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Purpose: To report the experience of the Princess Margaret Hospital/University Health Network with the treatment of iris melanoma (IM) with (125)Iodine plaque brachytherapy. Design: Retrospective noncomparative case series. Methods: All cases of IM submitted to (125)Iodine plaque radiotherapy were included. Patients' demographic, clinical, management, and follow-up data were reviewed. Outcome measures included rates of tumor control, eye preservation, systemic metastases, and brachytherapy-related complications. Results: Fourteen IMs were included in the study. All patients had blue/green irises. Mean largest basal dimension and thickness were 7.1 +/- 2.1 mm (range, 4.0 to 11.5 mm) and 2.2 +/- 0.8 mm (range, 1.0 to 3.5 mm), respectively. Ten patients (71%) had seeding and 2 (14%) had glaucoma at presentation. Median follow-up was 26.6 +/- 19.5 months (range, 6 to 72 months). Tumor control was achieved in 100% of the cases and no eye was enucleated because of radiation-induced complications. At last visit, all patients were alive and free of metastasis. Final visual acuity was the same as or better than before treatment in 9 patients (75%). Cataract was the most common complication (8; 75%), followed by persistent glaucoma (2; 17%) and anterior uveitis (1; 8%). No other significant complication was seen during the follow-up period. Conclusions: Plaque radiotherapy is a safe and effective conservative treatment option for IM, although cataract is a common, yet treatable, complication. This treatment scheme circumvents an intraocular procedure and may avoid the dissemination of malignant cells, and provides a margin of safety in the treatment of clinically undetectable disease. [ABSTRACT FROM AUTHOR]

Narrow iridocorneal angles, a very rare condition in the pediatric population, can lead to visual loss through angle closure glaucoma. In the workup for patients with narrow iridocorneal angles, plateau iris must be considered in the differential diagnosis. We describe 5 children with plateau iris, the youngest 5 years of age. All were confirmed using ultrasound biomicroscopy and were offered iridotomy for treatment., (Copyright © 2015 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the use of optical coherence tomography (OCT) in verifying the specificity of the ultrasonographic "apical double echo" sign in detecting subtle subretinal fluid (SRF) associated with small choroidal melanocytic tumors., Methods: Retrospective review of consecutive patients demonstrating ultrasonographic "apical double echo," indicative of subtle SRF, who concurrently underwent OCT on initial evaluation of untreated small choroidal melanocytic tumors. Ultrasonography was performed with eyecubed version 3, ophthalmic ultrasound system (Ellex/Innovative Imaging, Inc, Adelaide, Australia) and OCT with spectral-domain OCT, Cirrus HD-OCT, model 4000 (Carl Zeiss; Meditec, Dublin, CA). Optical coherence tomographic images were examined to verify the presence of SRF and to identify other retinal pathology producing apical double echo in the absence of SRF., Results: The study included 36 patients. With OCT, subtle SRF was present at tumor apex and/or margins in 20 patients (55%) and absent in 16 patients (45%). When SRF was present, it was detected at tumor apex only in 3 of 20 patients (14%), gravitated at the inferior margin only in 13 of 20 patients (64%), and at apex and inferior margin in 4 of 20 patients (22%). When SRF was absent, the retina over the tumor showed degenerative cystic changes in 10 of 16 patients (65%), retinal thickening in 4 of 16 patients (25%), and retinal pigment epithelium detachment in 2 of 16 patients (10%), accounting for the ultrasonographic apical double echo., Conclusion: Ultrasonography showed limited specificity for detecting subtle SRF related to small choroidal melanocytic tumors, with 45% of patients showing ultrasonographic apical double echo in the absence of SRF with OCT. The retinal changes that yielded false-positive results included retinal cystic degenerations, retinal thickening, and retinal pigment epithelium detachment. Optical coherence tomography is preferred to verify the presence of subtle SRF over small choroidal melanocytic tumors, provided that the inferior tumor margin is included in imaging.

Purpose: To evaluate the use of spectral-domain optical coherence tomography (SDOCT) for imaging of nonpigmented iris tumors, through its comparison with ultrasound biomicroscopy (UBM)., Design: Retrospective observational case series., Methods: Consecutive patients with non-pigmented iris tumors, not extending to the ciliary body, who were concurrently evaluated with SD-OCT and UBM were included. Demographics, anterior segment clinical photographs, images obtained with SD-OCT (Cirrus HD-OCT, Zeiss Meditec, Dublin, California, USA) with 5.1.1 anterior segment software upgrade, and UBM (Humphrey Instruments, San Leandro, California, USA) were reviewed. The images produced were compared regarding the degree of anterior and posterior tumor surface resolution, internal structures, tumor thickness measurement, image artefacts, and overall tumor visualization., Results: Thirty-seven patients with nonpigmented iris tumors were included. Comparing SDOCT to UBM, the image definitions of anterior tumor surface and internal tumor heterogeneity were equivalent. Posterior tumor surface was well defined in 54% of SDOCT vs 100% in UBM images. Full tumor thickness measurement was possible in 86% of SDOCT vs 100% with UBM. The maximum measurable tumor thickness with SDOCT was 1.34 mm. SDOCT images showed optical aberrations such as shadowing and ghost images in 22 tumors (59%), which encroached on the tumor image in 8 patients (22%). The overall tumor visualization with SDOCT was possible in 65% of the iris tumors., Conclusions: UBM generally provides superior imaging quality and reproducible measurements of nonpigmented iris tumors. Nevertheless, SDOCT, being a noncontact technique, can be a reliable alternative in imaging and following some selected nonpigmented iris tumors., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To describe the ultrasound biomicroscopy (UBM) findings of the ciliary body in patients with ocular/oculodermal melanocytosis., Design: Retrospective observational case series study., Methods: A retrospective chart and imaging database review was conducted for patients with unilateral ocular/oculodermal melanocytosis who underwent UBM examination at the Ocular Oncology Clinic of Princess Margaret Hospital. Radial images of the ciliary body at the 3-, 6-, 9-, and 12-o'clock positions were obtained in both eyes. UBM characteristics included ciliary body thickness and reflectivity. The eye with ocular/oculodermal melanocytosis was compared with the contralateral unaffected eye as a control. Statistical significance was analyzed with Student t test., Results: Twelve patients were included. All patients showed unilateral diffuse pigmentation involving episclera and anterior chamber angle. The iris showed diffuse pigmentation in 10 cases and sectorial in 2. Mean ciliary body thickness of the affected eyes was 0.581 ± 0.058 mm (range 0.489-0.744) compared with 0.475 ± 0.048 mm (range 0.406-0.622) in the contralateral eye, which was found to be a statistically significant difference (P < .001). The affected ciliary body showed hyperreflectivity when compared with the unaffected eye. All affected eyes were graded as medium to high reflectivity compared with the unaffected eyes that showed a medium to medium/low reflectivity., Conclusion: Ciliary body involvement in ocular/oculodermal melanocytosis presents as increased thickness and higher ultrasound reflectivity on UBM when compared with the unaffected eye. UBM is helpful in imaging clinically undetectable areas of melanocytosis involving the ciliary body., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Flat choroidal pigmented lesions have few differential diagnoses but encompass a wide range of clinical presentations. The authors report two cases of bilateral multifocal choroidal hyper-pigmented patches discovered in asymptomatic patients. Fluorescein angiography showed a normal pattern without blockage in the hyperpigmented areas with an otherwise normal choroidal vascular architecture. Optical coherence tomography with enhanced depth imaging demonstrated normal choroidal thickness and structure in the hyperpigmented areas. These cases may represent an atypical presentation of previously described bilateral isolated choroidal melanocytosis or a different clinical entity. Histopathological evidence and longer follow-up of these patients and patients with isolated choroidal melanocytosis may elucidate the best descriptive term for this unusual condition., (Copyright 2013, SLACK Incorporated.)

A 67-year-old man was referred for evaluation of a small mass on the sclera of the right eye. Ultrasound biomicroscopy of the mass suggested the diagnosis of Axenfeld loop., (Copyright 2012, SLACK Incorporated.)

Purpose: To determine the clinical and ultrasound biomicroscopy (UBM) features associated with growth in iris melanocytic lesions., Study Design: Retrospective case series analysis., Methods: We included all iris melanocytic lesions that were monitored between January 2005 and November 2009. At the end of the analysis, 44 eyes of 44 patients were included in the final analysis. The clinical features analyzed were: iris color, largest base diameter, radial location of the lesion epicenter, circumferential location of the lesion epicenter, lesion configuration, lesion pigmentation, intrinsic vascularity within the lesion, presence of associated pigmentation, the impact on the pupil, presence of iris atrophy, and lesion-induced localized cataracts. The UBM features included lesion thickness, presence of corneal touch, presence of surface plaque, internal structure, and internal reflectivity. Regression analysis was performed to define the features associated with growth., Results: Twenty-three percent of the lesions showed documented growth. Mean follow-up was 21.4 months (range: 10-48). Clinical features associated with growth were a large basal diameter at baseline (P = .004) and inferior location (P = .004). UBM features associated with growth were: a greater baseline thickness (P = .01), presence of corneal touch (P = .007), an irregular internal structure (P = .0001), and the presence of dots and linear streaks (P < .0001). Clinical features that were not associated with growth were the radial location of the lesion in the iris (P > .999), lesion configuration (P > .999), lesion pigmentation (P > .999), the presence of pigment dispersion (P = .70), iris freckles (P = .15), corectopia (P > .999), ectropion (P > .999), and intrinsic vascularity (P = .70). UBM features not associated with growth were the presence of a surface plaque (P = .07) and the internal reflectivity (P = .77)., Conclusion: Substantial growth in iris melanocytic lesions is associated with original larger basal diameter and inferior lesion location. On UBM growth is associated with greater original thickness, presence of corneal touch, and an irregular internal structure. Presence of these features could modify the frequency of observation of those lesions., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: Conjunctival squamous dysplasia can often be confused with pterygium and pinguecula. Incomplete excision of dysplastic tissue can lead to recurrence and rarely intraocular invasion. This study describes two cases in which invasive squamous cell carcinoma (SCC) of the conjunctiva was originally partially resected as pterygium and eventually required enucleation for intraocular invasion., Methods: In this clinicopathologic small case series, two cases of intraocular SCC managed at a single tertiary ocular oncology institution are described. Clinical features, pathologic characteristics, and relevant imaging are described., Results: In both cases, incomplete excision of conjunctival SCC was followed by rapid regrowth of the conjunctival lesion and signs of intraocular inflammation. An intraocular mass within the substance of the ciliary body was identified using ultrasound biomicroscopy in both the cases. Enucleation was performed. Pathologic features were typical to SCC., Conclusions: Intraocular spread on conjunctival SCC occurs only rarely but tends to follow recurrence of the conjunctival lesion after attempted excision. Modes of invasion may include direct invasion through sclera, along the tract of the anterior ciliary vessels, or inoculation through intraocular surgery incision.

Purpose: To demonstrate the correlation of ultrasound biomicroscopy (UBM) features of iris melanoma with histopathology., Design: Retrospective analysis of medical records., Methods: The medical records of patients that underwent surgery for iris melanoma at the Princess Margaret Hospital, University of Toronto, from June 1990 to October 1998 were reviewed. The clinical features, as well as the UBM findings prior to surgical intervention, were evaluated. The anatomic features noted on UBM were correlated with histopathologic features seen in the surgical specimens., Results: Fourteen cases met the inclusion criteria and were included in the final analysis. The ultrasound acoustic characteristics showed a broad spectrum of findings among iris melanomas. Tumor acoustic parameters correlated well with histologic features, including tumor vascularity, surface plaque, extrascleral extension, ciliary body involvement, and integrity of iris pigment epithelium., Conclusions: UBM is a useful imaging technique for the in vivo assessment of primary iris melanoma and can provide detailed imaging of the tumor's interface with the angle structures. The preoperative assessment of these tumors by UBM may aid the surgeon in choosing the most appropriate technique to ensure total removal., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: To report the host, tumour, and radiation-related predictive factors for developing radiation retinopathy post (125)Iodine brachytherapy for uveal melanoma., Design: A retrospective clinical case series., Participants: Three hundred consecutive patients with uveal melanoma treated with (125)Iodine brachytherapy., Methods: Electronic chart review of demographic, clinical, treatment, and follow-up data. Proliferative and (or) nonproliferative radiation retinopathy patients were included. Cumulative incidence rates were calculated using Kaplan-Meier estimates. Univariate and multivariate statistical regression analyses were performed to identify factors predictive of radiation retinopathy., Results: The mean follow-up period was 48 months. Radiation retinopathy occurred in 107 patients (36%). Actuarial incidence of radiation retinopathy was 30% (CI 24%-36%) at 24 months post-treatment. In the multivariate model, the predictive factors were a younger age (hazard ratio [HR] 0.98, p < 0.03), diabetes (HR 2.17, p < 0.007), and hypertension (HR 2.17, p < 0.004). Tumour-related factors were proximity to optic disc (HR 0.95, p < 0.02) and proximity to foveola (HR 0.96, p < 0.02). Pretreatment tumour dimensions, other tumour characteristics, and total radiation dose did not demonstrate statistically significant risks for developing radiation retinopathy., Conclusions: Radiation retinopathy affects 30% of patients 2 years following (125)Iodine brachytherapy for uveal melanoma. The predictive factors for radiation retinopathy are a younger age, comorbidity with diabetes or hypertension, and proximity of the tumour margin to the optic disc or foveola. Identifying the predictive factors for developing radiation retinopathy can modify follow-up for patients at risk, which may permit earlier management of the developing radiation-induced ischemic retinal changes.

Purpose: To determine the role of ultrasound biomicroscopy (UBM) in the management of children affected with retinoblastoma., Methods: A review of clinical records of children with the diagnosis of retinoblastoma at the Hospital for Sick Children from January 1995 to December 2007, for whom UBM was used to determine the extent of intraocular tumor. Clinical characteristics were compared with UBM. Pathological correlation was performed for enucleated eyes., Results: In total, 101 eyes of 75 patients were included in the final analysis. Only 11 eyes were diagnosed on UBM to have extension of the tumor anterior to the ora serrata, and were enucleated. Histopathological examination confirmed the anterior extension in all the 11 eyes. In total, 50 eyes were enucleated because of various reasons, such as poor visual prognosis (12 eyes), unilateral group D or E (23 eyes), recurrences (8 eyes), and treatment failure (7 eyes). None of those patients were found to have anterior extension of the disease on histopathological examination. UBM did not yield any false negative (0/50) or any false positives (0/11)., Conclusions: The UBM provided a sensitive and reproducible visualization of the anterior retina, ciliary region, and anterior segment allowing a better staging of the advanced disease process. Primary assessment of the true extent of retinoblastoma is critical for the selection of an optimal management approach.

Purpose: To establish the growth behavior of small ciliary body tumors in a relatively large cohort of patients over an extended period., Design: Retrospective, noncomparative case series., Methods: Ciliary body tumors less than 4 mm in size within the penetration power of ultrasound biomicroscopy (UBM) were included. Tumor height was assessed by ultrasound biomicroscopy. Tumor growth was defined as an increase in height of at least 20% from baseline, as measured on 2 consecutive UBM readings. The data were collected longitudinally, and a statistical analysis was performed., Results: Forty-two patients were included in the study with a median follow-up of 9.0 years (range, 1.0 to 17.2 years). The median age was 59 years (range, 17 to 82 years). Median initial tumor height was 2.05 mm (range, 1.11 to 3.80 mm). The overall average rate of growth was 0.0014 mm per year (P = .68). The 5- and 10-year accumulative tumor growth rates were 12% and 29%, respectively. In the first 3 years after diagnosis, the growth rate of ciliary body lesions with an initial tumor thickness less than or equal to 2 mm was 0.054 mm per year (P = 0.0001); thereafter, tumor size appeared to stabilize. Tumors with an initial thickness greater than 2 mm showed a small but significant rate of regression of 0.0125 mm per year (P = 0.04)., Conclusions: Most small tumors of the ciliary body show little growth over an extended period and can be managed conservatively without invasive diagnostic interventions. However, long-term follow-up is required. Indications for treatment include growth in height or lateral extension, extrascleral extension or the need for cataract surgery., (Copyright 2010 Elsevier Inc. All rights reserved.)

Purpose: To report ultrasound biomicroscopic (UBM) findings of iris-sutured foldable posterior chamber intraocular lenses (PCIOLs)., Design: Prospective, noninterventional consecutive case series., Methods: Fifteen eyes with foldable acrylic IOL implantation using peripheral iris suture fixation in the absence of capsular support were included. UBM was used to determinate the haptic position in relation to the ciliary sulcus and ciliary body in these eyes. Additionally, anterior chamber depth, lens tilt, site of suture fixation, focal iris or angle abnormalities, and relationship of iris to lens were determined. Main outcome measures were haptic position, anterior chamber depth, and iris anatomic changes., Results: Of the 30 haptics imaged, 16 (53.3%) were positioned in the ciliary sulcus. Nine (30%) haptics were found over the ciliary processes, and 5 (16.7%) were over pars plana. No patients were found to have peripheral anterior synechiae present at the haptic position. The mean (+/- standard deviation) depth of the anterior chamber was 3.84 +/- 0.36 mm. The iris profile was altered in all patients at the iris-haptic suture fixation site. No angle abnormalities or tilted lenses were found., Conclusions: Iris-sutured PCIOL haptics were found to be in the ciliary sulcus or over the ciliary body with no significant tilt on UBM analysis. The procedure respects the angle anatomy, and no evidence of angle closure was found. The anterior chamber was deeper than has been reported previously for scleral sutured PCIOLs and was similar to that of pseudophakic eyes. This may have implications for surgical technique, IOL power calculations, and postoperative complications., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Objective: Because ciliary body melanoma often defies early diagnosis, and its treatment is controversial, we report our experience with the clinical presentation and management of ciliary body melanoma, treated with iodine-125 plaque brachytherapy., Study Design: A retrospective noncomparative case series., Participants: Forty-two patients with ciliary body melanoma treated with iodine-125 brachytherapy., Methods: Electronic chart review of ciliary body melanoma patients treated at Princess Margaret Hospital, University of Toronto, Toronto, Ont. Patients' demographics and clinical, management, and follow-up data, including brachytherapy-related complications, were reviewed. Outcome measures included rates of tumour control, eye preservation, systemic metastases, and brachytherapy-related complications., Results: Median age at diagnosis was 58 years and median follow-up was 43 months. Ciliary body melanoma was asymptomatic in 55% of patients, whereas floaters or flashes were the main symptom in 33%. Median tumour thickness before brachytherapy was 5.2 mm and after brachytherapy was 3.3 mm. Radiation-induced cataract was the main complication in 55% of patients, radiation retinopathy in 24%, and neovascular glaucoma in 15%, which was controlled by topical treatment in half of the cases. Two patients developed metastases and 3 required secondary enucleation., Conclusions: Medium-sized ciliary body melanoma produced no or minimal symptoms on presentation in 88% of the patients. Iodine-125 plaque brachytherapy offered 98% tumour control at 43 months' follow-up. Radiation-related complications are generally manageable in most patients, which permits retention of the treated eye.

Purpose: To evaluate the utility of anterior segment optical coherence tomography (OCT) in the imaging of anterior segment tumors and compare the images to ultrasound biomicroscopy (UBM)., Design: Prospective observational case series., Methods: Eighteen eyes of 18 patients with anterior segment tumors were evaluated at Princess Margaret Hospital. The evaluation included clinical examination, clinical photography, anterior segment OCT, and UBM. Comparison of images obtained by both methods was done., Results: Anterior segment OCT imaged small hypopigmented tumors with complete penetration. Cysts were incompletely imaged behind the iris pigment epithelium. Highly pigmented tumors, large tumors, and ciliary body tumors were incompletely penetrated. Even without complete penetration it was possible to differentiate cystic lesions from solid lesions. UBM penetrated all tumors completely., Conclusions: Anterior segment OCT can penetrate small hypopigmented tumors and supply some information on internal characteristics of other tumors. UBM is preferable for clinical anterior tumor assessment and follow-up because of its superior ability to penetrate large tumors, highly pigmented tumors, and ciliary body tumors.

Background: Diagnosis of ring melanoma is clinically difficult since the mass can remain hidden with standard slit-lamp biomicroscopy. The aim of this study was to evaluate the utility of ultrasound biomicroscopy (UBM) as a diagnostic tool for ring melanoma of the ciliary body., Methods: This was a retrospective study of 6 eyes of 6 patients at Princess Margaret Hospital, Toronto, Ont., with a diagnosis of ring melanoma of the ciliary body. The tumor extension was measured clinically, gonioscopically, ultrasonographically (by UBM), and pathologically., Results: Since 2000, 6 cases of ring melanoma have been diagnosed at Princess Margaret Hospital: 2 women and 4 men, median age 57 years. Five patients presented as uncontrolled hyperchromic glaucoma (83%). Ciliary body involvement on slit-lamp examination ranged from 60 to 180 degrees. Ciliary body involvement as assessed by UBM ranged from 180 to 300 degrees. Tumor extension according to pathological examination ranged from 210 to 360 degrees. With these measures, the ring melanoma clinical criteria were not filled by 5 patients., Interpretation: UBM is an important tool in determining the extent of ciliary body involvement and classifying these lesions.

Objective: The purpose of this study was to investigate the presence and duration of vascular permeability changes induced by the combination of ultrasound and an intravascular microbubble contrast agent in the rabbit eye., Methods: Five eyes were studied in 8 anaesthetized rabbits. Insonation was performed with a diagnostic B-mode system (center frequency = 2 MHz; mechanical index [MI] = 0.2 and 1.7) for 5 minutes after administration of perflutren microbubbles (0.07 mL/kg). Fluorescein fundus angiography was performed before and 3 minutes after insonation; at 6 minutes, color fundus photography was used to assess the dye leakage, bleeding, and alteration of the diameter of fundus vessels., Results: Alteration of fundus vessel diameters was observed in 1 of 5 cases at a low MI and in 4 of 5 cases at a higher MI. In 1 case, leakage of fluorescein indicated increased permeability at the higher MI. No bleeding was detected in any case., Conclusions: The permeability change induced by insonation and this dose of an ultrasound contrast agent appears to be transient under the conditions studied, although the time delay between insonation and optical assessment limits the completeness of the findings. This preliminary study may be relevant to drug delivery strategies using ultrasound and microbubbles.

Purpose: Detecting and following small tumors of the ciliary body is a particular challenge because of their location. Recently high-frequency ultrasound biomicroscopy (UBM) has been used to assist in this task. The aim of this study was to evaluate this subset of small ciliary body tumors through the use of UBM., Design: Retrospective, noncomparative case series., Methods: Forty-two patients with small ciliary body tumors (less than 4 mm) from our institution were included in the study with a median follow-up of 4.3 years. UBM was used to assess tumor characteristics including height, location, and internal and external features. The data were collected longitudinally, and statistical analysis was performed., Results: Median initial tumor height was 2.05 mm (range 1.1 to 3.8 mm) as measured by UBM. By 5 years after diagnosis, five tumors (12%) exhibited growth. The overall mean growth rate was 0.026 mm per year (P = .00007). The most rapid period of growth was in the first year after diagnosis (growth rate 0.128 mm per year), after which the mean tumor size appeared to stabilize., Conclusions: UBM is a valuable tool for detecting and following small ciliary body tumors (less than 4 mm), as these lesions may go undetected by other methods. Despite the potential for local extension into the iris or choroid, few of the tumors in this study exhibited growth, suggesting that many of these tumors can be managed conservatively. UBM can be used to assess various internal tumor features; however, arriving at a specific diagnosis without histologic correlation is difficult.

Purpose: Ultrasound biomicroscopy (UBM) can noninvasively provide anatomical information about mouse ocular structures. We present the quantitation of postnatal murine eye development using UBM., Materials and Methods: The eyes from CD-1 mice were examined at 1, 2, 4, 6, and 8 weeks of postnatal development using 40 MHz UBM. Patterns of ocular tissue growth including the lens, globe, and anterior chamber were calculated., Results: Postnatal CD-1 lens and globe volumes are consistent with an exponential decay of growth during the first 8 postnatal weeks. Anterior chamber depth increases most sharply in the first 2 postnatal weeks but continues to increase up to the 8th postnatal week. Anterior segment angle was observed to increase from 1 to 4 weeks., Conclusions: UBM can be used to obtain in vivo quantitative measurements of postnatal murine ocular structures. Our ability to obtain ocular anatomical information will facilitate future assessments of mouse models of human disease.

Purpose: To examine the effect of accommodation on iris profile in pigmentary glaucoma and its relationship to age., Design: Interventional case series., Methods: We measured change in iris profile with accommodation in 92 eyes of 92 patients with pigmentary glaucoma., Results: Mean age was 42 years. Mean change in posterior iris excursion from nonaccommodated to accommodated state was 144.5 microm. (P < .001). Age was plotted against iris excursion with an estimated least-squares regression line. The estimated Pearson correlation coefficient was -0.60, (P < .001). Patients younger than 42 years of age had a mean change in excursion of 209.2 microm compared with 79.8 microm for those patients older than 42 years. (P < .001), Conclusion: This study found that there is a significant increase in posterior iris bowing in the accommodated state. Increasing age is associated with decreased posterior iris deviation. These findings add evidence to the theory of accommodation-induced reverse pupillary block in pigmentary glaucoma.

Background: Punctal plugs may be associated with complications, the most common being secondary epiphora due to canalicular obstruction. Simple lacrimal irrigation will diagnose an obstruction within the canaliculus but will not determine whether the plug is still present at the site of the obstruction. We performed a study to determine the feasibility of imaging retained intracanalicular plugs with ultrasound biomicroscopy (UBM)., Methods: We performed in vitro evaluation of an EagleVision punctal plug and a Herrick intracanalicular plug to obtain information about the UBM characteristics of the two plugs. We then performed UBM in two patients with suspected intracanalicular plugs, one with prolapse of an EagleVision punctal plug into the canaliculus and one with bilateral epiphora secondary to inserted intracanalicular Herrick plugs., Results: In both cases, UBM enabled location of the plugs within the canalicular system at the level of obstruction., Interpretation: UBM is a useful diagnostic tool in determining the presence and location of a presumed retained intracanalicular plug, either placed directly within the canaliculus or prolapsed into the canaliculus from a punctal position.

Purpose: To quantitatively analyze the anterior chamber depth (ACD) in patients with pupillary block and plateau iris syndrome., Design: Retrospective, consecutive, observational case series., Methods: We measured the ACD in 318 eyes of 318 patients who had been diagnosed by ultrasound biomicroscopy as having either pupillary block or plateau iris syndrome. Pupillary block patients were all preiridotomy and plateau iris patients were all postiridotomy. Anterior chamber depth was measured axially from the internal corneal surface to the lens surface using the ultrasound instrument's internal measuring capability., Results: The mean ACD in patients with plateau iris syndrome (n = 181) was significantly smaller than the hypothesized normal ACD (2.04 +/- 0.30 mm vs 3.0 mm, P =.0001). The mean ACD in patients with pupillary block (n = 137) was also significantly smaller than the hypothesized normal ACD (2.17 +/- 0.30 mm vs 3.0 mm, P =.0001). The mean ACD in patients with plateau iris syndrome was significantly smaller than the ACD in patients with pupillary block (2.04 +/- 0.30 mm vs 2.17 +/- 0.30 mm, P =.001)., Conclusions: Review of the literature suggests that patients with plateau iris have a normal or deeper axial ACD compared with pupillary block. This study found that the ACD associated with plateau iris syndrome is shallower than normal and also shallower than in pupillary block.

Purpose: New imaging tools now provide an unprecedented opportunity to visualize anatomic and functional development of the mouse eye. In this study, normal embryonic development of the mouse eye was studied by ultrasound biomicroscopy (UBM), with a focus on the formation of the retina, lens, and cornea., Methods: The growth of 65 embryonic eyes from timed-pregnant CD-1 mice was examined at various stages of development between embryonic day (E)11.5 and E18.5, using 40-MHz UBM., Results: The morphogenesis of ocular tissues including the lens, retina, and orbit were revealed from the earliest stages of development. The major axis of the CD-1 lens grows at a rate of 68 micro m/d, whereas that of the globe grows at a rate of 122 microm/d, with a concomitant exponential increase in volume., Conclusions: UBM allows noninvasive assessment of ocular morphogenesis in vivo and can be used to calculate relative growth rates of ocular structures.

Purpose: To report the use of ultrasound biomicroscopy in the screening of two premature infants with retinopathy of prematurity., Methods: Observational case reports. A premature infant born at 26 weeks' gestation had bilateral stage II, zone II retinopathy of prematurity at 36 weeks' gestation and was imaged with ultrasound biomicroscopy. A second premature infant born at 25 weeks' gestation developed subthreshold stage III, zone II retinopathy of prematurity in the right eye and was imaged with ultrasound biomicroscopy., Results: In case 1, ultrasound biomicroscopy imaged a ridge present nasally in zone II of the right eye, consistent with stage II retinopathy of prematurity. In case 2, ultrasound biomicroscopy imaged a neovascular frond present nasally in zone II of the right eye, consistent with stage III retinopathy of prematurity., Conclusion: Ultrasound biomicroscopy may be useful for screening retinopathy of prematurity, when optical methods fail to visualize the peripheral retina.

Purpose: To describe the ability of high-frequency ultrasound biomicroscopy (UBM) to diagnose occult wound leaks as a cause for hypotony after cataract surgery., Methods: Six patients with persistent hypotony after cataract surgery were sent for UBM examination. Slitlamp examination and gonioscopy of the 6 eyes had not revealed a cause for the hypotony., Results: Ultrasound biomicroscopy showed subtle wound separation with shallow conjunctival elevation at the site of the cataract wound in the 6 patients. Two eyes had surgical repair of the subconjunctival wound leak, and the other 4 were treated medically. In the 2 eyes with surgically repaired wounds, the hypotony cleared after wound closure. Of the 4 medically treated eyes, hypotony resolved in 2 and 1 had a recurrence of hypotony. The other 2 eyes had fluctuating intraocular pressure for an extended period., Conclusions: Hypotony after cataract surgery occurred in 6 eyes due to subtle wound leaks difficult to detect by clinical observation. Ultrasound biomicroscopy can be a helpful aid to clinical examination in detecting these leaks.

Background: In evaluating young patients with choroidal melanomas, which are uncommon in people less than 30 years old, we noted that some had the ultrasound appearance of posterior scleral bowing. The purpose of this study was to determine the incidence of posterior scleral bowing in young patients with choroidal melanoma., Methods: We reviewed the ultrasonograms of 24 patients less than 30 years of age (mean age 25 years [standard deviation (SD) 4.7 years]) who presented to an ocular oncology service in Toronto between May 1984 and May 1997. In all cases the diagnosis was choroidal melanoma. Histologic specimens were available in six cases., Results: Scleral indentation posterior to the normal curvature of the globe was identified in 14 patients (58%). These patients had a mean tumour height of 4.4 mm (SD 2.0 mm) and mean tumour diameter of 9.5 mm (SD 2.9 mm). In the 10 patients with no scleral bowing the mean tumour height was 5.7 mm (SD 3.1 mm) and mean tumour diameter 11.5 mm (SD 3.8 mm). Pathological study (results available in nine cases in the scleral bowing group and four cases in the group without bowing) showed that all the tumours in the former group and three of those in the latter group were of the more indolent cell types, either mixed with predominantly spindle cells, or spindle cell. The six patients with histologic specimens were all in the scleral bowing group. The histologic features supported the ultrasound finding of posterior scleral bowing. No transscleral invasion occurred over the tumour region., Interpretation: Posterior bowing of the sclera at the tumour site was observed in over half of young patients with choroidal melanoma. This phenomenon can be detected by ultrasonography and has a different appearance from that of choroidal excavation.

Purpose: Nocardia infection of the eye is uncommon. A case of choroidal abscess due to Nocardia farcinica infection is presented, and the literature is reviewed., Methods: A 41-year-old immunocompromised man with chronic myeloid leukemia developed a unilateral choroidal abscess. N. farcinica was isolated from a simultaneous subcutaneous abscess and both infections responded to systemic sulfonamide therapy., Results: Three weeks after discontinuation of the sulfonamides, the choroidal abscess recurred with involvement of the vitreous. The infection was brought under control after reinstitution of the same drug., Conclusions: Nocardiosis is a multisystem disease that has high mortality and ocular morbidity rates. The eyes of immunocompromised patients should be examined frequently as early detection and administration of the proper antibiotics may reduce the risk of this life-threatening infection.

The development of higher frequency ultrasound imaging systems affords a unique opportunity to visualize living tissue at the microscopic level. This work was undertaken to assess the potential of ultrasound imaging in vivo using the 100-200 MHz range. Spherically focused lithium niobate transducers were fabricated. The properties of a 200 MHz center frequency device are described in detail. This transducer showed good sensitivity with an insertion loss of 18 dB at 200 MHz. Resolution of 14 /spl mu/m in the lateral direction and 12 /spl mu/m in the axial direction was achieved with f/1.14 focusing. A linear mechanical scan system and a scan converter were used to generate B-scan images at a frame rate up to 12 frames per second. System performance in B-mode imaging is limited by frequency dependent attenuation in tissues. An alternative technique, zone-focus image collection, was investigated to extend depth of field. Images of coronary arteries, the eye, and skin are presented along with some preliminary correlations with histology. These results demonstrate the feasibility of ultrasound biomicroscopy In the 100-200 MHz range. Further development of ultrasound backscatter imaging at frequencies up to and above 200 MHz will contribute valuable information about tissue microstructure.

The visualisation of living tissues at microscopic resolution is attracting attention in several fields. In medicine, the goals are to image healthy and diseased tissue with the aim of providing information previously only available from biopsy samples. In basic biology, the goal may be to image biological models of human disease or to conduct longitudinal studies of small-animal development. High-frequency ultrasonic imaging (ultrasound biomicroscopy) offers unique advantages for these applications. In this paper, the development of ultrasound biomicroscopy is reviewed. Aspects of transducer development, systems design and tissue properties are presented to provide a foundation for medical and biological applications. The majority of applications appear to be developing in the 40-60-MHz frequency range, where resolution on the order of 50 microm can be achieved. Doppler processing in this frequency range is beginning to emerge and some examples of current achievements will be highlighted. The current state of the art is reviewed for medical applications in ophthalmology, intravascular ultrasound, dermatology, and cartilage imaging. Ultrasound biomicroscopic studies of mouse embryonic development and tumour biology are presented. Speculation on the continuing evolution of ultrasound biomicroscopy will be discussed.

Background: Primary cysts occur spontaneously, whereas secondary cysts arise following surgical or nonsurgical injury and can lead to further complications. We performed a study to observe and characterize primary iridociliary cysts through the examination of ultrasound biomicroscopic (UBM) images from affected patients., Methods: The UBM images from 210 patients were analysed and the characteristics of each cyst were observed and recorded. The patients had been examined and received the diagnosis of iridociliary cysts between 1990 and early 1998 at a major referral centre for the diagnosis and treatment of cancer in Toronto., Results: Of the 210 cysts 169 (80%) occurred in isolation, and the remainder occurred in the presence of a tumour. The mean horizontal diameter of the isolated cysts was 1.72 mm, and the mean vertical diameter was 1.04 mm. Isolated cysts were solitary in 101 cases (60%) and showed multiple loculations in 68 (40%). Solitary cysts were slightly larger than those with multiple loculations. Isolated cysts were associated with markedly narrowed or closed angles locally in 110 cases (65%)., Interpretation: Primary iridociliary cysts are common and need to be differentiated from iris and ciliary body tumours. UBM is a definitive method of diagnosing these lesions. Cysts can cause localized angle closure but rarely cause clinical complications. Cysts associated with anterior segment tumours may give an erroneous impression as to tumour size.

Purpose: To report changes in angle configuration associated with dark, light, and pilocarpine administration in plateau iris syndrome., Method: In 10 eyes of 10 patients with plateau iris syndrome and persistent narrow angles after patent peripheral Nd:YAG laser iridotomy, ultrasound biomicroscopy was used to image variations in angle opening, iris thickness, and trabecular-ciliary process distance. Measurements were taken in the dark, in full room light, and after administration of pilocarpine 2%., Results: Average angle opening distance increased in the light compared with the dark (113+/-34 microm vs. 22+/-34 microm, P = .0001) and increased further after pilocarpine administration (171+/-52 microm vs. 113+/-34 microm, P = .0034). Average iris thickness decreased in the light compared with the dark (338+/-34 microm vs. 436+/-58 microm, P = .0009) and decreased further after pilocarpine administration (253+/-48 microm vs. 338+/-34 microm, P = .0002). Average trabecular meshwork-ciliary process distance measurements were smaller than normal and did not change significantly in the light compared with the dark (481+/-42 microm vs. 464+/-44 microm, P = .4001) or after pilocarpine administration compared with light (451+/-67 microm vs. 481+/-42 microm, P = .1304)., Conclusions: In plateau iris syndrome, anteriorly located ciliary processes support the peripheral iris. Changes in angle opening in dark and light are solely related to changes in iris thickness. Pilocarpine produces iris thinning and is an effective method of opening the angle. Ultrasound biomicroscopy can be used to perform a darkroom provocative test, which provides information on whether the angle anatomically closes in the dark.

Three patients in whom Ridley intraocular lenses (IOLs) were successfully implanted more than 42 years ago are presented. One case had traumatic cataract at age 13. The other 2 had surgery for unilateral cataract of unknown etiology at about age 40 and surgery on the second eye approximately 40 years later. A review of other reports of late-term results with this IOL is included.

Objective: Although the associations of retinitis pigmentosa (RP) with nanophthalmos/microphthalmos and RP with optic disc drusen have previously been recognized, the concurrence of all three features, as far as the authors are aware, has not previously been reported., Design: Case report., Results: The authors report a sporadic case of nanophthalmos, RP, and optic nerve drusen with the additional complication of chronic angle closure glaucoma., Conclusions: Visual loss may be secondary to the complications of nanophthalmos, RP, or optic nerve drusen. Chronic angle closure may be caused by choroidal effusion with serous retinal detachment, which may, in turn, cause a pseudo-RP picture. It is therefore important to recognize the possible association of true RP with nanophthalmos as a cause for visual deterioration.

Purpose: To quantitatively analyze the changes in anterior chamber angle and iris configuration induced by varying illumination in patients with narrow angles and pupillary block., Methods: Twenty-four eyes of 24 patients with pupillary block (mean age, 52.5 years) had ultrasound biomicroscopic images of the angle and iris structures obtained superiorly, nasally, inferiorly, and temporally. Images were performed in the light and the dark. We measured the angle opening distance, iris thickness, iris chord length, iris-lens touch, and iris curvature., Results: Changes in iris and angle configuration occurred within a few seconds of a change in lighting. The mean dark measurements were statistically significantly less than the mean light measurements for angle opening distance (96 +/- 18 vs 185 +/- 26 microm, P = .0001), iris chord length (2,505 +/- 61 vs 3,001 +/- 69 microm, P = .0001), and iris-lens touch (350 +/- 20 vs 693 +/- 35 microm, P = .0001). The mean dark measurements were statistically significantly greater than the mean light measurements for iris thickness at 500 microm from the scleral spur (367 +/- 10 vs 307 +/- 25 microm, P = .0001), and 1,500 microm from the scleral spur (404 +/- 14 vs 347 +/- 12 microm, P = .0001). Iris curvature in all four quadrants was statistically significantly greater in the dark than the light., Conclusions: This study quantitatively confirms that angle narrowing in the dark in eyes with pupillary block is associated with iris shortening, increased iris thickness, and increased iris convexity. Iris-lens touch is relatively small in pupillary block and decreases with dilation. Angle narrowing with dilation is not related to increased iris-lens touch and occurs promptly without requiring time for aqueous pressure buildup behind the iris.

Purpose: To demonstrate that the interface between the normal iris and the lens surface functions as a flap valve., Method: Microbubble ultrasound contrast agent was injected into the anterior and posterior chambers of human eye bank eyes and the distribution of contrast imaged with high-frequency ultrasound., Results: Contrast agent did not enter the posterior chamber when injected into the anterior chamber, but contrast agent injected into the posterior chamber easily flowed into the anterior chamber., Conclusions: The iris-lens interface normally functions as a flap valve, preventing retrograde flow from the anterior to the posterior chamber. A temporary increase in anterior chamber pressure thus results in iris concavity in pigmentary dispersion syndrome.

Purpose: To show that extending Doppler imaging into the high-frequency domain could allow detection and characterization of blood flow in small arterioles and capillaries., Methods: A 40-MHz continuous wave Doppler system and a 60-MHz pulsed-wave Doppler system were constructed, tested, and used to examine the ciliary body region in two normal volunteers., Results: Ciliary body circulation in the region of the great circle of the iris, which is undetectable by conventional 7.5-MHz duplex Doppler, was consistently and reproducibly detectable by high-frequency (40-MHz and 60-MHz) Doppler systems., Conclusion: High-frequency Doppler imaging may provide a unique new tool for the characterization and assessment of anterior segment ocular blood flow.