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Home , Cataract surgery, Corneal transplantation, Strabismus surgery

Physicians Update

FALL 2016 Issue

Corneal Transplantation p. 1

Molded p. 3

Cataract p. 6

Thyroid Disease p. 8

Strabismus p. 10

TRANSPLANT Improvements in Achieving Better Outcomes

Corneal transplantation is the most customized corneal transplantation,” says common and most successful type of human Anthony J. Aldave, MD, Walton Li Chair in transplant surgery. With improvements in and Uveitis and chief of the Cornea surgical approaches over the last decade, and Uveitis Division at the UCLA Stein Eye major eye centers such as UCLA are Institute. “Rather than always transplanting achieving better visual results with fewer the full-thickness cornea the way we used postoperative complications. to, we now replace only the portions of the cornea that are diseased. That means we are “There have been significant advances not altering the natural anatomy as much, as we have moved toward more continued on p. 4 treatment options available or imminent for UCLA with kidney, bladder or prostate cancer. UCLA Eye Care Robotic Technology Extends Locations Clinical Updates Minimally Invasive Colorectal Surgery Colorectal robotic-assisted surgery is the latest Learn about the Latest advance in minimally invasive procedures for UCLA Stein Eye Institute Advances from UCLA colon and rectal diseases, including colorectal Westwood cancers, diverticulitis and inflammatory bowel 100 Stein Plaza UCLA disease (ulcerative colitis and Crohn’s disease). Los Angeles, CA 90095 UCLA Adult Cystic Fibrosis Program (310) 825-5000 UCLA has an adult cystic fibrosis clinic focused on 4 for Patients with patients 18 years and older that provides careful Recurrent Glioblastoma attention to the seamless transition of pediatric This external beam radiation therapy, which UCLA Stein Eye Center patients to adult care. can deliver a dose of radiation more precisely, Santa Monica is currently available only at UCLA as part of a 1807 Wilshire Blvd., Suite 203 Low-Testosterone Diagnosis and Treatment Phase 1 clinical trial for patients with recurrent Santa Monica, CA 90403 A significant decline in testosterone can produce glioblastoma multiforme. (310) 829-0160 symptoms ranging from low sex drive and memory Spinal Deformity Program problems to fatigue and depression. Doheny Eye Center UCLA The Spinal Deformity Program at UCLA offers Pasadena Undiagnosed Diseases Network comprehensive clinical care services for infants, 625 S. Fair Oaks Avenue As part of the nationwide Undiagnosed Diseases children, adolescents and adults with scoliosis Network, UCLA’s Department of Human Genetics and other spinal deformity disorders. Suites 280, 285, 240, 227 and other clinical departments are now treating Pasadena, CA 91105 select patients at no cost to them or their insurance Pediatric Blood and Marrow (626) 817-4747 in an attempt to diagnose rare and difficult conditions. Transplant Program UCLA has been a pioneer in many alternative Doheny Eye Center UCLA Minimally Invasive Diagnoses and transplant protocols, including the use of Arcadia Treatment for Chest Diseases haploidentical bone-marrow transplantation, and 622 W. Duarte Road, Suite 101 UCLA’s Interventional Pulmonology Program continues to find new ways to improve survival Arcadia, CA 91007 offers an expanding list of minimally invasive rates and decrease complications. (626) 254-9010 procedures, giving patients the most advanced and comprehensive clinical care while benefitting Surgery for Congenital Anomalies of from shorter recovery times. the Kidney and Urinary Tract Doheny Eye Center UCLA Congenital anomalies of the kidney and urinary Orange County Immunotherapy Checkpoint Blockers tract are birth defects that are often discovered in 18111 Brookhurst Street, Suite 6400 Immunotherapy checkpoint blockers are a new a routine fetal ultrasound during pregnancy. While Fountain Valley, CA 92708 class of drugs that help release restraints on the some resolve on their own after birth, others (714) 963-1444 immune system. require close monitoring and corrective surgery, often within the first year of life. Immunotherapy Approaches for For more information, go to: Genitourinary Cancers To download these and other clinical uclahealth.org/eye Breakthroughs in immunotherapy are revolutionizing advances at UCLA Health, go to: the treatment of genitourinary cancer, with new uclahealth.org/clinicalupdates

UCLA pushes the boundaries of minimally invasive Pediatric Blood and Marrow Transplant Program Program focuses on unique needs colorectal surgery with robotic technology offers new therapies for cancer and blood disorders of adults with cystic fibrosis

A major advance in Patients benefit Convenient care colorectal surgery from expanded for adult CF patients on the Westside Overcoming the challenges donor pool and limitations of traditional “Children without traditional The adult cystic fibrosis open and laparoscopic surgery, marrow donors can increasingly program at UCLA offers colorectal robotic-assisted surgery find transplant donors today convenient and coordinated using the da Vinci Surgical thanks to alternative donor care to better serve patients on System is becoming the approach transplants,” says Theodore B. the Westside of Los Angeles, of choice for the surgical Moore, MD, director of the says Patricia H. Eshaghian, MD, treatment of both benign and Pediatric Blood and Marrow adult director, Cystic Fibrosis malignant colorectal diseases. Transplant Program and division Program, and assistant professor “The application of robotic chief of Pediatric Hematology/ of medicine in Pulmonary and surgery in treatment of complex Oncology. “Advances in drug Critical Care Medicine. conditions of the colon and therapy that prevent the “Because there are so many rectum has revolutionized the from rejecting donated marrow guidelines on how you manage field of colorectal surgery,” says have made possible haploidentical cystic fibrosis, it’s important Kevork Kazanjian, MD, associate bone-marrow transplants — that patients receive care at a professor of surgery and chief of using half-matched cells from a specialized center,” she says. “We the Section of Colon and Rectal first-degree relative. And because have access to all the specialists Surgery. “With this innovative, an infant’s immune system is a patient might need.” minimally invasive technique, immature, umbilical-cord blood Colorectal robotic-assisted surgery (CRS) Careful attention is devoted to the is the latest advance in minimally invasive gain more vision, transplantation requires less Blood and marrow transplantation (BMT), also called stem-cell transplantation, About half of all cystic fibrosis patients seamless transition of pediatric procedures for colon and rectal diseases including colorectal cancers, diverticulitis and precision and control while making precise recipient tissue matching. in the United States today are adults, can be a lifesaving treatment option for children with cancers and blood disorders, CF patients to adult care. inflammatory bowel disease (ulcerative colitis and Crohn’s disease). smaller, less invasive incisions.” according to the Cystic Fibrosis Patient Registry. This remarkable statistic represents including leukemia, lymphomas, neuroblastomas and sickle cell disease, as well as “The outcomes associated with significant progress in the care of patients with the autosomal recessive disorder. More “What used to be a pediatric While laparoscopic surgical techniques have provided an alternative to the large “The continued evolution of disorders of metabolism and the immune system. these alternative donors for disease has become a disease of robotic technology will further effective therapies in childhood and the emergence of detailed treatment guidelines abdominal incision and long recovery period required by conventional open surgery, the treatment of hematologic adulthood,” she says. “As these facilitate the widespread BMT replaces stem cells — blood-cell precursors found in hematopoietic (blood- have extended the median predicted survival age to 40 years. laparoscopy has presented technical challenges with limited, two-dimensional malignancies and non-malignant patients enter adulthood, they application of robotic surgery cell-forming) bone marrow — injured or destroyed by disease, chemotherapy or hematologic disorders have The growing number of adults with cystic fibrosis has created a need for specialized have to take more responsibility visualization and tight pelvic space in which to maneuver instruments. to colorectal disease,” says radiation treatment. After entering the bloodstream via IV catheter, the stem cells reached the point where they are in caring for themselves. Dr. Kazanjian. “We are seeing the services unique to this population. UCLA has an adult CF clinic focused on patients Robotic-assisted laparoscopic surgery — using the da Vinci Surgical System — offers make their way to the bone marrow. In a process called engraftment, they begin to nearly the same as transplants Education about the disease tip of the iceberg. What we 18 years and older. The clinic is part of UCLA’s Cystic Fibrosis Program, which is a minimally invasive alternative to both open and standard laparoscopic colorectal- from closely matched sibling becomes very important. It can thought was impossible 10 years produce new blood cells, restoring the patient’s hematopoietic and immune system. accredited by the Cystic Fibrosis Foundation. related interventions. donors,” says Dr. Moore. “Today, be hard to adhere to treatments. ago is now commonplace.” UCLA was one of the first centers worldwide to successfully perform a pediatric we rarely have to turn away Patients need a medical team The colon and rectal robotic surgical team at UCLA is one of the most experienced in stem-cell transplant. The UCLA Pediatric Blood and Marrow Transplant Program someone who needs a transplant New oral medications that understands and helps them Southern California and UCLA is among the top centers in CRS volume nationwide. was formally established in 1973. for lack of a donor. Most Progress in the care of cystic fibrosis patients is attributed to following best practices with compliance.” importantly, we offer the chance as well as the introduction of new oral medications that target the underlying cause How colorectal robotic-assisted surgery works To date, nearly 1,000 children from around the — many with the most for a cure to many children who complex, rare or severe types of cancers and blood disorders — have had stem-cell previously did not have one.” of the disease and slow the decline of lung function. In 2012, the Food and Drug State-of-the-art robotic arms — three tipped with specially designed laparoscopic surgical transplants performed at UCLA. Success rates and donor-match rates meet or Administration approved Kalydeco® (ivacaftor), a cystic-fibrosis transmembrane instruments and one with a light and fiber-optic camera — are inserted through tiny exceed the national averages despite the increased complexity of cases. conductance regulator potentiator. The drug works by increasing the transfer of abdominal incisions. The robotic tools enable a three-dimensional, high-definition view chloride into cells and is approved for patients ages 6 years and older with the of the entire surgical area and enhanced 360-degree wrist and finger micro-movements.

UCLAHEALTH.ORG 1-800-UCLA-MD1 (1-800-825-2631) UCLAHEALTH.ORG 1-800-UCLA-MD1 (1-800-825-2631) UCLAHEALTH.ORG 1-800-UCLA-MD1 (1-800-825-2631)

UCLAHEALTH.ORG 1-844-4UCLADR (1-844-482-5237) Molded Lens Custom Molded Lens Benefits Patients with Irregular Eye Surface

Patients with irregularities to the surface of their She explains that fitting patients with basic that have prevented them from benefiting scleral lenses involves drawing from a fitting from visual correction now can achieve better set of approximately 20 prefabricated lenses vision with a new technology that enables that come in different shapes. Dr. Shibayama custom lens fabrication. The new product, which chooses the one closest to the patient’s shape, has been offered since 2015 at UCLA’s Stein Eye then adjusts the curvatures on the lenses to Institute, is a boon for patients who have been approximate the patient’s fit. But this can be unable to benefit from and can’t wear particularly challenging for patients with an contact lenses due to factors such as a corneal irregular eye surface, Dr. Shibayama notes. transplant, scarring, chemical burns or ocular She estimates that about 5-to-10 percent of trauma that has altered their . her patients are unable to wear the lenses. “Traditionally, it has been very hard to fit Up to now, many of these individuals have been Photo: Courtesy of EyePrintPro these patients,” says Vivian Shibayama, OD, forced to go without visual correction — or, an optometrist at the UCLA Stein Eye Institute in some cases, to have transplant surgery. “The who performs specialty fits for patients with EyePrintPRO has made an incredible difference in irregular resulting from conditions the lives of these individuals,” Dr. Shibayama says. The EyePrintPRO is a such as , corneal transplants, “Because it’s molded to their eye, it’s a perfect fit scars and dry eyes. every time, as opposed to the traditional scleral type of scleral-lens design lens where waiting for remakes can take weeks The EyePrintPRO is a type of scleral-lens design based on impressions of to finalize a fit.” based on impressions of the patient’s ocular the patient’s ocular surface surface so that it can match the contour of any Using the same material as a dentist would eye. The custom-made lens, fabricated from a employ to make a mold for teeth, Dr. Shibayama so that it can match the high-oxygen permeable material, improves vision, takes an impression by inserting a tray contour of any eye. much like standard corrective lenses, through a containing the puddy-like material into the eye smooth refractive surface for the affected eye. and allowing it to set for one minute to mold the irregularities of the cornea and sclera surface. Scleral contact lenses — designed to vault over The impression is then sent to a prosthetics lab, the corneal surface and land on the sclera — are which builds a custom lens based on the scan. effective in many patients with hard-to-fit eyes in need of correction who are unable to wear Dr. Shibayama says EyePrintPRO is effective for either soft lenses or the standard gas-permeable most patients with an irregular sclera, including hard lenses that can smooth the irregularity on those who have had multiple eye , the cornea, Dr. Shibayama explains. The types such as surgeries as well as corneal of patients for whom scleral lenses are most transplants. “Not only does this lens provide commonly prescribed include individuals with therapeutic relief in eye pain and discomfort irregular corneas, as well as those with refractive associated with ocular-surface disease, but these errors and . Because they can hold patients typically have irregular fluid against the cornea, scleral lenses are also that cannot be fully corrected by glasses,” prescribed for patients with severe dry eyes. she explains. “Assuming the poor vision is due to the irregular cornea and not another But not everyone who needs a scleral lens has factor like a detached retina or severe glaucoma, been able to wear them. “The scleral lens that the EyePrintPRO lens will mask this corneal is available on the market right now fits about irregularity and give the patient better vision.” 90 percent of the population that needs it,” Dr. Shibayama says. “However, there are some EyePrintPRO lenses are designed to last at least patients — those with irregular , those a year and can be kept longer if maintained with surgical tubes and blebs — who can’t wear properly and no changes occur in the eyes, this lens because the lens needs to land on a Dr. Shibayama says. “The visual result is more smooth surface to fit properly.” effective because of the perfect fit,” she says.

3 UCLA Update Transplant

COVER STORY Improvements in Corneal Transplantation Achieving Better Outcomes

(continued from cover) and because there is less tissue transplanted, it entire cornea,” says Dr. Hsu. “This has led to reduces the risk of rejection.” major improvements in along with more rapid recovery and lower rejection risk.” Hugo Y. Hsu, MD, a corneal transplant Following the DSEK, a significant portion of at Doheny Eye Center UCLA in Pasadena, patients with otherwise healthy eyes can expect Arcadia and Fountain Valley, notes that until the to achieve up to 20/40 vision with glasses — far mid-2000s, corneal transplants had been done better than what most could have expected from using what he calls a “one-size-fits-all” approach. older techniques, Dr. Hsu notes. “Now we are much more selective and accurate in how we transplant the cornea, and for the Dr. Aldave, who began performing DSEK in vast majority of patients, that’s translating into 2006, notes that in the last several years, a better visual outcomes and faster recovery,” new version of DSEK has been popularized at Photo: Superstock Dr. Hsu says. “The techniques are still evolving UCLA and other highly specialized centers, and improving, but we are getting closer to particularly for patients whose corneal edema making this on par with surgery in is caused by endothelial dysfunction or failure, terms of the visual success, rehabilitation and including Fuchs’ patients. Descemet’s membrane minimal rates.” endothelial keratoplasty (DMEK) replaces only Descemet’s membrane, the thin innermost layer The cornea — the clear, outermost layer of of the cornea on which the endothelial cells the eye — plays a central role in focusing reside, with no stromal tissue involved. This has sight. The cornea can become diseased, led to a further improvement in results for the affecting vision, from a variety of conditions, surgeons who perform the procedure. including protrusion of the center of the cornea STORY HIGHLIGHTS (keratoconus), scarring or inflammation For patients with keratoconus, a corneal disorder from or and cloudiness of that affects approximately one-in-2,000 people the cornea’s inner layer (Fuchs’ dystrophy). in the U.S., Descemet’s membrane is the only Improvements in surgical approaches Approximately 50,000 cornea transplants are healthy portion of the cornea. “In this case it’s a to corneal transplantation over the performed in the United States each year. problem with the cornea’s shape that progresses, last decade have led to major eye usually affecting people in their teens or 20s, The most common indication for corneal centers, such as UCLA, achieving to the point where they may not see well with transplantation in the United States is Fuchs’ better visual results with fewer glasses or contact lenses,” Dr. Aldave explains. , an inherited disorder of postoperative complications. For these patients, the surgeons transplant the the cornea’s innermost layer, the endothelium. diseased portion of the cornea while leaving the Two developments have significantly Beginning in the mid-2000s, the approach critical inner Descemet’s membrane layer intact improved outcomes: modifications in known as Descemet’s stripping endothelial in a surgery known as deep anterior lamellar the design of the surgical device and keratoplasty (DSEK) gained traction in the keratoplasty (DALK). This, too, has led to better better medical therapy after surgery. U.S., marking a major advance. Unlike full- outcomes, including elimination of the risk of thickness corneal transplantation, DSEK corneal endothelial rejection. selectively replaces the posterior portions of the cornea with the donor’s corneal tissue. “The For patients who can’t benefit from donor tissue, cornea has multiple layers, and it’s clear that including those who have had previous corneal in most patients we don’t need to replace the transplants, advances in artificial corneal

UCLAHEALTH.ORG 1-844-4UCLADR (1-844-482-5237) transplantation ensure an important alternative. Improvements in Corneal What was once considered experimental is now an accepted approach for a variety of indications. Dr. Aldave notes that two developments have Transplantation Achieving significantly improved outcomes in the last decade: modifications in the design of the surgical device and improved medical therapy Better Outcomes after the surgery. Advances in corneal transplantation are having an impact on indications: Because the outcomes are better, patients with less severe disease are increasingly recommended for surgery. “When the surgery wasn’t likely to give you much better vision, we tended to wait until the patient’s vision was really poor,” says Dr. Hsu. “Now, the it doesn’t require systemic immunosuppression (Left) Image shows a patient with corneal results are so much better that it makes more after the surgery. Patients who are in need swelling and advanced glaucoma. sense to address the problem at an early stage. should be encouraged not to delay seeking Corneal transplantation is the most successful a consultation.” (Right) Four years after Descemet’s solid-organ transplant, and unlike other organs, stripping endothelial keratoplasty, the clear round donor cornea can be seen on the posterior surface and the patient continues to enjoy 20/20 corrected visual acuity. “ Corneal transplantation is the most successful solid organ transplant, and unlike other organs it doesn’t require systemic immunosuppression after the surgery. Patients who are in need should be encouraged not to delay seeking a consultation.”

Optical cross-section of cornea following deep anterior lamellar keratoplasty. The total corneal thickness is 483 microns; the transplanted portion is 453 microns and the remaining inner layer of host cornea (arrow) measures 30 microns.

Image: Courtesy of Dr. Anthony Aldave

5 UCLA Physicians Update Femtosecond Increases Precision of

STORY HIGHLIGHTS The femtosecond laser — a “micro-scalpel” scale with an incredible level of precision,” says capable of cutting tissues on a microscopic scale Kevin M. Miller, MD, Kolokotrones Chair in with extreme precision — has increased the Ophthalmology at the UCLA Stein Eye Institute. The femtosecond laser has increased accuracy of the most common surgical procedure “With a femtosecond laser, we can operate more the accuracy of cataract surgery, in the United States. The instrument now being efficiently and more precisely. For our patients, emitting optical pulses at one-millionth- used for many precision cataract procedures at it reduces the time the eye is open and eases the of-one-billionth of a second. the UCLA Stein Eye Institute’s outpatient surgical stress on the internal structures of the eye. And The “micro-scalpel” reduces the time center and the Doheny Eye Center UCLA in with such accuracy at our disposal, we believe the eye is open and eases the stress on Arcadia emits optical pulses of a femtosecond — that the laser will open new avenues of treatment the internal structures of the eye, all one-millionth-of-one-billionth of a second. that have never been possible before.” with a precision that has opened new “A femtosecond laser can be thought of as a Dr. Miller and other UCLA eye surgeons have treatment avenues. micro-scalpel, incising the cornea and lens capsule been using a femtosecond laser to assist with and breaking up the cataract on a microscopic several steps of cataract surgery, under imaging

UCLAHEALTH.ORG 1-844-4UCLADR (1-844-482-5237) Cataract

to map the internal structures of the eye. Prior to (Left) Dr. Kevin Miller uses a femtosecond the operation, the surgeon programs the location laser to perform refractive cataract and size of the incisions as well as the region of surgery. The patient’s eye, which is the lens to be softened. After the imaging, the docked to the laser, can be seen on surgeon can make adjustments to the location the computer monitor. and size of the incisions and the region of lens Photo: Courtesy of Dr. Kevin M. Miller softening. The surgeon then depresses a foot pedal, which fires the laser to create the incisions and lens fragmentation pattern. The eye is undocked from the laser and the patient is moved under the operating microscope. The surgeon proceeds to remove the cataract and implant the to complete the surgery. Cataract procedures are already highly successful, Dr. Miller notes, but the femtosecond laser offers an incremental improvement in the precision and reproducibility of the incisions for modifying the patient’s astigmatism and for removing the cataract. “It can make a 90-degree turn inside the cornea, which we can’t possibly do with a metal blade or diamond knife,” Dr. Miller says. “And it eliminates surgeon variability by stamping out a perfect incision every time.” But the femtosecond laser does more than “ With a femtosecond laser, produce precise repeatable incisions in cataract procedures. It also makes a perfectly round and we can operate more centered opening in the anterior lens capsule — efficiently and more the capsulorrhexis. This has benefits that go beyond the cosmetic and into the realm of precisely. For our patients, improving safety, Dr. Lu notes. In addition, by it reduces the time the eye pre-softening the cataract, the femtosecond laser guidance. These procedures include corneal reduces the amount of cumulative dissipated is open and eases the stress incisions to remove the cataract and manage energy needed — thereby reducing the time on the internal structures astigmatism, lens softening and making an spent emulsifying the cataract with ultrasound. opening in the capsular bag. This is particularly important for dense-cataract of the eye. And with such patients, improving safety by limiting exposure “I explain to patients that this is like what they accuracy at our disposal, as well as leading to faster recovery. see in the movies, where a laser is applied to we believe that the laser whatever needs to be cut easily,” says Kenneth Lu, Drs. Miller and Lu believe future lens designs MD, an ophthalmologist at Doheny Eye Center will take advantage of the technology’s will open new avenues of UCLA in Arcadia. “We can use it to do all of the capabilities, including the precisely sized and treatment that have never cutting portion of the surgery, in an automated positioned capsulorrhexis. “Multifocal lenses have fashion rather than being manually performed, to be perfectly centered on the to function at been possible before.” which makes it more precise.” Dr. Lu say their optimum,” Dr. Miller says. “Locking the lens she employs the femtosecond technology for implant in would ensure quality each time. That approximately one-third of the cataract surgeries is just one example of what I believe will be many he performs, depending on factors such as the new compelling reasons to use the femtosecond difficulty of the case and patient preference. laser in the future.” For cataract procedures, the femtosecond laser system is gently docked to the patient’s eye and optical coherence tomography imaging is used

7 UCLA Physicians Update Thyroid Eye Disease

New Approaches to Treating Patients with Thyroid Eye Disease

New minimally invasive surgical techniques wide range of severity with this disease,” says developed by UCLA ophthalmologists are Robert Alan Goldberg, MD, Karen and Frank improving the overall function and aesthetic Dabby Endowed Chair in Ophthalmology at the appearance of patients with thyroid eye UCLA Stein Eye Institute and director of the disease — a disorder that can not only cause UCLA Orbital Disease Center. “The swelling can vision problems but also be disfiguring. The cause double vision and even vision loss. And new approaches, which can be utilized alone or the cosmetic concerns are significant; patients in conjunction with more traditional therapies, can become quite disfigured.” are allowing a much wider range of patients to The condition affects about five times more benefit from treatment. Among patients who women than men, and it generally occurs when can benefit are those with milder forms of the they are in their 30s or 40s. “Although the classic disease who were not considered candidates picture of thyroid eye disease is a patient with when the treatment was more invasive, as well red, bulging, misaligned eyes, the disease is as patients with active inflammatory disease distinctly heterogeneous and most patients are This illustration shows two common who previously might have been advised to more mildly affected,” says Daniel B. Rootman, symptoms of Graves’ hyperthyroidism: wait until their symptoms subsided, even if MD, MS, an orbital and ophthalmic exophthalmos or bulging eyes and an that meant living with the disfigurement. surgery specialist who sees patients at Doheny enlarged thyroid. Thyroid eye disease, most commonly associated Eye Center UCLA in Pasadena and at the UCLA Image: Science Source with Graves’ hyperthyroidism, is an autoimmune Orbital Disease Center in Westwood. “But, disorder in which the muscles and soft tissue whether severe or not, patients are often deeply behind the eye become inflamed. “There is a affected by these alterations in their appearance.” STORY HIGHLIGHTS

New approaches to minimally invasive surgical techniques, which can be utilized alone or in conjunction with more traditional therapies, are allowing a much wider range of patients with thyroid eye disease to benefit from treatment.

UCLAHEALTH.ORG 1-844-4UCLADR (1-844-482-5237) Dr. Rootman explains that historically, surgical rehabilitation has been offered only in the most severe cases, and usually only after the disease has passed through its active phase over the course of some 18 months. At that point, treatments are typically focused on the functional goals of reducing eye bulging, double vision and retraction. “This concentration tends to neglect a range of patients who do not fit classic anatomic or physiologic indications, yet still are transformed by the course of this disease,” Dr. Rootman says. “Further, patients in this paradigm are often left untreated for more than two years, which can feel like a lifetime.” At the UCLA Orbital Disease Center, Dr. Rootman notes. And newer techniques Drs. Goldberg and Rootman have advanced that involve focusing on the deep orbital bone Minimally invasive approaches to orbital techniques that are changing this paradigm. while leaving the lateral bony wall intact have decompression surgery performed by Most notably, they have developed minimally minimized complications that were common surgeons of the UCLA Orbital Disease invasive approaches to orbital decompression, in the past. Center focus on both functional and the core surgery for thyroid eye disease. Orbital aesthetic concerns with thyroid eye These and other approaches developed at the decompression addresses both the functional disease by addressing the increased UCLA Orbital Disease Center — including and aesthetic concerns with thyroid eye size of the muscles and fat behind the rehabilitative surgeries for the , eye disease by seeking to reduce the proptosis and eye that occurs in the disease. muscles and facial changes — have resulted congestion that occur as a result of the increased Photo: Courtesy of Dr. Robert Alan Goldberg in less-visible scars and significantly reduced size of the muscles and fat behind the eye that rates of double vision, improving aesthetic and occurs in the disease. functional results while reducing side effects “In the past, this was done through large and complications of the disease. Surgeries that incisions,” Dr. Goldberg explains. “It involved once took two-to-three hours can be completed taking a lot of bone out from around the eye, in less than an hour on an outpatient basis. and the techniques were unpredictable. They All of this has expanded surgical indications could cause numbness or double vision, and for the population. “In the past, we would only “ In the past, we would only usually required hospitalization. Our newer subject patients to the big scars and potential techniques go through smaller incisions, take complications if they had severe vision or subject patients to the out more of the fatty tissue and less of the aesthetic problems,” Dr. Rootman says. “Now we big scars and potential bone, and use improved instrumentation and can offer this to a much wider range of people, anatomic techniques for much more delicate including patients with less severe symptoms.” complications if they had bone removal.” The UCLA Orbital Disease Center is a major severe vision or aesthetic Whereas surgeons once made incisions on the international referral facility for thyroid problems. Now we can eyelid or the side of the face, often introducing eye disease patients, in part because of such new cosmetic and visual problems, tiny approaches. “These are patients with a very offer this to a much incisions involving the mucous membrane have difficult disease, who may be looking at multiple wider range of people, minimized complications and scarring, stages of surgical rehabilitation,” Dr. Goldberg says. “It’s especially important to minimize the including patients with invasiveness and side effects of the surgery — less severe symptoms.” both for psychological reasons and for medical (Left) This axial (cross sectional) CT image from a person purposes. That is what has driven our efforts at with Graves’ hyperthyroidism shows excessive fat desposition this center for the last 25 years.” in both orbits with bilateral proptosis. These findings can be seen with thyroid ophthalamopathy (thyroid eye disease) without thickening of the extra-ocular muscles. Image: Science Source

9 UCLA Physicians Update Photo: Science Photo Library Alternative Surgery Offers Significant Benefits for Patient Outcomes STORY HIGHLIGHTS Surgery to tighten and strengthen eye muscles is among the standard Plication spares blood vessels, procedures to correct misaligned eyes in patients with strabismus. causes less inflammation and , Now a UCLA Stein Eye Institute group is pioneering the North American and is technically easier to perform than resection. introduction of an alternative muscle-strengthening approach that represents a fundamental change in the way is performed. Instead of amputating the front part of the eye muscle and tendon, the surgeon simply folds it up and leaves it in place. The alternative method, known as plication, than resection. We are constantly looking offers numerous advantages and virtually no for ways to optimize surgery and make it less disadvantages compared to the approach taught invasive. The technical innovation of plication for many decades in the United States, says does that, while expanding the options surgeons Joseph L. Demer, MD, PhD, the Leonard Apt have for treating strabismus.” Professor of Pediatric Ophthalmology and chief Plication has been practiced in Europe for of pediatric ophthalmology and strabismus. several decades. Dr. Demer learned the approach “This operation is less traumatic and more from strabismus surgeons in Heidelberg, Germany, potentially reversible,” Dr. Demer explains. “It more than 10 years ago. Since then, he has worked spares blood vessels, causes less inflammation with UCLA Stein Eye Institute colleagues on and bleeding and is technically easier to perform studies to validate plication’s benefits.

UCLAHEALTH.ORG 1-844-4UCLADR (1-844-482-5237) Strabismus

One objective of strabismus surgery is to the muscle could snap back into the eye socket shorten an eye muscle so that it pulls harder — irreversibly, leaving the patient with a very analogous to shortening the length of a rubber difficult strabismus to correct. “If the sutures band so that the elastic material, stretched over break following the plication approach, the the same distance, exerts more tension. “If the patient would simply be back to where he or eye is crossed, for instance, the lateral rectus she was before the surgery,” Dr. Demer says. muscle can be tightened in this way to correct “The muscle would simply unfold to its “ We are constantly looking the crossing,” Dr. Demer explains. In the United original configuration.” States, eye-muscle tightening has traditionally for ways to optimize Dr. Demer has also experienced success using the been accomplished through resection — cutting procedure for patients with complicated forms of surgery and make it less out the tendon and a portion of the front of the strabismus and nystagmus in which his team has muscle, then sewing it back into the eye, with invasive. The technical had to operate on as many as eight muscles in a the shortened muscle pulling tighter along the single setting. In such cases, surgery by traditional innovation of plication same path as a result. resection methods would have been impossible does that, while expanding Plication takes an alternative approach — because of the threat it would pose to blood flow placing sutures through the tendon or muscle an to the front of the eye, he notes, but plication the options surgeons have equivalent distance from the attachment point, doesn’t compromise blood flow. for treating strabismus.” and farther back along the length of the muscle, For typical cases, plication is technically easier and then sewing those sutures to the wall of to perform and less invasive than resection, the eye at the original insertion point. While Dr. Demer says, because while the suturing the muscle is still tightened just as much as in task is basically the same, plication avoids the resection, in plication the redundant front part extra step of cutting away the muscle through simply folds underneath rather than being cut two large incisions. Although not all strabismus away. “Instead of amputating the front part of patients stand to benefit from a muscle-tightening the eye muscle and tendon, the surgeon simply procedure, Dr. Demer estimates that the folds it up and leaves it in place,” Dr. Demer says. (Below left) Double-armed sutures approach can be beneficial for up to three- are placed in the exposed tendon’s Plication carries several advantages, he says. fourths of strabismus patients. margins at a distance from the insertion Traditional resection surgery removes blood “Plication is an innovative improvement corresponding to desired shortening, vessels when the tendon is removed, and this that can be adopted overnight by any then passed superficially through. sacrifices part of the blood supply to the front ophthalmologist who has ever learned to (Below center) When the suture is of the eye. When the blood vessels are plicated operate on the eye muscles,” Dr. Demer tightened, the redundant anterior tendon rather than removed, they continue to supply says. “Considering that it is very easy to do is folded posteriorly over a sweep. blood to the interior of the eye. Folding, rather and has many advantages and essentially no than amputating, a portion of the tendon and (Below right) Because the tendon is not disadvantages compared to resection, I expect muscle also reduces the risk of inflammation and cut, there is little bruising, inflammation that as more strabismus surgeons learn about bleeding. And, finally, if the sutures break after or edema, and no interruption of plication, it will be adopted widely.” part of the muscle is removed through resection, ciliary vessels. Image: Courtesy of Dr. Joseph L. Demer

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Save the Date: Annual DEI/SEI Comprehensive Ophthalmology Review Course Physicians – – Thursday Sunday, February 9 12, 2017 Update UCLA Stein Eye Institute, RPB Auditorium, Los Angeles, California FALL 2016

This four-day, intensive didactic review course for residents, fellows and practicing ophthalmologists will CHIEF COMMUNICATIONS & MARKETING OFFICER review the clinical essentials of each subspecialty in ophthalmology. It will be a clinically oriented review, Nancy Jensen with updates on accepted protocols, to help prepare participants for the Ophthalmic Knowledge DIRECTOR, MARKETING COMMUNICATIONS Assessment Program, American Board of Ophthalmology Judi Goodfriend

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