Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9

Ocular motility problems following treatment for uveal malignant melanoma

E.L.M. Dawson & J.P. Lee

Moorfields Eye Hospital, London, England

ABSTRACT: A retrospective review of case notes was carried out of referrals over the past 5 years, from our Ocular Oncology service of patients treated with a plaque for uveal malignant melanoma, that developed ocular motility problems after the removal of the plaque. There were 9 males and 6 females, with an average age of presentation of 56 years. In 5 cases the superior oblique was disinserted. The other muscles reported as disinserted were the lateral rectus, inferior oblique, inferior rectus, superior rectus and medial rectus. Three patients did not have muscles removed. Six patients developed vertical strabismus, 2 horizontal, the other patients were aware of diplopia in different positions of gaze post removals. Eleven patients complained of diplopia. The 4 patients without diplopia developed central scotomas. Five patients were treated with fresnel prisms, 3 underwent successful superior oblique surgery, one had inferior rectus surgery, 4 had botulinum toxin and 2 patients had no treatment. Treatment using plaques can result in troublesome diplopia but can be treated with prisms, botulinum toxin or surgery.

1INTRODUCTION

Patients may complain of binocular diplopia after treatment for uveal malignant melanoma. When melanomas are treated by brachytherapy it is often necessary to disinsert extra ocular muscles. In addition, patients with poor vision post-treatment may develop sensory deviations. Plaque brachytherapy has the advantage of preserving the globe with relatively low radiation exposure to healthy adjacent tissues.

2METHOD

A retrospective review of case notes was carried out of referrals from our Ocular Oncology service over the past 5 years treated with a plaque for uveal malignant melanoma, that developed ocular motility problems after the removal of the plaque. The plaques were applied was under general anesthesia. The conjuctiva and Tenon’s capsule were dissected and the borders of the tumour were defined. The plaque was placed on the sclera in correct alignment with the tumour to completely cover the tumour margins by more than 2 mm. When the exact location of the tumour was under an extra ocular muscle, the muscle was temporarily disinserted using the hang-back technique. After the radiation was delivered to the tumour apex, the plaque was removed within 5 days.

3RESULTS

There were 9 males and 6 females, with an average age of presentation of 56 years. There was a wide range of 23 to 80 years. In 5 cases the superior oblique was disinserted. The other muscles

235

reported as disinserted were the lateral rectus in 5 cases. The superior rectus in 3 cases. The inferior rectus and medial rectus in 2 cases and the inferior oblique in one case. Three patients did not have muscles removed. Six patients developed vertical strabismus, 2 horizontal, the other patients were aware of diplopia in different positions of gaze post removal. Eleven patients complained of diplopia. The 4 patients without diplopia developed central scotomas. Five patients were treated with fresnel prisms, 3 underwent successful superior oblique surgery. In 2 cases the superior oblique tendon was found to be displaced by the plaque and was dissected free. A similar appearance has been seen following encirclement for retinal detachment. One patient underwent inferior rectus surgery, 4 had botulinum toxin and 2 patients had no treatment.

4CONCLUSIONS

Treatment using plaques can result in troublesome diplopia but can be treated with, prisms, botulinum toxin or surgery.

REFERENCES

1.Langmann A, Langmann G, Unlucerci G, Haleer E.1995. Motility disorders after brachytherapy for uveal melanomas with 106 ruthenium plaques. Ophthalmologe;92:76–78.

2.Sener E, Kiratli H, Gedik S, Sanac A. 2004. Ocular Motility Disturbances After Episceral Plaque Brachytherapy for Uveal Melanoma J AAPOS;8:38–45.

236

Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9

Recurrent strabismus caused by orbital tumour arising from pulley smooth muscle tissue?

P.Ph. van den Broek, J.T.H.N. de Faber & A.D.A. Paridaens

The Rotterdam Eye Hospital, Rotterdam, The Netherlands

M. Kliffen

Department of Pathology, Erasmus University, Rotterdam, The Netherlands

ABSTRACT: A 35-year-old female patient presented a vascular conjunctival lesion and recurrent exotropia with limitation of adduction. Although at first a retention cyst was suspected, the lesion was not located at a former surgical site. Imaging revealed a well circumscribed anterior tumour located medial to the medial rectus muscle. Following excision, pathological examination demonstrated a benign smooth muscle neoplasm.

1INTRODUCTION

Orbital smooth muscle neoplasms are exceedingly rare and only sporadically reported in literature. Most cases of benign orbital leiomyoma are located in the posterior orbit and often a vascular wall origin is speculated (Nath et al. 1969, Jacobiec et al. 1975).

2CASE REPORT

A 35-year-old Caucasian female patient, with previous recession of the IO and LR muscles for exotropia and elevation in adduction with V-pattern, presented a painless vascular conjunctival lesion and recurrent exotropia with limitation of adduction (Fig. 1). She had first noticed the lesion during her pregnancy ten months earlier. On examination there was a large, round, subconjunctival swelling with prominent overlying vessels, a superotemporal translation of the right bulbus and minimal proptosis. Best corrected visual acuity was 20/20 in both eyes. Fundoscopy showed an inferomedial indentation of the right eye. MR-imaging showed an extraconal oval soft tissue mass, inferomedial to the bulbus in the anterior right orbit (Fig. 2). A large yellow-white tumour (23 15 10 mm) was dissected free from its attachment to the medial rectus muscle via a transconjunctival incision. Histopathological and immunohistochemical examination showed the characteristic picture of a benign smooth muscle tumour: leiomyoma. Postoperatively the patient had normal eye motility and visual acuity.

3DISCUSSION

The paucity of smooth muscle cells might explain why leiomyoma is exceedingly rare in the orbit. Most of the sporadic cases reported in literature are located in the posterior orbit and a vascular wall origin is often speculated (Sanborn et al. 1979). We suggest this anterior located leiomyoma may have arisen from the pulley of the medial rectus muscle because Miller described a relatively abundant presence of smooth muscle cells in this pulley and a dense band connecting it with the inferior rectus muscle around the globe equator (Miller et al. 2003).

237

Figure 1. Clinical photographs showing a large subconjunctival swelling with prominent vessels medial in the right orbit and exotropia with limitation of adduction.

Figure 2. Coronal T1-weighted MR-image showing an extraconal tumour located medial to the medial rectus muscle.

Although very rare, leiomyoma should be considered in the differential diagnosis of a well circumscribed orbital tumour.

REFERENCES

Jakobiec FA, Howard GM, Rosen M, Wolff M. Leiomyoma and leiomyosarcoma of the orbit. Am J Ophthalmol. 1975 Dec; 80(6): 1028–42.

Miller JM, Demer JL, Poukens V, Pavlovski DS, Nguyen HN, Rossi EA. Extraocular connective tissue architecture. J Vis. 2003; 3(3): 240–51.

Nath K, Shukla BR. Orbital leiomyoma and its origin. Br J Ophthalmol. 1963 Jun; 47: 369–71.

238