PRESUMPTIVE RECURRENCE OF INTRAOCULAR LYMPHOMA DESPITE CHIMERIC ANTIGEN RECEPTOR T-CELL THERAPY.

PURPOSE: To present the first reported case of presumptive intraocular recurrence of lymphoma following Chimeric Antigen Receptor (CAR) T-cell therapy despite systemic control by CD19-CAR T cells. METHODS: Observational case report. RESULTS: A 59-year-old man with diffuse, large, B-cell lymphoma subsequently developed secondary central nervous system disease despite chemotherapy. He underwent stem cell transplantation but relapsed again and was scheduled to receive CAR T-cell therapy. He developed vitritis several weeks before treatment, with vitreous biopsy showing non-Hodgkin B-cell lymphoma. He received CAR T-cell therapy following the vitrectomy. He presented 3 months following CAR T-cell therapy with nonspecific right eye floaters and discomfort, with the optical coherence tomography revealing subretinal saw-tooth deposits in the right eye, highly suggestive of lymphoma. This is despite having good systemic control with no other disease elsewhere in the body. He received intravitreal methotrexate to good effect. CONCLUSION: To our knowledge, this is the first case of a vitreoretinal lymphoma nonresponsive to CAR T-cell therapy, despite good central nervous system and systemic control. This is suggestive of anti-CD19 CAR T cells not trafficking into the eye in sufficient numbers to eliminate CD19-expressing neoplastic B cells. We suggest regular ophthalmic follow-up after CAR-T-cell therapy for patients where there is evidence of ocular involvement.

Comparison of Primary Duet Lens Procedures: In-The-Bag Monofocal with Sulcus Multifocal, and Standard Single Multifocal Lens for Cataract Surgery.

Purpose: To assess the safety and efficacy of primary duet intraocular lens (IOL) procedure using an in-The-bag monofocal IOL and a sulcus-based multifocal reversible platform for cataract surgery. The visual outcomes were compared with a single in-The-bag multifocal IOL. Patients and Methods: Retrospective cohort study. Consecutive patients who underwent primary duet IOL procedures were compared with consecutive patients who underwent single multifocal IOL surgery. Primary outcomes were uncorrected distance and near visual acuities (UDVA and UNVA), refraction and spherical equivalent data. Secondary outcomes included surgical complications. Results: The study group consisted of 32 eyes (22 toric IOLs) whilst the control group had 57 eyes (29 toric IOLs). There were no statistically significant differences between the two groups on post-operative 1-month and 1-year UDVA (p=0.1522 and 0.4926, respectively) and UNVA (p=0.1248 and 0.2738, respectively). There were no statistically significant differences in the postoperative 1-month spherical equivalent within ± 0.5 diopter (p=0.1891). Postoperative intraocular pressure spikes were observed on day-1 in both groups, with most returned to their baseline at 1-month and all were normal at 1-year post surgery. There were no statistically significant differences in intraocular pressure between the two groups on day-1, 1-month and 1-year after surgery (p=0.6421). There were no statistically significant differences in the IOL axis deviation from the intended axis in the toric subgroup analysis (p=0.5843). Conclusion: Primary duet IOL procedure is equally effective and safe in correcting distance and near vision when compared with single multifocal IOL in the capsular bag.

Predictors of longitudinal seizure outcomes after epilepsy surgery in childhood.

There is a paucity of data on longitudinal seizure outcome of children undergoing epilepsy surgery. All children (n = 132) who underwent resective epilepsy surgery from January 1998 to December 2015 were identified. Relevant clinical, neurophysiological, imaging, surgical and seizure outcome data were extracted. Multivariable logistic regression analysis and Kaplan-Meier survival with Cox proportional hazard modelling were performed. The mean age at surgery was 7.8 years (range 0.2-17.9). 71% were seizure-free at a mean follow up of 5.3 ± 2.7 years. Of those who were seizure-free, 65 patients were able to completely wean off anti- seizure medications successfully. Using survival analysis, the probability of Engel Class I outcome at one year after surgery was 81% (95% confidence interval [CI] 87%-75%). This dropped to 73% at two years (95% CI 81%-65%), 58% at five years (95% CI 67.8%-48%), and 47% at ten years. Proportional hazard modelling showed that the presence of moderate to severe developmental disability (HR 6.5; p = 0.02) and lack of complete resection (HR 0.4; p = 0.02) maintain association as negative predictors of seizure-free outcome. Our study demonstrates favorable long-term seizure control following pediatric epilepsy surgery and highlights important predictors of seizure outcome guiding case selection and counseling of expectations prior to surgery.

Determining the learning curve for a novel microsurgical procedure using histopathology.

PURPOSE: Wet laboratories are becoming an increasingly important training tool as part of a push to a proficiency-based training model. We created a microsurgical wet laboratory to investigate the utility of histopathology use in assessing surgical outcomes and determine the learning curve of a novel microsurgical procedure. METHODS: A microsurgical wet laboratory was established using pig eyes to simulate the human cornea. Three novice surgeons and an experienced surgeon performed an anterior cornea lamellar dissection and the duration of the procedure was recorded. With the aid of histological analysis, the thickness and characteristics of the dissected graft was recorded. The number of attempts to complete the experiment, defined as three successful dissections with mean thickness below 100 µm, was documented. RESULTS: The use of histopathology was highly successful allowing in-depth analysis of the dissected graft for each attempt. Trainees reached the endpoint of the study in 21, 26 and 36 attempts (mean: 28 attempts) whilst the corneal surgeon completed the experiment in 12 attempts (p = 0.07). Mean dissection thickness decreased over time for all participants. The mean dissection time for trainees was 10.6 ± 4.2 min compared to the corneal surgeon with a mean of 8.2 ± 3.1 min (p = 0.03). CONCLUSION: We propose a corneal wet laboratory model that allows for simple, efficient, and flexible microsurgical training. The use of histopathological analysis allows for careful graft analysis, providing objective feedback throughout the training exercise. Trainees demonstrated improvements in the three key aspects of the procedure: accuracy as evidenced by decreasing histological thickness, confidence by self-report and fluidity by decreasing duration of the procedure.

Post-renal transplant urolithiasis in children: an increasingly diagnosed complication: a retrospective cohort study.

OBJECTIVE: Urolithiasis in renal transplant (RTx) recipients is a potential cause of allograft loss if obstruction is untreated. It is not clear if paediatric transplant recipients are following the global trend for increased prevalence of urolithiasis over time. DESIGN/SETTING/PATIENTS: A retrospective chart review was undertaken to evaluate the frequency, risk factors and characteristics of post-RTx urolithiasis over two decades (1995-2016), in a tertiary Australian paediatric hospital. RESULTS: Stones were diagnosed in 8 of 142 (5.6%) recipients, 6 of whom were transplanted in the latter decade. All patients were male, with a median age 4.9 years and median weight 11.8 kg. Presentation was with haematuria (n=4), pain (n=2), dysuria (n=2), stone passage (n=1) and asymptomatic (n=1). Time to presentation was bimodal; three stones were identified in the initial 3 months post RTx and the remainder after 31-53 months. Two stones were in association with retained suture material and two patients had recurrent urinary tract infections. The average stone size was 8.4 mm. Five stones were analysed; all contained calcium oxalate, three were mixed, including one with uric acid. Five (83.3%) children had hypercalciuria but none had hypercalcaemia. Cystolithotripsy was the the most common treatment (n=5), in combination with citrate supplementation. No graft was lost due to stones. CONCLUSIONS: Calculi occur with increasing frequency after renal transplantation. Clinicians need a high index of suspicion as symptoms may be atypical in this population. The cause for the increased frequency of stones in transplant recipients is not clear but is in keeping with the increase seen in the general paediatric population.

Intra-abdominal Complications After Pediatric Kidney Transplantation: Incidence and Risk Factors.

BACKGROUND: The incidence and types of intra-abdominal complications after pediatric transplantation are not well established, and specific risk groups have not been clearly identified. METHODS: A retrospective chart review of all pediatric transplant recipients between 1995 and 2016 was undertaken. Intra-abdominal complications were grouped into 4 categories: fluid collections, gastrointestinal, vascular, and urogenital. Donor, recipient, and transplant characteristics were evaluated using univariate and multivariate logistic regressions. RESULTS: There were 146 transplants meeting the inclusion criteria. The mean follow-up time was 4.6 ± 3.7 years (range, 0.3-18 y). The mean weight at transplantation was 31.5 ± 16.5 kg (range, 9-78), with 24 (16%) recipients being <15 kg and 23% younger than 5 years. Thirty-four (23%) patients had previous abdominal surgery. There were 32 complications identified in 27 (18%) transplant recipients. Fluid collections requiring surgical drainage developed in 9 (6.2%), gastrointestinal surgical complications in 12 (8.2%), vascular complications in 5 (3.5%), and urogenital complications in 6 (4.1%). There were only 3 graft losses due to abdominal complications, all after renal vein thrombosis. Weight <15 kg at the time of transplant (P = 0.016), previous abdominal surgery (P = 0.047), and intraperitoneal surgical technique (P = 0.008) were risk factors in the univariate analysis using Cox regression models, whereas only weight <15 kg (P = 0.003) and previous abdominal surgery (P = 0.008) were retained in the multivariate analysis. CONCLUSIONS: Intraabdominal complications occur in almost 1 in 5 pediatric renal transplant recipients. Weight <15 kg and previous abdominal surgery are risk factors for developing such complications.