Uveal Melanoma Treated With Iodine-125 Episcleral Plaque: An Analysis of Dose on Disease Control and Visual Outcomes

In the treatment of uveal melanomas, the optimal prescribed dose to maximize disease control, but minimize radiation-related complications is unknown. Historically our institution has treated uveal melanomas to doses less than 85 Gy to the tumor apex even if the apex was less than 5mm in height. Here, we investigate how tumor control and visual outcomes are affected by the radiation dose at the tumor apex

Water Disease

Thyroid related orbitopathy (TRO) is the most common cause of bilateral proptosis in adults. We report a previously-healthy 67-year-old man with progressive bilateral proptosis for 6 months, who was initially diagnosed with TRO but on follow-up was found to have bilateral neoplastic infiltrative orbital disease

Orbital arteriovenous fistula presenting with choroidal pulsations on optical coherence tomography

Purpose: To describe a case of orbital arteriovenous fistula diagnosed based on choroidal pulsations on optical coherence tomography (OCT). Observations: A 69-year-old female originally referred for evaluation of macular degeneration. During acquisition of OCT images, choroidal pulsations of the right eye were noted on the B-scan on the instrument display. The pulsations were not noted on gross or funduscopic examination. Fluorescein angiography was unremarkable. Indocyanine green angiography revealed engorged choroidal vasculature in the right eye. OCT angiography revealed relative tortuosity and dilation of the superficial and deep vascular complexes respectively. B-scan ultrasonography revealed orbital pulsations on the right. MRI imaging of the brain and orbits was unremarkable. Findings were attributed to a low-flow orbital arteriovenous fistula. The patient subsequently developed mild stasis retinopathy for which anti-VEGF therapy was initiated. Conclusions and importance: Arteriovenous fistulas of the brain and orbit classically present with gross pulsatile proptosis among other clinical features. Low flow orbital fistulas may present with subtle choroidal pulsations only detectable on OCT. Keywords: Choroidal pulsations, Optical coherence tomography, Orbital arteriovenous fistul

SUCCESSFUL REPAIR OF RECURRENT OPTIC DISK PIT MACULOPATHY WITH AUTOLOGOUS PLATELET RICH PLASMA: REPORT OF A SURGICAL TECHNIQUE.

PURPOSE: To describe vitreoretinal surgical technique of using autologous platelet-rich plasma to aid in surgical repair of optic pit maculopathy refractive to previous vitrectomy. METHODS: A case of an 18-year-old woman presenting with serous macular detachment secondary to optic pit is reported. Patient had previously undergone vitrectomy and peripapillary laser, but had recurrence of subretinal fluid and worsening visual acuity. Autologous platelet-rich plasma was harvested from the patient\u27s blood and purified using Arthrex ACP kit (Arthrex, Inc, Naples, FL). Repeat pars plana vitrectomy was performed with internal limiting membrane peeling extending to the optic nerve. Platelet-rich plasma was layered over the pit and long-acting gas tamponade performed with face-down positioning. RESULTS: At 8 months of follow-up, subretinal fluid was resolved, the connection between optic pit and subretinal space collapsed and the ellipsoid zone near completely reconstituted on optical coherence tomography. The patient\u27s vision improved significantly from 20/100 to 20/50, which is largely limited by posterior subcapsular cataract. CONCLUSION: Platelet-rich plasma can augment anatomical and visual outcomes in surgical repair of optic pit maculopathy

Acute retinal pigment epithelium detachments after photocoagulation

To characterize the morphology of patterned scanning laser (PASCAL) panretinal photocoagulation. In this prospective cohort study, patients with proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy with high-risk characteristics, who were treated with PASCAL panretinal photocoagulation as part of their indicated clinical course, were serially imaged with spectral domain optical coherence tomography. Thirty eyes of 25 patients were studied from 1 hour to 21 weeks after laser treatment. Over a quarter (26.1%) of all treatment spots were imaged by spectral domain optical coherence tomography 1 hour after PASCAL panretinal photocoagulation. At 1 hour (±30 minutes) after PASCAL treatment, spectral domain optical coherence tomography demonstrated retinal pigment epithelium detachment in 23 of 27 eyes (85.2%) and in 36.1% of all imaged laser spots. Detachments occurred preferentially at the photocoagulation edges in 48.4% of pigment epithelium detachments (PEDs). Linear regression analysis revealed that average laser power (Pearson's r = 0.671, P 1,200 mW. By a 1-week follow-up, no PEDs were observed, and the retinal pigment epithelium appeared morphologically similar to its preoperative structure by 3 weeks. Patient characteristics (study eye, sex, race, diagnosis, age, preoperative blood glucose, hemoglobin A1C, duration of diabetes, and body mass index) and other PASCAL parameters (number of laser applications, spot size, pulse duration, and average laser fluence) were not significantly associated with PEDs. Retinal pigment epithelium detachment occurs 1 hour after PASCAL treatment over a wide range of laser settings. Laser power and energy are positively correlated with the occurrence of PEDs, which are no longer observed by 1-week follow-up. Future studies might examine various acute posttreatment time points and directly compare the morphology of PASCAL burns with that of longer pulse-duration laser modalities

Optical Coherence Tomography and Wide-Field Fluorescein Angiography in Retinopathy of Prematurity

The advent and adaptation of many imaging modalities promise to revolutionize our understanding of retinopathy of prematurity (ROP) by improving the detection, diagnosis, and monitoring of response to treatment of this disease. Diagnosis and classification of ROP traditionally relies on an eye exam by an ophthalmologist expert in this area who characterizes extent and character of retinal vascularization via indirect ophthalmoscopy. Many tools now exist that allow for data acquisition by nurses, technicians, and other trained staff with the images analyzed in a more centralized location. We will focus on two rapidly evolving technologies, optical coherence tomography (OCT), and wide field fluorescein angiography (FA), to better understand how these tools may change our current understanding and management of ROP

Supraselective intra-arterial chemotherapy: evaluation of treatment-related complications in advanced retinoblastoma

Lejla Mutapcic Vajzovic1, Timothy G Murray1, Mohammad A Aziz-Sultan2, Amy C Schefler1, Stacey Quintero Wolfe2, Ditte Hess1, Cristina E Fernandes3, Sander R Dubovy1,41Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA; 2Department of Neurological Surgery, University of Miami/Jackson Memorial Hospital, Miami, FL, USA; 3Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA; 4Florida Lions Oculopathology Laboratory, Miami, FL, USA Purpose: The purpose of this study is to report the complication profile and safety evaluation of supraselective intra-arterial melphalan chemotherapy in children undergoing treatment with advanced retinoblastoma.Methods: Twelve eyes of 10 children with advanced retinoblastoma (Reese-Ellsworth Group Vb or International Classification Group D) were treated with supraselective intra-ophthalmic artery infusion of melphalan. Eleven eyes of nine children had previously failed traditional management with systemic chemotherapy and laser ablation and underwent intra-ophthalmic artery infusion of melphalan as an alternative to enucleation. Serial ophthalmic examinations, retinal photography, and ultrasonographic imaging were used to evaluate treatment regime.Results: Ophthalmic artery cannulation was successfully performed in 12 eyes of 10 patients (total 16 times). Striking regression of tumor, subretinal and vitreous seeds were seen early in each case. No severe systemic side effects occurred. Grade III neutropenia was seen in one patient. No transfusions were required. Three patients developed a vitreous hemorrhage obscuring tumor visualization. One patient developed periocular edema associated with inferior rectus muscle inflammation per orbital MRI. This same patient had scattered intraretinal hemorrhages and peripapillary cotton wool spots consistent with a Purtscher’s-like retinopathy that resolved spontaneously. At the 6-month follow-up examination, nine eyes had no evidence of tumor progression, whereas three eyes were enucleated for tumor progression. In each enucleated case, viable tumor was identified on histopathologic examination.Conclusions: Ophthalmic intra-arterial infusion with melphalan is an excellent globe-conserving treatment option in advanced retinoblastoma cases with minimal systemic side effects. Local toxicities include microemboli to the retina and choroid (1/12, 8%), vitreous hemorrhage (3/12, 25%), and myositis (1/12, 8%). Enucleation remained a definitive treatment for tumor progression in 3 of 12 eyes in this small case series with limited follow-up. Further studies are necessary to establish the role of supraselective intra-arterial melphalan chemotherapy for children with retinoblastoma.Keywords: retinoblastoma, intra-arterial chemotherapy, melphala

Impact of vitrectomy on intraocular pressure (IOP) during and after intraocular injections

Purpose: Intraocular injections raise intraocular pressure (IOP). Our hypotheses: (1) elevated IOP may limit subretinal bleb creation; (2) IOP will return to baseline faster in an eye with complete vitrectomy, including the area around the infusion port, as compared to one with more limited vitrectomy. We tested the impact of vitrectomy technique on IOP during and after intravitreal injections. Methods: We created 4 groups with 3 postmortem porcine eyes per group based on level of vitrectomy: (1) no vitrectomy; (2) core vitrectomy; (3) complete vitrectomy under wide-field view without indentation and without attention to vitrectomy around the infusion port (3); and (4) complete vitrectomy under wide-field view with indentation and attention to vitrectomy around the infusion port. Infusion IOP was set to 25 mmHg via the Constellation vitrectomy system, and actual IOP values were recorded from a pressure transducer connected to the anterior chamber. Following assigned vitrectomy, we injected 0.1mL of fluid into the vitreous cavity while recording: baseline IOP, IOP at peak and at 1 minute after injection, and time interval until return to baseline IOP. Each injection test was repeated 2 additional times per eye. We compared differences between and among means of continuous variables for these groups with generalized estimating equation used to account for multiple measurements on the same eye. Results: Mean peak IOP was \u3e 80 mmHg in groups 1-3 but \u3c 30 mmHg in group 4. Mean time for IOP to return to baseline was \u3e 5 mins in groups 1 and 2 (SD: 191, 137 secs), 42 secs in group 3 (SD, 35), and just over 7 secs (SD, 1.7) in group 4. Compared to mean peak IOPs for each of groups 1, 2, or 3, that for group 4 was different (p\u3c0.001 for all); similarly, group 4’s mean time to return to baseline (7.2 sec) was also lower from that of groups 1, 2 (p \u3c 0.001), and 3 (p = 0.015). Among all four groups, mean time to return to baseline IOP differed (p = 0.020). Conclusions: Compared to limited vitrectomy, complete vitrectomy with indentation and attention to vitrectomy around the infusion port decreases both the pressure spike that occurs with intravitreal injections as well as the time to return to baseline IOP. This suggests that thorough vitrectomy around the infusion port may have a notable impact on stability of set IOP during and after intraocular injections, especially in pediatric eyes, which have dense vitreous comparable to our model. We are studying this impact on subretinal injections

Applicant Perceptions of In-Person versus Virtual Interview Format for Surgical Retina Fellowship

Purpose This article compares applicants' perceptions of and experiences with virtual and in-person interviews for surgical retina fellowship