Glaucomas Secondary to Intraocular Melanomas

Abstract

Intraocular melanomas are not common entities but often lead to secondary glaucoma. Intraocular melanomas should be considered in the differential diagnosis of patients with unilateral glaucoma. Occasionally, the workup of unilateral glaucoma leads to a diagnosis of an intraocular melanoma. Intraocular melanomas represent the majority of intraocular tumors. The prevalence of intraocular melanomas as well as associated secondary glaucomas will be reviewed. The workup needed for unilateral glaucoma will be covered in detail. Treatment options for secondary glaucomas include topical and oral medications as well as argon laser trabeculoplasty and transscleral cyclophotocoagulation.

Outcomes of Glaucoma Drainage Device Surgery in Eyes with Treated Uveal Melanoma

“…However, there remains concern and significant controversy regarding glaucoma surgery in eyes with an intraocular tumor due to fear of both orbital and systemic tumor dissemination, increasing metastatic risk [1, 9, 10, 13, 15, 26]. Although there are published cases of tumor dissemination following glaucoma surgery, in almost all cases local ocular tumor control had not been achieved [13-16, 27].…”

“…However, our data support the assumption that in cases in whom the primary tumor has been definitively treated (i.e., eyes with no evidence of tumor growth at the time of GDD placement), the risk to the patient following invasive glaucoma surgery is not greater than clinical risk factors, namely tumor size and molecular prognostic profile, would suggest. Treatment of glaucoma in eyes with intraocular tumors, which is often caused by multiple mechanisms (incidence rate of 15.3% [Kim et al, manuscript under revision]) [1, 3, 28], may be challenging, and medical therapy, laser trabeculoplasty, and cyclophotocoagulation may not lead to adequate IOP control [11, 29, 30]. Cyclophotocoagulation is a treatment that may result in eventual phthisis if repeated more than once; therefore, offering cyclophotocoagulation may be minimally better than enucleation for ocular preservation [31].…”

“…The risk factors for neovascular glaucoma were larger tumor size, pseudophakia, and greater extent of retinal ischemia on wide-field fluorescein angiography. Other studies have reported the incidence of glaucoma in eyes with treated uveal melanoma to vary from 3 to 59% [1-3, 5-7]. …”

“…Uncontrolled glaucoma from neovascularization is the main reason for enucleation of the eye in patients with anterior uveal melanoma [8-10]. Conventional modalities to control IOP include medical treatment, trabeculectomy, or placement of a glaucoma drainage device (GDD) and ciliary body ablation [1]. Medical therapy alone is frequently inadequate for controlling IOP in eyes with treated uveal melanoma [11, 12].…”

“…The uveal tissue of the eye is the second most common site for primary melanoma. Among uveal melanomas, melanoma of the choroid (69–90%) is the most common site followed by the iris (5–8%) and ciliary body (4–7%) [1-4]. We have recently reported the incidence of secondary open-angle glaucoma after brachytherapy to be 8.6% in a series of 374 uveal melanoma patients [Kim et al, manuscript under revision]; the incidence of neovascular glaucoma in the same cohort was 6.7%.…”