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PURPOSE To evaluate the features and long-term outcomes of hydroxyapatite (HA) orbital implant following enucleation in pediatric patients. METHODS A retrospective review was performed on clinical records of patients ≤18 years of age , managed with enucleation and HA implant placement. Recorded outcomes included implant-related complications, implant and prosthesis motility, and patient cosmetic satisfaction. RESULTS There were 525 children (531 sockets) with HA implant following enucleation. The mean age at HA implant placement was 3 years (median, 2 years; range, 4 days to 17 years). Indications for enucleation included retinoblastoma (n = 457, 86%), uveal melanoma (n = 17, 3%), medulloepithelioma (n = 8, 2%), and others (n = 49, 9%). The HA implant was uncoated (n = 370, 70%) or polymer coated (n = 161, 30%). For the 370 uncoated implants, wrapping was provided with scleral (n = 346, 94%) or bovine pericardium (n = 1

Diabetic macular oedema (DMO) results from alterations of several biochemical pathways in diabetic eyes. Centre-involving DMO is an important cause of visual loss in diabetes. Anti-vascular endothelial growth factor agents are now the mainstay of centre-involving DMO treatment. Oedema that does not achieve optimal response to these agents occurs in a sizeable proportion of eyes and is called refractory or persistent DMO. Management of refractory DMO is challenging. In this paper, the pathophysiology of DMO, and the definitions used in various studies are summarised. Therapeutic options for refractory DMO management including corticosteroids, laser, combination therapies, and surgery are explored. Novel agents on the horizon for DMO control that are being investigated at present are discussed as well. A literature review was performed and a summary of the research studies for each of the agents is provided in order to guide the reader regarding the existing evidence for their application in DMO. Importance of early recognition of disease and prompt treatment to achieve best visual outcome is discussed. Utility of optical coherence tomography to guide disease diagnosis and monitoring is highlighted. An algorithmic approach for DMO management is described. Finally, the impact that personalized medicine and genetics might have on DMO management is assessed.

Purpose To evaluate the clinical features, treatment, and prognosis of patients with uveal metastasis from lung cancer. Design Retrospective chart review. Participants There were 194 patients with a diagnosis of uveal metastasis from lung cancer. Intervention Radiotherapy, chemotherapy, enucleation, or observation. Main Outcome Measures Ocular tumor control, final visual acuity, and tumor-related death. Results There were 374 uveal metastatic tumors originating from primary lung cancer in 229 eyes of 194 patients. Tumor location included choroid (88%), ciliary body (2%), and iris (10%), with bilateral involvement in 18%. Diagnosis of uveal metastasis preceded the diagnosis of primary lung cancer in 44% of patients. The choroidal metastatic focus had a mean basal diameter of 8 mm and mean thickness of 3 mm, and were mostly located posterior to the equator (91%). The choroidal metastasis commonly had yellow or orange color (98%), had plateau (61%) or dome (38%) configuration, and displayed associated subretinal fluid (85%). Choroidal tumors were multifocal in 49 cases (23%). Ciliary body tumors were commonly dome shaped (75%) with an episcleral sentinel vessel (75%). Iris tumors were multifocal in 2 cases (13%), had visible intrinsic vessels (97%), and were associated with tumor seeding in the angle (38%) or on the iris stroma (25%). The uveal metastases were treated with teletherapy (31%), chemotherapy (18%), brachytherapy (9%), chemotherapy combined with teletherapy or brachytherapy (14%), enucleation (3%), or observation (21%). At last visit, eyes with follow-up showed tumor regression (66%), stability (12%), growth (14%), recurrence (3%), or new metastasis (5%). Visual acuity improved or remained stable in 59% eyes. One-year mortality from the time of detection of uveal metastasis was 54%. Conclusions Of 194 patients with uveal metastasis from lung cancer, 44% did not have a history of known lung cancer. Current methods of ocular treatment allow globe salvage in 92% of patients and improved/stable vision in 59% of patients. Systemic prognosis remains poor with tumor-related death in 54% of patients at 1 year.

Purpose To evaluate the efficacy of intravitreal bevacizumab for prevention of macular edema after plaque radiotherapy of uveal melanoma. Design Retrospective, single-center, nonrandomized, interventional comparative study. Participants Patients with uveal melanoma treated with plaque radiotherapy were divided into 2 groups: a bevacizumab group and a control group. Intervention The bevacizumab group received intravitreal bevacizumab injection at the time of plaque removal and every 4 months thereafter for 2 years (total, 7 injections). The control group had no intravitreal bevacizumab injection. Both groups had periodic follow-up with ophthalmoscopy and optical coherence tomography (OCT). Main Outcome Measures Development of OCT-evident macular edema. Results There were 292 patients in the bevacizumab group and 126 in the control group. The median foveolar radiation dose was 4292 cGy (bevacizumab) and 4038 cGy (control; P = 0.327). The cumulative incidence of OCT-evident macular edema over 2 years (bevacizumab group vs. control group) was 26% versus 40% ( P = 0.004), respectively; that for clinically evident radiation maculopathy was 16% versus 31% ( P = 0.001), respectively; that for moderate vision loss was 33% versus 57% ( P P = 0.004), respectively. There was no statistically significant difference in clinically evident radiation papillopathy ( P = 0.422). Kaplan-Meier estimates at 2 years showed statistically significantly reduced rates of OCT-evident macular edema ( P = 0.045) and clinically evident radiation maculopathy ( P = 0.040) in the bevacizumab group compared with controls. Conclusions Patients receiving intravitreal bevacizumab injection every 4 months after plaque radiotherapy for uveal melanoma demonstrated OCT-evident macular edema, clinically evident radiation maculopathy, moderate vision loss, and poor visual acuity less frequently over a period of 2 years than patients not receiving the injections.

Objective To evaluate the patient’s understanding of the importance and adherence to the various lifestyle and Age-Related Eye Disease Study (AREDS) supplement recommendations for age-related macular degeneration (AMD). Design Cross-sectional study. Participants Patients with AMD treated at the vitreoretinal service clinic. Methods Telephone questionnaire survey was administered to assess knowledge and adherence to various recommendations made to patients with AMD about lifestyle and AREDS supplements in this single-institution study. Results Among 92 patients with AMD contacted, dietary modification, exercise and weight reduction, smoking cessation, and AREDS supplementation recommendations were recalled by 47 (51%), 21 (23%), 5 (5%), and 90 (98%) patients, respectively. The necessity of making these interventions was believed by 29 (62%), 16 (76%), 4 (80%), and 67 (74%) patients, respectively. Patient adherence to dietary modification was 81%, to exercise and weight reduction was 76%, to smoking cessation was 0%, and to AREDS supplementation was 88% (71% on correct dose). Financially, 29% of the patients noted a mean increase of $88 per month in expenditure because of making dietary modifications, but most reported such as justified; 61% noted a mean increase of $25 per month in expenditure from consumption of AREDS supplements, and most (96%) believed this was justified. Conclusions Patients with AMD recalled recommendations for AREDS supplementation more often than other lifestyle changes but generally felt recommendations were necessary and affordable. Adherence to smoking cessation recommendation was poor (0%), but to other recommendations was good.

To assess the efficacy of interferon alpha-2b (IFNα2b) in the management of ocular surface squamous neoplasia (OSSN).This is a retrospective, nonrandomized interventional case series study of 80 patients with 81 tumors treated with IFNα2b eye drops and/or injection combined with surgical excision when necessary. The main outcome measure was complete response or partial response based on the American Joint Committee on Cancer classification.The OSSN was classified as Tis (n = 10, 12%), T1 (n = 13, 16%), T2 (n = 6, 7%), T3 (n = 51, 63%), and T4 (n = 1, 1%). IFNα2b was used as immunotherapy alone (n = 22, 27%) or combined with surgery (n = 59, 73%). Overall (n = 81), complete response was achieved in 90% Tis, in 100% T1, in 100% T2, in 94% T3, and in 100% T4. Specifically for immunotherapy (n = 22), IFNα2b alone achieved complete response in 75% (3/4) Tis, in 100% (8/8) T1, and in 70% (7/10) T3. Planned IFNα2b plus surgery (n = 59) achieved control in 100% (6/6) Tis, in 100% (5/5) T1, in 100% (6/6) T2, in 100% (41/41) T3, and in 100% (1/1) T4. Tumor recurrence was noted in 5% (4/81) of cases over a median follow-up of 1 year. Ocular side effects included conjunctival hyperemia (n = 4, 5%), ocular irritation (n = 3, 4%), superficial punctate keratitis (n = 3, 4%), and conjunctival follicles (n = 1, 1%). Systemic side effects included postinjection flu-like syndrome for 1 day (n = 7, 9%).IFNα2b, when appropriately combined with surgical excision for OSSN, provides complete control in 95% of cases overall, specifically in 90% Tis, in 100% T1, in 100% T2, in 94% T3, and in 100% T4.

To compare intravitreal bevacizumab monotherapy with intravitreal dexamethasone delayed delivery system monotherapy for persistent diabetic macular edema. Single-center, randomized, subject-masked study of eyes with persistent diabetic macular edema, defined as central subfield thickness (CST) >340 μm despite ≥3 anti–vascular endothelial growth factors injections within 5 months. The intravitreal bevacizumab monotherapy (n = 23 eyes) and delayed delivery system monotherapy (n = 27 eyes) groups received treatments q1month and q3months, respectively. Baseline best-corrected visual acuity and CST were similar in the two groups. At Month 7, the mean final best-corrected visual acuity (mean ± SD) was 65 ± 16 letters (mean Snellen visual acuity 20/50) and 64 ± 11 letters (20/50) (P = 0.619), the mean change in best-corrected visual acuity was +5.6 ± 6.1 and +5.8 ± 7.6 letters (P = 0.785), the mean final CST was 471 ± 157 and 336 ± 89 μm (P = 0.001), and the mean change in CST was −13 ± 105 and −122 ± 120 μm (P = 0.005) in the intravitreal bevacizumab monotherapy and delayed delivery system monotherapy groups, respectively. The number of injections was 7.0 ± 0.2 and 2.7 ± 0.5 (P < 0.001) in the 2 groups. The two groups had similar best-corrected visual acuity gains. The delayed delivery system monotherapy group achieved a significantly greater reduction of CST compared with the intravitreal bevacizumab monotherapy group, with a q3month interval of treatment, and had no recurrent edema at any visit.

To compare a single image with a computer-generated summarized image from the ultra-wide-field fluorescein angiogram (UWFFA) sequence for evaluation of ischemic index (ISI).UWFFA sequences from patients with diabetic retinopathy (DR) (n=5), branch retinal vein occlusion (BRVO) (n=5), and central retinal vein occlusion (CRVO) (n=5) were evaluated by six graders. A single image best illustrating retinal non-perfusion was compared to a summarized image generated by computerized superimposition of angiograms. Non-perfused and ungradable retinal areas were outlined and the ISI between the single and summarized images was compared.The mean ISI in the single versus (vs) summarized images was 17% vs 15% in BRVO (p=0.12), 48% vs 48% in CRVO (p=0.67), and 25% vs 23% in DR (p=0.005). Inter-grader agreement of ISI in single versus summarized images was 0.43 vs 0.40 in BRVO, 0.69 vs 0.71 in CRVO, and 0.53 vs 0.34 in DR.Computer-generated summarized images were similar to single images for grading ISI in BRVO and CRVO, but underestimated it in DR.

Purpose To describe the characteristics of choroidal nevus using the enhanced depth imaging (EDI) feature of spectral-domain optical coherence tomography (OCT). Design Retrospective, observational case series. Participants One hundred four eyes with choroidal nevus. Methods Spectral-domain EDI OCT was performed with a Heidelberg Spectralis HRA+OCT (Heidelberg Engineering, Heidelberg, Germany) using a custom scan acquisition protocol of up to 13 raster lines of 9-mm scan length with automatic real-time image averaging set at 100 images. The thickness of choroidal nevus was measured by combining Heidelberg's autosegmentation with manual segmentation. Main Outcome Measures Imaging features and thickness correlation of choroidal nevus by EDI OCT versus standard ultrasonography. Results Of 104 eyes with choroidal nevus imaged with EDI OCT, 51 (49%) displayed image detail suitable for study. The remaining 53 cases were suboptimal because of statistically identified factors of age older than 60 years ( P = 0.027), female gender ( P = 0.008), extramacular location of nevus ( P P = 0.002), mean distance from optic disc more than 4 mm ( P P = 0.006). Of the 51 suitable cases, mean nevus thickness was 685 μm (median, 628 μm; range, 184–1643 μm) by EDI OCT compared with 1500 μm (median, 1500 μm; range, 1000–2700 μm) by ultrasonography. The most common EDI OCT imaging features included partial (59%) or complete (35%) choroidal shadowing deep to the nevus, choriocapillaris thinning overlying the nevus (94%), retinal pigment epithelial (RPE) atrophy (43%), RPE loss (14%), RPE nodularity (8%), photoreceptor loss (43%), inner segment–outer segment junction (IS–OS) irregularity (37%), IS–OS loss (6%), external limiting membrane irregularity (18%), outer nuclear and outer plexiform layer irregularity (8%), and inner nuclear layer irregularity (6%). Overlying subretinal fluid was identified by EDI OCT (16%), ophthalmoscopic examination (8%), and ultrasonographic evaluation (0%). A comparison of pigmented versus nonpigmented nevus showed only 1 significant difference of more intense choroidal shadowing with pigmented nevus ( P = 0.046). Conclusions Imaging of choroidal nevus with EDI OCT enables precise measurement of tumor thickness with comparatively reduced thickness relative to ultrasonography. Using EDI OCT, 94% of choroidal nevi were found to have overlying choriocapillaris thinning. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Objective To evaluate the efficacy of interferon alpha-2b (IFNα2b) for extensive ocular surface squamous neoplasia (OSSN). Design Retrospective, interventional case series. Participants Eighteen eyes in 18 patients. Methods Each patient with giant OSSN (a single tumor ≥15 mm basal diameter or ≥6 limbal clock-hours) was managed with topical IFNα2b (1 million IU/ml) 4 times daily or with injection IFNα2b (a portion of 10 million IU/ml vial) with follow-up every 1 to 3 months. Main Outcome Measures Tumor response, recurrence, and treatment complications were evaluated. Results Eighteen patients with giant OSSN (median diameter [MD], 20 mm; median clock-hours [MCH], 6) were treated with topical IFNα2b (n = 12), injection IFNα2b (n = 3), or both (n = 3). The IFNα2b achieved complete tumor control (immunotherapy) in 13 eyes and partial tumor control with reduction in size (immunoreduction) in 5 eyes. Topical IFNα2b alone (n = 12) provided complete immunotherapy in 7 eyes (MD, 12 mm; MCH, 9) over a median period of 5 months and immunoreduction by 74% in 5 eyes (MD, 20 mm; MCH, 3), allowing for subsequent surgical excision (n = 3), photodynamic therapy (n = 1), or cryotherapy (n = 1) for tumor control. Injection IFNα2b alone (n = 3; median, 1 injection) provided complete control of giant tarsal conjunctival OSSN (MD, 20 mm) over a 1-month period. A combination of topical and injection IFNα2b (n = 3; median, 3 injections) completely resolved larger tumors (MD, 30 mm; MCH, 6) over a 6-month period. Complications of IFNα2b included transient flu-like symptoms (n = 3), corneal epithelial defect (n = 2), and conjunctival hyperemia (n = 1). During a median follow-up of 11 months, there were no tumor recurrences, but 2 new tumors appeared at a remote site from the original tumor, requiring operative intervention. Conclusions In 72% of giant OSSNs IFNα2b achieved complete control (immunotherapy); there was a reduction in size (immunoreduction) in 28% of giant OSSNs. Financial Disclosure(s) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Purpose To assess the efficacy of less than 3 cycles of intra-arterial chemotherapy (IAC) for retinoblastoma. Design Retrospective, nonrandomized, interventional case series. Participants Eight patients. Intervention Intra-arterial chemotherapy. Main Outcome Measures Tumor control and globe salvage. Results Eight patients received fewer than 3 cycles of IAC for retinoblastoma because there was complete tumor control with no residual viable tumor (n = 7) or poor response (n = 1) with little hope that further therapy would benefit the patient. In 3 cases, additional vascular compromise precluded further IAC. The treatment was primary in 6 cases and secondary after failure of other treatment in 2 cases. The 8 eyes were classified (International Classification of Retinoblastoma) as group C (n = 2), group D (n = 3), group E (n = 1), and secondary treatment (n = 2). At initial examination, the main tumor showed a mean basal diameter of 16 mm, a thickness of 8.6 mm, vitreous seeds (n = 2), subretinal seeds (n = 6), and iris neovascularization (n = 1). Three patients were treated with a single cycle of IAC, and 5 patients were treated with 2 cycles of IAC. After IAC, complete tumor response was found in 7 eyes (88%) and partial response was found in 1 eye (13%). Over a mean of 13 months follow-up, there was intraretinal tumor recurrence (n = 1), subretinal seed recurrence (n = 1), and no case of vitreous seed recurrence. Globe salvage was achieved in 2 of 2 group C eyes (100%), 3 of 3 group D eyes (100%), 0 of 1 group E eye (0%), and 1 of 2 secondary treatment eyes (50%). Globe salvage was achieved in 6 of 8 eyes (75%), and 2 of 8 eyes (25%) required enucleation. Conclusions One or 2 cycles of IAC can be sufficient for selected eyes with group C or D retinoblastoma, with remarkable tumor control. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

BACKGROUND AND OBJECTIVE: This study assessed the effect of introduction of diabetic retinopathy screening using non-mydriatic digital fundus photography (nDFP) in an urban academic family practice clinic on patient compliance to recommended dilated eye examination (REE). PATIENTS AND METHODS: Two hundred four patients with diabetes mellitis who were noncompliant to annual REE were screened for diabetic retinopathy using nDFP. The images were electronically transmitted to the retinal specialist to triage them for follow-up REE based on the photographic findings. Retrospective review of their medical records compared the compliance to REE before and after nDFP screening. RESULTS: Compliance to REE increased from 9% before screening to 66.5% after screening ( P < .0001). Good quality fundus images were obtained in 93% of the eyes. CONCLUSION: Introduction of nDFP for diabetic retinopathy screening in the family practice clinic can result in a dramatic increase in compliance to REE among patients with diabetes mellitis previously poorly compliant to REE.

Optical coherence tomography (OCT) has revolutionized the field of ophthalmology since its introduction 20 years ago. Originally intended primarily for retina specialists to image the macula, it has found its role in other subspecialties that include glaucoma, cornea, and ocular oncology. In ocular oncology, OCT provides axial resolution to approximately 7 microns with cross-sectional images of the retina, delivering valuable information on the effects of intraocular tumors on the retinal architecture. Some effects include retinal edema, subretinal fluid, retinal atrophy, photoreceptor loss, outer retinal thinning, and retinal pigment epithelial detachment. With more advanced technology, OCT now provides imaging deeper into the choroid using a technique called enhanced depth imaging. This allows characterization of the thickness and reflective quality of small (

Background: Chordomas are rare, slow-growing malignant neoplasms derived from remnants of the embryological notochord. Pediatric cases comprise only 5% of all chordomas, but more than half of the reported pediatric chordomas are intracranial. For patients of all ages, intracranial chordomas typically present with symptoms such as headaches and progressive neurological deficits occurring over several weeks to many years as they compress or invade local structures. There are only reports of these tumors presenting acutely with intracranial hemorrhage in adult patients. Case Description: A 10-year-old boy presented with acute onset of headache, emesis, and diplopia. Head computed tomography and magnetic resonance imaging of brain were suspicious for a hemorrhagic mass located in the left petroclival region, compressing the ventral pons. The mass was surgically resected and demonstrated acute intratumoral hemorrhage. Pathologic examination was consistent with chordoma. Conclusion: There are few previous reports of petroclival chordomas causing acute intracranial hemorrhage. To the authors’ knowledge, this is the first case of a petroclival chordoma presenting as acute intracranial hemorrhage in a pediatric patient. Although uncommon, it is important to consider chordoma when evaluating a patient of any age presenting with a hemorrhagic lesion of the clivus.

To evaluate morphologic features and the evolution of inner retinal dimples using spectral domain optical coherence tomography after internal limiting membrane peeling.A single-center retrospective study of spectral domain optical coherence tomography features in 43 eyes after full-thickness macular hole surgery with internal limiting membrane peeling without adjunctive internal limiting membrane staining.Postoperatively, a total of 210 dimples were noted in 37 eyes (86%), with a mean of 5.7 dimples per eye (median, 5; range, 1-20), most frequently located in the inferotemporal quadrant (n = 122, 58%, P0.0001). At initial detection, mean dimple dimensions were 199 μm wide (median, 183; range, 87-442 μm) and 19 μm deep (median, 17; range, 7-35 μm). During follow-up, mean maximum dimensions were 351 μm wide (median, 305; range, 219-494 μm) and 30 μm deep (median, 31; range, 15-55 μm). Dimple dimension reached a maximum at 12 months (median, 10; range, 2-22 months) followed by a modest decline. Mean preoperative and final postoperative visual acuity were 0.70 logMAR (median, 0.54; range, 0.09-1.4 logMAR) and 0.38 logMAR (median, 0.30; range, 0-1.4 logMAR), respectively.Inner retinal dimples are common after adjunct-free internal limiting membrane peeling and evolve in the postoperative period with enlargement over the first 12 months followed by reduction in size, and have no apparent impact on the visual acuity.

Entering into its fifth decade, vitrectomy continues to be an effective and safe solution for a myriad of vitreoretinal diseases. As knowledge about vitreous and the vitreoretinal interface continues to expand, vitrectomy technology and techniques have responsively evolved. The most recent innovations have included refinements of vitreous cutter and aspiration systems, improvements in illumination source and light delivery devices, and enhancements to intraoperative visualization systems. More excitingly, there are several emerging developments on the horizon, including the integration of augmented reality technology, robotic vitreoretinal surgery, gene and stem cell-based therapies, retinal prostheses, and novel drug delivery methods. This fantastic process of evolution continues to improve the safety and efficacy of vitrectomy, as well as expand its indications. As surgical outcomes continue to improve and complications are mitigated, new indications for vitrectomy have developed. Minimal vitrectomy that involves removal of floaters or early preretinal membranes along with the posterior vitreous cortex and sparing the anterior vitreous may become the standard of care for certain indications, thereby reducing post-vitrectomy cataract development [see chapter V.B.8. Floaters and vision – current concepts and management paradigms]. With advanced imaging, such as spectral-domain OCT, we have identified new pathologies like vitreo-macular adhesion, which has been shown to play a role in diabetic retinopathy (DR) and exudative AMD. “Preventive surgery” for AMD and DR may become acceptable to arrest disease process early on. Such preemptive surgery may help to reduce blinding complications in their advanced stages. Application of pharmacologic vitreolysis before pars plana vitrectomy will encourage even more liberal use of vitrectomy for such “new indications” [see chapter VI.A. Pharmacologic vitreolysis].

Background: HIV has various ocular manifestations and with the widespread introduction of highly active antiretroviral therapy (HAART), their pattern and prevalence is expected to change. Therefore, we evaluated the HIV/AIDS patients on HAART for ocular manifestations and blindness. Methods: In this cross-sectional study, 112 HIV-positive patients on HAART presenting to the HIV clinic with CD4 count ⩽200 cells/µl were enrolled. The WHO clinical stage, CD4 count, duration of HIV and HAART were recorded. An ocular examination was conducted, and the prevalence of ocular manifestations and blindness was determined. Results: The prevalence of ocular manifestations in HIV/AIDS patients on HAART was 8% (nine out of 112). Seven (6%) of the patients had visual impairment including one patient with blindness. The ocular manifestations included HIV retinopathy (5%), immune recovery uveitis (3%), immune recovery vitritis (3%) and Cytomegalovirus retinitis (2%). The prevalence of ocular manifestations and visual impairment was higher with the CD4 count of 0–100 cells/µl (p = 0.002). The prevalence of ocular manifestations was also higher in patients with WHO clinical stages 3 and 4 (p = 0.017). Conclusions: HAART may be the cause for decline in the prevalence of ocular diseases and visual impairment in HIV/AIDS patients. CD4 count and WHO clinical stage may help predict their occurrence.

PURPOSE To assess the overall risk of needlestick injuries (NSIs) associated with intravitreal injection, and more specifically related to the practice of compounding pharmacies of applying informational adhesive stickers to repackaged bevacizumab injection syringes. METHODS This cross-sectional study involved an online survey of retina specialists in the United States. RESULTS Of the 717 invited retina specialists, 158 (22%) responded to the online survey. The respondents reported using 1 pair of gloves (51%), no gloves (46%), or 2 pairs of gloves (3%) during intravitreal injection. Repackaged bevacizumab syringes distributed by compounding pharmacy were used by 89% of the respondents, and 63% reported that the adhesive sticker was applied directly to the syringe. Unintentional adhesion between the sticker and hand or glove was experienced by 9% of respondents. At least 1 NSI during intravitreal injection was experienced by 8% of respondents, and sticker-related injury was reported by 3%. The sticker was perceived to increase risk for NSI by 33% of respondents. CONCLUSION This survey showed that 8% of the responding physicians surveyed have experienced at least one NSI during intravitreal injections, of which approximately one third was attributed to the adhesive sticker. Direct application of misfitting stickers to repackaged syringes by compounding pharmacies may be a practice that can aggravate the risk of NSI.

To evaluate the clinical features, treatment, and prognosis of patients with uveal metastasis from lung cancer.Retrospective chart review.There were 194 patients with a diagnosis of uveal metastasis from lung cancer.Radiotherapy, chemotherapy, enucleation, or observation.Ocular tumor control, final visual acuity, and tumor-related death.There were 374 uveal metastatic tumors originating from primary lung cancer in 229 eyes of 194 patients. Tumor location included choroid (88%), ciliary body (2%), and iris (10%), with bilateral involvement in 18%. Diagnosis of uveal metastasis preceded the diagnosis of primary lung cancer in 44% of patients. The choroidal metastatic focus had a mean basal diameter of 8 mm and mean thickness of 3 mm, and were mostly located posterior to the equator (91%). The choroidal metastasis commonly had yellow or orange color (98%), had plateau (61%) or dome (38%) configuration, and displayed associated subretinal fluid (85%). Choroidal tumors were multifocal in 49 cases (23%). Ciliary body tumors were commonly dome shaped (75%) with an episcleral sentinel vessel (75%). Iris tumors were multifocal in 2 cases (13%), had visible intrinsic vessels (97%), and were associated with tumor seeding in the angle (38%) or on the iris stroma (25%). The uveal metastases were treated with teletherapy (31%), chemotherapy (18%), brachytherapy (9%), chemotherapy combined with teletherapy or brachytherapy (14%), enucleation (3%), or observation (21%). At last visit, eyes with follow-up showed tumor regression (66%), stability (12%), growth (14%), recurrence (3%), or new metastasis (5%). Visual acuity improved or remained stable in 59% eyes. One-year mortality from the time of detection of uveal metastasis was 54%.Of 194 patients with uveal metastasis from lung cancer, 44% did not have a history of known lung cancer. Current methods of ocular treatment allow globe salvage in 92% of patients and improved/stable vision in 59% of patients. Systemic prognosis remains poor with tumor-related death in 54% of patients at 1 year.

To evaluate the patient's understanding of the importance and adherence to the various lifestyle and Age-Related Eye Disease Study (AREDS) supplement recommendations for age-related macular degeneration (AMD).Cross-sectional study.Patients with AMD treated at the vitreoretinal service clinic.Telephone questionnaire survey was administered to assess knowledge and adherence to various recommendations made to patients with AMD about lifestyle and AREDS supplements in this single-institution study.Among 92 patients with AMD contacted, dietary modification, exercise and weight reduction, smoking cessation, and AREDS supplementation recommendations were recalled by 47 (51%), 21 (23%), 5 (5%), and 90 (98%) patients, respectively. The necessity of making these interventions was believed by 29 (62%), 16 (76%), 4 (80%), and 67 (74%) patients, respectively. Patient adherence to dietary modification was 81%, to exercise and weight reduction was 76%, to smoking cessation was 0%, and to AREDS supplementation was 88% (71% on correct dose). Financially, 29% of the patients noted a mean increase of $88 per month in expenditure because of making dietary modifications, but most reported such as justified; 61% noted a mean increase of $25 per month in expenditure from consumption of AREDS supplements, and most (96%) believed this was justified.Patients with AMD recalled recommendations for AREDS supplementation more often than other lifestyle changes but generally felt recommendations were necessary and affordable. Adherence to smoking cessation recommendation was poor (0%), but to other recommendations was good.

Objectives: Cytochrome P4502E1 (CYP2E1) is involved in the metabolism of isoniazid and the mediation of its hepatotoxicity. It exhibits genetic polymorphism in humans. This study evaluated the polymorphism of CYP2E1 in adult healthy Western Indians and patients on antituberculous drugs by phenotyping and genotyping. Methods: A 500 mg single dose of chlorzoxazone (CZX) was administered to 136 healthy adult Western Indian participants. Venous blood samples 2 h postdose were analyzed for the levels of CZX and 6-hydroxy CZX, and the metabolic ratio (MR) was calculated to determine the extent of rapid and poor metabolizers using probit plot analysis. Patients on antituberculous drugs who had raised the liver enzymes or clinical symptoms of hepatotoxicity were also recruited. Genotyping for CYP2E1 * 5B allele was performed by polymerase chain reaction - rapid fragment length polymorphism technique. Results: A total of 139 healthy participants were enrolled, of which the final analysis consisted of data from 136 participants for genotyping and 137 for phenotyping. Only 1 participant had reported mild drowsiness 2 h postdose, and no other adverse events were observed. The median (range) MR of population was 0.2 (0.1-4.0), and no polymorphisms were detected using phenotype data. A total of 134/136 (98.5%) had c1/c1 genotype and 1/136 each (0.75%) had c1/c2 and c2/c2 genotypes, respectively. Of the 2/136 participants harboring c2 allele, one had MR of 0.1 (c1/c2) and another had 0.5 (c2/c2). A total of 25 cases of antituberculous drug-induced hepatotoxicity and 50 control patients were recruited, of which finally 22 cases and 49 controls were available for evaluation. All the cases had c1/c1 genotype while 42/49 (85.7%) controls had c1/c1, 6/49 (12.2%) had c1/c2, and 1/49 (2.1%) had c2/c2 genotype and the crude odds ratio was 7.9 (0.4, 145.6). Conclusions: A background prevalence of CYP2E1*5B polymorphism and their activity in Western Indian population was observed. The study suggests no association between the CYP2E1 genotyping with antituberculous drug-induced hepatotoxicity.

Purpose of review To review the literature for recent advancements in the femtosecond laser technology with regard to its applications in corneal transplantation and eye banking. Recent findings Advancements in corneal surgery have encouraged the use of disease-specific corneal subcomponents, utilized in procedures such as anterior-lamellar keratoplasty and endothelial keratoplasty, instead of traditional transplant procedures to minimize adverse effects of penetrating keratoplasty. Femtosecond laser microkeratomes can precisely create flaps for such transplant procedures, achieve better wound stability, and promote healing by shaped wound configurations. Laser microkeratomes have been compared to traditional mechanical microkeratomes for keratoplasty procedures from various aspects and are superior in some aspects and offer unique capabilities. Summary Femtosecond laser applications in eye banking include preparation of donor and recipient corneas for use in penetrating keratoplasty, anterior-lamellar keratoplasty, and endothelial keratoplasty. Advantages of femtosecond laser microkeratomes include higher precision of the cut, ability to achieve thinner flaps, and wound configurations that allow greater wound stability, shorter recovery time, and less postoperative pain. However, cost and availability at the eye-bank level may hinder widespread and immediate application.

Purpose To describe the outcome of intraocular tumor resection by partial lamellar sclerouvectomy (PLSU) in the pediatric age group. Design Retrospective, interventional case series. Participants We included 37 patients who underwent PLSU for intraocular tumors under age 21 years. Methods Medical records were reviewed for clinical, operative, and histopathologic features. Main Outcome Measures Globe salvage, visual acuity, surgical side effects, tumor control, and tumor-related metastasis and death. Results The mean patient age was 9 years (median, 10; range, 0.25–17) and there were 22 (59%) females and 15 (41%) males. The tumor involved mainly the iris (n = 27; 73%), ciliary body (n = 7; 19%), or choroid (n = 3; 8%). The mean tumor basal dimension was 7 mm (median, 6; range, 3–15) and thickness was 3.6 mm (median, 3; range, 0.2–9.6). The histopathologic diagnosis was melanoma (n = 19; 51%), cyst (n = 5; 14%), medulloepithelioma (n = 4; 10%), melanocytoma (n = 3; 8%), lacrimal gland choristoma (n = 2; 5%), gliosis (n = 1; 3%), nevus (n = 1; 3%), hemorrhage (n = 1; 3%), and leiomyoma (n = 1; 3%). Intraoperative adverse effects included vitreous loss in 19 (51%) and hyphema in 4 (11%). Postoperative side effects included early transient hyphema in 9 (24%) and late cataract in 12 (32%). Local tumor recurrence was detected in 5 cases (13%) at mean interval of 28 months, including melanoma (n = 3) and medulloepithelioma (n = 2). Enucleation was necessary in 9 (24%) cases for recurrence in 3 (8%), prophylactic in eyes with high-grade malignancy in 5 (13%), and for blind painful eye in 1 (3%). Of the 28 salvaged eyes, final visual acuity was ≥20/40 in 18 (64%), 20/50 to 20/100 in 5 (18%), and Conclusions A surgically challenging procedure, PLSU can achieve control of selected intraocular tumors. Medulloepithelioma responds poorly to local resection and in most cases enucleation is required. If the globe is salvaged, visual acuity is ≥20/40 in 64% of children. Financial Disclosure(s) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Purpose To evaluate the outcomes of iris melanoma managed with plaque radiotherapy on the basis of the initial presence or absence of glaucoma. Design Retrospective, comparative case series. Participants A total of 144 patients. Intervention Custom-designed iodine-125 plaque radiotherapy delivering planned 8000 cGy to melanoma apex using transcorneal application. Main Outcome Measures Tumor control and treatment-related complications. Results Of 144 patients with iris melanoma, glaucoma was present at the initial visit in 58 (40%). Causes of elevated intraocular pressure included angle infiltration by melanoma in 50 patients (86%), angle neovascularization in 4 patients (7%), and hyphema in 4 patients (7%). At presentation, the eyes displaying iris melanoma with glaucoma (vs. without glaucoma) were statistically more likely to display angle tumor (66% vs. 43%), with minimal thickness (1.9 vs. 2.9 mm), and melanoma seeding in iris stroma (7 vs. 3 clock hours) and angle (5 vs. 2 clock hours). Plaque radiotherapy was performed in all cases. Kaplan–Meier estimates at 7 years post-treatment revealed no statistical differences in outcomes of local recurrence (14% vs. 15%), enucleation (14% vs. 11%), or metastasis (2% vs. 0%) comparing eyes with and without glaucoma. Of the entire group, multivariate analysis for factors predictive of recurrence included partial (vs. complete) anterior segment irradiation and postradiotherapy glaucoma. Factors related to enucleation included diabetes mellitus, poor initial visual acuity, higher radiation dose to tumor apex, and tumor recurrence. There were no factors predictive of metastasis. Conclusions Iodine-125 plaque radiotherapy provides adequate tumor control for iris melanoma with a low metastatic potential of 1% at 7 years. Iris melanoma with secondary glaucoma showed a statistically significant greater likelihood of flat tumor with iris and angle seeding and no difference in outcomes compared with eyes without glaucoma. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Objective To evaluate the efficacy of topical interferon alfa-2b in the management of ocular surface squamous neoplasia (OSSN). Methods Clinically visible OSSN in 20 patients (23 tumors) was managed with topical interferon alfa-2b, 1 million IU/mL, 4 times daily. Tumor control and complications were evaluated according to American Joint Committee on Cancer classification. Results Complete tumor resolution was achieved in 19 tumors (83%) following topical interferon alfa-2b treatment for a median period of 6 months (mean, 7 months; range, 1-12 months) and maintained for up to 24 months of follow-up. Of the 4 tumors with partial resolution (17%), tumor surface area was reduced 44% (median) during 4 months (median) without further response and alternative therapy was used. Based on American Joint Committee on Cancer classification, complete control was achieved in 2 of 3 Tis (67%), 17 of 20 T3 (85%), 19 of 23 N0 (83%), and 19 of 23 M0 (83%) category tumors. Tumors involving the cornea responded earlier compared with those without corneal involvement (P = .01). Initial tumor size did not correlate with time to response (P = .27). Recurrence was noted in 1 case (Tis, 4%) at 3 months. Adverse effects included conjunctival hyperemia (2 [10%]), follicular hypertrophy (2 [10%]), giant papillary conjunctivitis (1 [5%]), irritation (1 [5%]), corneal epithelial defect (1 [5%]), and flulike symptoms (1 [5%]); all resolved within 1 month of medication discontinuation. Conclusion According to American Joint Committee on Cancer classification, complete control with topical interferon alfa-2b can be achieved in 67% of Tis, 85% of T3, and 83% of all OSSN.

PURPOSE: To study the effect of intraarterial chemotherapy (IAC) on retinoblastoma-induced retinal detachment. METHODS: Retrospective, noncomparative, interventional case series including 15 patients, with intraarterial (ophthalmic artery) chemotherapy as the intervention. Resolution of retinal detachment was the main outcome measure. RESULTS: Of 15 patients with retinoblastoma-induced retinal detachment managed with IAC, 7 (47%) presented with total retinal detachment and 8 (53%) with partial detachment. The eyes were classified as International Classification of Retinoblastoma group C (n = 2, 13%), group D (n = 4, 27%), and group E (n = 5, 33%). There were 4 eyes (27%) that received IAC as secondary treatment after the failure of other treatment methods. After IAC, all tumors showed regression. Of the 7 eyes with initial total retinal detachment, complete resolution of fluid was found in 3 (43%) and partial resolution in 4 (57%). Of the 8 eyes with initial partial retinal detachment, complete resolution of subretinal fluid was found in all 8 (100%), but 1 eye later developed recurrent subretinal fluid. The mean interval to complete resolution of subretinal fluid was 2 months. Globe salvage was achieved in 5 of 7 eyes (71%) with total retinal detachment and 6 of 8 eyes (75%) with partial retinal detachment. CONCLUSION: Eyes with retinoblastoma-induced total or partial retinal detachment showed complete resolution of detachment after IAC in 43% and 100%, respectively.

Background Analysis of 52 eyes with high-risk retinoblastoma managed with postenucleation adjuvant chemotherapy using vincristine sulfate, etoposide phosphate, and carboplatin showed no evidence of systemic metastasis in any case during a mean (range) follow-up of 66 (12-202) months. Purpose To determine the efficacy of postenucleation adjuvant chemotherapy with vincristine, etoposide, and carboplatin in the prevention of metastasis for patients with high-risk retinoblastoma. Methods Retrospective, nonrandomized, interventional case series of 52 eyes in 51 patients with high-risk retinoblastoma consisting of tumor invasion into the anterior segment, posterior uvea 3 mm or greater, postlaminar optic nerve, or any combination of posterior uvea and optic nerve involvement. Results Of 51 consecutive patients with high-risk retinoblastoma, there were 30 males (59%) and 21 females (41%), with a median age of 28 months at diagnosis. All 52 eyes were classified as group E. The main histopathologic risk factors included anterior segment invasion (7 [13%]), isolated massive posterior uveal invasion of 3 mm or greater (6 [12%]), isolated postlaminar optic nerve invasion (15 [29%]), or any posterior uveal invasion with any optic nerve involvement (24 [46%]). There was additional invasion into the sclera (3 [6%]) and extrascleral structures, including the orbit (1 [2%]). A single histopathologic high-risk factor was present in 32 eyes (62%), whereas 20 eyes (38%) manifested 2 or more high-risk characteristics. Based on previously published series, untreated high-risk retinoblastoma carries at least a 24% risk for metastatic disease. In the present series, using vincristine, etoposide, and carboplatin in all cases, there was no metastasis during a mean follow-up of 66 months (median [range], 55 [12-202] months). Conclusions Retinoblastoma with invasion into the postlaminar optic nerve and/or posterior uvea is at high risk for metastasis and death. In this study, postenucleation chemotherapy using vincristine, etoposide, and carboplatin was effective in preventing metastasis in every case (100%).

Purpose To evaluate iris melanoma in children versus adults. Methods Retrospective, nonrandomized clinical case series including all patients with a clinical diagnosis of iris melanoma managed at the Ocular Oncology Service at Wills Eye Institute over 40 years. Patients were divided into three age categories based on age at presentation: children (≤20 years), mid-adults (21-60 years), and older adults (>60 years). The clinical features, treatments, and outcomes were statistically analyzed based on patient age at presentation. The main outcome measures were melanoma features and related metastasis and death. Results Of 8,101 eyes with uveal melanoma, there were 317 (4%) with iris melanoma, including 24 (8%) children (≤20 years), 187 (59%) mid-adults (21-60 years), and 106 (33%) older adults (>60 years). There was no age-related difference in race, sex, tumor quadrant, thickness, pigmentation, associated corectopia, ectropion uveae, hyphema, or extraocular extension. Significant age-related differences were found with mean tumor basal diameter, tapioca appearance, mean intraocular pressure, secondary glaucoma, tumor seeding in angle, and mean number of clock hours of angle seeding. Multivariate analysis of factors predictive of metastasis included extraocular extension and high intraocular pressure. Factors predictive of death included increased tumor thickness and high intraocular pressure. There was no difference in metastasis or death by age group. Conclusions Iris melanoma shows significant clinical differences in children versus adults, with smaller tumor size, less tumor seeding in angle, and lower incidence of secondary glaucoma. There was no significant difference in metastasis or death by age group.

Introduction: Tamoxifen retinopathy is usually diagnosed on fundoscopy and fluorescein angiography. Microcystoid maculopathy associated with tamoxifen was reported previously using a research-grade high resolution Fourierdomain optical coherence tomography (Fd-OCT) in a patient with vision loss unexplained on fundoscopy, fluorescein angiography and Stratus OCT. This report describes two new cases of microcystoid maculopathy diagnosed using commercially available Fd-OCT in patients who have been previously treated with tamoxifen. Case presentation: Two patients had visual complaints which started while on tamoxifen but persisted or worsened after stopping tamoxifen at least two years earlier. Both patients had normal or near normal visual acuity and fundoscopy. Fluorescein angiography was normal in all but one eye which showed foveal hyperfluorescence. No angiographic cystoid macular edema was noted. Commercially available Fd-OCT (RTVue and Cirrus) showed microcystoid changes in the central macula with patches of loss of photoreceptor inner segment-outer segment junction (IS-OS) near the fovea in all four eyes. The eye with foveal hyperfluorescence on fluorescein angiography had foveal detachment on Fd-OCT in addition which resolved spontaneously on follow-up Fd-OCT nine months later. The microcystoid changes and IS-OS loss persisted on follow-up Fd-OCT. Conclusion: Maculopathy associated with prior tamoxifen use may be detected using commercial Fd-OCT though not evident on fundoscopy or fluorescein angiography. Maculopathy may persist over 2 years after stopping tamoxifen.

Purpose To evaluate plaque radiotherapy for management of residual or recurrent iris melanoma after surgical resection. Design Retrospective, nonrandomized interventional case series. Participants We included 32 patients with residual or recurrent iris melanoma after surgical resection. Intervention Custom designed iodine-125 plaque radiotherapy. Main Outcome Measures Tumor control, recurrence, poor visual acuity, enucleation, metastasis, and radiation complications. Results There were 32 eyes with residual (n = 12) or recurrent (n = 20) iris melanoma after surgical resection that were treated with iodine-125 plaque radiotherapy. The residual melanoma was evident clinically in 3 cases and histopathologically in 9; plaque radiotherapy was delivered at a mean interval of 2 months after resection. For the recurrent cases, the mean interval from initial tumor resection to detection of recurrence was 58 months, at which time plaque radiotherapy was applied. For all cases, the mean tumor basal diameter was 6 mm (range, 1–13) and thickness was 2 mm (range, 0.8–4.0) at the time of radiotherapy. Anterior chamber seeding was present in 26 (81%) eyes and glaucoma in 11 (34%) eyes. Visual acuity at presentation was good (20/20–20/50) in 27 (84%), intermediate (20/60–20/150) in 3 (9%), and poor (≤20/200) in 2 eyes (6%). At 6 years after plaque radiotherapy, outcomes included complete tumor control in 87%, poor visual acuity in 9%, enucleation in 13% (for reasons of tumor recurrence [n = 3] and severe glaucoma [n = 1]), and metastasis in 3%. At 6 years, radiation complications included corneal epitheliopathy in 6%, scleral necrosis in 3%, cataract in 53%, elevated intraocular pressure (from tumor or radiotherapy) in 19%, and macular edema in 6%. Conclusions Iodine-125 plaque radiotherapy is effective in the management of residual or recurrent iris melanoma after surgical resection, providing tumor control in 87% of patients at 6 years and avoiding enucleation in most cases. Financial Disclosure(s) The authors have no proprietary or commercial interest in any of the materials discussed in this article.