PURPOSE:To compare the predicted and actual corneal ablation depth in wavefront-guided laser in situ keratomileusis (WFG LASIK) and keratorefractive lenticule extraction (KLEx). METHODS:This prospective, randomized, contralateral eye study included 26 patients 22 years or older with sphere between -0.75 to -8.00 diopters and 3.00 diopters of cylinder or less undergoing WFG LASIK and KLEx performed by a single surgeon at a large academic hospital. Actual ablation depth was calculated from preoperative and postoperative central corneal thickness. The iDesign aberrometer (Johnson & Johnson Vision) and VisuMax 500 femtosecond laser (Carl Zeiss Meditec AG) were used to derive predicted ablation depth for WFG LASIK and KLEx, respectively. Analyses included t-tests and mixed-effects linear regression. RESULTS:Actual ablation depth was greater than predicted (66.5 ± 27.0 vs 56.3 ± 22.9 µm, P < .001) for WFG LASIK and less than predicted (69.0 ± 25.0 vs 73.6 ± 24.3 µm, P = .04) for KLEx. The difference between actual and predicted ablation depth was -4.6 ± 10.6 µm in KLEx and 10.2 ± 14.8 µm in WFG LASIK (P < .001). Postoperative spherical equivalent was not significantly different between WFG LASIK and KLEx eyes (P = .53). LASIK was independently associated with a greater absolute difference between actual and predicted ablation depth compared to KLEx (β: 6.2; 95% CI: 1.7 to 10.7; P = .02). CONCLUSIONS:Corneal ablations were deeper than predicted after WFG LASIK and shallower than predicted after KLEx. WFG LASIK was independently associated with greater ablation depth inaccuracy, but there was no difference in postoperative spherical equivalent between WFG LASIK and KLEx.

Importance Tumor thickness is a well-established risk factor for malignant transformation of choroidal nevus into melanoma. To date, reliable evaluation of tumor thickness relies on B-scan ultrasonography, which is frequently unavailable at nonsubspecialty clinics where most melanocytic choroidal lesions (MCLs) are first diagnosed. Objective To describe a technique for potential rapid and reliable estimation of MCL thickness using only Optomap ultra-widefield (UWF) images without B-scan ultrasonography. Design, Setting, and Participants This retrospective, exploratory, cross-sectional analysis of consecutive MCLs diagnosed at Byers Eye Institute, Stanford University, Palo Alto, California, investigates the quantitative correlation between B-scan ultrasonographic thickness of MCLs with the relative pixel intensity of MCLs on green-channel (GC) Optomap UWF images. Pixel intensity overlying the lesion was standardized to the pixel intensity surrounding the lesion (pixel intensity difference [PID]), which was then correlated with ultrasonographic tumor thickness in all study lesions using linear regression analysis. Data were collected from January 1, 2019, to July 1, 2021. Main Outcomes and Measures The correlation between ultrasonographic tumor thickness and PID was measured. Performance (sensitivity and specificity) of the regression analysis trendline in estimating tumor thickness was also determined. Results A total of 138 MCLs from 138 patients (mean age, 57.0 years; 51% female) were included, comprising 125 that were nevi and 13 that were melanoma. The mean ultrasonographic tumor thickness was 1.1 mm (median, 0.8 mm; range, 0.2-5.5 mm), with a mean PID of 2.13. Stratifying lesions by ultrasonographic thickness (<1.0 mm vs 1.0-2.0 mm vs >2.0 mm), the mean PID increased (-1.95 vs 3.72 vs 17.62; P < .001) as mean thickness increased (0.5 mm vs 1.4 mm vs 3.3 mm; P < .001). PID was correlated with tumor thickness (R-2 = 0.823; 95% CI, 0.770-0.875; P < .001) across lesions of all sizes. Conclusions and Relevance In this proof-of-principle study, GC-derived lesion intensity correlated well with ultrasonographic tumor thickness. Leveraging this correlation, this study demonstrates a technique for potentially reliable and rapid estimation of tumor thickness using UWF Optomap images without the use of B-scan ultrasonography.

Purpose:To describe long term follow-up of two cases of corneally displaced conjunctival melanoma with multiple recurrences. Observations:Case 1 is a 49-year-old male with recurrent conjunctival melanoma and primary acquired melanosis treated over 13 years, who eventually presented with an elevated amelanotic corneal mass. Case 2 is a 61-year-old female with a similar history of recurrent conjunctival melanoma and primary acquired melanosis treated over 21 years, who presented with a subepithelial corneal opacity. Both patients were treated with a combination of topical chemotherapy, wide excision, map biopsy, cryotherapy, and local and systemic workup showing no evidence of metastasis. Conclusions and importance:Conjunctival melanoma has a high risk of recurrence and can present as amelanotic corneally displaced conjunctival melanoma, warranting thorough workup to detect potential subclinical spread of the disease.

Purpose of review With a decline in the use of scleral buckling for rhegmatogenous retinal detachment (RRD) repair in recent years, this review seeks to provide a summary of the most recent research findings regarding the role of scleral buckling in the repair of RRD. Recent findings Many recent studies have compared visual and anatomic outcomes between scleral buckling and pars plana vitrectomy (PPV) for RRD repair. Some suggest superior outcomes with primary scleral buckling, particularly in younger, phakic patients, and in association with other risk factors that we review. Children do best with primary scleral buckling surgery. Functionally, scleral buckling may also result in lower rates of retinal displacement compared to PPV. When PPV is necessary, a supplemental buckle may benefit certain patients, while the advantage remains unclear in other clinical scenarios and necessitates further investigation. Summary Scleral buckling is an important technique for the repair of RRD and it is crucial to continue training retina surgeons in this technique to maximize patient outcomes.

Purpose We describe the case of an 80-year-old man with bilateral minocycline-induced retinal pigment epithelium (RPE) hyperpigmentation, which initially masqueraded as AMD. Secondarily, using multimodal imaging features, we propose a mechanism for the development of minocycline-induced RPE hyperpigmentation. Observations The patient was referred with concern for AMD given the presence of macular drusenoid deposits on optical coherence tomography. However, funduscopic evaluation showed dense granular parafoveal hyperpigmentation, with a diffuse slate-colored hyperpigmentation throughout the peripheral fundus. Short-wavelength fundus autofluorescence of the macula disclosed no irregularities (as would be expected with drusen) while on near-infrared reflectance (NIR) imaging, numerous hyperreflective foci were noted corresponding to the hyperpigmented granules observed clinically (as would instead be seen with melanin deposits). Clinical examination was notable for blue-gray hyperpigmentation of the lower and upper extremities, as well as of the face, periorbital skin, and sclera. Upon further questioning, the patient disclosed daily oral minocycline use for 15 years for acne rosacea, confirming a diagnosis of minocycline-induced hyperpigmentation of the RPE. Conclusions Multimodal imaging can be useful for differentiating minocycline-induced RPE hyperpigmentation from similar masquerade entities. Timely diagnosis can prevent progressive vision loss.

Purpose: To determine the sensitivity of brain magnetic resonance imaging (MRI) in the detection of choroidal metastasis (CM) from systemic primary cancers. Methods: A retrospective chart review identified patients with clinically confirmed CM seen on the Oncology Service (Byers Eye Institute) between January 2018 and March 2022. Patients had an MRI brain and/or orbits performed within 3 months of CM diagnosis. Evaluation of CM detection by MRI was then divided into two parts: an initial “standard read,” where determination of CM detection was based solely on the original radiology report, to reflect real-world performance, and a subsequent “dedicated read,” for which a board-certified neuroradiologist, blinded to the laterality and location of the CM, re-evaluated the studies to provide an objective “gold standard” interpretation regarding the radiographic detection of CM. Results: The study included 42 eyes of 40 patients with confirmed CM. On standard read, MRI detection of CM occurred in 21 of 42 eyes (50%), with no significant difference between MRI brain and orbit protocols (p=0.249). Features associated with improved detection were increased tumor basal diameter (p<0.001) and ultrasonographic tumor thickness (p=0.003). On dedicated read, MRI detection of CM improved to 26 of 33 eyes (76%). Post-gadolinium 3D FLAIR sequence was the most sensitive (88%) for CM detection. 42% and 58% of lesions were visualized using conventional pre-gadolinium T1- and T2-weighted imaging, respectively. Conclusions: MRI sensitivity improved from 50% to 76% with focused reinterpretation. Increased utilization of the FLAIR sequence and increased ocular scrutiny may contribute to earlier diagnosis of CM.

BACKGROUND AND OBJECTIVE:The objective was to evaluate factors associated with clinical presentation of uveal melanoma (UM) during the initial two years of the coronavirus disease 2019 pandemic. PATIENTS AND METHODS:This was a multi-site, retrospective cohort study of patients treated for uveal melanoma during the first (early) and second (late) year of the pandemic compared with the year prior (control). RESULTS:A total of 48, 67, and 75 patients were in the control, early, and late cohorts, respectively. The early cohort had a higher frequency of large tumors (control: 29.2%, early: 40.3%, late: 29.3%; P < 0.001) at presentation. Both the early and late cohorts had higher rates of enucleation (control: 8.33%, early: 20.9%, late: 18.67%; P ≤ 0.0338) compared to the control cohort. CONCLUSIONS:While there was an increase in large tumors along with a rise in enucleation during the first year of the pandemic, enucleation rates remained elevated even while tumor sizes normalized. [Ophthalmic Surg Lasers Imaging Retina 2024;55:278-284.].

Introduction:The objective of this study was to determine the sensitivity of brain magnetic resonance imaging (MRI) in the detection of choroidal metastasis (CM) from systemic primary cancers.Methods:A retrospective chart review identified patients with clinically confirmed CM seen on the Oncology Service (Byers Eye Institute) between January 2018 and March 2022. Patients had an MRI brain and/or orbits performed within 3 months of CM diagnosis. Evaluation of CM detection by MRI was then divided into two parts: an initial "standard read," where determination of CM detection was based solely on the original radiology report, to reflect real-world performance, and a subsequent "dedicated read," for which a board-certified neuroradiologist, blinded to the laterality and location of the CM, reevaluated the studies to provide an objective "gold standard" interpretation regarding the radiographic detection of CM.Results:The study included 42 eyes of 40 patients with confirmed CM. On standard read, MRI detection of CM occurred in 21 of 42 eyes (50%), with no significant difference between MRI brain and orbit protocols (p = 0.249). Features associated with improved detection were increased tumor basal diameter (p < 0.001) and ultrasonographic tumor thickness (p = 0.003). On dedicated read, MRI detection of CM improved to 26 of 33 eyes (76%; limited to eyes with full complement of pre- and post-gadolinium sequences). Post-gadolinium 3D fluid-attenuated inversion recovery (FLAIR) sequence with fat suppression was the most sensitive (88%) for CM detection. 42% and 58% of lesions were visualized using conventional pre-gadolinium T1- and T2-weighted imaging, respectively.Conclusions:MRI sensitivity to detect CM improved from 50% to 76% with focused reinterpretation. Increased utilization of the post-gadolinium 3D FLAIR sequence and increased ocular scrutiny in cancer patients undergoing brain imaging may facilitate earlier diagnosis of CM.

PurposeDespite several publications on ophthalmic surgical cancellations discussing preventative causes in academic institutions, there remains a paucity of similar studies for safety-net hospitals. This study analyzed cancellation rates at a county hospital over a 10-year period.MethodsThis retrospective, open cohort study investigated a total of 11,350 surgeries scheduled at a tertiary-level county hospital between January 1, 2012 and December 31, 2021. Surgical cancellation reasons were collected from chart review and categorized into eight groups to allow for analyses. Cancellation rates were then calculated per year and per subspecialty. The primary statistical analyses were paired, 2-tailed t test and chi 2 test.ResultsThe most common reason for cancellation overall was institution-related (1065 surgeries), which was also the most common reason per year from 2012 to 2019 (range: 37.4% - 60.6%). In 2020, during COVID-19 stay-at-home mandates, the most common reason became COVID-related rescheduling, and in 2021, it was patient-driven. The cancellation rate in 2020 was significantly higher than 2019 (+9.27%,95% CI:4.96%-13.6%,p = .05), and significantly lower from 2021 to 2020 (-22.8%,95% CI:-26.8%-(-)18.7%,p = .001). Pediatric surgery had the highest cancellation rate overall (36.4%), but oculoplastics had the highest cancellation rate in 2020 (48.9%).ConclusionThe most common reason for cancellation over the 10-year period was institution-related, in contrast to other publications based in academic centers. The study also had a higher cancellation rate than previously reported, again suggesting the difference between county and academic centers. The COVID-19 pandemic had a significant impact on cancellations, even after the COVID-19 stay-at-home orders were eased.

The diagnosis of primary vitreoretinal lymphoma and central nervous system lymphoma is challenging. In cases with intraocular involvement, vitreous biopsy plays a pivotal role. Several diagnostic tests are employed to confirm a diagnosis and include cytologic evaluation, immunohistochemistry, flow cytometry, and cytokine analysis. The limitations of these conventional diagnostic tests stem from the often paucicellular nature of vitreous biopsy specimens and the fragility of malignant cells ex vivo. Several emerging molecular techniques show promise in improving the diagnostic yield of intraocular biopsy, possibly enabling more accurate and timely diagnoses. This article will review existing diagnostic modalities for intraocular lymphoma, with an emphasis on currently available molecular tests.

Dry eye disease (DED) affects up to one-third of the global population. Traditional therapies, including topical lubricants, have been employed with variable success in the treatment of DED. Recently, neurostimulation of the lacrimal functional unit (LFU) has emerged as a promising alternative therapy for DED. In this review, we describe the neuroanatomical and pathophysiological considerations of DED and the LFU that make neurostimulation a viable therapeutic alternative. We further detail the various neurostimulatory approaches taken thus far-from implanted stimulators to external devices to chemical neurostimulation. Existing studies reveal the strengths of the neurostimulatory approach in increasing tear volume and improving dry eye symptoms, but further studies are needed to elucidate its true potential in treatment of DED.

Aims To develop a nomogram for prediction of visual acuity outcome following plaque radiotherapy for uveal melanoma. Methods Retrospective review of uveal melanoma treated with plaque radiotherapy and prophylactic intravitreal bevacizumab injections at 4-month intervals for 2 years duration. Two nomograms for poor visual acuity outcome (Snellen <20/200) were developed based on (1) Clinical risk factors. (2) Or clinical and treatment risk factors. Results There were 1131 included cases. The most important clinical risk factors (points for nomogram) for poor visual acuity outcome included subretinal fluid involving four quadrants (100), tumour thickness >4 mm (69), presenting visual acuity ≤20/30 (65), non-Caucasian race (58), tumour shape mushroom, bilobed, or multilobulated (57), and insulin-dependent diabetes (54). Risk of poor visual acuity at 2 years and 4 years increased from 11% and 24% with 40 points to 97% and >99% with 304 points. A second analysis was performed using both clinical and treatment risk factors. The most important factors included presenting visual acuity ≤20/30 (100), tumour largest basal diameter >11 mm (80), radiation dose rate to tumour base ≥164 cGy/hour (78), tumour thickness >4 mm (76), insulin-dependent diabetes (75) and abnormal foveolar status by optical coherence tomography at presentation (72). Risk of poor visual acuity at 2 years and 4 years increased from 6% and 14% with 56 points to 88% and 99% with 496 points. Conclusions A nomogram using clinical or treatment risk factors can predict visual acuity outcome following plaque radiotherapy and prophylactic intravitreal bevacizumab for uveal melanoma and is available online at https://fighteyecancer.com/nomograms/.

PURPOSE:To report a case of retinal cavernous hemangioma with intralesional phleboliths, simulating retinoblastoma.METHODS:A healthy 5-month-old girl developed left esotropia and was noted to have atraumatic vitreous hemorrhage with underlying partially calcified mass, suspicious for retinoblastoma.RESULTS:On examination, the visual acuity was fix and follow in the right eye and absent fixation in the left eye. Evaluation of the right eye revealed normal findings. The left eye demonstrated healthy anterior segment and dense vitreous hemorrhage with no view of the postequatorial structures, but with hazy view of the flat peripheral retina and a superonasal retinal mass, covered with fresh hemorrhage. Three white intralesional flecks, consistent with calcification, each measuring 300 μm, were visualized. B-scan ultrasonography confirmed the dense mass with several foci of calcification, suspicious for retinoblastoma, despite poor visualization on funduscopy. Prophylactic intravenous chemotherapy was delivered for globe salvage and systemic protection. At 12-month follow-up, the hemorrhage showed resolution, revealing a superonasal dark blue multilobulated mass with saccular aneurysms, measuring 16 mm in diameter, and with 3 phleboliths (intralesional calcification). Fluorescein angiography demonstrated early and midphase hypofluorescence with late-phase filling and with plasma-erythrocyte separation in some larger aneurysms, characteristic of retinal cavernous hemangioma.CONCLUSION:Retinal cavernous hemangioma can be associated with intralesional calcification (phleboliths).