Impact of COVID-19 pandemic on eye cancer care in United Kingdom.

The COVID-19 pandemic has had an unprecedented impact on the National Health Service in United Kingdom. The UK Ocular Oncology Services evaluated the impact on the adult eye cancer care in the UK. All four adult Ocular Oncology centres participated in a multicentre retrospective review comparing uveal melanoma referral patterns and treatments in a 4-month period during the national lockdown and first wave of the COVID-19 pandemic in 2020 with corresponding periods in previous 2 years. During the national lockdown, referral numbers and confirmed uveal melanoma cases reduced considerably, equalling to ~120 fewer diagnosed uveal melanoma cases compared to previous 2 years. Contrary to the recent trend, increased caseloads of enucleation and stereotactic radiosurgery (p > 0.05), in comparison to fewer proton beam therapy (p < 0.05), were performed. In the 4-month period following lockdown, there was a surge in clinical activities with more advanced diseases (p < 0.05) presenting to the services. As the COVID-19 pandemic continues to mount pressure and reveal its hidden impact on the eye cancer care, it is imperative for the Ocular Oncology Services to plan recovery strategies and innovative ways of working.

Telemedicine in Oculoplastics: The Real-Life Application of Video Consultation Clinics.

PURPOSE: Our oculoplastic service piloted a new video consultation (VC) clinic in response to the COVID-19 pandemic. Data were collected to determine whether specific patients are better suited to VC, and to quantify the true benefit of VC in patients that successfully attended. METHODS: Data were collected prospectively on predetermined data collection forms, including consultation duration, diagnosis, management plan, and issues that arose. RESULTS: 37.8% of new referrals and 60.9% of return patients were vetted as suitable for VC. Of those invited to attend, 83.4% agreed to a VC appointment. Of the patients appointed to a VC clinic, 71.7% (new)/75% (return) successfully completed VC, 14.9%/15.8% attempted a VC which ultimately failed, and 13.4%/9.2% did not attend. VC successfully prevented face-to-face consultation in 81.3% of new cases and 91.1% of returns. Ectropion, entropion and dermatochalasis (new referrals), and postoperative follow-up (return patients) were well suited to VC, while patients with "watery eye" (new), and lid or conjunctival lesions (return), often required face-to-face consultation. Problems (most common issues with patients connecting to the consultation, video quality, and audio quality) were encountered during 50.3% of calls, although 82.6% of attempted calls were ultimately successful. Age was not associated with the proportion of calls that were successful. CONCLUSIONS: VC is a useful tool for oculoplastic patients, irrespective of age, as long as the patient's notes/referrals are carefully vetted to determine suitability. Patients with ectropion, entropion and dermatochalasis, and postoperative reviews are better suited to VC than those with "watery eye," lid lesions, and conjunctival lesions.

Lagophthalmos and Ptosis in Inclusion Body Myositis.

Sporadic inclusion body myositis is the most commonly acquired type of idiopathic inflammatory myopathy in people aged 50 and above. There is early weakness and atrophy of forearms and quadriceps and a third of patients also have mild facial weakness. Extraocular muscles are not affected and ptosis is rarely seen. The authors describe a unique case in which inclusion body myositis presented with early mid face weakness and atrophy resulting in unilateral lagophthalmus, and ptosis, which have not been documented before. This case is not only unique in its presentation but also emphasizes the importance of considering differential diagnoses and conservative measures before contemplating surgery.

Impact of sphenoid trigone size and extraocular muscle thickness on the outcome of lateral wall orbital decompression for thyroid eye disease.

BACKGROUND: To retrospectively review lateral wall orbital decompression for thyroid eye disease (TED) and to evaluate pre-operative CT scans to analyse the variation in proptosis reduction. METHODS: Consecutive lateral wall orbital decompressions performed by a single surgeon were retrospectively reviewed. Pre-operative CT scan features and post-operative proptosis reduction were analysed. The sphenoid trigone cross-sectional areas were summed and multiplied by the slice thickness to yield bone volume. Cumulative extraocular muscle thickness was calculated by combining the maximum thickness of the four recti. "Trigone volume" and "cumulative muscle thickness" were correlated with proptosis reduction at 3 months post-surgery. RESULTS: Out of 73 consecutive lateral wall orbital decompressions, 17 orbits had prior endonasal medial wall orbital decompression. In the remaining 56 orbits, the mean pre-operative and post-operative proptosis were 24.3 ± 1.6 mm and 20.9 ± 2.3 mm respectively. The proptosis reduction ranged from 1 to 7 mm (mean of 3.5 mm ± 1.3 (p < 0.001)). Mean sphenoid trigone volume was 895 ± 434.4 mm3. The mean cumulative muscle thickness was 20.4 ± 5 mm. The correlation coefficient between muscle thickness and proptosis reduction was - 0.3 and was statistically significant (p = 0.043). The correlation coefficient between sphenoidal trigone volume and proptosis reduction was 0.2 (p = 0.068). With a multivariate analysis, the coefficient of efficient of regression for muscle thickness was - 0.007 (p = 0.42) and the coefficient of regression for trigone volume was 0.0 (p = 0.046). CONCLUSION: Proptosis reduction following lateral wall orbital decompression can be variable. Extraocular muscle thickness had a significant correlation with the outcome, with greater proptosis reduction in orbits with thin muscles. The sphenoidal trigone size had a weak correlation with decompression outcome.

Post-enucleation outcomes of patients with uveal melanoma in Scotland.

BACKGROUND/OBJECTIVES: To investigate post-enucleation outcomes and assess the effect of extrascleral extension (ESE) on these outcomes for patients with uveal melanoma (UM) managed at a tertiary referral centre in Scotland. SUBJECTS/METHODS: Retrospective review of all cases of UM managed by the Scottish Ocular Oncology Service for which enucleation was undertaken between 13/03/2008 and 31/12/2020. Primary outcomes were length of survival, time-to-metastasis (TTM) and local recurrence rate. Secondary outcomes were the effects of the presence of ESE, ESE size, and the use of adjuvant external beam radiotherapy (EBRT) on the primary outcomes. RESULTS: Of 172 enucleated UMs, 32 (18.6%) had ESE. Over a median follow-up period of 33.7 months (range = 1.1-163.7 months), 91 (52.9%) patients died. The median length of all-cause survival of 54.1 months (range = 1.1-163.7 months). One-year, 5-year, and 10-year survival rates were 84.8%, 49.1%, and 30.9%, respectively. Eighty-four (49.7%) patients had metastatic disease. The median TTM of 42.2 months (range = 0.4-106.8 months). Proportions of patients who developed metastases within 1-year, 5-years and 10-years post-enucleation were 22.7%, 52.8%, and 71.8%, respectively. There was one instance of local orbital recurrence. ESE was associated with a significantly shorter length of survival (p = 0.03). There was a trend towards a shorter length of survival and TTM with ESE > 5 mm and those who received adjuvant EBRT. CONCLUSIONS: ESE was present in one-sixth of our cohort and was associated with a significantly shorter length of survival, particularly in the presence of ESE > 5 mm or high-risk characteristics warranting adjuvant EBRT. This data will aid prognostication of the patients in our service.

Consensus statement for metastatic surveillance of uveal melanoma in Scotland.

Ophthalmic treatments are successful in managing uveal melanomas achieving good local control. However, a large number still metastasise, primarily to the liver, resulting in mortality. There is no consensus across the world on the mode, frequency, duration or utility of regular liver surveillance for metastasis and there are no published protocols. The Scottish Ocular Oncology Service (SOOS) constituted a Scottish Consensus Statement Group (SCSG) which included ocular oncologists, medical oncologists, radiologists and a uveal melanoma patient as a lay member. This group carried out an extensive review of literature followed by discussions to arrive at a consensus regarding surveillance planning for posterior uveal melanoma patients in Scotland. The Consensus Statement would provide a framework to guide each patient's surveillance plan and provide all patients with clarity and transparency on the issue. The SCSG was unable to find adequate evidence on which to base the strategy. The consensus statement recommends a risk-stratified approach to surveillance for these patients dividing them into low to medium-risk and high-risk groups defining the mode and duration of surveillance for each. It supplements the UK-wide Uveal Melanoma National Guidelines and allows a more uniform consensus-based approach to surveillance in Scotland. It has been adopted nationally by all health care providers in Scotland as a guideline and is available to patients on a publicly accessible website.

Is an image-based eyelid management service safe and effective?

INTRODUCTION: The COVID-19 pandemic created a requirement for reduced patient contact and reduced capacity in clinics. We previously published results of an Image-Based Eyelid Lesion Management Service (IBELMS) which was found non-inferior to traditional face-to-face clinic at diagnosing lesions and identifying eyelid malignancies. We now present first-year safety and efficacy data from this service. METHODS: Data were collected retrospectively on all patients seen in NHS Greater Glasgow and Clyde eyelid photography clinics from 30th September 2020 to 29th September 2021, including referral source and diagnosis, time to clinic review, treatment and patient outcomes. RESULTS: 808 patients were included in the study. Chalazion was the most common diagnoses recorded (38.4%). There was a statistically significant decrease in mean time from referral to appointment time between the first 4 months and last 4 months of the service (93 days to 22 days, p ≤ 0.0001). 266 (33%) of patients were discharged following photographs, 45 (6%) were discharged for non-attendance and 371 (46%) were booked for a minor procedure. 13 biopsy-confirmed malignant lesions were identified; only 3 had been referred as suspected malignancy. 23 patients out of 330 with at least 6 months follow up (7%) were re-referred within 6 months of treatment or discharge; however, none of them with a missed periocular malignancy. DISCUSSION: Eyelid photography clinics effectively reduce patient waiting times and maximise clinic capacity. They accurately identify eyelid lesions including malignancies with a low re-referral rate. We propose that an image-based service for eyelid lesions is a safe and effective way of managing such patients.

When Is the Optimum Radiological Response to Proton Beam Therapy in Uveal Melanoma?

Introduction: Proton beam therapy (PBT) is an effective treatment option for uveal melanomas. Following treatment, it may take many months for the tumour to respond and it may initially enlarge. We reviewed our PBT patients to determine when they showed a radiological response to treatment. Methods: Patients undergoing PBT for ciliary body or choroidal melanomas between 2008 and 2018 were included. Data were collected on patient demographics, treatments before and after PBT and survival. All ultrasound investigations prior and since PBT were reviewed and tumour volume calculated using a validated formula for a half-ellipsoid shape. Results: 193 patients were analysed, 169 with choroidal and 24 with ciliary body melanomas. 31.6% patients had other treatment prior to PBT. At a mean of 8 months post-PBT, 64.7% of patients had a reduced tumour volume with 20.2% having larger tumours. At a mean of 15 months post-treatment, these figures were 67.8% and 10.3%. 18.1% of patients had an enucleation during the study period. The earliest responses were seen at 2 months, the latest at 32 months post-treatment. 5-year melanoma-specific survival was 82.3%. Conclusions: In our study, by 6 months post-PBT, a majority of patients show a reduction in tumour volume. Of those that do not, many respond in the next 6 months and a response may be seen up to 32 months after treatment. Patients may need to be monitored for up to 32 months to see a final response to PBT treatment.

Outcomes of cataract surgery in patients previously treated with orbital radiotherapy.

PURPOSE: To quantify the risks for cataract surgery in patients who have previously undergone external beam radiotherapy (EBRT). SETTING: Tertiary ophthalmology and oncology hospital. DESIGN: Retrospective case series. METHODS: Patients treated with orbital EBRT at the Beatson West of Scotland Cancer Centre between 2001 and 2019 were identified, and clinical records were reviewed to identify those who had subsequently undergone cataract surgery. Preoperative and postoperative case records, and operation records, were reviewed to identify demographic data and data regarding complications and surgical outcomes. RESULTS: 46 eyes (of 33 patients) were included. The indications for EBRT included thyroid eye disease, lymphoma, choroidal metastases, and other orbital malignancies. Mean corrected preoperative Snellen visual acuity was 20/100 (range 20/30 to 20/2000) improving to 20/25 (20/12 to 20/160, 1-way analysis of variance P < .01). Mean visual gain was 0.5 logMAR (-0.9 to 1.9). There was 1 case of posterior capsule (PC) rupture with vitreous loss (2%). Dense PC plaque was noted intraoperatively in 19.5% (n = 9). 13% (n = 6) required Nd:YAG laser posterior capsulotomy. There were 6 cases (13%) of cystoid macular edema (CME). CONCLUSIONS: Visual outcomes after cataract surgery in this cohort of patients were similar to those obtained in a nationwide cohort. EBRT seemed to be associated with an increased incidence of intraoperative PC plaque, postoperative CME (which in most cases settled with treatment), and need for posterior capsulotomy.

Caliber persistent artery of the eyelid.

BACKGROUND: To report three cases of caliber persistent artery presenting in the eyelid. METHODS: A case series describing three patients with vascular lesions of the eyelid that were biopsied. One case was bilateral. RESULTS: All three patients presented with a painless red lesion on the eyelid. These were on the lower eyelid in two patients and the upper eyelid in one patient. For the bilateral case, the lesions were both on the lower eyelid. Histological examination of all four biopsies showed a large caliber artery within the dermis extending almost at right angles to the skin surface and consistent with caliber persistent artery. CONCLUSIONS: These are the first reports of caliber persistent artery of the eyelids, an entity that is most commonly recognized on the lips. Clinicians should consider this entity in the differential diagnosis of patients presenting with a painless, vascular lesion of the eyelid.

Outcomes following Notched Ruthenium-106 Plaque Brachytherapy for Juxtapapillary Choroidal Melanomas.

PURPOSE: This study aimed to evaluate the outcomes of juxtapapillary choroidal melanomas treated with notched ruthenium-106 plaques. METHODS: Juxtapapillary choroidal melanomas (tumours within 2 disc diameters from the optic disc) treated with notched ruthenium-106 plaques (Eckert & Ziegler, BEBIG, Berlin, Germany) at the Scottish Ocular Oncology Service between 2009 and 2015 were retrospectively reviewed. The data were analysed with respect to various outcome measures including recurrence, complications, vision, and eye preservation. RESULTS: We reviewed 40 patients with a median tumour diameter of 8.4 mm (range 5-17 mm) and a median thickness of 2.5 mm (range 1.1-6 mm). AJCC tumour category distribution was 62.5% T1, 32.5% T2, and 5% T3 tumours. The mean presenting vision was 0.3 logMAR, and the mean final vision was 0.7 logMAR, with 62.5% retaining >1.0 logMAR and 50% retaining >0.3 logMAR at the final follow-up. The median follow-up was 51 months (14-100 months). Over the maximum follow-up time, 13 tumours (32.5%) recurred. Six of these were treated with salvage proton beam therapy (PBT), 2 with transpupillary thermotherapy followed by PBT, and 5 with enucleation. The final eye retention rate was 87.5%. Complications included maculopathy (10%), retinal detachment (5%), neovascular glaucoma (2.5%), and diplopia (2.5%). The observed risk of recurrence over 5 years was 31% (95% CI: 14.1%, 47.8%), and the risk of enucleation over 5 years was 11.5% (95% CI: 0.9%, 21.8%). CONCLUSION: Juxtapapillary choroidal melanomas treated with notched ruthenium plaques have a high recurrence rate and frequently need salvage treatment with PBT for tumour control. This has led to a change in our practice toward offering PBT as the first-line treatment for these patients.

Multifocal Intraretinal Tumour Deposits following Treatment of an Ipsilateral Choroidal Melanoma.

BACKGROUND/AIMS: The aim of this study was to report a patient who, following plaque brachytherapy for a choroidal melanoma, developed two separate retinal foci of malignant melanoma in the same eye, and suggest possible mechanisms that might explain such an occurrence. METHODS: We conducted a retrospective case report. RESULTS: A 79-year-old Caucasian male developed a left inferotemporal choroidal melanoma in 2016 and subsequently underwent ruthenium-106 plaque brachytherapy under the care of the Scottish Ocular Oncology Service. Serial B-scan ultrasonography demonstrated a post-treatment reduction in tumour height to <2 mm. In 2018, 27 months after the treatment, the patient complained of a "black spot" in the centre of his left eye vision. His visual acuity had reduced to counting fingers from 6/24 (corrected Snellen visual acuity). Several new areas of pigmentation and elevation were observed, and uveal melanoma recurrence was initially suspected. Given the multifocal nature of the presentation, the multi-disciplinary team recommended enucleation. Histological examination of the enucleated eye revealed three discrete foci of malignant melanoma - the previously treated choroidal malignant melanoma, and two solitary deposits of malignant melanoma within the retina. CONCLUSION: Retinoinvasive melanoma is a rare subtype of uveal melanoma, characterised by transvitreal melanoma invasion of the retina at a site non-contiguous with the uveal tumour, which may explain the clinical and pathological findings of the reported case.

A refractive optical device potentially masking an intraocular tumor.

A 62-year-old woman was referred with reduced vision in her left eye and suspected retinal detachment. Bilateral laser in situ keratomileusis with KAMRA corneal inlay insertion was performed in the left eye 2 years earlier. On examination, a shadow from the corneal inlay limited posterior segment examination even with dilated fundoscopy, but a temporal raised lesion extending over the macula was noted. Ocular ultrasound confirmed a large tumor consistent with malignant melanoma, requiring enucleation. It is unclear whether the patient had baseline dilated fundoscopy before corneal inlay implantation; however, a pinhole effect for the patient will cause a pinhole effect for the clinician, potentially limiting the fundal view. The authors emphasize the importance of appropriate informed consent patients, including discussion of rare risks and complications, which can have profound implications. In this case, the elective refractive procedure potentially masked an intraocular tumor. Enucleation may have been avoided if the lesion had been identified at an earlier stage.

Unwrapped hydroxyapatite orbital implants: our experience in 347 cases.

OBJECTIVES: To report the results of a large case series of enucleations with primary insertion of an unwrapped hydroxyapatite (HA) orbital implant. METHODS: We retrospectively reviewed consecutive enucleations with primary orbital (HA) implant insertion performed at the Scottish Ocular Oncology Service, Glasgow between 1990 and 2014. The unwrapped hydroxyapatite orbital implant was placed in the posterior portion of the socket and recti muscles sutured end-to-end over the implant. RESULTS: Out of 347 consecutive enucleations, the indication for enucleation was tumour-related pathology in 59.7% and painful blind eye in 40.3%. Majority (70%) received an implant of 22-mm diameter. At an average follow-up of 3.5 years, complications included post-enucleation socket syndrome (11.5%), chronic discharge (9.2%), chronic pain (4.3%), recurrent conjunctival infection (2.3%),conjunctival cysts (2%), contracted socket (1.4%), implant exposure (1.2%), haematoma (0.6%) and ill-fitting prosthesis (0.6%). Implant exposure (1.2%, n = 4) occurred at a mean of 4.5 months post surgery and was managed by temporalis fascia graft (n = 1), tarsoconjunctival flap (n = 1), implant removal (n = 1) and observation (n = 1). Overall, 9.8% of patients needed further surgery including lower lid tightening (4.3%), ptosis repair (2.3%), conjunctival cyst excision (1.2%), fornix reconstruction (1.2%), graft/flap for exposure (0.6%) and implant removal (0.3%). CONCLUSIONS: A low rate of implant exposure indicates that absence of wrapping material around hydroxyapatite orbital implants does not compromise surgical outcomes and has the added benefit of reduced surgical time and avoidance of complications from wrapping materials. Posterior implant placement and end-to-end recti suturing contribute to the success of the procedure.

Uveal melanoma-associated survival in Scotland.

BACKGROUND/OBJECTIVES: The Scottish Ocular Oncology Service (SOOS) manages all patients with uveal melanoma (UM) in Scotland. Our aim was to determine the long-term all-cause and cause-specific survival of patients with UM, irrespective of treatment modality. SUBJECTS/METHODS: A retrospective single-centre cohort study including all patients diagnosed with UM by the SOOS between 1/1/1998 and 31/12/2002. Data from the SOOS database were correlated with death records held by National Records of Scotland, which provided date, and all listed causes, of death for all deceased patients. RESULTS: Two hundred and eighteen patients were newly diagnosed with UM between 1/1/1998 and 31/12/2002. One hundred and fifteen (52.8%) were female. The mean (median) age at diagnosis was 63(65) years (range: 16-89). Of 179 choroidal melanomas, melanoma-specific survival was 92.3%, 87.4% and 83.8% at 5, 10 and 15 years, respectively. Cancer-specific survival was 85.8%, 71.8% and 62.3%. All-cause survival was 81.6% (146/179), 62.0% (111/179) and 46.7% (computed, fraction inexpressible). Of 26 ciliary body melanomas, melanoma-specific survival was 87.2%, 81.3% and 81.3% at 5, 10 and 15 years. Cancer-specific survival was 62.9%, 40.6% and 40.6%. All-cause survival was 61.5% (16/26), 38.5% (10/26) and 26.9% (7/26). Of 13 iris melanomas, at all three timepoints (5/10/15 years), melanoma-specific survival was 100%, cancer-specific survival was 92.3%, and all-cause survival was 76.9% (10/13). CONCLUSIONS: Correlation of SOOS and national records survival data confirms 15-year melanoma-specific survival of 83.8%, 81.3% and 100% for choroidal, ciliary body and iris melanomas, respectively. We can now provide accurate survival data to our patients in Scotland.

A systematic literature review of surgical interventions for limbal stem cell deficiency in humans.

PURPOSE: To evaluate the relative benefits and to identify any adverse effects of surgical interventions for limbal stem cell deficiency (LSCD). DESIGN: Systematic literature review. METHODS: We searched the following electronic databases from January 1, 1989 through September 30, 2006: MEDLINE, EMBASE, Science citation index, BIOSIS, and the Cochrane Library. In addition, reference lists were scanned to identify any additional reports. The quality of published reports was assessed using standard methods. The main outcome measure was improvement in vision of at least two Snellen lines of best-corrected visual acuity (BCVA). Data on adverse outcomes also were collected. RESULTS: Twenty-six studies met the inclusion criteria. There were no randomized controlled studies. All 26 studies were either prospective or retrospective case series. For bilateral severe LSCD, keratolimbal allograft was the most common intervention with systemic immunosuppression. Other interventions included eccentric penetrating keratolimbal allografts and cultivated autologous oral mucosal epithelial grafts. An improvement in BCVA of two lines or more was reported in 31% to 67% of eyes. For unilateral severe LSCD, the most common surgical intervention was contralateral conjunctival limbal autograft, with 35% to 88% of eyes gaining an improvement in BCVA of two lines or more. The only study evaluating partial LSCD showed an improvement in BCVA of two lines or more in 39% of eyes. CONCLUSIONS: Studies to date have not provided strong evidence to guide clinical practice on which surgery is most beneficial to treat various types of LSCD. Standardized data collection in a multicenter LSCD register is suggested.

Photodynamic Therapy for Circumscribed Choroidal Haemangioma in a Scottish Cohort.

PURPOSE: The aim of this study was to evaluate the safety and efficacy of photodynamic therapy (PDT) with verteporfin as a treatment for circumscribed choroidal haemangioma (CCH). PROCEDURES: This is a retrospective cohort study of all treatment-naïve patients undergoing PDT with verteporfin for CCH in a single centre between April 1, 2007, and September 30, 2016. Best corrected visual acuity (BCVA; using ETDRS letter score), optical coherence tomography (OCT) measurements and a subjective measurement of visual function were recorded before treatment, at 3-month follow-up and at each annual follow-up. RESULTS: Seventeen Caucasian patients with CCH received PDT, with a re-treatment rate of 23.5% (n = 4). Mean (±SD) follow-up was 36.5 (±32.6) months (range 2-106). Mean (±SD) pre-PDT BCVA was 58.5 (±15.5) letters, with a mean improvement from baseline of 8.2 letters at 3 months, of 13.8 letters at 1 year, of 21.1 letters at 2 years and of 19.5 letters at 3 years of follow-up. Subjective visual improvement was noted in 67% at 3 months, in 93% at 1 year, in 86% at 2 years and in 100% at 3 years of follow-up. OCT demonstrated no intraretinal/subretinal fluid in 63% at 3 months, in 77% at 1 year, in 86% at 2 years and in 100% at 3 years of follow-up. No complications of PDT were noted during the study. CONCLUSIONS: PDT is a safe and effective treatment for CCH which results in both structural and functional improvements, and these findings are particularly applicable to patients of Caucasian ethnicity. OCT provides a useful and readily available option to monitor CCH disease activity and its response to PDT.