Predictive factors for the development of rubeosis following proton beam radiotherapy for uveal melanoma

AIMS/BACKGROUND

Proton beam radiotherapy can effectively treat primary uveal melanomas of any size. Some patients, however, develop adverse late effects following treatment and the purpose of this study was to determine which factors give rise to a poor local outcome.

METHODS

The hospital records from a first cohort of 127 patients treated by protons from 1989 to 1992 were reviewed retrospectively. The presence of rubeosis was selected as a measure of significant ocular damage. Split file analysis was performed with 73 cases forming a test group with the remaining 54 cases acting as a validation group.

RESULTS

Large tumour size and the presence of retinal detachment were significant, independent risk factors for developing rubeosis for both the test and validation groups. These factors also predicted subsequent enucleation for uncontrolled ocular pain. Patients with tumours too large to plaque and with an associated retinal detachment had a 90% chance of developing rubeosis within 4 years of proton beam radiotherapy.

CONCLUSIONS

Patients with a uveal melanoma too large for plaque therapy and an associated retinal detachment run a very high risk of developing rubeosis after proton beam radiotherapy and one third of individuals developing rubeosis required enucleation for pain even if local tumour control was satisfactory.

Iris Colour and the Risk of Developing Uveal Melanoma

Uveal melanoma (UM) is a global disease which especially occurs in elderly people. Its incidence varies widely between populations, with the highest incidence among Caucasians, and a South-to-North increase in Europe. As northern Europeans often have blond hair and light eyes, we wondered whether iris colour may be a predisposing factor for UM and if so, why. We compared the distribution of iris colour between Dutch UM patients and healthy Dutch controls, using data from the Rotterdam Study (RS), and reviewed the literature regarding iris colour. We describe molecular mechanisms that might explain the observed associations. When comparing a group of Dutch UM patients with controls, we observed that individuals from Caucasian ancestry with a green/hazel iris colour (Odds Ratio (OR) = 3.64, 95% Confidence Interval (CI) 2.57-5.14) and individuals with a blue/grey iris colour (OR = 1.38, 95% CI 1.04-1.82) had a significantly higher crude risk of UM than those with brown eyes. According to the literature, this may be due to a difference in the function of pheomelanin (associated with a light iris colour) and eumelanin (associated with a brown iris colour). The combination of light-induced stress and aging may affect pheomelanin-carrying melanocytes in a different way than eumelanin-carrying melanocytes, increasing the risk of developing a malignancy.

Role of nitric oxide (NO) in ocular inflammation

1. The actions of nitric oxide (NO) have been investigated in the rabbit eye, with particular emphasis on the relationship between NO and C-fibres and on those effects of NO that may be of importance in the inflammatory response to C-fibre stimulation. 2. The NO synthase inhibitor, NG-nitro-L-arginine (L-NAME; 10-200 mg kg-1), but not the inactive analogue D-NAME (200 mg kg-1), was found to block the inflammatory response induced by infrared irradiation of the iris in a dose-dependent manner. The inhibitory effects of L-NAME (200 mg kg-1) were partially reversed by L-arginine (500 mg kg-1), but not by D-arginine (500 mg kg-1). 3. L-NAME (200 mg kg-1) virtually abolished the ocular effects of intravitreal injection of calcitonin gene-related peptide (CGRP) (0.3 nmol). 4. The concentration of CGRP in aqueous humour from untreated rabbit eyes was 0.1 +/- 0.001 nmol l-1. Irradiation of the iris raised the CGRP concentration to 8.9 +/- 1.5 nmol l-1. L-NAME (200 mg kg-1) greatly suppressed the irradiation-evoked release of CGRP, the concentration in the aqueous humour being 1.2 +/- 0.2 nmol l-1 (P < 0.001). L-Arginine reversed the L-NAME-induced inhibition of release of CGRP, the concentration of CGRP in the aqueous humour being 9.7 +/- 0.6 nmol l-1. 5. In addition, a NO donor, sodium nitroprusside (0.9 mumol), was found to raise the concentration of CGRP in the aqueous humour (14.8 +/- 0.8 nmol l-1) and to induce symptoms of ocular inflammation. The elevation in concentration of CGRP induced by sodium nitroprusside was not affected by L-NAME (200 mg kg-1) (14.5 +/- 1.2 nmol l-1). Ocular responses were not inhibited by L-NAME. 6. Our findings suggest that NO plays an important role in ocular inflammation by activating C-fibres (directly or indirectly) and by mediating CGRP-induced responses.

Neodymium-YAG laser sclerostomy in primates

A one-stage sclerostomy procedure was performed "noninvasively" in four cynomolgus monkeys solely with the neodymium-YAG laser. The neodymium (Nd)-YAG laser was focused, for the most part, a few diopters behind the focus of the helium-neon aiming beam. This enabled optical breakdown to occur entirely within the sclera to produce a perforating micropuncture of the scleral tissue. Two monkeys were treated with higher energy (23 and 24 joules) and two were treated at lower energy levels (12 and 14 joules). An immediate reduction of intraocular pressure in the treated eye was associated with a significant increase in outflow facility. The sclerostomy remained patent for more than 180 days, as determined by tonography and histologic examination. Scanning electron microscopic examination of the cornea revealed no significant damage to the central cornea or to tissue adjacent to the visual axis in any of the treated eyes. However, there was some endothelial cell loss at the site of the laser treatment at the peripheral cornea and in the area immediately posterior to the incision; there was also a focal break in Descemet's membrane.

Corneal transmissibility of diode versus argon lasers and their photothermal effects on the cornea and iris

PURPOSE

Diode laser (810 nm) may possess theoretical advantages over the argon blue-green laser (488 nm) for iridotomy/iridoplasty in an eye with oedematous cornea, such as the acute angle-closure glaucoma (AACG) patient, because of better diode laser tissue penetration in opaque media. We assessed the transmissibility of diode and argon lasers through corneas of varying clarity and evaluated the histopathological features of cornea and iris burns produced by these lasers.

METHODS

The transmission of diode and argon lasers through human donor corneal buttons of three grades of clarity--clear, intermediate, and hazy--were compared. Corneal buttons of these varying levels of clarity were also treated with argon and diode lasers, with the beams deliberately focused onto the mid-stroma to assess their photothermal effects. Exposed pigmented irides from whole human eyes were treated directly with argon and diode lasers. The lasers were delivered via slit-lamp systems and the energy settings used were 1000 mW for argon and 980 mW for diode; spot sizes for both lasers were 100 microm, with exposure durations of 0.1 s. Light microscopy studies of these tissues were performed.

RESULTS

Transmissibility of diode laser in clear, intermediate, and hazy corneas were 89, 87 and 85% respectively and was significantly superior to argon laser (78, 73 and 70% respectively; P < 0.001, paired Student's t-test). Diode laser did not produce morphological changes in all three grades of corneas whereas argon-laser-treated hazy corneas showed photothermal damage. Both lasers produced deep iris burns, with the diode laser tending to produce deeper burns.

CONCLUSION

Our findings suggest that diode laser may be the ideal laser for iridotomy/iridoplasty in the AACG patient with hazy cornea.

Increased sensitivity of the non-human primate eye to microwave radiation following ophthalmic drug pretreatment

Previous studies in our laboratory have established that pulsed microwaves at 2.45 GHz and 10 mW/cm2 are associated with production of corneal endothelial lesions and with disruption of the blood-aqueous barrier in the non-human primate eye. In the study reported here we examined ocular damage in monkeys (M. mulatta and M. fascicularis) following topical treatment with one of two ophthalmic drugs (timolol maleate and pilocarpine) that preceded exposure to pulsed microwaves. Anesthetized monkeys were sham exposed or exposed to pulsed, 2.45 GHz microwaves (10 microseconds, 100 pps) at average power densities of 0.2, 1, 5, 10, or 15 mW/cm2 4 h a day for 3 consecutive days (respective SARs were 0.052, 0.26, 1.3, 2.6, and 3.9 W/kg). Immediately before microwave exposure, one or both eyes were treated topically with one drop of 0.5% timolol maleate or of 2% pilocarpine. Following administration of a drug, we observed a significant reduction in the power-density threshold (from 10 to 1 mW/cm2) for induction of corneal endothelial lesions and for increased vascular permeability of the iris. Diagnostic procedures (in vivo specular microscopy and fluorescein iris angiography) were performed following each exposure protocol. In addition, increased vascular permeability was confirmed with horseradish peroxidase tracer techniques. Although we did not measure intraocular temperatures in experimental animals, the results suggest that a mechanism other than significant heating of the eye is involved. Our data indicate that pulsed microwaves at an average SAR of 0.26 W/kg, if administered after pretreatment with ophthalmic drugs, can produce significant ocular effects in the anesthetized primate.

Shock-wave effect on anterior segment structures following experimental neodymium:YAG laser iridectomy

The short-pulse laser may prove superior to the argon laser in producing noninvasive iridectomies. Little is known of the effects of the laser shock-wave on anterior segment structures adjacent to the iris. To investigate this question, iridectomies were produced in two owl monkeys using a neodymium (Nd):YAG laser and tissues were evaluated by light microscopy and scanning and transmission electron microscopy. For purposes of comparison, one eye received an iridectomy produced by an argon laser. Results indicate that while clean iris colobomas can be produced with a well-focused Nd:YAG laser, its shock-wave affects tissues in both the trabecular meshwork and corneal endothelium if the iridectomy is located within 0.8 mm of the limbus. No damage to the trabecular meshwork or corneal endothelium was evident after the argon laser iridectomy.

Argon versus krypton panretinal photocoagulation side effects on the anterior segment

The modification of corneal sensitivity, accommodation, pupillary diameter and endothelial cell density after argon versus krypton panretinal photocoagulation were studied prospectively in 88 eyes of 64 diabetic patients with proliferative diabetic retinopathy, randomized for one of the two laser treatments. In both groups a marked internal ophthalmoplegia and reduction of corneal sensitivity occurred after laser photocoagulation. At no time, 2, 90 and 180 days after PRP, were these parameters significantly different. Endothelial cell loss was non significantly greater in the krypton group. The results indicated that the side effects commonly observed on the anterior segment after PRP are comparable using argon or krypton lasers.

On the effects of different laser energy sources upon the iris of the pigmented and the albino rabbit

The irides of pigmented and albino rabbits have been irradiated by a) a CW argon laser beam (exposure duration up to 1 s), b) a 1 ms pulses Nd:YAG laser and c) a 30 ns pulses Q-switched ruby laser. The immediate and long-term pathologies were analysed by scanning and transmission electron microscopy over a period of 13 months. At both the gross and ultrastructural levels, damage configuration may differ considerably, depending on the three modes of irradiation. For each source there are both thermal and mechanical damage components and the significance of mechanical effects increases with decreasing pulse duration for a constant pulse energy. In the argon experiments, tissue destruction is predominantly a consequence of heat, resulting from conduction and convection. The subsequent regeneration of tissue after such heat-induced trauma is fast. The effects of the Nd:YAG laser, at the irradiance levels used in the present study, are again predominantly of a thermal nature and are caused by heating and local evaporation. The pigmented and the nonpigmented iris epithelium are destroyed and widespread decay of the stroma occurs over some months. Such damage never results in full repair. The most prominent feature of Q-switched ruby laser irradiations is their independence of the iris pigment content. In contrast, at the energy levels studied, the argon laser is entirely ineffective, whilst the effect of the Nd:YAG laser is much reduced in the absence of pigment. The consequences of these findings for the clinical applications of such lasers are discussed.

Giant corneal keloid: case report and review of the literature

PURPOSE

To report a patient with a tumor-like corneal keloid.

METHODS

Retrospective review of clinical features and histopathologic findings.

RESULTS

A 68-year-old woman with a remote history of an orbital tumor treated with radiation developed a corneal tumor. A biopsy of the tumor showed fibrocellular tissue, and her blind painful eye was enucleated. Pathologic findings in the enucleated eye showed that the corneal mass was consistent with a large keloid.

CONCLUSIONS

A corneal keloid may clinically appear as a large corneal tumor.

Proton beam therapy and iris neovascularisation in uveal melanoma

PURPOSE

Local treatment of uveal melanoma by radiotherapy involves the use of brachytherapy with radioactive plaques attached to the sclera, or proton irradiation. Both treatments induce growth arrest within the tumour and its slow involution over several years. Although ocular retention rates are excellent, regrowth of tumours due to resistance and neovascular glaucoma leads to enucleation of up to 10% of affected eyes. Proton irradiation involves part of the iris in most cases and we noticed that neovascularisation only occurred in the part of the iris that was not irradiated. We therefore conducted this study to determine the relationship between the development of iris neovascularisation and iris irradiation.

METHODS

A total of 21 enucleation specimens from patients who had previously had proton irradiation were collected from the files of the Department of Pathology, Moorfields Eye Hospital during the 5-year period from 1994 to 1999. Sections of these eyes were assessed for VEGF-A, bFGF, and von Willebrand Factor (vWF) by immunohistochemistry. Ophthalmic notes and radiotherapy records were reviewed to assess the extent of iris irradiation.

RESULTS

In all, 11 cases showed clinical evidence of iris neovascularisation and were selected for further study. Three of these eyes also showed clinical evidence of regrowth of the tumour. Histological evidence of iris neovascularization was noted in all 11 of the eyes examined, and was only present in the nonirradiated side of the iris in 8/11 eyes. NVI was present on both sides of the iris in three cases, but was less severe in the irradiated part. Expression of VEGF-A was at most weak within the tumour, but was present in the detached retina and in the epithelium of both ciliary body and iris. Some bFGF staining was noted around vessels in the iris stroma.

CONCLUSIONS

Our results suggest that irradiation leads to iris atrophy, and that atrophic, irradiated iris is resistant to the development of neovascularisation.

A quantitative assessment of the burden and distribution of Lisch nodules in adults with neurofibromatosis type 1

PURPOSE

The presence of two or more Lisch nodules (melanocytic hamartomas of the iris) is one of seven diagnostic criteria for neurofibromatosis type 1 (NF1), a common monogenic disorder of dysregulated neurocutaneous growth. The hypothesis that Lisch nodules arise secondary to exposure to ultraviolet (UV) radiation from sunlight was investigated.

METHODS

Lisch nodule burden was mapped and quantified in the irides of 77 adults with NF1. Lifetime sunlight (UV radiation) exposure was inventoried, NF1 neurocutaneous severity determined, and two NF1 mutations predictive of severity selectively genotyped.

RESULTS

There was high interindividual variability in Lisch nodule burden. Lisch nodules were primarily located in the inferior hemifield (half) of the iris, regardless of its color (P = 3.0 x 10(-20)). Light irides harbored significantly more Lisch nodules than dark irides (P = 4.8 x 10(-5)). There was no statistically significant correlation of Lisch nodule burden to lifetime sunlight exposure "dose" or NF1 neurocutaneous severity.

CONCLUSIONS

The difference in Lisch nodule burden between the superior and inferior iris hemifields is most likely due to the sunlight-shielding effects on the superior half by periocular structures. The difference in Lisch nodule burden between light and dark irides is probably due to the photoprotective effects of pigmentation. The genes underlying the control of iris color may thus be viewed as modifiers of severity of Lisch nodule burden in NF1. Given the role of UV radiation and, presumably, DNA damage in Lisch nodule pathogenesis, "benign tumor of the iris," not "hamartoma," may be a better descriptor.

Effects of XeCl excimer laser on the eyelid and anterior segment structures

We evaluated the in vitro and in vivo effects of an XeCl excimer laser on the eyelid and anterior segments of the eye. The wavelength of this laser was successfully transmitted through a quartz fiberoptic system. The action of the XeCl excimer laser through our system was more photocoagulative than photoablative.

Parasympathetic control of the pupillary light response in the red-eared slider turtle (Pseudemys scripta elegans)

OBJECTIVE

We investigated effects of both vecuronium bromide, a nicotinic cholinergic antagonist, and atropine, a muscarinic cholinergic antagonist, on the pupil of the turtle to determine whether responses to light are controlled by parasympathetic innervations acting on the iris.

ANIMAL STUDIED

Three red-eared slider turtles, Pseudemys scripta elegans.

PROCEDURE

Turtles were secured to immobilize their head movements and then inserted into a light-integrating sphere. Both pupils were monitored through small apertures by digital video cameras. Pupil diameters were measured manually with a digital caliper. During each trial, drugs (0.4%) were topically applied, four times at 15 min intervals, to the corneas of each eye. One eye was randomly selected for treatment of the drug while the other, treated with saline (0.9% NaCl), was used as control. Pupil sizes under adaptation to light were tracked after drug or saline applications.

RESULTS

Mean pupillary diameters of eyes treated with vercuronium bromide increased by 28%, reaching peak size in 90 min. Onset of response occurred 20 min after drug application and then increased at a rate having a time constant of 26 min. Recovery began at 120 min after initial application. Atropine had no effect on pupil size. No systemic side effects by drugs were observed in turtles.

CONCLUSIONS

Although atropine does not cause mydriasis, vecuronium bromide does. These results suggest that the parasympathetic system in turtles acts through acetylcholine onto nicotinic receptors to stimulate pupillary light constriction.

Iris transillumination defects in the pigment dispersion syndrome as detected with infrared videography: a comparison between a group of blacks and a group of nonblacks

BACKGROUND

Infrared image analysis has been reported to be the most sensitive method to detect iris transillumination defects (ITDs) associated with the pigment dispersion syndrome (PDS). Although a common sign of PDS in patients with lighter irides, ITDs that are demonstrated with standard slit lamp examination are frequently absent in blacks with the disease. This absence may lead to confusion in diagnosis; therefore improved methods of evaluation could be beneficial. Although infrared image analysis has been investigated in nonblacks, it has not been applied to a group of blacks with the condition.

METHODS

Six blacks (11 eyes, all irides brown) with PDS and eight nonblacks (15 eyes, 10 blue irides, 5 brown irides) with PDS underwent analysis. ITDs were searched for with traditional slit lamp examination and with infrared videography.

RESULTS

Among the blacks, 2 of 11 eyes (18%) showed ITDs via infrared analysis, a frequency that was significantly lower (p < 0.001) than the frequency exhibited among the nonblacks (100%) when examined with the same technique. Standard slit lamp examination also showed a significantly lower frequency of ITDs among the blacks compared to the nonblacks (p < 0.001). Infrared videography detected ITDs at least one grade higher in 1 of 11 eyes (9%) among the black group and in 7 of the 15 eyes (47%) among the nonblacks. Using the Wilcoxon signed ranks test, the difference in the ability of infrared videography to detect and rank the iris defects in the nonblack PDS group was significantly greater when compared to standard slit lamp examination (p = 0.011), but infrared analysis did not increase detection or change the mean ranking of those in the black group (p = 0.317).

CONCLUSION

In this group of patients, infrared videography did not significantly improve the detection and visibility of ITDs in blacks, as it did in the nonblacks. The frequency that ITDs were detected with standard slit lamp examination and with infrared videography was significantly greater in the group of nonblacks compared to the blacks who exhibited PDS.

Retinal hazards during laser irradiation of the iris

Images

Timolol and intra-ocular pressure elevation following neodymium: YAG laser surgery

The intra-ocular pressure in 76 patients, undergoing Neodymium: YAG laser surgery was measured just before treatment, and one and two hours afterwards. The fellow eye served as a control. Serious elevation of the intra-ocular pressure was demonstrated, especially in capsulotomy in the aphakic eye, to a lesser extent in pseudophakic eyes. Intra-ocular pressure elevation of more than 20 mm was seen in iridectomies. Timolol 1/2% eyedrops given before Neodymium: YAG laser treatment minimized the elevation of the intra-ocular pressure. Prolonged follow-up of the intra-ocular pressure is recommended.

Thermal effect of visible light and infra-red radiation (i.r.-A, i.r.-B and i.r.-C) on the eye: a study of infra-red cataract based on a model

Exposure to intense optical radiation leads to the development of infra-red (i.r.) cataracts in the workplace. To investigate the importance of the wavelength of optical radiation in i.r. cataract formation, the temperature rises induced in the eye by monochromatic optical radiation (visible light and i.r.) were calculated on the basis of a mathematical model. It is shown that, in accordance with Goldmann's theory when visible light or i.r.-A (780 nm < or = lambda < or = 1400 nm) is incident on the eye, the radiation is absorbed by the iris and converted into heat which is then conducted to the lens and induces cataracts. When i.r.-B (1400 nm < lambda < or = 3000 nm) or i.r.-C (3000 nm < or = lambda < or = 1 mm) is incident on the eye, on the other hand, it is absorbed by the cornea and converted into heat which is then conducted to the lens and induces cataracts. It is suggested that i.r. cataracts are induced by i.r.-B or i.r.-C in the workplace.

Dark-light change of iris parameters and related factors among American Caucasians, American Chinese, and Mainland Chinese

PURPOSE

To assess the distribution of dark-light changes in iris features and associated factors amongst American Caucasians, American Chinese and mainland Chinese aged 40 years and over.

METHODS

Four gender- and age-matched cohorts: Caucasians, American Chinese, Southern Chinese and Northern Chinese comprised the study population. Anterior segment optical coherence tomography (ASOCT) images were acquired under dark and light conditions. Customized software was used to calculate iris thickness at 750 μm from the scleral spur (IT750), iris curvature (ICurv), iris area (IArea), and pupil diameter (PD) from ASOCT images.

RESULTS

Data from 121, 124, 121 and 120 subjects were available for American Caucasian, American Chinese, Southern and Northern Chinese subjects respectively. Caucasians had significantly less dark-light change (Δ) of IT750 and greater ΔPD than Chinese. When using multiple linear regression analyses, the inter-ethnic difference for ΔIT750 was independent of age, gender, refractive error, anterior chamber width and axial length. After controlling for ΔPD, ΔICurv was found to be inversely associated with age (β = -0.001, P = 0.001). Independent predictors of greater ΔPD included younger age (β = -0.02, P = 0.001), Caucasian ethnicity (β = -0.022, P = 0.009) and wider anterior chamber (β = 0.18, P = 0.03).

CONCLUSIONS

Compared with Caucasians, Chinese irides show greater thickening with light to dark adaptation despite the lesser change of PD in Chinese. The change of iris area per unit change of pupil diameter from dark to light did not differ between ethnicities. These dynamic characteristics intrinsic to Chinese irides may partially account for the substantially increased risk for angle closure among this ethnic group.

Modulation of the response of a photosensitive muscle by beta-adrenergic regulation of cyclic AMP levels

The light-induced constriction of the irises of some vertebrates is mediated by photosensitive pupillary sphincter cells, which have rhodopsin molecules in their sarcolemmas. Light-induced isomerization of these rhodopsin molecules leads to the release of Ca2+ from an internal pool, which in turn activate the contractile proteins. A central nervous reflex is therefore not essential for the light responsiveness of these irises, but they do appear to be innervated. The photosensitive iris of the toad receives sympathetic (adrenergic) innervation. Stimulation of sympathetic nerves to the eye or application of adrenergic agonists to the iris cause pupillary dilation due to relaxation of the sphincter muscle. We show here that beta-adrenergic stimulation of toad sphincter cells modulates their photoresponses by elevating the intracellular levels of cyclic AMP. However, cyclic AMP does not appear to be involved in the transduction event but rather alters the availability of Ca2+ for contraction.

Long-term administration of a substance P antagonist, (D-Pro2, D-Trp7,9)-SP, abolishes the response to ocular trauma

The long-term effect of ocular administration of a substance P (SP) antagonist, (D-Pro2, D-Trp7,9)-SP, was studied in the rabbit. After 2-3 months of topical administration of the antagonist twice daily, a mild trauma was applied in the form of infrared irradiation of the iris. The control eye responded with disruption of the blood-aqueous barrier, the eye treated with the antagonist did not. Two days after termination of treatment, the response to ocular injury was still reduced. Another 2 days later, ocular injury evoked a normal response, which shows that the protection was reversible. No adverse reaction to the SP antagonist was noted.