Ocular Survival Research Articles

Outcome following initial external beam radiotherapy in patients with Reese-Ellsworth group Vb retinoblastoma.

To describe patient and ocular outcomes following initial treatment with external beam radiotherapy (EBT) in eyes with Reese-Ellsworth group Vb retinoblastoma. Retrospective case series (from January 1, 1979, to February 28, 2002). The Kaplan-Meier method was used to analyze survival (ocular and patient) and incidence (second cancer) data. Two hundred forty-three patients with 1 or more Reese-Ellsworth group Vb eyes were identified. Of 284 group Vb eyes, 63 (22.2%) initially received EBT, vs 172 (60.6%) that were initially enucleated. Of the 63 radiated group Vb eyes, 31 (49.2%) had no further tumor growth, 26 (41.3%) developed a recurrence, and 8 (12.7%) developed a new tumor. Of the 63 radiated group Vb eyes, 33 (52.4%) developed ocular complications. The ocular survival rate of radiated group Vb eyes was 81.4% at 1 year and 53.4% at 10 years. Twenty-eight radiated group Vb eyes survived to the last follow-up with visual acuity information. Thirteen patients developed second cancers, 11 in the field of radiation. The probability of developing a second cancer following initial EBT for group Vb disease in patients with bilateral disease was 29.7% by 10 years after diagnosis. Survival from second cancers in patients with bilateral disease initially receiving EBT for group Vb disease was 93.6% at 5 years and 52.6% at 18(1/4) years. No patient with unilateral disease developed a second cancer. Deaths due to metastatic retinoblastoma were uncommon. To our knowledge, this is the first study focusing exclusively on group Vb eyes treated initially with EBT, most of which were salvaged with vision. Outcome data provided herein are clinically relevant when choosing treatment options for advanced intraocular retinoblastoma.

Visual outcome and ocular survival after sports related ocular trauma in playing golf.

To study eye injuries. More specifically, to study the visual performance and ocular findings in people generating the eye trauma while golfing and to define the main mechanisms of injury. We retrospectively reviewed a case series of seven patients with golf-related eye injuries treated at Austrian hospitals over the last seven years in a multicenter setting. Five men and two women received treatment. The mean age was 46 (range, 29-63), and three of the patients had blunt close globe trrauma and four suffered from a ruptured globe. Following the injuries, the patients' initial visual acuity ranged from no light perception to 20/40. All of the patients recquired surgery, with the resulting visual acuily ranging from moving hands to 20/20. It should be noted that three eyes required enucleation. Visual outcome from surgery is frequently very poor in golf related injuries. This is further complicated by these traumas frequently being accompanied by a high enucleation rate. Among the patients reviewed, it was observed that ruptured globe trauma has a worse prognosis than close blunt trauma. Due to the severe resulting complications of golf-related ocular injuries, we believe eye protection should be considered and emphasized.

Screening for retinoblastoma: presenting signs as prognosticators of patient and ocular survival.

To correlate 3 common presenting signs of retinoblastoma with patient and ocular survival and to assess the efficacy of current pediatric screening practices for retinoblastoma. A retrospective study was conducted of 1831 retinoblastoma patients from our center (1914-June 2000). Patient survival (excluding deaths from other primary neoplasms) and ocular survival (presenting eyes) rates were calculated and analyzed using the Kaplan-Meier method. Leukocoria correlated with excellent patient survival (>86%, 5 years) but poor ocular survival in unilateral (4%, 5 years) and bilateral patients (29%, 5 years). A total of 308 (19%) of 1654 patients presented with strabismus: patient survival was excellent (90%, 5 years), and ocular survival was poor (17%, 5 years) yet better than leukocoria. Patients who had a family history of retinoblastoma and were clinically screened for retinal tumors from birth were diagnosed younger (8 months of age) and earlier (Reese Ellsworth group 1 = 26 [58%] of 45) and had better ocular survival than nonscreened patients with a family history. More patients were initially detected by family/friends (1315 [80%] of 1632) than pediatricians (123 [8%] of 1632) or ophthalmologists (156 [10%] of 1632). Most US children whose retinoblastoma is diagnosed initially present with leukocoria detected by a parent, despite routine pediatric screening for leukocoria via the red reflex test. Initial disease detection at the point of leukocoria or strabismus correlated with high patient survival rates and poor ocular survival rates for the presenting eye. Saving eyes and vision requires disease recognition before leukocoria, as demonstrated by the better ocular salvage rate among patients who had a positive family history and received clinical surveillance via early, routine dilated funduscopic examinations by an ophthalmologist.

Current trends in the treatment of ocular melanoma by radiotherapy.

The Collaborative Ocular Melanoma Study (COMS) has recently confirmed once and for all that it is safe to attempt to preserve an eye with a posterior uveal melanoma by demonstrating no survival advantage of enucleation over plaque radiotherapy. While COMS has been under way, we have set out in London to define the selection criteria for conservative therapy versus enucleation for the various categories of melanoma in terms of size, location within the eye, and presence or absence of retinal detachment. The evolution of this approach has culminated in an overall ocular survival rate of 94% in 597 patients following radiation therapy combined with a mean loss of visual acuity of only 2.4 Snellen lines in the eyes preserved.

(Neonatal) Retinoblastoma in the First Month of Life

To identify patients with retinoblastoma whose conditions were diagnosed at the age of 1 month or younger and to describe their clinical features (including ocular and patient survival) and the development of second nonocular tumors. A retrospective study of 1831 patients. The cumulative incidence of second cancer development was analyzed using the Kaplan-Meier method. Forty-six patients were identified as having a diagnosis of retinoblastoma at the age of 1 month or younger (mean age, 18.5 days). Family history (31 patients [67%]) exceeded leukocoria (6 patients [13%]) as the most common reason for detection. Twenty-six (56%) of the 46 patients were seen with unilateral retinoblastoma, with 22 ultimately developing cancer in the fellow eye. At the initial diagnosis, 81 (85%) of the 95 tumors were detected in zones 1 and 2. Eighty-two (93%) of the 88 subsequent tumors were located in zones 2 and 3. In the 26 patients who had unilateral retinoblastoma, 16 of the initially affected eyes and 21 of the fellow eyes were salvaged. In the 19 (44%) of 20 patients who were seen initially with bilateral retinoblastomas, 31 (82%) of the 38 eyes were salvaged. The mean follow-up was 10.9 years. The incidence of second nonocular cancers reached 54% by 23.7 years for the patients who received radiation therapy, while the incidence was 0% for the patients who did not. Four (8.7%) of the 46 patients developed metastatic disease and died; 3 of these patients had documented metastases in the first month of life (one at birth). The most common manifesting sign of children diagnosed as having retinoblastoma in the first month of life is family history. Eyes with Reese-Ellsworth group I retinoblastomas were the most common. In patients with bilateral and unilateral retinoblastoma, new (subsequent) ocular tumors developed in a centrifugal pattern. Despite an early diagnosis, patients' eyes came to enucleation, and metastatic disease and death occurred from ocular metastases. In patients who received radiation therapy, the probability of developing second nonocular cancer is 54% by 23.7 years; no second cancers developed in patients who did not receive radiation therapy.

Discussion

The experimental design in the accompanying article is a nonrandomized, prospective, single-arm trial involving 20 consecutive patients with multifocal retinoblastoma: 4 unilateral and 16 bilateral. The patients received eight cycles of carboplatin and vincristine without local therapy. Outcome measures are disease progression defined as tumor growth, new tumor formation, or vitreous base seeding; delay of external beam radiotherapy (EBRT); and ocular survival. Bilateral tumors from the same patient are considered as independent observations for tests of statistical significance.

Multiagent chemotherapy as neoadjuvant treatment for multifocal intraocular retinoblastoma

Purpose To evaluate the efficacy of multiagent chemotherapy in the neoadjuvant treatment of retinoblastoma. Design Noncomparative, prospective case series. Participants Twenty consecutive patients with multifocal intraocular retinoblastoma (4 unilateral, 16 bilateral [36 eyes]). Intervention Eight cycles of chemotherapy with carboplatin and vincristine were administered at 3-week intervals over a 6-month period. Supplemental therapy was withheld until disease progression was documented. Main outcome measures Disease progression (defined as tumor growth, vitreous or subretinal seed progression, and new tumor formation), delay of external beam radiotherapy, and ocular survival. Results Thirty-six eyes were treated. Eighteen eyes had Reese-Ellsworth group I–III tumors, and 16 eyes had Reese-Ellsworth group IV–V tumors at diagnosis. Two patients, who had unilateral disease at diagnosis, subsequently had tumors develop in the contralateral eye. Nineteen of 20 patients (95%) completed eight cycles of chemotherapy without disease progression. Three eyes of three different patients were successfully treated with chemotherapy alone. Thirty-three of 36 eyes (92%) progressed after completion of chemotherapy: 15 of the 18 eyes (83.3%) with Reese-Ellsworth group I–III and 16 of 16 eyes (100%) with Reese-Ellsworth group IV–V tumors. Seventeen eyes (52%) had growth of a tumor, whereas 14 eyes (42%) had progressive vitreous seeding, and 2 eyes (6%) had new tumors develop. Fifteen eyes (42%) required external beam radiotherapy. Twenty-nine of 36 (80.5%) eyes were salvaged. The median follow-up after chemotherapy was 19 months (range, 3–42 months). Conclusions Multiagent chemotherapy alone does not ensure a cure for multifocal intraocular retinoblastoma. Supplemental focal therapy is needed to control disease progression.

Equine ulcerative keratomycosis: visual outcome and ocular survival in 39 cases (1987-1996).

The medical records of 39 horses treated for ulcerative keratomycosis over a 10 year period were reviewed. Records were evaluated to determine the medical and/or surgical treatment protocol, visual outcome, globe survival and whether the outcome was influenced by the fungal species isolated. Stromal abscesses and iris prolapses caused by fungi were not included. Twenty of the horses underwent medical treatment only, and 19 horses had combined medical and surgical treatment. Most horses had been treated with topical antibiotics (n = 32) and atropine sulphate (n = 23) prior to referral; topical antifungals had been employed less frequently (n = 14). Fungi were identified by cytology (n = 31), culture (n = 33) and/or surgical histopathology (n = 6). Aspergillus (n = 13) and Fusarium (n = 10) were the most commonly isolated fungi. Miconazole (n = 35) was the most common topical antifungal medication utilised. Median duration of treatment was 48 days (range 31-192 days). Associated bacterial infection (n = 13) was frequently encountered. Visual outcome was favourable in 36/39 (92.3%) eyes. All eyes (20/20) retained vision following medical management only, and 16/19 (84%) retained vision following combined medical and surgical therapy. All medically treated horses (20/20), and 17/19 (89%) of those treated medically and surgically retained their globes. Overall ocular survival was favourable in 37/39 (94.9 %) eyes. Aggressive therapy can result in successful results for equine ulcerative keratomycosis.

Visual Outcome and Ocular Survival in Patients With Retinal Detachments Secondary to Openor Closed-Globe Injuries

A retrospective study was undertaken to establish predictive clinical features for final visual outcome and ocular survival for patients who have sustained traumatic retinal detachments (RDs). The authors reviewed 191 cases of RD following open- or closed-globe trauma. The clinical features that were analyzed included the initial visual acuity, the location of the wound, the mechanism of injury (blunt, sharp, or projectile), and the number of quadrants of RD. The significant predictive factors for good visual outcome (1/200 or better) included an initial visual acuity of hand motions or better, wounds located anterior to the equator, closed-globe injuries, sharp injury in open globes, and three or fewer quadrants of RD. The factors that predicted enucleation included an initial visual acuity of light perception or no light perception, wounds located posterior to the equator, and four quadrants of RD. The significant predictive factors for final visual outcome in patients with traumatic RD were the initial visual acuity, the location of the wound, the mechanism of injury, and the number of quadrants of RD.

Effects of daunomycin implants on filtering surgery outcomes in rabbits

Purpose. To evaluate the effects of a novel daunomycin (DM) implant on intraocular pressure (TOP), bleb survival, and anterior segment complications when administered during filtering surgery on New Zealand White rabbits.Methods. Implants were prepared by covalent coupling of DM to a high molecular weight hyaluronic acid (HA) and fabricated into solid implants containing 250, 65, and 25 μg of DM. Full thickness sclerostomies were performed, and rabbits received no implant (control), placebo implant containing HA, or an implant containing HA-DM conjugate at the time of surgery. Rabbits were then followed for 30 days to assess change in IOP, bleb survival, and anterior segment associated complications.Results. In vitro, the release of DM from the implants was a first order process with a half-life of 51 h. In control rabbits, rabbits receiving placebo implant, and rabbits receiving HA-DM (250 μg) implants, the mean IOPs on day 3 were 11.1 ± 1.6, 10.8 ± 2.7, and 14 ± 0.98 mm of Hg, respectively. On days 5 through 9, IOP in the control and placebo-implanted groups returned to preoperative levels. However, in rabbits receiving 250 μg of conjugated DM, mean IOP on day 7 was reduced from preoperative levels by 11.8 ± 3.2 mm of Hg (P<0.05). This reduction in IOP was significantly different (P<0.05) from both control and placebo implant groups, and IOPs remained at these levels until studies were terminated on day 30. In control and placebo-implanted rabbits, bleb size started decreasing on day 1, and by day 7, no blebs were observed. In rabbits receiving 250 μg HA-DM implants, mean bleb survival time was greater than 30 days. The DM-induced reduction in IOP and enhanced bleb survival was dose-dependent. In rabbits receiving 65 μg of conjugated DM, IOPs were significantly reduced through day 30; however, at times beyond day 19 there was a gradual rise in mean IOP as filtering procedures in individual animals began to fail. Mean bleb survival time was greater than 30 days for implants containing 65 μg of conjugated DM. In rabbits receiving HA-DM implant containing 25 μg of DM, IOPs were not significantly different from preoperative levels beyond day 9, and no significant enhancement in bleb survival was observed in these animals. Comparison of HA-DM conjugated implants to those containing equal doses of free DM demonstrated that the mean IOP change at 30 days were similar; however, there was a reduction in anterior segment complications associated with the use of HA-DM conjugated implants.Conclusions. This study provides evidence that the controlled release of DM when conjugated to HA can significantly improve the success of filtering procedures. The maintenance of ocular hypotension and bleb survival along with the reduction in anterior segment complications supports the idea that HA-DM conjugate will be more efficacious than the use of free DM in improving the success rate of filtering surgery. Curr. Eye Res. 17:844–850, 1998.

Visual outcome and ocular survival following Iris prolapse in the horse: a review of 32 cases

The medical records of 32 horses treated for iris prolapse (IP) during an 8 year period, at the University of Florida Veterinary Medical Teaching Hospital, were reviewed. Iris prolapse was associated with perforated corneal ulcers in 15 horses (47%), ruptured stromal abscesses in 2 horses (6%), and full thickness corneal lacerations in 15 horses (47%). Initial ophthalmic examinations revealed IP with severe iridocyclitis in all eyes and keratomalacia in 8 eyes with corneal ulcers, one with a stromal abscess and 1 with a corneal laceration. Hyphema was present in 7 eyes with corneal lacerations. Thirty horses were managed with combined medical and surgical therapy. Two horses were only treated medically with topically administered antibiotics. Of the 24 perforations surgically repaired, 21 were closed primarily and 13 were then covered with a conjunctival graft. After combined therapy and a minimum of 4 months of follow-up, vision was retained in 6 of the horses (40%) with perforating corneal disease and 5 of the horses (33%) with perforating corneal lacerations. Post operatively, of the 11 (37%) horses blind at discharge, 6 (55%) subsequently developed phthisis bulbi. Enucleations were performed in 4 cases with extensive keratomalacia and/or endophthalmitis, 2 cases with limbal rupture and total hyphema, and one case with a chronic IP. One horse was subjected to euthanasia after 3 surgical treatments failed to stabilise stromal melting. Horses presented with ulcerative keratitis of fewer than 15 days duration, or horses with corneal lacerations less than 15 mm in length, tended to have a favourable visual outcome. Keratomalacia, hyphema, corneal lacerations longer than 15 mm and lacerations extending to, along, or beyond the limbus, adversely influenced visual outcome. Iridectomy did not appear clinically to exacerbate anterior uveitis or adversely affect visual outcome. Ocular survival following combined therapy was 80% (12/15) in horses with corneal lacerations and 67% (10/15) in horses with ulcerative keratitis.

External beam radiation for retinoblastoma: Results, patterns of failure, and a proposal for treatment guidelines

Purpose : To analyze treatment results and patterns of failure following external beam radiation for retinoblastoma and propose treatment guidelines according to specific clinical variables. Methods and Materials : We analyzed 27 patients (34 eyes) with retinoblastoma who received external beam radiation as initial treatment at Hahnemann University Hospital from October 1980 to December 1991 and have been followed for at least 1 year. Of the 34 eyes, 14 were Groups I–II (Reese-Ellsworth classification), 7 were Group III, and 13 were Groups IV–V. Doses ranged from 34.5–49.5 Gy (mean 44.3 Gy, median 45 Gy) in 1.5–2.0 Gy fractions generally delivered through anterior and lateral wedged pair fields. Results : At a mean follow up of 35.2 months (range 12–93 months), local tumor control was obtained in 44% (15 out of 34) of eyes with external beam radiation alone. Salvage therapy (plaque brachytherapy, cryotherapy, and/or photocoagulation) controlled an additional 10 eyes (29.5%), so that overall ocular survival has been 73.5%. Local tumor control with external beam radiotherapy alone was obtained in 78.5% (11 out of 14) of eyes in Groups I–II, but in only 20% (4 out of 20) of eyes in Groups III–V. A total of 67 existing tumors were identified prior to treatment in the 34 treated eyes and local control with external beam radiation alone was obtained in 87% (46 out of 53) of tumors measuring 15 mm or less and in 50% (7 out of 14) of tumors measuring more than 15 mm. When analyzing patterns of failure in the 19 eyes that relapsed, a total of 28 failure sites were identified and consisted of progression of vitreous seeds in seven instances (25% of failure sites) recurrences from previously existing tumors in 10 instances (36% of failure sites) and development of new tumors in previously uninvolved retina in 11 instances (39% of failure sites). Conclusions : 1) We find that external beam radiation to a dose of 45 Gy in fractions of 1.5 to 2.0 Gy provides adequate tumor control in retinoblastoma eyes Groups I–II (Reese-Ellsworth classification) or tumors measuring 15 mm in diameter or less. Eyes in more advanced group staging or containing tumors larger than 15 mm seem to require higher radiation doses. We propose treatment guidelines for external beam radiation of retinoblastoma that specifically take into account the important clinical variables of tumor stage and patient age. 2) External beam radiation does not prevent the appearance of new tumors in clinically uninvolved retina. Therefore, the traditional belief that external beam radiation can treat the retina “prophylactically” should be seriously questioned. Due to this finding and their significant less morbidity, focal treatment modalities (plaque brachytherapy, photocoagulation and/or cryotherapy), when clinically feasible, should be considered the treatment of choice for intraocular retinoblastoma. External beam radiation should be considered only when focal treatment modalities are not clinically indicated.

Visual Outcome and Ocular Survival after Penetrating Trauma: A Clinicopathologic Study

Ocular trauma is a leading cause of blindness in the United States. This study was undertaken to identify clinical and histopathologic factors that predict ocular survival and final visual acuity after penetrating ocular trauma. One hundred seventy-six cases of ruptured globe were reviewed. Factors analyzed included (1) initial visual acuity, (2) wound location, (3) wound length, (4) mechanism of injury (sharp, blunt, or missile), (5) presence of intraocular foreign body, (6) type of ocular wound (perforating versus nonperforating), (7) performance of vitrectomy, and (8) histopathologic features (n = 40). Data were analyzed using univariate and multivariate logistic regression analysis. Predictors of excellent final visual acuity (20/60 or better) were initial visual acuity of 20/200 or better, wound location anterior to the plane of insertion of the four rectus muscles, wound length 10 mm or less, and sharp mechanism of injury. In contrast, predictors of poor vision were initial visual acuity of light perception or no light perception, wounds extending posterior to rectus muscle insertion plane, would length greater than 10 mm, and blunt or missile injury. Vitrectomy did not improve final vision. Factors predicting enucleation were similar to those predicting poor vision; however, vitrectomy decreased the likelihood of enucleation. Histopathologic review showed fibrous ingrowth in 93% of eyes enucleated more than 14 days after injury, and none of those enucleated within 2 weeks. Significant predictive factors of final visual acuity after penetrating trauma include visual acuity, wound location and length, and mechanism of injury. Establishment of predictors of ocular survival and visual function may assist clinicians in selecting salvageable eyes for surgical repair.

Treatment of choroidal melanoma with I-125 plaque

Purposes : To evaluate efficacy of I-125 episcleral plaque therapy in patients with ocular melanoma and determine survival, eventual visual acuity, and complications. Methods and Materials : Between July 1, 1984 and January 1,1991,144 patients with diagnosis of ocular melanoma were treated with high activity I-125 episcleral plaques. Tumor volumes ranged from 14 to 3449 mm 3. Lesion size included small (n = 15; height < 5 mm, and/or largest basal diameter of 8–16 mm) and large (n = 45; height > 8 mm, and/or largest basal diameter > 16 mm). Apical doses ranged from 74.25 to 83.66 Gy with scleral doses ranging from 41 and 160 Gy. Follow-up has ranged from 25 to 90 months (Med = 46 months). Results : Ocular survival was noted in 130/144. Reasons for enucleation included progressive tumor growth (n = 4), extrascleral extension (n = 4), or blind/painful eye (n = 6), 94 patient developed complications which included cataract (n = 43), optic neuropathy (n = 12), neovascular glaucoma (n = 8) and retinopathies (n = 31). Visual acuity testing pre-episcleral plaque therapy revealed 102 patients with 20/200 vision; at last follow-up 59 patients demonstrated visual acuity testing of 20/200 or better. Conclusion : The use of episcleral I-125 plaque therapy allows for safe and effective therapy in patients with ocular melanoma of various size depending on location and probable visual acuity outcome. A total apical dose of 75 Gy given at 60–65 cGy/hour provides durable local control with acceptable complication rates.

Malignant Melanoma: Analysis of an Autopsy Population

This report analyzes 92 malignant melanoma cases from a series of 12,383 consecutive autopsies. There were 12 cases of primary ocular malignant melanoma, 76 cases of primary nonocular malignant melanoma, and 4 cases of unknown primary site. Subjects with malignant melanoma were characterized by age, sex, and race; metastatic disease patterns as well as survival periods were analyzed. In the 12 ocular malignant melanoma cases, tumor size, cell type, and survival were considered. Discussion is concerned with the distribution of primary tumor site, the location of metastatic lesions secondary to malignant melanoma, and survival in cases with primary ocular malignant melanoma.

Influence of protein deficiency and sex on the development of ocular lesions and survival time of the vitamin A deficient rat.

Influence of protein deficiency and sex on the development of ocular lesions and survival time of the vitamin A deficient rat.