Cataract Extraction after Melanoma Tx

[KHE]

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Last summer, I had a 37 year old woman in the office for a routine contact lens exam. Unfortunately, a malignant melanoma was also found. The melanoma fit the COMS criteria as being "small" though it was definately on the large end of small.

She was treated by a local retinal surgeon with laser which was giving promising results up until the time that she devolped a BRVO. Since the surgeon couldn't see the tumor to continue the laser treatments, he had to wait until the bleeding resolved. He did start her on lucentis injections.

Fast forward a few months and now of course she has a massive cataract which was removed successfully by a local surgeon.

Would this patient be MORE or LESS likely to develop CME after cataract extraction?

What role, if any would the lucentis injections play in the development or hinderance of CME in a patient like this?

 

[MR1]

First off, maybe I am not informed enough about melanomas since all of ours go to a ocular oncologist for treatment but I didn't think anyone was just treating melanomas with laser. I thought the standard was plaque brachytherapy. I know laser has been tried but thought it was experimental and if a "local" retina guy is doing it that just doesn't seem to jive.

Second, I know with retinoblastoma there is a "seeding" risk with sticking needles in the eye, I don't know about melanomas but doing intravitrael injections with a ocular tumor just worries me. Same goes with removing the cataract.

Third, why did she get a cataract from Lucentis, you see that more with steroid injections.

Lastly, we know if there is DME and you do cataract surgery there is a risk of making it worse, you need the DME dry first. I don't know of any specific studies with vein occlusions and cataract surgery but imagine it would be similar. The anti-VEGF should help hinder the CME though.

 

[KHE]

First off, maybe I am not informed enough about melanomas since all of ours go to a ocular oncologist for treatment but I didn't think anyone was just treating melanomas with laser. I thought the standard was plaque brachytherapy. I know laser has been tried but thought it was experimental and if a "local" retina guy is doing it that just doesn't seem to jive.

Well, I'm lucky because I practice in Connecticut so my "local" retina guy was one of the principle investigators in COMS and former director of the ocular oncology service at USC. My recollection also is that plaque therapy is the standard for "medium" sized melanomas and this patients tumor did not meet that criterion.

Second, I know with retinoblastoma there is a "seeding" risk with sticking needles in the eye, I don't know about melanomas but doing intravitrael injections with a ocular tumor just worries me. Same goes with removing the cataract.

Well the reason for removal of the cataract was not just the vision but so that the tumor could continue to be treated and monitored.

Third, why did she get a cataract from Lucentis, you see that more with steroid injections.

Don't know.

Lastly, we know if there is DME and you do cataract surgery there is a risk of making it worse, you need the DME dry first. I don't know of any specific studies with vein occlusions and cataract surgery but imagine it would be similar. The anti-VEGF should help hinder the CME though.

So then it seems to me that you're saying that the lucentis injections should DECREASE the probability that this patient would develop CME.

 

[7ontheline]

I'm going to take a wild leap of faith and say that there are very few randomized, double-blind studies regarding patients with simultaneous BRVOs, ocular melanomas, and Lucentis injections.

So. . .based on nothing scientific, I would imagine that CME is more likely than average in this patient. Anyone who has had a BRVO already as well as other retinal pathology just seems like someone more likely to have CME. I am NOT a retinal specialist, so feel free to ignore me.

Edit: Why does this matter? She clearly needed the cataract surgery due to the tumor, so if she develops CME you treat it. Other than using a topical NSAID, I can't think of any other interventions you would take to prevent the possible CME anyway.

 

[MR1]

Kinda just missed the small part. Makes more sense now.

Anyway, yes anti-VEGF in theory helps with CME, to my knowledge no RCT has been done but just a bunch of prospective stuff.

Agree with above about risk of CME with BRVO and melanoma after cataract surgery. Who knows exactly but bet you BRVO by itself, if the edema isn't dry, makes CME more likely after surgery.

Lastly hopefully the retina guy is on top of this possibility and is following closely

 

[Jokestr]

I don't see anyone talking about CME related to the BRVO....
BRVO generally speaking would be more likely to cause CME than cataract surgery. So the CME should be a concern, but more because of the BRVO.

Treatment for BRVO related CME based on past studies would have been grid laser, but with the recent release of the large steroid studies it could also be treated with intravitreal steroids. (SEE BVOS and SCORE studies) There are a few small studies and case studies with relation to VEGF inhibitors and and CME(BRVO or Cataract) and although the results seem to be good, to my knowledge there has yet to be a large scale prospective double blind randomized control trial etc.

As for sticking a needle in the eye of those with tumors, there are studies already published doing/having done this. Don't know if there are specific melanoma studies but logically think there could be some correlation.

Done correctly, one should not develop a cataract from intravitreal VEGF inh injections...As mentioned above, steroid injections could contribute...Also, depending on tumor growth, vitreous heme, age etc there may have been other factors not mentioned here contributing to the development of the cataract and need for extraction.

Seems like forward thinking was done on this...cool case.

 

[MR1]

Yeah I agree, any CME that develops would probably be more due to the BRVO than cataract surgery. Like with DME though, if there is still edema present and you do cataract surgery, the risk of making the DME is higher. Would assume this is the case with BRVO's if there is CME present.

 

[MstaKing10]

How about the risk of seeding tumor by doing intra-ocular surgery? Is that a concern? Seems like this would trump the CME debate.

 

[KHE]

Edit: Why does this matter? She clearly needed the cataract surgery due to the tumor, so if she develops CME you treat it. Other than using a topical NSAID, I can't think of any other interventions you would take to prevent the possible CME anyway.

No reason. It was merely an academic exercise.

The patient was seen in my office this morning 7 days post op. Good result. 20/25 corrected to 20/20 with low refractive error.

This was also my first opportunity to see the tumor since last summer and it is definately much smaller and much flatter. She was only ever able to undergo two out of the three planned laser treatments before the BRVO stopped the process.

 

[KHE]

How about the risk of seeding tumor by doing intra-ocular surgery? Is that a concern? Seems like this would trump the CME debate.

Again, I did not mean to stir a debate. This was merely an academic question.

 

[Mirror Form]

How about the risk of seeding tumor by doing intra-ocular surgery? Is that a concern? Seems like this would trump the CME debate.

I think you are jumping to conclusions b/c of the term "melanoma." This patient's lesion has not been biopsied and found to be malignant. The term melanom here is simply being used based on tumor size and possibly a few non-specific characteristics (which you cannot hang your hat on). This patient's "small" melanoma is most likely a benign nevus.

Of course seeding is always a concern, but it's mainly in issue with specific tumors like retinoblastoma. Since you'd have to be crazy to enucleate (or radiate) a seeing eye with a small melanoma, you have to remove the cataract in order to monitor it.

 

[MullerCell]

I imagine that this patient was treated with TTT. Laser isn’t commonly used and older studies showed poor results. A biopsy is not required to diagnose a choroidal melanoma, is rarely needed, and often provides inadequate information unless performed by very experienced hands. Differentiating between a small melanoma and a high risk atypical nevus is essentially semantics and different people will have a different threshold to treat. Good echography and clinical exam is enough to make a very accurate diagnosis the vast majority of the time if there is sufficient elevation of the lesion. Performing an Avastin injection is common as treatment of radiation retinopathy following I-125 brachytherapy of choroidal melanomas and works well. The tumor is dead after treatment, and there is almost no risk of seeding the needle tract (this is definitely different from retinoblastoma). As far as the CME after CE/IOL, I imagine that anyone with a BRVO is at slightly increased risk. It is odd that they used off label Lucentis, this would cost the patient an arm and a leg. Avastin works well and I've seen a few resistant cases of macular edema from a BRVO respond really well to Ozurdex and it is covered by insurance. The SCORE data isn’t great, and once you given a patient steroid induced glaucoma that requires a trab, then a tube you will think twice about IVK, especially the 4mg dose.

 

[Visionary]

I agree with most of what has been stated.

I would not second-guess the diagnosis. With the appropriate clinical exam and imaging (B-scan, OCT, angiography), a nevus can usually be discriminated from melanoma. This tumor was most likely treated with TTT (trans-pupillary thermal therapy), which uses repeated thermal laser treatments to obliterate the tumor. It's good for smaller tumors, particularly if they are in difficult locations (e.g., peripapillary).

Unfortunately, collateral damage, such as BRAO/BRVO, is common, because of the destructive nature of TTT. I suspect this patient's BRVO was actually a consequence of the TTT. I would have used Avastin, as I would expect a considerable amount of associated ischemia in this scenario and, therefore, high levels of VEGF.

I do still use triamcinolone acetonide (2 mg dose only) for CME in non-ischemic BRVO and for diffuse DME (unless associated with extensive peripheral ischemia), as the anti-inflammatory effect is greater. Inflammation is a known player in these processes. I have had good results without significant side effects at this dose. SCORE did demonstrate good results, with dose-dependent side effects (i.e., lower for the 1 mg dose). BRAVO showed good results for Lucentis in BRVO, but it was not compared to standard of care (i.e., observation +/- grid laser), as triamcinolone acetonide was in SCORE. I've avoided Ozurdex, as the 22 gauge needle looks barbaric compared to the 30 gauge used for other office-based intravitreal injections. Heck, it's larger than some vitrectomy trocars! If the results and duration of action were A LOT better than triamcinolone acetonide, I would consider it. Fact is, they aren't. I'll stick with my 30 gauge needle, thanks.

As for the cataract, the rate of progression wasn't given. Was there any significant cataract prior to the treatment of the tumor? It could have just progressed naturally. Perhaps the retina doc felt the TTT wasn't having as good an effect, so he wanted the cataract out. Maybe there were some steroid injections given that we weren't aware of. I wouldn't assume it was the result of injection- or laser-induced injury. With melanoma, there should not be a problem with tumor seeding with intraocular surgery or intravitreal injection. Such procedures are common in melanoma patients.

Regarding post-cataract CME, this patient would surely be at higher risk. Any patient with a history of macular edema will have a greater likelihood of recurrent edema after intraocular surgery. The fact remains that the cataract needed to come out. Treat the CME as needed.

 

[KHE]

The term melanom here is simply being used based on tumor size and possibly a few non-specific characteristics (which you cannot hang your hat on). This patient's "small" melanoma is most likely a benign nevus.

I'm not sure what you're basing that on.

This patient has been seen in my office yearly for a number of years and dilated on a regular basis including last year at which time the lesion was not present.

This is a nearly 4 disc diameter lesion with obvious elevation which was not present 12 months ago and with a nearly 3mm height at it's apex confirmed on ultrasound and examined by a retinal surgeon with nearly 30 years in practice who happened to be a principal investigator in the COMS study and the former head of the ocular oncology service at Doheny who said "it's a melanoma."

If that's your definition of a "benign nevus" then more power to you.

 

[KHE]

I agree with most of what has been stated.

I would not second-guess the diagnosis. With the appropriate clinical exam and imaging (B-scan, OCT, angiography), a nevus can usually be discriminated from melanoma. This tumor was most likely treated with TTT (trans-pupillary thermal therapy), which uses repeated thermal laser treatments to obliterate the tumor. It's good for smaller tumors, particularly if they are in difficult locations (e.g., peripapillary).

Unfortunately, collateral damage, such as BRAO/BRVO, is common, because of the destructive nature of TTT. I suspect this patient's BRVO was actually a consequence of the TTT. I would have used Avastin, as I would expect a considerable amount of associated ischemia in this scenario and, therefore, high levels of VEGF.

This is exactly what happened.

I do still use triamcinolone acetonide (2 mg dose only) for CME in non-ischemic BRVO and for diffuse DME (unless associated with extensive peripheral ischemia), as the anti-inflammatory effect is greater. Inflammation is a known player in these processes. I have had good results without significant side effects at this dose. SCORE did demonstrate good results, with dose-dependent side effects (i.e., lower for the 1 mg dose). BRAVO showed good results for Lucentis in BRVO, but it was not compared to standard of care (i.e., observation +/- grid laser), as triamcinolone acetonide was in SCORE.

There has been a lot of discussion on this thread about CME after BRVO. That's obviously important but this particular patient did not have any CME following the BRVO.

As for the cataract, the rate of progression wasn't given. Was there any significant cataract prior to the treatment of the tumor? It could have just progressed naturally. Perhaps the retina doc felt the TTT wasn't having as good an effect, so he wanted the cataract out. Maybe there were some steroid injections given that we weren't aware of. I wouldn't assume it was the result of injection- or laser-induced injury. With melanoma, there should not be a problem with tumor seeding with intraocular surgery or intravitreal injection. Such procedures are common in melanoma patients.

I do not know if any steroid injections were given to this patient. She said "no" but obviously may not be correct. The catarct progressed very rapidly. She had no cataract before the diagnosis. This was a healthy 38 year old woman.

As far as seeding goes, that's waaay outside the area of my expertise. My recollection was that seeding was only a significant concern with retinoblastoma as compared to melanoma and even then, only significant in endophytic retinoblastoma.

Regarding post-cataract CME, this patient would surely be at higher risk. Any patient with a history of macular edema will have a greater likelihood of recurrent edema after intraocular surgery. The fact remains that the cataract needed to come out. Treat the CME as needed.

So far, the patient has not developed any CME and has no history of CME, even after the BRVO. My reason for starting this thread was simply to ask that question.....would a patient with this history be MORE or LESS likely to develop CME following cataract extraction and to ask what people thought the role, if any, the previous anti-VEGF therapy would have on the possible formation of CME. Thank you Visionary for your opinion.

 

[MR1]

KHE, very interesting patient by the way. So she never had CME, I guess I didn't realize she got the Lucentis solely to clear up the hemorrhage from the BRVO, I guess the blood was obscuring the tumor.

Has anyone ever heard of using anti-VEGF for this purpose, it makes sense it would work though.

Finally I imagine it is nice having a retina guy close that can handle these. We don't see alot in residency because there is a local center close that specializes in them.

Also she does have 2 reasons for having a higher chance of developing CME now, post cataract and BRVO. I would probaby keep her on NSAIDs and steroids for longer than usual to try and prevent it, but hopefully the previous anti-VEGF should help prevent as well. There are some basic studies out where they injected right after cataract surgery in diabetics and seemed to get good results preventing macular edema.

 

[Visionary]

Thanks, KHE, for the clarification.

I've not used anti-VEGF for RVO, except in the case of secondary CME. Not sure what the rationale would be otherwise. You're putting the patient at risk, albeit small, of injection-related complications. I doubt that injections would help resolve hemorrhage more quickly, as suggested by MR1. Of course, no one has, or likely will, studied this specifically. If there was, however, neovascularization, that would be an indication.

As to the actual reason for your post (sorry!), if there has not been prior CME, I don't know that this scenario would necessarily make me worry about a higher risk of post-cataract CME. My concern would definitely be less, if the BRVO had already been present for weeks to months without CME. Another consideration is the location of the BRVO. If it's not macular, you don't need to worry about CME at all. I assume this patient's was. Regarding anti-VEGF therapy and CME, Lucentis is only effective for ~4 wks. Avastin is effective for ~6 wks. I suspect that cataract surgery performed outside the efficacy window of the last injection would carry the same risk of CME as that of an untreated patient. If performed within the efficacy window, there may be some protective effect. Of course, this hasn't been formally studied, to my knowledge.

 

[KHE]

If anyone is interested, I thought I would attach a photograph of what this patient's lesion looked like at the time of initial presentation last August.

 

[Visionary]

If anyone is interested, I thought I would attach a photograph of what this patient's lesion looked like at the time of initial presentation last August.

KHE, photo looks like superonasal OS. Is that correct? If the BRVO was also in that location, I definitely wouldn't worry about a higher risk of CME in the post-op period.

 

[KHE]

KHE, photo looks like superonasal OS. Is that correct? If the BRVO was also in that location, I definitely wouldn't worry about a higher risk of CME in the post-op period.

It's actually superotemperal OD. I've attached another photograph. The technician took a postior pole photograph initally and you can just see the edge of the tumor on the left side of the photograph.

 

[Visionary]

It's actually superotemperal OD. I've attached another photograph. The technician took a postior pole photograph initally and you can just see the edge of the tumor on the left side of the photograph.

Wow, good result then! It's only a few mm from the fovea. The TTT would overlap the tumor borders somewhat, so she may have a noticeable scotoma, but great central vision! Given that location, I imagine the BRVO was actually temporal to the macula. Still should not pose significant CME risk.

 

[Mirror Form]

I'm not sure what you're basing that on.

This patient has been seen in my office yearly for a number of years and dilated on a regular basis including last year at which time the lesion was not present.

This is a nearly 4 disc diameter lesion with obvious elevation which was not present 12 months ago and with a nearly 3mm height at it's apex confirmed on ultrasound and examined by a retinal surgeon with nearly 30 years in practice who happened to be a principal investigator in the COMS study and the former head of the ocular oncology service at Doheny who said "it's a melanoma."

If that's your definition of a "benign nevus" then more power to you.

Huh? I never said I disagreed with the treatment plan, or the opinion of the retina specialist. My only point was to explain the reason for cataract surgery. That is, the lesion is too low risk for aggressive therapy, but needs to at least be monitored.

In regard to the definition of a "benign nevus," Mueller stated it better that me. That is, the difference b/w a high risk nevus (which is still benign) and a small melanoma is semantics.

If we were for some reason to biopsy the lesion of a patient with a "small melanoma," it would most likely be benign. The COMS study didn't evalute treatment for "small melanomas" because they rarely progress (not sure off the top of my head, but I think about 10-15%). Therefore the standard of care is to observe. Now if this tumor is showing signficant growth and had other high risk characteristics, then relatively conservative treatment such as the TTT performed by your retina specialist seems reasonable.

 

[KHE]

Huh? I never said I disagreed with the treatment plan, or the opinion of the retina specialist. My only point was to explain the reason for cataract surgery. That is, the lesion is too low risk for aggressive therapy, but needs to at least be monitored.

This is your posting from earlier in the thread:

I think you are jumping to conclusions b/c of the term "melanoma." This patient's lesion has not been biopsied and found to be malignant. The term melanom here is simply being used based on tumor size and possibly a few non-specific characteristics (which you cannot hang your hat on). This patient's "small" melanoma is most likely a benign nevus.

I'm trying to understand on what basis you are saying that this case is a benign nevus. And I've posted the picture of it. That lesion was not present 12 months ago. Are you saying you would continue to observe that?

In regard to the definition of a "benign nevus," Mueller stated it better that me. That is, the difference b/w a high risk nevus (which is still benign) and a small melanoma is semantics.

I understand the semantics involved in that definition but I'm still trying to figure out on what basis you are saying that this is a benign nevus in this particular case.

 

[MullerCell]

I think that later in the discussion KHE stated that the lesion was nowhere to be seen and 12 months later was 3 mm elevated. It can be unclear if a lesion is an atypical nevus or small melanoma if you are evaluating at a single point in time, but this type of rapid growth makes it almost certainly a melanoma. A nevus can grow a very small amount on occasion, but not 3 mm in height in 1 year. With significant growth, I would call it a melanoma.

 

[Mirror Form]

I understand the semantics involved in that definition but I'm still trying to figure out on what basis you are saying that this is a benign nevus in this particular case.

It's not really that hard to understand. I was basing my earlier post off of your original post:

Last summer, I had a 37 year old woman in the office for a routine contact lens exam. Unfortunately, a malignant melanoma was also found. The melanoma fit the COMS criteria as being "small" though it was definately on the large end of small.

As you can see, there were no pictures and no mention of the rapid growth in that post. You posted all of that later. Sorry if I came across as questioning the treatment plan. That was not my intention. I was just explaining why cataract surgery was necessary.