Publications by authors named "Armin R Afshar"

32 Publications

Need for Retinal Detachment Reoperation Based on Primary Repair Method Among Commercially Insured Patients, 2003-2016.

Am J Ophthalmol 2021 Apr 22;229:71-81. Epub 2021 Apr 22.

From the Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, (M.G.R.R., S.P.), Palo Alto; Veterans Affairs Palo Alto Health Care System, (S.P.), Palo Alto, California, USA. Electronic address:

Purpose: To examine associations between primary repair, patient characteristics, and rhegmatogenous retinal detachment (RRD) reoperation.

Design: Retrospective cohort study.

Methods: We used administrative claims to identify enrollees with incident RRD treatment by laser barricade, pneumatic retinopexy (PR), pars plana vitrectomy (PPV), or scleral buckle (SB) between 2003 and 2016. Analysis excluded patients with less than 3 years of continuous enrollment, previous RRD diagnosis, or repair. We determined reoperation frequency (PPV, PR, or SB) within 90 days postrepair and used multivariable logistic regression to identify associations between reoperation and patient and primary repair characteristics.

Results: Of 16,190 patients with documented primary RRD repair, 2,918 (18.0%) required reoperation within 90 days. Reoperation was significantly associated with male sex (odds ratio [OR] 1.24, P < .001), pseudophakia (OR 1.25, P < .001), vitreous hemorrhage (OR 1.22, P = .001), and worse systemic health (OR 1.19-1.25, P < .05, for Charlson Comorbidity Index ≥3). Pseudophakia had higher reoperation odds after all primary procedures except PPV. In addition, 28.7% of primary PR cases required reoperation, vs 19.1% of SB and 17.9% of PPV repairs. Adjusting for other patient characteristics, PR had highest odds of reoperation (OR 1.90, P < .001, vs primary PPV). Primary laser barricade had lowest odds of reoperation (OR 0.49, P < .001). PPV was the most frequent reoperation procedure.

Conclusions: Nearly 1 in 5 patients require reoperation within 90 days after primary RRD repair. Cases requiring only primary laser barricade had lowest reoperation odds, likely representing less severe RRDs. Primary PR had highest reoperation odds; PPV and SB were similar to each other. These findings are important for patient education and surgical decision-making.
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http://dx.doi.org/10.1016/j.ajo.2021.04.007DOI Listing
April 2021

As the worm turns: An infant with exotropia.

Surv Ophthalmol 2020 Dec 10. Epub 2020 Dec 10.

Ratner Children's Eye Center, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA.

A two-year-old full-term boy with a history of an intermittent exotropia presented to the pediatric ophthalmology clinic for routine follow-up. He was found to have a stable sensorimotor examination however dilated funduscopic examination of the right eye was significant for a dim foveal reflex with a new discrete, white, elevated retinal lesion superotemporal to the fovea with surrounding subretinal exudates. An examination under anesthesia (EUA) was performed two days later that revealed a subretinal posterior pole granuloma with hyperfluorescence and late leakage from the lesion without telangiectatic vessels on fluorescein angiography. A repeat EUA one month later demonstrated an increase in surrounding subretinal and overlying intraretinal fluid. The patient was started on topical 1% prednisolone with a presumed diagnosis of Toxocara granuloma. At EUA, three months later, the subretinal and intraretinal fluid had resolved. The topical steroids were tapered, and the patient continues to be followed closely.
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http://dx.doi.org/10.1016/j.survophthal.2020.12.003DOI Listing
December 2020

A Pediatric Patient With an Asymptomatic, Unilateral Retinal Mass.

JAMA Ophthalmol 2020 Nov;138(11):1211-1212

Department of Ophthalmology, University of California, San Francisco, San Francisco.

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http://dx.doi.org/10.1001/jamaophthalmol.2020.2040DOI Listing
November 2020

Systemic Corticosteroid Use after Central Serous Chorioretinopathy Diagnosis.

Ophthalmology 2021 01 30;128(1):121-129. Epub 2020 Jun 30.

Byers Eye Institute, Stanford University, Palo Alto, California; Veterans Affairs Palo Alto Health Care System, Palo Alto, California. Electronic address:

Purpose: To analyze the frequency of systemic corticosteroid prescriptions before and after central serous chorioretinopathy (CSC) diagnosis.

Design: Retrospective claims-based analysis.

Participants: A nationally representative sample of commercial insurance beneficiaries who received care between 2007 and 2015.

Methods: We limited the study population to beneficiaries with incident CSC diagnosed by an eye care provider, excluding those with other major ophthalmologic comorbidities. We developed a non-CSC comparison cohort matched to CSC patients by age, sex, general health (Charlson Comorbidity Index), and geographic region. We compared systemic corticosteroid prescriptions before and after CSC diagnosis and by diagnosing provider (optometrist vs. ophthalmologist) and evaluated likelihood of steroids treatment among CSC versus matched control patients using logistic and Cox proportional hazard regression models.

Main Outcome Measures: Systemic corticosteroid prescription frequency among CSC patients within 12 months pre-diagnosis and at 6, 12, and 24 months post-diagnosis, median time to steroid initiation and discontinuation, and odds of receiving steroids post-diagnosis among CSC and control patients.

Results: We identified 3418 CSC patients. Nearly 39% (n = 1326) were prescribed systemic steroids at some point during the analysis period, versus 23% of controls (4033 of 17 178 patients). Over 12% of CSC patients (n = 430) within 1 year pre-diagnosis, and nearly 12% (n = 404) within 1 year post-diagnosis. Most patients who received steroids after diagnosis were steroid naive (n = 231). Among those receiving steroids, CSC patients demonstrated longer median time to first post-diagnosis steroid prescription (1.82 years vs. 0.50 years for non-CSC patients) and longer time to last steroid prescription (1.62 years vs. 0.35 years for non-CSC patients). Although CSC patients were significantly less likely to receive steroids within 6 months post-diagnosis compared with non-CSC patients (odds ratio, 0.72; 95% confidence interval, 0.59-0.89), they were significantly more likely to receive steroids by 2 years post-diagnosis. Prescribing patterns were similar for patients diagnosed by an ophthalmologist versus optometrist.

Conclusions: Despite evidence showing that steroids contribute to CSC development, many patients continue to be prescribed systemic corticosteroids after CSC diagnosis. Our results suggest a need for greater communication and collaboration among providers to ensure that clinical practice reflects evidence-based recommendations.
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http://dx.doi.org/10.1016/j.ophtha.2020.06.056DOI Listing
January 2021

Coccidioidal Endophthalmitis: Excellent Recovery of Vision with Aggressive Use of Intravitreal Antifungals and Vitrectomy.

Retin Cases Brief Rep 2020 Jun 8. Epub 2020 Jun 8.

Retina Service, Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA.

Purpose: To report a case of Coccidioides immitis endophthalmitis with severe vision loss and a return to excellent vision following aggressive intervention.

Methods: Case report.

Results: A 41-year-old male with a history of solid organ transplantation who complained of floaters and decreased vision in the setting of disseminated Coccidioides infection was found to have presumed coccidioidal endophthalmitis with visual acuities (VA) of 20/20 in the right eye and 20/200 in the left eye. The patient was managed with intravenous amphotericin B, oral voriconazole, and intravitreal injections of amphotericin B and voriconazole in the left eye every three days. Five weeks after presentation, VA remained 20/20 in the right eye and improved to 20/40 in the left eye. The patient was transitioned to twice weekly intravitreal injections and oral voriconazole upon hospital discharge. One week later, vision in the left eye decreased to 20/500 with worsening vitritis, prompting vitrectomy. Vision in the left eye subsequently improved to 20/30. Five weeks later, the patient developed a macula-on inferior rhegmatogenous retinal detachment in the left eye and underwent a second vitrectomy, with scleral buckle, laser, and gas injection. Vision in the left eye returned to 20/25. In total, the patient received 22 amphotericin B and 17 voriconazole intravitreal injections in the left eye with two vitrectomies. Vision in the right eye remained 20/20 throughout his treatment course. At four months after presentation, the patient remained on oral voriconazole with no evidence of active intraocular infection on exam.

Conclusions: Aggressive medical and surgical management can be successful in ocular conservation and restoration of vision in coccidioidal endophthalmitis. Very mild disease may be conservatively monitored and managed with systemic antifungal therapy alone. In severe disease, early diagnosis and prompt and aggressive use of systemic and intravitreal antifungals may spare panophthalmitis and preserve vision.
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http://dx.doi.org/10.1097/ICB.0000000000001022DOI Listing
June 2020

Choroidal melanoma overlying scleral buckle evading detection treated with proton beam radiotherapy.

Am J Ophthalmol Case Rep 2020 Jun 8;18:100688. Epub 2020 Apr 8.

Ocular Oncology Service, Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA.

Purpose: to present a case of a choroidal melanoma located along a scleral buckle contour and was successfully treated with proton beam radiotherapy, without disturbing the scleral buckle.

Observations: A 60-year-old woman presented with photopsias and history of retinal detachment repair with scleral buckle 36 years prior. She had annual dilated exams with her ophthalmologist over the last several years. While initially diagnosis of choroidal detachment, hemorrhage and intraocular buckle intrusion were suspected, the patient was referred to an ophthalmic oncology center and choroidal melanoma was confirmed. The patient underwent tantalum marker placement, trans-retinal biopsy and proton beam radiotherapy. Despite no evidence of metastatic disease on systemic imaging, prognostic genetic testing of the tumor revealed high-risk alterations for future metastasis, and the patient enrolled in an adjuvant clinical trial.

Conclusions: The location of this choroidal melanoma along a scleral buckle contour presented a unique therapeutic challenge. We successfuly treated the tumor with proton beam radiotherapy without disturbing the scleral buckle.

Importance: chorioretinal elevations adjacent a scleral buckle may be presumed to be due to the buckle element; ultrasound can be helpful in distinguishing an intraocular tumor. Proton beam radiotherapy has the advantage over plaque brachytherapy in this setting as removing the scleral buckle is not needed and placing a plaque over the scleral buckle risks altering the effective radiotherapy dose.
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http://dx.doi.org/10.1016/j.ajoc.2020.100688DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7154985PMC
June 2020

The diagnostic utility of next-generation sequencing on FNA biopsies of melanocytic uveal lesions.

Cancer Cytopathol 2020 07 20;128(7):499-505. Epub 2020 Mar 20.

Department of Pathology, University of California, San Francisco, San Francisco, California.

Background: Uveal melanoma is highly aggressive, and overall prognosis depends on mutation status. Fine-needle aspiration biopsies (FNABs) play an important role in obtaining fresh tissue for cytologic diagnosis and molecular studies. It has been suggested that, although FNAB usually provides high diagnostic accuracy, there may be limited cellularity, which may compromise diagnostic potential for molecular studies. FNABs of uveal melanocytic lesions were evaluated to assess sample adequacy for both cytologic evaluation and next-generation sequencing (NGS).

Methods: The authors retrospectively evaluated 36 cases of melanocytic uveal lesions from 2015 to 2018. Samples were obtained by ophthalmologist-performed FNAB and aliquoted for cytology and NGS. Various combinations of direct smears, liquid-based cytology slides, cell blocks, and immunohistochemical stains for melanocytic markers were performed. All samples were tested for molecular alterations using hybrid-capture-based NGS.

Results: There was sufficient material for cytologic diagnosis in 33 of 36 cases (92%), for NGS testing in 30 of 36 cases (83%), and for both cytologic diagnosis and NGS testing in 28 of 36 cases (78%). Of 7 cases that were cytologically categorized as indeterminate or diagnosed as "atypical" or "nondiagnostic," NGS testing was sufficient and diagnostic for melanoma in 5 cases. Of the cases diagnosed as melanoma on pathology, 20 cases (87%) had concordant NGS testing results, 2 lacked molecular alterations, and 1 was insufficient for testing.

Conclusions: FNA sampling of melanocytic uveal lesions is adequate for both cytologic diagnosis and NGS testing. In a subset of cases in which pathologic findings were indeterminate, NGS testing results were clarifying for diagnosis. In addition, specific molecular alterations identified can aid in evaluating prognosis and guide further management.
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http://dx.doi.org/10.1002/cncy.22264DOI Listing
July 2020

Next-Generation Sequencing of Retinoblastoma Identifies Pathogenic Alterations beyond RB1 Inactivation That Correlate with Aggressive Histopathologic Features.

Ophthalmology 2020 06 12;127(6):804-813. Epub 2019 Dec 12.

Department of Ophthalmology, University of California, San Francisco, San Francisco, California; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.

Purpose: To determine the usefulness of a comprehensive, targeted-capture next-generation sequencing (NGS) assay for the clinical management of children undergoing enucleation for retinoblastoma.

Design: Cohort study.

Participants: Thirty-two children with retinoblastoma.

Methods: We performed targeted NGS using the UCSF500 Cancer Panel (University of California, San Francisco, San Francisco, CA) on formalin-fixed, paraffin-embedded tumor tissue along with constitutional DNA isolated from peripheral blood, buccal swab, or uninvolved optic nerve. Peripheral blood samples were also sent to a commercial laboratory for germline RB1 mutation testing.

Main Outcome Measures: Presence or absence of germline RB1 mutation or deletion, tumor genetic profile, and association of genetic alterations with clinicopathologic features.

Results: Germline mutation or deletion of the RB1 gene was identified in all children with bilateral retinoblastoma (n = 12), and these NGS results were 100% concordant with commercial germline RB1 mutation analysis. In tumor tissue tested with NGS, biallelic inactivation of RB1 was identified in 28 tumors and focal MYCN amplification was identified in 4 tumors (2 with wild-type RB1 and 2 with biallelic RB1 inactivation). Additional likely pathogenic alterations beyond RB1 were identified in 13 tumors (41%), several of which have not been reported previously in retinoblastoma. These included focal amplifications of MDM4 and RAF1, as well as damaging mutations involving BCOR, ARID1A, MGA, FAT1, and ATRX. The presence of additional likely pathogenetic mutations beyond RB1 inactivation was associated with aggressive histopathologic features, including higher histologic grade and anaplasia, and also with both unilateral and sporadic disease.

Conclusions: Comprehensive NGS analysis reliably detects relevant mutations, amplifications, and chromosomal copy number changes in retinoblastoma. The presence of genetic alterations beyond RB1 inactivation correlates with aggressive histopathologic features.
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http://dx.doi.org/10.1016/j.ophtha.2019.12.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7246167PMC
June 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

An audit of retinal lymphoma treatment at the University of California San Francisco.

Eye (Lond) 2020 03 29;34(3):515-522. Epub 2019 Jul 29.

Department of Hemato-Oncology, University of California, San Francisco, San Francisco, CA, USA.

Background/objectives: To evaluate retinal lymphoma treatment at the University of California San Francisco.

Subjects/methods: Prospective observational audit. Patients were treated systemically, usually with: methotrexate, temozolomide, and rituximab induction; etoposide consolidation; and maintenance with lenalidomide or another immunomodulatory agent. Persistent disease was treated initially by ocular radiotherapy or intravitreal melphalan and latterly by vitrectomy.

Results: The cohort comprised eight females and two males. The median age was 58 years (range, 38-73). Ocular manifestations were initially unilateral in four patients. Vitreous and subretinal infiltrates were initially present in 16 and 12 eyes, respectively, with three eyes having vision of 20/200 or worse. Four patients had a history of central nervous system (CNS) lymphoma. The median ophthalmic follow-up was 37 months (range, 8-56). Diagnostic and therapeutic vitrectomy were performed in 10 and 2 eyes, respectively. All patients had systemic chemotherapy and eight received maintenance immunotherapy. Four patients underwent ocular radiotherapy, bilaterally in two. One patient received bilateral intravitreal melphalan injections. Two eyes of four patients developed lymphoma during the study and two patients developed CNS disease. At study close, subretinal deposits were subtle in nine eyes and more prominent in two, whereas vitreous infiltrates were minimal in nine eyes, mild in one and moderate in one. The latest visual acuity was significantly worse than at presentation in two eyes and better in two. All patients were alive with no active CNS disease.

Conclusions: Subretinal lymphomatous infiltrates respond to systemic chemotherapy with immunomodulatory maintenance, but dense vitreous infiltrates require therapeutic vitrectomy.
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http://dx.doi.org/10.1038/s41433-019-0539-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042248PMC
March 2020

A Novel Hybrid Fixed and Mobile Ultra-Widefield Imaging Program for Diabetic Teleretinopathy Screening.

Ophthalmol Retina 2019 07 20;3(7):576-579. Epub 2019 Mar 20.

Department of Ophthalmology, University of California, San Francisco, San Francisco, California. Electronic address:

Purpose: To describe a new approach for telemedicine screening of diabetic retinopathy (DR) using a combination of a mobile ultra-widefield camera, mounted in a van and able to travel to areas of need, and several fixed-location cameras in high-volume clinics and to report predictors of DR in a diverse urban population of 2788 patients.

Design: Cross-sectional study.

Participants: Two thousand seven hundred eighty-eight patients enrolled in the San Francisco Health Network who underwent DR screening using the novel hybrid telemedicine system.

Methods: The study was carried out at Zuckerberg San Francisco General Hospital in the San Francisco Health Network. A van was specially equipped to allow an ultra-widefield fundus camera to be mounted inside, and the van was sent with a technician to primary care clinics throughout the city on a rotation schedule determined according to clinical need. Additional fundus cameras were placed in several high-volume clinic locations. Patient demographic and clinical information was collected at the time of screening. Photographs were transmitted to a reading center and were graded for DR and other findings by trained readers.

Main Outcome Measures: Prevalence of DR subtypes and odds ratios for development of DR and proliferative DR (PDR).

Results: The hybrid mobile and fixed-location ultra-widefield camera screening system was able to be deployed to carry out the telemedicine screening program for diabetic patients throughout the city of San Francisco referred for screening during the period of the study. Of 2788 patients screened, 736 (27%) were found to have DR. Of these, 34 (5%) had PDR, and 702 (95%) had nonproliferative DR. In multivariate analysis, factors found to be associated with development of any DR were diabetes duration, hemoglobin A1C level, insulin use, and end-organ damage. Diabetes duration was the only factor associated with PDR.

Conclusions: Diabetic retinopathy screening can be accomplished in an urban setting using a combination of fixed-location and mobile ultra-widefield cameras to extend the reach of the screening opportunity throughout a health network. In a diverse group of patients, factors associated with DR and PDR were identified and support ongoing efforts to screen for retinopathy and maintain diabetic control.
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http://dx.doi.org/10.1016/j.oret.2019.03.007DOI Listing
July 2019

Next-Generation Sequencing of Uveal Melanoma for Detection of Genetic Alterations Predicting Metastasis.

Transl Vis Sci Technol 2019 Mar 17;8(2):18. Epub 2019 Apr 17.

Hellen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA.

Purpose: To clinically use the UCSF500, a pancancer, next-generation sequencing assay in uveal melanoma (UM) and to correlate results with gene expression profiling (GEP) and predictive factors for metastasis.

Methods: Cohort study. Tumor samples of adult UM patients were analyzed with the UCSF500 and GEP. Main outcomes were copy number changes in chromosomes 1, 3, 6, and 8 and mutations in , , , , , , , and . Chromosome 3 loss (a metastasis predictor) was tested for correlation with GEP class, tumor characteristics (largest basal diameter, thickness, ciliary body involvement, and extraocular extension), and histology (presence of epithelioid cells, closed loops, and mitotic count).

Results: The 62 patients had a mean age of 59 years (range, 24-89 years). Chromosome 3 loss was detected in 30 patients and was associated with larger basal tumor diameter (Wilcoxon rank sum test, = 0.015), greater thickness (Wilcoxon rank sum test, = 0.016) and tumor, node, metastasis stage (Fisher test, = 0.006), epithelioid cytology (Fisher test, < 0.001), mutation (Fisher test, < 0.001), and chromosome 8q gain (Fisher test, < 0.001). Class 2 tumors were much more likely to have chromosome 3 loss than class 1 (odds ratio, 121; < 0.001). Eleven patients developed metastatic UM, of which five died during the study. All metastatic cases had chromosome 3 loss, 8 gain, mutation, and class 2 GEP. Five class 1 tumors had chromosome 3 loss.

Conclusions: UCSF500 detects chromosomal copy number changes and missense mutations that correlate strongly with metastasis predictors, including GEP.

Translational Relevance: Next-generation sequencing of UM should enhance survival prognostication.
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http://dx.doi.org/10.1167/tvst.8.2.18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6472431PMC
March 2019

The Relative Impact of Patient, Physician, and Geographic Factors on Variation in Primary Rhegmatogenous Retinal Detachment Management.

Ophthalmology 2020 01 12;127(1):97-106. Epub 2019 Apr 12.

Department of Ophthalmology, University of California, San Francisco, San Francisco, California.

Purpose: To evaluate geographic variation and characterize the relative contributions of patient characteristics, physician practice, and geographic region on variation in primary rhegmatogenous retinal detachment (RRD) management.

Design: Retrospective claims-based analysis.

Participants: Commercially insured patients with incident RRD diagnosed between 2008 and 2016 (12 779 patients).

Methods: We determined whether patients underwent primary RRD repair within 60 days of diagnosis and identified repair type. We characterized physicians using physician identifier variables and characterized geography by Combined Statistical Areas or Core-Based Statistical Area. We used multilevel mixed effects logistic regression models to evaluate patient-, physician-, and geographic-level variation in whether patients underwent RRD repair and used multilevel mixed effects multinomial models to characterize variation in repair type. For each model, we evaluated patient fixed effects and physician random effects nested within geographic random effects. We estimated intraclass correlation coefficients and variance partition coefficients, respectively, to compare relative contributions of patient, physician, and geography to overall variation.

Main Outcome Measures: Odds ratios for RRD repair and variation estimates for patient, physician, and geography.

Results: Most incident RRD patients received treatment within 60 days post-diagnosis. Pars plana vitrectomy was most common (49%), followed by laser barricade (23%), scleral buckle and pneumatic retinopexy (both 11%), and cryotherapy (5%). Physician-level variation showed greater impact on receipt of any treatment than geographic-level variation (estimated variance coefficients of 1.09 and 0.32, respectively). Patient-level characteristics represented approximately 82% of overall variation in receipt of any repair, versus 16% from physician-level and 2% from geographic-level factors. Among RRD patients who underwent repair, estimated variance coefficients were 0.07 for geography and 3.37 for physician. Physician-level factors represented approximately 50% of total variation in repair type, followed by patient-level (49%), and geographic-level (1%) factors.

Conclusions: Rhegmatogenous retinal detachment repair decisions are influenced by patient-level and physician-level factors, less so by geographic variation. Patient characteristics account for most of the variation in receipt of repair, and physician practice accounts for most of the variation in choice of procedure. These findings indicate a need for additional studies to understand drivers behind differences in care and clinical outcomes and to identify barriers in access to care.
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http://dx.doi.org/10.1016/j.ophtha.2019.04.019DOI Listing
January 2020

Metastatic Cutaneous Melanoma Presenting with Choroidal Metastasis Simulating Primary Uveal Melanoma.

Ocul Oncol Pathol 2019 Feb 8;5(2):135-138. Epub 2018 Aug 8.

Department of Ophthalmology, University of California, San Francisco, California, USA.

Purpose: To report a case of metastatic cutaneous melanoma presenting with choroidal metastasis simulating primary uveal melanoma.

Design: Case report.

Method: Presentation of clinical, radiographic, histopathologic, and tumor genetic findings in a patient with cutaneous melanoma with choroidal metastasis.

Results: A 50-year-old man with a remote history of stage 1A cutaneous melanoma presented with eye pain, peripheral vision loss, floaters, red eye, and choroidal mass that was originally diagnosed as a primary uveal melanoma at an outside institution; however, subsequent imaging and clinical evaluation demonstrated that this choroidal mass was the first manifestation of widely metastatic cutaneous melanoma (liver, pancreas, lung, bone, brain, and orbit lesions). Histopathologic analysis of the tumor after enucleation was consistent with cutaneous melanoma, and tumor genetic testing was positive for V600E mutation, confirming the choroidal lesion to be a cutaneous melanoma metastasis rather than a primary choroidal melanoma.

Conclusions: Metastatic cutaneous melanoma to the orbit or globe occurs rarely. Tumor genetic testing may help differentiate metastatic cutaneous melanoma from primary uveal melanoma in cases where the diagnosis is uncertain, and can also inform therapy and prognostic counseling.
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http://dx.doi.org/10.1159/000488708DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6422132PMC
February 2019

The University of California, San Francisco Documentation System for Retinoblastoma: Preparing to Improve Staging Methods for This Disease.

Ocul Oncol Pathol 2019 Jan 14;5(1):36-45. Epub 2018 Jun 14.

Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA.

Background/aims: Current retinoblastoma staging systems do not adequately describe the disease, especially in eyes with multiple tumors. The aims of this study were to develop methods for documenting individual tumors and to score disease burden over time.

Methods: A coding system was devised to describe each tumor according to affected eye, meridian, anteroposterior location, activity, growth pattern, type of seed, and treatment. A scoring system for quantifying disease burden was developed, taking account of tumor number, size, spread, and secondary effects on the eye.

Results: Our coding system allowed contemporaneous tumor documentation, producing datasets that enabled generation of fundus diagrams, Kaplan-Meier curves, and tables summarizing disease progression in individual tumors and eyes. Our data showed disparities between ocular and tumor documentation, e.g., indicating earlier tumor development in the left eye but younger age at presentation if disease was worse in the right eye. Actuarial rates of local treatment failure were lower when individual tumors were analyzed than when data were reported in terms of whole eyes.

Conclusion: Our methods for documenting individual retinoblastomas have facilitated the review of patients' progress in our routine practice and may provide data that could be used to refine retinoblastoma classifications in the future.
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http://dx.doi.org/10.1159/000488147DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341334PMC
January 2019

Insights from a Case of Vitreoretinal Lymphoma.

Ocul Oncol Pathol 2019 Jan 17;5(1):13-19. Epub 2018 Apr 17.

Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California, USA.

Purpose/background: The aim of this study was to report a patient with vitreoretinal lymphoma with clinical features providing hypothesis-generating insights into the pathophysiology of this disease.

Methods: Clinical history and imaging studies (i.e., fundus photography, optical coherence tomography, fundus autofluorescence, and fluorescein angiography) were documented.

Results: A 71-year-old woman presented with a 2-month history of blurred vision in the right eye and bilateral vitreous infiltrates unresponsive to topical and systemic steroids. Vitreous biopsy of the left eye was diagnostic for lymphoma. Bulky subretinal deposits in the right eye responded to systemic therapy. The left fundus showed diffuse hypoautofluorescence and punctate, hyperfluorescent sub-retinal pigment epithelial tumor deposits, which resolved leaving hypoautofluorescent atrophic retinal pigment epithelium (RPE) scars, except inferotemporally, where retinal vasculopathy had occurred.

Conclusions: The clinical features suggest that occlusion of the inferotemporal retinal arteriole prevented sub-RPE lymphomatous deposits and subsequent RPE atrophy in this area of vascular nonperfusion. This suggests that "primary" vitreoretinal lymphoma is secondary to hematogenous spread from systemic loci. This finding, together with the ocular tumor control achieved entirely by systemic therapy, indicates scope for studies investigating systemic treatment protocols, especially those including immune-modulatory agents.
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http://dx.doi.org/10.1159/000487949DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341330PMC
January 2019

Choroidal Lymphoma Discovered on Ultrasound in a Patient with Suspected Corneal Tumor.

Ocul Oncol Pathol 2018 Sep 14;4(5):318-321. Epub 2018 Feb 14.

Department of Ophthalmology, University of California, San Francisco, California, USA.

Background/aims: To report the case of a 77-year-old male with a blind, painful eye, referred for suspected corneal mass, with finding of choroidal B-cell lymphoma on pathology of enucleated globe.

Methods: This is a retrospective case report of a single patient.

Results: A 77-year-old male with a longstanding history of poor vision in the left eye was referred for a scarred, vascularized corneal mass. The patient had reported occasional mild ocular discomfort in the left eye and loss of light perception over the last year. Visual acuity was 20/20 in the right eye and no light perception in the left eye. Intraocular pressure was 32 mm Hg in the left eye. Fundoscopic visualization was not possible due to corneal opacity. B-scan ultrasound showed an infiltrative, low-reflective choroidal lesion and inferior retinal detachment. Pathology from the enucleated globe revealed diffuse sheets of CD20+ small B cells replacing the choroid, characteristic of a low-grade small B-cell extranodal marginal zone lymphoma.

Conclusion: This is an unusual presentation of choroidal lymphoma in an eye with severe corneal opacification and scarring, and underscores the diagnostic value of ultrasonography in examination of eyes without view to the posterior segment.
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http://dx.doi.org/10.1159/000486039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6167682PMC
September 2018

The Patient's Experience of Ocular Melanoma in the US: A Survey of the Ocular Melanoma Foundation.

Ocul Oncol Pathol 2018 Sep 8;4(5):280-290. Epub 2018 Feb 8.

Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA.

Background: Ocular melanomas threaten patients with early death, visual handicap, and loss of the eye. The aims of this study were to identify aspects of care that patients with ocular melanoma considered most important and to determine whether patients felt their needs had been adequately addressed.

Methods: A cross-sectional study including US ocular melanoma patients and their caregivers. An online survey of US ocular melanoma patients was designed and conducted by the Ocular Melanoma Foundation.

Results: The cohort included 180 patients with uveal melanoma and 4 with conjunctival melanoma. Median follow-up was 3 years. A third of patients reported that their uveal melanoma had initially been diagnosed as a nevus. Most uveal melanomas were treated with brachytherapy. Almost 50% of patients had no genetic tumor analysis. Screening methods reported most commonly were computed tomography and liver function tests. Metastatic disease developed in 11% of patients. Few patients (13.3%) reported an offer of psychological support. Most dissatisfaction was with lack of advice on financial aspects of care and lack of psychological counseling, with women tending to express more dissatisfaction with care. Many patients complained about the way ophthalmologists delivered bad news to them.

Conclusions: This patients' perspective highlights directions for research, education, and other measures to improve the care of patients with ocular melanoma in the US and elsewhere.
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http://dx.doi.org/10.1159/000485189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6170915PMC
September 2018

Choice of Primary Rhegmatogenous Retinal Detachment Repair Method in US Commercially Insured and Medicare Advantage Patients, 2003-2016.

Am J Ophthalmol 2018 12 23;196:82-90. Epub 2018 Aug 23.

Retina Service, Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA.

Purpose: To evaluate trends for rhegmatogenous retinal detachment (RRD) repair and the influence of patient characteristics on repair type in a large US population including children and adults, between 2003 and 2016.

Design: Retrospective cohort study.

Methods: Setting: Administrative claims for beneficiaries in a large nationwide managed-care network, including Medicare Advantage, employer-sponsored, and commercial insurance.

Population: Beneficiaries undergoing RRD primary repair procedures.

Main Outcome Measure: RRD repair procedure type.

Results: We identified 31 995 beneficiaries with RRD over the study period, mean age 59.8 years. Ocular comorbidities, including pseudophakia (16.9%), vitreous hemorrhage (14.6%), myopia (2.9%), and lattice degeneration (11.0%), were more common among RRD than non-RRD patients. Pars plana vitrectomy (PPV) was consistently the most common repair procedure, increasing over time. Scleral buckle utilization declined and utilization of other procedures remained relatively constant. After adjustment for age, demographics, and geographic region, PPV was more likely among patients with pseudophakia (OR = 1.81, P < .001) and vitreous hemorrhage (OR = 1.38, P < .001). Lattice degeneration (OR = 1.42, P < .001) and younger age were associated with higher odds of scleral buckle. Pneumatic retinopexy was more likely among patients with better systemic health and less likely among patients with ocular comorbidities including vitreous hemorrhage or lattice degeneration.

Conclusions: PPV is increasingly the most common RRD repair procedure across a broadly representative US population. However, other techniques are still preferred for some patients and, in aggregate, choice of repair procedure seems influenced by patient characteristics in a manner consistent with recommendations in the literature.
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http://dx.doi.org/10.1016/j.ajo.2018.08.024DOI Listing
December 2018

THERAPEUTIC VITRECTOMY AS AN ADJUNCT TREATMENT TO SYSTEMIC CHEMOTHERAPY FOR INTRAOCULAR LYMPHOMA.

Retin Cases Brief Rep 2020 ;14(2):116-119

Ocular Oncology Service, Department of Ophthalmology, University of California San Francisco, San Francisco, California; and.

Purpose: To report the outcome of a previously vitrectomized eye having less lymphoma disease burden compared with the contralateral nonvitrectomized eye over the course of 3.5 years while on systemic chemotherapy.

Methods: Case report.

Results: A 51-year-old man with vitreoretinal lymphoma with central nervous system involvement underwent vitrectomy in his left eye. Over the following 3.5 years on systemic chemotherapy, the left eye had less lymphoma disease burden compared with the contralateral nonvitrectomized right eye.

Conclusion: Therapeutic vitrectomy may be a useful adjunct to systemic chemotherapy in vitreoretinal lymphoma, particularly in cases of vitreous predominant disease manifestation.
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http://dx.doi.org/10.1097/ICB.0000000000000668DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089662PMC
February 2021

POLYPOIDAL CHOROIDAL VASCULOPATHY: A CLINICOPATHOLOGIC STUDY.

Retin Cases Brief Rep 2017 Winter;11 Suppl 1:S128-S131

*Department of Ophthalmology, University of California, San Francisco, San Francisco, California; †Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, California; and ‡Department of Ophthalmology, Santa Clara Valley Medical Center, San Jose, California.

Purpose: To present a unique case of polypoidal choroidal vasculopathy presenting as a blind, painful eye with a suspected intraocular mass, and to correlate clinical findings with histopathologic studies.

Methods: Clinical case report and literature review.

Results: A 58-year-old Vietnamese man presented with a blind, painful eye with concern for an intraocular mass. B-scan ultrasonography showed massive intraocular hemorrhage and could not rule out a tumor. The patient underwent enucleation and the histopathologic findings were consistent with polypoidal choroidal vasculopathy.

Conclusion: Polypoidal choroidal vasculopathy can present with dense vitreous hemorrhage and may masquerade as an intraocular mass. It can progress rapidly and lead to profound, irreversible vision loss. A diagnosis of polypoidal choroidal vasculopathy should be considered in patients of African or East Asian origin presenting with vitreous hemorrhage.
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http://dx.doi.org/10.1097/ICB.0000000000000464DOI Listing
June 2017

DOME-SHAPED MACULA WITH THICKENED CHOROID IN AN EMMETROPIC PATIENT.

Retin Cases Brief Rep 2015 ;9(4):307-10

University of California, San Francisco, San Francisco, California.

Purpose: To report a rare case of bilateral dome-shaped macula in an emmetropic patient.

Method: Clinical case report and literature review.

Results: A 42-year-old woman presented with a history of blurred vision in the right eye. Visual acuity was 20/30 in the right eye and 20/20 in the left eye. Intraocular pressure and anterior segment were unremarkable. Fundus examination revealed dull macular reflex and subretinal fluid nasal to the fovea in the right eye and a hyperpigmented area inferotemporal to the fovea in the left eye. Spectral domain optical coherence tomography showed subretinal fluid under the fovea in the right eye and elevation of the macula with increased choroidal thickness in both eyes. Fluorescein angiography revealed abnormal hyperfluorescence without any leakage in both eyes. B-scan ultrasound showed irregular globe contour with high internal reflectivity and dome-shaped lesions at the posterior pole in both eyes. Axial length was 24.6 mm in the right eye and 25.6 mm in the left eye.

Conclusion: Although most commonly reported in myopic eyes, dome-shaped macula can occur in an emmetropic patient and can be associated with subretinal fluid.
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http://dx.doi.org/10.1097/ICB.0000000000000198DOI Listing
July 2016

OUTER RETINAL ATROPHY ON SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY AFTER RESOLUTION OF GLAUCOMA SURGERY-ASSOCIATED HYPOTONY MACULOPATHY.

Retin Cases Brief Rep 2016 ;10(1):96-9

*Department of Ophthalmology, University of California, San Francisco, San Francisco, California; †The Third Affiliated Hospital, Nanchang University, Nanchang, China; and ‡The Second Affiliated Hospital, Harbin Medical University, Harbin, China.

Purpose: To report two cases of persistent central vision loss after resolution of filtration surgery-associated hypotony, corresponding with foveal outer retinal atrophy on spectral domain optical coherence tomography.

Methods: Retrospective observational case series. A retrospective chart review was conducted of two patients with persistent vision loss after normalization of intraocular pressure and resolution of glaucoma surgery-associated hypotony maculopathy.

Results: Several months after glaucoma surgery and resolution of hypotony, both patients suffered persistent vision loss and new foveal photoreceptor loss on spectral domain optical coherence tomography.

Conclusion: This is the first case series demonstrating foveal outer retinal atrophy on spectral domain optical coherence tomography after resolution of glaucoma surgery-associated hypotony maculopathy. Both patients had previous uveitis that was controlled at the time of hypotony. Eyes with previous hypotony and compromised ciliary body function may be at greater risk of photoreceptor damage.
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http://dx.doi.org/10.1097/ICB.0000000000000173DOI Listing
September 2016

Outcomes of chronic macular hole surgical repair.

Indian J Ophthalmol 2014 Jul;62(7):795-8

Department of Ophthalmology and Visual Science, Pritzker School of Medicine, The University of Chicago, Chicago, Illinois, USA.

Purpose: To report visual and anatomic outcomes of chronic macular hole surgery, with analysis of pre-operative OCT-based hole size and post-operative closure type.

Settings And Design: An IRB-approved, retrospective case series of 26 eyes of 24 patients who underwent surgery for stage 3 or 4 idiopathic chronic macular holes at a tertiary care referral center.

Statistical Analysis: Student's t-test.

Results: Nineteen of 26 eyes (73%) had visual improvement after surgery on most recent exam. Twenty-one of 26 eyes (81%) achieved anatomic closure; 16 of 26 eyes (62%) achieved type 1, and five of 26 eyes (19%) achieved type 2 closure. Post-operative LogMAR VA for type 1 closure holes (0.49) was significantly greater than for type 2 closure and open holes (1.26, P < 0.003 and 1.10, P < 0.005, respectively), despite similar pre-operative VA (P = 0.51 and 0.68, respectively). Mean pre-operative hole diameter for eyes with type 1 closure, type 2 closure, and holes that remained open were 554, 929, and 1205 microns, respectively. Mean pre-operative hole diameter was significantly larger in eyes that remained open as compared to eyes with type 1 closure (P = 0.015).

Conclusion: Vitrectomy to repair chronic macular holes can improve vision and achieve long-term closure. Holes of greater than 3.4 years duration were associated with a greater incidence of remaining open and type 2 closure. Larger holes (mean diameter of 1205 microns) were more likely to remain open after repair.
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http://dx.doi.org/10.4103/0301-4738.138302DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4152650PMC
July 2014

Author reply: To PMID 24246828.

Ophthalmology 2014 Oct 27;121(10):e57. Epub 2014 Jun 27.

Department of Ophthalmology, University of California, San Francisco, San Francisco, California.

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http://dx.doi.org/10.1016/j.ophtha.2014.05.026DOI Listing
October 2014

Dexamethasone intravitreal implant trapped at the macula in a silicone oil-filled eye.

Ophthalmology 2013 Dec;120(12):2748-2749.e1

University of California, San Francisco, Department of Ophthalmology, San Francisco, California.

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http://dx.doi.org/10.1016/j.ophtha.2013.08.024DOI Listing
December 2013

Toxic corneal epitheliopathy after intravitreal methotrexate and its treatment with oral folic acid.

Cornea 2013 Aug;32(8):1171-3

Department of Ophthalmology, University of California, San Francisco, San Francisco, CA 94143-0730, USA.

Purpose: To determine whether oral folic acid can ameliorate an iatrogenic, visually significant corneal epitheliopathy, which commonly occurs with intravitreal injections of methotrexate for the treatment of intraocular lymphoma.

Methods: We report 2 cases of visually significant corneal epitheliopathy occurring after intravitreal injections of methotrexate for intraocular lymphoma. The first patient did not receive any treatment for the corneal disease, and the second patient with bilateral intraocular lymphoma received 1 mg of oral folic acid daily, a commonly used dosage for patients on systemic methotrexate.

Results: In the first patient without treatment, there was a complete regression of the corneal epithelial disease only when the frequency of intravitreal methotrexate was reduced from weekly to monthly as per a commonly used dosage regimen for methotrexate. In the second patient, the corneal disease improved 80% within 1 week of initiating oral folic acid for her eye already experiencing severe epitheliopathy during her weekly dosing regimen of methotrexate and also had significantly decreased epithelial disease in her second eye that started weekly intravitreal methotrexate several weeks after beginning oral folic acid.

Conclusions: Currently, oral folic acid supplements are recommended for patients using systemic methotrexate to minimize drug toxicity. We suggest a similar use in patients undergoing intravitreal methotrexate injections to decrease toxic effects on the corneal epithelium.
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http://dx.doi.org/10.1097/ICO.0b013e3182910106DOI Listing
August 2013

Cystoid macular edema associated with fingolimod use for multiple sclerosis.

JAMA Ophthalmol 2013 Jan;131(1):103-7

Departments of Ophthalmology and Visual Science, Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA.

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http://dx.doi.org/10.1001/jamaophthalmol.2013.570DOI Listing
January 2013