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Roderick O'Day,1 Daniel Barthelmes,1 Meidong Zhu,1 Tien Yin Wong,2,3 Ian L McAllister,4 Jennifer J Arnold,5 Mark C Gillies11Clinical Ophthalmology and Eye Health, The University of Sydney, Sydney, NSW, Australia; 2Singapore Eye Research Institute, National University of Singapore, Singapore; 3Center for Eye Research Australia, The University of Melbourne, Melbourne, VIC, Australia; 4Lions Eye Institute, The University of Western Australia, Perth, WA, Australia; 5Marsden Eye Specialists, Sydney, NSW, AustraliaPurpose: To identify baseline characteristics that predict the number of treatments with intravitreal triamcinolone acetonide (IVTA) plus laser photocoagulation needed to treat diabetic macular edema over a 2-year period.Methods: Individual data from 42 eyes of 42 participants treated with IVTA plus laser photocoagulation for diabetic macular edema during a prospective, randomized, double-masked, placebo-controlled trial were used for this post hoc analysis. Baseline characteristics – age, gender, best-corrected visual acuity, glycosylated hemoglobin, phakic status, intraocular pressure, and central macular thickness (CMT) – were correlated with the number of IVTA plus laser treatments received during the 2 years of this study.Results: The median number of treatments received over the 2-year period was 2.5 (interquartile range 1.0–3.0), with 21 (50%) eyes needing three or more treatments. Eyes that received more IVTA plus laser treatments had a higher mean baseline CMT and eyes with a higher baseline CMT were more likely to receive three or more treatments (odds ratio 5.13, 95% confidence interval 1.75–15.04, P=0.003 per 100 µm increase in CMT). No significant relationship was found between other baseline characteristics and the number of IVTA plus laser treatments received.Conclusion: Higher baseline CMT was strongly linked with receiving more IVTA plus laser treatments. These patients may be at higher risk of developing dose-dependent steroid-related adverse events, cataract progression, and intraocular pressure rise.Keywords: diabetic macular edema, intravitreal triamcinolone, central macular thickness

Purpose: To evaluate high-risk histopathological features following primary enucleation of eyes with retinoblastoma and assess the patient outcomes across continents., Methods: A retrospective study of 1,426 primarily enucleated retinoblastoma eyes from five continents., Results: Of all, 923 (65%) were from Asia (AS), 27 (2%) from Australia (AUS), 120 (8%) from Europe (EUR), 162 (11%) from North America (NA), and 194 (14%) from South America (SA). Based on the continent (AS vs. AUS vs. EUR vs. NA vs. SA), the histopathological features included massive choroidal invasion (31% vs. 7% vs. 13% vs. 19% vs. 27%, P = 0.001), postlaminar optic nerve invasion (27% vs. 0% vs. 16% vs. 21% vs. 19%, P = 0.0006), scleral infiltration (5% vs. 0% vs. 4% vs. 2% vs. 7%, P = 0.13), and microscopic extrascleral infiltration (4% vs. 0% vs. <1% vs. <1% vs. 4%, P = 0.68). Adjuvant chemotherapy with/without orbital radiotherapy was given to 761 (53%) patients. Based on Kaplan-Meier estimates in different continents (AS vs. AUS vs. EUR vs. NA vs. SA), the 6-year risk of orbital tumor recurrence was 5% versus 2% versus 0% versus 0% versus 12% ( P < 0.001), systemic metastasis was reported in 8% versus 5% versus 2% versus 0% versus 13% ( P = 0.001), and death in 10% versus 3% versus 2% versus 0% versus 11% ( P < 0.001) patients., Conclusion: There is a wide variation in the infiltrative histopathological features of retinoblastoma across continents, resulting in variable outcomes. SA and AS had a higher risk of orbital tumor recurrence, systemic metastasis, and death compared to AUS, EUR, and NA., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Opthalmic Communications Society, Inc.)

Objective: Ruthenium-106 brachytherapy is commonly used to treat uveal melanomas. Most centres prescribe a radiation dose to the tumour apex that is calculated with the tumour located in the centre of the plaque. Recent work suggests that D 99% -the minimum radiation dose delivered to 99% of tumour volume-may be a better predictor of tumour control than apex dose. Both dosing regimens may be affected by tumour and treatment variables differently. We explored the effect of differences in these variables on volume and apex dose using a 3-dimensional planning model., Methods: The time required to deliver 100 Gy to the tumour apices of representative tumours ranging from 2- to 6-mm thickness with central plaque positioning was calculated in Plaque Simulator™. This treatment time was used for further calculations, including D 99% with central plaque placement, and apical and tumour volume doses when tumour and plaque characteristics were altered, including eccentric plaque placement, either away from (tilt) or along (offset) scleral surface, tumour shape, and plaque type., Results: D 99% was always greater than the apex dose when plaques were placed centrally, and the difference increased with tumour thickness. Increasing degrees of tumour offset reduced apical dose and D 99% , with a greater effect on apical dose for thicker and D 99% for thinner tumours, respectively. Differences in tumour shape and plaque type had idiosyncratic effects on apical and volume dosing., Conclusion: D 99% and apex dose are affected by tumour and treatment characteristics in different ways, highlighting the complexity of radiation delivery to uveal tumours., Competing Interests: Footnotes and Disclosure Funding: This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors Commercial relationships disclosures: Emeritus Professor M.A. Astrahan is the proprietary founder and owner of the Plaque Simulator(TM) software. Nil additional disclosures by any other author., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Stereotactic radiotherapy (SRT) is used for choroidal melanoma (CM) abutting the optic nerve. Visual acuity (VA) deterioration to ≤6/60 is common. We report a pilot study of reduced-dose SRT using 2 Gy/day, aiming to preserve vision without compromising survival., Method: 60 Gy SRT was delivered in 30 fractions over 6 weeks. Liver metastasis surveillance was annual ultrasound. The primary endpoint was 5-year metastasis-free survival (5yMFS). Secondary endpoints were 2-year freedom from local progression (2yFFLP), VA, enucleation rate, and radiation toxicity., Results: Twenty adults aged ≤70 years with T1-T2M0 CM without diabetes mellitus were enrolled. Median follow-up was 5.1 years. About 85% and 90% of tumours were ≤3 mm of the macula and optic disc, respectively. Median tumour height was 2.2 mm (range 1.0-4.4 mm), and median basal diameter was 8.2 mm (range: 4.3-15.0 mm). 5yMFS was 88% (95% CI: 61-97), and the 2yFFLP rate was 90% (95%: CI 66-97). There were three enucleations for disease progression. Final VA in retained eyes was ≥6/7.5 in 6 (30%), 6/9 to 6/12 in 5 (25%), 6/15 to 6/48 in 2 (10%), and ≤6/60 in 4 (20%) eyes. Retinopathy was the main cause of vision loss besides tumour progression., Conclusion: Meaningful vision was preserved 5 years after SRT, despite high-risk tumour locations for vision loss. 2yFFLP and 5yMFS were acceptable. This dose fractionation warrants further investigation., Competing Interests: No conflicting relationship exists for any author., (© 2024 S. Karger AG, Basel.)

Purpose: To report the effective use of neoadjuvant darovasertib and crizotinib in a patient with a large uveal melanoma (UM) in his only functional eye., Design: Case report., Subjects: One patient with T4b UM., Intervention: Neoadjuvant darovasertib and crizotinib, followed by plaque brachytherapy., Main Outcome Measures: Objective tumor response and conversion from planned enucleation to placement of fovea- and optic nerve-sparing plaque brachytherapy., Results: A patient with a history of left eye blindness from retinal artery occlusion presented with rapidly declining right eye vision due to a primary UM measuring 18 mm in maximal diameter and 16.5 mm in maximal thickness. To salvage vision, neoadjuvant treatment was initiated using darovasertib and crizotinib. After 6 months of neoadjuvant treatment, which included intraocular lens replacement for tumor-associated cataract, the tumor regressed to 14.1 mm in maximal diameter and 2.6 mm in maximal thickness, enabling treatment with plaque brachytherapy rather than enucleation., Conclusions: The combination of darovasertib and crizotinib for UM is an effective neoadjuvant strategy that warrants further investigation as an approach to improve visual outcomes from the treatment of primary UM., Financial Disclosure: The other authors have no proprietary or commercial interest in any materials discussed in this article., (Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: Ruthenium-106 brachytherapy is a common treatment for small to medium-sized uveal melanomas. In certain clinical contexts, plaques may be placed eccentrically to tumor center. The effect of plaque decentration, a common radiation dose measurement in radiotherapy: D 98% , the percentage of the tumor volume receiving at least 98% of the prescribed dose (a commonly used term in radiation oncology), is unknown. We investigated this using two commonly used plaques (CCA and CCB; Eckert & Ziegler, BEBIG GmbH) in silico ., Material and Methods: Using a Plaque Simulator™ (Eye Physics) plaque modelling software, treatment time required to deliver 100 Gy D 98% with central plaque placement was calculated for both plaque models, treating tumors with basal dimensions of 10 mm (CCB plaque only) and 7 mm (CCA and CCB plaques), and a range of thicknesses. D 98% was calculated for plaque-tumor edge distances of 0-5 mm. Additionally, we defined minimum plaque-tumor edge distances, at which D 98% fell by 10% and 5% (safety margins)., Results: D 98% decreased as plaque-tumor edge distance decreased, i.e. as plaque eccentricity increased. Minor (< 1 mm) plaque decentration caused minimal D 98% changes across tumor thicknesses. Safety margins did not follow a consistent pattern., Conclusions: Eccentric plaque placement reduces the radiation dose delivered to choroidal tumors. Both tumor (thickness, diameter) and plaque (size, location) characteristics are important D 98% modulators. Further investigation of the effect of these characteristics and dose to organs at risk is essential., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Termedia.)

Uveal melanoma represents the most common intraocular neoplasia among adults. Brachytherapy (interventional radiotherapy; IRT) has a great advantage, when compared with enucleation, both in terms of organ and function sparing. The Collaborative Ocular Melanoma Study introduced into clinical practice a standardised procedure that allowed the equivalence of IRT with enucleation in terms of overall survival to be demonstrated. IRT is carried out by placing a plaque in direct contact with the sclera under the uveal melanoma. Several radioactive sources may be used, including 106-ruthenium, 125-iodine, 103-palladium and 90-strontium. It is a multidisciplinary procedure requiring the collaboration of interventional radiation oncologists and ophthalmologists in the operating theatre and medical physicists for an accurate treatment time calculation. It also relies on ultrasound imaging to identify the lesion and verifiy the correct plaque placement. An emerging tool of paramount importance could be the use of artificial intelligence and predictive models to identify those patients at higher risk of developing late side-effects and therefore who may deserve preventive and supportive therapies., (Copyright © 2023 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

We describe the case of a 76-year-old man who developed an asymptomatic choroidal osteoma in the left eye 10 years after receiving retinal laser photocoagulation for treatment of a peripapillary choroidal neovascular membrane. The choroidal osteoma presented as a progressively enlarging, well-circumscribed yellow lesion adjacent to the region of retinal fibrosis. Optical coherence tomography showed a choroidal lesion with superficial lamellations and ultrasonography demonstrated increased echogenicity. The choroidal osteoma was not encroaching on the fovea and is currently being monitored. This is only the third report of a de novo choroidal osteoma developing subsequent to retinal laser photocoagulation., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Oman Ophthalmic Society.)

Clinical relevance : The malignant potential of choroidal melanocytic tumours detected incidentally in the community is thought to be low, but this has not been assessed using a validated screening tool. An accurate characterisation of the malignant potential of these lesions has implications for resource allocation, service provision, education, and training. Background : MOLES (Mushroom shape, Orange Pigment, Large size, Enlargement, and Subretinal fluid) categorises tumours as 'common naevus', 'low-risk naevus', 'high-risk naevus', and 'probable melanoma'. The MOLES system recommends that patients with common naevi (score = 0) undergo review by a community optometrist every two years, ideally with sequential colour photography. For the remaining patients (score ≥ 1), specialist imaging and assessment are recommended, with referral triaged as non-urgent for patients with low-risk (score = 1) or high-risk naevi (score = 2) and urgent for patients with probable melanoma (score > 2). Methods : Lesions flagged as choroidal melanocytic tumours on retinal photographs taken during the Australian National Eye Health Survey were retrospectively analysed by an ocular oncologist. Each lesion was assigned a MOLES score and categorised as common, low-risk, high-risk or probable melanoma. Results : Seventy-seven choroidal naevi were identified. Seventy-five (97%) of the choroidal naevi were categorised as common naevi, with a MOLES score of 0. Two (3%) choroidal naevi had a score of 1 and diagnosed as low-risk naevi due to their size. No naevi had a score of 2 or more. Conclusion : All choroidal naevi detected in this nationally representative population survey were innocuous. This suggests that the vast majority of choroidal melanocytic tumours that are incidentally detected in Australia can be managed in primary eye care settings without the need for specialist referral. MOLES provides a simple evidence-based method for choroidal naevi assessment in primary care.

Objective: The aim of this study was to determine the sensitivity and specificity of the MOLES scoring system in differentiating choroidal melanomas from nevi according to Mushroom shape, Orange pigment, Large tumor size, Enlarging tumor, and Subretinal fluid (SRF)., Methods: Color photographs, fundus-autofluorescence images, and optical coherence tomography of 222 melanocytic choroidal tumors were reviewed. Each MOLES feature was retrospectively scored between 0 and 2 and tumors categorized as "common nevus," "low-risk nevus," "high-risk nevus," and "probable melanoma" according to the total score. MOLES scores were compared with the experts' diagnosis of melanoma., Results: The MOLES scoring system indicated melanoma in all 81 tumors diagnosed as such by ocular oncologists (100% sensitivity) and nevus in 135 of 141 tumors given this diagnosis by these experts (95.7% specificity). Of the 6 tumors with discordant diagnoses, 4 had basal diameters exceeding 6 mm, all with SRF and/or orange pigment, and 2 small tumors showed either significant SRF with traces of orange pigment, or vice versa., Conclusions: The MOLES system for diagnosing melanocytic choroidal tumors compares well with expert diagnosis but needs to be evaluated when deployed by ophthalmologists and community optometrists in a wide variety of working environments., Competing Interests: The authors have no conflicts of interest to report. This manuscript has not previously been submitted for publication. None of the authors have any financial disclosures to declare., (Copyright © 2021 by S. Karger AG, Basel.)

This study investigated the diagnostic performance, feasibility, and end-user experiences of an artificial intelligence (AI)-assisted diabetic retinopathy (DR) screening model in real-world Australian healthcare settings. The study consisted of two components: (1) DR screening of patients using an AI-assisted system and (2) in-depth interviews with health professionals involved in implementing screening. Participants with type 1 or type 2 diabetes mellitus attending two endocrinology outpatient and three Aboriginal Medical Services clinics between March 2018 and May 2019 were invited to a prospective observational study. A single 45-degree (macula centred), non-stereoscopic, colour retinal image was taken of each eye from participants and were instantly screened for referable DR using a custom offline automated AI system. A total of 236 participants, including 174 from endocrinology and 62 from Aboriginal Medical Services clinics, provided informed consent and 203 (86.0%) were included in the analysis. A total of 33 consenting participants (14%) were excluded from the primary analysis due to ungradable or missing images from small pupils (n = 21, 63.6%), cataract (n = 7, 21.2%), poor fixation (n = 2, 6.1%), technical issues (n = 2, 6.1%), and corneal scarring (n = 1, 3%). The area under the curve, sensitivity, and specificity of the AI system for referable DR were 0.92, 96.9% and 87.7%, respectively. There were 51 disagreements between the reference standard and index test diagnoses, including 29 which were manually graded as ungradable, 21 false positives, and one false negative. A total of 28 participants (11.9%) were referred for follow-up based on new ocular findings, among whom, 15 (53.6%) were able to be contacted and 9 (60%) adhered to referral. Of 207 participants who completed a satisfaction questionnaire, 93.7% specified they were either satisfied or extremely satisfied, and 93.2% specified they would be likely or extremely likely to use this service again. Clinical staff involved in screening most frequently noted that the AI system was easy to use, and the real-time diagnostic report was useful. Our study indicates that AI-assisted DR screening model is accurate and well-accepted by patients and clinicians in endocrinology and indigenous healthcare settings. Future deployments of AI-assisted screening models would require consideration of downstream referral pathways., (© 2021. The Author(s).)

Purpose: To report local disease control and all-cause mortality in patients with extraocular extension (EOE) of uveal melanoma undergoing enucleation followed by observation or external beam radiotherapy (EBRT)., Methods: Charts of patients enucleated between January 1, 1997 and December 31, 2019, with histopathological evidence of EOE of uveal melanoma were reviewed., Results: The cohort comprised 51 patients with a mean age of 67 ± 15 years, 22 (43%) of whom underwent adjuvant postenucleation EBRT. Risk factors for metastasis included presence of epithelioid cells (29/45; 88%), closed loops (20/43; 47%), monosomy 3 (16/25; 64%), and gain of 8q (20/22; 91%). Patients undergoing EBRT had more extensive EOE (median: 5.1 mm vs. 2.6 mm, p = 0.008) and surgical excision was less likely to be histologically complete (2/20; 10% vs. 14/25; 56%, p = 0.002). Local side effects following EBRT were seen in 64% (14/22). At latest follow up, 59% of patients (30/51) were alive, with a median follow up of 1.8 years (interquartile range: 2.9; range: 0.1-6.5]. By Kaplan-Meier survival analysis, the 5- and 10-year overall survival rates were 56% and 12%, respectively. There was no difference in all-cause mortality between those receiving adjuvant EBRT and those who were observed (log rank, p = 0.273). No cases of orbital recurrence were documented., Conclusions: Orbital EBRT causes significant morbidity. Cases with relatively small EOE undergoing enucleation can be safely observed, without adjuvant EBRT. Multicenter studies are required to better assess the role of EBRT when EOE is more extensive., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Background and Objective: Circumscribed choroidal haemangioma (CCH) has several characteristic clinical and angiographic features. We aimed to compare indocyanine green angiography (ICG) findings of CCH captured on a traditional digital camera system (DCS) to newer scanning laser ophthalmoscopy (SLO) platforms., Study Design/materials and Methods: A total of 35 patients over a 10-year period diagnosed with CCH using ICG were included (18 imaged with DCS and 17 with SLO)., Results: On early ICG frames, intrinsic vessels were apparent in two-thirds (12/18; 67%) of the DCS group compared with all of eyes in the SLO group (p = 0.020). In addition, at maximal hyperfluorescence, most eyes imaged with DCS had a feathery appearance (16/18; 89%) compared with those in the SLO group which all (17/17; 100%) displayed a granular appearance (p < 0.001). The presence of hot spots at maximal hyperfluorescence was also more common in the SLO group (12/17; 71%) versus the DCS group (0/18; 0%) (p < 0.001). Finally, intrinsic vessels and vascular loops could be identified throughout the entire duration of the ICG in 100% of the SLO cases (17/17) versus only 11% (2/18) of DCS cases (p < 0.001)., Conclusions: The visualization of intrinsic vessels, vascular loops, and "hot spots" in CCH is significantly enhanced with SLO compared with DCS. Many characteristic mid-late angiographic findings of CCH are more optimally visualized on SLO which may negate the need for late frames (>30 min) without compromising diagnostic accuracy.

We thank Capasso et al [...].

Objective: To define the characteristics of solitary idiopathic choroiditis (SIC) in a consecutive series of patients and propose a nomenclature change to idiopathic scleroma., Materials and Methods: Electronic patient records were retrospectively interrogated to identify all patients diagnosed with SIC between 2002 and 2019 in a tertiary referral ophthalmic hospital in the United Kingdom., Results: Thirty-four eyes of 34 patients were found to have SIC. The mean age at diagnosis was 48 years (range 24-78) and 23 patients (68%) were female. All lesions were located posterior to the equator, most frequently in the inferotemporal quadrant (13 eyes, 38%). The lesions had a mean largest basal diameter of 1.2 ± 0.4 disc diameters (range 0.5-2) and their distance to the optic disc had a mean of 1.2 ± 0.9 disc diameters (range 0-3.3). All lesions were intrascleral on enhanced depth imaging optical coherence tomography, demonstrating a hypo-reflective zone within the sclera, with an underlying hyper-reflective zone in some cases. No lesion enlarged or developed features consistent with active inflammation after a median follow-up time of 0.9 years (range 0-16.8)., Discussion/conclusion: Optical coherence tomography shows SIC to be an intrascleral lesion. Furthermore, we found no evidence of any inflammatory component. A nomenclature change to idiopathic scleroma is appropriate to prevent unnecessary investigation., Competing Interests: The authors declare no disclosures or conflicts of interest., (Copyright © 2020 by S. Karger AG, Basel.)

We report a 61-year-old female who presented to our service with recent growth of a thickened, pigmented, sub-conjunctival lesion within an area of ocular melanocytosis in her left eye. Lamellar sclerectomy was performed. Histopathological assessment revealed a localized melanocytic proliferation with features of blue nevus arising within the area of ocular melanocytosis. There was a small zone of cells showing cytological atypia and expansion of the scleral stroma. We believe this case to be the first report of intrascleral blue nevus arising within an area of ocular melanocytosis. Given the cytological atypia, the blue nevus may perhaps represent an intermediate stage within a progression from ocular melanocytosis towards melanoma. Patients with oculodermal melanocytosis merit regular long-term surveillance for early detection of melanoma, not only in the uvea, but also in the orbit and potentially the ocular surface., Competing Interests: None of the authors have any disclosures or conflicts of interest to declare., (Copyright © 2020 by S. Karger AG, Basel.)

Purpose: To determine if ultrasonography is necessary to detect progression of choroidal melanocytic tumors undergoing sequential multi-modal imaging with color photography, autofluorescence (AF) and optical coherence tomography (OCT). Methods: All patients with choroidal melanoma undergoing treatment at Moorfields Eye Hospital between January 2016 and March 2020 were reviewed to identify those with treatment deferred by ≥2 months. Tumors that showed progression prior to treatment, defined as an increase in (a) basal dimensions (b) thickness (c) orange pigment and/or (d) sub-retinal fluid, were included. Mushroom shape, Orange pigment, Large size, Enlargement and Sub-retinal fluid (MOLES) scores were assigned to all tumors at earliest date and date of treatment. Results: A total of 99 patients with a mean age of 66 years (range: 26-90) were included. The initial MOLES score was 1 in 2 cases, 2 in 23 cases, and ≥3 in 74 cases. Progression was detected with sequential color photography alone in 100% of MOLES 1/2 and 97% of lesions with a MOLES score of ≥3. When findings on AF and OCT were included, sensitivity for detecting subtle change without ultrasonography improved to 100% for MOLES 3 and 97% for MOLES 4/5. Only one patient included in this study had an isolated increase in thickness that may have been missed had sequential ultrasonography not been performed. Overall, the sensitivity for detecting progression with color photographs alone was 97% (95% CI 93-100%) and increased to 99% (95% CI 97-100%) by including autofluorescence and OCT. Conclusions: Monitoring of choroidal nevi, particularly those classified as MOLES 1 or 2 (i.e., low-risk or high-risk naevi), can be accomplished safely without the need for ultrasonography. The findings of this study may remove barriers to the implementation of tele-oncology clinics for the monitoring of choroidal melanocytic tumors.

Purpose: To evaluate the MOLES system for identifying malignancy in melanocytic choroidal tumors in patients treated for choroidal melanoma., Methods: Records of 615 patients treated for choroidal melanoma between January 2017 and December 2019 were reviewed. Patients were excluded if iris and/or ciliary body involvement (106 patients), inadequate fundus photography (26 patients), no images available for review (21 patients) and/or treatment was not primary (11 patients). Demographic data and AJCC TNM Stage were collected. Color fundus and autofluorescence photographs (FAF), optical coherence tomography (OCT) and B-scan ultrasounds were prospectively reviewed. MOLES scores were assigned according to five criteria: mushroom shape, orange pigment, large size, enlarging tumor and subretinal fluid., Results: A total of 451 patients (mean age, 63.9 ± 13.9 years) were included. At treatment, mean largest basal tumor diameter (LBD) and thickness were10.3 ± 2.8 mm (range, 3.0-23.0) and 4.3 mm (range, 1.0-17.0). All but one (0.2%) had MOLES scores of ≥3. Eighty-two patients were treated after surveillance lasting a mean of 1.5 years. Initially, most (63/82; 76.8%) had a MOLES score ≥ 3. Importantly, none of the 451 tumors had a score of <2, and as such, the MOLES protocol would have indicated referral to an ocular oncologist for 100% of patients., Conclusion: The MOLES scoring system is a sensitive (99.8%) tool for indicating malignancy in melanocytic choroidal tumors (MOLES ≥ 3). If the examining practitioner can recognize the five features suggestive of malignancy, MOLES is a safe tool to optimize referral of melanocytic choroidal tumors for specialist care.

Background: To evaluate the safety and efficacy of a treat-and-extend protocol of aflibercept for cystoid macular oedema (CMO) secondary to central retinal vein occlusion (CRVO)., Methods: Twenty patients with CMO secondary to CRVO were included in this prospective cohort study. After 3 loading 4-weekly injections, treatment intervals were increased by 2 weeks if there was no clinical activity, to a maximum of 12 weeks. If clinical activity recurred or persisted, the interval between injections was shortened by 2 weeks, to a minimum of 4 weeks. Main outcome measures were change in visual acuity and the proportion of patients gaining 15 or more Early Treatment of Diabetic Retinopathy Study (ETDRS) letters from baseline at 6, 12 and 18 months., Results: Mean BCVA gain from baseline was 19.7 ± 13.8, 22.2 ± 13.9 and 21.9 ± 15.8 ETDRS letters at 6, 12 and 18 months, respectively. Sixty-five percent of patients gained 15 or more ETDRS letters at 6 months, increasing to 70.6% at 12 and 18 months. Patients received 5.0 [4.0 to 6.0], 8.5 [8.0 to 10.3] and 11.0 [9.0 to 12.5] injections by 6, 12 and 18 months, respectively., Conclusions: The visual outcomes achieved with a treat-and-extend protocol in this study were similar to the pivotal trials of aflibercept for CMO secondary to CRVO, which used monthly and then as-needed protocols., Trial Registration: Australian and New Zealand Clinical Trials Registry, registration number ACTRN12615000417583, 01/05/2015.

The authors report a case of bilateral diffuse uveal melanocytic proliferation associated with transitional cell carcinoma of the bladder. A novel imaging finding on indocyanine green angiography of a "string of sausages" pattern in the large choroidal vessels is described. This occurs in areas of alternating retinal pigment epithelial hypertrophy and destruction, which is likely to be its cause. To the authors' knowledge, it has not been previously described. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:525-528.]., (Copyright 2019, SLACK Incorporated.)