Treatment Compliance and Outcomes for Women With Locoregionally Advanced Cervical Cancer Treated in a Safety Net Health System.

OBJECTIVE: This study aims to assess treatment compliance among women undergoing definitive chemoradiation with weekly cisplatin for cervical cancer within a safety net health system and to quantify the impact of chemotherapy compliance on outcomes. MATERIALS AND METHODS: All women who were treated for International Federation of Gynecology and Obstetrics stage IB2 to stage IVA cervical cancer between April 2008 and May 2014 were identified. Treatment delays were attributed to toxicity, comorbid conditions, or system issues, or categorized as patient-initiated. Disease-free survival and overall survival of women who received fewer than 6 versus 6 or more doses of weekly cisplatin 40 mg/m were compared using Kaplan-Meier analyses. RESULTS: One hundred nineteen women (mean [SD] age, 48.5 [11.8] years) were identified. Most women (n = 112; 94.1%) completed definitive radiotherapy, requiring a mean (SD) of 56.5 (20.1) days. Sixty-four women (57.1%) completed definitive radiotherapy in 56 days or less. Only 44 women (36.4%) received 6 or more cycles of cisplatin. Of 122 delayed cycles, reasons for delay were as follows: grade 2 or higher toxicity (n = 70; 57.4%), medical comorbidity (n = 12; 9.8%), system issues (n = 9; 7.4%), and patient-initiated (n = 14; 11.5%). Multiple issues complicated treatment for 3 doses (2.5%). Reasons for delay were not documented in 14 doses (11.5%). Among patients who received 6 or more cycles, disease-free survival improved by 17.4 months (mean [SD], 61.1 [3.7] vs 43.7 [4.3] months, P = 0.002) and overall survival improved by 8.6 months (mean [SD], 68.7 [2.3] vs 60.1 [3.7] months, P = 0.011). CONCLUSIONS: Higher rates of toxicity and psychosocial barriers to chemotherapy compliance adversely impact survival among women who seek care in low-resource settings. In our population, administration of all 6 cycles of cisplatin was necessary for optimal survival benefit. Future efforts to improve cervical cancer outcomes should address preventable reasons for treatment delays among underinsured or uninsured individuals.

VISION LOSS IN A PATIENT WITH PRIMARY PULMONARY HYPERTENSION AND LONG-TERM USE OF SILDENAFIL.

PURPOSE: To describe a case of bilateral, asymmetrical outer macular atrophy in a patient with pulmonary hypertension treated with long-term sildenafil (Revatio). METHODS: Case report with fundus photography, spectral domain optical coherence tomography, fundus autofluorescence, and fluorescein angiography imaging. RESULTS: A 32-year-old African American woman with a history of primary pulmonary hypertension and 5-year history of oral sildenafil (Revatio) use presented with decreasing central vision in her left eye. She reported a decline in central vision in the left eye that started 1 month after treatment initiation and progressed until discontinuation 5 years later. Visual acuity was 20/20 in the right eye and 20/100 in the left eye. Fundus photography revealed retinal pigment epithelial mottling and atrophy in the right eye and parafoveal retinal pigment epithelial mottling and atrophy in a ring-like configuration of the left eye. Optical coherence tomography demonstrated outer retinal irregularity in the right eye and disrupted outer retina involving the external limiting membrane, inner segment/outer segment junction, and the retinal pigment epithelium in the left eye; no choroidal thickening was observed. Fundus autofluorescence showed mild hypoautofluorescence in the foveal center with an irregular autofluorescence pattern in the parafovea of the left eye. Fluorescein angiography revealed capillary dropout with pinpoint hyperfluorescence and leakage in the far periphery bilaterally. A window defect was also observed in the foveal center of the left eye. CONCLUSION: Sildenafil and other PDE5 inhibitors have been associated with several ocular side effects. However, this is the first report in the literature of outer macular atrophy in a patient with pulmonary hypertension and long-term use of oral sildenafil. All patients with long-term use of sildenafil should be educated on the risk of potential visual adverse effects.

Secondary intraocular lens implantation: Complication rates, visual acuity, and refractive outcomes.

PURPOSE: To compare complication rates, visual acuity, and refractive outcomes of secondary intraocular lens (IOLs) implantation. SETTING: Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA. DESIGN: Retrospective case series. METHODS: All secondary IOLs placed by the anterior segment service were reviewed. Preoperative data, operative reports, and data from each subsequent postoperative visit were evaluated. Patients were divided into 5 groups based on the final IOL position: (1) sulcus with optic capture, (2) sulcus without optic capture, (3) anterior chamber (AC), (4) iris-fixated, and (5) transscleral-sutured. Complication rates, visual acuity, and refractive outcomes were compared for each group. RESULTS: The sulcus with and without optic capture groups had the lowest complication rates and best visual acuity outcomes. There was no difference in final corrected distance visual acuity (CDVA) between the transscleral-sutured IOL, iris-fixated IOL, and AC IOL groups, although the AC IOL group had the lowest rates of early postoperative complications and a significant improvement in vision. The transscleral-sutured IOL group had the highest complication rates, and 25% of patients in the iris-fixated IOL group lost 2 or more lines of CDVA. CONCLUSIONS: When a secondary IOL cannot be placed within the capsular bag, sulcus with optic capture is the best alternative, followed by sulcus without optic capture. There was no difference in visual acuity outcomes between transscleral-sutured IOLs, iris-fixated IOLs, and AC IOLs. Anterior chamber IOLs resulted in fewer early complications.

Refractive outcomes after multifocal intraocular lens exchange.

PURPOSE: To evaluate the refractive outcomes after multifocal intraocular lens (IOL) exchange. SETTING: Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA. DESIGN: Retrospective case series. METHODS: Patients had multifocal IOL explantation followed by IOL implantation. Outcome measures included type of IOL, surgical indication, corrected distance visual acuity (CDVA), and refractive prediction error. RESULTS: The study comprised 29 patients (35 eyes). The types of IOLs implanted after multifocal IOL explantation included in-the-bag IOLs (74%), iris-sutured IOLs (6%), sulcus-fixated IOLs with optic capture (9%), sulcus-fixated IOLs without optic capture (9%), and anterior chamber IOLs (3%). The surgical indication for exchange included blurred vision (60%), photic phenomena (57%), photophobia (9%), loss of contrast sensitivity (3%), and multiple complaints (29%). The CDVA was 20/40 or better in 94% of eyes before the exchange and 100% of eyes after the exchange (P = .12). The mean refractive prediction error significantly decreased from 0.22 ± 0.81 diopter (D) before the exchange to -0.09 ± 0.53 D after the exchange (P < .05). The median absolute refractive prediction error significantly decreased from 0.43 D before the exchange to 0.23 D after the exchange (P < .05). CONCLUSIONS: Multifocal IOL exchange can be performed safely with good visual outcomes using different types of IOLs. A lower refractive prediction error and a higher likelihood of 20/40 or better vision can be achieved with the implantation of the second IOL compared with the original multifocal IOL, regardless of the final IOL position.

Assessment of Plasma Cytokine Profile Changes in Bevacizumab-Treated Retinopathy of Prematurity Infants.

PURPOSE: We compared changes of plasma angiogenesis cytokine profiles in infants who were treated with intravitreal injection of bevacizumab (IVB) for type 1 retinopathy of prematurity (ROP) with age-matched preterm non-ROP infants. METHODS: Thirteen infants with type 1 ROP and 13 age-matched preterm non-ROP infants were included. Blood samples were collected prior to treatment (time 0) and 6 weeks after the treatment (time 42). Plasma levels of nine cytokines from the angiogenesis growth factor panel and seven soluble cytokine receptors were measured using a magnetic multiplex assay. RESULTS: Plasma cytokine profiles changed from time 0 to time 42 in both groups. In bevacizumab-treated ROP infants, the following plasma angiogenesis growth factor and soluble cytokine receptor levels decreased significantly: soluble VEGF-A (sVEGF-A; P = 0.0001), sVEGF-D (P = 0.04), angiopoietin-2 (Ang-2; P = 0.002), sVEGF receptor 1 (R1) and R2 (P = 0.005), soluble IL-6 receptor (sIL-6R; P = 0.002), soluble glycoprotein 130 (spg130; P = 0.0001), and soluble TNF receptor (sTNFR) I and II (P = 0.0001). The following factors and receptors increased significantly: sVEGF-C (P = 0.05), placental growth factor (PlGF; P = 0.02), endothelin-1 (ET-1; P = 0.0001), and FGF-1 (P = 0.02). At time 42, sVEGF-A, sgp130, sIL-6R, sTNFR I, and sTNFR II were lower, and ET-1 level was higher, in bevacizumab-treated ROP infants compared to age-matched non-ROP infants. CONCLUSIONS: The results suggest that bevacizumab treatment resulted in significant angiogenic cytokine profile changes in infants with severe ROP. The long-term clinical impact of these changes should be studied carefully.