Quality-based pharmacokinetic model selection on DCE-MRI for characterizing orbital lesions.

BACKGROUND: Although several studies have evaluated dynamic contrast-enhanced (DCE) MRI in the orbit, showing its utility when detecting and diagnosing orbital lesions, none have evaluated the pharmacokinetic models. PURPOSE: To provide a quality-based pharmacokinetic model selection for characterizing orbital lesions using DCE-MRI at 3.0T. STUDY TYPE: Prospective. POPULATION: From December 2015 to April 2017, 151 patients with an orbital lesion underwent MRI prior to surgery, including a high temporal resolution DCE sequence, divided into one training and one test dataset with 100 and 51 patients, respectively. FIELD STRENGTH/SEQUENCE: 3T/DCE. ASSESSMENT: Six different pharmacokinetic models were tested. STATISTICAL TESTS: Univariate and multivariate analyses were performed using Wilcoxon-2-sample tests and a logistic regression to compare parameters between malignant and benign tumors for each pharmacokinetic model for the whole cohort. Receiver operating characteristic (ROC) curve analyses were performed on the training dataset to determine area under curve (AUC) and optimal cutoff values for each pharmacokinetic model, then validated on the test dataset to calculate sensitivity, specificity, and accuracy. RESULTS: Regardless of the model, tissue blood flow and tissue blood volume values were significantly higher in malignant vs. benign lesions: 103.8-195.1 vs. 65-113.8, P [<10-4 -2.10-4 ] and 21.3-36.9 vs. 15.6-33.6, P [<10-4 -0.03] respectively. Extracellular volume fraction and permeability-surface area product or transfer constant appeared to be less relevant: 17.3-27.5 vs. 22.8-28.2, P [0.01-0.7], 1.7-4.9, P [0.2-0.9] and 9.5-38.8 vs. 8.1-22.8, P [<10-4 -0.6], respectively. ROC curves showed no significant differences in AUC between the different models. The two-compartment exchange (2CX) model ranked first for quality. DATA CONCLUSION: DCE MRI pharmacokinetic model-derived parameters appeared to be useful for discriminating benign from malignant orbital lesions. The 2CX model provided the best quality of modeling and should be recommended. Perfusion-related DCE parameters appeared to be significantly more relevant to the diagnostic process. Level of Evidence 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:1514-1525.

Repeatability of apparent diffusion coefficient and intravoxel incoherent motion parameters at 3.0 Tesla in orbital lesions.

OBJECTIVES: To evaluate repeatability of intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) parameters in the orbit. METHODS: From December 2015 to March 2016, 22 patients were scanned twice using an IVIM sequence with 15b values (0-2,000 s/mm2) at 3.0T. Two readers independently delineated regions of interest in an orbital mass and in different intra-orbital and extra-orbital structures. Short-term test-retest repeatability and inter-observer agreement were assessed using the intra-class correlation coefficient (ICC), the coefficient of variation (CV) and Bland-Altman limits of agreements (BA-LA). RESULTS: Test-retest repeatability of IVIM parameters in the orbital mass was satisfactory for ADC and D (mean CV 12% and 14%, ICC 95% and 93%), poor for f and D*(means CV 43% and 110%, ICC 90% and 65%). Inter-observer repeatability agreement was almost perfect in the orbital mass for all the IVIM parameters (ICC = 95%, 93%, 94% and 90% for ADC, D, f and D*, respectively). CONCLUSIONS: IVIM appeared to be a robust tool to measure D in orbital lesions with good repeatability, but this approach showed a poor repeatability of f and D*. KEY POINTS: • IVIM technique is feasible in the orbit. • IVIM has a good-acceptable repeatability of D (CV range 12-25 %). • IVIM interobserver repeatability agreement is excellent (ICC range 90-95 %). • f or D* provide higher test-retest and interobserver variabilities.

Prospective, Split-Face, Randomized, Long-Term Blinded Objective Comparison of the Performance and Tolerability of Two New Hyaluronic Acid Fillers.

BACKGROUND: There are requirements for long-term, objective comparisons of hyaluronic acid (HA) dermal fillers. OBJECTIVE: To compare efficacy and tolerability of ART FILLER Universal (AFU) and ART FILLER Fine lines (AFFL) with the existing HA fillers for the treatment of nasolabial folds and crow's feet. MATERIALS AND METHODS: Prospective, randomized, rater- and patient-blind, split-face comparison of AFU with JUVEDERM Ultra 3 (JUV) and AFFL with FIRST LINES PureSense (FLPS). The severity of nasolabial folds and crow's feet was assessed by independent blinded evaluators using the Lemperle scale at baseline, day (D) 30/D45, D90, and D180. Tolerability, Global Aesthetic Improvement Scale (GAIS), wrinkle volumes, and skin thickness and density were also measured at D30/D45, D90, and D180. RESULTS: At D30 and D180 respectively, 61 and 57 patients were assessed. Scores for nasolabial folds and crow's feet showed statistically significant improvements at D30, D90, and D180. AFU and AFFL were noninferior to JUV and FLPS, respectively. Most patients showed GAIS improvements, maintained until at least D180 and significant increases of collagen synthesis in crow's feet and nasolabial folds. Treatments were well tolerated. CONCLUSION: AFU and AFFL are noninferior to comparators. The methodology used represents a novel approach to augment existing clinical assessment of HA fillers.

Tear trough rejuvenation: A safety evaluation of the treatment by a semi-cross-linked hyaluronic acid filler.

The aim of this study is to describe the experience of 33 physicians, dermatologists and surgeons, with the use of a semi-cross-linked hyaluronic acid (HA) gel as a tear trough deformity filler within one month following injection, and to assess patient satisfaction with the procedure. This study is a case series conducted between February 2012 and December 2012 with the use of semi-cross-linked HA to correct tear trough deformity. The filler was administered in the preperiosteal tissues. The study involved case note review and a patient satisfaction survey. A total of 302 eyes of 151 patients were treated by 33 physicians, with a mean follow-up of 3 weeks. Patients were mainly female (86%), and middle-aged (mean age 48 years old). The gel was placed preperiosteally, deep to the orbicularis, anterior to the inferior orbital rim, with a mean volume of 0.48 ml per eye to achieve correction. The injection procedure was performed without local anesthetic for 79% of the patients. No serious adverse event was recorded. Side effects reported by investigators immediately after injection included bruising (11%), swelling (12%), and redness (inflammation 12%). Very few transitional blue discolorations (2.6%) were observed. No patient required dissolution with hyaluronidase. According to our satisfaction survey, all patients had cosmetic improvement. Most patients (97%) described marked or moderate satisfaction with the treatment. At one month, 18% requested additional hyaluronic acid gel for a touch-up injection. This case series confirms the effective use of a semi-cross-linked HA gel in tear trough rejuvenation. It has excellent patient tolerability, minimal complications, and excellent patient satisfaction.

Clinical equivalence of conventional OnabotulinumtoxinA (900 KDa) and IncobotulinumtoxinA (neurotoxin free from complexing proteins - 150 KDa): 2012 multidisciplinary French consensus in aesthetics.

Botulinum neurotoxins are the most popular non-surgical treatments for aesthetic indications, but there is uncertainty about whether certain formulations are comparable in efficacy and safety and can be substituted for one another by a simple one to one dose conversion ratio. An expert panel of French practitioners was convened to establish a consensus on the clinical equivalence in efficacy and safety of OnabotulinumtoxinA (900 KDa) and IncobotulinumtoxinA (neurotoxin free from complexing proteins - 150 KDa). The consensus was divided into three sections incorporating a biological, bibliographic and clinical analysis of the two toxins. This included a review of the published data that have directly compared the two toxins for aesthetic indications and a survey of the panel's extensive clinical experience with the two toxins in terms of efficacy and safety. All panel members reviewed and endorsed the content of each section. Among this expert panel of French aesthetic physicians and biologists there was consensus that OnabotulinumtoxinA and IncobotulinumtoxinA are clinically equivalent in terms of efficacy and safety, and that a switch from one drug to the other can be made using a simple 1:1 conversion ratio.

Adult-onset asthma associated with periocular xanthogranuloma: new diagnostic and therapeutic approaches in a very rare systemic disease.

PURPOSE: To report some novel findings concerning the systemic manifestations and treatment of adult-onset asthma and periocular xanthogranuloma, a rare type of non-Langerhans histiocytosis that can lead to important visual dysfunction. METHODS: A retrospective case series of 2 patients was evaluated for orbital and systemic manifestations using fluorodeoxyglucose positron emission tomography/CT and/or orbital MRI. Histological specimens were reviewed in all patients. Oral prednisone was initiated at 1 mg/kg daily and gradually tapered to a minimum effective dose. Efficacy was assessed on the basis of an objective observation of decreased swelling. RESULTS: One patient displayed original uptake foci involving intrathoracic lymphadenopathies, the trajectory of the paraumbilical vein and perirectal fat. Low-dose prednisone was able to induce a durable response in the authors' patients. CONCLUSIONS: Fluorodeoxyglucose positron emission tomography/CT may be useful for the diagnostic workup and follow-up assessment of patients with adult-onset asthma and periocular xanthogranuloma. Oral corticosteroids can be used successfully as first-line treatment in such patients.

Effectiveness and safety of cataract surgery in laminar air flow device versus traditional scrubs: A 1-year non-inferiority pilot study.

Purpose: The study aimed to assess the safety and the non-inferiority of cataract surgery outside an operating room using the Surgicube®, a mobile laminar airflow (LAF) device. Settings: This single-center study was conducted at the Rothschild Foundation, Paris, France. Design: This is a retrospective cross-sectional study. Methods: All patients operated on for cataracts using the Surgicube® between February 2020 and February 2021 were included and controlled by a cohort of patients operated on for cataracts in the traditional theater during the same period. Patients with a postoperative follow-up of less than 1 month were excluded. Data collection was carried out using the patient's medical record. The primary endpoint was the evaluation of the number of endophthalmitis in the two groups. The secondary judgment criteria were the analysis of the various complications and the Logmar visual acuity at 1 month in the two groups. All the patients underwent an OCT retinal examination. Results: A total of 923 randomized patients who underwent cataract surgery between 2020 and 2021 have been included in the study. Among them, 448 patients were operated on using the Surgicube, and 475 patients underwent surgery in the traditional operating room using the same lens phacoemulsification technique. There are no significant differences between the two groups (p > 0.05). Conclusion: Cataract surgery using the Surgicube® outside a conventional operating room seems non-inferior to conventional scrub.

Oculofacial contour asymmetries: Management of combined treatment with hyalurostructure and botulinum toxin injections.

PURPOSE: To assess the long-term results of the treatment of oculofacial asymmetries using a combined injection schedule for injections of hyaluronic acid, with a specific micro cannula and botulinum toxin. METHOD: A retrospective study was conducted from January 2009 to January 2010. Patients were treated in the Alcazar Eye Clinic and Oculoplastic Department in Princess Grace Hospital, Monaco. We selected patients complaining of asymmetrical periorbital features who received treatment with hyalurostructure and botulinum toxin injection in one or more sessions. Nine patients were selected and presented with the following symptoms: asymmetry of eyebrow position (2 patients), superior orbital hollow (2 patients), tear trough (2 patients) and orbital volume (ocular prosthesis) (3 patients). The objective was to evaluate the efficiency of combined treatment in one or more sessions on these oculofacial asymmetries. Hyaluronic acid injections were done using hyalurostructure. Hyaluronic acid gel (Restylane Lidocaine) was used with a 25 gauge reinforced micro-cannula (pix'l +, Thiebaud). This was combined with injections of botulinum toxin (azzalure*) to areas of muscular hyperaction. Follow-up was done at 1 year by clinical examination, photography and patient satisfaction. Complications of this combined treatment have been identified. RESULTS: At 1-year follow-up, 88% of patients were satisfied or very satisfied with their results. There were no more complications secondary to both treatments in the same session. It was not noticed more hematomas and bruises than in classical injection method. The action of toxin is constant over time despite the association of hyaluronic acid injections. CONCLUSION: Combined treatments with toxin and hyaluronic acid in oculofacial asymmetries are efficient and can be proposed in the same session. These treatments must be repeated to maintain and optimize muscle contraction and volume loss. Use of hyalurostructure and botulinum toxin treatment in the same session is effective and safe.

F-18 Fluorodeoxyglucose PET/CT as a Diagnostic Tool in Orbital Inflammatory Disorders.

PURPOSE: To assess the usefulness of FDG-PET/CT as a potential diagnostic tool for detecting underlying systemic diseases (SD) in patients with orbital inflammatory disorders (OID). METHODS: All consecutive patients managed for new-onset OID between 2011 and 2018 in a tertiary referral center, who underwent FDG-PET/CT as part of the etiological diagnostic workup were evaluated. To quantify the incremental value of FDG-PET/CT over standard diagnostic workup, the Net Reclassification Index (NRI) and Integrated Discrimination Index (IDI) were used. RESULTS: Among the 22 patients enrolled, 11 (50%) had a positive FDG-PET/CT. After clinicobiological evaluation, FDG-PET/CT correctly reclassified 4(29%) of 14 patients with SD (p = .04) and 1(13%) of 8 with idiopathic orbital inflammation syndrome (p = .32). NRI and IDI were 0.41 ± 0.17 (p = .03) and 0.38 ± 0.08 (p < .001), respectively. FDG-PET/CT successfully detected asymptomatic lesions in all (n = 4) patients with lymphoma. CONCLUSION: FDG-PET/CT enabled accurate reclassification of more than one-quarter of patients with SD, especially extraorbital lymphomas.

Phantom vision after eye removal: prevalence, features and related risk factors.

AIM: Phantom eye syndrome is a poorly understood and underestimated complication of eye removal (ER). Seeing with the amputated eye, referred to as phantom vision (PV), is undoubtedly the most intriguing and confusing complication experienced by anophthalmic patients. The aim of the study was to assess PV prevalence, clinical features and risk factors after ER. METHODS: A multicentric questionnaire-based study was conducted between April 2016 and July 2017. Patients >18 years who underwent ER >3 months ago had a socket examination before inclusion. Data recorded included patients' demographics, and preoperative, surgical and postoperative features. RESULTS: One hundred patients (53 men) with a mean age of 65.1 years (29-92; SD=13.0) were included. ER indications were: uveal melanoma (n=24, 24%), trauma (n=20, 20%), retinal detachment (n=20, 20%), glaucoma (n=14, 14%) and endophthalmitis (n=12, 12%). Thirty (30%) patients experienced PV. Elementary and complex visual hallucinations were experienced by 80% and 20% of patients, respectively. PV usually appeared within the first postoperative month and tended to decrease over time. Risk factors for PV were the preoperative use of proton beam therapy (p=0.006), uveal melanoma (p=0.014), enucleation (p=0.015), anxiety with a Hospital and Anxiety Depression (HAD) score ≥8 (p=0.042), depression with a HAD score ≥8 (p=0.030), phantom eye pain (p=0.044) and phantom eye sensations (p=0.002). CONCLUSION: PV was reported by one-third of our patients. Despite being widely misunderstood, ophthalmologists and neurologists should be aware of this complication to adequately reassure patients.

How to achieve synergy between volume replacement and filling products for global facial rejuvenation.

The objective of this paper is to provide an expert consensus regarding facial rejuvenation using a combination of volume replacement (Juvéderm(®) VOLUMA(®)), filling products (Juvéderm(®) Ultra product line) and botulinum toxin. The Juvéderm product line exploits innovative 3-D technology, producing a range of cohesive, homogenous gels that produce predictable, long-lasting and natural results. The products are easy to use by practitioners and are well-tolerated by patients, and used in combination can provide additional benefits not achieved with one product alone. An assessment of facial anatomy and consideration of the aging process, as well as available treatment options, are also addressed in determining the best combination of products to use. Outcomes from a questionnaire and workshop sessions focusing on specific aspects of use of the Juvéderm product line and botulinum toxin in daily clinical practice are discussed, and recommendations for product use following debate amongst the experts are provided.

Autologous dermis graft versus conchal cartilage graft for managing lower eyelid retraction: A comparative study.

PURPOSE: Lower eyelid management is challenging. The conchal cartilage is often considered a spacer of choice for treating lower eyelid retraction. However, dermis graft has also recently been shown to be a viable spacer. The aim of this study was to compare the efficacy of dermis graft to that of conchal cartilage graft in this indication. METHODS: A retrospective comparative study was conducted in patients who underwent lower eyelid lengthening with autologous dermis graft (group 1) or autologous conchal cartilage graft (group 2). The main outcome measure was the reduction in inferior scleral show (ISS) assessed by three independent masked surgeons. Secondary outcome measures was the assessment of lagophthalmos and corneal keratitis. Complications were also recorded. RESULTS: Twenty-five eyelids of 23 patients were included: 11 and 14 eyelids, respectively in group 1 (dermis graft) and group 2 (conchal cartilage graft). Patient mean follow-up was 12.3 (±12.5) and 7.1 (±7.7) months, respectively. No statistical differences in postoperative ISS reduction, lagophthalmos and exposure keratitis was observed (p = 0.540, p = 0.946, p = 0.934, respectively). Three patients experienced a grade I Clavien-Dindo complication in group 1 and one patient experienced a grade II complication in group 2 (p = 0.540). CONCLUSION: Autologous dermis grafts and conchal cartilage grafts provide favorable outcomes without major complications.

Phantom eye pain: a multicentric study in 100 patients.

PURPOSE: Phantom eye syndrome (PES) is an underestimated complication of eye amputation (EA) characterized by phantom eye pain (PEP), phantom visions and/or phantom sensations. The aim of this study was to assess PEP prevalence, features, risk factors, social and psychological consequences and associated quality of life. METHODS: A questionnaire study was conducted in three oculoplastic departments between April 2016 and July 2017. Patients >18 years who had undergone EA ≥3 months earlier were included and asked to complete a prestamped questionnaire. Patient's characteristics, preoperative, surgical and postoperative data were collected. RESULTS: Of the 185 questionnaires given, 115 (62%) were returned for analysis. Hundred patients with a mean age of 65.1 years (29-92; SD = 13.0) were included. Eye amputation (EA) indications were uveal melanoma (n = 24, 24%), trauma (n = 20, 20%), retinal detachment (n = 20, 20%), glaucoma (n = 14, 14%) and endophthalmitis (n = 12, 12%). Forty-seven (47%), 30 (30%) and 38 (38%) patients experienced PEP, phantom visions and phantom sensations, respectively. Anxiety and depression [Hospital Anxiety Depression scale (HADS) score ≥8 for both] were diagnosed in 34 (34%) and 42 (42%) patients, respectively. The mean EQ-5D-3L and EQ-5D visual analogue scale scores were 0.8 (0.06-1; SD = 0.2) and 68 (0-100; SD = 22), respectively. Preoperative eye pain (p = 0.031), glaucoma (p = 0.027), postoperative anxiety with HADS score ≥8 (p = 0.012) and ≥11 (p = 0.014), aesthetic discomfort (p = 0.002) and EQ-5D-3L score <0.8 (p < 0.001) were significantly associated with PEP in the univariate analysis. In the multivariate analysis, only anxiety (HADS score ≥8) was significantly associated with PEP (p = 0.009). CONCLUSION: Phantom eye pain (PEP) is a common complication of EA strongly associated with postoperative anxiety.

An Unusual Case of Perineural Infiltration and Orbital Invasion of Squamous Cell Carcinoma Associated with Actinic Keratosis.

Actinic keratosis is considered a precancerous lesion, constituting a precursor to squamous cell carcinoma (SCC) formation. Perineural invasion has been observed in patients with cutaneous carcinoma due to local subcutaneous tissue destruction and primarily involves the trigeminal nerve due to rich innervation provided by the supraorbital nerve in addition to the facial nerve. An unusual case of perineural infiltration and orbital invasion of squamous cell carcinoma associated with actinic keratosis is presented. A 70-year-old Caucasian woman presented with complete left eye ophthalmoplegia, total left upper-eyelid ptosis, and facial pain with paresthesia. Computed tomography revealed a process of the soft tissues in the left cheek infiltrating the infraorbital canal, pterygopalatine fossa, inferior orbital fissure, and left cavernous sinus with periosteal adherence. Magnetic resonance imaging revealed pathological extension via the left infraorbital canal with a considerable area of necrosis. Treatment of facial actinic keratosis may not prevent malignant transformation and can delay diagnosis and treatment of SCC. A deep biopsy appears to be essential for a correct diagnosis. Perineural spread of cutaneous SCC may be characterized by insidious progression in the cranial trigeminal nerve, abnormal ocular motility, diplopia, or external ophthalmoplegia.

Adenoid Cystic Carcinoma of the Lacrimal Gland: High Dose Adjuvant Proton Therapy to Improve Patients Outcomes.

Introduction: Lacrymal cystic adenoid carcinoma is a rare disease for which optimal treatment is still debated. In fact, despite aggressive treatment such as eye sparing surgery or orbital exenteration, following by adjuvant radiotherapy, local recurrence and distant metastatic disease are common. This study aims to describe outcomes of eye surgery associated with high dose exclusive adjuvant proton beam irradiation. Materials and Methods: This is a monocentric institutional retrospective study. We retrospectively reviewed records of patients treated in our institution since 2008 with high dose adjuvant proton irradiation for a lacrymal cystic adenoid carcinoma up to a maximum of 75.6Gy(RBE). Other histologies or patients treated with a mix of photon-proton were excluded. A total of 15 patients were finally included. Results: Fifteen patients (80% women, 100% Performance status 0-1) with locally advanced disease (33% T3-T4, 47% R1-R2) were included. After a median follow-up of 67.4 months [13.4-122] the 3 years Overall Survival, local Progression free survival, and progression free survival rates were 78, 70, and 58%, respectively. Six patients exhibited a local recurrence. All patients with conservative surgery maintained their base-line visual acuity and visual field at last follow up. Four patients developed brain radionecrosis. Conclusion: This is the largest series of patients with ACC treated with high dose adjuvant proton therapy. Proton therapy is a safe and efficient treatment and should be considered as an adjuvant irradiation modality to privilege, for patients with lacrimal ACC after conservative or radical eyeball surgery. Dose delivered to temporal lobe should be limited to avoid brain radionecrosis.

Objective 18-month Comparison of the Tolerability of 2 Dermal Fillers Formulated with Tri-Hyal Technology.

The first phase of this study showed that ART FILLER Universal filler (AFU; FILORGA Laboratories) and ART FILLER Fine lines (AFFL) were non-inferior to JUVÉDERM Ultra 3 (Allergan) and FIRST LINES PureSense (Teoxane), respectively. The clinical benefits of AFU and AFFL on nasolabial folds and crow's feet persisted until at least Day 180. This article reports results from an open-label extension phase that assessed the tolerability and efficacy of AFU and AFFL for up to 18 months based on clinical evaluation and ultrasound high-frequency imaging. METHODS: Eligible subjects were enrolled at D180 and assessed on D270, D360, and D540. The primary outcome measured was local tolerability. Secondary outcomes measured included: proportion of subjects in whom the severity of nasolabial folds and crow's feet remained at least 1 point below the baseline measurement (Lemperle scale); general safety; Global Aesthetic Improvement Scale scores by subjects and investigators; wrinkle volumes; and skin thickness by high-frequency ultrasound. RESULTS: Adverse events were consistent with the product information and the initial study. No serious adverse events were recorded. In exploratory analyses, wrinkle correction with AFU and AFFL is sustained for at least 18 months: 48.4% and 98.3% of subjects respectively still showed at least a 1-point decrease in the mean Lemperle score compared with the baseline. The benefits were sustained irrespective of whether subjects received additional injections. Modifications in wrinkle volume and skin thickness at D540 were statistically significant compared with the baseline. CONCLUSION: AFU and AFFL were well tolerated and, in exploratory analyses, showed a sustained efficacy for at least 18 months.

Dysthyroid optic neuropathy: atypical initial presentation and persistent visual loss.

PURPOSE: Dysthyroid Optic Neuropathy (DON) can lead to irreversible visual loss. We report risk features correlated with poor visual recovery despite an intensive treatment in a series of patients with DON. DESIGN: Retrospective analysis of a non-comparative interventional series. METHODS: Between 1997 and 2007, 300 consecutive patients with Graves' orbitopathy were seen at the Rothschild Foundation (Paris). Medical records of all consecutive patients who developed a DON were reviewed. Demographic, clinical features and visual function were collected at the time of the first onset, one month follow-up after medical and sometime surgical treatment and at the last examination. Statistical analysis (reflected as p values) gathered the significant observations into detrimental visual recovery prognostic factors for DON. RESULTS: Fifty-six eyes of 29 patients developed a DON. Sixteen eyes (28%) did not improve vision despite usual treatment (intravenous steroids and surgical decompression when necessary). An inferior altitudinal visual field defect (AVF, p=0.0004) and/or a lack of response to intravenous steroids boluses (p= 0.011) were related to a poor recovery. CONCLUSION: DON prognosis is highly variable. Our results suggest that a non-inflammatory element, probably vascular could be involved in atypical DONs. An earlier recognition could prompt to rapid surgical treatment for these patients.

Malignant Transformation of a Multi-Operated Divided Nevus of the Eyelids.

A woman in her early fifties had regular follow-up for a medium-sized divided nevus of the eyelids which had undergone several surgical excisions during childhood for functional and esthetic reasons. Malignant transformation of the nevus occurred in the inferior eyelid, with the appearance of a new pigmented flat lesion. Histology showed in situ melanoma, and an NRAS activating mutation was found. A full-thickness excision of the inferior eyelid was performed, followed by reconstruction. Local recurrence of the melanoma occurred 1 year after surgery. Lifelong follow-up of divided nevi of the eyelids is recommended, even if very few cases of malignant transformation have been reported so far.

Small Choroidal Melanoma Revealed by a Large Extrascleral Extension.

AIMS: Orbital extraocular extension of choroidal melanoma is very rare with small melanomas. We report the case of a patient whose small choroidal melanoma was initially overlooked and was revealed by a large extrascleral extension. METHODS: A 48-year-old Caucasian woman presented with sudden total visual loss in the right eye. Multicolor imaging of the fundus showed right optic disc edema and an orange and green lesion near the optic disc. The diagnosis of unilateral optic neuritis was made. Magnetic resonance imaging showed an extraocular mass adjacent to the optic nerve; on ultrasound, this mass was acoustically hollow and a small intraocular component was visible. RESULTS: Choroidal melanoma with a large extrascleral extension was diagnosed (T4eN0M0, stage IIIC according to the AJCC 7th TNM classification, 2010). The size of the extraocular nodule was 13 × 5 mm. Treatment consisted of enucleation followed by adjuvant external beam orbital radiotherapy. Tumor analysis showed a mixed cell type melanoma with monosomy 3. The patient developed liver metastasis 10 months after local treatment. CONCLUSION: Extraocular extension of choroidal melanoma can occur with small lesions. Prognosis is generally poor according to AJCC TNM. This case is a reminder that fundus examination may reveal the nature of the mass in some patients with orbital tumors.