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Papers by Miguel Materin

Purpose To report a clinically challenging case of a choroidal nevus with retinal invasion with a... more Purpose To report a clinically challenging case of a choroidal nevus with retinal invasion with accompanying ancillary testing. Observations A 60-year-old Caucasian female was referred for a suspicious melanocytic choroidal lesion in her left eye. Ophthalmoscopic examination revealed a melanocytic choroidal lesion, measuring 10 mm × 10 mm in basal diameter. The lesion had a clinically evident area of retinal invasion seen as a protruding choroidal mass at its center, darker in appearance compared to the rest of the lesion, obscuring retinal vessels. The choroidal nevus had associated chronic retinal changes and the absence of overlying orange pigment or subretinal fluid. On fundus autofluorescence, there was a hypoautofluorescent area showing the site of retinal invasion. Fluorescein angiography at the lesion site exhibited central blocked perfusion corresponding to the area of retinal invasion. Ultrasonography showed a dome-shaped choroidal lesion that was optically dense with a me...

BACKGROUND Uveal melanoma (UM) is the most common primary malignant eye tumor in adults, though r... more BACKGROUND Uveal melanoma (UM) is the most common primary malignant eye tumor in adults, though rare with 2500 cases diagnosed annually in the US. Despite a growing understanding of the molecular characteristics, there remains uncertainty regarding epidemiologic trends and environmental risk factors. We have identified three geographic accumulations of UM: 1) Huntersville, NC, 2) Auburn, AL, and 3) Broome/Tioga Counties, NY. Evaluation into these groups will guide ongoing efforts to discover potential risk factors and assist with future treatment and prevention. DESIGN Observational case series METHODS: Descriptive data from medical records, patient interviews, and questionnaires was obtained on 5 patients from NC, 6 from AL, and 14 from NY. Standard incidence ratio (SIR) calculations were provided by the respective states' cancer registries. RESULTS In NC, 5 females who were identified as living in Huntersville, NC were diagnosed with UM at ages 20, 22, 24, 30, and 31. The SIR ...

The NCCN Guidelines for Uveal Melanoma include recommendations for staging, treatment, and follow... more The NCCN Guidelines for Uveal Melanoma include recommendations for staging, treatment, and follow-up of patients diagnosed with uveal melanoma of the choroid or ciliary body. In addition, because distinguishing between uveal melanoma and benign uveal nevi is in some cases difficult, these guidelines also contain recommendations for workup of patients with suspicious pigmented uveal lesions, to clarify the tests needed to distinguish between those who should have further workup and treatment for uveal melanoma versus those with uncertain diagnosis and low risk who should to be followed and later reevaluated. These NCCN Guidelines Insights describe recommendations for treatment of newly diagnosed nonmetastatic uveal melanoma in patients who have already undergone a complete workup.

Ophthalmic Plastic & Reconstructive Surgery

A woman in her early 50s previously treated 7 years prior with iodine-125 plaque brachytherapy wi... more A woman in her early 50s previously treated 7 years prior with iodine-125 plaque brachytherapy without a biopsy for gene expression profiling for uveal melanoma in the left eye presented with a 3-week history of intermittent diplopia and headache. Ophthalmic examination was significant for limitation in left eye upward gaze; otherwise, examination revealed a stable, regressed tumor in the left eye, and normal vision, pressure, and pupils in both eyes. Neuroimaging showed a left cavernous sinus lesion, suggestive of a meningioma. Excisional biopsy revealed metastatic melanoma. The patient was treated with radiotherapy, and her diplopia resolved. Slight enlargement of the lesion was noted on neuroimaging 20 months later, and was treated with stereotactic radiosurgery. Serial neuroimaging in the following 6 months did not reveal any recurrences or new metastases. This case demonstrates the importance of investigating persistent diplopia in a patient with a history of uveal melanoma, and the possibility of metastases occurring in organs besides the liver or lung.

Ocular Oncology and Pathology

Introduction: Prognosis of uveal melanoma (UM) is assessed using clinical staging or molecular te... more Introduction: Prognosis of uveal melanoma (UM) is assessed using clinical staging or molecular testing. Two modalities often used for prognostication are the American Joint Committee on Cancer (AJCC) staging and a tumor gene expression profile (GEP), the outcomes of which are often discordant. This article discusses a total risk score created to combine the discordant information from both sources. Methods: A retrospective case series was conducted of all patients presenting with UM over 6 years to 2 referral centers. Each tumor was classified using the AJCC and the GEP. A total risk score was calculated for each patient using results from both AJCC and GEP. Kaplan-Meier analysis of metastasis-free survival was used to compare groups. Results: A total of 294 patients were included in the study. Kaplan-Meier estimates showed significant curve separation between individual AJCC and GEP risk groups. The combined total risk score provided an accurate estimate of prognosis that incorpora...

Ocular Oncology and Pathology

Purpose: This report describes a case of relapsed primary breast lymphoma (PBL) presenting as vit... more Purpose: This report describes a case of relapsed primary breast lymphoma (PBL) presenting as vitreoretinal lymphoma (VRL). Methods: We describe the clinical and hematopathologic findings in a patient with relapsed PBL involving the vitreous of both eyes. Results: A 59-year-old woman was treated for PBL with systemic and intrathecal chemotherapy 5 years prior to presentation. Three years later, she presented to an outside clinic with blurred vision in both eyes and bilateral vitritis. She was referred to our clinic with concern for ocular lymphoma. On presentation, the patient’s best-corrected visual acuity was 20/40 in the right eye and 20/25 in the left eye with 3+ vitreous cells in the right eye and 2+ vitreous cells in the left eye. Vitreous biopsy of the right eye revealed CD5-negative/CD10-negative B-cell lymphoma cells on flow cytometry. She had no evidence of disease on brain MRI, lumbar puncture, bone marrow biopsy, or full-body CT scans. She was treated with a regimen of r...

RETINAL Cases & Brief Reports

PURPOSE To report a case of a benign iridociliary melanocytoma recurring as malignant melanoma af... more PURPOSE To report a case of a benign iridociliary melanocytoma recurring as malignant melanoma after excision. METHODS Observational case report with clinical data, slit lamp exam findings, ultrasound biomicroscopy (UBM) results, and histopathological and genetic analyses. RESULTS A 40-year-old African-American woman initially presented with a superonasal iridociliary mass with a maximal thickness of 2.5 mm. Visual acuity of the involved eye was 20/25, IOP was 52 mmHg on maximal pressure-lowering medications, and Humphrey Visual Field testing revealed an inferior altitudinal defect. Fine needle aspiration biopsy (FNAB) and incisional biopsy followed by tumor excision confirmed a benign melanocytoma. After five years of stability, possible recurrence was detected on ultrasound biomicroscopy (UBM) as an increase in ciliary body thickness. The new lesion grew to a thickness of 5.1 mm over the next 18 months of observation. FNAB and gene expression profile (GEP) of the recurrent lesion diagnosed a malignant melanoma with high metastatic potential (Class 2). The patient underwent plaque brachytherapy and has ongoing regression of the tumor. CONCLUSION Transformation of benign iridociliary melanocytoma to melanoma is rare. To the best of the authors' knowledge, this is the first documented case of a melanoma arising in an eye after initial excision of a melanocytoma. Close monitoring of these patients is warranted even years after the initial excision.

Graefe's Archive for Clinical and Experimental Ophthalmology

Purpose-To investigate the relationship between surgical approach for intraocular tumor biopsy of... more Purpose-To investigate the relationship between surgical approach for intraocular tumor biopsy of uveal melanoma and tumor morphologic features such as size and intraocular location and the effect of these variables on diagnostic yield and biopsy outcome. Methods-Consecutive patients from nine Ocular Oncology centers with uveal melanoma (UM) undergoing tumor biopsy immediately preceding I 125 plaque brachytherapy with tissue sent for gene expression profiling (GEP) testing were reviewed retrospectively.

Ophthalmic Surgery, Lasers and Imaging Retina

A 45-year-old man was referred for 2 months of decreasing vision in his left eye. His visual acui... more A 45-year-old man was referred for 2 months of decreasing vision in his left eye. His visual acuity was 20/200 secondary to a subtle juxtapapillary choroidal hemangioma producing profound cystoid macular edema, with the affected retina measuring 330 microns thick by optical coherence tomography. Due to the severe cystoid macular edema, visual prognosis was judged to be poor. One month following photodynamic therapy to the tumor using verteporfin, the cystoid macular edema completely resolved, foveal anatomy returned to normal, optical coherence tomography thickness was 179 microns, and visual acuity recovered to 20/25. Photodynamic therapy of choroidal hemangioma may be effective in resolving associated cystoid macular edema and improving visual acuity.

JAMA Ophthalmology

In this study paper, we examined the magnetohydrodynamic (MHD) flow of three combined fluids, Max... more In this study paper, we examined the magnetohydrodynamic (MHD) flow of three combined fluids, Maxwell, Jeffry, and Oldroyed-B fluids, with variable heat transmission under the influence of thermal radiation embedded in a permeable medium over a time-dependent stretching sheet. The fluid flow of liquid films was assumed in two dimensions. The fundamental leading equations were changed to a set of differential nonlinear and coupled equations. For this conversion, suitable similarity variables were used. An optimal tactic was used to acquire the solution of the modeled problems. The convergence of the technique has been shown numerically. The obtained analytical and numerical consequences are associated graphically and tabulated. An excellent agreement was obtained between the homotropy analysis method (HAM) and numerical methods. The variation of the skin friction and Nusslet number and their influence on the temperature and concentration profiles were scrutinized. The influence of the thermal radiation, unsteadiness effect, and MHD were the main focus of this study. Furthermore, for conception to be physically demonstrated, the entrenched parameters are discussed graphically in detail along with their effect on liquid film flow.

Journal of Pediatric Ophthalmology & Strabismus

To investigate the role of optical coherence tomography (OCT) in the evaluation of fundus tumors ... more To investigate the role of optical coherence tomography (OCT) in the evaluation of fundus tumors and simulating lesions in children. We report the results of a retrospective single-center case series of 44 eyes of 44 children younger than age 18 with fundus lesions who were evaluated with OCT. In comparison, 12 eyes of 12 children with a normal macula were evaluated with OCT. Main outcome measures were cooperation of children while undergoing OCT and correlation of OCT findings with clinical and ultrasonographic findings The OCT was performed without difficulty in all 56 children. Mean patient age was 12 years (median, 12 years; range, 4 to 17 years). The mean horizontal foveal thickness in the 12 normal eyes was 137 microm (median, 132 microm; range, 109 to 185 microm). Clinical diagnoses included retinoblastoma in 10 (23%) eyes, Coats' disease in 4 (9%) eyes, retinal capillary hemangioma in 3 (7%) eyes, astrocytic hamartoma of the retina in 3 (7%) eyes, toxocara granuloma in 2 (5%) eyes, and others. OCT was more sensitive than clinical examination in detection of macular pathology including shallow posterior vitreous detachment, surface wrinkling maculopathy, cystoid and noncystoid macular edema, subfoveal fluid, and retinal thinning. In comparison to ultrasonography, OCT was more sensitive in detection of surface wrinkling maculopathy, macular edema, and subfoveal fluid. Ultrasonography was more sensitive in detection of posterior vitreous detachment. OCT is a useful and well-tolerated diagnostic modality for macular evaluation in children. It is more sensitive than clinical examination and ultrasonography in the detection of surface wrinkling maculopathy, macular edema, and subfoveal fluid.

Retinal Cases & Brief Reports

PURPOSE To report a case of a woman diagnosed with choroidal melanoma during pregnancy, as well a... more PURPOSE To report a case of a woman diagnosed with choroidal melanoma during pregnancy, as well as review similar cases published in the literature. The prevalence, risk factors, treatment, prognosis, and outcomes of choroidal melanoma in pregnancy are addressed. METHODS An extensive search of the literature was conducted by accessing PubMed, MEDLINE, and Scopus databases in January 2018 to identify cases of choroidal or uveal melanoma diagnosed during pregnancy. PATIENT A 37-year-old white woman pregnant with twins and diagnosed with choroidal melanoma. RESULTS Choroidal melanoma in pregnancy has a prevalence ranging from 4.3% to 7.5% among women of childbearing age with the disease. Pregnancy has been linked to increased incidence of choroidal melanoma, but female hormones have not been shown to play a role in the pathogenesis of the disease. Other factors such as melanocyte-stimulation hormone and fetal-induced angiogenesis may be implicated. Choroidal melanoma in pregnancy has not resulted in a worse maternal or fetal outcome. CONCLUSION Although rare, choroidal melanoma in pregnancy is a clinical challenge. Management of these patients should be tailored to maternal and fetal needs.

Ophthalmic Surgery, Lasers and Imaging Retina

To review trends in the management of circumscribed choroidal hemangioma (CCH) and to propose tre... more To review trends in the management of circumscribed choroidal hemangioma (CCH) and to propose treatment guidelines based on review of recent literature and the authors' personal experience with more than 250 The English-language literature on the management of CCH was reviewed, with emphasis on changing concepts in recent years. Xenon arc and argon laser photocoagulation and thermotherapy have been used to treat CCH with localized retinal detachment, but there has recently been enthusiasm for photodynamic therapy (PDT) using fluorescein angiography and optical coherence tomography to monitor subretinal fluid and cystoid retinal edema before and after treatment. Tumors with extensive retinal detachment have been managed by surgical attempts at retinal reattachment followed by photocoagulation or cryotherapy, and more recently by radiotherapy. Management currently includes observation, argon laser photocoagulation, transpupillary thermotherapy, PDT, and radiotherapy. Enucleation may be necessary in rare cases. The goal of treatment should be to induce resolution of existing retinal detachment and to improve or stabilize visual loss. There is increasing use of PDT for CCH with localized retinal detachment and radiotherapy for CCH with more extensive detachment. Although follow-up is short, current methods may achieve better tumor control and better visual outcome. However, caution is advised because long-term follow-up is still not available.

American journal of ophthalmology, 2018

To evaluate the prognostication of choroidal melanoma (CM) by the gene expression profiling (GEP)... more To evaluate the prognostication of choroidal melanoma (CM) by the gene expression profiling (GEP) test. Cohort study. Retrospective review of 293 CM patients from 2 centers. Of 293 patients, 132 (45%) were class 1A by GEP, 63 (22%) were class 1B, and 98 (33%) were class 2. Class 2 tumors had more ciliary body involvement and greater largest basal dimension (LBD), and were thicker. GEP results and increasing LBD were independently predictive of time to metastasis. Kaplan-Meier survival analysis estimated the probability of 3-year metastasis-free survival (MFS) of 0.99 in class 1A, 0.90 in class 1B, and 0.60 in class 2. The probability of 3-year MFS was 0.49 in class 2 patients with LBD ≥ 12 mm vs 1.00 in those with LBD < 12 mm, 0.89 in class 1B with LBD ≥ 12 mm vs 0.93 in those with LBD < 12 mm, and 0.99 in class 1A with LBD ≥ 12 mm vs 1.00 in those with LBD < 12 mm. In American Joint Committee on Cancer (AJCC) stage I CMs, the probability of 3-year MFS was 1.0 for class 1A ...

Retina

PURPOSE To study the relationship between gene expression profile (GEP) subclass and American Joi... more PURPOSE To study the relationship between gene expression profile (GEP) subclass and American Joint Committee on Cancer (AJCC) stage in patients with uveal melanoma (UM). METHODS A retrospective, multicenter study was undertaken with patients entered from nine major ocular oncology centers from across the United States. Three hundred sixty eligible patients had UM and underwent I-125 plaque brachytherapy with concurrent tumor biopsy with GEP testing between January 1, 2010, and October 28, 2014. Patient demographics and UM features were analyzed by both GEP and AJCC status. RESULTS Gene expression profile class divided the cohort into three groups: Class 1a (n = 186), Class 1b (n = 77), and Class 2 (n = 113). When classified using AJCC staging criteria, we found the following: Stage I in 91 cases (25.3%), Stage IIA in 143 cases (39.7%), Stage IIB in 89 cases (24.7%), Stage IIIA in 36 cases (10%), and Stage IIIB in 1 case (0.3%). There were no Stage IV cases, as lymph node and metastatic data were not collected as a part of this study. Among Stage I tumors, both high tumor height and high largest basal diameter were associated with a higher frequency of Class 2 status (P < 0.05). As UMs progress to a larger AJCC tumor group (T1-T4), the odds ratio of having a worse prognosis based on GEP class was 1.75 (95% CI, 1.36-2.25; P < 0.001). Similarly, as UMs progress to a higher AJCC stage, the odds ratio of having a worse prognosis based on GEP class was 1.69 (95% CI, 1.36-2.10; P < 0.001). CONCLUSION This report details the differences in clinical features between GEP subclasses and how they are distributed among the AJCC stages. When the tumors were grouped by AJCC staging criteria, both larger AJCC tumor (T) group and worsening AJCC stage were associated with worsening predicted prognosis, based on GEP subclass.

Ocular Oncology and Pathology

body, measuring 18 mm in the greatest dimension. Spindled cells with fibrillary cytoplasmic proce... more body, measuring 18 mm in the greatest dimension. Spindled cells with fibrillary cytoplasmic processes suggested a neural origin though negative for S-100, Melan-A, and HMB-45. The cells stained strongly positive for smooth muscle actin and vimentin, leading to the diagnosis of mesectodermal leiomyoma of the ciliary body. Results: We review the literature to expand upon the clinical findings, diagnostic methods, and histopathologic and immunohistochemistry characteristics of mesectodermal leiomyoma. Conclusion: Leiomyoma must be in the differential diagnosis for ciliary body mass, especially in women of reproductive age. Diagnosis relies on histopathology and immunohistochemistry. The mechanism of acute symptom onset may be multifactorial. This case emphasizes the possibility of acute presentation of a rare, benign intraocular tumor.

Brachytherapy

To quantify the dosimetric impact of incorporating patient-specific CT-based models rather than t... more To quantify the dosimetric impact of incorporating patient-specific CT-based models rather than the conventional stylized-standard model for eye plaque brachytherapy planning. Plaque Simulator was used to plan 16 patients using both CT-based patient-specific eye model and stylized-standard (SS) eye models. Plaque position was initially based on the SS model and compared against their patient-specific model without changing the plaque loading pattern and seed strength. Dosimetric parameters were compared for tumor and healthy ocular structures. Patient-specific ocular parameters ranged from 0.40 to 1.38 of SS model values. If plaques were placed based on SS model eyelet positions, target volume receiving prescription dose (V100%) is overpredicted by 5.9% on average (max: 27%), and D95% is overpredicted by 17.2 Gy on average (max: 58.1 Gy). If the plaques were recentered, 13 of 16 patients had changes in V100% of less than 2%, whereas half of the patients still had optic disc dose difference greater than 5 Gy (max: 36.2 Gy). The largest differences were observed with a target-to-optic disk distance less than 6 mm. No substantial dose differences were observed for the tumor apex, fovea, lens, and opposing retina. Patient-specific modeling is recommended for clinical planning, especially with target-to-optic disk distances less than 6 mm, due to significant differences compared with SS model.

Journal of the National Comprehensive Cancer Network

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) are a statement of consensu... more The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) are a statement of consensus of the authors regarding their views of currently accepted approaches to treatment. The NCCN Guidelines ® Insights highlight important changes to the NCCN Guidelines ® recommendations from previous versions. Colored markings in the algorithm show changes and the discussion aims to further the understanding of these changes by summarizing salient portions of the NCCN Guideline Panel discussion, including the literature reviewed. These NCCN Guidelines Insights do not represent the full NCCN Guidelines; further, the National Comprehensive Cancer Network ® (NCCN ®) makes no representation or warranties of any kind regarding the content, use, or application of the NCCN Guidelines and NCCN Guidelines Insights and disclaims any responsibility for their applications or use in any way. The full and most current version of these NCCN Guidelines are available at NCCN.org.

Purpose To report a clinically challenging case of a choroidal nevus with retinal invasion with a... more Purpose To report a clinically challenging case of a choroidal nevus with retinal invasion with accompanying ancillary testing. Observations A 60-year-old Caucasian female was referred for a suspicious melanocytic choroidal lesion in her left eye. Ophthalmoscopic examination revealed a melanocytic choroidal lesion, measuring 10 mm × 10 mm in basal diameter. The lesion had a clinically evident area of retinal invasion seen as a protruding choroidal mass at its center, darker in appearance compared to the rest of the lesion, obscuring retinal vessels. The choroidal nevus had associated chronic retinal changes and the absence of overlying orange pigment or subretinal fluid. On fundus autofluorescence, there was a hypoautofluorescent area showing the site of retinal invasion. Fluorescein angiography at the lesion site exhibited central blocked perfusion corresponding to the area of retinal invasion. Ultrasonography showed a dome-shaped choroidal lesion that was optically dense with a me...

BACKGROUND Uveal melanoma (UM) is the most common primary malignant eye tumor in adults, though r... more BACKGROUND Uveal melanoma (UM) is the most common primary malignant eye tumor in adults, though rare with 2500 cases diagnosed annually in the US. Despite a growing understanding of the molecular characteristics, there remains uncertainty regarding epidemiologic trends and environmental risk factors. We have identified three geographic accumulations of UM: 1) Huntersville, NC, 2) Auburn, AL, and 3) Broome/Tioga Counties, NY. Evaluation into these groups will guide ongoing efforts to discover potential risk factors and assist with future treatment and prevention. DESIGN Observational case series METHODS: Descriptive data from medical records, patient interviews, and questionnaires was obtained on 5 patients from NC, 6 from AL, and 14 from NY. Standard incidence ratio (SIR) calculations were provided by the respective states' cancer registries. RESULTS In NC, 5 females who were identified as living in Huntersville, NC were diagnosed with UM at ages 20, 22, 24, 30, and 31. The SIR ...

The NCCN Guidelines for Uveal Melanoma include recommendations for staging, treatment, and follow... more The NCCN Guidelines for Uveal Melanoma include recommendations for staging, treatment, and follow-up of patients diagnosed with uveal melanoma of the choroid or ciliary body. In addition, because distinguishing between uveal melanoma and benign uveal nevi is in some cases difficult, these guidelines also contain recommendations for workup of patients with suspicious pigmented uveal lesions, to clarify the tests needed to distinguish between those who should have further workup and treatment for uveal melanoma versus those with uncertain diagnosis and low risk who should to be followed and later reevaluated. These NCCN Guidelines Insights describe recommendations for treatment of newly diagnosed nonmetastatic uveal melanoma in patients who have already undergone a complete workup.

Ophthalmic Plastic & Reconstructive Surgery

A woman in her early 50s previously treated 7 years prior with iodine-125 plaque brachytherapy wi... more A woman in her early 50s previously treated 7 years prior with iodine-125 plaque brachytherapy without a biopsy for gene expression profiling for uveal melanoma in the left eye presented with a 3-week history of intermittent diplopia and headache. Ophthalmic examination was significant for limitation in left eye upward gaze; otherwise, examination revealed a stable, regressed tumor in the left eye, and normal vision, pressure, and pupils in both eyes. Neuroimaging showed a left cavernous sinus lesion, suggestive of a meningioma. Excisional biopsy revealed metastatic melanoma. The patient was treated with radiotherapy, and her diplopia resolved. Slight enlargement of the lesion was noted on neuroimaging 20 months later, and was treated with stereotactic radiosurgery. Serial neuroimaging in the following 6 months did not reveal any recurrences or new metastases. This case demonstrates the importance of investigating persistent diplopia in a patient with a history of uveal melanoma, and the possibility of metastases occurring in organs besides the liver or lung.

Ocular Oncology and Pathology

Introduction: Prognosis of uveal melanoma (UM) is assessed using clinical staging or molecular te... more Introduction: Prognosis of uveal melanoma (UM) is assessed using clinical staging or molecular testing. Two modalities often used for prognostication are the American Joint Committee on Cancer (AJCC) staging and a tumor gene expression profile (GEP), the outcomes of which are often discordant. This article discusses a total risk score created to combine the discordant information from both sources. Methods: A retrospective case series was conducted of all patients presenting with UM over 6 years to 2 referral centers. Each tumor was classified using the AJCC and the GEP. A total risk score was calculated for each patient using results from both AJCC and GEP. Kaplan-Meier analysis of metastasis-free survival was used to compare groups. Results: A total of 294 patients were included in the study. Kaplan-Meier estimates showed significant curve separation between individual AJCC and GEP risk groups. The combined total risk score provided an accurate estimate of prognosis that incorpora...

Ocular Oncology and Pathology

Purpose: This report describes a case of relapsed primary breast lymphoma (PBL) presenting as vit... more Purpose: This report describes a case of relapsed primary breast lymphoma (PBL) presenting as vitreoretinal lymphoma (VRL). Methods: We describe the clinical and hematopathologic findings in a patient with relapsed PBL involving the vitreous of both eyes. Results: A 59-year-old woman was treated for PBL with systemic and intrathecal chemotherapy 5 years prior to presentation. Three years later, she presented to an outside clinic with blurred vision in both eyes and bilateral vitritis. She was referred to our clinic with concern for ocular lymphoma. On presentation, the patient’s best-corrected visual acuity was 20/40 in the right eye and 20/25 in the left eye with 3+ vitreous cells in the right eye and 2+ vitreous cells in the left eye. Vitreous biopsy of the right eye revealed CD5-negative/CD10-negative B-cell lymphoma cells on flow cytometry. She had no evidence of disease on brain MRI, lumbar puncture, bone marrow biopsy, or full-body CT scans. She was treated with a regimen of r...

RETINAL Cases & Brief Reports

PURPOSE To report a case of a benign iridociliary melanocytoma recurring as malignant melanoma af... more PURPOSE To report a case of a benign iridociliary melanocytoma recurring as malignant melanoma after excision. METHODS Observational case report with clinical data, slit lamp exam findings, ultrasound biomicroscopy (UBM) results, and histopathological and genetic analyses. RESULTS A 40-year-old African-American woman initially presented with a superonasal iridociliary mass with a maximal thickness of 2.5 mm. Visual acuity of the involved eye was 20/25, IOP was 52 mmHg on maximal pressure-lowering medications, and Humphrey Visual Field testing revealed an inferior altitudinal defect. Fine needle aspiration biopsy (FNAB) and incisional biopsy followed by tumor excision confirmed a benign melanocytoma. After five years of stability, possible recurrence was detected on ultrasound biomicroscopy (UBM) as an increase in ciliary body thickness. The new lesion grew to a thickness of 5.1 mm over the next 18 months of observation. FNAB and gene expression profile (GEP) of the recurrent lesion diagnosed a malignant melanoma with high metastatic potential (Class 2). The patient underwent plaque brachytherapy and has ongoing regression of the tumor. CONCLUSION Transformation of benign iridociliary melanocytoma to melanoma is rare. To the best of the authors' knowledge, this is the first documented case of a melanoma arising in an eye after initial excision of a melanocytoma. Close monitoring of these patients is warranted even years after the initial excision.

Graefe's Archive for Clinical and Experimental Ophthalmology

Purpose-To investigate the relationship between surgical approach for intraocular tumor biopsy of... more Purpose-To investigate the relationship between surgical approach for intraocular tumor biopsy of uveal melanoma and tumor morphologic features such as size and intraocular location and the effect of these variables on diagnostic yield and biopsy outcome. Methods-Consecutive patients from nine Ocular Oncology centers with uveal melanoma (UM) undergoing tumor biopsy immediately preceding I 125 plaque brachytherapy with tissue sent for gene expression profiling (GEP) testing were reviewed retrospectively.

Ophthalmic Surgery, Lasers and Imaging Retina

A 45-year-old man was referred for 2 months of decreasing vision in his left eye. His visual acui... more A 45-year-old man was referred for 2 months of decreasing vision in his left eye. His visual acuity was 20/200 secondary to a subtle juxtapapillary choroidal hemangioma producing profound cystoid macular edema, with the affected retina measuring 330 microns thick by optical coherence tomography. Due to the severe cystoid macular edema, visual prognosis was judged to be poor. One month following photodynamic therapy to the tumor using verteporfin, the cystoid macular edema completely resolved, foveal anatomy returned to normal, optical coherence tomography thickness was 179 microns, and visual acuity recovered to 20/25. Photodynamic therapy of choroidal hemangioma may be effective in resolving associated cystoid macular edema and improving visual acuity.

JAMA Ophthalmology

In this study paper, we examined the magnetohydrodynamic (MHD) flow of three combined fluids, Max... more In this study paper, we examined the magnetohydrodynamic (MHD) flow of three combined fluids, Maxwell, Jeffry, and Oldroyed-B fluids, with variable heat transmission under the influence of thermal radiation embedded in a permeable medium over a time-dependent stretching sheet. The fluid flow of liquid films was assumed in two dimensions. The fundamental leading equations were changed to a set of differential nonlinear and coupled equations. For this conversion, suitable similarity variables were used. An optimal tactic was used to acquire the solution of the modeled problems. The convergence of the technique has been shown numerically. The obtained analytical and numerical consequences are associated graphically and tabulated. An excellent agreement was obtained between the homotropy analysis method (HAM) and numerical methods. The variation of the skin friction and Nusslet number and their influence on the temperature and concentration profiles were scrutinized. The influence of the thermal radiation, unsteadiness effect, and MHD were the main focus of this study. Furthermore, for conception to be physically demonstrated, the entrenched parameters are discussed graphically in detail along with their effect on liquid film flow.

Journal of Pediatric Ophthalmology & Strabismus

To investigate the role of optical coherence tomography (OCT) in the evaluation of fundus tumors ... more To investigate the role of optical coherence tomography (OCT) in the evaluation of fundus tumors and simulating lesions in children. We report the results of a retrospective single-center case series of 44 eyes of 44 children younger than age 18 with fundus lesions who were evaluated with OCT. In comparison, 12 eyes of 12 children with a normal macula were evaluated with OCT. Main outcome measures were cooperation of children while undergoing OCT and correlation of OCT findings with clinical and ultrasonographic findings The OCT was performed without difficulty in all 56 children. Mean patient age was 12 years (median, 12 years; range, 4 to 17 years). The mean horizontal foveal thickness in the 12 normal eyes was 137 microm (median, 132 microm; range, 109 to 185 microm). Clinical diagnoses included retinoblastoma in 10 (23%) eyes, Coats&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; disease in 4 (9%) eyes, retinal capillary hemangioma in 3 (7%) eyes, astrocytic hamartoma of the retina in 3 (7%) eyes, toxocara granuloma in 2 (5%) eyes, and others. OCT was more sensitive than clinical examination in detection of macular pathology including shallow posterior vitreous detachment, surface wrinkling maculopathy, cystoid and noncystoid macular edema, subfoveal fluid, and retinal thinning. In comparison to ultrasonography, OCT was more sensitive in detection of surface wrinkling maculopathy, macular edema, and subfoveal fluid. Ultrasonography was more sensitive in detection of posterior vitreous detachment. OCT is a useful and well-tolerated diagnostic modality for macular evaluation in children. It is more sensitive than clinical examination and ultrasonography in the detection of surface wrinkling maculopathy, macular edema, and subfoveal fluid.

Retinal Cases & Brief Reports

PURPOSE To report a case of a woman diagnosed with choroidal melanoma during pregnancy, as well a... more PURPOSE To report a case of a woman diagnosed with choroidal melanoma during pregnancy, as well as review similar cases published in the literature. The prevalence, risk factors, treatment, prognosis, and outcomes of choroidal melanoma in pregnancy are addressed. METHODS An extensive search of the literature was conducted by accessing PubMed, MEDLINE, and Scopus databases in January 2018 to identify cases of choroidal or uveal melanoma diagnosed during pregnancy. PATIENT A 37-year-old white woman pregnant with twins and diagnosed with choroidal melanoma. RESULTS Choroidal melanoma in pregnancy has a prevalence ranging from 4.3% to 7.5% among women of childbearing age with the disease. Pregnancy has been linked to increased incidence of choroidal melanoma, but female hormones have not been shown to play a role in the pathogenesis of the disease. Other factors such as melanocyte-stimulation hormone and fetal-induced angiogenesis may be implicated. Choroidal melanoma in pregnancy has not resulted in a worse maternal or fetal outcome. CONCLUSION Although rare, choroidal melanoma in pregnancy is a clinical challenge. Management of these patients should be tailored to maternal and fetal needs.

Ophthalmic Surgery, Lasers and Imaging Retina

To review trends in the management of circumscribed choroidal hemangioma (CCH) and to propose tre... more To review trends in the management of circumscribed choroidal hemangioma (CCH) and to propose treatment guidelines based on review of recent literature and the authors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; personal experience with more than 250 The English-language literature on the management of CCH was reviewed, with emphasis on changing concepts in recent years. Xenon arc and argon laser photocoagulation and thermotherapy have been used to treat CCH with localized retinal detachment, but there has recently been enthusiasm for photodynamic therapy (PDT) using fluorescein angiography and optical coherence tomography to monitor subretinal fluid and cystoid retinal edema before and after treatment. Tumors with extensive retinal detachment have been managed by surgical attempts at retinal reattachment followed by photocoagulation or cryotherapy, and more recently by radiotherapy. Management currently includes observation, argon laser photocoagulation, transpupillary thermotherapy, PDT, and radiotherapy. Enucleation may be necessary in rare cases. The goal of treatment should be to induce resolution of existing retinal detachment and to improve or stabilize visual loss. There is increasing use of PDT for CCH with localized retinal detachment and radiotherapy for CCH with more extensive detachment. Although follow-up is short, current methods may achieve better tumor control and better visual outcome. However, caution is advised because long-term follow-up is still not available.

American journal of ophthalmology, 2018

To evaluate the prognostication of choroidal melanoma (CM) by the gene expression profiling (GEP)... more To evaluate the prognostication of choroidal melanoma (CM) by the gene expression profiling (GEP) test. Cohort study. Retrospective review of 293 CM patients from 2 centers. Of 293 patients, 132 (45%) were class 1A by GEP, 63 (22%) were class 1B, and 98 (33%) were class 2. Class 2 tumors had more ciliary body involvement and greater largest basal dimension (LBD), and were thicker. GEP results and increasing LBD were independently predictive of time to metastasis. Kaplan-Meier survival analysis estimated the probability of 3-year metastasis-free survival (MFS) of 0.99 in class 1A, 0.90 in class 1B, and 0.60 in class 2. The probability of 3-year MFS was 0.49 in class 2 patients with LBD ≥ 12 mm vs 1.00 in those with LBD < 12 mm, 0.89 in class 1B with LBD ≥ 12 mm vs 0.93 in those with LBD < 12 mm, and 0.99 in class 1A with LBD ≥ 12 mm vs 1.00 in those with LBD < 12 mm. In American Joint Committee on Cancer (AJCC) stage I CMs, the probability of 3-year MFS was 1.0 for class 1A ...

Retina

PURPOSE To study the relationship between gene expression profile (GEP) subclass and American Joi... more PURPOSE To study the relationship between gene expression profile (GEP) subclass and American Joint Committee on Cancer (AJCC) stage in patients with uveal melanoma (UM). METHODS A retrospective, multicenter study was undertaken with patients entered from nine major ocular oncology centers from across the United States. Three hundred sixty eligible patients had UM and underwent I-125 plaque brachytherapy with concurrent tumor biopsy with GEP testing between January 1, 2010, and October 28, 2014. Patient demographics and UM features were analyzed by both GEP and AJCC status. RESULTS Gene expression profile class divided the cohort into three groups: Class 1a (n = 186), Class 1b (n = 77), and Class 2 (n = 113). When classified using AJCC staging criteria, we found the following: Stage I in 91 cases (25.3%), Stage IIA in 143 cases (39.7%), Stage IIB in 89 cases (24.7%), Stage IIIA in 36 cases (10%), and Stage IIIB in 1 case (0.3%). There were no Stage IV cases, as lymph node and metastatic data were not collected as a part of this study. Among Stage I tumors, both high tumor height and high largest basal diameter were associated with a higher frequency of Class 2 status (P < 0.05). As UMs progress to a larger AJCC tumor group (T1-T4), the odds ratio of having a worse prognosis based on GEP class was 1.75 (95% CI, 1.36-2.25; P < 0.001). Similarly, as UMs progress to a higher AJCC stage, the odds ratio of having a worse prognosis based on GEP class was 1.69 (95% CI, 1.36-2.10; P < 0.001). CONCLUSION This report details the differences in clinical features between GEP subclasses and how they are distributed among the AJCC stages. When the tumors were grouped by AJCC staging criteria, both larger AJCC tumor (T) group and worsening AJCC stage were associated with worsening predicted prognosis, based on GEP subclass.

Ocular Oncology and Pathology

body, measuring 18 mm in the greatest dimension. Spindled cells with fibrillary cytoplasmic proce... more body, measuring 18 mm in the greatest dimension. Spindled cells with fibrillary cytoplasmic processes suggested a neural origin though negative for S-100, Melan-A, and HMB-45. The cells stained strongly positive for smooth muscle actin and vimentin, leading to the diagnosis of mesectodermal leiomyoma of the ciliary body. Results: We review the literature to expand upon the clinical findings, diagnostic methods, and histopathologic and immunohistochemistry characteristics of mesectodermal leiomyoma. Conclusion: Leiomyoma must be in the differential diagnosis for ciliary body mass, especially in women of reproductive age. Diagnosis relies on histopathology and immunohistochemistry. The mechanism of acute symptom onset may be multifactorial. This case emphasizes the possibility of acute presentation of a rare, benign intraocular tumor.

Brachytherapy

To quantify the dosimetric impact of incorporating patient-specific CT-based models rather than t... more To quantify the dosimetric impact of incorporating patient-specific CT-based models rather than the conventional stylized-standard model for eye plaque brachytherapy planning. Plaque Simulator was used to plan 16 patients using both CT-based patient-specific eye model and stylized-standard (SS) eye models. Plaque position was initially based on the SS model and compared against their patient-specific model without changing the plaque loading pattern and seed strength. Dosimetric parameters were compared for tumor and healthy ocular structures. Patient-specific ocular parameters ranged from 0.40 to 1.38 of SS model values. If plaques were placed based on SS model eyelet positions, target volume receiving prescription dose (V100%) is overpredicted by 5.9% on average (max: 27%), and D95% is overpredicted by 17.2 Gy on average (max: 58.1 Gy). If the plaques were recentered, 13 of 16 patients had changes in V100% of less than 2%, whereas half of the patients still had optic disc dose difference greater than 5 Gy (max: 36.2 Gy). The largest differences were observed with a target-to-optic disk distance less than 6 mm. No substantial dose differences were observed for the tumor apex, fovea, lens, and opposing retina. Patient-specific modeling is recommended for clinical planning, especially with target-to-optic disk distances less than 6 mm, due to significant differences compared with SS model.

Journal of the National Comprehensive Cancer Network

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) are a statement of consensu... more The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) are a statement of consensus of the authors regarding their views of currently accepted approaches to treatment. The NCCN Guidelines ® Insights highlight important changes to the NCCN Guidelines ® recommendations from previous versions. Colored markings in the algorithm show changes and the discussion aims to further the understanding of these changes by summarizing salient portions of the NCCN Guideline Panel discussion, including the literature reviewed. These NCCN Guidelines Insights do not represent the full NCCN Guidelines; further, the National Comprehensive Cancer Network ® (NCCN ®) makes no representation or warranties of any kind regarding the content, use, or application of the NCCN Guidelines and NCCN Guidelines Insights and disclaims any responsibility for their applications or use in any way. The full and most current version of these NCCN Guidelines are available at NCCN.org.