Anterior plaque brachytherapy placement for treatment of iris and iridociliary melanomas - surgical procedure and institutional experience

ABSTRACT

Surgical placement of eye plaque brachytherapy (EPB) is the standard of care for the treatment of uveal melanomas, including iris/iridociliary melanomas. However, unique challenges exist in anterior EPB placement. Here, we describe a surgical technique for anterior EPB placement when placement requires plaque positioning onto the cornea. Blunt conjunctival peritomy exposes the sclera overlying the tumor. A "dummy" plaque is placed, with positioning confirmed by direct visualization. The amniotic membrane is draped across the cornea and anchored with the eyelet sutures, the plaque is placed overlying the membrane, the conjunctiva is closed over the plaque, and a temporary tarsorrhaphy is performed. One week later, the conjunctival incision is reopened for plaque/amniotic membrane removal. This technique was employed in the treatment of 12 iris/iridociliary melanomas at our institution, with no instances of corneal damage. In placing an anterior plaque, employing this technique allows appropriate cancer treatment while optimizing patient comfort and corneal integrity.

Intraocular Spread of Ocular Surface Squamous Neoplasia Presenting as a Postoperative Anterior Chamber Opacity after Excisional Biopsy

We describe a rare case of ocular surface squamous neoplasia (OSSN) with intraocular spread after excisional biopsy which presented as a postoperative anterior chamber (A/C) opacity, initially thought to be a hypopyon. A 60-year-old female with history of a right (OD) conjunctival mass involving the cornea, surgically excised and diagnosed as OSSN, presented 2 months postoperatively with an A/C opacity concerning for infection. The patient was prescribed prednisolone acetate and ofloxacin drops postoperatively; topical chemotherapy was not given. When the opacity did not respond to 3 weeks of topical treatment, they were referred to an ocular oncologist for management. Intraoperative records from biopsy were unavailable; use of cryotherapy is unknown. On presentation, the patient had reduced vision OD. On slit-lamp exam, a white plaque in the A/C was seen, obscuring the iris. Given concern for postoperative intraocular cancer spread and extent of disease, enucleation with extended conjunctival excision was done. Gross pathology revealed an A/C mass with a diffuse hazy membrane. Histopathology diagnosed moderately differentiated OSSN with extensive intraocular invasion; a full-thickness limbal defect was visualized. Disease was confined to the globe, without residual conjunctival malignancy. This case emphasizes the importance of taking surgical precaution when excising conjunctival lesions, especially large lesions which obscure ocular anatomy, to maintain scleral integrity and Bowman's layer with limbal lesions. Intraoperative cryotherapy and postoperative chemotherapy should also be employed. If a patient with history of ocular surface malignancy displays symptoms concerning postoperative infection, this case highlights the importance of considering invasive disease.

The 100 Most Mentioned Glaucoma Articles Online With Highest Altmetric Attention Scores

PRCIS

Characteristics of the most mentioned glaucoma articles on the internet were analyzed, allowing a better understanding of the dissemination of glaucoma research to the general public.

PURPOSE

The aim was to determine the 100 most mentioned articles on the internet in the field of glaucoma and analyze their characteristics.

MATERIALS AND METHODS

We identified the top 100 glaucoma articles with the highest Altmetric Attention Score (AAS), an automatically calculated metric for monitoring social media. Each article was evaluated for several characteristics including year of publication, title, journal name, journal impact factor (IF), article topic, article type, affiliation, and online mentions (news, blog, policy, Twitter, Facebook, etc.). Correlation analysis was conducted for AAS with these characteristics.

RESULTS

The selected 100 articles came from 44 journals with more than half (56%) published in ophthalmology-specific journals. There was no significant correlation between IF and number of articles in a specific journal or AAS (P>0.1), but the number of articles in the top 100 was higher for ophthalmology journals with a higher IF (P<0.05). Original study was the most common study type (87%), of which clinical observation study was the most common subgroup (40%). Epidemiology/risk factor and basic science were the most common article topics (each 24%), followed by medical treatment (13%). Article topics regarding medical treatment had a significantly greater AAS than other topics (P<0.05). Of the top 5 articles, more than half (60%) were related to "Lifestyle choice" topics.

CONCLUSIONS

There was no association between journal IF and AAS, consistent with previous studies. 90% of journals that had articles in the top 100 had a Twitter page. "Lifestyle choice" activities and other modifiable risk factors attracted significant online attention regarding glaucoma studies, with two of the top three most mentioned articles related to dietary intake. The present study thus provides a better understanding of online engagement with glaucoma research and the dissemination of this research to the general public.

Dropped Nucleus during Cataract Surgery in South India: Incidence, Risk Factors, and Outcomes

Purpose: To determine incidence, risk factors for, and outcomes of dropped nucleus (DN) during cataract surgery.Methods: This is a matched case-control study at the Aravind Eye Hospital in Madurai, India. Out of 184 consecutive DN cases, 171 were included. The case immediately preceding the DN case by the same surgeon served as matched concurrent control. The proportion of cataract surgeries with DN was calculated with a 95% confidence interval (CI). Conditional logistic regression was used to generate odds ratios for potential risk factors.Results: Among 415,487 consecutive cataract surgeries, incidence risk of DN was 0.044% [95% CI 0.038%, 0.051%], or 0.44 per 1,000 surgeries in 52 months. Significant preoperative risk factors were posterior polar cataract (adjusted odds ratio [aOR] 21.73, p = .003); suspected loose zonules (aOR 8.85, p < .001); older age (aOR 1.57, p = .001); and presence of diabetes mellitus (aOR 1.79, p = .03). Associated intraoperative complications included zonular dialysis (OR 34.49, p < .001), vitreous disturbance (OR 193.36, p < .001), and posterior capsule rent (OR 384.39, p < .001). Phacoemulsification and manual small incision cataract surgery did not significantly differ in DN incidence. DN most commonly occurred during nucleus removal (35.1%) or during/immediately following hydrodissection (24.0%). Visual outcomes of DN were worse than controls on average, but 51.9% achieved visual acuity 20/40 or better at 1 month.Conclusions: DN occurred rarely, with low absolute risk even when a strong risk factor was present. Nearly all cases followed posterior capsular rent or zonular dialysis, usually with observed vitreous loss. In spite of increased risk of postoperative complications in the DN group, the majority achieved favorable results.

Malpractice Litigation in Glaucoma

PURPOSE

To analyze and report the causes and outcomes of malpractice litigation for patients with a diagnosis of glaucoma.

DESIGN

Retrospective case series.

PARTICIPANTS

Malpractice litigation cases.

METHODS

The WestLaw database was reviewed for all malpractice litigation with ophthalmologist defendants in the United States between 1930 and 2014. All litigation involving glaucoma was included in this analysis and was compared with litigation in ophthalmology as a whole.

MAIN OUTCOME MEASURES

The primary outcomes were the number of cases, jury award amounts, whether the case resolved in favor of the defendant, and the type of glaucomatous disease or procedure with the highest amount of litigation.

RESULTS

Sixty-nine glaucoma malpractice cases were included. Overall, 62.3% of cases were resolved in favor of defendants. Twenty-nine cases were resolved via jury trial, 8 of which were associated with plaintiff verdicts with a mean adjusted jury award of $994 260. Ten cases resulted in settlements with mean adjusted indemnity of $1 210 414. Commonly litigated allegations included mismanagement of glaucoma (20.3%), failure to diagnose glaucoma (17.4%), failure to diagnose or mismanagement of angle-closure glaucoma (18.5%), adverse drug effects (14.5%), and trabeculectomy complications (8.7%). Overall, the median plaintiff award for all of glaucoma litigation was $977 476; the median award across all ophthalmic subspecialties was $568 302 (P = 0.25). For jury verdicts alone, the median award in glaucoma was $977 474, compared with $604 352 for all ophthalmology (P = 0.05). For settlements alone, the median indemnity payment in glaucoma was $955 988, compared with $827 051 for all ophthalmology (P = 0.24).

CONCLUSIONS

Overall, the rate of plaintiff verdicts was similar in glaucoma and in ophthalmology as a whole; however, the magnitude of plaintiff awards was higher in glaucoma than in ophthalmology overall. Common scenarios leading to litigation included failure to diagnose or mismanagement of glaucomatous disease, as well as adverse drug effects and surgical complications. Many cases could have been avoided with careful examinations, thorough documentation in the patients' charts, and detailed conversations with patients.

Malpractice Litigation in Ophthalmic Trauma

Objective

To report and analyze the causes and outcomes of malpractice litigation in ophthalmic trauma.

Methods

The Westlaw^® database was reviewed for ophthalmology litigation in the United States between 1930 and 2014. All ophthalmic trauma cases were included and compared to non-traumatic ophthalmology malpractice cases.

Results

Forty-four ophthalmic trauma cases were included. Of these cases, 90.9% of ophthalmic trauma plaintiffs were male compared to 54.8% of plaintiffs in ophthalmology as a whole (P=<0.001); 34.1% of cases involved minor plaintiffs compared to 6.4% in ophthalmology as a whole (P=<0.001). Cases involving minors were more likely to be resolved in favor of the plaintiff than cases involving adult plaintiffs (53.3% vs 37.9%); however, this was not found to statistically significant (P=0.35). Overall, 54.5% of cases were resolved in favor of defendants; 40.9% of cases were resolved via jury trial with 50.0% resulting in payments to plaintiffs compared to the 29.6% rate of plaintiff verdicts in ophthalmology as a whole. Open globe injuries represented 61.4% of cases; 55.6% of these cases had intraocular foreign bodies and 37.0% developed endophthalmitis. Most cases (63.6%) alleged insufficient intervention. Of these cases, 31.8% of cases involved surgical or procedural claims, and 4.5% involved medical claims only.

Conclusion

Males and minors were overrepresented among plaintiffs in ocular trauma litigation. Most cases involved open globe injuries, often complicated by retained intraocular foreign bodies and endophthalmitis. Analysis of malpractice litigation in ophthalmic trauma calls attention to commonly litigated scenarios to improve clinical practice and to inform risk management.

Malpractice Litigation in Vitreoretinal Surgery and Medical Retina

BACKGROUND AND OBJECTIVE

To report and analyze the causes and outcomes of vitreoretinal surgery and medical retina malpractice litigation.

PATIENTS AND METHODS

The WestLaw database was reviewed for all vitreoretinal malpractice litigation in the United States between 1930 and 2014.

RESULTS

One hundred forty-two retina cases were included. Overall, 64.1% of cases were resolved in favor of defendants. Eighty-three (58.5%) cases were resolved via jury trial, 30.1% of which were associated with plaintiff verdicts with mean adjusted jury award of $5,222,894 (median, $691,974). Eight cases (5.6%) resulted in settlements with mean adjusted indemnity of $726,003 (median: $437,165). Jury awards were higher than settlement awards (P = .04). Commonly litigated scenarios included retinal detachment (46.5%) and retinopathy of prematurity (9.2%).

CONCLUSIONS

The complexity of treating vitreoretinal problems and the high potential for vision loss inherent in many diagnoses make treating retinal problems high-risk. Many cases in this series resulted in multi-million-dollar plaintiff awards. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:272-278.].

Malpractice Litigation in Ocular Oncology

Aims

The aim of this study was to report and analyze the causes and outcomes of ocular oncology malpractice litigation.

Methods

The WestLaw® database was reviewed for all litigation related to ophthalmology in the United States from 1930 to 2014. All ocular oncology cases were included in this analysis and compared to other ophthalmic subspecialties.

Results

Sixteen ocular oncology malpractice cases were included in this study. Overall, 56.3% of the cases were resolved in favor of the defendant. A total of 62.5% of cases were resolved via jury verdict, with 30.0% resulting in plaintiff verdicts with mean adjusted awards of USD 511,244.48, comparable to ophthalmology as a whole. Three cases (18.8%) resulted in settlements with mean adjusted indemnities of USD 828,928.14. A total of 87.5% of cases alleged insufficient intervention resulting in loss of vision and/or death. The most common clinical entities were uveal melanoma (31.3%), retinoblastoma (12.5%), and sebaceous cell carcinoma (12.5%).

Conclusions

Ocular oncology malpractice litigation was relatively rare and outcomes generally favored defendants; however, unlike other subspecialties in ophthalmology, blindness or premature death were common to all cases, highlighting both the importance of prompt diagnosis and treatment and the difficulty inherent in diagnosing ocular malignancies.

Medical Malpractice in Uveitis: A Review of Clinical Entities and Outcomes

PURPOSE

To guide risk management in uveitis.

METHODS

Retrospective review of malpractice verdicts, rulings, and settlements.

RESULTS

The WestLaw® database was reviewed for lawsuits related to uveitis in the United States from 1930-2014. Twenty-five cases met inclusion criteria, and 48% of these were infectious. Overall, 64% of outcomes favored the defendant ophthalmologist. The most common diagnoses were viral retinitis (28%), iritis (12%), syphilis (8%), and toxoplasmosis (8%). Seven suits (28%) were resolved by settlement, with mean adjusted indemnities of $724,302 (median, $409,390; range, $127,837-2,021,887). Two cases (8%) resulted in plaintiff verdict, with adjusted awards of $1,399,800 and $630,799.

CONCLUSIONS

Despite being a rare diagnosis, viral retinitis (especially acute retinal necrosis) is the most common clinical entity associated with litigation in uveitis and should be considered early. Educating patients about potential adverse events, early testing for syphilis, and maintaining a positive relationship may also minimize risk.

Ocular hypertension and hypotony as determinates of outcomes in uveitis

Purpose

To assess ocular hypertension (OHT) and hypotony as outcomes of uveitis in patients managed in a mid-Atlantic tertiary care center.

Methods

Retrospective, observational study of uveitis patients seen at the University of Virginia from 1984 to 2014.

Results

A total of 442 patients (582 eyes) with uveitis were identified and included in the study. The patient population was 57.0% female. Overall, 61.9% were Caucasian and 26.6% were African American. Mean age was 46.8 years. Overall, 11.5% of the eyes had OHT at initial visit, and 7.9% had OHT at final visit (P=0.035). For each additional decade of life, the odds that an eye had OHT were elevated by a factor of 1.15 (95% confidence interval [CI]: [1.02, 1.30], P=0.027) at initial visit and by a factor of 1.15 (95% CI: [1.00, 1.32], P=0.055) at final visit. The odds that an anterior uveitis eye had OHT were greater by a factor of 2.50 (95% CI: [1.22, 5.14], P=0.013) than the odds for a nonanterior uveitis eye at initial visit and greater by a factor of 2.61 (95% CI: [1.24, 5.50], P=0.011) at final visit. For each additional 0.5 logarithm of the minimum angle of resolution increase in initial visual acuity, the odds that an affected eye had OHT were elevated by a factor of 1.18 (95% CI: [1.00, 1.39], P=0.047) at initial visit and 1.23 (95% CI: [0.99, 1.54], P=0.065) at final visit. Overall, 21 of 582 eyes (3.6%) were hypotonous initially, while 24 of 582 eyes (4.1%) were hypotonous at final follow-up (P=0.631).

Conclusion

OHT was associated with increasing age, anterior uveitis, and poor presenting visual acuity. Ocular hypotony was more common in anterior uveitis than in nonanterior uveitis. Fluctuations in intraocular pressure are an important cause of visual impairment in patients with uveitis. Careful monitoring of all uveitis patients, and especially those most at risk for fluctuations in intraocular pressure, can preserve vision and improve patient outcomes.

Traumatic uveitis in the mid-Atlantic United States

Purpose

The purpose of this study was to conduct an in-depth analysis of traumatic uveitis in patients managed in a mid-Atlantic tertiary care center with the goal of better characterizing the clinical features and outcomes of this large and important subset of uveitis patients.

Methods

This was a retrospective, observational study comparing traumatic uveitis patients with nontraumatic uveitis patients seen at the University of Virginia, Charlottesville, VA, USA, from 1984 to 2014.

Results

Fifty-four traumatic uveitis patients (55 eyes) were identified. The patient population was 70.4% male, 57.4% Caucasian, and 37.0% African American. Mean age at diagnosis was 31.2 years; mean duration of follow-up was 5.4 years; and mean number of visits to the clinic was 4. The most common treatment modality was local steroids (77.8%). Glaucoma was medically managed in eight patients (14.8%). Cataract surgery was performed in five patients (9.3%). Mean best-corrected visual acuity at baseline for traumatic uveitis patients was 0.33 logMAR (SD 0.42) at the initial visit and 0.16 logMAR (SD 0.33) at the final visit. Mean baseline intraocular pressure (IOP) in the traumatic uveitis group was 15.5 mmHg (SD 7.4) at the initial visit and 14.6 mmHg (SD 4.0) at the final visit. Patients in the traumatic uveitis cohort tended to have better visual outcomes than those in the nontraumatic uveitis cohort.

Conclusion

In our series, traumatic uveitis patients tended to be young and male and present with unilateral disease, all findings consistent with other reports. Despite relatively good visual outcomes, the traumatic uveitis patients still experienced a high burden of disease, measured both in the number of clinic visits and duration of follow-up. Due to the young mean age of patients, these disease burdens and decreased quality of life are nontrivial, emphasizing the importance of careful management and prompt treatment of this subset of uveitis patients.

Infectious uveitis in Virginia

PURPOSE

To report the causes, clinical features, and outcomes of infectious uveitis in patients managed in a mid-Atlantic tertiary care center.

METHODS

Retrospective, observational study of infectious uveitis patients seen at the University of Virginia from 1984 to 2014.

RESULTS

Seventy-seven of 491 patients (15.7%) were diagnosed with infectious uveitis (mean age 58 years, 71.4% female, 76.6% Caucasian). The mean follow-up was 5 years. Anterior uveitis was the most common anatomic classification (39 patients, 50.6%) followed by panuveitis (20 patients, 26.0%) and posterior uveitis (18 patients, 23.4%). The most common infectious etiology was herpetic anterior uveitis (37 patients, 48.1%) followed by toxoplasma uveitis (14 patients, 18.2%). The most prevalent viral pathogen was varicella-zoster virus (21 patients, 27.3%) followed by herpes simplex virus (20 patients, 26.0%). Acute retinal necrosis (ARN) was diagnosed in 14 patients (18.2%). Aqueous humor yielded an etiologic diagnosis in seven (50%) of ARN patients, four of whom tested positive for cytomegalovirus and three for varicella-zoster virus. On presentation, 43 patients (55.8%) had a visual acuity (VA) better than 20/40 and 17 (22.1%) had a VA worse than 20/200. VA at the final follow-up was better than 20/40 in 39 patients (50.6%) and worse than 20/200 in 22 patients (28.6%). In all, 16 (20.8%) and 10 (13.0%) patients required cataract and vitrectomy surgery, respectively. A total of 14 patients (18.2%) were on glaucoma topical treatment and four (5.2%) required glaucoma surgery.

CONCLUSION

The most common type of infectious uveitis seen over the study period was herpetic anterior uveitis secondary to varicella-zoster virus or herpes simplex virus, found to be most prevalent in patients over 60 years of age. This finding is comparable to other American epidemiologic studies. Ocular toxoplasmosis and ARN were also common causes of infectious uveitis. In all, 50.6% of patients had a VA better than 20/40 at the final follow-up visit, indicating the importance of prompt referral and appropriate treatment.

Intermediate uveitis, posterior uveitis, and panuveitis in the Mid-Atlantic USA

BACKGROUND

The purpose of this study was to identify the causes, clinical features, and outcomes of intermediate uveitis, posterior uveitis, and panuveitis in patients managed in a mid-Atlantic tertiary care center.

METHODS

This was a retrospective observational study of intermediate uveitis, posterior uveitis, and panuveitis patients seen at the University of Virginia from 1984 to 2014.

RESULTS

One hundred and fifty-nine intermediate uveitis, posterior uveitis, and panuveitis patients (237 eyes) were identified. The patient population was 54.72% female; 67.30% of patients were Caucasian, and 22.01% were African-American. Mean age at diagnosis was 45.5 years. Mean duration of follow-up was 3.95 years. Mean number of visits to the clinic was 10.35. Of 491 uveitis patients, 26 (5.30%) had intermediate uveitis, 62 (12.60%) had posterior uveitis, and 71 (14.50%) had panuveitis. The leading diagnoses in the intermediate uveitis group were pars planitis (73.08%) and sarcoidosis (11.54%); toxoplasma uveitis (17.74%), multifocal choroiditis (14.52%), undifferentiated posterior uveitis (14.52%), and birdshot chorioretinitis (11.29%) in the posterior uveitis group; and undifferentiated panuveitis (29.58%), post-surgical panuveitis (18.31%), sarcoidosis (12.68%), acute retinal necrosis (12.68%), and toxoplasma uveitis (4.23%) in the panuveitis group. The most common treatment modalities included local steroids (57.23%) and systemic steroids (42.14%). Ocular hypertension was found in 38 patients (23.90%). Glaucoma surgery was performed in 18.24% of patients and cataract surgery in 21.38%. Mean best-corrected visual acuity was 0.66 logMAR at baseline across all anatomical locations and 0.57 logMAR at final follow-up. Best-corrected visual acuity improved or remained stable during follow-up in all groups.

CONCLUSION

The most common diagnoses in our series by anatomical location were pars planitis (intermediate uveitis), toxoplasmosis (posterior uveitis), and undifferentiated uveitis (panuveitis). Panuveitis had significantly worse visual outcomes and higher rates of complications than did intermediate or posterior uveitis, a finding that confirms earlier reports. In this series, unilateral disease, regardless of anatomical location, was associated with poorer visual outcome, in contrast with the findings of other reports.

Causes of uveitis in children without juvenile idiopathic arthritis

BACKGROUND

The purpose of this study was to report the demographics, disease characteristics, treatments, and visual outcomes of pediatric uveitis patients without juvenile idiopathic arthritis managed in a tertiary medical center.

METHODS

A retrospective, observational study was performed in pediatric uveitis patients without juvenile idiopathic arthritis and aged 0-18 years, who were seen at the University of Virginia from 1984 to 2014.

RESULTS

Thirty-nine pediatric uveitis patients (57 eyes) were identified. The patient population was 51.28% female, 51.28% Caucasian, and 33.33% African American. The mean age at diagnosis was 11.9 years. The mean duration of follow-up was 3.11 years. The mean number of visits to the clinic was 10.41. Of 57 eyes, 31 (54.39%) had anterior uveitis, 12 (21.05%) had intermediate uveitis, nine (15.79%) had posterior uveitis, and five (8.77%) had panuveitis. The leading diagnoses were traumatic uveitis (25.64%), undifferentiated anterior uveitis (17.95%), undifferentiated intermediate uveitis (15.38%), HLA-B27-associated anterior uveitis (7.69%), and herpetic anterior uveitis (7.69%). Systemic associations included sarcoidosis, ulcerative colitis, and psoriatic arthritis (n=3). The most common treatment modalities included local steroids (66.67%), systemic steroids (23.08%), and antimetabolites (20.51%). Ocular hypertension was found in five (12.82%) patients. Ocular surgery was performed in six (15.38%) patients. Mean best-corrected visual acuity (BCVA) at baseline across all anatomical locations was 0.458 logMAR, and was 0.411 logMAR at final follow-up. Mean BCVA improved during follow-up in all but the anterior uveitis group. The mean baseline intraocular pressure was 14.27 mmHg, and was 14.22 mmHg at final follow-up.

CONCLUSION

Uveitis in childhood is a vision-threatening group of inflammatory disorders arising from numerous etiologies that vary geographically and historically. Because of the high burden of disease, the difficulty of making precise etiologic diagnoses, and the complicated management, it is imperative that affected children be referred to and closely monitored by uveitis specialists to prevent devastating ocular damage. This study found that BCVA and intraocular pressure did not vary significantly during follow-up, suggesting that close management by an ophthalmologist may prevent adverse visual outcomes, and highlighted the high prevalence of traumatic uveitis in children, which tends to have good visual outcomes.