Background. Optic nerve invasion is one of the predictors for retinoblastoma metastases. This study was designed to investigate the risk of optic nerve invasion and clinical features that may identify those children with optic nerve invasion. Methods. We reviewed the charts of 289 children with retinoblastoma treated initially with enucleation. Logistic regression analysis was performed to assess the risk for metastases from varying degrees of optic nerve invasion and to assess the clinical and histopathologic predictors of optic nerve invasion. Results. There were 84 eyes (29%) with optic nerve invasion. The invasion was prelamina cribrosa in 44 cases (15%), up to but not posterior to the lamina cribrosa in 21 cases (7%), posterior to the lamina cribrosa but not to the cut end of the optic nerve in 17 cases (6%), and to the site of optic nerve transection in 2 cases (1%). Patients with optic nerve invasion were more likely to develop metastasis (P = 0.0016), particularly those with invasion to the postlaminar and cut section of the optic nerve (P = 0.0001). Development of metastasis was not statistically associated with laminar or prelaminar involvement. If those patients with choroidal invasion simultaneous with optic nerve invasion were excluded from evaluation, the presence of optic nerve invasion alone was not significant for development of metastasis. The clinical factors found to be predictive for optic nerve invasion from a univariate analysis included exophytic growth pattern (P = 0.011), elevated intraocular pressure (> 22 mm Hg) (P = 0.02), and tumor thickness greater than or equal to 15 mm (P = 0.03). The histopathologic factor significantly associated with optic nerve invasion (univariate analysis) was simultaneous choroidal invasion (P = 0.001). A trend toward an association with optic nerve invasion was found with vitreous hemorrhage (P = 0.06), iris neovascularization (P = 0.10), and poorly differentiated retinoblastoma (P = 0.07). A multi‐variate analysis showed the most significant clinical factors to be exophytic growth pattern (P = 0.002), tumor thickness greater than or equal to 15 mm (P = 0.01), and vitreous hemorrhage (P = 0.05). Conclusions. Optic nerve invasion of retinoblastoma beyond the lamina cribrosa is associated with a greater metastatic risk. Large exophytic retinoblastoma with secondary glaucoma is at highest risk for optic nerve invasion.
There is considerable debate about the significance of choroidal invasion of retinoblastoma with regard to metastatic disease. The charts of patients with retinoblastoma were reviewed over a 17 year period to determine the frequency of histopathological choroidal invasion of retinoblastoma and its risk for eventual metastatic disease. Sixty seven of 289 eyes (23%) enucleated for retinoblastoma had histopathological evidence of choroidal invasion. Those patients with choroidal invasion (with or without optic nerve invasion) were more likely to develop metastases than those without choroidal invasion (p=0O0001). When considering those patients with isolated choroidal invasion ofretinoblastoma, excluding those with associated optic nerve invasion, there was no significant risk but there was a trend towards the development ofmetastases (p=010). The clinical factors found to be predictive for choroidal invasion from retinoblastoma from a univariate analysis included increased intraocular pressure (p=0.04) and iris neovascularisation (p=0007) and, from a multivariate analysis, iris neovascularisation (p=0.02). The histopathological factors statisticaily associated with choroidal invasion included the presence of optic nerve invasion (p=0.002) and poorly differentiated retinoblastoma (p=0.003). Factors not predictive for choroidal invasion included the age, race, and sex of the patient and the tumour laterality, inheritance, size, and growth pattern. Choroidal invasion of retinoblastoma is a risk for metastases, especially if it is associated with any degree of optic nerve invasion.
between the sclera and the conjunctival flap, taking care not to expose the cut back edge of the conjunctival flap to the 5-FU soaked sponge. A typical sponge measured 6 mm (length) by 2 mm (width) by 1 mm (thickness). The sponge was removed, resoaked, and replaced every minute up to 5 minutes. The area was then rinsed with 20 ml of balanced salt solution over a period of 30-60 seconds through a Southampton irrigating cannula. Only after this was completed was a third to a half thickness rectangular scleral flap (4 mm by 3 mm) dissected and raised to the limbus. This was to minimise any intraocular penetration of 5-FU. A block of tissue measuring approximately 3 mm by 1 mm was resected and a peripheral iridectomy performed. The flap was then sutured down with four 10/0 nylon sutures. The back edge of the conjunctival incision was closed in a single layer with 10/0 nylon suture. All patients received postoperative topical dexamethasone metasulphobenzoate 0 1% eye drops four to six times a day and chloramphenicol eye drops four times a day.Eyes were examined on at least day 1, week 1, month 1, 3, 6, and 9 and intervals in between if clinically indicated. Postoperative observations and measurements included visual acuity, intraocular pressure (Goldmann applanation tonometry), slit-lamp biomicroscopy, and fundal examination. ResultsSurgery was performed on 34 eyes of 33 patients with intraocular pressure uncontrolled on maximally tolerated medical therapy. The causes of glaucoma in the eyes are listed in Table 1
For grade II FACs because of overfiltration in the early postoperative period after trabeculectomy, reformation of the anterior chamber with drainage of choroidal effusion may be associated with greater long-term trabeculectomy success, but is associated with greater visual acuity loss relative to medicinal therapy alone. Reformation with viscoelastic resulted in a trend toward lowest final IOP in comparison to medicinal therapy alone.
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