Malignancies that masquerade as chronic intraocular inflammation

COS 2012, July 6 - Chronic intraocular inflammation may be more than what it seems. In a review of the topic, Dr. Nupura Bakshi, staff ophthalmologist at Mount Sinai Hospital and with the department of ophthalmology at the University of Toronto, provided tips on identifying malignant masquerades in chronic idiopathic uveitis.

Uveitis masquerade syndromes (UMS) were first described in 1967 and include malignant conditions such as primary intraocular lymphoma, leukemia, carcinomas that are metastatic to the eye, uveal melanoma, pediatric malignancy and paraneoplastic syndromes.

Primary intraocular lymphomas are not fully understood, Bakshi said. There are a number of warning signs that may indicate malignancy that ophthalmologists should watch for. Along with patient history, red flags can include new onset of uveitis in elderly patients, a history of prior malignancy and use of immunosuppressive drugs. There can be a painless decline in vision. Physicians should also monitor for constitutional, neurologic or other end-organ symptoms.

Significant intermediate or posterior uveitis should be present on examination. There may also be choroidal, subretinal or retinal infiltrates.

Another clue to malignancy is limited or no response to steroidal treatment of the uveitis - or there can be an initial response but recurrent steroid-resistant disease, Bakshi stated.

She cited several types of investigations that may help with diagnosis. Ocular investigations include intravenous fluorescein angiography, indocyanine green angiography and fundus autofluorescence. Performing an aqueous or vitreous biopsy, a B-scan ultrasound or an electroretinography may also be useful.

There are also systemic tests that may be used to help confirm the diagnosis. Among these are complete blood count and sending the patient for magnetic resonance imaging or computed tomography of the chest, abdomen, pelvis or breast. Ultrasound tests can also help detect malignancies.

If there is suspicion of a malignancy, the patient should be referred to an oncologist.