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Phansalkar R, Lu T, Alyono J, Lee J, Dosiou C, Kossler AL. Reduction of Teprotumumab-Induced Hearing Loss With Comparable Efficacy Using Half-Dose Therapy. Ophthalmic Plast Reconstr Surg 2023; 39:e101-e104. [PMID: 36877549 DOI: 10.1097/iop.0000000000002355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Teprotumumab has been shown to be effective in the treatment of thyroid eye disease, a potentially vision-threatening condition. Adverse events, including sensorineural hearing loss, have been associated with teprotumumab. The authors present the case of a 64-year-old female who discontinued teprotumumab due to significant sensorineural hearing loss after 4 infusions, along with other adverse events. The patient was unresponsive to a subsequent course of intravenous methylprednisolone and orbital radiation, during which she experienced worsening thyroid eye disease symptoms. Teprotumumab was restarted 1 year later, at a half dose of 10 mg/kg for 8 infusions. Three months post-treatment, she retains resolution of double vision and orbital inflammatory signs, and significant improvement in proptosis. She tolerated all infusions with an overall reduction in the severity of her adverse events and without return of significant sensorineural hearing loss. The authors conclude that a lower dose of teprotumumab can be effective for patients with active moderate-severe thyroid eye disease who experience significant or intolerable adverse events.
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Affiliation(s)
| | - Tracy Lu
- Department of Ophthalmology, Byers Eye Institute, Stanford University
| | | | - Jennifer Lee
- Department of Otolaryngology, Stanford University
| | - Chrysoula Dosiou
- Department of Medicine-Endocrinology, Stanford University, Palo Alto, California, U.S.A
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2
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Mohamed A, Tzoulis P, Kossler AL, Dosiou C. New Onset or Deterioration of Thyroid Eye Disease After mRNA SARS-CoV-2 Vaccines: Report of 2 Cases and Literature Review. J Clin Endocrinol Metab 2023; 108:979-985. [PMID: 36251747 PMCID: PMC9619817 DOI: 10.1210/clinem/dgac606] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/13/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Occurrence of Graves' disease (GD) has been reported following SARS-CoV-2 vaccine administration, but little is known about thyroid eye disease (TED) after SARS-CoV-2 vaccination. OBJECTIVE We describe 2 cases of TED activation following mRNA SARS-CoV-2 vaccination and review additional cases reported in the literature. METHODS We report 2 cases of TED activation following SARS-CoV-2 vaccination: 1 case of TED worsening in a patient with GD, and 1 of de novo active TED progressing to dysthyroid optic neuropathy in a patient with a history of Hashimoto hypothyroidism. Our literature search revealed 8 additional reported TED cases associated with SARS-CoV-2 vaccination until June 2022. We review the characteristics, duration, and management of TED following SARS-CoV-2 vaccination in these cases. RESULTS Of all 10 reported TED cases following SARS-CoV-2 vaccination, 4 developed new-onset TED and 6 previously stable TED cases experienced significant deterioration. Six patients had known GD and 2 patients had Hashimoto thyroiditis. Two cases progressed to dysthyroid optic neuropathy, 6 had moderate/severe active disease, and 2 had mild disease that did not require treatment. Seven TED cases received teprotumumab and had a favorable response, 2 of whom had prior limited response to initial prednisone or methylprednisolone and tocilizumab therapy. CONCLUSION New diagnosis or deterioration of TED after mRNA SARS-CoV-2 vaccination can occur, with most cases described in patients with underlying autoimmune thyroid disease. Our report raises awareness to this potential complication to promote early recognition and prompt management of TED associated with mRNA SARS-CoV-2 vaccines. Further studies are needed to explore the mechanism, risk factors, prevention, and treatment of TED following mRNA SARS-CoV-2 vaccination.
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Affiliation(s)
- Abubakr Mohamed
- Corresponding Author: Abubakr Mohamed, MD, Division of Endocrinology, Stanford University School of Medicine, 300 Pasteur Drive Stanford, CA 94304, USATel.: (650) 723-6054, E-mail:
| | - Ploutarchos Tzoulis
- Department of Metabolism & Experimental Therapeutics, Division of Medicine, University College London, London, UK
- Department of Endocrinology, IASO General Clinic, Athens, Greece
| | - Andrea Lora Kossler
- Department of Ophthalmology, Stanford University School of Medicine, Stanford, CA, USA
| | - Chrysoula Dosiou
- Division of Endocrinology, Stanford University School of Medicine, Stanford, CA, USA
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Abstract
CONTEXT Graves orbitopathy (GO) or thyroid eye disease is a potentially sight-threatening and disfiguring autoimmune disease. Teprotumumab is a monoclonal antibody against the insulin-like growth factor-I receptor that was recently approved for GO treatment. Hyperglycemia is a recognized adverse event of teprotumumab, occurring in 10% of patients in 2 recent randomized controlled trials. OBJECTIVE Our study aimed to report the incidence, severity, management, and longitudinal glycemic changes in patients treated with teprotumumab in an academic practice cohort. METHODS This longitudinal, observational study included all consecutive patients treated with teprotumumab between March 2020 and May 2022 at 1 institution. Hemoglobin A1c (HbA1c) was measured every 3 months. RESULTS Forty-two patients with baseline normoglycemia (n = 22), prediabetes (n = 10), and diabetes (n = 10) were followed for a mean of 47.5 weeks. Overall, HbA1c increased by 0.5% at 3 months. Least-squares mean changes in HbA1c at 3 months were 1.3 (P < .001), 0.7 (P = .01), and 0.1 (P = .41) in patients with diabetes, prediabetes, and normoglycemia, respectively. Twenty-two patients (52%) had hyperglycemia, which was graded as mild, moderate, and life-threatening in 55% (12/22), 41% (9/22), and 5% (1/22) of cases, respectively. Age, pre-existing diabetes, and Hispanic and Asian race/ethnicity were significant risk factors for hyperglycemia. Among patients with hyperglycemia, 36.4% (8/22) returned to baseline glycemic status at last follow-up. CONCLUSION While effective, teprotumumab carries a significant risk of hyperglycemia, especially in patients with diabetes. Hyperglycemia may persist after stopping teprotumumab. These findings underscore the importance of guidelines for screening and management of teprotumumab-related hyperglycemia.
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Affiliation(s)
- Linus Amarikwa
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Abubakr Mohamed
- Division of Endocrinology, Gerontology and Metabolism, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Sun H Kim
- Division of Endocrinology, Gerontology and Metabolism, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94305, USA
- Stanford Diabetes Research Center, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Andrea Lora Kossler
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Chrysoula Dosiou
- Division of Endocrinology, Gerontology and Metabolism, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94305, USA
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Abstract
CONTEXT Thyroid eye disease (TED) is a sight-threatening and debilitating autoimmune condition, with limited therapies available, that often poses diagnostic and therapeutic challenges. In recent years, the treatment landscape has shifted to early intervention with targeted therapy. METHODS A PubMed review of the literature was conducted for the period between 1979 and 2021. Search terms included thyroid eye disease, teprotumumab, targeted therapy, Graves disease, Graves ophthalmopathy, dysthyroid optic neuropathy, and related terms in different combinations. Novel biologic therapies for TED have emerged as alternatives to traditional steroid regimens in recent years. New insights into TED pathophysiology have uncovered the role of the insulin-like growth factor 1 receptor (IGF-1R) and led to the development of teprotumumab, an IGF-1R-inhibiting monoclonal antibody. RESULTS Randomized clinical trials demonstrating the efficacy of teprotumumab for TED led to Food and Drug Administration approval. Teprotumumab is gradually replacing immunosuppressive agents as first-line therapy in the United States for active moderate-to-severe TED, while emerging reports also show its use in other stages of the disease. Recent data highlight risk factors for adverse events and screening protocols to maximize patient safety. Personalized therapeutic plans developed through effective partnership between endocrinologists and ophthalmologists aim to enhance the safety and outcomes of TED treatments and improve care for this complex disease. CONCLUSION TED management is shifting to an era of targeted therapy with multidisciplinary care. Teprotumumab has demonstrated superior efficacy to conventional treatments and has transformed our therapeutic and surgical algorithms. Clinical guidelines and additional studies are needed to further guide and refine therapy.
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Affiliation(s)
- Andrea Lora Kossler
- Correspondence: Andrea Lora Kossler, MD, Department of Ophthalmology, Stanford University School of Medicine, 2452 Watson Ct, Palo Alto, CA 94303, USA.
| | - Raymond Douglas
- Cedars–Sinai Medical Center, Los Angeles, California 90048, USA
| | - Chrysoula Dosiou
- Division of Endocrinology, Stanford University School of Medicine, Palo Alto, California 94305, USA
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Hung JY, Chen KW, Perera C, Chiu HK, Hsu CR, Myung D, Luo AC, Fuh CS, Liao SL, Kossler AL. An Outperforming Artificial Intelligence Model to Identify Referable Blepharoptosis for General Practitioners. J Pers Med 2022; 12:jpm12020283. [PMID: 35207771 PMCID: PMC8877622 DOI: 10.3390/jpm12020283] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/25/2022] [Accepted: 02/06/2022] [Indexed: 02/05/2023] Open
Abstract
The aim of this study is to develop an AI model that accurately identifies referable blepharoptosis automatically and to compare the AI model’s performance to a group of non-ophthalmic physicians. In total, 1000 retrospective single-eye images from tertiary oculoplastic clinics were labeled by three oculoplastic surgeons as having either ptosis, including true and pseudoptosis, or a healthy eyelid. A convolutional neural network (CNN) was trained for binary classification. The same dataset was used in testing three non-ophthalmic physicians. The CNN model achieved a sensitivity of 92% and a specificity of 88%, compared with the non-ophthalmic physician group, which achieved a mean sensitivity of 72% and a mean specificity of 82.67%. The AI model showed better performance than the non-ophthalmic physician group in identifying referable blepharoptosis, including true and pseudoptosis, correctly. Therefore, artificial intelligence-aided tools have the potential to assist in the diagnosis and referral of blepharoptosis for general practitioners.
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Affiliation(s)
- Ju-Yi Hung
- Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA 94303, USA; (J.-Y.H.); (K.-W.C.); (C.P.); (D.M.)
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei 10617, Taiwan;
| | - Ke-Wei Chen
- Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA 94303, USA; (J.-Y.H.); (K.-W.C.); (C.P.); (D.M.)
- Department of Biomedical Engineering, National Cheng Kung University, Tainan City 70101, Taiwan
| | - Chandrashan Perera
- Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA 94303, USA; (J.-Y.H.); (K.-W.C.); (C.P.); (D.M.)
| | - Hsu-Kuang Chiu
- Computer Science, Stanford University, Stanford, CA 94305, USA;
| | - Cherng-Ru Hsu
- Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
| | - David Myung
- Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA 94303, USA; (J.-Y.H.); (K.-W.C.); (C.P.); (D.M.)
| | - An-Chun Luo
- Department of Electronic and Optoelectronic System Research Laboratories, Industrial Technology Research Institute, Hsinchu 31040, Taiwan;
| | - Chiou-Shann Fuh
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei 10617, Taiwan;
| | - Shu-Lang Liao
- Ophthalmology, National Taiwan University Hospital, Taipei 100, Taiwan
- College of Medicine, National Taiwan University, Taipei 10617, Taiwan
- Correspondence: (S.-L.L.); (A.L.K.)
| | - Andrea Lora Kossler
- Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA 94303, USA; (J.-Y.H.); (K.-W.C.); (C.P.); (D.M.)
- Correspondence: (S.-L.L.); (A.L.K.)
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Abstract
Corneal neurotization is a fast-evolving surgical procedure for sensory reinnervation in neurotrophic keratopathy. After neurotization, prior reports document return of corneal sensation on average 8 months after surgery with 38 mm of sensation gain measured via cochet bonnet esthesiometer testing. Here, the authors describe a dual nerve grafting approach via simultaneous parallel sural nerve grafts from both the supratrochelar and supraorbital nerves to the affected contralateral cornea with return of sensation by postoperative week 11.
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Affiliation(s)
- Emily Sarah Charlson
- Oculofacial, Orbital and Aesthetic Plastic Surgery, Department of Ophthalmology, Pacific Eye Associates, California Pacific Medical Center, San Francisco, California
| | - John Paul Pepper
- Division of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto
| | - Andrea Lora Kossler
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology—Head and Neck Surgery, Stanford University, Stanford, California, U.S.A
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Chandramohan A, Sears CM, Huang LC, Beres S, Fredrick D, Kossler AL. Microphthalmia and orbital cysts in DiGeorge syndrome. J AAPOS 2021; 25:358-360. [PMID: 34597781 PMCID: PMC10838402 DOI: 10.1016/j.jaapos.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 06/14/2021] [Accepted: 06/20/2021] [Indexed: 10/20/2022]
Abstract
We report the case of a 4-month-old boy diagnosed with DiGeorge syndrome with novel ocular features. The patient was diagnosed through genetic testing, with a noted 22q11.2 deletion, and had the additional clinical findings of cardiac anomalies, Hirschsprung's disease, and intracranial microhemorrhages. Eye findings included bilateral microphthalmia, persistent fetal vasculature, chorioretinal coloboma, and a unilateral orbital cyst. Given no known additional inciting exposures, a dysgenic mechanism resulting in failed closure of developmental fissures associated with the chromosomal deletion likely gave rise to these combined pathologies.
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Affiliation(s)
- Arthika Chandramohan
- Division of Pediatric Ophthalmology & Strabismus, Department of Ophthalmology, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Connie Martin Sears
- Division of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, Byers Eye Institute, Stanford University, Stanford, California
| | - Laura C Huang
- Division of Pediatric Ophthalmology & Strabismus, Department of Ophthalmology, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Shannon Beres
- Division of Pediatric Ophthalmology & Strabismus, Department of Ophthalmology, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Douglas Fredrick
- Division of Pediatric Ophthalmology and Adult Strabismus, Department of Ophthalmology, Oregon Health Sciences University, Portland, Oregon
| | - Andrea Lora Kossler
- Division of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, Byers Eye Institute, Stanford University, Stanford, California.
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Hung JY, Perera C, Chen KW, Myung D, Chiu HK, Fuh CS, Hsu CR, Liao SL, Kossler AL. A deep learning approach to identify blepharoptosis by convolutional neural networks. Int J Med Inform 2021; 148:104402. [PMID: 33609928 PMCID: PMC8191181 DOI: 10.1016/j.ijmedinf.2021.104402] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/22/2021] [Accepted: 01/24/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE Blepharoptosis is a known cause of reversible vision loss. Accurate assessment can be difficult, especially amongst non-specialists. Existing automated techniques disrupt clinical workflow by requiring user input, or placement of reference markers. Neural networks are known to be effective in image classification tasks. We aim to develop an algorithm that can accurately identify blepharoptosis from a clinical photo. METHODS A total of 500 clinical photographs from patients with and without blepharoptosis were sourced from a tertiary ophthalmic center in Taiwan. Images were labeled by two oculoplastic surgeons, with an independent third oculoplastic surgeon to adjudicate disagreements. These images were used to train a series of convolutional neural networks (CNNs) to ascertain the best CNN architecture for this particular task. RESULTS Of the models that trained on the dataset, most were able to identify ptosis images with reasonable accuracy. We found the best performing model to use the DenseNet121 architecture without pre-training which achieved a sensitivity of 90.1 % with a specificity of 82.4 %, compared to the worst performing model which was used a Resnet34 architecture with pre-training, achieving a sensitivity of 74.1 %, and specificity of 63.6 %. Models with and without pre-training performed similarly (mean accuracy 82.6 % vs. 85.8 % respectively, p = 0.06), though models with pre-training took less time to train (1-minute vs. 16 min, p < 0.01). CONCLUSIONS We report the use of AI to accurately diagnose blepharoptosis from a clinical photograph with no external reference markers or user input requirement. Most current-generation CNN architectures performed reasonably on this task, with the DenseNet121, and Resnet18 architectures without pre-training performing best in our dataset.
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Affiliation(s)
- Ju-Yi Hung
- Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, United States; Ophthalmology, Taipei Medical University Hospital, Taipei, Taiwan; Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan
| | - Chandrashan Perera
- Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, United States
| | - Ke-Wei Chen
- Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, United States; Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - David Myung
- Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, United States
| | - Hsu-Kuang Chiu
- Computer Science, Stanford University, Stanford, California, United States
| | - Chiou-Shann Fuh
- Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan
| | - Cherng-Ru Hsu
- Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan; Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shu-Lang Liao
- Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan; College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Andrea Lora Kossler
- Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, United States.
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Abstract
Thyroid eye disease (TED) is a complex inflammatory disease that can have a long clinical course with sight-threatening and debilitating ocular sequelae. Until recently, there were limited therapeutic options available. In the last decade we have gained a deeper understanding of the underlying pathophysiology, which has led to the development of novel effective targeted therapies. This article discusses the challenges encountered in the clinical evaluation and treatment of TED patients, with the goal to empower endocrinologists and ophthalmologists to work together to provide effective multidisciplinary care. We will review recommendations of past clinical guidelines around evaluation and management of TED patients, discuss the randomized controlled trials of new biologic therapies, and explore how to navigate the emerging therapeutic landscape.
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Affiliation(s)
- Chrysoula Dosiou
- Division of Endocrinology, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Andrea Lora Kossler
- Department of Ophthalmology, Stanford University School of Medicine, Stanford, California 94305, USA
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Abstract
Merkel cell carcinoma (MCC) is a highly aggressive cutaneous malignancy, with a high metastasis rate and a significant proportion of cases affecting the eyelid or periocular region. Current treatments for periocular MCC include wide local excision (WLE) with or without adjuvant radiotherapy and can result in profound morbidity and visual deficit. Metastatic disease has been traditionally treated with chemotherapy, though durable responses are typically poor and toxicity is high. Avelumab (Bavencio®, Merck KgaA, Darmstadt, Germany and Pfizer Inc., New York, NY, USA), the first FDA-approved human anti-programmed death-ligand 1 (PD-L1) antibody for the treatment of metastatic MCC (mMCC), has demonstrated safety and efficacy as first-line treatment and in chemotherapy-refractory cases. This review summarizes pivotal clinical trial data for avelumab in the treatment of mMCC, including efficacy, safety and tolerability, and describes the efficacy of two other immune checkpoint inhibitors, pembrolizumab (Keytruda®, Merck & Co., Inc., Kenilworth, NJ, USA) and nivolumab (Opdivo®, Bristol‐Myers Squibb, New York, NY, USA and Ono Pharmaceuticals, Trenton, NJ, USA) for the treatment of advanced MCC. Our purpose is to provide the rationale to further investigate avelumab as a potential therapy for advanced or metastatic eyelid and periocular MCC.
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Affiliation(s)
- Giancarlo A. Garcia
- Department of Ophthalmology, Byers Eye Institute at Stanford University, Palo Alto, California
| | - Andrea Lora Kossler
- Department of Ophthalmology, Byers Eye Institute at Stanford University, Palo Alto, California
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Cremers SL, Kossler AL, Ciolino J, Henderson BA. Objective surgical assessments for residents and experienced surgeons in the Yelp Era. J Cataract Refract Surg 2015; 41:2593-5. [PMID: 26703521 DOI: 10.1016/j.jcrs.2015.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/09/2015] [Indexed: 10/22/2022]
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