An Update from Leaders in the Field

MARCH 2020 VOL. 15, NO. 2 | RETINATODAY.COM RETINA WOMEN An update from leaders in the field

With Guest Editor Judy E. Kim, MD

PEARLS FOR THE WOMEN IN LEADERSHIP: A CONVERSATION WITH JOURNAL CLUB WITH THE WILLS EYE YAMANE TECHNIQUE JULIA A. HALLER, MD, AND JOAN W. MILLER, MD HOSPITAL RETINA FELLOWS

0320rt_Cover.indd 1 3/6/20 12:41 PM This is

Laser-ablated micro-surface is designed to support atraumatic ILM peel initiation1

Optimized grasping platform and angled tip closure to help mitigate membrane shredding2

GRIESHABER® DSP IMPORTANT PRODUCT INFORMATION Caution: Federal (USA) law restricts this device to sale by, or on the order of, a physician. Indications for Use: GRIESHABER® DSP instruments are a line of single-use vitreoretinal microinstruments which are used in ophthalmic surgery, for cases either in the anterior or the posterior segment. The GRIESHABER® Advanced Backflush Handles DSP are a family of instruments for fluid and gas handling in vitreoretinal surgery. Warnings and Precautions: • Potential risk from reuse or reprocessing GRIESHABER® DSP instruments include: foreign particle introduction to the eye; reduced cutting or grasping performance; path leaks or obstruction resulting in reduced fluidics performance. • Verify correct tip attachment, function and tip actuation before placing it into the eye for surgery. • For light fiber instruments: Minimize light intensity and duration of exposure to the retina to reduce risk of retinal photic injury. The light fiber instruments are designed for use with an ALCON® illumination source. • Good clinical practice dictates the testing for adequate irrigation and aspiration flow prior to entering the eye. If stream of fluid is weak or absent, good fluidics response will be jeopardized. • Use appropriate pressure supply to ensure a stable IOP. • If unwanted tissue gets engaged to the aspiration port, it should be released by interrupting aspiration before moving the instrument. Attention: Please refer to the product labeling for a complete listing of indications, warnings, and precautions.

Reference: 1. Data on File. Alcon Laboratories Inc; May 2018. 2. Data on File. Alcon Laboratories Inc; September 2017.

US-GUS-18-E-1175 RT.indd 1 1/8/20 10:05 AM This is

Designed to: Enhance stability with a continuously open port and CONSTELLATION® Vision System’s IOP compensation1 Reduce pulsatile traction with 20 000 cuts per minute using 25+® and 27+® gauge probes*, 2,3 Improve vitreous flow4 Enable closer access to tissue plane with beveled tip5

*At similar single-blade flow rates

MIVS IMPORTANT PRODUCT INFORMATION Caution: Federal law restricts this device to sale by, or on the order of, a physician. Indications for Use: The CONSTELLATION® Vision System is an ophthalmic microsurgical system that is indicated for both anterior segment (i.e., phacoemulsification and removal of cataracts) and posterior segment (i.e., vitreoretinal) ophthalmic surgery. The ULTRAVIT® Vitrectomy Probe is indicated for vitreous cutting and aspiration, membrane cutting and aspiration, dissection of tissue and lens removal. The valved entry system is indicated for scleral incision, canulae for posterior instrument access and venting of valved cannulae. The infusion cannula is indicated for posterior segment infusion of liquid or gas. Warnings and Precautions: • The infusion cannula is contraindicated for use of oil infusion. • Attach only Alcon supplied products to console and cassette luer fittings. Improper usage or assembly could result in a potentially hazardous condition for the patient. Mismatch of surgical components and use of settings not specifically adjusted for a particular combination of surgical components may affect system performance and create a patient hazard. Do not connect surgical components to the patient’s intravenous connections. • Each surgical equipment/component combination may require specific surgical setting adjustments. Ensure that appropriate system settings are used with each product combination. Prior to initial use, contact your Alcon sales representative for in-service information. • Care should be taken when inserting sharp instruments through the valve of the Valved Trocar Cannula. Cutting instrument such as vitreous cutters should not be actuated during insertion or removal to avoid cutting the valve membrane. Use the Valved Cannula Vent to vent fluids or gases as needed during injection of viscous oils or heavy liquids. • Visually confirm that adequate air and liquid infusion flow occurs prior to attachment of infusion cannula to the eye. • Ensure proper placement of trocar cannulas to prevent sub-retinal infusion. • Leaking sclerotomies may lead to post operative hypotony. • Vitreous traction has been known to create retinal tears and retinal detachments. • Minimize light intensity and duration of exposure to the retina to reduce the risk of retinal photic injury. ATTENTION: Please refer to the CONSTELLATION® Vision System Operators Manual for a complete listing of indications, warnings and precautions.

References: 1. Irannejad A, Tambat S, Abulon DJK. Retropulsion and mass flow of 27-gauge vitrectomy probes: comparison of dual-blade/flat-tipped probes and single-blade/beveled probes. Poster presented at: 18th Congress of the European Society of Retina Specialists; September 20–23, 2018; Vienna, Austria. 2. Alcon data on file. Alcon Laboratories, Inc; June 2018. 3. Alcon data on file. Alcon Laboratories, Inc; June 2018. 4. Alcon data on file. Alcon Laboratories, Inc; June 2018. 5. Alcon data on file. Alcon Laboratories, Inc; May 2017.

US-GAU-19-E-0842 RT.indd 1 1/8/20 10:05 AM EDITORIAL ADVISORY BOARD CHIEF MEDICAL ASSOCIATE Thomas Albini Pravin U. Dugel John W. Kitchens Elias Reichel EDITOR MEDICAL EDITOR Miami, FL Phoenix, AZ Lexington, KY Boston, MA Allen C. Ho Robert L. Avery J. Fernando Arevalo Jay S. Duker Derek Y. Kunimoto Carl D. Regillo Philadelphia, PA Santa Barbara, CA Baltimore, MD Boston, MA Phoenix, AZ Philadelphia, PA Carl C. Awh Jorge Fortun Baruch Kuppermann Kourous A. Rezaei Nashville, TN Miami, FL Irvine, CA Chicago, IL SECTION EDITORS G. William Aylward Thomas R. Friberg Rohit Ross Lakhanpal Philip J. Rosenfeld RETINA PEARLS GLOBAL PERSPECTIVES London, UK Pittsburgh, PA Owings Mills, MD Miami, FL Dean Eliott Albert J. Augustin Caroline R. Baumal Julia A. Haller Theodore Leng Steven D. Schwartz Boston, MA Karlsruhe, Germany Boston, MA Philadelphia, PA Palo Alto, CA Los Angeles, CA Ingrid U. Scott Ehab El Rayes Rubens Belfort Jr. Tarek S. Hassan Xiaoxin Li Carol L. Shields Hershey, PA Cairo, Egypt São Paulo, Brazil Royal Oak, MI Beijing, China Philadelphia, PA Audina M. Berrocal Stanislao Rizzo Miami, FL Jeffrey Heier Jordi M. Mones Richard F. Spaide BUSINESS MATTERS Boston, MA Barcelona, Spain New York, NY Florence, Italy María H. Berrocal Alan Ruby S.K. Steven Houston III Andrew A. Moshfeghi Ramin Tadayoni Royal Oak, MI San Juan, Puerto Rico Lihteh Wu Lake Mary, FL Los Angeles, CA Paris, France San José, Costa Rica David M. Brown MEDICAL RETINA Houston, TX Jason Hsu Timothy G. Murray Sjakon George Tahija Philadelphia, PA Miami, FL Jordana G. Fein FELLOWS’ FOCUS David S. Boyer Jakarta, Indonesia Fairfax, VA Thomas Jenkins Los Angeles, CA Michael Ip Anton Orlin Nadia Waheed Los Angeles, CA New York, NJ Boston, MA Heeral R. Shah Philadelphia, PA Robison V. Paul Chan Chicago, IL Glenn J. Jaffe Yusuke Oshima Joplin, MO George A. Williams Ravi Pandit Steve Charles Durham, NC Osaka, Japan Royal Oak, MI EYETUBE RETINA CHIEF Philadelphia, PA Memphis, TN Kazuaki Kadonosono Kirk H. Packo Charles C. Wykoff Michael A. Klufas David Xu Allen Chiang Yokohama City, Japan Chicago, IL Houston, TX Philadelphia, PA Philadelphia, PA Philadelphia, PA Peter K. Kaiser Jonathan L. Prenner Young Hee Yoon David R. Chow Cleveland, OH New Brunswick, NJ Seoul, South Korea VISUALLY SPEAKING Mississauga, Canada Richard S. Kaiser Aleksandra Rachitskaya Manish Nagpal Kim Drenser Philadelphia, PA Cleveland, OH Gujarat, India Royal Oak, MI Szilárd Kiss Ehsan Rahimy New York, NY Palo Alto, CA BUSINESS David Levine, Executive Vice President, Stephen Daily, Executive Editor, News Digital & Custom Media +1 484 581 1871; [email protected] David Cox, President/Cofounder +1 609 933 6799; [email protected] +1 484 581 1814; [email protected] Cara Deming, Director, Special Projects Laura O’Connor, Director, +1 484 581 1889; [email protected] Adam Krafczek Jr, Esq, Cofounder Market Analysis & Strategy +1 484 581 1815; [email protected] +1 484 581 1860; [email protected] ART/PRODUCTION Tamara Bogetti, MBA Alvin Fu, Senior Director, Analytics & Technology Executive Vice President/Group Publisher +1 484 581 1888; [email protected] John Follo, Creative/Production Director +1 714 878 0568; [email protected] +1 484 581 1811; [email protected] Janet Burk, Publisher Dominic Condo, Art/Production Director +1 214 394 3551; [email protected] EDITORIAL +1 484 581 1834; [email protected] Gaynor Morrison, Scott Krzywonos, Editor-in-Chief Joe Benincasa, Digital Art Director Vice President, Sales +1 484 581 1880; [email protected] +1 484 581 1822; [email protected] +1 484 581 1836; [email protected] Katie Herman, Associate Editor Rachel McHugh, Associate Art Director Barbara Bandomir, Vice President, Operations +1 484 581 1897; [email protected] +1 484 581 1853; [email protected] +1 484 581 1810; [email protected] Tim Donald, ELS, Consulting Editor Camela Pastorius, CMP, Vice President, [email protected] Meetings & Events, Gillian McDermott, MA, Editor-in-Chief, Clinical Bryn Mawr Communications Group Content, Anterior Segment +1 484 581 1807; [email protected] +1 484 581 1812; [email protected]

Retina Today (ISSN 1942-1257) © 2020 Bryn Mawr Communications LLC is published January/February, March, April, May/June, July/August, September, October, and November/December by Bryn Mawr Communications LLC, 1008 Upper Gulph Road, Wayne, PA 19087. Subscription is free to all applicable US retina physicians. All others, applicable subscription charges apply. For subscription information call +1 800 492 1267 (US only) or e-mail [email protected]. Pending periodi- cal postage paid at Wayne PA and additional entry offices. POSTMASTER Please send address changes to Bryn Mawr Communications LLC, 1008 Upper Gulph Road, Wayne, PA 19087. Bryn Mawr Communications LLC provides certain customer contact data, which may include customer names, addresses, phone numbers and e-mail addresses, to third parties for promotional and/or marketing purposes. If you do not wish Bryn Mawr Communications LLC to make your contact information available to third parties for any marketing purposes, please contact us at 800-492-1267 or e-mail us at [email protected]. This publication is intended for health care professionals and providers only. The information contained in this publication, including text, graphics and images, is for informational purposes only and is not intended to be a substitute for professional medical advice. Bryn Mawr Communications LLC, via its Editors and the Publisher, accepts no responsibility for any injury or damage to persons or property occasioned through the implementation of any ideas or use of any product described herein. While great care is taken by the Publisher and Editors to ensure that all information is accurate, it is recommended that readers seek independent verification of advice on drug or other product usage, surgical techniques and clinical processes prior to their use. The opinions expressed in this publication are those of the authors and are not attributable to the sponsors, the publication or the Editorial Board. References made in articles may indicate uses of medical equipment or drugs at dosages, for periods of time and in combinations not included in the current prescribing information. Inclusion of advertising material in this publication, or in supplements thereof, does not constitute any representation or guarantee by Bryn Mawr Communications LLC of the quality of such products or of the claims made by the manufacturers. © 2020 Bryn Mawr Communications LLC. All Rights Reserved. Reproduction in whole or in part without permission is strictly prohibited.

4 RETINA TODAY | MARCH 2020

0320RT_Edboard/Staff.indd 4 3/6/20 12:41 PM Discover continuous calm in uveitis

YUTIQ® (fluocinolone acetonide intravitreal implant) 0.18 mg:

• Proven to reduce uveitis recurrence at 6 and 12 months1* [At 6 months–18% for YUTIQ and 79% for sham for study 1 and 22% for YUTIQ and 54% for sham for study 2 (P<.01). At 12 months–28% for YUTIQ and 86% for sham for study 1 and 33% for YUTIQ and 60% for sham for study 2.] • Innovative Durasert® technology is designed for a sustained release of fluocinolone acetonide for up to 36 months with just 1 YUTIQ implant2 For more information, visit J code: J7314 YUTIQ.com

*Study design: The efficacy ofUTIQ Y was assessed in 2 randomized, multicenter, sham-controlled, double-masked, phase 3 studies in adult patients (N=282) with noninfectious uveitis affecting the posterior segment of the eye. The primary endpoint in both studies was the proportion of patients who experienced recurrence of uveitis in the study eye within 6 months of follow-up; recurrence was also assessed at 12 months. Recurrence was defined as either deterioration in visual acuity, vitreous haze attributable to noninfectious uveitis, or the use of prohibited medications.1,3

INDICATIONS AND USAGE YUTIQ® (fluocinolone acetonide intravitreal implant) 0.18 mg is indicated for the treatment of chronic noninfectious uveitis affecting the posterior segment of the eye. IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS Ocular or Periocular Infections: YUTIQ is contraindicated in patients with active or suspected ocular or periocular infections including most viral disease of the cornea and conjunctiva including active epithelial herpes simplex keratitis (dendritic keratitis), vaccinia, varicella, mycobacterial infections and fungal diseases. Hypersensitivity: YUTIQ is contraindicated in patients with known hypersensitivity to any components of this product. WARNINGS AND PRECAUTIONS Intravitreal Injection-related Effects: Intravitreal injections, including those with YUTIQ, have been associated with endophthalmitis, eye inflammation, increased or decreased intraocular pressure, and choroidal or retinal detachments. Hypotony has been observed within 24 hours of injection and has resolved within 2 weeks. Patients should be monitored following the intravitreal injection. Steroid-related Effects: Use of corticosteroids including YUTIQ may produce posterior subcapsular catar acts, increased intraocular pressure and glaucoma. Use of corticosteroids may enhance the establishment of secondary ocular infections due to bacteria, fungi, or viruses. Corticosteroids are not recommended to be used in patients with a history of ocular herpes simplex because of the potential for reactivation of the viral infection. Risk of Implant Migration: Patients in whom the posterior capsule of the lens is absent or has a tear ar e at risk of implant migration into the anterior chamber. ADVERSE REACTIONS In controlled studies, the most common adverse reactions reported were cataract development and increases in intraocular pressure. References: 1. YUTIQ® (fluocinolone acetonide intravitreal implant) 0.18 mg full U.S. Prescribing Information. EyePoint Pharmaceuticals, Inc. October 2018. 2. EyePoint Pharmaceuticals Receives FDA Approval of YUTIQ™ (fluocinolone acetonide intravitreal implant) 0.18 mg. Global Newswire. https://www.globenewswire.com/news-release/2018/10/15/1621023/0/en /EyePoint-Pharmaceuticals-Receives-FDA-Approval-of-YUTIQ-fluocinolone-acetonide-intravitreal-implant-0-18-mg.html. Accessed February 7, 2020. 3. Data on file. Please see next page for Brief Summary of full Prescribing Information. ©2020, EyePoint Pharmaceuticals, Inc. All rights reserved. 480 Pleasant Street, Suite B300, Watertown, MA 02472 YUTIQ, Durasert, and the EyePoint logo are registered trademarks and 2/2020 the YUTIQ logo is a trademark of EyePoint Pharmaceuticals, Inc. US-YUT-2000020 YUTIQ™ (fluocinolone acetonide intravitreal implant) 0.18 mg, Table 1: Ocular Adverse Reactions Reported in ≥ 1% of Subject Eyes and for intravitreal injection Non-Ocular Adverse Reactions Reported in ≥ 2% of Patients Initial U.S. Approval: 1963 Ocular BRIEF SUMMARY: Please see package insert for full prescribing information. YUTIQ Sham Injection 1. INDICATIONS AND USAGE. YUTIQ™ (fluocinolone acetonide intravitreal implant) 0.18 mg is indicated for the treatment of chronic non-infectious uveitis ADVERSE REACTIONS (N=226 Eyes) (N=94 Eyes) affecting the posterior segment of the eye. n (%) n (%) 4. CONTRAINDICATIONS. 4.1. Ocular or Periocular Infections. YUTIQ is contra - Vitreous Hemorrhage 4 ( 2%) 0 indicated in patients with active or suspected ocular or periocular infections includ- Iridocyclitis 3 ( 1%) 7 ( 7%) ing most viral disease of the cornea and conjunctiva including active epithelial herpes simplex keratitis (dendritic keratitis), vaccinia, varicella, mycobacterial infec- Eye Inflammation 3 ( 1%) 2 ( 2%) tions and fungal diseases. 4.2. Hypersensitivity. YUTIQ is contraindicated in Choroiditis 3 ( 1%) 1 ( 1%) patients with known hypersensitivity to any components of this product. Eye Irritation 3 ( 1%) 1 ( 1%) 5. WARNINGS AND PRECAUTIONS. 5.1. Intravitreal Injection-related Effects. Intravitreal injections, including those with YUTIQ, have been associated with Visual Field Defect 3 ( 1%) 0 endophthalmitis, eye inflammation, increased or decreased intraocular pressure, Lacrimation Increased 3 ( 1%) 0 and choroidal or retinal detachments. Hypotony has been observed within 24 hours of injection and has resolved within 2 weeks. Patients should be monitored follow- Non-ocular ing the intravitreal injection [see Patient Counseling Information (17) in the full YUTIQ Sham Injection prescribing information]. 5.2. Steroid-related Effects. Use of corticosteroids ADVERSE REACTIONS (N=214 Patients) (N=94 Patients) including YUTIQ may produce posterior subcapsular cataracts, increased intraocu- n (%) n (%) lar pressure and glaucoma. Use of cortico steroids may enhance the establishment of secondary ocular infections due to bacteria, fungi, or viruses. Corticosteroids are Nasopharyngitis 10 ( 5%) 5 ( 5%) not recommended to be used in patients with a history of ocular herpes simplex Hypertension 6 ( 3%) 1 ( 1%) because of the potential for reactivation of the viral infection. 5.3. Risk of Implant Migration. Patients in whom the posterior capsule of the lens is absent or has a Arthralgia 5 ( 2%) 1 ( 1%) tear are at risk of implant migration into the anterior chamber. 1. Includes cataract, cataract subcapsular and lenticular opacities in study eyes 6. ADVERSE REACTIONS. 6.1. Clinical Studies Experience. Because clinical trials that were phakic at baseline. 113 of the 226 YUTIQ study eyes were phakic at are conducted under widely varying conditions, adverse reaction rates observed in baseline; 56 of 94 sham-controlled study eyes were phakic at baseline. the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. Adverse reac- Table 2: Summary of Elevated IOP Related Adverse Reactions tions associated with ophthalmic steroids including YUTIQ include cataract forma- YUTIQ Sham tion and subsequent cataract surgery, elevated intraocular pressure, which may be ADVERSE REACTIONS (N=226 Eyes) (N=94 Eyes) associated with optic nerve damage, visual acuity and field defects, secondary ocu- n (%) n (%) lar infection from pathogens including herpes simplex, and perforation of the globe IOP elevation ≥ 10 mmHg where there is thinning of the cornea or sclera. Studies 1 and 2 were multicenter, 50 (22%) 11 (12%) randomized, sham injection-controlled, masked trials in which patients with non- from Baseline infectious uveitis affecting the posterior segment of the eye were treated once with IOP elevation > 30 mmHg 28 (12%) 3 (3%) either YUTIQ or sham injection, and then received standard care for the duration of the study. Study 3 was a multicenter, randomized, masked trial in which patients Any IOP-lowering medication 98 (43%) 39 (41%) with non-infectious uveitis affecting the posterior segment of the eye were all Any surgical intervention treated once with YUTIQ, administered by one of two different applicators, and then for elevated IOP 5 (2%) 2 (2%) received standard care for the duration of the study. Table 1 summarizes data available from studies 1, 2 and 3 through 12 months for study eyes treated with YUTIQ Figure 1: Mean IOP During the Studies (n=226) or sham injection (n=94). The most common ocular (study eye) and non- ocular adverse reactions are shown in Table 1 and Table 2. Table 1: Ocular Adverse Reactions Reported in ≥ 1% of Subject Eyes and Non-Ocular Adverse Reactions Reported in ≥ 2% of Patients Ocular YUTIQ Sham Injection ADVERSE REACTIONS (N=226 Eyes) (N=94 Eyes) n (%) n (%) Cataract1 63/113 (56%) 13/56 (23%) Visual Acuity Reduced 33 ( 15%) 11 (12%) Macular Edema 25 ( 11%) 33 (35%) Uveitis 22 ( 10%) 33 (35%) Conjunctival Hemorrhage 17 ( 8%) 5 ( 5%) Eye Pain 17 ( 8%) 12 (13%) 8. USE IN SPECIFIC POPULATIONS. 8.1 Pregnancy. Risk Summary. Adequate and well-controlled studies with YUTIQ have not been conducted in pregnant women to Hypotony Of Eye 16 ( 7%) 1 ( 1%) inform drug associated risk. Animal reproduction studies have not been conducted Anterior Chamber Inflammation 12 ( 5%) 6 ( 6%) with YUTIQ. It is not known whether YUTIQ can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Corticosteroids have been Dry Eye 10 ( 4%) 3 ( 3%) shown to be teratogenic in laboratory animals when administered systemically at Vitreous Opacities 9 ( 4%) 8 ( 9%) relatively low dosage levels. YUTIQ should be given to a pregnant woman only if the Conjunctivitis 9 ( 4%) 5 ( 5%) potential benefit justifies the potential risk to the fetus. All pregnancies have a risk of birth defect, loss, or other adverse outcomes. In the United States general population, Posterior Capsule Opacification 8 ( 4%) 3 ( 3%) the estimated background risk of major birth defects and miscarriage in clinically rec- Ocular Hyperemia 8 ( 4%) 7 ( 7%) ognized pregnancies is 2% to 4% and 15% to 20%, respectively. 8.2 Lactation. Risk Summary. Systemically administered corticosteroids are present in human milk and Vitreous Haze 7 ( 3%) 4 ( 4%) can suppress growth, interfere with endogenous corticosteroid production. Clinical or Foreign Body Sensation In Eyes 7 ( 3%) 2 ( 2%) nonclinical lactation studies have not been conducted with YUTIQ. It is not known Vitritis 6 ( 3%) 8 ( 9%) whether intravitreal treatment with YUTIQ could result in sufficient systemic absorption to produce detectable quantities of fluocinolone acetonide in human milk, or Vitreous Floaters 6 ( 3%) 5 ( 5%) affect breastfed infants or milk production. The developmental and health benefits of Eye Pruritus 6 ( 3%) 5 ( 5%) breastfeeding should be considered, along with the mother’s clinical need for YUTIQ and any potential adverse effects on the breastfed child from YUTIQ. 8.4 Pediatric Conjunctival Hyperemia 5 ( 2%) 2 ( 2%) Use. Safety and effectiveness of YUTIQ in pediatric patients have not been estab- Ocular Discomfort 5 ( 2%) 1 ( 1%) lished. 8.5 Geriatric Use. No overall differences in safety or effectiveness have been Macular Fibrosis 5 ( 2%) 2 ( 2%) observed between elderly and younger patients.

Glaucoma 4 ( 2%) 1 ( 1%) Manufactured by: Photopsia 4 ( 2%) 2 ( 2%) EyePoint Pharmaceuticals US, Inc., 480 Pleasant Street, Watertown, MA 02472 USA (continued) Patented. MEDICAL EDITORS’ PAGE s THE PATHS TO SUCCESS

I believe in using our voices and the circle of MD; Nancy M. Holekamp, MD; Shlomit Schaal, MD, PhD; and influence to empower others, both men and Carol L. Shields, MD, offered their observations about the field’s women, to create positive changes. What challenges. Dr. Fekrat’s astute observation—“Medical schools better way to do this than to work with are now more than 50% female, and, as a result, more women other exceptional physicians, learn and share will choose ophthalmology and thus retina”—reminds us exact- their wisdom on issues facing retina special- ly why this issue of Retina Today is so timely. ists—especially women—and help guide others to success? In Dr. Shields contributed to another cover article, this time addition, 2020 is especially meaningful for women because it with her husband, Jerry Shields, MD, to discuss their careers, marks the 100th anniversary of women’s suffrage in the United their marriage, and the solutions they have found along the way. States. Therefore, I was honored to accept the invitation from Not only is this profile of a retinal couple an integral component Retina Today’s Chief Medical Editor Allen C. Ho, MD, and of this issue’s focus on success inside and outside the clinic, but Associate Medical Editor Robert L. Avery, MD, to serve as Guest it also serves as a record of the lives of two people whose influ- Editor for the “Women in Retina” issue. ence on our field cannot be measured. Never short of ideas (I have constant a flood of ideas like a It has long been observed that the proportion of women Times Square ticker tape!), my head was bursting with potential on the podium is not reflective of the population of retina topics and authors, and choosing which topics to cover and specialists. Tala Al-Khaled, BA, and Ann-Marie Lobo-Chan, MD, with whom to collaborate was more difficult than I imagined; address this topic in “Pathway to the Podium,” a pearls piece there were numerous facets of issues to consider and many that aspiring women and men in retina may find useful when qualified people to expertly address them. “Women in Retina” in navigating the meeting landscape. A discussion on mentorship the modern era is a complex topic that will continue to evolve, with Audina M. Berrocal, MD; Zelia M. Correa, MD , PhD; and and I tried my best to balance complexity with accessibility and Adrienne W. Scott, MD, yields useful information for future applicability. We know that the definition of success differs for retina leaders who are seeking a mentor or wishing to become everyone. Nevertheless, we present here paths that these physi- one. Without mentors, as they point out, navigating the road to cians have chosen, experienced, and are advising, to offer some success would be far more difficult. examples of success in the field of retina for readers to consider. Julia A. Haller, MD, and Joan W. Miller, MD, sat down with me The authors of this issue aced the difficult task of explaining for a roundtable discussion about their pathways to leadership the reality for women in retina—describing the barriers and and their “views from the top” on women in retina as depart- opportunities they encounter and foresee, and proposing solu- ment leaders. Their perspectives on the price and benefits of tions to the problems they’ve observed—in order for us to con- departmental leadership serve as a useful glimpse inside the tinue to pave the path to success. I thank them for sharing their minds of two of retina’s important leaders. insights and life experiences with thoughtfulness and honesty. As I worked on this issue, I was reminded once again that I believe many of their comments are not uniquely applicable the best ally we have as we pave the road to success in any only to women in retina, but rather can be applied to other endeavor is each other. The contributors to this issue worked fields in which women are still a minority and to both men and hard to make it a success. I know you’ll find these leading retina women in their early careers. specialists’ experience and knowledge useful. I thank them and Avni Finn, MD, MBA, and Caroline Baumal, MD, interviewed the Retina Today editorial staff from the bottom of my heart. a number of women leaders for their piece “Closing the Enjoy the issue. Cheers! n Gender Gap in Retina.” María H. Berrocal, MD; Sharon Fekrat, — Judy E. Kim, MD, Guest Editor

UPDATE ON A CASE FROM A PAST ISSUE After the January/February issue went to press, Brian C. Joondeph, MD, MPS, informed the editorial staff that the patient profiled in the cover series article “An Elusive Macular Hole Closed by Eye Drops Alone” returned to his office for follow-up. As of February 2020, the patient’s VA was 20/30 and further fluid reduction had been demonstrated. To read this case, visit bit.ly/Joondeph0320.

MARCH 2020 | RETINA TODAY 7

0320rt_MedEd.indd 7 3/10/20 10:26 AM RETINA WOMEN TABLE OF CONTENTS

Cover image credit: ©iStockphoto.com MARCH 2020 • VOLUME 15, NO. 1 FEATURES 31 Profiles in Retina: Drs. Carol and Jerry Shields 39 Departmental Leadership 34 Hear It From the Attendings: Mentorship in Retina Interview by Judy E. Kim, MD Interviews with Audina M. Berrocal, MD; Zelia M. Correa, MD, PhD; With Julia A. Haller, MD; and Joan W. Miller, MD and Adrienne W. Scott, MD 43 The Pathway to the Podium 36 Closing the Gender Gap in Retina By Tala Al-Khaled, BA; and Ann-Marie Lobo-Chan, MD By Avni Finn MD, MBA; and Caroline Baumal, MD With Contributions From María H. Berrocal, MD; Sharon Fekrat, MD; Nancy M. Holekamp, MD; Shlomit Schaal, MD, PhD; and Carol L. Shields, MD

DEPARTMENTS UP FRONT FELLOWS’ FOCUS 7 Medical Editors’ Page 20 Fellows’ Focus Journal Club By Judy E. Kim, MD 9 Retina News SURGICAL PEARLS 26 Pearls for the Yamane Technique By Brandon D. Ayres, MD; Zaina Al-Mohtaseb, MD; VISUALLY SPEAKING Steven G. Safran, MD; and Manjool Shah, MD 11 Hypotony Maculopathy After Phacoemulsification By Wee-Min Teh, MD, MMED; and Wei-Chi Wu, MD, PhD SPECIAL REPORT 47 Literature Review: Predictors of Neovascular MEDICAL RETINA Glaucoma in Central Retinal Vein Occlusion 12 A Primer on Pentosan Polysulfate Sodium Maculopathy By Cissy Yang, MD; and Noga Harizman, MD By Meera S. Ramakrishnan, MD; Amar Patel, MD; Ronald Melles, MD; and Robin A. Vora, MD IN THE BACK 22 Distinguishing VKH From CSCR By Sneha Padidam, MD; Brian K. Do, MD; Jordana G. Fein, MD; 49 Ad Index and Heeral Shah, MD 50 5Q With Krik Packo, MD, FACS

GLOBAL PERSPECTIVES 18 Up Against Global Poverty By Zaiba Malik, MD

8 RETINA TODAY | MARCH 2020

0320RT_TOC_US.indd 8 3/9/20 12:21 PM MARCH 2020 RT NEWS VOL. 15, NO. 2 | RETINATODAY.COM NOVARTIS RESPONDS TO ASRS NOTE ON SAFETY CONCERNS FOR BROLUCIZUMAB; DRUG RECEIVES EU APPROVAL

Novartis is launching an internal and external review of s WATCH IT NOW new information that raises serious safety concerns over its wet age-related macular degeneration (AMD) drug brolucizumab-dbll (Beovu), the company confirmed to Eyewire News in February. Separately, the company announced that the drug had received marketing approval from regulators in the European Union (EU). On February 23, the American Society of Retina Specialists (ASRS) shared a note with its membership stating that, since Beovu was approved by the US FDA in October 2019, ASRS has received reports of 14 cases of vasculitis associated with the drug, of which 11 were designated by the reporting provider as occlusive retinal vasculitis, a vision-threatening bit.ly/Eyewire0320 inflammatory eye condition. physicians should follow the guidance in the prescribing In a statement sent to Eyewire News, Novartis said it is information that patients with active ocular inflammation aware of recently reported adverse events following treat- should not be injected with brolucizumab. The product ment with brolucizumab and is evaluating the cases. information for brolucizumab in the US lists a 4% rate of “Novartis stands behind the safety and efficacy of [broluci- intraocular inflammation and a 1% rate of retinal artery zumab]. In addition to our own internal assessment, we have occlusion as adverse events reported in the HAWK and engaged an external safety review committee to further eval- HARRIER clinical trials of the drug. uate these post-marketing cases. We will continue to share In a separate development, Novartis in February received details as they become available,” the Novartis statement approval for brolucizumab from the European Medicines said. “The FDA is aware of our ongoing review and we’re in Agency, making it the first anti-VEGF agent approved in the process of informing other health authorities. Our clini- the EU to demonstrate superior resolution of retinal fluid cal development and pharmacovigilance teams are working (intraretinal fluid/subretinal fluid) compared with aflibercept with healthcare professionals to quickly obtain and evaluate (Eylea, Regeneron). all available information in order to classify these events and The EU approval was based on findings from the phase 3 identify potential risk factors.” HAWK and HARRIER clinical trials, in which brolucizumab An estimated 46,000 injections of brolucizumab have been met the primary endpoints, demonstrating gains in BCVA administered in the United States as of February 21, 2020, that were noninferior to aflibercept at year 1 (week 48). according to Novartis. Vision gains at year 1 were maintained at year 2. The company noted that brolucizumab is contraindicated The approval is applicable in all 27 EU member states, as well for patients with active intraocular inflammation, and that as the United Kingdom, Iceland, Norway, and Liechtenstein.

RP UPDATE: PHASE 1/2A TRIAL FOR STEM date for retinitis pigmentosa (RP) will be expanded based on interim efficacy data in an ongoing phase 1/2a study, CELL THERAPY WILL EXPAND; according to the therapy’s developer, the ReNeuron Group. GENE THERAPY FOR XLRP SHOWED Three patients in the study successfully received treatment in one eye. Mean difference in VA improvement SAFETY IN PHASE 1 STUDY between treated eyes and untreated eyes was +7.3 letters at A study evaluating the safety and efficacy of a human 12 months, the company stated in a February press release. retinal progenitor cell (hRPC) stem cell therapy candi- The company has submitted a protocol amendment to

MARCH 2020 | RETINA TODAY 9

0320rt_News.indd 9 3/6/20 12:39 PM 3/6/20 12:39 PM thera-

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on X-linked retinitis pigmentosa caused by mutations in RPGR [published online ahead of print February 24, 2020]. on X-linked retinitis pigmentosa caused

MARKET 2025 BY BILLION $2 NEARLY REACH TO XLRP is caused by a mutation on the gene the on mutation a by caused is XLRP The retinal surgical device market is expected to total more than $1.5 billion total more than $1.5 billion to market is expected surgical device The retinal be performed glob- vitrectomies will estimated that 1.84 million Market Scope for that than times greater 10 to 15 is typically The per-procedure revenue market, surgical device in the global retinal 55 companies compete More than trial

uating the safety of gene therapy for XLRP in 18 patients, patients, 18 in XLRP for therapy gene of safety the uating observed. were improvements field visual some 1. Cehajic-Kapetanovic J, py Nat Med. >> MARKET DEVICE SURGICAL RETINAL SCOPE: blocks production of a protein necessary for photoreceptorfor necessary protein a of production blocks function. cell XLRP. of casesall of in 2020, with revenue rising to nearly $2 billion in 2025, according to the health according to the health in 2020, with revenue rising to nearly $2 billion in 2025, care data firm Market Scope. ally in 2020. for a vitrectomy. Still, cataract surgery due to the numerous products required surgeries cataract the number of vitrectomies is far lower than the 30 million performed in 2020. expected to be Eight companies— but most specialize in only one or two product categories. (DORC), Geuder, Research Center Alcon, Bausch + Lomb, Dutch Ophthalmic for 82% of Beaver-Visitec International (BVI), Nidek, Oertli, and Hoya—account in this market. global revenue 1

| MARCH 2020| MARCH Mina Chung, MD, died in February. She was 51. was She February. in died MD, Chung, Mina Eye Flaum Center Medical Rochester of University the at ophthalmology of professor associate an was Chung Dr.

Institute and a faculty member at the University of Rochester’s Center for Visual Science. She completed her fel- her completed She Science. Visual for Center Rochester’s of University the at member faculty a and Institute University USC the at residency and Medicine of College Iowa of University the at surgery vitreoretinal in lowship Yale. at degree medical and studies undergraduate her completed She resident. chief was she where Hospital, The Valeda System (LumiThera), a photobiomodulation platform being com- The Valeda System (LumiThera), a the Valeda System in the commercialize Mark to LumiThera received the CE RETINOPATHY WILL EXPAND WILL RETINOPATHY STUDY REMEMBERING MINA CHUNG, MD In a 6-month, phase 1/2 dose-escalation clinical trial eval- trial clinical dose-escalation 1/2 phase 6-month, a In In an unrelated study also in patients with RP, no signifi- no RP, with patients in also study unrelated an In > DIABETIC FOR THERAPY LIGHT OF mercialized in Europe for the treatment of dry AMD, will also be investigated for will also be investigated for treatment of dry AMD, in Europe for the mercialized maker. (DR), according to its treating diabetic retinopathy use in II study AMD; the LIGHTSIDE including dry the treatment of ocular diseases EU for of for the treatment is evaluating the safety and efficacy of the Valeda System in the United States. Preclinicaldry AMD that the and clinical work has shown diabetic edema, the benefits in treating system also has potential light therapy company stated in a press release. NEWS BRIEFS at Eyewire.news/interests/retina. latest retina news Eyewire’s Read cant safety concerns were observed after application of the the of application after observed were concerns safety cant now Therapeutics; (NightStar AAV8-RPGR therapy gene (XLRP). RP X-linked of treatment the for Biogen) the FDA to expand the phase 1/2a study to treat up to a to up treat to study 1/2a phase the expand to FDA the study the of segment 2a phase the in patients nine further cells million 1 of dose a cells; hRPC million 2 of dosage a at far. thus study the in used been has RETINA TODAY

10 s RT NEWS 0320rt_News.indd 10 VISUALLY SPEAKING s HYPOTONY MACULOPATHY AFTER PHACOEMULSIFICATION A late complication after cataract surgery was resolved with treatment.

BY WEE-MIN TEH, MD, MMED; AND WEI-CHI WU, MD, PHD

56-year-old man noted no visual improvement in his left eye (OS) 2 weeks after uneventful phacoemulsification surgery. He was a high myope (-10.00 D OS) with a history that included retinal detachment surgery in the same eye 1 year before the cataract oper- Aation was performed. BCVA before the cataract surgery was 20/100 OS (top left and top right images). Examination revealed VA of 20/250 OS and IOP of 5 mm Hg. The cornea was clear, and the IOL was posi- tioned well in the capsular bag without tilt or decentration. Dilated fundus examination showed a slightly blurred disc margin, dilated and tortuous retinal vessels, and multiple chorioretinal folds (bottom left image). Spectral-domain OCT (Spectralis, Heidelberg) demonstrated numerous characteristic undulations of the choriocapillaris and retina 1. Gass JD. Hypotony maculopathy. In: Bellows JG, ed. Contemporary ophthalmology honoring Sir Stewart Duke-Elder. with retinal thickening. There was no serous detachment. Baltimore: Williams & Wilkins; 1972:343-366. Flattening of the posterior sclera was also seen (bottom 2. Pederson JE. Ocular hypotony. In: Ritch R, Krupin T, Shields MB, eds. The Glaucomas. 2nd ed. Mosby: St. Louis; 1996:385- 395. right image). 3. Schubert HD. Postsurgical hypotony: relationship to fistulization, inflammation, chorioretinal lesions, and the vitreous. On further inspection of the corneal wound, wound leak Surv Ophthalmol. 1996;41:97-125. 4. Costa VP, Arcieri ES. Hypotony maculopathy. Acta Ophthalmologica Scandinavica. 2007;85(6):586-597. was suspected, and Seidel test was positive. A therapeutic 5. Stamper RL, McMenemy MG, Lieberman MF. Hypotonous maculopathy after trabeculectomy with subconjunctival bandage contact lens was applied. Over the next 6 months, 5-fluorouracil. Am J Ophthalmol. 1992;114:544-553. the patient gradually improved, with IOP at 17 mm Hg and BCVA restored to 20/100 at 6 months. The term hypotony maculopathy was coined by Gass in WEE-MIN TEH, MD, MMED 1972.1 It can be defined statistically (IOP < 6.5 mm Hg, or n Vitreoretina Fellow, Department of Ophthalmology, Chang Gung Memorial three standard deviations below mean IOP) or clinically Hospital, Taoyuan, Taiwan (IOP low enough to cause visual loss).2,3 Common causes of n [email protected] postoperative hypotony include wound leak, overfiltration, n Financial disclosure: None iridocyclitis, retinal detachment, cyclodialysis, and mito- mycin C toxicity of the ciliary body.4 Risk factors include WEI-CHI WU, MD, PHD younger age, myopia, and male sex.5 n Chairman, Department of Ophthalmology, Chang Gung Memorial Hospital, Successful treatment of hypotony maculopathy depends Taoyuan, Taiwan n on timely and correct identification of its cause. Visual Professor, College of Medicine, Chang Gung University, Taoyuan, Taiwan n [email protected] recovery is variable depending on the timing of interven- n Financial disclosure: None tion. The treatment goal in this patient was aimed at nor- malizing IOP to reverse the inward bowing of the sclera To share an image, contact Manish Nagpal, MS, DO, FRCS(Edin), at and resolve the chorioretinal folds. n [email protected]. Note: Images should be 400 dpi or higher and at least 10 inches wide.

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In these studies, affected patientsaffected studies, these In 6-8 Subsequent case series and cohortand series case Subsequent studies demonstrated a pattern of PPSof pattern a demonstrated studies fea- clinical and characteristics exposure tures. tended to be white women of median agemedian of women white be to tended Symptomsyears). 37-79 (range years 60 blurredwere reported commonly most PPS Annual exams chronic PPS exposure. Patients exposed developing maculopathy. 1986. since by patients and hasbeenused cystitis to treatinterstitial is used patients whohavehad recommended for with imagingare riskof (PPS) haveincreased to pentosanpolysulfatesodium AT A GLANCE s s s MISDIAGNOSED WITH AGE-RELATED MACULAR MACULAR MISDIAGNOSED WITH AGE-RELATED DYSTROPHIES, WHICH MAY DEGENERATION OR RETINAL MANY PATIENTS WITH PPS EXPOSURE MAY HAVE BEEN EXPOSURE MAY HAVE BEEN MANY PATIENTS WITH PPS IRREVERSIBLE VISION LOSS ... . HAVE LED TO PREVENTABLE, and near-infrared reflectance (NIR) imag- (NIR) reflectance near-infrared and geneticunderwent patients These ing. hereditaryfor evaluation and screening mitochondrialand dystrophies retinal negative.were which of all cytopathies, wasPPS to exposure and IC of Diagnosis patients. all in denominator common the

5 PPS is the only the is PPS 1,2 3,4

ounting evidence links chroniclinks evidence ounting poly- pentosan to exposure Elmiron, (PPS; sodium sulfate withPharmaceuticals) Janssen novela of development the

| MARCH 2020| MARCH

The association of PPS with macu- with PPS of association The lopathy was first reported in 2018 by2018 in reported first was lopathy seriescase single-center a in al et Pearce medianwomen, white (six patients six of years) 37-62 range age years, 60 age paracentral reading, difficulty reporting adaptationdark prolonged and scotomas, acuity. visual preserved relatively despite pigmentary maculopathy. PPS is a semi- a is PPS maculopathy. pigmentary macromoleculeheparin-like synthetic a(IC), cystitis interstitial treat to used syndromepain bladder incurable chronic, pelvicor bladder relentless as manifesting Itdyspareunia. and incontinence, pain, thanmore affects IC that estimated is States,United the in individuals million 1 women. predominantly oral option of the two US FDA–approvedUS two the of option oral use compassionate Since IC. for therapies 1996,in approval regulatory and 1986 in andurologists by prescribed been has PPS thousandsof hundreds to gynecologists IC. with patients of Examination revealed paracentral retinalparacentral revealed Examination hyperpigmen- (RPE) epithelium pigment vitelliform- subtle by surrounded tation appear- irregular highly with deposits like (FAF)autofluorescence fundus on ances Evidence of a new maculopathy is emerging in the clinic. is emerging in Evidence of a new maculopathy PATEL, MD; RONALD MELLES, MD; AND ROBIN A. VORA, MD BY MEERA S. RAMAKRISHNAN, MD; AMAR POLYSULFATE SODIUM MACULOPATHY SODIUM POLYSULFATE A PRIMER ON PENTOSAN PENTOSAN ON PRIMER A M RETINA TODAY

12 s MEDICAL RETINA 0320rt_Medical_Vora.indd 12 MEDICAL RETINA s

1A 1B 2A 2B

3A 3B

Figure. Clinical characteristics of PPS maculopathy are demonstrated here, with bilateral symmetric pathology centered on the fovea. Hyperpigmented spots, pale yellow-orange deposits, and/or patchy RPE atrophy are observed on color fundus photography (1 A, B). FAF imaging reveals a dense array of hyper- and hypoautofluorescent spots in the posterior pole that tend to be much more striking than relatively subtle fundus examination findings (2 A, B). OCT imaging demonstrates focal thickening or elevation of the RPE layer with associated hyperreflectance on NIR imaging (3 A, B).

vision, prolonged dark adaptation, and 14 patients with definite clinical char- fied.11-13 Pathogenesis remains unclear. metamorphopsia. The most common acteristics of PPS maculopathy had Based on the prolonged exposure presenting diagnoses for these cases exposure to PPS.7 No other IC therapy time and cumulative dose, the mech- were macular or pattern dystrophy demonstrated a significant association anism is potentially related to toxic and age-related macular degeneration with maculopathy. Patients with mac- PPS metabolites accumulating in the (Figure). ulopathy reported duration of PPS RPE, thereby disrupting processing of Longitudinal follow-up suggests a intake ranging 3 to 22 years (median photoreceptor outer segments or the progressive maculopathy that spreads 16-17 years).5-9 A retrospective cohort interphotoreceptor matrix.6 centrifugally. Macular pigment clumps study by Jain et al involving a large These findings represent a major appear to be a sign of early disease and US claims database found that, by patient safety issue. Many patients may ultimately progress to RPE atro- 7 years, PPS users had significantly with PPS exposure may have been phy in later stages. Visual acuity tends increased odds (odds ratio = 1.41) of misdiagnosed with age-related to be preserved, except in cases of developing maculopathy compared macular degeneration or retinal center-involving RPE atrophy and cys- with matched controls.10 dystrophies, which may have led to toid macular edema.6,8 To date, there In a large cohort of patients, Vora preventable, irreversible vision loss or is also a single case report of choroidal et al reported definite signs of PPS unwarranted genetic counseling. It neovascularization associated with PPS maculopathy in 11% of patients tak- remains unclear whether discontinu- maculopathy that resulted in vision ing 500 to 999 g PPS daily, and in 42% ing PPS will halt or alter the course of loss.9 Full-field electroretinography of those taking more than 1,500 g PPS maculopathy. For now, evidence sug- demonstrates variable mild attenu- daily.8 Patients with maculopathy had gests that the smallest effective dose ation of response amplitudes that is ingested an average of 14,067 capsules should be used for the least amount consistent with macular disease, and compared with 10,561 capsules in of time. multifocal electroretinography reveals those without maculopathy.8 It may be advisable to perform mild to severe attenuation. annual exams with imaging (ie, fun- IMPLICATIONS dus photography, FAF, NIR, and OCT) RELATIONSHIP TO PPS EXPOSURE It is unusual for a potential drug of patients with chronic PPS expo- In a cohort of 219 patients with IC toxicity to manifest decades after sure. Discussion with urology and and PPS exposure, the odds ratio for initial FDA approval. PPS safety was gynecology colleagues is ongoing to developing an unspecified pigmen- not a major issue in clinical trials, and raise awareness of PPS toxicity; at the tary maculopathy was 11.25, and all no ocular adverse events were identi- time of publication, the FDA has not

MARCH 2020 | RETINA TODAY 13

0320rt_Medical_Vora.indd 13 3/6/20 12:39 PM ECADE D O F A 2009-2019 1

E X E P ERIEN C

To improve vision in DME,* macular edema following RVO,† ® or noninfectious posterior segment uveitis CALL OZURDEX

• Achieves clinically signifi cant 3-line gains IMPORTANT SAFETY INFORMATION Adverse Reactions OZURDEX® (dexamethasone intravitreal implant) group and 20 in BCVA 2,‡ Contraindications Diabetic Macular Edema for Sham) of the studies. Ocular or Periocular Infections: OZURDEX® (dexamethasone Ocular adverse reactions reported by greater than or equal to 1% of intravitreal implant) is contraindicated in patients with active or patients in the two combined 3-year clinical trials following injection Retinal Vein Occlusion and Posterior Segment Uveitis • ® Adverse reactions reported by greater than 2% of patients in Signifi cantly reduces vitreous haze vs sham suspected ocular or periocular infections including most viral diseases of OZURDEX (dexamethasone intravitreal implant) for diabetic ® in noninfectious posterior segment uveitis2 of the cornea and conjunctiva, including active epithelial herpes macular edema include: cataract (68%), conjunctival hemorrhage the fi rst 6 months following injection of OZURDEX for retinal simplex keratitis (dendritic keratitis), vaccinia, varicella, mycobacterial (23%), visual acuity reduced (9%), conjunctivitis (6%), vitreous vein occlusion and posterior segment uveitis include: intraocular infections, and fungal diseases. fl oaters (5%), conjunctival edema (5%), dry eye (5%), vitreous pressure increased (25%), conjunctival hemorrhage (22%), eye • Suppresses infl ammation by inhibiting multiple pain (8%), conjunctival hyperemia (7%), ocular hypertension ® detachment (4%), vitreous opacities (3%), retinal aneurysm (3%), infl ammatory cytokines2 Glaucoma: OZURDEX is contraindicated in patients with glaucoma, foreign body sensation (2%), corneal erosion (2%), keratitis (2%), (5%), cataract (5%), vitreous detachment (2%), and headache who have cup to disc ratios of greater than 0.8. anterior chamber infl ammation (2%), retinal tear (2%), eyelid ptosis (4%). † ® * Diabetic macular edema. Retinal vein occlusion: branch retinal vein occlusion ® (2%). Non-ocular adverse reactions reported by greater than or equal Increased IOP with OZURDEX peaked at approximately week ‡ Torn or Ruptured Posterior Lens Capsule: OZURDEX is (BRVO) or central retinal vein occlusion (CRVO). Best-corrected visual acuity. contraindicated in patients whose posterior lens capsule is torn or to 5% of patients include: hypertension (13%) and bronchitis (5%). 8. During the initial treatment period, 1% (3/421) of the patients who received OZURDEX® required surgical procedures for ruptured because of the risk of migration into the anterior chamber. Increased Intraocular Pressure: IOP elevation greater than or Laser posterior capsulotomy in pseudophakic patients is not a management of elevated IOP. Indications and Usage ® equal to 10 mm Hg from baseline at any visit was seen in 28% Diabetic Macular Edema contraindication for OZURDEX use. of OZURDEX® patients versus 4% of sham patients. 42% of the Please see Brief Summary of full Prescribing Information ® ® on adjacent page. OZURDEX (dexamethasone intravitreal implant) is a corticosteroid Hypersensitivity: OZURDEX® is contraindicated in patients with patients who received OZURDEX were subsequently treated indicated for the treatment of diabetic macular edema. known hypersensitivity to any components of this product. with IOP-lowering medications during the study versus 10% of sham patients. References: 1. Data on fi le, Allergan. 2. OZURDEX® Prescribing Information. Retinal Vein Occlusion Warnings and Precautions ® The increase in mean IOP was seen with each treatment cycle, OZURDEX is a corticosteroid indicated for the treatment of macular Intravitreal Injection-related Effects: Intravitreal injections, edema following branch retinal vein occlusion (BRVO) or central ® and the mean IOP generally returned to baseline between including those with OZURDEX, have been associated with treatment cycles (at the end of the 6-month period). retinal vein occlusion (CRVO). endophthalmitis, eye infl ammation, increased intraocular pressure, Posterior Segment Uveitis and retinal detachments. Patients should be monitored regularly Cataracts and Cataract Surgery: The incidence of cataract ® following the injection. development in patients who had a phakic study eye was higher OZURDEX is indicated for the treatment of noninfectious uveitis ® affecting the posterior segment of the eye. Steroid-related Effects: Use of corticosteroids including OZURDEX® in the OZURDEX group (68%) compared with Sham (21%). The may produce posterior subcapsular cataracts, increased intraocular median time of cataract being reported as an adverse event was Dosage and Administration ® pressure, glaucoma, and may enhance the establishment of approximately 15 months in the OZURDEX group and 12 months in FOR OPHTHALMIC INTRAVITREAL INJECTION. The intravitreal ® secondary ocular infections due to bacteria, fungi, or viruses. the Sham group. Among these patients, 61% of OZURDEX subjects injection procedure should be carried out under controlled versus 8% of sham-controlled subjects underwent cataract surgery, aseptic conditions. Following the intravitreal injection, patients Corticosteroids are not recommended to be used in patients with a generally between Month 18 and Month 39 (Median Month 21 for should be monitored for elevation in intraocular pressure and history of ocular herpes simplex because of the potential for reactivation for endophthalmitis. Patients should be instructed to report any of the viral infection. symptoms suggestive of endophthalmitis without delay. © 2019 Allergan. All rights reserved. All trademarks are the property of their respective owners. Ozurdex.com OZU120550 02/19 183140

allergan_ad.indd 14 3/9/20 2:29 PM

Retinal Today - 4/Color Spread Live = 17.25” x 10” Trim = 18” x 10.75”--each page - ruled to 8" x 10.875" Bleed = 18.5" x 11.25" DVC Work Order # 29049 REF #28200 ECADE D O F A 2009-2019 1

E X E P ERIEN C

To improve vision in DME,* macular edema following RVO,† ® or noninfectious posterior segment uveitis CALL OZURDEX

allergan_ad.indd 15 3/9/20 2:29 PM

Retinal Today - 4/Color Spread Live = 17.25” x 10” Trim = 18” x 10.75”--each page - ruled to 8" x 10.875" Bleed = 18.5" x 11.25" DVC Work Order # 29049 REF #28200 ® ® Following a second injection of OZURDEX (dexamethasone intravitreal implant) in cases where a second injection was indicated, the overall incidence of cataracts OZURDEX was higher after 1 year. (dexamethasone intravitreal implant) 0.7 mg In a 2-year observational study, among patients who received >2 injections, the

® most frequent adverse reaction was cataract 54% (n=96 out of 178 phakic eyes at Brief Summary—Please see the OZURDEX package insert for full baseline). Other frequent adverse reactions from the 283 treated eyes, regardless of Prescribing Information. lens status at baseline, were increased IOP 24% (n=68) and vitreous hemorrhage INDICATIONS AND USAGE 6.0% (n=17). Retinal Vein Occlusion: OZURDEX® (dexamethasone intravitreal implant) is a Diabetic Macular Edema corticosteroid indicated for the treatment of macular edema following branch retinal The following information is based on the combined clinical trial results from 2 vein occlusion (BRVO) or central retinal vein occlusion (CRVO). randomized, 3-year, sham-controlled studies in patients with diabetic macular Posterior Segment Uveitis: OZURDEX® is indicated for the treatment of non-infectious edema. Discontinuation rates due to the adverse reactions listed in the table below uveitis affecting the posterior segment of the eye. were 3% in the OZURDEX® group and 1% in the Sham group. The most common Diabetic Macular Edema ocular (study eye) and non-ocular adverse reactions are as follows: OZURDEX® is indicated for the treatment of diabetic macular edema. Ocular Adverse Reactions Reported by ≥ 1% of Patients and Non-ocular Adverse Reactions Reported by ≥ 5% of Patients CONTRAINDICATIONS Ocular or Periocular Infections: OZURDEX® (dexamethasone intravitreal implant) MedDRA Term OZURDEX® Sham is contraindicated in patients with active or suspected ocular or periocular infections N=324 (%) N=328 (%) including most viral diseases of the cornea and conjunctiva, including active epithelial Ocular herpes simplex keratitis (dendritic keratitis), vaccinia, varicella, mycobacterial Cataract1 166/2432 (68%) 49/230 (21%) infections, and fungal diseases. Conjunctival hemorrhage 73 (23%) 44 (13%) Glaucoma: OZURDEX® is contraindicated in patients with glaucoma, who have cup to disc ratios of greater than 0.8. Visual acuity reduced 28 (9%) 13 (4%) Torn or Ruptured Posterior Lens Capsule: OZURDEX® is contraindicated in patients Conjunctivitis 19 (6%) 8 (2%) whose posterior lens capsule is torn or ruptured because of the risk of migration Vitreous floaters 16 (5%) 6 (2%) into the anterior chamber. Laser posterior capsulotomy in pseudophakic patients Conjunctival edema 15 (5%) 4 (1%) ® is not a contraindication for OZURDEX use. Dry eye 15 (5%) 7 (2%) ® Hypersensitivity: OZURDEX is contraindicated in patients with known Vitreous detachment 14 (4%) 8 (2%) hypersensitivity to any components of this product [see Adverse Reactions]. Vitreous opacities 11 (3%) 3 (1%) WARNINGS AND PRECAUTIONS Intravitreal Injection-related Effects: Intravitreal injections, including those with Retinal aneurysm 10 (3%) 5 (2%) OZURDEX®, have been associated with endophthalmitis, eye inflammation, increased Foreign body sensation 7 (2%) 4 (1%) intraocular pressure, and retinal detachments. Corneal erosion 7 (2%) 3 (1%) Patients should be monitored regularly following the injection [see Patient Keratitis 6 (2%) 3 (1%) Counseling Information]. Anterior Chamber 6 (2%) 0 (0%) Steroid-related Effects: Use of corticosteroids including OZURDEX® may produce Inflammation posterior subcapsular cataracts, increased intraocular pressure, glaucoma, and Retinal tear 5 (2%) 2 (1%) may enhance the establishment of secondary ocular infections due to bacteria, fungi, or viruses [see Adverse Reactions]. Eyelid ptosis 5 (2%) 2 (1%) Corticosteroids are not recommended to be used in patients with a history of Non-ocular ocular herpes simplex because of the potential for reactivation of the viral infection. Hypertension 41 (13%) 21 (6%) ADVERSE REACTIONS Bronchitis 15 (5%) 8 (2%) Clinical Studies Experience: Because clinical studies are conducted under widely 1 Includes cataract, cataract nuclear, cataract subcapsular, lenticular opacities in varying conditions, adverse reaction rates observed in the clinical studies of a drug patients who were phakic at baseline. Among these patients, 61% of OZURDEX® cannot be directly compared to rates in the clinical studies of another drug and subjects vs. 8% of sham-controlled subjects underwent cataract surgery. may not reflect the rates observed in practice. 2 ® ® 243 of the 324 OZURDEX subjects were phakic at baseline; 230 of 328 Adverse reactions associated with ophthalmic steroids including OZURDEX include sham-controlled subjects were phakic at baseline. elevated intraocular pressure, which may be associated with optic nerve damage, visual acuity and field defects, posterior subcapsular cataract formation, secondary Increased Intraocular Pressure ocular infection from pathogens including herpes simplex, and perforation of the Summary of Elevated IOP Related Adverse Reactions globe where there is thinning of the cornea or sclera. Treatment: N (%) Retinal Vein Occlusion and Posterior Segment Uveitis IOP OZURDEX® Sham The following information is based on the combined clinical trial results from N=324 N=328 3 initial, randomized, 6-month, sham-controlled studies (2 for retinal vein occlusion IOP elevation ≥10 mm Hg 91 (28%) 13 (4%) and 1 for posterior segment uveitis): from Baseline at any visit Adverse Reactions Reported by Greater than 2% of Patients ≥30 mm Hg IOP at any visit 50 (15%) 5 (2%) ® MedDRA Term OZURDEX Sham Any IOP lowering medication 136 (42%) 32 (10%) N=497 (%) N=498 (%) Any surgical intervention for 4 (1.2%) 1 (0.3%) Intraocular pressure increased 125 (25%) 10 (2%) elevated IOP* Conjunctival hemorrhage 108 (22%) 79 (16%) * OZURDEX®: 1 surgical trabeculectomy for steroid-induced IOP increase, 1 surgical Eye pain 40 (8%) 26 (5%) trabeculectomy for iris neovascularization,1 laser iridotomy, 1 surgical iridectomy Conjunctival hyperemia 33 (7%) 27 (5%) Sham: 1 laser iridotomy Ocular hypertension 23 (5%) 3 (1%) The increase in mean IOP was seen with each treatment cycle, and the mean Cataract 24 (5%) 10 (2%) IOP generally returned to baseline between treatment cycles (at the end of the 6 month period). Vitreous detachment 12 (2%) 8 (2%) Headache 19 (4%) 12 (2%) Cataracts and Cataract Surgery At baseline, 243 of the 324 OZURDEX® subjects were phakic; 230 of 328 Increased IOP with OZURDEX® peaked at approximately week 8. During the initial sham-controlled subjects were phakic. The incidence of cataract development in treatment period, 1% (3/421) of the patients who received OZURDEX® required patients who had a phakic study eye was higher in the OZURDEX® group (68%) surgical procedures for management of elevated IOP. compared with Sham (21%). The median time of cataract being reported as an adverse event was approximately 15 months in the OZURDEX® group and 12 months in the Sham group. Among these patients, 61% of OZURDEX® subjects vs.

allergan_ad.indd 16 3/9/20 2:29 PM 8% of sham-controlled subjects underwent cataract surgery, generally between MEDICAL RETINA s Month 18 and Month 39 (Median Month 21 for OZURDEX® group and 20 for Sham) of the studies. USE IN SPECIFIC POPULATIONS Pregnancy Risk Summary ® There are no adequate and well-controlled studies with OZURDEX in pregnant 14-17 women. Topical ocular administration of dexamethasone in mice and rabbits during issued any warnings. Further investigation is warranted the period of organogenesis produced cleft palate and embryofetal death in mice, to explore pathogenesis and to inform screening guidelines and malformations of the abdominal wall/intestines and kidneys in rabbits at doses for this sight-threatening condition. n 5 and 4 times higher than the recommended human ophthalmic dose (RHOD) of ® OZURDEX (0.7 milligrams dexamethasone), respectively. 1. Parsons CL. Evidence-based strategies for recognizing and managing IC. Contemp Urol. 2003;15(2):22-35. In the US general population, the estimated background risk of major birth 2. Curhan GC, Speizer FE, Hunter DJ, et al. Epidemiology of interstitial cystitis: a population based study. J Urol. defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 1999;161(2):549-552. to 20%, respectively. 3. Kivlin D, Lim C, Ross C, et al. The diagnostic and treatment patterns of urologists in the United States for interstitial cystitis/painful bladder syndrome. Urol Pract. 2016;3(4):309-314. Data 4. Davis NF, Brady CM, Creagh T. Interstitial cystitis/painful bladder syndrome: epidemiology, pathophysiology and Animal Data evidence-based treatment options. Eur J Obstet Gynecol Reprod Med. 2014;175(4):30-37. Topical ocular administration of 0.15% dexamethasone (0.75 mg/kg/day) on 5. Pearce WA, Chen R, Jain N. Pigmentary maculopathy associated with chronic exposure to pentosan polysulfate sodium. gestational days 10 to 13 produced embryofetal lethality and a high incidence Ophthalmology. 2018;125(11):1793-1802. of cleft palate in mice. A dose of 0.75 mg/kg/day in the mouse is approximately 6. Davis NF, Brady CM, Creagh T. Interstitial cystitis/painful bladder syndrome: epidemiology, pathophysiology and ® 2 evidence-based treatment options. Eur J Obstet Gynecol Reprod Med. 2014;175(4):30-37. 5 times an OZURDEX injection in humans (0.7 mg dexamethasone) on a mg/m 7. Hanif AM, Shah R, Jiong Yan, et al. Strength of association between pentosan polysulfate and a novel maculopathy. basis. In rabbits, topical ocular administration of 0.1% dexamethasone throughout Ophthalmology. 2019;126(10):1464-1466. organogenesis (0.20 mg/kg/day, on gestational day 6 followed by 0.13 mg/kg/ 8. Vora R, Patel A, Melles RS. Maculopathy associated with pentosan polysulfate therapy: the KPNC experience. Paper day on gestational days 7-18) produced intestinal anomalies, intestinal aplasia, presented at: AAO Retina Subspecialty Day; October 12-13, 2019; San Francisco, CA. gastroschisis and hypoplastic kidneys. A dose of 0.13 mg/kg/day in the rabbit is 9. Mishra K, Patel TP, Singh MS. Choroidal neovascularization associated with pentosan polysulfate toxicity. Ophthalmol approximately 4 times an OZURDEX® injection in humans (0.7 mg dexamethasone) Retina. 2019;4(1):111-113. on a mg/m2 basis. A no-observed-adverse-effect-level (NOAEL) was not identified 10. Jain N, Li AL, Yu Y, et al. Association of macular disease with long-term use of pentosan polysulfate sodium: findings from a US cohort [published online ahead of print November 6, 2019]. Br J Ophthalmol. in the mouse or rabbit studies. 11. Nickel JC, Herschorn S, Whitmore KE, et al. Pentosan polysulfate sodium for treatment of interstitial cystitis/bladder Lactation pain syndrome: Insights from a randomized, double-blind, placebo controlled study. J Urol. 2015;193(3):857-862. Risk Summary 12. Anderson VR, Perry CM. Pentosan polysulfate: a review of its use in the relief of bladder pain or discomfort in interstitial Systemically administered corticosteroids are present in human milk and can cystitis. Drugs. 2006; 66(6) 821-835. 13. Hanno PM. Analysis of long-term Elmiron therapy for interstitial cystitis. Urology. 1997;49:93-99. suppress growth and interfere with endogenous corticosteroid production or 14. Pearce WA, Hanif AM, Jain N. Re: FDA BRUDAC 2018 criteria for interstitial cystitis/bladder pain syndrome clinical trials: cause other unwanted effects. There is no information regarding the presence of future direction for research: J. C. Nickel and R. Moldwin. J Urol. 2018;200:39-42. J Urol. 2018; 200(5):1122-1123. dexamethasone in human milk, the effects on the breastfed infants, or the effects 15. Nickel JC, Moldwin R. Reply by authors. J Urol. 2018;200(5):1122-1123. on milk production to inform risk of OZURDEX® to an infant during lactation. The 16. Ferguson TJ, Gaerets RL, Barker MA. Chronic use of pentosan polysulfate sodium associated with risk of vision- developmental and health benefits of breastfeeding should be considered, along threatening disease. Int Urogynecol J. 2019;30(3):337-338. with the mother’s clinical need for OZURDEX® and any potential adverse effects 17. Wein AJ. Re: pigmentary maculopathy associated with chronic exposure to pentosan polysulfate sodium. J Urol. on the breastfed child from OZURDEX®. 2020;203(2):259-260. Pediatric Use: Safety and effectiveness of OZURDEX® in pediatric patients have not been established. RONALD MELLES, MD Geriatric Use: No overall differences in safety or effectiveness have been observed n Ophthalmologist, Redwood City Medical Center, The Permanente Medical Group, between elderly and younger patients. Redwood City, California NONCLINICAL TOXICOLOGY n Carcinogenesis, Mutagenesis, Impairment of Fertility [email protected] Animal studies have not been conducted to determine whether OZURDEX® n Financial disclosure: None (dexamethasone intravitreal implant) has the potential for carcinogenesis or mutagenesis. Fertility studies have not been conducted in animals. AMAR PATEL, MD PATIENT COUNSELING INFORMATION n Ophthalmologist, Kaiser Permanente Oakland, Oakland, California Steroid-related Effects n Advise patients that a cataract may occur after repeated treatment with OZURDEX®. [email protected] If this occurs, advise patients that their vision will decrease, and they will need an n Financial disclosure: None operation to remove the cataract and restore their vision. Advise patients that they may develop increased intraocular pressure with OZURDEX® MEERA S. RAMAKRISHNAN, MD treatment, and the increased IOP will need to be managed with eye drops, and, n Ophthalmology Resident Physician, Scheie Eye Institute, Philadelphia rarely, with surgery. n [email protected] Intravitreal Injection-related Effects n Financial disclosure: None Advise patients that in the days following intravitreal injection of OZURDEX®, patients are at risk for potential complications including in particular, but not limited to, the development of endophthalmitis or elevated intraocular pressure. ROBIN A. VORA, MD When to Seek Physician Advice n Co-Chair of Ophthalmology, Oakland Medical Center, Oakland, California Advise patients that if the eye becomes red, sensitive to light, painful, or develops n [email protected] a change in vision, they should seek immediate care from an ophthalmologist. n Financial disclosure: None Driving and Using Machines Inform patients that they may experience temporary visual blurring after receiving an intravitreal injection. Advise patients not to drive or use machines until this has been resolved. Rx only Distributed by: Allergan USA, Inc. Madison, NJ 07949 © 2018 Allergan. All rights reserved. All trademarks are the property of their respective owners. Patented. See: www.allergan.com/patients

Based on: v1.OUSP13348 OZU119208 12/18 MARCH 2020 | RETINA TODAY 17

0320rt_Medical_Vora.indd 17 3/9/20 2:32 PM 3/6/20 12:40 PM Poverty is ais Poverty 3 Such disparities result in a lack of health equity. health of lack a in result disparities Such 4 Health equity occurs when every individual has a fair andfair a has individual every when occurs equity Health The concept of global poverty may, for some, conjure some, for may, poverty global of concept The elderlyan Hendrix, Mr. like look can inequality Health who refugee a Noor, Mrs. like look can inequality Health Poverty and poor health are interwoven. are health poor and Poverty major cause of poor health as well as a barrier to health carehealth to barrier a as well as health poor of cause major poverty.of cause major a is health poor Conversely, access. medications, consultations, with associated costs The work—can missed and transportation as well tests—as and livingthose for burdensome care health accessing make in disparities to lead further inequalities These poverty. in mortal- and sanitation, nutrition, health, literacy, education, ity. just opportunity to be healthy. Its achievement requires the requires achievement Its healthy. be to opportunity just anddiscrimination including obstacles, several of removal housing,employment, education, to barriers socioeconomic inequality, health actuality, in is, disparity Health food. and groups.various between health in differences in resultsit and up images of malnourished children living on a roadside orroadside a on living children malnourished of images up asharing and room one in living families multigenerational ways.many in presents poverty However, porridge. of bowl innations wealthiest the of one States, United the in Even myIn seen. be can disparities health of examples world, the IOhio, Dayton, in population patient uninsured and under- undergo- between choose must who patients see frequently rent.monthly their paying and treatments vision-saving ing importantso was it decided who patient underinsured eat- to resorted he that drops glaucoma his get to him for theWhen them. afford to order in food cat canned ing heonce practice our call didn’t he why him asked technician herealized heartbreakingly she charge, copay his out found medica- of class his change could we that considered hadn’t his assumed he program; assistance drug a him find or tion option. other no had he that and best knew doctor lost hasnoises, loud at flincheson, lights the with sleeps PICTURES OF GLOBAL POVERTY PICTURES OF GLOBAL POVERTY and hurricanes in Haiti are just some examples of the destruc- the of examples some just are Haiti in hurricanes and regions.impoverished affect that disasters natural tive POVERTY AND HEALTH 2 1

A closer look at the challenges of achieving health equity around the world. around the health equity the challenges of achieving A closer look at BY ZAIBA MALIK, MD

| MARCH 2020| MARCH

n 2015, the World Bank reset the international poverty international the reset Bank World the 2015, n theof picture a represents figure This day. per $1.90 to line whoIndividuals shelter. and clothing, food, basic of costs inliving be to considered are amount this than less on live estimates,recent most the to According poverty. extreme Additionally, in some low-income areas, recurrent catastroph- recurrent areas, low-income some in Additionally, - pover global to contribute factors diverse of multitude A The international poverty line is determined by an indi- an by determined is line poverty international The The percentage of individuals living below the interna- the below living individuals of percentage The ic natural disasters pose significant obstacles to eradicating pov- eradicating to obstacles significant pose disasters natural ic earthquakesand Africa, in drought Bangladesh, in Flooding erty. ty, and the lines between cause and effect are often blurred.often are effect and cause between lines the and ty, formerare world the in nations poorest the Historically, andremoved systematically were resources where colonies, accessingfrom people prevent to created were conditions upheavalpolitical and War education. and land, capital, theseof security and safety, stability, the strain to continue harnessingfrom inhabitants preventing thereby regions, In food. nutritious and water clean as such resources basic zonesconflict infrastructure, stable of lack a to addition educationformal to access no to little provide these as such employment.or vidual’s purchasing power to fulfill his or her daily needs.daily her or his fulfill to power purchasing vidual’s the food, to allocated is $1.90 daily the of most Although nutritional and quality in low be might affords it that food bycovered be must care health and education, Shelter, value. chooseto forced is individual an When well. as amount this orfood as such necessities other and care health between seat.back a takes often care health housing, tional poverty line has decreased significantly since 1990since significantly decreased has line poverty tional world’sthe of distribution the in disparity a however, (36%); inliving people of number the example, For remains. poor withincountries most in decreased has poverty extreme Sub- in increase to continues it but Asia, Southeast and East theof half than more to home is region This Africa. Saharan - inhabit its of 42% and population, poor extremely world’s line. poverty international the below live currently ants

CAUSES OF GLOBAL POVERTY CAUSES OF GLOBAL POVERTY UP AGAINST GLOBAL POVERTY GLOBAL AGAINST UP

this includes more than 702 million people worldwide, orworldwide, people million 702 than more includes this population. global the of 10% I RETINA TODAY

GLOBAL PERSPECTIVES s 18 0320rt_Global_Malik.indd 18 GLOBAL PERSPECTIVES s

often face socioeconomic barriers to Individuals in extreme poverty health care that mirror what is seen in are defined as those living below developing countries. the international poverty line of $1.90 PER DAY Globally, building self-sustaining health care systems is crucial to allow communities to develop and thrive instead of relying on one-time efforts of volunteers. One way to create a longer-term impact More than 700 MILLION people is to invest in the community’s economy worldwide, or 10% of the global population, live below the by procuring medicine and equipment locally. Most US medical groups partner international poverty line with country-specific nongovernmental organizations to provide humanitarian trips and intra-country specialty training. More than half of the world’s extremely poor live in Skills transfer, therapeutic indications, Sub-Saharan Africa, and 42% of the region’s inhabitants procedure training, and community 42% development projects are all means live below the international poverty line through which physicians can help make a difference. In addition, physician mentorship (via webinar, for example) is important for providing ongoing education of local staff. family members in war-torn Syria, and refuses to attend a health and wellness workshop because she believes doing CONCLUSION so implies she has a mental disease. Or health inequality Global poverty is a complex and multifactorial challenge, can look like the people of Vanua Levu, the second larg- and a great deal of work must still be done to combat it. est island in Fiji, where, despite a population of more than Although progress has been made, in some nations it has 135,000, not a single ophthalmologist exists. Here, all I can been slow, and in others poverty has only worsened. As 2030 offer as a visiting ophthalmologist is 40 cataract cases per nears, we must strive to identify solutions to alleviate global week, leaving the remaining patients untreated until the poverty and all of its consequences, including health inequal- next group of volunteers comes through. ity. When communities and governments around the world begin to treat health care as a human right and commit ENDING GLOBAL POVERTY to improving access to health care for everyone, we will be The World Bank and the United Nations have set a lofty much closer to breaking the cycle of global poverty. n goal of ending extreme poverty by 2030.1 With only a decade left, it is unclear whether this can be achieved. 1. The World Bank. Poverty. https://www.worldbank.org/en/topic/poverty/overview. Updated October 2, 2019. Accessed November 11, 2019. There is no single solution to ending global poverty. 2. United Nations. Ending poverty. https://www.un.org/en/sections/issues-depth/poverty/. Accessed November 11, 2019. Reaching this goal requires cross-collaboration between gov- 3. The World Bank. Poverty and health. https://www.worldbank.org/en/topic/health/brief/poverty-health. Updated ernments and communities. By working with nonprofits and August 25, 2014. Accessed November 11, 2019. governmental aid organizations to increase food security, pro- 4. The Borgen Project. What are the causes of poverty? https://borgenproject.org/what-causes-global-poverty/. Accessed November 11, 2019. mote child survival, strengthen health systems, and improve 5. The Borgen Project. Top 10 global poverty advocacy nonprofits. https://borgenproject.org/top-10-global-poverty- 5 education, we can reach this goal. Innovations in economic advocacy-nonprofits/. Accessed November 19, 2019. development, health care access, job growth, and pay equity all contribute to inclusive economic growth and health equity. For physicians, acquiring knowledge of the problem is ZAIBA MALIK, MD the first step. The second step is to become involved in n Medical Director, Medpace, Cincinnati, Ohio advocacy efforts. Our involvement in health care delivery n Physician CEO, EyeMD LLC and advocacy can have a significant impact on communities. n Clinical Assistant Professor, Wright State University Boonshoft School of Medicine, Of course, making donations to reputable organizations is a Dayton, Ohio step that all people can take. But, as physicians, we have the n Adjunct Faculty, Premedical Programs, University of Dayton, Ohio skill set to work directly with those in need and provide on- n the-ground services, training, and mobilization both locally [email protected]; www.linkedin.com/in/zaiba-malik-md and abroad. Our local inner-city and rural communities n Financial disclosure: None

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0320rt_Global_Malik.indd 19 3/6/20 12:40 PM FELLOWS’F CUS

FELLOWS’ FOCUS JOURNAL CLUB Summaries of two recent journal pieces.

BY THOMAS L. JENKINS, MD; AND RAVI R. PANDIT, MD, MPH

Delayed Retinal Breaks and despite the common practice of scheduling follow-up Detachments After Acute examinations within 6 weeks.3 Posterior Vitreous Detachments Uhr and colleagues conducted a study to determine the timing and incidence of delayed PVD-related complications Uhr JH, Obeid A, Wibbelsman TD, et al.1 after an initial examination.1

atients frequently present to retinal specialists for STUDY DESIGN evaluation after an acute posterior vitreous detach- Researchers at Wills Eye Hospital Retina Service and Mid ment (PVD). The incidence of retinal tear after an acute Atlantic Retina performed this retrospective case-control symptomatic PVD ranges widely, from 8% to 43%,2 study of eyes diagnosed with a PVD and undergoing an but less is known about the development of new reti- extended ophthalmoscopic examination on presentation Pnal tears or detachments following an initial examination from October 2015 to August 2018. They subsequently TABLE. HAZARD RATIOS FOR RISK FACTORS FOR DEVELOPMENT OF A DELAYED BREAK OR DETACHMENT Eyes With Delayed Retinal Breaks Eyes with Delayed Retinal Detachments Hazard Ratios (95% P Value Hazard Ratios (95% P Value Confidence Interval) Confidence Interval) Vitreous Hemorrhage 2.53 (1.84-3.49) < .001 2.88 (1.51-5.17) .001 Intraretinal Hemorrhage 0.88 (0.60-1.30) .52 0.69 (0.36-1.33) .27 Lattice Degeneration 1.21 (0.89-1.65) .22 1.27 (0.67-2.39) .47 Pseudophakia* 1.09 (0.75-1.58) .64 2.10 (1.27-3.50) .004 Male Gender 1.36 (1.04-1.80) .03 1.87 (1.12-3.11) .02 Age 0.99 (0.97-1.01) .39 0.96 (0.93-0.99) .01 *This includes one aphakic eye in the retinal detachment cohort. Table adapted from Uhr JH, Obeid A, Wibbelsman TD, et al. Delayed retinal breaks and detachments after acute posterior vitreous detachments [published online ahead of print October 23, 2019]. Ophthalmology.

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compared the dates of initial exami- tears were found in 209 (2.6%) eyes delayed break within 6 weeks was nation to those of subsequent treat- and delayed retinal detachments vitreous hemorrhage. Risk factors ment with laser retinopexy, cryother- in 80 (1%) eyes. Of the eyes with for the development of delayed apy, or retinal detachment repair to a delayed retinal tear, 116 (55.5%) retinal detachments included vitre- determine the duration to develop- occurred within 6 weeks of initial ous hemorrhage, pseudophakia at FELLOWS’F CUS ment of new peripheral pathology. examination and 93 (44.5%) occurred presentation, younger age, and male The study’s primary outcome mea- more than 6 weeks after initial exami- gender (Table). sure was the development of a retinal nation. Delayed retinal detachments break or detachment after initial eval- tended to occur later, with 54 (67.5%) SIGNIFICANCE uation. Secondary outcomes included occurring more than 6 weeks after This study demonstrated that incidence of retinal tear on initial visit presentation. New or worsening symp- delayed retinal tears and detachments and risk factors for the development toms were present in 84 (40.2%) eyes occur after initial examination for of delayed retinal tear or detachment. at the time of delayed retinal tear and acute PVD. A substantial percentage 54 (67.5%) eyes when a delayed retinal of patients with delayed pathology RESULTS detachment was diagnosed. were asymptomatic and were diag- Of the 7,999 eyes diagnosed with Vitreous hemorrhage and male nosed at more than 6 weeks after an acute PVD, 1,280 (16%) and 499 gender were both associated with presentation. The study showed the (6.2%), respectively, were found to the development of a delayed retinal importance of follow-up examina- have a retinal tear or retinal detach- break. The only risk factor associ- tions after acute PVD to detect ment at presentation. Delayed retinal ated with greater incidence of a potentially treatable pathology.

Effect of Initial Management STUDY DESIGN of patients in the observation group With Aflibercept vs Laser The Protocol V study was conducted required aflibercept rescue. Sixteen Photocoagulation vs Observation at 91 sites across North America.4 A percent of patients in the aflibercept on Vision Loss Among Patients total of 702 treatment-naïve (or with group, 17% of patients in the photoco- With Diabetic Macular Edema no treatment within 12 months) agulation group, and 19% of patients Involving the Center of Macula adult diabetic patients were randomly in the observation group lost at least and Good Visual Acuity: A assigned to receive 2 mg aflibercept 5 letters from baseline; this finding was Randomized Clinical Trial (DRCR (Eylea, Regeneron), photocoagulation, not statistically significant. Protocol V) or observation. In the aflibercept group, No difference was detected in injections were administered every change in mean visual acuity at 2 years Baker CW, Glassman AR, Beaulieu WT, 4 weeks if visual acuity or central sub- among all groups. Seventy-seven et al; DRCR Retina Network4 field thickness (CST) on OCT improved percent of patients in the aflibercept or worsened; injections were deferred if group, 71% of patients in the photoco- Center-involving diabetic macular measurements were stable for two con- agulation group, and 66% of patients edema (CI-DME) is a frequent cause secutive visits. Patients in the photoco- in the observation group retained of vision loss worldwide. Intravitreal agulation group received treatment at 20/20 VA or better at 2 years; the dif- anti-VEGF injections have been shown in baseline and every 13 weeks as needed. ference between the aflibercept group numerous trials to reduce CI-DME and Patients in the photocoagulation and and observation group was statistically improve visual acuity; however, these observation groups could receive significant (P = 0.03). trials have historically excluded patients aflibercept if their visual acuity declined When considering cumulative with 20/25 vision or better (good vision). by at least 10 letters at one visit or by improvement in vision over time Many patients will nevertheless present 5 to 9 letters at two consecutive visits. (area under the curve), aflibercept with CI-DME and good vision; the opti- Individuals who required aflibercept therapy was superior to photocoagu- mal management for these patients is rescue were still grouped according lation (+1.9 letters) and observation unclear. This study sought to determine to their initial randomization in an (+2.1 letters; P < .001 for both). whether initial anti-VEGF treatment intention-to-treat approach. No difference was detected among in eyes with CI-DME and good vision the groups in mean change of CST resulted in better long-term visual acuity RESULTS on OCT or 2-step improvement in outcomes as compared with observation At 2 years, 25% of patients in the diabetic retinopathy severity level, or focal/grid laser photocoagulation. photocoagulation group and 34% (Continued on page 48)

MARCH 2020 | RETINA TODAY 21

0320rt_Fellows_Special Report.indd 21 3/9/20 11:54 AM 3/6/20 12:40 PM - At the next visit, no significant no visit, next the At patient’s the and findings these Given worsened. At this time, the decision the time, this At worsened. dexamethasone a inject to made was (Ozurdex, mg 0.7 implant intravitreal eye. left patient’s the into Allergan) in fluid subretinal the of improvement upon visit, this At seen. was eye left the revealed patient the questioning, further - oxymetho oral taking been had he that anabolic and androgenic strong a lone, physique-enhancement for steroid, not had he which purposes—something visits. previous at reported most is it steroids, to response variable of variant a had patient the that likely (CSCR). chorioretinopathy serous central the and stopped, were steroids oral The the using cease to instructed was patient recent most the At pills. oxymetholone stopping after months 2 visit, up follow 20/70 was BCVA prednisone, oral the resolving with eye right patient’s the in eye left the in 20/30 and fluid subretinal was initially thought to have VKH and was treated for was initially thought to have VKH and was (negative), In this case report, the patient that condition. When The retinopathy (CSCR) share characteristics and can sometimes be confused with one characteristics and can sometimes be confused with share retinopathy (CSCR) another. changed. the diagnosticpicture information emerged, additional serous chorio disease andcentral (VKH) acute stagesofVogt-Koyanagi-Harada AT A GLANCE s s s Our initial differential diagnosis includeddiagnosis differential initial Our patient’s the month, next the Over eyes (Figure 3) without evidence of evidence without 3) (Figure eyes leakage. disc exudativeinflammatory an of causes Vogt-Koyanagi- as such choroidopathy, sympatheticor disease (VKH) Harada panuveitis,of causes Other ophthalmia. syphi- and sarcoidosis,tuberculosis, as such was patient The excluded. be to had lis, anddaily mg 80 prednisone oral on started fur- for specialist uveitis a to referred was includedevaluation Further workup. ther gondii for Toxoplasma testing negative),(Qiagen; Gold QuantiFERON-TB lyso- and enzyme angiotensin-converting reaginplasma rapid (normal), levels zyme antibody treponemal fluorescent and negative),(nonreactive; testing absorption (normal). x-ray chest and improved detachments retinal serous prednisone of dose the while slightly reached taper the When tapered. was again once exudation the mg/day, 40

| MARCH 2020| MARCH 58-year-old white man presented man white 58-year-old blurred of history 1-week a with reported He eyes. both in vision and pain eye or photophobia no The trauma. ocular of history no

Imaging with spectral-domain OCT spectral-domain with Imaging On examination, his Snellen BCVASnellen his examination, On (SD-OCT) showed subretinal fluid with fluid subretinal showed (SD-OCT) fluid membrane limiting sub–external in fluid subretinal and eye right the in angi- Fluorescein 2). (Figure eye left the pinpoint multifocal revealed ography both in pole posterior the in leakage was counting fingers at 1 foot in his righthis in foot 1 at fingers counting was wasIOP eye. left his in 20/200 and eye Hgmm 22 and eye right his in Hg mm 2 evalua- segment Anterior eye. left his in pigmentendothelial corneal revealed tion seg- Posterior eyes. both in deposition retinalserous revealed examination ment choroidaland eyes both in detachments 1). (Figure eye right the in effusions patient’s ocular history was relevant for for relevant was history ocular patient’s both in glaucoma open-angle primary trabeculectomy undergone had He eyes. taking was and 2015 in eye right his in fixed a and bimatoprost, brinzolamide, timolol and brimonidine of combination presenta- of time the at eye left the in significant no had He center. our to tion tak- not was and history medical past review the In medications. oral any ing headaches, no reported he systems, of time the At pains. joint or loss, hearing denied patient the evaluation, initial of oral or inhaled, topical, any of use the medications. corticosteroid-based BY SNEHA PADIDAM, MD; BRIAN K. DO, MD; JORDANA G. FEIN, MD; AND HEERAL SHAH, MD MD; AND HEERAL SHAH, MD MD; BRIAN K. DO, MD; JORDANA G. FEIN, BY SNEHA PADIDAM, A patient’s undisclosed medication makes for a difficult differential diagnosis in this case report. this case in for a difficult differential diagnosis medication makes A patient’s undisclosed DISTINGUISHING VKH FROM CSCR FROM VKH DISTINGUISHING A RETINA TODAY

22 s MEDICAL RETINA 0320rt_Medical_Padidam.indd 22 MEDICAL RETINA s

with no subretinal fluid (Figure 4). Observation of the patient continues, awaiting further improvement.

DISCUSSION CSCR is a common condition characterized by accumulation of subretinal fluid in the macula along with pigment epithelial detachments (PEDs). The pathogenesis of CSCR is not fully elucidated, but studies have shown that it may be related to abnormally hyperperme- Figure 1. Fundus photographs of the right and left eyes show serous retinal detachment in each eye. able choroidal capillaries.1 CSCR has a strong association with exogenous and endogenous corticosteroids.2 An association has been suggested between CSCR and certain personality factors, including type A personality and psychological stress.3 Our patient was taking oxymetholone, a powerful synthetic androgenic and anabolic steroid, for body-building purposes. Nudleman et al reported on a series of nine patients using exogenous testosterone therapy who developed CSCR.4 Those authors hypothesized that exogenous testosterone may lead to increased choroidal blood flow and hence increased choroidal permeability. VKH is an autoimmune disorder affecting pigmented tissues. Acute Figure 2. OCT of the right eye (top) demonstrates extensive intraretinal cystic fluid. OCT of the left eye (bottom) dem- VKH is characterized by bilateral onstrates subretinal/subexternal limiting membrane fluid. exudative retinal detachments and increased choroidal thickness on SD-OCT. VKH commonly affects darkly pigmented individuals and usually has a prodromal stage with influenza-like symptoms. Patients can also have various neurologic and auditory symptoms, such as headaches, dizziness, orbital pain, and sensorineural hearing loss.5 Initial treatment of VKH consists of high- dose oral corticosteroids, and some patients later require immunomodu- latory therapy. Our patient was initially thought to have VKH, given his bilateral exudative retinal detachments with subretinal septa in his right eye on Figure 3. Fluorescein angiography of the right (top) and left (bottom) eyes shows multifocal areas of pinpoint OCT, as well as fluorescein angiogra- leakage in each eye.

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Joplin, Missouri Group of Washington, Fairfax, Virginia [email protected] Financial disclosure: Regeneron (Consultant) Retina Specialist, Ramesh R. Shah, MD, PC, Cofounder, International Society for the [email protected] Financial disclosure: None Vitreoretinal Surgeon & Uveitis Specialist, Retina [email protected] Financial disclosure: None Retina Fellow, Retina Group of Washington/ Georgetown University, Washington, DC [email protected] Financial disclosures: None Retina Specialist, The Retina Group of Cofounder, International Society for the Advancement of Medical Retina Advancement of Medical Retina Washington, Fairfax, Virginia

SECTION EDITOR HEERAL R. SHAH, MD BRIAN K. DO, MD SNEHA PADIDAM, MD n n n n n n n n n n n n SECTION EDITOR JORDANA G. FEIN, MD, MS n n n

Am J Ophthalmol. 2001;131:647-652. - demon here presented case The ofabsence or presence the Noting strates the importance of making themaking of importance the strates VKHof diagnosis differential correct VKHfor therapy Initial CSCR. versus - corticoste high-dose of consists usually aMaking CSCR. worsen can which roids, negativeprevent helps diagnosis correct outcomes. visual septae, subretinal hyperemia, disc optic ofuse and symptoms, systemic PEDs, in benefit of be can medications any Ourentities. two these distinguishing informa- withheld initially had patient high-dosea of use his regarding tion Despitesteroid. androgenic and anabolic oralwith treatment starting initially improvedhas patient the prednisone, theof cessation after observation with steroid. androgenic 1. Prünte C, Flammer J. Choroidal capillary and venous congestion in central 1. Prünte C, Flammer J. Choroidal capillary and venous congestion in central serous chorioretinopathy. Am J Ophthalmol. 1996;121(1):26-34. 2. Carvalho-Recchia CA, Yannuzzi LA, Negrão S, et al. Corticosteroids and central serous chorioretinopathy. Ophthalmology. 2002;109(10):1834-1837. 3. Spahn C, Wiek J, Burger T, Hansen L. Psychosomatic aspects in patients with central serous chorioretinopathy. Br J Opththalmol. 2003;87(6):704- 708. 4. Nudleman E, Witmer MT, Kiss S, et al. Central serous chorioretinopathy in patients receiving exogenous testosterone therapy. Retina. 2014;34:2128- 2132. 5. Read RW, Holland GN, Rao NA, et al. Revised diagnostic criteria for Vogt-Koyanagi-Harada disease: report of an international committee on nomenclature. 6. Yang P, Ren Y, Li B, et al. Clinical characteristics of Vogt-Koyanagi-Harada syndrome in Chinese patients. Ophthalmology. 2007;114:606-614. 7. Shin WB, Kim MK, Lee CS, Lee SC, Kim H. Comparison of the clinical mani- festations between acute Vogt-Koyanagi-Harada Disease and acute bilateral central serous chorioretinopathy. Korean J Ophthalmol. 2015;29(6):389-395. 8. Lin D, Chen W, Zhang G, et al. Comparison of the optical coherence tomographic characters between acute Vogt-Koyanagi-Harada disease and acute central serous chorioretinopathy. BMC Ophthalmol. 2014;14:87. CONCLUSION CONCLUSION

6 8 Of note in that study,that in note Of 7 | MARCH 2020| MARCH

The acute stages of VKH and CSCRand VKH of stages acute The The patient demonstrated a variablea demonstrated patient The In a study including 35 patients withpatients 35 including study a In alet Shin CSCR, with 25 and VKH opticand CSCR in PED that found high- the had VKH in hyperemia disc (100%),values predictive positive est respectively. can sometimes be confused withconfused be sometimes can of90 report, one In another. one haddisease VKH with patients 410 CSCR. as misdiagnosed been initially response to high-dose corticosteroids. high-dose to response - con concealed) (initially his Given hisand oxymetholone of sumption stoppingafter improvement clinical pictureclinical the prednisone, oral the CSCR. atypical with consistent more is phy showingleak- macular multifocal hadalso patient The eyes. both in age intraretinalof mass dome-shaped a detachment,bacillary a termed fluid, patientsin seen commonly is which notdid patient our note, Of VKH. with fluores- on leakage nerve optic have seenoften is which angiography, cein VKH. in during late-phase fluorescein angiogra- fluorescein late-phase during observedwas leakage multifocal phy, Lingroup. CSCR the in eyes of 90% in andsepta subretinal that found al et epitheliumpigment retinal of folds acutewith eyes in only seen were hadCSCR with patients whereas VKH, retinal of bulging and PEDs significant epithelium. pigment RETINA TODAY

24 MEDICAL RETINA s fluid. OCT of the left eye (right photo) shows of the right eye (left photo) shows interval improvement in the subretinal after the discontinuation of the patient’s steroids. OCT Figure 4. OCT was taken 2 months resolution of the subretinal fluid. 0320rt_Medical_Padidam.indd 24

3/9/20 11:34 AM

Figures 1–6 courtesy of Brandon D. Ayres, MD & Refractive SurgeryRefractive & Retina Today wasToday Retina Cataract t: Before inserting the IOL into the into IOL the inserting Before t: The Yamane technique involves theinvolves technique Yamane The exactthe for measure Carefully Hin to important is it chamber anterior present. is vitreous no that ensure completed,is measuring the Once Step No. 1 Step No. 1 Step No. 2

following steps: following theat haptics the of placement This1). (Figure case the of beginning ofrisk the minimize to critical is IOL.the of tilt or decentration • STEP BY STEP STEP BY STEP s s ’s sister publication publication sister ’s Today Retina A RUNDOWN OF THE STEPS INVOLVED INVOLVED STEPS THE OF RUNDOWN A SUTURELESS THIS PERFORMING IN THE IN FIXATION IOL FOR TECHNIQUE AND SUPPORT, CAPSULAR OF ABSENCE IT. MASTERING FOR PEARLS Figure 1. Measuring and marking of the needle insertion sites. Figure 1. Measuring and marking of the needle insertion sites. of a three-piece IOL using thin-walledusing IOL three-piece a of through needles 27-gauge or 30- sclerotomies.transconjunctival two carefullyare IOL the of haptics The needlesthe of lumen the into laced theThen forceps. intraocular using theexternalize to used are needles surface.conjunctival the on haptics usedis cautery low-temperature Next, theof end the at flange a make to preventsbulb or flange This haptics. back prolapsing from haptics the theand chamber, posterior the into fixated thereby is IOL three-piece insegment posterior the in efficiently support. capsular of absence the —Chief Medical Editor Allen C. Ho, MD; and Associate Medical Editor Robert L. Avery, MD Avery, L. Robert Editor Medical Associate and MD; Ho, C. Allen Editor Medical —Chief

YAMANE YAMANE BY BRANDON D. AYRES, MD by step. Step Yamane technique: The

| MARCH 2020| MARCH

seudoexfoliation syndrome is oneis syndrome seudoexfoliation forreasons common most the of cataractduring dislocation lens forand cases, such For surgery. supportcapsular which in eyes This has been our primary techniqueprimary our been has This The idea behind the Yamanethe behind idea The There has been plenty of buzz in the retina community about the Yamane technique. When the team at team the When technique. Yamane the about community retina the in buzz of plenty been has There for scleral fixation of an IOL for thefor IOL an of fixation scleral for itshas procedure The years. 2 past performinginvolves and complexities specifica in components multiple becan technique the Now, order. FixationIOL Scleral the using simplified MicroSurgical(SFP; Pack Solutions theall provides which Technology), Yamanethe use to required tools IOLs. of fixation scleral for approach is absent, multiple IOL fixation tech- fixation IOL multiple absent, is years.the over used been have niques transitionedhave we practice, my In elegantan to techniques suture from technique,fixation haptic sutureless technique. Yamane the technique is to externalize the hapticsthe externalize to is technique THE CONCEPT THE CONCEPT TECHNIQUE THE PEARLS FOR FOR PEARLS strategizing how best to cover the topic, we decided that deferring to our colleagues in the anterior segment was a good starting good a was segment anterior the in colleagues our to deferring that decided we topic, the cover to best how strategizing from story cover a of version modified a is which article, This place. bit.ly/RetinaTodayYamane. at online entirely its in viewed be can Today,

BY BRANDON D. AYRES, MD; ZAINA AL-MOHTASEB, MD; STEVEN G. SAFRAN, MD; AND MANJOOL SHAH, MD MD G. SAFRAN, MD; AND MANJOOL SHAH, MD; ZAINA AL-MOHTASEB, MD; STEVEN BY BRANDON D. AYRES, P RETINA TODAY

26 s SURGICAL PEARLS 0320rt_Surgical Pearls.indd 26 SURGICAL PEARLS s

Figure 2. After the first sclerotomy is created, the leading haptic is placed into the lumen of the needle. Figure 3. The leading haptic is left fixed inside the needle to avoid potential difficulties with externalization of the trailing haptic.

trailing haptic into a challenging position for lacing the haptic into the second needle. Placing the main incision slightly to the left will help ease placement of the trailing haptic (Figure 3).

Figure 4. Externalization of the trailing haptic. s Step No. 8 Introduce the trailing haptic into the anterior chamber, then grasp the second needle to perform the transconjunctival sclerotomy about 2.5 mm posterior to the limbus with core length of about 2 mm. This second sclerotomy is made exactly 180° across from the first one. Figure 5. Cauterization of the externalized haptics. • Hint: Ensure that the eye is pressurized with the anterior chamber maintainer whenever you make a sclerotomy. place the three-piece IOL in the intrascleral length of the tunnel is anterior chamber. My preferred IOL about 2 to 2.5 mm as well. s Step No. 9 for haptic fixation is the CT Lucia 602 Once the second sclerotomy is (Carl Zeiss Meditec) due to the s Step No. 6 made, visualize the lumen of the needle durability of its PVDF haptics. Typically Grasp the leading haptic using through the cornea and pupillary at this point, I place the leading haptic intraocular 25-gauge microforceps space. I always aim to achieve a similar in the nasal anterior chamber and and carefully lace it into the lumen of angle of the haptic and the needle for leave the trailing haptic hanging out the needle (Figure 2). even alignment of the IOL. Using the through the main incision. microforceps, grasp the second haptic s Step No. 7 and place it in the lumen of the needle. s Step No. 3 Once the first haptic is securely laced Maintain the anterior chamber. into the lumen of the needle, the hub s Step No. 10 I like to use an anterior chamber is released from the holding forceps, With the second haptic now maintainer in the eye in order to allowing the IOL to move into the eye. introduced into the lumen of the prevent hypotony. • Hint: Externalizing the trailing needle, externalize the haptic by haptic is the point when surgeons removing the needle through the s Step No. 4 can experience problems. To avoid transconjunctival sclerotomy, then Make the transconjunctival challenges with the trailing haptic, carefully grasp the haptic (Figure 4). sclerotomy with the thin-walled do not externalize the leading haptic 30-gauge needle. first. When the haptic is fixated in the s Step No. 11 needle, let the needle go. Externalizing With low-temperature cautery, s Step No. 5 the needle with the leading haptic melt about 1 to 2 mm of the terminal Make the first sclerotomy at this point would lead to rotation end of the haptic to create a flange or 2.5 mm posterior to the limbus. The of the IOL in the eye, moving the bulb that will prevent the haptic from

MARCH 2020 | RETINA TODAY 27

0320rt_Surgical Pearls.indd 27 3/9/20 11:34 AM 3/9/20 11:34 AM needle insertions are notare insertions needle thenot are insertions needle lengthin vary pathways scleral 180° apart;180° orlimbus; the from distance same direction. and/or are points insertion needle the If If the IOL is poorly centered or tilted,or centered poorly is IOL the If The The The The learning curve for thisfor curve learning The

• • orlimbus the from distances different hapticsthe of one apart, 180° not are andeye the into reinserted be must theIf pass. needle new a with refixated lengths,different of are tunnels scleral trimmedbe can haptics both or one centration.improve to recauterized and the three most common causes are:causes common most three the • PEARL NO. 5 PEARL NO. 5 1. Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged intrascleral intraocular lens fixation with double-needle technique. Ophthalmology. 2017;124(8):1136-1142. technique to place an IOL withoutIOL an place to technique oncebut steep, is support capsular onlyshouldtake it mastered is it myIn complete. to minutes 20 to 15 challengesgreatest the experience, for measuring are technique this with sites insertion needle the of placement theinto haptic trailing the lacing and difficult most The needle. the of lumen probablyis maneuver intraocular veryis This haptic. trailing the lacing approachright the with but challenging, unnecessaryinstrumentation, and avoided. be can complications CONCLUSION CONCLUSION Loosely attach each 30-gauge each attach Loosely amount small a with syringes Fill maintainer chamber anterior an Use Prolapse the haptic through thethrough haptic the Prolapse well-centereda be should result The Step No. 13 Step No. 13 Step No. 14

needle and do not use a luer-locka use not do and needle possibilitythe avoid will This syringe. detaching difficulty experiencing of syringe.the make and solution saline balanced of before needle the irrigate to sure to help can This pass. scleral the interfere can that bubbles air avoid insertion needle for view the with fixation. haptic during theduring eye firm a ensure to sclerotomies. the of creation PEARL NO. 2 PEARL NO. 2 PEARL NO. 3 PEARL NO. 4 180° across, where the needle is stillis needle the where across, 180° theholding sclera the penetrating ExternalizeIOL. the of haptic leading the on haptic the grasp and needle the themelt Again, surface. conjunctival cautery. low-temperature using end s scleralthe into it force and conjunctiva channel. s thein suspended IOL three-piece suturesno with segment posterior 6).(Figure BY ZAINA AL-MOHTASEB, MD A few pearls for the Yamane technique. | MARCH 2020| MARCH

for use in eyes with absence ofabsence with eyes in use for 1 Technically any three-piece IOL canIOL three-piece any Technically The small-incision, sutureless, small-incision, The Go to the other side of the eye,the of side other the to Go Step No. 12 Step No. 12

capsular support involves the creationthe involves support capsular aand sclerotomies small-gauge of resultingincision, corneal clear small risklow a and recovery visual fast a in fewA hypotony. postoperative of theovercome surgeons help can pearls technique.this performing of challenges be used in the Yamane technique; Yamane the in used be withIOLs that found have we however, resistantand durable are haptics PVDF reason,this For breaking. and kinking to IOLpreferred our is 602 Lucia CT the procedure.this performing for transconjunctival scleralfixation transconjunctival Yamaneby described first technique al et PEARL NO. 1 PEARL NO. 1 prolapsing through the scleral incision scleral the through prolapsing 5).(Figure s Figure 6. A well-centered three-piece IOL placed using IOL placed using Figure 6. A well-centered three-piece the Yamane technique. RETINA TODAY

28 s SURGICAL PEARLS 0320rt_Surgical Pearls.indd 28 SURGICAL PEARLS s

BY STEVEN G. SAFRAN, MD Adequate vitrectomy and an infusion cannula are must-haves. For me, the most important aspects is useful when making the tunnels. If the eye and not go into the tunnel. I just of the Yamane technique are ensuring the eye is at a constant and firm IOP, make a little mushroom tip, and that can an adequate vitrectomy and placing an I can control the tunnel length and be pushed into the tip of the tunnel. infusion cannula. I always use a trocar there will be less bleeding. I enter a little and perform a pars plana vitrectomy acutely with the needle, then create the ADDITIONAL POINTERS when performing the Yamane tunnel, then enter acutely again. The Inject OVD before performing technique. The vitrectomy is essential tunnels should be more or less parallel the vitrectomy. A vitrectomized because I am going to be maneuvering to the limbus; they can be angled ever eye will not hold an OVD; it will behind the iris, and I don’t want to be so slightly posterior, about 5° away from just drop into the back of the eye. I disturbing the vitreous. Additionally, the limbus, but no more than that. inject dispersive OVD into the eye the vitreous must be adequately and For a myopic patient, I may angle the using the iris and vitreous as a kind completely removed. Even if the eye tunnels a bit more than 5°, and a bit of backboard that allows me to press has had a vitrectomy previously, I less if the patient is hyperopic. This is the OVD up against the cornea and make sure that it was adequate and because the bigger the eye is, the less create protection for the cornea. In that all vitreous was removed. haptic there will be to work with. the vitrectomized eye, the IOL will An infusion cannula should be in serve as the backboard. place to control IOP because I don’t INSERTING THE HAPTICS Use self-sealing incisions. Self-sealing want to be sticking needles into a soft The next step is to feed both haptics incisions are important for the Yamane eye. Doing so will increase the risk of into the needles. I feed one haptic into technique—and any other technique, bleeding and choroidal hemorrhage. It one needle, let go of it, then move to for that matter. If the eye is leaking, is helpful to use an infusion line that is the second needle, feed that haptic in, the surgeon will not have control. I under footpedal control, so that it can and then rotate them simultaneously. make sure that my incisions—even be turned on and off as needed during I pull both needles out of the eye at larger incisions—are fashioned so that the procedure. the same time, and as I do that both when I put the infusion line in, they seal haptics come out of the eye at the themselves or close off. IOL SELECTION same time. When I do it this way, the A redock is my last resort. After I pull I use the CT Lucia 602 IOL because lens has to rotate. If the lens doesn’t both haptics out, I test the centration this lens has PVDF haptics, which are rotate, then one haptic will pull out, and tilt of the optic by manipulating robust and do not kink or break easily. but the other haptic won’t come out the haptics so that there is an equal Additionally, even when the haptics of because it hasn’t rotated. But if both amount of externalized haptic—about this IOL have been bent acutely, they haptics are rotated by extracting both 1 to 2 mm on each side. If everything return to their original configuration. at the same time, the lens will rotate has been done symmetrically, the lens and both haptics will come out at the should center well at this point, and MARKING AND NEEDLE TUNNEL same time. With a 30-gauge needle, the if it does, I will go ahead and melt the CREATION haptics will not slip back into the eye. I haptic tips and be done. If, on the other Controlling the entry point into the can just pull the haptics out, let go, and hand, there appears to be some tilt or eye and the length of the tunnels is the haptics won’t go anywhere. decentration, I pull one haptic out a vital for this technique. It’s important Next I grab both haptics with the for- bit more than the other to see if I can to mark the patient carefully and to ceps and push them so that each side compensate and center the IOL. If that make sure that the marks are exactly is only a little bit out, to see if the lens does not fix the problem, I melt the side 180° apart and exactly the same is centering the way I want it to. If I’ve I consider the most optimal and redock distance from the limbus, and that the done everything symmetrically, the lens the other side. What I mean by redock tunnel length and angle of entry are should center. If it looks like it’s going is that I will create a flange on one side symmetric. If anything is off, the IOL will to center well, I do a small haptic melt to secure it and I make another needle be decentered. I put both of my marks on each side and push it into its tunnel, path with the 30-gauge needle, designed exactly 2 mm behind the limbus. and I’m done. to correct for whatever centration or Each tunnel should be about The haptic melt should not be too big. tilt issue is present by compensating for 1 to 1.5 mm in length. An infusion line If it is too big, it will sit on the surface of the asymmetry causing the positioning

MARCH 2020 | RETINA TODAY 29

0320rt_Surgical Pearls.indd 29 3/9/20 11:34 AM 3/9/20 11:34 AM

2,3 n

Perform peripheral iridotomyPerform peripheral University of Michigan, Ann Arbor [email protected]; Twitter @ManjoolShah Financial disclosure: None Private Practice, Lawrenceville, New Jersey [email protected] Financial disclosure: None acknowledged Clinical Assistant Professor, Kellogg Eye Center,

using the vitrector or after the IOLvitrector or after the using the anis is This successfully fixated. preventto order in step important putgenerally I block. pupillary reverse temporally.iridotomy peripheral the lacking capsular and zonular stability,zonular and capsular lacking of degree great a exhibit can iris the ofrisks the increasing iridodonesis, IOL the between contact intermittent block,pupillary reverse iris, the and optic. the of capture pupil even and A simple iridotomy placed at the timethe at placed iridotomy simple A riskthat mitigate can fixation IOL of cuttervitreous a use typically I greatly. getcan I so rate minute per cut 1 a at opening. clean small, single, a 1. Van Buskirk, EM. The anatomy of the limbus. Eye. 1989;3:101-108. 2. Singh H, Modabber M, Safran SG, Ahmed II. Laser iridotomy to treat uveitis-glaucoma-hyphema syndrome secondary to reverse pupillary block in sulcus-placed intraocular lenses: Case series. J Cataract Refract Surg. 2015;41(10):2215-2223. 3. Singh H, Safran SG, Ahmed II. Laser iridotomy for pseudophakic reverse pupillary block in patients with pupillary optic capture after sulcus-placed intraocular lenses. J Cataract Refract Surg. 2017;43(2):299. STEVEN G. SAFRAN, MD MANJOOL SHAH, MD n n n n n n

I routinelyI 1 . I doI . redocking CRST Editorial Advisory Board Another key pearl for anyfor pearl key Another Surgeon on the Cornea Service, Wills Eye Hospital, Philadelphia Member, [email protected] Financial disclosure: Consultant (MicroSurgical Technology)

lumen of the needle once to externalize to once needle the of lumen position.haptic new a create and again it as process this to refer I 40% to 30% about in side one on this excellentwant I because cases my of amI maneuver this with and centration, positionlens the improve to able usually that. achieve to place my needle tracks at least 2 mm2 least at tracks needle my place waythis in and spur, the to posterior body.ciliary the into running avoid I thethat ensure to try I Additionally, surfacethe to perpendicular is needle internalthe keeps which sclera, the of thefrom distance same the at entry needlethe If entry. external the as spur riskis there plane, iris the in angled is emergingentry needle internal the of theputting again anterior, relatively ciliary body and posterior iris at risk for chafe.IOL-induced tois procedure IOL scleral-fixated eyesIn iridotomy. peripheral a place the surgical limbus, always correlatesalways surgicallimbus, the anatomy. intraocular to BRANDON D. AYRES, MD n n n n

Measure posteriorly from the scleral spur, not the limbus. spur, not Measure posteriorly from the scleral BY MANJOOL SHAH, MD BY MANJOOL SHAH, CRST Executive Advisory Board | MARCH 2020| MARCH

As a glaucoma and complexand glaucoma a As Member, [email protected]; Twitter @zaina1225 Financial disclosure: None acknowledged Associate Professor of Ophthalmology, Associate Residency Program Director, and Cornea, Cataract, and Refractive Surgeon, Baylor College of Medicine, Houston

n n n ZAINA AL-MOHTASEB, MD n problem. For example, I may make themake may I example, For problem. posterior, anterior, more pass second as pass first the to temporal or nasal, issue tilt or centration the by indicated thefix thereby and it for compensate to needlenew a creating After problem. backhaptic externalized that pull I pass, thein again it dock and eye the into anterior segment specialist, I amI specialist, segment anterior fixationIOL some that aware problems.real cause can techniques capsule-independentSpecifically resultingof risk the runs fixation IOL uveitis-glaucoma-hyphemain purelyis which syndrome, (UGH) markedis eye the When iatrogenic. measuresoften one passes, needle for toeasy is it and limbus, the from intraocularvital where mischaracterize arebody ciliary the as such structures measuringadvocate I Instead, located. whichspur, scleral the from posteriorly withouteven visualized be often can asperitomy conjunctival a making orspur, The zone. blue the of end the RETINA TODAY

30 s SURGICAL PEARLS 0320rt_Surgical Pearls.indd 30 Profiles in Retina: Drs. Carol and Jerry Shields A landmark interview with one of the power couples of retina.

AN INTERVIEW WITH CAROL SHIELDS, MD, AND JERRY SHIELDS, MD

When I asked Retina Today if profiling Wills had a mixed doubles tennis event, and they needed someone to fill in, so I volunteered. Tennis wasn’t my favorite Carol L. Shields, MD, and Jerry A. Shields, MD, (my sport is basketball), but I said sure, I’ll play. My partner was a good fit for the Women in Retina issue, was Jerry Shields. We played tennis—he was pretty good— and when the evening was over, I thought that was it. We they agreed that an intimate portrait answer- just went our separate ways.

ing the questions we all have—How do they Jerry: And then I asked her to join me at a Philadelphia 76ers game because I knew that she played college basketball do it? What’s the secret?—was long overdue. at the University of Notre Dame. Here, two leaders in ocular oncology sit Carol: It was a lot of fun. And about a month later, I host- down for an all-too-brief discussion about ed a Christmas party for my class at Wills. And who shows up? Jerry Shields. I had only invited my class to the party, so I their partnership. The interview has been knew he was up to something.

edited for length and clarity. Jerry: After that, I invited her to join me on New Year’s Eve —Judy Kim, MD for dinner with Bill Benson, MD, and his wife. Guest Editor, Retina Today Carol: I looked at him cross-eyed and said, “Are you kid- ding me? I’m not sure we’re a couple yet.” So we laid low for a while, and then later we went public.

Retina Today: Tell us about how you first met. Jerry: People were pretty surprised, but that’s how life goes, right? Jerry A. Shields, MD: We first met when Carol came to Philadelphia for her ophthalmology residency. I was already Carol: Jerry was a bachelor—and a desperately handsome on staff there and was fortunate enough to meet her when young doctor—who was married to his work. she joined Wills Eye Hospital. Jerry: Carol had a brother in Pittsburgh, and she wanted to Carol L. Shields, MD: It was 1984 and I was fresh out of return there and practice with him. If she did that, it would my internship, and I was sort of dating a nice young man from have been the end of me. Pittsburgh. I had no intention of meeting anybody at Wills and was happy-go-lucky on my own. When I arrived, I had never Carol: That was 36 years ago. I still haven’t made up my even heard the words Jerry Shields. mind if I’ll join my brother or not.

MARCH 2020 | RETINA TODAY 31

0320rt_Cover_Shields_Cover_Lobo-Chan.indd 31 3/9/20 11:39 AM 3/9/20 11:39 AM Photo credit: Roger Barone

I knew it would affect myaffect would it knew I Carol: Carol: We both come from large families;large from come both We Drs. Carol and Jerry Shields paused for a picture in the Wills Eye Eye Drs. Carol and Jerry Shields paused for a picture in the Wills Hospital OR. career. When our kids were young,were kids our When career. AnnualAAO the to go couldn’t I - meet retina big the of any or Meeting workmuch too was it because ings But babysitters. with kids the leave to andschool grade in were kids the after things started going smoothly, I started becom- and meetings more attending career-oriented.more ing reallyI children. eight had family each pos- as life a normal as have to wanted children. wanted definitely I sible. out one evening for the two of us gous of two the for evening one out Jerrytogether. dinner a have and out socializeand out go to wanted always tosure made we but everyone, with timespend just to evening one keep things how on reminisce and together lives. our and kids the with going are THE INTERSECTION OF FAMILY AND CAREERS AND CAREERS a to start you decided RT: When about how it did you think family, careers? to affect your was going It’s true, we never competed.never we true, It’s Being in same business and business same in Being It was so nice because itbecause nice so was It It’s fair to say that we workedwe that say to fair It’s But that’s part of the ben- the of part that’s But Carol: Carol: We actually had a very good work- good very a had actually We Jerry: Carol: Carol: Jerry: Jerry: Carol: Carol: If you’re a married couple, you shouldyou couple, married a you’re If hemean, I yourselves. compare never and established well very already was out.starting just was I everyone; knew allcrossed I because relationship ing madeand I’s the all dotted and T’s the waswhich seamless, care patient the whatthan job different completely a lecturingout was He doing. was Jerry anwas and patients in bringing and figure. international in the same office but had two verytwo had but office same the in jobs. different attending the same meetings can be abe can meetings same the attending fun. of lot a and work, of lot efit. Every time we went to a Maculaa to went we time Every efit. SocietyRetina a or meeting Society vacation. a like was it meeting, was just us. We would always carvealways would We us. just was I can name three things thatthings three name can I I knew Carol was a great per- great a was Carol knew I | MARCH 2020| MARCH

Drs. Carol and Jerry Shields are flanked by their children. Left to right, they are Jerry F., John, Charlotte Nelle, Left to right, they are Jerry F., John, Charlotte Nelle, Drs. Carol and Jerry Shields are flanked by their children. William, and Patrick. Jerry A. Shields Sr., Carol L. Shields, Mary Rose, Margaret, a pictorial view into into view pictorial a Today offered Retina MD, Shields, A. Jerry and MD, Shields, L. Carol decades. three the spanning photographs of selection a is Here lives. personal their Jerry: Jerry: The third challenge: Wills EyeWills challenge: third The Carol: Carol: histook I challenge: second The Hospital was 99% male doctors backdoctors male 99% was Hospital getto challenge a was it and then, awere there say, to have I But referrals. startedwho Wills at doctors of couple getto nice just me—it’s to referring feelyou makes It referrals. own your impact. an making actually you’re like last name. I’ve often wondered if Iif wondered often I’ve name. last namemaiden my kept just should’ve twous made have would that because people. different I felt were challenges. The first chal- first The challenges. were felt I wouldJerry and wife, his was I lenge: asnot wife, his as me introduce littlea was that So Shields. Carol Dr. difficult. CHALLENGES IN RETINA CHALLENGES IN RETINA the were some of RT: What from being you faced challenges field and in the same a couple workplace? son and we didn’t compete in any way.any in compete didn’t we and son RETINA TODAY

32 s RETINA WOMEN 0320rt_Cover_Shields_Cover_Lobo-Chan.indd 32 RETINA WOMEN s

Drs. Carol and Jerry Shields with a copy of Intraocular Tumors: An Atlas and Textbook, Second Edition, which they coauthored. The A picture of the happy book’s third edition was couple on the day of their released in 2016. wedding.

Drs. Carol and Jerry Shields (left photo) set out on a bike riding adventure with their seven children (right photo) approximately 15 years ago.

Jerry: I didn’t worry about it because broken doorknobs and drove the kids Carol: Every child was a blessing. I’ve I knew that I’d finally met a fantastic to school, while the wife got the kids never looked back for one minute and woman who believes everything like I up in the morning, got breakfast ready, ever regretted having a family, skipping do. We were good buddies. and later prepared dinner. There was this meeting to go to a lacrosse game, enough to keep them both busy. or cutting out of clinic a little early Carol: Yeah, we’re soul mates. to go watch one of our kids play in a Jerry: The first couple we hired were tennis match. We’ve had a lot of fun Jerry: We have a total of seven chil- Polish immigrants. We’re still in touch watching the kids grow up. dren, and during all of that time she with them. They are wonderful people; was taking fellowships. they actually raised their daughter Jerry: Absolutely. I wouldn’t trade Carol went to England for fellow- with our seven children. It was like a that for anything. ship training a few months right after family of eight kids. we had our first baby, and this was a RESERVING TIME FOR EACH OTHER giant step in our marriage. Following Carol: When we were looking to AND FAMILY fellowship, we went ahead and had hire a second couple after the first a few additional children. Every time couple moved on, we turned to a RT: You had a family with seven she would have another baby, I would woman who worked at Wills Eye as a children and the rigorous hang in there as best I could. She was typist. She wanted to have a career as calendars of retina specialists. hanging in there better than I was. a housekeeper. She took over the job, Your schedules must have been and her husband joined her in the cot- packed. How did you reserve that Carol: We realized that we probably tage. We employed them until the kids time for yourselves? needed really skilled home-help for our were grown and gone. growing family. We soon found a hus- Carol: Every day is busy, but if I band and wife couple to help us with Jerry: Carol and I were very close to could line up all the things in our joint the kids. We moved out of the city of our respective families, and both of us career, the best thing was having a Philadelphia to a little farm that had a came from large families. Our other family. Don’t you think? cottage on it. We hired a couple who siblings had children, and our kids worked full-time at our house; the grew up with their children and those Jerry: Absolutely. We worked hard husband did some cleaning and fixed in the neighborhood. (Continued on page 44)

MARCH 2020 | RETINA TODAY 33

0320rt_Cover_Shields_Cover_Lobo-Chan.indd 33 3/9/20 11:39 AM Hear It From the Attendings: Mentorship in Retina An honest, casual conversation about mentorship from those who lead.

INTERVIEWS WITH AUDINA M. BERROCAL, MD; ZELIA M. CORREA, MD, PHD; AND ADRIENNE W. SCOTT, MD

great mentor helps you to find your personal path. Mentorship requires What qualities do you look for What makes a good mentor? self-knowledge, assessment of strengths in a potential mentee? and weaknesses, and comfort with one’s career and life. Self-knowledge allows a mentor to learn a mentee’s strengths and weaknesses and helps the mentee Audina M. Berrocal, Adrienne W. Scott, take the steps that allow them to grow. MD: The perfect men- MD: A good mentee is the individual tor is someone with who is either early in whom you can build their training or at a a relationship. Keep in How does one find a mentor? crossroads in their career. The men- mind that a mentor is not necessar- tee needs to be open to guidance ily a friend. It is usually someone who even when that guidance requires is senior to you, who has walked the introspection or comes at a perceived path to success that you’re trying to personal cost. A great mentee needs achieve. A mentor must be available Dr. Berrocal: I believe that we are to be ready to grow, which, at times, and supportive, and it must be some- surrounded by mentoring opportuni- requires honesty and focus. For men- one that the mentee feels comfortable ties. The best mentoring occurs natu- toring to impact your life, you must going to when they are challenged. rally and it is not forced. But if you be willing to be mentored. “I’m having trouble and struggling with are not open to mentoring, then you this next step,” is a sentence that a will not recognize those opportuni- Zelia M. Correa, MD, mentor must be willing to respond to ties. Fixed mentoring, in which you are PhD: I look for those by explaining how they navigated it. assigned a mentor, has a place in many with drive, goals, and organizations, but often doesn’t have talent, in that order. Dr. Correa: A good mentor opens the depth of an organic mentoring But none of those doors and opportunities for their relationship. features are worth investing in if the mentee. A good mentor establishes a mentee is not respectable, trustwor- positive relationship, carefully listens Dr. Correa: Finding a mentor can thy, humble, and open to advice and before offering advice, and allows the happen by chance, but it is more counseling. An individual with energy mentee to make their own decisions. productive as an intentional action. and drive aims to be prepared and The first step is to identify people competent and is, therefore, better Dr. Berrocal: A good mentor under- you would like to mirror, then study equipped to overcome obstacles, stay stands who you are, where you come their attitude, circle of influence, and on task, and work on their goals. from, and where you want to go. A professionalism. If there is still interest,

34 RETINA TODAY | MARCH 2020

0320rt_Cover_Roundtable.indd 34 3/10/20 9:25 AM RETINA WOMEN s

request a meeting to establish a rap- my mentees and teach them how to Dr. Correa: Every situation and port and discuss a mentoring relation- recognize and understand the silent experience should be an opportunity ship. Be sure that your potential men- and hidden biases that exist for both to learn, not only professionally but tor has the time to advise you. Finally, men and women. personally. Even when the experience it is important to realize that anyone is negative, it is an opportunity to fig- can have multiple mentors who may Dr. Scott: I wouldn’t advise a man ure out what not to do. An important advise on different aspects of life, or a woman differently as mentees. I part of our profession is to be in con- including professional, academic, and do think, however, that women in this tinual learning mode. family mentors. space might have to work harder to prove themselves, as this is a field that Dr. Scott: Work hard, particularly has been traditionally male-dominated. in training when you have a dedicated I do think that as a woman, particu- support system and an opportunity Have you seen differences larly as a woman from an underrep- to learn everything about the field. in men and women mentees? resented minority background, I have Being a fellow, particularly in a field experienced a unique path. like retina, it’s a unique opportunity to In general, I do give the same advice learn literally at the side of an expert. to anyone I’m mentoring, regardless Work as hard as possible, learn as Dr. Berrocal: I think there are dif- of gender, ethnicity, or professional much as possible, ask as many ques- ferences, but these are more based achievement: The most important tions as possible because when you’re on personality, career goals, personal part of achieving any goal is to be a out of training you will not have the life, and ethnicity rather than gender. very hard worker and to stay focused same opportunities to learn. Take Nonetheless, I sometimes address on what it is you’re trying to achieve. advantage of every resource, including some of the classic stereotypes your attendings. to be the best mentor for each of Of course, when you’re in the real my mentees. world, you can always go back to a What general advice do you mentor and ask him or her questions. Dr. Scott: I’ve not noticed differ- offer to your mentees? But there’s nothing like a full-time ences between the genders of the apprenticeship, which is what vitreo- mentees that I have or have had. I retinal fellows have. n think it’s very individual depending on how driven somebody is and how Dr. Correa: I don’t mentor based on focused someone is. So I can’t gener- gender, but I do alert women to the AUDINA M. BERROCAL, MD alize a man mentee versus a woman challenges we face, especially regarding n Professor of Clinical Ophthalmology; Medical Director mentee. I think it all comes from your moving up the professional ladder. I of Pediatric Retina and Retinopathy of Prematurity; and own internal drive. make sure junior women around me Vitreoretinal Fellowship Codirector, Bascom Palmer Eye get equal access to opportunities, and Institute, Miami I always tell them that they don’t need n Editorial Advisory Board Member, Retina Today to fit any particular mold and that n [email protected] Do you tailor guidance for diversity is the secret ingredient to the n Financial disclosure: None acknowledged women differently than for most successful teams. men? If so, how? ZELIA M. CORREA, MD, PHD Dr. Berrocal: It is so important to n Tom Clancy Endowed Professor of Ophthalmology, Johns understand that, if you don’t find that Hopkins Wilmer Eye Institute, Baltimore one lifelong mentor, look for mentors n [email protected] Dr. Berrocal: I do not tailor guid- that come into your life at important n Financial disclosure: None acknowledged ance based on gender, but rather moments. I call these situational men- based on the individual. That said, as a tors or temporary mentors. They are ADRIENNE W. SCOTT, MD woman I can help women mentees in very valuable. For many, it is ideal to n Associate Professor of Ophthalmology, Johns Hopkins the many aspects of becoming a better have an ideal single mentor; for most Wilmer Eye Institute; Medical Director, Wilmer Eye woman physician-surgeon. There are that is impossible to find. Learn to be Institute; Head of the Retina Fellowship, Wilmer Eye experiences, challenges, and hurdles mentored by many different people Institute; all in Baltimore for women that men will never experi- for different moments and different n [email protected] ence. At the same time, I like to guide parts of your life. n Financial disclosure: None acknowledged

MARCH 2020 | RETINA TODAY 35

0320rt_Cover_Roundtable.indd 35 3/10/20 9:25 AM Closing the Gender Gap in Retina The landscape is changing, but more is yet to come.

BY AVNI FINN MD, MBA; AND CAROLINE BAUMAL, MD; WITH CONTRIBUTIONS FROM MARÍA H. BERROCAL, MD; SHARON FEKRAT, MD; NANCY M. HOLEKAMP, MD; SHLOMIT SCHAAL, MD, PHD; AND CAROL L. SHIELDS, MD

“More gender diversity… can trans- of research, and equality in pay are As Carol L. Shields, MD, Director late to increased productivity, greater all potential barriers to gender bal- of the Ocular Oncology Service at innovation, better decision-making... .” ance in retina.3-7 For this article, we Wills Eye Hospital and a Professor of —2017 Report on Gender Diversity, interviewed several female leaders who Ophthalmology at Thomas Jefferson Morgan Stanley1 are at the forefront of mentorship, University, noted, “It is difficult to research, and clinical care in retina and break into a field without support esearch in the business world asked them to share their thoughts on from a seasoned player, whether that has shown that greater gender gender imbalance in the field. be a male or female physician. Those balance in a company translates of us in retina and ocular oncology into better returns and less vola- NOT JUST RETINA have a special opportunity to influence tility for investors. The case for Shlomit Schaal, MD, PhD, Professor younger women and men, and this Rgreater gender balance in medicine is and Chair of the Department of likely impacts their choice of specialty. similarly compelling. Ophthalmology and Visual Sciences “Once in the field, there is another Most retina physicians, men and at the University of Massachusetts factor to consider, and that is the sense women alike, are proponents of Medical School, commented, “I see evi- of belonging,” Dr. Shields added. “This gender diversity within our field, but dence of gender inequality not only in depends on all of us welcoming new increasing diversity remains challeng- our field of retina, but also in academic members and including them in all the ing. The reasons behind continued medicine as a whole. The 2019 report aspects of our field, regardless of age, gender inequality are complex. They from the Association of American race, or gender. This allows these new are not limited to medical education Medical Colleges clearly shows that at members to grow into their careers and physician practice, but rather stem the highest levels of academic medi- and contribute to their fullest.” from all aspects of society. Among the cine (department chairs and deans) ophthalmology subspecialties, retina women are underrepresented. I’m BEYOND LEADERSHIP attracts the smallest percentage of optimistic that this is going to change The gender imbalance extends women. As of 2018, 19% of US retina in the future as more women take beyond the leadership gap. The very specialists were women, compared to on these challenges and serve as role nature of the specialty—the chal- 26% in oculoplastics, 29% in cornea, models for the younger generation, lenges that interest and captivate 34% in glaucoma, and 47% in pediatric both for women and for men.” us—may be the same ones that turn ophthalmology.2 This anticipated change is likely to some trainees away. A major step toward improving gen- have a trickle-down effect: Having Nancy M. Holekamp, MD, a der balance in our field is understand- women in leadership roles not only sets Professor of Clinical Ophthalmology ing why the imbalance exists. Lack of an example for younger trainees but also and Visual Sciences at Washington leadership, support, and mentorship broadly changes the perceptions of what University School of Medicine and the during surgical training, sponsorship a woman in ophthalmology can achieve. Director of Retina Services for Pepose

36 RETINA TODAY | MARCH 2020

0320rt_Cover_Finn.indd 36 3/6/20 12:42 PM RETINA WOMEN s

Vision Institute, had some thoughts on this. She said, “I think a gender imbalance exists in retina for the same reason it exists in general surgery and neurosurgery: Extra years of training, more emergency calls, less predictable schedules. We are the ones getting called in the middle of the night to surgically fix emergency problems— infections, posteriorly ruptured globes, retinal detachments. Retina is distinct enough from other ophthalmology specialties to create a gender disparity not observed in those specialties.” Sharon Fekrat, MD, a Professor of Ophthalmology, Associate Professor in the Department of Surgery, and Surgical Retina Fellowship Director at Duke Emily Y. Chew, MD; María H. Berrocal, MD; Shlomit Schaal, MD, PhD; and Caroline Baumal, MD, are among the women leaders in retina. Here, they were gathered at the Retina Society annual meeting in Paris in 2015. University School of Medicine, agreed. “Although many women definitely think that vitreoretinal surgery is fun and exciting, they likely make a work- life balance decision not to enter the field,” she said. “However, what they may not realize is that, irrespective of which ophthalmic specialty they choose, they still have to deal with complex ophthalmic conditions.” María H. Berrocal, MD, Director of Berrocal & Associates, noted that changes and innovation in the field may increasingly attract more women and calls attention to the need to close disparities in salaries between male and female retina specialists. Female vitreoretinal surgeons at the Duke Eye Center. “Fortunately, with retina cases being shorter and with the trend toward in- office, pharmaceutical treatment of dis- in the workplace are changing due to who have both a successful career and eases, I think more women will be choos- the work of leaders and pioneers in personal life will ultimately attract ing retina as a subspecialty,” she said. the field. The leaders we interviewed more women to our field.” “Transparency in salaries is neces- pointed to important ways to close Dr. Shields remarked, based on her sary, particularly in academia, to the gender gap and shared their opti- own experience, that barriers may be a reduce the gender disparity in wages,” mism for the future. matter of perception. she added. “Sadly, women retina spe- Dr. Fekrat noted that the field is “I did not see the gender gap as a cialists’ base salaries in many academic already evolving. problem, but rather as an opportu- settings are less than their male coun- “Medical schools are now more nity,” she said. “Women can be exqui- terparts’ salaries. This practice persists than 50% female, and, as a result, more sitely talented, both intellectually and because of the lack of transparency.” women will choose ophthalmology surgically, and achieve high standards and thus retina,” she said. “In fact, similar to men. Women tend to be ATTITUDES ARE CHANGING an increasing percentage of retina precise, with excellent delicate fine Despite what may seem like a fellows are female, so we are almost motor skills—traits that are of utmost gloomy landscape as described above, there. Seeing strong and accomplished importance to our field.” thoughts and attitudes toward gender female role models within our field Dr. Shields said she has observed the

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Retina Today Retina Today Retina Today University School of Medicine, Durham, North University School of Medicine, Durham, North Carolina Director of the Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University; Professor of Ophthalmology, Thomas Jefferson University, both in Philadelphia Editorial Advisory Board Member, [email protected] Professor of Ophthalmology and Associate Professor in the Department of Surgery, Duke University School of Medicine, Durham, North Carolina Surgical Retina Fellowship Director, Duke Professor of Clinical Ophthalmology and Visual [email protected] Professor and Chair, Department of Ophthalmology and Visual Sciences, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts [email protected] Professor of Ophthalmology, New England Eye Professor of Ophthalmology, Tufts University, Center, Tufts Medical Center, Boston Editorial Advisory Board Member, [email protected] California Retina Vitreoretinal Surgeon, Northern [email protected] Director, Berrocal & Associates, San Juan, Puerto Editorial Advisory Board Member, [email protected] Sciences, Washington University School of Medicine; Director of Retina Services, Pepose Vision Institute, both in St. Louis Vitreous Associates, Mountain View, California Vitreous Associates, Mountain Rico

[email protected]

INTERVIEWEE NANCY M. HOLEKAMP, MD INTERVIEWEE SHLOMIT SCHAAL, MD, PHD INTERVIEWEE CAROL L. SHIELDS, MD AUTHOR AVNI FINN, MD, MBA INTERVIEWEE MARÍA H. BERROCAL, MD INTERVIEWEE SHARON FEKRAT, MD son of hospital mortality and readmission rates for Medicare patients treated and readmission rates for Medicare son of hospital mortality JAMA Intern Med. 2017;177(2):206-213. by male vs female physicians. Specialists staff. with American Society of Retina 9. Personal communication January 2020. n n n n n n n n n n AUTHOR CAROLINE BAUMAL, MD AUTHOR CAROLINE BAUMAL, n n n n n n n n n

The proportion ofproportion The 9 At present, we have ahave we present, At 8 Mentorship of women by both menboth by women of Mentorship Raising awareness of potential bar- potential of awareness Raising female fellows-in-training members ismembers fellows-in-training female 30%. at higher, even sponsorshipincluding women, and societalto addition in promotion, and roles,gender of perceptions in changes mustWomen change. about bring will seekingby table the at seats their take - member committee accepting and lead- and engagements, speaking ships, col- must field the in We roles. ership short- analyze continually and lectively retina The diversity. gender in comings theat be to strive must community genderimprove to change of forefront ourpropel and field our in balance potential. fullest its to subspecialty riers can help lead to transformation.to lead help can riers incrediblebeen already have There fewpast the in field our in changes the in membership Female decades. SpecialistsRetina of Society American over19% to 11% from increased has decade. past the 1. An Investor’s Guide to Gender Diversity. Morgan Stanley. January 127, 2017. https://www.morganstanley.com/ideas/gender-diversity-investor-guide. Accessed February 18, 2020. 2. Personal communication with George Williams, MD. American Academy of Ophthalmology, 2018. 3. Dotan G, Qureshi HM, Gaton DD. Chairs of United States academic ophthalmology departments: A descriptive analysis and trends. Am J Ophthalmol. 2018;196:26-33. 4. Gong D, Winn BJ, Beal CJ, et al. Gender differences in case volume among ophthalmology residents. JAMA Ophthalmol. 2019;137(9):1015-1020. 5. Reddy AK, Bounds GW, Bakri SJ, et al. Representation of women with industry ties in ophthalmology. JAMA Ophthalmol. 2016;134(6):636-643. 6. Reddy AK, Bounds GW, Bakri SJ, et al. Differences in clinical activity and Medicare payments for female vs male ophthalmologists. JAMA Ophthalmol. 2017;135(3):205-213. 7. Kramer PW, Kohnen T, Groneberg DA, Bendels MHK. Sex disparities in ophthalmic research: A descriptive bibliometric study on scientific authorships. JAMA Ophthalmol. 2019;137(11):1223-1231. 8. Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK. Compari- improved patient satisfaction, greater satisfaction, patient improved article recent a as and, empathy, reducedand outcomes better showed, mortality. RAISING AWARENESS system that values and remuneratesand values that system aspossible, as patients many as seeing currentthe With feasible. as quickly results-orientedvaluing toward trend startwill women sure am I outcomes, moreas Also, more. valued be to become will we field, the enter women familiarity.” a but rarity a not | MARCH 2020| MARCH

Just as our patient populations arepopulations patient our as Just “It may seem quite daunting for afor daunting quite seem may “It Dr. Schaal similarly underscored theunderscored similarly Schaal Dr. Our interviewees agreed thatagreed interviewees Our “Over the past 33 years of my career,my of years 33 past the “Over diverse, a diverse group of vitreoretinalof group diverse a diverse, theserve best to necessary is surgeons BerrocalDr. needs. patient’s individual valueincrease can women how noted can“Women retina: of field the in theirto and field the to lot a bring patients,with practices—connection young rising female retina specialist tospecialist retina female rising young betweenlife her balance adequately andcareer demanding developing her said.she family,” growing beloved her canI daughters, four of mother a “As offeelings these to relate certainly uncertainty.and restlessness, anxiety, ambitiousan navigate to easy not is It mustWe home. happy a with career reassurance,support, that recognize fromboth needed, are guidance and peers.” from and mentors importance of female leadership and leadership female of importance field. the within guidance mentorship is crucial to bring aboutbring to crucial is mentorship remarked,Holekamp Dr. As change. womensmart and talented, “Young, programstraining ophthalmology in modelsrole encouraging need simply themtell to male) and female (both it.” do can they MENTORS CRUCIAL MENTORS CRUCIAL there has been a slow rise in the num- the in rise slow a been has there ocu- and retina both in women of ber anattend I when Now, oncology. lar estimateI symposium, oncology ocular attendeesthe of more or 50% that hasThis women. are speakers and thisof Part evolution. gradual a been mentor- male) (and female to due is philosophies,workplace changing ship, Iskills. their in believing women and inwomen of presence the that feel hasoncology ocular and retina both fieldsthese push to continue will and topwith levels, higher to and forward andinsights new providing performers thinking.” creative more increasing number of women in thein women of number increasing career. her of tenure the during field RETINA TODAY

38 s RETINA WOMEN 0320rt_Cover_Finn.indd 38 Departmental Leadership

Retina Today Guest Editor Judy Kim, MD, sat down with two women who lead academic departments to discuss the view from the top.

INTERVIEW BY JUDY E. KIM, MD; WITH JULIA A. HALLER, MD; AND JOAN W. MILLER, MD

When I sketched out the topics for this issue of Retina Today, I wanted to include women in leadership roles commenting on how they achieved professional success, the price of their ambition, and their proposed solutions for both real and perceived barriers. Julia A. Haller, MD, is Ophthalmologist-in-Chief and William Tasman, MD, Endowed Chair at Wills Eye Hospital and Professor and Chair of Ophthalmology at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia. Joan W. Miller, MD, is the David Glendenning Cogan Professor of Ophthalmology and Chair of the Department of Ophthalmology at Harvard Medical School and is Chief of Ophthalmology at Mass Eye and Ear and Mass General, and Ophthalmologist-in-Chief at Brigham and Women’s Hospital in Boston. I was fortunate to have these amazing women share their insights on these topics of interest. We had so much to talk about! Therefore, the interview has been edited for brevity and clarity. I hope you enjoy learning from their perspectives as much as I did! —Judy E. Kim, MD

PATHWAY TO LEADERSHIP tunity to fill this role arose, as many opportunities do, by my just putting one foot in front of the other—sometimes Judy E. Kim, MD: No two leaders arrive in their with missteps—and working hard, trying to make contri- positions via identical paths. How did you wind up butions where I could, and then having chance favor the a chairperson? prepared woman! There are many routes to leadership positions in academic Julia A. Haller, MD: Well, I can’t claim that I ever set out medicine, and everyone’s path is different, but there are to be the Ophthalmologist-in-Chief at Wills Eye Hospital, some basic common denominators. Mine included clinical although in retrospect, had I known I would love my job research productivity and the lucky opportunity to work this much, I certainly would have made it a goal! The oppor- with teams advancing the field in many groundbreaking

MARCH 2020 | RETINA TODAY 39

0320rt_Cover_Miller Haller.indd 39 3/9/20 3:12 PM 3/9/20 3:12 PM All department chair positions dif- positions chair department All theyand changes, big were Those price.a has Everything Haller: Dr. rolechair new my into Moving conversa - difficult Having Miller: Dr. fer, and mine includes serving on theon serving includes mine and fer, Ear,and Eye Mass of Directors of Board wellas strategy institutional in involved EyeMass of wellbeing financial the as tookI When task. small no It’s Ear. and call,retina taking stopped I role, the on trans- and hours, practice my limited to otherof my patients a number ferred stoppedI ago, years 7 About doctors. onfocus to choosing well, as operating work. clinical for retina medical when about think to something aren’t pas- and training of out coming you’re Still,surgery. performing about sionate whenencounter you challenges the yourkeep role new a into moving exciting.career somethingsaid Thoreau David Henry theis anything of value “The like, it.”for exchange you life of amount RooseveltTeddy as And there. Bullseye thatprize best the away and “Far said, workto chance the is offer to has life causeThe doing.” worth work at hard (andvision restoring and preserving of ais life) of quality patients’ our it, with weprice the worth well and one, noble hardand training of years in it for pay ourand we that sacrifices and work that. believe truly I make. families institutionan behind leaving meant asloved, and knew I that city a and surgicallarge a on back cutting as well myways many in was that practice stra- into gears changing and identity, andrecruitment and planning tegic rewardingthe of part But fundraising. andreinvention, is life of challenge ofaspects special really the of one arethere that is medicine academic - contribu and roles different many so engagedus keeps It make. to tions energized. and Andchallenge. a is people with tions trainand physicians mentor you when yousometimes leadership, for them Before adopting a rolea adopting Before Miller: Dr. Whenchairdepartment a accepting I knew of only three schools— three only of knew I clinician-sci- a as life my enjoyed I like department chairperson, youchairperson, department like servicea it’s that understand to need department,a leading You’re role. facultyof success the about all it’s and trainees.and stagea at be to need you position, sat- personal your met you’ve where Yourgoals. professional and isfaction one.thoughtful a be must decision wouldn’t describe my decision-makingmy describe wouldn’t well-thought-outa as time that at process. putMIT—and and Yale, Princeton, appli- SAT my on down three those and MIT from back heard I cation. greata like looked it that thought inmoved and admitted was I place. endedI it. seen having ever without wasand School Medical Harvard at up surgery the because retina to drawn onthink to had fascinating—you was thebecause OR—and the in feet your Iplenty. were opportunities research photody- developing in involved was foundationalthe and therapy namic technology. anti-VEGF on work wasn’tI and surgeon, retina and entist opportunities. leadership for looking 2000s,early and 1990s late the in But opportuni- leadership some were there ofOne School. Medical Harvard at ties MD,Friedman, Ephraim mentors, my backgive to turn my was it me told anbuild to and institution, the to thatpeople young for environment me,to appealed That success. fostered organiza- the lead to chosen was I and butrole, my enjoyed really have I tion. cer- was position chair department a plan. the not tainly Dr. Kim: When you move from Kim: When you Dr. a clinician-scientist-surgeon there chair, to department and professional are personal What adjustments sacrifices. a when becoming did you make leader? department | MARCH 2020| MARCH

I’m Canadian, I’m MD: Joan W. Miller, Meanwhile I found opportunities in opportunities found I Meanwhile Alternatively, some people followpeople some Alternatively, and most Canadians stay in Canada forCanada in stay Canadians most and Unitedthe considered I But university. wasfriend good a because States I there. scholarships golf for applying important organizations in our field,our in organizations important theand Society Retina the as such Specialists.Retina of Society American commit- planning first the on served I DaySubspecialty Retina AAO for tee suchorganizations launch helped and ClinicalRetinopathy Diabetic the as - transfor much So Network. Research ourin done been has work mational beenhas it and career, my during field thatwith associated be to privilege a tocame chance the When evolution. HospitalEye Wills the for interview aof opportunity the was it position, andring, the in hat my threw I lifetime. pickedthey that enough lucky was I up.it paths through basic research or edu- or research basic through paths leadership administrative and cational chairvice departmental to on roles, wasI positions. chair ultimately and excite- surgical technical the to drawn offield the of trajectory and ment experi- valuable hugely the and retina, theat Resident Chief as serving of ence fellow- my after Institute Eye Wilmer wasThat MD. Michels, Ron with ship depart- a being for preparation great opportu- many had then I chair! ment trialsnumerous in involved be to nities movecould I which in projects and upmoved and roles, leadership into eventu- and ladder, professorial the Mortonof honor huge the had ally mentor,wonderful a MD, Goldberg, Katharineinaugural the me naming atOphthalmology in Chair Graham thrill! a Wilmer—what projects—which were exciting in andin exciting were projects—which expe- me gave also That themselves! of anin teamwork academic with rience andteaching which in environment everyat prioritized were mentoring break- and excellence fed and level, care. patient in throughs RETINA TODAY

40 s RETINA WOMEN 0320rt_Cover_Miller Haller.indd 40 RETINA WOMEN s

feel like you take two steps forward and EGALITARIAN ASPIRATIONS ship level. I found even within my own one step back. Attending long institu- IN RETINA LEADERSHIP organization that sometimes it was tional logistics meetings is not always hard to be heard. At other times, ideas a good use of one’s time, and in the Dr. Kim: What institutional barriers that I articulated were attributed to meetings I convene and run, I really try to success have you identified that others; I had heard about this happen- never to waste people’s time. Managing may affect women in retina who ing, but it was something else to actu- difficult human resources– related seek to become leaders? ally experience it. I also learned that, issues is not invigorating, and you need as a woman academic leader, I had a to balance it with fun tasks such as Dr. Haller: Mentorship is a major new role in advocating for women as mentoring emerging leaders. factor in the success of anyone. I see speakers, as award recipients, and for a lot of well-trained women get to leadership roles. Dr. Haller: Timing is part of the the assistant professor level and then The lack of women in leadership problem that women face as they step off the track. They don’t get the positions is not, in my estimation, an advance through the academic ranks. encouragement and mentoring and issue with the talent pipeline. There The period of our life when we’d most support that they need. They know is a bias in how we select leaders, like to start a family often coincides that they can still be a good doctor, and hopefully it will change. Having with the period of our professional but they feel that they must choose women leaders is the first fix, and careers that requires the most hours between spending time with their fam- having women leaders and male col- and where there is the least flexibility. ily and dedicating time to ambitions. leagues advocating for the develop- Woman are joining as junior faculty Some academic institutions have ment of women in leadership positions or still in training in their mid 20s dedicated themselves to figuring is an important next step. through early 30s, which is when many out how to solve some institutional women consider having children. Thus barriers. Johns Hopkins Medicine Dr. Kim: During your training, did their timeline is compressed and the was an early proponent of strategi- you experience the biases you challenges for balance can become cally restructuring the work week. have observed in your role as more concentrated as these compet- Historically, Hopkins grand rounds in chairperson? ing interests intensify. This is probably medicine and surgery were held on the time point at which the personal Saturday morning, which meant that Dr. Miller: When I was in my train- and professional sacrifices to which that time could not be spent with ing, I never framed the field in terms you allude are most obvious and need family. After moving grand rounds to a of a male-to-female ratio. There were the most intentional thought. weekday morning, more woman began many more men than women, but I participating and getting recognized as never felt like I was treated differently. Dr. Kim: How does one balance clinical leaders. I took the attitude that you should professional ambitions with Hopkins also made an effort to work hard, be yourself, do a good job, family needs? delineate the steps of academic prog- and things will work out on a merit ress. The team there clearly defined basis. That held true for me through Dr. Haller: I don’t think any of us deadlines, steps, and milestones of aca- those stages. But again, my perspec- ever feel like we’ve achieved perfect demic promotion. If there were an old tive shifted somewhat after I moved balance. I am lucky to have a husband boys’ club membership that previously into leadership. who is also in academic ophthalmol- had been key to department leader- ogy, who understands the stresses ship, it was rendered moot—at least a Dr. Haller: Absolutely true—having of my lifestyle, and who is a great good bit—by this transparency. women in leadership positions is very friend and partner. We were also important, and it is our responsibil- fortunate in having great kids, and Dr. Kim: Do the barriers become ity to pay it forward. When a young finding wonderful childcare helped less obstructive as your career person sees a woman in a position of bolster our support system; my advances and you take on responsibility, then it becomes clear parents, who were both local physi- leadership roles? that she can do it, too. cians, were wonderful grandparent I recently heard a talk by Jeffrey resources. But there were plenty of Dr. Miller: It wasn’t until I was actu- Goldberg, MD, PhD, at Stanford that times when the kids got packed up ally in a leadership role that I paid made some great points about level- and dragged into the hospital for a much attention to being a woman ing the playing field for recruiting and few hours on weekends—I hope it professional. I realized that there is a interviewing. Let’s say a department was character-building! representation problem at the leader- head (or someone in a similar position

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Retina Today I have a final note about note final a have I Miller: Dr. [email protected]; Twitter: @JuliaHallerMD Financial disclosure: None relevant David Glendenning Cogan Professor of Chief of Ophthalmology, Mass Eye and Ear and Mass General, Boston Ophthalmologist-in-Chief, Brigham and Women’s Hospital, Boston [email protected] Financial disclosure: None relevant Ophthalmology and Chair of the Department of Ophthalmology and Chair of the Department of Ophthalmology, Harvard Medical School, Boston Wisconsin, Milwaukee Professor of Ophthalmology, Medical College of Director, Teleophthalmology and Research, Medical College of Wisconsin, Milwaukee [email protected] Financial disclosure: None relevant Ophthalmologist-in-Chief and William Tasman, MD, Professor and Chair of Ophthalmology, Thomas Jefferson University, Philadelphia Editorial Advisory Board Member, Endowed Chair, Wills Eye Hospital, Philadelphia

JOAN W. MILLER, MD JULIA A. HALLER, MD leadership. Leadership is engaging, is Leadership leadership. - perspec different a you gives it and a Being retina. of field the on tive to me encouraged has chairperson skills communication my improve where areas on advice out seek to and con- you’re If improvement. need I an it’s that know leadership, sidering keep will that opportunity exciting way. new a in retina in interested you n n n n n n n n n n n n n n Dr. Kim: Thank you, Joan and Kim: Thank you, Dr. many will that I am certain Julia! wisdom your wonderful appreciate I hope on leadership. and candor and successful to be you continue the top! the view from enjoy GUEST EDITOR JUDY E. KIM, MD Over time, I’ve challenged my own my challenged I’ve time, Over must leader future A Haller: Dr. talents.different has Everyone municate one’s ideas and thoughts,and ideas one’s municate and digest, listen, to ability the also but agenerate can they If others. to respond then input, on based it execute and plan high.are skills communication their I’m what of notions preconceived see to want I as for—just looking their of outside mentees potential of outside be to have I zone, comfort time. to time from mine suc- be to stick-to-it-iveness a have physicians superb see I When cessful. and tenacity, drive, grit, have also who opportunities find to try I ambition, are Theselead. and grow to them for much as twice do who people the projects, finish who ask, you as work to pleasure absolute an is it whom for and recommendation of letters write commit- and awards for nominate to you whom for jobs—those and tees fel- a call and phone the up pick will chair. a or director lowship thefrom obvious are strengths Some eveninteractions, our of beginning sureI’m and students, medical with Youthis. experienced has everyone labwet one after away right see might fellowsor residents of group a in who whoor surgeon, crackerjack a be will offlaugh to temperament the has getand off, themselves dust setbacks, aof pressures The fray. the into back havewe one the like residency busy anddiplomats the out bring Wills at getwho clinicians the negotiators, the theimmediately, line bottom the to forflair a with questioners insightful theof One question. research key the theseknow to getting is job this of joys helpingand people, young brilliant rewardingmost the into them launch world. the in field | MARCH 2020| MARCH

- impor also are skills Communication First and foremost, you foremost, and Miller: First Dr. tant. This includes the ability to com- to ability the includes This tant. want physicians who care about care who physicians want future identifying Then, patients. who people finding about is leaders their of outside engage to willing are startwith could This zone. comfort and group, a or program a leading be can potential leadership their these handle they how on assessed leaders emerging the If assignments. an as it use and assignment, the enjoy might you then grow, to opportunity hands. your on leader future a have FINDING THE NEXT GENERATION FINDING THE NEXT GENERATION OF LEADERS do you Kim: What qualities Dr. leaders while potential look for in mentoring them? you’re of power) is meeting a potential newpotential a meeting is power) of someoneit’s If dinner. for colleague - simi a from someone or know you talkmight you then background, lar experiences.or friends mutual about orknow don’t you someone it’s If overlapsocietal less has who someone con- restrict might you then you, with professionaland research to versation theObviously accomplishments. isconversation social engaging more stiltedmore the than appealing more interviewerthe and one, professional a have they that feeling up end may personthe with connection closer mirrorslife and background whose - bet a be would they that and theirs, to tend We job. the for choice ter recommendand promote and choose diversityseeking ourselves; like people intentionalrequires inclusiveness and practiceand preparation and thought toapples compare really to order in professionally. apples RETINA TODAY

42 s RETINA WOMEN 0320rt_Cover_Miller Haller.indd 42 RETINA WOMEN s THE PATHWAY TO THE PODIUM Get involved in as many activities as you can.

BY TALA AL-KHALED, BA; AND ANN-MARIE LOBO-CHAN, MD

career path is a journey involving various phases of FINDING YOUR NICHE development. Traveling along that path requires you Identify a subject about which you are passionate, such to demonstrate initiative and dedication to the field. as a specific disease, and choose the realm in which you Consider taking some of the following steps dur- wish to work (benchwork, clinical trials, educational pro- ing ophthalmology training and your early years of grams, global ophthalmology, etc.). Before initiating your Apractice to direct your path toward establishing yourself in project, it is of great value to conduct a search of the pub- your profession. lished literature on your topic of interest. This allows you to familiarize yourself with progress that has already been GETTING INVOLVED made in that field and can help you to identify aspects During residency and fellowship training, immerse yourself that have yet to be explored. After you have selected your in each subspecialty rotation, and identify the unique surgi- unique focus, the key is to strive toward becoming an cal or clinical aspects of that subspecialty that may interest expert on that topic. you. When you work alongside faculty, keep an eye out for Building your reputation stems from sharing your work their regularly scheduled lab meetings or journal clubs. By with the community. It is important to set goals for each joining these activities, you can expand your knowledge and stage of your projects so that you can prepare updates to identify mentors and potential projects. Early in practice, join present at annual meetings. Delivering oral presentations at your local ophthalmologic and subspecialty societies as a smaller meetings, academic institutions, or through webi- way of staying informed and involved; this will also give you nars is a way to highlight your findings and create forums opportunities to meet colleagues in your field. for discussion. When you submit an abstract, allow time for you and your SHOWING UP team to compose and later revise your submission. Ultimately, At every stage in your career, it is important to attend contributing to the scientific community through publications annual ophthalmology meetings, including both large-scale international conferences and more intimate subspecialty symposia. International meetings allow you to connect with AT A GLANCE colleagues from around the world and learn about diag- s nostic and surgical advances occurring in other countries. Join committees and societies to get involved, Exposure to current developments allows you to ask ques- informed, and noticed. tions and may inspire new ideas. Smaller meetings can pro-

vide more interpersonal communication with presenters and s facilitate opportunities for collaboration and mentorship. Seek out what’s interesting to you and become the When you attend an annual meeting, step outside the expert; know your topic and share your knowledge. conference rooms to network at the social events, as this s is where colleagues become friends and seeds of ideas for Find a mentor who can guide you toward opportu- future projects and collaborations may develop. nities in your field for presenting and developing If your ability to attend meetings is limited, participate in webinars and online discussions. These are becoming more research; as you advance, you can then in turn be a readily available and are now provided by many meetings mentor to others. and societies.

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n n

When you find a person whoperson a find you When We’re a strong couple and weand couple strong a We’re I would tell them to developto them tell would I Yes, you need to mesh very well.very mesh to need you Yes, As you progress along the path- the along progress you As Jerry: Jerry: Carol: Carol: Jerry: Jerry: Carol: at Chicago College of Medicine, Chicago at Chicago College of Medicine, Chicago of Ophthalmology & Visual Sciences, University of Illinois at Chicago, Illinois Eye and Ear Infirmary, Chicago [email protected] Financial disclosures: Consultant (Alcon, Novartis, Phoenix Technology) Fourth-Year Medical Student, University of Illinois Fourth-Year Medical Student, [email protected] Financial disclosures: None Co-Director of Uveitis Service, Department

ANN-MARIE LOBO-CHAN, MD way of your career, it is important to important is it career, your of way ongoing in Partake proactive. remain inves- subspecialty, your in activities you, intrigue that areas subject tigate building By expert. the become and be you’ll steps, these with career your path career your in succeed to able podium. the to way your make and n n CONCLUSION CONCLUSION TALA AL-KHALED, BA n n n n couple or as a family, and not just you just not and family, a as or couple person. single as a close relationship and try to keep itkeep to try and relationship close a successfulvery been We’ve way. that oursupporting always regard, that in family. our and children own understands you and your specialty,your and you understands understandwill They treasure. a that’s towant you night Thursday every why day.next the rounds grand for prepare have similar interests, but Jerry and I,and Jerry but interests, similar have athink, I is, Jerry alike. exactly not we’re moreI’m and guy, happy-go-lucky more differencesour And organizer. an of well. other each complemented have

I would tell them three them tell would I It takes a lot of organization of lot a takes It Jerry: Jerry: Carol: paving your way to speaking roles.speaking to way your paving careeryour to look you mentee, a As tomeetings on advice for mentors becometo opportunities and attend to interests your Express involved. work your presenting including them, bemay mentors your as meetings, at rolestheir through you help to able plan- on or organizations meeting in throughrise you As committees. ning yourwhen and ranks, professional the been already has podium the to path mentor- a on take then can you paved, recentlyor Trainees yourself. role ship wishmay ophthalmologists specialized taketo and work your about learn to projects.ongoing your in positions on colleagues,junior these promoting By ownyour improve only not can you helpalso but field the to contributions independent own their foster to them attendto unable are you If projects. col- junior a send can you meeting, a gainto place your in mentee or league widera and presenting in experience field.your in those from recognition things. Number 1, be yourself, and yourself, be 1, Number things. Number else. anybody be to try don’t make matures, relationship this as 2, And communicate. always you sure con- to careful be always 3, number a yourselvesas of needs the all sider ADVICE FOR YOUNG DOCTORS IN ADVICE FOR YOUNG DOCTORS IN SIMILAR CIRCUMSTANCES retina two young RT: Imagine it off are who have hit specialists your date. Given on their first going of advice what piece experience, give? would you to have a big family. No matter what matter No family. big a have to it’s not or whether in, you’re field work- two are there when medicine, job big a it’s family, the in people ing kids. of lot a having We didn’t initially have time have initially didn’t We | MARCH 2020| MARCH

Throughout your career, yourcareer, your Throughout In addition to attending and present- and attending to addition In - inter your communicate you When Carol: theon candle lit a had always We mentors play an important part inpart important an play mentors ing at meetings, consider joining a com- a joining consider meetings, at ing role. designated a on taking and mittee committeea on participating Actively demon- only not will year after year butfield the to dedication your strate mem- senior to you introduce also may inpartake to you invite may who bers youAs activities. or committees other youramong presence your establish on take to opportunities colleagues, orga- as such arise, may roles leadership andspeakers, inviting meetings, nizing discussions. panel constructing MENTORING MENTORING ests and end goals to your mentors,your to goals end and ests submis- the on you guide help can they processes. presentation and sion VOLUNTEERING is the cornerstone to establishing your establishing to cornerstone the is field. chosen your in expertise (Continued from page 33) from (Continued table. We still do. It symbolizes thesymbolizes It do. still We table. forhere all are we that and unit family other. each in our practice, but always slipped timeslipped always but practice, our in familythe with vacations take to aside practice. the build to later then and first we when night date a on go to organized we but family, a started us give to lives our around office our early opened office Our time. more check could we so morning, the in tests, imaging complete patients, in every- have and examination, provide could we that so up wrapped thing dinner for home get to time in finish it made I and Jerry children. our with so 6:00 or 5:00 by home be to point a every family a as dinner ate we that night. single RETINA TODAY

44 s RETINA WOMEN 0320rt_Cover_Shields_Cover_Lobo-Chan.indd 44 ADVERTORIAL New Generation Lasers: How They Differ

Sponsored by Quantel Medical The Role of the New Generation of Lasers in Retina BY VICTOR CHONG, MD, FRCS, FRCOPHTH

Through the years, laser has evolved dramatically. SUBTHRESHOLD LASERS AVAILABLE ON THE MARKET Although intravitreal injec- SubLiminal Endpoint management/ Nanosecond/Rejuvenation tions have become the first Non-damaging line of treatment of macular Duration of laser in 0.1 ms 10 to 20 ms 0.000003 ms pathologies such as diabetic macular edema each pulse (DME), laser application within clinical settings continues to prove efficacious in OCT change after None visible Clearly visible Seen in some cases treatment macular conditions. When introduced more than 50 years AF imaging after None visible Clearly visible No published data but RPE changes ago, macular laser was initially used as a treatment visible on color fundus photos photocoagulator to destroy lesions. Today, Randomized Several in DME None Reduced AMD progression the newest lasers can be customized to controlled trials and CSC (in post-hoc analysis) deliver energy in different ways by varying published power settings, shortening duration, and employing a train of pulses to achieve a tar- Figure 1. Comparison of available subthreshold lasers available on the market. geted endpoint. To fully comprehend how This was considered to be the threshold point minimal damage, less-invasive laser treat- new lasers are different from each other, separating the power needed to cause a color ments were introduced. This paved the and to ensure its proper clinical use, it is change in the neurosensory retina during the way for subthreshold laser photocoagula- important to examine how and why lasers procedure visible to the surgeon. As some tion. Subthreshold, using micropulsing, has work, how laser is delivered, and how the retinal specialists alternatively defined thresh- shown efficacy without any visible changes target tissue in the retina reacts. old as needing a clearly visible reaction, this on the retina.3 Indeed, if the energy is The evolution of the laser treatment of inherently led to the question, “If we don’t see reduced, the reaction can barely be seen, DME illustrates this topic well: a reaction, is the treatment effective?” and we are able to achieve a positive clinical At the very beginning, we simply learned effect with no visible scarring. to “shoot the red dots,” in order to perform CONVENTIONAL VERSUS Nowadays, three main types of subthresh- a direct coagulation of the leaking microan- SUBTHRESHOLD LASER old retina lasers are available on the market: eurysms. However, it was not uncommon PHOTOCOAGULATION Endpoint Management (Topcon) to miss these microaneurysms and to dis- Conventional continuous-wave laser is based on continuous delivery with cover that the treatment remained effective. photocoagulation has been used to treat decreased power levels and duration in We gradually learned that most of the different macular retinal diseases for many an attempt to achieve no visible scar- laser energy is absorbed primarily by mela- years. As an example, the treatment set- ring with positive clinical effect. Though nin in the retinal pigment epithelium (RPE) tings for DME were defined by the ETDRS this approach makes sense in theory, it is and the choroid. Furthermore, it is believed study in 1987.1 These treatment settings unclear how this translates in clinical prac- that the energy induces a change in the were thermal laser therapy and based on tice. To date, there is only one case series4 RPE cells, changing the micro-environment, the idea of obtaining a clearly visible reac- showing clinical success without retinal which improves the edema instead of directly tion while lasering. Reported complications damage on central serous chorioretinopa- destroying the microaneurysms. This led to in patients with DME who undergo ETDRS thy (CSC). There are no controlled trials a debate of “light” versus “classic” laser treat- laser include scotoma, visual field defects, published in the treatment of DME, howev- ment for clinically significant DME. The idea and chorioretinal atrophy.2 er, independent investigators have reported was to reduce power to obtain a barely visible To address these risks, and to implement scarring and changes to RPE visible by using burn but still have microaneurysm absorption. a process of delivering more energy with fundus autofluorescence imaging and OCT.

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rt0320_Quantel_insert.indd 45 3/9/20 9:57 AM New Generation Lasers: How They Differ ADVERTORIAL

I wonder what other retinal diseases could be treated? Evidence supports SubLiminal laser therapy can be used to supplement treatment in idiopathic polypoidal choroidal vasculopathy cases with suboptimal response to anti-VEGF treatment. Currently, there are several clinical trials using SubLiminal laser therapy for AMD. The goal is to show that SubLiminal laser therapy could also remove drusen and potentially slow the evolution of AMD without the limits of 2RT.

CONCLUSION What we know today about SubLiminal Figure 2. SubLiminal laser therapy treatment: Train pulse. laser therapy encourages us to move away The 2RT nanosecond laser (Ellex) is and no detectable photoreceptor loss. from using conventional laser for macu- using similar specifications to selective This further results in the improvement lar treatment. In addition to the study of laser trabeculoplasty (SLT laser). 2RT treat- of retinal sensitivity in edematous retina SubLiminal laser therapy on AMD, there ment energy is based on power testing to a and reading speed, while also preventing are other exciting studies taking place right threshold color change and uses short pulse retinal damage. now to examine SubLiminal laser contribu- duration (0.000003 ms) and multiple beams The latest SubLiminal laser uses a 577-nm tions to other retinal diseases, including delivered at 400-μm spot size (Figure 1). true yellow wavelength that provides peak retinitis pigmentosa, Stargardt disease, and 2RT is thought to cause RPE death without absorption of oxyhemoglobin, excellent geographic atrophy. I encourage you to damage to the retina. Nevertheless, it is lesion visibility, low intraocular light scat- monitor future updates, follow industry causing some “RPE changes,” which could tering and pain, and negligible xanthophyll leaders conducting ongoing studies, and be considered as scarring. absorption. With these absorption charac- implement the technologies available to Its use to stimulate a natural, biological teristics, the subliminal laser 577-nm yellow you today. n

healing response to slow the degenerative wavelength has the versatility of the 532-nm 1. Treatment techniques and clinical guidelines for photocoagulation of diabetic macular edema. process that causes retinal diseases, such as green wavelength yet causes less scatter, uses Early Treatment Diabetic Retinopathy Study report number 2. Ophthalmology. 1987;94:761-774. 6 2. Schatz H, Madeira D, McDonald HR, et al. Progressive enlargement of laser scars follow- intermediate age-related macular degenera- lower energy levels, and also allows titration ing grid laser photocoagulation for diffuse diabetic macular edema. Arch Ophthalmol. tion (iAMD), has recently started to garner as compared with 810-nm infrared laser. 1991;109(11):1549-1551. 3. Berger JW. Thermal modelling of micropulsed diode laser retinal photocoagulation. Lasers in some attention. However, a controlled clini- Surgery and Medicine. 1997;20(4):409-415. cal trial (LEAD study5) demonstrating the CLINICAL STUDIES SHOWING THE 4. Lavinsky D, Palanker D. Nondamaging photothermal therapy for the retina: initial clinical experience with chronic central serous retinopathy. Retina. 2015; 35(2): 213-222. slowing of AMD progression failed to meet BENEFITS OF SUBLIMINAL LASER 5. Guymer RH, Wu Z, Hodgson LAB, et al. Subthreshold nanosecond laser intervention in age-related macular degeneration: The LEAD randomized controlled clinical trial. Ophthalmology. its targeted endpoint. Only a post-hoc anal- Quantel Medical’s technology allows a 2019 Jun;126(6):829-838. doi: 10.1016/j.ophtha.2018.09.015. Epub 2018 Sep 20. ysis excluding the reticular pseudodrusen combination of multispot and SubLiminal 6. Mainster MA. Wavelength selection in macular photocoagulation. Ophthalmology. 1988;93:952-958. demonstrated a slowing of the pathology, delivery modes and features a customizable 7. Scholz P, Ersoy L, Boon CJ, et al. SubLiminal micropulse laser (577 nm) treatment in chronic so it remains to be seen how effective 2RT macular grid allowing the surgeon to central serous chorioretinopathy. Ophthalmologica. 2015;234(4):189-194. will be. customize the treatment area of the SubLiminal laser therapy (Quantel edema on the macula. In CSC, studies7 Victor Chong, MD, FRCS, FRCOphth Medical) offers laser energy delivery have demonstrated that SubLiminal n C onsultant Ophthalmic Surgeon, Optegra Eye Hospital, through a series of extremely short laser therapy is a promising alternative London, United Kingdom (microsecond) laser pulses (Figure 2). treatment strategy. The study concluded n v [email protected] SubLiminal laser therapy is based on a that SubLiminal laser is an effective n Financial disclosures: Consultant (Quantel Medical), stimulation concept, which allows for a treatment even in patients without Employee (Boehringer Ingelheim International GmbH) cooling period between pulses resulting sufficient improvement after photodynamic in no visible scarring (even with fundus therapy. As I am confident in SubLiminal This manuscript is not endorsed by Boehringer Ingelheim, autofluorescence imaging and OCT), laser therapy for treating DME and CSC, and it was written as the personal opinion of the author.

46 INSERT TO RETINA TODAY | MARCH 2020

rt0320_Quantel_insert.indd 46 3/9/20 9:57 AM SPECIAL REPORT s PREDICTORS OF NEOVASCULAR GLAUCOMA IN CENTRAL RETINAL VEIN OCCLUSION Investigators explored ways to identify patients at increased risk of developing glaucoma or experiencing disease progression.

BY CISSY YANG, MD; AND NOGA HARIZMAN, MD

Rong AJ, Swaminathan SS, Vanner EA, Parrish RK 2nd1 Industry support: No

STUDYs IN BRIEF A retrospective cohort study found that a history of systemic hypertension, worse visual ABSTRACT SUMMARY acuity, and the presence of a relative afferent pupillary defect at presentation were risk For this retrospective cohort study, factors for developing neovascular glaucoma (NVG) after central retinal vein occlusion (CRVO) investigators identified clinical risk factors and that intravitreal anti-VEGF injections delayed but did not prevent the onset of NVG. for the development of neovascular glaucoma (NVG) after central retinal WHY IT MATTERS vein occlusion (CRVO). They reviewed s the charts of 646 patients with CRVO NVG is a rare but potentially visually devastating complication of CRVO. To date, physicians’ who presented to the Bascom Palmer ability to predict which patients will develop NVG after CRVO is limited. These investigators Eye Institute between 2013 and 2017. examined demographic data, systemic health data, and ophthalmologic examination findings Ninety-eight of these patients met the to identify potential risks factors that may signal which patients are at increased risk of study’s inclusion criteria: CRVO onset developing NVG. These patients may then be monitored more closely and for longer durations within 90 days of presentation, no to allow prompt identification and treatment of neovascularization and thus prevent vision anterior segment neovascularization loss from glaucoma. on presentation, and no history of receiving an intravitreal anti-VEGF injection. Thirteen of the 98 patients (13%) developed NVG during an average risk of developing NVG. Age at edema nor central retinal thickness at follow-up duration of 17 months (range, presentation, sex, body mass index, presentation was associated with an 0.4–66.6 months). The mean time to systolic or diastolic blood pressure at increased risk of NVG, which suggests NVG onset was 421 days after initial the initial visit, a history of diabetes, that macular edema and NVG are presentation and 212 days after the last degree of diabetic retinopathy, and independent sequelae of CRVO. intravitreal anti-VEGF injection. IOP at presentation did not differ Patients who had a history of significantly between patients who DISCUSSION systemic hypertension (P = .026), developed NVG and those who did not. What was the relationship between a worse visual acuity on initial An anti-VEGF injection at the first visit intravitreal anti-VEGF injection and a presentation (P = .034), or a relative did not reduce the risk of developing patient’s risk of developing NVG? afferent pupillary defect (RAPD, NVG, but it did delay the onset of Commonly referred to as P = .002) were found to be at high NVG. Neither the presence of macular 100-day glaucoma, the conversion to

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0320rt_Fellows_Special Report.indd 47 3/9/20 12:16 PM s SPECIAL REPORT

NVG after CRVO has been thought risk of developing NVG. Furthermore, only one (4%) developed NVG. The to occur within the first 3 months although anti-VEGF therapy has been investigators recommended monitor- after CRVO onset. This impression shown to be effective for treating ing patients who present with these is based on CRVO natural history CRVO–related macular edema, this clinical signs at closer intervals and studies conducted before the era form of therapy did not decrease informing them of their increased of anti-VEGF therapy. Rong and patients’ risk of developing NVG risk of neovascularization so as to colleagues found the time to NVG in this study. Macular edema and facilitate timely treatment and refer- onset to be significantly longer than NVG therefore may be independent ral for subspecialty care. Patients with the commonly accepted 100 days, and sequelae of CRVO, as noted earlier. CRVO who later develop an RAPD or they found no significant difference in The researchers cautioned against who experience a sudden decrease the rate of NVG between patients who mistakenly associating improved in vision should alert their providers; received anti-VEGF therapy and those macular edema with decreased NVG these changes may signal conversion who did not. The researchers con- risk because the assumption could from nonischemic to ischemic CRVO cluded that anti-VEGF therapy may give physicians a false sense of secu- and a higher risk of NVG. n reset the clock, so to speak, and delay rity about extending the duration 1. Rong AJ, Swaminathan SS, Vanner EA, Parrish RK 2nd. Predictors of NVG onset but that therapy does not between follow-up visits after CRVO. neovascular glaucoma in central retinal vein occlusion. Am J Ophthalmol. decrease a patient’s risk of developing 2019;204:62-69. NVG. Their findings suggest that eye How can the findings from this study care providers should observe CRVO affect the clinical management of patients receiving anti-VEGF injections patients with CRVO? NOGA HARIZMAN, MD closely for neovascularization beyond Clinical features associated with n Assistant Clinical Professor, New York Eye and Ear the traditional 90 days. an increased risk of NVG included a Infirmary of Mount Sinai, New York history of hypertension and worse n [email protected] What is the relationship between visual acuity or RAPD on presenta- n Financial disclosure: None macular edema and the risk of tion. There was an increased risk of developing NVG? NVG for every 0.5-logMAR decrease CISSY YANG, MD Rong and colleagues did not find an in visual acuity at presentation. n Resident, New York Eye and Ear Infirmary of Mount association between macular edema Furthermore, of the 25 eyes with an Sinai, New York or central retinal thickness and the initial visual acuity of 20/50 or better, n [email protected] n Financial disclosure: None

1. Uhr JH, Obeid A, Wibbelsman TD, et al. Delayed retinal breaks and detachments after acute posterior vitreous detachments [published online ahead of print October 23, 2019]. Ophthalmology. WANT TO DIVE DEEPER ON PROTOCOL V? 2. Tasman WS. Posterior vitreous detachment and peripheral retinal breaks. Trans Am Acad Ophthalmol Otolaryngol. 1968;72(2):217-224. In the September issue of Retina Today, Chirag Jhaveri, MD, an executive committee member 3. Dayan MR, Jayamanne DG, Andrews RM, Griffiths PG. Flashes and floaters as predictors of vitreoretinal pathology: is follow-up necessary for posterior for the DRCR Retina Network, examined Protocol V. Read “DME and Good Vision: Do We Need to vitreous detachment? Eye. 1996;10(Pt 4):456e458. Treat Early?” at bit.ly/Jhavari0320. 4. Baker CW, Glassman AR, Beaulieu WT, et al; DRCR Retina Network. Effect of initial management with aflibercept vs laser photocoagulation vs observation on vision loss among patients with diabetic macular edema involving the center of the macula and good visual acuity: a randomized clinical trial. JAMA. 321(19):1880-1894.

(Continued from page 21) and good vision can be observed SECTION EDITOR THOMAS L. JENKINS, MD although there was a borderline sta- initially. With this strategy, most n Second-Year Vitreoretinal Fellow, Wills Eye tistically significant decrease in 2-step patients will retain good vision, and Hospital, Philadelphia worsening of diabetic retinopathy those with functional or anatomic n [email protected] severity level in the aflibercept group worsening may be treated with anti- n Financial disclosure: None compared with the observation group VEGF without sacrificing final visual (4% vs 11%, P = 0.05). acuity at 2 years. This has significant SECTION EDITOR RAVI R. PANDIT, MD, MPH implications for individual treatment n Second-Year Vitreoretinal Fellow, Wills Eye SIGNIFICANCE burden as well as the public health Hospital, Philadelphia Overall, this study lends confi- expenditures associated with anti- n [email protected] dence that patients with CI-DME VEGF treatment. n n Financial disclosure: None

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Dr. Packo with his show-stopping 1956 Thunderbird. His love of toys shows. Dr. Packo with his show-stopping 1956 Thunderbird. His love Remember, you’re on stage. Make it memorable, make it make memorable, it Make stage. on you’re Remember, workahol- a of bit a creative, as me describe people Most Professor and Chairman of the Department of Ophthalmology and Director of Professor and Chairman of the Department of Ophthalmology and Director of the Retina Section at Rush University Medical Center, Chicago [email protected] Financial disclosures: None visually exciting, not just a boring sea of numbers and text.and numbers of sea boring a just not exciting, visually once—keepat information much too give to try don’t Also, audienceon smile a Put entertaining. it keep and moving it fun. have and something, them teach you while faces members’ creativ- The presentations. great gives who someone and ic, drama a was I that fact the and father my from came ity and York New in acting studied actually I college. in major directing and acting My living. a for that do to planned and teacher a as life my to backbone great a as served days that in improv, to similar is patients Seeing speaker. public important. all are speaking, just not reacting, and listening patients your to Listening same. the do to need Doctors key. is comments their with working and KIRK PACKO, MD, FACS n n n AS A PROLIFIC AND IN-DEMAND PUBLIC SPEAKER, WHAT SPEAKER, WHAT AS A PROLIFIC AND IN-DEMAND PUBLIC ADVICE DO YOU GIVE TO NOVICE SPEAKERS? HOW WOULD YOUR COLLEAGUES DESCRIBE YOU?

. In recognition of this, at at this, of recognition In Times. Retina | MARCH 2020 | MARCH KIRK PACKO, MD, FACS MD, PACKO, KIRK Although my role as a teacher to my residents and and residents my to teacher a as role my Although As a kid, I loved to take toys apart to see how thingshow see to apart toys take to loved I kid, a As One of the biggest influences in my life was my father. He father. my was life my in influences biggest the of One fellows is probably the most personally rewarding, the the rewarding, personally most the probably is fellows for involvement my is of proudest I’m accomplishment Retina of Society American the of board the on years 20 it Society, Vitreous the as Founded (ASRS). Specialists this viewed I retina. for society open truly only the was for representative it make help to opportunity great a as brokered I retina. things all does that organization all—an Survey, PAT the started and ASRS to change name the and Festival, Film Packo the established board the meeting annual 2019 the the to contributions exceptional recognizes which Award, me for honor overwhelming an is This field. our and ASRS some- now, from years 100 that, think To family. my and - mind-bog is Award Packo the with honored be will one deserve to accomplished has person that Whatever gling. the as honor the of proud as is she or he hope I award, the name. the behind guy worked and to think of ways to make them better. My firstMy better. them make to ways of think to and worked scis- intraocular vibrating for was 1990s early the in patent based was and fellowship my during came idea The sors. plastica was Snippy Snippy. called child a as had I toy a on scienceThe shear. tremendous but jaws, vibrating with fish Isurface. retinal the to perfectly itself lent toy the behind thor- to is it critical how fellows and residents my teach also them.behind science the and instruments your know oughly instru- making in interest my fueled only not principle This thisTo surgeon. better a me made also but better, ments use. I tool every understand scientifically to try still I day, was a professional photographer, so I grew up with opticswith up grew I so photographer, professional a was Ophthalmology focus. and iris, diopters, like lingo and ofis, photography because me to language same the spoke wantedI learned dad my When visual. the about all course, perfec- a was He thrilled. was he ophthalmology into go to triedI’ve artist. extraordinary an also but work, his in tionist afor terrific only not are which qualities, those emulate to surgicalOur surgeon. a for vital also are but photographer whatto art an is certainly there but perfect, be must efforts doctor.eye great a made have would dad My do. we WHICH PROFESSIONAL ACCOMPLISHMENT ARE YOU MOST ARE YOU MOST WHICH PROFESSIONAL ACCOMPLISHMENT PROUD OF? DESCRIBE YOUR INTEREST IN SURGICAL INSTRUMENT INSTRUMENT DESCRIBE YOUR INTEREST IN SURGICAL DEVELOPMENT. YOU’VE STATED THAT WHEN YOU DISCOVERED WHEN YOU DISCOVERED YOU’VE STATED THAT FELT LIKE HOME. WHY IS THAT? OPHTHALMOLOGY, IT RETINA TODAY

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