Jonathan Adler, M.D., FAAEM

• Assistant in Emergency Medicine,
• Massachusetts General Hospital
• Instructor in Medicine,
• Harvard Medical School
• Boston, MA

Color depends on frequency diabetes mellitus or diabetes insipidus buy duetact online, so that the color of a ray of light is not altered as it passes through optical media except by selective nontransmittance or fluorescence diabetes 90 day test order duetact 17mg fast delivery. The optical characteristics of a substance can only be defined with respect to clearly specified frequencies of light diabetes type 1 vegetarian diet purchase duetact 16 mg mastercard. A substance to be used for lenses to refract visible light is usually tested with the yellow sodium light (D line) and the blue (F line) and the red (C line) of a rarefied hydrogen discharge tube can diabetes 1 prevention cheapest duetact. In a vacuum, the speed of all frequencies of light is the same (approximately 8 3 10 meters per second). The effect of an optical substance on the speed of light is expressed as its index of refraction, n; the higher the index, the slower the speed and the greater the effect on refraction. Refraction of light as it enters a transparent medium of higher refractive index n. The absolute index of refraction of a substance is the ratio of the speed of light in a vacuum to the speed of light in the substance. The relative index of refraction of a substance is calculated with reference to the speed of light in air. Thermal Coefficient of Index of Refraction the index of refraction increases with increasing temperature of the medium, but the rate of change varies from one medium to another, being approximately 150 times greater for plastic and aqueous than for glass. In the human eye, the problem is overcome by the maintenance of a steady temperature. Dispersion of Light In all media besides a vacuum, the index of refraction is different for each color (frequency), being larger at the blue end and smaller at the red end of the spectrum. This difference can be quantified as the dispersion value, V: where nD, n, and nF C are the indices of refraction for the yellow sodium line 887 and the blue and the red hydrogen lines. Indices of Refraction and Dispersion Values of Some Substances of Ophthalmologic Interest Transmittance of Light Optical materials vary in their transmittance or transparency to different frequencies. Optical media must be selected according to the specific wavelength of light with which they are to be used. Incident, reflected, and refracted rays all reside in a plane known as the plane of incidence, which is normal (at a right angle) to the interface. For reflection, relative to the normal, the angles of reflection and incidence are equal. Conversely, if the arriving ray were in the denser medium, it would be refracted away from the normal. In this situation, as the angle of incidence is increased, the critical angle is reached when the light is totally reflected (total internal reflection) and the sine of the incident ray in the denser medium reaches the value n/ n. Total internal reflection obeys the laws of regular reflection, allowing perfect reflection without coatings and being used extensively in fiberoptics. The trigonometric method is more valid and exact, as it makes no assumptions other than those already determined by the laws of refraction. The algebraic method is based on a number of assumptions that greatly simplify calculation of the effects of various lenses but also limit accuracy to an ever-increasing extent as the lens systems become more complex. The algebraic method cannot be relied on for accurate results, particularly in the assessment of the optical effects of contact lenses, intraocular lenses, and keratorefractive procedures. For any optical system, the object and its image are said to lie in conjugate planes. If the object were to be placed in the plane of its own image, the optical system would produce its new image in the original object plane. Thus, the effects of any optical system will be the same for whichever direction light travels through the system. The zonal ray represents the average luminous flux of light passing through the lens. The trigonometric method provides an exact determination of the point of focus and information on the quality of the image formed by a lens system. Similarly, if rays of different color (frequency), with their different indices of refraction in each medium, are plotted through the system, the degree of chromatic aberration (see later in the chapter) will be determined. The optical pathway is the sum of the actual distance a ray passes through the substances multiplied by the index of refraction in the various substances through which it passes. The brightness and contrast of the final image are determined by how closely the optical pathways of the marginal and paraxial rays match. The results are the thin lens equations used by opticians to calculate curves for lenses. The position of the lens, reduced to a single line, is the principal plane, which intersects the optical axis at the nodal point (optical center). The primary focal point (F) is that point along the optical axis where an object must be placed to form an image at infinity. The secondary focal point (F) is that point along the optical axis where parallel incident rays are brought to a focus. If the medium on either side of the lens is of the same refractive index, the distance between the nodal point and each of the focal points, the focal length, is the same. It is defined as the reciprocal of the focal length of a lens in air measured in meters. The result of combining lenses of high power varies greatly with their thickness and the separation distance. High-power lenses must be described by three values: (1) radii of curvature, (2) index of refraction, and (3) thickness. The nodal points lie on the principal planes only if the refractive medium is the same on either side of the lens. The reciprocal of the back focal length corresponds to the back vertex power as measured with a lensometer. The ray tracing method commonly described in ophthalmic optics texts is a graphic representation of the algebraic method (in contrast to true graphic ray tracing, which is a graphic representation of the trigonometric method). The positions of the conjugate planes are derived mathematically from the thin lens equations. The size and orientation of the object are then determined by tracing the central ray, which passes straight through the tip of the image, the nodal point of the lens (without being refracted), and the tip of the object. For multiple lens systems, the conjugate planes and the path of the central ray are determined for each lens in succession, producing an image that becomes the object for the next lens until the size and orientation of the final image is located.

Special attention should be not eliminate the possibility of the patient actually being paid to any adhesions or synechiae diabetes diet sheet nhs 16mg duetact otc, anterior to the cornea blind due to a central lesion affecting the visual pathways or posterior to the lens capsule leven met diabetes mellitus type 2 janssen purchase duetact online. The size of the pupil is determined by the afferent and effer Dilated and immobile pupils also result from third nerve ent pathways for pupillary light refexes diabetes insipidus alcohol purchase duetact with american express, and the function of palsies (absolute paralysis of the pupil); if the paralysis the sphincter and dilator pupillae muscles diabetes university discount duetact 16 mg without prescription. Dilatation of the also affects the third nerve fbres to the ciliary muscle, ac pupils with retained mobility is found sometimes in myopia commodation is also paralysed (ophthalmoplegia interna). This results in lesions affecting the third nerve nucleus, Conversely, the pupils are small in babies and in old people. This may be due to conditions hand and watch the pupil, noting if its constriction to light such as swollen lymph nodes in the neck, apical pneumo is well maintained. Replace this hand and remove the other, nia, apical pleurisy, cervical rib and thoracic aneurysm. Most of the conditions causing an process is repeated while observing the other pupil. When all sympathetic function on to an absence of natural light or diffuse illumination. More one side is lost, resulting in miosis, a narrowed palpebral over, when the reaction to light is feeble and the pupils are fssure and slight enophthalmos (due to loss of tone already small, it is diffcult to be certain of the results in of Muller muscle), sometimes associated with unilateral bright, diffuse daylight. In such cases the examination absence of sweating, the condition is called the Horner should be carried out in a dark room and light concentrated syndrome. Still fner observations can be iritis with posterior synechiae, and should be investigated made with the slit-lamp, when the microscope is focussed with a mydriatic such as cyclopentolate to ascertain if the on the papillary margin and the beam is abruptly switched pupil dilates regularly. If there is no irritation of the third nerves, arousing suspicion of a central movement in these conditions it may be concluded that the nervous disease in their vicinity. The light is focused frst on the large, immobile and oval, with the long axis vertical. The best source of illumination for this purpose is the focal beam of Pupillary Refexes the slit-lamp reduced to a spot. If the reaction is present During routine examination of the eyes, the pupils should the pupil will react briskly when one half of the retina is be examined at an early stage, before any mydriatic is em illuminated, but very slightly when the other half is illumi ployed. This is so because it is impossible to prevent diffusion and is best carried out with low background illumination of light onto the sensitive half of the retina, so the test is using a bright focused light with the patient looking into the rarely unequivocal. This swinging to-and-fro of the light is repeated several times l Illumination in the examination room should be low while observing the response of the pupil to which the light l the patient should look into the distance, and is transferred (Fig. The patient is asked to look consensual response has the same magnitude as a direct into the distance to prevent accommodative constriction of response. Note the size, shape and contour of each pupil, input from that side is less than that from the normal side. This is referred to as light near determined by asking the patient to look to the far end dissociation. The movement of associated with syphilis, occurs usually in young women, is the pupils is studied while he converges. This When properly conducted, the above method provides pupil is slightly dilated and always larger than its fellow; reliable information as to the shape and relative size of the the unilateral Argyll Robertson pupil is always smaller. A few of the common conditions Although in the tonic pupil the reaction to light seems ab are considered here. The reaction of the pupil on convergence is sluggish with a long latent period and is Abnormal Reactions of the Pupil unduly sustained. As mentioned pine; the Argyll Robertson pupil does not; fnally, the tonic earlier, loss of light refexes results from a lesion in the retina pupil constricts with 0. A lesion in the third due to the pupil size, which do not last longer than a few nerve abolishes both light and convergence refexes. The affected More complex lesions may result from damage to the eye usually has a slight accommodative paresis and astheno relay paths in the tectum between the afferent and efferent pia is often induced by near effort. The most important of these is the Argyll Robertson get the two eyes to work together when reading and are best pupil, usually caused by a lesion, almost invariably syphilitic, advised to use dilute pilocarpine and fx with the other eye. Any opaci Diffuse illumination allows an observer to obtain a direct ties in the pupillary area can be seen by inspection, aided by and tangential view of the anterior segment of the eye. The Diffuse illumination allows determination of general fea haze is much more pronounced in an old person and the tures, such as colour, size and relative position of structures. This is followed by tangential illumination with a large It is probable that the patient has a cataract, but examina angle of illumination, which helps to increase contrast and tion by distant direct ophthalmoscopy shows a clear red highlight the texture of ocular tissues. The explanation is that the refractive index of the lens substance increases with age, and scattering of light from its surface is greater. Various forms of cataract are view of the eye illuminated by a slit-lamp beam of light of diagnosed according to their distribution and nature but moderate width, entering the eye from the left side. Opti observation must always be confrmed by ophthalmoscopic cally the homogeneous media appear quite black; struc examination, and the opacities localized with the help of the tures such as the cornea, lens and suspended particles in slit-lamp (see Figs 11. On the left the pupil, looking as if it were on the surface of the lens, of both Fig. The black space on the right is the anterior appearance over the whole pupillary area suggests a total or chamber. A mature cataract; if it is yellowish-white, with white spots of dim central interval can be distinguished, formed by the calcifcation and the iris is tremulous, a shrunken calcare embryonic nucleus with its Y-sutures. Ocular problems can be identifed by different meth ods of examination, which differ in the positioning of the illuminating light and the angle between the illumination and observation arms. Various permutations and combina tions of these techniques are used, some simultaneously and others sequentially. Specular Refection Specular refection allows the observer to visualize the cor neal endothelium by viewing light refected back from this interface. This is placed immediately adjacent to the refection of the slit-lamp bulb on the cornea. A golden sheen with darker lines outlining the hexagonal endothelial cells is seen (Fig. This light is totally internally refected through the thickness of the cornea, like a fbre-optic light pipe, and emerges at the opposite limbus. The fundal glow highlights the pre Tonometry is the assessment of the intraocular pressure of the sence of opacities in the media, such as cataracts (Fig. It also highlights the presence of Subjective method: It may be done digitally in the defects in the integrity of the normally opaque iris. The light refected off the iris allows Instruments known as tonometers have been devised for visualization of subtle, transparent corneal irregularities, such measuring the intraocular pressure of the intact eye and are as ghost vessels or keratic precipitates. An assistant the nearest mm Hg for the different weight of the Schiotz may separate the lids while you concentrate on proper placement tonometer. After anesthetic drops use the nest highest weight that will give a reading of 5 or are instilled, the patient will not experience any pain from this more. It is important to have a relaxed patient because squinting and blepharospasm may interfere with the reading. Note: Use the above chart to determine the converted reading Gloves should be worn. The depth and the volume of the Rod indentation are dependent on the intraocular pressure and the distensibility of the ocular walls. Housing the instrument is calibrated so that the equivalent read ings in millimetres of mercury can be read off a chart.

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Convergence-retraction nystagmus may represent asynchronous diabetes prevention zumba buy duetact online now, opposed diabetes insipidus juvenile order 16mg duetact with mastercard, 696 adducting saccades due to inappropriate activation of the medial rectus muscles diabetes in dogs care purchase generic duetact line. Although it is uncommon diabetes hot dogs cheap 16 mg duetact with mastercard, it occurs with acquired and congenital chiasmal lesions in association with a bitemporal hemianopia, and midbrain lesions. There does not appear to be a single underlying pathogenesis, but it is likely that dysfunction of the interstitial nucleus of Cajal or the rostral interstitial nucleus of the medial longitudinal fasciculus is important in the cases with midbrain disease. Periodic Alternating Nystagmus this is a horizontal jerk nystagmus regularly alternating between leftward and rightward directions, with each phase lasting approximately 2 minutes. The acquired form usually results from cerebellar disease, such as cerebellar degeneration; congenital hindbrain anomaly, such as Chiari malformation; multiple sclerosis; or anticonvulsant therapy. It may also occur with bilateral blindness and be suppressed if vision is restored. Periodic alternation may also be a feature of congenital nystagmus (see earlier in the chapter). There is also a variety of abnormal eye movements that occur in coma, including ocular bobbing, ocular dipping, and ping-pong gaze. Superior oblique myokymia (see earlier in the chapter) is a tremor of the superior oblique muscle leading to episodic monocular vertical or torsional oscillopsia. About 5% of normal individuals can generate short bursts of ocular oscillations (voluntary nystagmus) that resemble small-amplitude, fast, horizontal pendular nystagmus. Eye movement recordings show the movements to be rapidly 697 alternating saccades. They also occur in thrombotic disorders such as hyperviscosity states or antiphospholipid syndrome and from other causes of impaired ocular or cerebral perfusion such as giant cell arteritis, migraine, vertebrobasilar ischemia (see later in the chapter), severe hypotension, or shock. There may be associated transient ischemic attacks or completed strokes of the ipsilateral cerebral hemisphere. Fleeting episodes of visual loss that last a few seconds (transient visual obscurations) may occur in papilledema, affecting one or both eyes together, or monocularly with orbital tumors. Cholesterol, platelet-fibrin, and calcific are the three main types of retinal emboli. Cholesterol emboli (Hollenhorst plaques) may be visible with the ophthalmoscope as small, glistening, yellow-red crystals at bifurcations of the retinal arteries. The nonreflective gummy white plugs filling retinal vessels, which characterize platelet-fibrin emboli, are less commonly seen because they quickly disperse and traverse the retinal circulation. Calcific emboli, which usually originate from damaged cardiac valves, have a duller, white-gray appearance compared with cholesterol emboli. Retinal emboli may also produce branch or, particularly in the case of calcific emboli, central retinal arterial occlusions. Most patients require antiplatelet agent, usually low-dose (81 mg/d) aspirin, and may require treatment to reduce blood pressure and serum lipids. Incidentally noted cholesterol retinal emboli in asymptomatic individuals are associated with a tenfold increased risk of cerebral infarction, but the role of carotid endarterectomy in such individuals is uncertain. After 12 hours, the clinical picture is usually irreversible, although many exceptions to this rule have been reported. Visual acuity better than counting fingers on presentation has a better prognosis with vigorous treatment. Embolic retinal arterial occlusion has a poorer 5-year survival rate due to attendant cardiac disease or stroke than occlusion due to thrombotic disease. Slow flow (venous stasis) retinopathy is a sign of generalized ocular ischemia and indicative of severe carotid disease, usually with complete occlusion of the ipsilateral internal carotid artery. It is characterized by venous dilation and tortuosity, retinal hemorrhages, macular edema, and eventual neovascular proliferation. It resembles diabetic retinopathy, but the changes occur more in the retinal midperiphery than the posterior pole. In more severe cases, there may be vasodilation of the conjunctiva, iris neovascularization, neovascular glaucoma, and frank anterior segment ischemia with corneal edema, anterior uveitis, and cataract. Diagnosis is most easily confirmed by demonstration of reversal of blood flow in the ipsilateral ophthalmic artery using orbital ultrasound, but further investigation by angiography is usually required to determine the full extent of arterial disease. Carotid endarterectomy may be indicated but carries a risk of precipitating or exacerbating intraocular neovascularization. The role of panretinal laser photocoagulation in treating intraocular neovascularization is uncertain. Occlusion of the Middle Cerebral Artery 699 this disorder may produce severe contralateral hemiplegia, hemianesthesia, and homonymous hemianopia. The lower quadrants of the visual fields (upper radiations) are most apt to be involved. Vascular Insufficiency of the Vertebrobasilar Arterial System Brief episodes of transient bilateral blurring of vision commonly precede a basilar artery stroke. An attack seldom leaves any residual visual impairment, and the episode may be so minimal that the patient or doctor does not heed the warning. The blurring is described as a graying of vision just as if the house lights were being dimmed at a theater. Episodes seldom last more than 5 minutes (often only a few seconds) and may be associated with other transient symptoms of vertebrobasilar insufficiency. Antiplatelet drugs can decrease the frequency and severity of vertebrobasilar symptoms. Occlusion of the Basilar Artery Complete or extensive thrombosis of the basilar artery nearly always causes death. These include nystagmus, supranuclear eye movement abnormalities, and involvement of third, fourth, sixth, and seventh cranial nerves. Prolonged anticoagulant therapy has become the accepted treatment of partial basilar artery thrombotic occlusion. Occlusion of the Posterior Cerebral Artery Occlusion of the posterior cerebral artery seldom causes death. Occlusion of the cortical branches (most common) causes homonymous hemianopia, usually superior quadrantic (the artery supplies primarily the inferior visual cortex). Lesions on the left in right-handed persons can cause aphasia, agraphia, and alexia if extensive with parietal and occipital involvement. Involvement of the occipital lobe and splenium of the corpus callosum can cause alexia (inability to read) without agraphia (inability to write); such a patient would not be able to read his or her own writing. Occlusion of the proximal branches may produce the thalamic syndrome (thalamic pain, hemiparesis, hemianesthesia, choreoathetoid 700 movements), and cerebellar ataxia. Subdural Hemorrhage Subdural hemorrhage results from tearing or shearing of the veins bridging the subdural space from the pia mater to the dural sinus. It leads to an encapsulated accumulation of blood in the subdural space, usually over one cerebral hemisphere. The trauma may be minimal and may precede the onset of neurologic signs by weeks or even months. In infants, subdural hemorrhage produces progressive enlargement of the head with bulging fontanelles. Ocular signs include strabismus, pupillary changes, papilledema, and retinal hemorrhages. In adults, the symptoms of chronic subdural hematoma are severe headache, drowsiness, and mental confusion, usually appearing hours to weeks (even months) after trauma. Ipsilateral dilation of the pupil is the most common and most serious sign and is an urgent indication for immediate surgical evacuation of blood. Unequal, miotic, or mydriatic pupils can occur, or there may be no pupillary signs. Other signs, including vestibular nystagmus and cranial nerve palsies, also occur. Many of these signs result from herniation and compression of the brainstem, and therefore often appear late with stupor and coma.

Spontaneous and laser-induced regression diabetes diet rules purchase duetact 17mg overnight delivery, or at least decalcification blood sugar solution buy generic duetact 17mg line, of choroidal osteomas has been reported diabetes mellitus kurze zusammenfassung buy duetact 17 mg online, but this is not usually associated with improvement of visual acuity blood sugar healthy range cheap 17 mg duetact amex. Because the tumor has no recognized malignant potential, no destructive treatment for the tumor is indicated. There are small caliber blood vessels on its surface and localized subretinal blood superiorly. Biopsy may reveal benign cells, malignant cells, or borderline malignant cells according to cytologic or histologic criteria. Nevus versus Melanoma Category Approximately 95% of uveal nevi never exceed 5 mm in maximal basal diameter and 1 mm in thickness, but the remaining 5% can achieve substantially larger dimensions. Uveal nevi are substantially more common than uveal melanomas, so there is considerable overlap between nevi and melanomas among lesions with a 5 to 10-mm basal diameter and/or 1 to 3. In the absence of a tumor specimen that can be evaluated pathologically, one can never be certain which of these tumors is benign (nevus) and which is malignant (melanoma). Because of this diagnostic uncertainty, some ocular tumor experts recommend diagnostic biopsy, usually by fine-needle aspiration, for any small lesions in this category prior to any treatment. Amelanotic melanocytic iris neoplasm in nevus versus melanoma category (iris nevoma). Note peaking of the pupil, limited ectropion iridis, and intralesional blood vessels. Histopathologic study of the excised tumor showed it to be a spindle A melanocytic tumor (ie, a nevus). Melanocytic subfoveal choroidal tumor in nevus versus 364 melanoma category (choroidal nevoma). It exhibits a prominent ring of subretinal orange pigment (lipofuscin) on its surface and an associated blister of overlying and surrounding exudative subretinal fluid. It was left untreated, spontaneously flattening slightly with disappearance of the orange pigment and subretinal fluid. Atypical Lymphoid Hyperplasia of the Uvea Atypical lymphoid hyperplasia of the uvea (previously termed benign reactive lymphoid hyperplasia) is focal or diffuse infiltration of the uvea by activated but benign-appearing lymphoid cells. Pathologically, the lymphoid cells are frequently organized into germinal centers that are evident on low to high power microscopy. Immunohistochemically, the lymphoid cells comprising the infiltrates are usually of B-cell lineage but frequently exhibit polyclonal features. Clinically, these lesions appear as tan to creamy focal to diffuse infiltrates in the iris or choroid. B-scan ultrasonography shows generalized choroidal thickening (sometimes with locally accentuated prominence) in diffuse cases, and ultrasound biomicroscopy confirms the solid soft tissue character of iris and iridociliary infiltrates. The retina usually remains attached or shows limited shallow detachment over the choroidal infiltration, but progressive disruption of the retinal pigment epithelium develops in many cases. There may be focal or diffuse pink anterior epibulbar masses reminiscent of primary conjunctival lymphoma, or posterior peribulbar extraocular soft tissue masses that may only be evident on B-scan ultrasonography, computed tomography scanning, or magnetic resonance imaging. Biopsy, usually transcleral incisional biopsy, is required to establish the diagnosis and rule out malignant uveal lymphoma. Treatment usually consists of relatively low-dose fractionated external beam radiation therapy that usually results in prompt and sustained clinical regression. If vision is poor prior to treatment, it may not recover even if all of the uveal infiltrates completely regress. Occasional patients with atypical lymphoid hyperplasia of the uvea develop systemic lymphoma, so all affected patients should probably be monitored for systemic disease. Invasive clinical and pathologic features are generally evident, and metastasis may occur. Primary Uveal Melanoma Primary uveal melanoma is an acquired malignant neoplasm that arises from uveal melanocytes. Although characteristic chromosomal abnormalities are present within individual tumor cells, primary uveal melanoma does not usually exhibit any familial hereditary pattern. Uveal melanomas are rare in persons under the age of 20 years but become progressively more frequent with advancing age. The average age at diagnosis is 40 to 45 years for iris melanoma and 55 to 60 years for choroidal and ciliary body melanoma. In the United States, the overall mean age-adjusted incidence is approximately 5 per million persons per year. In Europe a correlation has been identified between increasing incidence and increasing latitude, consistent with a protective effect of ocular pigmentation. Iris melanomas are frequently detected by the patient or family member as a newly appearing or changing spot on the iris, whereas choroidal melanomas and most ciliary body melanomas are not evident cosmetically and are detected on fundus examination prompted by visual symptoms or on routine examination. It frequently attracts prominent intralesional blood vessels and routinely causes peaking and/or splinting of the pupil and ectropion iridis. Loss of cohesiveness of the tumor cells frequently results in satellite tumors on the adjacent iris and in the angle on the trabecular meshwork, commonly leading to secondary glaucoma. Darkly melanotic iris melanoma, filling the anterior chamber angle inferonasally and approximately 3 mm thick. The tumor sometimes extends into the peripheral iris, where it may be evident on slitlamp biomicroscopy and gonioscopy. If thick enough, it may indent and even displace the crystalline lens and cause progressive astigmatism. The tumor occasionally invades the overlying sclera and extends to the external surface of the eye, where it appears as a dark brown flat to nodular vascularized episcleral mass. Darkly melanotic ciliary body melanoma, which has invaded the peripheral iris, with the main portion of the melanoma lying posterior to the iris and indenting the lens. B-scan ultrasonography is appropriate for determining the size, shape, and intraocular location of choroidal and ciliary body melanomas; identifying scleral invasion and transscleral extension to the orbit; and showing (on dynamic imaging) vascular pulsations within the tumor. It is also useful for monitoring after eye-preserving treatment, such as plaque radiotherapy (brachytherapy) and proton beam irradiation, for regression or relapse. Patients with primary uveal melanoma are at risk of metastasis, especially to the liver, regardless of how the primary intraocular tumor is managed. Prognostic factors for metastasis and metastatic death include tumor size (larger size unfavorable), location (ciliary body least favorable, iris most favorable), melanocytic cell type (epithelioid least favorable, spindle most favorable), vasculogenic mimicry pattern (complex loops and networks unfavorable), and chromosome 3 status (monosomy unfavorable, disomy favorable) and gene expression profile (Class 2 unfavorable, Class 1 favorable) of tumor cells. Several different treatment options are available for primary uveal melanomas of different sizes, intraocular locations, and associated clinical features. Iodine-125 (I-125; United States) or ruthenium-106 (Europe) plaque radiotherapy and proton beam irradiation are the most commonly employed treatments for small to relatively large choroidal and ciliary body melanomas. In some centers, they are also being used with increasing frequency instead of iridectomy and iridocyclectomy for many iris and iridociliary melanomas. All three types of radiation therapy usually induce tumor shrinkage, which is sustained long term, but are frequently associated with delayed-onset radiation induced cataract, retinopathy, and optic neuropathy, and may possibly result in iris neovascularization, neovascular glaucoma, and profound or even total visual loss. Transscleral tumor resection is employed in a few centers for selected ciliary body and choroidal melanomas, almost always in conjunction with preoperative proton beam irradiation or postoperative plaque radiotherapy. Transvitreal endoresection of selected postequatorial choroidal melanomas is undertaken in a few centers, almost always in conjunction with preoperative plaque or proton beam radiation therapy. No prospective comparative clinical trials of surgical resection versus enucleation or plaque radiotherapy have been reported. Most iris and iridociliary melanomas are treated by surgical excision (iridectomy, iridocyclectomy) or plaque radiotherapy. There is no compelling evidence that any method of treatment of primary uveal melanomas improves survival. There are no natural history data of survival in uveal melanoma that encompass the entire spectrum from extremely small asymptomatic lesions of uncertain pathologic nature to frankly malignant tumors filling much or all of the eye. In the absence of such information, there is no valid standard against which to judge effectiveness of any treatment. It has been suggested that the longer survival of patients with smaller tumors at the time of treatment demonstrates that treatment is effective if provided early enough, but there are no comparative clinical trials comparing survival in treated versus untreated primary uveal melanomas of any defined size category.

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