Inadvertent evisceration of eyes containing uveal melanoma

Abstract

Objectives: To report an important complication of ocular evisceration therapy for blind, painful eyes that has been unreported in the literature, and to stress the need for careful preoperative evaluation to exclude occult neoplasms prior to therapy.

Design: Multicenter, retrospective, nonrandomized clinicopathological case series of patients found to have previously unsuspected uveal malignant melanoma during histopathological examination of blind, painful eyes treated by evisceration.

Results: Histopathological examination of evisceration specimens disclosed previously unsuspected uveal melanoma in 7 patients who were treated for blind, painful eyes. Inflammation caused by necrosis of the tumor and other ocular tissues led to misdiagnosis as endophthalmitis, orbital cellulitis, or idiopathic orbital inflammation in several cases. Preoperative imaging was not performed in 3 cases and failed to detect tumors in the remaining 4 cases. Failure of necrotic tumors to enhance contributed to misdiagnosis.

Conclusions: The presence of a malignant intraocular neoplasm should be excluded prior to evisceration of any blind eye or blind, painful eye, particularly with opaque media. Necrosis-related inflammation can confound the clinical diagnosis of occult lesions, as can failure of necrotic tumors to enhance on imaging studies.

Figure

Cases 1 (A–D) and 4 (E–H). A, The blind left eye containing occult melanoma is injected and chemotic. B, A computed tomographic scan shows increased signal in the vitreous cavity of the involved eye and eyelid edema. Inset, Arrowhead indicates apex of probable tumor. C, Histopathological examination of the evisceration specimen shows viable and necrotic tumor (asterisk) (hematoxylin-eosin, original magnification ×25). D, Necrotic tumor. Arrows indicate nuclei with prominent nucleoli consistent with epithelioid cells (hematoxylin-eosin, original magnification ×400). E, The proptotic right globe with unsuspected melanoma shows massive chemosis. F, The right intraocular contents on computed tomography are hyperintense compared with the normal left eye. A massive area of extraocular extension forms a contiguous orbital mass. G, Histopathological examination of the evisceration specimen shows areas of viable and necrotic tumor (asterisk) (hematoxylin-eosin, original magnification ×25). H, The necrotic cells are poorly cohesive (hematoxylin-eosin, original magnification ×250).