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SOCCEP Q/A Monday, April 13

Time Session Details Question Answer

9:00 – 10:00 AM Andrew Meagher, OD, When you get an artifact or a poor scan, I don’t think that is necessary and when FAAO do you recommend completely deleting you generate an actual report, you can Getting the Most Out of that scan from the database? select the scan you want to use and will have the signal strength number in Your OCT parentheses next to it so you know you are choosing the right one, also when you generate a GPA which requires at least 3 OCTs, you can select the specific ones you want. You could always delete the bad scans to declutter but otherwise you have the option to select the correct one without deleting—hope that helps!

What information does the OCT analyze Great question! To my knowledge, OCTs when calculating the symmetry utilize all the parameters to collect this percentage? Sometimes my average information. Specifically I found on thickness looks very symmetrical but Zeiss’s website what they deem as then I’m surprised by how low the asymmetry % is normal symmetry and have attached it to this response. There is also a useful article also on the topic and how that symmetry can vary greatly even in healthy eyes whether you look at total RNFL, clock hour and quadrant assessment —hope it helps! “Thus, the current study demonstrates that the statistical normal upper limit of right eye/left eye differences in mean RNFL thickness measured with Stratus OCT is between approximately 9 and 12 μm, depending on which eye is thicker and which algorithm is used for testing. When one expands this to measurements of RNFL thicknesses in quadrants and clock hours, the differences between eyes are much higher and, perhaps, not as useful to quantify and use clinically. The larger differences in quadrant and clock-hour measurements may be explained by several factors. First, the test-retest variability of clock-hour and quadrant measurements, even in the same eye on the same day by the same operator on the same instrument, has been found to be higher in these smaller areas than SOCCEP Q/A Monday, April 13

the mean RNFL thickness over the entire circumference.” Article link: https://www.ncbi.nlm.nih.gov/pmc/arti cles/PMC2646446/

What do you consider a clinically This question was asked from a previous significant decrease in RNFL thickness? lecture so I’ll share my response with you: “Great question! This is going to vary based on the OCT you are using. Each OCT has a micron resolution that varies (ie: Spectral domain>Time Domain) Once you know this resolution you then have to also consider signal strength (SS), a lower SS is going to yield a lower resolution, from what I’ve read in the literature this doesn’t truly make a difference until your SS goes below 7, with each decrease in SS the OCT loses roughly 2 microns of resolution. So there are a lot of artifacts to consider, the OCT our clinic uses, the Stratus, has 10 microns of resolution, so on a perfect scan the minimal change I’d see to consider progression is just that, 10 microns, but I tend to increase my personal parameters based on how the OCT measured other parameters, so if the disc area was measured vastly different between two scans then you aren’t comparing apples to apples anymore. Given this notion I tend to use 12-15 microns for the Stratus as my personal rule for progression, hope that helps! Below are the two sources I utilized to obtain this information for my presentation. I. https://www.ncbi.nlm.nih.gov/pmc/arti cles/PMC3170667/ II. SOCCEP Q/A Monday, April 13

https://www.reviewofophthalmology.c om/article/managing--with- oct-secrets-to-success" Hope that helps!

What changes in RNFL values do you This question was asked from a previous lecture consider indicate glaucomatous so I’ll share my response with you: “Great question! This is going to vary based on the OCT progression and how did you decide on you are using. Each OCT has a micron resolution those values? that varies (ie: Spectral domain>Time Domain) Once you know this resolution you then have to also consider signal strength (SS), a lower SS is going to yield a lower resolution, from what I’ve read in the literature this doesn’t truly make a difference until your SS goes below 7, with each decrease in SS the OCT loses roughly 2 microns of resolution. So there are a lot of artifacts to consider, the OCT our clinic uses, the Stratus, has 10 microns of resolution, so on a perfect scan the minimal change I’d see to consider progression is just that, 10 microns, but I tend to increase my personal parameters based on how the OCT measured other parameters, so if the disc area was measured vastly different between two scans then you aren’t comparing apples to apples anymore. Given this notion I tend to use 12-15 microns for the Stratus as my personal rule for progression, hope that helps! Below are the two sources I utilized to obtain this information for my presentation. I. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3 170667/ II. https://www.reviewofophthalmology.com/article/ managing-glaucoma-with-oct-secrets-to-success" Hope that helps! I’ll also add that you want to ensure this matches any suggestive visual field defect, with that notion however know that the literature states you can lose up to 30-50% of RNFL before there is ANY visual field defect present, which is exactly where an OCT can play a great role in early detection

10:00 – 11:00 am Jeffrey Sterling, OD, Do you combine the topical and oral No. The Herpetic Study FAAO Antivirals? showed no benefit to doing so. Its a If there’s a trabculitis, would you I would likely start anti-

consider anti-ocualhypertensives as well ocularhypertensive meds for any IOP or just start with anti-virals and see if over 30. In this case, you would also that alone brings the pressures down? most likely being adding a topical steroid as well. That will require more vigilance.

For treating Herpes Simplex in a Zirgan over viroptic for faster re- patient, have you found the topical epithelialization. I also like it because it viroptic or zirgan to be more effective is thick and acts like a lubricating ung to compared to oral acyclovir or some extent. Zirgan, in my opinion, has valacyclovir? similar efficacy to the orals. But when SOCCEP Q/A Monday, April 13

doing orals, always give some lubricants drops or ointment to aid in managing discomfort.

Hi, if there is deeper corneal involvement For stromal, I use orals and steroids. The in the stroma, what would your Tx plan amount of steroid should be be? Steroids? Oral antivirals for proportionate to amount of prophylaxis long-term? inflammation seen. And this can be altered upon follow up. A long taper of 10 weeks or so is recommended. Acyclovir 400mg bid po for prophylaxis

when do you follow up after starting Probably around 3 days, depending on anti-virals? objective and subjective findings. For smaller dendrites, zirgan has often fixed the epithelium after just a few days and I can start reducing the taper sooner.

Can we get contact info? [email protected]

11:00 – 12:00 pm Kelsey Jordan, OD, MS, Hello, post-PKP pts exhibit progressive Great question. I manage these patients FAAO endothelial cell loss, and a low by following them closely. Once I Managing the Irregular endothelial cell count may be achieve a final scleral fit that I am contraindicated for scleral lens wear due satisfied with, I will monitor the patient to risk of corneal edema and every 3 months for medical decompensation, so what is your management. In this patient’s case, his approach when it comes to managing vision is hand motion without a scleral these pts? lens – yet acheives 20/20 vision with a scleral lens. In this case, the patient is able to use both eyes providing him good binocularity and overall improved quality of life with scleral lens wear. I monitor these patients closely for any signs of complications and address them as they arise.

1:00 – 2:00 pm Sharon Park Keh, OD, how long do PK sutures usually stay in Great question! It will vary between FAAO for? patient and surgeons. Some A Family of Corectopia, interrupted sutures may be removed soon post-op and I’ve seen some , running sutures removed years after the MicroCornea Managed procedure. What we are concerned with Contacts about most are suture-related complications, e.g. loosened or ruptured sutures, which can lead to infection or graft failure. Sutures also can be removed strategically to normalize corneal shape.

How do you choose a specific soft CLs Great question! It depends on the SOCCEP Q/A Monday, April 13

power & BC for piggyback fitting? REASON for piggyback fitting. In my mind, there are 2 major reasons I consider piggybacking – (1) comfort; (2) fit. If for comfort, a well-fit soft lens will work great with minimal power. If for fit, you can be strategic by using lens thickness (center vs. edge) to assist with your GP fitting. For example, if your GP alone exhibits too much central clearance, you may consider a high-plus soft lens underneath as this lens will be thicker centrally. Other considerations include: (1) replacement schedule; (2) Dk; (3) cost. If a very irregular corneal shape, you may need a custom soft lens for piggybacking.

May be silly of me to ask... but is it Not silly to ask, great question, and no alright to dilate the son (with the issues. multiple /corectopia)?

Any thoughts of a cosmetic correction Great question – in this case, there for the polycoria? would be 2 indications: (1) cosmesis; (2) symptomatic, i.e. glare. As the patient had no complaints about either, I didn’t pursue it. Also, because of the irregular cornea, i.e. KC, a soft lens could only help with vision so much. However, we do have a completely case where we piggybacked using the Acuvue Oasys Transitions lens for an irregular /cornea combo =)

Would you be concerned about In this case, the patient was wearing no worsening in the son who correction at all so the glasses > preferred gls over cl? nothing. Also, the patient was older, in his 20’s so I am less concerned than if he were a child? Also, recall, that ambylopia is “in the absence of disease” but this patient had a reason for decreased vision (Keratoconus) so it’s not truly amblyopia (in my opinion).

2:00 – 3:00 pm Joseph Kane, OD, FAAO You say you wouldn’t expect a 30 micron Hello, it’s a great question and one I Let’s Do The Twist: change in the RNFL between 6 years, but think about a lot in clinic. One of the Retinal Vascular is there data anywhere that gives us a key aspects of the case that I should’ve normal expected amount of RNFL Abnormalities highlighted perhaps a bit more was the thinning over the years? ASYMMETRY in this case. The superior RNFL sectors thinned by quite a lot more (approx. 30 microns) in the left SOCCEP Q/A Monday, April 13

eye when compared to the right eye (approx. 10-15 microns). The asymmetric nature of the thinning stands out and should catch our attention.

In terms of what’s “normal” for RNFL thinning (i.e. related to normal aging), I think it’s a tough answer. I generally think of a change of ~10% as potentially significant (i.e. 100 microns thick last year, decrease to 90 microns or less). However, I think it’s important to look at the whole case (i.e. is there IOP or VF changes, is there an imaging artifact/quality issue, etc).

There is also test/retest variability to consider (i.e. scan the same patient twice in the same day, you might get 100 microns avg RNFL then 104 microns avg RNFL).

I also like to look at trends/graphs, which are available on reports in some OCT models. This can avoid “outliers” confounding the overall clinical picture. This also compares the patient to him/herself.

Several studies (from 2007, 2012, 2019) found that there was an age-related RNFL thinning of approximately 2 microns avg RNFL decrease on average per decade (note that this was the MEAN or average RNFL, not individual sectors). RNFL thickness is likely dependent on a variety of factors including age, gender, , etc.

Here are some references/articles to check out: http://dx.doi.org/10.1016/j.ajo.2013.04.037 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2 916163/ http://dx.doi.org/10.3341/kjo.2012.26.3.163 SOCCEP Q/A Monday, April 13

https://doi.org/10.1155/2020/1873581

Can you please repeat what SUPVAL SUPVAL = sudden unilateral painless stands for? visual acuity loss

3:00 – 4:00 pm Emily Carell, OD, FAAO Do you think the excessive cough had I think that’s a great thought. However, What We Know This anything to do with the conjunctival I don’t think that this is the cause; Far...COVID19 and the redness/signs? i.e. the excessive valsalva particularly as other etiologies of that patients are putting themselves excessive cough do not cause this eye Eye through? presentation. I suspect this is more infectious/inflammatory from the virus.

Would we treat this 29 year old patient Well, seeing as you’ve heard as many with steroid drop to help her with her reports as I have about COVID-19 symptoms since she tested positive for , I don’t have a good COVID-19? answer. I think it’s a very viable thought, but at this point there isn’t literature to support it. That being said, I would think IF you did, I’d keep an antibiotic on board as well, particularly as in her case there were epithelial defects.

4:00 – 5:00 pm Rachelle Lin, OD, MS, No Questions FAAO Genetic Testing & Gene Therapy for Inherited Retinal Dystrophies

5:00 – 6:00 pm Amy Waters, OD, FAAO How do you educate parents that their I discuss the findings of optic nerve Pediatric Optic Nerve young child needs an MRI? hypoplasia and then talk about the fact Hypoplasia that it can have associations with changes in the brain, so we typically perform an MRI to rule this out. I also talk about how these changes and changes in hormones that can be associated can affect overall growth and development, so that is why we recommend an MRI and endocrine evaluation

Isn’t there a link to alcohol or drug There has been some association with abuse? Do you question to delve into this, as well as , and young family history more? maternal age, this is not an exhaustive list. . I do ask about birth history, growth SOCCEP Q/A Monday, April 13

and development on every pediatric patient. As long as I do not have concerns about the patients overall safety/well-being I do not ask about this specifically as it would not change the outcome for the patient. The majority of the time the cause of ONH is unknown . From aapos.org “Most cases of ONH have no clearly identifiable cause. There are no known racial or socioeconomic factors in the development of ONH, nor is there a known association with exposure to pesticides. ONH has been associated with maternal ingestion of phenytoin, quinine, and LSD, as well as with fetal alcohol syndrome.”

Would you recommend surgical Due to the fact he will not have good evaluation for his constant for binocularity due to structural changes cosmetic purposes? to his optic nerve, I usually discuss the option of surgery around 5-6 years old. This is when most studies have shown that kids start to notice difference between each other. We talk about the option for surgery later in life to restore normal alignment of the eye, but that it will not improve vision. I also educate that the is more likely to be recurrent after surgery due to the fact that the vision is poor in the affected eye. If at any point the family would like to discuss with a surgeon earlier, I would refer them for that consultation. https://www.ncbi.nlm.nih. gov/pubmed/20720253

At what point do you generally refer to Bilateral cases- unilateral cases should low vision? have normal visual acuity in the other eye.

Do you order the MRI yourself or You can order the MRI or refer to recommend to pediatrician, but the patient needs an pediatrician/endocrinologist? endocrine evaluation even if an MRI is ordered or is normal. SOCCEP Q/A Monday, April 13

Do you expect vision to stay stable/not The vision should not get worse in optic get progressively worse with optic nerve nerve hypoplasia, if vision is worsening hypoplasia? you should investigate as to another cause for this. how do we go back to watch these Your professors are receiving links to lectures later? the recordings.

At what magnitude of tropia do you Approximately 20 prism diopters consider referring for surgery in children?

SOCCEP Q/A Tuesday, April 14

Time Session Details Question Answer

9:00 – 10:00 AM Mashael Namaeh, OD, No Questions PhD, FAAO Gerontology & Low Vision

10:00 – 11:00 am Nivedita If the patient asks, Would you refer to In the case of a patient with a new Chandrasekharan, OD, the oncologist or retinal specialist first suspicious lesion, I would refer to a FAAO especially for same-day referral? retinal specialist, with an additional letter to their PCP. This would be the fastest Choroidal Melanoma approach. We can make

recommendations for the oncologists, but the clinic and factors such as the patient’s insurance will influence final decisions.

If you suspect an ambiguous nevus or Suspicious lesions with 0-2 RF on the possible melanoma, how frequent do TFSOM-UHHD penumonic can be you schedule follow-ups to check for followed with imaging q3 months. When progression? in doubt, refer! Get your Ophthalmologist/ retinal specialists’ opinion for additional peace of mind.

Did you say red free filter shows the Red-free analysis or fundus melanoma Hypofluores and SRF around autofluorescence (FAF): HYPER- hyperfluores autofluorescence occurs in the presence of lipofuscin. Areas of lipofuscin/ orange pigment in melanoma auto hyper- fluoresce, typically speckled (the lesion will be a darker underlying structure); drusen in nevi will also hyper- autofluoresce.

In the example on ppt slide #10, elevation around the main lesion as seen on DFE corresponds to an area of SRF/ PED/ and appears as a cuff of smooth relative hyper-autofluorescence. This is an example and not diagnostic of melanoma/ SRF. Literature indicates gravity-dependent SRF can hypo/ hyper autofluoresce. Therefore, SRF/ PED is better evaluated in all retinal pathology using OCT.

please address hollowness- this is a Presence of hollowness is a risk-factor for positive finding? melanoma. On the B-scan, melanomas SOCCEP Q/A Tuesday, April 14

appear as hollow lesions with low- medium internal reflectivity (and a highly reflective anterior border.)

Can you explain again where choroidal Stats on metastasis: ~90% to liver, ~24% melanomas are likely to metastatize to? to lung, ~16% bone (per COMS). General And the rate of occurrence? consensus >50% aim for the liver. Hence the q6months hepatic panel and q1yr imaging of the liver for these patients.

11:00 – 12:00 pm Stephanie Pisano, OD, If a patient was starting to forming This likely would be referred out, most FAAO symblepharon, would you just observe or patients I see are co-managed with Ocular Graft-vs-Host refer out right way? Would it be to corneal specialists in the same practice. oculoplastics? They will sometimes manage this Disease & Scleral Lenses themselves, or get oculoplastics involved depending on the case.

Is any amount of blanching acceptable in Some blanching can be acceptable in a difficult fit/ is it possible for there to be cases like GVHD. The inflammation can a small amount of initial blanching the be very transient and a perfect fit may resolves after adaptation? not be achievable in every case. Many eyes that are inflamed at the time of the fit will calm down as the patient increases scleral lens wear because the ocular surface is being bathed in saline constantly and rehabilitating the tissue.

For Case 1 was this scleral lens covered The lenses and the fitting/evaluation by insurance? were not. In our office we have a high volume of medically necessary lens fits and now have a contact lens billing coordinator to help with assessing coverage. In most cases, when the lens is medically necessary from the practitioner’s perspective (improves VA when glasses do not, improves symptoms from systemic condition, etc) it may not be considered medically necessary from the insurance perspective. This is extremely frustrating for the patient.

Most medical insurances will defer to the patient’s vision coverage, which also has exclusions and coverage for specific diagnoses. Billing/coverage of medically necessary lenses takes a significant amount of staff and doctor time. Ultimately, it is ideal to give the patient all opportunities for coverage. We SOCCEP Q/A Tuesday, April 14

usually will send a “per-determination” to the insurance companies with the diagnosis codes and fitting codes we intend to bill.

Would you try to cal the eye down Treating the eye when it is inflamed first before releasing the lens to the patient? is always an option but in many cases the If so, what did you do fort the second lens will help. In the 2 cases for this patient? presentation, the patients were having severe quality of life issues with their condition and using excessive amounts of topical lubricants. In both of these cases, the lenses were able to calm the eye down and they did not need any other topical therapies. The scleral lens will help to calm the eye down if the fit is appropriate. Allowing the ocular surface to be bathed continually with the lens in place usually significantly helps.

For these very dry patients, would you That is an option, but expensive. I have every have the patient fill the entire many patients do 2-3 drops of PFAT then bowl with PFAT? fill the remainder of the lens bowl with saline. The reason for this is most of the fluid is going to be pushed out with application. Also, this combination seems to work well for patients I have tried this with. Most vials have 6-8 drops – so if the patient can split this between two lenses, and use one saline vial to fill the rest, that can be cost effective for the patient.

When are the steroids inserted? What is If the patient is using topical steroids the the dosing and how long after drop steroid would be instilled at least 20 insertion until they can put their scleral minutes prior to lens application. Most back in? GVHD patients that are referred and already taking topical steroids are able to taper off once they are consistently wearing the lenses. If they have a flare of GVHD with ocular sequelae, I will dose depending on the level of inflammation. Usually QID for severe cases – but patient will need to remove lens to apply steroid, wait 20 minutes, then reapply. Usually they are having their GVHD regimen adjusted at the same time by their care team, so they won’t need to be on the steroid very long.

In the past, I have had attendings tell me Usually for ocular surface disease, I fit to fit GVHD with a lower vault compared the lens to be larger with a looser haptic to KCN patients - how much vault do you to allow for more tear exchange. Vault SOCCEP Q/A Tuesday, April 14

aim for with GVHD patients? can vary but goal to aim for is usually 200-400. However, with ocular surface disease patients the amount of lens settling into the / may fluctuate based on underlying disease, which will cause fluctuations in vault. So if you fit with lower vaults, you could run into a situation when they are inflamed where the lens will settle more and mechanically touch the cornea.

I usually do not notice any issues with hypoxia with a larger/looser fit and vaults as above. But as always – we have to take into account – Dk of material, center thickness, patient’s corneal health (testing endothelial cell count can be extremely helpful), etc.

I saw a patient who had a corneal One extremely important step at every transplant. We fit him with a scleral lens specialty lens exam is to look at the and he was ecstatic. However, at his one settled lens appearance (make sure week follow up, his cornea became patient applies lens 2-4 hours prior to cloudy, and the lens was uncomfortable. appt), then remove the lens yourself, So we prescribed prednisilone apply new NaFl and assess the cornea indefinitely. Can a patient wear scleral with no lens. There should be no staining lenses with prednisione? after lens removal that was not there before. If there is staining, the lens fit needs to be adjusted.

Patients can frequently have no complaints – good vision, good comfort, no issues with removal, and the fit looks good on eye but once you remove the lens you observe edema. Always remove the lens and apply new stain to check this.

For any graft, make sure you have adequate history on the graft – if they have had any rejection episodes in the past, any complications, what regimen of drops the corneal specialist prescribed (patients frequently will stop their pred regimen on their own when the corneal specialist wanted them to continue). If you have ability to take endothelial cell counts, that can give you great information on where you are starting and how much that cornea can handle.

Transplant patients need as much oxygen SOCCEP Q/A Tuesday, April 14

as possible – high Dk, low vault, as much tear exchange as possible (I do use fenestrations and channels if needed). One way to have transplant patients monitor at home is with a sign called Sattler’s Veil. If a patient looks at a light source (pen light, street light, light bulb) and sees a rainbow halo around it, they likely have corneal edema. I use this to have patients self-monitor at home, they know if they start seeing “rainbows” to call our office.

The other issue with transplants is the varying elevations on the cornea, especially the superior nasal quadrant. Elevation data on topographies can give you data on where to look specifically. If you don’t have that, make sure you are assessing the vault carefully throughout the cornea, not just the center.

Do you have an AT that you recommend In general, the best options would be for using over scleral lenses? non-oil based preservative free options or those with vanishing preservatives. I

1:00 – 2:00 pm Crystal Lewandowski, OD, Swallowing my pride, what does MEWDS Multiple Evanescent White Dot FAAO stand for? Syndrome Common Complaints with an Uncommon Does the granular appearance to the Macular granularity can fade with macula resolve in MEWDS? Diagnosis; A Review of time, but may persist after resolution MEWDS of white retinal spots and symptoms.

2:00 – 3:00 pm Alissa Coyne, OD, FAAO Why warm compresses vs cold compress Warm compresses were recommended MRSA and the Eye for a ? due to the suppurative nature of the discharge. Using warm compresses would assist in clearing the lashes as the heat loosens the dried discharge. Cool compresses could also be used to alleviate pain but needed assistance in her treatment regimen due to being in an assisted living facility.

Did she have a giant fornix?? Do you I cannot definitively state she had giant follow-up with treating nose with fornix syndrome as in-depth views were Mupirocin? limited as a result of the inability to view SOCCEP Q/A Tuesday, April 14

the anterior segment with typical slit lamp. Portable slit lamp revealed large papillae inferiorly but patient cooperation and mental status were contributory in clinical assessment. Part of the treatment regimen included betadine wash in office. Despite the antimicrobial wash and vancomycin treatment, the conjunctivitis did not resolve leading me to ascertain a subclinical source of the infection – ultimately .

In following up with the patient’s NP, she chose to treat the patient empirically with mupirocin due to her ocular MRSA status. This was done as the patient typically shares a room and common spaces with other residents in the living facility.

Decolonization is considered if infections are recurrent despite good hygiene and wound care. Mupirocin bid x 5-10 days applied to anterior nares is the usual recommendation for nasal decolonization. Antiseptic skin solution can also be added to this regimen if other skin/soft tissue is involved. Oral antimicrobial therapy is not routinely recommended for decolonization.

What about Bactrim? Bactrim (TMP/SMX), Clindamycin, Tetracylines (mino, doxy), and Rifampin (in combination with previous drugs listed) are used in the treatment of MRSA infections. Other IV antibiotics are available for use, when indicated. Bactrim wasn’t chosen for this specific patient due to the localized conjunctivitis.

Oral antimicrobial therapy is not typically recommended for decolonization measures. Please see above answer for further details.

Can you comment on possible posterior Anterior segment findings are more eye involvement? common compared to posterior segment findings. Posterior segment involvement can occur due to ocular surgeries, penetrating injuries, or endogenous SOCCEP Q/A Tuesday, April 14

spread from a distant site. MRSA exogenous can occur s/p extraction at the site of the CCIs or internally due to the surgical procedure. Endogenous spread with resultant endophthalmitis is unusual (2- 8% of all endophthalmitis) but possible especially in immunocompromised patients. is also a posterior segment finding associated with endogenous spread. Intravitreal antibiotics, sometimes concurrently with IV antibiotics, are the mainstay of treatment in order to achieve therapeutic levels in the vitreous.

If you have a bacterial infection that’s Empirical use of antibiotics can decrease not improving on antibiotics and you’re the sensitivity of cultures. In this patient, starting to consider MRSA as an etiology, there was no response to empirical is there any concern when culturing after treatment increasing my suspicion of antibiotic treatment has already started? MRSA. While not optimal, growth can still occur if the microbe isn’t sensitive to the treatment initiated. From a corneal standpoint, we typically D/C antibiotic use for 24 hours before culturing to improve sensitivity testing if there is no response or worsening of the condition (if cultures weren’t taken upon initial presentation).

3:00 – 4:00 pm Mashael Namaeh, OD, No Questions PhD, FAAO Preparations Used with Contact Lenses

4:00 – 5:00 pm Sandra Harpster, OD How soon should you see a patient with Good question. Patients with ischemic Unusual Vessels of the CRVO that has lots of CWS compared to CRVOs, OR any CRVOs with macular Optic Nerve flame hemes? Would you monitor to see edema, I refer them to retina for if it resolves or refer to retina for FA to treatment. For nonischemic CRVO the

see if anti-VEGF is needed soon? degree of hemes vs cotton wool spots does not change my follow up. I see them every month for 3 months, then 3 months after that, then 6 months after that. I am monitoring for , signs of conversion to ischemic CRVO and neovascularization at these follow ups (so gonio and dilate every visit). If the eye converts from non-ischemic to SOCCEP Q/A Tuesday, April 14

ischemic, or visually significant macular edema is present during any of these follow ups then I refer to retina.

Does VEGF trigger formation of shunt Good question. VEGF does not trigger vessels? If so, why we don’t get the formation of optociliary shunt neovascularization instead? vessels. These collateral vessels form when the pressure of blood flowing out through the central retinal vein (CRV) is greater than the pressure in the choroidal circulation (this happens when the CRV is obstructed or compromised for some reason, not from ischemic factors).

Can you describe the difference between Good question! So there is IRMA IRMA and Collateral vessels? (intraretinal microvascular abnormalities), Retinal Collaterals, and also Optociliary Shunt Vessels (aka optic nerve head collaterals). Retinal collaterals develop from the existing retinal capillary network in situations where one vessel becomes occluded but adjacent vascular channels are patent and functioning (think BRVO). Retinal collaterals are like optociliary shunt vessels in the sense that they are always there but just microscopic and you don’t see them until you get that pressure differential from some sort of obstruction. Optociliary shunt vessels are connecting retina to choroidal circulations where as retinal collateral connect retina to retina. IRMA is not directed by pressure differentials, but instead my ischemic factors from areas of nonperfusion. The traditional view was that IRMAs represent vascular remodeling. However, there is also the concept that IRMA is a forme fruste of retinal NV.

Are patient with congenital prepapillary Good question. There are a few case loops more prone to vitreous reports in the literature of vitreous hemorrhages if they get vitreous hemorrhage associated with prepapillary detachment? loops. Theoretically they may make a patient more prone to vitreous hemorrhage in the setting of acute PVD, particularly if the vitreous has any sort of attachment to the loop. Overall it is not SOCCEP Q/A Tuesday, April 14

something I worry about and the literature on the topic is very limited.

can you explain how OIS does not lead to Yes good question! I know I rushed shunt vessels again? thank you! through that at the end. For optociliary shunt vessels to form, the pressure of blood flowing through the central retinal vein (CRV) needs to be greater than the pressure in the choroidal circulation. This happens when the CRV is obstructed or compromised for some reason, and then blood gets diverted through the optociliary shunt vessels to the choroidal circulation and out via vortex veins. In Ocular Ischemic Syndrome (OIS), the issues is that there is low perfusion of blood entering the eye. To get the ONH collaterals you have to have high pressure in the venous system which is caused by blockage downstream. In OIS it’s backed up at the proximal end of the artery so low pressure in both arteries and veins. However, because this blood is a bit stagnant in OIS this venous stasis could theoretically cause thrombus formation in the vein, and theoretically I suppose if the patient had a carotid endarterectomy or stent which restored the pressure in the artery, then you might get a CRVO and collaterals from that.

5:00 – 6:00 pm Henrietta Wang, BOptom No Questions (Hons), BSc, FAAO Assessing the Optic Nerve: Does Retinal Vasculature Matter?

SOCCEP Q/A Wednesday, April 15

Time Session Details Question Answer

9:00 – 10:00 AM Alex Hynes, OD, FAAO topical anesthetic?? Worry of epithelial toxicity with long Managing Corneal term use. And again in centrally Neuropathic Pain 2' to sensizitized patients likely wouldn’t be LASIK/PRK From a Patient 100% effective. Topical lacosomide Perspective might hold some promise (some reports of it being applied to the scleral lens bowl along with the PF saline). Mexiletine, an oral sodium channel blocker is 3rd line given its side effect profile.

Is it possible for the central sensitization Drugs such as gabapentonoids can to be down-regulated eventually? down-regulate elements of central sensitization but it is very difficult to reverse it completely. For example, at a molecular level, astroglial activity might allow central sensitization (by upregulating receptors/noci-receptors) more efficiently than at a greater rate than glutamate receptor degradation reverses central sensitization PMID: 29875641

Have you tried Cymbalta? Yes duloxetine in combination with pregablin (both were in the orals chart). No ocular studies yet.

How about Oxervate? any changes in Not available in Canada yet. However nerve growth w/confocal microscopy? has been show to help with neurotrophic ulcers/persistent epithelial defects vs placebo. Interestingly in the trials some patients developed ‘pain’ from the drops presuambly because of nerve regeneration! I haven’t seen studies of oxervate with confocal microscopy changes as the endpoint (endpoints have been more fluorescein staining area related)

any trials with medroxyprogesterone Haven’t seen any (most of the trials (topical)? seem to be related to treating ulcers/corneal thinning/neovasc. Might be beneficial due to the anti- inflammatory effect for ex. in neuropathic pain patients plausibly. SOCCEP Q/A Wednesday, April 15

Can you spend a little more time Both are characterized by nerve distinguishing neurotrophic and dysfunction. Neurotrophic keratitis neuropathic please? features epithelial breakdown, lack of healing, ulceration, and even sometimes melting or perforation. Think lack of sensitivity ‘patients might not even be aware they have an ulcer’ due to improper innervation ex. herpetic or post surgical damage to trigeminal nerve. Pain without stain would be a great way meanwhile of describing trigeminal nerve dysfunction in neuropathic cases.

10:00 – 11:00 am John Gialousakis, OD, Would modified monovision lenses not Of course! I gave a brief overview of the FAAO be appropriate in this case? lenses trialed in-office, but did not go : When into the troubleshooting part much. But this patient was more Type-A, so Contact Lenses Work and anything that caused a loss in stereopsis Don't Work was not her favorite.

11:00 – 12:00 pm Matthew Lee, OD & Mari I saw a patient with a corneal graft. I fit It is typical to have a small level of Fujimoto, OD him into a scleral lens, and he was edema with scleral lens wear even in a When Scleral Lenses extremely happy. However, at his 1 week normal cornea, roughly 2-4%. However, follow up, his cornea was hazy. in the presence of haze, that is a Aren't the Answer Thoughts? clinically significant level of edema that needs to be addressed. Especially if you went through the effort of fitting a scleral lens initially, prior to switching lens modality, you may want to try a few different strategies. In new scleral lens wearers, it's important to build up wear time to get the cornea used to the physiological demand. There may also be an I&R/care regimen issue that you may need to address and review. Otherwise, you may need to optimize the fitting relationship even more, or switch to a high Dk material. Putting the patient on a maintenance dose of hyperosmotic saline solution/ointment may help. If those strategies don't improve the edema, I would say that switching lens modality is indicated."

SOCCEP Q/A Wednesday, April 15

1:00 – 2:00 pm Micaela Gobeille, OD, May I please have a copy of the Thanks for your question! MS, FAAO directions of how to fit the pelli prism? Chadwick optical is the company Low Vision Management which manufactures and sells these Using Prism for a Patient prisms, and there’s a lot of with Homonymous Visual information on their website. Field Loss Here’s their instructions for the stick on prisms: http://www.chadwickoptical.com/fit ting-the-temporary-prisms/ Also, if you wanted to see the written instructions that come in the package, follow this link for a picture: http://www.chadwickoptical.com/pr oduct/peli-lens-single-pack/

I should note that when I’m fitting these, a lot of times the patient shifts fixation while I’m trying to get them lined up, so sometimes I’ll just dot the pupil on the lens and stick the template on after I’ve already taken the frame off of the patient’s face. That way I’m sure the prism is landing where I wanted it to with respect to the patient’s pupillary center. When you first start fitting these, you’ll notice that you need to adjust the prism to get it to line up just right, and that’s okay! You just want to make sure the prisms are aligned right when you’re done so they work properly.

Feel free to email me if any other questions come up: [email protected]

2:00 – 3:00 pm Mark Wilkinson, OD, This lecture seemed at little rushed, does The best flow sheet is at FAAO the doctor have a flowsheet he can share stonerounds.org. It has case examples Vision Rehabilitation for to keep all these conditions he covered with fundus photos, visual fields and clear? OCT images, as well as genetic testing Individuals with Inherited information. Eye Diseases SOCCEP Q/A Wednesday, April 15

3:00 – 4:00 pm Barbara Mihalik, OD, Can you explain the different An ERM that pulls up the fovea and FAAO presentations of ERM on oct again? flattens it out is easier to remove than Traction, Membranes, Which one is easier to treat with a peel? one that distorts it into a hole shape (lamellar hole). This is because if you and Holes, OH MY! peel one that forms a lamellar hole you risk pulling up the outer retina with it and causing a macular hole.

what is the prognosis for your patient? is The patient should stay quite stable. there any chance vision could Updating their refractive error may help spontaneously improve during some. In some cases, a retina specialist observation? will peel the membrane, but, the patient needs to understand the risk of causing a macular hole in the process and if it is worth that risk to maybe gain some improvement in vision.

If the patient did have a macular hole The most common and successful what treatment options are there? treatment is a vitrectomy with a membrane peel and insertion of a gas bubble with positioning.

Do you have any tips for telling between Pseudohole is generally a term used to a lamellar/partial hole and psuedo- describe fundus finding on examination. holes? Then OCT is used to determine what is causing the pseudohole appearance, just an ERM, a lamellar hole and ERM, or is it actually a mac hole.

Do lamellar holes convert to macular Lamellar holes are usually pretty stable. holes? They can turn into a mac hole if an ERM peel is attempted and the outer retina comes up with the membrane.

Is lamellar hole the same as a stage 1 No, lamellar holes only involve the inner macular hole? I know stage 2 is when it is retina layers leaving outer retina intact. "classified" as full thickness. A mac hole at any stage by definition must be involving the outer retinal layers and can progress to involve inner retina by becoming a full thickness hole.

Are lamellar holes always associated with There are varying points of view on this an ERM? in the literature. In general, there should be some form of an ERM present that resulted during VMT/PVD or from fibrosis like sometimes seen in diabetes. This extra layer of tissue contracts and distorts the inner retinal layers of the fovea resulting in a lamellar hole. A less accurate use of the lamellar hole term would be naming distorted foveal contour, like that which can occur after SOCCEP Q/A Wednesday, April 15

release of VMT that causes the fovea to have an odd shape, with no ERM present.

4:00 – 5:00 pm Raman Deol, OD, FAAO No Questions Low Vision Management of Person with Ring

5:00 – 6:00 pm Chelsea Bradley, OD is the tinting of the CLs done in office? Some offices may have limited ability to Tinted Contact Lenses As Can any CL be tinted? tint lenses in-office, but I have never Therapeutic Devices - Not done it. The company will generally tell you specifically what kind of lens needs Just for Cosmesis to be used, and it is generally a 55% water content lens (we use Kontur 55). For the simple tinted lenses the lab will generally supply the lens after you specify the power. For the hand-painted lenses, if your patient has no vision, the lab will paint their own lens. If the pt has vision, you need to supply the lens with the correct power to them (we supply Kontur 55 lenses to Adventures in Colors who paints them)

Which labs/companies can you send We use Kontur for the simple tinted pictures to for trials? lenses and Adventures in Colors (AIC) for the handpainted lenses. I have also hear Alden and ABB/Concise do some tinted lenses, as do many other labs I’m sure, but I have never personally used any other than Kontur and AIC

Can you bill monocular double vision as Generally, you can’t bill symptoms as a medically necessary? reason for medically necessary. However, each insurance company will give you a list of conditions they will cover CLs for under medically necessary, and if the condition that is causing the symptom is on the list, then it will be covered. Some insurance companies will also separate the tint from the contact lens; i.e. they will cover the lens itself for vision but the patient will have to pay out of pocket for the tinted part if it is only treating a cosmetic problem.

How do we go about getting tinted lens Ask the labs that you want to use to samples? send you samples; some will send them SOCCEP Q/A Wednesday, April 15

for free, some will ask you to pay for them. If you are fitting a specific patient, they will send you samples that match your patient. (The companies that do hand-painted will not usually send you just generic samples since they are so expensive. They will only send you trials to match to a specific patient you are trying to fit.) what is the replacement schedule for 1 year replacement, as long as they take hand painted lens? good care of them. Recommended care is using BioTrue as it is normally used, but in a glass container instead of a standard plastic contact lens case because the plastic will leach the color out of the lens.

How do you care for the hand painted 1 year replacement, as long as they take lenses? Are they replaced yearly? good care of them. Recommended care is using BioTrue as it is normally used, but in a glass container instead of a standard plastic contact lens case because the plastic will leach the color out of the lens.

Does insurance cover the hand-painted Generally, you can’t bill symptoms as a lenses for the patient who had ? reason for medically necessary. Is that medically necessary? However, each insurance company will give you a list of conditions they will cover CLs for under medically necessary, and if the condition that is causing the symptom is on the list, then it will be covered. Some insurance companies will also separate the tint from the contact lens; i.e. they will cover the lens itself for vision but the patient will have to pay out of pocket for the tinted part if it is only treating a cosmetic problem.

How long are the category 3 lenses good The recommended replacement is 1 to use? Can they also be ordered in year, but it can be less if they take poor prescription? Thanks! care of it. Recommended care is BioTrue used as it normally is but in a glass case instead of a standard plastic case, as the plastic will leach the color out of the lenses. For the hand-painted lenses, if your patient has no vision, the lab will paint their own lens. If the pt has vision, you need to supply the lens with the correct power for them to pain (we supply Kontur 55 lenses to Adventures in Colors who paints them) SOCCEP Q/A Wednesday, April 15

SOCCEP Q/A Friday, April 17

Time Session Question Answer Details

9:00 – 10:00 am Brigitte Keener, OD, how would you recommend this Excellent question. With a central FAAO loading of fortified antiobiotics in >2mm in diameter, it is Femtosecond Laser- regards to sleep? Would you recommended to dose the fortified recommend to the patient to wake antibiotics hourly for at least the first Assisted Anterior from sleep to continue this loading? 24 hours, even overnight. The patient Lamellar Keratoplasty shall be evaluated the following day. (FALK) Once the resolves, overnight dosing is not typically required.

I’m a current resident and I’ve found You bring up a great point. If you will with my ulcers that many of the be referring a patient same day with a ophthalmologist we refer to don’t central corneal ulcer, it is a good idea want us to start antibiotic drops prior to reach out to the provider to inquire to sending the patient to them since if he or she prefers to hold antibiotics they want to do their own in house for the culture. If this is cultures. Because of this I always call recommended, then the patient the doc before I refer to see if they should be sent directly to the other want me to initiate antibiotics [every provider’s office and this plan should hour like you mentioned] or if they be well documented in the patient’s would prefer me to hold off. I just chart. If the provider is unable to wanted to voice that as I was always evaluate the patient on the same day, taught as a student to hit them hard then I would recommend initiating regardless of if you refer, but in clinical antibiotics in office. practice I have found that not to be true.

10:00 – 11:00 am Paul Karpecki, OD, FAAO Any considerations for other Yes AzaSite works well for Treatment Options for blepharitis Tx vs. standard topical? given its anti-inflammatory traits. Common Inflammatory Azasite, ointments, etc.? Ointments like Bacitracin also work well especially if external (not in the Eye Conditions eye except QHS)

Shouldn’t we consider herpetic In children yes - this is a common blepharitis when we see vesicules on form of primary HSV which would the ? then be treated with oral acyclovir.

Your preferred Tx for persistent ocular Oral doxycycline 20mg or 50 mg (but rosacea that no longer responds to never 100mg due to side effects) BID x topical steroids 2 months then QD x 1 month provided there are no contraindications

what are you going to use to treat a kid Depends on age. Normal weight older with systemic symptoms and than age 8 can be treated with adult conjunctivitis? dosing such as amoxicillin 500mg BID x 7 days. Consider Augment for adults and older children. Elixer for younger SOCCEP Q/A Friday, April 17

children.

11:00 am – Paul Karpecki, OD, FAAO You just quoted up to 15% of patients Of course there are very few 12:00 pm Antibiotic Resistance in with COVID can have conjunctivitis? If published peer reviewed papers on Ocular Surface so, can you please cite the source? All the subject but most reliable sources the sources I’ve seen are below 2% are showing ~15%. Infections https://www.webmd.com/lung/news/ 20200401/pink-eye-often-a-symptom- of-covid-19#1

1:00 – 2:00 pm Christina Twardowski, can you read aloud the K values? it was OD: 46.90/62.58 OD, FAAO a little small OS: 46.57/58.63 Pediatric Keratoconus There was the question about why was the retinoscopy not symmetric if the Ks are? To follow up, remember these K values are only giving a one image view of the cornea (anterior corneal structure) there are still pachy values and post corneal architecture that will factor into the overall refractive findings.

And following up - what K value are There is no specific K value that is of you concerned about in this concern, but more the collection of population? findings that are consistent with Keratoconus. In patients whose Keratoconus is diagnosed early their K values may only be around 47 D…but they show a thinning cornea with pachy, an abnormal posterior corneal structure with pentacam and an abnormal reflex…remember to look at the overall clinical picture!

Hi! Would you be willing to send me Of course! Please let me know if you the article about diagnosing or anyone else would like any keratoconus with retinoscopy? My additional articles email is [email protected] Thanks so much!

Could you prescribe topical NSAIDs for In theory, yes you could. But the pain? cornea is already compromised from the procedure/condition and NSAIDS have known risk of corneal complications. Because the pain has a short duration and improves well with ice packs and systemic meds we find no need to add NSAIDS to our post-op regimen. SOCCEP Q/A Friday, April 17 what is the dosing on steroid and The steroid (pred forte) is dosed QID vigamox on post op day 1 and 2? and Vigamox is dosed QID as well until Was the KC diangosed based on the KC the epithelial defect has healed. At predictability index and the irregular this time the patient stops Vigamox reflex on ret? The topography looks and is tapered off the steroid actually really regular (4,3,2,1).

The topography looks regular because of the location of the cone, but: 1)The K values are outside normal limits 2)The retinoscopy reflex was consistent with keratoconus 3)corneal findings were present on slit lamp examination which were also consistent with Keratoconus

How do you category progression? Progression would be a true change does it have to be repeatable or a seen in your tomography findings (i.e. particular value? thinner pachy value, progression in posterior corneal curvature, increase in K value of ant corneal findings)

Just to clarify, the CXL can only hault Correct, you cannot get rid of any progression but not reverse anything, existing but you can right? prevent any further corneal changes from happening. the OMD here in Miami does cross- Yes – I would say all surgeries will vary linking on with min 300 pachs. from OMD to OMD (varying comfort I guess its OMD specific? levels and resources). Remember, we are also discussing only pediatric patients and still waiting for a lot of the long-term data. I would suggest there is more evidence to support good prognosis on adult patients post CXL with 300 micron corneas compared to the data available for peds in that same scenario.

Is there a minimum age required for No – the only requirement is the crosslinking? diagnosis of keratoconus

How thin is too thin for corneal 400 microns is what you will read in crosslinking? So sorry I might have literature. There are some OMDs that missed this earlier are comfortable performing the surgery (with specific modifications) on thinner corneas (~350 microns).

How thin is too thin for corneal See above crosslinking? So sorry I might have missed this earlier SOCCEP Q/A Friday, April 17

Do MDs fit CLs post crosslinking in their I have yet to find an OMD that fits offices or will they co-manage with their own patients in contact lenses. ODs? That does not mean there isn’t an OMD out there that may want to, but I would say the majority of OMDs rely on optometry and are happy to co- manage these patients.

2:00 – 3:00 PM Jeff Gerson, OD, FAAO No questions Making Sense of Ocular Nutrition

3:00 – 4:00 Arthur Epstein, OD, No questions FAAO Crossroads in Clinical Care of Red Eyes

4:00 – 5:00 pm Milton Hom, OD, FAAO No questions Is the Whole Story?

5:00 – 6:00 pm Richard Mangan, OD, What about irrigating and patients who If the patient is at home or the work FAAO where contact lenses? place when the accident happens, Ocular Chemical Burn - irrigation should begin without attempting to remove the lenses. Are You Prepared Once the patient arrives at the ER or eye clinic, the CLs can be removed.

What do you suggest for facial burns. Necrotic tissue should be removed. Silvadene? Varying ointments or creams can be used, including e-mycin. If an explosion caused metallic lithium burns, even coconut oil can be helpful. IV & Oral Abs are often prescribed for severe burns as well.

Are there any chemical burn situations No. As long as the irrigation process where adding NaFl or any other vital has been completed, you should be dyes would be contraindicated? fine to use vital dyes.

are we able to debride? if we are, how You can use a wek-cell sponge, SOCCEP Q/A Friday, April 17 do we do that?? moistened Q-tip, Jewelers forceps. for trace-1st degree chemical burns, if Steroid drops during the first week do you use a steroid does it delay healing not adversely affect wound healing, so time? and is the steroid used only to yes…good to use. What it does slow is decrease edema and prevent scarring? keratocyte migration in the stroma. So once the epithelium has filled in, you want to taper the steroid gtts.

Two Questions: 1) Most still use Goldman Tonometry, unless the patient has had the Boston 1. What do you suggest is the best K-Pro. Schiotz has been shown to method of measuring intraocular most accurate for these cases. pressure on a severely damaged Transpalpebral tonometry may be a corneal surface due to a chemical good idea for this population. burn? Cryopreserved are preferred for hot / 2. What is your opinion/experience on angry / inflamed eyes. With that said, using ambiodiscs (dry amniotic if a second membrane is needed and membranes) rather than prokera in the patient didn’t tolerate the Prokera terms of patient prognosis? ring, I have no problem with someone using the dehydrated tissue.