Eyelids and anterior segment: Case four

This 46 year old woman was referred by the hospice doctor because of a three-week history of pain in her right eye. She was known to widespread carcinomatosis of unknown origin. Slit-lamp examination revealed this iris appearance.

a. What is the differential diagnosis?

The differential diagnosis of an iris mass include:

• iris naevus
• iris melanoma
• iris metastasis
• primary iris cyst
• Lisch's nodules
• liomyoma

In this patient, iris metastasis should be high on the list.
Iris metastasis is less common than choroidal metastasis. Ultrasound of the ocular structures is useful in supporting the diagnosis as it may reveal deposits in orbit or choroid.

b. What may be the causes of her ocular pain?

Metastatic tumour often causes anterior segment reaction: inflammation, glaucoma and sometimes hyphaema. The pain in this patient is due to anterior uveitis.

c. How can the lesion be treated?

Therapy is aimed at alleviating ocular symptoms as the long-term prognosis of this patient is poor. Topical steroid is useful in reducing the inflammation and anti-glaucoma should be given for raised intraocular pressure.

In cases where topical treatment does not relieve the symptom, radiation therapy has a high rate of success in reducing the tumour size.

The tumour may also undergo regression with chemotherpy for the primary tumour.