Publications by authors named "Amy C Schefler"

64 Publications

Endophthalmitis after intravitreal injections during the COVID-19 pandemic with implementation of universal masking.

Retina 2021 Apr 23. Epub 2021 Apr 23.

Department of Ophthalmology, Baylor College of Medicine, Houston, TX USA Retina Consultants of Houston, Houston, TX USA Blanton Eye Institute, Houston Methodist Hospital, Houston, TX USA.

Purpose: To evaluate the rates of post-intravitreal injection related endophthalmitis during the COVID-19 pandemic with institution of both physician and patient face masking.

Methods: All eyes receiving intravitreal injections of any kind from a single large tertiary retina practice in Houston, TX, USA before (August 2017-March 22, 2020) and after (March 23, 2020-Sept 2020) COVID-19 pandemic universal masking protocols. The total number of injections and cases of acute injection-related endophthalmitis were determined from billing records and subsequent retrospective chart review. The primary outcome was the rate of endophthalmitis after intravitreal injection. Secondary outcomes included visual acuity, time until initial presentation, patient age, and differences in overall number of injections performed monthly pre- and post-COVID 19.

Results: A total of 134, 097 intravitreal injections were performed during the study period (111,679 pre-COVID-19 and 22,418 post-COVID-19 masking protocols). A total of 41 cases of acute endophthalmitis occurred in the pre-COVID group (0.04%, 1 in 2500) and 7 cases in post COVID group (0.03%, 1 in 3333) p = 0.85.

Conclusion: In this single center, retrospective study, the implementation of universal patient and physician masking as practiced during the COVID-19 pandemic did not significantly affect the rate of post intravitreal injection endophthalmitis.
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http://dx.doi.org/10.1097/IAE.0000000000003193DOI Listing
April 2021

Locally Invasive Diffuse Iris Ring Melanoma Presenting as Unilateral Severe Glaucoma: Case Report and Review of Molecular Genetics.

Case Rep Oncol 2021 Jan-Apr;14(1):403-410. Epub 2021 Mar 11.

Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA.

We report the clinical history and histopathological findings in a case of diffuse iris ring melanoma (DIM) and review the most recent literature and modern molecular genetics of this entity. An 85-year-old Hispanic man presented with severe unilateral glaucoma, managed at an outside institution for 2 years prior to presentation. Diffuse pigmentation was noted in the angle, on the intraocular lens implant, and in the vitreous without clear demonstration of a mass on ultrasound biomicroscopy. Workup for metastatic cutaneous melanoma was negative. Histopathological examination of the enucleated eye revealed a mixed cell type iris ring melanoma with diffuse intraocular involvement. Gene expression profiling (GEP) revealed a class 2 molecular signature indicating a very high risk for metastases. Unilateral glaucoma presenting with marked pigmentation in the anterior chamber angle should be managed as melanoma until proven otherwise. Iris ring melanomas are known to have an aggressive clinical course, and recent molecular analyses indicate that they are likely primarily GEP class 2 with a very poor prognosis, similar to the majority of ciliary body melanomas.
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http://dx.doi.org/10.1159/000512012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7983622PMC
March 2021

Eye plaque brachytherapy versus enucleation for ocular melanoma: an analysis from the National Cancer Database.

J Contemp Brachytherapy 2020 Aug 21;12(4):303-310. Epub 2020 Aug 21.

Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA.

Purpose: There is no current randomized data comparing the efficacy of brachytherapy and enucleation for patients with larger sized tumors. The purpose of the present study was to use a large, contemporary database to determine current practice patterns and compare survival outcomes between different management options for patients with choroidal melanoma of various sizes.

Material And Methods: The National Cancer Database was queried (2004-2014) for histologically-confirmed choroidal melanoma for patients treated with brachytherapy versus enucleation. Chi-square test was used to compare categorized demographic and clinical variables in both arms. Kaplan-Meier analysis evaluated overall survival (OS). Cox proportional hazards assessment determined variables associated with OS. Patients were divided into cohorts representing small, medium, and large tumors. Propensity scores matching (PSM) was utilized to compare more similar cohorts.

Results: A total of 7,096 patients met the selection criteria; 5,501 (78%) patients received brachytherapy and 1,595 (22%) patients were treated with enucleation. After PSM, 5-yr OS for small tumors was 87% vs. 64%, for medium tumors was 77% vs. 57%, and for large tumors was 68% vs. 46% for brachytherapy and enucleation, respectively ( < 0.001). Following PSM, multivariate Cox regression found older age (hazard ratio [HR] = 1.76, 95% confidence interval [CI] = 1.51-2.06), more comorbidities (HR = 1.46, 95% CI = 1.25-1.70), extraocular extension (EOE) (HR = 1.25, 95% CI = 1.06-1.48), ciliary body invasion (CBI) (HR = 1.20, 95% CI = 1.02-1.40), and larger size (HR = 1.52, 95% CI = 1.40-1.66) were negative prognosticators of survival. Brachytherapy was a positive prognosticator of survival (HR = 0.45, 95% CI = 0.40-0.51).

Conclusions: Patients selected for brachytherapy had improved survival compared to enucleation in all size cohorts. EOE and CBI are significantly higher in the enucleation cohort and are important negative prognosticators for survival selected against patients having brachytherapy. Brachytherapy is a reasonable treatment option for certain patients with large size tumors.
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http://dx.doi.org/10.5114/jcb.2020.98108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7690235PMC
August 2020

Panuveitis in patient on ipilimumab/nivolumab combination for small-cell lung cancer treated with an intravitreal dexamethasone implant.

J Oncol Pharm Pract 2020 Oct 27:1078155220969792. Epub 2020 Oct 27.

Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA.

Background: Immunotherapy with checkpoint inhibitors has demonstrated durable responses and remarkable antitumor effects in a variety of cancers. Although these agents are generally well-tolerated, patients can experience immune-related adverse events (irAEs) that require prompt recognition by healthcare providers. Immune-related ocular toxicities are rare, but serious adverse events have been reported with the use of checkpoint inhibitors. Here, we describe a rare case of panuveitis during Nivolumab and Ipilimumab combination treatment in a patient being treated for recurrent Small Cell Lung Cancer (SCLC). The patient was managed with an injection of Ozurdex (Allergan, Madison, NJ), a dexamethasone intravitreal implant. The patient had a resolution of inflammation and an improvement in her vision and was able to resume nivolumab monotherapy without recurrence of the panuveitis.

Conclusion: This case highlights the importance of early recognition of ocular irAEs by ocular oncologists and the successful approach to treatment of immunotherapy-induced panuveitis in order to avoid permanent cessation of therapy.
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http://dx.doi.org/10.1177/1078155220969792DOI Listing
October 2020

Practice Patterns for the Treatment of Uveal Melanoma with Iodine-125 Plaque Brachytherapy: Ocular Oncology Study Consortium Report 5.

Ocul Oncol Pathol 2020 May 11;6(3):210-218. Epub 2019 Dec 11.

Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon, USA.

Background: Treatment planning for I-125 plaque therapy for uveal melanoma has advanced significantly since the Collaborative Ocular Melanoma Study trial, with more widely available image-guided planning and improved dosimetry.

Objective: We evaluated real-world practice patterns for I-125 plaque brachytherapy in the United States by studying practice patterns at centers that comprise the Ocular Oncology Study Consortium (OOSC).

Methods: The OOSC database and responses to a treatment practice survey were evaluated. The database contains treatment information from 9 institutions. Patients included in the database were treated between 2010 and 2014. The survey was conducted in 2018 and current treatment planning methods and prescriptions were queried.

Results: Examination of the OOSC database revealed that average doses to critical structures were highly consistent, with the exception of one institution. Survey responses indicated that most centers followed published guidelines regarding dose and prescription point. Dose rate ranged from 51 to 118 cGy/h. As of 2018, most institutions use pre-loaded plaques and fundus photographs and/or computed tomography or magnetic resonance imaging in planning.

Conclusions: While there were differences in dosimetric practices, overall agreement in plaque brachytherapy practices was high among OOSC institutions. Clinical margins and planning systems were similar among institutions, while prescription dose, dose rates, and dosimetry varied.
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http://dx.doi.org/10.1159/000504312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7250354PMC
May 2020

Prospective evaluation of risk-appropriate management of uveal melanoma patients informed by gene expression profiling.

Melanoma Manag 2020 Mar 11;7(1):MMT37. Epub 2020 Mar 11.

Dept. of Ophthalmology, Dean McGee Eye Institute, University of Oklahoma, Oklahoma City, OK 73104, USA`.

Aim: The Clinical Application of DecisionDx-UM Gene Expression Assay Results study aimed to evaluate the clinical utility of the prognostic 15-gene expression profile (15-GEP) test for uveal melanoma (UM) patients in a large, prospective multicenter cohort.

Patients & Methods: Nine centers prospectively enrolled 138 UM patients clinically tested with the 15-GEP. Physician-recommended specialty referrals and metastatic surveillance regimens were collected.

Results: A total of 93% of high-risk class 2 patients were referred to medical oncology for follow-up, compared with 51% of class 1 patients. A majority (62%) of class 2 patients were recommended overall high-intensity metastatic surveillance, while 85% of class 1 patients were recommended low-intensity metastatic surveillance.

Conclusion: Treatment plan recommendations for UM patients are aligned with GEP-informed metastatic risk, consistent with prior studies.
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http://dx.doi.org/10.2217/mmt-2020-0001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7212504PMC
March 2020

Randomized Trial of Monthly Versus As-Needed Intravitreal Ranibizumab for Radiation Retinopathy-Related Macular Edema: 1-Year Outcomes.

Am J Ophthalmol 2020 08 9;216:165-173. Epub 2020 Apr 9.

Retina Consultants of Houston, Houston, Texas, USA; McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA.

Purpose: To assess efficacy of intravitreal ranibizumab injections and targeted panretinal photocoagulation (TRP) for radiation retinopathy-related macular edema.

Design: Phase IIb, prospective, randomized clinical trial.

Methods: Setting: Multicenter.

Subjects: Forty eyes in 40 treatment-naïve patients with radiation-induced macular edema and a resulting decrease in visual acuity ranging between 20/25 and 20/400 (Snellen equivalent).

Intervention: Patients either received intravitreal 0.5 mg ranibizumab monthly, monthly ranibizumab with TRP, or 3 monthly ranibizumab (loading doses) followed by as-needed (PRN) injections and TRP. After week 52, all subjects entered a treat-and-extend protocol for ranibizumab. MainOutcomeMeasures: Mean Early Treatment Diabetic Maculopathy Study (ETDRS) BCVA change from baseline.

Results: Mean patient age was 57 years (range, 22-80 years), ETDRS BCVA was 56.7 letters (20/74 Snellen equivalent), and central macular thickness (CMT) was 423 μm (range, 183-826 μm). Thirty-seven patients completed the month 12 visit (92.5%), at which time the change in mean BCVA was +4.0 letters, -1.9 letters, and +0.9 letters in the monthly, monthly plus laser, and PRN plus laser cohorts, respectively. There was a significant difference in mean BCVA at 1 year among all 3 cohorts (P < .001), as well as between cohorts in pairwise comparisons, with the most significant gains in the monthly group. A total of 82.5% of the patients retained visual acuity of 20/200 or better, and 20.0% improved 10 or more ETDRS letters.

Conclusions: Ranibizumab may improve vision and anatomy in patients with radiation retinopathy-related macular edema and prevent vision loss through 48 weeks of therapy. Monthly injections were more effective than as-needed approach, and the addition of TRP yielded no therapeutic benefits.
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http://dx.doi.org/10.1016/j.ajo.2020.03.045DOI Listing
August 2020

Global Retinoblastoma Presentation and Analysis by National Income Level.

JAMA Oncol 2020 05;6(5):685-695

Imam Hussein Cancer Center, Karbala, Iraq.

Importance: Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale.

Objectives: To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis.

Design, Setting, And Participants: A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017.

Main Outcomes And Measures: Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis.

Results: The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]).

Conclusions And Relevance: This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs.
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http://dx.doi.org/10.1001/jamaoncol.2019.6716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7047856PMC
May 2020

CORRELATION OF GENE EXPRESSION PROFILE STATUS AND AMERICAN JOINT COMMISSION ON CANCER STAGE IN UVEAL MELANOMA.

Retina 2020 Feb;40(2):214-224

Byers Eye Institute, Stanford University, Palo Alto, California; and.

Purpose: To study the relationship between gene expression profile (GEP) subclass and American Joint Committee on Cancer (AJCC) stage in patients with uveal melanoma (UM).

Methods: A retrospective, multicenter study was undertaken with patients entered from nine major ocular oncology centers from across the United States. Three hundred sixty eligible patients had UM and underwent I-125 plaque brachytherapy with concurrent tumor biopsy with GEP testing between January 1, 2010, and October 28, 2014. Patient demographics and UM features were analyzed by both GEP and AJCC status.

Results: Gene expression profile class divided the cohort into three groups: Class 1a (n = 186), Class 1b (n = 77), and Class 2 (n = 113). When classified using AJCC staging criteria, we found the following: Stage I in 91 cases (25.3%), Stage IIA in 143 cases (39.7%), Stage IIB in 89 cases (24.7%), Stage IIIA in 36 cases (10%), and Stage IIIB in 1 case (0.3%). There were no Stage IV cases, as lymph node and metastatic data were not collected as a part of this study. Among Stage I tumors, both high tumor height and high largest basal diameter were associated with a higher frequency of Class 2 status (P < 0.05). As UMs progress to a larger AJCC tumor group (T1-T4), the odds ratio of having a worse prognosis based on GEP class was 1.75 (95% CI, 1.36-2.25; P < 0.001). Similarly, as UMs progress to a higher AJCC stage, the odds ratio of having a worse prognosis based on GEP class was 1.69 (95% CI, 1.36-2.10; P < 0.001).

Conclusion: This report details the differences in clinical features between GEP subclasses and how they are distributed among the AJCC stages. When the tumors were grouped by AJCC staging criteria, both larger AJCC tumor (T) group and worsening AJCC stage were associated with worsening predicted prognosis, based on GEP subclass.
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http://dx.doi.org/10.1097/IAE.0000000000002385DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506408PMC
February 2020

Multi-center analysis of intraocular biopsy technique and outcomes for uveal melanoma: Ocular Oncology Study Consortium report 4.

Graefes Arch Clin Exp Ophthalmol 2020 Feb 6;258(2):427-435. Epub 2019 Dec 6.

Department of Ophthalmology, Duke University, Durham, NC, USA.

Purpose: To investigate the relationship between surgical approach for intraocular tumor biopsy of uveal melanoma and tumor morphologic features such as size and intraocular location and the effect of these variables on diagnostic yield and biopsy outcome.

Methods: Consecutive patients from nine Ocular Oncology centers with uveal melanoma (UM) undergoing tumor biopsy immediately preceding I plaque brachytherapy with tissue sent for gene expression profiling (GEP) testing were reviewed retrospectively.

Results: Three hundred sixty patients were included (50% men, mean age 60.2 years). Overall biopsy yield was 99% and 83% for GEP and cytopathology, respectively. Surgeon choice of biopsy approach (trans-vitreal vs. trans-scleral) was found to associate with both tumor location and tumor thickness. A trans-scleral rather than trans-vitreal approach was used more commonly for anteriorly located tumors (92% vs. 38% of posterior tumors, p < 0.001) and thicker tumors (86% vs. 55% of thin tumors, p < 0.001). When performing trans-vitreal biopsies, ocular oncologists with previous vitreoretinal surgery fellowship training were more likely to use wide-field surgical viewing systems, compared with indirect ophthalmoscopy (82.6% vs. 20.6%, p < 0.001). Surgical complications were rare and occurred more frequently with trans-vitreal biopsies (3.6% vs. 0.46%, p = 0.046).

Conclusions: In this multi-center analysis of UM tumor biopsy, surgical yield was high for obtaining tumor tissue for GEP and cytopathology analysis with both trans-scleral and trans-vitreal techniques. Fellowship-trained ocular oncologists' preferred intraocular biopsy techniques associated strongly with tumor location, tumor thickness, and fellowship training of the surgeon. Short-term complication rates were low.
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http://dx.doi.org/10.1007/s00417-019-04531-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7738203PMC
February 2020

Intraocular Metastasis in Unilateral Multifocal Uveal Melanoma Without Melanocytosis or Germline BAP1 Mutations.

JAMA Ophthalmol 2019 Dec;137(12):1434-1439

Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, Florida.

Importance: There has been speculation on the pathogenesis of unilateral multifocal uveal melanoma, but there remains no convincing explanation. Genetic analysis suggests that unilateral multifocal uveal melanoma may represent intraocular metastasis with increased risk of systemic metastasis.

Objective: To evaluate the pathogenesis of unilateral multifocal uveal melanoma.

Design, Setting, And Participants: This clinical case series was conducted in tertiary academic ocular oncology referral centers and included patients with unilateral multifocal uveal melanoma.

Main Outcomes And Measures: Gene expression and mutation profiling of tumor samples.

Results: Four patients (all male; age range, 54-77 years) who were diagnosed with uveal melanoma were treated with plaque brachytherapy, and subsequently developed a second discrete uveal melanoma in the same eye were included. None demonstrated ocular or oculodermal melanocytosis. All 8 tumors available for analysis exhibited class 2 gene expression profiles. In all 4 cases, the initial and subsequent tumors were available for targeted DNA sequencing and identical driver mutations were present in both tumors. Data were collected from September 2015 to August 2018.

Conclusions And Relevance: Unilateral multifocal uveal melanoma in the absence of ocular melanocytosis appears to occur preferentially in tumors with the class 2 gene expression profile and a BRCA1-associated protein 1 gene (BAP1) mutation. The presence of identical BAP1 mutations in multiple tumors in the same eye in the absence of a germline BAP1 mutation suggests intraocular metastasis rather than independent primary tumors. These findings indicate that the first site of metastasis can be within the eye itself and suggest that patients with unilateral multifocal uveal melanoma may be at increased risk of systemic metastasis.
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http://dx.doi.org/10.1001/jamaophthalmol.2019.3941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6777244PMC
December 2019

Relationship between clinical features, GEP class, and PRAME expression in uveal melanoma.

Graefes Arch Clin Exp Ophthalmol 2019 Jul 7;257(7):1541-1545. Epub 2019 May 7.

University of Cincinnati, Cincinnati, OH, USA.

Background: Metastatic risk for uveal melanoma (UM) patients can be characterized by gene expression profiling (GEP) (Castle Biosciences, Friendswood, TX). Class 1A tumors carry low metastatic risk; class 1B tumors have intermediate risk; and class 2 tumors have high risk. Preferentially expressed antigen in melanoma (PRAME) is a tumor-associated antigen which is expressed in various neoplasms including UM. Recently, PRAME expression in uveal melanoma was first recognized to confer an additional metastatic risk beyond GEP status.

Methods: This was a retrospective, consecutive, multicenter chart review study. All patients diagnosed with UM at two major ocular oncology centers from August 2016 to February 2018 who underwent both GEP and PRAME mRNA expression testing were included. Patient age at diagnosis, gender, and tumor variables such as thickness, largest basal diameter (LBD), tumor volume, TNM stage, and GEP class and PRAME status were extracted from the medical records. Statistical analysis was performed to analyze the association of PRAME +/- status with all clinical and molecular variables.

Results: One hundred forty-eight UM patients were identified. TNM was stage I in 51 (34.5%), stage IIA in 33 (22.3%), stage IIB in 34 (23%), stage IIIA in 20 (13.5%), and stage IIIB in 10 (6.8%) patients. Fifty-five patients (37%) were PRAME-positive, a significant fraction. There was no association between higher TNM stage and positive PRAME status (p = 0.129). PRAME expression was found to be independent of gender, patient age, and tumor thickness. PRAME expression was statistically associated with LBD and tumor volume. Higher GEP class was associated with higher TNM staging (p < 0.001). Worsening GEP class was associated with PRAME+ status with 28% of GEP class 1A tumors having PRAME+ status, 29% of GEP class 1B tumors having PRAME+ status, and 56% of GEP class 2 tumors having PRAME+ status.

Conclusions: In this study cohort, PRAME+ status was significantly associated with LBD and tumor volume as well as worsening GEP class. Nearly a third of GEP class 1A tumors expressed PRAME. Given the recent published data on increased metastatic risk among patients with tumors expressing PRAME, this study suggests that a significant fraction of 1A patients may harbor an increased metastatic risk. Future large, multicenter studies with long-term follow-up will clarify this finding.
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http://dx.doi.org/10.1007/s00417-019-04335-wDOI Listing
July 2019

Trends in Radiation Practices for Female Ocular Oncologists in North America: A Collaborative Study of the International Society of Ocular Oncology.

Ocul Oncol Pathol 2019 Jan 12;5(1):54-59. Epub 2018 Jun 12.

USC Roski Eye Institute, University of Southern California, Los Angeles, California, USA.

Background: The aim of this study was to determine the known radiation exposure, attitudes, and consequent risk modifications among female ocular oncologists in North America who routinely administer radioactive plaque brachytherapy treatment and are members of the International Society of Ocular Oncology.

Methods: Nineteen female ocular oncologists completed an anonymous 17-question radiation exposure survey.

Results: Eleven of the participants chose to routinely wear lead protection during surgery; 8 did not. Fifteen of 19 participants reported using an unloaded "nonactive" template to prepare for plaque implantation. During pregnancy, 11 of 13 participants continued to perform plaque brachytherapy. Eight of these 11 undertook measures to decrease radiation exposure self-reported as lead wear and other. The average reported anxiety regarding fertility was 2.1 (SD, 2.2) on a scale from 1 to 10.

Conclusion: This study corroborates prior literature that surgeons' exposure to radiation during plaque brachytherapy is minimal. Nonetheless, there remains some anxiety regarding exposure risk to women, due to potential effects on fertility and fetal health. We found variability in exposure monitoring, required training, and precautions during pregnancy amongst this group of surgeons. Improved education and clearer pregnancy guidelines may equip female ocular oncologists with optimal knowledge regarding risk of radiation exposure.
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http://dx.doi.org/10.1159/000489219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341326PMC
January 2019

Elevated Choroidal Thickness and Central Serous Chorioretinopathy in the Fellow Eyes of Patients with Circumscribed Choroidal Hemangioma.

Ocul Oncol Pathol 2018 Nov 20;4(6):375-380. Epub 2018 Apr 20.

Retina Consultants of Houston, Houston, Texas, USA.

Objective: To determine whether increased choroidal thickness (CT) is associated with circumscribed choroidal hemangioma (CCH) and whether patients with CCH are predisposed to central serous chorioretinopathy (CSCR).

Methods: We performed a retrospective consecutive observational study of 15 fellow eyes of 15 patients who had CCH. A- and B-scan ultrasonography, fluorescein angiography (FA), and optical coherence tomography (OCT) findings were reviewed to confirm the diagnosis of CCH. Fellow eye CT was measured using enhanced depth imaging OCT. FA, indocyanine green angiography, and OCT images of fellow eyes were reviewed for signs of CSCR.

Results: Mean subfoveal CT was significantly greater in the fellow eyes of patients with CCH than in age-matched normal eyes ( = 0.004). Three of 15 (20.0%) fellow eyes of CCH patients had retinal pigment epithelium disruptions and/or pigment epithelial detachments indicative of previous asymptomatic CSCR.

Conclusion: In this pilot study, elevated CT was associated with a risk of developing CCH as well as CSCR in patients of varying ages. Patients diagnosed with CCH should be screened for CSCR in the fellow eye. Further exploration of this association may reveal useful clues about the biology of abnormally elevated choroidal hyperpermeability and its various clinical manifestations.
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http://dx.doi.org/10.1159/000486864DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6288715PMC
November 2018

Biopsy of a Choroidal Melanoma Using Transvitreal Pars Plana Vitrectomy.

Ophthalmic Surg Lasers Imaging Retina 2018 08;49(8):645-647

Determining when a previously benign choroidal nevi becomes malignant can be challenging, as traditional biopsy methods are often invasive and can lead to secondary complications such as endophthalmitis and vitreous hemorrhage. Using a transvitreal approach with the 27-gauge vitrectomy system provides several advantages, including direct visualization, theoretically lower risk of inadvertent seeding, and collection of a larger sample size. In this video, the authors present their technique for transvitreal biopsy of choroidal lesions using the 27-gauge vitreous cutter.
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http://dx.doi.org/10.3928/23258160-20180803-16DOI Listing
August 2018

A rare presentation of choroidal metastasis from primary esophageal adenocarcinoma successfully treated with intensity-modulated radiation therapy.

Am J Ophthalmol Case Rep 2018 Sep 23;11:19-22. Epub 2018 Apr 23.

Department of Ophthalmology, Baylor College of Medicine, 6565 Fannin St., NC-205, Houston, TX 77030, USA.

Purpose: In this case report, we present a case of choroidal metastasis from a primary esophageal adenocarcinoma that was treated successfully with intensity-modulated radiation therapy.

Observations: A 65-year-old male with known stage IV esophageal adenocarcinoma presented with a central scotoma in his left eye and was ultimately found to have a large choroidal metastatic lesion with overlying subretinal fluid. IMRT was administered over the course of four weeks, resulting in restoration of the patient's vision, regression of the metastatic lesion, and resolution of the subretinal fluid. As of 16 months following completion of radiation, there remains no evidence of choroidal recurrence or radiation-associated ocular complications.

Conclusions: and Importance: To our knowledge, this is the first published case report of a choroidal metastasis from esophageal cancer responding durably to IMRT. IMRT should therefore be considered a viable treatment option for this rare disease.
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http://dx.doi.org/10.1016/j.ajoc.2018.04.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6062644PMC
September 2018

Recent advancements in the management of retinoblastoma and uveal melanoma.

F1000Res 2018 18;7. Epub 2018 Apr 18.

Retina Consultants of Houston, Houston, TX, 77030, USA.

Retinoblastoma and uveal melanoma are the most common intraocular malignancies observed in pediatric and adult populations, respectively. For retinoblastoma, intra-arterial chemotherapy has dramatically improved treatment outcomes and eye salvage rates compared with traditional salvage rates of systemic chemotherapy and external beam radiation therapy. Intravitreal injections of chemotherapy have also demonstrated excellent efficacy for vitreous seeds. Uveal melanoma, on the other hand, is treated predominantly with iodine-125 plaque brachytherapy or with proton beam therapy. Major strides in uveal melanoma genomics have been made since the early 2000s, allowing ocular oncologists to better understand the metastatic risks of the tumor on the basis of specific genetic signatures. Loss-of-function mutations of the gene are associated with the highest metastatic risk, whereas gain-of-function mutations of and often confer a better prognosis. Expression of a cancer-testis antigen called PRAME (preferentially expressed antigen in melanoma) has been shown to increase metastatic risks in both low-risk and high-risk melanomas. New therapeutic approaches, including molecular therapies and nanoparticle phototherapy, are currently being investigated as alternative treatment modalities for uveal melanoma.
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http://dx.doi.org/10.12688/f1000research.11941.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5911936PMC
April 2018

RELATIONSHIP OF CLINICAL FEATURES AND BASELINE TUMOR SIZE WITH GENE EXPRESSION PROFILE STATUS IN UVEAL MELANOMA: A Multi-institutional Study.

Retina 2019 Jun;39(6):1154-1164

Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas.

Purpose: To study the relationship between gene expression profile subclass and clinical features in a multicenter cohort of patients with uveal melanoma.

Methods: A retrospective, multicenter study was undertaken with patients entered from nine major ocular oncology centers from across the United States. Eligible patients had uveal melanoma and underwent I-125 plaque brachytherapy with concurrent tumor biopsy with gene expression profile testing between January 1, 2010, and October 28, 2014. Data were collected regarding patient demographics, baseline tumor clinical features, and gene expression profile results. Statistical analyses were performed using the Fisher's exact test, Wilcoxon rank-sum test, Kruskal-Wallis test, and proportional-odds cumulative logit modeling.

Results: Inclusion criteria were met for 379 patients. Gene expression profile class divided the cohort into two main groups, Class 1 (n = 263) and Class 2 (n = 113). Class 1 tumors were further subdivided into Class 1a (n = 186) and Class 1b (n = 77). The differences between Class 1 and Class 2 tumors were similar to previous studies, except the finding of Class 2 tumors being more likely to have associated exudative retinal detachment (P < 0.001). There was no statistically significant difference between Class 1 and Class 2 tumors based on the presence of lipofuscin, drusen, or subretinal fluid. Class 1a tumor patients, compared with Class 1b, were significantly older (P = 0.034). Class 2 tumors, when compared with Class 1b, were associated with increasing patient age (P < 0.001), larger tumor height (P = 0.010), ciliary body involvement (P = 0.001), exudative retinal detachment (P = 0.024), and anterior tumor location (P < 0.001). When the tumors were grouped into Collaborative Ocular Melanoma Study size categories, increasing tumor size category was significantly associated with Class 2 status: 6% of small tumors, 32% of medium tumors, and 53% of large tumors were Class 2.

Conclusion: In a multi-institutional setting, we found that the only significant difference in clinical features between Class 1a and Class 1b tumors was that patients with Class 1a tumors were older at the time of diagnosis. We also found that Class 1a and Class 1b have clinical features distinct from Class 2 tumors. The distribution of the gene expression profile subclasses among the size groups was similar to reported time-to-metastasis data among the same size groupings. Our clinical findings support the current molecular classification-based survival data previously reported in uveal melanoma.
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http://dx.doi.org/10.1097/IAE.0000000000002113DOI Listing
June 2019

Association between traditional clinical high-risk features and gene expression profile classification in uveal melanoma.

Graefes Arch Clin Exp Ophthalmol 2018 Feb 28;256(2):421-427. Epub 2017 Nov 28.

Retina Consultants of Houston, 6560 Fannin Street, Suite 750, Houston, TX, 77030, USA.

Purpose: To evaluate the association between traditional clinical high-risk features of uveal melanoma patients and gene expression profile (GEP).

Methods: This was a retrospective, single-center, case series of patients with uveal melanoma. Eighty-three patients met inclusion criteria for the study. Patients were examined for the following clinical risk factors: drusen/retinal pigment epithelium (RPE) changes, vascularity on B-scan, internal reflectivity on A-scan, subretinal fluid (SRF), orange pigment, apical tumor height/thickness, and largest basal dimensions (LBD). A novel point system was created to grade the high-risk clinical features of each tumor. Further analyses were performed to assess the degree of association between GEP and each individual risk factor, total clinical risk score, vascularity, internal reflectivity, American Joint Committee on Cancer (AJCC) tumor stage classification, apical tumor height/thickness, and LBD.

Results: Of the 83 total patients, 41 were classified as GEP class 1A, 17 as class 1B, and 25 as class 2. The presence of orange pigment, SRF, low internal reflectivity and vascularity on ultrasound, and apical tumor height/thickness ≥ 2 mm were not statistically significantly associated with GEP class. Lack of drusen/RPE changes demonstrated a trend toward statistical association with GEP class 2 compared to class 1A/1B. LBD and advancing AJCC stage was statistically associated with higher GEP class.

Conclusions: In this cohort, AJCC stage classification and LBD were the only clinical features statistically associated with GEP class. Clinicians should use caution when inferring the growth potential of melanocytic lesions solely from traditional funduscopic and ultrasonographic risk factors without GEP data.
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http://dx.doi.org/10.1007/s00417-017-3856-xDOI Listing
February 2018

Risk of Extraocular Extension in Eyes With Retinoblastoma Receiving Intravitreous Chemotherapy.

JAMA Ophthalmol 2017 12;135(12):1426-1429

Department of Ophthalmology, Jules-Gonin Eye Hospital, Lausanne, Switzerland

Importance: The risk of extraocular extension from injecting chemotherapy into eyes with retinoblastoma is minimally understood; however, understanding this risk is important because of the increasing use of intravitreous chemotherapy.

Objective: To evaluate the risk of extraocular extension in eyes with retinoblastoma that have received intravitreous chemotherapy injections.

Design, Setting, And Participants: This retrospective cohort study was performed in 655 patients at 10 retinoblastoma centers in North and South American, European, Israeli, and Chinese centers. Physicians at the retinoblastoma centers administered more than 120 intravitreous chemotherapy injections in eyes with retinoblastoma from February 1, 1999, through February 28, 2017.

Main Outcomes And Measures: Risk of extraocular extension with secondary observational variables, including injection and precautionary techniques.

Results: A total of 3553 intravitreous chemotherapy injections (3201 melphalan hydrochloride, 335 topotecan hydrochloride, and 17 methotrexate sodium) were administered to 704 eyes in 655 patients with retinoblastoma (mean [SD] age of patients at the time of the initial injections, 31.6 [11.6] months; 348 male [53.1%]). There were no extraocular tumor events related to prior intravitreous injections. This finding resulted in a calculated proportion of zero extraocular events per eye. According to the rule of 3, the risk is no greater than 0.08% injections. All 10 centers included in this study used at least 2 presumed precautionary injection methods (lowering of intraocular pressure, cryotherapy, ocular surface irrigation, ultrasonic biomicroscopy surveillance of the injection site, and subconjunctival chemotherapy deposition).

Conclusions And Relevance: With use of at least 2 presumed precautionary safety methods, no extraocular extension of tumor events occurred. According to the rule of 3, this finding suggests that the risk is no greater than 0.08% injections.
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http://dx.doi.org/10.1001/jamaophthalmol.2017.4600DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583521PMC
December 2017

USE OF FEMORAL ARTERY ULTRASOUND DURING INTRAARTERIAL CHEMOTHERAPY FOR CHILDREN UNDER 10 KG WITH RETINOBLASTOMA.

Retina 2018 07;38(7):1420-1426

Retina Consultants of Houston, Houston, Texas.

Purpose: To demonstrate the safety and efficacy of intraarterial chemotherapy (IAC) in small infants (<10 kg) with retinoblastoma.

Methods: Retrospective, consecutive, observational case series of patients treated with IAC. Femoral arterial access was obtained using a micropuncture kit and ultrasound guidance, which enabled direct visualization. Melphalan (1.5-5.0 mg), topotecan (0.3-2.0 mg), and/or carboplatin (30-40 mg) were used. Patients underwent adjuvant therapies including laser, cryotherapy, and intravitreal melphalan if persistent disease or recurrence was observed.

Results: Fifty-nine injections were administered to 11 eyes of 6 patients. All eyes but one were classified as International Classification Groups C or D. Median patient weight at first IAC cycle was 9.2 kg (mean, 8.9 kg). Median diameter of the femoral artery at the catheterization site was 3.74 mm, measured by two independent observers. Median follow-up was 21.4 months (range 13.1-34.5 months). All eyes were salvaged.

Conclusion: This study confirmed the safety and efficacy of IAC in infants under 10 kg. Ultrasound guidance enabled successful catheterization of femoral arteries as small as 2.7 mm in diameter. Patients in this study appeared to require fewer injections and lower total doses of chemotherapy compared with previously reported series of comparably advanced disease in larger infants.
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http://dx.doi.org/10.1097/IAE.0000000000001713DOI Listing
July 2018

Early outcomes of uveal melanoma treated with intraoperative ultrasound guided brachytherapy using custom built plaques.

Pract Radiat Oncol 2017 Jul - Aug;7(4):e275-e282. Epub 2017 Jan 7.

Retina Consultants of Houston, Houston, Texas; Blanton Eye Institute, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas.

Purpose: To report early outcomes of patients with uveal melanoma treated with Eye Physics iodine-125 episcleral plaque therapy using modern biopsy techniques and intraoperative ultrasound guidance at our institution.

Methods And Materials: A retrospective chart review was conducted for 48 consecutive patients with uveal melanoma who were treated with Eye Physics plaque brachytherapy performed by 1 ocular oncologist. All patients underwent intraoperative ultrasound for image guidance of plaque placement. A dose of 85 Gy was prescribed to the apical height of the tumor or 5 mm from the inner sclera, whichever was greater. Forty-five patients underwent biopsy. Visual acuity, complication data, and recurrence rates were recorded.

Results: Median age at presentation was 63.0 years (range, 19-86 years). Median follow-up was 21.6 months. Median tumor apical height was 3.3 mm (range, 1.8-11.5 mm). Median dose at apex for tumor height >5 mm was 85.0 Gy and 142.5 Gy for tumor height ≤5 mm. Mean percent decrease in tumor height from baseline at 12, 24, and 36 months was 39.6%, 51.8%, and 53.8%, respectively. At 24 months, 19/23 (82.6%) patients maintained vision within 3 lines of baseline visual acuity. Twelve patients developed radiation retinopathy, 6 of whom were treated with anti-vascular endothelial growth factor therapy in the context of a clinical trial. No patients to date have local failure. Three patients are alive with confirmed hepatic metastases.

Conclusions: We reported 0% early local failure rate and steady reduction in tumor height in 48 patients with uveal melanoma, ranging from small to large size, who were treated with Eye Physics iodine-125 episcleral plaque therapy using intraoperative ultrasound guidance. This promising result emphasizes the importance of image guided brachytherapy with intraoperative ultrasound at the time of plaque placement.
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http://dx.doi.org/10.1016/j.prro.2017.01.002DOI Listing
March 2018

Histopathologic Analysis of Transvitreal Fine Needle Aspiration Biopsy Needle Tracts for Uveal Melanoma.

Am J Ophthalmol 2017 Feb 4;174:9-16. Epub 2016 Nov 4.

Retina Consultants of Houston, Houston, Texas; Blanton Eye Institute, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas. Electronic address:

Purpose: Perform the first in vivo examination of fine needle aspiration biopsy (FNAB) scleral tracts to determine the incidence of iatrogenic extension of tumor cells.

Design: A prospective, consecutive, observational case series.

Methods: This study was performed in a clinical/surgical setting at Retina Consultants of Houston and Houston Methodist Hospital, Houston, Texas, and included 10 patients who were scheduled for enucleation as primary treatment for uveal melanoma. Treatment included FNAB, enucleation, and histopathologic analysis. The primary outcomes were tumor location and dimension as identified by B-scans and histopathologic analysis. Tumor type was classified by gene expression profile and American Joint Committee on Cancer staging. Twenty-five- or 27-gauge needles were used for FNAB under direct visualization. Cell blocks of acquired specimens were examined using hematoxylin-eosin stain and double immunostain using HMB45 with red chromogen and Ki67 with brown 3,3'-diaminobenzidine chromogen.

Results: Mean follow-up after enucleation was 20.4 months (range 9.9-31.7). All biopsy specimens had adequate yields for genomic analysis. No enucleation specimen contained tumor cells within sclera, pars plana, or pars plicata. One specimen contained a small collection of tumor cells within the anterior vitreous in the quadrant of the biopsy site. No patient developed an orbital recurrence. Four patients developed nonorbital metastatic uveal melanoma during the study period. Three of them died, and 1 is alive with hepatic metastasis.

Conclusions: No iatrogenic extension of tumor was reported. FNAB is a safe procedure that produces a high cellular yield for cytologic and genomic analyses with minimal risk of extraocular dissemination.
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http://dx.doi.org/10.1016/j.ajo.2016.10.019DOI Listing
February 2017

ENDOPHTHALMITIS AFTER INTRAVITREAL INJECTION: Role of Prophylactic Topical Ophthalmic Antibiotics.

Retina 2016 Jul;36(7):1349-56

*Retina Consultants of Houston, Houston, Texas; and †Blanton Eye Institute and Houston Methodist Hospital, Houston, Texas.

Purpose: To determine the rate of postintravitreal injection endophthalmitis and to assess microbiological features and outcomes with and without the use of peri-intravitreal injection topical ophthalmic antibiotics.

Methods: Consecutive series of endophthalmitis cases retrospectively identified after intravitreal injection at a multicenter, retina-only referral practice (Retina Consultants of Houston) from January 1, 2011 to December 31, 2014. Prophylactic peri-intravitreal injection topical antibiotics were routinely used during the initial 12-month period (January 1, 2011-December 31, 2011) and not used in the final 24-month period (January 1, 2013-December 31, 2014). Main outcome measures were incidence of endophthalmitis, microbiology results, treatment strategies, and visual outcomes.

Results: Of 90,339 intravitreal injections, 30 cases of endophthalmitis were identified (endophthalmitis rate = 0.033%; 95% confidence interval, 0.021-0.045%; or approximately 1 of 3,011 intravitreal injections). The most common organisms isolated were coagulase-negative staphylococci (n = 10, 33%), followed by Streptococcus mitis (n = 2, 7%). Fourteen cases (47%) were culture negative. Peri-intravitreal injection topical antibiotic prophylaxis did not decrease the rate of endophthalmitis (0.035% [95% CI, 0.007-0.064%] with antibiotic use versus 0.021% [95% CI, 0.008-0.033%] without antibiotic use; P = 0.261).

Conclusion: The risk of endophthalmitis after intravitreal injection remains low, with coagulase-negative staphylococci and Streptococcus mitis the most common bacterial isolates identified. Prophylactic peri-intravitreal injection topical ophthalmic antibiotic use did not decrease the endophthalmitis rate.
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http://dx.doi.org/10.1097/IAE.0000000000000901DOI Listing
July 2016

Extraocular extension of uveal melanoma after fine-needle aspiration, vitrectomy, and open biopsy.

JAMA Ophthalmol 2013 Sep;131(9):1220-4

Retina Consultants of Houston, Houston, Texas.

Importance: The most potentially devastating complication of fine-needle aspiration biopsy (FNAB) or open biopsy is extraocular extension of the tumor. In this collaborative case series, we report 4 cases of orbital recurrence of malignant melanoma as a late complication of biopsy and/or vitrectomy performed at referring institutions and then sent to us for evaluation.

Observations: Four cases of extraocular extension of melanoma are documented following multiple procedures including FNAB, vitrectomy, and open biopsies. Three of the patients in this series underwent more than 1 FNAB, biopsy, and/or vitrectomy. One underwent FNAB only but did not undergo brachytherapy afterward. Most of the FNABs, open biopsies, and vitrectomies reported in these cases were not performed by us, so details of the technique are not available. From these cases, we are not able to determine whether the FNAB or additional invasive procedures caused the subsequent extraocular disease or if growth of the tumor into the extraocular space occurred independent of or prior to the procedures.

Conclusions And Relevance: Large series of FNAB for uveal melanoma with no extraocular recurrence have been reported by multiple experienced centers, and the vast majority of these procedures are performed without effect on the patient's prognosis. However, the patients described in this series demonstrate that this complication is rarely possible.
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http://dx.doi.org/10.1001/jamaophthalmol.2013.2506DOI Listing
September 2013

Delayed-onset endophthalmitis associated with corneal suture infections.

J Ophthalmic Inflamm Infect 2013 Jun 11;3(1):51. Epub 2013 Jun 11.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL 33136, USA.

Background: The purpose of the current study was to report the microbiology, risk factors, and treatment outcomes in patients with delayed-onset endophthalmitis associated with corneal suture infections. For this retrospective consecutive case series, a search of the ocular microbiology department database was performed to identify all patients with positive corneal and intraocular cultures (anterior chamber and/or vitreous) between 01 January 1995 and 01 January 2010. A subset of patients with a history of corneal suture infections and delayed-onset endophthalmitis was identified.

Results: Over the 15-year period of the study, 68 patients were identified to have both positive corneal and intraocular cultures. Among them, six patients were identified to have a culture-proven, delayed-onset endophthalmitis that developed from a culture-positive corneal suture infection. All of the patients in the current study were using topical corticosteroids at the time of diagnosis. In four of six patients, there was documented manipulation of a suture before the development of endophthalmitis. Streptoccocus was identified as the causative organism in five of six patients in the current study. All of the Streptoccocus isolates were sensitive to vancomycin. The single case of Serratia marcescens endophthalmitis was sensitive to amikacin, ceftazidime, ciprofloxacin, gentamicin, and tobramycin. Treatment modalities varied and were guided by the attending ophthalmologist depending upon clinical presentation. One patient with severe Streptococcus pyogenes keratitis and endophthalmitis underwent a primary enucleation after developing a wound dehiscence. Of the remaining five patients, all received topical and intravitreal antibiotics. Therapeutic penetrating keratoplasty was performed in three patients. Pars plana vitrectomy was performed in two patients. Visual acuity outcomes ranged from 20/150 to no light perception.

Conclusions: In the current study, Streptococcus was isolated in nearly all patients with delayed-onset endophthalmitis associated with corneal suture infections. Topical steroid use and suture manipulation were identified as associated factors for developing endophthalmitis. Visual acuity outcomes were poor despite the prompt recognition of endophthalmitis and appropriate antibiotic therapy.
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http://dx.doi.org/10.1186/1869-5760-3-51DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3717107PMC
June 2013

Update on Ophthalmic Oncology 2012: Advances in Retinoblastoma and Uveal Melanoma.

Asia Pac J Ophthalmol (Phila) 2013 Mar-Apr;2(2):119-31

From the *Retina Consultants of Houston, Houston, TX; and †Memorial Sloan-Kettering Cancer Center, New York, NY.

Purpose: The purpose of this article was to review the major advances in both translational and clinical research in 2 diseases, retinoblastoma and uveal melanoma, from November 2011 through October 2012.

Design: Literature Review.

Methods: A MEDLINE search was performed using the search terms "retinoblastoma" and "uveal melanoma." All relevant articles were reviewed, and articles with the most clinical relevance were reported.

Results: In retinoblastoma, new clinical data are emerging every year regarding the safety and efficacy of intra-arterial chemotherapy as well as other even newer modalities such as intravitreal chemotherapy. Globe salvage rates for eyes without vitreous seeding approach 100% and are increasing to 80% for those with seeds with new methods of treatment. In uveal melanoma, our understanding of the genetic pathways underlying this disease is improving each day and leading to the initiation of clinical trials for adjuvant therapy and metastatic disease.

Conclusions: Ocular oncology is a small but dynamic field in which our knowledge is increasing every day. Exciting data emerged in the fields of both retinoblastoma and uveal melanoma this year.
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http://dx.doi.org/10.1097/APO.0b013e3182900492DOI Listing
June 2015

Mushroom-shaped secondary vasoproliferative tumor.

Ophthalmic Surg Lasers Imaging 2012 Oct 4;43 Online:e104-6. Epub 2012 Oct 4.

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL 33136, USA.

The authors report a clinical and echographic correlation of a retinal vasoproliferative tumor that assumed a mushroom shape. A 64-year-old man with a history of retinal detachment repair presented with vitreous hemorrhage. A clinical examination including standardized ultrasound was performed, which revealed a mushroom-shaped tumor with high reflectivity. The patient underwent pars plana vitrectomy with fine needle aspiration biopsy. Histopathology of the biopsy specimen demonstrated vascular proliferation. The lesion was diagnosed to be a retinal vasoproliferative tumor. Clinicians should be aware that a mushroom-shaped configuration can be seen in such cases, although it is common for uveal melanoma.
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http://dx.doi.org/10.3928/15428877-20120927-03DOI Listing
October 2012

Irido-lenticular abscess as the initial sign of Candida albicans endogenous endophthalmitis.

Ophthalmic Surg Lasers Imaging 2011 Dec 8;42 Online:e107-9. Epub 2011 Dec 8.

Department of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA.

A-33-year-old man presented with 9 days of conjunctival erythema, pain, and worsening vision in the left eye. Anterior segment examination was significant for a well-defined, cream-colored iridociliary mass. Ultrasound biomicroscopy demonstrated an iris lesion with ciliary body and lenticular involvement. The authors performed a pars plana vitrectomy and lensectomy with an iris biopsy. Culture of the vitreous cassette and iris mass yielded a diagnosis of Candida albicans endophthalmitis. Clinicians encountering an iris nodule with lenticular involvement, even in an immunocompetent adult, are urged to consider a diagnosis of an endogenous endophthalmitis secondary to C. albicans.
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http://dx.doi.org/10.3928/15428877-20111201-01DOI Listing
December 2011