Amniotic Membrane Augmentation for Enucleation After Chemotherapy in Retinoblastoma

PURPOSE

To describe amniotic membrane augmentation for enucleation after chemotherapy in retinoblastoma.

METHODS

This was a retrospective study of patients with retinoblastoma who underwent enucleation. The study also evaluated the utility of amniotic membrane grafting in enucleation after chemotherapy in eyes with retinoblastoma.

RESULTS

In this study, 110 eyes of 107 patients were analyzed, and 49 patients had previous systemic chemotherapy, 13 eyes had previous intra-arterial chemotherapy, and 7 eyes had external beam radiation. Amniotic graft was used in 8 eyes (5 following IAC, 2 following systemic chemotherapy, and 1 after both). After IAC, 3 of 7 eyes without amniotic graft had implant exposure compared to 0 of 6 eyes with amniotic graft (P = .05). Pathological examination of the conjunctiva after intra-arterial chemotherapy showed goblet cell hypoplasia that hinders wound healing.

CONCLUSIONS

Amniotic membrane augmentation improves wound integrity in patients with retinoblastoma, especially following intra-arterial chemotherapy. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XXX-XXX.].

Three-Dimensional Ultrasound Imaging of Retinoblastoma and Its Correlation With Pathology

BACKGROUND AND OBJECTIVE

Monitoring the response of retinoblastoma to globe-salvaging therapies is based on subjective assessments of changes determined by fundoscopy, ultrasound, and optical coherence tomography. Advances in organ-preserving therapies have increased the need for objective, quantitative estimates of tumor response to treatment. Primary tumor volume is a metric that can be objectively determined as a surrogate measure of treatment response.

PATIENTS AND METHODS

We evaluated the correlation of objective, quantitative estimates of tumor volume made with two-dimensional (2D) and three-dimensional (3D) ultrasound with gold standard pathological tumor volumes derived by analysis of enucleation specimens.

RESULTS

Twelve eyes in 12 patients undergoing primary enucleation were evaluated by 2D and 3D ultrasound during ophthalmic examination under anesthesia prior to enucleation. 2D- and 3D-ultra-sound measurements of tumor volume were both strongly correlated with pathological estimates of tumor volume (r = 0.69, P = 0.018; and r = 0.66, P = 0.027, respectively).

CONCLUSIONS

2D- and 3D-ultrasound measurements of retinoblastoma primary tumor volume are highly correlated with pathological estimates. 3D measurements are easy to perform with volumetric probes and consider the irregular morphology of the tumor. Further study should be undertaken to evaluate the performance of these metrics as surrogate markers of tumor response to treatment. [Ophthalmic Surg Lasers Imaging Retina 2024;55:136-140.].

Microvascular flow ultrasound imaging for retinoblastoma

PURPOSE

To present the results of a pilot study of microvascular flow imaging (MFI) in characterizing tumor vasculature of retinoblastoma.

METHODS

The medical records of consecutive patients with retinoblastoma presenting at our institution between July 2019 and June 2022 that were imaged using MFI were reviewed retroactively. Each patient underwent diagnostic evaluation according to standard of care by examination under anesthesia with fluorescein angiography and ocular ultrasound imaging, including color Doppler and MFI.

RESULTS

Thirteen eyes of 10 patients with retinoblastoma were included. MFI showed a prominent feeder vessel in 8 eyes, basket vasculature in 6 eyes and tumor bed vascularity in 10 eyes. MFI showed a more extensive vascular branching pattern that was not visible on color Doppler and fluorescein angiography in all eyes.

CONCLUSIONS

MFI of retinoblastoma patients could add information about tumor vascularity not detectable by color Doppler or fluorescein angiography. Further study is needed to determine whether this information could be used to predict prognosis for ocular salvage and tumor response to treatment.

Orbital cellulitis with panophthalmitis and scleral necrosis - a case report

BACKGROUND

Orbital cellulitis is common in young children and is often secondary to coexisting sinus disease. Coexisting orbital cellulitis and panophthalmitis is a rare clinical event and usually occurs secondary to trauma or from an endogenous source.

CASE PRESENTATION

A febrile 2-year-old male presented with periorbital inflammation and exudative retinal detachment. Imaging showed acute sinusitis and extensive orbital cellulitis. Because of progressive scleral thinning, the patient underwent enucleation.

CONCLUSION

We present a case of concurrent orbital cellulitis, panophthalmitis, and scleral necrosis in an immunocompetent pediatric patient. Timely intervention is important to prevent life threatening complications with the rare occurrence of coexistent orbital cellulitis and panophthalmitis.

BRAF Immunohistochemical Studies of Pediatric Conjunctival Lesions

PURPOSE

The purpose of this study was to analyze the prevalence of an activating mutation in the B-Raf proto-oncogene (BRAF) V600E immunoreactivity in pediatric conjunctival lesions.

METHODS

This retrospective case-control study included 32 pediatric patients who underwent surgical excision of conjunctival lesions between Jan 2019 and May 2022. The collected data included demographic data, clinical features, and histopathologic characteristics of the lesion, including BRAF V600E positivity. The Student t test and the Fisher exact test were used to determine the significance of the associations between clinical variables and BRAF positivity.

RESULTS

BRAF immunoreactivity was positive in 11/32 lesions (34%). Age at diagnosis did not correlate with BRAF positivity, with a mean age at diagnosis of 131.7 months for patients with BRAF+ lesions and 134.7 months for those with BRAF- lesions ( P > 0.1). No clinical or pathological features were found to be significantly correlated with BRAF positivity, although there was a trend toward BRAF positivity in the presence of cysts ( P = 0.072).

CONCLUSIONS

BRAF reactivity was present in approximately one-third of pediatric conjunctival nevi but does not correlate significantly with unique clinical or histopathological features.

Diffuse Pigment Release in a Patient Undergoing Tumor-Infiltrating Lymphocyte Immunotherapy for Acral Malignant Melanoma

This is a Photo Essay and does not have an abstract. Please download the PDF or view the article in HTML.

Efficacy of a prolonged stability melphalan formulation for intra-arterial treatment of retinoblastoma

BACKGROUND

Melphalan, which is poorly soluble at room temperature, is widely used for the treatment of retinoblastoma by selective ophthalmic artery infusion. Evomela, a propylene glycol-free formulation of melphalan with improved solubility and stability, has recently been used as an alternative.To compare the safety and efficacy of Evomela with standard-formulation melphalan (SFM) in the treatment of retinoblastoma by selective ophthalmic artery infusion.

METHODS

We performed a retrospective case-control study of patients with retinoblastoma undergoing selective ophthalmic artery infusion with SFM or Evomela at a single institution. Cycle-specific percent tumor regression (CSPTR) was estimated by comparing photos obtained during pretreatment examination under anesthesia (EUA) with those obtained during post-treatment EUA 3-4 weeks later. CSPTR, ocular salvage rates, complication rates, operation times (unadjusted and adjusted for difficulty of ophthalmic artery catheterization), and intraprocedural dose expiration rates were compared between Evomela- and SFM-treated groups. Univariate and multivariate analyses were performed.

RESULTS

Ninety-seven operations (melphalan: 45; Evomela: 52) for 23 patients with 27 retinoblastomas were studied. The ocular salvage rate was 79% in the SFM-treated group and 69% in the Evomela-treated group. Multivariate regression controlling for tumor grade, patient age, and treatment history revealed no significant differences in ocular salvage rate, CSPTR, complication rates, or operation times. Although the dose expiration rate was higher for the SFM-treated group, the difference was not statistically significant. Notably, there were no ocular or cerebral ischemic complications.

CONCLUSION

Evomela has non-inferior safety and efficacy relative to SFM when used for the treatment of retinoblastoma by selective ophthalmic artery infusion.

MRI Features for Identifying MYCN-amplified RB1 Wild-type Retinoblastoma

Background MYCN-amplified RB1 wild-type (MYCNARB1+/+) retinoblastoma is a rare but clinically important subtype of retinoblastoma due to its aggressive character and relative resistance to typical therapeutic approaches. Because biopsy is not indicated in retinoblastoma, specific MRI features might be valuable to identify children with this genetic subtype. Purpose To define the MRI phenotype of MYCNARB1+/+ retinoblastoma and evaluate the ability of qualitative MRI features to help identify this specific genetic subtype. Materials and Methods In this retrospective, multicenter, case-control study, MRI scans in children with MYCNARB1+/+ retinoblastoma and age-matched children with RB1-/- subtype retinoblastoma were included (case-control ratio, 1:4; scans acquired from June 2001 to February 2021; scans collected from May 2018 to October 2021). Patients with histopathologically confirmed unilateral retinoblastoma, genetic testing (RB1/MYCN status), and MRI scans were included. Associations between radiologist-scored imaging features and diagnosis were assessed with the Fisher exact test or Fisher-Freeman-Halton test, and Bonferroni-corrected P values were calculated. Results A total of 110 patients from 10 retinoblastoma referral centers were included: 22 children with MYCNARB1+/+ retinoblastoma and 88 control children with RB1-/- retinoblastoma. Children in the MYCNARB1+/+ group had a median age of 7.0 months (IQR, 5.0-9.0 months) (13 boys), while children in the RB1-/- group had a median age of 9.0 months (IQR, 4.6-13.4 months) (46 boys). MYCNARB1+/+ retinoblastomas were typically peripherally located (in 10 of 17 children; specificity, 97%; P < .001) and exhibited plaque or pleomorphic shape (in 20 of 22 children; specificity, 51%; P = .011) with irregular margins (in 16 of 22 children; specificity, 70%; P = .008) and extensive retina folding with vitreous enclosure (specificity, 94%; P < .001). MYCNARB1+/+ retinoblastomas showed peritumoral hemorrhage (in 17 of 21 children; specificity, 88%; P < .001), subretinal hemorrhage with a fluid-fluid level (in eight of 22 children; specificity, 95%; P = .005), and strong anterior chamber enhancement (in 13 of 21 children; specificity, 80%; P = .008). Conclusion MYCNARB1+/+ retinoblastomas show distinct MRI features that could enable early identification of these tumors. This may improve patient selection for tailored treatment in the future. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Rollins in this issue.

Prenatal Diagnosis of Retinoblastomas: A Scoping Review

Purpose

The objective of this review is to explore the prenatal diagnosis of retinoblastoma and the recommended screening practices.

Patients and Methods

An electronic literature search on prenatal diagnosis of retinoblastoma was conducted on the PubMed database. Publications within the last 20 years that matched the inclusion criteria were selected. The literature search included the following keywords: retinoblastoma, prenatal, diagnosis, screening, and associated synonyms to increase search sensitivity. Nine studies were included for investigation and extracted to identify prenatal diagnostic and screening techniques for retinoblastoma, their associated impact, and the target population that should receive prenatal screening for retinoblastoma.

Results

Familial retinoblastoma has an autosomal inheritance pattern and 90% penetrance. Therefore, future parents with a family history of retinoblastoma are strongly advised to get tested for retinoblastoma (Rb) gene mutations; if one of the parents is positive for a mutated allele of the RB1 gene, there is a 45% chance that their child will inherit a mutated allele of the retinoblastoma gene, rendering the allele non-functional in all of the cells of the individual and predisposing the child to a higher risk of developing retinoblastoma as well as other secondary cancers. Thus, prenatal screening and diagnosis of retinoblastoma is crucial for early diagnosis and optimal treatment.

Conclusion

Prenatal testing for retinoblastoma in high-risk families is important for everyone in the family. For the parents, prenatal screening has been shown to improve their family planning decisions and psychological well-being as they can mentally prepare beforehand and make informed decisions. More importantly, these practices have shown to yield better treatment and vision outcomes in the newborn.

Response assessment in pediatric craniopharyngioma: recommendations from the Response Assessment in Pediatric Neuro-Oncology (RAPNO) Working Group

BACKGROUND

Craniopharyngioma is a histologically benign tumor of the suprasellar region for which survival is excellent but quality of life is often poor secondary to functional deficits from tumor and treatment. Standard therapy consists of maximal safe resection with or without radiation therapy. Few prospective trials have been performed, and response assessment has not been standardized.

METHODS

The Response Assessment in Pediatric Neuro-Oncology (RAPNO) committee devised consensus guidelines to assess craniopharyngioma response prospectively.

RESULTS

Magnetic resonance imaging is the recommended radiologic modality for baseline and follow-up assessments. Radiologic response is defined by 2-dimensional measurements of both solid and cystic tumor components. In certain clinical contexts, response to solid and cystic disease may be differentially considered based on their unique natural histories and responses to treatment. Importantly, the committee incorporated functional endpoints related to neuro-endocrine and visual assessments into craniopharyngioma response definitions. In most circumstances, the cystic disease should be considered progressive only if growth is associated with acute, new-onset or progressive functional impairment.

CONCLUSIONS

Craniopharyngioma is a common pediatric central nervous system tumor for which standardized response parameters have not been defined. A RAPNO committee devised guidelines for craniopharyngioma assessment to uniformly define response in future prospective trials.

The Global Retinoblastoma Outcome Study: a prospective, cluster-based analysis of 4064 patients from 149 countries

Background

Retinoblastoma is the most common intraocular cancer worldwide. There is some evidence to suggest that major differences exist in treatment outcomes for children with retinoblastoma from different regions, but these differences have not been assessed on a global scale. We aimed to report 3-year outcomes for children with retinoblastoma globally and to investigate factors associated with survival.

Methods

We did a prospective cluster-based analysis of treatment-naive patients with retinoblastoma who were diagnosed between Jan 1, 2017, and Dec 31, 2017, then treated and followed up for 3 years. Patients were recruited from 260 specialised treatment centres worldwide. Data were obtained from participating centres on primary and additional treatments, duration of follow-up, metastasis, eye globe salvage, and survival outcome. We analysed time to death and time to enucleation with Cox regression models.

Findings

The cohort included 4064 children from 149 countries. The median age at diagnosis was 23·2 months (IQR 11·0–36·5). Extraocular tumour spread (cT4 of the cTNMH classification) at diagnosis was reported in five (0·8%) of 636 children from high-income countries, 55 (5·4%) of 1027 children from upper-middle-income countries, 342 (19·7%) of 1738 children from lower-middle-income countries, and 196 (42·9%) of 457 children from low-income countries. Enucleation surgery was available for all children and intravenous chemotherapy was available for 4014 (98·8%) of 4064 children. The 3-year survival rate was 99·5% (95% CI 98·8–100·0) for children from high-income countries, 91·2% (89·5–93·0) for children from upper-middle-income countries, 80·3% (78·3–82·3) for children from lower-middle-income countries, and 57·3% (52·1-63·0) for children from low-income countries. On analysis, independent factors for worse survival were residence in low-income countries compared to high-income countries (hazard ratio 16·67; 95% CI 4·76–50·00), cT4 advanced tumour compared to cT1 (8·98; 4·44–18·18), and older age at diagnosis in children up to 3 years (1·38 per year; 1·23–1·56). For children aged 3–7 years, the mortality risk decreased slightly (p=0·0104 for the change in slope).

Interpretation

This study, estimated to include approximately half of all new retinoblastoma cases worldwide in 2017, shows profound inequity in survival of children depending on the national income level of their country of residence. In high-income countries, death from retinoblastoma is rare, whereas in low-income countries estimated 3-year survival is just over 50%. Although essential treatments are available in nearly all countries, early diagnosis and treatment in low-income countries are key to improving survival outcomes.

Funding

Queen Elizabeth Diamond Jubilee Trust.

IMG-08. Response assessment for pediatric craniopharyngioma: recommendations from the Response Assessment in Pediatric Neuro-Oncology (RAPNO) working group

INTRODUCTION: Craniopharyngioma (CP) is a histologically benign tumor of the pituitary stalk that accounts for 4% of pediatric central nervous system (CNS) tumors. Given its location, CP often causes neuro-endocrine, hypothalamic, and vision dysfunction. Standard therapy consists of maximally safe resection +/- radiation therapy (RT). Medical management, including intra-cystic therapy, may have utility in certain contexts. Survival after CP is excellent, but quality of life is often poor secondary to functional deficits from the tumor and/or treatment. Few prospective CP trials have been performed, and response assessment has not been standardized. METHODS: The Response Assessment in Pediatric Neuro-Oncology (RAPNO) committee, formed of international experts in relevant subspecialties, devised consensus guidelines from published literature and/or expert opinion to assess CP response in prospective clinical trials. RESULTS: Magnetic resonance imaging (MRI) is the recommended radiological modality for baseline and follow-up CP assessment. Computed tomography can be useful for identification of calcification in the initial diagnostic work-up. The committee defined specific standard MRI-based sequences focused on comprehensive evaluation of the suprasellar space. Radiologic CP response is defined by two-dimensional measurements of both solid and cystic tumor components. Three-dimensional measurements are also encouraged in prospective trials. In certain clinical contexts, response of solid and cystic disease may be differentially considered based on their unique natural histories and responses to treatment (including transient cyst growth during or after RT). Importantly, the committee incorporated functional endpoints related to neuro-endocrine and visual assessments into CP response definitions. In most circumstances, cystic disease should be considered progressive only if growth is associated with acute, new-onset or progressive functional impairment. CONCLUSION: CP is a common pediatric CNS tumor for which standardized response parameters have not been defined. A RAPNO committee devised guidelines for baseline and longitudinal assessments of CP to uniformly define response in future prospective trials.

Blue nevi of the palpebral conjunctiva: report of 2 cases and review of literature

PURPOSE

To describe two patients with blue nevi of the palpebral conjunctiva and to review the existing literature on common and cellular blue nevi of the conjunctiva.

METHODS

Report of two cases and literature review.

RESULTS

We present two cases of blue nevi in the palpebral conjunctiva: an atypical cellular blue nevus of the left upper eyelid and a common blue nevus around the lacrimal punctum of the left lower eyelid. Both patients underwent full thickness eyelid excision with wide margins. There was no tumor recurrence at 11 and 4 months postoperatively.

CONCLUSIONS

Blue nevi are a group of melanocytic tumors that rarely involve the ocular adnexa. They may arise in the palpebral conjunctiva and should be considered in the differential diagnosis of pigmented lesions in this location as they can mimic melanoma.

Meibum Lipid Composition and Conformation in Parkinsonism

PURPOSE

Patients with Parkinson's disease (PD) exhibit unstable tear films. Tear film lipid composition and structure are related to tear film stability and dry eye and tear lipids have not been characterized in people with PD. The aim of this study is to characterize Meibum tear lipids in donors with PD using ¹H-NMR and infrared spectroscopy.

METHODS

Three cohorts were compared: meibum from donors with PD (Mp) n = 10, meibum from donors with PD and dry eye (Mpd) n = 3, meibum from donors without PD (Mn) n = 29.

RESULTS

There were no significant differences, P > 0.05, in hydrocarbon branching for Mp compared with Mn. Mn contained twice as much cholesteryl esters compared with Mp, P < 0.0001. The cooperativity of the phase transition was significantly 37% lower for Mp compared with Mn, P < 0.0001. Mpd was much more ordered (stiffer) with compared with Mp and Mn, P < 0.0001.

CONCLUSION

Changes in meibum lipid composition and structure could be a marker for and/or contribute to increase the susceptibility of dry eye in patients with PD. A less cooperative phase transition for Mp compared with Mn indicates that Mp was more heterogeneous and/or contained more contaminants than Mn. The data support the idea that more ordered lipid contributes to dry eye.

Prenatal diagnosis of bilateral retinoblastomas by multimodality fetal imaging: case report and review of the literature

Retinoblastoma is the prototypic genetic tumor. Caused by mutations in the RB1 gene, retinoblastomas are heritable in 40% of the cases and, in such cases, tumors are bilateral in 80%, unilateral in 15%, and trilateral in 5% of the cases. Trilateral retinoblastoma is a term that describes bilateral retinoblastomas plus a midline suprasellar or pineal neuroectodermal tumor. Patients with a germline RB1 mutation have 45% chance of having an offspring with retinoblastoma. Prenatal diagnosis is important because the doubling time is fast, ranging from 7 to 15 days. Thus, late diagnosis during infancy is associated with larger tumors and increased risk of death, need for globe enucleation and vision loss. We report a case of bilateral retinoblastomas diagnosed by targeted high-resolution ultrasonography of the orbits at 32 weeks of gestation in a patient at risk. This report demonstrates the feasibility of accurately detecting even tiny retinoblastomas by ultrasound with current technology. We also review prenatally published cases to date and comment on the technical strengths and limitations of ultrasound and fetal MRI for prenatal diagnosis of retinoblastomas.

Changes in meibum composition following plaque bachytherapy for choroidal melanoma

Objectives

Dry eye is common when external beam radiation is used for the treatment of choroidal melanoma (CM). As meibum structure and composition have been related to dry eye, we determined if plaque bachytherapy for CM alters meibum composition.

Design

¹H-NMR spectroscopy was used to measure the lipid composition of meibum.

Setting

The University of Louisville, Kentucky, USA.

Participants

All 13 participants had CM and one participant had iris melanoma.

Main outcome measures

Cholesteryl ester (CE) to wax ester (WE) ratio, amount of meibum esters (ME) and meibum lipid saturation were measured.

Results

ME decreased by 80%±18% (±99% CI) in 11 eyes that were treated compared with the contralateral untreated eye. ME increased by 181% in two eyes that were treated compared with the contralateral untreated eye. The mole % CE/WE for meibum was significantly (p<0.0001) 67% lower in eyes that were irradiated compared with control eyes from donors without CM and were not treated. Plaque brachytherapy induced the de-esterification of CE. The intensity of the meibum cis double bond resonances did not change significantly (p>0.05).

Conclusion

Eyes that had plaque brachytherapy had a lower amount of expressible meibum and a lower CE/WE ratio compared with meibum from the contralateral eye that received no treatment and eyes that did not have uveal melanoma. Both the quality and quantity of meibum should be considered in designing a therapy for dry eye after plaque brachytherapy.

Global Retinoblastoma Presentation and Analysis by National Income Level

Importance

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

Objectives

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

Design, Setting, and Participants

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

Main Outcomes and Measures

Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis.

Results

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

Conclusions and Relevance

This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs.

Structural Differences in Meibum From Teenagers Without and With Dry Eye and Allogeneic Hematologic Stem Cell Transplantations

Although dry eye occurs mostly in adults, dry eye may be induced in teens receiving allogeneic hematologic stem cell transplantations (AHSCT). Changes in meibum composition and structure has been associated with dry eye. The structure of meibum from teens with dye eye or teens with dry eye and AHSCT has not been studied, so in this study, we compared the structure of meibum from teens receiving AHSCT that had a dry eye with meibum from teens without AHSCT and without dry eye symptoms.

Differences in Meibum and Tear Lipid Composition and Conformation

PURPOSE

The compositional, structural, and functional relationships of meibum may provide insights into the loss of tear film stability. Although the conformation of meibum lipids has been studied rigorously, that of tear lipids has not.

METHODS

Tear lipids (TLHSCT) and meibum (MHSCT) from patients who had hematopoietic stem cell transplantation were pooled prospectively. The infrared spectra of meibum from donors with (MMGD) and without (Mn) meibomian gland dysfunction were retrospectively analyzed to measure the lipid composition and structure. The infrared CH stretching region was used to measure the relative content of CH3 and CH2 moieties in the meibum.

RESULTS

The 3 major findings of the current study are as follows: 1) compared with Mn, MHSCT and MMGD had 18% fewer CH3 moieties; 2) compared with MHSCT, the phase transition temperature, cooperativity, and order were approximately 20% greater for TLHSCT; and 3) compared with Mn and MMGD, MHSCT and TLHSCT contained fewer double bonds.

CONCLUSIONS

Tear lipids are more ordered than meibum lipids, which could have functional consequences. The human meibum peak height ratio of the CH3/CH2 bands is not a factor related to tear film stability with age or sex. The amount of CH3 moieties relative to CH2 moieties and saturation could contribute to a higher meibum lipid order associated with a younger age, meibomian gland dysfunction, and dry eye from hematopoietic stem cell transplantation. Therefore, the hydrocarbon order may be a marker of or contribute to an unstable tear film layer.

Human Meibum Cholesteryl and Wax Ester Variability With Age, Sex, and Meibomian Gland Dysfunction

Purpose

Relationships between tear film lipid (TFL) layer composition, structure, and function could provide insight into the etiology of dry eye. The molar ratio of cholesteryl ester (CE)/wax ester (WE) was measured in meibum from normal donors (M_n) and compared with meibum from donors with meibomian gland dysfunction (M_MGD).

Methods

CE/WE was measured using nuclear magnetic resonance spectroscopy.

Results

CE/WE was distributed into two populations with 81% distributed near 0.55 and 19% near 0.3. CE/WE were higher in donors 13 to 19 years old compared with donors 1 to 12 years old and 20 to 88 years old. CE/WE for M_MGD was 30% lower, 0.34 ± 0.04, compared with M_n, 0.49 ± 0.04. There were no sex differences in CE/WE. There were no significant racial differences between the CE/WE ratios for Asians and Caucasians. The CE/WE ratio was higher for blacks and lower for Hispanics compared to Caucasians. Due to the small number sampled, confirmation of the later racial results is needed. The packing of CE and WE in the TFL layer was proposed.

Conclusions

Although M_MGD contains much less CE than M_n, factors other than the CE content, such as the levels of saturation and/or proteins, may be responsible for the higher order of M_MGD. In addition to saturation, CE could contribute to the increase in order of M_n between 0 and 20 years of age. Observed changes in the meibum content of CE alone is not likely to influence tear film stability.

Surface-Modified Melphalan Nanoparticles for Intravitreal Chemotherapy of Retinoblastoma

Purpose

The goal of this work was to design and assess the ability of unmodified and surface-modified poly(lactic-co-glycolic acid) (PLGA) nanoparticles (NPs) to enhance cell association, provide efficacy in retinoblastoma cells, and overcome current administration challenges, including hydrolysis and precipitation, of intravitreal administration.

Methods

A single emulsion method was used to encapsulate Coumarin 6, to enable NP visualization via fluorescence microscopy. Melphalan NPs were synthesized using an adapted double-emulsion method to reduce melphalan loss during fabrication. Melphalan loading and release were quantified against a free melphalan standard. The cellular association and internalization of unmodified and surface-modified NPs were determined using flow cytometry, and the efficacy of melphalan NPs was quantified in retinoblastoma cells.

Results

The highest cell association was observed with TET1 and MPG-NPs after 24 hours administration; however, a significant fraction of NPs were associated with the cell surface, instead of undergoing internalization. MPG-NPs fabricated with the low saturation process were most efficacious, while all surface-modified NPs improved efficacy relative to unmodified NPs when formulated using the highly saturated process. Similar effects were observed as a function of NP dose, with TET1 and MPG-NPs particularly efficacious.

Conclusions

Surface-modified NPs achieved enhanced association and efficacy in retinoblastoma cells relative to unmodified NPs, with MPG and surface-modified NPs exhibiting the strongest efficacy relative to other NP groups. In future work we seek to assess the ability of these NPs to improve transport in the vitreous, where we expect a more dramatic impact on efficacy as a function of surface modification.

Treatment of Coats' disease: an analysis of pooled results

AIM

To elucidate the association of treatment modality to vitreoretinal fibrosis and traction retinal detachment (TRD) in Coats' disease.

METHODS

A PubMed search for Coats' disease with included studies describing eyes with clinical features and treatment course of Coats' disease. Binary logistic regression with fibrosis at presentation and treatment type as independent variables was performed to determine predictors of TRD historically (since 1921) and in the anti-vascular endothelial growth factor (VEGF) era (since 2007). Odds ratios (OR) with 95% confidence intervals (CI) reported.

RESULTS

Of 175 articles described 1183 eyes. Vitreoretinal fibrosis increased from presentation (5.4%) to follow-up (15.5%) and TRD increased from 0.44% to 3.9% at follow up. Laser was protective against vitreoretinal fibrosis (OR 0.6, 95%CI 0.4-0.9) but TRD was borderline (OR 0.6, 95%CI 0.3-1.1). Cryotherapy showed a higher association with TRD (OR 1.9, 95%CI 1.0-3.7) than with vitreoretinal fibrosis (OR 0.8, 95%CI 0.5-1.2). Similarly, intravitreal anti-VEGF alone was not associated with fibrosis (OR 1.1, 95%CI 0.6-1.8) nor TRD (OR 1.1, 95%CI 0.5-2.6) but the combination of laser and anti-VEGF therapy was protective [Fibrosis: 0.1 (0.03, 0.35); TRD: 0.05 (0.01, 0.23)] compared to anti-VEGF plus cryotherapy (P<0.001). Disease stage ≤2B or ≥3A was not associated with TRD.

CONCLUSION

Vitreoretinal fibrosis and TRD increase after treatment in Coats' disease. The combination of anti-VEGF agents and cryotherapy may lead to higher risk for TRD. Presence of pre-treatment fibrosis is the highest risk factor for post-treatment worsening of vitreoretinal fibrosis and TRD.

Early Detection of Radiation Retinopathy in Pediatric Patients Undergoing External Beam Radiation Using Optical Coherence Tomography Angiography

BACKGROUND AND OBJECTIVE

Detection of early vascular changes observed on optical coherence tomography angiography (OCTA) in children who have received external beam radiation and are at risk of developing radiation retinopathy (RR).

PATIENTS AND METHODS

Eleven pediatric patients (20 eyes) with history of irradiation and nine healthy subjects (14 eyes) were retrospectively studied after dilated fundus exam and imaging.

RESULTS

Four eyes of three patients had clinical RR. Eyes with radiation exposure but no RR had worse vision (no RR: logMAR 0.09 ± 0.14, Snellen 20/25) than controls (logMAR 0.01 ± 0.03, Snellen 20/21; P = .04) and increased superficial foveal avascular zone (FAZ) area (radiation: 0.31 ± 0.15 vs. control: 0.18 ± 0.10; P = .005). Eyes with RR had worse vision (RR: logMAR 0.34 ± 0.31, Snellen 20/44) than eyes with no RR (P = .001) and had increased deep FAZ (RR: 1.23 ± 0.40 vs. no RR: 0.68 ± 0.25; P = .01), but similar superficial FAZ (RR: 0.44 ± 0.28 vs. no RR: 0.31 ± 0.15; P = .42).

CONCLUSIONS

Eyes with mildly decreased vision but no RR show superficial but not deep plexus changes. Eyes with RR have both superficial and deep plexus changes. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:145-152.].

Insights into Tear Film Stability from Babies and Young Adults: A Study of Human Meibum Lipid Conformation and Rheology

Babies have the most stable tears and people with dry eye have the least stable tears. Meibum may contribute to tear film stability, so in this study, the hydrocarbon chain conformation and rheology of meibum from babies was studied for the first time. Infrared spectroscopy was used to measure lipid phase transitions. Rheology was measured using Langmuir film technology. Meibum from 25 donors 1 to 13 years old was compared with meibum from 18 donors 13 to 25 years old. The phase transition temperature and lipid order (stiffness) increased with increasing age from 1 to 25 years. The increase in meibum lipid order from 1 to 25 years of age may contribute to the instability of the tear film with age and contribute to films with a higher reciprocal compressibility modulus that are not as compressible and not as viscoelastic. Changes in the lipid phase transition parameters of meibum lipid with dry eye are an exacerbation of the changes observed with age. The lower reciprocal compressibility moduli of meibum films from children and babies compared with meibum from adults reiterates higher stability in their films which spread better, resist deformation, and facilitates their ability to be quickly restored after blinking.

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

Background

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

Methods

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

Results

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

Conclusion

This study corroborates prior literature that surgeons' exposure to radiation during plaque brachytherapy is minimal. Nonetheless, there remains some anxiety regarding exposure risk to women, due to potential effects on fertility and fetal health. We found variability in exposure monitoring, required training, and precautions during pregnancy amongst this group of surgeons. Improved education and clearer pregnancy guidelines may equip female ocular oncologists with optimal knowledge regarding risk of radiation exposure.

Human Meibum Age, Lipid-Lipid Interactions and Lipid Saturation in Meibum from Infants

Tear stability decreases with increasing age and the same signs of instability are exacerbated with dry eye. Meibum lipid compositional changes with age provide insights into the biomolecules responsible for tear film instability. Meibum was collected from 69 normal donors ranging in age from 0.6 to 68 years of age. Infrared spectroscopy was used to measure meibum lipid phase transition parameters. Nuclear magnetic resonance spectroscopy was used to measure lipid saturation. Increasing human meibum lipid hydrocarbon chain unsaturation with age was related to a decrease in hydrocarbon chain order, cooperativity, and in the phase transition temperature. The change in these parameters was most dramatic between 1 and 20 years of age. Meibum was catalytically saturated to determine the effect of saturation on meibum lipid phase transition parameters. Hydrocarbon chain saturation was directly related to lipid order, phase transition temperature, cooperativity, changes in enthalpy and entropy, and could account for the changes in the lipid phase transition parameters observed with age. Unsaturation could contribute to decreased tear film stability with age.

Ocular dysmotility after intra-arterial chemotherapy for retinoblastoma

We report the case of a 15-month-old boy with retinoblastoma who developed exotropia secondary to a right medial rectus infarct after intra-arterial chemotherapy. He had unilateral sporadic group C tumor (International Classification of Retinoblastoma) and was treated with intra-arterial melphalan. One week after the first session of intra-ophthalmic arterial melphalan chemotherapy, he was noted to have orbital congestion, exotropia, and right adduction limitation. Magnetic resonance imaging was suggestive of a right medial rectus infarct. The tumor showed a good response to intra-arterial chemotherapy but the exotropia persisted.

Utility of Head CT Scan for Acute Inpatient Delirium

 Delirium is a common occurrence in hospitalized patients, especially in the geriatric age group. Data was retrospectively reviewed for patients who developed delirium during hospitalization. Acute intracranial changes on imaging were noted only in four patients (11%) and all had preimaging clinical symptoms and signs, which warranted imaging. Imaging should be considered only in the presence of head injury, fall, history of anticoagulation, focal neurological signs, fever, and raised intracranial pressure. Development of more clear guidelines will result in decreased ordering of unnecessary neuroimaging, substantial cost savings, and less radiation exposure for patients.

Pediatric genetic ocular tumors

Pediatric genetic ocular tumors include malignancies like retinoblastoma and phakomatosis like neurofibromatosis, tuberous sclerosis, von Hippel-Lindau syndrome, and nevoid basal cell carcinoma syndrome. It is important to screen for ocular tumors both for visual prognosis and also for systemic implications. The phakomatosis comprise of multitude of benign tumors that are aysmptomatic but their detection can aid in the diagnosis of the syndrome. Retinoblastoma is the most common malignant intraocular tumor in childhood and with current treatment modalities, the survival is more than 95%. It is transmitted as an autosomal dominant fashion and hence the offsprings of all patients with the germline retinoblastoma need to be screened from birth. This review discusses the various pediatric genetic ocular tumors discussing the clinical manifestation, diagnosis and treatment.

Corneal endothelial cell characteristics after pediatric cataract surgery

PURPOSE

To describe the corneal endothelial cell characteristics after pediatric cataract surgery.

METHODS

Retrospective case series of 29 study eyes and 26 controls were evaluable. Specular microscopy was performed and endothelial cell features were correlated with clinical and surgical features.

RESULTS

Mean age at testing was 106 months in the study group and 116 months in the control group with a mean interval of 78 months after cataract surgery. Mean endothelial cell density in study eyes was 2,668 cells/mm(2) (control eyes, 3,002 cells/mm(2), P < .01). Mean coefficient of variation was 35% (control eyes, 31%, P < .01), and mean percentage of hexagonal cells was 40% (control eyes, 51%, P < .01). There was no significant difference based on age, duration since cataract surgery, contact lens use, glaucoma, number of intraocular procedures, or presence of intraocular lens.

CONCLUSIONS

This study demonstrates endothelial cell loss with polymegathism and pleomorphism in children undergoing cataract surgery. This poses a risk of developing long-term corneal complications and hence close monitoring of the endothelial cell count is advisable.