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.

Ocular surface squamous neoplasia in Northern Thailand: a 16-year review

Purpose

To evaluate clinical characteristics, treatments, and outcomes in patients with ocular surface squamous neoplasia (OSSN) at a tertiary center in Northern Thailand.

Methods

Patients diagnosed with either corneal-conjunctival intraepithelial neoplasia (CIN) or squamous cell carcinoma (SCC) from May 2000 to December 2015, were recruited. The patients’ demographics, symptoms, clinical characteristics, cytopathology, treatments, and outcomes were reviewed.

Results

Overall 171 eyes from 168 patients, 92 eyes were CIN and 79 eyes were SCC. Males were affected in 65.5%. The mean age was 58.8 ± 16.8 (29–99) years. In most cases (60.3%), the tumors were located at the limbus. The most common clinical characteristic was papilliform appearance (46.2%). Human immunodeficiency virus (HIV) infection was found in 37 (22.0%) patients with a mean age of 40.5 ± 7.7 years. The treatments and outcomes were evaluated in 136 eyes whose main initial treatment was wide excision with adjunctive cryotherapy (47.8%), followed by topical mitomycin C (30.9%). The mean follow-up time after treatment was 20.8 ± 2.2 (3–110) months and the recurrence occurred in 18 eyes (13.2%) during the follow-up period. The mean recurrence-free time (months) for CIN was significantly longer than that of SCC (81.3 ± 10.0 [95%CI 61.5 – 101.1] vs 33.2 ± 4.6 [95%CI 24.0 – 42.3], p = 0.030). SCC was the only significant risk factor that influences the recurrence of the tumors with the adjusted hazard ratio of 5.69 (p = 0.005).

Conclusion

OSSN in Northern Thailand usually involved a limbal area and presented as a papilliform mass. HIV infection should be suspected in young patients. CIN had better outcomes after treatments than invasive SCC.

Accuracy of Computed Tomography and Magnetic Resonance Imaging for Detection of Pathologic Risk Factors in Patients Diagnosed with Retinoblastoma

Aim: To assess and compare the diagnostic accuracy of magnetic resonance imaging (MRI) and computed tomography (CT) for detecting the extent of tumor invasion in eyes with advanced retinoblastoma prior to enucleation using histopathologic analysis as a reference.Methods: A total of 56 patients (68 eyes) enucleated for retinoblastoma were reviewed. Eyes with complete data (CT 28, MRI 16) were included for analysis. Imaging data were reviewed by a pediatric radiologist, blinded to histopathology results. Four high-risk factors which included scleral, choroidal, anterior eye segment invasion, and postlaminar optic nerve invasion were assessed.Results: For CT, the diagnostic odds ratio (DOR), sensitivity, and specificity for detecting postlaminar optic nerve invasion were 1.7%, 25%, and 83.3%. Choroidal invasion was correctly identified in only 2 of 10 eyes (DOR 0.5, sensitivity 20%, specificity 66.7%). For scleral invasion, CT showed a diagnostic ratio of 1.5%, sensitivity 40%, specificity 69.6% whereas for anterior segment invasion DOR was 9.2%, sensitivity 100%, and specificity 65.4%. MRI showed a higher DOR for detecting postlaminar optic nerve invasion of 39%, sensitivity 77.8%, and specificity 100%. Choroidal and scleral invasion on MRI had a DOR of 6.5% (sensitivity 25%, specificity 100%) and 6% (sensitivity 33.3%, specificity 92.3%) respectively while DOR for anterior segment invasion was 1.3% (sensitivity 50%, specificity 57.1%).Conclusion: CT showed a poor diagnostic accuracy for all four high-risk factors in advanced retinoblastoma and therefore may not be a useful tool for assessment of tumor extension. For MRI, detection of postlaminar optic nerve invasion was moderately accurate although less accurate for detection of other risk factors. Decision-making for each child should not be based on any single parameter but rather on consideration of clinical factors in combination with radiologic findings.

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.

Development and psychometric properties of the Thai Graves' ophthalmopathy quality of life (GO-QOL) questionnaire

Purpose

To develop and assess the psychometric properties of the Thai version of the Graves’ Ophthalmopathy Quality of Life (GO-QOL) questionnaire.

Background

Graves’ ophthalmopathy (GO) is a chronic condition that causes negative self-image and impaired visual function. These conditions impact quality of life (QOL) but are rarely documented. Graves’ Ophthalmopathy Quality of Life Questionnaire (GO-QOL) has good validity, reliability and responsiveness. In this study we developed a Thai GO-QOL questionnaire by translating the questionnaire from English to the Thai language and evaluated its reliability and validity.

Patients and methods

Forward and backward translations were performed independently by four translators with extensive experience in both English and Thai. Seventy patients at the thyroid clinic responded to the Thai translated version upon their first visit and again 2–3 weeks afterwards. Validity was assessed by the content validity index (CVI) and correlation with relevant clinical parameters. Reliability was evaluated by Cronbach’s alpha, the intraclass correlation coefficient, and the Bland-Altman plot.

Results

The Thai GO-QOL version showed high CVI (0.97) and a moderate negative correlation of the functional QOL score with disease severity (r = − 0.49), the clinical activity score (r = − 0.31), and exposure parameter (r = − 0.32). It showed good reliability with a high intraclass correlation coefficient (0.92) and high Cronbach’ s coefficient (0.86).

Conclusion

The Thai GO-QOL has good validity and reliability. It can be used to evaluate the quality of life of Graves’ ophthalmopathy patients as a consequence of their disease in thyroid treatment programs.

Clinical presentation and treatment outcomes of primary ocular adnexal MALT lymphoma in Thailand

Background

Primary ocular adnexal extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (POML) is the most common subtype of lymphoma involving the eyes in Thailand. We sought to assess the characteristics and treatment outcomes of patients with POML in Thailand.

Methods

We retrospectively reviewed patient data and included patients diagnosed with POML between January 2004 and December 2016 at Chiang Mai University Hospital and King Chulalongkorn Memorial Hospital, Thailand. We collected and analyzed patients' clinical characteristics and treatment outcomes.

Results

Among 146 patients with lymphoma involving the eyes, 121 (82%) were diagnosed with POML. Sixty-four (52.9%) were women with median age 58 (range, 22–86) years. The most common presenting symptom was orbital mass (71.1%). Common sites of origin were the orbit (46.3%) and lacrimal gland (34.7%). At presentation, 22.3% of patients had bilateral eye involvement. About half of patients had stage I disease (N=59, 56.2%) and 20% had stage IV. Most patients (73.3%) had a low-risk International Prognostic Index. Radiotherapy was the main treatment for patients with limited-stage disease (66.7% in stage I and 56.5% in stage II). The overall response rate was 100% with complete response rates 80%, 77.3%, and 64.7% for stages I, II, and IV, respectively. Five-year progression-free survival (PFS) and overall survival were 66.1% and 94.0%, respectively. For patients with limited-stage disease, radiotherapy significantly improved PFS compared with treatment not involving radiotherapy (5-year PFS 89.9% vs. 37.3%, P=0.01).

Conclusion

We revealed that POML has good response to treatment, especially radiotherapy, with excellent long-term outcome.

Incidence of short-term complications and associated factors after primary trabeculectomy in Chiang Mai University Hospital

BACKGROUND

To determine the incidence of early postoperative complications and associated factors after primary trabeculectomy in Thai glaucoma patients.

DESIGN

This was a retrospective observational study performed in Chiang Mai University Hospital.

PARTICIPANTS

One hundred and eighteen glaucoma patients participated in the study.

METHODS

All glaucoma patients underwent primary trabeculectomy with mitomycin C (MMC) using fornix-based conjunctival flap technique between December 2011 and May 2013. Surgical complications during the first 3 months of follow-up were recorded, and associated risk factors were analyzed.

MAIN OUTCOME MEASURES

The incidence of posttrabeculectomy complications was the main outcome measure.

RESULTS

One hundred and eighteen eyes of 118 patients were included. Early postoperative complications developed in 55 eyes (56.7%). Complications included hypotony (25 eyes, 27.2%), serous choroidal detachment (CD) (14 eyes, 15.6%), subconjunctival hemorrhage (12 eyes, 13.0%), hyphema (11 eyes, 12.4%), bleb leak (8 eyes, 8.8%), encapsulated bleb (2 eyes, 2.2%), aqueous misdirection (1 eyes, 1.1%), corneal epithelial defect (1 eyes, 1.1%), and overfiltration (1 eyes, 1.1%). There were no reported cases of endophthalmitis or blebitis. Hypotony was associated with serous CD (P = 0.006), and hyphema was associated with neovascular glaucoma (NVG) patients (P = 0.009). NVG was not associated with the increased rate of surgical failure (P = 0.083).

CONCLUSIONS

The incidence of early complications after first-time trabeculectomy with MMC was high (56.7%) in this Thai clinic setting, but most were transient and self-limited conditions. The correlations between hypotony and CD as well as hyphema and NVG were compatible with the previous studies.

The effect of music with and without binaural beat audio on operative anxiety in patients undergoing cataract surgery: a randomized controlled trial

PurposeTo investigate the anxiolytic effects of binaural beat embedded audio in patients undergoing cataract surgery under local anesthesia.MethodsThis prospective RCT included 141 patients undergoing cataract surgery under local anesthesia. The patients were randomized into three groups; the Binaural beat music group (BB), the plain music intervention group (MI), and a control group (ear phones with no music). Blood pressure (BP) and heart rate were measured on admission, at the beginning of and 20 min after the start of the operation. Peri-operative anxiety level was assessed using the State-Trait Anxiety Inventory questionnaire (STAI).ResultsThe BB and MI groups comprised 44 patients each and the control group 47. Patients in the MI group and BB group showed significant reduction of STAI state scores after music intervention compared with the control group (P<0.001) but the difference was not significant between the MI and BB group (STAI-S score MI group -7.0, BB group -9.0, P=0.085). Systolic BP was significantly lower in both MI (P=0.043) and BB (0.040) groups although there was no difference between the two groups (P=1.000). A significant reduction in heart rate was seen only in the BB group (BB vs control P=0.004, BB vs MI P=0.050, MI vs control P=0.303).ConclusionMusic, both with and without binaural beat, was proven to decrease anxiety level and lower systolic BP. Patients who received binaural beat audio showed additional decrease in heart rate. Binaural beat embedded musical intervention may have benefit over musical intervention alone in decreasing operative anxiety.

Histopathological diagnosis of eyelid tumors in Chiang Mai University Hospital

OBJECTIVE

To report the histopathological diagnosis ofeyelid tumors and to study the prevalence of eyelid tumors in Chiang Mai University Hospital Chiang Mai, Thailand.

MATERIAL AND METHOD

A retrospective review of medical and pathological records ofpatients diagnosed as eyelid tumor that underwent histopathological biopsy between January 2007 and December 2013 in Chiang Mai University Hospital was done.

RESULTS

Three hundred sixteen cases of eyelid tumors were reviewed. The mean age at diagnosis was 54.2 +/- 19.6 years (range 1 month-99 years), women were 59.5% (n = 188) and men 40.5% (n = 128). The tumor sites were left lower eyelid (27.5%), right upper eyelid (24.4%), right lower eyelid (21.2%), and left upper eyelid (18.7%). There were 204 (64.6%) benign tumors and 112 (35.4%) malignant tumors. Nevi were the most common in benign group (16.4%) and basal cell carcinoma was the most common eyelid malignancy (18.0%).

CONCLUSION

The most common histopathological diagnosis for benign eyelid tumor was nevus, while the most common malignant eyelid tumor was basal cell carcinoma at Chiang Mai University Hospital.

Cutis laxa with pulmonary emphysema, conjunctivochalasis, nasolacrimal duct obstruction, abnormal hair, and a novel FBLN5 mutation

We report on a 4-year-old girl with autosomal recessive cutis laxa, type IA, or pulmonary emphysema type (ARCL1A; OMIM #219100), with loose and wrinkled skin, mitral and tricuspid valve prolapse, conjunctivochalasis, obstructed nasolacrimal ducts, hypoplastic maxilla, and early childhood-onset pulmonary emphysema. Mutation analysis of FBLN5 showed a homozygous c.432C>G missense mutation, and heterozygosity in the parents. This is predicted to cause amino acid substitution p.Cys144Trp. Conjunctivochalasis or redundant folds of conjunctiva and obstructed nasolacrimal ducts have not been reported to be associated with FBLN5 mutations. Histopathological study of the conjunctival biopsy showed that most blood vessels had normal elastic fibers. The gingiva appeared normal, but histologically elastic fibers were defective. Scanning electron micrography of scalp hair demonstrated hypoplastic hair follicles. The cuticles appear intact underneath the filamentous meshwork.

A survey of pterygium surgery in Thailand 2010

OBJECTIVE

To survey and investigate the pterygium surgery among Thai ophthalmologists in 2010.

MATERIAL AND METHOD

Questionnaires were distributed to 930 ophthalmologists who were the member of the Ophthalmological Society and Royal Colleges of Ophthalmologists of Thailand. Data received from 414 respondents were assessed and analyzed

RESULTS

The majority of respondents were male (53.1%) while 46.9 % were female. Visual disturbance (57.6%) was the most common indication for surgery. Most of the respondents (41.1%) preferred pterygium excision combined with conjunctival autograft transplantation. Bare scleral technique was the second most common preferential procedure. Recurrence was the main postoperative complication.

CONCLUSION

Although there was a great variation pterygium surgical pattern, excision with conjunctival autograft transplantation was the major preferential practice. Recurrent pterygium was the most common complication.

Management of optic neuropathy from an apical orbital-cavernous sinus hemangioma with radiotherapy

We document a case of reversal of compressive optic neuropathy caused by a cavernous sinus-orbital cavernous hemangioma following treatment by conformal stereotactic radiotherapy.