Download Analysis of Epiretinal Membranes Using Spectral Domain Optical

BASCOM PALMER EYE INSTITUTE
48th Annual Residents’ Days
June 15-16, 2012
Jose Berrocal Auditorium
Bascom Palmer Eye Institute
Miami, Florida
Presented by
Bascom Palmer Eye Institute Alumni Association
Department of Ophthalmology
University of Miami Miller School of Medicine
Sponsored by the
University of Miami Miller School of Medicine
Table of Contents
Upcoming Courses .............................................................................................................. 1
Accreditation Information .................................................................................................. 3
Faculty Disclosure of Relationships .................................................................................... 5
Program Faculty .................................................................................................................. 8
Schedule of Events ............................................................................................................ 11
Infectious Keratitis Progressing to Endophthalmitis: a 15-year-study of Microbiology, Risk
Factors, and Clinical Outcomes
Christopher R. Henry, MD ................................................................................................. 18
Endogenous Endophthalmitis Caused by Yeast: Risk Factors, Management Strategies,
and Visual Acuity Outcomes
Jayanth Sridhar, MD .......................................................................................................... 20
Management of Submacular Hemorrhage Secondary to Neovascular Age-related
Macular Degeneration with Anti-vascular Endothelial Growth Factor Monotherapy
Gary Shienbaum, MD ........................................................................................................ 22
Clinical Outcomes of Optic Pit Maculopathy
Jonathan H. Tzu, MD ......................................................................................................... 24
Retinal Detachment Caused By Giant Retinal Tears: Etiologies, Techniques and Outcomes
Marco A. Gonzalez, MD .................................................................................................... 26
Glaucoma Tube Associated Endophthalmitis
Avnish A. Deobhakta, MD ................................................................................................. 28
Intra-ocular Lens Implantation in the Pediatric Population
Hassan A. Aziz, MD............................................................................................................ 30
Anaerobic Bacteria Causing Endophthalmitis: Spectrum, Frequency and Sensitivities
Andres Emanuelli, MD ...................................................................................................... 31
Systemic Complement Inhibition with Eculizumab for the Treatment of Geographic
Atrophy in AMD: The COMPLETE Study
Gene W. Chen, MD ........................................................................................................... 33
A Review of Femtosecond Assisted Anterior Lamellar Keratoplasty at Bascom Palmer
Jane Fishler, MD ................................................................................................................ 35
Evaluation of Optic Disc Progression in Glaucoma using Spectral Domain Optical
Coherence Tomography
Ben J. Harvey, MD ............................................................................................................. 37
Evolving Fluoroquinolone Resistance Among Coagulase-Negative Staphylococcus Isolates
Causing Endophthalmitis
Andrew M. Schimel, MD ................................................................................................... 39
Vitrectomy and Membrane Peeling In Patients with Myopic Macular Retinoschisis
Jonathan S. Chang, MD ..................................................................................................... 41
Molecular Mechanisms of Blood-Retina Barrier Permeability
Daniel L. Chao, MD, PhD ................................................................................................... 43
Long Term Outcomes Of Anti-Vegf Therapy For Age Related Macular Degeneration
Luis J. Haddock, MD .......................................................................................................... 45
Comparison of Blood Culture Bottles and Membrane Filter System for Culturing Vitreous
Specimens
Aleksandra V. Rachitskaya, MD ........................................................................................ 47
Correlations between Baseline Characteristics and Disease Progression in Eyes with NonExudative Age-Related Macular Degeneration: The Complete Study
Mathew K. George, MD .................................................................................................... 49
Natural History of Glaucoma Drainage Implants and Penetrating Keratoplasty
Jessica L. Chen, MD ........................................................................................................... 52
Clinical Outcomes of Immediate vs. Delayed Pars Plana Vitrectomy for Retained Lens
Fragments over a 22-Year Period
Yasha S. Modi, MD ............................................................................................................ 54
Treatment of Choroidal Melanoma with Adjuvant Bevacizumab Following Plaque
Brachytherapy Enhances Tumor Volume Reduction and Resolution of Exudative
Detachment
Samuel K. Houston III, MD ................................................................................................ 56
Comparison of Corneal Stromal Bed Quality by Scanning Electron Microscopy Using
Mechanical and Femtosecond Laser Keratomes
Jessica H. Chow, MD ......................................................................................................... 59
A Comparative Analysis of OCT Findings in Posterior Uveitis
Ashkan M. Abbey, MD ...................................................................................................... 61
Effect of Plate Location on Initial Glaucoma Drainage Device Success Rates
Amy Z. Martino, MD.......................................................................................................... 63
Preparation Techniques and Intravitreal Injections: a Clinical and Microbiological
Evaluation
Roger A. Goldberg, MD, MBA ........................................................................................... 65
Outcomes Following Intravitreal Injection of Aflibercept in Patients with Exudative
Disease
Dimple Modi, MD .............................................................................................................. 67
In Vitro Collagen Cross Linking for Acanthamoeba Keratitis
Ravi D. Patel, MD, MBA..................................................................................................... 69
Anterior Segment OCT in Eyes with Cyclodialysis after Trabectome Glaucoma Surgery
Robert M. Knape, MD ....................................................................................................... 71
Ophthalmology Specific Emergency Departments Utilization Review: A Multicenter
Analysis
Ryan F. Isom, MD .............................................................................................................. 73
Visual Field Outcomes in the Tube vs. Trabeculectomy Study
Lauren S. Blieden, MD ....................................................................................................... 75
An Animal Model of Epithelial Downgrowth
Matthew J. Weiss, MD ...................................................................................................... 76
Effect of VP/LP Shunts on Visual Function in Idiopathic Intracranial Hypertension
Timothy W. Winter, DO .................................................................................................... 78
Evaluation of Intracorneal Ring Segment Placement with a 200 kHz Femtosecond Laser
John W. French, MD.......................................................................................................... 80
Molecular Surveillance of Contact Lenses, Cases, and Solutions for the Presence of Freeliving Amoeba among Patients with Infectious Keratitis
Ryan C. Young, MD............................................................................................................ 82
Clinical Course Of Unoperated Eyes With Vitreomacular Traction Syndrome
Vishak John, MD................................................................................................................ 84
Analysis of Epiretinal Membranes Using Spectral Domain Optical Coherence Tomography
Ajay E. Kuriyan, MD, MS ................................................................................................... 86
Total Thyroidectomy for the Treatment of Severe Progressive Thyroid Eye Disease
Andrea Kossler, MD .......................................................................................................... 88
Outcomes of Adjustable Suture Strabismus Surgery: 2% Lidocaine vs. 2% Lidocaine with
0.4% Ropivacaine
Kara M. Cavuoto, MD ........................................................................................................ 90
Anterior Segment OCT in the Diagnosis and Treatment of Subclinical Conjunctival
Intraepithelial Neoplasms (CIN)
Benjamin J. Thomas, MD .................................................................................................. 92
Changes in Clinical Practice: A Survey of the American Glaucoma Society
Joseph Panarelli, MD......................................................................................................... 94
Management of Acute Severe Ocular Surface Disorders, From the Bedside to the Bench
Guillermo Amescua, MD ................................................................................................... 96
Factors Affecting DSAEK Lenticule Adhesion
Ana Paula Canto, MD ........................................................................................................ 98
Antifungal Sensitivities in Culture Proven Exogenous Fungal Endophthalmitis
Ruwan A. Silva, MD ......................................................................................................... 100
Mycobacterial Endophthalmitis
David W. Parke III, MD .................................................................................................... 102
Optic Coherence Tomography (OCT) Findings in Posterior Uveitis Secondary to Syphilis
Swetangi D. Bhaleeya, MD .............................................................................................. 103
Systemic Complement Inhibition with Eculizumab for the Treatment of Drusen in AMD:
The COMPLETE Study
Jyoti R. Dugar, MD........................................................................................................... 105
Differentiating Papilledema and Optic Disc Drusen Using Optical Coherence Tomography
Kaushal M. Kulkarni, MD................................................................................................. 107
Predictors of Ocular Surface Squamous Neoplasia Recurrence after Excisional Surgery
Fasika Woreta, MD.......................................................................................................... 109
The Effect of Pulsed Light Therapy on Meibomian Gland Dysfunction and Dry Eye
Syndrome
Bradford W. Lee, MD, MSc ............................................................................................. 111
Orbital Trauma and Retrobulbar Hemorrhage at Bascom Palmer and Jackson Memorial
Hospital
Benjamin P. Erickson, MD ............................................................................................... 113
Comparison of Postoperative Pain and Surgical Outcomes with Two Different Types of
Local Anesthesia for Conjunctival Mullerectomy
Chad C. Zatezalo, MD ...................................................................................................... 114
Bascom Palmer Eye Institute, Department of Continuing Medical Education
Program Schedule
Academic Year 2012-2013
XXXIV Inter-American Course in Clinical Ophthalmology
Date:
Location:
Course Directors:
CME Credits:
November 18-21, 2012
Intercontinental Hotel, Miami, FL
Eduardo C. Alfonso, MD,
Paul F. Palmberg, MD, PhD, and Victor L. Perez, MD
N/A
Ophthalmic Imaging 2013: Optical Coherence Tomography (OCT) Applications and
Future Technology
Date:
Location:
Course Directors:
December 1, 2012
The Breakers Hotel, Palm Beach, FL
Donald L. Budenz, MD, MPH
Carmen A. Puliafito, MD, MBA
Dr. Richard K. Lee, MD, PhD
Glaucoma 2.0
Date:
Location:
Course Directors:
January 26, 2013
Bascom Palmer Eye Institute
Jose Berrocal Auditorium, Miami, FL
Richard K. Parrish, II, MD
Jeffrey L. Goldberg, MD, PhD
Angiogenesis, Exudation, and Degeneration 2013
Date:
Location:
Course Directors:
February 9, 2013
Mandarin Oriental Miami, Miami, FL
Harry W. Flynn, Jr, MD
Philip J. Rosenfeld, MD, PhD
Carmen A. Puliafito, MD, MBA
Cataract & Refractive Surgery Congress 2013
Date:
Location:
Course Directors:
February 23, 2013
Bascom Palmer Eye Institute
Jose Berrocal Auditorium, Miami, FL
Sonia H. Yoo, MD
William W. Culbertson, MD
2013 Vitreoretinal Course Update
Date:
Location:
Course Directors:
William E. Smiddy, MD
TBD
Bascom Palmer Eye Institute
Jose Berrocal Auditorium, Miami, FL
Harry W. Flynn, Jr., MD
49th Annual Residents’ Days
Date:
Location:
Course Directors:
June 14-15, 2013
Bascom Palmer Eye Institute
Jose Berrocal Auditorium, Miami, FL
Patrick E. Rubsamen, MD
48th ANNUAL RESIDENTS’ DAYS
June 15-16, 2012
Bascom Palmer Eye Institute
Miami, FL
ACCREDITATION
The University of Miami Leonard M. Miller School of Medicine is accredited by the Accreditation Council
for Continuing Medical Education (ACCME) to provide continuing education for physicians.
CREDIT DESIGNATION
University of Miami Leonard M. Miller School of Medicine designates this live activity for a maximum of
10.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the
extent of their participation in the activity.
LEARNING OBJECTIVES
Upon completion of the course, participants will be able to:
• Compare indications and techniques for vitreoretinal surgical procedures
• Diagnose ocular infectious diseases through the use of microbiology
• Identify ocular neoplasms and other corneal conditions
• Determine appropriate use of intraocular injections
• Examine diagnostic capabilities of imaging for glaucoma and formulate treatment plans based on
imaging data
DOCUMENTATION OF ATTENDANCE FOR CME
1. Complete Credit Adjustment Form.
2. Certificates of Attendance will be e-mailed to attendees approximately 4 to 6 weeks after the
conference.
EVALUATIONS
Conference evaluations are a valuable tool in assisting to better serve you. An e-mail
with a link to the electronic evaluation form will be sent to you at the end of the
program. Please complete your evaluation form on-line. We welcome your
comments and suggestions. You may access the evaluation by visiting:
https://www.surveymonkey.com/s/48thResidentsDay or scanning the QR code pictured
here.
An outcome evaluation will be conducted 2 to 3 months following the course to measure the impact this
activity has had in changing performance and patient outcomes. We encourage and appreciate your
participation.
3
ACKNOWLEDGEMENTS
This CME Activity is partially supported by unrestricted educational grants from:
Alcon
Allergan
AMO
Bausch & Lomb
Merck
4
48th ANNUAL RESIDENTS’ DAYS
June 15-16, 2012
Bascom Palmer Eye Institute
Miami, FL
The following speakers and planners have indicated that they do not have relevant financial interests
with commercial interests:
•
Ashkan M. Abbey, MD
•
Eduardo C. Alfonso, MD
•
Guillermo Amescua, MD
•
Hassan A. Aziz, MD
•
James T. Banta, MD
•
Swetangi D. Bhaleeya, MD
•
Lauren S. Blieden, MD
•
Ana Paula Canto, MD
•
Kara M. Cavuoto, MD
•
Jonathan S. Chang, MD
•
Daniel L. Chao, MD, PhD
•
Gene W. Chen, MD
•
Jessica L. Chen, MD
•
Jessica H. Chow, MD
•
Avnish A. Deobhakta, MD
•
Jyoti R. Dugar, MD
•
Andres Emanuelli, MD
•
Benjamin P. Erickson, MD
•
Jane Fishler, MD
•
John W. French, MD
•
Steven J. Gedde, MD
•
Mathew K. George, MD
•
Roger A. Goldberg, MD, MBA
•
Marco A. Gonzalez, MD
•
Luis J. Haddock, MD
•
Ben J. Harvey, MD
•
Christopher R. Henry, MD
•
Samuel K. Houston III, MD
•
Carol L. Karp, MD
•
Ryan F. Isom, MD
•
Vishak J. John, MD
•
Robert M. Knape, MD
•
Kaushal M. Kulkarni, MD
•
Ajay E. Kuriyan, MD
•
Bradford W. Lee, MD
•
Andrea Lora Kossler, MD
•
Amy Z. Martino, MD
•
Dimple Modi, MD
•
Yasha S. Modi, MD
•
Joseph Panarelli, MD
•
David W. Parke III, MD
•
Ravi D. Patel, MD
•
Aleksandra V. Rachitskaya, MD
•
Patrick E. Rubsamen, MD
•
Andrew M. Schimel, MD
•
Gary Shienbaum, MD
•
Ruwan A. Silva, MD
•
Jayanth Sridhar, MD
•
Benjamin J. Thomas, MD
•
Jonathan H. Tzu, MD
•
Matthew J. Weiss, MD
•
Timothy W. Winter, DO
•
Fasika Woreta, MD
•
Ryan C. Young, MD
•
Chad C. Zatezalo, MD
The following speakers and planners have indicated relevant financial relationships with the following
commercial interests:
Speaker Name
Richard K. Lee, MD, PhD
Philip J. Rosenfeld, MD,
PhD
Sonia H. Yoo, MD
Name(s) of Commercial Interest(s)/
Financial Relationship
American Glaucoma Society: Grants/Research
Support
Merck: Consultant; Speaker’s Bureau
Acucela: Consultant
Advanced Cell Technology: Grants/Research
Support
Alexion: Grants/Research Support
Boehringer Ingelheim ThromboGenics: Advisory
Board/Panel
Carl Zeiss Meditec: Grants/Research Support,
Lecture Fee
Cheengdu Kanghong Biotech: Consultant
GlaxoSmithKline: Grants/Research Support
Oraya: Consultant
Sucampo: Advisory Board/Panel
Alcon: Consultant
48th ANNUAL RESIDENTS’ DAYS
June 15-16, 2012
Course Director
Patrick E. Rubsamen, MD
Retina Group of Florida
Boca Raton, Florida
Bascom Palmer Eye Institute Faculty
Eduardo C. Alfonso, MD
Professor and Chairman, Department of Ophthalmology
James T. Banta, MD
Associate Professor of Clinical Ophthalmology
Steven J. Gedde, MD
Professor of Ophthalmology
Carol L. Karp, MD
Professor of Clinical Ophthalmology
Richard K. Lee, MD
Associate Professor of Ophthalmology
Philip J. Rosenfeld, MD, PhD
Professor of Ophthalmology
Sonia H. Yoo, MD
Professor of Ophthalmology
Bascom Palmer Eye Institute Residents
FIRST YEAR
Hassan A. Aziz, MD
Daniel L. Chao, MD, PhD
Benjamin P. Erickson, MD
Ajay E. Kuriyan, MD, MS
Yasha S. Modi, MD
Jayanth Sridhar, MD
Ryan C. Young, MD
8
SECOND YEAR
Ashkan M. Abbey, MD
Marco A. Gonzalez, MD
Christopher R. Henry, MD
Samuel K. Houston III, MD
Bradford W. Lee, MD
Benjamin J. Thomas, MD
Jonathan H. Tzu, MD
THIRD YEAR
Jonathan S. Chang, MD
Avnish A. Deobhakta, MD
Roger A. Goldberg, MD, MBA
Luis J. Haddock, MD
Aleksandra V. Rachitskaya, MD
Ruwan A. Silva, MD
Matthew J. Weiss, MD
CHIEF RESIDENTS
Thomas S. Shane, MD
Anita R. Shirodkar, MD
Bascom Palmer Eye Institute Fellows
Guillermo Amescua, MD (Cornea)
Swetangi D. Bhaleeya, MD (Uveitis)
Lauren S. Blieden, MD (Glaucoma)
Ana Paula Canto, MD (International Cornea)
Kara M. Cavuoto, MD (Pediatrics)
Gene W. Chen, MD (Medical Retina)
Jessica L. Chen, MD (Glaucoma)
Jessica H. Chow, MD (Cornea)
Andres Emanuelli, MD (Retina)
Jane Fishler, MD (Cornea)
John W. French, MD (Cornea)
Mathew K. George, MD (Medical Retina)
Ben J. Harvey, MD (Glaucoma)
Vishak John, MD (Retina)
Robert M. Knape, MD (Glaucoma)
Andrea Kossler, MD (Oculoplastics)
Kaushal M. Kulkarni, MD (Neuro-ophthalmology)
Amy Z. Martino, MD (Glaucoma)
Dimple Modi, MD (Medical Retina)
Joseph Panarelli, MD (Glaucoma)
9
David W. Parke III, MD (Retina)
Ravi D. Patel, MD (Cornea)
Andrew M. Schimel, MD (Retina)
Gary Shienbaum, MD (Retina)
Timothy W. Winter, DO (Neuro-ophthalmology)
Fasika Woreta, MD (Cornea)
Chad C. Zatezalo, MD (Oculoplastics)
10
48th Annual Residents’ Days
June 15-16, 2012
Bascom Palmer Eye Institute
Miami, FL
Friday, June 15, 2012
(Subject to change)
7:30 am
Registration and Continental Breakfast
8:00
Introduction/Welcome
Eduardo C. Alfonso, MD and Patrick E. Rubsamen, MD
Session I
Moderator: Phillip J. Rosenfeld, MD, PhD
Discussion will follow each presentation
8:10
Infectious Keratitis Progressing to Endophthalmitis: a 15-year-study of
Microbiology, Risk Factors, and Clinical Outcomes
Christopher R. Henry, MD
8:22
Endogenous Endophthalmitis Caused by Yeast: Risk Factors, Management
Strategies, and Visual Acuity Outcomes
Jayanth Sridhar, MD
8:34
Management of Submacular Hemorrhage Secondary to Neovascular Age-related
Macular Degeneration with Anti-vascular Endothelial Growth Factor
Monotherapy
Gary Shienbaum, MD
8:46
Clinical Outcomes of Optic Pit Maculopathy
Jonathan H. Tzu, MD
8:58
Retinal Detachment Caused By Giant Retinal Tears: Etiologies, Techniques and
Outcomes
Marco A. Gonzalez, MD
9:10
Glaucoma Tube Associated Endophthalmitis
Avnish A. Deobhakta, MD
9:22
Intra-ocular Lens Implantation in the Pediatric Population
Hassan A. Aziz, MD
9:34
Anaerobic Bacteria Causing Endophthalmitis: Spectrum, Frequency and
Sensitivities
Andres Emanuelli, MD
9:46
Systemic Complement Inhibition with Eculizumab for the Treatment of
Geographic Atrophy in AMD: The COMPLETE Study
Gene W. Chen, MD
9:58
Break
Session II
Moderator: James T. Banta, MD
Discussion will follow each presentation
10:20
A Review of Femtosecond Assisted Anterior Lamellar Keratoplasty at Bascom
Palmer
Jane Fishler, MD
10:32
Evaluation of Optic Disc Progression in Glaucoma using Spectral Domain Optical
Coherence Tomography
Ben J. Harvey, MD
10:44
Evolving Fluoroquinolone Resistance Among Coagulase-Negative Staphylococcus
Isolates Causing Endophthalmitis
Andrew M. Schimel, MD
10:56
Vitrectomy and Membrane Peeling In Patients with Myopic Macular
Retinoschisis
Jonathan S. Chang, MD
11:08
Molecular Mechanisms of Blood-Retina Barrier Permeability
Daniel L. Chao, MD, PhD
11:20
Long Term Outcomes Of Anti-Vegf Therapy For Age Related Macular
Degeneration
Luis J. Haddock, MD
11:32
Comparison of Blood Culture Bottles and Membrane Filter System for Culturing
Vitreous Specimens
Aleksandra V. Rachitskaya, MD
11:44
Correlations between Baseline Characteristics and Disease Progression In Eyes
with Non-Exudative Age-Related Macular Degeneration: The Complete Study
Mathew K. George, MD
11:56
Lunch
Session III
Moderator: Carol L. Karp, MD
Discussion will follow each presentation
1:00 pm
Natural History of Glaucoma Drainage Implants and Penetrating Keratoplasty
Jessica L. Chen, MD
1:12
Clinical Outcomes of Immediate vs. Delayed Pars Plana Vitrectomy for Retained
Lens Fragments over a 22-Year Period
Yasha S. Modi, MD
1:24
Treatment of Choroidal Melanoma with Adjuvant Bevacizumab Following Plaque
Brachytherapy Enhances Tumor Volume Reduction and Resolution of Exudative
Detachment
Samuel K. Houston III, MD
1:36
Comparison of Corneal Stromal Bed Quality by Scanning Electron Microscopy
Using Mechanical and Femtosecond Laser Keratomes
Jessica H. Chow, MD
1:48
A Comparative Analysis of OCT Findings in Posterior Uveitis
Ashkan M. Abbey, MD
2:00
Effect of Plate Location on Initial Glaucoma Drainage Device Success Rates
Amy Z. Martino, MD
2:12
Preparation Techniques and Intravitreal Injections: a Clinical and Microbiological
Evaluation
Roger A. Goldberg, MD, MBA
2:24
Outcomes Following Intravitreal Injection of Aflibercept in Patients with
Exudative Disease
Dimple Modi, MD
2:36
In Vitro Collagen Cross Linking for Acanthamoeba Keratitis
Ravi D. Patel, MD, MBA
2:48
Break
Session IV
Moderator: Sonia H. Yoo, MD
Discussion will follow each presentation
3:08
Anterior Segment OCT in Eyes with Cyclodialysis after Trabectome Glaucoma
Surgery
Robert M. Knape, MD
3:20
Ophthalmology Specific Emergency Departments Utilization Review: A
Multicenter Analysis
Ryan F. Isom, MD
3:32
Visual Field Outcomes in the Tube vs. Trabeculectomy Study
Lauren S. Blieden, MD
3:44
An Animal Model of Epithelial Downgrowth
Matthew J. Weiss, MD
3:56
Effect of VP/LP Shunts on Visual Function in Idiopathic Intracranial Hypertension
Timothy W. Winter, DO
4:08
Evaluation of Intracorneal Ring Segment Placement with a 200 kHz Femtosecond
Laser
John W. French, MD
4:20
Molecular Surveillance of Contact Lenses, Cases, and Solutions for the Presence
of Free-living Amoeba among Patients with Infectious Keratitis
Ryan C. Young, MD
4:32
Clinical Course Of Unoperated Eyes With Vitreomacular Traction Syndrome
Vishak John, MD
4:44
Adjourn
Saturday, June 16, 2012
7:30 am
Registration and Continental Breakfast
8:00
Introduction/Welcome
Eduardo C. Alfonso, MD and Patrick E. Rubsamen, MD
Session I
Moderator: Richard K. Lee, MD, PhD
Discussion will follow each presentation
8:10
Analysis of Epiretinal Membranes Using Spectral Domain Optical Coherence
Tomography
Ajay E. Kuriyan, MD, MS
8:22
Total Thyroidectomy for the Treatment of Severe Progressive Thyroid Eye
Disease
Andrea Kossler, MD
8:34
Outcomes of Adjustable Suture Strabismus Surgery: 2% Lidocaine vs. 2%
Lidocaine with 0.4% Ropivacaine
Kara M. Cavuoto, MD
8:46
Anterior Segment OCT in the Diagnosis and Treatment of Subclinical Conjunctival
Intraepithelial Neoplasms (CIN)
Benjamin J. Thomas, MD
8:58
Changes in Clinical Practice: A Survey of the American Glaucoma Society
Joseph Panarelli, MD
9:10
Management of Acute Severe Ocular Surface Disorders, From the Bedside to the
Bench
Guillermo Amescua, MD
9:22
Factors Affecting DSAEK Lenticule Adhesion
Ana Paula Canto, MD
9:34
Antifungal Sensitivities in Culture Proven Exogenous Fungal Endophthalmitis
Ruwan A. Silva, MD
9:46
Break
Session II
Moderator: Steven J. Gedde, MD
Discussion will follow each presentation
10:00
Mycobacterial Endophthalmitis
David W. Parke III, MD
10:12
Optic Coherence Tomography (OCT) Findings in Posterior Uveitis Secondary to
Syphilis
Swetangi D. Bhaleeya, MD
10:24
Systemic Complement Inhibition with Eculizumab for the Treatment of Drusen in
AMD: The COMPLETE Study
Jyoti R. Dugar, MD
10:36
Differentiating Papilledema and Optic Disc Drusen Using Optical Coherence
Tomography
Kaushal M. Kulkarni, MD
10:48
Predictors of Ocular Surface Squamous Neoplasia Recurrence after Excisional
Surgery
Fasika Woreta, MD
11:00
The Effect of Pulsed Light Therapy on Meibomian Gland Dysfunction and Dry Eye
Syndrome
Bradford W. Lee, MD, MSc
11:12
Orbital Trauma and Retrobulbar Hemorrhage at Bascom Palmer and Jackson
Memorial Hospital
Benjamin P. Erickson, MD
11:24
Comparison of Postoperative Pain and Surgical Outcomes with Two Different
Types of Local Anesthesia for Conjunctival Mullerectomy
Chad C. Zatezalo, MD
11:36
Best of Grand Rounds
12:00 pm
Adjourn
12:05
BPEI ALUMNI ASSOCIATION BUSINESS MEETING
7:00
COCKTAILS /DINNER
RITZ CARLTON, COCONUT GROVE
PRESENTATIONS
17
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Infectious Keratitis Progressing To Endophthalmitis: A 15-YearStudy Of Microbiology, Associated Factors, And Clinical
Outcomes
Christopher R. Henry, MD
Primary Supervisor: Harry W. Flynn Jr., MD
Co-Authors: Darlene Miller DHSc, Richard K. Forster MD, Eduardo C. Alfonso MD
Purpose: To describe the incidence, microbiology, associated factors and clinical
outcomes of patients with infectious keratitis progressing to endophthalmitis.
Methods: Non-randomized, retrospective, consecutive case series. Ocular microbiology
and medical records were reviewed on all patients with positive corneal and intraocular
cultures between January 1, 1995 and December 31, 2009 at the Bascom Palmer Eye
Institute.
Results: A total of 9934 corneal cultures were performed for suspected infectious
keratitis. Only 49 eyes (0.5%) progressed to culture-proven endophthalmitis. Fungi
(n=26) were the most common responsible organism followed by gram positive bacteria
(n=13) and gram negative bacteria (n=10). Topical steroid use (37/49[76%]) was the
most common associated factor identified in the current study, followed by previous
surgery (30/49[61%]), corneal perforation (17/49[35%]), dry eye (15/49[31%]), relative
immune compromise (10/49[20%]), organic matter trauma (9/49[18%]) and contact lens
wear (3/49[6%]). There were 27 patients in which a primary infectious keratitis
developed into endophthalmitis, and 22 patients in which an infectious keratitis
adjacent to a previous surgical wound progressed into endophthalmitis. Patients in the
primary keratitis group were more likely to be male (22/27[81%] vs. 8/22[36%],
p=0.001), have history of organic matter trauma (8/27[30%] vs. 1/22[5%]), p=0.030),
and have fungal etiology (21/27[78%] vs. 5/22[23%], p<0.001). Patients in the surgicalwound-associated group were more likely to use topical steroids (20/22[91%] vs.
18
17/27[63%], p=0.024). Visual acuity of ≥20/50 was achieved in 7/49[14%] patients, but
was <5/200 in 34/49[69%] patients at last follow up. Enucleation was performed in
15/49[31%] patients.
Conclusion: Progression of infectious keratitis to endophthalmitis is relatively
uncommon. The current study suggests that patients at higher risk for progression to
endophthalmitis include patients using topical corticosteroids, patients with fungal
keratitis, patients with corneal perforation, and patients with infectious keratitis
developing adjacent to a previous surgical wound. Patients with sequential keratitis and
endophthalmitis have generally poor visual outcomes.
References:
1. Scott IU, Flynn HW Jr, Feuer W, et al. Endophthalmitis associated with microbial
keratitis. Ophthalmology 1996;103:1864-70.
2. Wykoff CC, Flynn HW Jr, Miller D, et al. Exogenous fungal endophthalmitis:
microbiology and clinical outcomes. Ophthalmology 2008;115:1501-7.
3 .Pflugfelder SC, Flynn HW Jr, Zwickey TA, et al. Exogenous fungal endophthalmitis.
Ophthalmology 1988;95:19-30.
4. Dursun D, Fernandez V, Miller D, Alfonso EC. Advanced fusarium keratitis progressing
to endophthalmitis. Cornea 2003;22:300-3.
19
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Endogenous Endophthalmitis Caused By Yeast: Risk Factors,
Management Strategies, and Visual Acuity Outcomes
Jayanth S. Sridhar, MD
Primary Supervisor: Harry W. Flynn Jr., MD
Co-Authors: Darlene Miller DHSc, MPH, CIC, Thomas A. Albini, MD
Purpose: To report the risk factors, management strategies, and visual outcomes in
patients with culture-proven endogenous endophthalmitis caused by yeast.
Methods: A non-randomized consecutive case series of all patients with culture-proven
unilateral or bilateral endogenous endophthalmitis caused by yeast at the Bascom
Palmer Eye Institute between January 1, 1990 and December 31st, 2006.
Results: Study criteria were met in 50 eyes of 38 patients. Patients had a mean followup of 16.7 months from presentation to last follow-up visit.
Decreased vision was the most common presenting symptom (74.3%) followed by
redness (46.1%) and pain (38.5%). 65.8% of patients had a current or recent (< 6
months) hospitalization at the time of diagnosis. Recent surgery was the most common
identified risk factor (31.6%) followed by cancer (23.7%). None of the patients were
diagnosed on routine screening for fungemia.
Diffuse anterior and posterior inflammation was the most common finding on
examination of affected eyes (64.7%) followed by focal posterior inflammation (23.5%).
Hypopyon was noted in only 5.8% of affected eyes.
Initial treatment consisted of a combination of medical and surgical treatment in 33.3%
of eyes. 37.2% of eyes received medical treatment consisting of systemic antifungal
therapy, intravitreal injection of antifungals, or both. 43.1% of eyes underwent
vitrectomy with or without lensectomy, with or without intravitreal injection.
The most common organism cultured by vitreous aspirate or vitrectomy specimen was
Candida albicans (87.2%) followed by Candida tropicalis (7.7%) and Cryptococcus
neoformans (5.1%). Blood cultures were positive in 17.9% of patients.
20
Visual acuity on presentation was 20/200 or better in 41.3% of eyes. Visual acuity of
20/200 or better was present in 61.3% of eyes at last follow-up. Retinal detachment
occurred in 29.4% of eyes.
Conclusion: In this study of endogenous endophthalmitis caused by yeast, Candida
albicans was the predominant etiology. Decreased vision was the most common
presenting symptom. Endogenous endophthalmitis is associated with poor visual acuity
outcomes despite early and appropriate management. Retinal detachment is a frequent
event in the clinical course.
References:
Lingappan A, Wykoff CC, Albini TA, Miller D, Pathengay A, Davis JL, Flynn HW Jr.
Endogenous fungal endophthalmitis: causative organisms, management strategies, and
visual acuity outcomes. Am J Ophthalmol. 2012 Jan;153(1):162-6.e1. Epub 2011 Sep 13.
Sallam A, Taylor SR, Khan A, McCluskey P, Lynn WA, Manku K, Pacheco PA, Lightman S.
Factors determining visual outcome in endogenous Candida endophthalmitis. Retina.
2012 Jun;32(6):1129-34.
Wykoff CC, Flynn HW Jr, Miller D, Scott IU, Alfonso EC. Exogenous fungal
endophthalmitis: microbiology and clinical outcomes. Ophthalmology. 2008
Sep;115(9):1501-7, 1507.e1-2. Epub 2008 May 16.
21
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Management Of Submacular Hemorrhage Secondary To
Neovascular Age-Related Macular Degeneration With AntiVascular Endothelial Growth Factor Monotherapy
Gary Shienbaum, MD
Primary Supervisor: Harry W. Flynn Jr., MD
Co-Authors: Carlos Alexandre De A. Garcia Filho, MD, Philip J. Rosenfeld, MD, PhD
Purpose: To report the visual and anatomic outcomes of anti-vascular endothelial
growth factor (VEGF) monotherapy in the management of significant submacular
hemorrhage secondary to neovascular age-related macular degeneration (AMD).
Methods: Retrospective, interventional, consecutive case series. Thirteen eyes of 12
patients with neovascular AMD and fovea involving submacular hemorrhage comprising
greater than 50% of the lesion area were evaluated. Treatment consisted of multiple
injections of ranibizumab (9 eyes) or bevacizumab (4 eyes). Main outcome measures
included mean visual acuity change from baseline, mean central lesion thickness change
from baseline, mean number of injections at 6 months, and adverse events. Central
lesion thickness was measured to be the distance from the internal limiting membrane
to Bruchs membrane at the center of the fovea on spectral-domain optical coherence
tomography (SD-OCT) images. Snellen visual acuity was converted to approximate
ETDRS letter score for the purpose of statistical analysis.
Results: The mean follow-up period was 9.3 months. The mean change in approximate
ETDRS letter score from baseline was +12.2 letters at 3 months (P = 0.01), +23.3 letters
at 6 months (P = 0.002), and +19.3 letters at 12 months follow-up (P = 0.04). The mean
number of injections at 6 months was 4.7. The mean OCT central lesion thickness
decreased from 766 μm to 332 μm at 6 months (P = 0.02).
22
Conclusion: Eyes with submacular hemorrhage secondary to neovascular AMD may
experience significant visual improvements when managed with anti-VEGF
monotherapy.
References:
1. Rosenfeld PJ, Brown DM, Heier JS, et al. Ranibizumab for neovascular age-related
macular degeneration. N Engl J Med 2006;355(14):1419-31.
2. Brown DM, Kaiser PK, Michels M, et al. Ranibizumab versus verteporfin for
neovascular age-related macular degeneration. N Engl J Med 2006;355(14):1432-44.
3. Fine HF, Iranmanesh R, Del Priore LV, et al. Surgical outcomes after massive
subretinal hemorrhage secondary to age-related macular degeneration. Retina
2010;30(10):1588-94.
4. Chang MA, Do DV, Bressler SB, Cassard SD, Gower EW, Bressler NM. Prospective oneyear study of ranibizumab for predominantly hemorrhagic choroidal neovascular lesions
in age-related macular degeneration. Retina 2010;30(8):1171-6.
5. Todorich B, Scott IU, Flynn HW, Johnson MW. Strategies in the management of
submacular hemorrhage associated with choroidal neovascularization in the anti–
vascular endothelial growth factor era. Retina 2011;31:1749-52.
23
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Clinical Outcomes of Optic Pit Maculopathy
Jonathan H. Tzu, MD
Primary Supervisor: Harry W. Flynn, Jr., MD
Co-Authors:
Purpose: To evaluate a series of patients with optic disc pit maculopathy in terms of
their clinical characteristics including SD-OCT, clinical courses, and outcome of
treatment if given.
Methods:
Retrospective review
Inclusion criteria : diagnosis of optic disc pit at Bascom Palmer Eye Institute seen
between the years 2001 and 2012.
Exclusion criteria:
1)
no OCT imaging
2)only one clinic visit with no follow up
Two main groups:
1)
patients with optic pit maculopathy that were observed without surgery, and
2) patients with optic pit maculopathy that received surgical intervention.
Results: N = 27
Mean Age (years)
36.4
Mean on presentation (years)
Gender
M = male, F = female M = 10
F = 13
Laterality
RE = Right eye
LE = Left eye RE = 11
LE = 16
27.3
24
Bilateral (patients) 4/23
Location of pit Superotemporal = 1/27
Temporal = 12/27
Inferotemporal = 12/27
Inferior = 2/27
Macula involvement 20/27 (78%)
Median follow up (months) 17.5
Observed patients:
N=7
Visual acuity on presentation >20/200 – 3/7
20/200 or worse – 4/7
Final visual acuity
>20/200 – 3/7
20/200 or worse – 4/7
Length of follow up Median = 16
Surgery patients:
N= 10 (8 operated, 2 laser only)
Visual acuity on presentation >20/200 – 6/10
20/200 or worse – 4/10
Final visual acuity
>20/200 – 4/10
20/200 or worse – 6/10
Length of follow up Median = 19.5 months
Conclusion:
In the current study, patients with better than 20/200 initial visual acuity were often
observed and remained stable during follow up. Surgical intervention in eyes with
progressive or sustained visual loss had variable outcomes, with persistent
intraretinal/subretinal fluid being a common occurrence.
References:
1) Sugar HS. Congenital pits of the optic disc and their equivalents (congenital
colobomas and colobomalike excavations) associated with submacular fluid. Am J
Ophthalmol 1967;63:298-307.
2) Lincoff H, Lopez R, Kreissig I, Yannuzzi L, Cox M, Burton T. Retinoschisis associated
with optic nerve pits. Arch Ophthalmol 1988;106:6-67.
3) Hirakata A, Okada AA, Hida T. Long-term results of vitrectomy without laser
treatment for macular detachment associated with an optic disc pit. Ophthalmology
2005;112(8):1430-1435.
4) Lalwani GA, Punjabi OS, Flynn HW Jr, Knighton RW, Puliafito CA. Documentation
optic nerve pit with macular schisis-like cavity by spectral domain OCT. Ophthalmic Surg
Lasers Imaging 2007;38(3):262-264.
5) Imamura Y, Zweifel SA, Fujiwara T, Freund KB, Spaide RF. High-resolution optical
coherence tomography findings in optic pit maculopathy. Retina 2010;30(7):1104-1112.
25
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Retinal Detachment Caused By Giant Retinal Tears: Techniques
And Outcomes
Marco A. Gonzalez, MD
Primary Supervisor: Harry W. Flynn, MD
Co-Authors: William E. Smiddy, MD, Timothy G. Murray, MD, MBA, FACS, Thomas A.
Albini, MD
Purpose: To evaluate surgical techniques and outcomes for patients with giant retinal
tears (GRT) undergoing surgery.
Methods: A non-comparative consecutive case series between 2005 and 2011.
Results: With a mean follow-up of 16.1 months, 95 eyes of 95 patients were identified.
Trauma (29.5%) was a common etiology. All patients underwent vitrectomy with gas or
oil tamponade. 82.1% underwent scleral buckle. 62.1% had perfluorocarbon liquid use
during surgery. 15.8% underwent re-operation for recurrence. 96% achieved anatomic
success at last follow-up. Visual acuity outcomes were ≥ 20/200 in 81% (<4 clock hours)
and 50% (≥4 clock hours).
Conclusion: GRT patients undergoing surgery achieved high rates of anatomic success
but visual outcomes were variable. Better visual outcomes were associated with smaller
GRTs.
References:
Ang GS, Townend J, Noemi L. Epidemiology of Giant Retinal Tears in the United
Kingdom: The British Giant Retinal Tear Epidemiology Eye Study (BGEES). Investigative
Ophthalmology & Visual Science, September 2010, Vol. 51, No. 9
26
Scott IU, Murray TG, Flynn HW Jr, Feuer WJ, Schiffman JC. Outcomes and complications
associated with giant retinal tear management using perfluoro-n-octane.
Ophthalmology. 2002;109:1828 –1833.
Sirimaharaj M, Balachandran C, Chan WC, et al. Vitrectomy with short term
postoperative tamponade using perfluorocarbon liquid for giant retinal tears. Br J
Ophthalmol. 2005;89:1176–1179.
Al-Khairi AM, Al-Kahtani E, Kangave D, Abu El-Asrar AM. Prognostic
factors associated with outcomes after giant retinal tear management using
perfluorocarbon liquids. Eur J Ophthalmol. 2008;18:270–277.
Lee SY, Ong SG, Wong DW, Ang CL. Giant retinal tear management: an Asian experience.
Eye. 2009;23(3):601– 605.
27
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Glaucoma Tube Associated Endophthalmitis
Avnish A. Deobhakta, MD
Primary Supervisor: Harry W. Flynn Jr., MD
Co-Authors: Michael R. Banitt, MD, MHA, Thomas A. Albini, MD, William E. Smiddy,
MD
Purpose: To identify the risk factors, pathogens, treatment modalities, and subsequent
clinical outcomes of patients with Glaucoma tube associated Endophthalmitis.
Methods: A retrospective case series was done using the medical records of all patients
at the Bascom Palmer Eye Institute diagnosed with endophthalmitis associated with a
Glaucoma tube shunt between January 1, 1999 and July 31, 2011. Patients with culturepositive endophthalmitis were included in the study. Symptoms and signs at the time
of diagnosis of endophthalmitis were documented. Diagnostic paracenteses of the
vitreous was performed in all patients, and culture results were collected. The
treatment regimen and clinical course were reviewed for all patients.
Results: 9 patients were identified with endophthalmitis. The average time elapsed
from tube placement to endophthalmitis was 20 months with a range of 1 week to 4
years. Median pre-infection visual acuity was 20/100 with a range of 20/50 to HM.
Median post-infection visual acuity was 20/400 with a range of 20/60 to NLP. Average
loss of vision was 3.4 lines, with one patient progressing to LP and two patients to NLP.
7 of 9 culture positive infections were of gram positive origin, a majority of which were
Staphylococcus sp. One patient tested positive for atypical Mycobacerium. 3 of 7
patients had gram negative growth, two with Serratia marcescens and one with Proteus
mirabilis. 5 of 9 patients had tube exposure. 2 patients required evisceration. 3
patients required tube removal.
Conclusion: Glaucoma tube associated endophthalmitis is a rare and devastating event
associated with severe vision loss. Gram positive organisms such as Staphylococcus sp.
28
are often implicated, with a minority being caused by rare gram negative pathogens. In
a majority of patients, graft erosion of the tube occurs and tube explantation or
evisceration is necessary.
References: 1. Al-Torbak AA, Al-Shahwan S, Al-Jadaan I, Al-Hommadi A, Edward DP.
Endophthalmitis associated with the Ahmed glaucoma valve implant. Br J Ophthalmol.
2005 Apr;89(4):454-8.
2 Gedde SJ, Scott IU, Tabandeh H, Luu KK, Budenz DL, Greenfield DS, Flynn HW Jr. Late
endophthalmitis associated with glaucoma drainage implants. Ophthalmology. 2001
Jul;108(7):1323-7.
3. Krebs DB, Liebmann JM, Ritch R, et al. Late infectious endophthalmitis from exposed
glaucoma setons [case report]. Arch Ophthalmol 1992;110:174–5.
4. Al-Torbaq A, Edward DP. Delayed endophthalmitis in a child following an Ahmed
Glaucoma Valve Implant. JAAPOS 2002;6:123–125.
5. Francis BA, Diloreto DA, Chong LP, et al. Late onset bacterial endophthalmitis
following glaucoma drainage implantation. Ophthalmol Surg Lasers
Imaging2003;34:128–30.
.
29
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Intra-Ocular Lens Implantation In The Pediatric Population
Hassan A. Aziz, MD
Primary Supervisor: Audina M. Berrocal, MD
Co-Authors: Nikisha Kothari, MS; James T. Banta, MD; Kara M. Cavuoto, MD
Purpose: One of the most common pediatric intraocular surgeries throughout the world
is cataract surgery. The surgery is not without risks, especially in such a young
population. Our study will examine the clinical outcomes and rates of complicaitons in
children (age birth to 9 yaers old) undergoing cataract surgery from year 2000-2009 at
Bascom Palmer Eye Institute.
Methods: An IRB-approved, consecutive retrospective case series. Records of Bascom
Palmer Eye Institute were reviewed to identify pediatric cataract surgeries who
underwent treatment by our faculty between 2000 and 2009.
Results: To be presented.
Conclusion: To be presented.
References: To be presented.
30
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Anaerobic Bacteria Causing Endophthalmitis: Spectrum,
Frequency And Sensitivities
Andrés Emanuelli, MD
Primary Supervisor: Harry W. Flynn, MD
Co-Authors: Darlene Miller, DHSc
Purpose: To report the spectrum, frequency and sensitivities of anaerobic bacteria
causing endophthalmitis over the last 20 years.
Methods: From the Microbiology Laboratory Department records, all anaerobic
bacterial cases of endophthalmitis were reviewed between January 1, 1991 and
September 30, 2011. All the vitreous isolates were tested for vancomycin, ceftazidime,
gatifloxacin and moxifloxacin sensitivities at high and low dose.
Results: Anaerobic bacteria accounted for 115 of 1386 (8.3%) in vitreous culturepositive endophthalmitis isolates from 1991 to 2011. The most common bacteria for the
isolates was Propionibacterium acnes (89.4%). Other etiologies included, Bacteroides
species (5.3%), Peptostreptococcus species (2.6%), Propionibacterium granulosum
(0.9%), Propionibacterium avidum (0.9%), and Clostridum subterminale (0.9%). The
sensitivities were as follows: 92% of the isolates were sensitive to vancomycin (222
µg/ml & 22 µg/ml), 66.7% were sensitive to high dose ceftazidime (5 µg/ml) and 33.3%
were sensitives to low dose ceftazidime (0.5 µg/ml). The sensitivities to
fluoroquinolones, was as follows: 41.7% of the isolates were sensitive to high dose
moxifloxacin (1.1 mg/ml), 25% were sensitive to low dose moxifloxacin
(0.11 mg/ml), 50% of the isolates were sensitive to high dose gatifloxacin (0.67 mg/ml),
and 8.3% were sensitive to low dose gatifloxacin (0.07 mg/ml).
31
Conclusion: In the current study, anaerobic bacteria account for less than 10% of culture
positive endophthalmitis. The most common etiology was Propionibacterium acnes.
Regarding the sensitivities, vancomycin was the most effective antibiotic against
anaerobes pathogens. The fluoroquinolones had a variable effect in the high dose group,
but were not generally effective in the low dose group.
References:
1. Shirodkar AR, Pathengay A, Flynn HW Jr, et al. Delayed – versus cute-onset
endophthalmitis after cataract surgery. Am J Ophthalmol. 2012 Mar;153 (3) :391398..e2
2. Clark WL, Kaiser PK, Flynn HW Jr, et al. Treatment strategies and visual acuity
outcomes in chronic postoperative Propionibacterium acnes endophthalmitis.
Ophthalmology. 1999 Sep;106(9):1665-70
3. Fox GM, Joondeph BC, Flynn HW Jr, et al. Delayed-onset pseudophakic
endophthalmitis. Am J Ophthalmol. 1991 Feb 15;111(2):163-73
32
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Systemic Complement Inhibition with Eculizumab for the
Treatment of Geographic Atrophy in AMD: The COMPLETE Study
Gene W. Chen, MD
Primary Supervisor: Philip J. Rosenfeld, MD, PhD
Co-Authors: Zohar Yehoshua; Carlos Alexandre de Amorim Garcia Filho; Renata
Portella Nunes MD; Dimple Modi; Jyoti R. Dugar; Mathew K. George; Ying Li; William
Feuer; Fernando M. Penha; SriniVas Sadda; Kang Zhang; Giovanni Gregori; Andrew A.
Moshfeghi; Philip J. Rosenfeld
Purpose: The COMPLement Inhibition with Eculizumab for the Treatment of NonExudative Age-Related Macular Degeneration (COMPLETE) Study was designed to
prospectively evaluate the effect of eculizumab, an FDA-approved systemic inhibitor of
complement component 5 (C5), on the growth rate of geographic atrophy (GA) in eyes
of patients with non-exudative age-related macular degeneration (AMD).
Methods: Patients with GA measuring at least 1.26 mm2, but no larger than 17 mm2,
were randomized 2:1 to receive intravenous eculizumab or saline. The first 10 patients
randomized to active treatment received 600 mg eculizumab for 4 weeks followed by
900 mg every 2 weeks until week 26, while the next 10 patients received 900 mg
eculizumab for 4 weeks followed by 1200 mg every two weeks until week 26. After 26
weeks, patients were followed without treatment every 3 months for an additional 6
months. Ophthalmologic exam, normal and low luminance ETDRS visual acuity testing,
and imaging studies were performed at baseline and at months 3, 6, 9, and 12. GA was
studied using multiple imaging modalities. All patients were genotyped for the major
AMD risk alleles. The primary endpoint was the change in area of GA at 6 months.
Results: Thirty study eyes of 30 patients were enrolled and randomized 1:1:1 to the low
dose, high dose, and placebo groups. At baseline, the mean areas of GA (SD) measured
by SDOCT were 7.3 mm2 (4.8) and 4.7 (3.6) mm2 for the eculizumab and placebo groups,
respectively (p=0.13). Baseline mean ETDRS visual acuity scores (SD) were 71.3 (7.8) and
33
78.6 (5.2) letters for the eculizumab and placebo groups respectively, (p=0.01). Low and
high dose eculizumab groups had similar areas of GA (p=0.44), but the high dose
patients read 7 fewer letters (p=0.040). At baseline the mean low luminance visual
acuity scores (SD) were48.1 (15.4) and 56.1 (11.7) letters for the eculizumab and
placebo groups respectively, (p=0.16). In addition, 19 fellow eyes were found to meet
entry criteria and will be evaluated as a secondary endpoint. All patients completed the
infusions through 26 weeks and no drug-related adverse events were identified.
Conclusion: Systemic complement inhibition with the FDA-approved C5 inhibitor known
as eculizumab was well tolerated through 6 months. The outcome data describing the
effect of eculizumab on the growth rates of GA will be presented.
References:
1. Gregori, G., F. Wang, et al. (2011). "Spectral domain optical coherence tomography
imaging of drusen in nonexudative age-related macular degeneration." Ophthalmology
118(7): 1373-1379.
2. Yehoshua, Z., F. Wang, et al. (2011). "Natural history of drusen morphology in agerelated macular degeneration using spectral domain optical coherence tomography."
Ophthalmology 118(12): 2434-2441.
3. Yehoshua, Z., P. J. Rosenfeld, et al. (2011). "Progression of geographic atrophy in agerelated macular degeneration imaged with spectral domain optical coherence
tomography." Ophthalmology 118(4): 679-686.
4. Sunness, J. S., G. S. Rubin, et al. (2008). "Low luminance visual dysfunction as a
predictor of subsequent visual acuity loss from geographic atrophy in age-related
macular degeneration." Ophthalmology 115(9): 1480-1488, 1488 e1481-1482.
5. Chen, Y., J. Zeng, et al. (2011). "Assessing susceptibility to age-related macular
degeneration with genetic markers and environmental factors." Arch Ophthalmol
129(3): 344-351.
34
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
A Review of Femtosecond Assisted Anterior Lamellar
Keratoplasty at Bascom Palmer
Jane Fishler, MD
Primary Supervisor: Sonia H. Yoo, MD
Co-Authors: Ana P. Canto, MD, Pravin Vadavalli, MD
Purpose: To evaluate the results of femtosecond laser-assisted anterior lamellar
keratoplasty (FALK) for anterior corneal pathologies.
Methods: A retrospective, noncomparative, case series of six consecutive patients who
underwent femtosecond laser assisted sutureless anterior lamellar keratoplasty by
FS200 and Visumax femtosecond lasers. Best corrected visual acuity, need for
adjunctive surgery and complications were reported.
Results: Mean follow up ranged from 3 months to 1 year. No intraoperative
complications were found. Best corrected visual acuity (BCVA) improved in 50% of the
patients. One patient's BCVA remained unchanged and two patients' BCVA decreased.
One average, 3 patients' (50%) BCVA improved by 6.6 lines, and 2 patients' (33%) BCVA
dropped by 3.5 lines. In 2 eyes, adjuvant surgical procedures were performed (one
treated with phototherapeutic keratectomy and the other with photorefractive
keratectomy. No graft rejection, infection, or epithelial ingrowth was found in this case
series of patients.
Conclusion: Femtosecond laser assisted sutureless anterior lamellar keratoplasty by
FS200 and Visumax lasers could improve the BCVA in patients with anterior lamellar
pathologies. It is also a safe procedure with low rates of complications.
35
References:
1. Shousha MA, Yoo SH, Kymionis GD, Ide T, Feuer W, Karp CL, O’Brien TP, Culbertson
WW, Alfonso E. Long-term results of femtosecond laser-assisted sutureless anterior
lamellar keratoplasty. Ophthalmology
2011;118:315-323.
2. Yoo SH, Hurmeric V. Femtosecond laser-assisted keratoplasty. Amer J
Ophthalmology, 2011;151(2)189-191.
3. Yoo SH, Kymionis GD, Koreishi A, Ide T, Goldman D, Karp CL, O’Brien TP, Culbertson
WW, Alfonso E. Femtosecond laser-assisted sutureless anterior lamellar keratoplasty.
Ophthalmology 2008;115:1303-1307.
36
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Evaluation Of Optic Disc Progression In Glaucoma Using Spectral
Domain Optical Coherence Tomography
Ben J. Harvey, MD
Primary Supervisor: David S. Greenfield, MD
Co-Authors: Iverson SM, Sehi M, Greenfield DS, and Advanced Imaging in Glaucoma
Study (AIGS) Group1,2,3,4.
1) Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami
Miller School of Medicine, Palm Beach Gardens, FL; 2) Casey Eye Institute, Department
of Ophthalmology, Oregon Health and Science University, Portland, OR; 3) UPMC Eye
Center, Eye and Ear Institute, Ophthalmology and Visual Science Research Center,
University of Pittsburgh School of Medicine, Pittsburgh, PA; 4) Doheny Eye Institute,
Department of Ophthalmology, Keck School of Medicine, University of Southern
California, Los Angeles, California.
Purpose: To examine the rate of optic nerve head (ONH) progression measured using
spectral domain optical coherence tomography (SDOCT) in glaucoma suspect and
glaucomatous eyes with visual field progression.
Methods: Both eyes of glaucoma suspect and glaucoma patients in Advanced Imaging in
Glaucoma Study with ≥30 months of follow-up underwent standard automated
perimetry (SAP, 24-2 SITA Standard) and SDOCT (RTVue, Optovue Inc, Fremont, CA)
measurements every 6 months. Inclusion criteria consisted of age between 40 and 85
years, refractive error spherical equivalent between -8.00D and +4.00D, best corrected
visual acuity ≥20/40, reliable SAP (<33% fixation loss, false positive and false negative
rates) and no prior intraocular surgery except for uncomplicated cataract extraction.
SDOCT Images obtained during eye movement, or images that were unfocused, poorly
centered or had a scan score index of ≥30 were excluded. Functional progression was
defined as a significant (p<0.05) negative slope of visual field index (VFI) over time.
37
Results: One hundred sixty eyes consisting of 96 glaucoma suspect and 64 glaucomatous
eyes were enrolled (mean age 64±9.2, mean follow-up 37.7±5.1 months). 21 eyes had
SAP progression. Rates of ONH loss were significantly faster in progressing compared
with non-progressing eyes for cup area (p=0.03), ONH volume (p=0.02), rim volume
(p=0.007), and horizontal (p=0.02), vertical (p=0.006) and overall C/D ratios (p=0.01).
Conclusion: Rate of ONH progression is faster in glaucoma suspect and glaucomatous
eyes with SAP progression.
References: 1. Keltner JL, Johnson CA, Anderson DR, et al. The Association between
Glaucomatous Visual Fields and Optic Nerve Head Features in the Ocular Hypertension
Treatment Study. Ophthalmology 2006;113:1603-12.
2.
Medeiros FA, Zangwill LM, Alencar LM, et al. Detection of Glaucoma Progression
with Stratus OCT Retinal Nerve Fiber Layer, Optic Nerve Head, and Macular Thickness
Measurements. Am J Ophthalmol 2009;50:5741-8.
3.
Chauhan BC, Nicolela MT, Artes PH. Incidence and Rates of Visual Field
Progression after Longitudinally Measured Optic Disc Change in Glauycoma.
Ophthalmology 2009;116:2110-8.
4.
Johnson CA, Sample PA, Zangwill LM, et al. Structure and Function Evaluation
(SAFE): II. Comparison of Optic Disk and Visual Field Characteristics. Am J Ophthalmol
2003;135:148-54.
5.
Mansouri K, Leite MT, Medeiros FA, et al. Assessment of Rates of Structural
Change in Glaucoma using Imaging Technologies. Eye 2011;25:269-77.
38
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Evolving Fluoroquinolone Resistance Among Coagulase-Negative
Staphylococcus Isolates Causing Endophthalmitis
Andrew M. Schimel, MD
Primary Supervisor: Harry W. Flynn Jr., MD
Co-Authors: Darlene Miller, DHSc
Purpose: Endophthalmitis is a serious, sight-threatening condition resulting in
substantial morbidity. With the widespread use of fluoroquinolone antibiotic eyedrops
as a prophylactic agent, there is concern regarding increased frequency of
fluoroquinolone resistance. We evaluated the evolution of fluoroquinolone resistance
among coagulase-negative staphylococcus endophthalmitis isolates at the Bascom
Palmer Eye Institute. We further reviewed the endophthalmitis isolates and antibiotic
susceptibilities of all culture-proven cases of endophthalmitis over the past 10 years.
Methods: The study was approved by the Institutional Review Board of the University of
Miami School of Medicine Medical Sciences Subcommittee for the Protection of Human
Subjects. This was a retrospective, noncomparative, consecutive case series. The
microbiology was reviewed of all cases with culture-proven endophthalmitis (positive
cultures from the vitreous cavity) at the Bascom Palmer Eye Institute between January 1,
1990, and July 1, 2011. Susceptibility testing of the intraocular isolates was performed
using an automated system – the VITEK (Automatic Microbial System; Biomerieux Vitek,
Hazelwood, Missouri, USA) or the E test (A, B, Biodisk; NA, Remel, Lenexa, Kansas, USA).
Frozen isolates were reconstituted as needed to evaluate sensitivities of newergeneration fluoroquinolones to earlier cases.
Results: During the 21.5 years of the current study, 168 patients were identified with
culture-proven endophthalmitis caused by coagulase-negative staphylococcus. The
increasing resistance rates for the various time periods are: 1990 – 1994 (N=29), 1995 –
1999 (N=23), and 2000 – 2004 (N=26), and 2005 – 2011 (N=89): ciprofloxacin resistance
(10.3%, 17.4%, 38.4%), levofloxacin resistance (0%, 17%, 38.4%), moxifloxacin resistance
39
(0%, 21.8%, 26.9%), gatifloxacin resistance (0%, 21.8%, 30.7%). The mean resistance rate
for January 1st, 2005 – July 1st, 2011 (N=89) was 60.5% for ciprofloxacin, 58.6% for
levofloxacin, 57.8% for moxifloxacin, and 60.5% for gatifloxacin
Conclusion: In spite of the dual mechanisms of fluoroquinolones to avoid resistance to
coagulase-negative staphylococcus, their frequency of resistance to these organisms is
increasing. There is recent evidence that repeated exposure of ocular and
nasopharyngeal flora to ophthalmic antibiotics, including fluoroquinolones, selects for
resistant strains.1, 2 It has further been shown that resistant strains of coagulasenegative staphylococcus may be associated with greater ocular inflammation, virulence,
and increased ocular infection rate than susceptible strains.3, 4
Fourth-generation fluoroquinolones are significantly more expensive than
generic traditional antibiotic eyedrops such as gentamicin and polymyxin
B/trimethaprim, which have been shown to cover endophthalmitis isolates at least as
well.5 There are additional recent reports demonstrating that the fourth-generation
fluoroquinolones achieve subtherapeutic levels in the aqueous humor and vitreous
against the most frequently identified staphylococcal endophthalmitis isolates.6 Given
the frequent and increasing resistance, subtherapeutic penetration and higher cost
compared to other antibiotic eyedrops, the widespread perioperative and
periprocedural use of fourth-generation fluoroquinolone antibiotic eyedrops should be
reevaluated.
References:
1.
Kim SJ, Toma HS. Ophthalmic antibiotics and antimicrobial resistance a
randomized, controlled study of patients undergoing intravitreal injections.
Ophthalmology. Jul;118(7):1358-1363.
2.
Kim SJ, Toma HS, Midha NK, Cherney EF, Recchia FM, Doherty TJ. Antibiotic
resistance of conjunctiva and nasopharynx evaluation study: a prospective study of
patients undergoing intravitreal injections. Ophthalmology. Dec;117(12):2372-2378.
3.
Mino De Kaspar H, Hoepfner AS, Engelbert M, et al. Antibiotic resistance pattern
and visual outcome in experimentally-induced Staphylococcus epidermidis
endophthalmitis in a rabbit model. Ophthalmology. Mar 2001;108(3):470-478.
4.
Miller D, Flynn PM, Scott IU, Alfonso EC, Flynn HW, Jr. In vitro fluoroquinolone
resistance in staphylococcal endophthalmitis isolates. Arch Ophthalmol. Apr
2006;124(4):479-483.
5.
Benz MS, Scott IU, Flynn HW, Jr., Unonius N, Miller D. Endophthalmitis isolates
and antibiotic sensitivities: a 6-year review of culture-proven cases. Am J Ophthalmol.
Jan 2004;137(1):38-42.
6.
Donnenfeld ED, Comstock TL, Proksch JW. Human aqueous humor
concentrations of besifloxacin, moxifloxacin, and gatifloxacin after topical ocular
application. J Cataract Refract Surg. Jun;37(6):1082-1089.
40
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Vitrectomy and Membrane Peeling in Patients with Myopic
Macular Retinoschisis
Jonathan S. Chang, MD
Primary Supervisor: Harry W. Flynn, Jr., MD
Co-Authors: Anita R. Shirodkar, MD, William E. Smiddy, MD
Purpose: To analyze anatomical and functional outcomes of surgical treatment for
myopic macular retinoschisis with vitrectomy, membrane peeling and gas
tamponade.
Methods: Non-randomized consecutive case series of patients from January 1, 2002 –
October 31, 2011 at the Bascom Palmer Eye Institute. All patients had fundus changes of
high myopia and optical coherence tomography (OCT) findings of intraretinal schisis,
with or without foveal detachment or macular hole. To qualify, patients were required
to have had surgical intervention and at least 6 months of post-operative follow-up.
Results: To be presented.
Conclusion: To be presented.
References:
1.
Takano M et al. Foveal retinoschisis and retinal detachment in severely myopic
eyes with posterior staphyloma. AJO 1999; 128(4):472-6.
2.
Kuhn F. Internal limiting membrane removal for macular detachment in highly
myopic eyes. AJO 2003; 135(4):547-9.
3.
Kumagai K. et al. Factors correlated with postoperative visual acuity after
vitrectomy and internal limiting membrane peeling for myopic foveoschisis. Retain
2010; 30(6):874-80.
41
4.
Kim SK., et al. Vitrectomy and Internal Limiting Membrane Peeling With and
Without Gas Tamponade for Myopic Foveoschisis. AJO 2012’ 153(2):320-326e1.
42
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Molecular Mechanisms Of Blood-Retina Barrier Permeability
Daniel L. Chao, MD, PhD
Primary Supervisor: Jeffrey L. Goldberg, MD, PhD
Co-Authors: Enrique Salero, PhD
Purpose: Dysfunction of the blood retina barrier is central to the pathology of many
retinal disorders. The goal of this study was to develop an in vitro assay to investigate
molecules that regulate blood retina barrier permeability.
Methods: Rat retinal capillary endothelial cells (RBE4) and human retinal pigment
epithelial cells (ARPE-19) were seeded to form a monlayer over a semipermeable
membrane. Blood retinal barrier integrity was measured using permeability to sodium
fluoroscein as well as measurement of trans endothelial resistance (TER).
Results: Both RBE4 and ARPE-19 monolayers are able to form tight junctions in
vitro.Validation of these model was done be assaying sodium fluoroscein permeability
and TER when adding molecules known to affect blood retina permeability such as
vacular endothelial growth factor and glucocorticoids.
Conclusion: An in vitro assay has been developed and validated that will allow for high
thoroughput screening of molecules which affect blood retina barrier permeability.
These may lead to new therapuetics which would be relevant for a host of
ophthalmological diseases including retinal vascular disorders such as diabetic
retinopathy as well as age related macular degeneration.
References:
1. Cecchelli R, Berezowski V, Lundquist S, Culot M, Renftel M, Dehouck MP, Fenart L.
Modelling of the blood-brain barrier in drug discovery and development. Nat Rev Drug
Discov. 2007 Aug;6(8):650-61.
43
2. Runkle EA, Antonetti DA. The blood-retinal barrier: structure and functional
significance. Methods Mol Biol. 2011;686:133-48
3. Antonetti DA, Klein R, Gardner TW. Diabetic retinopathy. N Engl J Med. 2012 Mar
29;366(13):1227-39.
44
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Long Term Outcomes of Anti-VEGF Therapy for Age Related
Macular Degeneration
Luis J. Haddock, MD
Primary Supervisor: Philip J. Rosenfeld, MD, PhD
Co-Authors:
Purpose: To review the long term outcomes of patients from the initial anti-VEGF trials
of PRONTO, MARINA, ANCHOR and FVF 2425
Methods: Retrospective chart review was performed after IRB approval to record the
visit dates, visual acuity, IOP, intravitreal injection frequency , medication injected, and
OCT findings in patients with wet AMD that had more than 5 years of follow up from
their initial injection.
Results: Over 30 patients were found to meet the above criteria and visual acuity results
were highly variable. Further details to be presented.
Conclusion: Long term treatment with anti-VEGF for wet age related macular
degeneration results in variable visual outcomes. Some patients were able to maintain
excellent visual acuity while others showed progression of the geographic atrophy
limiting their visual potential. Further results to be presented
References:
1. Rosenfeld PJ, Brown DM, Heier JS, et al.; MARINA Study Group. Ranibizumab for
neovascular age-related macular degeneration N Engl J Med. 2006;355:1419-31.
2. Brown DM, Kaiser PK, Michels M, et al; ANCHOR Study Group. Ranibizumab versus
verteporfin for neovascular age-related macular degeneration. N Engl J Med.
2006;355:1432-44.
45
3. Rosenfeld PJ, Moshfeghi AA, Puliafito CA. Optical coherence tomography findings
after an intravitreal injection of bevacizumab (avastin) for neovascular age-related
macular degeneration. Ophthalmic Surg Lasers Imaging. 2005;36:331-5.
4. CATT Research Group, Martin DF, Maguire MG, Ying GS, et al. Ranibizumab and
bevacizumab for neovascular age-related macular degeneration. N Engl J Med.
2011;364:1897-908.
46
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Comparison of Blood Culture Bottles and Membrane Filter
System for Culturing Vitreous Specimens
Aleksandra V. Rachitskaya, MD
Primary Supervisor: Harry W. Flynn, Jr., MD
Co-Authors: Darlene Miller, DHSc
Purpose:
Diluted pars plana vitrectomy (PPV) vitreous samples are conventionally cultured using
the membrane filter system (MFS). MFS needs to be set-up promptly and requires
trained personnel and technical skills unavailable in most non-hospital settings and after
hours and on weekends. Blood culture bottles (BCB), in comparison, are quick and
simple to inoculate. The purpose of this study is to compare BCB with MFS for culturing
PPV vitreous specimens.
Methods:
Retrospective review of PPV vitreous specimens from 3/07 to 5/11 cultured using both
BCB and MFS. For MFS, vitreous effluent from the vitrectomy cassette was filtered
through a 0.45 μm filter. The filter membrane was cut into parts and cultured on blood
agar, chocolate agar, Sabouraud agar, Lowenstein-Jensen agar, and Thioglycolate broth.
Approximately 10 cc of undiluted vitreous effluent was also injected into BCB. If growth
was detected in BCB, a Gram-stained smear was prepared and appropriate subculture
was set-up.
Results:
A total of 201 patients had vitreous wash samples processed from 3/07 to 5/11. Of
those, 69 positive cultures were recorded using either MFS or BCB.
By 48 hours, 52 organisms were recovered: 40 (77%) in both MFS and BCB, 8 (15%) only
in MFS, and 4 (8%) only in BCB. The organisms that grew only in the MFS included:
Methicillin-susceptible S. aureus, Mold x 2, Coagulase negative Staphylococcus species x
2, Yeast, Methicillin-susceptible S. epidermidis, and Mycobacterium. Those that grew
47
only in the BCB included: Methicillin - resistant S. epidermidis x 2, Coagulase negative
Staphylococcus species, Streptococcus species.
By 2 weeks, 17 additional organisms were identified: 7 (41%) in both MFS and BCB, 5
(29%) only in MFS, and 5 (29%) only in BCB. The ones that grew only in the MFS
included: Mycobacteria x 2 and Mold x 3. The ones that grew only in the BCB were:
Propionibacterium acnes x 2, Coagulase negative Staphylococcal species, Gram-positive
organism, Methicillin - resistant S. epidermidis.
Conclusion:
Based on the microbiological outcomes, BCB represent a viable and easy to set-up
alternative or adjunct for culturing of PPV vitreous specimens in suspected infectious
endophthalmitis as compared to traditional MFS that requires prompt attention of a
trained laboratory personnel, which is not available at all times or in all ophthalmology
settings.
References:
1. Barza M, et al. Evaluation of microbiological diagnostic techniques in postoperative
endophthalmitis in the endophthalmitis vitrectomy study. Arch Ophthalmol.
1997;115(9):1142-1150.
2. Chiquet C, et al. Analysis of diluted vitreous samples from vitrectomy is useful in eyes
with severe acute postoperative endophthalmitis. Ophthalmology. 2009;116(12):243741.e1.
3. Donahue SP, et al. Vitreous cultures in suspected endophthalmitis. biopsy or
vitrectomy? Ophthalmology. 1993;100(4):452-455.
4. Eser I, et al. The use of blood culture bottles in endophthalmitis. Retina.
2007;27(7):971-973.
5. Forster RK. Etiology and diagnosis of bacterial postoperative endophthalmitis.
Ophthalmology. 1978;85(4):320-326.
6. Joondeph BC, et al. A new culture method for infectious endophthalmitis. Arch
Ophthalmol. 1989;107(9):1334-1337.
7. Kratz A, et al. Broth culture yield vs traditional approach in the work-up of
endophthalmitis. Am J Ophthalmol. 2006;141(6):1022-1026.
8. Sharma S, et al. Sensitivity and predictability of vitreous cytology, biopsy, and
membrane filter culture in endophthalmitis. Retina. 1996;16(6):525-529.
9. Tan HS, et al. The additional value of blood culture bottles in the diagnosis of
endophthalmitis. Eye (Lond). 2011;25(8):1069-1073.
10. Yospaiboon Y, Sareet al. Blood culture and conventional media for vitreous culture in
infectious endophthalmitis. J Med Assoc Thai. 2005;88(5):639-642.
48
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Correlations between Baseline Characteristics and Disease
Progression in Eyes with Non-Exudative Age-Related Macular
Degeneration: The Complete Study
Mathew K. George, MD
Primary Supervisor: Philip J. Rosenfeld, MD, PhD
Co-Authors: Mathew K. George; Zohar Yehoshua; Carlos Alexandre de Amorim Garcia
Filho; Renata Portella Nunes MD; Dimple Modi; Gene W. Chen; Jyoti R. Dugar; Ying Li;
William Feuer; Fernando M. Penha; SriniVas Sadda; Kang Zhang; Giovanni Gregori;
Andrew A. Moshfeghi; Philip J. Rosenfeld
Purpose: The COMPLement Inhibition with Eculizumab for the Treatment of NonExudative Age-Related Macular Degeneration (COMPLETE) Study was designed to
prospectively evaluate the effects of eculizumab, an FDA-approved systemic inhibitor of
complement component 5 (C5), on the growth of geographic atrophy (GA) and drusen
volume in eyes of patients with non-exudative age-related macular degeneration (AMD).
Methods: Patients with eyes containing GA and eyes containing drusen were
randomized 2:1 to receive intravenous eculizumab or placebo. In the GA cohort, the
area of atrophy had to be at least 1.26 mm2, but no larger than 17 mm2 in size. In the
drusen cohort, the drusen volume had to be at least 0.03 mm3 within the central 3 mm
of the macula using spectral domain optical coherence tomography (SDOCT) imaging.
The first 10 patients randomized to active treatment in each cohort received 600mg
eculizumab for 4 weeks followed by 900mg every 2 weeks, while the next 10 patients
received 900mg eculizumab for 4 weeks followed by 1200mg every two weeks. After 26
weeks, patients were followed without treatment every 3 months for 6 months.
Ophthalmologic exam, ETDRS visual acuity testing, and imaging studies were performed.
The primary endpoints were the change in area of GA and the change in drusen volume
at 6 months. Baseline characteristics to be studied as predictors of disease progression
included normal luminance and low luminance visual acuity scores, distance from the
49
edge of GA to the foveal center, choroidal thickness measurements, C-reactive protein
levels, glomerular filtration rates, and genotype profiles for the major AMD risk alleles
Results: Thirty patients (study eyes) were enrolled in each cohort and randomized 1:1:1
to the low dose, high dose, and placebo groups. In the GA cohort at baseline, the mean
areas of GA (SD) measured by SDOCT were 7.3 mm2 (4.8) and 4.7 (3.6) mm2 for the
eculizumab and placebo groups, respectively (p=0.13). Baseline mean ETDRS visual
acuity scores (SD) were 71.3 (7.8) and 78.6 (5.2) letters for the eculizumab and placebo
groups, respectively (p=0.01). Low and high dose eculizumab groups had similar areas of
GA (p=0.44), but the high dose patients read 7 fewer letters (p=0.040). At baseline, the
mean low luminance visual acuity scores (SD) were 48.1 (15.4) and 56.1 (11.7) letters
for the eculizumab and placebo groups respectively, (p=0.16). In addition, 19 fellow eyes
were found to meet entry criteria and will be evaluated as a secondary endpoint. All
patients completed their follow-up through 26 weeks.
In the drusen cohort at baseline, the mean drusen areas (SD) were 2.1 mm2 (1.0) and
1.9 mm2 (0.7) for the eculizumab and placebo groups, respectively (p=0.80). The mean
drusen volumes were 0.15 mm3 (0.17) and 0.12 mm3 (0.08) for each group, respectively
(p=0.64). Low and high dose eculizumab groups did not differ significantly in drusen area
and volume measurements, p=0.058 and p=0.077 respectively. Baseline mean ETDRS
visual acuity scores were 80.9 (5.9) and 78.0 (10.0) letters for the eculizumab and
placebo groups. The deficits in the low luminance visual acuity scores at baseline were
14.4 (4.9) and 15.5 (5.4) letters (p=0.58). In addition, 12 fellow eyes were found to meet
entry criteria and will be evaluated as a secondary endpoint. Twenty-eight out of 30
patients (93%) completed the follow-up through 26 weeks. No drug-related adverse
events were identified in either cohort.
Conclusion: Systemic complement inhibition with the FDA-approved C5 inhibitor known
as eculizumab was well tolerated through 6 months. The outcome data describing the
correlations between baseline characteristics and disease progression will be presented.
References:
1. Gregori, G., F. Wang, et al. (2011). "Spectral domain optical coherence tomography
imaging of drusen in nonexudative age-related macular degeneration." Ophthalmology
118(7): 1373-1379.
2. Yehoshua, Z., F. Wang, et al. (2011). "Natural history of drusen morphology in agerelated macular degeneration using spectral domain optical coherence tomography."
Ophthalmology 118(12): 2434-2441.
3. Yehoshua, Z., P. J. Rosenfeld, et al. (2011). "Progression of geographic atrophy in agerelated macular degeneration imaged with spectral domain optical coherence
tomography." Ophthalmology 118(4): 679-686.
50
4. Sunness, J. S., G. S. Rubin, et al. (2008). "Low luminance visual dysfunction as a
predictor of subsequent visual acuity loss from geographic atrophy in age-related
macular degeneration." Ophthalmology 115(9): 1480-1488, 1488 e1481-1482.
5. Chen, Y., J. Zeng, et al. (2011). "Assessing susceptibility to age-related macular
degeneration with genetic markers and environmental factors." Arch Ophthalmol
129(3): 344-351.
51
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Natural History of Glaucoma Drainage Implants and Penetrating
Keratoplasty
Jessica L. Chen, MD
Primary Supervisor: Michael R. Banitt, MD, MHA
Co-Authors: David Chu, MD, Anne Ko, MD, William Feuer, MS, Joyce Schiffman, MS,
Richard K. Lee, MD, PhD
Purpose: To report the natural history of eyes with failed trabeculectomy requiring
glaucoma drainage implant (GDI) followed by penetrating keratoplasty (PKP).
Methods: Retrospective chart review of 24 eyes of 24 patients, with collection and
analysis of data triggered by clinical event and/or procedure. Inclusion criteria were a
history of prior trabeculectomy (>1) and subsequent GDI (>1) and PKP. Patients were
excluded if there was preexisting corneal decompensation prior to GDI placement or
tube-cornea touch. Primary data points included corneal and glaucoma diagnoses, visual
acuity (VA), intraocular pressure (IOP), status of corneal transplant, timing of surgical
interventions, requirement for additional surgery. Tube failure was defined as
requirement of additional glaucoma surgery, and graft failure was defined as persistent
edema as documented in clinic notes or need of additional PKP.
Results: There was a high rate of corneal graft failure within the first 5 years after PKP,
73%. Graft failure can be early or late. The rate of GDI failure after PKP was 20% over 5
years. The majority of graft failures occurred at IOP between 0 and 22 mmHg.
Conclusion: Although corneal graft survival in post-GDI eyes is 27% within the first 5
years, these eyes maintained good IOP control, which suggests that PKP failure is not
due to damage from increased IOP. GDIs are a good option for IOP control in post-PKP
patients.
52
References: 1. Arroyave CP, et al. Corneal graft survival and intraocular pressure
control after penetrating keratoplasty and glaucoma drainage device implantation.
Ophthalmology. 2001 Nov;108(11):1978-85.
2. Lee RK, Fantes F. Surgical management of patients with combined glaucoma and
corneal transplant surgery. Curr Opin Ophthalmol. 2003 Apr;14(2):95-9.
3. Alvarenga LS, et al. The long-term results of keratoplasty in eyes with a glaucoma
drainage device. Am J Ophthalmol. 2004 Aug;138(2)200-5.
53
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Clinical Outcomes of Immediate Versus Delayed Pars Plana
Vitrectomy for Retained Lens Fragments over a 22-Year Period
Yasha S. Modi, MD
Primary Supervisor: Harry W. Flynn, MD
Co-Authors: W.E. Smiddy, MD, T.G. Murray, MD, MBA, FACS, L. Olmos, MD
Purpose: To study visual acuity outcomes and adverse events in patients with retained
lens fragments managed by pars plana vitrectomy (PPV).
Methods: Retrospective, consecutive case series evaluating all cases of retained lens
fragments that underwent PPV over a 22-year period (1990-2011) at the Bascom Palmer
Eye Institute.
Results: 594 patient met study inclusion criteria. To date 459 of the 594 patients have
been evaluated spanning 18 years. Median follow-up time was 6.7 months (2 weeks – 8
years). The overall incidence of retinal detachment was 11.8 % (54/459) with 6.1 %
(28/459) occurring before or during PPV and 5.7 % (26/459) occurring post-PPV.
The primary causes of decreased vision (<20/40) included a prior history of RD (23 %),
corneal edema (17%), persistent macular edema (12 %), POAG (10 %), and persistent RD
(12 %).
Conclusion: Retained lens fragments after cataract surgery is a serious and visionthreatening complication with long-term complications including CME, retinal
detachment, and elevated IOP. This is the longest case series to date evaluating
outcomes and adverse events in patients with retained lens fragments.
54
References:
1.
Moore JK, Scott IU, Flynn HW Jr, et al. Retinal detachment in eyes undergoing
pars plana vitrectomy for revmoal of retained lens fragments. Ophthalmology
2003;110:709-714.
2.
Blodi BA, Flynn HW Jr, Smiddy WE, et al. Clinical features and outcomes of pars
plana vitrectomy in patients with retained lens fragments. Ophthalmology
2003;110:1567-1572.
3.
Baker PS, Spirn MK, Kaiser RS, et al. 23-Guage transconjunctival pars plana
vitrectomy for removal of retained lens fragments. American Journal of Ophthalmology
2011;152 (4): 624-7.
4.
Colyer MH, Berinstein DM, Garfinkel RA, et al. Same-day versus delayed
vitrectomy with lensectomy for the management of retained lens fragments. Retina
2011;31 (8): 153-40.
5.
Vanner EA, Stewart MW, et al. Vitrectomy timing for retained lens fragments
after surgery for age-related cataracts: A systematic Review and Meta-Analysis.
American Journal of Ophthalmology 2011;152 (3):345-57.
55
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Treatment of Choroidal Melanoma with Adjuvant Bevacizumab
Following Plaque Brachytherapy Enhances Tumor Volume
Reduction and Resolution of Exudative Detachment
S.K. Steven Houston, MD
Primary Supervisor: Timothy G. Murray, MD, MBA, FACS
Co-Authors: Nisha Shah, Christina Decatur, Marcela Lonngi, William Feuer, Arnold M.
Markoe
Purpose: To evaluate intravitreal bevacizumab as an adjuvant treatment to plaque
brachytherapy in the treatment of choroidal melanoma.
Methods: This is an IRB-approved, retrospective, consecutive case series of 124 patients
treated from 2007 – 2009 for choroidal melanoma with plaque brachytherapy. Patients
were treated with iodine-125 plaque brachytherapy with 2 mm margins and 85 Gy to
the tumor apex. Consecutive patients were injected intravitreally with 2.5mg/0.1cc
bevacizumab at a site away from the primary tumor and immediately following plaque
removal. Choroidal melanomas were observed with indirect ophthalmoscopy, wideangle photography, and ultrasound.
Results: 124 patients met inclusion criteria and were included in the analysis. Mean
patient age was 65.7 years, with mean tumor apical height of 4.0 mm (SD 2.7) and basal
diameter of 12.7 mm (SD 3.0). Mean follow-up was 24 months. Prior to treatment,
100% of tumors had exudative retinal detachments, and pre-treatment visual acuity was
20/55 (median 20/40). Tumor control was 100% and metastasis was 0% at last followup. 89.8% had complete resolution of exudative retinal detachment (ERD), with a mean
time to resolution of 3.36 months. At 1 month, 43% had complete resolution of ERD,
which increased to 73% at 4 months. Visual acuity was 20/62 (median 20/40) at 4
months, with stabilization to 20/57 (median 20/40) at 8 months, 20/56 (median 20/30)
at 12 months, and 20/68 (median 20/50) at 24 months. Tumor burden was shown to be
56
reduced 22.2% at 3 months, 28.9% at 6 months, 39.3% at 12 months, and 52.2% at 24
months (all P < 0.001). Patients tolerated the procedure well without systemic side
effects.
Conclusion: Intravitreal bevacizumab may be used as an adjuvant agent when used
following plaque brachytherapy. Treated choroidal melanomas show reduction in
tumor burden as well as exudative retinal detachments.
References:
1.
Diener-West M, Earle JD, Fine SL, et al. The COMS randomized trial of iodine 125
brachytherapy for choroidal melanoma, III: initial mortality findings. COMS Report No.
18. Arch Ophthalmol 2001;119:969-982.
2.
Jampol LM, Moy CS, Murray TG, et al. The COMS randomized trial of iodine 125
brachytherapy for choroidal melanoma: IV. Local treatment failure and enucleation in
the first 5 years after brachytherapy. COMS report no. 19. Ophthalmology
2002;109:2197-2206.
3.
Nath R, Anderson LL, Luxton G, Weaver KA, Williamson JF, Meigooni AS.
Dosimetry of interstitial brachytherapy sources: recommendations of the AAPM
Radiation Therapy Committee Task Group No. 43. American Association of Physicists in
Medicine. Med Phys 1995;22:209-234.
4.
Ray SK, Bhatnagar R, Hartsell WF, Desai GR. Review of eye plaque dosimetry
based on AAPM Task Group 43 recommendations. American Association of Physicists in
Medicine. Int J Radiat Oncol Biol Phys 1998;41:701-706.
5.
The COMS randomized trial of iodine 125 brachytherapy for choroidal
melanoma: V. Twelve-year mortality rates and prognostic factors: COMS report No. 28.
Arch Ophthalmol 2006;124:1684-1693.
6.
Wilson MW, Hungerford JL. Comparison of episcleral plaque and proton beam
radiation therapy for the treatment of choroidal melanoma. Ophthalmology
1999;106:1579-1587.
7.
Gunduz K, Shields CL, Shields JA, Cater J, Freire JE, Brady LW. Radiation
complications and tumor control after plaque radiotherapy of choroidal melanoma with
macular involvement. Am J Ophthalmol 1999;127:579-589.
8.
Karlsson UL, Augsburger JJ, Shields JA, Markoe AM, Brady LW, Woodleigh R.
Recurrence of posterior uveal melanoma after 60Co episcleral plaque therapy.
Ophthalmology 1989;96:382-388.
9.
Vrabec TR, Augsburger JJ, Gamel JW, Brady LW, Hernandez C, Woodleigh R.
Impact of local tumor relapse on patient survival after cobalt 60 plaque radiotherapy.
Ophthalmology 1991;98:984-988.
10.
Harbour JW, Murray TG, Byrne SF, et al. Intraoperative echographic localization
of iodine 125 episcleral radioactive plaques for posterior uveal melanoma. Retina
1996;16:129-134.
11.
Shields CL, Cater J, Shields JA, et al. Combined plaque radiotherapy and
transpupillary thermotherapy for choroidal melanoma: tumor control and treatment
complications in 270 consecutive patients. Arch Ophthalmol 2002;120:933-940.
57
12.
Bartlema YM, Oosterhuis JA, Journee-De Korver JG, Tjho-Heslinga RE, Keunen JE.
Combined plaque radiotherapy and transpupillary thermotherapy in choroidal
melanoma: 5 years' experience. Br J Ophthalmol 2003;87:1370-1373.
13.
Kreusel KM, Bechrakis N, Riese J, Krause L, Wachtlin J, Foerster MH. Combined
brachytherapy and transpupillary thermotherapy for large choroidal melanoma: tumor
regression and early complications. Graefes Arch Clin Exp Ophthalmol 2006;244:15751580.
14.
Sagoo MS, Shields CL, Mashayekhi A, et al. Plaque radiotherapy for juxtapapillary
choroidal melanoma: tumor control in 650 consecutive cases. Ophthalmology 118:402407.
15.
Barbazetto IA, Lee TC, Rollins IS, Chang S, Abramson DH. Treatment of choroidal
melanoma using photodynamic therapy. Am J Ophthalmol 2003;135:898-899.
16.
Horgan N, Shields CL, Mashayekhi A, et al. Periocular triamcinolone for
prevention of macular edema after iodine 125 plaque radiotherapy of uveal melanoma.
Retina 2008;28:987-995.
17.
Garcia-Arumi J, Zapata MA, Balaguer O, Fonollosa A, Boixadera A, MartinezCastillo V. Endoresection in high posterior choroidal melanomas: long-term outcome. Br
J Ophthalmol 2008;92:1040-1045.
18.
Querques G, Bux AV, Iaculli C, Delle Noci N. Local resection versus combined
local resection and plaque radiotherapy in the treatment of choroidal melanoma. Eur J
Ophthalmol 20:194-200.
19.
Newman H, Finger PT, Chin KJ, Pavlick AC. Systemic bevacizumab (Avastin) for
exudative retinal detachment secondary to choroidal melanoma. Eur J Ophthalmol
21:796-801.
20.
Lima BR, Schoenfield LR, Singh AD. The impact of intravitreal bevacizumab
therapy on choroidal melanoma. Am J Ophthalmol 151:323-328 e322.
21.
Missotten GS, Notting IC, Schlingemann RO, et al. Vascular endothelial growth
factor a in eyes with uveal melanoma. Arch Ophthalmol 2006;124:1428-1434.
22.
Boyd SR, Tan D, Bunce C, et al. Vascular endothelial growth factor is elevated in
ocular fluids of eyes harbouring uveal melanoma: identification of a potential
therapeutic window. Br J Ophthalmol 2002;86:448-452.
23.
Boutrid H, Pina Y, Cebulla CM, et al. Increased hypoxia following vessel targeting
in a murine model of retinoblastoma. Invest Ophthalmol Vis Sci 2009;50:5537-5543.
24.
Gragoudas ES, Egan KM, Saornil MA, Walsh SM, Albert DM, Seddon JM. The time
course of irradiation changes in proton beam-treated uveal melanomas. Ophthalmology
1993;100:1555-1559; discussion 1560.
25.
Abramson DH, Servodidio CA, McCormick B, Fass D, Zang E. Changes in height of
choroidal melanomas after plaque therapy. Br J Ophthalmol 1990;74:359-362.
26.
Harbour JW, Ahmad S, El-Bash M. Rate of resolution of exudative retinal
detachment after plaque radiotherapy for uveal melanoma. Arch Ophthalmol
2002;120:1463-1469.
27.
Kivela T, Eskelin S, Makitie T, Summanen P. Exudative retinal detachment from
malignant uveal melanoma: predictors and prognostic significance. Invest Ophthalmol
Vis Sci 2001;42:2085-2093.
58
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Comparison of Corneal Stromal Bed Quality by Scanning Electron
Microscopy Using Mechanical and Femtosecond Laser
Keratomes
Jessica H. Chow, MD
Primary Supervisor: Sonia H. Yoo, MD
Co-Authors: Noel Ziebarth, PhD
Purpose: To compare the roughness of the corneal stromal bed in porcine eyes using
mechanical and femtosecond laser keratomes.
Methods: Three groups of lamellar corneal cuts were compared. In Group 1, LASIK
corneal flaps were created in porcine globes with a Moria microkeratome with a 320um
head. In Group 2, LASIK corneal flaps at a depth of 120um were created in porcine
globes with the VISUMAX femtosecond laser. Group 3 consisted of porcine corneal
lenticules created using the Small Incision Lenticule Extraction (SMILE) study protocol.
The corneal stromal beds were imaged with scanning electron microscopy (SEM).
Qualitative and quantitative surface roughness was assessed, the latter using SPIP
software for roughness analysis.
Results: There was no difference in qualitative stromal bed roughness between the
three groups. Quantitative results were also analyzed.
Conclusion: The VISUMAX femtosecond laser and the Moria 320um head both produced
smooth, good-quality, compact stromal beds.
References:
1. Sarayaba MA, Ignacio TS, Binder PS, Tran, DB. Comparative Study of Stromal Bed
Quality by Using Mechanical, IntraLase Femtosecond Laser 15- and
30-kHz Microkeratomes Cornea 2007;26:446–451.
59
2. Sekundo W, Kunert K, Russmann C, Gille A, Bissmann W, Stobrawa G, Sticker M,
Bischoff M, Blum M. First efficacy and safety study of femtosecond lenticule extraction
for the correction of myopia: six-month results. J Cataract Refract Surg. 2008
Sep;34(9):1513-20.
60
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
A Comparative Analysis of OCT Findings in Posterior Uveitis
Ashkan M. Abbey, MD
Primary Supervisor: Thomas A. Albini, MD
Co-Authors: Krishna Surapaneni
Purpose: To characterize and determine the prevalence of unique membranous
structures seen on time-domain and spectral-domain optical coherence tomography
(OCT) images of serous retinal detachments (RDs) in Vogt-Koyanagi-Harada (VKH)
syndrome and compare these findings with serous RDs of other posterior uveitidies and
central serous retinopathy (CSR).
Methods: 40 eyes of 22 patients with serous RDs from VKH were compared with 40 eyes
of 40 patients with serous RDs from CSR. OCT images of serous RDs from both groups
were compared.
Results: 33/40 (82.5%) VKH eyes with serous RDs showed a unique membranous and/or
granular structure within the subretinal space. These OCTs demonstrate Irregular,
hyperreflective deposits along the photoreceptor layer and retinal pigment epithelium.
17/40 (42.5%) CSR eyes with serous RDs showed similar deposits within the subretinal
space.
Conclusion: In a majority of the serous RDs shown in acute VKH, a unique membranous
and/or granular structure was noted within the area of fluid on OCT. Further
comparisons with OCT images of other causes of posterior uveitis will elucidate whether
this structure is a pathognomic OCT finding of VKH.
References:
1. Ikewaki J, Kimoto K, Choshi T, Nagata M, Motomura Y, Tamura K, Shinoda K,
Nakatsuka K. Optical coherence tomographic assessment of dynamic macular changes
in patients with Vogt-Koyanagi-Harada disease. Int Ophthalmol. 2011 Feb;31(1):9-13.
2. Maruko I, Iida T, Sugano Y, Oyamada H, Sekiryu T, Fujiwara T, Spaide RF.
Subfoveal choroidal thickness after treatment of Vogt-Koyanagi-Harada disease. Retina.
2011 Mar;31(3):510-7.
3. Ishihara K, Hangai M, Kita M, Yoshimura N. Acute Vogt-Koyanagi-Harada disease in
enhanced spectral-domain optical coherence tomography. Ophthalmology. 2009
Sep;116(9):1799-807. Epub 2009 Jul 30.
4. Yamaguchi Y, Otani T, Kishi S. Tomographic features of serous retinal detachment
with multilobular dye pooling in acute Vogt-Koyanagi-Harada disease. Am J Ophthalmol.
2007 Aug;144(2):260-5.
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Effect of Plate Location on Initial Glaucoma Drainage Device
Success Rates
Amy Z. Martino, MD
Primary Supervisor: David S. Greenfield, MD
Co-Authors: Shawn M. Iverson, DO; William J. Feuer, MS
Purpose: To compare the safety and intraocular pressure (IOP) lowering efficacy of
initial glaucoma drainage device implantation performed at the superior and inferior
limbus.
Methods: A retrospective chart review was conducted to identify glaucoma patients
that had undergone initial Baerveldt™ glaucoma drainage device (GDD) surgery at the
inferior limbus between 2006 and 2010 for uncontrolled IOP. All eyes had a minimum of
6 months of postoperative follow-up. These eyes were matched using 2:1 frequency
matched to eyes with GDD implantation performed at the superior limbus to within 5
years of age and 6 months of follow-up in a roughly 2:1 ratio to create a comparison
group. Data extracted from the medical record consisted of demographic information,
presence of diabetes or hypertension, use of anticoagulation medication, prior
glaucoma surgery, type of glaucoma, preoperative and postoperative IOP, visual acuity,
and number of anti-glaucoma medications. Statistical methods consisted of Student’s ttests, chi-squared test, and Kaplan-Meier time to failure analysis.ere to enter methods
Results: Fifty eyes (17 inferior, 33 superior) of 43 patients (mean age 68.4 and 72.8
years, respectively) were enrolled. Mean postoperative follow-up in the inferior and
superior GDD groups (26.2 ± 15.2 and 23.9 ± 10.43 months) was similar (p=0.54).
Preoperative glaucoma diagnoses among both groups consisted of POAG (74%), CACG
(10%), and other (16%) and were similar among both groups (p=0.21). Prior glaucoma
filtering surgery had been performed in 8/17 (47%) and 11/33 (33%) eyes (p=0.34) with
inferior and superior GDD implants, respectively. Mean preoperative IOP (mmHg) in the
superior GDD group (26 ± 10) was significantly (p=0.02) greater than the inferior GDD
63
group (21 ± 6); the mean number of preoperative anti-glaucomatous medication was
similar in both groups (p=0.9), 3.5± 1.2 for inferior GDD and 3.4±0.8 for superior GDD.
The mean postoperative intraocular pressure (mmHg) at 6, 12, 18, and 24 months was
similar (all p>0.05) in the inferior GDD (16 ± 6, 15 ± 5, 16 ± 6, 15 ± 7) and the superior
GDD group (13 ± 4, 13 ± 4, 17 ± 7, and 20 ± 9). The mean number of postoperative
medications used in both groups was similar (p=0.5), averaging 2.4 ± 1.6 in the inferior
GDD group and 2.7±1.5 in the superior GDD group. The frequency and types of
postoperative complications in both groups were similar. re to enter results
Conclusion: No differences were observed in the safety and IOP lowering efficacy of
initial GDD implantation performed at the superior and inferior limbus in this cohort
here to enter conclusion
References:
1.
Krishna R, Godfrey DG, Budenz DL, Escalona E, Gedde SJ, Greenfield DS, Feuer W,
Scott IU. Intermediate-term Outcomes of 350-mm2 Baerveldt Glaucoma Implants.
Ophthalmology 2001;108:621-6.
2.
Wilson MR, Mendis U, Smith SD et al. Ahmed Glaucoma Valve Implant vs
Trabeculectomy in the Surgical Treatment of Glaucoma: A Randomized Clinical Trial. Am
J Ophthalmol 2000;130:267-73.
3.
Budenz DL, Barton K, Feuer WJ, et al. Treatment Outcome in the Ahmed
Baerveldt Comparison Study after 1 Year of Follow-up. Ophthalmology 2011;118:443-52.
4.
Harbick KH, Sidoti PA, Budenz DL, Venkatrman A, Bruther M, Grayson DK, Ko A, Yi
GN. Outcomes of inferonasal Baerveldt glaucoma drainage implant surgery. J Glaucoma
2006;15:7-12.
5.
Sidoti PA. Inferonasal Placement of Aqueous Shunts. J Glaucoma 2004;13:520-3.
6.
Rachmiel R, Trope G, Buys Y, et al. Intermediate-term Outcome and Success of
Superior Versus Inferior Ahmed Glaucoma Valve Implantation. J Glaucoma 2008;17:58490.
64
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Preparation Techniques and Intravitreal Injections: A Clinical and
Microbiological Evaluation
Roger A. Goldberg, MD, MBA
Primary Supervisor: Harry W. Flynn, Jr., MD
Co-Authors: Ryan F. Isom, Darlene Miller, Serafin Gonzalez, Sander R. Dubovy, Jared L.
Matthews, Paulo M. Bispo
Purpose: To report the long-term outcomes, microbiological profile, and possible
contamination sources of an endophthalmitis outbreak.
Methods: Non-comparative case series; PCR sequencing; medical records and
investigative reports were reviewed
Results: 12 patients were affected by this outbreak: eight (67%) underwent pars plana
vitrectomy (PPV), and seven (58%) underwent evisceration or enucleation. After eight
months, only one patient regained pre-injection visual acuity. DNA analysis confirmed
microbiological testing identifying a common strain of Streptococcus. Issues with syringe
preparation and environmental sterility were cited as possible sources of contamination
at the compounding pharmacy.
Conclusion: Contamination likely occurred at the compounding pharmacy. PPV did not
improve visual outcomes.
References:
1. Goldberg RA, Flynn HW, Isom RF, et al. An Outbreak of Streptococcus Endophthalmitis
After Intravitreal Injection of Bevacizumab. Am J Ophthalmol 2012;153:204–208.
2. Gonzalez S, Rosenfeld PJ, Stewart MW, et al. Perspective: Avastin Doesn’t Blind
People, People Blind People. Am J Ophthalmol 2012;153:196–203.
65
3. McCannel CA. Meta-analysis of endophthalmitis following intravitreal injection of
anti-VEGF agents: causative organisms and possible prevention strategies. Retina
2011;31(4):654–661.
4 Moshfeghi AA, Rosenfeld PJ, Flynn HW Jr, et al. Endophthalmitis after intravitreal antivascular endothelial growth factor antagonists: a six-year experience at a university
referral center. Retina 2011;31(4):662– 668.
5. The CATT Research Group. Ranibizumab and bevacizumab for neovascular age-related
macular degeneration. N Engl J Med 2011;364(20):1897–1908.
66
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Outcomes Following Intravitreal Injection of Aflibercept in
Patients with Exudative Disease
Dimple Modi, MD, MPH
Primary Supervisor: Philip J. Rosenfeld, MD, PhD
Co-Authors: Gene Chen, MD, Jyoti Dugar, MD, Mathew George, MD, Renata Portella
Nunes, MD, Giovanni Gregori, PhD
Purpose: To determine if intravitreal injections of aflibercept (Eylea, Regeneron
Pharmaceuticals, Inc) result in visual acuity improvement and a decrease in injection
frequency in patients who had received prior injections of bevacizumab (Avastin,
Genentech/Roche) or ranibizumab (Lucentis, Genentech/Roche) for persistent macular
fluid at intervals no greater than 6 weeks for the treatment of neovascular age-related
macular degeneration (AMD).
Methods: IRB approval was obtained for a retrospective chart review of patients
undergoing treatment with inhibitors of vascular endothelial growth factor (VEGF).
Patients from one physician's clinic (PJR) were identified as having received anti-VEGF
therapy for least one year at intervals no greater than 6 weeks apart before being
switched to aflibercept. Visual acuity, the time interval between injections, and the
characteristics of optical coherence tomography (OCT) imaging of the neovascular
lesions were collected. Pertinent OCT characteristics included quantification of the
volume and area of retinal pigment epithelial detachments (PEDs).
Results: A total of 49 eyes from 43 patients were evaluated. Of these 49 eyes, 41 eyes
were found to have vascularized PEDs at the start of aflibercept therapy. The response
of these PEDs to aflibercept therapy were followed and the change in the volume and
area of these lesions will be presented.
Conclusion: Aflibercept therapy is believed to result in an increase in the treatment
interval compared with bevacizumab or ranibizumab therapy. This is believed to be due
to the higher affinity of aflibercept for VEGF compared with the other drugs.4,5
67
Whether this increased binding affinity also results in an improvement in the volume
and area of PEDs will be presented.
References:
1. Rosenfeld, P. J., D. M. Brown, et al. (2006). "Ranibizumab for neovascular age-related
macular degeneration." N Engl J Med 355(14): 1419-1431.
2. Brown, D. M., M. Michels, et al. (2009). "Ranibizumab versus verteporfin
photodynamic therapy for neovascular age-related macular degeneration: Two-year
results of the ANCHOR study." Ophthalmology 116(1): 57-65 e55.
3. Martin, D. F., M. G. Maguire, et al. (2012). "Ranibizumab and Bevacizumab for
Treatment of Neovascular Age-Related Macular Degeneration: Two-Year Results."
Ophthalmology.
4. Chakravarthy, U., S. P. Harding, et al. (2012). "Ranibizumab versus Bevacizumab to
Treat Neovascular Age-related Macular Degeneration: One-Year Findings from the IVAN
Randomized Trial." Ophthalmology.
5. Stewart, M. W., P. J. Rosenfeld, et al. (2012). "Pharmacokinetic rationale for dosing
every 2 weeks versus 4 weeks with intravitreal ranibizumab, bevacizumab, and
aflibercept (vascular endothelial growth factor trap-eye)." Retina 32(3): 434-457.
68
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
In-Vitro Collagen Crosslinking for Treatment of Acanthamoeba
Keratitis
Ravi D. Patel, MD, MBA
Primary Supervisor: Terrence P. O'Brien, MD
Co-Authors: Darlene Miller, PhD, Noel Ziebarth, PhD, Michael Lorenzo
Purpose: To evaluate the in vitro effect of collagen crosslinking with riboflavin and
ultraviolet light (UVA 378 nm) on Acanthamoeba polyphaga keratitis.
Methods: Cadaveric corneal buttons were harvested from the Florida Lion Eye Bank
from tissue designed for research purposes. The 16 corneas were randomized into two
groups. All 16 corneas were infected with 1000 cysts/0.03mL Page's Saline Solution of
Acanthamoeba polyphaga and then incubated for 48 hours and then cultured to ensure
viable cysts. Group 1 had 8 corneas which were dehydrated with Sodium Chloride 5%
and Glycerin 98.5% drops and then saturated with Riboflavin 0.1% for 30 minutes.
Group B had 8 corneas which were dehydrated with Sodium Chloride 5% and Glycerin
98.5%. All 16 corneas were crosslinked using a homemade light source of ultraviolet
light for 30 minutes during which Group 1 corneas were given both Sodium Chloride 5%
as well as Riboflavin 0.1% and Group two were given Sodium Chloride 5% only during
the treatment. The 16 buttons were once again incubated in a moist chamber for 48
hours, again cultures were obtained and corneal buttons were analyzed histologically
Results: Groups A and B were not statistically dissimilar in baseline characteristics. In all
cases cysts were detected 48 hours after infection. After crosslinking the rate of culture
positive keratitis was 37.5% in Group 1 and 37.5% in Group 2. There was no difference in
culture positive keratitis between treatment Group 1 and control Group 2. Histological
analysis was completed.
Conclusion: The results obtained in our study show that a single 30 minute dose of
crosslinking cannot achieve eradication of Acanthamoeba polyphaga. However, in vitro
69
results do not always indicate in vivo efficacy, so future studies should test the validity
of this treatment for Acanthamoeba keratitis.
References:
del Buey MA, Cristóbal JA, Casas P, Goñi P, Clavel A, Mínguez E, Lanchares E, García A,
Calvo B. Evaluation of in vitro efficacy of combined riboflavin and ultraviolet a for
Acanthamoeba isolates. Am J Ophthalmol. 2012 Mar;153(3):399-404. Epub 2011 Oct 11.
Morén, Håkan MD; Malmsjö, Malin MD, PhD; Mortensen, Jes MD; Öhrström, Arne MD,
PhD. Riboflavin and Ultraviolet A Collagen Crosslinking of the Cornea for the Treatment
of Keratitis. Cornea. January 2010 - Volume 29 - Issue 1 - pp 102-104
Kashiwabuchi RT, Carvalho FRS, Khan YA, de Freitas D, Foronda AS, Hirai FE, Campos MS,
McDonnell PJ. Invest. Ophthalmol. Vis. Sci. December 9, 2011 vol. 52 no. 13 9333-9338
Assessing Efficacy of Combined Riboflavin and UV-A Light (365 nm) Treatment of
Acanthamoeba Trophozoites Invest. Ophthalmol. Vis. Sci. December 9, 2011 vol. 52 no.
13 9333-9338
70
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Anterior Segment OCT in Eyes with Cyclodialysis after
Trabectome Glaucoma Surgery
Robert M. Knape, MD
Primary Supervisor: Michael R. Banitt, MD
Co-Authors: Fouad E. Sayyad, MD
Purpose: The Trabectome® (NeoMedix, Inc., Tustin, CA) is a novel surgical device used
to perform ab interno trabeculotomy. An electrosurgical bipolar instrument is used to
unroof Schlemm's canal and expose aqueous collector channels. The purpose of this
study is to utilize Spectral-Domain high resolution anterior segment optical coherence
tomography (AS-OCT) to evaluate the iridocorneal angle in patients with a cyclodialysis
cleft after Trabectome glaucoma surgery.
Methods: All Trabectome® glaucoma surgeries performed at the Bascom Palmer Eye
Institute were reviewed with the operating surgeons. All cases were performed in
conjunction with phacoemulsification cataract surgery. Three patients were noted to
have a cyclodialysis cleft after Trabectome® glaucoma surgery. AS-OCT and full
ophthalmic examination with gonioscopy were performed in the study patients.
Subsequent examinations followed the postoperative course.
Results:
Patient 1
•
Received laser photocoagulation x 2
•
Cyclodialysis cleft resolved on gonioscopy on POM #4
•
Cyclodialysis cleft still minimally patent on AS-OCT on POM #7 and POM #10
Patient 2
•
Observation
•
Cyclodialysis cleft resolved on gonioscopy on POM #5
•
Cyclodialysis cleft resolved on AS-OCT on POM #7
Patient 3
71
•
•
Observation
Cyclodialysis cleft resolved on both gonioscopy and AS-OCT on POM #1
Conclusion:
•
Cyclodialysis is a rare event seen in combination phacoemulsificationTrabectome® surgery
•
Cyclodialysis can be noted intraoperatively or postoperatively
•
High resolution AS-OCT in this study revealed variably sized areas of persistent
cyclodialysis despite apparent resolution on gonioscopy
•
AS-OCT can guide postoperative management of hypotony associated with
cyclodialysis
•
Laser photocoagulation or observation are reasonable treatment options
•
Outcomes in patients with cyclodialysis after combination phacoemulsificationTrabectome® in this study were excellent with no long-term sequelae
References:
1.
Mosaed S, Dustin L, Minckler DS. Comparative outcomes between newer and
older surgeries for glaucoma. Trans Am Ophthalmol Soc. 2009 Dec;107:127-33. Review.
2.
Jea SY, Francis BA, Vakili G, et al. Ab interno trabeculectomy versus
trabeculectomy for open-angle glaucoma. Ophthalmology. 2012 Jan;119(1):36-42. Epub
2011 Oct 7.
3.
Vold SD. Ab interno trabeculotomy with the trabectome system: what does the
data tell us? Int Ophthalmol Clin. 2011 Summer;51(3):65-81. Review. No abstract
available.
4.
Minckler D, Dustin L, Mosaed S, et al. (2001.) Trabectome Update: 2004-2010.
Poster presented at American Glaucoma Society 2010 Meeting in Naples, FL.
5.
Mosaed S, Rhee DJ, Filippopoulos T et al. Trabectome outcomes in adult openangle glaucoma patients: one-year follow-up. Clin Surg Ophthalmol. 2010;28:5–9.
72
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Ophthalmology Specific Emergency Departments Utilization
Review: A Multicenter Analysis
Ryan F. Isom, MD
Primary Supervisor: James T. Banta, MD
Co-Authors: Joyce Schiffman, MS, Matthew Gardiner, MD
Purpose: To determine the utilization of the Bascom Palmer and Massachusetts Eye and
Ear Infirmary ophthalmology specific emergency rooms and identify areas where
efficiency and cost-effective care may be enhanced.
Methods: Prospective survey of residents, fellows, and attendings in the ER for each
patient visit over a period of at least 30 days. The survey contained information on the
date of service, time of day, gender, age, duration of symptoms, physician referral,
insurance status, preliminary diagnosis, and follow up date. The physician was also
asked to classify the visit as emergent or non-emergent.
Results: To be presented.
Conclusion: To be presented.
References: Fenton S, Jackson E, Fenton M. An audit of the ophthalmic division of the
accident and emergency department of the Royal Victoria Eye and Ear Hospital, Dublin.
Ir Med J. 2001 Oct;94(9):265-6.
Hau S, Ioannidis A, Masaoutis P, Verma S. Patterns of ophthalmological
complaints presenting to a dedicated ophthalmic Accident & Emergency department:
inappropriate use and patients' perspective. Emerg Med J. 2008 Nov;25(11):740-4.
73
Prendiville C, Nasser QJ, McGettrick P. Patients presenting to an Ophthalmic Emergency
Department after 5pm. Ir Med J. 2008 Apr;101(4):116-8.
Vernon SA. Analysis of all new cases seen in a busy regional centre ophthalmic casualty
department during 24-week period. J R Soc Med. 1983 Apr;76(4):279-82.
74
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Visual Field Outcomes in the Tube vs. Trabeculectomy Study
Lauren S. Blieden, MD
Primary Supervisor: Steven J. Gedde, MD
Co-Authors: Steven J. Gedde, Joyce C. Schiffman, William J. Feuer, Phil Chen, Douglas
Anderson
Purpose: To review the visual field examinations collected as part of the Tube vs.
Trabeculectomy Study (TVT) and determine whether there was significant difference
between the two study groups.
Methods: Visual fields were collected at yearly visits from all patient enrolled in the TVT
study. These visual fields were analyzed for reliability and progression based on mean
deviation as a marker of progression. Some patients in the study were unable to
perform visual fields for various reasons which were documented by the primary
opthalmologist (i.e. loss of fixation, corneal decompensation, etc).
Results: To be determined.
Conclusion: To be determined.
References:
75
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
An Animal Model of Epithelial Downgrowth
Matthew J. Weiss, MD
Primary Supervisor: Jeffery L. Goldberg, MD, PhD
Co-Authors: Jessica Weinstein, MS
Purpose: In this project we will attempt to create a practical animal model for epithelial
downgrowth.
Methods: Rodent corneal epithelial cells were cultured them in vitro. During this period
they were transfected the cells with lentivirus GFP. The resulting labeled epithelial cells
were then placed in suspension and injected sterilely into the anterior chamber of living
adult rats. The rats were then followed for one day, one week and one month to allow
for the development of intraocular epithelial membranes analogous to those seen in
human epithelial downgrowth. Epithelial cells were then examined through both
immunohistological and immunofluorescence techniques, using a combination of serial
sectioning.
Results: Pending.
Conclusion: Pending.
References:
1) Burris, T. et al. Model of Epithelial Downgrowth: 1. Clinical Correlations and Light
Microscopy. Cornea 1983 2: 277-87.
2) Burris, T. et al. Model of Epithelial Downgrowth: 2. Scanning and Transmission
Electron Microscopy of Corneal Epithelialization. Cornea 1984 3: 141-51
3) Burris, T. et al. Long-term Evaluation of Epithelial Downgrowth Models. Cornea 1986
5(4): 211-21.
4) Forster, RK. Corneoscleral block excision of postoperative anterior chamber cysts.
Transactions of the American Ophthalmologic Society. 1995; 93: 97-104.
76
5) Pai, et al. MUC16 as a Sensitive and Specific Marker for Epithelial Downgrowth. Arch
Ophthalmol. 2010;128(11):1407-1412.
6) Smith et al. Specular Microscopy of Epithelial Downgrowth. Arch Ophthalmol 1978;
96:1222-1224.
7) Vargas, et al. Epithelial Downgrowth after Clear Cornea Phacoemulsification.
Ophthalmology 2002;109:2331–2335.
8) Weiner MJ, Trentacoste J, Pon DM. Epithelial downgrowth: a 30-year
clinicopathological review. British Journal of Ophthalmology.1989;73:6-11.
77
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Effect of Vp/Lp Shunts on Visual Function in Idiopathic
Intracranial Hypertension
Timothy W. Winter, DO
Primary Supervisor: Byron L. Lam, MD
Co-Authors: Laura Huang, Sudarshan Ranganathan, William Feuer, Mike Tawfik,
Giovanni Gregori
Purpose: Evaluate long-term visual function in patients with cerebrospinal fluid shunt
(CFS) placement for Idiopathic Intracranial Hypertension (IIH).
Methods: Retrospective chart review from a single institution with diagnosis of IIH
beginning January 2000 to December 2010. Evaluation included history of visual and
non-visual symptoms, presence of co-morbid diseases affecting the visual pathway, use
of medications, self-reported height/weight, presence of neuro-imaging (including MRV
to evaluate for central venous sinus thrombosis), lumbar puncture opening pressure,
presence of ventro- or lumboperitoneal CFS placement, and presence of re-operations
for shunt failure. Additionally, a specialized neuro-ophthalmic examination was
performed, Humphrey and/or Goldmann visual fields, and optical coherence
tomography of macula/retinal nerve fiber layer.
Results: To be presented.
Conclusion: To be presented.
References:
1. Banta JT, Farris BK. Pseudotumor cerebri and optic nerve sheath decompression.
Ophthalmology, October 2000;17(10):1907-12.
2. Brazis PW. Clinical review: The surgical treatment of idiopathic pseudotumor cerebri
(idiopathic intracranial hypertension). Cephalgia, 2008;28:1361-1373.
78
3. Feldon SE. Visual outcomes comparing surgical techniques for management of severe
idiopathic intracranial hypertension. Neurosurg Focus, 2007;23(5):E6,1-7.
4. Uretsky S. Surgical interventions for idiopathic intracranial hypertension. Current
Opinion in Ophthalmology, 2009;20:451-55.
5. McGirt MJ, Woodworth G, Thomas G, Miller N, Williams M, Rigamonti D.
Cerebrospinal fluid shunt placement for pseudotumor cerebri-associated intractable
headache: Predictors of treatment response and an analysis of long-term outcomes. J
Neurosurg, 2004;101:627-32.
79
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Evaluation of Intracorneal Ring Segment Placement with a 200
Khz Femtosecond Laser
John W. French, MD
Primary Supervisor: Sonia H. Yoo, MD
Co-Authors: Kemel Ozulken, MD
Purpose: This present study aims at presenting high-speed femtosecond laser assisted
Intacs segment implantation.
Methods: Nineteen eyes of fifteen patients with keratoconus, clear central corneas, and
contact lens intolerance had implantation of a symmetrical 0.45 mm Intacs segment
(Addition Technology, Inc.) using 200 kHz femtosecond laser (WaveLight GmbH,
Erlangen, Germany). The outcome of the procedure was evaluated in terms of
uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA),
average keratometry value (K value) and spheric equivalent (SE).
Results: We did not observe any intra or postoperative complications. Intacs
implantation after tunnel creation with 200 kHz femtosecond laser was performed
easily. At postoperative complete examination, clinically significant improvement was
observed in mean UCVA which improved from 0.95± 0.39 to 0.66± 0.28 logMAR mean
BSCVA improved from 0.46± 0.13 to 0.29± 0.21 logMAR, mean spherical equivalent
considerably reduced from -7.15 ± 4.57 to -4.38±4.07 and K value reduced from 52.39 ±
5.79 to 49.78±6.84 D Improvement in parameters remained stable during the 3-month
follow up period.
Conclusion: Using a 200 kHz femtosecond laser in the channel creation for Intacs
implantation makes the procedure faster compared to slower femtosecond laser
systems without increasing the risk of operative and postoperative complications and
provides good visual and refractive outcomes.
80
References:
1)
Pearson RM. Kalt, keratoconus, and contact lens. Optom Vis Sci. 1989; 66:643646.
2)
Rabinowitz YS. Keratoconus. Surv Ophthalmol 1998; 42:297-319.
3)
Alió JL, Shabayek MH. Corneal higher order aberrations: a method to grade
keratoconus. J Refract Surg 2006; 22:539-545.
4)
Gobbe M, Guillon M. Corneal wavefront aberration measurements to detect
keratoconus patients. Con Lens Anterior Eye 2005; 28: 57-66.
5)
Ohguro N, Mastuda M, Shimomura Y, et al. Effects of penetrating keratoplasty
rejection on the endothelium of the donor cornea and recipient peripheral cornea. Am J
Ophthalmol. 2000; 129:468-471.
81
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Molecular Surveillance of Contact Lenses, Cases, and Solutions
for the Presence of Free-Living Amoeba among Patients with
Infectious Keratitis
Ryan C. Young, MD
Primary Supervisor: Harry W. Flynn, MD
Co-Authors: Jorge Maestre-Mesa, Eduardo C. Alfonso, MD, Darlene Miller, DHSc
Purpose: To determine the prevalence of free-living amoeba among patients’ contact
lenses, cases, and solutions and to compare multiplex PCR with traditional culture
techniques in the detection of free-living amoeba among patients with infectious
keratitis.
Methods: We evaluated the efficacy of a multiplex PCR assay for the detection of freeliving amoeba (Acanthamoeba, Vahlkampfia, Naegleria, and Hartmanella) and compared
PCR results with cultures of 187 contact lenses and lens cases and 47 contact lens
solutions collected within the last 5 years.
Results: Free-living amoeba were isolated in 27 of 187 contact lenses and cases by
combined PCR and culture techniques, for an overall prevalence of 14.4%. 10 cases of
amoeba (9 verified Acanthamoeba and one unidentified free-living amoeba) were
identified by culture techniques alone (5.3%), while 17 cases of amoeba (8
Acanthamoeba and 9 Hartmanella) were identified by multiplex PCR (9.1%) (χ2 = 12.213,
p = 0.0005). The sensitivity and specificity of culture, using PCR as the gold standard,
were 23.5% and 96.%, respectively. Acanthamoeba was isolated in one of 47 contact
lens solutions by PCR, for a prevalence of 2.1%. All cultures of contact lens solutions
were negative for free-living amoeba. Among the 187 patients with contact lenses and
cases cultured, 42 had corneal cultures done, of which 5 were positive for
Acanthamoeba for a prevalence of 11.9%. Three of the 5 cases were confirmed by
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cultures of contact lens cases. No cases of Vahlkampfia or Naegleria were identified in
this study.
Conclusion: Acanthamoeba and Hartmanella were more frequently isolated by PCR than
by traditional culture techniques. Multiplex PCR assay is a useful adjunct to traditional
culture techniques for the detection of free-living amoeba in contact lenses, cases, and
solutions in patients with recalcitrant infectious keratitis. Hartmanella may be a more
frequent cause of amoebic keratitis than previously recognized in South Florida.
References: Dart KJG, Saw VPJ, Kilvington S. Acanthamoeba Keratitis: Diagnosis and
Treatment Update 2009. Am J Ophthalmol 2009;148:487-499.
83
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Clinical Course of Unoperated Eyes with Vitreomacular Traction
Syndrome
Vishak J. John, MD
Primary Supervisor: Harry W. Flynn, Jr., MD
Co-Authors: William E. Smiddy, MD
Purpose: To investigate the clinical course of patients with Vitreomacular Traction
Syndrome [VMTS] on OCT who did not undergo any surgical intervention.
Methods: Retrospective, non-consecutive, case series of patients of two vitreoretinal
surgeons at Bascom Palmer Eye Institute [HF&WS]. Patients with VMTS noted on SDOCT were included.
Results: • 49 study eyes in 35 patients analyzed
• Mean age of 75.6 years [range 41—92]
• Race:21 White, 10 Hisp, 2 Black, 2 Asian
• Mean follow up time: 21 months [1-91 ]
• Over the course of the study,
•2/16 [12%] pts with Stage 1 resolved spontaneously
•5/27[19%] with Stage 2 resolved spontaneously
•4/6 [66%] with Stage 3 resolved spontaneously
Conclusion: • Patients with VMTS diagnosed by OCT but with minimal or nonprogressive symptoms should be considered for noninterventional observation rather
than surgery or pharmacologic injection
• 11/49 eyes [22%] resolved spontaneously
• Surgery or pharmacotherapy can be considered for eyes with progressive visual and
anatomic worsening.
84
References:
1. Schneider EW, et al. Emerging nonsurgical methods for the treatment of
vitreomacular adhesion: a review. Clin Ophthalmol. 2011;5:1151-65. Epub 2011 Aug 18.
2.Mirza RG, Johnson MW, Jampol LM. Optical coherence tomography use in evaluation
of the vitreoretinal Interface: a review. Surv Ophthalmol. 2007 Jul-Aug;52(4):397-421.
3. Ocriplasmin for the treatment of symptomatic VMA: MIVI-TRUST Phase 3 data.
Provided by Thrombogenics.
85
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Analysis of Epiretinal Membranes Using Spectral Domain Optical
Coherence Tomography (OCT)
Ajay E. Kuriyan, MD
Primary Supervisor: William E. Smiddy, MD
Co-Authors: Delia Cabrera DeBuc, PhD, Wei Gao, PhD, Yuduan Gao, MD
Purpose: To use spectral domain optical coherence tomography (SD-OCT) to determine
differences in reflectivity and thickness between normal control eyes and eyes before
and after epiretinal membrane (ERM) removal.
Methods: Thirty-six eyes with idiopathic ERM and 12 normal fellow eyes were imaged
preoperatively and postoperatively using SD-OCT. Differences in preoperative and
postoperative best corrected visual acuity (BCVA, logMAR) were analyzed using a paired
t-test. The thickness and reflectivity of each foveal SD-OCT image were assessed using a
custom-built algorithm. Differences in reflectivity and thickness between the control,
pre-operative ERM patients, and post-operative ERM patients were analyzed using a
one-way ANOVA with post-hoc Newman-Keuls test. Receiver operating characteristic
(ROC) curves were constructed to describe the ability of each parameter to discriminate
between the normal, pre-operative ERM, and post-operative ERM eyes . A p-value or
asymptotic significance less than 0.05 was considered statistically significant.
Results: There was an improvement (p = 0.007) in postoperative BCVA (logMAR, mean:
0.37, SD: 0.20) compared to preoperative BCVA (logMAR, mean: 0.50, SD: 0.25).
Preoperative (p = 0.02) and postoperative (p = 0.02) ERM patients had lower foveal
mean reflectance (MR) than normal eyes. Preoperative ERM patients (p = 0.02) had
higher foveal total reflectance (TR) than normal eyes. There was no statistically
significant difference in foveal TR between postoperative ERM patients and normal eyes.
Preoperative (p = 0.0001) and postoperative (p = 0.002) ERM patients had thicker foveal
retinas than normal eyes. Postoperative ERM patients had a decrease in foveal retina
thickness compared to preoperative ERM patients (p = 0.0001). ROC analysis comparing
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pre- and postoperative foveal SD-OCTs estimated an area under the ROC (AUROC) of
0.68 (asymptomatic sig. = 0.009) for TR and 0.83 (asymptomatic sig. = 0.000) for
thickness. Similarly, when comparing preoperative foveal and normal and SD-OCTs, an
AUROC of 0.74 (asymptomatic sig. = 0.015) for TR and 0.97 (asymptomatic sig. = 0.000)
for thickness was estimated.
Conclusion: ERM-peeling surgery resulted in significantly improved BCVA. Decreased
MR, TR, and thickness are seen when comparing SD-OCTs of pre-operative ERM patients
to normal eyes. ERM surgery results in improvement of SD-OCT TR and thickness. These
changes measured by SD-OCT may represent anatomical recovery of the retina once
traction is released by epiretinal-peeling surgery and may contribute to improved BCVA.
References:
1. Gao W, Tátrai E, Ölvedy V, et al. Investigation of changes in thickness and reflectivity
from layered retinal structures of healthy and diabetic eyes with optical coherence
tomography. J. Biomedical Science and Engineering 2011;4:657–665.
2. Inoue M, Morita S, Watanabe Y, et al. Inner segment/outer segment junction
assessed by spectral-domain optical coherence tomography in patients with idiopathic
epiretinal membrane. Am J Ophthalmol 2010;150:834–839.
3. Legarreta JE, Gregori G, Knighton RW, et al. Three-Dimensional spectral-domain
optical coherence tomography images of the retina in the presence of epiretinal
mambranes. Am J Ophthalmol 2008;145:1023–1030.
4. Michalewski J, Michalewska Z, Cisiecki S, Nawrocki J. Morphologically functional
correlations of macular pathology connected with epiretinal membrane formation in
spectral optical coherence tomography (SD-OCT). Graefe’s Arch Clin Exp Ophthalmol
2007;245:1623–1631.
5. Oster SF, Mojana F, Brar M, et al. Disruption of the photoreceptor inner
segment/outer segment layer on spectral domain-optical coherence tomography is a
predictor of poor visual acuity in patients with epiretinal membranes. Retina
2010;30:713–718.
6. Smiddy WE, Maguire AM, Green RW, et al. Idiopathic epiretinal membranes
ultrastructural characteristics and clinicopathologic correlation. Ophthalmology
1989;96:811–821.
7. Suh MH, Seo JM, Park KH, Yu HG. Associations between macular findings by optical
coherence tomography and visual outcomes after epiretinal membrane removal. Am J
Ophthalmol 2009;147:473–480.
87
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Total Thyroidectomy for the Treatment of Severe Progressive
Thyroid Eye Disease
Andrea Lora Kossler, MD
Primary Supervisor: David T. Tse, MD
Co-Authors:
Purpose: To investigate whether bilateral total thyroidectomy (TT) is effective in halting
the progression of severe thyroid associated ophthalmopathy in patients already
treated with maximal medical therapy or radioactive iodine (RAI) treatment.
Methods: 20 patients with severe progressive thyroid associated ophthalmopathy
despite anti-thyroid drug treatment, euthyroid state, or radioactive iodine treatment
underwent bilateral total thyroidectomy. The ophthalmopathy was classified as severe
based on decrease in visual acuity, afferent pupil defect, restriction of extraocular
movements, visual field compromise, and optic nerve changes. Orbital ultrasound (US),
magnetic resonance imaging (MRI), or computed tomographic (CT) scan was used to
further evaluate the extent of orbital disease and optic nerve compression. Finally,
immunologic markers including TSI and TBII were compared before and after
thyroidectomy.
Results: Total thyroidectomy was accomplished with very low morbidity and provided a
reduction in TSI and TBII levels with an improvement or stabilization in thyroid
associated ophthalmopathy in the majority of patients in this study.
Conclusion: Total thyroidectomy is effective and should be considered as treatment for
patients with severe progressive thyroid associated ophthalmopathy despite radioactive
iodine therapy, euthyroid state, or anti-thyroid drug treatment.
88
References:
1. Menconi F. Marino M. Pinchera A. Rocchi R. Mazzi B. Nardi M. Bartalena L. Marcocci C.
Effects of total thyroid ablation versus near-total thyroidectomy alone on mild to
moderate Graves orbitopathy treated with intravenous glucocorticoids. Journal of
Clinical Endocrinology & Metabolism. 92(5):1653-8, 2007 May.
2. Nart A. Uslu A. Aykas A. Yuzbasioglu F. Dogan M. Demirtas O. Simsek C. Total
thyroidectomy for the treatment of recurrent graves disease with ophthalmopathy.
Asian Journal of Surgery. 31(3):115-8, 2008 Jul.
3. Marushak D. Faurschou S. Blichert-Toft M. Regression of ophthalmopathy in Graves
disease following thyroidectomy. A systematic study of changes of ocular signs. Acta
Ophthalmologica. 62(5):767-79, 1984
89
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Outcomes of Adjustable Suture Strabismus Surgery with 2%
Lidocaine Versus 2% Lidocaine with 0.4% Ropivacaine
Kara M. Cavuoto, MD
Primary Supervisor: Hilda Capo, MD
Co-Authors: Howard Palte, MD, Steven Gayer, MD, Raina Moyer
Purpose: The local anesthetic agent ropivacaine provides longer sensory blockade
duration than lidocaine without prolonging motor blockade, which could be
advantageous to the strabismus surgeon. Our study seeks to precisely define the
recovery of extraocular muscle function and sensory acquisition (pain) in patients
undergoing elective adjustable suture strabismus surgery with lidocaine versus lidocaine
with ropivacaine blockade.
Methods: The study is a prospective, randomized, double-blinded clinical study.
Patients will be randomized to anesthetic blockade with either 2% lidocaine or 2%
lidocaine with 0.4% ropivacaine. Lancaster red-green testing will be conducted
preoperatively, and at two, four, and six hours after the surgical procedure to evaluate
recovery of muscle function. Pain will be assessed at similar intervals using the Visual
Analog Pain scale.
Results: A series of patients will be presented in both the lidocaine alone and in the
lidocaine with ropivacaine arms of the study.
Conclusion: Patients randomized to the lidocaine plus ropivacaine group may have a
decreased need for additional analgesia post-operatively while still maintaining the
same level of comfort and success of suture adjustment.
90
References:
Brown Dr, Pacheco EM, Repka MX. Recovery of extraocular muscle function after
adjustable suture strabimus surgery under local anesthesia. J Pediatr Ophthalmol
Strabismus. 1992;29(1):16-20.
Walters G, Stewart OG, Bradbury JA. The use of subtenon ropivacaine in managing
strabismus with adjustable sutures. J AAPOS. 2001 Apr;5(2):95-7.
91
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Anterior Segment OCT in the Diagnosis and Treatment of
Subclinical Conjunctival Intraepithelial Neoplasms (CIN)
Benjamin J. Thomas, MD
Primary Supervisor: Carol L. Karp, MD
Co-Authors: Patrick Oellers, MD
Purpose: To examine the clinical features of the use of ultra high-resolution, anterior
segment OCT (UHR-OCT) in the detection, monitoring, and differentiation of
conjunctival neoplasms, especially in the setting of subclinical disease.
Methods: Retrospective case series.
Results: The cases of 16 patients with varying presentations of ocular surface neoplastic
disease were reviewed. Using UHR-OCT, an experienced observer was able to detect
conjunctival intraepithelial neoplasms (CIN) which are subclinical in presentation,
monitor these lesions to full resolution, and differentiate epithelial neoplasms from
other forms of ocular surface disease, including subepithelial scarring, Salzmann's
nodular degeneration, and conjunctival melanoma.
Conclusion: Anterior segment UHR-OCT can be used to effectively detect subclinical
presentations of CIN and monitor these lesions until full resolution, when performed by
an experienced observer. Additionally, this imaging modality can be used to
differentiate epithelial neoplasms from other ocular surface neoplastic and
degenerative diseases.
References:
Wang J, et al. Ultra-high resolution optical coherence tomography for imaging the
anterior segment of the eye. Ophthalmic Surg Lasers Imaging. 2011;42 Suppl:S15-27.
92
Kieval JZ, et al. Ultra-high resolution optical coherence tomography for differentiation
of ocular surface squamous neoplasia and pterygia. Ophthalmology. 2012;119(3):481486.
Shousha MA, et al. Diagnosis and management of conjunctival and corneal
intraepithelial neoplasia using ultra high-resolution optical coherence tomography.
Ophthalmology. 2011;118(8):1531-1537.
Vajzovic LM, et al. Ultra high-resolution anterior segment optical coherence
tomography in the evaluation of anterior corneal dystrophies and degenerations.
Ophthalmology. 2011;118(7):1291-1296. Epub 2011 Mar 21.
93
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Changes in Clinical Practice: A Survey of the American Glaucoma
Society
Joseph F. Panarelli, MD
Primary Supervisor: Michael R. Banitt, MD, MHA
Co-Authors: Donald L. Budenz, MD, Paul Sidoti MD, Kuldev Singh MD
Purpose: To determine the clinical impact of eight randomized, multicenter, clinical
trials in glaucoma.
Methods: An electronic survey consisting of 26 total questions was generated and
emailed to the 894 members on the AGS listserv. Each participant was asked to answer
two study specific questions as well as one general question common to all 8 studies.
The final two questions were to determine the participants’ type of practice and
number years in practice. A 5-point Likert scale was used for rating individuals’
responses.
Results: There were 206 total responses received with 193 unique IP addresses
identified. The individual response rate was 23% (206 out of 894). 46.4% of participants
were clinicians in academic practice while 53.6% were in private practice. The greatest
number of responses came from clinicians in practice over twenty years. Mean Likert
scores based upon the standard question for each RCT showed that the OHTS study had
the greatest clinical impact while the EGPS had the least.
Conclusion: In conclusion, it is often difficult to translate how the results of an RCT
affect clinical practice, but clinician surveys are one tool that can give meaningful results.
This survey provides a subjective assessment of 8 large-scale, randomized, multicenter,
clinical trials in glaucoma. Although responses may have been influenced by features of
the study itself, several interesting trends were identified by this survey. The practice of
evidence-based medicine is subject to individual and community biases in addition to
objective data presented in the literature.
94
References:
1. De Moraes CG, Ritch R, Liebmann JM. Bridging the major prospective National
Eye Institute-sponsored glaucoma clinical trials and clinical practice. J
Glaucoma. 2011 Jan;20(1):1-2.
2. Singh K. The randomized clinical trial: beware of limitations. J Glaucoma.
2004 Apr;13(2):87-9.
3. Schwartz AL. Argon Laser Trabeculoplasty in Glaucoma: What’s Happening (Survey
Results of the American Glaucoma Society Members). J Glaucoma 1993; 2(4): 329-336
4. Mansberger SL, Cioffi GA. The probability of glaucoma from ocular hypertension
determined by ophthalmologists in comparison to a risk calculator. J Glaucoma.
2006;15(5):426–31.
5. Caprioli J. The Tube Versus Trabeculectomy Study: why its Findings May Not Change
Clinical Practice. American Journal of Ophthalmology. 2011 151(5): 742-3
95
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Management of Acute Severe Ocular Surface Disorders from the
Bedside to the Bench
Guillermo Amescua, MD
Primary Supervisor: Victor L. Perez, MD
Co-Authors: Nicholas Cutrufello
Purpose: Establish a mouse model of alkali ocular surface burns to study the wound
healing mechanism after a chemical burn and also to study the role of amniotic
membrane transplantation (AMT) in corneal wound healing after an alkali burn.
Methods: C57B6 mice were used to create a standardized model of chemical burns that
can consistently develop limbal stem cell deficiency. Different dilution of an alkali
substance at different exposure times were tested in order to obtain LSCD and avoiding
corneal perforation. Also, with the use of Enhanced Green Fluorescent Protein
technology, C57B6 chimeric EGFP mice were developed and used to test the innate
immune response after a chemical burns and the role of amniotic membrane.
Results: A consistent mouse model of LSCD after a chemical burn was developed. The
early use of Amniotic membrane grafting after a chemical burns improved the
epithelium healing time, decreases corneal neovascularization and may decrease
corneal scarring.
Conclusion: Our animal data correlates with the clinical data that shows that early
medical and surgical intervention with AMT in patients with severe ocular surface burns
improved the clinical prognosis. The new eye model can be used to better understand
the wound healing mechanisms and possible areas of intervention to improve the
outcomes.
References:
1.Gregory DG, Treatment of acute Stevens-Johnson syndrome and toxic epidermal
necrolysis using amniotic membrane: a review of 10 consecutive cases.Ophthalmology.
2011 May;118(5):908-14
2.Tandon R, Gupta N, Kalaivani M, Sharma N, Titiyal JS, Vajpayee RB.Amniotic
membrane transplantation as an adjunct to medical therapy in acute ocular burns.Br J
Ophthalmol. 2011 Feb;95(2):199-204
3.Fu Y, Gregory DG, Sippel KC, Bouchard CS, Tseng SC.The ophthalmologist's role in the
management of acute Stevens-Johnson syndrome and toxic epidermal necrolysis.Ocul
Surf. 2010 Oct;8(4):193-203.
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Factors Affecting DSAEK Lenticule Adhesion
Ana Paula F.S. Canto, MD
Primary Supervisor: Michael R. Banitt, MD
Co-Authors: Sonia H. Yoo, MD, Pravin Vaddavalli, MD
Purpose: To determ in vitro the estimation of the minimum IOP required for optimal
donor adhesion during DSAEK and the effect of corneal massage and venting incisions
on donor adhesion during DSAEK.
Methods: Graded increase in intraocular pressure with an air bubble was performed in
10 in vitro DSAEK surgeries. Areas of donor non-adhesion were measured on serial highresolution spectral domain OCT. Serial high-resolution spectral domain OCT imaging was
performed before and after corneal massage and venting incisions in 10 in vitro DSAEK
surgeries and areas of donor non-adhesion were measured.
Results: An air bubble with IOP at 30mmHg for 5 minutes achieved optimal adhesion,
which improved over an hour compared to reducing the pressure to 10mmHg or by an
air fluid exchange. Corneal surface massage did not seem to improve adhesion but
venting incisions followed by surface massage resulted in better donor adhesion.
Conclusion: In this in vitro study, we found that the minimum intraocular pressure
required by an air bubble in the anterior chamber to achieve optimal adhesion in DSAEK
surgery was 30 minutes and further increase in pressure did not improve adhesion
significantly. It was also seen that leaving an air bubble in the anterior chamber for an
hour, improved adhesion compared to exchanging it for fluid after 5 minutes. We also
found that corneal surface massage did not reduce interface fluid gaps and had no role
to play in improving donor adhesion by itself but did result in both reduced interface
gaps and better donor adhesion if done following corneal venting incisions.
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References: To be presented.
99
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Management of Acute Severe Ocular Surface Disorders, from the
Bedside to the Bench
Ruwan A. Silva, MD, MPhil
Primary Supervisor: Harry W. Flynn, MD
Co-Authors:
Charles C. Wykoff, MD, PhD
Darlene Miller, DHSc, MPH
Purpose: To report the fungal species isolated from ocular specimens in a large series of
patients with exogenous fungal endophthalmitis.
Methods: Retrospective, single institution, consecutive case series. The microbiologic
and medical records of all patients treated at the Bascom Palmer Eye Institute between
January 1, 1990, and June 30, 2010, for culture-proven exogenous fungal
endophthalmitis were reviewed.
Results: From 151 culture proven cases of fungal endophthalmitis, exogenous fungal
endophthalmitis occurred in 85 eyes, including 32 cases (38%) associated with fungal
keratitis and 38 cases (45%) occurring after penetrating ocular trauma or intraocular
surgery. Twenty five distinct species were isolated. Thirty three percent (28/85) of
exogenous fungal endophthalmitis cases were caused by yeast species and 67% (57/85)
were caused by mold species. In total, 5 yeast species and 20 mold species were isolated.
The most common yeasts were Candida albicans (19/28) and Candida parapsilosis (5/28)
accounting for 86% (24/28) of cases. The most common molds were Fusarium
oxysporum (12/57), Fusarium species (7/57), Aspergillus fumigatus (6/57) and
Aspergillus terreus (5/57) accounting for 53% (30/57) of cases.
Conclusion: This report highlights the differences between the clinical categories of
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exogenous fungal endophthalmitis. Although 76% of all cases were caused by molds,
most commonly Fusarium and Aspergillus, the most common fungal species varied by
clinical category.
References:
1. Hariprasad, S.M., et al., Voriconazole in the treatment of fungal eye infections: a
review of current literature. Br J Ophthalmol, 2008. 92(7): p. 871-8.
2. Varma, D., et al., Use of voriconazole in candida retinitis. Eye (Lond), 2005. 19(4): p.
485-7.3.
3. Rychener, R.O., Intra-Ocular Mycosis. Trans Am Ophthalmol Soc, 1933. 31: p. 47796.
4. O'Day, D.M., et al., Intraocular penetration of systemically administered antifungal
agents. Curr Eye Res, 1985. 4(2): p. 131-4.
5. Baldinger, J., et al., Retinal toxicity of amphotericin B in vitrectomised versus nonvitrectomised eyes. Br J Ophthalmol, 1986. 70(9): p. 657-61.
101
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Mycobacterial Endophthalmitis
D Wilkin Parke III, MD
Primary Supervisor: Thomas A. Albini, MD
Co-Authors: Harry W. Flynn Jr, MD, Milan Shah, MD
Purpose: To review all recent cases of culture-proven mycobacterial endophthalmitis at
Bascom Palmer Eye Institute.
Methods: Retrospective chart review of consecutive patients with culture-proven
mycobacterial endophthalmitis from 1990 to 2012.
Results: To be presented.
Conclusion: To be presented.
References: To be presented.
102
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
OCT Findings in Posterior Uveitis Secondary to Syphilis
Swetangi D. Bhaleeya, MD
Primary Supervisor: Thomas A. Albini, MD
Co-Authors: Janet L. Davis, MD; Jane Fishler, MD
Purpose: To analyze optical coherence tomography (OCT) findings in syphilis posterior
uveitis.
Methods: A retrospective chart review was performed of 20 patients with laboratoryconfirmed syphilis uveitis. Those with ocular inflammation limited to the anterior
segment were excluded. Cases with no OCT at the time of active inflammation were also
excluded. Demographic data such as age and gender were noted. Clinical exam findings
at the time of presentation and at last follow-up visit were recorded. OCT scans were
reviewed and key findings were noted.
Results: Of the 20 laboratory-confirmed cases of syphilis uveitis reviewed, 7 cases (12
eyes) were included. All 7 patients were male with a mean age of 46. Five of the 7
patients had bilateral involvement. Four out of seven were HIV positive. Fifty-seven
percent (n=4) of the patients tested positive for both RPR and FTA-ABS, whereas two
had a non-reactive RPR but reactive FTA-AB. Three patients had chorioretinitis, two had
retinal vasculitis, one had neuroretinitis, and one had optic neuritis. A variety of OCT
findings were seen. Central retinal thickness ranged from 167 to 558 microns. Three
eyes revealed subretinal fluid, two had foveal thinning, one had shallow retinal pigment
epithelial (RPE) detachments, and one showed inner retinal hyperreflectivity.
Conclusion: Multiple OCT findings were observed in posterior segment syphilitic uveitis.
Shallow neurosensory detachment was the most common finding in this small case
series. OCT maybe a useful imaging modality to monitor response to treatment in
syphilis posterior uveitis that have findings of neurosensory retinal detachement.
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References:
1. Fonollosa A, Giralt J, Pelegrı´n L, Sa´nchez-Dalmau B, Segura A, Garcı´a-Arumı´ J, et al.
Ocular syphilis—back again: understanding recent increases in the incidence of ocular
syphilitic disease. Ocul Immunol Inflamm. 2009;17:207–12.
2. Browning DJ. Posterior segment manifestations of active ocular syphilis, their
response to a neurosyphilis regimen of penicillin therapy, and the influence of human
immunodeficiency virus status on response. Ophthalmology. 2000;107:2015–23.
3. Brito P, Penas S, Carneiro A, Palmares J, Reis FF. Spectral-domain optical coherence
tomography features of acute syphilitic posterior placoid chorioretinitis: the role of
autoimmune response in pathogenesis. Case Report Ophthalmol. 2011 Jan 25;2(1):3944
4. Meira-Freitas D, Farah ME, Höfling-Lima AL, Aggio FB. Optical coherence tomography
and indocyanine green angiography findings in acute syphilitic posterior placoid
choroidopathy: case report. Arq Bras Oftalmol. 2009 Nov-Dec;72(6):832-5.
5. Zorn C, Kook P, Glaser E, Feucht N, Lanzl I, Maier M, Lohmann CP. Spectral domain
OCT in patients with unclear uveitis. Ophthalmologe. 2011 Aug;108(8):766-9
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Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Systemic Complement Inhibition with Eculizumab for the
Treatment of Drusen in AMD: The COMPLETE Study
Jyoti R. Dugar, MD
Primary Supervisor: Philip J. Rosenfeld, MD, PhD
Co-Authors: Zohar Yehoshua, M.D.; Carlos Alexandre de Amorim Garcia Filho, M.D.;
Renata Portella Nunes, M.D.; Mathew K. George, M.D.; Dimple Modi, M.D.; Gene W.
Chen, M.D.; Ying Li, M.D.; William Feuer, M.D.; Fernando M. Penha, M.D.; SriniVas
Sadda, M.D.; Kang Zhang, M.D.; Giovanni Gregori, M.D.; Andrew A. Moshfeghi, M.D.
Purpose: The COMPLement Inhibition with Eculizumab for the Treatment of NonExudative Age-Related Macular Degeneration (COMPLETE) Study was designed to
prospectively evaluate the effect of eculizumab, an FDA-approved systemic inhibitor of
complement component 5 (C5), on drusen area and volume in eyes of patients with
non-exudative age-related macular degeneration (AMD).
Methods: Patients with eyes containing drusen were randomized 2:1 to receive
intravenous eculizumab or placebo. The drusen volume measured at least 0.03 mm3
within the central 3 mm of the macula using SDOCT imaging. The first 10 patients
randomized to active treatment received 600mg eculizumab for 4 weeks followed by
900mg every 2 weeks, while the next 10 patients received 900mg eculizumab for 4
weeks followed by 1200mg every two weeks. After 26 weeks, patients were followed
without treatment every 3 months for 6 months. Ophthalmologic exam, ETDRS visual
acuity testing, and imaging studies were performed. Genotyping was performed on all
patients. Primary endpoint was the change in drusen volume at 6 months.
Results: Thirty patients (study eyes) were enrolled and randomized 1:1:1 to the low
dose, high dose, and placebo groups. At baseline, the mean drusen areas (SD) were 2.1
mm2 (1.0) and 1.9 mm2 (0.7) for the eculizumab and placebo groups, respectively
(p=0.80). The mean drusen volumes were 0.15 mm3 (0.17) and 0.12 mm3 (0.08) for
each group respectively (p=0.64). Low and high dose eculizumab groups did not differ
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significantly in drusen area and volume measurements, p=0.058 and p=0.077
respectively. Baseline mean ETDRS visual acuity scores were 80.9 (5.9) and 78.0 (10.0)
letters for the eculizumab and placebo groups. The deficits in the low luminance visual
acuity scores at baseline were 14.4 (4.9) and 15.5 (5.4) letters (p=0.58). In addition, 12
fellow eyes were found to meet entry criteria and will be evaluated as a secondary
endpoint. Twenty-eight out of 30 patients (93%) completed the follow-up through 26
weeks. No drug-related adverse events were identified through 6 months.
Conclusion: Systemic complement inhibition with the FDA-approved C5 inhibitor known
as eculizumab was well tolerated through 6 months. The outcome data describing the
effect of eculizumab on drusen area and volume will be presented.
References:
1. Gregori, G., F. Wang, et al. (2011). "Spectral domain optical coherence tomography
imaging of drusen in nonexudative age-related macular degeneration." Ophthalmology
118(7): 1373-1379.
2. Yehoshua, Z., F. Wang, et al. (2011). "Natural history of drusen morphology in agerelated macular degeneration using spectral domain optical coherence tomography."
Ophthalmology 118(12): 2434-2441.
3. Yehoshua, Z., P. J. Rosenfeld, et al. (2011). "Progression of geographic atrophy in agerelated macular degeneration imaged with spectral domain optical coherence
tomography." Ophthalmology 118(4): 679-686.
4. Sunness, J. S., G. S. Rubin, et al. (2008). "Low luminance visual dysfunction as a
predictor of subsequent visual acuity loss from geographic atrophy in age-related
macular degeneration." Ophthalmology 115(9): 1480-1488, 1488 e1481-1482.
5. Chen, Y., J. Zeng, et al. (2011). "Assessing susceptibility to age-related macular
degeneration with genetic markers and environmental factors." Arch Ophthalmol
129(3): 344-351.
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Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Differentiating Papilledema and Optic Disc Drusen Using Optical
Coherence Tomography
Kaushal M. Kulkarni, MD
Primary Supervisor: Byron L. Lam, MD
Co-Authors: Joshua Pasol, MD, Byron L. Lam, MD
Purpose: To determine whether spectral domain optical coherence tomography (SDOCT) can be used to reliably differentiate papilledema from buried optic nerve head
drusen (ONHD).
Methods: Patients with papilledema due to idiopathic inracranial hypertension and
patients with buried ONHD diagnosed by B-scan ultrasonagraphy were recruited from
the neuro-ophthalmology service. Each patient underwent a complete neuroophthalmic exam, automated visual field testing, color fundus photography,
autofluorescence of the optic disc, nerve fiber layer analysis, and SD-OCT through the
optic nerve head. The images were qualitatively assessed to identify differentiating
features between the two groups.
Results: Eyes with buried ONHD typically demonstrate an irregular peripapillary retinal
contour with a subretinal hyporeflective space on SD-OCT. Eyes with optic disc elevation
due to papilledema may demonstrate elevation of the peripapillary retina with inward
angulation of the retinal pigment epithelium.
Conclusion: SD-OCT may have utility in differentiating papilledema from buried ONHD.
However, B-scan ultrasonagrphy remains the most reliable method.
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References:
1. Wester ST, Fantes FE, Lam BL, Anderson DR, McSoley JJ, Knighton RW. Characteristics
of optic nerve head drusen on optical coherence tomography images. Ophthalmic Surg
Lasers Imaging 2010;41:83-90.
2. Kupersmith MJ, Sibony P, Mandel G, Durbin M, Kardon RH. Optical coherence
tomography of the swollen optic nerve head: deformation of the peripapillary retinal
pigment epithelium layer in papilledema. Invest Ophthalmol Vis Sci 2011;52:6558-64.
3. Lee KM, Woo SJ, Hwang JM. Differentiation of optic nerve head drusen and optic disc
edema with spectral-domain optical coherence tomography. Ophthalmology
2011;118:971-7
4. Sarac O, Tasci YY, Gurdal C, Can I. Differentiation of Optic Disc Edema From Optic
Nerve Head Drusen With Spectral-Domain Optical Coherence Tomography. J
Neuroophthalmol 2012 Mar 31 [Epub ahead of print].
5. Johnson LN, Diehl ML, Hamm CW, Sommerville DN, Petroski GF. Differentiating optic
disc edema from optic nerve head drusen on optical coherence tomography. Arch
Ophthalmol 2009;127:45-9.
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Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Predictors of Ocular Surface Squamous Neoplasia Recurrence
after Excisional Surgery
Fasika A. Woreta, MD, MPH
Primary Supervisor: Carol L. Karp, MD
Co-Authors: Patrick Oellers, Anat Gallor, Julia Stein, Andrew Kao, Amany
Abdelaziz,William Feuer, Sander Dubovy
Purpose: To identify predictors of ocular surface squamous neoplasia (OSSN) recurrence
after surgical excision.
Methods: Retrospective chart review of 389 patients with OSSN excised at the Bascom
Palmer Eye Institute from January 1, 2001 to September 20,2010.
Results: Of the 389 completely excised OSSN lesions, forty-four (11%) recurred during
follow-up, with a mean time to recurrence of 2.5 years. The presence of positive surgical
margins (HR=2.73,p=.008) and tarsal involvement (HR=4.12,p=0.007) were associated
with an increased risk of tumor recurrence (HR=2.73, p=0.008). Treatment with adjuvant
cryotherapy significantly decreased the risk of tumor recurrence (HR=0.51,p=0.03). In
those patients with postiive margins, the use of topical inteferon therapy reduced the
recurrence rate to a level similar to that of patients with negative margins.
Conclusion: Patients with OSSN should be monitored carefully for recurrence after
surgical excision. Adjuvant cryotherapy should be performed to decrease the risk of
tumor recurrence. In patients with high risk OSSN characateristics such as positive
surgical margins or tarsal involveent, post-operative adjuvant therapy should be
considered.
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References:
1.
Karp CL, Galor A, Chhabra S, et al. Subconjunctival/perilesional recombinant
interferon alpha2b for ocular surface squamous neoplasia: a 10-year review.
Ophthalmology 2010;117(12):2241-6.
2.
Kiire CA, Srinivasan S, Karp CL. Ocular surface squamous neoplasia. International
ophthalmology clinics 2010;50(3):35-46.
3.
Sudesh S, Rapuano CJ, Cohen EJ, et al. Surgical management of ocular surface
squamous neoplasms: the experience from a cornea center. Cornea 2000;19(3):278-83.
4.
Karp C, Gupta A. Current strategies for surgical management for conjunctival and
corneal intraepithelial neoplasia. Annals of ophthalmology 2009;41(2):72-6.
110
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
The Effect of Pulsed Light Therapy on Meibomian Gland
Dysfunction and Dry Eye Syndrome
Bradford W. Lee, MD, MSc
Primary Supervisor: Wendy W. Lee, MD, MS
Co-Authors: Fouad El Sayyad, Mohammed Gomaa, Samantha Herretes, Hilal Ozturk,
Victor L. Perez
Purpose: Our primary aim is to determine whether pulsed light therapy (PLT) is effective
in reducing symptoms and improving clinical stigmata of dry eye syndrome (DES)
associated with meibomian gland dysfunction (MGD) in patients with facial rosacea. Our
secondary aim is to compare the efficacy of PLT versus conservative treatment (i.e.
warm eyelid compresses/massage, eyelid hygiene, and artificial tears) and whether PLT
has an adjunctive benefit in patients already on conservative treatment.
Methods: We are conducting a prospective randomized controlled trial with three arms:
conservative therapy (i.e. warm compresses/massage BID, baby shampoo lid scrubs, and
preservative-free artificial tears) + sham light treatment, conservative therapy + pulsed
light therapy (PLT), and PLT only. Subjects are being recruited from the cornea and
oculoplastics clinics at Bascom Palmer Eye Institute with chief complaints of dry eyes
and must have meibomian gland disease as well as oculofacial rosacea. All subjects
undergo baseline evaluation for DES with the Ocular Surface Disease Index (OSDI)
questionnaire, evaluation of tear properties (tear breakup time, Schirmer's Test,
osmolarity), staining of the cornea and conjunctiva with fluoresceine and lissamine
green, and grading of the meibomian glands and their secretions. Primary outcomes will
be anatomical improvement of the meibomian glands and their secretions.
All subjects will come for their initial visit and treatment session, followed by two
subsequent treatment sessions spaced 2-4 weeks apart. Following this, subjects in all
groups undergo a post-treatment DES evaluation.
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Results: To be announced at Residents Day.
Conclusion: Pulsed light therapy is a new technology used in the treatment of rosacea
and telangiectasias that may have potential applications in the treatment of DES related
to MGD and ocular rosacea. Further studies will be needed to confirm its safety,
efficacy, and ideal treatment regimen in the periocular region for this off-label
indication.
References:
1. Tomlinson A, Bron AJ, Korb DR, et al. The International Workshop on Meibomian
Gland Dysfunction: Report of the Diagnosis Subcommittee. Invest Ophthalmol & Vis Sci.
2011 Mar 30;52(4):2006-49.
2. Geerling G, Tauber J, Baudouin C, et al. The International Workshop on Meibomian
Gland Dysfunction: Report of the Subcommittee on Management and Treatment of
Meibomian Gland Dysfunction. 2011 Mar 30;52(4):2050-64.
3. Toyos R. Intense, Pulsed Light for Dry Eye Syndrome. Cataract & Refractive Surgery
Today. 2009 April: 71-73.
4. Papageorgiou P, Clayton W, Norwood S, et al. Treatment of rosacea with intense
pulsed light: significant improvement and long-lasting results. British Journal of
Dermatology. 2008 Sep;159(3):628-32.
5. Babilas P, Schremi S, Szeimies RM, et al. Intense pulsed light (IPL): a review. Lasers
Surg Med. 2010 Feb;442(2):93-104.
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Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Orbital Trauma and Retrobulbar Hemorrhage at Bascom Palmer
and Jackson Memorial Hospital
Benjamin P. Erickson, MD
Primary Supervisor: Wendy W. Lee, MD
Co-Authors:
Purpose: To elucidate the clinical characteristics and outcomes of patients with orbital
fractures and retrobulbar hemorrhage presenting to Bascom Palmer Eye Institute and
Jackson Memorial Hospital emergency services, and to refine evidence-based treatment
algorithms.
Methods: Retrospective review of clinical documentation and imaging for consecutive
adult patients presenting to the Bascom Palmer emergency department, Ryder Trauma
Center, and Jackson Memorial Hospital emergency wards with orbital fractures and/or
retrobulbar hemorrhage from 2010 onward. Calculations were performed with SPSS
software using a variety of stastical tests.
Results: Full results to be presented.
Conclusion: Full conclusions to be presented.
References: References to be presented.
113
Bascom Palmer Eye Institute Residents’ Days 2012
Resident, Fellow, and Alumni Research Presentations
June 15-16, 2012
Comparison of Postoperative Pain and Surgical Outcomes with
Two Different Types of Local Anesthesia for Conjunctival
Mullerectomy
Chad C. Zatezalo, MD
Primary Supervisor: Wendy W. Lee, MD, MS
Co-Authors: Sara Wester, MD
Purpose: To evaluate postoperative pain and surgical outcomes with two different types
of anesthesia for ptosis correction via conjunctival mullerectomy.
Methods: Prospective Randomized Double Arm Comparative Study.
Results: TBA.
Conclusion: TBA.
References:
1. Mercandetti M, Putterman AM, Cohen ME, Mirante JP, Cohen AJ. Internal levator
advancement by Muller’s muscle-conjunctival resection: technique and review. Arch
Facial Plast Surg. 2001 Apr-Jun;3(2):104-10.
2. Beard C. Muller’s superior tarsal muscle: anatomy, physiology and clinical
significance. Ann Plast Surg. 1985;14:324-333
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