Disclosures Walter O. Whitley, OD, MBA, FAAO has received consulting fees, honorarium or research funding from: Rapid Fire Grand Rounds • Alcon • Science Based Health COPE#52118- PO • Allergan • Shire • Bausch and Lomb • Sun Pharmaceuticals • Biotissue • TearLab Corporation • Beaver-Visitec • Tearscience Walter O. Whitley, OD, MBA, FAAO • Ocusoft Director of Optometric Services Virginia Consultants • Publications Residency Program Supervisor – Advanced Ocular Care – Co-Chief Medical Editor PCO at Salus University – Review of Optometry – Contributing Editor – Optometry Times – Editorial Advisory Board

Virginia Eye Consultants Pearls on Optometric Co-management Tertiary Referral Eye Care Since 1963

• John D. Sheppard, MD, MMSc • Walter Whitley, OD, MBA, FAAO • Get to know your surgeon • Stephen V. Scoper, MD • Mark Enochs, OD • David Salib, MD • Chris Kuc, OD, FAAO • Convey patient preferences, observations and • Elizabeth Yeu, MD • Cecelia Koetting, OD, FAAO • Thomas J. Joly, MD, PhD • Leanna Olennikov, OD conditions to your surgeon • Dayna M. Lago, MD • Chris Kruthoff, OD • Constance Okeke, MD, MSCE • Jillian Janes, OD • Inform your patients on your role in perioperative • Esther Chang, MD • Jay Starling, MD care • Samantha Dewundara, MD • Rohit Adyanthaya, MD • Successful co-management is the result of • Albert Cheung, MD continuous communication

1 Today’s Optometrists TODAY’S CATARACT PATIENT

• In 2015, people aged 50 and older represented 45% of the US population1 “To be on the cutting edge of • There were approximately 4 million cataract procedures in 2015 and optometry, you need to be on the that number is expected to grow by 3% in 20166 cutting edge of science and Active Outgoing Still Digitally technology.” working savvy

1. Centers for Disease Control and Prevention website. http://www.cdc.gov/healthcommunication/pdf/audience/audienceinsight_boomers.pdf. Accessed December 21, 2016. 2. Hill W. Distribution of corneal astigmatism in normal adult population. Keratometry database: http://www.doctor-hill.com/iol-main/astigmatism_chart.htm. Accessed January 13, 2017. US-ODE-16-E-5238 6 3. AcrySof® IQ Toric IOL Directions for Use. Alcon data on file, 2009.

High Patient Expectations in Cataract Why Become Involved? Refractive Surgery • By 2020 the U.S. population over 65 will Cataract Outcomes*** 100% • Patient expectations are at an all- double from current levels – 12.9% of time high for refractive surgery 90% 97% total population • Positive experiences with LASIK 80% have produced high expectations, 70% at a minimum achieving: • CMS allows ODs/MDs to bill for non- 71% 60% – 92.6% of LASIK patients with vision of covered services 20/40 or better* 50% – 95.4% of patients satisfied with their 40% outcome after LASIK surgery** 41% • Tangible vs. Intangible benefits 30% • outcomes may not be meeting the target of 0.5D 20% ± that is considered the standard 10%

0% ±0.25D ±0.5D ±1.0D

*“LASIK Surgery Statistics.” Docshop.com. http://www.docshop.com/education/vision/refractive/lasik/statistics **Solomon, K et al. (2009) “LASIK world literature review: quality of life and patient satisfaction.” Ophthalmology. 16(4):691-701 ***Graph: Data from Dr. Warren Hill & Behndig A, et al. Aiming for emmetropia after cataract surgery: Swedish National Cataract Register study. J Cataract Refract Surg. 2012;38(7):1181-6.

8/13 VRN13066SK 8

2 What Do Our Patients Know About Advanced Technology: Cataracts? The Players • What is a cataract? • When do I need cataract surgery? • How is the surgery done? • Who do I go to? • What are my options? • Will I need glasses? • Will I still see you after the surgery?

SYMFONY First Extended Depth of Focus Lens (EDOF)

Coupling of two new principles: – Diffractive echelette to elongate the range of focus – Reduction in chromatic aberration to increase contrast sensitivity Different than a MF-IOL: – Rather than splitting incoming light into two focal points, it elongates depth of focus – Not affected by pupil diameter

3 Glare and Halos

Tecnis Symfony AcrySof® IQ ReSTOR® IOL1,2,3

+2.5 D Parameter +3.0 D Model • First EDOF IOL approved in the US SV25T0 SN6AD1 number ADD power +2.5 D +3.0 D @ IOL plane • Available in both toric and non-toric ADD power +2.0 D @ Spectacle +2.5 D Plane Central ring • Offers patients extended range of vision 0.94 mm 0.86 mm diameter 7 # rings 9 Apodized 10.2 mm2 • Lower glare/halo side effect profile 8.4 mm2 Diffractive Area Dist: 69% Energy Dist: 59% Near: distribution Near: 18.0% (3 mm) 25.5% RES14040SK-D 16 1. AcrySof® IQ ReSTOR® +2.5 D IOL Directions for Use. Asphericity -0.1µm 2. AcrySof® IQ ReSTOR® +3.0 D IOL Directions for-0.2µm Use. 3. Data on Fil e, Alcon Inc.

4 Defocus Curves1,2 Introducing…..Restor Toric

RES14040SK-D 17 1. AcrySof® IQ , AcrySof® IQ ReSTOR® +3.0 D 2. AcrySof® IQ ReSTOR® +2.5 Directions for http://www.alconsurgical.ca/images/CataractIOLs/Calculator_Product_Sp . ec_image3.JPG

“The Pipeline”: Future IOLs Setting Expectations

• Akkommodative 1CU (Human Optics) • Individual patient perceptions vary • Tetraflex IOL (Lenstec) • Sarfarazi Elliptical IOL (B&L) • Synchrony (Visiogen) • Best vision after bilateral implantation • FlexOptic Lens (Quest Vision Technologies) • NuLens (NuLens) • Glare/Halos • FluidVision IOL (PowerVision) • LiquiLens (Vision Solutions) • Smart IOL (Medenium) • Lighting considerations • Light Adjustable Lens (Calhoun Vision) • Readers

• Possibility of refinement

5 Preparation for Ocular Surgery Ocular Pathology • Optimize the Ocular Surface • Normalize the Lids • Prepare the • Eliminate Intra-ocular Inflammation • Control Glaucoma • Satisfy the Macula • Evaluate the Retinal Periphery • Patient Education

Cat Sx and OSD Testing only when Patients Management of Patient Expectations Complain of Dryness is Insufficient

• Chair time about source(s) of “BLURRY VISION” • > 40% of people with 70 Do you have FBS? 59% objective evidence of dry 60 eye are asymptomatic1 50 • Cataract surgery can worsen DED for months 40 28% 30 after surgery • Cataract surgery patients 20 13% often complain of 10 0 fluctuating vision rather Most or Some of Never • Refractive cataract surgery: quality of vision may than dryness or FBS2 all the the time time require chronic DED Rx Despite a lack of discomfort, • Cyclosporine ophthalmic emulsion 0.05%, dryness or FBS, >60% of subjects lifetegrast 5%, Topical amniotic membrane drops had significant signs of OSD2

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

6 Dry Eye Prevalence in Patients Dry Eye Prevalence in Patients Scheduled for Cataract Surgery Schedule for Cataract Surgery • 80% of Patients had dry eye severity score of Level 2 or • Study Design: Prospective, multicenter, observational, Higher pilot study (N=143) of which 136 met the inclusion criteria at 9 sites across the United States to determine the • Tear Break Up Time: 62.9% with < 5 sec incidence and severity of Dry Eye Disease in consecutive patients 55 and older scheduled for cataract surgery (68 • 76.8% of were positive for Nafl corneal staining male and 68 female patients) • Only 22.1% (30 pts) received a previous Dx of Dry Eye • Primary outcome measure: Incidence of Dry Eye as evaluated by grade on International Task Force (ITF) level

• Secondary outcome measures: TBUT, corneal staining with fluorescein, and conjunctival staining with lissamine

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

Goal of Therapy: Cataract Surgery and Dry Eye Stabilize Interblink Tear Film

• Ocular surface must be optimized pre-operatively for accurate keratometry

27 28 Photo accessed from http://i1.ytimg.com/vi/IFRJw1xeVJI/hqdefau lt.jpg on 12/28/15

7 “Hot spots” and “Flat spots” Irregularly Shaped or Smudgy are Abnormal Placido Disk is Abnormal!

Take a Closer Look if Average K Values are Different

8 Dry Eye Preparation for Case Example Cataract Sx Measurements • 71 yo WF, physician’s wife, presents for 1. Frequent NPAT use evaluation of blurred vision 2. Topical steroid course • Guillan Barre Syndrome distant past  Lag - Fluoromethalone, loteprednol ophthalmos R > L - PF Dexamethasone 0.01% to 0.1% • “Another MD has been treating my dry eye for 3. Upper and/or lower punctal occlusion one year and says I’m still not ready for cataract 4. MGD management: MiboFlo, Lipiflow surgery” 5. Prokera Self-retaining AMT • Meds: clonidine, Crestor, Fentanyl, Cymbalta, 6. Address any other issues, i.e. blepharospasms, Lasix, Dilaudid, Cymbalta, Fioricet lag ophthalmos, filamentary keratitis

Case Example

• 2+ MGD with telangiectasia • Poor blink rate • Lag OD > OS (1-2mm) • Diffuse 2-3+ stain within central and inferior cornea OD, +KNV with ant stromal scar inferior periphery

9 Management of Patient Expectations Case Example

• ACUTE preparation for cataract surgery different • Treatment from chronic management of DED – Fire/Ice Mask bid, Ocusoft Plus lid wipes – Topical steroid drops and/or ointment: First line – Loteprednol ointment qhs x 1 week therapy – PF Dexamethasone 0.1% qid – Aggressive NPAT – Aggressive lubrication – Lipiflow thermal pulsation  After 2 weeks, minimal improvement, and Prokera – If imaging unimproved after 3-4 weeks, consider self-retaining AMT placed Prokera AMG

Case Example S/P Prokera Self-retaining AMT

• Patient returned 1 week later for Prokera removal OD Pre-Prokera

• Cataract surgery measurements acquired the day after

s/p Prokera (placed for 5 days)

10 Blepharitis Endophthalmitis Study • 69% of patients with bacterial endophthalmitis were • Lid hygiene culture-positive Gram-negative • BlephEx organisms • ABx/steroid ointment bid 6% • Demodex treatment 24% 70% • Wait 1-2 months before Other cataract sx: ? Bacteria Gram-positive released from lid hygiene organisms

Gram-positive coagulase-negative

1. Han DP, Wisniewski SR, Wilson LA, et al. Spectrum and susceptibilities of microbiologic organisms (Staphylococcus isolates in the endophthalmitis vitrectomy study. Am J Ophthalmol 1996;122(1):1-17. 2. Speaker MG, Milch FA, Shah MK, et al. Role of external bacterial flora in the epidermidis) 41 pathogenesis of acute postoperative endophthalmitis. Ophthalmology. 1991;98:639-649. 41

Call to Action!!!

ARE MIGS THE ANSWER?

OSDI SPEED

11 Case Presentation Case Presentation

• CC: vision cloudy OS>OD • BCVA : 20/40 OD, 20/50 OS • HPI: 68 yo WM presents for cataract evaluation • Present Rx: OD -0.50+1.00 x 075 with h/o controlled moderate OAG OS>OD OS -1.00 +0.75 x 110 • Current meds: Levobunolol QD OU, Travatan • Keratometry: OD 43.67/44.00 x 055 qhs OU, Optive OS 43.25/44.37 x 85 • POHx: SLT OU 2007 • IOP: OD 14, OS 14 (Applanation) • FamHx: mother with glaucoma • CCT: OD 527, OS 512 • Tmax: OD 20; OS 24 • : OU open to scleral spur • SLE 2+ NS OU

Case Presentation

• Dilated Fundus Exam: • Optic Nerve: CDR OD: 0.55 / 0.5 (thin rim infer/sup) CDR OS: 0.7 / 0.65 • Macula: OU Flat • Vessels: WNL • Periphery: WNL

12 Case Presentation What Do You Get When You Add? • Diagnosis: VS Cataract OU, Controlled Glaucoma • Type of Glaucoma: open angle glaucoma + – Stage of Glaucoma: Moderate to severe OS>OD – What is the target pressure? Low teens OU – Is current treatment adequate? Yes =

Which Comes First, Patient Compliance and Dosing The Chicken or the Egg? • Literature review of 76 • Glaucoma Evaluation First studies show – Permanent loss of vision if not controlled – Compliance increases with decreased dosage • Cataract Evaluation Second regimen and complexity1 – Cataract surgery is an elective procedure and – 79% compliance with can wait QD regimen vs 51% for

Compliance QID regimens • Consider combined procedure (p=0.001)1 – Simpler, less-frequent dosing results in better Dosing compliance in a variety 1 (Times/day) of therapeutic classes

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

13 How Adherent are Glaucoma Minimally Invasive Glaucoma Patients with QD Medication? Surgery (MIGS) Ab Externo Ab Interno • Canaloplasty • Glaukos iStent • Stegmann Canal • Neomedix Expander Trabectome • Gold Microshunt • Excimer laser trabeculotomy • Hydrus Microstent • Cypass Microstent*** • Kahook Dual Blade • Xen Gel Stent***

Trabecular Bypass Devices Anatomical Considerations

• These procedures facilitate the flow of aqueous into Schlemm’s canal by: – Shunting the canal • Express MiniShunt (Alcon) – Stenting the canal • iStent (Glaukos Corp) – Divert aqueous into the suprachoroidal space • Cypass Microshunt (Alcon) – Divert aqueous into the subconjunctival space • Xen Gen Stent (Allergan) Photo accessed from http://www.downstate.edu/ophthalmology/patient-info/patient-info- PN:glaucoma.html 400-0135-on2013 11/4/16-US Rev. 0 Release Date: 08/27/2013

14 Are Patients Interested in MIGS? Combined Phaco / Trabectome

• 28pts • 79% did not mind instilling drops • 64% did not mind wearing glasses • 86% were interested in reducing their need for topical medications

Trabectome - IOP & Glaucoma Medication Use Outcome Combined Phaco / iStent

IOP (mmHg)

Mean pre-op IOP

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

Glaucoma Medication Use Mean pre-op medication use

Mean medication use after surgery over 72 months

15 US IDE Trial - Primary Endpoint The XEN® Gel Stent

Percent of Patients With IOP ≤21 mm Hg Without Medication Use • A glaucoma implant designed to 100 reduce intraocular pressure in eyes suffering from refractory 80 1 72% glaucoma 50% 60 • 6-mm length, 45-micron inner 40 diameter—about the length of an eyelash1,2 20 ® 0 • Composed of gelatin, cross- 1 Cataract Surgery iStent linked with glutaraldehyde

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

The XEN® Procedure The XEN® Procedure Creates a Low-Lying, Ab-interno Bleb in Refractory Glaucoma1

Ab-Externo Bleb Ab-Interno Bleb

2 Controlled flow through lumen Suture wounds restriction1 Tenon capsule Dissected tenon 1 capsule layer2 adhesions intact Undistrubed, low-lying Diffuse, mildly drainage space1 elevated bleb2

• Example of elevated, • Low-lying and In the clinical investigation, standard ophthalmic surgery cystic bleb2 diffuse1 techniques, viscoelastic, and mitomycin C (0.2 mg/mL) 1. Dapena and Ros. Revista Española de Glaucoma e Hipertensión Ocular. 2015; 2. Errico et al. Clin 1. XEN® Directionswere for usedUse. before injection.1 Ophthalmol. 2011.

16 XEN® Ab-interno Bleb Examples Cypass Microstent

• Ab-interno insertion into the supraciliary space • Fenestrated microstent made of biocompatible polyimide material • Magnetic resonance safe

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

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

Why Target the Uveoscleral Outflow Clinical Data Delivers superior, long- Pathway? term IOP-lowering efficacy Two-year COMPASS Trial is the largest MIGS randomized controlled trial • Uveoscleral outflow: considered completed to date pressure independent and Landmark FDA study with two-year follow-up on >500 patients with baseline/terminal washout contributes up to 50% of total aqueous outflow.2 • 72.5% of eyes • 61.2% of eyes achieved a maintained an ≥20% reduction unmedicated • Aqueous percolates through the in unmedicated diurnal IOP ciliary body and exits into the diurnal IOP range between at 2 years* 6 and 18 mmHg suprachoroidal space, at 24 months primarily through the sclera and (a 41% increase)* choroidal blood vessels.3

• The highest point of resistance is the ciliary body, which is thought to regulate this drainage.3

*Prospective, randomized, multicenter clinical trial in patients (n=505) with open-angle glaucoma undergoing cataract surgery randomized to microstent (n=374) or (n=131). Primary outcome measure was unmedicated diurnal IOP reduction at 24 months versus cataract surgery alone at baseline. Secondary outcomes measures included mean change in 24 month DIOP from baseline and 24 month unmedicated mean IOP (between 6 mmHg to 18 mmHg) versus cataract surgery alone. Medication use at 24 months was also analyzed. The primary and secondary effectiveness analyses were performed using intent to treat (ITT) population.

17 Demonstrated safety as compared to cataract surgery alone How To Choose Which Procedure?

CyPass® ▪ Intraoperative adverse events Micro-Stent Phaco only Adverse Event, % • Discuss with your surgeon which + Phaco n=131 ▪ A total of 25 intraoperative n=374 were reported in 20 out of procedures they perform? Blepharitis 1.9% 0.0% 374 CyPass subjects Corneal abrasion 1.9% 1.5% (5.3%) Corneal edema 3.5% 1.5% • Based on Stage and Severity Conjunctivitis 1.1% 2.3% ▪ Incidence of postoperative Cyclodialysis cleft 1.9% 0.0% adverse events – Moderate to advanced cases – Trabectome Hyphema, intraoperative 2.7% 0.0% ▪ 39% of CyPass® Micro- Hypotony IOP <6 mmHg 2.9% 0.0% – Early to Moderate – iStent, Xen, Cypass IOL complication 1.1% 0.0% Stent patients IOP elevation, ≥10 mmHg above 36% of Control patients 4.3% 2.3% ▪ – ? multiple iStents off label baseline Iritis 8.6% 3.8% ▪ Postoperative AEs were Loss of BCVA; ≥10 letters read 8.8% 15.3% generally manageable and – iStent inject shows promise Maculopathy/retinopathy transient and did not negatively 3.2% 3.1% (cystoid, diabetic, other) affect functional outcomes such Microstent obstruction 2.1% N/A as visual acuity Subconjunctival hemorrhage 2.1% 0.8% Surgical reintervention 5.1% 5.3% Worsening of ocular symptoms 5.6% 3.1% Visual field loss progression 6.7% 9.9% Safety Population, events occurring at rate of 1.0% or greater

Post-operative Cataract IOP Spikes in Glaucoma Patients

• Adequate control prior to surgery – Additional drops – SLT prior • Consideration of combined glaucoma and cataract procedures • Aggressive treatment perioperatively POSTOP MANAGEMENT – Diamox at the end of the case, early post-op PEARLS • Closer follow-up post-operatively

18 Traditional Cataract Surgery: What to Look for After Cataract Common Complications Surgery? • 1 day – low IOP • 3-7 days – Endophthalmitis • 4-6 weeks – CME • 2 months – Posterior capsule opacification 10-40% PCO 2-12% CME

1-5% Vitreous prolapse 4-10% K endo loss Photo Accessed from Dr. John Marinelli

Postoperative Pearls for What to Look for After Advanced Technology IOLs Toric IOL Surgery?

• Remind patient that it is normal for vision to be • Crossed Cyl effect blurry and eyes out of balance – +sphere – double the astigmatism • Avoid “buyer’s remorse” – ie. +100-200x130 • 5% of patients experience halos – Can dilate in one week if suspicious • Bilateral implants • Consider posterior corneal astigmatism • Use -2.25D Glasses to reassure decision • Crystalens considerations • Communication with surgeon / referral center • Check toric axis at one week

19 Case Example DC

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

• BCVA OD 20/70-2 PH 20/60 OS 20/25-2 BAT 20/50-

• SLE: Cataracts OD>OS

• 12/02/08 – Unremarkable Cataract Sx OD

Postoperative Day 1 Postoperative Medication

• Pain last night, today better  Review medications • UCVA OD: 20/40 PH 20/30  No restrictions on physical activity • IOP - 18 at 1:55pm • SLE:  Remind patient that it is normal for vision to be blurry and eyes out of balance – Wound secure – 2+ SPK  F/U 1 week – AC well formed with about 1+ cell – IOL well centered in pupil  Fax results to surgeon if co-managed

20 Weekend Emergency Thoughts???

• CC: VA decreased and foggy, no pain • Sudden decrease in vision • BCVA: OD 20/200 PH/NI • Increase in inflammation • IOP: 10 mmHg • No PVD noted previously • SLE: 3-4+ cells / deep / PVD / 3+ Vitritis / Dot • No pain / discomfort hemes / whitening throughout periphery • Dot hemorrhages in the periphery • A: Increased post op inflammation OD • P: Omnipred q1h OD, Nevanac TID, Vigamox TID / F/u tomorrow

What is the Most Common Organism Differentials Found in Bacterial Endophthalmitis?

TASS Endophthalmitis • S. aureus • S. epidermidis • S. pneumonia • H. influenza

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

21 Endophthalmitis Vitrectomy Study Endophthalmitis Vitrectomy Study

• 69% of patients with bacterial endophthalmitis were culture-positive VA Gram-negative Outomes organisms Presenting 20/40 or 20/100 or Les than Recommen VA better better 5/100 d Treatment 6% HM or better TAP 62% 84% 3% TAP 24% 70% PPV 66% 86% 5% Light TAP 11% 30% 47% PPV Other Perception Gram-positive organisms PPV 33% 56% 20%

Gram-positive PPV = pars plana vitrectomy and intravitreal injection of antibiotics coagulase-negative TAP = vitreous tap and intravitreal injection of antibiotics

1. Han DP, Wisniewski SR, Wilson LA, et al. Spectrum and susceptibilities of microbiologic organisms (Staphylococcus isolates in the endophthalmitis vitrectomy study. Am J Ophthalmol 1996;122(1):1-17. 2. Speaker MG, Milch FA, Shah MK, et al. Role of external bacterial flora in the epidermidis) pathogenesis of acute postoperative endophthalmitis. Ophthalmology. 1991;98:639-649.

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

Next Day Visit What’s She Have????

• Increase in pain today  Possible Acute Retinal Necrosis ◦ Foscarnet 2.4 mg/ 0.1cc injected intravitreally ◦ Vicodin 5/325 1 tab every 4-6 hrs PRN • OD VA: 20/400 NI w/ Pinhole ◦ Valtrex 1000mg every 8 hrs for 10 days ◦ Ordered blood cultures, fungal, PCR for VZV, HSV I, HSV 2, gram stain, CBC, Chem 7, ESR, and C- reactive protein • SLE: Central K stain w/ Dendritic appearance /  Cannot r/o bacterial endophthalmitis 2+ Cells in AC / 3 + Cells in Vitreous / Dot ◦ Recommend intravitreal injections of Vancomycin hemorrhages / Retinal whitening 1mg/0.1cc and Ceftazidime 2.25 mg/ 0.1 cc. ◦ Vitreous specimen sent to lab ◦ Monitor very closely

22 Lab Reports Acute Retinal Necrosis

 Definition ◦ Necrotizing herpetic retinitis. May present unilaterally or bilaterally (20%)  Epidemiology ◦ Usually occurs in young, healthy adults. ◦ Less common are elderly and immunocompromised ◦ Caused by infection with HZV or HSV  History ◦ Iritis or episcleritis ◦ Rapid decline in VA with intense vitritis

Acute Retinal Necrosis Acute Retinal Necrosis

 Important Clinical  Diagnosis  Management Signs ◦ Diagnosis based on ◦ Systemic antiviral treatment ◦ Vitritis with peripheral clinical exam ◦ IV acyclovir 10mg/km tid retinal whitening that ◦ Polymerase chain coalesces for 7 to 10 days reaction ◦ Followed by 3 month ◦ Retinal biopsy course of acyclovir po  Associated signs  800mg five times per ◦ Iridocyclitis, day photophobia, vitritis, ◦ Risk of RD is 8 to 12 optic neuritis, and weeks retinal arteriolitis ◦ Laser photocoagulation ◦ Pars Plana Vitrectomy

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

23 Clinical Pearls Common Corneal Procedures

• Corneal crosslinking  If patient calls with symptom of sudden decrease VA or pain during the first week: the doctor must see the patient • Penetrating keratoplasty

 Treat as infectious until proven otherwise • Descemet’s stripping endothelial keratoplasty

 Importance of communicating with surgeon • Pterygium surgery

• Superficial keratectomy

Corneal Crosslinking Patient Selection

• CXL increases the rigidity of the cornea • CCT > 400 μ – Less than 400 μ, hypotonic riboflavin to induce swelling • Indications: • K’s < 60.00 D – Corneal ectatic disorders – May not flatten enough for – Post-LASIK ectasia significant improvement – Infectious keratitis • POcHx – HSV – Advanced corneal edema – Dry eye syndrome

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

24 Corneal Crosslinking Complications

• Treatment failure – 7.6% – Risk factors - 35 yrs or older / VA 20/25 or better / Ks >58D

OD → post-CXL OS → untreated 2.8D flattening 2.6 D steepening • Postoperative infection/ulcer

• Stromal haze

• Increased IOP POM 18 after C3R OD only Raiskup-Wolf F. J Cataract Refract Surg 2008; 34:796-801

What’s new in CXL? Background

• CXL and other corneal refractive treatments – Topo-guided PRK – Corneal ring segment • Trans-epithelial treatments: “epithelium on” • CXL for microbial keratitis • CXL for corneal edema • Other advances and applications

25 ABC’s of Corneal Transplants Penetrating Keratoplasty

• PK

• DALK

• PLK / DLEK

• DSEK / DSAEK

• DMEK / DMAEK

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

Descemet’s Stripping Endothelial Indications for DSEK/DSAEK Keratoplasty (DSEK)

• Sutureless transplant of the posterior cornea

• Replaces diseased portion of cornea with donor graft

• Donor tissue obtained by – Manual dissection – Microkeratome dissection – Femtosecond laser

1. Photos accessed from http://www.moria-surgical.com/ on 8/26/11 1. http://emedicine.medscape.com/article/1193218-overview 2. Photos accessed from http://www.alcon.com/en/alcon-products/refractive-surgery.aspx 2. http://webeye.ophth.uiowa.edu/eyeforum/cases/case5.htm

26 Advantages of DSEK/DSAEK vs. PK DSEK/DSAEK Complications

• Sutures • Caused by any of the following • Visual recovery – Graft-recipient interface • Astigmatism / ametropia – Fragile graft tissue • Epithelial complications – Graft location • Corneal allograft rejection – Glaucoma • Wound strength – Infection • Globe stability – CME • Length of surgery – Retinal detachment • Intraoperative complications • Post op visits Miller, J. Accessed from http://www.revoptom.com/content/d/technology/c/16179/

Graft Rejection Graft Failure

• Keratic precipitates (EK/PK) • Primary vs. Iatrogenic (EK)

• Stromal edema (EK/PK) • Dehiscence (EK)

• Subepithelial infiltrates (PK) • Edematous cornea (EK/PK) • Gray epithelial line (PK) • Scarring (PK)

• Vascularization (PK)

Price, F. Accessed on October 1, 2011 from http://one.aao.org/lms/courses/dsek/LO15.htm • Astigmatism (PK) Allan BDS, Terry MA, Price FW, et al. Corneal transplant rejection rate and severity after endothelial keratoplasty. Cornea. 2007;26:1039–1042

27 Stand-Alone vs. Combined Case Example Procedures

• 65 YOWF Referred for Cataract Sx • Significance of the cataract – Blurred VA X 6 months Dist / Near

• Does the cornea need surgical intervention?

• Sequential versus triple procedure

• Convenience, cost, visual recovery

Case Example

• 67 year old white female – OS has been tearing for 3 weeks, some burning and irritation, h/o allergies • Ocular Medications – Visine prn • Meds: OTC Zyrtec, lisinopril NO MORE • NKDA • Assessment: Epiphora OS

28 9 Steps to Evaluating the Tearing Patient The Big Four

1. History 1. History 2. Lid Exam, Palpation of Lacrimal Sac 2. Lid Exam 3. Slit Lamp Exam 4. Schirmer Tear Testing 3. Dye Disappearance Test 5. Dye Disappearance Test & Jones I 4. Lacrimal Irrigation 6. Lacrimal Irrigation, Probing, & Jones II 7. Lower Lid Taping 8. Nasal Speculum Exam Not all steps are needed in every patient 9. Radiography

Step 1: History Step 1: History

• Usually will distinguish hyperlacrimation from • Usually will distinguish hyperlacrimation from reduced excretion: reduced excretion: – Hyperlacrimation associated with discomfort – Hyperlacrimation associated with discomfort – Hyperlacrimation usually not monocular • Blepharitis—itch, burn • Allergic conjunctivitis—itch – Hyperlacrimation rarely causes frank epiphora • Corneal foreign body—pain • Trichiasis—irritation • Prior treatment: • Dry Eyes—FB sensation, burn • Iritis—ache, photophobia – Artificial tears, allergy drops • Photosensitivity--photophobia – Punctal plugs, lacrimal probings

29 Step 1: History Step 2. Lid Exam

• Time course, duration • Facial musculature – Severe epiphora, intermittent: lacrimal stone – Duration less than 6 months: may benefit from probing • CNVII weakness or intubation • Lid laxity – “Slowly progressive” does not really help distinguish between PANDO and secondary (neoplasia, • Ectropion infiltration) • Entropion • Lacrimal sac palpation • Associated disorders – Previous surgery, trauma – Previous infections (conjunctivitis, dacryocystitis, sinusitis) – Facial nerve palsy

Step 3. Slit Lamp Exam Step 5. Dye Disappearance Test

• Canalicular punctal size, position • Functional tear drainage test, positive result could be due to: • Tear meniscus – Tear lake malposition • Lid motion during blink – Poor tear pump function – Punctal stenosis or blockage of canaliculus, sac or • Conjunctivochalasis NLD • Ocular Surface • Everted upper lid for papillae • Lid margin, lashes for blepharitis

30 Step 6. Lacrimal Irrigation Rational Treatment of The Tearing Patient

Tearing • So what is positive? History History Slit Lamp Exam Dye Disappearance • Three possible outcomes Hypersecretion Reduced excretion – Free flow to nose—No obstruction (beyond punctum) Schirmer SLE Lid exam – Reflux out upper punctum upon irrigating Corneal Trichiasis lower—obstruction beyond common Dry Eyes Blepharitis Allergy canaliculus Exposure Entropion – Resistance to irrigation or reflux around Lid scrubs Lash Lid irrigation cannula—canalicular obstruction Art tears Compresses Topical or Removal or Tightening Punctal plugs Abx systemic Tx Lid surgery

Rational Treatment of The Tearing Patient Rational Treatment of The Tearing Patient

Tearing Tearing History History History History Slit Lamp Exam Dye Disappearance Slit Lamp Exam Dye Disappearance

Hypersecretion Reduced excretion Hypersecretion Reduced excretion

Speculum Irrigation SLE SLE Lid exam Sac or NLD Canaliculus Punctal Punctal Nasal block Conjuctivochalasis Lid laxity Ectropion block block malposition stenosis CNVII palsy Entropion Radiology Lid taping Medial Jones tube Conjunctival Ectropion ENT Referral ectropion Punctoplasty Probing Trephination resection Lid or Entropion DCR repair tightening repair

31 Chemical Burns Chemical Burns

• Emergency!!! - Every minute counts • Absolute Emergency • Do not waste time on Hx and PE • Alkali burns more common and worse than acid – Alkali • Immediate irrigation • Household cleaners, fertilizers, drain cleaners – Acid • Check VA • Industrial cleaners, batteries, vegetable preservatives • Check pH if possible

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Hughes Classifications of Ocular Burns Management of Chemical Burns

• Debride necrotic tissue • Grade 1 (Very good prognosis) • Frequent ATS – No corneal opacity nor limbal ischemia. • Bandage contact lens • Grade 2 (Good prognosis) • Quinolone: 1 gtt 4-6x/day (prevents infection) – Corneal haze but iris details are clear. Less than • Prednisolone phosphate: 1 gtt q 1-2 hr while awake (reduces inflammation) 1/3 cornea limbus ischemia. • Vitamin C: 1-2 gm po QD (reduces corneal thinning/ulceration) • 10% sodium citrate: 1 gtt q 2 hr while awake (chelates Ca++ and impairs • Grade 3 (Guarded prognosis) PMN chemotaxis) – Sufficient corneal haze to obscure iris details. 1/3 • Scopolamine 0.25%: 1 gtt TID (reduces pain/scarring with AC to 1/2 of cornea limbus ischemia inflammation) • 10% Mucomyst (n-acetyl-cysteine): 1 gtt 6x/day (mucolytic agent and • Grade 4 (Poor prognosis) collagenase inhibitor) – Opaque cornea without view of iris or pupil. More • Oral pain meds than 1/2 of cornea limbus ischemia. • Doxycycline 100 mg po bid (collagenase inhibitor) • Glaucoma gtts/oral diamox if IOP elevated • Significant injury may require admission

32 Pearls - Prevention is KEY!!! You’ve Got to be Kidding Me!

• Know the potential eye safety dangers • 27yowm presents with red, painful, blurry VA OS. Started 10 days ago after returning from a • All chemical injuries should be lavaged immediately trip to Italy. Taking 500mg Naprosyn for HA. • Health – Unremarkable • Extent of damage is dependent on concentration and pH of acid or base • Vasx: OD 20/20-3 OS 20/25-3 with NI • IOP: 9 / 10 • Eliminate hazards before starting work • SLE: – OD Mild limbal flush / 1+ Cells • Use protective measures – OS 2+ Inj / 2+ Cells

What is Your Treatment? Case #3

• Prednisolone acetate 1% vs. difluprednate • Acute, bilateral non-granulomatous, 0.05% vs. loteprednol etabonate .5% anterior uveitis OU • Cause??? • Homatropine 5% vs. Scopolamine 0.25% vs. Atropine 1% • Treatment – Difluprednate qid OD, q2h OS • Would you consider lab testing? – Cyclopentolate 2% TID OU

• Would you prescribe an oral medication?

33 Screening Tests for Syphilis

• Venereal Disease Research Lab (VDRL) – VDRL may become non-reactive in latent syphilis or after successful treatment – False positives may occur in: • Pregnancy • Infectious mononucleosis • Systemic lupus erythematosis • Rapid Plasma Reagin (RPR) – Alternative to VDRL

Fluorescent Treponemal Antibody Syphilis Absorption (FTA-ABS)

• Detects specific antibodies against T pallidum • STD caused by T pallidum / great imitator / any tissue and organ • Confirms diagnosis of syphilis • Sexually active / multiple partners – More specific than VDRL • Systemic Sx – Depends on stage – primary - painless ulcer / – More sensitive in primary syphilis secondary - skin rash palms, soles, trunk / tertiary - neurosyphilis • Test may remain positive for life • All types of ocular inflammation • Labs • Reactive: – VDRL / RPR – Primary syphilis 95% – FTA – ABS – Secondary 100% – ESR elevated – Late latent 100% • Tx – penicillin therapy – Tertiary 96% • Good prognosis if treated early – False positives may occur in pregnancy and SLE

34 So He Has an Allergy to PCN? Comanagement Pearls

• Augenbraun M, Workowski K. Ceftriaxone • Communication is key! therapy for syphilis: report from the emerging infections network. Clin Infect • Opportunity to provide cutting edge Dis. 1999 Nov. 29(5):1337-8 technology – Tetracycline, erythromycin, and ceftriaxone have shown antitreponemal activity in clinical trial • Importance of your recommendation

• Patient education is critical!

Comanagement Pearls • Identify potential causes of surgical complications

• Educate your patients your role within medical eye care

• We are all judged by the visual outcomes our patients. Comfort and quality of vision is the key!

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