Hypofractionated adjuvant surgical cavity radiotherapy following resection of limited brain metastasis.

BACKGROUND: Following surgical resection of oligometastatic disease to the brain there is a high rate of local relapse which is reduced by the addition of focal radiation therapy, often delivered as single fraction stereotactic radiosurgery (SRS) to the surgical cavity. This study audited the outcomes of an alternative approach using hypofractionated radiation therapy (HFRT) to the surgical resection cavity. METHODS AND MATERIALS: Seventy-nine patients who received surgical resection and focal radiation therapy to the surgical cavity using HFRT with intensity modulated radiation therapy with or without stereotactic radiotherapy were identified. Doses were delivered in five fractions every second day for 10 days. Follow-up involved MRI surveillance with three-monthly MRI scans post resection. The major endpoints were local control at the surgical cavity site, and presence of radiation necrosis at the treated site. RESULTS: Seventy-nine patients were included for the analysis with a median follow-up of 10.8 months. Of the cohort, 56% experienced intracranial progression, with all patients progressing distant to the resection cavity, and 7% progressing locally in addition. The one-year local control rate was 89.8%. The median progression-free survival was 10.0 months and median overall survival was 14.3 months. There was one CTCAE grade 3 toxicity of symptomatic radiation necrosis with no grade 4-5 toxicities seen. CONCLUSIONS: The rate of local relapse following HFRT to the surgical cavity is low with minimal risk of radiation necrosis. HFRT can be considered as an alternative to SRS for focal radiotherapy after brain metastasis resection.

Pattern of failure in anaplastic glioma patients with an IDH1/2 mutation.

PURPOSE: The current study aimed to assess patterns of failure (PoF) in anaplastic glioma (AG) patients managed with intensity-modulated radiation therapy (IMRT) and their relationship to molecular subtype. METHODS: The outcomes of AG patients managed between 2008 and 2014 and entered into a prospective database were assessed, including PoF. AG was initially defined using the WHO 2007 classification, but for analysis, patients were subsequently recategorised based on WHO 2016 as anaplastic oligodendroglioma (AOD), astrocytoma isocitrate dehydrogenase (IDH) mutant (AAmut) or astrocytoma IDH wildtype (AAwt). Management involved IMRT and temozolomide (TMZ), including from 2011 patients with an IDH mutation (IDHmut) planned with 18F-fluoroethyltyrosine (FET) and 18F-fluorodeoxyglucose (FDG) positron-emission tomography (PET). PoF was local, marginal or distant in relation to the IMRT volume. Relapse-free survival (RFS) was calculated from the start of IMRT. RESULTS: A total of 156 patients were assessed, with median follow-up of 5.1 years. Of these patients, 75% were IDHmut, 44% were managed at first or later relapse and 73% received TMZ. Relapse occurred in 68 patients, with 6­year RFS of 75.0, 48.8 and 2.5% for AOD, AAmut and AAwt, respectively (p < 0.001). There was a component of local relapse in 63%, of marginal relapse in 19% and of distant relapse in 37% of relapses. Isolated local, marginal and distant relapse was evident in 51, 9 and 22%, respectively. A distant relapse pattern was more frequent in IDHmut compared to IDHwt patients (26% vs. 45%, p = 0.005), especially within the first 2 years post-IMRT. In multivariate analysis, distant relapse remained associated with AAmut (p < 0.002) and delayed IMRT until the second relapse (p < 0.001). CONCLUSION: Although patients with IDH-mutated AG have improved outcomes, there was a higher proportion of distant relapses occurring during the 2 years after IMRT.

Understanding the Revised Fourth Edition of the World Health Organization Classification of Tumours of the Central Nervous System (2016) for Clinical Decision-making: A Guide for Oncologists Managing Patients with Glioma.

The recognition of specific molecular prognostic factors has altered the management of primary brain tumours over the past decade. These factors have allowed stratification of morphologically similar tumours into different prognostic groups and are now also being used to determine clinical trial eligibility. Many of these factors have been included in the revised fourth edition of the World Health Organization (WHO) Classification of Tumours of the Central Nervous System, released in May 2016. This revised edition places greater emphasis on molecular testing and, for certain tumour types, molecular testing is required for diagnosis. Many pathology departments have also adopted the four-tiered report format suggested in the Haarlem guidelines, and provide a final 'integrated diagnosis' incorporating a morphological diagnosis, the WHO grade and molecular findings. Pathologists need to perform and report these molecular tests in a timeframe that is relevant for clinical decision-making. Clinicians need to understand and incorporate these changes into their daily practice, as they have direct effects on both the type and intent of therapeutic interventions.

Reduction in postoperative endophthalmitis with intracameral cefuroxime.

Postoperative endophthalmitis is an uncommon complication of cataract surgery with grave consequences. This report describes the trend of endophthalmitis in a district general hospital in England over eight years, and attempts made to modify this trend. An outbreak of endophthalmitis in 2007 led to a detailed investigation and subsequent changes in practice. Intracameral cefuroxime (ICC) was introduced in place of subconjunctival cefuroxime. Use of ICC in patients with 'penicillin allergy' was explored, found to be safe and resulted in a change of policy. This led to a four-fold reduction in the rate of endophthalmitis.

Recovery of visual function in patients with biopsy-proven giant cell arteritis.

OBJECTIVE: To assess the visual function of patients with giant cell arteritis (GCA) who had visual loss from either anterior ischemic optic neuropathy (AION) or central retinal artery occlusion and had a subsequent improvement in visual acuity after treatment with corticosteroids. DESIGN: Retrospective, observational case series. PARTICIPANTS: Thirty-two consecutive patients with biopsy-proven GCA treated at one institution between January 1992 and December 1997. INTERVENTION: Treatment with intravenous methylprednisolone 250 mg every 6 hours for 3 days, followed by oral prednisone 1 mg/kg daily for at least 4 weeks duration. MAIN OUTCOME MEASURES: The number of patients with an improvement in visual acuity after treatment with intravenous methylprednisolone; neuro-ophthalmic evaluation, including visual acuity, funduscopy, and visual field examination of these patients. RESULTS: Improvement in visual acuity occurred in 5 of 39 eyes (13%) with visual loss from biopsy-proven GCA, and all 5 patients had AION. Despite the improvement of visual acuity in these 5 patients, perimetry revealed marked constriction of the visual field in each affected eye. CONCLUSIONS: The prognosis for visual improvement in GCA is poor. Although an improvement in visual acuity occurred in 5 of our patients, marked constriction of the visual field was present in all of them.

Acute bilateral ophthalmoplegia in a young woman.

A 34-year-old woman presented with bilateral ophthalmoplegia, ptosis, and mild gait ataxia. Tensilon test, magnetic resonance imaging, and cerebrospinal fluid analysis were normal. She initially denied any alcohol intake but later admitted to significant alcohol and multisubstance abuse. The patient improved dramatically after treatment with thiamine. Wernicke's encephalopathy is discussed, highlighting that it may be present with normal mentation. It should be considered in the differential diagnosis of bilateral ophthalmoplegia even in the absence of altered mental status.

Correlation between early, measurable improvement in quality of life and speed of visual rehabilitation after phacoemulsification.

PURPOSE: To assess whether improvements in measurable health-related quality-of-life (HR-QoL) functions parallel the rapid visual recovery after phacoemulsification. SETTING: The Cataract Treatment Center, Sunderland Eye Infirmary, Sunderland, England. METHODS: This study comprised 144 patients having first-eye phacoemulsification cataract extraction. They were assessed using a standard EuroQoL generic (non-disease specific) multidimensional HR-QoL instrument to evaluate preoperative and 1 month postoperative health profile measures in social, psychological, and general health aspects. RESULTS: Within 1 month of phacoemulsification, change in vision was accompanied by significant changes in HR-QoL functions such as home activities, social activities, self-care, mobility, and psychological well-being. CONCLUSION: The speed of visual rehabilitation after phacoemulsification was paralleled by improvement across HR-QoL functions, resulting in the rapid recovery of functional independence and health status.

New generation hydroxypropyl methylcellulose (HPMC-Ophtal H) for intraocular surgery: a confocal laser scanning microscopy study.

PURPOSE: To determine the abundance and variety of particulate debris in new generation hydroxypropyl methylcellulose (HPMC) samples. METHOD: Three samples of sterile HPMC-Ophtal H were examined using a confocal laser scanning microscope, scanning electron microscope and mass spectrometry. RESULTS: Confocal laser scanning microscopy of the samples showed that particulate matter in HPMC was less than 30 microns in size and at a density of less than 1000 particles per millilitre. No discernible details were seen by the scanning electron microscope, and mass spectrometry did not identify and bands. CONCLUSION: Improved methods of preparation including filtration may be responsible for decreased particulate debris in new generation HPMC.

Ocular morbidity following renal transplantation.

BACKGROUND: Long-term visual outcome following renal transplantation is poorly documented in medical literature. The purpose of this study was to determine the ocular morbidity in a group of renal transplant patients receiving immunosuppressive therapy. METHODS: Patients who had undergone renal transplantation were identified from the renal outpatient register, and patients who were at least 8 years posttransplantation were included in the study. Ocular examination was on average 14.6 years post-surgery. There were 43 males and 28 females, with ages ranging from 29 to 74 years. The patients had undergone renal transplantation between March 1968 and September 1986. The ophthalmic examinations were carried out over a 15-month period in a research clinic. RESULTS: Visual acuity was greater than or equal to 6/9 in 75% of the eyes. 10% of eyes had visual acuities of less than 6/24. Four eyes had central/branch retinal-vein occlusions; four eyes had posterior subcapsular lens opacities; three eyes had optic atrophy; one eye had complications of proliferative diabetic retinopathy; one eye had diabetic maculopathy and one eye had a central retinal artery occlusion. Only five eyes had irreversible visual loss resulting in visual acuities of less than 6/60. CONCLUSION: The incidence of sight-threatening complications in long-term survivors of renal transplantation was low. The results indicate that long-term prognosis for normal vision in patients who have undergone renal transplantation is good. Regular ophthalmic examinations are recommended for early detection of sight-threatening complications.

Haemodynamic responses to subconjunctival mydriatic agents (Mydricaine) used for maintenance of perioperative mydriasis in patients undergoing vitreoretinal surgery.

PURPOSE: To assess the systemic effects of subconjunctival mydriatic agents (Mydricaine). METHODS: Haemodynamic variables were recorded at baseline and during the first 60 min following subconjunctival injection of Mydricaine and normal saline. RESULTS: Statistical analysis of the change in heart rate showed a highly significant difference between the two groups (p < 0.001). There was no significant difference in the effect on systolic or diastolic blood pressure between the two groups. CONCLUSIONS: We advise extreme caution when using Mydricaine via the subconjunctival route in patients with compromised cardiac function.

Effectiveness of topical diclofenac in relieving photophobia after pupil dilation.

PURPOSE: To test the effectiveness of topical diclofenac in relieving photophobia after pupil dilation. SETTING: Department of Ophthalmology, Newcastle General Hospital, Newcastle-upon-Tyne, United Kingdom. METHODS: Twenty healthy patients and volunteers from the outpatient ophthalmology clinic were enrolled in a prospective, double-blind, placebo-controlled comparison in which the patient's fellow eye served as a control. Photophobia after pupil dilation was tested subjectively using a visual analog scale and a neutralization scale at 30 minute intervals for 2 hours after instillation of topical diclofenac. RESULTS: Both tests show a statistically significant reduction in photophobia in the diclofenac-treated eyes at each time interval (P < or = .05). This difference was also considered clinically relevant. CONCLUSION: Topical diclofenac given at the time of pupil dilation significantly reduced photophobia. The mechanism of action is unknown and requires further evaluation.

The effectiveness of topical diclofenac in relieving discomfort following traumatic corneal abrasions.

Diclofenac is a non-steroidal anti-inflammatory drug available in an ophthalmic preparation. We present a prospective randomised double-masked placebo-controlled trial involving 40 patients that assessed the effectiveness of topical diclofenac in relieving pain from traumatic corneal abrasions. Statistical analysis of visual analogue and categorical pain scores revealed a significant reduction in pain experienced by subjects in the diclofenac group (p < 0.02).

The outcome of 2.3 mm incision combined phacoemulsification, trabeculectomy and lens implantation of non-foldable intraocular lenses.

We report the results of 100 eyes in 88 patients that underwent combined phacoemulsification and implantation of non-foldable intraocular lenses (IOLs) following enlargement of the initial 2.3 mm opening and trabeculectomy. Intraocular pressure (IOP) control (< 21 mmHg) was attained in 96% of the eyes. Visual acuity of 6/12 or better was attained in 76% of the eyes. A filtering bleb was absent in only 11% of the eyes. All these outcomes were favourable compared with previously reported series in which foldable IOLs were inserted without enlargement of the initial trabeculectomy openings. We conclude that the combination of small-incision cataract surgery and trabeculectomy with implantation of non-foldable IOLs is a successful surgical approach for visual rehabilitation and glaucoma control in patients with concurrent cataract and glaucoma.

The role of staphylococcal superantigens in the pathogenesis of marginal keratitis.

Previous studies have demonstrated an increased incidence of delayed-type hypersensitivity to staphylococcal antigens in patients with blepharitis, but this does not predict subsequent development of marginal keratitis (MK). Superantigens are potent immune-modifying molecules produced by pathogenic organisms including Staphylococcus aureus. To study whether staphylococcal superantigens play a role in the development of MK, conjunctival and lid margin cultures were taken from 26 subjects with MK and 24 controls. Four of 8 eyes with their first episode of MK grew strains of S. aureus, of which only one was superantigen-producing. None of the subjects with recurrent MK and only one control grew S. aureus. We conclude that staphylococcal superantigens are unlikely to play a central role in the development of MK. The absence of S. aureus on the lids of subjects with recurrent MK may reflect an alteration in lid flora due to previous topical antibiotic and steroid treatment.

Do patients with facial trauma to the orbito-zygomatic region also sustain significant ocular injuries?

A retrospective study of orbito-zygomatic injuries presenting to eye casualty over 3-year period revealed the majority of patients with pure orbital "blow-out' fractures had no other associated ocular abnormalities and 96% of these patients had a visual acuity of 6/9 or greater at discharge. In contrast only 74% of patients with multiple facial fractures had a visual acuity of 6/9 or greater at discharge. Severe ocular trauma was uncommon in patients with orbito-zygomatic injuries. Decrease in visual acuity was the main clinical finding accompanying significant eye injury. Early ophthalmic assessment is recommended in these cases to exclude potentially serious complications such as traumatic optic neuropathy. All patients with blow-out fractures managed conservatively had complete resolution of troublesome diplopia without extra-ocular muscle surgery.

Flashes and floaters as predictors of vitreoretinal pathology: is follow-up necessary for posterior vitreous detachment?

PURPOSE: The aim of the study was to determine whether patients presenting with an isolated posterior vitreous detachment require follow-up to identify retinal breaks not apparent at presentation and whether some histories are more predictive of associated serious posterior segment pathology. METHODS: The notes of 295 patients presenting to eye casualty with flashes and/or floaters were reviewed. RESULTS: One hundred and eighty-nine patients (64%) had isolated posterior vitreous detachments, 49 (16.6%) had retinal detachments and 31 (10.5%) had flat retinal tears. Three new breaks (3.3% of all tears found, 1.9% of review appointments) were identified only at follow-up. Although a subjective reduction in vision and a history of less than 6 weeks' duration were strongly predictive of retinal breaks, the large group of patients presenting with floaters alone (124/295, 42%) still harboured a significant proportion (26.7%) of the retinal breaks. CONCLUSIONS: A follow-up visit for patients with an isolated posterior vitreous detachment can be justified to detect the small percentage of asymptomatic retinal breaks. Although a subjective reduction of vision is the symptom most predictive of serious posterior segment pathology, it would be unsafe to identify particular subgroups of patients alone for careful examination.

The effectiveness of peri-operative cardiac monitoring and pulse oximetry.

Life-threatening systemic complications during ophthalmic surgery under local anaesthesia are rare. However, respiratory and cardiovascular complications can cause significant morbidity and mortality. In this study continuous peri-operative oxygen saturation and cardiac monitoring provided the surgeon with early warning of life-threatening complications, resulting in rapid intervention and full recovery of the patients. Pre-operative venous cannulation aided rapid treatment. Due to ease of handling and interpretation, the equipment can be used effectively for peri-operative monitoring without any specialist training. All patients should be carefully monitored during local anaesthesia with pulse oximetry and cardiac monitors.