Investigating Vitreous Cytokines in Choroidal Melanoma.

Due to the close relationship between the vitreous and posterior eye layers, the microenvironment of these layers can affect the composition of the vitreous. Molecular analysis of the vitreous may therefore provide important insights into the pathogenesis of chorioretinal diseases. In this study, vitreous cytokines (n = 41) were evaluated to gain further insights into the tumor microenvironment in uveal melanoma (UM) arising from the choroid (CM). Cytokine levels were measured using a bead-based multiplex immunoassay panel in vitreous samples obtained from 32 eyes, including 18 with CM and 14 controls. Median fluorescence intensity values were extracted and used as relative quantification of the cytokine abundance. Vitreous cytokine levels were compared between the CM and non-CM groups and between different prognostic categories within the CM group (classified as having low or high metastatic risk using tumor biopsy-based gene expression profiling). Correlations between vitreous cytokine levels and tumor dimensions were also evaluated. Our analysis revealed twenty-six vitreous cytokines significantly upregulated in CM-affected eyes compared to the control eyes. Within the CM group, six vitreous cytokines showed altered levels (five upregulated and one downregulated) in eyes with high- vs. low-risk tumors. Levels of these six plus several other cytokines showed correlations with the tumor dimensions. In conclusion, our study has uncovered several UM-relevant vitreous cytokines, worthy of follow-up in larger studies as potential candidates for liquid biopsy-based biomarker development and/or new therapeutic targeting.

Simplified technique for lateral canthal tendon canthopexy.

Purpose: Different techniques for lateral canthal suspension have been used in the management of various eyelid malpositions. We describe a simplified technique for lateral canthal suspension and review its outcome along with a review of existing variations. Methods: We conducted a retrospective chart review of 28 eyelids in 22 patients who underwent simplified lateral canthal suspension. Demographics, symptoms at presentation, and associated eyelid malposition were noted. We evaluated the palpebral fissure and margin-reflex distance 2 (MRD2) on the preoperative and final postoperative photographs by using MEEI FACE-gram software. We also reviewed existing literature on different surgical management options for comparison. Results: At three-month postoperative follow-up, presenting symptoms resolved in all cases. The average postoperative decease in palpebral fissure was 0.73 mm (P = 0.018) and the average decrease of the MRD2 was 1.02 mm (P = 0.0003). Recurrence occurred by three months in one eyelid (4%) with ectropion due to moderate eyelid laxity, and this case was managed with tarsal strip procedure. One patient (5%) who had bilateral surgery had asymmetric lower eyelid position and one patient (5%) had persistent edema of the operated eyelid for six months. Conclusion: This simplified canthal suspension is a simple and effective technique that tightens the lateral canthal tendon and improves the lower eyelid position. It can be used in various mild-to-moderate eyelid laxities and has favorable operative characteristics compared with many existing techniques.

Management of Peripapillary Choroidal Neovascular Membrane in Patients With Idiopathic Intracranial Hypertension.

OBJECTIVE: To report the clinical features and treatment outcomes of patients with peripapillary choroidal neovascular membrane (CNVM) secondary to idiopathic intracranial hypertension (IIH). METHODS: Retrospective, multicenter chart review of patients diagnosed with peripapillary CNVM in the course of the treatment and follow-up of IIH. RESULTS: Records were reviewed from 7 different institutions between 2006 and 2016. Ten patients (13 eyes) with a diagnosis of IIH and at least 3 months of follow-up developed CNVM. Three of the total 10 patients developed bilateral CNVM. The mean time from the diagnosis of IIH to CNVM diagnosis was 41 months. Mean follow-up period was 8 months after diagnosis of CNVM. All patients were treated with acetazolamide for IIH. Seven eyes were observed, and 6 eyes were given anti-vascular endothelial growth factor (anti-VEGF) injections, including bevacizumab, ranibizumab, and aflibercept. All CNVMs regressed with subretinal fibrosis, and visual acuity improved in most patients. Papilledema resolved in only 1 eye, while the other 12 eyes had persistent papilledema at last follow-up. CONCLUSIONS: Peripapillary CNVM, a rare complication of IIH, often resolves spontaneously with treatment of IIH. In vision-threatening and/or persistent cases, intravitreal anti-VEGF treatment may be a safe and effective therapeutic option.

Peripheral Persistent Fetal Vasculature: A Report of Three Cases.

The authors report three cases of persistent fetal vasculature (PFV) presenting with an atypical peripheral fibrovascular stalk. A 5-month-old with congenital exotropia with a vitreous hemorrhage in the right eye underwent vitrectomy, and a mid-peripheral vitreal vascular stalk was visualized within the area of hemorrhage. The second case is of an 8-year-old with two fetal vascular remnants in the right eye: (1) a stalk superotemporally extending from the pars plana to the mid-peripheral retina that was associated with a retinal break and (2) a focal lens opacity. The third case is a 12-year-old with a history of familial exudative vitreoretinopathy and peripapillary choroidal neovascular membrane found to have a peripheral vitreal stalk in the right eye. These cases demonstrate a rare form of PFV with primarily peripheral remnants. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e83-e88.].

Do Largest Basal Tumor Diameter and the American Joint Committee on Cancer's Cancer Staging Influence Prognostication by Gene Expression Profiling in Choroidal Melanoma.

PURPOSE: To evaluate the prognostication of choroidal melanoma (CM) by the gene expression profiling (GEP) test. DESIGN: Cohort study. METHODS: Retrospective review of 293 CM patients from 2 centers. RESULTS: Of 293 patients, 132 (45%) were class 1A by GEP, 63 (22%) were class 1B, and 98 (33%) were class 2. Class 2 tumors had more ciliary body involvement and greater largest basal dimension (LBD), and were thicker. GEP results and increasing LBD were independently predictive of time to metastasis. Kaplan-Meier survival analysis estimated the probability of 3-year metastasis-free survival (MFS) of 0.99 in class 1A, 0.90 in class 1B, and 0.60 in class 2. The probability of 3-year MFS was 0.49 in class 2 patients with LBD ≥ 12 mm vs 1.00 in those with LBD < 12 mm, 0.89 in class 1B with LBD ≥ 12 mm vs 0.93 in those with LBD < 12 mm, and 0.99 in class 1A with LBD ≥ 12 mm vs 1.00 in those with LBD < 12 mm. In American Joint Committee on Cancer (AJCC) stage I CMs, the probability of 3-year MFS was 1.0 for class 1A and 1B, and 0.79 for class 2. In stage II CMs, the probability of 3-year MFS was 0.99 for class 1A, 0.89 for class 1B, and 0.61 for class 2. In stage III CM, the probability of 3-year MFS was 1.0 for class 1A, 0.60 for class 1B, and 0.41 for class 2. CONCLUSIONS: GEP testing provided significant prognostic information for CM. Class 2 tumors with LBD ≥ 12 mm and class 2 and 1B tumors with AJCC stage III showed significantly worse prognosis.

Arterial macroaneurysm of the optic disc.

PURPOSE: We present fundus and spectral domain optical coherence tomography findings of a patient with an arterial macroaneurysm of the optic disc. OBSERVATIONS: An 87-year-old woman presented with blurry vision and was found to have a retinal arterial macroaneurysm on the optic disc. Spectral domain optical coherence tomography revealed abnormal saccular arterial dilatation on the disc with an elongation anteriorly and superficial prepapillary hemorrhages. After 2 months, aneurysm thrombosed spontaneously without any visual consequences. CONCLUSIONS AND IMPORTANCE: Spectral domain optical coherence tomography can be used for the diagnosis and follow up of optic disc arterial macroaneurysms. Our case documents the natural history and unique spectral domain optical coherence tomography appearance of an optic disc arterial macroaneurysm.

Aflibercept Versus Bevacizumab and/or Ranibizumab for Recurrent Macular Edema Secondary to Central Retinal Vein Occlusion.

PURPOSE: To compare functional and anatomic outcomes of treatment with intravitreal aflibercept versus bevacizumab and/or ranibizumab in patients with recurrent macular edema (ME) secondary to central retinal vein occlusion (CRVO). METHODS: Retrospective, comparative case series of patients with recurrent ME in the setting of CRVO. Patients with recurrent ME received treatment with aflibercept (Group 1, G1) or bevacizumab and/or ranibizumab (Group 2, G2). Primary outcome measures were best-corrected visual acuity (BCVA) and central foveal thickness (CFT). RESULTS: Of the 20 eyes (20 patients) with recurrent ME included in the study, 9 received aflibercept (G1) and 11 received bevacizumab and/or ranibizumab (G2). Median BCVA at recurrence of ME and at most recent follow-up was 20/60 (G1) and 20/80 (G2) and 20/40 (G1) and 20/50 (G2, P > 0.05 for all comparisons), respectively. Median CFT at recurrence of ME and at most recent follow-up was 492 µm (G1) and 448 µm (G2) and 291 µm (G1) and 295 µm (G2, P > 0.05 for all comparisons), respectively. Complete resolution of ME for at least 4 months was found in 78% (G1) and 55% (G2) of patients with a median injection free interval of 11 (G1) and 13 (G2) months (P > 0.05). CONCLUSIONS: In patients with recurrent ME secondary to CRVO, there was improvement in BCVA and CFT in all groups, although patients treated with aflibercept showed a trend toward better anatomical outcomes decreased need for recurrent injections.

Clinical features and management of dacryops.

PURPOSE: To describe clinical, imaging findings, and management of dacryops cases. METHODS: A retrospective chart review was performed to identify the patients diagnosed with dacryops over a 5-year period. The clinical features based on clinical findings, computerized tomography and ultrasonography, and observation and surgical excision results were noted when available. RESULTS: We included 14 eyes of 14 patients. Seven (50%) were men with a median age of 48 years. The most common symptom was non-painful upper eyelid mass. All patients had the visible protruding cyst while eversion of the upper eyelid. Imaging studies, including orbital computerized tomography and ultrasonography were performed in six cases. Histological assessment of the excised cyst was done in two cases. Surgical excision was performed in five (36%) cases and observation was elected for nine (64%) cases. The median follow-up was 30 months. There was no recurrence of cysts in patients underwent surgery and the symptoms were not deteriorated in patients elected observation. CONCLUSION: Dacryops is a rare clinical entity that can be diagnosed easily with or without imaging methods. Surgical excision of the cyst could be curative and observation is also a safe method in selected cases.

SELF-PEELING EPIRETINAL MEMBRANE.

PURPOSE: To present a self-peeling epiretinal membrane (ERM) in a patient with spontaneously improved retinal capillary hemangioma in the left eye. METHODS: The authors demonstrate the improvement of an untreated retinal capillary hemangioma and resolution of ERM with fundus photography, fluorescein angiography, and spectral domain optical coherence tomography. Genetic testing excluded von Hippel-Lindau disease in this patient. RESULTS: Evaluation of a patient with rheumatoid arthritis revealed retinal capillary hemangioma with retinal exudates at the temporal peripheral fundus and an ERM in the left eye. Patient was asymptomatic and elected observation. Three years after the initial examination, visual acuity and macular appearance improved after spontaneous resolution of the ERM. Capillary hemangioma was smaller and retinal exudates resolved without treatment. CONCLUSION: This case report demonstrates a self-peeling ERM associated with a retinal capillary hemangioma. This case contributes the literature describing the natural history of ERMs associated with peripherally located capillary hemangiomas in patients without von Hippel-Lindau disease.

NOVEL CLASSIFICATION SYSTEM FOR COMBINED HAMARTOMA OF THE RETINA AND RETINAL PIGMENT EPITHELIUM.

PURPOSE: To develop an anatomical classification scheme for combined hamartoma of the retina and retinal pigment epithelium (RPE) and specify recommendations for follow-up interval. METHODS: Retrospective review of patients with combined hamartoma of the retina and RPE examined during a 7-year period (2008-2015). The clinical presentation, fundus examination, and optical coherence tomography were analyzed. RESULTS: Lesions were classified based on location, fundus features, and optical coherence tomography findings. Lesion location: macular/peripapillary-Zone 1; mid-periphery-Zone 2; and far periphery-Zone 3. Associated fundus findings: no retinal traction-Stage 1; retinal traction and/or retinoschisis-Stage 2; and retinal detachment-Stage 3. Optical coherence tomography findings: epiretinal component only-A; partial retinal involvement-B; and complete retinal and RPE involvement-C. Complete ophthalmologic evaluation is recommended at least every 6 months for patients younger than 12 years, with more frequent follow-up in patients with: lesions in the macula/peripapillary (Zone 1) or with retinal traction, retinoschisis, or retinal detachment (Stage 2 and 3). Surgical intervention is recommended in patients with vision loss secondary to macular traction or retinal detachment. CONCLUSION: A new clinical classification system is proposed for evaluating and managing patients with combined hamartoma of the retina and RPE. The zone and stage of combined hamartoma of the retina and RPE lesion will assist in determining follow-up interval and surgical intervention. Application of a uniform classification scheme will facilitate assessment and comparison of findings across different studies.

The Use of Integra® Dermal Regeneration Template for the Orbital Exenteration Socket: A Novel Technique.

PURPOSE: Integra® dermal regeneration template is a bilayer membrane system that acts as a scaffold for regenerating dermal skin cells. It is used for wound reconstruction following burns, extensive injuries, and a large tumor excision in multiple parts of the body. The dermal layer is made of porous matrix of bovine tendon collagen and glycosaminoglycan. The epidermal layer is made of polysiloxane layer. In this study, the authors evaluated the use of Integra® dermal regeneration template for the immediate reconstruction of the orbital exenteration socket. METHODS: Five patients who underwent exenteration and immediate reconstruction of the socket with Integra® dermal regeneration template were included in this study. Demographic and clinical features, healing time, complications, and follow-up time were recorded. RESULTS: The study included 4 male patients and 1 female patient with a mean age of 74 years (range, 49-87 years). The primary diagnoses were orbital extension of conjunctival melanoma in 2 patients, squamous cell carcinoma in 1 patient, and uveal melanoma in 1 patient, and aggressive orbital Wegener granulomatosis in 1 patient. There was no postoperative infection, necrosis, hematoma, or fluid accumulation in any patients. The mean postoperative follow-up period was 20 months (range, 11-42 months). The sockets were completely granulated by 4 weeks, and epithelized, getting ready for the prosthesis in 8 weeks. CONCLUSIONS: Integra® dermal regeneration template can be used for the immediate reconstruction of the socket following exenteration. It is easy to use, and provides a short healing time without any need for any additional reconstructive procedures.

ACCIDENTAL DUPLICATION: Combined Vitrectomy and Glaucoma Drainage Device Implantation Surgical Approach for Complex Pediatric Glaucomas.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.jaapos.2017.02.001. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Combined vitrectomy and glaucoma drainage device implantation surgical approach for complex pediatric glaucomas.

PURPOSE: To evaluate efficacy of combined vitrectomy with posteriorly placed glaucoma drainage device (GDD) in lowering intraocular pressure (IOP) in children. METHODS: The medical records of children who underwent vitrectomy with posteriorly placed GDD were reviewed retrospectively. Patients with a minimum of 6 months' follow-up were included. The first eye operated on for each patient was analyzed. Success was defined as IOP of 5-20 mm Hg and no additional IOP-lowering surgery or visually devastating complications. RESULTS: A total of 20 patients were included, with the following etiologies: primary infantile-onset glaucoma, 5 (25%); traumatic glaucoma, 3 (15%); Peters anomaly, 3 (15%); microphthalmia, 5 (25%); glaucoma following cataract surgery, 2 (10%); microspherophakia, 1 (5%); and retinopathy of prematurity, 1 (5%). Eyes with corneal opacification (8 [40%]) underwent endoscopic vitrectomy (5 [25%]), concurrent penetrating keratoplasty (3 [15%]) and/or keratoprosthesis surgery (1 [5%]). Mean follow-up was 1.9 ± 1.1 years (range, 6.5-49.2 months). Vision remained stable or improved in 17 eyes (85%). Mean IOP decreased from 27.2 ± 10.1 mm Hg to 14.5 ± 6.8 mm Hg (P < 0.0001) at last follow-up or at failure. Kaplan-Meier curves showed 12- and 24-month rate of IOP control of 69% and 62%, respectively. The number of glaucoma medications decreased from a mean of 2.3 ± 1.4 to 1.3 ± 1.2 (P < 0.015) at last follow-up or at failure. Overall success rate was 65%. Complications included hypotony (3 [15%]), vitreous hemorrhage (1 [5%]), and retinal detachment (1 [5%]). Two eyes (10%) required surgery for hypotony; 4 eyes (20%) underwent additional glaucoma surgery. CONCLUSIONS: Combined surgical approach with vitrectomy and posteriorly placed GDD decreased IOP in complex pediatric glaucomas. Further, endoscope-assisted vitrectomy is useful in cases with corneal opacification. Complication rates of this combined procedure appear to be comparable to traditional anterior chamber approach.

Macular hole closure following spontaneous release of vitreomacular traction.

We describe the temporal changes observed with spectral-domain optical coherence tomography (SD-OCT) in the left eye of a 65-year-old man who developed a stage 1 macular hole secondary to vitreomacular traction (VMT). After 1 month, VMT had resolved spontaneously with a complete posterior vitreous detachment. Following VMT resolution, macular hole demonstrated progressive improvement and outer retinal disruption recovered spontaneously. This report highlights the importance of observation before any intervention for cases of stage 1 macular hole associated with VMT.

Novel biomarkers for patients with idiopathic acute anterior uveitis: neutrophil to lymphocyte ratio and platelet to lymphocyte ratio.

AIM: To assess the levels of the neutrophil to lymphocyte ratio (N/L) and the platelet to lymphocyte ratio (P/L) in patients with idiopathic acute anterior uveitis (AAU) and to compare with healthy controls. METHODS: Thirty-six male patients with idiopathic AAU and 36 male healthy subjects were enrolled in this retrospective study. Complete ophthalmological examination and complete blood count measurements results of all subjects were evaluated. RESULTS: There was a significant difference in N/L and P/L between idiopathic AAU and control groups (P=0.006, P=0.022). Also, correlation analysis revealed a significant correlation between C-reactive protein (CRP) and N/L (P=0.002; r=0.461). CONCLUSION: Our study for the first time provides evidence of N/L and P/L may be useful biomarkers in patients with idiopathic AAU. N/L is correlated with CRP, so it can be a useful biomarker to predict the prognosis in idiopathic AAU.

Retinal Nerve Fiber Layer and Peripapillary Choroidal Thicknesses in Non-Glaucomatous Unilateral Optic Atrophy Compared with Unilateral Advanced Pseudoexfoliative Glaucoma.

PURPOSE: To investigate retinal nerve fiber layer thickness (RNFL-T) and peripapillary choroidal thickness (PC-T) in non-glaucomatous optic atrophy (OA) patients in comparison with unaffected and control eyes, furthermore, to compare thickness profiles with unilateral pseudoexfoliative advanced glaucoma. MATERIALS AND METHODS: Thirty-three eyes with OA (Group A), 33 unaffected fellow eyes (Group B), 25 right eyes of 25 control subjects (Group C), and 15 eyes with advanced glaucoma (Group D) were enrolled. RNFL-T was measured in six regions by spectral-domain optical coherence tomography. Enhanced depth imaging optical coherence tomography was obtained to evaluate PC-T in corresponding regions. RESULTS: RNFL-T was significantly lower in Group A than in Groups B and C globally and at all peripapillary regions (all p < 0.001). P-CT in Group A was significantly lower globally (p = 0.03) and in three regions (temporal, p = 0.001; temporal-superior, p = 0.01; and nasal-inferior, p = 0.037) versus Group C. However, it was significantly thinner than in Group B in all regions (temporal, p = 0.02; temporal-superior, p = 0.013; nasal-superior, p = 0.044; nasal, p = 0.02; nasal-inferior, p < 0.001; and temporal-inferior, p < 0.001) and globally (p < 0.001). In Group A RNFL-T (thicker superiorly and inferiorly; thinner temporally and nasally) and PC-T (superior > temporal > nasal > inferior) profiles were almost identical to that in unaffected fellow eyes and control eyes. However, Group D showed different patterns with less regional differences in RNFL-T, and the greatest value of PC-T in nasal quadrant. CONCLUSIONS: Besides retinal nerve fiber layer thinning, non-glaucomatous OA is associated with choroidal thinning. The RNFL-T and PC-T profiles in advanced glaucoma eyes differed from the common patterns seen among OA eyes, unaffected fellow eyes, and control eyes.