Faculty Bibliography

Purpose. To report on intravitreal bevacizumab treatment for external beam radiation therapy (EBRT)-related radiation maculopathy. Methods. Three patients (4 eyes) with EBRT-related maculopathy were treated with periodic (4- to 8-week) intravitreal injections of bevacizumab (1.25 mg in 0.05 cc). Outcome measures included best-corrected Early Treatment Diabetic Retinopathy Study visual acuity, retinal examination, fundus photography, fluorescein angiography, and optical coherence tomography. Results. Patients were diagnosed with Stage 3 radiation maculopathy occurring 12, 19, and 48 months after irradiation. One received 50 Gy of 6-MV photon EBRT for a maxillary carcinoma, the second 30.6 Gy of 6-MV photon EBRT for intraocular lymphoma, and the third 72 Gy proton beam irradiation for adenoid cystic carcinoma of the lacrimal gland. With up to 33 months follow-up, visual acuities improved (8 and 11 letters) in 2 eyes, gained 5 letters in 1 eye and 1 decreased 5 letters from 20/16 to 20/20. All cases demonstrated clinical findings of decreased intraretinal hemorrhages, cotton-wool spots, and retinal edema. There were no significant ocular or systemic side effects. Conclusions. Intravitreal anti-VEGF therapy was associated with reductions of EBRT-related retinopathy. No ocular or systemic side effects were noted. Anti-VEGF therapy may be considered radiation maculopathy secondary to EBRT

BACKGROUND AND OBJECTIVE: To determine the normal ultrasonographic thickness of the iris and ciliary body. PATIENTS AND METHODS: This prospective 35-MHz ultrasonographic study included 80 normal eyes of 40 healthy volunteers. The images were obtained at the 12-, 3-, 6-, and 9-o'clock radial meridians, measured at three locations along the radial length of the iris and at the thickest section of the ciliary body. Mixed model was used to estimate eye site-adjusted means and standard errors and to test the statistical difference of adjusted results. Parameters included mean thickness, standard deviation, and range. RESULTS: Mean thicknesses at the iris root, midway along the radial length of the iris, and at the juxtapupillary margin were 0.4 +/- 0.1, 0.5 +/- 0.1, and 0.6 +/- 0.1 mm, respectively. Those of the ciliary body, ciliary processes, and ciliary body + ciliary processes were 0.7 +/- 0.1, 0.6 +/- 0.1, and 1.3 +/- 0.2 mm, respectively. CONCLUSION: This study provides standard, normative thickness data for the iris and ciliary body in healthy adults using ultrasonographic imaging

BACKGROUND: A 73-year-old patient presented in our clinic with multiple pigmented iris nodules in the left eye. Though asymptomatic, there was a reported increase in size and number of the nodules during the past year. METHODS: Interventional case report describing a biopsy-proven multifocal iris melanoma treated with a palladium-103 plaque to include the entire anterior chamber within the targeted zone. Biopsy was performed utilizing a 25-gauge aspiration-cutter under viscoelastic. The cornea was protected during radiation therapy with the amniotic membrane buffer technique. Evaluation parameters included visual acuity and clinical assessments aided by slit-lamp photography as well as high-frequency ultrasound imaging. RESULTS: Plaque radiation therapy was well tolerated. Her visual acuity has remained within five letters at 20/25 at 1-year follow-up. Clinical evaluation revealed no evidence of corneal epitheliopathy, iris neovascularization, or visually significant cataract. High-frequency ultrasound imaging revealed a 15% reduction of the tumor's height. Serial abdominal imaging revealed no metastatic uveal melanoma. CONCLUSIONS: We present a biopsy-proven iris diffuse melanoma treated with palladium-103 plaque radiation therapy. Though the entire anterior segment was irradiated, there were no significant side-effects. Local tumor control was excellent during the first postoperative year

BACKGROUND: Multiple myeloma is the most common plasma cell tumor; however, ocular plasmacytomas are rare and can appear in almost any structure of the eye. We present 3 cases, including 2 with unique ophthalmic ultrasound images of ocular plasmacytoma. CASE REPORTS: Three patients with ocular manifestations of multiple myeloma are described. All were noted to have known synchronous systemic disease. In this study, patients presented with epibulbar (n = 2), iridociliary (n = 1), and orbital (n = 2) plasmacytomas. Presenting signs included clinically visible tumor (n = 2), blurred vision (n = 2), diplopia (n = 2), and glaucoma (n = 1). The iridociliary plasmacytoma was defined by high-frequency 35-MHz ultrasonography that revealed 360 degrees of anterior chamber involvement, secondary angle-closure, and extent of iridociliary invasion. In another case, low-frequency B-scan ultrasonography found multiple myeloma of the orbit. Ocular manifestations of multiple myeloma, histopathology, treatment, and prognosis are described. CONCLUSION: Ocular manifestations of plasma cell neoplasms are rare. In multiple myeloma, plasmacytomas can present as a solitary tumor, as an initial sign of systemic disease, or as recurrence. This study presents 3 cases in which epibulbar, orbital, and iridociliary plasmacytoma with secondary glaucoma were presenting signs of uncontrolled multiple myeloma

Two patients were diagnosed as having unilateral iris pigment epithelial (IPE) cysts that were documented to enlarge and induce angle closure. Transpupillary IPE cystotomies were performed using the Nd:YAG laser as a prophylactic measure to prevent angle-closure glaucoma. Anterior chamber anatomy and cyst dimensions were assessed before, during, and after long-term follow-up using slit-lamp biomicroscopy, gonioscopy, and 20- or 35-MHz high-frequency ultrasound imaging. Cystotomy resulted in immediate, visible deflation of both IPE cysts with subsequent resolution of angle closure. The cyst contents appeared clear and no secondary inflammation or glaucoma occurred. No evidence of cyst recurrence has been noted during 3 and 8 years of follow-up, respectively. Transpupillary Nd:YAG laser cystotomy offered a minimally invasive and effective treatment for angle closure induced by progressive IPE cysts

PURPOSE: To evaluate changes in [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) standardized uptake values (SUV) in uveal melanoma before and after plaque brachytherapy. METHODS AND MATERIALS: A cohort of 217 patients diagnosed with uveal melanoma and eligible for ophthalmic plaque brachytherapy underwent preoperative PET/CT to evaluate their intraocular tumor and screen for metastasis. Subsequent to undergoing plaque brachytherapy, patients' PET/CT SUV were periodically reevaluated over 42 months. RESULTS: In this series, 37 (17%) choroidal melanoma patients were found to have an SUV of >2.0. Of these, 18 patients were able to undergo interval follow-up PET/CT scanning. There were 3 patients with T2, 11 patients with T3, and 4 patients with T4 melanomas according to 7th edition AJCC-UICC criteria. Mean apical thickness was 8.8 mm (range, 3-12.3 mm), and the largest mean tumor diameter was 15.1 mm (range, 12-19.9 mm). The mean initial SUV was 3.7 (range, 2.1-7.3). Patients were followed for a median 16 months (range, 6-42 months). The median time to a tumor SUV of 0 was 8.0 months (range, 6-18 months). There was one case of one interval increase in SUV that diminished after circumferential laser treatment. CONCLUSIONS: Intraocular PET/CT imaging provides a physiological assessment of tumor metabolism that can be used to evaluate changes after treatment. In this study, ophthalmic plaque radiation therapy was associated with extinguished tumor PET/CT SUV over time. PET/CT imaging can be used to assess choroidal melanomas for their response to treatment

PURPOSE: To investigate dosimetric differences among several clinical treatment planning systems (TPS) and Monte Carlo (MC) codes for brachytherapy of intraocular tumors using 125I or 103Pd plaques, and to evaluate the impact on the prescription dose of the adoption of MC codes and certain versions of a TPS (Plaque Simulator with optional modules). METHODS: Three clinical brachytherapy TPS capable of intraocular brachytherapy treatment planning and two MC codes were compared. The TPS investigated were Pinnacle v8.0dp1, BrachyVision v8.1, and Plaque Simulator v5.3.9, all of which use the AAPM TG-43 formalism in water. The Plaque Simulator software can also handle some correction factors from MC simulations. The MC codes used are MCNP5 v1.40 and BrachyDose/EGSnrc. Using these TPS and MC codes, three types of calculations were performed: homogeneous medium with point sources (for the TPS only, using the 1D TG-43 dose calculation formalism); homogeneous medium with line sources (TPS with 2D TG-43 dose calculation formalism and MC codes); and plaque heterogeneity-corrected line sources (Plaque Simulator with modified 2D TG-43 dose calculation formalism and MC codes). Comparisons were made of doses calculated at points-of-interest on the plaque central-axis and at off-axis points of clinical interest within a standardized model of the right eye. RESULTS: For the homogeneous water medium case, agreement was within approximately 2% for the point- and line-source models when comparing between TPS and between TPS and MC codes, respectively. For the heterogeneous medium case, dose differences (as calculated using the MC codes and Plaque Simulator) differ by up to 37% on the central-axis in comparison to the homogeneous water calculations. A prescription dose of 85 Gy at 5 mm depth based on calculations in a homogeneous medium delivers 76 Gy and 67 Gy for specific 125I and 103Pd sources, respectively, when accounting for COMS-plaque heterogeneities. For off-axis points-of-interest, dose differences approached factors of 7 and 12 at some positions for 125I and 103Pd, respectively. There was good agreement (approximately 3%) among MC codes and Plaque Simulator results when appropriate parameters calculated using MC codes were input into Plaque Simulator. Plaque Simulator and MC users are perhaps at risk of overdosing patients up to 20% if heterogeneity corrections are used and the prescribed dose is not modified appropriately. CONCLUSIONS: Agreement within 2% was observed among conventional brachytherapy TPS and MC codes for intraocular brachytherapy dose calculations in a homogeneous water environment. In general, the magnitude of dose errors incurred by ignoring the effect of the plaque backing and Silastic insert (i.e., by using the TG-43 approach) increased with distance from the plaque's central-axis. Considering the presence of material heterogeneities in a typical eye plaque, the best method in this study for dose calculations is a verified MC simulation

BACKGROUND AND OBJECTIVE: To evaluate optical coherence tomography/scanning laser ophthalmoscopy (OCT/SLO) imaging for optic nerve head drusen (ONHD). PATIENTS AND METHODS: Nine consecutive eyes with ONHD were imaged. Each underwent visual field testing, 20-MHz B-scan ultrasonography, photography, and OCT/SLO imaging of the nerve head. Similar evaluation was performed on 12 matched, disease-free control eyes for comparison. RESULTS: OCT/SLO imaging of ONHD demonstrated lucencies (100%), variable amounts of displacement, and thickening of the overlying nerve fiber layer, as well as disorganization of the adjacent retinal pigment epithelium (44%). Optic nerve head topography was measured (using horizontal and vertical electronic calipers). Mean disc diameter was 1.81 mm (range: 1.49 to 2.12 mm). All ONHD demonstrated anterior displacement of the base of the optic nerve cup (shallowing) compared to controls. The cup base was a mean +0.32 mm anterior to the retinal pigment epithelium for ONHD versus -0.23 mm for normal controls. CONCLUSION: OCT/SLO revealed unique and clinically helpful views of ONHD

BACKGROUND AND OBJECTIVE: To correlate fundus autofluorescence (FAF) characteristics of metastatic choroidal tumors with optical coherence tomography/scanning laser ophthalmoscope (OCT/SLO). PATIENTS AND METHODS: A retrospective review of 10 choroidal metastases in 9 patients. RESULTS: All tumors were amelanotic, although 8 exhibited surface pigmentation. FAF imaging revealed hyperautofluorescence in areas of focal pigmentation and subretinal fluid with hypoautofluorescent margins (n = 5) corresponding to OCT evidence of retinal pigment epithelial (RPE) thickening and subretinal fluid. Loss of RPE was FAF imaging hypoautofluorescent. FAF images changed with tumor growth. OCT best revealed elevation of the RPE and retina, RPE thickening and folds, and retinal detachment. CONCLUSION: FAF imaging best defined surface characteristics and tumor margins. FAF imaging hyperautofluorescence correlated to focal hyperpigmentation, subretinal fluid, and advancing tumor edges. OCT better demonstrated intraretinal findings (atrophy, subretinal fluid, and increased and lost RPE). This study shows that FAF imaging and OCT reveal unique tumor characteristics of choroidal metastasis

PURPOSE: To determine how tumor characteristics and radiation dose affect the incidence of radiation maculopathy (RM). DESIGN: Retrospective, consecutive case series. METHODS: A consecutive case series of 384 uveal melanomas irradiated (mean apical dose, 71.2 Gy) were followed up for a mean 47.2 months. Tumor locations included: 122 (32%) centered anterior to the equator, 27 (7%) equatorial, and 235 (61%) posterior. Tumor sizes were American Joint Committee on Cancer class T1 (n = 180), T2 (n = 150), T3 (n = 47), and T4 (n = 7). RESULTS: RM occurred in 8 (7%) eyes with anterior uveal melanomas. In contrast, it was found in 82 (41%) eyes with posterior tumors. Multivariate analysis revealed the risk related to posterior location was greater compared with anterior location with a hazard ratio of 6.66 (95% confidence interval [CI], 4.94 to 22.50; P = .0001). Tumor height (> 6.0 mm) also demonstrated a high risk for RM (hazard ratio, 4.5; 95% CI, 2.68 to 10.17; P = .0001). A significant dose-response relationship was found between dose to fovea and RM (P = .0005, for trend). As compared with a dose of < 35 Gy, the risk of RM was 1.74 (95% CI, 0.98 to 3.1) for doses from 35 to 70 Gy, and the risk of RM was 2.43 (95% CI, 1.48 to 4.0) for doses of 70 Gy or more. Of interest, those anterior melanomas with RM had a mean apical height of 9.4 mm, as compared with a mean height of 3.3 mm for anterior tumors not associated with RM. Visual acuity was preserved if the fovea dose was less than 35 Gy. CONCLUSIONS: This study suggests that tumor location, tumor thickness, and radiation dose to the fovea are risk factors for the development of RM