The Role of Specular Micrography in the Lions Eye Clinic

Mission Statement: “The Lions Eye Foundation preserves and restores the gift of sight by providing free ophthalmic examinations, operations and medications to the less fortunate members of our community.”

The Lions Eye A Publication of the

Lions Eye Foundation of California-Nevada, Inc.Winter 2015- 2016

Many patients referred to the Lions Eye Clinic have issues that are more complex than they first appear. In the case of Mr. X, he was referred to the Lions Eye Clinic by his local optometrist for a complaint of “poor vision” and was thought to need a routine surgery to remove his cataract and replace it with an artificial intraocular lens. However, upon examination in the clinic it was discovered that while indeed he did have an age related cataract, he also had corneal changes which complicates the decision as to whether or not to have surgery. His visual acuity at that time was 20/100. One of the questions the physicians had was how much of the decreased vision could be attributed to the cataract and what impact the corneal changes were having on the decreased vision.What is the Cornea?The cornea is the clear, highly specialized tissue at the very front of the eye ball. It is optically clear to allow light to pass through the surfaces inside the eye to the retina. Blood vessels don’t grow into the cornea. This means that nourishment of this small structure must be unique. There are five distinct layers of the cornea. The bottom layer, or “basement” layer is called the endothelium. This single layer of hexagonal cells is largely responsible for pumping the nourishment into and out of the rest of the cornea. If this cell layer fails, the cornea becomes thick and is no longer clear.Research has shown that we are given a limited number of endothelial cells at birth. If we scratch our skin or the surface of the cornea, the cells grow back to cover that area by duplication. This doesn’t happen with the corneal endothelium. If they are damaged due to disease or trauma, they don’t grow back as these cells do not have the ability to replicate. Humans are born with the maximum number of endothelial cells they will ever have. Histologically, these cells initially have a hexagonal shape. As endothelial cells die, neighboring cells enlarge to cover the empty space once occupied by the cell. This, in turn, causes the remaining cells to lose their hexagonal shape. The healthy endothelium, the most posterior layer of the cornea, is a monolayer of highly specialized cells. Our corneal endothelial cells decrease as we age. Given that Mr. X was also exhibiting signs of corneal disease, it was determined in the best interests of this patient that a test called as Specular Endothelial Cell Count, or Specular Micrography be performed as a precursor to any decisions regarding surgery. In the advent that Mr. X’s cornea was found to be deficient in endothelial cells this might influence decision to proceed with surgery. An unhealthy eye is not generally considered a great candidate for cataract surgery and further discussions might be necessary depending on the outcome of the micrography.The Specular MicroscopeThe specular microscope is a special instrument that allows the doctor and photographer to see and record the corneal endothelial cells. Modern Specular Microscopes are non-contact, meaning they do not need to physically touch the cornea to record the necessary data. These instruments take advantage of a bright specular or mirror like image that is created when the angle of the light for photography is at the correct angle. Since the cornea is clear, only a small amount of light returning from the cornea to the instrument is needed to record an image.

Retina Fellow Ananda Kalevar, M.D.

Ananda Kalevar, M.D.

How Does Specular Micrography Work?The specular microscope projects light onto the cornea, and then captures the image that is reflected from the optical interface between the corneal endothelium and the aqueous humor (the fluid in the front chamber in back of the cornea and in front of the colored part of the eye, the iris. The microscope quantitatively (provides hard numbers) analyzes this information and generates a variety of biometric reports that denote the density of cells, how much they vary from “normal”, their size and shape. These indices are useful for measuring endothelial cell death.

The microscope is brought toward the eye and light is projected into the eye, illuminating the 5 layers of the cornea. It is the deepest layer, the endothelium that is backlit using light to create contrast. The resulting image is of the single layers of the endothelium. The endothelial cells are brought into focus and the images which result from the procedure allow a “cell count.

Uses of Specular MicrographyBecause Specular Micrography allows us to visualize the corneal endothelium at the cellular level in vivo, taking an endothelial cell count can be helpful before referring patients for cataract or refractive surgery so that any potential endothelial dysfunction or thinning is recognized before they have the surgical intervention. Pre-existing corneal conditions, such as Fuchs’ dystrophy, dry eye, epithelial basement membrane dystrophy and other degenerations can decrease the potential for positive surgical outcomes. Certain inherited changes cause a premature loss of corneal endothelial cells. A cell count might be ordered for a suspicious change in the appearance or thickness of the cornea or evidence of corneal disease. Eye and tissue banks routinely use the specular microscope as one method of evaluating a donor cornea prior to corneal transplant.

Fortunately for our patient, his Endothelial Cell counts were found to be sufficient to support cataract surgery and thus, he underwent the procedure and had a favorable outcome of 20/30 vision post op.

The Konan Cell CheckThe Lions Eye Foundation purchased the Konan Cell Check for the Ophthalmic Diagnostic Center in 2015. This replaced our previous microscope which was not only 14 years old, but was not a digital instrument. It only printed on thermal paper and because it was not a digital instrument you could not perform the variety of analysis programs which are required for state of the art evaluation of the cornea. The Cell Chek was chosen as it is the model used by the top corneal research centers and Eye Banks throughout the USA. The approximate cost of this instrument was $35,000.

Denice Barsness, CRA, COMT, CDOS, ROUBSupervisor and Chief Technologist, ODC

The Role of Specular Micrography in the Lions Eye Clinic (continued)

Ananda “Andy” Kalevar, MD was born in Sherbrooke, Quebec in Canada. He received his undergraduate degree in Chemistry and Economics from Queen’s University in Kingston, Ontario. He received his medical degree and his residency training in Ophthalmology at McGill University in Montreal, Canada. He elected to get away from the cold winter in Canada and pursue a surgical retina fellowship with West Coast Retina and California Pacific Medical Center. He was interested in this program due to excellent surgical and medical retina exposure and having such great attending’s.

His favorite part of being a retina specialist is being able to perform complex surgeries that can bring back vision to eyes that have lost a significant amount and also to diagnose medical cases that are puzzles.

After his retina training, he will be returning to Canada and working at the University of Sherbrooke. In his free time, he enjoys playing tennis, golf, and exploring what Northern California has to offer!

Acknowledgements and Thanks

Total number of Patients ------ 48New Referrals -------------------- 74Actual Dollars Spent --- $143,060Estimated Value ------ $1,338,820

LEVERAGE 9.4:1

Fast Facts• The most prevalent surgery was for cataracts • There were 15 surgeries for retina, cornea or strabismus problems that would have cost $25,000 - $35,000 each • The youngest patient was 8 years old; and the oldest was 83 years old • There were also 22 Laser Procedures and 129 Intravitreous injections, 3 minor surgeries and 440 Opthalmic procedures with an estimated value of $127,570 (incl. in $’s above)

October - December 2015Memorial Donations (at least $200)• Wanda Adams • Everett “Sam” French • Charleen Gavette• Sally Territo Wong • Redwood City Sunrise Lions Club

New and Progressive Helen Keller Fellows:• John G. Cox • Mike Mortensson • Harvey Sanders

Capital or General Donations (at least $200)• Lisa Adukia • David & Barbara Anger • Leila Chinn• Monica Giotta • Rodolfo Mercado • Jeanne Mok • RichardQuadri • Charlene & Jerry Winges • Arvin Lions Club• Geneva Excelsior Lions Club • Menlo Park Live Oaks Lions Club • Oildale Lions Club

General or Capital Campaign Donations (at least $1000)• Anonymous • Barbara Anne Swain • Mark & Hopkins Stanley-Paskvan • Danford Foundation • Los Gatos Lions Club

Capital Campaign Don Stanaway Fellows • Augi Bisi • Richard Hoffman

New Don Stanaway Life Members:• William “Bill” McDonald • George “Beef” Contos

Total Received: General Fund $66,260 Capital Campaign $19,130

Statistics and Leverage

Work on the first phase of our Lions Eye Clinic project located at 711 Van Ness, San Francisco has started with this symbolic demolition. The sledge hammers have hit the wall and reconstruction will soon commence with the new clinic opening later this year.

Update: Demolition Has Begun!

left to right: LEF Executive Director John Schroeder, LEF Program Coordinator Mark Paskvan, Tami Chin, Dept. of Ophthalmology Director, Mary Lanier, Vice President Specialty Services CPMC, Michael Mahoney, CEO Pacific Vision Foundation.

0 2 4 6 8

10 12 14 16 18 20 22

C6 C4 C3 C2 C1 A3 A2 A1 '46

Number of Patients by District from 10/1/15 to 12/31/15

Letter From The Editor

Pat Neal

It looks like the new Lions Eye Clinic is finally becoming a reality. Ground has been broken, or should I say the golden hammer has been swung. Congratulations to everyone who has worked so long and so hard. Kudos to the Los Gatos Lions Club for their recent additional donation of $15,000 making their total contribution $25,000. Executive Director John Schroeder forwarded copies of two thank you notes that I thought should be shared with everyone who belongs to LEF. The first note, from Denice Barness, Supervisor ODC at CPMC, thanks the Lions Eye Foundation for approving the funding for ODC Education. Without continuing education, states Denice, it would be impossible to

stay abreast of continually changing technology. I personally would like to thank Denice. I have had the opportunity to watch Denice work, to see how she handles patients and the technology she uses to provide the best care possible. The second note, from a patient referred to LEF, simply states “You gave back the sight in my eyes,” signed with “eternal gratitude.” What could be more touching and heartwarming than that simple statement? Apologies to Kertice Poon, between the two of us we forgot to include the information that Kertice is a Past District Governor for District 4-C2, having served for FY 2010-2011.

P.O. Box 7999San Francisco, California 94120www.lionseyefoundation.com(415) 600-3950

Officers & Key PersonnelPresident – Dennis NobleFirst Vice President – John PoseySecond Vice President – Mike RogalskiTreasurer – Leila ChinnSecretary – Jan AhearnExecutive Director – John SchroederProgram Coordinator – Mark Paskvan

ContributorsEditor – Pat NealPhotography – Fred Sommer, John Schroeder, Mark PaskvanArticles – Mark Paskvan, John Schroeder, Denice BarnessContributor – Fred SommerLayout & Production – Roger WeinerPrinting – Forté Press Corporation, BurlingameDistribution – Precise Mailing, S. San Francisco

For More Information: www.lionseyefoundation.com