Faculty Bibliography

PURPOSE/OBJECTIVE:Evaluate Super-Thick Amniotic Membrane Graft(ST-AMG) for ocular surface reconstruction. DESIGN/METHODS:Retrospective, interventional case series. METHODS:SETTING: Single center, clinical practice POPULATION: Selected patients with typically large ocular surface abnormalities that required reconstruction. INTERVENTION/METHODS:Surgical insertion of ST-AMG for reconstruction or repair of the ocular surface. MAIN OUTCOME MEASURES/METHODS:Intraoperative handling, graft position at 1 week post-implantation, graft dissolution at 3-weeks, epithelialization of the ocular surface and symblepharon. RESULTS:Eleven ST-AMG were implanted after resection with cryotherapy: 5 conjunctival melanoma, 4 squamous cell carcinoma, 1 sebaceous carcinoma, 1 pterygium. Additionally, 1 was implanted for scleral necrosis. ST-AMG up to 9-times thicker than standard amniotic grafts and thus amenable to both running and interrupted 7-0 Vicryl sutures without cheese-wiring. All cases had a well-positioned ST-AMG at 1-week and 75%(n=9/12) had partial graft dissolution at 3 weeks. Complete epithelialization without wound dehiscence as noted in all cases. However, secondary (after additional tumor treatment) symblepharon formed in 16.7%(n=2/12). In all cases, the mean visual acuity and intraocular pressures remained unchanged during conjunctival reconstruction and subsequent secondary. Post-epithelialization adjuvant topical chemotherapy was given to extend treatment margins and treat presumed occult disease in 50%(n=6/12). At mean follow-up of 25.5 months (median 10, range 3-90),10 cases (83.3%) showed complete local tumor control, 1 showed revascularization of the scleral melt and 1 required orbital exenteration. CONCLUSION/CONCLUSIONS:ST-AMG were easy to suture and relatively persistent. Epithelialization of the ocular surface without primary symblepharon formation was noted. ST-AMG should be considered an alternative for ocular surface reconstruction.

PURPOSE: To describe a patient with a presumed retinal pigment epithelium (RPE) tumor originating from unilateral RPE dysgenesis. METHODS: Case report. RESULTS: A 30-year-old woman with an unremarkable medical and ocular history was referred for an evaluation of progressive central metamorphopsia in her left eye. Visual acuity was 20/20 in her right eye and 20/25 in her left eye. Funduscopic examination of the left eye revealed an elevated mass within an area of unilateral RPE dysgenesis showing hyperpigmentation and hypopigmentation with scalloped margins. Fundus autofluorescence of the lesion showed a marginal pattern of hyperautofluorescence and hypoautofluorescence that was the inverse of the fluorescein angiography pattern. A well-circumscribed subretinal mass appeared to originate from the unilateral RPE dysgenesis lesion with surrounding subretinal fluid extending beneath the fovea. Ultrasonography showed medium-to-high reflectivity of the mass with no evidence of choroidal involvement. Optical coherence tomography showed a subretinal hyporeflective mass consistent with a tumor of RPE origin. The tumor appeared to invade the overlying retina where fluorescein angiography showed hyperfluorescent leakage and OCT angiography showed retinal vascular deformation. Indocyanine green angiography showed no evidence of choroidal neovascularization. Findings in the right fundus were normal. Over a 5-month follow-up, intravitreal anti-vascular endothelial growth factor therapy induced a resolution of subretinal exudation and modest reduction in tumor thickness. CONCLUSION: To the authors' knowledge, this is the first report of a presumed RPE tumor described as originating from unilateral RPE dysgenesis. Multimodal imaging was crucial for establishing the diagnosis and showing that the patient's visual symptoms were a product of the exudation produced by the tumor's invasion of the retina.

A 39-year-old female presented with a painless yellow-pink tumor on her right eye. High-frequency ultrasound imaging revealed an epibulbar lesion with homogenous low internal reflectivity and no evidence of intraocular invasion. The patient underwent excisional biopsy leading to a pathology diagnosis of myxoma. Additional surgical margins as well as adjuvant cryotherapy margins were followed by extensive conjunctival repair. Herein, we report on a conjunctival myxoma with unique ultrasonographic findings.

Ocular cancers are unique among the diseases of the eye, threatening both vision and life. In most cases, the diagnosis can be made utilizing a careful clinical history and specialized ocular examination. Eye cancer diagnosis relies heavily on imaging techniques such as high-frequency ultrasound, fluorescein angiography, anterior and posterior segment optical coherence tomography, computed tomography (CT), and magnetic resonance imaging (MRI). Once the diagnosis is established, treatment decisions depend on the tumor's location, size, local extension, patterns of growth, and secondary complications. Treatment options include observation, local resection, chemotherapy (topical, intravenous, intra-arterial, or intravitreal), and radiation (ophthalmic plaque or external beam). Enucleation or exenteration is only employed if these eye- and vision-sparing treatments are not possible. The core of this comprehensive review is a consecutive series of the most common ocular tumor of each structure of the eye, anterior to posterior, including basal cell carcinoma of the eyelid, squamous conjunctival neoplasia, choroidal melanoma, retinoblastoma, ocular adnexal lymphoma, and metastatic orbital tumors.

PURPOSE/OBJECTIVE:To present a unique approach to eye and vision sparing for a patient with squamous cell carcinoma invading through a penetrating keratoplasty (PK) wound. METHODS:A 56-year-old functionally monocular man was found to have squamous cell carcinoma with intraocular invasion through a PK wound. Eye- and vision-salvaging palladium-103 plaque radiation was performed. An amniotic membrane graft was used to buffer and thus protect the cornea during the 7-day treatment. Leaded eye glasses were worn during the day to block emitted radiation and allow functional vision during irradiation. RESULTS:At 3.5 years status posttreatment, the tumor has regressed, PK has become progressively hazy (within the irradiated zone), and his vision is stable at 20/320. The epicorneal tumor has disappeared, and the intraocular tumor nodules are more highly reflective, but persistent. There has been no intraocular tumor progression, worsening of his glaucoma, or evidence of intraocular radiation vasculopathy. CONCLUSIONS:Transcorneal intraocular tumor invasion was controlled using palladium-103 ophthalmic plaque radiation therapy applied through the natural and donor cornea. Definitive treatment resulted in local tumor control and preservation of vision.

The authors present a case of a pregnant woman with uveal melanoma treated with plaque brachytherapy. Her calculated fetal radiation dose was significantly below accepted levels. The use of the authors' novel, custom-made lead chin shield further diminished irradiation of the fetus. This patient had uncomplicated treatment course, delivered a healthy child full term, achieved local tumor control, and maintained 20/25 vision at 1-year follow-up. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:364-368.].

PURPOSE/OBJECTIVE:To describe the patterns of regression of choroidal melanoma after treatment with plaque brachytherapy. METHODS:Pd eye plaque radiation for choroidal melanoma. Outcome measures were changes in tumor thickness, surface characteristics, tumor vascularity, ultrasonography, fluorescein angiography, optical coherence tomography, and histopathology. RESULTS:The mean initial tumor thickness was 3.9 mm (median 2.8 mm; range 2-11.3 mm) that decreased to 1.7 mm (median 1.2 mm; range 0-7.1 mm) after plaque brachytherapy. On imaging, tumors were pigmented in 51% ( n = 86/170), amelanotic in 10% ( n = 17/170), and variably pigmented in 39% ( n = 67/170). Tumor pigmentation increased in 64% ( n = 106/166), decreased in 18% ( n = 30/166), and was unchanged in 18% ( n = 30/166). Of the 120 that demonstrated intrinsic vascularity, 10% ( n = 12/120) had decreased tumor-related vascularity and 90% ( n = 108/120) showed complete resolution. Subretinal fluid was present in 34% ( n = 58/170) of eyes at presentation. Of them, 15% (9; n = 9/58) had persistent SRF at last follow-up. On ultrasound imaging, 88% ( n = 149/170) tumors presented with low to moderate internal reflectivity of which 61% ( n = 91/149) showed increased reflectivity on regression. We noted a crescendo-decrescendo fluctuation in the presence of orange pigment lipofuscin along with complete resolution of drusenoid retinal pigment epithelial detachments. In the entire series of 170 patients, there was 0.5% (1) failure of local control, 2% (4) secondary enucleations, and 6% (10) patients developing metastasis. CONCLUSION/CONCLUSIONS:Pd plaque brachytherapy included decreased intrinsic tumor vascularity, decreased tumor-related subretinal fluid, increased pigmentation, specific changes in orange pigment lipofuscin and resolution of drusenoid retinal pigment epithelial detachments, as well as decreased tumor thickness with an increase in internal reflectivity on ultrasound.

PURPOSE/OBJECTIVE:Pd) plaque brachytherapy. METHODS:Pd radioactive plaque in the right eye followed by the left at an interval of 2 months. RESULTS:At 1-year follow-up, bilateral local control has been associated with apical tumor height regression, and visual acuity has been preserved (20/20 in the right eye and 20/25 in the left). Exudative subretinal fluid has resolved. There has been no metastasis. CONCLUSION/CONCLUSIONS:Bilateral choroidal melanomas are rare, reported to be either simultaneous or sequential as well as treatable. In this case, we were able to achieve tumor regression and preserve visual acuity in both eyes after plaque brachytherapy.

PURPOSE/OBJECTIVE:Pd plaque-irradiated ciliary body melanoma with extrascleral extension while attempting to preserve a subadjacent glaucoma filtering bleb. METHODS:Pd radioactive plaque over the functioning trabeculectomy, with removal 7 days later. At plaque insertion, amniotic membrane grafts were used to cover the plaque and protect the filtering site. RESULTS:The tumor was successfully treated without clinical evidence of harm to the filtering bleb, with resultant stable intraocular pressure. However, the patient developed blebitis 1.5 years later. Though it resolved with topical antibiotic therapy, the bleb became less succulent. Two years postoperatively, she developed a spontaneous hyphema that resolved after one injection of transscleral bevacizumab 1.25 mg. Her tumor continually regressed in thickness. Without additional glaucoma surgery, her intraocular pressure remained well-controlled on topical medications for 6 years. CONCLUSIONS:Ciliary body melanoma with minimal extrascleral extension beneath a functioning filtering bleb can be treated using radioactive plaque therapy. In this case, we were able to achieve both tumor regression and glaucoma control by covering the plaque with an amniotic membrane graft.

PURPOSE/OBJECTIVE:To present our 12-year experience with low energy photon, slotted eye plaque radiation therapy. DESIGN/METHODS:Retrospective interventional case series METHODS: SETTING: The New York Eye Cancer Center. STUDY POPULATION/METHODS:Fifty-two consecutive patients with uveal melanomas near, touching or surrounding the optic disc. INTERVENTION/METHODS:Slotted eye plaque radiation therapy. MAIN OUTCOME MEASURES/METHODS:change in visual acuity, local tumor control, radiation side effects, eye salvage and systemic metastases. RESULTS:Tumors were peripapillary within 1.5-mm of the optic disc (n=8,15%), juxtapapillary touching ≤180 degrees (n=23,44%), or circumpapillary >180 and encircling the disc (n=21,41%). Mean follow-up was 47 months (median 34 months; range 6-146 months). Radiation induced a mean 41.2% reduction in tumor thickness. Life table analysis showed that 69% patients retained their visual acuities ≥20/40 and had a vision loss free survival 84 month after treatment. Also, 90% patients retained their visual acuity between 20/50-20/200 and had a vision loss free survival 36 month after treatment. Slotted plaque brachytherapy was associated with 4% secondary cataract, 11% neovascular glaucoma, no dry eye or eyelash loss. Local tumor control (no recurrence) was achieved in 98.1% patients. Life table analysis showed an overall enucleation-free survival of 93% and metastasis-free survival of 94%. CONCLUSIONS:Slotted plaque radiation therapy provided a normalized plaque-tumor position; such that the entire choroidal melanoma plus a 2-3 mm free margin of normal appearing tissue was included in the targeted zone. At 12-years, slotted plaque radiation therapy resulted in high rates of local tumor control, vision and eye retention.