Extrascleral Extension of Uveal Melanoma Along Intravitreal Needle Tracts Associated With Periodic Anti-Vascular Endothelial Growth Factor Therapy for Neovascular Age-Related Macular Degeneration

This case report describes a 94-year-old man who was seen for evaluation of a left choroidal mass after receiving periodic anti–vascular endothelial growth factor (anti-VEGF) therapy for neovascular age-related macular degeneration.

A Systematic Comparison of Dose Distributions Delivered in 125I Plaque Brachytherapy and Proton Radiation Therapy for Ocular Melanoma

PURPOSE

To characterize dose distributions with ¹²⁵I plaque brachytherapy compared with proton radiation therapy for ocular melanoma for relevant clinical scenarios, based on tumor base diameter (d), apical height (h), and location.

METHODS AND MATERIALS

Plaque and proton treatment plans were created for 4 groups of cases: (1) REF: 39 instances of reference midsize circular-base tumor (d = 12 mm, h = 5 mm), in locations varying by retinal clock hours and distance to fovea, optic disc, and corneal limbus; (2) SUP: 25 superiorly located; (3) TEMP: 25 temporal; and (4) NAS: 25 nasally located tumors that were a fixed distance from the fovea but varying in d (6-18 mm) and h (3-11 mm). For both modalities, 111 unique scenarios were characterized in terms of the distance to points of interest, doses delivered to fovea, optic disc, optic nerve at 3 mm posterior to the disc (ON@3mm), lens, and retina. Comparative statistical evaluation was performed with the Mann-Whitney U test.

RESULTS

Superior dose distributions favored plaque for sparing of (1) fovea in large (d + h ≥ 21 mm) NAS tumors; (2) ON@3mm in REF cases located ≤4 disc diameters from disc, and in NAS overall. Protons achieved superior dose sparing of (1) fovea and optic disc in REF, SUP, and TEMP; (2) ON@3mm in REF >4 disc diameters from disc, and in SUP and TEMP; and (3) the lens center overall and lens periphery in REF ≤6 mm from the corneal limbus, and in TEMP with h = 3 mm. Although protons could completely spare sections of the retina, plaque dose was more target conformal in the high-dose range (50% and 90% of prescription dose).

CONCLUSIONS

Although comparison between plaque and proton therapy is not straightforward because of the disparity in dose rate, prescriptions, applicators, and delivery techniques, it is possible to identify distinctions between dose distributions, which could help inform decisions by providers and patients.

A Comparison of Treatment Outcomes after Standard Dose (70 Gy) versus Reduced Dose (50 Gy) Proton Radiation in Patients with Uveal Melanoma

OBJECTIVE

To compare outcomes in a large patient cohort with small-medium tumors located within 1 disc diameter (DD) of the optic nerve and/or fovea treated with 50 Gy or 70 Gy proton therapy.

DESIGN

Retrospective cohort study.

SUBJECTS

A total of 1120 patients with uveal melanomas ≤ 15 mm in largest basal diameter, ≤ 5 mm in height, located within 1 DD of the optic nerve and/or fovea, who received primary treatment with protons between 1975 and 2016 at Massachusetts Eye and Ear/Massachusetts General Hospital.

METHODS

The rates of outcomes were estimated using the Kaplan-Meier method. Differences between the radiation dose groups were tested using the log-rank test.

MAIN OUTCOME MEASURES

Local tumor recurrence, melanoma-related mortality, and visual acuity preservation (≥ 20/200, ≥ 20/40).

RESULTS

Local tumor recurrence was observed in 1.8% of the 50 Gy group and 1.5% of the 70 Gy group. The median time to recurrence was 30.7 months for patients treated with 50 Gy and 32.0 months for those treated with 70 Gy (P = 0.28). Five-year rates of vision retention (≥20/40, ≥ 20/200) were 19.4% and 49.3% for patients treated with 50 Gy and 16.4% and 40.7% in those treated with 70 Gy. Ten-year rates of melanoma-related mortality were 8.4% in the 50 Gy group and 8.9% in the 70 Gy group (P = 0.47).

CONCLUSIONS

Comparable rates of local control are achieved treating small-medium tumors near the optic nerve and/or fovea with 50 Gy or 70 Gy proton therapy, supporting the use of the lower dose in patients with these tumor characteristics.

The Effect of Sample Medication Use on Subsequent Anti-VEGF Agent Selection for Neovascular Age-Related Macular Degeneration

PURPOSE

Medication samples of anti-VEGF agents can represent a good option for retina specialists to provide timely treatment for newly converted neovascular age-related macular degeneration (nvAMD) while prior-authorizations (PA) are pending. Our study examines the effect of medication sample use (ranibizumab or aflibercept) on future anti-vascular endothelial growth factor (VEGF) agent selection in nvAMD.

DESIGN

Retrospective cohort study.

PARTICIPANTS

nvAMD patients who underwent an initial anti-VEGF injection with a sample medication were compared to nvAMD control patients who never received a medication sample.

METHODS

Charts from 2017 through 2020 were reviewed for data regarding demographics, anti-VEGF agent selection, and visual acuity outcomes for both groups. The utilization of different anti-VEGF agents in each group was compared at various time points using chi-square tests for independence of proportions.

MAIN OUTCOME MEASURES

Anti-VEGF agent selection for the first four injections and at one year were examined.

RESULTS

Adherence to the initial agent was high between first and subsequent injections (2^nd, 3^rd, 4^th injection, and 1 year) in sample (96.2%, 95.9%, 91.9%, 93.4%, respectively), and control groups (98.1%, 94.2%, 94.9%, 87.8%, respectively). Bevacizumab usage was significantly lower among eyes receiving samples relative to controls at the second (1.9% vs. 38.7%, p < .001), third (3.1% vs. 41.3%, p < .001), fourth injections (4.7% vs. 40.4%, p < .001), and at 1 year (0% vs. 33.8%, p < .001). Aflibercept usage was significantly higher in sample eyes relative to controls at the second (78.3% vs. 43.4%, p < .001), third (76.3% vs. 41.5%, p < .001), and fourth injections (76.7% vs. 43.4%, p < .001), and at 1 year (77.0% vs. 52.7%, p < .001).

CONCLUSIONS

Sample medications in nvAMD may be initiated for many reasons, including awaiting PA approval. Our study found that eyes receiving a sample anti-VEGF agent (ranibizumab or aflibercept) for their initial injection were less likely to receive bevacizumab at future visits relative to eyes that did not receive an anti-VEGF sample, even after one year of treatment. Given the persistent use of more expensive medications at subsequent injections for patients who were initiated on samples, insurance payors may consider waiving PA requirements for bevacizumab to avoid a paradoxical increase in health-care costs.

Clinical Outcomes in Vitrectomized versus Non-vitrectomized Eyes in Patients with Primary Vitreoretinal Lymphoma

AIM

To evaluate if there is a difference in the clinical course of primary vitreoretinal lymphoma (PVRL) in vitrectomized versus non-vitrectomized eyes.

METHODS

Observational multicenter retrospective case series of patients diagnosed with PVRL between 2007 and 2019, at three tertiary centers. The main outcomes were relapse rates, inflammatory parameters, and best-corrected visual acuities (BCVA). Statistical methods used were an adjusted generalized estimating equation model, and a proportional Cox model.

RESULTS

Eighty patients (150 eyes) were followed for a median of 1.7 years. At presentation, there were no clinical differences between the groups. The relapse rate was 0.091/eye-year (EY) for vitrectomized eyes and 0.087/EY for non-vitrectomized eyes (p = .35). Vitrectomized eyes had better BCVA than non-vitrectomized eyes (p < .001).

CONCLUSIONS

Vitrectomy had no effect on the relapse rate in eyes with PVRL. However, the decrease in vitreous cell and debris led to vitrectomized eyes having better visual acuity than non-vitrectomized eyes.

Treatment of Aggressive Retinal Astrocytic Hamartoma with Oral mTOR Inhibition

OBJECTIVE OR PURPOSE

To describe the clinical course and outcomes of aggressive retinal astrocytic hamartoma (RAH) treated with oral mTOR inhibitors (mTORi).

DESIGN

Retrospective clinical case series.

SUBJECTS, PARTICIPANTS, AND/OR CONTROLS

Five patients with genetically confirmed TSC and visually significant RAH due to tumor growth or exudation.

METHODS, INTERVENTION, OR TESTING

Review of the electronic medical record in this retrospective clinical case series was performed to determine baseline and follow-up ophthalmologic examination characteristics along with ancillary imaging findings, in patients receiving off-label treatment with either oral sirolimus or everolimus for symptomatic RAH.

MAIN OUTCOME MEASURES

Visual acuity, change in tumor size, degree of exudation, and adverse effects of mTORi were evaluated.

RESULTS

The five patients in this series ranged in age from 8 months to 54 years. Four were treated with sirolimus, and one received everolimus. In all cases, tumor height was stable or decreased following treatment (median follow-up: 39 months, range 11-73 months). Exudation improved following treatment in all cases. In the 8-month-old infant, frequent upper respiratory tract infections prompted cessation of treatment. In one patient, the mTORi was temporarily held due to elevated liver enzymes. No other significant adverse effects were noted.

CONCLUSIONS

Sirolimus and everolimus should be considered in the management of vision-threatening RAH, particularly in the setting of exudative and rapidly growing tumors. Four out of five patients in this series tolerated oral mTORi and continued on therapy. There were no serious complications.

Rapid, Spontaneous Resolution of Prominent Subretinal Infiltrate in Vitreoretinal Lymphoma

Purpose:

This case report describes a patient with vitreoretinal lymphoma who subacutely developed a large, peripapillary subretinal infiltrate that rapidly and spontaneously resolved.

Methods:

A case report is presented.

Results:

A 65-year-old Asian-American woman was referred for evaluation of a dense, peripapillary subretinal infiltrate in the left eye. A diagnostic vitrectomy revealed large, atypical lymphocytes with irregularly shaped nuclei, and mutational testing was positive for myeloid differentiation primary response 88 ( MYD88). Prior to surgery, the patient’s subretinal infiltrate had begun to resolve spontaneously, a process that continued after surgery without initiation of systemic or local ocular therapy.

Conclusions:

Patients with vitreoretinal lymphoma may present with transient, subretinal infiltrates that can resolve without treatment.

Estrogen Receptor Is Expressed in Uveal Melanoma: A Potential Target for Therapy

Background

Metastatic uveal melanoma (UM) has no effective treatment. To date, no publications have reported immunohistochemical evidence of estrogen receptors (ERs) in UM; however, changes in pathologic reporting for ER in breast carcinoma prompted a re-examination of ER in UM, as it could represent a potential therapeutic target.

Objective

To determine if UM tumors express ER by immunohistochemistry (IHC) using current methodology for breast cancer and to evaluate ER gene expression using a publicly available UM database.

Methods

A retrospective IHC analysis with clinical correlation was performed on 2 cohorts: 57 cases from the Cleveland Clinic (CC) and 50 from the Ohio State University Wexner Medical Center (OSUWMC). Analysis of The Cancer Genome Atlas Project (TCGA) UM Dataset of 80 patients was also performed.

Results

Presence of ER was detected by IHC in 20 of 34 (59%) analyzable cases in the CC cohort. Of the 50 patients in the OSU cohort, 52 specimens from 47 patients were sufficient for analysis. Of these 47 cases, 29 (62%) had tumor that was ER positive in ≥1% nuclei. In the second cohort, positivity was classified as positive (≥10% nuclei, 34% cases) or low positive (1-9% nuclei, 28% cases). In 5 patients, there were paired samples, that is, primary tumor and subsequent recurrence or metastasis, with concordance for ER in 4 of 5 cases. In the TCGA database, elevated ESR1 and ESR2 gene expression was identified in a subset of UM tumors with poor genetic prognostic features.

Conclusions and Relevance

Potentially actionable ER expression is present in greater than half of UM cases by IHC. Gene expression of ESR1 and ESR2 was elevated in a subset of UM tumors with poor prognostic features. These data provide a rationale to evaluate ER as a potential target for therapy in UM.

Primary central nervous system lymphoma - ocular variant: an interdisciplinary review on management

Primary central nervous system lymphoma-ophthalmic variant (PCNSL-O) is an ocular subset of PCNSL predominantly involving subretinal pigment epithelium space, retina, and vitreous. The ophthalmic manifestations can precede, occur simultaneously, or follow other compartments of the CNS. Clinical trials have resulted in a significantly improved outcome in PCNSL patients over the past 2 decades, with a higher proportion of patients receiving frontline high dose methotrexate-based polychemotherapy regimens with curative intent; however, the current management of PCNSL-O remains controversial owing to lack of prospective data. The goals of PCNSL-O treatment are both to achieve local (ocular) control and to prevent tumor-specific mortality from further CNS involvement. Despite achieving high rates of ocular control with intravitreal agents like methotrexate and rituximab, the overall survival is poor, as 65-85% of patients eventually succumb to CNS disease. Few studies define the role of systemic chemotherapy with/without local treatment as a first line induction treatment for PCNSL-O considering limiting factors such as ocular penetration of systemically administered drugs and treatment related neurotoxicity. Also, the role of adjuvant treatment for PCNSL-O to prevent CNS progression and to improve overall survival is unknown. In this systematic review of the literature, we analyze treatment outcomes of various regimens (local, systemic, and combination) in terms of local control, CNS progression, and overall survival.

Paediatric ocular adnexal lymphoma: a population-based analysis

Objective

To investigate the incidence, clinicopathological characteristics and survival of ocular adnexal lymphoma (OAL) in the paediatric population.

Methods and analysis

In this retrospective case series, the Surveillance, Epidemiology and End Results database was accessed to identify individuals with OAL ≤18 years of age, diagnosed between 1973 and 2015. OAL located in the eyelid, conjunctiva, lacrimal apparatus and orbit were included. Main outcome measures were the age-adjusted incidence rates (IRs) per 1 000 000 population at risk (calculated for the period 2000–2015) and descriptive statistics of demographic and clinicopathological features.

Results

The IR of paediatric OAL was 0.12 (95% CI 0.08 to 0.16) per 1 000 000. Males (0.15; 95% CI 0.10 to 0.22) and blacks (0.24; 95% CI 0.13 to 0.42) had a higher tendency for OAL development. A total of 55 tumours in 54 children were identified. The majority were localised (78.4%), conjunctival (49.1%) lymphomas. Extranodal marginal zone lymphoma (EMZL, 45.5%, n=25) was the most frequent subtype, followed by diffuse large B-cell lymphoma (DLBCL, 9.1%, n=5), B lymphoblastic lymphoma (7.3%, n=4), follicular lymphoma (5.5%, n=3), Burkitt lymphoma (5.5%, n=3), anaplastic large cell lymphoma (ALCL, 3.6%, n=2), small lymphocytic lymphoma (1.8%, n=1), diffuse large B-cell lymphoma, immunoblastic (1.8%, n=1) and panniculitis-like T-cell lymphoma (1.8%, n=1). Localised, low-grade, conjunctival lymphomas were frequently treated with complete excision with or without radiation, while high-grade and distant tumours usually received chemotherapy. Only 29.1% of paediatric OAL cases were treated with radiation. Three out of five (60%) patients with DLBCL died of lymphoma at a median follow-up of 21 (range 10–86) months, and 1 out of 2 (50%) patients with ALCL died of lymphoma at 23 months from diagnosis.

Conclusion

OAL in the paediatric population is rare. The majority of OAL are EMZL and are characterised by excellent prognosis. The histological subtype was found to be the main predictor of outcome with cancer-specific deaths observed in patients with DLBCL and ALCL.

Juvenile cataract in association with tuberous sclerosis complex

BACKGROUND

Tuberous sclerosis complex (TSC) is an autosomal dominant genetic disorder characterized by benign hamartomas occurring in multiple organ systems including the brain, kidneys, heart, lungs, liver, skin, and the eyes. Typical retinal findings associated with TSC include astrocytic hamartoma and achromic patch. While rare cases of cataract occurring in the setting of TSC have been reported, this is the first analysis of a large series of individuals with TSC that aims to quantify the frequency of this finding and to describe its clinical and genetic associations.

MATERIALS AND METHODS

This is a retrospective chart review of 244 patients from the Herscot Center for Tuberous Sclerosis Complex at the Massachusetts General Hospital who underwent complete ophthalmic examination. We describe the clinical and genetic findings in five individuals with TSC and juvenile cataract.

RESULTS

Four of five cases (80%) were unilateral. The cataract was described as having an anterior subcapsular component in 3 of 5 cases (60%). Three individuals (60%) underwent lensectomy with intraocular lens (IOL) implant and two individuals (40%) were observed. Genetic testing revealed a known disease-causing mutation in TSC2 in 100% of cases.

CONCLUSIONS

Recent evidence suggests that mTOR signaling may play a role in cataract formation which could explain the relatively high incidence of juvenile cataract in this population. Juvenile cataract is a potentially under-recognized ocular manifestation of TSC.

Relationship between Conjunctival Intraepithelial Dendritic Melanocytes and Nevocytes

A 52-year-old male presented with a perilimbal-epibulbar, flat, pigmented lesion of 7 months' duration. Microscopic evaluation disclosed a proliferation of intraepithelial dendritic melanocytes without frank atypia, a lesion formerly termed "primary acquired melanosis." Within the lesion there were also intraepithelial basal junctional nevocytic nests and occasional small subepithelial nevocytic clusters which were positive for MART-1, HMB-45, and SOX-10 and negative for Ki-67. This remarkable lesion was suggestive of dendritic melanocytes transforming into rounded nevocytes lacking dendrites. The embryologic and biologic implications of these findings are explored, notably in regard to the unusual acquisition in mature adults of common nevomelanocytic nevi.

Diagnosis and Management of Rare Immune-Related Adverse Events

Oncologic treatment is being revolutionized by a burgeoning number of immune checkpoint inhibitors (ICPis). To date, seven ICPis have received Food and Drug Administration approval, targeting cytotoxic T-lymphocyte antigen, programmed cell death, or programmed cell death ligand. Adverse events associated with checkpoint inhibition have been described in the literature. Guidelines exist for the most common of these, but as the use of ICPis becomes more common, the number of patients presenting with rare events will increase. This article reviews the diagnosis and management of rare ocular, hematological, luminal gastrointestinal, and rheumatological toxicities arising from ICPi treatment. KEY POINTS: As the use of immune checkpoint inhibitors (ICPis) becomes more common, the number of rare immune-related adverse events (irAEs) will increase. A high level of suspicion is required to identify and treat these toxicities. Although it can be difficult to definitively attribute rare irAEs to ICPis, a temporal and mechanistic relationship and the absence of other etiologies should make the treating physician suspicious for a rare irAE. Certain rare irAEs, such as celiac disease, do not require treatment with glucocorticoids. Thus, differentiating this irAE from other gastrointestinal irAEs has important implications for treatment.

The Association of Aspirin Use with Age-Related Macular Degeneration Progression in the Age-Related Eye Disease Studies: Age-Related Eye Disease Study 2 Report No. 20

PURPOSE

To analyze the potential association between aspirin use and progression of age-related macular degeneration (AMD).

DESIGN

Two prospective cohort studies within 2 controlled clinical trials of oral supplementation for age-related eye disease.

PARTICIPANTS

Age-Related Eye Disease Study (AREDS) participants 55 to 80 years of age and AREDS2 participants 50 to 85 years of age.

METHODS

Propensity scores for aspirin use were calculated for AREDS and AREDS2 participants separately by logistic regression. Of the participants without late AMD (geographic atrophy [GA] or neovascular AMD) in either eye at study baseline, aspirin users were matched 1:1 with nonusers by propensity score (separately for AREDS and AREDS2). Proportional hazards regression was performed, adjusting for age, on the matched participants to evaluate associations between aspirin propensity score and progression to late AMD (and its subtypes).

MAIN OUTCOME MEASURES

Progression to late AMD on color fundus photographs, graded centrally.

RESULTS

Of the 3734 eligible AREDS participants, 1049 (28.1%) were taking aspirin, and of the 2403 eligible AREDS2 participants, 1198 (49.9%) were taking aspirin. After matching by propensity score, the characteristics of the users and nonusers were similar in both studies. Of the 1950 matched AREDS participants and 1694 matched AREDS2 participants, over a median follow-up of 10.1 years and 5.0 years, respectively, the numbers who progressed to late AMD, GA, or neovascular AMD were 454 (23.3%), 345 (17.7%), and 278 (14.3%), respectively, in AREDS and 643 (38.0%), 402 (24.6%), and 341 (20.1%) in AREDS2. The hazard ratios of progression in quintile 5 (highest propensity for aspirin use) versus 1 (reference) were 1.17 (P = 0.35), 1.24 (0.25), and 0.95 (0.81), respectively, in AREDS and 1.26 (0.09), 1.46 (0.03), and 1.12 (0.58) in AREDS2. No significant association with progression to late AMD was observed for quintiles 2 through 5 for any of the 3 outcomes in either study.

CONCLUSIONS

Aspirin use was not associated significantly with progression to late AMD or its subtypes in either the AREDS or AREDS2. Patients with AMD need not avoid aspirin for this reason when its use is medically indicated.

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.

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.

Uveal Melanoma: 5-Year Update on Incidence, Treatment, and Survival (SEER 1973-2013)

Purpose

To analyze trends in incidence, treatment, and survival of uveal melanoma in the United States from 1973 to 2013 using the Surveillance, Epidemiology, and End Results database.

Materials and Methods

Patients were identified using International Classification of Disease for Oncology codes: C69.3 (choroid), C69.4 (ciliary body and iris), and C69.2 (retina). Trends in age-adjusted incidence, treatment (surgery or radiation), and 5-year relative survival were calculated.

Results

There were 4,999 cases of uveal melanoma. The majority (97.8%) were reported by hospital inpatient/outpatient clinics. Histopathologic confirmation was available in 67.8%. The mean age-adjusted incidence was 5.2 per million (95% CI 5.0-5.4). When the incidence was standardized for race, a small but statistically significant (p < 0.05) annual percentage change of 0.5% was detected in Whites. There was a decline in patients treated with surgery alone (94.2% from 1973 to 1975 vs. 24.7% from 2012 to 2013). A corresponding increase was observed in radiation as primary treatment selection (1.3% from 1973 to 1975 vs. 68.3% from 2012 to 2013). No change in the 5-year relative survival (80.9%) was observed.

Conclusions

The age-adjusted incidence of uveal melanoma has remained stable with a minor increase in Whites. Despite a shift towards globe-preserving treatment, there has not been a concomitant improvement in survival.

Fine-needle aspiration biopsy of uveal melanoma: outcomes and complications

PURPOSE

To report outcomes and complications of fine-needle aspiration biopsy (FNAB) of uveal melanoma performed for diagnostic and prognostic purposes.

METHODS

Prospective interventional case series of 150 consecutive patients with a clinical diagnosis of uveal melanoma. The FNAB approach (transcorneal (TCO), transscleral (TSC) and transvitreal (TVT) was primarily determined by the location of the tumour. The FNAB was performed using a 25-gauge needle using a previously published technique. Prognostication was done using fluorescent in situ hybridisation detection of monosomy of chromosome 3.

RESULTS

FNAB was obtained via TCO (8), TSC (71) and TVT (64) approach and impression smear in seven cases. Diagnostic yield was 92%. False-negative results were observed in 8%. Diagnostic yield was significantly correlated to biopsy approach (TCO 100%, TSC 96%, TSV 86%; p=0.029) and tumour size (basal diameter >5.0 mm; height >2.5 mm). Persistent haemorrhage (subretinal haemorrhage or vitreous) requiring surgical intervention (1%) and rhegmatogenous retinal detachment (1%) were rare. Endophthalmitis, hypotony, tumour recurrence, episcleral seeding were not observed over the average follow-up of 37 months. Prognostication could be performed in 85% of cases. Overall, only 47% of eligible patients enrolled into the adjuvant therapy trial.

CONCLUSIONS

FNAB for uveal melanoma with 25-gauge needle is a safe procedure that can yield diagnostic and prognostic information in vast majority of cases (92% and 85%, respectively). Even so, only about half of the eligible cases eventually enrolled into the adjuvant therapy trial. Possibility of negative FNAB yield should be considered when counselling patients with small tumours. Alternative means of diagnostic biopsy and methods of prognostication need to be assessed for small tumours.

Intraocular Lymphoma Models

Primary vitreoretinal lymphoma (PVRL) is a subtype of primary central nervous system lymphoma (PCNSL), a high-grade, extranodal, non-Hodgkin's lymphoma, predominantly of B-cell origin. PVRL is an aggressive disease with a poor prognosis. Human studies are not ideally suited for the study of intraocular lymphoma pathogenesis or treatment strategies due to the rare nature of the disease, its variable presentation, limited volume of available ocular fluids, and fragility of sampled lymphoma cells. Animal models have been critical in making progress in understanding intraocular lymphoma pathogenesis and investigating potential therapeutic strategies. Early murine models for intraocular lymphoma used intraperitoneal injection of mouse T-cell lymphomas. This was followed by intravitreal T-cell murine models. More recent murine models have used B-cell lymphomas to more closely mimic human disease. The most current B-cell lymphoma models employ a combined approach of inoculating both the mouse vitreous cavity and brain. The challenge in murine models for intraocular lymphoma lies in recreating the clinical features, disease behavior, molecular profile, systemic immunity, and the microenvironment observed in human disease. In the future, animal models will continue to be central to furthering our understanding of the disease and in the investigation of potential treatment targets.

Genomic microarray analysis on formalin-fixed paraffin-embedded material for uveal melanoma prognostication

Cytogenetic alterations are strong outcome prognosticators in uveal melanoma (UVM). Monosomy 3 (-3) and MYC amplification at 8q24 are commonly tested by fluorescence in situ hybridization (FISH). Alternatively, microarray analysis provides whole genome data, detecting partial chromosome loss, loss of heterozygosity (LOH), or abnormalities unrepresented by FISH probes. Nonfixed frozen tissue is conventionally used for microarray analysis but may not always be available. We assessed the feasibility of genomic microarray analysis for high resolution interrogation of UVM using formalin-fixed paraffin-embedded tissue (FFPET) as an alternative to frozen tissue (FZT). Enucleations from 44 patients (clinical trial NCT00952939) yielded sufficient DNA from FFPET (n = 34) and/or frozen tissue (n = 41) for comparative genomic hybridization and select single nucleotide polymorphism analysis (CGH/SNP) on Roche-NimbleGen OncoChip arrays. CEP3 FISH analysis was performed on matched cytology ThinPrep material. CGH/SNP analysis was successful in 30 of 34 FFPET and 41 of 41 FZT samples. Of 27 paired FFPET/FZT samples, 26 (96.3%) were concordant for at least four of six major recurrent abnormalities (-3, +8q, -1p, +6p, -6q, -8p), and 25 of 27 (92.6%) were concordant for -3. Results of CGH/SNP were concordant with the CEP3 FISH results in 27 of 30 (90%) FFPET and 38 of 41 (92.6%) FZT cases; partial -3q was detected in two CEP3 FISH-negative cases and whole chromosome 3, 4, and 6 SNP-LOH in one case. CGH detection of -3, +8q, -8p on FFPET and FZT showed significant correlation with the clinical outcome measures (metastasis development, time to progression, survival). Results of the UVM genotyping by CGH/SNP on FFPET are highly concordant with those of the FZT analysis and with those of the CEP3 FISH analysis, and therefore CGH/SNP is a practical method for UVM prognostication. Genome-wide coverage provides additional data with potential relevance to UVM biology, diagnosis, and prognosis.

Classical pathology of sympathetic ophthalmia presented in a unique case

The ocular pathology of sympathetic ophthalmia is demonstrated in a 10 year-old boy who sustained a penetrating left globe injury and subsequently developed sympathetic ophthalmia in the right eye two months later. Two and a half weeks following extensive surgical repair of the left ruptured globe, he developed endophthalmitis and was treated with oral and topical fortified antibiotics. One month after the initial injury, a progressive corneal ulcer of the left eye led to perforation and the need for emergent corneal transplantation. The surgical specimen revealed fungus, Scedosporium dehoogii. The boy received systemic and topical anti-fungal therapy. Two months following the penetrating globe injury of the left eye, a granulomatous uveitis developed in the right eye. Sympathetic ophthalmia was suspected and the patient began treatment with topical and oral corticosteroids. Given the concern of vision loss secondary to sympathetic ophthalmia in the right eye, as well as poor vision and hypotony in the injured eye, the left eye was enucleated. Microscopically, granulomatous inflammation with giant cells was noted within a cyclitic membrane which filled the anterior and posterior chamber of the left globe. Other classic features including Dalen-Fuchs nodules were identified. Small, choroidal, ill-defined granulomas and relative sparing of the choriocapillaris were present. Molecular analysis did not identify evidence of remaining fungal infection. The pathology findings were consistent with previously described features of sympathetic ophthalmia. The present case is unique in that co-existing fungal infection may have potentiated the risk for developing sympathetic ophthalmia in the fellow eye.

Radiation therapy: conjunctival and eyelid tumors

While the primary treatment of eyelid and conjunctival tumors is frequently surgical, several forms of ophthalmic radiation therapy have also been used to treat these malignancies. The goal of radiation therapy is to eradicate tumor burden in a manner that maintains visual function and preserves surrounding sensitive ocular tissues. Ophthalmic radiation may be used as a curative therapy, as adjuvant treatment following surgical excision, or as palliative therapy for advanced cases of eyelid and conjunctival tumors. The following review discusses the indications and outcomes of various modalities of radiation (external beam radiotherapy and brachytherapy) used to treat eyelid tumors (squamous cell carcinoma, basal cell carcinoma, sebaceous gland carcinoma, and melanoma) and conjunctival tumors (squamous cell carcinoma and melanoma).

Paraneoplastic vitelliform retinopathy: clinicopathologic correlation and review of the literature

Traditionally, the paraneoplastic retinopathies have been classified into two groups: melanoma-associated retinopathy (MAR) and cancer-associated retinopathy. MAR occurs in individuals with metastatic cutaneous or uveal melanoma and is characterized by nyctalopia, photopsias, and variable vision loss. In most cases, the fundus is essentially normal in appearance. More recently, there have been multiple reports of a MAR-like retinopathy with associated detachments of the retinal pigment epithelium and neurosensory retina. Such a clinical presentation has been termed paraneoplastic vitelliform retinopathy. We describe an 80-year-old man with metastatic cutaneous melanoma who developed paraneoplastic vitelliform retinopathy. For the first time, histopathology from enucleation specimens provides a clinicopathologic disease correlation with focal abnormalities in the inner nuclear and outer plexiform layers.

Chromosome 3 status in uveal melanoma: a comparison of fluorescence in situ hybridization and single-nucleotide polymorphism array

PURPOSE

To compare fluorescence in situ hybridization (FISH) using a centromeric probe for chromosome 3 (CEP3) and 3p26 locus-specific probe with single-nucleotide polymorphism array (SNP-A) analysis in the detection of high-risk uveal melanoma.

METHODS

Fifty cases of uveal melanoma (28 males, 22 females) treated by enucleation between 2004 and 2010 were analyzed. Fresh tissue was used for FISH and SNP-A analysis. FISH was performed using a CEP3 and a 3p26 locus-specific probe. Tumor size, location, and clinical outcome were recorded during the 7-year study period (median follow-up: 35.5 months; mean: 38.5 months). The sensitivity, specificity, positive predictive value, and negative predictive value were calculated.

RESULTS

Monosomy 3 was detected by FISH-CEP3 in 27 tumors (54%), FISH-3p26 deletion was found in 30 (60%), and SNP-A analysis identified 31 (62%) of the tumors with monosomy 3. Due to technical failures, FISH and SNP-A were noninterpretable in one case (2%) and two cases (4%), respectively. In both cases of SNP-A failure, tumors were positive for FISH 3p26 deletion and in a single case of FISH failure, monosomy 3 was found using SNP-A. No statistically significant differences were observed in any of the sensitivity or specificity measures.

CONCLUSIONS

For prediction of survival at 36 months, FISH CEP3, FISH 3p26, and SNP-A were comparable. A combination of prognostication techniques should be used in an unlikely event of technical failure (2%-4%).

Ocular adnexal lymphoma (OAL)-outcomes for 82 patients (pts) treated at a single center

8071

Background: OALs comprise 1-2% of NHL and are extranodal marginal zone (EMZL) in 80% of cases. We present a retrospective review of 82 pts with OAL managed at the Cleveland Clinic between January 2004 and November 2011. Methods: 82 pts with NHL of the OA were identified. All biopsies were performed/reviewed at the Cleveland Clinic. Survival and relapse were estimated using the Kaplan-Meier method. Risk factors for relapse and survival were identified using Cox proportional hazards analysis. Risk factors included age at diagnosis (dx), gender, prior autoimmune disease, prior lymphoma history (hx), hx of other malignancy, bilateral disease, and ocular disease site. Results: The table lists pt characteristics. Median follow-up was 25.8 months (range 0.3-307.4). Age at dx (HR=1.45, CI 1.04-2.02) and prior lymphoma hx (HR=3.35, CI 1.33-8.46) were predictive of relapse in a multivariate analysis. There was no difference in relapse rates between pts with EMZL and other lymphoma types (p=0.82). Relapse occurred in 26 (31.7%) pts with most common sites being ipsilateral eye (n=8), contralateral eye (n=3), distant lymph node (n=11), and other organs (n=11). Most common organ was breast (n=4). Of the 10 pts who had eye-only relapses, 8 received rituximab (R) and 2 were observed. Of the 16 with extraocular relapse, 9 received radiation (RT), 2 received R, 3 received other therapies, and 2 were observed. 7 deaths were recorded with a 5 year overall survival of 84.2%. Survival was similar to a matched healthy population (p=0.69). Causes of death were lymphoma in 4, another cancer in 1, and unknown in 2. Conclusions: OAL relapse patterns differ depending on initial treatment. Initial RT was more likely to relapse at distant sites; where as initial R was more likely to relapse in the OA. RT should be used for localized OAL. With bilateral ocular or systemic disease, R results in a high rate of long-term disease control. [Table: see text]

Tuberous sclerosis complex: genotype/phenotype correlation of retinal findings

OBJECTIVE

To evaluate genotype/phenotype correlations in individuals with astrocytic hamartoma (AH) and retinal achromic patch (AP) in the setting of tuberous sclerosis complex (TSC).

DESIGN

Retrospective consecutive case series.

PARTICIPANTS

A total of 132 patients enrolled in the Cleveland Clinic Foundation Tuberous Sclerosis Program (CCF-TSCP) and 907 patients from the Tuberous Sclerosis Alliance (TSC-A).

METHODS

Patient gender, age at TSC diagnosis, presence of TSC1 or TSC2 mutations, detailed ophthalmic examination findings, systemic manifestations, and whether or not the patient had a diagnosis of epilepsy or cognitive impairment were analyzed.

MAIN OUTCOME MEASURES

Genotype/phenotype correlation of retinal findings and systemic disease manifestations.

RESULTS

No significant difference was found in the prevalence of AH or AP in the CCF-TSCP (36.1%) and TSC-A (34.1%) groups (P = 0.743). Astrocytic hamartomas were bilateral in 43.3% and 18.1% (P=0.009) and multiple in 40.0% and 15.3% (P = 0.008) in the CCF-TSCP and TSC-A groups, respectively. In the CCF-TSCP group, the average number of AH was 4 (range, 2-7). Average tumor size was 1.0 disc diameter (range, 0.5-2.5 disc diameters). The most common location was along the arcades (41.5%), adjacent to the optic nerve (29.2%), and in the retinal periphery (27.7%). In the CCF-TSCP group, AP was observed in 12.0% of patients (40.0% bilateral, 50.0% multiple). The presence of retinal features was associated with giant cell astrocytoma (37.1% vs. 14.6%; P = 0.018), renal angiomyolipoma (60.0% vs. 27.1%; P = 0.003), cognitive impairment (77.1% vs. 43.8%; P = 0.002), and epilepsy (91.4% vs. 70.8% (P = 0.022) in those with and without retinal findings, respectively. In patients with retinal findings in both the CCF-TSCP and TSC-A groups, mutations in TSC2 were more frequent than in TSC1, 3.3 times and 5.8 times, respectively; in those without retinal findings, the relative rates were 0.67 times and 2.3 times, respectively.

CONCLUSIONS

Individuals with retinal findings are more likely to have concomitant subependymal giant cell astrocytomas, renal angiomyolipomas, cognitive impairment, and epilepsy. TSC2 mutations are more frequent in patients with retinal findings than in those without retinal findings.