Spontaneous Peeling of Epiretinal Membrane Associated with Nd:YAG Laser Injury

CASE REPORTS AND SMALL CASE SERIES

An Ocular Endoscope Enables a Goniotomy Despite a Cloudy Cornea

Infantile glaucoma is often initially treated with a surgical goniotomy or trabeculotomy. A goniotomy is not possible if the cornea is too cloudy, despite preoperative glaucoma medi- cations and removal of the corneal epithelium. Bimanual endoscopic goniotomy has been reported in 1 child, but this technique requires great dexterity to maintain the endoscopic image on the needle tip.1 In the following case, we used a new technique, coaxial endoscopic go- A niotomy,2 that allowed a goniotomy to be performed when the anterior chamber angle could not be distinguished through the surgical gonioprism.

Report of a Case. A 19-month-old girl was referred with a several- month history of film covering both eyes. The child was photophobic, tearing, and had bilateral buphthal- mos with extremely cloudy cor- neas. She was prescribed timolol ma- leate, latanoprost, and acetazolamide sodium syrup while undergoing treatment for otitis media. She had no other health problems. An examination under anesthesia 9 days later revealed intraocular pressures B of 31 mm Hg OD and 33 mm Hg OS, corneal diameters of 14.5 mm OD Figure 1. Images are from surgical videotapes. A, Structures in the anterior chamber angle in the left eye and 15 mm OS, circumferential and were not clearly visualized through a surgical gonioprism. A Haab stria is also present (arrow). B, The anterior chamber angle that was treated by coaxial endoscopic goniotomy is viewed several weeks later horizontal Haab striae in both eyes, through a surgical gonioprism. The incised area is to the right of the arrow. a cup-disc ratio of 0.8 OU, axial eye lengths of 25.4 mm OD and 27.0 mm mother and approved by the insti- scopic image. The coaxial endo- OS, and attached retinas by B-scan tutional review board of Vanderbilt scopic goniotomy needle was then ultrasound. A high-iris insertion was University, Nashville, Tenn. A thin inserted through a paracentesis af- present in the right eye by gonios- blood lancet (Microlance; Becton- ter viscoelastic material was placed copy, but the view was too hazy in Dickinson Co, Rutherford, NJ) had into the anterior chamber; the needle the left eye (Figure 1A). been formed to wrap tightly around was directed to the anterior cham- The child underwent bilateral a 20-gauge ocular endoscope (En- ber angle (Figure 2). The image of goniotomies with the aid of a co- doptiks, Little Silver, NJ) and was the anterior chamber angle was axial ocular endoscope in the left eye. sterilized separately. The lancet was viewed on a videoscreen as the lan- Permission for this procedure had placed on the endoscope with the cet tip cut the high-iris insertion for been obtained from the child’s needle tip observable in the endo- 130° (Figure 3). The corneal inci-

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 3. Sun W, Shen JH, Shetlar DJ, Joos KM. Endo- scopic goniotomy with the free electron laser in congenital glaucoma rabbits. J Glaucoma. 2000; 116:199-202.

Tissue Adhesive in the Management of Leaking Pars Plana Sclerotomy Causing Hypotony and Choroidal Detachment

Nonhealing or persistent wound leakage can be encountered in sclerotomy sites after multiple pars plana vitrectomies. Therapeutic modali- ties such as patch graft have been reported to manage the persistent limbal wound leaks.1 Cyanoacrylate tissue adhesives have been success- Figure 2. The coaxial endoscopic goniotomy needle was inserted through a paracentesis and was fully used in the management of cor- directed to the anterior chamber angle. The endoscope tip (arrow) is present inside the lancet. neal perforation and leaking filter- ing bleb to circumvent the need for visualization of the anterior cham- surgical interventions such as thera- ber angle structures is required. peutic keratoplasty and conjuncti- Coaxial endoscopic goniotomy val flap.2,3 We describe herein the permits visualization, as previously technique and successful use of cya- demonstrated in cadaver eyes2 and noacrylate adhesives to manage post- in the successful treatment of rab- operative hypotony and associated bits with congenital glaucoma.3 choroidal detachment caused by The coaxial alignment requires leakage from sclerotomy after pars only 1 corneal incision and permits plana vitrectomy. the lancet tip to be continuously viewed on the videoscreen as it Report of a Case. A 51-year-old incises the angle structures. The white woman with a history of in- operating time is similar to that of sulin-dependent diabetes had un- Figure 3. The image of the anterior chamber a routine goniotomy. dergone 3 prior pars plana vitrecto- angle was viewed on a videoscreen as the lancet tip cut the high-iris insertion. The incised angle mies in the right eye between 1995 is observable on the left side of the image. Karen M. Joos, MD, PhD and 1998 for proliferative diabetic Jin H. Shen, PhD retinopathy and recurrent vitreous sion was closed, and a routine go- Nashville, Tenn hemorrhage. After the first 2 sur- niotomy was performed on the right geries, the visual acuity had re- eye. This project was supported by a grant turned to 20/20 for several months. At the child’s next examina- from Research to Prevent Blindness Six months after the third surgery, tion under anesthesia, her intra- Inc, New York, NY. the visual acuity OD had decreased ocular pressures were still uncon- The authors have no commer- to counting fingers owing to recur- trolled at 35 mm Hg OD and 34 cial, financial, or proprietary inter- rent vitreous hemorrhage and mm Hg OS with poor medication est in the product or company, nor do nuclear sclerotic cataract. In the left compliance, but her left cornea had they receive payment as consultants, eye she had had a persistent retinal substantially cleared so that regular reviewers, or evaluators. detachment after pars plana vitrec- bilateral goniotomies could be per- Reprints: Karen M. Joos, MD, tomy in 1999 for a combined trac- formed. Corneal diameters were PhD, Department of Ophthalmology tional and rhegmatogenous retinal 14.5 mm OD and 14.5 mm OS, and Visual Sciences, Vanderbilt Uni- detachment. She was then referred and axial eye lengths were 25.4 versity, 1215 21st Ave S, 8017 MCE, to us for further management. mm OD and 26.8 mm OS. The pre- Nashville, TN 37232-8808. (e-mail: On our initial examination, her viously treated angle in the left eye [email protected]). best-corrected visual acuity was hand was observed by gonioscopy (Fig- motion in the right eye and light per- 1. Medow NB, Sauer HL. Endoscopic goniotomy ure 1B). for congenital glaucoma. J Pediatr Ophthalmol ception in the left. Ophthalmic echog- Strabismus. 1997;34:258-259. raphy showed dense vitreous hem- Comment. A goniotomy is a rela- 2. Joos KM, Alward WLM, Folberg R. Experimen- orrhage without retinal detachment tal endoscopic goniotomy: a potential treat- tively simple procedure to treat ment for primary infantile glaucoma. Ophthal- in the right eye and a rigid funnel- congenital glaucoma. However, mology. 1993;100:1066-1070. shaped retinal detachment with dif-

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 tiple intraocular surgeries, a deci- sion was made to seal the leaking sclerotomy with cyanoacrylate tissue adhesives instead of further surgical intervention. For leaking sclerotomy with a soft globe in this patient, tissue adhesive was applied under a slitlamp biomicroscope using topical anesthesia and a lid specu- lum. After the loose suture was removed, the necrotic scleral and con- junctival tissues overlying the scleral perforation were debrided. Prior to gluing, a sterile plastic disk was cut to the size slightly larger than the sclerotomy using a 3-mm skin biopsy punch (Acu-Punch; Acuderm, Ft Lauderdale, Fla). The plastic disk was then placed on a small amount of ophthalmic ointment, which was pre- Figure 1. Leakage from pars plana sclerotomy associated with choroidal detachment (inset). placed at the end of the wooden stick of a cotton-tipped applicator as previously reported.3 A small meniscus (about 1 to 2 µL) of the tissue adhesive (Histoacryl; B. Braun, Melsun- gen AG, Germany) was placed on the Leaking Sclerotomy 3-mm plastic disk (Figure 2, inset). The leaking area was dried with a cel- lulose sponge. The glue on the disk was gently pressed against the sclerotomy for 10 to 20 seconds with the end of the applicator (Figure 2). On observing the polymerization of tissue adhesive and adequate adher- ence of the disk over the sclerotomy, the cotton-tipped applicator was removed. The preplaced ointment facilitated the separation of the disk from the end of the applicator Ointment Glue and prevented dislodging of the po- Disk lymerized glue on the disk. Because the adhesive plug had a rough edge Figure 2. Application of tissue adhesive on a plastic disk (inset) over the sclerotomy. around the disk and could be poten- tially irritating, a therapeutic con- fuse vitreous hemorrhage in the left. lamp examination showed loosen- tact lens was used to ensure the pa- Because of the guarded visual prog- ing of the 8-0 polyglactin 910 (Vic- tient’s comfort and to prevent nosis for the left eye, surgery was rec- ryl) suture at the superotemporal dislodgement of the glue by eyelid ommended for the right. A pars plana sclerotomy site in the right eye blinking (Figure 3). Application of vitrectomy, lensectomy, endolaser (Figure 1). An open sclerotomy with 0.3% topical ofloxacin 4 times a day panretinal photocoagulation, and im- partially retracted conjunctiva and and 1% prednisolone acetate every 2 plantation of a posterior chamber in- very thin surrounding sclera was hours were prescribed. On the fol- traocular lens were performed in the noted. Findings from the Seidel test lowing day, persistent hypotony with right eye. The visual acuity im- were positive. The anterior chamber a slow leakage was noted at the in- proved to 20/400 with a normal in- remained formed with moderate Des- ferior edge of the glued disk. An- traocular pressure on the first post- cemet membrane folds and corneal other application of the tissue adhe- operative day. One week later, she edema. Fundus examination re- sive on a disk to the inferior edge of complained of aching with de- vealed a 360o choroidal detachment the initial disk was performed. On the creased vision in the right eye. The vi- more prominent in the superotem- fourth day, no leakage was detected sual acuity remained at 20/400 OD poral quadrant with overlying pho- and the intraocular pressure was 10 and light perception in the left eye. tocoagulation scars (Figure 1, inset). mm Hg. Minimal corneal edema with However, the intraocular pressure was Because of the thin remaining residual folds of Descemet mem- 4 mm Hg OD and 12 mm Hg OS. Slit- sclera and medical history of mul- brane was noted, but the choroidal

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 if leakage occurs. As demonstrated in this case, the gluing technique can be repeated in sclerotomies with persistent wound leakage.

Pongmas Wichiensin, MD Therapeutic Rhea L. McDonough, MD Adherent Disk Soft Contact Andrew J. W. Huang, MD, MPH to Leaking Lens Sclerotomy Harry W. Flynn, Jr, MD Miami, Fla

The authors have no financial inter- ests in the products or procedures men- tioned. Dr Huang is now with the Uni- versity of Minnesota in Minneapolis. Corresponding author: Andrew J. W. Huang, MD, MPH, Department of Ophthalmology, University of Min- nesota, University of Minnesota, 420 Delaware St SE, MMC 493, Minne- Figure 3. A therapeutic contact lens over the glued-on disk to prevent mechanical irritation. apolis, MN 55455 (e-mail: huang088 @umnedu).

1. Soong HK, Meyer RF, Wolter JR. Fistula exci- sion and peripheral grafts in the treatment of persistent limbal wound leaks. Ophthalmology. 1988; 95:31-36. 2. Hirst LW, Smiddy WE, Stark WJ. Corneal perforations: changing methods of treatment. Oph- thalmology. 1982;89:630-635. 3. Hyndiuk R, Hull D, Kinyoun J. Free tissue patch and cyanoacrylate in corneal perforations. Oph- thalmic Surg. 1974;5:50-55. 4. Chen CJ. Sutureless pars plana vitrectomy through self-sealing sclerotomies. Arch Ophthal- mol. 1996;114:1273-1275.

Spontaneous Peeling of Epiretinal Membrane Associated With Nd:YAG Laser Injury

The increasing use of high-energy laser instrumentation for scientific and Figure 4. Healed sclerotomy with complete resolution of corneal edema and resolution of choroidal therapeutic purposes has resulted in detachment (inset). the proliferation of inadvertent retinal injuries. The expanding use of detachment persisted. During the ex- by cyanoacrylate tissue adhesive. Nd:YAG technology poses new amination, the 2 glued disks dis- This gluing method should be con- threats from accidental exposure. Re- lodged and the tissue adhesive on a sidered as an effective alternative to action of retinal tissues from new disk was reapplied. Five days af- resuturing or to applying a scleral Nd:YAG laser insult differs from the ter the last gluing, the third glued disk patch graft. The application of tis- typical thermal injuries caused by ar- dislodged and the scleral wound was sue adhesive is simple and can be gon and krypton lasers. We report healed without evident leakage readily performed in the office. Tis- a case of laser injury to the macula (Figure 4). Complete resolution of sue adhesive applied to the thinned in which we were able to closely corneal edema and choroidal detach- sclera or macerated sclerotomy may monitor the evolving retinal re- ment (Figure 4, inset) was noted. The prevent further tissue degradation sponse to Nd:YAG disruption. visual acuity improved to 20/100 OD and facilitate wound healing and vas- with an intraocular pressure of 20 cularization. Sutureless pars plana Report of a Case. A 23-year-old re- mm Hg. sclerotomy is a recently described vi- searcher suffered sudden vision loss trectomy technique using a local- in his right eye while focusing a re- Comment. This report demon- ized scleral tunnel.4 The gluing flected beam from a frequency- strates the successful management method could also be used to rein- doubled Nd:YAG laser. He was not of a leaking pars plana sclerotomy force these sutureless sclerotomies wearing protective eyewear. His best-

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Figure 1. A, Fundus photographs obtained 1 day after injury. There was some clearing of the vitreous hemorrhage permitting visualization of the macula. Preretinal and vitreous hemorrhages are noted with focal foveal hypopigmentation. B, Two weeks after injury, only small amounts of vitreous hemorrhage persist. Magnified view of the macula reveals the presence of a small macular hole with residual subretinal blood and surrounding gray discoloration.

A B

Figure 2. A, Photograph taken 1 month following initial injury demonstrating well-organized epiretinal membrane measuring 2ϫ1.5 mm with striae radiating to the arcades. Contracture of these striae resulted in wrinkling of the underlying retina. B, Seven months later, the epiretinal membrane has spontaneously peeled and rolled into a small parafoveal scroll residing superotemporal to the fovea. The retinal striae have also resolved.

corrected visual acuity was 20/200 vealed a distinct epiretinal mem- mechanical disruption. Vitreous OD and 20/15 OS. He noted a large brane (Figure 2A). and subretinal blood likely act as gray floater, with metamorphopsia Seven months later the patient stimulants for fibroglial and reti- and central scotoma identified by had a visual acuity of 20/20 OU and nal pigment epithelium prolifera- Amsler grid. Fundus evaluation re- spontaneous regression of the tion, resulting in an epiretinal vealed vitreous hemorrhage ob- epiretinal membrane (Figure 2B). membrane over the macular hole. structing adequate macular visual- On subsequent visits, the patient’s Contraction of the gliotic mem- ization. Examination results from the vision and retinal examination re- brane causes macular pucker and left eye were unremarkable. sults have remained stable. reapproximation of the edges of The next day, his visual acuity the hole. In this case, subsequent had improved to 20/60 OD Comment. Previously reported spontaneous peeling of the mem- (Figure 1A). Fluorescein angio- cases of accidental Nd:YAG laser brane resulted in restoration of gram showed early and late foveal injuries describe several common visual acuity and resolution of the hyperfluorescence, consistent with features such as early subretinal, macular hole. Similar progression Bruch’s membrane penetration. retinal, and vitreous hemorrhage was reported in an idiopathic Within 2 weeks his visual acuity had with macular hole and pucker.1-4 macular hole associated with an improved to 20/25 OD (Figure 1B). We describe a single case of epiretinal membrane.5 However, 2 weeks later, the patient Nd:YAG injury that demonstrated The vast majority of retinal la- had a decline in visual acuity to several interesting features of the ser injuries occur in the absence of 20/40 OD. Fundus evaluation re- retinal response to focal thermo- appropriate eyewear, illustrating the

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 paramount importance of eye pro- is true that it has seldom been re- pigmented metastases in the left ven- tection while operating lasers. ported in the literature. We are aware tricular wall. Case 2. Multiple pig- Subhransu Ray, MD, PhD of 4 reports of cardiac metastasis mented metastases 2 to 3 mm in from uveal melanoma in 14 pa- diameter in the left ventricular epi- Trexler Topping, MD 1-4 Lucy H. Y. Young, MD, PhD tients. A fifth article mentions 2 pa- cardium and myocardium, and a Boston, Mass tients with cardiac metastasis from subendocardial metastasis 2 mm in an ocular primary melanoma, but it diameter in the anterior papillary Corresponding author: Lucy H. Y. does not specify whether the pri- muscle. Case 3. Multiple, small me- Young, MD, PhD, Department of Oph- mary site was the uvea or conjunc- tastases in the pericardium, epicar- thalmology, Massachusetts Eye and Ear tiva.5 The purpose of the present re- dium, and myocardium (Figure 1) Infirmary, Harvard Medical School, 243 port is to describe 5 patients with in the apex of the heart. Case 4. One Charles St, Boston, MA 02114. cardiac metastasis and to estimate pigmented myocardial metastasis 1 1. Wolfe J. Laser retinal injury. Mil Med. 1985;150: the frequency of metastasis to the cm in diameter in the posterior wall 177-185. heart from uveal melanoma. of the heart, together with several 2. Haifeng L, Guanghuang G, Dechang W, Liang- shun S, Jiemin X, Haibiao W. Ocular injuries endo- and pericardial metastases 2 from accidental laser exposure. Health Phys. 1989; Report of Cases. To get a reliable es- to 3 mm in diameter. Case 5. A soli- 56:711-716. timate of the spectrum and frequency tary metastasis in the epicardium. 3. Thach AB, Lopez PF, Snady-McCoy LC, Golub BM, Frambach DA. Accidental Nd:YAG laser injuries of cardiac metastasis, we reviewed The frequency of cardiac metas- tothemacula.AmJOphthalmol.1995;119:767-773. clinical and autopsy data of a consecu- tasis at autopsy was 19% (5 of 27 4. Lam T, Tso M. Retinal injury by neodynium: YAG laser. Retina. 1996;16:42-46. tive series of 167 patients who had an cases) (95% confidence interval [CI], 5. Lewis H, Cowan GM, Straatsma BR. Apparent eyeenucleatedbetween1972and1981 6%-38%). This finding is essentially disappearance of a macular hole associated with because of a choroidal or ciliary body identical to that of a 1963 population- development of an epiretinal membrane. Am J 6 Ophthalmol. 1986;102:172-175. melanoma. These patients have com- based Danish study, which reported plete, validated follow-up data. By De- pericardial and myocardial metasta- cember 1999, tumors had dissemi- ses in 9 (24%) of 38 patients who were 2 Cardiac Metastasis nated in 80 patients (48%). Autopsy autopsied (95% CI, 11%-40%). The From Uveal Melanoma had been performed on 27 (34%) of frequency of cardiac metastasis in the these 80 patients, who all died of dis- entire series of 167 patients who had Ruiz and coworkers1 recently de- seminated uveal melanoma. Sites of an eye enucleated was thus 3.0% (95% scribed an elderly woman who de- metastases that were identified clini- CI, 1%-7%), and the frequency of veloped cardiac metastasis from cho- cally or by macroscopic examination symptomatic cardiac metastasis was roidal melanoma and died of a at autopsy were recorded. Metastases 0% (95% CI, 0%-2%). We recognize ruptured myocardium. Because of a that were detected only incidentally the limitations of our study in that the scarcity of other reports, they con- by microscopy, including 1 in the autopsy rate was not high and patients cluded that cardiac metastasis from heart, were disregarded. Statistical were not selected for autopsy at ran- uveal melanoma was extremely rare, analysis was based on exact probabil- dom. Autopsies were done on an in- perhaps with the exception of pa- ity distributions (StatXact-3; Cytel dividual basis according to the pref- tients with widespread micrometas- Software, Cambridge, Mass). erence of the attending physician and tases that might go undetected with- Five patients (Table) had car- the relatives of the deceased. out autopsy.1 In our experience, diac metastases, all of which were Retrospective evidence did not macroscopically detectable metas- clinically asymptomatic. Macro- suggest any obvious bias regarding se- tasis from uveal melanoma to the scopic autopsy reports gave the fol- lection of patients for autopsy. Of the heart is not uncommon, although it lowing descriptions: Case 1. Three 27 patients who underwent autopsy,

Clinical Characteristics of 5 Patients With Malignant Uveal Melanoma*

Patient No./ Time From Time From Sex/Age at Largest Basal Microvascular Enucleation to Metastasis Enucleation, y Site Cell Type Diameter, mm Loops Metastasis, y to Death, mo Sites of Metastasis at Autopsy 1/M/47 Choroidal Mixed 12 Networks 15.9 2 Heart (myocardium), liver, pancreas, and lymph node 2/F/48 Choroidal Mixed 6 None 6.9 6 Heart (myo-, endo-, and epicardium), liver, pancreas, lung, stomach, kidney, thyroid, adrenal, brain, and lymph node 3/F/72 Choroidal Epithelioid 6 Loops 1.2 3 Heart (myo-, epi-, and pericardium), liver, pancreas, lung, kidney, bladder, thyroid, and skin 4/M/72 Choroidal Necrotic 10 NA 9.3 1 Heart (myo-, endo-, and pericardium), liver, pancreas, bladder, and lymph node 5/M/57 Ciliochoroidal Necrotic 25 NA 1.3 4 Heart (epicardium), liver, kidney, lung, adrenal, lymph node, and skin

*All 5 patients had cardiac metastasis at autopsy. NA indicates not assessable.

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Figure 1. Epithelioid melanoma cells infiltrate within the myocardium (A) diffusely (hematoxylin-eosin, original magnification ϫ225) and (B) as small nodules (hematoxylin-eosin, original magnification ϫ360) (case 3). Ͻ 10 topsy (Figure 2)(P .001, Pearson many of them have concurrent heart ␹2 test). None (95% CI, 0%-17%) of disease, which may obscure the ori- the 20 patients who had 3 or fewer gin of cardiac symptoms or of electro- metastatic sites had cardiac metasta- cardiographicfindingsrelatedtometa- 5 ses, whereas 5 (71%; 95% CI, 29%- static uveal melanoma. 96%) of 7 patients with 4 or more Since submission of the manu-

Sites at Autopsy 7 No. of Metastatic metastatic sites had cardiac metasta- script,Rosarioetal recentlydescribed ses. Presence of cardiac metastases a woman who experienced syncope 0 No Yes among the 80 patients who died of attacks because of endocardial and left Cardiac Metastasis disseminated uveal melanoma was ventricular metastasis from choroidal Figure 2. Number of macroscopic metastatic not associated with the age at diag- melanoma. She died of complications sites detected in 27 autopsied patients with nosis of uveal melanoma (P=.47, during cardiac surgery. metastatic uveal melanoma. Except for one patient with cerebral metastasis, 10 of the 11 Mann-Whitney test) or with the time patients who had only one metastatic site had from enucleation to death (P=.82, Teemu Ma¨kitie, MD hepatic metastases. The 5 patients who had log-rank test). Tero Kivela¨,MD cardiac metastases had a higher number of Helsinki, Finland metastatic sites than those who did not (PϽ.001, Comment. Based on our data, we es- Pearson ␹2 test). Bar indicates median. timate that cardiac metastasis from Corresponding author and reprints: 5 were autopsied without suspicion uveal melanoma is found in approxi- Teemu Ma¨kitie, MD, Ophthalmic Pa- of metastasis, which argues against se- mately one fifth of patients who die of thologyLaboratory,DepartmentofOph- lection for autopsy of patients with this tumor. It is possible that the abil- thalmology, Helsinki University Cen- known widespread dissemination. ity to spawn widespread visceral me- tral Hospital, Haartmaninkatu 4 C, PL Furthermore, no difference between tastasis, often with cardiac involve- 220,FIN-00029HUS,Helsinki,Finland autopsied and nonautopsied patients ment,isapropertydevelopedbyasub- (e-mail: [email protected]). who died of disseminated uveal mela- set of uveal melanomas, as opposed to being the result of longer survival 1. Ruiz RS, El Harazi S, Albert DM, Bryar PJ. Car- noma was observed in the age at diac metastasis of choroidal melanoma. Arch Oph- enucleation (P=.25, Mann-Whitney time that would allow more extensive thalmol. 1999;117:1558-1559. test), the presence of metastatic symp- dissemination. Such metastases, how- 2. Jensen OA. Malignant melanomas of the uvea in ␹2 Denmark 1943-1952: a clinical, histopathologi- toms (P=.16, Pearson test), or the ever, seldom cause clinical symptoms. cal, and prognostic study. Acta Ophthalmol. 1963; time from enucleation to the onset of In addition to the case report of Ruiz 75(suppl):1-220. and coworkers,1 we are aware of one 3. Einhorn LH, Burgess MA, Gottlieb JA. Meta- symptoms and signs of metastatic dis- static patterns of choroidal melanoma. Cancer. ease (P=.96, log-rank test). Compari- lethal cardiac metastasis from uveal 1974;34:1001-1004. son of the number of clinically known melanoma.4 This 69-year-old man de- 4. Matturri L, Nappo A, Varesi C, Rossi L. Metas- tasi cardiache di melanoma maligno. Patho- metastasesatthetimeofdeathbetween veloped an atrioventricular block and logica. 1993;85:97-102. autopsied and nonautopsied patients atrial fibrillation and died of cardiac 5. Glancy DL, Roberts WC. The heart in malig- indicated no statistically significant arrest. At autopsy, he was found to nant melanoma: a study of 70 autopsy cases. Am J Cardiol. 1968;21:555-571. difference between groups (mean, 1.3 havemetastasesintheheart,liver,pan- 6. Ma¨kitie T, Summanen P, Tarkkanen A, Kivela¨T. vs 1.7, respectively; P=.18, Mann- creas,adrenalgland,andlymphnodes. Microvascular loops and networks as prognostic The cardiac metastases involved the indicators in choroidal and ciliary body melano- Whitney test). mas. J Natl Cancer Inst. 1999;91:359-367. Presence of cardiac metastasis atrioventricularnodeandleftandright 7. Rosario RT, DiMaio DJ, Lapham RL, Sweeney was statistically significantly associ- bundle branches.4 On the other hand, M, Smalling R, Barasch E. Metastatic ocular melanoma to the left ventricle inducing near- ated with a large number of macro- patients who die of uveal melanoma syncope attacks in an 84-year-old woman. scopic metastatic sites detected at au- are generally 56 years or older, and Chest. 2000;118:551-553.

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