1

Rapid Fire Grand RoundsCOPE#52118- PO

Walter O. Whitley, OD, MBA, FAAO

Director of Optometric Services

Virginia Eye Consultants

Residency Program Supervisor

PCO at Salus University

Disclosures

• Alcon

• Allergan

• Bausch and Lomb

• Biotissue

• Beaver-Visitec

• Ocusoft

• Publications

– Advanced Ocular Care – Co-Chief Medical Editor

– Review of Optometry – Contributing Editor

– Optometry Times – Editorial Advisory Board

Walter O. Whitley, OD, MBA, FAAO has received consulting

fees, honorarium or research funding from:

• Science Based Health

• Shire

• Sun Pharmaceuticals

• TearLab Corporation

• Tearscience

Virginia Eye ConsultantsTertiary Referral Eye Care Since 1963

• John D. Sheppard, MD, MMSc

• Stephen V. Scoper, MD

• David Salib, MD

• Elizabeth Yeu, MD

• Thomas J. Joly, MD, PhD

• Dayna M. Lago, MD

• Constance Okeke, MD, MSCE

• Esther Chang, MD

• Jay Starling, MD

• Samantha Dewundara, MD

• Rohit Adyanthaya, MD

• Albert Cheung, MD

• Walter Whitley, OD, MBA, FAAO

• Mark Enochs, OD

• Chris Kuc, OD, FAAO

• Cecelia Koetting, OD, FAAO

• Leanna Olennikov, OD

• Chris Kruthoff, OD

• Jillian Janes, OD

Pearls on Optometric Co-management

• Get to know your surgeon

• Convey patient preferences, observations and

conditions to your surgeon

• Inform your patients on your role in perioperative

care

• Successful co-management is the result of

continuous communication

2

Today’s Optometrists

“To be on the cutting edge of optometry, you need to be on the

cutting edge of science and technology.”

US-ODE-16-E-5238 6

TODAY’S CATARACT PATIENT

Active Outgoing Still

working

Digitally

savvy

1. Centers for Disease Control and Prevention website. http://www.cdc.gov/healthcommunication/pdf/audience/audienceinsight_boomers.pdf. Accessed December 21, 2016.

2. Hill W. Distribution of corneal astigmatism in normal adult population. Keratometry database: http://www.doctor-hill.com/iol-main/astigmatism_chart.htm. Accessed January 13, 2017.

3. AcrySof® IQ Toric IOL Directions for Use. Alcon data on file, 2009.

• In 2015, people aged 50 and older represented 45% of the US

population1

• There were approximately 4 million cataract procedures in 2015 and

that number is expected to grow by 3% in 20166

Why Become Involved?

• By 2020 the U.S. population over 65 will

double from current levels – 12.9% of

total population

• CMS allows ODs/MDs to bill for non-

covered services

• Tangible vs. Intangible benefits

• Patient expectations are at an all-

time high for refractive surgery

• Positive experiences with LASIK

have produced high expectations,

at a minimum achieving:

– 92.6% of LASIK patients with vision of

20/40 or better*

– 95.4% of patients satisfied with their

outcome after LASIK surgery**

• Cataract surgery outcomes may

not be meeting the target of ±0.5D

that is considered the standard

High Patient Expectations in Cataract

Refractive Surgery

*“LASIK Surgery Statistics.” Docshop.com. http://www.docshop.com/education/vision/refractive/lasik/statistics

**Solomon, K et al. (2009) “LASIK world literature review: quality of life and patient satisfaction.” Ophthalmology. 16(4):691-701

***Graph: Data from Dr. Warren Hill & Behndig A, et al. Aiming for emmetropia after cataract surgery: Swedish National Cataract Register study. J Cataract Refract Surg. 2012;38(7):1181-6.

41%

71%

97%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

±0.25D ±0.5D ±1.0D

Cataract Outcomes***

88/13

VRN13066SK

3

What Do Our Patients Know About

Cataracts?

• What is a cataract?

• When do I need cataract surgery?

• How is the surgery done?

• Who do I go to?

• What are my options?

• Will I need glasses?

• Will I still see you after the surgery?

Advanced Technology:

The Players

SYMFONY First Extended Depth of Focus Lens (EDOF)

Coupling of two new principles:

– Diffractive echelette to elongate the range of focus

– Reduction in chromatic aberration to increase

contrast sensitivity

Different than a MF-IOL:

– Rather than splitting incoming light into two focal

points, it elongates depth of focus

– Not affected by pupil diameter

4

Glare and Halos

Tecnis Symfony

• First EDOF IOL approved in the US

• Available in both toric and non-toric

• Offers patients extended range of vision

• Lower glare/halo side effect profile

AcrySof® IQ ReSTOR® IOL1,2,3

RES14040SK-D 161. AcrySof® IQ ReSTOR® +2.5 D IOL Directions for Use.2. AcrySof® IQ ReSTOR® +3.0 D IOL Directions for Use. 3. Data on Fil

e, Alcon Inc.

Parameter

SV25T0Model

numberSN6AD1

+2.5 DADD power @ IOL plane

+3.0 D

+2.0 DADD power

@ Spectacle Plane

+2.5 D

0.94 mmCentral ring

diameter0.86 mm

7 # rings 9

8.4 mm2Apodized

Diffractive Area

10.2 mm2

Dist: 69%

Near: 18.0%

Energy

distribution (3 mm)

Dist: 59%

Near: 25.5%

-0.2µmAsphericity -0.1µm

+2.5 D +3.0 D

5

Defocus Curves1,2

RES14040SK-D 171. AcrySof® IQ , AcrySof® IQ ReSTOR® +3.0 D 2. AcrySof® IQ ReSTOR® +2.5 Directions for

.

Introducing…..Restor Toric

http://www.alconsurgical.ca/images/CataractIOLs/Calculator_Product_Sp

ec_image3.JPG

“The Pipeline”: Future IOLs

• Akkommodative 1CU (Human Optics)

• Tetraflex IOL (Lenstec)

• Sarfarazi Elliptical IOL (B&L)

• Synchrony (Visiogen)

• FlexOptic Lens (Quest Vision

Technologies)

• NuLens (NuLens)

• FluidVision IOL (PowerVision)

• LiquiLens (Vision Solutions)

• Smart IOL (Medenium)

• Light Adjustable Lens (Calhoun Vision)

Setting Expectations

• Individual patient perceptions vary

• Best vision after bilateral implantation

• Glare/Halos

• Lighting considerations

• Readers

• Possibility of refinement

6

Preparation for Ocular Surgery

• Optimize the Ocular Surface

• Normalize the Lids

• Prepare the Cornea

• Eliminate Intra-ocular

Inflammation

• Control Glaucoma

• Satisfy the Macula

• Evaluate the Retinal Periphery

• Patient Education

Ocular Pathology

• Chair time about source(s) of “BLURRY VISION”

• Cataract surgery can worsen DED for months

after surgery

• Refractive cataract surgery: quality of vision may

require chronic DED Rx

• Cyclosporine ophthalmic emulsion 0.05%,

lifetegrast 5%, Topical amniotic membrane drops

Cat Sx and OSD

Management of Patient Expectations

Testing only when Patients

Complain of Dryness is Insufficient

• > 40% of people with

objective evidence of dry

eye are asymptomatic1

• Cataract surgery patients

often complain of

fluctuating vision rather

than dryness or FBS2

13%

28%

59%

010203040506070

Most orall thetime

Some ofthe time

Never

Do you have FBS?

Despite a lack of discomfort, dryness or FBS, >60% of subjects had significant signs of OSD2

1. Bron AJ, Tomlinson A, Foulks GN, et al. The Ocular Surface 2014; In press.2. Trattler W, Reilly C, Goldberg D, et al. Prospective Health Assessment of Cataract Patients Ocular Surface Study; Poster, ASCRS 2011.

7

Dry Eye Prevalence in Patients

Scheduled for Cataract Surgery

• Study Design: Prospective, multicenter, observational,

pilot study (N=143) of which 136 met the inclusion criteria

at 9 sites across the United States to determine the

incidence and severity of Dry Eye Disease in consecutive

patients 55 and older scheduled for cataract surgery (68

male and 68 female patients)

• Primary outcome measure: Incidence of Dry Eye as

evaluated by grade on International Task Force (ITF) level

• Secondary outcome measures: TBUT, corneal staining

with fluorescein, and conjunctival staining with lissamine1. Trattler WB, et al. Clinical Study Report: Cataract and Dry Eye: prospective health assessment of cataract patients ocular surface study. 2010.

Dry Eye Prevalence in Patients

Schedule for Cataract Surgery• 80% of Patients had dry eye severity score of Level 2 or

Higher

• Tear Break Up Time: 62.9% with < 5 sec

• 76.8% of eyes were positive for Nafl corneal staining

• Only 22.1% (30 pts) received a previous Dx of Dry Eye

27

• Ocular surface must be optimized pre-operatively for

accurate keratometry

Cataract Surgery and Dry Eye

Photo accessed from http://i1.ytimg.com/vi/IFRJw1xeVJI/hqdefau lt.jpg on 12/28/1528

Goal of Therapy:

Stabilize Interblink Tear Film

8

“Hot spots” and “Flat spots”are Abnormal

Irregularly Shaped or Smudgy Placido Disk is Abnormal!

Take a Closer Look if Average K Values are Different

9

Dry Eye Preparation for

Cataract Sx Measurements

1. Frequent NPAT use

2. Topical steroid course

- Fluoromethalone, loteprednol

- PF Dexamethasone 0.01% to 0.1%

3. Upper and/or lower punctal occlusion

4. MGD management: MiboFlo, Lipiflow

5. Prokera Self-retaining AMT

6. Address any other issues, i.e. blepharospasms, lag ophthalmos, filamentary keratitis

Case Example

• 71 yo WF, physician’s wife, presents for

evaluation of blurred vision

• Guillan Barre Syndrome distant past Lag

ophthalmos R > L

• “Another MD has been treating my dry eye for

one year and says I’m still not ready for cataract

surgery”

• Meds: clonidine, Crestor, Fentanyl, Cymbalta,

Lasix, Dilaudid, Cymbalta, Fioricet

• 2+ MGD with telangiectasia

• Poor blink rate

• Lag OD > OS (1-2mm)

• Diffuse 2-3+ stain within central and inferior

cornea OD, +KNV with ant stromal scar inferior

periphery

Case Example

10

• ACUTE preparation for cataract surgery different

from chronic management of DED

– Topical steroid drops and/or ointment: First line

therapy

– Aggressive NPAT

– Lipiflow thermal pulsation

– If imaging unimproved after 3-4 weeks, consider

Prokera AMG

Management of Patient Expectations

• Treatment

– Fire/Ice Mask bid, Ocusoft Plus lid wipes

– Loteprednol ointment qhs x 1 week

– PF Dexamethasone 0.1% qid

– Aggressive lubrication

After 2 weeks, minimal improvement, and Prokera

self-retaining AMT placed

Case Example

Case Example

• Patient returned 1 week later for Prokera

removal OD

• Cataract surgery measurements acquired the

day after

S/P Prokera Self-retaining AMT

Pre-Prokera

s/p Prokera

(placed for 5

days)

11

• Lid hygiene

• BlephEx

• ABx/steroid ointment bid

• Demodex treatment

• Wait 1-2 months before

cataract sx: ? Bacteria

released from lid hygiene

Blepharitis

4141

• 69% of patients with bacterial endophthalmitis were culture-positive

Endophthalmitis Vitrectomy Study

1. Han DP, Wisniewski SR, Wilson LA, et al. Spectrum and susceptibilities of microbiologic isolates in the endophthalmitis vitrectomy study. Am J Ophthalmol 1996;122(1):1-17.2. Speaker MG, Milch FA, Shah MK, et al. Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. Ophthalmology. 1991;98:639-649.

24%

Other

Gram-positive

organisms

70%

6%

Gram-positive

coagulase-negative

organisms (Staphylococcus

epidermidis)

Gram-negative

organisms

Call to Action!!!

OSDI SPEED

ARE MIGS THE ANSWER?

12

Case Presentation

• CC: vision cloudy OS>OD

• HPI: 68 yo WM presents for cataract evaluation

with h/o controlled moderate OAG OS>OD

• Current meds: Levobunolol QD OU, Travatan

qhs OU, Optive

• POHx: SLT OU 2007

• FamHx: mother with glaucoma

Case Presentation

• BCVA : 20/40 OD, 20/50 OS

• Present Rx: OD -0.50+1.00 x 075

OS -1.00 +0.75 x 110

• Keratometry: OD 43.67/44.00 x 055

OS 43.25/44.37 x 85

• IOP: OD 14, OS 14 (Applanation)

• CCT: OD 527, OS 512

• Tmax: OD 20; OS 24

• Gonioscopy: OU open to scleral spur

• SLE 2+ NS OU

Case Presentation

• Dilated Fundus Exam:

• Optic Nerve:CDR OD: 0.55 / 0.5

(thin rim infer/sup)

CDR OS: 0.7 / 0.65

• Macula: OU Flat

• Vessels: WNL

• Periphery: WNL

13

What Do You Get When You Add?

+

=

Case Presentation

• Diagnosis: VS Cataract OU, Controlled

Glaucoma

• Type of Glaucoma: open angle glaucoma

– Stage of Glaucoma: Moderate to severe

OS>OD

– What is the target pressure? Low teens OU

– Is current treatment adequate? Yes

Which Comes First,

The Chicken or the Egg?

• Glaucoma Evaluation First

– Permanent loss of vision if not controlled

• Cataract Evaluation Second

– Cataract surgery is an elective procedure and

can wait

• Consider combined procedure

Patient Compliance and Dosing

• Literature review of 76 studies show– Compliance increases

with decreased dosage regimen and complexity1

– 79% compliance with QD regimen vs 51% for QID regimens (p=0.001)1

– Simpler, less-frequent dosing results in better compliance in a variety of therapeutic classes1

Com

plia

nce

Dosing

(Times/day)

1. Claxton et al. Clinical Therapeutics. 2001; 23:1296-1310.

14

How Adherent are Glaucoma

Patients with QD Medication?

Minimally Invasive Glaucoma

Surgery (MIGS)

Ab Externo

• Canaloplasty

• Stegmann Canal

Expander

• Gold Microshunt

Ab Interno

• Glaukos iStent

• Neomedix

Trabectome

• Excimer laser

trabeculotomy

• Hydrus Microstent

• Cypass Microstent***

• Kahook Dual Blade

• Xen Gel Stent***

Trabecular Bypass Devices

• These procedures facilitate the flow of

aqueous into Schlemm’s canal by:

– Shunting the canal

• Express MiniShunt (Alcon)

– Stenting the canal

• iStent (Glaukos Corp)

– Divert aqueous into the suprachoroidal space

• Cypass Microshunt (Alcon)

– Divert aqueous into the subconjunctival space

• Xen Gen Stent (Allergan)

PN: 400-0135-2013-US Rev. 0 Release Date: 08/27/2013

Photo accessed from http://www.downstate.edu/ophthalmology/patient-info/patient-info-

glaucoma.html on 11/4/16

Anatomical Considerations

15

Are Patients Interested in MIGS?

• 28pts

• 79% did not mind

instilling drops

• 64% did not mind

wearing glasses

• 86% were interested in

reducing their need for

topical medications

Combined Phaco / Trabectome

Trabectome - IOP & Glaucoma Medication Use

Outcome

Mean pre-op IOP

Mean IOPs with standard deviations at various intervals after surgery over 72 months

Mean pre-op medication use

Mean medication use after surgery over 72 months

IOP (mmHg)

Glaucoma Medication

Use

Combined Phaco / iStent

16

US IDE Trial - Primary Endpoint

61

0

20

40

60

80

100

Cataract Surgery iStent

Percent of Patients With IOP ≤21 mm Hg Without Medication Use

50%

72%

®

The XEN® Gel Stent

• A glaucoma implant designed to reduce intraocular pressure in eyes suffering from refractory glaucoma1

• 6-mm length, 45-micron inner diameter—about the length of an eyelash1,2

• Composed of gelatin, cross-linked with glutaraldehyde1

1. XEN® Directions for Use; 2. Vogt et al. In: Blume-Peytavi et al, eds. Hair Growth and Disorders. 2008.

The XEN® Procedure

1. XEN® Directions for Use.

In the clinical investigation, standard ophthalmic surgery

techniques, viscoelastic, and mitomycin C (0.2 mg/mL)

were used before injection.1

The XEN® Procedure Creates a Low-Lying,

Ab-interno Bleb in Refractory Glaucoma1

• Example of elevated, cystic bleb2

1. Dapena and Ros. Revista Española de Glaucoma e Hipertensión Ocular. 2015; 2. Errico et al. Clin

Ophthalmol. 2011.

Ab-Externo Bleb

Suture wounds2

Dissected tenon

capsule layer2

Diffuse, mildly

elevated bleb2

Ab-Interno Bleb

• Low-lying and diffuse1

Controlled flow through lumen

restriction1

Tenon capsule

adhesions intact1

Undistrubed, low-lying

drainage space1

17

XEN® Ab-interno Bleb Examples

Post-op day 1 Post-op month 12 Post-op month 18

Actual patient. Images courtesy of: Francisco Millan, MD, and Vanessa Vera, MD.

Cypass Microstent

• Ab-interno insertion

into the supraciliary

space

• Fenestrated

microstent made of

biocompatible

polyimide material

• Magnetic resonance

safe

Why Target the Uveoscleral Outflow

Pathway?• Uveoscleral outflow: considered

pressure independent and

contributes up to 50% of total

aqueous outflow.2

• Aqueous percolates through the

ciliary body and exits into the

suprachoroidal space,

primarily through the sclera and

choroidal blood vessels.3

• The highest point of resistance

is the ciliary body, which is

thought to regulate this

drainage.3

Clinical Data Delivers superior, long-

term IOP-lowering efficacy Two-year COMPASS Trial is the largest MIGS randomized controlled trial

completed to date Landmark FDA study with two-year follow-up on >500 patients with baseline/terminal washout

• 72.5% of eyes achieved a

≥20% reduction

in unmedicated

diurnal IOP

at 2 years*

• 61.2% of eyes maintained an

unmedicated

diurnal IOP

range between

6 and 18 mmHg

at 24 months

(a 41% increase)*

*Prospective, randomized, multicenter clinical trial in patients (n=505) with open-angle glaucoma undergoing cataract surgery randomized to

microstent (n=374) or phacoemulsification (n=131).

Primary outcome measure was unmedicated diurnal IOP reduction at 24 months versus cataract surgery alone at baseline. Secondary outcomes

measures included mean change in 24 month

DIOP from baseline and 24 month unmedicated mean IOP (between 6 mmHg to 18 mmHg) versus cataract surgery alone. Medication use at 24

months was also analyzed. The primary and

secondary effectiveness analyses were performed using intent to treat (ITT) population.

18

Demonstrated safety as compared to

cataract surgery alone

Intraoperative adverse events▪

A total of ▪ 25 intraoperative were reported in 20 out of 374 CyPass subjects (5.3%)

Incidence of postoperative ▪

adverse events

39▪ % of CyPass® Micro-Stent patients

36▪ % of Control patients

Postoperative AEs were ▪

generally manageable and transient and did not negatively affect functional outcomes such as visual acuity

Adverse Event, %

CyPass®

Micro-Stent

+ Phaco

n=374

Phaco only

n=131

Blepharitis 1.9% 0.0%

Corneal abrasion 1.9% 1.5%

Corneal edema 3.5% 1.5%

Conjunctivitis 1.1% 2.3%

Cyclodialysis cleft 1.9% 0.0%

Hyphema, intraoperative 2.7% 0.0%

Hypotony IOP <6 mmHg 2.9% 0.0%

IOL complication 1.1% 0.0%

IOP elevation, ≥10 mmHg above

baseline4.3% 2.3%

Iritis 8.6% 3.8%

Loss of BCVA; ≥10 letters read 8.8% 15.3%

Maculopathy/retinopathy

(cystoid, diabetic, other)3.2% 3.1%

Microstent obstruction 2.1% N/A

Subconjunctival hemorrhage 2.1% 0.8%

Surgical reintervention 5.1% 5.3%

Worsening of ocular symptoms 5.6% 3.1%

Visual field loss progression 6.7% 9.9% Safety Population, events occurring at rate of 1.0% or greater

How To Choose Which Procedure?

• Discuss with your surgeon which

procedures they perform?

• Based on Stage and Severity

– Moderate to advanced cases – Trabectome

– Early to Moderate – iStent, Xen, Cypass

– ? multiple iStents off label

– iStent inject shows promise

Post-operative Cataract IOP Spikes in

Glaucoma Patients

• Adequate control prior to surgery

– Additional drops

– SLT prior

• Consideration of combined glaucoma and

cataract procedures

• Aggressive treatment perioperatively

– Diamox at the end of the case, early post-op

• Closer follow-up post-operatively

POSTOP MANAGEMENT

PEARLS

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Traditional Cataract Surgery:

Common Complications

10-40% PCO 2-12% CME

4-10% K endo loss1-5% Vitreous prolapse Photo Accessed from Dr. John Marinelli

What to Look for After Cataract

Surgery?

1 • day – low IOP

• 3-7 days – Endophthalmitis

• 4-6 weeks – CME

2 • months – Posterior capsule opacification

Postoperative Pearls for

Advanced Technology IOLs

• Remind patient that it is normal for vision to be

blurry and eyes out of balance

• Avoid “buyer’s remorse”

• 5% of patients experience halos

• Bilateral implants

• Use -2.25D Glasses to reassure decision

• Crystalens considerations

• Communication with surgeon / referral center

• Check toric axis at one week

What to Look for After

Toric IOL Surgery?

• Crossed Cyl effect

– +sphere – double the astigmatism

– ie. +100-200x130

– Can dilate in one week if suspicious

• Consider posterior corneal astigmatism

20

Case Example DC

• CC: Decreased VA OD, > 2 yrs, progressive, affects near and far, Glare OD>OS

• BCVA OD 20/70-2 PH 20/60

OS 20/25-2 BAT 20/50-

• SLE: Cataracts OD>OS

• 12/02/08 – Unremarkable Cataract Sx OD

Postoperative Day 1

• Pain last night, today better

• UCVA OD: 20/40 PH 20/30

• IOP - 18 at 1:55pm

• SLE:

– Wound secure

– 2+ SPK

– AC well formed with about 1+ cell

– IOL well centered in pupil

Postoperative Medication

Review medications

No restrictions on physical activity

Remind patient that it is normal for vision to be blurry and eyes out of balance

F/U 1 week

Fax results to surgeon if co-managed

21

Weekend Emergency

• CC: VA decreased and foggy, no pain

• BCVA: OD 20/200 PH/NI

• IOP: 10 mmHg

• SLE: 3-4+ cells / deep / PVD / 3+ Vitritis / Dot hemes / whitening throughout periphery

• A: Increased post op inflammation OD

• P: Omnipred q1h OD, Nevanac TID, VigamoxTID / F/u tomorrow

Thoughts???

Sudden decrease in vision•

Increase in inflammation•

No PVD noted previously•

No pain / discomfort•

Dot hemorrhages in the periphery•

Differentials

TASS Endophthalmitis

Taken from http://www.retinalphysician.com/article.aspx?article=100059

What is the Most Common Organism

Found in Bacterial Endophthalmitis?

• S. aureus

• S. epidermidis

• S. pneumonia

• H. influenza

22

Endophthalmitis Vitrectomy Study

• 69% of patients with bacterial endophthalmitis were culture-positive

1. Han DP, Wisniewski SR, Wilson LA, et al. Spectrum and susceptibilities of microbiologic isolates in the endophthalmitis vitrectomy study. Am J Ophthalmol 1996;122(1):1-17.2. Speaker MG, Milch FA, Shah MK, et al. Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. Ophthalmology. 1991;98:639-649.

24%

Other

Gram-positive

organisms

70%

6%

Gram-positive

coagulase-negative

organisms (Staphylococcus

epidermidis)

Gram-negative

organisms

Endophthalmitis Vitrectomy Study

VA

Outomes

Presenting

VA

20/40 or

better

20/100 or

better

Les than

5/100

Recommen

d Treatment

HM or better TAP 62% 84% 3% TAP

PPV 66% 86% 5%

Light

Perception

TAP 11% 30% 47% PPV

PPV 33% 56% 20%

PPV = pars plana vitrectomy and intravitreal injection of antibiotics

TAP = vitreous tap and intravitreal injection of antibiotics

http://www.nei.nih.gov/neitrials/viewstudyweb.aspx?id=29#Results

Next Day Visit

• Increase in pain today

• OD VA: 20/400 NI w/ Pinhole

• SLE: Central K stain w/ Dendritic appearance / 2+ Cells in AC / 3 + Cells in Vitreous / Dot hemorrhages / Retinal whitening

What’s She Have????

Possible Acute Retinal Necrosis◦ Foscarnet 2.4 mg/ 0.1cc injected intravitreally

◦ Vicodin 5/325 1 tab every 4-6 hrs PRN

◦ Valtrex 1000mg every 8 hrs for 10 days

◦ Ordered blood cultures, fungal, PCR for VZV, HSV I, HSV 2, gram stain, CBC, Chem 7, ESR, and C-reactive protein

Cannot r/o bacterial endophthalmitis◦ Recommend intravitreal injections of Vancomycin

1mg/0.1cc and Ceftazidime 2.25 mg/ 0.1 cc.

◦ Vitreous specimen sent to lab

◦ Monitor very closely

23

Lab Reports Acute Retinal Necrosis

Definition◦ Necrotizing herpetic retinitis. May present

unilaterally or bilaterally (20%)

Epidemiology◦ Usually occurs in young, healthy adults. ◦ Less common are elderly and

immunocompromised◦ Caused by infection with HZV or HSV

History◦ Iritis or episcleritis◦ Rapid decline in VA with intense vitritis

Acute Retinal Necrosis

Important Clinical Signs◦ Vitritis with peripheral

retinal whitening that coalesces

Associated signs◦ Iridocyclitis,

photophobia, vitritis, optic neuritis, and retinal arteriolitis

Taken from www.emedicine.medscape.com/article/1223047-media on October 19, 2009

Acute Retinal Necrosis

Diagnosis

◦ Diagnosis based on

clinical exam

◦ Polymerase chain

reaction

◦ Retinal biopsy

Management◦ Systemic antiviral

treatment

◦ IV acyclovir 10mg/km tidfor 7 to 10 days

◦ Followed by 3 month course of acyclovir po

800mg five times per day

◦ Risk of RD is 8 to 12 weeks

◦ Laser photocoagulation

◦ Pars Plana Vitrectomy

24

Clinical Pearls

If patient calls with symptom of sudden

decrease VA or pain during the first week: the

doctor must see the patient

Treat as infectious until proven otherwise

Importance of communicating with surgeon

Common Corneal Procedures

Corneal • crosslinking

Penetrating • keratoplasty

Descemet’s• stripping endothelial keratoplasty

Pterygium• surgery

Superficial keratectomy•

Corneal Crosslinking

• CXL increases the rigidity of the cornea

• Indications:

– Corneal ectatic disorders

– Post-LASIK ectasia

– Infectious keratitis

– Advanced corneal edema

Photo accessed from http://www.mccarthyeye.com/corneal-cross-linking.php

Patient Selection

• CCT > 400 μ

– Less than 400 μ, hypotonic

riboflavin to induce swelling

• K’s < 60.00 D

– May not flatten enough for

significant improvement

• POcHx

– HSV

– Dry eye syndrome

25

OD → post-CXL

2.8D flattening

OS → untreated

2.6 D steepening

POM 18 after C3R OD onlyRaiskup-Wolf F. J Cataract Refract Surg 2008;

34:796-801

Corneal Crosslinking Complications

• Treatment failure – 7.6%

– Risk factors - 35 yrs or older / VA 20/25 or better / Ks

>58D

• Postoperative infection/ulcer

• Stromal haze

• Increased IOP

What’s new in CXL?

• CXL and other corneal refractive treatments

– Topo-guided PRK

– Corneal ring segment

• Trans-epithelial treatments: “epithelium on”

• CXL for microbial keratitis

• CXL for corneal edema

• Other advances and applications

Background

26

ABC’s of Corneal Transplants

• PK

• DALK

• PLK / DLEK

• DSEK / DSAEK

• DMEK / DMAEK

Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2880365/ on 10/3/11

Penetrating Keratoplasty

Descemet’s Stripping Endothelial

Keratoplasty (DSEK)

• Sutureless transplant of the posterior cornea

• Replaces diseased portion of cornea with donor

graft

• Donor tissue obtained by

– Manual dissection

– Microkeratome dissection

– Femtosecond laser

1. Photos accessed from http://www.moria-surgical.com/ on 8/26/11

2. Photos accessed from http://www.alcon.com/en/alcon-products/refractive-surgery.aspx

Indications for DSEK/DSAEK

1. http://emedicine.medscape.com/article/1193218-overview

2. http://webeye.ophth.uiowa.edu/eyeforum/cases/case5.htm

27

Advantages of DSEK/DSAEK vs. PK

• Sutures

• Visual recovery

• Astigmatism / ametropia

• Epithelial complications

• Corneal allograft rejection

• Wound strength

• Globe stability

• Length of surgery

• Intraoperative complications

• Post op visits

DSEK/DSAEK Complications

• Caused by any of the following

– Graft-recipient interface

– Fragile graft tissue

– Graft location

– Glaucoma

– Infection

– CME

– Retinal detachment

Miller, J. Accessed from http://www.revoptom.com/content/d/technology/c/16179/

Graft Rejection

Keratic• precipitates (EK/PK)

Stromal• edema (EK/PK)

Subepithelial• infiltrates (PK)

Gray epithelial line (PK)•

Price, F. Accessed on October 1, 2011 from http://one.aao.org/lms/courses/dsek/LO15.htm

Allan BDS, Terry MA, Price FW, et al. Corneal transplant rejection rate and severity after endothelial keratoplasty. Cornea.

2007;26:1039–1042

Graft Failure

• Primary vs. Iatrogenic (EK)

• Dehiscence (EK)

• Edematous cornea

(EK/PK)

• Scarring (PK)

• Vascularization (PK)

• Astigmatism (PK)

28

Case Example

• 65 YOWF Referred for Cataract Sx

– Blurred VA X 6 months Dist / Near

Stand-Alone vs. Combined

Procedures

Significance of the cataract•

Does the cornea need surgical •

intervention?

Sequential versus triple procedure•

Convenience, cost, visual recovery•

NO MORE TEARS

• 67 year old white female – OS has been

tearing for 3 weeks, some burning and

irritation, h/o allergies

• Ocular Medications – Visine prn

• Meds: OTC Zyrtec, lisinopril

• NKDA

• Assessment: Epiphora OS

Case Example

29

1. History

2. Lid Exam, Palpation of Lacrimal Sac

3. Slit Lamp Exam

4. Schirmer Tear Testing

5. Dye Disappearance Test & Jones I

6. Lacrimal Irrigation, Probing, & Jones II

7. Lower Lid Taping

8. Nasal Speculum Exam

9. Radiography

9 Steps to Evaluating the Tearing Patient

History1.

Lid Exam2.

Dye Disappearance Test3.

Lacrimal Irrigation4.

Not all steps are needed in every patient

The Big Four

• Usually will distinguish hyperlacrimation from

reduced excretion:

– Hyperlacrimation associated with discomfort

• Blepharitis—itch, burn

• Allergic conjunctivitis—itch

• Corneal foreign body—pain

• Trichiasis—irritation

• Dry Eyes—FB sensation, burn

• Iritis—ache, photophobia

• Photosensitivity--photophobia

Step 1: History

• Usually will distinguish hyperlacrimation from reduced excretion:– Hyperlacrimation associated with discomfort

– Hyperlacrimation usually not monocular

– Hyperlacrimation rarely causes frank epiphora

• Prior treatment:– Artificial tears, allergy drops

– Punctal plugs, lacrimal probings

Step 1: History

30

• Time course, duration– Severe epiphora, intermittent: lacrimal stone

– Duration less than 6 months: may benefit from probing or intubation

– “Slowly progressive” does not really help distinguish between PANDO and secondary (neoplasia, infiltration)

• Associated disorders– Previous surgery, trauma

– Previous infections (conjunctivitis, dacryocystitis, sinusitis)

– Facial nerve palsy

Step 1: History

• Facial musculature

• CNVII weakness

• Lid laxity

• Ectropion

• Entropion

• Lacrimal sac palpation

Step 2. Lid Exam

• Canalicular punctal size, position

• Tear meniscus

• Lid motion during blink

• Conjunctivochalasis

• Ocular Surface

• Everted upper lid for papillae

• Lid margin, lashes for blepharitis

Step 3. Slit Lamp Exam

• Functional tear drainage test, positive result could be due to:– Tear lake malposition

– Poor tear pump function

– Punctal stenosis or blockage of canaliculus, sac or NLD

Step 5. Dye Disappearance Test

31

So what is positive? •

Three possible outcomes•

Free flow to nose– —No obstruction (beyond punctum)

Reflux out upper – punctum upon irrigating lower—obstruction beyond common canaliculus

Resistance to irrigation or reflux around –irrigation cannula—canalicular obstruction

Step 6. Lacrimal Irrigation Rational Treatment of The Tearing Patient

Tearing

Hypersecretion

History

Slit Lamp Exam

Reduced excretion

History

Dye Disappearance

Schirmer

Dry EyesCorneal

ExposureBlepharitis Allergy

Trichiasis

Entropion

Art tears

Punctal plugs

Lid

Tightening

Lid scrubs

Compresses

Abx

Topical or

systemic Tx

Lash

Removal or

Lid surgery

SLE Lid exam

Reduced excretion

History

Dye Disappearance

Rational Treatment of The Tearing Patient

Tearing

Hypersecretion

History

Slit Lamp Exam

Reduced excretion

History

Dye Disappearance

Speculum

Nasal blockSac or NLD

block

Canaliculus

block

Punctal

malposition

Punctal

stenosis

ENT Referral Probing

DCR

Jones tube

Trephination

Medial

ectropion

repair

Punctoplasty

Irrigation SLE

Radiology

Rational Treatment of The Tearing Patient

Tearing

Hypersecretion

History

Slit Lamp Exam

Reduced excretion

History

Dye Disappearance

SLE

ConjuctivochalasisLid laxity

CNVII palsy

Ectropion

Entropion

Conjunctival

resection Lid

tightening

Ectropion

or Entropion

repair

Lid exam

Lid taping

32

Chemical Burns

• Emergency!!! - Every minute counts

• Do not waste time on Hx and PE

• Alkali burns more common and worse than acid

– Alkali

• Household cleaners, fertilizers, drain cleaners

– Acid

• Industrial cleaners, batteries, vegetable

preservatives

Chemical Burns

• Absolute Emergency

• Immediate irrigation

• Check VA

• Check pH if possible

Photo accessed from http://www.globalspec.com/ImageRepository/LearnMore/20124/PH-

Scale3125510458de479190dd027baaf7a2c2.png

Hughes Classifications of Ocular Burns

• Grade 1 (Very good prognosis) – No corneal opacity nor limbal ischemia.

• Grade 2 (Good prognosis)– Corneal haze but iris details are clear. Less than

1/3 cornea limbus ischemia.

• Grade 3 (Guarded prognosis)– Sufficient corneal haze to obscure iris details. 1/3

to 1/2 of cornea limbus ischemia

• Grade 4 (Poor prognosis)– Opaque cornea without view of iris or pupil. More

than 1/2 of cornea limbus ischemia.

Management of Chemical Burns

• Debride necrotic tissue

• Frequent ATS

• Bandage contact lens

• Quinolone: 1 gtt 4-6x/day (prevents infection)

• Prednisolone phosphate: 1 gtt q 1-2 hr while awake (reduces inflammation)

• Vitamin C: 1-2 gm po QD (reduces corneal thinning/ulceration)

• 10% sodium citrate: 1 gtt q 2 hr while awake (chelates Ca++ and impairs

PMN chemotaxis)

• Scopolamine 0.25%: 1 gtt TID (reduces pain/scarring with AC

inflammation)

• 10% Mucomyst (n-acetyl-cysteine): 1 gtt 6x/day (mucolytic agent and

collagenase inhibitor)

• Oral pain meds

• Doxycycline 100 mg po bid (collagenase inhibitor)

• Glaucoma gtts/oral diamox if IOP elevated

• Significant injury may require admission

33

Pearls - Prevention is KEY!!!

• Know the potential eye safety dangers

• All chemical injuries should be lavaged immediately

• Extent of damage is dependent on concentration and pH of acid or base

• Eliminate hazards before starting work

• Use protective measures

You’ve Got to be Kidding Me!

27• yowm presents with red, painful, blurry VA

OS. Started 10 days ago after returning from a

trip to Italy. Taking 500mg Naprosyn for HA.

Health • – Unremarkable

Vasx• : OD 20/20-3 OS 20/25-3 with NI

IOP: • 9 / 10

SLE: •

OD Mild – limbal flush / 1+ Cells

OS – 2+ Inj / 2+ Cells

What is Your Treatment?

• Prednisolone acetate 1% vs. difluprednate

0.05% vs. loteprednol etabonate .5%

• Homatropine 5% vs. Scopolamine 0.25% vs.

Atropine 1%

• Would you consider lab testing?

• Would you prescribe an oral medication?

Case #3

• Acute, bilateral non-granulomatous,

anterior uveitis OU

• Cause???

• Treatment

– Difluprednate qid OD, q2h OS

– Cyclopentolate 2% TID OU

34

Screening Tests for Syphilis

Venereal Disease Research Lab (VDRL)•

VDRL may become non– -reactive in latent

syphilis or after successful treatment

False positives may occur in:–

Pregnancy•

Infectious mononucleosis•

Systemic lupus • erythematosis

Rapid Plasma • Reagin (RPR)

Alternative to VDRL–

Fluorescent Treponemal Antibody

Absorption (FTA-ABS)

• Detects specific antibodies against T pallidum

• Confirms diagnosis of syphilis– More specific than VDRL

– More sensitive in primary syphilis

• Test may remain positive for life

• Reactive: – Primary syphilis 95%

– Secondary 100%

– Late latent 100%

– Tertiary 96%

– False positives may occur in pregnancy and SLE

Syphilis

• STD caused by T pallidum / great imitator / any tissue and organ

• Sexually active / multiple partners

• Systemic Sx – Depends on stage – primary - painless ulcer /

secondary - skin rash palms, soles, trunk / tertiary - neurosyphilis

• All types of ocular inflammation

• Labs

– VDRL / RPR

– FTA – ABS

– ESR elevated

• Tx – penicillin therapy

• Good prognosis if treated early

35

So He Has an Allergy to PCN?

• Augenbraun M, Workowski K. Ceftriaxone

therapy for syphilis: report from the

emerging infections network. Clin Infect

Dis. 1999 Nov. 29(5):1337-8

– Tetracycline, erythromycin, and ceftriaxone

have shown antitreponemal activity in clinical

trial

Comanagement Pearls

• Communication is key!

• Opportunity to provide cutting edge

technology

• Importance of your recommendation

• Patient education is critical!

Comanagement Pearls

• Identify potential causes of surgical

complications

• Educate your patients your role within

medical eye care

• We are all judged by the visual outcomes

our patients. Comfort and quality of vision

is the key!