bluish or greenish protrusion of the retina into the vitreous from any part of the fundus, we suspect that it is caused by the presence of a sarcoma in the choroid. If it has a light pink, or flesh color we may believe it to be a leucosarcoma, but, as a rule, the various histo- logical varieties cannot be differentiated ophthalmoscopically. A sharply defined scotoma, and a tense, smooth surface of the swelling, taken together with the history, may make us practically certain of our diagnosis, but very often enough detachment of the retina is added to make us uncertain, and sometimes the differentiation of a small tumor in the midst of a large detachment is quite difficult. A soft eyeball inclines us to believe that no tumor is present, while a hard one tends to strengthen our suspicions, but the tension is at best an unreliable guide. The best means of differentiation that we possess is transillumination, which has been described already under detachment of the retina. Once in a while we meet with a carcinoma of the choroid, and it is important that we should be able to differentiate this from sar- coma. If the patient has had a rapid loss of vision, so that one or both eyes have become practically blind within two or three weeks, especially if there has been much pain in the eye that was not ac- counted for by any externally visible conditions or by an increase of the intraocular tension, and we see near the posterior pole a yellowish elevation that slopes away gradually into the surrounding tissues, probably associated with a more or less extensive detach- ment of the retina, which may be flat, or if a detachment is the only thing visible with such a history, we suspect a metastatic carcinoma of the choroid. ‘This diagnosis may be considered fairly well established if we can find a primary cancer somewhere else in the body, for in this situation it is almost if not quite invariably secondary. The primary growth usually is to be found in the breast, but it may be in some other part. The patients almost always are elderly. A flat sarcoma, or an endothelioma, may resemble a carcinoma quite closely, particularly when it is not pigmented and is situated near the posterior pole of the eye, but the history is that of a slow THE RETINA AND CHORDOID 407 loss of vision, and we are unable to find a primary growth in any other part of the body. The differentiation between the two iS important, because the indications for treatment are exactly opposite. Unless necessary to relieve pain enucleation is contraindicated in carcinoma of the choroid, because the operation seems to shorten life rather than to prolong it, while it is indicated in sarcoma as the only means by which life can be prolonged.<Callout type="warning" title="Rapid Vision Loss">If a patient experiences rapid vision loss, consider metastatic carcinoma.</Callout><Callout type="important" title="Primary Cancer Location">Always check for primary cancer elsewhere if suspecting metastatic carcinoma.</Callout>
Key Takeaways
- Sarcoma, leucosarcoma, and carcinoma in the choroid can be differentiated using ophthalmoscopic examination.
- Transillumination is a critical tool for diagnosing retinal detachments and tumors.
- Rapid vision loss within weeks may indicate metastatic carcinoma of the choroid.
Practical Tips
- Always perform a thorough history taking to identify any associated symptoms that could aid in diagnosis.
- Use transillumination as part of your examination routine for suspected retinal detachments or tumors.
- Consider enucleation only if sarcoma is confirmed, as it can potentially shorten the patient's life.
Warnings & Risks
Incorrect Diagnosis
Misdiagnosing a tumor as benign when it is malignant can lead to poor treatment outcomes.
Enucleation should only be performed by experienced professionals due to the risk of complications and infection. Failure to identify a primary cancer can lead to ineffective treatment.
Modern Application
While the techniques described in this chapter are historical, the principles of thorough examination and differential diagnosis remain crucial. Modern technology such as OCT (Optical Coherence Tomography) and digital imaging can enhance accuracy but do not replace the importance of clinical history and physical examination.
Frequently Asked Questions
Q: How can a rapid loss of vision be diagnosed?
A rapid loss of vision, especially within two to three weeks, may indicate metastatic carcinoma of the choroid. Look for associated symptoms such as pain in the eye that cannot be explained by external conditions or increased intraocular tension.
Q: What is the significance of a yellowish elevation near the posterior pole during diagnosis?
A yellowish elevation near the posterior pole, often associated with retinal detachment, may suggest metastatic carcinoma. This finding, combined with other symptoms like rapid vision loss and pain, can help in making this diagnosis.
Q: Why is enucleation contraindicated for carcinoma of the choroid?
Enucleation is generally not recommended for carcinoma of the choroid because it may shorten the patient's life. Instead, treatment should focus on addressing the primary cancer elsewhere in the body.