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Microphthalmia-associated transcription factor (MITF) is an important regulator of melanogenesis and melanocyte development. In cutaneous melanoma, MITF loss has been linked to an increased expression of stem cell markers, a shift in epithelial-to-mesenchymal transition (EMT)-related factors, and increased inflammation. We explored the role of MITF in Uveal Melanoma (UM) using a cohort of 64 patients enucleated at the Leiden University Medical Center. We analysed the relation between MITF expression and clinical, histopathological and genetic features of UM, as well as survival. We performed differential gene expression and gene set enrichment analysis using mRNA microarray data, comparing MITF-low with MITF-high UM. MITF expression was lower in heavily pigmented UM than in lightly pigmented UM (p = 0.003), which we confirmed by immunohistochemistry. Furthermore, MITF was significantly lower in UM with monosomy 3/BAP1 loss than in those with disomy 3/no BAP1 loss (p < 0.001) and with 8q gain/amplification 8q (p = 0.02). Spearman correlation analysis showed that a low MITF expression was associated with an increase in inflammatory markers, hallmark pathways involved in inflammation, and epithelial-mesenchymal transition. Similar to the situation in cutaneous melanoma, we propose that MITF loss in UM is related to de-differentiation to a less favourable EMT profile and inflammation.

Contains fulltext : 291768.pdf (Publisher’s version ) (Open Access) PURPOSE: To understand and compare perspectives of patients and professionals on current ophthalmologic care for high myopia, and to identify challenges and future opportunities. METHODS: Self-reported data were collected through two online questionnaires. Patient perspective was obtained from highly myopic members of a patient organisation based in the Netherlands using a 17-item questionnaire consisting of open and multiple-choice questions regarding personal experience with myopia care. The ophthalmologist perspective was obtained from practising Dutch ophthalmologists with a 12-item questionnaire of multiple-choice questions on work-related demographics, myopia care in daily practice and need for improvement. The response rate for patients was 27% (n = 136/500) and for ophthalmologists, 24% (n = 169/716). RESULTS: Patients were highly concerned about personal progressive loss of vision (69%) and feared their psychological well-being (82%) in case this would happen. The quality of performance of care provided by ophthalmologists was rated as excellent or satisfactory by 64% of the patients. These ratings for multidisciplinary care and insurance reimbursement were as low as 28% and 18% respectively. The mean concern among ophthalmologists about the rise in high myopia was 6.9 (SEM 0.1) on a 10-point scale. Sixty-nine per cent of the ophthalmologists reported that asymptomatic myopic patients should not be examined regularly at outpatient clinics. Ophthalmologists urged the development of clinical guidelines (74%), but did report (95%) that they informed patients about risk factors and complications. This contrasted with the view of patients, of whom 42% were discontent with information provided by ophthalmologists. CONCLUSIONS: These questionnaires demonstrated that the current clinical care delivered to highly myopic patients is in need of improvement. The expected higher demand for myopia care in the near future requires preferred practice patterns, professionals specifically trained to manage myopic pathology, accurate and comprehensive information exchange and collaboration of in- and out-of-hospital professionals across the full eye care chain.

Purpose To describe and present results after a technique for cataract surgery combined with explantation of an iris-fixated phakic intraocular lens (IF-pIOL). Methods The medical records of all patients, who had undergone cataract surgery combined with IF-pIOL explantation and subsequent implantation of a posterior chamber IOL by the Single Incision Technique (SIT), were reviewed. Data collection included preoperative and postoperative corrected distance visual acuity (CDVA), manifest refraction, and endothelial cell density (ECD) up to a follow-up time of 24 months. Results Fifty myopic eyes (34 patients) and 9 hyperopic eyes (6 patients) had undergone a SIT procedure mainly because of cataract (67%). Postoperative CDVA improved in both the myopic eyes to 0.16 ± 0.37 logMAR, as in the hyperopic eyes to − 0.10 ± 0.55 logMAR with no eyes having loss of Snellen lines. Mean postoperative spherical equivalent was − 0.34 ± 0.72 D and − 0.10 ± 0.55 D, respectively. ECD loss 6 months after surgery was 5% and remained stable thereafter. Conclusion SIT for combined phacoemulsification and IF-pIOL removal yields good visual and refractive results and is a safe procedure in regard to ECD loss. The technique has advantages over the conventional procedure and is easy to perform.

Conversely to most tumour types, magnetic resonance imaging (MRI) was rarely used for eye tumours. As recent technical advances have increased ocular MRI’s diagnostic value, various clinical applications have been proposed. This systematic review provides an overview of the current status of MRI in the clinical care of uveal melanoma (UM) patients, the most common eye tumour in adults. In total, 158 articles were included. Two- and three-dimensional anatomical scans and functional scans, which assess the tumour micro-biology, can be obtained in routine clinical setting. The radiological characteristics of the most common intra-ocular masses have been described extensively, enabling MRI to contribute to diagnoses. Additionally, MRI’s ability to non-invasively probe the tissue’s biological properties enables early detection of therapy response and potentially differentiates between high- and low-risk UM. MRI-based tumour dimensions are generally in agreement with conventional ultrasound (median absolute difference 0.5 mm), but MRI is considered more accurate in a subgroup of anteriorly located tumours. Although multiple studies propose that MRI’s 3D tumour visualisation can improve therapy planning, an evaluation of its clinical benefit is lacking. In conclusion, MRI is a complementary imaging modality for UM of which the clinical benefit has been shown by multiple studies.

Purpose To investigate the agreement and reliability of anterior segment optical coherence tomography (AS-OCT) and Scheimpflug imaging in measuring the distance from the anterior edge of an iris-fixated phakic intraocular lens (IF-pIOL) to the corneal endothelium. Methods Anterior segment configuration was assessed in a total of 62 eyes of which 25 hyperopic and 37 myopic eyes, all corrected with an IF-pIOL. Measurements were performed by two independent observers using AS-OCT (Visante, Model 1000, Carl Zeiss Meditec Inc.) and Scheimpflug imaging (Pentacam HR, Oculus Optikgerate). The distance from the anterior edge of the pIOL to the endothelium was measured in five different positions using both modalities with their corresponding pIOL software. The measurements as well as the inter- and intra-observer reliability of the two imaging modalities were then compared. Results Distance measurements for all positions performed by AS-OCT were found to be significantly larger than those performed by Scheimpflug imaging, with mean differences ranging from 0.11 to 0.22 mm. Both instruments exhibited good inter- and intra-observer reliability. Conclusion Anterior pIOL edge to endothelium distance measurements by AS-OCT and Scheimpflug imaging have good intra- and inter-observer reliability. However, as AS-OCT provides larger measurements, these two modalities cannot be used interchangeably. Correction of this difference might be essential for proper decision-making during pre-operative screening for pIOL implantation and post-operative safety monitoring.

Clinical evaluations combined with ray-tracing analyses in patients with negative dysphotopsia supported the role of an increased angle κ., Purpose: To provide insights into the anatomical characteristics associated with negative dysphotopsia using quantitative clinical data. Setting: Department of Ophthalmology, Leiden University Medical Center, Leiden, the Netherlands. Design: Case-control study. Methods: Anterior chamber tomography and peripheral aberrometry were measured in 27 pseudophakic patients with negative dysphotopsia and 30 pseudophakic control subjects. Based on these measurements, the total corneal power, anterior chamber depth, pupil location and diameter, iris tilt, and peripheral ocular wavefront up to 30 degrees eccentricity were compared between both groups. In addition, ray-tracing simulations using pseudophakic eye models were performed to establish a connection between these clinical measurements and current hypotheses on the etiology of negative dysphotopsia. Results: Twenty-seven patients with negative dysphotopsia and 25 pseudophakic controls were included in the analysis. The patients with negative dysphotopsia had a smaller (P = .03/P =

Objective: Uveal melanoma (UM) is the most common primary intra-ocular tumour. Treatment is determined by tumour size and location. Generally, smaller tumours are eligible for brachytherapy unless they are located close to posterior pole. Larger tumours are enucleated or undergo proton beam therapy (PBT), which is more expensive than brachytherapy and less available. Accuracy of tumour size determination is critical for accurate planning and delivery of treatment, particularly to ensure tumour coverage, critical structure sparing, and for the choice of treatment modality. This is particularly the case for tumour dimensions that are close to the cut-off point for a specific type of treatment: in the case of the brachytherapy protocol at our institution, 6-8 mm. Ultrasound is conventionally used, but magnetic resonance imaging (MRI) has recently become an additional available tool. Although more expensive, it enables more accurate measurements and is particularly useful in combination with clinical fundus examination, fundus photography and ultrasound. Our aim in this paper was to determine the economic value of MRI for UM treatment.Methods: We retrospectively analysed 60 patients' MRI scans acquired as part of a study or for clinical care. For each patient, we assessed whether the extra cost of an MRI generated economic benefit or change in optimal treatment.Results: MRI indicated a smaller tumour prominence than US in 10% of patients with intermediate tumour size, resulting in a change from PBT to brachytherapy. The costs of MRI, (sic)200-(sic)1000, are significantly lower than the higher costs of PBT compared to brachytherapy, (sic)24,000 difference. In addition, the annual total economic burden of severe vision impairment associated with eye removal is (sic)10,000. Furthermore, for patients where ultrasound was impossible due to previous surgery, MRI enabled eye-preserving treatment.Conclusion: An additional MRI for specific patients with UM improves economic value as it enables less expensive treatment in a sufficient percentage of patients to compensate for the MRI costs. Value is increased in terms of quality of care as it enables for some a treatment option which spares more vision.

textabstractIntroduction: During our clinical practice and research, we encountered an interchangeability problem when using the SP-2000P and SP-3000P TopCon corneal specular microscopes (CSMs) (TopCon Medical Systems, Tokyo, Japan) regarding the endothelial cell count (ECC). We describe a method to improve interchangeability between these CSMs. Methods: Five consecutive good-quality endothelial cell photographs were obtained in 22 eyes of 11 subjects. An ECC comparison between the two CSMs was performed after (I) gauging and calibration by the manufacturer, (II) adjustment of the magnification, (III) correction after external horizontal and vertical calibration. Results: There was a statistically significant difference between the ECC of the SP-2000P and SP-3000P at the start. The SP-2000P counted an average of 500 cells/mm2 more than the SP-3000P (p=0.00). After correction for magnification and determining a correction factor based on external calibration, the difference between the ECC of the SP-2000P and the SP-3000P was then found to be 0.4 cells/mm2 and was not statistically significant (p=0.98). Discussion: We propose a method for improving interchangeability, which involves checking magnification settings, re-checking magnification calibration with external calibration devices, and then calculating correction factors. This method can be applied to various specular or confocal microscopes and their associated endothelial cell analysis software packages to be able to keep performing precise endothelial cell counts and to enable comparison of ECCs when a CSM needs to be replaced or when results from different microscopes need to be compared.

Purpose To evaluate the magnetic resonance imaging (MRI) characteristics of uveal melanoma (UM), to compare them with fundoscopy and ultrasound (US), and to validate them with histopathology. Methods MR images from 42 UM were compared with US and fundoscopy, and on 14 enucleated cases with histopathology. Results A significant relationship between the signal intensity on T1 and pigmentation on histopathology was found (p=0.024). T1 hyperintense UM were always moderately or strongly pigmented on histopathology, while T1-hypointense UM were either pigmented or non-pigmented. Mean apparent diffusion coefficient (ADC) of the UM was 1.16 ± 0.26 × 10−3 mm2/s. Two-thirds of the UM had a wash-out and the remaining a plateau perfusion time-intensity curve (TIC). MRI was limited in evaluating the basal diameter of flat tumors. US tends to show larger tumor prominence (0.5mm larger, p=0.008) and largest basal diameter (1.4mm larger, pp=0.030) and favored a wash-out TIC (p=0.028). An increase of tumor ADC correlated with a plateau TIC (p=0.011). Conclusions The anatomical and functional MRI characteristics of UM were comprehensively assessed. Knowing the MRI characteristics of UM is important in order to confirm the diagnosis and to differentiate UM from other intra-ocular lesions and because it has implications for treatment planning. MRI is a good technique to evaluate UM, being only limited in case of flat tumors or on identifying scleral invasion.

Background Magnetic resonance imaging (MRI) is increasingly being used in the diagnosis and treatment planning of uveal melanoma (UM), the most common primary intraocular tumor. Initially, 7 T MRI was primarily used, but more recently these techniques have been translated to 3 T, as it is more commonly available. Purpose Compare the diagnostic performance of 3 T and 7 T MRI of UM. Study Type Prospective. Population Twenty-seven UM patients (19% female). Field Strength/Sequence 3 T: T1- and T2-weighted three-dimensional (3D) spin echo (SE) and multi-slice (MS) SE, 7 T: T1-weighted 3D gradient echo (GE), T2-weighted 3D SE and MS SE, 3 T and 7 T GE dynamic contrast-enhanced. T1 weighted images: acquired before and after Gadolinium (Gd) administration. Assessment For all sequences, scan and diagnostic quality was quantified using a 5-point Likert scale. Signal intensities on T1 and T2 relative to choroid and eye muscle respectively were assessed as well as the tumor prominence. Finally, the perfusion time-intensity curves (TICs) were classified as plateau, progressive, or wash-out. Statistical Tests Image quality scores were compared between both field strengths using Wilcoxon signed-rank and McNemar tests. Paired t-tests and Bland-Altman were used for comparing tumor prominences. P < 0.05 was considered statistically significant. Results Image quality was comparable between 3 T and 7 T, for 3DT1, 3DT2, 3DT1Gd (P = 0.86; P = 0.34; P = 0.78, respectively) and measuring tumor dimensions (P = 0.40). 2DT1 and 2DT2 image quality were rated better on 3 T compared to 7 T. Most UM had the same relative signal intensities at 3 T and 7 T on T1 (17/21) and T2 (13/17), and 16/18 diagnostic TICs received the same classification. Tumor prominence measurements were similar between field strengths (95% confidence interval: -0.37 mm to 0.03 mm, P = 0.097). Data Conclusion Diagnostic performance of the evaluated 3 T protocol proved to be as capable as 7 T, with the addition of 3 T being superior in assessing tumor growth into nearby anatomical structures compared to 7 T. Level of Evidence 2 Technical Efficacy Stage 3

Objective Dynamic contrast enhanced (DCE)-MRI is currently not generally used for intraocular masses as lesions are small, have an inhomogeneous T1 and the eye is prone to motion. The aim of this paper is to address these eye-specific challenges, enabling accurate ocular DCE-MRI. Materials & methods DCE-MRI of 19 uveal melanoma (UM) patients was acquired using a fat-suppressed 3D spoiled gradient echo sequence with TWIST (time-resolved angiography with stochastic trajectories sequence). The analysis consisted of a two-step registration method to correct for both head and eye motion. A T1 map was calculated to convert signal intensities to concentrations. Subsequently, the Tofts model was fitted voxel wise to obtain Ktrans and ve. Results Registration significantly improved the concentration curve quality (p 1 of melanotic lesions was significantly lower than amelanotic lesions (888 ms vs 1350 ms, p = 0.03). The average achieved B1+ in the lesions was 91%. The average Ktrans was 0.46 min−1 (range 0.13–1.0) and the average ve was 0.22 (range 0.10–0.51). Conclusion Using this eye-specific analysis, DCE of intraocular masses is possible which might aid in the diagnosis, prognosis and follow-up of UM.

Uveal melanoma (UM) is a rare ocular malignancy which originates in the uveal tract, and often gives rise to metastases. Potential targets for immune checkpoint inhibition are lymphocyte-activation gene 3 (LAG3) and its ligands. We set out to analyse the distribution of these molecules in UM. The expression of mRNA was determined using an Illumina array in 64 primary UM from Leiden. The T lymphocyte fraction was determined by digital droplet PCR. In a second cohort of 15 cases from Leiden, mRNA expression was studied by Fluidigm qPCR, while a third cohort consisted of 80 UM from TCGA. In the first Leiden cohort, LAG3 expression was associated with the presence of epithelioid cells (p = 0.002), monosomy of chromosome 3 (p = 0.004), and loss of BAP1 staining (p = 0.001). In this Leiden cohort as well as in the TCGA cohort, LAG3 expression correlated positively with the expression of its ligands: LSECtin, Galectin-3, and the HLA class II molecules HLA-DR, HLA-DQ, and HLA-DP (all p &lt, 0.001). Furthermore, ligands Galectin-3 and HLA class II were increased in monosomy 3 tumours and the expression of LAG3 correlated with the presence of an inflammatory phenotype (T cell fraction, macrophages, HLA-A and HLA-B expression: all p &lt, 0.001). High expression levels of LAG3 (p = 0.01), Galectin-3 (p = 0.001), HLA-DRA1 (p = 0.002), HLA-DQA1 (p = 0.04), HLA-DQB2 (p = 0.03), and HLA-DPA1 (p = 0.007) were associated with bad survival. We conclude that expression of the LAG ligands Galectin-3 and HLA class II strongly correlates with LAG3 expression and all are increased in UM with Monosomy 3/BAP1 loss. The distribution suggests a potential benefit of monoclonal antibodies against LAG3 or Galectin-3 as adjuvant treatment in patients with high-risk UM.

Uveal melanoma (UM) metastasize haematogeneously, and tumor blood vessel density is an important prognostic factor. We hypothesized that proangiogenic factors such as angiopoietin-1 (ANG-1) and angiopoietin-2 (ANG-2), two targetable cytokines, might play a role in tumor development and metastatic behavior. mRNA levels of ANG-1 and ANG-2 were determined in 64 tumors using an Illumina HT-12 v4 mRNA chip and compared to clinical, pathologic, and genetic tumor parameters. Tissue expression was also determined by immunohistochemistry (IHC). Samples of aqueous humor were collected from 83 UM-containing enucleated eyes and protein levels that were determined in a multiplex proximity extension assay. High tissue gene expression of ANG-2, but not of ANG-1, was associated with high tumor thickness, high largest basal diameter, involvement of the ciliary body, and with UM-related death (ANG-2 mRNA p &lt, 0.001, ANG-2 aqueous protein p &lt, 0.001). The presence of the ANG-2 protein in aqueous humor correlated with its mRNA expression in the tumor (r = 0.309, p = 0.03). IHC showed that ANG-2 was expressed in macrophages as well as tumor cells. The presence of ANG-2 in the tumor and in aqueous humor, especially in high-risk tumors, make ANG-2 a potential targetable cytokine in uveal melanoma.

Item does not contain fulltext PURPOSE: To study the relatively high effect of the refractive error gene GJD2 in human myopia, and to assess its relationship with refractive error, ocular biometry and lifestyle in various age groups. METHODS: The population-based Rotterdam Study (RS), high myopia case-control study MYopia STudy, and the birth-cohort study Generation R were included in this study. Spherical equivalent (SER), axial length (AL), axial length/corneal radius (AL/CR), vitreous depth (VD), and anterior chamber depth (ACD) were measured using standard ophthalmologic procedures. Biometric measurements were compared between GJD2 (rs524952) genotype groups; education and environmental risk score (ERS) were calculated to estimate gene-environment interaction effects, using the Synergy index (SI). RESULTS: RS adults carrying two risk alleles had a lower SER and longer AL, ACD and VD (AA versus TT, 0.23D vs. 0.70D; 23.79 mm vs. 23.52 mm; 2.72 mm vs. 2.65 mm; 16.12 mm vs. 15.87 mm; all P < 0.001). Children carrying two risk alleles had larger AL/CR at ages 6 and 9 years (2.88 vs. 2.87 and 3.00 vs. 2.96; all P < 0.001). Education and ERS both negatively influenced myopia and the biometric outcomes, but gene-environment interactions did not reach statistical significance (SI 1.25 [95% confidence interval {CI}, 0.85-1.85] and 1.17 [95% CI, 0.55-2.50] in adults and children). CONCLUSIONS: The elongation of the eye caused by the GJD2 risk genotype follows a dose-response pattern already visible at the age of 6 years. These early effects are an example of how a common myopia gene may drive myopia.

Simple Summary Uveal melanoma (UM) is a rare ocular malignancy that often gives rise to metastases. Tumours with an inflammatory phenotype have an especially bad prognosis. As an increased HLA expression and the presence of tumour-infiltrating lymphocytes and macrophages may be regulated by miRNAs, we set out to investigate whether any miRNAs are associated with inflammatory parameters in this malignancy. Some miRNAs were increased in UM with a high HLA expression and high T cell numbers, while others were decreased, showing two opposing patterns; however, both patterns were related to the tumour’s chromosome 3/BAP1 status. We conclude that specific miRNAs are related to the inflammatory phenotype and that these are differentially expressed between disomy 3/BAP1-positive versus monosomy 3/BAP1-negative UM. Abstract MicroRNAs are known to play a role in the regulation of inflammation. As a high HLA Class I expression is associated with a bad prognosis in UM, we set out to determine whether any miRNAs were related to a high HLA Class I expression and inflammation. We also determined whether such miRNAs were related to the UM’s genetic status. The expression of 125 miRNAs was determined in 64 primary UM from Leiden. Similarly, the mRNA expression of HLA-A, HLA-B, TAP1, BAP1, and immune cell markers was obtained. Expression levels of 24 of the 125 miRNAs correlated with expression of at least three out of four HLA Class I probes. Four miRNAs showed a positive correlation with HLA expression and infiltration with leukocytes, 20 a negative pattern. In the first group, high miRNA levels correlated with chromosome 3 loss/reduced BAP1 mRNA expression, in the second group low miRNA levels. The positive associations between miRNA-22 and miRNA-155 with HLA Class I were confirmed in the TCGA study and Rotterdam cohort, and with TAP1 in the Rotterdam data set; the negative associations between miRNA-125b2 and miRNA-211 and HLA-A, TAP1, and CD4 were confirmed in the Rotterdam set. We demonstrate two patterns: miRNAs can either be related to a high or a low HLA Class I/TAP1 expression and the presence of infiltrating lymphocytes and macrophages. However, both patterns were associated with chromosome 3/BAP1 status, which suggests a role for BAP1 loss in the regulation of HLA expression and inflammation in UM through miRNAs.

Simple Summary Uveal melanoma (UM) is an ocular malignancy which is derived from melanocytes in the uveal tract. Epigenetic regulators such as Histone Deacetylase (HDACs) inhibitors are being tested as treatment of UM metastases. Expression of different HDACs is variable, and some are increased in high-risk tumors with loss of one chromosome 3. As this genetic abnormality is also associated with an inflammatory phenotype, we analyzed whether HDAC expression was influenced by inflammation. In two cohorts of UM cases, expression of several HDACs showed a positive correlation with tumor-infiltrating T cells, while HDACs 2 and 11 showed a negative association with macrophages. Interferon-gamma stimulated expression of some HDACs on UM cell lines. These data suggest that cytokines produced by T cells may be responsible for the increased expression of some HDACs in UM with monosomy 3. In Uveal Melanoma (UM), an inflammatory phenotype is strongly associated with the development of metastases and with chromosome 3/BAP1 expression loss. As an increased expression of several Histone Deacetylases (HDACs) was associated with loss of chromosome 3, this suggested that HDAC expression might also be related to inflammation. We analyzed HDAC expression and the presence of leukocytes by mRNA expression in two sets of UM (Leiden and TCGA) and determined the T lymphocyte fraction through ddPCR. Four UM cell lines were treated with IFN gamma (50IU, 200IU). Quantitative PCR (qPCR) was used for mRNA measurement of HDACs in cultured cells. In both cohorts (Leiden and TCGA), a positive correlation occurred between expression of HDACs 1, 3 and 8 and the presence of a T-cell infiltrate, while expression of HDACs 2 and 11 was negatively correlated with the presence of tumor-infiltrating macrophages. Stimulation of UM cell lines with IFN gamma induced an increase in HDACs 1, 4, 5, 7 and 8 in two out of four UM cell lines. We conclude that the observed positive correlations between HDAC expression and chromosome 3/BAP1 loss may be related to the presence of infiltrating T cells.

Purpose: To investigate the effect of refractive correction on straylight. Patients and methods: Straylight values were measured with the C-Quant (Oculus Optikgerate, GmbH, Wetzlar, Germany) in 1) near-emmetropic eyes (n=30) with various negative powered refractive lenses and in 2) myopic eyes (n=30) corrected with prescribed eyeglasses and contact lenses. The straylight measurements in each group were compared in the different conditions. Results: In the near-emmetropic group, a significant effect (p

Purpose: The optimal treatment strategy for uveal melanoma (UM) relies on many factors, the most important being tumor size and location. Building on recent developments in high-resolution 3D ocular magnetic resonance imaging (MRI), we developed an automatic image-processing framework to create patient-specific eye models and to subsequently determine the full 3D tumor shape and size automatically.Methods and Materials: From 15 patients with UM, 3D inversion-recovery gradient-echo (T1-weighted) and 3D fat-suppressed spin-echo (T2-weighted) images were acquired with a 7T MRI scanner. First, the sclera and cornea were segmented from the T2 weighted image by mesh-fitting. The T1-and T2-weighted images were then coregistered. From the registered T1-weighted image, the lens, vitreous body, retinal detachment, and tumor were segmented. Fuzzy C-means clustering was used to differentiate the tumor from retinal detachments. The tumor model was verified and (if needed) edited by an ophthalmic MRI specialist. Subsequently, the prominence and largest basal diameter of the tumor were measured automatically based on the verified contours. These results were compared with manual assessments on the original images and with ultrasound measurements to show the errors in manual analysis.Results: The framework successfully created an eye model fully automatically in 12 cases. In these cases, a Dice similarity coefficient (mean surface distance) of 97.7%+/- 0.84% (0.17 +/- 0.11 mm) was achieved for the sclera, 96.8%+/- 1.05% (0.20 +/- 0.06 mm) for the vitreous body, 91.6%+/- 4.83% (0.15 +/- 0.06 mm) for the lens, and 86.0%+/- 7.4% (0.35 +/- 0.27 mm) for the tumor. The manual assessments deviated, on average, 0.39 +/- 0.31 mm in prominence and 1.7 +/- 1.22 mm in basal diameter from the automatic measurements.Conclusions: The described framework combined information from T1- and T2-weighted images to accurately determine tumor boundaries in 3D. The proposed process may have a direct effect on clinical workflow, as it enables an accurate 3D assessment of tumor dimensions, which directly influences therapy selection. (C) 2021 Published by Elsevier Inc. on behalf of American Society for Radiation Oncology.

Purpose To study the feasibility and diagnostic value of vascular imaging using optical coherence tomography (OCT)-angiography (OCTA) of melanocytic lesions of the conjunctiva and iris. Design Cross-sectional study. Methods Twenty-five patients with an untreated conjunctival lesion (5 melanoma, 13 nevus, 7 primary acquired melanosis [PAM]) and 52 patients with an untreated iris lesion (10 melanoma, 42 nevus) were included. Patients were imaged using a commercially available OCTA device, with the addition of an anterior segment lens and manual focussing. Tumor vessel presence, vascular patterns and vascular density were assessed. Results Good OCTA images were obtained in 18 of 25 conjunctival lesions and 42 of 52 iris lesions. Failure was caused by lack of patient cooperation, an unfavorable location, or mydriasis. In all imaged conjunctival lesions and 77% of iris lesions, vascular structures were detected. Conjunctival melanoma and nevi demonstrated the same intralesional tortuous patterns, whereas vasculature in eyes with PAM was similar to normal conjunctiva. Both iris melanoma and nevi demonstrated tortuous patterns, distinct from the radially oriented normal iris vasculature. Conclusions Optical coherence tomography angiography (OCTA) allows for noninvasive imaging of the vasculature in melanocytic lesions of the conjunctiva and iris. Good image quality depends highly on patient cooperation and lesion characteristics. Differentiation of benign and malignant lesions was not possible. New software is called for to improve image acquisition and analysis.

ObjectiveTo analyse ocular and systemic findings of patients presenting with systemic metastasis.Methods and analysisIt is an international, multicentre, internet-enabled, registry-based retrospective data analysis. Patients were diagnosed between 2001 and 2011. Data included: primary tumour dimensions, extrascleral extension, ciliary body involvement, American Joint Committee on Cancer (AJCC)-tumour, node, metastasis staging, characteristics of metastases.ResultsOf 3610 patients with uveal melanoma, 69 (1.9%; 95% CI 1.5 to 2.4) presented with clinical metastasis (stage IV). These melanomas originated in the iris, ciliary body and choroid in 4%, 16% and 80% of eyes, respectively. Using eighth edition AJCC, 8 (11%), 20 (29%), 24 (35%), and 17 (25%) belonged to AJCC T-categories T1–T4. Risk of synchronous metastases increased from 0.7% (T1) to 1.5% (T2), 2.6% (T3) and 7.9% (T4). Regional lymph node metastases (N1a) were detected in 9 (13%) patients of whom 6 (67%) had extrascleral extension. Stage of systemic metastases (known for 40 (59%) stage IV patients) revealed 14 (35%), 25 (63%) and 1 (2%) had small (M1a), medium-sized (M1b) and large-sized (M1c) metastases, respectively. Location of metastases in stage IV patients were liver (91%), lung (16%), bone (9%), brain (6%), subcutaneous tissue (4%) and others (5%). Multiple sites of metastases were noted in 24%. Compared with the 98.1% of patients who did not present with metastases, those with synchronous metastases had larger intraocular tumours, more frequent extrascleral extension, ciliary body involvement and thus a higher AJCC T-category.ConclusionsThough higher AJCC T-stage was associated with risk for metastases at diagnosis, even small T1 tumours were stage IV at initial presentation. The liver was the most common site of metastases; however, frequent multiorgan involvement supports initial whole-body staging.

Additional file 1: Supplementary Table 1. Context sequences, PCR annealing temperatures and supplier information for all assays used. Supplementary Data 1. Methodical overview of all digital PCR experimental setups. Supplementary Figure 1. CYSLTR2 p.L129Q mutation detected by Sanger sequencing of choroidal nevus 12B compared to the reference sequence from a healthy control. Supplementary Figure 2. SNP-array copy number profile and B-allele fractions of the CYSLTR2 mutant melanomas from the TCGA cohort. Supplementary Figure 3. Distribution of arm-level copy number alterations in 77 CYSLTR2 wild-type uveal melanomas from the TCGA cohort. Supplementary Figure 4. Origin of CYSLTR2 expression and characterisation of the immune microenvironment in uveal melanoma based on the single cell RNA expression analysis of the six tumours with > 2% CYSLTR2+ cells.

Background: In order to improve medical care for uveal melanoma (UM) patients, we need to monitor disease and survival to guide our research efforts. We analyzed the data of UM patients who underwent an enucleation at the Leiden University Medical Center over the last five decades and investigated trends in patient and tumor characteristics and survival. Methods: Data were collected from charts and pathology reports from all patients who underwent an enucleation for UM between 1973 and 2019 (n = 1,212), of which 1,066 were primary enucleations; data were analyzed according to five time periods: 1973–1979 (n = 209), 1980–1989 (n = 148), 1990–1999 (n = 174), 2000–2009 (n = 280), and 2010–2019 (n = 401). Results: Over time, mean patient age at the time of enucleation for UM increased from 54.9 to 64.7 years (p < 0.001), more tumors showed histopathological involvement of the ciliary body (p < 0.001), and were classified in a high TNM/AJCC class (p < 0.001). Overall, the 5- and 10-year UM-related survival rates were 0.68 and 0.59, respectively. Over time, survival showed no change in patients with tumors in AJCC stages I or III, with recently a slightly worse survival in stage II UM (p = 0.02). Conclusion: Between 1973 and 2019, we found similar rates of UM-related survival following enucleation, although we noticed a strong increase in more unfavorable patient and tumor characteristics over time, such as an older age and larger tumor size. The lack of improvement indicates that more research should take place to develop adjuvant treatments to prevent metastases and efficient treatments once metastases develop.

Supplemental Digital Content is Available in the Text. Noninvasive retinal oximetry demonstrates alterations in eyes with untreated choroidal melanoma, including an increased difference between arterial and venous saturation. These changes were not observed in eyes with choroidal nevi and may be related to the tumour's metabolism or inflammatory changes., Purpose: To compare retinal vessel oxygenation in eyes with an untreated choroidal nevus or choroidal melanoma. Methods: The affected and fellow eye of patients with an untreated choroidal nevus (n = 42) or choroidal melanoma (n = 45) were investigated using noninvasive retinal oximetry (Oxymap T1). Oxygen saturation of arterioles (ArtSat) and venules (VenSat) was determined, together with the arteriovenous difference (AV-difference). Results: In choroidal nevus patients, retinal oximetry did not differ between the affected and fellow eye: the mean ArtSat was 94.5% and 94.2% (P = 0.56), the VenSat was 60.5% and 61.3% (P = 0.35), and the AV-difference was 34.0% and 32.9% (P = 0.18), respectively. In choroidal melanoma patients, alterations were detected: the mean ArtSat was 94.8% and 93.2% (P = 0.006), the VenSat was 58.0% and 60.0% (P = 0.014), and the AV-difference was 36.8% and 33.2% (P < 0.001), respectively. The largest increase in AV-difference was observed between the retinal halves without the lesion in melanoma eyes compared with the corresponding half in the fellow eye (37.5% vs. 32.1%, P < 0.001). Conclusion: Although retinal oximetry was not significantly altered in eyes with a choroidal nevus, eyes with choroidal melanoma showed an increased ArtSat and decreased VenSat, leading to an increased AV-difference. These changes may be caused by inflammation and a higher metabolism, with larger oxygen consumption, leading to altered blood flow and intraocular oxygen relocation.

Contains fulltext : 235455.pdf (Publisher’s version ) (Open Access) PURPOSE: To determine the long-term longitudinal axial length changes in myopic and hyperopic adults with an iris-fixated phakic intraocular lens (pIOL). METHODS: The medical records of patients aged ≥18 years with myopia or hyperopia who were treated with pIOL implantation between 1996 and 2011 for refractive correction with a minimum follow-up of 5 years after pIOL implantation were analyzed. The main outcome measure was change in ocular axial length over time. RESULTS: 149 eyes of 149 myopic patients and 27 hyperopic eyes of 27 patients were included in this study. Mean patient age was 37.1 ± 10.4 years (35% male) in the myopic group and 39.4 ± 9.4 years (4% male) in the hyperopic group. The eyes of the myopic patients showed a significant mean increase in axial length of 0.45 ± 0.61 mm after a mean follow-up time of 144 ± 38 months (p

Purpose To assess potential relationships of intraocular lens (IOL) position and retinal shape in negative dysphotopsia (ND). Setting Department of Ophthalmology, Leiden University Medical Center, Leiden, the Netherlands. Design Case-control study. Methods High-resolution ocular magnetic resonance imaging (MRI) scans were performed in patients with ND and pseudophakic controls, and subsequently used to determine the displacement and tilt of the in-the-bag IOL about the pupil and iris. In addition, anterior segment tomography was used to assess the iris-IOL distance. Furthermore, the retinal shape was quantified from the MRI scans by fitting an ellipse to the segmented inner boundary of the retina. Both the IOL position and retinal shape were compared between groups to assess their potential role in the etiology of ND. Results In total, 37 patients with ND and 26 pseudophakic controls were included in the study. The mean displacement and tilt of the IOL were less than 0.1 mm and 0.5 degrees, respectively, in both groups and all directions. The corresponding mean iris-IOL distance was 1.1 mm in both groups. Neither of these values differed statistically significantly between groups (all P values >.6). The retinal shape showed large variations but was not statistically significantly different between the groups in both the left-right (P = .10) and the anterior-posterior (P = .56) directions. Conclusions In this study, the in-the-bag IOL position and retinal shape did not statistically significantly differ between patients with ND and the general pseudophakic population. Given the large variation in retinal shape between subjects, however, it could still be an important factor in a multifactorial origin of ND.

Highlights • Eye and tumour deformation due to gravity is less than 0.4 mm. • Conformity index between flexed and supine position for eyes is >0.95. • Conformity index between flexed and supine position for tumours is >0.85. • Supinely acquired MR images can be used for PBT planning., Proton beam therapy (PBT) for uveal melanoma (UM) is performed in sitting position, while the acquisition of the Magnetic resonance (MR)-images for treatment planning is performed in supine position. We assessed the effect of this difference in position on the eye- and tumour- shape. Seven subjects and six UM-patients were scanned in supine and a seating mimicking position. The distances between the tumour/sclera in both positions were calculated. The median distance between both positions was 0.1 mm. Change in gravity direction produced no substantial changes in sclera and tumour shape, indicating that supinely acquired MR-images can be used to plan ocular-PBT.

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.

Background/objectives To evaluate the management of conjunctival melanoma with local excision and adjuvant brachytherapy. Subjects/methods Data of all patients who received local excision and adjuvant brachytherapy for conjunctival melanoma between 1999 and 2016 in a Dutch national referral centre were reviewed. A protocol with Sr-90 was used until 2012, a protocol with Ru-106 was used hereafter. Local recurrence, metastasis, survival, visual acuity and treatment complications were assessed. Results A total of 58 patients was identified: 32 patients were treated with Sr-90 and 26 with Ru-106. Mean follow-up time was 97.3 months (143.1 months after Sr-90, and 40.2 months after Ru-106). All lesions were epibulbar, the median tumour thickness was 0.9 mm. Local recurrence occurred in 13/58 cases (22%), with a 5-year recurrence rate of 21%. Local recurrence occurred equally often in both protocols, with 5-year recurrence rates of 19% (Sr-90) versus 23% (Ru-106) (p = 0.68). Metastasis developed in 3/58 cases (5%), with 2 cases after Sr-90, and 1 after Ru-106 (p = 1.00). The most reported complications were pain (29%), dry eyes (21%), symblepharon (9%), ptosis (12%) and cataract (9%). No severe corneal or scleral complications were observed. Median visual acuity was 1.00 pre-surgery, at the end of follow-up this was 1.00 (Sr-90) and 0.95 (Ru-106). Conclusion Local excision with adjuvant brachytherapy provides good tumour control with excellent visual outcome and mild side effects in patients with limited conjunctival melanoma. Results after Sr-90 or Ru-106 were comparable; a choice for either treatment may be based on experience of the clinician and availability of materials.

Uveal melanoma (UM) is fatal in ~50% of patients as a result of disseminated disease. This study aims to externally validate the Liverpool Uveal Melanoma Prognosticator Online V3 (LUMPO3) to determine its reliability in predicting survival after treatment for choroidal melanoma when utilizing external data from other ocular oncology centers. Anonymized data of 1836 UM patients from seven international ocular oncology centers were analyzed with LUMPO3 to predict the 10-year survival for each patient in each external dataset. The analysts were masked to the patient outcomes. Model predictions were sent to an independent statistician to evaluate LUMPO3&rsquo, s performance using discrimination and calibration methods. LUMPO3&rsquo, s ability to discriminate between UM patients who died of metastatic UM and those who were still alive was fair-to-good, with C-statistics ranging from 0.64 to 0.85 at year 1. The pooled estimate for all external centers was 0.72 (95% confidence interval: 0.68 to 0.75). Agreement between observed and predicted survival probabilities was generally good given differences in case mix and survival rates between different centers. Despite the differences between the international cohorts of patients with primary UM, LUMPO3 is a valuable tool for predicting all-cause mortality in this disease when using data from external centers.

The iris-fixated phakic intraocular lens (pIOL) has been available for over 25 years. To provide a clear picture of outcomes and risks, for this systematic review and meta-analysis, the literature was searched for reports on middle- and long-term effects. The iris-fixated phakic intraocular lens (pIOL) has been available for over 25 years. To provide a clear picture of outcomes and risks, for this systematic review and meta-analysis, the literature was searched for reports on middle- and long-term effects of iris-fixated pIOLs on myopic and hyperopic eyes with a follow-up of at least 2 to 4 years. Visual and refractive results after implantation for correction of myopia are positive and the complication rate is low. Endothelial cell loss appears to be at an acceptable rate, although the range of endothelial cell change is too wide to draw firm conclusions. Care should be taken when considering an iris-fixated pIOL for hyperopic eyes because complication rates, particularly pigment dispersion, might be higher than those in myopic eyes. More well-designed, long-term studies are needed, especially in hyperopic eyes. The authors advocate for standardized reporting of refractive surgery data. Initiatives proposed by joumal authors and editors to achieve uniformity should be supported. (C) 2019 Published by Wolters Kluwer on behalf of ASCRS and ESCRS

The understanding of correlations between different biometric parameters is essential for personalized eye care in the field of cataract and refractive surgery. This systematic review offers a clear overview of the previous literature assessing these correlations including a meta-analysis. The review is focused on the following five correlations: (1) axial length and refractive error; (2) anterior chamber depth and refractive error; (3) axial length and anterior chamber depth; (4) corneal power and refractive error; (5) corneal power and axial length. An expected strong correlation between axial length and refractive error was found. Correlations including corneal power were weak and might be clinically insignificant.

Purpose To analyse ophthalmological adverse events associated with mitogen-activated protein kinase kinase (MEK) inhibition with pimasertib treatment for metastatic cutaneous melanoma (CM). Methods In this prospective observational, cohort-based, cross-sectional study, eight patients treated with the MEK inhibitor pimasertib received a complete ophthalmic examination. This included Early Treatment of Diabetic Retinopathy Study best-corrected visual acuity, visual field testing, colour vision testing, slit-lamp examination, applanation tonometry, indirect ophthalmoscopy, digital colour fundus photography and optical coherence tomography (OCT). In selected cases, fluorescein angiography was performed. Results Serous subretinal fluid (SRF) developed in all patients, within a time frame of 9-27 days after the start of treatment. The fovea was involved in six of eight patients (75%). None of the patients with foveal SRF [excluding a patient who developed a bilateral retinal vein occlusion (RVO)] experienced visual symptoms. Subretinal fluid (SRF) decreased or resolved in all patients, despite continuation of study medication in six of eight patients (75%). Complaints in the CM patient (13%) consisted of experiencing a dark fleck in the inferior part of the visual field of the right eye 1 week after the start of treatment, due to an RVO. Subsequent intravitreal bevacizumab treatment resulted in functional and anatomical improvement. Conclusion Patients with metastatic CM who are treated with the MEK inhibitor pimasertib are at high risk of development of ocular adverse events including serous retinopathy and possibly RVO, stressing the need of adequate ophthalmological follow-up including OCT during administration of pimasertib, despite the fact that SRF generally does not lead to ophthalmological complaints.

Danial Mohabati,1,2 Thomas J van Rijssen,1 Elon HC van Dijk,1 Gregorius PM Luyten,1 Tom O Missotten,3 Carel B Hoyng,4 Suzanne Yzer,3 Camiel JF Boon1,5 1Department of Ophthalmology, Leiden University Medical Center, Leiden, the Netherlands; 2Department of Ophthalmology, Rotterdam Ophthalmic Institute, Rotterdam, the Netherlands; 3Department of Ophthalmology, The Rotterdam Eye Hospital, Rotterdam, the Netherlands; 4Department of Ophthalmology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands; 5Department of Ophthalmology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands Purpose: The aim of this study was to investigate disease onset and disease progression in patients with severe chronic central serous chorioretinopathy (cCSC). Patients and methods: The medical records of 143 cCSC patients (199 eyes) were reviewed. All cases had visual complaints for >6months and showed signs of a severe disease phenotype on optical coherence tomography (OCT) and fluorescein angiography (FA). Clinical presentation at onset was evaluated, together with disease progression on multimodal imaging and final treatment outcome. Results: Twenty-eight cases (14%) had a documented history of an acute episode of CSC, whereas 145 cases (73%) showed pre-existing features of chronicity already at first presentation. The first clinical presentation could not be evaluated in 13% of cases. Best-corrected visual acuity (BCVA) was 70 ± 18 Early Treatment of Diabetic Retinopathy Study (ETDRS) letters at onset and 70 ± 22 ETDRS letters at final visit (p = 0.770). Among all studied cases, 173 eyes (87%) were treated, which resulted in complete resolution of subretinal fluid (SRF) in 76% of eyes at final visit. In eyes with fluorescein angiographic follow-up, the area of diffuse atrophic retinal pigment epithelium (RPE) abnormalities (diffuse atrophic RPE alterations [DARA]) had increased significantly in 43 eyes (68%) at final visit. Conclusion: CSC encompasses a clinical spectrum that includes a range of severe phenotypes, in which retinal abnormalities tend to be progressive. Nevertheless, the long-term visual acuity may remain fairly stable with treatment. Few patients with severe chronic CSC have a history of acute CSC, which could indicate that there may be pathogenetic differences between these 2 CSC variants. Keywords: chronic central serous chorioretinopathy, long-term outcome, severity, treatment, photodynamic therapy, posterior cystoid retinal degeneration

Importance Uveal melanoma (UM) is an intraocular primary malignant neoplasm that often gives rise to metastatic disease for which there are no effective therapies. A substantial proportion of UMs express the cancer-testis antigen PRAME (preferentially expressed antigen in melanoma), which can potentially be targeted by adoptive T-cell therapy. Objective To determine whether there may be a rationale for PRAME-directed T-cell therapy for metastatic UM. Design, Setting, and Participants An experimental study using a retrospective cohort of 64 patients with UM (median follow-up, 62 months) was conducted from January 8, 2015, to November 20, 2016, at the Leiden University Medical Center. Clinical, histopathologic, and genetic parameters were compared between 64 PRAME -positive and PRAME -negative UMs. HLA class I restricted, PRAME-specific T cells were stimulated with UM cell lines to measure their antigen-specific reactivity against these cell lines, which were analyzed for PRAME expression by real-time quantitative polymerase chain reaction. Uveal melanoma metastases from 16 unrelated patients were assessed for PRAME expression by messenger RNA fluorescence in situ hybridization and for HLA class I expression by immunofluorescence staining. Main Outcomes and Measures Interferon γ production for antigen-specific reactivity and detection of PRAME and HLA class I expression in primary and metastatic UM. Results Of the 64 patients in the study (31 women and 33 men; mean [SD] age at the time of enucleation, 60.6 [15.6] years), PRAME expression was negative in 35 primary UMs and positive in 29 primary UMs. Positive PRAME expression was associated with a high largest basal diameter (15.0 vs 12.0 mm; P = .005), ciliary body involvement (59% vs 26%; P = .008), and amplification of chromosome 8q (66% vs 23%; P = .002). PRAME-specific T cells reacted against 4 of 7 UM cell lines, demonstrating that T-cell reactivity correlated with PRAME expression. Metastatic UM samples were positive for PRAME messenger RNA in 11 of 16 patients and for HLA class I in 10 of 16 patients, with 8 of 16 patients demonstrating coexpression of both PRAME and HLA class I. Conclusions and Relevance PRAME is expressed in many primary and metastatic UMs, and about half of the metastatic UMs coexpress PRAME and HLA class I. The finding that PRAME - specific T cells in this study reacted against PRAME -positive UM cell lines suggests a potential role for PRAME-directed immunotherapy for selected patients with metastatic UM.

Objective Uveal melanoma (UM) is the most common primary intra-ocular tumour. Treatment is determined by tumour size and location. Generally, smaller tumours are eligible for brachytherapy unless they are located close to posterior pole. Larger tumours are enucleated or undergo proton beam therapy (PBT), which is more expensive than brachytherapy and less available. Accuracy of tumour size determination is critical for accurate planning and delivery of treatment, particularly to ensure tumour coverage, critical structure sparing, and for the choice of treatment modality. This is particularly the case for tumour dimensions that are close to the cut-off point for a specific type of treatment: in the case of the brachytherapy protocol at our institution, 6–8 mm. Ultrasound is conventionally used, but magnetic resonance imaging (MRI) has recently become an additional available tool. Although more expensive, it enables more accurate measurements and is particularly useful in combination with clinical fundus examination, fundus photography and ultrasound. Our aim in this paper was to determine the economic value of MRI for UM treatment. Methods We retrospectively analysed 60 patients’ MRI scans acquired as part of a study or for clinical care. For each patient, we assessed whether the extra cost of an MRI generated economic benefit or change in optimal treatment. Results MRI indicated a smaller tumour prominence than US in 10% of patients with intermediate tumour size, resulting in a change from PBT to brachytherapy. The costs of MRI, €200–€1000, are significantly lower than the higher costs of PBT compared to brachytherapy, €24,000 difference. In addition, the annual total economic burden of severe vision impairment associated with eye removal is €10,000. Furthermore, for patients where ultrasound was impossible due to previous surgery, MRI enabled eye-preserving treatment. Conclusion An additional MRI for specific patients with UM improves economic value as it enables less expensive treatment in a sufficient percentage of patients to compensate for the MRI costs. Value is increased in terms of quality of care as it enables for some a treatment option which spares more vision.

Inflammation, characterized by high numbers of infiltrating leukocytes and a high HLA Class I expression, is associated with a bad prognosis in uveal melanoma (UM). We wondered whether mutations in GNA11 or GNAQ differentially affect inflammation and HLA expression, and thereby progression of the disease. We analyzed data of 59 primarily enucleated UM eyes. The type of GNAQ/11 mutation was analyzed using dPCR, chromosome aberrations were determined by Fluorescence in Situ Hybridization (FISH), karyotyping, and single nucleotide polymorphism (SNP) analysis, and mRNA expression by Illumina PCR. Comparing tumors with a GNAQ mutation with those with a GNA11 mutation yielded no significant differences in histopathological characteristics, infiltrate, or HLA expression. When comparing the Q209L mutations with Q209P mutations in tumors with monosomy of chromosome 3, a higher mitotic count was found in the Q209P/M3 tumors (p = 0.007). The Kaplan-Meier (KM) curves between the patients of the different groups were not significantly different. We conclude that the type (Q209P/Q209L) or location of the mutation (GNA11/GNAQ) do not have a significant effect on the immunological characteristics of the tumors, such as infiltrate and HLA Class I expression. Chromosome 3 status was the main determinant in explaining the difference in infiltrate and HLA expression.

One of the characteristics of prognostically infaust uveal melanoma (UM) is an inflammatory phenotype, which is characterized by high numbers of infiltrating T cells and macrophages, and a high HLA Class I expression. We wondered how this inflammation is regulated, and considered that one of the most important regulators of inflammation, the NFkB pathway, might play a role. We analyzed 64 UM samples for expression of HLA Class I, its regulators, and of members of the NFkB transcription family, using an Illumina HT12V4 array. HLA Class I expression and infiltrating immune cells were also determined by immunohistochemical staining. Information was obtained regarding chromosome status by Affymetrix Nsp array. Our analysis shows that expression of NFkB1, NFkB2 and RELB positively correlates with the level of HLA Class I expression and the number of infiltrating T cells and macrophages, while SPP1 and PPAR&gamma, are negatively correlated. Increased levels of NFkB1 and NFkB2 and decreased levels of SPP1 and PPAR&gamma, are seen in Monosomy 3/BAP1-negative tumors. This is also the case in non-inflammatory UM, indicating that our observation not only involves infiltrating leukocytes but the tumor cells themselves. We report that the NFkB pathway is associated with inflammation and HLA Class I expression in UM, and is upregulated when BAP1 expression is lost.

In primary conjunctival melanoma (CoM), one of the characteristics that is associated with an increased risk of metastases and death is a lack of tumour pigmentation. The aim of this study was to investigate whether the degree of pigmentation of CoM recurrences relates similarly to clinical outcome. A data set of 177 patients with a CoM recurrence from the Wills Eye Hospital (USA) and the Leiden University Medical Center (The Netherlands) was analysed. The relation between clinical tumour pigmentation of the recurrences, the characteristics of the primary lesions and clinical outcome was investigated. In 117 (66%) of 177 patients with a CoM recurrence, tumour pigmentation was known: 71 patients (61%) had recurrences with low pigmentation. Primary lesions had low pigmentation in 39% of cases, which is significantly different (p = 0.001). However, low tumour pigmentation of recurrences correlated with low tumour pigmentation of the primary lesion (p

Expression of DNA repair genes was studied in uveal melanoma (UM) in order to identify genes that may play a role in metastases formation. We searched for genes that are differentially expressed between tumors with a favorable and unfavorable prognosis. Gene-expression profiling was performed on 64 primary UM from the Leiden University Medical Center (LUMC), Leiden, The Netherlands. The expression of 121 genes encoding proteins involved in DNA repair pathways was analyzed: a total of 44 genes differed between disomy 3 and monosomy 3 tumors. Results were validated in a cohort from Genoa and Paris and the The Cancer Genome Atlas (TCGA) cohort. Expression of the PRKDC, WDR48, XPC, and BAP1 genes was significantly associated with clinical outcome after validation. PRKDC was highly expressed in metastasizing UM (p &lt, 0.001), whereas WDR48, XPC, and BAP1 were lowly expressed (p &lt, 0.001, p = 0.006, p = 0.003, respectively). Low expression of WDR48 and XPC was related to a large tumor diameter (p = 0.01 and p = 0.004, respectively), and a mixed/epithelioid cell type (p = 0.007 and p = 0.03, respectively). We conclude that the expression of WDR48, XPC, and BAP1 is significantly lower in UM with an unfavorable prognosis, while these tumors have a significantly higher expression of PRKDC. Pharmacological inhibition of DNA-PKcs resulted in decreased survival of UM cells. PRKDC may be involved in proliferation, invasion and metastasis of UM cells. Unraveling the role of DNA repair genes may enhance our understanding of UM biology and result in the identification of new therapeutic targets.

AimTo investigate whether differences in iris colour, skin colour and tumour pigmentation are related to clinical outcome in conjunctival melanoma.MethodsData of 70 patients with conjunctival melanoma from the Leiden University Medical Center (Leiden, The Netherlands) and 374 patients from the Wills Eye Hospital (Philadephia, USA) were reviewed. The relation between iris colour, skin colour and tumour pigmentation versus clinical parameters and outcome was investigated using univariate and multivariate regression analyses.Results A light iris colour (blue, grey, green) was present in 261 (59%) patients and a dark colour (hazel, brown) in 183 (41%). A low tumour pigmentation was detected in 130 (40%) and a high pigmentation in 197 (60%) patients. Low tumour pigmentation was associated with light iris colour (p=0.021) but not related to skin colour (p=0.92). In univariate analysis, neither iris nor skin colour was related to clinical outcome, while a low tumour pigmentation was related to metastasis formation (HR 2.37, p=0.004) and death (HR 2.42, p=0.020). In multivariate analysis, low tumour pigmentation was related to the development of recurrences (HR 1.63, p=0.043), metastasis formation (HR 2.48, p=0.004) and death (HR 2.60, p=0.014).Conclusion Lightly pigmented tumours occurred especially in individuals with lightly coloured irises. While iris colour or skin colour was not significantly related to clinical outcome, a low tumour pigmentation was related to a worse outcome in patients with conjunctival melanoma. The amount and type of melanin in conjunctival melanocytes may be involved in the pathogenesis and behaviour of selected conjunctival melanoma.

Increased angiogenesis is associated with a higher metastasis- and mortality rate in uveal melanoma (UM). Recently, it was demonstrated that genetic events, such as 8q-gain and BAP1-loss, influence the level of immune infiltrate. We aimed to determine whether genetic events, and specific cytokines, relate to angiogenesis in UM. Data from UM patients who underwent enucleation between 1999 and 2008 were analysed. Microvascular density (MVD) and the presence of infiltrating immune cells were determined with immunohistochemistry (IHC) and immunofluorescence in 43 cases. Chromosome status, BAP1 IHC and mRNA expression of angiogenesis-related genes were known in 54 cases. Tumours with monosomy 3/BAP1-loss showed a higher MVD compared to tumours with disomy 3/normal BAP1 expression (p = 0.008 and p = 0.004, respectively). Within BAP1-positive lesions (n = 20), 8q-gain did not relate to MVD (p = 0.51). A high MVD was associated with an increased expression of angiopoietin 2 (ANGPT2) (p = 0.041), Von Willebrand Factor (VWF) (p = 0.010), a decreased expression of vascular endothelial growth factor B (VEGF-B) (p = 0.024), and increased numbers of tumour-infiltrating macrophages (CD68+, p = 0.017, CD68+CD163+, p = 0.031) and lymphocytes (CD4+, p = 0.027). Concluding, vascular density of UM relates to its genetic profile: Monosomy 3 and BAP1-loss are associated with an increased MVD, while an early event (gain of 8q) is not independently related to MVD, but may initiate a preparation phase towards development of vessels. Interestingly, VEGF-B expression is decreased in UM with a high MVD.

A high HLA expression in uveal melanoma (UM) is part of the prognostically unfavorable inflammatory phenotype. We wondered whether the presence of soluble HLA (sHLA) in the aqueous humour is associated with clinical, histopathological or genetic tumour characteristics, and represents tumour HLA expression and intratumoural inflammation. Aqueous humour from 108 UM patients was analysed for the presence of sHLA, using a Luminex assay specific for HLA Class I. Clinical and genetic parameters were compared between sHLA-positive and negative eyes. A qPCR analysis was performed on tumour tissue using a Fluidigm assay. In 19/108 UM-containing eyes, the sHLA level in the aqueous was above the detection limit. Tumours in sHLA-positive eyes were significantly larger, more frequently involved the ciliary body, and more often showed monosomy 3, gain of chromosome 8q and loss of BAP1 staining. Melanoma-related survival was worse in patients with sHLA-positive aqueous humour. sHLA in the aqueous did not represent the tumour&rsquo, s HLA expression and did not relate to immune cell infiltration in the tumour. We conclude that UM-containing eyes may contain sHLA in the aqueous humour, where it is a prognostically-unfavourable sign and may influence local immune responses.