1/15/2013
Wide angle fundus imaging and
Fuorescein angiography in evaluation
and
management of intraocular
tumors
Ihab Saad Othman, MD, FRCS
Professor of Ophthalmology
Cairo University
Cairo, Egypt
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Advances in Ocular Imaging
Kowa
Topcon
Retcam
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
1/15/2013
Wide-Field (Digital)
Imaging.
Field-of-view: The instantaneous
field-of -view (FOV).
Field-of-regard (FOR): Total field
of imaging available with camera.
Ora serrata
Equator
ORA
SERRATA
Standard fundus
camera field-of-view
(FOV)
EQUATOR
What would we do differently if we could
remotely image the entire eye?
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Wide Angle Imaging
Retcam
Panoret
Optos
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
1/15/2013
Wide angle viewing:
Staging of Retinoblastoma
Reese-Ellsworth Staging
system (1963): Predicts visual
prognosis with external beam
radiotherapy
Group I: Very favorable
prognosis:
Single tumor, 4 DD at or
behind the equator.
Multiple tumors, 4 DD at or
behind the equator
Group II: favorable prognosis:
Solitary tumor , 4-10 DD at or
behind the equator.
Multiple tumors, 4-10 DD at or
behind the equator.
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Reese-Ellsworth Staging
system
Group III: doubtful
prognosis:
Any lesion anterior to the
equator
Solitary tumors larger than
10 disc diameters behind
the equator
Group IV: unfavorable
prognosis:
Multiple tumors, some >10
DD
Any lesion extending
anteriorly to ora serrata.
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
1/15/2013
Reese-Ellsworth
Staging system
Group V: very
unfavorable
prognosis:
Massive tumor involving
over half the retina.
Vitreous seeding.
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Retinoblastoma
Staging:
International classification of retinoblastoma (2003)
is based on the rate of ocular salvage with systemic
chemotherapy
A
B
Very favorable. Tumor confined to
C
the retina
D
Unfavorable. Tumor dispersed to
adjacent spaces
Unsalvageable
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
1/15/2013
Retinoblastoma
Staging:
International classification
of retinoblastoma
Group A:
Tumor Not more than 3mm
Located more than 1.5 mm
from optic disc and 3 mm
from fovea
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Retinoblastoma
International classification
of retinoblastoma
Group B:
Tumors confined to the
retina 10mm
Any location
No subretinal fluid beyond
3 mm from the base of the
tumor
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
1/15/2013
Retinoblastoma
Group C:
Any size tumor < the eye
Subtle dispersion
Fine vitreous seeds
No dispersed tumor
masses
Subretinal seeds less than
3 mm from the tumor
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Retinoblastoma
Group D:
Diffuse disease with
significant vitreous or
subretinal seeding
Subretinal fluid in more
than one quadrant of
the retina
Subretinal fluid, present
or past, without
seeding, involving up to
total retinal detachment
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
1/15/2013
Group D:
Tumor(s) may be massive
or diffuse
Diffuse subretinal seeding,
present or past, may
include subretinal plaques
or tumor nodules
Diffuse or massive vitreous
disease may include
"greasy" seeds or
avascular tumor masses
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Wide Angle Viewing
Extremely valuable in:
Treatment monitoring
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
1/15/2013
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
1/15/2013
Documents Plaque Centration
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
IOAM, 3 cycles
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
1/15/2013
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
IOAM, 3 cycles
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
10
1/15/2013
5 months follow up: Subretinal
seeds recurrence/ Enucleation
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Direct
Gonioscopy:
Case: 1.5 year-old
male
Ciliochoroidal mass:
PLSU
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
11
1/15/2013
Case: 1.5 year-old
male
Ciliochoroidal mass:
PLSU
Pathology:
Ectopic lacrimal gland
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Direct Gonioscopy:
Medulloepithelioma
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
12
1/15/2013
CB masses
18 YOM
CB mass followed for the
last 4 years
Growing on UBM
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
UBM: AP
UBM: Transverse
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
13
1/15/2013
Differential Diagnosis
Adenoma (non-pigmented ciliary
epithelium)
Medulloepithelioma
Metastasis
Melanoma
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Transcleral Resection
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
14
1/15/2013
Specimen
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Specimen
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
15
1/15/2013
Granulaomatous inflammation
Non-caseating
ZN-negative
?? Sarcoidosis, chest X-ray normal, ACE
normal
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Opto Tx 200
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
16
1/15/2013
Follow up of
Pediatric age group
> 3 years vs GA
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
8 YOF
VA: 6/24
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
17
1/15/2013
4 YOF
VA: 6/6
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
10 YOF
VA: 6/24
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
18
1/15/2013
5 YOM
Monophthalmic
VA: 6/36
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
32 YOF
Mom
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
19
1/15/2013
Choroidal Tumors Diagnosis
and Management
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Choroidal Melanoma:
Most common primary
intraocular malignancy
in adults
Dendritic melanocytes
(neural crest origin)
20
1/15/2013
Opaque media
Initial evaluation of
thickness
Follow up of treatment
response
A-scan: Low to medium
reflectivity
B-scan: Acoustic
hollowness, choroidal
excavation, + angle
kappa
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
21
1/15/2013
45 year-old-female
with choroidal
melanoma
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
16 YOF
Peripheral
choroidal
mass
Wide Angle
FF/A
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
22
1/15/2013
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
23
1/15/2013
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
63 YOF: Melanoma
Post-Ru 106 / TTT
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
24
1/15/2013
Tumor Extent
55 YOF
Enucleation
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Autofluorescence
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
25
1/15/2013
48 YOM
Tumor
control
post
PLSU/TTT
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
2 months
VA: 6/36
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
26
1/15/2013
18 month
VA: 6/9
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
28 YOF
PLSU/TTT
3 months
VA: 6/36
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
27
1/15/2013
1 year
VA: 6/9
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
28
1/15/2013
Choroidal
Metastases
4 7 year-old female
with multiple breast
metastases
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
FNAB:
Highly reliable
Uncertain diagnosis
Difficult technique
Experienced
cytopathologist
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
29
1/15/2013
72 year-old female
with choroidal mass:
unknown primary
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Classically:
FNAB: indirect
ophthalmoscopy:
Inverted image
Laterally rotated image
Mastering and
meticulous
manipulations
Hundreds of cases with
a steep learning curve
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
30
1/15/2013
Interventional
Photo-guided
choroidal biopsy
Retcam
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Interventional Photo-guided
choroidal biopsy
Adenocarcinoma
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
31
1/15/2013
57 YOF
DVA OS for 3 months
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
32
1/15/2013
Lymphoma: 60 YOF
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
FNAB
Plasmacytoma in a 65
YOF
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
33
1/15/2013
Hemorrhagic Lesions
Simulating Melanoma
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
58 year-old female
Choroidal Mass OS x
1 month
VA: 6/18
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
34
1/15/2013
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
35
1/15/2013
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
36
1/15/2013
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
37
1/15/2013
Vertical
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Transverse
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
38
1/15/2013
Revise History:
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Discussion
New Investigative tools: Wide Angle FF/A is a
primordial tool in management of intraocular
tumors
Paradigm shift with a whole chapter in
panoramic view and peripheral fundus changes
In tumors: Early diagnosis and timely
intervention is imperative in SURVIVAL
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
39
1/15/2013
Remember:
WHEN DEALING WITH CANCER
YOU ARE DELAING WITH LETHAL DISEASE
YOU ARE DELAING WITH HUMAN LIFE
NO ROOM FOR TRIAL AND ERROR
EYE SALVAGE WILL DEPEND ON PROPER
DIAGNOSIS AND SOUND MANAGEMENT
EVERY EFFORT IS JUSTIFIED TO SAVE AN EYE
WITHOUT COMPROMISING LIFE
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Wide angle fundus
Digital Screening:
Retcam
ihabsaad@[Link]
Ihab S Othman, Consultant
Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
40
1/15/2013
Opto Tx 200
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
Opto Tx 200
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
41
1/15/2013
Ihab S Othman, Consultant Ophthalmic Oncologist and VR Surgeon
ihabsaad@[Link]
42
