 Our next presenter is Jack Lee. He's a fourth year medical student coming from Texas A&M, and he's going to present the dark side of the iris. All right. Good morning. My name is Jack Lee, fourth year medical student from Texas A&M. Today I have a clinical case. So thank you for your attention. And the title of the presentation is the Dark Side of the Iris. We have a 30-year-old Caucasian male who was referred for red and comfortable left eye. This has been going on for about nine months. And we saw him, he did not complain of any pain or changes in vision. On review of his history, he did not really have any ocular history, trauma, or surgery. His past medical history includes diabetes, hypertension, reflux, depression. His allergies and medications are listed above. On social history, he is a moderate alcohol user in a restaurant tour. Examination, his vision, pressures, pupil, visual, fields, extracular movements and alignments, and funds exam are all normal. And slit-lamp examination of the left eye is presented in the next slide. So this is an external photograph of his left eye, the eye that he's complaining of redness. I'll go through a little bit of what I see, but if anybody has other comments, which should be helpful, if you're good for my education, it's out of battery. You can use the app. OK. So when I look at this, what I see is immediately I see here. This is a, I see a lesion here, a dark lesion, at approximately 6.30 to 8 o'clock. And I think this looks like a masked lesion because I see this is actually changing the shape of the pupil here. On slit-lamp exam, slit-beam examination, we see that this is, this appears to be a 3D lesion, which seems to be protruding out into the anterior chamber. On a more magnified photo, we get more detail of the anterior surface of this lesion. On this photo, on the left photo here, we see that this is a, this appears to be a dark, opaque, melanocytic lesion. And I think also interestingly if you see that the shadow here by the beam also demonstrates that this is a 3D lesion which protrudes out. Gonioscopy was also performed on this patient. And here we see the lesion, we see the same lesion here from a different view. And it appears to be some angle involvement with this lesion. So to help me understand Irish tumors, I simplify it down. Irish tumors are typically divided into cystic or solid. Solid tumors are comprised of a majority, at approximately 80% of Irish tumors. Here I want to share some photos of what a cystic tumor looks like. On photo F, we see this is a bubble-like lesion. Typically cysts could be fluid-filled, bubble-like, smooth, and often translucent. D and E shows very well the fluid-filled nature of these lesions. And F shows the smooth, translucent bubble shape. This, now these photos, I present these photos to contrast with our photo because ours does not look anything like a cyst. And ultrasound biomilacroscopy was also performed on our patient to further elucidate the internal structure of this lesion. Here on ultrasound, we see here's the cornea. And the contralateral iris demonstrates a more normal architecture of the iris. And here we see the lesion. What I see is, this appears to be a solid lesion which involves the entire stroma of the iris. And here it's a little bit faint, but on a higher quality on the machine, we can see that this posterior border of the lesion actually extends behind the iris. I don't know if Dr. Harry has anything to add on this image. I already can't see the sorority body here on this view. Do you have other images that show the sorority body at all? No, this is the only view I have. And so, based on the UBM and our clinical examination, this looks, appears to be more of a solid tumor. Solid tumors are broadly divided into melanocytic and non-melanocytic. Dark lesions or melanocytic lesions comprise the majority of the lesions. And based on our clinical photo, this appears to be more of a melanocytic lesion. And the most common differential from melanocytic lesions are iris nevi, melanoma, and melanocytoma. And here I want to show some photos of what these individual lesions may look like. A nevi is one of the benign lesions of the iris. These are localized proliferation melanocytic cells that generally appears darkly pigmented lesions in the iris stroma. Importantly, the nevi does not extend beyond one millimeter into the iris stroma, or typically they do not. The most important thing is that, histopathologically, there's no cellular atypia and no significant increase in metade activity. Second differential, the dark pigmented lesion, is the melanocytoma. Some would say that melanocytoma is really just a really specialized kind of iris nevis, but importantly, this is another benign lesion of the iris, meaning that there would not be cellular atypia or greatly increased metade activity. These are typically dark browns with black dome-shaped masses. And on examination, they have a granular and the classic descriptions mound of black sand appearance. The surface could be cobblestone appearance or smooth. And iris melanoma is the true malignant lesion of the iris. Characteristics of the iris melanoma are, they are typically located in the inferior quadrant. They could, on average, they invade about 2.5 millimeters into the iris. They are associated with correctotopia, ectropion UVI, hythema glaucoma, and extraocular extension. In our case, what kind of points us towards more of a malignant lesion is that there's a rapid growth of this lesion. The patient did notice this within the past nine months. It's located in the inferior location and this appears to involve the entire thickness of the iris. So a little information about UVI melanomas. It is the most common primary intraocular malignancy. UVI melanomas comprise about 5% of all melanomas, approximately 5.1 cases per million occurred in the United States. Among these melanomas, only about 3% of the UVI melanomas are located in the iris. So this is a rare lesion. Iris melanomas are most commonly occur in men, especially among Caucasians. Risk factors are UBV exposure, light skin, light color, inability to tan. So very similar to a skin melanoma, antiplasic needed syndrome. Also saw the welding was a risk as well. The presentation could be pretty nonspecific, which include blurred vision, simple topsy of floaters, visual field reduction, or simply a visible tumor. However, some cases could also be asymptomatic. Diagnosis could be made by looking at the lesion with the slit lamp examination. However, further characterization with imaging modalities such as UBM or OCT could also be used, such as in this case to provide more information. So in terms of imaging, which is better, UBM or OCT, many centers have capabilities for both. In a series of looking at 200 eyes, confirmed cases of iris lesions, it was found that UBM provided much better resolution of the internal structure and the posterior border of this of iris lesion, especially among pigmented lesions. One example I want to draw attention to is this here. This is iris tullary melanoma. And this is a good example because this actually looks quite like our lesion here. You can see that with UBM, we have good internal structure, good illustration of the internal structure of this lesion, as well as clear delineation of the posterior border. The same lesion image with OCT, with OCT we lost the internal structure and the posterior border. And so the conclusion would be that for an iris lesion, especially pigmented one, OCT would give us much more information. And here I just wanted to show that the UBM here, in fact, for this patient, in fact, does show us good information about the internal structure and the posterior border. So what are some ways that iris lesions or iris melanoma could be treated? Typically, the treatment is divided into surgery or radiation. Specifically, which treatment is highly individualized and depends on location of the lesion, depth of invasion, size of the lesion, and patient preference. Some things I would point towards a surgical resection often is if the lesion is in a place that surgery can easily reach. Brachytherapy can deliver localized radiation and a radio plaque is sewn under the conjunctiva. Proton beam irradiation could be used to treat UV melanoma, which are located more posteriorly. And nucleation is a bit of a last resort in eyes in which the tumor is too big or radiation would destroy the vision. And prognosis, what is the prognosis for our patient? And patients who are between 21 to 60 years old his risk of metastasis at 10 years is just under 8% and risk of death at 10 years is about under 3%. And this is, so actually pretty high. In pathology lab, Dr. Mellon, whenever we see a tumor, he would say beware the yellow man with a glass eye. So the most common location of metastasis is the liver. So in a patient who has some distant history of eye surgery and presenting with painless jaundice, something to consider is could this patient have had a melanoma in the distant past. Factors that are predictive of metastasis is presence of glaucoma ed diagnosis, extraocular extension angle seating and factors predictive of death is the depth of invasion of the lesion. And these statistics are actually more for the UV melanoma in general than specifically iris. And so actually the risk of death is lower in iris melanomas than UV melanomas in general. I elevated intraocular pressure. And I'd like to thank Bikes Lynn and the neuro team, my preceptors for putting up with medical students and thank Miko for helping me go through the presentation. Yeah, that's it.