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Eagle Jr. R.C.,Wills Eye Institute | Eagle Jr. R.C.,Thomas Jefferson University
Eye (Basingstoke) | Year: 2013

Primary cancers of the eye are rare. These include uveal melanoma, a tumor that preferentially affects the choroid of light-eyed, fair-skinned Europeans, and the pediatric retinal neoplasm retinoblastoma, which is slightly more common worldwide. Uveal melanoma kills about half of affected patients. Most succumb to hepatic metastases, which are unresponsive to current therapy. Factors indicative of poor prognosis include tumor size, ciliary body involvement, epithelioid cells, extraocular extension, lymphocytic and melanophagic infiltration, mitotic activity, vascular mimicry patterns, and most importantly, the detection of monosomy 3 and class 2 gene expression profile in tumor cells using special tests. Most retinoblastomas are caused by sporadic somatic mutations in the RB1 gene, but about one-third arise in infants with germline mutations. The latter tend to develop earlier, are often bilateral and are transmissible to offspring as an autosomal dominant trait. Retinoblastoma displays varying degrees of differentiation including Homer Wright and Flexner-Wintersteiner rosettes and photoreceptor differentiation (fleurettes). Rosettes are more common in eyes enucleated from very young infants. Tumors composed entirely of fleurettes (retinoma/retinocytoma) are thought to be retinoblastoma precursors, and like retinoblastoma, harbor mutations in both copies of the RB1 gene. Retinoblastoma is a major cancer treatment success story in developed countries where most deaths are caused by secondary tumors in germline mutation carriers. High-risk histopathological features that are an indication for adjuvant chemotherapy include massive uveal invasion and retrolaminar optic nerve invasion. Eye-sparing therapies including brachyradiotherapy and systemic and intra-arterial chemotherapy have reduced the number of eyes with retinoblastoma requiring enucleation in recent years. © 2013 Macmillan Publishers Limited All rights reserved.

Stalmans P.,University Ziekenhuizen Leuven | Benz M.S.,Retina Consultants of Houston | Gandorfer A.,Ludwig Maximilians University of Munich | Kampik A.,Ludwig Maximilians University of Munich | And 3 more authors.
New England Journal of Medicine | Year: 2012

BACKGROUND: Vitreomacular adhesion can lead to pathologic traction and macular hole. The standard treatment for severe, symptomatic vitreomacular adhesion is vitrectomy. Ocriplasmin is a recombinant protease with activity against fibronectin and laminin, components of the vitreoretinal interface. METHODS: We conducted two multicenter, randomized, double-blind, phase 3 clinical trials to compare a single intravitreal injection of ocriplasmin (125 μg) with a placebo injection in patients with symptomatic vitreomacular adhesion. The primary end point was resolution of vitreomacular adhesion at day 28. Secondary end points were total posterior vitreous detachment and nonsurgical closure of a macular hole at 28 days, avoidance of vitrectomy, and change in best-corrected visual acuity. RESULTS: Overall, 652 eyes were treated: 464 with ocriplasmin and 188 with placebo. Vitreomacular adhesion resolved in 26.5% of ocriplasmin-injected eyes and in 10.1% of placebo-injected eyes (P<0.001). Total posterior vitreous detachment was more prevalent among the eyes treated with ocriplasmin than among those injected with placebo (13.4% vs. 3.7%, P<0.001). Nonsurgical closure of macular holes was achieved in 40.6% of ocriplasmin-injected eyes, as compared with 10.6% of placebo-injected eyes (P<0.001). The best-corrected visual acuity was more likely to improve by a gain of at least three lines on the eye chart with ocriplasmin than with placebo. Ocular adverse events (e.g., vitreous floaters, photopsia, or injection-related eye pain - all self-reported - or conjunctival hemorrhage) occurred in 68.4% of ocriplasmin-injected eyes and in 53.5% of placebo-injected eyes (P<0.001), and the incidence of serious ocular adverse events was similar in the two groups (P = 0.26). CONCLUSIONS: Intravitreal injection of the vitreolytic agent ocriplasmin resolved vitreomacular traction and closed macular holes in significantly more patients than did injection of placebo and was associated with a higher incidence of ocular adverse events, which were mainly transient. (Funded by ThromboGenics; ClinicalTrials.gov numbers, NCT00781859 and NCT00798317.) Copyright © 2012 Massachusetts Medical Society.

Gunton K.B.,Wills Eye Institute
Pediatrics | Year: 2013

Amblyopia is the most common cause of preventable visual loss in children. This article reviews treatment options, durations, and efficacy in randomized multicentered trials conducted by the Pediatric Eye Disease and Investigator Group in the last decade. Parents and patients should be counseled that many forms of treatment are efficacious, allowing the option of choice of best-tolerated treatment method. Compliance is key to successful treatment. The course of treatment is likely at least 6-12 months, with yearly follow-up suggested once amblyopia has been treated to monitor for regression. Copyright © 2013 by the American Academy of Pediatrics.

Baskin D.E.,Wills Eye Institute
Current Opinion in Ophthalmology | Year: 2010

Purpose of Review: Because optical coherence tomography (OCT) has developed quite rapidly in recent years, the purpose of this review is to synthesize much of the recent literature on the use of OCT in the diagnosis and management of diabetic macular edema (DME). Recent Findings: OCT has become increasingly utilized in clinical management and in research protocols in the approach to DME. Spectral domain OCT has given clinicians and researchers an even greater pathophysiologic understanding of DME. Summary: OCT has now added another quantitative dimension in the assessment of DME and could lead to better visual outcomes via earlier detection and more targeted therapeutic approaches. Arguably, OCT is the single most important diagnostic and prognostic tool in the management of DME. © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Alley C.L.,Wills Eye Institute
Current Opinion in Ophthalmology | Year: 2013

PURPOSE OF REVIEW: To discuss the current preschool vision screening (PVS) guidelines and review some of the newest vision screening techniques. The different vision screening practices and barriers to screening are discussed. RECENT FINDINGS: Vision screening guidelines, which have been developed in response to the advances in technology and increased understanding of the developing visual system, have been recently updated by some of the major medical organizations that endorse vision screening. With advances in vision screening technology, there is a growing trend for screening at younger ages. SUMMARY: PVS has been widely endorsed by various medical organizations as an effective way to detect preventable and treatable vision problems of childhood. Although PVS is widely recommended, actual screening rates remain low. There are several real and perceived barriers to screening which often prevents successful screening programs. Current vision screening guidelines take into account the recent advances in technology. With the development of new devices, vision screening can effectively be performed at younger ages. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Schnall B.M.,Wills Eye Institute
Current Opinion in Ophthalmology | Year: 2013

PURPOSE OF REVIEW: Review the current management for pediatric nasolacrimal duct obstruction and congenital dacryocele. RECENT FINDINGS: Early probing in the office, and probing beyond 1 year of age in a facility with general anesthesia are equally effective. Congenital nasolacrimal duct obstruction is associated with anisometropic amblyopia. Infants with unilateral dacryocele are at risk for developing a dacryocele on the unaffected side. SUMMARY: The decision to probe early in the office or continue medical management and probe beyond a year of age in a facility with a general anesthetic is at the discretion of the ophthalmologist. Failed probings should be treated in a facility under general anesthesia with a balloon catheter or intubation. Children with congenital nasolacrimal duct obstruction need to be followed to make certain they do not develop anisometropic amblyopia. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Rapuano C.J.,Wills Eye Institute
Current Opinion in Ophthalmology | Year: 2010

PURPOSE OF REVIEW: To discuss the primary types of lesions most amenable to excimer laser phototherapeutic keratectomy (PTK) and the specific techniques to best treat each of these disorders. RECENT FINDINGS: Elevated and anterior stromal lesions respond best to PTK. PTK can also be used to effectively treat recurrent erosions. Smoothing agents and intraoperative mitomycin C can be helpful for certain disorders. SUMMARY: The preoperative evaluation is very important in order to establish whether the eye is a good candidate for excimer laser PTK. Careful slit lamp evaluation and ancillary testing can not only determine how good a candidate they are but just as importantly, the best surgical approach. Surgeons and patients need to understand the limitations of PTK for proper informed consent. PTK is a minimally invasive procedure that is often successful in delaying or avoiding more aggressive corneal surgeries. © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Witkin A.J.,Wills Eye Institute | Brown G.C.,Wills Eye Institute
Current Opinion in Ophthalmology | Year: 2011

Purpose of Review: Treatment for diabetic macular edema (DME) is continuously evolving. While focal laser photocoagulation remains the standard of care, a new wave of studies is emerging that shows benefit of adjunctive therapy for DME. Recent Findings: With the advent of intravitreal corticosteroid and antivascular endothelial growth factor medications, new interest in the treatment of DME has been piqued, and a number of clinical trials have been designed to evaluate these therapies. Summary: The goal of this article is to briefly summarize recent data from these trials, in order to aid the clinician in evaluating the most appropriate and up-to-date nonsurgical management options in treating diabetic macular edema. The key points are to summarize the most recent peer-reviewed literature regarding therapy for diabetic macular edema. Particular attention is paid to focal laser, corticosteroid, and anti-VEGF therapies. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Chiang A.,Wills Eye Institute | Regillo C.D.,Wills Eye Institute
Current Opinion in Ophthalmology | Year: 2011

Purpose of Review: This report reviews the current treatment strategies and ongoing clinical trials in the treatment of neovascular age-related macular degeneration (AMD). Recent Findings: The functional and anatomic outcomes achieved in the pivotal ranibizumab trials with monthly injections set the standard for comparison. Since then, various modified dosing regimens with the aim of lessening the treatment burden associated with monthly injections have been investigated. Combination therapy incorporating photodynamic therapy and antivascular endothelial growth factor (anti-VEGF) therapy may represent an alternative treatment approach and randomized multicenter clinical trials are ongoing. In addition, new pharmacologic agents like VEGF Trap-Eye are being developed and investigated; preliminary 1-year results with VEGF Trap-Eye are encouraging. Summary: Ranibizumab or bevacizumab monotherapy remains the preferred therapy in the management of neovascular AMD at the present time. Ongoing clinical trials will help determine the efficacy of ranibizumab relative to bevacizumab, evaluate the long-term efficacy and safety of combination therapy modalities, and assess the role of new pharmacologic agents. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Murchison A.P.,Wills Eye Institute | Bilyk J.R.,Wills Eye Institute
Ophthalmology | Year: 2012

Objective: Temporal artery biopsy (TAB), performed for the diagnosis of giant cell arteritis, has a low reported rate of complications. One complication is damage to the facial nerve branches, which can result in brow ptosis and/or orbicularis oculi weakness. However, the incidence of facial nerve damage after TAB is unknown. Design: Prospective, institutional review board-approved study of all TABs performed by 2 surgeons over a 17-month period. Participants: Seventy patients undergoing 77 TABs. Methods: Demographic data, including age, gender, and race/ethnicity, were collected for all patients. Frontalis and orbicularis oculi muscle function were evaluated pre- and postoperatively in all patients. The use of blood thinners, location of the incision, length of incision and biopsy, biopsy results, and procedure difficulty were recorded. Incidence of postoperative facial nerve damage, other complications, and rates of facial nerve recovery were evaluated. Analysis of variables was performed for any potential correlation with facial nerve damage. Main Outcome Measures: Incidence of facial nerve damage. Results: Analysis included 75 biopsies performed in 68 patients. The majority of the patients were white (75.0%) and female (67.6%). The mean age was 72.6 years (range, 51-96). Postoperative facial nerve damage was found in 12 patients (16.0%) and 58.3% of these fully resolved at an average of 4.43 months (range, 1-6). Two patients (2.7%) had postoperative infections. There was no correlation with facial nerve damage and use of blood thinners, biopsy result, surgeon, procedure difficulty, incision length, or specimen length. The distance from the incision to both the orbital rim and the brow was significant: Incisions farther from the orbital rim and brow were less likely to have postoperative facial nerve damage. Conclusions: There is a 16.0% incidence of postoperative facial nerve damage with TABs, which recovers fully in over half of patients. Incisions closer to the orbital rim and brow were more likely to have postoperative facial nerve dysfunction. Incisions >35 mm from both the orbital rim and brow or above the brow were less likely to have postoperative brow ptosis. Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article. © 2012 American Academy of Ophthalmology.

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