73 year-old man who has had this lesion on his left iris for over 50 years. There has never been any documented growth.

Iris Melanoma: First seen at age 27 with a mass in the right eye that was first noted by the patient eight years ago. She was followed with standardized echography and clinical evaluation and after seven years was shown to have progressive growth. A fine needle aspiration biopsy showed a melanoma with spindle and epitheliod cells and so she underwent an iridocyclectomy. The margins of the wound were free of tumor and she has been followed for 14 years without recurrence. In the 13th post-operative year she developed a cataract that was removed with placement of a lens with an artificial iris.

Atypical Nevus: 19-year-old white female with a history of a stable iris nevus in her right eye since age 2 years. Significant family history: both father and grandfather died of cutaneous melanoma. This iris lesion was stable until July 2002 when it started to enlarge. This baseline video was obtained. In 2007 the lesion was clearly larger. VA 20/20 IOP = 14 mm Hg bilaterally. She underwent enucleation. Pathologic diagnosis: “Atypical iris nevus, most consistent with borderline spindle cell nevus type. Lesion extends into trabecular meshwork. Satellite lesions are present in the angle.”

Ring Melanoma - 1: 71 year-old man referred for an IOP of 44 mmHg in his left eye. He had 20/30 vision. His ultrasound was compatible with ciliary body melanoma.”

Heterochromia Ring: 49 year-old referred for trabeculectomy with the diagnosis of pigmentary glaucoma. He had a history of elevated IOP in the right eye for 4 years. He had had pressures as high as 47 mmHg. At present he was on four medications and had undergone a trabeculoplasty. On examination he had an IOP of 38 mmHg and total cupping of the optic nerve with a 5-degree visual field. The patient underwent enucleation, which confirmed the diagnosis of diffuse melanoma.”

Recurrent Iris Melanoma: This 40 year-old female first presented in 1991 with a pigmented iris mass lesion OD. She underwent an iridectomy with excisional biopsy of the pigmented iris mass in 1992. She was doing well a year later and then was lost to follow-up for 11 years when she returned with recurrences on her iris. She underwent enucleation.”

Ademona of the Ciliary Body Non-Pigmented Epithelium: This thirteen year-old male first noted a spot on the iris seven moths before this evaluation. A fine needle aspiration biopsy revealed was most consistent with a congenital iris cyst of epithelial origin. Five years later the lesion had grown substantially and an iridocyclectomy was performed. The mass was found to be an adenoma of the non-pigmented epithelium of the ciliary body.”

Melanocytoma: Seen in 1996 at age 36 with a spot on his right eye for 1 - 2 years. Fine needle aspiration biopsy revealed melanocytoma. Followed 11 years without significant change.”

Metastatic Breast Carcinoma: Six years after a diagnosis of breast cancer this patient noted a lesion in her eye that led her to consult her ophthalmologist. The mass seen here was found to be highly reflective and vascular on a standard echography. A chest x-ray revealed a lung lesion that was felt to be a metastatic breast tumor. The patient was started on Tamoxifen and was followed closer to her home.”

Ciliary Body Melanoma - 1: 14 year-old noted to have a mass OS. Echo was highly reflective. The fine-needle aspiration biopsy positive for melanoma. Enucleated, diagnosis spindle cell melanoma.

Ciliary Body Melanoma - 2: This 36 year-old man has a history of superficial skin melanoma on his right forearm that was removed at age 21. A few months prior to this video he developed a red eye and was found to have cell and flare and was started on steroids. Two months later on follow-up this mass was noted. He had a decreasing visual acuity with myopic shift. On exam his visual acuity was 20/125 but refracted to 20/25 with -2.25 diopters of sphere. His intraocular pressure was normal at 13 mmHg. On ultrasound this lesion is 10 mm thick. The patient underwent metastatic workup and was found to have lesions in his brain, spleen and liver. He was treated with chemotherapy and radiation.

Iris Melanoma - Huge: This patient was seen in 1985 at age 66 with a pigmented flat iris lesion on his left eye. He was not seen again until 23 years later at age 89 when this mass had grown to the size seen here. His intraocular pressure had required three medications to keep it in a normal range. On ultrasound the mass extended 3 mm above the iris plane. Interestingly his referring physician had done a phacoemulsification three years earlier and, on ultrasound, the haptic of the IOL appeared to be engulfed in tumor. The patient refused enucleation and had radiation plaque therapy performed.

Ring Melanoma - 2: This 86-year-old woman was found to have more prominent pigmentation of her left iris than previously. Her IOP climbed into the 20s and she was begun on glaucoma medications. Recently she had developed anemia and had colonoscopy during which time a suspicious lesion was identified. This lesion looks like an iris / ring melanoma.

Ciliary Body Melanoma - 3: The iris lesion in this 79 year old patient developed rather suddenly. He had been followed in the same practice for 35 years and three years before this video had undergone cataract extraction with no mention of an iris abnormality. We see a large mass that has broken through the iris and a really nice example of the value infrared video transillumination to see the extent of this lesion posteriorly. This patient was returned to his home state for enucleation and an oncology evaluation.

Ciliary Body Melanoma - 4: This 47 year old woman first noted a dark spot on her iris approximately 5 months before this video was taken. She seemed to have a large dark mass that pushes against her cornea and appears to push the iris out of the way rather than sit on top of the iris. On ultrasound this mass is quite large extending well posteriorly to the iris. The patient returned to her home state for oncology workup.

Iris and Ciliary Body Melanoma: A 57 year old woman noted a light spot on her iris 10 months before being seen at our institution. Her local optometrist had never seen this over the 3 years that the patient had been followed by him. The patient was healthy and had no history of other tumors. One can see a thick angle lesion on slit-lamp examination and gonioscopy. On echography the lesion appeared to be confined to the iris and anterior ciliary body however, in surgery the mass was larger than anticipated. The histopathology was that of a malignant melanoma with epitheloid cells extending to the clinically- uninvolved ciliary body. The patient was advised to consider enucleation and preceded with this.

Adenomatous Tumor of the Ciliary Body: This 35 year old woman was first noted to have an iris lesion on the left side 3 to 4 months prior to presentation. She was in excellent health and has no history suggestive of another malignancy. On ultrasound the lesion measured 3.8 mm in height and one-third of the lesion was behind the ciliary body. A fine needle aspiration biopsy was performed that was not consistent with melanoma but contained eosinophils and macrophages suggesting a granulomatous process. A biopsy was attempted but the tumor was quite friable. Ultimately the entire mass was removed with iridocyclectomy. The pathology was suggestive of either a benign adenoma of the nonpigmented ciliary body epithelium or a metastatic lesion. The patient was evaluated for other primary tumors and none were found.

Amelanotic Iris Lesion: 22 year-old female found to have this lesion on routine examination. Over four years of follow-up it had not changed.

Masquerade Syndrome (slit lamp only): This 60-year-old patient was diagnosed with glaucoma 12 years prior to being seen. He had a history of chronic uveitis in the right eye. In 2012 he was diagnosed with sarcoid based on a positive lung biopsy. In July 2012 he was seen in our glaucoma clinic with an intraocular pressure of 40 mmHg, 360° of peripheral anterior synechia and a cataract. He underwent cataract extraction with intraocular lens and Ahmed seton. Twelve weeks after his surgery he had a hypopyon with an atypical appearance. A tap and inject was performed and no growth was found. Parallel to this he developed epididymitis which worsened on oral steroids. He was also losing weight on oral steroids. A paracentesis demonstrated a high grade B-cell lymphoma and a PET scan showed lymphoma in the retroperitoneal abdominal wall and testes. He had a right orchiectomy which was positive for B-cell lymphoma.

Ciliary Body Ademona: This patient was discovered to have a mass on routine examination. It is noted that the mass is very closely intertwined with the haptic of her intraocular lens. A fine needle aspiration biopsy was performed that demonstrated a probable adenoma of the non-pigmented ciliary epithelium.

Cyst cases from

Iris Cyst: On routine eye examination this 33 year-old woman was found to have a mass in her right iris. This had never been noted before. The patient was asymptomatic. Her visual acuity and intraocular pressures were normal. By echography she has a fluid-filled cyst in her iris.

Epithelial Inclusion Cyst (1): Presented at age 32 with a mass in the left eye. He had a vague history of trauma but was not sure which eye. Vision 20/25, IOP 18 mmHg. Underwent iridocyclectomy. At last follow-up, 3 years after surgery, he had no evidence of epithelium. His visual acuity was 20/15 vision and his IOP was 16 mmHg.

Iris Stromal Cyst: 79yo male presented in 2003 with iris stromal cyst OD. This was noted on a routine eye examination and had not been noted three years before. On echography this lesion is cystic. In four years of follow-up there was no interval change.

PDS from Iris Cysts (1): This 42 year-old woman had elevated intraocular pressures with evidence of pigment dispersion. Rather than having the typical slit-like defects in the pigment epithelium that one would see in pigment dispersion syndrome she had large globular areas of pigment epithelial loss and on ultrasound biomicroscopy was found to have cysts of the iris pigment epithelium pushing the pigment epithelium against the zonules. The patient is seen 6-years later at which time one of the cysts has grown large enough to reach into the pupil. You can see that she has undergone a trabeculectomy for intractably elevated intraocular pressures. The video was taken not long after her trabeculectomy, which explains the blood subconjuctivally inferiorly. This patient was reported in the Archives of Ophthalmology volume 113, pages 1574-1575, 1995.

PDS from Iris Cysts (2): This 47 year-old man presented with bilateral narrow angles. On examination he was found to have large iris cysts of the pigment epithelium. His intraocular pressures were normal in both eyes but there were portions of his iridocorneal angle that were closed and therefore an iridotomy was performed in the left eye. This video shows the patient before and after the iridotomy. This patient also had pigment dispersion caused by abrasion of the pigment epithelium against the lens zonules.

Cyst of the Iris Pigment Epithelium: When this patient was undergoing cataract extraction her surgeon noted a mass that had not been seen before and aborted the case. She has a cyst of the iris pigment epithelium that, on dilated examination, extends into the pupillary space.

Epithelial Inclusion Cyst (2): This 25 year old man was struck in the right eye with a screwdriver 6 years before this video was taken. His visual acuity was light perception. He has had a normal intraocular pressure and as can be seen a dense white cataract as well as a small clear cyst in the anterior chamber. The patient had the lens and epithelial cyst removed with placement of a posterior chamber intraocular lens. When he was last seen, 9 months after his surgery he refracted to 20/20 and had no evidence of recurrence of the cyst, which had been removed intact.

Iris Pigmented Epithelial Cysts: On routine examination this 65 year-old female was found to have an area of fullness in the iris of her right eye. Here she was found to have multiple iris cysts in both eyes.

Cyst of the Iris Pigment Epithelium (2): This 61-year-old man had a large iris pigment epithelial cyst that protruded into his pupil. It was so large that it compromised the inferior 180° of his iridocorneal angle. The cyst was lasered where it was very thin in the pupil and his angle opened markedly.

Epithelial Inclusion Cyst with Debris: This 58-year-old woman had a trabeculectomy in her left eye in March 2011. In December 2011, she was found to have a cyst in her inferior anterior chamber and a year later this had grown so she was referred to see us. The cyst was drained and the contents were consistent with an epithelial inclusion cyst. This is interesting in that one can see cellular debris moving within the cyst in convection currents.