Ocular Neoplasia Bumps in, on, and behind the eye Daniel M. Dorbandt, DVM Ophthalmology Resident University of Illinois Urbana-Champaign Topic Outline & Objectives Ocular & periocular masses Eyelids 3 rd eyelid Cornea & sclera Uvea Orbit Exophthalmos vs buphthalmos Differential diagnoses Suggestive findings Treatment options Feline-specific ocular masses Early Detection and Treatment is Key 1
Early Detection and Treatment is Key One month later Dogs Meibomian gland adenoma - Minimally invasive - 85-90% are benign - Low rate of metastasis - Responsive to therapy - Cryotherapy or surgery Melanoma Cats - Majority are malignant - If it s important enough to remove, it s important enough to submit. 2
Meibomian gland neoplasia - Located on eyelid margin Meibomian gland neoplasia - Continued monitoring - Surgical excision or cryo Meibomian gland neoplasia - Surgical excision - 10% recurrence House resection From: Slatter s Fundamentals of Veterinary Ophthalmology 5 th Edition Limits of surgical excision - Affects less than 33% of lid length - Exception in longer lids 3
Meibomian gland neoplasia - Surgical excision - 10% recurrence H-plasty From: Slatter s Fundamentals of Veterinary Ophthalmology 5 th Edition Meibomian gland neoplasia - Debulk and cryotherapy - 15% recurrence Papilloma Squamous papilloma - Cauliflower-like appearance 4
Papilloma Squamous papilloma - Similar therapy & prognosis as meibomian gland tumors Papilloma Squamous papilloma cryotherapy - Surgical resection or debulking with cryotherapy Histiocytoma - Young dogs - Tan to pink, alopecic mass - Spontaneous regression - Surgical resection or cryo BERNESE MOUNTAIN DOG = BAD 5
Melanoma - Darkly pigmented, smooth - Possible to be on lid margin Melanoma - Surgical resection or cryo - Prognosis is good (metastasize?) Mast cell tumor - Comes and goes - Mast cells on cytology Photo courtesy of Dr. Anne Barger 6
Mast cell tumor - Surgical resection is best - Intralesional triamcinolone - Exenteration with rotational skin graft - 1 mg triamcinolone diluted in 1 ml 0.45% NaCl may recur Triamcinolone causes apoptosis Hypotonic saline causes lysis Cutaneous lymphoma - Locally extensive, irregular - Often ulcerated Diagnosis - Often requires biopsy vs cytology - Rule out auto-immune skin disease Cutaneous lymphoma - Surgery (reconstructive) if focal - Medical if metastatic 7
Impacted meibomian gland - Lance and extrude material - Neo/poly/dex ointment BID-TID - Prolapsed gland - Everted cartilage - Follicular hyperplasia 3 rd - Signalment can help determine the diagnosis Adenoma Adenocarcinoma - Prolapsed gland - Everted cartilage - Follicular hyperplasia 3 rd - Older dogs - Progressively growing mass - Multilobular appearance - Entire 3 rd eyelid visible - May have exophthalmos 8
Adenoma Adenocarcinoma - Prolapsed gland - Everted cartilage - Follicular hyperplasia 3 rd - Complete surgical excision - Prognosis good 3 rd Eyelid Surgical Resection 1 2 3 3 rd eyelid adenoma Prolapsed gland - Everted cartilage - Follicular hyperplasia 3 rd - Young to middle-aged Bulldog or Cocker Spaniel - Smooth appearance - Sometimes inflamed - 3 rd eyelid may not be visible 9
Prolapsed gland - Everted cartilage - Follicular hyperplasia 3 rd - Pocket technique to replace - Orbital rim tacking Prolapsed gland - Everted cartilage - Follicular hyperplasia 3 rd - Pocket technique to replace - Orbital rim tacking - Prolapsed gland Everted cartilage - Follicular hyperplasia 3 rd - Large breeds Great Dane - See smooth bend in cartilage - Monitor purely cosmetic - Thermocoagulation 10
- Prolapsed gland - Everted cartilage Follicular hyperplasia 3 rd - Pale multifocal masses - Often present on bulbar surface (grasp & invert eyelid) 3 rd - DO NOT remove the 3 rd eyelid unless necessary Prolapsed gland of the 3 rd eyelid Smooth appearance 3 rd eyelid not visible Adenoma of the 3 rd eyelid gland Lobular appearance 3 rd eyelid entirely visible 3 rd - DO NOT remove the 3 rd eyelid unless necessary Prolapsed gland and deep stromal ulcers Conjunctival flaps 11
Corneal & Scleral Masses - Limbal melanocytoma - Dermoid - Nodular episcleritis - Pannus (superficial chronic keratitis) - Granulation tissue - Iris prolapse Corneal & Scleral Masses Limbal melanocytoma - Dermoid - Nodular episcleritis - Pannus (superficial chronic keratitis) - Granulation tissue - Iris prolapse - Located at limbus - Corneal degeneration - Debulk and cryotherapy - Enucleation if problematic Corneal & Scleral Masses - Limbal melanocytoma Hemangiosarcoma - Dermoid - Nodular episcleritis - Pannus (superficial chronic keratitis) - Granulation tissue - Iris prolapse - Very vascular - Resection with cryotherapy - Enucleation (may be metastatic) 12
Corneal & Scleral Masses - Limbal melanocytoma Dermoid - Nodular episcleritis - Pannus (superficial chronic keratitis) - Granulation tissue - Iris prolapse - Present since birth - Hair protruding from mass - Surgical resection - Due to corneal irritation Corneal & Scleral Masses - Limbal melanocytoma - Dermoid Nodular episcleritis - Pannus (superficial chronic keratitis) - Granulation tissue - Iris prolapse - Smooth, raised, red mass - Adjacent corneal edema Corneal & Scleral Masses - Limbal melanocytoma - Dermoid Nodular episcleritis - Pannus (superficial chronic keratitis) - Granulation tissue - Iris prolapse - Topical therapy - Cyclosporine or tacrolimus - 0.1% dexamethasone - Systemic prednisone - Try topical first 13
Corneal & Scleral Masses - Limbal melanocytoma - Dermoid - Nodular episcleritis Pannus (superficial chronic keratitis) - Granulation tissue - Iris prolapse - German Shepherds - Cyclosporine or tacrolimus Corneal & Scleral Masses - Limbal melanocytoma - Dermoid - Nodular episcleritis - Pannus (superficial chronic keratitis) Granulation tissue - Iris prolapse Chronic entropion - Topical therapy - Cyclosporine or tacrolimus - Dexamethasone 4 weeks later Corneal & Scleral Masses - Limbal melanocytoma - Dermoid - Nodular episcleritis - Pannus (superficial chronic keratitis) - Granulation tissue Iris prolapse - Known trauma - Currently treating ulcer - Anterior synechia - Associated corneal edema - Surgical stabilization (best) - Medical management - Topical Ofloxacin - Systemic antibiotics - Systemic NSAIDs - +/- tarsorrhaphy 14
- Iridal - Choroidal - Ciliary body neoplasia - Uveal cysts Uveal Masses Melanoma - Iridal - Choroidal - Ciliary body neoplasia - Uveal cysts Uveal Masses - Darkly pigmented & raised - Dyscoria Uveal Masses Melanoma - Iridal - Choroidal - Ciliary body neoplasia - Uveal cysts Cataract formation from touching lens - Enucleation (uveitis, glaucoma) - Laser photocoagulation - Unreliable if not small Uveal melanoma contacting lens 15
- Iridal - Choroidal Ciliary body neoplasia - Uveal cysts Uveal Masses - Pink or red in color - Located behind iris - May be displacing lens - Iridal - Choroidal Ciliary body neoplasia - Uveal cysts Uveal Masses - Enucleation (uveitis, glaucoma) - Cryotherapy - Unpredictable - Iridal - Choroidal - Ciliary body neoplasia Lymphoma - Uveal cysts Uveal Masses - Frequently have uveitis - Lymphadenomegaly - Topical corticosteroids - Systemic corticosteroids - Systemic chemotherapy 16
- Iridal - Choroidal - Ciliary body neoplasia Uveal cysts Uveal Masses - Transilluminate easily - Smooth and round - Free-floating or narrow base - Iridal - Choroidal - Ciliary body neoplasia Uveal cysts Uveal Masses - Typically none needed - Diode laser photocoagulation if obscuring vision - If present in Golden Retriever, may be suggestive of Golden Retriever/pigmentary uveitis - Often results in of 2º glaucoma - Metastatic Neoplasia - Nasal adenocarcinoma - Squamous cell carcinoma - Primary Orbital Neoplasia - Any tissue origin - Abscess - Foreign body - Tooth root abscess Orbital Masses 17
Metastatic Neoplasia - Nasal adenocarcinoma - Squamous cell carcinoma - Primary Orbital Neoplasia - Any tissue origin - Abscess - Foreign body - Tooth root abscess Orbital Masses - Chronic & slowly progressive - Typically non-painful - +/- decreased nasal air flow - Generous ointment if keratitis is present - Enucleation or exenteration for palliation Orbital Masses - Metastatic Neoplasia - Nasal adenocarcinoma - Squamous cell carcinoma Primary Orbital Neoplasia - Any tissue origin - Abscess - Foreign body - Tooth root abscess - Chronic & slowly progressive - Typically non-painful 3 rd eyelid gland adenoma - Metastatic Neoplasia - Nasal adenocarcinoma - Squamous cell carcinoma - Primary Orbital Neoplasia - Any tissue origin Abscess - Foreign body - Tooth root abscess - Acute and often painful - Rapid response to therapy Orbital Masses 18
Orbital Masses - Metastatic Neoplasia - Nasal adenocarcinoma - Squamous cell carcinoma - Primary Orbital Neoplasia - Any tissue origin Abscess - Foreign body - Tooth root abscess Orbital Abscess 2 weeks after therapy - Clavamox or Simplecef x 3-4 weeks - Systemic NSAID x 2-3 weeks Exophthalmos vs Buphthalmos Exophthalmos - Cause by an orbital mass - Abscess, neoplasia, mucocele - Typically maintain vision - Decreased retropulsion - Globes are same size Exophthalmos Buphthalmos - Caused by chronic glaucoma - Blind & lose light perception - Typically have normal or near-normal retropulsion - Globes are different sizes Buphthalmos Specific Feline Masses - Cornea - Eosinophilic keratitis - Uvea (possibly amelanotic) - Uveal cysts 19
Feline Eosinophilic Keratoconjunctivitis - Eosinophils on cytology - Roughened, pink to white corneoconjunctival mass - Topical 0.2-2% cyclosporine or 0.02% tacrolimus - Topical corticosteroids - ± Megestrol acetate - 5 mg/kg q24 hrs x 1 week Then 2.5 mg/kg q24 hrs x 1 week. Then 2.5 mg/kg q48 hours x 1 week http://eyemicrobiology.upmc.com Feline Uveal Melanoma - Darkly pigmented, raised, velvety lesion - Dyscoria - Benign melanosis tends to be bronze, flat, and does not distort iris architecture - Monitoring every 3-4 months - Laser photocoagulation - Enucleation - Especially with uveitis or 2º glaucoma Feline Uveal Cysts - Often darkly pigmented - Different than in dogs - Smooth - None needed 20
Iridal Lymphoma - Smooth, pink iridal mass - Topical corticosteroids - Systemic corticosteroids - Systemic chemotherapy - Enucleation if 2º glaucoma QUESTIONS? E-mail: dorbandt@illinois.edu 21