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Singh AD, Raval V, Wrenn J, Zabor EC. Small Choroidal Melanoma: Outcomes After Surveillance Versus Immediate Treatment. Am J Ophthalmol 2022; 241:47-56. [PMID: 35358487 DOI: 10.1016/j.ajo.2022.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/09/2022] [Accepted: 03/18/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE To quantify potential loss (loss of vision) and gain (freedom from metastasis) in patients with small choroidal melanoma treated after a period of surveillance to document growth. METHODS A total of 167 patients with small choroidal melanoma (size: 5.0-16.0 mm in largest basal diameter and 1.0-2.5 mm in height) were identified: 42 treated after surveillance (documented growth) and 125 treated immediately. A prediction model was applied to each patient in the immediate treatment group to obtain the predicted risk of melanoma (high risk vs low risk). Potential loss (loss of vision) and gain (freedom from metastasis) were compared between the low-risk immediate treatment group and those treated after surveillance. RESULTS By using the optimal cut point (0.60; 95% confidence interval: 0.37-0.61) of predicted risk for small choroidal melanoma (sensitivity: 0.74, specificity: 0.95), we identified 94 (75%) patients as high risk (score: ≥0.6) and the remaining 31 (25%) as having low-risk melanoma (score: <0.6). Over a median follow-up of 34.6 months, 5 developed metastasis (high risk = 4, low risk = 1) compared with 1 patient in the surveillance group. Initial visual acuity and loss of <15-letter visual acuity were not significantly different at 36 months between the low-risk patients immediately treated and those treated after surveillance (81% vs 83%), respectively. CONCLUSIONS Low-risk choroidal melanoma identified by the prediction model can be labeled as an indeterminate melanocytic tumor. Such patients can be managed by surveillance to document growth before receiving vision-threatening treatment without increased risk of metastatic death. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.
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Affiliation(s)
- Arun D Singh
- From the Ophthalmic Oncology, Cole Eye Institute, Cleveland Clinic (A.D.S., V.R., J.W.), and.
| | - Vishal Raval
- From the Ophthalmic Oncology, Cole Eye Institute, Cleveland Clinic (A.D.S., V.R., J.W.), and
| | - Jacquelyn Wrenn
- From the Ophthalmic Oncology, Cole Eye Institute, Cleveland Clinic (A.D.S., V.R., J.W.), and
| | - Emily C Zabor
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic (E.C.Z.), Cleveland, Ohio, USA
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Raval V, Luo S, Zabor EC, Singh AD. Small Choroidal Melanoma: Correlation of Growth Rate with Pathology. Ocul Oncol Pathol 2021; 7:401-410. [PMID: 35087817 PMCID: PMC8740066 DOI: 10.1159/000517203] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/12/2021] [Indexed: 01/13/2023] Open
Abstract
PURPOSE The aim of the study was to evaluate equivalence of growth rate and pathologic confirmation in small choroidal melanoma (SCM). DESIGN This study is a case series. SUBJECTS PARTICIPANTS AND CONTROLS A total of 61 patients with a choroidal melanocytic tumor of size 5.0-16.0 mm in the largest basal diameter and 1.0-2.5 mm in thickness were classified into the pathology-confirmed group (n = 19), growth-confirmed group (n = 30), and with combined observations (n = 12). METHODS Distribution of clinical variables (age, gender, laterality, tumor dimensions, tumor location, and presence of orange pigment, subretinal fluid, drusen, and retinal pigment epithelial [RPE] atrophy) between the groups was analyzed. Patient and disease characteristics were summarized as the median and interquartile range for continuous variables and the frequency and percentage for categorical variables. Comparisons were made using the Wilcoxon rank sum test for continuous variables and either Fisher's exact test or the χ2 test for categorical variables with a p value threshold of 0.05 for statistical significance. Growth rate (change in basal dimension/12 months) diagnostic of SCM was quantified. MAIN OUTCOME MEASURES The primary aim of this study was to test the hypothesis that "growth" was diagnostic of SCM with the secondary aim of quantifying the malignant "growth rate" (growth rate of SCM). RESULTS The clinical characteristics among all 3 groups were similar except more patients with symptoms (68 vs. 20 vs. 42%, p = 0.004) and juxtapapillary location (p = 0.03) were in the pathology group than in the growth-confirmed group. Those in the combined and growth-confirmed groups had more patients with drusen (11 vs. 60 vs. 50%, p = 0.003) and RPE atrophy (11 vs. 23 vs. 67%, p = 0.003), respectively, than in the pathology group. The median time to detect growth was 9 months (range 3-26 months). The mean growth rate in basal dimension was 1.8 mm/12 months (range, 0.0-7.4 mm; [95% CI: 1.32-2.28]). CONCLUSIONS AND RELEVANCE Choroidal melanocytic lesions exhibiting a defined growth rate can be clinically diagnosed as SCM without a need for biopsy.
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Affiliation(s)
- Vishal Raval
- Ophthalmic Oncology, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shiming Luo
- Ophthalmic Oncology, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Emily C. Zabor
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arun D. Singh
- Ophthalmic Oncology, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Luo S, Raval V, Zabor EC, Singh AD. Small Choroidal Melanoma: Correlation between Clinical Characteristics and Metastatic Potential. Ocul Oncol Pathol 2021; 7:437-446. [PMID: 35087820 PMCID: PMC8740206 DOI: 10.1159/000519672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 09/10/2021] [Indexed: 11/19/2022] Open
Abstract
IMPORTANCE Diagnosis of small choroidal melanoma is based upon clinical features and presence of factors predictive of local malignant growth. Prognostic biopsy quantifies risk of metastasis. OBJECTIVE The aim of this study is to explore relationship between clinical characteristics and metastatic potential of a small choroidal melanoma. DESIGN Retrospective review of 53 patients with small choroidal melanoma treated in a tertiary oncology clinic. Patients were derived from 3 cohorts, with pathologic confirmation, with growth confirmation, and those treated only on clinical basis. Based upon prognostic biopsy outcomes, each case was classified into low or high metastatic potential groups. Distribution of clinical characteristics such as age, laterality, symptoms, tumor dimensions, tumor distance from optic nerve and fovea, presence of surface orange pigment, drusen, retinal pigment epithelial atrophy, and subretinal fluid was analyzed between metastatic groups. MAIN OUTCOME MEASURES Distribution of clinical characteristics between low or high metastatic potential groups was analyzed. RESULTS A total of 53 patients [mean age, 61 years (range, 27-81 years); 32 (60%) men and 21 (40%) women] were classified into pathology confirmed group (n = 13), growth confirmed group (n = 26), and with clinical group (n = 14). Prognostic biopsy in the growth, pathology, and clinical groups revealed low metastatic potential in 23, 10, and 11 patients, respectively, and high metastatic potential in 3 patients in each group. Distribution of clinical characteristics between low or high metastatic potential groups was not statistically significantly different. CONCLUSION Clinical characteristics do not identify metastatic potential of a small choroidal melanoma.
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Affiliation(s)
- Shiming Luo
- Department of Quantitative Health Sciences & Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vishal Raval
- Department of Quantitative Health Sciences & Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Emily C Zabor
- Ophthalmic Oncology, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arun D Singh
- Department of Quantitative Health Sciences & Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Shields CL, Lally SE, Dalvin LA, Sagoo MS, Pellegrini M, Kaliki S, Gündüz AK, Furuta M, Mruthyunjaya P, Fung AT, Duker JS, Selig SM, Yaghy A, Ferenczy SR, Eydelman MB, Blumenkranz MS. White Paper on Ophthalmic Imaging for Choroidal Nevus Identification and Transformation into Melanoma. Transl Vis Sci Technol 2021; 10:24. [PMID: 34003909 PMCID: PMC7900849 DOI: 10.1167/tvst.10.2.24] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Purpose To discuss the evolution of noninvasive diagnostic methods in the identification of choroidal nevus and determination of risk factors for malignant transformation as well as introduce the novel role that artificial intelligence (AI) can play in the diagnostic process. Methods White paper. Results Longstanding diagnostic methods to stratify benign choroidal nevus from choroidal melanoma and to further determine the risk for nevus transformation into melanoma have been dependent on recognition of key clinical features by ophthalmic examination. These risk factors have been derived from multiple large cohort research studies over the past several decades and have garnered widespread use throughout the world. More recent publications have applied ocular diagnostic testing (fundus photography, ultrasound examination, autofluorescence, and optical coherence tomography) to identify risk factors for the malignant transformation of choroidal nevus based on multimodal imaging features. The widespread usage of ophthalmic imaging systems to identify and follow choroidal nevus, in conjunction with the characterization of malignant transformation risk factors via diagnostic imaging, presents a novel path to apply AI. Conclusions AI applied to existing ophthalmic imaging systems could be used for both identification of choroidal nevus and as a tool to aid in earlier detection of transformation to malignant melanoma. Translational Relevance Advances in AI models applied to ophthalmic imaging systems have the potential to improve patient care, because earlier detection and treatment of melanoma has been proven to improve long-term clinical outcomes.
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Affiliation(s)
- Carol L Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sara E Lally
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lauren A Dalvin
- Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA
| | - Mandeep S Sagoo
- Ocular Oncology Service, Moorfields Eye Hospital and NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital and University College London Institute of Ophthalmology, London, UK
| | - Marco Pellegrini
- Eye Clinic, Department of Biomedical and Clinical Science "Luigi Sacco", Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Swathi Kaliki
- The Operation Eyesight Universal Institute for Eye Cancer, LV Prasad Eye Institute, Hyderabad, India
| | - Ahmet Kaan Gündüz
- Department of Ophthalmology, Ankara University School of Medicine, Ankara, Turkey
| | - Minoru Furuta
- Department of Ophthalmology, Fukushima Medical University, Fukushima, Japan and Department of Ophthalmology, Yachiyo Medical Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Prithvi Mruthyunjaya
- Ocular Oncology Service, Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Adrian T Fung
- Westmead and Central Clinical Schools, Discipline of Clinical Ophthalmology and Eye Health, University of Sydney, Australia and Department of Ophthalmology, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Jay S Duker
- New England Eye Center, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Sara M Selig
- Melanoma Research Foundation, Washington, DC, USA
| | - Antonio Yaghy
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sandor R Ferenczy
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA
| | - Malvina B Eydelman
- Office of Ophthalmic, Anesthesia, Respiratory, Ear, Nose and Throat (ENT), and Dental Devices, Food & Drug Administration (FDA), Washington, DC
| | - Mark S Blumenkranz
- Department of Ophthalmology, Ophthalmology Innovation Program, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
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Shields CL, Sioufi K, Srinivasan A, Di Nicola M, Masoomian B, Barna LE, Bekerman VP, Say EAT, Mashayekhi A, Emrich J, Komarnicky L, Shields JA. Visual Outcome and Millimeter Incremental Risk of Metastasis in 1780 Patients With Small Choroidal Melanoma Managed by Plaque Radiotherapy. JAMA Ophthalmol 2019; 136:1325-1333. [PMID: 30267070 DOI: 10.1001/jamaophthalmol.2018.3881] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Early detection of choroidal melanoma at a small tumor size is emphasized in the literature. However, there is little published information on the specific risks of plaque-irradiated small choroidal melanoma on visual acuity and metastasis. Objective To analyze outcomes of plaque radiotherapy for small choroidal melanoma 3 mm in thickness or less. Design, Setting, and Participants This retrospective noncomparative series at a tertiary referral center included 1780 consecutive patients who had received plaque radiotherapy treatment for small choroidal melanoma. Main Outcomes and Measures Visual acuity outcomes and melanoma-associated metastasis, assessed by Kaplan-Meier analyses. Results The mean (SD) patient age at melanoma diagnosis was 58 (14) years. Of 1780 patients, 908 were female (51.0%), and 1752 were white (98.4%). Visual acuity was 20/40 OU or better in 1276 of the patients (71.7%), and the mean (SD) visual acuity was 20/40 (20/50) OU (median, 20/30; range, 20/20 to counting fingers). The mean (SD) tumor basal dimension was 8.8 (2.9) mm (median, 8.0 mm; range, 2.0-20.0 mm) and mean (SD) tumor thickness was 2.6 (0.5) mm (median, 2.7; range, 0.2-3.4 mm). Mean (SD) distance to the foveola was 3.4 (3.9) mm and to the optic disc was 3.7 (3.7) mm. The Kaplan-Meier rate of visual acuity loss (≥3 Snellen lines) was 9.5% (95% CI, 8.2%-11.0%) at 1 year, 39.2% (95% CI, 36.5%-42.0%) at 5 years, and 48.9% (95% CI, 45.6%-52.3%) at 10 years, whereas poor visual acuity (≤20/200) was 7.1% (95% CI, 5.9%-8.4%) at 1 year, 38.2% (95% CI, 35.5%-41.1%) at 5 years, and 53.5% (95% CI, 50.1%-57.1%) at 10 years. Regarding melanoma-associated metastasis, the rate was 0.2% (95% CI, 0.09%-0.6%) at 1 year, 4.5% (95% CI, 3.4%-5.9%) at 5 years, and 8.8% (95% CI, 6.9%-11.1%) at 10 years. Using 1.0-mm thickness increments, the 10-year risk for metastasis was 25.0% (95% CI, 3.9%-87.2%) at 0-mm to 1.0-mm thickness, 5.9% (95% CI, 2.5%-13.5%) at 1.1-mm to 2.0-mm thickness, 8.1% (95% CI, 5.9%-11.0%) at 2.1-mm to 3.0-mm thickness, and 13.4% (95% CI, 8.7%-20.4%) at thicknesses greater than 3.0 mm. The greater relative risk (RR) for metastasis in thinnest tumors was 1.83 (95% CI, 1.09-3.07), which likely represented more aggressive diffuse (flat) melanoma. By multivariable analysis, clinical features predictive of melanoma-associated metastasis included increasing patient age (RR, 1.32 [95% CI, 1.07-1.63] per decade; P = .01), tumor diameter (RR, 1.15 [95% CI, 1.06-1.24] per mm; P < .001), tumor thickness (RR, 2.22 [95% CI, 1.22-4.05] per mm; P = .01), photopsia symptoms (RR, 2.45 [95% CI, 1.35-4.43]; P = .003), and prior treatment before plaque radiotherapy (RR, 3.31 [95% CI, 1.31-8.33]; P = .01). Conclusions and Relevance This retrospective study suggests that small choroidal melanoma treated with plaque radiotherapy has a 10-year risk for visual acuity loss of 48.9% (95% CI, 45.6%-52.3%) and a 10-risk of systemic metastasis of 8.8% (95% CI, 6.9%-11.1%). In this analysis, each millimeter of increasing thickness and diameter contributed risk for metastatic disease.
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Affiliation(s)
- Carol L Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kareem Sioufi
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Archana Srinivasan
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Maura Di Nicola
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Babak Masoomian
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Laura E Barna
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Vladislav P Bekerman
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Emil A T Say
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Arman Mashayekhi
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jacqueline Emrich
- Department of Radiation Oncology, Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Lydia Komarnicky
- Department of Radiation Oncology, Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Jerry A Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
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Yaghy A, Yu MD, Dalvin LA, Mazloumi M, Ferenczy SR, Shields CL. Photoreceptor morphology and correlation with subretinal fluid chronicity associated with choroidal nevus. Br J Ophthalmol 2019; 104:863-867. [PMID: 31533930 DOI: 10.1136/bjophthalmol-2019-314755] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/05/2019] [Accepted: 09/09/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Subretinal fluid (SRF) can be associated with choroidal nevus and can cause progressive change in the morphology of overlying photoreceptors. METHODS A retrospective observational study was performed using optical coherence tomography to assess nevus and SRF features, as well as photoreceptor morphology over time. RESULTS There were 232 choroidal nevi that presented with or developed SRF. Photoreceptor morphology at presentation was classified as normal (n=60, 26%), shaggy (elongated) (n=73, 31%), retracted (stalactite appearance) (n=76, 33%), or absent (n=23, 10%). There was a progression in photoreceptor morphology with increasing SRF chronicity (p=0.003). For nevus presenting with normal photoreceptors and later developed SRF (n=60), photoreceptors became shaggy in 29 (48%), retracted in 24 (40%), and absent in 7 (12%) after 15, 19 and 22 months, respectively. For nevus presenting with SRF and shaggy photoreceptors (n=73), progression to retracted photoreceptors occurred in 31 (42%) after a mean of 22 months; for nevus with SRF and retracted photoreceptors (n=76), progression to absent photoreceptors occurred in 19 (25%) after a mean of 34 months; and for nevus with absent photoreceptors (n=23), photoreceptor morphology showed no change after mean follow-up of 33 months. Risk of nevus growth to melanoma was not associated with photoreceptor morphology at presentation (p=0.19). CONCLUSION In eyes with choroidal nevus and SRF, there is a longitudinal evolution in photoreceptor morphology from normal to shaggy to retracted then absent with increasing SRF chronicity. SRF chronicity, as indicated by photoreceptor morphology on presentation, did not correlate with nevus growth to melanoma.
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Affiliation(s)
- Antonio Yaghy
- Ocular Oncology Service, Wills Eye Hospital, Philadelphia, PA, USA
| | - Michael D Yu
- Ocular Oncology Service, Wills Eye Hospital, Philadelphia, PA, USA
| | - Lauren A Dalvin
- Ocular Oncology Service, Wills Eye Hospital, Philadelphia, PA, USA.,Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA
| | - Mehdi Mazloumi
- Ocular Oncology Service, Wills Eye Hospital, Philadelphia, PA, USA
| | | | - Carol L Shields
- Ocular Oncology Service, Wills Eye Hospital, Philadelphia, PA, USA
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Dalvin LA, Shields CL, Ancona-Lezama DA, Yu MD, Di Nicola M, Williams BK, Lucio-Alvarez JA, Ang SM, Maloney SM, Welch RJ, Shields JA. Combination of multimodal imaging features predictive of choroidal nevus transformation into melanoma. Br J Ophthalmol 2018; 103:1441-1447. [PMID: 30523045 DOI: 10.1136/bjophthalmol-2018-312967] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 11/13/2018] [Accepted: 11/16/2018] [Indexed: 12/16/2022]
Abstract
AIM To characterise combinations of multimodal imaging risk factors and predictive value for choroidal nevus transformation into melanoma. METHODS This is a retrospective review of multimodal imaging features for 3806 choroidal nevi from 1 January 2007 through 1 January 2017. Kaplan-Meier estimates and Cox regression analyses were used to calculate 5-year percentages of growth to melanoma and HR. RESULTS Using multimodal imaging, six risk factors predictive of choroidal nevus transformation into melanoma were identified, namely tumour thickness >2 mm, subretinal fluid, symptoms of visual acuity loss to 20/50 or worse, orange pigment, hollow acoustic density and tumour largest basal diameter >5 mm. Kaplan-Meier 5-year estimated tumour growth was found in 1% of nevi with no risk factors, 11% (range 9%-37%) with one factor, 22% (12%-68%) with two factors, 34% (21%-100%) with three factors, 51% (0%-100%) with four factors and 55% (0%-100%) with five factors. HR for growth was 0.1 with no factor, 2.1-7.8 with one factor, 1.8-12.1 with two factors, 4.0-24.4 with three factors, 4.6-170.0 with four factors and 12.0-595.0 with five factors. The highest HR with each combination of two, three, four or five risk factors always included symptoms of visual acuity loss and orange pigment. CONCLUSION Six risk factors for choroidal nevus transformation into melanoma by multimodal imaging have been identified. Risk for transformation into melanoma is 1% when no factors are present, and approaches 100% with specific combinations of three or more risk factors. Understanding how combinations of factors influence risk of transformation into melanoma can guide counselling and treatment decisions.
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Affiliation(s)
- Lauren A Dalvin
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA
| | - Carol L Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David Arturo Ancona-Lezama
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael D Yu
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maura Di Nicola
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Basil K Williams
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - J Antonio Lucio-Alvarez
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Su Mae Ang
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sean M Maloney
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - R Joel Welch
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jerry A Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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