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  • retinal detachment
    separation of the inner layers of the retina from the pigment epithelium, which remains attached to the choroid. Retinal detachment occurs most often as a result of degenerative changes in the peripheral retina and vitreous body, which produce holes or tears in the retina that can range from minute breaks no larger than 0.1 mm to extensive holes that extend over the entire fundus. Causes include trauma to the eyeball, severe contusions, inflammatory lesions and sometimes ocular surgery.
    rhegmatogenous detachment
    retinal detachment with holes.
    nonrhegmatogenous detachment
    retinal detachment with no holes present.
  • Transverse B-scan showing a large, endophytic, irregularly shaped lesion (green arrow) involving most of the posterior fundus with associated retinal detachment (red arrow). There are multiple, focal calcified areas (blue arrow), causing shadowing of the orbit.
  • Ultrasonographic (US) image obtained with a high-frequency linear transducer shows the heterogeneous, nodular mass (arrow) in the globe apposed to the retina and posterior to the lens (arrowhead). (f) US image shows posterior acoustic shadowing (arrow).
  • Figure 7d.  Retinoblastoma in a 7-year-old girl who complained of blurry vision in her right eye. (a) Photomicrograph (original magnification, ×400; H-E stain) shows Flexner-Wintersteiner rosettes with central lumina (straight arrows). Numerous mitotic figures are noted (arrowheads) as well as areas of necrosis (*). Also note the central focus of proliferative vessels with plump endothelial cells (curved arrow). (b) Photomicrograph (original magnification, ×20; H-E stain) shows a homogeneous mass of tumor cells in the posterior globe (*) that invade the optic nerve (arrows). (c) Photomicrograph (original magnification, ×100; H-E stain) shows basophilic neoplastic cells in the optic disc (*) crossing the lamina cribrosa (arrows) into the optic nerve (arrowheads). (d) Photograph of the sectioned gross specimen shows an irregular whitish mass (*) arising from the thickened retina (arrowhead). (e) Ultrasonographic (US) image obtained with a high-frequency linear transducer shows the heterogeneous, nodular mass (arrow) in the globe apposed to the retina and posterior to the lens (arrowhead). (f) US image shows posterior acoustic shadowing (arrow).
  • CT is the preferred method to image the
    child with leukokoria because it is sensitive to calcification
    in retinoblastoma. CT demonstrates clumped or punctate calcification
    (in 95 per cent of cases) in the posterior part of
    the globe extending into the vitreous, with minimal enhancement.
    In advanced cases the tumour may fill the globe (Fig.
    61.1). If CT shows calcification in an intra-ocular mass in a
    child less than 3 years of age, it should be considered a retinoblastoma
    until proven otherwise. Absence of calcification
    means this diagnosis is unlikely, since it is rare in other causes
    of leukokoria.
  • Huge retinoblastoma with orbital and intracranial
    involvement. Axial CT image with contrast medium. The right globe is
    filled by a calcified mass. The optic nerve is also calcified and surrounded
    by a soft tissue mass that replaces orbital fat and extends through the
    optic foramen. There is involvement of the suprasellar cistern, temporal
    lobe, greater wing of sphenoid and temporal fossa.
  • Figure 8a.  Trilateral retinoblastoma in a child of unknown age. (a) Axial CT image enhanced with intravenous contrast material shows bilateral hyperattenuating nodular masses containing dense foci of calcification (arrowheads). (b) Axial CT image enhanced with intravenous contrast material shows a large, round, intensely enhancing mass in the pineal region, which causes hydrocephalus.
  • Coronal T1 weighted image shows a
    mass in the lower part of the left globe with relative high signal intensity. Note the smaller RB in the upper part of the right
  • Axial high-resolution three-dimensional T2 weighted image shows low signal intensity left
    intraocular mass with a few signal void regions that correspond to areas of calcification
  • Multifocal retinoblastoma (RB). Axial threedimensional
    T2 weighted image of the globe at 3 T shows
    multifocal RBs (arrows) seen in the left globe.
  • Endophytic retinoblastoma. Contrast T1 weighted
    image shows intense contrast enhancement of the right
    intraocular mass.
  • Diffuse retinoblastoma. Contrast T1 weighted
    image at 3 T with surface coil shows diffuse infiltrative
    placode lesion with retinal detachment (arrow).
  • Anterior segment eye enhancement. Axial contrast
    T1 weighted image shows enhancement (arrows) of
    anterior segment in a patient with retinoblastoma (RB),
    which may be due to extension of RB or a tumour-induced
    angiogenesis in the iris.
  • Retinoblastoma (RB) with optic nerve invasion. (a) Axial contrast T1 weighted image shows right RB with infiltration
    of a small part of the right optic nerve (arrowhead). (b) Axial contrast T1 weighted image in another patient shows left ocular
    mass infiltrating most of the left optic nerve (arrow).
  • Retinoblastoma

    1. 1. Case presentation Dr Tariq Masood TMO Radiology Department, HMC
    2. 2. Case 2 year old male child Mother had noticed some white spot in the window of his left eye since early childhood And gradual protrusion of the eye
    3. 3. Clinical differentials?
    4. 4. Leucocoria • TUMOR – Retinoblastoma (most common cause--58%) – Retinal astrocytic hamartoma (3%): – Medulloepithelioma (rare) • DEVELOPMENTAL – Persistent hyperplastic primary vitreous • (2nd most common cause--28%) – Coats disease (16%) – Retrolental fibroplasia (3--5%) – Coloboma of choroid / optic disc
    5. 5. • INFECTION – Uveitis – Larval granulomatosis (16%) • DEGENERATIVE – Posterior cataract • TRAUMA – Retinopathy of prematurity (5%) – Organized vitreous hemorrhage – Long-standing retinal detachment
    6. 6. • Leukocoria in Normal-sized Eye • CALCIFIED MASS – Retinoblastoma – Retinal astrocytoma • NONCALCIFIED MASS – Toxocaral endophthalmitis – Coats disease • Leukocoria with Microphthalmia • UNILATERAL – Persistent hyperplastic primary vitreous (PHPV) • BILATERAL – Retinopathy of prematurity – Bilateral PHPV
    7. 7. Diagnosis?
    9. 9. History/Overview • In 1597 it starts with a man named Pieter Pauw and his autopsy findings of cancerous tumor originating in a 3 year-old eye. The results of the autopsy were later found by Edwin B. Dunphy who suggested Retinoblastoma.
    10. 10. In 1872 a Brazilian ophthalmologist called Hilário de Gouvêa treated a boy with retinoblastoma. Later in life, the boy had two daughters that also had retinoblastoma. This proposed perhaps the disease was genetic.
    11. 11. In 1986 Dr. Knudson discovered the retinoblastoma gene and then a year later he isolated the gene making it the first ever tumor suppressor to be identified.
    12. 12. In one of Knudson’s cases he found that one family had a genetic past of the disease and found that the gene causing the disorder is located in chromosome 13 that has been mutated.
    13. 13. Retinoblastoma Rare malignant congenital intraocular tumor arising from primitive photoreceptor cells of retina (included in primitive neuroectodermal tumor group) AKA neuroepithelioma of the retina
    14. 14. Cause of Retinoblastoma 1. Mutations Mutations in the RB1 gene are responsible for most cases of retinoblastoma. RB1 is a tumor suppressor gene, which means that it normally regulates cell growth and keeps cells from dividing too rapidly or in an uncontrolled way.
    15. 15. 2.Chromosomal anomaly– A small percentage of retinoblastomas are caused by deletions in the region of chromosome 13 that contains the RB1 gene. Because these chromosomal changes involve several genes in addition to RB1, affected children usually also have; microcephaly, ear changes, facial dysmorphism, mental retardation, finger + toe abnormalities, malformation of genitalia.
    16. 16. TYPES A.Non-Heritable form B.Heritable form
    17. 17. A.Non-Heritable form(60%) RB1 mutations occur only in the eye and cannot be passed to the next generation. typically only one eye is affected and there is no family history of the disease. Affected individuals are born with two normal copies of the RB1 gene. Then, usually in early childhood, both copies of the RB1 gene in retinal cells acquire mutations or are lost Mean age at presentation--23 months
    18. 18. B.Heritable form(40%) RB1 mutations occur in all of the body's cells, including reproductive cells (sperm or eggs). People with germinal retinoblastoma may have a family history of the disease, and they are at risk of passing on the mutated RB1 gene to the next generation. Mutations in the RB1 gene appear to be inherited in an autosomal dominant pattern.
    19. 19. Autosomal dominant inheritance suggests that one copy of the altered gene in each cell is sufficient to increase cancer risk. A person with germinal retinoblastoma may inherit an altered copy of the gene from one parent, or the altered gene may be the result of a new mutation that occurs in an egg or sperm cell or just after fertilization.
    20. 20. For retinoblastoma to develop, a mutation involving the other copy of the RB1 gene must occur in retinal cells during the person's lifetime. This second mutation usually occurs in childhood, typically leading to the development of retinoblastoma in both eyes.
    21. 21. B.Heritable form 1.Heritable sporadic form 2.Familial retinoblastoma
    22. 22. 1.Heritable sporadic form (20-25%)-- sporadic germinal mutation (50% chance to occur in subsequent generations) Mean age at presentation: 12 months--bilateral retinoblastomas in 66%
    23. 23. 2.Familial retinoblastoma (5-10%) autosomal dominant with abnormality in chromosome 13 Mean age at presentation: 8 months usually 3 to 5 ocular tumors per eye bilateral tumors in 66% Risk of secondary nonocular malignancy: Osteo, chondro, fibrosarcoma, malignant fibrous histiocytoma
    24. 24. Trilateral retinoblastoma (rare variant) bilateral retinoblastomas + neuroectodermal pineal tumor (pineoblastoma)  Quadrilateral retinoblastoma trilateral retinoblastoma + 4th focus in suprasellar cistern 
    25. 25. Incidence 1:15,000 to 30,000 livebirths  Most common intraocular neoplasm in childhood  1% of all pediatric malignancies
    26. 26. Mean age at presentation is 18 months 98% in children <5 years of age M:F = 1:1
    27. 27. Patterns of growth Endophytic Growth occurs inwards into the vitreous ± anterior chamber Cell clusters may detach and float in the vitreous (vitreous seeding)
    28. 28. Exophytic Growth occurs outwards Proliferation into subretinal space with non- rhegmatogeneous retinal detachment + invasion of vascular choroid (hematogenous spread)
    29. 29. Combined Endophytic and Exophytic
    30. 30. Location Posterolateral wall of globe (most commonly) 60% unilateral 40% bilateral + frequently synchronous (90% bilateral in inherited forms) Normal ocular size/Enlarged
    31. 31. Presentations of retinoblastoma • Leukocoria - 60% • Strabismus - 20% • Secondary glaucoma • Anterior segment invasion • Orbital inflammation • Orbital invasion
    32. 32. PROPTOSIS
    33. 33. Imaging of RB Ultrasound CT scan MRI
    34. 34. Imaging is crucial for timely management and survival of patients with retinoblastoma.  Cross-sectional imaging are done to exclude ; Other retrobulbar tumours with globe invasion, Optic nerve invasion by the retinoblastoma Intracranial metastases
    35. 35. US Heterogeneous hyperechoic solid intraocular mass Cystic appearance upon tumor necrosis Secondary retinal detachment in all cases Acoustic shadowing (in 75%) Vitreous hemorrhage frequent
    36. 36. Figure 7e. Retinoblastoma in a 7-year-old girl who complained of blurry vision in her right eye.
    37. 37. Figure 7d. Retinoblastoma in a 7-year-old girl who complained of blurry vision in her right eye. Chung E M et al. Radiographics 2007;27:1159-1186
    38. 38. CT Scan CT is sensitive to calcification.  Clumped or punctate calcification (in 95 per cent of cases) in the posterior part of the globe extending into the vitreous Minimal enhancement.
    39. 39. CT Scan • Calcification in an intra-ocular mass in a child (3 yrs, retinoblastoma until proven otherwise. Absence of calcification means this diagnosis is unlikely, since it is rare in other causes of leukocoria. • Retinoblastoma is the most common cause of orbital calcifications!
    40. 40. CT Scan Solid smoothly marginated lobulated retrolental hyperdense mass in endophytic type  Exophytic type grows subretinally causing retinal detachment Partial punctate / nodular calcification
    41. 41. Dense vitreous (common) Extraocular extension (in 25%): optic nerve enlargement, abnormal soft tissue in orbit, intracranial extension ± Macrophthalmia
    42. 42. CT diagnosis of retinoblastoma Calcification
    43. 43. Figure 8a. Trilateral retinoblastoma in a child of unknown age.
    44. 44. MRI MRI is the modality of choice for pre-treatment staging on retinoblastoma T1 : Intermediate signal intensity, hyperintense c.f. vitreous T2 : Hypointense c.f. vitreous subretinal exudate usually hyperintense on T1WI + T2WI (proteinaceous fluid)
    45. 45. T1 C+ (Gd) The mass usually enhances relatively homogeneously when small Larger tumours often have areas of necrosis, rendering it heterogeneous
    46. 46. Linear enhancement of the choroid beyond the margins of the tumour should raise the possibility of choroidal involvement, although inflammation may lead to similar appearance
    47. 47. Enhancement of the anterior chamber need not represent tumour involvement, with hyperaemia, uveitis and iris neovascularisation all leading to asymmetric enhancement
    48. 48. Careful assessment of the optic disc and optic nerve should be carried out to assess for involvement
    49. 49. Extra-ocular extension through the sclera will be visible as interruption of the otherwise hypointense non-enhancing sclera by enhancing tumour
    50. 50. PROGNOSIS Spontaneous regression in 1%;
    51. 51. Poor prognostic signs Contrast enhancement Anterior locations Optic nerve Poor cellular involvement Choroidal invasion Large tumor differentiation Older children
    52. 52. COMPLICATIONS  (1) Metastases to: meninges (via space), bone marrow, lung, subarachnoid liver, lymph nodes (2) Radiation-induced sarcomas develop in 15-20%
    53. 53. Mortality Choroidal invasion: 65% if significant, 24% if slight Optic nerve invasion: <10% if not invaded 15% if through lamina cribrosa 44% if significantly posterior to lamina cribrosa Margin of resection not free of tumor: >65%
    54. 54. Differential diagnosis Retinal Astrocytic hamartoma Retrolental fibroplasia Coat’s disease Peristent hypertrophic primary vitreous Toxocaral infestation Norrie’s disease
    55. 55. DDx Retinal astrocytic hamartoma. May occur in association with TS or NF or an isolated abnormality. May be bilateral multiple small retinal masses.  calcification may occur in the older child
    56. 56. • Coats disease • Coats’ disease is a primary congenital, non-familial idiopathic vascular anomaly of the retina. It is characterised by telangiectatic, leaky retinal vessels that lead to progressive retinal exudates. It usually occurs in young males (70%) with an incidence peak at age 6–8 years. It is mostly unilateral (90%). Patients present with leukocoria, strabismus or painful glaucoma..
    57. 57. Calcification is rare,allowing differentiation from RB. CT shows homogeneous increased density within the vitreous chamber,retinal detachment and lack of enhancement after contrast administration. The MRI findings are retinal detachment without intraocular mass and high signal subretinal effusion on both T1W and T2W MRI
    58. 58. Retrolental fibroplasia Retinopathy of prematurity causes retro-lental fibroplasia with the development of retrolental membranes. Present usually with bilateral leucocorea at the age of 7-10weeks with a history of prematurity and oxygen therapy. No Calcification. Microphthalmia.
    59. 59. Persistent hyperplastic primary vitreous is caused by the failure of the embryonic hyaloid vascular system to regress normally and extensive proliferation of embryonic connective tissue It is characterised by a leukocoria in a microphthalmic eye. Small irregular lens with shallow anterior chamber. If bilateral,PHPV may be part of the diagnosis of Norrie’s disease.
    60. 60. On CT No calcification. Increased attenuation of vitreous with enhancement of abnormal intravitreal tissue. Triangular retrolental density with its apex on the posterior lens and base on the posterior globe.
    61. 61. Toxocara canis infection Sclerosing endophthalmitis is a granulomatous chorioretinitis uveitis that develops secondary to a Toxocara canis infestation, in more than 5 yrs age Present with leucocorea----often bilateral. It differs from RB by its central position, the fact that it is hyperintense to vitreous on T2 weighted images, the patient age and a positive serologic enzymelinked immunosorbent assay (ELISA).
    62. 62. CT demonstrate a hyperdense vitreous cavity,sometimes with retinal detachment.No enhancement is seen.
    63. 63. Norrie disease Rare X-linked recessive syndrome consisting of retinal malformation, deafness and mental retardation. Female carriers are completely healthy. The ocular changes in male patients include retinal detachments and vitreo-retinal haemorrhage
    64. 64. Treatment • Depends on tumour size and the stage of disease and involves one or more modalities: • Conservative external-beam radiation therapy cryotherapy laser photocoagulation radioactive plaque therapy thermochemotherapy tumour reduction chemotherapy • Surgical enucleation en bloc resection
    65. 65. Treatment Advantages Disadvantages Photocoagulation (Laser Therapy) The laser beam focuses on the cancerous tumor, cuts off blood supply to the tumor and shrinks it. Depending on the size of the tumor, chemotherapy may be needed for larger tumors that cannot be shrunk by just laser. Cryotherapy (Freezing Treatment) The tumor is frozen and thawed a several times by a cold gas and it deflates the tumor with no signs of a tumor at all. The tumor will leave a pigmented scar and the eye lid will swell for a couple of days. Chemotherapy After the extensive cycles of chemo, the cancer cells are reduced, therefore, shrinking of the tumor. There are several cycles, and there is a port necessary to draw blood, and insert the drugs. Enucleation This is removal of the eyeball and the tumor is extracted when no other option is possible due to the size of the tumor. The whole eyeball is removed and it causes permanent eye damage because there is no way of an eye transplant.
    67. 67. THANKS