Clinical outcomes and cost analysis of frontalis sling

suspension for congenital ptosis

Purpose Frontalis sling suspension is the treatment of choice for drooping

eyelids (congenital ptosis) which are associated with poor levator
function. The materials used include autologous fascia lata (muscle
grafts), palmaris longus (a small muscle visible as a tendon) and
artificial materials. However, harvesting autologous material is often
not possible in young children. A retrospective case series analysis to
elucidate the clinical outcomes using 3-0 Ethilon, autologous fascia lata
and palmaris longus tendon was performed. Additionally, a cost
analysis of the various methods was performe

Methods A consecutive case series of patients who underwent frontalis sling

procedures for congenital ptosis between October 2010 and May 2017
was retrospectively analysed. The cost analysis was conducted using
NHS Tariffs

Main Outcome The main outcome measure was whether cosmetic surgical outcome
Measures was satisfactory or not, as agreed by the operating surgeon, the patient
and family

Results The outcomes of 23 procedures from 15 patients were also analysed.

Median age at first frontalis sling surgery was 9.2 years (interquartile
range: 14.8). Median follow-up before discharge was 26.6 months
(interquartile range: 25.5). Materials included Ethilon (n=19
procedures), autologous fascia lata (n=1) and palmaris longus (n=3).
Satisfactory cosmetic correction was achieved in all patients at 12-
month review after initial surgery. Five frontalis sling suspension slips
occurred in Ethilon cases following trauma, each requiring frontalis
sling redo, one of which slipped again following trauma. Cost analysis
revealed that operations using synthetic materials cost less as a single
operation but more overall if one or more repeat operation is required

Conclusions: Ethilon, autologous fascia lata, and palmaris longus are safe and
effective materials for use in frontalis sling suspension in the correction
of congenital ptosis. Synthetic material costs less as a single operation
but cost effectiveness suffers when repeat operations are required.
Treatment should be individually tailored to the patient.

Point of Ethilon for frontalis sling suspension is a safe and effective option for
Learning the correction of ptosis, though further surgery is required when there is
slippage. Similar clinical outcomes were achieved in our study using
Ethilon when compared to previous study which used silicone rod
(Bansal and Sharma, 2015). However, granuloma or chronic
inflammation in this case study was avoided.
 Surgical Reconstruction of Ocular Surface Tumors Using
Fibrin Sealant Tissue Adhesive

Purpose To evaluate the surgical outcomes of ocular surface reconstruction in

corneal-conjunctival tumors using fibrin tissue adhesive

Methods A prospective noncomparative study was performed between May 2013

and February 2015. Patients were submitted to routine surgical
procedure for corneal-conjunctival tumor excision followed by amniotic
membrane graft transplantation using fibrin tissue adhesive (Evicel ® ,
Omrix Biopharmaceuticals Ltd., Israel). Results were assessed on the
1st, 7th, 15th and 30th postoperative days to analyze subjective
complaints, adhesiveness and positioning of the graft, potential
complications and recurrences

Main Outcome to get the best technique for reconstruction of the ocular surface
Measures

Results Twenty-five eyes were analyzed (male, 14). The diagnosis after the
treatment was categorized as squamous cell neoplasia, dysplasia, actinic
keratosis, squamous papilloma and compound melanocytic nevus. Few
significant symptoms were reported, such as mild hyperemia and ocular
dyscomfort. One case developed a conjunctival granuloma which
regressed after topical treatment. All grafts were successful with no
displacements or retraction postoperatively. There was no clinical
recurrence of the tumor in a mean time of follow-up of 11 months.

Conclusions: Fibrin tissue adhesive is safe and effective in the surgery of ocular
surface tumor. In this series, sutureless amniotic membrane
transplantation using fibrin glue has the potential to shorten the surgical
time, mitigate inflammation postoperatively and improve patient
discomfort.

Point of
Learning Amniotic membrane transplantation has been used successfully in
conjunctival surface reconstruction due to its anti-inflammatory
property and minimal scar formation. Fibrin tissue adhesive has been
widely applied in various medical fields, including ophthalmic surgery
such as vitreoretinal, glaucoma, ocular surface, cataract and refractive
surgery
 Research Article The Improvement of Dry Eye Symptoms
after Pinguecula Excision and Conjunctival Autograft
with Fibrin Glue

Purpose To evaluate the association between pinguecula excision and

subsequent improvement in dry eye syndrome

Methods We included 30 consecutive patients with primary nasal pinguecula and

dry eye symptoms undergoing ocular surgery for the first time. Criteria
for pinguecula excision surgery were nasal location, yellowish color,
and protrusion of conjunctiva at least 2 times thicker than adjacent
normal conjunctiva as measured by anterior segment optical coherence
tomography.

Main Outcome were 3-month postoperative changes in tear film breakup time (TBUT),
Measures Schirmer test, and a dry eye symptom score. R

Results 30 eyes from 30 different patients (12 men and 18 women) underwent
pinguecula excision and conjunctival autografting using fibrin glue. ,e
mean age was 42.5 ± 8.35 (range 28–63) years. ,e preoperative
protrusion ratio of pinguecula was 2.33 ± 0.28 (range 2.00–2.90). Mean
preoperative TBUT, Schirmer test, and dry eye symptom scores were
5.10 ± 1.27 seconds, 6.07 ± 2.27 mm, and 2.80 ± 0.76 points. Mean
postoperative 3-month TBUT, Schirmer test, and dry eye symptom
scores were 7.80 ± 1.13 seconds, 7.27 ± 2.02 mm, and 0.30 ± 0.47
points, respectively. ,e median pre- and postoperative changes were
found to be statistically significant by Wilcoxon signed-rank tests for
TBUT, Schirmer test score, and dry eye symptom score

Conclusions: Surgical excision of pinguecula and conjunctival autograft using fibrin

glue is an effective and safe method to improve symptoms of dry eye
syndrome.

Point of Greater protrusion was moderately correlated with lower TBUT and
Learning Schirmer test scores. It was also moderately correlated with higher dry
eye symptom scores and a greater postexcision improvement in
symptoms. It follows that pinguecula protrusion may affect tear film
stability and therefore TBUT, but we also found that tear film
production improved postoperatively. ,is finding is supported by
evidence in the literature of lower tear osmolarity after pterygium
excision surgery

Factors affecting outcome in ocular myasthenia gravis

Purpose 50% to 60% of patients with ocular Myasthenia Gravis (OMG) progress to
generalized disease (GMG) within 2 years.Aim of our study was to explore
factors affecting prognosis of OMG and to test the predictive role of several
independent clinical variables.

Methods We reviewed a cohort of 168 Caucasian patients followed from September

2000 and January 2016. Several independent variables were considered as
prognostic factors: gender, age of onset, results on electrophysiological tests,
presence and level of antibodies against acetylcholine receptors (AChR-Abs),
treatments, thymic abnormalities.Primary outcome was the progression to
GMG and/or presence of bulbar symptoms. Secondary outcomes were either
achievement of sustained minimal manifestation status (MMS) or worsening
in ocular quantitative MG subscore (O-QMGS) or worsening in total QMG
score (T-QMGS), assessed by Myasthenia Gravis Foundation of America
(MGFA) quantitative scores.Changes in Mental (MCS) and Physical (PCS)
subscores of health-related quality of life (HRQoL) was assessed with SF-36
questionnaire.Variance analysis was used to interpret the differences between
AChR-Abs titers at different times of follow up among the generalized and
non-generalized patients.

Main Outcome Analysis of QMG status was assessed by changing of final (“f”) severity score
Measures minus the initial (“i”).The O-QMG scoring was performed in timed fashion
for presence of ptosis and diplopia.
168 subjects were followed in a consistent manner over 15 years by the same
neurologists,with the goal of minimizing evaluation bias and different
treatment approach.

Results Conversion to GMG occurred in 18.4% of patients; it was significantly

associated with sex, later onset of disease, anti-AChR Ab positivity. Antibody
titer above mean value of 25.8 pmol/ml showed no significant effect on
 generalization. Sex and late onset of disease significantly affected T-QMGS
worsening. None of the other independent variables significantly affected O-
QMGS and HRQoL .

Conclusions: Sex, later onset, anti-AChR–Ab positivity were significantly associated with
clinical worsening.

Point of females are more frequently affected by thymic hyperplasia and have higher
Learning antibody levels. .It is well established that sex hormones, primarily estrogen
but also progesterone and testosterone, can affect immune cells quantitatively
and qualitatively; they can impact on cytokine production by different effector
cells and on immunoglobulin production, maturation, selection and antibody
secretion by B lymphocytes.
A link between autoimmunity so far has been proved by experimental models;
estrogens typically favor immune processes involving CD4+ Th2 cells and B
cells,promoting B cell-mediated autoimmune diseases

Asteroid hyalosis removal during phacoemulsification: an

anterior approach

Purpose The aim of this study was to evaluate the safety and efficacy of asteroid
hyalosis (AH) removal by means of anterior vitrectomy through posterior
capsulorhexis during phacoemulsification.

Methods The study was conducted on 16 eyes of 16 cataractous patients associated with
AH. Phacoemulsification was performed, followed by removal of the AH
through posterior capsulorhexis by means of anterior vitrectomy and before
intraocular lens implantation. Patients were examined at 1 day, 1 week, 1, 3,
and 6 months postoperatively. Data were analyzed using paired t-tests to
compare the preoperative and postoperative uncorrected visual acuity and
corrected visual acuity. The basic postoperative parameters at each follow-up
visit were assessment of uncorrected visual acuity and corrected visual acuity
and slitlamp examination to evaluate the corneal condition and to detect any
postoperative inflammation. The disappearance of AH was confirmed
clinically using slit-lamp examination.

Main Outcome postoperative visual acuity

Measures
Results All patients in this study showed a statistically significant improvement in
postoperative visual acuity (P=0.001) at the last follow-up visit. One patient
who had diabetic retinopathy and maculopathy showed deteriorated visual
acuity at the last postoperative visit (P=0.2). Two patients had suboptimal
best-corrected visual acuity after 6 months due to the presence of cellophane
maculopathy detected clinically and using ocular coherence tomography
(OCT) examination (P=0.01)
Conclusions: Removal of AH by means of anterior vitrectomy during phacoemulsification
through a posterior capsulorhexis is safe and effective and enables the surgeon
to treat undiagnosed missed retinal lesions that were not obvious
preoperatively

Point of Asteroid hyalosis (AH) is a degenerative process of the vitreous humor,

Learning resulting in the formation of small white opacities, which consist of calcium
phosphate and lipid deposits

Current Treatment of Bilateral Retinoblastoma: The

Impact of Intraarterial and Intravitreous Chemotherapy

Purpose To evaluate the management and outcomes of naïve bilateral

retinoblastoma treated at a single-center over a 5-year period during the
era of ophthalmic artery chemosurgery (OAC) and intravitreous
chemotherapy

Methods Retrospective cohort study of 46 patients (92 eyes) with naïve bilateral
retinoblastoma treated at Memorial Sloan Kettering Cancer Center
between January 2012 and February 2017. Indirect ophthalmoscopy,
fundus photography, ultrasonography, and ultrasonic biomicroscopy
were used to evaluate clinical response. Patient, ocular, ocular
progression-free, ocular recurrent event–free, and second ocular
survivalswere assessed by Kaplan-Meier estimates.Retinal toxicitywas
evaluatedby electroretinography. Snellen visual acuity and complete
blood count metrics were recorded.
Main Outcome Patient, ocular, ocular progression-free, ocular recurrent event–free, and
Measures second ocular survivalswere assessed by Kaplan-Meier
estimates.Retinal toxicitywas evaluatedby electroretinography. Snellen
visual acuity and complete blood count metrics were recorded. R
Results Sixty-four eyes (70%) in 41 patients (89%) received ophthalmic artery
chemosurgery as part of their treatment. Twenty-six patients (56%)
received tandem OAC(bilateral simultaneous infusions). Seven eyes
were primarily enucleated. No eye receiving initial OAC was
enucleated. There was a single secondary enucleation in an eye initially
treatedwith focal therapywith anterior chamber recurrence. The 3-year
Kaplan-Meier estimates for overall ocular, secondary ocular (survival
after treatment for recurrence), progression-free, and recurrent event–
free survival were 91.3% [95% confidence interval(CI) 83.4-95.5],
98.7%(95%CI 91.3-99.8), 91.5%(95%CI 83.0-95.8), and 78.9%(95%CI
68.2-86.3), respectively.Overall and secondary ocular survivals were
100% for International Classification of Retinoblastoma (ICRB) groups
A-C. Overall ocular survival was 91.5% (95% CI 70-97.8) for ICRB
group D and 71.4% (95% CI 47.1-79.4) for group E. Secondary ocular
survival was 95.4% (95% CI 71.8-99.3) for ICRB group D and 100%
for group E. There were no treatment-related deaths, three patients
developed trilateral retinoblastoma (one died), and one patient (who did
not receive OAC) developed metastatic disease and is in remission at
32-month follow-up.

Conclusions: The majority (89%) of bilateral retinoblastoma patients in the current

era and at this center were treated with OAC. This has resulted in
saving a historic number of eyes. A quarter of eyes developed recurrent
disease (defined as recurrent disease requiring any treatment including
focal), themajority ofwhich occurred in the firstyear after treatment, and
all but one was saved. There has been no compromise in patient
survival.

Point of .Historically, bilateral retinoblastoma was treated with bilateral

Learning enucleation, rendering the patient blind and severely impacting quality
of life. In 1936, in an effort to improve vision and quality of life

Nivolumab and Ipilimumab in the Treatment of

Metastatic Uveal Melanoma: A Single-Center Experience

Purpose To assess the clinical outcome of patients with MUM treated with a
combination of checkpoint inhibitors

Methods This was a retrospective case series of 8 patients with MUM managed
at the University of Cincinnati between January 2015 and January 2018.
The immune-related Response Evaluation Criteria in Solid Tumors
(irRECIST) 1.1 criteria were used for patient evaluation, and magnetic
resonance imaging was used for evaluation at treatment checkpoints.

Main Outcome to report the clinical outcome and toxicity associated with this treatment
Measures approach

Results The series included eight patients, six men and two women, with MUM.
Their median age at MUM diagnosis was 69 (range, 55–77) years. All
patients were treated with ipilimumab and nivolumab combination
along with transarterial chemoembolization (TACE), followed by
nivolumab maintenance and monthly TACE procedures. The majority
of patients had a partial response or stable disease. Two of the patients
had partial response, while four others had stable disease. Two other
patients experienced disease progression

Conclusions: We report the outcomes of eight patients with MUM treated with the
combination of ipilimumab and nivolumab. We report the clinical
outcome and toxicity associated with this treatment approach. Further
studies are warranted to explore immunotherapy in MUM. These
findings support the consideration of immunotherapy in MUM.

Point of MUM is associated with a poor prognosis with no current standard of

Learning care. There is an urgent need for new strategies for patients with MUM
as no therapy has succeeded in improving the OS. Given the
development of molecular profiling techniques and the availability of
additional immunotherapeutic agents, chemotherapeutic agents, and
target therapies, dedicated management strategies and guidelines should
be feasible. Immunotherapy in MUM remains an area of active
exploration.

Conjunctival Melanoma in Chinese Patients: Local

Recurrence, Metastasis, Mortality, and Comparisons With
Caucasian Patients

Purpose To evaluate the prognosis in Chinese patients with conjunctival

melanoma and determine its predictors. Further, to explore the racial
differences in clinical characteristics and outcomes between Chinese and
Caucasian patients.

Methods This cohort study included 57 eyes of 57 consecutive patients with

pathologically verified conjunctival melanoma between 1996 and 2016.
Medical records were reviewed for factors associated with the local
 recurrence, metastasis, and tumor-related mortality. All eligible patients
were followed up for these three outcome measures. The demographic
data, clinical characteristics, and outcomes were compared between
Chinese and Caucasian patients.

Main Outcome prognostic factors for conjunctival melanoma in Chinese patients, and
Measures compare, in detail, the clinical characteristics and outcomes between
Chinese patients and their Caucasian counterparts, to partially elucidate
the reasons for the racial differences in prognoses. 

Results The mean follow-up period was 52.2 ± 49.4 months. Among the total 57
patients, 29 (51%) patients experienced local recurrence. The 1-, 5-, and
10-year recurrence rate was 31.0%, 59.7%, and 66.4%, respectively.
Treatment complications detected in the follow-up included dry eye (32,
56.1%), irregular eyelid margin (25, 43.9%), eyelid retraction (18,
31.6%), blepharoptosis (9, 15.8%), mixed pigmentation of the tarsus
reconstructed by mucosal membrane graft, corneal opacities (6, 10.5%),
and symblepharon (2, 3.5%). Twenty (35%) patients developed
metastasis. The 1-, 5-, and 10-year metastasis rate was 16.7%, 38.7%,
and 50.9%, respectively. Fourteen (25%) patients died of conjunctival
melanoma, with a median survival time of 24 months. The 1-, 5-, and 10-
year tumor-related mortality was 3.8%, 30.5%, and 37.4%, respectively.
Tumor hemorrhage is an independent risk factor for tumor-related death
(hazard ratio [HR]: 18.81, P = 0.01) and metastasis (HR: 4.57, P = 0.02).
Significant differences were noted between Chinese and Caucasians
patients from America, Germany, and England in demographics, clinical
characteristics, and outcomes. Compared to Caucasians, Chinese
patients tended to have more male cases (P < 0.01) and to be younger
(P = 0.03). At initial presentation, more Chinese patients had de novo
tumor origin (P < 0.01), epithelioid cell type (P < 0.01), nonbulbar tumor
location (P < 0.01), greater basal diameter (P = 0.04), multifocal tumor
(P < 0.01), feeder vessels (P < 0.01), eyelid (P < 0.01) and orbit
involvement (P < 0.01), and advanced T stages (P < 0.01). Over a similar
follow-up period with Caucasians patients (52.2 vs. 52 months, P = 0.97),
a significantly larger proportion of Chinese patients exhibited eyelid
invasion (P = 0.04) and orbital invasion (P < 0.01) at follow-up, local
recurrence (P < 0.01), metastasis (P < 0.01), and tumor-related death
(P < 0.01).

Conclusions: Conjunctival melanoma is a rare malignancy with great potential for

mortality in Chinese. Special attention should be paid to patients with
tumor hemorrhage. Compared to Caucasians, Chinese patients exhibit
more aggressive clinical signs with compromised prognosis

Point of Learning Though melanoma is less common in Asians than in Caucasians, it is

often associated with increased morbidity and mortality in people of
color
 Efficacy of Autologous Serum in Fixing Conjunctival Autografts of
Various Sizes in Different Types and Grades of Pterygium

Purpose To evaluate the efficacy of autologous serum in fixing conjunctival autografts

of various sizes in different grades and types of pterygium and to determine
the largest successfully secured graft size.

Methods this prospective interventional study comprised 151 eyes of 151 patients
belonging to age group of 21 to 64 years with different grades and types of
primary and recurrent pterygium that underwent excision with inferior
conjunctivo - limbal autograft secured with autologous serum. The autografts
were measured with calipers and were grouped by size into three categories:
Group A, small (5 × 5 mm); Group B, medium (5–7 × 5 mm); and Group C,
large (>7 × 5 mm). The adhesive fixation power of autologous serum for the
various conjunctival autograft sizes was determined for each group using the
following criteria: graft stability, cosmetic appearance and complications in
the immediate (first week) and two-months postoperative follow-up visits.
Descriptive statistical analysis was used to calculate the percentage frequency
of the variables.

Main Outcome The presenting complaints of patients were visual impairment, chronic
Measures irritation, recurrent inflammation of the pterygium and unsightly looks.
Cosmesis was a concern with most of the patients, followed by chronic
irritation, visual impairment and recurrent inflammation. In several patients,
there was more than one presenting complaint

Results The groups A, B, and C included 48%, 22%, and 30% of the autografts,
respectively. Overall, 93.34% of the grafts were stable with good cosmetic
appearance. However, subconjunctival hemorrhage (36%), graft edema (36%)
and graft retraction (13.5%) were the most common complications. The
largest successfully fixed graft was 14 × 5 mm in size

Conclusions: Autologous serum is efficient in securing conjunctival autografts of various

sizes with minimal complications and satisfactory results, including good
cosmesis

Point of nadequate graft fixation. Autologous serum forms a fibrin clot which adheres
Learning the conjunctivo-limbal autograft to the bare sclera. As this is the patient’s
serum and we are not using any foreign material, there is nothing to promote
inflammation, and there is no issue of market scarcity [Figure 5]. Without
inflammation, most of the suture and glue related complications are
eliminated, and the subsequent chance of recurrence is lowered. Also, this
method does not incur the additional cost of suture or glue. With all these
advantages, we felt the need to evaluate the unprecedented benefits of
autologous serum, for various kinds of pterygium. Therefore, we studied the
efficacy of this novel technique in 151 eyes with different sizes, sites, grades
and types of pterygium.
 Super-Thick Amniotic Membrane Graft for Ocular
Surface Reconstruction

Purpose The purpose of this study was to evaluate super-thick amniotic

membrane grafts (ST-AMGs) for ocular surface reconstruction.

Methods This was a single-center study of clinical practice that included select
patients with typically large ocular surface abnormalities that required
reconstruction. The intervention studied was surgical insertion of a ST-
AMG for reconstruction or repair of the ocular surface.
Main Outcome intraoperative handling, graft position at 1 week post implantation, graft
Measures dissolution at 3 weeks, epithelialization of the ocular surface and
symblepharon.

Results Eleven ST-AMGs were implanted after resection with cryotherapy: 5

conjunctival melanoma, 4 squamous cell carcinoma, 1 sebaceous
carcinoma, and 1 atypical pterygium. In addition, 1 was implanted for
scleral necrosis. ST-AMGs were up to nine times thicker than standard
amniotic grafts and were therefore amenable to both running and
interrupted 7-0 Vicryl sutures without cheese-wiring. All cases had a
wellpositioned ST-AMG at 1 week and 75% (n [ 9) had partial graft
dissolution at 3 weeks. Complete epithelialization without wound
dehiscence was noted in all cases. However, secondary (after additional
tumor treatment) symblepharon formed in 16.7% (n [ 2). In all cases,
the mean visual acuity and intraocular pressures remained unchanged
during conjunctival reconstruction and subsequent secondary
treatments. Post epithelialization adjuvant topical chemotherapy was
given to extend treatment margins and treat presumed occult disease in
50% (n [ 6). At mean follow-up of 25.5 months (median 10, range 3-
90), 10 cases (83.3%) showed complete local tumor control, 1 showed
revascularization of the scleral melt, and 1 required orbital exenteration.

Conclusions: ST-AMGs were easy to suture and relatively persistent.

Epithelialization of the ocular surface without primary symblepharon
formation was noted. ST-AMGs should be considered an alternative for
ocular surface reconstruction.

Point of Amniotic membrane grafts (AMGs) promote epithelialization by acting

Learning as a basement membrane and facilitating conjunctival cell migration.
 ST-AMGs demonstrated excellent intraoperative handling, suturability,
and persistence to enable epithelialization of the ocular surface.
This technique offers several advantages over the use of conventional
thickness single and multilayer AMG. Firstly, (z0.5–0.9 mm) ST-AMG
was easier to suture and handle and did not suffer a tear, cheese-wiring,
or dehiscence. It has been our experience that conventional (z0.1 mm)
AMGs are smaller, less durable, and more difficult to sew into place

Reconstruction of the eyelid and periocular region: Our

experience

Purpose To use periocular flaps for defects involving different zones of eyelid.

Methods This study was conducted from 2015 to 2017. Twenty four patients with
lid defects were managed by cheek rotation and advancement flap(8),
Limberg flap(5), forehead flap(5), Mustarde’s lid switch flap (3),
primary closure(1), SSG(2). Thirteen of our patients suffered from
carcinoma, BCC(9) and SCC(4), patients with benign lesions had
congenital melanocytic nevi(3), vascular malformation(2), congenital
coloboma(3), cleft lower eyelid (1) and post traumatic eyelid defect(2).
Eleven patients had full thickness defects and the rest had defect
involving the anterior lamella.

Main Outcome adequate coverage and uneventful healing.

Measures
Results Cheek rotation and advancement flap gave good results for anterior
lamella, full thickness defect of zone II and adjoining periocular region
with inconspicuous scar but ectropion in 2 cases. Limberg flap was used
for defect involving lateral part of upper, lower eyelid and canthal
region. In one case wound dehiscence occurred. Forehead flap gave
linear scar. Mustarde’s lid switch flap was an ideal flap giving minimal
donor site morbidity. All flaps survived with adequate coverage and
uneventful healing.

Conclusions: Periocular flaps are reliable, versatile flaps for reconstruction of all five
zones of eyelid with good donor scar, colour and contour match

Point of Various types of flaps can be used depending on the location, nature,
Learning and size of the defect. Reconstruction with local flaps has the following
advantages: • Excellent tissue match • Minimal donor-site deformity •
Reconstruction of anterior and posterior lamella in eyelid switch
procedure • Simultaneous reconstruction of canthal and eyelid defects.
Reconstruction with regional flaps has several disadvantages as follows:
 • Poorly matched flap skin in color, texture, and thickness •
Compromised eyelid function • Considerable discomfort to patient due
to immobilization • Scar and deformity at the donor site.

Free Flaps Reconstruction after Orbital Exenteration: A

Single Centre Case Series

Purpose to report a single centre series of free flap reconstruction, which adds to
the literature base on flap choice and potential complications

Methods A retrospective single centre consecutive case series of twenty patients

who has an orbital exenteration and free flap reconstruction.

Main Outcome Flap success rates, cosmetic outcome

Measures
,

Results The surgical indication was malignant tumour with orbital involvement
in all 20 cases. The rectus abdominis flap was most commonly used
(10/20, 50%). Anterolateral thigh and radial and ulnar forearm were
also used. Flap failure occurred in 1/20 (5%) of cases. Flap necrosis (1
case), flap infection (1 case) and haematoma (3 cases) all required
intervention but the flap survived. At last follow up (mean 57 months
follow up) 8/20 (40%) patients were alive.

Conclusions: Free flaps are an effective way of reconstructing exenteration defects.

They have a low likelihood of failure and relatively quick recovery
time.

Point of Free flaps are a safe and reliable method of repairing the large defect
Learning created by orbital exenteration. Complete flap failure rates are low and
minor complication rates are within an acceptable range and have little
to no impact on the convalescence time. This single centre series has
 found that although minor complications do occur, overall flap failure
rates and flap morbidity are low. Furthermore the recovery time is
significantly faster and less arduous than allowing the defect to heal by
secondary intention

Updates in Ocular Surface Tumor Diagnostics

Purpose To evaluate technologies and techniques available for the diagnosis of

ocular surface tumors.

Methods A review of the literature from 1947 to 2017, through the PubMed
Database, was conducted in order to evaluate current diagnostic
methods for ocular surface tumors.

Main Outcome Differentiating between benign and malignant lesions, as well as

Measures between these three malignant conditions.
various modalities available for the diagnosis of conjunctival tumors
and in particular for these three most common malignant tumors.

Results Ocular surface squamous neoplasia, conjunctival melanoma, and

conjunctival lymphoma are the three most common ocular surface
malignancies. Technologies available to assist with diagnosis of these
conditions, in addition to full thickness biopsy, include vital dyes,
aspiration and impression cytology, in vivo confocal microscopy,
ultrasound biomicroscopy, genetic testing, and anterior segment optical
coherence tomography.

Conclusions: Histology remains the gold standard for diagnosis for all 3 of these
malignancies. However, multiple diagnostic techniques are available to
assist in making preliminary and early diagnoses, in differentiating
 between similar-appearing lesions, and in some cases, avoiding biopsy
prior to initiating treatment. As imaging and technology continue to
evolve, these adjunctive techniques will likely continue to play a greater
role in clinical practice.

Point of Ocular surface tumors represent a range of conditions, from benign to

Learning malignant lesions. They originate from a variety of cell types, forming
epithelial, melanocytic, lymphoid, leukemic, fibrous, lipomatous, and
other lesions. The most common malignant tumors of the cornea and
conjunctiva are ocular surface squamous neoplasia (OSSN),
conjunctival melanoma (CM), and conjunctival lymphoma (CL).
Ocular surface squamous neoplasia, conjunctival melanoma, and
conjunctival lymphoma are the most common malignant tumors of the
ocular surface. Each has a classic clinical appearance, but may also
present in a subtle or atypical fashion, thus requiring more than slit
lamp examination for diagnosis. The gold standard for diagnosis of
each of these lesions remains histology. However, numerous modalities
including cytology, IVCM, AS-OCT, and UBM can assist with prompt
diagnosis. Understanding the genetics of these tumors is also important,
as it improves the development of targeted therapies. As technology
continues to improve, we will likely see a host of new diagnostic
modalities in the future and an expansion of their use for ocular surface
pathologies.

Uveal Metastasis: Clinical Features and Survival

Outcome of 2214 Tumors in 1111 Patients Based on
Primary Tumor Origin

Purpose The purpose of this study is to evaluate patients with uveal metastasis based
on primary tumor site

Methods Retrospective analysis from Wills Eye Hospital, Philadelphia, PA,

USA, for uveal metastasis clinical features and outcomes based on the
primary tumor site.

Main Outcome clinical features and management, and survival outcome

Measures
Results There were 2214 uveal metastases diagnosed in 1111 consecutive
patients. The demographics included mean age of 60 years (median 61
years), Caucasian race (88%), and female gender (64%). The tumor was
unilateral (82%) and primary site was established before uveal
metastasis (67%). The primary tumor originated in the breast (37%),
lung (26%), kidney (4%), gastrointestinal (GI) tract (4%), cutaneous
melanoma (2%), lung carcinoid (2%), prostate (2%), thyroid (1%),
pancreas (1%), other sites (3%), and unknown (16%). Comparative
 analysis of the 5 most common primary sites (breast, lung, kidney, GI
tract, and cutaneous melanoma), revealed metastasis at mean age (57,
62, 66, 61, 59 years), as unilateral tumor (74%, 86%, 85%, 93%, 85%),
with mean number of metastasis/eye (1.9, 1.7, 1.0, 1.1, 2.0), and in
females (99%, 46%, 26%, 25%, 30%). Choroidal metastases measured
mean base (9.3, 10.2, 9.1, 11.0, 7.3 mm), mean thickness (2.4, 3.6, 4.4,
4.0, 2.9 mm), and demonstrated predominant color yellow (94%, 91%,
56%, 97%, 36%). Of the 769 patients with documented follow-up,
mean patient survival was poor (22.2, 11.5, 8.6, 12.4, 11.4 months) and
Kaplan–Meier analysis revealed 3-year survival (33%, 19%, 0%, 14%,
21%) and 5-year survival (24%, 13%, 0%, 14%, 21%). The worst
survival was found in patients with pancreatic metastasis (mean 4.2
months) and best survival with lung carcinoid (92% at 5 years).

Conclusions: In a tertiary referral service, uveal metastasis originates from cancer in

the breast, lung, kidney, GI tract, cutaneous melanoma, or others.
Overall prognosis is poor with 5-year survival at 23% and worst
survival with pancreatic metastasis whereas best survival with lung
carcinoid metastasis.

Point of The uveal tract is the most common ophthalmic site for hematogenously
Learning dissemination of metastatic tumors from remote sites, predominantly
related to the luxurious blood flow within the choroidal tissue. Less
common ophthalmic sites for hematogenous metastasis include the
orbit, eyelid, conjunctiva, retina, and vitreous.

Screening Children at Risk for Retinoblastoma

Consensus Report from the American Association
of Ophthalmic Oncologists and Pathologists
Purpose To provide a set of surveillance guidelines for children at risk for development
of retinoblastoma.

Methods A group of members of the American Association of Ophthalmic Oncologists

and Pathologists (AAOOP) with support of the American Association for
Pediatric Ophthalmology and Strabismus and the American Academy of
Pediatrics (AAP) was convened. The panel included representative ophthalmic
oncologists, pathologists, and geneticists from retinoblastoma referral centers
located in various geographic regions who met and discussed screening
approaches for retinoblastoma. A patient “at risk” was defined as a person
with a family history of retinoblastoma in a parent, sibling, or first- or second-
degree relative.

Main Outcome Screening recommendations for children at risk for retinoblastoma

Measures
Results Consensus statement from the panel: (1) Dedicated ophthalmic screening is
recommended for all children at risk for retinoblastoma above the population
risk. (2) Frequency of examinations is adjusted on the basis of expected risk
for RB1 mutation. (3) Genetic counseling and testing clarify the risk for
retinoblastoma in children with a family history of the disease. (4)
Examination schedules are stratified on the basis of high-, intermediate-, and
low-risk children. (5) Children at high risk for retinoblastoma require more
frequent screening, which may preferentially be examinations under
anesthesia.

Conclusions: Risk stratification including genetic testing and counseling serves as the basis
for screening of children at elevated risk for development of retinoblastoma

Point of Early detection of retinoblastoma is critical to achieving the best outcomes for
Learning vision and survival.
Systematic screening of children at elevated risk because of family history of
retinoblastoma has dual purposes: (1) to provide a method for detecting
disease at the earliest possible stage and (2) to focus care on the children at
highest risk, while decreasing unnecessary evaluations for children at low or
no risk above that of the general population.
The goal of these screening guidelines is to educate primary care providers
and ophthalmologists and to optimize care by creating a more uniform
approach to care for children with family history of retinoblastoma, ensuring
that children receive timely and appropriate genetic counseling, testing, and
screening for familial retinoblastoma.