Differentiating Chorodial Lesions - Yacoub Material Disease Final

1. According to Dr. Yacoub there were 11 things you needed to differentiate a nevus from a melanoma. Which of the following statements is not a possible red flag for a melanoma?

Patient complaints about flashes and floaters and other visual symptoms

Presence of drusen or RPE changes

Presence of Lipofuscin

9. B-Scan shows a solid mass with acoustic hallow area/low internal reflectivity

10. Mottled hyperfluorescence in the early stage and intense/progressive hyperfluorescence in the late stages of an FA

• Having drusen or RPE changes is a GOOD sign. It indicates that nevus has been there for a long time. Things that are longstanding are typically going to be benign; melanoma will be new and growing quickly. Want to see drusen and RPE changes = good signs!
• B-Scan will show you elevation. They KEY thing though - Big difference is you will have a spike initially, but because the inside of the melanoma is hallow, the A-scan goes down, the sensitivity goes down and it will have a low internal reflectivity. Initially will have a high reflectivity at the edge but the actual melanoma itself is hallow so the reflectivity will go down. That is the indication of a melanoma.

Explanation

• Having drusen or RPE changes is a GOOD sign. It indicates that nevus has been there for a long time. Things that are longstanding are typically going to be benign; melanoma will be new and growing quickly. Want to see drusen and RPE changes = good signs!
• B-Scan will show you elevation. They KEY thing though - Big difference is you will have a spike initially, but because the inside of the melanoma is hallow, the A-scan goes down, the sensitivity goes down and it will have a low internal reflectivity. Initially will have a high reflectivity at the edge but the actual melanoma itself is hallow so the reflectivity will go down. That is the indication of a melanoma.

2. Chorodial melanomas and Metastic Tumors vary in several ways, which of the following statments is false?

Metastatic tumors are usually multifocaland multilobular while chorodial melanomas are singular.

A B-scan will show a Metastic Tumor as possessing high internal reflectivity while a chorodial melanoma has low internal reflectivity

Both chorodial melanomas and Metastic Tumors can have characteristic sign known as a Leopard Skin in which brown pigment is overlying the lesion.

Treatment for metastatic tumors and chorodial melanomas is the same

Leopard skin only for metastic tumors.

Explanation

Leopard skin only for metastic tumors.

3. What is the best way to treat a chorodial melanoma

Enucleation

TTT(transpupillary thermal therapy)

Radiotherapy - plaque brachytherapy

Proton Beam radiation

Enucleation - carries risk of releasing malignant cells into bloodstream.

Explanation

Enucleation - carries risk of releasing malignant cells into bloodstream.

4. Choroidal Hemangioma is:

The presence of multiple discrete yellow placoid lesions that are usually bilateral

A benign growth, a vascular tumor, very well-defined, elevated and looks orange-red in appearance. It is large in size, can get sub-retinal fluid like in choroidal melanoma. At the posterior pole, it is unilateral. The one systemic disease it is associated with Sturge-Weber Syndrome (Port Wine stain).

Inflammatory material that develops into a little ball inside the retina.

Calcification of the retina, or more so in the choroid. It comes from the bones in the body

Choroidal Hemangioma is a benign growth that is a vascular tumor. It is well-defined, elevated, and has an orange-red appearance. It is usually large in size and can cause sub-retinal fluid, similar to choroidal melanoma. It is typically unilateral and is associated with Sturge-Weber Syndrome, which is characterized by a Port Wine stain.

Explanation

Choroidal Hemangioma is a benign growth that is a vascular tumor. It is well-defined, elevated, and has an orange-red appearance. It is usually large in size and can cause sub-retinal fluid, similar to choroidal melanoma. It is typically unilateral and is associated with Sturge-Weber Syndrome, which is characterized by a Port Wine stain.

5. Dark areas around vortex vein ampullas are typically nevus.

True

False

if there is pigment around the ampulla it is not a nevus. It is actually normal to have pigment migration around the ampulla which is NOT a nevus, just normal choroidal pigment.
It is flat, dark, and very common.

Explanation

if there is pigment around the ampulla it is not a nevus. It is actually normal to have pigment migration around the ampulla which is NOT a nevus, just normal choroidal pigment.
It is flat, dark, and very common.

6. Which of the following conditions is typically associated with uveitis, toxocariasis or sarcoidosis?

Choroidal Osteoma

Choroidal Granuloma

Reticular degeneration

Honeycomb degeneration

Uveitis is inflammation of the uvea, the middle layer of the eye, and it can be associated with various conditions. Toxocariasis is an infection caused by roundworm parasites, and sarcoidosis is an autoimmune disease that causes inflammation in different organs, including the eyes. Choroidal granuloma refers to a granulomatous inflammation in the choroid, which is the layer of blood vessels and connective tissue between the retina and the sclera. Therefore, choroidal granuloma is typically associated with uveitis, toxocariasis, or sarcoidosis.

Explanation

Uveitis is inflammation of the uvea, the middle layer of the eye, and it can be associated with various conditions. Toxocariasis is an infection caused by roundworm parasites, and sarcoidosis is an autoimmune disease that causes inflammation in different organs, including the eyes. Choroidal granuloma refers to a granulomatous inflammation in the choroid, which is the layer of blood vessels and connective tissue between the retina and the sclera. Therefore, choroidal granuloma is typically associated with uveitis, toxocariasis, or sarcoidosis.

7. Lymphomas in the eye differ from chorodial melanomas and metastatic tumor is that it is often accompanied by a vitritis.

True

False

Lymphomas in the eye can be distinguished from choroidal melanomas and metastatic tumors by the presence of vitritis, which is inflammation of the jelly-like substance in the eye. This inflammation is often observed in cases of lymphomas in the eye, setting it apart from other types of tumors. Therefore, the statement is true.

Explanation

Lymphomas in the eye can be distinguished from choroidal melanomas and metastatic tumors by the presence of vitritis, which is inflammation of the jelly-like substance in the eye. This inflammation is often observed in cases of lymphomas in the eye, setting it apart from other types of tumors. Therefore, the statement is true.

8. Which of the following degenerations is most likely to result in a retinoschisis?

Honeycomb degeneration

Pavingstone degeneration/Cobblestone

Peripheral Cystoid Degeneration (RP clumping)

Reticular Degeneration

Snowflake degeneration

Cystoid degeneration is in older pts, will see white/black and sometimes red dots. These little cysts are in the outer plexiform and inner nuclear layer. When the cysts expand and coalesce in the inner nuclear layer and outer plexiform layer RETINOSCHESIS can happen. PCD can lead to a retinoschisis. A retinoschisis will occur: a separator between the cyst (muller cells, photoreceptors and axons), they separate the cysts. Once they break down the cysts start to coalesce together and will get senile retinoschisis. If the outer wall is intact, there is little risk of further complications. Tx: nothing, just watch. Remember the honeycomb degeneration may protect the retina and prevent that retinoschisis from enlarging or coming toward the posterior pole.

Snowflake degeneration - Typically will see larger floaters and cataracts associated with them and can lead to retinal breaks, detachments, and neovascularization but usually you just watch it, it is benign.

Explanation

Cystoid degeneration is in older pts, will see white/black and sometimes red dots. These little cysts are in the outer plexiform and inner nuclear layer. When the cysts expand and coalesce in the inner nuclear layer and outer plexiform layer RETINOSCHESIS can happen. PCD can lead to a retinoschisis. A retinoschisis will occur: a separator between the cyst (muller cells, photoreceptors and axons), they separate the cysts. Once they break down the cysts start to coalesce together and will get senile retinoschisis. If the outer wall is intact, there is little risk of further complications. Tx: nothing, just watch. Remember the honeycomb degeneration may protect the retina and prevent that retinoschisis from enlarging or coming toward the posterior pole.

Snowflake degeneration - Typically will see larger floaters and cataracts associated with them and can lead to retinal breaks, detachments, and neovascularization but usually you just watch it, it is benign.

9. Select the false statement regarding chorodial nevi

Chorodial nevi will not cause a visual dysfunction a majority of the time but it can lead to a decrease in vision if there is compression of the choriocapillaris. That will lead to RPE and Photoreceptor degeneration.

They are benign neoplasms of melanocytes in the outer layers of the choroid that are found in 5-10% of the general population.

They can be measured with a B-scan

When you find them you should refer the pt to their PCP in order to get the following tests: CBC, Liver enzyme panel, CT or ultrasound of the abdomen/liver.

The most common site of chorodial melanoma metastasis is the liver.

Explanation

The most common site of chorodial melanoma metastasis is the liver.

10. Select the false statement regarding congenital Hypertrophy of the RPE.

Lacunae usually cause the visual field defect if the CHRPE is in the posterior pole. Similar as the nevi because you have damage or drop out of the RPE, damage to the choriocapillaris which can give you a visual field defect.

Grouped CHRPE lack lacunae, are typically smaller and be referred to as bear tracks

Multiple CHRPE is associated with Familial; Adenomatous Polyps and come in various sizes and shapes.

When you evaluate CHRPEs, if you look at it with fundus lens in the periphery, a lot of the time you will see floaters, vitreal condensation over the area which indicates an inflammatory event that happened around there which is an indication of CHRPE. Because of the condensation over that area the pt is at risk of retinal breaks so they need to be watched.

Chorio-retinal Scar
Looks like CHRPE with lacunae but will be more irregular. If you look at it with fundus lens in the periphery, a lot of the time you will see floaters, vitreal condensation over the area which indicates an inflammatory event that happened around there which is an indication of chorio-retinal scar. Because of the condensation over that area the pt is at risk of retinal breaks so they need to be watched.

Explanation

Chorio-retinal Scar
Looks like CHRPE with lacunae but will be more irregular. If you look at it with fundus lens in the periphery, a lot of the time you will see floaters, vitreal condensation over the area which indicates an inflammatory event that happened around there which is an indication of chorio-retinal scar. Because of the condensation over that area the pt is at risk of retinal breaks so they need to be watched.