Uveal melanoma (UM) is the most common intraocular malignancy in adults. Despite successful ocular treatment, about 50% of patients succumb to metastatic dissemination, which occurs haematogenously and mainly affects the liver. On the basis of clinical, histopathological and genetic features of the primary tumour it is possible to predict if the individual patient is at high risk (HR) or low risk (LR) of developing metastases. However, the mechanisms responsible for the development of metastatic disease in UM are still largely unknown; therefore no adjuvant treatment is currently offered to HR patients to prevent development of fatal disease. As the time to discovery of clinically detectable metastases can range from months to decades, a secreted biomarker(s) that could be routinely tested in blood is much needed. The scope of the work presented in this thesis was to use proteomics as a tool to identify potential novel, UM-specific biomarkers. Moreover, the proteomic data acquired would complement genomic and transcriptomic information already generated by the Liverpool Ocular Oncology Research Group, with the ultimate aim of increasing our understanding of UM development and dissemination. The aim of Chapter 2’s project was to compare the proteome of UM tissue samples at HR versus LR of developing metastatic disease using isobaric tags for relative and absolute quantitation (iTRAQ) labelling and mass spectrometry (MS). The quantification of proteins in our samples, proteomic analysis and further validation by immunohistochemistry has led to the identification of two novel prognostic and potentially therapeutic target, S100A6 and the tumour suppressor PDCD4. In Chapter 3 we focused on proteins released in the conditioned medium (secretome) of short-term cultures of HR and LR UM cells, as well as normal melanocytes. Using a label-free quantitative proteomic approach, almost 2000 proteins were identified and quantified, with more than 30% of these identified as secreted and/or previously described in exosomes. Using these data, an 18-protein signature able to discriminate between HR and LR UM was identified. Further validation will be necessary in secretome samples and in the peripheral blood of UM patients, but this has the potential of being translated into a clinically useful assay to detect early development of metastatic disease. As reported in Chapter 4, we also conducted a pilot clinical study on circulating tumour cells (CTC) in UM, using the CellSearch® platform with the novel melanoma kit to enumerate CTC in the peripheral blood of UM patients at LR, HR or with overt metastatic disease. CTC were detected in metastatic and HR tumours and were not present in LR UM, however, the number of CTC detected varied widely, calling into question the clinical value of using this platform in UM patients. The research detailed in Chapter 5 had a direct clinical value, as it addressed the procedures undertaken during the acquisition and processing of prognostic biopsies from UM tumours treated conservatively. The modifications introduced led to a significant improvement of the success rate of such prognostic biopsies for risk stratification, which is essential for clinical management, follow-up and research purposes. In conclusion, the work conducted throughout this PhD has provided further insight into the molecular characteristics that can differentiate between HR and LR UM, identifying novel potential biomarkers that will need validation in the clinical setting.

BACKGROUND: Using laser speckle flowgraphy to calculate retinal blood flow, we sought to measure changes in optic nerve blood flow compared to the normal fellow eye (relative blood flow) and changes in vision in patients with central retinal artery occlusions of varying duration. METHODS: Laser speckle flowgraphy was used to measure optic nerve blood flow in eyes with central retinal artery occlusions and the normal fellow eye of patients seen at Beth Israel Deaconess Medical Center to calculate relative blood flow. Visual acuity was assessed monocularly using Snellen Charts in a standardized fashion. RESULTS: In healthy control patients (n=20), relative blood flow was calculated to be 1.02 (p= 0.6843), indicating no significant difference in blood flow between eyes. In patients with unilateral central retinal artery occlusions (n=7), relative blood flow was calculated to be 0.66 ± 0.13 (p < .001), indicating on average a 33 percent loss in blood flow through the optic nerve head. When comparing relative blood flow values of CRAO patients measured within one year of vision loss versus patients when measured after one year of reported vision loss, values of patients measured within one year were lower. CONCLUSIONS AND RELEVANCE: Laser Speckle Flowgraphy has been shown to be a useful diagnostic tool that can reliably provide quantitative information on retinal blood flow. Results suggest that blood flow through the optic nerve head does return over time, presumably as the occlusion resolves or recanalizes. Longitudinal analysis determined a higher relative blood flow in patients one-year post incident versus within one year. However no statistically significant difference in visual acuity between these groups was found, indicating that return of blood flow is not associated with a return in visual acuity. Relative blood flow may be a useful measure of retinal perfusion in other retinal vascular disorders.

Thesis (M.A.)--Boston University / During the past ten years argon laser trabeculoplasty (ALT) has evolved from a novel to a commonplace intervention in the management of open-angle glaucoma. Despite its widespread usage, the exact effect of ALT on the trabecular meshwork is only partially understood. Nonetheless, its effect of lowering intraocular pressure through enhancement of aqueous humor outflow is well documented. Laser photocoagulation of the trabecular meshwork focally destroys, but also diffusely stimulated trabecular meshwork cells. The laser induced shape alterations in the trabecular meshwork are thought to influence aqueous humor outflow only at very high intraocular pressure levels. It appears more probable that most of the aqueous humor outflow occurring after ALT results from laser induced metabolic changes within the cells of the trabecular meshwork. This review chronicles the history of the use of the laser in glaucoma management, the clinical experience and some of the experimental studies which have been conducted to answer the questions regarding the mechanism of action of ALT.

Cataract surgery is one of the most common procedures performed in the entire world. Cataracts are inevitable in anyone who live to old age and as the global population continues to age, the number of cataract surgeries that are expected to be performed each year is only expected to increase. The procedure is also one of the oldest and has matured a substantial amount since its first utilization but it is still not perfect. It is crucial that we continue to improve to procedure in pursuit of improved post-operative outcomes for patients. In this study, a delayed phacoemulsification after the femtosecond laser anterior capsulotomy and lens fragmentation was introduced into the procedure with the hypothesis that this may allow the cataract to hydrate and soften, leading to an intraoperative reduced phacoemulsification power and a post-operative preservation of the corneal endothelium in grade 4 nuclear cataracts. This study is a new study with very little data collected so far but it is planned that we will initially perform the procedure on 10 patients with bilateral grade 4 cataracts. Each patient will have the new procedure done on one eye and then the typical cataract surgery procedure done on the other eye to be used as a statistical comparator. This thesis specifically explores the concept of introducing a delay between the capsulotomy and the phacoemulsification process and the safety and feasibility of such procedure in practice. The new procedure, so far, has been performed on one patient with the surgery data for the other eye currently pending. Relevant data such as cumulative dissipated energy and intraocular pressures were recorded during and after the surgery for future comparisons. Without a complete set of data, a statistical conclusion cannot be made about the efficacy of the new procedure, but as addressed in this thesis, the procedure has been concluded to be safe and feasible with a good post-operative outcome.

Thesis (M.A.)--Boston University / Procedures to reshape the cornea to correct refractive errors have been a longstanding and fast-evolving area of interest for centuries. As recent advances in excimer laser technology allow keratorefractive treatments to deliver precise treatments with fewer associated risks and complications, the popularity of modern refractive procedures continues to grow at unprecedented rates. For this reason, it is imperative to continue correlating patient characteristics to outcomes so that refractive surgeons can more accurately foresee the results of the selected procedure. This study examined the outcomes of refractive surgeries at a full-scope ophthalmology clinic from January 2011 to November 2011. The main objectives of th is study were to determine the differences between the outcomes of LASIK vs. LASEK, Custom vs. Traditional treatment plans, myopic vs. hyperopic patients and MMC exposure vs. no MMC exposure (LASEK only). More importantly, the data was scrutinized to determine whether or not any of these treatments and/or patient characteristics correlated with poor visual outcomes or the need for an enhancement. Of the 590 myopic eyes treated with Custom LASIK, 90.85% (n=536 eyes) had UDVA of 20/20 or better, 96.10% (n=567 eyes) had UDVA of 20/25 or better and 99.32% (n=586 eyes) had UDVA of 20/40 or better. Of the 170 myopic eyes treated with Custom LASEK, 70.59% (n=120 eyes) had a UDVA of 20/20 or better, 82.94% (n=141 eyes) had a UDVA of 20/25 or better and 96.47% (n=164 eyes) had a UDVA of 20/40 or better. Of the 45 hyperopic eyes that were treated with Traditional LASIK, 44.44% (n=20 eyes) had postoperative UDVA of 20/20 or better, 62.22% (n=28 eyes) had postoperative UDVA of 20/25 or better and 82.22% (n=37 eyes) had postoperative UDVA of 20/40 or better. Of the 536 eyes receiving LASIK, 91.42% (n=490 eyes) had an UDVA of 20/20 or better, 96.46% (n=517 eyes) had an UDVA of 20/25 or better and 99.44% (n=533 eyes) had an UDVA of 20/40 or better. Of the 146 low or moderately myopic eyes receiving Custom LASEK, 74.65% (n=106 eyes) had an UDVA of 20/20 or better, 86.62% (n=123 eyes) had an UDVA of 20/25 or better and 96.48% (n=137 eyes) had an UDVA of 20/40 or better. Of the 54 highly myopic eyes treated with Custom LASIK, 85.19% (n=46 eyes) had an UDVA of 20/20 or better, 92.59% (n=50 eyes) had an UDVA of 20/25 or better, and 98.15% (n=53 eyes) had an UDVA of 20/40 or better. Of the 28 highly myopic eyes treated with Custom LASEK, 53.57% (n=15 eyes) had an UDVA of 20/20 or better, 64.29% (n=18 eyes) had an UDVA of 20/25 or better, and 96.43% (n=27 eyes) had an UDVA of 20/40 or better. An analysis of these data yields significantly greater percentages of myopic (low, moderate and high) eyes achieving 20/20 or better after treatment by Custom LASIK versus Custom LASEK. The data suggested no correlations between poor visual outcomes and/or the need for an enhancement treatment and intraoperative complications, magnitude of ametropia, pupil size, age, treatment type, and treatment plan. All of the LASEK patients who underwent an enhancement treatment were exposed to MMC during their original procedure. Hyperopic patients displayed significantly reduced visual outcomes than comparable myopic treatments. Future studies should investigate similar preoperative characteristics and attempt to correlate them to results to improve predictability and, thus, visual outcomes.

BACKGROUND: Epiretinal membranes are a common disease that can either be idiopathic, meaning no cause can be detected this is usually caused by aging, or secondary which is caused by injury disease or surgery. Despite current treatment methods, there are still persistence of this disease in some rare cases. Methotrexate although traditionally used to treat cancer and rheumatoid arthritis has been being explored as a treatment option in the field of ophthalmology for use against proliferative and migrating cellular diseases coupled with inflammation. Methotrexate has been reported in a few ocular diseases to reduce or stop cell migration and proliferation due to this finding a case study was conducted with this recurrent ERM patient to test its effectiveness against this disease. PURPOSE: To investigate a potential new treatment method for recurrent epiretinal membranes. After a visually significant epiretinal membrane develops there would be an epiretinal membrane (ERM) peel performed. Traditionally if there is recurrence of epiretinal membranes post ERM peeling the patient will be treated with an internal limiting membrane (ILM) peel. For most cases, this will resolve the issue. In the rare instances where an ILM peel doesn’t resolve recurrence, like in this case, we sought to test whether a series of methotrexate injections could help prevent ERM re-proliferation. CASE REPORT: Reporting on a case of a 65-year-old woman with a recurrent recalcitrant epiretinal membrane. This membrane was treated with a pars plana vitrectomy and ERM peeling. The membrane grew back and was met with an ILM peel in hopes of resolution. With continuing recurrence, the patient was treated with another ERM and ILM peel and 12 weekly intravitreal methotrexate (MTX) injections. METHODS: A patient with persistent recurrent epiretinal membranes underwent three surgeries in an attempt to cure the ERM. At every clinical visit, best corrected distance visual acuity was assessed with a Snellen Vision Test and the retina was imaged using optical coherence tomography. Measurements were taken using the machines built in analysis technology to measure retinal thickness and retinal volume at each visit. These were graphed alongside visual acuity to determine complimenting trends. RESULTS: At the first visit the patient began treatment at a visual acuity of 20/200 and a central macular thickness of 676. Seven months after the final methotrexate injection the patient was at a visual acuity of 20/80 and a central macular thickness of 328. The overall results were that visual acuity and central macular thickness significantly improved without ERM recurrence at seven months after treatment. CONCLUSION: When an ERM is significantly impacting the patient’s visual acuity surgery is usually performed in the form of an ERM peel or ILM peel. Although treatment of recurrent epiretinal membranes is well maintained by these procedures there are a small percentage of cases where recurrence is still found post ILM surgery. This case represents the first documented use of MTX to treat recurrent ERM and it suggests great potential for its use in otherwise treatment resistant cases. More research is required to better understand the true potential of this treatment option as well as associated risks.

No description available.

No description available.

No description available.

No description available.