Long-Term Stability of Melanocytomas With Persistent Vascular Activity Without Malignant Transformation.

Purpose: To present 2 cases of large atypical melanocytomas that simulate melanoma. Methods: The largest risk factors for malignant transformation from melanocytoma into malignant melanoma are a combination of lesions with a thickness greater than 2 mm, visual symptoms, and tumor margin at the disc. The patients in this report were chosen because they both presented these factors with their lesions. Results: Because the lesions were properly identified as melanocytomas of the optic disc, the decision was made to monitor them closely and treat the associated vascular activity. Ultrasounds and close observations are key in differentiating these benign lesions from malignant melanomas. Conclusions: Both patients experienced long-term stability with intravitreal injections when needed for vascular activity.

Gene Expression Profile Class Change in a Case of Aggressive, Recurrent Melanoma.

Purpose: To report a novel case of a recurrent melanoma that had a change in its genetic expression profile (GEP) class over a 2-year period. Methods: This retrospective case study evaluated a patient with a recurrent uveal melanoma that changed classes from 1A to 1B. Results: A large melanoma was first treated with brachytherapy, and during that time genetic testing revealed a class 1A tumor. Two years later the tumor was noted to be enlarging, and the patient elected for enucleation. Subsequent GEP showed a class 1B tumor. Conclusions: An aggressive and large recurrent uveal melanoma that had changed from a class 1A to a class 1B tumor on subsequent GEP testing has never been reported before to our knowledge. It may imply that a recurrent or aggressive tumor has more mutations over time that could lead to a higher risk for metastasis. The natural course of a tumor's GEP class should be explored further.

Circumscribed Choroidal Hemangioma Simulating Choroidal Melanoma on Advanced Ultrawide-Field Pseudocolor Retinal Imaging: A Case Series.

The purpose of this case series was to evaluate the features of circumscribed choroidal hemangioma on pseudocolor ultrawide-field (UWF) retinal images simulating choroidal melanoma and compare it to fundoscopic appearance. All four patients underwent full ophthalmological examination, including dilated fundus examination, ultrasonography, and UWF imaging (UWFI). All circumscribed choroidal hemangioma appeared clinically as orange-red choroidal lesions which were echodense with regular internal structure on ultrasonography. All lesions appeared green-grey in color on pseudocolor UWFI. Pseudocolor UWFI of circumscribed choroidal hemangioma represents distortion of true color appearance and may simulate choroidal melanoma. [Ophthalmic Surg Lasers Imaging Retina 2023;54:292-296.].

Clinical Outcomes of Combined Phacoemulsification With Intraocular Lens Placement and Microincision Vitrectomy in Adult Vitreoretinal Disease.

Purpose: To evaluate the safety and clinical outcomes of combined phacoemulsification with intraocular lens (IOL) placement and microincision vitrectomy surgery (MIVS) in adult patients with concomitant cataract and vitreoretinal disease. Methods: A consecutive series of patients with comorbid vitreoretinal disease and cataract who had combined phacoemulsification with IOL placement and MIVS was retrospectively analyzed. The main outcome measures were visual acuity (VA) and intraoperative and postoperative complications. Results: The analysis comprised 648 eyes of 611 patients. The median follow-up was 26.9 months (range, 12-60 months). The most common vitreoretinal pathology was intraocular tumor (53%). The best-corrected Snellen VA improved from 20/192 at baseline to 20/46 at the 12-month follow-up. The most frequent intraoperative complication was capsule tear (3.9%). The most common postoperative adverse events after 3 months of follow-up (mean, 24 months) were vitreous hemorrhage (3.2%) and retinal detachment (1.8%). No patient developed endophthalmitis. Conclusions: Combined phacoemulsification with IOL placement and MIVS is a safe, effective technique to manage a broad range of vitreoretinal diseases in patients with significant cataract.

Sequential Short Interval Anti-VEGF for the Treatment of Stage 4 Retinopathy of Prematurity.

A 23-month-old girl born at 23 weeks' gestational age with a birth weight of 453 g and retinopathy of prematurity (ROP) stage 4A in 360° and plus disease in both eyes was treated in another institution with laser; her treatment was complicated with two cardiac arrests during the procedure. The patient was referred and treated at 31 weeks with repeated intravitreal bevacizumab injection in both eyes secondary to progressive ROP. Treatment with multiple anti-vascular endothelial growth factor (VEGF) therapy as monotherapy led to the resolution of a retinal detachment and full vascularization of the retina in both eyes. To the best of the authors' knowledge, this is the first description of a patient with stage 4A ROP treated solely with anti-VEGF after failed laser treatment that led to complete resolution of a retinal detachment without surgical intervention. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:159-163.].

Multimodal treatment of Coats-like exudative vitreoretinopathy in Goldmann-Favre syndrome.

PURPOSE: To report a Coats-like exudative vitreoretinopathy in Goldmann-Favre syndrome. OBSERVATIONS: A 64 year-old woman with prior diagnosis of retinal dystrophy presented with decreased vision in the right eye (OD). Ophthalmologic examination was remarkable for bilateral arteriolar attenuation, mid-peripheral bony-spicules, and waxy disc pallor. Coats-like exudative vitreoretinopathy and cystoid macular edema were present OD. Genetic testing showed a homozygous pathogenic mutation in gene NR2E3, variant c.932G>A (p.Arg311Gln), consistent with Goldmann-Favre syndrome. Targeted laser ablation and combination intravitreal therapy were effective in decreasing macular edema. CONCLUSIONS AND IMPORTANCE: A Coats-like exudative vitreoretinopathy may occur in the setting of Goldmann-Favre syndrome. Targeted laser ablation in combination with intravitreal therapy can be efficacious in select patients.

Erdafitinib-Induced Secondary Maculopathy.

Purpose: This work presents a case of secondary maculopathy associated with the use of erdafitinib (Balversa) for the management of bladder urothelial carcinoma with bony metastasis. Methods: A case report is presented. Results: A 58-year-old Hispanic man presented with blurry vision 3 weeks after starting erdafitinib for the management of bony metastases associated with urothelial carcinoma. A comprehensive evaluation identified multiple areas of subretinal fluid induced by erdafitinib. Throughout treatment, the ocular condition progressed, causing worsening of vision; this led to discontinuation of the drug. Discontinuation was associated with visual and anatomic function improvement. Conclusions: Fibroblast growth factor receptor (FGFR) plays a major role in maintaining mature and premature retinal pigment epithelium cells. Drugs that inhibit the FGFR pathway block the activation of the mitogen-activated protein kinase pathway, leading to synthesis of antiapoptotic proteins. Erdafitinib is associated with ocular toxicity and leads to multifocal pigment epithelial detachments associated with secondary subretinal fluid.

Atypical Event Profiling of Intra-Arterial Chemotherapy.

Purpose: Three cases of atypical events following intra-arterial chemotherapy for the treatment of retinoblastoma are presented. Methods: Case report. Results: One patient had acute orbital swelling with proptosis, another with extravasation of the chemotherapeutic agent, and the final with total ipsilateral hearing loss. Conclusions: These cases underscore the importance of maintaining close follow-up when using intra-arterial chemotherapy for treatment of retinoblastoma.

Retinoblastoma in the Presence of Persistent Fetal Vasculature.

Purpose: This work aims to report the challenging diagnosis, treatment, and follow-up of a patient with persistent fetal vasculature (PFV) and retinoblastoma (RB). Methods: A 22-month-old boy presented with unilateral RB stage VB in the right eye and PFV in both eyes. The patient was treated with transpupillary laser ablation and systemic chemotherapy. Results: Treatment resulted in complete tumor regression. Two years after the last systemic chemotherapy treatment, magnetic resonance imaging (MRI) showed increased signal intensity with progressive optic nerve enhancement, where intraneural malignancy could not be excluded. Enucleation of the right eye was performed. Histopathologic review showed no residual active malignancy in the enucleated globe. Conclusions: This case demonstrates the importance of a thorough clinical examination to establish the correct diagnosis and to rule out RB before any surgery. This case also highlights the importance of regular follow-ups after tumor regression with full a ophthalmologic examination, B-scan, and periodic MRI.

Adolescent Plaque Brachytherapy for Large Choroidal Metastasis from Lung Carcinoid Tumor.

The purpose of this publication is to report a child with choroidal metastasis from a primary lung carcinoid tumor treated with 125-iodine plaque brachytherapy while achieving complete tumor regression. A 15-year-old girl with a history of stage IV lung carcinoid tumor developed painless progressive visual loss in her right eye. Ophthalmological exam documented a unilateral solitary large choroidal mass with complete exudative retinal detachment. Planned palliative treatment with plaque brachytherapy was performed utilizing a total dose of 45 Gy to the tumor apex. No tumor regression was noted after 6 months of follow-up. Ten months after primary therapy, re-treatment with a total dose of 90 Gy to the tumor apex was performed due to tumor progression. Complete regression was achieved after secondary treatment without evidence of recurrence after 18 months of follow-up. In conclusion, high-dose plaque brachytherapy may induce complete tumor regression in select adolescent patients with choroidal metastasis from lung carcinoid tumor.

Alphabet Soup: Clinical Pearls for the Retina Specialist-Ocular Toxicity of Advanced Antineoplastic Agents in Systemic Cancer Care.

Targeted antineoplastic agents and immunotherapies have revolutionized management strategies available for previously refractory cancer. Despite the growing list of pharmacologic agents and indications, many of the currently Food and Drug Administration-approved therapies are associated with ocular adverse effects. Retina specialists and oncologists should be aware of potential side effects because some may be severe and permanent. Although most ocular side effects require conservative treatment without discontinuation of life-preserving therapies, rare severe adverse reactions can be potentially blinding and may warrant an extensive discussion regarding different management strategies, including cessation of life-preserving therapy.

Case Series: Small Full-thickness Macular Hole Treated with Topical Dorzolamide and Bevacizumab Intravitreal Injections.

SIGNIFICANCE: This article reports two cases reported of combined treatment with topical dorzolamide and intravitreal bevacizumab injections, successfully treating small full-thickness macular hole without the need for traditional macular hole surgery. PURPOSE: This study aimed to report the potential effectiveness of combination treatment with topical dorzolamide and bevacizumab intravitreal injection therapy for small macular holes. CASE REPORTS: Case 1 was a 68-year-old woman presented with distorted and decreased vision in her right eye for 9 months. Fundus examination showed a full-thickness macular hole, which was confirmed with spectral domain optical coherence tomography measuring 96 µm. Treatment with topical dorzolamide and intravitreal bevacizumab 1.25 mg/0.05 mL injections was initiated. Spectral domain optical coherence tomography showed gradual improvement of the full-thickness macular hole with complete hole closure and visual improvement in just 1 month. Case 2 was a 73-year-old woman who presented with distorted and decreased vision in her right eye for 8 months. Fundus examination showed a full-thickness macular hole in the right eye, confirmed with spectral domain optical coherence tomography, measuring 76 µm. Treatment with topical dorzolamide and intravitreal bevacizumab 1.25 mg/0.05 mL injections was initiated. Spectral domain optical coherence tomography showed gradual improvement of the full-thickness macular hole with complete closure at 2 months and improvement in visual acuity. CONCLUSIONS: The combination of topical dorzolamide and bevacizumab intravitreal injection is a reasonable consideration for small macular holes with vascular components before considering surgery. Both cases had early macular closure in less than 3 months.

Case Report: Two Genetically Distinct Choroidal Melanomas in the Same Eye Treated with Endolaser Therapy.

SIGNIFICANCE: This case report highlights the merits of using fine needle aspiration biopsy to obtain gene expression profiling of individual choroidal melanomas when more than one tumor arises in the same eye. It is also the first such case to document laser ablation therapy as the primary treatment. PURPOSE: This report describes a case of two primary choroidal melanomas with different genetic profiles in the same eye. CASE REPORT: An 80-year-old man presented to the office with a neoplasm of uncertain behavior in the left eye. The patient's visual acuity and IOP in the left eye, respectively, at the time of his first visit to the office were 20/25 and 8 mmHg. A dilated fundus examination revealed that there were two choroidal lesions in the left eye. The macular lesion was classified as type 1A, and the ciliochoroidal lesion was classified as type 1B. The patient underwent a vitrectomy of the left eye, followed by endolaser ablation of the tumors. The patient was also injected with bevacizumab. To date, the patient is free of known metastasis. Most recently, his visual acuity and IOP in the left eye were 20/30 and 14 mmHg, respectively. CONCLUSIONS: Although rare, multiple melanomas in the same eye may have differing genetic profiles, which may alter prognosis and management, depending on the class of tumor detected.

New Classification for the Reporting of Complications in Retinal Detachment Surgical Trials.

IMPORTANCE: Quantifying severity of complications in rhegmatogenous retinal detachment (RRD) surgical trials is needed. A consensus classification system will help surgeons to more effectively compare harms of different surgical techniques. OBJECTIVE: To develop a new consensus-based classification to quantify severity of complications of RRD surgery. DESIGN, SETTING, AND PARTICIPANTS: A comprehensive list of complications was developed followed by a Delphi consensus survey of international vitreoretinal surgeons. The survey was conducted in 17 countries in mainland Europe, the United Kingdom, the United States, Asia, South Africa, and Australia. Seventy vitreoretinal surgeons were invited to take part in the Delphi survey; 45 agreed to participate. Participants were selected through boards/members lists of retinal societies. Data were analyzed between April 2019 and August 2019. MAIN OUTCOMES AND MEASURES: Consensus-derived classification of complications of RRD surgery, according to their severity. RESULTS: Forty-three of 45 vitreoretinal surgeons who agreed to participate in the Delphi survey completed round 1 (96%); all but 1 (98%) completed round 2. Consensus was reached for 96% of the 84 complications assessed. Examples of complications classified as least severe (graded 1) included subconjunctival hemorrhage and chemosis while those classified as most severe included endophthalmitis and sympathetic ophthalmia (graded 9) and phthisis (graded 10). CONCLUSIONS AND RELEVANCE: We propose a new classification for quantifying severity of surgical complications based on an international consensus of vitreoretinal surgeons to quantify harm and improve the reporting of complications of RRD surgery.

Reporting of Complications in Retinal Detachment Surgical Trials: A Systematic Review Using the CONSORT Extension for Harms.

IMPORTANCE: Knowledge on the frequency and severity of complications in surgical trials for rhegmatogenous retinal detachment (RRD) is essential to determine whether surgical procedures are developed and compared adequately, taking into account not only efficacy but also harms. OBJECTIVE: To review standards of reporting of complications in recent randomized clinical trials of RRD surgery. EVIDENCE REVIEW: This systematic review included randomized clinical trials on RRD surgery published between January 2008 and January 2021 in Embase, MEDLINE, and Web of Science Core Collection databases. Titles, abstracts, and full-text articles retrieved were reviewed for eligibility by 2 independent authors. Eligible studies were evaluated against checklist items from the Consolidated Standards of Reporting Trials Extension for Harms criteria by 2 independent authors, and discrepancies were resolved by discussion with a third author. FINDINGS: Fifty studies were included. The median number of checklist items fulfilled was 8 (range, 0-15), of a possible total of 18. Frequently reported items were discussions balanced with regard to efficacy and adverse events (42 studies [84%]) and inclusions of harm-associated timing of data collection (41 studies [82%]). The least frequently reported items were distinctions between expected and unexpected adverse events (1 study [2%]) and mentions of the use of a validated instrument to report adverse event severity (4 studies [8%]). Frequency of complications was commonly reported (29 studies [58%]) in contrast with complication severity (10 studies [20%]). CONCLUSIONS AND RELEVANCE: This review suggests that severity of complications of RRD surgery has been infrequently quantified and reported in randomized clinical trials and potentially represents an important area of improvement in future RRD surgical trials.

Pharmacotherapy as an adjunct to vitrectomy.

Vitreoretinal surgery has advanced extensively from the first days of vitrectomy. During the last decade, new developments in intravitreal pharmacotherapy have created new opportunities to enhance the surgical outcomes of our patients. In this article, we review and discuss some of the supporting evidence of different pharmacotherapies that may be used as an adjunct to vitrectomy for select common etiologies. Triamcinolone acetonide, dexamethasone, and angiogenesis inhibitors are among the most commonly used drugs given their safety profile and proven efficacy. Other pharmaceuticals have also shown promising results in small studies. The adoption of individualized medical treatments prior, during, and after vitrectomy will continue to increase as new evidence supporting the benefit of pharmacotherapy as an adjunct to vitrectomy becomes available.

Treatment response assessment following transarterial radioembolization for hepatocellular carcinoma.

Transarterial radioembolization with yttrium-90 microspheres is an established therapy for hepatocellular carcinoma. Post-procedural imaging is important for the assessment of both treatment response and procedural complications. A variety of challenging treatment-specific imaging phenomena complicate imaging assessment, such as changes in tumoral size, tumoral and peritumoral enhancement, and extrahepatic complications. A review of the procedural steps, emerging variations, and timelines for post-treatment tumoral and extra-tumoral imaging changes are presented, which may aid the reporting radiologist in the interpretation of post-procedural imaging. Furthermore, a description of post-procedural complications and their significance is provided.

How to Approach a Hip PARTI With Confidence: Ultrasound-Guided Parallel Transverse in-Plane Technique for Intra-articular Hip Interventions.

The "parallel transverse in-plane" technique for ultrasound-guided intra-articular hip interventions ensures needle visualization for the entire procedure, with the needle clearly shown entering the joint. With the widely described longitudinal in-plane approach, needle visualization can be poor, necessitating reliance on tissue distortion, which can reduce user confidence and safety. The parallel transverse in-plane approach is invaluable in those with anterior thigh skin breakdown and where anterior access is contraindicated. The approach also allows a broad width of the synovium to be traversed and is therefore well suited to synovial biopsy. This short Technical Innovation highlights this alternative approach to hip joint intervention.

Brolucizumab: Evaluation of Compassionate Use of a Complex Anti-VEGF Therapy.

OBJECTIVE: To report a consecutive series of compassionate, off-label use of intravitreal brolucizumab as a rescue therapy for complex, non-responsive macular edema. This report delineates primary diagnosis, indications for treatment, adverse events, and visual and anatomic outcomes after intravitreal brolucizumab. METHODS: A retrospective review of a consecutive clinical case series of 110 eyes treated with intravitreal brolucizumab between January 1st and March 1st. 2020. All patients were included if they received intravitreal brolucizumab in an off-label delivery and had ongoing macular edema in the setting of prior, multiple intravitreal anti-VEGF and/or intravitreal triamcinolone acetonide. All patients had spectral domain OCT documented before, at the time of, and in serial follow-up after intravitreal brolucizumab. RESULTS: Ninety-eight of 98 patients had marked decrease in macular edema. Indications for treatment were assigned to the primary etiologic diagnosis leading to the macular edema secondary to radiation retinopathy, complex epiretinal membrane, or complex diabetic retinopathy. In this series, sdOCT central point thickness decreased by an average of 71.5 microns, subretinal fluid resolved, and visual acuity was improved in 40% (greater than two Snellen lines) and stable in 60% (within two Snellen lines). No patient experienced a severe adverse event to specifically include vitritis and/or vasculitis. CONCLUSION: In this series, brolucizumab intravitreal injection was associated with significant improvement in macular edema in each diagnostic category. No serious complications to treatment were found in this series. Brolucizumab, though associated with known intraocular inflammation and vasculitis, demonstrated marked benefit in these complex eyes previously unresponsive to aggressive intravitreal pharmacotherapy.