Sachin M. Salvi

Central corneal thickness changes after phacoemulsification cataract surgery

PURPOSE: To evaluate changes occurring in central corneal thickness (CCT) immediately after uneventful cataract surgery. METHODS: Thirteen consecutive patients who had uneventful phacoemulsification surgery by the same experienced surgeon were prospectively evaluated for CCT measurements 1 hour preoperatively and 1 hour, 1 day, and 1 week postoperatively. The unoperated eye also had CCT measurements simultaneously on all occasions and served as a control. All patients provided informed consent. SETTING: Department of Ophthalmology, Royal Glamorgan Hospital, Llantrisant, UK RESULTS: Mean age of the patients was 69 years. Central corneal thickness was 550.34 μm preoperatively, 626.39 μm at 1 hour, 585.80 μm at 1 day, and 553.80 μm at 1 week. In the control group, CCT remained stable, within ±2 μm of preoperative readings. CONCLUSIONS: Central corneal thickness increased by approximately 13.81% in the immediate postoperative period (at 1 hour). It remained increased by 6.44% on day 1 compared with preoperative values and gradually reduced to preoperative levels by the 1‐week postoperative period (0.57% difference). Intraocular pressure (IOP) measured postoperatively in the first week may be falsely elevated to some extent because of the increased corneal thickness in the immediate postoperative period; thus, not all IOP rises have be treated in this period in healthy uncompromised eyes.

Uveal Melanoma UK National Guidelines

The United Kingdom (UK) uveal melanoma guideline development group used an evidence based systematic approach (Scottish Intercollegiate Guidelines Network (SIGN)) to make recommendations in key areas of uncertainty in the field including: the use and effectiveness of new technologies for prognostication, the appropriate pathway for the surveillance of patients following treatment for primary uveal melanoma, the use and effectiveness of new technologies in the treatment of hepatic recurrence and the use of systemic treatments. The guidelines were sent for international peer review and have been accredited by NICE. A summary of key recommendations is presented. The full documents are available on the Melanoma Focus website.

Treatment of invasive ocular surface squamous neoplasia with proton beam therapy

Sir, Ocular surface squamous neoplasia (OSSN) has the potential for causing significant ocular and systemic morbidity and mortality. We present two cases of invasive OSSN successfully treated with proton beam therapy (PBT). Both were non-resectable due to deeper scleral invasion.

Failure of intravitreal bevacizumab in the treatment of choroidal metastasis

BackgroundMetastasis to choroid is the most common intraocular malignancy, arising most frequently from carcinoma of breast in women and lung in men. Recent case reports have described successful use of intravitreal bevacizumab to achieve local control of such tumours.Materials and methodsFive cases of choroidal metastases from varying primaries: breast, lung, and colon were treated with intravitreal bevacizumab, and tumour response observed and documented with serial photographs and B-scans.ResultsFour of the five tumours were seen to progress despite intravitreal bevacizumab treatment.ConclusionsIntravitreal bevacizumab as the primary treatment of choroidal metastases is not recommended and should not delay more effective alternative treatments.

Sympathetic ophthalmia after ruthenium plaque brachytherapy

Sympathetic ophthalmia is a rare, bilateral inflammatory process with an incidence of 0.03/100 000 in the UK and Ireland.1 It usually follows either penetrating eye injury or intraocular surgery. Although sympathetic ophthalmia has previously been described after irradiation of ocular melanoma,2,3 it has never been reported after simple 106Ru plaque brachytherapy. We present a case which confirms that there is a risk of developing sympathetic ophthalmia after charged-particle therapy in the absence of a penetrating injury of the uveal tract. A 41-year-old lady was referred by her optician for a slow-growing iris lesion. Fine needle aspiration biopsy confirmed the diagnosis of ciliary body malignant melanoma. Systemic investigations for metastatic disease were negative. The patient underwent routine surgery for the …

The Pediatric Choroidal and Ciliary Body Melanoma Study: A Survey by the European Ophthalmic Oncology Group

PURPOSE To collect comprehensive data on choroidal and ciliary body melanoma (CCBM) in children and to validate hypotheses regarding pediatric CCBM: children younger than 18 years, males, and those without ciliary body involvement (CBI) have more favorable survival prognosis than young adults 18 to 24 years of age, females, and those with CBI. DESIGN Retrospective, multicenter observational study. PARTICIPANTS Two hundred ninety-nine patients from 24 ocular oncology centers, of whom 114 were children (median age, 15.1 years; range, 2.7-17.9 years) and 185 were young adults. METHODS Data were entered through a secure website and were reviewed centrally. Survival was analyzed using Kaplan-Meier analysis and Cox proportional hazards regression. MAIN OUTCOME MEASURES Proportion of females, tumor-node-metastasis (TNM) stage, cell type, and melanoma-related mortality. RESULTS Cumulative frequency of having CCBM diagnosed increased steadily by 0.8% per year of age between 5 and 10 years of age and, after a 6-year transition period, by 8.8% per year from age 17 years onward. Of children and young adults, 57% and 63% were female, respectively, which exceeded the expected 51% among young adults. Cell type, known for 35% of tumors, and TNM stage (I in 22% and 21%, II in 49% and 52%, III in 30% and 28%, respectively) were comparable for children and young adults. Melanoma-related survival was 97% and 90% at 5 years and 92% and 80% at 10 years for children compared with young adults, respectively (P = 0.013). Males tended to have a more favorable survival than females among children (100% vs. 85% at 10 years; P = 0.058). Increasing TNM stage was associated with poorer survival (stages I, II, and III: 100% vs. 86% vs. 76%, respectively; P = 0.0011). By multivariate analysis, being a young adult (adjusted hazard rate [HR], 2.57), a higher TNM stage (HR, 2.88 and 8.38 for stages II and III, respectively), and female gender (HR, 2.38) independently predicted less favorable survival. Ciliary body involvement and cell type were not associated with survival. CONCLUSIONS This study confirms that children with CCBM have a more favorable survival than young adults 18 to 25 years of age, adjusting for TNM stage and gender. The association between gender and survival varies between age groups.

Excision and delayed reconstruction with paraffin section histopathological analysis for periocular sebaceous carcinoma.

Purpose: To evaluate the use of excision and delayed reconstruction with rapid paraffin section analysis in patients with sebaceous carcinoma (SC) of the periocular region. Methods: A retrospective study of patients with SC. Patients were identified from a contemporaneously maintained database and medical notes reviewed. Data were collected on known risk factors. Standard management started with conjunctival mapping biopsies. The tumor was excised with a 3-mm clinical margin and sent in formalin for histopathological analysis. The patient went home with dressings and returned 3 days later. Further excision or reconstruction was performed as indicated. Follow-up data were collected. Results: Seventeen patients had excision and delayed reconstruction with paraffin section control. Ten had clear margins after 1 excision, and 7 were clear after 2 excisions. Reconstructive technique varied according to the defect. Three patients developed further tumor. One of these had a local recurrence treated with further excision and reconstruction. One developed a multicentric tumor with regional metastasis, and the third patient developed distant metastasis. Two patients died from SC. Average follow up was 5 years (2–9 years). Conclusions: Excision and delayed reconstruction using paraffin section histopathological analysis are in widespread use for the management of basal cell carcinomas in the periocular region. While some authors advocate the use of Mohs’ micrographic surgery in patients with SC, this technique has been questioned due to the possible misinterpretation of subtle intraepithelial pagetoid spread with frozen section analysis. To preserve the function of the eyelid and ease of reconstruction, it is important to try and preserve as much healthy tissue as possible while effecting a successful excision. Excision and delayed reconstruction offer an excellent option for the management of this rare and highly malignant tumor.

What is the significance of vortex vein invasion in uveal melanoma

PurposeTo correlate vortex vein invasion with established prognostic factors for uveal melanoma.MethodsEnucleated eyes with a confirmed histopathological diagnosis of uveal melanoma with vortex vein invasion were identified, over a 10-year period. Established uveal melanoma prognostic factors, with tumour genetics were correlated with vortex vein invasion and patient survival.ResultsMicroscopic vortex vein involvement was present in 29 of 244 (11.9%) uveal melanomas. Of 29, 6 (20.7%) tumours had macroscopic evidence of vortex vein invasion. Of 29, 14 (48.3%) tumours also showed evidence of non-vortex vein, ‘direct’ scleral invasion. 23 (79.3%) of 29 melanomas involved only the choroid. The mean maximum diameter of tumours with vortex vein invasion was 15.8 mm and the mean thickness was 9.7 mm. The uveal melanoma was a discrete nodule in 27 of 29 (93.1%) cases. Histologically, 8 of 29 tumours (27.6%) were spindle cell, 19 of 29 (65.5%) were mixed cell, and 2 of 29 (6.9%) were epithelioid cell type. Of 29, 22 (75.9%) uveal melanomas with vortex vein invasion contained extracellular matrix networks and loops. Genetic abnormalities correlated with poor prognosis were seen in 25 of 29 (86.2%) tumours with vortex vein invasion. Liver metastasis was confirmed in 19 of 29 (65.5%) patients with vortex vein invasion. No patients with uveal melanomas showing vortex vein invasion suffered orbital recurrence of disease following enucleation.ConclusionsThe trends show that vortex vein invasion is associated with a choroidal location, large tumour size, spindle cell bias, presence of extracellular matrix loops/networks and genetic markers. A higher proportion of patients with vortex vein invasion progress to develop liver metastasis compared with the general uveal melanoma population.

Iatrogenic Lateral Rectus Transection Secondary to Dental Implantation Surgery

A 48-year-old patient noted right subconjunctival hemorrhage and double vision immediately following dental implant surgery. CT scan confirmed implant screw misplaced into the right orbit, and exploration revealed transection of right lateral rectus muscle belly. Diagnostic and management challenges are discussed.

Fresh frozen amniotic membrane for conjunctival reconstruction after excision of neoplastic and presumed neoplastic conjunctival lesions

PurposeSuspicious neoplastic conjunctival lesions often require wide excision with tumour-free margins, leaving significant conjunctival defects requiring reconstruction. In this study we report the results of using fresh frozen amniotic membrane grafts (AMG) after wide excision of potentially malignant lesions.MethodsRetrospective review of 53 patients; between January 2011 and April 2014. Conjunctival lesions were excised with a non-touch technique (2 mm margin) and sent for histopathological analysis. The surgical margins were treated with cryotherapy and a fresh frozen AMG was used to cover the defect. The main features examined were for any signs of recurrence, the conjunctivalisation of the AMG, complications and cosmetic appearance.ResultsFifty-three patients; 35 males and 18 females. Mean age was 54.9 (range 19–88). The mean follow up to January 2015 for all lesions was 21.4 months (range 8–48 months). The most common lesions were invasive malignant melanoma. There were no local surgical complications in 77.3% of patients; minimal scarring (11.3%), symblepharon (11.3%), and granuloma (7.5%). Five patients with conjunctival melanoma developed in-transit metastasis and orbital extension, none of it was at the site of the AMG.ConclusionOur case series is the largest reported to date, with the largest number of melanomas. The use of fresh frozen AMG has improved the local surgical outcomes by improving healing and reducing scarring as well as allowing for a wider surgical margin.