- - - - And it did much more: It helped mehelped It more: much did it And patients the to speaking When mehelped also has experience This to better educate the patients in myin patients the educate better to howmatter No practice. clinical daily sur cataract or vitrectomy a routine theresurgeon, the to seem may gery can we and involved, risks always are completely.risks those eliminate not informcarefully always must we Thus, takewe before patients educate and OR. the into them my career in the direction of otherof direction the in career my trials clinical and surgeries innovative Palmer. Bascom at the appreciate and understand truly counsel preoperative careful of value expectationsrealistic setting and ing treat new undergoing patients for experiencesthe observing After ments. IIArgus an receiving patient my of carefullyto sure make now I implant, oflimitations and risks the explain whopatients to options vision artificial technology. the in interested are gene choroideremia the in enrolled for Palmer, Bascom at trials therapy understand they sure make I example, vision their that involved: risks the the that improve, not may or may they vision what preserve to is goal own its has surgery the that and have, to minimize course of we which risks, abilities. our of best the - - - For me as a retina surgeon, it wasit surgeon, retina a as me For limits as a surgeon, opened my mindmy opened surgeon, a as limits launchedand learning, continuous to ONE CASE, MANY LESSONS LEARNED ONE CASE, MANY LESSONS LEARNED toable be to rewarding incredibly irreversiblyan with patient a treat previouslyhad who condition blinding awas It options. therapeutic no had closea develop to opportunity unique patientthe with connection personal com frequent through family her and viaand institute the at munication thisaddition, In telephone. and emails mypushed procedure groundbreaking sort light and dark clothes, see light see clothes, dark and light sort the identify windows, the in coming even and refrigerator, the on handle and numbers, letters, some identify screen. computer a on words simple recognize however, cannot, She environ the in people and objects read. or faces, see consistently, ment the with frustrated is she times, At the and vision bionic of limitations while feels she exhaustion mental associ activities for II Argus the using living. daily with ated vision requires daily practice and hard hard and practice daily requires vision intense an had patient The work. her of ahead process rehabilitation the of sense make to her help to light identify to able now is She lights. backgrounds, dark againstobjects - -

years since devel since years By Ninel Z. Gregori, MD patient 52-year-old A nothingseen had who forlight weak but 19

Three retina specialists share stories of patient encounters that left lasting impressions. patient encounters that left lasting share stories of Three retina specialists CASES THAT CHANGED THE THE CHANGED THAT CASES PRACTICE WE WAY | OCTOBER 2018

The surgery lasted more than more lasted surgery The After a visit to the University ofUniversity the to visit a After planned. After the patient had healed had patient the After planned. programmed we weeks, several for it turned and prosthesis retinal the and mesmerized was patient The on. new the by confused simultaneously Artificial saw. she lights fluttering protocol with diagrams and sketchesand diagrams with protocol surgicalmy lead to ready was and Bascomat case first our on team 2014. in Palmer as went everything but hours, 4 A BASCOM PALMER FIRST A BASCOM PALMER FIRST Markwatch to California Southern OlmosLisa and PhD, MD, Humayun, Argusan implant MBA, MD, Koo, de surgicalown my drafted I patient, a in US FDA had approved the first retinalfirst the approved had FDA US dis I RP. with patients for prosthesis ProsthesisRetinal II Argus the cussed thewith Sight) (Second System awas she that agreed we and patient, implant. the receive to candidate good oping end-stage retinitis pigmentosaretinitis end-stage oping 2013,in Then, care. my into came (RP) artificialof promise long-awaited the the because reality a became vision LET THERE BE LIGHT BE THERE LET RETINA TODAY

54 CONSEQUENTIAL CASES CONSEQUENTIAL CASES s CONSEQUENTIAL CASES s

TEAMWORK MAKES THE DREAM WORK It taught me to keep my mind open 31 patients as part of phase 1/2 and In 2018, I became one of the sur- when listening and to consider the phase 3 gene therapy trials, learning geons at Bascom Palmer to perform expertise of others, while at the same new subretinal injection techniques subretinal injections of the first FDA- time trusting my own abilities as a and designing safer, more controlled approved ocular gene therapy, voreti- surgeon. Participating in these trials surgical approaches. I look forward to gene neparvovec-rzyl (Luxturna, Spark has also helped me to understand that performing more innovative surgeries Therapeutics), for treatment of Leber a team approach with talented junior as my lifelong learning continues. congenital amaurosis or severe early and senior colleagues is the ultimate onset RP due to biallelic mutations of path to surgical excellence and better the RPE65 gene. Participating in gene outcomes for patients. NINEL Z. GREGORI, MD therapy and stem cell therapy trials at It is important to continue to n Associate Professor of Clinical Ophthalmology, Bascom Palmer years after completing evolve throughout our careers. Since Bascom Palmer Eye Institute, Miami, Florida my vitreoretinal fellowship opened my that first patient, I have implanted n [email protected] mind to incorporating input from oth- three more Argus devices and have n Financial disclosure: Grant Support (Nightstar ers regarding my surgical technique. participated in gene therapy for Therapeutics) AN UNUSUAL PRESENTATION OF HORV By Tarek S. Hassan, MD Later that evening, the patient called (EVS) would recommend continued I have been in clinical complaining of worsening pain and observation over vitrectomy. But the practice for more than decreased vision. He was examined significant pace and worsening severity 20 years, and I still try within an hour and was found to have of symptoms, even over the course to learn something increased anterior chamber fibrin, of 1 day, gave us pause. The patient new each time I am in the office or more vitreous opacities, a poorer view returned the following day, less than OR. However, it has been quite a of the posterior segment, and visual 48 hours after initial presentation, with while since a case has fundamentally acuity that had decreased to 20/800. light perception vision, unchanged changed how I manage patients as He was reassured that often after pain, and an anterior chamber much as the one I detail below. injection of antibiotics for endophthal- with more fibrin but no hypopyon mitis there is a short period when the (Figure 1). B-scan still demonstrated A STRAIGHTFORWARD CASE OF clinical picture appears worse because only mild to moderate vitritis. ENDOPHTHALMITIS? of increased inflammation. Topical We proceeded with vitrectomy later Two years ago, a 60-year-old obese steroids were increased. No gram stain that evening, which began with remov- and hypertensive man was referred report was yet available from the vitre- al of the prominent central fibrin clot. to me with pain and decreased vision ous tap done a few hours earlier. With our improved view, we found a (20/200) in his right eye 3 days after nearly confluent hemorrhagic retinitis uncomplicated cataract extraction. RECONSIDERING THE DIAGNOSIS with no retinal detachment and only His medical history was unremarkable. The patient returned the next day mild vitreous inflammatory debris At presentation, his eye displayed with no relief of his pain, a rise in (Figure 2). We diagnosed hemorrhagic injection and he had a mild subcon- IOP to 30 mm Hg, increased corneal occlusive retinal vasculitis (HORV). junctival hemorrhage. He had 2+ cells, edema, and vision that had dropped to We completed a simple vitrectomy trace fibrin in the anterior chamber, hand motions. B-scan ultrasonography and sent vitreous fluid for bacterial and and no hypopyon. His fundus was showed that the retina was attached fungal cultures, universal bacterial and visible, although the view was slightly and there was only mild vitritis. At fungal primer polymerase chain reac- hazy. We noted a few scattered intra- only 1 day after the tap and inject, we tions, viral polymerase chain reactions retinal hemorrhages in the posterior were concerned about his worsening for herpes simplex virus, varicella zoster pole but otherwise noted no remark- clinical picture and discussed the virus, and cytomegalovirus, and patho- able findings. We made a diagnosis of possibility of repeat antibiotic injec- logic evaluation. All of these studies endophthalmitis and proceeded with tion but more likely vitrectomy. The were negative. We initiated a uveitis a vitreous tap and injection using 1 mg patient had postcataract endophthal- workup for common inflammatory and of vancomycin and 2.25 mg of ceftazi- mitis with hand motions vision. The infectious causes of retinal vasculitis, dime per our usual protocol. Endophthalmitis Vitrectomy Study and this was also entirely negative.

OCTOBER 2018 | RETINA TODAY 55 ------1 There had been no prior reports ofreports prior no been had There At presentation, this patientthis presentation, At thought some of the immediate visualimmediate the of some thought cornealincreased to due was decline fibrin. chamber anterior and edema theprolonged have may delay This isch segment anterior severe of effects significantpersistent, caused that emia oldthe by more swayed were We pain. canthere that fact the and dogma EVS bothin worsening clinical initial an be initially, but did so after the vitrectomy.the after so did but initially, intracam used he that us informed He I surgery. his during vancomycin eral dosesecond our that concerned am havemay vancomycin intravitreal of initialthe of effects the compounded theworsening thereby vancomycin, HORV. patient’s the of severity inHORV of form endophthalmitic an sus not did we thus and literature, the Although presentation. initial at it pect intraretinalmild of couple a saw we theyvisit, initial the at hemorrhages indescribed that like nothing looked Thus,presentation. HORV classic the cataractthe ask specifically not did we intracameralused had he if surgeon intra our initiating before vancomycin alsoWe treatment. antibiotic vitreal maythan longer so or day a waited thetaking before ideal been have visionhis because vitrectomy to patient (theperception light than better was byintervention for suggestedthreshold weand stabilized, was pain his EVS), the vasculopathy without vasculitis,without vasculopathy choroiditis, nongranulomatous chronic prolifera glomeruloid unusual an and choroidthe in cells endothelial of tion than rather eye, the in elsewhere and hadwhich vasculitis, retinal overt an never but expected been traditionally pathologically. verified actually RETRACING OUR STEPS postcataract routine have to appeared proto standard Our endophthalmitis. specialists,retina most of that like col, anteriorand/or vitreous a perform to is chamber tap and injection of vancomy con not had We ceftazidime. and cin surgeoncataract patient’s the tacted that its pathophysiology is complex,is pathophysiology its that retinal necrotizing a by highlighted and found to have a diffusely necroticdiffusely a have to found and theof necrosis hemorrhagic severe iris, choroidthe of thickening body, ciliary theof infiltration lymphocytic with diffuseand uvea, posterior entire ofnecrosis fibrinoid and hemorrhagic of vasculitis without vessels retinal the Iand colleagues My itself. retina the everfirst these and case this reported entitythe of findings histopathologic emphasized and HORV as known | OCTOBER 2018

Figure 2. Intraoperative appearance showing a nearly confluent hemorrhagic retinitis with perivascular retinal Figure 2. Intraoperative appearance showing a nearly confluent hemorrhagic retinitis with perivascular retinal whitening. Figure 1. Appearance of the patient’s right eye on day 2. Figure 1. Appearance of the patient’s right eye on day 2. The eye was examined pathologically examined was eye The A week after vitrectomy, fluoresceinvitrectomy, after week A patient developed intractable eye pain,eye intractable developed patient perception light having despite and, withinenucleation requested he vision, presentation,initial after weeks 2 out. carried was which angiography showed nearly completenearly showed angiography in vasculature retinal the of occlusion periphery.the and macula the both aggressivewith treated being Despite thesteroids, systemic and topical FOLLOWING UP FOLLOWING UP RETINA TODAY

56 CONSEQUENTIAL CASES s CONSEQUENTIAL CASES s

the anterior and posterior chamber • In cases of suspected postsurgical more straightforward small-gauge vit- after intravitreal antibiotic injection in endophthalmitis, always ask the rectomy techniques, with results that endophthalmitis eyes than we were referring surgeon if intraocular van- may not be applicable today. alarmed by the rapid pace of decline comycin was given at the time of 1. Todorich B, Faia LJ, Thanos A, et al. Vancomycin-associated hemorrhagic and persistent pain in this patient’s eye. cataract extraction. occlusive retinal vasculitis: a clinical pathophysiological analysis. Am J • If I do not see the posterior pole Ophthalmol. 2018;188:131-140. LESSONS LEARNED with any significant detail to deter- Because of this case, I have changed mine if hemorrhages are present TAREK S. HASSAN, MD my approach to managing patients within 24 hours of intravitreal antibi- n Professor of Ophthalmology, Oakland University with severe postsurgical posterior otic injection—in the face of notable William Beaumont School of Medicine, Auburn segment inflammation and/or infec- worsening of vision or other clinical Hills, Michigan tion. Here are the lessons I learned findings—I am now much more likely n Senior Partner and Director of the Vitreoretinal from this particular case: to take the patient to vitrectomy Fellowship Training Program, Associated Retinal • There is no such thing as “routine” (even with vision appreciably better Consultants, Royal Oak, Michigan endophthalmitis. than light perception) rather than n Member, Retina Today Editorial Advisory Board • HORV can mimic bacterial follow old guidelines from the EVS, n [email protected] endophthalmitis. a study done in an era prior to safer, n Financial disclosure: None THE PILOT AND THE PRISONER By Michael A. Klufas, MD The first is from a mentor who to retinal detachments. The second As a physician at Wills once told me, “Every retinal detach- touches on the ethics of patient care. Eye Hospital, I treat a ment is like a snowflake; they are all a lot of retinal detach- little bit different.” The second is one MAKE TIME FOR NECESSARY ments, which isn’t too that I always share with my fellows TREATMENT surprising, given that it is a regional and when we have many add-on cases I have heard other retina surgeons worldwide referral center. Often, when that go into the evening: “We always express relief over a macula-off case, a vitreoretinal procedure becomes do a good job for every patient, even saying they can simply work it into common, it’s easy to take the operative if it is late.” their next scheduled OR day. I prefer approach or steps of the procedure Below I share two cases that have to determine the urgency of opera- for granted. That’s why, every time I had lasting effects on the way I practice. tive repair based on how long the step into the OR, I carry two pieces of The first highlights the importance macula has been off to ensure the advice from training with me. of never applying all the same rules best outcome. If the macula came © istockphoto

OCTOBER 2018 | RETINA TODAY 57 - © istockphoto n For patients with retinal detach retinal with patients For Faculty Member of the Retina Service, Wills Eye Faculty Member of the Retina Service, Wills Eye Retina Chief, Eyetube.net [email protected]; Twitter: @NJRetinaDoc Financial disclosure: None Hospital; Vitreoretinal Surgeon, Mid Atlantic Hospital; Vitreoretinal Surgeon, Mid Atlantic Retina; Assistant Professor of Ophthalmology, Thomas Jefferson University; all in Philadelphia, Pennsylvania     MICHAEL A. KLUFAS, MD n n n n ABOVE ALL, DO YOUR BEST ABOVE ALL, DO YOUR BEST the with high are stakes the ments, vitreoretinal the as intervention, first this at opportunity the has surgeon great a is It vision. restore to point and ability, this have to privilege I detachments retinal the of many several past the over treated have need the reinforce to continue years approach individualized an take to the do always to and case each to of regardless patient, each for best situation. the - - - - Chris explained his reasoning: that, reasoning: his explained Chris released the patient, never knowing never patient, the released committed. had he crime of sort what history should have no impact on the on impact no have should history my receives, she or he care of quality MD, Aderman, M. Christopher fellow, immediately spoke up, saying, “No, we ques this to answer the have cannot unethical.” is It tion. practitio medical as we though even treat not would we think may ners cannot we differently, any patient the sub our guarantee or predict always courseOf decision-making. conscious and treated we and right, was he presence of armed guards in the OR the in guards armed of presence The area. OR the outside just and repair detachment retinal patient’s general under performed be to was anes under was he After anesthesia. one asked staff OR the of one thesia, tell could he if guards armed the of incarcerated, was patient the why us of amount high unusually the given is there mind my in While security. social patient’s a that question no - - gas tamponade to maximizeto tamponade gas | OCTOBER 2018 6

On another occasion, a federal a occasion, another On This case was a reminder that notthat reminder a was case This Within 2 weeks, our patient’s vision patient’s our weeks, 2 Within I recently treated a commercial airline commercial a treated recently I days, for example, then I schedule schedule I then example, for days, ALWAYS PUT THE PATIENT FIRST ALWAYS PUT THE PATIENT FIRST Eye Wills to brought was prisoner detachment retinal a have to Hospital the required prison The treated. patient with a retinal detachment anddetachment retinal a with patient preoperative,the of note careful take deci postoperative and intraoperative, sions that affect patient outcomes. Read willseye.org/ at: case this about more patient/i-am-back-piloting-airliners/. return to flying the friendly skies. I skies. friendly the flying to return says he and patient, this saw recently years. 20 another for fly to plans he shoulddetachment macula-off every Weweek.” 1 within “done be necessarily eachfor judgment best our use to have was back to 20/25 in the affected eye, affected the in 20/25 to back was After success. a considered we which implan IOL and phacoemulsification patient’s the later, months 6 tation to him enabling 20/20, was vision breaks in the affected eye. I opted toopted I eye. affected the in breaks usingvitrectomy buckle a with proceed SF 25% andsuccess single-surgery of chance the adeveloping his of chance the limit to cataract. progressive to get the macula back on as quicklyas on back macula the get to tochance every him give to possible as tocontinue could he so vision regain ORSaturday’s that knew also I pilot. Thecases. six with packed was schedule multiplehad and phakic was patient inferotemporaland breaks superior he came to the Wills Eye EmergencyEye Wills the to came he awith presented and Department detachment retinal macula-off recent fellow,My vision. fingers counting with patientthe saw MD, Talcott, Katherine hadwe knew I and evening, Friday that 7 week. 1 within OR the in time flightsof series a started had who pilot Eastthe to back way his on was and his in curtain a noted he when Coast Philadelphia,in landed he After vision. off 1 day ago, I like to go to the OR OR the to go to like I ago, day 1 off for off been has it If day. 1 within RETINA TODAY

58 CONSEQUENTIAL CASES s