Global Retinoblastoma Presentation and Analysis by National Income Level

Importance

Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale.

Objectives

To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis.

Design, Setting, and Participants

A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017.

Main Outcomes and Measures

Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis.

Results

The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]).

Conclusions and Relevance

This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs.

The Global Retinoblastoma Outcome Study: a prospective, cluster-based analysis of 4064 patients from 149 countries

Background

Retinoblastoma is the most common intraocular cancer worldwide. There is some evidence to suggest that major differences exist in treatment outcomes for children with retinoblastoma from different regions, but these differences have not been assessed on a global scale. We aimed to report 3-year outcomes for children with retinoblastoma globally and to investigate factors associated with survival.

Methods

We did a prospective cluster-based analysis of treatment-naive patients with retinoblastoma who were diagnosed between Jan 1, 2017, and Dec 31, 2017, then treated and followed up for 3 years. Patients were recruited from 260 specialised treatment centres worldwide. Data were obtained from participating centres on primary and additional treatments, duration of follow-up, metastasis, eye globe salvage, and survival outcome. We analysed time to death and time to enucleation with Cox regression models.

Findings

The cohort included 4064 children from 149 countries. The median age at diagnosis was 23·2 months (IQR 11·0–36·5). Extraocular tumour spread (cT4 of the cTNMH classification) at diagnosis was reported in five (0·8%) of 636 children from high-income countries, 55 (5·4%) of 1027 children from upper-middle-income countries, 342 (19·7%) of 1738 children from lower-middle-income countries, and 196 (42·9%) of 457 children from low-income countries. Enucleation surgery was available for all children and intravenous chemotherapy was available for 4014 (98·8%) of 4064 children. The 3-year survival rate was 99·5% (95% CI 98·8–100·0) for children from high-income countries, 91·2% (89·5–93·0) for children from upper-middle-income countries, 80·3% (78·3–82·3) for children from lower-middle-income countries, and 57·3% (52·1-63·0) for children from low-income countries. On analysis, independent factors for worse survival were residence in low-income countries compared to high-income countries (hazard ratio 16·67; 95% CI 4·76–50·00), cT4 advanced tumour compared to cT1 (8·98; 4·44–18·18), and older age at diagnosis in children up to 3 years (1·38 per year; 1·23–1·56). For children aged 3–7 years, the mortality risk decreased slightly (p=0·0104 for the change in slope).

Interpretation

This study, estimated to include approximately half of all new retinoblastoma cases worldwide in 2017, shows profound inequity in survival of children depending on the national income level of their country of residence. In high-income countries, death from retinoblastoma is rare, whereas in low-income countries estimated 3-year survival is just over 50%. Although essential treatments are available in nearly all countries, early diagnosis and treatment in low-income countries are key to improving survival outcomes.

Funding

Queen Elizabeth Diamond Jubilee Trust.

Toward Universal Eye Health Coverage-Key Outcomes of the World Health Organization Package of Eye Care Interventions: A Systematic Review

Importance

Despite persistent inequalities in access to eye care services globally, guidance on a set of recommended, evidence-based eye care interventions to support country health care planning has not been available. To overcome this barrier, the World Health Organization (WHO) Package of Eye Care Interventions (PECI) has been developed.

Objective

To describe the key outcomes of the PECI development.

Evidence Review

A standardized stepwise approach that included the following stages: (1) selection of priority eye conditions by an expert panel after reviewing epidemiological evidence and health facility data; (2) identification of interventions and related evidence for the selected eye conditions from a systematic review of clinical practice guidelines (CPGs); stage 2 included a systematic literature search, screening of title and abstracts (excluding articles that were not relevant CPGs), full-text review to assess disclosure of conflicts of interest and affiliations, quality appraisal, and data extraction; (3) expert review of the evidence extracted in stage 2, identification of missed interventions, and agreement on the inclusion of essential interventions suitable for implementation in low- and middle-income resource settings; and (4) peer review.

Findings

Fifteen priority eye conditions were chosen. The literature search identified 3601 articles. Of these, 469 passed title and abstract screening, 151 passed full-text screening, 98 passed quality appraisal, and 87 were selected for data extraction. Little evidence (≤1 CPG identified) was available for pterygium, keratoconus, congenital eyelid disorders, vision rehabilitation, myopic macular degeneration, ptosis, entropion, and ectropion. In stage 3, domain-specific expert groups voted to include 135 interventions (57%) of a potential 235 interventions collated from stage 2. After synthesis across all interventions and eye conditions, 64 interventions (13 health promotion and education, 6 screening and prevention, 38 treatment, and 7 rehabilitation) were included in the PECI.

Conclusions and Relevance

This systematic review of CPGs for priority eye conditions, followed by an expert consensus procedure, identified 64 essential, evidence-based, eye care interventions that are required to achieve universal eye health coverage. The review identified some important gaps, including a paucity of high-quality, English-language CPGs, for several eye diseases and a dearth of evidence-based recommendations on eye health promotion and prevention within existing CPGs.

Multidisciplinary management of adult orbital rhabdomyosarcoma*

We report the case of a 52-year-old man who presented with a 10-day history of right eye and eyelid inflammation and intermittent diplopia following blunt trauma to the right eyebrow. The CT and MRI scans revealed an extraconal soft tissue mass on the orbital floor with maxillary and ethmoid sinus wall destruction, which on orbital biopsy was proven to be an Alveolar Rhabdomyosarcoma. The patient had a central retinal vein occlusion due to mass effect that resulted in total visual loss at 2 months. He was referred to oncologists who treated him according to the paediatric RMS protocol and is still in remission at 2-year follow-up. Rhabdomyosarcoma is a rare tumour in adults which requires multi-disciplinary management. This highlights the necessity of considering rhabdomyosarcoma in the differential diagnosis of orbital tumours in any age group.

Efficacy and safety of intravitreal injection of triamcinolone-moxifloxacin after cataract surgery in a low to middle income country - a one-year audit

OBJECTIVE

To evaluate the safety and efficacy of intravitreal injection of triamcinolone and moxifloxacin regime administered immediately following cataract surgery.

METHODS

The retrospective study was conducted from January to June 2021 at a tertiary care referral centre in Karachi and comprised record of all patients who underwent dropless cataract surgery from April 2018 to June 2019. Data included slit lamp examination, dilated fundal exam, uncorrected visual acuity, best corrected visual acuity, and intraocular pressure. Cataract assessment and anterior chamber reaction were graded according to the World Health Organisation cataract grouping system. Efficacy of the regime was defined as the ability to prevent postoperative endophthalmitis. Stratification analysis was done to note if gender has any role in terms of effectiveness. Data was analysed using Microsoft Excel version 16.0 and IBM SPSS version 27.

RESULTS

Of 240 eyes of 161 patients analysed, 114(47.5%) were of men who had a mean age of 57.89±14.32 years, and 126(52.5%) were of females with a mean age of 58.02±10.85 years. Overall, 2(1.75%) male subjects and 1(0.8%) female subject developed breakthrough inflammation within one week of the procedure. They were treated with anti-inflammatory drops and in 1(33%) of the cases antibiotic drop for 1 week. At day 90, no patient had residual inflammation or new onset inflammation. Also, 15(6.25%) patients developed raised intraocular pressure from day 7 to day 30. Most cases 10(66.7%) resolved within 1 week of using intraocular pressure-lowering drops. No patient developed endophthalmitis postoperatively.

CONCLUSIONS

Dropless cataract regime was found to be an effective and safe alternative that was easy to administer.

Evaluation of visual outcomes with toric intraocular lens implantation using digital marker during cataract surgery

Objectives

To assess the visual improvement and mean residual astigmatism in patients who underwent cataract surgery with toric intraocular lens.

METHODS

The retrospective, observational study was conducted at the Department of Ophthalmology, Aga Khan University Hospital, Karachi, and comprised data from January 1, 2018, to December 31, 2020, related to adult patients who had regular astigmatism of at least 0.75D and underwent cataract surgery with toric intraocular lens implantation using a digital marker. The patients were followed up on post-operative days 1, 7, 30, 90 and 180. Along with age, the degree of astigmatism was noted. The visual acuity was calculated pre- and post-operatively. The mean residual astigmatism was then noted for all patients post-operatively. Data was analysed using SPSS 22.

RESULTS

The sample comprised 240 eyes of 177 patients; 99(55.9%) males and 78(44.1%) females. The mean age of the sample was 62.5±10.6 years. The mean unaided visual acuity improved post-operatively from 0.57±0.38 to 0.07±0.22 at 90 days. At the 30-day follow-up, mean residual astigmatism had reduced from 1.52±0.84 to 0.01±0.09 (p<0.001). The mean intraocular lens rotation from the intended axis was 0.73°±0.92° on day 30.

CONCLUSIONS

Toric intraocular lens implantation using a digital marker could effectively reduce the post-operative cylinder, and improve the unaided visual acuity following cataract surgery.

Accuracy of swept source biometry device in detecting macular diseases compared with swept source OCT

OBJECTIVE

To assess the diagnostic accuracy of the IOLMaster 700 foveal scans to detect foveal pathology compared with a standard swept-source optical coherence tomography (SS-OCT) device.

RESULTS

One hundred seventy eye scans of 95 patients were included in the final analyses. Ninety-nine (58.2%) scans were classified as abnormal by SS-OCT. Mean sensitivity of the biometry device was 67.5% (range: 51-84%) and mean specificity was 69.5% (range: 44-95%). Intra-class correlation coefficients were 0.912 and 0.835, for reader 1 and 2, respectively. Area under the curve for receiver operating curve was 0.726. Foveal scans of the IOLMaster 700 can provide clinically useful information. Clinicians should pay attention to the macular scans when reviewing biometry prior to cataract surgery and standard macular OCT should ideally be supplemented in suspicious cases.

Relationship of Gender With Laser Retinopexy for Retinal Breaks

PURPOSE

To explore the relationship of gender with laser retinopexy for retinal breaks in the Pakistani population.

MATERIALS AND METHODS

This was a 10-year retrospective observational study conducted at Aga Khan University Hospital, Karachi, Pakistan. All consecutive patients who underwent laser retinopexy between January 2009 and December 2018 for a retinal tear or high-risk retinal degeneration (such as lattice degeneration) were included in this study. Data were collected from patients' files. Index eyes with a history of or treatment for retinal detachment were excluded. A structured pro forma was used to collect information. Descriptive statistics were used to explore the relationship between gender and laser retinopexy.

RESULTS

We identified 12,457 patients through the coding system of our hospital who underwent various laser procedures from January 2009 to December 2018. Yttrium aluminium garnet (YAG) laser, laser peripheral iridotomy (PI), and laser trabeculoplasty procedures were all excluded. A total of 3,472 patients' files were reviewed for this study, out of which 958 patients met the inclusion criteria. Males accounted for a higher number (n=515, 53.87%). The mean age was 43.99±15.37 years. For exploratory analysis, participants were divided into five age groups: <30 years (24.16%); 31-40 years (16.59%); 41-50 years (19.45%); 51-60 years (26.40%); and >60 years (13.49%). Bilateral laser retinopexy was performed in 48.12% of patients; 24.79% and 27.13% of patients underwent unilateral laser retinopexy for the right and left eyes, respectively.

CONCLUSION

In our cohort study, laser retinopexy was more commonly performed in men than in women. The ratio was not significantly different from the prevalence of retinal tears and retinal detachment in the general population, which has a slightly higher male preponderance. We did not find evidence of significant gender bias among patients who underwent laser retinopexy in our study.

Atypical Takayasu arteritis: a family with five affected siblings

BACKGROUND

Takayasu disease is a giant cell arteritis, primarily affecting the aorta and its main branches, particularly over the first 1.5 cm. It is more common in South-East Asian countries and in young females, whose clinical manifestations range from asymptomatic to catastrophic neurological impairment.

CASE REPORT

We report on a Pakistani family in which five of seven siblings, aged 12 to 19 years, are affected with atypical Takayasu arteritis. The proband is a 14-year-old male who presented with sudden, painless loss of vision. He was found to have absent pulses, retinal changes and magnetic resonance angiography (MRA) findings diagnostic of Takayasu arteritis. In addition, though, he had decreased intraocular pressure, murmur of mitral valve prolapse, as well as atypical involvement of the aorta as visualized in MRA and decreased renal blood flow; these last three findings are not usual features of the disease. The unique involvement in the aorta indicates that this patient corresponds to yet another sub-type in the angiographic classification of TA. Four siblings of the proband are asymptomatic but fulfill the diagnostic criteria of the American College of Rheumatology. This is the first reported multiplex family with Takayasu arteritis, in which more than two members meet the diagnostic criteria.

CONCLUSIONS

Previous reports indicate possible HLA associations of Takayasu disease in Japanese patients. Our present study indicates both that there may be clinical and etiological heterogeneity in Takayasu disease, and the possibility that an autosomal recessive form of the disease exists.

Acute syphilitic posterior placoid chorioretinopathy: A case report

A 25-year-old male presented with a complaint of acute visual loss in his right eye for two days. There was a history of visual loss in the left eye six months ago. Comprehensive eye examination showed evidence of posterior uveitis, and a placoid lesion on the right fundus. Further physical examination showed maculopapular rashes on the upper back which was highly suggestive of syphilis. Blood tests for venereal disease research laboratory (VDRL) test and fluorescent treponemal antibody absorption (FTA-ABS) test were ordered, which were both positive. Ocular syphilis should be suspected in all cases of uveitis. Early diagnosis and prompt treatment with appropriate antibiotics can prevent permanent visual loss.

Safety of simultaneous bilateral intravitreal versus unilateral anti-vasculo-endothelial growth factors injection in an operating room setting

OBJECTIVES

Chorioretinal diseases requiring the use of anti-vascular endothelial growth (anti-VEGF) injections often occur in both eyes simultaneously. This can necessitate injecting both eyes together rather than one eye at a time. The purpose of the study was to determine whether simultaneous bilateral intravitreal injections of anti-VEGF agents are safe when administered in an operation theatre setting.

METHODS

Retrospective review of data was conducted. Single center study conducted in a tertiary care hospital in Karachi Pakistan. Approximately 30,000 eyes that received anti-VEGF injection during a 10-year study period were included (March 2008-February 2018). Patients who were lost to follow up prior to completion of treatment were excluded. Consecutive sampling technique was employed. The patients who received bilateral anti-VEGF injections were analysed separately from the ones who received unilateral injections. All injections were administered in operating theatre setting. The rate of endophthalmitis was measured in each group.

RESULTS

A total of 30,258 injections were administered of which 15,338 were bilateral injections. Four cases (4/30,258, 0.013%) of endophthalmitis occurred during the study period. Only one case (1/15,338, 0.0065%) of endophthalmitis occurred after the administration of simultaneous bilateral anti-VEGF injections.

CONCLUSIONS

Administration of simultaneous bilateral anti-VEGF injections was safe in our population.