Download Optometry`s Meeting - American Optometric Association

Poster Presentations
of the 117th Annual AOA Congress &
44th Annual AOSA Conference:
Optometry’s Meeting®
therapy three to four times a week.
Binocular vision disorders can go undetected
without the proper diagnostic testing and can heavily
impact a patient’s quality of life. In addition to near
binocular testing, a cycloplegic refraction is essential
in symptomatic patients, and healthy patients who
are not correctable to 20/20. Further, it is important
to discourage minus lenses during refraction when
patients have near complaints. Performing distance
retinoscopy not only shows the appropriate refraction
but the integrity of the reflex. Vision therapy is the
right treatment option for these patients.
Posters are peer-reviewed and only those that meet
the acceptance criteria are selected for presentation.
Poster 1
The Benefits of a Cycloplegic Examination
in a Complicated Refractive Case with
Associated Binocular Vision Disorders
BV - Binocular Vision
Jennifer Cusson
Illinois College of Optometry
2909 St. Marks Ave.
Melbourne, Florida 32935
Poster 2
Spontaneous Non-Aneurysmal
Perimesencephalic Subarachnoid
Hemorrhage Presenting as Binocular Vertical
Diplopia
Binocular vision disorders are more prevalent
than ocular diseases in the majority of the population.
Yet, these disorders are often undiagnosed due
to insufficient evaluation. Issues may stem from
deficiencies in the patient’s vergence, accommodative
and oculomotor systems. Common symptoms
include double/blurry vision, headaches, eye strain,
fatigue, asthenopia, and avoidance of near tasks.
A 23-year-old Caucasian female presented with
eye strain and fatigue at the end of the day along with
blurry vision when alternating from near to far. Her
ocular history includes longstanding decreased vision
in her right eye, contact lens wear for 15 years, and
a positive family history of keratoconus. Entering
visual acuities with her current glasses were 20/50
OD through -1.50-2.50x002 and 20/25 OS through
-2.00-2.00x170. On manifest refraction, she accepted
minus lenses without significant visual improvement.
Cycloplegic retinoscopy was performed and revealed,
+2.00-4.00x010 OD and +1.00-2.25x180 OS.
Further binocular vision testing showed esophoria
at near, reduced stereoacuity, poor accommodation
amplitudes, decreased facility testing, and limited
divergence ranges. Topography was done and
demonstrated with-the-rule astigmatism with no signs
of keratoconus. Due to the patient’s inconsistent
work hours, home vision therapy was initiated for
accommodative infacility and convergence excess.
Over the next six months the patient returned every
three to four weeks. Over the course, she accepted
+1.00-3.75x010 OD and pl-2.25x180 OS eye in
both contact lenses and glasses with vision at 20/20
OU distance and near. Currently, she is free of
eye fatigue and strain. Her esophoria, stereoacuity,
accommodation, and vergence ranges have all
improved. She continues maintenance home vision
BV - Binocular Vision
Ruben Roman, OD, CCHP
Inter American University of Puerto Rico
School of Optometry
PMB 114-220 Western Auto Ste. 101
Trujillo Alto, PR, Florida 00976
Subarachnoid hemorrhage is classified as a
medical emergency, life-threatening condition and its
early detection and treatment is critical. In the United
States, 21,000-31,000 new cases are reported
annually. Common complications of subarachnoid
hemorrhages are aneurysms (85% of all cases).
Ten percent (10%) of all episodes of spontaneous
subarachnoid hemorrhages correspond to
perimesencephalic type. The diagnostic techniques
include computerized tomography (CT), lumbar
puncture, magnetic resonance imaging (MRI),
cerebral angiography, complete blood count including
platelets, partial thromboplastin time and
prothrombin time to evaluate the clotting function.
This case presents a 54-year old Hispanic male
complaining of binocular diplopia, partial hearing
loss, headaches and vomiting. No recent ocular or
head trauma was reported. Retinal hemorrhages, a
common complication of subarachnoid hemorrhages
were not found. The cover test performed in
nine cardinals position of gaze revealed 4-prism
diopters constant right hypertropia at distance
and at near causing a binocular diplopia. A CT
scan revealed a perimesencephalic subarachnoid
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hemorrhage. The patient was hospitalized during
twelve days for proper treatment. However, the
patient’s complain about diplopia persisted. A 2
prism-diopter Fresnel press-on prism was adapted
to the non-dominant right eye without reducing his
visual acuity. The minimum amount of prisms that
permitted fusion should be prescribed. The binocular
vertical diplopia disappeared and eventually, the
prism was discontinued. Fusion was unstable and a
visual therapy program was performed in order to
stabilize fusion.
A CT Scan is an invaluable test in patients with
diplopia symptoms in order to establish a differential
diagnosis. A Fresnel prism is a useful tool to treat
diplopia in patients with comitant strabismus. This
type of case reaffirms that Optometrists are uniquely
qualified to manage patient’s ocular health, and these
professionals can play a decisive role in the diagnosis
and subsequent treatment of neurological, cardiac or
systemic diseases that could be life-threatening.
than 14 days later to repeat ten consecutive trials of
the same programs in the same order. Subjects were
positioned at eye-level 50cm from the SVI. Testing
was performed under normal room illumination using
a black background and white stimulus.
The results of the Proactive test revealed an
intraclass correlation coefficient (ICC) of 0.383 for
the mean of trials 1-3 for visit 1 and 2. The ICC for
Trial 4 only was 0.766. The Reactive data for Visit
1 and Visit 2 using Trial 1 data only was 0.491. The
ICC for the average of Trial 1 and Trial 2 was 0.52
and the ICC for the average of Trial 1, Trial 2, and
Trial 3 was 0.51. The Hand Speed program data
yielded an ICC of 0.59 for Trial 1 of Visit 1 and Visit
2. The ICC for Trial 3 only was 0.77
Poster 3
CL - Contact Lens
Test-Retest Reliability of the Eye-Hand
Programs of the Sanet Vision Integrator
JulieAnne M. Roper, OD, MS
WJB Dorn VA Medical Center
500 Gills Creek Parkway Hampton Greene Apt 108
Columbia, South Carolina 29209
Poster 4
A wrinkle in time: Transient corneal
epitheliopathy induced by scleral lens wear
BV - Binocular Vision
Additional Author(s): William J. Denton, OD
Eric A. Baas, OD
Illinois College of Optometry
3241 S. Michigan Ave.
Chicago, Illinois 60616
As scleral lenses are a fairly new mode of
correction for irregular corneas and ocular surface
disease, those who fit them are still finding new fitting
difficulties. While some of the more troublesome
complications include lens adherence and solution
hypersensitivity, we introduce a unique case of
corneal epitheliopathy induced by improper insertion
and removal techniques.
A 76-year-old Caucasian male was fit with a
scleral lens in his left eye due to traumatic corneal
scarring complicated by severe dry eye syndrome
(DES) from ocular rosacea. The resultant BCVA
was 20/20 and proper insertion and removal was
observed. At his 1-month post-scleral lens fitting
follow-up appointment he presented with a chief
complaint of fluctuating blurred vision OS and
expressed difficulty removing his scleral lens. His
BCVA OS with the lens had reduced to 20/80 and slit
lamp examination showed elevated superiotemporal
corneal folds with associated corneal edema crossing
into the visual axis. Upon removal of the lens,
BCVA OS with the lens improved to 20/40-2 within
1.5 hours and had returned to 20/20-2 at the 3-day
Additional Author(s): Naiya Panchal,
Brian Coffey, Susan Ann Kelly, PhD.
There has been considerable research to
determine the relationship between visual skills and
athletic performance. One of the most important
factors in visual skills testing is that tests be reliable.
The Sanet Vision Integrator (SVI) is used to assess
visual guidance of motor performance including eyehand coordination, visual reaction time, and hand
speed and accuracy. The purpose of this investigation
is to determine test-retest reliability of the Proactive,
Reactive, and Hand Speed programs of the SVI.
These programs evaluate the speed of a motor
response to visual stimuli, which can be applied to
athletic performance.
Twelve male and female subjects, ages 23-29,
performed ten consecutive trials of the Proactive,
Reactive, and Hand Speed programs during the
initial visit. There were asked to return no sooner
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follow-up. Both the initial presentation and the
resolution of the corneal folds was documented with
anterior segment OCT, anterior segment photos,
and corneal topography. The patient demonstrated
insertion using excessive force and subsequent
forceful removal with incorrect plunger placement
in the center of the lens. Upon refitting the patient in
a scleral lens with a thicker flange and reinstructing
insertion/removal techniques, the patient was able to
successfully wear his scleral lens without inducing
corneal epitheliopathy.
In addition to creating patient discomfort,
improper insertion and removal of scleral lenses can
also lead to transient corneal changes. In patients
with complaints of blurred vision after wearing
scleral lenses, induced corneal epitheliopathy should
be considered. In these patients, it is importance to
review or directly observe the patient’s scleral lens
insertion and removal technique during the follow-up
visit. When removal seems difficult a thicker flange
can assist.
amblyopia presented for contact lens fitting right eye
only. Corneal topography confirmed 13.4 diopters
of irregular astigmatism secondary to corneal
scarring. Slit lamp examination revealed patchy
anterior stromal haze without vascularization and
an intact epithelium OD. Corneal gas permeable
contact lens fitting was attempted first but failed
due to the location and amount of irregularity. The
patient was fit in a small diameter Blanchard One
Fit Cone scleral lens. • Case 2: fifty-nine year old
female with a history of sphenoid wing meningioma
with involvement of cranial nerves V, VI, VII and
VIII on the right side. She had received radiation
therapy six- years prior. Since 2009, she has
presented with repeated episodes of a non-healing
corneal epithelial defect exacerbated by incomplete
lid closure. Although treated appropriately with
topical antibiotics and soft bandage contact lenses,
these lenses fell out repeatedly due to surface dryness
and corneal anesthesia. The patient was fit in an
Advanced Vision Technology scleral lens.
The end goal for each patient above was very
different. For patient 1, the objective was to provide
optimal vision correction eventually promoting
visual improvement in the amblyopic eye as well as
binocularity and eye alignment. For patient 2, the
aim was to assist epithelial healing by providing a
lubricated anterior surface to decrease the risk of
stromal melt and potential perforation. Both patients
benefited immensely from treatment.
Poster 5
Scleral contact lens fitting for
pediatric immune stromal keratitis and
sphenoid wing meniogoma-induced
neurotrophic keratopathy
CL - Contact Lens
Sharon Park, OD
SUNY College of Optometry
330 W. 39th Street, Apt. 11F
New York, New York 10018
Poster 6
Utilization of an Orion Biocolors Contact
Lens on a Photophobic Patient
Additional Author(s): Jennifer Gould, OD, M.S.,
David Libassi, OD, FAAO
CL - Contact Lens
Mark MacMillan, OD
UAB
1716 University Blvd
Birmingham, Alabama 35205
When traditional contact lens options fail, a
scleral lens is an excellent alternative to provide
the vision, comfort, protection and lubrication
that patients require. The fluid reservoir of saline
behind the scleral contact lenses not only masks
corneal toricity but also promotes healing of the
ocular surface. These indications prompted scleral
lens fitting in two cases: (1) inactive, immune
stromal keratitis which led to corneal scarring and
irregular astigmatism; and, (2) neurotrophic keratitis
secondary to an extraparenchymal tumor.
• Case 1: four-year old female with a history
of unilateral: (1) herpetic epithelial keratitis; (2)
immune stromal keratitis; and, (3) form deprivation
The following case will discuss the management
of a patient with photophobia secondary to a fixed
pupil. Using a prosthetic contact lens(CL) to control
the amount of light entering the patient’s eye has
been shown to limit the amount of photophobia
resulting from many iris disorders. The options for
prosthetic colored lenses include using fitting sets
in office or sending a photo of the normal eye for
color matching.
A 65 year old white male presented with
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photophobia OS. He reports an injury resulting in a
fixed dilated pupil many years previous. No CL has
been attempted in the past to alleviate this problem.
Refractive error will attempt to be corrected with CLs
as well. The Orion Biocolors lens was fit using the
fitting set and guide with provided good intial results.
Color match was achieved by layering different lens
elements on the provided fitting device. Correct lens
power was achieved by over refracting the toric trial
lens. Initial lens selection was an Orion Biocolors
8.3/14.2/Pl-1.75x179 with underprint U-2, color 41,
Limbal ring E, and Starburst V. A good initial color
match was achieved with decent vision. Initial lens
fitting was successful with good results limiting the
photophobia the patient experiences.
Reducing photophobia for this patient was the
primary goal and this was achieved. In addition,
reliance on glasses for refractive correction has been
decreased. There are many options for limiting
photophobia, but the Orion Biocolors lens worked
well for this particular patient. The variety of color
combinations made it ideal for a lens fitted in office
instead of sending a picture out to have the eyes
color matched.
Practitioners will also find custom soft lenses ideal
as the fitting technique for these lenses is not as
complex as GP lenses. This case report demonstrates
a successful use of custom soft lenses for patients
with postoperative corneal irregularity.
A 49-year-old Caucasian female was referred
for custom soft contact lens fitting after penetrating
keratoplasty (PKP) procedure in the left eye. The
patient had previously tried GP lenses but could not
tolerate them.
The patient’s best corrected visual acuities were
-1.50+0.75×001 20/20- OD and -8.50+4.75×
045 20/400 OS. Pinhole acuities at distance were
20/20 OD and 20/60-2 OS. Pentacam topography
revealed irregular corneal astigmatism worse in the
left eye. Slit lamp evaluation showed inferior corneal
scars OD and a clear graft with two corneal sutures
OS. The patient was fitted with KeraSoft IC (Baush
& Lomb) soft lenses according to the manufacturer’s
recommendations. A successful fit was found with a
second diagnostic pair. The patient was happy with
vision and lens comfort. The final corrected visual
acuity was 20/20- in each eye.
The advancement of soft lens design has
expanded the available lens option for patients with
postoperative corneal irregularity. Practitioners
can enjoy relatively easy fitting process of soft
lenses without worrying about the patient’s corneal
health and satisfactory vision. Patients can enjoy
comfortable and longer contact lens wear. Custom
soft lenses are a safe and effective option of vision
correction for patients with postoperative corneas.
Poster 7
Successful Use of Custom Soft
Lenses for Patients with Postoperative
Corneal Irregularity
CL - Contact Lens
Keren H. Yang, OD
The Doctors Clinic
2200 NW Myhre Road
Silverdale, Washington 98383
Poster 8
Astigmatic Correction with Scleral Lenses:
A Case Series
Gas permeable (GP) contact lenses have been
considered as a lens of choice for fitting irregular
corneas. Although patients most often achieve
good vision with GP contact lenses, they often
experience lens discomfort and develop intolerance
to GP lenses, which often result in giving up the
lens wear entirely. The complexity of GP lens fitting
and the patient’s lack of tolerance to GP lenses have
made it challenging for practitioners to incorporate
postoperative contact lens fitting into their everyday
practice. With the expanded lens design options,
custom soft lenses are now a viable option for fitting
postoperative corneas. Custom soft lenses are great
for patients with a lack of tolerance with GP lenses.
CL - Contact Lens
Muriel Schornack, OD
Mayo Clinic
1403 City View Court NE
Rochester, Minnesota 55906
One of the visual benefits of rigid gas permeable
lenses (RGP’s) is neutralization astigmatic refractive
error. However, when refractive cylinder does not
exactly correspond to corneal cylinder, residual
astigmatism can reduce the quality of the visual
image through the lenses. If a front surface toricity
is required, rotational stabilization of a corneal RGP
can be difficult. Scleral lenses (ScL) can provide the
5
Poster 9
degree of rotational stability necessary to allow for
correction of residual astigmatic refractive error on
the front surface of the lens.
Two cases demonstrate the use of front surface
toric ScL’s for correction of residual astigmatism.
A 19-year-old Caucasian male, diagnosed
with keratoconus at age 17, presented with bestcorrected spectacle acuity was 20/50 in each eye.
He was unable to achieve adequate visual acuity
with hydrogel lenses, and was not able to tolerate
either hybrid lenses or corneal RGP’s. He was fit
with custom ScL’s, and achieved 20/30 acuity in
each eye with spherical correction. Over-refraction
revealed residual astigmatism of 1.25 D OD and
3.00 D OS, and spherical keratometry readings over
the lenses eliminated lens flexure as the origin of
this astigmatism. With front surface toric ScL’s,
the patient achieved 20/20-2 OD, 20/20-1 OS, and
20/20+2 OU.
Case #2: A 12-year-old male had been diagnosed
with keratoconus in the right eye at the age of 10.
When the left eye began to show signs of progression
to clinically significant keratoconus, corneal crosslinking was performed on both eyes. Following
crosslinking, both eyes were fit with ScL’s. Spherical
lenses provided VA of 20/50 OD and 20/30 OS. With
toric ScL’s, he was able to achieve 20/30 OD and
20/20-2 OS.
Residual astigmatism may limit visual acuity
that can be obtained with spherical ScL’s in patients
with keratoconus. Although higher order aberrations
may preclude attainment of 20/20 acuity in these
patients, front surface toric ScL’s may provide
improved visual acuity compared to spherical lenses,
and offer stability that would be difficult to achieve
in corneal RGP’s. Incorporation of correction for
higher order aberrations onto the anterior surface of
ScL’s may eventually provide even more pronounced
visual improvement.
Fitting Success of a New Color Silicone
Hydrogel Contact Lens in Lotrafilcon B Clear
Sphere Wearers
CL - Contact Lens
Jason R. Miller, OD, MBA
Private Practice
9711-C Sawmill Pkwy
Powell, Ohio 43065
Purpose: To determine whether clear, sphere
lotrafilcon B contact wearers require a refit into color,
sphere lotrafilcon B lenses.
Methods: A novel color SiHy lens (lotrafilcon
B color, Alcon) was compared to a clear, sphere
SiHy lens (lotrafilcon B; Alcon) in a randomized,
parallel group, multisite study of existing lotrafilcon
B contact lens wearers. Overall fit and centration
were each graded on a 5-point scale. The proportion
of subjects attaining same fit in both eyes was
determined for both lotrafilcon B color and lotrafilcon
B at Day 14 and Day 28. Same fit was defined as an
eye that achieved an acceptable or optimal overall
lens fit with the study lens that was also within one
grade of the value observed on the same eye with the
habitual lotrafilcon B lens.
Results: Lotrafilcon B and lotrafilcon B color
are comparable in terms of lens material, plasma
surface treatment, blister pack solution, base curve
(8.6mm), diameter (14.2mm), center thickness
(0.08mm at -3.00D), Dk/t (136 at -3.00D), water
content (33%) and available powers (lotrafilcon B
color includes plano power). The lotrafilcon B color
lens incorporates 3 layers of ink encapsulated within
the silicone material near the back surface of the lens.
251 subjects were evaluated in this study. Overall,
99.2% of subjects had the “same fit” at both visits
with lotrafilcon b color lenses compared to habitual
lenses; while 100% of subjects at Day 14 and 99.2%
of subjects at Day 28 had the same fit with lotrafilcon
B test lenses compared to habitual lenses. 99% of
lotrafilcon B color lenses and 100% of lotrafilcon B
lenses had acceptable centration at both visits.
6
Poster 10
preference of 4 to 1 over habitual SiHy lenses when
using computers for long hours.
Clinical Performance of Bausch + Lomb
Ultra™ with MoistureSeal™ technology
silicone hydrogel contact lenses
Poster 11
GP Wearers’ Comfort and Cleaning
Experiences with Two Hydrogen
Peroxide Solutions
CL - Contact Lens
Mohinder Merchea, OD, PhD
Bausch + Lomb
1400 N Goodman St.
Rochester, New York 14609
CL - Contact Lens
Jeffery Schafer, OD, MS
Bausch + Lomb
1400 N. Goodman St
Rochester, New York 14609
Additional Author(s):
Robert Steffen, OD, MS, Dan Hook
Physical and surface chemistry properties can
have significant impact on end of day comfort.
Although there have been some improvements in
silicone hydrogel (SiHy) materials, contact lenses are
rarely as comfortable at the end of the day versus the
beginning. A proprietary combination of formulation
and manufacturing process, was used to create a
novel silicone hydrogel contact lens (samfilcon A)
with very high concentrations of PVP (a humectant)
and with low modulus, high wettability, low COF
and high Dk/t. This unique combination of chemical
and physical properties was hypothesized to improve
comfort over currently marketed SiHy lenses.
The purpose of this study was to evaluate patient
satisfaction with samfilcon A contact lenses.
Subjects currently wearing Acuvue Oasys (AO),
Air Optix Aqua (OA), and Biofinity (B) contact
lenses were enrolled in a 2-week daily wear study.
Subjects were fitted with Bausch + Lomb Ultra
(samfilcon A) contact lenses and used Biotrue
multi-purpose solution. Subjects were instructed to
complete an Internet-based questionnaire after 7 days
of use of the novel SiHy lenses to assess satisfaction
and preference using a standard agree/disagree
6-point scale.
Twenty-two clinical sites enrolled 327 subjects
who completed the Internet based satisfaction
questionnaire. Overall comfort of the Bausch + Lomb
Ultra was preferred 3 to 1 and comfort throughout
the day preference was reported as 3 to 1, over all
habitual SiHy lenses. Subjects reported that Bausch +
Lomb Ultra was as comfortable at the end of the day
versus the beginning of the day with a preference of
3 to 1 over habitual SiHy lenses. Eyes feeling moist
throughout the day was also preferred 3 to 1 over
habitual SiHy lenses. Subjects reported a comfort
Additional Author(s): Robert Steffen, OD, MS
A resurgence of gas permeable (GP) contact
lens fitting has resulted in hydrogen peroxide-based
lens care regimens being recommended more often
for cleaning and disinfection of these lens types.
Some peroxide-based product formulations contain
surfactants that act as cleaning agents and also help
retain moisture on some lenses, and thereby may
enhance comfort. The purpose of this analysis was to
compare two hydrogen peroxide solution regimens
with respect to GP wearers’ subjective comfort and
cleaning experiences.
Thirty-three habitual GP lens wearers participated
in a three month study to evaluate the safety and
efficacy of PeroxiClear, a novel one-step hydrogen
peroxide solution. Subjects were randomly assigned
to receive either PeroxiClear or Clear Care solution
regimen. All subjects were dispensed a new pair
of their habitual GP lenses, and were to wear their
study lenses and use their assigned care regimen on
a daily basis for three months. Comfort and cleaning
related symptoms/complaints were recorded for
four scheduled follow-up visits: 2-weeks, 1-month,
2-month and 3-month. Symptoms/complaints scores
were captured on a scale from 0 to 100, with 100
being the most favorable score. Statistical analysis
was based on comparisons of means and employed
two-sided t-tests.
For all comfort and cleaning related symptoms/
complaints scores at each follow-up visit and overall,
PeroxiClear was either superior or non-inferior to
Clear Care in every category. Statistically significant
differences (p<0.05) over all follow-up visits were
found in favor of PeroxiClear for Overall Comfort,
Comfort at End of Day, [Less] Burning/Stinging on
Insertion, and [Less] Dryness. For the final 3-Month
7
follow-up visit, statistically significant differences
were found in favor of PeroxiClear for Comfort at
End of Day, [Less] Burning/Stinging on Insertion,
[Less] Dryness, [Less] Itchiness, and Lens Cleanness
upon Removal.
lenses cleaned using Clear Care was 241.6 and 239.3,
respectively (p=0.011). Average percent surface
coverage of the lenses was calculated to be 8.0%
when cleaned using PeroxiClear and 33.0% when
using Clear Care.
Poster 12
Poster 13
In vitro Cleaning Studies of One-Step
Hydrogen Peroxide Systems
Ocular comfort and dryness during 4 weeks
of toric silicone hydrogel contact lens wear
CL - Contact Lens
CL - Contact Lens
Kimberly Millard, MS
Institution
1400 North Goodman Street
Rochester, New York 14609
Gary Orsborn, OD, MS, FAAO, FBCLA
CooperVision
370 Woodcliff Drive
Fairport, New York 14450
Additional Author(s): Jeffrey Schafer, OD, MS,
Robert Steffen, OD, MS
Additional Author(s):
Robert Montés-Micó, OD, MPhil, PhD,
Santiago García-Lázaro, OD, MSc, PhD,
Teresa Ferrer-Blasco, OD, MSc, PhD,
César Albarrán-Diego, OD, BScStats, MSc
A recent clinical evaluation of Bausch + Lomb
PeroxiClear, a novel hydrogen peroxide system and
a currently marketed hydrogen peroxide system
indicated high levels of patient satisfaction with
PeroxiClear. This study compared cleaning efficacy
of these two systems using an in vitro deposition
model to support these clinical findings.
Senofilcon A lenses were deposited in vitro with
a combination of lipids and proteins commonly
found in the tear film. The lenses were soaked in
the deposition solution at 37ºC overnight, followed
by a cleaning with both test systems. A total of 14
cycles was completed simulating 2 weeks of daily
wear and daily cleaning. The cleaning regimen for
Peroxiclear one-step hydrogen peroxide disinfecting
system included a 5 second rise per lens with solution
followed by neutralization of the hydrogen peroxide
via a novel lens case containing a platinum coated
disk. The manufacturer’s suggested regimen was
followed for Clear Care with its companion case.
Total deposits and percent coverage of lens surface
were evaluated after 14 cycles using computer
enhanced image analysis. An image of each lens was
converted to mean grey scale with a higher value
representing less total deposits. Percent coverage of
the deposited lens surface was calculated.
The mean grey scale value (MGSV) determined
by image analysis revealed a statistically significant
difference between senofilcon A lenses subjected
to cleaning using PeroxiClear one-step hydrogen
peroxide disinfecting system compared to Clear Care.
The MGSV of lenses cleaned using PeroxiClear and
The aim of this study was to investigate
differences in comfort and dryness sensation between
comfilcon A toric (CA) and lotrafilcon B toric (LB)
silicone hydrogel contact lenses over 4 weeks of
daily wear, using a subjective questionnaire.
Sixty patients with low to moderate astigmatism
(from 0.75D to 2.25D) were enrolled in a patient
masked, open label, randomized, bilateral, crossover
study comparing CA toric and the LB toric lenses.
Each subject was randomized to wear one lens or
the other for 4 weeks of daily wear before repeating
the schedule for the second pair without a washout
period. Patients were asked about comfort and
dryness during 4 days over a 4 week period (days 3,
7, 13 and 27) and at different wearing times within
each of those days (on insertion and at 4, 8 and 12
hours of wearing) using a 0-10 scale (0 very poor and
10 excellent). All patients wore the lenses a minimum
of 12-hours a day and 7-days a week.
For each of the lenses separately, there were
no differences in comfort during days 3, 7 and 13,
but there was a statistically significant decrease in
comfort and increase in dryness sensations the last
tested day (27) compared to the other days (ANOVA,
p<0.001). After 4 hours on each of the tested days,
comfort decreased in the same way for both lenses
(ANOVA, p<0.001). Comfort ratings were higher
(better) and dryness sensation was lower (better) for
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the CA toric for each of the tested days and each of
the tested hours during the day (ANOVA, p<0.001).
Dk/t of 163 barrers and CoF of 0.03 (static) and 0.07
(slow kinetic).
Poster 14
Poster 15
MoistureSeal: The design of a new silicone
hydrogel material that works in unison with a
new manufacturing process
PVP Content of a Silicone Hydrogel Material
with Dual Phase Polymerization Processing
CL - Contact Lens
CL - Contact Lens
Andrew Hoteling, Ph.D.
Bausch and Lomb, Inc.
1400 N. Goodman St.
Rochester, New York 14609
Daniel Hook, Ph.D.
Bausch + Lomb
1400 North Goodman Street
Rochester, New York 14609
Additional Author(s): William Nichols,
Patricia Harmon, Daniel Hook, Ivan Nunez
Additional Author(s): Andrew Hoteling, Ph.D.,
Ivan Nuñez, Ph.D., Joseph McGee, M.S.,
Joseph Hoff, M.S.
Polyvinylpyrrolidone (PVP) is a desirable
component of contact lenses due to its water
attracting properties. In-situ formation of PVP
was used in a new silicone hydrogel lens material,
samfilcon A, which was designed to polymerize in
two time-resolved phases initially creating a silicone
network followed by the creation of high molecular
weight PVP. This reaction sequence allowed for
the formation of a silicone matrix (with high Dk/t
and low bulk modulus) and a separate PVP phase
that drives high water content, exceptional surface
wettability and low coefficient of friction.
The extractable PVP measurements were based
on an extraction with isopropanol followed by
quantitation with high temperature Atmospheric
Pressure Chemical Ionization (APCI) high resolution/
accurate mass (HR/AM) mass spectrometry. Unworn
and worn (30 days) lenses were analyzed to evaluate
the retention of PVP in the lens during wear. Bulk
PVP content was measured using an off-line tube
furnace connected to a cold trap to directly pyrolyze
cryo-ground lens material. Unworn samfilcon A and
senofilcon A lenses were analyzed to determine the
total PVP content.
For lens extracts, the APCI technique provides
a limit of quantitation < 0.1 ppm and R2= 0.999+.
The total variance including patient-to-patient
variance was 11.3% CV and 5.1% CV for controls.
No statistical difference in PVP concentration was
observed between worn and unworn samfilcon
A lenses. The bulk measurement technique was
calibrated using PVP standards to determine the
weight percent PVP in lens materials. The technique
demonstrated the capability to differentiate lenses of
know differences in PVP content. Detection limits
A new silicone hydrogel lens material, samfilcon
A, was designed to polymerize in two time resolved
phases. This reaction sequence in combination with
a newly created manufacturing platform allows for
the formation of a silicone matrix (with high Dk/t
and low bulk modulus) and a separate PVP phase
that drives high water content, exceptional surface
wettability and low coefficient of friction.
The two phase reaction of samfilcon A was monitored
using Photo Differential Scanning Calorimetry
(Photo-DSC), Gas Chromatography with a Flame
Ionization Detector (GC-FID), and high resolution/
accurate mass (HR/AM) Liquid ChromatographyMass Spectrometry (LC-MS). Water content was
determined using a gravimetric procedure while
modulus was measured using ASTM method 1708.
Modulus and % water were collected on 30 lenses.
Dk/t (oxygen transmissibility) was calculated using
the polarographic technique outlined in ANSI
Z80.20:2010 and the mean central thickness on 4 lots
of lenses, each of different thickness. Coefficient
of friction was measured on 10 lenses per lens type
using a highly controlled shear rheometer operated at
0.052N of force to simulate eyelid pressure.
Photo-DSC exotherms demonstrate two distinct
phases of polymerization for samfilcon A. Phase 1
initiates at 1 min with an exotherm of 0.5W/g while
phase 2 initiates at 8.5 minutes with an exotherm
of 0.68W/g. GC-FID and LC-MS demonstrate
consumption of silicone monomers corresponding to
phase 1, and NVP to PVP conversion corresponding
to the phase 2. Physical properties of samfilcon A are
a mean modulus of 70 g/mm2, water content of 46%,
9
are less than 1 ppm of PVP and exhibit variances
ranging from 2.5 to 5.5 % CV. Substantially more
PVP was observed in the samfilcon A lens material
than observed in senofilcon A lens material, as
expected based on in-situ formation of PVP.
mOsms/L. Subjective measurements of comfort
gained 26% and 38.4% in the afternoon and evening
with no change in the am. The subjective visual
acuity improved after 1 month at 13.9%, 22%,
and 22.3% from morning, afternoon to evening
perceptions. The administration of the OSDI at
baseline was an average of 27.6 and at the 1-month
mark it was reduced 41.8% to 16.04. A tear break up
time in the occluded eyes was increased 2 seconds
(7.2 to 9.2) and the control eyes had a reduction in
TBUT of .2 seconds (8.35 to 8.15 seconds). A sodium
fluorescein (NaFL) stain was applied to cornea and
an average grading score of 2.4 to the occluded eyes
and at the 1-month grade of 0.75, 68.8% reduction.
The control NaFL staining had an average increase
of 13% (2.35 to 2.7) A conjunctival stain, lissamine
green, had similar average changes with the occluded
eyes reducing staining by 37.5% and the average
stain of the control increased by 25%.
Conclusion: The use of a punctal plug in contact
lens patients resulted in a reduction in all aspects
of ocular surface disease. The occluded eyes had
subjective improvement in comfort (OSDI, patient
survey) as well as objective improvement in the dry
eye testing. Most notable was the 43% of eyes that
gained lines of visual acuity. This study demonstrates
that punctal plugs can help keep patients in their
contacts longer and improve visual acuity.
Poster 16
Lacrimal punctum occlusion in soft contact
lens patients for increased comfort and
improved visual acuity
CL - Contact Lens
Marc Bloomenstein, OD
Schwartz Laser Eye Center
5101 E Calavar Rd
Scottsdale, Arizona 85254
Purpose: The ocular surface is critical for the
visual acuity and comfort of soft contact lenses.
A controlled uniocular study evaluated the shortterm efficacy of lacrimal puntcal occlusion for
the improvement in vision, OSDI, osmolarity and
comfort in a soft contact lens cohort.
Methods: Uniocular punctum occlusion (Parasol,
Odyssey Medical) by punctum in the lower lid in
1 eye was performed on (N=50) patients who wear
contact lenses. To overcome possible interindividual
variability between patients, the other eye, in the
same patient, was not occluded and served as a
control eye. The eye to be occluded was randomly
selected and patients returned in 30 days. Objective
measurement of visual acuity, osmolarity, corneal
staining and conjunctival staining were obtained.
Subjective analysis of the patients was evaluated
by a questionnaire regarding the comfort of the
lens throughout the day, as well as the perceived
visual acuity. The administration of the OSDI was
utilized for further subjective analysis. Patients were
instructed to continue cleaning their contacts and
using there dry eye regiments.
Results: 1 month after baseline testing and
continuation of normal contact lens related treatment
33% of the eyes, with a punctal occlusion gained
1 line of acuity, 5% gained 2 lines and 5% gained
3 lines; while no eyes lost any lines of acuity. The
control group had 9.3% of eyes gain a line of acuity,
with 19% losing 1 line of acuity and 5 % losing 2
lines of acuity. The osmolarity on average in the
occluded eyes was reduced by 17.2 mOsms/L and
the control group had an average reduction of 0.25
Poster 17
Non-physiologic visual field loss with mild
TBI: a case of malingering
LV - Low Vision/Vision Impairment &
Rehabilitation
Muriel M. Ferreira, OD
UHCO
4901 Calhoun Rd
Houston, Texas 77204
Additional Author(s):
Suzanne Wickum, OD, FAAO
Malingering is a purposeful deception performed
in order to obtain a reward. In adults such rewards
include, but are not limited to: drugs, disability
benefits, and evading incarceration. Malingering
can lead to abuse of the medical system, with
unnecessary tests being performed and time being
wasted by clinicians. A study by Halligan et.al.
found that 37% of physicians reported their patients
10
Poster 18
‘sometimes, often or very often’ asked them to
deceive health care payers.
A 46 year old Hispanic male had previously been
diagnosed with “optic nerve and visual pathway
disorder” two years after he suffered a “mild
complicated traumatic brain injury” secondary to a
small explosion. The patient had been on disability
for 4 years and claimed to have bilateral 360 degree
field constriction with only 5-10 degrees of central
vision. Aided distance visual acuities were 20/20
in each eye and 20/30 at near. Binocular vision was
intact, EOMs were normal, pupils were equal, round
and reactive to light with no APD, IOPs were normal,
and all other external and internal ocular health
findings (including ONH OCT) were normal. Prior
VEP and ERG findings were normal. Humphrey 30-2
threshold visual field testing was inconsistent with
complete loss of the visual field in each eye indicative
of total blindness. Tangent screen visual field
testing was administered under two settings: 1. Best
corrected monocular fields tested at 1 meter, and 2.
Best corrected monocular fields tested at 1 meter with
a 2.2x reverse telescope. When used in the reverse
setting the telescope minifies objects in our field of
vision thus expanding the field by 2.2x. The results
acquired under the first setting were consistent with
those found at previous examinations: constriction
of the visual field to <5 degrees. The results acquired
under the second setting showed a 5-6 times increase
in the claimed visual field, much greater improvement
than expected. These results were implausible and
support a diagnosis of malingering.
It is important for health care practitioners to be
proficient in the evaluation of suspected malingerers
in order to prevent financial or other gain for those
who are undeserving.
Creative way to use filters for relief of
extreme photosensitivity post central retinal
artery occlusion
LV - Low Vision/Vision Impairment
& Rehabilitation
Negin Nikahd, Ph.D
Southern California College of Optometry The Center for the Partially Sighted
4735 Sepulveda Blvd. #227
Sherman Oaks, California 91403
Additional Author(s): Tina MacDonald, OD
81 year old Caucasian male presented to the
Center for the Partially Sighted for a low vision
evaluation. His chief complaint was extreme
photophobia in both eyes. Past ocular history was
positive for central retinal artery occlusion in the
right eye. He complained of extreme “migraine-like”
pain when attempting to use his vision in any way.
Previous eye doctors have advised him to patch his
right eye; however the patient stated that he could
still not perform tasks such as watching television or
reading for longer than 10 minutes.
Patient’s best corrected visual acuity (BCVA)
in the right eye was hand motion and 20/30 in the
left eye. Initially, the patient was prescribed a black
out lens for the right eye and a yellow polarized tint
for the left eye using a Cocoons frame. The patient
returned stating that he did achieve relief with the
new lenses; however he did not like the cosmetic
appearance, especially in social settings. The use of
a wraparound Nike frame with a gray tint in the right
eye and 527 CPF match tint in the left eye produced
relief of photosensitivity as well as the desired
comfort and cosmesis.
Use of different color filters for relief of extreme
photosensitivity should be attempted as the cause of
photosensitivity in each eye might be different.
11
Poster 19
Poster 20
Assessment of Choroidal Morphologic
Features and Vasculature in Healthy
Saudi Adults
Eyelash Resection Surgery for the Treatment
of Chronic Trichiasis Secondary to StevensJohnson Syndrome
OD - Ocular Disease
OD - Ocular Disease
Haya AlFarhan, Ph.D
King Saud University
Department of Optometry KSU
P.O. Box 10219 Riyadh 11433, KSA.
Riyadh, Pennsylvania 11433
Erika Anderson, OD
Chinle Hospital, Navajo Area Indian
Health Services
PO Box 2661
Chinle, Arizona 86503
Additional Author(s):
Lulwah Ahmed ALShibel, BA
Additional Author(s): Christian Thompson, OD
Stevens-Johnson Syndrome (SJS) is a rare,
self-limiting, immune-mediated disorder of the
skin and mucous membranes that is triggered by a
reaction to a medication, and rarely secondary to a
Mycoplasma pneumoniae infection. In many cases
it can manifest in ocular tissues. In its early stages
it may cause ulceration of the lids, conjunctivitis,
pseudomembrane formation, and rarely iritis. In
its late stages it can cause cicatricial entropion
which can lead to ocular disease such as exposure
keratitis and trichiasis. Treatment for the ocular
manifestations of this disease can range from ocular
lubrication to surgical intervention.
This is a case report of a 67-year old, Navajo
female who presented with cicatrical entropion
and trichiasis. The patient had suffered from the
sequelae of SJS for over 50 years following treatment
for an eye infection as a teenager, in which, a
sulfonamide was used. She had undergone prior
eyelid surgeries and eyelash electrolysis for treatment
of the condition, but continued to have ongoing
trichiasis and corneal scarring of the right eye. She
presented to our clinic for eyelash epilation weekly
for several months. For a more definitive treatment
the patient was sent to an oculoplastic surgeon with
the suggestion of eyelash resection surgery of the
right eye.
In cases of patients suffering from chronic
cicatricial entropion and trichiasis complete eyelash
surgical resection proves to be a better surgical
option than entropion repair alone. This procedure
eliminates the potential for recurring trichiasis by
eliminating the causative agent. Practitioners should
consider this procedure for treatment of chronic
trichiasis to eliminate the need for multiple clinical
The aim of this study to assist choroid
morphological parameters and vascularization in
normal healthy young adult Saudi eyes using Spectral
OptosOCT SLO. Methods In this prospective study,
one eye was selected from each of 110 subjects
for the assessments and measurements of choroid
morphological parameters and vascularization. One
examiner performed these functions and images
were assessed subjectively by one experienced rater.
Results were statistically analyzed using Paired t-test,
correlation coefficient, and regression.
Results All the images show normal foveal
contour with no retinal pathology or abnormalities of
the choroid. The choroid is thickest subfoveally than
750μm nasally and 750μm temporally. The results of
paired t test between the age groups show statistically
significant difference (p < 0.001). The regression
analysis indicated that there is strong negative
correlation between age and SFCT (r = -0.815,
P < 0.01), and SFCT decreased by 5.53μm each
year. The regression analysis indicated very weak
correlation between refractive error and SFCT (r =
0.076, P < 0.214). The comparison result of paired
t test between the male and female groups show
statistically significant difference (p = 0.02), and the
SFCT of the females was thicker than males.
The choroid is thickest subfoveally than 750μm
nasally and 750μm temporally. A strong negative
correlation between age and SFCT, and the SFCT of
the females is thicker than males.
12
visits, several surgical procedures, and to improve
patient satisfaction status post surgery.
Muriel Schornack, OD
Mayo Clinic
1403 City View Court NE
Rochester, Minnesota 55906
that is not yet well-described in the literature. It is
currently thought to occur when a central defect
develops within an ERM, which weakens that area.
Compression of photoreceptors, along with mild
macular edema, results in an anteriorly directed
force posterior to the membrane. Tractional forces
generated by the ERM itself compound this force,
and may eventually rupture the defect, allowing
foveal tissue to herniate. Clinical appearance of
this condition is similar to an early macular hole or
pseudohole. OCT allows for definitive diagnosis and
prompt intervention.
Additional Author(s): Alaina Softing Hataye, OD
Poster 22
Ocular coherence tomography (OCT) allows
us to visualize disturbances of retinal architecture
in much greater detail than was possible without
this technology, and allows us to differentiate
between conditions that would have similar
clinical appearance. We describe a case of foveal
herniation through an epiretinal membrane (ERM).
Its diagnosis is facilitated by examination of
macular OCT.
A 61 year old Caucasian male reported blurred
vision without metamorphopsia OD, along with
relative magnification OD. Symptoms had
worsened over several months. Ocular history
was unremarkable. Medical history included
hyperlipidemia and basal cell carcinoma, but was
otherwise unremarkable. Best corrected visual
acuity was 20/40-2 OD, 20/20 OS. Cover test,
motilities, pupillary reaction and confrontation fields
were normal. Amsler grid was positive for mild
distortion OD only. Goldmann tonometry measured
intraocular pressure at 11 OD, 13 OS. Dilated
fundus examination revealed an epiretinal membrane
(ERM) with vitreoretinal traction and straightening
of macular vasculature OD, with no abnormalities
OS. OCT confirmed a significant ERM OD, along
with tractional retinoschisis, mild cystoid edema
and foveal herniation through the center of the
ERM. OCT OS showed normal retinal architecture.
Fluorescein angiography OD showed mild late
phase cystoid macular edema and straightening of
macular vessels and no abnormalities OS. Pars
plana vitrectomy with an uncomplicated ERM peel
was performed OD. On post op day #39, the patient
reported slow resolution of symptoms, visual acuity
was 20/20 OD and the OCT revealed normalization
of the foveal contour with no recurrence of the ERM.
Foveal herniation through an ERM is a condition
The Utilization of the Visante OCT in the
Management of Acute Corneal Hydrops
Poster 21
Epiretinal Membrane with Foveal Herniation
OD - Ocular Disease
OD - Ocular Disease
Hillary B. Schweihs, OD
Illinois College of Optometry
3241 S. Michigan Ave
Chicago, Illinois 60616
Additional Author(s):
Jennifer S. Harthan, OD, FAAO
Corneal hydrops is a rare but potentially visually
significant complication of keratoconus. An acute
rupture of Decement’s membrane occurs, leading
to stromal edema and loss of corneal transparency.
Patients present clinically with a varying degree
in severity of symptoms making the diagnosis
challenging to make in some cases. The utilization
of the Visante OCT can assist the practioner in the
diagnosis and management of these complex cases.
A 48-year-old African American female presented
with complaints of acute vision loss, redness, tearing,
and photophobia in her right eye. Her medical history
is significant for hypertension and hyperlipidemia.
The patient had no history of eye rubbing or atopic
disease. Ocular history was positive for keratoconus.
Entering vision without correction was CF@ 1 foot
in the right eye, pinhole no improvement. Corrected
vision in the left eye through a Rose K contact lens
was 20/30.. Biomicroscopy evaluation of the right
eye revealed 1+conjunctival injection and a 5mm
central edematous cornea with few scattered bullae.
Secondary to the edema, a break in Descemet’s
was difficult to appreciate. Anterior segment OCT
confirmed a central Decement’s membrane rupture.
Left eye findings showed central corneal thinning
13
with stromal scarring and Decement’s folds. The
patient was started on atropine 1% QD, moxeza
QID, muro 128 solution QID, and preservative-free
artificial tears every hour while awake. The patient
was monitored closely over the course of three
months and resolution was noted with Visante OCT.
Acute corneal hydrops occurs in less than
three percent of keratoconic patients. Although the
condition is rare, the acute vision loss is significant
for the patient. Repair of Decement’s break and
resolution of edema typically occurs within two
to four months, however residual stromal scarring
will occur in its place. Treatment of acute hydrops
focuses on reducing patient discomfort, preventing
further complications and decreasing stromal edema.
Management of these patients is often difficult
as the secondary corneal edema often obscures
the Descemet’s break. The Visante OCT is a noninvasive procedures that provides high-resolution
anterior segment images of these complications
and assists the practitioner in the diagnosis and
management of these conditions.
The second case presentation in the series is a 27
year old African American female who presented to
the clinic post-blunt trauma OD 2 days prior. She
refused to provide details behind the injury and
reported 9/10 pain, with visual acuity of counting
fingers at 2’ OD. Hyphema was noted along with
corneal edema, chemosis, anterior chamber fibrin,
and subconjunctival hemorrhage. She was monitored
closely through several follow-ups including retinal
consult for vitreous hemorrhage and open globe that
had self-sealed. She was also referred for cataract
extraction due to subsequent development of
traumatic cataract.
Included in this multimedia poster are various
anterior segment photographs, ophthalmic
ultrasounds, radiology scans, surgical notes, ultimate
patient outcomes, and a review of evaluation and
management options for ocular trauma.
Poster 24
A Presentation of Ocular Ischemic
Syndrome.
Poster 23
OD - Ocular Disease
Moderate-to-Severe Orbital Trauma: 2 Case
Reports and a Review of Evaluation &
Management Considerations
Reena Lepine, OD
Southern College of Optometry
535 N Jefferson Pl. Apt 6
Memphis, Tennessee 38105
OD - Ocular Disease
Additional Author(s): Joanne Smith, OD
Addie Smith, OD
Family Practice Residency through
Southern College of Optometry
60007 West Way Dr.
Amite, Louisiana 70422
Ocular ischemic syndrome (OIS) results from
chronic hypoperfusion that leads to ischemia of the
entire eye. It is usually secondary to at least a 90%
stenosis of the ipsilateral carotid artery. OIS is a rare
condition that maybe misdiagnosed due to its subtle
presentation in some patients. The ultimate treatment
is to manage the underlying cause to prevent further
complications. The mortality rate for patients with
OIS is 40% at five years, and the two leading causes
of death are cardiovascular disease and cerebral
infarction. Furthermore, the visual prognosis can be
devastating. With such drastic potential outcomes,
early diagnosis is necessary for the best possible
systemic and ocular results.
A 55 year old female patient came into the
clinic with a complaint of a throbbing left eye
with indistinct vision for a week. She has a
history of hypertension and smokes daily. Her
best corrected visual acuity was 20/20 OD and
OS. Pupils were equal, round, and reactive with
Additional Author(s): Chris Wroten, OD
This poster presents two different cases of orbital
trauma, both of which led to surgical intervention.
The first case involves a 39 year old African
American male who presented to clinic after being
elbowed in the left eye during a basketball game four
days prior. He reported with 6/10 pain that increased
in extreme left gaze, visual acuity of 20/20 OS, and
no afferent pupillary defect. He displayed extreme
ecchymosis and a subconjunctival hemorrhage OS,
but retina remained flat and intact. Subsequent CT
revealed a left medial wall fracture with no muscle
entrapment, and the patient was referred to
oculoplastics for a surgical consult.
14
no afferent pupillary defect. Extraocular motilities
and confrontation visual fields showed normal
results. Intraocular pressures measured at 16
mmHg OD and 14 mmHg OS. Anterior segment
findings of the left eye revealed dilated episcleral
vessels and engorged iris vessels. The posterior
segment showed mid-peripheral hemorrhages with
dilated veins and narrowed arteries in the left eye.
An OIS diagnosis was confirmed by intravenous
fluorescein angiography (IVFA) which showed
delayed choroidal and arteriole venous filling,
diffuse vascular leakage, and peripheral capillary
non-perfusion. Doppler carotid ultrasound and CT
angiography revealed a 95% stenosis of the left
internal carotid artery. The patient is currently on
medical therapy and being monitored. A carotid
endarterectomy is recommended after resolution of
her concurrent thrombocytopenia.
This case stresses the importance of a proper
diagnosis in a presentation of OIS in order to
prevent severe ocular and systemic consequences. It
addresses the signs, diagnostic testing, and treatments
of OIS. Images include IVFA, anterior segment
photography, and fundus photography.
73 y/o Caucasian male presented for a
comprehensive eye exam. Ocular health history
included cataracts and pseudoexfoliative glaucoma
controlled with latanoprost. The patient’s last IOP
check was three months prior. Recent medical history
indicated the patient was hospitalized for pneumonia
and suffered a fall with subsequent internal bleeding.
Entrance testing revealed new onset anisocoria and
external examination revealed ptosis of right upper
lid but he denied anhidrosis. All other cranial nerve
testing was normal. Although apraclonidine use
did not produce reversal of anisocoria, the affected
pupil dilated 1mm while the unaffected pupil did
not dilate, which supports the diagnosis of HS.
Subsequent imaging revealed pulmonary nodules of
the right upper lobe that were metabolically inactive
and not impinging on the sympathetic chain. MRI
of the neck and thoracic spine revealed bilateral
severe neuroforaminal stenosis at C2-C6 which is the
probable cause of the new onset of HS.
New onset of Horner Syndrome can present
with the clinical triad of ptosis, miosis and facial
anhidrosis; however, these signs do not always
present equivocally. The use of 0.5% apraclonidine
has at least the same sensitivity and specificity as
the cocaine test for diagnosis of HS. Given its wide
availability, it is important for primary eye care
providers to employ apraclonidine in the diagnosis of
new onset Horner Syndrome.
Poster 25
Apraclonidine in the diagnosis of a new
onset Horner
OD - Ocular Disease
Poster 26
Anna L.O. Moore, OD
Southern Arizona VA Healthcare System,
Marshall B. Ketchum, Southern California
College of Optometry
5470 Waco Dr.
Sierra Vista, Arizona 85635
Delayed Onset Reversible Bilateral Corneal
Edema From Amantadine
OD - Ocular Disease
Neal K Shastri, OD
Seidenberg Protzko Eye Associates
Additional Author(s): Danielle. L. Weiler, OD
Additional Author(s): Scott Smearman, OD
The use of apraclonidine in the diagnosis of
Horner Syndrome (HS) as an alternative to cocaine
and hydroxyamphetamine is well documented. Loss
of sympathetic innervation in HS leads to the upregulation of alpha-1 receptors in uveal tissue. In this
sensitive state, apraclonidine can cause mydriasis.
Although the use of apraclonidine in the diagnosis
of HS is supported, the time frame between onset
and reliable use of apraclonidine for diagnosis has
not been determined. This case provides support for
the use of apraclonidine in the diagnosis of Horner
Syndrome within three months of onset
Amantadine is an antiviral drug approved to
treat influenza A, Parkinson’s disease, and certain
movement disorders, and used off-label to treat
chronic fatigue in patients with multiple sclerosis
(MS). Listed in the product label are rare corneal
side effects of punctate subepithelial opacities with
superficial punctate keratitis, corneal epithelial
edema, and reduced visual acuity. Although an
occasional patient developing bilateral corneal edema
15
from amantadine has been reported, we describe an
unusual case of bilateral corneal edema after three
years of continuous use of amantidine at 100mg
PO BID, that dramatically responded to stoppage
of amantadine.
A 53 year old female patient with MS, on
Amantadine and Gilenya, presented with three
weeks of gradual blurred vision in her left eye.
Upon examination, her BCVA was 20/40 and
20/70. Externals were unremarkable. Angles were
open. IOPs were 15 and 16 respectively. Slit lamp
examination was unremarkable OD , and revealed
diffuse stromal corneal edema with descemet’s folds
OS. There was no evidence of epithelial abnormality,
guttata, or uveitis OU. Dilated fundus exam and OCT
of the optic nerves/maculae were also unremarkable.
She was treated with muro-128 drops QID OS and
Lotemax QID OS. On two week follow up, her
BCVA was 20/70 and 20/80. Slit lamp exam showed
corneal edema OS>OD with descemets folds OU.
Pachymetry was 774 and 741. After a discussion
with her neurologist, amantadine was discontinued.
One month later, her vision improved. BCVA was
20/30+2 OU. Corneas showed minimal edema, and
pachymetry was 551 and 600.
Corneal edema is associated with herpes keratitis,
corneal dystrophy, or post-surgical endothelial
dysfunction. Without these conditions, toxic insult
should be considered in the differential diagnosis.
We presented this case to alert clinicians about
amantadine induced corneal edema, since high
index of suspicion and a careful medication history
is required for correct diagnosis; it can occur after a
long duration of treatment, and might be reversible.
Early recognition and stoppage of amantadine may
prevent severe endothelial cell loss, and potentially
irreversible corneal edema.
diagnosed with Iridocorneal Endothelial syndrome
with secondary angle closure glaucoma. Early
diagnosis and treatment may have prevented severely
restricted peripheral fields. Case Presentation: 57
year-old white female presented with progressively
blurring vision in her left eye over the past 6 months.
Medical Hx: heart disease, HTN, hypercholesteremia,
anxiety Medications: exforge, nexium, aspirin,
vytorin, celebrex, metoprolol, and xanax Fm Hx:
Glaucoma-sister Ocular Hx: None BCVAs: 20/20
OD, OS Pupils: OD: WNL OS: irregular, poor
reactivity, APD by reverse CF: OD: WNL OS:
peripheral constriction Anterior segment: OD:
WNL OS: beaten metal appearance on corneal
endothelium iris: ectropion uveae, atrophy with TI
defects and high PAS at 5 o’clock IOP: OD: 22 OS:
57 C/D OD: .6/.6 OS: .85/.8 thinning inferiorly/
nasally, deep/excavated cup Peripheral retina and
Macula: WNL OD, OS Gonioscopy OS: multiple
areas of high PAS extending past Schwalbe’s line
Specular microscopy: OD: normal endothelial size/
count OS: pleomorphism and polymorphism, light/
dark reversal OCT: OD: healthy NFL OS: significant
thinning inferiorly and superiorly VF: OD: WNL OS:
dense superior arcuate and inferior nasal step defect
Ddx: ICE syndrome, Axenfeld-Reiger Syndrome,
aniridia, PPMD
Diagnoses and treatment: Based on clinical exam
and specular microscopy she was diagnosed with ICE
syndrome causing severe secondary glaucoma. She
was started on Combigan BID, Azopt TID, Travatan
qhs OS and referred to a glaucoma specialist.
Trabeculectomy was performed and pressures
equalized to 7. Discussion: ICE syndromes are rare,
usually unilateral, and occur in young-middle aged
patients. Corneal endothelial cells are replaced with
epithelial-like cells with migratory characteristics.
These ICE cells can lead to corneal edema, iris
changes/atrophy, and secondary angle closure
glaucoma. Specular microscopy is an important
diagnostic tool showing asymmetric cells loss and
atypical cell morphology: light/dark reversal. Fifty
percent of ICE patients will develop glaucoma.
ICE syndromes are an important differential
diagnose in young/middle-aged patients who present
with unilateral glaucoma, endothelial abnormalities,
corneal decompensation and iris changes/atrophy.
Regular eye exams are important to catch ICE
syndromes before significant visual field loss occurs
from secondary angle closure glaucoma.
Poster 27
A Case of Unilateral Glaucoma -Iriodocorneal
Endothelial Syndrome
OD - Ocular Disease
Julianne Jantzi, OD
Seidenberg Protzko Eye Associates
1200 Brice Square
Belcamp, Maryland 21017
Abstract: A 57 year-old white female with a
chief complaint of blurry vision in her left eye was
16
Poster 28
Poster 29
Electrocution Cataracts
Acute Retinal Pigment Epithelitis
OD - Ocular Disease
OD - Ocular Disease
Roslyn Howell, OD
Northeastern State University
3469 Southridge Place
Tahlequah, Oklahoma 74464
Allissun Hoppert, OD
Arizona College of Optometry
19555 N. 59th Ave
Glendale, Arizona 85308
Cataracts can be caused by many things,
including trauma, but we don’t typically think
of them being caused by electrocution trauma.
Even though we may not see cataracts caused by
electrocution very often, they are a well documented
effect of electrocution: usual onset being several
months after the event. This case illustrates a classic
example of electrocution cataracts.
A 39 year old male presents with gradual onset
blurred vision and glare, over the past 3 months.
While working as a lineman, six months previous,
he was electrocuted and lost his right arm, as well
as having significant neck and facial scarring. Best
corrected visual acuities were 20/40 OD and OS. On
examination 3-4+ cortical cataracts were found in
both eyes with no other ocular health abnormalities.
It is assumed that these cataracts are related to the
electrocution event, due to the patient’s young age
and the appearance of the cataracts. The cataracts
were completely cortical with no nuclear sclerosis
or posterior subcapsular component. The patient was
referred for cataract surgery.
Cataracts are a fairly common outcome after
a high voltage electric shock. Patients should be
screened several months after the event. Cataract
surgery is no more risky in these patients then it is for
patients with age related cataracts.
Additional Author(s):
Wendy Harrison, OD, PhD, FAAO
Acute Retinal Pigment Epithelitis is an
uncommon, self-limiting condition that tends to
affect young healthy adults. It is characterized by
blurred vision and often a central scotoma. Although
cases have been well documented in the literature, the
etiology is still unknown.
AF, a 23 year old female medical student
presented to clinic as an urgent walk-in appointment
after a dark gray hole had formed in the central vision
of her left eye. The hole had remained constant in
size over the last two days and was large enough to
obstruct entire words on her computer monitor. The
patient denied ocular pain and any history of ocular
disease, surgeries, or trauma OU. Neither she, nor
any family member had ever had similar symptoms
in the past. Her systemic history was unremarkable
except for a single bout of supraventricular
tachycardia which she had experienced one month
earlier a few hours after receiving the flu shot. The
patient’s corrected entering visual acuities were
20/15 OD and 20/60-1 OS. Pupil testing, IOP’s and
a slit lamp examination revealed no abnormalities
OD, OS. The fundus exam unveiled a circular, well
circumscribed hypopigmentation of the left macula.
An OCT revealed a small focal foveal disruption
at the level of the RPE and the photoreceptor
layers with a small amount of overlying fluid. The
patient was referred first to a retinal specialist for an
evaluation and Fluorescein angiogram, and then for
an ERG.
The Fluorescein angiogram revealed inconclusive
results. The full field ERG was normal OD, OS, but
the multifocal ERG demonstrated a missing central
hexagon with decreased amplitudes and normal
timing OS. All tests failed to identify an exact
diagnosis. Repeat OCT’s over the next few weeks
showed no residual fluid and an improvement in
the initial foveal disruption OS. One month later,
the patient spontaneously regained 20/20 acuity
17
in her left eye and the central scotoma dissipated
leaving only residual foveal scarring. Upon
reviewing the clinical course of the disease, the
patient was determined to have an Acute Retinal
Pigment Epithelitis.
neuritis. Early recognition is crucial in treating
this condition. The discovery of aquaporin-4
autoantibodies has helped identify and differentiate
NMO from other similar diseases. This case
illustrates the importance of testing for NMO in
cases of recurrent optic neuritis especially in the
presence of normal MRI findings and concurrent
autoimmune disease.
Poster 30
Recurrent Optic Neuritis Leading to the
Diagnosis of Neuromyelitis Optica
Poster 31
OD - Ocular Disease
Treatment of Gout Reactivates Herpes
Simplex Keratitis
George Hanna, OD
Illinois College of Optometry
655 W Irving Park Rd #3705
Chicago, Illinois 60613
OD - Ocular Disease
Mariem Abdou, OD
The Pennsylvania College of Optometry
4040 Presidential Blvd #2409
Philadelphia, Pennsylvania 19131
Neuromyelitis optica (NMO) is an autoimmune
demyelinating disease that targets astrocytes in
the spinal cord and optic nerves. Patients often
present with optic neuritis months, or years, before
NMO is diagnosed. The most common ophthalmic
presentation is a recurrent optic neuritis resulting in
severe vision loss.
A 31 year old African American Female presented
to the emergency clinic at the Illinois Eye Institute
in 2013. She reported sudden painful vision loss in
the right eye. She had previously been diagnosed
with optic neuritis in the left eye in 2010. Her
medical history is remarkable for Systemic Lupus
Erythematosus. Vision at this visit was 20/50 OD and
20/15 OS with an afferent pupillary defect, abnormal
color vision and pain on eye movement in the right
eye. The dilated fundus exam revealed moderate
disc edema in the right eye and disc pallor in the
left eye. An MRI of the brain and orbit showed only
enhancement of the right optic nerve. The patient was
seen four days later and vision had recovered to 20/30
OD. The patient presented about 4 weeks later with a
complaint of painful vision loss in the left eye. Vision
was 20/20 OD and NLP OS with an afferent pupillary
defect OS. Dilated fundus exam revealed resolving
disc edema OD and moderate disc edema OS. An
MRI was repeated and showed only enhancement
of the left optic nerve. Blood work was ordered
including FTA-ABS, RPR, serum lysozyme, ACE
and NMO IgG titer. The NMO IgG titer was positive.
The patient was diagnosed with Neuromyelitis optica
and was started on oral methotrexate.
NMO is a rare condition that may be mistaken
for other demyelinating diseases such as Multiple
Sclerosis (MS) when the initial presentation is optic
Additional Author(s): Andrew Gurwood, OD,
FAAO, Diplomate, Optometry
Herpes simplex is a double stranded DNA
virus that is present in 60-95% of the world’s
population. It is one of the leading causes of
infectious corneal blindness. When an initial
infection occurs, the virus travels retrograde
through sensory nerves to the neural ganglia and
remains latent until an immunocompromised state
permits reactivation and the variable provocation
of signs and symptoms. The literature recognizes
increased stress, immunosuppression, trauma,
nerve damage and systemic corticosteroid therapy
as potential triggers. The use of topical or oral
steroids provoke resurfacing of the virus via an
immunosuppressive mechanism.
A 57 year old Asian male presented with
complaints of unilateral ocular pain and redness
OS of 3 weeks duration. The ocular history was
remarkable for an episode of herpes simplex keratitis
with associated uveitis six months prior, successfully
treated with topical and oral antivirals and a topical
steroid. The systemic history was remarkable for
gout, recently medicated with increased prednisone.
The best corrected visual acuities were 20/20 at
distance and near, both eyes. External examination
was normal with no afferent defect. Biomicroscopy
revealed a dendritic lesion in the left eye surrounded
by stromal haze and diffuse punctate epithelial
erosions in both eyes. A large stromal scar in the left
eye was noted secondary to a previous HSV event.
18
The patient was prescribed Viroptic 1% nine times
per day for one week and tapered to four times a
day at the subsequent visit in conjunction with a
topical steroid consistent with the recommendations
of the Herpetic Eye Disease Study. Oral medications
were also initiated to limit the risk of recurrences.
Correspondence was sent to the medical team
advising them of what had happened along with
recommendations describing how additional events
might be avoided.
Topical or systemic steroids have the potential
to induce reactivation of the herpes simplex virus.
Ophthalmic and systemic practitioners should
prescribe steroids with caution in patients who have
a history of herpes simplex keratitis. Prophylactic
oral antivirals should be considered for patients
who require oral of topical steroid administration to
reduce the likelihood of recurrence.
hemorrhage superiorly, and a mass beneath the
palpebral conjunctiva superiorly. Intraocular
pressure by tonometry were 10 mmhg OD, 13 mmhg
OS. Posterior segment evaluation was unremarkable
for both eyes. Orbital CT scan with contrast revealed
an enhancing superior left orbital mass causing mild
infero-posterior displacement of the globe without
obvious globe deformity. Orbital mass biopsy
had no formal read, but flow cytometry revealed
B-cell lymphoma.
The patient subsequently underwent three
weeks of radiotherapy without ocular or systemic
complications. At the follow up examination, bestcorrected visual acuities were 20/20 OD, 20/20
OS. Extra-ocular muscles evaluation was smooth
and unrestricted for both eyes. The left orbital
subconjunctival lesion resolved and posterior
segment evaluation was unremarkable for both
eyes. The patient continued follow up visits with
his radiation oncologist and will undergo further
treatment if indicated. Through collaboration with
colleagues and careful attention to clinical findings
led to the proper diagnosis and management of
the patient.
Poster 32
“I think the ficus fig trees caused my eyelid
to become droopy”
OD - Ocular Disease
Charlie Ngo, OD
UC Berkeley School of Optometry
1919 Dwight Way #311
Berkeley, California 94704
Poster 33
A 68 year old Caucasian male initially presented
the clinic with chief complaint of a new upper
lid ptosis and vision changes to his left eye. He
described that five weeks ago while in the Key West,
his eyes were red the next day after trimming ficus
fig trees. He started over-the-counter anti-histamine
eye drops and Visine with little relief. One week
later he noted that his left upper lid became droopy
and has been stable since the initial presentation. The
patient denies diplopia, eye pain, headaches, facial
numbness, recent infection, injuries, and history of
any cancer.
The patient’s incoming visual acuity was 20/20
OD, 20/50 OS, pinhole improved to 20/20-2 OS.
Distance cover test revealed a left hypotropia. Extraocular muscles evaluation of the left eye revealed
grade 2- superior restriction. Confrontational
visual fields and pupils were unremarkable with
no afferent pupillary defect of both eyes. Hertel
revealed mild asymmetry, 18 mm OD, 19 mm OS.
Anterior segment evaluation of the left eye revealed
2-3 mm upper lid ptosis, diffuse subconjunctival
OD - Ocular Disease
Cystoid Macula Edema In a Diabetic Patient
After Cataract Surgery: A Case Report
Betty Harville, OD
Southern College of Optometry
1245 Madison Ave.
Memphis, Tennessee 38104
Additional Author(s): Leroy Norton, OD
Cystoid Macula Edema is the most common
complication and subsequent cause of decreased
visual acuity after cataract surgery, especially in
diabetic patients. Research suggests cataract surgery
worsens macula edema in diabetic patients and
may show progression of diabetic retinopathy. This
is especially true for patients who undergo longer
surgical procedures secondary to dense cataracts and
those who have long standing diabetes. Management
of diabetics includes pretreatment with non-steroidal
anti-inflammatory drugs and steroids to decrease
CME. Visual acuity and OCT can be utilized to
monitor changes post-operatively to minimize
poor outcomes.
19
An 86 year old female reported for an eye
exam in May of 2013, with complaints of blurred
vision OD, OS. The patient’s visual acuity was
OD 20/40, OS 20/50 at distance and 20/30 OD,
OS at near. No improvement with pinhole. Internal
ocular examination showed 4+ nuclear sclerosis
and anterior cortical cataracts OD, OS. Patient was
positive for longstanding DM, HTN and arthritis.
Medication included Lidoderm patch, Insulin 70/30,
cilostazal and diltiazem. Patient was referred for
cataract surgery July 2013 with follow-up performed
at surgery center. Patient returned October 2013
with decreased VA OS. OCT showed CME OS with
large cystic pockets. Visual acuity was reduced.
Patient restarted on Pred Forte (steroid) and Prolensa
(NSAID). OCT was repeated one month later with
improvement noted. Two months later improvement
continued, but not completely resolved. Patient was
counseled on other treatment options especially
intravitreal Avastin, but patient refused. Continue
monitoring patient utilizing NSAID and steroid to
reduce CME and improve the patients outcome.
This patient presented with decreased visual
acuity and history of DM. Patient had dense cataracts
OS> OD and was referred for cataract surgery. The
outcome with NSAIDs and steroid prior to surgery
did not prevent CME. Patients with DM are more
prone to decreased visual acuity after cataract surgery
when the cataracts are more mature. The ideal
management is intravitreal injections, but the patient
did not desire further surgical intervention. Photodocumentation and OCT results along with follow-up
care will be included in this poster.
hyphemas of varied etiology are referred to as
spontaneous hyphemas. Causes of spontaneous
hyphemas include ocular surgery, neovascularization
of the iris, intraocular malignancies, vascular
abnormalities, blood dyscrasias and medications.
Approximately one third of all hyphema patients
experience an increase in intraocular pressure.
Hyphema is usually a self-limiting condition causing
little to no permanent vision loss. Hyphemas greater
than 50% or persistent elevation of intraocular
pressure usually necessitate medical or surgical
intervention. Patients need to be closely monitored
until the IOP is normalized and the hyphema has
resolved.
A 58 year old Caucasian male was referred by
another eye group due to high intraocular pressure
in the left eye as a consequence of anterior uveitis.
The visual acuity was 20/20 OD and 20/25 OS. The
intraocular pressures were 18 and 35 mmHg in the
right and left eyes, respectively. Anterior segment
examination revealed a small amount of fibrin coated
with blood in the anterior chamber with no associated
cell and flare. A microhyphema in the inferior
quadrant of the anterior chamber was discovered on
gonioscopy. The intraocular pressure was lowered
in office and a complete fundus examination was
performed. A Blood work up was ordered and the
results were negative. The patient was followed more
frequently until the intraocular pressure was stable at
or below the target and the hyphema was cleared.
Thorough evaluation and prompt management
can usually prevent permanent vision loss in patients
with spontaneous hyphema. When a local cause
for the spontaneous hyphema cannot be found, a
search for an underlying medical condition should
be initiated. Our case illustrates the evaluation and
management of a patient with spontaneous hyphema
associated with elevated intraocular pressure.
Poster 34
Spontaneous Hyphema
OD - Ocular Disease
Salma Kiani, OD
Omni Eye Specialists-Affiliated with
Salus University
5 Skipworth Court
Catonsville, Maryland 21228
Additional Author(s): Edward Wasloski, OD
Any disruption of the vascular uveal structures
that results in bleeding into the anterior chamber is
called a hyphema. Hyphemas are most commonly
caused by blunt or penetrating trauma, either to the
head or directly to the orbit itself. Non-traumatic
20
Poster 35
an area of localized inflammation and the patient
was symptomatic a steroid/antibiotic suspension was
prescribed to decrease inflammation and quiet any
underlying infectious process.
The Case of the Hidden Cyst
OD - Ocular Disease
Poster 36
Rebecca L. Pietrasik, OD
West Haven VA/NECO
224 Elm St Apt 206
West Haven, Connecticut 6516
Uncovering CIN: How Atypical Benign
Lesions Can Appear Malignant
OD - Ocular Disease
Additional Author(s): Kassandra Wedeking, OD,
Nancy Shenouda-Awad, OD, Charles Haskes, OD
Astrid Campagna, OD
West Haven VA/NECO
224 Elm St Apt 206
West Haven, Connecticut 6516
Dacryops are rare lacrimal duct lesions that occur
due to obstruction and consequent enlargement of
the lacrimal gland duct. They account for 2-6%
of pathologies of the lacrimal gland and typically
present in young adults or middle-aged patients with
female predominance. Dacryops can form after an
infection or inflammatory episode. Treatment options
include observation, topical or oral antibiotics/
steroids, puncture/aspiration, and surgical excision.
This poster discusses the case of a patient with an
inflammatory unilateral dacryops.
An 85 year old white male presented to the
Optometry clinic at the West Haven VA Medical
Center with foreign body sensation for three
days prior. The patient had the symptoms of mild
irritation/foreign body sensation located temporally
in the right eye only. Patient presented with no other
associated symptoms. For relief, the patient tried
using Lacrilube ointment qhs without any relief.
Upon clinical examination, a conjunctival cyst with
a focus of white cells in the center was found when
the lid was pulled temporally OD on the palpebral
conjunctiva. The cyst was treated with Tobradex
suspension QID, Preservative Free Artificial Tears
BID-QID, and Erythromycin ung qhs. Five days
later at the patient’s follow up appointment, the
dacryops was much improved and almost completely
resolved. The patient was no longer symptomatic.
He was educated to continue the current regimen for
three more days and then discontinue the Tobradex
suspension and Erythromycin ung.
Dacryops are a rare, but important differential
to be considered when evaluating conjunctival
lesions. This case was atypical because the
dacryops occurred in an elderly male with no
history of infection/inflammation. When choosing
treatment for a patient with dacryops, symptoms,
reoccurrence, and evidence of active infection are
three important factors to consider. Since there was
Additional Author(s):
Rebecca L. Pietrasik, OD, Charles Haskes, OD,
Nancy Shenouda-Awad, OD
Conjunctival lesions can be challenging to
diagnose just based on clinical appearance and
range from benign to malignant. Conjunctival
intraepithelial neoplasia (CIN) is considered to be
the most common tumor of the ocular surface. As
CIN can be a precursor to conjunctival squamous
cell carcinoma, it must be promptly treated as it can
threaten not only the patient’s visual function but also
his or her life.
A 68 year old Caucasian male presented to the
Optometry Clinic at the West Haven VA Medical
Center for his yearly eye exam. His only complaint
was redness OS which he had noticed for two
months. His clinical exam was significant for a
temporal 8x7mm gelatinous and highly vascularized
conjunctival growth extending two millimeters within
the limbus onto the cornea OS. The main differentials
at that exam were an atypical presentation of a
pterygium, a viral papilloma or CIN. The patient
was subsequently presented to the corneal specialist
who agreed that the lesion was highly suspicious
for CIN. She recommended excisional biopsy of the
lesion with cryotherapy. The patient consented to the
procedure and had the lesion removed. Though the
final pathology report noted the lesion as consistent
with a pterygium, this case discusses differentials,
work up, and proper management of a patient when
CIN is suspected. It also illustrates that a pterygium
has a tendency to masquerade as other lesions.
As this case highlights, a benign pterygium can
at times present atypically and in ways very similar
to other more ominous conditions. The vessels of a
21
pterygium are usually normal caliber and straight
because they are dragged by the pterygium lesion.
However, one of the most important conditions to
rule out in a patient presenting with a conjunctival
lesion is CIN. This patient’s lesion was gelatinous,
located within and around the limbus and contained
engorged and tortuous vessels. All of these factors
can be associated with malignancy so an excisional
biopsy was the appropriate course of action. It is very
important to consider all differentials and order a
biopsy when malignancy is suspected.
PIL above drusen and visual threshold as measured
by microperimetry. Microperimetry enables
clinicians to identify visual sensitivity at individual
drusen or drusen-like lesions, and to monitor visual
thresholds over time.
Poster 38
Glaucoma is the Pits!
OD - Ocular Disease
MaryCarol Graby, OD
VHA Connecticut West Haven
219 Fountain St Apt 10
New Haven, Connecticut 6515
Poster 37
SD-OCT and Microperimetry Correlates in
Drusen and Drusen-like Lesions
Additional Author(s): Astrid Campagna, OD,
Charles Haskes, OD, MS, Theresa ZerilliZavgorodni, OD, Nancy Shenouda-Awad, OD
OD - Ocular Disease
Daniel Epshtein, OD
SUNY College of Optometry
33 West 42 st
New York City, New York 10036
Acquired optic cup pits (AOCP) represent a
focal excavation of the neural rim and loss of the
lamina cribosa. Their presence is thought to be
pathognomonic for glaucoma. It is well known that
congenital pits often cause fluid accumulation and
subsequent serous macular detachments, but is the
same true for acquired optic cup pits in glaucoma?
While visual fields and optic nerve OCTs are
important for monitoring for progression in patients
with glaucoma, it may also be prudent to follow
patients with concurrent acquired optic pits with
macular OCT’s. This poster will discuss the proper
management strategy for patients with glaucoma
and AOCPs and discuss why macular OCTs may
be prudent.
A 61 year old white female presented to the West
Haven VA Optometry clinic for a Glaucoma consult,
with an incoming diagnosis of Normal Tension
Glaucoma and AOCPs. She was being treated with
Latanoprost qhs OU, and had consistently been
meeting target pressures. Previous visual fields
had shown inferior nasal defects OD, matching
the superior temporal location of her optic pit,
and inferior central defects OS, with a superiorly
located pit. Her most recent field showed possible
progression OS due to an increased number of
depressed central points. Upon examination of
the patient’s optic nerves and visual fields, the
Glaucoma specialist agreed that her field defects
were attributable to the AOCPs. He recommended
monitoring the patient not only with visual fields and
OCT of the RNFL/ONH, but also with OCT of the
Additional Author(s): Jerome Sherman, OD
The maia™ (Macular Integrity Assessment)
microperimeter unites perimetry with scanning
laser ophthalmoscopy (SLO) and eye tracking
technology. The Expert Test enables monitoring
of visual threshold at precisely selected fundus
loci. This technology enables investigation of the
impact of individual drusen on visual sensitivity.
The correlation of this functional information
with SD-OCT (spectral domain optical coherence
tomography) structural analysis provides insight
into the relationship between visual sensitivity and
localized retinal integrity.
A case series demonstrates variable sensitivity of
drusen on maia™. One case demonstrates a patient
in whom drusen show differing impacts on visual
sensitivity. SDOCT identifies concordant impact
of these drusen on the photoreceptor integrity line
(PIL): Reduced integrity corresponds with reduced
visual sensitivity. Another case shows a patient
with dry age-related macular degeneration (AMD)
and multiple drusen in whom maia™ identifies a
severely reduced threshold over one particular “white
spot.” SD-OCT reveals this locus to be a finite area
of geographic atrophy of the RPE amidst a sea of
drusen. Additional cases confirm these relationships
between visual sensitivity and retinal integrity.
There is a correlation between the integrity of the
22
macula, as patients with optic cup pits can develop
associated maculopathy and decreased vision from
damage to the papillomacular bundle fibers.
It is common practice for glaucoma patients
to be monitored with 24-2 visual fields and optic
nerve/RNFL OCT’s, but additional testing should be
performed when an acquired cup pit is present. Optic
cup pits in many cases may present with central
visual field defects that are not typically associated
with early glaucoma. This makes it essential to
monitor these patients with serial macula OCT and
10-2 visual fields.
patient was lost to follow-up and the hyphema never
completely resolved. Ten weeks later, the patient
returned with severe ocular pain. Exam findings
revealed a 10% re-bleed, inducing an IOP of 70
mmHg and provoking a grade 3 uveitic response.
She was prescribed Homatropine every 12 hours,
Pred Forte every 3 hours, Azopt twice a day, and
Alphagan three times a day, OD. Ultimately, she
underwent an anterior chamber washout and an
Ahmed valve implantation to normalize the IOP level
and restore her comfort.
Hyphema has the potential to produce
complications that may be sight threatening. Frequent
follow-up is required so timely intervention can be
administered. When medical therapy fails, surgical
modalities may be warranted.
Poster 39
Medical and Surgical Management of
Intractable Hyphema
Poster 40
OD - Ocular Disease
Degenerated Cornea: An Atypical Case of
Salzmann’s Nodular Corneal Degeneration
Giezel M. Rivera, OD
Salus University
1050 N. Hancock Street #715
Philadelphia, Pennsylvania 19123
OD - Ocular Disease
Kassandra M. Wedeking, OD
West Haven VA - Connecticut
Healthcare System
219 Fountain Street, Apt 10
New Haven, Connecticut 6515
Additional Author(s): Andrew Gurwood, OD
Hyphema is defined as layered blood in the
anterior chamber. While it is often a result of
trauma, it may develop following intraocular
surgery, secondary to conditions that cause iris
neovascularization, as a complication of systemic
diseases, or use of substances that have anticoagulation properties. The goal of therapeutic
management is to stabilize the clot to prevent
complications such as re-bleeding, corneal
blood-staining and glaucoma, and to manage any
concomitant iritis.
A 70-year-old African American female
presented for a surgical consultation regarding an
anticoagulative hyphema with a protracted and
painful course, OD. Systemic history included
hypertension and cerebral vascular accident,
medicated with Diovan and Coumadin. Ocular
history was significant for a choroidal detachment
and longstanding traumatic glaucoma, OD. Initial
episode of the hyphema (occurring 10 weeks
earlier) was presumed secondary to use of medical
anticoagulation. It manifested as 75% filling and
produced an IOP of 40 mmHg, OD. Treatment
consisted of topical cycloplegic, topical antiinflammatory, and topical anti-glaucoma medications.
According to the referring practitioner’s records, the
Additional Author(s): MaryCarol Graby, OD,
Shannon Santapaola, OD, Nancy ShenoudaAwad, OD, FAAO
A condition characterized by superficial greyish
corneal nodules, Salzmann’s Nodular Corneal
Degeneration (SNCD) is a relatively rare, slowly
progressive condition most commonly seen among
middle-aged women. Though SNCD can be
idiopathic, chronic ocular surface inflammatory
conditions are known to be associated, most
commonly: meibomian gland dysfunction, contact
lens wear, peripheral corneal vascularization,
pterygium, keratoconjunctivitis sicca, and exposure
keratitis. Symptoms of SNCD are variable and
range from asymptomatic to moderate irritation
with wide ranges of reduced vision. This poster
will demonstrate an atypical case of SNCD
with discussion of differential diagnoses and
management options.
A 74 y/o white male presented for new glasses
without complaints or changes in vision. Ocular
history was remarkable for dry eye syndrome,
23
Poster 41
proptosis and lid retraction OD, pseudophakia OU,
low-risk glaucoma suspect, and history of mild
NPDR OS. Systemic history was remarkable for
stage 3A lung cancer, type 2 diabetes, and chronic
kidney disease. Exam revealed a reduction in BCVA
of 20/40+ OD and 20/25 OS with large variability
between follow-up visits over the course of two
weeks. Corneal examination showed multiple
peripheral superficial whitish-grey elevations with
overlying epithelial compromise and positive
staining with sodium fluorescein, OD>OS. Posterior
segment findings were unremarkable and macular
OCT was normal. SNCD was diagnosed based
on clinical appearance and the attributed cause of
reduced vision. Corneal topography showed irregular
astigmatism OU consistent with SNCD. The patient
was started on Restasis OU in addition to artificial
tears six times daily and lubricating ointment at
bedtime. Warm compresses and lid hygiene were
recommended OU BID. Vision at follow-up was
improved to 20/30+ OD and 20/20- OS.
This case demonstrates an atypical presentation
of SNCD with unexpected vision loss due to induced
irregular astigmatism. Management of this patient
was conservative as the patient was asymptomatic
with significant comorbid health concerns; surgical
options are available for more severe cases. Though
symptoms may vary, SNCD can significantly affect
vision and should be differentiated from bullous
keratopathy, spheroidal degeneration, hereditary
hypertrophic scarring, granular dystrophy, and
amyloidosis. Appropriate management of SNCD
involves treating the associated factors, and patient
compliance is vital for optimal outcome.
Spectral-domain OCT findings of retinal
ischemia in Neurofibromatosis Type 1
OD - Ocular Disease
Ashley Cowart, OD
University of Florida-Jacksonville
Department of Ophthalmology
580 West 8th Street, Tower II, 3rd Floor
Jacksonville, Florida 32209
Additional Author(s): Wassia Khaja, MD,
Sandeep Grover, MD
Optic nerve glioma is a well-known ocular
finding in patients with Neurofibromatosis Type I
(NF-1). The diagnosis of optic nerve involvement
can be made based on clinical examination, visual
field testing and radiological imaging. The following
case describes gradually progressive unilateral vision
loss in a child with NF-1 caused by retinal ischemia,
without evidence of optic nerve glioma.
A 12-year old Caucasian boy presented with
unilateral progressive decrease of central vision from
20/25+2 to 20/400 over a period of approximately 4
years. There was clinically evident optic nerve pallor,
an afferent pupillary defect on the same side and
reduced color vision in that eye. Serial radiological
studies showed a normal appearing optic nerve
without any evidence of glioma. Although the retinal
examination was normal, spectral-domain optical
coherence tomography (SD-OCT) showed diffuse
inner retinal thinning, also involving the macular
area. The thinning was more in the inferior half of
the retina as compared to superior half. Digital video
angiography showed delayed and patchy choroidal
flush with delayed filling of central retinal artery,
relatively sparing the superior temporal artery. A
full-field electroretinogram (ERG) performed on that
eye showed a negative ERG with selective reduction
of b-wave confirming diffuse retinal ischemia. The
fellow eye was normal on examination and SDOCT testing.
Undoubtedly, a patient with NF-1 presenting
with decreased vision and signs of optic nerve
involvement should be appropriately investigated
with radiological studies for any evidence of optic
nerve glioma. However, in the absence of glioma,
it is important to consider a relatively rare finding
of ‘retinal ischemia’ as a probable cause. This case
24
report highlights the utilization of recent technology
such as SD-OCT and digital fluorescein video
angiography to diagnose this condition and confirm it
with ERG testing.
with Idiopathic Bilateral Granulomatous Uveitis. Her
signs and symptoms have since resolved with oral
prednisone. She will be followed by Rheumatology
and Optometry on a regular basis.
While the negative test results did not indicate a
particular systemic cause for her chronic uveitis thus
far, the patient continues to have symptoms of fatigue
and back pain. Research has shown that many cases
of bilateral anterior uveitis that have been classified
as idiopathic have eventually revealed a positive
diagnostic test and thus indicated an underlying
systemic disorder. Regular monitoring for change is
crucial in order to detect whether this idiopathic case
will remain idiopathic or if it is more than just an
ocular issue.
Poster 42
Idiopathic may not always stay idiopathic:
A case of chronic bilateral anterior
granulomatous uveitis
OD - Ocular Disease
Amy Moy, OD
New England Eye, New England College
of Optometry
75 Bickford St.
Jamaica Plain, Massachusetts 2130
Poster 43
A Bumpy Road to Diagnosis: Follicular
Conjuncitvitis to Ocular Lymphoma
Additional Author(s): Syeda Kutub
Chronic bilateral anterior granulomatous uveitis
usually indicates a systemic cause. In some cases,
however, all lab tests may initially show negative
results while the patient continues to have episodes
of uveitis and other nonspecific systemic complaints.
Over time, these cases can progress and finally
produce a positive test, inherently revealing the
underlying systemic disease. This case illustrates the
need for optometry to diligently co-manage chronic
uveitic patients with their primary care physician
(PCP) by periodically re-assessing and re-testing for
a possible systemic cause.
A 15 year old Hispanic female presented
with red, painful eyes with photophobia. She was
diagnosed with acute bilateral anterior granulomatous
uveitis, which resolved. Four months later, she
had a recurrent episode. The optometrist referred
to the PCP for a full workup, but only an ESR and
CBC panel were ordered. ESR values were only
minimally elevated, which led the PCP to preclude
further testing. Meanwhile, the patient still reported
nonspecific complaints of fatigue and body aches
over a 4-month period. Despite switching from Pred
Forte to Durezol, her signs and symptoms continued
to progress over several weeks. She developed a 2
diopter myopic shift, posterior synechia OD, and
pars planitis OU. The optometrist pursued a full
workup with the PCP, and requested specific tests.
When all results returned normal, the PCP referred
the patient to Rheumatology. After repeating all
lab tests and chest x-ray, all of which returned
negative, Rheumatology officially diagnosed her
OD - Ocular Disease
Stephanie R Fromstein, OD
Illinois College of Optometry
3241 South Michigan Ave.
Chicago, Illinois 60616
Ocular lymphoma is a malignant lesion of the
orbital soft tissue, conjunctiva or eyelid. It can
present as intraocular, orbital or adnexal growth.
Ocular adnexal lymphoma is characterized by
painless, pink, fleshy lesions of the conjunctiva
known as salmon patches. Notably, the condition
can also masquerade as a pronounced follicular
conjunctivitis. Most ocular adnexal lymphomas
are categorized as non-Hodgkins, low-grade B-cell
tumors. An infectious and autoimmune etiology
has been suggested for the disease, but has not been
definitively proven. The lifetime risk of ocular
lymphoma is 2.8%, making it the most common
primary malignant tumor.
A 79 year old African American female presented
for a consultation regarding “bumps” on the inside
of her lids, which were persistent over two months.
She was referred by another practitioner with no
treatment initiated. The patient noted some mild
foreign body sensation and irritation, but denied
pain, photophobia or discharge. Her ocular history
was significant for a complicated cataract extraction
OS five years prior. Acuities were 20/30 OD and
CF@5ft OS. All preliminary testing was normal,
noting a surgical pupil OS. Anterior segment
25
evaluation revealed a bilateral 4+ inferior follicular
conjunctivitis. The patient was treated with steroid
drops QID in both eyes, and a conjunctival biopsy
was performed due to a suspicion of malignant or
non-malignant growth. At the one-month follow-up,
all pertinent examination findings were identical.
Biopsy results were reviewed and revealed a stage 1
B-cell follicular lymphoma, positive for biomarkers
CD20 and BCL2. The patient was referred to
oncology to rule out systemic lymphoma. Following
testing, the disease was determined to be localized,
and the patient was started on Rituximab therapy.
Fortunately, many ocular lymphomas are low
grade, localized tumors which follow an indolent
course and tend to respond well to systemic therapy.
Therapy includes observation, radiation, cryotherapy,
interferon, monoclonal antibodies and chemotherapy.
The overall five-year survival rate for non-Hodgkins
lymphoma is approximately 60%, with the rate for
ocular adnexal disease being significantly higher at
86-100% with treatment. As this disease can present
as a chronic follicular conjunctivitis, recalcitrant
follicular disease warrants reconsideration and
prompt referral if the condition fails to improve.
categorizes macular holes into stages based on
macular appearance and presence of vitreomacular
traction (VMT).
A 61 year old, Caucasian male presented for his
annual eye exam. He is monocular due to trauma
while in military service and he had a history of
macula pseudohole in his remaining eye with a best
corrected visual acuity (BCVA) of 20/30. His BCVA
had decreased to 20/80-, and on spectral domain
OCT, the patient was found to have a stage three
macular hole with a 216 µm aperture size. He was
referred to retina for surgical consideration. At his
three month follow-up visit his vision had improved
to 20/40-, however he had never received surgical
intervention. The OCT showed a bridge formation
of inner retinal tissue. At the five month follow-up
visit the retinal layers showed complete closure and a
mostly intact IS/OS junction with BCVA of 20/30!
The spectral domain OCT has proven to be a
very helpful tool in determining structure differences
between pseudohole, lamellar hole, and macular hole
stages along with establishing anatomical success
post surgical intervention. RN Johnson and JDM
Gass found spontaneous closure of stage 2 or 3
macular hole at being less than 10%, and suggests
surgical intervention at stage two macular hole
especially if there is deteriorating BCVA. Anatomical
closure does not always correlate with successful
vision recovery, studies have proven that having
an intact IS/OS photoreceptor layer is the only
correlating factor related to visual recovery.
Poster 44
“On the Verge of Closure” a Case of
Spontaneous Macular Hole Resolution
OD - Ocular Disease
Jessica Cameron, OD
South Georgia North Florida Veterans
Optometry Clinic
4700 SW Archer Rd. Apt C24
Gainesville, Florida 32608
Poster 45
One and a Half Syndrome with a Partial
Seventh Nerve Palsy in Multiple Sclerosis
OD - Ocular Disease
Additional Author(s): Carrie Heller, OD
Rosaline Cha, OD
Illinois College of Optometry
3241 S. Michigan Ave.
Chicago, Illinois 60616
A macular hole is a partial to full thickness retinal
defect involving the fovea, symptoms including
metamorphopsia, central scotoma, and decreased
visual acuity. Treatment consists of pars plana
vitrectomy (PPV) with inner limiting membrane
peel and gas tamponade. The historical classification
of macular holes, first reported by JDM Gass in
1988, has been used to plan macular hole treatment.
Recently a new classification system based on
optical coherence tomography (OCT) was developed
by the International Vitreomacular Traction Study
(IVTS) Group. It focuses specifically on the
vitreomacular interface (VMI). This new system
One and a half syndrome is a manifestation of
central brain stem disease not commonly observed
in every day optometric practice. One and a half
syndrome occurs due to a unilateral lesion in the
dorsal pontine tegmentum involving the ipsilateral
paramedian pontine reticular formation, abducens
nucleus, and medial longitudinal fasciculus. This
interaction causes a distinctive clinical appearance
26
Poster 46
which is characterized by a complete lateral
gaze palsy in one direction with an internuclear
ophthalmoplegia in the other. Due to the location
of the 6th and 7th nerve nuclei, multiple cranial
nerve palsies may also be observed. Patients often
present with blur, oscillopsia, or double vision.
Common causes of the syndrome include vascular
insults, brainstem tumors, and multiple sclerosis.
Treatment and prognosis depend on the etiology of
the condition.
A 28 year old African American female presents
with sudden onset blur in right gaze only, for
three days. Entering acuities were 20/20 OD, OS
and EOM pattern was normal. Pupils were equal,
round, and reactive with no APD and dilated fundus
examination was unremarkable. Three days later she
returned with a complaint of ongoing blur in right
gaze and reported “crossing eyes.” EOMs revealed
complete paralysis of right gaze OD, OS, and
paralysis of nasal eye movement OD with horizontal
nystagmus OS in left gaze. Convergence was spared.
In addition, she had a widened palpebral fissure and
decreased definition of her nasolabial folds on the
right side of her face. MRI revealed an enhancing
lesion of the right facial colliculus with greater than
fifteen non-enhancing lesions of the paraventricular
white matter. The patient was referred to a
neurologist and was diagnosed with and managed for
multiple sclerosis.
One and a half syndrome with partial seventh
nerve palsy in patients is specific for the anatomical
site of the disorder, but not for the cause. Resolution
of the syndrome within days to weeks is common,
however, demyelinating conditions, ischemia, and
masses must be ruled out. When multiple sclerosis
is the underlying cause, referral to a neurologist for
early treatment is imperative to preserve not only
visual but systemic function.
Contents Under Pressure: An Atypical
Presentation of Pseudotumor Cerebri
OD - Ocular Disease
Benjamin Thayil, OD
Bill Hefner VAMC
7808 Kotz Ct. Apt 226
Charlotte, North Carolina 28269
Additional Author(s): Jarett Mazzarella, OD
Pseudotumor cerebri (PTC) or Idiopathic
Intracranial Hypertension is associated with increased
intracranial pressure without a mass lesion and
normal cerebral spinal fluid (CSF) composition. PTC
is considered a diagnosis of exclusion and classically
presents in obese females in their third decade of life.
This case study presents an atypical case of PTC,
investigates modes of recognition, and evaluates
current treatment modalities.
A 66-year-old African-American male presented
to our VA eye clinic after examination by telehealth
imaging. Immediate referral for in-office evaluation
of bilateral blurred disc margins was recommended.
The patient complained of painless visual loss, onset
four months ago. Significant systemic history
included diabetes, hypertension and bilateral above
the knee amputation. The patient’s quality of vision
was subjectively described as a generalized blur at
distance and near. The patient also complained of
transient visual loss when turning his head left and
right. There was subsequent denial of headaches,
nausea, tinnitus and diplopia. Preliminary testing
including motilities, confrontation fields, and pupils
were evaluated and unremarkable. Entering acuities
were 20/40 OU. Red cap desaturation testing
revealed no dyschromatopsia. Dilated funduscopic
evaluation revealed edematous optic discs OU with
associated disc hemorrhaging. Baseline nerve fiber
layer analysis was performed to evaluate the extent of
edema. The patient was sent immediately to the
emergency department for an MRI of the head and
complete blood count including sedimentation rates
and C-reactive protein. The patient was admitted for
further neurological workup. Carotid ultrasound and
lab work was unremarkable; MRI revealed no
associated pathology. Opening pressure of the
lumbar puncture was 340mmHg, which lead to the
diagnosis of pseudotumor cerebri. Treatment was
with oral acetazolamide. Ophthalmology and
27
neurology were consulted for comprehensive co-management.
Several differential diagnoses must be ruled
out before diagnosing PTC: diabetic papilitis,
hypertensive optic neuropathy, pharmaceutical
induction, ischemic optic neuropathies, infiltration
of the discs, and mass lesions must be considered.
Traditional treatment for PTC include oral
acetazolamide, weight loss, discontinuation
of causative pharmaceuticals, optic sheath
decompression or oral steroids. To ensure a good
prognosis, atypical presentations of conditions not
presenting with textbook signs and symptoms require
meticulous evaluation and appropriate management
in a timely manner.
anterior and middle cranial fossa as well as the left
orbit. Mass compression and displacement of the
optic nerve sheath complex, superior and lateral
rectus muscles appeared significant. Therapeutic
intervention consisted of a transfacial and transorbital
resection of the orbitotemporal, inferotemporal
fossa, and middle fossa meningioma with extradural
resection of the tumor. One month later, patient
presented with a perforated left cornea likely due
to a history of exposure keratopathy or a possible
neurotrophic keratopathy. A tectonic corneal graft
procedure was performed.
This case highlights the importance of prompt
diagnosis, neuroimaging, treatment, and close
monitoring for recurrence because atypical
meningiomas exhibit a more aggressive biological
behavior, with the potential to cause significant
morbidity. Atypical meningiomas, correspond with
the World Health Organization (WHO) grade II
classification and tend to grow much more quickly
than benign meningiomas and recur at a much higher
rate. Pain alone is rarely a presenting feature of
orbital meningiomas, but orbital tumors or orbital
apex tumors commonly present with insidiously
progressive visual loss or proptosis. Mild and
inconsistent headache is described in some patients
but significant pain is rare.
Poster 47
Painful Recurring Orbital Frontal
Meningioma with Compressive Optic
Neuropathy and subsequent Corneal
Perforation
OD - Ocular Disease
Dong C Suk, OD
James H Quillen VAMC, Southern College
of Optometry
115 Beechnut ST, Ste. #B5
Johnson City, California 37601
Poster 48
The use of interferon alfa- 2b in the
treatment and management of ocular surface
squamous neoplasia (OSSN)
Additional Author(s): Loren Bennett, OD,
FAAO, Nanette Coelho, OD
Meningiomas represent approximately 4% of
all infraorbital tumors and 20% of all intracranial
tumors. Although meningiomas are typically
benign and slow growing in about 90% of cases,
the intermediate and high-grade subtypes of
meningiomas (WHO grades I and II) constitute
10% of cases. For most nervous system tumors the
World Health Organization (WHO) grade is really an
estimate of malignancy, reflecting the likelihood of
recurrence and aggressive behavior. Meningiomas in
the orbit are challenging lesions to manage because
of their typical posterior location and progressive,
painless, and variable visual loss.
A 65-year-old male presented with a painful
proptotic, inferiorly displaced left orbit with extraocular muscle restrictions and secondary exposure
keratopathy in an eye with longstanding reduced
vision. Radiologic and neuropathologic evaluation
revealed a large atypical meningioma in the
OD - Ocular Disease
Jessica E. Rodriguez, OD
Aran Eye Associates, Nova
Southeastern University
9985 SW 2nd terrace
Miami, Florida 33174
OSSN consists of a spectrum of neoplastic
squamous epithelial abnormalities including
squamous dysplasia, squamous cell carcinoma in
situ (also known as CIN), and invasive squamous
cell carcinoma. These can affect the conjunctiva,
cornea, and even invade the globe and orbit.
Patients at high risk include those exposed to UVB
radiation, cigarette smoke, HPV, HIV, petroleum
products, and immunosuppressive agents used for
organ transplants. These abnormalities tend to be
28
unilateral, leukoplakic lesions that have a gelatinous
appearance. If left untreated, they can evolve to
invasive squamous cell carcinoma. The preferred
treatment is a complete excisional biopsy followed
by cryotherapy to the surrounding tissue. There are
topical treatments available including mitomycin C,
5- fluorouracil, and interferons. Interferon alfa-2b
is ideal due to its low toxicity and non-threatening
adverse effects.
An 89 year old Hispanic male presents with
complaints of blurry vision in the left eye. It has
been progressive for the past 6 months. The BCVA
in the right eye was 20/30 and the left eye was
CF at 1 ft. Slit lamp examination of the right eye
was unremarkable. The cornea of the left eye had
epithelial keratinization with a raised vascularized
lesion. The patient was diagnosed with a CIN in the
left eye and started on alfa-2b interferon, 1 million
units/ml, 5 times a day, and was to return in 1 month.
After 10 weeks of treatment BCVA was CF at 3 ft.
The cornea had sub-epithelial scarring with complete
resolution. The patient was instructed to continue the
medication and return in 2 months for a follow up.
Several studies have successfully reported that
topical treatment of interferon alfa- 2b has shown
an 80-100% tumor control in the CIN subtype.
Currently, interferon alfa-2b is not FDA approved
for OSSN. Surgical excision remains the primary
treatment strategy. Topical treatment is beneficial for
those patients that are ineligible for surgery, due to
age or medical history. Shah et al reported complete
control with interferon alfa 2-b in 67% of CINs and
83% of OSSN overall.
neuritis is an inflammatory attack of the optic nerve
and a common manifestation of multiple sclerosis.
Visual impairments are a common finding of multiple
sclerosis in patients with and without a history of
optic neuritis. The utilization of spectral domain OCT
technology allows the ability to monitor and correlate
subjective visual symptoms with pathophysiology
at the level of the retina and optic nerve in patients
with no clinical presentation or known history of
optic neuritis.
We present a case of a 64 YOWM with multiple
sclerosis being followed for symptoms of diplopia,
relieved with prism and complaints of progressive
decreased vision OU. The patient was followed for
over a 1 year period with significant fluctuations in
refraction and vision ranging from 20/40 to 20/25 OD
and 20/100 to 20/40 OS at sequential visits. Anterior
segment was only remarkable for mild nuclear
sclerosis that was not contributing to visual reduction
OU. Fundus examination revealed pink and perfused
optic nerves without pallor and no clinical findings of
optic neuritis were revealed on MRI of the head with
gadolinium contrast. Cirrus OCT of retinal nerve
fiber layer revealed mild superior nasal thinning OD
and superior temporal thinning OS while ganglion
cell analysis demonstrated progressive thinning of
the ganglion cell complex as well as the inner nuclear
layer OU from his initial visit 9 months earlier. These
findings suggest a subclinical state of progressive
axonal loss and retinal degeneration/thinning leading
to reduced best corrected visual acuity OU, without
clinical or MRI findings of acute optic neuritis or past
optic neuritis events OU.
In multiple sclerosis spectral domain OCT
technology can be used to detect subclinical
neurodegeneration at the level of the retina in patients
without any prior presentation of optic neuritis.
OCT with retinal ganglion cell complex analysis and
retinal layer segmentation technology is a useful tool
to help detect neurodegeneration of the inner retina
layers without the presence of acute optic nerve
inflammation or retrograde degeneration that could
be contributing to visual and ocular complications.
Poster 49
Ganglion Cell Analysis utilization in
detecting progressive neurodegeneration of
the retina in Multiple Sclerosis
OD - Ocular Disease
Kristine Loo, MS, OD
W.G. (Bill) Hefner VA Medical Center
3507 French Woods Rd.
Charlotte, North Carolina 28269
Additional Author(s):
Jarrett Mazzarella, OD, FAAO
Multiple sclerosis is a systemic
neurodegenerative disease that can lead to many
ocular complications including vision loss. Optic
29
Poster 50
Poster 51
Retinal capillary hemangioma: A review of
key retinal features
Regressed Proptosis: A sphenoid metastatic
lesion targeted with groundbreaking new
treatment, Radium-223
OD - Ocular Disease
OD - Ocular Disease
Sandip K Randhawa, OD, M.Sc.
University of Waterloo
474 Duncan Lane
Milton, Ontario, Alabama
Emily Lubbers, OD
WG Hefner VAMC residency
6207 Grandeur Drive
Salisbury, North Carolina 28146
There is a large variety of retinal tumors
associated with abnormal retinal vasculature. The
use of key diagnostic tools, such as fluorescein
angiography and optical coherence tomography
(OCT), are used in aiding in the final diagnosis and
management.
Forty-eight year old female presented with
complaints of left eye blur. No associated
symptoms of flashes or floaters. Past ocular history
remarkable for non-central corneal scar secondary
to a contact lens related ulcer. Systemic health
overall unremarkable; current medications include
tri-cyclen lo and omega-3 supplements. Reduced
visual acuity in the left eye was noted. Facial
amsler revealed an inferior temporal paracentral
scotoma in the left eye, pupil testing revealed no
relative afferent pupillary defect. Dilated fundus
examination revealed a vascular lesion within the
retina and optic nerve superiorly surrounded by
intraretinal hemorrhages and paramacular exudates
with macular edema. OCT confirmed cystic spaced
in the outer plexiform layer. Differential diagnoses
include vasoproliferative tumors of the retina, Coat’s
disease, Racemose hemangioma (Wyburn-Mason
syndrome), retinal capillary hemangioma (sporadic
versus von Hippel-Lindau associated) and retinal
cavernous hemangioma.
Fluorescein angiography confirmed the presence
of a vascular tumor with a feeder vessel from the
superior retinal arteries with late leakage. Magnetic
resonance imaging of the brain and orbits revealed
no additional lesions. Sporadic juxtapapillary retinal
capillary hemangioma was confirmed. The treatment
for juxtapapillary lesions have been difficult due
to the close proximity to the optic nerve. The
patient underwent photodynamic therapy reducing
the macular edema with slight improvement in
visual acuity.
Additional Author(s): Charles Davis, OD,
MPH, MHA, Benjamin Thayil, OD
Orbital metastases are an infrequent etiology
of adult proptosis. Approximately 3-7% of
orbital biopsies have demonstrated a metastatic
tumor. Clinically evident bone metastases occur in
almost all patients with advanced prostate cancer,
typically involving the lumbar spine, rib and pelvis
. Involvement of skull convexity is frequent, but the
skull base and orbits are less commonly affected.
64 year old Caucasian male first presents to
the eye clinic with painful proptosis, diplopia, and
ptosis of the left eye. Pertinent history includes
Stage 4 prostate cancer with multiple metastases to
bone. Clinical testing revealed limited extra ocular
motilities in supraduction, a red cap desaturation,
and a trace afferent pupillary defect of the left eye.
Palpebral apertures were measured at 14 mm in the
right eye and 8 mm in the left eye. Bilateral optic
disc edema was evident upon fundus examination
and measured by OCT. Same day CT scan of the
orbits revealed a 2.9 cm by 2.8 cm lesion at the left
sphenoid wing with extension anteriorly into the
retro bulbar space. Ocular status was communicated
to the managing oncologist and additional treatment
was implemented with radium - 223 dichloride.
Radium-223 is an alpha-emitting alkaline earth
metal ion which is preferentially absorbed into bone
by virtue of its chemical similarity to calcium. This
treatment was recently FDA approved in May 2013
and specifically designed to target bone metastasis
from prostate cancer. Radium-223 emits 95% alpha
radiation with a short range in tissues of 2-10 cells.
Tissue damage is therefore reduced in surrounding
healthy tissues and a localized effect is produced.
At 1 week follow-up after administration of
treatment, patient displayed dramatic improvement in
presentation. Pain and diplopia were improved, as
30
well as the appearance of proptosis and ptosis.
Due to this patient’s dramatic response to
Radium-223, we will continue to monitor him over
time and other treatment options of radiation or
excision of the orbital lesion have been halted. We
hope that our patient will be a success story to
represent a new novel, less invasive treatment that
can treat orbital metastases, preserve vision, and
improve quality of life.
diagnostic findings, discusses differential diagnoses,
provides rare photodocumentation of the vortex
vein varix with a portable posterior segment camera
in different gazes, a spectralis optical coherence
tomography (OCT) and B-scan ultrasonography
which eliminates the need for more invasive
diagnostic procedures such as Flourescein angiogram.
Poster 52
Septo-Optic Dysplasia
Now you see it. Now you don’t. A rare case
of vortex vein varix.
OD - Ocular Disease
Poster 53
Kara Lynn Tison, OD
Southern College of Optometry
672 Harbor Edge Circle #201
Memphis, Tennessee 38103
OD - Ocular Disease
Babita Gounden, OD
Orlando Veterans Affairs Medical Center
759 Birgham Place
Lake Mary, Florida 32746
Additional Author(s):
Marie Bodack, OD, FAAO, FCOVD
Septo-optic dysplasia is a congenital condition
involving optic nerve hypoplasia, an absent septum
pellucidum and thinning of the corpus callosum.
Endocrine dysfunctions may also be present.
A 6-year-old African American male presented
for an eye exam due to failing a school vision
screening the prior year. Mom also reported that
she noticed that the patient’s right eye turns out
occasionally. The patient had no significant medical
or family history. He also had no history of trauma
and was born full term. Entering distance visual
acuity without correction was OD: 20/500, OS:
20/20. The patient was not responsive to near visual
acuity testing for OD. Near acuity OS was 20/25.
Extra ocular motilities were full without pain or
diplopia reported. Cover test revealed orthophoria at
distance and near. No nystagmus was noted. Pupils
were equal, round and reactive to light with grade 1+
relative afferent pupillary defect OD. No significant
refractive error OU. Anterior segment was
unremarkable with pressures being 14mm Hg OD
and 13mmHg OS with the iCare tonometer. Upon
dilation, the right eye was positive for a double ring
sign. Cup to disc ratio was observed at 0.45H/0.50V
OD. All findings were normal OS, with the cup to
disc ratio being 0.30H/0.35V. An OCT confirmed
the small size of the right optic nerve relative to the
left. The patient was diagnosed with Optic Nerve
Hypoplasia OD and the parents were educated on the
condition. The patient was prescribed polycarbonate
protective glasses. An MRI of the brain was ordered
Additional Author(s): Derek Richardson, OD,
Maria J. Mandese, OD, FAAO
A varix of the vortex vein ampulla is a rare,
interesting, yet benign finding that can cause
diagnostic confusion with other choroidal
malignancies.
A 46 year old white male presents for an eye
exam without complaint. Best visual acuity was
20/20 od, os. Anterior segment was clear and
unremarkable. His posterior segment exam revealed
a large, steeply elevated 3 disc diameter pigmented
lesion with distortion and asymmetry in the inferior
nasal peripheral retina od upon examination with
binocular ophthalmoscopy. Resolution or flattening
of the lesion occurred when the patient was in the
supine position, and in manipulation of gaze or
head position.
Asymptomatic findings of the retina should be
thoroughly investigated for malignancy or other
morbidity/mortality systemic conditions. Despite
being asymptomatic, it was necessary to consider
the differential diagnoses in this case. When large
enough, vortex vein varices can simulate a choroidal
melanoma. Other benign differentials include a
nevus, congenital hypertrophy of the retinal pigment
epithelium and hyperplasia of the retinal pigment
epithelium. When nonpigmented lesions are
apparent, careful consideration is given to posterior
scleritis , choroidal metastases, choroidal osteoma,
and hermangioma. The case report explains the
31
to rule out midline cranial anomalies. The MRI
revealed a hypoplastic optic nerve OD and partial
absence of the septum pellucidum, consistent
with the diagnosis of septo-optic dysplasia. ​The
patient will be monitored for development of
endocrine dysfunctions.
While only 30% of patients have a triad of optic
nerve hypoplasia, absence of septum pellucidum and
pituitary dysfunctions, early diagnosis of this disorder
is important. This case report will help optometrists
with the diagnosis of septo-optic dysplasia, treatment
of the signs and symptoms from this condition, and
the appropriate referrals and testing that is needed for
these patients.
Lamotrigine, and Fluoxetine. The patient was
20/25 OD and OS with a low myopic prescription.
The anterior segment was unremarkable and color
vision was unaffected as evaluated with pseudoisochromatic plates. Funduscopy revealed subtle
perifoveal pigmentary changes correlating to
Photoreceptor Integrity Line (aka ellipsoid/inner
segment-outer segment junction) disruption on OCT
and slight increased fluorescence on both FA and
ultra-widefield FAF. A shallow incomplete perifoveal
ring scotoma was found on central VF with points
tested 0.7 degrees apart. The patient was then referred
to the Vitreous-Retina-Macula Consultants of New
York for AO and to Columbia University for genetic
screening for a mild Stargardt mutation G1961E. AO
studies revealed perifoveal cone disorganization and
the foveal cone mosaic was imaged surprisingly well.
AO is becoming a leading diagnostic modality
in retinal degenerations. Further increases in
resolution are necessary to follow foveal changes
with AO in most patients. Regardless of this limit,
current generation AO systems may emerge as a
useful technology in the assessment of early bull’s
eye maculopathy.
Poster 54
Adaptive Optics Reveals Foveal Cone Mosaic
in Bull’s Eye Maculopathy
OD - Ocular Disease
Daniel Epshtein, OD
SUNY College of Optometry
33 West 42 Street
New York City, New York 10036
Poster 55
Additional Author(s): Ayah Ahamed,
Jerome Sherman, OD
Neovascularization of the Iris as the
Presenting Sign of Complete Unilateral
Intracranial Carotid Artery Occlusion
Bull’s Eye Maculopathy is a common finding in
many retinal degenerations including cone dystrophy,
cone-rod dystrophy, Stargardt disease, benign annular
concentric macular dystrophy, and Plaquenil toxicity.
Bull’s Eye Maculopathy presents as pigmentary
changes perifoveally on funduscopy and is often
confirmed with ancillary testing such as OCT,
visual field, ERG, fundus autofluorescence (FAF),
fluoroscein angiography (FA), and most recently
adaptive optics (AO). Adaptive Optics is an emerging
technology that is quickly improving in its ability to
aid in clinical diagnosis. One major constraint of AO
is its insufficient resolution to image the increased
cone density of the fovea. In our 19 year old patient
with bull’s eye maculopathy, the foveal cones are
much more defined, possibly as a consequence of
decreased foveal cone density as a result of retinal
degeneration. AO imaging of this patient with bull’s
eye maculopathy revealed a subtle finding not seen
with other diagnostic studies.
A 19 year old female presented for evaluation
of reduced BCVA OU. Her history was positive for
ADD and bipolar disorder treated with Vivance,
OD - Ocular Disease
Tina R. Porzukowiak, OD, FAAO
Midwestern University, Arizona College
of Optometry
19379 N. 59th Ave.
Glendale, Arizona 85308
Additional Author(s): Laura Addy, BS,
Matthew Kaminsky, BS, Elizabeth Lyon, BS,
Ryan Anderson, BS
This case illustrates a rare presentation of ocular
ischemic syndrome (OIS) where the primary ocular
finding was neovascularization of the iris and
angle. Complete, unilateral, intracranial carotid
artery occlusion was diagnosed via brain magnetic
resonance angiography (MRA).
An asymptomatic 82-year-old Caucasian female
presented for a routine eye examination. Medical
history included Type II diabetes mellitus, congestive
heart failure, essential hypertension, peripheral
32
vascular disease, and myocardial infarction. Bestcorrected visual acuity was 20/30 OD, OS. Entrance
testing was unremarkable. Slit lamp examination
revealed neovascularization of the iris and angle
OD; negative OS. The cornea showed 2+ guttata
with trace endothelial edema OD, OS consistent with
Fuch’s Corneal Dystrophy. The intraocular pressures
were normal OD, OS. Dilated fundoscopy revealed
moderate optic nerve head cupping OD, OS. Rare
scattered microaneurysms were noted throughout
the posterior pole OD, OS; there was no evidence of
retinal neovascularization. Humphrey visual field
demonstrated glaucomatous loss OD, OS. Bilateral
carotid duplex revealed 50% stenosis of the internal
carotid arteries. CBC w/ diff, ESR, and CRP was
normal. Brain MRA revealed 100% occlusion of
the right intracranial portion of the internal carotid
artery (ICA). Neovascular glaucoma secondary
to OIS OD and normal tension glaucoma OS was
treated with topical anti-glaucoma medication.
Retina consultation did not advise panretinal
photocoagulation (PRP). The primary care physician
added oral anti-platelet therapy.
This case was managed conservatively. PRP
was not pursued in the absence of retinal ischemia
as intraocular pressure has been documented to rise
post-treatment leading to further compromise of
optic nerve perfusion. This case further supports
the theory that uveal ischemia alone in the absence
of retinal ischemia may be a significant contributor
for the neovascularization noted in ocular ischemic
syndrome. Clinicians must maintain a high index
of suspicion for intracranial ICA stenosis in the
presence of anterior segment neovascularization of
unknown etiology and essentially normal Carotid
Duplex ultrasonography.
Unlike lung cancer, more than 90% of patients
with uveal metastasis from breast cancer have a
history of treatment prior to ocular involvement
or known multi-organ metastasis. When breast
cancer metastasizes to the eye, the risk of it
spreading to the brain or central nervous system
increases significantly.
This poster will review a case of a 53 year old
Caucasian female whose recent visual complaints and
medical history lend to a diagnosis of an intraocular
choroidal metastasis after being diagnosed, treated
and in remission for breast cancer for nearly
fifteen years.
Breast cancer metastasis can take place 10
years or even longer after the original treatment.
According to the American Academy of
Ophthalmology, metastases to the eye are being
diagnosed with increasing frequency for various
reasons:
• Increasing incidence of certain tumor types
that metastasize to the eye
• Prolonged survival of patients with certain
cancer types
• Increasing awareness among medical
oncologists and ophthalmologists
[and optometrists] of the pattern of
metastatic disease
Not every patient will present at the earliest
onset of their symptoms or be forthcoming with
all of their medical history. A thorough history, in
addition to further imaging helps assist in confirming
a diagnosis of a choroidal metastasis. Early detection
and referrals help in saving ones eye physically and
functionally, as well as discovering additional sites
of metastasis that can be treated early in hopes to
prolonged survival.
Poster 56
Poster 57
Breast Cancer “Eye”wareness
Idiopathic Central Serous Chorioretinopathy
in an Operation Enduring Freedom Veteran
OD - Ocular Disease
OD - Ocular Disease
Essence N. Robinson, OD, FAAO
Texas State Optical, Beaumont, TX
6105 N Major Drive #317
Beaumont, Texas 77713
Christopher L. Suhr, OD, MPH
Department of Veterans Affairs
11031 US HWY 19, Ste. 102
Port Richey, Florida 34668
Breast cancer is the second deadliest cancer
among American women, the first is lung cancer.
Twenty to forty percent of all breast cancers will
metastasize at some point, and when they do
they are staged as an invasive (stage IV) cancer.
Additional Author(s): Mark Phebus, OD
Idiopathic central serous chorioretinopathy
(ICSC) is a condition of which there is a serous
33
detachment of the neurosensory retina at the macula.
It occurs over an area of edema and leakage from
hyperpermeability of the choriocapillaris through
dysfunctional retinal pigment epithelium (RPE). The
localized serous detachment occurs in the absence of
subretinal blood or lipid exudates. The detachment
is typically round, or oval, with a blister-like
appearance and sloping margins that gradually merge
into intact retina. ICSC is not fully understood, and
there are current hypotheses that include disruption
of ion transport across the RPE, focal choroidal
vasculopathy, or a combination of the two for the
pathophysiology of this disease.
A 38 year-old white male veteran presented to
our clinic because of distorted vision in his left eye.
The patient described his vision through his left eye
by stating it is “like looking through a peephole in
a door.
Although traditional dilated fundus examination
will provide the clinician with the ability to
diagnose ICSC, the advent of OCT allows for more
precise analysis of the compromised macula. OCT
should be considered when the diagnosis is in
question, for monitoring as resolution occurs, and
patient education.
their underlying cause for the ophthalmic findings
were different and thus required a different treatment
plan. The male patient was diagnosed with multiple
sclerosis; the female patient was diagnosed with
idiopathic optic neuritis.
These two cases illustrate a multidisciplinary
approach to clinical management of optic neuritis.
Poster 59
Rapid Visual Field Improvement of
Macroprolactinoma after Treatment with
Cabergoline
OD - Ocular Disease
Mayur Bhavsar, OD
VA NJ Healthcare System
325 Page Ave
Lyndhurst, New Jersey 7071
Prolactinomas are non-cancerous pituitary
tumors which result in an excess release of prolactin
hormone. I present a case of macroprolactinoma
detected with hemianopic VF defects. CT, MRI and
lab testing confirmed the diagnosis of prolactinoma
and treatment with cabergoline was initiated. 5 weeks
after treatment was initiated absolute VF defects,
APD and color vision deficits began to improve.
Furthermore, prolactin levels normalized and tumor
shrinkage was noted.
A 54 yo BM presented with complaints of
blurred vision. His systemic history included
pericarditis, asthma, and HTN for which he was
taking medications. There was a grade 2 left APD but
full motilities. Confrontation VF showed a temporal
deficit OD and constriction in all quadrants OS.
Color vision testing showed OD 7/7 and OS 0/7.
Red cap was desaturated by 80% OS. His BCVA
was OD 20/20 and OS 20/70. Slit-lamp findings
were unremarkable. His IOP’s were 21 OU. Dilation
revealed a healthy 0.35 optic nerve OD and a 0.4
optic nerve with disc pallor 360 OS. Visual field
testing exposed a temporal hemianopsia OD and
complete defect with mild temporal sparing OS.
An immediate CT revealed a 4.3 cm bilobed sellar/
suprasellar mass lesion with local mass effect.
Pituitary specific lab tests and MRI were ordered.
Prolactin levels were elevated to 4700 µg/L and
MRI confirmed a large mass originating from the
pituitary with outward extension to involve the
cavernous sinuses, posterior ethmoids, sphenoid air
Poster 58
Optic Neuritis: Getting to the Root of the
Problem
OD - Ocular Disease
Adrienne B. Ari, OD, MPH
US Army
37 Hunt St
Fort Bragg, North Carolina 28307
Optic neuritis is an inflammation of the
optic nerve caused by demylination, infection,
inflammation and autoimmune diseases. Commonly,
these patients present with reduced visual acuity,
an afferent pupillary defect (APD), pain with eye
movement and abnormal color vision. Patients
may present similarly but have very different
clinical outcomes.
This case report will discuss two young healthy
patients (Caucasian male, 28 years old and Caucasian
female, 25 years old) that presented to our clinic
with papillitis, reduced visual acuity, mild APD, pain
on eye movement, and inferior altitudinal visual
field defects. Although they presented similarly,
34
cells and clivus. The endocrinologist started him on
0.5 mg cabergoline 3 times/week. 5 weeks later, VA,
VF, and optic nerve improvement were noted. Also,
prolactin levels decreased to 3 µg/L. 1 month later;
VF findings showed further improvement and repeat
MRI imaging indicated shrinkage of tumor by 50%.
Studies have shown that prolactin levels decrease
by 96% within 3-6 months, VF improve, and
tumors shrink. Our patient reports quick resolution
of prolactin levels and VF improvement. This may
be due to a high level of D2 dopamine receptor
expression on the tumor. Literature reveals that quick
resolution may lead to CSF rhinorrhea, chiasmal
herniation, or pituitary apoplexy. MRI records of our
patient reveal no such complications.
recommended. Annual follow-ups with a dilated
fundus exam and OCT is preferred. It is important
for clinicians to educate the patient on the possible
genetic component of the disease. As clinicians, we
should also remember the functional implications this
disease can have on a patient’s daily activities, and to
refer for low vision rehabilitation when needed.
Poster 60
Clinical Diagnosis and Management of Adult
Type Vitelliform Dystrophy
OD - Ocular Disease
Salma Kiani, OD
Omni Eye Specialists-Affiliated with
Salus University
5 Skipworth Court
Catonsville, Maryland 21228
Additional Author(s): Stephanie
Schmiedecke Barbieri, OD, F.A.A.O
Adult type vitelliform dystrophy is a rare,
autosomal dominant disease that leads to bilateral,
foveal lesions in the retinal pigment epithelium
layer of the retina. This condition is grouped with
other macular dystophies called pattern dystrophies.
This dystrophy affects adults between the ages of
30-50 years. Patients with this condition present
to clinic with mild to moderate decrease in vision
(20/30-20/100). It can be associated with a choroidal
neovascular net resulting in severe visual impairment.
Researchers have found two genes associated with
this disease that can have mutations. Consequently,
genetic counseling as well as low vision
rehabilitation is an essential part of the management
of this patient as a whole.
A 75 year old Caucasian female presented to the
clinic with blurry vision that she had, for a long time.
The diagnosis was made primarily on clinical
results such as OCT, corrected acuities, and fundus
findings. Even though the prognosis of this condition
is favorable, careful monitoring of the patient is
35
Poster 61
Poster 62
Spontaneous Hyphema
Urgent Care Facility Misdiagnoses HSV
Disiform Keratitis
OD - Ocular Disease
OD - Ocular Disease
Salma Kiani, OD
Omni Eye Specialists-Affiliated with
Salus University
5 Skipworth Court
Catonsville, Maryland 21228
Utham Prathap Balachandran, OD
Pennsylvania College of Optometry
2033 Christian Street Apt. 2
Philadelphia, Pennsylvania 19146
Additional Author(s): Edward Wasloski, OD
Additional Author(s): Helene Kaiser, OD,
FAAO, Connie Chronister, OD, FAAO
Any disruption of the vascular uveal structures
can cause bleeding into the anterior chamber called
a hyphema. Hyphemas are most commonly caused
by blunt or penetrating trauma to the head or directly
to the orbit itself. Non-traumatic hyphemas of varied
etiology are referred to as spontaneous hyphemas.
Some causes of spontaneous hyphemas include
surgery, neovascularization of the iris, malignancies,
vascular abnormalities, blood dyscrasias and
medications. Approximately a third of all hyphema
patients can experience an increase in intraocular
pressure. It is usually a self-limiting condition
causing little to none permanent vision loss. If the
hyphema is greater than 50% or total hyphema is
seen with the IOP remaining elevated, then treatment
is preferred. Patients need to be followed up until the
IOP is lowered and the hyphema is cleared.
A fifty eight year old Caucasian male was
referred by another eye group due to high intraocular
pressure with an active uveitis in the left eye. The
visual acuity was 20/20 OD and 20/25 OS with
pressures of 18 and 35 mmHg OD, OS. Anterior
segment examination revealed a small fibrin coated
with blood in the anterior chamber with no associated
cell and flare. This was a key finding that prompted
performing gonioscopy. A hemorrhage in the inferior
quadrant of the anterior chamber was seen.
In most cases, spontaneous hyphemas are a selflimiting condition causing little to no permanent
vision loss if followed and treated appropriately.
This can include, IOP lowering methods and
constant monitoring until the hyphema is cleared.
A general blood work up should be ordered as well.
Our case represents how we managed and treated a
patient with spontaneous hyphema associated with
an increase in intraocular pressure, with no history
of trauma.
Herpes simplex virus (HSV) disciform keratitis
is an example of endotheliitis, caused by an immune
response to HSV antigens on the endothelial cells.
We present a case of unilateral blurred vision
preceded by pain and photophobia that was originally
treated with an antibiotic at an urgent care facility.
The vision worsened until presentation to our clinic
where the correct diagnosis of HSV disciform
keratitis was made. The patient was followed over
nine weeks with photos and OCT. This is a unique
presentation of disciform keratitis with no prior
history of herpetic incidence. The case illustrates
the importance of accurate diagnosis and appropriate
management of herpetic disease at the initial onset.
The inception of the Affordable Care Act could be
expected to increase such cases as more patients
may seek treatment at timely urgent care facilities
rather than emergency rooms that often have
ophthalmic instruments and personnel, but require
long wait times. A subsequent rise in the incidence
of misdiagnosed non-bacterial ocular pathology may
occur in the near future.
A 46 year-old female complains of progressively
“cloudy” vision in the left eye. She reports that
three weeks ago she felt pain and photophobia in the
same eye as well blisters along the left side of her
nose. The best-corrected acuity measured 20/50OS. Gross examination revealed faint scabs where
the patient had reported blisters. Biomicroscopic
examination revealed a central area of stromal and
microcystic corneal edema with folds in Descemet’s
membrane. Marked corneal thickening was measured
at 859 microns. Clinical presentation suggested
disciform herpetic keratitis. The patient was treated
with Pred Forte, Trifluridine, and Valtrex. Ultimately,
acuity returned to 20/20, corneal thickness measured
533 microns, and only a faint stromal scar remained.
Following resolution, a maintenance dose of
36
Acyclovir was initiated.
A rare condition, untreated HSV disciform
keratitis can result in permanent endothelial injury
and decompensation. Endotheliitis can result from
other viral infections, thus making it a diagnostic
dilemma. Appropriate diagnosis is important in
establishing the correct therapeutic regiment. The
goal of treatment is to reduce corneal inflammation
while suppressing any lingering viral infection or risk
of reactivation.
revealing a large area of irregularity in the superior
cornea which altered the topographical structure of
the cornea, inducing corneal astigmatism and visual
distortion. The patient was managed by Prednisolone
Acetate 1% drops every 2 hours for 2 days and then
4 times daily for two weeks . At two weeks followup, the patient’s vision had returned to baseline with
inflammation resolved.
Corneal involvement, especially with vision
loss involving inflammation of the superior limbus,
is not found widely in literature. This atypical case
presentation was clearly triggered by an inflammatory
reaction as it was responsive to steroid treatment.
Although it is possible that a concurrent viral and
episcleritis event occurred, it is still unclear as to
why such a vigorous inflammation involved only the
superior limbus. Oculus pentacam tomography and
anterior segment images will be presented along with
further discussion and differentials.
Poster 63
A unique case of acute unilateral vision loss
from Keratoconjunctivitis isolated to the
superior limbus
OD - Ocular Disease
Emily Lubbers, OD
WG Hefner VAMC resident
6207 Grandeur Drive
Salisbury, South Carolina 28146
Poster 63.2
Optic Nerve Head Elevation Secondary to
Vitreopapillary Traction
Additional Author(s): Joan Sears, OD, FAAO
OD - Ocular Disease
The superior limbus is prone to a number of
conditions due to a mild hypoxia and increased
mechanical sensitivity due to lid and tarsal plate
apposition. Disorders involving the superior
limbus include a wide range of conditions from
keratoconjunctivitis to episcleritis and from GPC to
SLK. However, most of these conditions are either
not isolated to the superior limbus or if so, tend to be
bilateral in nature.
A 64 year old caucasian male presents with
complaint of blurred vision, monocular diplopia
and throbbing pain in the left eye for 1 week. His
symptoms started after he suffered a flu-like virus 1
week prior. Acuity in the left eye upon examination
was 20/50 with ghosting of images. Slit lamp
examination revealed severe inflammation isolated to
the superior bulbar conjunctiva with engorged vessels
and limbal hypertrophy. A large area of coalesced
infiltration with elevated epithelial overlying defect
was observed on the superior cornea. Corneal
edema extended from the superior half of the cornea
towards fixation. Palpebral response showed
minimal follicular response inferiorly and upper
palpebral conjunctiva was clear with lid eversion. A
macular scan was ordered to rule out other pathology
contributing to decreased vision; but none was
noted. Pentacam tomography images were obtained
Andria M Pihos, OD
Illinois College of Optometry
3241 South Michigan Ave.
Chicago, Illinois 60616
Additional Author(s): Bruce Teitelbaum, OD
Complete posterior vitreous detachments are a
common and well documented finding in elderly
patients. Incomplete vitreous detachments are less
frequently described and occur when there is a partial
separation of the vitreous cortex from its attachment
to the optic nerve head. Vitreopapillary traction is
recognized when the posterior hyaloid retains an
incomplete adhesion to the optic nerve head resulting
in traction and the appearance of optic nerve head
elevation. Vitreopapillary traction is not widely
reported in elderly patients in the absence of diabetic
retinopathy or other retinal vascular disease.
A 76-year-old female presented to the primary
eye care clinic with a complaint of gradual onset
of blurry vision over the past month. The patient’s
medical history was significant for diabetes and
hypertension and her ocular history was negative.
Her best corrected acuity at this time was 20/20 OD
and 20/30 OS. Her pupils were round and equally
37
reactive with no relative afferent pupillary defect.
Extraocular motilities were normal. The patient’s
anterior segment was normal with the exception of
mild cataracts in both eyes. Intraocular pressures
were 22 mmHg OD, OS. Dilated fundus exam
revealed mild nasal disc elevation OS greater than
OD. The maculae were flat and the retinal vessels
and background were normal without any retinal
hemorrhages or exudates in both eyes. Visual field
testing revealed a very mildly enlarged blind spot
OS. Optical coherence tomography of both eyes
demonstrated nasal vitreopapillary traction and
mild el evation to the nasal aspect of the optic
nerve heads.
Primary eye care providers should be aware
of this condition in the differential diagnosis of
optic disc elevation. This case also demonstrates
the appropriate use of OCT technology to avoid
expensive and unnecessary medical testing.
of the right eye, with no significant findings OS.
The patient indicated no history of trauma, known
systemic disease, or awareness of right eye visual
deficit. The retinal changes were photo documented
and though present, were not in proportion to the
extent and severity of the visual field defect. An
MRI of the brain and orbits was ordered to rule out
a pre-chiasmal lesion. The MRI was unremarkable
and the patient was referred for a retinal consult.
The visual fields were repeated with similar results,
with the specialist noting mild retinal variations in
the left eye and atypical sector retinitis pigmentosa
OD much greater than OS was diagnosed with
vitamin A therapy initiated. Six month follow up
revealed unchanged visual fields and mild pigment
clumping OD.
This case highlights the variable nature of
retinitis pigmentosa and the challenges in diagnosing
the condition when it presents without its most
classic signs and confounding visual fields. The
earliest signs of RP are retinal granularities, and
pigment can be lacking for variable lengths of time.
Genetic counseling is one of the most important
aspects of this diagnosis, however, this patient had no
previous family history (simplex RP), which occurs
50% of the time in RP cases.
Poster 64
Atypical Sectoral Retinitis Pigmentosa:
A Case Report
PC - Primary Care
Lindsay Elkins, OD
Southern College of Optometry
1225 Madison Ave
Memphis, Tennessee 38104
Poster 65
Bilateral Abduction Deficit Secondary to
Influenza
Retinitis pigmentosa (RP) is a heritable retinal
degeneration classically presenting with bilateral
RPE rearrangement mimicking “bone spicules,” night
blindness, progressive “ring scotoma” visual field
defects, and abnormal electroretinography. There are
many variations in presentation, including sectoral
RP; typically bilateral, symmetric, with a hallmark of
pigment deposition in the inferior quadrants.
A 32 year old female complained of eye strain,
both eyes, worse at night, especially driving, over
the last three months. Distance acuities, uncorrected
were 20/20 OD, 20/15 OS. Confrontation visual
fields were completely constricted temporally OD,
and normal OS. Other entrance testing was within
normal limits. Posterior segment evaluation was
normal OS, though OD revealed abnormal retinal
stippling nasally and along the superior temporal
arcade, with no pigment deposition. Humphrey’s
24-2 testing was reliable, demonstrating absolute
visual field defects respecting the vertical midline
and encompassing the entire temporal hemi-field
PC - Primary Care
Chelsea M. Dunn, B.S. Chemistry
Pennsylvania College of Optometry at
Salus University
1200 West Godfrey Ave.
Philadelphia, Pennsylvania 19141
Additional Author(s): Kelly A. Malloy, OD,
Erin M. Draper, OD, Maegan E. Folk, Student
An abduction deficit can be caused by many
etiologies, and may localize to either extra-ocular
muscles, neuro-muscular junction, the entire
course of CN VI, or the pons. The localization of a
bilateral abduction deficit may be similar. However,
a bilateral presentation is more concerning for
increased intracranial pressure or a clivus lesion,
especially when no other signs localizing to the
orbit or brainstem are present. When work-up,
including neuro-imaging and laboratory testing
38
Poster 66
are unremarkable, a vasculopathic process is often
considered. However, if the diplopia is preceded
or accompanied by cold/flu symptoms or a recent
flu vaccination, a viral etiology always needs to
be considered.
A 60-year-old man complains of constant
horizontal diplopia starting 2 weeks ago. Three
weeks ago, the patient reports suffering from
cold symptoms, including temporal headache,
hypersensitivity to taste, decreased appetite, and
pulsing sensation throughout his body. His PCP
treated him with antibiotics and over-the-counter
pain relievers. He has had elevated blood pressure
over the past few months without a diagnosis of
hypertension and has smoked for 40 years. Clinical
examination is remarkable for a bilateral abduction
deficit with an abducting capacity of 40-50% OD
and 60% OS. A 30 diopter eso deviation is present
in primary gaze. Blood pressure is 140/95 mmHg.
MRI of brain and orbits is unremarkable. Laboratory
testing shows slightly elevated erythrocyte
sedimentation rate (ESR) and c-reactive protein
(CRP). At follow-up 10 days later, the patient reports
resolution of cold symptoms. Cover testing shows
an improvement in the eso deviation to 20 diopters.
Repeat ESR and CRP are normal.
A thorough history including investigation into
recent cold/flu symptoms is pertinent in all cranial
nerve palsies. Mildly elevated inflammatory
indicators such as ESR and CRP will also help
differentiate an active virus from vasculopathic
processes. These indicators can also be elevated in
GCA, but they will not return to normal levels as
they did in this case. Although other more urgent
etiologies need to be ruled out, viral etiologies can
be differentiated by improvement in the nerve palsy
concurrent with resolution of cold symptoms.
Eliminating the need for binocular balancing
with point spread function technology
PC - Primary Care
David I Geffen, OD
Gordon Weiss Schanzlin Vision
8695 Robinhood Laneq
La Jolla, California 92037
Additional Author(s): Mille Brujic, OD,
FAAO, OD
Binocular balancing is the step in subjective
refractions that involves matching the
accommodative stimulus for the two eyes. It also
relaxes the accommodation as a result of both eyes
being open and enables the matching of the visual
acuity between two eyes. Binocular balancing is
required because there is a risk of overminusing a
patient during a subjective refraction when using
a phoropter and Snellen letters. However, this
procedure can be confusing or even disturbing to
patients, and may not be possible in patients with
differing visual acuities in the two eyes. Moreover,
binocular balancing can be technically challenging
for optometric staff and technicians, making the
delegation of a subjective refraction difficult. A
device that utilizes point spread function (PSF) for
the subjective refraction (PSF Refractor, VMax
Vision, Maitland, FL) instead of Snellen letters
provides the opportunity to obtain an accurate
refraction without the need for binocular balancing.
Our center participated in a clinical study comparing
the performance of this technology with that of a
traditional phoropter.
The assessments were conducted in the right
eyes of 30 patients who presented for a routine
visual examination. Each patient underwent a
subjective refraction first with a standard phoropter
with binocular refraction using +1.0 D fogging in
the fellow eye, and binocular balancing at the end.
In the same patient and the same eye, monocular
refraction was performed with a PSF Refractor and
without binocular balancing. The manifest refraction
and visual acuity (VA) were recorded. Results The
mean age of the patients was 37.3 years (range 10−68
years). In 70% of patients, the spherical equivalent
(SE) with the PSF Refractor was within 0.13 D of
that with a binocularly balanced phoropter. In 27%
and 3% of patients, respectively, the SE differed by
39
more than 0.13 D and 0.255 D. PSF refraction results
were equal to or better than those obtained with the
phoropter binocular method in 93.5% of patients.
The point spread function based refractor
provides accurate manifest refraction and visual
acuity readings without the need for binocular
balancing, which makes subjective refraction a
simpler and faster process.
used to follow the patient. With observation alone,
vision in the left eye improved to 20/60, and the
patient reported a near full functional recovery with
a new appreciation for the sight he feared he would
not regain.
Patient education and counseling is an important
part of an optometrist’s role in patient care. It is
crucial for clinicians and patients alike to understand
any underlying pathology before expectations and
visual prognosis are discussed. In this case, a patient
was surprised to recover some vision after being
prematurely told it was a lost cause.
Poster 67
Traumatic Optic Atrophy
PC - Primary Care
Poster 68
Janet Garza, OD
University of Houston
10711 Staghill Dr.
Houston, Texas 77064
Additional Author(s): Pat Segu, OD
The Problem of Pain: A Delayed Diagnosis of
Ankylosing Spondylitis
PC - Primary Care
Amy Moy, OD
New England Eye, New England College
of Optometry
75 Bickford St.
Jamaica Plain, Massachusetts 2130
Ocular trauma is an unfortunate, yet relatively
common ocular condition seen in optometric
practice. Approximately three million cases of
ocular injuries are seen in the United States per year.
Incidence of traumatic optic atrophy ranges from 0.5
to 5% of all ocular trauma related cases, and 60%
of traumatic optic atrophy cases present with severe
vision loss. Although there are different mechanisms
which can result in optic atrophy, it is imperative to
conduct a thorough eye examination as well as obtain
proper diagnostic testing and imaging to properly
understand viable treatment options and visual
prognosis for the patient.
A 41 year old Hispanic male experienced a
blow to the face involving the left eye during a
robbery altercation. Immediately after the offending
injury, the patient reported to the emergency room
because he had seemingly lost all vision to the
eye in question. No imaging was performed at the
emergency room, yet the patient was told that he
had no hope of regaining any degree of vision.
The patient reported to clinic one month post
trauma and emergency room visit for his first ever
comprehensive eye examination. The chief complaint
was that of reduced, however improving, vision in
the left eye following the injury. Initial examination
findings for the left eye included a best corrected
acuity of 20/200, +APD, generalized depression on
visual field, defects on Amsler and red cap saturation
test, and temporal ONH pallor with associated
RNFL thinning. Over the course of two and a half
months, objective and subjective measures were
Additional Author(s): Andrea Liu
Ankylosing spondylitis (AS) is diagnosed due
to age, history of back pain due to inflammation
of the sacroiliac joint, physical exam, x-rays, and
positive response to non-steroidal inflammatory
drugs (NSAIDS). A positive HLA-B27 result can
indicate AS, but does not always mean that a patient
has AS. Acute anterior uveitis occurs in a significant
percentage of patients with AS over the course of
their condition.
A 44-year-old Columbian female presented to
our clinic with her second occurrence of bilateral
granulomatous uveitis. Upon initial questioning, she
did not have significant pain in her body. However,
it was later found in previous primary care notes
that she had chronic right-sided body pain and knee
pain, and had been trying palliative treatment and
physical therapy for years. It was later revealed that
after her first episode of bilateral anterior uveitis,
she tested positive for HLA-B27 and Rheumatoid
Factor. X-ray testing showed mild osteoarthritis of
the knee. The consulting rheumatologist reported
no evidence of a spondyloarthropathy or connective
tissue disorder, and the plan was to monitor. Three
years went by in which the patient had chronic
pain in her buttocks and knees, but no further
40
rheumatological assessment was ordered by her PCP.
Due to the recurrent nature of the uveitis and history
of chronic pain, the optometrist contacted the PCP
and ordered an inflammatory workup. The HLA-B27
and Rheumatoid factor results were again positive,
with no other significant lab findings. After referral
to Rheumatology and further testing, the patient was
finally diagnosed with AS, mostly due to her history
and symptomatology. She now has a diagnosis
for her chronic pain, and takes oral Etodolac with
marked improvement.
An optometrist can have significant impact on
finding a diagnosis for a patient in chronic pain. Even
if the uveitis was not present, it may be prudent for
the optometrist to probe more deeply into a patient’s
pain history if there is prior history of bilateral
granulomatous uveitis. In coordinating care between
Primary Care, Rheumatology, and Optometry, the
optometrist was able to make the interdisciplinary
connections that were needed to improve the patient’s
health and well-being.
conducted at one, four, and eight days. By the fourth
day the epithelium had healed but the iritis remained.
Erythromycin ointment was discontinued and Pred
Forte was added four times a day in the right eye.
At the one week follow up the iritis had resolved
completely and distance VA was correctable to
20/25+2 OD, OS.
Corneal abrasions heal quickly, often with 24 to
72 hours depending on the initial size of the defect.
Possible secondary complications include bacterial
infections and traumatic iritis. Antibiotic ointments
can be very beneficial both to ensure antibacterial
coverage in a population that often resists drops and
as a barrier between the abrasion and eyelid, helping
to decrease pain. Cycloplegic agents are unnecessary
for pain management unless an anterior chamber
reaction is occurring. Pressure patching is no longer
recommended for healing or pain reduction. Oral
OTC analgesics can be used to manage pain during
the healing process. There is a lack of evidence
comparing pain reduction in topical NSAIDs with
oral analgesics. Topical NSAID use in children has
not been studied and should be avoided. Potential
devastating complications in adults include corneal
melting. Corneal scaring is rarely seen in children
with corneal abrasions.
Poster 69
Treatment of a Corneal Abrasion in a
Pediatric Patient
PC - Primary Care
Poster 70
Casandra Solis, OD
Children’s Mercy Hospital
8979 Renner Blvd #1604
Lenexa, Kansas 66219
Diagnosis of a hemi-retinal vein occlusion
with only half the case history.
PC - Primary Care
Corneal abrasions are one of the most common
forms of ocular trauma found in the pediatric
population. Current treatment for corneal abrasions
in children is based off of accepted treatment for
adults. Limited research and publications exist
regarding this specialized population and confusion
on proper treatment still exists, both for the
optometrist and primary care provider.
A 7-year-old male presents with pain, reduced
vision and photophobia. Patient reported something
got in his eye at school, but was unsure of the
substance. Distance VA measures 20/100 OD, 20/20
OS. Anterior segment exam revealed a large corneal
abrasion, diffuse moderate injection and 2+ cells in
the anterior chamber OD. He was instructed to use
erythromycin ointment three to four times a day in
the right eye. In addition, cyclopentalate 1% twice a
day was added in the right eye to help with comfort
due to secondary traumatic iritis. Follow-ups were
Stacey Chong, BSc, MSc, OD
School of Optometry and Vision Science
200 University Ave West
Waterloo, Ontario, Alabama 99999
Additional Author(s): Tammy Labreche, OD,
Patricia Hrynchak, OD, FAAO, MScCH(HPTE),
Michelle Steenbakkers, BSc (Hons), OD, FAAO
A 90 year-old Caucasian female presented for
a full oculovisual assessment at the long term care
facility where she resided. The patient reported an
episode one-month prior where the vision in her
left eye was quite reduced but had since returned
to normal. The patient’s systemic history was
positive for gastroesophageal reflux disease, transient
ischemic attacks, Alzheimer’s disease, iron-deficient
anemia, systemic hypertension and vertigo. The
patient’s ocular history included glaucoma that
41
was being treated with Xalacom® (latanoprost
0.005% and timolol 0.5%). Best-corrected visual
acuities were 20/20-3 in the right eye and 20/253 in the left eye. Intraocular pressures were
11mmHg and 10mmHg in the right and left eyes,
respectively. A dilated fundus exam of the right
eye was unremarkable; left eye revealed an inferior
hemi-retinal vein occlusion. Macular edema was
minimal in the left eye. Glaucomatous damage was
not detected in either eye. A family member later
provided her new ocular history, which included
“leaking blood vessels in the back of her left eye”
which was diagnosed during a routine glaucoma
follow-up visit with her ophthalmologist. She had
received one of a series of three monthly injections.
This new information was not in the patient’s
medical record.
This case outlines the challenges in patient
care when there is cognitive impairment and a
caregiver or family member is not present. In this
case, the patient’s son was often present but was not
at this exam. As a result, the majority of the case
history was determined after the eye exam. Lack of
communication resulted in duplication of services
and increased cost to the health care system. The
lack of co-ordination has also resulted in multiple
visits for the patient that can be strenuous on the
patient as well as the family.
Effective communication between healthcare
practitioners is essential in providing care for all
patients, especially those who are affected by
cognitive impairment.
which cleared with +2.50 OTC readers. Ocular
history included laser peripheral iridotomies (LPI)
4-weeks prior. A short course of topical steroids
post-LPI was complete and he was currently using
an unknown drop for irritation. Visual acuity
improved from 20/25-2 to 20/15 in each eye with
+1.25DS in the right eye and +1.50 - 0.25 x 100 in
the left eye. Intraocular pressures were 18mmHg
in each eye, slit lamp biomicroscopy was negative
for inflammation and blood. The LPIs were patent.
Fundus examination revealed flat maculae and
cup-to-disc ratios of 0.25 and 0.30 in the right and
left eye, respectively. The patient was referred to
his ophthalmologist and seen 4-weeks later when
the unaided vision had returned to baseline. There
was no evidence of macular edema, as confirmed
with optical coherence tomography. At a followup 3 months later the patient’s unaided vision was
stable at 20/15 in each eye. Updating the medical
history revealed recent diagnosis of Type 2 diabetes
managed with Janumet (sitagliptin metformin).
This case presents a patient with a hyperopic shift
in refraction, likely secondary to a decrease in bloodglucose levels after initiating Janumet. Post-LPI
complications include post-operative increase in IOP,
anterior uveitis, release of pigment, bleeding, focal
cataract, corneal decompensation, blurred vision
and glare. It was hypothesized that ciliary body
displacement or macular swelling may have caused
the hyperopic shift; however, ciliary body effusion
has been documented to cause a myopic shift and in
this patient, there was no evidence of macular edema.
A review of medical history was vital to
determining potential causes for the hyperopic
shift. Post-LPI complications causing hyperopic
refractive shifts are not documented in the literature
and the refractive error change warranted further
investigated in this case. The patient was not
initially forth coming with the diagnosis of Type 2
diabetes but when asked about any changes in health
or medications, the patient provided an updated
medical history.
Poster 71
Post Laser Peripheral Iridotomy
Complications: A Case of Differential
Diagnosis
PC - Primary Care
Stacey Chong, BSc, MSc, OD
University of Waterloo School of Optometry
and Vision Science
200 University Ave West
Waterloo, Ontario, Alabama 99999
Additional Author(s): Patricia Hrynchak,
OD, FAAO, MScCH(HPTE), Michelle
Steenbakkers, BSc (Hons), OD, FAAO
A 56-year-old white male presented with
complaints of a 24-hour history of decreased vision
42
Poster 72
patient with forme fruste keratoconus who developed
significant astigmatism following diamond burr
polishing for RCE. The safety profile of these
procedures for RCE in patients with keratoconus has
not been established thus making it imperative that
thorough screening for concomitant corneal disease
be performed before referral for surgery.
Traumatic Recurrent Corneal Erosion in a
Keratoconic Eye
PC - Primary Care
Hitomi Ezumi, OD
Pennsylvania College of Optometry at
Salus University
1050 N Hancock St #715
Philadelphia, Pennsylvania 19123
Poster 73
Fighting the Silent Killer: One Role of
Primary Care Optometry in Managing the
Patient with Hypertension
Recurrent corneal erosions (RCE) are
characterized by sudden pain during sleep or upon
awakening often accompanied by a history of
trauma. This condition is commonly managed with
lubrication, bandage contact lenses (BCL), and
hypertonic solutions and ointments. In cases where
these treatments fail, surgical intervention such
as anterior stromal puncture (ASP), diamond burr
debridement, or phototherapeutic keratectomy (PTK)
may be necessary.
A 24 year old Hispanic male presented to the
emergency service with a complaint of severe pain,
redness, photophobia, and tearing in the right eye
upon awakening the previous day. He reported a
history of an altercation three months prior for which
he was evaluated in the emergency room but was not
treated. Since then he had experienced five episodes
of pain upon awakening but none severe enough to
seek treatment. Upon examination the patient was
found to have reduced vision, mild lid edema, a large
corneal epithelial defect, corneal edema, conjunctival
injection, and an anterior chamber reaction. Initial
treatment involved cycloplegia, BCL, and a topical
antibiotic. He was subsequently treated with a
topical corticosteroid and hypertonic solution and
ointment. Prior exam records indicated that the
patient had keratoconus which became more apparent
as the corneal edema resolved. The patient has had
no further episodes of RCE.
While most cases of RCE can be managed with
topical therapy, recalcitrant cases may need more
aggressive treatment. Corneal abrasions and erosions
are not uncommon in keratoconic eyes corrected
with rigid gas-permeable contact lenses, though in
this case the erosion was related to trauma. ASP
and PTK have been used to treat RCE secondary
to subepithelial nodular scars in keratoconus,
though there was a report of keratolysis leading to a
descemetocele following PTK. One case described a
PC - Primary Care
Amanda Phelps, OD
Southern College of Optometry
1424 River Boat Circle
Memphis, Tennessee 38103
Additional Author(s): Beth Sparrow, OD
Retinal arterial macroaneurysms are
outpocketings of major arteries within the retina
most commonly seen in hypertensive females in the
6-7th decade and usually are indicative of severe
cardiovascular disease. Macroaneurysms have
several sight-threatening sequelae including macular
edema, exudates, multi-layer retinal and vitreal
hemorrhages. A multi-layered retinal hemorrhage
is considered pathognomonic for the presence of
a macroaneurysm and includes the simultaneous
presentation of subretinal, intraretinal, and preretinal/
subhyaloid hemorrhages.
A 74 year old black female presented with
sudden, painless vision loss for two weeks in the
left eye. Medical history was positive for NIDDM
for fifteen years and hypertension for twenty years.
Ocular history included mild non-proliferative
diabetic retinopathy OU for three years, primary
open angle glaucoma suspect OU for three years, and
pseudophakia OS. LEE was one year prior. BCVA
was 20/20-1 OD and 20/400 @ 2 feet OS. All chair
skills and anterior segment findings were normal and
intraocular pressures were 16 mmHg OU. Posterior
segment findings revealed A/V crossing changes
OU, one dot heme OD, and a multi-layered retinal
hemorrhage in the left eye effecting the macula.
The patient was referred to a retinal specialist and
an injection of Avastin© was administered with
the patient to be monitored in one month. Her one
month follow up with the retinal specialist showed
43
significant resolution of the hemorrhage in the left
eye. This case is currently in progress and a follow
up examination has been scheduled with the referring
optometrist and the patient is being closely monitored
by her primary care physician.
Macroaneurysms are associated with
hypertension, typically have sight-threatening
complications and may indicate a potentially lifethreatening cardiovascular condition. The presence
of a macroaneurysm warrants a referral to the
patient’s primary care physician or cardiologist
depending on the presence and severity of comorbidity factors. This case demonstrates the role
of the primary care optometrist in identifying the
potential lethality of systemic disease during an
ocular examination.
lens was ordered with an opaque backing, blue iris
(specifications 42-V, U-3) and limbal ring to match
the right eye. After dispensing the trial, the patient
remained in the office for an hour then walked into
the sunlight. She immediately noted relief from
photophobia, increased clarity on the left side and
was pleased with the appearance of the contact lens.
As optometrists, our assumption may be that
cosmesis is the primary concern for a patient with
anisocoria, but this may not always be true. Our
patient stated “I’m not really concerned with the
way it looks. I’m used to it, but it just feels weird
over here.” Our responsibility is to understand the
complaints of our patients based on our knowledge
of anisocoria and its effects on the visual system.
Optometrists must be sensitive to all possible
symptoms and at the same time, deliver an acceptable
cosmetic solution. Before and after photos will be
included in the poster.
Poster 74
Traumatic Anisocoria: More than Cosmesis
Poster 75
PC - Primary Care
Amanda Phelps, OD
Southern College of Optometry
1424 River Boat Circle
Memphis, Tennessee 38103
Retention of Knowledge of Retinal
Microanatomy by Optometric Students,
Faculty, and Practitioners
Additional Author(s): Beth Sparrow, OD
Ruth Trachimowicz, OD, Ph.D.
Illinois College of Optometry
3241 South Michigan Ave.
Chicago, Illinois 60616
PC - Primary Care
Traumatic anisocoria not only presents the patient
with obvious cosmetic issues but can also result
in functionally debilitating symptoms including
photophobia that often prove more bothersome than
the appearance of differing pupil sizes.
A 43 year old female was referred to our
academic institution from a local military base for
a prosthetic contact lens fit for relief of symptoms
due to traumatic anisocoria OS for seven years.
She presented with complaints of photophobia,
“headache” on the effected side, blurred vision
and a sense of being “off balance.” She was an
uncorrected compound myopic astigmat in each eye
with BCVA of 20/20 OD, OS. Her pupil diameters
were 3.5 mm OD, 7.5 mm OS in light and 5 mm
OD, 8 mm OS in dark conditions with appropriate
reaction to direct light OD and minimal reaction to
direct light OS. Her iris color was light blue with
a dark limbal ring. All other medical and ocular
findings were unremarkable.After one fitting session
with a diagnostic fitting set, an Orion BioColors©
soft contact lens with base curve 8.8, 14.3 diameter,
clear pupil 4.2 mm and plano power was chosen.This
Additional Author(s):
Barclay W. Bakkum, D.C., Ph.D
Anatomy can be considered one of the basic
pillars of optometric training. Because advanced
imaging technology allows cross-sectional ocular
microanatomy to be visualized, this study was
developed in order to identify the ability of fourth
year optometric students, faculty members at an
optometric college (including residents), and a
group of private practice optometrists to label a
histologic image of the retina showing the 10 layers
in a similar orientation as represented on optical
coherence tomography.
After an IRB approved consent process, the
subjects were asked to provide information about
how many years since they had graduated and any
self-reported optometric specialties, e.g., primary
care, contact lenses, pediatrics/binocular vision, low
vision, or a combination of these. They were then
44
allowed 5 minutes maximum to label the layers of the
retina on a histologic image provided to them.
A total of 172 participants were recruited for this
study: 35 4th-year optometry students, 41 optometry
school faculty optometrists (including 9 residents),
and 96 private practitioners. Nearly ½ of the private
practitioners and about 1/3 of the faculty members
had graduated over 15 years ago. The students
correctly identified an average of 7.3 (±3.3) retinal
layers. The faculty members identified an average
of 3.5 (±3.5), and the private practitioners identified
an average of 1.1 (±1.9). The retinal pigmented
epithelium and the internal limiting membrane were
the most commonly identified layers. Nearly 1/3 of
the private practitioners either left their answer sheet
blank or had non-retinal structures as answers.
latency, average constriction velocity, dilation
velocity, and 75% recovery time.
Poster 77
Comfort and Cost Comparisons of Ketotifen
Anti-Allergy Drops
PH - Public Health / Policy
Jennifer M. Snyder, OD
Southern College of Optometry
1245 Madison Ave.
Memphis, Tennessee 38104
Additional Author(s): Andrew Neighbors,
B.A., William Edmondson, MAT, OD, FAAO,
Earlena McKee, M.A., OD, FAAO
Poster 76
This study compares the perceived ocular comfort
and cost of three current formulations of OTC
Ketotifen fumarate (0.025%) anti-allergy ophthalmic
solution. Ketotifen drops provide mast cell stabilizing
as well as antihistamine activity.
A double blind study at Southern College of
Optometry compared the comfort of three different
Ketotifen brands based on a comfort survey scale
from 1-10 with 10 representing very comfortable
and 1 representing very uncomfortable. The first
drop instilled in the patient’s right eye, TheraTears
lubricating eye drop, was used as a reference of
very comfortable with a grade of 10. Following the
reference drop, the three anti-allergy drops were
instilled in the subject’s right eye in random order,
allowing five minutes between drops. Subjects
completed the drop comfort survey following
each drop.
Data were analyzed with a single factor ANOVA
testing and on a pair-wise basis using a two-tailed
t-test for a difference of means. Two significantly
distinct groups (p<0.05) of comfort rankings resulted.
Of the three OTC Ketotifen brands, there were was
no significant comfort difference (p=0.689) between
TheraTears Allergy Eye Itch Relief (Advanced Vision
Research) and Zaditor (Alcon), the original Ketotifen
formulation. Alaway (Bausch & Lomb) was rated
as the significantly least comfortable drop (p<0.05).
TheraTears Allergy Eye Itch Relief and Alaway
are available in 10mL bottles, while Zaditor is only
available in 5mL bottles and costs twice as much as
the two other medications.
Objective Biomarker for Early Identification
of Blast-Induced mTBI: Pupillary Light Reflex
(PLR)
PC - Primary Care
Grace Lea Y. Dumayas, OD
Womack Army Medical Center,
Northeastern State University
771 Sun Road
Aberdeen, North Carolina 28315
Additional Author(s):
Jose E. Capo-Aponte, OD, Ph.D
There is an increase in mild traumatic brain injury
(mTBI) in US Warfighters resulting from exposure
to explosive devices. However, there is a lack of
objective biomarkers to accurately identify mTBI in
order to make a return-to-duty (RTD) determination
in the battlefield. The present study examined
pupillary light reflex (PLR) as a potential objective
biomarker for early identification of mTBI.
The PLR-200â„¢ monocular infrared
pupillometer was used to quantify PLR under
mesopic conditions in 20 U.S. military personnel
with blast induced-mTBI and 20 age-matched nonTBI military personnel. Eight PLR parameters were
assessed: maximum diameter; minimum diameter;
percent of constriction; constriction latency; average
constriction velocity; maximum constriction velocity;
75% recovery time; average dilation velocity.
Four of the eight PLR parameters were
statistically different between the groups: constriction
45
Poster 78
Improving Follow-up Attendance by Patients
Examined at a Community Service Event for
the Homeless Population
rate after the September event was only 18.5%. Onsite scheduling did not appear to improve follow-up
compliance. There was a much higher pick-up rate
for prescription glasses of 82% (February) and 85%
(September).
PH - Public Health / Policy
Poster 79
Zakiya Nicks, OD
Southern College of Optometry
1225 Madison Ave
Memphis, Tennessee 38104
Short-term (2 month) subjective and
objective improvement for meibomian gland
dysfunction after a single treatment using
the LipiFlow Thermal Pulsation System.
Additional Author(s): Wilson McGriff, OD, MPH
PH - Public Health / Policy
Access and utilization of healthcare services
is a significant area of concern in the homeless
population. A recent survey revealed 92% of
homeless individuals in Memphis and Shelby
County, TN had no health insurance coverage. Over
60% of these individuals have been diagnosed
with health conditions that required routine
medical attention. Project Homeless Connect
Memphis (PHC), coordinated by The Community
Alliance for the Homeless, is a large-scale, oneday service delivery event through which hundreds
of community volunteers work hand-in-hand with
homeless neighbors to break down barriers to
services needed to leave the streets of Shelby County.
The objective of this study was to determine if onsite scheduling improved follow-up compliance for
eye care in the homeless population served during
PHC events.
Through funding provided by Optometry
Cares®- The AOA Foundation 2013 Healthy Eyes
Healthy People® State Association Grant, The Eye
Center (TEC) at Southern College of Optometry
(SCO) participated in PHC Memphis at the Cook
Convention Center in Memphis, TN on February
14 and September 19, 2013. Comprehensive eye
exams were provided to registered individuals in a
temporary clinic at both events. Patients diagnosed
with or identified as at risk of having an ocular
disease were referred for medical follow-up care at
TEC and its clinical partners. In February, patients
were provided contact information and instructed to
contact TEC after the PHC event to schedule their
follow-up appointment. In September, TEC staff
scheduled the recommended follow-up appointments
before the patients left the event.
A total of 346 patients ages 18-72 were seen over
the course of two PHC events. The follow-up rate
after the February event was 20%. The follow-up
Leslie E. O’Dell, OD, FAAO
May Eye Care- Private practice
250 Fame Av Ste. 225
Hanover, Pennsylvania 17331
Additional Author(s):
Raman Bedi, MD, Ophthalmology
To determine short-term (2 month) subjective
and objective outcomes following treatment with
the LipiFlow Thermal Pulsation System for patients
with Meibomian gland dysfunction and dry eye
symptoms.
Data from 101 charts were reviewed after
having one or both eyes treated with a single 12-min
treatment using the LipiFlow Thermal Pulsation
System. Meibomian gland function, classified
as the number of glands secreting clear oil and
patient symptoms using the SPEED questionnaire
were measured. Data is presented for pretreatment
(baseline) and 2-months post-treatment.
Statistically significant improvement in the
number of Meibomian glands secreting clear oil was
found in all treatment scenarios, OU, right and left
eye treatments. Speed scores, a subjective measure
of symptom relief were also significantly reduced
with baseline scores of 15.2176 (5.61356) and 2
month scores reduced by half at 8.1683 (5.30107)
p< 0.001.
One 12-min. treatment with the LipiFlow
Thermal Pulsation System can improve both function
of Meibomian gland and reduce patient symptoms.
This review demonstrates Lipiflow as a efficacious
treatment choice in patients diagnosed with
Meibomian gland dysfunction.
46
Poster 80
Poster 81
Assessment of Eye Health Awareness
through Community Engagement: “Eyeâ€
Evidence-Based Optometry and the Need for
New Clinical Practice Guidelines
PH - Public Health / Policy
Trennda Rittenbach, OD
Minneapolis VA Medical Center
7600 Lyndale Ave S Unit 330
Minneapolis, Minnesota 55423
Zakiya Nicks, OD
Southern College of Optometry
1225 Madison Ave.
Memphis, Tennessee 38104
Additional Author(s):
Bennett McAllister, OD, FAAO
Additional Author(s): Lindsay Elkins, OD
Clinical Practice Guidelines (CPG) have
traditionally been based on expert opinion and
consensus but must now be supplanted by higher
level evidence as required by the Institute of
Medicine (IOM). The American Optometric
Association (AOA) developed consensus-based
guidelines in the mid-1990s that have been
periodically reviewed and revised as needed since
their introduction. Originally, they were intended to
be used as a resource for clinicians, policymakers
and the general public. Recently, the IOM has
been mandated by the U.S. Congress through the
Medicare Improvements for Patients and Providers
Act of 2008 to find the best methods for developing
quality, trustworthy, evidence-based clinical practice
guidelines. Any clinical guidelines not meeting
the new IOM standards would not be eligible to be
listed as a trustworthy guideline. Therefore, as the
optometric leader in CPGs, the AOA assembled a
guideline-development group (GDG) that includes
a multidisciplinary panel of content experts and
representatives from key stakeholder groups with
transparency of process, clearly identified conflicts
of interest and an open development process. The
first of the new, Evidence-Based Optometry (EBO)
guidelines that follow the eight IOM standards
for trustworthiness are now coming online with
more scheduled for future dissemination as they
are developed. In conclusion, Clinical Practice
Guidelines are entering a new era of evidence basis
that will lead the way for better care of patients, more
informed policy and legislative decisions and general
public knowledge of optometry’s scope of practice.
Parents completed a registration form including
the child’s gender, age, race, and home zip code,
which was used to assess the population serviced.
Upon completion of the event, parents were asked
to answer the following questions to assess the
perceived effectiveness of this model of eye health
awareness delivery and the need for further education
about the importance of a comprehensive eye exam
to this population:
1) How many children did you bring to the event?
2) Of those you brought, how many have had a
comprehensive eye exam?
3) Did this event increase your understanding of
the eye and vision?
4) Did this event influence your understanding of
the importance of an eye exam (for your child)?
Of the 536 kids that registered for the event,
48% reported not having an eye exam in the last
year with 33% never having had a comprehensive
eye exam. The event was far reaching with fifteen
states represented, including California, Colorado,
and Wisconsin. A majority of the families were from
the local mid-south area (TN 42%, MS 31.4%, AR
16.6%). Of the 118 parents that answered the last
two survey questions, 94% agreed that this event
increased their understanding of the eye and vision,
and 92% agreed that this event influenced their
understanding of the importance of an eye exam for
their child.
There was a high level of perceived effectiveness
with this model of eye health awareness delivery.
With a third of children reporting never receiving
an eye exam, there is need for further education
regarding its importance. Visual health is important
for all populations, but none more so than children,
as visual impediments are more likely to affect early
learning and potentially future achievements.
47
Poster 82
number of schools and colleges of optometry in the
US currently participating in IPE, the profession
is attempting to embrace the importance of this
health-care trend. However, it is also noteworthy
that an equal number of schools reported barriers
for IPE. It is ASCO’s mission to provide optometry
degree programs with the tools to break through
these barriers in order to more effectively prepare
graduates for the healthcare delivery system within
which they will practice with the ultimate goal of
improved patient outcomes.
Interprofessional Education at Schools and
Colleges of Optometry in the US; Current
Practices and Challenges
Melissa A Vitek, OD
Pennsylvania College of Optometry,
Salus University
1521 Old Welsh Road
Huntingdon Valley, Pennsylvania 19006
Poster 83
Additional Author(s):
John L. Baker, OD, MSEd, Jenny Smythe, OD, MS
TITLE Family Practice Residents and
Optometry Students Collaborate in
Clinical Care at PCO: An Example of Interprofessional Education at Salus University
Background: Interprofessional education (IPE)
occurs when students from two or more professions
learn about, from, and with each other to enable
effective collaboration and improve health outcomes.
The importance of interprofessional education in
optometric education is a basic tenet of ASCO’s
2011 revised “Attributes of Graduates of the Schools
and Colleges of Optometry” report. In 2013, ASCO
developed an interprofessional education task
force that was, in part, charged with identifying
best practices within ASCO institutions to prepare
graduates for team-based practice. Methods: A
Survey of Interprofessional Education Programs in
the Schools and Colleges of Optometry was mailed
to each President and Chief Academic Officer of the
twenty-one schools and colleges of optometry in
July 2013. The sixteen question survey, originally
developed in 2011 by an ASCO Government Affairs
staff member was modified to ask about existing
IPE activity, as well as about attitudes, challenges
and future plans relating to IPE at each institution.
Results: Nineteen of the twenty-one schools and
colleges of optometry reported their institution
participated in IPE activites and eight reported it was
a requirement of their programs. Eight schools and
colleges of optometry described IPE coursework
involving students from different programs teaching
one another. Fourteen programs indicated they
were providing interprofessional patient care while
eight institutions have a partnership with schools
and programs outside of their own institution.
Representatives from eleven institutions have taken
part in an Interprofessional Education Collaborative
(IPEC) sponsored workshop. Nineteen programs
reported barriers for initiating or furthering IPE
at their institution. Conclusion: As evident by the
Melissa Vitek, OD
Salus University
1521 Old Welsh Road
Huntingdon Valley, Pennsylvania 19006
Additional Author(s): Linda Casser, OD,
Valerie Pendley, MD
AUTHORS Melissa Vitek, OD, Director of
Electives and Advanced Studies, PCO Academic
Liaison to International Programs, Assistant
Professor, PCO at Salus University; Linda Casser,
OD, Professor, Dean, PCO at Salus University
BACKGROUND Beginning in October, 2012, The
Eye Institute at PCO, Philadelphia, PA and Chestnut
Hill Hospital Family Practice, Philadelphia, PA, have
joined forces in both patient care and education by
implementing a model in which second year family
practice residents take part in weekly sessions of
active observation of comprehensive ophthalmic
patient care at The Chestnut Hill satellite clinic of
The Eye Institute. The satellite clinic is conveniently
located just minutes away from Chestnut Hill
Hospital. METHODS Drs. Melissa Vitek, OD and
Valerie Pendley, MD, clinical educators and patient
care providers in their respective programs, in
recognition of their patient needs and the opportunity
for a unique educational opportunity, presented
the idea of this clinical/educational collaboration
to their supervisors, Drs. Linda Casser, OD, PCO
Dean, and Marc McKenna, MD, Residency Program
Director, both of whom were instrumental in bringing
the concept to fruition. RESULTS A total of six
48
residents have taken part in four sessions of patient
care each since its initiation. The residents have the
opportunity to take part in primary, pediatric, and
emergency eye care. The residents have been so
pleased with the experience that they have recently
indicated they would like to expand their role to
two sessions per week. Plans to accommodate this
request are in place. CONCLUSION On a direct
level, this initiative has allowed practitioners from
both professions to gain further respect for each
profession’s contribution to patient care. On a larger
scale, the collaboration represents a synergistic model
of both inter-professional healthcare and education.
Most importantly, this approach to patient care and
education promises more effective healthcare delivery
ultimately leading to improved patient outcomes.
yellow) anomaloscope testing, as well as the Cone
Contrast Test, used USAF-wide, to diagnose type
and severity of hereditary color deficiency. This
presentation will describe the unique capabilities of
the VNS, exemplary cases, as well as opportunities
for research and development which encourages
collaboration between Optometry, Ophthalmology,
Neurology and myriad other fields directed at interprofessional collaboration.
Poster 84
UIWRSO Visual Neurophysiology Service
Jeff Rabin, OD, MS, PHD
UIWRSO
9725 Datapoint Druve
San Antonio, Texas 78229
Additional Author(s): Andrew Buzzelli, OD,
MS, James Chapman, OD, MS,
Timothy Wingert, OD
The University of the Incarnate Word Rosenberg
School of Optometry Visual Neurophysiology Service
(VNS) is a unique clinical service with the goal
of detection, diagnosis, and monitoring of myriad
visual, systemic, and neurologic conditions. The
VNS offers state-of-the-art visual electro-diagnostic
testing, as well as color and contrast sensitivity
assessment to identify origin and etiology of visual
dysfunction. Testing includes electro-oculograms
(EOGs) to assess RPE and outer retinal function;
full field flash electroretinograms (ERGs) to assess
outer and middle retinal function; multifocal ERGs
to assess focal areas of visual loss mapped to rthe
etina and visual field; pattern ERGs to assess inner
retina/optic nerve function; flash and pattern visual
evoked potentials (VEPs) to asses macular function
at the level of the visual cortex. Moreover, the
VNS includes full-scope color vision diagnosis
using multiple pseudo-isochromatic book tests (e.g.,
Ishihara, HRR, Dvorine), hue arrangement tests (D15,
de-saturated D15, FM100 with quantitative computerscoring), Rayleigh (red-green) and Moreland (blue49