 Well, I hope you guys read up on Lucalchoria. A little bit on Lucalchoria, which means what? My pupil from which language? The geek, of course. That's processing. It's getting better. So actually the lecture on Wednesday of Grand Rounds was really good because he talked a lot about some of the things we're going to talk about today. So that turned out to be very fortuitous that Grand Rounds was talking about tumors in kids, especially. So we're going back to the Grand T-tons, floating along the snag at the base of the Grand T-tons. And we have a close-up. So a table like... Climbs. Those things and so much. It's a little table, a lot of screws up to the top there for the grand. And here we go. This is as big a rapid as you get on this part of the snake. I mean, this is definitely calm. It's like sitting in your living room floating by a picture of the mountains. And believe it or not, this is Mount Moran. Named after the Moran Ice Center? No, not really. John Moran was a naturalist at the turn of the century. And so this is named after Moran, not John Moran. And there you can see the grand looking up through the trees. All right, so we're looking at a patient like this. This is a child. Mom notices something funny in the pupil. Maybe it's taking a picture. Maybe it's looking at what the eye is doing. And then we dilate the kid's eye and we see this picture right here. So this child had leukocorius. What I want to do is I want to talk about some of the entities that we have to think about when we think about leukocorius. Becca, he thought you could hide back there. We're doing that. We're going backwards today. He gets on your toes. Differential diagnosis of leukocoria. What's the first thing that comes to mind when you think of leukocoria? Retinoblastoma. Retinoblastoma. Tara. Do you have cataract? Cataract. General cataract. Fever. Fever. What does that stand for? I always use the abbreviations. So let me think of this. Familial exadata. Fissure retinol. All right. So on a list of 12 causes, that would be 13. But it's on the list. Very good, too. PHPV. PHPV. What does that stand for? It's a fetal vasculature. Yeah. Now it's called persistent fetal vasculature. It used to be called PHPV. So if you see that, persistent primary hyperplastic vitreous with PHPV here now, it's persistent fetal vasculature. P, F, B. Coast. Coast disease. Toxoplasmosis. Another type of maturity. Amen. Oh, OK. So that would be 28th on the list. It's a four. Yeah, now we're getting it happening now. So just a regular retinol detachment. Yeah, OK. This could be a retinol detachment. This used to be a little white. This could be a retinol detachment. The other one is very obscure one. Trust me, 13. Is this your sarcosis? Toxoplasmosis. Toxoplasmosis. What did I say? Toxoplasmosis. What did I say? Toxoplasma. Well, it could be a severe toxoplasma where there's just a whiteed-out macular scar. But that's uncommon. I meant plexocoriasis. Sorry about that. In those cat parasites and dog parasites, you can get mixed up. UVIs can get it, too. UVIs chronically or anything like that. So we're looking at a person that's saying we look at that when we come around. All right, back out again. What are we seeing right here? I'm not sure exactly what we are looking at here. There's a large growth of some sort. Fairly white, yellowish, a little bit. I don't even know what this picture is of. I'm sorry. Is this the retina? This is a dilated retina. Unfortunately, this is in the posterior pole. It's kind of obscuring the macular and the optic nerve. Let's pretend this was a bad patient. This is in the days when we did a nucleation. You nucleated the eye. We cut it in half-saturately. We see this growth right here. That's not just reflux from the camera. That's all white, little white speckles all over the place. What would you be thinking about here? It's like maybe calcium deposits. Okay. And what are these entities? It has calcium in it. So retinoblastoma. One of the things that we use to help us discern retinoblastoma from these other lesions is calcification. So if you put an ultrasound on here. Now, obviously, kids, especially for young kids, they're not going to let you just put an ultrasound probe on them. So you have to do this under anesthesia. But if you put an ultrasound probe on there, and you just do a B scan, the stimer mass will show up on the B scan. Then you slowly turn down the gain and when some waves hit calcium, they bounce off. And so you get all these high spikes on an A scan. On a B scan, you have these bright spots. And then as you turn down the gain, the whole eye disappears, but the calcium still stays there. And so calcification is one way to help differentiate some of these lesions. And when you have a retinoblastoma, one of the characteristics of it is it tends to be calcified. And you can see right here on this gross picture, these white flecks on you with all calcification that's on that tumor. So when we look at a retinoblastoma, the first thing we do is we describe grossly what the growth pattern is. And Terrell, what are the growth patterns that we have of retinoblastomas? Grossly. They are two of them, the way they can grow. One of them they can grow in toward the vitreous, others they grow out underneath the retinoblastoma and ensofating. So those are the two ways they grow. So sometimes they grow off the retinoblastoma into the eye, into the vitreous. That's endophating inside. Or they can grow underneath the retinoblastoma and even cause this extruded retinal detachment. So this is called exophatic. So they can grow under the retinoblastoma or in front of the retinoblastoma. Exophatic endophatic. Now here you can see why I'm grossly right here. Here's an eye that's been removed and this one is growing kind of inside of the retinoblastoma. So this is now what we call endophatic. But when you look at these already, even at low power, these little areas of this magenta strain, this is the areas of calcification. Alright, so when we look at that, Chris, what are we seeing here that kind of characterizes the growth pattern of these lesions? So we've got the areas of calcification and that necrosis kind of separating these areas of dividing cells. They're percolation. So what happens is these tumor cells grow very fast. You know, in the third world, unfortunately, they have a lot of trouble recognizing these and Bob was talking about some of the cases he's seeing, unfortunately, in Indonesia where the kids just start coming in early and these can grow explosively. And when you look at these at low power, you'll see in the center of each of these questions of cells of blood vessel. So what happens is these cells start growing and they literally outgrow their blood supply. And when they grow far enough away from the blood vessel, they die. And these areas here are necrotic and then you get secondary calcification and the necrotic areas we call dystrophic calcification. That's where the cells up, where their blood supply they die, they become secondary to calcify. Here you see again, viable tumor cells around the blood vessel in the center and then they outgrow their blood supply. They die and then you get the secondary dystrophic calcification. That's a real tip-off because these other lesions that do this don't form those calcified areas like this. All right, what's the junior, what's the classic finding we see at a higher microscopic level that discerns these retinoblastomas? All right, so these are called flexner winterstyler rosettes and these are the guys who describe it either or not as even a little mitotic figure there. And so that just shows you don't use mitotic figures in the retinas. For some reason when retina becomes dysplastic either from benign overgrowth or from a tumor, it tends to form circles. And so you get these flexner winterstyler rosettes. What's interesting is in the center of these they will often try to form a little bit of an outer limiting membrane. And so you'll often see a little alignment. They'll even be crude attempts at making early rods in the center there. And so these look similar to what you see in another CNS tumor in kids, a neuroblastoma. They get, of course, everybody puts their name on something. There's Homerite rosettes in there that look very similar to these but they don't have that attempt at an external limiting membrane. And so these are the classic flexner winterstyler rosettes. And one extra bonus point for this one, Ashley. What kind of stain is this and why would I be showing you this with these rosettes? Okay, so right here, this was a trick. Here's the rosette and right here there's this little blue in here. This is an ocean blue stain. Now remember our corneal lecture? What is our corneal dystrophy? What is the ocean blue stain for? Euclopolisaccharide. So you eat a little euclopolisaccharide. Remember, underneath the normal retina where the rod and cone segments are there's little euclopolisaccharides in there. And so when they're trying to make these flexner winterstyler rosettes they actually make people polyseparative. So you don't get kind of an off for that because that was a bonus question. Now here's your real question. This kind of looks like a rosette but it's a little bit different than a rosette. It's almost like it's a broad horseshoe instead of a rosette and if you look at it there's the external limiting membrane and it's a tendency to make rods here. What do we call that? A floret. And a floret is a sign of differentiation. So a really well differentiated retinoblastoma will have florets and this is a good sign. This tells you that these are almost forming retinents almost like someone takes a rosette and tries to unzip it and lay it out. So this is a sign of actual differentiation so this is a good thing to see. So what we're trying to show here is what kind of structure is this right here and this right here. Why is it dark around there? It's actually not calcium believe it or not it's DNA. I mean you can't stand for DNA but as these necrotic cells break down they lose a lot of their nuclear contents and the nuclear contents come out to the veins and deposit it in the walls so you see that not uncommonly in these rapidly growing tumors. Here you see the close up. This is all that nuclear material that's been released from these dying cells and gathers around the veins. There's a close up. It does get some calcium also. There's definitely some calcium. You do get half ready. Eileen What are we looking at right here? There's the lens at the top. That must be the iris. Here's the iris. Here's the lens. What are these things? Ciliary processes kind of seen, not a Greek word in French word, on phos. So flat or as they'd say out there in West Valley in Facy so this is an in Facy view and so this is a view almost like a flat prep and we're looking here's the ciliary processes here's the lens, iris tumor what's going on here? Well not quite invaded the ciliary body located around ciliary processes so what do we call this? What stuff is usually in the hollow space there behind the lens? Vitruous These are vitruous seeds and so these are bad pregnancy, this is not a good pregnancy because you can get bits of the tumor break off from the main tumor itself and you seed the vitruous. This is the anterior vitruous. Remember there's vitruous even between the ciliary processes and so these are seeds of tumor in the anterior vitruous the reason why that's important, these are tough to treat systemic chemo sometimes doesn't get in there and even intra arterial chemo has trouble getting there. These are the ones where you may even have to do intra vitriol chemo injections to get these vitruous seeds. Other Chris, what are we looking at here? Photograph So what's wrong with this picture? Oriented, incorrect. Exactly See I put one in everyone's home, I'll see if you're paying attention so this is upside down and you see here's iris, here's corny, what's going on here? Looks like a necrotic tissue in the angle, it's caught in that picture Not even necrotic some of the cells are still alive Seed, did you see the spread of the angle? Exactly, you can actually get tumor seeds from the spreading of the angle and in fact in advanced cases you can even get almost like a hypopia on it. Looks like they're layering out of white blood cells in the anterior chamber and it's tumor cells So again, not a good sign, you don't want these tumor cells here in the trabecular meshwork where they can get access outside the eye and spread and so this is anterior seeding of the trabecular meshwork in the anterior chamber angle Now, when retinoblastoma spread from the eye Jason, how do they spread? Most commonly through the optic nerve, so you see in this particular one here is the tumor here and look at the tumor beyond the laryngeal growth set in the optic nerve head Now, this is an old slide that I copied from the FIP collection, this is probably you know, 40 years old maybe 50 years old, 40 to 50 years old and these are the percentages and this was when the treatment of retinoblastoma was you recognized it, you evaluated it, if it was small you may try to laser it or maybe you do cryo, but that's the only treatments they had and so this is the percent who would metastasize and this was back, you know say 40 years ago, so if the tumor were just inside the eye you had about an 8% chance it was the lamina corrosive 15 in the optic nerve almost half and then if you have tumor at the cut surface of that optic nerve it was 65% when metastasizing these kids would die and so those numbers aren't viable anymore because we now have new treatments that have come out in the last 40 years, but it's important that you remember that concept so when the tumor is strictly in the eye chance of that metastasizing is less than when it's at the fibrosa in the nerve, but the worst problem is if it's in the back posterior cut surface of the nerve these kids would put in a blastoma they take as long a piece of nerve as they can and really go back far the first thing we do when we get one of these specimens is we take the distal end of the nerve and we actually cut it off and look at it separately just to make sure it's prognostically it's very important whether there's still tumor left behind in that optic nerve or not and this is what can happen if you don't this is a kid from Nigeria and so if you don't get the kids in right away they can have explosive growth of these tumors these are very very rapidly growing too Kay Lee, we're looking inside an eye here and we're seeing this kind of picture in the center of the pupil Tell me what you're seeing here Well you're seeing what looks like retinal tissue elevated up close into the anterior vitreous you also see dilate vessels this is kind of reminiscent of like the coats Exactly this is actually almost like a coroidal attachment you've seen coroidals, kissing coroidals they call this this is a child so this child will say he's 8 or 10 and what you see is you'll see that it's almost like there's a massive exudate underneath the retina pushing it forward but if you see all these corkscrew vessels and these dilated helangectatic vessels this is a classic for coats disease and this is true color this has got a yellowish color to it not a whitish color it's kind of yellowish from that exudated attachment and here you can see a little different but here is the retina is bulging forward it's out of focus because there's all this exudate underneath it look at these dilagectatic vessels so coats disease, unilateral or bilateral unilateral for like 8 or something yeah so older retinoblastoma most common ages if you look at most studies is roughly 2 or less, years older than last these kids are 8, 10 years old and this shows up male or female more male for some reason that's what that is either and so you don't have all males a little bit older than retinoblastoma and when we look this is kind of half sagittal and this is a globe growth state if you look this is all exudated so when Jason looks at one of these in the lab, exudate is the consistency of jello and so you hit that with a forceps it's like gelatin because it's protein rich, it's lipid rich it's almost like super serum and what are we showing here looks like lipid deposits these are those dilagectatic vessels there's a lot of lipid in here and then we look at the exudate what causes these banana shaped cracks what causes the exudate where does that cause the cholesterol cholesterol, exactly so remember when we talked about if you want to look at a tumor that's got fat in it you have to do it fresh because when you process this you put it through cycles of dehydration and other things what happens is the lipid gets leached out so it just leaves an empty space where it was and cholesterol leaves like a banana shape so you've got these banana shaped cracks what kind of cells are all these right here macrophages and so they're attempting to kind of come here and eat up the section so these are all macrophages and again if you want to stop intelligent you say macrophages you put a fake British accent on to use your intelligence macrophages sorry Reese but for some reason I don't know maybe I'm culturally biased but when you put a southern ax that a lot of it like takes three points off of your perception of the speaker if you put a British accent on he's like oh you must be smart there's that in the opposite alright so that got a weird I'm sorry there's pictures out of focus I apologize I don't take pictures of kids in my clinic I don't have kids in my clinic so this is a copy of a picture what do we see in here the pupillary reflex looks abnormal so you've got a little cori again I don't like pupil right here this is kind of the crystalline lens here and it's pretty clear and then over here you've got all this stuff either behind the lens or even starting to go into the lens this is clear and this is behind it or starting to go in here's the last one here's the pupil right here are those zonials those are zonials exactly going behind the lens maybe even going into the lens and it's pulling the material toward the center so it's stretching those zonials you can actually see zonials here you can see some blood vessels here and this part of the lens is clear so what we should give you a picture like this so this is what we used to call phpv persistent hypoplastic primary features now they call it persistent fetal vasculature it's the same thing and so this is it from behind kind of showing these pulling in of the scleric processes and pulling in of those zonial bundles with this lesion now what is thought to be the cause of this lesion that's what's left over what is that thing I'm showing here kind of looks like a blood vessel so this is caused by non-regression of the hyaloid system that serves the eye when it's forming so an embryology remember you get a hyaloid artery that comes in and actually branches out gives blood supply to the inside of the eye also to the area behind the lens and around the lens if it doesn't regress that's when you get phpv and so you can see right here here's that persistent hyaloid artery this is a beautiful gross picture here's this mass growing behind the lens even into the lens a little blood here look at it pulling those processes forward this is a beautiful picture and in I actually claim credit for this because it's beautiful so it's really nice I feel good if it's stupid it's not the fellas obviously it's one of my pictures and so this is a nice gross picture but this really illuminates that persistent hyaloid system so phpv, unilateral or bilateral actually mostly unilateral which is weird you would say wait a minute both eyes are forming at the same time why would it involve just one and not the other again it's actually mostly unilateral there's a little bit lower power as we back off and that stock actually goes all the way to the optic nerve which is where that hyaloid artery came in and here you can see this mass it can sometimes get almost fibrotic it has lots of blood vessels in it and then it will shrink down and so this is the crystalline lens believe it or not this is that hyaloid artery coming into it a bunch of little arteries behind it and then some connective tissue actually invading the crystalline lens this is what's left of the lens material up here Dr. Melitz two pictures back could toxic air also look like that? it could but you usually don't have a stock going back to the optic nerve in toxic air so you can get a mass behind here although it's usually maybe open over here but you don't have that stock of that remnant hyaloid artery so that's what you don't see you can get a retinal detachment from toxic air but you can see the retinas still back here so this is actually a vessel remnant and here we have some pathology and you can see that here's the growth into the crystalline lens and it's pulling the saline processes over look at that the saline processes here's the auricerata the auricerata is behind the actual iris and so it's really pulled everything in as a tricking this is a big extra data to catch and here you can see it pulling it in here's the iris here's the auricerata the saline processes being pulled over so it can really suck them over and so this is a phpv kind of pulling into the center and causing these problems these are kind of tough to treat sometimes because even if you remove you get rid of all the stuff that's in there you still have a retina that just doesn't want to catch properly so you can do heroic measures and these kids still don't do well Tara what do we see in here? birdmeister papilla well yeah birdmeisters papilla go along with it now the birdmeisters papilla is the connective tissue associated with this and this is, it's called a corkscrew vessel this is the posterior part of the hyaluridata system completely regressed so this isn't quite phpv this is just normally the hyaluridata regresses and at this point it didn't completely regress so you're left with this little corkscrew vessel and the birdmeister's papilla is the connective tissue around it so here you can see part of the hyaluridata re that is still present coming off there and then this is what it looks like so you see that we're in the hyaluridata we're coming up off the nerve bleep remember not these people see fine this usually doesn't affect the vision and this is just kind of the the most mild form of a non regression of the hyaluridata re system and phpv is the most severe form these are one of the things here well not really usually don't, it's very uncommon all right chris what do we see in here so you see kind of a white reflex there on the left eye I don't see an associated basket it's actually a bilateral I don't see any other kind of thing that suggests something other than a cataract or a bilateral cataract so when you see a bilateral white pupil the first thing you gotta think of is a bilateral congenital cataract that's important that you recognize that right away because congenital cataracts are like an emergency because kids can get hemorrhagic they have a unilateral congenital cataract they get severe life-long gliobase you gotta get that out of there right away this could be a bilateral cataract and we look inside and let's say this isn't quite that kid but same disease entity we look in and we see this so there's a dragging of the vessels vessels are pulled temporarily here so what entity gives you that our OB exactly, so right now with the prematurity this is a severe phase before we knew what this entity was retinopathy of prematurity can give you bilateral white pupils because you get retinal detachment that pulls up behind the crystalline lens and you can look like this this is the phase that we'll often see that when they've been treated or when it's regressed you can see years later there's a drag of this appearance in retinopathy of prematurity now this is the end stage of retinopathy of prematurity and we need to call this condition retro-mental fibroplasia and it's not really fibroplasia it's a total RD and so you get a total retinal detachment from neovascularization that can occur so remember what happens to trigger these is these kids actually get too much oxygen and these kids are in the NICU they need lots of oxygen you really want to monitor the oxygen closely because if you give them too much it'll actually cause the normal retina to stop cold and then you have an area of avascularity especially temporally and then you get neovascularization so that's when they do cryotherapy or laser to try to kill that off and so this is the end stage you actually do a total retinal detachment it's got a lot of actually in it and you get this closed funnel behind the optic nerve you can almost look like a congenital counter you can have a white space there again once it gets to this stage and Steve Charles who's a just a crazy I know him, he's just a crazy guy I mean he's the most aggressive retina guy I've ever seen he does like, you know, points intensity he does like 12 for trekking he's in an egg and he's just a wonderful gifted surgeon and even he can't make these kids see better so these are really tough once they get to this point so this is the situation when you want to prevent it from getting to this point this is what it looks like pathologically okay Chris, bonus points what kind of surgery does this kid have well he's had like a sclerobuckle exactly, so he's had a sclerobuckle how can you tell that well so there's four minutes of it so this is where the sclerobuckle was right here and so they tried to do a sclerobuckle to save the sun you can see again a funnel shaped retinal detachment and previous sclerobuckle in this kid Julia what are we seeing here specimen of the whole line it looks like a white mass essentially and a width of some rd yeah, a white mass of some rd with an rd so I mean it could be a lot of different things could be lots of things and then we do the path and the heck is that exactly, that's a toxicaris system so how do these kids get toxicarisis in the eye exactly, so what do kids do what do puppies do puppies eat their stools what do kids do, they play with puppies and puppies lick their faces and they get this stuff that goes into their GI system and goes through the GI wall and then could be disseminated it's about the body and one of the end organs and so again, these are very difficult to treat because if the parasite keeps growing in there it could cause damage to the eye but if you try to kill the parasite then that dead parasite releases all kinds of bad humors into the eye and that can make the eye have a lot of inflammation fortunately very rare but toxicaris is always on boards as a potential cause for leukocortia alright, Ashley what the heck am I showing here first of all, where in the eye am I so you're the ciliary body exactly, you're the iosopharynia ciliary body yeah, there's a large mass of cells looks like weird stuff that's not usually in the eye I'll give you a hint, it's kind of part of the stuff oh, is this cartilage yeah, it's cartilage in the ciliary body very weird what can cause cartilage to form in the ciliary body it can, medrogathelioma or dicteoma, what's another one that can cause that it's been named today trisomy 13 can cause this and again, this is one of those things you have to memorize before trisomy 13 can cause this and you get retinal dysplasia which gives you a white pupil but you get this cartilage in the ciliary body and here's the retinal dysplasia remember I said it doesn't necessarily mean a tumor but when retinas abnormally forming it forms rosettes so you can get some funny abnormal retina in these kids and you get these rosettes starting to form in there but this is one of the two entities that can give you cartilage in the ciliary body the other one was medrogathelioma or dicteoma I love this, I didn't even plant that what does dicteoma mean netlite so netlite, dicteoma see everything comes from the gait okay, so you've beaten to death the the idea of leukocorrhea but realize that you need to rule out retinal glistoma but then all these other things can cause it they love this stuff on board so when you're studying for OCAPS you know all of your potential sources for white pupils and kids, now we're going to shift to adults Reese, what are we seeing here what are we seeing here okay, so exactly it's pulling the iris over so when you see pigmented lesions like this you want to say okay are they elevated are they irregular which you look for as you look for pulling of the iris board over there, sometimes you'll even get the posterior iris pigment at the end and pull it around the corner what do we call that condition ectropion uv so these are the suspicious signs now this looks even more suspicious what are we seeing here so look at the slit beam here's the slit beam on the iris I mean on the cornea here's the slit beam on the iris look at it coming up it's almost touching so this is a very, very thick mask what would your differential diagnosis here come from iris melanomas exactly, so people would say well maybe it could be a nevus, no probably not it could be an iris melanoma and see you know iris melanomas were really benign in fact they're 90% curable and people don't die from metastases and the reason for that is because what we were calling iris melanomas in the past were mostly nevus because you know you could see them and you remove them early so Fred Jacobiak went through all of the iris melanomas at the AFIP and he found like 185 of these and they looked at them all when they looked at the cellular characteristics of them were actually nevi and so they recalcified iris melanotic lesions and so there's a classification that you really do have to memorize again from benign to normal ligand so priest the very first one if we're looking at this is an iris lesion pigmented and we see this what do we call this this is a spindle, well we don't do A's and B's so much in the iris as we do in the rest of the corae this is a spindle nevus so they used to call these melanomas this really isn't a melanoma it's a spindle nevus this is the equivalent of a spindle A cell which technically we call we call it nevus even in the corae so look at these spindly shaped nucleus they just think cytoplasm and they'll sell your border spindle A nevus I didn't even quit cheating nice so ha ha so we've got now this is a piece of iris what's different about this one it's pigmented and there's a lot of cells and where are these cells right here here's the iris itself on the surface and so some people would call this a plaque so you have spindle nevus or some adion nevus then you can get spindle nevus with plaque these look a little bit more alarming because these start to grow more and so people get excited and do a big peripheral iridectomy on these okay we've got beyond spindle nevus what do we see in here chris I'll say spindle B but I don't want to close it yeah kind of the equivalent of a spindle B in the cord you see now they're getting more oval more cigar shaped not that perfect spindly one that we see here so this is now called a borderline spindle nevus so again spindle nevus spindle nevus with plaque borderline spindle nevus excuse me this one would be a melanoma exactly so we go to a spindle melanoma so this is a true spindle B melanoma cigar shaped oval cells a single nucleos in the indistinct cytoplasm no sediment borders between so this is a true spindle B spindle melanoma in the iris right what do we see in right here the rarest of these lesions so this is actually epithelioid cell nevus I've seen one of these in my career again you can get nevi you almost look like epithelioid cells epithelioid cell nevus very very rare and then you can get that's frequently in this is an epithelioid melanoma just like melanoma is in corollates you can get epithelioid cell nevus epithelioid cell melanoma these are just like the melanomas of the corollate these are the worst type epithelioid melanomas okay and then there's a couple of other obscure ones that are on that list but now this is something different Becca what's going on here so now we have something dark structure growing in the inferior portion of the iris there's another cell binding on here that you can see also through the pupil you can see some this right here there's a leech and right here it kind of looks like it goes behind the iris and maybe you would have x-ray eyes and you could actually see through that and see those are all connected so where does that feature arise from the ciliary body this is a ciliary body melanoma so I actually took this picture myself so this guy was when I was in residency he's a University of Illinois alum goes to all their football games first game of the season could see the scoreboard from his seats third game started being fuzzy and by the last game of the season he had trouble seeing the scoreboard from his seats and the reason is is the tumor was growing here and was pushing on the lens and causing a counteract and so he came in his complaint was blurred vision it's weird he didn't even notice that which I find interesting well I'm guys because I don't know if it's anything until the eye falls out his wife was with him he would look for stuff like that he would obviously notice it but he didn't even notice that he had a counteract so he couldn't see the scoreboard this is a ciliary body melanoma a ciliary body and coroid we all link together so they're a separate group from the iris melanoma and he said here's another one here's that tumor poking out right there and then here it is poking up here and sure enough here is a counteract starting to form next to it so in that first picture what we were seeing in the lens that was a counteract exactly well the tumor was pushing part of it this is the tumor here this is a counteract and here's a nice goniom view that tumor is sitting in the ciliary body here and then it's pushing up into the angle it's a ciliary body melanoma with extension now what are we seeing here Tara it's like there is either a a counteract or something and then seeing kind of line there's that really large feeder vessel and what do we call that it's called a sentinel vessel and the reason that that's important is it will point you right to the tumor so when you see a dilated vessel like this and it's isolated the rest of the area around the lindus and the congee tide in any square are not dilated this is a sentinel vessel this points you right to the tumor I feel like sometimes I don't know where one would develop a true tumor you can see early changes where you'll actually get more vascularity than you get soil induced degenerative changes so you can see that too in chronic irritation so don't over call these but if you see that the ice totally quiet there's this one area where there's a vessel you really neary about something looking behind it so it comes to that area it's called a sentinel vessel arising from the ciliary body pushing against the crystalline lens going back almost to the equator and in this particular case it's going from posterior to anterior so it's secondarily invading the anterior-chamber angle so you can get a secondary opening with glaucoma in these patients with this ciliary body melanoma now the reason we worry about the ciliary body melanoma there's two reasons compared to coronal melanomas one theory is that they sit behind the eye so they can grow a long time and you don't notice symptoms so this could be growing for a while and people don't notice it but the second thing is remember you've got all these aqueous veins over here and they drain blood and they drain aqueous eventually drain out so this is an area where there's a lot of potential places for these tumor cells to go so if you look at this the ciliary body melanoma but look up here at low power there's some loose cells in there so that raises suspicion and then we look at a close-up and sure enough here's one of the aqueous veins here's the vein on the epi-sclare there's two more cells already being out of the eye and so the ciliary body melanomas can gain access to get out of the eye quicker too so they're a little bit worse than parietal so from vaginal epithelialomas remember if I had enough time to put one in here with this structure that's short but they do look different you can get some stretch processes that they can go almost looking like a kid that's got ph can be but sometimes they can be confused for melanomas and one of the important things to tell them apart is you do an ultrasound Marjorie's got that 50 hertz probe which is really good and when you look at menstrual epithelialomas there's cells trying to make ciliary body and then in between them you've got tissues so you get a lot of high and low spikes whereas the melanoma is very solid and so when Roger does the ultrasound and the ace can you get really low reflectivity inside so that's the way you tell them apart alright we're sitting here Chris, what are we seeing here? that looks like a royal penis so first the melanoma again it's really good that the lecture was last Wednesday Marjorie Shields and Carol Shields is mnemonic that you do to tell you if something is worrisome if it's a choroidal lesion of what was their mnemonic to look I was just thinking about this one actually because I think it's too fine oh yeah too fine small I feel like the last two parts of it oh yeah alright so do you remember that mnemonic because that tells you the things to look for to make you suspicious for something that's a nevus that's a melanoma as opposed to a simple nevus so it's a nice way of looking at they talk about lipofusin they talk about fluid they talk about location and how big it is and so if you remember that mnemonic it really helps you to say could this be benign or this looks pretty benign it's not elevated there's no fluid there's no lipofusin on there now this on the other hand would you be more suspicious of this so you can see now this is focusing on the surface of this growth and that's why the optic nerve is out of focus because there's a tumor underneath the retina pushing it forward and so this is really suspicious for a tumor in the choroid now if you look right here this was something that at one time was called a nevus so this isn't quite as easy to tell this little orange area is here that's lipofusin and it is elevated there's even a little bit of fluid around it so this was something that was followed as a nevus that then started to show suspicious findings for a possible melanoma Dr. Malus so they say that if it has drusen on it it's supposed to be considered benign right, drusen is a good thing but lipofusin looks orange as opposed to the little yellow drusen is this here so that's actually a bad sign where a little tiny drusen or a big sign now here's the classic growth pattern Julia, what pattern are we showing here so you see the mushroom shape which is really commonly seen in these choroidal melanomas why do you get a mushroom shape because the tumor breaks through the breast membrane and that's where it pinches off that stop and the rest of the growth so remember brooks membrane was that there was a red sandwich and the innermost layer was an elastic layer so it almost acts as a tether so the tumor cells break through but brooks still is kind of elastic so it almost acts like a ring there and then the tumor cells break through and then they start mushrooming out growing so here's where brooks membrane would be here to here and then that tumor broke through and then it spreads out underneath the retina when it's growing so thus the mushroom shape that you can see the tumor broke here now because this is on the posterior pole this is recognized early so you can see that early now cell types one more time what do we have here Julia? spindle A so we would call this almost a nevus but same thing spindly nuclei no nuclei industry side of plasma no thin cellular borders actually what do you want to call this? the top one is like third or fourth spindle B in the bottom so spindle B how do we tell those? so there's slightly more of a long not quite a split-sharp edge and then you start just getting the nuclei out so you see kind of a cigar shaped cell and the nuclei in the still kind of an industry side of plasma the cell borders all run together Reese what are these? those are more epithelioids epithelioids so you see that they're bigger lots of disruption of the side of the nuclei as you see chromatin you can see multiple nuclei but you see cellular borders now very big cell but you even get multi-nucleated cells so epithelioid and that's important because that's the main prognostic factor of these tumors spindle E tumors, spindle B pure epivest prognosis a mixture of the two spindle epithelioid have a modern prognosis pure epithelioid and these are uncommon have a worse prognosis so they're the most aggressive and this is what you call kind of a mix there's a few little spindle cells in here not many and a lot of epithelioid cells so these can be pretty bad okay Eileen what are we showing here? what is this thing that or set this whole thing up? it could be a blood vessel yeah it could be a blood vessel so how do these tumors get out of the eye? yeah so they go through the channels and we call them emissarial channels emissary is something that goes through the front line to the other side so emissary you're going to talk peace with the other guys you wave your white flag and you go through the line and so this is an emissarial channel so these tumors they can't just eat through sclera sclera is really tough and so anywhere where the sclera has a weak point like a vein draining it an artery coming in, a nerve coming in that is where the tumors go so this is a vortex vein and now here you can see a tumor growing it doesn't necessarily have to go inside the vein but it goes along that channel where the vein has come and then eventually it can even get outside the eye it goes through the sclera and eventually on the surface and we look very carefully at these globes that are removed the tumors in and make sure that they have a desicc and where they would desiccize to the liver and let's start saying how we remember where they go beware of the yellow man with the glass eye think about it alright so when you're on all the boards do we sit there going yellow man so because these are the gaseous sites to the liver most commonly alright Chris 70 year old woman being guy complains in an irregular condition under the retina alright so it's definitely not melanotic sometimes they're unilateral sometimes they're bilateral so if we're looking at tumors to the coroid some people say number one is melanoma others would say no the most common tumor of the coroid is not a melanoma it is a metastatic tumor and so metastatic lesions could go to the coroid if you took autoxies you'll probably find more of these in the thing because when people get widespread tumors they'll often go to the coroid so in women the most common tumor that you see is breast carcinoma so you see these white they can be multilovulated lesions irregular borders even bilateral and sure enough when we do this it's an adenocarcinoma and so this is a breast adenocarcinoma now if you really look at them now the carcinoma used to be here lung carcinoma used to be here and now it's getting closer and closer and closer so when they used to allow cigarette advertising on TV there's this really sleek sophisticated woman and she smoked these really cool looking cigarettes and the catch line if you've come a long way baby that was it advertising in the sixties and so the idea was that women are sleek and sophisticated too women now smoke like men and so they can die just like men do from lung cancer so lung cancer metastases are going up and up and up in terms of women now because women are now smoking like men fortunately population dates smoking in the last 30 years has really gone down from like half the population to fourth but still fourth of the population smoke so lung tumors are commonly seen this is a metastatic lung which is the most common in men and here you can see this is a lung carcinoma metastatic to the core sometimes you can get prostate tumors you can get GI tumors and we say goodbye to the Teton so when we do our review for OCAPS we're just going to flash slides as quick as we can you guys are going to say pattern recognition that's this questions alright