David R. Lally

Metastasis of Uveal Melanoma Millimeter-by-Millimeter in 8033 Consecutive Eyes

OBJECTIVE To determine the rate of metastasis of uveal melanoma on the basis of tumor thickness in millimeters. METHODS Retrospective medical record review. RESULTS The mean (median) patient age was 58 (59) years. A total of 8033 eyes were examined. Of the 285 eyes with iris melanoma, the mean tumor thickness was 2.7 mm and metastasis occurred in 0.5%, 4%, and 7% at 3, 5, and 10 years, respectively. Of the 492 eyes with ciliary body melanoma, the mean tumor thickness was 6.6 mm and metastasis occurred in 12%, 19%, and 33% at 3, 5, and 10 years, respectively. Of the 7256 eyes with choroidal melanoma, the mean tumor thickness was 5.5 mm and metastasis occurred in 8%, 15%, and 25% at 3, 5, and 10 years, respectively. For all uveal melanoma, metastasis at 5, 10, and 20 years was 6%, 12%, and 20% for small melanoma (0-3.0 mm thickness), 14%, 26%, and 37% for medium melanoma (3.1-8.0 mm), and 35%, 49%, and 67% for large melanoma (>8.0 mm). More specifically, metastasis per millimeter increment at 10 years was 6% (0-1.0 mm thickness), 12% (1.1-2.0 mm), 12% (2.1-3.0 mm), 16% (3.1-4.0 mm), 27% (4.1-5.0 mm), 28% (5.1-6.0 mm), 29% (6.1-7.0 mm), 41% (7.1-8.0 mm), 50% (8.1-9.0 mm), 44% (9.1-10.0 mm), and 51% (>10.0 mm). Clinical factors predictive of metastasis by multivariate analysis included increasing patient age, ciliary body location, increasing tumor diameter, increasing tumor thickness, having a brown tumor, and the presence of subretinal fluid, intraocular hemorrhage, or extraocular extension. CONCLUSION Increasing millimeter thickness of uveal melanoma is associated with increasing risk for metastasis.

Vascular endothelial growth factor and diabetic macular edema.

Diabetes mellitus is a major global health epidemic, and diabetic macular edema is the leading cause of vision loss in this population. Macular focal and/or grid laser photocoagulation applied to microaneurysms and thickened retina had long been primary therapy for diabetic macular edema. Chronically elevated serum glucose is known to cause breakdown in the inner and outer retinal blood barrier resulting in upregulation of vascular endothelial growth factor (VEGF). Intravitreal anti-vascular endothelial growth factor agents, including ranibizumab, bevacizumab, and aflibercept, have been shown in randomized clinical trials to be superior to macular laser for the treatment of clinically relevant diabetic macular edema. The READ-2, RISE/RIDE, and RESTORE trials established ranibizumabs superiority to macular laser, whereas the BOLT trial demonstrated bevacizumabs superiority to laser. The DRCR.net Protocol T results showed that intravitreal aflibercept, bevacizumab, and ranibizumab were all effective in reducing retinal thickness secondary to diabetic edema and in improving vision. When the presenting vision was 20/40 or better, visual improvement was equivalent. With eyes presenting with 20/50 or worse vision, aflibercept was superior with respect to visual improvement. Intravitreal anti-VEGF therapy can be burdensome for the patient and health care system, often requiring monthly treatment visits. To reduce burdens, anti-VEGF strategies are in development to lengthen the treatment interval.

Retinal injury after inadvertent handheld laser exposure

Purpose: To evaluate acute and long-term clinical and spectral domain optical coherence tomography features after handheld laser exposure to the retina. Methods: Retrospective case series of three children with retinal injury secondary to inadvertent handheld laser exposure. All individuals underwent ophthalmologic examination and spectral domain optical coherence tomography at presentation and follow-up 11 months to 18 months after exposure. Results: Three male children aged 6 years to 10 years sustained bilateral macular injury after exposure to a handheld green or red laser. Two of the three handheld lasers were ordered from foreign internet retailers and were labeled as Class 3B devices. Acutely, flat yellow deep retinal lesions with pigment irregularity were apparent. Spectral domain optical coherence tomography demonstrated disruption of the external limiting membrane and outer photoreceptors, a hyperreflective mound extending from the external limiting membrane to the retinal pigment epithelium, and linear opacification in Henles layer. Over time, there was partial restoration of the external limiting membrane and persistent irregularity of the outer photoreceptor layers. Two individuals with severe vision loss acutely had some improvement of Snellen acuity at a 1-year follow-up. Conclusion: Handheld lasers can produce permanent retinal damage with visual sequelae if improperly used. Spectral domain optical coherence tomography demonstrates chronic disruption, primarily in the retinal pigment epithelium/photoreceptor region.

Foveal injury from a red laser pointer.

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Optical Coherence Tomography Angiography for Detecting Choroidal Neovascularization Secondary to Choroidal Osteoma

Choroidal osteoma is an ossifying tumor that is found predominantly in the peripapillary and macular areas. It typically affects otherwise healthy females. Vision loss may occur secondary to the development of choroidal neovascularization (CNV). Fluorescein angiography (FA) remains the gold standard for diagnosing CNV; however, the use of optical coherence tomography angiography (OCTA) as an adjunct to FA is growing. In this report, a 16-year-old female with a large, unilateral peripapillary choroidal osteoma presented with blurred vision. Exam revealed scattered intraretinal hemorrhage, but FA was unable to detect CNV overlying the tumor. OCTA detected abnormal flow in the outer retina corresponding to a type 2 CNV. Following intravitreal anti-vascular endothelial growth factor therapy, the CNV regressed, the hemorrhage resolved, and there was less fluid. OCTA may be helpful in detecting CNV noninvasively in eyes in which FA is equivocal, such as those with choroidal osteoma.

Subretinal drusenoid deposits associated with complement-mediated IgA nephropathy.

Subretinal Drusenoid Deposits Associated With Complement-Mediated IgA Nephropathy Complement-mediated IgA nephropathy is the most common cause of chronic glomerulonephritis worldwide. The pathogenesis of renal damage is related to complement activation secondary to IgA immune complex deposition in the glomerulus. To our knowledge, this is the first report of IgA nephropathy associated with bilateral subretinal drusenoid deposits (SDDs). A hypothesis for the role of complement is proposed.

Natural History of Valsalva-Induced Subhyaloid Hemorrhage

A, A 29-year-old man presented with subhyaloid hemorrhage in his left eye after lifting weights. B, After 1 month of observation, the hemorrhage dehemoglobinized. C, At 3 months, his vision improved with resolution of the hemorrhage. CF indicates counting fingers. The fundus photographs and spectral-domain optical coherence tomographic images were provided by Dennis C. Donovan, COA. JAMA Ophthalmol. 2015;133(2):e143268. doi:10.1001/jamaophthalmol.2014.3268

Pigmented free-floating vitreous cyst in a child.

An 8-year-old asymptomatic boy was referred for a pigmented fundus lesion in his left eye that was suspected to be a possible choroidal melanoma. Visual acuity was 20/20 in each eye. Ocular examination in the upright position revealed a pigmented lesion measuring 4 mm in diameter and 3 mm in thickness located inferior to the fovea. Following supine positioning, the mass floated to the superior macular region. UI-trasonography confirmed a cystic vitreous mass. Observation of the benign vitreous cyst was advised. A free-floating pigmented cyst can resemble a pigmented intraocular tumor, particularly if it is immediately preretinal.

Ectopia Lentis in Marfan's Syndrome

A 27-year-old woman with Marfans syndrome presented with worsening vision and glare in each eye. Superotemporal partial subluxation of the lens was noted in each eye. Close inspection revealed a decrease in the number of zonules, with widened spaces between zonules.

Muscle cramping over the diagnosis

A 44-year-old man with hypogonadism and adrenal insufficiency presented with transient blurred vision and halos around lights. Visual acuity was 20/20 in both eyes, and he had mild bilateral optic disk edema. Brain imaging was unremarkable, and lumbar puncture showed an opening pressure of 28.5 cm H2O with elevated protein. He also complained of muscle cramping, and magnetic resonance imaging of the spine demonstrated a heterogenous bone marrow signal. Bone survey showed a mixed lytic and sclerotic lesion within the left femur that proved to be a plasmacytoma. Serum protein electrophoresis had a small IgA spike, and plasma vascular endothelial growth factor (VEGF) was elevated. He was diagnosed with POEMS syndrome and underwent radiation to the plasmacytoma. Two years later he had a stable neuro-ophthalmologic exam with no signs of multiple myeloma. POEMS syndrome is a rare paraneoplastic syndrome from a plasma cell dyscrasia that may cause optic disk edema.