Cemiplimab for metastatic squamous cell carcinoma of the orbit, periocular adnexa, and thigh.

The current case presentation highlights the potential of cemiplimab, a programmed cell death protein-1 (PD-1) inhibitor, as first-line treatment for periocular metastatic cutaneous squamous cell carcinoma (SCC) without requiring curative surgery or radiotherapy. A 64-year-old male presented with a progressing 4.5 × 3.0 cm left upper eyelid lesion initially diagnosed as psoriasis. Work-up revealed cutaneous SCC with tumor invasion into extraconal fat and lacrimal gland, and metastasis to the left parotid lymph node. The patient also presented with a suspicious lesion on his left medial thigh found to be a second primary on pathology. To avoid orbital exenteration and treat the multifocal disease, the patient was started on intravenous cemiplimab immunotherapy. Following six doses, repeated FGD-PET-CT revealed a complete response of the left eyelid lesion and residual low-grade hypermetabolic activity of the left medial thigh lesion. Biopsy confirmed chronic inflammation and fibrosis with no signs of malignancy. This unique case with dual primary cutaneous SCC provides support for cemiplimab in treating locally invasive periocular SCC, and potentially abrogating the need for highly morbid exenteration procedures to preserve binocular vision.

Predicting Progression of Untreated Macular Pucker Using Retinal Surface En Face Optical Coherence Tomography.

PURPOSE: To review visual outcomes in untreated premacular membrane (PMM) with macular pucker (MP) and evaluate novel predictors of progression. METHODS: In this retrospective observation study, we included 342 eyes with untreated PMM with MP between 2012 and 2015. PMMs were characterized by spectral-domain optical coherence tomography (SD-OCT) imaging based on foveal morphologies, number of retinal contraction centers, central subfield thickness (CST), inner segment ellipsoid band integrity, and photoreceptor deformation index. Additionally, the thickened retina portion was identified by en face OCT and processed digitally to calculate its area. Parameters were retrospectively analyzed using multiple regression analyses to identify associations with change in visual acuity (VA) between initial to final follow-up visit. RESULTS: In 468 eyes with untreated PMM, VA and CST did not change significantly during a mean observation period of 448 days (p = 0.52 and 0.35, respectively). Specifically, VA improved or stayed the same in 80% and worsened by 2 lines or more in 20% of eyes. The only consistent predictor of PMM progression was area of retinal thickening: for every 1 mm2 of retinal thickening at baseline, the odds of having worsened vision at follow-up increased by 6% (OR 1.0606, 95% CI 1.0031-1.1214, p = 0.0387). CONCLUSIONS: The majority of eyes with PMM and good visual function at baseline remain stable or spontaneously improve in VA and macular thickness. Area of retinal thickening as evaluated by en face OCT may be a novel predictor of vision loss in untreated PMM with MP.

The future of retinal imaging.

PURPOSE OF REVIEW: This article reviews emerging technologies in retinal imaging, including their scientific background, clinical implications and future directions. RECENT FINDINGS: Fluorescence lifetime imaging ophthalmoscopy is a technology that will reveal biochemical and metabolic changes of the retina at the cellular level. Optical coherence tomography is evolving exponentially toward higher resolution, faster speed, increased portability and more cost effective. Adaptive optics scanning laser ophthalmoscopy fluorescein angiography will provide unprecedented detail of the retinal vasculature down to the level of capillaries, enabling earlier and more sensitive detection of retinal vascular diseases. SUMMARY: Continued developments in retinal imaging focus on improved resolution, faster speed and noninvasiveness, while providing new information on the structure-function relationship of the retina inclusive of metabolic activity at the cellular level.

Simple Preoperative Ink Test as a Novel Adjunct to Intrastromal Keratopigmentation for Post-laser Peripheral Iridotomy Dysphotopsias.

PURPOSE: To describe a simple preoperative ink test as a novel adjunct to intrastromal keratopigmentation for post-laser peripheral iridotomy (LPI) dysphotopsias. METHODS: A surgical marking pen is applied to the area over a peripheral iridotomy before intrastromal keratopigmentation. The patient can then assess whether there is any improvement in their symptoms of dysphotopsias. Manual intrastromal keratopigmentation can then be performed using a crescent blade into the clear cornea at 50% depth and tunneled centrally to create a pocket ensuring that the peripheral iridotomy is fully occluded. The crescent blade is coated with an alcohol-based commercially available black tattoo pigment, and the pocket is filled. RESULTS: We have used the preoperative ink marker test on 5 eyes in patients with post-LPI (4 temporal and 1 superior) dysphotopsias before performing intrastromal keratopigmentation, with good patient satisfaction. Patients report immediate symptomatic relief after the procedure. This ink marking technique can also be extended to help identify which iris defect is symptomatic in patients with multiple iris defects. CONCLUSIONS: The preoperative ink test before intrastromal keratopigmentation is a novel adjunct to the treatment of post-LPI dysphotopsias.

Swept-Source OCT Visualization of Macular Hole Closure in Gas-Filled Eyes.

BACKGROUND AND OBJECTIVE: To assess the utility of swept-source optical coherence tomography (SS-OCT) in visualizing macular hole (MH) closure through gas-filled eyes on postoperative day (POD) 1 using a dual scanning protocol. PATIENTS AND METHODS: We examined 30 consecutive patients with full-thickness MH who underwent standard vitrectomy with SF6 (25%) gas tamponade between July 2015 and April 2016. SS-OCT imaging was performed using horizontal raster and 16-line radial scans with manual delicate focusing to evaluate MH closure status. RESULTS: On POD1, optically clear images with visualization of all retinal layers at the fovea were obtained in 80% of eyes, of which 71% achieved complete MH closure. Reasons for unsuccessful imaging included: hyphema (two eyes), dense cataract (two eyes), and gas meniscus interference (two eyes). CONCLUSION: SS-OCT with dual scanning protocol and manual delicate focusing enabled consistent early visualization of foveal architecture for assessment of MH closure through gas-filled eyes. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:392-398.].

Multimodal Imaging Features in Acute Exudative Paraneoplastic Polymorphous Vitelliform Maculopathy.

An 85-year-old woman with stage IV breast cancer was referred for gradually progressive blurred vision. Dilated fundus examination revealed unifocal, yellow, round vitelliform lesions in the macular region of both eyes. The diagnosis of acute exudative paraneoplastic polymorphous vitelliform maculopathy (AEPPVM) was confirmed with swept-source optical coherence tomography (SS-OCT), fundus autofluorescence, and fluorescein angiography. SS-OCT angiography revealed normal vascular findings in both eyes. Multimodal imaging is useful in the diagnosis and monitoring of AEPPVM and may further the understanding of its pathophysiology. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:1143-1146.].

Swept-Source Optical Coherence Tomography Angiography and Vascular Perfusion Map Findings in Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) is a highly prevalent chronic sleep disorder associated with considerable systemic and ophthalmic consequences. The authors present the retinal vascular findings of a visually asymptomatic 56-year-old man clinically diagnosed with OSA using swept-source optical coherence tomography and vascular perfusion mapping. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:880-884.].

Statin Safety in Chinese: A Population-Based Study of Older Adults.

BACKGROUND: Compared to Caucasians, Chinese achieve a higher blood concentration of statin for a given dose. It remains unknown whether this translates to increased risk of serious statin-associated adverse events amongst Chinese patients. METHODS: We conducted a population-based retrospective cohort study of older adults (mean age, 74 years) newly prescribed a statin in Ontario, Canada between 2002 and 2013, where 19,033 Chinese (assessed through a validated surname algorithm) were matched (1:3) by propensity score to 57,099 non-Chinese. This study used linked healthcare databases. FINDINGS: The follow-up observation period (mean 1.1, maximum 10.8 years) was similar between groups, as were the reasons for censoring the observation period (end of follow-up, death, or statin discontinuation). Forty-seven percent (47%) of Chinese were initiated on a higher than recommended statin dose. Compared to non-Chinese, Chinese ethnicity did not associate with any of the four serious statin-associated adverse events assessed in this study [rhabdomyolysis hazard ratio (HR) 0.61 (95% CI 0.28 to 1.34), incident diabetes HR 1.02 (95% CI 0.80 to 1.30), acute kidney injury HR 0.90 (95% CI 0.72 to 1.13), or all-cause mortality HR 0.88 (95% CI 0.74 to 1.05)]. Similar results were observed in subgroups defined by statin type and dose. CONCLUSIONS: We observed no higher risk of serious statin toxicity in Chinese than matched non-Chinese older adults with similar indicators of baseline health. Regulatory agencies should review available data, including findings from our study, to decide if a change in their statin dosing recommendations for people of Chinese ethnicity is warranted.

Risk of adverse events among older adults following co-prescription of clarithromycin and statins not metabolized by cytochrome P450 3A4.

BACKGROUND: The cytochrome P450 3A4 (CYP3A4) inhibitor clarithromycin may also inhibit liver-specific organic anion-transporting polypeptides (OATP1B1 and OATP1B3). We studied whether concurrent use of clarithromycin and a statin not metabolized by CYP3A4 was associated with an increased frequency of serious adverse events. METHODS: Using large health care databases, we studied a population-based cohort of older adults (mean age 74 years) who were taking a statin not metabolized by CYP3A4 (rosuvastatin [76% of prescriptions], pravastatin [21%] or fluvastatin [3%]) between 2002 and 2013 and were newly prescribed clarithromycin (n=51,523) or azithromycin (n=52,518), the latter an antibiotic that inhibits neither CYP3A4 nor OATP1B1 and OATP1B3. Outcomes were hospital admission with a diagnostic code for rhabdomyolysis, acute kidney injury or hyperkalemia, and all-cause mortality. All outcomes were assessed within 30 days after co-prescription. RESULTS: Compared with the control group, patients co-prescribed clarithromycin and a statin not metabolized by CYP3A4 were at increased risk of hospital admission with acute kidney injury (adjusted relative risk [RR] 1.65, 95% confidence interval [CI] 1.31 to 2.09), admission with hyperkalemia (adjusted RR 2.17, 95% CI 1.22 to 3.86) and all-cause mortality (adjusted RR 1.43, 95% CI 1.15 to 1.76). The adjusted RR for admission with rhabdomyolysis was 2.27 (95% CI 0.86 to 5.96). The absolute increase in risk for each outcome was small and likely below 1%, even after we considered the insensitivity of some hospital database codes. INTERPRETATION: Among older adults taking a statin not metabolized by CYP3A4, co-prescription of clarithromycin versus azithromycin was associated with a modest but statistically significant increase in the 30-day absolute risk of adverse outcomes.