Intravitreal bevacizumab at 4-month intervals for prevention of macular edema after plaque radiotherapy of uveal melanoma.

PURPOSE: To evaluate the efficacy of intravitreal bevacizumab for prevention of macular edema after plaque radiotherapy of uveal melanoma. DESIGN: Retrospective, single-center, nonrandomized, interventional comparative study. PARTICIPANTS: Patients with uveal melanoma treated with plaque radiotherapy were divided into 2 groups: a bevacizumab group and a control group. INTERVENTION: The bevacizumab group received intravitreal bevacizumab injection at the time of plaque removal and every 4 months thereafter for 2 years (total, 7 injections). The control group had no intravitreal bevacizumab injection. Both groups had periodic follow-up with ophthalmoscopy and optical coherence tomography (OCT). MAIN OUTCOME MEASURES: Development of OCT-evident macular edema. RESULTS: There were 292 patients in the bevacizumab group and 126 in the control group. The median foveolar radiation dose was 4292 cGy (bevacizumab) and 4038 cGy (control; P = 0.327). The cumulative incidence of OCT-evident macular edema over 2 years (bevacizumab group vs. control group) was 26% versus 40% (P = 0.004), respectively; that for clinically evident radiation maculopathy was 16% versus 31% (P = 0.001), respectively; that for moderate vision loss was 33% versus 57% (P < 0.001), respectively; and that for poor visual acuity was 15% versus 28% (P = 0.004), respectively. There was no statistically significant difference in clinically evident radiation papillopathy (P = 0.422). Kaplan-Meier estimates at 2 years showed statistically significantly reduced rates of OCT-evident macular edema (P = 0.045) and clinically evident radiation maculopathy (P = 0.040) in the bevacizumab group compared with controls. CONCLUSIONS: Patients receiving intravitreal bevacizumab injection every 4 months after plaque radiotherapy for uveal melanoma demonstrated OCT-evident macular edema, clinically evident radiation maculopathy, moderate vision loss, and poor visual acuity less frequently over a period of 2 years than patients not receiving the injections.

Iris melanoma management with iodine-125 plaque radiotherapy in 144 patients: impact of melanoma-related glaucoma on outcomes.

PURPOSE: To evaluate the outcomes of iris melanoma managed with plaque radiotherapy on the basis of the initial presence or absence of glaucoma. DESIGN: Retrospective, comparative case series. PARTICIPANTS: A total of 144 patients. INTERVENTION: Custom-designed iodine-125 plaque radiotherapy delivering planned 8000 cGy to melanoma apex using transcorneal application. MAIN OUTCOME MEASURES: Tumor control and treatment-related complications. RESULTS: Of 144 patients with iris melanoma, glaucoma was present at the initial visit in 58 (40%). Causes of elevated intraocular pressure included angle infiltration by melanoma in 50 patients (86%), angle neovascularization in 4 patients (7%), and hyphema in 4 patients (7%). At presentation, the eyes displaying iris melanoma with glaucoma (vs. without glaucoma) were statistically more likely to display angle tumor (66% vs. 43%), with minimal thickness (1.9 vs. 2.9 mm), and melanoma seeding in iris stroma (7 vs. 3 clock hours) and angle (5 vs. 2 clock hours). Plaque radiotherapy was performed in all cases. Kaplan-Meier estimates at 7 years post-treatment revealed no statistical differences in outcomes of local recurrence (14% vs. 15%), enucleation (14% vs. 11%), or metastasis (2% vs. 0%) comparing eyes with and without glaucoma. Of the entire group, multivariate analysis for factors predictive of recurrence included partial (vs. complete) anterior segment irradiation and postradiotherapy glaucoma. Factors related to enucleation included diabetes mellitus, poor initial visual acuity, higher radiation dose to tumor apex, and tumor recurrence. There were no factors predictive of metastasis. CONCLUSIONS: Iodine-125 plaque radiotherapy provides adequate tumor control for iris melanoma with a low metastatic potential of 1% at 7 years. Iris melanoma with secondary glaucoma showed a statistically significant greater likelihood of flat tumor with iris and angle seeding and no difference in outcomes compared with eyes without glaucoma. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Ciliary body and choroidal pseudomelanoma from ultrasonographic imaging of hypermature cataract in 20 cases.

PURPOSE: To describe a series of 20 patients with opaque media, referred with uveal melanoma, but subsequently found to have pseudomelanoma from oblique imaging of hypermature cataract on ultrasonography. DESIGN: Case series. PARTICIPANTS: Twenty patients. METHODS: Retrospective chart review. MAIN OUTCOME MEASURES: Ultrasound imaging. RESULTS: All eyes had opaque media from hypermature cataract with no view of the fundus. All were referred because of suspected uveal melanoma, based on ultrasonographic imaging. The echogenic mass appeared to be in the ciliary body (n = 17) or choroid (n = 3). The median patient age was 54 years (range, 17-86 years). Most patients were white (n = 13) or black (n = 4). There was a history of eye trauma (n = 3) and ocular surgery (n = 1). Visual acuity was light perception to hand movements (n = 18) and 20/50 to 20/100 (n = 2). The cataract was in an anatomic position (n = 18) or subluxated (n = 2). On B-scan ultrasonography, the mass was dome-shaped (n = 10) or elliptical (n = 10), displayed an acoustically hollow center with a dense rim (n = 20), and was located in the ciliary body (n = 17) or choroid (n = 3). The mean thickness was 7.2 mm and the mean base was 9.3 mm. Features suggestive of cataract rather than melanoma included a lack of contiguity with the uvea (n = 20) on videoimaging using standard ultrasonography and ultrasound biomicroscopy, a lack of a transillumination shadow, and a lack of a sentinel vessel. For those in the ciliary body region, an additional feature was the ultrasonographic presence of mass in all 4 quadrants (n = 17), representing oblique imaging of the lens equator. For those in the choroid region, the pseudomelanoma shifted when the patient was imaged in a reclined compared with an upright position. After cataract surgery, the lack of melanoma was confirmed. CONCLUSIONS: Dense cataract can preclude a fundus view, necessitating ultrasonography for imaging the posterior segment of the eye. Ultrasonographic confusion with a ciliary body and choroidal melanoma can occur because the dome-shaped cataract can simulate a dome-shaped melanoma.

Plaque radiotherapy for residual or recurrent iris melanoma after surgical resection in 32 cases.

PURPOSE: To evaluate plaque radiotherapy for management of residual or recurrent iris melanoma after surgical resection. DESIGN: Retrospective, nonrandomized interventional case series. PARTICIPANTS: We included 32 patients with residual or recurrent iris melanoma after surgical resection. INTERVENTION: Custom designed iodine-125 plaque radiotherapy. MAIN OUTCOME MEASURES: Tumor control, recurrence, poor visual acuity, enucleation, metastasis, and radiation complications. RESULTS: There were 32 eyes with residual (n = 12) or recurrent (n = 20) iris melanoma after surgical resection that were treated with iodine-125 plaque radiotherapy. The residual melanoma was evident clinically in 3 cases and histopathologically in 9; plaque radiotherapy was delivered at a mean interval of 2 months after resection. For the recurrent cases, the mean interval from initial tumor resection to detection of recurrence was 58 months, at which time plaque radiotherapy was applied. For all cases, the mean tumor basal diameter was 6 mm (range, 1-13) and thickness was 2 mm (range, 0.8-4.0) at the time of radiotherapy. Anterior chamber seeding was present in 26 (81%) eyes and glaucoma in 11 (34%) eyes. Visual acuity at presentation was good (20/20-20/50) in 27 (84%), intermediate (20/60-20/150) in 3 (9%), and poor (≤20/200) in 2 eyes (6%). At 6 years after plaque radiotherapy, outcomes included complete tumor control in 87%, poor visual acuity in 9%, enucleation in 13% (for reasons of tumor recurrence [n = 3] and severe glaucoma [n = 1]), and metastasis in 3%. At 6 years, radiation complications included corneal epitheliopathy in 6%, scleral necrosis in 3%, cataract in 53%, elevated intraocular pressure (from tumor or radiotherapy) in 19%, and macular edema in 6%. CONCLUSIONS: Iodine-125 plaque radiotherapy is effective in the management of residual or recurrent iris melanoma after surgical resection, providing tumor control in 87% of patients at 6 years and avoiding enucleation in most cases.

Fluorescein angiographic findings after intra-arterial chemotherapy for retinoblastoma.

PURPOSE: To evaluate fluorescein angiography (FA) findings after intra-arterial chemotherapy (IAC) for retinoblastoma. DESIGN: Retrospective case series. PARTICIPANTS: Twenty-four eyes of 24 patients. INTERVENTION: Fifty-five IAC procedures for delivery of melphalan 5 mg and possible carboplatin 30 mg. MAIN OUTCOME MEASURES: Vascular flow of iris, retina, and choroid after IAC. RESULTS: All patients received melphalan 5 mg, whereas the first 6 patients also were treated with additional carboplatin 30 mg. The IAC was performed as primary treatment in 17 eyes and as secondary treatment (after systemic chemotherapy) in 7 eyes. Two patients also received external-beam radiotherapy before IAC. At presentation, FA revealed neovascularization of the iris (NVI) in 8 eyes, and after IAC, complete NVI regression was noted in 5 eyes (63%). After a mean follow-up of 13 months after IAC, FA depicted the main tumor with decreased fluorescence in 22 eyes (92%). After 55 ophthalmic artery catheterizations, retinal vascular abnormalities by FA were detected in 7 eyes (13%) and choroidal vascular abnormalities were detected in 6 eyes (11%). The retinal abnormalities included ophthalmic artery obstruction (n = 1), transient ophthalmic artery spasm (n = 1), central retinal artery obstruction (n = 1), branch retinal artery obstruction (n = 2), and peripheral retinal ischemia (n = 2). Additional retinal neovascularization was found in 1 patient. The choroidal abnormalities included sector (n = 5) or diffuse (n = 1) choroidal nonperfusion. New-onset iris neovascularization was found in 2 patients. Retinal vascular abnormalities were diagnosed after median of 1 month after the first IAC, whereas choroidal vascular abnormalities were found after median of 5 months after the first IAC. CONCLUSIONS: Fluorescein angiography suggests that vascular perfusion to the retina and the choroid can be compromised after IAC for retinoblastoma. The most common vascular abnormality was choroidal sector or diffuse nonperfusion.

Minimal exposure (one or two cycles) of intra-arterial chemotherapy in the management of retinoblastoma.

PURPOSE: To assess the efficacy of less than 3 cycles of intra-arterial chemotherapy (IAC) for retinoblastoma. DESIGN: Retrospective, nonrandomized, interventional case series. PARTICIPANTS: Eight patients. INTERVENTION: Intra-arterial chemotherapy. MAIN OUTCOME MEASURES: Tumor control and globe salvage. RESULTS: Eight patients received fewer than 3 cycles of IAC for retinoblastoma because there was complete tumor control with no residual viable tumor (n = 7) or poor response (n = 1) with little hope that further therapy would benefit the patient. In 3 cases, additional vascular compromise precluded further IAC. The treatment was primary in 6 cases and secondary after failure of other treatment in 2 cases. The 8 eyes were classified (International Classification of Retinoblastoma) as group C (n = 2), group D (n = 3), group E (n = 1), and secondary treatment (n = 2). At initial examination, the main tumor showed a mean basal diameter of 16 mm, a thickness of 8.6 mm, vitreous seeds (n = 2), subretinal seeds (n = 6), and iris neovascularization (n = 1). Three patients were treated with a single cycle of IAC, and 5 patients were treated with 2 cycles of IAC. After IAC, complete tumor response was found in 7 eyes (88%) and partial response was found in 1 eye (13%). Over a mean of 13 months follow-up, there was intraretinal tumor recurrence (n = 1), subretinal seed recurrence (n = 1), and no case of vitreous seed recurrence. Globe salvage was achieved in 2 of 2 group C eyes (100%), 3 of 3 group D eyes (100%), 0 of 1 group E eye (0%), and 1 of 2 secondary treatment eyes (50%). Globe salvage was achieved in 6 of 8 eyes (75%), and 2 of 8 eyes (25%) required enucleation. CONCLUSIONS: One or 2 cycles of IAC can be sufficient for selected eyes with group C or D retinoblastoma, with remarkable tumor control. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Clinical survey of 3680 iris tumors based on patient age at presentation.

OBJECTIVE: To report the spectrum of iris lesions based on patient age at presentation. DESIGN: Retrospective, nonrandomized, single-center case series. PARTICIPANTS: We included 3680 iris tumors in 3451 patients. METHODS: Chart review. MAIN OUTCOME MEASURES: Diagnostic category based on age. RESULTS: The mean age at presentation was 48 years and there were 449 (12%) tumors in children (≤20 years), 788 (21%) in young adults (21-40 years), 1308 (36%) in mid adults (41-60 years), and 1135 (31%) in senior adults (>60 years). Of 3680 tumors, the diagnostic category was cystic (n = 768; 21%) or solid (n = 2912; 79%). The cystic tumors originated from iris pigment epithelium (IPE; n = 672; 18%) or iris stroma (n = 96; 3%). The solid tumors included melanocytic (n = 2510; 68%) and nonmelanocytic (n = 402; 11%). The melanocytic tumors comprised nevus (n = 1503; 60%), melanocytoma (n = 68; 3%), melanoma (n = 645; 26%), and melanocytosis (n = 64; 3%). Of 2510 melanocytic tumors, the first and second most common diagnoses by age (children, young adult, mid adult, senior adult) were nevus (53%, 57%, 63%, and 63%, respectively) and melanoma (17%, 27%, 26%, and 27%, respectively). The nonmelanocytic tumors included categories of choristomatous (n = 4; <1%), vascular (n = 57; 2%), fibrous (n = 2; <1%), neural (n = 3; <1%), myogenic (n = 2;, <1%), epithelial (n = 35; 1%), xanthomatous (n = 8; <1%), metastasis (n = 67; 2%), lymphoid (n = 12; <1%), leukemic (n = 2; <1%), secondary (n = 12; <1%), and nonneoplastic simulators (n = 198; 5%). The median age (in years) at diagnosis included cystic (39), melanocytic (52), choristomatous (0.7), vascular (56), fibrous (53), neural (8), myogenic (42), epithelial (63), xanthomatous (1.9), metastasis (60), lymphoid (57), leukemic (25.5), secondary (59), and nonneoplastic simulators (49). Overall, the 3 most common specific diagnoses (children, young adult, mid adult, senior adult) were nevus (25%, 36%, 47%, and 47%, respectively), IPE cyst (28%, 30%, 15%, and 14%, respectively), and melanoma (8%, 16%, 20%, and 19%, respectively). CONCLUSIONS: In an ocular oncology practice, the spectrum of iris tumors includes cystic (21%) and solid (79%) tumors. The solid tumors were melanocytic (68%) or nonmelanocytic (11%). At all ages, the most common specific diagnoses were nevus (42%), IPE cyst (19%), and melanoma (17%).

Intravenous and intra-arterial chemotherapy for retinoblastoma: what have we learned?

PURPOSE OF REVIEW: To review the recent literature on two methods of chemotherapy for retinoblastoma using intravenous versus intra-arterial route. RECENT FINDINGS: In 1996, the era of intravenous chemotherapy (chemoreduction) for retinoblastoma was introduced with major centers providing published information on impressive tumor control, without the need for external beam radiotherapy or enucleation. Later reports heralded continued impressive long-term control, minimal systemic toxicities, likely prevention of pinealoblastoma (trilateral retinoblastoma), and reduction in numbers of germline mutation second cancers. There is no reported ophthalmic toxicity and no evidence of reduction in fertility with chemoreduction. In 2011, the era of intra-arterial chemotherapy was announced with several studies and three conflicting editorials in the literature. This technique requires a catheterization through the arterial tree from the femoral artery into the ophthalmic artery. Outstanding tumor control is achieved with only three cycles, but more-than-expected ocular ischemic events have been noted. Further improvements in this technique could minimize complications. SUMMARY: Both intravenous and intra-arterial chemotherapy are powerful methods for retinoblastoma control. In addition to tumor control, intravenous chemotherapy protects from systemic metastasis and pinealoblastoma, minimizes long-term second cancers, and has few systemic and no ocular toxicities. Intra-arterial chemotherapy provides excellent tumor control for slightly more advanced eyes with retinoblastoma and, in addition, can be used to treat eyes that fail other methods. However, local ocular toxicities can be vision-threatening and long-term systemic toxicities are not yet understood.

Sector laser photocoagulation for the prevention of macular edema after plaque radiotherapy for uveal melanoma: a pilot study.

OBJECTIVE: To investigate the role of sector laser photocoagulation for prevention of macular edema after plaque radiotherapy for uveal melanoma. METHODS: Noncomparative, pilot interventional case series. The main outcome measure was optical coherence tomography-evident macular edema. RESULTS: A total of 29 patients had sector laser photocoagulation (sector panretinal photocoagulation) and sub-Tenon triamcinolone injection. The median tumor thickness and base was 3.3 mm and 10.0 mm. The median radiation dose and rate to the macula was 2,944 cGy and 31.0 cGy/hour. At the 12-month and 24-months follow-up, cystoid macular edema was found in 17% and 24% of the sector panretinal photocoagulation group. There were no major side effects registered. CONCLUSION: Sector panretinal photocoagulation in combination with sub-Tenon triamcinolone appears to show potential as a safe and beneficial intervention for the prevention of macular edema after plaque radiotherapy for uveal melanoma in this series.

Effect of intraarterial chemotherapy on retinoblastoma-induced retinal detachment.

PURPOSE: To study the effect of intraarterial chemotherapy (IAC) on retinoblastoma-induced retinal detachment. METHODS: Retrospective, noncomparative, interventional case series including 15 patients, with intraarterial (ophthalmic artery) chemotherapy as the intervention. Resolution of retinal detachment was the main outcome measure. RESULTS: Of 15 patients with retinoblastoma-induced retinal detachment managed with IAC, 7 (47%) presented with total retinal detachment and 8 (53%) with partial detachment. The eyes were classified as International Classification of Retinoblastoma group C (n = 2, 13%), group D (n = 4, 27%), and group E (n = 5, 33%). There were 4 eyes (27%) that received IAC as secondary treatment after the failure of other treatment methods. After IAC, all tumors showed regression. Of the 7 eyes with initial total retinal detachment, complete resolution of fluid was found in 3 (43%) and partial resolution in 4 (57%). Of the 8 eyes with initial partial retinal detachment, complete resolution of subretinal fluid was found in all 8 (100%), but 1 eye later developed recurrent subretinal fluid. The mean interval to complete resolution of subretinal fluid was 2 months. Globe salvage was achieved in 5 of 7 eyes (71%) with total retinal detachment and 6 of 8 eyes (75%) with partial retinal detachment. CONCLUSION: Eyes with retinoblastoma-induced total or partial retinal detachment showed complete resolution of detachment after IAC in 43% and 100%, respectively.

Vitreous hemorrhage after plaque radiotherapy for uveal melanoma.

PURPOSE: The purpose of this article is to determine the incidence, etiology, management, and outcome of vitreous hemorrhage (VH) after plaque radiotherapy for uveal melanoma. METHODS: Retrospective review of medical records. RESULTS: Of 3,707 eyes treated with plaque radiotherapy for uveal melanoma, VH developed in 4.1% at 1 year, 15.1% at 5 years, and 18.6% at 10 years by Kaplan-Meier analysis. Presumed causes of VH included tumor necrosis (29%), proliferative radiation retinopathy (24%), posterior vitreous detachment (16%), vascular occlusion (5%), and unknown (19%). Tumor necrosis was the most common cause of VH early in the follow-up period (3% at 1 year), while proliferative radiation retinopathy was the most common source of VH later (6.2% at 15 years). The most common initial management was conservative observation for resolution in 48%, laser photocoagulation in 24%, and vitrectomy in 18%. After a mean follow-up period of 5 years, the VH was completely resolved in 41%, partially resolved in 19%, unresolved in 20%, worsened in 5%, and enucleation was necessary in 15%. By multivariable analysis, risk factors for development of VH were the presence of diabetic retinopathy at first visit (relative risk, 6.64), shorter tumor distance to the optic disc (relative risk, 1.07), greater initial tumor thickness (relative risk, 1.1), and break in the Bruch membrane (relative risk, 2.93). The rates of local tumor recurrence, extraocular extension, and distant metastasis in 74 patients who underwent vitrectomy for VH removal after tumor regression were similar to those in patients who did not have vitrectomy for VH. CONCLUSION: Vitreous hemorrhage occurs after plaque radiotherapy for uveal melanoma in 15.1% of the patients by 5 years. The main factors predictive of VH included underlying diabetic retinopathy, closer tumor proximity to the disc, greater tumor thickness, and break in the Bruch membrane. After tumor regression, vitrectomy for blood removal appears to be safe.

Intravitreal bevacizumab for choroidal neovascularization associated with choroidal nevus.

PURPOSE: To report 10 cases of occult choroidal neovascularization (CNV) associated with choroidal nevus managed with intravitreal bevacizumab. METHODS: Interventional case series. Each nevus was examined and imaged with fluorescein angiography, B-scan ultrasonography, and optical coherence tomography. Data were retrospectively analyzed to evaluate outcomes of treatment response and visual acuity. RESULTS: Nine patients presented with CNV overlying a chronic choroidal nevus with a posterior margin within 1.5 mm of the foveola. In the 10th patient, the posterior margin of the nevus was located 10 mm from the foveola with extension of subretinal fluid into the macula. The CNV was subfoveolar in four cases, juxtafoveolar in two cases, and extrafoveolar in four cases. Initial visual acuity was 20/20 to 20/50 in 5, 20/60 to 20/100 in 2, and 20/200 or worse in 3 cases. Clinical features included subfoveolar fluid in nine, exudation in five, and hemorrhage in four cases. Intravitreal bevacizumab (1.25 mg/0.05 cc) was injected with regression of CNV in all 10 cases using 2 to 14 injections (median 3 injections). In 2 eyes, after therapeutic response to bevacizumab later consolidation with photodynamic therapy (juxtafoveolar CNV) (n = 1) or conventional laser (extrafoveolar CNV) (n = 1) was provided. In the remaining 8 eyes, after discontinuation of bevacizumab, there was no recurrence of CNV over mean 10.1 months. At overall mean follow-up of 22.5 months, final visual acuity decreased by 1 line in 4 cases and improved by mean of 3 lines (range, 1-8 lines) in 6 cases. There were no adverse effects from bevacizumab injections. All 10 choroidal nevi remained stable. CONCLUSION: Intravitreal bevacizumab appears to be an effective treatment option for CNV secondary to choroidal nevus. In some cases, depending on the proximity of the CNV to the foveola, photodynamic therapy or conventional laser may be useful adjunctive therapy.

Oncocytic lesions (oncocytoma) of the ocular adnexa: report of 15 cases and review of literature.

PURPOSE: To describe the clinical, imaging, and pathology features of oncocytic lesions in the ocular adnexa. METHODS: Retrospective, noncomparative, interventional case series. RESULTS: Fifteen oncocytic neoplasms (n = 15 patients) were classified as oncocytoma in 14 (93%) and oncocytic hyperplasia in 1 (7%). The mean patient age was 66 years (median = 66, range = 44-82), and 9 (60%) were male. The tumor involved the caruncle (n = 13, 86%), bulbar conjunctiva (n = 1, 7%), and plica semilunaris (n = 1, 7%). All cases were unifocal and most often presented as a painless mass (n = 12, 80%), evolving over a median 6 months (mean = 12, range = 1-48 months). The mean tumor base was 4.1 mm (median = 4.0, range = 1-10), and the tumor was well-circumscribed (n = 14), dark blue (n = 7), and cystic (n = 10). Ultrasound biomicroscopy and anterior segment optical coherence tomography disclosed mixed solid and cystic components. Complete surgical excision was curative without recurrence after a mean follow up of 39 months. Histopathology disclosed columnar cells with copious quantities of intensely eosinophilic cytoplasm in the lining epithelium (oncocytic hyperplasia) and in some cases with cystadenomatous proliferation (oncocytoma). CONCLUSION: Oncocytic lesions of the ocular adnexae are typically well-circumscribed, cystic lesions that most often involve the caruncle. Surgical excision can be curative. Epithelial cells with copious quantities of intensely eosinophilic cytoplasm characterize oncocytic transformation histopathologically.

Prognosis of uveal melanoma in 500 cases using genetic testing of fine-needle aspiration biopsy specimens.

PURPOSE: To determine the relationship between monosomy 3 and incidence of metastasis after genetic testing of uveal melanoma using fine-needle aspiration biopsy (FNAB). DESIGN: Noncomparative retrospective case series. PARTICIPANTS: Five hundred patients. METHODS: Fine-needle aspiration biopsy was performed intraoperatively immediately before plaque radiotherapy. The specimen underwent genetic analysis using DNA amplification and microsatellite assay. Systemic follow-up was obtained regarding melanoma-related metastasis. MAIN OUTCOME MEASURES: Presence of chromosome 3 monosomy (loss of heterozygosity) and occurrence of melanoma metastasis. RESULTS: Disomy 3 was found in 241 melanomas (48%), partial monosomy 3 was found in 133 melanomas (27%), and complete monosomy 3 was found in 126 melanomas (25%). The cumulative probability for metastasis by 3 years was 2.6% for disomy 3, 5.3% for partial monosomy 3 (equivocal monosomy 3), and 24.0% for complete monosomy 3. At 3 years, for tumors with disomy 3, the cumulative probability of metastasis was 0% for small (0-3 mm thickness), 1.4% for medium (3.1-8 mm thickness), and 23.1% for large (>8 mm thickness) melanomas. At 3 years, for tumors with partial monosomy 3, the cumulative probability of metastasis was 4.5% for small, 6.9% for medium, and [insufficient numbers] for large melanomas. At 3 years, for tumors with complete monosomy 3, the cumulative probability of metastasis was 0% for small, 24.4% for medium, and 57.5% for large melanomas. The most important factors predictive of partial or complete monosomy 3 included increasing tumor thickness (P = 0.001) and increasing distance to optic disc (P = 0.002). CONCLUSIONS: According to FNAB results, patients with uveal melanoma demonstrating complete monosomy 3 have substantially poorer prognosis at 3 years than those with partial monosomy 3 or disomy 3. Patients with partial monosomy 3 do not significantly differ in outcome from those with disomy 3.

Anterior segment optical coherence tomography of conjunctival nevus.

PURPOSE: To evaluate conjunctival nevi using anterior segment optical coherence tomography (AS-OCT). DESIGN: Retrospective interventional case series. PARTICIPANTS: There were 22 eyes of 21 patients with conjunctival nevus imaged with AS-OCT for evaluation and detection of cysts within conjunctival nevi. INTERVENTION: Anterior segment OCT. MAIN OUTCOME MEASURES: Evaluation and detection of intralesional cysts. RESULTS: All margins of the nevus, including the deep margin, could be visualized on AS-OCT with high resolution of the anterior margin in 100% of cases, posterior margin in 82% of cases, and lateral margin in 86% of cases. The nevus was optically dense with homogeneous pattern in all cases. Some degree of deep optical shadowing, mostly from pigmented nevi, was noted in 86%. Intrinsic cysts within the nevus were detected by slit-lamp biomicroscopy in 18 cases (82%) and by AS-OCT in 17 cases (77%). In comparison with histopathologic findings, AS-OCT detected intrinsic cysts with a sensitivity of 80%, specificity of 100%, positive predictive value (PPV) of 100%, and negative predictive value (NPV) of 60%. Slit-lamp biomicroscopy (by experienced observers) compared with histopathology revealed detection of cysts with a sensitivity of 100%, a specificity of 100%, a PPV of 100%, and an NPV of 100%. CONCLUSIONS: Anterior segment OCT provides high-resolution imaging of conjunctival nevi with the ability to demonstrate all margins and to provide information on the presence of intralesional cysts, which are important in the diagnosis. The main drawback is optical shadowing of deeper structures from pigment within nevi.

Assessment of anterior segment tumors with ultrasound biomicroscopy versus anterior segment optical coherence tomography in 200 cases.

PURPOSE: To compare ultrasound biomicroscopy (UBM) versus anterior segment optical coherence tomography (AS-OCT) for imaging of tumors of the anterior segment of the eye. DESIGN: Retrospective, noninterventional case series. PARTICIPANTS: We included 200 patients. METHODS: Review of medical records of patients who underwent both UBM and AS-OCT for evaluation of anterior segment tumors. MAIN OUTCOME MEASURES: Comparison of tumor surface and internal visualization. RESULTS: There were 200 eyes with anterior segment tumors involving the iris stroma in 96 (48%), ciliary body in 14 (7%), combined iris and ciliary body in 32 (16%), iris pigment epithelium (IPE) in 44 (22%), conjunctiva in 6 (3%), sclera in 4 (2%), and others in 6 (1% each). The diagnoses included nevus in 75 eyes (38%), melanoma in 47 (24%), cyst in 48 (24%), epithelioma (adenoma) in 5 (3%), metastasis, melanocytosis and melanocytoma in 4 eyes each (2%), and others (1% each). Image analysis (UBM vs AS-OCT) revealed adequate visualization of all tumor margins (189 [95%] vs 80 [40%]), posterior tumor shadowing (9 [5%] vs 144 [72%]), and high overall image quality (159 [80%] vs 136 [68%]). Comparison for better image resolution (UBM vs AS-OCT) disclosed UBM provided better overall tumor visualization (138 [69%] vs 62 [31%]) and better resolution of the posterior margin (147 [74%] vs 53 [27%]), whereas AS-OCT provided better resolution of the anterior margin (40 [20%] vs 160 [80%]) as well as better overall resolution of anterior segment anatomy (41 [21%] vs 159 [80%]). Better resolution was found with UBM for pigmented tumors (n = 162; 107 [66%] vs 55 [34%]) as well as for nonpigmented tumors (n = 38; 23 [61%] vs 15 [39%]). Regarding location, iris tumor resolution was similar with each technique (49 [52%] vs 45 [48%]). CONCLUSIONS: For anterior segment tumors, UBM offers better visualization of the posterior margin and provides overall better images for entire tumor configuration compared with AS-OCT.

Ocular surface squamous neoplasia (squamous cell carcinoma) of the socket: management of extensive tumors with interferon.

PURPOSE: To describe the clinical features and management of extensive ocular surface squamous neoplasia (OSSN) (squamous cell carcinoma) of the socket. METHODS: Retrospective interventional case series. Interferon α 2b (IFNa2b) eye drops (1 million units/cc) 4 times daily and IFNa2b sublesional injection (5 million units/0.5cc to 8 million units/0.8 cc) were delivered for tumor control. Participants were 3 patients with ocular prosthesis who developed extensive socket OSSN. Tumor control was graded as complete regression, partial regression, or no regression. RESULTS: OSSN was detected in the socket at age 60, 43, and 20 years in patients who had worn ophthalmic prostheses for 54, 26, and 13 years, respectively. The patients had chronic discharge and irritation (n = 3) managed with intermittent topical corticosteroids (n = 2). There were no predisposing factors of cigarette exposure, radiation exposure, eczema, systemic immune suppression, or organ transplantation. The prosthesis fit well with nonirritative edges. At presentation, OSSN was subtle (n = 3), vascular (n = 3), and multifocal (n = 3), with largest lesions or confluence of lesions measuring 20, 25, and 20 mm, respectively. The tumors involved the tarsal (n = 3), bulbar (n = 2), and forniceal (n = 2) surfaces. All patients were treated with topical and injection IFNa2b, with complete regression achieved in 2 cases (at 1 months and 20 months) and partial regression in one case (at 9 months). All patients continue on chronic maintenance IFNa2b topically. There were no recurrences, and IFNa2b injection side effects of nausea and chills were minor, lasting 1 day. No patient required surgical removal of tumors from the socket and no patient required exenteration. CONCLUSIONS: Patients wearing ophthalmic prosthesis over a socket should be monitored for the development of OSSN. Combined topical and injection IFNa2b could represent a potentially effective therapy for this condition.

Topical imiquimod for periocular lentigo maligna.

PURPOSE: To evaluate the efficacy of topical imiquimod 5%, a local immune response modifier, in the treatment of periocular lentigo maligna. DESIGN: Retrospective, interventional case series. PARTICIPANTS: Five consecutive patients with biopsy-proven periocular lentigo maligna. METHODS: Periocular lentigo maligna was treated with topical imiquimod 5%. The clinical features, treatment schedule, response to treatment, and complications were analyzed retrospectively. MAIN OUTCOME MEASURES: Response to treatment and complications. RESULTS: The mean patient age was 73 years. The anatomic location of lentigo maligna was the medial canthal area in 2 patients, the lateral canthal area in 1 patient, and the lower eyelid in 2 patients. Topical imiquimod 5% was used for 5 days per week in 3 patients and for 7 days per week in 2 patients. The medication was placed only on the skin and not the globe. The mean duration of treatment was 9 months (range, 1-14 months). Lentigo maligna partially resolved in 3 patients and completely resolved in 2 patients. The most common side effects included localized erythema and discomfort (n = 4), swelling (n = 3), and cutaneous excoriation (n = 2). There were no patients with toxicity to the conjunctiva, cornea, or globe. Treatment was discontinued in 2 patients (one temporarily and the other permanently) because of intolerable local side effects of discomfort, redness, swelling, and cutaneous excoriation. There was no recurrence of lentigo maligna in those with complete or partial response (mean follow-up, 20 months). CONCLUSIONS: Periocular lentigo maligna seems to respond to topical imiquimod 5% treatment. Topical imiquimod 5% treatment for periocular lentigo melanoma deserves further study. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Proliferative radiation retinopathy after plaque radiotherapy for uveal melanoma.

PURPOSE: To determine risk factors, occurrence rate, management, and outcome of proliferative radiation retinopathy (PRR) after plaque radiotherapy for uveal melanoma. DESIGN: Case-control study. PARTICIPANTS: Three thousand eight hundred forty-one patients who underwent plaque radiotherapy for uveal melanoma were entered into the study. METHODS: Retrospective review of medical records. MAIN OUTCOME MEASURES: Proliferative radiation retinopathy after plaque radiotherapy for uveal melanoma. RESULTS: Of 3841 eyes treated with plaque radiotherapy for uveal melanoma, PRR developed in 5.8% at 5 years and in 7% at 10 and 15 years using Kaplan-Meier analysis. The mean time to onset of PRR was 32 months (median, 30 months; range, 4-88 months). On univariate analysis, baseline factors predictive of PRR (P<0.05) included young age, diabetes, hypertension, Hispanic race, shorter tumor distance to the optic disc and to the foveola, Bruch's membrane rupture, choroidal location of the tumor, subretinal fluid, higher radiation dose to the optic nerve and to the foveola, higher radiation rate to the tumor apex and to the tumor base, additional transpupillary thermotherapy, and notched plaque. In the multivariate model, young age (odds ratio [OR], 1.44; 95% confidence interval [CI], 1.25-1.67, per decade decrease), diabetes mellitus (OR, 2.73; 95% CI, 1.69-4.40), and shorter tumor distance to the optic disc (OR, 1.10; 95% CI, 1.04-1.17) were related to the occurrence of PRR. The most common forms of management included panretinal photocoagulation (70%), vitrectomy (21%), and observation (17%). Resolution of the neovascularization was obtained in 63% of eyes after treatment. CONCLUSIONS: Proliferative radiation retinopathy developed in 7% of eyes by 10 years after plaque radiotherapy for uveal melanoma. The main factors for development of PRR included young age, preexistent diabetes mellitus, and shorter tumor distance to the optic disc.