Andrew Kao

Sirolimus‐based immunosuppression in liver transplantation for hepatocellular carcinoma: A meta‐analysis

Sirolimus (SRL) is a novel immunosuppressant with antitumor properties. We performed a meta‐analysis to determine whether SRL can improve patient survival and decrease the risks of tumor recurrence in patients with a pretransplant diagnosis of hepatocellular carcinoma (HCC). We searched databases for controlled clinical trials assessing the survival and oncological benefits of SRL for liver transplant recipients with pretransplant HCC. Five studies with a total of 2950 participants were included in this study. In comparison with SRL‐free regimens, SRL‐based regimens improved overall survival at 1 [odds ratio (OR) = 4.53, 95% confidence interval (95% CI) = 2.31‐8.89], 3 (OR = 1.97, 95% CI = 1.29‐3.00), and 5 years (OR = 2.47, 95% CI = 1.72‐3.55). The pooled results showed that in comparison with SRL‐free regimens, SRL‐based regimens decreased tumor recurrence (OR = 0.42, 95% CI = 0.21‐0.83). No significant differences in the frequencies of episodes of major posttransplant complications were observed between the groups. In conclusion, SRL is generally safe and prolongs patient survival in liver transplant recipients with pretransplant HCC. Liver Transpl 18:62–69, 2012.

Diagnostic power of optic disc morphology, peripapillary retinal nerve fiber layer thickness, and macular inner retinal layer thickness in glaucoma diagnosis with fourier-domain optical coherence tomography.

PurposeTo evaluate the capability of the optic disc, peripapillary retinal nerve fiber layer (P-RNFL), macular inner retinal layer (M-IRL) parameters, and their combination obtained by Fourier-domain optical coherent tomography (OCT) in differentiating a glaucoma suspect from perimetric glaucoma. MethodsTwo hundred and twenty eyes from 220 patients were enrolled in this study. The optic disc morphology, P-RNFL, and M-IRL were assessed by the Fourier-domain OCT (RTVue OCT, Model RT100, Optovue, Fremont, CA). A linear discriminant function was generated by stepwise linear discriminant analysis on the basis of OCT parameters and demographic factors. The diagnostic power of these parameters was evaluated with receiver operating characteristic (ROC) curve analysis. The diagnostic power in the clinically relevant range (specificity ≥80%) was presented as the partial area under the ROC curve (partial AROC). ResultsThe individual OCT parameter with the largest AROC and partial AROC in the high specificity (≥80%) range were cup/disc vertical ratio (AROC=0.854 and partial AROC=0.142) for the optic disc parameters, average thickness (AROC=0.919 and partial AROC=0.147) for P-RNFL parameters, inferior hemisphere thickness (AROC=0.871 and partial AROC=0.138) for M-IRL parameters, respectively. The linear discriminant function further enhanced the ability in detecting perimetric glaucoma (AROC=0.970 and partial AROC=0.172). ConclusionsAverage P-RNFL thickness is the optimal individual OCT parameter to detect perimetric glaucoma. Simultaneous evaluation on disc morphology, P-RNFL, and M-IRL thickness can improve the diagnostic accuracy in diagnosing glaucoma.

Racial and ethnic disparities in adherence to glaucoma follow-up visits in a county hospital population.

OBJECTIVES To identify predictors of inconsistent attendance at glaucoma follow-up visits in a county hospital population. METHODS Prospective recruitment from August 1, 2008, through January 31, 2009, of 152 individuals with glaucoma, with 1-to-1 matching of patients (those with inconsistent follow-up) and controls (those with consistent follow-up). Data were collected via oral questionnaire. Survey results were correlated with attendance at follow-up examinations, using the t test, χ(2) test, and multivariate stepwise logistic regression analysis to calculate the odds ratios (ORs) and 95% confidence intervals. RESULTS After adjusting for covariates in the logistic regression analysis, factors independently associated with inconsistent follow-up included black race (adjusted OR, 7.16; 95% confidence interval, 1.64-31.24), Latino ethnicity (adjusted OR, 4.77; 1.12-20.29), unfamiliarity with necessary treatment duration (adjusted OR, 3.54; 1.26-9.94), lack of knowledge of the permanency of glaucoma-induced vision loss (adjusted OR, 3.09; 1.18-8.04), and perception that it is not important to attend all follow-up visits (adjusted OR, 3.54; 1.26-9.94). CONCLUSIONS Demographic factors, including race and ethnicity, may directly or indirectly affect adherence to recommended glaucoma follow-up visits. Lack of information regarding irreversible vision loss from glaucoma, need for lifelong treatment, and lack of visual symptoms may be significant barriers to follow-up in this population. Targeted glaucoma education by physicians may improve follow-up, thereby decreasing the morbidity associated with glaucomatous disease.

Differences in baseline dark and the dark-to-light changes in anterior chamber angle parameters in whites and ethnic Chinese.

PURPOSE To assess the anterior chamber drainage angle width in the dark and the dark-to-light change (Δ) between Caucasians and Chinese aged 40 years and older. METHODS The study groups comprised four age- and sex-matched cohorts: American Caucasians, American Chinese, southern mainland Chinese, and northern mainland Chinese. Anterior segment optical coherence tomography (ASOCT) images of the anterior chamber angles were obtained under both light and dark conditions. The parameters analyzed included angle opening distance (AOD), angle recess area (ARA), and trabecular-iris space area (TISA). RESULTS Data were obtained from 121, 124, 121, and 120 participants who were American Caucasians, American Chinese, and southern and northern mainland Chinese, respectively. In a multiple linear regression analysis, adjusted for age, sex, refractive status, pupil size, lens location, and anterior chamber depth (ACD) and width (ACW), the ethnic Chinese had significantly smaller ARAs (regression coefficient, β = -0.06, P < 0.001) and TISAs (β = -0.01, P = 0.039), as well as greater ΔAODs (β = 0.03, P = 0.009) and ΔTISAs (β = 0.02, P = 0.029) than did the Caucasians. For the dark-to-light change analysis, the independent associations between angle width and iris thickness (IT) and iris curvature (ICurv) were identified only in the Chinese. CONCLUSIONS Compared with the Caucasians, the ethnic Chinese had smaller ARA and TISA, but greater dark-to-light changes in AOD and TISA, independent of refractive status and overall ocular anterior segment dimensions.

Dark-light Change of Iris Parameters and Related Factors Among American Caucasians, American Chinese, and Mainland Chinese

Purpose: To assess the distribution of dark-light changes in iris features and associated factors amongst American Caucasians, American Chinese and mainland Chinese aged 40 years and over. Methods: Four gender- and age-matched cohorts: Caucasians, American Chinese, Southern Chinese and Northern Chinese comprised the study population. Anterior segment optical coherence tomography (ASOCT) images were acquired under dark and light conditions. Customized software was used to calculate iris thickness at 750 μm from the scleral spur (IT750), iris curvature (ICurv), iris area (IArea), and pupil diameter (PD) from ASOCT images. Results: Data from 121, 124, 121 and 120 subjects were available for American Caucasian, American Chinese, Southern and Northern Chinese subjects respectively. Caucasians had significantly less dark-light change (Δ) of IT750 and greater ΔPD than Chinese. When using multiple linear regression analyses, the inter-ethnic difference for ΔIT750 was independent of age, gender, refractive error, anterior chamber width and axial length. After controlling for ΔPD, ΔICurv was found to be inversely associated with age (β = −0.001, P = 0.001). Independent predictors of greater ΔPD included younger age (β = −0.02, P = 0.001), Caucasian ethnicity (β = −0.022, P = 0.009) and wider anterior chamber (β = 0.18, P = 0.03). Conclusions: Compared with Caucasians, Chinese irides show greater thickening with light to dark adaptation despite the lesser change of PD in Chinese. The change of iris area per unit change of pupil diameter from dark to light did not differ between ethnicities. These dynamic characteristics intrinsic to Chinese irides may partially account for the substantially increased risk for angle closure among this ethnic group.

Management of Primary Acquired Melanosis, Nevus, and Conjunctival Melanoma.

BACKGROUND The management of conjunctival melanoma is difficult because of the rarity of the disease, confusing terminology, high rates of local tumor recurrence, controversies regarding treatment, a poor evidence base, unreliable prognostication, and significant mortality rates. METHODS The medical literature was reviewed, focusing on treatment and management options for conjunctival melanoma. Recent trends and developments were summarized with respect to terminology, local treatment, histology, genetic analysis, prognostication, and systemic treatment, highlighting the scope for research and possible improvements in patient care. RESULTS Histopathological diagnostic terminology for primary acquired melanosis is being superseded by more explicit terminology, thus differentiating hypermelanosis from conjunctival melanocytic intraepithelial neoplasia. Topical chemotherapy and increased use of adjunctive radiotherapy have helped improve rates of local tumor control. Use of exenteration has become rare. Regional and systemic metastases are common in patients with nonbulbar conjunctival melanoma, although long-term survivors with metastases are growing in number. Prognostication is mainly based on tumor size and location, but histological and genetic data into multivariate analyses will soon be incorporated. The role of sentinel lymph-node biopsy continues to be controversial. Chemotherapy for metastatic disease is being superseded by targeted therapy based on genetic abnormalities such as BRAF mutations. CONCLUSIONS The management of conjunctival melanoma requires expert care from an experienced, multidisciplinary team. The goal of therapy is to provide good local tumor control with minimal morbidity, high-quality pathology, and adequate psychological support. Maximizing patient enrollment in multicenter clinical trials is likely to strengthen evidence-based decision-making.

Patient-related and system-related barriers to glaucoma follow-up in a county hospital population.

PURPOSE To identify the barriers to glaucoma follow-up and to assess how ethnicity influences the effect of such barriers among patients in a county hospital population. METHODS This cross-sectional study included 152 patients, 76 with poor clinic follow-up and 76 with good clinic follow-up, who were recruited at the San Francisco General Hospital glaucoma clinic as part of a case-control study. All subjects were required to be established patients with glaucoma initially seen and diagnosed in the clinic at least 1 year before enrollment. An oral questionnaire pertaining to the barriers to follow-up for glaucoma, as well as patient ethnicity, was administered to all participating subjects. The main outcome measure was the prevalence of significant barriers to follow-up, both overall and stratified by ethnicity. RESULTS The most prevalent barriers to follow-up included long clinic waiting times (75%), appointment scheduling difficulties (38%), the effect of other medical or physical comorbidities (29%), and difficulties related to medical interpretation (23%). While several barriers were cited as being important across different ethnicities, Latinos and Asian-Pacific Islanders were particularly affected by difficulties related to medical interpretation (P = 0.0001) and long waiting times in the clinic (P = 0.048). CONCLUSIONS Understanding patient-reported barriers to glaucoma follow-up and their variation based on ethnicity may give providers insight as to why patients do not adhere to follow-up recommendations. Strategies to improve follow-up may include reduced clinic wait times, simplified appointment scheduling, and provision of appropriate education and counseling regardless of the patients native language and ethnicity.

Ethnic Variation in Optic Disc Size by Fundus Photography

Abstract Purpose: To compare optic disc size among Caucasian, Chinese, African, Filipino and Hispanic subjects recruited from a university-based general ophthalmology clinic. Methods: In this retrospective cross-sectional study, optic disc size was calculated from fundus photographs. Differences in age, sex and spherical equivalent among the ethnic groups were examined with either Kruskal--Wallis test or Chi-square test. Ethnic differences in optic disc size were evaluated with linear mixed-effects regression models that adjusted for age, sex, spherical equivalent, glaucoma status, lens status and use of both eyes in the same subject. Results: Five hundred and seventy-four eyes of 305 subjects were analyzed. The mean and standard deviation of the optic disc size were 2.16 ± 0.41 mm2 for Caucasian, 2.30 ± 0.56 mm2 for Chinese, 2.31 ± 0.41 mm2 for Filipino, 2.38 ± 0.40 mm2 for African and 2.40 ± 0.38 mm2 for Hispanic subjects. Age and spherical equivalent differed among the ethnic groups by Kruskal--Wallis test (p < 0.05). Sex differed among the ethnic groups by Chi-square test (p < 0.05). Ethnic differences in optic disc size were not observed among African, Hispanic, Filipino and Chinese subjects in linear mixed-effects regression analyses (p > 0.05). However, Caucasian differed from the other ethnicities in linear mixed-effects regression analyses (p < 0.05). Conclusions: Optic disc size was significantly smaller in Caucasian compared to the other ethnic groups. Optic disc size differences among non-Caucasian ethnic groups were not significant.

Proton beam radiotherapy for uveal melanoma

Proton beam radiotherapy for uveal melanoma can be administered as primary treatment, as salvage therapy for a recurrent tumor, as neoadjuvant therapy prior to surgical resection, or as adjuvant therapy after surgical resection. Of all eye-conserving forms of uveal melanoma treatment, proton beam is associated with the lowest overall risk of local tumor recurrence. The physical properties of proton beams make it possible to deliver high-radiation doses to tumors with relative sparing of adjacent tissues from collateral damage. The chances of survival, ocular conservation, visual preservation, and avoidance of iatrogenic morbidity depend greatly on the tumor size, location, and extent. When treating side effects and/or complications, it is helpful to consider whether the etiology is collateral damage to healthy ocular tissues, such as the optic disc, or exudation and release of angiogenic factors from the irradiated tumor, possibly resulting in neovascular glaucoma (‘toxic tumor syndrome’). As with any therapy, it is important to treat not only the tumor but the patient, addressing all needs and concerns with appropriate psychological counseling.

Metastatic Cutaneous Melanoma Presenting with Choroidal Metastasis Simulating Primary Uveal Melanoma

Purpose: To report a case of metastatic cutaneous melanoma presenting with choroidal metastasis simulating primary uveal melanoma. Design: Case report. Method: Presentation of clinical, radiographic, histopathologic, and tumor genetic findings in a patient with cutaneous melanoma with choroidal metastasis. Results: A 50-year-old man with a remote history of stage 1A cutaneous melanoma presented with eye pain, peripheral vision loss, floaters, red eye, and choroidal mass that was originally diagnosed as a primary uveal melanoma at an outside institution; however, subsequent imaging and clinical evaluation demonstrated that this choroidal mass was the first manifestation of widely metastatic cutaneous melanoma (liver, pancreas, lung, bone, brain, and orbit lesions). Histopathologic analysis of the tumor after enucleation was consistent with cutaneous melanoma, and tumor genetic testing was positive for BRAF V600E mutation, confirming the choroidal lesion to be a cutaneous melanoma metastasis rather than a primary choroidal melanoma. Conclusions: Metastatic cutaneous melanoma to the orbit or globe occurs rarely. Tumor genetic testing may help differentiate metastatic cutaneous melanoma from primary uveal melanoma in cases where the diagnosis is uncertain, and can also inform therapy and prognostic counseling.