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BUSINESS NAME

NEWSLETTER T ITLE

Diseases | Surgery of the Retina and Vitreous

RETINA UPDATE 2021 ANNUAL CME/CE CONFERENCE

RVA Annual Retina Update is one of the largest vitreoretinal, uveitis, and ocular oncology educational

conferences in the country. Its legacy has spanned 4 decades and continues to provide up-to-date information to

the eye community every year.

October 2021– More details to follow.

Space is limited this year due to COVID-19 restrictions.

THIS EDITION ’S MYSTERY CASE

A 38 year old female with no significant past medical or ocular history was referred for evaluation of possible choroidal nevus. Visual acuity was 20/25 and intraocular pressure was 14 both eyes. On examination, the left eye showed a solitary round, flat amelanotic choroidal lesion approximately 1.5 x 1.5 mm in size, located in the inferior macula (Figure 1). There was no vitritis, overlying lipofuscin, or subretinal fluid.

B scan ultrasound demonstrated a 1.5 mm (base) x 0.9 mm (height) lesion without the characteristic collar stud or dome shaped configuration of a choroidal melanoma (Figure 2). B scan also showed absence of posterior shadowing typical for a calcified lesion. A scan ultrasound showed high internal reflectivity which is atypical for choroidal melanoma which classically shows low internal reflectivity.

Enhanced depth imaging optical coherence tomography (EDI OCT, Spectralis, Heidelberg, Germany) (Figure 3) which showed the lesion originating from the sclera. The lesion was minimally elevated, dome shaped with anterior bowing of the inner sclera producing focal compression of the overlying choriocapillaris, but no obliteration or compaction as seen in choroidal nevi or melanoma was seen (Figure 3).

What is your diagnosis and treatment recommendation? (Answer on last page)

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Fig 1: Color fundus photograph demonstrating a solitary amelanotic flat lesion inferior macula.

Fig 2: B-scan ultrasonography: 1.5 mm x 0.9 mm minimally elevated lesion without acoustic shadowing.

Fig 3: EDI OCT: moderately hyporeflective lesion with thinning of the overlying choriocapillaris and preservation of the retinal layers

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By Dr. Ramsudha Narala, Vitreoretinal Surgery and Ocular Oncology

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CURRENTLY ENROLLING CLINICAL TRIALS

Retina-Vitreous Associates Medical Group has participated in clinical research for over 15 years and is committed to the development of novel diagnostic and therapeutic modalities for retinal disease. All of our physicians participate in clinical trials, giving patients unique and easy access to the latest developments in treatments of vitreoretinal diseases. We are com-mitted to bettering the quality, efficacy, and ease of treatment for our patients. Transportation may be provided.

RETINITIS PIGMENTOSA (RP)

A genetic condition causing progressive vision loss. Night blindness usually occurs first, followed by peripheral, central, and color vision loss.

We are investigating surgical implantation of human stem cell-derived retinal progenitor cells that may offer long-term visual benefits to patients who otherwise have no other treatments available.

MACULAR DEGENERATION (Age-related/AMD) DRY & WET

The leading cause of vision loss in America, AMD is progressive disorder affecting the central vision in patients 50 years or older.

We provide trials for both early and end stage DRY and WET AMD using in-office as well as surgical treatments. We are now inves-tigating treatments with Stem Cells, oral medications, subretinal injections, subcutaneous injections, and intravitreal injections.

DIABETIC RETINOPATHY

Patients with type 1 and type 2 diabetes can suffer from damage to the blood vessels in the retina, causing mild to severe vision loss and potentially blindness.

Currently under investigation are trials for moderately severe to severe Non Proliferative Diabetic Retinopathy & PDR.

DIABETIC MACULAR EDEMA (DME)

An accumulation of swelling in the central retina that causes vision loss in diabetic patients. This is a component of diabetic retinopa-thy.

Our trials look for novel treatments for diabetic macular edema and in combination with current gold-standard treatment.

Trials available for both Treatment Naïve and Previously Treated patients.

RETINAL VEIN OCCLUSION (CRVO and BRVO)

Commonly referred to as a “stroke in the eye”, a blood clot in the retinal blood vessels can cause vision loss and secondary glaucoma.

We are investigating multiple novel treatments to improve outcomes and decrease the number of necessary visits and procedures.

UVEITIS: ANTERIOR, INTERMEDIATE, POSTERIOR, AND PAN-UVEITIS

A broad term for inflammation of the eye, it can be classified based on the parts of the eye that are affected.

We offer a spectrum of trials: subcutaneous injections, intravitreal injections, and oral medication for various types of uveitis.

STARGARDT DISEASE

A rare genetic macular condition with ABCA4 mutation.

MACULAR TELANGIECTASIA/IDIOPATHIC JUXTAFOVEAL RETINAL TELANGIECTASIS

A rare bilateral macular disease of unknown cause that usually causes mild to moderate vision loss.

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RECENT RESEARCH PUBLICATIONS BY RVA

1.Safety and Efficacy of Intravitreal Risuteganib for Non-Exudative AMD: A Multicenter, Phase 2a, Randomized, Clinical Trial. Boyer DS, Gonzalez VH, Kunimoto DY, Maturi RK, Roe RH, Singer MA, Xavier S, Kornfield JA, Kuppermann BD, Quiroz-Mercado H, Aubel J, Karageozian HL, Park JY, Kara-geozian VH, Karageozian L, Sarayba MA, Kaiser PK. Ophthalmic Surg Lasers Imaging Retina. 2021 Jun;52(6):327-335. 2.The use of neuroprotective agents in treating geographic atrophy. Scholl HPN, Boyer D, Giani A, Chong V. Ophthalmic Res. 2021 Jun 21. 3.Diagnostic and Therapeutic Challenges. Binkley EM, Biscotti CV, Singh A, Sears J, Singh AD, Narala R, Mruthyunjaya P. Retina. 2021 Jun 1;41(6):1356-1359. 4.Understanding Retinal Vasculitis Associated with Brolucizumab: Complex Pathophysiology or Occam's Razor? Sharma A, Kumar N, Parachuri N, Singh S, Bandello F, Regillo CD, Boyer D, Nguyen QD. Ocul Immunol Inflamm. 2021 May 20:1-3. 5.Amine oxidase copper-containing 3 (AOC3) inhibition: a potential novel target for the management of diabetic retinopathy. Boyer DS, Rippmann JF, Ehrlich MS, Bakker RA, Chong V, Nguyen QD. Int J Retina Vitreous. 2021 Apr 12;7(1):30. 6.Intravitreal Aflibercept Injection vs Sham as Prophylaxis Against Conversion to Exudative Age-Related Macular Degeneration in High-risk Eyes: A Ran-domized Clinical Trial. Heier JS, Brown DM, Shah SP, Saroj N, Dang S, Waheed NK, Wykoff CC, Prenner JL, Boyer DS. JAMA Ophthalmol. 2021 May 1;139(5):542-547. 7.Brolucizumab-foreseeable workflow in the current scenario. Sharma A, Kumar N, Parachuri N, Kuppermann BD, Bandello F, Regillo CD, Boyer D, Nguyen QD. Eye (Lond). 2021 Jun;35(6):1548-1550. 8.Superior Wide-Base Internal Limiting Membrane Flap Transposition for Macular Holes: Flap Status and Outcomes. Tabandeh H, Morozov A, Rezaei KA, Boyer DS. Ophthalmol Retina. 2021 Apr;5(4):317-323. 9.The Timing of Large Submacular Hemorrhage Secondary to Age-Related Macular Degeneration Relative to Anti-VEGF Therapy. Matsunaga DR, Su D, Sioufi K, Obeid A, Wibbelsman T, Ho AC, Regillo CD. Ophthalmol Retina. 2021 Apr;5(4):342-347. 10.Brolucizumab-early real-world experience: BREW study. Sharma A, Kumar N, Parachuri N, Sadda SR, Corradetti G, Heier J, Chin AT, Boyer D, Dayani P, Arepalli S, Kaiser P. Eye (Lond). 2021 Apr;35(4):1045-1047. 11.Management of repository corticotropin injection therapy for non-infectious uveitis: a Delphi study. Nguyen QD, Anesi SD, Chexal S, Chu DS, Dayani PN, Leng T, Meleth AD, Sallam AA, Sheppard JD, Silverstein SM, Toyos M, Wang RC, Foster CS. Acta Ophthalmol. 2021 Mar 9. 12.A Cost-Benefit Analysis of VEGF-Inhibitor Therapy for Neovascular Age-Related Macular Degeneration in the United States. Brown GC, Brown MM, Rapuano SB, Boyer D. Am J Ophthalmol. 2021 Mar;223:405-429. 13.Suprachoroidal CLS-TA for non-infectious uveitis: an open-label, safety trial (AZALEA). Henry CR, Shah M, Barakat MR, Dayani P, Wang RC, Khura-na RN, Rifkin L, Yeh S, Hall C, Ciulla T. Br J Ophthalmol. 2021 Feb 5 14.Spontaneous Conversion of Lamellar Macular Holes to Full-Thickness Macular Holes: Clinical Features and Surgical Outcomes. Chehaibou I, Hubsch-man JP, Kasi S, Su D, Joseph A, Prasad P, Abbey AM, Gaudric A, Tadayoni R, Rahimy E. Ophthalmol Retina. 2021 Jan 5 15. Cost-Utility Analysis of VEGF Inhibitors for Treating Neovascular Age-Related Macular Degeneration. Brown GC, Brown MM, Rapuano S, Boyer D. Am J Ophthalmol. 2020 Oct;218:225-241. 16.Long-term outcomes of treat-and-extend ranibizumab with and without navigated laser for diabetic macular oedema: TREX-DME 3-year results. Payne JF, Wykoff CC, Clark WL, Bruce BB, Boyer DS, Brown DM; TREX-DME Study Group. Br J Ophthalmol. 2021 Feb;105(2):253-257. 17.PHASE 2 STUDY OF THE SAFETY AND EFFICACY OF BRIMONIDINE DRUG DELIVERY SYSTEM (BRIMO DDS) GENERATION 1 IN PA-TIENTS WITH GEOGRAPHIC ATROPHY SECONDARY TO AGE-RELATED MACULAR DEGENERATION. Kuppermann BD, Patel SS, Boyer DS, Augustin AJ, Freeman WR, Kerr KJ, Guo Q, Schneider S, López FJ; Brimo DDS Gen 1 Study Group. Retina. 2021 Jan 1;41(1):144-155. 18.Laser vitreolysis for symptomatic floaters is not yet ready for widespread adoption. Su D, Shah CP, Hsu J. Surv Ophthalmol. 2020 Sep-Oct;65(5):589-591. 19."Giant cell arteritis manifesting as retinal arterial occlusion and paracentral acute middle maculopathy in a patient on pembrolizumab for metastatic uveal melanoma". Narala R, Reddy SA, Mruthyunjaya P. Am J Ophthalmol Case Rep. 2020 Aug 25;20:100891. 20.Occlusive Retinal Vasculitis Following Intravitreal Brolucizumab. Witkin AJ, Hahn P, Murray TG, Arevalo JF, Blinder KJ, Choudhry N, Emerson GG, Goldberg RA, Kim SJ, Pearlman J, Schneider EW, Tabandeh H, Wong RW.J Vitreoretin Dis. 2020 Jul;4(4):269-279.

1. Dr. David Boyer: Recognized as an Expertscape World Expert in Macular Degeneration: Top 0.1% of scholars writing about Macular Degeneration over the past 10 years.

Awarded the Designation of Fellow of The American Society of Retina Specialists (ASRS)

2. Dr. Firas Rahhal: Ophthalmology Innovation Summit (OIS) Retina Industry Panel Moderator 2021

OIS - Retina Podcast Host (Monthly) 2020-2021

OIS at American Society of Retina Specialists (ASRS) Meeting Chairperson October 2021

RECENT HONORS , AWARDS , RECOGNITIONS

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CONTACT INFORMATION

Main Phone: (213) 483-8810 Clinical Trials Center: (310) 289-2478 x3

www.LAretina.com Clinical Trials Fax: (310) 652-1956

Beverly Hills 9001 Wilshire Blvd., Suite 301 Beverly Hills, CA 90211 P: (310) 854-6201 F: (310) 652-7520

Los Angeles 1245 Wilshire Blvd., Suite 380 Los Angeles, CA 90017 P: (213) 483-8810 F: (213) 481-1503

North Hollywood 12840 Riverside Drive, Suite 333 North Hollywood, CA 91607 P: (818) 754-2090 F: (818) 508-9420

Pasadena 301 S. Fair Oaks Ave, Suite 407 Pasadena, CA 91105 P: (626) 204-1410 F: (626) 204-1420

Tarzana 5525 Etiwanda Ave. Suite 112 Tarzana, CA 91356 P: (818) 578-7408 F: (818) 578-7409

Torrance 3400 Lomita Blvd., Suite 202 Torrance, CA 90505 P: (310) 891-1000 F: (310) 891-1003

Glendale 1510 S. Central Ave, Ste 230 Glendale, CA 91204 P: (818) 797-4870 F: (818) 797-4970

Daniel D. Esmaili, MD Alexander C. Walsh, MD Jeffrey J. Tan, MD David S. Liao, MD

Richard H. Roe, MD Pouya N. Dayani, MD David S. Boyer, MD Thomas G. Chu, MD Firas M. Rahhal, MD Homayoun Tabandeh, MD

Daniel Su, MD

Based on multimodal imaging, the diagnosis of focal scleral nodule was made. This condition is a diagnosis of ex-clusion described previously as a yellow-white solitary choroidal mass termed unifocal helicoid choroiditis or solitary idiopathic choroiditis. A later study using EDI OCT identified that it involves the sclera in addition to the choroid. In the most recent and extensive study to date, it was concluded that these lesions in fact originate from the sclera rather than the choroid, and proposed the new name of Focal Scleral Nodule (FSN).

Solitary lesions mimicking FSN have been associated with tuberculosis (TB), syphilis, sarcoidosis, and less commonly cat scratch disease, toxoplasmosis, toxocariasis, fungal and viral infections, and other inflammatory conditions. There-fore, a thorough ocular examination should be performed to look for active inflammation and a basic uveitis work up should be pursued in all cases. Our patient had a positive Quantiferon gold suggesting prior exposure to TB but chest X-ray was normal, and since she did not have any systemic or ocular signs of TB, we did not treat her latent tuberculosis. Serial monitoring of the lesion with multimodal imaging was performed.

MYSTERY CASE : ANSWER AND DISCUSSION

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Ramsudha Narala, MD