Armin R. Afshar

Cystoid macular edema associated with fingolimod use for multiple sclerosis.

Fingolimod is the first oral drug approved by the US Food and Drug Administration for multiple sclerosis (MS). It is a sphingosine-1phosphate–receptor modulator that prevents lymphocyte egress from lymph nodes and enhances astrocyte function. In this retrospective case series, 4 eyes from 3 patients developed cystoid macular edema (CME) after initiating fingolimod therapy. The study was approved by the University of Chicago Institutional Review Board.

Use of intravitreous bevacizumab to treat macular edema in West Nile virus chorioretinitis

tion for Research in Ophthalmology, and Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia; and Wilmer Eye Institute, Johns Hopkins University, School of Medicine, Baltimore, Maryland. Correspondence: Dr Tabbara, The Eye Center, 241 Makkah Rd, PO Box 55307, Riyadh 11534, Saudi Arabia (k .tabbara@nesma.net.sa). Financial Disclosure: None reported. Funding/Support: This work was supported in part by a grant from The Eye Foundation for Research in Ophthalmology and The Eye Center, Riyadh, Saudi Arabia. Additional Contributions: Naser Elkum, PhD, Department of Biostatistics and Epidemiology, Dasman Diabetes Institute, Dasman, Kuwait, assisted in the statistical analysis.

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 RESULTS Histopathological diagnostic terminology for primary acquired melanosis is being superseded by more explicit terminology, thus differentiating hypermelanosis from conjunctival melanocytic intraepithelial neoplasia.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.

Outcomes of chronic macular hole surgical repair

Purpose: To report visual and anatomic outcomes of chronic macular hole surgery, with analysis of pre-operative OCT-based hole size and post-operative closure type. Settings and Design: An IRB-approved, retrospective case series of 26 eyes of 24 patients who underwent surgery for stage 3 or 4 idiopathic chronic macular holes at a tertiary care referral center. Statistical Analysis: Students t-test. Results: Nineteen of 26 eyes (73%) had visual improvement after surgery on most recent exam. Twenty-one of 26 eyes (81%) achieved anatomic closure; 16 of 26 eyes (62%) achieved type 1, and five of 26 eyes (19%) achieved type 2 closure. Post-operative LogMAR VA for type 1 closure holes (0.49) was significantly greater than for type 2 closure and open holes (1.26, P < 0.003 and 1.10, P < 0.005, respectively), despite similar pre-operative VA (P = 0.51 and 0.68, respectively). Mean pre-operative hole diameter for eyes with type 1 closure, type 2 closure, and holes that remained open were 554, 929, and 1205 microns, respectively. Mean pre-operative hole diameter was significantly larger in eyes that remained open as compared to eyes with type 1 closure (P = 0.015). Conclusion: Vitrectomy to repair chronic macular holes can improve vision and achieve long-term closure. Holes of greater than 3.4 years duration were associated with a greater incidence of remaining open and type 2 closure. Larger holes (mean diameter of 1205 microns) were more likely to remain open after repair.

Uveal melanoma: evidence for efficacy of therapy.

More than 90% of all uveal melanomas involve the choroid, with the remainder being confined to the ciliary body and/or iris. Melanomas involving the choroid cause visual loss as a result of retinal pigment epitheliopathy overlying the tumor and serous retinal detachment. Ciliary body tumors can also cause astigmatism and cataract formation. Tumors in the anterior chamber can cause glaucoma with secondary visual loss. The eye can become painful as a result of neovascular glaucoma or uveitis. There can be extraocular spread into the episclera or orbit, causing proptosis. If neglected, uveal melanomas can form a fungating mass and can spread posteriorly to the brain. Almost 50% of all patients with uveal melanoma develop metastatic disease, which usually involves the liver and is nearly always fatal. Metastatic disease occurs almost exclusively in patients whose tumor shows chromosome 3 loss and/or a class 2 gene-expression profile. These abnormalities are highly lethal, with survival time correlating inversely with basal tumor diameter and mitotic count. The objectives of ocular treatment are to prevent metastatic spread, and if possible, to conserve the eye and useful vision. Eye-conserving therapeutic modalities include various forms of phototherapy, radiotherapy and local resection, which can be administered individually or in combination. Patient care also includes education, prognostication, counseling, and emotional support, to enhance quality of life. The aims of this review are: (1) to discuss the efficacy of ocular treatment in terms of local tumor control, preservation of vision, ocular conservation, quality of life, and survival; and (2) to discuss the evidence currently available. It is assumed that the reader is familiar with the therapeutic modalities mentioned in this review.

OUTER RETINAL ATROPHY ON SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY AFTER RESOLUTION OF GLAUCOMA SURGERY-ASSOCIATED HYPOTONY MACULOPATHY.

PURPOSE To report two cases of persistent central vision loss after resolution of filtration surgery-associated hypotony, corresponding with foveal outer retinal atrophy on spectral domain optical coherence tomography. METHODS Retrospective observational case series. A retrospective chart review was conducted of two patients with persistent vision loss after normalization of intraocular pressure and resolution of glaucoma surgery-associated hypotony maculopathy. RESULTS Several months after glaucoma surgery and resolution of hypotony, both patients suffered persistent vision loss and new foveal photoreceptor loss on spectral domain optical coherence tomography. CONCLUSION This is the first case series demonstrating foveal outer retinal atrophy on spectral domain optical coherence tomography after resolution of glaucoma surgery-associated hypotony maculopathy. Both patients had previous uveitis that was controlled at the time of hypotony. Eyes with previous hypotony and compromised ciliary body function may be at greater risk of photoreceptor damage.

Toxic corneal epitheliopathy after intravitreal methotrexate and its treatment with oral folic acid.

Purpose: To determine whether oral folic acid can ameliorate an iatrogenic, visually significant corneal epitheliopathy, which commonly occurs with intravitreal injections of methotrexate for the treatment of intraocular lymphoma. Methods: We report 2 cases of visually significant corneal epitheliopathy occurring after intravitreal injections of methotrexate for intraocular lymphoma. The first patient did not receive any treatment for the corneal disease, and the second patient with bilateral intraocular lymphoma received 1 mg of oral folic acid daily, a commonly used dosage for patients on systemic methotrexate. Results: In the first patient without treatment, there was a complete regression of the corneal epithelial disease only when the frequency of intravitreal methotrexate was reduced from weekly to monthly as per a commonly used dosage regimen for methotrexate. In the second patient, the corneal disease improved 80% within 1 week of initiating oral folic acid for her eye already experiencing severe epitheliopathy during her weekly dosing regimen of methotrexate and also had significantly decreased epithelial disease in her second eye that started weekly intravitreal methotrexate several weeks after beginning oral folic acid. Conclusions: Currently, oral folic acid supplements are recommended for patients using systemic methotrexate to minimize drug toxicity. We suggest a similar use in patients undergoing intravitreal methotrexate injections to decrease toxic effects on the corneal epithelium.

POLYPOIDAL CHOROIDAL VASCULOPATHY: A CLINICOPATHOLOGIC STUDY.

Purpose: To present a unique case of polypoidal choroidal vasculopathy presenting as a blind, painful eye with a suspected intraocular mass, and to correlate clinical findings with histopathologic studies. Methods: Clinical case report and literature review. Results: A 58-year-old Vietnamese man presented with a blind, painful eye with concern for an intraocular mass. B-scan ultrasonography showed massive intraocular hemorrhage and could not rule out a tumor. The patient underwent enucleation and the histopathologic findings were consistent with polypoidal choroidal vasculopathy. Conclusion: Polypoidal choroidal vasculopathy can present with dense vitreous hemorrhage and may masquerade as an intraocular mass. It can progress rapidly and lead to profound, irreversible vision loss. A diagnosis of polypoidal choroidal vasculopathy should be considered in patients of African or East Asian origin presenting with vitreous hemorrhage.

DOME-SHAPED MACULA WITH THICKENED CHOROID IN AN EMMETROPIC PATIENT.

PURPOSE To report a rare case of bilateral dome-shaped macula in an emmetropic patient. METHOD Clinical case report and literature review. RESULTS A 42-year-old woman presented with a history of blurred vision in the right eye. Visual acuity was 20/30 in the right eye and 20/20 in the left eye. Intraocular pressure and anterior segment were unremarkable. Fundus examination revealed dull macular reflex and subretinal fluid nasal to the fovea in the right eye and a hyperpigmented area inferotemporal to the fovea in the left eye. Spectral domain optical coherence tomography showed subretinal fluid under the fovea in the right eye and elevation of the macula with increased choroidal thickness in both eyes. Fluorescein angiography revealed abnormal hyperfluorescence without any leakage in both eyes. B-scan ultrasound showed irregular globe contour with high internal reflectivity and dome-shaped lesions at the posterior pole in both eyes. Axial length was 24.6 mm in the right eye and 25.6 mm in the left eye. CONCLUSION Although most commonly reported in myopic eyes, dome-shaped macula can occur in an emmetropic patient and can be associated with subretinal fluid.

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.