Mark S. Dikopf

Characteristics of Primary and Secondary Hepatic Malignancies Associated with Hepatopulmonary Shunting

PURPOSE To identify liver tumor characteristics associated with low (<10%), intermediate (10%-20%), and high (>20%) lung shunt fraction (LSF) at technetium 99m ((99m)Tc) macroaggregated albumin (MAA) imaging performed before yttrium 90 ((90)Y) radioembolization (RE). MATERIALS AND METHODS In this single-center retrospective study, 141 patients (70 with hepatocellular carcinoma [HCC], 71 with other tumors; 95 men, 45 women; median age, 61 years) underwent mapping arteriography with (99m)Tc-MAA LSF calculation before (90)Y RE from 2006 to 2012. Tumor characteristics, including tumor type, index lesion size and morphologic structure (circumscribed, infiltrative), focality (solitary oligonodular, multinodular), disease distribution (unilobar, bilobar), tumor burden (≤50%, 50%), portal vein invasion (present, absent), and arterioportal shunting (present, absent) were correlated with (99m)Tc-MAA imaging-calculated LSFs at univariate and multivariate analysis. RESULTS Median LSF was 8.4% (HCC, 9.0%; other tumors, 8.3%). LSF greater than 20% occurred in 14% of HCCs, but only in 3% of other tumors (P = .004). For HCC, tumor morphologic structure (P = .022), tumor burden (P < .001), main portal vein invasion (P = .033), and arterioportal shunting (P < .001) were significantly associated with different LSF categories at univariate analysis; infiltrative morphologic structure, tumor burden greater than 50%, portal vein invasion, and shunting had confirmed association with high LSF at multivariate analysis. For other liver tumors, tumor size (P = .001) and tumor burden (P = .003) were significantly associated with different LSF categories at univariate analysis. Multivariate confirmation was precluded by small sample size. Patients underwent a median of one (90)Y RE session (range, one to six), with median per-treatment and cumulative lung doses of 6.0 Gy and 8.5 Gy, respectively. CONCLUSION LSF greater than 20% periodically occurs in HCC but is uncommon in other liver tumors. Specific tumor characteristics are associated with LSF greater than 20% and may indicate need for interventions to reduce LSF.

Topical treatment of glaucoma: established and emerging pharmacology

ABSTRACT Introduction: Glaucoma is a collection of optic neuropathies consisting of retinal ganglion cell death and corresponding visual field loss. Glaucoma is the leading cause of irreversible vision loss worldwide and is forecasted to precipitously increase in prevalence in the coming decades. Current treatment options aim to lower intraocular pressure (IOP) via topical or oral therapy, laser treatment to the trabecular meshwork or ciliary body, and incisional surgery. Despite increasing use of trabecular laser therapy, topical therapy remains first-line in the treatment of most forms of glaucoma. Areas covered: Novel glaucoma therapies are a long-standing focus of investigational study. More than two decades have passed since the last United States Food and Drug Administration (FDA) approval of a topical glaucoma drug. Here, the authors review established topical glaucoma drops as well as those currently in FDA phase 2 and 3 clinical trial, nearing clinical use. Expert opinion: Current investigational glaucoma drugs lower IOP, mainly through enhanced trabecular meshwork outflow. Although few emerging therapies show evidence of retinal ganglion cell and optic nerve neuroprotection in animal models, emerging drugs are focused on lowering IOP, similar to established medicines.

Systemic Disease and Long-term Intraocular Pressure Mean, Peak, and Variability in Nonglaucomatous Eyes

PURPOSE Elevated intraocular pressure (IOP) is a well-known risk factor in glaucoma development and progression. As most glaucoma risk factors are not modifiable, IOP remains the sole focus of medical and surgical therapy. Identifying modifiable factors and their effects on IOP, such as systemic diseases, is therefore of interest. The objective is to assess the long-term, longitudinal relationship between systemic diseases and IOP mean, peak, and variability, including diabetes, hypertension, body mass index (BMI), and smoking status. DESIGN Secondary analysis of randomized clinical trial data. METHODS Longitudinal IOP and systemic disease data from the Age-Related Eye Disease Study (AREDS), a randomized clinical trial of high-dose antioxidants, was analyzed. STUDY POPULATION A total of 3909 older participants without a reported diagnosis of glaucoma or glaucoma treatment during AREDS with up to 12 years of annual IOP and systemic disease data. MAIN OUTCOME MEASURES Independent systemic disease risk factors associated with IOP. RESULTS Univariate analysis identified numerous systemic disease factors associated with IOP mean, peak, and variability. Longitudinal adjusted models identified diabetes, obesity, and systolic hypertension as significantly associated with increased IOP, while systemic beta-blocker use was inversely associated. CONCLUSIONS Results demonstrate a relationship between multiple systemic diseases and IOP; moreover, they demonstrate that systemic diseases influence additional parameters beyond mean IOP, such as IOP peak and variability. Although only to be taken within the context of IOP, these population-level trends reveal potentially modifiable factors in IOP control, and are particularly important in the context of increasing obesity and diabetes prevalence rates in American adults.

Circumscribed iris elevation in a middle-aged woman

A woman in her 40s was referred to her local university for ophthalmic examination. She had been receiving care for dry eye syndrome, hyperopia, and presbyopia by another eye care clinician, and on routine examination a circumscribed elevation of her right iris was found. She noted intermittent shooting pain responsive to artificial tears in this eye; otherwise, she was without ophthalmic symptoms. She did not have any significant medical or family history, and review of symptoms was unremarkable. On examination, corrected distance Snellen acuity was 20/20 OU. Intraocular pressures were 12 mm Hg OD and 10 mm Hg OS. Slitlamp examination revealed a circumscribed elevation of the right iris inferotemporally (Figure, A). Her iris was uniformly pigmented, and gonioscopy revealed an iridocorneal angle open to scleral spur with a circumscribed area of iris insertion anterior to the Schwalbe line inferotemporally, not deepening on compression. Her lens was clear, and no iridociliary lesions were appreciated after pupillary dilation. The optic nerve and fundus appeared normal. The left eye appeared healthy with a uniformly deep anterior chamber. Ultrasound biomicroscopy of the right eye was performed, showing an inferotemporal lesion (Figure, B), with few similar-appearing lesions located in other quadrants. Slitlamp examination A Ultrasound biomicroscopy B

Bilateral Optic Nerve Head Changes in an Asymptomatic Preadolescent Girl

A preadolescent girl presented to the pediatric ophthalmology clinic for evaluation and treatment of possible papilledema, discovered by an outside eye care professional during routine eye examination. Aside from mild hyperopic astigmatism, there was no significant ocular, medical, or family history. The patient denied any change in vision, scotomas, transient visual obscurations, dimming of light, photophobia, or pain. She denied headache, pulsatile tinnitus, weight gain, joint pain, lethargy, decreased appetite, fever, or chills. The patient was not taking any prescription or over-the-counter medicines; however, she had recently used a short-term course of oral antibiotics for a tooth infection. On examination, Snellen visual acuity with correction was 20/20 OD and 20/25 OS. Confrontation visual fields and ocular motility were normal. External examination was unremarkable, and slitlamp examination revealed normal eyelids, conjunctiva, and sclera. There were 1+ anterior chamber white blood cells and trace anterior vitreous cells bilaterally. Posterior segment examination revealed 360° nerve hyperemia with elevation of nasal disc borders bilaterally (Figure 1), without vitreous haze, snowballs, or snowbanks. There was no vascular sheathing, choroidal granulomas, or chorioretinal scarring in the periphery. Right eye A Left eye B