Excellent long-term local control (10y 94% PBRT and 99% Helium cohorts) and eye preservation is seen in UM patients aged ≤ 45 treated with proton and helium ion radiation. Specific clinical and dose-volume parameters may be utilized to assess patient prognosis.

Proton beam treatment for ocular tumors has been well established with dedicated eye beamlines internationally. Given the emergence of universal, high-energy, non-fixed beamline options, we share key practices for uveal melanoma (UM) treatment planning and delivery. We focus particularly on practical clinical and physics concepts to minimize important ocular side effects. Practices were studied from two well-established international dedicated proton ocular institutions with very longstanding facilities, both using fixed, low-energy, ocular beamlines to treat eye tumors only. Since the 1970s and 1980s until now, the respective cyclotrons produce 67.5 and 60.0 MeV proton beams (range up to 3 cm). In total 5927 ocular patients, 93% with UM, have been treated. Standard UM dose is 56 Gray Equivalent (GyE) and 57.2 GyE, respectively, delivered in 4 fractions. Planning and delivery procedures were analyzed as a bi-institutional effort to communicate key concepts to newer developing proton centers. Normal eye tissue sparing is related to critical beam characteristics provided in the setting of low-energy dedicated eye beamlines. Both centers offer a very sharp dose fall off (distal ∼1 mm and lateral ∼1.1-1.6 mm), high dose homogeneity, excellent range precision and short treatment time (∼0.5-2 minutes). Planned doses to critical ocular structures are independent predictors of ocular complications such as vision loss and neovascular glaucoma, including the following parameters: 28 GyE to macula [P<.0001], optic nerve [P<0.0004], lens [P<.0001], and ciliary body [P<.0001]. A systematic tumor/critical structure dose evaluation is used to optimize treatment parameters, i.e. lateral margin, distal range, gaze angle, and aperture shape. New high-energy non-dedicated beam designs, which degrade energy to deliver ocular treatment, may require significant beam adjustment and treatment planning procedures to achieve adequate characteristics. Regarding UM dose, a common regimen is 60 GyE in 4 fractions globally. Unrandomized early retrospective data shows lower local tumor control with 48 GyE (P = 0.02). Critical structures including the retina, lacrimal gland, cornea, tear ducts, lids, bony orbit, and limbal stem cells are methodically evaluated to minimize side effects. Eyelid toxicity is reduced by institutional retraction techniques or treatment through closed lids. Experienced international specialty proton ocular centers with dedicated, low-energy, fixed eyelines, provide important practical concepts for consideration by developing centers to optimize high-energy universal beamline designs for eye treatments. As new centers with different beam designs emerge globally, key clinical and treatment planning/delivery practices will need to be applied, particularly to reduce potential normal tissue toxicity for ocular patients.

Purpose/Objective(s)To evaluate control and complication rates from our current standard proton beam radiation therapy (PBRT) technique of 56 GyE in 4 fractions and anterior eye structure sparing in patients with uveal melanoma (UM).Materials/MethodsBetween 1994 and 2006, 622 patients with UM were given PBRT at the University of California San Francisco/Tumori Foundation. All patients were operated upon by a single surgeon (D.C.). Forty-seven patients who underwent eye wall resection prior to PBRT will be reported separately. The remaining 575 patient charts were reviewed. During 1994–1995, 42 patients were treated with 48 GyE in 4 fractions (fx). Thereafter, 533 patients were treated with our revised dose of 56 GyE in 4 fx. In addition, treatment practice was modified to reduce ciliary body/lens dose to decrease neovascular glaucoma (NVG) rates (Daftari et al., IJROBP 1997;39:997-1010; Rajendran et al., IJROBP 2004;60:S311-S312). Tumor location was ciliary body in 11%, 27% macular, and 62% choroidal. Median age at dx was 60 years (range, 13–94 years). Mean largest tumor diameter was 10.8 mm (2–23.7 mm). Mean tumor height was 5.1 mm (1.3–18.3 mm); 6.3% were Stage T1, 82% T2, and 11.7% T3. Median follow-up after PBRT was 41 months (range, 0.1–159 months). For patients who received 56 GyE median follow-up was 40.8 months (0.1–152 months); for the 48 GyE group, median follow-up was 72 months (8.6–159 months). Kaplan-Meier methods, chi-square test, and Cox proportional hazards model were utilized to calculate recurrence and survival rates and test for variables correlating with control and survival.ResultsLocal control (LC) at 2 years was 98.1 ± 0.6% and 5 years 95.6 ± 1.3% for patients undergoing treatment with current clinical standard of 56 GyE. In the 48 GyE group, 8 of 42 patients (19%) failed vs. 20 of 533 patients (3.8%) in the 56 GyE group (p < 0.01). A detailed analysis was completed for our 56 GyE group. Median time to local failure was 25.5 months. Distant metastasis (DM) free survival at 5-years was 86.2 ± 2.3%. Median time to DM was 38.6 months (4.8–92 months). Overall survival at 5-years was 84.8 ± 2.3%. None of the patients with T1 tumors recurred during follow-up. The enucleation rate was 7.5% and the NVG rate was 6.6%. On multivariate analysis, macular location (p = 0.014) and ciliary body involvement (CBI) (p = 0.013) were poor prognostic features for LC. T-Stage (p = 0.07) and CBI (p = 0.001) were poor prognostic features for OS.ConclusionsExcellent local control rates, 98% at 2 years and 96% at 5 years, have been maintained with proton therapy for patients with uveal melanoma. The lower dose of 48 GyE resulted in lesser control. Our current revised clinical practice of PBRT for uveal melanoma with delivering 56 GyE in 4 fractions and focusing on sparing of the lens and ciliary body has yielded very low enucleation and NVG rates without sacrificing a high LC rate compared with historical data. Purpose/Objective(s)To evaluate control and complication rates from our current standard proton beam radiation therapy (PBRT) technique of 56 GyE in 4 fractions and anterior eye structure sparing in patients with uveal melanoma (UM). To evaluate control and complication rates from our current standard proton beam radiation therapy (PBRT) technique of 56 GyE in 4 fractions and anterior eye structure sparing in patients with uveal melanoma (UM). Materials/MethodsBetween 1994 and 2006, 622 patients with UM were given PBRT at the University of California San Francisco/Tumori Foundation. All patients were operated upon by a single surgeon (D.C.). Forty-seven patients who underwent eye wall resection prior to PBRT will be reported separately. The remaining 575 patient charts were reviewed. During 1994–1995, 42 patients were treated with 48 GyE in 4 fractions (fx). Thereafter, 533 patients were treated with our revised dose of 56 GyE in 4 fx. In addition, treatment practice was modified to reduce ciliary body/lens dose to decrease neovascular glaucoma (NVG) rates (Daftari et al., IJROBP 1997;39:997-1010; Rajendran et al., IJROBP 2004;60:S311-S312). Tumor location was ciliary body in 11%, 27% macular, and 62% choroidal. Median age at dx was 60 years (range, 13–94 years). Mean largest tumor diameter was 10.8 mm (2–23.7 mm). Mean tumor height was 5.1 mm (1.3–18.3 mm); 6.3% were Stage T1, 82% T2, and 11.7% T3. Median follow-up after PBRT was 41 months (range, 0.1–159 months). For patients who received 56 GyE median follow-up was 40.8 months (0.1–152 months); for the 48 GyE group, median follow-up was 72 months (8.6–159 months). Kaplan-Meier methods, chi-square test, and Cox proportional hazards model were utilized to calculate recurrence and survival rates and test for variables correlating with control and survival. Between 1994 and 2006, 622 patients with UM were given PBRT at the University of California San Francisco/Tumori Foundation. All patients were operated upon by a single surgeon (D.C.). Forty-seven patients who underwent eye wall resection prior to PBRT will be reported separately. The remaining 575 patient charts were reviewed. During 1994–1995, 42 patients were treated with 48 GyE in 4 fractions (fx). Thereafter, 533 patients were treated with our revised dose of 56 GyE in 4 fx. In addition, treatment practice was modified to reduce ciliary body/lens dose to decrease neovascular glaucoma (NVG) rates (Daftari et al., IJROBP 1997;39:997-1010; Rajendran et al., IJROBP 2004;60:S311-S312). Tumor location was ciliary body in 11%, 27% macular, and 62% choroidal. Median age at dx was 60 years (range, 13–94 years). Mean largest tumor diameter was 10.8 mm (2–23.7 mm). Mean tumor height was 5.1 mm (1.3–18.3 mm); 6.3% were Stage T1, 82% T2, and 11.7% T3. Median follow-up after PBRT was 41 months (range, 0.1–159 months). For patients who received 56 GyE median follow-up was 40.8 months (0.1–152 months); for the 48 GyE group, median follow-up was 72 months (8.6–159 months). Kaplan-Meier methods, chi-square test, and Cox proportional hazards model were utilized to calculate recurrence and survival rates and test for variables correlating with control and survival. ResultsLocal control (LC) at 2 years was 98.1 ± 0.6% and 5 years 95.6 ± 1.3% for patients undergoing treatment with current clinical standard of 56 GyE. In the 48 GyE group, 8 of 42 patients (19%) failed vs. 20 of 533 patients (3.8%) in the 56 GyE group (p < 0.01). A detailed analysis was completed for our 56 GyE group. Median time to local failure was 25.5 months. Distant metastasis (DM) free survival at 5-years was 86.2 ± 2.3%. Median time to DM was 38.6 months (4.8–92 months). Overall survival at 5-years was 84.8 ± 2.3%. None of the patients with T1 tumors recurred during follow-up. The enucleation rate was 7.5% and the NVG rate was 6.6%. On multivariate analysis, macular location (p = 0.014) and ciliary body involvement (CBI) (p = 0.013) were poor prognostic features for LC. T-Stage (p = 0.07) and CBI (p = 0.001) were poor prognostic features for OS. Local control (LC) at 2 years was 98.1 ± 0.6% and 5 years 95.6 ± 1.3% for patients undergoing treatment with current clinical standard of 56 GyE. In the 48 GyE group, 8 of 42 patients (19%) failed vs. 20 of 533 patients (3.8%) in the 56 GyE group (p < 0.01). A detailed analysis was completed for our 56 GyE group. Median time to local failure was 25.5 months. Distant metastasis (DM) free survival at 5-years was 86.2 ± 2.3%. Median time to DM was 38.6 months (4.8–92 months). Overall survival at 5-years was 84.8 ± 2.3%. None of the patients with T1 tumors recurred during follow-up. The enucleation rate was 7.5% and the NVG rate was 6.6%. On multivariate analysis, macular location (p = 0.014) and ciliary body involvement (CBI) (p = 0.013) were poor prognostic features for LC. T-Stage (p = 0.07) and CBI (p = 0.001) were poor prognostic features for OS. ConclusionsExcellent local control rates, 98% at 2 years and 96% at 5 years, have been maintained with proton therapy for patients with uveal melanoma. The lower dose of 48 GyE resulted in lesser control. Our current revised clinical practice of PBRT for uveal melanoma with delivering 56 GyE in 4 fractions and focusing on sparing of the lens and ciliary body has yielded very low enucleation and NVG rates without sacrificing a high LC rate compared with historical data. Excellent local control rates, 98% at 2 years and 96% at 5 years, have been maintained with proton therapy for patients with uveal melanoma. The lower dose of 48 GyE resulted in lesser control. Our current revised clinical practice of PBRT for uveal melanoma with delivering 56 GyE in 4 fractions and focusing on sparing of the lens and ciliary body has yielded very low enucleation and NVG rates without sacrificing a high LC rate compared with historical data.

Purpose/ObjectiveWe previously hypothesized that sparing the anterior segment of the eye would reduce the incidence of neovascular glaucoma (NVG) (Daftari, I. K., et al., IJROBP 1997, 39:997–1010; Meecham, W.J., et al., Arch Ophthalmol 1994, 112:197–203). To test this hypothesis, we examined the incidence and contributing factors of NVG in patients treated with proton beam therapy at the Crocker Nuclear Lavoratory faculty in Davis, California using techniques for sparing anterior structures of the eye.Materials/MethodsUsing anterior structure sparing techniques, 346 patients were treated with proton beam therapy between June 1996 and November 2003 and included in the ocular melanoma database of the Tumori Foundation. Twenty-four patients were excluded due to prior surgical resection and 3 patients because they were treated for recurrences after 125I plaque therapy. This resulted in 319 evaluated patients treated with anterior structure sparing techniques. The patients in the study received 56 GyE in 4 fractions. The primary endpoint of this study is the occurrence of NVG. The median follow-up is 24.7 months. The log rank test was used to compare distributions of the occurrence of NVG. The likelihood ratio test (LLRT) from Cox’s proportional hazard model was used to compare models to identify independent predictors of outcome.ResultsNVG occurred among 39 of the patients. The probability of remaining free of NVG at 3 years was 89%. The smaller the tumor diameter was, the better the outcome with 3 year estimates of NVG for the quartiles <7.5 mm, >7.5 mm - 10.5 mm, >10.5 mm - 12.0 mm vs. >12.0 mm of 96%, 81%, 80% and 77%, respectively (p = 0.001). When none of the lens received at least 50% of the dose there was a lower probability of NVG (p < 0.0001). The further away the tumor was from the fovea or from the disc the later NVG occurred (p = 0.003, p = 0.006) with the 3 year estimates for distances of 0 and >0 mm of 72% and 89% to the fovea and 76% and 88% to the disc. If <100% of the macula and optic disc and less than 29% (upper quartile) of the ciliary body received at least 50% of the dose, the NVG outcome was more favorable (p = 0.02, p = 0.006 and p < 0.0001). Factors in univariate analysis that were not predictors of NVG are age of the patient, gender, or the eye involved.When the factors determined to be significant predictors of NVG with univariate methods are considered simultaneously, the most significant predictor of NVG is when at least 30% of the ciliary body received at least 50% of the dose (LLRT: p < 0.0001). There is also a significant association between the macula and optic disc being treated with at least 50% of the dose (p < 0.0001). For 50% of the patients <100% of both sites and for 23% of the patients 100% of both sites were treated with at least 50% of the dose. Therefore, using these cut-points, the final predictive model was either ciliary body proportion plus macula or plus disk proportion (LLRT: p = 0.003).ConclusionsWe have previously shown that only. 65% of patients treated with particle therapy for ocular melanoma without anterior structure sparing techniques remained free of NVG at three years of follow-up. These data demonstrate that prospectively sparing anterior structures in the eye increases the probability of remaining free of NVG to 89% at three years. Additional new findings are the strong influence of ciliary body dose, and the effect of irradiation of the macula or the disc on NVG risk Purpose/ObjectiveWe previously hypothesized that sparing the anterior segment of the eye would reduce the incidence of neovascular glaucoma (NVG) (Daftari, I. K., et al., IJROBP 1997, 39:997–1010; Meecham, W.J., et al., Arch Ophthalmol 1994, 112:197–203). To test this hypothesis, we examined the incidence and contributing factors of NVG in patients treated with proton beam therapy at the Crocker Nuclear Lavoratory faculty in Davis, California using techniques for sparing anterior structures of the eye. We previously hypothesized that sparing the anterior segment of the eye would reduce the incidence of neovascular glaucoma (NVG) (Daftari, I. K., et al., IJROBP 1997, 39:997–1010; Meecham, W.J., et al., Arch Ophthalmol 1994, 112:197–203). To test this hypothesis, we examined the incidence and contributing factors of NVG in patients treated with proton beam therapy at the Crocker Nuclear Lavoratory faculty in Davis, California using techniques for sparing anterior structures of the eye. Materials/MethodsUsing anterior structure sparing techniques, 346 patients were treated with proton beam therapy between June 1996 and November 2003 and included in the ocular melanoma database of the Tumori Foundation. Twenty-four patients were excluded due to prior surgical resection and 3 patients because they were treated for recurrences after 125I plaque therapy. This resulted in 319 evaluated patients treated with anterior structure sparing techniques. The patients in the study received 56 GyE in 4 fractions. The primary endpoint of this study is the occurrence of NVG. The median follow-up is 24.7 months. The log rank test was used to compare distributions of the occurrence of NVG. The likelihood ratio test (LLRT) from Cox’s proportional hazard model was used to compare models to identify independent predictors of outcome. Using anterior structure sparing techniques, 346 patients were treated with proton beam therapy between June 1996 and November 2003 and included in the ocular melanoma database of the Tumori Foundation. Twenty-four patients were excluded due to prior surgical resection and 3 patients because they were treated for recurrences after 125I plaque therapy. This resulted in 319 evaluated patients treated with anterior structure sparing techniques. The patients in the study received 56 GyE in 4 fractions. The primary endpoint of this study is the occurrence of NVG. The median follow-up is 24.7 months. The log rank test was used to compare distributions of the occurrence of NVG. The likelihood ratio test (LLRT) from Cox’s proportional hazard model was used to compare models to identify independent predictors of outcome. ResultsNVG occurred among 39 of the patients. The probability of remaining free of NVG at 3 years was 89%. The smaller the tumor diameter was, the better the outcome with 3 year estimates of NVG for the quartiles <7.5 mm, >7.5 mm - 10.5 mm, >10.5 mm - 12.0 mm vs. >12.0 mm of 96%, 81%, 80% and 77%, respectively (p = 0.001). When none of the lens received at least 50% of the dose there was a lower probability of NVG (p < 0.0001). The further away the tumor was from the fovea or from the disc the later NVG occurred (p = 0.003, p = 0.006) with the 3 year estimates for distances of 0 and >0 mm of 72% and 89% to the fovea and 76% and 88% to the disc. If <100% of the macula and optic disc and less than 29% (upper quartile) of the ciliary body received at least 50% of the dose, the NVG outcome was more favorable (p = 0.02, p = 0.006 and p < 0.0001). Factors in univariate analysis that were not predictors of NVG are age of the patient, gender, or the eye involved.When the factors determined to be significant predictors of NVG with univariate methods are considered simultaneously, the most significant predictor of NVG is when at least 30% of the ciliary body received at least 50% of the dose (LLRT: p < 0.0001). There is also a significant association between the macula and optic disc being treated with at least 50% of the dose (p < 0.0001). For 50% of the patients <100% of both sites and for 23% of the patients 100% of both sites were treated with at least 50% of the dose. Therefore, using these cut-points, the final predictive model was either ciliary body proportion plus macula or plus disk proportion (LLRT: p = 0.003). NVG occurred among 39 of the patients. The probability of remaining free of NVG at 3 years was 89%. The smaller the tumor diameter was, the better the outcome with 3 year estimates of NVG for the quartiles <7.5 mm, >7.5 mm - 10.5 mm, >10.5 mm - 12.0 mm vs. >12.0 mm of 96%, 81%, 80% and 77%, respectively (p = 0.001). When none of the lens received at least 50% of the dose there was a lower probability of NVG (p < 0.0001). The further away the tumor was from the fovea or from the disc the later NVG occurred (p = 0.003, p = 0.006) with the 3 year estimates for distances of 0 and >0 mm of 72% and 89% to the fovea and 76% and 88% to the disc. If <100% of the macula and optic disc and less than 29% (upper quartile) of the ciliary body received at least 50% of the dose, the NVG outcome was more favorable (p = 0.02, p = 0.006 and p < 0.0001). Factors in univariate analysis that were not predictors of NVG are age of the patient, gender, or the eye involved. When the factors determined to be significant predictors of NVG with univariate methods are considered simultaneously, the most significant predictor of NVG is when at least 30% of the ciliary body received at least 50% of the dose (LLRT: p < 0.0001). There is also a significant association between the macula and optic disc being treated with at least 50% of the dose (p < 0.0001). For 50% of the patients <100% of both sites and for 23% of the patients 100% of both sites were treated with at least 50% of the dose. Therefore, using these cut-points, the final predictive model was either ciliary body proportion plus macula or plus disk proportion (LLRT: p = 0.003). ConclusionsWe have previously shown that only. 65% of patients treated with particle therapy for ocular melanoma without anterior structure sparing techniques remained free of NVG at three years of follow-up. These data demonstrate that prospectively sparing anterior structures in the eye increases the probability of remaining free of NVG to 89% at three years. Additional new findings are the strong influence of ciliary body dose, and the effect of irradiation of the macula or the disc on NVG risk We have previously shown that only. 65% of patients treated with particle therapy for ocular melanoma without anterior structure sparing techniques remained free of NVG at three years of follow-up. These data demonstrate that prospectively sparing anterior structures in the eye increases the probability of remaining free of NVG to 89% at three years. Additional new findings are the strong influence of ciliary body dose, and the effect of irradiation of the macula or the disc on NVG risk

Aim: To assess in a prospective manner, high frequency ultrasound diagnosis of deep invasion by conjunctival squamous cell carcinoma. Methods: Prospective, non-randomised case series comparing 20 MHz high frequency ultrasonographic and clinicopathological data. Results: 20 MHz high frequency ultrasound delineated the degree of deep involvement of this tumour into the sclera, globe, and orbit. The results of ultrasonography correlated with the clinicopathological results. Conclusions: High frequency ultrasound is a useful diagnostic adjunctive test in patients with possible deep involvement by a conjunctival squamous cell carcinoma.

Aim-To increase the understanding of the long term results in pseudoretinoblastoma eyes with infantile Coats' syndrome.Methods-This study design was a retrospective case review. 10 patients were analysed who were initially referred with a diagnosis of retinoblastoma but had Coats' syndrome on the basis of ocular oncological evaluation. Vision, fundus photography, ultrasonography, and computed tomography scans were obtained and evaluated. Changes in vision and retinal status were measured.Results-The initial age at presentation was 2.4 years (range 0.25-4 years). All patients had retinal detachment at diagnosis. Nine of 10 retinas were reattached after various treatments. Reattached retinas had closure of peripheral telangiectasia and visible intraretinal crystals. Vision was dismal. At last follow up (mean 8.8 years), only two patients had 20/400 or better visual acuities. Five eyes had no light perception despite early treatment to reattach the retina. Nine of 10 eyes remain cosmetically acceptable. One patient wore a cosmetic shell.Conclusions-Long term results indicate that these eyes can be salvaged and the retina reattached but the visual outcome is poor.

AIM:To evaluate retrospective data on the clinical findings, histological features, radiological diagnosis, and management outcomes in orbital lymphangioma. METHODS:Data on 26 orbital lymphangioma patients managed over 16 years were re-evaluated. The computed tomograph and magnetic resonance scans and histological slides were reviewed. Parametric techniques were used to assess correlations among clinical, radiological, and histopathological factors. RESULTS:At presentation proptosis was present in 85%, ptosis in 73%, and restrictive eye movements in 46% of patients. The accuracy of the initial radiology interpretations was 77%. 24 cases required one or more surgeries. The mean follow up was 9.2 years (range 1-14 years). 58% of patients developed recurrences. In cases that recurred, motility restriction was significantly more frequent at initial examination than cases without recurrence (p < 0.05). After therapy, 75% of patients were satisfied with their visual function and cosmetic appearance. CONCLUSIONS:Conservative management of orbital lymphangioma with multiple partial resections may achieve satisfactory results.

Orbital ossifying fibroma is an extremely rare condition, especially in adults. This rare tumor mostly develops at the medial wall of the orbit. We report a histopathologically confirmed ossifying fibroma involving the lateral orbital wall in an adult. This case suggests that orbital ossifying fibroma should be considered in the differential diagnosis of orbital bony lesions in adults and that unusual presentations may occur.

Objective: To report the clinical and histologic features of combined nevi of the conjunctiva, a type of nevus that is not uncommon in the skin but rarely has been reported in the conjunctiva.Methods: Conjunctival nevi and melanomas in the files of the University of California at San Francisco Eye Pathology Laboratory from 1984 to 1999 were reviewed for the presence of features of both standard nevocytic nevi and blue nevi. Clinical histories and, when available, clinical photographs were obtained.Results: Thirty combined nevi were discovered between 1984 and 1999. One case before 1984 had been incorrectly diagnosed as a junctional nevus. The dendritic and spindle-shaped blue nevus cells had been over-looked because they were not recognized as distinct from the standard nevocytic nevus cells. The recognition of blue as well as a brown color, a deep as well as a superficial component in the lesion, or a history of pigmentation since birth may help to establish the correct clinical diagnosis and prevent an unnecessarily deep surgical resection. Although growth of the lesion or "satellites" in some may favor a clinical diagnosis of melanoma, no lesions in this series were malignant.Conclusion: Despite a paucity of reports of combined nevi of the conjunctiva in the medical literature, this type of nevus, a combination of a nevocytic and a blue nevus, is common and has been overlooked in the past.

Aim-To evaluate the clinical features, treatment results, and recurrence rates in patients with either intraepithelial or invasive squamous cell carcinoma of the conjunctiva.Methods-Retrospective analysis of 60 cases (22 conjunctival intraepithelial and 38 invasive squamous cell carcinomas) to determine patterns of clinical presentation, aetiological factors, and treatment results. The mean patient age was 64 years old. 70% of the patients were male. Patients were treated with a variety of therapies, depending on the degree of tumour involvement; most cases were treated with frozen section controlled excision and adjunctive cryotherapy. Modified eye wall resection or enucleation was done for intraocular invasion and exenteration was done for orbital involvement.Results-Red eye (68%) and ocular irritation (57%) were the most common presenting symptoms. 44% of the patients had other eye findings consistent with extensive solar exposure. 20% of the patients had a history of malignant skin tumours. Visceral malignancies developed in 8%. Scleral involvement was present in 14 (37%), intraocular involvement in five (13%), and orbital invasion in four (11%) cases with invasive squamous cell carcinoma. After a mean follow up of 56 months (18-226 months) the rate of new or recurrent tumours was 4.5% for intraepithelial squamous carcinoma and 5.3% for invasive squamous cell carcinoma. No patient developed metastases or tumour related deaths.Conclusion-Excision with intraoperative control of the surgical margins and adjunctive cryotherapy results in good tumour control rates.

"Cavernous hemangiomas of the orbit (reply to the 2nd letter by Alan A. McNab)." Orbit, 17(3), p. 208

Purpose: To report a minimally symptomatic patient with bilateral carcinoid tumors metastatic to the choroid who was followed up for 42 months without any treatment.

Objective: To determine the causes and patterns of mortality after uveal melanoma radiation.Design: A cohort study from a single institution was performed. Mortality was modeled using semiparametric survival techniques. All cause and cause-specific mortality analyses were performed. Mortality was compared with expected mortality from the U.S. census data.Participants: A total of 731 patients were studied, and 710 (97%) of these had medium or large melanomas. The mean tumor diameter was 11.3 mm, and the mean tumor thickness was 5.8 mm. Ciliary body was involved in 122 (17%) of patients. Complete follow-up was available on 99.6% (728 of 731) of patients.Main Outcome Measures: The authors analyzed the distribution and causes of post-treatment mortality.Results: The 5- and 10-year all-cause Kaplan-Meier survival rates were 75.6% and 62.3%, respectively. Both melanoma risk factors (older age, ciliary body involvement, and larger tumor diameter) and nonmelanoma risk factors (older age and medical condition) were significant prognostic factors of all-cause mortality. Deaths from nonmelanoma causes accounted for 91 (42.3%) of 215 deaths. The 5-year and 10-year estimates of nonmelanoma deaths were 8.3% and 15.9%, respectively. Nonmelanoma mortality was similar to that observed in the general U.S. population (91 observed, 98.1 expected). Melanoma metastases accounted for 124 (57.7%) of 215 deaths. The 5- and 10-year estimates for probability of metastatic death were 16.1% and 21.8%, respectively. The largest tumor diameter was the best predictor for melanoma mortality; ciliary body involvement, older age, and distance from the fovea also were significant in multivariate analyses.Conclusion: A significant proportion of patients with uveal melanoma die of nonmelanoma causes after radiation. In analyzing prognostic factors, considerable information may be lost if analyses are based on all-cause mortality rather than cause-specific mortality.

Aims - Three issues were investigated in adult outpatients with orbital metastases. One, how accurate are current diagnostic methods? Two, what is the survival associated with orbital metastases? Three, did any clinical factors correlate with prognosis in this patient cohort?Methods - Retrospective analysis of patients with orbital metastases managed in an ocular oncology unit.Results - 11 of 31 (35%) patients had no known primary malignancy at the time of orbital diagnosis. In eight of 31 (26%) computed tomography and/or magnetic resonance imaging data did not yield the diagnosis of metastases. In 15 of 17 (88%) cases a fine needle aspiration biopsy was diagnostic. Several types of therapy were used. The median survival was 1.3 years.Conclusion - Orbital metastases, even with newer diagnostic techniques can be difficult to diagnose. Management was based on location and extent of both orbital and systemic disease as well as vision. In most cases, orbital symptoms were palliated; however, survival was dismal. No clinical factor correlated with prognosis.