Sclerouvectomy plus intraoperative ophthalmic brachytherapy for iris-ciliary body melanomas.

BACKGROUND: Partial lamellar sclerouvectomy was designed more than 30 years ago by Jerry and Carol Shields, in order to remove melanomas that involved the ciliary body and/or the choroid, while leaving intact the outer portion of the sclera and the overlying sensory retina [1]. METHODS: We present two cases of iris-ciliary body melanoma with different size. The performed surgery was a partial lamellar sclerouvectomy plus iridectomy, complemented by intraoperative juxtalimbar ruthenium-106 brachytherapy. RESULTS: Both cases achieved anatomical success without developing chronic ocular hypotony in the postoperative period, an infrequent but possible complication [2]. Even one of them reached a best-corrected visual acuity of 0.7 after silicone oil removal and intravitreal implant of dexamethasone because of secondary macular edema. The other remains stable with counting fingers vision. In this case, the poor functional outcome might be influenced by larger size and longer evolution of the tumor, as well as the uncontrolled arterial hypertension and older age of the patient. DISCUSSION: Intraoperative ophthalmic brachytherapy may have a beneficial effect not only over neoplastic activity [2], but also over early choroidal detachments. Its pro-fibrotic/hemostatic stimulus should be further examined by comparative studies with larger cohorts, either prospectively or retrospectively. Other protective factors could be the utilization of equine pericardial grafts for covering scleral defects as well as leaving high-density silicone oil. Another key aspect is to maintain low blood pressure levels during these procedures in order to avoid intraocular hemorrhages [3], especially when the patient exceeds the sixth decade, so the anaesthesiologist will also play a decisive role in the operating room. We prefer to anticipate the likely development of lens opacification after this operation [4], performing cataract surgery at the beginning and using a Cionni capsular tension ring due to a probable zonular instability. Pars plana vitrectomy would also remove peripheral vitreoretinal tractions and seal the retina preventing a detachment. CONCLUSION: As can be observed during the surgical video, a wide range of complications could occur during a partial lamellar sclerouvectomy. Tackle them ahead of time is crucial to achieve anatomical and functional success.

Study of minimally invasive radiofrequency ablation of the ciliary body for the treatment of glaucoma in rabbits.

The aim of the present study was to explore the safety and effectiveness of radiofrequency ablation (RFA) of the ciliary body for the treatment of glaucoma. A glaucoma model was established in New Zealand white rabbits, which were then treated with RFA of the ciliary body, utilizing an XL­1­type RF meter developed by the Chinese PLA General Hospital. After treatment, general ocular investigation, including ocular pressure was carried out, the anterior chamber was imaged via ultrasound biomicroscopy, and the pathological changes were observed via hematoxylin and eosin (H&E) staining. It was determined that the glaucoma model was successfully established in the New Zealand white rabbit by inducing high intraocular pressure (IOP). After RFA treatment, ablation spots were observed but no clear anterior chamber reaction was found. The ablation group showed a steady and continuous decrease of IOP, which was significantly lower than the model group at days 3 and 7 (P<0.05). A sclera pathway was observed in the ablation site 1­day post­treatment, which had mostly recovered by day 7. H&E staining demonstrated shedding of the ciliary epithelium, and an unclear boundary between muscle layer and blood vessel at day 1. This had fully recovered by day 14, with clear ciliary layers and well­arranged muscle structures observed. The present study suggested that treatment with RFA could decrease IOP without substantial side effects in the glaucoma model in the rabbit. Therefore, it could be used as a strategy to control IOP and as a treatment for glaucoma in the clinic.

Argon laser-assisted hypotony model in the rabbit.

To investigate whether ocular hypotony formation with 360 degrees endocyclophotocoagulation is possible. Twelve male New Zealand White rabbits were used. Entire ciliary body epithelium was destructed with green laser photocoagulation after pars plana lensectomy and anterior vitrectomy in six rabbits. Endocyclophotocoagulation was not performed to the remaining six rabbits (control group). Intraocular pressure (IOP) was measured preoperatively and followed up everyday in the first week and weekly until the end of month one. All of the rabbits were sacrificed and ciliary bodies were left for gross and light microscopic examination. Mean baseline IOPs were similar in laser and non-laser group (14.8 ± 1.4 (range 12.2-17.3) vs 14.4 ± 1.4 (range 12.2-15.9), p = 0.650). Mean IOP was 6.6 ± 0.45 mmHg (range 5.9-7.1) in the laser group and 11.5 ± 1.2 mmHg (range 10.2-13.4) in the non-laser group in postoperative day 1. IOP was below 4 mmHg in all eyes on the second day and after in laser group. In the macroscopic evaluation, the entire ciliary body had a white (loss of pigmentation) and atrophic appearance in all of the eyes in the laser-treated group compared to non-laser group. In the laser group, light microscopic examination demonstrated a severe 360 degrees disruption of ciliary processes. Ciliary processes were covered with fibrin exudation consisting of fibroblasts. There was a mild inflammation with disruption or atrophy of ciliary body epithelium with cystic vacuolar degeneration. Three hundred sixty degrees endocyclophotocoagulation yielded severe ciliary epithelium damage. IOP reduction started very early and continued in hypotonic levels during follow up period.

Ruthenium-106 brachytherapy for iris and iridociliary melanomas.

BACKGROUND AND PURPOSE: To evaluate ruthenium-106 (Ru106) brachytherapy as eye-conserving treatment of iris melanomas (IMs) and iridociliary melanomas (ICMs). MATERIALS AND METHODS: Eighty-eight patients received Ru106 brachytherapy between 2006 and 2016. Primary outcome was local control, and secondary outcomes were metastasis, survival, eye preservation, complications and visual acuity (VA). RESULTS: Overall median follow-up was 36 months. Of 88 patients, 58 (65.9%) had IM and 30 (34.1%) had ICM. ICM were on average larger and more advanced than IM. Local failure-free survival at 3years was 98.9% (SE 1.2%). Metastasis-free survival was 98.2% (SE 1.8%) at 3years; no deaths due to melanoma occurred during follow-up. Eye preservation rate was 97.7%. Treatment-related toxicities were mostly mild and observed in 80.7% of the patients. Common toxicities were worsening of pre-existing or new cataract (51.1%), dry eyes (29.5%) and glaucoma (20.5%). VA was not affected by Ru106 brachytherapy, with only 2.3% having VA <0.33 (low vision) at follow-up. CONCLUSIONS: Ru106 for IM and ICM yielded excellent local control (98.9%) and eye preservation (97.7%). Toxicities were common, but mostly mild and transient. Moreover, Ru106 did not affect visual acuity.

Palladium-103 plaque radiation therapy for ciliary body melanoma through a functioning glaucoma filtering bleb.

PURPOSE: To provide a clinical description of the long-term outcome of a 103Pd plaque-irradiated ciliary body melanoma with extrascleral extension while attempting to preserve a subadjacent glaucoma filtering bleb. METHODS: A 75-year-old woman with pseudoexfoliative glaucoma for 17 years, 16 years status post argon laser trabeculoplasty, and 15 years status post trabeculectomy in the left eye, was diagnosed with an ipsilateral ciliary body melanoma with visible extrascleral extension. Treatment involved insertion of a 103Pd radioactive plaque over the functioning trabeculectomy, with removal 7 days later. At plaque insertion, amniotic membrane grafts were used to cover the plaque and protect the filtering site. RESULTS: The tumor was successfully treated without clinical evidence of harm to the filtering bleb, with resultant stable intraocular pressure. However, the patient developed blebitis 1.5 years later. Though it resolved with topical antibiotic therapy, the bleb became less succulent. Two years postoperatively, she developed a spontaneous hyphema that resolved after one injection of transscleral bevacizumab 1.25 mg. Her tumor continually regressed in thickness. Without additional glaucoma surgery, her intraocular pressure remained well-controlled on topical medications for 6 years. CONCLUSIONS: Ciliary body melanoma with minimal extrascleral extension beneath a functioning filtering bleb can be treated using radioactive plaque therapy. In this case, we were able to achieve both tumor regression and glaucoma control by covering the plaque with an amniotic membrane graft.

Radiation induced violations of blood circulation in the ciliary body and changes of the anterior chamber angle in the pathogenesis of glaucoma in clean up workers of the Chornobyl NPP accident and residents of contaminated areas. / RADITsIY̆NO INDUKOVANI PORUShENNIa KROVOOBIGU V TsILIARNOMU TILI TA ZMINY KUTA PEREDN'OI KAMERY OKA V PATOGENEZI GLAUKOMY V UChASNYKIV AVARIY̆NYKh ROBIT NA ChORNOBYL'S'KIY̆ AES I MEShKANTsIV ZABRUDNENYKh TERYTORIY̆.

OBJECTIVE: Estimate changes blood filling of the ciliary body and changes of the anterior chamber angle; study their influence to glaucoma pathogenesis in irradiated persons. MATERIALS AND METHODS: Used the results of a randomly selected group survey of 41 clean up workers of the Chornobyl NPP accident (clean up workers), and 18 inhabitants of the zone of guaranteed voluntary resettlement; age at the time of the survey was 45-50 years. The control group consisted of 41 persons of the same age had not radiation exposure. State of the anterior chamber angle studied by gonioscopy, which was conducted 35 clean up workers and 35 persons of the control group. Changes of the blood circulation in the ciliary body examine by the ophtalmoreog raphy, what was done on 12 eyes of 6 clean up workers, control was 12 eyes of 6 persons had not radiation exposure. RESULTS: Detection revealed of the blood circulation in the ciliary body in all clean up workers, reography coefficient was probably lower (p < 0.05), than in the control group. The research of the state of the anterior chamber angle revealed a higher relative risk of appearance of involution changes of the anterior chamber angle in clean up work ers of ChNPP accident, in comparison with the control group was 3.5 (1.27; 9.5) χ2 = 7.48, p = 0.031. The same changes are characteristic for inhabitants of radiation polluted territories. CONCLUSIONS: Influence ionizing radiation causes a blood circulation decrease in the ciliary body and development changes of the angle of the anterior chamber. Presence of these changes can explain the features of the pathogene sis of glaucoma in irradiated late manifestation and, at the same time, severe course.

Treatment outcomes of micropulse transscleral cyclophotocoagulation in advanced glaucoma.

Glaucoma is the leading cause of irreversible blindness worldwide. The goal of this study was to describe our experience with the novel micropulse transscleral cyclophotocoagulation (MP-TSCPC; IRIDEX IQ810 Laser Systems, CA) in patients with advanced glaucoma. Patients with advanced glaucoma who underwent MP-TSCPC were included in our study. Laser settings were 2000 mW of 810 nm infrared diode laser set on micropulse delivery mode. The laser was delivered over 360° for 100-240 s. The duty cycle was 31.3 %, which translated to 0.5 ms of "on time" and 1.1 ms of "off time." Surgical success was defined as an intraocular pressure (IOP) of 6-21 mmHg or a reduction of IOP by 20 % at the last follow-up visit. Failure was defined as an inability to meet the criteria for success or a need for incisional glaucoma surgery. Nineteen patients underwent MP-TSCPC with mean follow-up of 60.3 days. Mean IOP dropped from 37.9 mmHg preoperatively to 22.7 mmHg at last follow-up, representing a 40.1 % decrease. The success rate for initial treatment was 73.7 % (n = 14). Three patients underwent a second treatment, increasing the overall success rate to 89.5 % (n = 17). Four patients gained one line of vision, and four patients lost one line of vision. The novel MP-TSCPC laser had a high rate of surgical success after a short follow-up period in patients with advanced glaucoma. Further long-term evaluation and comparison to the traditional transscleral cyclophotocoagulation are warranted.

Study of microcirculation of the ocular ciliary body in experimental kidney disease.

We studied disorders in ciliary body microcirculation in experimental chronic glomerulonephritis with tubulointerstitial nephritis and evaluated the hemodynamic effects of low-frequency pulsed electromagnetic field in this pathology. Laser Doppler flowmetry demonstrated vasospasm with reduced nutrient blood fl ow in the ciliary body of animals with experimental chronic glomerulonephritis with tubulointerstitial nephritis. The exposure to low-frequency pulsed electromagnetic field using developed technology will lead to significant reduction of the vascular tone and improve arterial blood supply to the microcirculatory bed.

Malignant teratoid ciliary body medulloepithelioma in a neonate.

Ciliary body medulloepithelioma is an intraocular tumor manifesting in early childhood, rarely at birth. A unique case of intraocular malignant teratoid ciliary body medulloepithelioma in a neonate presenting as buphthalmos at birth is reported. There was rapid progression with extraocular extension within 2 months and developed regional lymph node metastasis despite enucleation. The child underwent lymph node dissection and local radiotherapy with complete remission.

[The study of opportunity of aqueous humor filtration increase after nondestructive laser exposure of sclera in the site of pars plana projection (experimental study)].

Increase of scleral water permeability due to formation of porous structure after exposure of pulsed periodic radiation of erbium-glass optical fiber laser with wave length 1,56 pm was demonstrated in experimental study of cadaver human eyes in vitro and eyes of experimental animals (rabbits) in vivo. Simultaneous complex laser exposure of pars plana and ciliary processes results in summation of morphological changes that provide decrease of aqueous humor secretion, uveal drainage and extension of suprachoroid space. A base for new noninvasive technology of nondestructive laser exposure in glaucoma treatment is established.

Does beta-ray emitting therapy of ciliary body tumors decrease central corneal endothelial cell density.

PURPOSE: To evaluate the effect of plaque radiation therapy using beta-radioactive isotope for anterior segment tumors on the density and morphology of endothelial cells. 
 METHODS: Endothelial cell density (ECD) and morphometry in 15 eyes of 15 patients with ciliary body tumor was examined prior to and 6 months after radiation therapy. After irradiation, central ECD values were also compared with peripheral (2.0 mm from limbus) ECD values measured around the plaque. The ECD, average cell area, coefficient of variation of cell area, and pachymetry measurements were conducted with contact specular microscopy.
 RESULTS: The mean corrected ECD values prior to irradiation were 2147 ± 128 cells/mm2 and 2050 ± 108 cells/mm2 after the radiation therapy. After irradiation, the mean peripheral ECD values were 2056 ± 101 cells/mm2. A significant decrease in ECD values was observed after radiation (p = 0.007). Peripheral ECD values measured around the plaque showed no significant difference (p = 0.86) as compared to central ECD values.
 CONCLUSIONS: According to our measurements, plaque therapy for tumors in the anterior segment decreases ECD significantly, but not highly, even in case of plaques containing beta-radiation isotope, and the plaques are not placed direct on the cornea surface. The decreased ECD causes no changes in corneal thickness or transparency, but it may have an influence on a subsequent cataract surgery, which generates further endothelial loss.

Long-term results of carbon ion radiation therapy for locally advanced or unfavorably located choroidal melanoma: usefulness of CT-based 2-port orthogonal therapy for reducing the incidence of neovascular glaucoma.

PURPOSE: To determine the long-term results of carbon ion radiation therapy (C-ion RT) in patients with choroidal melanoma, and to assess the usefulness of CT-based 2-port irradiation in reducing the risk of neovascular glaucoma (NVG). METHODS AND MATERIALS: Between January 2001 and February 2012, a total of 116 patients with locally advanced or unfavorably located choroidal melanoma received CT-based C-ion RT. Of these patients, 114 were followed up for more than 6 months and their data analyzed. The numbers of T3 and T2 patients (International Union Against Cancer [UICC], 5th edition) were 106 and 8, respectively. The total dose of C-ion RT varied from 60 to 85 GyE, with each dose given in 5 fractions. Since October 2005, 2-port therapy (51 patients) has been used in an attempt to reduce the risk of NVG. A dose-volume histogram analysis was also performed in 106 patients. RESULTS: The median follow-up was 4.6 years (range, 0.5-10.6 years). The 5-year overall survival, cause-specific survival, local control, distant metastasis-free survival, and eye retention rates were 80.4% (95% confidence interval 89.0%-71.8%), 82.2% (90.6%-73.8%), 92.8% (98.5%-87.1%), 72.1% (81.9%-62.3%), and 92.8% (98.1%-87.5%), respectively. The overall 5-year NVG incidence rate was 35.9% (25.9%-45.9%) and that of 1-port group and 2-port group were 41.6% (29.3%-54.0%) and 13.9% (3.2%-24.6%) with statistically significant difference (P<.001). The dose-volume histogram analysis showed that the average irradiated volume of the iris-ciliary body was significantly lower in the non-NVG group than in the NVG group at all dose levels, and significantly lower in the 2-port group than in the 1-port group at high dose levels. CONCLUSIONS: The long-term results of C-ion RT for choroidal melanoma are satisfactory. CT-based 2-port C-ion RT can be used to reduce the high-dose irradiated volume of the iris-ciliary body and the resulting risk of NVG.

Intraocular collision tumour: case report and literature review.

BACKGROUND: "Collision" tumours consist of different neoplasms coexisting within a single lesion. Whilst quite common in the skin, the gastrointestional tract, and the ovaries, intraocular collision tumours are exceedingly rare. We describe an exceptional case of a combined uveal melanoma and intraocular plasmacytoma. METHODS: Observational case report. A 61-year-old woman underwent enucleation for rubeotic glaucoma and cells in the anterior chamber after proton-beam radiotherapy of a cilio-choroidal melanoma of the right eye. Examination of the enucleated eye was performed with immunohistochemistry, multiplex ligation dependent probe amplification (MLPA), and polymerase chain reaction (PCR) for immunoglobulin heavy- and light-chain gene rearrangements. A review of the literature on ocular collision tumours and uveal involvement by plasma cell neoplasms was also performed. RESULTS: Morphological, immunophenotypical, and genotypical examination of the tumour revealed the co-existence of both a melanoma and a plasmacytoma within the choroid and ciliary body. The glaucoma was caused by extensive infiltration of the iris and trabecular meshwork by the plasmacytoma cells. Review of the literature revealed only four collision tumours involving the eyelid and three involving the choroid. All three intraocular collision tumours consisted of uveal melanoma and choroidal non-Hodgkin lymphoma. Uveal involvement by plasma cell neoplasms is also extremely rare, with only six reported cases. CONCLUSIONS: This is the first documented intraocular collision tumour consisting of a uveal melanoma and isolated plasmacytoma. If a patient presents with 'uveitis' after proton-beam radiotherapy of a cilio-choroidal melanoma, there may be scope for performing biopsies to determine whether the lymphoid infiltrate is reactive or neoplastic.

Ruthenium plaque radiation therapy for iris and iridociliary melanomas.

PURPOSE: To determine the long-term effects of ruthenium-106 plaque radiation therapy for iris and iridociliary melanomas in terms of tumour regression and complications. METHODS: Between 1 November 1997 and 31 December 2007, 36 patients with an iris or iridociliary melanoma were treated with Ruthenium-106 (Ru-106) ophthalmic plaque radiation therapy. The median follow-up was 6.5 years with a range of 2-11 years. The mean tumour apex dose was 151.5 Gy. Main outcome measures were local tumour control and radiation-related ocular complications. RESULTS: The mean age of the patients at the time of treatment was 54 years (range 14-82). The tumours had a median largest basal dimension of 4.8 mm (range 3-11) and a prominence of 2.3 mm (range 0.8-5), with a median involvement of three clock hours (range 1-6). The tumours were confined to the iris in 14 patients (39%), extended into the anterior ciliary body in 12 (33%), while the anterior ciliary body tumour extended into the iris in ten patients (28%). Tumours regressed in all patients (100%) with a mean regression of 80% of the original tumour size at 7 years of follow-up. Radiation-related complications included corneal erosions on the first postoperative day in nine patients (25%), cataract in four of 11 patients free of cataract before treatment (36%) and postradiation glaucoma in one patient (3%). Visual acuity of 20/200 or worse was present in one of 20 patients (5%) at 6 years of follow-up. Local recurrences occurred in two patients (5%), 2 and 5 years after the radiation therapy respectively, and both underwent enucleation. Distant metastases occurred in one of these enucleated patients (3%) 2 years after treatment. CONCLUSION: Ru-106 plaque radiation therapy for iris and iridociliary melanoma resulted in good local tumour control and preservation of visual acuity with few and treatable side-effects.

(106)Ruthenium brachytherapy for ciliary recurrence with supraciliary effusion in retinoblastoma.

PURPOSE: A 2-year-old boy with syndromic bilateral retinoblastoma resulting from a (del(13)(q12.3q14.3)) developed a recurrent tumor measuring 2.3 X 2.3 mm at the ora serrata 15 months following last treatment. METHODS: Ultrasound biomicroscopy (UBM) revealed a mass invading the ciliary body 6.6 mm in diameter associated with a localized supraciliary effusion. RESULTS: Complete tumor regression was achieved 1 month after brachytherapy with a (106)Ruthenium plaque. There was no recurrence at 16 months. CONCLUSION: This is the first clinical demonstration of supraciliary effusion in recurrent retinoblastoma. Brachytherapy appears to be effective in the treatment of this type of recurrence.

Management of ciliary body melanoma with iodine-125 plaque brachytherapy.

OBJECTIVE: Because ciliary body melanoma often defies early diagnosis, and its treatment is controversial, we report our experience with the clinical presentation and management of ciliary body melanoma, treated with iodine-125 plaque brachytherapy. STUDY DESIGN: A retrospective noncomparative case series. PARTICIPANTS: Forty-two patients with ciliary body melanoma treated with iodine-125 brachytherapy. METHODS: Electronic chart review of ciliary body melanoma patients treated at Princess Margaret Hospital, University of Toronto, Toronto, Ont. Patients' demographics and clinical, management, and follow-up data, including brachytherapy-related complications, were reviewed. Outcome measures included rates of tumour control, eye preservation, systemic metastases, and brachytherapy-related complications. RESULTS: Median age at diagnosis was 58 years and median follow-up was 43 months. Ciliary body melanoma was asymptomatic in 55% of patients, whereas floaters or flashes were the main symptom in 33%. Median tumour thickness before brachytherapy was 5.2 mm and after brachytherapy was 3.3 mm. Radiation-induced cataract was the main complication in 55% of patients, radiation retinopathy in 24%, and neovascular glaucoma in 15%, which was controlled by topical treatment in half of the cases. Two patients developed metastases and 3 required secondary enucleation. CONCLUSIONS: Medium-sized ciliary body melanoma produced no or minimal symptoms on presentation in 88% of the patients. Iodine-125 plaque brachytherapy offered 98% tumour control at 43 months' follow-up. Radiation-related complications are generally manageable in most patients, which permits retention of the treated eye.

Recurrence of treated ciliary body melanoma following trabeculectomy.

A 69-year-old man was treated for a right ciliary body melanoma with plaque radiotherapy. One year later, he had uncomplicated cataract extraction but developed prolonged postoperative inflammation and secondary glaucoma. The tumour remained unchanged on yearly ultrasound B scans but intraocular pressures became uncontrolled despite maximal medical therapy. After radiotherapy, he underwent trabeculectomy with 5-fluorouracil and revision with mitomycin C 2 years later. The melanoma recurred with extrascleral extension under the trabeculectomy bleb 14 years after plaque radiotherapy and 5 years after trabeculectomy surgery. Enucleation was performed and histological analysis showed a ring melanoma involving the root of the iris, filling the trabecular meshwork and extending into the anterior chamber. The predominant cell type was epithelioid with large nuclei and prominent nucleoli. Trabeculectomy surgery may increase the risk of extrascleral extension of ciliary body melanoma even after apparently successful plaque radiotherapy and long-term local tumour control.