The breadth of pathology within the scope of ocular oncology spans all ocular, orbital, and adnexal struc¬tures. As such, the clinical assessment of patients must be accordingly comprehensive and tailored for the detec¬tion and surveillance of neoplastic processes. While the essential modalities of standard ophthalmic examination are utilized in the practice of ocular oncology, a nuanced perspective is necessary to optimize management for this subset of patients. In this chapter, we present the system¬atic approach to clinical examination employed at The New York Eye Cancer Center as a basis for the assessment of patients in ophthalmic oncology practice.
Chapter Keyword: ultrasound
Multimodality Imaging of Intraocular Tumors
Ophthalmology and ophthalmic oncology are blessed with excellent intraocular imaging modalities.1-4 Tradi-tionally, we had slit-lamp examination, gonioscopy, and direct and indirect ophthalmoscopy (see Chapter 3). However, these techniques did not provide a recorded image and thus required both observational and recol-lection skills utilized over relatively short observational periods. Clearly, what we observe and recollect is pro-cessed to determine the diagnosis and condition of the eye. It is no wonder that ophthalmology quickly added photographic imaging to anterior and posterior segment examinations.
Photography not only provided a “snapshot” of the patient’s condition at a specific time but also allowed specialists to take more time to observe the ocular con¬dition without the previously required cooperation of the patient. Such “snapshot” photographic images document the patient’s condition at one specific time, allowing for side-by-side comparisons with future or past images to assess change. For example, in ophthalmic oncology, we may use side-by-side imaging to monitor for tumor growth, increased SRF, or the presence of radiation side effects. Then, more complex ophthalmic imaging systems evolved. Angiographic (e.g., fluorescein [FA], indocyanine green [ICGA]) imaging is utilized to assess differences in tumor circulation, patterns of regression, and treatment-related side effects.5,6 Ultrasound imaging allows eye specialists to “see” within eyes with opaque media, evaluate mass lesions for internal reflectivity, and measure tumors prior to treatment. In addition, ultrasonography offers a method to measure intraocu¬lar neoplasms as well as reveal their internal reflectivity and interstitial extent. Three-dimensional ultrasound made a brief appearance in ophthalmology and offered interactive computerized reconstructions also like com¬puterized radiographic imaging (e.g., MRI and CT). More recently, optical coherence tomography (OCT) with and without angiography uses laser-based imag¬ing to create 2-D slices and 3-D reconstructions such as those previously limited to computerized radiographic imaging.7
However, multimodality imaging is what eye cancer specialists use to achieve a clinical diagnosis so accurate it is often used instead of pathology. For example, it is the low-lying, yellow tumor with scalloped edges com¬bined with slow fluorescein uptake and internal acoustic reflectivity so high that it shadows the orbit which makes the clinical diagnosis of choroidal osteoma. Herein, we describe the use of ophthalmic imaging techniques to diagnose intraocular tumors. The process of diagnosis is dependent upon visible tumor characteristics as well as those that can only be uncovered with multiple ophthal¬mic imaging techniques (Mind map 4-1 and 4-2).