2018 Northwest Residents Conference
Saturday, June 9, 2018 9:00 am‐3:00 pm (6.0 hours) 2018 Perspectives on Principles sof Diagnosi (PD) Linda Shi, OD: Go With the Flow ‐ Exploring OCT Angiography. 2018 Perspectives on Glaucoma (GL) • Stephanie Rettenmeier, OD: Detection of Glaucomatous Visual Field Progression: A Review of Current and Future Developments. • Daniel Cleveland, OD: Early ab interno intervention: Advances in surgical techniques and their impact on glaucoma management 2018 Perspectives on Peri‐Operative Management of Ophthalmic Surgery (PO) Brian Ki, OD: Post‐Operative Endophthalmitis. 2018 Perspectives on Treatment & Management of Ocular Disease Anterior Segment (AS) Katherine Homa, OD: Capsular Bag Distention Syndrome Eight Years after Cataract Surgery. 2018 Perspectives on Functional Vision (FV) • Neil Renaud, OD: Treatment of Infantile Exotropia with Lenses and Vision Therapy • Elizabeth Powers, OD: Practical Solutions to Complex Problems: A Survey of the Visual‐Evoked Potential’s Usefulness in Altering the Course of Therapy. • Jamison Soupir, OD: Efficient and Comfortable Uses of Monovision in Diplopia Management. • Megan Thistle, OD: Visual‐Vestibular Therapy of a Female Patient 3 Years Post‐Concussion. 2018 Perspectives on General Optometry (GO) • Steve Turpin, OD: The Use of Tinted to Contact Lenses to Treat Photophobia in Patients with Sensory Integration Disorders, Migraine, and TBI. 2018 Perspectives on Refractive Surgery and Management (RS) • Amanda Thurmes, OD: What are Patient’s SMILE‐ing About? 2018 Perspectives on Treatment & Management of Ocular Disease Posterior Segment (PS) |Part 2 • Ben Nielson, OD: Ocular Ischemic Syndrome.
1 Residents Conference Continuing Education Program
is supported by an education grant from Alcon Partners in Education
with additional support from Allergan Novartis Learning Objectives
• Understand how to analyze optical coherence tomography Go with the Flow: angiography images for diagnosis and management of numerous ocular conditions, including: Exploring OCT Angiography • Diabetic retinopathy LINDA SHI, OD, MBA • Macular degeneration VA PORTLAND HEALTH CARE SYSTEM • Vein occlusion • Glaucoma • Optic neuropathy • Others
Optical Coherence Tomography Financial Disclosure • No financial interests or relationships to • Time Domain disclose.
• Spectral / Fourier Domain
• Swept Source
Angiography Side effects! • Fluorescein Angiography • Indocyanine Green Angiography
2 What is OCT Angiography? What is OCT Angiography? “Optical coherence tomography angiography (OCTA) is a new non‐invasive imaging technique that employs motion contrast imaging to high‐resolution volumetric blood flow information generating angiographic images in a matter of seconds. OCTA compares the decorrelation signal […] between sequential OCT b‐scans taken at precisely the same cross‐section in order to construct a map of blood flow.” Sambhav K, Grover S, Chalam K. The application of optical coherence tomography angiography in retinal diseases. Survey of de Carlo T, Romano A, Waheed N, Duker J. A review of optical coherence tomography angiography (OCTA). International Journal of Retina and Vitreous. Ophthalmology. 2017;62(6):838‐866. doi:10.1016/j.survophthal.2017.05.006. 2015;1(1). doi:10.1186/s40942‐015‐0005‐8.
Why is OCTA better? • Asdf
Sambhav K, Grover S, Chalam K. The application of optical coherence tomography angiography in retinal diseases. Survey of Ophthalmology. 2017;62(6):838‐866. Tan, A., Tan, G., Denniston, A., Keane, P., Ang, M., Milea, D., Chakravarthy, U. and Cheung, C. (2017). An overview of the clinical applications of optical coherence doi:10.1016/j.survophthal.2017.05.006. tomography angiography. Eye, 32(2), pp.262‐286.
What should normal look like? What does abnormal look like? • Vascular conditions • Diabetic Retinopathy • Macular Degeneration • Choroidal neovascularization • Artery and vein occlusions • Optic nerve conditions • Glaucoma • NAION
Sambhav K, Grover S, Chalam K. The application of optical coherence tomography angiography in retinal diseases. Survey of Ophthalmology. 2017;62(6):838‐866. • Other doi:10.1016/j.survophthal.2017.05.006.
3 CLINICAL APPLICATIONS: Diabetic Retinopathy Diabetic Retinopathy • Increased size of foveal avascular • Increased size of foveal avascular zone (FAZ) zone (FAZ) • Decreased vessel density • Relationship • Vascular changes with vision?
Sambhav K, Grover S, Chalam K. The application of optical coherence tomography angiography in retinal diseases. Survey of Ophthalmology. 2017;62(6):838‐866. doi:10.1016/j.survophthal.2017.05.006.
Diabetic Retinopathy Diabetic Retinopathy • Decreased vessel density • Vascular changes
Ting D, Tan G, Agrawal R et al. Optical Coherence Tomographic Angiography in Type 2 Diabetes and Diabetic Retinopathy. JAMA Ophthalmology. 2017;135(4):306. Gao S, Jia Y, Zhang M et al. Optical Coherence Tomography Angiography. Investigative Opthalmology & Visual Science. doi:10.1001/jamaophthalmol.2016.5877. 2016;57(9):OCT27. doi:10.1167/iovs.15‐19043.
CLINICAL APPLICATIONS: Macular Degeneration
• Dry: Geographic atrophy • Wet: Choroidal neovascular membrane
Ishibazawa, A., Nagaoka, T., Yokota, H., Takahashi, A., Omae, T., Song, Y. S., ... & Yoshida, A. (2016). Characteristics of retinal neovascularization in proliferative diabetic retinopathy imaged by optical coherence tomography angiography. Investigative ophthalmology & visual science, 57(14), 6247‐6255.
4 Macular Degeneration Macular Degeneration
• Geographic atrophy • Choroidal neovascular membrane
Sambhav K, Grover S, Chalam K. The application of optical coherence tomography angiography in retinal diseases. Survey of Sambhav K, Grover S, Chalam K. The application of optical coherence tomography angiography in retinal diseases. Survey of Ophthalmology. 2017;62(6):838‐866. doi:10.1016/j.survophthal.2017.05.006. Ophthalmology. 2017;62(6):838‐866. doi:10.1016/j.survophthal.2017.05.006.
Eandi C, Ciardella A, Parravano M et al. Indocyanine Green Angiography and Optical Coherence Tomography Angiography of Choroidal Neovascularization in Age‐ Eandi C, Ciardella A, Parravano M et al. Indocyanine Green Angiography and Optical Coherence Tomography Angiography of Choroidal Neovascularization in Age‐ Related Macular Degeneration. Investigative Opthalmology & Visual Science. 2017;58(9):3690. doi:10.1167/iovs.17‐21941. Related Macular Degeneration. Investigative Opthalmology & Visual Science. 2017;58(9):3690. doi:10.1167/iovs.17‐21941.
CLINICAL APPLICATIONS: CLINICAL APPLICATIONS: Artery Occlusion Vein Occlusion
Sambhav K, Grover S, Chalam K. The application of optical coherence tomography angiography in retinal diseases. Survey of Ophthalmology. 2017;62(6):838‐866. doi:10.1016/j.survophthal.2017.05.006. Sambhav K, Grover S, Chalam K. The application of optical coherence tomography angiography in retinal diseases. Survey of Ophthalmology. 2017;62(6):838‐866. doi:10.1016/j.survophthal.2017.05.006.
5 CLINICAL APPLICATIONS: Sickle Cell CLINICAL APPLICATIONS: Glaucoma • asdfassadf • Vessel density • Superficial vascular complex • Optic nerve head • Foveal avascular zone • Peripapillary retina
Sambhav K, Grover S, Chalam K. The application of optical coherence tomography angiography in retinal diseases. Survey of Ophthalmology. 2017;62(6):838‐866. doi:10.1016/j.survophthal.2017.05.006.
NORMAL GLAUCOMA
• Superficial vascular complex (SVC) vessel density (VD) • Best diagnostic accuracy for differentiating normal and glaucoma eyes • Good correlation with GCC thickness, VF sensitivity, glaucoma stage • SVC VD and GCC thickness may provide an objective, quantitative measure of glaucoma severity
Glaucoma
• Optic nerve vessel density
• Significant relationship between vessel density and severity of visual field damage • Vessel density may be a better reflection of retinal ganglion cell functioning than structural loss • Glaucoma eyes had significantly sparser vessel density within Jia Y, Morrison JC, Tokayer J, et al. Quantitative OCT angiography of optic nerve head blood flow. Biomed Opt Express. 2012; 3: 3127–3137. the RNFL compared with glaucoma suspect and healthy eyes
6 Glaucoma
• Foveal avascular zone
Zivkovic, M., Dayanir, V., Kocaturk, T., Zlatanovic, M., Zlatanovic, G., Jaksic, V., ... & Jovanovic, S. (2017). Foveal Avascular Zone in Normal Tension Glaucoma Measured by Yarmohammadi A, Zangwill L, Diniz‐Filho A et al. Relationship between Optical Coherence Tomography Angiography Vessel Density and Severity of Optical Coherence Tomography Angiography. BioMed Research International, 2017. Visual Field Loss in Glaucoma. Ophthalmology. 2016;123(12):2498‐2508. doi:10.1016/j.ophtha.2016.08.041.
Glaucoma
• Peripapillary vessel density
• OCTA documented a reduction of the peripapillary perfusion in NTG and unilateral NAION. • In presence of similar functional damage, the lower perfusion densities in NTG may indicate greater vascular alterations in chronic compared to acute
Liu, Liang, et al. "Optical coherence tomography angiography of the peripapillary retina in glaucoma." JAMA ophthalmology133.9 (2015): 1045‐1052. ischemic optic neuropathies.
CLINICAL APPLICATIONS: NAION
• Peripapillary vascular flow density • Why use OCTA? • Retinal peripapillary capillary flow impairment corresponded to • Ganglion cell layer complex (GCC) (100%) • Automated visual field deficits (90%) • Retinal nerve fiber layer (RNFL) (80%) • Peripapillary choriocapillaris flow impairment corresponded to • Ganglion cell layer complex (GCC) (80%) Tan, Anna CS, et al. "An overview of the clinical applications of optical coherence tomography angiography." Eye 32.2 (2018): 262.
7 CLINICAL APPLICATIONS: CLINICAL APPLICATIONS: Anterior Segment Other conditions
Villegas V, Monroig A, Aguero L, Schwartz S. Optical Coherence Tomography Angiography of Two Choroidal Nevi Variants. Case Reports in Ophthalmological Kang, A. S., Welch, R. J., Sioufi, K., Say, E. A. T., Shields, J. A., & Shields, C. L. (2017). Optical Tan, Anna CS, et al. "An overview of the clinical applications of optical coherence Medicine. 2017;2017:1‐4. doi:10.1155/2017/1368581 coherence tomography angiography of iris microhemangiomatosis. American journal of tomography angiography." Eye 32.2 (2018): 262. ophthalmology case reports, 6, 24‐26.
Limitations
• Cannot show leakage • Small field of view • Limited normative database • Image artifact due to patient movement
Wide‐Angle OCTA
•Similar rates of identification of CNV, MAs, and macular ischemia, in addition to superior inter‐reader agreement.
Sawada, Osamu, et al. "Comparison between wide‐angle OCT angiography and ultra‐wide field fluorescein angiography for detecting non‐perfusion areas and retinal neovascularization in eyes with diabetic retinopathy." Graefe's Archive for Clinical and Experimental Ophthalmology (2018): 1‐6.
8 Other Considerations •Purchase of a new, faster OCT device •No modification in billing code for OCT‐A currently exists beyond that of “In short, I believe that OCTA will impact conventional structural OCT B‐scan patient care in the next 10 years as significantly as OCT has impacted patient care in the past 10 years.” ‐ Dr. Amir H. Kashani, MD, PhD USC Eye Institute, Keck School of Medicine
References References (continued)
• New Views of Retina With OCT Angiography. (2015, Jul). Retrieved from American Academy of Ophthalmology. • Jia, Y., Morrison, J. C., Tokayer, J., Tan, O., Lombardi, L., Baumann, B., ... & Huang, D. (2012). Quantitative OCT • Babiuch, A. S., Khan, M., Hu, M., Kaiser, P. K., Srivastava, S. K., Singh, R. P., ... & Ehlers, J. P. (2017). Comparison angiography of optic nerve head blood flow. Biomedical optics express, 3(12), 3127‐3137. of OCT Angiography Review Strategies to Identify Vascular Abnormalities in the AVATAR Study. Ophthalmology • Kang, A. S., Welch, R. J., Sioufi, K., Say, E. A. T., Shields, J. A., & Shields, C. L. (2017). Optical coherence Retina. tomography angiography of iris microhemangiomatosis. American journal of ophthalmology case reports, 6, 24‐ • De Carlo, T. E., Romano, A., Waheed, N. K., & Duker, J. S. (2015). A review of optical coherence tomography 26. angiography (OCTA). International Journal of Retina and Vitreous, 1(1), 5.de Carlo, T. (2018). Will OCT • Liu, L., Jia, Y., Takusagawa, H. L., Pechauer, A. D., Edmunds, B., Lombardi, L., ... & Huang, D. (2015). Optical Angiography Replace FA?. Retrieved from Retina‐specialist.com. coherence tomography angiography of the peripapillary retina in glaucoma. JAMA ophthalmology, 133(9), • Jia, Y., Bailey, S. T., Wilson, D. J., Tan, O., Klein, M. L., Flaxel, C. J., ... & Fujimoto, J. G. (2014). Quantitative optical 1045‐1052. coherence tomography angiography of choroidal neovascularization in age‐related macular • Mammo, Z., Heisler, M., Balaratnasingam, C., Lee, S., Yu, D. Y., Mackenzie, P., ... & Navajas, E. (2016). degeneration. Ophthalmology, 121(7), 1435‐1444. Quantitative optical coherence tomography angiography of radial peripapillary capillaries in glaucoma, • Gao, S. S., Jia, Y., Zhang, M., Su, J. P., Liu, G., Hwang, T. S., ... & Huang, D. (2016). Optical coherence tomography glaucoma suspect, and normal eyes. American journal of ophthalmology, 170, 41‐49. angiography. Investigative ophthalmology & visual science, 57(9), OCT27‐OCT36. • Mansoori, T., Sivaswamy, J., Gamalapati, J. S., Agraharam, S. G., & Balakrishna, N. (2017). Measurement of • Holló, G. (2018). Comparison of Peripapillary OCT Angiography Vessel Density and Retinal Nerve Fiber Layer radial peripapillary capillary density in the normal human retina using optical coherence tomography Thickness Measurements for Their Ability to Detect Progression in Glaucoma. Journal of glaucoma, 27(3), 302‐ angiography. Journal of glaucoma, 26(3), 241‐246. 305. • Mase, T., Ishibazawa, A., Nagaoka, T., Yokota, H., & Yoshida, A. (2016). Radial peripapillary capillary network Ishibazawa, A., Nagaoka, T., Yokota, H., Takahashi, A., Omae, T., Song, Y. S., ... & Yoshida, A. (2016). visualized using wide‐field montage optical coherence tomography angiography. Investigative ophthalmology & Characteristics of retinal neovascularization in proliferative diabetic retinopathy imaged by optical coherence visual science, 57(9), OCT504‐OCT510. tomography angiography. Investigative ophthalmology & visual science, 57(14), 6247‐6255.
References (continued) References (continued)
• Matsunaga, D. R., Jack, J. Y., De Koo, L. O., Ameri, H., Puliafito, C. A., & Kashani, A. H. (2015). Optical coherence • Tang, F. Y., Ng, D. S., Lam, A., Luk, F., Wong, R., Chan, C., ... & Lai, F. (2017). Determinants of Quantitative Optical tomography angiography of diabetic retinopathy in human subjects. Ophthalmic Surgery, Lasers and Imaging Coherence Tomography Angiography Metrics in Patients with Diabetes. Scientific reports, 7(1), 2575. Retina, 46(8), 796‐805. • Takusagawa, H. L., Liu, L., Ma, K. N., Jia, Y., Gao, S. S., Zhang, M., ... & Huang, D. (2017). Projection‐resolved • Mayes, E. W., Cole, E. D., Dang, S., Novais, E. A., Vuong, L., Mendoza‐Santiesteban, C., ... & Hedges III, T. R. optical coherence tomography angiography of macular retinal circulation in glaucoma. Ophthalmology, 124(11), (2017). Optical coherence tomography angiography in nonarteritic anterior ischemic optic neuropathy. Journal 1589‐1599. of Neuro‐ophthalmology, 37(4), 358‐364. • Ting, D. S. W., Tan, G. S. W., Agrawal, R., Yanagi, Y., Sie, N. M., Wong, C. W., ... & Wong, T. Y. (2017). Optical • Sawada, O., Ichiyama, Y., Obata, S., Ito, Y., Kakinoki, M., Sawada, T., ... & Ohji, M. (2018). Comparison between coherence tomographic angiography in type 2 diabetes and diabetic retinopathy. JAMA ophthalmology, 135(4), wide‐angle OCT angiography and ultra‐wide field fluorescein angiography for detecting non‐perfusion areas 306‐312. and retinal neovascularization in eyes with diabetic retinopathy. Graefe's Archive for Clinical and Experimental • Villegas, V. M., Monroig, A. L., Aguero, L. H., & Schwartz, S. G. (2017). Optical Coherence Tomography Ophthalmology, 1‐6. Angiography of Two Choroidal Nevi Variants. Case reports in ophthalmological medicine, 2017. • Salz, D. A., Talisa, E., Adhi, M., Moult, E., Choi, W., Baumal, C. R., ... & Waheed, N. K. (2016). Select features of • Yarmohammadi, A., Zangwill, L. M., Diniz‐Filho, A., Suh, M. H., Yousefi, S., Saunders, L. J., ... & Weinreb, R. N. diabetic retinopathy on swept‐source optical coherence tomographic angiography compared with fluorescein (2016). Relationship between optical coherence tomography angiography vessel density and severity of visual angiography and normal eyes. JAMA ophthalmology, 134(6), 644‐650. field loss in glaucoma. Ophthalmology, 123(12), 2498‐2508. • Sambhav, K., Grover, S., & Chalam, K. V. (2017). The application of optical coherence tomography angiography • Zivkovic, M., Dayanir, V., Kocaturk, T., Zlatanovic, M., Zlatanovic, G., Jaksic, V., ... & Jovanovic, S. (2017). Foveal in retinal diseases. Survey of ophthalmology, 62(6), 838‐866. Avascular Zone in Normal Tension Glaucoma Measured by Optical Coherence Tomography Angiography. BioMed • Tan, A. C., Tan, G. S., Denniston, A. K., Keane, P. A., Ang, M., Milea, D., ... & Cheung, C. M. G. (2018). An overview Research International, 2017. of the clinical applications of optical coherence tomography angiography. Eye, 32(2), 262.
9 Questions?
10 Learning Objectives Detection of Glaucomatous Visual Field Progression: Understand Current approaches used to assess visual field progression A Review of Current & Describe Characteristic patterns of visual field progression Which methods are most useful for measuring visual field Future Developments Recognize progression in different stages of glaucoma Identify Factors for predicting progressive visual fields Stephanie Rettenmeier, OD | June 9, 2018 VA Portland Health Care System, Salem CBOC Recognize Future developments of visual field monitoring in glaucoma
» Projected to have 111.8 million no financial affected by 2040 globally20 interests or Financial Disclosure relationships » By 2050 glaucoma will more to disclose than double in the United States
Photo credit: https://nei.nih.gov/eyedata/glaucoma
review of Can I Rely On visual field reliability the Data? indices Photo credit: https://en.wikipedia.org/wiki/Seidel_sign#/media/File:Types_ of_scotomas_and_the_location_on_the_retina.png Photo credit: https://entokey.com/visual‐fields‐in‐glaucoma/
Retinal Nerve Fiber Layer Distribution & Glaucomatous Visual Field Defects
11 Reliability Indices
» Humphrey Visual Field Analyzer software cutoffs24
False Positives False Negatives Fixation Losses 33% 33% 20%
Photo source: https://applications.zeiss.com/C1257BB3003850AB/0/E91C309ACB2BC8A9C12 57A29005B27E9/$FILE/HFA_Sample_Cases_brochure_HFA.4002.pdf
Guidelines to Consider 24 Study Findings
Fixation losses: False positives: False negatives: Test duration: Fixation False False Test caution in new caution with > 14‐20% more needed to longer test Losses Positives Negatives Duration visual field takers or high FP in advanced be unreliable in indicates disease advanced disease unreliable Impact on Reliability Minimal High Low Moderate (< 5 visual fields) Clinically Significant Predictors of Visual Field Reliability No YES YES YES (in established visual field takers) Early disease: Advanced caution when FN disease: caution >25% when FN >35%
Yohannan, J., Wang, J., Brown, J., Chauhan, B. C., Boland, M. V., Friedman, D. S., & Ramulu, P. Y. (2017). Evidence‐based Criteria for Assessment of Visual Field Reliability. Ophthalmology, 124(11), 1612‐1620. 14 Exercise caution in reliability indices approaching 15% or >15%
analysis & the landmark What Defines detection of glaucoma visual field studies Current Methods Progression? progression
12 Strategies for Detecting Progression Glaucoma Hemifield Test
› Superior and inferior hemifields Subjective Assessment in Clinical Practice affected asymmetrically › Threshold measured and compared Glaucoma Hemifield Analysis at five sets of points based on pattern deviation map2,8 Event Based Analysis › Outside Normal Limits: can indicate glaucomatous field loss is present
Trend Based Analysis Photo source: Boland, M. V., & Quigley, H. A. (2011). Evaluation of a › Now: Structure – function disparity? combined index of optic nerve structure and function for glaucoma diagnosis. BMC ophthalmology, 11(1), 6.
› Anatomical variations can cause inaccurate mapping of visual field to GHT: WITHIN NORMAL LIMITS optic nerve and corresponding RNFL NP AND HMD: ASYMMETRICAL/OUTSIDE NORMAL LIMITS
› New criteria proposed: › Number of Test Pairs (NP) › Hemifield Mean Deviation (HMD) › Hemifield Standard Deviation (HSD)
Ghazali, N., Aslam, T., & Henson, D. B. (2015). New superior–inferior Ghazali, N., Aslam, T., & Henson, D. B. (2015). New superior–inferior visual field asymmetry indices for detecting POAG and their visual field asymmetry indices for detecting POAG and their agreement with the glaucoma hemifield test. Eye, 29(10), 1375. agreement with the glaucoma hemifield test. Eye, 29(10), 1375.
Event Based Analysis Event Based › Guided Progression Analysis (GPA)11,14,18,19 › Progression using pattern deviation plot which targets localized change 18 Analysis › New glaucoma defects › Expansion/deepening of existing defects Guided Progression › Better for progression in early glaucoma Analysis (GPA) › Poor at indicating diffuse progression or in severe glaucoma
Photo source: https://www.zeiss.com/content/dam/Meditec/us/download/cer tified‐pre‐owned‐systems/perimetry‐brochure‐HFA.pdf
13 Glaucoma Stages Defined Trend Based Analysis |Linear Regression American Glaucoma Society Mild/Early •Optic nerve appearance consistent with glaucoma › Use of Mean Deviation (MD) to monitor for changes in • No visual field defects on any visual field OR abnormalities present on SWAP threshold sensitivity over time19 or FDT › Decline of ‐1.00 to ‐1.20 dB/year at two or more test points Moderate is significant4,19 •Optic nerve appearance consistent with glaucoma •AND glaucomatous visual field defects in one hemifield NOT involving central › Normal MD value within 0 to ‐2dB4 5 degrees of fixation › MD does not distinguish between focal and diffuse change Advanced/Severe •Optic nerve appearance consistent with glaucoma •AND glaucomatous visual field defects in BOTH hemifields •AND/OR involving central 5 degrees of fixation in one or both hemifields
Trend Based Analysis › Percentage of functional vision Visual Field compared to age norms Trend Based 4,11,19 › 100% is normal Analysis Index (VFI) › 0% is functionally blind › Accounts for media opacity effects Visual Field on declining MD4,19 Index4 › Poor in early & very advanced glaucoma (MD less than ‐20dB)11,19
Photo source: Mendel, M & Monhart, M. (2016) ZEISS ophthalmic diagnostics trainings. GPA educational slides. Guided progression analysis in structure and function. Personal collection of Mely Medel & Matthias Monhart, ZEISS.
Photo source: Mendel, M & Monhart, M. (2016) ZEISS ophthalmic diagnostics trainings. GPA educational slides. Guided progression analysis in structure and function. Personal collection of Mely Medel & Matthias Monhart, ZEISS.
Trend Based Analysis Patterns Visual Field how visual field defects are expected Index to progress & where to look
Chauhan, B. C., Garway‐Heath, D. F., Goñi, F. J., Rossetti, L., Bengtsson, B., Viswanathan, A. C., & Heijl, A. (2008). Practical recommendations for measuring rates of visual field change in glaucoma. British Journal of Ophthalmology, 92(4), 569‐573.
14 How Will Current Defects Change? How Will Current Progression occurs where there is already depression6 Defects Debated whether glaucomatous damage is linear or non‐linear Change?
Source: Kim, J. M., Kyung, H., Shim, S. H., Azarbod, P. , & Caprioli, J. (2015). Location of initial visual field defects in Central vs. Peripheral defects glaucoma and their modes of deterioration. Investigative ophthalmology & visual science, 56(13), 7956‐7962.
24‐2 24‐210‐2 10‐2
30% of RGC are in the macula
More superior hemifield 16‐34% of normal 24‐2 24‐210‐2 defects on 10‐2 (consistent with visual fields had abnormal more vulnerable inferior RNFL) visual fields on 10‐211,21
Source: Traynis, I., De Moraes, C. G., Raza, A. S., Liebmann, J. M., Ritch, R., & Hood, D. C. (2014). Prevalence and nature of early glaucomatous defects in the central 10 of the visual field. JAMA ophthalmology, 132(3), 291‐297.
“Dual” Nasal Step Frequency of “ideal” versus reality How does testing inferior RNFL thinning cause an inferior 5 nasal step? 6 visual fields within 2 years of diagnosis for baseline Photo source: https://en.wikipedia.org/wiki/Seidel_sign#/media/File:Types_of_scotom Photo source: https://www.reviewofoptometry.com/article/back‐to‐the‐basics‐ as_and_the_location_on_the_retina.png part‐5‐my‐patient‐has‐an‐rapd‐now‐what
15 o Tests 24 degrees, 52 points o Fast‐threshold 3dB staircase Virtual Reality o High correlation between VRVF and HVF Visual Fields
Source: Tsapakis, S., Papaconstantinou, D., Diagourtas, A., Droutsas, K., Andreanos, K., Moschos, M. M., & Brouzas, D. (2017). Visual field examination method using Future Developments virtual reality glasses compared with the Humphrey perimeter. Clinical on the horizon ophthalmology (Auckland, NZ), 11, 1431‐1443.
Virtual Reality Visual Fields Objective Visual Field Testing
Photo source: Tsapakis, S., Papaconstantinou, D., Diagourtas, A., Droutsas, K., Andreanos, K., Moschos, M. M., & Brouzas, D. (2017). Visual field Source: Moon, C., Han, J., Ohn, Y., & Park, T. (2015). Local Relationship between Global‐Flash Multifocal Electroretinogram examination method using virtual reality glasses compared with the Humphrey perimeter. Clinical ophthalmology (Auckland, NZ), 11, 1431‐1443. Optic Nerve Head Components and Visual Field Defects in Patients with Glaucoma. Journal of Ophthalmology., 2015, 397495.
Testing for Different Stages of Glaucoma16 To Consider EARLY ADVANCED
Guided Progression Analysis1 10‐2 central visual field17 o We need more comprehensive normative data pools 10‐2 tests macular function17 Goldmann manual perimetry o Run 10‐2 in those with GCC/macular defects 20% of patients with pre‐ Target Size V11 o Structure‐Function integration for monitoring perimetric glaucoma on SAP have functional loss on: SITA SWAP7 FDT7,23
16 the gold standard is still….. standard automated perimetry static III4e white‐white
Photo source: http://medilexcaribbean.com/wp‐content/uploads/2016/10/HFA3_Main_980x308‐1.jpg
References 1. Arend, K. O., & Plange, N. (2006). Diagnostic approaches for early detection of glaucoma progression. Klinische Monatsblatter fur Augenheilkunde, 223(3), 194‐216. in summary… 2. Boland, M. V., & Quigley, H. A. (2011). Evaluation of a combined index of optic nerve structure and function for glaucoma diagnosis. BMC ophthalmology, 11(1), 6. 3. Brandao, L., Ledolter, A., Monhart, M., Schötzau, A., & Palmowski‐Wolfe, A. (2017). Ganglion cell layer segmentation and the two‐flash multifocal electroretinogram improve structure function analysis in early glaucoma. Graefe's Archive for Clinical and Experimental Ophthalmology., 255(10), 1991‐2000.
4. Chaglasian, M. (2013, February 15). Sharpen Your Visual Field Interpretation Skills. Retrieved from https://www.reviewofoptometry.com/article/sharpen‐your‐visual‐field‐interpretation‐ skills VISUAL FIELDS PLAY AN 5. Chauhan, B. C., Garway‐Heath, D. F., Goñi, F. J., Rossetti, L., Bengtsson, B., Viswanathan, A. C., & Heijl, A. (2008). Practical recommendations for measuring rates of visual field change in glaucoma. British Journal of Ophthalmology, 92(4), 569‐573. IMPORTANT ROLE IN 6. De Moraes, C. G., Liebmann, J. M., & Levin, L. A. (2017). Detection and measurement of clinically meaningful visual field progression in clinical trials for glaucoma. Progress in retinal and eye research, 56, 107‐147.
7. Ferreras, A., Polo, V., Larrosa, J. M., Pablo, L. E., Pajarin, A. B., Pueyo, V., & Honrubia, F. M. (2007). Can frequency‐doubling technology and short‐wavelength automated perimetries detect GLAUCOMA MANAGEMENT visual field defects before standard automated perimetry in patients with preperimetric glaucoma?. Journal of glaucoma, 16(4), 372‐383.
8. Ghazali, N., Aslam, T., & Henson, D. B. (2015). New superior–inferior visual field asymmetry indices for detecting POAG and their agreement with the glaucoma hemifield test. Eye, 29(10), 1375.
9. Glaucoma stage definitions. American Glaucoma Society and American Academy of Ophthalmology. Revised: February 2015. Retrieved from: THERE IS NO GOLD STANDARD http://www.americanglaucomasociety.net/professionals FOR DETECTING VISUAL FIELD 10. Hirooka, K., Sato, S., Nitta, E., & Tsujikawa, A. (2016). The relationship between vision‐related quality of life and visual function in glaucoma patients. Journal of glaucoma, 25(6), 505. 11. Iester, M., Capris, E., De Feo, F., Polvicino, M., Brusini, P., Capris, P., ... & Manni, G. (2010). Agreement to detect glaucomatous visual field progression by using three different methods: a multicentre study. British Journal of Ophthalmology, bjo‐2010.
PROGRESSION 12. Kim, J. M., Kyung, H., Shim, S. H., Azarbod, P., & Caprioli, J. (2015). Location of initial visual field defects in glaucoma and their modes of deterioration. Investigative ophthalmology & visual science, 56(13), 7956‐7962.
References continued… 13. Ledolter, A., Monhart, M., Schoetzau, A., Todorova, M., & Palmowski‐Wolfe, A. (n.d.). Structural and functional changes in glaucoma: Comparing the two‐flash multifocal electroretinogram to optical coherence tomography and visual fields. Documenta Ophthalmologica., 130(3), 197‐209.
14. Mendel, M& Monhart, M. (2016) ZEISS ophthalmic diagnostics trainings. GPA educational slides. Guided progression analysis in structure and function. Personal collection of Mely Medel & Matthias Monhart, ZEISS.
15. Moon, C., Han, J., Ohn, Y., & Park, T. (2015). Local Relationship between Global‐Flash Multifocal Electroretinogram Optic Nerve Head Components and Visual Field Defects in Patients with Glaucoma. Journal of Ophthalmology., 2015, 397495.
16. Nouri‐Mahdavi, K. (2014). Selecting visual field tests and assessing visual field deterioration in glaucoma. Canadian Journal of Ophthalmology, 49(6), 497‐505.
17. Rao, H. L., Begum, V. U., Khadka, D., Mandal, A. K., Senthil, S., & Garudadri, C. S. (2015). Comparing glaucoma progression on 24‐2 and 10‐2 visual field examinations. PloS one, 10(5), e0127233.
18. Sample, P.A. (2007). Documenting progression on Humphrey visual fields: using the glaucoma progression analysis software in clinical practice. Glaucoma today, NOV/DEC 2007, p33‐36. Retrieved from: http://glaucomatoday.com/2007/12/GT1107_04.php/
19. Tanna, A. P., & Desai, R. U. (2014). Evaluation of Visual Field Progression in Glaucoma. Current Ophthalmology Reports, 2(2), 75‐79. 20. Tham, Y. C., Li, X., Wong, T. Y., Quigley, H. A., Aung, T., & Cheng, C. Y. (2014). Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and Questions? meta‐analysis. Ophthalmology, 121(11), 2081‐2090.
21. Traynis, I., De Moraes, C. G., Raza, A. S., Liebmann, J. M., Ritch, R., & Hood, D. C. (2014). Prevalence and nature of early glaucomatous defects in the central 10 of the visual field. JAMA ophthalmology, 132(3), 291‐297. thank you for your attention 22. Tsapakis, S., Papaconstantinou, D., Diagourtas, A., Droutsas, K., Andreanos, K., Moschos, M. M., & Brouzas, D. (2017). Visual field examination method using virtual reality glasses compared with the Humphrey perimeter. Clinical ophthalmology (Auckland, NZ), 11, 1431‐1443.
23. Wall, M., Johnson, C. A., & Zamba, K. D. (2018). SITA‐Standard perimetry has better performance than FDT2 matrix perimetry for detecting glaucomatous progression. British Journal of Ophthalmology, bjophthalmol‐2017.
24. Yohannan, J., Wang, J., Brown, J., Chauhan, B. C., Boland, M. V., Friedman, D. S., & Ramulu, P. Y. (2017). Evidence‐based Criteria for Assessment of Visual Field Reliability. Ophthalmology, 124(11), 1612‐1620.
17 Contact Information
Stephanie Rettenmeier, OD [email protected]
Russell Jew, OD [email protected]
18 Description
Early Ab Interno Intervention: • Patient case studies combined with research Advances in surgical techniques and their impact on glaucoma on the newest MIGS and procedures that can management be used with and without cataract extraction. Deciding when to refer, and what surgical procedure would be in your patients’ best Dr. Daniel Cleveland interest. ICON EYECARE
Learning Objectives Categorization By the end of the presentation, attendees will be able to • POAG vs angle closure, neovascular, uveitic, 1. Recognize the need for surgical intervention steroid induced, postsurgical ect. 2. Identify ideal candidates for each procedure – POAG‐ could be as many as 76 million world wide by 3. Explain the medical and financial benefit to surgical intervention 2020, 6.1 billion in pharmaceutical revenue 4. Describe new and currently approved procedures most likely – Goal is to lower IOP to a level that will preserve visual to be used function for a pts lifetime* 5. Define anatomical location and method of action for each procedure – Mild, Moderate, Advanced, and Severe: Based on 6. Distinguish between failed surgery and progressive disease Hodapp, Parrish, Anderson Grading from 1993, using 7. Differentiate between complications and expected outcomes Humphrey MD score and other qualifying criteria of 8. Discuss the efficacy and safety profile of each procedure visual fields 9. Determine what procedure is appropriate based on disease – OCT floor of 55‐45um RNFL measurement course
Jerry Gergich Maximize Topicals – EMGT‐ Early Manifest Glaucoma Trial • Every mmHg counts; 10‐13% risk reduction • Contrary to what CIGTS found, no increased risk from fluctuation; Mean IOP is the objective measure to follow • Disease rate of progression is variable and difficult to predict; affected by – Age, initial IOP, and degree of glaucomatous damage – AGIS‐ Advanced Glaucoma Intervention Study • Trabeculoplasty vs Trabeculectomy in uncontrolled advanced glaucoma • Group with the lowest IOP had the Lowest amount of field loss • <18mmHg is protective – CIGTS‐ Collaborative Initial Glaucoma Treatment Study • Surgery vs topical therapy • Although pressure was lower in surgery pts, there was no difference in progression based on field loss
19 Current Topicals Med Implants and Injectables
• Prostaglandin analogues • Beta Blockers • CAIs • Alpha 2 Agonists • Fixed combinations – Cosopt – Combigan – Simbrinza • Vyzulta (latanoprostene bunod 0.024%)‐ Nitric oxide donating prostaglandin analogue • Roclatan (Netarsudil 0.02%/ Latanoprost 0.005%QHS)
SLT VS ALT Vocabulary
• MIGS • Ab Interno • Canaloplasty • Goniotomy and Trabeculotomy • GATT • Stent
MIGS
• Kahook Dual Blade • ABiC‐Ab Interno Canaloplasty • iStent Trabecular Micro‐Bypass Stent • Xen Gel Stent • CyPass Micro Stent • Many others of similar design
20 Kahook Dual Blade Kahook Dual Blade
Garry Gergich ABiC‐Ab Interno Canaloplasty
Bilateral Kahook Duel Blade with Cataract Extraction
IOP OD OS Highest 31 30 Pre‐Op 24 25 1 day Post‐Op 14 15 4 month Post‐Op* 11 12
ABiC‐Ab Interno Canaloplasty(GATT) Barry Gergich
Bilateral ABiC‐Ab Interno Canaloplasty with CE
IOP OD OS Highest 15 15 Pre‐Op 15 15 1 day Post‐Op* 9 23 4 month Post‐Op** 7 10
21 Larry Gergich iStent Trabecular Micro Bypass Stent
Bilateral ABiC‐Ab Interno Canaloplasty+ Kahook with CE
IOP OD OS Highest 26 27 Pre‐Op 20 20 1 day Post‐Op 23 23 4 month Post‐Op 12 11
iStent Trabecular Micro Bypass Stent iStent Trabecular Micro Bypass Stent
Parry Gergich Xen Gel Stent
Bilateral single iStent with mandatory cataract extraction
IOP OD OS Highest 24 32 Pre‐Op* 16 16 1 day Post‐Op 24 17 4 month Post‐Op 13 14
22 Xen Gel Stent Xen Gel Stent
Tarry Gergich CyPass Micro Stent
Bilateral Xen Gel Stents with Cataract Extraction
IOP OD OS Highest 39 26 Pre‐Op* 26 23 1 day Post‐Op 6 11 4 month Post‐Op 12 11
CyPass Micro Stent CyPass Micro Stent
23 Carry Gergich Ab Externo
Unilateral CyPass OD with Cataract Extraction OU • Tube shunts – Ahmed Glaucoma Valve – IOP OD OS Baerveldt Glaucoma Implant • Trabeculectomy Highest* 20 20 • Microshunt Pre‐Op* 20 20 1 day Post‐Op 10 17 4 month Post‐Op 10 14
Ab Externo Ahmed Valve
InnFocus Microshunt InnFocus Microshunt
24 Cyclophotocoagulation Medicare Surgical Approach
MIGS Comparison Cost Comparison
Annual Topical Cost Bibliography
• A.S. Khouri et al. Broaden Understanding of Glaucoma (Ab Interno Trabeculectomy With a Dual Blade: Surgical Technique for Childhood Glaucoma).2017, September 10. Medical Devices & Surgical Technology Week, 1005. • • Arriola‐Villalobos, Pedro, et al. “Glaukos iStent inject® Trabecular Micro‐Bypass Implantation Associated with Cataract Surgery in Patients with Coexisting Cataract and Open‐Angle Glaucoma or Ocular Hypertension: A Long‐Term Study.” Journal of Ophthalmology, vol. 2016, 2016, 1‐7. • Budenz, D. L., Barton, K., Gedde, S. J., Feuer, W. J., Schiffman, J., Costa, V. P., … and the Ahmed Baerveldt Comparison Study Group. (2015). Five‐year Treatment Outcomes in the Ahmed Baerveldt Comparison Study. Ophthalmology, 122(2), 308–316. • • Cheema A, Chang RT, Shrivastava A, Singh K. Update on the medical treatment of primary open‐angle glaucoma. Asia‐Pacific J Ophthalmol. 2016;5(1):51‐8. • • De Keyser, M., De Belder, M., De Belder, S., & De Groot, V. (2016). Where does selective laser trabeculoplasty stand now? A review. Eye and Vision, 3, 10. • • Ederer, M. A., Sullivan, E. K., & Caprioli, J. (1994). Advanced Glaucoma Intervention Study. Ophthalmology, 101(8), 1445‐1455. • • Fox AR, Risma TB, Kam JP, Bettis DI. MIGS: Minimally Invasive Glaucoma Surgery. EyeRounds.org. posted September 27, 2017 • • Francis, B. A., Akil, H., & Bert, B. B. (2017). Ab interno Schlemm's Canal Surgery. In Glaucoma Surgery (Vol. 59, pp. 127‐146). Karger Publishers. • • Gallardo, M. J., M.D. (2017). ABiC viable option for different stages, severities of glaucoma. Ophthalmology Times, 42(14), 26‐27. • • Gedde, S. J., Schiffman, J. C., Feuer, W. J., Herndon, L. W., Brandt, J. D., Budenz, D. L., & Tube Versus Trabeculectomy Study Group. (2012). Treatment Outcomes in the Tube Versus Trabeculectomy (TVT) Study After Five Years of Follow‐up. American Journal of Ophthalmology, 153(5), 789–803 • • Greenwood, M. D., Seibold, L. K., Radcliffe, N. M., Dorairaj, S. K., Aref, A. A., Román, J. J., ... & Bahjri, K. A. (2017). Goniotomy with a single‐use dual blade: Short‐term results. Journal of Cataract & Refractive Surgery, 43(9), 1197‐1201. • • Grover, Davinder S,M.D., M.P.H. (2017). Expanding regimen with gel stent for surgical glaucoma management. Ophthalmology Times, 42(14), 14‐15.
25 Bibliography Bibliography
• Harvey, B. J., & Khaimi, M. A. (2011). A review of canaloplasty. Saudi Journal of Ophthalmology, 25(4), 329–336. • Perez, C. I., Chansangpetch, S., Hsia, Y. C., & Lin, S. C. (2018). Use of Nd: YAG laser to recanalize occluded Cypass Micro‐Stent in the early post‐operative period. American Journal of Ophthalmology Case Reports, 10, 114‐116. • • • Henderson, Leon W., Moore, Daniel B.. “Take‐Home Messages From the Advanced Glaucoma Intervention Study.” Glaucoma Today, May/June 2013, • Razeghinejad, M. R., Fudemberg, S. J., & Spaeth, G. L. (2012). The changing conceptual basis of trabeculectomy: a review of past and current surgical techniques. Survey of pp20‐24. ophthalmology, 57(1), 1‐25. • • • Sarkisian SR, Allan EJ, Ding K, Dvorak J, Badawi DY. New Way for Ab Interno Trabeculotomy: Initial Results [poster]. ASCRS ASOA Symposium and Congress; 17‐21 April 2015 • Hoy, Sheridan M. “Netarsudil Ophthalmic Solution 0.02%: First Global Approval.” Drugs, 2018, pp. Drugs, 16 February 2018. • • • Seibold, L. K., SooHoo, J. R., Ammar, D. A., & Kahook, M. Y. (2013). Preclinical investigation of ab interno trabeculectomy using a novel dual‐blade device. American journal of • Juzych, et al. “Comparison of Long‐Term Outcomes of Selective Laser Trabeculoplasty versus Argon Laser Trabeculoplasty in Open‐Angle ophthalmology, 155(3), 524‐529. Glaucoma.” Ophthalmology, vol. 111, no. 10, 2004, pp. 1853–1859. • • • Schweitzer, J. (2016). Two is Better than One. Review Of Optometry, 153(8), 74. • • Kaufman, P. L. (2017). Latanoprostene bunod ophthalmic solution 0.024% for IOP lowering in glaucoma and ocular hypertension. Expert opinion on • Serle, J. B., Katz, L. J., McLaurin, E., Heah, T., Ramirez‐Davis, N., Usner, D. W., ... & Kopczynski, C. C. (2018). Two Phase 3 Clinical Trials Comparing the Safety and Efficacy of Netarsudil to pharmacotherapy, 18(4), 433‐444. Timolol in Patients With Elevated Intraocular Pressure: Rho Kinase Elevated IOP Treatment Trial 1 and 2 (ROCKET‐1 and ROCKET‐2). American journal of ophthalmology, 186, 116‐127. • • • Kerr, N. M., Wang, J., & Barton, K. (2017). Minimally invasive glaucoma surgery as primary stand‐alone surgery for glaucoma. Clinical & experimental • Toyos, M. M., & Toyos, R. (2016). ClInIcal outcomes of mIcropulsed transcleral cyclophotocoagulatIon In moderate to severe glaucoma. J Clin Exp Ophthalmol, 7(620), 2. ophthalmology, 45(4), 393‐400. • • Van den Bogerd, B., Dhubhghaill, S. N., Koppen, C., Tassignon, M. J., & Zakaria, N. (2017). A review of the evidence for in vivo corneal endothelial regeneration. survey of ophthalmology. • • • M. Reza Razeghinejad, Scott J. Fudemberg, George L. Spaeth, The Changing Conceptual Basis of Trabeculectomy: A Review of Past and Current • Vold, S., Ahmed, I. I. K., Craven, E. R., Mattox, C., Stamper, R., Packer, M., ... & Ianchulev, T. (2016). Two‐year COMPASS trial results: supraciliary microstenting with phacoemulsification in Surgical Techniques, Survey of Ophthalmology, Volume 57, Issue 1, 2012, Pages 1‐25 patients with open‐angle glaucoma and cataracts. Ophthalmology, 123(10), 2103‐2112. • • • Weinreb, R. N., Sforzolini, B. S., Vittitow, J., & Liebmann, J. (2016). Latanoprostene bunod 0.024% versus timolol maleate 0.5% in subjects with open‐angle glaucoma or ocular • Medeiros, F. A., Martin, K. R., Peace, J., Sforzolini, B. S., Vittitow, J. L., & Weinreb, R. N. (2016). Comparison of latanoprostene bunod 0.024% and hypertension: the APOLLO study. Ophthalmology, 123(5), 965‐973. timolol maleate 0.5% in open‐angle glaucoma or ocular hypertension: the LUNAR study. American journal of ophthalmology, 168, 250‐259. • • • Weinreb, R. N., Ong, T., Sforzolini, B. S., Vittitow, J. L., Singh, K., & Kaufman, P. L. (2014). A randomised, controlled comparison of latanoprostene bunod and latanoprost 0.005% in the • Ndulue, Jideofor, et al. “Evolution of Cyclophotocoagulation.” Journal of Ophthalmic and Vision Research, vol. 13, no. 1, 2018, pp. 55–61. treatment of ocular hypertension and open angle glaucoma: the VOYAGER study. British Journal of Ophthalmology, bjophthalmol‐2014. • • Okeke,Constance O.MIGS as a first‐line treatment?Drops can be a compliance issue; but minimally invasive techniques can reduce their use and untoward side effects.Ophthalmology Management, Volume: 20, Issue: February 2016, page(s): 47‐49 • • Okumura, N., Sakamoto, Y., Fujii, K., Kitano, J., Nakano, S., Tsujimoto, Y., ... & Matsuyama, A. (2016). Rho kinase inhibitor enables cell‐based therapy for corneal endothelial dysfunction. Scientific reports, 6, 26113.
26 Description & Learning Objectives
Post‐Operative Endophthalmitis COPE Category: Peri‐Operative Management of Ophthalmic Surgery (PO) Description: BRIAN KI, OD This presentation focuses on the diagnosis and management of post‐ operative endophthalmitis. This will explore different cases with varying etiology, presentations, final outcomes, as well as clinical pearls in our role Douglas K. Devries, OD; Residency Coordinator as a co‐managing provider. Mackenzie Macintyre III, OD; Attending Warren J. Whitley, OD; Attending Learning Objectives: Identify and diagnose endophthalmitis Eye Care Associates of Nevada Timeline and differentials 2285 Green Vista Drive How/when to refer out for atypical post‐operative complications Sparks, NV Understand our role as co‐managing providers in decreasing the risk of [email protected] endophthalmitis 775‐674‐1100
Case #1 Case #1
76 YO male 4‐day POV same‐day appointment; Maxitrol QID OD, Xiidra BID OU VA: HM 4 days s/p cataract surgery OD IOP: 12 mmHg Friday 5:00 am via on‐call answering service. Anterior exam: Quiet conjunctiva Chief complaint: 1‐2+ corneal edema, few PEK AC: Deep with fibrous reaction, Overnight right eye pain near 360 posterior synechiae ”I woke up this morning I cannot see anything. Looks like there is (‐)hypopyon blood in my vision. I also see areas of blue.” Dilation with tropicamide/phenylephrine, cyclopentolate 1% Poor view of posterior segment A&P: Post‐operative uveitis
Continue Maxitrol QID OD Photo source: Retinal Physician, Issue May 20081 Durezol q2h OD, retinal consult today
Endophthalmitis
Acute Post‐Operative Endophthalmitis
~1:1000 post‐operative cases (0.1‐0.2%)2 Two types: Endogenous (endocarditis) Exogenous (surgery, foreign body, trauma) Organisms:
95% of cultured organisms are gram+ bacteria3 Common:
Gram positive: coagulase negative staphylococcus epidermis ~80%, 4 Staphylococcus aureus, streptococcal species (except pneumococcus) Less common: Gram negative: pseudomonas, aerobacter, proteus species, haemophilus influenza, klebsiella species, e. coli, bacillus, etc.
Sierra Eye Associates 2018
27 Endophthalmitis Acute Endophthalmitis
Category Most Common Pathogen Symptoms Acute Postoperative Coagulase‐negative staphylococci Pain (~74%) Chronic Postoperative Propionibacterium Decrease in vision (~95%) Post‐injection Viridans streptococci Redness (~80%) Coagulase‐negative staphylococci Timeline: 75% within the first week of surgery (~2‐5 days) Bleb‐related Streptococci Haemophilus influenzae Signs Post‐traumatic Bacillus cereus Lid edema Endogenous Staphylococcus aureus Conjuncitival chemosis Streptococci Corneal edema Gram‐negative bacilli Vitritis Fungal Candida, Aspergillus, Fusarium Wound abnormalities *Higher rates of fungal in tropical, humid Table reference6 Black = gram + Hypopyon (~75%) climates such as India ~10‐15%5 Red = gram ‐ Nevada Retina Associates 2018 *Negative culture occurs in 30% of cases3 Reference for values above3,7,8
Acute Endophthalmitis Risk Factors for Endophthalmitis
Differentials (Aseptic Endophthalmitis)9 Major risks –American Academy of Ophthalmology: Cataract in the Adult Toxic reaction to irrigating fluid or foreign material Eye Preferred Practice Pattern®13 Toxic Anterior Segment Syndrome (TASS) Older Age 12‐48 hours post‐operatively Leaky incision No to mild pain Iatrogenic communication between anterior and posterior segment (e.g. posterior capsular rupture or zonular tears; ruptured capsule increases risk ~14x) Hypopyon, fibrous membrane 14 No vitritis Other risks: Increased IOP Immunodeficiency Active blepharitis, lacrimal duct obstruction Retained lens material in anterior chamber or vitreous (~1% of PE)10,11 Male gender Nuclear fragments frequently cause chronic inflammation more than cortical12 Phacoanaphylaxis, granulomatous inflammation Previous intraocular injections Requires surgical removal Prolonged surgical time Vitreous loss Excess tissue manipulation during surgery IOL type or material? No consistent evidence Hypopyon Clear corneal incision (CCI)? Mild vitreous cellular reaction Rates increased as ophthalmology transitioned from scleral tunnel incision to CCI No progressive vision loss or pain 15,16 Wound architecture, sutures beneficial Resolves with topical steroid therapy
Management Management
Immediate retinal referral Vitrectomy ‐ Endophthalmitis Vitrectomy Study (EVS)4 Immediate pars planar vitrectomy beneficial in patients with light Intravitreal tap and inject 17 perception. PPV no additional benefit if HM or better Identify causative organisms (vitreous tap) Samples can be obtained through the vitrectory for culturing Injection of antibiotics Systemic antibiotics controversial (EVS) Vancomycin (GRAM+) and Ceftazidime (GRAM‐) or Amikacin No additional advantage to visual outcome Intravitreal antibiotics persist in the Primarily for endogenous endophthalmitis vitreous only 24 to 48 hours. Possible steroid injection, oral steroids Severe cases may require subsequent vitrectomy
Photo reference: Practice of Infectious Diseases, Updated Edition Eighth Edition18
28 Topical Management Case #1: Retina Management
Day 6 (Consult) Day 7Day 8Day 9Day 11 Day 17 Vision HM HM HM CF CF CF Durezol/prednisolone acetate 1% q1‐2h for 24‐48 hours IOP 12 38 50 10 12 6 Treatment PPVX Vigamox QID Vigamox QID Vigamox QID Vigamox QID Vigamox QID 4th generation fluoroquinolones IVAbx Durezol 6x Durezol 6x Durezol 6x Durezol 6x Taper Durezol MP Simbrinza Simbrinza Simbrinza Simbrinza Oral Pred Fortified antibiotics (vancomycin and tobramycin) q1h Vigamox QID Combigan Combigan Combigan Combigan Cyclopentolate Durezol 6x/day Travatan Travatan Travatan Travatan Taper Oral More important for blebs, wound leaks, exposed sutures Diamox Cyclopentolate Cyclopentolate Vit. Paracentesis Oral Pred Oral Pred Require transition to regular strength antibiotics w/ 30G PI Atropine 1% TID to QID Cyclopentolate QID Follow‐up: Day 25 Day 40 2 month 3 month 3.5 month q12h or daily, monitor for improvement Vision CF 100+ 60‐1PH: 20/60 PH: 20/30‐ Taper topical and oral steroid IOP 13 10 12 10 12 Treatment Durezol QID Durezol QID Durezol TID Durezol QID Durezol QID Cyclopentolate
Prognosis for Endophthalmitis
Factors for poor visual Factors for good visual outcome (20/100 or outcome (20/40 or better 45%) worse) Absence of surgery complications Cataract surgery Shorter duration of surgery complications Initial VA Longer duration of surgery Fundus visibility Poor initial VA No microorganism on culture (30% of cultures) Poor fundus visibility. Coagulase‐negative Detection of bacterial Staphylococcus species (CNSP) species other than G+ CNSP ~80% of positive cultures Hypopyon no greater than 1.5 mm High bacterial virulence Younger age Hypopyon greater than 1.5 mm
Results from French Institutional Endophthalmitis Study Group, Prospective Study 201319
Prognosis Prevention
One of the strongest predictors of poor visual outcome Surgical factors: Asepsis and antisepsis to reduce risk was light perception only vision 5% Povidone‐iodine Multiple studies on prophylaxis with various antibiotics and delivery ‐ Patients with NLP do not recover vision subconjunctival injections, intracameral, irrigating fluid13 “Due to the lack of sufficiently large prospective clinical trials, impracticality of SEVERITY OF PRESENTATION, TIMELY DIAGNOSIS & conducting such trials, there is insufficient evidence to recommend a specific antibiotic drug or method of delivery for endophthalmitis prophylaxis.” –AAO TREATMENT ARE FUNDAMENTAL TO IMPROVE VISUAL Preferred Practice Pattern 2016® OUTCOME European Society of Cataract & Refractive Surgeons (ESCRS) Multicenter study and guidelines20,21,22 Prophylactic intracameral cefuroxime injections –most evidence supporting Topical prophylaxis levofloxacin, ofloxacin or combo of neomycin/polymyxin B/bacitracin 24‐48 hours before surgery Pre‐operative/Post‐operative: Ocular hygiene and topical antibiotics
29 Case #2 Case #2
71 YOF 1‐Day OS / 9‐day OD POV: Maxitrol QID OU, Bromsite BID Cataract Evaluation: OU BCVA 20/100 OD, 20/25 OS VA OD: 20/100+ PH: NI Macular edema OD, likely secondary to CRVO OD VA OS: 20/20‐1 Referral to retina IOP: 16/19mmHg Retina notes: Anterior exam: OD: few PEK, quiet conjunctiva Recommended treatment for macular edema D/ tr cells Pt declined treatment OS: 1+ PEK w/ 1+ temp edema, quiet conjunctiva Cleared for cataract surgery D/1‐2+ cells Mac OCT performed
Case #2 Case #2
Eye Care Associates of Nevada Plan: recommended CPM until f/u with co‐managing optometrist at next Retinal Evaluation S/P cataract surgery (OD 7.5 weeks, OS 6 POV, f/u retinal consult in 6‐8 weeks weeks) VA OD: 20/200 PH: NI, VA OS: 20/50+ PH: NI
Case #2 Case #2
1‐day Retina F/u: Assessment and Plan: CC: OS blurred vision, worse than before, sudden onset, Cystoid macular edema OU: severely decreased in one day OD: longstanding, stable VA OD: 20/200 PH: NI OS: new edema post cataract surgery VA OS: CF in distance Kenalog injection OS today IOP: 11/12 mmHg OD: Stable findings, chronic CME OS: Anterior exam: 1‐2+ injection, clear cornea 3+ cells, fine fibrin on PCIOL, hypopyon present “thin white layer” Iris: flat Posterior exam: No view of nerve, white kenalog visible below, periphery attached 360
30 B‐Scan Postinjection Endophthalmitis
Study of 41,000 patients with anti‐VEGF injections for
neovascular AMD in a Medicare database23 0.09% risk per injection (similar to post‐cataract) Gram+ most common
Prognosis (better visual outcome at 3 months) 24 No culture > G+ CNSP culture > positive cultures of different species
Nevada Retina Associates Category Pathogen B‐scan OS: Total PVD, vitreous echos and subhyaloid Acute Postoperative (PE) Coagulase‐negative echoes, no RD staphylococci (CNSP) Post‐injection Coagulase‐negative staphylococci (CNSP) Viridans streptococci (25%)
Case #2: Retina Management Case #2
Consult Day 1Day 2Day 3Day 7 Vision CF Distance CF 3 feet CF 4 feet CF 5 feet 20/40 1‐month: IOP 12 19 19 9 15 OD: 20/200 PH: NI Treatment PPVX Tobramycin q4h Tobramycin q4h Tobramycin q4h Tobramycin q4h OS: 20/30+2 PH: 20/20 Vancomycin/ PF 1% QID PF 1% QID PF 1% QID PF 1% QID Ceftazidime Tobramycin q4h PF 1% QID
Notes: Slight vitreous haze, D/B hemes in periphery Tr macular edema “Sterile eye”
Nevada Retina Associates
Case #2 Case #3
4‐month POV at ECAN: 64 YO Female OD: 20/200 Cataract Surgery OS 1‐Day POV OS: Maxitrol QID OS, Xiidra BID OU, Systane AT BID OS: 20/30‐2 PH: NI OU Assessment: VA: 20/50‐2 PH: 20/20‐2 H/o Endophthalmitis OS IOP: 24 mmHg Anterior Exam: Good outcome Eye Care Associates of Nevada Mild injection Chronic CME OD>OS 1+ corneal edema temporally –?CRVO, uncertain etiology AC: Deep/1+ cells (+)HLAB51 ~ likely Behçet’s disease Macula: flat Rheumatology consult pending, continue PF1% bid OS per retina Plan: CPM, RTC 1 week
31 Case #3 Case #3
Day‐6 POV OS: Maxitrol QID OS, Xiidra BID OU, Systane AT Posterior Exam (cyclopentolate 1%) OS: BID OU Retina: flat/intact 360 Few ant. vitreous cells? CC: very red, painful left eye; light sensitivity, constant Consulted ophthalmologist, confirmed no vitritis redness and FB sensation. Patient tried warm/cold Appears as inflammatory, non‐infectious compresses with no improvement A&P: VA: 20/50‐2 PH: 20/30 Pseudophakia OS w/ rebound inflammation Anterior Exam OS: Hold cataract surgery OD 1‐2+ injection, 1+chemosis D/c Maxitrol Tr diffuse edema Start: Durezol q2h, Cyclopentolate 1% TID, Vigamox QID OS AC: Deep/2‐3+ cells, no hypopyon, RTC 1 day with operating surgeon
Case #3 Follow‐up Case #3
Day 7 Day 8Day 10 Day 14 Day 17 Day‐21 POV OS Symptoms Stable Stable Stable Greatly improved Mild blur PF 1% Q2H OS BCVA/PH 20/70 20/60 20/40+2 20/30‐1 20/50+2 Overall improving, but blurred vision in distance, no pain. “Spider Tr injection Mild injection Mild injection Quiet conj. Quiet conj. webs in left eye developed over the weekend” 3‐4+ cells 2‐3+ cells 1+ cells Tr cells Diffuse PEK VA: 20/70‐, PH: NI Ant. Seg Tr cells IOP: 14 mmHg IOP: 16 23 26 20 20 BCVA: ‐0.75 +0.25 x154, 20/20 Anterior exam: Vigamox QID Vigamox QID Vigamox QID Vigamox until out Begin taper Conjunctiva – quiet PF% q1h PF% q1h PF% q1h Cyclo until out PF1% q2h No edema, few PEK Cyclo TID Cyclo TID Cyclo TID PF1% q1h D/2‐3+ cells (‐)fibrin (‐)hypopyon Lotemax ung Gonioscopy OS: WNL, No lenticular material in inferior angle QHS Posterior exam: *Poor (+)PVD, Clear view of disc, flat and dry macula, flat/intact 360, ?Cells in ant. vitreous compliance A&P: Consultation with operating surgeon ‐ Rebound inflammation *Consulted Lotemax ung Lotemax ung *Consulted MD again, increase PF1% from q2h to q1h OS, RTC 1 day operating QHS QHS Likely to begin surgeon taper at f/u
Case #3 Chronic Endophthalmitis
Day‐22 POV OS Delayed post‐operative bacterial endophthalmitis PF 1% Q1H OS Subacute (weeks to months) Rare, difficult diagnosis –cultures frequently negative Increase number of floaters, spider webs, flashes OS only. Decrease in vision, started yesterday. “Pain around eye socket” Often are misdiagnosed as anterior uveitis May be treated for months with topical corticosteroids VA: 20/100, PH: 80+1 Pain ‐ often mild and gradual IOP: 16 mmHg White blood cells in the anterior chamber and usually in the anterior Pupils: PERRL (‐)APD vitreous Anterior exam: 50% have a small hypopyon, nearly all patients have white plaque on the Mild injection residual posterior lens capsule No edema, few PEK 25 D/2‐3+ cells (‐)fibrin (‐)hypopyon Most require at least vitrectomy and intravitreal vancomycin for Posterior exam: treatment PCIOL: 2+ posterior‐capsular haze 50% of cases recur with this therapy alone2 Cells in vitreous, (+)PVD, Clear view of disc, flat and dry macula, scleral depression May need removal of IOL with difficult hazy views, appears flat 360 Systemic antibiotic therapy is not indicated A&P: Retinal consult immediately (tomorrow AM)
32 Case #3 Retinal Mangement MAC OCT
Day 23 (Consult) Day 36 Day 58 Day 64 Vision 20/80 20/80 PH: 20/60‐ 20/50‐ PH: 20/25‐1 ‐‐
IOP ‐‐ 19 22 ‐‐ Findings ‐‐ AC: 1+ cells/Fibrin AC: 2+ cells/fibrin ‐‐ Vit: 2+ cells
Treatment Tap & inject: Posterior sub‐tenon ceftazidime/ PF QID PF QID kenalog dexamethasone Atropine QID Atropine BID PF q2h Cipro QID Atropine QID Ciprofloxacin QID
Notes: Improving slowly Doing well, still 2+ C/F Sierra Eye Associates RTC 1.5 weeks
Sierra Eye Associates Sierra Eye Associates
Post‐operative visits: Tips for the atypical POV
Patient symptoms, Visual Acuity, IOP, compliance Identify limits to vision Document progress, pertinent negatives Anterior chamber: Cells/flare, rule out fibrin, hypopyon, capsular opacities Attention: corneal wound, IOL, pupil, iris, inferior chamber ‐ gonioscopy Dilated exam Note clarity of views, vitreous, absence of retained material Follow‐ups based on suspicion of post‐operative recovery Change topical steroids or increase dosing as needed Ophthalmology consult –contact operating surgeon**
Sierra Eye Associates
33 Instructions following Cataract Surgery Pre‐operative Visit
General hygiene and compliance Majority of offending pathogen for post‐operative infection is gram+ staphylococcus epidermis Avoid hot tubs, swimming pools and saunas Lid hygiene and ocular surface disease management No eye makeup for 1‐week University Complutense of Madrid Study (2016)26 Commercial available lid wipes (hot compresses and digital massage BID) DO NOT RUB YOUR EYE –eye shields useful for night time decreased microbial load by 58‐63% of eyelid Sunglasses when outside Does not sterilize tissue or replace peri‐operative antibiotic prophylaxis No studies on regarding microbiota recovery after use of eyelid wipes, or Include 24 hour phone number on instruction sheet, long term use patient and staff signature. Report immediately: Patients to manage carefully: Severe pain in or around the eye Blepharitis Progressively worsening vision Conjunctivitis/Keratoconjunctivitis Contact lens wearers Injuries to eye H/o hordeolum, dacryocystitis, canaliculitis, etc.
Pre‐operative Visit Endophthalmitis Summary
Useful screening tools: The majority of species for post‐operative endophthalmitis is gram+ staphylococcus epidermis SPEED Score, InflammaDry/TearLab Screen patients for ocular surface disease and treat prior to Artificial tears, lid scrubs, warm compresses cataract surgery Xiidra/Restasis, lotemax gel, fluoromethalone, Manage ocular surface disease for patients receiving routine intraocular injections erythromycin Identify and document limits to vision at each post‐operative Lid cleaners: Hypochlor, Avenova, ocusoft cleaners, visit BlephEx Document progress and pertinent negatives for suspicious patients Contact the operating surgeon Understand that severity of presentation, timely diagnosis and treatment are fundamental to improve visual outcome
References
1. Photo Reference, Retinal Physician, Issue May 2008; URL: https://www.retinalphysician.com/archive/2008/May/images/RP_May_A05_Fig02.jpg 2. Durand, Marlene L. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, Updated Edition (Eighth Edition). Saunders, 2015. 116, 1415‐1422.e2 3. Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol 1995; 113: pp. 1479‐1496 4. Bannerman TL, Rhoden DL, McAllister SK, et al: The source of coagulase‐negative staphylococci in the Endophthalmitis Vitrectomy Study: a comparison of eyelid and intraocular isolates using pulsed‐field gel electrophoresis. Arch Ophthalmol 1997; 5. Gupta A, Gupta V, Gupta A, et al: Spectrum and clinical profile of postcataract surgery endophthalmitis in north India. Indian J Ophthalmol 2003; 51: pp. 139‐145 6. TABLE 116‐1 Endophthalmitis Categories and the Most Common Pathogens in Each from Durand, Marlene L. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, Updated Edition (Eighth Edition). Saunders, 2015. 116, 1415‐1422.e2 7. Lalwani GA, Flynn HW Jr, Scott IU, Quinn CM, Berrocal AM, Murray TG, Smiddy WE, Miller D.Acute‐onset endophthalmitis after clear corneal cataract surgery (1996‐2005). Clinical features, causative organisms, and visual acuity outcomes. Ophthalmology, 2008 Mar; 115(3):473‐6. Epub 2007 Dec. 11 8. Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM, McDonnell PJ Acute endophthalmitis following cataract surgery: a systematic review of the literature. Arch Ophthalmol. 2005 May; 123(5):613‐20. 9. Will’s Eye: The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease A.T. Gerstenblith MD, M.P. Rabinowitz MD (Mar 19, 2012) pp 384‐388 10. Kwok AKH, Li KKW, Lai TYY, Lam DSC. Pars plana vitrectomy in the management of retained intravitreal lens fragments after cataract surgery. Clin Experiment Ophthalmol 2002; 30:399‐403. 11. Leaming DV. Practice styles and preference of ASCRS members: 1994 survey. J Cataract Refract Surg 1995;21:378‐85. 12. Smiddy WE , FlynnHWJr. Managing retained lens fragments and dislocated posterior chamber IOLs after cataract surgery.Focal Points: Clinical Modules for Ophthalmologists. San Francisco: American Academy of Ophthalmology; 1996, module 7. 13. American Academy of Ophthalmology , Cataract in the Adult Eye Preferred Practice Pattern ® 2016 http://dx.doi.org/10.1016/j.ophtha.2016.09.027 Published by Elsevier Inc. 14. T Y Wong, S‐P Chee, Risk factors of acute endophthalmitis after cataract extraction: a case‐control study in Asian eyes, Br J Ophthalmol. 2004 Jan; 88(1): 29–31. 15. Taban M, Behrens A, Newcomb RL, et al: Acute endophthalmitis following cataract surgery: a systematic review of the literature. Arch Ophthalmol 2005; 123: pp. 613‐620. 16. Nichamin, Louis D, et al. ASCRS White Paper What Is the Association between Clear Corneal Cataract Incisions and Postoperative Endophthalmitis. ASCRS and ESCRS, J Cataract Refractive Surgery, Volume 32, Sept. 2006, 17. Kernt M, and Kampik A: Endophthalmitis: pathogenesis, clinical presentation, management, and perspectives. Clin Ophthalmol 2010; 4: pp. 121‐135 18. Photo reference: FIGURE 116‐3 Vitreous aspirate and vitrectomy. Diagram of vitreous aspirate (A) and vitrectomy (B) from Durand, Marlene L. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, Updated Edition (Eighth Edition). Saunders, 2015. 116, 1415‐1422.e2 19. Combey de Lambert A1, Campolmi N, Cornut PL, Aptel F, Creuzot‐Garcher C, Chiquet C , Baseline factors predictive of visual prognosis in acute postoperative bacterial endophthalmitis in patients undergoing cataract surgery.; French Institutional Endophthalmitis Study Group. JAMA Ophthalmol. 2013 Sep;131(9):1159‐66. doi: 10.1001/jamaophthalmol.2013.4242. 20. Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons, Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors, J Cataract Refract Surg. 2007 Jun;33(6):978‐88. 21. Gower, Emily W.; Lindsley, Katrina; Tulenko, Smantha E.; Nanji, Afshan A.; Leyngold, Ilva; McDonnell, Peter J. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery. Gower, Emily W, et al. The Cochrane Database of Systematic Reviews, U.S. National Library of Medicine, 13 Feb. 2017, 22. Friling E1, Lundström M, Stenevi U, Montan P., Six‐year incidence of endophthalmitis after cataract surgery: Swedish national study. J Cataract Refract Surg. 2013 Jan;39(1):15‐21. doi: 10.1016/j.jcrs.2012.10.037. 23. Acquah K, Mruthyunjaya P, et al: Ocular complications after anti‐vascular endothelial growth factor therapy in Medicare patients with age‐related macular degeneration. Retina 2011; 31: pp. 2032‐2035 24. Sachdeva MM, Moshiri A, Leder HA, et al: Endophthalmitis following intravitreal injection of anti‐VEGF agents: long‐term outcomes and the identification of unusual micro‐organisms. J Ophthalmic Inflamm Infect. 2016; 6: pp. 2 25. Clark WL, Kaiser PK, Flynn HW, et al: Treatment strategies and visual acuity outcomes in chronic postoperative . Ophthalmology 1999; 106: pp. 1665‐1670 26. Assumpta Peral, Ph.D., Jose Alonso, Ph.D., Concepción García‐García, Ph.D., Cristina Niño‐Rueda, Ph.D., and Patricia Calvo del Bosque, M.Sc. Eye Contact Lens. 2016 Nov; 42(6): 366–370. Published online 2015 Dec 9. doi: 10.1097/ICL.0000000000000221 PMCID: PMC5098457 Importance of Lid Hygiene Before Ocular Surgery: Qualitative and Quantitative Analysis of Eyelid and Conjunctiva Microbiota 27. Mitchell S. Fineman, MD; Allen C. Ho, MD. Color Atlas and Synopsis of Clinical Ophthalmology ‐ Wills Eye Institute –Second Edition. 2012 Lippincott Williams and Wilkins.
34 81 year old white male Chief complaint: no visual or ocular complaints Six month planned follow-up for remote history of diabetic retinopathy with clinically Katherine Homa, O.D. significant macular edema, OD
Medical history Ocular history ◦ Type II Diabetes mellitus ◦ Pseudophakia, OU – 2009 ◦ Hypertension ◦ Mild/moderate nonproliferative diabetic retinopathy ◦ Hyperlipidemia with clinically significant macular edema, OD – s/p ◦ Hypothyroidism FALP and lucentis injection x 2 ◦ Depression ◦ Operculated hole, OS, s/p laser - 2013 ◦ Malignant neoplasm of skin ◦ Chronic obstructive pulmonary disease ◦ Chronic congestive heart failure ◦ Chronic kidney disease, stage 5
Entrance testing Slit lamp exam ◦ Pupils: PERRL (-)RAPD ◦ Diffuse haze between PC IOL and posterior capsule ◦ EOM: full and smooth OD ◦ Confrontation fields: FTFC OU ◦ Otherwise unremarkable Refraction Dilated fundus exam ◦ OD: +0.25+1.25x180 20/40-2 ◦ Mild nonproliferative diabetic retinopathy without ◦ OS: -0.50+2.75x180 20/20 clinically significant macular edema
35 Capsular bag distension syndrome Posterior capsular opacity Capsular contraction Aqueous misdirection syndrome
Distension of posterior capsular bag Contact/adhesion of IOL and anterior capsule following cataract extraction Likely caused by Turbid fluid buildup between IOL and ◦ Trapped viscoelastic or cortical material capsular bag ◦ Proliferation of lens epithelial cells ◦ Associated findings Anterior chamber reaction ◦ Forward displacement of IOL and iris/lens diaphragm ◦ Myopic shift ◦ Increase in IOP
Unique to continuous curvilinear capsulorhexis Four haptic IOL Increased axial length
36 Onset ◦ Intraoperative ◦ Early post-operative ◦ Late post-operative Clinical characteristics ◦ Noncellular ◦ Inflammatory ◦ Fibrotic
Clinical characteristics Sodium hyaluronate ◦ Noncellular ◦ Ingredient in viscoelastic materials Within one day after surgery Alpha-2 crystallins Shallow anterior chamber ◦ Transparent fluid Major lens protein ◦ Inflammatory Propionibacterium acnes Several days after surgery ◦ Gram positive anaerobe Severe inflammatory reaction and fibrinous exudate ◦ Can lead to delayed onset endophthalmitis around pupil Capsular block released with treatment of steroid ◦ Fibrotic Late postoperative Fibrosis over opening of anterior capsule
Anterior segment OCT Observation Posterior YAG capsulotomy – most common Anterior YAG capsulotomy Surgical intervention with aspiration of bag contents Slit lamp needle revision
37 One week later Treated with YAG posterior capsulotomy ◦ Fluid in capsular bag began to dissipate
Two weeks post YAG cap Complete resolution of fluid from capsular bag Refraction: ◦ OD: -1.00+2.00x180 20/25-3 ◦ OS: -0.50+2.00x180 20/25-2
Initial presentation Immediately 2 weeks post YAG following YAG capsulotomy capsulotomy
38 Capsular bag distension syndrome is a rare complication following cataract surgery Optometrists who perform peri-operative care need to be aware and look for this at all Initial presentation stages of post-op care
2 weeks post YAG capsulotomy
Agrawal, S., Agrawal, J., & Agrawal, T. P. Capsular Bag Distension Syndrome. D STimes, 17.
González-Martín-Moro, J., González-López, J. J., Gómez-Sanz, F., Zarallo-Gallardo, J., & Cobo-Soriano, R. (2015). Posterior capsule opacification, capsular bag distension syndrome, and anterior capsular phimosis: A retrospective cohort study. Archivos de la Sociedad Española de Oftalmología (English Edition), 90(2), 69-75.
Grover, D. S., Goldberg, R. A., Ayres, B., & Fantes, F. (2012). Treatment of late-onset capsular distension syndrome with a neodymium: YAG laser peripheral iridotomy and anterior capsulotomy. Journal of Cataract & Refractive Surgery, 38(6), 938-940.
Jain, A. K., Sukhija, J., & Saini, J. S. (2004). Surgical management of early postoperative capsular bag distension syndrome. Journal of Cataract & Refractive Surgery, 30(5), 1143-1145.
Kim, H. K., & Shin, J. P. (2008). Capsular block syndrome after cataract surgery: clinical analysis and classification. Journal of Cataract & Refractive Surgery, 34(3), 357- 363.
Kollias A.N., Vogel M.A., de Kaspar H.M. Propionibacterium acnes in capsular bag distension syndrome. J Cataract Refract Surg. 2010;36:167–169.
Mardelli, P. G. (2008). Slitlamp needle revision of capsular block syndrome. Journal of Cataract & Refractive Surgery, 34(7), 1065-1069.
Miyake, K., Ota, I., Miyake, S., & Horiguchi, M. (1998). Liquefied aftercataract: a complication of continuous curvilinear capsulorhexis and intraocular lens implantation in the lens capsule. American journal of ophthalmology, 125(4), 429-435.
Miyake, K., Ota, I., Ichihashi, S., Miyake, S., Tanaka, Y., & Terasaki, H. (1998). New classification of capsular block syndrome. Journal of Cataract & Refractive Surgery, 24(9), 1230-1234.
Omar, O., Eng, C. T., Chang, A., Durcan, F. J., Liss, R. P., & Stark, B. I. (1996). Capsular bag distension with an acrylic intraocular lens. Journal of Cataract & Refractive Surgery, 22, 1365-1367.
Qu J, Bao Y, Li M, Zhao M, Li X. Surgical management of late capsular block syndrome. J Cataract Refract Surg. 2010;36(10):1687–1691.
Sorenson, A. L., Holladay, J. T., Kim, T., Kendall, C. J., & Carlson, A. N. (2000). Ultrasonographic measurement of induced myopia associated with capsular bag distention syndrome. Ophthalmology, 107(5), 902-908.
Sugiura T, Miyauchi S, Eguchi S, et al. Analysis of liquid accumulated in the distended capsular bag in early postoperative capsular block syndrome. J Cataract Refract Surg. 2000;26:420–425.
39 6/5/2018
Treatment of Infantile Overview Esotropia with Lenses and Background Vision Therapy Signs and Findings of Infantile Esotropia Treatment Approaches Vision Therapy and Lenses Neil Renaud, OD Resident Optometrist, Vision Northwest
Background Background
Infants normally develop the ability to Infantile esotropia is the most prevalent fixate, track moving targets, locate objects type of esotropia, and is developmental in in space, perceive stereopsis, and maintain origin single binocular vision. ◦ Onset 2-4 months, usually seen by 6 months ◦ Human visual system develops bilaterally and at different stages, so there is the risk of asymmetric or delayed development of visual skills
Background Background
What is the outcome? Rule out: ◦ Spontaneous resolution ◦ Pathology ◦ Improvement to resolution with treatment ◦ High refractive error ◦ Residual syndrome after treatment ◦ Development of inappropriate adaptation in visual development
40 6/5/2018
Signs and Findings Signs and Findings
Esotropia – unilateral or alternating, Abduction deficit – early, but releases constant or intermittent, large angle later ◦ Hirschberg ◦ Cover Test if able
Signs and Findings Signs and Findings
Cross fixation – temporal-nasal tracking Cross Fixation dominates, and fixating eye becomes whichever is in the adducting field
Signs and Findings Signs and Findings
Monocular motion processing asymmetry Decreased stereopsis – not viewing – temporal-nasal tracking is subcortical targets bifoveal and present at birth, nasal-temporal ◦ Decorrelation of binocular cells in visual tracking develops cortically at 3-6 months cortex
41 6/5/2018
Signs and Findings – other Signs and Findings – other adaptations adaptations Inferior Oblique over-action – when Latent Nystagmus looking into a lateral gaze, ◦ Monocular motion processing asymmetry adducting eye suppresses N-T does not equal T-N and elevates ◦ We need equal innervation of adduction and abduction for steady fixation ◦ Cosmetic ◦ Reduced visual field
Signs and Findings – other Treatment Approaches adaptations Amblyopia Monitor ◦ Typically not a problem due to most infantile ◦ Watch for spontaneous resolution ET being alternating ◦ Consider treatment if ET remains ◦ If fixation dominance sets in and ET becomes Botox unilateral, this can cause strabismic amblyopia ◦ Prevent medial rectus from over-firing to straighten the eye Patching ◦ No binocular vision development
Treatment Approaches Strabismus Surgery
Strabismus Surgery Mortality Rate – low, but exists ◦ Goal is to cosmetically align the eyes Infant under general anesthesia ◦ Most common treatment, but has many Pulling on eye muscles engages drawbacks and questions oculocardiac reflex, which slows heart rate and can cause cardiac arrest
42 6/5/2018
Strabismus Surgery Strabismus Surgery
High failure rate requiring multiple Study by Pediatrics on early exposure to operations anesthesia before age 2 Summary of 27 studies on infantile ET ◦ Learning disabilities are 2x more likely showed 28-54% success rates ◦ Speech/Language delay 4x more likely ◦ >50% of cases require more than 1 surgery ◦ “We cannot exclude the possibility that multiple exposures to anesthesia/surgery at an early age may adversely affect human neurodevelopment with lasting consequences.”
Strabismus Surgery Strabismus Surgery
Criteria for Success Complications ◦ Cosmetically aligned, small ET/XT is okay ◦ Consecutive Exotropia ◦ Repeat surgeries – further degradation of EOM proprioception ◦ Amblyopia – incidence increases from 0-14% to 41-72% post-Sx
Strabismus Surgery
Cochrane Review has found no consensus “Treatment should be directed toward what is established for: best for the patient, not for the surgeon.” ◦ Best treatment, surgical or nonsurgical - Stefan Rethy, MD ◦ Type of surgery ◦ Timing of surgery (best age of intervention)
43 6/5/2018
Treatment Approaches Vision Therapy for Infantile ET
Optometric Vision Therapy Must use a problem-focused approach ◦ Effective, but few practitioners Find common signs in examination and ◦ Low public awareness that this is an option then tailor therapy as interventions to acquired behavioral adaptations
Abduction Deficit and Esotropia Abduction Deficit and Esotropia
Introduce targets (ie food, bottle) in Optokinetic Nystagmus - Occlude one eye, turn patient’s lateral periphery. When they patient toward the occluded eye. As they fixate become aware of the target, they will on objects, they will hold fixation and OKN will drive abduction subcortically abduct toward it This works on abducting pursuits Also increases peripheral awareness Can also reverse for abducting saccades
Abduction Deficit and Esotropia Cross Fixation
Binasal Occlusion ◦ Block adducting field with tape or clear nail polish to promote fixating with the abducting eye ◦ Measure width by where lateral tracking normalizes ◦ If there is no treatable refractive error, low plus works well in improving peripheral awareness and motion processing
44 6/5/2018
Binasal Occlusion Cross Fixation
Monocular Motion Processing Suppression/decreased peripheral Asymmetry awareness Promote Abduction Monocular fixation in a binocular field ◦ Pursuits: moving target into abducting field ◦ Make sure OD sees targets on right and OS ◦ Saccades: shift attention into abducting field sees targets on left both eyes abducting ◦ Vestibulo-Ocular Reflex: turn infant L/R while ◦ Anti-suppression promotes binocularity and fixating on stationary target normal development of binocular cells in ◦ Optokinetic Nystagmus: slow monocular visual cortex rotations toward the occluded eye
MFBF Ideas MFBF Ideas
45 6/5/2018
MFBF Ideas MFBF Ideas
MFBF Ideas Other Considerations
Bilateral Integration ◦ Trampoline, Straw, Catch with two hands Peripheral Awareness ◦ Peripheral High Fives and Finger Taps Vestibular Loading ◦ Turn and Clap/Catch/Toss, Pen in Cap after spin
Final Step: Vergence Final Thoughts
Divergence: address esophoria Infants/Toddlers may appear to be difficult Convergence: improve smooth control to treat and eliminate all-or-nothing response to ◦ We need to think inside their world, then give near targets opportunities to use vision appropriately ◦ Visual system is young, learning, and plastic Bring fixation target in toward patient and back away for gross convergence and Manage their condition, rather than cure divergence ◦ Address common signs/symptoms ◦ Lead them toward a lifetime of clear, comfortable, single, binocular vision
46 6/5/2018
References
Flick, Randall T, et al. “Cognitive and Behavioral Outcomes After Early Exposure to Anesthesia and Surgery.” Pediatrics, vol. 128, no. 5, 2011, doi:10.1542/peds.2011-0341d. Diamond, Gary R. “Forms of Nonsurgical Strabismus Management.” Ophthalmology, 2009, pp 368-1369, doi:10.1016/b978-0-323-04332 -8.00228-6 Elliott, Sue, and Ayad Shafiq. “Interventions for Infantile Esotropia.” Cochrane Database of Systematic Reviews, 2013, doi:10.1002/14651858.cd004917.pub3. Ludlam, William. “Management of Infantile Esotropia; Research Issues and Standard of Care.” Journal of Optometric Vision Development, vol. 24, 1993, pp. 8–14. Scheiman, Mitchell. “Surgical Success Rates in Infantile Esotropia.” Journal of the American Optometric Association, vol. 60, no. 1, Jan. 1989, pp. 22–31. Sondhi N, Archer SM, Helveston EM. Development of normal ocular alignment. J Pediatr Ophthalmol Strabismus 1988; 25:210- 1.
47 ELIZABETH POWERS TODAY’S DISCUSSION PRACTICAL SOLUTIONS TO COMPLEX PROBLEMS:
A SURVEY OF THE WHAT IS RELEVANCE CASE VISUALLY EVOKED THE VEP? TO CLINICAL EXAMPLES POTENTIAL’S OPTOMETRY USEFULNESS IN ALTERING THE COURSE OF THERAPY
VEP: VISUAL PATHWAY WHAT IS Uses one specific portion of the EEG Specific waveform THE VEP? N75 / P100 / N135 complex Measures amplitude and latency of visual signal from eye to occipital lobe In general, latency less variable than amplitude
TYPES OF VEP
Short-duration transient most common clinical usage
Flash poor visual function
Pattern reversal research Color research
Multifocal the future of the VEP
48 RELEVANCE TO CLINICAL OPTOMETRY WHAT IS RELEVANCE CASE THE VEP? TO CLINICAL EXAMPLES GLAUCOMA / AMBLYOPIA / FUNCTIONAL OPTOMETRY VISION
“HISTORICAL” VEP & USES FOR VEP GLAUCOMA
Optic nerve concerns optic neuritis, postbulbar disease, Studies by Pillai et al. (2013) and Prata et al. (2012) show ischemic/toxic/compressive significant ability of VEP to detect glaucomatous eyes vs non- damage glaucomatous eyes7,8 Objective visual acuity 91.1% sensitivity / 93.3% specificity (cf. Humphrey SITA fast: 85% infants & nonverbal adults sensitivity for mild)
Malingering/functional vision Significant correlation between visual field loss and VEP loss (FVL) latency in multiple studies using low contrast parameters
But with more research…
VEP & VEP & GLAUCOMA AMBLYOPIA
Why you might care: PRE-perimetric glaucoma (OCT thinning with no Humphrey VF defect) detected using low-contrast VEP Best use: for determining prognosis post-therapy1 (15% contrast)5 P100 latency is the strongest predictor M pathway more susceptible to glaucomatous change: VEP P100 and N135 latency significantly increased in amblyopic eye3 can isolate M pathway with threshold contrast and large checker size P100 latency helpful in diagnosis as seen with FDT fields Useful in preverbal children to determine visual function Useful for patient/parent education
49 VEP & VEP VISUAL PROTOCOLS FUNCTION For glaucoma: Can help to rule out functional 32x32, 16x16, 8x8 vision loss as diagnosis High and low contrast
Useful in determining refractive For amblyopia: error and compensation3 128x128, 64x64, 32x32, 16x16, 8x8 helpful in situations when refractive High contrast error difficult to measure by For visual disturbance/visual function: conventional means Maximum checker size that produces waveform such as: Start with flash, proceed to 4x4, 8x8, etc. difficult retinoscopy poor cognitive status High contrast poor communication ability microphthalmia
VEP PROTOCOLS Q: What are we looking for?
A: Changes over time intra-patient
Age- & sex- matched norms WHAT IS RELEVANCE CASE Pre- & post- treatment values and trends THE VEP? TO CLINICAL EXAMPLES OPTOMETRY
CASE #1: GLAUCOMA
LF: 60 yof IOPs: 12/12 mmHg CASE #1 Hx of brain tumor w/ surgery 2007 S/meds: Oxcarbazepine, simvastatin, amlodipine O/meds: none
Normotensive glaucoma suspect based on nerve appearance
50 CASE #1: CASE #1: GLAUCOMA GLAUCOMA VEP 12/2014 VEP 05/2017
OD OS OD OS 15% 85% 15% 85% 15% 85% 15% 85% 93.7 ms 112.3 ms 107.4 ms 133.8 ms 118.2 ms 122.1 ms 127.9 ms 131.8 ms 12.16 μV 15.18 μV 15.90 μV 10.94 μV 11.71 μV 11.68 μV 11.05 μV 11.31 μV
CASE #1: CASE #1: GLAUCOMA GLAUCOMA VEP 08/2017 VEP 03/2018
OD OS OD OS 15% 85% 15% 85% 15% 85% 15% 85% 0.0 ms 121.1 ms 0.0 ms 119.1 ms 106.4 ms 114.3 ms 134.8 ms 121.1 ms 0.00 μV 6.99 μV 0.00 μV 10.30 μV 5.12 μV 11.34 μV 8.69 μV 10.19 μV
Lumigan CASE #1: qHS OU GLAUCOMA 11/2017
140 120 CASE #2 100 80 60 40 20 0 AMPLITUDE LATENCY Dec-14 May-17 Aug-17 Mar-18
51 CASE #2: CASE #2: AMBLYOPIA AMBLYOPIA FIRST VEP: VEP 07/2017 ZB: 6 yowf Cycloplegic refraction: No systemic issues/injuries +2.00 – 0.50 x 167 S/O meds: none +7.00 – 0.50 x 020 VAs: OD 20/25+ OS 20/200 (20/70- at time of first VEP) 16∆ CLXT dist/near OD OS 16x16 64x64 16x16 64x64 99.6 ms 94.7 ms 95.7 ms 95.7 ms 27.91 μV 21.23 μV 16.82 μV 39.71 μV
CASE #2: CASE #2: AMBLYOPIA AMBLYOPIA VEP 01/2018 CLRx: +1.50 DS +7.00 DS Therapy: combination patching OD with MFBF, monocular oculomotor work, and eventually binocular activities 25 45-min sessions, 8 30-min sessions
SECOND VEP: VAs: OD 20/25+ OS OS 20/50 16x16 64x64 106.4 ms 120.1 ms 32.67 μV 28.91 μV
CASE #3: VISUAL FUNCTION UG: 6 yohm Hx of premature birth and CASE #3 ROP 104.5 ms 7.57 μV Large-angle CRET VAs: OD: NLP OS: LP No cognitive impairment Retinoscopy: -35.00 OS
VEP with and without lenses: 111.3 ms 14.11 μV
52 CASE #3: VISUAL
FUNCTION w/ -35.00 VIDEO
OS 4x4 8x8 100.6 ms 125.0 ms 9.23 μV 7.48 μV
WHEN SHOULD WE ORDER VEPs?
ADDITIONAL AMBLYOPIA WHEN SUBJECTIVE CASE #2 PIECE OF THE PROGNOSIS DATA UNRELIABLE PUZZLE …FOR OUR WHEN FOR GREAT INVESTIGATING CONSIDERING PATIENT VISUAL PHARMACEUTICA EDUCATION & PROCESSING & L TREATMENT EXPECTATIONS COMPENSATION PATIENTS.
REFERENCES 1. Chung W, Hong S, Lee JB, Han S-H. Pattern Visual Evoked Potential as a Predictor of Occlusion Therapy for Amblyopia. Korean Journal of Ophthalmology : KJO. 2008;22(4):251-254. doi:10.3341/kjo.2008.22.4.251. 2. Gromová M, Gerinec A. [Visual evoked potentials in management of amblyopia in children]. Ceska A Slovenska Oftalmologie: Casopis Ceske Oftalmologicke Spolecnosti A Slovenske Oftalmologicke Spolecnosti [serial online]. November 2010;66(5):223-228. Available from: MEDLINE, Ipswich, MA. 3. Hamilton, R., Bradnam, M.S., Dutton, G.N. et al. Doc Ophthalmol (2013) 126: 99. https://doi.org/10.1007/s10633-012-9362-x 4. http://www.ophthalmologytimes.com/ophthalmologytimes/news/vep-erg-testing-brings-objective-data-clinical-practice 5. Peter Derr, Rafael Furlanetto, Gustavo De Moraes, Alberto Gonzalez Garcia, Celso Tello, Jeffrey Liebmann, Robert Ritch; Evaluation of Pre-perimetric Glaucoma Patients using Short Duration Transient Visual Evoked Potentials (SD-tVEP). Invest. Ophthalmol. Vis. Sci. 2013;54(15):797.
6. Halfeld Furtado de Mendonça R, Abbruzzese S, Bagolini B, Nofroni I, Ferreira EL, Odom JV. Visual evoked potential importance in the complex mechanism of amblyopia. International Ophthalmology. 2013;33(5):515-519. doi:10.1007/s10792- 013-9734-6.
7. Pillai, C., Robert Ritch, Peter Derr, Alberto Gonzalez, Laurie Kopko Cox, John Siegfried, Jeffrey M. Liebmann, Celso Tello; Sensitivity and Specificity of Short-Duration Transient Visual Evoked Potentials (SD-tVEP) in Discriminating Normal From Glaucomatous Eyes. Invest. Ophthalmol. Vis. Sci. 2013;54(4):2847-2852. doi: 10.1167/iovs.12-10097.
8. Prata, Tiago Santos MD*,†; Lima, Verônica C. MD*,†; De Moraes, Carlos Gustavo V. MD*; Trubnik, Valerie MD*; Derr, Peter PE‡; Liebmann, Jeffrey M. MD*,§; Ritch, Robert MD*,∥; Tello, Celso MD; Short Duration Transient Visual Evoked Potentials in Glaucomatous Eyes. Journal of Glaucoma: 2013;21(6):415-420. doi: 10.1097/IJG.0b013e3182182551. 9. Tello C, De Moraes CGV, Prata TS, et al. Repeatability of short-duration transient visual evoked potentials in normal subjects. Documenta Ophthalmologica Advances in Ophthalmology. 2010;120(3):219-228. doi:10.1007/s10633-010-9216-3. THANK YOU! QUESTIONS?
53 54 No financial disclosures
Jamison Soupir, OD
Resident, Pacific University Vision Therapy, Rehabilitation, and Pediatric Optometry
76 year old White male VA: 20/25 OD, OS @ D and N CT: CC: Headaches and horizontal double • 3m: ortho 40cm 14 XP’ vision after 1 hour of computer/reading • Onset: 3-4 months before NFV’:18/22/18 • Relief: stopping the activity, breaks PFV’ 12/26/-4
Oc Hx: mild NSC OU, asymptomatic ERM Stereo: 125” Global
Capobianco: white: 50 cm, red: 50cm MHx: HTN – Tx w/ verapamil
Pang, Y., Gabriel, H., Frantz, K., & Saeed, F. (2010). A prospective study of different test targets for the near point of convergence. Ophthalmic and Physiological Optics, 30(3), 298-303.
Observation Observation Lenses Lenses • Monovision Prisms Prisms Pharmaceutical • Reverse Prism Pharmaceutical Vision Therapy Occlusion Surgery Vision Therapy Surgery
Goal: Help patients fuse/ Goal: Help patient be efficiently be binocular monocular
Caloroso, E., Rouse, Michael W, & Cotter, Susan A. (1993). Clinical management of strabismus. Boston: Butterworth- London R. CLINICAL MANAGEMENT OPTIONS FOR TREATMENT OF DIPLOPIA. In: Onofrey BES, Leonid; Holdeman, Heinemann Nicky R., ed. Ocular Therapeutics Manual: A Clinical Manual. 3rd Edition ed. 530 Walnut Street, Philadelphia, PA 19106 USA: Lippencott Williams & Wilkins; 2011.
55 When binocularity is not practical • Non-concomitant deviations • Minimal zone of binocularity
Improved cosmesis vs. patch
Passive treatment option • Can provide immediate relief
Non-concomitant deviations Observation Lenses Horror fusionis • Monovision • Sensory Fusion Disruption Syndrome Prisms Pharmaceutical Fused at far and diplopic at near or vice Occlusion versa VT Surgery Presbyopes
Monovision Found glasses to be comfortable, but not Prisms practical Occlusion • Back to old glasses… • and headaches VT Patient opted for computer/near OD: +1.75 -0.50 x 070 4.5BI progressive glasses w/ 9 ΔBI OS: +1.75 -0.50 x 050 4.5BI ADD: +1.25
RTC in 2.5 months Interested in monovision
56 Habitual Good on computer and house • OD: +0.50 -0.50 x 070 Not comfortable for driving • OS: +0.50-0.50 x 050 • ADD: +2.50 PAL 5 out of 10 on “Loving Glasses” scale Monovision Trial • Still motivated • OD: +0.50 -0.50 x 070 SVD • OS:+2.00-0.50x050 • ADD: +1.00 PAL OS ONLY Discussed training techniques RTC in 1.5 months RTC: 2 months
No complaints, loves glasses, came in Equal acuity in both eyes smiling Using glasses full time Eye Dominance • Computer, driving • Depends
Visual Acuity (Distance) More mobile eye set for near • OD:20/20-1 • OS:20/40-2 Visual Acuity (Near) Don’t think about what eye is being used!
London R. Monovision correction for diplopia. J Am Optom Assoc 1987;58(7):568 –570. • OS:20/25+1 Bujak, M., Leung, A., Kisilevsky, M., & Margolin, E. (2012). Monovision Correction for Small-Angle Diplopia. American Journal Of Ophthalmology, 154(3), 586-592. Pardhan S, Gilchrist J. The effect of monocular defocus on binocular contrast sensitivity. Ophthalmic Physiol Opt 1990; 10(1):33–36.
Generally start w/ +2.50-+3.00 to Training promote suppression • Occlude one eye while doing a distance activity • Remove after 10-20 min Pre-presbyopic • Repeat if needed. Repeat at near • Over-minus of distance, over-plus for near • Dominant eye near eye
Try different lens modifications
London R. CLINICAL MANAGEMENT OPTIONS FOR TREATMENT OF DIPLOPIA. In: Onofrey BES, Leonid; Holdeman, Nicky R., ed. Ocular Therapeutics Manual: A Clinical Manual. 3rd Edition ed. 530 Walnut Street, Philadelphia, PA 19106 USA: Lippencott Williams & Wilkins; 2011. London R. Monovision correction for diplopia. J Am Optom Assoc 1987;58(7):568 –570.
57 Consider partial occlusion • Clear Contact Paper/ Press-and-Seal • Frosting the lens/nail polish/tape • Full central occlusion
Be flexible – don’t throw in the towel • Switch Distance and Near Eye • Cycloplegia • Can be done with contact lenses
-Kirschen, D., & Flom, M. (1977). Monocular central-field occlusion for intractable diplopia. American Journal of Optometry and Physiological Optics, 54(5), 325-31.
-London R. CLINICAL MANAGEMENT OPTIONS FOR TREATMENT OF DIPLOPIA. In: Onofrey BES, Leonid; Holdeman, Nicky R., ed. Ocular Therapeutics Manual: A Clinical Manual. 3rd Edition ed. 530 Walnut Street, Philadelphia, PA 19106 USA: Lippencott Williams & Wilkins; 2011.
44 yo white female VA: 20/20 OD, OS at 3 m, 20/25 OD, OS at 40cm CC: Constant double vision, in all gazes, at all distances 1mm anisocoria OS, no APD, FTFC OD, OS S/P mulitple surgeries to remove meningioma EOMs 000 000 Managed w/ clear contact paper on 00-10 safety glasses 0 0 0 -2 -1 0
58 Health Exam: unremarkable except for: 2 EP Cornea: • OD: trace-1+ staining on the inferior 1/3 of the cornea 14 LHyper 10LHyper 8LHyper • OS:1+ diffuse at 3 and 9 in the left 5ET 4ET 14ET *Worse in Left Tilt
TBUT: 20 Lhyper • OD:3 sec 5ET • OS:1-2 sec
Trialed 8 BU OD w/ red lens Observation • Brief fusion Lenses • Monovision Yoked Pr ism Prisms • Fusion w/ 16BD OD and 20 BD OS Pharmaceutical • Small area of fusion Occlusion VT Surgery
Monovision Habitual - none Occlusion Monovision Trial Surgery OD: plano DS OS: +2.50DS
Good response in office
RTC: 2 months
59 Double vision and headaches w/ new Dr. Redo glasses OD: +1.75DS • Used contact paper over OS (near) OS: -0.25-0.25x165 • Alternated between safety glasses • Right eye: hypotropic/more mobile
Still double in primary gaze Blurry but single at near Contact paper on above lower lid margin • Noticeable improvement immediately
RTC in 1 month
Forgot to try contact paper • Placed above lower lid
Returned 2 months later No double vision More confident and comfortable Visual Acuity (Distance) • OS:20/20-1 Visual Acuity (Near) • OD:20/20-1
Monovision is a viable option for relieving patients who suffer from ? diplopia
Get creative!
60 Kirschen, D., & Flom, M. (1977). Monocular central-field occlusion for intractable diplopia. American Journal of Optometry and Physiological Optics, 54(5), 325-31.
Migneco, M. K. (2008). Alleviating Vertical Diplopia Through Contact Lenses Without the Use of Prism. Eye & Contact Lens: Science & Clinical Practice, 34(5), 297-298.
Bujak, M., Leung, A., Kisilevsky, M., & Margolin, E. (2012). Monovision Correction for Small-Angle Diplopia. American Journal Of Ophthalmology, 154(3), 586-592.
Pang, Y., Gabriel, H., Frantz, K., & Saeed, F. (2010). A prospective study of different test targets for the near point of convergence. Ophthalmic and Physiological Optics, 30(3), 298-303.
Caloroso, E., Rouse, Michael W, & Cotter, Susan A. (1993). Clinical management of strabismus. Boston: Butterworth-Heinemann
London R. CLINICAL MANAGEMENT OPTIONS FOR TREATMENT OF DIPLOPIA. In: Onofrey BES, Leonid; Holdeman, Nicky R., ed. Ocular Therapeutics Manual: A Clinical Manual. 3rd Edition ed. 530 Walnut Street, Philadelphia, PA 19106 USA: Lippencott Williams & Wilkins; 2011.
1London R. Monovision correction for diplopia. J Am Optom Assoc 1987;58(7):568 –570.
61 Financial Disclosure Vestibular-ocular rehabilitation of a female patient three years post- • Nothing to disclose concussion
Megan Thistle, OD Bright Eyes Vision Clinic Pediatric and Neuro-Rehab Residency
Affiliated Residency Orientation July 9, 2013
Objectives Vestibular-Ocular Dysfunction
• Be able to identify common post-concussion symptoms • How is your vestibular and ocular system connected? • Be able to use visual tests necessary to diagnose post-concussion vision symptoms • Be able to explain the importance of inter-disciplinary care of a concussion patient • Peripheral Vestibular System • Be able to describe how the vestibular system relates to vision in a post-concussion patient. – Semi-circular canals • Be able to describe multiple vision therapy activities to help with vestibular-ocular symptoms in a post-concussion patient. – Otoliths • Be able to discuss how to implement testing protocols to identify patients suffering from vestibular-ocular symptoms after a concussion • Central Vestibular System • Be able to discuss how to start a vision therapy program that incorporates vestibular-ocular – Vestibular nucleus, ocular, proprioception activities. – Neuronal connections between them all!
Herdman, S. (2007). Vestibular rehabilitation (3rd ed) Wong, A. (2008). Eye movement disorders.
62 Classic Symptoms of Vestibular Ocular Dysfunction? Dysfunction • Dysfunction occurs when there is a mismatch between • Dizziness w/ VOR testing peripheral vestibular system and what makes up the • Dizziness w/ saccades or pursuits central vestibular system, which results in symptoms • Increase in other symptoms (HA, nausea) with head or eye movement • Complaints of difficult driving • Complaints of balance issues • Avoidance of visually busy environments (grocery stores, malls, public events)
How do we test vestibular-ocular function? VOMS Cont. VOMS (Vestibular/Ocular Motor Screening) •Tests • Symptom Scale rating: 0 (none) to 10 (severe) – Smooth pursuit – Horizontal and vertical saccades • VOR was associated with the highest percentage of concussed patients reporting symptom provocation – Convergence (NPC) – Horizontal and Vertical VOR • Found that, pursuit eye movements, NPC and saccades – Visual motion Sensitivity were the most helpful in identifying symptomatic concussion patients. • Symptoms provocation – Verbally rate changes in HA, dizziness, nausea and fogginess
VOR and VMS Ruling Out Other Problems
• Visual • Other causes – Vertical Misalignment – Otoliths – Abnormal egocentric localization • BPPV – Anisometropia – Dix-Hallpike and Epley Maneuver – Meniere’s Disease – PAL/lens material – Gait Problems – Uncompensated refractive error
Mucha, A., Collins, M., Elbin, R., Furman, J., Troutman-Enseki, C., DeWolf, R., . . . Kontos, A. (2014). A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions.
63 Treatment for Vestibular-Ocular Dysfunction • Do they need a referral to somewhere else? – ENT? OT? Vestibular PT? • Lenses/Prism • Vision Therapy! – aka Neuro-Optometric Vision Rehabilitation
How can you ID these patients, test for these symptoms, and help? Brain Injury Vision Symptom Survey • Do you have a symptom check-list? Credit to Dr. Laukkanen – Know the common symptoms! • Know risk factors for vestibular-ocular dysfunction (concussion) • Ask the right questions • VOMS protocol
Meet the Patient: JD Chief Complaint
• 43 yo WF, Professor at a local university, physical • Headache therapist, hockey coach – Has a low grade HA all day, gets worse with computer work • MVA Oct, 2014. • Struggles with driving – Suffered a neck injury and hit left side of head • Struggles with reading • Referred by her OT, was first seen in our office Dec, 2015 • Dizzy • Has been through two rounds of PT and currently in OT • Light Sensitive
64 Symptom Checklist Exam Findings (VOMs format)
• Tests: – Smooth pursuit: smooth, no symptoms – Horizontal saccades: Jerky. Uncomfortable to perform, caused nausea – Convergence (NPC): 10cm, dizzy w/ testing – Horizontal VOR: uncomfortable, felt ‘behind’ – Visual motion Sensitivity: not tested, but based on symptoms
*Before BIVSS was implanted in our office of dizziness with driving, would likely be positive result.
Other Exam Findings Diagnoses
• BO: 25/20 • Paresis of Accommodation • BI: 16/10 • Headache • NRA: +1.50 • Convergence insufficiency • PRA: -0.50 • Dizziness and Giddiness • Saccadic Eye Movements
Plan Treatment for our patient: JD
• Distance and near glasses, low amount of BI prism, • Individualized vestibular-ocular activities! recommend non-polycarbonate lenses • Goals: no headaches, able to work on computer • Patient still in OT and PT, would like to complete that comfortably, no dizziness, feel ‘normal.’ course of treatment • Discuss, educate and recommend in-office vision therapy. • Patient commits to VT in Dec 2016 • Starts VT in Oct 2017
65 Level 4: Head Tilt • Level3: Alternate Headand EyeMovement • Level 2: Head movement only • Do not wear any correction! • Wantto be ableto a once do activity dayfor 1 week • Note symptoms: • First Weeks supine Activity-ground Gravity iv.Collier sitting iii.Calisthenics- (Patched) Movements Eyeii.Greenwald Trace Circle i.Chalkboard without anysymptoms beforegoing on to next level! – Do the same procedure at above-but with head tilted back about 50 at with head tiltedback Do theprocedureabove-butsame – or contacts No glasses – nausea or tipping,spinning, rocking,tilting Floating, – – Do patched and then Do patchedbotheyestogether – I.e.: follow with eye only for 3 swings then switch and follow with head only – Switchthe from following ball with your eye to with your head when the – eye Do witheach andthenbotheyes – Same procedurewith patched eye-onlymove head, no eye movement! – degrees ball crosses the centerof ball crossesthe patient Greenwald Eye Contd. Movement Collier Gravitycontinued Few Weeks In Activity-sitting Gravity iii.Collier and metronome arrows directional w/ rail ii.Walking Head only Eye-i.Greenwald
Middle Weeks Diagonal, patched iii.Greenwald walking Chart ii.McDonald metronome Chart Hart and w/ rail i.Walking
Final Weeks above eyelevel eye level and ball-below Marsden w/ rail iv.Walking Chart Hart 80 bpm w/ Rail iii.Walking Rail Walking w/ Pursuits Ball ii.Marsden Activity-Standing Gravity i.Collier 66 https://visionhelp.wordpress.com/2016/07/12/peripheral-awareness-old-macdonald-had-a-form/ Level 1: Eye MovementOnly • pursuit smooth achieve Goal: • • Last Level: Standing with the same sequence the same with Standing Level: Last • sequence same Sittingand Level: Next • closed eyesfloor with on lay Level: First • Goalof and vestibular Activity: visual help integrate • v – Report any symptoms of dizziness, nausea, loss of balance, jumpyloss ofbalance, nausea, of Report anysymptomsdizziness, – Do for 1 eyeand both min witheach thenwitheyes. – with Follow eye only, do not movehead – ball sidetoin side frontof Swingpatient – Patch one eye – front ofpatient in. in 6-8 Ball Marsden Suspend – estibular system estibular sy Check baselinebodyand motion awareness/recovery – Gothrusequence3-10times – positions 9 cardinal eyesin all Move – eye movements stem Greenwald Eye Movement McDonald Chart Collier Gravity s s while integratingthe Don’t Forget! Action Plan for you!
• Adjunct skills needed! • Saccades • Ask if your patients have had concussions! • Oculomotor • Syntonics! – MVA, or any other head injury (may not be diagnosed) • Accommodation • Visual Memory – This simple question can be added to your history form! – Monocular vs Binocular • And any other processing • Some kind of ABI/TBI Questionnaire • Vergence deficiencies… • VOMs protocol in your exam room as a screener – In free space! • Therapy/Rehabilitation! – Not comfortable with this? Refer to a colleague who is!
TBI/ABI Questionnaire Sources • Baxstrom, C. Clopton, J. (2010). Vestibular processing: A key component of visual functioning and balance. COPE #21778. • BIVSS • Herdman, S. (2007). Vestibular rehabilitation (3rd ed., Contemporary perspectives in rehabilitation (Series)). Philadelphia: F.A. Davis. • COVD Checklist • Leigh, R., & Zee, David S. (2006). The neurology of eye movements (4th ed., Contemporary neurology series ; 70). New York: Oxford University Press. • Mucha, A., Collins, M., Elbin, R., Furman, J., Troutman-Enseki, C., DeWolf, R., . . . Kontos, A. (2014). A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions. The American Journal of Sports Medicine, 42(10), 2479-2486. • National institute of deafness and other communication disorders. (2017). Meniere’s Disease. National Institutes of Health. Retrieved from: https://www.nidcd.nih.gov/health/menieres-disease • Newman-Toker, D.E. (2017). Neuro-vestibular examination. The Johns Hopkins university school of medicine. Baltimore, MD. • Wong, A. (2008). Eye movement disorders. Oxford ; New York: Oxford University Press.
67 68 69 70 71 72 Overview
• History of refractive surgery What are patients SMILE-ing • What is SMILE? about? • Benefits of SMILE • Patient selection and education Amanda Thurmes, O.D. • Healing process Refractive and Ocular Surgery Resident Chu Vision Institute • Post-operative care Bloomington, MN • Patient case • Conclusions
Corneal Flattening Concept
• The initial goal of early refractive surgery was to flatten the central (or partial sections) of the cornea to reduce myopic refractive error • Radial keratotomy • Incisions made radially on the cornea to cause the mid-periphery to bulge forward History of Refractive Surgery and flatten central cornea, decreasing myopia Corneal flattening • Arcuate keratotomy • Paired arcuate incisions made to flatten the steep meridian reducing astigmatism Keratotomy • Automated lamellar keratoplasty Excimer laser • Microkeratome made a flap on the cornea, then the same instrument was reset to PRK resect a disc of tissue from the underlying stromal bed, then the flap was LASIK repositioned Refractive lenticule extraction
Radial Keratotomy Excimer Laser
• 1970: a young myopic boy presented with corneal lacerations from • Developed in the early 1970s by researchers at IBM glass fragments • After the injuries healed, the boy’s vision was better than before the injury • Modified for ophthalmic use in the early 1980s • Technique • Idea introduced to use the laser to reshape the cornea tissue to correct • A series of radial incisions were created using a specially calibrated diamond refractive error knife starting near the limbus and ending at the “clear optical zone” which was • Patented for vision correction and first laser eye surgery performed on a 4 mm diameter circle surrounding the visual axis a real patient in 1987 – volunteer who was scheduled for enucleation • Study over 10 years showed only 60% of patients were within 1 D of intended result with 53% of patients seeing 20/20 • FDA approved for its use for PRK in 1995 in U.S. • Complications • Postoperative photophobia and glare, decentered clear zone and/or incisions across visual axis, poor refractive error stability over time, and accidental perforations during procedure
73 Photorefractive Keratectomy Laser Assisted In Situ Keratomileusis
• aka ASA (advanced surface ablation) • With the development of precise surgical cutting instruments, the use of the excimer laser was combined with an incision to produce a • FDA approved in 1995 in U.S. particular surgical result • Approved initially to treat myopia • Flaps created with a microkeratome • Flap lifted up and the excimer laser beam is applied to the exposed interior • Later refinements in technology allowed for treatment of hyperopia and surface of the cornea to reshape the tissue astigmatism • Flap the replaced over the treated area and serves as a natural bandage, eliminating discomfort and expediting the healing process • Laser applied directly to the surface of the cornea to sculpt • First procedure performed in 1991 tissue and alleviate refractive error • FDA approved in 1998 in U.S. • Over 30 million procedures performed worldwide • Approved to treat myopia, hyperopia, astigmatism • Has become the most commonly performed refractive surgery procedure used today
LASIK Advancements Refractive Lenticule Extraction
• Improved corneal mapping technologies • The newest option in refractive surgery • Wavefront-guided laser • An intrastomal lenticule is created with a femtosecond laser • Topography-guided laser • The lenticule is manually extracted to correct refractive error • Wavefront-optimized laser • Eye tracking technology • Small incision lenticule extraction (SMILE) • Over 1 million procedures performed worldwide • Femtosecond laser flaps • “Bladeless LASIK” • More predictable corneal flap thickness and potential for thinner corneal flaps
Cornea Anatomy
• Epithelium • Bowman’s Layer • Stroma • Descemet’s membrane • Endothelium
What is SMILE? Corneal anatomy Surgical procedures Clinical trial results
https://discovery.lifemapsc.com/library/images/the‐anatomy‐and‐structure‐of‐the‐adult‐human‐cornea
74 Cornea Biomechanical Stability Laser Vision Correction
• Risk of ectasia = one of the most important considerations prior to • Laser removes a specific amount of corneal tissue in a specific laser vision correction pattern to reshape the cornea and correct refractive error • Ectasia is the bulging forward of a thinned, unstable cornea leading • Different pattern for different refractive errors to irregular astigmatism and decreased vision • Amount of tissue dependent on degree of refractive error • Flap creation on cornea disrupts corneal biomechanical stability • No flap = more stability • Ability to treat higher refractive errors with PRK vs. LASIK • Treatment for post-LASIK ectasia • Corneal collagen crosslinking
Laser Vision Correction Surgical Procedures
• LASIK • Two laser system • Flap creation
• ASA/PRK • Epithelial removal • Surface ablation
•SMILE • One laser system • Series of lamellar resections • Lenticule extraction
Corneal Incision: LASIK vs. SMILE
LASIK SMILE
75 Series of Lamellar Resections
•1st lamellar cut defines posterior surface of lenticule •1st side cut defines lenticule diameter •2nd lamellar cut defines anterior surface of lenticule/posterior surface of attached cap •2nd side cut creates incision for removal of lenticule
Clinical Trial: Design & Objectives Post-Operative UCVA
• Prospective, multi-center, open label, single-arm study • Proposed sample size: 360 subjects • Unilateral treatment with 12-month follow-up period • Fellow eye treatment with approved laser procedure • Objective: to evaluate the safety and effectiveness of the femtosecond laser lenticule removal procedure for the reduction or elimination of myopia from ≥ -1.00 D to ≤ -10.00 D with ≤ - 0.50 D cylinder and MRSE ≤ -10.25 D (subjects with ≤ -0.50 D cylinder were enrolled, but the cylinder was not treated as part of the clinical trial)
Mean Change in MRSE Predicted MRSE at 12 months
76 Patients with Post-op UCVA ≥ Pre-op Clinical Trial: Patient Reception BSCVA • Effectiveness and safety of procedure well received by patients • 99% reported they were satisfied with the SMILE procedure • 96% reported they would have refractive surgery again
One-laser system
• Femtosecond Laser creates intrastromal lenticule and surgeon dissects and removes lenticule through the small incision • Patient does not have to move from one laser to the other • Potential for less anxiety for patient during procedure Benefits of SMILE • Easier for patients with physical disabilities One-laser system Flapless procedure Dry eye incidence Potential to treat higher myopia
Flapless Procedure Dry Eye: Corneal Nerve Disruption
Removing tissue from deeper corneal layers result in less impact on the corneal surface and • More biomechanical stability of cornea – similar to PRK nerves and lower risk of dry eye • Less induction of optical aberrations as no flap is created • Studies reported less glare/haloes compared to LASIK • Patients typically experience less discomfort and dryness during and immediately after procedure compared to LASIK and PRK • SMILE is not performed on the surface of the eye, so vision recovers more quickly than PRK • No flap-related complications • Lower risk of epithelial ingrowth Dry eye disease after refractive surgery: comparative outcomes of small incision lenticule extraction versus LASIK. Ophthalmology 2015 Apr, Denoyer A, Landman E, Trinh L, Faure JF, Auclin F, Baudouin C.
77 Dry Eye: Corneal Nerve Disruption Potential to treat higher myopia
• Due to more biomechanically stable cornea, some studies have shown SMILE to be safe even for higher levels of myopia • Other studies have shown similar incidences of ectasia with SMILE long-term compared to LASIK • At this time, especially with current FDA approval parameters, SMILE is being calculated and performed with similar methods to LASIK/PRK
Patient selection and education
• General candidacy requirements • Healthy eyes • Age 18+ • Stable refraction • Not pregnant or nursing • Clinical Evaluation • Topography • Pattern: regular vs. irregular astigmatism Patient Selection & Education • Posterior float Parameters • Apical displacement FDA approval • Pachymetry: thick vs. thin cornea • Localized or displaced thinning? Limitations • Is there enough tissue to safely perform LVC? Expectations • These measurements are factored in to determine risk for developing ectasia
FDA Approved Indications for SMILE Limitations of SMILE
• Reduction or elimination of myopia -1.00 D to -8.00 D with ≤ -0.50 D • Only treating myopia in U.S. at this time – FDA approval cylinder and MRSE -8.25 D in the eye to be treated in patients who are 22 years of age or older with documentation of stable manifest • No astigmatism correction, even myopic astigmatism refraction over the past year. • Clinical trials being performed in U.S. for astigmatism and • U.S. Indications hyperopia treatments • Sphere: -1.00 to -8.00 D • Cylinder: Not FDA approved • Spherical equivalent: up to -8.25 D • Outside of U.S. Indications • Sphere: -0.50 to -10.00 D • Cylinder 0.00 to 5.00 D • Spherical equivalent: -0.50 to -12.50 D
78 Healing process PRK LASIK SMILE
https://advancedvisionsurgery.com/blog/2472016latest‐update‐on‐smile‐laser‐eye‐surgery
Healing Process Healing process: SMILE
•PRK • The minimally invasive nature of SMILE may enable more rapid • Discuss healing ridge and slower visual recovery resumption of regular activities • Need for BCL and significant discomfort • Removal of BCL 3-7 days postop • Slower healing for older patients, diabetics, etc. • LASIK • Extra caution for rubbing eyes • More glare/haloes • Many patients achieve 20/20 vision within 24 hours •SMILE • Driving vision usually restored within 24 hours, then improves and sharpens over time • Full visual recovery achieved for all procedures 3-6 months after surgery
Healing Process: Interface Quality Patient expectations and education
• Uncovering the patient’s daily visual demands and expectations for vision after surgery is an important component of the pre- operative evaluation for any refractive surgery • Setting the right mindset for healing process • Post-surgical healing route often different than that of LASIK or PRK • May or may not be comfortable returning to work the next day • Educate to allow proper life-planning for patients wanting to pursue SMILE
Indian Journal of Ophthamology, Feb 2018. 66:212‐218
79 Post-Operative Care
• Patients typically seen 1 day, 3-7 days, 1 month, and 3 months • Monitor for infection, DLK, epithelial ingrowth, retained lenticule fragments, epithelial abrasions, dry eye, residual refractive error • Post-operative treatment regimen at Chu Vision Institute: • Topical prophylactic broad-spectrum antibiotic QID x 1 week • Topical steroid Q1hr day of surgery (surgeries typically performed in Post-operative care early evening), then QID x 4-7 days, BID x 1 week • Preservative free artificial tears Q1-2hr
22 y/o Asian Female presented on 8/16/17
• Full refractive evaluation – out of CLs x 2 weeks • cc: Looking to gain independence from glasses and CLs • Wears glasses more than CLs due to dryness • Spends many hours a day at computer or studying and eyes feel dry and tired • Full time student at U of MN – majoring in mathematics • LEE: 2 years ago – myopia Patient Case • LME: 1 year ago – no current health conditions or medications • Current non-drinker of alcohol and never smoker • Family history unknown – adopted • No known drug allergies
Entrance Testing OD OS VA sc distance 20/400 20/400 VA cc distance 20/25‐ (PH 20/20) 20/25‐ (PH 20/20) VA cc near J1+ J1+ Pupils PERRLA (no APD), 6 mm dim, 4 mm bright PERRLA (no APD), 6 mm dim, 4 mm bright EOM FROM FROM CVF FTFC FTFC Habitual SRx ‐7.00 + 0.25 x 038 ‐6.25 sph Manifest Refraction ‐7.25 sph (20/20) ‐6.50 + 0.25 x 088 (20/20) IOP 16 mmHg via GAT @ 14:19 16 mmHg via GAT @ 14:19 Dilation 1.0% Tropicamide @ 15:17 1.0% Tropicamide @ 15:17 Cycloplegic Manifest Refraction ‐7.00 sph (20/20) ‐6.25 sph (20/20)
80 Posterior Segment OD OS Anterior Segment OD OS Optic Nerve Head NRR pink, margins distinct NRR pink, margins distinct Adnexa Normal Normal C/D ratio 0.2/0.2 0.2/0.2 Lids Normal Normal Macula Flat and Clear Flat and Clear Bulbar Conjunctiva Clear Clear Vessels 0.7 A/V ratio 0.7 A/V ratio Palpebral Conjunctiva Clear Clear Periphery Normal, (‐) holes/tears/detachments Normal, (‐) holes/tears/detachments Cornea Clear Clear Vitreous Clear Clear Tear film Normal Normal Lenses 90D, 20D 90D, 20D Sclera White & Quiet White & Quiet Anterior Chamber Deep & Quiet Deep & Quiet Iris Normal Normal Lens Clear Clear
81 Assessment & Plan Tissue Calculation: SMILE vs. LASIK
• Myopia, OU • FDA standards: 250 µm left in “bed” to prevent ectasia • Pachymetry = 576 µm OD, 556 µm OS • Risks, benefits, alternatives of LASIK and SMILE surgery discussed • Refractive error = -7.00 D OD, -6.25 D OS with patient including loss of eye, decreased vision, glare, arc, • LASIK calculation starburst, and halo. • Treatment thickness (per Zeiss MEL-80 6.0 optical zone nomogram) •OD: 86 µm • Risk of DLK, corneal abrasions, epithelial ingrowth, and dry eye worse • OS: 79 µm • Tissue available for ablation ( flap = 100 µm) after surgery also discussed with patient. • OD: 576 – 100 – 86 = 390 µm residual bed • Discussed laser vision correction with patient and educated on course • OS: 556 – 100 – 79 = 377 µm residual bed • SMILE calculation (per VisuMax Femtosecond laser ReLEx SMILE nomogram) of healing. Patient expressed understanding and wishes to consider •OD SMILE OU. • Lenticule thickness = 118 µm • Cap = 120 µm • 576 – 118– 120 = 338 µm residual bed •OS • Lenticule thickness = 108 µm • Cap = 120 µm • 556 – 108 – 120 = 328 µm residual bed
SMILE Treatment 8/23/17 1 day post-operative visit on 8/24/17
• SMILE procedure performed OU by Y. Ralph Chu, M.D. without • Reports good vision improving since yesterday complication • Mild discomfort OS>OD • Medications: • Durezol Q1hr OU, Vigamox QID OU, and artificial tears Q2hr OU • Durezol 0.05% - 1 drop in surgical eye as directed every hour day 1, Entrance Testing & Anterior OD OS then QID x 4 days, then BID until gone Segment Evaluation • Vigamox 0.5% - 1 drop in surgical eye QID x 1 week VA sc distance, near 20/20‐2, J1+ 20/25‐2 (PH 20/20‐2), J1+ • Artificial tears – Q1-2 hr while awake Pupils, EOM, CVF PERRLA (‐) APD, FROM, FTFC PERRLA (‐) APD, FROM, FTFC IOP 14 mmHg @ 8:47 via iCare 12 mmHg @ 8:47 via iCare Manifest Refraction ‐0.50 sph (20/20) ‐0.50 + 1.00 x 096 (20/25+2) Cornea S/P SMILE: (‐) DLK, (‐) epi ingrowth, S/P SMILE: (‐) DLK, (‐) epi ingrowth, (‐ (‐) retained lenticule fragments ) retained lenticule fragments
Assessment & Plan
• S/P SMILE, OU • Taper Durezol to QID OU • Continue Vigamox QID OU • Continue preservative free artificial tears Q1-2hr OU • RTC for 5 day postop, or sooner PRN
82 5 day post-operative visit on 8/28/17
• Reports good vision and comfort OU • Durezol QID OU, Vigamox QID OU, and artificial tears Q2hr OU
Entrance Testing & Anterior OD OS Segment Evaluation VA sc distance, near 20/20, J1+ 20/20‐1, J1+ Pupils, EOM, CVF PERRLA (‐) APD, FROM, FTFC PERRLA (‐) APD, FROM, FTFC IOP 13 mmHg @ 15:24 via iCare 12 mmHg @ 15:24 via iCare Manifest Refraction ‐0.25 sph (20/20) ‐0.75 + 0.50 x 103 (20/20) Cornea S/P SMILE: (‐) DLK, (‐) epi ingrowth, S/P SMILE: (‐) DLK, (‐) epi ingrowth, (‐ (‐) retained lenticule fragments ) retained lenticule fragments
Assessment & Plan 1 month post-operative visit 9/22/17
• S/P SMILE, OU • No complaints or discomfort – very happy with vision • Taper Durezol to BID OU x 1 week then discontinue • Artificial tears BID OU, feeling less need to use them • Continue Vigamox QID OU x 2 days then discontinue • Continue preservative free artificial tears Q1-2hr OU Entrance Testing & Anterior OD OS Segment Evaluation • RTC for 1 month postop, or sooner PRN VA sc distance, near 20/20, J1+ 20/20, J1+ Pupils, EOM, CVF PERRLA (‐) APD, FROM, FTFC PERRLA (‐) APD, FROM, FTFC IOP 14 mmHg @ 15:52 via iCare 14 mmHg @ 15:52 via iCare Manifest Refraction ‐0.25 sph (20/20) ‐0.50 + 0.25 x 090 (20/20) Cornea S/P SMILE: (‐) DLK, (‐) epi ingrowth, S/P SMILE: (‐) DLK, (‐) epi ingrowth, (‐ (‐) retained lenticule fragments ) retained lenticule fragments
Assessment & Plan
• S/P SMILE, OU • Continue preservative free artificial tears BID OU or more PRN • RTC for 3 month postop, or sooner PRN
83 3 month post-operative visit 12/1/17
• No complaints or discomfort – very happy with vision • Not using any artificial tears, eyes comfortable when studying
Entrance Testing & Anterior OD OS Segment Evaluation VA sc distance, near 20/20, J1+ 20/20, J1+ Pupils, EOM, CVF PERRLA (‐) APD, FROM, FTFC PERRLA (‐) APD, FROM, FTFC IOP 12 mmHg @ 15:52 via iCare 12 mmHg @ 15:52 via iCare Manifest Refraction ‐0.25 sph (20/20) ‐0.50 + 0.25 x 090 (20/20) Cornea S/P SMILE: (‐) DLK, (‐) epi ingrowth, S/P SMILE: (‐) DLK, (‐) epi ingrowth, (‐) (‐) retained lenticule fragments retained lenticule fragments
Assessment & Plan Conclusions
• S/P SMILE, OU • SMILE is the newest option in U.S. for patients considering • Continue use of artificial tears PRN OU refractive surgery • Return to primary OD for annual exam. RTC CVI PRN. • SMILE has the potential to provide better outcomes to specific patients including dry eye patients, higher refractive error, etc. • Has replaced LASIK as the most commonly performed refractive surgery in Asia • Future of SMILE/refractive surgery • Astigmatism • Hyperopia
References
• Damgaard, I.B., Ivarsen, A., & Hjortdal, J. “Refractive Correction and Biomechanical Strength Following SMILE With a 110- or 160-µm Cap Thickness, Evaluated Ex Vivo by Inflation Test.” Invest Ophthalmol Vis Sci, 2018. 59:1836-1843. • Ganesh, S., Brar, S., Pandey, R., Pawar, A. “Interface healing and its correlation with visual recovery and quality of vision following small incision lenticule extraction.” Indian Journal of Ophthamology, February 2018. 66:212-218 • Ivarsen, A., Asp, S., Hjortdal, J. “Safety and Complications of More Than 1500 Small- Incision Lenticule Extraction Procedures.” Ophthalmology, April 2014. 121(4):822-828. • Recchioni, A., Hartwig, A., Dermott, J., Vaswani, S., Bhatt, J., Morris, R., O’Donnel, C. “Early clinical outcomes after small incision lenticule extraction surgery (SMILE).” Contact Lens and Anterior Eye, 2018. 41:132-135. Questions? • Retrieved on 5/15/18 from https://collaborativeeye.com/articles/2018-jan-feb/what-ods- need-to-know-three-major-differences-between-lasik-and-smile/ • Retrieved on 5/15/18 from www.eyedoctornetwork.org/history-of-refractive-surgery.html • Retrieved on 5/16/18 from http://www.reviewofcontactlenses.com/article/something-to- smile-about
84 OBJECTIVES
• Identify the salient characteristics of ocular ischemic syndrome • Be able to explain the optometrist’s role in providing care for this condition.
DISCLOSURES OCULAR ISCHEMIC SYNDROME • None BENJAMIN G. NIELSON, OD MANN GRANDSTAFF VAMC
CASE REPORT CASE REPORT
• LR 73 yo WM Walk‐In • VAcc: OD: 20/60, PH 20/50; OS: 20/20 • CC: Constant dull pain OD that woke him up, also blurry vision and photophobia • EOMS: FULL, (+)pain OD sup & sup/temp • Pupils: PURL, (‐)APD • OHx: Cataracts, mild ERM, DES, Presbyopia • IOP 16/16 • MHx: hypertension, hyperlipidemia, hypothyroidism, sleep apnea, GERD, BPH, obesity • SLE OD: • Lids: Mild tylosis • Meds: nifedipine, simvastatin, levothyroxine, pantoprazole na, doxazosin mesylate • Conj: 2+ diffuse injection • Cornea: (‐)staining, deep stromal edema, 1‐2+ KPs • AC: 2‐3+ cells • Iris: (‐)NVI, PS, dilation of vessels • Lens: 1‐2+ NS, Trace Cortical
CASE REPORT HISTORY OF OCULAR ISCHEMIC SYNDROME
• Dilated Fundus Exam: • “Venous Stasis Retinopathy” • Nerve: OU: (‐)edema, margins distinct • “Hypotensive Retinopathy” • C/D: OD: 0.30R OS: 0.35R • “Ocular Inflammatory Syndrome” • Macula: OU: mild patchy ERM • P. Pole: OD: blot heme inf to ONH OS: unremarkable • A/V Ratio: 2/3 • Periphery: OD: limited views OS: dot & blot hemes sup, sup/nas, temp • Vitreous: OU: (‐)cells
85 ETIOLOGY ASSOCIATED SYSTEMIC DISEASES
• Demographics • Atherosclerosis • Reduction of blood flow • Systemic Hypertension • Fall in mean blood pressure • Diabetes Mellitus • Rise in IOP • Coronary Artery Disease • Occlusion or stenosis of carotid a. or ophthalmic a. • Cerebrovascular Disease • Smoking • Vasculitis • Compression https://g.co/kgs/xG6R6w
SYMPTOMS SIGNS: ANTERIOR SEGMENT
• Slowly progressive loss of vision • Neovascularization of the iris • Pain: peri‐ocular, retro‐orbital, or in the upper face • Dilated episcleral vessels
• Ischemic damage to V1 • Anterior chamber inflammation • Anterior segment inflammation • Low IOP ‐‐‐> High IOP • Elevated IOP‐neovascular glaucoma • Neovascular Glaucoma • Light‐induced amaurosis • Marked NVI • Unilateral • (+/‐)hyphema • Corneal edema • Asymptomatic • Mid‐dilated, poorly reactive pupil • Cataract http://n.neurology.org/content/79/11/e92
SIGNS: POSTERIOR SEGMENT DIFFERENTIAL DIAGNOSES
• Narrowed retinal arteries • Non‐Granulomatous Anterior Uveitis • Dilated and irregular retinal veins • Central Retinal Vein Occlusion • Not tortuous • Diabetic Retinopathy • Intraretinal hemorrhages • Midperiphery not posterior pole • Aortic Arch Disease • Retinal microaneurysms • Neovascularization • Cotton wool spots • Retinal artery pulsations
http://imagebank.asrs.org/file/3344/ocular‐ischaemic‐syndrome‐colour‐2
86 DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES
Ocular Ischemic Syndrome Anterior Uveitis Ocular Ischemic Syndrome Central Retinal Vein Occlusion
360° of dilated episcleral vessels Ciliary flush‐limbal Dilated Veins‐not tortuous Dilated and tortuous veins Greater flare than expected Cells and flare Optic disc‐not swollen Swollen optic disc Poor response to steroid Responds well to topical steroid Hemorrhages in mid‐periphery Hemorrhages throughout fundus Rubeosis iridis Absent Elicit pulsations of central retinal a. Does not occur Asymmetric cataract n/a
DIFFERENTIAL DIAGNOSES CAROTID AUSCULTATION
Ocular Ischemic Syndrome Diabetic Retinopathy • Useful screening procedure • Simple Marked asymmetry Symmetric presentation • Non‐invasive Unilateral Bilateral • Perform in office Hemorrhages in mid‐periphery Hemorrhages in posterior pole Dilated veins Dilated and beaded veins Absent Hard exudates
https://www.medistudents.com/en/learning/osce‐skills/other‐skills/thyroid‐examination/
DIAGNOSTIC INVESTIGATION METHODS DUPLEX CAROTID ULTRASONOGRAPHY
• Duplex Carotid Ultrasonography • High sensitivity and specificity • Fluorescein Angiography • Readily available, inexpensive, noninvasive • Indocyanine Green Angiography • Essential! • Electroretinography • Visual‐Evoked Potential • Ophthalmodynamometry • Magnetic Resonance Angiography • Arteriography
http://www.bournemouthprivateclinic.co.uk/services/diagnostic‐vascular‐imaging‐ https://www.sciencedirect.com/science/article/pii/S0039625709001374 interventional‐radiology/carotid‐artery‐ultrasound.aspx
87 DUPLEX CAROTID ULTRASONOGRAPHY STRANDNESS CLASSIFICATION
• A 0% <125 • B 1%‐15% <125 • C 16%‐49% <125 • D 50%‐79% >125 • D+ 80%‐99% >125 >140 • E N/A N/A NO FLOW IN ADEQUATELY VISUALIZED
http://www.malhotralabs.com/Colour‐Doppler.aspx http://ccok.adam.com/content.aspx?productId=117&pid=1&gid=003336
LR’S ULTRASOUND RESULTS
• Impression:
• 1. Right carotid artery Strandness class D (50‐79% )
• 2. Left carotid artery Strandness class D+ (80‐99%)
TREATMENT PROGNOSIS
• Control underlying systemic conditions! • Poor! • Anticoagulation • Serious blinding condition • Endarterectomy • Iris neovascularization=poor visual outcome • High 5 year mortality rate • Manage ocular issues • Myocardial infarction • Cerebral infarction • Some hope if initial presentation is mild
88 ROLE OF THE OD SOURCES
• Alizai, A.M.,Trobe, J.D., Thompson, B.G., et al. 2005. Ocular ischemic syndrome after occlusion of both external carotid arteries. J • Recognize the condition Neuro‐ophthalmo 25. 268‐272
• Bennett L.W. 1997 Ocular ischemic syndrome as initial manifestation of bilateral carotid occlusive disease. J Am Optom Assoc 68. • Auscultation of carotid arteries 250‐260
• Chen C.S., Miller N.R. 2007. Ocular ischemic syndrome: review of clinical presentations, etiology, investigation, and management. • Order carotid work up Compr Ophthalmol Update 8. 17‐28 • Contact PCP, cardiologist • Chen K.J., Chen S.N., Kao L.Y., et al. 2001. Ocular ischemic syndrome, Chang Gung Med J 24. 483‐491 • Gerstenblith, Adam T., and Michael P. Rabinowitz. The Wills Eye Manual Office and Emergency Room Diagnosis and Treatment of • Coordinate care for the patient Eye Disease. Wolters Kluwer/Lippincott Williams & Wilkins, 2012. • Kawaguchi, S., Okuno, S., Sakaki, T., Nishikawa, N. 2001. Effect of carotid endarterectomy on chronic ocular ischemic syndrome due to internal carotid artery stenosis, Neurosurgery 48. 328‐333
• Mendirinos, E., Machinis, T.G., Pournaras, C.J. 2010. Ocular ischemic syndrome, Survey of Ophthalmology 55. 2‐34
• Mizener, J.B., Podhajsky, P., Hayreh, S.S. 1997. Ocular ischemic syndrome, Ophthalmology 104. 859‐864
• Terelak‐Borys, B., Katarzyna, S., Grabska‐Liberek, I. 2012 Ocular ischemic syndrome – a systematic review, Med Sci Monit 18. 138‐ 144
QUESTIONS?
89 Mark your calendar – UPCOMING CE EVENTS
Northwest Residents Conference Pacific University Campus June 8-9, 2018 11.5 hours of continuing education with clinical case presentations from 2017-2018 Optometric Residents $100
2018 Victoria Conference Hotel Grand Pacific July 12 – 15, 2018 Up to 20 hours of Continuing Education featuring: Lee Carr, Anthony DeWilde, Beth Kinoshita, James Kundart and Cathy Evans $575
2019 Island Eyes Conference January 20 – 26, 2019 Fairmont Orchid, Kohala Coast, Hawaii This winter classic offers up to 30 hours of CE with a family-friendly schedule of lectures in the mornings and afternoons and evenings free. Invited speakers include: Steve Laukaitis, MD; Nate Lighthizer, OD; Brian Mathie, OD; Stuart Richer, OD, PhD; Stan Teplick, MD; and Maria Walker, OD, MS. Early registration: $700
No time to get away? Explore our online CE options: https://online-ce.opt.pacificu.edu/
90