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Jain P, Finger PT, Damato B, Coupland SE, Heimann H, Kenawy N, Brouwer NJ, Marinkovic M, Van Duinen SG, Caujolle JP, Maschi C, Seregard S, Pelayes D, Folgar M, Yousef YA, Krema H, Gallie B, Calle-Vasquez A. Multicenter, International Assessment of the Eighth Edition of the American Joint Committee on Cancer Cancer Staging Manual for Conjunctival Melanoma. JAMA Ophthalmol 2019; 137:905-911. [PMID: 31169891 PMCID: PMC6555476 DOI: 10.1001/jamaophthalmol.2019.1640] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Eye cancer staging systems used for standardizing patient care and research need to be validated. Objective To evaluate the accuracy of the eighth edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual in estimating metastatis and mortality rates of conjunctival melanoma. Design, Setting, and Participants This international, multicenter, registry-based case series pooled data from 10 ophthalmic oncology centers from 9 countries on 4 continents. A total of 288 patients diagnosed with conjunctival melanoma from January 1, 2001, to December 31, 2013, were studied. Data analysis was performed from July 7, 2018, to September 11, 2018. Interventions Treatments included excision biopsy, cryotherapy, topical chemotherapy, radiation therapy, enucleation, and exenteration. Main Outcomes and Measures Metastasis rates and 5-year and 10-year Kaplan-Meier mortality rates according to the clinical T categories and subcategories of the eighth edition of the AJCC Cancer Staging Manual. Results A total of 288 eyes from 288 patients (mean [SD] age, 59.7 [16.8] years; 147 [51.0%] male) with conjunctival melanoma were studied. Clinical primary tumors (cT) were staged at presentation as cT1 in 218 patients (75.7%), cT2 in 34 (11.8%), cT3 in 15 (5.2%), and cTx in 21 (7.3%). There were no T4 tumors. Pathological T categories (pT) were pTis in 43 patients (14.9%), pT1 in 169 (58.7%), pT2 in 33 (11.5%), pT3 in 12 (4.2%), and pTx in 31 (10.8%). Metastasis at presentation was seen in 5 patients (1.7%). Metastasis during follow-up developed in 24 patients (8.5%) after a median time of 4.3 years (interquartile range, 2.9-6.0 years). Of the 288 patients, 29 died (melanoma-related mortality, 10.1%) at a median time of 5.3 years (interquartile range, 1.8-7.0 years). The cumulative rates of mortality among patients with cT1 tumors were 0% at 1 year, 2.5% (95% CI, 0.7%-7.7%) at 5 years, and 15.2% (95% CI, 8.1%-27.4%) at 10 years of follow-up; among patients with cT2 tumors, 0% at 1 year, 28.6% (95% CI, 12.9%-58.4%) at 5 years, and 43.6% (95% CI, 19.6%-77.9%) at 10 years of follow-up; and among patients with cT3 tumors, 21.1% (95% CI, 8.1%-52.7%) at 1 year of follow-up and 31.6% (95% CI, 13.5%-64.9%) at 5 years of follow-up. Patients with cT2 and cT3 tumors had a significantly higher cumulative mortality rate compared with those presenting with cT1 tumors (log-rank P < .001). Patients with ulcerated melanomas had significantly higher risk of mortality (hazard ratio, 7.58; 95% CI, 1.02-56.32; P = .04). Conclusions and Relevance This multicenter, international, collaborative study yielded evidence that the conjunctival melanoma staging system in the eighth edition of the AJCC Cancer Staging Manual can be used to accurately estimate metastasis and mortality rates. These findings appear to support the use of AJCC staging as a tool for patient care and research.
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Rose K, Krema H, Durairaj P, Dangboon W, Chavez Y, Kulasekara SI, Hudson C. Retinal perfusion changes in radiation retinopathy. Acta Ophthalmol 2018; 96:e727-e731. [PMID: 29998553 DOI: 10.1111/aos.13797] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 03/24/2018] [Indexed: 12/31/2022]
Abstract
PURPOSE To investigate retinal blood flow and oxygen saturation changes in patients diagnosed with retinopathy following plaque radiation treatment to treat choroidal melanoma. METHODS Eight patients (mean age 55.75 years, SD 12.58 years) who have developed unilateral ischaemic radiation-related retinopathy as confirmed by wide-field fluorescein angiography were recruited for the study. The fellow eye with no other ocular or retinal pathology was used as control. Both eyes underwent measurement of total retinal blood flow (TRBF) and retinal blood oxygen saturation using prototype methodologies of Doppler Spectral Domain Optical Coherence Tomography (OCT) and Hyperspectral Retinal Camera, respectively. RESULTS The average TRBF in the retinopathy eye was significantly lower compared to the fellow eye (33.48 ± 12.73 μl/min versus 50.37 ± 15.26 μl/min; p = 0.013). The arteriolar oxygen saturation (SaO2 ) and venular oxygen saturation (SvO2 ) were higher in the retinopathy eye compared to the fellow eye (101.11 ± 4.26%, versus 94.45 ± 5.79%; p = 0.008) and (62.96 ± 11.05% versus 51.24 ± 6.88%, p = 0.051), respectively. CONCLUSION The ionizing radiation seems to have an impact on the TRBF, SaO2 and SvO2 , clinically presenting similar to a rapidly developing diabetic retinopathy. The results show an altered retinal vascular physiology in patients with radiation-related retinopathy.
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Hahn E, Velazquez-Martin J, Somani S, Payne D, Waldron J, Krema H, Simpson R, Laperriere N, Chung C. Hypofractionated Palliative Radiation Therapy for Choroidal Metastases: Clinical Outcomes and Predictors of Overall Survival. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.1908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Navajas EV, Krema H, Hammoudi DS, Lipton JH, Simpson ER, Boyd S, Easterbrook M. Retinal toxicity of high-dose hydroxychloroquine in patients with chronic graft-versus-host disease. Can J Ophthalmol 2016; 50:442-50. [PMID: 26651304 DOI: 10.1016/j.jcjo.2015.08.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Revised: 08/21/2015] [Accepted: 08/26/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate retinal toxicity in patients treated with high-dose hydroxychloroquine (HCQ) (Plaquenil, Sanofi Pharmaceuticals) for chronic graft-versus-host disease (GVHD). DESIGN Cohort study. PARTICIPANTS Twelve patients with chronic GVHD treated with 800 mg/day HCQ between June 2005 and December 2010. METHODS Patients in this study underwent ophthalmologic examination yearly and ancillary studies including colour vision, Amsler grid, fundus photographs, Humphrey 10-2 automated perimetry, spectral-domain optical coherence tomography (SD-OCT), and multifocal electroretinography (mfERG). Evidence of HCQ toxicity was determined by the presence of scotomas in the Amsler grid and Humphrey 10-2 automated perimetry, and confirmed by at least 1 objective test including SD-OCT or mfERG. RESULTS Of the 12 patients, 7 were male and 5 were female. Mean age was 49 years. Mean best corrected visual acuity at baseline was 20/25 and remained 20/25 at final follow-up. Median duration of HCQ treatment was 22.8 months. Median adjusted daily dosage was 11.5 mg/kg/day. Seven patients developed vortex keratopathy. No signs of pigmentary retinopathy or bull's-eye maculopathy were found in any of the patients. Three patients developed retinal toxicity with scotomas in the Amsler grid and Humphrey 10-2 automated perimetry, as well as abnormal mfERG. Retinal structure measured by SD-OCT was abnormal in 2 of the 3 patients with retinal toxicity. Colour vision measured by Ishihara plates, as well as by 100 Hue colour test, was abnormal in 2 of the 3 patients with retinal toxicity. CONCLUSIONS High-dose HCQ in patients with GVHD was associated with higher incidence and earlier development of retinal toxicity.
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Iakovlev E, Ghorab Z, Krema H, Iakovlev V, Kertes P, Yucel Y. Differentiation between Melanin-Laden Macrophages and Melanoma Cells in Vitreous Aspirates. Acta Cytol 2016; 60:25-30. [PMID: 26937744 DOI: 10.1159/000444208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 01/19/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The differential diagnosis between retinal detachment and melanoma metastatic to the vitreous can be challenging, both clinically and cytologically. We demonstrate the diagnostic features and pitfalls of the cytological assessment. STUDY DESIGN A case of a metastatic melanoma to the vitreous is compared to a case of retinal detachment initially suspected as melanoma metastasis. Case 1 was a 54-year-old patient with a vague history of pigmented lesions 20 years previously and a current presentation of a visual defect. Case 2 was a 68-year-old patient with a history of melanoma and a presentation of floaters and flashing lights. RESULTS The vitreous fluid of case 1 contained atypical, pigment-laden cells positive for HMB-45 and assessed as melanoma. On enucleation, a melanoma metastatic to the vitreous was diagnosed. The vitreous fluid of case 2 revealed atypical cells containing pigment granules. The cells were negative for melanocytic markers, while the granules stained positive for melanin. Macrophage marker CD163 was positive in all cells. The interpretation was one of macrophages reactive to the retinal detachment. CONCLUSION Melanin-laden macrophages can mimic melanoma cells. This needs to be considered in the differential diagnosis. Additional stains can help the distinction.
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Al-Jamal RT, Cassoux N, Desjardins L, Damato B, Konstantinidis L, Coupland SE, Heimann H, Petrovic A, Zografos L, Schalenbourg A, Velazquez-Martin JP, Krema H, Bogdali A, Markiewicz A, Romanowska-Dixon B, Metz CHD, Biewald E, Bornfeld N, Kiratli H, Bronkhorst IHG, Jager MJ, Marinkovic M, Fili M, Seregard S, Frenkel S, Pe'er J, Salvi SM, Rennie IG, Rospond-Kubiak I, Kociecki J, Kiilgaard JF, Heegaard S, Cohen VML, Sagoo MS, Amiryan A, Saakyan S, Eide N, Krohn J, Midena E, Parrozzani R, Grange JD, Kilic E, Blasi MA, Saornil MA, Kivelä TT. The Pediatric Choroidal and Ciliary Body Melanoma Study: A Survey by the European Ophthalmic Oncology Group. Ophthalmology 2016; 123:898-907. [PMID: 26854035 DOI: 10.1016/j.ophtha.2015.12.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 12/13/2015] [Accepted: 12/14/2015] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To collect comprehensive data on choroidal and ciliary body melanoma (CCBM) in children and to validate hypotheses regarding pediatric CCBM: children younger than 18 years, males, and those without ciliary body involvement (CBI) have more favorable survival prognosis than young adults 18 to 24 years of age, females, and those with CBI. DESIGN Retrospective, multicenter observational study. PARTICIPANTS Two hundred ninety-nine patients from 24 ocular oncology centers, of whom 114 were children (median age, 15.1 years; range, 2.7-17.9 years) and 185 were young adults. METHODS Data were entered through a secure website and were reviewed centrally. Survival was analyzed using Kaplan-Meier analysis and Cox proportional hazards regression. MAIN OUTCOME MEASURES Proportion of females, tumor-node-metastasis (TNM) stage, cell type, and melanoma-related mortality. RESULTS Cumulative frequency of having CCBM diagnosed increased steadily by 0.8% per year of age between 5 and 10 years of age and, after a 6-year transition period, by 8.8% per year from age 17 years onward. Of children and young adults, 57% and 63% were female, respectively, which exceeded the expected 51% among young adults. Cell type, known for 35% of tumors, and TNM stage (I in 22% and 21%, II in 49% and 52%, III in 30% and 28%, respectively) were comparable for children and young adults. Melanoma-related survival was 97% and 90% at 5 years and 92% and 80% at 10 years for children compared with young adults, respectively (P = 0.013). Males tended to have a more favorable survival than females among children (100% vs. 85% at 10 years; P = 0.058). Increasing TNM stage was associated with poorer survival (stages I, II, and III: 100% vs. 86% vs. 76%, respectively; P = 0.0011). By multivariate analysis, being a young adult (adjusted hazard rate [HR], 2.57), a higher TNM stage (HR, 2.88 and 8.38 for stages II and III, respectively), and female gender (HR, 2.38) independently predicted less favorable survival. Ciliary body involvement and cell type were not associated with survival. CONCLUSIONS This study confirms that children with CCBM have a more favorable survival than young adults 18 to 25 years of age, adjusting for TNM stage and gender. The association between gender and survival varies between age groups.
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Hahn E, Velazquez-Martin JP, Somani S, Salazar P, Domville D, Payne D, Xu W, Su J, Pavlin C, Simpson R, Laperriere N, Krema H, Waldron JN, Chung C. Outcomes of hypofractionated palliative radiotherapy for choroidal metastases. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.29_suppl.194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
194 Background: External beam radiotherapy (RT) is an effective palliative treatment for choroidal metastases aimed at preserving vision and obtaining local tumor control. Delivery of 30-40 Gy in 2 Gy daily fractions is a standard approach in many centers. At our center, a shorter, more convenient schedule of 20 Gy in 5 fractions has been used in this palliative setting. This study reports the efficacy and toxicity of this hypofractionated RT approach. Methods: We conducted a retrospective review of patients treated in the Ocular Oncology clinic at Princess Margaret Cancer Center who received RT (20 Gy in 5 fractions) for choroidal metastases between January 1, 1999 and November 30, 2012. Primary outcome measures were change in visual acuity and tumor response. Secondary outcomes included toxicities of RT, tumor control, and overall survival from the date of choroidal metastases diagnosis. Results: A total of 55 patients with 71 involved eyes were included. Decreased vision was the presenting symptom in 43 eyes (61%). Visual acuity improved from a median of 20/70 to 20/40 between baseline assessment and last follow-up, and remained stable or improved in 56 eyes (80%). On ultrasound, tumor regression was observed in 64 eyes (91%) with complete response in 47 eyes (67%). Metastases progressed in 4 eyes (6%) despite RT with 1 eye requiring enucleation. Median survival after diagnosis of choroidal metastases was 13 months with estimated overall survival at 1, 2, and 3 years to be 50% (36-62), 23% (12-35), and 8% (3-18), respectively. Forty-nine patients (89%) did not experience any acute complications. Mild acute toxicities included transitory dryness in 5 patients and episcleritis in 1 patient. Cataracts developed in 4 eyes (6%), retinopathy in 1 eye, optic neuropathy in 7 eyes (10%), pigmentary maculopathy in 5 eyes (7%), and neovascular glaucoma in 1 eye. Conclusions: A short fractionation schedule of 20 Gy in 5 fractions is a well-tolerated treatment that effectively preserves vision and gains local tumor control for many patients with choroidal metastases. This hypofractionated approach would help reduce the burden of a longer treatment course in this palliative patient population.
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Alrashidi S, Aziz AA, Krema H. Bilateral diffuse uveal melanocytic proliferation: a management dilemma. BMJ Case Rep 2014; 2014:bcr-2014-204387. [PMID: 24855079 DOI: 10.1136/bcr-2014-204387] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A female patient suffered from gradual decline of vision for few months. She presented with bilateral multiple pigmented choroidal tumours, associated with overlying retinal changes. The clinical presentation suggested bilateral diffuse uveal melanocytic proliferation (BDUMP) syndrome, which is a paraneoplastic disease, although there was no evidence of any concurrent malignancy. The periodic systemic surveillance that was undertaken for the following 4 years failed to reveal any occult cancer. Nevertheless, there has been relentless progressive deterioration in vision as a consequence of BDUMP syndrome. The management of the declining vision in BDUMP syndrome is challenging and controversial.
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Krema H, Simpson R, McGowan H. Choroidal melanoma in phacomatosis pigmentovascularis cesioflammea. Can J Ophthalmol 2014; 48:e41-2. [PMID: 23769789 DOI: 10.1016/j.jcjo.2012.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 11/23/2012] [Accepted: 11/28/2012] [Indexed: 10/26/2022]
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Krema H, El-Bolkainy N. A stepwise multimodality treatment of diffuse angiolymphoid hyperplasia of the orbit. Orbit 2013; 33:75-7. [PMID: 24195724 DOI: 10.3109/01676830.2013.851254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The definite treatment of angiolymphoid hyperplasia is debatable. We report the case of a middle-aged man with an extensive angiolymphoid hyperplasia of the orbit that has been recalcitrant to multiple single-line treatments for 9 years. His previous treatment included several short courses of full-dose systemic steroids, debulking surgeries, and orbital radiotherapy. A stepwise multimodality treatment approach in this case could achieve a lasting satisfactory functional and cosmetic outcome.
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Abstract
We report the technique and outcome of surgical excision of subcutaneous orbital capillary hemangioma causing eye globe displacement in two children. Primary surgical excision was performed with blunt dissection along the tumor walls using a cotton-tipped applicator as the dissecting tool with simultaneous outward gentle traction on the tumor wall. Despite the deep and extensive orbital involvement, complete excision of the hemangiomas was achievable with this technique, which permitted excellent visualization of the surgical planes throughout the procedures. Deep and extensive pediatric orbital capillary hemangioma can be surgically excised with the suggested technique, which obviates the need for intralesional or systemic medical therapy, yielding optimal cosmetic and functional outcomes, shortly after surgery.
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Pavlin CJ, Velasquez-Martin JP, Krema H, Simpson ER. Reply: To PMID 23219068. Am J Ophthalmol 2013; 156:628. [PMID: 23953161 DOI: 10.1016/j.ajo.2013.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 05/17/2013] [Accepted: 05/23/2013] [Indexed: 11/27/2022]
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Krema H, El-Bolkainy N. Rapid growth of an epibulbar complex choristoma in organoid nevus syndrome. Can J Ophthalmol 2013; 48:e82-5. [PMID: 23931491 DOI: 10.1016/j.jcjo.2013.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Revised: 12/31/2012] [Accepted: 02/21/2013] [Indexed: 11/15/2022]
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Krema H, Fernandes B, Simpson R, Lutchman C, Yucel Y. Diffuse metastatic melanoma to the retina: a clinicopathologic report. Can J Ophthalmol 2013; 48:e20-1. [PMID: 23561612 DOI: 10.1016/j.jcjo.2012.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 09/28/2012] [Accepted: 10/14/2012] [Indexed: 10/26/2022]
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Krema H, Heydarian M, Beiki-Ardakani A, Weisbrod D, Xu W, Laperriere NJ, Sahgal A. Dosimetric and Late Radiation Toxicity Comparison Between Iodine-125 Brachytherapy and Stereotactic Radiation Therapy for Juxtapapillary Choroidal Melanoma. Int J Radiat Oncol Biol Phys 2013; 86:510-5. [DOI: 10.1016/j.ijrobp.2013.02.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 12/22/2012] [Accepted: 02/05/2013] [Indexed: 12/01/2022]
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Alrashidi S, Yousef YA, Krema H. Visual loss from scleritis in C-ANCA-positive microscopic polyangiitis. BMJ Case Rep 2013; 2013:bcr-2013-009583. [PMID: 23761504 DOI: 10.1136/bcr-2013-009583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Scleritis is an inflammation of the outer eye coating that manifests with redness and ocular pain, and tends to be more severe when associated with a systemic collagen disease. Antineutrophil cytoplasmic antibody (ANCA)-positive microscopic polyangiitis is an autoimmune, multisystem, chronic disease characterised by damage to the endothelial lining of small vessels, and can be associated with severe scleritis that necessitates early aggressive therapy to prevent severe ocular complications.
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Krema H, Yousef YA, Durairaj P, Santiago R. Failure of systemic propranolol therapy for choroidal hemangioma of Sturge-Weber syndrome: a report of 2 cases. JAMA Ophthalmol 2013; 131:681-3. [PMID: 23538554 DOI: 10.1001/jamaophthalmol.2013.2879] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Krema H, Herrmann E, Albert-Green A, Payne D, Laperriere N, Chung C. Orthovoltage radiotherapy in the management of medial canthal basal cell carcinoma. Br J Ophthalmol 2013; 97:730-4. [DOI: 10.1136/bjophthalmol-2012-302991] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Krema H, Fernandes B, Simpson R, McGowan H, Yücel YH. Knapp-Rønne choroidal melanoma: a clinicopathological report. Can J Ophthalmol 2013; 48:e14-5. [PMID: 23419307 DOI: 10.1016/j.jcjo.2012.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 08/29/2012] [Accepted: 09/04/2012] [Indexed: 10/26/2022]
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Velazquez-Martin JP, Krema H, Gottlieb CC, Simpson ER, Pavlin CJ. Bilateral multifocal choroidal melanosis: a report of two cases. Ophthalmic Surg Lasers Imaging Retina 2013; 44:193-5. [PMID: 23402368 DOI: 10.3928/23258160-20130130-03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 12/31/2012] [Indexed: 11/20/2022]
Abstract
Flat choroidal pigmented lesions have few differential diagnoses but encompass a wide range of clinical presentations. The authors report two cases of bilateral multifocal choroidal hyper-pigmented patches discovered in asymptomatic patients. Fluorescein angiography showed a normal pattern without blockage in the hyperpigmented areas with an otherwise normal choroidal vascular architecture. Optical coherence tomography with enhanced depth imaging demonstrated normal choroidal thickness and structure in the hyperpigmented areas. These cases may represent an atypical presentation of previously described bilateral isolated choroidal melanocytosis or a different clinical entity. Histopathological evidence and longer follow-up of these patients and patients with isolated choroidal melanocytosis may elucidate the best descriptive term for this unusual condition.
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Krema H, Heydarian M, Beiki-Ardakani A, Weisbrod D, Xu W, Simpson ER, Sahgal A. A comparison between125Iodine brachytherapy and stereotactic radiotherapy in the management of juxtapapillary choroidal melanoma. Br J Ophthalmol 2013; 97:327-32. [DOI: 10.1136/bjophthalmol-2012-302808] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Krema H, McGowan H, Tanzer H, Simpson R, Laperriere N. Unusual orange-colored choroidal metastases. J Ophthalmic Vis Res 2013; 8:53-7. [PMID: 23825713 PMCID: PMC3691979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 12/19/2012] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To report the clinical and paraclinical features of two patients with orange- colored choroidal metastases in whom the primary cancers have not previously been associated with such lesions. CASE REPORT Orange-colored choroidal lesions were detected on the fundus examination of one patient with metastatic small cell neuroendocrine tumor of the larynx and oropharynx, and in another subject with metastatic alveolar soft part sarcoma of the leg. Although ultrasonographic characteristics of the choroidal masses were comparable to those of choroidal hemangiomas, fluorescein angiography revealed delayed initial fluorescence along with minimal fluorescence in subsequent phases of the angiogram which were in clear distinction from the earlier appearing and progressively intense fluorescence observed with circumscribed choroidal hemangiomas. CONCLUSION Small cell neuroendocrine tumors and alveolar soft part sarcomas should be considered among the differential diagnoses for orange-colored choroidal metastases. Identifying these choroidal lesions could facilitate localizing the occult primary tumor. Fluorescein angiography may differentiate a unifocal orange choroidal metastasis from a circumscribed choroidal hemangioma.
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Law C, Krema H, Simpson ER. Referral patterns of intraocular tumour patients to a dedicated Canadian ocular oncology department. Can J Ophthalmol 2012; 47:254-61. [PMID: 22687302 DOI: 10.1016/j.jcjo.2012.03.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2011] [Revised: 12/27/2011] [Accepted: 02/03/2012] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Intraocular tumours are uncommon lesions requiring comprehensive management at tertiary referral centers. This study analyzes referral patterns of intraocular tumours, accuracy of referral diagnosis, and modes of treatment provided for patients at a dedicated Canadian Ocular Oncology Department. DESIGN Retrospective chart review. PARTICIPANTS A total of 1050 new patient referrals of intraocular tumours to the department of Ocular Oncology at Princess Margaret Hospital (PMH) between 2005 and 2008 inclusive. METHODS Data collected for each patient included demographics, referral diagnosis, final diagnosis, and treatment provided or recommended. Home address postal codes were used to determine patients' geographical distance to PMH. RESULTS Most patients originated from Ontario (81.5%) followed by Alberta (7.1%) with a median age of referral at 61 years old. The most common referral diagnoses were unknown diagnosis (47.6%), uveal melanoma (26.9%), and nevus (18.9%). After evaluation at PMH, uveal nevus was the most common final diagnosis (39.7%) followed by melanoma (39.2%). The referring physicians correctly diagnosed 48.5% of total melanomas. The proportion of melanoma diagnosis relative to total referrals by province ranged from 29.6% for Ontario to 100% for Quebec. Distance from the patient's address to PMH was <200 kilometres in 64.5% of patients and >1000 kilometres in 21.6% of patients. CONCLUSIONS The limited accuracy of referral diagnoses and increased proportion of melanoma referrals from greater distances demonstrates the need for increased knowledge in ocular oncology, improvement of eye cancer care facilities at the referral base, and/or the implementation of tele-ophthalmology.
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Santiago RA, Krema H, Pavlin CJ. Ultrasound biomicroscopy diagnosis of an axenfeld loop. Ophthalmic Surg Lasers Imaging Retina 2012; 43 Online:e85-6. [PMID: 22849807 DOI: 10.3928/15428877-20120726-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 05/29/2012] [Indexed: 11/20/2022]
Abstract
A 67-year-old man was referred for evaluation of a small mass on the sclera of the right eye. Ultrasound biomicroscopy of the mass suggested the diagnosis of Axenfeld loop.
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Giuliari GP, Krema H, McGowan HD, Pavlin CJ, Simpson ER. Clinical and ultrasound biomicroscopy features associated with growth in iris melanocytic lesions. Am J Ophthalmol 2012; 153:1043-9. [PMID: 22321804 DOI: 10.1016/j.ajo.2011.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 11/07/2011] [Accepted: 11/08/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE To determine the clinical and ultrasound biomicroscopy (UBM) features associated with growth in iris melanocytic lesions. STUDY DESIGN Retrospective case series analysis. METHODS We included all iris melanocytic lesions that were monitored between January 2005 and November 2009. At the end of the analysis, 44 eyes of 44 patients were included in the final analysis. The clinical features analyzed were: iris color, largest base diameter, radial location of the lesion epicenter, circumferential location of the lesion epicenter, lesion configuration, lesion pigmentation, intrinsic vascularity within the lesion, presence of associated pigmentation, the impact on the pupil, presence of iris atrophy, and lesion-induced localized cataracts. The UBM features included lesion thickness, presence of corneal touch, presence of surface plaque, internal structure, and internal reflectivity. Regression analysis was performed to define the features associated with growth. RESULTS Twenty-three percent of the lesions showed documented growth. Mean follow-up was 21.4 months (range: 10-48). Clinical features associated with growth were a large basal diameter at baseline (P = .004) and inferior location (P = .004). UBM features associated with growth were: a greater baseline thickness (P = .01), presence of corneal touch (P = .007), an irregular internal structure (P = .0001), and the presence of dots and linear streaks (P < .0001). Clinical features that were not associated with growth were the radial location of the lesion in the iris (P > .999), lesion configuration (P > .999), lesion pigmentation (P > .999), the presence of pigment dispersion (P = .70), iris freckles (P = .15), corectopia (P > .999), ectropion (P > .999), and intrinsic vascularity (P = .70). UBM features not associated with growth were the presence of a surface plaque (P = .07) and the internal reflectivity (P = .77). CONCLUSION Substantial growth in iris melanocytic lesions is associated with original larger basal diameter and inferior lesion location. On UBM growth is associated with greater original thickness, presence of corneal touch, and an irregular internal structure. Presence of these features could modify the frequency of observation of those lesions.
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