Asrs Annu Mtg 2011 Program

The American Society of Retina Specialists

is accredited by the Accreditation Council

for Continuing Medical Education (ACCME)

to provide continuing medical education

for physicians.

Our annual meeting is successful for both our society and our patients because it provides us a collegial open

education forum in which to network and collaborate with peers in many practice settings from all around the world.

This year’s attendance includes U.S. colleagues representing 43 states and Puerto Rico and also colleagues from

34 countries. Our meeting also provides us with a unique opportunity to connect with old acquaintances and make

new friends. To each of more than 700 members and physician guests and 300 corporate representatives, I want

to welcome you to the city of Boston.

With nearly 100 papers, over 200 posters, 24 instructional courses, and 29 new films, this year’s educational

program spans a wide spectrum of topics and features the latest research in our field. New this year, are special

instructional courses on Saturday afternoon, from 1:00-4:15 pm. The first hour will be devoted to a discussion of the

advantages and challenges of retinal surgicenters. The remaining time will be split between a series of updates in

subspecialties outside of retina which are designed to help us take better care of our patients and to prepare for

recertification. These updates are presented by outstanding faculty from Massachusetts Eye and Ear Infirmary

and Tufts Medical Center. The reviews will include: cornea/anterior segment, oculoplastics/orbit, pediatric ophthal-

mology, and glaucoma. The Retina Case Conference will take place late Saturday afternoon. Our Welcome Dinner

will follow at the Top of the Hub, in the adjacent Prudential Building with panoramic views of Boston. We hope you

will join us to celebrate our great successes this year.

The Sunday morning scientific session will feature the macular degeneration papers including a presentation of the

VIEW and CATT study results. This will be followed by the Pyron Award Lecture honoring Drs. Jeanne Bennett and

Albert Maguire, and the Founders Award Lecture presented by Dr. Bill Mieler. Sunday morning concludes with the

ASRS Business Meeting. The Young Physicians Section hosts lunch. For those who no longer qualify as a young

physician, we have good news. For your convenience, box lunches will be provided Sunday, Monday and Tuesday in

the exhibit hall. Sunday afternoon features diabetic retinopathy presentations including the RISE/RIDE, Da Vinci and

DRCR Network studies following by vitreoretinal surgery papers including the MIVI trials. At the conclusion of the

Sunday sessions, The American Retina Foundation hopes to see all of us at the “RunWalk for the Retina.” Our Sunday

evening is free to explore the beautiful sights of Boston!

Monday will be another day of outstanding presentations with retinal vein occlusion treatment including the Galileo/

Copernicus results and intravitreal dexamethasone implant followed by new imaging studies. A panel discussion

about the optimal ways to treat macular edema from vein occlusion and diabetic retinopathy in the anti-VEGF era

will be followed by the special socioeconomic session and the pediatric retina session. Monday lunch features the

Women in Retina (WinR) Symposium. The afternoon will begin with sessions on macular degeneration including use

of high dose ranibizumab for eyes not responding to conventional dosing. Monday afternoon will conclude with

the wine and cheese poster reception where you can talk informally with the poster authors about their studies.

Tuesday morning will begin with the ocular oncology papers followed by additional papers on macular degenera tion

and vitreoretinal surgery. A panel discussion will review avoidance and management of vitreoretinal surgery compli-

cations. Tuesday afternoon will feature 19 courses including a wet lab for learning anterior segment surgery

techniques and the always popular Retinaws. For those athletically inclined, separate golf and tennis tournaments

will be offered on Tuesday afternoon. Tuesday concludes with our spectacular Gala Dinner and Umbo Lounge.

Wednesday morning will begin with papers on the use of enhanced depth imaging in eyes with hereditary diseases

and improved anesthesia techniques for intravitreal injection. The treatment of diabetic macular edema with

panretinal laser and anti-VEGF drugs guided by wide field angiography will be discussed.

The final session will highlight new treatment strategies for severe traumatic injuries from

the military and new methods to treat leaking sclerotomies. The Wednesday session will

end at 12 noon.

I hope all of you will enjoy this beautiful city and plan your free time to take a walk on the

Freedom Trail, enjoy some shopping at Faneuil Hall, hop on the T for a quick ride to the

Kennedy Library and Museum, or have a great meal right in Back Bay. Enjoy the meeting!

John T. Thompson, MDProgram Chair and President-Elect

Welcome to Boston and the ASRS 29th Annual Meeting!

The mission of the American Society

of Retina Specialists is to provide a collegial

open forum for education, to advance

the understanding and treatment of

vitreoretinal diseases, and to enhance the

ability of its members to provide the

highest quality of patient care.

MISSION STATEMENT

asrs 29th annual MeeTing

Program Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Financial Interest Disclosures . . . . . . . . . . . . . . . . . . 6

Scientific Report Guidelines . . . . . . . . . . . . . . . . . . . . 8

Continuing Medical Education. . . . . . . . . . . . . . . . . 10

Program by Day

saTurDay, augusT 20

Instructional Courses . . . . . . . . . . . . . . . . . . . . . . . . 11

Retina Case Conference . . . . . . . . . . . . . . . . . . . . . . 12

sunDay, augusT 21

Symposium 1: Macular Degeneration I . . . . . . . . . 13

CATT Mini-symposium . . . . . . . . . . . . . . . . . . . . . . . . 16

Symposium 2: Awards and Special Presentations . . . . . . . . . . . . . . . . . . . . . . . . 16

Young Physicians Section Symposium . . . . . . . . . 17

Symposium 3: Diabetic Retinopathy . . . . . . . . . . . 18

Symposium 4: Vitreoretinal Surgery I . . . . . . . . . . 24

MonDay, augusT 22

Special Interest Groups Breakfast . . . . . . . . . . . . . 31

Symposium 5: Retinal Vascular/Imaging . . . . . . . 31

Symposium 6: Socioeconomics . . . . . . . . . . . . . . . 38

Symposium 7: Pediatric Retina . . . . . . . . . . . . . . . . 40

Women in Retina (WinR) Symposium . . . . . . . . . . . 42

Symposium 8: Macular Degeneration II . . . . . . . . . 43

Symposium 9: Vitreoretinal Surgery II . . . . . . . . . . 50

TuesDay, augusT 23

Symposium 10: Ocular Oncology . . . . . . . . . . . . . . 55

Symposium 11: Macular Degeneration III . . . . . . . 58

Symposium 12: Vitreoretinal Surgery III . . . . . . . . 64

Instructional Courses . . . . . . . . . . . . . . . . . . . . . . . . 68

WeDnesDay, augusT 24

Symposium 13: Hereditary/Inflammatory/Diabetic Retinopathy . . . . . . . . . . . 73

Symposium 14: Vitreoretinal Surgery IV . . . . . . . . 79

scienTific PosTers

Macular Degeneration. . . . . . . . . . . . . . . . . . . . . . . . 83

Diabetic Retinopathy/Hereditary/Inflammatory. . . . . . . . . . . . . . . . . . . . . 99

Vitreoretinal Surgery . . . . . . . . . . . . . . . . . . . . . . . 119

Retinal Vascular/Imaging. . . . . . . . . . . . . . . . . . . . 151

Practice Management and Socioeconomics. . . . . . . . . . . . . . . . . . . . . . . . 180

Pediatric Retina – ROP . . . . . . . . . . . . . . . . . . . . . . 180

Ocular Oncology. . . . . . . . . . . . . . . . . . . . . . . . . . . . 186

filM fesTival

Introduction and 2011 Entries . . . . . . . . . . . . . . . 189

2010 Award Winners . . . . . . . . . . . . . . . . . . . . . . . . 193

inDex

Financial Interest Disclosures . . . . . . . . . . . . . . . . 195

Participant Index . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

Contents

The American Society of Retina Specialists is accredited by the AccreditationCouncil for Continuing Medical Education (ACCME) to provide continuing medicaleducation for physicians.

The American Society of Retina Specialists designates this live educational activity for a maximum of 29.5 AMA PRA Category 1 Credit(s).™ Physicians shouldonly claim credit commensurate with the extent of their participation in the activity.

4

EvENT LocATioNSAll events take place at the SheratonBoston Hotel unless otherwisenoted.

Breaks Exhibit Hall D, Hynes Convention Center

cocktail reception 2nd Floor, Republic Ballroom

continental Breakfast Exhibit Hall D, Hynes Convention Center

exhibitsExhibit Hall D, Hynes Convention Center

film festival Theater 2nd Floor, Back Bay Ballroom A

gala Dinner and umbo lounge 2nd Floor, Grand and Constitution Ballrooms

guest Breakfast 5th Floor, Riverway

instructional courses 2nd, 3rd, 5th Floors

new Member reception5th Floor, Pool Deck

PaT survey Exhibit Hall D, Hynes Convention Center

retina case conference 2nd Floor, Grand Ballroom

run/Walk for the retina Joseph Lee Playground Park

scientific Posters Exhibit Hall D, Hynes Convention Center

speaker ready room 3rd Floor, Gardner Room

special interest groups BreakfastConstitution Ballroom

Welcome reception and Dinner Top of the Hub Skywalk Observatory at the Prudential Center

Women in retina (Winr) symposium and lunch 2nd Floor, Constitution Ballroom

young Physicians section (yPs) symposium and lunch 2nd Floor, Constitution Ballroom

SATURDAY, AUGUST 20

1:00-4:15 PM

Instructional Courses

1:00-2:00

Advantages and Challenges of Retinal SurgicentersDavid Callanan, MD, Wayne A. Solley, MD,Pravin U. Dugel, MD and Jeff Brockette

2:15-4:15

SUBSPECIALTY REVIEWSCornea/Anterior Segment Roberto Pineda, II, MD

Glaucoma Cynthia Mattox, MD

Oculoplastics and Orbit Suzanne K. Freitag, MD

PediatricsMitchell B. Strominger, MD

4:30-6:30

Retina Case Conference

7:00-10:00

Welcome Reception and Dinner

SUNDAY, AUGUST 21

7:00-7:30 aM

Continental Breakfast/Exhibits

7:30-9:30

SYMPOSIUM 1: Macular Degeneration I

8:35-9:05

CATT Mini-symposium

9:05-9:30

Macular Degeneration Panel: How Do You Treat ChoroidalNeovascularization Following CATT Study Results?

9:30-10:05

Refreshment Breaks/Exhibits

10:05 aM-12:00 PM

SYMPOSIUM 2: Awards and Special Presentations

10:05-10:40

PYRON AWARD LECTUREThe Evolution of Retinal GeneTherapy: From DNA to FDAJean Bennett, MD, PhD and Albert M. Maguire, MD

10:40-11:15

FOUNDERS AWARD LECTURETreatment and Prevention of Endophthalmitis: Past, Present, and FutureWilliam F. Mieler, MD

11:15-11:30

American Retina Foundation Report

Young Physicians Section Crystal Apple Award Presentation

PAT Survey Presentation

11:30 aM-12:00 PM

ASRS Business MeetingMembers only

12:00-1:15

Young Physicians Section Symposium and LunchCRYSTAL APPLE AWARD LECTURESurgical Delivery of Human Adult Stem Cells forAtrophic AMD: Rationale and Preliminary ExperienceAllen C. Ho, MD

12:00-1:15

Lunch in Exhibit Hall

1:20-3:02

SYMPOSIUM 3: Diabetic Retinopathy

Program Overview

5

3:02-3:35

Refreshment Breaks/Exhibits

3:35-5:45

SYMPOSIUM 4: Vitreoretinal Surgery I

5:30-6:30

American Retina Foundation’sRun/Walk for the Retina

5:45

Free Evening

MoNDAY, AUGUST 22

6:15-7:15 aM

Special Interest Groups Breakfast

7:00-7:30


7:30-10:05

SYMPOSIUM 5: Retinal Vascular/Imaging

10:05-10:40

Refreshment Break/Exhibits

10:40-11:16

SYMPOSIUM 6: Socioeconomics

10:40-10:50

Pharmacotherapy for Neovascular AMD – 100% Part BFee-For-Service Medicare Claims Data – 2008-2009Ross J. Brechner, MD, MS, MPH

10:50-11:00

The Value Modifier: Payment for Quality and EfficiencyWilliam L. Rich, III, MD

11:00-11:10

Scope of Practice Battles and the Retina SpecialistDavid W. Parke II, MD

11:10-11:16

Discussion

11:16 aM-12:16 PM

SYMPOSIUM 7: Pediatric Retina

12:16-1:25

Women in Retina (WinR) Symposium and Lunch

12:16-1:25


1:33-3:35

SYMPOSIUM 8: Macular Degeneration II

3:35-4:10


4:10-5:18

SYMPOSIUM 9: Vitreoretinal Surgery II

5:20-6:40

Poster Session and Exhibit Hall Wine and Cheese Reception

6:00

American Retina Foundation’sNorth End Secrets, Saints, and Sips Crawl

6:40

Free Evening

6:45

New Member Reception

TUESDAY, AUGUST 23

7:00-7:30 aM


7:30-8:20

SYMPOSIUM 10: Ocular Oncology

8:20-10:10

SYMPOSIUM 11: Macular Degeneration III

10:10-10:35


10:35 aM-12:00 PM

SYMPOSIUM 12: Vitreoretinal Surgery III

12:00-1:20


12:00

Golf and Tennis Tournament DeparturesExact times to be announced.

1:30-5:45

INSTRUCTIONAL COURSESRefer to Scientific Program for course descriptions and times.

7:00 PM-1:00 aM

Cocktail Reception, Gala Dinnerand Umbo Lounge

WEDNESDAY, AUGUST 24

8:00-8:30 aM


8:30-10:20

SYMPOSIUM 13: Hereditary/Inflammatory/Diabetic Retinopathy

10:20-10:50


10:50 aM-12:00 PM

SYMPOSIUM 14: Vitreoretinal Surgery IV

12:00

Meeting Adjourns

6

The American Society of Retina Specialists (ASRS)seeks to balance the important benefits of physician-industry relationships with the significant risk that the financial goals of industry may conflict with theprofessional goals of ASRS members. In doing so, the ASRS recognizes that it has a profound duty to its members, the larger medical community and thepublic to ensure the integrity of all of its scientific,educational, and advocacy activities and materials.

educational content Development

As the ACCME accredited provider for the ASRS29th Annual Meeting, the American Society of RetinaSpecialists requires all Program committee members,abstract graders, staff, and any others in a position tocontrol the educational content to disclose anycommercial financial interests prior to the develop -ment of educational content. A process for resolutionof conflict of interest is used for those committeemembers who do have financial interests related to the development of content.

Program committee members, abstract graders, andstaff members who fail to provide financial disclosuresare not permitted to participate in the abstract gradingprocess or the development of educational content.

Presenters

The ASRS considers financial relationships to createactual conflicts of interest when Presenters or theirimmediate family (defined as spouse, domestic partner,parent, child or spouse of child, or sibling or spouse of sibling of the Presenter) have both a financialrelationship with a commercial interest and the oppor-tunity to affect ASRS policy or the content of CMEabout the products or services of that commercialinterest. The potential for Presenter to maintain orincrease the value of the financial relationship withthe commercial interest creates an incentive toinfluence the content of the CME – an incentive to insert commercial bias.

All presenters of CME content should familiarizethemselves with the new ASRS Policy on FinancialDisclosures and Resolution of Conflicts of Interest,which may be viewed in their entirety on the ASRS website at www.asrs.org. All ASRS memberspresenting CME are required to disclose to the activityaudience the following information prior to beginning their presentation:

• Any relevant financial relationships a CME pres -enter has had with manufacturers of commercialophthalmic products or providers of commercialophthalmic services within the past 12 months. TheASRS defines “relevant” financial relationships asthose with a commercial ophthalmic interest andthe opportunity to affect the content of CME about the products or services of that commercialophthalmic interest.

• CME presenters who report they have no knownrelevant financial relationships to disclose willdeclare “No Financial Relationships.”

noTe: All presenters are required to report financialdisclosures, using the codes below, as part of theabstract submission process. An individual’s financialdisclosure for the ASRS 29th Annual Meeting will beindicated by an asterisk (*) in the Scientific Programand cross-referenced in the Participants FinancialDisclosure Index. (See the Participant Index tab of the Scientific Program). Any presenter not listed withan asterisk, or not listed by name on the ParticipantsFinancial Disclosure list, informed the AmericanSociety Retina of Specialists that they have norelevant financial disclosures to report.

Description of financial interest

TyPes of relaTionsHiP(s) A Advisory BoardB Board of DirectorsC ConsultantE EmployeeF FounderI InvestigatorSP SpeakerSH StockholderO Other

naTure of coMPensaTionE Equipment (dept or practice) G GrantsH HonorariaIP Intellectual Property RightsNC No Compensation ReceivedOB Other Financial BenefitR RoyaltyRF Residency or Fellowship Program FundingS Salary ST Stock SO Stock Options

Financial Interest Disclosures

7

commercial Type of name interest relationship compensation

John T. Thompson, MD, Chair NIH I GGenentech I GRegeneron I G

Carl C. Awh, MD ArcticDx A, C, SH H, STNeoVista A, C, I G, HBausch + Lomb A, C, SP HSynergetics A, C, SH IP, R, HNotal Vision A, C HGenentech SP, I G, H

Brett T. Foxman, MD No Financial Disclosures

Tarek S. Hassan, MD ArcticDx C, SH H, STBausch + Lomb C, SP HClarus Acuity Group SH STEyetech C, A HGenentech C H Insight Instruments C HOptiMedica C, SH H, STSynergetics C H

Suber S. Huang, MD, MBA Alcon C HBausch + Lomb C HDRCR C HDigital Healthcare SH STi2i Innovative Ideas E SLux Biosciences C HMacuSight C HMerck & Co., Inc. C HNEHEP/NEI/NIH C HNeurotech C HPfizer C HRetinal Dis Image AnalysisReading Center C HSecond Sight C HSurModics Pharmaceuticals C, SH H, STTDNMI C HTherapeutic Nanoparticle and Molecular Imaging C HVitreo Retinal Technologies C H

Timothy G. Murray, MD, MBA Alcon A H

STAFF

Jill F. Blim No Financial DisclosuresExecutive Vice President

Robyn Lira No Financial DisclosuresManager, Membership and Communication

Kristen A. Weber No Financial DisclosuresDirector of Education

8

guidelines for the scientific report ofstudies and conduct of research involvingHuman subjects

The goal of the ASRS 29th AnnualMeeting in Boston is to enhance the competence of the vitreoretinalspecialists to diagnose and treatvitreous and retinal disorders anddiseases using the most advancedconcepts and tech niques available.

The ASRS 29th Annual Meetingin Boston will provide a forum forthe rapid dissemination of the mostrecent scientific research results tothe target audience in attendance.Its purpose is to allow the presen-tation of new and ongoing researchdata to assist the practicing vitreo-retinal specialist with theadvancement of knowledge andskills in their field.

The ASRS 29th Annual Meetingcontains papers, posters, and panelpresentations that may includeresearch conducted on human sub -jects. All members are responsiblefor declaring whether or not theirpresentation involves researchinvolving human subjects, andshould adhere to the accepted ethicsof such research.

The ASRS supports the regula-tions defined by the Office ofHuman Subjects of the NationalInstitutes of Health, and the Officefor Human Research Protections ofthe Depart ment of Health andHuman Resources. Listed below areguidelines and resources designed toassist members to adhere to scientificreporting requirements at the ASRSAnnual Meeting.

Definitions of “research” and “Human subjects”

research: Research is any systematicinvestigation designed to develop or contribute to generalizableknowledge. Obvious research is thestudy of techniques, drugs anddevices as part of prospective institu-tional or collaborative clinical trial.Less obvious, but still falling intothis category, are retrospective chartreviews, uncontrolled evaluations of off label drugs and devices, andprospective evaluations of newsurgical techniques and devices.

Human subjects: A “human subject”is a living individual about whom an investigator obtains either:

(1) data through interaction orintervention with the individual, or

(2) identifiable private information.

In many cases, the determination of whether a particular researchactivity involves human subjects isnot difficult, but in some cases, theline is blurred. This is often the caseinvolving a retrospective review of office and hospital charts onexisting data.

When it is not clear to an investi-gator whether research activitiesinvolve human subjects, he or she is encouraged to seek the advice of a local Institutional Review Board (IRB).

institutional review Boards (irB)

An IRB is a group of diverseindividuals charged to protecthuman subjects and promote ethicalresearch. The IRBs evaluate andapprove that:

(1) the design of a study is consistentwith sound scientific principlesand ethical norms;

(2) the necessary elements ofinformed consent have beenfulfilled, and

(3) appropriate safeguards are taken to prevent harm or undue risksto participants.

Local hospital or institutionalIRBs are typically willing to reviewwith clinical research conductedboth at their hospital as well aswithin the private office setting.

exemptions from irB activity

Not all research that involves datacollected on human subjects requiresIRB approval. Studies involvinghuman tissue obtained from estab-lished cell lines not linked to patientidentification e.g. human RPEcultures are exempt.

Another exemption is the retro-spective collection of data fromexisting records such as office charts,provided that subjects cannot beidentified directly or through identi-fiers such as name codes linked to the subjects.

Chart reviews conducted bystudents or office staff in which confidential information is kept onthe chart, and possibly viewed bynon-physicians, remains a “greyarea.” When in doubt, the researchershould obtain the advice from alocal IRB.

Other exemptions involve surveysand anonymous patient interviews,data from deceased individuals, and reviews of pathologic specimensprovided that no link to patientidentification is present or kept during the review.

Scientific Report Guidelines

9

“off-label” use of Marketed Drugs, Biologicsand Medical Devices

If physicians use a product for anindication not in the approvedlabeling, they have the responsibilityto be well informed about theproduct, to base its use on firmscientific rationale, and to maintainrecords of the product’s use andeffects.

Use of a marketed product in this manner when the intent is the“practice of medicine” does notrequire the submission of an Investigational New Drug Appli -cation (IND), InvestigationalDevice Exemption (IDE) or reviewby an IRB. However, the institutionat which the product will be usedmay, under its own authority, require IRB review.

Presentations at the ASRS 29thAnnual Meeting on such “off label”use may however fall outside the“practice of medicine” definition asdefined below.

investigational use ofMarketed Drugs, Biologicsand Medical Devices

The reporting of investigational useof products in an off label capacitydiffers from the situation describedabove. “Investigational use” suggeststhe use of an approved product inthe context of a clinical studyprotocol. When the principal intentof the investigational use of a testarticle is to develop informationabout the product’s safety or efficacy,submission of an IND or IDE may be required.

The clinical investigation of anoff label application does not requiresubmission of an IND if all of thefollowing conditions are met:

(1) it is not intended to be reportedto FDA in support of a newindication for use or to supportany other significant change inthe labeling for the drug;

(2) it is not intended to support asignificant change in the adver-tising for the product;

(3) it is conducted in compliancewith the requirements for IRBreview and informed consent, and

(4) does not involve a route ofadministration or dosage levelthat significantly increases therisks (or decreases the accept-ability of the risks) associatedwith the use of the drug product.

The last requirement often appliesto medications and devices notintended for intraocular use. Again,the researcher should seek theadvice of a local IRB when in doubt.

resources

Several on-line resources areavailable for researchers that provideadditional help and guidelines indetermining when research mayrequire IRB approval and IDE/INDapplications.

An excellent computer basedtutorial is available at the NIHwebsite at http://ohsr.od.nih.gov.This tutorial gives an overview ofconcepts, principles, and issuesrelated to protection of humanparticipants, and is intended to actas a companion piece to local IRBpolicy, as well as local, state, andfederal regulations applicable tohuman research.

Presenters at the ASRS 29thAnnual Meeting have a funda-mental responsibility to safeguardthe rights and welfare of the peopleparticipating in their research activities. Studies involving humansubjects require special protections,depending on the nature of thestudy, such as informed consent, IRB approval, and protection ofconfidentiality, unless waived.

If presenters are going to presentdata from patients, they will berequired to include (on disclosureslide for those giving paper presen -tations, or printed on the poster)“Data from human research ispresented.”

10

The American Society of RetinaSpecialists is accredited by theAccreditation Council for ContinuingMedical Education (ACCME) toprovide continuing medical educationfor physicians.

The American Society of RetinaSpecialists designates this live edu -cational activity for a maximum of29.5 AMA PRA Category 1 Credit(s).™

Physicians should only claim creditcommensurate with the extent of theirparticipation in the activity.

The Retina Case Conference, scientific sessions, and panel discus-sions are identified for credit. Onecredit is awarded for each hour ofparticipation.

Please see page 7 for financialinterest disclosures of programcommittee members, abstract graders,and those involved with managingprogram content. For an up-to-datelisting, please visit www.asrs.org.

cME Mission Statement

Purpose

The American Society of RetinaSpecialists (ASRS) is a non-profitcorporation, which provides a scien-tific forum designed to promote thesharing of 1) new scientific research of vitreoretinal diseases and surgeryand 2) ideas for optimization ofclinical practice. The overall goal ofthe ASRS CME Program is to provideCME activities that will address theprofessional practice gaps of ASRSmembers by offering activities that aid in enhancing our participants’competence in the fields of vitreo-retinal diseases, surgery, and practicemanagement.

Target audience

The ASRS CME audience is theportion of the Society’s membershipthat is licensed to practice medicine

in the United States (U.S. Members).U.S. members of the ASRS havecompleted one or more years of avitreoretinal disease fellowship and are engaged in an active retinalspecialty practice or are a member-in-training in a vitreoretinalfellowship program.

Types of activities Provided

To accomplish the goals of the ASRS CME Program, the ASRSorganizes scientific meetings andinstructional courses.

content

The scope of the ASRS CME Programincludes the presentation of scientificpapers, panel discussions, posters,videos by vitreoretinal specialists from around the world on topicsconcerning the diagnosis and manage -ment of vitreoretinal disorders, andtopics concerning the business ofmedicine. These activities are pre -sented at the Annual Meeting and at adjunctive meetings approved bythe American Society of RetinaSpecialists Board of Directors.

expected results

The expected results of the ASRSCME Program are enhancements inour physician participants’ competence.The ASRS educational content isexpected to provide the members of the American Society of RetinaSpecialists with expanded knowledgeto enable them to diagnose and treatvitreoretinal diseases with the mostadvanced concepts and techniquesavailable.

cMe evaluation forms

CME evaluation forms for eachsymposium will be emailed prior toeach session. In accordance with theACCME Criteria and Guidelines, weask that all attendees evaluate eachpresentation and identify the effec-

tiveness with which the educationalgoals are met. Suggestions for theimprovement of future educationalprograms and the identification ofspecific educational needs are alsorequested.

cME credit Awards

CME credit certificates will be mailed to registrants after the meeting.The number of hours awarded will bebased on documentation of atten-dance provided by the registrant on a form which will be available at the meeting.

Educational objectives and Goals

The purpose of the ASRS 29thAnnual Meeting is to enhance thecompetence of vitreoretinal specialistsin the diagnosis and treatment ofvitreous and retinal disorders using the most advanced concepts andtechniques.

The ASRS 29th Annual Meetingwill provide a forum for the rapiddissemination of the most recentscientific research results to the targetaudience in attendance. Its purpose isto allow the presentation of new andongoing research data to assist thepracticing vitreoretinal specialist withthe advancement of knowledge andskills in their medical field.

Upon completion of the scientificsessions, the participant shall be ableto: describe the findings, diagnosis and treatment of various vitreoretinaldisorders such as macular degener-ation, choroidal neovascularization,diabetic retinopathy, venous occlusivedisease, macular holes, epiretinalmembranes, ocular inflammatorydisease, retinal oncology, and retinaldetachment.

Continuing Medical Education

Saturday

Saturday, August 20

11

Saturday, August 20

1:00-4:15 pM

instructional coursesSheraton Boston Hotel, Constitution Ballroom

1:00-2:00 pMadvantages and challenges of retinal surgicenters

David Callanan, MD*, (Arlington, TX), Wayne A. Solley, MD*, (Arlington, TX), Pravin U. Dugel, MD* (Phoenix, AZ), Jeff Brockette (Arlington, TX)

David Callanan, MD Wayne A. Solley, MD Pravin U. Dugel, MD

Ambulatory surgicenters (ASC) are being used withincreased frequency by retina specialists. Some advan-tages include a more pleasant patient experience, fasterturnaround for patients and physicians, more physiciancontrol of OR and potential ASC ownership with ashare of profits. Disadvantages include less flexiblescheduling of emergency cases, inability to useexpensive surgical adjuncts, reluctance of surgicentersto update equipment after initial purchases and diffi-culty performing more complex surgeries on patientswith multiple medical problems. This course willexamine the pros and cons of using an ASC for vitreoretinal surgery.

2:15-4:15 pMsubspecialty reviews

Ophthalmology subspecialities continue to enjoyimportant advances in the diagnosis and treatment ofocular disorders. The American Society of RetinaSpecialists presents the most important advances inretina at our annual meeting and other educationalforums. Our members may not be as familiar withimportant progress in areas outside of retina. Thiscourse will help to update our members about impor tantdevelopments in the past 5 years in cornea/externaldisease, glaucoma, oculoplastics and pediatric ophthal-mology from subspecialty faculty at Massachusetts Eye and Ear Infirmary and Tufts University.

2:15-2:45 pMcornea/anterior segmentRoberto Pineda, II, MD* (Boston, MA)

2:45-3:15 pMglaucomaCynthia Mattox, MD* (Boston, MA)

3:15-3:45 pMoculoplastics and orbitSuzanne K. Freitag, MD (Boston, MA)

3:45-4:14 pMPediatricsMitchell B. Strominger, MD (Boston, MA)

12

reTina case conference

4:30-6:30 pM

Retina caseconference

MODERATORS

Carl C. Awh, MD William F. Mieler, MD Richard F. Spaide, MD

PresenTers

4:30 PMCarol L. Shields, MD (Philadelphia, PA)

4:35 PMYoreh Barak, MD (Louisville, KY)Shlomit Schaal, MD, PhD Todd J. Purkiss Melissa G. Tong, MD

4:40 PMSunir J. Garg, MD(Philadelphia, PA)Jeffrey L. Lipkowitz, MD Nikolas London, MD

4:45 PMShree K. Kurup, MD (Winston Salem, NC)

4:50 PMRishi P. Singh, MD (Cleveland, OH)Nathan C. Steinle, MD Careen Lowder Peter K. Kaiser, MD Daniel F. Martin, MD

4:55 PMGuillermo Salcedo-Villanueva, MD (Mexico City, MX)Juan Manuel Jimenez-Sierra, MD Virgilio Morales-Canton, MD Efrain Romo-Garcia, MD

5:00 PMGustavo Barreto Melo, MD (Aracaju, Sergipe, BR)Eduardo C. Souza, MD

5:05 PMCyrus M. Shroff, MD (New Delhi, IN)Sima Das, MDJyotirmay Biswas, MD Shishir Narain, MDCharu Gupta, MD Daraius Shroff, MD, FRCS

5:10 PMHua Gao, MD, PhD (West Bloomfield, MI)Hua Gao, MD, PhD

5:15 PMBoris Josue Bajaire, MD (Santafé de Bogota, CO)Diego F. Paipilla

5:20 PMJ. Fernando Arevalo, MD (Caracas, VE)

5:25 PMMallika Goyal, MD (Hyderabad, IN)

5:30 PMGeoffrey G. Emerson, MD, PhD (Minneapolis, MN)

5:35 PMSumit P. Shah, MD (Boston, MA)Jay S. Duker, MDElias Reichel, MD

5:40 PMJulie M. Rosenthal, MD (Portland, OR)Peter Francis

5:45 PMVassiliki Poulaki, MD, PhD (Boston, MA)

5:50 PMAlex Yuan, MD (Cleveland, OH)Justis P. Ehlers, MD

5:55 PMFranco M. Recchia, MD (Nashville, TN)

6:00 PMEmmanouil Mavrikakis, MD, PhD (Athens, GR)Varun Chaudhary

6:05 PMJerry A. Shields, MD (Philadelphia, PA)

6: 10 pMDiscussion

6:30 pMadjourn

7:00-10:00 pMWelcome reception and DinnerTop of the Hub Skywalk Observatory at the Prudential Center

Sunday

Sunday, August 21

13

7:00-7:30 AMcontinental Breakfast and exhibitsHynes Convention Center, Hall D

7:30-9:30 AM

Symposium 1:Macular Degeneration iModerators: Tarek S. Hassan, MD and David F. Williams, MD, MBA

Related poster abstracts are on pages 83-98.

7:30 AMopening remarksSuber S. Huang, MD, MBA, ASRS PresidentJohn T. Thompson, MD, ASRS Vice President and Program Chair

7:35 AMPhase i clinical Trial using Human umbilical Tissue-Derived cells (cnTo 2476)administered sub-retinally to Treat geographic atrophy secondary to aMD

Tom S. Chang, MD* (Pasadena, CA), Michael A. Samuel, MD*, Allen Ho*, Paul Williamson, MD, Sicco Popma, MD, Ian Harris, MD

PurPose Human umbilical tissue-derived cells preservedphotoreceptors in a rodent model of retinal degeneration (Lund RD et al.). Cell-based therapy targets pathologic micro -environments with trophic factors or by replacing diseasedtissue. Targeted delivery creates a local pharmacodynamiceffect, mitigates potential safety issues with systemic use andunfavorable risk benefit ratio of surgical procedures.

MeTHoD Phase 1/2a, Multicenter, Randomized, Dose EscalationStudy Evaluating a Single, Subretinal Administration ofHuman Umbilical Tissue-Derived Cells (CNTO 2476) inSubjects with Geographic Atrophy (GA) Secondary to AMD.Primary objective is safety assesment of CNTO 2476, using asubretinal microcatheter delivery system (MDS). Secondaryobjectives are clinical response assessment, visual function and MDS performance. Inclusion criteria are age ≥ 50 years,bilateral geographic atrophy (GA) by AMD with macularinvolvement and a suitable surgical candidate. Subjects willreceive one of 4 doses by a trans-scleral sub-retinal micro-catheterization and evaluated for efficacy and safety for 5 years.

resulTs Six eyes from six patients have been enrolled andreceived microcatheter administration of CNTO2476 to thesubretinal space. The administration procedure involved trans-scleral placement of the microcather through a 3-4 mmsclerotmomy over the peripheral retina. A choroidotomy

was created to allow placement of the microcather into thesubretinal space. The microcatheter was advanced to themacular region under direct vision through the pupillaryaperature and wide view opthalmoscopy. After injection of theCNTO 2476, the microcatheter was withdrawn and surgicalclosure performed.

conclusion Unmet medical needs will drive demand forinnovative solutions. Cell-based products combined with safeand effective delivery systems targeted to the retina have thepotential to satisfy some of these needs. An ongoing clinicaltrial of CNTO 2476 will show one approach using a celltherapy administered directly adjacent to the diseased posterior retina.

7:43 AMclinical applications of a novel sD-ocTalgorithm Designed to Measure the area and volume of retinal Pigment epithelial Deformations

Zohar Yehoshua, MD* (Miami, FL), Fenghua Wang, MD, Giovanni Gregori, Fernando M. Penha, MD, PhD, William Feuer, Philip J. Rosenfeld, MD, PhD*

PurPose A novel algorithm was developed to measure the areaand volume of retinal pigment epithelial detachments anddrusen imaged with spectral domain OCT (SD-OCT) for use inthe routine clinical care of patients, especially those undergoinganti-VEGF therapy, and for use in clinical trials.

MeTHoD Eyes with drusen and retinal pigment epithelial detach-ments secondary to AMD were enrolled in an IRB-approved,prospective study at the Bascom Palmer Eye Institute. Theseeyes were scanned using the Cirrus SD-OCT instrument (CarlZeiss Meditec, Dublin, CA). A novel algorithm was then usedto quantitatively assess the area and volume measurements ofthese lesions. Changes in PED area and volume measurementswere assessed after anti-VEGF therapy in a subset of patients.The measurements were analyzed using a suitable scale transfor-mation, in particular, a square-root transformation was use forarea measurements and a cube-root transformation was used forvolume measurements.

resulTs 143 eyes were enrolled with drusen volumes rangingfrom 0.0009 mm3 to 0.7479 mm3. On average, drusen volumeand area increased over time with the magnitude of this increasedependent on the length of follow-up (p=0.001). In eyes withdecreasing drusen volume, the magnitude of the decrease wasdependent on the baseline drusen volume (p=0.001), andindependent of the length of follow-up. 63 eyes with PED wereenrolled. Both the qualitative appearance and the quantitativemeasurements of the PED area and volume were highly repro-

* Financial interest disclosed

Sunday, August 21

ducible. 31 eyes had anti-VEGF therapy with the mean PEDarea changing from 6.22 mm2 to 5.53 mm2 (p=0.078), and thePED volume changing from 1.17 mm3 to 0.74 mm3 (p=0.04).We found that an increase in area or volume of the PEDwithout the recurrence of sub/intraretinal fluid was useful inpredicting the need for re-treatment at the next follow-up visitwhen using OCT-guided therapy.

conclusion SD-OCT imaging of RPE deformations was highlyreproducible. Drusen morphology is dynamic with a tendencyfor drusen to increase in volume and area over time. PEDsmeasurements were useful for following disease progression anddeciding when to retreat eyes undergoing OCT-guided anti-VEGF therapy. This novel algorithm should also be a valuablequantitative tool in designing clinical trials for AMD.

7:51 AMeffect of anti-vegf Therapy on choroidalThickness in Patients with neovascular aMD

Srinivas Sadda, MD* (Los Angeles, CA), Emma McDonnell, MD, Florian Heussen, Humberto Ruiz-Garcia, MD, Yanling Ouyang, Ramsudha Narala, MD, Alexander Craig Walsh, MD*

PurPose Choroidal thickness has been shown to decrease insome diseases following treatment (e.g. PDT), and choroidalthinning has been associated with decreased vision. In thisstudy, we evaluate the changes in choroidal thickness asmeasured by spectral domain optical coherence tomography(SD-OCT) in patients with neovascular age-related maculardegeneration (NVAMD) undergoing chronic anti-VEGFtherapy.

MeTHoD Patients with a diagnosis of NVAMD in at least oneeye and serial SD-OCT volume scans obtained over a minimum12 month follow-up period were retrospectively collected. Foreach case, subfoveal choroidal thickness (SCT) was measuredfrom Bruch’s membrane to the choroid-sclera junction invalidated OCT review software, both at baseline and at the lastfollow-up date after start of therapy. SCT measurements wereperformed independently and adjudicated by two maskedreading center graders. Only cases in which the full extent ofthe choroid was visible were included in subsequent quanti-tative analyses. SCT measurements were correlated with otherpatient and treatment characteristics.

resulTs 94 eyes of 59 patients with a mean follow-up of 22.4months met the inclusion criteria. Mean age was 83.3 years and56 % were female. Eyes in the treatment group received a meanof 7.8 intra vitreal anti-VEGF injections. SCT at baseline was134.7 µm (SD 58.0) for untreated eyes and 140.2 µm (SD 62.3)in the treated group (p=0.6583). The average reduction in SCT over time was observed to be 13.5 µm (p<0.0001) and10.0 µm (p=0.0088) for the respective groups. However, changein SCT did not differ significantly between the two groups

(p=0.4614), and did not correlate with the number of re-treat-ments (p=0.552). Neither visual acuity at baseline (p=0.618),last follow-up (p=0.174), or the change in visual acuity overtime (p=0.429) correlated significantly with SCT.

conclusion Although choroidal thickness decreased over timein eyes with neovascular AMD, intra vitreal anti-VEGF therapydid not appear to accelerate or otherwise alter this decline.

7:59 AMDiscussion

8:05 AMThe role of genetics and smoking in response to anti-vegf Therapy for Wet aMD

Jaclyn L. Kovach, MD (Naples, FL), William Cade, Bill Scott*, Anita Agarwal*, Stephen G. Schwartz, MD*, MBA, Kelly Taylor, Gaofeng Wang, Jonathan Haines, Margaret Pericak-Vance*

PurPose What is the relationship between high-risk geneticpolymorphisms and smoking history and the response to anti-VEGF therapy in wet AMD?

MeTHoD Case series of 52 patients with wet AMD treated withan anti-VEGF agent, bevacizumab and/or ranibizumab, for atleast 1 year. Genotypes at ARMS2 A69S and CFH Y402H wereidentified from DNA analysis with genomic screen and parti -cipants completed a smoking history questionnaire. Patientshad been treated with anti-VEGF therapy for at least one year. Response to treatment was dichotomized into those thatgained at least 2 lines of Snellen vision and had a reduction in intraretinal or subretinal fluid (responders) and those thatmaintained or lost vision and had persistent, recurrent orincreased intraretinal or subretinal fluid (non-responders).

resulTs Of the 52 total patients with wet AMD (diagnosedgrade 5 AMD in at least 1 eye), 37 (71%) are non-responderscompared to 15 (29%) responders. We found that responderswere more likely to have at least one risk allele for both genes(CFH and ARMS2) and non-responders were more likely tohave no risk alleles (p=0.02683). A higher proportion ofresponders than non-responders carry at least one risk allele atARMS2 (85% vs. 55%), at CFH (100% vs. 81%) or at bothgenes (87% vs. 51%). No significant association was detectedbetween response to treatment and the individual risk factors(Fisher’s exact test p-values: CFH-0.0933, ARMS2-0.0891,Smoking (past)-0.7455, Smoking (present)-1).

conclusion We found a statistically significant associationbetween CFH and ARMS2 risk alleles and a positive responseto anti-VEGF treatment. Expanding our sample size and testingother high risk alleles will further elucidate the relationshipbetween genetic AMD risk factors and treatment response.

* Financial interest disclosed14 SCIENTIFIC PAPER ABSTRACTS

Macular DegeneraTion i 7:30–9:30 AM1

SCIENTIFIC PAPER ABSTRACTS

15

8:13 AMgenotypic analysis of subtypes of choroidal neovascularization and Theirresponse to anti-vegf Monotherapy

Mark H. Nelson, MD* (Winston-Salem, NC), Seanna R.Grob, MD, Matt Bedell, MD, Guy Hughes, MD, Clara Lee, MD, Bin Lin, MD, Robert Shaw, MD, Peter Shaw, MD,Sara Bozorg, MD, Igor Kozak, MD, Henry Ferreyra, MD,William R. Freeman, MD, Kang Zhang, MD, PhD

PurPose Genotypic analysis of different subtypes of choroidalneovascularization gives an insight into the mechanisms oftreatment response with the goal of providing targeted patienttherapy for AMD.

MeTHoD This study is a retrospective analysis of 281 eyes from240 patients with Exudative ARMD treated with anti-VEGFmonotherapy. Visual acuity was measured using ETDRS chartsand the exam and imaging was used to determine diagnosis andchoroidal neovascularization subtype. Twelve single nucleotidepolymorphisms (SNPs) in genes CFH, HTRA1, C5, C2, andVEGF were genotyped. The patients were considered non-responders to anti-VEGF monotherapy if their visual acuity didnot improve by 1 ETDRS line or if their foveal thickness didnot decrease as a result of therapy. Chi-squared tests were usedfor analysis of genetic data.

resulTs Of the 240 patients, 62.5% were females and 37.5%were males with a mean age of 81. 10.8% were current smokers,55.4% were past smokers, and 33.8% never smoked. Meanbaseline VA was 20/100 and current VA for responders was20/50 and 20/200 for non-responders. Of the subtypes that werecompared, 23% of patients had occult, 51% had classic, and30% had polypoidal choroidal vascuopathy (PCV). Genotypeswere compared between the subtypes and statistical significancewas achieved for the comparison of classic to occult with C3-rs2230199 with an allelic p-value of 0.026, with occult having ahigher frequency of the risk allele. In addition, when comparingclassic to PCV, statistical significance was achieved for CFH-rs7542235 with a p-value of 0.024. Significance was notachieved for the SNPs analyzed when comparing all respondersto non-responders.

conclusion This study suggests that there may be differences ingenotypic frequency of risk alleles between choroidal neovascu-larization subtypes and genotypes and may affect the patientresponse to anti-VEGF monotherapy. Further studies on morecandidate genes with a larger patient population will providemore information about the mechanism and effects of genotypeon treatment.

8:21 AManalysis of 2457 Patients in the Phase 3 view 1 and view 2 studies comparing vegfTrap-eye and ranibizumab in neovascular aMD

Jeffrey S. Heier, MD* (Boston, MA), Ursula Schmidt-Erfurth, MD*

PurPose VIEW 1 and VIEW 2, evaluating VEGF Trap-Eye(VTE) vs ranibizumab, are the two largest prospective interven-tional studies of patients with neovascular age-related maculardegeneration (AMD). Data from the 1-year results of thesephase 3 studies were combined to provide a comprehensive dataset to further analyze the efficacy and safety of VTE relative tothe current standard of care (ranibizumab).

MeTHoD VIEW 1 and VIEW 2 were designed as non-inferioritystudies, with the non-inferiority margin set at 10%. A total of2457 patients were randomized in the two studies to VTE 0.5mg every month (0.5q4), 2 mg every month (2q4), 2 mg every 2 months following 3 monthly doses (2q8;) or to 0.5 mgranibizumab every month (Rq4). The primary outcome of thecombined analysis reported here was the proportion of patientswho maintained visual acuity (avoided loss of <15 ETDRSletters) at 1 year. Secondary outcomes included the meanchange from baseline in best-corrected visual acuity (BCVA) in ETDRS letters and the proportion of patients who gained≥15 letters.

resulTs Proportions of patients losing <15 letters were 96.1%, 95.4%, 95.3%, and 94.4% for 0.5q4, 2q4, 2q8 and Rq4,respectively. All VTE groups, including VTE dosed 2 mg every 2 months, met the non-inferiority test compared withranibizumab dosed monthly. Mean changes from baseline inBCVA at Week 52 were +8.3, +9.3, +8.4, and +8.7 letters for0.5q4, 2q4, 2q8 and Rq4, respectively. Incidences of oculartreatment-emergent adverse events (TEAEs) were similar across treatment arms. The most frequent ocular TEAEs wereconjunctival hemorrhage, eye pain, macular degeneration,retinal hemorrhage, and reduced visual acuity.

conclusion The results of this analysis are consistent withthose reported previously for each study. All VTE groups,including 2 mg dosed every 2 months, were non-inferior toranibizumab. VTE was generally well tolerated and had agenerally favorable safety profile. These results further indicateVEGF Trap-Eye may provide predictable therapy for wet AMD with every-2-months dosing.

8:29 AMDiscussion

8:35-9:05 AM

cATT Mini-symposiumThe CATT study evaluated 1208 patients with neovascularmacular degeneration who were randomly assigned to monthlyranibizumab, monthly bevacizumab, as needed ranibizumab oras needed bevacizumab with monthly office visits. The primaryoutcome measure was mean change in visual acuity for each of the four groups at one year. This symposium will review theCATT study results to allow clinicians to incorporate this information into the management of patients with choroidalneovascularization associated with age-related macular degeneration.

8:35 AM

caTT: Background and study DesignDavid F. Williams, MD, MBA* (Minneapolis, MN)

8:43 AM

caTT: visual and anatomic resultsGlenn J. Jaffe, MD* (Durham, NC)

8:51 AM

caTT: adverse events and applications to clinical PracticeDaniel F. Martin, MD (Cleveland, OH)

8:59 AMDiscussion

9:05 AMPanel Discussion: How Do you Treat choroidal neovascularization following caTT study results?Moderator: David M. Brown, MDPanelists: Jeffrey S. Heier, MD, Glenn J. Jaffe, MD, Daniel F. Martin, MD, David F. Williams, MD, MBA

9:30–10:05 AMrefreshment Break and exhibitsHynes Convention Center, Hall D

10:05 AM-12:00 pM

Symposium 2:Awards and Special presentationsModerators: Suber S. Huang, MD, MBA and John T. Thompson, MD

10:05 AMintroduction of gertrude D. Pyron award recipients: Jean Bennett, MD, PhD and albert M. Maguire, MDSuber S. Huang, MD, MBA

10:10 AMreTina researcH founDaTion Pyron aWarD lecTure

The evolution of retinal gene Therapy: from Dna to fDa

Jean Bennett, MD, PhD and Albert M. Maguire, MD* (Philadelphia, PA)

Gene therapy has the potential to reverse disease or preventfurther deterioration of vision in patients with currentlyincurable retinal disease. Two decades ago, the idea of retinalgene therapy was pure fantasy. Since that time, many of therelevant genes have been identified and cloned, gene delivery“toolkits” have been developed, and surgical skills have beenapplied to demonstrate that gene delivery can halt and evenreverse blindness. The recent demonstration of safe and stablerecovery of retinal/visual function in children and adults withcongenital blindness has fueled excitement about gene therapyapplications to other blinding diseases.

resulTs To move to the point where a retina specialist canwrite a prescription for gene therapy to a visually impairedpatient will require considerable effort and changes in thepolicies of regulatory agencies. The FDA is re-evaluating thetraditional outcome measures used to develop ocular medica-tions to assure that these measures are appropriate for a diverseset of blinding conditions. The progress in genetics, genedelivery, retinal surgery, and re-evaluation of drug developmentissues will help to expand our armamentarium and provideoptions for reversing blindness that seemed like science fictiona couple of decades ago.


caTT 8:35–9:05 AM

AWARDS AND SPECIAL PRESENTATIONS

17

10:40 AMintroduction of founders award recipient:William f. Mieler, MDJohn T. Thompson, MD

10:45 AMfounDers aWarD lecTure

Treatment and Prevention of endophthalmitis:Past, Present, and future

William F. Mieler, MD* (Chicago, IL)

The treatment of endophthalmitis has evolved considerablyover the past 35 years. While most interest has centered onpost-cataract endophthalmitis, infections are also seen in thesetting of open-globe injuries, associated with glaucomafiltration surgery, occur following intravitreal injections, anddevelop from endogenous settings.

Approximately 30 years ago, the introduction of intravitrealantibiotics led to a marked improvement in visual and anatomicoutcomes. Starting in the late 1980s, the EndophthalmitisVitrectomy Study (EVS) helped to refine and standardize thetreatment of postoperative infections, though it still leftnumerous questions regarding the best management of thesechallenging cases.

Over the past 15 years, there have been significant advances inanti-microbial therapy, and these new developments have aidedour manage ment of endophthalmitis. This presentation willsummarize and review the progress which has been made in thetreatment and prevention of endophthalmitis, and will discussexpectations for the future.

11:15 AMamerican retina foundation reportThe American Retina Foundation

11:20 AMyoung Physicians section –crystal apple award Presentation to allen c. Ho, MDJonathan L. Prenner, MDASRS Young Physicians Section Committee, Chair

11:25 AMPaT survey PresentationJ. Michael Jumper, MD

11:30 AMasrs Business MeetingMembers only

12:00–1:15 pMlunch in exhibit HallHynes Convention Center, Hall D

12:00–1:15 pMyoung Physicians section symposium and lunch

crysTal aPPle aWarD lecTure

surgical Delivery of Human adult stem cells for atrophic aMD: rationale and Preliminary experience

Allen C. Ho, MD* (Philadelphia, PA)

Cellular therapies, and in particular stem cell therapies, havethe potential to replace or restore function to diseased tissue ina variety of human diseases. Stem cells may be sourced fromhuman embryos or from adult sources such as bone, blood,corneal limbus, or umbilical cord.

First in human delivery of human adult umbilical stem cells was performed for retinitis pigmentosa by a transvitreal surgicalapproach. A new surgical approach is evolving to deliversubretinal human adult umbilical stem cells via a speciallydesigned subretinal catheter and injection system for patientswith atrophic age related macular degeneration.

Surgical aims of the new approach are to minimize delivery ofstem cells into the vitreous space and to keep them in thesubretinal space. Safety goals for the tech nique remain primaryat this time. Efficacy goals include a reduction in the rate of progression of geographic atrophy and changes in visual acuity.

1:20 pM-3:02 pM

Symposium 3:Diabetic RetinopathyModerators: David S. Boyer, MD and John S. Pollack, MD


1:20 pMDexamethasone intra vitreal implant Plus laser Photocoagulation vs. Monotherapywith laser for Treatment of Diffuse Diabetic Macular edema

Baruch Kuppermann, MD*, PhD (Irvine, CA), David Callanan, MD*, Sunil Gupta, Thomas Ciulla, MD,David Boyer, MD*, Ching-Chi Liu, Jean Lou, Xiao-Yan Li*, David Hollander, MD, Rhett Schiffman,Scott Whitcup, MD*

PurPose To compare the efficacy and safety of combinationtherapy with dexamethasone intra vitreal implant (DEXimplant) plus laser photocoagulation versus laser alone fortreatment of diffuse diabetic macular edema (DDME).

MeTHoD This masked study randomized (1:1) DDME patientswith central retinal thickness (CRT) of ≥275 µm on temporaldomain optical coherence tomography and best-corrected visualacuity (BCVA) of ≥34 to ≤70 letters to receive DEX implant atday 0 followed by laser photocoagulation at month 1 (n=126)or sham at day 0 and laser at month 1 (n=127). If needed,patients were retreated with DEX implant at month 6 or 9 andwith laser at months 4, 7, and 10. The primary outcome was theproportion of patients with BCVA improvement ≥10 lettersfrom baseline at month 12. Efficacy outcomes were reported for99 combination patients and 101 laser-alone patients withconfirmed DDME at baseline.

resulTs At month 12, the proportion of patients with ≥10-letter improvement from baseline BCVA was 28% in thecombination group and 24% in the laser group (P=.453).Compared with laser alone, patients treated with combinationtherapy had significantly higher mean increases from baselineBCVA at months 1, 4, 6, 7, and 9 (P<.05); AUC0-12 was1843±2256 vs 814±2539 for combination therapy vs laser alone(P<.001). Significantly greater mean reductions from baselinein central retinal thickness (CRT) at months 1, 4, and 9(P<.045) and in diffuse leakage area based on fluoresceinangiography at months 4, 6, 9, and 12 (P<.017) were alsoobserved for combination therapy vs laser. Elevation ofintraocular pressure (IOP) was the only adverse event thatoccurred significantly more in the combination group (25/125[20%]; P<.001) than the laser group (2/127 [1.6%]), though atmonth 12, only 1% and 0% of patients, respectively, had ≥10mm Hg increase from baseline IOP.

conclusion DEX implant plus laser was well tolerated andimproved BCVA, CRT, and leakage area more than laser alonein DDME patients.

1:28 pMone iluvien (0.2 µg/d fluocinolone acetonide)insert Provides improvement in visual acuityover 36 Months in Diabetic Macular edema:faMe subanalyses

David S. Boyer, MD* (Los Angeles, CA)

PurPose The purpose of the FAME (Fluocinolone Acetonidein Diabetic Macular Edema) program was to determine theefficacy of ILUVIEN (0.2 µg/d fluocinolone acetonide, FAc)nonbioerodible insert for improving visual acuity (VA) inpatients with diabetic macular edema (DME) over 36 mo. Here, key subanalyses of the FAME data are presented tofurther highlight strategies for appropriate clinical use.

MeTHoD The FAME program consisted of 2 randomized,prospective, multicenter, phase 3, double-masked, sham-controlled, parallel-group trials evaluating 2 doses of FAc in patients with DME who had received prior macular lasertreat ment. A total of 956 patients were randomized 2:2:1 to 0.2 µg/d FAc (n = 376), 0.5 µg/d FAc (n = 395), or shamcontrol (n = 185). Six weeks after randomization all patientswere eligible for rescue laser therapy. The primary studyendpoint was the proportion of patients with ≥ 15-letterimprovement in VA at 24 mo. Here, we present a post-hocanalysis of efficacy in the subset of patients receiving only 1 study treatment over 36 mo.

resulTs Significantly more patients receiving 0.2 µg/d FAc had≥ 15-letter improvement in VA compared with sham control at 36 mo (28.7% vs 18.9%, P =.018). Only 1 study treatment(sham injection or FAc insert) was needed by 71.4% and 74.4%of patients in the control and 0.2 µg/d FAc groups, respectively,by 36 mo. Significantly more patients receiving only 1 studytreatment had ≥ 15-letter improvement in VA compared withcontrol at 24 mo (35.5% vs 18.4%, P =.006) and 36 mo (36.7%vs 22.6%, P =.031). Improvements in best-corrected VA weresignificantly greater for patients receiving a single 0.2 µg/d FAcinsert vs 1 sham injection at 24 mo (7.2 vs 2.9, P =.029) and 36mo (9.5 vs 4.3, P =.024). Mean center point retinal thicknessdecreased in all groups. By 36 mo, 80.0% of phakic patients inthe 0.2 µg/d FAc group underwent cataract surgery vs 27.3% of phakic controls, and 4.8% of patients in the 0.2 µg/d FAcgroup required intraocular pressure (IOP)-lowering surgery vs0.5% for controls.

conclusion ILUVIEN (0.2 µg/d FAc) provides rapid andsustained improvements in VA for 24-36 mo without the needfor frequent injections. After 24 and 36 mo, a significantlygreater percentage of patients with DME receiving a singleILUVIEN experienced ≥ 15-letter improvement in VA versus asingle sham injection. ILUVIEN was well tolerated, with a lowrate of incisional procedures required for elevated IOP.


DiaBeTic reTinoPaTHy 1:20–3:02 PM3


19

1:36 pMrandomized Trial to assess effects of intravitreal ranibizumab or Triamcinoloneacetonide on DMe after focal/grid laser in eyes also receiving PrP

Andrew N. Antoszyk, MD* (Charlotte, NC)

PurPose Randomized trial evaluating the short term effects of intra vitreal ranibizumab or triamcinolone in eyes receivingfocal/grid laser for diabetic macular edema (DME) andpanretinal photocoagulation (PRP) for diabetic retinopathy.

MeTHoD Three hundred forty-five eyes with a visual acuity(Snellen equivalent) of 20/320 or better, center-involved DME receiving focal/grid laser, and diabetic retinopathyreceiving prompt PRP were prospectively randomized to sham (n=123) at baseline and 4 weeks, 0.5-mg ranibizumab(n=113) at baseline and 4 weeks, or 4-mg triamcinolone atbaseline and sham at 4 weeks (n=109). Follow-up visits wereconducted at 1, 4, 14 (primary outcome), 34, and 56 weeks after randomization. Treatment was at investigator discretionafter the 14-week visit.

resulTs Mean changes (±standard deviation) in visual acuityletter score from baseline were significantly better in theranibizumab (+1±11, P<0.001) and triamcinolone (+2±11,P<0.001) groups compared with the sham group (-4±14) at the14-week visit. Reduction in mean central subfield thicknessmirrored the visual acuity outcomes. These results were notmaintained by 56 weeks. One eye (0.9%, 95% CI: 0.02% to4.7%) developed endophthalmitis after receiving ranibizumab.Arterial thromboembolic events occurred in 4%, 7%, and 3% of the sham, ranibizumab, and triamcinolone groups, respectively.

conclusion Focal/grid laser for DME had an average loss ofvision with little thinning of the retina, short term, when PRPalso was given. Addition of 1 intra vitreal triamcinolone or 2 ranibizumab injections in eyes receiving focal/grid laser forDME and PRP had superior VA and OCT CSF thickness out -comes by 14 weeks, effects were not maintained by 56 weekswith discontinuation of treatments after 4 weeks.

1:44 pMexpanded 2-year follow-up of a Trial evaluating ranibizumab Plus Prompt or Deferred laser or Triamcinolone Plus Prompt laser for DMe

Thomas W. Stone, MD* (Lexington, KY)

PurPose To report 2-year expanded follow-up of a trial evalu-ating intra vitreal 0.5-mg ranibizumab or 4-mg triamcinolonecombined with focal/grid laser compared with focal/grid laseralone for treatment of diabetic macular edema (DME).

MeTHoD Eight hundred and fifty four study eyes of 691 partici-pants with visual acuity (approximate Snellen equivalent) of20/32 to 20/320 and DME involving the fovea were enrolled ina multicenter, randomized clinical trial. Expanded 2-year datawere available for 642 eyes among 526 participants.

resulTs At the 2-year visit, compared with the sham+promptlaser (SPL) group (N=211), the mean difference in the changein VA letter score from baseline was +3.7 (95% CI adjusted formultiple comparisons [aCI]: -0.4 to +7.7) letters in theranibizumab+prompt laser (RPL) group (N=136), +5.8 (95%aCI: +1.9 to +9.8) letters in the ranibizumab+deferred laser(RDL) group (N=139), and -1.5 (95% aCI: -5.5 to +2.4) lettersin the triamcinolone+prompt laser (TPL) group (N=142).After the 1-through the 2-year visit in the RPL and RDLgroups, median numbers of injections were 2 and 3. At the 2-year visit, percentages of eyes with central subfield thickness≥250µm were 59% in the SPL group, 43% in the RPL group,42% in the RDL group, and 52% in the TPL group. Nosystemic events attributable to study treatments were apparent.Three eyes (0.8%) of 375 participants had endophthalmitis inthe ranibizumab groups while elevated intraocular pressure andcataract surgery were more frequent in the TPL group.

conclusion Two-year expanded results reinforce conclusionsoriginally reported; ranibizumab should be considered forpatients with DME and characteristics similar to the cohort inthis clinical trial, including vision impairment with DMEinvolving the center of the macula.

1:52 pMDiscussion

2:00 pMTwo-year efficacy and safety outcomes of rise and riDe – Two Phase 3 randomized controlled Trials of ranibizumabfor Diabetic Macular edema

Quan Nguyen, MD, MSC* (Baltimore, MD), David M. Brown, MD*, Linda Yau, MD*, Jason S. Ehrlich, MD*, J. Jill Hopkins, MD*

PurPose DME is a leading cause of visual loss in working-agedadults in the developed world. Vascular endothelial growthfactor (VEGF) is directly involved in the pathogenesis of DME.The RISE and RIDE trials were designed to assess the efficacyand safety of monthly intra vitreal ranibizumab (RBZ) injectionscompared to sham injections in patients with DME.

MeTHoD RISE and RIDE were methodologically identical,prospective, double-masked, phase 3 sham-controlled trials.Patients with DME who met prespecified eligibility criteria(RISE, n=377; RIDE, n=382) including BCVA 20/40-20/320Snellen equivalent and central subfield thickness ≥275µm ontime-domain optical coherence tomography (OCT) wererandomized 1:1:1 to receive monthly RBZ (0.5mg or 0.3mg) orsham injections. The need for macular rescue laser was assessedmonthly starting at month 3. The primary efficacy outcome wasthe proportion of patients gaining ≥15 ETDRS letters in BCVAfrom baseline at month 24. Safety was assessed based on ocularand systemic adverse events (AEs).

resulTs At the month-24 primary efficacy endpoint, theproportion of subjects gaining ≥15 letters in RISE was 18.1%(23/127) in the sham group, 44.8% (56/125) in the 0.3 mggroup (P<0.0001 vs. sham), and 39.2% (49/125) in the 0.5 mggroup (P=0.0002 vs. sham). In RIDE, the correspondingnumbers were 12.3% (16/130), 33.6% (42/125), and 45.7%(58/127) respectively for sham, 0.3 mg RBZ, and 0.5mg RBZ. InRISE mean change from baseline BCVA letter score at month24 was 12.5 and 11.9 in the 0.3 mg and 0.5 mg RBZ groups, and2.6 in the sham group (P<0.0001 for each RBZ group vs. sham;Figure 1). Mean foveal thickness decreased by 133.6 µm in thesham group and 250.6 to 253.1 µm in the ranibizumab groups(P<0.0001 for each RBZ group vs. sham; Figure 2). In bothRISE and RIDE, ocular and systemic AEs were generallyconsistent with prior studies of RBZ. AEs associated withdiabetic retinopathy (such as vitreous hemorrhage) were lesscommon in patients treated with ranibizumab.

conclusion In RISE and RIDE, patients with DME treatedwith monthly RBZ experienced rapid, sustained, and statisti-cally significant improvements in BCVA and OCT comparedto subjects in the sham injection group. Incidence of ocular AEswas consistent with prior clinical trials involving intra vitrealinjections. Overall rates of ATEs were similar to those reportedin other Phase III studies of DME with RBZ.

Mean change in Bcva from Baseline over Time in the rise Trial

Mean change in ocT central foveal Thickness (cfT) over Time in the rise Trial

2:08 pMsubgroup analyses of efficacy outcomes in rise and riDe – Two Phase 3 randomizedcontrolled Trials of ranibizumab for Diabetic Macular edemaDennis M. Marcus, MD* (Augusta, GA), Pamela Wong*, J. Jill Hopkins, MD*, Jason S. Ehrlich, MD*

PurPose RISE and RIDE were methodologically identical,prospective, double-masked, phase 3 trials designed to assess theefficacy and safety of monthly intra vitreal (IVT) ranibizumabinjections in patients with DME. We conducted a series ofprespecified subgroup analyses to examine the effect ofdemographic and baseline characteristics on the efficacy ofranibizumab and sham injections in DME patients.

MeTHoD Eligible patients with study eye BCVA 20/40-20/320Snellen equivalent and center subfield thickness ≥275µm onoptical coherence tomography (OCT) were randomized 1:1:1 toreceive monthly ranibizumab (0.5mg or 0.3mg) or sham injec-tions. Starting at month 3 eligible patients could receive rescue




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laser. The primary efficacy outcome was the proportion ofpatients gaining ≥15 Early Treatment Diabetic RetinopathyStudy (ETDRS) letters in BCVA from baseline at month 24.Prespecified variables for subgroup analyses includeddemographics (age, gender, race), baseline BCVA (>55 or ≤55ETDRS letters), baseline HbA1c (>8% or ≤8%), focal edema atbaseline, and prior therapy for DME.

resulTs RISE study results are presented here. In RISE, 377eligible patients were randomized to sham (n=127), 0.3 mgranibizumab (n=125) or 0.5 mg ranibizumab (n=125). Atmonth 24 the overall proportion of ≥15-letter gainers was 18.1%in the sham group, 44.8% in the 0.3 mg group (P<0.0001 vs.sham) and 39.2% in the 0.5 mg group (P=0.0002 vs. sham).Within each treatment group, neither a history of prior therapyfor DME (yes/no) nor baseline HgbA1C (>8%/≤8%) appearedto affect the relative proportions of patients improving by ≥15letters from baseline at month 24. Patients with relatively goodbaseline BCVA (>55 letters) were less likely to achieve a ≥15gain at Month 24 than patients with worse baseline BCVA(≤55 letters), but the results still favored ranibizumab over sham regardless of baseline BCVA (Table). Results of additionalsubgroup analyses from both the RISE and RIDE studies will be presented.

conclusion DME patients treated with monthly ranibizumabexperienced statistically significant BCVA improvementscompared to subjects in the sham group. In the RISE study,some baseline patient characteristics (particularly baselineBCVA) had an effect on outcomes, but no prespecifiedsubgroup was identified in which sham patients had betteroutcomes than ranibizumab-treated patients.

subgroup analysis of ≥15 letter gains from baseline at month 24 in the rise study

2:16 pMaggressive anti-vegf Treatment is necessary to control Diabetic Macular edema: Month-36 outcomes of the reaD-2 study

Thomas Gerald Chu, MD, PhD* (Los Angeles, CA), Diana Do*, Quan Dong Nguyen*, Afsheen Khwaja,Roomasa Channa, Yasir Sepah, MD, David S. Boyer, MD*, Jeffrey S. Heier, MD*, Jennifer I. Lim, MD, Peter A. Campochiaro, MD*

PurPose The READ-2 clinical trial was initially designed to be completed in 2 years. A study amendment was offered topatients upon completion of month 24 to be followed andtreated for an additional year, the purpose of which was to seewhether patients with residual macular edema could benefitfrom more frequent monthly dosing of ranubizumab, if fovealthickness was >250 µm.

MeTHoD A randomized prospective clinical trial, the READ-2trial, compared ranibizumab (RBZ) injections (group 1) to laser(group 2) and RBZ + laser (group 3) for 6 months in patientswith diabetic macular edema; patients were then seen every 2months (groups 1 and 2) or 3 months (group 3) and receivedassigned treatment or RBZ for foveal thickness (FTH) > 250µm. A one year extension was offered to patients with monthlyvisits. Patients who developed recurrent macular edema couldreceive the following: Group 1 study eyes could receivemonthly injections of RBZ; Group 2 study eyes receive monthlyRBZ or laser every 3 months: Group 3 study eyes could receivemonthly RBZ and laser every 3 months.

resulTs Of the 30, 24, and 25 patients in groups 1, 2, and 3who continued after M24, 28, 22 and 24 completed M36. Themean improvement in BCVA between baseline and M36 was10.3, 1.4, 9.5 letters, compared to 7.1, 3, and 7.1 in the samepatients at M24. The percentage of patients who gained ≥3lines from baseline was 35.7, 9.1, and 25 at M36 compared to25, 9.1, and 20.8 at M24. With a mean number of injections of5.5, 4.6, and 2.9, mean FTH was reduced from 352.4, 300.7,and 249.8 µm at M24 to 282.3, 264.7, and 214.5 µm at M36.The percentage of patients with FTH ≤ 250 µm was 39.3, 68.2,87.5 at M36 compared to 32.1, 45.4, and 66.7 at M24. Therewere no drug related ocular or systemic adverse events.

conclusion A protocol amendment study for an additional 12 months allowing prn RBZ treatment every month instead of every 2 months resulted in a significant reduction in meanFTH and improvement in BCVA in groups 1 and 3. The resultssuggest that many patients with recurrent or persistent diabeticmacular edema could benefit from more frequent injections ofRBZ to optimally control edema and maximize vision.

2:24 pMDiscussion

2:32 pMeffects of ranibizumab on Patient-reportedvisual function Through 24 Months in Patients with vision impairment from Diabetic Macular edema

Neil M. Bressler, MD* (Baltimore, MD), Rohit Varma, Paul Lee, Ivan J. Suner, MD, Chantal Dolan, James Ward, Jason S. Ehrlich, MD*, Shoshana Colman

PurPose To examine the impact of intra vitreal ranibizumab on patient-reported visual function using the National EyeInstitute Visual Function Questionnaire-25 (NEI VFQ-25)through 24 months in patients with vision impairment fromclinically significant diabetic macular edema (DME) involvingthe center of the macula.

MeTHoD Two multicenter Phase III trials (RISE and RIDE)enrolled participants with vision impairment from DME(approximate Snellen equivalent 20/40 or worse) involving the center of the macula. In RISE, subjects were randomized1:1:1 to receive monthly sham injections (n=127), or monthlyintra vitreal injections of 0.3-mg (n=125) or 0.5-mg (n=125)ranibizumab for 24 months, in one eye (the study eye). Frommonth 3, study participants could receive laser if OCT was≥250µm with <50µm change from the prior month, no laser forDME had been applied in the prior 3 months, and the evalu-ating physician deemed laser therapy to be beneficial. The NEIVFQ-25 was administered at 0, 6, 12, 18, and 24 months.

resulTs In RISE, in approximately 21% of the cases in eacharm, the study eye was the better-seeing eye. In each treatmentarm, the mean visual acuity (approximate Snellen equivalent)at baseline was 20/80 while the mean NEI VFQ-25 compositescore ranged from 64.3 to 69.1 points. In both ranibizumab-treated groups, patients reported greater mean improvements inthe NEI VFQ-25 overall composite score compared with shampatients at 24 months (P=0.010, P=0.034 for 0.3mg and 0.5 mggroups, respectively, Figure). Substantial differences were notedas early as 6 months after randomization. Results from RIDE aswell as global ranibizumab data (RESTORE) will also bepresented and discussed.

conclusion At 24 months and as early as 6 months, patientswith vision impairment from DME treated monthly withranibizumab report greater improvements in patient-reportedvisual function. These findings are consistent with results at 12months reported from RESTORE in which the initial visualacuity (approximate Snellen equivalent) was 20/50 andranibizumab was compared with laser treatment for DME.

Mean NEI VFQ-25 composite scores are shown by study group up to 24 months. Last observation carried forward method was used to impute for missing values.

2:40 pMPrimary intravitreal Bevacizumab Plus glP or Primary intravitreal Bevacizumab or glP for DDMe: The Pan-american collaborative retina study group

J. Fernando Arevalo, MD (Caracas, Venezuela), Andres Lasave, Lihteh Wu, MD, Manuel Diaz-Llopis, Roberto Gallego-Pinazo, MD, Arturo Alezzandrini, MD, Maria Berrocal, MD*

PurPose To evaluate the anatomical and functional outcomesat 24 months of follow up in patients with diffuse diabeticmacular edema (DDME) treated with primary intra vitrealbevacizumab (IVB) plus grid laser photocoagulation (GLP) or primary IVB alone or GLP alone.

MeTHoD Retrospective interventional comparative multicenterstudy. We reviewed the clinical records of all consecutivepatients with DDME treated with IVB, GLP or combined IVBplus GLP. ETDRS best-corrected visual acuity (BCVA) andcentral macular thickness (CMT) with optical coherencetomography (OCT) were obtained at baseline, 1, 3, 6, 12 and24 months of follow up. Re-treatment was based on clinical orOCT-based evidence of persistent macular edema or deterio-ration in BCVA. In addition, BCVA and CMT were comparedamong the three groups using the ANOVA method.

resulTs We included 418 eyes of 318 patients. One hundredforty-one eyes of 120 patients with DDME were treated withprimary IVB alone (Group A), 120 eyes of 94 patients withGLP therapy (Group B), and 157 eyes of 104 patients weretreated with IVB plus GLP (Group C). The total number ofinjection was 5.8 ± 3.2 in Group A and 6.2 ± 4.9 in Group C.




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In Group A, BCVA improved from logMAR from 0.87 ± 0.4 to0.65 ± 0.4 (p < 0.0001); in Group B, BCVA improved fromlogMAR from 0.76 ± 0.35 to 0.62 ± 0.43 (p= 0.0061); and inGroup C, BCVA improved from logMAR from 0.76 ± 0.45 to0.60 ± 0.39 (p = 0.0009). The improvement rate was similaramong the three groups (ANOVA; p=0.41). In Group A, therewas a decrease from 446.2 ± 155.8 um to 273.8 ± 79 um (p <0.0001), in Group B from 379.1 ± 91 µm to 271 ± 78.6 µm (p <0.0001), and Group C from 415.5 ± 144.8 µm to 333 ± 138.5µm (p < 0.0001). The comparison among three groups showedhigher CMT decrease in group A than in groups B and C(ANOVA; p < 0.001).

conclusion Primary IVB with or without GLP seems to havesimilar efficacy to provide stability or improvement in BCVA ascompared to GLP alone in patients with DDME at 24 months.CMT improved in all treatment groups at 24 months of followup. However, primary IVB alone produced greater decrease inCMT than treatments in Group B and C. GLP did not decreasethe number of injections in group C.

2:48 pMone-year results of the Da vinci study ofvegf Trap-eye in Diabetic Macular edema

Diana V. Do, MD* (Baltimore, MD), Ursula Schmidt-Erfurth, MD*, Quan Nguyen, MD*, MSc, Jeffrey S. Heier, MD*

PurPose To compare different doses and dose regimens ofVEGF Trap-Eye (VTE) versus laser photocoagulation inpatients with diabetic macular edema (DME). VEGF Trap-Eyeis an intra vitreally administered fusion protein that inhibits the vascular endothelial growth factor A (VEGF-A) andplacental growth factor.

MeTHoD A total of 219 patients were randomized and treatedwith 1 of 5 regimens: VTE 0.5 mg every 4 weeks (0.5q4); 2 mgevery 4 weeks (2q4); 2 mg every 8 weeks following 3 initialmonthly doses (2q8); 2 mg as needed following 3 initialmonthly doses (2PRN); or laser photocoagulation. The changein best-corrected visual acuity (BCVA) was measured at Week 24 (the primary endpoint) and at Week 52. Additionalsecondary endpoints assessed at Week 52 included the propor -tion of patients who gained ≥15 ETDRS letters in BCVA andmean change in central retinal thickness (CRT) from baseline.

resulTs Mean improvements in BCVA in the VTE groups at Week 24 were 8.6, 11.4, 8.5, and 10.3 letters for 0.5q4, 2q4,2q8, and 2PRN, respectively, versus 2.5 letters for the laser group(P<0.01 for each VTE group versus laser). Mean improve mentsin BCVA in the VTE groups at Week 52 were 11.0, 13.1, 9.7,and 12.0 letters for 0.5q4, 2q4, 2q8, and 2PRN, respectively,versus -1.3 letters for laser (P<0.0001 for each VTE groupversus laser). Proportions of patients with gains in BCVA of≥15 ETDRS letters in the VTE groups at Week 52 were 41%,46%, 24%, and 42% versus 11% for laser. VEGF Trap-Eye wasgenerally well tolerated. The most frequent ocular adverseevents were conjunctival hemorrhage, eye pain, ocularhyperemia, and increased intraocular pressure.

conclusion VEGF Trap-Eye provided significant benefit in thetreatment of DME. Significant gains in BCVA from baselineachieved at Week 24 were maintained or improved up at Week52 in all VEGF Trap-Eye groups, including the group receiving2 mg VEGF Trap-Eye every 2 months.

2:56 pMDiscussion

3:02-3:35 pMrefreshment Break and exhibitsHynes Convention Center, Hall D

3:35 pM-5:45 pM

Symposium 4:vitreoretinal Surgery iModerators: G. William Aylward, MD and Pravin U. Dugel, MD


3:35 pMa comparison of indocyanine green, Trypan Blue and Brilliant Blue for Macular Hole surgery

Cyrus M. Shroff, MD (New Delhi, India), Neelam Atri, MD, Charu Gupta, MD, A.K. Singh, MD, Bhavana Sharma, MD, Daraius Shroff, MD, FRCS

PurPose To study the outcome of macular hole surgery usingthree different dyes to stain the ILM, and to compare theefficacy of Brilliant blue to the conventionally used dyes –Trypan Blue and Indocyanine green.

MeTHoD Retrospective non-randomized comparative analysisbetween three groups – 1. Trypan Blue 2. Indocyanine Greenand 3.Brilliant blue. 104 patients of idiopathic macular holewho underwent vitrectomy and ILM peeling were included.Pre- and post-operative best-corrected visual acuity, lens statusand Optical Coherence Tomography were done for all patients.66 patients underwent ILM staining with Trypan Blue (TB), 24 patients with Indocyanine Green (ICG) staining and 17 patients with Brilliant Blue (BB).

resulTs Mean pre and post operative log MAR best correctedvisual acuity (BCVA) was 0.87±0.38 and 0.38±0.30 in the TBgroup (p<.001), 0.90±0.28 and 0.44±0.24 in ICG group and0.66±0.27 and 0.37±0.21 in the BB group (p<.001). Post opera-tively all eyes had BCVA ≥ 20/200, 36 eyes (54.5%) in the TBgroup, 10 eyes (41.7%) in the ICG group and 7 eyes (41.2%) inthe BB group achieved BCVA ≥ 20/40. No patient had postoperative retinal detachment.

conclusion There was no statistical difference in the visualoutcome between the three groups. (P= 0.228) Brilliant Bluestained ILM well facilitating complete and atraumatic removal.Moreover, in the Brilliant Blue group the absence of fluid-airexchange during staining reduced the chances of lenticular hazeduring surgery as compared to TB group.

3:43 pMa Detailed evaluation of Brilliant Blue g Dye in chromovitrectomy

Eduardo Rodrigues, MD (Florianopolis, Brazil), Fernando Penha, MD, Mauricio Maia, Milton Moraes-Junior, MD, Magno Ferreira, MD, Michel Farah, MD, PhD

PurPose Brilliant blue G (BBG) arises as excellent novel dye inchromovitrectomy. This work aims to present a detailed investi-gation of the vital dye BBG in a variety of research settings aslaboratory of biochemistry, cell-culture model, rabbit toxicitymodel, and clinical study in patients.

MeTHoD The paper investigates various aspects of BBG: 1.Biochemistry profile of the blue dye in regard to pH, osmolarity,binding properties, and formation of decomposition products(DPs); 2. Effect of the dilution in saline solution, 5% glucose, ordeuterated water; 3 In-vitro retinal pigment epithelium (RPE)toxicity in ARPE-19 cell-culture model in various concentra-tions and in comparison to other dyes; 4. Intravitreal retinaltoxicity in rabbits; 5. An interventional prospective study inpatients that examined the binding properties of the dye dilutedin saline or 5% glucose to epiretinal membranes (ERMs) andinternal limiting membranes (ILMs) of macular hole surgeriesin fifty-one patients.

resulTs BBG is an anionic aminotryarylmethane dye with greataffinity to collagen. The pH of BBG varies from 6.9 to 7.2,while the osmolarity ranges from 291 to 205 mOsm. In contrastto indocyanine green (ICG), BBG generates no significant DPs;2. BBG in deuterated water promotes faster and more concen-trated reach of dye onto the macula Fig. 1; 3. BBG induces noreduction in RPE cell viability lower then 0.25%, differentlyfrom ICG toxic in all concentrations; 4. In the lower concen-tration 0.05%, BBG promotes no significant histologyaltera tions; however, at 0.5% BBG causes diffuse vacuolizationand edema of the photoreceptors Fig. 2, confirmed by eletror-retinography; 5. BBG has been an appropriate dye for ILM inthe majority (82%) of surgeries, however, in 45% of surgeries it has been considered not enough for ERMs visualization.There is a tendency of BBG to stain the ILM better with salinesolution over glucose 5% (P= 0.64). BBG diluted in deuteratedwater promotes excellent ILM coloring.

conclusion BBG became the state-of-the-art dye for ILMidentification. Differences in staining properties may imply thatbrilliant blue should not be considered as first-line stain forERMs surgery. Deuterated water may be the best solvent for thenovel blue agent. At clinically used concentrations under0.05%, the blue dye poses little or no risk of retinal toxicity.


viTreoreTinal surgery 3:35–5:45 PM4


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Laboratory picture revealing the differences in dye drop. Left: BBG diluted in saline mixes with vitreous solution. Right: BBG diluted in deuterated water falls into the posterior area enabling faster and more selective epirretinal coloring.

Histology examination of BBG. Upper image:BBG at 0.05% induced no significant retinaldamage. Lower image: BBG at 0.5% promotedouter retina vacuolization and edema. Suchfinding may explain the recently reportedclinical observations of outer retinal edemaafter BBB use in patients.

3:51 pMvitrectomy for lamellar Macular Hole: somesD-ocT characteristics Have a Prognosticvalue for the Postoperative outcomeGrazia Pertile, MD (Negrar, Italy), Matteo Cereda, MD, Barbara Parolini, MD

PurPose Surgery for lamellar macular hole is still controversial.The aim of the study was to identify prognostic factors based onOCT findings that can guide this therapeutic decision.

MeTHoD Forty eyes with a lamellar macular hole diagnosed withSpectral-Domain optical coherence tomography (SD-OCT)(Heidelberg Engineering, Heidelberg, Germany) and recentvisual loss were included in this study. Twenty-six eyes had athin epiretinal membrane with tangential traction – classicepiretinal membrane (C-ERM) – and 14 eyes presented thick,moderately reflectant tissue on the edge of the lamellar hole (T-ERM). All the eyes underwent pars plana vitrectomy with ERMand internal limiting membrane peeling. Air tamponade wasused after surgery in all cases. BCVA, a complete ophthalmo-logic examination and OCT were performed before the surgeryand at 3,6 and12 months after the surgery.

resulTs The mean postoperative BCVA was 0.05 logMar in theC-ERM group and 0.2 LogMar in the T-ERM group. In bothgroups a statistically significant improvement compared withthe pre-operative BCVA (0.3 LogMar and 0.4 LogMar respec-

tively) was noted. Nevertheless, the C-ERM group had a statis-tically significantly better outcome. In the T-ERM group, 4 eyes developed a full thickness macular hole and neededadditional treatments while no significant complications werereported in the C-ERM group.

conclusion The SD-OCT characteristics of lamellar macularhole have prognostic value related to anatomic and functionaloutcome after surgery.

Classic epiretinal membrane (C-ERM) in lamellar macular hole

Thick epiretinal membrane (T-ERM) in lamellar macular hole

3:59 pMDiscussion

4:05 pMocriplasmin, a Pharmacologic option for the Treatment of symptomatic vitreomacular adhesions (svMa): Phase iii clinical Trials results

Pravin U. Dugel, MD* (Phoenix, AZ)

PurPose The purpose of this study was to evaluate the safetyand efficacy of a single dose of 125µg ocriplasmin for thetreatment of sVMA at day 28. Patients with vitreomaculartraction, full thickness macular hole, and epiretinal membranewere included.

MeTHoD These studies (MIVI-006 & MIVI-007) wererandomized, placebo-controlled, double-masked, multicentertrials, investigating a single dose of 125µg (100 µl) intra vitrealinjection of ocriplasmin for treatment of vitreomacular

adhesion as compared to a 100 µl placebo intra vitreal injection.The primary endpoint was nonsurgical resolution of fVMA atday 28, determined by Central Reading Centre OCT evalu-ation. Secondary endpoint assessments included total posteriorvitreous detachment (PVD) at day 28, nonsurgical FTMHclosure, avoidance of vitrectomy, visual acuity, and VFQ-25.

resulTs 652 eyes were treated at clinical sites in Europe andthe United States. 464 eyes were randomized to receive a singledose of 125µg ocriplasmin and 188 eyes received 100 µl ofplacebo. Patient age range was 18 to 93 years. At day 28 VMAresolution was achieved in 26.5% of ocriplasmin treated eyesand 10.1% of eyes receiving placebo (p<0.001). Of treatmentresponders, 74% achieved VMA resolution by day 7. Theproportion of eyes that achieved total posterior vitreous detach -ment at day 28 was 13.4% in the ocriplasmin group and 3.7% inthe placebo group (p<0.001). Closure of full thickness macularhole was achieved by day 28 in 40.6% of eyes treated withocriplasmin and 10.6% of eyes in the placebo group (p<0.001).

conclusion The MIVI-TRUST program is the largest Phase IIIprogram ever conducted to evaluate a pharmacologic interven -tion for the treatment of symptomatic vitreomacular adhesion.The significant clinical results observed in these trials indicatethat ocriplasmin can potentially become the first pharmacologicoption for the treatment of symptomatic vitreomacularadhesion including macular holes.

4:13 pMTreatment of symptomatic vitreomacularadhesions with ocriplasmin: 6 Month outcomes from the Mivi-TrusT Phase iii Program

Peter K. Kaiser, MD* (Cleveland, OH)

PurPose The purpose of this study was to evaluate the safetyand efficacy of a single dose of 125µg ocriplasmin for thetreatment of sVMA at day 28. Patients were then followed upto 6 months to assess the durability of primary and secondaryefficacy outcomes and safety. Patients with vitreomaculartraction, full thickness macular hole, and epiretinal membranewere included.

MeTHoD These studies (MIVI-006 & MIVI-007) wererandomized, placebo-controlled, double-masked, multicentertrials, investigating a single dose of 125µg (100 µl) intra vitrealinjection of ocriplasmin for treatment of vitreomacularadhesion as compared to a 100 µl placebo intra vitreal injection.The primary endpoint was nonsurgical resolution of fVMA atday 28, determined by Central Reading Centre OCT evalu-ation. Secondary endpoint assessments included total PVD atday 28, nonsurgical FTMH closure, avoidance of vitrectomy,visual acuity, and VFQ-25. Eyes were followed for 6 months.

resulTs 652 eyes (age 18-93) were enrolled by 90 investigatorsat clinical sites in Europe and the United States. 464 eyes wererandomized to receive a single dose of 125µg ocriplasmin and188 eyes received a 100 µl placebo injection. By month 6,VMA resolution was achieved in 26.9% of ocriplasmin treatedeyes and 13.3% of eyes receiving placebo (p<0.001). At 1 monthand 6 months following treatment 40.6% of eyes receivingocriplasmin achieved closure of full thickness macular hole(FTMH), compared to 10.6% (p<0.001) at 1 month and 17.0%(p=0.004) at 6 months for placebo. Significant improvement of 2 or more lines (10 letters) in visual acuity (28.0%, p=0.003)and 3 or more lines (12.3%, p=0.024) of visual acuity wasobserved in ocriplasmin group. Patients treated with ocriplasmindemonstrated significant improvement in visual function ascompared to placebo.

conclusion A single dose of 125µg ocriplasmin intra vitrealinjection achieved clinically significant and sustainedanatomical and visual acuity results in eyes with vitreomaculartraction, full thickness macular hole, & epiretinal membrane ascompared to a 100 µl placebo injection. Treatment was welltolerated by patients and appears to be a minimally invasivepharmacologic option for the treatment of sVMA.

4:21 pMDiscussion

4:25 pMoptic nerve Pit with Macular Detachment(fluid origin and Better Management)

Ehab N. El-Rayes, MD (Cairo, Egypt)

PurPose Chronic serous macular detachment, macularretinoschesis and cystic degeneration of the inner retina arecomplication of fluid access from the pit damaging the macula.In this study we report cases of managing the fluid intraopera-tively decreasing the risk of vision threatening complication,this fluid was analyzed to trace the source of this fluid.

MeTHoD We report 6 eyes of 4 patients with maculardetachment due to optic nerve pits. 2 eyes were managed withvitrectomy ,laser and air. The other 4 eyes were treated withvitrectomy and aspiration of the viscous intra as well as subretinal fluid with 38 gauge translocation canula to dry themacular intraoperatively. The collected fluid was sent foranalysis , including B.trace protein detection. OCT was doneon day 3 and one week then monthly for 3 month.

resulTs Successful macular attachment with layer restorationwas immediately achieved in all 4 eyes with in the first week on OCT in the eyes that had aspiration. All eyes had rapidimprovement in visual acuity and fundus appearance. In the




27

vitrectomy without aspiration eyes , complete macularattachment was seen by one month in one eye and up to 2month in the second eye ,with residual intra-retinal cysts.The intra retinal fluid was noted to decrease gradually over 3month period. Sub retinal fluid analysis showed positive B traceprotein in 2 eyes (50%), in favor of CSF fluid component accessto submacular space.

conclusion Intraoperative aspiration of intra and sub retinalfluid leads to immediate restoration of macular structure. Thisreflects on visual function improvement. Fluid analysis showedthat there is contact between the CSF to sub retinal space.Vitrectomy with aspiration sub retinal fluid should be consider-ation as the line of management of macular detachment due to optic pit.

4:33 pMretinal Detachments following cataractsurgery with Presbyopia-correcting intraocular lenses

Michael M. Lai, MD, PhD (Chevy Chase, MD), Janine Collinge, MD, Neil F. Martin, MD

PurPose To determine the incidence of retinal detachment(RD) following cataract surgery with implantation of multifocal(ReSTOR®) or accommodative (Crystalens®) intraocular lens(IOL), and to compare the rates of post-cataract RD betweenthese two types of IOLs.

MeTHoD This is a retrospective cohort study consisting ofconsecutive eyes that underwent cataract surgery by a singlesurgeon between 2004 and 2010. All eyes were implanted witheither a ReSTOR (Alcon) multifocal IOL or a Crystalens(Bausch & Lomb) accommodative IOL. Eyes with history ofRD or retinal tear prior to cataract surgery, or follow-up lessthan 3 months after cataract surgery were excluded from thestudy. The primary outcome was the rate of RD followingcataract surgery with each type of IOLs. The RD rates werecompared between the two groups to determine whether significant differences exist.

resulTs 315 eyes with ReSTOR multifocal IOL and 172 eyeswith Crystalens accommodative IOL met the inclusion andexclusion criteria. The two groups were similar with respect tomean axial length, follow-up duration, and final best-correctedvisual acuity. There were no intraoperative complicationsincluding capsular rupture in any eye. During the follow-upperiod (mean = 25.7 months), 2 eyes (0.6%) in the multifocalIOL group and 7 eyes (4.1%) in the accommodative groupdeveloped RD (p=0.0112, Fisher’s exact test). The mean timeto RD was 13 months following cataract surgery (range 1-37months). When using logistic regression modeling adjusting forthe effects of age, gender, axial length, and follow-up duration,

and analyzing only one eye per patient, Crystalens wasassociated with a higher RD rate than ReSTOR (OR 4.6, 95%CI 0.8-26.2), although the difference did not reach statisticalsignificance due to small sample size (p=0.087).

conclusion Compared to multifocal IOL (ReSTOR), accom-modative IOL (Crystalens) implantation with cataract surgerymay be associated with a higher rate of postoperative RD. Dueto the relatively small sample size and the retrospective natureof this study, these results will need to be verified by futurestudies.

4:41 pMDiscussion

4:45 pMcomparison of Pars Plans vitrectomy With and Without scleral Buckle for the repair ofPrimary rhegmatogenous retinal Detachment

Joseph Moisseiev, MD (Tel Aviv, Israel), Michael Kinori, MD, Elad Moisseiev, MD, Nadav Shoshani, MD, Ido Fabian, MD, Alon Skaat, MD, Adiel Barak, MD*, Anat Loewenstein, MD*

PurPose To compare pars plana vitrectomy (PPV) withcombined PPV and scleral buckle (PPV/SB) for the repair ofnoncomplex primary rhegmatogenous retinal detachment(RRD).

MeTHoD A retrospective review of the charts of 469 patientsthat underwent vitrectomy for primary RRD’s in two majormedical centers in Israel. Included in this study are 181 eyeswith non-complicated RRD and at least 3 months of follow up.There were 96 eyes in the PPV group and 85 eyes in PPV/SBgroup.

resulTs Single surgery anatomic success (SSAS) was achievedin 81.3% and 87.1% in the PPV and PPV/SB groups, respec-tively (P=NS). Final anatomic success rates were 98.9% and98.8%, respectively (P=NS). Final visual acuity (logMAR) was0.41 in the PPV group and 0.53 in the PPV/SB group (P=NS).The final VA was significantly better than the pre-operativeVA in both group (P<0.0001). In detachments caused byinferior tears SSAS were 80.9% and 81.5% in the PPV andPPV/SB groups, respectively (P=NS). In phakic eyes SSAS was92% and 87.5% and in pseudophakic eyes 77.5% and 86.7%, inthe PPV and PPV/SB groups, respectively (P=NS).

conclusion The re-attachment rate and the final VA weresimilar in both groups. The addition of SB did not improve theresults, and was associated with slightly lower visual acuity thanwith PPV alone. Tear location or lens status had no significanteffect on success rates. It is likely that in eyes undergoing PPVfor primary RRD addition of a SB is not warranted.

4:53 pMretinal Detachment repair: a comparison of Pneumatic retinopexy, Pars Planavitrectomy and scleral Buckling within a group Private Practice

Robert L. Avery, MD (Santa Barbara, CA), Ma’an Nasir, MD, Dante Pieramici, MD, Alessandro Castellarin, MD, Robert See, MD, Stephen Couvillion, MD, Melvin Rabena

PurPose To compare visual and anatomical outcomes includingthe incidence of recurrent detachment between four differentsurgical approaches to repair primary rhegmatogenous retinaldetachment (RRD): scleral buckle (SB), primary pars planavitrectomy (PPV), pneumatic retinopexy (PR) and combi-nation primary pars plana vitrectomy with scleral buckling(PPV+SB).

MeTHoD A retrospective review was conducted on consecutiveeyes that underwent surgical repair for primary (RRD) over the past 10 years within a group private practice. Cases withruptured globe, penetrating injury, giant retinal tear (> 3 clockhours), proliferative diabetic retinopathy, stage C or worseproliferative vitreoretinopathy (PVR), or less than 3 monthfollow-up were excluded. Analysis of preoperative character-istics included vision, PVR status, vitreous hemorrhage (VH),lens status, and extent of detachment. Postoperative adverseevents analyzed were recurrent retinal detachment, number ofretinal reattachment procedures, development of PVR, VH andepiretinal membrane.

resulTs Entry criteria were met by 793 eyes with primary RRD; 72 eyes were repaired by pneumatic retinopexy (PR), 91 by scleral buckle (SB) only, 533 by combined pars planavitrectomy and scleral buckle (PPV+SB) and 91 by pars planavitrectomy only (PPV). There were 472 (57.8%) phakic eyes,353 (44.5%) pseudophakic eyes, and 4 (0.5%) eyes wereaphakic at the time of initial repair. The macula was attachedin 536 (67.6%) eyes. Preoperatively proliferative vitreo-retinopathy (grade B or less) was found in 122 (15.4%) eyes,vitreous hemorrhage was present in 71 (8.9%) eyes. The meanlength of follow-up was 28 months. Redetachment rates were6.1% (48/793) for the entire group and 31.9% (PR), 9.9% (SB),2.4% (PPV+SB) and 3.1% (PPV). Final anatomic success ratewas 100% with an average of 1.17 additional reattachmentsurgeries performed on the 48 failed cases.

conclusion Patients undergoing PR had higher redetachmentrates than other groups, but had good final visual and anatomicoutcomes. As a non-randomized trial, there was probably aselection bias with more difficult cases undergoing PPV+SB.Despite a higher incidence of PVR, VH, and macula offdetachment in the PPV+SB group, this group had the highestsuccess rate with 97.6% reattachment with one surgery.

5:01 pMscleral Buckling surgery for Treatment of rhegmatogenous retinal Detachment

Kourous A. Rezaei, MD* (Harvey, IL), Anna Gabrielian, MD

PurPose To review the characteristics and outcomes of patients who underwent scleral buckling surgery for repair ofrhegmatogenous retinal detachment.

MeTHoD A retrospective chart review was conducted onpatients who underwent primary scleral buckling (SB) surgeryfrom 2005 to 2009 by ten surgeons. Patients with <6 months of follow-up were excluded. Data collected on each patientincluded: duration of follow-up, age, sex, lens status, presence of posterior vitreous detachment (PVD), vitreous hemorrhage(VH), lattice degeneration, myopia, proliferative vitreo-retinopathy (PVR), status of the macula, number of retinalbreaks, extent of detachment, pre-operative and final visualacuity (VA), the number of procedures needed to reattach theretina, and the final anatomic status of the retina. 135 eyes of133 patients were evaluated.

resulTs Mean follow-up was 29.8 months (6-62). 5.2% of theeyes were pseudophakic, 31.1% had lattice degeneration, and10.4% had PVR upon presentation. The mean number ofbreaks was 1.8 (1-6) and the mean extent of detachment was4.9 clock hours (1.5-12). On presentation macula was off in 67 eyes (49.6%). Reattachment rate after one procedure was87.4% (118/135), while overall reattachment rate was 100%.Seventeen eyes (12.6%) required more than one procedure toreattach the retina. Three eyes (2.2%) developed epiretinalmembranes requiring surgery, two eyes (1.5%) required SBremoval, and one eye (0.7%) developed macular hole. Themean VA at presentation was 20/100 (20/15-light perception(LP)) and mean final VA was 20/40 (20/20-2/200). In maculaoff patients, the mean initial VA was 20/100 (20/15-LP), andthe mean final VA was 20/40 (20/15-2/200). 62.7% of maculaoff patients had final VA of 20/40 or better, while 72% ofmacula on patients had final VA of 20/40 or better.

conclusion Our findings further confirm that primary scleralbuckling procedure leads to successful anatomic reattachmentwith significant visual improvement. In 87.4% of the eyes theretina was re-attached with a single procedure. 62.7% of maculaoff patients recovered a visual acuity of 20/40 or better.




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5:09 pMcost-effectiveness analysis of vitrectomy vs. scleral Buckle for repair ofrhegmatogenous retinal Detachment

Jay M. Stewart, MD (San Franciso, CA), Michael I. Seider, MD, Ayman Naseri, MD*, Travis C. Porco, MD

PurPose Many RRDs are suitable for repair with either PPV or SB. These two approaches generally achieve final anatomicsuccess at similar rates. Anecdotally, PPV may be supersedingSB in many practices and training programs. We have performeda cost-effectiveness analysis so that clinicians and others canfactor this information into their surgical planning if they so choose.

MeTHoD The relative effectiveness of primary SB versus PPV inphakic or pseudophakic patients was derived from the largestpublished randomized trial comparing these surgical interven-tions (Heimann et al, Ophthalmology 2007). The costs for each procedure were determined by CPT code as the Medicare-reimbursed physician fee, the surgical center fee, and anesthesiafee using published 2010 rates adjusted for the San Francisco,CA, region. Costs associated with procedures required toachieve final success including additional retina-affecting inter-ventions and cataract surgery were assigned at an estimatedaverage frequency.

resulTs As a single procedure, primary repair of RRD with PPVcosts $4,164, and SB costs $3,584. SB generally requires moresecondary procedures to achieve final reattachment but is lesslikely to drive a need for cataract surgery. Returning to theoperating room for a second vitreoretinal surgery costs an extra$3,811, while performing in-office gas injection costs $1,183.Cataract surgery costs $1,973. If these additional procedures areperformed at an average frequency, PPV is $92 cheaper than SBin pseudophakic patients and $500-1000 more expensive thanSB in phakic patients.

conclusion At current Medicare reimbursement rates, primaryPPV as a single procedure is more costly than SB for repair ofRRD. The overall cost-effectiveness is determined by theprimary surgery and the number of secondary procedures. Inphakic patients primary SB is substantially more cost-effectivethan PPV for treating RRD, while in pseudophakic patientsPPV is slightly more cost-effective than SB.

5:17 pMoutcomes of vitrectomy and Pars Planalensectomy for Dropped cataractous lensMaterial in Previously vitrectomized eyes

Tarek S. Hassan, MD* (Royal Oak, MI)

PurPose To present the first consecutive series that reports thevisual acuity (VA) and anatomic outcomes of vitrectomy (VIT)with pars plana lensectomy (PPL) for dropped cataractous lensmaterial from complicated cataract surgery in previously vitrec-tomized eyes, and, to describe the impact of the lens dislocationand second vitreous surgery on the course of the existing vitreo-retinal condition.

MeTHoD We retrospectively reviewed the records of all consec-utive phakic eyes (n=23) that underwent VIT in our practicebetween 1/1/00 and 1/1/11 for routine indications – VH/PDR(8), RD (7), ERM (6), macular hole (1), CSDME (1) – thatthen, later, underwent VIT, PPL by us for dislocated lensmaterial from complicated phacoemulsification with theiranterior segment surgeons after recovery from the initial VIT.No eye had any known history of lens trauma, including intra-operatively during the initial VIT and postoperatively beforecataract extraction. VA, anatomic outcomes, complications,and an assessment of the alteration of the expected postoper-ative course of the initial VIT are presented.

resulTs Ten women and 13 men (mean age = 64 yrs)underwent VIT, PPL for dropped lens material after compli-cated phacoemulsification in their previously vitrectomizedeyes. No mean VA improvement was seen after the initial VIT(preop = 20/490, postop = 20/390) due to significant cataractformation. All eyes had standard phacoemulsification withanterior segment surgeons (at a mean of 8.2 mos) but suffereddislocation of crystalline lens material (estimated, 5-100%nucleus, mean = 47%) into the vitreous cavity. All eyes thenhad VIT, PPL within 5 days of lens dislocation. At the latest f/uvisit (mean = 20.6 mos, range = 3-86 mos), mean VA improvedfrom 20/564 to 20/73 (p<0.0001), with increased VA noted in22/23 eyes. Post-VIT, PPL complications included PVR (1 eye,h/o prior PVR), ERM (1 eye, h/o prior ERM), macular hole (1 eye, h/o prior RD); these eyes were successfully repaired with one additional VIT. CME developed in 3 eyes and thenresolved with successful medical therapy.

conclusion This is the first report to describe a consecutiveseries of eyes that had current VIT, PPL techniques for droppedcataractous lens material in previously vitrectomized eyes. Goodoutcomes were achieved, though the proliferative complicationsin previously stable eyes suggest that the cataract dislocation(and possibly its repair) may have contributed to worsening thepatients’ overall course.

5:25 pMTorsional Phacoemulsification facilitatesremoval of Posterior segment retained lensMaterial during Pars Plana vitrectomy

Sunir J. Garg, MD* (Philadelphia, PA), Richard G. Lane, MD, Allen Chiang, MD, Jason Hsu, MD, Marc J. Spirn, MD, Carl D. Regillo, MD,Joseph I. Maguire, MD*, James F. Vander, MD, Richard S. Kaiser, MD, Arunan Sivalingam, MD

PurPose To determine the utility of the OZil torsionalphacoemulsification hand piece instead of the Fragmatomeduring pars plana vitrectomy (PPV) for the removal of posteriorsegment retained lens material.

MeTHoD This was a retrospective case series of all eyes thatunderwent PPV for retained lens material between Septemberand March 2011. Following 23-gauge PPV, the torsionalphacoemulsification hand piece (OZil, Alcon, Fort Worth, TX)without the irrigating sleeve was inserted through a 20-gaugesclerotomy for the removal of posterior segment retained lensmaterial. Retained lens fragments were graded by nucleardensity (1 to 4+) and size as a percentage of the total cataract.Primary outcome measures consisted of total ultrasound time,phaco time, and torsional time. Secondary outcome measuresincluded intraoperative complications or mechanical malfunc-tions (e.g., hand piece clogging).

resulTs All 16 eyes successfully underwent pars planalensectomy (PPL) with the OZil hand piece. Mean nucleardensity was 3.78+ and mean size was 51% of the total cataract.Mean total ultrasound time was 33.9 seconds, mean phaco timewas 9 seconds, and mean torsional time was 24.7 seconds. Allcases demonstrated excellent followability based on indepen -dent observations by the various surgeons. In one case, 2inferior retinal breaks were identified during PPV, but wereunrelated to PPL. No other intraoperative complications ormechanical issues were observed. In particular, clogging of thehand piece by nuclear material was not seen in any case.

conclusion Use of the OZil torsional emulsification hand piece during PPV for retained lens material represents a novelapproach with advantages over the conventional Fragmatome,including improved followability and efficient removal of denselens material due to the addition of torsional ultrasonicmovement.

5:33 pMDiscussion

5:30 pM4K Twilight run/Walk for the retina Sponsored by the American Retina Foundation

5:45 pMfree evening

8:00-10:00 pMfellows in Training (fiT) receptionSonsie Restaurant, 327 Newburg Street, Boston



Monday

Monday, August 22

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6:15-7:15 AM

Special interest GroupsBreakfastroundtable Discussion groupsRepublic Ballrooms AB

Organizer: Sophie J. Bakri, MD

Wake up to a casual roundtable discussion and jumpstart your senses with fresh perspectives on a variety of conditions,treatment, and procedures for the practicing retinal specialist.Attendees are asked to pick and sign up for a breakfast tabletopic of their choice on the first day of the meeting. Each tablewill have an “expert in the field” help direct the topic discussion in a casual relaxed atmosphere.

Topics will include:

• CATT Trial

• Diabetic Macular Edema: Treatment Algorithms

• Diabetic Retinopathy and Diabetic Edema: A Comprehensive Evidence-Based Approach

• Diabetic Vitrectomy: Approaches in the Era of AntiVEGF Therapy and Small Gauge Vitrectomy

• Electronic Medical Records

• Epiretinal Membranes and Vitreomacular Traction

• Macular Holes and Lamellar Holes

• Management of Anti-VEGF Non-Responders in AMD

• Managing Posterior Uveitis: Current Approaches and New Treatments in the Pipeline

• New Drugs in AMD

• New Tools in Vitrectomy: Pearls for Endoillumination

• OCT and Autofluorescence

• Ocular Inflammation: Endophthalmitis and Posterior Uveitis

• Ocular Oncology

• Payment Reform: Bundling, ACOs and Value Based Payments

• Pediatric Retina: The Role of Laser, Anti-VEGF, and Surgery

• Proliferative Vitreoretinopathy in as Few Operations as Possible

• Retinal Coding/Office Management

• Retinal Drug Delivery: The Pipeline

• Retinal Vein Occlusions: The Role of Laser, Steroids and Anti-VEGF Therapy

• Scleral Buckles, Pneumatic or Vitrectomy for Retinal Detachment?

• Small Gauge Vitrectomy

• Treatment Algorithms for Wet AMD: Which Anti-VEGF and When?

• Vitreoretinal Surgery in an ASC


7:30-10:05 AM

Symposium 5:Retinal vascular/imagingModerators: Mathew W. MacCumber, MD, PhD and Virgilio Morales-Canton, MD


7:30 AMThe effect of Posterior vitreous Detachmenton anti-vegf Treatment of Macular edemasecondary to retinal vascular occlusion

Nancy M. Holekamp, MD* (St. Louis, MO)

PurPose There is an emerging literature that suggests thatvitreous anatomy, specifically the presence or absence ofposterior vitreous detachment (PVD), may play a role inexudative AMD. The purpose of this study is to determine ifthe presence or absence of PVD plays a role in the treatment of macular edema due to retinal vascular occlusive disease with 6 monthly intra vitreal ranibizumab injections.

MeTHoD Consecutive patients meeting the following inclusioncriteria were enrolled in the study: best-corrected visual acuityof 20/40-20/800, perfused macular edema secondary to BRVOor CRVO, and duration of symptoms less than 6 months. Atbaseline, month 4, and month 7, each patient underwent 3examination techniques to determine the presence of absenceof posterior vitreous detachment: slit-lamp biomicroscopy, b-scan ultrasound, and spectral-domain OCT. Each patientreceived 6 monthly injections of intra vitreal ranibizumab. Keyendpoints of the study were the number of patients gaining 3 or more lines of best-corrected visual acuity and the failure togain best-corrected visual acuity.

resulTs Thirty of 31 patients enrolled in the trial completed allstudy visits. Seventeen eyes had macular edema due to a branchretinal vein occlusion (BRVO) and 13 eyes had macular edemadue to a central retinal vein occlusion (CRVO). Mean patientage was 70.9 years (range 19-90 years). For eyes with BRVO,median visual acuity was 20/63 (range 20/40-20/200). For eyeswith CRVO, median visual acuity was 20/163 (range 20/50 to20/800). Sixteen eyes had a PVD, (11 BRVO and 5 CRVO,mean age 74.2 years) and 14 eyes had no PVD (6 BRVO and 8 CRVO, mean age 61.1 years) at the initial visit. Three eyes


Monday, August 22

with no PVD at the initial visit developed a PVD by the finalvisit at month 7. The percentage of patients gaining 3 or morelines of vision were: BRVO/PVD+: 27%, BRVO/PVD -: 33%,CRVO/PVD+ 60%, CRVO/PVD-: 87.5%. The percentage ofeyes with no visual improvement were: BRVO/PVD+: 36%,BRVO/PVD-: 17%, CRVO/PVD+: 20%, CRVO/PVD-: 0%.

conclusion The eyes that responded best to 6 monthly intra -vitreal ranibizumab injections had macular edema due toCRVO and had no PVD. The eyes that responded the least well to 6 monthly intra vitreal ranibizumab injections hadmacular edema due to BRVO and had a PVD. Vitreous anatomymay play a role in the response to anti-VEGF therapy formacular edema due to retinal vascular occlusive disease.

7:38 AMgreater Benefit from Dexamethasone intravitreal implant Treatment started earlyfollowing onset of Macular edema Due to Branch retinal vein occlusion

Julia A. Haller, MD* (Philadelphia, PA), Baruch D. Kuppermann, MD*, PhD, Francesco Bandello*, Jenny Jiao*, Xiao-Yan Li*, Scott M. Whitcup, MD*

PurPose This study retrospectively examined treatmentoutcomes by duration of disease from two phase 3 studies ofdexamethasone intra vitreal (DEX) implant (Ozurdex®) 0.7 mgcompared with sham procedure in patients with vision losscaused by macular edema (ME) following branch or centralretinal vein occlusion (BRVO; CRVO).

MeTHoD Patients ≥18 years with ME involving the fovea due toBRVO or CRVO, best-corrected visual acuity (BCVA) between≥34 (20/200) and ≤68 (20/50) letters, and retinal thickness≥300 µm were enrolled. Patients were randomly assigned totreatment with DEX implant 0.7 mg or sham procedure. Theprimary outcome was ≥15-letter improvement from baseline inBCVA at day 180. Secondary outcomes included mean BCVAchange from baseline and other BCVA variables. The effect ofduration of ME on BCVA improvement was examined usingmultiple linear regression models based on pooled data fromtwo phase 3 trials. Duration of ME was analyzed as a binary(≤90 days or >90 days) as well as a continuous variable.

resulTs Of 427 patients receiving DEX implant and 426receiving sham, 67% had BRVO and 33% had CRVO. Themean duration was 5.3 months for BRVO and 4.9 months forCRVO. Sixteen percent of patients entered the study with aduration ≤90 days. BRVO patients with ≤90-day duration

exhibited greater improvement in BCVA compared to thosewith >90-day duration. Specifically, the additional BCVA gainwas up to 3.4 letters for DEX and 1.3 letters for sham BRVOpatients. The observed difference was consistent at all visits.When duration of ME was analyzed as a continuous variableand with adjustment for treatment, age and baseline BCVA, theeffect was borderline significant at day 60 (P=0.053) when peakeffect was seen, and at day 180 (P=0.051) which is themaximum time for drug effect. Results for CRVO showed largervariations due to small sample sizes and natural history of thedisease. Analysis of 15-letter improvement in BCVA providedsimilar results for duration effect.

conclusion Analysis of pooled data from two phase 3 trialsindicates that BRVO patients with shorter duration of disease(eg, ≤90 days) at study entry exhibited greater improvement inBCVA comparing to patients with longer duration of disease(eg, >90 days). These results suggest that early treatment withDEX implant may provide greater clinical benefit in patientswith ME due to BRVO.

7:46 AManatomic outcomes in Bravo and cruise:resolution rates of cystoid Macular edemaand subretinal fluid with ranibizumab for retinal vein occlusionRobert B. Bhisitkul, MD (San Francisco, CA), Peter Campochiaro, MD*,Howard Shapiro*, Namrata Saroj*, Roman Rubio*

PurPose In BRAVO and CRUISE, RBZ treatment for retinalvein occlusion (RVO) resulted in significant improvements invisual acuity and macular edema. Two subcomponents ofincreased central foveal thickness (CFT), cystoid macularedema (CME) and subretinal fluid (SRF), were independentlyassessed by OCT to determine their incidence and to compareresolution rates at 7 days to 12 months with RBZ therapy.

MeTHoD BRAVO (branch RVO) and CRUISE (central RVO)were phase III, multicenter, randomized studies to evaluate the efficacy and safety of intra vitreal RBZ. Patients receivedmonthly RBZ (0.3 mg or 0.5 mg) or sham treatment for aninitial 6-month period; for a further 6 months all groupsincluding sham were eligible for PRN RBZ. A post-hoc dataanalysis was performed using time-domain OCT imagescollected at days 0 and 7, and months 6 and 12. Two anatomicsubcomponents, CME and SRF, were graded in a maskedfashion at the Wisconsin Reading Center.

resulTs CME improved rapidly in both studies. In the 0.3 mgand 0.5 mg RBZ groups in CRUISE, 70.1% and 61.0% ofpatients, respectively, had no CME by day 7, compared with1.5% and 1.6% at baseline. Comparable results were seen in theRBZ groups in BRAVO (60.0% and 55.7% with no CME at day


reTinal vascular/iMaging 7:30–10:05 AM5


33

7 compared with 2.3% and 1.5% at baseline). These improve-ments were similar in the 0.5 mg, but not 0.3 mg, RBZ group at6 and 12 months in both studies. In CRUISE, the percentage of0.3 mg and 0.5 mg RBZ patients with no SRF improved from39.2% and 41.4% at baseline to 55.9% and 61.0% at Day 7, andto 92.7% and 94.6% by month 6. Similar results were seen inthe RBZ groups in BRAVO at months 6 and 12. In both studies,SRF resolution was attained in 90% to 98% of RBZ patients at month 12.

conclusion Treatment of RVO patients with RBZ significantlyimproved both CME and SRF, but each subcomponent dis -played different response patterns. CME responded rapidly totreatment as early as 7 days, but did not resolve in all patients.Conversely, improvements in SRF were less rapid, but resolu -tion in almost all patients was observed at 6 months andmaintained through to 12 months.

Table 1. CRUISE Study: Percentage of patients with no CME or SRFon OCT (n (%) = number (percentage) of patients with absence ofCME or SRF; N = number of patients assessed at timepoint).

Table 2. BRAVO Study: Percentage of patients with no CME or SRF on OCT (n (%) = number (percentage) of patients with absence ofCME or SRF; N = number of patients assessed at timepoint).

7:54 AMvariable schedule intravitreal injection,efficacy, and safety of ranibizumab inPatients with retinal vein occlusion in the Horizon extension study

Dante J. Pieramici, MD* (Santa Barbara, CA), Linda Yau, MD*, Tatiana Beres, MD, Phillip Lai, MD*

PurPose RBZ administration to RVO patients results in significant visual improvements. We evaluated efficacy andsafety, as well as explored associations between number of injec-tions and visual outcomes and predictors for the number ofinjections, in the first 12 months of HZN, an open-label PRN-dosing extension trial following the 12-month BRAVO andCRUISE studies.

MeTHoD HZN RVO was an open-label, single-arm, multicenterextension for patients who completed BRAVO or CRUISE.Enrolled patients received intra vitreal RBZ (0.5 mg) at ≥30-dayintervals if they met PRN criteria (central subfield thickness≥250 µm or macular edema that affected visual acuity) and werefollowed for up to 24 months or study termination (30 days afterFDA approval of RBZ for RVO). Efficacy outcome includedmean change from HZN baseline in best corrected visual acuity(BCVA) at Month 12 (M12). Post-hoc analyses of the associ-ation between number of injections and efficacy outcomes andpredictors for the number of injections were explored by statis-tical modeling.

resulTs HZN RVO enrolled 608 patients (n=304 each fromBRAVO and CRUISE) with 205 (67%) BRAVO and 181 (60%)CRUISE patients completing M12 of HZN. Mean study durationwas 14 months for all patients. BCVA remained stable over thefirst 12 months of HZN in BRAVO patients, with mean changesfor the randomized groups in BRAVO of +1 to -2 letters fromHZN baseline. In CRUISE patients, mean reductions of 4–5letters from HZN baseline were observed by M12. BRAVOpatients received a mean of 2.5 injections and CRUISE patientsreceived a mean of 3.8 injections of 0.5 mg RBZ through M12 inHZN. 66% (135/205) of BRAVO patients and 80% (145/181) ofCRUISE patients received at least 1 injection in HZN. Amongpatients who received at least 1 RBZ injection in HZN, over50% (163/280) received 4 or fewer injections during the first 12 months in HZN. Association between number of injectionsand change from baseline in BCVA and predictors for thenumber of injections will be presented.

conclusion RBZ administration using HZN trial-specifiedPRN dosing maintained BCVA for BRAVO patients, butresulted in a mean decrease of 4-5 letters for CRUISE patientsby M12 of HZN. The majority of patients who completed M12of HZN received ≤4 and 27% received no injections in thestudy. Ocular and systemic adverse event rates were similar toprevious RBZ trials and no new safety events were identified.

8:02 AMinitial Treatment of Macular edema secondary to retinal vein occlusion with intravitreal Bevacizumab

Michael J. Davis, MD* (Arcadia, CA), Ritchie Yuson, MD, Michael A. Samuel, MD*, Tom S. Chang, MD*

PurPose What is the most effective initial treatment regimenwith intra vitreal bevacizumab injection for the treatment ofmacular edema secondary to retinal vein occlusion with regardsto improvement in visual acuity, decrease in central fovealthickness, minimizing recurrences and maximizing remission?

MeTHoD This is a retrospective, chart review of patients withmacular edema secondary to branch (n=51) and central retinalvein occlusion (n=64) treated primarily and solely with intra -vitreal bevacizumab from 2004-2011. A total of 115 eyes wereincluded. Visual acuity (VA) and OCT central foveal thickness(CFT) were reviewed. The initial response to treatment withnumber of injections, remission rate and time to recurrencewere analyzed.

resulTs The mean VA on presentation was 20/100 for BRVOand 20/400 for CRVO. The mean CFT on presentation was404. 67 microns for BRVO and 465. 29 microns for CRVO.After initial bevacizumab treatment, 72.6% of BRVO and42.9% of CRVO patients had an improvement. The meannumber of injections for initial treatment was 2.47 ± 0.92(range 1–5) for BRVO and 2.39 ± 1.06 (range 1–6) for CRVO.The greatest VA improvement was after 3 injections for BRVO,with a mean gain of 4 lines, and 4 injections for CRVO, with a mean gain of 2.5 lines. The greatest CFT response in bothgroups was after 4 injections, with a decrease of 352 micronsand 102 microns for BRVO and CRVO, respectively. Thelength of remission was longest after 3 initial injections for bothgroups (215 days for BRVO and 65 days for CRVO). The recur-rence rates were higher for patients that received 3 injections(18.5% for BRVO and 42.9% for CRVO) and were the least forpatients who had 4 or more injections (0% for BVO and 20%for CRVO).

conclusion Patients with RVO tend to respond best to at least 3 initial injections with regards to mean VA improvementand mean OCT response and have a longer remission period.Recurrence rates were higher with those receiving 3 injectionswhen compared to those who received at least 4 injections.Bevacizumab treatment with at least 3 injections followed by as needed treatment is an effective regimen.

8:10 AMDiscussion

8:20 AMThe 6-Month (Primary endpoint) results of the Phase 3 galileo study: vegf Trap-eye in crvoJean-Francois Korobelnik, MD* (Bordeaux, France)

PurPose VEGF Trap-Eye is an intra vitreally administeredfusion protein designed to bind the pro-angiogenic factorsvascular endothelial growth factor A (VEGF-A) and placentalgrowth factor with higher affinity than their native receptors.This study evaluated the efficacy and safety of intra vitrealVEGF Trap-Eye in patients with macular edema secondary tocentral retinal vein occlusion (CRVO) to week 24.

MeTHoD In this double-masked, multi-center, controlled Phase3 study, 177 patients were randomized to 2 mg VEGF Trap-Eyeor sham injections every 4 weeks. The primary endpoint is theproportion of patients who gained ≥15 ETDRS letters frombaseline at Week 24. Secondary outcomes at week 24 includethe change from baseline in best-corrected visual acuity, scoredbased on the number of ETDRS letters read correctly.

resulTs Week 24 data will be available at the time of presentation. Efficacy and safety results will be discussed.

conclusion Primary and secondary endpoints results of thisstudy should provide important information about the efficacyand safety of VEGF Trap-Eye for the treatment of patients with CRVO.

8:28 AMvegf Trap-eye in crvo: 1-year results of the Phase 3 coPernicus studyW. Lloyd Clark, MD* (West Columbia, SC), Julia A. Haller, MD*, David S.Boyer, MD*, Jeffrey S. Heier, MD*, David B. Brown, MD*, Robert Vitti, MD

PurPose To evaluate the efficacy and safety of VEGF Trap-Eyein patients with macular edema secondary to central retinalvein occlusion (CRVO). VEGF Trap-Eye is an intra vitreallyadministered fusion protein designed to bind all isoforms ofVEGF-A and placental growth factor that are involved inabnormal angiogenesis.

MeTHoD In this randomized, double-masked, controlled, Phase 3study, patients received 6 monthly injections of either 2 mgVEGF Trap-Eye (114 patients) or sham injections (73 patients).Through Week 24 to Week 52, patients received either 2 mgVEGF Trap-Eye as-needed (PRN) or sham injections accordingto retreatment criteria. The primary endpoint was the propor -tion of patients who gained ≥15 ETDRS letters from baseline atWeek 24. A key secondary outcome measure was the change inbest-corrected visual acuity from baseline to Week 24. Week 52data will be available at the time of presentation, and theseresults will be reported and discussed.




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resulTs Results at Week 24 showed statistically significantdifferences between the two groups: 56.1% of VEGF Trap-Eyepatients gained ≥15 ETDRS letters from baseline, comparedwith 12.3% of sham patients (p<0.0001). VEGF Trap-Eyepatients gained a mean of 17.3 letters of vision compared with a mean loss of 4.0 letters with sham injection (p<0.001). Themost common treatment-emergent adverse events (AEs) among all patients were conjunctival hemorrhage, visual acuityreduced, and eye pain. Proportions of patients who experiencedserious ocular AEs were 3.5% in the VEGF Trap-Eye group and13.5% in the sham group. The incidence of non-ocular seriousAEs was generally well balanced between the treatment andsham groups.

conclusion Dosing monthly with 2 mg VEGF Trap-Eye inpatients with macular edema secondary to CRVO resulted in astatistically significant improvement in visual acuity comparedwith control sham treatment. VEGF Trap-Eye was generallywell tolerated and had a generally favorable safety profile.

8:36 AM index for the Quantification of retinal non-perfusion in Branch retinal vein occlusionPradeep Prasad, MD (Los Angeles, CA), Andrew Kaines, Irena Tsui, Gad Heilweil, Jean-Pierre Hubschman, Steven Schwartz

PurPose To quantify retinal non-perfusion in patients withbranch retinal vein occlusion and to evaluate the relationshipbetween macular edema and neovascularization with differentlevels of non-perfusion

MeTHoD Ultra wide-field fluorescein angiograms from patientswith BRVO not previously treated with focal macular laser,scatter photocoagulation or intravitreal pharmacotherapy weregraded for the presence of non-perfusion, neovascularizationand macular edema. Areas of non-perfusion were quantitativelymeasured and a retinal ischemic index calculated, defined asthe total area of non-perfused retina divided by the total area of retina visualized. The sensitivity and specificity of variousdegrees of non-perfusion for the presence of neovascularizationand macular edema were calculated.

resulTs 25 angiograms from 25 patients were analyzed. Neo -vascularization and macular edema were seen in 28% and 80%of patients, respectively. Ischemic index values ranged from0.1% to 30%. An ischemic index of 7% was 100% sensitive and79% specific for the presence of neovascularization and 50%sensitive and 100% specific for the presence of macular edema.Increasing ischemic index was significantly associated withneovascularization in all patients (p < 0.01) and macular edemain patients with major BRVO (p =0.028).

conclusion Retinal non-perfusion can be quantified utilizingultra wide-field fluorescein angiography and may help risk-stratify BRVO patients for the development of neovasculari-zation and macular edema.

8:44 AMDiscussion

8:50 AMsD-ocT analysis of subretinal Deposits in Patients with acute central serous retinopathy

Gennady Landa, MD (New York, NY), Jonathan Barnett, MD, Patricia Garcia, Katy Tai, MD, Richard B. Rosen, MD*

PurPose To perform qualitative and quantitative analysis of subretinal protein deposits, seen in acute central serousretinopathy (CSR) patients, using high resolution SD-OCT, inorder to investigate whether protein deposits present have anysignificant impact on best corrected visual acuity (BCVA).

MeTHoD Patients presenting to the Retina Center of the NewYork Eye and Ear Infirmary between July 2009 and July 2010with evidence of acute CSR were included. SD-OCT wasperformed and multiple parameters were measured: central total retinal thickness, central neurosensory retinal thickness,maximum vertical and horizontal lengths of subfovealsubretinal fluid and thickness of any subfoveal protein deposit(PD) layer, if present. Additionally, height and width of anyPED present subfoveally, was measured.

resulTs 38 patients with acute CSR were included. Four types of PD, based on their shape and appearance (hanging,integrated, scattered, and massive), were noted. At least onetype of PDs was seen at baseline SD-OCT exam in 84. 2%(32/38) eyes. PD subfoveal thickness could be measured in 20(52.6%) out of 38 eyes. A significant correlation was foundbetween the subfoveal thickness of PD layer and baseline/finalvisual acuities: (r = 0.60, p = <0.001 and r = 0.45, p = 0.008,respectively). Those eyes with PDs which demonstrated aresolution of CSR (resolved subgroup, n = 11) at 3 (± 1)months of follow-up, had a significantly thinner (p = 0.003)subfoveal thickness of the PD layer at baseline exam (28.8 ±12.5 µm) than the unresolved group of eyes (n = 21)(57.0 ±27.2 µm). At final follow-up, a signifi cant difference (p=0.012)in BCVA was found between the resolved and unresolvedsubgroups. The final BCVA in eyes with and without PED atbaseline was not significantly different (p=0.19).

conclusion The thickness of subfoveal protein deposits atbaseline appears to be an important parameter related to theBCVA and time of CSR resolution, whereas the presence ofPED at baseline didn’t have an impact on the final BCVA.

8:58 AMlow Dose oral Methotrexate for the Treatment of chronic central serousretinopathy (csr)

Armando L. Oliver, MD (San Juan, PR), David Callanan, MD*, Shree K. Kurup, MD*

PurPose To evaluate if weekly, low dose, oral methotrexate is effective in helping patients with chronic CSR achieveimprovement in visual acuity and reabsorption of sub-retinal fluid.

MeTHoD Retrospective review of all patients who had used low dose oral methotrexate as treatment for chronic CSR in 3 different centers. Patients who had history of photodynamictherapy with verteporfin where excluded from the analysis. VA as well as OCT central macular thickness and total volumeparameters were recorded from each visit and subjected tostatistical analysis. The percentage of patients achievingresolution of CSR (defined as the absence of sub-retinal fluidon all OCT cross sections) was also calculated. CBC and SerumChemistry results were reviewed to identify patients who hadpotentially developed systemic toxicity secondary to the use of methotrexate.

resulTs Nine patients were treated with methotrexate forchronic CSR and met the criteria for our analysis. The meanduration of CSR in these patients was 28 months. The meanstarting dose of oral methotrexate was 7.04mg (range 5-10mg)and the mean final dose was 7. 27mg (range 5-10mg). Themean duration of treatment was 89 days. The mean VA improvedfrom 20/67 at baseline to 20/35 at 8 weeks (p = 0.0076, paired t-test). The mean central macular thickness improved from 309 microns at baseline to 213 microns at 8 weeks (p = 0.001,paired t-test). The mean total macular volume improved from8.14 to 7. 21 at 8 weeks (p = 0.0161, paired t-test). 83% of thepatients who had completed the treatment regimen achievedtotal resolution of sub-retinal fluid. None of the patientsdeveloped CBC or serum chemistry abnormalities suggestive of methotrexate toxicity.

conclusion Our study suggests that the use of weekly, low dose,oral methotrexate is beneficial for the treatment of chronicCSR. Patients in our cohort had a significant improvement VAas well as central macular thickness and total macular volumeas measured by OCT. A randomized controlled clinical trial iswarranted to better understand the effects of methotrexate inpatients with this condition.

Vertical OCT Cross-sections of a 58 year old man with history ofchronic CSR OS. The patient achieved total resolution of the sub-retinal fluid for the first time ever in 3 years after being treated with weekly low dose oral methotrexate.

9:06 AMThe expanded spectrum of focal choroidal excavation

K. Bailey Freund, MD* (New York, NY), Ron Margolis, MD, Sri Krishna Mukkamala, Lee M. Jampol, MD, Richard F. Spaide, MD*, Michael D. Ober, MD*, John Alan Sorenson, MD, Ronald Gentile, MD*, Joel A. Miller, MD, Jerome Sherman*

PurPose To describe the clinical and multimodal imagingfindings in patients with focal choroidal excavation (FCE).

MeTHoD This study was a retrospective observational case series.The medical records of 12 patients (13 eyes) with FCE werereviewed. Clinical histories and multimodal imaging findingsincluding color photography, fundus autofluorescence (FAF),fluorescein angiography (FA), indocyanine green angiography(ICGA), spectral domain optical coherence tomography (SD-OCT) and enhanced depth imaging SD-OCT (EDI-OCT)were analyzed.

resulTs The mean age of patients was 45 years. 5 patients wereAsian. Mean visual acuity was 20/31. Mean refractive error was-4.75 D. Unilateral lesions were seen in 11 of the 12 patients,and 1 patient had bilateral involvement. All lesions involvedthe fovea and manifested varying degrees of pigmentary changesthat were usually hypoautofluorescent on FAF imaging. Mostlesions appeared hypofluorescent with ICGA, but FA findingsvaried with the degree of RPE alterations. In 7 eyes, OCTshowed the outer retinal layers conforming to the RPE withinthe excavation. In the other 6 eyes, OCT demonstrated aseparation between the outer retina and RPE within theexcavation. In 7 eyes studied with EDI-OCT, there was noevidence of scleral ectasia. Mean choroidal thickness of theuninvolved choroid was thicker than normal at 319 um. Alllesions remained stable except in 1 eye that had additionalfindings of CSC and secondary type 2 neovascularization. One patient had a history of CSC in the fellow eye.




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conclusion FCE is a newly described idiopathic entity in which there are one or more focal areas of choroidal exca -vation. In some patients, there may be an association withCSC. Although most lesions remain stable, secondary choroidal neovascularization may occur.

33-year-old male with focal choroidal excavation. (Top) Photograph,fundus autofluorescence image, and fluorescein angiogram (latevenous & recirculation phase). (Bottom) Spectral domain OCT scanthrough the fovea shows a conforming focal choroidal excavation.

62-year-old female with focal choroidal excavation. (Left) Photo-graph shows atrophic retinal pigment epithelium changes beneaththe fovea. (Right-top) Time domain OCT scan from 2003 shows anon-conforming focal choroidal excavation. (Right-bottom) Spectraldomain optical coherence tomography scan from 2009 showsfindings similar to the scan taken 6 years earlier.

9:14 AManatomic correlates to the Bands seen in the outer retina by ocT: literature review and Model

Richard F. Spaide, MD* (New York, NY), Christine A. Curcio

PurPose To evaluate the validity of commonly used anatomicdesignations for the 4 hyper-reflective outer retinal bands seenin current generation optical coherence tomography (OCT), a scale model of outer retinal morphology was created usingpublished information for direct comparison to OCT scans.

MeTHoD Articles and books concerning histology of the outerretina from 1900 until 2009 were evaluated, and data were used to create a scale model drawing. Boundaries between outer retinal tissue compartments described by the model werecompared with intensity variations of representative spectraldomain (SD) OCT scans using longitudinal reflectance profilesto determine the region of origin of the hyper-reflective outerretinal bands.

resulTs This analysis showed a high likelihood that the SD-OCT bands attributed to the external limiting membrane (the1st, innermost band) and to the retinal pigment epithelium(RPE) the 4th, outermost band) are correctly attributed. Com -parative analysis showed that the 2nd band, often attributed tothe boundary between inner and outer segments of the photo -receptors, actually aligns with the ellipsoid portion of the innersegments. The 3rd band corresponded to an ensheathment ofthe cone outer segments by apical processes of the RPE in astructure known as the contact cylinder.

conclusion Anatomic attributions and subsequent patho -physiologic assessments pertaining to the 2nd and 3rd outerretinal hyper-reflective bands may not be correct. This analysishas identified testable hypotheses for the actual correlates of the2nd and 3rd bands; the 2nd band corresponds to the ellipsoidand the 3rd band appears to be the contact cylinder.

OCT of the perifoveal region with a highlighted box 10 pixels wideused to create the longitudinal reflective profile (LRP). The 1st bandof the OCT represents the ELM and the 4th band was aligned to theRPE. The 2nd band corresponded very closely with the ellipsoidsection of the IS. The 3rd band encompassed the region of the coneOS/contact cylinder region.

OCT of the perifoveal region with a highlighted box 10 pixels wideused to create the longitudinal reflective profile (LRP). The 1st bandof the OCT represents the ELM and the 4th band was aligned to theRPE. The 2nd band corresponded very closely with the ellipsoidsection of the IS. The 3rd band merged with the 4th band as coneOS/contact cylinder region is in direct contact with the RPE.

9:22 AMintra-operative sD-ocTSunil Srivastava, MD (Cleveland, OH), Robin Ray, MD, G. Baker Hubbard, MD, Jonathan Sears, MD, Rishi P. Singh, MD, Daniel F. Martin, MD, Peter K. Kaiser, MD*, Justis P. Ehlers, MD

PurPose Spectral domain optical coherence tomography (SD-OCT) offers high resolution imaging of the retinal anatomy.Due to this high resolution anatomic information, SD-OCTmay be a useful component to operative decision making. Thisstudy reviewed the microstructural changes in retinal anatomyidentified with intra-operative SD-OCT during vitreoretinalsurgical procedures.

MeTHoD A retrospective review was performed on patients whounderwent surgery and intra-operative SD-OCT scanning. Twoprototype mounting systems were used to attach a hand-heldSD-OCT probe to the operating microscope. Images weretypically obtained prior to retrobulbar block, before and aftercritical surgical maneuvers (e.g., membrane peel) and at com -pletion of surgery. Images were analyzed to identify changes inretinal anatomy. Postoperative images were reviewed whenavailable and compared to intra-operative images.

resulTs Intraoperative imaging was successfully performed on55 patients. Poor quality images were uncommon and wereusually due to media opacity (e.g., hemorrhage, corneal edema).Changes in retinal microstructure were seen in all casesinvolving membrane peeling. All epiretinal membrane casesdeveloped subretinal hyporeflectance after epiretinal membranepeeling which increased in size with internal limiting mem -brane (ILM) peeling. All macular holes exhibited changes inanatomic configuration following ILM peeling, includingenlargement of the subretinal fluid cuff at the edges of the hole.In complex retinal detachment cases, intra-operative SD-OCTidentified tissue planes for dissection and revealed corrugationsin the inner retina after dissection or development of subretinalhyporeflectance after membrane peeling. Imaging throughperfluorocarbon liquid revealed persistence of subfovealsubretinal fluid in macula-involving retinal detachments.

conclusion Intra-operative SD-OCT imaging was successfullyperformed during surgery. The use of a microscope mount facili-tated fast reproducible imaging during surgery. Changes in theretinal microstructure were identified during surgery that havenot been previously described and may have functional conse-quences. Intra-operative SD-OCT imaging is a useful imagingadjuvant during vitreoretinal surgery

9:30 AMDiscussion

9:40AMPanel Discussion: How Do you Treat retinal vein occlusions and Diabetic Macular edema?Moderator: Peter K. Kaiser, MD*Panelists: Neil M. Bressler, MD*, K. Bailey Freund, MD* Julia A. Haller, MD* and Dante J. Pieramici, MD

10:05-10:40 AMrefreshment Break and exhibitsHynes Convention Center, Hall D

10:40-11:16 AM

Symposium 6:SocioeconomicsModerators: Lawrence S. Halperin, MD and Reginald J. Sanders, MD

Related poster abstract is on page 180.

10:40 AMPharmacotherapy for neovascular aMD –100% Part B fee-for-service Medicare claims Data – 2008-2009

Ross J. Brechner, MD, MS (Stat.), MPH (Catonsville, MD) Lead Medical Officer, National Centers for Medicare,Philip J. Rosenfeld, MD, PhD*

PurPose To describe the usage patterns and potential complica-tions of pharmacological treatments for neovascular age-relatedmacular degeneration among all the Medicare fee-for-service(FFS) beneficiaries in 2008 and 2009.

MeTHoD One hundred percent of all FFS Medicare beneficiarieshaving undergone pharmacological treatment for wet AMDwere identified. The data collected for each visit for a givenbeneficiary included age, race, gender, Medicare region,state/zip code of residence, date of visit, whether or not thebeneficiary had a treatment, the type and amount of drug,dollars paid by Medicare, and complications. The main out -come measures were the number and rate of treatments, thetypes of drugs used for treatment, payments for these drugs,incidence of Wet AMD and complications from treatment.

resulTs Of 222,886 unique beneficiaries (UB) in 2008,146,276 (64%) received bevacizumab (BEV) and 80,929 (36%)received ranibizumab (RAN). Comparable numbers in 2009were 251,774 (UB), 166,684 (BEV: 60%) and 91,188 (RAN:40%). The number of incident cases of wet AMD treated witheither anti-VEGF drug in 2009 was over 107,129. Of 824,525intra vitreal injections (IVTs) in 2008, 480,025 were BEV(58%) and 336,898 were RAN (41%). Of 1,028,187 IVTs in2009, 608,878 were BEV (60%) and 400,328 (40%) were RAN.Total payments by Medicare in 2008/2009 were $20,290,952/$24,970,468 for BEV and $536,642,693/$673,978,477 for RAN. In 78% of the states, the rate of injection was higher for bevacizumab. Endophthalmitis occurred in 1,121 of theunique beneficiaries representing a rate of approximately 1 in 300 beneficiaries.




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conclusion In 2008/2009, BEV was used at a higher rate thanRAN for wet AMD. Even though BEV accounted for 59.6% ofall injections in 2008-2009, Medicare paid over $500 millionmore for RAN than BEV each year. Despite its off-label desig-nation, BEV is currently the standard-of-care treatment forneovascular AMD in the U.S. Additional ocular and systemicdiagnoses associated with IVTs will be presented.

10:50 AMThe value Modifier: Payment for Quality and efficiency

William L. Rich, III, MD (Falls Church, VA)Medical Director of Health Policy American Academy of Ophthalmology

• Run away costs• Health care spending caused decreases in disposable

personal income• 43 million uninsured• Perceived poor quality and safety• Little comparative effectiveness research• Disparities of care

The biggest drivers of escalating costs are new technology,payments that reward volume and unexplained variation inhow services are delivered. Quality of care is a huge problem inthe United States with only 50% of process of care validated byNIH clinical trials adopted into practice within ten years. TheValue Modifier is part of the PPACA and is an attempt toaddress costs, variation and quality.

Beginning in 2015 CMS will begin measuring physicians ontheir ability to achieve meaningful quality outcomes in a costeffective manner for selected high impact diseases. Those whoseresource use is high will see their payments cut for all clinicalservices in the ensuing year. This will immediately stimulatephysicians to consider the evidence base, cost and volume oftheir resource use. In effect, CMS has made the physician the“prudent buyer” of services.

11:00 AMscope of Practice Battles and the vitreoretinal specialist

David W. Parke, II, MD (San Francisco, CA)Executive Vice President and CEO American Academy of Ophthalmology

The US ophthalmologic and optometric communities probablyspend a combined $4 million annually on scope of practicebattles. This does not count the innumerable hours of timespent by dedicated professionals – on both sides of the issue.

Scope of practice battles have been going on longer than theconflict in Iraq or Afghanistan. Were it a military operation, itwould rank behind the Hundred Year War as the second longestcampaign in history.

Scope of practice has devolved into an issue regarding the right to perform surgery in an environment between professionswhere surgical privileges are determined not by a logical,evidence-based process taking into account knowledge, skillsacquisition, competence, and experience – but by politics. As a politically-based process, all of the above factors are significantly devalued and the relevant factors become money,relationships, and perceived political power. The pawn in the process is the patient. Healthcare reform and cost andaccess issues become new weapons in the political scope ofpractice debate.

I will address the following issues from the standpoint of a vitreoretinal surgeon:• Why is the battle still being fought?• What tactics do physicians face and what have we

found to be effective?• What have ophthalmologists achieved?• What does this mean for the vitreoretinal specialist?

11:10 AMDiscussion

11:16 AM-12:16 pM

Symposium 7:pediatric RetinaModerators: Antonio Capone, Jr., MD and Kimberly A. Drenser, MD


11:16 AMcomparison of systemic Morbidity associated with laser ablation of Thresholdand Pre-threshold Type 1 roP using sedative vs. non-sedative anesthesiaNatalia Matti, MD (Los Angeles, CA), Enrique Ariza, MD, Khaled A. Tawansy, MD

PurPose To review experience over past decade of one pediatricretina group performing laser ablation in a variety of clinicalsettings, including hospitals that routinely sedate or intubatepreemies and others who have adopted a minimally sedativeprotocol that includes use of acetaminophen 15mg/kg orallyand suckling using sugar on a pacifier or finger.

MeTHoD Retrospective ophthalmic and medical chart review of100 consecutive cases receiving ablative laser in each of 4possible clinical settings: 1) hospitals that routinely sedate andintubate, 2) hospitals that routinely sedate without intubation,3) hospitals that routinely use the acetaminophen and sugarprotocol with narcotics or sedatives available if needed, and 4) an outpatient clinic where sedation of neonates is notpermitted. More critically ill preemies that were alreadyintubated at the time of ablation were excluded from thisanalysis.

resulTs Of 100 neonates intubated for laser in group one, 7 developed cardiopulmonary complications (3 developedpneumonia). In group two, 4 of 100 required urgent intubationafter sedation induced apnea by administration of fentanyl (didnot occur with midazolam alone). Of the 100 babies in groupthree receiving acetaminophen and sugar for laser, 98 toleratedthe procedure, while 2 required intra-venous sedation. All ofthe neonates in group four who received ablation in the officetolerated the procedure with acetaminophen/sugar protocol;these were less critically ill and older neonates.Duration of theprocedure lasted a mean of 55 minutes for group 1, 36 minutesfor group 2, 29 minutes for group 3, and 21 minutes for group4.Mean length of stay in the hospital post laser was 42 days ingroup one, 31 days in group two, 20 days in group three, and 0days in group four.None of the eyes treated with laser for type 1ROP progressed to retinal detachment and all had resolution of ROP.

conclusion Minimally sedative laser for ROP using a protocolthat involves a combination of oral acetaminophen andsuckling on a sugar pacifier can be performed reliably and withgood structural and visual outcome; it may be associated with alower incidence of systemic complications than intubation ordeeper sedation, especially when fentanyl is used.

11:24 AMBevacizumab vs. laser ablation for Treatment-warranted roP: recommendationsBased on the BeaT-roP experience

Khaled A. Tawansy, MD (Los Angeles, CA), Enrique Ariza, MD, Natalia Matti, MD

PurPose To review 150 cases of posterior ROP in the BEAT-ROP Study randomized to bevacizumab versus laser and anadditional 150 cases of traditional ROP treated with standardlaser ablation in order to weigh advantages and pitfalls of eachmodality and develop a treatment paradigm.

MeTHoD Retrospective review of charts with collection ofparameters including Zone (I, IIp, IIm, IIa, and III), Stage (I-IV), Level of Plus (0-2), Vascular Activity Score (VAS 0-10,see abstract), category of ROP (traditional, aggressive posterior,or smoldering), gestational age, post-conception age, systemicmorbidity associated with the treatment and anatomic andfunctional response to therapy. Included were cases that hadpersistence or recurrence and required re-treatment with either modality.

resulTs Traditional laser ablation when applied to diseaselocated anterior to the equator was relatively non-traumatic(fewer than 500 burns per eye) with minimal systemicmorbidity and prompt resolution of disease, absence ofpersistent peripheral non-perfusion or late recurrence, and goodlong-term visual and functional outcomes. Disease posterior tothe equator or associated with a VAS of 6 or more respondedwell to bevacizumab 0.6 mg injected intra-vitreal with mostminimal trauma and opportunity for continued development of intrinsic vessels to the periphery, minimizing visual field lossand myopia. These cases required closer and more continuedlong-term follow up to prevent potential late detachment ormacular dragging associated with an avascular periphery(smoldering ROP). Rare cases that demonstrated ROPprogression after bevacizumab responded well to ablative laser,while those that progressed despite laser had only fleeting andincomplete response to bevacizumab.

conclusion Bevacizumab is first line therapy for AP ROP.Follow up is required until retinal vessels reach the ora serrataor late fibrovascular proliferation needs ablation.Anterior casesrespond well to laser. Equivocal cases are better treated withbevacizumab and cases of posterior pre-threshold ROP may beobserved until more significant plus and neovascularizationdevelops.


PeDiaTric reTina 11:16 AM–12:16 PM7


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11:32 AMregression Patterns after intravitrealBevacizumab for Zones i and Posterior ii stage 3 Plus roP

Amin Kherani, MD (Calgary, Canada), Khaled A. Tawansy, MD

PurPose To study the effect of intra-vitreal bevacizumab ontiming and extent of retinal vascular development in posteriorischemic ROP, regression of plus, resolution or cicatrization ofneovascularization, recovery of intrinsic retinal vessels, and late complications associated with persistent peripheral non-perfusion and/or fibrovascular proliferation including maculardragging and retinal detachment.

MeTHoD Retrospective review of clinical notes, fundus drawings,photographs, and fluorescein angiograms of 30 preemies whoreceived bilateral intra-vitreal bevacizumab at a dose of 0.625mg as first-line therapy for ROP Stage 3 Plus Zone II and IIp(diameter < 3X fovea to disc) within or outside of the BEAT-ROP study. Patients were followed indefinitely until retinalvessels reached the ora serrata or complications occurred,sometimes requiring treatment.

resulTs Intravitreal bevacizumab resulted within 48 hours inuniform resolution of plus disease and diminution of flat andelevated neovascularization in the absence of cicatrization(crunch phenomenon). Retinal vascular development wassimultaneously stunted, without progression until 4 weeks afterinjection. In 48/60 (80%) eyes, retinal vessels extended towithin 2 disc diameters of the ora serrata by 60 weeks postconception; while the remaining 12/60 (20%) had persistentperipheral non-perfusion, 4 (33%) had silent abrupt termi-nation of vessels in a brush-border pattern, while the remaining8 (67%) had vascular changes, including dilated and leaky end-terminal buds (2/12, 17%), an active ridge with fluoresceinstaining (2/12, 17%), and fibrous contraction with maculardragging (2/12, 17%) or retinal detachment(2/12, 17%). 2 casesof retinal detachment onset was later than in non-bevacizumabeyes(52 vs. 41 weeks) and associated with less vascular activityand multiple ridges(stuttering growth pattern).

conclusion Posterior ischemic ROP receiving bevacizumabrespond with regression of plus and neovascularization; somedevelop late complications associated with a smoldering form of ROP, with late macular dragging and retinal detachment.Close follow up beyond 60 weeks post conception is warranted,until retinal vessels reach the ora serrata or intervention forvascular or fibrous complications present

11:40 AMDiscussion

11:46 AManatomic and visual outcomes of surgical intervention for familial exudative vitreoretinopathyCaesar K. Luo, MD (Royal Oak, MI), S. Chien Wong, MBBS, FRCSEd (ophth),MRCOphth, Tushar M. Ranchod, MD, Lawrence U. Ho, MD, Kimberly A.Drenser, MD*, Antonio Capone, MD, Michael T. Trese, MD*

PurPose To review the outcomes of surgery for retinaldetachment (RD) in familial exudative vitreoretinopathy(FEVR).

MeTHoD A retrospective, noncomparative interventional caseseries of 102 eyes of 71 patients with RD associated with FEVRrequiring vitrectomy or scleral buckle surgery from 1984 to2009. Patients with less than 6 months of follow-up wereexcluded. Birth histories, interventions, anatomical and visualoutcomes were reviewed. Anatomical success was defined aseither partial or complete retinal reattachment.

resulTs Median age at the time of surgery was 1.1 years (IQR0.3-6.1). Median follow-up was 45 months (IQR 26-86). Atpresentation, extent of RD was as follows: 7% (7/102) of eyeswith stage 3 (macular-sparing), 48% (49/102) of eyes with stage 4 (macular-involving) and 45% (46/102) of eyes withstage 5 (total). Of these, 13% (13/102) had prior unsuccessfulvitrectomy or scleral buckling surgery. Anatomical success orstabilization was achieved in 83% (83/102) of eyes after a meanof 1.4 (SD 0.67) procedures. In surgery naive eyes, final retinalreattachment was achieved in 43% (13/30) of eyes havingvitrectomy alone and 50% (2/4) of eyes having scleral bucklealone. Of the 45 eyes with visual acuity follow-up data, 40%(18/45) improved and 27% (12/45) remained stable. In stage 5eyes, partial or complete retinal reattachment occurred in 61% (28/46), vision improved in 24% and 88% (23/26)maintained at least light perception vision with a median of 75 months follow-up.

conclusion Patients with macular-involving and macular-sparing RDs in FEVR can be treated successfully withvitrectomy or scleral buckling surgery. The risk of blindnessfrom surgery is low.

11:54 AMWnt-directed vascular remodeling in a Model of retinopathy

Kimberly A. Drenser, MD* (Royal Oak, MI), Michael T. Trese, MD*, Antonio Capone, Jr., MD*, Clayton Tokunaga

PurPose Capillary drop-out and ischemia due to various formsof retinopathy remains an untreated event. The purpose of thisstudy was to evaluate the ability to drive vascular remodelingthrough Wnt-induced pathways.

MeTHoD A mouse model of oxygen-induced retinopathy wasused to study normal and abnormal vascular growth and remodeling. Eyes received intra vitreal injections with eitherPBS (control), norrin (specific Wnt activator), or DKK1 (Wnt canonical inhibitor) and evaluated for non-vascularretina, neovascular tufts, and capillary bed remodeling.

resulTs Eyes treated with norrin showed a statistically signif-icant difference in the areas of avascular retina and neovasculartufts. Vascularized retina increased by 30% in norrin treatedeyes compared to PBS control eyes and similarly demonstrated adecrease in neovascular tufts. Interestingly, DKK1 treated eyesshowed increased vascular retina compared to control eyes, butalso showed a decrease in the level of capillary remodeling,indicating that norrin works by canonical and non-canonicalWnt signaling.

conclusion Wnt signaling plays an important role in vasculargrowth and remodeling in the retina. Additionally, it appearsthat specific Wnt activation, such as that seen with norrin,more precisely drives appropriate capillary formation. It may bepossible to promote vascular growth in a controlled fashionwithout inducing neovascular changes.

12:02 pMangiogenesis and angiomaintenance in Pediatric retinal Disease

Michael T. Trese, MD* (Royal Oak, MI), Antonio Capone, Jr., MD*, Kimberly A. Drenser, MD*

PurPose To demonstrate the role of Wnt signaling in develop -ment of and maintenance of the retinal vasculature includingFEVR, ROP, Norrie disease, and juvenile diabetic retinopathy.

MeTHoD Both animal models of retinal vasculature and capillarydevelopment by the oxygen induced retinopathy model andhuman angiographic study in FEVR and ROP are used todemonstrate capillary loss and disease progression. The corre-lation between Wnt signaling mutations and disease severitywill be presented showing animal data of treatment with Norrinto drive Wnt signaling blocks these disease processes.

resulTs Data showing Norrin treatment as an intra vitrealinjection can alter capillary development in the OIR modelsuggests that other vascular diseases may be amenable to Wntmodulator. In addition, capillary dropout is seen precedingdisease reactivation in FEVR. Also, the severity of disease suchas ROP and FEVR and diabetes may be in part mediated byWnt signaling mutations.

conclusion Wnt signaling appears to be involved in retinalvessel development and maintenance. These mutations in theface of premature birth or diabetes may contribute to moresevere disease and may be able to be treated with Norrin.

12:10 pMDiscussion

12:16-1:25 pMlunch in exhibit HallHynes Convention Center, Hall D

12:16-1:25 pMWomen in retina (Winr) symposium and lunch

Balancing career and family

Susan B. Bressler, MD (Baltimore, MD)


PeDiaTric reTina 11:16 AM–12:16 PM7


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1:33-3:35 pM

Symposium 8:Macular Degeneration iiModerators: Harry W. Flynn, MD and Jonathan L. Prenner, MD


1:33 pMaMD: update on nature, nurture andPrediction Models for clinical Management and Trials

Johanna M. Seddon, MD* (Boston, MA)

PurPose To assess risk and protective factors for AMD; todevelop algorithms based on these factors to estimate rates ofprogression to geographic atrophy and neovascular disease; toapply this information for use in managing patients and forplanning clinical trials.

MeTHoD Using our AMD databases, we have shown thatsmoking, higher body mass index, and unhealthy diet andlifestyles influence susceptibility to onset and progression ofAMD. We have assessed multiple risk prediction models (1-5)incorporating these variables. We evaluated an expanded modelof progression to geographic atrophy and neovascular diseasewhich included 2937 individuals and 819 progressors, withlonger follow-up, time varying analyses, additional baselineocular phenotype data, and validation in a test sample.

1) Nature Genetics 2006; 38:1055-10592) Hum Heredity 2006: 61:157-1653) JAMA 2007; 287:1793-18004) IOVS 2009:50:5818-58275) IOVS 2009; 50: 2044-2053.

resulTs Age, smoking, body mass index, and genetic variantsin 5 genes, as well as AMD status in the fellow eye and drusensize at baseline were collectively associated with progression toadvanced stages of AMD. Knowledge of genetic variants addedto the predictive models. The AUC, a measure of the model,was excellent (0.915).

conclusion Factors reflective of nature and nurture were incorporated into our expanded algorithms for risk prediction.The models and risk scores we developed may be useful forAMD surveillance and for designing clinical trials.

1:41 pMophthalmic antibiotic use and Multidrugresistant staphylococcus epidermidis: a controlled, longitudinal study

Stephen J. Kim, MD (Nashville, TN), Sarita Dave, Hassanain S. Toma

PurPose To analyze the emergence of multidrug resistantStaphylococcus epidermidis after repeated conjunctivalexposure to topical macrolide or fluoroquinolone antibiotics.

MeTHoD This was a prospective study involving 48 eyes of 24patients undergoing serial unilateral intra vitreal (IVT) injec-tions for choroidal neovascularization (CNV). Subjectsreceived 4 consecutive monthly unilateral IVT injections andthen were treated as needed. Each subject was randomlyassigned to 1 of 4 antibiotics (azithromycin 1%, gatifloxacin0.3%, moxifloxacin 0.5%, ofloxacin 0.3%). Conjunctivalcultures of the treated and untreated fellow eye (control) weretaken at baseline and following each injection. All bacterialisolates were tested for antibiotic susceptibility to 16 differentantibiotics using the Kirby-Bauer disc diffusion technique.

resulTs After 4 consecutive treatments, a total of 58 isolates of S. epidermidis were each isolated from control and treatedeyes. Resistance to ≥ 3 antibiotics was present in 69% of S.epidermidis isolated from control eyes compared to 90% fromtreated eyes (P < 0.02). A total of 46 and 38 isolates of S.epidermidis were cultured from control and treated eyes respec-tively from their 5th until final injection. Resistance to ≥ 5antibiotics was present in 48% of control eyes compared to 71%of treated eyes (P < 0.05). In a significant number of fluoro-quinolone-treated eyes, S. epidermidis developed resistance to3rd (P < 0.01) and 4th (P < 0.01) generation fluoroquinolonesand developed resistance to trimethoprim/sulfamethoxazole (P < 0.01), gentamicin (P < 0.03), and clindamycin (P < 0.05).A significant number of azithromycin-treated eyes developed S. epidermidis resistant to macrolides (P < 0.01) and totrimethoprim/sulfamethoxazole (P < 0.02) and doxycycline (P < 0.01).

conclusion Conjunctival S. epidermidis repeatedly exposed tofluoroquinolone or azithromycin antibiotics rapidly developresistance. Co-resistance to other antibiotics was also observed.

1:49 pMDiscussion

1:55 pMProphylaxis for endophthalmitis associated with intravitreal injection:antisepsis and antibiotics

Harry W. Flynn, MD* (Miami, FL), Charles C. Wykoff, MD, PhD, Philip J. Rosenfeld, MD, PhD*

PurPose To discuss clinical issues related to the use of antisepsis and antibiotics for the prophylaxis of endophthalmitisfollowing intra vitreal injections.

MeTHoD Review of medical literature with an emphasis onauthor-selected studies.

resulTs Povidone-iodine (PI) confers broad spectrum micro -bicidal activity with a rapid kill time ranging from 15 to 120seconds for concentrations of 10% to 0.1%. There are noreported cases of resistance to its bactericidal effects. PI isinexpensive and widely available.

In comparison, topical antibiotics have significantly longer kill-times than PI and likely have insufficient time to achieveadequate biological effect when given immediately prior toinjection. When applied before the day of injection, topicalantibiotics are no more effective than immediate pre-injectiontopical PI in reducing conjunctival bacterial counts. Repeatedexposure of ocular flora to topical antibiotics selects for resistantstrains. Topical antibiotics have poor intra vitreal penetrationand are unlikely to achieve therapeutic levels post-injection.Moreover, antibiotics are variably expensive and also may bedifficult for patients to procure and apply.

conclusion The retina community’s standard practice for ofusing periocular antisepsis and antibiotics for the prevention ofendophthalmitis related to intra vitreal injections continues toevolve. The current literature and clinical experience suggestthat the rationale and clinical use of PI without antibiotics isincreasing.

2:03 pMchanges in antibiotic resistance Patterns ofconjunctival flora Due to repeated use ofTopical antibiotics after intravitreal injectionEugene A. Milder, MD (Philadelphia, PA), James F. Vander, MD*, Chirag P. Shah, MD*, Sunir J. Garg, MD*

PurPose To determine the change in conjunctival bacterialflora and antibiotic resistance patterns due to repeated shortcourses of topical antibiotics after intra vitreal injections forexudative AMD.

MeTHoD Patients with unilateral exudative AMD who hadreceived at least three prior intra vitreal injections were enrolledin this cross-sectional study. Each injection was administered

using a standard protocol including a drop of 5% povidoneiodine prior to injection and a drop of topical fluoroquinoloneafter. Topical antibiotics, either fluoroquinolone or polymyxinB/trimethoprim, were used 4 times a day for 4 days after eachinjection. At the time of enrollment, the inferior fornix of botheyes was swept with a culture swab prior to use of povidoneiodine; fellow eyes served as a control group. The culture andsensitivity data from the study and control eyes was gatheredand analyzed.

resulTs 40 patients (80 eyes) were enrolled in the study. 29 patients had used polymyxin B/trimethoprim drops while 11 used fluoroquinolone drops after each prior injection. 58bacterial colonies were isolated from 50 eyes, with no differencebetween study and control eyes (p=0.01). Coagulase-negativestaphylococcus accounted for 41 of the 58 bacterial colonies(71%); other species included staphylococcus aureus, staphylo-coccus lugdunensis, streptococcus mitis, and coryneformbacteria. There was a 63.6% resistance rate to fluoroquinolonesamong study eyes, compared to 32.1% among control eyes(p<0.05). In the subset of 11 study eyes using fluoroquinolonedrops for 4 days after injection, there was an 87.5% resistancerate (p=0.012).

conclusion Use of fluoroquinolone drops after intra vitrealinjection leads to increased resistance in the conjunctival flora,with even higher rates when fluoroquinolone drops are used for4 days after injection. Repeated use of topical antibiotics afterintra vitreal injections may have a detrimental effect on eyehealth by breeding antibiotic resistance in the bacterial flora.

2:11 pMunderstanding and reporting visual acuity Measurements in Publications of clinical research in retina

Susan B. Bressler, MD* (Baltimore, MD), Mariana Silva Lopes, Shiri Zayit-Soudry, MD, Ala Moshiri, Neil M. Bressler, MD*, Ala Moshiri, MD

PurPose To investigate methods used to report visual acuity inthe published retina literature in the United States, andevaluate understanding of those methods among ophthalmolo-gists at various stages in their careers.

MeTHoD All retina papers published in 2008 among four leadingAmerican clinical journals (Ophthalmology, Archives of Ophthal-mology, American Journal of Ophthalmology, and Retina) werereviewed. The full text of each paper was examined by at leasttwo authors, and each method of visual acuity reporting usedwas recorded. Five residents, four ophthalmologists in retinatraining, and five full-time retina faculty at an academic insti-tution were surveyed to evaluate their ability to interpretvarious visual acuity methods.


Macular DegeneraTion ii 1:33–3:35 PM8


45

resulTs Among 356 retina papers, 206 reported visual acuity,including 172 (83%) which used visual acuity as an outcomemeasure. Snellen acuities were reported in 175 (85%) of the206 papers. Other methods included a letter score based on thelog of the minimal angle of resolution (logMAR) in 106 papers(51.5%), a letter score derived from the number of letters readon an Early Treatment Diabetic Retinopathy Study (ETDRS)chart in 67 papers (32.5%), decimal notation in 13 papers(6.3%), and fractions other than Snellen equivalent in 1 paper(0.5%). Among the 140 papers using notations other thanSnellen, 31 (22.1%) did not provide a Snellen equivalent. Themajority of physicians surveyed, regardless of level of training,were unable to translate an ETDRS letter score or logMARvalue to an approximate Snellen equivalent correctly.

conclusion Many publications in major ophthalmic journals inthe US describing clinical research in retina do not provideSnellen equivalent of letter scores derived from an ETDRSchart or logMAR values. Journals should consider requiringSnellen equivalents until data show a greater understanding orfacility with letter scores or logMAR values.

2:19 pMDiscussion

2:25 pMlong-term outcomes of neovascular aMDTreated with ranibizumab

Chirag P. Shah, MD (Boston, MA), Carolyn Chen, MD, Jordana Firestone Goren, MD, Kitia Paul, MD, Jeffrey S. Heier, MD*

PurPose To describe the long-term visual and anatomicoutcomes of patients enrolled initially in 2128 and 2425 Phase I/II trials, the first clinical trials evaluating multi-doseranibizumab for neovascular AMD. These trials enrolledpatients between 2001 and 2002.

MeTHoD This is a single-center retrospective case series of 34patients with neovascular AMD enrolled originally in trials2128 and 2425 at Ophthalmic Consultants of Boston, Boston,MA, from July 3, 2001 to January 15, 2011. Trial 2128 includedpatients with subfoveal, predominantly or minimally classicneovascular AMD. Visual acuity ranged from 20/40 to 20/400.Trial 2425 included patients with subfoveal neovascular lesionsthat did not meet treatment criteria for laser or PDT. Visualacuity ranged from 20/40 to 20/100. The long-term outcomesmeasures included visual acuity, degree of subretinal fibrosis andretinal pigment epithelium atrophy, timing and total number ofranibizumab injections.

resulTs Patients were followed for an average of 80.5 ± 25.3months (range 27 to 110 months). An average of 11.4 ± 4.8ranibizumab injections were administered in the first two years,

with a total of 14.5 ± 7.8 by the end of follow-up. The incidencerate of visual loss to 20/200 or worse among patients with neo -vascular AMD initially treated with intra vitreal ranibizumabwas 11.8% per person-year. Kaplan-Meier analysis showed that25% of these patients will reach 20/200 or worse by 1 year, 50%by 3.5 years, and 75% by 5 years. The percentage of macularfibrosis and RPE atrophy progressed over time, with three-quarters of eyes having evidence of either. Eyes with significantamounts of fibrosis, RPE atrophy, or both were more likely toprogress to poor visual acuity.

conclusion This cohort among the first neovascular AMDpatients treated with multiple ranibizumab injections experi-enced significant visual loss with extended follow-up due tosubretinal fibrosis and RPE atrophy, despite initial visual gains.Future studies evaluating treatment modalities to prevent orretard fibrosis and atrophy may complement anti-VEGFtreatment and maximize long-term visual outcomes.

Kaplan-Meier curve showing proportion of patients reaching 20/200 visual acuity or worse by year of follow-up.

2:33 pMlong-term results of anti-vegf Therapy for choroidal neovascularization associated with aMD

John T. Thompson, MD* (Towson, MD), Erica A. Conlan, MD

PurPose To evaluate the long-term results of anti-VEGFtherapy for neovascular age-related macular degeneration andthe effects of extended dosing in eyes which attain good versuspoor visual acuities from treatment.

MeTHoD Visual acuity was measured in a retrospective caseseries of 183 consecutive eyes treated with either intra vitrealbevacizumab (63 eyes or 34.4%), ranibizumab (108 eyes or59%) or both (12 eyes or 6.6%) for subfoveal choroidal neovas-cularization (CNV) arising from age-related maculardegeneration. Eyes were treated with dosing every 4-6 weekswith ranibizumab or bevacizumab for the first year following by

extended dosing (every 2 months or less frequently) if stableduring subsequent years. If eyes developed decreased visualacuity or signs of recurrent activity of CNV, dosing every 4-6weeks was repeated for 3 doses followed by attempts at repeatextended dosing.

resulTs Mean visual acuity was 20/125 -2 at baseline, 20/100 -1 at 3 months (P<.001), 20/100 +2 at 1 year (P<.001),20/100 -1 at 2 years (P=.002), 20/100 at 3 years (P=.036) and20/125 +1 at 4 years (P=.73). The visual acuity was 20/100 orbetter in 137/183 eyes (74.9%). This subgroup was 20/100 +1 at baseline, 20/63 at 3 months (P<.001), 20/63 +2 at 1 year(P<.001), 20/63 -2 at 2 years (P.002), 20/80 +2 at 3 years(P=.039) and decreased to 20/100 at 4 years (P=.59). 66 eyes(48.2%) developed a 3-line loss and recovered in only 19/66eyes (28.8%) with regular anti-VEGF dosing. The 3-line lossoccurred during regular dosing (q 4-6 weeks) in 19/66 eyes(28.8%), extended dosing (< 6 weeks) in 40/66 eyes (60.6%)and both in 7/66 eyes (10.6%). 46 eyes (25.1%) never achieveda visual acuity of 20/100 or better. This subgroup was 20/400 at baseline, 20/400 at 3 months (P=.733), 20/400 +2 at 1 year(P=.273), 20/320 -2 at 2 years (P=.58), 20/320 -1 at 3 years(P=.695) and 20/320 at 4 years (P=.159).

conclusion The initial visual acuity gains during regular anti-VEGF dosing diminish during extended dosing, but the gainswere significant for 3 years. Eyes with visual acuities of 20/100or better have a higher risk of visual acuity loss with extendeddosing. Many eyes with good visual acuities require long-termregular dosing of intra vitreal anti-VEGF drugs to minimizevisual acuity losses.

2:41 pManalysis of intraocular Pressure in eyesreceiving Monthly intravitreal ranibizumab in the Marina and ancHor Trials

Sophie J. Bakri, MD* (Rochester, MN), Darius M. Moshfeghi, MD*, Steven Francom, MD*, Daniel Reshef, MD*, Roman Rubio*, Phillip Lai, MD*

PurPose RBZ administration to AMD patients results in signifi -cant visual improvements. In the MARINA and ANCHORtrials there were no long-term increases in mean pre-injectionIOP from baseline. Recent publications have reported increasedIOP during RBZ treatment. We performed a post-hoc analysisto characterize pre-injection IOP in the study eye during thetwo Phase III AMD trials: MARINA and ANCHOR.

MeTHoD All safety evaluable patients (those who received atleast 1 injection and had a Month 1 IOP recorded in the studyeye) were included in this analysis. Pre-injection IOP for studyeyes in MARINA and ANCHOR were reviewed at Day 0 andat each monthly visit through Month 24 (M24). Analysesincluded highest pre-injection IOP; occurrence at ≥1 study visitof an absolute IOP ≥21, ≥25, and ≥30 mmHg; IOP increasefrom baseline of ≥6, ≥8 and ≥10 mmHg; and an IOP increasefrom baseline of ≥6 or ≥8 mmHg concurrent with an absoluteIOP of ≥21 or ≥25 mmHg; new glaucoma medications that wereused greater than 45 days; and glaucoma filtration surgeries.

resulTs A total of 1124 patients were included in this analysis.The majority of study eyes had a highest post-baseline pre-injection IOP measurement of ≤21 mmHg (Fig.1). Whencompared to sham/PDT, eyes in the RBZ groups had higherrates of any occurrences at ≥1 study visit of IOP ≥21, ≥25 and≥30 mmHg; IOP increase from baseline of ≥6, ≥8 and ≥10mmHg; and combinations of an IOP increase from baseline of≥6 or ≥8 mmHg concurrent with an absolute IOP of ≥21 or ≥25 mmHg. These differences were significant (p<0.05) for allcomparisons except IOP ≥30 mmHg and IOP increase frombaseline ≥10 mmHg (Table 1). New glaucoma medications wereinitiated in the study eye in 5.3% of sham/PDT, 7.5% of 0.3mgRBZ and 7.2% of 0.5mg RBZ patients (not significant). Nopatient required glaucoma filtration surgery in the study eye.

conclusion During the 24 mo. treatment period, more RBZ-treated eyes had increases in pre-injection IOP than sham/PDT-treated eyes. Differences in rates between RBZ andsham/PDT-treated eyes for the IOP endpoints ranged from1.3%-14.2%. Less than 8% of all study eyes required chronicglaucoma medications; none required glaucoma filtrationsurgery. IOP should be evaluated prior to and after RBZ injection.




47

Fig. 1: Distribution of the Highest Pre-injection IOP in the Study Eyeduring the 24-month treatment period of MARINA and ANCHOR.

Table 1: Rates of pre-injection IOP at ≥ 1 study visit.

2:49 pMfrequency and clinical Predictors of sustained intraocular Pressure elevation Due to intravitreal anti-vascular endothelial growth factor Therapy

Quan V. Hoang, MD, PhD (New York, NY), Luis S. Mendonca, MD, Kara Dellatorre, MD, Jesse Jung, MD, Angela J. Tsuang, MD, K. Bailey Freund, MD*

PurPose Intraocular pressure (IOP) elevations as a compli-cation of anti-vascular endothelial growth factor (VEGF)injections were not noted in ANCHOR and MARINA trials,but recent reports suggest sustained ocular hypertension canoccur. We assess for frequency and predictive factors related toIOP elevations in neovascular age-related macular degeneration(NVAMD) patients receiving anti-VEGF injections.

MeTHoD 349 NVAMD patients (474 eyes) that presented to asingle physician over a 6-month period were retrospectivelyassessed for baseline demographic/clinical information, examfindings, total number of bevacizumab and ranibizumab injectionsand sustained IOP elevation (>21 mmHg for 2+ consecutivevisits). The frequency and odds ratio of sustained IOP elevationwas stratified by number of injections. Association betweeneach possible confounder (demographic or clinical character-istic) and the dependent and independent variables wereassessed individually. A multivariate, logistic regression wasperformed to determine if total number of injections showed anassociation with sustained IOP elevation.

resulTs 39 eyes (8.2%) experienced sustained IOP elevation.Eyes with ≥ 31 injections had a greater odds ratio (7.973, CI 1.75-36.44, p=0.007) compared to ≤ 10 injections. Thefollowing showed an association with sustained IOP elevation:total number of injections (OR 1.664, p=0.004, univariateanalysis), history of intra vitreal steroid injections (OR 2.894,p=0.006), history of IOP elevation soon after intra vitrealsteroid injection (OR 3.437, p=0.038), history of glaucoma(p=0.009, Fisher’s exact test), prior eye surgery other thancataract extraction (OR 4.448, p=0.033) and prior posteriorcapsulotomy (OR 2.982, p=0.026). Of these factors, only priorintra vitreal steroids (p < 0.0001) and IOP elevation soon afterintra vitreal steroid injection (p=0.001) were found to be alsoassociated with the total number of injections. After adjustingfor these confounders, the association between total number ofinjections and sustained IOP elevation was still statisticallysignificant (p=0.013).

conclusion Our results suggest that a greater number of injec-tions may increase the risk for sustained IOP elevation in eyeswith neovascular AMD receiving intra vitreal anti-VEGFtherapy. Eyes having received prior intra vitreal steroid injec-tions and those which have experienced IOP elevations soonafter receiving intra vitreal steroids may be at greater risk for thiscomplication of treatment.

2:57 pMDiscussion

3:05 pMDouble-dose ranibizumab for choroidalneovascularization assoc. with aMD Minimallyresponsive to Prior α-vegf Treatment

Carolyn Chen, MD (Boston, MA), Jeffrey S. Chang, MD, Chirag P. Shah, MD, Kavita Bhavsar, Jeffrey S. Heier, MD*

PurPose To evaluate the efficacy of double-dose (1 mg) injectionsof intra vitreal ranibizumab for choroidal neovascularization(CNV) minimally responsive to prior ranibizumab orbevacizumab treatments.

MeTHoD A retrospective, non-randomized, consecutive, inter-ventional case series was conducted among all patients treatedby one researcher (JSH) at Ophthalmic Consultants of Boston,Boston, MA, between Dec. 2009, and Mar. 2011. All patientsreceiving at least one double-dose ranibizumab injection (1.0 mg in 1.0 mL) for CNV were included. Patients receivingdouble-dose ranibizumab for conditions other than neovascularAMD, retinal angiomatous proliferation (RAP), or idiopathicpolypoidal choroidal vasculopathy (IPCV) were excluded. Priortreatments, visual acuity (VA) and central foveal thickness(CFT), determined by spectral domain optical coherencetomography, were recorded and analyzed.

resulTs Thirty eyes in 29 patients received double-doseranibizumab after minimal anatomic and visual response tomultiple previous ranibizumab (0.5 mg in 0.5 mL) and/orbevacizumab (1.25 mg) injections. Most eyes had neovascularAMD (19); six had RAP and five had IPCV. During the twostandard-dose treatments (mean 10.3 weeks) prior to treatmentwith double-dose ranibizumab, mean VA declined from 20/66(logMAR=0.52) to 20/83 (logMAR=0.62; p = 0.48), and CFTincreased from 344 to 373 microns (p = 0.981). Following onedouble-dose ranibizumab injection, mean VA improved to20/71 (logMAR= 0.55, p = 0.067), and mean CFT decreasedsignificantly to 338 microns (p = 0.03). No adverse events were noted.

conclusion Patients recalcitrant or minimally responsive tomultiple prior ranibizumab and/or bevacizumab treatments forCNV experienced an improvement in CFT after a singledouble-dose ranibizumab injection. VA also improved withborderline stat. significance. These findings suggest that theremay be a subset of patients poorly responsive to standard dosethat may benefit from double-dose ranibizumab.

3:13 pMincreased Dose ranibizumab for Persistent choroidal neovascular activity in neovascular aMD

Jared S. Nielsen, MD* (West Des Moines, IA), Tyler A. Fick, MD, Kyle A. Alliman, MD, David D. Saggau, MD

PurPose AntiVEGF therapy with intra vitreal injection (IVI) of bevacizumab 1.25mg or ranibizumab 0.5mg is the standard of care for nvAMD treatment. While most patients respond toconventional dose therapy, CNV activity can persist despitemonthly IVI. Patients with CNV activity while on monthlyconventional dose therapy may benefit from increased dose (0.7 or 1.0) ranibizumab (IDR) using 0.7 or 1.0mg.

MeTHoD We performed a retrospective electronic record reviewof eyes treated with IDR for persistent CNV activity despiteconventional antiVEGF therapy. Subjects were excluded if:vision <20/400 in the treated eye, follow-up after IDR <12weeks, prior IVI <22 or >34 days before IDR, confoundingocular disease, irregular IDR treatment intervals, or adjunctivetherapy (steroids, PDT, or thermal laser) during or <3 monthsprior to IDR. Demographic information, treatment, visualacuity, exam, and OCT data were collected. Each IDR injectionincluding the dose and any complications were noted.

resulTs 89 eyes of 32 male and 57 female nvAMD patients,mean age 80.9 (SD±9.1), treated with IDR were identified. Eyeshad received antiVEGF therapy for a mean of 75.4 (SD±55.1)weeks before IDR. Prior therapy is summarized in Table 1.Subjects received IDR for a mean of 40.5 (SD±17.3) weeks(range 12-65 weeks). A total of 923 IDR were injected, anaverage of 10.5 (SD±4.2) IDR IVI per eye. IDR was adminis-tered monthly. If CNV activity resolved then IVI intervals wereextended in some cases. LogMar VA prior to IDR was 0.33(SD±0.27), snellen 20/43. IDR acuity improved in 36% of eyes,maintained in 42%, and worsened in 22%. Overall meanlogMAR VA remained stable at 0.32 (SD±0.30). Initial OCTfindings and clinical response are summarized in Table 2. OCTimproved in 61 (68.5%) eyes, remained stable in 15 (16.9%)eyes, and declined in 13 (13.5%) eyes. For eyes with sdOCT(n=82) mean central subfield thickness (CST) was 344.1µ(SD±65.4) and improved to 312.5µ (SD±68.2); t-testp<0.0001.

conclusion Eyes with persistent CNV activity despite monthlyconventional dose antiVEGF therapy can benefit from IDR.Two subjects with a prior history of CAD suffered non-fatalarterial thromboembolic events while receiving IDR. It isuncertain if these events are related to IDR. IDR can beperformed without increasing injection frequency or cost and may improve clinical outcomes.




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3:21 pMManagement of vascularized Pigmentepithelial Detachments Due to aMD with High (2.0 mg) vs. conventional-dose (0.5 mg) ranibizumab

Clement K. Chan, MD* (Palm Springs, CA), Prema Abraham, MD, David Sarraf, MD*, Asha S.O. Nuthi DO*, Steven G. Lin, MD*, Colin A. McCannel, MD*

PurPose To investigate the efficacy and safety of 2.0 MG vs. 0.5 MG ranibizumab injections (RI), and monthly (QM) vs. asneeded (PRN) reinjection protocol for treating vPED due toAMD in a prospective randomized clinical trial.

MeTHoD The RI groups were:1) 0.5 MG monthly (QM) x 12months (M), 2) 0.5 MG QM x 4 M followed by PRN injectionsto 12 M, 3) 2.0 MG QM x 12 M, 4) 2.0 MG QM x 4 Mfollowed by PRN injections to 12 M. Primary outcome measureswere pre- & post-RI (last visit) ETDRS visual acuity (VA).Secondary measures were pre-and post OCT central 1-mmthickness; PED height; surface area (A2), greatest lineardiameter (GLD) of PED & choroidal neovascularization(CNV); subretinal fluid (SRF); cystoid macular edema(CME);adverse events. Baseline & follow-up VA, biomicroscopy,fundus photography, fluorescein angiography & OCT weredone to set schedule. Statistics included ANOVA, T-Test,Wilcoxon Signed Ranks, Mann-Whitney & Fisher tests.

resulTs There were 38 eyes in 38 patients (12 men) with mean age of 79.3 years & mean follow-up of 8.9 months. MeanETDRS VA post-RI was better than pre-RI for 2.0 MG eyes(65.4±14.4 [20/50] vs. 58.4±10.8 [20/71], p=0.004), but not for0.5 MG eyes (p=0.26). Comparison of other post-RI results for2.0 MG vs. s0.5 MG eyes, and comparison of results between

QM vs.PRN for either 2.0 MG or 0.5 MG eyes showed nosignificant differences (all p>0.05). There were significantdecreases between pre and post-RI measurements for PEDheight,1-mm, PED A2, & SRF in 2.0 MG eyes, and for PEDheight, 1-mm, PED A2, PED GLD, CNV A2, SRF & CME in0.5 MG eyes (all p<0.05). There were also greater VA improve -ment and much earlier decreases in PED height & SRF (Week 4 or 8) in 2.0 MG eyes compared with 0.5 MG eyes (allp<0.05). Resolution of PED was more consistent in 2.0 MGeyes compared with 0.5 MG eyes(p=0.04). Three eyes (0.5 MGPRN, 2.0 MG QM, 2.0 MG PRN) formed an RPE tear and in 1 eye cataract worsened (0.5 MG QM).

conclusion High-dose (2.0MG) but not 0.5 MG ranibizumabled to significantly improved post-RI vision in eyes with vPED.Visual recovery and decreased vPED dimensions also developedsubstantially earlier in the course of the study in 2.0 MG eyesthan in 0.5 MG eyes. There was more consistent flattening ofPED in 2.0 MG eyes but not in 0.5 MG eyes. The safety profilewas similar for both medication doses.

Substantial VA improvement much earlier in the post-treatment course(Week-8) was noted for eyes receiving 2.0MG ranibizumab (P=0.008) in comparison to 0.5MG ranibizumab (p=0.08). Final VA was also betterthan pre-treatment VA for the 2.0 MG eyes (p=0.004), but not the 0.5 MG eyes (p=0.26).

More rapid decreases in post-treatment PED heights (Week-4) werenoted for eyes receiving 2.0MG ranibizumab (p=0.016) in comparisonto eyes receiving 0.5MG ranibizumab (p=0.29).

3:29 pMDiscussion

3:35-4:10 pMrefreshment Break and exhibitsHynes Convention Center, Hall D

4:10-5:18 pM

Symposium 9:vitreoretinal Surgery iiModerators: Mark S. Humayun, MD, PhD and Timothy G. Murray, MD, MBA


4:10 pMManagement of aqueous Misdirection syndrome (aMs) –role of Pars Plana vitrectomy

Pramod S. Bhende, MBBS (Chennai, India), Vijaya Lingam, MD*, B. Shantha, MD, Ronnie George, MD

PurPose To report anatomical and functional outcome in eyesthat underwent combined surgery for management of aqueousmisdirection syndrome.

MeTHoD Retrospective, noncomparative, interventional caseseries of 23 patients (26 eyes) diagnosed as AMS and refractoryto medical and conventional surgical therapy. All eyes under -went initial pars plana anterior vitrectomy, anterior chamberreformation (pseudophakic eyes) and phacoemulsification +IOL implantation (phakic eyes) followed by completion ofvitrectomy including induction of posterior vitreous detach -ment. At conclusion a communication was established between the anterior and the posterior chambers to allow freeflow of fluid through the peripheral iridotomy and posteriorcapsulotomy.

resulTs All surgeries were performed by a single surgeon using the above described approach. All eyes had at least onefiltration procedure prior to surgery for AMS. Mean intervalbetween primary filtration surgery and diagnosis of AMS was14.01 weeks and between diagnosis of ASM and vitrectomy was 16.37 wks. Mean preoperative and final IOP was 16.97 and 12.75 mm of Hg. 20 eyes did not need any anti glaucomamedication after surgery. Ultrasound biomicroscopy (UBM) was done in 19 eyes both pre and post operatively and showedreversal of anterior rotation of ciliary processes in all casesfollowing surgery. At mean follow up of 104.35 weeks, all theeyes had well-formed central anterior chamber. Vision wasmaintained or improved in 23 eyes. Late complicationsincluded corneal decompensation in 3 and choroidaldetachment in 2 eyes.

conclusion Creation of single cavity using a combinedprocedure of complete vitrectomy (with phacoemulsification inphakic eyes) and a peripheral iridotomy with posterior capsu-lotomy using the parsplana route can yield excellent anatomicaloutcome in phakic and pseudophakic eyes with AMS.

4:18 pMimplications of 23/25+ gauge Microincisionalvitrectomy surgery with adjunctive intravitreal steroid Pharmacotherapy

Timothy G. Murray, MD, MBA* (Miami, FL), Robert A. Sisk, MD, Charles C. Wykoff, MD, PhD, David W. Parke III, MD, Audina M. Berrocal, MD, Samuel K. Houston

PurPose Recent concerns have focused on incidence ofimmediate post operative hypotony/endophthalmitis and latedevelopment of secondary glaucoma associated with pars planavitrectomy. We report a consecutive series of 23/25+ MIVSsurgery using intra-operative triamcinilone acetonide withextended followup focused on IOP, retinal anatomy, and visual function.

MeTHoD An IRB approved retrospective review of a consecutiveseries of 327 eyes undergoing 23/25+ gauge MIVS surgery withintraoperative triamcinolone acetonide within the OcularOncology Service at the Bascom Palmer Eye Institute. Pre-operative evaluation included OCT evaluation, fundusphotography and/or ultrasound. Extended followup includedvisual function, IOP evaluation and macular imaging withOCT/fundus photography. A standard surgical procedureemployed oblight trocar insertion, pars plana vitrectomy,removal of the posterior hyaloid with, or without ERM/ILMpeeling, and placement of intra vitreal triamcinolone acetonide4 mg. All cases were evaluated for surgical complications.

resulTs 327 surgical procedures were performed on 299patients. Mean patient age was 68 years (18 to 96 years) withsurgical indications including radiation associated retinaldetachment (54.2%), VMT/ERM/CME (21.6%), diabeticretinopathy (15.9%) and exudative neovascular AMD relatedretinal detachment (8.3%). Mean followup was 23 months (12to 60 months). No cases of endophthalmitis were seen (0/327).Hypotony occurred in 1/2% (4/327). Mean IOP was 15.7 mmHg at baseline, 17.6 at one day, 15.6 at one month, 14.8 atthree months, 14.9 at 6 months, 15.0 at 12 months and 15.8 at24 months. The subset of patients with elevated IOP (>25 mmHg) was 5.3% at baseline, 2.4% at 1 month, 1.2% at 6 months,1.1 % at 12 months, and 0.9% at 24 months. One patientunderwent glaucoma surgery (1/327, 0.003%).

conclusion 23/25+ MIVS utilizing intraoperative triamcino -lone acetonide appears to have a low complication rate withoutsignificant concerns for hypotony, choroidal detach ment,retinal detachment or endophthalmitis. Concerns for secondaryglaucoma associated with primary pars plana vitrectomy appearto be ameliorated by the use of 23/25+ MIVS surgery withadjunctive intra vitreal triamcinolone acetonide.


viTreoreTinal surgery ii 4:10–5:18 PM9


51

4:26 pMvitrectomy and Pars Plana Baerveldt implantwith ripcord Technique for Treatment of complex glaucoma

Ma’an A. Nasir, MD (Santa Barbara, CA), Alessandro Castellarin, MD, Dante J. Pieramici, MD, Robert F. See, MD, Stephen S. Couvillion, MD, Melvin D. Rabena

PurPose To evaluate the efficacy of vitrectomy and pars planaBaerveldt implants utilizing a ripcord technique in patientswith elevated intraocular pressure (IOP) unresponsive tomaximal medical treatment.

MeTHoD A retrospective study of consecutive eyes undergoingpars plana Baerveldt implantation for glaucoma. In all patients,a novel ripcord technique was utilized to control the timing ofopening the tube and lowering the IOP. Pre- and post-operativeanalysis includes IOP, number of glaucoma medications, andocular adverse events. Complete Success is defined as a finalIOP 6≤x≤21 mmHg, with no glaucoma medication; QualifiedSuccess as IOP 6≤x≤21mmHg with at least one glaucomamedication; Qualified Failure as IOP 6>x>21mmHg andComplete Failure as an eye progressing to no light perception(NLP), phthisis bulbi, or requiring a second surgery to control IOP.

resulTs Inclusion criteria were met in 119 eyes; 69 withneovascular glaucoma (NVG) and 50 eyes without NVG. Many of the non-NVG eyes had corneal transplants as parsplana placement of tubes may reduce graft failure. Mean followup was 26 months and the ripcord was removed a mean of 46days after implantation. At the last follow-up visit (LFV), themean IOP was 12.8 mmHg compared to 32.1 mmHg beforesurgery and 21.1 mmHg at day 1 after surgery. The meannumber of glaucoma medications at LFV was 0.9 compared to2.6 at the preoperative visit. Complete Success was found in47.8% (57/119) of eyes; Qualified Success in 38.7% (46/119);Qualified Failure in 3.4% (4/119); and Complete Failure in10.1% (12/119). Of the 12 complete failures, 5 had NLPvision – all felt to be due to progression of underlying diseaserather than IOP control, and 3 of these eyes developed phthisis.Surgery was required due to hypotony (1), elevated IOP despiteimplant (4), and tube erosion requiring replacement (2).

conclusion Vitrectomy and pars plana Baerveldt implantationwith a novel ripcord technique appears to be an effective methodto control IOP in patients with complex glaucoma. The parsplana approach also permits simultaneous treatment ofassociated posterior segment pathology.

4:34 pMDiscussion

4:40 pMa novel surgical approach to the Treatment of Blinding Macular Disease

Suber S. Huang, MD, MBA* (Cleveland, OH)

PurPose Can magnetic nanoparticles be used to deliver therapeutic drug/genes to treat diseases of the retina and macula?

MeTHoD Green-fluorescence protein (GFP) plasmids wereassociated with paramagnetic nanoparticles. Gene delivery was then targeted to cultured human diploid retinal pigmentepithelial (ARPE-19) cells by application of a magnetic field.Fluorescence microscopy was used to assay cells for GFPexpression. Magnetic nanoparticles were then tagged with redfluorescence and delivered to cultured ARPE-19 cells withapplication of a magnetic field. Uptake of particles into cellswas detected using fluorescence microscopy. This procedure wasrepeated using Polyethylenamine (PEI)-GFP nanoparticlescomplexes as a standard control. Transfection efficiencies werecompared using fluorescence microscopy.

resulTs Micrographs quantitating transfection efficiency ofARPE-19 cells using GFP-magnetic nanoparticle complexeswill be presented and demonstrate significantly higherintegration than that of PEI-RPE nanoparticles. In addition,fluorescently tagged magnetic nanoparticles showed nearlydiffuse uptake by ARPE-19 cells. Finally, transfection of ARPE-19 cells using GFP-magnetic nanoparticle complexes requiredonly 15 minutes of incubation time while exposed to magneticfield in order to achieve optimal gene delivery. In contrast, PEI-GFP nanoparticle complexes required 4 hours (as per standardprotocol) of incubation time to achieve optimal delivery.

conclusion We describe a novel approach to biologic therapyto the macula using two kinds of nanoparticles. Selectivedelivery to retinal tissue layers will be clinically useful inpatients with genetic, degenerative, and apoptotic mechanismsfor disease. The ability to target specific cell types in the retinawill be a step towards improved methods of treating retinablinding disease.

4:48 pMintraocular lens Placement via a novel, sutureless, scleral fixation Technnique

Jonathan L. Prenner, MD* (Lawrenceville, NJ), Harold Wheatley, MD, Howard P. Fine, MD*, Connors Daniel, MD, Daniel B. Roth, MD*

PurPose To report the outcomes of a study cohort treated with a novel, sutureless, scleral fixated intraocular lensplacement technique.

MeTHoD Six eyes of 6 patients were included. Four eyes wereaphakic and 2 eyes had a dislocated 3-piece IOL. A 25-g PPVwas performed in all eyes. Dislocated IOL’s were freed fromresidual lens capsule so that the haptics were accessible. A 20-g ciliary sulcus sclerotomy (CSS) was created 2 mm from thelimbus at six and twelve o’clock. A 23-g trochar blade was used to create a 3 mm partial thickness scleral tunnel into theopening of each CSS. For aphakic eyes, a foldable 3-piece IOLwas inserted through the clear cornea. Dislocated IOL’s werebrought into the pupillary axis. A 25-g forceps was used toexternalize each haptic via the CSS. The haptics were thenplaced into the 23-g tunnels.

resulTs All eyes were followed for at least three months. Atthat time point, all eyes demonstrated well-positioned IOL’swithout evidence of decentration or dislocation. None of theintrascleral haptics became exposed or intruded. Five out of sixeyes had uncomplicated postoperative courses. One eye with adislocated IOL had a vitrectomy for epiretinal membrane priorto the lens repositioning procedure. This eye had documentedCME both before and after the IOL was repositioned. The sameeye also developed transient hypotony (IOP=6), which resolvedspontaneously three weeks after the procedure. Visual acuityimproved significantly in all eyes, as would be expected aftertreating their state of functional aphakia with the placement of a centered, sulcus based IOL.

conclusion Sutureless scleral fixation appears to be areasonable way to secure an IOL in the posterior chamber. This technique allows for efficient posterior chamber IOLplacement and avoids the potential complications of anteriorchamber IOLs, as well as the complication of scleral fixationsutures breaking after sutured scleral fixation techniques.

4:56 pMoutcomes and lens stability in combinedTransconjunctival sutureless vitrectomy and cataract surgery with Toric intraocularlens implantation

Christopher D. Riemann, MD (Cincinnati, OH), Matthew F. Appenzeller, MD, Daniel M. Miller*, Michael R. Petersen, MD, PhD, Robert E. Foster, MD, Christine Hunt

PurPose To report the outcomes of combined transconjunctivalsutureless pars plana vitrectomy and cataract surgery with toricintraocular lens implantation.

MeTHoD A retrospective analysis of 46 consecutive eyes of 42patients who underwent combined simultaneous small incisioncataract surgery with toric intraocular lens implantation, andtransconjunctival sutureless vitrectomy surgery from April 2007to May 2010. Anatomic results, post operative uncorrectedvisual acuity, astigmatism, and rotational stability of theintraocular lens are evaluated.

resulTs Preoperative visual acuity was 0.33 ± 0.16 LogMar andimproved to 0.11 ± 0.13 postoperatively (p < 0.000000001).Preoperative astigmatism was 1.75 ± 1.0 diopters (range 0-3.75diopters) and improved to 0.5 ± 0.75 diopters (range 0-2.5diopters) postoperatively (p < 0.000000001). Final measuredpostoperative IOL axis deviation from target axis was 5 ± 6degrees (range 0-32). Final IOL axis was within five degrees oftarget in 38 (83%) eyes, within 10 degrees of target in 42 (91%)eyes, and was within 15 degrees of target in 43 (93%) eyes.

conclusion Toric lens implantation is reasonable for selectpatients undergoing combined cataract surgery and transcon-junctival sutureless vitrectomy. As combined phaco-vitrectomycontinues to increase in popularity, it is important for retinalsurgeons to maintain standard of care from both the anteriorand posterior segment perspective. This includes offering toricIOL implantation when appropriate.

Pre and post operative visual acuity in 46 eyes undergoing combined CE/IOL and TSV with toric IOL implantation.


viTreoreTinal surgery ii 4:10–5:18 PM9


53

Pre and post operative astigmatism in 46 eyes undergoing combined CE/IOL and TSV with toric IOL implantation.

5:04 pMPosterior Hyaloid Detachment and Peeling of the internal limiting Membrane assisted by 10 Different natural vital Dyes: a Post-mortem Pilot study

Magno A. Ferreira, MD (Uberlandia, Brazil), Raquel Ferreira, Michel Farah, MD, PhD, Eduardo Rodrigues, MD, Aca’cio Filho, MD, Cristiane Peris, MD, Eber Ferreira, MD, Jane Chen, MD, Mauricio Maia

PurPose To determine whether natural dyes from the extract of ten different sources (pomegranate, haematoxylon campechi -anum, chlorophyll, cochineal, hibiscus, indigo, paprika, rosella,fustec wood and grape) stains and facilitates posterior hyaloiddetachment and peeling of the retinal internal limitingmembrane (ILM) in human eyes.

MeTHoD Open sky vitrectomy including removal of theposterior hyaloid and ILM was performed in 80 cadaveric eyes.Ten different dyes were injected into the posterior vitreouscavity to promote hyaloid detachment and after this procedureeach specific dye was injected to perform the ILM removal. The dyes were allowed to settle on the macula for 5 minutesand were then removed by mechanical aspiration. Peeling ofthe ILM was initiated and completed with intraocular forceps.Specimens were submitted to light and electron microscopy.

resulTs The natural dyes were a useful tool to allow theposterior vitreous detachment and internal limiting membranepeeling. Extract of haematoxylon campechianum, cochinealand fustec wood allows posterior vitreous detachment in 100% of the cases. The results of posterior hyaloid detachmentassisted by these vital dyes were comparable with posteriorhyaloid detachment assisted by triamcinolone previouslyperformed in such model for comparison purposes. Cochineal

and chlorophyll were the best dyes to stain de ILM. Chlorophyllallows intensely staining (comparable with ICG, tested beforein cadaveric eyes) in 25% of the eyes and moderately in 75% ofthe eyes. Cochineal stains intensely in 50% of the eyes, 37,5%moderately and 12.5% poorly. Light microscopic and ultrastructural studies confirmed removal of the ILM in all cases.

conclusion Natural vital dyes allow staining of the vitreousand ILM in human cadaveric eyes and may be a useful tool forvitreoretinal surgery. Cochineal was the best dye to stain thevitreous and ILM, following extract of haematoxylon campechi -anum and fustec wood for vitreous and chlorophyll for ILM.

5:12 pMDiscussion

5:20-6:40 pMPoster session and exhibit Hall Wine and cheese receptionHynes Convention Center, Hall D

6:00-8:00 pMBoston’s north end secrets, saints and sips crawlSponsored by the American Retina Foundation

6:40 pMfree evening

6:45-8:30 pMasrs new Member reception5th Floor, Pool Deck

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54

Tuesday

Tuesday, August 23

55


7:30-8:20 AM

Symposium 10:ocular oncologyModerators: Tara A. McCannel, MD, PhD and Carol L. Shields, MD


7:30 AMsafety of Pars Plana vitrectomy in eyes with Treated Posterior uveal MelanomaAlok S. Bansal, MD (Philadelphia, PA), Carlos Bianciotto, Joseph I. Maguire, MD*, Carl D. Regillo, MD, Jerry A. Shields, MD, Carol L. Shields, MD

PurPose Vitreous hemorrhage (VH) after treated choroidalmelanoma can reduce visual acuity and can be treated with parsplana vitrectomy (PPV). There have been concerns regardingtumor dissemination with vitreous surgery. The purpose of this study is to determine the rates of systemic metastasis, local tumor recurrence, and enucleation in eyes with treatedposterior uveal melanoma undergoing PPV for VH.

MeTHoD Single-center, retrospective review of 45 cases ofposterior uveal melanoma treated with plaque radiotherapy thatsubsequently underwent PPV for VH. Baseline patient infor-mation included patient age, tumor thickness, interval betweentumor treatment and VH, and interval between VH and PPV.Main outcomes evaluated were systemic metastasis, local tumorrecurrence, and enucleation at last follow up.

resulTs 45 eyes underwent PPV for VH after plaque radio-therapy for posterior uveal melanoma. At baseline, mean patientage was 58 years old (21-81 years), mean tumor thickness 4.9mm (1.5-10.5 mm), mean interval between plaque therapy andVH was 21 months (1-81 mos.), and mean interval betweenVH and PPV was 17 months (0-126 mos.). The mean follow-upafter PPV was 43 months (5-130 mos.). 3 of 45 eyes (7%)developed systemic metastasis with a mean time from PPV tometastasis of 37 months (5-71 mos.). In these 3 eyes, the mean time from plaque treatment to metastasis was 60 months(36-95 mos). No eyes developed local tumor recurrence afterPPV. 5 of 45 eyes (11%) were enucleated with a mean timefrom PPV to enucleation of 9 months (3-21 mos.).

conclusion Based on previous studies, systemic metastasis fromuveal melanoma occurs in 8% and 15% of patients at 3 and 5 years, respectively. The current results suggest that pars planavitrectomy in eyes with treated posterior uveal melanoma doesnot increase the risk of metastasis. Additionally, there were nocases of local tumor recurrence.

7:38 AMPlaque radiotherapy for Juxtapapillary,circumpapillary, and epipapillary choroidalMelanoma. analysis of 650 cases

Carol L. Shields, MD (Philadelphia, PA), Mandeep Sagoo, Arman Mashayekhi, MD, Lydia Komarnicky, Jerry A. Shields, MD, Linda Komarnicky, MD

PurPose To evaluate efficacy of plaque radiotherapy for juxtapapillary, circumpapillary, and epipapillary choroidalmelanoma.

MeTHoD Retrospective case review of 650 consecutive eyes with juxtapapillary, 37 with circumpapillary, and 141 withepipapillary choroidal melanoma.

resulTs Of 650 eyes with juxtapapillary melanoma, the median basal tumor diameter was 10 mm and thickness 4 mm.Kaplan-Meier estimates for tumor recurrence, metastasis, and death were 14%, 11%, and 4% at 5 years and 21%, 24%,and 9% at 10 years, respectively. Using multivariable analysis,factors predictive of tumor recurrence included foveolarinvolvement (relative risk (RR) 5.07, p<0.001) and greatertumor thickness (RR 1.29 per mm, p<0.001). The factorpredictive of metastasis included greater tumor base (RR 1.21per mm increase, p<0.001). Of 37 eyes with melanoma encir-cling the disc (circumpapillary), tumor recurrence, metastasis,and death were found in 14%, 4%, and 0% at mean 52 monthsfollow up. Of 141 eyes with melanoma overhanging the disc(epipapillary), tumor recurrence, metastasis, and death werefound in 10%, 13%, and 3% at mean follow up of 56 months.

conclusion Patients with juxtapapillary, circumpapillary, and epipapillary choroidal melanoma face enucleation unlesscustom designed radiotherapy can be provided. Plaque radio-therapy provides tumor control in nearly 80% or more ofaffected patients at 10 years follow up. Melanoma-related deathis approximately 9% or less for each group, mostly related totumor size.


Tuesday, August 23

7:46 AMsufficiency of fnaB aspirates of Posterior uveal Melanoma for cytodiagnosisvs. geP class and relative Prognostic significance of these Tests

Zelia M. Correa, MD, PhD (Cincinnati, OH), James J. Augsburger, MD, J. William Harbour, MD*

PurPose To determine the relative sufficiency of pairedaspirates of posterior uveal melanomas obtained by fine needleaspiration biopsy (FNAB) for cytopathologic classification andgene expression profile (GEP) classification, and to determinethe relative prognostic significance of these different classifica-tions for predicting subsequent patient death from metastasis.

MeTHoD Prospective non-randomized IRB-approved singlecenter longitudinal clinical study of 159 patients with posterioruveal melanoma sampled by FNAB in at least two tumor sites atone center between 09/2007 and 12/2010. Cases were analyzedwith regard to sufficiency of the obtained aspirates for cyto -pathologic classification and GEP classification. Cumulativeactuarial survival curves of subgroups of these patients based on their cytopathologic versus GEP-assigned categories werecomputed by the Kaplan-Meier method. The endpoint for thissurvival analysis was death from metastatic uveal melanoma.

resulTs FNAB yielded an insufficient aspirate for cytodiagnosisin 34 of 159 cases (21.4%). FNAB aspirates were insufficient for GEP in 1 of 159 cases (0.6%) (P < 0.001). Six of 34 cases(17.6%) with an insufficient aspirate for cytodiagnosis provedto be Class 2 tumors by GEP and 43 of 104 cases (34.7%) thatyielded a sufficient aspirate for cytodiagnosis were Class 2 byGEP. Currently 11 of 49 Class 2 tumors (22.4%) but 2 of 109Class 1 tumors (1.8%) developed metastasis. Eleven of 125 cases(8.2%) with a sufficient aspirate for cytodiagnosis while 2 of 34 cases (5.9%) with an insufficient aspirate for cytodiagnosisdeveloped metastasis. Cumulative 3-year mortality from metastasis was 4.5% for those with an insufficient aspirate forcytology versus 21.4% for those with sufficient aspirates (log rank P = 0.39). Three year mortality from metastasis was4.3% for the those with insufficient/unsatisfactory aspirate forGEP versus 35.2% for those with a sufficient aspirate (log rank P = 0.005).

conclusion This study confirmed that GEP classification ofposterior uveal melanoma cells obtained by FNAB is feasible in almost all cases, including most in which FNAB yields aninsufficient aspirate for cytodiagnosis. The study also confirmedthat GEP classification is substantially better than cytologicclassification for predicting subsequent metastasis andmetastatic death.

Crosstabulation of method of testing versus sufficiency of FNAB aspirates of posterior uveal melanomas.

Three-year mortality rate from metastasis (n=159 patients)reflecting the prognostic significance of GEP classification of posterior uveal melanomas.


ocular oncology 7:30–8:20 AM10


57

7:54 AMsafety of fine needle aspiration Biopsy in choroidal Melanoma

Tara A. McCannel, MD, PhD* (Los Angeles, CA), Melinda Y. Wu, MD, Barry L. Burgess, MD

PurPose The safety of FNAB in choroidal melanoma remainscontroversial. Orbital dissemination, local treatment failure,and an increased risk of metastatic spread have been speculatedwith FNAB but their true occurrence has not been reported.We sought to report on the local and systemic follow-up ofpatients undergoing transscleral FNAB with brachytherapy fortreatment of choroidal melanoma.

MeTHoD All patients with choroidal melanoma treated withiodine-125 brachytherapy and intraoperative FNAB fromJanuary 2005 to January 2010 with at least one year of clinicalfollow-up were included. Outcomes examined were endoph-thalmitis, orbital dissemination, local treatment failure,rhegmatogenous retinal detachment, monosomy 3 status, andchoroidal melanoma metastasis.

resulTs 175 patients with a follow-up interval of between 1 and 6 years (mean 2.7 years) were included. For tumors ofheight less than 3.0 mm, between 3.0 mm and 5.0 mm, andgreater than 5.0 mm, sufficient biopsy material for FISH wasobtained in 59%, 72%, and 91%, respectively. There was nocase of postoperative endophthalmitis; no patient developedorbital dissemination; no patient developed local treatmentfailure; and 3 patients developed rhegmatogenous retinaldetachment within one year of treatment. Fourteen patientsdeveloped metastasis. Of the 14, 8 had monosomy 3 of theprimary tumor, 2 had disomy 3, 1 had trisomy 3, and 2 patientshad insufficient material for FISH. The cumulative 5-yearmetastatic rate using a Kaplan-Meier plot was 12.3%.

conclusion Transscleral FNAB with iodine-125 brachytherapywas found to be a safe procedure. The cumulative 5-year rate of metastasis was no greater than that reported by the Collaborative Ocular Melanoma Study (13% for medium-sizedtumors). Rhegmatogenous retinal detachment may occur inyoung patients secondary to posterior vitreous detachmentinduced by tumor response to radiation, unrelated to FNAB.

8:02 AMchanging concepts regarding Management of orbital extension of uveal Melanoma

Jerry A. Shields, MD (Philadelphia, PA), Carol L. Shields, MD

PurPose There is widespread belief that extraocular extension(EOE) of uveal melanoma requires orbital exenteration.However, it is now recognized that many patients with EOEalready have subclinical distant metastases. Hence, orbitalexenteration seems excessive and less aggressive treatmentseems advisable in most cases.

MeTHoD The authors developed a classification of EOE of uveal melanoma and surveyed 30 years experience with itsmanagement.

resulTs Among >10,000 patients with uveal melanoma, EOE occurred in < 5%. EOE was classified according to size,location, and how and when it was detected. Treatment evolvedover the years and varied, depending on the clinical situation.Small and medium sized EOE were managed by enucleationwith localized conjunctivectomy / tenonectomy or plaque radio-therapy. Large or extra large anterior circumscribed EOE weremanaged by modified enucleation. Large or extra-large posteriorcircumscribed lesions were managed by modified enucleationvia a lateral orbitotomy, lateral rectus muscle disinsertion, eyeremoval with long section of optic nerve, and hydroxyapatiteimplant. Large and extra large poorly circumscribed lesions were managed by eyelid-sparing orbital exenteration. Less than5% of patients with EOE required orbital exenteration. Basedon current knowledge of metastatic behavior, the method oftreatment appeared to have no adverse effect on systemicprognosis.

conclusion There are several options to orbital exenterationfor EOE of uveal melanoma. More than 95% of patients arecurrently managed with methods other than orbital exenter-ation, thus preserving eyes and vision.

8:10 AMDiscussion

8:20-10:10 AM

Symposium 11:Macular Degeneration iiiModerators: Carl C. Awh, MD and Trexler T. Topping, MD


8:20 AMresults from the PDex and luceDexProspective randomized Pilot studies for eyes with neovascular aMD

Tushar M. Ranchod, MD (Walnut Creek, CA), Subhransu K. Ray, MD, PhD, Stewart A. Daniels, MD, Craig J. Leong, MD, Daniel Ting, MD, PhD, Allen Z. Verne, MD

PurPose The PDex study compared monthly intra vitrealranibizumab to triple therapy utilizing intra vitreal ranibizumab,reduced-fluence photodynamic therapy (PDT) and intra vitrealdexamethasone. The LuceDex study compared intra vitrealranibizumab to combination therapy employing intra vitrealranibizumab and intra vitreal dexamethasone.

MeTHoD PDex subjects were randomized between triple therapywith reduced-fluence PDT, ranibizumab and dexamethasone(Group I, therapy repeated on indication) and ranibizumabmonotherapy (Group II, 12 monthly injections). LuceDexsubjects were randomized between combination therapy withintra vitreal ranibizumab and dexamethasone (Group I) andintra vitreal ranibizumab monotherapy (Group II). All studyeyes received four monthly treatments followed by monthlytreatment on indication. Primary outcomes in both studies were safety and ETDRS best-refracted visual acuity.

resulTs A total of 60 patients were enrolled in the PDex studyand 40 patients in the LuceDex study. In the PDex study, eyesgained an average of 8.7 and 8.9 ETDRS letters in Groups I andII respectively at month 12. No more than zero ETDRS letterswere lost in 77% of Group I eyes and 71% of Group II eyes.Group I patients received an average of only 3.4 treatments byMonth 12, compared to the 12 treatments for Group II.

In the LuceDex study, eyes gained an average of 11.1 and 5.9ETDRS letters in Groups I and II respectively at month 12(p<0.23). No more than zero ETDRS letters were lost in 88% ofGroup I eyes and 70% of Group II eyes. The average number oftreatments per study eye by Month 12 was 7.1 in Group I and6.6 in Group II. None of the Group I vs. Group II outcomesreached statistical significance for either study.

conclusion PDex and LuceDex demonstrated safety and non-inferiority of combination therapies compared to ranibizumabmonotherapy. The PDex study demonstrated non-inferiority invisual and anatomical outcomes utilizing triple therapy with areduction in total treatments. The LuceDex study suggestedthat serial intra vitreal dexamethasone injections may be safewith a trend towards better visual outcomes.

8:28 AMTreat and extend Dosing Has fewersubmacular Hemorrhages and Better visualacuity in neovascular aMD Treated withranibizumab compared to Prn Dosing

John H. Niffenegger, MD (Sarasota, FL), Keye L. Wong, MD

PurPose This retrospective study investigated the frequency ofsubmacular hemorrhage in eyes treated with ranibizumab whengiven Treat and Extend dosing compared with PRN dosing(treatment as needed). Secondary outcomes were the effect ofhemorrhage and dosing on visual acuity, the average number ofexaminations and injections, and the occurrence complications.

MeTHoD In this consecutive retrospective case series all patients age 50 years or older with a diagnosis of neovascularage-related macular degeneration (AMD) and treatment in2008 with ranibizumab were identified. Eyes with activeprimary or recurrent neovascular AMD were reviewed. In Treatand Extend, the interval of treatment was increased one to twoweeks if the eye was dry on OCT, there was no new blood andno visual acuity loss. In PRN, treatment was given if there wasevidence of progression, fluid, hemorrhage or drop in vision.Treat and Extend was compared to PRN dosing. Snellen Acuitywas converted to LogMAR for analysis. Eyes given combinationtreatment were excluded.

resulTs 462 patients were identified (average follow-up 1.9years). Submacular hemorrhage was less frequent in the Treatand Extend eyes (2.6%) compared to PRN (6.7%) at year oneand at year 2 (2.9% and 11.8% respectively).

Average visual acuity was less affected by submacular hemor-rhage in the Treat and Extend eyes compared the PRN eyes.The 5 Treat and Extend eyes suffering hemorrhage in year 2were stable at 2 years follow-up compared to baseline. The 20PRN eyes developing a hemorrhage in year 2 lost 1.9 lines onaverage. Treat and Extend naïve eyes had greater improvementin average visual acuity (2.6 lines) compared to PRN (1.1lines). The mean number of examinations was greater in Treatand Extend eyes (7.7) compared to the PRN eyes (5.6) in year2. Treatment was more frequent in the Treat and Extend eyes inthe second year with 7.4 treatments compared 2.8 in the PRNeyes. Endophthalmitis occurred in 0.88 cases per 1000 injec-tions per year. One eye had a retinal break.

conclusion Treat and Extend dosing yielded fewer submacularhemorrhages and better visual acuity results in eyes withneovascular AMD treated with ranibizumab compared to eyesgiven PRN dosing. Complications of endophthalmitis andretinal break were rare.


Macular DegeneraTion iii 8:20–10:10 AM11


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8:36 AMalternating Bi-monthly intravitrealranibizumab and Bevacizumab for refractory exudative aMD

Andre J. Witkin, MD (Phildelphia, PA), Sunir J. Garg, MD*, Joseph I. Maguire, MD*, Richard S. Kaiser, MD*, Jason Hsu, MD, James F. Vander, MD, Allen Ho, MD*

PurPose To describe visual acuity and optical coherencetomography (OCT) results of an eight week series of alternatingbi-monthly ranibizumab/bevacizumab intra vitreal injections in patients with refractory exudative age-related macular degeneration (AMD)

MeTHoD Study Design: Retrospective interventional case series.Patients included had exudative AMD with no change in visualacuity along with persistent macular fluid despite at least 6monthly injections of either ranibizumab or bevacizumab. Thesepatients started receiving bi-monthly alternating ranibizumab/bevacizumab intra vitreal injections; four injections were givenover 8 weeks in all patients. Snellen visual acuity (converted tologMAR), central foveal thickness, and central foveal choroidalneovascular (CNV) thicknesses were recorded at each visit.

resulTs Nineteen eyes of 19 patients were included in thestudy. Patients had previously received a mean of 22 (range 11 to 41) intra vitreal injections of anti-VEGF medications. Atenrollment, mean visual acuity was logMAR 0.642 (Snellen20/88), mean central foveal thickness was 186 µm, and meancentral foveal CNV thickness was 448 µm. After 8 weeks of bi-monthly anti-VEGF injections, mean visual acuity significantlyimproved to logMAR 0.505 (Snellen 20/64) (p = 0.001). Meancentral foveal thickness decreased to 164 µm (p = 0.08), andmean central foveal CNV thickness significantly decreased to378 µm (p = 0.02).

conclusion An eight week series of bi-monthly intra vitrealanti-VEGF therapy in patients who have no visual acuityimprovement with the standard monthly regimen can improvevisual acuity, and this regimen should be considered for patientswith refractory exudative AMD.

OCT images from patient #13.Images are from time ofenrollment, and from 1 and 2months after starting bi-weeklyinjections. All images arehorizontal images through thefovea, taken with the Zeiss CirrusSDOCT. Note complete resolutionafter 2 months of hyporeflectivefluid causing a large pigmentepithelial detachment at thetime of enrollment.

8:44 AMDiscussion

8:50 AMvitreomacular adhesion is not a further risk factor for aMDEmilia Maggio, MD (Negrar, Italy), Antonio Polito, MD, Andrea Giani, Barbara Parolini, MD, Grazia Pertile, MD

PurPose To evaluate the role of abnormal and persistent vitreo-macular adhesion (VMA) in the pathogenesis of age-relatedmacular degeneration (AMD) and in the response to anti-vascular endothelial growth factor (anti-VEGF) therapy.

MeTHoD A total of 200 eyes with neovascular AMD, 198 with nonexudative AMD and 203 included as control groupwere examined with Spectral Domain scanning laser ophthal -moscope and optical coherence tomography. All patients were studied to identify the presence of VMA. Main outcomemeasures were the number of eyes with posterior vitreousdetachment (PVD), vitreomacular traction (VMT), andpersistent vitreomacular adhesion to the macula with a non-tractional configuration (VMANT). Together the VMANTand VMT subgroups formed the VMA group. Characteristics of the vitreoretinal interface in eyes affected by neovascularAMD exhibiting a resistance to therapy with anti-VEGF werecarefully evaluated.

resulTs VMA was present in 59 (29,5 %) eyes with neovas-cular AMD, 52 (26,2%) with nonexudative AMD and in 66(32,5 %) control eyes. VMT was present in 6 (3 %) eyes withneovascular AMD, 5 (2,5%) with nonexudative AMD and in 7 (3,4 %) control eyes. In the group affected by neovascularAMD, eyes with VMA have not been found to have a differentresponse to anti-VEGF therapy.

conclusion Eyes with AMD do not exhibit a higher prevalenceof vitreoretinal interface abnormalities compared to eldernormal eyes. The results of the study suggest that persistentVMA may not have a role in the pathogenesis of neovascularAMD nor in the resistance to anti-VEGF therapy. Surgicallyinduced PVD is not a sufficiently supported strategy for thetreatment of the disease.

8:58 AMsimple estimation of clinically-relevant lesion volumes using sD-ocT in neovascular aMD

Alexander C. Walsh, MD* (Los Angeles, CA), Yanling Ouyang, Srinivas R. Sadda, MD*, Florian Heussen

PurPose To evaluate simple methods of estimating the volumeof clinically-relevant features such as cystoid macular edema(CME), subretinal fluid (SRF) and pigment epithelial detach-ments (PED) using spectral domain OCT (SD-OCT) inneovascular AMD (NVAMD).

MeTHoD Cases with CME, SRF or PEDs were randomly selectedfrom a database of NVAMD patients imaged with macular cubeSD-OCT scans over a 3 year period. A cross-sectional analysiswas performed for single visits while patients with 3 or morefollow-up visits were analyzed in a longitudinal analysis (LA)group. The volume of each feature (CME, SRF, PED) wasmeasured by manually outlining them on OCT B-scans usingcustom software. Simplified measurements were made byestimating the maximum height of each feature as well as the # of B-scans and A-scans involved by each feature. Themanually-measured volumes were correlated with the simplifiedmeasures and automated measurements from the OCTmachines.

resulTs A total of forty-five visits for 25 patients were includedin this study. The CSA group was comprised of 26 scans from26 eyes of 25 patients and the LA group had 24 scans from 5eyes of 5 patients. Table 1 shows the correlations betweenmanual grading and the simplified and automated measure-ments. In the CSA group, the single simplified measures thatcorrelated best with manual grading were maximum lesionheight for CME and SRF(r2 values of 0.95 and 0.86) and B-scan count for PED volume (r2 value =0.79). In the LA group,B-scan count correlated well with SRF volume (r2=0.97) while maximum height correlated with CME and PED volume(r2=0.98 and 0.43 respectively). The sensitivity and specificityfor detection of changes in these features was also much higherfor simplified measures than for the automated measurementsproduced by the OCT machines (Table 2).

conclusion These data suggest that simplified estimators ofSRF, CME and PED volumes from SD-OCT images exist incases of NVAMD and are accessible for use by clinicianswithout the need for specialized software or time-consumingmanual segmentation. These simple approaches could enhancequantitative disease monitoring strategies in clinical trials andclinical management of patients being treated for NVAMD.

Table 1: Correlation between manual volumetric grading and bothsimplified and automated measurements for both the CSA and LA groups. Correlations shown are r-squared values.

Table 2. Sensitivity and specificity values for detection of changes in SRF and CME values using simplified measurements (left half) and automated measurements (FCS and MV shown in right half).

9:06 AMPearl study: continuous Monthlyranibizumab injections for Polypoidalchoroidal vasculopathy with active exudation or Bleeding (1 year results)

Raymond Wee, MD (Aiea, HI), Gregg T. Kokame, MD*, MMM, James C. Lai, MD, Ling Yeung, MD, Kyla Teramoto, MD

PurPose What is the short-term efficacy and safety of monthly intra vitreal injections of ranibizumab in patients with polypoidal choroidal vasculopathy?

MeTHoD Prospective, open-label trial of monthly intra vitrealranibizumab (0.5 mg) injections for PCV in 13 eyes of 13patients. Primary outcome measure was stabilization of vision(<15 ETDRS letters lost) after 12 monhs. Secondary outcomemeasures included incidence of ocular and systemic adverseevents, and changes in subretinal hemorrhage, central fovealthickness, and polypoidal complexes on ICG angiography after12 months.




61

resulTs Mean VA at baseline was Snellen 20/100 with amedian Snellen 20/80. Baseline findings included 9/13 eyes wihsubretinal fluid (69%), 6/13 eyes with RPED (46%), and 7/13eyes with subretinal exudates (54%). 5/13 eyes (38%) presentedwith significant macular edema, as defined as central fovealthickness on OCT greater than 250 microns. No patient lost>15 letters at 6 or 12 months. Mean VA at 12 months wasSnellen 20/63 with a median of Snellen 20/63. 3/13 eyes (23%)gained 15 letters, 11/13 eyes (85%) gained 5 or more letters,1/13 eyes (8%) remained unchanged, and 1/13 eyes (8%) lost<5 letters. Subretinal fluid decreased in 2/9 eyes (22%),resolved in 4/9 eyes (44%) and increased in 3/9 eyes (33%).Subretinal hemorrhage resolved in 9/9 eyes (100%). Polypoidalcomplexes decreased in 5/13 eyes (38%), remained unchangedin 4/13 eyes (31%), and increased in 4/13 eyes (31%).

conclusion Continuous monthly intra vitreal ranibizumab issafe and well tolerated in eyes with PCV. Twelve month resultsshow stabilization of vision, complete resolution of subretinalhemorrhage, and resolution of macular edema. Polypoidallesions decreased in 5/13 (38%) eyes, but branching choroidalvessels persisted. Further investigation with high-doseranibizumab or combination with PDT is indicated.

9:14 AMraPTraP: reduction by intravitrealBevacizumab Preceding Thermal laser Photocoagulation for retinal angiomatous Proliferation

Susan M. Malinowski, MD (Southfield, MI), Felise M. Barte, MD, Michael D. Ober, MD*

PurPose To report our experience with the RAPTraP protocol(Reduction by intra vitreal bevacizumab preceding thermallaser photo coagulation) for the treatment of retinalangiomatous proliferation (RAP).

MeTHoD This is a retrospective analysis of vision and anatomicresponses of patients with newly diagnosed, untreated RAPtreated with RAPTraP therapy – a novel combination of oneintra vitreal bevacizumab injection followed by one session oflaser photocoagulation. A bevacizumab injection (1.25mg) wasgiven within 2 weeks of diagnosis. Imaging was repeated within3 weeks after injection and thermal laser was applied. Allpatients had a minimum 1year follow up.

resulTs Thirty three lesions of 26 patients received oneRAPTraP treatment. Intravitreal bevacizumab was given anaverage of 8.8 days (range: 0-41d) following initial diagnosis.Laser ablation was performed an average of 3.4 weeks (range:1.7-8weeks) following bevacizumab injection. Average followup was 20.3 months (12.2mo-44mo). Twenty lesions (60%)remained inactive with only a single treatment. Thirteenlesions recurred after an average of 10.7 months. Ten of the

13 (77%) became inactive after an average of 9.4 monthsfollowing additional retreatment. For all patients, mean bestvisual acuity of 20/70 improved to 20/60. Overall, 91% of allpatients had an improvement or stabilization in vision. Meancentral OCT thickness decreased from 290 ± 80um to 220 ±55um in all patients (p<0.001). There were no complicationsrelated to injections or laser treatments.

conclusion RAPTraP treatment appears to offer long termanatomic and visual stability utilizing a less intrusive, non-repetitive and more cost effective method of treating RAP. Ourresults suggest additional controlled studies are warranted tofurther evaluate this new technique

9:22 AMDiscussion

9:30 AMintravitreal Tnf-alpha inhibitors for refractoryneovascular aMD: a Pilot study from the Pan american collaborative retina study(Pacores) group

Lihteh Wu, MD (San Jose, Costa Rica), J. Fernando Arevalo, MD, Erick Hernandez-Bogantes, Caio V.S. Regatieri, Jose A. Roca, MD, Michel Eid Farah, MD, PhD

PurPose To report the short term visual and anatomicoutcomes following intra vitreal injections of 2 different tissuenecrosis factor (TNF) α inhibitors in eyes with choroidalneovascularization (CNV) secondary to age-related maculardegeneration (AMD) refractory to anti-VEGF agents.

MeTHoD A multicenter retrospective interventional case series of 20 eyes with refractory CNV that were injected withadalimumab (n=4 for 2 mg) or infliximab (n=8 for 1 mg; n=8for 2 mg). The main outcome measures were the best correctedvisual acuity (BCVA) and the central macular thickness(CMT) at 3 months of follow-up.

resulTs The mean log MAR BCVA changed from 1.04 ± 0.23at baseline to 1.06 ± 0.51 at 3 months (p=0.9375) in the 1mginfliximab group; 0.94 ± 0.48 at baseline to 0.85 ± 0.43 in the 2 mg infliximab group (p=0.4375) and 1.58 ± 0.50 at baselineto 1.38 ± 0.43 in the adalimumab group (p=0.500). The meanCMT changed from 387 ± 54 µm at baseline to 342 ± 108 µm(p=0.2898) in the 1mg infliximab group; 301 ± 42 µm atbaseline to 284 ± 73 µm (p=0.7548) in the 2 mg infliximabgroup and remained unchanged at 348 ± 106 µm (p=0.308) inthe adalimumab group. Adverse events included uveitis in37.5% (6/16) of eyes injected with infliximab.

conclusion Intravitreal infliximab and adalimumab do notappear to benefit eyes with refractory CNV secondary to AMD.Intravitreal injections of infliximab may elicit a severeintraocular inflammatory reaction.

9:38 AMnew Developments in information DisplayTechnology and reading Performance in Patients with aMD

Mark S. Blumenkranz, MD (Palo Alto, CA), Anne E. Fung, MD, Daniel Palanker, Neil Friedman, MD, Patrick Coady, MD

PurPose There is a need to quantify the effects of maculardisease on reading performance, compared to conventionalprinted materials. We studied the relationship between standardETDRS visual acuity (VA) and various other tests of near visualfunction with standard printed materials and compared themwith a specialized back-illuminated liquid crystal display (LCD)in patients with macular disease.

MeTHoD Thirty consecutive patients with macular disease andvision better than 20/400 and 20 normal controls were recruited.Their distance visual acuity was measured in both eyes withETDRS letter charts at 4 meters. Near vision was measuredwith both a Rosenbaum Card and a specially programmedvision test on an iPhone at a distance of 14”. Both near visiontests were performed using the patient’s current correction.Statistical methods were employed to compare various measuresof visual function.

resulTs Distance vision correlated with the near card at thelevel r=0.83, and the LCD near screen displaying black fonts on white background correlated well (r=0.89) with the printedcard. In evaluating the accuracy of the backlit near test, 45% of eyes were within 0.1 LogMar and 70% of eyes within 0.2LogMar of the distance vision measured by ETDRS chart. Thenear test overestimated in all eyes outside 0.2 LogMar of theETDRS chart. Reading inverted letters (white letters on blackscreen) on the LCD screen provided results closer to theETDRS chart - (55% within 0.1 LogMar and 76% within 0.2LogMar). Decreases in contrast sensitivity at near were detectedin eyes with more advanced macular disease, particularly thosewith less than 20/40, with changes of dark letters on lightbackground being more discriminant than light letters on blackbackground. In addition, there was a tendency for decreased VAwith blue fonts, compared to red fonts.

conclusion Measurement of near visual acuity appears to be aviable alternative or supplement to ETDRS distance vision inpatients with macular disease. The psycho-physics of computerscreens may be impactful in assessing treatment outcomes andin optimizing digital reading devices. More frequent testing mayfacilitate greater individualization of treatment regimens withanti VEGF agents.

9:46 AMThe use of a flash recovery Testing Device to Differentiate Between Patients With or Without Macular Disease

Daniel B. Roth, MD* (Lakewood, NJ), Anmol Gupta, MD, Ankit Shah, MD, Howard F. Fine, MD, Jonathan L. Prenner, MD*, William J. Feuer

PurPose Flash recovery testing is a semi-objective test formacular function, as macular disease can prolong recovery time.A novel hand-held device, named the macular adaptometer,was used to determine whether flash recovery testing canprovide a useful indicator of macular health and disease.

MeTHoD Flash recovery testing after a bright flash wasperformed on 481 eyes in 275 patients. Information regardingvisual acuity, intraocular pressure, ocular diagnosis, medicalhistory, history of glaucoma or retinal detachment, smoking andalcohol use, use of eyedrops, use of glasses for distance, difficultywith dark adaptation, was also collected. Linear regressionanalyses were performed to determine statistically significantcorrelations between recovery time and variables such as age,visual acuity, and IOP. One-sided t-test was used to determinewhether any of the variables or diseased states was associatedwith a statistically significant prolonged recovery time.

resulTs Normal subjects’ mean recovery time was 9.8 seconds(±5.8 SD). After controlling for visual acuity, subjects with dryAMD (n=67) had a mean recovery time of 15.4 seconds (± 11.9SD) and subjects with wet AMD (n=63) had a mean recoverytime of 20.6 seconds (±12.3 SD), which was significantlydifferent than normal (p<0.001). Other diagnoses associatedwith lengthened recovery times included proliferative diabeticretinopathy (p=.015), diabetic macular edema (p=.032), cystoidmacular edema (p=.022), and epiretinal membrane (p=.020).Drusen alone or nonproliferative diabetic retinopathy did notprolong recovery times (p>0.05). Statistically significant correlations were observed between recovery time and age(r=0.27, p<0.001), logMAR visual acuity (r=.030, p<0.001),and logMAR near visual acuity (r=0.37, p<0.001). Amongmedical and eye history variables, only COPD appeared to beassociated with a longer recovery time (p=.017).

conclusion Flash recovery testing with the macularadaptometer may be an effective and inexpensive method to identify patients with macular disease in a primary caresetting, by screening for a prolonged recovery time after a bright flash.




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9:54 AMa community-based survey of genetic risk for advanced aMD: implications for sight-preserving Practice guidelines

Carl C. Awh, MD (Nashville, TN)

PurPose The genetic risk for AMD measured in a large group ofretina and general eye care patients may differ from that knownfor the general population. If these differences correlate withclinical staging, it may provide further support for the use ofgenetic testing to better identify patients at risk and to guideindividual management strategies.

MeTHoD Retrospective review of 1074 pts tested from 10/2010to 02/2011 (final results will be include additional 1000+ pts)with MaculaRisk obtained from retina, and general eye care practices. All were age > 65 and signed informed consent.We surveyed validated genetic risk factors. These includedCom plement Factor H haplotype markers(1) (rs1048663,rs412852, rs3766405, rs11582939, rs1066420), the ARMS2insertion/deletion polymorphism(2) NM_001099667.1:c.**372_815del443ins54), the mitochondrial A4917Gpolymorphism(3) (rs28357980), complement factor 3(4)(rs2230199) and hx of smoking(5). Genotype and smoking hx were used to stratify patients into one of 5 risk categories.

resulTs Individuals were Caucasian (92%), African American(3.8%), Asian (0.5%) and Latino (2.6%). Clinical distributionwas: AREDS cat 1 (4.4%), AREDS cat 2 (66%), AREDScategory 3” (21%), AREDS category 4a, 4b” (6.6%), and“unknown” (2.1%). Smoking history was: “never” (55%), “quit” (37%), and “current” (8%). Using an algorithm tostratify observed genetic AMD risk we compared this topredicted population average genetic risk based on the knownfrequency of risk alleles in populations of northern Europeanancestry using HapMap frequency data. There was a displace -ment of risk scores toward higher levels in our study set. Only37% of our population fell into the lowest 50% of population-predicted risk (a reduction of 26%) and 31.8% of study individualfell into the highest 20% of predicted risk (a 66.5% increase).Among individuals with AREDS cat 3 and 4 AMD, the averagegenetic risk exceeded average population risk, although someindividuals were found to have lower than average genetic risk.

conclusion Although individuals with advanced AMD mayhave variable degrees of genetic risk, the average genetic risk for this group of patients is higher than normal. The ability tocorrelate clinical findings with genetic risk for advanced AMDmay lead to individualized management strategies and anoverall reduction in vision loss.

10:02 AMDiscussion


10:35 AM-12:00 pM

Symposium 12:vitreoretinal Surgery iiiModerators: G. Philip Matthews, MD and Paul E. Tornambe, MD


10:35 AMPerformance of a Modified vitrectomy Probe in small gauge (g) vitrectomy: an experimental and clinical study

Stanislao Rizzo, MD (Pisa, Italy), Michele Palla, MD, Federica Genovesi-Ebert, MD,Gualtiero Fantoni, MD, Jonathan Ciampi, MD, Giovanni Vozzi, MD

PurPose 25 and 23 gauge new generation vitrectors of 2 majorfactories have been modified in order to improve their effec-tiveness The performance of all modified probes were comparedin vitro and in vivo with the corresponding commerciallyavailable ones. The study was performed in collaboration withthe Engineering Department of Pisa University without anycommercial research support.

MeTHoD Changes carried out concerned only the cutters, machinesand softwares were not involved. In the experimental studymain outcome measures were evaluation of flow/minute andprobe strength. Vitrectomy systems were set at fixed parameters(5000 cuts/min, 650-600 mmHg vacuum) and every pair of probes(standard vs modified) were compare analyzing: time taken toaspire 10 cc of BSS. To test strength, cutters were inspectedunder the microscope, after 120 minutes of work. to check wearand tear. Clinically, we compared standard and modified 25 an 23 gauge cutters during vitreoretinal surgery (40 cases) byevaluating vitrectomy time, and incidence of complications.

resulTs In vitro all modified cutters showed a significantincrease of the flow/min in comparison with the standard probes.Both in modified 23 and 25 gauge probes the aspiration time of 10 cc of BSS were significantly reduced in comparison withstandard ones, about 50% less dealing with both the brands.Standard 23 gauge needed 44 seconds (sec) vs modified 23-g 25 sec (P<.0001). Standard 25 gauge took 70 seconds (sec) vsmodified 25-g 44 sec (P<.0001).No damage to the probes wasshown. In vivo we evaluated during the surgery vitrectomy times that were respectively: with standard 25 g (10 cases) 764seconds ± 200 vs modified 25.g (10 cases) 512 ±190; withStandard 23 g (10 cases): 711 seconds ± 230 vs modified 23.g(10 cases) 490 ±190. No intraoperative complications occurredin both groups.

conclusion Dealing with the modified cutters we achieved asmall gauge vitrectome with a greater suction power but asimilar safety in comparison with the standard models. How -ever, whether improved performance characteristics will resultin improved clinical results , will require additional study andclinical correlation.

10:43 AMa new Dual Port vitreous cutter for vitrectomy surgery

Luiz H. Lima, MD (Sau Paulo, Brazil), Charles DeBoer, Prashant Bhadri, MD, Matthew McCormick, MD, Ralph Kerns, MD, Mark S. Humayun, MD, PhD*

PurPose To evaluate and compare the performance of severaldesigns of dual port (DP) vitreous cutter tips with a standardsingle port (SP) tip.

MeTHoD In a pilot study, five designed and fabricated 20-gaugepneumatic vitreous DP cutter tips with different sizes and portpositions (180 degrees 0.0125 DP, same-side up 0.020 DP, 180degrees 0.024 DP, 180 degrees up 0.020 DP, and 180 degrees0.020 DP) were compared with a normal SP control tip andevaluated by the measurement of water and porcine vitreousflow rates, and surgical examination in enucleated porcine eyes.With each cutter, five trials were performed at 1,500 cuts perminute (CPM) at vacuum levels of 100, 200, 300, 400, and 550 mmHg.

resulTs For instruments tested in water at 1,500 CPM, the 180 degrees 0.024 DP, 180 degrees 0.020 DP, 180 degrees 0.0125DP, 180 degrees up 0.020, and same-side up 0.020 DP tips hadhigher flow rates than those of the 180 degrees 0.016 DP, 180degrees 0.006 DP, and SP tips at 1,500 CPM for all testedvacuum levels (P<0.05). For vitreous flow rate performed at1,500 CPM, the 180 degrees 0.024 DP tip had the best per -formance at vacuum levels of 100, 200, 300, and 400 mmHg,and the 180 degrees 0.020 DP tip had the highest vitreous flowat 550 mmHg of vacuum (P<0.05). The 180 degrees 0.006 DPand same-side up 0.020 DP tips had the lowest vitreous flowrates at all vacuum levels (P<0.05). With reference to surgicalevaluation, most of surgeons (90%) classified the 180 degrees0.020 DP and 180 degrees 0.024 DP tips as better than SP tipfor bulk vitreous removal. The SP tip was considered by allsurgeons to perform better than the DP tips for shaving thevitreous base.

conclusion The DP cutter system has the potential to increasethe flow rates depending on the size and position of the extraport. In the future, the DP cutter may allow the surgeon toperform bulk vitrectomy more efficiently.


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The five study tips along with a control tip.

Vitreous flow rates of the tested DP and SP tips operated at 1,500CPM and various vacuum pressures with a 20-gauge Accurus hand -piece. Each bar represents five trials performed for that cutter tip.

10:51 AMflow-controlled vitrectomy

Keith A. Warren, MD* (Overland Park, KS)

PurPose To determine the safety and efficacy of flow-controlledvitrectomy surgery compared to standard vacuum basedvitrectomy.

MeTHoD : Thirty-six consecutive eyes (36) with a wide varietyof retinal pathology underwent surgery using either a venturivacuum based (V) or peristaltic pump based (P) vitrectomy unit.Twenty (20) patients had surgery using the venturi vacuumsystem (V) (ALCON), and sixteen (16) patients had surgeryusing a peristaltic pump system (P) (DORC). All patients were pretreated with a fourth generation flouroquinolone andthen underwent the standard three port vitrectomy. Patientswere followed for a minimum of six (6) weeks and outcomesevaluated included: Length of surgery, incidence of retinabreaks, need for hand-held instruments and complications.

resulTs No difficulty with completion of surgery was encoun-tered using either system. The average time of vitrectomy was32.6 minutes for the (V) group and 32.9 minutes for the (P)group. Five (5) inadvertent intra-operative retinal breaksoccurred in the (V) group (0.25breaks/case) and three (3)inadvertent intra-operative breaks occurred in the (P) group(0.187 breaks/case). The use of hand instruments was requiredin both groups, but only for membrane peeling in macula cases.Dissection of fibrovascular tissue was successfully accomplishedin both groups using the vitrectomy handpiece alone. However,the cutter speed was able to be greatly reduced in the (P) group (1000cpm) without causing an inadvertent break or asubjective change in the retinal mobility. No attempt was madeto reduce the cutter speed using the (V) system, because ofretinal stability due to flow concerns. Post-operative complica-tions occurred in 3 of 20 eyes in the (V) group and 2 of 16 eyesin the (P) group.

conclusion Both vitrectomy systems provide for theperformance of safe retinal surgery. There was no statisticaldifference noted in operative time, retinal tears or post-operative complications. The peristaltic (P) group allowed for agreater range of cut rates without an increase in complications.The peristaltic system may allow for greater utility and flexi-bility and warrants further investigation.

10:59 AMslow Motion videography analysis of Pars Plana lensectomy

Kirk H. Packo, MD* (Chicago, IL), David Buboltz, Dina Joy K. Abulon, Aditi Ray, MD

PurPose Both ultrasonic fragmentation and vitrectomy probelens removal begin by aspiration of lens to the port, followed byeither cavitation or sectioning into small pieces. Flow decreasesbut surges occur when the port is not occluded (occlusion break).Dangerous swings in intraocular pressure (IOP) and flow canoccur. This study compares the maneuvers with suggestions forthe safest parameters.

MeTHoD Pig eyes were microwaved to create cortical cataracts.Following vitrectomy, the cataract was dislocated with either 23 ga or 25+ ga UltraVit® vitrectomy probes from the Constellation® Vision System (Alcon Surgical, Ft. Worth, TX).Transducers and flow sensors measured IOP and flow rates.Lensectomies were performed with 20 ga ultrasonic fragmentors(frag) at various powers, vacuums, and pulse modes, or with 23ga and 25+ ga vitrectomy probes at various vacuums and cutrates. Slow motion videography using the Phantom v210 highspeed digital camera (Vision Research, Inc., Wayne, NJ) at1000 fps was synchronized with the fluidic data, and analyzedduring the occlusion break (OB).

resulTs When lens material occludes the port of any instru ment(frag or vit probe), the flow consistently decreases while IOPrises. When lens material no longer occludes the port (duringOB), flow into the port quickly rises and IOP drops. Themaximum IOP swing seen during OB was 55 mm Hg. Swings inIOP & flow were the greatest using the frag, and least with the25+ vit probe. More stable IOP and flow is consistently seenusing vit probes compared to the frag. High cut rates providedthe most stable fluidics, while still allowing easy lens removal.Low cut rates were not needed, and in fact gave greater fluidsurges and IOP swings with each OB. The acoustic waveemanating from the frag was also recorded while inducingcavitation in gelatin cubes and seen to move forward from thetip but also laterally from the shaft. This contributes to materialbeing shattered forward, away from the frag tip during operation.

conclusion In contrast to removing vitreous, removing lensmaterial results in large swings in flow and IOP, with moreunstable fluidics. 20 ga frag removal can give dangerous surgesin fluid following the occlusion break. Removal of lens materialwith small gauge vitrectomy probes allows more fluidic stability.Changing to low cut rates for lens is not needed, and createsgreater fluid surges.

Laboratory set up for porcine vitrectomy-lensectomy withcontinuous IOP and flow data using “LabView” digital recorders,synchronized with Phantom high speed videography at 1,000frames per second (fps).

Still capture images of 20 fragmentor, 25 ga Ultravit vitrectomyprobe and 23 ga Ultravit vitrectomy probe at the point of theocclusion break (when lens material no longer occludes the port).

11:07 AMDiscussion

11:15 AMThe current role of scissors in DiabeticTraction retinal Detachment surgery

Steve T. Charles, MD* (Memphis, TN)

PurPose Many anecdotal reports have suggested that highercutting rates (5000 cuts/minute), ports closer to the tip, smallerdiameter cutters (25 gauge) and technique evolution haveeliminated the need for scissors in diabetic traction retinaldetachment surgery. The purpose of this study was to determineif scissors are still necessary and if so the optimal scissors configuration and technique.

MeTHoD Observational, single surgeon series encompassing 35 years of diabetic traction retinal surgery (2000 total cases),eight years (400 cases) using 25 gauge sutureless surgery (AlconAccurus, later Constellation vitrectomy system), 15 years exclu-sively using curved scissors (Alcon 25 gauge DSP) instead ofhorizontal or vertical scissors and 15 years of using endophoto-coagulation instead of diathermy for hemostasis.

resulTs foldback cutter delamination and cutter segmentationbetween epicenters was effective for non-tabletop TRDs withless rigid epiretinal membrane (ERM), 2. conformal cutterdelamination was necessary for rigid ERM, 3. delamination withcurved 25G scissors was the best approach for tabletop TRDs,especially with rigid ERM combined with thin, atrophic retina.Curved scissors were found to be more effective than vertical or horizontal scissors for both segmentation and delaminationbecause they conformed to the curvature of the retina and blade thickness is less than blade width making insertion in the potential space between ERM and retina safer.

conclusion Higher cutting rates (5000 cuts/minute), portscloser to the tip, and smaller diameter cutters (25 gauge) havereduced the need for scissors in diabetic TRD surgery butscissors are required for most tabletop TRDs. It was found thatcurved scissors were more effective than vertical or horizontaland endophotocoagulation was better than diathermy forhemostasis.


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11:23 AMDoes suturing of 23-gauge sclerotomiesreduce Post-operative vitreous Hemorrhage in Diabetic vitrectomy?

G. Baker Hubbard, MD (Atlanta, GA), Leon O. Charkoudian, MD

PurPose To determine if suturing 23-gauge sclerotomies reducesthe rate of significant post-operative VH in diabetic patients.To explore associations between post-operative VH and othervariables including pre-operative bevacizumab use, intra-operative membrane dissection, post-operative hypotony, and surgeon.

MeTHoD Retrospective chart review. All patients undergoing23-gauge vitrectomy at The Emory Eye Center for PDR wereidentified from September 2009 through March 2011. Forsutured sclerotomies, a single interrupted polyglactin or plaingut suture was placed trans-conjunctivally though all wounds.The primary outcome was the presence or absence of significantVH at the one-month (28-41 day) post-operative visit. Signifi -cant VH was defined as obscuration of the posterior pole suchthat fundus details (cup/disc, 2nd order vessels) could not bedetermined.

resulTs Sixty-six cases met the study criteria. Overall, rates ofsignificant VH at the one-month post-operative visit were 24%in the sutured group and 24% in the unsutured group. Post-operative hypotony was rare (1 in 66 total cases; occurred in theunsutured group) and did not result in significant post-operativeVH. Rates varied slightly by surgeon. All cases of significantpost-operative VH (16 of 16) involved intra-operativemembrane dissection. One-third of all membrane dissectioncases resulted in significant post-operative VH (16 of 48). Pre-operative bevacizumab was associated with an increasedrelative risk of significant post-operative VH (RR = 1.9).

conclusion Suturing 23-gauge sclerotomies did not reduce therates of significant post-operative diabetic VH. Post-operativehypotony was rare. Intra-operative membrane dissection andpre-operative bevacizumab use were associated with increasedrisk of significant post-operative hemorrhage, though the latterlikely included selection bias.

11:31 AMDiscussion

11:35 AMPanel Discussion: Management of surgical complications: a Bad Day in the or – i Wish i Had stayed in BedModerator: Kirk H. Packo, MD*Panelists: Mark S. Blumenkranz, MD, Steve T. Charles, MD, Dean Eliott, MD, and G. Baker Hubbard, III, MD

12:00-1:20 pMlunch in exhibit HallHynes Convention Center, Hall D

12:00-5:30 pMgolf and Tennis TournamentsExact departure times and locations to be announced

1:30-5:45 pM

instructional coursesSheraton Boston Hotel, 2nd, 3rd and 5th Floors (various rooms)

1:30-2:30 pMThe Fens

Practical evidence-based Pearls in theDiagnosis and Management of endophthalmitis

Mallika Goyal, MD (Hyderabad, India)Alay Banker, MD, Pramod Bhende, MBBS, S. Natarajan, MD

synoPsis Clinical manifestations of endophthalmitis varydepending on the mode of infection and the virulence of theorganism. These and several other factors help personalize amanagement plan. Infection following intravitreal injectionshas clinical features different from that following cataractsurgery. Endogenous endophthalmitis is a clinical challenge thatrequires a high index of suspicion. Early diagnosis maybe aidedby Fundus Fluorescein Angiography that reveals characteristicchanges more dramatic and extensive than the lesions seenclinically. Culture of vitreous is negative in upto 40% cases.DNA chip analysis gives a higher rate of success and cancomplement conventional microbiology. Fungal endoph-thalmitis needs aggressive and prolonged therapy. Antifungalsof different groups may work synergistically, hence combinationof intravitreal antifungals maybe more effective than any singledrug. These and several other evidence-based pearls will bepresented and discussed.

eDucaTional oBJecTive To highlight: 1. Specifics in thediagnosis and management of endophthalmitis based on themode of infection and etiology. 2. Role of Fundus FluoresceinAngiography in the early diagnosis of endogenous endophthal -mitis. 3. DNA chip analysis in the identification of causativeorganism, specifically in culture-negative cases. 4. Efficacy ofprolonged combination therapy for fungal endophthalmitis.

1:30-2:30 pMPublic Garden

is endoscopic retinal surgery right for you?

Thomas Lee, MD (Los Angeles, CA)Victor Gonzalez, MD*Jeffrey S. Heier, MD*

synoPsis This workshop will present the advantages of endo -scopic retinal surgery and how it can be used in conjunctionwith a standard wide angle viewing system for retinal detach -ment surgery. The course will review the basic techniques withextensive use of surgical videos as well as a live demonstration

using a model eye. Specifically, we will demonstrate techniquesfor addressing anterior PVR, dislocated IOLs, endophthalmitis,cycltic membranes with hypotony, pediatric retinal detach-ments, and intraocular foreign bodies. In addition, we willdiscuss the potential for adding posterior endoscopic cyclopho-tocoagulation (ECP) to the management of glaucoma patientswith or without underlying retinal disease. The workshop willend with a panel discussion to present cases and addressaudience questions.

eDucaTional oBJecTive The goal of the course is to teach theaudience how to address complex retinal surgery using anendoscopic viewing system. We will review steps on how toachieve the best orientation and field of view as well as a review of the endoscopic literature.

1:30-2:30 pMFairfax

intraocular Tumors and Pseudotumors: rapid fire cases and clinical Pearls

Jerry A. Shields, MD (Philadelphia, PA)Carol L. Shields, MD

synoPsis The course will consist of rapid fire cases of intra -ocular lesions likely to be seen in a retinal practice. For eachcase, the instructors show a slide quickly and raise questionsabout diagnosis and management with active audience partici-pation. This is followed by a few quick teaching pearls. Thesequence will be repeated for each subsequent case. It is enter-taining, fun, and educational.

eDucaTional oBJecTive To update retinal specialists on new,interesting, and useful information about selected benign andmalignant tumors and pseudotumors of choroid, retina, RPE,and vitreous.

1:30-2:30 pMBack Bay B

enzymatic Management of symptomatic vitreomacular adhesion

Michael Trese, MD (Royal Oak, MI)*

synoPsis This course is directed toward the use of enzymaticagents to liquefy the vitreous gel centrally or to attempt to lysethe symptomatic vitreomacular adhesion. Different techniqueswill be described to maximize the enzymatic and mechanicaleffects including use of the quadraport needle. Enzymes such asOcriplasmin (microplasmin) and Plasmin will be discussed.


insTrucTional courses 1:30–5:45 PM

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eDucaTional oBJecTive The attendee will gain an under-standing of enzymatic manipulation of the vitreous and whydelivery is an important aspect of use of enzymatic agents in thevitreous cavity, timing of injections, and use as a primary oradjunctive therapy for symptomatic vitreomacular adhesion.

1:30-3:30 pMRepublic

retinaws: When the going gets Tough, the Tough get going, challenging cases in vitreoretinal surgery

Kourous Rezaei, MD (Harvey, IL)*Anna Gabrielian, MD

synoPsis Retina specialists often work in a “shark-infested”world. Unexpected events are a fact of life. Learning how “not to get bit” is an effective way to practice safely andefficiently. This course consists of video presentationsdescribing challenging cases and unexpected events duringretinal surgery. Faculty share their experience to predict, treat,and prevent unexpected outcomes during retinal detachmentsurgery, diabetic vitrectomy surgery, small gauge surgery, andcomplex vitreoretinal surgery. The pit falls associated with usingperfluorocarbon liquid, silicone oil, and various intraoculargases will be discussed.

eDucaTional oBJecTive Attendees will become familiar with avariety of complicated events during retinal surgery. They learnhow to predict, treat, and prevent unexpected events duringand after vitreoretrinal surgery.

1:30-3:30 pMCommonwealth

contemporary Management of retinal Detachment repair: Techniques,outcomes, and case studies

Gaurav Shah, MD (Jacksonville, FL)*Thomas Aaberg, MD, Kevin Blinder, MD,* Pravin Dugel, MD, Dean Eliott, MD, J. Jumper, MD, John Mason, MD, Robert Mittra, MD, Franco Recchia, MD, Asheesh Tewari, MD,

David Wong, MD, FRCS(C), Peter Stalmans, MD, PhD*

synoPsis This course will educate the attendee in applicationsof various retinal detachment repair techniques, includingscleral buckle, vitrectomy, and pneumatic retinopexy. State ofthe art techniques including small gauge surgery, complicationsand current outcome measures will be described and discussed.Pediatric retinal detachments will be discussed and manage -ment will be presented. Various cases of retinal detachment andmanagement with audience response system will be utilized togauge the changing nature of detachment repair. Audienceparticipation will be significant along with faculty interaction.

eDucaTional oBJecTive This course will educate the attendeein applications of various retinal detachment repair techniques,including scleral buckle, vitrectomy, and pneumatic retinopexy.State of the art techniques including small gauge surgery,complications and current outcome measures will be describedand discussed.

1:30-3:30 pM Constitution A

Moxie with the Masters

Paul Tornambe, MD (Poway, CA)*Gabriela Lopezcarasa Hernandez, MDCalvin Mein, MDKang Zhang, MD

synoPsis The purpose of this audience interactive course is topresent interesting cases, unknowns, or problems encountereddaily in the retina specialist’s practice for the group to discuss.The Masters are the audience, the case presenters are facilitators.

eDucaTional oBJecTive The goal of this course is to share inter-esting cases with fellow retina specialists for their opinions andmanagement. Most cases will have ‘take home’ messages and‘news you can use.’


scleral Tunneling Techniques for the vitreoretinal surgeon: 20-g sutureless vitrectomy and sutureless scleral Buckling surgery

Kanishka T. Jayasundera, MD (Ann Arbor, MI)John C. Chen, MD, FRCS(C), I. Galic, MD, FRCS(C), Mikael Sebag, MD

synoPsis This is an interactive session with surgical videos andpanel discussion on the pearls and pitfalls of scleral tunnelingtechniques for sutureless 20-gauge vitrectomy and suturelessscleral buckling surgery. Sutureless 20-gauge vitrectomy (stepsof technique:conjunctival peritomy, construction of tunneledsclerotomies, vitrectomy techniques, including removal ofintraocular foreign bodies, closure of sclerotomies and peritomy).Pearls and pitfalls of transconjuctival 20-gauge suturelessvitrectomy techniques will be discussed. Sutureless scleralbuckling (steps of technique: construction of scleral loops infour quadrants for scleral buckle placement, silicone sleeve fortying buckle, closure of peritomy). The additional steps ofcombined surgery (vitrectomy and scleral buckling, vitrectomyand phacoemusification) will be discussed.

eDucaTional oBJecTive To teach the techniques and advan-tages of scleral tunneling used for 20-G sutureless vitrectomyand sutureless scleral buckling surgery.

2:45-3:45 pMFairfax

Pneumatic retinopexy: Pearls and Pitfalls

Peter Kertes, MD, FRCS(C) (Toronto, ON)Robert Devenyi, MD, MBA, FRCS(C)*Wai-Ching Lam, MD, FRCS(C)Matthew Schlenker, MD

synoPsis This course will outline a simplified technique foroffice based pneumatic retinopexy, discuss clinical examinationtechniques and provide an approach to extended indications. In addition, management of complications will be discussedincluding: new/missed retinal breaks, persistent subretinal fluid,fish eggs, subretinal gas and prehyaloidal gas. Audience participation will be encouraged and a comprehensive handoutwill be provided.

eDucaTional oBJecTive At the conclusion of the course theparticipant will be able to identify appropriate patients for thistechnique, understand the fundamental principles necessary forsuccess of pneumatic retinopexy and manage subsequentcomplications.


electronic Health record – The Basics

Colin A. McCannel, MD* (Los Angeles, CA)

synoPsis The Health Information Technology for Economicand Clinical Health (HITECH) Act’s limited window in timeto obtain stimulus funds for adopting an Electronic HealthRecord (EHR) has created an atmosphere of haste andconfusion. A wide range of topics will be covered including:“meaningful use,” selection criteria that should be considered,possible impact on the practice and work flow, informationtechnology considerations and the importance of EHRstandards.

eDucaTional oBJecTive At the end of this course, the partici-pants will have a working knowledge of what the characteristicsof a good EHR might be, an understanding of the relativebenefits and disadvantages of various EHR technologies, andthe impact on a practices’ productivity and workflow. Theparticipants will also understand the key aspects of theHITECH Act and ‘meaningful use’.


Managing corneal opacities and Temporary Kerato-prosthesis surgery for vitreo-retinal surgeonShashi Ganti, MD, MBA (Fresno, CA),Dinesh Chawla, MD, Christopher Ta

synoPsis This Course may be complementary to AnteriorSegment Surgery Course. Didactic, technique and Wet lab willbe offered. Steps of Corneal trephining followed by placementof Landers Temporary non-disposable Keratoprosthesis andparsplana 23G Vitrectomy. Preparation of Donor button, treph-inition and Suturing the donor button on to the recipient afterremoval of the Temporary Keratoprosthesis with InterruptedSutures. Above steps will be discussed with video and didacticpresentation, followed by Wet lab. The level and depth ofdiscussion can be tailored to the degree of participants enthusiasm.

eDucaTional oBJecTive Understanding cornea and learnanterior segment surgery in case of emergency when we aremarooned in the OR. Knowledge of the steps of surgery andfinal outcome is expected of the participants at the conclusionof the course.

2:45-3:45 pMBack Bay A

icg imaging for the Diagnosis and Management of exudative aMD

Mark Nelson, MD (Winston-Salem, NC)*

synoPsis ICG videoangiography with concurrent spectral-domain OCT elucidates the choroidal origin of occult andclassic neovascularization. More importantly, it identifies anti-VEGF resistant lesions, namely arteriolarized neovascularizationand polypoidal vasculopathy, both of which are responsible forpatients who are classified as ‘anti-VEGF resistant’ and ‘anti-VEGF dependent’ during the course of anti-VEGFmonotherapy.

eDucaTional oBJecTive ICG imaging is critical for determiningthe presence of anti-VEGF resistant lesions and will be instru-mental in creating strategy for ‘anti-VEGF resistant’ and‘anti-VEGF dependent’ patients.



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3:45-5:45 pMBack Bay CD

anterior segment surgery for the vitreoretinal surgeon: Discussion and Wetlab

Carl C. Awh, MD* (Nashville, TN)

synoPsis A didactic and hands-on review of current techniquesand devices for cataract surgery, complications of cataractsurgery, and combined cataract-vitrectomy cases. Participantswill be able to perform surgery with state-of-the-art equipmentin a wetlab setting.

eDucaTional oBJecTive To educate vitreoretinal surgeons about current techniques for cataract and lens implant surgery,to better improve their ability to manage the complications ofcataract and related surgeries.

3:45-5:45 pMCommonwealth

asrs research and Development committeesymposium: clinical Trials “unplugged”: real, Practical Questions and answers

Pravin U. Dugel, MD* (Phoenix, AZ)David Boyer, MD*, David Brown, MD*, Jeffrey S. Heier, MD*,Allen Ho, MD*, Peter Kaiser, MD*, Dan Martin, MD,William Mieler, MD*, Timothy G. Murray, MD, MBA*,Guarav Shah, MD*, Michael Singer, MD*

synoPsis An unprecedented number of clinical trials willconclude this year. Synthesizing and comparing the data,planning for changes in practice patterns and predicting theeconomic implications will be both necessary and challenging.The purpose of this symposium is to go beyond the podiumpresentation. The PI will be questioned by respected expertsnot involved in the trial as well as by the audience.

eDucaTional oBJecTive 1. Judge the merits of each trial in anobjective and critical manner. 2. Ask the PI direct questionswith unparalleled access. 3. Prepare for the practice pattern andeconomic implications of each trial.

4:00-5:00 pMFairfax

Pathogenesis, imaging and Treatment of Dry aMD: 2011

Jaclyn Kovach, MD (Naples, FL)William Scott*Kimberly Stepien, MD

synoPsis Current knowledge of the pathogenesis of dry age-related macular degeneration (AMD) including known geneticassociations will be reviewed. Current and future treatmentoptions will be discussed in detail.

eDucaTional oBJecTive At the conclusion of this course, theparticipant will have an updated understanding of the patho-genesis of dry AMD, current imaging modalities, and emergingtreatment options.


eMr – How to choose the right one for you

Sanjay Logani, MD, MBA* (Northridge, CA)

synoPsis The government stimulus program for using EMR hasbegun. EMR has become a requirement for future healthcareservices but remains difficult to understand. Retina specialistsneed to know how to identify and implement EMR packagesthat meet stimulus requirements. We have over 9 years ofexperience in successfully using EMR in an ophthalmic multi-specialty, multi-location practice setting. The instructor intendsto discuss and inform attendees on what it will take to qualifyfor the full government incentive package. They will learn howto select an efficient and cost effective Ophthalmic EMRpackage. Instruction will cover: 1. Important selection criteriato evaluate Ophthalmic EMRs 2. Demonstrating meaningfuluse of an EMR for an Ophthalmic office 3. How to do a cost/benefit analysis of Ophthalmic EMR systems The instructor will discuss and inform attendees on what it will take to qualifyfor the full government incentive package.

eDucaTional oBJecTive 1. How to evaluate different EMRpackages. 2. How to select the right EMR for your practice. 3. How to avoid the wrong EMR for your practice. 4. When is the best time to buy EMR?


natural language Processing enables retina specialists to use eHr More effectively and efficiently

James Maisel, MD* (Hicksville, NY)

synoPsis Natural Language Processing (NLP) allows physiciansto dictate and convert unstructured text to structured data.These include SNOMED, ICD-9, ICD-10, CPT-4, RxNormand LOINC. The standardized structured terminology can beoutput from a data repository into EHRs to meet interoperabilityrequirements, provide billing and coding solutions, or allowdata mining for secondary uses

eDucaTional oBJecTive • Show the audience via a live demon-stration how NLP facilitates generating structured medicalcodes for retina specialists from dictation. • Explain how theabove method can increase the efficiency of data capture incertain cases. • Educate the audience on the different medicalcodes that can be generated from NLP and their clinical uses for EHR interoperability and secondary uses.


Past, Present and future of antiangiogenic Therapy for the Treatment of retinopathy of Prematurity

Maria Martinez-Castellanos, MD (Toluca, Mexico)Alay Banker, MDRobison Chan, MDHugo Quiroz-Mercado, MD

synoPsis We will discuss the role that antiangiogenic therapyhas in the treatment for retinopathy of prematurity (ROP) fromits basis to the potential use of the pharmacologic agents in thisblinding disease. We will divide the course as follows: History of antiangiogenic drugs in ROP Antiangiogenic therapy inROP, 5 years of experience in two continents Use of new tech -nologies in the diagnosis, research and data sharing in ROP Ablink into the future in the treatment of ROP.

eDucaTional oBJecTive The use of pharmacologic agents totreat ROP has been growing as a snow ball worldwide. In thiscourse we will discuss the use of antiangiogenic therapy amongtwo groups that have been using this therapy for the last 5 years,the findings, complications, variations in the techniques, followup and where the future is going to take us in the treatment of a blinding disease.

4:00-5:00 pMBack Bay A

laser Treatment of Diabetic Macular edema –Maximizing vision improvement and edema reduction While Minimizing injury

Stephen Sinclair, MD* (Media, PA)Jose Cardillo, MDJeffrey Luttrull, MD

synoPsis Ophthalmologists have utilized primarily focal/gridlaser with sub- or supra-threshold, continuous wave photo -coagulation to treat diabetic macular edema while some havebegun to use low intensity, high density micropulse laserpainting. The techniques and outcomes of both types will bediscussed including results of randomized trials and personalobservations.

eDucaTional oBJecTive Provide understanding of the tech -niques, rationale, indications, and expected structural andvision outcomes of both laser treatments that will improve case and treatment selection to maximize results

7:00 pM–1:00 AMcocktail reception, gala Dinner and umbo loungeRepublic, Grand and Constitution Ballrooms



Wednesday

Wednesday, August 24

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8:30-10:20 AM

Symposium 13:Hereditary/inflammatory/Diabetic RetinopathyModerators: Dean Eliott, MD and Philip J. Ferrone, MD


8:30 AMenhanced Depth imaging ocT in Hereditary retinal Diseases

Dilsher S. Dhoot, MD (Cleveland, OH), Siya Huo, MD, Peter K. Kaiser, MD*, Elias Traboulsi, MD

PurPose To investigate the spectral-domain ocular coherencetomography (SD-OCT) features of the choroid in hereditaryretinal diseases using enhanced depth imaging (EDI) technique.

MeTHoD EDI SD-OCT imaging was performed on 21 patientswith inherited retinal diseases, using the Spectralis OCT.Subfoveal choroidal thickness (CT) measurements wereobtained. Measurements were taken at 1000 µm intervals of a horizontal section from 3 mm nasal and temporal to the fovea. Patients were grouped based on their primary diagnosis,which included 15 patients with retinitis pigmentosa (RP), 5 patients with Stargardt macular dystrophy, and one patientwith choroideremia. Statistical analysis was performed toevaluate CT at each location and to correlate CT with visualacuity, retinal thickness, outer retinal features on OCT, andclinical appearance.

resulTs Mean ages were 45.8 years for the RP patients and 33.2 years for the Stargardt patients. The choroideremia patientwas 15 years of age. Mean visual acuity was 20/49 in the RPpatients, 20/148 in the Stargardt patients, and 20/22 in thechoroideremia patient. Mean choroidal thickness measurementswere 224.6 ± 106 µm in the RP patients, 385.2 ± 177 µm in the Stargardt patients, and 413 ± 14 µm in the choroideremiapatient. RP patients tended to have thinner choroids than agematched controls, while the Stargardt and choroideremiapatients had thicker choroids than controls. There was nocorrelation between subfoveal choroidal thickness and visualacuity in any of the patient groups.

conclusion Choroidal thickness as measured by SD-OCT EDI is reduced in patients with RP, and increased in patientswith Stargardt disease. Visual acuity does not correlate withchoroidal thickness measurements in the patients enrolled inthis study.

8:38 AManalysis of long-term outcomes for intravitreal Bevacizumab Treatment ofchoroidal neovascularization secondary to ocular Histoplamosis syndrome

Daniel M. Miller, MD, PhD* (Cincinnati, OH), Douglas Cionni, MD, Shawn A. Lewis, MD, Michael K. Petersen, MD, PhD, Robert E. Foster, MD,Christopher D. Riemann, MD, Robert A. Sisk, MD, Robert K. Hutchins, MD

PurPose To assess the long-term outcomes of intra vitrealbevacizumab (IVB) in the treatment of choroidal neovasculari -zation (CNV) secondary to presumed ocular histoplasmosissyndrome (POHS).

MeTHoD Consecutive, interventional case series involving 104 eyes in 95 patients who received injections of IVB alone orin combination with photodynamic therapy (IVB/PDT) fortreatment of subfoveal or juxtafoveal CNV secondary to POHSwith at least 12 months of follow up from January 2006 throughJanuary 2010.

Only subfoveal and juxtafoveal lesions were included in theanalysis. Exclusion criteria included extrafoveal POHS CNV,prior vitrectomy, concomitant diabetic retinopathy, retinal veinocclusion, or CNV secondary to any other cause, and ARMD.Similarly, subjects with inherited retinal degeneration or anyother visually significant maculopathy were excluded.

resulTs Seventy-seven eyes received IVB monotherapy and 27 eyes underwent combination IVB/PDT treatment. For bothgroups, the average pretreatment logMAR vision was 0.66(Snellen Equivalent 20/131) with a final logMAR vision of0.46 (Snellen Equivalent 20/58). The mean follow-up was 28.0 months with an average of 3.09 intra vitreal bevacizumabinjections per year. There was no significant difference in initial vision, final vision, or number of eyes with a 3-line gainbetween the IVB monotherapy and IVB/PDT groups. Thirty-eight percent (39/104) of eyes gained 3-lines or more and81.2% (84/104) of subjects had at least stable vision or bettervision at one year. The proportion of subjects maintaining a 3-line gain in vision was relatively preserved at 2 years (29.8%,17/57) and 3 years (30.3%, 10/32) follow-up. There was noincrease in the proportion of subjects losing 3-lines of vision or more over 3 years of follow-up.


Wednesday, August 24

conclusion There is no significant difference in visual acuityoutcomes between IVB monotherapy versus IVB/PDT combi-nation therapy for POHS CNV. IVB is an effective treatmentfor CNV secondary to POHS resulting in a long-term stabilizingeffect on visual acuity.

Post-treatment fluorescein angiograms for a subject treated withintravitreal bevacizumab over a 4 year time period. There is a lineargrowth in CNV size and surrounding RPE abnormalities despitesuccessful treatment with intravitreal bevacizumab. Her visual waspreserved at 20/30 after 4 years of follow-up.

8:46 AMDiscussion

8:50 AMclinical comparison of Two anesthetic Preparations for intravitreal injection

Ninel Z. Gregori, MD (Miami, FL), Matthew Weiss, MD, Raquel Goldhardt, MD

PurPose To determine which of two topical anesthetic prepara-tions patients prefer for intra vitreal injections of ranibizumabwith a 32 gauge needle. One preparation was a topical applica -tion utilizing three Q-tips soaked in 4% lidocaine; the other wasapplication of 3.5% lidocaine hydrochloride ophthalmic gel.

MeTHoD Randomized prospective clinical trial. Patients whohad at least 3 previous intra vitreal ranibizumab injections weredivided into two strata and randomized to receive one of thetwo anesthetic preparations in each eye (bilateral stratum) oron subsequent visits in one eye (unilateral stratum). Bilateralstratum consisted of patients receiving an injection in each eyeon the same day. Patients’ discomfort level, overall satisfactionwith the preparation and injection, as well intraocular pressure(IOP), corneal staining, and subconjunctival hemorrhage(SCH) were compared. The patients were also asked whichpreparation method they preferred.

resulTs 50 patients were recruited. Patients’ discomfort score(1=none to 5=extremely severe) during the preparation was 2.0 (s.d.=1.1) vs 1.9 (s.d.=0.8,) in the Q-tip vs gel group,respectively (P=0.4, paired t-test). Discomfort score during the injection was 1.7 (s.d.=1.0) in the Q-tip group vs 2.0(s.d.=0.9) in the gel group (P=0.058, paired t-test.) Mean IOPimmediately after injection was 41.1 mmHg (s.d.=8, range=21to 68) vs 46 (s.d.=10, range=29 to 69) in the Q-tip vs gel eyesrespectively (P=0.002). There was significantly less SCH(P=0.031, paired t-test) and corneal staining (P=0.001, pairedt-test) in the gel group. When asked the next day, patientsreported significantly less discomfort in the gel group vs the Q-tip group (1.5 vs 1.8, P=0.036)

conclusion The data suggest patients prefer the gel preparation,however, the Q-tips produce a lower IOP elevation.

8:58 AMranibizumab Dose comparison for theTreatment of Diabetic Macular edema

Philip J. Ferrone, MD* (Great Neck, NY), Jonathan Jonisch, MD

PurPose To compare ranibizumab dose response in thetreatment of clinically significant diabetic macular edema.

MeTHoD Investigator sponsored, prospective, randomizedclinical trial. Eyes with clinically significant macular edemasecondary to diabetic retinopathy were randomized to one oftwo groups, 0.5mg or 1.0mg ranibizumab at baseline. During thefirst year, three monthly injections were given followed by as-needed injections on alternate months. Starting at month 12,patients were followed monthly and could receive as-neededtreatments at these visits. An amendment allowed treatmentwith 2.0mg ranibizumab in patients who had completed at least12 months of follow-up.

resulTs A 24-month interim analysis was performed. Bothgroups had similar baseline characteristics. At Month 24, significant visual acuity gains from baseline were observed inboth 0.5mg and 1.0 mg groups. There was a significant meandecrease in central foveal thickness in both the 0.5mg and1.0mg groups. In the 0.5mg group, a smaller proportion ofpatients gained 15 or more ETDRS letters compared to patientsin the 1.0mg group. The average number of injections in the0.5mg group was similar as compared to the 1.0mg group.Fourteen patients received 2.0mg ranibizumab starting at orafter month 24. In this subset, visual and anatomic outcomeswere maintained through follow-up. When compared to the 12 months preceding the transition to the 2.0mg dose, theaverage time (days) between treatments increased in bothgroups (0.5mg vs 2.0mg: 54 vs 75 days; and, 1.0mg vs 2.0mg: 68 vs 73 days).


HereDiTary/inflaMMaTory/DiaBeTic reTinoPaTHy 8:30–10:20 AM13


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conclusion Treatment of CSDME with 1.0 mg of ranibizumabresulted in a statistically significant improvement in visualacuity from baseline. There was a trend towards greaterimprovement in ETDRS vision and decreased macular edemawith 1.0 mg ranibizumab versus 0.5 mg ranibizumab at 24months. The 2.0 mg dose showed a trend towards a longertreatment interval.

9:06 AMeconomic analysis of Treatment withranibizumab with Prompt or Deferred laser vs. laser alone for Diabetic Macular edemaJennifer K. Sun, MD* (Boston, MA), Neil M. Bressler, MD*, Adam R. Glassman, MD, Michael O’Grady, MD

PurPose Results from the Diabetic Retinopathy ClinicalResearch Network (DRCR.net) demonstrated conclusively that treatment with ranibizumab with prompt or deferred laserprovides superior visual acuity outcomes than treatment withprompt laser alone for center-involved DME. The purpose ofthis study is to determine potential federal and state govern -ment costs and savings associated with this treatment.

MeTHoD Potential costs and savings were estimated usingCongressional Budget Office and the Office of the Actuary atthe Centers for Medicare and Medicaid Services style tech -niques to measure change in spending and savings associatedwith improved clinical outcomes without evaluating quality of life measures. Billing associated with ranibizumab+promptlaser, ranibizumab+deferred laser, and prompt laser alone weresimulated; including initial office visits, follow-up, testing,medication, laser procedures, and ranibizumab treatments.Medicare codes and payment amounts were used for consistencyand replicability. Economic modeling was based on the 2complete years of DRCR.net clinical trial data.

resulTs Over 2 years, ranibizumab therapy for DME and itsassociated clinical costs are estimated to require approximately$26,000 more per patient treated with ranibizumab+promptlaser or ranibizumab+deferred laser as compared with standardlaser treatment alone. Concurrently, ranibizumab is expected toreduce rates of visual impairment and therefore the potential todisplace costs elsewhere in the system. For those individualswho would have to leave the labor force and go on SocialSecurity Disability, the ranibizumab treatment over 2 yearscould reduce costs by about $45,000. This would includemaintaining approximately $17,605 in federal income, socialsecurity and Medicare taxes and $3,138 in state income taxesand $24,108 in Social Security disability benefits that wouldnot need to be paid. Not all patients will fit this maximumoffset scenario, but many should have at least some combi-nation of tax and disability offsets.

conclusion The use of ranibizumab for center-involved DMEin eyes with vision impairment offer not only improved clinicaloutcomes but also savings in areas to help offset the cost of thenew treatment. The decreasing number of injections given overtime in the DRCR.net study coupled with the maintenance ofvision, suggest that costs savings will continue over time.

9:14 AMerythropoietin levels in the vitreous fluid of non-diabetic Patients and Diabetic Patients with Progressive stages of Diabetic retinopathyNikolaos Trichopoulos, MD (San Antonio, TX), Dip Jadav, MD, Neeru Kumar, MD, Randolph Glickman, MD

PurPose EPO is reported to have angiogenic activity but itsrole in retinal neovascularization is not completely understood.The purpose of this study was to evaluate whether the levels ofEPO are elevated in the vitreous fluid of patients with DR. Wehypothesized that EPO is progressively increased in advancedstages of DR. We also assessed if DR is associated with thepresence of inflammatory markers.

MeTHoD Prospective analysis of undiluted vitreous samples wasperformed in discarded vitreous fluid of 34 patients undergoingscheduled vitrectomies. Patients with retinal vascular abnor-malities other than DR (e.g. central retinal vein occlusion)were excluded. Twelve patients were non-diabetics and 22 haddiabetes mellitus (DM). Four of these 22 DM patients did nothave DR, 5 had non-proliferative diabetic retinopathy (NPDR)and 13 had proliferative diabetic retinopathy (PDR) with orwithout vitreous hemorrhage. All vitreous samples wereanalyzed for EPO content; while a subset of 6 samples werescreened for a panel of pro-inflammatory cytokines, usingenzyme-linked immunosorbent assay kits.

resulTs A clear difference in the amount of vitreous EPO wasfound between non-diabetics (n = 12), diabetics with NPDR or no DR (n = 9), and diabetics with proliferative retinopathy(PDR) (n=13). Figure 1 shows histogram plots of the measuredEPO levels in each of these 3 patient groups. Average EPO levelswere as follows: non-diabetics: 11.17 ± 5.50 mIU/ml; diabeticswith NPDR or no DR: 33.87 ± 33.78 mIU/ml; and diabeticswith PDR: 186.91 ± 153.05 mIU/ml. A Mann-Whitney non-parametric test was used to compare these differences. The EPOlevels of the non-diabetics and the diabetics with NPDR or noDR did not differ significantly from each other (p > 0.05). Incontrast, there were significant differences between the EPOlevels of the diabetics with PDR and the diabetics with NPDRor no DR (p ≤.009) and the non-diabetics (p ≤.001). There wasa two-fold increased level of the pro-inflammatory cytokine, IL-8, in samples from eyes with PDR, compared to vitreous from non-DM patients (figure 2).

conclusion Our findings suggest that EPO is increasinglyelevated as a consequence of the ischemia induced by worseningstages of DR. EPO may serve as an indicator for advancement of ischemic ocular damage. Whether inhibition of EPO couldprovide a new therapeutic strategy in precluding or arrestingpathologic angiogenesis in DR, and if chronic inflammationstimulates EPO production, remain to be determined.

Figure 1. Histogram plots comparing EPO levels in the three patient groups. Top: non-diabetics, n = 12. Middle: diabetics with noretinopathy or NPDR only, n = 9. Bottom: diabetics with PDR, n = 13.The level of EPO in the vitreous of diabetics with PDR was signifi-cantly greater than that of either the diabetics with no DR or NPDRonly, or the non-diabetic patients (p ≤ 0.009, Mann-Whitney test).

Figure 2. Relative expression levels of pro-inflammatory cytokines in three diabetic patients with PDR and high levels of EPO, and inthree non-diabetic patients with low levels of EPO. There was aclear, two-fold difference in the relative expression level of IL-8between the diabetics with PDR and non-diabetics.

9:22 AMDiscussion

9:30 AMchanges in Macular Microvasculature in eyes with Diabetic Macular edema Treatedwith ranibizumab over a 24-month Period

Homayoun Tabandeh, MD* (Los Angeles, CA), Jang Won Heo, MD, Jeong Hee Lee, MD, Yasir J. Sepah, MD,Roomasa Channa, Morgan Renner, MD, Ahmed Fahmy,MD, Afsheen Khwaja, Zubir Rentiya, MD, David S. Boyer, MD*, Quan Dong Nguyen*, Diana V. Do, MD*

PurPose To evaluate the changes in macular vasculature of eyeswith diabetic macular edema (DME) treated with ranibizumab(RBZ).

MeTHoD Fluorescein angiograms (FA) from patients in theRanibizumab for Edema of the mAcula in Diabetes: Protocol 2(READ-2 Study) were analyzed in the Reading Center (RIRRC)by 3 independent graders. In the READ-2 study, 126 patientswith DME were randomized (1:1:1) to receive 0.5 mg of RBZ(group 1), focal/grid laser photocoagulation (group 2), or acombination of RBZ and focal/grid laser (group 3). After month6, majority of subjects received monotherapy with RBZ. FA atbaseline (BL) and month 24 were analyzed for 39 randomlyselected subjects. Three variables were evaluated: areas ofcapillary non-perfusion, source and type of leakage, and numberof MAs contributing to leakage.

resulTs At month 24, the area of capillary non-perfusion didnot change in any group when compared with BL. There wasno change in the pattern of leakage in 83%, 55.6%, and 45.5% of eyes in groups 1, 2, and 3, respectively. The averagenumber of leaking MAs decreased by 15.6% (group 1), 21.6%(group 2), and 9.2% (group 3). There was no statistically significant difference among the three groups in their longi -tudinal changes (BL to M24) based on the three definedvariables (p=0.657, 0.332, 0.304).

conclusion Analyses showed that vascular endothelial growthfactor (VEGF) inhibition over 24 months with RBZ in eyeswith DME did not result in increased capillary non-perfusionwithin the macula. In addition, RBZ injections appeared todecrease the number of leaking MAs. Further studies are neededin a larger study population to determine the effects of chronicVEGF suppression in eyes with DME.




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9:38 AM The effect of Bevacizumab on fibro-angiogenicgrowth factors in Proliferative Diabeticretinopathy: a randomized, Double-masked,controlled study

Dean Eliott, MD (Boston, MA),Elliott H. Sohn, MD, Leo A. Kim, MD, PhD, Hani Suleni-Had, MD, Michael Javaheri, MD, Shikun He, MD, David Hinton, MD

PurPose The exact mechanisms underlying the pathogenesis of TRD in PDR are unclear. VEGF and connective tissuegrowth factor (CTGF) are mediators of angiogenesis andfibrosis, respectively, and both are increased in eyes with PDR.The purpose of this study was to assess the effect of preoperativeintravitreal bevacizumab on VEGF and CTGF in eyes withTRD and to determine postoperative outcome.

MeTHoD In this prospective trial, 20 eyes of 19 patients wererandomized (10 in each arm) to receive 1.25mg intravitrealbevacizumab or sham injection 3-7 days prior to vitrectomy forTRD. Patient and surgeon were masked to treatment. Fundusphotographs and spectral-domain OCT were obtained at thetime of injection and on the day of surgery. Degree of vascu-larity and fibrosis were assessed at the time of injection andagain at surgery. Amount of intraoperative bleeding was recorded.Aqueous samples were collected prior to injection and duringsurgery. Undiluted vitreous samples and fibrovascular mem -branes were also obtained. Enzyme linked immunosorbentassays for VEGF and CTGF were performed.

resulTs Five eyes had decreased vascularization of membranesfrom pre-injection to time of surgery, and all of these eyes werein the treatment arm. Only 1 eye in the treatment group hadsevere intraoperative bleeding compared with 5 eyes in thecontrol group. Median vitreous levels of VEGF (pg/mL) weresignificantly lower in the treatment group (undetectable withthe conditions applied) than the control group (397, p=0.03).Aqueous levels of CTGF were strongly correlated with those inthe vitreous of controls (p<0.001). Median vitreous levels ofCTGF (pg/mL) were 980 in the treatment group and 1235 inthe control group (p=0.38). There was a significant correlationbetween VEGF and CTGF levels in the vitreous of the treat -ment group (p=0.01) that was not observed in the controlgroup.

conclusion Intravitreal bevacizumab (1.25mg) administeredwithin 3-7 days of vitrectomy in eyes with TRD due to PDRreduces vitreous levels of VEGF and produces a clinicallyobservable alteration in fibrovascular membranes. There is apositive correlation between VEGF and CTGF levels in eyestreated with bevacizumab. Aqueous CTGF is a useful surrogatemarker for vitreous CTGF in these eyes.

9:46 AMPanretinal Photocoagulation (PrP) vs. PrP Plus intravitreal ranibizumab for High-risk Proliferative Diabetic retinopathy

Rodrigo Jorge, MD*, (Ribeirao Preto, Brazil), José Ramos-Filho, Felipe P. Almeida, Jefferson A. Ribeiro, Rogerio A. Costa, MD, PhD, Ingrid U. Scott, MD, MPH, Andre Messias

PurPose To evaluate the effects of panretinal photocoagulation(PRP) compared with PRP plus intra vitreal injection of 0.5 mgof ranibizumab (IVR) in patients with high-risk proliferativediabetic retinopathy (PDR).

MeTHoD Prospective study including patients with high-riskPDR and no prior laser treatment randomly assigned to receivePRP (PRP group) or PRP plus IVR (PRPplus group). PRP wasadministered in two sessions (weeks 0 and 2), and IVR wasadministered at the end of the first laser session in the PRPplusgroup. Ophthalmic evaluations including best corrected visualacuity measured according to the methods used in the EarlyTreatment Diabetic Retinopathy Study (BCVA), fluoresceinangiography to measure area of fluorescein leakage (FLA), andoptical coherence tomography (OCT) for assessment of centralsubfield macular thickness (CSMT), were performed at baselineand at weeks 16 (±2), 32 (±2) and 48 (±2).

resulTs Twenty-nine out of 40 patients (n=29 eyes) completedthe 48-week study follow-up period. At baseline, mean±SE FLA(mm2) was 9.0±1.3 and 11.7±1.3 (p=0.15); BCVA(logMAR)was 0.31±0.05 and 0.27 ± 0.06 (p=0.66); and CSMT(µm) was216.3±10.7 and 249±36 (p=0.39), in the PRP and PRPplusgroups, respectively. There was a statistically significant (p<0.05)FLA reduction at all study visits in both groups, with thereduction observed in the PRPplus group statistically signifi-cantly larger than that in the PRP group at week 48 (p=0.02).BCVA worsening was observed at 16, 32 and 48 weeks aftertreatment in the PRP group (p<0.05), while no statisticallysignificant BCVA changes were observed in the PRPplus group.A statistically significant CSMT increase was observed in thePRP group at all study visits (p<0.05), while a significantdecrease in CSMT was observed in the PRPplus group at week16 (p<0.05), and no statistically significant difference in CSMTfrom baseline was observed at weeks 32 and 48.

conclusion IVR after PRP was associated with a largerreduction in FLA at week 48 compared to PRP alone in eyeswith high-risk PDR, and the adjunctive use of IVR appears toprotect against the modest visual acuity loss and macularswelling observed in eyes treated with PRP alone.

9:54 AMcombination Treatment using anti-vegf Therapy and sustained releaseDexamethasone 0.7 mg for retinal vascular Disease – Twelve Month results

Michael A. Singer, MD* (San Antonio, TX), Darren J. Bell, MD, Paul Woods, MD, Beatrice Guajardo, MD

PurPose The purpose of the study is to evaluate the effects of repeated use of combination therapy (Anti-VEGF andDexamethasone 0.7mg sustained release implant) for thetreatment of Retinal Vein Occlusion in terms of visual acuityand OCT central field thickness over a twelve month period.

MeTHoD The study is a prospective open label pilot extention to the orignial combination study presented last year. Patientswith both CRVO and BRVO received Anti-VEGF injectionfollowed by Dexamethasone 0.7mg sustained release implanttwo weeks later. Previously treated and naive patients wereincluded.

Best corrected visual acuity (Snellen), Cirrus OCT, and IOPmeasurements were obtained at every visit. Patients wereretreated if OCT central field thickness increased by 50microns from previous measurements of if vision decreased by six letters. IOP greater than 22 was treated with topicalmedication. Patients were converted to FDA approvedRandibizumab from Bevacizumab if insurance permitted.

resulTs 58 patients had combination therapy. 28 pateints ofthe original 32 had at least 12 months of follow up. 33 patientshad Bevacizumab initally, 9 had Randibixumab and 16 switchedduring the study. Mean visual acuity improved by 11 letters inmonth 1, 15 letters in month 3, 18 letters in month 6, 13 lettersin month 8, 13 letters in month 12. Three line or more gains invisual acuity were 38% in month 1, 35% in month 3, 40% inmonth 6, 46 % in month 8, and 34% in month 12. Mean OCTThickness decreased by 140 um at 2 weeks, 144um month 1, 96um in month 3, 93um in month 6, 173um in month 9.159 umin month 12. Patients with OCT thickness <300 um were seen54% at 2 weeks, 80% month 1, 65% in month 3, 59% in month6, 55% in month 9, 74% in month in 12. Mean time to thoseretreated was 17 weeks in the 1st cycle, and in the 16 weeks inthe 2nd cycle. 18 patients (30%) were treated once. IOP >23was seen in 17% (10/58) in the 1st 6 months, and 18% (18/45)in the 2nd 6 months.

conclusion Combination therapy using Anti-VEGF agents andDexamethasone 0.7mg sustained release implant, can providesustained increases in visual acuity as well as reduction incentral field thickness over time in patients with retinal veinocclusion. In addition, this therapy can provide predictableintervals for reinjection. The IOP profile is similar to otherDexamethasone implant studies.

10:02 AMDiabetic Macular edema (DMe) is a Peripheral retinal Disorder and Peripheral PrP Directed to areas of Poor PerfusionPositively affects DMe

Paul G. Tornambe, MD* (Poway, CA)

PurPose In eyes with DME, peripheral retinal ischemia elaborates cytokines, such as VEGF, which affects vascularpermeability. PRP directed to these ischemic areas, down-regulates cytokine production which decreases vascular leakage,and positively affects macular edema without repeated VEGF-Iinjections nor direct macular photocoagulation.

MeTHoD 10 eyes with severe recalcitrant DME underwent wide field FA which demonstrated untreated peripheral retinalischemia and retinal vascular leakage. Scatter laser photocoagu-lation was delivered only to the areas of peripheral ischemia,and no laser treatment was applied to the macular region. Insome cases the macular edema acutely increased in the treatedeye and in the fellow untreated eye, suggesting PRP initiallyupregulates VEGF and may have a X-over effect. An IVtVEGF-I injection to the treated eye quickly reversed the maculaedema in both the treated eye and also decreased the edema inthe fellow untreated eye, suggesting a cross over effect for laseraggravated DME.

resulTs Peripheral laser PRP directed by wide field FA toischemic retina, with no macular laser PC, ultimately positivelyaffected diabetic macular edema in all eyes treated. InitiallyPRP upregulates VEGF production and increases macularedmea. A VEGF-I given prior to and a month or two after PRP(1) addressed VEGF associated DME and blunted the up-regulated PRP VEGF effect and (2) allowed time for the PRPdown regulating VEGF effect to develop. This study suggeststhat peripheral ischemic retina elaborates cytokines, includingVEGF, which induces vascular permeability and macularleakage. PRP to only ischemic peripheral retina ultimatelydecreases cytokine production and resolves macular edema. Thistreatment approach should decrease the number of VEGF-Iinjections to control DME and avoids the secondary damagingeffects of laser photocoagulation in the macular region.

conclusion DME is a peripheral retinal disorder. PRP topreipheral ischemic retina using widefield FA ultimatelydecreases diabetic macular edmea. PRP initially upregulatesVEGF, therefore a VEGF-I should be injected prior to PRP andfor a month or two following PRP. This treatment approachshould decrease the number of injections needed to controlDME and avoids direct macular photocoagulation entirely.




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S OCT, Left Eye: 65 y/o diabetic female S/P PRP, PPV, 3 IVTA OS and 3 Avastin injections OS with persistent DME. Pre PRP OS directed laser to untreated mid peripheral and peripheral ischemic retina. Note florid CME.

S OCT Left Eye: 8 weeks s/p Peripheral PRP directed laser to untreated mid peripheral and peripheral ischemic retina (432 spots). CME has decreased dramatically.

10:10 AMDiscussion


10:50 AM-12:00 pM

Symposium 14:vitreoretinal Surgery ivModerators: Francesco Boscia, MD* and Peter Stalmans, MD*


10:50 AMendoscopic vitrectomy vs. Temporary Keratoprosthesis vitrectomy for severe combined corneal and Posterior segment ocular Trauma

Dal W. Chun, MD (Washington, DC), Marcus H. Colyer, MD

PurPose To report the baseline characteristics and the threeand six month functional and anatomic outcomes followingendoscopic vitrectomy (EV) compared to temporary kera -toprosthesis vitrectomy (TKV) in eyes with severe combinedcorneal and posterior segment ocular trauma.

MeTHoD Retrospective, comparative, interventional case series.All of the eyes that underwent secondary repair with eitherTKV or EV for severe ocular trauma at Walter Reed ArmyMedical Center from March 2003 to October 2010 werereviewed. Eight eyes of eight patients that underwent TKVwere assigned to Group 1. Nine eyes of eight patients thatunderwent EV were assigned to Group 2. Ocular traumavariables, baseline characteristics, surgical variables, and 3 and6 month postoperative functional and anatomic outcomes werecompared between the two groups using the Wilcoxon ranksum test and the Fischer exact test.

resulTs The groups were similar with respect to the oculartrauma variables. Median baseline logMAR was 3.0 in bothgroups but macular retinal detachment (RD) and peripheral RD were more common in Group 1 (P = 0.015 and 0.050,respectively). The median time from injury to surgery wassignificantly longer in Group 1 (38 days) than in Group 2 (14 days) (P = 0.034). The median surgical time was also longer in Group 1 (8.4 hours) than in Group 2 (2.8 hours) (P < 0.0005). The surgical variables differed only in the rates ofmacular membrane peeling (P = 0.029) and perfluoro-n-octaneuse (P < 0.0005) which were more common in Group 1. At 3 months, median logMAR was 3.0 in Group 1 and 2.0 inGroup 2 (P = 0.34). At 6 months, there was a trend towardbetter median logMAR in Group 2 (1.3) than in Group 1 (3.0)(P = 0.093). The functional and anatomic success rates weresimilar (P = 0.64 and 0.62, respectively) although there was a trend toward more failures in Group 1 than in Group 2 (P = 0.082).

conclusion The results of this study suggest that EV is com -parable to TKV. An advantage of EV is that it allows earlierintervention without complex corneal surgery. Prompt diagnosisand treatment of occult pathology may result in less surgicalmanipulation and time. The disadvantages of EV includelimited image quality, dynamic intraocular perspective, anddifficulty of performing bimanual surgery.

10:58 AMoperations iraqi freedom and enduring freedom 2003-2009: The Walter reed experience

Marcus H. Colyer, MD (Washington, DC), Dal W. Chun, MD, Farhad Safi, Michael Smith, Michael Mines

PurPose To report the injury patterns and visual outcomes ofpatients evaluated by the Walter Reed Army Medical CenterOphthalmology Service between 2003 and 2009.

MeTHoD Retrospective, noncomparative case series of 783 eyesof 574 military healthcare beneficiaries who were evaluated bythe Walter Reed Army Medical Center Ophthalmology Servicefrom January 2002 through March 2009 with a diagnosis ofocular trauma. Injury characteristics, specific surgical tech -niques employed, and postoperative visual and anatomicoutcomes at 6 months and final followup were evaluated.

resulTs The median ocular trauma score was 80±26 (range 12-100). Closed globe injuries comprised 347 eyes (44%) while open globe injuries occurred in 289 eyes (37%). Of eyessustaining closed globe injuries, zone 1 and 2 injuries occurredin 158 eyes (20%), while zone 3 injuries occurred in 199 eyes(25%). Intraocular foreign bodies were present in 118 eyes withopen globe injuries (15%), while perforating injuries occurredin 74 eyes (9.5%). Simple penetrating injuries occurred in 41eyes (5%), while blunt-force globe ruptures occurred in 54 eyes(6.9%). Orbital or eyelid injuries were present in 421 eyes(54%) while neuro-ophthalmic injuries occurred in 176 eyes(23%). In total, 336 surgical procedures were performed on 237 patients. The average initial logMAR was 0.75 ± 1.0, while at 6 months average best corrected visual acuity was 0.39 ± 0.74. At final follow-up, 425 patients (54%) wereachieved 20/40 or better visual acuity.

conclusion Nearly 10% of all casualties Operation IraqiFreedom and Operation Enduring Freedom sustained somedegree of ocular injuries, and nearly half of those patients have been treated at the Walter Reed Army Medical Center.Fortunately, the majority of patients retain excellent vision;however, devastating ocular injuries have occurred.

11:06 AMnovel Technical Developments to improvesurgical safety During (Phaco) vitrectomy

Peter Stalmans, MD, PhD* (Leuven, Belgium)

PurPose During (phaco)vitrectomy, the surgeon can encounterseveral intra-operative complications: posterior capsuleaspiration and rupture during lens surgery, aspiration of retinaltissue in the vitrectome during vitreous base shaving and intra-operative pressure alterations leading to hypotony (inducing eye collaps and even subchoroidal haemorrhage) or hypertony(compromising the retinal perfusion).

MeTHoD Several soft- and hardware features were developed onthe Dual Associate device (DORC):

1. During phaco surgery, a vacuum sensor monitors the amount of aspiration that is generated by the venturi system. A threshold vacuum setting is programmed, resulting in a highvacuum during tip occlusion to ease the lens removal while an automated reduced vacuum level is generated without tip occlusion.

2. For using the vitrectome in close proximity to the retina, apersistalic pump system with a preset fluid flow and automatedvacuum adaptation was designed.

3. A feedback system between the aspiration rate (vitrectome)and the infusion rate (air-driven infusion line) was developed.

resulTs 1. Using the threshold venturi setting during lenssegment removal, aspiration of the lens pieces is facilitatedbecause of the amount of vacuum available, but the thresholdsystem also avoids aspiration of the posterior lens capsule.

2. The peristaltic vitrectomy setting results in a constant fluidflow, which is the key factor to avoid inadvertent retinalaspiration when the vitrectome opening is moved in and outthe remaining peripheral vitreous during vitreous base shaving.The automated vacuum level control avoids variations in flowrate during this delicate intra-ocular maneuver.

3. By developing a feedback system between the vitrectomeaspiration and infusion rate, a highly stable intra-ocular pressureis obtained, regardless of the amount or speed of fluid aspiratedfrom the eye, and without need to change the intra-ocularpressure settings during the procedure.


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conclusion The newly developed features provide an improved safety during vitrectomy, by avoiding surgical damageto the eye:

• An extremely stable anterior chamber is obtained duringphaco surgery.

• Inadvertent aspiration of the retina with the vitrectome is avoided.

• During vitrectomy, the intra-ocular pressure is kept at aconstant level, regardless of the amount of aspirationgenerated by the vitrectome.

11:14 AMDiscussion

11:20 AMPolyethylene glycol (Peg) Hydrogel Polymer sealant for sclerotomy closure:Preliminary in vivo clinical results

Fabio Patelli, MD (Milan, Italy), Seenu M. Hariprasad, MD*, Enrico Giacomotti, Paolo Radice, Sandro Vergani

PurPose To test a PEG-based hydrogel bandage for effectivelysecuring sutureless pars plana vitrectomy incisions. This wouldentail the sealant preventing the entry of surface fluid as well as the leakage of intraocular fluid in the early postoperativeperiod. This is relevant as entry of fluid and leakage ofintraocular fluid are associated with postoperative endoph-thalmitis and hypotony respectively

MeTHoD Sealing of 23g and 20g sclerotomies after vitrectomysurgery using PEG hydrogel polymer sealant will be presented.Use of PEG Sclerotomy Sealant in conditions of intra vitrealBalanced Salt Solution (BSS), air and silicone oil fill will be presented. Video, as well as, application techniques will be reviewed.

resulTs The application of PEG Hydrogel sealant wassuccessful in all eyes tested with various substitutes. In sclerotomies leaking BSS, the gel time of PEG hydrogel sealant is longer, therefore surface must be dry for successfulapplication. Once gelled, PEG Hydrogel sealant successfullysecured all the sclerotomies tested.

conclusion The use of a hydrogel bandage to close suturelesssclerotomies is an alternative to sutures. Closure of suturelesssclerotomies may reduce the entry of ocular surface fluid intothese incisions and prevent leakage of intraocular fluid in theimmediate post operative period. Incision closure may reducethe incidence of post operative endophthalmitis and hypotonyin sutureless vitreous surgery.

A ring is containing the PEG hydrogel polymer sealant over the 20 gauge sclerotomy until it jellify.

11:28 AMcauterization of leaking sclerotomies after 23-gauge Transconjunctival Pars Plana vitrectomy

Francesco Boscia, MD* (Bari, Italy)

PurPose To evaluate efficacy and safety of bipolar cauterizationto ensure wound closure of leaking sclerotomies in 23-gaugetransconjunctival sutureless pars plana vitrectomy (TSV).

MeTHoD One-hundred-thirty-six eyes of 136 patients with avariety of pathologies were enrolled and monitored for a meanfollow-up of 19.44 weeks (range 12-53 weeks). Eighty-nine eyeswere operated on with the Constellation system (Alcon, Inc,Forth Worth, TX), and 47 with the PentaSys 2 platform (FritzRuck GmbH, Germany). Vitreous was removed entirely withtriamcinolone staining. At the end of the procedure, whenleakage was observed, bipolar cauterization was applied onsclerotomy.

Number of persistent leakage with ensuing sutured sclerotomieswas recorded. Postoperative IOP, hypotony (<6 mmHg), Seidelpositivity, conjunctival blebs, and complications were evaluatedat hour 6, day 1 and 3.

resulTs A total of 240/408 (58.8%) sclerotomies showingleakage at the end of the procedure were included. Only 7/240(2,9%) sclerotomies needed sutures because of intraoperativeleakage even after cauterization. At 6 and 24 hours, hypotonyoccurred in 6/132 (5%) and 2/132 (1.5%) eyes, respectively.Postoperatively, no leakage and/or conjunctival blebs wereobserved. In only one case (1/233, 0.43%) a positive Seidel wasobserved, that needed suturing. Mean intraocular pressure didnot vary significantly at any postoperative time point. Nocomplication was recorded.

conclusion Bipolar cauterization of sutureless sclerotomies is a simple, safe and effective method to obtain completesclerotomy closure in leaking sclerotomies after 23-gauge TSV,without significant postoperative complications.

11:36 AMa Minimally invasive intravitreal subconjuctival Jet injectorGholam A. Peyman, MD* (Phoenix, AZ), Kamran Hosseini, MD*, Michel Cormier, MD*

PurPose To evaluate a minimally invasive intra vitreal andsubconjuctival jet injector for the administration of a pharma-cological agents in the vitreous or in the subconjuctival space.

MeTHoD The system is equipped with a microneedle in commu-nication with an internal formulation chamber that is adaptedto receive and contain the pharmacological agents. A piercingdepth limiting flange restricts the penetration depth of themicroneedle into the sclera to < 0.1mm, and simultaneouslydefines the location of the pars plana from the limbus. Theinjection is achieved using a defined pressure. The system was evaluate on the enucleated rabbit eye and in vivo on rabbit eyes.

resulTs When activated by the operator, the system forces,with pressure of <1000 Psi, the medication through theremaining scleral thickness into the vitreous cavity in a fewmicroseconds. At low jet pressures, (<400 PSi) it producedreadily a subconjuctival injection.. There were not wetinjection of the medication outside the conjunctiva. No intra-operative or short term post-operative complications related to the lens or retinal injury was observed by clinical or histo-logical examination of the eyes.

conclusion The device simplifies both intra vitreal and sub -conjuctival injection of a medication. Because the needle doesnot enter the eye, it may reduce patient’s apprehension ofhaving one or multiple intraocular injections.

11:44 AMa retrospective clinical Trial review of the incidence of intraocular Pressure riseswith Difluprednate ophthalmic emulsion,0.05%, Treatment

Andrew A. Moshfeghi, MD, MBA* (Palm Beach Gardens, FL), Thomas A. Albini, MD*

PurPose Difluprednate is increasingly being used to treatposterior segment inflammation. It has been studied periopera-tively and in uveitis, and most recently demonstrated efficacy in two small case series of diabetic macular edema. Because it is a potent steroid, IOP elevation is a concern. This review will identify the incidence of IOP increases observed indifluprednate clinical trials.

MeTHoD A retrospective literature review of randomized,controlled US clinical trials was performed. A total of 432patients received difluprednate, and dosing regimens were asfollows: twice-daily (n=111) or four times daily (n=107)postoperatively, twice-daily (n=81) or four times daily (n=83)preoperatively, and four times daily (n=50) as treatment foranterior uveitis. The mean exposure to difluprednate was 27.1days. A criterion increase in IOP was defined as a value of ≥21mmHg and change from baseline ≥10 mm Hg at the same visit.The total number and percentage of patients treated withdifluprednate that experienced a criterion increase in IOP wasidentified for each clinical trial.

resulTs In two phase 3 trials, 3/111 (2.7%) patients receivingpostoperative difluprednate BID and 3/107 (2.8%) patientsreceiving the drug QID after surgery had a rise in IOP. In twophase 3b studies, treatment with difluprednate began one dayprior to surgery; the BID arm (n=81) included 3 patients(3.7%) and the QID arm (n=83) included 5 patients (6.0%)with a rise in IOP. The rates of IOP increase in the aforemen-tioned studies were comparable to the respective placebo arms.Lastly, in an anterior uveitis study of QID difluprednate, 3/50(6.0%) patients had a rise in IOP, which was comparable to2/40 patients (5%) in the comparator group that receivedprednisolone acetate 1.0% eight times daily (Table 1). Overall,the incidence of clinically significant IOP increases for thesestudies ranged from 2.7%-6.0%. Increases either resolvedspontaneously or were treated with IOP-lowering medications.Additionally, mean IOP remained similar to baseline measuresthroughout the trial periods.

conclusion An overall low incidence of clinically significantIOP rises in patients receiving treatment with difluprednate was observed in a retrospective review of five clinical trials.Difluprednate ophthalmic emulsion, 0.05%, is a potent steroidbeing used to treat inflammation, and further study regarding itsuse and safety profile in the posterior segment is warranted.

11:52 AMDiscussion

12:00 pMclosing remarks and Meeting adjourns


viTreoreTinal surgery iv 10:50 AM–12:00 PM14

Scientific Posters

Scientific Posters

83

Macular Degeneration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AMD – NeovascularPOSTERS 101-127

101Effects of Music Therapy on Patients Receiving Intravitreal Injections: A Randomized Clinical Trial

Ron A. Adelman, MD, MPH (New Haven, CT), Xuejing Chen, MD, Veena S. Rao, Rajeev K. Seth, MD

PURPOSE To study the effects of classical music on anxiety,perceived pain and satisfaction of patients undergoing intra -vitreal injections in the outpatient setting.

METHOD Randomized clinical trial. Patients who were scheduledfor intra vitreal injections were randomized into a music therapy group receiving music or a control group not receivingmusic. Prior to the injection, each patient filled out an English version of the state portion of the State Trait Anxiety Inven -tory (STAI-S). Patients in the music therapy group listened to classical music from an Internet radio site as they waited forand during the procedure. Patients in the control groupunderwent the procedure in the same setting without music.Afterwards, all patients filled out the STAI-S again, as well as an additional satisfaction and pain survey with a visualanalog scale (VAS).

RESULTS The main outcome measures were self-reported satis-faction and pain levels, as well as anxiety derived from theSTAI-S scores. Sixty nine patients participated, with 35patients (57% female, 43% male) in the music therapy groupand 34 patients (41% female, 59% male) in the control group.

The mean ages for the music therapy group and control groupwere 72 and 72 respectively. There was a trend toward a greaterdecrease in anxiety after the injection in the music therapygroup as compared to the control group (p = 0.058). Further -more, subjects in the music therapy group (83%) requestedmusic in future injections more frequently than those in thecontrol group (59%) (p = 0.0356). Both the music therapygroup and control group were similar in their reported levels of pain during the procedure (p = 0.638).

CONCLUSION Classical music has a trend to decrease anxiety inpatients without decreasing perceived pain. Patients who listenedto music during intra vitreal injections desired to have musicplayed for future injections. Music therapy is a low-cost and easyintervention with minimal risks that may be helpful in reducinganxiety during intra vitreal injections in an outpatient setting.

102Sixty Month Follow-up Data in Patients Receiving Anti-VEGF Therapy for Exudative AMDMathew W. Aschbrenner, MD (St. Louis, MO), Daniel P. Joseph, MD, PhD*

PURPOSE To determine visual acuity (VA) and central macularthickness (CMT) in patients with wet age-related maculardegeneration (AMD) receiving bevacizumab and/or ranibizumabwith five year (60 month) follow-up.

METHOD Retrospective chart review of eligible patients with wetAMD treated with either bevacizumab or ranibizumab on orbefore 11.1.2005 with follow-up of five years or 60 months at asingle institution. Snellen VA was recorded for each visit andconverted to logMAR. VA at first injection, 6, 12, 18, 24, 30,36, 42, 48, 54 and 60 month follow-up visits were analyzed.CMT was recorded using optical coherence tomography (OCT)at first injection, 12, 24, 36, 48 and 60 month follow-up. Valueswere compared using paired T-test.

RESULTS Nine eyes had a mean logMAR VA 0.65 (sd ± 0.27) at initial injection. Mean logMAR VA at six, 12, 18, 24, 30, 36,42, 48, 54, 60 months was 0.49 (sd ± 0.12), 0.53 (sd ± 0.15),0.66 (sd ± 0.35), 0.53 (sd ± 0.37), 0.63 (sd ± 0.43), 0.58 (sd ±0.45), 0.58 (sd ± 0.29), 0.57 (sd ± 0.45), 0.56 (sd ± 0.42), 0.64(sd ± 0.45) respectively. There was no statistically significantchange in VA at 60 months (p=0.429). At 60 months, 33.3%,77.8% and 100% of patients had maintained Snellen VA of20/40, 20/100 and 20/400. Mean CMT was 328 µm (sd ± 17) at the initial injection visit. Mean CMT was 212 µm (sd ± 28)215 µm (sd ± 34) 195 µm (sd ± 26) 197 µm (sd ± 29) 192 µm(sd ± 20) at follow-up visits 12, 24, 36, 48 and 60 months. Thedifference in CMT between initial visit and 60 month follow-up was statistically significant (p=<.001). Mean follow-up was7.7 weeks (sd ± 2.2). Patients received intra vitreal bevacizumabor ranibizumab at a mean of 47.7% of visits.

CONCLUSION To date, there are no known studies analyzing VA of patients treated with anti-VEGF agents with 60 monthfollow-up. In this study, VA was maintained by giving treatmenton an as needed basis. This study also showed CMT was signifi-cantly decreased at 60 months. Thus, anti-VEGF treatment on an as needed basis can achieve improvement in macularanatomy and maintain VA over five years.


Scientific Posters

84 SCIENTIFIC POSTER ABSTRACTS

103Hypoxia Induces a Post-transcriptionalRegulator, SIRT1 (Histone Deactylase; HDAC)Mediated VEGF Activation in Choroidal Retinal NeovascularisationSankarathi Balaiya, PhD (Jacksonville, FL), Vijay Khetpal, MD*, K.V. Chalam, MD, PhD, MBA, FRCS(C)

PURPOSE Hypoxia, a critical pathological factor in retinaldiseases including AMD, up regulates angiogenic growth factorslike erythropoietin (EPO), vascular endothelial growth factor(VEGF) and promotes neovascularization. Hypoxia changescellular redox state and activate class III HDACs, sirtulin1(SIRT1). Activated SIRT 1 signals HIF2α (hypoxia induciblefactor) which transactivate VEGF and EPO.

METHOD Choroidal endothelial cells (RF/6A) were maintainedin a semi-confluent state in an appropriate condition. Hypoxiawas induced by exposing the cells to cobalt chloride for 24hours and confirmed by flow cytometric analysis. The role ofSirt1 in cell viability was evaluated using WST-1 assay with andwithout blocking Sirt1 inhibitor, sirtinol. The activation ofHIF-2α during hypoxia in presence or absence of SIRT1 wasnoted using immunoblot analysis. VEGF levels were quantifiedusing enzyme linked immunosorbent assay (ELISA).

RESULTS Flow cytometric analysis confirmed the induction ofhypoxia by cell cycle arrest at starting at 200 µM concentrationof cobalt chloride. In comparison to control, the viability ofchoroidal endothelial cell decreased to 46.2% after blockingSIRT 1 activity. However, the viability significantly increasedto 55.2% and 52.4% after inducing hypoxia at 100 and 200 µMconcentrations respectively, compared to control (p<0.01).After the induction of hypoxia, immunoblot analysis showed a four-fold increased expression of HIF-2α and the expressionwas suppressed by blocking SIRT 1 activity (p=0.01). VEGFlevels decreased after blocking sirt1 activity in hypoxic cells,compared to control.

CONCLUSION Activation of SIRT1 during pathological hypoxialeads to VEGF induced choroidal endothelial cell proliferation,a cell culture model of choroidal neovascularisation. Furtherdetailed mechanistic evaluation of SIRT1 in choroidal neo -vascularisation may serve as a therapeutic target for age relatedmacular degeneration.

104Analysis of Intravitreal Anti-VEGF on ChoroidalThickness in Neovascular AMD Using SD-OCT

Caio V. Regatieri, MD, PhD (Boston, MA), Lauren A. Branchini, BA, Mehreen Adhi, MDIgnacio Flores-Moreno, Varsha Manjunath, BS, J.G. Fujimoto, Jay S. Duker, MD*

PURPOSE To evaluate choroidal thickness using spectral domainoptical coherence tomography (SD-OCT) imaging both beforeand six months after initiation of treatment with intra vitrealanti-vascular endothelial growth factor (anti-VEGF) in patientswith neovascular age-related macular degeneration (AMD).

METHOD For this prospective case-control investigation, 22 eyesof 22 patients with neovascular AMD were identified prior tofirst-time anti-VEGF treatment. All patients with concomitantocular pathologies were excluded. Twenty healthy eyes of 20subjects without ocular pathology were also identified. Patientswere imaged with SD-OCT prior to first time treatment withanti-VEGF, 3 and 6 months subsequently. Healthy eyes wereimaged at the time of identification and 6 months subsequently.Sub-foveal choroidal thickness measurements were manuallyperformed by two independent observers. Two-way ANOVAwith Bonferroni’s post-test and paired t-tests were used tocompare measurements.

RESULTS A total of 22 eyes of 22 patients were included in this study. Twenty two patients were scanned at 3 months and 17 patients were scanned at 6 months. 5 patients were lostto follow-up. Average age of patients is 79 (range 66-88). Sub -foveal choroidal thickness was thinner at 6 months by 18.0µm(95% CI 4.7µm to 31.3µm) compared with pre-treatment. No significant difference between pre-treatment and 3 monthswas observed 13.7µm (95% CI -2.0 µm to 29.5 µm). Subfovealchoroidal thickness in healthy eyes did not decrease over 6 months p=0.722.

CONCLUSION Over a three month period, treatment with intra -vitreal anti-VEGF for neovascular AMD is not associated withsignificant choroidal thinning. However, over 6 months, use ofintra vitreal anti-VEGF is associated with significant thinning of the choroid where choroidal thickness of healthy eyes over6months remains stable. This may have implications for thephysiologic functions of the choroid.

Graph of mean choroidal thickness in normal subjects and diabeticpatients. Mean choroidal thickness at each of the 11 locations measured at 500 μm (0.5 mm) intervals temporal (T) and nasal (N). NPDR: non-proliferative diabetic retinopathy; DME: diabetic macularedema; PDR: proliferative diabetic retinopathy. P-value represents theresult of statistical analyses (ANOVA).

AMD – NEOVASCULAR


SCIENTIFIC POSTER ABSTRACTS

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105Impact of Availability of Anti-VEGF Therapy on Legal Blindness and Other Levels of Visual Impairment Due to Neovascular AMDJohn P. Campbell, MD (Baltimore, MD), Susan B. Bressler, MD*, Neil M. Bressler, MD*

PURPOSE Theoretical modeling suggests that anti-VEGF therapymay reduce the frequency of legal blindness substantially due tochoroidal neovascularization (CNV) secondary to age-relatedmacular degeneration (AMD), assuming access to and appli-cation of monthly ranibizumab for 2 years. This study wasperformed to determine if this hypothesis is supported byoutcomes noted within a clinical setting.

METHOD A retrospective cohort study of patients with incidentneovascular AMD in 2002 and 2008. Main eligibility criteriawere as follows: age > 50; incident CNV due to AMD in 2002or 2008, and at least 12 months of follow-up. The primaryoutcome was prevalence of legal blindness (20/200 or worse inthe better-seeing eye). Secondary outcomes included preva-lence of moderate visual impairment or worse (20/80 or worsein the better-seeing eye) or mild visual impairment or worse(20/40 or worse in the better-seeing eye) at two years. Additionaloutcomes included the percentage of patients with 20/200 orworse, 20/80 or worse, or 20/40 or worse in the study eye at two years.

RESULTS The 2002 cohort consisted of 91 eyes of 84 patients;the 2008 cohort had 43 eyes of 41 patients. Two years afterpresentation, the prevalence of legal blindness was 29% (95%confidence interval [CI]: 19% to 39%) in the 2002 cohort and2% (95% CI: 0.1% to 13%) in the 2008 cohort, a 95%reduction in odds of legal blindness (P = 0.006) in the 2008cohort relative to the 2002 cohort (95% CI: 59% to 99.5%);the prevalence of moderate visual impairment or worse was45% (95% CI: 34% to 56%) in the 2002 cohort and 17% (95% CI: 5% to 29%) in the 2008 cohort, a 78% risk reduction(95% CI: 33% to 92%) in odds of moderate visual impairment(P= 0.007); a difference in the prevalence of mild visualimpairment or worse between the two cohorts was notidentified. The reduction in prevalence of 20/200 or worse,20/80 or worse, and 20/40 or worse in study eyes 2 years afterpresentation of CNV in the study eyes appeared similar to theresults for the better-seeing eyes of each subject.

CONCLUSION Although there are several limitations to thisretrospective study, the conclusions provide additional evidencethat AMD no longer may be the leading cause of blindnessamong people in the United States over age 50, especially ifaccess and application of ranibizumab as often as every month is available.

106OCT in the Management of Neovascular AMD: A Comparison of Spectral-domain and Time-domain Retinal Imaging Systems

David M. Brown, MD* (Houston, TX), James C. Major, MD, PhD*, Angeline Mariani, MD

PURPOSE Most patients with neovascular AMD are treated with intra vitreal anti-VEGF agents guided by ocular coherencetomography (OCT). To assess the relative sensitivity ofcommonly available OCT machines and to test the hypothesisthat spectral domain (SD) OCT would detect more diseasethan time-domain (TD) OCT, we performed a head to headcomparison in a population with a high prevalence of retinalpathology.

METHOD Stratus 512 A-scan 6-line OCT scans, Cirrus HD 512 x 128 macular thickness cube scans, Cirrus HD 5-line rasterscans, Spectralis OCT high resolution 6-line 20 degree radialscans with 9x averaging, Spectralis OCT high resolution 7-lineRaster scans with 15x averaging, and a custom Spectralis OCThigh speed 49 scan 20x20 degree macular volume scan with 9xaveraging were performed on 50 patients at each exam in theprospective Super Dose Anti-VEGF (SAVE) trial evaluating2.0 mg ranibizumab for refractory neovascular AMD and wereanalyzed independently for signs of disease. Comparisonsbetween time-domain and spectral-domain were made withFisher exact test.

RESULTS Out of 191 total visits, the Stratus identified evidenceof disease activity on 72.4% of exams where pathology wasvisualized by any machine (118/163), the SD Cirrus HDidentified pathology on 93.9% (153/163) of exams (p<0.001compared to Stratus), and SD Spectralis OCT 99.4% (162/163)of exams (p<0.001 compared to Stratus). As many practitionersbase retreatment decisions only on pathology above the RPE,classification of disease was defined as the presence of intra -retinal cysts or subretinal fluid. Stratus imaging failed toidentify a cyst in 36.1% of exams positive on any machine(30/83) and failed to identify subretinal fluid in 33.6% of exams positive for such on any machine (39/116) (p<0.001).Sensitivity for identifying subretinal fluid and intraretinal cysts is shown in the figure below. With both spectral-domainmachines, examination of all lines of the cube was most likely to identify pathology.


CONCLUSION In a population with a high prevalence ofpathology, spectral-domain OCT (SD Cirrus HD and SDSpectralis OCT) significantly identified more disease activitythan the highest resolution scan available on the time-domainStratus machine. For the most vigilant screening and manage -ment of neovascular AMD, careful examination of all lines ofthe spectral-domain cubes is recommended.

Neovascular AMD OCT pathology identified by TD or SD OCT scanning in the SAVE 2.0 mg ranibizumab trial for recalcitrant AMD.

107Predictive Factors for Repeat Dosing in Wet AMD: Results from the DODO Trial

Brandon G. Busbee, MD (Nashville, TN)*, Chengqing Wu, MD, Mary Ann McCain, MD

PURPOSE This report from the DODO (“double dose”) trialevaluates baseline characteristics, including duration ofsymptoms and baseline ETDRS score, and ranibizumab dose(0.5mg, 1.0mg or 2.0mg) for their effect on the timing of thesecond ranibizumab injection for naïve wet AMD.

METHOD This is an on-going prospective single-masked, single-center, randomized two-year trial comparing 0.5mg, 1.0mg and 2.0mg PRN ranibizumab injections for naïve wet AMD.Following the initial injection at baseline, additional injectionsare given only if ETDRS vision decreased by 5 letters or opticalcoherence tomography (OCT) demonstrated recurrent fluid.During the first 6 months of this trial, subjects are evaluatedbimonthly. Baseline factors, including weeks of patient-reportedsymptoms prior to the initial treatment and baseline ETDRSscore, and ranibizumab dose were analyzed as potentialpredictors of timing for the second ranibizumab injection.

RESULTS 25 subjects were included in this analysis. The onlybaseline characteristic that was significantly correlated with theinterval between first and second ranibizumab injections was

the patient-reported symptoms prior to initial injection. Multi-variate regression analysis demonstrates one additional week ofsymptoms prior to treatment will lead to 0.55 weeks less forinjection interval. When an arbitrary cutoff of ≤4 weeks ofsymptoms prior to treatment versus subjects with >4 weeks ofsymptoms prior to treatment was analyzed, the mean time torepeat injection was 10.92 weeks versus 5.75 weeks (p<0.0001),respectively. Ranibizumab dose did not appear to influencetiming of the second injection.

CONCLUSION In the first study to evaluate a higher dose ofranibizumab using a purely PRN dosing regimen for wet AMD,baseline characteristic analysis suggests patient-reportedduration of symptoms is predictive in the timing of the secondranibizumab injection. Long-term data from this trial is neededto better define predictive factors and ranibizumab treatmentinterval.

108Resveratrol Inhibits Proliferation of Choroidal Endothelial Cells in Hypoxia: A Model for Neovascular AMD

K.V. Chalam, MD, PhD, MBA, FRCS(C) (Jacksonville, FL), Vijay Khetpal, MD, Sankarathi Balaiya

PURPOSE Resveratrol, a common antioxidant present in redwine and natural plants has been shown to be anti-angiogenicin carcinoma and modulates vascular endothelial cell functionin diverse angiogenic beds. We evaluated its role in regulationof choroidal endothelial cell proliferation after chronic hypoxia,a cell culture model of age related macular degeneration.

METHOD Choroidal endothelial cells (RF/6A) were maintainedin a semi-confluent state. Hypoxia was induced using cobaltchloride at two different concentrations to mimic lower andhigher hypoxia (200 and 400µM) and degree of hypoxia wasconfirmed with flow cytometric analysis. Cells were thenexposed to escalating doses of resveratrol from 2, 4, 8, 12µg/mland cell viability was analysed by WST-1 assay. Followingoptimization, the effect of resveratrol (4 and 12µg/ml) onhypoxic cells was evaluated. Further, hypoxia induced VEGFrelease from choroidal endothelial cells was assessed withELISA.

RESULTS We observed a dose dependent increase of cell viability(127.43±1.6%, 136.33±1.8%, 132.9±2.5% and 115.6±2.3% atdoses of 2, 4, 8 and 12µg/ml) of hypoxic choroidal endothelialcells (200 µM) that were exposed to resveratrol compared tocontrols. Similar trend continued at higher levels of hypoxia

AMD – NEOVASCULAR



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(400 µM). Cell viability decreased to 45.4±2.7% after severehypoxia but was rescued with addition of resveratrol at 4µg/mlto 76.1±5.6% (p value <0.01). The VEGF levels proportion-ately decreased from 20.78±3.8pg/ml to 13.44±4.6pg/ml afteraddition of resveratrol (4µg/ml).

CONCLUSION Exudative AMD is characterized by hypoxic proliferation of choroidal endothelial cells. Resveratrol inhibitshypoxia induced proliferation of choroidal endothelial cells andhas potential to be of therapeutic use in exudative form of agerelated macular degeneration.

109Visual Outcomes of Intravitreal Anti-VEGFTherapy for Neovascular AMD with Advanced Visual Loss at Initial Presentation

Nauman A. Chaudhry, MD (New London, CT), Homayoun Tabandeh, MD*, Veronica A. Kon-Jara, MD, David S. Boyer, MD*, Nikolas London, MD, Thomas G. Chu, MD, PhD*

PURPOSE Many clinical studies that established the beneficialeffect of intra vitreal anti-VEGF therapy did not include thecohort of patients with poor presenting visual acuity. Thepurpose of the current study is to report outcomes of intra vitrealanti-VEGF therapy for Neovascular AMD (nvAMD) inpatients with presenting best corrected visual acuity (BCVA) < 20/400.

METHOD Retrospective case series. Inclusion criteria: patientswith previously untreated nvAMD and presenting BCVA<20/400. Exclusion criteria: subretinal fibrosis involving centralfovea, subfoveal hemorrhage greater than 1 disc area, presenceof other ocular pathology reducing vision.

RESULTS Twenty two eyes of 22 patients, mean age 80.6 (range70-97) years. BCVA at presentation was 20/400 in 7 (32%),and worse than 20/400 in 15 (68%) patients. Treatmentincluded ranibizumab in 11, bevacizumab in 8, and ranibizumaband bevacizumab in 3 patients. At the last follow-up (mean16.1 months) BCVA was >20/40 in 5 (22%), 20/50-20/100 in 3 (14%), 20/200 in 4 (18%), 20/400 in 6 (27%), and <20/400in 4 (18%) eyes. Mean number of injections was 7.3 injections.

CONCLUSION In the absence of subfoveal fibrosis or extensivesubretinal hemorrhage, anti-VEGF therapy may be beneficial in patients with previously untreated nvAMD and severe visionloss. Treatment decisions should not be based on presentingvisual acuity but on the characteristics of the lesion. Larger,prospective studies are needed to better answer this importantclinical question.

110Epimacular Brachytherapy in Treated AMD Patients: The MERITAGE Study 18 Month Results

Pravin U. Dugel, MD* (Phoenix, AZ), Tim Jackson, MD, Michael Bennett, MD, Adiel Barak*, MD, Dov Weinberger, MD

PURPOSE To assess the safety and efficacy of epimacularbrachytherapy (EMBT) in previously treated neovascular age-related macular degeneration (nAMD) patients.

METHOD 53 patients with previously treated classic, minimallyclassic and occult lesions were enrolled. Patients had received a mean of 12 injections prior to enrolment. Patients underwentpars plana vitrectomy and 24 Gray beta irradiation, using aninvestigational device to deliver Strontium-90 brachytherapy(NeoVista). Anti-VEGF injections were administered if therewas a 5 ETDRS letter loss, >50 micron central retinal thicknessincrease on optical coherence tomography (OCT), newmacular hemorrhage, or new lesion activity, visible with fundusfluorescein angiography (FFA). The response to EMBTaccording to lesion type was studied.

RESULTS 18 months after EMBT, a mean of 5.6 anti-VEGFinjections, including the mandated injection at baseline, wasrequired.18% of patients remained injection free and 47%improved vision (mean improvement 7.5 letters). 84% ofpatients did not lose more than 15 ETDRS letters. At 12months 67% of patients with a classic lesion component and100% with a predominantly classic lesion showed completelesion regression.

CONCLUSION Patients requiring chronic anti-VEGF treatmentrepresent a rapidly growing population. This is the first studywith the longest follow-up in these difficult patients who bearthe burden of our current, unsustainable monotherapy treat -ment. EMBT not only reduced the treatment burden, but alsoimproved vision and caused significant neovascular membranelesion regression in selected patients.


111Comparison of Anti-VEGF Agents Administered by PRN Dosing for the Treatment of Neovascular AMD

Alan J. Franklin, MD, PhD (Mobile, AL), John P. Myers, MD, Magdalena Shuler, MD, Neel M. Kumar, Sunil Gupta

PURPOSE This study aims to compare the efficacy ofbevacizumab alone or mixed with low dose triamcinolone withranibizumab. To determine the relative effectiveness of thesetreatments we collected 3, 6, and 12 month data that includedvisual acuity, central OCT thickness, treatment burden as wellas incidence of CNVM in the fellow eye over a two year period.

METHOD This is a retrospective chart review of approximately130 patients who received either intra vitreal injection ofbevacizumab or ranibizumab in a treat and extend algorithim aswell as 300 patients who received intra vitreal injection ofbevacizumab combined with 750 micrograms of triamcinolonein a PIER-type protocol of every three month injection for thetreatment of neovascular AMD. We measured Snellen visualacuity, central macular thickness analyzed by time domain OCTat 3, 6, and 12 months after new onset of CNVM. We alsocompared the treatment burden amongst each group over theinitial 12 months of treament as well as incidence of newneovascularization in the fellow eye over 2 years.

RESULTS We compared patients who received intra vitreal injec-tions of bevacizumab (Bev), bevacizumab with triamcinolone(Bev + TA), or ranibizumab (Ran). Patients were similar withrespect to initial visual acuity, OCT thickness, sex, and eyeaffected, whereas patients that received Ran tended to be olderthan those injected with Bev or Bev + TA. After 1 year patientsin the Bev and Ran groups had an almost identicalimprovement in Logmar visual acuity, 0.09 p=0.98. The averagechange in Central OCT thickness was similar with a 37 and 54micron reduction for Bev and Ran, respectively, p=0.50.Patients with Bev required less injections over the first year toachieve these results, 6.01 vs. 7.35, p<0.05. However, dimin-ishing the treatment further by administering Bev + TA in aPIER-type protocol, 5.23 injections over 1 year, led only tovisual stabilization, Logmar difference 0.01, p<0.05 compared toBev and Ran together. Finally, incidence of new CNVM in thefellow eye was similar in all groups.

CONCLUSION On average patients who received intra vitrealbevizumab or ranibizumab for new onset neovascular AMDgained one line of vision, Logmar 0.09, and the visual benefitfrom each of these ani-VEGF agents was virtually identical,p=0.98. Less injections of bevacizumab 6.01 vs. 7.35, p <0.05were needed to achieve this goal. A PIER type approach with5.23 injections was less effective, Logmar change 0.01.

Comparison of Intravitreal Bevacizumab and Ranibizumab 12 month data for the treatment of neovascular AMD. Intravitreal injection of both Bev and Ran improved Logmar vision by 1 line, 0.09, p=0.98. Thedifference in OCT thickness was also similar for Bev, 37 microns, and Ran 54 microns, p =0.50. However, the treatment burden of Bev wassignificantly less than Ran, 6.01 vs. 7.35 injections, p<0.05.

Comparison of Intravitreal anti-VEGF treat and extend vs. PIER-typealgorithim 12 month data for the treatment of neovascular AMD. Intravitreal injection of both Bev and Ran improved Logmar vision by 1 line, 0.09, and was superior to a PIER type approach Logmar 0.01,p<0.05. However, the change in OCT thickeness was similar 47 micronsfor treat and extend, and PIER type protocol 25 microns, p=0.19.

112Validity of Administrative Databases in Characterizing Veterans with Neovascular AMDPaul B. Greenberg, MD* (Providence, RI), Victoria L. Tseng, MD, Wen-Chih Wu, MD, Lan Jiang, MD, Peter D. Friedmann, MD

PURPOSE To evaluate the accuracy of VHA national codingdatabases by comparing characteristics of neovascular AMDpatients identified using administrative coding data versus acontent-based chart review.

METHOD Neovascular AMD patients at the Providence VAMedical Center (PVAMC) were identified using InternationalClassification of Diseases-Modification 9 (ICD-9) codes. Acontent-based chart review was performed on this cohort toidentify patients treated with ranibizumab or pegaptanib; thesecharts were then reviewed for demographics, systemic comor-bidities from the Charlson Comorbidity Index (CCI), andarterial thromboembolic events (ATEs) within one year of firstAMD treatment. The National Patient Care Database (NPCD)was used to identify the same parameters at PVAMC usingadministrative codes. Coding data was compared against chartdata for accuracy, sensitivity, and specificity.

RESULTS Of 434 patients from chart review and 424 patientsfrom coding review, the two methods found 405 commonpatients with a new diagnosis of neovascular AMD from 2002-2009. Identification of AMD treatment with ranibizumab orpegaptanib, systemic comorbidities, and ATE incidence wascompared. Accuracy was highest identifying systemic comor-

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bidities in pegaptanib-treated patients (1.00) and the studypopulation (0.99), and lowest identifying ATEs in pegaptanib-treated patients (0.50). Sensitivity was highest identifyingpegaptanib-treated patients (1.00; 95% confidence interval [CI] 0.46,1.00) and ranibizumab-treated patients (0.90; 95% CI 0.77,0.96), and lowest identifying ATEs in ranibizumab-treated patients (0.00; 95% CI 0.00,0.8). Specificity was highestidentifying systemic comorbidities in ranibizumab-treatedpatients (1.00; 95% CI 0.05,1.00) and the study population(0.99; 95% CI 1.00,1.00), and lowest identifying ATEs inpegaptanib-treated patients (0.50; 95% CI 0.13,0.86).

CONCLUSION With chart content as the gold standard, codingdata is excellent in identifying neovascular AMD diagnosis andtreatment. However, coding data is poor in identifying ATEincidence after AMD treatment. These findings suggest thatadministrative data should be interpreted with caution andvalidated against chart content when being used as the soledata source in retrospective research studies.

113Frequent Dosing of Intravitreal Anti-VEGFAgents for Treatment Refractory Neovascular AMDYu Hyon Kim, MD (Portland, OR), Christina J. Flaxel, MD, Peter Francis, Thomas S. Hwang, MD

PURPOSE This study evaluates the effects of shorter (2-3 weeks)than conventional monthly dosing interval of intra vitreal antiVEGF agents for treatment refractory neovascluar age relatedmacular degeneration.

METHOD A retrospective chart review was conducted on AMD patients who were receiving anti-VEGF treatments(bevacizumab or ranibizumab) from January 2009 to March2011 at The Casey Eye Institute. Patients who receivedfrequent anti-VEGF treatment (2 to 3 week dosing intervals)versus a conventional treatment regimen (4-6 week dosingintervals) for at least 3 consecutive injections at any timeduring the treatment course were included in the study. Visualacuity, central macular thickness (CMT), as measured on SDOCT, and the resolution of subretinal or intraretinal fluid were analyzed.

RESULTS 8 eyes of 8 patients were included in the study. Theaverage number of consecutive injections was 6.13 (range 3-17). The mean number of injections prior to increasing thedosing frequency was 25 injections (range: 8 - 49). Mean visualacuity prior to the increase in frequency was logMAR 0.407(SD=0.123) and after the increased frequency was logMAR0.365 (SD=0.132) (p=0.132). The mean central macularthickness (CMT) as measured on SD-OCT before the increasewas 352.2 um (SD=56.1) and after the increase was 294.3 um(SD=63.9) (p=0.055). The mean decrease in CMT was67.5um. Seven out of 8 patients demonstrated a decrease inCMT on SD OCT after increasing the dosing frequency. Morefrequent injections resulted in the resolution of intraretinal orsubretinal fluid in 6 out of 8 patients. Two out of the 6 patients

with a resolution of fluid with more frequent dosing requiredcontinued frequent injections to maintain vision and anatomic stability.

CONCLUSION An increase in the frequency of anti-VEGF dosing can result in the restoration of macular anatomy and areduction of CMT in treatment-refractory AMD patients. Thistreatment alternative should be considered in patients who arenon-responsive to conventional dosing regimens.

114One-year Results of Intravitreal Ranibizumab for Polypoidal Choroidal Vasculopathy

Young Jung Roh, MD (Seoul, South Korea), Hyun-Wok Ryu

PURPOSE To evaluate the efficacy of intra vitreal ranibizumabadministration with three initial monthly injections for thetreatment of polypoidal choroidal vasculopathy (PCV) in Korean.

METHOD A retrospective chart review of 20 patients (21 eyes)with PCV was conducted. Patients received three initialmonthly intra vitreal injections (0.5 mg) of ranibizumab andmonitored monthly for 12 months. Reinjection of ranibizumabafter three initial monthly loading was administered on as-needed basis guided by optical coherence tomography(OCT),fluorescein angiography(FAG) and indocyanine green angiog-raphy(ICGA). The main outcome measures were the change ofmean best corrected Snellen visual acuity and central macularthickness by OCT, the changes of polyps and branchingvascular network, and total number of injections received bypatients during the 12 months.

RESULTS The mean best corrected Snellen visual acuities atbase line, 1 month, 3 months, 6 months, 9 months, and 12 monthsafter primary injection were 0.59±0.43, 0.44±0.38, 0.45±0.44,0.43±0.35, 0.44±0.43, 0.38±0.35 logMAR, respectively andshowed significant improvement at 1,6,9 and 12 months (p<0.05,Wilcoxon signed-ranks test). The mean CMT at baseline, 1month, 3 months, 6 months, 9 months, and 12 months was289.91±114.24µm, 201.13±96.38µm, 173.22±55.57µm,181.70±78.38µm, 167.90±56.65µm, 171.45±46.35µm respec-tively, and showed significant reduction (p<0.05, Wilcoxonsigned-ranks test). Polypoidal lesions disappeared on ICGA in 3 eyes (14.2%) and a branching vascular network remained in18 eyes (85.7%). On the average, additional 1.30 injectionswere given after initial three injections over the 12 months.

CONCLUSION Intravitreal ranibizumab administration with three initial monthly injections for the treatment of PCVresulted in visual and anatomical improvement over one year follow-up.


115Anti-VEGF Monotherapy for Neovascular AMD in Vitrectomized Eyes

Kamal Kishore, MD, MBBS (Peru, IL), Sachin Jain, MD

PURPOSE Intravitreal injections of anti-VEGF medications haverevolutionized the management of N-AMD. Pivotal studies thatled to the FDA approval of ranibizumab excluded eyes withprior vitrectomy. It is well established that an intra vitreal drugis cleared faster in vitrectomized eyes. We, therefore, conducteda chart review to evaluate the efficacy of anti-VEGFmonotherapy in such eyes.

METHOD A retrospective chart review of 9 eyes with N-AMDthat had undergone a PPV and were treated with anti-VEGFmonotherapy was performed. Four eyes were treatment naïve,having undergone a PPV for macular hole (MH), macularpucker, retinal detachment and endophthalmitis 7,22,48 and 22 months prior to the onset of N-AMD. Five eyes were beingtreated for N-AMD with anti-VEGF monotherapy at the timeof PPV, which was performed 3-47 mos (mean 15) after thediagnosis of N-AMD for VMT (2 eyes), endophthalmitis (2 eyes) and MH (1 eye). Complete eye examination, FA andOCT were performed and monthly anti-VEGF monotherapywas initiated, or continued. Eyes with > 6months follow-upwere included.

RESULTS Treatment naïve group: Baseline Snellen VA at thetime of diagnosis of N-AMD was 20/25, 20/70, 20/400 and20/25 respectively. All eyes had a PCIOL. Three had occultCNVM and 1 classic. Treatment consisted of monthly intra -vitreal injections of bevacizumab (3 eyes) and ranibizumab (one eye). After 15, 25, 21 and 6 mos (mean 17) follow-up, alleyes showed improved or stable vision. A total of 14, 21, 16,and 5 injections were given respectively. Case 1 was switched to ranibizumab after 9 bevacizumab injections. Case 3 alsorequired 2 intra vitreal triamcinolone injections and a PDT.

Eyes with prior N-AMD: VA after PPV was 20/400, 20/200.20/80, 20/400 and 20/60. Three eyes were treated withbevacizumab, and two with ranibizumab. Case 3 was switchedto ranibizumab after 9 bevacizumab injections, and was treatedwith PDT after 5 ranibizumab injections. Final VA was 20/200in 3 eyes,counting fingers in one (Case 3) and 20/30 in one(Case 5). Poor VA was due to central GA in 3 eyes andunresponsive CNVM in one (Case 3).

CONCLUSION Monthly injections of anti-VEGF agents cancontrol N-AMD in most vitrectomized eyes. Both treatmentnaïve and those with pre-existing N-AMD had a good response,with resolution of subretinal and intraretinal fluid andimprovement or stabilization of VA in most eyes. Poor visualoutcome was mostly due to central geographic atrophy, andrarely due to progression of N-AMD.

116A Pilot Study of Pharmacogenetics as aPredictor of Outcome in Patients ReceivingIntravitreal Anti-VEGF Therapy in AMD

John W. Kitchens, MD* (Lexington, KY), Edward Wood, MD, William J. Wood, MD, Rick D. Isernhagen, MD, Thomas W. Stone, MD*, Nawal Kassem, MD, Lang Li, MD, Bryan Schneider, MD

PURPOSE Inhibition of VEGF is the standard therapy for wetAMD. The arbitrary duration of therapy and heterogeneouseffectiveness necessitates the need for predictive biomarkers.Prior studies have demonstrated that SNPs in CFH andARMS2 were correlated with progression to wet AMD. Thisstudy compares candidate genotypes with outcome for patientsreceiving intraocular anti-VEGF therapy.

METHOD Patients were identified by chart review and werecharacterized by one of 4 possible clinical outcomes with anti-VEGF treatments: 1) indefinite responders, 2) delayed relapser,3) immediate relapser, and 4) never responder. Saliva wascollected from the identified patients and DNA was extractedusing Oragene® DNA sample collection kit by DNA Genotek.Samples were then genotyped for candidate SNPs in the VEGF,CFH, and LOC387715 genes by Taqman-based Real Time-PCR. Genotypes and phenotypes were compared using achi-square test.

RESULTS 99 of 100 patients that were recruited were successfullygenotyped for all SNPs. The distribution of the 4 clinicaloutcomes was: indefinite responder (35%), delayed relapser(16%), immediate relapser (27%) and never responder (20%).Patients who carried the LOC387715 TT genotype were significantly more likely to be classified as a never responder(9/16) compared to those with alternate genotypes (12/84); p-value=0.0007. VEGF and CFH genotypes did not correlatewith therapeutic outcome.

CONCLUSION Our results suggest that those patients with AMD that carry the LOC387715 TT genotype not only have a higher risk for progressive AMD, but also have a markedlyhigher likelihood of not responding to standard anti-VEGFtherapy. Alternative therapies for this genetic subgroup shouldbe investigated.

117Triple Combination Therapy for Anti-VEGF Non-responders: A Retrospective Case SeriesJacob C. Lee, MD (Toronto, Canada), Wai-Ching Lam, MD, FRCS(C)

PURPOSE To report the effects of triple combination therapywith verteporfin photodynamic therapy (PDT), anti-vascularendothelial growth factor (anti-VEGF), and dexamethasone ona series of patients with neovascular AMD non-responsive toanti-VEGF monotherapy.

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METHOD A retrospective, observational, single center case series.9 consecutive patients with neovascular AMD who demon-strated poor anatomical response to 3 or more monthlyintra vitreal anti-VEGF injections were offered triple therapywith verteporfin half-fluence PDT, anti-VEGF, and intra vitrealdexamethasone from October 2008 to October 2010 at theToronto Western Hospital. After 3 or more treatments of anti-VEGF monotherapy, poor anatomical response was defined ascentral foveal thickness (CFT> 250 microns, and/or a change of CFT in response to anti-VEGF monotherapy < 50 microns.Vision and CFT were measured prior to initiation of tripletherapy, and at 2 and 3 month follow-up visits.

RESULTS The average number of anti-VEGF injections prior toinitiation of triple combination therapy was 10.0. At the threemonth follow-up visit: 88.9% of the patients had stable orimproved vision. The mean change in central foveal thicknesswas – 194.8 microns. 77.8% of patients had decreased CFT.

CONCLUSION Previous studies investigated combination therapyand found limited statistical differences between combinationtherapy and monotherapy ranibizumab when used as theprimary treatment. Our case series shows patients who fail todemonstrate an appropriate response to anti-VEGF mono -therapy may benefit with an anatomic response and visualstability from triple combination therapy.

118Oral Zeaxanthin Improves Anatomic and Visual Outcome of Triple Therapy for Subfoveal CNV in AMD, Prelim. ReportEnrique Peralta, MD (St. Louis, MO), R. Joseph Olk, MD, Samir I. Sayegh, MD, PhD, Dennis Gerhardt, MD

PURPOSE This consecutive case-controlled study was under-taken to determine whether the addition of 20mg of daily oralzeaxanthin would improve the anatomic and visual outcome ineyes with subfoveal CNV treated with triple therapy intra -vitreal bevacizumab, intra vitreal dexamethasone, and eitherprotodynamic therapy with Visudyne (classic CNV) or large-spot diode laser (occult CNV).

METHOD 143 eyes of 129 patients were placed on 20mg/day oforal zeaxanthin and sequentially treated with intra vitrealbevacizumab, intra vitreal dexamethasone, and either photo -dynamic therapy with Visudyne (classic CNV) or large-spotdiode laser (occult CNV) and followed for up to two years.Additional cycles of treatment were applied every six to eightweeks until the eyes were deemed stable anatomically andvisually. Criteria for retreatment included residual macular fluidon clinical examination, increased central foveal thickness onOCT, persistent leakage on Fluorescein Angiography, persistentplaque on ICG angiography, and /or worsening of visual acuity.

RESULTS 90% of eyes had stable or improved vision: 10%improved 3 or more lines (15 letters ETDRS), and 10% wereworse by 3 or more lines. Of 116 eyes with occult CNV, 89 eyes(77%) required 1 cycle of treatment; 19 eyes (16%) – 2 cycles;and 8 eyes (7%) – 3 or 4 cycles to stabilize. Of 27 eyes withclassic CNV, 23 eyes (85%) required 1 cycle: 3 eyes (11%) –2 cycles; and 1 eye (4%) – 3 cycles. Overall, the number oftreatment cycles for occult CNV were 1.7 at one year; 2.1 attwo years. The number of treatment cycles for classic CNV was1.55 at one year; 1.60 at two years. Compared to previouslyreported series of triple-therapy by the same authors, theaddition of 20mg/day of oral zeazanthin reduces the number oftreatment cycles on average by 25% at one year and 33% at twoyears with comparable visual results.

CONCLUSION These results suggest that the addition of 20mg./day oral zeaxanthin to patients undergoing triple-therapy forexudative age related macular degeneration reduces the numberof treatment cycles required to achieve anatomic stabilizationwith comparable visual results.


119A Closer Look at the Visual Landscape of Anti-VEGF Therapy of Wet Macular Degeneration: Lessons from OCT/SLOMicroperimetry on Function and Fixation

Richard B. Rosen, MD* (New York, NY), Gennady Landa, MD, Thomas O. Muldoon, MD, Patricia Garcia, Katy Tai, MD, Ronald C. Gentile, MD*, Alfonso Ponce

PURPOSE Anti-VEGF therapy of choroidal neovascularizationproduces functional-anatomic changes in the visual world ofpatients which are incompletely described by visual acuities orOCT imaging alone. OCT/SLO microperimetry was performedserially on naïve patients initiating ranibizumab therapy to testits value in elucidating the relationship between thickness,visual field, visual acuity and fixation.

METHOD Prospective case series of 10 patients with naïve CNVsecondary to AMD receiving monthly intra vitreal ranibizumab(0.5 mg/0.05 mL) injections during the first four months oftreatment. Best-corrected visual acuity (BCVA), assessed usingthe Early Treatment Diabetic Retinopathy Study (ETDRS)chart, microperimetry (MP) and central retinal thickness(CRT), obtained using the OCT/SLO-MP (OPKO Health,Miami, FL) were recorded at baseline and at months 1, 2, 3 and4 follow-up examinations. Fixation location and spread wasassessed serially from tracking recordings on SLO maps andcompared to visual acuity changes and OCT profiles.

RESULTS Ten patients (age, 75.8±8.3 years) had a Mean BCVAof 62.4±18.8 letters at baseline and 72.3±13.4 letters (P = 0.02)at month 4. Mean BCVA improved after 1st and 2nd injectionsbut not after 3rd and 4th injections. Mean MP scores atbaseline were 8.75±4.9 and 11.5±5.5 (P=0.016) at month 4.Mean Retinal Sensitivity progressively improved during the firstfour months of treatment most significantly following the 1stand 4th injections. Central Retinal Thickness decreased from340.6±52.9µ at baseline to 264.0±38.2µ at 4 months (P = 0.01).Monthly analysis of mean CRT change showed substantialimprovement following the 1st injection only. Mean MP andETDRS scores showed significant correlation (r = 0.69,p<0.001), as did MP and central macular thickness (r = 0.528,p=0.01). ETDRS scores and central macular thickness showedlimited correlation(r=0.33, p=0.043). Fixation location variedaccording to the distance of the membrane from the center ofthe anatomic fovea.

CONCLUSION Microperimetry appears to correlate better with CRT than ETDRS and may provide better indication ofretinal functional improvements in neovascular AMD patientstreated with Ranibizumab. The ability to track visual sensitivity,structure, and fixation appears to paint a more accurate pictureof the patient’s visual lanscape than conventional visual acuity testing.

120Retrospective Study of Long-term Efficiency of PDT of Central Serous Chorioretinopathy

Masaaki Saito, MD (New York, NY), David W. Switzer, MD, Richard F. Spaide, MD,* Jason Slakter, MD*, K. Bailey Freund, MD*, Irene A. Barbazetto, MD, Lawrence A. Yannuzzi, MD

PURPOSE To examine the long-term efficiency of photodynamictherapy (PDT) in central serous chorioretinopathy (CSC)patients.

METHOD All patients with CSC treated with PDT fromDecember 4, 2001 to January 27, 2011 were retrospectivelyreviewed. All patients had PDT guided by indocyanine green(ICG) angiography findings of hyperpermeability. Eyes withpre-existing choroidal neovascularization (CNV) wereexcluded. Eyes were retreated with PDT if there was not acomplete resolution of subretinal fluid as determined by opticalcoherence tomography. Risk factors were evaluated with logisticregression and visual acuity outcomes were assessed with gener-alized estimating equation (GEE) analysis.

RESULTS There were 77 patients with mean age 59 yearscollected over 41 months. Of 94 eyes, 33 had classic CSC and61 had chronic CSC. A single PDT session was used for 68eyes, in which visual acuity changed from 20/80 (logMAR0.594) to 20/60 (logMAR 0.47, P<.001). CNV developed in 3 eyes (4.4%). The remaining 26 eyes had >1 PDT session(range=2-5, mean 2.54). The mean visual acuity in the multiplytreated eyes was 20/147 at baseline (logMAR 0.866) and was20/152 (logMAR 0.882) at follow-up, a change that was notsignificant (P=.79). Of the 26 eyes with >1 PDT, 11 eyes gotCNV (42.3%, P<.001) as compared with single treatment. Bylogistic regression, the predictors of secondary CNV were longerfollow-up time and having >1 PDT. Full vs. half-fluence PDTwas not a significant predictor for CNV development. GEEanalysis showed the 2 significant predictors of follow-up visualacuity were pre-treatment acuity and having only 1 PDTtreatment as compared with multiple PDT treatments.

CONCLUSION PDT as guided by ICG angiography in a singlesession was associated with a long-term improvement in visualacuity in treated CSC patients. Caution should be taken whenconsidering any additional PDT sessions as there appears to be asignificant increase in risk of developing secondary CNV withlonger follow-up times, without evidence of improved visualacuity from the additional treatment.

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121Prospective Analysis of the Incidence and RiskFactors of RPE Tears in Eyes with FibrovascularPigment Epithelial Detachment and AMD

Clement K. Chan, MD* (Palm Springs, CA), David Sarraf, MD*, Abraham Prema, MD, Asha Nuthi DO, Steven G. Lin, MD*, Sharon Theodore, MD, Colin A. McCannel, MD*

PURPOSE To prospectively determine the incidence and riskfactors for RPE tears in eyes with fibrovascular PED andexudative AMD.

METHOD Eyes with exudative AMD and FV PED were prospec-tively randomized into groups receiving either 0.5 or 2.0 MGranibizumab. Baseline and follow-up ETDRS VA, fluoresceinangiography, and OCT imaging were done to a set schedule. All PEDs were analyzed with pre and post OCT and FA todeter mine PED height and surface area (A2), greatest lineardiameter (GLD) of PED and choroidal neovascularization(CNV), and severity of subretinal fluid (SRF) and cystoidmacular edema. The group of eyes with RPE tear was comparedto the group of eyes without RPE tear to prospectivelydetermine high risk factors for tear formation. Statisticalanalysis included Wilcoxon Signed Ranks and Mann-Whitneytests.

RESULTS A total of 38 eyes in 38 patients with mean follow-upof 8.9 months were randomized. Three eyes suffered RPE tears(1 grade-2 tear, 1 grade-3 tear and 1 grade-4 tear) for anincidence of 8%. Two eyes had received 2 MG ranibizumab and1 eye had received 0.5 MG. Each PED that tore was noted tohave an early grade-1 tear at baseline upon retrospectiveanalysis. Baseline logMarVA was nearly identical (p=1.00)between the RPE tear (0.60 or 20/80) and non-tear (0.60 or20/79) groups but was statistically worse (p=0.025) in the teargroup (0.83 or 20/134) versus the non-tear group (0.43 or20/54) at the most recent visit. Baseline PED height was signifi-cantly greater (P=0.046) in the RPE tear group (661 microns)versus the non-tear group (441 microns) as was PED SA andseverity of SRF. Baseline PED GLD was also significantlygreater (p=0.018) in the tear (5050 microns) versus the non-tear (3778 microns) group.

CONCLUSION To our knowledge, this is the first study evaluatingthe incidence and risk factors of RPE tears in AMD eyes withFV PED in a prospective manner. The incidence of RPE tearswas almost 10%. PED height ≥600 microns and GLD ≥5000microns constitute a high risk for RPE tears. Careful study forpresence of early grade-1 tears in evolution in eyes with high-risk PED is warranted before treatment.

122Nonarteritic Anterior Ischemic Optic NeuropathyAssociated with Intravitreal Anti-VascularEndothelial Growth Factor Therapy

Stephen G. Schwartz, MD, MBA* (Naples, FL), Kara Dellatorre, MD, Ninel Gregori, MD, Zohar Yehoshua, MD*, K. Bailey Freund, MD*

PURPOSE To describe 4 eyes of 4 patients who developed nonarteritic anterior ischemic optic neuropathy (NAION)while receiving intra vitreal anti-vascular endothelial growthfactor (anti-VEGF) therapy for neovascular age-related maculardegeneration (AMD).

METHOD This was a retrospective review of 4 eyes of 4 patientswho developed NAION while receiving intra vitreal anti-VEGFtherapy for neovascular AMD. All patients underwent com -plete ophthalmological examination. Medical history,ophthalmic history, and follow-up data were reviewed in anattempt to identify potential risk factors for this treatment-related adverse event.

RESULTS There were 3 males and 1 female, all Caucasian. Themedian age was 81 years. All patients had a “disc at risk”. Twopatients had hypertension, and two patients had no pertinentpast medical history. The affected eyes had received a median of12 previous anti-VEGF injections prior to the onset of NAION.Patient #1 received 8 doses of bevacizumab 1.25 mg/0.05 mland later developed NAION following a single dose ofbevacizumab 2.5 mg/0.1 ml. Patient #2 received 31 anti-VEGFinjections at monthly intervals and then developed NAIONfollowing 4 injections of bevacizumab 1.25 mg/0.05 ml at 2-weekintervals. Patient #3 received 7 injections of standard-dose anti-VEGF agents followed by 8 doses of bevacizumab 2.5 mg/0.1 mlprior to developing NAION. Patient #4 developed NAIONafter 5 monthly doses of ranibizumab 0.5 mg/0.05ml. Medianvisual acuity was 20/70 prior to developing NAION, 20/80 onpresentation with NAION, and 20/100 at the last recordedfollow-up (median 9 months).

CONCLUSION This small case series suggests that NAION may be a rare adverse event associated with intra vitreal anti-VEGFtherapy. Higher or more frequent dosing of bevacizumab maypossibly increase the risk of NAION. While our sample size istoo small to draw definitive conclusions, we advise cautionwhen considering more aggressive anti-VEGF treatmentstrategies in patients with risk factors for NAION.

See images on next page.


Fundus photograph of patient #3. Fluorescein angiogram of patient #3. Note pallid disc edema. Note hyperfluoresence of optic disc.

123Dexamethasone Implant Monotherapy or As an Adjunct to Ranibizumab to TreatChoroidal Neovascularization Due to AMD

Michael A. Singer, MD* (San Angonio, TX), Sunil S. Patel, MD, PhD*, Harvey S. Uy, MD, Xiao-Yan Li, MD*, Ching-Chi Liu, Scott M. Whitcup, MD*

PURPOSE This study assessed the short-term efficacy of intra -vitreal (DEX) implant (Ozurdex®) 0.7 mg alone or as anadjunct to ranibizumab in treatment-naive patients withsubfoveal choroidal neovascularization (CNV) secondary toage-related macular degeneration (AMD).

METHOD A total of 44 treatment-naive patients with subfovealCNV secondary to AMD in ≥1 eye, with a total lesion size of≤12 Macular Photocoagulation Study disc areas (approximately30.48 mm2), central retinal thickness (CRT) of ≥300 µm, andbest-corrected visual acuity (BCVA) of 19 to 75 letters (baseline)were enrolled. Patients received DEX implant 0.7 mg on day 1and intra vitreal ranibizumab (0.5 mg/500 µL) at week 2 or 3 ifBCVA worsened by ≥5 letters or from week 4 on for wet AMDat the investigator’s discretion. The mean change in CRT atweek 4, BCVA, macular leakage, and the total number ofranibizumab injections during the 26-week study were assessed.

RESULTS DEX implant reduced CRT by 40.3, 62.0, 124.6, and133.7 µm at weeks 1, 4, 8, and 26, respectively (P<.001 for allvs baseline). A ≥15-letter improvement in BCVA from baselinewas noted in 4.5% of eyes at week 4, 20.5% at week 22 (peakresponse), and 15.9% at week 26. The percentage of patientswith a ≥10% decrease in macular leakage by fluorescein angiography was 39.5% at week 4 and 74.4% at week 26.Increases of ≥10% in macular leakage occurred in 2.3% and7.0% of patients at weeks 4 and 26, respectively. With theaddition of DEX implant, 38.6% of patients required 1 to 3injections and 3 patients (6.8%) did not require any ranibizumabduring the 6-month study. In these patients, there was a large

reduction in CRT after the DEX implant, and vision remainedstable through week 26. The most commonly reported ocularadverse events were conjunctival hemorrhage (13.6%),increased IOP (6.8%), conjunctival edema (4.5%), dry eye(4.5%), and vitreous hemorrhage (4.5%).

CONCLUSION Intravitreal DEX implant monotherapy signifi-cantly improved mean CRT in patients with CNV secondary toAMD. The addition of DEX implant to repeated ranibizumabinjections safely improved macular edema and visual acuity, and decreased the number of ranibizumab injections than aretypically required in ranibizumab monotherapy.

124Outcomes of Cataract Surgery in Patients with Neovascular AMD in the Era of Anti-VEGF Therapy

Homayoun Tabandeh, MD* (Los Angeles, CA), Nauman A. Chaudhry, MD, David S. Boyer, MD*, Veronica A. Kon-Jara, MD, Harry W. Flynn, MD*

PURPOSE To evaluate visual outcomes, choroidal neovascularcomplex (CNV) status, and adverse events in patients withvisually significant cataract and neovascular age-relatedmacular degeneration (nvAMD) who underwent cataractsurgery.

METHOD Retrospective consecutive case series: Thirty four eyesof 32 patients with nvAMD treated by anti-VEGF therapy whounderwent cataract surgery.

Outcome measures: Best corrected snellen visual acuity(BCVA), number of intra vitreal injections, status of choridalneovascular complex (CNV), peri-operative adverse events.

RESULTS BCVA at the time of cataract surgery was ≥20/40 in 3(9%) eyes, 20/50 to 20/100 in 19 (56%) eyes, and ≤20/200 in12 (35%) eyes. Mean pre-cataract surgery LogMAR equivalentwas 0.75 + 0.42 (range 0.1-2.3). At the last follow-up (mean13.5, range 6-39 months) the BCVA was ≥20/40 in 15 (44%)eyes, 20/50 to 20/100 in 11 (32%) eyes, and ≤20/200 in 8(24%) eyes. The BCVA had significantly improved comparedto prior to cataract surgery with a mean change in LogMARequivalent of 0.23 + 0.25 (p<0.0001) at 2 months, 0.22 + 0.34(p=0.001) at 6 months, and 0.19 + 0.51 (p=0.01) at last follow-up. Subjects received an average of 0.34 injections / monthafter cataract surgery compared to 0.47 injections / month priorto cataract surgery. Of the 24 eyes that were in a drug-free

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phase, recurrence of leakage requiring anti-VEGF therapyoccurred in 9 (38%) at 2 months, 18 (75%) at 6 months, and21 (88%) at the last follow-up. Perioperative macular adverseevents did not occur in any of the eyes.

CONCLUSION In the era of anti-VEGF therapy cataract surgery isassociated with significant visual improvement in patients withnvAMD and visually significant cataract. Cataract surgery doesnot appear to be associated with significantly higher rate ofrecurrence or increased frequency of intra vitreal injections inthe intermediate term.

125Retinal Venular Caliber Predicts VisualOutcome Following Intra-vitreal RanibizumabInjection Treatments for Neovascular AMDSanjeewa S. Wickremasinghe, MBBS (Melbourne, Australia), Lucy Busija, Robyn H. Guymer, Tien Y. Wong, Salmaan H. Qureshi

PURPOSE To examine whether baseline retinal vascular caliberpredicts visual response to intra vitreal ranibizumab injections inpatients with neovascular age-related macular degeneration(AMD).

METHOD In this prospective cohort study, 107 eyes of 101patients with neovascular AMD received three intra vitrealinjections of ranibizumab according to a “loading dose” regimeat baseline , 1 and 2 months, followed by pro re nata dosing upto one year. Retinal vascular caliber was measured from digitalfundus photographs at baseline and summarized as centralretinal artery equivalent (CRAE) and venular equivalent(CRVE), representing average caliber of arterioles and venules,respectively. Visual outcome at 12 months was assessed and therelation to baseline retinal vascular caliber was determined.

RESULTS After accounting for age, gender, CNV size andnumber of injections, patients who deteriorated in visual acuityat 12 months had significantly larger baseline CRVE, 237.07(31.26)µm, than those who were stable, 210.99 (26.44)µm andthose who improved, 223.85 (26.44)µm p=0.012). BaselineCRAE was not significantly different in those whose visionimproved (147.27µm, 95% CI, 141.40, 153.13), compared tothose who were stable (142.63µm, 95% CI, 137.23, 148.04) andthose who deteriorated (146.34µm, 95%CI, 139.65, 153.04).

CONCLUSION In eyes with neovascular AMD treated with intra -vitreal ranibizumab, larger baseline retinal venular caliber wassignificantly associated with a poorer response to treatment.Larger venular caliber, possibly reflecting underlying levels ofretinal ischemia or inflammation in patients with neovascularAMD, may be useful to predict visual outcomes.

126Comparison of Intravitreal Bevacizumab and Ranibizumab in the Treatment of Exudative AMDJoo Yong Lee, MD (Seoul, South Korea), Soo Geun Joe, MD, Seung Jae Yang, MD, Young Hee Yoon, MD

PURPOSE To compare the effect of ranibizumab andbevacizumab for treatment of exudative age-related maculardegeneration (AMD) in patients who received bevacizumabinjections followed by ranibizumab injection.

METHOD Retrospective chart review was used to identifypatients who were diagnosed with exudative AMD in theinterval from August 2006 to March 2010.All enrolled patientsreceived intra vitreal bevacizumab and next intra vitrealranibizumab. Two or more injections of each drug were given,and mean follow-up period of each drug treatment was 6months. Best-corrected visual acuity (BCVA) and centralfoveal thickness (CFT) measured by optical coherence tomography (OCT) were recorded at the initial and all subsequent visits.

RESULTS A total of 49 eyes of 49 patients were treated withbevacizumab and next switched to ranibizumab. During theperiod of bevacizumab treatment, a mean of 3.4 bevacizumabinjections were given. While mean logMAR visual acuityworsened after initial improvement, mean CFT decreased from289.2 µm at baseline to 275.6 µm at 6months. During theperiod of ranibizumab treatment, a mean of 4.2 ranibizumabinjections were given. Mean logMAR visual acuity improvedfrom 0.65 to 0.63 and mean CFT decreased from 294.7 µm atbaseline to 243.4 µm at 6 months. Intravitreal ranibizumab waseven more superior to intra vitreal bevacizumab when givenwithout drug-free interval.

CONCLUSION Treatment with bevacizumab or ranibizumabappeared to stabilize visual acuity in patients with exudativeAMD. However, ranibizumab was more effective in decreasingCFT, at least over a short-term follow-up period.


127Effect of Patient Induced Risk Factors in Enhancing the Incidence of BacterialEndophthalmitis Following IntravitrealInjection TherapyShashi D. Ganti, MD, MBA (Fresno, CA), Dinesh K. Chawla, MD

PURPOSE Standard risk of Endophthalmitis following Intrav-itreal Injection is reported from 0.1 to 1.6 percent. We studiedaassociated precipitating risk factors and condition. We reportin our series from two retina practices a pooled risk of Endoph-thalmitis of 0.172 percent. When patient induced risk factorswere disregarded the incidence reduced to 0.05 percent(p=.015).

METHOD We report a prospective interventional case series ofpatients who underwent intra vitreal injection therapy. As perprotocol all patients received standard written post intra vitrealinjection instructions. The patients who developed endoph-thalmitis were seen immediately, a vitreous tap was performedwith culture and sensitivity test, microscopic analysis and intra -vitreal antibiotics were injected as per standardendophthalmitis protocol.

RESULTS 1750 injections were given to 262 patients for WAMD(195) CSDME (22) PDR (37) RVO 8, Ranibizumab 754,Bevacuzimab 908, Triamcinolone (88). 3 patients developedendophthalmitis. Patient 1: 69 yr psychologist received intra -vitreal bevacizumab for WAMD, 5 days following injection hewas loading hay from his truck when a branch with spores hithis treated eye, 6th day post injection, it became painful andwas hand motions from 20/80. Vit tap grew Staph Epidermidesand post treatment vision improved to 20/40. Patient 2: 75 yrhad intra vitreal Ranibizumab for WAMD. She wiped hertreated eye after defecation without washing her hands sameday post injection. Developed painful loss of vision. Culture was positive for Ent. Faecalis. Vit tap injections and vitrectomyresulted in NLP. Patient 3: 69 yr received Triamcinolone forCSDME developed redness pain with dense vitreous opacity 5 days post injection. Tap was negative and injection of anti -biotics cleared vitreous opacity and acuity to 20/40.

CONCLUSION Increased incidence of Endophthalmitis is seenwhen patient induced factors were considered. S.Fecalis is rare,precipitated by patient hygiene. S Epiderm patient sustainedpenetrating injury with sharp plant produce. Third patient,probably a sterile reaction, discounting these factors theadjusted incidence is zero if third case is considered sterilereaction. We updated post op instructions.

AMD – Non-NeovascularPOSTERS 128-133

128Tight Junctions of Human Embryonic Stem Cell Derived RPE

Ron A. Adelman, MD, MPH (New Haven, CT), Shaomin Peng, Caihong Qiu, MD, Lina Li, MD, Lawrence J. Rizzolo

PURPOSE Age-related macular degeneration (AMD) is theleading cause of blindness in patients over 60 in the world.Human embryonic stem cells (hESC) may serve as unlimiteddonor source of retinal pigment epithelium (RPE) cells fortransplantation. This report characterizes the tight junctions of RPE derived from hESC.

METHOD Embryoid bodies (EBs) from the H1 line were formedin knockout medium with 10nM nicotinamide. A week later,EBs were plated on laminin-coated culture dishes for 6 weeks.To promote RPE differentiation 140ng/ml activin A was addedduring the third and fourth weeks. Monolayers of pigmentedepithelial cells were isolated and cultured on laminin-coatedTranswell filters for 6-8weeks. The transepithelial electricalresistance (TER) was used to assess the function of tightjunctions. Gene expression of claudins and occludin wasexamined by quantitative real-time RT-PCR, and proteinexpression was examined by immunoblotting and confocal,immunofluorescence microscopy.

RESULTS The hESC-derived RPE cells exhibit the polygonalmonolayer morphology with melanin granules and RPE-specificgene markers such as RPE65, Bestrophin, CRALBP, Otx2,MITF, tyrosinase and PEDF. The TER was ~250Ωxcm2. Likenative fetal RPE, Claudin-19 mRNA was the most prominentmRNA and was >30x claudin-3, >100x claudin-1, and >900xclaudin-2. Other claudins were evident that are not normallyexpressed by native hfRPE included claudins-5, -6, -14, -15, and-18. Claudin-19 was evident by immunoblotting and localizedto tight junctions by immunofluorescence. Claudin-3 localizedto the tight junction and the rest of the lateral membrane.

CONCLUSION The hESC-derived RPE cells express appropriateRPE markers, including claudin-19 as the predominant claudin.Other native claudins were also evident but in low amountsrelative to native tissue and they are not restricted to tightjunctions. Non-native claudins were also evident, which mayindicate that cells within this population are not properly differentiated.

AMD – NEOVASCULAR



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129Short-term Effects of Oral Antioxidant Supplementation on Oxidative StressBiomarker Levels

Milam A. Brantley, MD, PhD (Nashville, TN), Melissa P. Osborn, MD, Kasra A. Rezaei, MD, Barton J. Sanders, MD, Jiyang Cai, MD, Paul Sternberg, MD

PURPOSE Oxidative stress has been implicated in the pathogenesisof age-related macular degeneration (AMD), and AREDSsupplements have been shown to decrease risk of AMDprogression. We have demonstrated that long-term supplemen-tation prevents age-related blood plasma oxidation. Our aim isto determine the short-term effects of antioxidant supplemen-tation on plasma biomarkers of oxidative stress.

METHOD Eighteen subjects, 11 with intermediate or advancedAMD (AREDS categories 3 or 4) and 7 controls, were admittedto the Vanderbilt General Clinical Research Center and placedon a controlled diet for 7 days. Antioxidant supplements werestopped two weeks prior to study enrollment. Dietary supple-mentation with 500 mg vitamin C, 400 IU vitamin E, 15 mgß-carotene, 80 mg zinc oxide, and 2 mg cupric oxide per daywas instituted on study day 3. Blood was drawn on study days 3 and 7, and plasma concentrations of the thiol metabolitescysteine (Cys), cystine (CySS), and glutathione (GSH) as wellas the lipid peroxidation products isoprostane (isoP) andisofuran (isoF) were determined.

RESULTS A 5-day course of AREDS supplements significantlylowered mean plasma levels of CySS in participants on aregulated diet (p = 0.034). None of the other biomarkersdemonstrated a significant change.

CONCLUSION This pilot interventional study indicates thatantioxidant supplements can modify plasma levels of CySS inone week, suggesting that this oxidative stress biomarker couldhelp predict how likely an individual is to benefit from AREDSsupplementation. Further, CySS may be useful for the evalu-ation of new AMD therapies, particularly those hypothesized toaffect redox status.

130To Compare the Efficacy of Preferential Hyperacuity Perimeter with Amsler Grid inDetecting Early Wet AMD in Cases of Dry AMDS. Natarajan, MD (Mumbai, India), Kumaramanick G., MD, Sharmila S. Pawar, MD, Arindam Chakravarti, Purshottam Naidu, MD

PURPOSE Efficacy of Preferential Hyperacuity Perimeter (PHP)as an adjuvant tool in diagnosing Wet AMD in cases of Dry AMD.

METHOD Prospective non-randomized study in Aditya Jyot EyeHospital, India over period of 6 months. 50 patients werestudied. Inclusion criteria: Age >50 years. BCVA>20/160.Patients diagnosed of having dry AMD or other eye Wet AMD

and not included in the exclusion criteria. Exclusion criteria:patients having ocular diseases other than AMD,any significantmedia opacity precluding the biomicroscopy and fundus photog-raphy. Subjects underwent signed informed consent, refraction,BCVA examination, PHP evaluation, amslers grid examination(black grid on white background), dilatation and fundus bio -microscopy, Stratus Optical Coherence Tomography (OCT)and fundus photography on Zeiss Visupac.

RESULTS Total 50 subjects were studied 35 males and 15 females.Age group 50-68 years. 14 patient were diagnosed as havingWet AMD on OCT. 36 patients were Dry AMD. PHP hadhigher sensitivity and specificity with higher accuracy thanamslers in detecting wet AMD from Dry AMD. Also it is goodadjuvant tool in diagnosing wet AMD.

CONCLUSION Preferential hyperacuity perimeter has good sensi-tivity and specificity as compared to amslers grid in diagnosingearly detection of wet AMD from Dry AMD.

131Novel Methods to Enhance Reading Ability in Patients with Macular Disease

Daniel B. Roth, MD *(Lakewood, NJ), Ankit Shah, MD, Howard F. Fine, MD, Jonathan L. Prenner, MD*, William J. Feuer

PURPOSE Patients with reduced visual acuity often complainabout difficulty with reading tasks. We sought to determinewhether reading magnification incorporated into reading glasses or back illuminated reading material would significantlyenhance reading performance.

METHOD All patients were asked to quantify their relative difficulty with reading books, newspaper or mail on a scale of 1 through 10. The nature of the patient’s macular disease wasdetermined and best corrected distance visual acuity wasobtained. Near vision testing was performed with theRosenbaum near vision card with patients wearing (1) theirown spectacle correction for reading, (2) over the counter(OTC) +3.00 or +4.00 reading glasses, and (3) a dual lensmagnification reading aid. Near vision tests were repeated withall three spectacles with a back illuminated near card projectedfrom the iPhone.

RESULTS 75 eyes of 42 patients were evaluated. Mean LogMarnear visual acuity of patients with their own reading spectacleswas 0.54 (SD=0.38), slightly worse than with OTC readers,where LogMar acuity was 0.50 (SD=0.37); however thisdifference was not significant (p=0.38). Dual lens magnificationdid not offer an advantage in reading ability compared withpatients’ own correction or OTC readers. Mean LogMar acuityusing the back illuminated iPhone was 0.40 (SD=0.31) usingpatients’ own reading glasses and 0.38 (SD=0.29) using OTCreaders, significantly better than similar conditions with the


Rosenbaum near card. Patients read 1.5 lines better with theiPhone than the near card using their own spectacle correction(P <0.001) and 1.0 line better with the iPhone using OTCreaders (P <0.001). The level of improve ment in reading abilitywith the iPhone near vision testing was significantly greater inpatients with poor visual acuity (≤20/100) than in eyes withbetter visual acuity (>20/100).

CONCLUSION Back illuminated devices may offer a significantadvantage to aid patients with reduced visual acuity functionbetter and read with less difficulty.

132Intravitreal Procrit in Eyes with Geographic Atrophy Secondary to AMD

Stephen H. Sinclair, MD* (Media, PA), Carolyn Majcher, MD

PURPOSE To investigate intra vitreal Procrit stabilization ofatrophic AMD GA and central discriminant visual field (CDVF)progression and to correlate OCT findings with CDVF andpatterns of GA progression.

METHOD Retrospective pilot study of patients with GA AMD inat least one eye with the fovea threatened or recently involved.Follow-up examinations every 4 months included OCT,fluorescein angiography, and CDVF. OCT images were analyzedfor loss or disruption of the inner-segment/outer-segmentjunction (IS/OS junction), loss of outer plexiform layer (OPL),and RPE redundancy/thickening. Primary outcome was rate ofGA progression in treated eyes compared with rates prior totreatment. Secondary outcomes were rate of GA progression intreated eyes compared to 5 atrophic fellow eyes, and the changein CDVF Global Macular Acuity (GMA) in treated eyescompared with change prior to treatment.

RESULTS Eight eyes of 8 patients were treated for an average of1.54 yrs with mean 9.6 injections. Seven of these eyes had beenexamined for an average of 1.3 years prior to treatment with amean decline in ETDRS VA prior to treatment of 0.054logMARcompared with 0.161logMar during treatment. The mean GAenlargement prior to treatment was 2.55mm²/yr (initial GA sizeof 7.50mm²) compared with an enlargement during treatmentof 2.06mm²/yr. The mean change in the CDVF GMA duringtreatment in 5 eyes was an improvement of 0.185 logMARcompared to a mean 0.082 decline for 3 eyes prior to treatment.In the 5 fellow eyes with GA (followed for a mean of 2.6yrs),the mean rate of GA progression was 2.25mm²/yr. GA wascharacterized by OCT loss of OS/IS junction and OPL.Disruption of the IS/OS junction often extended beyond GAwhile RPE thickening often lined the edge. Best indicators offuture GA progression were loss of OPL or RPE abnormalities.CDVF scotomas corresponded with OCT OS/IS junction loss.

CONCLUSION In a small pilot study, intra vitreal Procrit appearsto slow GA progression and vision loss. OCT and CDVF appear useful for mapping preserved retina and vision,monitoring disease progression, and may aid in prediction offuture GA growth.

133Choroidal Thickness and Early AMD

David W. Switzer, MD (New York, NY), Luis S. Mendonca, MD, Masaaki Saito, MD, Sandrine A. Zweifel, MD, Richard F. Spaide, MD*

PURPOSE To investigate the association of fundus features andchoroidal thickness in eyes with early age-related maculardegeneration (AMD).

METHOD Consecutive patients with AMD were evaluated in aretrospective observational case series at a retinal practice over2 months. Eyes were excluded for late AMD, myopia >6D, pastvitreoretinal surgery, or disease that could affect the macularfunction. Multimodal fundus imaging, including enhanceddepth optical coherence tomography, was reviewed for: ß-zoneperipapillary atrophy (ß-PPA), drusen, central foveal thickness,subfoveal choroidal thickness (SFCT), subretinal drusenoiddeposits (SDD), and outer retinal characteristics. Correlationswere calculated among the measured variables and SFCT.Generalized estimating equations were used to identifypredictors of visual acuity.

RESULTS There were 91 eyes with mean visual acuity 20/31(logMAR 0.193). Generalized estimating equation analysisshowed only age significantly predicted visual acuity. ThinnerSFCT was associated with increasing age (P=.004), increasingmyopic refractive error (P=.023), ß-PPA (P<.001), glaucoma(P=.003), SDD (P=.023), and absence of drusen (<.001).Analysis of outer retinal OCT features in eyes without lateAMD showed that some eyes had an absence of the 3rd bandattributed to overlap of outer segments and retinal pigmentepithelium apical processes, a structure known as the contactcylinder. Eyes without this band had a significantly decreasedSFCT (174.8µm) as compared with eyes having the band(222.6µm, P=.022). Twenty-five eyes (27.8%) met the criteriafor age-related choroidal atrophy (SFCT<125µm), and theseeyes were less likely to have drusen (P=.02), and more likely tohave SDD (P=.019). Patients with SFCT less than the median(187.3µm) were more likely to have glaucoma (P=.001).

CONCLUSION In AMD, general eye findings may be, in part,classified by choroidal thickness. There appears to be an association of thinner choroid with SDD, ß-PPA, glaucoma,and loss of the contact cylinder. Relatively thicker choroid did not show an association with glaucoma, but did show anassociation with drusen. These findings have an impact on ideas concerning the pathogenesis of glaucoma and AMD.

AMD – NON-NEOVASCULAR



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Diabetic Retinopathy/Hereditary/Inflammatory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diabetic RetinopathyPOSTERS 201-215

201Macular Tractional Retinoschisis in Proliferative Diabetic RetinopathyChung-May Yang, MD (Taipei, Taiwan), Chien-Chia Su

PURPOSE To evaluate the clinical manifestations and surgicaloutcome of macular tractional retinoschisis in proliferativediabetic retinopathy.

METHOD A retrospective review was conducted on cases with macular tractional retinoschisis in proliferative diabeticretinopathy confirmed by optical coherence tomography(OCT) at a single institution between January 2007 and August2010. Except those with localized subfoveal fluid, all cases withtraction detachment were excluded. Demographic data, clinicalpictures, surgical results, and optical coherence tomographicfindings were recorded and analysed.

RESULTS Twenty eyes in 18 patients were included. The meanfollow-up duration was 15.95 ± 17.23 months. All had predomi-nantly non-active fibrous proliferation. Three patterns werenoted by OCT: diffuse elevation, localized elevation, and more elevation at periphery; associated macular abnormalitiesincluded inner macular cyst (40.91%), lamellar hole (13.64%),foveal detachment (9.09%), and macular hole (4.55%); serialoptical coherence tomographies in some cases showed thatmacular structures might alter over time. Sixteen cases hadsurgery. Visual acuity improved statistically after surgery. Six of 16 cases showed persistent residual schisis on postoperativeOCT, 2 cases developed lamellar hole after surgery.

CONCLUSION Unique features exist in macular tractionalretinoschisis in proliferative diabetic retinopathy. Macularchanges may evolve over time. Vitreous surgery may improvevisual function despite persistent schisis or other macularchanges in some cases.

202Preoperative and Intraoperative Intravitreal Bevacizumab Only TransientlyInhibits Worsening of Diabetic Macular Edema Following Cataract Extraction

Michael A. Albert, MD (Birmingham, AL), Joshua Hicks, MD, Richard M. Feist, MD, Dustin L. Pomerleau, MD, Tracy Emond, Lindsey Wallace, MD, John O. Mason, MD, Martin L. Thomley, MD

PURPOSE Worsening of diabetic macular edema (DME) is welldocumented after cataract extraction (CE). Our study seeks toclarify both the efficacy and optimal timing of intra vitrealbevacizumab (IVB) in this context.

METHOD We performed a retrospective review of patients with DME who also underwent CE between 2006 and 2010.Study inclusion criteria were documented best-corrected visualacuity (BCVA) and OCT preop and at 1 and 3 month postopintervals. Subjects were stratified into 3 groups: those receivingpreop (within 1 month of surgery) IVB, those receiving intraop(not treated with IVB in the 6 weeks prior to surgery), and acontrol group. Patients receiving treatments other than IVBwithin 3 months of surgery or any DME therapy during follow-up were excluded. The outcome measures were change inlogMAR BCVA, central subfield thickness (CST), and totalmacular volume (TMV).

RESULTS Of 184 eyes initially evaluated, a total of 88 eyes of 66patients met the inclusion criteria (39 preop IVB, 27 intraopIVB, and 22 control eyes). There was no statistically significantdifference in the preop BCVA, CST, or TMV of the 3 groups.At 1 month postop, the mean (95% CI) Δ in CST for the preopIVB group was +47um (+14 to +79um) vs. +133um (+71 to+195um) in controls (p=0.02) and +16um (-33 to +64um) inthe intraop IVB group (p=0.30 vs. preop IVB, 0.005 vs.controls). The mean Δ TMV for the preop IVB group was +0.03cubic mm (-0.68 to +0.75 cubic mm) vs. +1.72 cubic mm(+0.99 to +2.45 cubic mm) in controls (p=0.002) and +0.14cubic mm (-0.43 to +0.71 cubic mm) in the intraop IVB group(p=0.80 vs. preop IVB, 0.002 vs. controls). There was no statis-tically significant difference in Δ BCVA at 1 month or in ΔBCVA, Δ CST or Δ TMV at 3 months postop.

CONCLUSION CST and TMV increase in patients with DMEafter CE. At 1 month postop, there is a transient reduction inthe magnitude of this increase in patients receiving preoper-ative and intraoperative IVB. This effect subsides after 3months and does not correlate well with BCVA outcomes.


203Results of 23 Gauge Bimanual VitreousSurgery for Very Advanced ProliferativeDiabetic Retinopathy with Severe Tractional Retinal Detachment

Ching Chen, MD (Jackson, MS), Zachary M. Robertson, MD

PURPOSE To report the surgical outcomes and complications ofbimanual 23 Gauge vitreous surgery using chandelier light forvery advanced proliferative diabetic retinopathy (PDR) withsevere tractional retinal detachment (TRD).

METHOD This is a retrospective case series study. BetweenJanuary 2008 and July 2010, 60 eyes of 50 patients withadvanced PDR and severe TRD were operated by a singlesurgeon (CJC). 23-G pars plana vitrectomy and bimanualsurgery were performed with the self retention chandelier light.Demographic data of the patients, pre-operative visual acuity(VA), extent of the TRD, intra-operative complications,postoperative VA, retinal anatomic outcomes and complica-tions were obtained for analysis.

RESULTS There were 52% male, 96% black and 17% bilateralTRD in the study.Mean follow-up was 10m and mean age was49y.Preoperative iris rubeosis occurred in 10%, vitroeus hemor-rhage (VH) in 75%. 82% were phakic. TRD involved up toequator and beyond in 62%. Iatrogenic tear occurred in 33%.Intraop. perfluoron was used in 20%, Silicone oil in 52%, andC3F8 gas tamponade in 48%. Postop. VH occurred in 42%,glaucoma in 17%. Initial anatomic success was 88% and finalsuccess after additional surgeries was 95%. Mean PreoperativeLogMAR VA was +1.71 and postoperative VA was +1.32. VA was stablized in 23%, improved in 62% and decreased in15%. Extent of TRD is significantly correlated to Postop. VA(p=0.002). Preop. VA is positively correlated with Postop. VA (P=0.000). Postop. VH is significantly negative correlatedwith Postop. VA (p=0.000). Patients with C3F8 is significantlypositive correlated with better Postop. VA (p=0.012). Use ofperfluoron and iatrogenic tear have no effect on postop. VA.

CONCLUSION The risks of intra- and post-operative complica-tions are relatively high in patients with advanced PDR andsevere TRD. Bimanual 23G vitreous surgery is extremelyhelpful in difficult membrane dissection. The anatomic successrate is high. The VA can be stabilized or improved in majorityof patients. Postoperative visual improvement is positivelyrelated to the preoperative visual function.

204Comparison of Flash ElectroretinogramChanges after PRP for Diabetic Retinopathy in Patients Treated with Standard Laser and PASCAL LaserSiddharth Dikshit, DO (Hyderabad, India), Subhadra Jalali, Raja Narayanan, MBBS

PURPOSE 1. To compare significance of Flash-ERG changes afterScatter PRP with 532nm YAG laser in Diabetic Retinopathy in patients treated with Standard laser and PASCAL laser. 2. To compare the changes in visual acuity and central fovealthickness, and, need for Add PRP in the two groups.

METHOD The study was a prospective randomized controlledtrial. Patients with hazy media, prior vitreo-retinal surgery,intra-vitreal anti-VEGF in previous 3 months, neovascularglaucoma, TRD were excluded.

The patients were randomized to receive PRP on PRP on either Standard Frequency Doubled Nd:YAG or PASCALLaser. A flash ERG (MetroVision) was performed prior to PRP,immediately after PRP, one month after PRP and 3 monthsafter PRP (primary end-point). Visual acuity using ETDRSchart at 4m and central foveal thickness using RTVue (OptovueInc.) was performed at baseline, 1 month and 3 months. Needfor add PRP was assessed based on fundus photographs by amasked observer.

RESULTS The baseline characteristics of the two groups werewell matched. 9 patients (16 eyes) in PASCAL group and 5patients (10 eyes) in Zeiss group were included. There was areduction in amplitude and prolongation of implicit time inphotopic as well as scotopic waves, including a and b waves onFlash ERG in both the groups. There was no statistically signifi -cant difference in the reduction of waves between the 2 groups.The logMAR visual acuity before and after laser PRP were 0.20and 0.25 in the PASCAL group (p= 0.125) and 0.6 and 0.4 inthe Zeiss group (p= 0.29). The central foveal thickness beforeand after laser PRP were 163.0±26.0 and 177.0±68.0 in thePASCAL group (p= 0.414) and 212.0±166.5 and 0.45 in theZeiss group (p= 0.29). The total energy delivered per eye in thePASCAL group was 33.6±11.7 J and 89.9±6.9 J in the standardlaser group (p=0.002) Add PRP was needed in 6/16 eyes inPASCAL group and 2/10 eyes in Zeiss group, with no signif-icant difference (p=0.4777).

CONCLUSION This was the first attempt of direct objective evalu-ation of the difference between two systems on the collateraldamage. Reduction in amplitude and prolongation of implicittime was found across all waves in Flash ERG. However, therewas no significant detectable difference in the two arms. There was no difference in adverse effect profile and centralfoveal thickness.

DIABETIC RETINOPATHy



101

205Ranibizumab for the Treatment of PersistentDiabetic Retinal Neovascularization asAssessed by Super Wide-Field Angiography

Anna Gabrielian, MD (Chicago, IL), Ryah P. Basham*, Mathew W. MacCumber, MD, PhD*

PURPOSE To compare the efficacy of intra vitreal ranibizumab(IVR) versus additional panretinal photocoagulation (PRP) for persistent retinal neovascularization (NV) after PRP forproliferative diabetic retinopathy (PDR). Concomitant macularedema (ME) after IVR was also studied in these patients.

METHOD Open-label, prospective, Phase I/II study of a singleinjection of IVR for persistent(>3 mo) NV due to PDR. 8subjects previously treated with PRP (~1200 500µm burns),were randomized to 0.5mg IVR or more PRP (~500 200µmburns). ETDRS best corrected visual acuity (BCVA), Optoscolor photos and fluorescein angiogram (OFA), and opticalcoherence tomography (OCT) were taken at baseline, andmonthly for 6 mos. Patients with tractional retinal detachment(TRD), pregnancy, and previous anti-VEGF intra vitreal injec-tions and/or vitrectomy were excluded. Primary outcomemeasures were change in area of NV and ME (measured byOFA and OCT). Secondary measures were change in BCVAand rate of complications.

RESULTS Six patients received IVR and two received additionalPRP. The percentage change in area of NV as measured byOptos FA in patients who had IVR showed an 84.1% decreaseat 4 weeks and a 29.8% increase by 6 months. For patients whohad additional laser, the percent change in area of NV showed a52.6% increase at 4 weeks and a 55.4% increase by 6 months.The percentage change of ME at 4 weeks, as measured by OCT,showed a 7.2% decrease in the IVR group and 8.4% decrease inthe PRP group. The percentage change of ME at 6 monthsshowed a 34.5% increase in the IVR group and 2.1% decreasein the PRP group. The mean change in BCVA at 1 monthshowed two lines gained from baseline in the IVR group and nochange from baseline in the PRP group. At 6 months, the IVRgroup had gained three lines from baseline and the PRP grouphad gained two lines from baseline. There were no PDR compli-cations in the IVR group. One patient in the PRP groupdeveloped vitreous hemorrhage.

CONCLUSION Intravitreal ranibizumab in patients with persistentNV despite standard PRP reduced area of NV to a greaterextent and sooner than additional PRP at 4 weeks and at 6months. Concomitant macular edema in the patients treatedwith IVR improved minimally at 4 weeks.

Baseline fluorescein angiogramof the study eye at 43.9seconds of transit. Areas ofretinal neovascularization areselected and numbered.

Six months after a single intra -vitreal injection of ranibizumab.Fluorescein angiogram of thestudy eye at 39 seconds oftransit. Areas of retinal neovas-cularization are selected andnumbered.

206An Interim Analysis of the Efficacy of Pegaptanib Sodium Injections Every 4 Weeksvs. 6 Weeks on OCT and BCVA During 24 Weeks in Patients with DME

Victor H. Gonzalez, MD (McAllen, TX)*, Valmore A. Semidey, MD*, Denisse Cornu, MD

PURPOSE To perform an interim analysis of the effect that theadministration of intra vitreal Pegaptanib sodium injectionsevery 4 weeks as compared to every 6 weeks could have onOCT Central Subfield Thickness (CST) in patients withDiabetic Macular Edema (DME) at their first follow-up visitduring an ongoing 24 week trial.

METHOD After IRB approval, 48 eyes diagnosed with DME by aRetina specialist, and who have not undergone intra vitrealinjections of Anti-VEGF, steroids or macular laser treatment for at least 3 months prior to baseline, were randomly assigned2:1 to receive 0.3 mg of intra vitreal pegaptanib sodium every 4 weeks (32 patients) or every 6 weeks (16 patients) during atotal of 24 weeks. An interim analysis was performed at the firstfollow-up visit for each of these groups, where we obtainedOCT-CST and ETDRS-BCVA.

RESULTS 32 patients treated every 4 weeks had a medianimprovement in VA of +3.8 letters from baseline BCVA with34% of these improving more than 5 letters; compared to amedian of 0 letter gain in the 6 week group with 18.8%improving more than 5 letters of BCVA. OCT-CST in the 4week arm improved by a median of 62 µm with 28.1% of theseimproving more than 100 µm from baseline whereas the 6 weekgroup showed a median improvement of 26.5 µm, where 12.5%averaged an improvement of 100 µm or better.


CONCLUSION Preliminary results show that administering 0.3 mgpegaptanib sodium every 4 or 6 weeks is beneficial in DME,although greater extent improvement was seen in the 4-weekgroup. We could attribute this to various causes; waning of drugeffect during the 4th-6th week period, or better initial VA andOCT profile in the 6-week group, limiting the percentage ofimprovement in either of these variables.

207Combination Therapy with Computer Guided Focal NAVILAS Laser Treatment and Intravitreal Anti-VEGF Therapy in theTreatment of Diabetic Macular EdemaArmin Afshar, MD (Chicago, IL), Rama D. Jager, MD, MBA, Madhu Amara, MD, Sandeep Grandhe, MD, Ravi D. Patel, MD

PURPOSE To report a case series of patients treated withNAVILAS computer-navigated focal laser treatment and intra vitreal bevacizumab in the management of diabeticmacular edema (DME).

METHOD A retrospective, noncomparative, interventional caseseries of eyes that underwent combined NAVILAS computernavigated focal laser treatment and intra vitreal bevacizumabinjections for diabetic macular edema was reviewed. Patientsreceived intra vitreal bevacizumab (1.25 mg/0.05 ml) andunderwent computer-navigated NAVILAS focal laser treat -ment. Pretreatment NAVILAS planning with typical lasersettings of 70 mW power,100 µm size, 70 ms duration resultedin pale, clinically visible lesions. Best-corrected visual acuityand average foveal thickness using spectral domain OCT weremeasured immediately before laser treatment and at visits up to the 6 months.

RESULTS Over 80 eyes have been treated as of March 2011. Of those, 12 eyes of 10 patients had 6 month follow-up andwere reviewed. Mean (± SD) foveal thickness at baseline was352 ± 64 microns that decreased to 323 ± 48 microns at 6months (p=ns). Mean visual acuity improved slightly from20/60 at baseline to 20/50 at 6 months in treated eyes (p=0.04). Average macular volume also decreased significantly.The average number of injections at 6 months was 1.6 ± 1.6. The average number of laser spots administered was 101 (range = 18-372). No adverse effects were observed in associ-ation with either intra vitreal injection or with NAVILAS laser treatment.

CONCLUSION Intravitreal bevacizumab used in combination withNAVILAS computer guided focal laser treatment appears to besafe and effective in eyes with diabetic macular edema at 6months follow-up. NAVILAS focal laser treatment appears safeand effective in the short term and has the potential to havesignificant long-term advantages when combined with anti-VEGF therapy.

Sample image of the NAVILAS planning screen

208The Effect of Glycemic Control on Visual and Anatomical Outcomes in Response toTherapy for Diabetic Macular EdemaTamer A. Macky, MD, PhD, FRCS(Ed) (Cairo, Egypt), Mohamed M. Mahgoub, MD, PhD, FRCSEd.

PURPOSE To evaluate the visual and anatomical response totherapy in patients with diabetic macular edema in relation totheir glycemic control using glycosolated hemoglobin measure-ments (HbA1c).

METHOD Patients with diabetic macular edema (DME) withcentral foveal thickness (CFT) > 250µm with no proliferativedisease had their HbA1c measured at baseline and 3 months.CFT optical coherence tomography (OCT), and best correctedvisual acuity (BCVA) in logMARs were measured at baseline,1, and 3 months. Exclusion criteria: laser or intra vitreal injec-tions within 6 months, hard exudates within 500um of thefoveal center, or macular traction. Therapy included laser andintra vitreal anti VEGFs. HbA1c graded as: G1=<7, G2= 7-7.9,G3= 8-8.9, G4 = >9; and as: low <8, high ≥ 8. HbA1c levels(baseline, 3 months) and its relation to CFT and LogMARBCVA (at baseline, 1 and 3 months) were analyzed.

RESULTS Fifty two eyes of 52 patients were included with meanage 56 (30-81), male: female ratio 2:3. Mean LogMAR BCVAand CFT: baseline 0.75 and 423.83±10µm; 1 month: 0.47 and293.33±69µm; and 3 months: 0.47 and 324.40±76µm. MeanHbA1c was 8.13±1.2 (6.4-10.5) and 7.63±1.0 (6.2-9.7) atbaseline and 3 months, respectively. Baseline HbA1c gradings:G1=23.1%, G2=23.1%, G3=30.8%, G4=23.1%, low=46.2%and high=53.8%; and at 3 months: G1=30.8%, G2=30.8%,G3=30.8%, G4=7.7%, low= 61.5%, high=38.5%. There was no statistically significant difference between any of the HbA1cgrades/levels (at baseline and 3 months) and the logMARBCVAs and CFTs at baseline, 1 and 3 months. However, there were positive correlations between baseline HbA1c levelsand each of: baseline LogMAR BCVA (p value=0.024),baseline CFT (p value<0.001) and 3 months LogMAR BCVA(p value=0.008). Patients with improved HbA1c by 3 monthsdid not show any correlation with logMAR BCVA and CFT at3 months (p values 0.159, and 0.322).




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CONCLUSION Patients with lower HbA1c appeared to havebetter visual acuity and lower CFT value at baseline. This groupof patients showed a significantly better visual acuity and nonsignificantly better CFT at 3 months as compared to baseline.Although rigorous glycemic control with improved HbA1c at 3 months did not result in a significantly better outcomes, yet alonger follow-up period is needed.

209Rationale of Diabetic Retinopathy Clinical Research Network Intravitreal Anti-VEGF Treatment and Follow-up of Center-involved Diabetic Macular EdemaMichael Elman, MD (Baltimore, MD), Raj Maturi, MD,* Neil M. Bressler, MD*

PURPOSE A web-based real time data entry system was used todetermine standardized guidance for intra vitreal injections,focal/grid laser, and follow-up intervals (1-4 months). Dupli-cation of this algorithmic approach is not practical in clinicalsettings, this report provides guidelines from DRCR.net investi-gators to assist ophthalmologists in providing anti-VEGF andfocal/grid laser treatment for DME.

METHOD The DRCR.net conducted a comparative effectivenessrandomized multi-center clinical trial in 854 study eyes of 691study participants to evaluate 3 different treatments, includingintra vitreal 0.5-mg ranibizumab combined with prompt ordeferred (>24 weeks) focal/grid laser or 4-mg triamcinolonecombined with prompt focal/grid laser, compared with shaminjections with prompt focal/grid laser alone for treatment ofdiabetic macular edema (DME). The underlying rationale forthis trial’s retreatment algorithm was used to develop clinicalguidelines for providing anti-VEGF and focal/grid laser forDME without a web-based real time data entry system.

RESULTS The DRCR.net trial found intra vitreal ranibizumabwith prompt or deferred laser was more effective through atleast 1 year compared with prompt laser alone for the treatmentof DME involving the central macula, although uncommonlyassociated with endophthalmitis. Guidelines for achieving thistreatment benefit in clinical practice, based on the underlyingrationale of the DRCR.net treatment algorithm, includerepeating treatment monthly as long as there is improvement inedema compared with the previous month, if treatment is notrepeated because of success or lack of improvement, treatmentis resumed if edema recurs or worsens. If the retina remains flat (or not worse) after treatment is deferred, the follow-upinterval could be doubled, up to 4 months. Focal/grid laser canbe added initially or deferred for at least 6 months and thenconsidered only if edema persists or is not improving from injections; laser can be repeated as often as every 4 months if there is edema to treat.

CONCLUSION Although the timing and amount of treatmentfollowing these guidelines is likely to be similar to that based on a web-based real time data entry system, it is unknown iffollowing this clinical protocol would result in better, same, orworse outcomes compared with the DRCR.net results. If a web-based algorithm is not practical clinically, then this approachmay be a practical clinical alternative.

DRCR.net required 4 injections every 4 weeks initially; it is not knownwhether a different number of injections initially would have worked aswell. Defined as >10% decrease in central subfield thickness on OCT or visual acuity improvement of 5 or more letters. a If focal/grid laser was deferred initially, it may be added if edema still present and there is no improvement from injections.

210Examining Recalcitrant Diabetic Macular Edema with Optos Wide-FieldFluorescein Angiography

Ravi D. Patel, MD (Chicago, IL), Seenu M. Hariprasad, MD*

PURPOSE This study has 2 objectives: i) to study the peripheralangiographic features of patients with recalcitrant diabeticmacular edema (DME) and peripheral retinal nonperfusion innon-proliferative diabetic retinopathy (NPDR) and prolifer-ative diabetic retinopathy (PDR) and ii) to demonstrate thediagnostic value of WFFA in elucidating the role of subtleperipheral pathology in diabetic retinopathy.

METHOD This is a retrospective observational case series ofapproximately 30 eyes of 60 patients who have been diagnosedwith DME for at least 2 years at an academic institution.Protocols were approved by the institutional review board atthe study site, and consent was obtained from each patient. Aretrospective review of all Optos WFFA and spectral domainOCT (SD-OCT) was performed at baseline (1 clinic visit).


Three study cohorts were enrolled. Cohort 1 (control) subjectswere diagnosed with NPDR without DME. Cohort 2 subjectswere diagnosed with NPDR and recalcitrant DME. Cohort 3subjects diagnosed with PDR and recalcitrant DME with orwithout previous pan retinal photocoagulation (PRP).

RESULTS Our preliminary data demonstrates an increasedincidence of peripheral nonperfusion on Optos wide-fieldfluorescein angiography with recalcitrant DME (on SD-OCT)in all non-control cohorts. Further statistical analysis is tofollow. Also, the diagnostic value of the WFFA was demon-strated by detecting subtle peripheral neovascularization thatwas not found on clinical exam.

CONCLUSION WFFA is an excellent diagnostic instrument thatprovides a reproducible method to detect subtle peripheralneovascularization in diabetic retinopathy. Areas of untreatedretinal nonperfusion may generate biochemical mediators that promote ischemia and recalcitrant DME. Targeted retinal photocoagulation to ischemic retina will likely showimprovement of recalcitrant DME.

Optos Wide-Field Fundus photo of a patient with mild recalcitrant diabetic macular edema and presumed quiescent PDR s/p PRP on clinical exam.

Optos Wide-Field Fluorescein Angiogram of a patient with recalcitrant diabetic macular edema and presumed quiescent PDR s/p PRP with fronds of neovascularization not detected on clinical exam.

211Ultra Wide Field Fluorescein AngiographyAccurately Evaluates Macular Pathology in Diabetic Retinopathy

John D. Pitcher, MD (Los Angeles, CA), Valentina Franco-Cardenas, MD, Irena Tsui, MD, Gad Heilweil, MD, Jean-Pierre Hubschman, MD, Steven D. Schwartz, MD*

PURPOSE High resolution fluorescein angiography correlateswell with spectral domain optical coherence tomography (SD-OCT) when assessing macular pathology in patients withdiabetic retinopathy (DR). Ultra wide field fluorescein angiog-raphy (UWFFA) has proven useful for detecting peripheralpathology. Validation for macular pathology in DR withUWFFA is to date uncertain.

METHOD A retrospective imaging review, which included allpatients diagnosed with DR who underwent UWFFA and SD-OCT on the same day, was performed. UWFFA was gradedfor presence of macular leakage (petalloid or diffuse pattern)and ischemic abnormalities of the foveal avascular zone (FAZ).SD-OCT was evaluated for signs of diabetic macular edema(cystoid or diffuse type), foveal thickness, average macularthickness, ganglion cell layer (GCL) atrophy and evidence ofepiretinal traction (ERM). Imaging reviews were performed bytwo separate vitreoretinal specialists who were blind to eachother’s results.

RESULTS Inclusion criteria were met by 216 eyes. Angiographicleakage on UWFFA was present in 132 eyes (61%) and 112eyes (52%) had macular edema on SD-OCT (p<0.0001) with akappa agreement (K) Κ=0.59. Petalloid angiographic leakageon UWFFA correlated with cystoid macular edema on SD-OCT (p<0.0001) (K=0.61). Diffuse angiographic leakagecorrelated with diffuse macular edema (p<0.0001) (K=0.46).The sensitivity of UWFFA for detection of any type of macularleakage was 89.3%, with a specificity of 69.2%. GCL atrophypresented with an abnormal FAZ on UWFFA (p<0.0001)(K=0.77) and ERM correlated well with any type of leakage in UWFFA (p< 0.0001). Any type of leakage detected inUWFFA had an increased foveal thickness (360.6±123µ vs273±53 µ) and macular thickness average (367±75µ vs 306±33µ)in SD-OCT when compared against the non leaking group(p<0.0001). The K value for agreement between graders was≥0.55 for all UWFFA parameters and ≥0.64 for all OCT parameters.

CONCLUSION The presence of macular pathology in this cohortof patients was high, allowing us to study the utility of UWFFAin diabetic maculopathy. UWFFA provided accurate angio-graphic macular assessment which closely correlated withSD-OCT findings. UWFFA seems to provide clinically usefulangiographic macular data.




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Late macular leakage in adiffuse pattern on ultra widefield fluorescein angiography(a) in a patient with corre-sponding diffuse diabeticmacular edema on SD-OCT (b).

Late macular leakage in apetalloid pattern on ultra widefield fluorescein angiography(a) in a diabetic patient withcorresponding cystoid macularedema on SD-OCT (b).

212Intravitreal Triamcinolone vs. Intravitreal Bevacizumab Injection for Chronic Diffuse Diabetic Macular Edema: Which Was Really Better?Su Jeong Song, MD, PhD (Seoul, South Korea), Man Mook Ha, MD, Jung Hoon Bae, MD

PURPOSE To compare the effect of IVTA and IVB for chronicdiffuse diabetic macular edema.

METHOD We retrospectively reviewed medical records of 84patients with DME who received single IVTA (4mg/0.1ml) orIVB (1.25mg/0.05ml) for the first time. All patients werefollowed up at least 6 months. Ophthalmic evaluation wasperformed at baseline and at 1, 3, 6 months after each injection.Changes of visual acuity (Log MAR) and central macularthickness (CMT) using optic coherence tomography wereevaluated. Clinical evidence of complications was alsorecorded.

RESULTS The baseline visual acuity and central macularthickness were similar between the 2 groups (visual acuity:0.73±0.37 in IVTA group and 0.65±0.40 in IVB group(p=0.06), central macular thickness: 438±141µm in IVTAgroup and 415±115µm in IVB group (p=0.051). The Log MARvisual acuity improved to 0.64±0.35, 0.59±0.36, and 0.62±0.41in IVTA group (p<0.001 each) after 1, 3, and 6 months. But inIVB group, Log MAR visual acuity improved to 0.62±0.34,0.59±0.38, and 0.60±0.38 after 1, 3, and 6 months withoutstatistic significance (p=0.15, 0.09 and 0.12). The CMTreduced to 297±50µm, 344±136µm, and 347±131µm in IVTAgroup (p<0.001 each) after 1, 3, and 6 months. Also in IVBgroup, CMT improved to 285±103µm, 286±66 µm and 283±32µm after 1,3, and 6 months (p= 0.05, 0.03, 0.03). During thefollow-up period, one eye in IVTA group underwent cataractsurgery and one eye in IVTA group had high intraocularpressure controlled with topical medication.

CONCLUSION In DME patients, single IVTA showed significanttherapeutic effect in aspect of both anatomical and functionaloutcome for 6 months. But single IVB showed limitedimprovement of functional outcome, although IVB hadanatomical improvement.

213Factors Associated with Changes in Visual Acuity and OCT Thickness at One year after Ranibizumab Treatment for Diabetic Macular Edema

John Wells, MD* (West Columbia, SC)

PURPOSE A Diabetic Retinopathy Clinical Research Networkmulticenter randomized clinical trial found ranibizumab, withimmediate or deferred focal/grid laser, to be superior to laseralone for center involving DME. We sought to identify factorsassociated with improvement in visual acuity (VA) and opticalcoherence tomography (OCT) central subfield (CSF) thicknessat 1 year following ranibizumab treatment.

METHOD As 1-year outcomes were similar, data from the tworanibizumab arms in the trial (361 eyes total) were pooled foranalysis. Regression models were used to evaluate baselinedemographic, systemic, ocular, OCT, and fundus photographicfactors for association with VA/OCT improvement frombaseline to 1 year. Evolution of CSF measurements relative tobaseline at months 4, 8, and 12 were evaluated for effect on VA at 1 year.


RESULTS Despite evaluating 37 baseline factors, no factor otherthan baseline VA affected the magnitude of change in visualacuity from baseline to 1 year, in eyes that started with center-involved DME causing vision impairment. Eyes with baselineVA letter score of < 66 letters, in which the average letter scorewas 56 (20/80) had a median 13 letter gain (25th and 75thquartiles: +7, +20) compared to a median 6 letter gain (+1,+11) in those with a letter score > 66 (P<0.001), in which theaverage letter score was 72 (20/40).VA of >20/32 at 1 year wasachieved by 76% of eyes with a letter score ≥ 66 at baselinecompared to 38% of eyes < 66 (P<0.001). Baseline CSFthickness was the only consistent baseline predictor of 1-yearCSF thickness outcomes. Eyes with baseline CSF thickness < 400 µm had median improvement of 71 µm while eyes with ≥ 400 µm had median of 219 µm improvement (P<0.001).

CONCLUSION No factors were found that suggested a clinicalscenario for which anti-VEGF would not be recommended.Eyes with better baseline VA are more likely to have betterfinal VA while those with worse baseline VA have greaterimprovement. This emphasizes that baseline VA must beconsidered when comparing percentage of eyes with improve -ment or worsening following treatments for DME across trials.

214The Effect of Intravitreal Bevacizumab Basedon OCT Patterns of Diabetic Macular EdemaSeung-Young Yu, MD (Seoul, South Korea), Moo Sang Kim, MD, Young Gun Kim, MD, Hyung-Woo Kwak, MD

PURPOSE To compare the effects of intra vitreal bevacizumab ondifferent morphologic patterns of diabetic macular edema(DME) classified using optical coherence tomography (OCT).

METHOD Medical records for 65 eyes of 48 patients were retro-spectively reviewed, and each subject was classified as one ofthree DME types according to the OCT features: diffuse retinalthickening (DRT), cystoid macular edema (CME), serousretinal detachment (SRD). Subjects were given three monthlyintra vitreal injections of bevacizumab (1.25 mg/0.05 ml). Theclinical course of best-corrected visual acuity (BCVA) with alogarithm of the minimum angle of resolution chart and centralfoveal thickness (CFT) using OCT was monitored for 12months after the injections. On follow-up, injections wererepeated if DME was aggravated.

RESULTS Of the 65 eyes with DME, 29 eyes were of the DRTtype, 21 of the CME type, and 15 of the SRD type. Before theinjection, CFT and BCVA were, respectively, 377.1±145.9 µmand 0.54±0.36 in the DRT type, 427.7±143.1 µm and0.59±0.42 in the CME type, and 485.1±187.1 µm and0.65±0.27 in the SRD type; there was no significant differencein CFT and BCVA between DME types (P>0.05). At 6months, the changes in BCVA and CFT differed significantlybetween OCT types (P<0.05). At 12 months, changes in CFTand BCVA from baseline were not significantly different

between groups (P>0.05). The DRT type was associated with agreater reduction in the CFT and greater BCVA improvementthan the CME or SRD types.

CONCLUSION Three monthly injections of intra vitrealbevacizumab seems to be effective treatment in the first 6months, but the therapeutic effect is temporary and repeatedinjections of bevacizumab should be considered to maintain thetherapeutic effect after 6 months. In addition, intra vitrealinjection of bevacizumab was more effective in the DRT typethan in the CME or SRD types of DME.

215Internal Tamponade in Proliferative Diabetic Retinopathy SurgeryRaja G. Zhioua, MD (Tunis, Tunisia), Imene Letaief, Amel Ouertani

PURPOSE To analyse results and complications of vitrectomyusing internal tamponade (gas or silicone oil SO) in prolifer-ative diabetic retinopathy (PDR).

METHOD 231 primary vitrectomies for PDR were retrospectivelyreviewed. Endo tamponade with SO or gas was used in 95 eyes(41%) of which we review clinical records. These eyespresented intraocular hemorrhage with fibrovascular prolifer-ation or tractional retinal detachment (RD) with or withoutrhegmatogenous element. Eyes were assigned in 2 groups ofvitreoretinal attachments (VRA). Group1 with absent or mildVRA attending one or 2 vascular arcads (48 eyes). Group 2with severe VRA attending 3 vascular arcads or more or VRAreaching the periphery of the retina (47 eyes). Anatomicoutcome and postoperative complications were analysed. Meanfollow-up was 20 months.

RESULTS 45 males and 45 females were included in our studywith mean age of 82 years (range: 20-82 years). Gas was used in20 eyes and SO in 75 eyes. Rubeosis was present in 1eye in gasgroup (5%) and 6 eyes in SO group (8%). Rhegmatogenouselements (combined RD or iatrogenic breaks) were present in47 eyes (gas was used in 10 eyes and SO was used in 37 eyes). InG2 with severe vitreoretinal proliferation internal tamponadeby SO (42 eyes 56% ) was used more frequently than gas (5 eyes25%) with significant statistically difference (P=0,02). SO wasremoved in 49 /75 (65,3%). Anatomical success achieved 85%in gas group (17/20) and 78.6% in SO group (59/75).

Postoperative complications included cataract in 31 eyes (40%in gas group and 47% in SO group), ocular hypertension in 17 eyes (25% in gas group and 24.4% in SO group) and post -operative fibrovascular reproliferation in 14 eyes (15% gasgroup and 17% SO group).

CONCLUSION During diabetic vitrectomy it may be necessary touse internal tamponade We obtained better anatomical resultsusing gas than SO which can be explained by the use of SO ineyes with more severe fibrovascular proliferation but the postoperative complications were similar.




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Hereditary Retinal Disease

216Spectral Domain Optical CoherenceTomographic Study of Cystoid Macula EdemaAssociated with Retinitis Pigmentosa

Young Hee Yoon, MD (Songpa-ku, South Korea), Yoon Jeon Kim, Jee Taek Kim, MD, Soo Geun Joe, MD, Joo Yong Lee, MD, Ju Byung Chae, MD

PURPOSE To see the frequency of cystoid macular edema (CME)among patients with retinitis pigmentosa (RP), and to inves-tigate the correlation of visual acuity with CME and othermacular microstructural features assessed by spectral domain-optical coherence tomography (SD-OCT).

METHOD Retrospective case series. Among 100 patients whowere diagnosed to have RP, the presence of cystoids macularedema was identified using SD-OCT. Several parametersincluding central retinal thickness (CRT), photoreceptor (PR)thickness, and the status of PR IS/OS junction at the foveawere also assessed. The correlation between best correctedvisual acuity (BCVA) and each parameter was analyzed.

RESULTS Thirty eight eyes from 27 patients (21.7%) had CME.While no correlation was noted between BCVA and age(p=0.217), the presence of cystoid macular edema (p=0.520),close correlation was observed between BCVA and CRT in eye with CME (p<0.001). Eyes with CME were frequentlyassociated epiretinal membrane or vitreomacular traction(60.6%, p=0.043). Also there was a high correlation betweenthe presence of ME and the disruptive status of IS/OS(p=0.007), PR thickness (p=0.015). As in other conditions, the IS/OS absent group had a significantly worse BCVA thanthe IS/OS present (either discontinuous or distinct) groups(p<0.001).

CONCLUSION The presence of CME in eyes with RP was notnecessarily associated with the loss of visual acuity. However,increase in CRT was highly correlated with the disruption of PR IS/OS, resulting in subsequent visual loss in eyes withCME among RP patients.

Inflammatory and Infectious Diseases POSTERS 217-238

217Is It Advanced Posterior Uveitis or End Stage Disease: Who Do you Not Treat?Multiple Case Scenarios, Two year Follow-up Analyzed by an Expert Panel

Shree K. Kurup, MD* (Winston Salem, NC), David Callanan, MD*, Sofia N. Androudi, MD, PhD, Anita Agarwal*, Sunir J. Garg, MD*, Kishan Govind, MD,David Hinkle, MD, Michael Samson, MD, AndresEmanuelli, MD, Nida Sen, MD, Craig M. Greven, MD

PURPOSE Would there be symmetry of opinion by experts(Macula Society and Uveitis Study Group) in various clinicalscenarios predicting the course of patients with advanceduveitis and could this study uncover some tips and therapy toavoid overlooking potentially treatable disease in the dailyretina practice?

METHOD Study design: Prospectively collected data with retro-spective analysis by a masked expert team with attention to theworse eye in bilateral uveitis to prognosticate response totherapy. Selection criteria: 1. Asymmetrically affected eyes withsevere posterior uveitis. 2. Each of these patients primary reasonfor therapy in was to improve VA in the lesser affected eye. 3. All patients were to receive standard of care immunomodu-latory therapy. Exclusion: 1. Inclusion in another study orexperimental protocol. 2. Inability to provide imaging data. 3. Any patient that potentially could not receive immuno -modulatory drugs. N: 80 Clinical scenarios derived fromnineteen eyes of ten patients.

RESULTS The visual acuity (VA) at 6 month was underestimatedby approximately 3 Snellen lines (0.27 LogMAR units [SD =0.66]). At 12 months the visual acuity was underestimated(0.24 LogMAR units (SD = 0.66) approximately 2.5 Snellenlines. When compared to the actual VA, it showed that it mainlystabilized at 6 months. The mean difference when comparingactual VA at 6 months vs. 12 months was just 0.06 LogMARunits (SD = 0.03). At two years the projected divergencebetween the evaluator curve and actual VA curve was evenmore pronounced. There was a distinct bias towards a conser-vative estimation of the predicted therapeutic response in thevast majority of the panel.


CONCLUSION It is likely there are patients with advanced uveitiswho could be visually rehabilitated to some extent if thera-peutic options were addressed. Some of these patients may notbe expecting any improvement in the worse eye due to durationof symptoms. It is relevant for the retinal specialist to be wary ofposterior uveitis that may masquerade as end stage disease andrequest a second opinion.

Serpiginous choroiditis involving fovea. Therapy coincided with VA 20/400 improving to 20/40 due to recovery of part of fovea over 6 months.

Graph illustrating the ACTUAL (lower line extending 2 years) visual acuityand PERCEIVED or PROJECTED (upper line) by the panel. The slopesdiverge over time. The VA is in logMAR (negative slope)This compositegraph represents the output from ten institutions.

218Endophthalmitis Following Intravitreal Anti-VEGF Injections: Specific Clinical Features and Management

Mallika Goyal, MD (Hyderabad, India)

PURPOSE 1. To analyse the presentation, clinical features,management and response to treatment of endophthalmitisfollowing intra vitreal anti-VEGF injections as opposed to post-operative infection. 2. To enable co-management of the primaryproblem of CNVM along with the infection. 3. To prolong theduration of action of anti-VEGF agent in a vitrectomised eyeafter infection resolution.

METHOD Retrospective review of the medical records of 3patients who developed endophthalmitis out of 3000 consecu -tive intra vitreal bevacizumab injections for CNVM fromSeptember 2005 to March 2011. Two patients had myopia-associated CNVM and one patient had wet age-related maculardegeneration. All were pseudophakic. Each patient required 2interventions: vitreous tap and intra vitreal antimicrobials andpars plana vitrectomy with antimicrobials injection. Intravitrealbevacizumab was added at the last intervention. Microbiologicevaluation of vitreous specimens was done. Main outcomevariables were visual acuity and CNVM status measured withSD-OCT after infection resolution.

RESULTS Important features specific to our cases included rapidvision loss over hours, complete absence of pain, dense vitreousexudates at presentation with minimal anterior chamberinflammation, suboptimal response to intra vitreal antimicro-bials alone, and the need for pars plana vitrectomy even whenthe first intervention was within 3 hours of presentation. Thesefeatures are different from those expected in post-operativeendophthalmitis where pain, and anterior chamber inflam-mation are common and vitrectomy may not be necessary in aproportion of cases treated with intra vitreal antimicrobials.These differences maybe attributed to the fact that during intra -vitreal injection organisms are introduced into the vitreous,whereas during cataract surgery the anterior chamber is the siteof inoculation. Injection of an anti-VEGF agent along withantimicrobials at the end of vitrectomy resulted in a dry maculaat the time of infection resolution in each of our cases.

CONCLUSION Endophthalmitis following intra vitreal injectionspresents with rapidly progressing painless vision loss and significant vitreous inflammation. Pars plana vitrectomy withantimicrobials rather than intra vitreal antibiotics alone shouldbe the procedure of first choice. Intravitreal anti-VEGF agentcan be administered at the last intervention for simultaneousmanagement of CNVM.

Case 2. Myopia-associated CNVM with fluid before bevacizumab injection.

Case 2. Dry Macula three weeks following pars plana vitrectomy with antimicrobials with bevacizumab injection.

INFLAMMATORy AND INFECTIOUS DISEASES



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219Post-viral Fever Neuroretinitis – Successful Treatment with Bevacizumab: A Case Series

Guruprasad S. Ayachit MBBS, MS (Hubli, India)

PURPOSE To determine the safety and efficacy of intra vitrealBevacizumab in presumed post-viral fever neuroretinitis.

METHOD In this prospective non randomised interventionalstudy between Feb 09 and Dec 10, 26 eyes of 18 patientspresenting with visual symptoms due to neuroretinitis develop -ing few weeks after an episode of viral fever with arthralgia &rashes were considered for intra vitreal Bevacizumab. Patientsunderwent baseline ophthalmic examination,fundus photographyand OCT on day 1,and thereafter at 1 week, 1 month and 3months. Fluorescein Angiography was performed in 4 patients.All eyes received 1.25 mg of intra vitreal bevacizumab.Improvement in visual acuity & reduction in macular edema/OCT thickness/volume were the main outcome measures.Minimum follow-up was for 3 months.

RESULTS Visual acuity improved from mean 1.62 LogMar atbaseline to 1.21 at 1 week, 0.84 at 1 month and 0.7 LogMar at 3 months (p < 0.05). Central macular thickness reduced frommean 596 microns at baseline to 356 at 1 week, 227 at 1 monthand 181 microns at 3 months (p < 0.0001). Volume reducedfrom mean 10.85 cu.mm at baseline to 9.51 at 1 week, 7.88 at 1 month and 6.50 cu.mm at 3 months (p < 0.0001). Only oneeye had a second injection for unsatisfactory improvement. Allfundus signs especially macular edema steadily subsided in alleyes. Faster resolution was seen in eyes given bevacizumabwithin 2 weeks of onset of symptoms. Epiretinal membrane was noted in 3 eyes in which the initial affection was severe.There was no recurrence of retinal edema noted in any eye inthe long term. There were no complications related to theinjection in any.

CONCLUSION Intravitreal 1.25 mg bevacizumab is safe, consis-tently effective and a one time treatment option in presumedpost-viral fever neuroretinitis. Injection within two weeks of onset gives better outcomes. A randomised control orcomparative study is necessary to establish the superiority ofbevacizumab over other methods of therapy.

Post Injection clinical course. Note the rapid resolution of retinal signs.

Post injection macular OCT. Note the steep reduction of macular thickness.

220Endogenous Endophthalmitis: Clinical Features, Etiologic Organisms, Fundus Fluorescein Angiographic Features and Management

Mallika Goyal, MD (Hyderabad, India)

PURPOSE Delayed diagnosis of endogenous endophthalmitis has an adverse implication on visual prognosis. This serieshighlights: 1. Characteristic FFA features that can help in earlydiagnosis; 2. Use of DNA chip analysis to expedite and improveidentification of etiological organism; and 3. The prolonged andaggressive nature of therapy that maybe indicated for fungalendophthalmitis.


METHOD Retrospective consecutive review of the records of 9 patients with endogenous endophthalmitis treated fromSeptember 2007 to March 2011 at our Retina Service. FFA wasused to confirm the clinical suspicion in 5 cases. DNA chipanalysis was used when conventional microbiological evalu-ation was negative. Oral fluoroquinolones or voriconazole wereused for systemic therapy in patients without antecedent orassociated systemic infection. Vitreous tap with intra vitrealantimicrobials or pars plana vitrectomy with intra vitrealantimicrobials were performed where systemic therapy alonewas inadequate. Combined intra vitreal amphotericin B andvoriconazole were used for fungal endophthalmitis.

RESULTS Age ranged from 8 years to 52 years; one patient wasimmunocompromised (acute lymphoblastic leukaemia); threepatients were diabetic; both cases of fungal endophthalmitisoccurred in young immunocompetent people; antecedent orassociated systemic infection was identifiable in 4 of 9 cases (3bacterial and one fungal). FFA findings were characteristic andmore dramatic and extensive than the lesions seen clinicallyallowing early confirmation of diagnosis. DNA chip analysisgave the microbiological diagnosis within 24 hours in 4 caseswhere conventional modalities were negative. One patient withcandida endophthalmitis with no systemic infection requiredaggressive ocular therapy for 8 months and systemic therapy fora year (Images 1 and 2). Combination of intra vitreal ampho-tericin B and voriconazole was used when amphotericin alonegave inadequate response.

CONCLUSION Endognous Endophthalmitis is an ophthalmicemergency. Our series highlights the need for very high index of suspicion even in young and immunocompetent patients.FFA can aid in early clinical diagnosis. DNA chip analysis cancomplement the conventional microbiology evaluation. Fungalendophthalmitis may need prolonged and aggressive therapywith combination antifungals for several months.

Endogenous candida endophthalmitis in a 26 year old immunocompetent patient.

Resolution of infection after 8 months of systemic and intra vitreal antifungal therapy.

221Bevacizumab Injection Induces Inflammatory Response in Quiescent Eyes with ToxoplasmosisNancy Kunjukunju, MD (Kansas City, MO), Anthony D. Mazzulla, MD*, Laurence W. Arend, MD

PURPOSE Bevacizumab may reactivate inflammatory conditionswhen used in quiescent eyes.

METHOD Restrospective case analysis of two patients.

RESULTS Case 1: An 84-year-old female, with CNVM secondaryto toxoplasmosis with no evidence of active inflammation,received eight intra vitreal bevacizumab injections off-labelwithout issue. After her ninth injection she developed a severeinflammatory response and was treated for presumed endoph-thalmitis. Cultures were negative and a repeat injection ofbevacizumab one year later caused a similar inflammatoryresponse. Subsequent to these episodes, she has been treatedwith ranibizumab with no increase in inflammation.

Case 2: A 75-year-old patient, with CNVM secondary to age-related macular degeneration and an inactive toxoplasmosislesion, received three ranibizumab injections without incidentbefore being switched to bevacizumab. After her secondbevacizumab injection, she developed a severe inflammatoryresponse with reactivation of her toxoplasmosis lesion. Cultureswere negative and the inflammation resolved. Her thirdinjection of bevacizumab reactivated the inflammation.

CONCLUSION Bevacizumab may need to be reevaluated as an off-label intra vitreal agent for the treatment of cystoid macularedema, choroidal and retinal neovascularization resulting fromor associated with uveitic conditions.

222Concordance of Anti-retinal Antibody Testing Between Laboratories in PatientsSuspected to Have Autoimmune or Cancer-associated RetinopathySepideh Faez, MD (Boston, MA), Lucia Sobrin, MD

PURPOSE To report the concordance of anti-retinal antibody(ARA) testing between two laboratories for patients with non-paraneoplastic autoimmune retinopathy (npAIR) orcancer-associated retinopathy (CAR).

METHOD We retrospectively reviewed the medical records ofpatients seen on the Uveitis/Retina Services of the Massachu-setts Eye and Ear Infirmary between 2008 and 2010 who weresuspected to have either npAIR or CAR based on clinicalexamination. We included the seven npAIR/CAR patients whohad their serum samples sent to two different laboratories forARA testing by Western blot (WB) and/or immunohisto -chemistry (IHC). The concordance rate for detection of ARAbetween the two laboratories was calculated.




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RESULTS Of the seven patients, four had CAR and three hadnpAIR. Using WB, the first laboratory detected ARA in six ofthe seven patients. Using a similar WB protocol, the secondlaboratory detected ARA in three patients and an equivocalARA result in another patient. The concordance rate fordetection of any ARA was 43% between the two laboratories.Of patients with concordant positive results, only one had thesame ARA detected by the two laboratories. That patient hadantibodies against a protein (enolase) that has been well estab-lished in the pathogenesis of CAR. IHC was used by the twolaboratories only to confirm some of the positive WB results.Among those who had positive WB results by both labs (n=3),only one patient received the confirmatory IHC by both labs;the result was positive in both cases.

CONCLUSION The concordance rate for ARA detection by WBbetween two laboratories was 43%. The variability in results forARA testing currently limits the utility of this method for theconfirmation of CAR and npAIR diagnoses.

223Endogenous Streptococcus PneumoniaeEndophthalmitis in a 40 year-old Man

Gaurav Gupta, MD (Providence, RI), Enchun M. Liu, MD

PURPOSE To present a case of endogenous endophthalmitis in an immunocompetent patient with streptococcus bacteremia.

METHOD Case report.

RESULTS A 40 year old immunocompetent man presented withone day history of enlarging central scotoma and countingfingers vision in his right eye. He also complained of inter-mittent fevers, malaise and joint pain. His fundus had a large,elevated area of retinal whitening, intraretinal hemorrhages,and arteriolar sheathing (Fig 1). The patient was hospitalizedfor systemic evaluation of a possible source of an intraocularinfection. Blood cultures were positive for Streptococcuspneumonia; additional imaging showed a right pleural effusion,thoracic spinal diskitis, and left knee effusion. The patient waspromptly treated with vitrectomy and intra vitreal antibioticssalvaging his eye; unfortunately his vision declined to no lightperception. A trans-esophageal echocardiogram revealed twoaortic valve vegetations, consistent with endocarditis. Threeweeks later, despite systemic intravenous vancomycin, he beganexhibiting signs of heart failure necessitating an aortic valvereplacement.

CONCLUSION Endogenous endophthalmitis from Streptococcuspneumoniae often takes on an aggressive clinical course and isassociated with a poor visual prognosis and multiple systemicco-morbidities compared to more common pathogens such asCandida spp and Staphylococcus aureas.

224Efficacy of Intravitreal Moxifloxacin vs. Intravitreal Vancomycin + Ceftazidime in the Treatment of Acute Bacterial Endophthalmitis in an Animal ModelTania N. Adabache-Guel, MD (Mexico City, Mexico), Blanca B. Figueroa-Magana, MD, Armando Meza-De Regil, MD, Adriana Perez Reguera-Gutierrez, MD, Virgilio Morales-Canton, MD, Juan Manuel Jimenez-Sierra, MD, Jose Guerrero-Naranjo, MD, Jans Fromow-Guerra, MD, PhD, Gerardo Garcia-Aguirre, MD, Hugo Quiroz-Mercado, MD, Jose Dalma-Weiszhausz, MD

PURPOSE Is intra vitreal moxiflacin more effecive and securethan the conventional treatment for endophthalmitis?

METHOD Phase 1: We injected intra vitreal moxifloxacin (MXF)at a dose of 0.5mg/0.1mL. Electroretinograms were performed at baseline, 7, 14, 21 and 30 days posterior to injection. Phase 2:We inoculated a 4.9.x105 colony-forming units (CFU) ofPseudomonas aeruginosa and 1.8X 105 UFC of Staphylococcusepidermidis. Treatment was either intra vitreal MXF at a dose of0.5mg/0.1mL or vancomycin 1 mg/0.1ml plus ceftazidime 2.25mg/0.1ml (V+C). The groups were: 1) S. epidermidis and MXF;2) S. epidermidis and V+C; 3) P.aeruginosa and MXF and4)P.aeruginosa and V+C. Clinical response to treatment,number of CFU in the vitreous humour and histopathologicalchanges were analyzed.

RESULTS Phase 1: In the ERG the mean postinjection A and Bwave were of 13.60µV and 36.80µV respectively, with no statis-tically significant difference.The histopathological analysisshowed no damage. Phase 2: Groups 1, 2, 3 and 4 the meannumber of CFU posttreament were 1.9x101, 0, 0, 1.86x101respectively. Comparing CFU in group 1 and 2 a statisticallysignificant difference was observed (p 0.012) and also betweengroups 3 and 4 (p 0.002), in favor of moxifloxacino.

CONCLUSION Intravitreal moxifloxacin is safer and moreefficient than vancomycin plus ceftazidima for the treatment of acute bacterial endophthalmitis in an animal model.



Hematoxylin-eosin staining of the retina at the posterior pole high magnification (40X). Marked loss of architecture of the retina and the presence of an extensive acute inflammatory infiltrate in the vitreous infiltrate all layers.

Hematoxylin-eosin staining of the retina at the posterior pole high magnification (40X). Showing extensive acute inflammatory infiltrate in vitreous, extending throughout the thickness of the retina and choroid.

225Interim Results of the LOHS Study:Ranibizumab in the Treatment of Choroidal Neovascularization Secondary to Ocular Histoplasmosis

John W. Kitchens, MD* (Lexington, KY), Edward Wood, MD, William J. Wood, MD, Thomas W. Stone, MD*, Rick D. Isernhagen, MD

PURPOSE To determine the level of safety and efficacy ofranibizumab for the treatment choroidal neovascularizationsecondary to Ocular Histoplasmosis.

METHOD An open-label, randomized, prospective studycomparing two different dosing strategies of 0.5 mg ofranibizumab. Group A received a single injection followed byPRN retreatment. Group B received 3 injections followed byPRN retreatment. Visual acuity, change in OCT and need forretreatment were analyzed as well as ocular and systemiccomplications.

RESULTS Mean best-corrected visual acuity from a baseline of20/38 (range: 20/20 to 20/100) to a final acuity of 20/24 (range:20/13 to 20/80). Mean central subfield thickness on OCTdecreased from a baseline of 349µ (range: 242µ to 442µ) to afinal OCT thickness of 258µ (range: 214µ to 310µ). No patientslost vision. There were no systemic or ocular adverse eventsobserved.

CONCLUSION Interim results indicate that ranibizumab is safeand efficacious in the treatment of choroidal neovascularizationsecondary to Ocular Histoplasmosis Syndrome.

226The Role of SD-OCT in the Evaluation andManagement of Infectious Retinitis

Manjot Gill, MD (Chicago, IL), Sudhi Kurup, MD

PURPOSE The purposes of this study are (1) to compare SD-OCT images of retinal lesions with clinical exam and fundusphotography to evaluate for any added benefit in identifyingand describing retinitis lesions and (2) to evaluate for changeson SD-OCT images to assess for any additional insight ondisease progression or response to therapy.

METHOD This is a retrospective chart review with a prospectivearm (given the rarity of retinitis cases). Inclusion criteriainclude patients above the age of 18 years with diagnosed orprobable infectious retinitis (including cytomegalovirus, herpessimplex, varicella zoster, toxoplasmosis) that have obtained full ophthalmologic exam including dilated fundus exam,fundus photography and SD-OCT imaging of the affected area.Exclusion criteria include those patients unable to obtain SD-OCT given significant media opacity.

RESULTS Patients with CMV retinitis and toxoplasmosis wereevaluated by SD-OCT at the time of diagnosis and during theirfollow-up. Qualitatively, the imaging helped identify affectedfrom unaffected retina as well as demonstrating the layers of theretina involved. The OCT images provided serial qualitativeevaluation to assess response to therapy. SD-OCT also helpeddifferentiate lesions such as cotton-wool spots that may mimicactive retinitis. There was also added information obtainedregarding vitreo-retinal interface abnormalities.

CONCLUSION SD-OCT has had a significant impact in the evaluation of the posterior segment. There may be a role for itsuse in helping evaluate and manage patients with infectiousretinitis by delineating the area of involvement, differentiatinglesions that may mimic retinits and monitoring the effect of therapy.




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Serial fundus photography of CMV retinitis.

Serial SD-OCT of affected area of CMV retinitis.

227Bilateral Serous Macular Detachment: Four Uncommon Etiologies

Armando G. Sandoval, MD (Quito, Ecuador), Jeffrey L. Lipkowitz, MD, Sandra X. Larco, Andrea E. Ayala, MD, Juan J. Chiriboga, MD

PURPOSE To present 4 different etiology cases of Bilateral SerousMacular Detachment: VKH, metastatic breast carcinoma,rheumatoid arthritis, myeloblastic leukemia, seen by the authorsin the last 2 years, and how it was managed.

METHOD Review of clinical charts of four private practicepatients with serous macular detachment in the past 2 years in Quito, Ecuador and Lawrenceville, NJ, due to differentetiologies: VKH type 1, metastatic breast carcinoma, rheumatoidarthritis and leukemia, that were treated medically withsystemic steroids or intra vitreal bevacizumab plus the specificdisease treatment. All were adults from 20 to 50 years old, 3 ofthem women and one man (leukemia). There was a bilateralmacular exudative serous detachment in all of the cases.

RESULTS Concerning to the serous macular detachment, allimproved after treatment. The VKH case recovered vision withoral prednisone during one year with tapering doses.Thechoroidal breast metastasis patient passed away 5 weeks afterrecognizing the ocular disease,but the SRD had a significantresolution after intra vitreal bevacizumab. The AR case also

gained vision with intra vitreal bevacizumab, and the patientwith leukemia did the same after oral corticosteroids.

CONCLUSION 1) Apart from the classical causes of exudativeretinal detachment: malignant hypertension, eclampsia andrenal failure; there are others not so common entities that canlead to this disease. 2) Usually the prognosis is good after theproper treatment is installed. 3) An extensive laboratory w/u ismandatory for completing the diagnosis. 4) OCT and FA areindispensable tools.

OS picture of a 47 y.old woman with choroidal breast metastasis. It is visible an extensive macular serous detachment.

Stratus OCT of OS of a 28 year old woman with severe serous retinaldetachment due to VKH , before treatment.

228Posterior Segment Manifestations of Scleritis:Etiology, Associated Systemic Conditions and TreatmentHassan T. Rahman, MD (Atlanta, GA), Sunil Srivastava, MD, Chris S. Bergstrom, MD, Jonathan Waltuck, MD, Steven Yeh, MD

PURPOSE Posterior segment manifestations of scleritis are likelyunder-recognized and may contribute to visual morbidity. Wecharacterize a series of patients with scleritis and posteriorsegment disease.

METHOD Retrospective, interventional consecutive case series of patients with scleritis and posterior segment disease wereidentified from a database of uveitis patients at a single tertiaryreferral center. Records were reviewed for visual acuity, etiologyand type of scleritis, posterior segment manifestations,associated systemic diagnoses, and need for steroid-sparingimmunosuppression.


RESULTS 13 patients with scleritis and posterior segment diseasewere identified. Scleritis classifications included diffuse anterior(46%), nodular anterior (31%), posterior (15%) and scleroma-lacia perforans (15%). Systemic associations were identified in46% of patients including chronic demyelinating inflammatorypolyneuropathy, rheumatoid arthritis, and relapsing polychon-dritis. Posterior manifestations (# of eyes) included exudativeRD (4), subretinal/choroidal granulomas (4), disc edema (3),panuveitis (3), retinal vasculitis (2), orbital pseudotumor (1),central serous retinopathy (1), and VMT/ERM (3). 85% of eyes(17/20) maintained or improved vision ≥ 2 lines during follow-up.3 eyes lost ≥ 2-lines of vision. The mean follow-up period was9.5 months. 92% of patients required systemic cortico steroid,and 84% required steroid-sparing agents including MTX,mycophenolate, azathioprine, and rituximab, and adalimumab.25% of patients required 2 or more steroid-sparing agents.

CONCLUSION Posterior segment disease in patients presentingwith scleritis may result in significant visual morbidity. Themajority of these patients require steroid-sparing immuno -suppression to stabilize inflammation and prevent visual loss.

229Resolution of Lyme-associated Uveitis after Detection and Treatment of Babesia CoinfectionBabak Roobini, MD (Stony Brook, NY), Thomas J. Federici, MD, Julie Tsai

PURPOSE To describe a case of Lyme disease presenting withuveitis in which resolution occurred only after detection andtreatment of Babesia coinfection was initiated.

METHOD Retrospective chart review. Data extraction includeddemographic information, clinical and medical history, andclinical examination findings including slit-lamp biomicroscopyand dilated ophthalmoscopy. Ophthalmic imaging was alsoextracted.

RESULTS A 44-year-old male being treated for Lyme disease for 6 weeks with doxycycline presented with blurred vision. Exami-nation revealed both aqueous and vitreous cell along withretinal vascular sheathing. Fluorescein angiography demon-strated optic nerve hyperfluorescence. Laboratory studiesindicated positive Lyme titer, Lyme IgM Western blot, andBabesiosis IgM titers. Resolution of inflammation andimprovement of optic nerve involvement was demonstrated at 6 weeks time following treatment with a 10 day course ofAtovaquone and Azithromycin.

CONCLUSION As babesiosis and Lyme disease are transmitted bythe same tick vector, the ophthalmologist should considercoinfection in patients with Lyme-associated uveitis in patientsthat are recalcitrant to standard therapy.

230Prevalence of Smoking in Patients with Vogt-Koyanagi-Harada Syndrome

Heitor Panetta, MD (Campinas, Brazil), Rafael S. Zacchia, MD, Ricardo Y. Abe, MD, Sergio Paiva, MD, Rodrigo P.C. Lira, MD

PURPOSE To evaluate the prevalence of smoking in patientswith Vogt-Koyanagi-Harada (VKH) Syndrome and to comparewith the Brazilian population.

METHOD We conducted a prospective case series of 17 patientswith VKH Syndrome, in Campinas, Brazil. We used a question-naire on habits related to smoking. It was used data from Vigitel(Surveillance System of Risk Factors for Chronic Diseases andProtection through Telephone Interviews) to determine theprevalence of smoking in Brazilian population (15.5%).

RESULTS The study found a smoking prevalence of 29.4% (5/17)in patients with VKH syndrome. All patients had been smokersbefore the diagnosis of VKH. There was no significantdifference in gender distribution between groups, 3/5 womenamong smokers and 8/12 women among nonsmokers (p <0.605). There was a tendency for smokers to be older (55 ± 3years old in the smokers versus 43 ± 17 years old in thenonsmokers – p < 0.227).

CONCLUSION Cigarette smoking is more prevalent in patients with VKH syndrome and it may be a risk factor for this disease.




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231Intravitreal Clindamycin and Dexamethasonefor Toxoplasmic Retinochoroiditis

Alay S. Banker, MD (Ahmedabad, India), J. Fernando Arevalo, MD, Martin A. Serrano, MD, Rohan Chauhan, MD

PURPOSE To report anatomic and functional outcomes of intra -vitreal clindamycin and dexamethasone for the treatment oftoxoplasmic retinochoroiditis (TRC).

METHOD Retrospective study of 16 patients with mean age 38.88years (21-68 years, Male : Female 6:10) with TRC (3: subfoveal,7: juxtafoveal, 6: extrafoveal) treated with intra vitreal clinda -mycin (1.5 mg/0.1 ml) and dexamethasone (400 µg/0.1 ml).Outcome measures included resolution of TRC, changes inBCVA, OCT, fundus photos, fluorescein angiography andassessment of adverse events.

RESULTS Resolution of TRC was achieved in all cases with amean number of injections of 3.2 (range: 1–5 injections). Meanvisual acuity improved to 0.67 from 1.15 LogMAR. At mean14.7 months (2-36 months) a significant reduction in CMT byOCT was observed. No ocular or systemic adverse events orrecurrences were observed.

CONCLUSION Intravitreal injection of clindamycin and dexamethasone may be an acceptable alternative to the classictreatment in ocular toxoplasmosis. It may offer the patient moreconvenience, a safer systemic side effect profile, greater avail-ability, and fewer follow-up visits and hematologic evaluations.

Pre-treatment acute toxoplasmic retinochoroiditis

Post-treatment healed lesion

232Wide-field Fundus Photography andFluorescein Angiography in the Diagnosis and Management of Retinal Vasculitis

Yasir J. Sepah MBBS (Baltimore, MD), John P. Campbell, MD, Henry A. Leder, MD, Theresa Gan, MD, Brian Cho, MD, Elham Hatef, MD,Mohamed Ibrahim, MD, Roomasa Channa, Abeer Akhtar, MD, Diana Do*, Quan Dong Nguyen *

PURPOSE To determine the utility of wide-field imaging andwide-field fluorescein angiography system in the diagnosis andmanagement of non-infectious retinal vasculitis.

METHOD In this prospective, comparative study of patients withnon-infectious retinal vasculitis, at baseline, and at scheduledfollow-up visits, patients underwent wide-field pseudo-colorimaging and angiography performed with Optos P200™System. Participating investigators were asked to determinedisease activity and management changes based on exam alone,wide-field pseudo-color images, and wide-field angiography.Management decisions at each time point were compared todetermine the influence of wide-field imaging on the clinician’sdecisions for diagnosis and treatment. Disease activity, retinalnon-perfusion, and changes over time were separatelyevaluated.

RESULTS 22 patients have been enrolled with a diagnosis ofretinal vasculitis. Diagnoses included: idiopathic (7); panuveitis(6); Wegener (1); Behcet (3); Sarcoid (3); Intermediate uveitis (1); and optic neuritis (1) associated retinal vasculitis. 8 patients had evidence of active vasculitis on clinical examalone, while 12 had evidence of active vasculitis on wide fieldfluorescein angiography but not on clinical exam. One patienthad peripheral non-perfusion requiring scattered laser directedby the angiogram. Subsequent visits demonstrated improvementin 3 of 4 patients and stability in 1 patient.

CONCLUSION Additional information provided by wide fieldimaging may allow earlier detection of active vasculitis whichmay lead to earlier treatment and better patient outcomes.Further studies are indicated to support our initial findings.


233Recurence of Active Disease in BirdshotChoroidopathy Following Treatment with LocalSustained Delivery of Fluocinolone Acetonide

Thomas A. Albini, MD *(Miami, FL), Sunil Srivastava, MD, Quan Dong Nguyen*, David Callanan, MD*, Debra Goldstein, MD

PURPOSE To describe the clinical outcomes of the subgroup ofpatients with birdshot choroidopathy enrolled in the sustaineddelivery fluocinolone acetonide (Retisert) randomized clinicaltrials.

METHOD Data from 3 separate randomized controlled clinicaltrials performed from 2000-2005 was compiled. Patients withevidence of birdshot choroidopathy were identified from thedata set and analyzed. Outcome measures analyzed includedrecurrence rates, ETDRS visual acuity, time to first recurrence,visual fields, angiographic evidence of leakage and ERG.

RESULTS A total of 39 patients were identified, 31 patients wererandomized to receive fluocinolone acetonide implantation and8 randomized to standard of care (SOC) medications. Only oneeye from each group was used as the study eye. Data was alsocollected on the fellow eye in the implant group. The averagepatient age was 46. 26 patients were female, 13 were male.Logmar baseline vision in the implant group was .5067, in thestandard of care group was .635 and the fellow eye of theimplant group was .2467. 36 month visual acuity resultsrevealed stabilization in the implant group and worsening inboth the SOC and fellow eye groups. Recurrence rates over 3years in the implant group was 22%, 62% in the SOC groupand 46% in the fellow eye group. Average time to recurrencewas 603 days in the implant group, 430 days in the SOC groupand 118 days in the fellow eye group.

CONCLUSION In the subgroup of patients with birdshotchoroidopathy, eyes implanted with the fluocinolone acetonideimplant maintained stable vision over a period of 36 monthswith a lower recurrence rate and longer time to recurrence incomparision to eyes treated with standard of care medicationsand fellow non-implanted eyes.

234Stellate Neuroretinitis Associated with Posterior Scleritis

Darin R. Goldman, MD (Los Angeles, CA), Mark W. Johnson, MD, David Sarraf, MD*

PURPOSE To describe two cases of stellate neuroretinitisassociated with posterior scleritis.

METHOD Retrospective observational case series.

RESULTS Two middle-aged female patients presented withunilateral decreased vision and clinical findings consistent withstellate neuroretinitis. A thorough diagnostic evaluation forknown causes of neuroretinitis was negative in each case.Radiography, ultrasonography, and fluorescein angiographyrevealed findings consistent with a diagnosis of posteriorscleritis in each patient.

CONCLUSION This is the first report of posterior scleritis causingstellate neuroretinitis. In patients with stellate neuroretinitis ofunknown etiology, posterior scleritis should be considered inthe differential diagnosis.

(A) CT scan shows smooth crescenteric thickening of the posterior wall ofthe right globe consistent with posterior scleritis. (B) Red free photographshows obscuration of the optic disc margin, inferior disc hemorrhage, hardexudates in a stellate pattern, and choroidal folds inferiorly. (C) FA showsoptic disc leakage and illustrates more clearly the choroidal folds.

(A) Color photograph of the left eye shows obscured disc margins,tortuous veins, and hard exudates in a stellate pattern. (B) B-scan ultrasound shows a “T-sign” consistent with posterior scleritis. (C) Color photograph 2 months after initiation of systemic steroids shows significant resolution of findings. (D) B-scan ultrasound showsresolution of the “T-sign.”

235Multimodality Diagnostic Imaging in Unilateral Acute Idiopathic MaculopathyJohn F. Payne, MD* (Atlanta, GA), Cecilia S. Jung, MD, Chris S. Bergstrom, MD, Blaine E. Cribbs, MD, Jiong Yan, MD, G. Baker Hubbard, MD, Timothy W. Olsen, MD, Steven Yeh, MD

PURPOSE To describe the clinical features and imaging charac-teristics in unilateral acute idiopathic maculopathy (UAIM).

METHOD A retrospective review of four patients diagnosed withUAIM. Clinical characteristics (age, symptoms, ocular/medicalhistory, Snellen visual acuity (VA), and funduscopic features)and images from spectral-domain optical coherence tomography(sd-OCT), fundus autofluorescence (FAF), fluorescein (FA),and indocyanine green (ICG) angiography were analyzed.




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RESULTS The median age at presentation was 31 years, and themedian interval between symptom onset and presentation wasfour weeks. Associated systemic findings included a viralprodrome (50%), hand-foot-mouth disease (25%), and positiveCoxsackie virus titers (50%). The median presenting VA was20/400 (range 20/70–1/400), which improved to 20/30 (range20/20–20/60) at final follow-up. The median follow-up timewas 6 weeks. Early in the disease course, the central maculadeveloped irregular areas of white-grey discoloration. Followingrecovery, the macula had a stippled retinal pigment epitheliumwith by rarefaction and hyperplasia. FA demonstrated irregularearly hyperfluorescence and late subretinal hyperfluorescence.SD-OCT showed a partially reversible disruption of the outerphotoreceptor layer. FAF initially revealed stippled autofluores-cence that eventually became more hypoautofluorescent. ICG showed “moth-eaten” appearing choroidal vasculature,suggestive of inflammation.

CONCLUSION The imaging characteristics highlight the struc-tural changes during the active and resolution phases of UAIM.The visual recovery correlates with structural changes andsuggests that the pathogenesis involves inflammation of theinner choroid, retinal pigment epithelium, and outer photo -receptor complex that is partially reversible.

(A) Fundus photograph 1 week after symptom onset shows granularhyperpigmention of the retina and RPE. (B) FA shows late staining andmild leakage in the central macula. (C) ICG angiography demonstates a“moth-eaten” choroidal vascular appearance and dilated choroidalvessels. (D) FAF shows a stippled autofluorescense. (E) Sd-OCT demon-strates disruption and irregularity of the photoreceptor layer

Color fundus photograph, FAF, and sd-OCT findings one week (A) and twomonths (B) after symptom onset. There is loss of the grey-white discol-oration and an increase in retinal pigment hyperplasia later in the diseasecourse. The FAF images show more hypoautofluorescence. Sd-OCTreveals disruption of the photoreceptor layer (arrows), which is partiallyrestored (arrowheads) at the two month visit.

236Inhibition of Ocular Inflammation in Endotoxin-induced Uveitis with the Calcium ChannelBlocker Nilvadipine But Not DiltiazemTakashi Koto, MD, PhD (Tokyo, Japan), Atsuro Uchida, MD, Makoto Inoue, MD

PURPOSE Calcium channel blockers (CCBs), widely used forhypertensive patients, have recently been shown to inhibitatherosclerosis due to their anti-oxidative action. The aim ofthe present study was to examine whether CCBs nilvadipineand diltiazem reduce ocular inflammation in endotoxin-induceduveitis (EIU).

METHOD EIU was induced in male C57/B6 mice by a singleintraperitoneal injection of LPS. Animals had receivedintraperitoneal injections of nilvadipine, diltiazem or vehiclefor 5 days until LPS application. Twenty-four hours after EIUinduction, adherent leukocytes to the retinal vasculature werecounted with a concanavalin A lectin perfusion-perfusion label -ing technique. Protein concentration in the aqueous humor was measured to assess blood-ocular barrier breakdown. Retinallevels of ICAM-1 and MCP-1 were analyzed by ELISA. LPS-stimulated generation of superoxide in murine microvascularendothelial cells was examined with nitroblue tetrazolium assay.

RESULTS Compared to vehicle treatment, application withnilvadipine, but not diltiazem, led to significant suppression ofEIU-associated retinal leukocyte adhesion together with anterior-chamber protein leakage, retinal expression of ICAM-1 andMCP-1, and LPS-induced superoxide generation in vitro.

CONCLUSION These results demonstrate the inhibitory effect of the CCB nilvadipine on the pathogenesis of ocular inflam-mation through the suppression of inflammation-relatedmolecules.

Suppression of Retinal Leukocyte Adhesion with Nilvadipine but not Diltiazem.


237Potential for Iatrogenic Contamination of Intravitreal Needles During Injection

John O. Mason, MD (Birmingham, AL), Duncan A. Friedman, MD, MPH, Tracy L. Emond, Lindsey Wallace, MD, Dustin L. Pomerleau, MD

PURPOSE Endophthalmitis is a devastating complication of anyintra vitreal injection. The current literature indicates that oralflora from clinicians could contaminate needles, increasing thepossibility of endophthalmitis. We sought to determine if iatro-genic needle contamination plays a significant role duringintra vitreal injections.

METHOD Using a previously described experimental culturemethod, we exposed sterilized 30 gauge needles to differentpotential sources of contamination. Cultures were taken fromneedles in three conditions: 1) taken directly from the package,2) a physician speaking directly in front of the needle for 30 seconds, and 3) needles exposed to the same physician’sbreathing for 30 seconds. These needles were then inoculatedonto blood and chocolate agar and allowed to incubate at 37 degrees for 6 days. A control throat swab was also culturedusing this same method.

RESULTS A total of 45 plates were divided evenly between the 3 conditions (15 blood and chocolate plates per group). Noneof the plates in Group 1 (sterile needle) grew positive cultures.Only one plate in each of the other groups grew a colonyforming unit. The control swab grew 335 and 180 colonyforming units on blood and chocolate agar, respectively.Compared to the control swab, the experimental groups had asignificant absence of growth (p<0.0001). The control swabgrew predominantly Gram positive organisms.

CONCLUSION Needles exposed to normal conditions duringoffice based injections (i.e. talking and breathing) did not yieldsubstantial growth of colony forming units. Compared to directthroat culture, there was a significant absence of growth fromany of the needles inoculated onto culture media. It appearsnormal oral flora may not be a major source for needle contami-nation during intra vitreal injections.

238Bacterial Dispersal Detectable in the Area of Injection Associated with Speech during Simulated Intravitreal Injection

Colin A. McCannel, MD* (Los Angeles, CA), Joanne C. Wen, MD, Brian Mochon, Omai Garner, MD

PURPOSE To investigate the amount of detectable bacterialdispersal associated with speech in various conditions during asimulated intra vitreal injection.

METHOD In the setting of simulated intra vitreal injection,fifteen healthy volunteers stood adjacent to an examinationchair with an open blood agar plate affixed near the head rest.The following conditions were tested while the volunteer read a5 minute script: facing the blood agar plate with and without afacemask, without a facemask with the face turned to the side,and while reclined in an ophthalmic exam chair with an openblood agar plate secured to the forehead (patient condition).Additionally, the volunteer stood in silence for 5 minutes facingan open blood agar plate. Total number of colony formingbacteria per plate were counted and identified.

RESULTS With no facemask, 12 of 15 plates grew at least 1bacterial colony [mean=10.5 colonies per plate (cpp), range=0-63]. When a facemask was worn, 3 of 15 plates had growth(mean=0.3 cpp, range=0-2). With the face turned away fromthe plate, 10 of 15 plates had growth (mean=1.8 cpp, range=0-6). When the volunteer stood in silence, 4 of 15 plates hadgrowth (mean=0.33 cpp, range=0-2). With the volunteerreclined in the patient’s position, 7 of 15 plates had growth(mean=1.5 cpp, range=0-13). Significantly higher bacterialgrowth was found in the “no facemask” condition compared to either “facemask” and “silence” (each p<0.001), and in the“face turn” condition compared to either “facemask” or“silence” (each p<0.05). Bacterial growth was not significantlydifferent comparing the conditions “facemask,” “silence,” and“room control.” Growth was significantly greater in the“patient” condition compared to the “room control” (p=0.015).

CONCLUSION Wearing a facemask or remaining silent signifi-cantly decreases the amount of bacterial growth due to dispersalassociated with speech. Physicians performing intra vitreal injec-tions should consider either minimizing speech or wearing afacemask, and advising patients to be silent to minimize theamount of oropharyngeal bacterial dissemination from speechduring intra vitreal injections.




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Vitreoretinal Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Complications of AnteriorSegment Surgery POSTERS 301-302

301Outcomes of 23-g Vitrectomy for Resistant-pseudomonas Cluster EndophthalmitisFollowing Cataract Surgery

Alay Banker, MD (Ahmedabad, India), Rohan Chauhan, MD

PURPOSE To describe outcomes of 23-G vitrectomy in acutecluster endophthalmitis.

METHOD This is a consecutive case series of eyes having acutecluster endophthalmitis following cataract surgery. All eyesunderwent primary 23-G vitrectomy and intra vitreal antibioticswith meticulous anterior chamber clean-up without removal ofIOL, on same day.. Anterior chamber fibrin and vitreoussamples were subjected to microbiological examination. Repeatintra vitreal injections or surgery were performed if there was noimprovement or worsening of inflammation. Outcome measuresincluded resolution of infection and visual improvement.

RESULTS Nine eyes with acute cluster endophthalmitis thatunderwent primary 23-G vitrectomy were included in the study.Presenting visual acuities in all eyes ranged from lightperception to hand movement. All eyes demonstrated severevitritis (+4), 7 had hypopyon, and 5 eyes had significant ACfibrin and corneal involvement. Thorough cleaning of theanterior chamber with removal of fibrin was achieved in all eyes with help of 23-G forceps. Microbiological examinationrevealed gram-negative short rods suggestive of pseudomonasorganisms. Sensitivity reports showed resistance to Vancomycinand Ceftazidime. Four eyes needed repeat intra vitreal injec-tions. Three eyes needed repeat vitrectomy and silicone oil. At12 weeks, all eyes showed complete resolution of inflammationand visual acuity improved to 20/63 or better in 7/9 eyes (range:20/200-20/32).

CONCLUSION Primary 23-G vitrectomy surgery is effective even in severe acute postoperative cluster endophthalmitis. It is extremely safe, efficacious and helps in early healing even in such severly inflammed eyes. Primary removal ofintraocular lens may not be required even in severe endoph-thalmitis cases.

Pre-operative cornea on presentation

Post-operative cornea at 12 weeks

302Early Postoperative Serous MacularDetachment Following Phacoemulsification

Osman Cekic (Istanbul, Turkey), Murat Aslankurt, MD, Inayet Andi, MD, Osman Dursun, MD

PURPOSE To report a new entity of serous macular detachmentthat developed next day after uneventful cataract extractionwith phacoemulsification.

METHOD In 8 eyes of 8 patients (6 male, 2 female) thatunderwent uneventful phacoemulsification and intraocular lensimplantation, visual acuity improvement could not be achievedat the first postoperative day. All eyes had normal appearingmacula preoperatively. Optical coherence tomography imagingrevealed serous macular detachment with intraretinal fluidaccumulation postoperatively.

RESULTS Patients received standard antibiotic and steroid eyedrops for four weeks after the surgery. No significant anteriorchamber reaction was observed postoperatively. Completerecovery of early postoperative macular edema happened withinfirst to fourth week after phacoemulsification. No risk factorcould be identified. Baseline median Snellen best-correctedvisual acuity (0.35) decreased to 0.2 at the first day andincreased to 0.9 at first week postoperatively (P<0.001).Median central macular thickness at first day (530 micron)decreased to 257 micron at first postoperative week (P<0.001).

CONCLUSION Early postoperative serous macular detachmentwith intraretinal fluid accumulation, which was transient in ourseries, may occur after phacoemulsification without any identi-fiable risk factor.


Macular Holes and MacularPucker – Epiretinal MembranePOSTERS 303-319

303To Peel or Not to Peel the Internal LimitingMembrane in Macular Hole Surgery: Resultsfrom the PanAmerican Collaborative Retina Study Group (PACORES)

Arturo A. Alezzandrini, MD (Buenos Aires, Argentina), J. Fernando Arevalo, MD, Lihteh Wu, MD, Maria H. Berrocal*, MD, Jose A. Roca, MD, Maria Belen Garcia

PURPOSE To evaluate the anatomical and functional outcomesat 24 months of follow-up in patients with macular hole (MH)stages II, III & IV that were treated with pars plana vitrectomy(PPV) plus internal limiting membrane (ILM) peeling with andwithout dye assistance.

METHOD Retrospective, interventional, multicenter study. Wereviewed the clinical records of all consecutive patients withmacular hole treated with PPV with ILM peeling. ETDRS BestCorrected Visual Acuity (BCVA), central macular thicknessmeasured by optical coherence tomography (OCT) and thepresence of adverse effects were evaluated at baseline, 1, 6, 12and 24 months of follow-up to compare the effectiveness ofeach technique. All eyes were divided in 3 groups. Group 1: 47 eyes with PPV and ILM peeling without any dye assistance.Group 2: 69 eyes with PPV and ILM peeling with IndocianineGreen assistance. Group 3: 47 eyes with PPV and ILM peelingwith Briliant Blue assistance.

RESULTS The anatomical results in Group 1 were: Primaryanatomical MH closure was obtained in 36 of 47 eyes (76.6 %);in Group 2 MH closure was obtained in 64 of 69 eyes (92.8%)and in Group 3 MH closure was obtained in 45 of the 47 eyes(95.7%). The results of Visual Acuity in Group 1 was MeanBCVA was 20/100 ETDRS and gained a mean of 4.36 lettersfrom baseline, in Group 2 Mean BCVA was 20/100 ETDRS andgained a mean of 2.87 letters from baseline. In Group 3 MeanBCVA was 20/80 ETDRS from baseline and gained a mean of3.79 letters from baseline. Analysis perfomed on the final VisualAcuity results showed no statistically significance amongst thedifferent groups (p>0.05). However, MH closure rate was statis-tically significant when results were analized between Group 1and Groups 2 and 3 (p<0.05). When comparing Group 2 andGroup 3, no statistically significant results were found, so as tobenefit the use of one dye over the other.

CONCLUSION ILM peeling with dye assistance was found toinduce higher closure rates that when the ILM peeling isperformed with no dye. No statistically significant differencewas found when comparing the use of ICG and BB. Functionalresults evaluated by BCVA were not statistically significantbetween the different groups.

304Description of Specific Foveal ConfigurationsPredisposing to the Development of Macular Holes

Yoreh Barak, MD (Louisville, KY), Mark P. Sherman, MD, Shlomit Schaal, MD, PhD

PURPOSE To clinically recognize and to mathematically analyze specific anatomic foveal configurations predisposing tothe formation of macular holes using optical coherence tomog-raphy (OCT) imaging of patients prior to the formation ofmacular holes.

METHOD 3882 OCT foveal thickness maps of 647 patients withmacular holes were analyzed. 96 foveal maps of 16 patients wereidentified prior to the formation of macular holes. Maps wereanalyzed using several measurements: (1) Retinal thicknessaround the fovea at 50 micron consecutive intervals (2)Maximal foveal slope at two intervals lateral to the centralfoveal depression, and (3) Central length of foveal depression.Using automated regression software Eureqa (version 0.82 beta)the mathematical analog of the foveal configuration wasanalyzed and the equation to describe the mathematicalrelationship in a 0.083 fit was derived for pre-macular-holefoveas in comparison to age matched foveas.

RESULTS Pre-macular hole anatomical configuration was foundto be significantly different from normal foveal anatomy formaximal slope (P<0.05) and for central length of fovealdepression (P<0.05). The mathematical regression function fornormal fovea followed a first order cosine curve of level 11complexity. The mathematical regression function for pre-macular-hole fovea followed a complex sine curve of level 30complexity. Normal foveas had higher symmetry (0.86±0.1P=0.03) along the midline whereas pre-macular hole foveas hadsteeper maximal slopes (20˚±0.1 P=0.01). 75% of pre-macularhole patients had similar foveal configuration in the fellow eye,50% of these indeed consequently developed bi-lateral macularholes.

CONCLUSION Pre-macular hole foveal anatomical configurationwas found to be significantly different from normal fovealconfiguration. The ability to identify a suspicious macularconfiguration on OCT scans may allow early diagnosis, follow-up and better management of macular-hole-prone patients.

MACULAR HOLES AND MACULAR PUCKER – EPIRETINAL MEMBRANE



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Figure 1. OCT image of pre-macular-hole configuration (A) demonstratinga-symmetrical foveal slopes with a steep maximal slope compared to acontrol (B).

Figure 2. The mathematical regression function for pre-macular-holefovea (A) followed a complex sine curve. The mathematical regressionfunction for normal fovea (B) followed a first order cosine curve.

305Bilaterality and Characteristics of Idiopathic Macular Holes in a Mostly Non-Caucasian Population

Lynn L. Huang, MD, MPH (Bronx, NY), Anurag Shrivastava, MD, Irena Tsui, MD

PURPOSE Previous epidemiologic data on bilaterality of macularholes varies widely between 1% to 25% among differentdemographics. The latest population-based study by McCannelet al reports an 11.7% prevalence in Olmsted County,Minnesota. This study describes the bilaterality and character-istics of idiopathic macular holes (IMH) among a large series ofnon-Caucasian patients in Bronx, New York.

METHOD A retrospective chart review was done of 136 patientswith the clinical diagnosis of macular hole among 15,600patient visits between December 1, 2007 and September 7,2010 at the Montefiore Medical Center Eye Institute. Opticalcoherence tomography (OCT) data, when available, was usedas adjunct information in staging of the disease. The prevalenceof bilateral IMH and their characteristics were described amongthe 74 patients with available medical record and no otheridentifiable cause.

RESULTS Among 74 patients in our study, 39% were African-Americans, 30% were Hispanic, 14% were mixed-racial, 11%were Caucasian, 4% were Asian, and 3% were undetermined.Average age was 70.7 years (SD=14.9). Female-to-male ratiowas 1.7: 1. Median visual acuity was 20/70 at the time ofdiagnosis or presentation. Nine (12.2%) of 74 patients hadmacular hole in the fellow eye. Of the 58 patients withdocumented staging by OCT or clinical exam, full-thicknessIMH were found in 33 (57.9%) of 58 first eyes, and in 1(22.5%) of 8 second eyes. Twelve (16.2%) patients underwentsurgery for macular hole repair in one eye. Among them, 8 of

10 patients with minimum of 4 month postoperative follow-uphad visual improvement of at least two lines on the Snellenchart, one had unchanged visual acuity, and one had worsened vision.

CONCLUSION The demographic of our study populations mirrorsthe ethnicity profile of Bronx County, New York according to Census 2010 data. The prevalence of bilateral IMH amongour mostly non-Caucasian patient population is similar to previously report data, whereas female-to-male ratio is lower.Our study supports that there is no racial predilection forbilateral IMH.

306Understanding Macular Holes: Macular Holes that Develop after Retinal Detachment Repair

Peter J. Kertes, MD, FRCS(C) (Toronto, Canada), Matthew B. Schlenker, MD, Robert G. Devenyi, MD, MBA, FRCS(C)*, Wai-Ching Lam, MD, FRCS(C)

PURPOSE What is the incidence, characteristics, and outcomesof macular holes (MH) that arise in eyes that have been treatedfor retinal detachment (RD)?

METHOD We performed a retrospective, consecutive case seriesand identified 18 patients who developed a new full-thicknessMH after prior RD management over a 4.5 year period.Inclusion criteria: a newly diagnosed MH after RD managementby either Pneumatic Retinopexy (PR), Pars Plana Vitrectomy(PPV), or Scleral Buckle. Data collected: past ocular history,management and visual outcome of their RD, and managementand visual outcome of their MH. All patients were offeredsurgery to repair their MH, which was performed on 14 patientsafter RD repair, and 2 in combination with RD repair after afailed PR. MH repair surgery included PPV, Internal LimitingMembrane peeling, and Gas Fluid exchange.

RESULTS 18 full-thickness MHs were detected from 985 eyes(1.9% incidence). On RD presentation 14/18 RDs involved themacula. 16/18 patients had best corrected visual acuity (BCVA)of 20/200 or worse. 10/18 RDs required multiple procedures toachieve reattachment. Post-RD BCVA was 20/200 or worse in15/18 patients. The median time to MH diagnosis after RDrepair was 1 month (range: 2 days–53 months), and from MHdiagnosis to MH repair 1.75 months (range: 3 weeks-8 months).14/16 eyes (89%) undergoing surgical repair achieved MHclosure, 1 requiring multiple PPVs. 11 saw at least one Snellenline improvement (median 1, range: 1-6), 2 lost vision (1 and 2Snellen lines respectively), and 3 remained unchanged at amedian follow-up of 3 months (1 month-25 months). 6 patientshad at least 20/80 BCVA at last follow-up.


CONCLUSION RDs preceding MHs are often severe macula-offRDs requiring multiple interventions for repair. Post-MH repairclosure rates are similar to rates for idiopathic MHs. Visualoutcomes are moderate and coincide with the degree ofimpairment post-RD repair. The findings suggest other patho-genic mechanisms besides vitreofoveal traction may be leadingto these MHs, such as cystoid macular edema.

Characteristics and Outcomes of Patients with Macular Holes Following Management for Retinal Detachments.

Proposed mechanism of macular hole (MH) formation post-retinaldetachment (RD) repair. (A) Sagittal cut of a macula-off RD with cystoidmacular edema. (B) After the retina is reattached cystoid pockets of fluidbecome under tension, and the overlying retina becomes stretched andweakened. (C) Some inner retina dehisces leading to a lamellar MH. (D)Further dehiscence leads to a full thickness MH

307Incidence of Postoperative Outer Layer Foveal Defect Following Idiopathic Macular Hole Repair

John O. Mason, MD (Birmingham, AL), Dustin L. Pomerleau, MD, Tracy Emond, Lindsey Wallace, MD, Shilpa Reddy, MD, Richard M. Feist, MD, Martin L. Thomley, MD, Michael A. Albert, MD

PURPOSE The incidence of outer layer foveal defect followingvitrectomy with internal limiting membrane peeling and macularhole repair has been reported as high as 59% in recent literature.Our study seeks to determine if the risk for this type of anatomicfinding is indeed that high for our patient population.

METHOD A retrospective chart review was performed of allpatients with an idiopathic macular hole who underwent parsplana vitrectomy with internal limiting membrane peeling fromJanuary 2008 to October 2010. Patients with a history of prior

vitrectomy or comorbid retinal disease other than macularpucker were excluded. Patients without successful hole closurepostoperatively were also excluded from the study. Macular holesize, duration of symptoms, BCVA, and anatomical appearanceon optical coherence tomography (OCT) testing were analyzedpreoperatively, and at 1, 3, and 6 months postoperative intervals.

RESULTS Two-hundred and twenty-two eyes were screened forinclusion and those without optical coherence tomography atall pre- and postop intervals were excluded. A total of 80 eyes(74 patients) were included. There were 53 females and 17males with a mean age of 69. The mean preop macular hole sizewas 484.38 diameters. Mean preop BCVA was 20/200. Two eyes(2.5%) developed an outer foveal defect within 3 weeks ofvitrectomy surgery; 1 resolved at 1 month postop and the otherwas resolved at 6 months postop. Both eyes with outer fovealdefects had BCVA of 20/50 at 6 months postop. The meanpostop BCVA for all eyes at 1, 3, and 6 months postop was20/100, 20/70, and 20/50, respectively. There were no othercomplications in any eye postoperatively.

CONCLUSION The incidence of outer foveal defects followingmacular hole repair surgery may be significantly lower thanpreviously reported. Further investigation is warranted utilizingstandardized OCT instrumentation and methods for analyzingand interpreting anatomic findings after successful macular hole repair.

308Clinical Comparison of Macular Hole RepairUtilizing Indocyanine Green Prepared with Sodium Based Fluid (BSS) vs. Sodium-free Fluid (D5W)

Kirk H. Packo, MD* (Chicago, IL), Alexander L. Grigalunas, MD

PURPOSE The potential toxic nature of ICG for ILM peeling has been widely debated. The RPE takes up ICG via a sodiumdriven pump. It has been suggested that reconstituting ICGpowder with a sodium-free fluid such as D5W rather than BSSminimizes this RPE uptake and may give superior results. Thisretrospective review compares consectuive cases of macularhole repair using these two ICG formulations.

METHOD All idiopathic macular holes operated on by a singlesurgeon (KHP) from 1997 to 2010 were reviewed. Patients withconcurrent ocular disease or less than 6 mo follow-up wereexcluded. Holes repaired prior to July 2003 utilized ICG assisted ILM peeling in which the dye was prepared with BSS,containing sodium at an isotonic concentration. Holes repairedsubsequently utilized ICG dye prepared with D5W, containingno sodium, however still isotonic to vitreous. Results were com -pared assesing anatomic closure of the hole, and pre-op and 6 mopost-op vision converted to logMar scale. Results were stratifiedto lens status to avoid bias by post-op cataract formation.




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RESULTS 52 eyes met the inclusion criteria. 22 eyes had ILMpeeling assited by ICG prepared with BSS (sodium based) and19 eyes had ILM peeling assisted by ICG prepared with D5W(sodium free). In the ICG-BSS group, primary hole closureoccured in 20/22; hole failed primary closure in 2/22; and 2 re-opened late. In the ICG-D5W group, primary hole closureoccured in all 19, with no late reopenings. In the ICG-BSSgroup, the mean preop acuity was 0.8344 (20/137); at 6 monthsthis improved to mean 0.6716 (20/93); at the final acuityfollowing cataract extractions, the mean acuity was 0.3348(20/43). In the ICG-D5W goup, the mean preop acuity was0.6942 (20/100); at 6 months this improved to mean 0.6529(20/90); at the final acuity following cataract extractions, themean acuity was 0.5046 (20/64). With BSS, 2 eyes ended withless acuity at final visit (one substantially), while with D5Wonly one eye worsened mildy. Due to small numbers, no statis-tical significance was seen.

CONCLUSION In this study, no difference in primary hole closureor final mean acuity was found between ICG-BSS anad ICG-D5W surgeries. In the ICG-BSS group, two eyes worsend, withone substantially (20/100 to 20/400). Only one eye worsenedwith ICG-D5W suggesting that D5W may prevent occasionalsevere visual loss. Lack of significance prevents conclusion.Further comparison data is indicated.

Preoperative acuity (logMar) compared to postoperative acuity (logMar) at the final visit after correcting for cataract formation withextractions iin the ICG-BSS group. Data points above the line indicateimprovement. Two eyes worsened, with one substantially (20/100 to 20/400) although the holes were closed in both.

Preoperative acuity (logMar) compared to postoperative acuity (logMar) at the final visit after correcting for cataract formation with extractions in the ICG-D5W group. Data points above the line indicate improvement. Only one eye worsened slightly.

309Non-supine Positioning is Preferred Over Face-down Positioning and Provides an Equivalent Closure Rate in 25 and 23 Gauge Macular Hole SurgeryDustin L. Pomerleau, MD (Birmingham, AL), Christopher J. Compton, MD,Richard M. Feist, MD, Richard Feist, Jr., MD, Tracy L. Emond, Lindsey Wallace, MD, John O. Mason, MD, Martin L. Thomley, MD, Michael A. Albert, MD

PURPOSE Face-down positioning after macular hole (MH)surgery has been thought to achieve hole closure, but recentpublications have called this into question. Our study seeks todetermine if strict face-down positioning is necessary in 25 or23 gauge macular hole repair and whether patients prefer short-term face-down or long-term non-supine positioning.

METHOD Retrospective chart review of all MH repairs by 4surgeons in a single practice from 2006 to 2008. Inclusioncriteria were preoperative documentation of patient demo -graphics, lens status, macular hole diameter, and preoperativeOCT, vitrectomy with gas tamponade and ILM peeling, andfollow-up of 12 weeks or until complete hole closure. Patientswere given a postoperative survey about their positioningpreference between strict face-down positioning for 7 days witha short-term acting gas or non-supine positioning for 30 dayswith a long-acting gas.

RESULTS A total of 52 eyes (52 patients) met inclusion criteria.All patients had 25 or 23 gauge vitrectomy with peeling of theILM with closure in 50 of the 52 eyes. Thirty-one patients wereinstructed to position face-down at all times and 21 patients tomerely avoid supine positioning. There was no significantdifference in the positioning groups with respect to age, gender,MH diameter, central subfield thickness, total macular volume,preoperative or final visual acuity, hole closure rate, or durationof follow-up. Given the choice, 15 of 31 patients (47%) in theface-down group reported that they would prefer non-supinepositioning for macular hole repair, even if longer positioningwas required, versus all 21 patients in the non-supine group.Seventeen of 21 phakic patients (81%) in the face-downpositioning group required cataract extraction before their final visit.

CONCLUSION Non-supine positioning with a long-acting gastamponade provides an equivalent MH closure rate to face-down positioning with a short-acting gas tamponade, and ispreferable to most patients. Strict face-down positioning doesnot appear to significantly mitigate cataract formation.


310Macular Hole Surgery Using Silicone Oil as Internal Tamponade AgentBhavin Shah, MD (Hyderabad, Indonesia), Raja Narayanan, MBBS, Siddharth Dikshit, DO

PURPOSE To evaluate the efficacy of silicone oil as an internaltamponade for macular hole closure during idiopathic macularhole surgery.

METHOD Eight eyes of 8 patients who underwent pars planavitrectomy with dye assisted internal limiting membranepeeling with silicone oil injection for idiopathic macular holewere studied retrospectively. Patients who had severe spondy-losis, had an immediate need to travel by air, or had only onefunctional eye underwent silicone oil injection instead of gastamponade. ILM peeling was performed in all cases. Opticalcoherence tomography (6mm line scan), best corrected visualacuity, intraocular pressure measurement using Goldmannapplanation tonometer were performed. Macular hole closurerate was the primary outcome measure. The secondary outcomemeasure was the best corrected visual acuity.

RESULTS The median age of patients in this study was 63 years.Five patients were males and 3 were females. The mean macularhole diameter at baseline was 855µm. The mean macular holeindex was 0.50. The hole closure rate was 100% (8/8). Themean logMAR best corrected visual acuity at baseline was 0.9 and at last follow-up was 0.85. The mean follow-up periodwas 5.33 months (range 3–7 months). The mean intraocularpressure at baseline was 15 mmHg and at last follow-up was 13 mmHg.

CONCLUSION Silicone oil may be used as internal tamponade for macular hole closure in selected cases where gas may berelatively contraindicated.

311Spectral Domain OCT Based Predictors of Visual Acuity Outcomes in Full ThicknessMacular Hole Repair SurgerySumit Sharma, MD (Cleveland, OH), Jack Shao, MD, Peter Kaiser, MD, Rishi Singh, MD, Jonathan Sears, MD, Justis Ehlers, MD, Daniel Martin, MD, Sunil Srivastava, MD

PURPOSE To identify features of pre-operative spectral domainoptical coherence tomography (SD-OCT) scans that maypredict the level of visual acuity (VA) improvement one yearafter macular hole (MH) surgery.

METHOD This is a retrospective, interventional, consecutive caseseries of patients with idiopathic MH who underwent vitrectomyfor MH repair and had a preoperative SD-OCT on the CirrusHD-OCT (Carl Zeiss Meditec). All patients underwent dilatedophthalmoscopic exam, SD-OCT, and protocol ETDRS VA(converted to logMAR), preoperatively as well as at six and

twelve months postoperatively. Correlation analysis wasconducted between VA at baseline and one year with sevenpreoperative OCT parameters: manually measured MH heightnasally/temporally, MH minimum/base width, total width of theinner segment (IS) outer segment (OS) defect, and distance ofIS/OS defect to temporal/nasal aspect of the MH.

RESULTS Data from 36 eyes from 36 patients were included. All had successful closure of the macular hole. Table 1 containsa summary of the values for the OCT parameters that wererecorded. One way ANOVA showed that there was a statisti-cally significant correlation between the preoperative IS/OSloss width and preoperative VA, the final VA at one year andthe change in VA at 1 year (p<0.05). There was no statisticallysignificant correlation between MH nasal height, MH temporalheight, MH base width or MH minimum width to the pre -operative visual acuity, the one year VA or the change in VA at one year.

CONCLUSION The length of the IS/OS defect preoperatively was the strongest predictor for both preoperative VA and VAone year after anatomically successful macular hole repair inthis study. This suggests that despite the macular hole size theappearance of the IS/OS segments should be evaluated by SD-OCT to predict the likelihood of visual recovery aftermacular hole repair.

Table 1: Shows the mean and standard deviation for each of themeasured macular hole parameters.

312Trypan Blue vs. Brilliant Blue for Macular Hole SurgeryDaraius Shroff, MD, FRCS (Delhi, India), Neelam Atri, MD, Bhavana Sharma, MD, A. K. Singh, MD, Charu Gupta, MD, Cyrus M. Shroff, MD

PURPOSE To study the anatomical and functional outcome ofmacular hole surgery using two different dyes to stain the ILM.

METHOD Retrospective non-randomized comparative analysisbetween study group (Brilliant Blue) and control group (TrypanBlue). 80 patients of idiopathic macular hole who underwentsurgery from January 2008 to September 2010 were included.Pre- and post-operative best-corrected visual acuity, lens statusand optical coherence tomography were done for all patients.80 patients underwent vitrectomy and ILM peeling. Cataractsurgery was combined in 29 cases. 66 patients underwent ILMstaining with Trypan Blue (TB), and 14 patients with BrilliantBlue (BB).




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RESULTS Mean pre and post operative logMAR best correctedvisual acuity (BCVA) was 0.87±0.38 and 0.38±0.30 in the TBgroup (p<.001) respectively, and 0.66±0.27 and 0.37±0.21 inthe BB group (p<.001). Post operatively 64 eyes (97%) in theTB group and 14 eyes (100%) had BCVA ≥ 20/200 (p = .679),36 eyes (54.5%) in the TB group and 7 eyes (41.2%) in the BBgroup achieved BCVA ≥ 20/40 (p = .238). 77 of 80 (96.3%)macular holes closed while 3 (3.8%) remained open. No patienthad post operative retinal detachment.

CONCLUSION There was no statistical difference in the func -tional outcome between the two groups. However, BrilliantBlue stains ILM better facilitating complete and less traumaticremoval. Moreover, in the Brilliant Blue group the absence offluid-air exchange during staining reduced the chances oflenticular haze during surgery.

313Anatomical and Visual Outcomes of Idiopathic Macular Hole Surgery with 23GPhaco-vitrectomy, ILM Peel and C3f8 GasTamponade without Head Posturing

Malhar Soni DO, MS, DNB, FRCS (England, UK), Gregory Ho Yen, MD, Minas Georgopoulos, MD

PURPOSE To evaluate the anatomical and visual outcomes of 23-gauge transconjunctival sutureless phaco-vitrectomy(TSPV) for idiopathic full thickness macular holes (FTMH)undergoing internal limiting membrane (ILM) peel and C3F8gas tamponade without head posturing.

METHOD Retrospective analysis of a consecutive case series. 50eyes of 50 consecutive patients underwent 23-gauge transcon-junctival sutureless phaco-vitrectomy, brilliant blue stainedinternal limiting membrane peel and 16% C3F8 gas tamponadesurgery for Spectral Domain Optical Coherence Tomography(SD-OCT) confirmed idiopathic stage II-IV macular holes. Allpatients were given the opportunity for surgery regardless of theduration of their symptoms. The patients were not advised toperform any head-posturing post-operatively except to avoidlying on their back. The main outcome measures were visualacuity and SD-OCT confirmed anatomical success at sixmonths follow-up.

RESULTS The mean duration of symptoms for 50 patients was8.6 months. The mean age for this group was 70.5 years. Therewere 4 eyes (8%) with stage II, 36 eyes (72%) with stage III and10 eyes (20%) with stage IV idiopathic full thickness macularholes. Forty nine (98%) out of fifty eyes achieved successfulanatomical macular hole closure with one surgery. The meanpre-operative visual acuity of 0.82 improved to mean post-

operative visual acuity of 0.39. One patient needed additionalsurgical management to achieve successful outcome. All eyes(100%) achieved SD-OCT confirmed anatomical closure at sixmonths. There was no case of post operative endophthalmitis or post-operative hypotony.

CONCLUSION 23-G phaco-vitrectomy is a safe and effectivemethod in the management of idiopathic full thickness macularholes. A high anatomical closure rate with significant visualacuity improvement can be attained with ILM peel and C3F8gas tamponade without the need of head posturing even inpatients with a long duration of symptoms.

314Pars Plana Vitrectomy with Membrane Peelingfor Diffuse and Focal Epiretinal Membranes: A Comparative Study

Osman Cekic, MD, PhD (Istanbul, Turkey), Mehmet Cakir, Ahmet T. Yazici, Kemal Yuksel, MD

PURPOSE To compare the results of pars plana vitrectomy withmembrane peeling in eyes with focal and diffuse epiretinalmembrane.

METHOD A retrospective comparative study. Medical records of68 eyes of 65 consecutive patients (mean age 65 years) whounderwent vitrectomy and membrane peeling for diffuse andfocal epiretinal membranes were included. A complete ophthal-mological examination and optical coherence tomographymeasurements were performed at baseline and postoperatively.

RESULTS The mean follow-up was 12 months (range, 8 to 22months). Epiretinal membrane was classified as primary in 35eyes, and as secondary in 33 eyes. Preoperative and final post -operative visual acuity were significantly higher in eyes withsecondary epiretinal membrane than that with primaryepiretinal membrane (P<0.05 and P<0.01, respectively). Pre -operative macular volume was significantly higher in eyes withprimary epiretinal membrane than that with secondary mem -brane (P<0.01). No difference was found in postoperative visualacuity and mean macular volume values between eyes withfocal adherence and diffuse adherence pattern (P>0.05). Pre -operative and postoperative visual acuity were significantlyhigher in eyes with intact inner segment/outer segment (IS/OS)junction than in patients with disrupted IS/OS junction(P<0.05 and P<0.05, respectively).

CONCLUSION Pars plana vitrectomy and membrane peelingimproves visual acuity and restores macular thickness in eyeswith both diffuse and focal epiretinal membrane.


315Visual and Anatomic Outcomes of EpiretinalMembrane Peel after Retinal DetachmentRepair in a Teaching Institution

Andres Emanuelli, MD (Miami, FL), Ninel Gregori, MD

PURPOSE To assess visual and anatomic outcomes afterepiretinal membrane (ERM) surgery in patients with priorretinal detachment (RD) surgery repair.

METHOD Patients who had undergone pars plana vitrectomy(PPV)/membrane peel(MP) for ERM after RD repair wereidentified and the charts were reviewed. We compared theSnellen best corrected visual acuity (BCVA), OCT charac -teristics at pre-op and post-op visits (1, 3, 6 months), lensstatus, surgical dates, dates and characteristics of prior retinaldetachment repair. The OCT obtained at each visit wasanalyzed to document the presence and location of retinal fluid and to assess the appearance of IS/OS junction. The time course of recovery of the IS/OS junction, central fovealthickness (CFT), macular volume (MV) and BCVA during the postoperative period was studied.

RESULTS Eight patients were identified, 6 with macula-off and 2 with macula-on RD. Median BCVA improved from 20 lettersat pre-op to 40, 40, 58 letters at 1, 3, and 6 months, respectfully.By 6-months, the CFT and MV improved in all eyes. A normalIS/OS junction and CFT seemed to correlate significantly with BCVA.

CONCLUSION VA can improve significantly after ERM peel inpatients with history of retinal detachment repair. VA andOCT improvements are seen through at least 6 months after surgery.

316Long-term Surgical Outcome of EpiretinalMembranes Associated with Hamartomas ofthe Retina and Retinal Pigment EpitheliumCesare M.C. Mariotti, MD (Ancona, Italy), Piergiorgio Neri, MD, Andrea Saitta, MD, Michele Nicolai, MD, Alfonso Giovannini, MD

PURPOSE Combined Hamartomas of Retina and RetinalPigment Epithelium (CHRRPE) are unfrequent benign tumors,presenting proliferation of retinal pigment epithelium (RPE)and glyal tissue. These tumors lead to retinal anomalies, particularly epiretinal membranes (ERM), compromising visualacuity. The aim of this study was to evaluate the long-termoutcome of surgical management in CHRRPE complicated by ERM.

METHOD The present study was designed as an interventionalretrospective case series, including patients affected byCHRRPE who underwent a vitrectomy and ERM removal witha minimum follow-up of 12 months. The following data werecollected for each patient: anterior segment examination, pre- and post-operative best-corrected visual acuity (BCVA),intraocular pressure (IOP), fundus examination, photographyand fundus fluorescein angiography (FA), spectral domainoptical coherence tomography (SD-OCT). All cases underwentstandard 3-port 25 gauge vitrectomy with an ERM peeling,without a tamponade.

RESULTS Four patients were included in the present study. Therewere 2 men (50%) and 2 women (50%). All patients werephakic. The mean age was 19.5-year (±3.9 SD, min: 15, max:21). The mean follow-up time was 16.5 months (±3.4 SD, min:13, max: 21). All the lesions considered were unilateral. Themean pre-operative BCVA was 0.19 (±0.09 SD), ranging from0.125 to 0.32 (median: 0.16), and post-operative BCVA was0.52 (±0.34 SD), ranging from 0.2 to 1.0 (median: 0.45). TheBCVA improved in all the patients after the surgeries andremained stable up to the last follow-up. The FA presenteddecrease of dye leakage at the late phases. In addition, theretinal vessels tortuosities got better in all the cases after thesurgical procedure (Figure 1). SD-OCT proved that ERM werecompletely removed in all their components (Figure 2), with anevident restoring of the physiologic retinal morphology and adecrease of underlying retina edema. No serious adverse eventwas recorded to date.

CONCLUSION CHRRPE is a unilateral benign tumor leading to a malformation both of the RPE and the neurosensory retina. In the present study, we have treated 4 patients with vitrectomyand ERM peeling, evaluating the long-term follow-up. The BCVA improved in all patients, as well as the retinalmorphology. Therefore, patients with CHRRPE and ERM may benefit from surgery as early as possible.

Figure 1. Selected case 1: The comparison between pre-operative (A) and post-operative (B) fundus photography shows the improvement ofretinal morphology, with an evident reduction of epiretinal traction.




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Figure 2. Selected case 2: OCT showing an evident ERM with underlyingretina edema (A). After surgery, the retinal morphology appears restored,with recovery of physiological foveal depression (B).

317SD-OCT in Epiretinal Membranes Before and After Surgery

Jerzy Nawrocki, MD, PhD (Lodz, Poland), Janusz Michalewski, MD, PhD, Magdalena Siwinska, MD, Zofia Michalewska, MD, PhD

PURPOSE To describe retinal morphology before and aftersurgery for idiopathic epiretinal membranes. Additionally toevaluate factors responsible for the final visual outcome.

METHOD A retrospective study of 150 eyes followed withspectral domain optical coherence tomography (SD-OCT) for a period of 12-38 months. In all eyes pars plana vitrectomy withinternal limiting membrane peeling was performed. Followingfactors were evaluated: central and maximum retinal thickness,photoreceptor defects, number of points of adhesion betweenepiretinal membranes and the retinal surface, posterior hyaloidstatus, presence of subfoveal deposits, presence of intraretinalcystoid spaces and changes in particular retinal layers in thefovea. Those factors were statistically correlated with pre- andpostoperative visual acuity.

RESULTS Increased preoperative central and maximum retinalthickness (p=0.04) and photoreceptor defects (p=0.03) wereassociated with worse final visual outcome. Eyes with multiplepoints of adhesion between epiretinal membranes and retinalsurface were more likely to have decreased visual acuity post -operatively. Postoperative visual acuity was found to benegatively correlated with photo receptor defects (p=0.02),preoperative maximum retinal thickness (p=0.01) and centralretinal thickness (p=0.03). All eyes having final visual acuity>0.6 had initial visual acuity >0.2 and no photoreceptordefects. Eyes with visual a photo receptor defect larger than1000µm were more probable to have final visual acuity below

0.2. Final visual acuity depends statistically significant onmaximum retinal thickness (p=0.008). Neither subfovealpigment deposits, nor the type of epiretinal membrane adhesionto the retina have an influence on post operative visual acuity.

CONCLUSION Careful analysis of three dimensional SD-OCTscans may enable better surgery planning and may enable topresume the final outcome, having in mind that photoreceptordefects and maximum retinal thickness are the most importantprognostic factors.

318Visual Prognosis after Idiopathic Epiretinal Membrane Surgery Based on High Resolution SD-OCTAmar Patel, MD* (New York, NY), Madhavi Kurli, MD, Richard B. Rosen, MD*

PURPOSE To evaluate features of spectral-domain opticalcoherence tomography (SD-OCT) of eyes before and afterepiretinal membrane surgery and correlate these with visualoutcomes.

METHOD Preoperative and postoperative SD-OCT images wereanalyzed and visual acuities were collected retrospectively in all patients who underwent surgery for idiopathic epiretinalmembranes from January 2008 to December 2010 at our insti-tution. SD-OCT features analyzed were internal limitingmembrane (ILM) profile (normal ILM or ILM distortion),integrity of the external limiting membrane (ELM) (normalELM line or ELM line disruption), integrity of the innersegment and outer segment junction (IS/OS) (normal IS/OSline or IS/OS line disruption), and foveal contour (normalfoveal contour or loss of foveal contour with or withoutintraretinal edema).

RESULTS There were 34 surgeries performed on 34 patients (18male, 16 female). Mean age was 64 years (range=43-80 years;SD=9.0 years). At postoperative month 3, 85.3% (29/34) ofeyes had an improvement in best-corrected visual acuity(BCVA) while 2 patients had no change in visual acuity andthe remaining 3 patients had a decline in visual acuity. Thebaseline ILM profile and foveal contour had no significantinfluence on BCVA at 3 months (P>0.05) whereas the baselineintegrity of the ELM (P=0.020) and IS/OS junction (P=0.013)significantly influenced BCVA at 3 months. Additionally,postoperative integrity of the ELM (P=0.0050), IS/OS junction(P=0.0039), and foveal contour (P=0.0081) significantly influ-enced BCVA at 3 months.

CONCLUSION Preoperative integrity of the ELM and IS/OSjunction may be prognostic factors for visual outcomes afterepiretinal membrane surgery. Furthermore, evaluating the ELM,IS/OS junction, and foveal contour postoperatively may help toexplain poor visual recovery.


319Intraoperative SD-OCT Evaluation of Internal Limiting Membrane Stripping inMacular Hole and Macular Pucker RepairJoshua Robinson, MD (Atlanta, GA), Robin Ray, MD, Chris S. Bergstrom, MD, G. Baker Hubbard, MD, Hans Grossniklaus, Sunil Srivastava, MD

PURPOSE To correlate intraoperative spectral domain opticalcoherence tomography (SD-OCT) with histopathologicfindings of internal limiting membrane (ILM) resection duringpars plana vitrectomy for full-thickness macular hole (FTMH)and macular pucker (MP) repair.

METHOD A retrospective chart review was performed andidentified 14 patients that underwent vitreoretinal surgery formacular pucker (n=8) or full-thickness macular hole (n=6). Allsurgeries were performed by experienced vitreoretinal surgeons(SS, GBH, CB) utilizing 20-guage, 23-guage, or 25-guagetechniques. Indocyanine Green or Triamcinolone Acetonidewas employed to stain the ILM per surgeon preference. Intra -operative SD-OCT imaging was obtained using a BioptigenSpectral Domain Ophthalmic Imaging System (Bioptigen Inc.)before and after each membrane peel. Tissue specimens fromeach membrane peel were submitted for light and electronmicroscopy.

RESULTS In all 6 FTMH cases and 2 of the eight MP cases, theILM and associated epiretinal membrane (ERM) were peeledsimultaneously. In the remainder of MP cases, the ILM andERM were peeled separately. Five of the 6 FTMH cases wereassociated with an identifiable ILM edge on intraoperative SD-OCT, with all but one case demonstrating ILM on light andelectron microscopy. Of the 14 submitted MP tissue samples (2 membranes from 2 single peel cases, and 12 membranes from 6 separate peel cases), 11 were recovered and analyzed. For all 11 cases, light and electron microscopic findings wereconsistent with clinical impression; however, in only one casecould a definite ILM edge be identified on SD-OCT. All of thecases lacking an identifiable ILM edge on SD-OCT demon-strated a highly corrugated post-peel retinal surface withidentifiable epiretinal membrane edges. Those cases correlatedwith a visible ILM edge on SD-OCT tended to have a muchsmoother post-peel retinal surface.

CONCLUSION Identification of an ILM edge on intra-operativeSD-OCT was a reliable indicator of ILM resection in FTMHrepair associated with mild epiretinal membranes withoutunderlying retinal distortion, but not in cases of macular puckerrepair associated with dense epiretinal membranes and highlycorrugated retinal surfaces.

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320A Study of Macula off Retinal DetachmentsAllowing Slow Subretinal Absorption of Fluid with Gas Tamponade

Sean David Adrean, MD (Fullerton, CA), Scott Grant, MD

PURPOSE The purpose of this study was to retrospectively reviewthe last 125 macula off retinal detachments repaired with avitrectomy, to determine if the visual results were superior topreviously reported studies by not flattening the posterior polewith perfluorocarbons or with a drainage retinotomy, butallowing subretinal reabsorption of the fluid with the assistanceof a gas tamponade.

METHOD This study retrospectively examined 125 macula offretinal detachments. Patients were excluded: if they did nothave at least 6 months of follow-up, if they developed prolifer-ative vitreoretinopathy (PVR), if the duration of the retinaldetachment was longer than 6 weeks, if they had a previousvitrectomy or scleral buckle surgery, if they had significantmacular pathology affecting the visual outcome. Seventypatients were identified that underwent a vitrectomy with orwithout a scleral buckle, with laser or cryotherapy, air-fluidexchange and gas injection. The pre-op visual acuity (Va) wascompared to the post-op Va at 6 months and final Va.

RESULTS The average duration of the retinal detachment was 9 days with a range of 1 day to 4 weeks. The average age of the study population was 64.5 years of age with 30.6% females.Overall initial repair rate was 91.9% with 8.1% of patientsdeveloping PVR. 35.5% of patients had a vitrectomy alonewhile 64.5% had a vitrectomy with scleral buckle. 45% ofpatients were phakic at the time of surgery and 40% of thosepatients had subsequent cataract surgery. Pre-operatively theaverage visual acuity was 20/400, post-operative visual acuitywas 20/50 and final best correct visual acuity was 20/40. The visual acuity improvement was statistically significant(p<0.0001). The median visual acuity at 6 months was 20/40and the median final visual acuity was 20/30.

CONCLUSION Leaving fluid in the macula at the end of thesurgery may allow the RPE pump to effectively remove the fluid in a more physiologic manner, allowing for better visual recovery.




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321Macula-on Rhegmatogenous Retinal Detachments: Does Time to Surgery Matter?

Arghavan Almony, MD (St. Louis, MO), Daniel P. Joseph, MD, PhD

PURPOSE To determine if time to surgical repair of macula-onrhegmatogenous retinal detachments (RRD) affects anatomicand visual outcomes.

METHOD Retrospective review of 68 eyes with macula-on RRD.The eyes were divided into three groups: Group 1 (18 eyes)included eyes that had emergent surgical repair of the retinaldetachment within eight hours of presentation; Group 2 (36eyes) included eyes that had urgent surgical repair, 8-24 hoursafter presentation; Group 3 (14 eyes) included eyes thatreceived surgical repair from 2-10 days after presentation.

RESULTS The median initial visual acuity was 20/30 and themedian final visual acuity was 20/40. The change in visualacuity from presentation to final follow-up was worst in Group1, which lost an average 1.2 lines per eye compared with Group2 which lost only 0.2 lines. Overall, 22.2% of Group 1 eyes lost≥3 lines of vision compared with only 11.1% in Group 2 and7.1% in Group 3. Furthermore, 72.2% of Group 1 eyes achieved≥20/50 final visual acuity compared with >90% of Group 2 and3 eyes. The mean follow-up was 8.9 months.

CONCLUSION In this study, emergent repair of macula-on retinal detachments does not seem to yield superior visual oranatomic outcomes.

322“Push Pull” Technique for Retinal Detachment in Vitrectomized Eyes

Amir Bukelman, MD (Rehovot, Israel), Yoel Grinwalled, Ofer Daphna, Ayala Pollack, MD

PURPOSE To investigate the safety and efficacy of an in officefluid gas exchange (“push pull” technique) for the treatment ofpost vitrectomy retinal detachment (RD) complications.

METHOD A retrospective computer search from 2005 till the end of 2010 of post vitrectomy patients who developed retinaldetachment (RD), that underwent an in office “push pull”technique which is fluid gas exchange. A 10ml syringecontaining 5ml of 16% PFP was used. We entered the eye frombellow through the pars-plana, withdraw some fluid and

injected gas, repeating the procedure several times until the eyewas filled completely with gas. After the retina was attached wetreated with laser barrage.

RESULTS We had 14 patients (14 eyes) underwent an in officefluid gas exchange – the push pull technique due to RD in avitrectomized eye. Average age was 69.8 years. The meanfollow-up was 12.2 (7-24) months. In 10 eyes (71.4%) theretina remain attached after the procedure. In 4 eyes the retinareattached only after an additional surgery – vitrectomy andsilicon injection. No complications were observed.

CONCLUSION The “Push Pull” Technique offers a good alternativefor revitrectomy in selected patients with RD in vitrec tomizedeyes. Failure to achieve retinal attachment by this techniquedoes not reduce the revitrectomy recovery rats. The advantagesover surgery are: simple procedure, time saving, few complica-tions and faster recovery.

323Visual Outcomes after Primary Repair ofChronic vs. Super-chronic Macula-offRhegmatogenous Retinal Detachments in an Underserved Population

Danielle S. Strauss, MD (New York, NY), Tahsin Choudhury, Shantan Reddy, MD, MPH

PURPOSE It has been reported that the chronicity of an RRD is a negative prognostic factor for anatomic success and visualimprovement following surgical repair. Previous studies have not compared visual acuity outcomes in patients whounderwent pars plana vitrectomy for repair of chronic (>14days-3 months) RRDs with patients who underwent the sameprocedure for super-chronic detachments (>3 months old).

METHOD A total of 12 eyes with macula-off RRDs which under -went pars plana vitrectomy, with or without scleral bucklingwere studied. The eyes were divided into two groups based ontime from presentation of symptoms to surgery. “Chronic”retinal detachment was defined as greater than 2 weeks (range 15-50 days), and “Super-Chronic” retinal detach mentwas defined as greater than 3 months duration (range 97-3650days). LogMar best corrected visual acuity (BCVA) wascompared pre-operatively and at the 3 month post-operativevisit. Retinal detachments with greater than grade A PVR andthose that needed silicone oil placement were excluded.

RESULTS Twelve eyes had repair of a retinal detachment with amean time from symptoms to surgery of 32.7 days (SD ±14.1) inthe chronic group, and a mean time of 842.2 days (SD ±1404.1)in the super-chronic group, P = 0.19. The mean pre-operativeBCVA was not statistically different between the chronic groupand the super-chronic group (2.0 (SD±1.0), vs. 1.4 (SD±1.1),P=0.37). At the 3 month post-surgical follow-up visit, the


LogMAR BCVA was also not statistically significant betweenthe two groups with BCVA of 1.5 (SD ±0.9) in the chronicgroup and 0.9(±0.6) in the super-chronic group, P=0.29. Asimilar mean gain in BCVA in both groups was observed. Thechronic group gained 0.5 (SD ±0.4) and the super-chronicgained 0.4 (SD ±0.5), P=0.84.

CONCLUSION Repair of super-chronic RRDs over three monthsold can improve visual acuity and visual recovery may not besignificantly different from chronic RRDs that have not beendetached for as long. Photoreceptor loss that occurs with retinaldetachments may slow with time. Clinicians should be aware of the benefit of repairing long-standing RRDs which are notuncommon in the underserved population.

324HSO as First Choice in Complicated RetinalDetachment: Checkmate in Two Moves!

Cesare Forlini, MD (Ravenna, Italy), Paolo Rossini, Matteo Forlini, Adriana Bratu

PURPOSE To show our strategy in complicated RD, with highpossibility to develope PVR and RD recurrence. In such cases,our first choice is to use HSO as tamponde agent to ensure anefficient tamponade action around and the inferior sectors andto “reallocate to the top” eventual recurrence to treat in asecond time.

METHOD 24 selected patients, with high risk of PVR recurrence(>C3) were treated with heavy silicon oil (Densiron 68,Fluoron); a 23 gauge vitrectomy with ILM peeling, priorstaining with ICG or Brilliant Peel; use of endolaser on presentbreak(s) and at 360°; PFCL or air-HSO exchange. All scleral-accesses are always sutured at the end of the operation, withtransconjuntival 8-0 suture. HSO is maintained within a periodamong 60 and 90 days. The removal is performed through theactive aspiration (vacuum 500-600 mmHg) with 20 or 23 gaugetransconjuntival system.

RESULTS Recurrence at the superior retina was present in 7 cases(30%) between 9 and 3 o’clock, at the moment of the secondprocedure performed among 60-90 days from the first operation.In 3 cases it was used 1000 cs oil, in 4 cases gas mix (C2F615%). Of the 3 cases were tamponade with 1000cs oil 2 caseshad to be re-operated with the use of 1000 cs oil. 4 cases arehighlighted of exudation in anterior chamber over the anteriorand posterior surface of the IOL, associated to increase ofintraocular pressure, all well controlled with medical therapy.

CONCLUSION The surgical strategy has allowed to reduce furtheroperations with reallocating critic area to superior sectors andto manage recurrence more easily (using different tamponadesubstances) and interrupting the multiple inferior recurrencechain. The strategy of using HSO as first choice in case ofcomplicated R.D. allows to ensure the anatomical andfunctional success in two passages.

325Decreased Mechanical Stiffness of Detached Retina Causes Increased Expressionof Genes Implicated in Proliferative Vitreoretinopathy (PVR)

William J. Foster, MD, PhD, FRCS(C) (Houston, TX), Joshua Davis, MD, Paul A. Janmey, MD, Deborah C. Otteson, MD

PURPOSE Retinal detachment is known to be associated with anincrease in the production in CTGF. We provide evidence for amodel where retinal stiffness influences the expression of genesimplicated in PVR.

METHOD A conditionally-immortalized Müller cell line wascultured on laminin-coated substrates of differing elasticmodulus. Real-time PCR was performed in triplicate for CTGF.Analytic calculations were performed to evaluate the change inlocal elastic modulus in detached and attached retina.

RESULTS Analytic calculations, utilizing the method of imagesand elasticity theory, predict that the tissue stiffness experi-enced by Müller cells will decrease when the retina becomesdetached. Expression of CTGF mRNA, as measured by quanti-tative real-time PCR, increases by 103-fold (p=0.04) assubstrate stiffness decreases over the predicted stiffness range.

CONCLUSION Increased expression of CTGF, as found in retinaldetachment in PVR, can be accounted for by mechanotrans-duction, the increase in gene expression when the retina isrelatively “softer” during retinal detachment. These findingshelp to explain the increased PVR in patients with areas ofchronic retinal detachment.

326High Percentage of Patients with RetinalDetachments Presenting to a Large PublicHospital Fail to Return for Treatment

Susan K. Gelman, MD, MPH (New York, NY), Carolyn P. Graeber, MD, Ilyse Haberman, MD, Jenna Friedenthal, MD, Shantan Reddy, MD, MPH

PURPOSE The purpose of this study is to review demographics,clinical characteristics and compliance with follow-up care ofunderprivileged patients with a retinal detachment (RD)treated by a level I public trauma center.

METHOD A retrospective review was performed of 81 consecutivepatients presenting with a loss of vision from a RD to a largeNew York City public hospital between 2003 and 2010, withNew York University Institutional Review Board approval. Factorsincluding age, gender, type of RD (rhegmatogenous (RRD),tractional (TRD), or serous (SRD); acute or chronic; macula on

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or off), visual acuity in LogMar (pre-operative, best-correctedpost-operative), and compliance with follow-up were studied.IBM SPSS Statistics 19 (Somers, NY) was used for data analysis.

RESULTS Positive outcomes were obtained after surgical repair of an acute RD at our public hospital. Patients with an acutemacula-on RD who underwent surgical repair had improvedmean visual acuity (0.85 versus 0.71 LogMar) as well as patientswith an acute macula-off RD (1.66 versus 1.21 LogMar).Younger age and early repair were correlated with better results.

Of 81 patients with a diagnosis of RD, 26 (32.1%) failed toreturn for treatment, including 7 of 19 (36.8%) with a macula-on RD, and 15 of 44 (34.1%) with a rhegmatogenous retinaldetachment. These patients received multiple certified lettersand calls indicating the need for follow-up. Mean presentingvisual acuity and age of those lost to follow-up was not signifi-cantly different than those compliant with follow-up.

CONCLUSION A large percentage of patients with an RD,including those with macula-on RDs, chose not to return forfollow-up care. Language and/or socioeconomic barriers maymake it less likely for underprivileged patients to return forneeded urgent treatment. Improved measures to increasecompliance should be developed to prevent patient disabilityand increased costs.

327Glial Tissue Peeling for Retinal DetachmentAssociated with Optic Disc PitEmily Gregory-Roberts MBBS, BSc (New York, NY), Carlos Mateo, MD, Stanley Chang, MD

PURPOSE Pits of the optic nerve head are associated with retinaldetachment (RD). The pathogenesis is unclear and it remainsunclear what surgical treatment is most effective. Some patientshave glial tissue in the optic nerve pit which may contribute tothe development of RD. We assess the efficacy of surgicalpeeling of the glial tissue within the pit for treatment of RD in these patients.

METHOD We report a retrospective case series of 4 patients from2 centers who presented with RD associated with an optic nervehead pit, with glial tissue evident in the pit. We assess theefficacy of treatment by vitrectomy, peeling of the glial tissue

within the pit, endolaser and gas tamponade. We compare pre-and post-operative visual acuity, fundus photographs and opticalcoherence tomography imaging for each of these patients.

RESULTS In 3 of 4 cases, optical coherence tomography imagingshowed complete resolution of the RD which was maintained atthe most recent follow-up visit, and in the remaining case witha short 6 month follow-up period, the subretinal fluid hadmarkedly decreased although residual macular detachmentpersisted. In 3 of 4 cases the visual acuity was improved at thelatest visit compared with the pre-operative visual acuity, and inthe remaining case where visual acuity was reduced this couldbe explained by cataract that had increased after vitrectomy.Figures 1 and 2 (attached) show the pre- and post-operativefundus photographs and optical coherence tomography images for case 1 and case 4 respectively, demonstrating themaculopathy and its resolution after surgery. We present similarimage compilations for the remaining two cases.

CONCLUSION These four cases of optic disc pits with associatedRD are unique as for all there was clear glial tissue visible overthe optic disc pit with demonstrable traction. Treatment bysurgical removal of this tissue produced good visual andanatomical outcomes. For patients with glial tissue adherent tothe optic disc pit, vitrectomy with surgical removal of this tissuemay be indicated.

Figure 1. Patient 1’s left fundus. A, B, photograph and OCT preoperativelyshowed a temporal optic disc pit, macular detachment, schisis andtraction. VA was 20/70. C, D, photograph and OCT 54 months aftervitrectomy and peeling of the glial tissue within the pit. The subretinalfluid and schisis have resolved and there is sub-foveal debris and anepiretinal membrane. VA is 20/30.

Patient 4’s left fundus. A, B, photograph and OCT preoperatively showedmacular schisis and detachment, and an optic disc pit with tissue in andover the disc cup. VA was 20/600. C, D, photograph and OCT 6 monthsafter vitrectomy and peeling of the glial tissue overlying the pit. There isreduction in the subretinal fluid and schisis, although the macula remainsdetached. VA is 20/100.


328Retinal Detachment after Posterior Vitreous Detachment Combined with Vitreous Hemorrhage

Guillermo Iribarren, MD (Buenos Aires, Argentina), Marcelo Valeiras, MD, Uriel Rubin, MD, Diego Bar, MD

PURPOSE To describe the incidence and surgical outcomes ofpatients with retinal detachment after acute posterior vitreousdetachment combined with vitreous hemorrhage.

METHOD Retrospective review of patients with retinaldetachment between 2005 and 2010. Inclusion criteria werepatients with regmatogenous retinal detachment after acuteposterior vitreous detachment with vitreous hemorrhage.Complete eye examination including ultrasound was performedin all cases. Results include final mean visual acuities, numberof eyes with at least one retinal tear, location of retinal tears,number of eyes that developed retinal detachment and numberof eyes repaired with scleral buckling surgery and or pars planavitrectomy. 11 eyes of 11 patients were selected.. Three werefemale and eight male, with a mean age of 61± 6 years. Meanfollow-up time 39.9 months.

RESULTS In 7 cases retinal tears where detected and treated withlaser or cryotherapy and the mean time to retinal detachmentwas 36 days. The remaining 4 cases had a dense hemorrhagemean time to retinal detachment, 9 days. Total number ofretinal breaks found was 15, 7 (46.6%) located in superiortemporal cuadrant, 3 ( 20%) superior nasal, 3 ( 20%) at the 12oclock hour , 1 at the 6 oclock hour and 1 temtporal inferior.Three cases had 2 breaks. Two patients were treated with scleralbuckling , two cases with primary vitrectomy and the remainingseven cases with vitrectomy combined with encircling band. Inall cases we were able to find at least one retinal tear prior orduring the surgical procedure. Mean initial visual acuity was20/496, final visual acuity was 20/123. 6 of the 11 patientsrequired at least 2 surgical procedures to reattach the retina. Inthose cases with one surgical procedure mean final visual acuitywas 20/39. Overall mean number of surgeries was 1.7.

CONCLUSION Acute, spontaneous, nontraumatic posteriorvitreous detachment combined with hemorrhage is associatedwith a high incidence of retinal tears and detachment. Closefollow-up with clinical examination and ultrasonography isnecessary. Aggressive management with early vitrectomy shouldbe considered to find and treat the retinal breaks and preventretinal detachment.

329OCT and Fundus Autofluorescence Abnormalities Are Associated with Visual Outcome in Rhegmatogenous Retinal Detachment

Szilard Kiss, MD (New York, NY), Guilleherme Favarone, MD, Robison Chan, MD, Jane Myung, MD*, Anton Orlin, MD, Minhee Cho, MD, Donald D’Amico, MD

PURPOSE Visual recovery after rhegmatogenous retinaldetachment (RD) repair can vary depending on clinical andanatomic factors. We investigated ultra wide-field fundusautofluorescence (AF) and spectral domain optical coherencetomography (OCT) abnormalities, pre- and postoperatively, in patients with RRD and correlated these findings with visual outcome.

METHOD Six patients, (4 female, 2 male) aged 25 to 69 yearspresenting to Weill Cornell Medical Center with non-traumaticRD were included in a retrospective, single-center, consecutivecase series. All patients underwent pre- and postoperative visualacuity (VA) testing, slit lamp biomicroscopy and dilated fundusexamination. Symptom duration prior to presentation rangedfrom 3 to 7 days. Spectral-domain OCT (HeidelbergEngineering, Inc., Vista, CA) and ultra wide-field AF (Optos,Marlborough, MA) were performed pre- and postoperatively.

RESULTS 5 patients (macula-off RD) underwent PPV; 1 (macula-on RD) had scleral buckle. Anatomical success was achieved inall. Pre-op VA ranged from 20/20 to finger counting, post-opVA from 20/20 to 20/100. Pre-op OCT revealed subretinal fluid(SRF) underneath the fovea. In the areas of SRF, there wasdisturbance of the external limiting membrane (ELM) anddisruption of the inner/outer segment (IS/OS) with increasedreflectivity of photoreceptors. 3 patients with worst VA hadretinal thickening, cystic changes in the plexiform layers andcorrugations of the outer retina. Pre-op AF showed hyper-AF atthe edge of SRF extending beyond the RD; areas with detachedretina were hypo-AF. Post-op OCT showed improvements inouter retinal architecture in all patients. Patients with the bestVA had normalization of ELM, IS/OS and photoreceptors andresolution of SRF. Post-op AF revealed persistent abnormalities(alternating circumferential lines of hypo-/hyper-AF) in 3patients with the worst VA.

CONCLUSION Pre-op OCT showing increased retinal thickness,cystic changes and corrugations were associated with worse VAcompared to disruption of IS/OS and ELM alone. Pre-op hyper-AF extended past the detachment, signifying dysfunction evenin attached retina. Persistent post-op OCT and AF abnormal-ities were associated with worse VA. OCT and AF may provideprognostic parameters for visual outcome in RD.

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Upper left: Hypo-AF of RD with adjacent hyper-AF in bordering attached retina. Lower left: OCT with thickened retina, outer retinal cysts, outer retinal corrugations, photoreceptor and IS/OS abnormalities.Upper right: Post-PPV, AF anomalies (circular hypo- and hyper-AF) persist in reattached retina. Lower right: OCT with attached retina,resolved cysts, and variable reflectivity of IS/OS.

330The Utility of Relaxing Retinectomies in Repair of Recurrent Retinal Detachments with Severe Proliferative Vitreoretinopathy

Jennifer I. Lim, MD (Chicago, IL), Daniel F. Kiernan, MD

PURPOSE The purpose of this study is to retrospectively reviewcases in which retinal detachment surgery was performed in the setting of severe proliferation and examine the preoperativeand surgical differences between cases that required relaxingretinectomies and those that did not to achieve anatomicretinal attachment.

METHOD A retrospective review of all cases with severe proliferative vitreoretinopathy and/or retinal incarceration with retinal detachment that underwent surgical repair by onesurgeon over a 40 month period was performed. All cases thatrequired a relaxing retinectomy to achieve retinal reattachmentwere identified. The preoperative characteristics, surgicaltechniques, and postoperative course and outcomes werereviewed for these cases and compared with cases that did notnecessitate retinectomy.

RESULTS Fifty-six eyes were identified with severe proliferativeretinopathy and retinal detachment that underwent surgicalrepair. Of these, 21 cases required relaxing retinectomies.Eighteen of these eyes showed retinal attachment at follow-up.Vision in these eyes was 20/400 on average (range 20/200 –hand motions). Three eyes were complicated by recurrentdetachment. Two of these underwent re-operation and achievedanatomically successful attachment. One eye remained chroni-cally detached and maintained light perception vision. Twoeyes progressed to no light perception and phthisis bulbi. Oneeye developed epithelial downgrowth and was treated with 5-FU and remained attached. Of the eyes that did not necessitateretinectomy, 29 maintained retinal attachment at follow-upwith vision averaging counting fingers (range 20/100 - handmotions). Three of these underwent reoperation and achievedanatomic attachment.

CONCLUSION Relaxing retinectomies may be required in cases ofretinal detachment with severe proliferation to allow completeretinal attachment. Many of these eyes are end-stage and wouldundoubtedly progress to a degenerative state. By restoringretinal anatomic integrity, a significant portion of these eyescan be maintained and in some cases improved vision, thoughminimal, can be achieved.

331Outcomes in Small Incision Pars Plana Vitrectomy without ScleralDepressed Trimming of Vitreous Base forRhegmatogenous Retinal Detachment

Nikolas London, MD (Philadelphia, PA), Homayoun Tabandeh, MD*, Thomas Gerald Chu, MD, PhD*, David S. Boyer, MD*

PURPOSE To describe the visual acuity and anatomic outcomesof small incision pars plana vitrectomy for rhegmatogenousretinal detachment without scleral depressed trimming ofvitreous base.

METHOD Retrospective consecutive case series of all cases ofrhegmatogenous retinal detachment who underwent PPVbetween January 2007 through September 2010. During thestudy period the surgical technique included small incision PPV(25G or 23G) in all cases. Scleral depressed vitreous basedissection was performed only in cases with anterior prolifer-ative vitreoretinopathy (PVR). Exclusion criteria included age<18, follow-up <3 months, and presence of proliferativediabetic retinopathy. Outcome measures included retinal re-attachment status and best corrected Snellen visual acuity(BCVA).

RESULTS Data were obtained on 156 eyes of 152 patients, with amean patient age of 62.2 years (range 19-90 years). The meanfollow-up was 13.9 months (range 3-41 months). The retinadetachment involved the macula in 115 (74%) eyes. Forty nineeyes were pseudophakic. Twenty seven eyes were highly myopic.Giant retinal tear was present in 7 eyes. PVR ranged from noneto closed-funnel total RD. The retina was reattached with oneprocedure in 146 (94%) cases. Final reattachment was achievedin 154 (99%) eyes. The BCVA at baseline was >20/40 in 34(22%) eyes, 20/50-20/100 in 14(9%) eyes, 20/200-20/400 in 27(17%) eyes, and <20/400 in 81 (52%) eyes. At the last follow-up the BCVA was >20/40 in 68 (44%) eyes, 20/50-20/100 in 37(24%) eyes, 20/200-20/400 in 25 (16%) eyes, and <20/400 in26 (16%) eyes.

CONCLUSION Small incision PPV without scleral depressedvitreous base trimming for rhegmatogenous retinal detachmentis associated with good anatomic outcomes and functionalimprovement.


332The New 25g Plus System Competes with the 23/20g System to TreatRhegmatogenous Retinal DetachmentsCesare M.C. Mariotti, MD (Ancona, Italy), Francesca Viti, MD, Michele Nicolai, MD, Andrea Saitta, MD

PURPOSE The 25g Plus system gives the same anatomical resultsas the 23/20g systems for all cases of retinal diseases that requirevitreoretinal surgery. In addition, it no longer gives anyparticular technical problems in spite of its smaller size. Itallows for a bi-manual approach, perfect illumination and easysilicon oil injection and removal.

METHOD Non-randomized restrospective study. A total of 97eyes with rhegmatogenous retinal detachment were recruitedfrom January 2009 to September 2010 and had a minimumfollow-up of 6 months. All patients were treated with the 25gplus system. Local-regional anesthesia was done for all eyes. Allphakic eyes had to undergo cataract surgery. All eyes underwenta complete vitrectomy. Perfluocarbon liquids were used duringall surgeries and then a PFCL-Air exchange was performed. Atthe end of the surgery the appropriate tamponade was injectedin all eyes (PDMS in 45 eyes, C3F8 in 37, air in 15). Laserretinopexy was done in all eyes.

RESULTS Surgery was performed on 97 eyes with rhegma -togenous retinal detachment. PDMS was used as a tamponadein 45 eyes. C3F8 was used as a tamponade in 37 eyes and 32had anatomical success after the first surgery. Air was used as atamponade in 15 eyes, 14 of which had anatomical success afterthe first surgery. 5 eyes with the C3F8 tamponade had arecurrent retinal detachment and PDMS was used to reattachthe retina. 1 eye with the air tamponade had a recurrent retinaldetachment and PDMS was used as new tamponade. Of these,44 resulted in anatomical success after the silicon oil wasremoved. The silicon oil is still in 7 eyes because they had arecurrent retinal detachment with PVR. They underwent arelaxing retinotomy with the 25g vitrectome. 92.8% of eyes hadan anatomical success after the first surgery with the 25g Plussystem.

CONCLUSION The 25g Plus system offered: excellent manage -ment of complete vitrectomy; peripheral retinal shaving andvitreous traction release; retinotomy with vitrectome withsilicon oil in the eye; bi-manual approach with 25G chandelier;easy oil injection and removal; endolaser photocoagulation;better sclerotomy closure without sutures (sutureless sclero-tomies); and less inflammatory reaction.

333Conservative Management vs. EarlyVitrectomy in Patients Presenting withFundus-obscuring Hemorrhagic PosteriorVitreous Detachment

Alexander Melamud, MD, MA, (Sterling, VA), Neha Serrano, MD

PURPOSE 1) To identify the incidence of retinal detachments(RD) and retinal tears (RT) in a population of patientspresenting with an acute, fundus-obscuring vitreous hemorrhage(VH) due to PVD. 2) To determine whether patients whoundergo early PPV benefit from improved visual acuity outcomesas compared to patients who are treated with conservativemanagement.

METHOD From 2003–2010, patients presenting within 1 week ofsymptom onset with VH were retrospectively identified. Eyeswere excluded if there was < 2 months of follow-up, if the VHwas not fundus-obscuring (better than 20/400 vision) or ifhistory of: retinopathy or macular degeneration in either eye;RD, RT, vein occlusion, macroaneurysm, trauma, uveitis, or eyesurgery (except uncomplicated cataract surgery) in the affectedeye. Data on PPV timing, visual acuity, and other factors werecollected. Visual outcomes in eyes which had PPV at ≤ 7days of presentation were compared to those who did not (later or no PPV) using the Student’s t-test and risk ratio. RT and RDincidence was also calculated.

RESULTS In total, of 41 eyes identified, 26.8% (n=11), 36.6%(n=15), and 46.3% (n=19) had retinal detachment, retinaltears, and underwent PPV, respectively. When eyes in the earlyPPV group (n=6) were compared to all other eyes (n=35) therewas a trend toward better final visual acuity but the results werenot statistically significant [t=-1.11 P=0.27; risk ratio (RR) 1.46Confidence Limit (CL):0.58;3.67]. However, when eyes in theearly PPV group were compared to eyes that underwent PPVmore than 7 days after presentation (n=13), there was a statisti-cally significant difference with better vision noted in eyes thatunderwent early PPV (t=2.21, P=0.04; RR 3.25 CL:0.72;14.64).

CONCLUSION Eyes presenting with acute, fundus-obscuring PVD have a high incidence of retinal tears and detachment. In these cases, early PPV might result in better visual acuity outcomes.

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334Scleral Buckling for Retinal Detachment –Results of 150 Consecutive Eyes

Naveenam Srinivasa Muralidhar, MD (Bangalore, India), Hemanth Murthy, MD, Manoj Gautam, MD

PURPOSE Vitrectomy has become more popular as primarysurgery for retinal detachment. We want to study the efficacy of scleral buckling surgery for uncomplicated RRD.

METHOD Records of consecutive patients who underwent surgeryfor rhegmatogenous retinal detachment were scrutinized. Allpatients who underwent scleral buckling as a primary procedurewith a minimum follow-up of 3 months were taken up for retro-spective analysis. Intervention: All the patients underwentcryotherapy and scleral buckling with or without drainage ofsub retinal fluid. In all the patients, the eye was encircled with a42 band. The 42 band itself was used as buckling and encirclingelement. Air injection was done in some eyes. The mainoutcome measure was retinal reattachment with the primarysurgery. Secondary outcome measures were the profile ofdetachment and visual outcome.

RESULTS 150 eyes of 149 patients were available for analysis. 88 were males and 61 were females. Average follow-up was 9 months. 107 (72%) patients were phakic, 34 (23%)pseudophakic, 4 (2.6%) aphakic and 1 (0.7%) had subluxatedlens. Horse shoe tear was the most common type of primarybreak, being seen in 38% of the eyes. Pre operatively, maculawas detached in 119 eyes (79.3%) and attached in 31 eyes(20.7%). In 131 eyes (87%) primary surgery was successful inattaching the retina, while 19 eyes (13%) required secondaryprocedure. Out of the 19 eyes, in 17 eyes retina got attachedwith the second surgery, while in two eyes retina remaineddetached. Visual acuity improved in 111 eyes (74%), stable in34 eyes (22.7%) and worsened in 5 eyes (3%).

CONCLUSION Scleral buckling is very effective for rhegma -togenous retinal detachment and can achieve success rate closeto 90%. Scleral buckling should be considered as a primaryprocedure for uncomplicated rhegmatogenous retinaldetachment.

335Segmental Buckling without Encircling Band for Primary Rhegmatogenous Retinal Detachment

Raja Narayanan MBBS (Hyderabad, India), Bhavin Shah, MD, Jay Kumar Chhablani, MD, Baruch D. Kuppermann, MD, PhD*

PURPOSE To study the anatomic and visual outcome ofsegmental buckling without encircling band for primaryrhegmatogenous retinal detachment (RRD)

METHOD Seventeen eyes of 17 patients who underwentsegmental buckling without encircling band for primary RRDwere studied retrospectively. Approval for the study wasobtained from the institutional review board. Patients withsingle retinal breaks or multiple breaks within 3 clock hourswere included. Patients with a history of trauma, proliferativevitreoretinopathy grade C or worse were excluded. The retinalreattachment rate after the first surgery was the primaryoutcome measure. Gain in best corrected visual acuity (BCVA)was the secondary outcome measure.

RESULTS Mean age of presentation was 35.28 yrs with 4 womenand 13 men. Mean duration of decreased vision was 137.5 dayswith 6 patients had history of trauma. The median preoperativebest corrected visual acuity was 20/800 (range: 20/30-20/4000).At presentation, the macula was detached in 13 eyes with totalretinal detachment (RD) in 3 eyes. Mean number of breaks was1.1. There were no intra-operative complications. The meanfollow-up was 212 days (7months). Sixteen (94.1%) patientshad attached retina till last follow-up with median BCVA of20/50 (20/20-20/2000).

CONCLUSION Segmental buckling without encircling band is asafe procedure with good anatomic and visual success inselected eyes with primary RRD.

336Macular Morphology in SD-OCT after Scleral Buckling or Primary Vitrectomy

Jerzy Nawrocki, MD, PhD (Lodz, Poland), Dominik Odrobina, MD, PhD, Janusz Michalewski, MD, PhD, Slawomir Cisiecki, MD, PhD, Maciej Bednarski, MD, Zofia Michalewska, MD, PhD

PURPOSE To compare spectral domain optical coherence (SD-OCT) after scleral buckling (SB) and primary pars planavitrectomy (pppV).


METHOD This is a single center, prospective analysis of 132 eyesafter SB and 121 eyes after pppV, which were evaluated withSD- OCT 1, 3 and 12 months after surgery. Patients withrhegmatogenous retinal detachment with no prior surgeryexcept phacoemulsification were included. The type of surgeryperformed was chosen by the surgeon. Following data werecompared: initial and final visual acuity, type of retinaldetachment, number of procedures performed, epiretinalmembrane, macular oedema, photoreceptor and externallimiting membrane defects, subretinal fluid, retinal pigmentepithelium defects, central retinal thickness.

RESULTS Mean initial visual acuity was 0,05 in the pppV groupand 0,26 in the SB group. Mean final visual acuity was 0,15 and0,32 respectively. Mean improvement of visual acuity in thepppV group was 0,1 and in the SB group 0,6. The mean numberof additional procedures including silicone oil removal was 1,2after pppV and 1,0, after SB, which was not statistically signif-icant (α=0,2). Photoreceptor and external limiting membranedefects were present in 63% of patients after pppV and in 24%after SB. Epiretinal membranes were present in 62% of cases inthe SB group and 55% of pppV group. Thinning of the foveawas observed in 13% of the SB group and 3% of the pppVgroup. Macular oedema was observed in 30% of patients afterSB and in 18% of patients after pppV. Mean central retinalthickness was similar in both groups (pppV: 273um, SB:277um). Subretinal fluid was present in 30% of patients afterSB and 18% of patients after pppV.

CONCLUSION The most important factor correlating with post -operative visual acuity was the size of photoreceptor defects,which occurred more often in patients after pppV. Otherchanges of retinal morphology were noted more often in thescleral buckling group but did not statisticaly significantinfluence visual acuity. Central retinal thickness had atendency to normalize during 12 months after surgery.

337Segmental Scleral Buckle Still is a Good Option for Treatment of Uncomplicated Retinal Detachment: A Case Series

Heitor Panetta, MD (Campinas, Brazil), Iuuki Takasaka, MD, Fernando Chaves, MD, Andrea Torigoe, MD, Valdir Balarin, MD, Rodrigo P.C. Lira, MD

PURPOSE The objective of this prospective case series was todescribe the reattachment rate and visual acuity results ofpatients with uncomplicated rhegmatogenous retinal detach -ment (RRD) who underwent segmental scleral buckle surgery.

METHOD Inclusion criteria were primary RRD with a singleperipheral retinal break. All patients had phakia, were 18 years or older, had partial or total PVD, and had visual loss orsymptoms (floaters and photopsia) of less than 30 days’

duration. No patient had a retinal break greater than 30° orRRD larger than 2 quadrants. The surgical procedure includedPeribulbar, drainage of subretinal fluid, and the placement ofthe segmental buckle in all patients. Cryopexy or laserpexy wasperformed around the break. The outcomes were the 1-week, 1-month and 6-month reattachment rates, best-corrected visualacuity (with ETDRS charts), rate of subsequent operations, andpostoperative complications.

RESULTS We enrolled 100 eyes of 100 patients scheduled toundergo scleral buckle surgery. The demographic data weremean age 53 (SD=12) years old, mean symptoms duration of 12 (SD=9) days, 54 (54%) males, and 72 (72%) patients withRD affecting macula. The 1-week, 1-month, and 6-monthanatomical success rates were 93% (93 patients), 100%, and100%, respectively. Seven (7%) patients underwent oneadditional retinal detachment surgery (pars plan vitrectomy)after primary failure at 1-week follow-up. The preoperative, 1-month, and 6-month best correct visual acuity were 20/100,20/80, and 20/50, respectively (Table 1 and Figure 1). Thepostoperative complications were: eyelid edema in 10% of thepatients (this patients received cryopexy), transient ocularhypertension (duration < 7 days) in 5%, macular pucker (these patients had RD affecting macula before surgery) in 3%,transient diplopia (duration < 30 days) in 3%, hyphema(<0.5mm) in 1%.

CONCLUSION It is not time to forget scleral buckle surgery. Mostof the adverse events in this study related to segmental scleralbuckle were minor postoperative complications, mainly eyelidedema. It still is as good and a cheaper option to vitrectomy.The results suggest that in patients with uncomplicated retinaldetachment, segmental scleral buckle provide satisfactoryanatomical and functional success.

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338Treatment of Choroidal Neovascularization in Central Serous Chorioretinopathy by Intravitreal BevacizumabAvinash Pathangey, MD (Hyderabad, India), Rajeev R. Pappuru, MD,Mudit Tyagi, MD, Raja Narayanan MBBS, Annie Mathai, MD, Ajit B. Majji, MD

PURPOSE Choroidal neovascular membranes (CNV) associatedwith chronic central serous chorioretinopathy (CSC) arepredominantly classic membraes. Photodynamic therapy hasbeen the standard of care for these membranes. There are fewcase report To evaluate the efficacy of Bevacizumab in choroidalneovascular membrane associated with chronic central serouschorioretinopathy.

METHOD Retrospective chart review of 7 eyes of 7 patients withCNV associated with chronic CSC diagnosed by fluoresceinangiogram and optical choherence tomography. Chronic CSC was diagnosed by documented episode of central serouschorioretinopathy with a previous history of a focal leak fromthe level of the RPE on fluorescein angiographic examinationalong with resolution of the sub-retinal fluid in the maculararea. Patients who received photodynamic therapy previouslywere excluded. Response to intra vitreal bevacizumab 1.25 mgwas assessed by visual acuity and optical coherence tomography.

RESULTS Best corrected visual acuity (BCVA) ranged from7/200 to 20/40 at presentation. Improvement or stabilization of Snellens visual acuity noted in all patients (Table 1).Subretinal fluid resolved in all patients.

CONCLUSION Intravitreal bevacizumab for CNV associated withchronic CSC showed anatomical and visual improvement.

Pre-treatment OCT showing sub-retinal tissue with sub-retinal fluid, and cystoid changes in retina which were reduced in post-treatment OCT.

339Evolving Retinal Detachment Repair Paradigms 1: Understanding How GlobeGeometry Impacts Retinal Detachment RepairRobert I. Park, MD (Asheville, NC)

PURPOSE Increased intraretinal stress is a factor in RT/RDdevelopment. Traditional models of RT/RD consider vitreo-retinal traction the inciting factor in RT/RD. MRI-basedbiomechanical analysis allows calculation of the additionalinherent intraretinal stress that increases the risk for RT/RD inmyopes. New guidelines for scleral buckle encircling band useare proposed.

METHOD Globe dimensions, including axial length, vertical/horizontal equatorial diameters, and retinal thicknesses fromsurface coil MRI scans were used to calculate the intraretinalstress in emmetropic and myopic (-4,-8,-12,-16D) eyes.Intraretinal stress was first calculated for the various measuredretinal diameters while keeping retinal thickness constant.Intraretinal stress was then calculated for various retinal thick-nesses while keeping ocular diameter constant. A combinedmodel of varying thicknesses and diameters was then used tocalculate combined intraretinal stress. Intraretinal stresses werethen compared to that of an emmetropic eye.

RESULTS Compared to emmetropic eyes, myopic eyes haveincreased axial length and increased vertical and horizontalequatorial diameters. Retinal thickness diminishes withincreased diameter only in the horizontal dimension. Intra -retinal stress increased for myopes (refractive error:-4,-8,-12,-16D) as compared to emmetropes: horizontally, 1%, 3%, 4%, and 6%; and vertically, 3%, 6%, 10%, and 13%.Intraretinal stress increased with myopic retinal thinning onlyin the horizontal dimension 9%, 19%, 32%, 48%, respectively.The combined effect of myopic increased diameter and retinalthinning (refractive error: -4,-8,-12,-16D) was an increase inintraretinal stress of: horizontally 10%, 22%, 38%, 56% andvertically 3%, 6%, 10%, 13%.


CONCLUSION Decreased retinal thickness and increased retinaldiameter cause increased intraretinal stress in myopia.Measurement of retinal thickness and equatorial diameter maybe useful in deciding how to repair RDs especially in myopes.Strategies to reduce intraretinal stress, i.e. encircling bandscleral buckles, should be considered in eyes with decreasedretinal thickness or increased diameters.

34023-gauge Pars Plana Vitrectomy Alone vs. 23-gauge Pars Plana Vitrectomy and Scleral Buckle for Primary Repair ofPseudophakic Retinal DetachmentVikram J. Setlur, MD (Philadelphia, PA), Jason Hsu, MD, Sunir J. Garg *, Caesar K. Luo, MD

PURPOSE To evaluate primary reattachment rates for two similargroups of patients who received either 23-gauge PPV or 23-gauge PPV/SB for repair of pseudophakic RRD. This study also compares visual acuity outcomes and complication ratesbetween 23-gauge PPV and PPV/SB.

METHOD A retrospective review was performed examining 113 eyes of 110 patients who underwent either 23-gauge PPV or PPV/SB for repair of pseudophakic RRD. All vitrectomysurgeries were done using 23-gauge instrumentation, endolaser,and intraocular gas tamponade. There were 70 eyes in the PPVgroup and 43 eyes in the PPV/SB group. Minimum follow-upwas 3 months. Patients with prior vitrectomy, prior scleralbuckle, or grade C PVR or worse were excluded.

RESULTS The 23-gauge PPV group achieved primary anatomicalsuccess in 58 out of 70 cases (83%). Primary success in thePPV/SB group occurred in 36 of 43 cases (84%). Finalanatomical success was achieved in all 113 cases (100%). Thedifference in primary success rates was not statistically signifi -cant (P = 1.000, Fisher exact test). Average visual acuity formacula-on RRDs in the PPV group showed a +0.07 improve -ment in the logarithm of the minimum angle of resolution(logMAR) (P = 0.58) versus a +1.34 improvement (P = 0.0001)in macula-off PPV cases. SB/PPV macula-on cases showed adecrease in logMAR visual acuity by -0.06 (P = 0.38) whilemacula-off SB/PPV cases improved by +1.28 (P = 0.002). Thenumber of detachments with multiple breaks was higher in thePPV/SB group (58%) versus PPV alone (33%) (P = 0.0145).There were no significant complications in either group. Twoeyes in the PPV/SB group had post-operative hypotony whileno eyes the PPV only group developed hypotony.

CONCLUSION 23-gauge PPV and PPV/SB are both effectiveprocedures for primary repair of pseudophakic retinaldetachment with good success rates and a low incidence ofserious complications. There was no statistically significantdifference for primary or final anatomical outcomes between23-gauge PPV and PPV/SB.

341Management of Retinal Detachments inAdolescents with Self-injurious Behavior

Robert Andrew Sisk, MD (Cincinnati, OH), William W. Motley, MD*, Michael Yang, MD, Constance E. West, MD

PURPOSE To assess the outcomes of retinal detachment (RD)repairs among a cohort of cognitively impaired adolescents withpersistent self-injurious behavior (SIB), and describe a protocolfor ensuring desired early postoperative positioning in eyes withsilicone oil (SO) tamponade.

METHOD Retrospective, consecutive, interventional case seriesof 9 eyes of 9 patients at a single pediatric multispecialtyhospital who underwent repair of self-induced, traumatic RDSeptember 2009 to January 2011. Scleral buckling and/orvitrectomy with SO tamponade were used for primary repair.Additional procedures were performed as indicated. 3 patientswere kept intubated and sedated overnight to facilitate post -operative prone positioning. A multidisciplinary team ofbehavioral specialists, psychiatrists, and pediatric ophthal -mologists was employed to limit self-injurious behavior andmaximize visual recovery. Main outcome measures were retinalattachment and postoperative complications.

RESULTS Complete retinal reattachment was initially achievedin all 9 eyes. 6 (67%) eyes had chronic RD at initial presen-tation, and 7 (78%) patients had limited vision from chronicRD in the fellow eye. Proliferative vitreoretinopathy (PVR) ledto recurrent RD in 4 (44%) eyes at a mean of 2.7 months. Finaltotal or partial retinal attachment was achieved in 67% and33%, respectively, with a mean of 1.6 procedures. SO emulsifi-cation led to progressive glaucoma in 4 (50%) of 8 eyes,requiring SO exchange (2 eyes) or removal (2 eyes). RecurrentRD developed in both patients after SO was removed, despiteretinal anatomic stability for greater than 6 months. A mean of 4 medications were required to limit SIB in addition tobehavioral therapy and protective orthotic devices. All patientswere actively self-injurious prior to surgery, and all had severecognitive impairment. 3 were victims of past domestic abuse; 5 lived in foster care; 7 were nonverbal; and 5 had neuro -muscular disease.

CONCLUSION Cognitively impaired adolescents with SIBtypically presented with severe visual impairment from chronicRD in one or both eyes. Despite initial anatomic success, PVRand continued self-abuse led to a high rate of recurrent RD.Long-term SO tamponade may prevent recurrent RD but isassociated with progressive glaucoma.

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342Barriers to Access Health Services for Persons with Rhegmatogenous RetinalDetachment in Sao Paulo, Brazil

Leandro C. Zacharias, MD (Sao Paulo, Brazil), Tatiana Tanaka, MD, Suellen T. Shibata, MD, Thiago A. Leite, MD, Pedro Carricondo, MD*, Walter Y. Takahashi, MD*

PURPOSE To verify the access barriers that patients with retinaldetachment face to arrive to a reference center and to evaluatewhat the patients know about this disease.

METHOD We performed a transversal study that applied aquestionary to 65 patients of the Clinical Hospital of theUniversity of Sao Paulo with the diagnosis of rhegmatogenousretinal detachment (RD) between February and August 2010.

RESULTS The reasons for not performing the surgery in otherservices were: 88% of the patients were referred directly to ourClinical Hospital. 47% were referred to us because there was novitreoretinal surgeon at the original service; 24% of the patientsdid not have money to pay for the surgery or had no healthinsurance, and 3% of the patients had no coverage at the healthinsurance plan for the procedure. The lag time between the firstsymptom and the arrival at our service was: 4 patients arrived inone day, 14 patients between 2 and 7 days, 19 patients between8 and 15 days; 15 patients between 16 and 30 days; 8 patientsbetween 31 and 90 days; 3 patients between 91 and 180 days;and 2 patients after more than 180 days. The reasons for thedelay were: 70% did not know how serious the pathology was;56% thought that it had spontaneous cure; 16% had no moneyto pay for an ophthalmic evaluation; 10% did not know whereto go, and 24% for other reasons.

CONCLUSION Educational programs focusing on the symptoms ofthe disease and measures to optimize the referral to specializedservices are needed in order to accelerate the attendance andtreatment of the patients with RD in Brazil. That wouldcontribute to improve the final visual recovery and the qualityof life of the patients. Our data may reflect the reality found inother countries in South America.

Retinal Instrumentation and Devices POSTERS 343-349

343Newly Designed Miniaturized Light Weight Wide Angle Contact Lens forDigital Fluorescien Angiographic Evaluation of Retinal Ischemia

K.V. Chalam, MD, PhD, MBA, FRCS (C) (Jacksonville, FL), Vijay Khetpal, MD, Ravi Radhakrishnan, MD

PURPOSE Scanning laser ophthalmoscopy (SLO) allowsdynamic high resolution retinal images using lower retinalirradiances. Accessory contact lenses significantly enlarge areaof imaging with a five fold increase in the field of view andassess peripheral circulation. We designed and evaluated anovel miniaturized wide field contact lens system and comparedit to the Staurenghi 230 SLO Retina Lens.

METHOD The novel lens consisted of an integrated threeelement convex-concave system with lens powers of 160D and40D with a plano contact lens element. FA as well as ICG wasperformed using Heidelberg retina angiograph (HeidelbergEngineering), with wide field novel contact lens in a variety ofretinal disorder including diabetic and sickle cell retinopathy,vascular occlusions, and a range of chorio-retinopathies. The images were compared to the commercially availableStaurenghi 150˚ Contact Lens system. The angiography imagesobtained from the two systems were compared for size of thefield, image resolution, details of peripheral vasculature, extentof capillary nonperfusion and ease of use.

RESULTS The newly designed lens increased the SLO’s 30°imaging fields to 150°. It was 70% less in weight ( 86g vs 36g)and 25% shorter in length (7.6 cm vs 5.7 cm). Peripheralretinal and choroidal findings can be readily observed andrecorded in both systems. Peripheral images obtained with thisminiaturized lens were found to be free of spherical aberrationswith excellent resolution of peripheral vasculature compared to Staurenghi lens (Figure. 1A, B). The novel lens system issmaller in size (Figure. 2) and allowed easier handling andbetter patient comfort compared to Staurenghi lens. Retinaland choroidal abnormalities, including neovascularization andcapillary nonperfusion, are easily detected and documented well beyond the range of conventional fundus cameras and SLOs.


CONCLUSION The novel design of low weight miniaturized widefield imaging lens offered readily obtainable, cost effective highresolution peripheral retinal imaging vascular details superior tomanual photomontages and Staurenghi contact lens system.This system was helpful in estimating the area of nonperfusionin retinal vasculopathies including DR, Sickle cell retinopathyand vascular occlusions.

Wide field late fluorescein angiography using A. staurenghi contact lens and B. newly designed contact wide field lens system.

Size comparision of the two contact lens system staurenghi (right) and newly designed system (left).

344Heavy Silicone Oil (Densiron 68) Extractionwith 18G Cannula vs. Extraction with a 23G Cannula. Case Reports

Sergio E. Hernandez-Da Mota, MD (Morelia, Mexico)

PURPOSE To compare the extraction of heavy silicone oil(HSO) with a 18G cannula versus a 23G cannula.

METHOD Interventional case reports. In case 1, a 18G cannulawas used to extract heavy silicone oil. In case 2, a 23G cannulawas used instead. The time required for the bubble extractionand the total surgery times were measured. These were thencompared with the Hagen-Pouseuille equation to check forconsistency.

RESULTS A total of 20 minutes and 20 seconds were required forbubble extraction in case 1, whereas case 2 required 65 minutes.Those values were very similar to the ones obtained by applyingthe Hagen-Pouseuille equation (19 minutes for case 1 and 63.3 minutes for case 2).

CONCLUSION The use of a larger caliber 18G cannula is a validmethod for extracting heavy silicone oil with some advantagesover smaller caliber cannulas such as 23G in these case reports.

Dimensions of the 18 Ga cannula

Dimensions of the 23 Ga cannula

345Comparison of Blade and Incision ArchitectureBetween New 25- and 23-ga MicrovitreoretinalBlades and Current Sclerotomy Entry Systems

Makoto Inoue, MD (Tokyo, Japan), Dina Joy Abulon, David Buboltz, Akito Hirakata, MD

PURPOSE To compare the blade sharpness and incision archi-tecture of various 25- and 23-ga sutureless trocar andmicrovitreoretinal (MVR) blades at oblique and straight anglesof entry.

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METHOD The 25- and 23-ga test samples of 7 different types oftrocar-cannula system included new and conventional MVRblade designs, conventional beveled trocar blades, and round-tipped trocars (23-ga only). A Scanning Electron Microscope(SEM) imaged cutting surfaces of each blade. In another test,high magnification imaging measured the incision length andlinearity of straight and obliquely angled incisions through acircular silicon coupon (n=10). Wound proof pressure testingwas conducted on sclerotomy sites after simulated vitrectomy inenucleated porcine eyes (n=4).

RESULTS Incision shape and SEM analysis showed distinct differ-ences in blade design and incision geometry: conventionalbeveled trocar blades generated asymmetrical chevron-shapedincisions, round-tipped trocar blades generated semi-circularincisions, new symmetrical MVR blades generated linearincisions, while a conventional MVR blade design generated aflattened M-shaped incision. The new 25-ga symmetrical MVRblade generated the smallest wound geometry with an incisionlength of 19.9 ± 0.9 µm (straight incision), linearity measure -ment of 0.2 ± 0.1 µm (straight incision), oblique incision length of 18.2 ± 1.1 µm, and oblique linearity measurement of0.8 ± 0.2 µm (all P<0.05). In wound leakage tests the newsymmetrical MVR blades leaked the least in every test (4 testsper blade).

CONCLUSION Compared to all blades, the new symmetrical MVR blades suggest better wound architecture by generatingless wound leakage, shorter incision lengths, and more linearwound apposition.

346Evaluation of a Novel, Non Contact,Automated Focal Laser with Integrated(NAVILAS®) Fluorescein Angiography forDiabetic Macular EdemaVijay Khetpal, MD (Jacksonville, FL), Ravi Radhakrishnan, MD, Ravi Keshavamurthy MBBS, MD, K.V. Chalam, MD, PhD, MBA, FRCS(C)

PURPOSE To evaluate the safety of a novel laser delivery systemNAVILAS® (OD-OS Teltow, Germany) that combinesautomated laser delivery with color fundus photography,fluorescein angiography (FA), fundus autofluorescence (FAF)and infra-red imaging with a frequency doubled YAG laser.

METHOD Diabetic macular edema (DME) is a leading cause ofblindness and focal macular laser photocoagulation is thestandard of care in the treatment of DME. In this prospectivepilot study, we treated 12 patients with the NAVILAS systemfor DME. Image overlays and tracking system allowed accuratedelivery of laser spots of varying size, duration and power.

RESULTS All patients tolerated the procedure well and noinadvertent foveal burns or damage to the lens was noted.

CONCLUSION In our pilot study, NAVILAS a novel integratedlaser delivery system proves to be safe and effective and nocomplications were noted during the treatment of diabeticmacular edema.

347Choroidal-scleral Junction Continuity and Outer Choroidal Vessel VisualizationAcross Spectral Domain OCT PlatformsPhoebe Lin, MD, PhD (Durham, NC), Priyatham Mettu, MD, Sina Farsiu, MD, Prithvi Mruthyunjaya, MD

PURPOSE To determine how visualization of the choroidal-scleral junction (CSJ) and outer choroidal vessels in threedifferent SD-OCT platforms using manual and automatedenhanced depth imaging (EDI) differed from upright modes and affected choroidal thickness measurements.

METHOD In a prospective comparative series, 22 eyes from 12normal subjects had 9 mm horizontal scans using 7 SD-OCTtechniques: Bioptigen, Cirrus, Spectralis (upright and inverted),and Spectralis automated EDI mode. The choroid borders weremanually segmented by 2 masked observers. Average choroidalthickness across a fovea-centered 4 mm segment was deter-mined with MATLAB. Image quality was defined by thepercentage of images with >90% continuity of the CSJ. Thenumber of large outer choroidal vessels (≥ 200 µm in diameter)was determined for each image using MATLAB. Statistics:paired t-test and Pearson correlation for inter-observer corre-lation (IOC) (p< 0.05 was statistically significant).

RESULTS CSJ continuity scores were higher for inverted (andEDI) vs upright modes: Bioptigen (67% vs 29%, p=0.02),Spectralis (72% vs 28%, p=0.004), Spectralis EDI (61%,p=0.04). The opposite was true in Cirrus images, in which theinverted mode is falsely pixilated: Cirrus (0% vs 58%,p<0.001). The average number of large choroidal vesselsvisualized were: Bioptigen upright 2.7 vs. inverted 5.9(p<0.0001), Spectralis upright 4 vs. inverted 11.3 (p<0.0001)vs. EDI 7.3 (p=0.0002 compared with upright, p=0.0001compared with inverted), and Cirrus upright 6.7 (p<0.0001compared with Bioptigen upright, p=0.135 compared withBioptigen inverted). Mean choroidal thickness was highest inSpectralis inverted (242.2 µm) and EDI modes (234.7 µm)compared with upright Spectralis images (203.8 µm) (p=0.05and 0.03, respectively). Choroidal thickness in Cirrus uprightimages (mean 226.8 µm) compared favorably to Spectralisinverted images (p=0.282).

CONCLUSION The best visualization of large outer choroidalvessels and CSJ occurred by either manual inversion orautomated enhanced depth SD-OCT modes. In these optimizedmodes, choroidal thickness measurements were also greatest.Future choroidal imaging studies should incorporate these SD-OCT modes to better discern the relationship of choroidal structures.


348Vitreous Cutter Velocities: Dual Pneumatic Drive vs. Single Pneumatic Drive with Spring Return

Christopher D. Riemann, MD (Cincinnati, OH), Jianbo Zhou, Dina Joy K. Abulon, David C. Buboltz

PURPOSE Cutter closing velocity affects tissue cutting shear rate,duty cycle and flow rate of vitreous cutters and has an impacton the cutting effectiveness of a vitreous cutter. High speedvideo of cutter movement in-vitro was generated to investigatecutter dynamics for two types of vitreous cutters – single pneu -matic drive and spring return (SPDSR) and dual pneumaticdrive (DPD) mechanisms.

METHOD High speed video of the cutter movement through theprobe port was captured at 25,000 fps. The SPDSR probes wererun at 2500 cpm. The DPD probes were run at 2500 and 5000cpm in core and shave modes. Six each of 25, 23, and 20 gaugeprobes for both types were tested. The cutter movement wasanalyzed from the captured video frames to calculate the cutterclosing and opening velocities and the durations of differentphases (fully open, closing, fully closed, and opening of theport) in a cut cycle.

RESULTS Closing/opening velocities (mm/s) for SPDSR probesat 2500 cpm were 165/79 for 25ga probes, 168/78 for 23gaprobes, and 188/73 for 20ga probes. Closing/opening velocities(mm/s) for DPD probes at 2500 cpm (core duty cycle) were338/304 for 25ga probes, 335/266 for 23ga probes, and 276/236for 20ga probes. Closing/opening velocities (mm/s) for DPDprobes at 2500 cpm (shave duty cycle) were 440/224 for 25gaprobes, 405/212 for 23ga probes, and 336/209 for 20ga probes.Closing/opening velocities (mm/s) for DPD probes at 5000 cpmwere 472/362 for 25ga probes, 453/319 for 23ga probes, and371/287 for 20ga probes. The percentage of the time a port wasfully open in a cut cycle at 2500 cpm was 26%, 38%, and 34%for the 25G, 23G, and 20G SPDSR probes, respectively; and66%, 67%, and 62% for the 25G, 23G, and 20G DPD probes(core mode), respectively.

CONCLUSION The DPD cutter closing and opening velocities aremuch higher than the SPDSR cutter creating a greater tissuecutting shear rate. For the DPD probes, the closing velocitiesare higher in smaller gauges, at the higher cut rate, and in theshave mode. The DPD probes in the core mode open the portfully much longer than the SPDSR probes.

349Topical Aqueous Suppression Does Not Affect Duration of Intraocular Gas Tamponade Following Vitrectomy

Chirag Shah, MD (Boston, MA), Jason Hsu, MD, Marc Spirn, MD, Larry Donoso, MD, Sunir Garg, MD*

PURPOSE To determine if topical aqueous suppression affects theduration of intraocular sulfur hexafluoride (SF6) gas tamponadeafter pars plana vitrectomy.

METHOD This prospective randomized controlled trial includedpatients undergoing 23-gauge pars plana vitrectomy with airfluid exchange and 20% SF6 gas tamponade. All sclerotomieswere sutured. Eyes were randomized to receive either topicaldorzolamide 2%-timolol 0.5% twice a day or no drops. Theprimary outcome was duration of SF6 gas tamponade.

RESULTS Twenty-one patients were recruited; four wereexcluded for non-compliance with dorzolamide-timolol drops.Eight patients were randomized to the treatment group withdorzolamide-timolol and nine patients were randomized to thecontrol group. There was no difference in duration of SF6 gastamponade between the two groups (p = 0.35). The mean gasduration was 17.1 ± 1.6 days in the dorzolamide-timolol groupwith a range of 15–20 days. The mean was 18.1 ± 2.4 days inthe control group with a range of 16–24 days. The meandifference was -1.0 days with a 95% confidence interval of -3.2to 1.2 days. The study was 93% powered to detect a four-dayincrease in gas duration. Secondary analyses did not reveal adifference in SF6 duration based on lens status, presence ofdiabetes or hypertension, vitrectomy vs. combined buckle withvitrectomy, or patient age.

CONCLUSION Topical aqueous suppression with dorzolamide-timolol does not significantly affect duration of SF6 gastamponade following pars plana vitrectomy.

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Surgical Techniques and Maneuvers POSTERS 350-362

350Clinical Outcomes of Bromfenac OphthalmicSolution 0.09% Qd vs. Nepafenac 0.1% Tid for Treatment of Ocular InflammationAssociated with Ocular Surgery

Melissa Cable, MD (Independence, MO)*, Timothy Stout, MD*

PURPOSE To investigate whether topical bromfenac 0.09%solution qd is as efficacious as topical nepafenac 0.1% tid inpatients undergoing uncomplicated cataract surgery by onesurgeon.

METHOD This randomized, prospective, investigator-maskedstudy comprised 18 patients undergoing uncomplicated cataract surgery randomized to receive bromfenac 0.09% qd ornepafenac 0.1% tid beginning 3 days prior to surgery, on the dayof surgery and 21 days subsequently. 10 patients completed sixweek postoperative evaluations. Outcomes were measured byobserving ETDRS visual acuity, summed ocular inflammationscore, and optical coherence tomography measurements ofretinal thickness and volume.

RESULTS Both treatment groups had similar baseline measure-ments of mean macular volume, mean letters read and meancell score with one outlying value in the bromfenac group withpoor baseline acuity due to posterior subcapsular cataract.Outcomes in mean macular volume, mean letters read andmean cell score were not statistically different in the post -operative period through six weeks.

CONCLUSION In the initial postoperative period, bromfenac0.09% solution qd and nepafenac 0.1% suspension tid wereequally effective in reducing summed ocular inflammation, inETDRS visual acuities, and in mean macular volume. Eithermedication may be considered after uncomplicated phaco -emulsification. Bromfenac may be preferred due to less frequent dosing.

351Incidence of Steroid Induced Ocular Hypertension Using Either Difluprednate or Prednisolone Acetate after Vitreoretinal Surgery

Daniel Connors (New Brunswick, NJ), Jonathan Prenner, MD*, Howard Fine, MD, Harold Wheatley, MD, Daniel Roth, MD*

PURPOSE Difluprednate (DP) is a new generation topicalophthalmic corticosteroid that has potent anti-inflammatoryeffects. We sought to determine if an increased incidence ofsteroid responsive ocular hypertension existed in postoperativepatients treated with DP as compared with those treated withprednisolone acetate (PA).

METHOD A retrospective chart review was performed on aconsecutive series of 127 surgical patients who were treated fora host of vitreoretinal pathologies. Over a two-month period,we began using DP instead of PA after the majority of oursurgery patients. We compared both the change in intraocularpressure (IOP) and the maximum IOP (Tmax) in patientstreated with DP and PA. We also examined the rate of ocularanti-hypertensive drug initiation in each group. Patients withknown glaucoma pre-operatively were excluded from the study cohort.

RESULTS Eighty-nine patients were treated with DP and 38patients were treated with PA. Mean baseline IOP was similarin the two groups (DP=17.32, PA=17.31, P=.99). No statisti-cally significant difference in IOP change existed between thetwo groups (DP=+9.47, PA=+7.72, P=. 32). No statisticallysignificant difference in Tmax existed between the two groups(DP=27.68, PA=25.34, P=.22). No statistically significantdifference in the rate of anti-hypertensive drug initiationexisted between the two groups (DP=23.6%, PA=23.6%,P=.99). Subgroup analyses by surgical indication and proceduredid not demonstrate and statistically significant differencebetween DP and PA groups.

CONCLUSION Difluprednate is a potent, new generation topicalcorticosteroid. Despite the potency of the drug, patients treatedwith DP in the postoperative setting did not demonstrate astatistically significant difference in terms of IOP elevationcompared with those treated with PA. Surgeons take on nogreater risk in terms of IOP rise by using DP instead of PA.


352Feasibility and Outcomes of Silicone OilRemoval with 25 Gauge InstrumentationFollowing Rhegmatogenous RetinalDetachment Repair

Dilsher S. Dhoot, MD (Cleveland, OH), Alex Yuan, MD, Jonathan Sears, MD, Rishi P. Singh, MD

PURPOSE To report the feasibility and outcomes of silicone oilremoval using a 25 gauge vitrectomy system.

METHOD Nine patients (9 eyes) underwent silicone oil removalin a prospective, interventional case series at a single insti-tution, between October 2010 and March 2010. A 25-gaugesystem featuring a 25 gauge silicone oil injection cannula(Synergetics, O’Fallon, MO) was utilized for active removal of1000 centistokes (cSt) silicone oil. Visual acuity, intraocularpressure (IOP), total silicone oil removal time, complications,and number of sutured sites were recorded in each case.

RESULTS Mean active silicone oil removal time was 6 minutesand 15 seconds (SD, 64.5 seconds). 56% of the silicone oilremoval sclerotomies were sutureless. Of those sclerotomies that did require suturing, a single interrupted transconjunctivalscleral suture was effective at closing the sclerotomy. Mean pre-operative IOP was 12 mmHg (range, 7.5-18 mmHg). Mean one day and one week post-operative IOP was 9 (range, 5-13mmHg) and 11.7 (range, 8-22 mmHg), respectively. No cases of post operative hypotony (IOP < 5 mmHg) were noted. Meanpre-operative visual acuity was 20/515. No intraoperative orpostoperative surgical complications were identified. Onepatient was noted to have minimal residual oil in the anteriorchamber on clinical exam. Mean one day, one week, and onemonth post-operative visual acuity was 20/3828, 20/1150, and20/486 respectively. Mean three month post-operative visualacuity was 20/542, where data available.

CONCLUSION We report on a new method for active removal of1,000 cSt silicone oil using a commercially available 25 gaugesystem. Larger randomized trials comparing 20G to 25Gremoval would be necessary to validate whether the techniqueleads to similar outcomes.

354Comparison of Iatrogenic Peripheral RetinalTears Between Small (23- or 25-) Gauge and 20-Gauge Vitrectomies

Hua Gao, MD (West Bloomfield, MI), PhD, Sweta Tarigopula, MD, Shareef Ahmed, MD, Anju G. Aggarwal, MD, Uday R. Desai, MD, Paul A. Edwards, MD

PURPOSE Iatrogenic peripheral retinal tears related tosclerotomy during vitrectomy are the most common iatrogenicretinal tears reported previously. The purpose of this study wasto compare the incidence of these retinal tears in small (23- or 25-) gauge to 20-gauge pars plana vitrectomy.

METHOD This is a retrospective comparative study comprising377 eyes who underwent pars plana vitrectomy for variety ofretinal disorders, such as proliferative diabetic retinopathy,macular pucker or macular hole, and retinal detachment, etc.226 eyes underwent 23- or 25-gauge pars plana vitrectomy and151 eyes underwent 20-gauge vitrectomy. The main outcomemeasure was the presence of iatrogenic retinal tears aroundsclerotomy found intraoperatively.

RESULTS In 151 eyes with 20-gauge vitrectomies, iatrogenicretinal tears related to sclerotomy were found in 11 eyes(7.28%). In 226 eyes with small gauge (23- or 25-gauge) vitrec-tomies, this type of iatrogenic retinal tears was only found in 3 eyes (1.32%). There is a much lower incidence of iatrogenicretinal tears related to sclerotomy in small gauge vitrectomycompared to 20-gauge vitrectomy (p=0.0052).

CONCLUSION Small gauge vitrectomy appears safer in iatrogenicretinal tears around sclerotomy than 20-gauge vitrectomy. It islikely that trocars prevent potential tractions on the vitreousbase from instruments when they are inserted into or withdrawnfrom eyes. This is probably why small gauge vitrectomy causesmuch less iatrogenic retinal tears than 20-gauge vitrectomywithout trocar protection.

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355Endoscopic Cyclophotocoagulation Via Pars Plana for the Treatment of Complicated Glaucoma

Victor Hugo Gonzalez, MD (McAllen, TX)*, Denisse Cornu, MD, Valmore Adrian Semidey, MD*, Veronica M. Calderon, MD

PURPOSE To evaluate the efficacy and safety of ECP via parsplana in achieving an IOP reduction in patients with glaucoma.

METHOD After IRB approval, retrospective consecutive caseseries of 20 eyes from 20 patients with different mechanismglaucomas [COAG, NVG, Mixed mechanism glaucoma (MMG)and Traumatic glaucoma (TG)], on topical medication and/orpost glaucoma drainage device surgery with a minimum of threemonths follow-up post ECP were identified. Eyes underwent180 degrees ECP via pars plana approach by a vitreoretinalsurgeon (VHG) during vitreous surgery for a variety of indica-tions using a standardized protocol. Preoperative and 3 monthspostoperative IOP, topical medication requirements and safetywere reviewed.

RESULTS patients who underwent ECP had the followingcharacteristics: 9 (45%) with COAG, 7 (35%) with NVG, 3 (15%) with MMG and 1(5%) with TG. 14 (70%) werepseudophakic, 2 (10%) aphakic and 4 (20%) phakic. Pre -operative IOP ranged from 12-66 mmHg (mean 27.9 mmHg).Of these patients 19 (95%) were using ≥3 glaucoma meds and 1 (5%) with only 1 med. 15 patients (75%) had a VA of 20/400 or worse, 4 (20%) of 20/200-20/50 and 1 (5%) of 20/40or better. 3 months postoperative IOP range of 2-23 (mean11.65mmHg) in which 17 patients (85%) had an IOP improve -ment of >10 mmHg. Of the total patients, 11(55%) continuedusing ≥3 meds, 2(10%) with 2 meds, 2(10%) with one med and 5(25%) discontinued the usage of all glaucoma meds. No significant ECP related adverse events were noted.

CONCLUSION In this retrospective case series pars plana ECPappears to be an effective and safe procedure for the manage -ment of various glaucomas encountered during vitreous surgery. Further controlled, randomized studies are warranted to validate our findings.

356Experience with Polydimethylsiloxane Perfluorohexyloctane (Densiron-68) in Proliferative Vitreoretinopathy

Sergio E. Hernandez-Da Mota, MD (Morelia, Mexico)

PURPOSE To describe the rate of retinal reattachment andimprovement in best corrected visual acuity (BCVA) inpatients with complicated retinal detachment (RD) and heavy silicon oil (HSO) Densiron-68.

METHOD Design: Retrospective, longitudinal case series study.Participants: Twelve eyes of 12 patients with RD complicatedwith proliferative vitreoretinopathy (PVR) grade B or greaterwere included. Methods: Pars plana vitrectomy (PPV) andpolydimethylsiloxane/perfluorohexyloctane intra vitrealinjection was performed in all patients. Retinal reattachmentrate, pre and postoperative best corrected visual acuity (BCVA)was evaluated as well as complications.

RESULTS Retinal reattachment was achieved in 10 cases (83.3%).Mean pre-operative BCVA was 2.59 logMAR (SD 0.71) (SE0.2) while average final BCVA was 1.57 logMAR (SD 1.27)(SE 0.36) (p=0.004, paired samples t test) (CI 95% 0.39-1.64).

CONCLUSION Although some complications were present insome patients, Densiron-68 proved to be effective enough insome RD complicated with PVR, with a high reattachment rate in this case series.

Preoperative retinal detachment with proliferative vitreoretinopathy.

Postoperative image of reattached retina with Densiron.


357Reproducing Image of Subjective Visual Sensations Experienced during Vitreous Surgery

Makoto Inoue, MD (Tokyo, Japan), Kei Shinoda, MD, Toru Noda, MD, Kazuhiko Ohnuma, MD, Akito Hirakata, MD

PURPOSE Visual sensations experienced by patients duringcataract surgery or vitreous surgery have been described.Patients sometimes describe that they observed that the instru-ments inside their eyes were moving or the membrane-likematerial was peeled during the surgery. The aim of this study is to reproduce the visual sensations experienced by patientsduring vitreous surgery.

METHOD A fluid-filled model eye with a translucent posterioreye wall and the frosted inner (retinal) surface was used. Theimages projected on the retinal surface could be observed fromthe backside of the model eye. On the retinal surface, a thinplastic sheet was attached to simulate an epiretinal membrane.The model eye was placed under a surgical microscope andsurgical procedure was simulated through three scleral ports likestandard pars plana vitrectomy. A flat contact lens was placedon the corneal surface of the model eye and the intraocularimages from the backside were recorded with a simultaneousobservation of the procedures through the surgical microscope.

RESULTS Analysis of the images from backside revealed thattriamcinolone crystals were observed as moving black particlesand intraocular instruments were observed as a black shaft.When the intraocular instruments were inserted from the port,the black shaft was observed to move from the periphery to thecenter of the visual field. When the epiretinal membrane waspeeled, the instruments was observed more focused and thecolor of the tip of the forceps was observed to be silver whenthe forceps was attached at the retinal surface of the model eye.

CONCLUSION Patients’ visual sensations may be precisely repro-duced with the model eye. Closer the instruments were locatedat the retinal surface, more focused objects were observed andthe colors of the instruments could be identified.

The image projected on the retinal surface of the model eye is captured from the backside of the model eye during an epiretinal membrane is peeled off.

358Vitreo-retinal Surgery in the Osteo-Odonto-Keratoprosthesis Patient:Indications and Techniques

Laurence Lim MBBS, FRCSEd (Singapore, Singapore), Edmund Wong MBBS, MMed, FRCS, Donald Tan*, Doric Wong

PURPOSE To describe the indications for vitreo-retinal (VR)surgery associated with OOKP implantation, and to discuss the surgical approaches with particular emphasis on achievingintra-operative visualization through opaque media.

METHOD This was a retrospective review of all patients who had undergone OOKP surgery performed from 2003 to 2010 atthe Singapore National Eye Centre. All study subjects wereidentified from the Singapore OOKP database, a prospectivedatabase tracking OOKP procedures performed at our centresince 2003. OOKP procedures were performed for severe ocularsurface disease according to the indications and techniquesdescribed in the Rome-Vienna Protocol. Patient demographics,indications for VR surgery, surgical outcomes, and intra-operative and post-operative complications were documented.Operative techniques were reviewed from the surgical records,and any subsequent surgeries were also recorded.

RESULTS 34 patients underwent OOKP, and VR surgery wasindicated in 10 (29.4%). The indications for and approaches to surgery were retinal detachment repair using an Eckardttemporary keratoprosthesis (TKP) in 4 cases, assessment ofretina and optic nerve health prior to OOKP surgery usingeither a TKP(2 cases) or endoscopically(1 case), endoscopiccyclophotocoagulation for intractable glaucoma(1 case), endo -scopic trimming of retro-prosthetic membrane(1 case), andvitrectomy for endophthalmitis with visualization through theOOKP optic using the binocular indirect viewing system in 1case. In all cases, VR surgical aims were achieved with a singleprocedure. Post-operative vitreous hemorrhage occurred in 16patients (47.1%) but all resolved spontaneously. SuccessfulOOKP implantation did not differ between eyes that did anddid not undergo VR surgery (81.8% vs. 90%; p=0.49), nor were there any differences in anatomical success with TKPutilization.(83.4% without vs. 87.5% with, p=0.63).

CONCLUSION OOKPs represent the last hope for restoration ofvision in severe ocular surface disease, and the VR surgeon isfrequently called upon in the assessment and management ofthese patients. TKP and endoscopic vitrectomy are valuablesurgical tools in these challenging cases, improving functionaloutcomes without compromising OOKP success.




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359Semiquantitative Assessment of the VisualAngle and Imaging Quality of a Grating Target in a Human Eye Model Viewed Through Wide-angle Viewing Systems

Yusuke Oshima, MD, PhD* (Suita, Japan), Jiro Hidaka, MD, Makoto Inoue, MD, Kohji Nishida, MD

PURPOSE To evaluate the field of view and the quality of theimage of a grating target placed in a model eye viewed throughwide-angle viewing systems.

METHOD An angle scale for evaluating the field of view and aUnited States Air Force resolution target was placed on theinner surface of a model eye with human corneal aberrations(Fig 1 and 2). The visual angles and contrasts of the gratingswere evaluated and compared to those obtained throughcontact (ClariVit®) or non-contact type (RESIGHT®, BIOM®,OFFISS®, or MERLIN®) wide-angle viewing systems withchanging intraocular parameters including the pupil size, lensstatus, and intraocular tamponades.

RESULTS The widest field of view was achieved through non-contact-type wide-angle viewing systems: 100 degrees in afluid-filled aphakic eye with the OFFISS and 125 degrees in anair-filled aphakic eye with the RESIGHT. The mean visualangle representing the field of view through panoramic viewingsystems is limited significantly (P=0.014) by the pupil size ineach system. Although the grating images located at theposterior pole were clear when observed through either thecontact type or non-contact type of wide-angle viewing system,those at the periphery were blurred and defocused with any ofthe non-contact type systems but less so with the contact-typesystem. The contrast decreased significantly (P<0.001) at lowfrequencies when viewed through the non-contact type systemin an air-filled pseudophakic eye.

CONCLUSION The non-contact type of panoramic viewingsystem achieves the widest field of view but blurs the quality ofthe grating images at the periphery. The contact type systemmay allow better visualization at the periphery by neutralizingoptical aberrations and corneal surface irregularities.

Cross-sectional schematic drawing of the model eye based on the Gullstrand model eye.

A, Superficial view of the model eye with a chandelier fiber passingthrough the insertion port for wide-angle endoillumination. B, Inner viewof the model eye through the wide-angle viewing system. The angle scale and United States Air Force grating target are glued to the posteriorsurface of the model eye from the central bottom to the periphery.

360Bevacizumab Followed by 23-gauge Transcleral Bimanual Vitrectomy for Retinal Detachment in a Case of Multiple Large Retinal AngiomasDaraius Shroff, MD, FRCS, (New Delhi, India) Charu Gupta, MD, A.K. Singh, MD, Neelam Atri, MD, Bhavana Sharma, MD, Cyrus M. Shroff, MD

PURPOSE To describe the outcome of intra vitreal bevacizumabfollowed by the surgical management of a case of total retinaldetachment with multiple large retinal angiomas with bimanual23 gauge vitrectomy.

METHOD Interventional case report. A 24-year-old manpresented with a sudden drop in vision. On fundus examinationhe had a total Retinal detachment with multiple large angiomasat the posterior pole, as well as in the periphery. Intravitrealbevacizumab 1.25mg was injected 4 days prior to surgery.Bimanual 23 gauge vitrectomy was performed with chandelierillumination. This facilitated membrane dissection around theangiomas with minimal trauma to the lesions. Intraoperativebleeding was minimal and was controlled by increasing infusion pressure. Intraoperative cryotherapy was done to theperipheral angiomas. The retina settled well, and silicon oil was injected.


RESULTS Bimanual surgery enabled atraumatic and morecomplete membrane dissection in this case of a complex retinaldetachment associated with multiple angiomas. There was nosignificant intra or post operative bleeding. The BCVA at 6weeks improved from 20/400 to 20/80 and the retina was well attached.

CONCLUSION Modified bimanual 23G transcleral vitrectomypreceded by intra vitreal bevacizumab enabled us to achieve agood anatomical and functional result in a total retinal detach -ment associated with multiple large angiomas.

Pre operative fundus photograph showing multiple large angiomas with total retinal detachment.

Post operative fundus photograph showing attached retina, laser and cryo reaction aroung the angiomas and silicon oil in situ.

361Sutureless Vitrectomy Incision Architecture in Vivo Using Fourier Domain OCTAnderson G. Teixeira Pinto, MD (Brasilia, Brazil), Flavio A. Rezende, MD, PhD,Camila Salaroli, Nonato Souza, Pinto Francisco, Norma Allemann

PURPOSE To investigate the in vivo incision architecture usingFourier Domain optical coherence tomography (FD-OCT) in23-gauge and 25-gauge sutureless vitrectomy.

METHOD A prospective observational study of 21 eyes of 20 patients that underwent 25-gauge (10 eyes) or 23-gauge (11 eyes) transconjunctival sutureless pars plana vitrectomy was performed. The three sclerotomies sites in each eye wereanalyzed by Corneal Adapter Model (CAM) RTVue FD-OCTwith wound cross-section images (longitudinal and transversal)on days one, seven, and 28 post-operatively. Wound length,thickness, and diameter were compared.

RESULTS All patients completed 4 weeks of follow-up and allsurgeries lasted less than 60 minutes. Three-port vitrectomyincisions were analyzed separate in length, thickness, diameterand angle for 25-gauge [e.g. infero-temporal mean incisionlength was 0.942 +0.126 (range, 0.775-1.137) with a meanthickness of 0.026 +0.06 mm (range, 0.019-0.038) and meanincision diameter was 0.228 +0.020 mm (range 0.197-0.261)]and 23-gauge [infero-temporal mean incision length was 1.218+0.168 (range, 1.026-1.540) with a mean thickness of 0.057+0.019 mm (range, 0.035-0.103) and mean incision diameterwas 0.361 +0.025 mm (range 0.337-0.417)]. The mean incisionangle was 31 degrees for 23-gauge and 22 degrees for 25-gauge.Wound thickness (P < 0.001), diameter (P < 0.001), and angle (p < 0.05) differences between 25-gauge and 23-gaugeincisions were found to be statistically significant. No statisticaldifference was found in incision length among differentquadrants or between 23- and 25-gauges.

CONCLUSION The 23-gauge and 25-gauge architectural woundconstruction was well visualized using FD-OCT. Statisticaldifferences between the two gauges were observed in thediameter and thickness throughout the study period.

Seven days post-operative.




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362Fibrovascular Ingrowth Post-Transconjunctival25-gauge Vitrectomy for Diabetic Vitreous Hemorrhage

Cynthia Xin-ya Qian, MD (Montreal, QC), Marie-Claude Robert, MD, Flavio Rezende, MD, PhD

PURPOSE To report 2 cases of fibrovascular ingrowth post-transconjunctival 25-ga PPV highlighting the surgical manage-ment with a modified transcleral 25-ga PPV.

METHOD Two patients with proliferative diabetic retinopathy inboth eyes were approached with transconjunctival 25-ga PPVfor dense vitreous hemorrhage (VH) and tractional retinaldetachment. After 10 months, both patients developedrecurrent VH. They were managed with in-office gas-fluidexchange and anti-vascular endothelium growth factor (VEGF)intra vitreal injection. Soon after gas bubble resorption, the VHrecurred. Close observation with color external photos detectedengorged episcleral vessels superotemporally and ultrasoundbiomicroscopy (UBM) confirmed the presence of fibrovascularingrowth (FVI) at the sclerotomy site in both patients. Theywere reoperated with a modified 25-ga PPV.

RESULTS The modified 25-ga PPV technique consisted ofconjunctival peritomy at the FVI site and where the pars planaincisions were to be made. Tenon’s capsule was removed,transcleral cryotherapy and external cautery were applied to the engorged episcleral vessels. The 25-ga cannulas were placedin bare sclera and extensive vitrectomy with vitreous baseshaving was carried out. After VH removal, additional pan -photocoagulation was done, endolaser was performed at the FVIregion, and the cases were completed followed by anti-VEGFintra vitreal injection. One year post-modified 25-ga PPV, bothpatients improved visual acuity and remained without VH.Post-operative UBM demonstrated complete FVI regressionwithout any residual traction at the site.

CONCLUSION Although FVI is a well recognized cause of VHrecurrences following conventional 20-ga vitrectomy, thepresent report seems to be the first to confirm FVI post-small-gauge vitrectomy. A modified 25-ga PPV technique seems to bea feasible alternative to treat FVI in these cases.

Trauma POSTERS 363-365

363Traumatic Ruptured Globes at a City Hospitalin Manhattan from 2006 to 2010Carolyn Page Graeber, MD (New York, NY), Jenna B. Friedenthal, MD, Susan Koreen Gelman, MD, MPH, Ilyse D. Haberman, MD, Shantan Reddy, MD, MPH

PURPOSE RGs secondary to trauma are the source of significantvisual morbidity and can ultimately lead to loss of the eye.What characteristics of RGs that present to a Level I traumacenter are correlated with better visual outcomes and withgreater change in pre- versus post-operative visual acuity?

METHOD The charts of consecutive RGs that were evaluated inthe Bellevue Hospital Emergency Room between April 2006and June 2010 were retrospectively reviewed with New YorkUniversity Internal Review Board approval. Pre-operative, post-operative and change in visual acuity (measured in LogMar)were compared with numerous factors to determine predictorsof better post-operative results.

RESULTS Of 41 RGs included, 74% were men, 49% were righteyes, 98% were traumatic, and 9.8% were enucleated oreviscerated. Removal of the eye was not significantly correlatedwith location of the rupture (p=0.171).

Visual acuity improved significantly after surgical repair (2.85 vs 2.13 LogMar, p=0.001). Patients with pre-operative vision ofcount fingers or better had better post-operative visual acuity(0.46 vs 2.65 LogMar, p<0.001) and had greater change in pre-versus post-operative visual acuity than those who had handmotion or worse (1.41 vs. 0.50 LogMar, p=0.035).

Mean follow-up was 4.0 months, with 11 patients (27%) beinglost to follow-up after 1 week. Patients who were lost to follow-up had worse best corrected post-operative visual acuity thanthose that were not (3.36 vs. 1.80 LogMar, p<0.001) and theirchange in pre- versus post-operative visual acuity trendedtoward less change than those who were not (p=0.067).

CONCLUSION Surgical repair of RGs at an urban trauma centerresulted in significant improvement in vision. Patients withbetter pre-operative vision had both a greater change in visionand a better overall visual outcome than those that had lowpre-operative vision. Patients with poor vision after repair wereless likely to follow-up and had less change in their pre- versuspost-operative vision.


364Early Limited Core Vitrectomy in Double Penetrating Globe InjuriesJulia Paula Shulman, MD (Salt Lake City, UT), Roger Harrie, MD, Mary Elizabeth Hartnett, MD

PURPOSE To present the visual and anatomic outcomes of threepatients with double penetrating or perforating injuries of theglobe with extensive corneal trauma that underwent earlylimited core vitrecomy without a keratoprosthesis to prevent a tractional detachment.

METHOD An IRB approved, retrospective chart review of 3patients from the Moran Eye Center, all of whom underwentcorneal laceration repair by an anterior segment surgeon andwere referred to the retina service for management of posteriorsegment pathology.

RESULTS Patients were 9 months, 3 years and 21 years old. Themechanism of injury in two of the patients was a knife injury tothe eye; the infant suffered trauma from a weed wacker cordhitting and perforating the globe. There was extensive anteriorsegment trauma in all three cases with corneal and lensinvolvement. Limited vitrectomies without removal of the corevitreous and posterior hyaloid were performed within 6 days ofthe initial ruptured globe repair. A keratoprosthesis was notdone in any case because of the concern of graft rejection,particularly in the infant and pediatric patients. One patientdeveloped retinal traction that was observed with serial ultra-sounds for 2 months, prior to repeat vitrectomy, endolaser andgas. All patients remain attached at postoperative follow-up of6 months.

CONCLUSION In this series, eyes maintained retinal attachmenteven though only limited vitrectomies were performed due topoor visualization of the posterior segment in the setting ofdouble penetrating globe injury. Further study is warranted toassess long-term outcomes with this approach that may providebetter corneal recovery particularly in pediatric patients.

365Posterior Segment Intraocular Foreign Bodies.Clinical and Epidemiological Features. 2007-2009

Luis M. Suarez Tata, MD (Miami, FL), Moravia Suarez-Tata, Reinaldo Garcia, Leonidas Rodriguez, Natassha Portillo, MD

PURPOSE To evaluate the epidemiologic factors, associatedocular involvement and visual results in patients withintraocular foreign bodies lodged in the posterior segment.

METHOD In this retrospective study, the clinical records of 28patients admitted Service Vitreous-Retina with intraocularforeign bodies between January 2007 and December 2009.Using the OTS classification for ocular injuries (United StatesEye Injury Registry). We evaluated the visual outcome andvarious pre-, intra- and postoperative clinical factors, Compli -cations and final visual acuity. Factors at presentation wereevaluated for prognostic value towards visual outcome. Statis-tical analysis was done using Univariate and Multivariateanalysis.

RESULTS All the patients were males, with a mean age of 28years (range: 5-56 yrs) and an average follow-up period of 25.02months. The foreign bodies were caused by accidents and workaccidents in 92.8% involved ferromagnet metal. All patientsunderwent vitrectomy to remove the intraocular foreign body.Final visual acuity was equal to or greater than 0.4 in 39,29% ofthe patients and there was no light perception in 10.71%. Theprincipal complications were vitreous haemorrhagies (64,29%)and endophthalmitis (28,57%) and the principal late compli -cations were local retinal detachment with PVR (17,86%),pthisis bulbi (10,71%).

CONCLUSION Most of the IOFB are found in young males as aconsequence of work accidents without protection. All requirevitrectomy to remove the foreign body and even though goodvisual results are obtained in many cases, other cases suffersevere visual loss. We concluded size of IOFB, endophthalmitis,are statistically significant factors affecting outcome in posteriorsegment intraocular foreign bodies.

TRAUMA



151

Retinal Vascular/Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Retinal Vascular Disease POSTERS 401-429

401Cystoid Macular Edema Associated with Paclitaxel Therapy for Breast Cancer: A Case Report and Review

Daniel Adelberg, MD (Mesa, AZ)

PURPOSE To determine the etiology and management of cystoid macular edema in patients being managed with breastcarcinoma.

METHOD Two female patients presented with bilateral cystoidmacular edema. Both patients were receiving paclitaxel andbevacizumab chemotherapy for breast carcinoma. Both patientswere phakic, had no prior intraocular surgery and other causesof cystoid macular edema were not identified. Managementincluded discontinuation of paclitaxel and alteration of theirchemotherapy by their oncologist, and topical nonsteroidalantiinflammatory therapy with bromfenac twice daily. Clinicalassessment included visual acuity, fundus examination, andspectral domain optical coherence tomography (OCT). A retrospective chart and medical literature review wasperformed.

RESULTS The patients were both female , with age of 49 and 74 years. Follow-up was 27 and 12 months , respectively. Visualacuity improved in one patient from 20/60 to 20/40 OD, andwas unchanged in left eye at 20/50. The second patient hadvisual acuity improved from 20/300 to 20/40 OD and 20/200 to20/60 OS. A decrease in central macular thickness (CMT) of159 microns and 156 microns in the right and left eye respec-tively in the first patient, with the second patient decreasing 3microns OD and 33 microns OS. Both patients had completeresolution of cystoid macular edema on spectral OCT. Onepatient underwent fluorescein angiography without evidence ofcystoid macular edema at last follow-up visit. A review of themedical literature revealed a prior publication of the associationof paclitaxel with cystoid macular edema.

CONCLUSION Cystoid macular edema is associated with pacli-taxel, and successful management included discontinuation ofpaclitaxel and concomitant therapy with bromfenac in twopatients. It is important to recognize this uncommon cause ofcystoid macular edema in patients with breast carcinoma so thatan accurate diagnosis can lead to improved vision in thesechallenging patients.

402Reversibility of Isotretinoin Retinal ToxicityThomas Federici, MD (Stony Brook, NY)

PURPOSE To describe a case of reversible retinal toxicitysecondary to isotretinoin use.

METHOD Retrospective case review. Data extracted from the chart included demographic information, medical andophthalmologic history, and clinical findings from slit-lampbiomicroscopy and dilated ophthalmoscopy.

RESULTS A 17-year-old white girl with facial acne developedprolonged retinal photostress recovery after 8 weeks ofisoretinoin use. Three weeks following discontinuing themedication, visual recovery following photostress improved tobaseline. Visual acuity measured 20/20 OU and color plateswere full OU (8/8). Slit-lamp bimicroscopy and dilatedophthalmoscopy were unrevealing. The patient declined anyfurther investigation.

CONCLUSION Prolonged retinal photostress recovery may anearly indicator of isotretinoin-associated retinal toxicity.Discontinuation of therapy at the advent of this symptom/signmay prevent permanent visual loss.

403Cystoid Macular Edema Secondary to Nab-Paclitaxel (Abraxane®) Therapy: Clinical Experience with BevacizumabHassan Rahman, MD (Atlanta, GA), Steven Yeh, MD, Chris Bergstrom, MD

PURPOSE CME is a rarely reported side effect of nanoparticlealbumin bound (nab)-paclitaxel therapy – an antimitotic agentused for breast cancer. We describe a patient with bilateralCME secondary to Abraxane that was minimally responsive to bevacizumab. This lack of efficacy and knowledge of themechanism of paclitaxel may provide insights into the mechanisms of CME without angiographic leakage.

METHOD Retrospective, interventional case report of a patientwith bilateral CME after starting Abraxane therapy forrecurrent breast cancer treated with intra vitreal bevacizumab(1.25mg/0.05mL) every 4 weeks. Records were reviewed forvisual acuity and macular edema as assessed by spectral-domainoptical coherence tomography (SD-OCT).

RESULTS A 73-year-old patient with recurrent, metastatic breast cancer presented with bilateral visual loss 3 months afternab-paclitaxel was initiated. Baseline VA was 20/100 OD and 20/200 OS. Fundus exam showed marked CME OU.Fluorescein angiography was notable for the marked absence ofpetalloid late phase leakage characteristic of vascular, ischemic,and inflammatory causes of CME. SD-OCT showed markedcystoid spaces predominantly involving the outer and innernuclear layers with central subfield thicknesses (CST) of 398


um OD and 441 um OS. Serial intra vitreal bevacizumab injec-tions (OD – 2 injections, OS – 3 injections) were administeredon a q 4 week basis with an improvement and stabilization ofVA at 20/50 OD and 20/70 OS. However, CME on SD-OCTpersisted with CST of 492 um OD and 478 um OS.

CONCLUSION The pathogenesis of CME without leakage ispoorly understood; however, fluid accumulation in Muller cellsdue to toxicity has been proposed. The persistence of CMEsuggests that additional non-VEGF-mediated mechanisms areinvolved. Improved understanding of the mechanisms under-lying paclitaxel-associated CME is needed, especially inpatients with limited systemic options for metastatic carcinoma.

Figure 1: Spectral domain OCT imaging shows significant CME on presen-tation for the right eye (A) and persistent CME despite 2 intravitrealbevacizumab injections (B). The left eye on presentation (C) shows relativelyunaffected CME despite 3 intravitreal bevacizumab injections (D).

Figure 2: Fluorescein angiography reveals normal vascular filling in the early frames (A) with only minimal leakage evident in the late frames (B). The right eye had similar findings.

404Early Experience with Rifampin for Treatmentof Central Serous Chorioretinopathy

Zac Ravage, MD (Chicago, IL), Kirk Packo, MD*

PURPOSE We have previously described a case of chronic CSCresponsive to rifampin. The effect was thought to occur viahepatic enzyme induction with a reduction in systemic cortisollevels. To further assess its efficacy, rifampin was offered as off-label therapy to patients with CSC. We describe the findingsfrom our early experience in these cases.

METHOD A retrospective interventional case series of 8 patientstreated with off-label rifampin for CSC was performed. 7patients were male, 1 female. Mean age was 53 years (45-71).

Eyes with acute (2) or chronic (6) CSC were included. Snellenvisual acuity, complete ophthalmic examination, fluoresceinangiography and optical coherence tomography were performedat baseline and throughout follow-up, as were liver functiontests. Patients were treated with rifampin 600 mg per day thenre-examined at approximately weeks 1, 8 and 12. The primaryendpoint was reduction in retinal pigment epithelial (RPE)leakage and sub-retinal fluid (SRF). The secondary endpointwas lines of vision gained.

RESULTS Mean follow-up was 13 weeks (5-24). 1 patient self-discontinued rifampin after 3 weeks of treatment. 1 patientdeveloped choroidal neovascularization after 8 weeks, wastreated with intra vitreal bevacizumab and excluded from furtheranalysis. 1 patient developed hepatitis after 24 weeks as a resultof concomitant alcohol consumption and withheld from furthertreatment. Other observed side effects included headache (1) and nausea (1). 4 of 8 patients experienced a reduction or resolution of SRF during treatment: 3 had chronic CSC(including 1 with leopard-spot pattern appearance), 1 had acuteCSC and experienced a more rapid improvement than would be expected from the natural course of the disease. 2 patientsshowed no effect of therapy and in 2 the effect was equivocal.Overall, central macular thickness decreased in 6 patients andremained stable in 2. Visual acuity remained unchanged in 5 patients and improved in 3.

CONCLUSION The results of this small case series suggest thatrifampin may potentially benefit some patients with CSC.Acute episodes appear to respond most favorably. Chronic SRFmay decrease gradually during treatment, while sub-RPE fluidoften persists. Vision typically remains stable or improves overthe course of therapy. A larger, controlled, prospective study of rifampin for CSC is warranted.

SD-OCT of the right eye of a patient with acute central serous chorioretinopathy on presentation.

The same eye after 1 week of treatment with rifampin. Significantly less sub-retinal fluid and fibrin were present.

RETINAL VASCULAR/IMAGING



153

405Retinal Bioavailability of a DHEA Synthetic Analogue in the Rat Retina after Parenteral Administration

Miltiadis Tsilimbaris, MD, PhD (Heraklion, Greece), Chrysanthi Tsika, MD, Pavlina Tsoka, MD, Manolis Tzatzarakis, MD, Ioannis Charalampopoulos, MD, Achilleas Gravanis, MD

PURPOSE To evaluate the retinal bioavailability of a syntheticDehydroepiandrosterone (DHEA) analogue, a molecule withpotential anti-apoptotic action, after systemic administration.

METHOD 8 Sprague Dawley rats were injected intraperitoneally with 10mg of the analogue in1 ml of an ethanol/Water For Injection(WFI) solution. The synthetic neurosteroid was injected in 2rats at each time point at the same concentration every time.The animals were euthanized at 15, 30, 60 and 120 min. Theeyes were enucleated and the retina was isolated from the eyecup with an eye sponge with suitable handling. After appropriatepreparation, the samples were measured with HPLC LC/MS.

RESULTS The recovery of the method was 82.9%. The Limit OfQuantification (LOQ) was 5ng/ml. The substance was detectedat 60 and 120 min in mean concentrations of 46.9 ng/ml and183.8 ng/ml respectively. At the time points 15 and 30 nosubstance was detected with this method. No substance wasdetected in the blind samples.

CONCLUSION The synthetic DHEA analogue was successfullydetected in the rat retina with an LC/MS HPLC method. Themolecule seems to reach the retina in approximately one hourafter systemic administration and is still detected there after twohours. Further investigation is obligatory for complete data ofthe pharmacokinetics of the substance in the rat retina.

406Intravitreal Triamcinolone Acetonide after Suboptimal Response to Multiple Intravitreal Bevacizumab Treatments inCentral Retinal Vein OcclusionRayan A. Alshareef, MD (Philadelphia, PA), Marc J. Spirn, MD, Jason Hsu, MD, Richard Kaiser, MD, Sunir J. Garg, MD*

PURPOSE To evaluate the effect of intra vitreal triamcinoloneacetonide (IVTA) for treating macular edema secondary tocentral retinal vein occlusion (CRVO) after suboptimal responseto multiple treatments with intra vitreal bevacizumab (IVB).

METHOD A retrospective chart review of 128 patients who hadIVB and IVTA for the treatment of CRVO was performed.Inclusion criteria included patients diagnosed with CRVO andwho had ≥2 IVB injections prior to IVTA. Outcomes includedchange in visual acuity, central foveal thickness on opticalcoherence tomography (OCT), number of injections and timebetween injections. Patients were excluded if they had received

any treatment other than IVB prior to IVTA, or if their lastfollow-up prior to IVTA was over 9 weeks.

RESULTS A total of 18 eyes of 18 patients with CRVO met theinclusion criteria. Average age of patients was 62.8 years. Themean number of IVB injections was 4.6 and mean time betweenIVB injections was 5.9 weeks. The average time intervalbetween IVB and IVTA was 5.2 weeks. The mean number ofIVTA injections was 1.8. The mean logMAR visual acuityimproved from 1.22 (~20/330) to 1.16 (~20/290, p<0.317)following treatment with IVTA. Macular thickness on OCTdecreased from a mean of 495 µm to 399 µm (p<0.05) followingtreatment with IVTA. No cases of endophthalmitis, retinaldetachment, or neovascularization were noted.

CONCLUSION Intravitreal triamcinolone acetonide appears to beeffective in additionally reducing macular edema secondary toCRVO in patients with a suboptimal response to multiple intra -vitreal bevacizumab injections; however this did not translateinto a significant improvement in vision.

407Intravitreal Ranibizumab after SuboptimalResponse to Multiple Intravitreal BevacizumabTreatments in Retinal Vein OcclusionsRayan A. Alshareef, MD (Philadephia, PA), Richard S. Kaiser, MD, Jason Hsu, MD, Marc J. Spirn, MD, Mitchell Fineman, MD, Sunir J. Garg, MD*

PURPOSE To evaluate the effect of intra vitreal ranibizumab(IVR) for treating macular edema secondary to retinal veinocclusion after suboptimal response to multiple treatments withintra vitreal bevacizumab (IVB).

METHOD A retrospective chart review of patients who had IVB and IVR injections for the treatment of macular edemasecondary to either central retinal vein occlusion (CRVO) orbranch retinal vein occlusion (BRVO). Inclusion criteriaincluded patients diagnosed with CRVO or BRVO and who hadbeen treated with at least 2 or more IVB injections prior toIVR. Outcomes included change in visual acuity, central fovealthickness on optical coherence tomography (OCT), number ofinjections and time between injections. Patients were excludedif they had received any treatment other than bevacizumabprior to ranibizumab, or if the last follow-up prior toranibizumab was over 9 weeks.

RESULTS AA total of 40 eyes with CRVO and 30 eyes withBRVO of 69 patients met the inclusion criteria. The meannumber of IVB injections was 6.2 (CRVO group) and 4.5(BRVO group). In the CRVO group, mean time between IVBinjections was 6.7 weeks and the mean time between IVB andIVR was 6.5 weeks, compared with 7.6 and 6.8 weeks, respec-tively, in the BRVO group. The mean number of IVR injectionswas 2.7 in the CRVO group and 2.6 in the BRVO group. In theCRVO group, mean logMAR visual acuity improved from 0.987(~20/200) to 0.904 (~20/160, p<0.025) following treatmentwith IVR and macular thickness on OCT decreased from amean of 400 µm to 270.4 µm following treatment with IVR


(p<0.001). In the BRVO group, mean logMAR visual acuityimproved from 0.734 (~20/110) to 0.650 (~20/90, p<0.324)following treatment with IVR and macular thickness on OCTdecreased from a mean of 377.3 µm to 297 µm followingtreatment with IVR (p<0.006).

CONCLUSION Intravitreal ranibizumab appears to be effective inadditionally reducing macular edema secondary to CRVO andBRVO in patients with a suboptimal response to multiplebevacizumab injections. In the subset of CRVO patients, intra -vitreal ranibizumab appeared to have a modest impact withregard to improving visual acuity.

408Combination Anti-VEGF and Sustained ReleaseSteroid for the Treatment of Macular EdemaSecondary to Retinal Vein Occlusions

Alan J. Franklin, MD (Mobile, AL), Magdalena Shuler, MD, John P. Myers, MD, Neel M. Kumar, Sunil Gupta

PURPOSE The purpose of this study is to analyze visual acuity,central OCT thickness, and treatment burden of intra vitrealanti-VEGF injections combined with sustained release intra -vitreal dexamethasone, Ozurdex.

METHOD This is a retrospective chart review of approximately 20patients who received intra vitreal anti-VEGF in combinationwith Ozurdex for the treatment of macular edema secondary toretinal vein occlusions. Both new onset vein occlusions andpatients chronic recalcitrant macular edema were studied. BothBRVO and CRVO patients were studied although a majority ofpatients analyzed suffered from CRVO. We measured Snellenvisual acuity, central macular thickness analyzed by time domainOCT, and treatment burden at 1, 3, 6, and 12 months afterinitial combination treatment. Data analysis was masked so thatthe investigators were unaware of patient identities.

RESULTS Initial visual acuity was Logmar 0.97, 20/188. Combi-nation anti-VEGF and Ozurdex improved visual acuity at 1, 3 month, Logmar 0.85 and 0.79, respectively, post-treatment.At 6 months post-treatment the average vision gain was lost sothat Logmar vision fell to 1.08. Most patients required retreat -ment 4-6 months after the initial Ozurdex administration.Central OCT thickness was dramatically reduced at 1 month,average 266 micron reduction, 3 months 246 micron reduction.At 6 month a persistent central OCT reduction of 107 micronswas still observed. The average treatment burden was 3 injec-tions, that included Ozurdex administration, over 6 months.

CONCLUSION Combination intra vitreal anti-VEGF and Ozudexled to a dramatic reduction of central OCT thickness andoverall visual improvement at 1 and 3 months post-treatment.These effects waned at 6 months post-treatment so that mostpatients required retreatment between 4 and 6 months. Onaverage, 3 intra vitreal administrations that included Ozurdexwere performed over the initial 6 month follow-up.

Visual Acuity and Central OCT thickness results following anti-VEGF and Ozurdex® combination treatment for macular edema secondary to retinal vein occlusions. Combination therapy caused a dramaticreduction of central macular thickness by OCT analysis and and averageimprovement in vision at 1 and 3 months post-treatment. Both of these positive effects were significantly attenuated at 6 months.

409Peripheral Polypoidal Choroidal Vasculopathy: A Report of 10 Eyes

Darin R. Goldman, MD (Los Angeles, CA), K. Bailey Freund, MD*, Colin A. McCannel, MD*, David Sarraf, MD*

PURPOSE Polypoidal choroidal vasculopathy (PCV) is charac-terized by polyp-like vascular abnormalities predominantlyfound in the macula and peri-papillary regions. More uncom-monly, polypoidal lesions can be found peripherally. We soughtto further describe the clinical spectrum of this peripheralvariation of PCV.

METHOD A retrospective chart review of 8 unique patients (10eyes) diagnosed with peripheral PCV was conducted. Each casewas diagnostically confirmed with indocyanine green angiographyand/or fluorescein angiography and optical coherence tomography.The clinical presentation, natural history, and clinical outcomewith and without interventional management were studied.

RESULTS Patients with peripheral PCV were more likely to bemale, Caucasian, asymptomatic, and to have the concomitantdiagnosis of age-related macular degeneration. The mean agewas 70 years (range, 59-82 years) with a mean follow-up of 32.5 months (range, 4-91 months). Four patients had unilateralinvolvement with minimal subretinal hemorrhage that resolvedspontaneously, one patient had unilateral involvement outsidethe macula that responded to anti-VEGF therapy, one patienthad unilateral involvement with subretinal hemorrhage threat-ening the macula that responded to anti-VEGF therapy, andtwo patients had extensive subretinal hemorrhage bilaterallyrequiring surgical intervention. All patients with multiplelesions in an eye also had bilateral lesions (2 of 8 patients).Lesions were most commonly located in the temporal periphery (8 of 10 eyes).

CONCLUSION We describe the largest case series to date ofperipheral PCV, which represents a unique form of type I neo -vascularization of the retina. While most eyes with peripheralPCV experience a benign course and resolve spontaneouslywithout sequelae, a subset of eyes can experience macula-threatening hemorrhage and require therapy with laser,anti-VEGF injections, or surgical intervention.




155

Right eye (A) Color fundus photograph shows dry AMD in the macula. Superonasal to the optic disk there is an area of subretinal and sub-RPEhemorrhage. (B) ICG angiography shows areas of blockage from hemorrhageand two nodular polypoidal lesions that hyperfluoresce. (C) OCT scanningthrough the polypoidal lesions shows their location in the sub-retinal pigment epithelial space.

Right Eye (A) Color fundus photograph, FA, and ICGA showing multiple areas of subretinal and sub-RPE hemorrhage at presentation. (B) Montage colorfundus photograph. (C) Enlargement of previous hemorrhages encroachinginto the macula three months later. (D) The areas of subretinal and sub-RPE hemorrhage have mostly resolved six months after treatment with intravitreal bevacizumab.

410Dexamethasone Intravitreal Implant RapidlyImproves Best-Corrected Visual Acuity inPatients with Retinal Vein Occlusion

Julia A. Haller, MD* (Philadelphia, PA), Francesco Bandello*, Anat Loewenstein, MD*, Baruch D. Kuppermann, MD, PhD*, Jenny Jiao*, Xiao-Yan Li, MD*, Scott Whitcup, MD*

PURPOSE This study evaluated the safety and efficacy of dexamethasone intra vitreal (DEX) implant (Ozurdex) 0.7 mgcompared with sham procedure in patients with vision loss dueto macular edema (ME) following branch or central retinal veinocclusion (BRVO; CRVO). We now present efficacy outcomesafter 7 days of treatment.

METHOD Two identical 6-month, randomized, prospective,multicenter, masked, parallel-group, clinical trials recruitedpatients aged ≥18 years with ME involving the fovea due toBRVO or CRVO, best-corrected visual acuity (BCVA) between34 letters (20/200) and 68 letters (20/50), and retinal thickness≥300 µm. Patients received either DEX implant 0.7 mg or shamprocedure. The primary outcome was time to ≥15-letter BCVAimprovement from baseline. Secondary outcomes included meanchange from baseline BCVA and proportion of eyes achievingimprovement of ≥10 or 15 letters from baseline BCVA.

RESULTS 427 patients (68% BRVO; 32% CRVO) received DEXimplant and 426 (66% BRVO; 34% CRVO) received shamprocedure. Baseline mean BCVA was 54.3 letters (20/80) and

54.8 letters (20/80) in the DEX implant and sham arms, respec-tively. At day 7, mean improvement in BCVA was 5.3 lettersand 1.6 letters in the DEX implant and sham arms, respectively(P≤.001). For BRVO patients, mean improvement in BCVAwas 5.1 letters and 2.3 letters in the DEX implant and shamarms (P≤.001), respectively, and, for CRVO patients, 5.8 lettersand 0.08 letters in the DEX implant and sham arms (P≤.001),respectively. The proportion of eyes achieving improvement inBCVA of ≥10 letters from baseline at day 7 in the DEX implantand sham procedure arms were 27% and 11%, respectively(P≤.001). The proportion achieving ≥15-letter BCVAimprovement was 10% and 5% in the DEX implant and shamarms (P=.025) in BRVO patients and 11% and 2% (P=.002) inCRVO patients, respectively.

CONCLUSION Significant improvements in BCVA were noted as early as 7 days after treatment with DEX implant in patientswith RVO. More than one-quarter of patients achieved improve -ments of ≥10 letters within 1 week of treatment. These resultssuggest that corticosteroids used to treat ME in patients withRVO provide rapid relief of symptoms of vision loss.

411Ranibizumab for Cystic Macular EdemaSecondary to Adult Onset Coats’ Disease – 12 Months Results of a Prospective Study

Irene A. Barbazetto, MD (New York, NY), James M. Klancnik, MD, Michael J. Cooney, MD, Lawrence A. Yannuzzi, MD

PURPOSE To investigate the safety and efficacy of intra vitrealranibizumab injections for cystic macular edema secondary toadult onset Coats’ disease.

METHOD Five patients (4 male, 1 female; age 26 to 54 years/mean: 44 years) were enrolled in a prospective, non-randomized,interventional case study. All patients received 3 initial doses of ranibizumab with monthly PRN treatment thereafter.Monthly follow-up examinations included clinical exami-nation, best corrected visual acuity (VA), and opticalcoherence tomography (OCT).

RESULTS Patients received an average of 8 injections (3-12)over 12 months. Mean visual acuity was 0.49 (LogMar) atbaseline, 0.41 at 1 week, 0.42 at 1 month and 0.45 at 12 months.Central macular thickness (CMT) measured 390, 265, 350 and408 µm respectively. Treatment was well tolerated with adverseevents limited to surface irritations following injections.

CONCLUSION Mono-therapy with ranibizumab may not allow for long-term control of CME in adult onset Coats’ disease.Although improvements in VA and CMT were seen after oneweek in some cases, these results were not sustained over 1 and 12 months.


412Visual Acuity Outcomes with IntravitrealBevacizumab for the Treatment of MacularEdema Secondary to Vein OcclusionJohn Mose Roberts, MD (Brookfield, IL), Jonathan Crews, Omar Al-Heeti, MD, Jeff Wongskhaluang, MD, Richard M. Ahuja, MD

PURPOSE To assess the visual outcomes in patients with macularedema secondary to retinal vein occlusion treated with primaryintra vitreal bevacizumab.

METHOD This is a retrospective interventional case series ofpatients with macular edema secondary to retinal veinocclusion who presented at (Stroger) Cook County Hospitalfrom September 2009 to March 2011. Patients with previoustreatment for macular edema were excluded. All patients had a complete ophthalmic exam and fluorescein angiography.Central macular thickness (CMT) was measured by StratusOptical Coherence Tomography (OCT). Patients with a visualacuity of <20/40 Snellen received intra vitreal injections ofbevacizumab 0.05ml (1.25 mg per 0.05 ml). Patients were re-treated every 2 months with intra vitreal bevacizumab if macularedema was present on OCT with a CMT > 250um.

RESULTS 15 eyes of 14 patients were included. The number ofinjections ranged from 1 to 6 (mean 3.3 injections). Visionimproved in 12 eyes, remained unchanged in one eye anddecreased in 2 eyes. Baseline visual acuity ranged from handmovements to 20/50, and endpoint visual acuity ranged fromcounting fingers at 3 feet to 20/40 over an average of 8.2months (range 3 to 20 months). No adverse events were notedduring the study period.

CONCLUSION Intravitreal bevacizumab appears to be an effica-cious treatment for macular edema secondary to retinal veinocclusion. However, multiple injections may be required. Thisshort-term study cannot determine the need for re-treatments.Additional studies are needed to determine long-term safetyand efficacy.

413Ultra-wide Angle Fluorescein AngiographyRevealed Peripheral Retinal Ischemia Correlates with Retinal Thinning in Asymptomatic Sickle Cell PatientsVijay Khetpal, MD (Jacksonville, FL), Ravi Radhakrishnan, MD, K.V. Chalam, MD, PhD, MBA, FRCS(C)

PURPOSE Proliferative sickle cell retinopathy developssecondary to sickling of the red blood cells (RBCs) and leads tocapillary occlusion and consecutive non perfusion and neovas-cularization. Vasoocclusion of the central retinal artery and itstributaries after sickling episodes compromise vasculature of theinner retinal circulation and lead to ischemia and loss of innerretinal layers.

METHOD A retrospective, case review was performed on fourpatients with sickle cell disease that were referred for preventiveretinal screening. SD-OCT revealed marked retinal thinning.A full ophthalmic examination including best corrected visualacuity, tonometry, slit lamp examination and dilated fundusexamination was performed. SD- OCT Wide field angiographyusing a Staurenghi 230 SLO Retinal Lens and SD-OCT usingthe Heidelberg Spectralis was obtained on each patient.

RESULTS Temporal thinning measured 133 microns compared to320 in normal subjects (P value <0.01). All patients exhibitedmarked temporal retinal capillary nonperfusion. (Figs 1) Noneof them were clinically symptomatic. Ages ranged from 16- 44.All were males, wide field angiography demonstrated peripheralcapillary dropout with early neovascularization and temporalthinning on SD-OCT. A wide-field angiography revealedbilateral peripheral retinal ischemia and neovascularization thatcorrelated with temporal retinal thinning (noted on SD-OCT).

CONCLUSION Temporal retinal thinning in asymptomatic sicklecell patients is a useful clinical sign in predicting peripheralischemia. Wide field angiography is a useful additional adjunctin delineating and quantifying the degree of peripheral ischemiaand guide the treatment including panretinal retinal photo -coagulation in proliferative sickle cell retinopathy.

Late wide field fluorescein angiography of right and left eye indicating temporal peripheral ischemia in both eyes.

414Serial SD-OCT Following Treatment of Retinal Vein Occlusion with DexamethasoneIntravitreal ImplantBryan M. Kim, MD (Chicago, IL), Jonathan Jonisch, MD, Kevin Blinder, MD*, Gaurav K. Shah, MD*

PURPOSE To describe the changes in vision and opticalcoherence tomography (OCT) measurements in the immediateweeks following treatment of retinal vein occlusion (RVO) withdexamethasone intra vitreal implant (DEX; Ozurdex); as well asobserved duration of effect and timing for retreatment.

METHOD Prospective study. Patients with macular edema (ME)due to BRVO (n=12 injections) or CRVO (n=9 injections)were treated with DEX implant. Following treatment, ETDRSvision and spectral domain OCT measurements were taken atweeks 1, 2, 3, 4, 6, 8, 10, 12, 16, 20, and 24. Patients wereretreated with repeat injection prior to week 24 if there was lossof efficacy, defined as 30% or greater increase in central OCT




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thickness from peak, or loss of 10 or more letters. Two-sampleT-tests were used to compare outcomes between the BRVO andCRVO patient groups.

RESULTS Mean baseline acuity was 45.1±18.3 letters (BRVO)and 49.7±20.3 letters (CRVO). Mean baseline central retinal thickness (CRT) was 645.0±136.2 µm (BRVO) and777.8±311.9 µm (CRVO). 40% of BRVO patients had previous focal laser, and all patients had been treated withintra vitreal bevacizumab. CRT significantly decreased at week 1(484.4±308.1 µm, p=0.02). Time to peak visual improvementamong all patients was 7.90±3.64 weeks, and time to peak OCTresponse was 7.30±3.25 weeks. Neither significantly differedbetween BRVO vs. CRVO (p=0.36 and p=0.06). Retreatmentwith DEX was required in 70% of patients, and ME recurred at11.2±3.43 weeks in BRVO. In CRVO, retreatment was requiredin 80% of patients, and ME recurred at 13.4±2.51 weeks. Therewas no significant difference in duration of effect of DEX inBRVO vs. CRVO (p=0.08). 2 patients with BRVO and 1patient with CRVO had IOP≥30 mmHG; all 3 patients had pre-existing glaucoma and were controlled by topical medications.

CONCLUSION This study provides OCT data not available in the original Ozurdex vein occlusion study. OCT thicknessdecreased 1 week post-treatment in both groups. Visual andOCT responses peaked at 8 weeks. ME returned approximately12 weeks post-treatment. Augmenting DEX with comple-mentary or repeat treatments at or before 12 weeks may helpsustain its effect, especially in previously treated eyes.

BRVO OCT central retinal thickness and ETDRS vision letter score by week

CRVO OCT central retinal thickness and ETDRS vision letter score by week

415Intravitreal Ranibizumab Therapy forPersistent Cystoid Macular Edema Secondaryto Retinal Vein Occlusions Following Standard Bevacizumab Therapy

Veronica A. Kon-Jara, MD (New Haven, CT), Nauman A. Chaudhry, MD, Travis A. Meredith, MD, Maurice B. Landers, MD, Odette M. Houghton, MD

PURPOSE Intravitreal bevacizumab is an important therapeuticmodality for the treatment of cystoid macular edema (CME)from retinal vein occlusions (RVO). Some of these eyes onlyshow a partial response despite continuous bevacizumabtherapy. We describe the visual and anatomic response of intra vitreal ranibizumab for persistent CME after suboptimalresponse to intra vitreal bevacizumab therapy.

METHOD Retrospective chart review. Patients with diagnosis of RVO who had a complete ophthalmological examination,fundus photography, SD optical coherence tomography (OCT)and fluorescein angiography (FA) were selected. 12 patientswith significant residual macular edema after consecutive treat-ments with bevacizumab met the inclusion criteria. Intravitrealinjections of 0.5 mg of ranibizumab were performed monthly ina standard sterile fashion.

RESULTS Eight patients with central retinal vein occlusion(CRVO) and 4 patients with branch retinal vein occlusion(BRVO) were identified. All patients had received an averageof 7.66 intra vitreal injections of 1.25 mg bevacizumab, had amean central macular thickness (CMT) of 675.43 microns, and a mean visual acuity (VA) of 20/200. After a mean of 1.6injections of ranibizumab 0.5 mg, the mean CMT decreased to292.8 microns and the VA improved to 20/70. Further follow-up will be provided.

CONCLUSION Intravitreal ranibizumab may be an effective rescuetherapy in cases of CME secondary to RVO with suboptimal orpartial response to intra vitreal bevacizumab. This appears to bemore common in eyes with CRVO. A prospective clinical trialwith larger sample size is needed to answer this importantclinical question.



Patient with Central Retinal Vein Occlusion: Initial macular edema of 1008 microns. After 3 consecutive injections of 1.25 mg intravitrealbevacizumab: Persistence of macular edema (815 microns).

One month later, response to intravitreal ranibizumab (429 microns).

416High Dose Ranibizumab for the Treatment of Idiopathic Parafoveal Telangiectasia [HD-LIPT] Trial: An Interim Analysis

Arthur Korotkin, MD* (Fort Collins, CO), Kent R. Crews, MD

PURPOSE Does treatment of patients with non-proliferativeIdiopatic Parafoveal Telangiectasia with ranibizumab 2.0mgimprove vision or reduce retinal thickness as measured byspectral-domain OCT?

METHOD Open label, prospective, randomized pilot studyinvolving six patients with three patients randomized totreatment and three to observation.

RESULTS An interim analysis will be presented of six patients (3 treated and 3 control) with ETDRS visual acuity andspectral domain central subfield thickness data.

CONCLUSION To be determined in assessing safety and efficacy of high dose ranibizumab 2.0mg in Idiopathic ParafovealTelangiectasia.

417Intravitreal Bevacizumab for Macular EdemaAssociated with Macular Telangiectasia

Nikolas London, MD (Philadelphia, PA), Mitchell S. Fineman, MD, Richard S. Kaiser, MD, Marc J. Spirn, MD

PURPOSE Does anti-VEGF therapy benefit patients withmacular edema associated with parafoveal telangiectasis?

METHOD We performed a retrospective review of patients withPFT who were treated with intra vitreal bevacizumab (IVB) atthe Retina Service of the Wills Eye Institute. LogMAR best-corrected visual acuity was recorded for all follow-up visits.Optical coherence tomography (OCT) obtained at baseline was compared to scans obtained at follow-up visits.

RESULTS Twenty-three eyes of 21 patients were identified, withan mean age of 61 years, and 8 of the 21 patients were women.Follow-up ranged from 1 to 36 months (average 12.8 months)and the mean number of injections was 2.6. The mean baselinevisual acuity (VA) was 20/80, 20/60 at month 1, 20/60 atmonth 6, 20/50 at month 12, and 20/100 at month 24. Overall,11/23 eyes showed any improvement in VA after the initialinjection. Five of the 11 eyes with any improvement in VA hadat least a doubling of the visual angle, and a single patientimproved from 20/400 to 20/50 after one injection. OCT datawere available for 15 eyes at both baseline and 1-month follow-up. In these eyes, the average OCT central retinal thicknesschanged from 249µm at baseline to 235µm at 1-month follow-up. OCT data were available for 5 of the 11 eyes that showedan apparent improvement in VA. In these eyes the averagebaseline thickness improved from 267µm to 229µm after asingle injection.

CONCLUSION Bevacizumab for macular edema associated withnonproliferative PFT appears to have a variable effect on VA,and no clear effect on retinal thickness. Future directions willinclude evaluation of angiographic and OCT changes, withparticular attention to differences between IVB-responders andnon-responders. Our hope is to identify PFT patients who maybenefit from anti-VEGF therapy.




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418Pars Plana Vitrectomy with Multiple Transvenous Chorioretinotomies for MacularEdema Complicating Retinal Vein Occlusion

Jeffrey K. Luttrull, MD (Ventura, CA), Charles Spink, MA, CRA

PURPOSE To review the results of pars plana vitrectomy withmultiple transvenous chorioretinotomies (MTC) to createchorioretinal anastomoses (CRA) for treatment of macularedema due to central and branch retinal vein occlusions.

METHOD A retrospective review of all patients undergoing MTC for branch (BRVO) and central retinal vein occlusions(CRVO) was performed. All eyes underwent a standardprocedure: Following vitrectomy, a branch retinal vein in thedistribution of the obstruction was identified and a site for TVCwas chosen and marked with a ring of endophotocoagulation.The intraocular pressure was elevated and the retinal veincompletely transected at each marked site with a 20g MVRblade penetrated through the retinal vein and underlyingchoroid into the sclera. Air-fluid exchange was performedfollowed by overnight prone positioning.

RESULTS 16 eyes of 16 patients operated between August 2008and January 2011 including 3 BRVO and 13 CRVO (5 ischemic)were included. MTC was performed 1–31 months (avg. 12)after diagnosis. Postop follow-up ranged 3–31 months (avg. 17).At least one CA was created in each eye. Intravitreal druginjections (bevacizumab and/or steroid) decreased post -operatively (P=0.0007). 7 eyes required no further injectionspostoperatively, 3 eyes only one. VA improved 3 or more linesin 7 eyes (3–10 lines); was unchanged in 6; and worsened in 3 (3 to 4 lines) (P=0.012). Central foveal thickness decreasedan average 254 um (P=0.003). Postoperative complicationsincluded one epiretinal membrane and one vitreous hemor-rhage requiring surgery.

CONCLUSION Vitrectomy with multiple transvenous chorio -retinotomies to create chorioretinal venous anastomoses may beuseful in the management of retinal vein occlusions, reducingmacular edema, improving visual acuity, and reducing or elimi-nating the need for long-term medical therapy.

Pt A: Fundus fluorescein (left) and indocyanine green (right) angiograms25 months postoperatively demonstrating resolution of a CRVO bymultiple surgical chorioretinal anastomoses. Duration of disease preoper-atively 22 months. Preop CFT 1046um; final postop CFT 147um. Preopinjections 15/22 months; postop injections 0/25 months. VA preop CF;final postop VA 20/30.

Pt. B: Pre- (top) and postoperative (bottom) SD-OCT 6 weeks followingvitrectomy with multiple transvenous chorio retinotomies for a central retinal vein occlusion 30 months in duration preoperatively.

419Bevacizumab for Choroidal NeovascularMembrane (CNVM) Secondary to Idiopathic Macular Telangiectasia (IMT)Naveenam Srinivasa Muralidhar, MD (Bangalore, India), Hemanth Murthy, MD, Kavitha S. Rao, MD, Manoj Gautam, MD

PURPOSE Bevacizumab has been used to treat CNVM due to avariety of etiologies. We wanted to analyze the efficacy of intra -vitreal bevacizumab in the treatment of CNVM due to IMT.We report the clinical, visual and OCT outcome of eyes withCNVM due to IMT treated by intra vitreal Bevacizumab.

METHOD Retrospective analysis of all patients of CNVM due to IMT were analyzed. Patients who had received any othertreatment like photodynamic therapy, transpupilary thermo -therapy were excluded. The diagnosis was established byFluorescein angiography (FFA) and Optical Coherence photography (OCT). 1.25 mg of Bevacizumab was injectedintravitreally under topical anesthesia with strict asepticprecautions. Vision and OCT were repeated at every visit.Decision to repeat the injection was based on OCT scanfindings suggestive of incomplete resolution or recurrence on follow-up visits. ‘prn’ dosing was used in most cases and‘loading dose’ concept was not followed.


RESULTS 10 eyes of 8 patients fulfilled all the criteria and wereavailable for analysis. Three were males and 5 were females.Two patients received injections in both the eyes, but atdifferent times as the involvement was at different times. Meanage was 46.5 years (range 45 to 62 years). follow-up ranged from4 months to 44 months, mean being 19.1 months. Six patientswere diabetic and 3 were hypertensive. Vision improved in 9out of 12 eyes (75 %), remained stable in 3 eyes (25 %). Visionimproved by 2 lines or more (Snellen Chart) in 5 eyes (50 %).OCT showed regression in all the eyes at last follow-up. Meannumber of injection was 2 (range 1-3).

CONCLUSION Intravitreal Bevacizumab is highly efficacious intreatment of CNVM secondary to IMT. Long term stabilityseems to be achieved by relatively less number on injectionscompared to CNVM due to age related macular degeneration.

420Efficacy of Anti-VEGF Therapy in Subretinal Neovascularisation Secondary to Macular Telangiectasia Type 2

Raja Narayanan MBBS (Hyderabad, India), Manish Sinha, MD, Vivek Dave, MD, Jay Chhablani, MD, Baruch D. Kuppermann, MD, PhD*

PURPOSE To evaluate the efficacy of intra vitreal anti-vascularendothelial growth factor (VEGF) in the treatment ofsubretinal neovascularisation (SRNVM) secondary to maculartelangiectasia (mactel) type 2.

METHOD A retrospective chart review of consecutive patientswith mactel and SRNVM who were examined between January2007 and January 2010 was performed. Patients with diabeticretinopathy, age-related macular degeneration or any othermacular pathology were excluded. The mean change in bestcorrected visual acuity at the final visit was the primaryoutcome measure. The mean number of intra vitreal injections,retinal thickness on optical coherence tomography andintraocular pressure were the secondary outcomes.

RESULTS A total of 14 eyes of 14 patients were included in the study. The mean age of the patients was 53.64 years (range44-65). There were 8 females and 6 males. Five patients had ahistory of diabetes mellitus. Six patients received ranibizumaband 8 patients received bevacizumab. Two patients receivedadditional verteporfin photodynamic therapy (PDT). The averagefollow-up duration was 13.1 months (range 3-42 months). Themean baseline decimal visual acuity was 0.14 ± 0.15 (Snellenequivalent 20/150) and the mean final visual acuity was 0.27 ±0.17 (Snellen equivalent 20/70) and this difference was statisti-cally significant (p=0.013). The mean number of intra vitrealinjections was 1.8 and there were no significant complications

CONCLUSION Intravitreal anti-VEGF therapy appears to beeffective and safe in SRNVM secondary to mactel.

421Progression of Ischaemic MaculopathyFollowing Multiple Intravitreal Bevacizumab for Recurrent Macular Edema from Central Retinal Vein Occlusion

Ogugua Ndubuisi Okonkwo, MD, FRCS (Edin) (Lagos, Nigeria), Kunle O. Hassan, Olufemi O. Oderinlo

PURPOSE Intravitreal Anti-VEGF have been used for thetreatment of macular oedema secondary to retinal veinocclussion with good results. Often multiple treatment isrequired, especially for recurrent or chronic oedema. In thesituation of macular oedema and significant macular ischaemiaare multiple injections of Anti VEGF safe?

METHOD A single case report of a 74 year old hypertensive male,bilateral psedophake. Suffered ischaemic central retinal veinocclussion of the left eye and developed macular oedema withreduction of vision to counting fingers. Fundus flouresceinangiography revealed areas of perifoveal capillary loss and anirregular FAZ. Responded favourably to initial 3 doses of intra -vitreal bevacizumab 1.25mg injection with resolution ofmacular oedema on OCT and improved visual acuity to 6/36.Macular edema recurred with CRT (Central Retinal Thickness)on OCT increasing from 269 to 596. Decision was taken tohave a second regimen of monthly injections of 1.25mgbevacizumab for 3 months.

RESULTS Three monthly injections of intra vitreal bevacizumab1.25mg were again given. Vision stabilized at 6/36 during thisperiod until a day after the third injection. He was noted tohave a drastic drop in visual acuity on the first day post the lastdose of injection to Hand Motion only. Despite dissappearanceof macular oedema, proven by OCT, vision remained poor.Flourescein angiography revealed progression of fovealischaemia. This was attributed to the intra vitreal bevacizumabinjection and probably may not have occurred if the last dose ofintra vitreal bevacizumab was not given. There may thereforehave been a cumulative damaging effect of the multiple doses of bevacizumab causing a progression of macular ischamia.

CONCLUSION Multiple intra vitreal bevacuzimab, should probablybe used with caution in patients with vein occlussion andmacular ischaemia. Mechanisms induced by this intra vitrealinjection can result in worsening of ischaemia, progression tothe macular and irreversible loss of vision. Further studies tobetter characterize the risk factors for this subset of patients andmodify treatment is required.




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422VOILA: Branch Vein Occlusion Treated with Intravitreal Bevacizumab and Focal Laser PhotocoagulationAnu Singla Patel, MD (Royal Oak, MI), Susan M. Malinowski, MD

PURPOSE To describe the efficacy of intra vitreal bevacizumabfollowed by focal laser photocoagulation for the treatment ofcystoid macular edema (CME) in branch retinal vein occlusionbased on visual acuity and mean OCT thickness.

METHOD A retrospective chart review was performed on patientsdiagnosed with macular edema from branch retinal veinocclusion. Patients included in the study received intra vitrealbevacizumab until resolution of edema and hemorrhage allowedfor focal laser photocoagulation. Each patient underwentfluorescein angiography and OCT at initial examination andOCT at each subsequent visit. Major outcome measuresincluded visual acuity (VA) and mean OCT thickness. Patientswho received any other treatment prior to focal laser photo -coagulation were excluded.

RESULTS 16 patients with macular edema secondary to branchretinal vein occlusion from 2006 to the present were examined.The average length of follow-up was 24.5 months (range 9-49months). Pretreatment VA ranged from 20/30 to countingfingers (average 20/80) and mean OCT thickness was 356.6.Patients were re-evaluated 2-6 weeks after initial intra vitrealbevacizumab. There was a significant improvement in VA(improvement to 20/40, p=.0073) and mean OCT thickness(258.7, p=<.0001). 8 patients experienced recurrence of CMEafter the initial treatment cycle (range 6 weeks to 36 months)and were re-treated as necessary. At final follow-up, visualacuity ranged from 20/20 to counting fingers, average 20/30(p=.05) and mean OCT thickness was 266.4 (p=.0002).

CONCLUSION Initial treatment of CME with intra vitrealbevacizumab followed by focal laser photocoagulation cansignificantly improve VA and decrease CME. The combinationof initial improvement in VA and long term efficacy of focallaser photocoagulation make this sequence of treatment avaluable, cost effective, initial treatment algorithm. Aprospective trial to clarify these findings is warranted.

423Reduced Central Retinal Thickness withDexamethasone Intravitreal Implant in Patients With Macular Edema Due to Retinal Vein Occlusion

Srinivas Reddy Sadda, MD* (Los Angeles, CA), Ronald P. Danis, MD, Jenny Jiao*, Xiao-Yan Li, MD*, Scott Whitcup, MD*

PURPOSE This study evaluated the efficacy and safety of intra -vitreal implanted sustained-released dexamethasone (DEX;Ozurdex) 0.7 mg compared with sham procedure in patientswith macular edema (ME) resulting from branch or centralretinal vein occlusion (BRVO; CRVO). Changes in centralretinal thickness (CRT) and visual acuity were determined 90and 180 days after insertion of the implant.

METHOD Adults with ME involving the fovea due to RVO, abest-corrected visual acuity (BCVA) of 34 letters (20/200) to 68letters (20/50), and retinal thickness ≥300 µm were randomized tointra vitreal DEX implant (n=427) or sham procedure (n=426).CRT was measured by optical coherence tomography (OCT) at baseline and months 3, 6, 9, and 12. At day 180, eligiblepatients (BCVA <84 letters or CRT >250 µm) received DEXimplant and were followed in an open-label, 6-month, exten -sion study. Correlation between changes in CRT and changesin BCVA during the initial phase and the extension phase weredetermined using the Pearson correlation coefficient.

RESULTS Ninety days after insertion of DEX implant 0.7 mg,CRT was reduced by a mean of 208 µm vs 85 µm in the shamgroup (P<.001). The percentage of patients with CRT <250 µmwas 36% in the DEX implant group, and 16% in the shamgroup (P<.001). The decrease in baseline CRT was correlatedwith an improvement in BCVA (90 days: slope = -0.013letters/µm, P<.001; 180 days: slope = -0.016 letters/µm,P<.001). At day 180, a total of 341 of 427 DEX implantpatients received a second DEX implant (DEX/DEX) and 326 of 426 sham patients received their first DEX implant(sham/DEX). On day 90 of the open-label phase, 53% ofDEX/DEX and 58% of the sham/DEX patients had a CRT <250 µm. The treatment effect decreased substantially 180 daysafter each treatment cycle. Multiple linear regression analysisindicated that a difference in baseline CRT of 100 µm wascorrelated with changes in BCVA ranging from approximately0.5 letters at day 30 to 1.5 letters at day 180 (P<.001).

CONCLUSION A significant reduction in OCT-measured CRTwas observed in the eyes of patients with ME secondary to RVO at 90 days after intra vitreal insertion of sustained-releasedexamethasone implant, but this effect lessened by day 180.DEX implant reduced CRT similarly after each of 2 treatmentphases. Baseline CRT and the change from baseline CRT correlated with the changes in BCVA.


424Long Term Natural History of Idiopathic Macular Telangiectasia

Shantanu Reddy Neravetla, MD (Springfield, OH), Vivek Dave, MD, Mudit Tyagi, MD, Benjamin Nicholson, MD, Jay Chhablani, MD, Raja Narayanan MBBS

PURPOSE To describe the baseline characteristics of eyes withidiopathic juxtafoveal retinal telangiectasia (MacTel) in atertiary care center in South India.

METHOD Ninety eyes of 45 patients were evaluated retrospec-tively. Patients with a minimum of 2 years follow-up wereincluded in the study.

RESULTS The mean age at baseline was 60.4 years. There were25 females and 20 males in the study. Ten patients had diabetesat baseline. At baseline 33 eyes showed intraretinal pigments;18 eyes showed parafoveal graying; 15 eyes had subretinalneovascularization. The average follow-up period was 33months (range 18-223 months). The mean visual acuity atbaseline was 20/40 and at last follow-up was 20/50. At finalfollow-up, 31 eyes maintained the same visual acuity asbaseline. Three eyes out of the 75 non-neovascular MacTel eyes at baseline developed subretinal neovascularization duringfollow-up period (incidence of 1.3% per year). Photodynamictherapy or intra vitreal anti-vascular endothelial growth factoragents or a combination of both were the mode of treatment forthe subretinal neovascularization.

CONCLUSION This is the largest study of macular telangiectasiafrom the Indian subcontinent describing the natural history ofthe disease over a 3-year period. Visual acuity remained stableover the study period.

425Combined Intravitreal Bevacizumab and Triamcinolone Acetonide as Primary Therapy for Macular Edema in Branch Retinal Vein Occlusion

Cyrus M. Shroff, MD (New Delhi, India), Daraius Shroff, MD, FRCS, Charu Gupta, MD, A. K. Singh, MD, Neelam Atri, MD, Prashant Naithani, MD, Bhavana Sharma, MD

PURPOSE To evaluate the safety and efficacy of combined intra -vitreal bevacizumab (1.25mg) and triamcinolone acetonide (2 mg) for treatment of macular edema in branch retinal veinocclusion.

METHOD Retrospective case series of 25 treatment naive eyes ofpatients with macular edema secondary to branch retina veinocclusion at a tertiary eye centre in North India Patients were

injected at the same sitting with 1.25 mg (0.05ml) bevacizumab,combined with 2 mg (0.05ml) triamcinolone. The visual andanatomical responses were evaluated.

RESULTS Mean duration of follow-up after first intra vitrealinjection was 5 months (range 1-12 months) Mean number ofcombined therapy intra vitreal injections were 1.24 per patient.The Central macular thickness reduced significantly from itsaverage baseline value of 540 ± 120 µm to 268 ± 77 µm at 1month post injection (p < 0.05) as well as at the time of lastfollow-up (average CMT 244 ± 45 µm; p < 0.005). The visualacuity increased from 0.2 ± 0.15 decimal units (approx 20/100)at baseline to 0.47 ± 0.27 decimal units (approx 20/40) at 1month follow-up and continued to improve to 0.59 ± 0.33decimal units (approx 20/33) at the last visit. Three patientswith IOP more than 21mm Hg were controlled with topicalmedication. There was no significant increase in cataractprogression in any eye requiring surgical intervention. No otherinjection related complication was observed.

CONCLUSION Combination therapy seems a safe option formacular edema in BRVO. Combining drugs with differentmodes of action seemed to increase the longevity of the drugeffect and may decrease chances of tachyphylaxis. The lowerdose (2mg) of steroid used decreased the chance of steroidrelated complications while still being efficacious. Largerprospective studies are required to validate our observations.

426Intravitreal Bevacizumab Treatment for Macular Edema Due to Branch Retinal Vein Occlusion

Ruth Axer Siegel, MD (Petah Tikva, Israel), Ayelet Dresnik, MD, Karin Mimouni, MD, Dan Bourla, MD, Elite Bor, MD, Dov Weinberger, MD

PURPOSE Current proven treatments for BRVO induced macularedema are laser, intra vitreal steroids, and monthly ranibizumabinjections. We report the functional and anatomical outcome of intra vitreal bevacizumab (IVB) treatment in a cohort ofpatients with macular edema due to BRVO in a tertiary retina clinic.

METHOD Retrospective analysis of the medical records of allconsecutive patients who received IVB due to BRVO inducedmacular edema from 2/07 till 8/10 was performed. The patientsreceived 3 to 4 loading doses of IVB (1.25 mg), and werefollowed every 6 to 8 weeks. IVB was repeated when macularedema was present. Grid laser photocoagulation was performedas well when macular edema persisted after 4 to 6 bevacizumabinjections.

RESULTS The cohort included 45 eyes of 45 patients, with amean age of 70.7 years, mean follow-up of 18.8 months, andmean number of injections of 8.8. 14 patients (33%) received




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grid laser treatment before the IVB, while 23 patients (51%)received grid laser during the study period. The mean initiallogMAR VA was 0.63 (mean snellen VA 6/43); the mean finallogMAR VA was 0.4 (mean snellen VA 6/21), p<0.0005. Themean initial and final central maculal thickness (CMT) were382.2 and 320.5 microns respectively (p=0.028). Positive corre-lations were found between the initial VA and the initial andfinal CMT (p=0.004), between initial and final VA (p<0.0005),and between the gain in VA and the reduction in the CMT(p=0.03). No correlations were found between the initial orfinal VA and laser treatment before or during the study.

CONCLUSION IVB for the management of BRVO, with andwithout laser treatment, reduced CMT and improved visualfunction.

427Intravitreal Bevacizumab Treatment for Macular Edema Due to Central Retinal Vein Occlusion

Ruth Axer Siegel, MD (Petah Tikva, Israel), Assaf Dotan, MD, Dan Bourla, MD, Karin Mimouni, MD, Elite Bor, MD, Dov Weinberger, MD

PURPOSE We report the visual acuity (VA) and anatomicaloutcome of a cohort of 35 patients who received intra vitrealbevacizumab (IVB) as a treatment for central vein occlusion(CRVO) induced macular edema.

METHOD Retrospective analysis of the medical records of allconsecutive patients who received IVB due to CRVO inducedmacular edema from 2/07 till 8/10 and were followed for at least 6 months in Rabin medical center, Beilinson campus, wasperformed. The patients received 3 to 4 loading doses of IVB(1.25 mg), and were followed every 6 to 8 weeks. IVB wasrepeated when macular edema was present.

RESULTS The cohort included 35 eyes of 35 patients, with amean age of 65.5 years, and a mean follow-up time of 17.7months, and mean number of injections of 9.3.

The mean initial logMAR visual acuity (VA) was 0.9, and themean initial Snellen VA was 6/98 , with improvement to 0.7,and 6/65 at the final visit (p= 0.009). Positive correlation wasfound between the initial and final VA (p<0.0005). The meaninitial central retinal thickness (CRT) was 489.5 microns, andthe final CRT was 395 microns (p=0.24). Positive correlationwas found between the gain in VA and the reduction in CRT(p<0.0001). No correlation was found between the VA and the number of injections.

CONCLUSION IVB for the management of CRVO, improvedvisual acuity and .reduced CRT. Patients with better initial VAhad better final VA.

428Collateral Vessel Presence in Branch and Central Retinal Vein Occlusions: The BRAVO and CRUISE Trials

Rishi Singh, MD (Cleveland, OH), Linda Yau, MD*, Wendy Yee Murahashi, MD

PURPOSE To examine the incidence of collateral vessels overtime and the potential impact on visual acuity (VA) outcomesin patients with branch or central retinal vein occlusion (RVO)receiving sham or intra vitreal (IVT) ranibizumab (RBZ) duringthe BRAVO or CRUISE trials.

METHOD BRAVO and CRUISE (phase 3 randomized studies)evaluated the efficacy and safety of monthly IVT injections of0.3-mg or 0.5-mg RBZ in patients with branch (BRAVO;n=397) or central (CRUISE; n=392) RVO. In both trials, theinitial 6-mo sham-injection-controlled treatment period wasfollowed by 6 mo of PRN treatment in all arms, in which sham-treated patients could receive 0.5-mg RBZ. Fundus photography(graded by the Univ of WI Reading Center) was used to assesscollateral vessel presence on the optic disc and within theretina in the study eye at baseline (BL), 6 and 12 mo. Meanchange from BL in best-corrected VA for patients with andwithout collateral vessels was also evaluated.

RESULTS The mean ages (SD) of enrolled patients from BRAVOand CRUISE were 66.4 (11.9) and 67.6 (12.5) yrs, respectively.Mean time from RVO diagnosis to study entry was 3.6 monthsfor BRAVO patients and 3.2 months for CRUISE patients.Mean baseline VA (SD) was 54.6 (12.3) ETDRS letters inBRAVO and 48.3 (14.7) ETDRS letters in CRUISE. Nodifference was observed in the presence of collateral vessels onthe disc or within the retina between the sham and RBZ arms(Table). The observed presence of collateral vessels on the discdeclined over time in BRAVO while a mild increase in thepresence was observed in CRUISE. Conversely, the observedpresence of collateral vessels within the retina increased inBRAVO and decreased in CRUISE post-baseline. Additionally,the presence or absence of collateral vessels on the optic discdid not appear to impact VA outcomes in BRAVO or CRUISE(Figure A and B).

CONCLUSION Treatment with ranibizumab did not appear toconsistently affect incidence of collateral vessels on the opticdisc or within the retina in patients from BRAVO or CRUISE.The presence of collateral vessels did not appear to impactvisual acuity outcomes in BRAVO or CRUISE.



Mean change in best-corrected visual acuity from baseline for patientsreceiving sham or ranibizumab with and without collateral vessels on the optic disc in (A) BRAVO and (B) CRUISE.

Collateral vessel formation in BRAVO and CRUISE trials.

429Comparison of Intravitreal Ranibizumab and Bevacizumab for the Treatment of Macular Edema Secondary to Retinal Venous Occlusive DiseaseAlex Yuan, MD (Cleveland, OH), Baseer Ahmad, MD, Rishi Singh, MD, Peter K. Kaiser, MD, Daniel F. Martin, MD, Jonathan Sears, MD, Andrew P. Schachat, MD, Justis P. Ehlers, MD

PURPOSE Recent studies suggest that vascular endothelial growthfactor (VEGF) inhibitors (e.g., ranibizumab, bevacizumab)can be an important therapeutic modality in the treatment ofretinal vein occlusions (RVO). Comparative studies of thevarious VEGF inhibitors have been lacking. This study aims to compare the efficacy of bevacizumab and ranibizumab in RVO.

METHOD A retrospective comparative case series was conductedidentifying eyes with macular edema secondary to RVO treatedwith ranibizumab or bevacizumab. Study eyes with macularedema from other concurrent causes (choroidal neovasculari -zation, diabetes) and eyes with follow-up <3 months wereexcluded. Three separate cohorts were identified: anti-VEGFtreatment naïve eyes treated with ranibizumab (R) orbevacizumab (B), and eyes treated initially with bevacizumaband then switched to ranibizumab (C). Clinical variablesincluding visual acuity, central subfield thickness (CST), andadverse events were analyzed. Student’s t-test or Fisher’s exacttest were used, as appropriate.

RESULTS Eleven eyes were identified in the R-group and werematched to 12 eyes in the B-group. There were no significantdifferences (p>0.05) in the visual and anatomic outcomes,including mean line change [+3.2±1.3 (R) vs +5.0±2.0 (B);mean±std error], eyes gaining ≥ 3 lines [6/11 (R) vs 8/12 (B)],eyes losing ≥ 3 lines [0/11 (R) vs 1/12 (B)], and mean change in CST [-148±100 µm (R) vs -152±91 µm (B)].

There were 20 eyes in the crossover (C) group. Prior tocrossover, the mean number of bevacizumab injections was4.7±0.8. The mean time between the last bevacizumabtreatment and the first ranibizumab treatment was 51±5 days.During initial bevacizumab therapy, there was a significant gain of 2.2±0.9 lines of vision [p=0.03]. After crossover toranibizumab, there were no significant changes (p>0.05) inlines gained 0.0±0.1, or CST -12±38 µm.

CONCLUSION Ranibizumab and bevacizumab appear to beeffective in treating macular edema secondary to retinal venousocclusive disease. Though small in size, this study suggestsoutcomes are comparable. Additionally, switching treatmentfrom bevacizumab to ranibizumab did not result in significantchanges in visual acuity.




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Imaging –Digital –AngiographyPOSTERS 430-457

430Fundus Autofluorescence Imaging Characteristics of Retinal Arteriolar Emboli(Hollenhorst Plaques) and Clinical Correlations

Andrew J. Barkmeier, MD (Rochester, MN)

PURPOSE Retinal arteriolar emboli may exhibit either hyper- orhypoautofluorescence on Heidelberg Fundus Autofluorescencetesting. The purpose of this study is to investigate autofluores-cence characteristics of these emboli correlate with clinicalcharacteristics, investigations, and outcomes.

METHOD A retrospective, single-institution review wasconducted on the medical records of 18 consecutive patientswith retinal embolic disease having received Heidelberg fundusautofluorescence (FAF) imaging. Case series inclusion criteriaincluded retinal embolic disease (CRAO, BRAO, cilioretinalarterial occlusion, and asymptomatic Hollenhorst plaques) withat least one visible embolic plaque on color photography andFAF imaging of the same location. Patient demographic andclinical data were recorded including plaque characteristics,results of embolic investigations, and outcomes. InstitutionalReview Board approval was obtained for this study.

RESULTS 18 patients meeting inclusion criteria were identifiedwith a mean age of 71.6 ± 8.7 years and 8.5 ± 11.2 monthsfollow-up (range: 0-47). Ratios between sex (10 M, 8 F) andinvolved eye (9 R, 9 L) were typical. 8 emboli were locatedwithin the superior vasculature (3 on nerve, 4 superotemporal,1 superonasal), 9 were inferior (1 on nerve, 8 inferotemporal),and one was within a cilioretinal arteriole. 10 emboli exhibitedhyperAF while 8 were hypoAF. Internal carotid arterial peaksystolic velocity (PSV) on Doppler ultrasonography was notsignificantly different between emboli that were hyperAF (92 ± 28 cm/sec) vs. those that were hypoAF (112 ± 50 cm/sec,p=0.28). 3 hypoAF plaques were associated with a PSV ≥ 140cm/sec (≥ 50% stenosis) vs. 1 hyperAF plaque (no pts with PSV ≥230 / stenosis 70-99%). 8 of 10 patients diagnosed witharteriolar occlusion had hyperAF emboli. Only one patient hada clinical embolic event during follow-up (TIA 18 months later,hypoAF embolus).

CONCLUSION Hyperautofluorescent emboli were more likely tobe associated with clinical arteriolar occlusion than werehypoautofluorescent emboli. (8/10 vs 2/8). No significant differ-ences in embolic clinical investigations were noted betweengroups and the rate of significant carotid stenosis was low.Retinal arteriolar embolus size and composition likely affectfundus autofluorescence characteristics.

431Grading the Severity of Posterior StaphylomaUsing SD-OCT Imaging and Correlation withMacular Disease Including VitreomacularTraction and SchisisRobert Beardsley, MD (Westwood, CA), David Sarraf, MD*

PURPOSE The purpose of this research is to evaluate posteriorstaphylomata imaged with SD-OCT and to determine theincidence of associated macular pathology including schisis,epiretinal membrane, and macular hole. Additionally, we seekto develop a novel grading system for the classification ofstaphylomata and the corresponding incidence of macularpathology using SD-OCT imaging with each grade.

METHOD A retrospective review 150 images with macula-involving posterior staphylomata imaged by a Cirrus SD-OCT(Carl Zeiss Meditec) system that were evaluated for posteriorvitreous detachment, vitreomacular traction, epiretinalmembrane, macular schisis, and lamellar and full thicknessmacular hole. Poor quality images and partially visualizedstaphylomata were excluded. A best fit circle was aligned withthe steepest curve of each staphylomata and arc of curvatureand best fit circle radius were calculated. The staphylomatawere stratified into 5 grades and the incidence of the macularpathologies was correlated to each grade. Statistical analysis was done using Cochrane-Armitage Trend testing.

RESULTS A total of 150 images from 93 patients were examinedeach of which had a posterior staphyloma. There were 60 with a depth of <500 microns (Grade 1), 63 with a depth of 500 to999 microns (Grade 2), 23 with a depth of 1000 to 1499microns (Grade 3), 1 with a depth of 1500 to 1999 microns(Grade 4), and 3 with a depth of greater than 2000 microns(Grade 5). The overall incidence of macular schisis was 20%(25/150) and was significantly greater with Grade 2 (17.4%)and Grade 3 (34.8%) staphylomata versus Grade 1 staphy-lomata (8.3%) (p=0.008). The overall incidence of epiretinalmembrane was 36% (54/150) and was greater in Grade 2 (44%)and Grade 3 (35%) versus Grade 1 (27%) though the trendfailed to reach statistical significance (p=0.14). The incidenceof VMT, lamellar hole, and FTMH similarly was increased inhigher grade staphylomata though not significantly.

CONCLUSION Imaging of staphylomata via SD-OCT can be avaluable tool for determining risk stratification for varyingmacular diseases. Increased grade of posterior staphyloma correlated to significantly increased incidence of macularpathology. We postulate that macular schisis may develop ineyes with higher grade posterior staphyloma and dispropor-tionate anterior vitreomacular traction.


432Effect of Wide-field Fundus Photography and Fluorescein Angiography System on the Management of Posterior Uveitis

Millena G. Bittencourt, MD (Baltimore, MD), John P. Campbell, MD, Henry A. Leder, MD, Theresa Gan, MD, Yasir Sepah MBBS, Elham Hatef Naimi, BrianCho, MD, Mohamed Ibrahim, MD, Roomasa Channa, Abeer Akhtar, MD, Quan Dong Nguyen*

PURPOSE To determine whether the use of wide-field fundusimaging system alters the management of patients withposterior uveitis.

METHOD In this prospective, observational study of patients withposterior uveitis, at baseline, and at scheduled follow-up visits,patients receive wide-field pseudo-color imaging and fluoresceinangiography (FA) following their routine evaluation. Partici-pating investigators successively determine disease activity andmanagement changes based on exam alone, exam and limited(60 degree FA), and then with the addition of wide-field pseudo-color images, and wide-field FA (performed with Optos P200System®). Management decisions at each time point are com -pared to determine whether the wide-field imaging system altersinitial management decisions made without wide-field images.

RESULTS Twenty-eight patients have been enrolled to date. At the enrollment visit, current management was altered in4/28 (14%) of patients based on examination findings alone,with or without 60 degree FA (25 of 28 patients received FA).Management was altered in 13/28 (46%) patients based on theaddition of wide-field SLO imaging and FA (P < 0.01).

CONCLUSION Our results suggest that wide-field imaging mayalter management decisions compared to standard-of-careimaging and clinical examination. Such difference may be dueto peripheral retinal imaging and angiographic findings noteasily visualized or identified without wide-field imaging.Additional studies are indicated to determine whether thesefindings may be able to improve patient outcomes.

433Choroidal Morphology of Healthy Eyes Using SD-OCTLauren Ann Branchini, BA (Boston, MA), Mehreen Adhi, MD,Caio Regatieri, MD, PhD, Namrata Nandakumar, MD, Jonathan Liu, J.G. Fujimoto, Jay S. Duker, MD*

PURPOSE To characterize the morphology of the choroid inhealthy eyes using SD-OCT. Techniques used include quali-tative description, manual measurement of large choroidalvessels as well as novel automated software techniques whichcalculate the ratio between the choroidal stromal area and large vessel lumen area.

METHOD In this cross sectional study, 42 eyes of 42 subjects with no ocular disease underwent SD-OCT. Two independentobservers evaluated the choroid for morphological charac -

teristics such as shape of the choroid sclera junction and distri-bution location and caliber of large choroidal vessels. Thicknessof the large vessel layer was measured by two independentobservers in three locations: at the fovea, 750 µm temporal tothe fovea, and 750 µm nasal to the fovea. Custom software wasused to calculate the ratio between stroma and large vessellumen area.

RESULTS The 42 subjects had a mean age of 51.6 years. Withregard to categorical observations, 100% of subjects had a bowlshape to the choroid-sclera junction. 97.6% of subjects had asmooth continuum of choroidal vessel size from large at thechoroid sclera junction to small at Bruch’s membrane. 98.8% of subjects had an even distribution of choroidal vessels in thenasal-temporal axis. The thickness of the large vessel layer atthe fovea was 204.3µm ± 65.9µm (mean ± SD), 750µmtemporal to the fovea was 203.7µm ± 60.3µm and 750µm nasalto the fovea was 198.6µm ± 62.5µm. Large vessel measurementshad strong inter-observer correlation (r = 0.90, P < .0001). Thesoftware generated ratio of stromal area to large vessel lumenarea had a mean of 0.27 and standard deviation of ± 0.08.

CONCLUSION We report a novel way to characterize the choroidin healthy eyes which includes qualitative description, manualmeasurement of choroidal layers and automated softwareanalysis. Further investigation using this protocol in eyes withdisease affecting the choroid such as age related macular degen-eration, diabetes and central serous retinopathy are needed.

Software to calculate the ratiobetween choroidal stroma andlarge vessel lumen area A: spectraldomain optical coherencetomograph of a normal eye. Bluebox represents the selection ofsubfoveal choroid area to beanalyzed B: magnified section ofsubfoveal choroidal area C: Area ofsubfoveal choroid after softwareanalysis. White area representsstroma, black area representslarge vessel lumen.

Measurement of large choroidal vessel layer on a spectral domain optical coherence tomograph of a healthy eye. Red lines demonstratemeasurement from the interface of the choroid and sclera to the inner most limit of the closest large choroidal vessel at the fovea, 750 um temporal to the fovea, and 750 um nasal to the fovea.

IMAGING –DIGITAL – ANGIOGRAPHy



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434Variability in Choroidal Thickness Using Spectralis SD-OCT

Jans Fromow-Guerra, MD, PhD (Mexico City, Mexico),Virgilio Morales-Canton, MD, Jose Guerrero-Naranjo, MD,Gerardo Garcia-Aguirre, MD, Maria A. Martinez-Castellanos, MD, Juan Manuel Jimenez-Sierra, MD,Carlos Gustavo Sanchez Bermudez, MD,

Ricardo Leal-Rodriguez, MD

PURPOSE To assess intraobserver and interobserver variability inchoroidal thickness measurements by two different techniquesusing Heidelberg Spectralis SD-OCT to determine which isbest for establishing normality.

METHOD We studied healthy and diabetic patients who under -went OCT within a 5 X 30-degree area centered at the foveausing Spectralis™ SD OCT. Each image was obtained with 100 averaged scans using Automatic Real-Time software. Eachpatient was scanned with conventional technique and withinverted Enhanced Depth Imaging (EDI) technique. Measure-ments were performed three times by 2 independent observers.Intraclass Correlation Coefficient (ICC) was used to assess thelevel of intraobserver agreement. For assessing interobservervariability the Limit of agreement (LoA95%), Bland-Altmanplots, ICC and Pearson correlation coefficients were used.

RESULTS We studied fifty-two eyes from 26 subjects. Choroidalthickness measurements had a mean ICC of 0.756 for observer1 and 0.857 for observer 2. The mean 95 % LoA range wasshorter for EDI (-69 to 77 µm) than for conventional technique(-120 to 94 µm). Choroidal thickness measurements had astronger inter-observer agreement for EDI than for conven-tional technique (r= 0.80 vs. r=0.35 p=<.0001).

CONCLUSION The EDI technique demonstrated lower variabilityand a stronger inter-observer correlation for choroidal thicknessmeasurements than the conventional technique. EDI techniqueshould be chosed for establishing normal variation thanconventional technique.

435Integrative Advancements for Intraoperative OCT

Justis P. Ehlers, MD (Shaker Heights, OH), Sunil Srivastava, MD, Yuankai Tao, MD, Joseph I. Izatt, MD, Cynthia Ann Toth, MD

PURPOSE The cross-sectional anatomic information obtainedwith OCT provides a natural complement to the retinalsurgeon. However, current OCT systems do not allow forvisualization of real-time motion. In addition, current intra -ocular instruments limit visualization of underlying tissues. Thisstudy aims to demonstrate OCT-based visualization of intra -operative motion and OCT-compatible instrumentation.

METHOD A prototype operating microscope-mounted spectraldomain OCT (MMOCT) system was used to concurrentlyacquire volumetric OCT images while performing operativemaneuvers in cadaveric porcine eyes. Multiple scanningprotocols were tested, including variations in orientation,dimension, and sampling rate. Custom image processing wasdeveloped to optimize visualization. Based on known OCTcharacteristics of materials currently used in instruments, novelmaterials were selected for OCT imaging and their reflectivitycharacteristics were tested. Based on these characteristics,optimal materials were selected and prototype instrumentationwas constructed from these materials.

RESULTS Using the MMOCT system, a customized scanprotocol was developed. The optimized protocol imaged an 8mm x 0.4 mm field-of-view with 256 A-scans x 5 B-scans. Thisprotocol allowed for real-time capture of instrument maneuversand tissue manipulations. Tissue deformation and translationalmotion of the instrument were well-visualized. Following acqui-sition, custom image processing algorithms resulted in improvedsignal strength, robust visualization of instrument-tissue inter-action, video-rate display of instrument maneuvers, and reducedinstrument shadowing artifacts. Materials were identified withoptimal OCT reflectivity profiles and selected for instrumentconstruction. Utilizing the novel materials, OCT-compatibleinstrumentation demonstrated improved instrument visuali-zation and reduced shadowing of underlying tissues compared to standard metallic instruments. This allowed for enhancedvisualization of instrument/tissue interactions.

CONCLUSION OCT-compatible instrumentation and high-resolution imaging of real-time intraocular surgical maneuversare possible. Both of these advancements are critical compo-nents to the feasibility of seamless integration of OCT into the surgical environment.


436Assessment of an Angiographic Ischemic Index Based on Common Retinal Vascular Diseases

Valentina Franco-Cardenas, MD (Los Angeles, CA), Irena Tsui, MD, Gad Heilweil, MD, Jean-Pierre Hubschman, MD, Pradeep Prasad, Steven Schwartz, MD*

PURPOSE Calculating an ischemic index (ISI) using ultra widefield fluorescein angiography (UWFFA) in eyes with retinalvascular disease may be clinically useful. Retinal non-perfusionmay be closely associated with vision threatening complicationssuch as neovascularization or macular edema. The purpose ofthis study is to investigate the reproducibility a calculated ISIwith UWFFA.

METHOD Rules for grading an ISI were created. Ten graders were asked to grade 15 different UWFFA images for ISI. Imageswere provided digitally and on paper and were graded on twodifferent days. Images consisted of 5 eyes with diabeticretinopathy (DR), 5 eyes with branch retinal vein occlusion(BRVO) and 5 eyes with central retinal vein occlusion(CRVO). To assess intragrader and intergrader agreement andvariability among the different diseases, an intraclass corre-lation coefficient (ICC) was calculated. Before calculating theISI, graders were asked to predict the value of the ISI andchoose their preferred treatment, based solely on the angio-graphic data.

RESULTS Intragrader agreement and variability for the ISI hadan ICC of 0.82 + 0.11 over all. By disease ISI ICC was DR 0.25+0.22, BRVO 0.72 +0.29 and CRVO 0.95 +0.5. Intergraderagreement and variability in calculating an ISI had an ICC inDR of <0.01-0.2, BRVO of 0.5-0.6, and in CRVO of 0.8-0.9when performed on paper and digitally. High concordance wasobserved between predicted and calculated ISI. The mostcommonly recommended treatment was laser photocoagulation,followed by a combination of laser treatment and anti-vascularendothelial growth factor.

CONCLUSION Intra and intergrader agreement and variability washigh when calculating an ISI in BRVO and CRVO images,proving ISI to be a useful and reliable tool for assessing retinalnon-perfusion. Agreement was not reached in DR images inthis small cohort. Strong trends towards concordance were seenamong more experienced graders suggesting ISI calculation forDR may need more training.

Ischemic index (ISI) was calculated as a percentage: Ischemic area/Totalarea*100. Fifteen pictures of UWFFA taken during the transit fase werechosen, including 5 BRVO, 5 CRVO and 5 DR. Ten graders were asked tocalculate the ISI on pictures provided both digitally and on paper toassess the intragrader and intergrader agreement.

437A New Endpoint for Longitudinal Measurements of Geographic Atrophy

Ron P. Gallemore, MD (Torrance, CA), Madeline Eells, Josh O. Wallsh, MD

PURPOSE To demonstrate the loss of macular tissue over time,volumetrically, using high resolution optical coherence tomography (HR-OCT) in patients with geographic atrophy(GA) secondary to age-related macular degeneration.

METHOD A prospective study of patients with GA using averagemacular volume (AMV) within a designated 3-mm diametercircle centered on the fovea measured with HR-OCT over time(7-30 mo). Patients with confounding diagnoses associated with macular edema were excluded. This data was then used todetermine the change in macular volume per year, as well as thepercent change in volume over time.

RESULTS The macular volume decreased significantly from 1.92to 1.86 cubic mm over the period of time (p < 0.05), whichcorrelated with an average decrease in AMV of 0.047±0.011cubic mm/year (n=11). From the same population, the percentdecrease in AMV over time was 2.48±0.55 percent/year.

CONCLUSION HR-OCT can be used to measure macular volume,which in turn was found to decrease significantly over time inpatients with geographic atrophy. Macular volume is a novelendpoint for demonstrating the loss of macular tissue in GAand may be useful in clinical trials assessing therapies for this disorder.




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438Correlation of Fundus Autofluorescence withSD-OCT Findings and Functional Changes inEyes with Central Serous ChorioretinopathySoo Geun Joe, MD (Seoul, South Korea), Sung Jae Yang, Joo Yong Lee, MD, Ju Byung Chae, MD, Young Hee Yoon, MD

PURPOSE To investigate correlations between autofluorescence(AF) findings and clinical progression in patients with centralserous chorioretinopathy (CSC).

METHOD Medical records of 21 eyes with complete resolution of CSC were reviewed retrospectively. Data obtained fromcomplete ophthalmologic examinations and from use of spectraldomain optical coherence tomography (SD-OCT) and AFincluding both short wave length AF (SW-AF) and nearinfrared AF (NIR-AF) before and after the resolution of CSC,were analyzed.

RESULTS Initial best corrective visual acuity was 0.27 ± 0.29(logMAR) and 0.15 ± 0.17 (logMAR) after healing of CSC.Increased AF intensity in inferior macular (IAF) on both SW-AF and NIR-AF was related to duration of CSC (p=0.019;p=0.009, respectively). IAF on SW-AF also showed correlationwith the height of subretinal fluid checked with SD-OCT(p=0.03) but that of NIR-AF did not. Inner and outer segmentjunction of photoreceptor (IS/OS) status after healing of CSCwas associated with IAF on SW-AF and IAF on NIR-AF(p=0.031; p=0.045, respectively).

CONCLUSION Image from AF including both SW-AF and IAF on NIR-AF could be useful methods which express the diseasestatus of CSC and predict disease progression.

439Analysis of SD-OCT Characteristics in Patients with Rod Monochromatism

Carlos Gustavo Sanchez Bermudez, MD (Mexico City,Mexico), Tania Adabache-Guel, MD, Juan ManuelJimenez-Sierra, MD, Virgilio Morales-Canton, MD, Jose Guerrero-Naranjo, MD, Hugo Quiroz-Mercado, MD, Guillermo Salcedo-Villanueva, MD,

Maria Martinez-Castellanos, MD

PURPOSE To evaluate structural changes by spectral domainoptical coherence tomography (OCT) by observation of thecentral retinal architecture in patients with rod monochro-matism (achromatopsia) in Mexican individuals.

METHOD Descripitive, transversal study. Eight patients with rodmonochromatism were included; the diagnosis was establishedby means of visual acuity, standard electroretinogram, and colorvision tests. SD-OCT was performed in all patients with theSpectralis™ OCT (Heidelberg Engineering). The examinationincluded a central linear 100-frame scan and 25° x 25° 30-framevolume cube. Images were analyzed by direct observation of the

foveal architecture, RPE, and Inner-Outer segment junction ofcentral photoreceptors. Measurement of foveal thickness wasalso performed with auto segmentation. OCT findings werecorrelated with best corrected visual acuity and electrophysio-logical studies.

RESULTS Eight patients (Sixteen eyes) with diagnosis of rodmonochromatism (complete and incomplete) were evaluated, 5 males (62.5%) and 3 females (37.5%). The mean age was20.6 years (4-42), the average BCVA was 20/100, the meancentral thickness was 186.3 ± 28.5 µm ; the foveal depressionwas normal in all patients; absence of the IS/OS junction wasobserved in the foveal region in both eyes on 4 patients (50%),which did not correlated with BCVA. None of the patients hadepiretinal membrane, cystoid macular edema or retinal pigmentepithelium abnormalities.

CONCLUSION Advanced Imaging techniques such as the SD-OCT are helpful for the structural analysis of the retinalarchitecture in a wide spectrum of retinal diseases including thecongenital retinal disorders. In this study we did not find aconsistent structural anomaly in patients with the samediagnosis. A larger population of patients should be evaluatedand compared with a control group.

440Real Time Intra-Surgical Imaging of Vitreoretinal Manipulations Using a Microscope-Mounted OCT System

Paul Hahn, MD, PhD (Durham, NC), Justin Migacz, MD, Rachelle O’Connell, MD, Joseph I. Izatt, MD, Cynthia Ann Toth, MD

PURPOSE Optical coherence tomography (OCT) has revolu-tionized diagnostic retinal imaging but thus far has been limitedprimarily to the clinic setting. We have recently developed amicroscope-mounted OCT (MMOCT) system to enable realtime intra-surgical retinal imaging. The purpose of this study isto investigate the utility of this system for imaging vitreoretinalsurgical manipulations.

METHOD A custom MMOCT scanner was constructed to mountonto a Leica surgical microscope and interface optically andmechanically with an Oculus Binocular Indirect OphthalmoMicroscope (BIOM). We tested the ability of the MMOCTsystem to visualize surgical maneuvers in model eyes with variousinstruments in real-time. We also examined post-processingmodifications for their ability to improve visualization.

RESULTS MMOCT enables non-contact cross-sectional imagingof retinal structures during surgical manipulations includingbrushing of the retinal surface with the Tano scraper andgrasping of superficial retinal layers with intraocular forceps.


These manipulations can be effectively visualized in real-timewith unprocessed video-rate serial B-scans. Post-processingmodifications can improve image resolution, permit three-dimensional spatial visualization, and limit artifact includingcomplex conjugate reflections and shadowing from surgicalinstrumentation.

CONCLUSION MMOCT may be useful for real time, cross-sectional retinal imaging during surgical manipulations. Furtherrefinement of instrumentation, hardware, and software iscurrently underway and will likely be important in improvingimaging quality, resolution, and speed.

Visualization of a diamond-dusted Tano scraper brushing against the surface of a cadaveric fresh porcine retina. Orthogonal views of summed images provide spatial orientation of maneuvers performed under the surgical microscope.

441Intraoperative Use of a Handheld SD-OCT for Macular Surgery

Atsushi Hayashi, MD (Toyama, Japan), Takaaki Yagou, Tatsuya Yunoki, Miyako Oka

PURPOSE To examine usefulness of SD-OCT images duringmacular surgery.

METHOD Interventional case series. Ten patients who underwentvitrectomy at Toyama University Hospital were included in this study. Five patients had an idiopathic macular hole and 5patients had an epiretinal membrane (ERM). A handheld SD-OCT, iVue (Optovue Inc.) was used intraoperatively. OCTimages were taken before and after removal of ERM andinternal limiting membrane (ILM) with the software of retinalmap scan or cross scan.

RESULTS Intraoperative SD-OCT images were successfully takenin all patients. ERM were imaged similarly to the preoperativeand remnants of the ERM or ILM were clearly detected on thesurface of the retina. With the aid of the OCT images the

remnants of ERM and ILM were removed in all cases during thesurgery. In 1 case of ERM, the ERM was not clearly dissectedfrom the nerve fiber layer and was removed around the foveaonly. On the other hand, there were some limitations in the useof a handheld SD-OCT intraoperatively. OCT had to be takenseparately from the microscopic view and the fundus view ofthe OCT was limited within 6 mm and it was difficult to findthe foveal center without the optic disc.

CONCLUSION Intraoperative use of a handheld SD-OCT ishelpful to perform the macular surgery more precisely eventhough there are some limitations. More improvements areneeded in the hardware and software of SD-OCT for an intra-operative use.

442Short-term Results of the Prospective Retinaland Optic Nerve Vitrectomy Evaluation(PROVE) Study: A Controlled Clinical TrialMaziar Lalezary, MD (Nashville, TN), Rahul K. Reddy, MD, Edward Cherney, MD, Franco M. Recchia, MD, Karen Joos, MD, Jeffery A. Kammer, MD, Rachel Kuchtey, MD, Stephen J. Kim, MD

PURPOSE Long-term complications of pars plana vitrectomy(PPV) such as open-angle glaucoma and indocyanine green(ICG) toxicity remain unknown. The PROVE Study is anongoing prospective, controlled clinical trial designed to assesschanges in structure and function of the macula and optic nerve following PPV. Three-month interim data of our studycohort is presented here.

METHOD Patients without glaucoma or prior PPV undergoingunilateral PPV were eligible. Enrollment goal is 80 eyes of 40subjects. Both eyes are examined by a retina and glaucomaspecialist pre-operatively (baseline), at 3-months post-opera-tively and then yearly for 5 years. The following data arerecorded; intraocular pressure (IOP), corneal thickness (CCT),gonioscopy (GON), Humphrey visual field (HVF), fundusphotography, and optical coherence tomography (OCT). Theprimary outcomes of this analysis are IOP, CCT, GON, HVFmean deviation (MD) and pattern standard deviation (PSD),cup-disc ratio (CDR), peripapillary retinal nerve fiber layer(RNFL), and macular central subfield thickness (CST).

RESULTS Forty eyes of 20 subjects have completed 3-monthfollow-up. Surgical indications were macular hole (MH; 7 eyes),epiretinal membranes (ERM; 8), and vitreous opacities (VO;5). At baseline, mean IOP, CCT, MD, PSD and GON weresimilar among all eyes. No statistically significantly changefollowing surgery was detected in these outcomes. One studyeye developed a paracentral scotoma presumably due to intra -operative optic nerve contusion. No significant progression ofcupping was observed in study eyes at 3 months. Baseline meanRNFL thickness (µm) was 93 ± 10 and 90 ± 6 for study andfellow eyes, respectively and 88 ± 11 and 91 ± 7 at 3-months,respectively. In 14 eyes that underwent membrane peeling,




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mean RNFL was 6 µm thinner compared with fellow eyes(P=0.01). Mean baseline CST (µm) of 8 subjects with ERM was404 for study eyes and 260 for fellow eyes; while mean CSTdecreased 83 µm at 3 months in study eyes, it remained 75 µmthicker when compared with fellow control eyes (P<0.01).

CONCLUSION In this ongoing prospective study, short-termanalysis suggests no significant change in IOP, CCT, GON,HVF (MD & PSD), or CDR following PPV. However, peri -papillary RNFL thinning was observed in eyes that underwentmembrane peeling and macular thickness (CST) remainedsignificantly increased at 3 month in these eyes. Long-termfollow-up of our study cohort should provide further insight.

443Non-invasive Multi-spectral Fundus Imaging is a Useful Tool for Structural and FunctionalEvaluation of the Choroidal Vasculature

Brian C. Leonard, MD* (Ottawa, Canada), Alan Boate, MD, Richard Clayton, MD*, Jeremy Gribben, MD*, Stuart Coupland, MD, Bernard Hurley, MD, John Hamilton, MD, David Priest, MD*, Robert G. Devenyi, MD*, MBA, FRCS(C)

PURPOSE To examine the structural and functional characteristics of the choroidal vasculature in a broad variety of pathologic conditions using non-invasive multi-spectralfundus imaging.

METHOD Both eyes of 58 patients with posterior polar and mid-peripheral choroidal pathology were assessed with clinicalexamination, color fundus photography, spectral domain opticalcoherence tomography and fluorescein angiography. Multi-spectral fundus imaging was performed using a wavelengthrange of 450 nm to 900 nm with four million pixel spatialresolution through a 41 degree field, with images acquired by apolychromatic camera and processed with dedicated software.

RESULTS Multi-spectral imaging provided high resolution enface and stereo structural images slices through wavelengthspecific tissue depths, from vitreomacular interface to deepchoroid, in a broad variety of choroidal disease. The choroidalvasculature and choroidal pathology were imaged clearlythrough retinal pigment epithelium. Tissue oxygenationmapping was imaged by software analysis of the ratio ofoxygenated hemoglobin to deoxygenated hemoglobin in retinaland choroidal structures. Many of the diagnostic insightsprovided by this technology were not evident in clinical exami-nation, spectral domain optical coherence tomography orfluorescein angiography.

CONCLUSION Multi-spectral fundus imaging may provide a non-invasive high resolution alternative to fluorescein angiography.

Non-invasive multispectral mosaic image of human choroid.

444Retinal Thickness Layer Analysis of ETDRS Regions in SD-OCT Maps for DiabeticNPDR Eyes with or without CSDME Using a Novel Thickness Analysis Program

Jennifer I. Lim, MD (Chicago, IL), Ruth U. Zelkha, Mahnaz Shahidi, MD

PURPOSE To compare thickness of inner and outer retinal layersin nine macular subfield areas from SD-OCT images amongstthree groups of eyes: non-proliferative diabetic retinopathy(NPDR) with clinically significant diabetic macular edema(CSDME), NPDR without CSDME and normals.

METHOD Patients with NPDR and normal subjects underwentSD-OCT imaging. The ILM, OPL and RPE boundaries weremanually drawn for each of 19 raster SD-OCT images. Acomputerized algorithm was used to calculate the inner retinal(IRT=ILM to OPL) and outer retinal (ORT= ONL to RPEdistance) thickness values. Total retinal thickness (TRT) wascalculated as the sum of the IRT and the ORT. Maps of IRT,ORT and TRT were generated and the average thickness ofeach of the nine ETDRS macular subfields was calculated. IR,ORT and TRT values obtained in NPDR with CSDME, NPDRwithout CSDME and normal eyes were compared using analysisof variance (ANOVA).

RESULTS Thickness data were obtained in 26 NPDR withCSDME (age 65 ± 8 years), 8 NPDR without CSDME (age 66± 7 years) and 15 normals (age 52 ± 6 years). Overall, retinalthickness was lowest in normal eyes and highest in NPDR withCSDME eyes. In the foveal areas, TRT was 337 ± 14 microns,276 ± 25 microns and 266 ± 18 microns in NPDR withCSDME, NPDR without CSDME and normal eyes respectively.Statistically significant differences were found for IRT in thefoveal area (p=0.03), ORT in the temporal parafoveal area(p=0.04) and TRT in the foveal, temporal parafoveal andperifoveal areas (p<=0.02).


CONCLUSION In NPDR with CSDME eyes, inner retinalthicken ing is responsible for the majority of retinal thickening.In both NPDR with and without CSDME, temporal macularthickening was found as compared with controls.

Retinal thickness maps for a normal control eye.

Retinal thickness maps for a NPDR with CSDME eye.

445Intraretinal Crystalline Deposits in Neovascular AMD

Luiz H. Lima, MD (Sao Paulo, Brazil), James M. Klancnik, MD, K. Bailey Freund, MD* Richard F. Spaide, MD,

PURPOSE The purpose of this study was to describe intraretinalcrystalline deposits detected in eyes with neovascular age-related macular degeneration.

METHOD A retrospective review of patients seen during a 6-month period with the diagnosis of neovascular age-relatedmacular degeneration was performed to identify patients withintraretinal crystalline deposits, defined as pinpoint refractilebodies within the neurosensory retina. The characteristics ofthe deposits, including their shape, size, distribution, andlocation within the retina, were determined by analyzing colorand red-free fundus photographs and spectral domain-opticalcoherence tomography images.

RESULTS Fourteen eyes of 13 patients with neovascular age-related macular degeneration manifesting intraretinal crystallinedeposits were identified. The patients had no history of ocularor systemic disease or prior medication use known to beassociated with intraretinal crystals. Intravitreal antivascularendothelial growth factor injection was used in 10 eyes, laserphotocoagulation in 3 eyes, and intra vitreal triamcinolone in 1eye. The retinal crystals were detected in the macula overlyingor adjacent to the areas of choroidal neovascularization. Thecrystalline deposits could be localized with spectral domain-optical coherence tomography to both the outer nuclear andthe outer plexiform layers.

CONCLUSION Intraretinal crystalline deposits localized to theouter nuclear and outer plexiform layers can be detected in eyeswith a history of neovascular age-related macular degeneration,often after treatment with a variety of different modalities.Potential etiologies of these deposits include residual lipidmaterial, degenerated Müller cell elements, and an externalfactor such as diet.

This 74-year-old female patient had a CNV diagnosed 4 years ago. Initially, she was treated with 1 session of PDT. Following PDT shestarted treatment with injections of intravitreal ranibizumab. The VA was 20/200. (A) In 2006, the fundus photograph revealed aprominent lipid extravasation associated with a CNV in the superiormacula. (B) One year later, there was a decrease in the amount oflipid exudation and crystalline deposits were observed in the superiormacula. (C) After a total lipid reabsorption, the crystalline depositsbecame more evident in the superior macula. (D) Observe the retinalcrystalline deposits in a magnified view.

(A) Fundus photograph from an 86-year-old female patient with a CNV diagnosed 6 years previously when she started treatment withphotodynamic therapy PDT and injections of intravitreal triamcino lone.Two years following that, she received 25 injections of either intra -vitreal ranibizumab or bevacizumab and crystalline deposits werenoted nearby to and overlying the CNV scar. She had resolution of her exudative manifestations with recurring episodes of CNV. (B)Magnified view of fundus photograph showing retinal crystals in thevicinity of the CNV. The best-corrected visual acuity (VA) was 20/60.(C) Series of four spectral domain optical coherence tomography (SD-OCT) scans showing crystalline deposits in the outer plexiformlayer (arrows).




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446Serial Wide-field Fluorescein Angiography of Preproliferative (Ischemic) CRVO Treated with Ranibizumab

James C. Major, MD, PhD* (Houston, TX), Angeline Mariani, MD, Eric Kegley, MD, David M. Brown, MD*

PURPOSE Preproliferative (Ischemic) Central Retinal VeinOcclusion (CRVO) results in vascular insult to the entireretinal circulation. Classically regarded as a single insult, it isunknown if progressive changes occur to the retinal circulationover time when treated with intra vitreal anti-VEGF therapy.Wide-field serial angiography was used to assess the posterior aswell as the peripheral retinal vascular changes.

METHOD Wide-field fluorescein angiography was performedserially in 10 patients with pre-proliferative CRVO who weretreated in the 3 year prospective Rubeosis Anti-VEGF (RAVE)trial evaluating intra vitreal ranibizumab. Angiography wasperformed utilizing the Staurenghi lens and a scanning laserophthalmoscope (Heidelberg Spectralis HRA) to allow 150degree imaging. Patients received monthly ranibizumab for 9 consecutive months followed by an observation period(month 9-12), and then two subsequent years of observationwith PRN therapy.

RESULTS Vascular pruning of the peripheral retinal circulationwas commonly seen as well as progressive loss of the secondaryand tertiary arterioles and venules while on monthlyranibizumab therapy. In the observation periods, posteriorneovascularization was common.

CONCLUSION The retinal vasculature in preproliferative/ proliferative CRVO (ischemic CRVO) undergoes progressivedegradation despite intensive ranibizumab therapy. Whenranibizumab is discontinued, posterior neovascularization is common.

Fluorescein angiography exhibiting progressive capillary dropout and pruning of the peripheral retinal vasculature by month 6 despite monthly intravitreal ranibizumab.

Fluorescein angiography exhibiting posterior neovascularization after discontinuation of monthly intravitreal ranibizumab treatment.

447The Rate of Adverse Reactions to Intravenous Fluorescein Angiography in a Pediatric Population

Emmanouil Mavrikakis, MD, PhD (Athens, Greece), Anne De Silva, MD, Cynthia VanderHoven, Wai-Ching Lam, MD, FRCS(C)

PURPOSE To report the incidence of adverse effects to intra-venous fluorescein angiography (IVFA) among a pediatricpopulation in an out-patient clinical setting

METHOD Retrospective chart review of all adverse reactions toIVFA performed at a children’s hospital between January 1992and May 2009. Patients 18 years and younger were seen for avariety of retina conditions and all reactions to IVFA using10% fluorescein were documented. A total of 373 fluoresceinangiograms were included.

RESULTS 75 (20.1%) adverse reactions were documented, mostof which were mild. Nausea and/or vomiting were the mostcommon mild reactions (14.48%). There were no severereactions or mortalities.

CONCLUSION Pediatric population may experience a higheroverall adverse reaction rate to IVFA as compared to reportedadult rates (1.1%-5.17%). Nausea and/or vomiting are the mostcommonly experienced reactions in both adult and pediatricpopulation. IVFA remains a safe and valuable diagnosticprocedure for the evaluation of pediatric retina conditions.


448Histopathologic Correlation of Retinal Layerson SD-OCT in Post-mortem Human Eyes

Christine Nichols Kay, MD (Iowa City, IA) Ryan M. Tarantola, Robert F. Mullins

PURPOSE To correlate histopathologic evaluation of retinalanatomy with spectral domain optical coherence tomography(OCT) findings in post-mortem human eyes. Prior studies havecorrelated histopathology to OCT in rats and monkeys. Webelieve this to be the first histopathologic correlation to sameeye high definition OCT imaging in human eyes.

METHOD Four human eyes were obtained from the Iowa LionsEyebank. Eyes were imaged within 5 hours of death withspectral domain OCT and tissue was subsequently fixed andevaluated histopathologically.

RESULTS Retinal layers seen on spectral domain OCT werecorrelated with retinal layers seen with histopathology. Retinalpigment epithelium, outer and inner retina, nerve fiber layer,and retinal vessels could be correlated in these images.

CONCLUSION Direct correlation between histopathology andspectral domain OCT provides valuable information intoanatomic identity of layers seen with high definition currentday OCT technology. We believe this to be the first correlationof post-mortem high definition OCT to histopathology in sameeye human subjects.

Spectralis OCT image of post-mortem human eye, superotemporal macula.

Histopathology in anatomically correlated location in superotemporal macula of same human eye. Layers including nerve fiber layer, inner retinal layers, outer retinal layers, and retinal pigment epithelium can be identified. A retinal vessel can be correlated to the vessel visualized on OCT.

449OCT Features of Choroidal Neovascularization Secondary to Chronic Central Serous ChorioretinopathyRajeev R. Pappuru MS (Hyderabad, India), Mudit Tyagi, MD, Raja Narayanan MBBS, Annie Mathai, Avinash Pathangey, MD, Ajit B. Majji, MD, Subhadra Jalali, Taraprasad Das, MD*

PURPOSE Choroidal neovascularization (CNV) secondary tochronic central serous chorioretinopathy (CSC) is a rarecomplication. Optical coherence tomography (OCT) has beenused to image retinal structures in eyes with Chronic CSC andCNVM with different pathologies. We describe OCT featuresof CNVM secondary to chronic CSC.

METHOD A retrospective review of medical records of choroidalneovascularisation secondary to chronic central serous chori-oretinopathy(CSC) imaged with optical coherence tomographywas performed. Patients had a history of episode of CSCdiagnosed based on documented angiographic leakage in thepast, or typical findings of retinal pigment epithelium changesincluding diffuse retinal pigment epithelial atrophy or retinalpigment epithelium tract in both or either macula, andconsistent findings in fundus fluorescein angiogram.

RESULTS Nineteen patients were evaluated, 17 men and 2women; age range, 25–61 years [mean, 42.36 years with a SD of10.89]). The mean BCVA was 20/50 (range, 20/20 to 20/200).Three patients had a prior history of focal laser. The intervalbetween laser and detection of CNV was 2-3 months. All theCNV were of subretinal membranes, predominantly subfoveal(63%). The mean foveal thickness was 239.6µm (range 124-677µm). All patients had a presence of subretinal fluid andsubretinal tissue. Seven eyes (35%) had a serous pigmentepithelial detachment (PED). No fibrovascular PED was noted.Intra-retinal cystic changes were noted in 6 eyes (30%).

CONCLUSION CNV secondary to Chronic CSC present as type 2membranes. Fibro-vascular PEDs are not seen in these cases.

OCT showing type 2 choroidal neovascular membrane with intraretinal cystoid changes.




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450Logarithmic Transformation of SD-OCT Data in Uveitis-Associated Macular Edema

John F. Payne, MD (Atlanta, GA), Beau B. Bruce, MD, Lee B.K. Lyndon, MD, Steven Yeh, MD

PURPOSE Logarithmic transformation of retinal thickness wasrecently shown to provide analytic advantages over centralsubfield thickness (CST) in evaluating clinically relevantchanges in retinal thickness. The purpose of this study was toevaluate the utility of logarithmic transformation of spectral-domain OCT (logSD-OCT) in evaluating clinically relevantchanges in macular edema secondary to uveitis.

METHOD Patients with noninfectious uveitis-associated macularedema at our institution between August 2010 and March 2011 were identified. Only those with SD-OCT imaging wereincluded. The clinical diagnoses, visual acuities, and CSTresults, as measured by the Zeiss Cirrus HD-OCT manufac-turer’s software, were recorded. Logarithmic transformation ofCST (logSD-OCT) was performed. Frequency histograms wereplotted for CST and logSD-OCT. Skewness and kurtosis ofboth data sets were determined. A linear mixed effects modelwas created to account for within patient correlation and corre-lation of the logarithm of the minimum angle of resolution(logMAR) visual acuity with logSD-OCT was performed.

RESULTS A total of 98 SD-OCT images from 34 patients wereanalyzed. Eight men and 26 women were included, and themean age at examination was 40 years (range: 11-69 years).Anatomic diagnoses included anterior/intermediate uveitis(23%), intermediate uveitis (21%), posterior uveitis (12%), and panuveitis (44%). Logarithmic transformation of SD-OCTdata provided a more normal distribution than CST (Figure 1).Skewness and kurtosis of CST data were 1.04 and 0.37, respectively. Skewness and kurtosis of logSD-OCT data were0.40 and -0.48, respectively. There was a significant correlationbetween logSD-OCT and logMAR visual acuity. For each 0.1unit increase in the logSD-OCT the logMAR visual acuitiesincreased (worsened) by 0.082 units (95%CI: 0.57-1.07,p<0.001).

CONCLUSION Logarithmic transformation of SD-OCT measure-ments provided a more normal distribution and positivelycorrelated with logMAR visual acuity. This transformation ofSD-OCT retinal thickness measurements may be valuable forthe assessment of clinically meaningful SD-OCT changes inuveitis research.

Distribution of SD-OCT central subfield thickness measurements (top)shows a positive skew, whereas logarithmic transformation of the centralsubfield thickness (logSD-OCT, bottom) shows a more normal distribution.

451SD-OCT and Infrared Imaging of Leukemic Infiltration of the Choroid

Ravi Radhakrishnan, MD (Jacksonville, FL), Jayson Edwards, MD, Vijay Khetpal, MD, K.V. Chalam, MD, PhD, MBA, FRCS(C)

PURPOSE To identify unique characteristics of infrared, auto fluorescence, and spectral-domain optical coherencetomography (SD-OCT) imaging in a patient with leukemicinfiltration of the choroid.

METHOD A patient with a known diagnosis of metastaticleukemia underwent complete ophthalmological examination,infrared (IR) fundus photography, fundus autofluorescence(FAF) imaging, fluorescein angiography and SD-OCT(Spectralis, Heidelberg Engineering).

RESULTS A 42 y.o. African American woman with a history ofdiabetes mellitus, hypertension, t-cell leukemia complained ofblurry vision for one month and was referred to the departmentof ophthalmology. FAF showed a patchy areas of decreased FAF


signal. IR showed wrinkling of the RPE and areas of decreasedsignal near the optic nerve. Areas of decreased signal corre-sponded to areas of subretinal fluid. Fluorescein angiographyshowed a multifocal hyperfluorescence in early phase withpooling of fluoresecein dye in late phases. SD-OCT revealedmultiple areas of subretinal fluid overlying thickened choroid.The thickened infiltrated choroid may serve as the pathogenesisfor the areas of subsensory detachment secondary to poorlyfunctioning RPE pumps.

CONCLUSION Thickened choroid in the area of leukemic infiltration alters permeability that results in patchy sensoryretinal detachments. In addition, RPE wrinkling noted oninfrared photography served as an anatomical marker fordysfunctional RPE.

Autofluorescence showing multiple patchy areas of decreased signal.

SD-OCT showing evidence of a thickened choroid with a subsensory retinal detachment. Infrared imaging shows wrinkling of the retinal pigment epithlium.

452Choroidal Thickness in Patients with Diabetic Retinopathy Analyzed by SD-OCT

Caio V. Regatieri, MD, PhD (Boston, MA), Lauren Branchini, BA, Jay S. Duker, MD*, Jill Carmodu, MD

PURPOSE Clinical and experimental studies suggested thatchoroidal vasculopathy in diabetes may play a role in the patho-genesis of diabetic retinopathy. Therefore this study was designto examine choroidal thickness in patients with diabetes usingspectral-domain optical coherence tomography (SD-OCT).

METHOD Forty-nine patients (49 eyes) with diabetes and 24 age-matched normal subjects underwent high-definition rasterscanning using SD-OCT with frame enhancement software.Patients with diabetes were classified into three groups: 11patients with mild or moderate non-proliferative diabeticretinopathy and no macular edema (NPDR), 18 patients withNPDR and diabetic macular edema (DME) and 20 patientswith treated proliferative diabetic retinopathy and no DME(PDR). Choroidal thickness was measured from the posterioredge of the retinal pigment epithelium to the choroid/sclerajunction at 500µm intervals up to 2500µm temporal and nasalto the fovea.

RESULTS Reliable measurements of choroidal thickness wereobtainable in 75.3% of eyes examined. Mean choroidal thick -ness showed a pattern of thinnest choroid nasally, thickening in the subfoveal region, and then thinning again temporally.There was a statistically significant difference betweenchoroidal thickness of normal subjects and patients in the DME group (P< 0.001) and PDR group (P< 0.001). Meansubfoveal choroidal thickness was thinner in patients withdiabetic macular edema (63.3 µm, 27.2% - P < 0.05) or PDR(69.6 µm, 30.0% - P < 0.01), compared with normal subjects.No correlation between central foveal thickness of the retinaand central foveal choroidal thickness was observed in DME group.

CONCLUSION Choroidal thickness can be measured using SD-OCT high-definition raster scans in the majority of diabeticeyes. Choroidal thickness is altered in diabetes and may berelated to the degree of severity of retinopathy. The presence of macular edema is associated with a significant decrease in the choroidal thickness.




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Graph of mean choroidal thickness in normal subjects and diabetic patients.Mean choroidal thickness at each of the 11 locations measured at 500 μm(0.5 mm) intervals temporal (T) and nasal (N). NPDR: non-proliferative diabeticretinopathy; DME: diabetic macular edema; PDR: proliferative diabeticretinopathy. P-value represents the result of statistical analyses (ANOVA).

453SD-OCT Characteristics of Central SerousChorioretinopathy in Older Adults

Caio V. Regatieri, MD, PhD (Boston, MA), Lauren Ann Branchini, BA, Jay S. Duker, MD*

PURPOSE The purpose of this study was to describe clinicalfindings including spectral domain optical coherencetomographic (SD-OCT) imaging cheracteristics of both theretina and choroid in patients older than 60 years presentingwith central serous chorioretinopathy (CSC).

METHOD Thirty eyes (29 patients) with findings consistent with central serous chorioretinopathy were divided into 2groups according to the duration of symptons: acute(<4months) or chronic (>4months). SD-OCT images werecaptured during active (with serous retinal detachment-SRD)and inactive (without SRD) phase. Extensive chart review wasperformed. Retinal characteristics, such as retinal pigmentedepithelial detachment (PED) and retinal pigmented epithelium(RPE) thickening were observed. The choroidal thickness wasmeasured in 10 patients at 500-µm intervals up to 2500 µmtemporal and nasal to the fovea. Additionally, these measure-ments were compared with those of 24 age matched normal subjects.

RESULTS Ten eyes (10 patients) and 20 eyes (19 patients) wereincluded in the acute and chronic groups, respectively. Therewas no difference in age between the acute and chronic groups(65.3 ± 6.1 years – acute; 67.7 ± 5.9 years – chronic). Twopatients in the acute group and 1 patient of the chronic groupwere using systemic steroids. The average time to resolution ofthe SRD was higher in the chronic group (18.85 weeks) whencompared to the acute group (15.2 weeks). In the chronic group,SD-OCT images demonstrated a higher percentage of eyes withPED (60%, chronic vs. 40% acute) and RPE thickening (45%-chronic vs. 20%- acute). Retinal cystic changes were observedin two patients in the chronic group. Choroidal thickness was significantly in eyes with active and inactive CSC whencompared to normal subjects (P<0.001). Further, there was adifference between subfoveal choroidal thickness in subjectsthat were active vs. inactive. (328 ± 52.9 µm, active vs. 311.1 ± 59.18, inactive; P=0.030).

CONCLUSION CSC in older adults should be remembered as partof the differential diagnosis of neovascular AMD. The choroidhas been shown to be significantly thicker in CSC which mayhelp to differentiate CSC from neovascular AMD. SD-OCTfindings are the same in this population of older subjects withCSC as observed in young patients though PED and RPE thickening are more common in chronic CSC.

454Comparison of Choroidal Visibility andThickness Using Two SD-OCT Instruments with Different Wavelength Light SourcesHumberto Ruiz-Garcia, MD (Los Angeles, CA), Florian M. Heussen, Ramsudha Narala, MD, Emma McDonnell, MD, Srinivas R. Sadda, MD*

PURPOSE To evaluate the effect of spectral domain opticalcoherence tomography (SD-OCT) light source wavelength(840 nm vs. 1050 nm) and B-scan averaging on the visibilityand thickness measurements of the choroid.

METHOD Retrospective study of 50 eyes of 31 patients thatunderwent volume scanning without averaging and high-definition raster scanning with frame 4x averaging using theCirrus HD-OCT (Zeiss-Meditec, 840nm) and a prototype OCT from Zeiss operating at 1050nm. Choroidal thickness wasmeasured at the foveal center. Cases with partial choroidalvisibility were noted and thickness measurements to the extentof the visible choroid were made. All eyes were measured bytwo independent observers. Choroidal thickness and thepercent of cases with full choroidal visibility were comparedbetween devices and scanning protocols. Choroidal thicknessmeasurements were also correlated with age and visual acuity.


RESULTS The mean age of the patients was 65 years (range=21to 100 years), and 48% (n=15) were women. The choroid wasfully visible in 60% (25/42) of eyes by non-averaged 1050nmSD-OCT imaging, in 40% (17/42) by non-averaged 840nm SD-OCT, in 82% (36/44) by averaged 1050nm SD-OCT, andin 61% (27/44) by averaged 840nm SD-OCT. Mean choroidalthickness did not differ significantly between eyes with fully orpartially visible choroids. Univariate regression identified alinear relationship between age and choroidal thickness whenmeasured using the averaged 1050nm scans (r=-2.48, p=0.005),but no relationship was found between choroidal thickness andvisual acuity.

CONCLUSION The use of a longer wavelength light source(1050nm) than the conventional wavelength (840nm) used incommercially available SD-OCT instruments allows for deeperpenetration and improved visualization of the choroid. Theenhanced visualization effect appears to be additive to otherenhancement strategies such as b-scan averaging.

Foveal scan of an eye with geographic atrophy shows fully visible choroid when imaged with the 1050nm (A) and the 840nm (B) light sourceinstruments. This is due to increased penetration of light with pigmentatrophy. Notice however, that with the 1050nm instrument vesselspenetrating the sclera can be visualized as hyporeflective structures.

Foveal scan of an eye with fibrovascular PED shows better penetrationand detail of the choroidal vasculature with the 1050nm (A) instrumentthan with the 840nm conventional instrument (B).

455Retinal Nerve Fiber Layer Thickness Analysiswith SD-OCT for Assessment of GlaucomaCormorbid to Retinal Pathology

Raymond N. Sjaarda, MD (Towson, MD)

PURPOSE To evaluate the benefit of retinal nerve fiber layer(RNFL) thickness analysis with spectral domain opticalcoherence tomography (SD-OCT) in assessing glaucoma as acondition comorbid to primary retinal pathology.

METHOD Retrospective review of a consecutive series of patientsundergoing analysis of the RNFL thickness by SD-OCT as partof a comprehensive examination assessing for comorbid condi-tions during evaluation of the primary suspected retinalpathology in a private referral retina practice.

RESULTS Of the 120 patients evaluated for comorbid glaucoma25 (21%) were being followed for ocular hypertension/glaucomasuspect/glaucoma. Of these 25 patients, 22 had RNFL thicknessbelow normative values, 2 were borderline, and 1 had normalthickness. Of the 95 patients without prior ocular hypertension/glaucoma, 21 wee found to have normal RNFL thickness, 60had thickness below normal values, and 14 were borderline. Of the 60 patients were abnormally low values 45 were referredto a comprehensive ophthalmologist or glaucoma specialist forfurther evaluation and management. Subsequent therapeuticinterventions included new medications in 6 patients andiridotomy in 4 patients.

CONCLUSION Evaluation of the RNFL by SD-OCT is useful inevaluating eyes with clinical findings suspicious for comorbidglaucoma in patients referred with retinal pathology.

456SD-OCT Features of Intra Retinal Silicone Oil in Eyes Following Silicone Oil Removal

Malhar Soni DO, MS, DNB, FRCS (London, England)

PURPOSE To describe the Spectral-domain optical coherencetomography features of intraretinal silicone oil followingsilicone oil removal, in patients with a history of silicone oiltamponade for retinal detachment.




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METHOD We retrospectively reviewed consecutive series of teneyes in ten patients who underwent retinal detachment repairwith silicone oil tamponade at our department. All eyesunderwent complete PFCL removal at the time of silicone oilinjection. All patients were examined with spectral-domainoptical coherence tomography at 3 and 6 months after siliconeoil removal. C-scans were correlated with their correspondingB-scans, infra-red imaging and fundus photograph. Thepresence of intra retinal silicone oil was compared with visualacuity, duration of silicone oil tamponade and number ofprevious vitreo-retinal procedures before silicone oil removal.

RESULTS Five out of ten eyes had intra retinal optically emptyvacuoles at the posterior pole on SD-OCT assessment whichwere also seen on infrared imaging. The appearance of welldefined, isolated, cystic spaces without surrounding tissue changewas typical of intraretinal silicone oil. The characteristic cysticspaces showed no significant change over an 24-month periodin one eye. The mean duration of tamponade was 5.9 monthsand the timing of SD-OCT ranged from 3 to 24 months postsilicone oil removal. The median number of vitreo-retinalprocedures prior to silicone oil removal was 3 in patients withintraretinal oil. Visual outcome was <20/80 in all cases.

CONCLUSION Spectral-domain optical coherence tomographyshould be routinely considered in eyes with silicone oiltamponade to detect intraretinal migration of silicone oil. Thismay help in making a case for early removal of silicone oil toprevent unexplained vision loss in such eyes. Prospectivestudies are needed to confirm whether this phenomenon has a demonstrable effect on macular function.

B-scan SD-OCT image showing well-defined optically empty vacuoles without surrounding tissue changes.

En-face imaging of optically empty vacuoles at various levels of retina.

457Comparing Adaptive Optics Imaging Modalities in Genetic Ocular Diseases – Is Information Lost with Better Resolution?

Kimberly G. Stepien, MD (Milwaukee, MI), Brett Schroeder, MD, Jungtae Rha, Adam Dubis, Robert Cooper, MD, Alfredo Dubra, MD, Joseph Carroll*

PURPOSE Both flood illuminated adaptive optics (AO-Flood)and adaptive optics scanning laser ophthalmoscopes(AOSLO)allow for high resolution in vivo visualization of individualretina cells. However, analyses of images from the same subjectobtained by AO-flood and AOSLO have not been reported.Here we compare AO-Flood and AOSLO images in patientswith no ocular pathology and with genetic ocular diseases.

METHOD AO-Flood and AOSLO images were obtained in 5subjects (2 normal, 1 albinism, 1 choroideremia, and 1 achro-matopsia). Subjects’ eyes were dilated using a combination ofphenylephrine hydrochloride (2.5%) and tropicamide (1%),and head stabilization was achieved using a dental impressionon a bit bar for each system. Individual frames from each AO system were registered and then averaged using a customMatLab-based algorithm for subsequent analysis. Individualcones in each image were identified using a semi-automatedcone identification program and cone density measurementswere obtained in all images. Resulting images were alsoinspected for further qualitative differences.

RESULTS Cone photoreceptor density values between the AO-flood and AOSLO imaging systems were in good agreementwith average difference of approximately 5% (2,200 cones/mm2)with the exception of the patient with achromatopsia whereAOSLO images were severely distorted due to nystagmus. Likelydue to the fact that AOSLO images are acquired confocallywhich improves axial resolution, the AOSLO consistently hadhigher cone density measurements. The AOSLO also allowedfor consistent visualization of rod photoreceptors, especiallyfarther from the fovea. In AO-Flood images of the patients withgenetic ocular diseases, heterogeneous photoreceptor structurechanges and patterns were observed. These were not seen onAOSLO, likely are related to the process of retina degeneration,and are of unknown significance. AO-flood images were notdistorted or blurred by nystagmus, even in the achromatopsiapatient, due to the short exposure used to capture the images.

CONCLUSION Adaptive optics retina imaging can play a role infurther understanding of photoreceptor pathology in geneticocular diseases. Elucidating the different information providedby various AO imaging modalities is necessary for better understanding of their clinical utility for assessment of geneticocular diseases.


Practice Management and Socioeconomics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

501Integration of a Telemedicine DiabeticRetinopathy Assessment System with anElectronic Personal Health Record

Ingrid Zimmer-Galler, MD (Baltimore, MD), Jay Braman, MD, Gary Gregory, MD

PURPOSE Microsoft HealthVault is on an-line platform to storeand maintain personal electronic health and fitness infor-mation. The purpose of this project was to develop an interfaceto allow patients with diabetes to access, review, share, storeand manage their relevant retinal imaging data captured via atelemedicine diabetic retinopathy assessment system in theprimary care setting.

METHOD An interface was produced with the Microsoft Health-Vault Software Development Kit to directly upload the retinalimage files, composite images and assessment and referralrecommendation reports from an established telemedicinediabetic retinopathy screening program into the patient’sHealthVault file repository. Additionally, an entry into theHealthVault supported subset of the Continuity of Care Recordhas been written to allow identification of retinal abnormalitiesthat have been detected during the assessment of the retinalimages. Submission of the diabetic retinopathy assessmentinformation to a personal HealthVault account is at thediscretion of the patient.

RESULTS This project demonstrates that remotely obtainedretinal images and reports from a telemedicine system to screenfor diabetic retinopathy can be stored and shared in individualaccounts on the Microsoft HealthVault platform. In turn, thisplatform allows patients to use the retinal image information tocomplement clinical and laboratory records and be utilized as aresource for patient care, comparison at future follow-up evalua-tions, access by multiple physician specialties and patienteducation. The HealthVault platform becomes an especiallypowerful diabetes management tool when retinal assessmentinformation is linked with other devices allowing glucosemonitoring and tracking weight and physical activity.

CONCLUSION This demonstration is the first known integrationof a telemedicine diabetic retinopathy program within a globallyavailable, open access electronic personal health record.

Pediatric Retina – ROP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

POSTERS 601-612

601Four Port Pars Plana Vitrectomy for Stage 4Band 5 Retinopathy of Prematurity (ROP)

Pramod S. Bhende MBBS (Chennai, India), Lingam Gopal, MBBS, Tarun Sharma, MBBS

PURPOSE To evaluate feasibility of 4 port bimanual parsplanavitrectomy (PPV) using chandelier illumination in eyes withstage 4B /5 ROP having very severe, florid and extensivefibrovascular proliferation.

METHOD A retrospective analysis of records of eyes undergoingfour port PPV for stage 4B and 5 ROP. Seven eyes of fiveinfants underwent four port PPV. The fourth port was for 25GChandelier light, placed at 12’o clock or in inferotemporalquadrant.

RESULTS Six eyes had stage 4B ROP while one had stage 5 ROP.All the eyes had prior laser ablation. 3 eyes had intra vitreal antiVEGF injections 5-7 days before surgery. In three eyes, 23Ginstruments were used while in the rest, 20G instruments wereused besides the Chandelier illuminator. Surgery could becompleted in all the eyes without any intra or post operativesclerotomy related complications.

CONCLUSION Four port PPV is a feasible option in selected eyeswith ROP needing surgery. 25G Chandelier light through 4thport gives excellent illumination to facilitate true bimanualmembrane dissection in these technically challenging eyes.

602The ROP Treatment Dilemma in the Time of Bevacizumab

Audina M. Berrocal, MD (Miami, FL), Darius Moshfeghi, MD*, Elias Mavrofrides, MD, Ditte Hess

PURPOSE How should we follow babies in clinic who weretreated with bevacizumab and are not completely vascularizedwith a persistent ridge?

PRACTICE MANAGEMENT AND SOCIOECONOMICS



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METHOD Observational study of three babies treated in the com -munity with bevacizumab that are followed in an outpatientclinic setting with serial photographs and/or fluoresceinangiograms.

RESULTS Serial photographs in the outpatient clinic show thepersistence and reactivation of the ridge in Zone 2 ROP. Lasersupplementation may be the best option in these babies that arenot completely vascularized.

CONCLUSION Bevacizumab has a role in the treatment of Zone1/Aggressive ROP as shown by the BEAT-ROP study, but lasersupplementation of those children who dont vascularizecompletely might be a better option.

603Comparison of Short Term Outcomes after Intravitreal Bevacizumab vs.Ranibizumab in the Treatment of Stage III Retinopathy of Prematurity

Gerardo Garcia-Aguirre, MD (Mexico City, Mexico), Hugo Quiroz-Mercado, MD, Jans Fromow-Guerra, MD,PhD, Jose Guerrero-Naranjo, MD, Virgilio Morales-Canton, MD, Jose Dalma-Weiszhausz, MD, Maria A. Martinez-Castellanos, MD

PURPOSE To compare ophthalmologic and neurodevelopmentalfindings after intra vitreal injection of bevacizumab vs.ranibizumab as monotherapy in treatment-requiring retinopathyof prematurity (ROP) in a three-year follow-up.

METHOD Retrospective analysis of patients who received intra -vitreal injections of bevacizumab or ranibizumab asmonotherapy for stage III ROP. Neovascular regression,neurodevelopmental outcomes, anatomical and functionalfindings were recorded.

RESULTS Six patients (twelve eyes) were included. Threepatients (six eyes) received off-label bevacizumab (0.03ml), the same number of patients and eyes received off-labelranibizumab (0.03ml). At a 3 years of follow-up, regression ofneovascularization and normal vascular growth was found in all patients, no systemic complications were recorded andneuro developmental findings were normal. No ocular adverseevents were recorded in any of the two groups. Best correctedvisual accuity with adler charts were in average logMar 0.2(range 0.3-0.0)

CONCLUSION Our results suggest no significant differencebetween bevacizumab and ranibizumab in treatment-requiringROP. Antiangiogenic therapy is a promising therapy forpatients with stage III ROP. Further studies are needed toestablish the ideal time of treatment, long term safety andefficacy issues, and whether it should be used as standalonetherapy, or as adjuvant to laser and/or cryotherapy.

604Adverse Events After Off-label Intravitreal Bevacizumab in the Treatment of Retinopathy of Prematurity

Jose Guerrero-Naranjo, MD (Mexico City, Mexico), Olivia Baldivieso-Hurtado, MD, Gerardo Garcia-Aguirre, MD, Virgilio Morales-Canton, MD, Hugo Quiroz-Mercado, MD, Robison V.P. Chan, MD, Maria A. Martinez-Castellanos, MD

PURPOSE To describe the ocular and systemic adverse events ofintra vitreal bevacizumab (IB) used off-label in the treatment ofRetinopathy of Prematurity (ROP).

METHOD Retrospective analysis of the records of 195 patientswith ROP (stage 3, threshold, pre-threshold, 4a and 4b) whounderwent IB (0.05cc or 0.03cc) from September 2005 toOctober 2010. Baseline characteristics of each infant andadverse events during and/or after treatment were collected.Follow-up of the injection was at least of 3 months.

RESULTS We had a total of 52 local adverse events (26.6%)including worsening of prior retinal detachment (2%) in stage 4 retinopathy, peripheral fibrous avascular membrane(1%), self-resolving vitreous hemorrhage (1.5%), avascularretina in the extreme periphery (4.1%) and subconjunctivalhemorrhage (6.1%). Three patients (1.5%) died. One by sepsisby P. aeruginosa 2 months after injection, 1 by neuro-infectionafter a ventriculo-peritoneal shunt 6 months after injection, 1 by multiorganic disfunction secondary to blood transfusion 1 week after injection.

CONCLUSION The use of IB appears to be safe for type 1 pre -threshold and threshold ROP. With regard to systemic adverseevents, we believe that systemic abnormalities in childrentreated with intra vitreal bevacizumab for ROP may be asequelae of prematurity itself and not related to the medication.


605Foveal Development in ROP Patients Treated with Bevacizumab

Geeta A. Lalwani, MD* (Miami, FL), Elias Mavrofrides, MD, Ditte Hess, Audina Berrocal, MD

PURPOSE To determine whether the foveal avascular zone isaltered by use of bevacizumab for ROP.

METHOD This study includes 3 patients with threshold ROPwhom underwent fluorescein angiography and/or OCT forpersistance of disease following treatment with bevacizumab.

RESULTS Fluorescein angiography in all 3 treated patientsrevealed a poorly defined foveal avascular zone with lateleakage.

CONCLUSION The use of bevacizumab for threshold ROP couldalter foveal anatomy. Further clinical studies are warranted.

606Vascular Activity Score (VAS) as a Marker of Disease Burden and Prognosis in Neonatal ROP

Adrian M. Lavina, MD (Palm Beach Garden, FL), Khaled A. Tawansy, MD

PURPOSE To describe experience at one clinical center withmultiple surgeons of a quantitative grading system that corre-lates to disease burden, need for intervention with laserablation or anti-VEGF therapy, and prognosis with surgery.

METHOD A quantitative grading scale was devised based onretrospective observations from 100 consecutive eyes with ROP that underwent wide-field photographic imaging andfluorescein angiography. Five vascular activity parameters weregiven a score from 0 to 2: Activity of tunica vasculosa lentis and hyaloidal artery, extent of plus, width-height of ridge,presence of pre-retinal or vitreous hemorrhage, and extent ofintra/extra-retinal neovascularization. The resulting cumulativescore was used as a prognosis factor of anatomic success in 310 eyes that underwent vitreous surgery for ROP retinaldetachment and in 20 eyes that had the score modified byintra-vitreal bevacizumab therapy before surgery.

RESULTS A VAS of 0-10 was given for each eye that underwentvitreous surgery based on independent study of the wide-fieldphotographs and fluorescein angiograms. In eyes that under -went bevazicumab therapy, VAS was determined on the day ofinjection and at vitreous surgery 5 to 10 days later. Eyes werethen divided into 5 groups based on score (0-2, 3-4, 5-6, 7-8,

9-10), and mean anatomic success was determined for eachgroup. All eyes receiving bevacizumab had a reduction of VASby a mean of 4.5 points (2-8). A linear relationship wasdiscovered between VAS and retinal reattachment rate for eyesundergoing vitrectomy for retinal detachment in vascularlyactive ROP, and the use of bevacizumab correlated with lowerVAS and better surgical success.

CONCLUSION VAS may be a useful quantitative measure of ROPdisease vascular activity that can estimate anatomic prognosiswith vitreous surgery in the setting of retinal detachment andhelp guide use of anti-VEGF therapy.

607Retinal Vascular Changes Following Intravitreal Anti-VEGF Therapy for TreatmentRequiring Retinopathy of Prematurity

Maria A. Martinez-Castellanos, MD (Toluca, Mexico), Mario J. Saravia, MD, Robison V.P. Chan, MD, Virgilio Morales-Canton, MD, Gerardo Garcia-Aguirre, MD, Jose Guerrero-Naranjo, MD, Gabriela LopezcarasaHernandez, MD, Hugo Quiroz-Mercado, MD

PURPOSE To describe the retinal vascular morphology in eyestreated with intra vitreal bevacizumab (IB) for treatmentrequiring retinopathy of prematurity (ROP).

METHOD Prospective, nonrandomized case series. We included10 patients (20 eyes) diagnosed with stage 3, threshold orprethreshold ROP. Fundus photographs and Fluorangiography(FA) were obtained before and after IB treatment using a wide-field digital pediatric imaging system.

RESULTS Before treatment, FA showed vascular abnormalities,including capillary non-perfusion throughout the vascularizedretina, shunting in the vascularized retina, a demarcation line,and limited vessel development, new vessels leakage, andavascular periphery. After the treatment with the suppression of VEGF, FA showed obliteration of abnormal new vessels,followed by involution of the neovascularization, flattening ofthe demarcation line and subsequent growth of vessels to thecapillary-free zones. During the following weeks large areasdevoid of microvessels were seen, 6 months post intra vitrealinjection of bevacizumab, vascular remodeling was seen withuneven spacing of the retinal capillaries and vascular loops inthe areas that were previously devoid of vessels. In somepatients, the retinal vessels in the far periphery never developed.Subsequently, these patients did not develop pathologicalneovascularization.

CONCLUSION Our study shows that even when the vascularpattern is abnormal after IB therapy, the creation of smallvessels, the establishment of directional flow, the associationwith mural cells and the adjustment of vascular density to meetthe requirements of the retina have been accomplished. Longerfollow-up is needed of prospective multicenter studies todetermine the safety profile of IB for ROP.

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608OCT Imaging Findings after IntravitrealBevacizumab for Treatment-requiringRetinopathy of Prematurity, Case Series

Virgilio Morales-Canton, MD (Mexico City, Mexico),Maria A. Martinez-Castellanos, MD, Jose Guerrero-Naranjo, MD, Jans Fromow-Guerra, MD, PhD, Veronica Giordano, MD, Gerardo Garcia-Aguirre, MD

PURPOSE To describe the morphological features of the maculain patients treated with intra vitreal bevacizumab (IB) forretinopathy of prematurity (ROP) assessed by optical coherencetomography (OCT).

METHOD Six patients of different ages all treated for ROP stageIII with IB underwent dilated fundus image and OCT imagingevaluation with a handheld device (I-vue, Optovue, Inc.).

RESULTS Six patients were included. One at a 4 year follow-upafter receiving bevacizumab as treatment for ROP stage III inboth eyes, macular morphology was found with no structuralchanges, the central thickness was of 230um. A 2nd patient at 1 year follow-up, presented with no changes in macularmorphology and central thickness of 140um. The third case was evaluated at 2 month follow-up after receiving IB, with nomacular abnormalities. The last 3 babies were screened afterfinding macular leakage in the fluorescein angiogram 2 weeksafter intra vitreal treatment, with no abnormalities in themacular architecture.

CONCLUSION The use of IB shows no structural damage to theretinal layers as shown in OCT at different follow-up visits inthese six cases. Macular leakage seems to be secondary toinmaturity of superficial plexus vessels rather than vascularabnormalities. The OCT in this short study shows us previouslyunknown valuable information in the follow-up of patients with new modalities of treatment for ROP.

Fluorescein angiography post intravitreal bevacizumab that shows parietal leakage.

OCT image of same case that demonstrate a normal macular area.

609Surgical Case Series: Perfluorocarbon LiquidInfusion-assisted External Drainage ofSubretinal Exudate in Advanced Coats’ Disease

Franco M. Recchia, MD (Nashville, TN), Maziar Lalezary, MD

PURPOSE Coats’ disease, especially in younger children, has apoor natural history. Therapeutic goals are optimization ofvision, comfort and cosmesis through reduction of exudationand avoidance of neovascular glaucoma and require serialexams and treatments under anesthesia. We describe a surgicaltreatment of total exudative detachment in Coats’ disease andpresent outcomes in a series of patients.

METHOD Retrospective review of consecutive patients withadvanced Coats’ disease treated with this surgical technique. Inbrief, an encircling element was placed followed by pars planavitrectomy, with or without lensectomy, with simultaneousperfluorocarbon liquid infusion and trans-scleral drainage ofsubretinal fluid and lipid exudates. Primary outcomes wereglobe salvage and patient comfort at one year postoperatively.Secondary outcomes were: intraoperative complications; retinalreattachment at 3 and 12 months; additional interventions.

RESULTS Four boys (ages 2 mos-12 yrs) with unilateral advancedCoats’ disease (3 with Stage 3B and one with Stage 4) wereincluded. All eyes underwent the described technique withoutintraoperative complications. Post-operative follow-up rangedfrom 12-34 months (mean, 19 months). All patients attainedglobe salvage and were comfortable at one year postoperatively.At 3 months, all eyes achieved successful retinal reattachment.At 12 months, three eyes maintained successful reattachmentwhile one patient developed a localized peripheral detachmentfollowing head trauma. Three of four eyes have undergonesuccessful removal of silicone oil. While no eyes displayeddisease progression following surgery, one child required lasertherapy for residual disease and another had mild subretinalfluid accumulation following silicone oil removal. In the mostadvanced case (5 year-old boy with glaucoma due to Stage 4disease), no further treatment was necessary for control ofintraocular pressure.

CONCLUSION The surgical technique described (combined scleral buckling, pars plana vitrectomy, and perfluorocarbonliquid-assisted external drainage of sub-retinal fluid) waseffective in achieving therapeutic goals in this small series ofpatients with advanced Coats’disease. This alternative approachmay reduce the need for serial examinations, treatments, andexposure to anesthesia.


610Comparison of Bevacizumab and Laser Therapy for the Treatment ofRetinopathy of PrematurityDustin Pomerleau, MD (Birmingham, AL), Richard Feist, MD, Tracy L. Emond, Lindsey Wallace, MD, John O. Mason, MD, Martin L. Thomley, MD, Michael A. Albert, MD, Thomas A. Finley, MD

PURPOSE Retinal laser is the current gold-standard for treatmentof retinopathy of prematurity (ROP). Evidence exists that intra -vitreal bevacizumab (IVB) may provide equivalent results tolaser therapy. Our study seeks to compare outcomes of the twomodalities within a single practice.

METHOD Retrospective review of all babies referred to a multi-physician retina practice for ROP from 2000 to 2008. Eyes wereclassified into 3 treatment groups: observation, IVB, and laser.Groups were compared with respect to baseline characteristicsand outcome at 8 weeks follow-up (no ROP, relative regression,stable, relative progression (including macular dragging &traction without retinal detachment), and progression to stage4A or greater (including surgical & endstage ROP). Relativeregression and progression were defined as: a change in ROPstage, resolution or new onset of plus disease, or specific docu -mentation by examiner that the number of clock-hours of ROPhad changed since baseline.

RESULTS Two-hundred-fifteen eyes of 107 children werescreened for inclusion and 172 eyes of 89 children wereincluded. Seventy-three eyes were observed, 32 eyes receivedIVB, and 67 eyes were treated with laser. There were no statisti-cally significant differences in gender distribution, gestationalage at birth, or birth weight between the groups. At the time of treatment there was no statistically significant difference inthe mean stage/zone of ROP or the proportion of patients withplus disease when comparing the IVB and laser groups. At 8 wkpost-treatment 10 eyes (31.3%) receiving IVB had relativeregression of ROP and 22 eyes (68.8%) had no ROP. Fifteeneyes (22.4%) receiving laser had relative regression of ROP and 26 eyes (38.8%) had no ROP. Seventeen eyes (25.4%)receiving laser had relative progression of ROP. None of theeyes receiving IVB progressed, p=<0.001 for all comparisons.There was no statistically significant difference in mortalitybetween the treatment groups, p=0.22.

CONCLUSION Intravitreal bevacizumab causes regression orcomplete resolution of ROP in the majority of patients, andmay reduce progression of ROP compared to laser therapy.

611Malaria Retinopathy in a 7 year Old Child from the Ecuadorian Tropics

Armando G. Sandoval, MD (Quito, Ecuador), Geoconda Leon, MD, Sandra X. Larco, Andrea E. Ayala, MD, Juan J. Chiriboga, MD

PURPOSE 1) To present a clinical case of presumed MalariaRetinopathy in a child from the Ecuadorian Tropics, who haspigmented maculopathy and disc pallor in one eye with poorvision , and reduced vision in the fellow eye. 2) To review themain features of Malaria Retinopathy.

METHOD Review of clinical chart of a 7 year old boy from LaConcordia , a city in the tropical region of Santo Domingo-Ecuador, who had malaria since he was born , needing intensivetreatment the first month in the hospital and then ambulatorilyfor 2 years. His mother, while pregnant also had malaria andreceived treatment from the first to the sixth month. Ophthal- mological findings: BCVA OD: LogMAR 0,3 (20/40), OS:LogMAR > 1,3 (CF 30cm). OS with sensorial exotropia of -45 Δ. Fundus: OD normal , OS: disc pallor and pigmentedmaculopathy in a horizontal spindle fashion.

RESULTS Retrospective revision of the clinical chart revealedplasmodium falciparum malaria in the boy and his mother, that was treated according to the WHO recommendations. The strabismus was present since the 6th month of life and wassurgically corrected in January 2011. The reduced vision in OD, -2,00x10 = 20/40 (LogMAR 0,3) can be attributed toamblyopia or an organic cause (cerebral malaria or malariaretinopathy?).

CONCLUSION 1) OS fundus suggests a sequel of malariaretinopathy, and the normal appearance of OD doesn’t rule out malaria retinopathy that solved with time. 2) Bull’s eyemaculopathy is not associated with prophylactic Rx of malaria,like in rheumatological diseases, because the dosages are rela -tively small and drugs are used in a short time. 3) MR occurs inaround 60% of children with cerebral malaria.

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OS picture showing severe disc pallor and pigmented maculopathy in a horizontal spindel fashion.

OD picture: normal appearance.

612Correlation of Microarray Gene ExpressionResults with Quantitative Trait Loci for Retinal Avascular Area in the Oxygen Induced Retinopathy Model

Robert Symons MBBS, PhD (Prairie Village, KS), Bliss O’Bryhim, MD

PURPOSE To use microarrays to identify candidate genes forquantitative trait loci that determine the difference in retinalavascular area at post-natal day 16 between BALB/c andC57BL/6 mice exposed to the oxygen induced retinopathymodel.

METHOD Mice were exposed to hyperoxia as per the standardoxygen induced retinopathy model for 120 hours from post-natal day 7 to post-natal day 12. The mice were sacrificed 24hours after they had returned to normoxia, the eyes wereenucleated and the retinas were snap frozen. Subsequently themRNA was extracted and microarray analysis was performed(Mouse 430 array, Affymetrix). Microarray studies wereperformed on 3 mice, each from a separate litter, from bothBALB/c and C57BL/6 strains. Normoxic controls were alsostudied. Limma was used for array normalization.

RESULTS Using an F2 intercross we have previously foundquantitative trait loci (QTL) that are associated with retinalavascular area at post-natal day 16. The 1.8-LOD supportintervals for these loci are: on chromosome 7, 88.3-146.2 Mbpand, on chromosome 9, 18.6-95.9 Mbp.

Transcripts were identified which (i) demonstrated 2-foldgreater expression in either C57BL/6 or BALB/c retinascompared to the other strain after exposure to the oxygeninduced retinopathy model, and (ii) had an adjusted P-value of< 0.001. Three genes that map within the chromosome 7 QTLwere differentially expressed between C57BL/6 and BALB/caccording to these criteria. These were: Tyr, Hdfgrp3 and Nmb.Sixteen genes that map within the chromosome 9 QTL weredifferentially expressed.

CONCLUSION The genes coding for the transcripts identified here are candidate quantitative trait genes for the QTL onchromosome 7 and 9.


Ocular Oncology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

POSTERS 701-705

701Expected Long-term Survival Prognosis of Posterior Uveal Melanoma Patients Whose Tumor Cells Exhibit Disomy 3 and/or Class 1 Gene Expression Profile

Zelia M. Correa, MD, PhD (Cincinnati, OH), James J. Augsburger, MD

PURPOSE To estimate the projected long term survival ofpatients with a posterior uveal melanoma whose tumor cellsexhibit disomy 3 and/or a class 1 gene expression profile (GEP)using a hypothetical survival modeling assuming two distinctsurvival distributions and outcomes based on data obtainedfrom published AFIP data.

METHOD Hypothetical survival modeling of patients withprimary uveal melanoma assuming two distinct survival distri-butions. Modeling attempted to predict the expected long-termsurvival of disomy 3 and/or class 1 GEP patients by making the combined subgroups’ survival distribution mirror that ofpatients without known chromosomal or GEP status. Short-term survival curves for patients evaluated by chromosomaltesting and/or GEP were obtained from recently publishedarticles, and long-term survival curves for patients withoutknown chromosomal or GEP status were obtained frompublished AFIP data. Authors will discuss potential explana-tions for early and late appearing metastasis in these patients.

RESULTS Survival modeling predicted that approximately 15 to25% of patients with primary choroidal or ciliary body melanomawhose tumor cells have been categorized by chromosomaltesting or gene expression profiling as disomy 3 or class 1 caseswill ultimately develop uveal melanoma metastasis; however,most of these patients will not exhibit this metastasis until morethan 5 years after treatment of the primary intraocular tumor.

CONCLUSION Current short-term predictions of survival prognosisof patients with uveal melanomas associated with disomy 3and/or class 1 GEP are likely to be substantial under estimates of these patients’ long-term survival prognosis. Meanwhile,patients with such tumors should be more cautiously advisedabout their risk of developing future metastasis.

Comparative Expected Survival of Chromosomal and Transcriptional Subgroups of Posterior Uveal Melanoma Patients

702Intravitreal Bevacizumab for Choroidal Metastases Secondary to Adenocarcinoma of the Lung

Manjot K. Gill, MD (Chicago, IL), Lee Jampol, MD, Ankur Shah, MD

PURPOSE To present a case of choroidal metastases from lungadenocarcinoma treated with intra vitreal bevacizumab prior toexternal beam radiotherapy and systemic chemotherapy.

METHOD Retrospective interventional case report of a 72-year-old male who presented with decreased visual acuity and arelative scotoma in his left eye. No significant past ocular ormedical history was present.

RESULTS Clinical exam revealed a pale elevated subretinal lesionin the macula of the left eye with fovea-involving subretinalfluid (SRF). SD-OCT confirmed choroidal elevation with SRF.Fluorescein angiography revealed early blockage with gradualincrease in hyperfluorescence. Ultrasound showed an irregularsolid mass with moderate to high internal reflectivity. Systemicworkup revealed primary adenocarcinoma of the lung withmetastases to the brain, scapula, ribs, and vertebrae. Thepatient was treated with 2 injections of intra vitreal bevacizumabto the left eye (1.25 mg followed by 2.5 mg) and 1 treatment in the right eye (1.25 mg) for an additional metastatic lesion.Exam of the left eye 1 week following the first injection didreveal onset of pigmentary changes. However given persistentSRF and deterioration of visual acuity, external beam radiationand systemic chemotherapy were initiated, which yieldedresolution of SRF, involution of the lesions, and restoration of visual acuity.

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CONCLUSION Although anti-vascular endothelial growth factor(anti-VEGF) therapy may represent a therapeutic option for choroidal metastases, with a favorable side effect profile,enthusiasm for positive results should be tempered. Treatmentwith anti-VEGF agents may instead have a more adjunctiverole to more established treatment modalities such as externalradiotherapy and systemic chemotherapy.

Fundus photo shows a large, elevated, pale subretinal lesion in the superotemporal macula of the left eye. This eye was subsequently injected with intravitreal bevacizumab.

Fundus photo showing pigmentation over the macular lesion 1 week following injection of 1.25 mg/0.1ml intravitreal bevacizumab in the left eye.

703Strategies for Chemotherapeutic DosingUtilizing Intra-arterial MelphalanChemotherapy for Primary and RescueTreatment of Pediatric Retinoblastoma

Timothy G. Murray, MD, MBA (Miami, FL), Mohammad Ali Aziz-Sultan, MD, Cristina E.Fernandes, MD, Lejla Mutapcic, Samuel Houston

PURPOSE This study evaluated a clinical dose and schedulingstrategy for advanced retinoblastoma treatment utilizing intra-arterial chemotherapy.

METHOD IRB approved retrospective review of a consecutivecase series of children treated with advanced intraocularretinoblastoma using intra-arterial chemotherapy. All patientsreceiving intra-arterial chemotherapy were evaluated. Datacollection included demographics, staging, prior treatment,intra-arterial chemotherapy treatment number, treatment dose,

complications, and outcome to include survival, globe conser-vation and visual function. All eyes received intra-arterialchemotherapy associated with pre, and post, chemotherapydirect transpupillary laser therapy.

RESULTS 26 intra-arterial chemotherapy (IAC) procedures wereperformed in 17 eyes of 15 children. Mean age at IAC treat -ment was 38 months (6 to 84 months). All 17 eyes presentedwith advanced vitreous seeding (RE Stage Vb). Mean follow-upwas 12 months (3 to 24 months). IAC Melphalan dose rangedfrom 3.0 to 7.5 mg. 76% of IAC treated eyes were salvaged(13/17 eyes). Treatment with higher dose 7.5 mg Melphalanwas associated with avoidance of enucleation (0% versus 36%, p <.05). Complications were IAC procedure specific andwere not associated with dose delivery. All eyes undergoingenucleation presented with clinically persistent viable tumorassociated with subretinal/preretinal hemorrhage. Histo -pathology of all 4 enucleated eyes confirmed viableretinoblastoma.

CONCLUSION Intra-arterial chemotherapy using selectiveophthalmic artery delivery effectively treats advanced intra-ocular retinoblastoma. Higher melphalan dosing (7.5 mg) andrepetitive treatment at/or above 5.0 mg melphalan improvedtumor control and globe salvage. Combining high dose IACwith focal laser tumor treatment appears promising as both aprimary, and “salvage” therapy for pediatric RB.

704Retrospective Review of Proton Beam Therapy for Ocular Melanoma

F. Ryan Prall, MD (Indianapolis, IN), Nam Keun Yoon, Nam Keun Yoon, MD, Clement K. Chan, MD*, Ramin Monshizadeh, MD, John P. Carlson, MD, Richard D. Pesavento, MD, Mark Schneider, Joseph T. Fan, MD

PURPOSE To evaluate the clinical outcomes of patients treated with proton beam radiation for ocular melanoma at a single facility.

METHOD Retrospective chart review.

RESULTS Over a 16 year period 138 patients were treated.Follow-up data was obtained for 77 patients with an averagefollow-up of 43 months. Twenty seven patients had tumorswithin the posterior pole and most (50 of 77) were medium-sized. Two mortalities occurred resulting in a 10-year diseasespecific survival of 96.4%. There were 11 treatment failures(Kaplan-Meier 10-year success rate: 78.1%) and 10 cases ofneovascular glaucoma.

CONCLUSION Proton Beam therapy is one option in thetreatment of ocular melanoma and outcomes are comparable to plaque brachytherapy and enucleation.


705Ophthalmoscopic Differentiation of Coats’ Disease and Retinoblastoma

Jerry A. Shields, MD (Philadelphia, PA), Carol L. Shields, MD

PURPOSE Coats’ disease is often confused clinically withretinoblastoma. It is important for clinical and medicolegalreasons to differentiate them. This study was to delineate thefeatures that differentiate Coats’ disease and retinoblastoma.

METHOD Approximately 1400 patients wih retinoblastoma and175 with Coats’ disease had detailed fundus drawings, fundusphotography, fluorescein angiography, and ultrasonographyThese were reviewed to establish clinical criteria that serve todifferentiate these conditions. Coats’ disease is often confusedclinically with retinoblastoma. It is important for clinical andmedicolegal reasons to differentiate them. This study was todelineate the features that differentiate Coats’ disease andretinoblastoma.

RESULTS Features that differed in Coats’ disease and retino -blastoma included the nature of the pupillary reflex, color ofsubretinal fluid, and caliber and distribution of the retinal bloodvessels. The pupillary reflex and color of subretinal material is generally yellow in Coats’ disease and white to gray withretinoblastoma. Macular involvement with Coats’ disease shows irregular lipoproteinaceous exudation, whereas macularinvolvement with retinoblastoma shows a distinct white mass.The retinal blood vessels in Coats’ disease disease are irregularin caliber, often with aneurysms, whereas in retinoblastoma theretinal vessels are uniformly dilated and more tortuous. Theblood vessels in Coats’ disease tend to remain visible from theposterior pole to the peripheral fundus, whereas those retino -blastoma tend to disappear into the adjacent neoplasm.

CONCLUSION Despite their superficial similarities, Coats’ diseaseand retinoblastoma usually have different clinical features.Recognition of these differences can avoid erroneous diagnosis,misdirected therapy, and legal repercussions.

OCULAR ONCOLOGy


Film Festival

Film Festival

Lights, Camera, Action…

A picture is worth a thousand words…

A moving picture – priceless…

One of the strongest of media for

medical and surgical education will be

at your fingertips at the 29th Annual

Meeting – 29 films were submitted

for what promises to be an outstanding Film Festival.

The festival will showcase the observational skills,

innovation, and creativity within our ranks in a most

entertaining venue.

Showings of the Film Festival will take place

each day of the meeting in the Film Festival Theater.

The opportunity to watch the Film Festival within

the comfort of your hotel room is also available.

Sit back, and enjoy some popcorn while you attend

this year’s premiere.

Each film will be judged according to overall

appeal, clinical value, special effects, production

quality, and entertainment. A panel of judges will

rate and score each film. The coveted Rhett Buckler

Award – an impressive 8-pound, 24 carat gold-plated

statuette, will be bestowed upon the top films. The

winners will be announced on Tuesday, August 23,

at the Gala Dinner.

Please join us for an exciting viewing

of films. It promises to be educational and

entertaining! We’ll supply the popcorn!

Brett T. Foxman, MDFilm Festival Program Subcommittee Chair

189* Financial interest disclosed

13th Annual ASRS Film Festival

Film Festival Entries

Amazing Visual Recovery after Surgery for Some Monstrous Intraocular Foreign BodiesGuruprasad S. Ayachit, MBBS, MS (Hubli, India)

SYNOPSIS Large intraocular foreign bodies are quite frequentlyencountered. Many times it is a mystery as to how they enteredthe eye and more surprising is the good visual recovery aftersurgical management. The videos of surgery for removal of five different monstrous foreign bodies are compiled in thispresentation. The need for customization and improvisation of techniques to suit individual cases will be highlighted.

Active Silicone Oil (SO) Removal with a Modified Vacuum SyringeBoris Josue Bajaire, MD (Santafe de Bogota, Colombia), Elena Oudovitchenko, MD, Andres Salguero, MD, Diego F. Paipilla

SYNOPSIS The number of indications for the use of SO hasincreased in vitreo-retinal surgery. We developed a simple activetechnique for SO removal based on a 5ml standard syringe withan 18G cannula. The oil is suctioned into the syringe by the pullingeffect of a spring assembled along the piston’s axis. No abruptchange in the intra-ocular pressure is produced, without anycomplication or device failure. 4 minutes is the average time forSO removal, which is in the range of other active techniques.

The Aahs and Oohs with First Time Use of Constellation Vitrectomy SystemAlay S. Banker, MD (Ahmedabad, India), Rohan Chauhan, MD

SYNOPSIS To demonstrate first experinces with ConstellationVitrectomy System. The video demonstrates controlled baseexcision of vitreous even in a mobile retina in a case of giantretinal tear and how even the finest tissue attached to the edgesof macular hole can be dissected safely. However, due to thevalve mechanism, while doing silicone oil injection the IOPsuddenly increases. Sudden failure of dual mode led to complica-tions like accidental suction of retinal tissue and increased IOP.

Management of Combined Exposure, Intrusion and Infection of Solid Silicone Scleral Buckle

Pramod S. Bhende, MBBS (Chennai, India), Muna Bhende, MD

SYNOPSIS Buckle migration, intrusion, exposure andinfection are known complications of scleral buckle surgery.

Managing each of these is challenging and involves significantrisk to the eye and vision. We present a patient who reportedwith a combination of all these in the only seeing eye includingthe extremely rare intracorneal migration of the encircling band.The surgical maneuvers used to successfully manage the case,including the use of fibrin glue with scleral patch graft will bedemonstrated.

Into the Deep with DSEKKevin J. Blinder, MD* (St. Louis, MO), Kamalesh J. Ramaiya, Gaurav K. Shah, MD*

SYNOPSIS A 40 y/o male status post trauma and RD repair subsequently developed corneal decompensation. A DSEKprocedure was performed for visual rehabilitation. Postoperativeday number one the graft was found on the surface of themacula. This surgical clip describes our solution to removing theDSEK graft despite an extremely poor view. Visualization withboth the BIOM and the endoscope are demonstrated. Successfulremoval to the DSEK graft is revealed.

Removal of a Posttraumatic Intraocular Eyelashfrom a Driven Tunnel Within the Vitreous Body by Using 23-gauge Vitrectomy InstrumentsOsman Cekic (Istanbul, Turkey), Ahmet Yazici, Mehmet Cakir, Kemal Yuksel, MD, Ugur H. Celik, MD

SYNOPSISWe describe a rapid, effective and safe technique for the removal of intraocular foreign bodies by creating a narrow tunnel within the vitreous body. No entire vitrectomy isperformed. With this technique, most of the vitreous bodyremains intact and the crystalline lens is preserved. Shortenedoperation time also minimizes the risk of light toxicity to the macula.

ILM Peeling for DummiesMartin Charles, MD (Buenos Aires, Argentina)

SYNOPSIS This video will review all the tips for performing asuccessful ILM peeling, from methods of visualization to surgicaltechnique, showing how to avoid difficulties that new surgeonshave during their first steps on this surgery.

Value of Digital Fluorescein Videoangiography in Diagnosis of Optic Nerve LesionsChing J. Chen, MD (Jackson, MS), Heather Hancock, MD, Zachary Robertson, MD, Matthew Olsen, MD

SYNOPSIS This video will illustrate the scanning laser ophthalmo-scope based diagital fluorescein videoangiography (DFVA) on 3cases of optic disc lesion, 2 with pulsatile nature and one without.DFVA provides a real time observation of a dynamic process ofretinal blood flow. It proved to be very helpful in confirming adiagnosis of a suspicious lesion by a regular fluorescein angiography. It is a very helpful teaching tool to provide real time information of pulsatile optic disc lesion.

Le Poinçonneur des LilasGilles Desroches, MD, FRCS(C) (Ottawa, Canada)

SYNOPSISWho would have guessed? Serge Gainsbourg, theFrench singer, had foreseen the plight of retinal surgeons 60years before intraocular injections were popular. The spiritedrhythm of the song reflects our crazy pace. The dramatic

conclusion may all be too true. In a symbolic way, a controller in amétro station in Paris reflects the discouragement we feel as weface the constant rush of injection after injection. Follow the lyricsfor a first class voyage in the depths of le Métro des Lilas.

Clove Hitch Scleral Fixation of Dislocated Toric IOLJoao Luiz Lobo Ferreira, MD (Florianopolis, Brazil)

SYNOPSIS Surgical approach: 25-Gauge ppv, clear corneatemporary externalization of the haptics of dislocated toric IOL,scleral fixation of the IOL using 10-0 prolene, clove hitch knot atthe external face of the haptic. IOL positioning was based on thehaptic location at the pre op SITE program. OD refraction: pre op -2.75 -3.00 x 20; dislocated IOL: -1.75 -3.00 X 165; post operativerefraction of OD was -2.75 (VA 20/40 -2). IOL repositioning wasadequate and stable.

Innovator or Heretic?Cesare Forlini, MD (Ravenna, Italy), Adriana Bratu, MD, Matteo Forlini, MD, Paolo Rossini, MD

SYNOPSIS This video is an allegorical representation of acomparison between Casanova and the surgeon in finding theirway. Very often the bureaucratic machine criticizes and inhibitsthis kind of surgeon (like the Inquisition did with Casanova), andtries to obstruct his/her creativity.How should we consider thiskind of surgeon, an innovator or a heretic? Is the Inquisition timeover? Or are we still living in the Inquisition age?

Temporary Keratoprosthesis in the “Pole to Pole” Surgery in Severe Trauma CasesCesare Forlini, MD (Ravenna, Italy), Adriana Bratu, MD, Matteo Forlini, MD, Paolo Rossini, MD

SYNOPSIS This video shows the use of temporary keratoprosthesis(TKP) for the visualization of intraocular structures during PPV ineyes with corneal and retinal pathologies and make possible tomanage both in a single surgical procedure. We use 25G anteriorchamber infusion and open sky vitrectomy, TKP with mini-invasive25/23G system for exploration and reconstruction. We try to givea chance to the patients to obtain a useful visual acuity

Submacular Surgery in the Anti-VEGF Therapy EraValentina Franco-Cardenas, MD (Los Angeles, CA), Jean-Pierre Hubschman, MD, Steven D. Schwartz, MD*

SYNOPSIS Anti-VEGF therapy is the treatment of choice forchoroidal neovascular membranes (CNV). Submacular surgery asa treatment for CNV has been abandoned. In very specific, wellselected cases where massive subretinal hemorrhage occurs,surgical intervention may have a role. Addressing these cases in asurgical way, has to do with the fact that blood in the subretinalspace may be toxic. We present cases of CNV and massivesubmacular hemorrhage managed with both Anti-VEGF therapyand surgery.

* Financial interest disclosed190 FILM FESTIVAL

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191

Staged Surgical Management of Retinal Detachment Resulting from Intrusion of a Miragel ExplantQuan V. Hoang, MD, PhD (New York, NY), Gregory Chang, MD, Stanley Chang, MD

SYNOPSIS A 67 year-old man presented 21 years after retinaldetachment repair OD with a vision of hand motions resultingfrom intrusion of a Miragel explant into the eye with lens contact.A staged repair was offered for retinal re-detachment andcataract. The patient initially underwent a lensectomy andMiragel explant removal internally via fragmatome. Uncontrolledbleeding developed. 9 days later, subretinal tissue plasminogenactivator was employed to complete the detachment repair.

Drainage of Choroidals with a Guarded Needle Technique: An Insiders ViewJohn W. Kitchens, MD* (Lexington, KY), James C. Pate, MD, Daniel Prescott, MD

SYNOPSIS A view inside the eye as a choroidal detachment is drained using a novel approach with a guarded 26 gaugeneedle.

Iatrogenic Subretinal Gas in a Patient with Post Trabeculectomy Hypotony: A Simplified Technique for Gas EvacuationPatrick C. Mitchell (Calgary, Canada), Amin Kherani, MD

SYNOPSIS A 16 year old female with a history of intermediateuveitis of the right eye underwent trabeculectomy for medicallyuncontrolled glaucoma. Post trabeculectomy she experiencedprolonged severe hypotony. She had been previously vitrec-tomized for treatment of a retinal detachment. Intravitrealinjection of 0.3cc of 100% C3F8 was attempted in the office but the gas went subretinal due to hypotony. This video demon-strates successful evacuation of the subretinal gas via anexternal drainage approach.

“The Art of Non-kissing”Sandra Rocio Montezuma, MD (Minneapolis, MN)

SYNOPSIS An 86-year-old woman status post Baerveldt valvehad kissing choroidals and underwent choroidal drainage. Shepresented with pain, visual acuity of light perception, recurrentkissing choroidals, flat anterior chamber, dislocated IOL and retinal detachment. This film entry illustrates a technique tosuccessfully treat complicated hemorrhagic choroidals. She underwent choroidal drainage, anterior segment recon-struction, valve revision, intraocular lens removal and retinaldetachment repair.

Silicon Oil Removal: The Final HurdleManish Nagpal, MD* (Gujarat, India), Pravin Jain, MD

SYNOPSIS Silicon oil is an important adjunct during vitrectomyand needs mandatory removal. Silicon oil removal (SOR) deter-mines the final visual outcomes of the eye. In this video wepresent the approach to SOR surgery. We use a 3 port pars planaapproach for SOR using wide angle viewing systems and alsodemonstrate various adjunct procedures such as cataractsurgery, membrane removal, Sub retinal oil removal, endolaseretc. Steps to reduce risk of redetachment are also discussed.

23 Gauge Bimanual Membrane Peeling for Diabetic Combined Retinal Detachment Using Chandelier IlluminationRaja Narayanan, MBBS (Hyderabad, India), Chinmaya Sahu, MD, Mudit Tyagi, MD

SYNOPSIS A 48 year old, diabetic presented with diminution ofvision in the right eye since 3 months. Her vision was 1.77 on thelogMAR chart. Fundus examination revealed presence ofcombined retinal detachment with fibrovascular proliferation atthe disc and macula. A bimanual 23 Gauge membrane peelingwas done for the patient using chandelier illumination. The videowill highlight that it is possible to attempt such difficult diabeticcases using 23 Gauge Vitrectomy using Bimanual approach.

Non Full Thickness Macular Holes. A Closer Look!Jerzy Nawrocki, MD, PhD (Lodz, Poland), Janusz Michalewski, MD, PhD, Zofia Nawrocka, MD, Zofia Michalewska, MD, PhD

SYNOPSIS A new theory of idiopathic non full thickness macularholes based on spectral domain OCT observations and clinicalappearance before and during surgery. All these entities arecaused by vitreoretinal traction, which produces local internallimiting membrane (ILM) defect in the fovea. These leads toepiretinal membrane (ERM) formation around the ILM defect inthe fovea. During the maturation of the membrane differentappearances in the fovea may be observed. Healing after surgery is presented.

New Technology for Fixating the Dislocated Intraocular LensJeffrey L. Olson, MD (Aurora CO), Michael Erlanger, MD

SYNOPSIS This video details a new surgical technique and novelsurgical instrumentation using a 30-gauge injectable shapememory alloy clip to fixate a dislocated intraocular lens. This newtechnology allows the surgeon to fixate the haptic of the lens to the mid-peripheral iris in less than 60 seconds, compared tothe 10 to 15 minutes per suture for conventional iris fixationtechniques. The video demonstrates the device in the laboratoryand the technique in a surgical setting.

When the Instruments Are Not Enough!! There Are Eyes Longer Than My Forceps...Sergio Rojas (Cuernauaca Moreios, Mexico)

SYNOPSIS Patient with atrophy of the retinal pigment epitheliumwith a market posterior staphyloma at the presence of subretinalfluid associated with macular hole, takes ultrasound scansshowing a 34 mm axial length and OCT where there is presenceof epiretinal membrane. He was scheduled for 23 gaugevitrectomy surgery. At the time of surgery is difficult to reach thesurface of the retina because our instruments measure 32mmlong and the length of the eye is larger.

Combined CRVO and Cilioretinal Artery Occlusion with Video Fluorescein Angiography of Pulsating Cilioretinal ArteryDavid Sarraf, MD* (Los Angeles, CA), Pradeep S. Prasad, MD

SYNOPSIS Angiographic pulsations within the cilioretinal arteryhave been described as a pathognomonic feature in patients withcombined cilioretinal artery and central retinal vein occlusion. Wepresent a video fluorescein angiogram demonstrating alternatingperfusion and nonperfusion of the cilioretinal artery in a youngpatient with CRVO.

Novel Instrument for Defining Sclerotomies in Small Gauge Vitrectomy SurgerySamir Sayegh, MD, PhD (Champaign, IL), R. Olk, MD

SYNOPSIS This film presents the evolution of fixation systems for 23G and 25G vitrectomies culminating in the development ofa novel instrument (Sayegh’s Vitroretinal Fixation System) forfixating the globe and facilitating positioning of 23G and highertrocar systems in a rational, safe and efficient manner

23-Gauge Chromovitrectomy for Macular Schisis inOptic Disc Pit: Triamcinolone Assisted Vitrectomy,Followed by Brilliant Blue Guided ILM PeelingCyrus M. Shroff, MD (New Delhi, India), Charu Gupta, MD, A K Singh, MD, Neelam Atri, MD, Gagan Bhatia, MD, Daraius Shroff, MD, FRCS

SYNOPSIS Presenting the surgical management of macularschisis associated with optic disc pit. The patient underwenttriamcinolone assisted 23-Gauge vitrectomy to ensure completeremoval of cortical vitreous. This was followed by brilliant bluestaining and ILM peeling using a Tano membrane scraper and end grasping forceps. Intraoperative diode endolaser was done to the margin of the pit, with C3F8 gas injection. Post operativeOCT showed restoration of foveal dip. Vision improved from20/80 to 20/30.

More Elusive Than the Scarlet Pimpernel! –Finding the Correct Surgical Plane in Diabetic Vitrectomy and Other Surgical PearlsCyrus M. Shroff, MD (New Delhi, India), Neelam Atri, MD, Charu Gupta, MD, A. K. Singh, MD, Bhavana Sharma, MD, Daraius Shroff, MD, FRCS

SYNOPSIS This video is a compilation of various surgical clipshighlighting some of the surgical nuances of diabetic vitrectomy.Included are tips for the identification of vitreoschisis and thecorrect surgical cleavage plane, bimanual membrane dissectionand hemostasis techniques, and tackling combined TRDs withmacular hole.

A Simple Alternative to Flute Cannula for the Vitreo-retinal Surgical ProceduresMalhar Soni, DO, MS, DNB, FRCS (London, United Kingdom)

SYNOPSIS The video demonstrates the construction and use ofan inexpensive and disposable alternative to the flute cannula for Vitreo- retinal surgical procedures. This cannula can beassembled using a 20, 23, 25 or 27 gauge blunt/soft tip cannulaand a leur 3-way tap. This model also aids the introduction of dyein the vitreous cavity. This instrument is as safe and effective as the original and benefits from being inexpensive and easilyconstructed from components ubiquitous to surgical units.

Vitreo-lenticular Interface – Its Surgical ImportanceMalhar Soni, DO, MS, DNB, FRCS (London, United Kingdom)

SYNOPSIS This video demonstrates the importance of identifi-cation and surgical removal of Weigert’s ligament of the vitreousin eyes with proliferative vascular diseases undergoing vitrectomyfor vitreous haemorrhage. The video illustrates signs to visualisethe vitreo-lenticular interface and describes technique to removeit. It helps in better visualisation of retina during surgery and helps in avoiding non-resolving vitreous cavity haemorrhage andaqueous misdirection syndrome in vitrectomised eyes.

Techniques for Improving Intraoperative Visualization of Surgical Planes in Complex Anterior Pediatric Retinal DetachmentsS. Chien Wong, MBBS, FRCSEd (Ophth) (Troy, MI), Caesar K. Luo, MD, MRCOphth, Antonio Capone, MD

SYNOPSIS Complex anterior pediatric tractional retinal detach-ments in diseases such as retinopathy of prematurity and familial exudative vitreoretinopathy pose specific intraoperativechallenges relating to identification of surgical planes. The risk of iatrogenic full-thickness retinal break is high and resultingoutcomes are often poor. In this video, we illustrate how theinnovative use of illumination can improve visualization, leading to more precise and safer manipulation of surgical planes.

* Financial interest disclosed192 FILM FESTIVAL


193

A replay of the award-winning films from the

12th Annual Film Festival in Vancouver.

BEST OF SHOW

Journey through a Normal Day of a Retina SurgeonVirgilio Morales-Canton, MD (Mexico City, Mexico)

SYNOPSIS This video demonstrates how everyday events on the life of a retina surgeon may influence the surgical techniqueand the final outcome. “A regular day may change your surgical maneuvers!”

Intraocular Cysticercosis Delivered Whole Via Pars Plana VitrectomyThomas M. O’Hearn, MD (San Marino, CA), Dean Eliott, MD, Rizwan A. Bhatti, MD, Narsing Rao, MD

SYNOPSIS A 17 year old Hispanic male presented with 3 weeks of decreased vision in his left eye to CF. Dilated exam revealed a 7mm mobile, light sensitive, cyst within the vitreous cavity. A pars plana vitrectomy, pars plana lensectomy and scleral bucklewas performed with removal of the cyst whole, without rupture of the cyst wall. Histological analysis was consistent with acysticercosis cyst. His vision improved to 20/25 and his systemicwork up was negative for any further cysticercosis infection.

Gnasty StomaAziz A. Khanifar, MD (New York, NY), R.V. Paul Chan, MD, Grant D. Aaker, MD

SYNOPSIS A 37-year old Ecuadorian man presented to theemergency room with uveitic glaucoma secondary to an intra vitreal parasite in his left eye. Our film will demonstrate our findings with fundus photography, fluorescein angiography, ultrasonography, and spectral domain opticalcoherence tomography. Furthermore, the surgical video of the worm’s removal via 23- gauge pars plana vitrectomy will be shown. Pathologic analysis was consistent withGnathostoma species.

Sutureless Intraocular Lens Fixation of a Dislocated Intraocular Lens-capsular Bag-capsular Tension Ring ComplexR. Kim, MBBS, DO, DNB (Madurai, India), Babu Naresh, MD

SYNOPSISWe report a technique for sutureless fixation of a 3-piece dislocated in the ciliary sulcus in an eye with dislocatedIOL-capsular bag-capsular complex. This secondary procedurewas performed 16 months after initial surgery in an eye withtraumatic zonular dialysis. The same lens was used afterseparating it from the CB-CTR complex through a pars planaapproach. This sutureless technique using 20 and 23-gaugevitrectomy to reinstall a dislocated PCIOL required no specialhaptic architecture.

Heavy Brilliant Blue: a New Dye for Peeling the Internal Limiting MembraneMurat Oncel, MD (Istanbul, Turkey)

SYNOPSIS In order to have a better staining effect with normal BB and prevent the staining of the posterior capsule of the lens,air-fluid exchange is performed before staining. With the use ofheavy BB, there is no need to perform air-fluid exchange. Afterturning off the infusion, dye is injected under fluid. Staining effectis better than normal BB in fluid filled eyes. Stains the ILM muchbetter than trypan blue, comparable to ICG, making the ILMpeeling procedure easier, safer and faster.

A Technique in Iridodialysis Repair and Suture Intraocular Lens ImplantationDavid T. W. Wong, MD, FRCS (C) (Toronto, Canada)

SYNOPSIS A simplified technique for suturing intraocular ab-external lenses in vitrectomized eyes is also applied to repairingan iridodialysis is presented in a combined method in a severeblunt trauma case.

Transconjunctival Drainage of Serous and Hemorrhagic Choroidal DetachmentFlavio A. Rezende, MD, PhD (Blainville, Canada)

SYNOPSIS The film aims to describe a choroidal drainagetechnique with minimal trauma to the conjunctiva on glaucomapatients. It also illustrates the differences between this techniqueand the previously described ones. Pearls and cautions to masterthis procedure will be highlighted.

2010 Film Festival Award Winners

Vitreoretinal Surgery for Subretinal Hidden Foreign BodiesJavier Elizalde, MD, PhD (Barcelona, Spain)

SYNOPSISManagement of intraocular foreign bodies is a surgicalchallenge for the ophthalmologist: a wide array of potentialclinical complications may be associated to these cases, patientsaffected are usually young and surgery must be carried out at the right time. The author includes in this video the preoperativeappearance, the surgical technique and the final outcome of twovery unusual and difficult cases, in which the metallic foreignbody was deeply located within the subretinal space.

Giant Retinal Tear! Size Does MatterManish Nagpal, MD (Gujarat, India), Nilesh Chaudhari, MD

SYNOPSIS Giant retinal tears (GRT) are characterised by tearsgreater than 90 degrees. In this video we present a variety ofcomplex presentations of GRT, which include extensive PVR andthose with associated nucleus drop. Various surgical techniquesand manouevers using Perfluorocarbon liquid (PFCL), Air PFCLexchange, Silicon oil including bimanual approach are demon-strated. Allied procedures such as Silicon oil removal and laserprophylaxis of lesions in the other eye are also shown.

Management of Posterior Dislocated Lens with Phakofragmentation, Ultra High SpeedVitrectomy and Foldable Suture in Posterior Chamber Lens ImplantChing J. Chen, MD (Jackson, MS), Michael Palmer, MD, Kevin Kosek, MD

SYNOPSIS This video will illustrate the technique of removal ofposterior dislocated lens or fragments of lens by a new gener-ation phako-fragmentation and high speed vitrectomy system.We will also demonstrate the technical detail of creating thescleral flap, passing the scleral suture, attachment of suture tothe implant, folding and insertion of the implant through the small clear corneal incision, and fixation of the implant byanchoring suture to the scleral bed.

2012 Call for Films

You are invited to prepare your film

entries and contribute to this wonderful

tradition of excellence in film. Submit a

film to the 2012 Film Festival and

you may just be a proud winner of the

coveted Rhett Buckler Award!

Deadline for submission of 2012 films

will be announced on the ASRS website,

www.asrs.org.

194 FILM FESTIVAL


Participant Index

Participant Index

195

The American Society of Retina Specialists (ASRS)seeks to balance the important benefits of physician-industry relationships with the significant risk that the financial goals of industry may conflict with theprofessional goals of ASRS members. In doing so, the ASRS recognizes that it has a profound duty to its members, the larger medical community and thepublic to ensure the integrity of all of its scientific,educational, and advocacy activities and materials.

Educational Content Development

As the ACCME accredited provider for the ASRS29th Annual Meeting, the American Society of RetinaSpecialists requires all Program committee members,abstract graders, staff, and any others in a position tocontrol the educational content to disclose anycommercial financial interests prior to the develop -ment of educational content. A process for resolutionof conflict of interest is used for those committeemembers who do have financial interests related to the development of content.

Program committee members, abstract graders, andstaff members who fail to provide financial disclosuresare not permitted to participate in the abstract gradingprocess or the development of educational content.

Presenters

The ASRS considers financial relationships to createactual conflicts of interest when Presenters or theirimmediate family (defined as spouse, domestic partner,parent, child or spouse of child, or sibling or spouse of sibling of the Presenter) have both a financialrelationship with a commercial interest and the oppor-tunity to affect ASRS policy or the content of CMEabout the products or services of that commercialinterest. The potential for Presenter to maintain orincrease the value of the financial relationship withthe commercial interest creates an incentive toinfluence the content of the CME – an incentive to insert commercial bias.

All presenters of CME content should familiarizethemselves with the new ASRS Policy on FinancialDisclosures and Resolution of Conflicts of Interest,which may be viewed in their entirety on the ASRS website at www.asrs.org. All ASRS memberspresenting CME are required to disclose to the activity audience the following information prior to beginning their presentation:

• Any relevant financial relationships a CME pres -enter has had with manufacturers of commercialophthalmic products or providers of commercialophthalmic services within the past 12 months. TheASRS defines “relevant” financial relationships asthose with a commercial ophthalmic interest andthe opportunity to affect the content of CME about the products or services of that commercialophthalmic interest.

• CME presenters who report they have no knownrelevant financial relationships to disclose willdeclare “No Financial Relationships.”

NOTE: All presenters are required to report financialdisclosures, using the codes below, as part of theabstract submission process. An individual’s financialdisclosure for the ASRS 29th Annual Meeting will beindicated by an asterisk (*) in the Scientific Programand cross-referenced in the Participants FinancialDisclosure Index. (See the Participant Index tab of theScientific Program). Any presenter not listed with anasterisk, or not listed by name on the ParticipantsFinancial Disclosure list, informed the AmericanSociety Retina of Specialists that they have norelevant financial disclosures to report.

Description of Financial Interest

TyPES OF RELATIONSHIP(S) A Advisory BoardB Board of DirectorsC ConsultantE EmployeeF FounderI InvestigatorSP SpeakerSH StockholderO Other

NATURE OF COMPENSATIONE Equipment (dept or practice) G GrantsH HonorariaIP Intellectual Property RightsNC No Compensation ReceivedOB Other Financial BenefitR RoyaltyRF Residency or Fellowship Program FundingS Salary ST Stock SO Stock Options

Financial Interest Disclosures

196

Agarwal, Anita Artic DX . . . . . . . . . . . . . . . . . . . . . . . . . . . O/IP

Albini, Thomas A.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HBausch + Lomb . . . . . . . . . . . . . . . . . . . . . A, SP/H

Antoszyk, Andrew N.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, I/HAlimera Sciences . . . . . . . . . . . . . . . . . . . C, I/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C, I/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . C, I, O, SP/H

Apte, Rajendra S.Alimera . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, C/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A, C/HBaxter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, C/HEyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . A, C/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . A, C/HOpthotech . . . . . . . . . . . . . . . . . . . . . . . . . C/SO

Awh, Carl Artic DX . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SH/SO, HBausch + Lomb . . . . . . . . . . . . . . . . . . . . . C/HSynergetics . . . . . . . . . . . . . . . . . . . . . . . . C, I/G, HNotalVision . . . . . . . . . . . . . . . . . . . . . . . . C, Sh, I/S, SOVolk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C,SGenentech. . . . . . . . . . . . . . . . . . . . . . . . . C, I/G, H

Bakri, Sophie J.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G

Bandello, Francesco Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB/HAllegan . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB/HBayer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB/HNeovista. . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB/H

Barak, Adiel Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GNeovista. . . . . . . . . . . . . . . . . . . . . . . . . . . I/GOptical Imaging. . . . . . . . . . . . . . . . . . . . . I/GOra Bio . . . . . . . . . . . . . . . . . . . . . . . . . . . . SH/SO

Basham, Ryah P.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/H, I/GAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . I/GRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G

Bennett, Jean Sanofi-Aventis . . . . . . . . . . . . . . . . . . . . . A/HAvalanche Biotechnologies . . . . . . . . . . A/SO

Berrocal, Maria H.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H, SAlimera . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H

Bhisitkul, Robert B.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . A, I/GSanten, Inc. . . . . . . . . . . . . . . . . . . . . . . . . c/HStructus Medical . . . . . . . . . . . . . . . . . . . F/SO

Blinder, Kevin J.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/HBausch + Lomb . . . . . . . . . . . . . . . . . . . . . C/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . SP/HiScience . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HJohnson & Johnson . . . . . . . . . . . . . . . . . C/HOcusoft . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H

Blumenkranz, Mark S.Avalanche . . . . . . . . . . . . . . . . . . . . . . . . . B, F, SH/STDigisight . . . . . . . . . . . . . . . . . . . . . . . . . . . B, F, SH/STGenentech. . . . . . . . . . . . . . . . . . . . . . . . . C/RFOptimedica . . . . . . . . . . . . . . . . . . . . . . . . B, F, SH/IP,

R, STPeak Surgical . . . . . . . . . . . . . . . . . . . . . . B, F, SH/STVantage Surgical . . . . . . . . . . . . . . . . . . . B/IP, SO

Boate, Alan Annidis Health Systems Corp . . . . . . . . E/S

Boscia, Francesco Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HBayer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HNovartis . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HPfizer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H

Boyer, David S.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/HEyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . A, SP/HICB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/NCNovaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HPfizer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/HQLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . A/H

Bressler, Neil M.Abbott Medial Optics . . . . . . . . . . . . . . . I/GAlimeria Sciences. . . . . . . . . . . . . . . . . . . I/GAllergan USA . . . . . . . . . . . . . . . . . . . . . . . I/GBausch + Lomb . . . . . . . . . . . . . . . . . . . . . I/GCarl Zeiss Meditec . . . . . . . . . . . . . . . . . . I/GDingnos . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GForSight Labs . . . . . . . . . . . . . . . . . . . . . . I/GGenentech. . . . . . . . . . . . . . . . . . . . . . . . . I/GGenzyme . . . . . . . . . . . . . . . . . . . . . . . . . . I/GLumenis . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GNotal Vision. . . . . . . . . . . . . . . . . . . . . . . . I/GNovartis Pharma . . . . . . . . . . . . . . . . . . . I/GOra. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GPfizer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GQLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/GResearch to Prevent Blindness. . . . . . . I/GSteba Biotech. . . . . . . . . . . . . . . . . . . . . . I/GThe Emmes Corporation. . . . . . . . . . . . . I/G

Bressler, Susan B.Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . I/GEmmes Corp . . . . . . . . . . . . . . . . . . . . . . . I/GGenetech . . . . . . . . . . . . . . . . . . . . . . . . . . I/GGlaxoSmithKline . . . . . . . . . . . . . . . . . . . . C/HNotal Vision. . . . . . . . . . . . . . . . . . . . . . . . I/GNovartis . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GQLT Ophthalmics . . . . . . . . . . . . . . . . . . . I/G

Brown, David M.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G, A/H, C/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . A/H, C/H, I/G,

SP/HRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . C/H, I/G

Busbee, Brandon G.Akorn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O/IGenentech. . . . . . . . . . . . . . . . . . . . . . . . . SP/H, A/H, I/GSynergetics . . . . . . . . . . . . . . . . . . . . . . . . C/H

Cable, Melissa MorrisonAlcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/E, SP/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/HBausch and Lomb. . . . . . . . . . . . . . . . . . . I/GISTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H, I/G

Callanan, David Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/HBausch + Lomb . . . . . . . . . . . . . . . . . . . . . A, C/H, SP/HForsight Labs. . . . . . . . . . . . . . . . . . . . . . . C/SOLux Biosciences . . . . . . . . . . . . . . . . . . . . A/NCNovartis . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G

Campochiaro, Peter A.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GAlimera . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . A, C, O, I/G, OBGenzyme . . . . . . . . . . . . . . . . . . . . . . . . . . I/GGlaxoSmithKline . . . . . . . . . . . . . . . . . . . . I/GLpath. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/OBMolecular Partners . . . . . . . . . . . . . . . . . I/GPfizer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, C/OBRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . A, C/OBSanten, Inc. . . . . . . . . . . . . . . . . . . . . . . . . C/HStructus Medical . . . . . . . . . . . . . . . . . . . F/SO

Capone, Jr., Antonio Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HAlimeria Sciences. . . . . . . . . . . . . . . . . . . C/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/GFocusROP . . . . . . . . . . . . . . . . . . . . . . . . . . O/RGlaxoSmithKline . . . . . . . . . . . . . . . . . . . . C/GOphthotec . . . . . . . . . . . . . . . . . . . . . . . . . C/GRetinal Soultion . . . . . . . . . . . . . . . . . . . . O/RThrombogenics. . . . . . . . . . . . . . . . . . . . . C/G

Carricondo, Pedro Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . C/H

Carroll, Joseph Imagine Eyes . . . . . . . . . . . . . . . . . . . . . . . O/NC

Chan, Clement K.Alimera Sciences . . . . . . . . . . . . . . . . . . . IAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A, I/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . A, I/G, HNEI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IOwen Locke Foundation . . . . . . . . . . . . . GRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . IThromboGenics . . . . . . . . . . . . . . . . . . . . I

Chang, Tom S.Iscience . . . . . . . . . . . . . . . . . . . . . . . . . . . SH/SOJohnson & Johnson . . . . . . . . . . . . . . . . . C/H

Charles, Steve T.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H

Chu, Thomas GeraldAlcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP, A/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . SP, A/H

Clark, W. LloydGenetech/Roche . . . . . . . . . . . . . . . . . . . A/H, I/GOphthotech. . . . . . . . . . . . . . . . . . . . . . . . I/GPfizer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GRegeneron Pharmaceuticals . . . . . . . . . A/H, I/GSanten . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G

Clayton, Richard Annidis Health Systems Corp . . . . . . . . E/S

Cormier, Michel KMG Pharma . . . . . . . . . . . . . . . . . . . . . . . F/OB

Das, Taraprasad Alcon, India . . . . . . . . . . . . . . . . . . . . . . . . A/NCNovartis, India . . . . . . . . . . . . . . . . . . . . . . SP/NC

Davis, Michael J.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HSynergetics . . . . . . . . . . . . . . . . . . . . . . . . C/H

Financial Interest or Relationship Disclosures

197

Devenyi, Robert G.Annidis Health Systems Corp . . . . . . . . E/S

Do, Diana V.Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/GHeidelberg . . . . . . . . . . . . . . . . . . . . . . . . . I/GRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G

Drenser, Kimberly A.Focus ROP . . . . . . . . . . . . . . . . . . . . . . . . . F/SORetinal Solutions . . . . . . . . . . . . . . . . . . . F/SOSynergetics . . . . . . . . . . . . . . . . . . . . . . . . C/R

Dugel, Pravin U. Abbott Medical Optics . . . . . . . . . . . . . . C/HAlcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HArticDX . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . C/HMacusight . . . . . . . . . . . . . . . . . . . . . . . . . C/HNeovista. . . . . . . . . . . . . . . . . . . . . . . . . . . C/SO

Duker, Jay S.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/OCarl Zeiss Meditec . . . . . . . . . . . . . . . . . . GEMD Serono. . . . . . . . . . . . . . . . . . . . . . . . IPGenentech. . . . . . . . . . . . . . . . . . . . . . . . . IPHemera. . . . . . . . . . . . . . . . . . . . . . . . . . . . SH/SMerck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IPNovartis . . . . . . . . . . . . . . . . . . . . . . . . . . . IPOphthotech. . . . . . . . . . . . . . . . . . . . . . . . IPOptiVue . . . . . . . . . . . . . . . . . . . . . . . . . . . GPaloma Pharmaceuticals . . . . . . . . . . . . GTopcon Medical Systems, Inc. . . . . . . . . G

Ehrlich, Jason S.Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/SRoche Group . . . . . . . . . . . . . . . . . . . . . . . SH/ST, SO

Ferrone, Philip J.Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A, I, SP/G, H

Fine, Howard Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . C/HOphthotech. . . . . . . . . . . . . . . . . . . . . . . . C/H

Flynn, Harry W.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HAllegan . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HPfizer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HSanten . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H

Francom, Steven F.Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/S, SO

Freund, K. BaileyAlcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HAlimera . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . A/HRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . C/H

Garg, Sunir J.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/H, I/G, SP/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A, A/H, SP/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . I/GLux. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GQLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G

Gentile, Ronald C.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GGenentech. . . . . . . . . . . . . . . . . . . . . . . . . I/GRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/GSiron Therapeutics . . . . . . . . . . . . . . . . . I/GUniversity of WI . . . . . . . . . . . . . . . . . . . . I/G

Glaser, Bert M.Ocular Proteomics . . . . . . . . . . . . . . . . . . E/NC

Gonzalez, Victor HugoEndoOptiks . . . . . . . . . . . . . . . . . . . . . . . . C/HEyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . C, I/G, HISTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/HRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G

Greenberg, Paul B.Genentech-PBG . . . . . . . . . . . . . . . . . . . . I/OB

Gribben, Jeremy Annidis Health Systems Corp . . . . . . . . E/S

Haller, Julia A.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . C/H

Harbour, J. William Castle Biosciences . . . . . . . . . . . . . . . . . O/IP

Hariprasad, Seenu M.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/HBayer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . C, SP/HOcular - Therpetuix . . . . . . . . . . . . . . . . . C/SHOptos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . C/H

Hassan, Tarek S.ArticDX . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SH/H, STBausch + Lomb . . . . . . . . . . . . . . . . . . . . . C, SP/HClarus Acuity Group. . . . . . . . . . . . . . . . . SH/STEyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . C, A/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . C/HInsight Instruments. . . . . . . . . . . . . . . . . C/HOptiMedica . . . . . . . . . . . . . . . . . . . . . . . . C, SH/H, STSynergetic . . . . . . . . . . . . . . . . . . . . . . . . . C/H

Heier, Jeffrey S.Acucela . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HAlcon Laboratories . . . . . . . . . . . . . . . . . C, I/GHAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C, I/G, HBausch + Lomb . . . . . . . . . . . . . . . . . . . . . C/HFovea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . C, A/OB,

CP/NC, SP,I/G, H

Genzyme . . . . . . . . . . . . . . . . . . . . . . . . . . C/OBGlaxoSmithKline . . . . . . . . . . . . . . . . . . . . C/OBHeidelberg Engineering . . . . . . . . . . . . . C, SP/HiScience . . . . . . . . . . . . . . . . . . . . . . . . . . . C/G, HLpath. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB, HNeoVista . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB, SP,

I/G, HNeurotech . . . . . . . . . . . . . . . . . . . . . . . . . I, GNotal Vision. . . . . . . . . . . . . . . . . . . . . . . . C/HNovartis Pharmaceuticals . . . . . . . . . . . C, I/G, HOraya Therapeutics . . . . . . . . . . . . . . . . . C/H, C/OBPaloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB, I/G, HPfizer Opthalmics. . . . . . . . . . . . . . . . . . . C, I/G, H, SPRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . C/OB, SP/NC,

I/G, HSequenom . . . . . . . . . . . . . . . . . . . . . . . . . C/OBVision Care Opthalmic Technologies . . C/OB, C/G, H

Hess, Ditte Charity Medical Systems . . . . . . . . . . . . C/H

Hines, Joshua Ocular Proteomics . . . . . . . . . . . . . . . . . . E/NC

Ho, Allen C.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I, SP, C/G, HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I, C/G, HCentocor/Johnson & Johnson . . . . . . . I/GGenentech. . . . . . . . . . . . . . . . . . . . . . . . . I, SP, C/G, HGSK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GMacusight . . . . . . . . . . . . . . . . . . . . . . . . . I/GOMerck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HNEI/NIH. . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GNeoVisa . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GOOphthotech. . . . . . . . . . . . . . . . . . . . . . . . I, C/G, HOptherion. . . . . . . . . . . . . . . . . . . . . . . . . . C/HOraya. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GPaloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HPRN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GQLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I, C/GRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I, C/G, HThrombogenics. . . . . . . . . . . . . . . . . . . . . C/H

Holekamp, Nancy M.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HGenetech . . . . . . . . . . . . . . . . . . . . . . . . . . A/HSequenom . . . . . . . . . . . . . . . . . . . . . . . . . A/H

Hopkins, J. Jill Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/S, SO

Hosseini, Kamran KMG Pharma . . . . . . . . . . . . . . . . . . . . . . . F/IP, S

Huang, Suber S. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HBausch + Lomb . . . . . . . . . . . . . . . . . . . . . C/HDRCR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HDigital Healthcare . . . . . . . . . . . . . . . . . . SH/STi2i Innovative Ideas . . . . . . . . . . . . . . . . . E/SLux Biosciences . . . . . . . . . . . . . . . . . . . . C/HMacuSight . . . . . . . . . . . . . . . . . . . . . . . . . C/HMerck & Co., Inc. . . . . . . . . . . . . . . . . . . . . C/HNEHEP/NEI/NIH . . . . . . . . . . . . . . . . . . . . C/HNeurotech . . . . . . . . . . . . . . . . . . . . . . . . . C/HPfizer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HRetinal Dis Image AnalysisReading Center . . . . . . . . . . . . . . . . . . . . C/HSecond Sight. . . . . . . . . . . . . . . . . . . . . . . C/HSurModics Pharmaceuticals . . . . . . . . . C, SH, H, STTDNMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HTherapeutic Nanoparticle and Molecular Imaging . . . . . . . . . . . . . . C/HVitreo Retinal Technologies. . . . . . . . . . C/H

Jiao, Jenny Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/NC, E/S

Jorge, Rodrigo Novartis . . . . . . . . . . . . . . . . . . . . . . . . . . . O/OB

Kaiser, Peter KAlcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HArctic DX . . . . . . . . . . . . . . . . . . . . . . . . . . C/SOBausch and Lomb. . . . . . . . . . . . . . . . . . . C/HBayer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HCarl Zeiss Meditec . . . . . . . . . . . . . . . . . . SP/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . A/HNovartis . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HOphthotech. . . . . . . . . . . . . . . . . . . . . . . . C/HOptovue . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/HOraya. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . C/HSKS Ocular. . . . . . . . . . . . . . . . . . . . . . . . . F, SH/STTopcon . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/H

Kitchens, John W.Synergetics . . . . . . . . . . . . . . . . . . . . . . . . C/H

198

Kokame, Gregg T.Acucela . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GAlcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GGenentech. . . . . . . . . . . . . . . . . . . . . . . . . A, I/G, HMacusight . . . . . . . . . . . . . . . . . . . . . . . . . I/GPfizer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GQLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, I/G, HRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . A, I/G, HSanten . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/S

Korobelnik, Jean-Francois Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HBayer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HNovartis . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HThea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/G

Korotkin, Arthur Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/G

Kuppermann, Baruch D.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GAlimera . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I, H, C/GBausch + Lomb . . . . . . . . . . . . . . . . . . . . . C/HEyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HFovea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . I/GGlaukos. . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HGlaxoSmithKline . . . . . . . . . . . . . . . . . . . . I/GLpath. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HNeovista. . . . . . . . . . . . . . . . . . . . . . . . . . . C/HOcucare . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HOphthotech. . . . . . . . . . . . . . . . . . . . . . . . C/HRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/GThromboGenics . . . . . . . . . . . . . . . . . . . . I/G

Kurup, Shree K.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/NCEyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HForsight Labs. . . . . . . . . . . . . . . . . . . . . . . I/GPfizer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G

Kymes, Steve Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . E, C/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . E, C/HPfizer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E, C/H

Lai, Phillip Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/SO, ST, SO

Lalwani, Geeta A.Genetech . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/H

Leonard, Brian C.Annidis Health Systems . . . . . . . . . . . . . C/SO

Li, Xiao-yan Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . E/NCAllergan, Inc. . . . . . . . . . . . . . . . . . . . . . . . E/NC

Lin, Steven G.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . IRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . IThromboGenics . . . . . . . . . . . . . . . . . . . . I

Loewenstein, Anat Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HAlimera . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HForsightLabs . . . . . . . . . . . . . . . . . . . . . . . C/HLumenis . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HNotal Vision. . . . . . . . . . . . . . . . . . . . . . . . C/HNovartis . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HOrabio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H

Logani, Sanjay Doctorsoft Corp . . . . . . . . . . . . . . . . . . . . SH/ST

MacCumber, Mathew W.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GArticDx . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/GGenentech. . . . . . . . . . . . . . . . . . . . . . . . . A, I, SP/H, GGlaxoSmithKline . . . . . . . . . . . . . . . . . . . . I/GOptos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/GSequenom . . . . . . . . . . . . . . . . . . . . . . . . . A/G

Maguire, Joseph I. Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A, SP/H

Maisel, James M.ZyDoc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B, F, SP,

SH/IP, ST

Major, James C.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/H

Marcus, Dennis M.Alimera . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GEli Lilly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GGenentech. . . . . . . . . . . . . . . . . . . . . . . . . A, C, I/H, GNeoVista . . . . . . . . . . . . . . . . . . . . . . . . . . I/GPfizer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/GSanten . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GThrombogenics. . . . . . . . . . . . . . . . . . . . . I/G

Mattox, Cynthia Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GTranscend . . . . . . . . . . . . . . . . . . . . . . . . . I/G

Maturi, Raj K.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . O/GEli Lilly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CLux Biosciencs . . . . . . . . . . . . . . . . . . . . . I/GNovagli . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GPfizer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G

McCannel, Colin A.Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/OB, I/GSavvient . . . . . . . . . . . . . . . . . . . . . . . . . . . SH/ST

Mieler, William F.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . H/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . C/H

Miller, Daniel M.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, C, SP, I/H,

OBGenentech. . . . . . . . . . . . . . . . . . . . . . . . . I/OBRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/OB

Moshfeghi, Andrew A.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HAlimera Sciences . . . . . . . . . . . . . . . . . . . C/HConvene . . . . . . . . . . . . . . . . . . . . . . . . . . . F, SH/STEyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . A, C, I, SP/G, HOraya. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/NCRAM Corporate Advisors . . . . . . . . . . . . A, C/STRealm Global . . . . . . . . . . . . . . . . . . . . . . . A, SH/SOThrombogenics. . . . . . . . . . . . . . . . . . . . . I/G

Moshfeghi, Darius M. Insitu Therapeutics . . . . . . . . . . . . . . . . . F, SH/SOMyWhiteCoat . . . . . . . . . . . . . . . . . . . . . . C, SH/STOcubell . . . . . . . . . . . . . . . . . . . . . . . . . . . . F, SH/STOraya Therapeutics . . . . . . . . . . . . . . . . . C, SH/SO

Motley, William WalkerAlcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/H

Mullins, Robert Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G

Murray, Timothy G.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H

Myung, Jane Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/H, I/GAllergon . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . I/GRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G

Nagpal, Manish Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H, B/HBayer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HOptimedica . . . . . . . . . . . . . . . . . . . . . . . . A, SP/H, SOTopcon Medical Systems, Inc. . . . . . . . . SP/H

Naseri, AymanAlcon Laboratories . . . . . . . . . . . . . . . . . C/OBAlimera Sciences . . . . . . . . . . . . . . . . . . . CAllergan, Inc. . . . . . . . . . . . . . . . . . . . . . . . C/SFocusRop LLC . . . . . . . . . . . . . . . . . . . . . . O/RGenentech. . . . . . . . . . . . . . . . . . . . . . . . . O/GGlaxoSmithKline . . . . . . . . . . . . . . . . . . . . O/GOphthotech. . . . . . . . . . . . . . . . . . . . . . . . O/GRetinal Solutions . . . . . . . . . . . . . . . . . . . O/RThrombogenics. . . . . . . . . . . . . . . . . . . . . O/GTranscend Medical. . . . . . . . . . . . . . . . . . C/H

Nelson, Mark H.Eyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HHeidelberg Engineering . . . . . . . . . . . . . C/HNovartis . . . . . . . . . . . . . . . . . . . . . . . . . . . A/GQLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/H

Nguyen, Quan DongBausch + Lomb . . . . . . . . . . . . . . . . . . . . . C/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . I/GGenentech–Spouse. . . . . . . . . . . . . . . . . I/GHeidelberg Engineering . . . . . . . . . . . . . I/GPfizer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/GRegeneron–Spouse . . . . . . . . . . . . . . . . . I/GSanten . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H, I/G

Nielsen, Jared S.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H

Nuthi, Asha S.D.Alimera Sciences . . . . . . . . . . . . . . . . . . . IAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . IGenetech . . . . . . . . . . . . . . . . . . . . . . . . . . I, GNEI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . IThromboGenics . . . . . . . . . . . . . . . . . . . . I

Ober, Michael D.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HOD-OS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/SO

Oshima, yusuke Alcon Japan. . . . . . . . . . . . . . . . . . . . . . . . E/HCarl Zeiss Meditec . . . . . . . . . . . . . . . . . . SP/HDORC International BV . . . . . . . . . . . . . . C, SP/HSanten Pharmaceutical . . . . . . . . . . . . . SP/HTopcon Medical Laser System . . . . . . . A/H

Packo, Kirk H.Alcon Surgical . . . . . . . . . . . . . . . . . . . . . . A, C, I/G, H, SAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GGenentech. . . . . . . . . . . . . . . . . . . . . . . . . I/GThrombogenics. . . . . . . . . . . . . . . . . . . . . I/G

Patel, Amar Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HOD-OS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/SO, H

Financial Interest or Relationship Disclosures

199

Patel, Sunil S.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, C/G, I/GAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C, C/G, I/G,HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . A/H, G, I/GHOpthotech . . . . . . . . . . . . . . . . . . . . . . . . . C/SO, G, S, A,

SH/G, SO

Pericak-Vane, MargaretArctic DX . . . . . . . . . . . . . . . . . . . . . . . . . . O/IP, SH/S

Perry-Ecker, Stephanie Ocular Protemics . . . . . . . . . . . . . . . . . . . E/NC

Peyman, Gholam A.K.M.G. Pharma . . . . . . . . . . . . . . . . . . . . . A/IP

Pieramici, Dante Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I, SP, CAlimera Sciences . . . . . . . . . . . . . . . . . . . I, SP, CNeovista/Topcon . . . . . . . . . . . . . . . . . . . IQLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I

Pineda, Roberto Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H

Prenner, Jonathan L.Alimeria . . . . . . . . . . . . . . . . . . . . . . . . . . . CHNeovista. . . . . . . . . . . . . . . . . . . . . . . . . . . C, SH/SOOpthotech . . . . . . . . . . . . . . . . . . . . . . . . . S, SH/S, SO

Priest, David Annidis Health Systsems. . . . . . . . . . . . E/S

Reshef, Daniel S.Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/S, SO

Rezaei, Kourous A.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, AP/G, H, OBAlcon–Spouse. . . . . . . . . . . . . . . . . . . . . . SP/HBMC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . SP, I/G, H

Rosen, Richard B.Claritin . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/SGenentech. . . . . . . . . . . . . . . . . . . . . . . . . SP/GOD-OS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/SOpko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/STopcon . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/H

Rosenfeld, Philip J.Bristol Meyers Squibb. . . . . . . . . . . . . . . C/SCarl Zeiss Meditec . . . . . . . . . . . . . . . . . . SP/HChengdu. . . . . . . . . . . . . . . . . . . . . . . . . . . C/HOraya. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H

Roth, Daniel B.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . SP/HNotal Vision. . . . . . . . . . . . . . . . . . . . . . . . C, SP/HQLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H, SP/HRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . A/H

Rubio, Roman Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E, SH/S, ST,

SORoche Group . . . . . . . . . . . . . . . . . . . . . . . SH/ST, SO

Sadda, Srinivas ReddyAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H, GCarl Zeiss Meditec . . . . . . . . . . . . . . . . . . O/GGenentech. . . . . . . . . . . . . . . . . . . . . . . . . C/H, GHeidelberg Engineering . . . . . . . . . . . . . A/HOptos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O/GOptovue . . . . . . . . . . . . . . . . . . . . . . . . . . . O/G

Samuel, Michael A.Iscience . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HJohnson & Johnson . . . . . . . . . . . . . . . . . C/H

Saroj, Namrata Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/S, SO

Sarraf, David Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G

Schmidt-Erfurth, Ursula M.Alcon Laboratories . . . . . . . . . . . . . . . . . C, C/OB, I/G,

SP/HBausch + Lomb . . . . . . . . . . . . . . . . . . . . . C/HBayer Healthcare . . . . . . . . . . . . . . . . . . . C, SP/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . I/GHeidelberg Engineering . . . . . . . . . . . . . I/GNovartis . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/HPfizer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G, SP/HRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/GSanten . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H

Schwartz, Stephen G.Bauch & Lomb. . . . . . . . . . . . . . . . . . . . . . SP/HUniversity of Miami . . . . . . . . . . . . . . . . . E/IP

Scott, William K.Artic DX . . . . . . . . . . . . . . . . . . . . . . . . . . . O/R

Seddon, Johanna M.Genetech . . . . . . . . . . . . . . . . . . . . . . . . . . I/GTufts Medical Center . . . . . . . . . . . . . . . I/P

Semidey, Valmore AdrianEyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB

Shah, Gaurav K.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/EAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/EBausch and Lomb. . . . . . . . . . . . . . . . . . . C/EDORC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/EHeidelberg Engineering . . . . . . . . . . . . . C/EI Science. . . . . . . . . . . . . . . . . . . . . . . . . . . C/E

Shapiro, Howard Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/S

Sherman, Jerome Carl Zeiss Meditec . . . . . . . . . . . . . . . . . . Sp/HTopcon . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sp/H

Sinclair, Stephen H.Vimetrics LLC . . . . . . . . . . . . . . . . . . . . . . B/SH,

SH/IP, ST

Singer, Michael A.Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A, C, SP, I/G, HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . A, C, SP, I/G, HNeovista. . . . . . . . . . . . . . . . . . . . . . . . . . . I/GOptos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GReneneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G

Slakter, Jason S.Novartic Pharmaceuticals . . . . . . . . . . . O/GQLT Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . O/G

Solley, Wayne A. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/H, G

Spaide, Richard F.Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C/GGlaxoSmithKline . . . . . . . . . . . . . . . . . . . . C/GHeidelberg . . . . . . . . . . . . . . . . . . . . . . . . . C/GTopcon Inc . . . . . . . . . . . . . . . . . . . . . . . . . C/G

Stalmans, Peter Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . I/EThrombogenics. . . . . . . . . . . . . . . . . . . . . I/E

Stone, Thomas W.Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/OPNational Eye Intitute . . . . . . . . . . . . . . . . I/OP

Stout, Timothy M.Eyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H

Sun, Jennifer K.Abbott Laboratories . . . . . . . . . . . . . . . . A/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . A/H, GNovartis . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H

Tabandeh, Homayoun Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H

Takahashi, Walter y.Novartis . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H

Tan, Donald Acufocus . . . . . . . . . . . . . . . . . . . . . . . . . . I/GAlcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/HBausch + Lomb . . . . . . . . . . . . . . . . . . . . . C, SP/HCarl Zeiss Meditec . . . . . . . . . . . . . . . . . . I/GNetwork Medical Products . . . . . . . . . . O/RSanten Pharmaceutical . . . . . . . . . . . . . C, SP/H

Thompson, John T.Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/GNational Institute of Health . . . . . . . . . I/GRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G

Tornambe, Paul E.Alimera . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HOptos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/H

Trese, Michael T.Alcon Laboratories . . . . . . . . . . . . . . . . . C/OBAlimera Sciences . . . . . . . . . . . . . . . . . . . CAllergan, Inc. . . . . . . . . . . . . . . . . . . . . . . . C/SFocusRop LLC . . . . . . . . . . . . . . . . . . . . . . C/RGenentech. . . . . . . . . . . . . . . . . . . . . . . . . O/GGlaxoSmithKline . . . . . . . . . . . . . . . . . . . . O/GNovartis . . . . . . . . . . . . . . . . . . . . . . . . . . . O/OBOphthotech. . . . . . . . . . . . . . . . . . . . . . . . O/GRetinal Solutions . . . . . . . . . . . . . . . . . . . O/RThrombogenics. . . . . . . . . . . . . . . . . . . . . O/G

Walsh, Alexander CraigTopcon Medical Systems . . . . . . . . . . . . O/R

Warren, Keith A.Alcon Labs . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/HDORC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . C, SP/H

Wells, John A.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/HDRCR.net . . . . . . . . . . . . . . . . . . . . . . . . . . I/NCEyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . A, C, I/HGenentech. . . . . . . . . . . . . . . . . . . . . . . . . I/GRegeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G

Whitcup, Scott M.Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . E, S, ST, SO/S

Williams, David F.Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C/H

Wong, Pamela Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/S

yau, Linda Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/SO, ST, S

yehoshua, Zohar Carl Zeiss Meditec . . . . . . . . . . . . . . . . . . I/G

yooh, young Hee Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/HAllergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/HBayer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/H

AAaberg, Jr., Thomas 69Abe, Ricardo 114Abraham, Prema 49, 93Abulon, Dina Joy 65, 140, 142Adabache-Guel, Tania 111, 169Adelberg, Daniel 151Adelman, Ron 83, 96Adhi, Mehreen 84, 166Adrean, Sean 128Afshar, Armin 102Agarwal, Anita 14, 107Aggarwal, Anju 144Ahmad, Baseer 164Ahmed, Shareef 144Ahuja, Richard 156Akhtar, Abeer 115, 166Albert, Jr., Michael 99, 122, 123, 184Albini, Thomas 82, 116Alezzandrini, Arturo 22, 120Al-Heeti, Omar 156Allemann, Norma 148Alliman, Kyle 48Almeida, Felipe 77Almony, Arghavan 129Alshareef, Rayan 153Amara, Madhu 102Andi, Inayet 119Androudi, Sofia 107Antoszyk, Andrew 19Appenzeller, Matthew 52Arend, Laurence 110Arevalo, J. 12, 22, 61, 115, 120Ariza, Enrique 40Aschbrenner, Mathew 83Aslankurt, Murat 119Atri, Neelam 24, 124, 147, 162, 192Augsburger, James 56, 186Avery, Robert 28Awh, Carl 7, 12, 58, 63, 71Ayachit, Guruprasad 109, 189Ayala, Andrea 113, 184Aylward, G. 24Aziz-Sultan, Mohammad Ali 187

BBae, Jung Hoon 105Bajaire, Boris 12, 189Bakri, Sophie 31, 46Balaiya, Sankarathi 84, 86Balarin, Valdir 136Baldivieso-Hurtado, Olivia 181Bandello, Francesco 32, 155Banker, Alay 68, 72, 115, 119, 189Bansal, Alok 55Bar, Diego 132Barak, Adiel 27, 87Barak, Yoreh 12, 120Barbazetto, Irene 92, 155Barkmeier, Andrew 165Barnett, Jonathan 35Barte, Felise 61Basham, Ryah 101Beardsley, Robert 165Bedell, Matt 15Bednarski, Maciej 135Bell, Darren 78Bennett, Jean 4, 16Bennett, Michael 87Beres, Tatiana 33Bergstrom, Chris 113, 116, 128, 151Berrocal, Audina 50, 180, 182Berrocal, Maria 22, 120Bhadri, Prashant 64Bhatia, Gagan 192Bhavsar, Kavita 48Bhende, Muna 189Bhende, Pramod 50, 68, 180, 189Bhisitkul, Robert 32Bianciotto, Carlos 55Biswas, Jyotirmay 12Bittencourt, Millena 166Blinder, Kevin 69, 156, 190Blumenkranz, Mark 62, 67Boate, Alan 171

Bor, Elite 162, 163Boscia, Francesco 79, 81Bourla, Dan 162, 163Boyer, David 18, 21, 34, 71, 76, 87, 94, 133Bozorg, Sara 15Braman, Jay 180Branchini, Lauren 84, 166, 176, 177Brantley, Jr., Milam 97Bratu, Adriana 130, 190Brechner, Ross 5, 38Bressler, Neil 22, 38, 44, 75, 85, 103Bressler, Susan 42, 44, 85Brown, David 16, 20, 34, 71, 85, 173Bruce, Beau 175Buboltz, David 65, 140, 142Bukelman, Amir 129Burgess, Barry 57Busbee, Brandon 86Busija, Lucy 95

CCable, Melissa 143Cade, William 14Cai, Jiyang 97Cakir, Mehmet 125, 190Calderon, Veronica 145Callanan, David 4, 11, 18, 36, 107, 116Campbell, John 85, 115, 166Campochiaro, Peter 21, 32Capone, Jr., Antonio 40, 42Cardillo, Jose 72Carlson, John 187Carmodu, Jill 176Carricondo, Pedro 139Carroll, Joseph 179Castellarin, Alessandro 28, 51Cekic, Osman 119, 125, 190Celik, Ugur 190Cereda, Matteo 25Chae, Ju Byung 107, 169Chakravarti, Arindam 97Chalam, K. 84, 86, 139, 141, 156, 175Chan, Clement 49, 93, 187Chan, Robison 72, 132, 181, 182Chang, Gregory 191Chang, Jeffrey 48Chang, Stanley 131, 191Chang, Tom 13, 34Channa, Roomasa 21, 76, 115, 166Charalampopoulos, Ioannis 153Charkoudian, Leon 67Charles, Martin 190Charles, Steve 66, 67Chaudhary, Varun 12Chaudhry, Nauman 87, 94, 157Chauhan, Rohan 115, 119, 189Chaves, Fernando 136Chawla, Dinesh 70, 96Chen, Carolyn 45, 48Chen, Ching 100, 190, 194Chen, Jane 53Chen, John 69Chen, Xuejing 83Cherney, Edward 170Chhablani, Jay 135, 160, 162Chiang, Allen 30Chiriboga, Juan 113, 184Cho, Brian 115, 166Cho, Minhee 132Choudhury, Tahsin 129Chu, Thomas 21, 87, 133Chun, Dal 79, 80Ciampi, Jonathan 64Cionni, Douglas 73Cisiecki, Slawomir 135Ciulla, Thomas 18Clark, W. 34Clayton, Richard 171Coady, Patrick 62Collinge, Janine 27Colman, Shoshana 22Colyer, Marcus 79, 80Compton, Christopher 123Conlan, Erica 45Connors, Daniel 52, 143

Cooney, Michael 155Cooper, Robert 179Cormier, Michel 82Cornu, Denisse 101, 145Correa, Zelia 56, 186Costa, Rogerio 77Coupland, Stuart 171Couvillion, Stephen 28, 51Crews, Jonathan 156Crews, Kent 158Cribbs, Blaine 116Curcio, Christine 37

DDalma-Weiszhausz, Jose 111, 181D’Amico, Donald 132Daniel, Connors 52, 143Daniels, Stewart 58Danis, Ronald 161Daphna, Ofer 129Das, Sima 12Das, Taraprasad 174Dave, Sarita 43Dave, Vivek 160, 162Davis, Joshua 130Davis, Michael 34De Silva, Anne 173DeBoer, Charles 64Dellatorre, Kara 47, 93Desai, Uday 144Desroches, Gilles 190Devenyi, Robert 70, 121, 171Dhoot, Dilsher 73, 144Diaz-Llopis, Manuel 22Dikshit, Siddharth 100, 124Do, Diana 21, 23, 76, 115Dolan, Chantal 22Donoso, Larry 142Dotan, Assaf 163Drenser, Kimberly 40, 41, 42Dresnik, Ayelet 162Dubis, Adam 179Dubra, Alfredo 179Dugel, Pravin 11, 24, 25, 69, 71, 87Duker, Jay 12, 84, 166, 176, 177Dursun, Osman 119

EEdwards, Jayson 175Edwards, Paul 144Eells, Madeline 168Ehlers, Justis 12, 37, 124, 164, 167Ehrlich, Jason 20, 22Eliott, Dean 67, 69, 73, 77, 193Elman, Michael 103El-Rayes, Ehab 26Emanuelli, Andres 107, 126Emerson, Geoffrey 12Emond, Tracy 99, 118, 122, 123, 184Erlanger, Michael 191

FFabian, Ido 27Faez, MD Sepideh 110Fahmy, Ahmed 76Fan, Joseph 187Fantoni, Gualtiero 64Farah, Michel 24, 53, 61Farsiu, Sina 141Favarone, Guilleherme 132Federici, Thomas 114, 151Feist, Richard 99, 122, 123, 184Fernandes, Cristina 187Ferreira, Eber 53Ferreira, Joao 190Ferreira, Magno 24, 53Ferreira, Raquel 53Ferreyra, Henry 15Ferrone, Philip 73, 74Feuer, William 13, 62, 97Fick, Tyler 48Figueroa-Magana, Blanca 111Filho, Aca’cio 53Fine, Howard 52, 62, 97, 143Fineman, Mitchell 153, 158

Finley, Thomas 184Flaxel, Christina 89Flores-Moreno, Ignacio 84Flynn, Jr., Harry 43, 44, 94Forlini, Cesare 130, 190Forlini, Matteo 130, 190Foster, Robert 52, 73Foster, William 130Foxman, Brett 7, 189Francis, Peter 12, 89Francisco, Pinto 148Franco-Cardenas, Valentina 104, 168, 190Francom, Steven 46Franklin, Alan 88, 154Freeman, William 15Freund, K. Bailey 36, 38, 47, 92, 93, 154, 172Friedenthal, Jenna 130, 149Friedman, Duncan 118Friedman, Neil 62Friedmann, Peter 88Fromow-Guerra, Jans 111, 167, 181, 183Fujimoto, J.G. 84, 166Fung, Anne 62

GG. Kumaramanick 97Gabrielian, Anna 28, 69, 101Galic, I. 69Gallego-Pinazo, Roberto 22Gallemore, Ron 168Gan, Theresa 115, 166Ganti, Shashi 70, 96Gao, Hua 12, 144Garcia, Maria Belen 120Garcia, Patricia 35, 92Garcia, Reinaldo 150Garcia-Aguirre, Gerardo 111, 167, 181, 182, 183Garg, Sunir 12, 30, 44, 59, 107, 138, 142, 153Garner, Omai 118Gautam, Manoj 135, 159Gelman, Susan 130, 149Genovesi-Ebert, Federica 64Gentile, Ronald 36, 92George, Ronnie 50Georgopoulos, Minas 125Gerhardt, Dennis 91Giacomotti, Enrico 81Giani, Andrea 59Gill, Manjot 112, 186Giordano, Veronica 183Giovannini, Alfonso 126Glassman, Adam 75Glickman, Randolph 75Goldhardt, Raquel 74Goldman, Darin 116, 154Goldstein, Debra 116Gonzalez, Victor 68, 101, 145Gopal, Lingam 180Goren, Jordana 45Govind, Kishan 107Goyal, Mallika 12, 68, 108, 109Graeber, Carolyn 130, 149Grandhe, Sandeep 102Grant, Scott 128Gravanis, Achilleas 153Greenberg, Paul 88Gregori, Giovanni 13Gregori, Ninel 74, 93, 126Gregory, Gary 180Gregory-Roberts, Emily 131Greven, Craig 107Gribben, Jeremy 171Grigalunas, Alexander 122Grinwalled, Yoel 129Grob, Seanna 15Grossniklaus, Hans 128Guajardo, Beatrice 78Guerrero-Naranjo, Jose 111, 167, 169, 181,182, 183Gupta, Anmol 62Gupta, Charu 12, 24, 124, 147, 162, 192Gupta, Gaurav 111Gupta, Sunil 18, 88, 154Guymer, Robyn 95

200

Participant Index

HHa, Man Mook 105Haberman, Ilyse 130, 149Hahn, Paul 169Haines, Jonathan 14Haller, Julia 32, 34, 38, 155Halperin, Lawrence 38Hamilton, John 171Hancock, Heather 190Harbour, J. William 56Hariprasad, Seenu 81, 103Harrie, Roger 150Harris, Ian 13Hartnett, Mary 150Hassan, Kunle 160Hassan, Tarek 7, 13, 29Hatef, Elham 115, 166Hayashi, Atsushi 170He, Shikun 77Heier, Jeffrey 15, 16, 21, 23, 34, 45, 48, 68, 71Heilweil, Gad 35, 104, 168Heo, Jang won 76Hernandez-Bogantes, Erick 61Hernandez-Da Mota, Sergio 140, 145Hess, Ditte 180, 182Heussen, Florian 14, 60, 177Hicks, Joshua 99Hidaka, Jiro 147Hinkle, David 107Hinton, David 77Hirakata, Akito 140, 146Ho Yen, Gregory 125Ho, Allen 4, 13, 17, 59, 71Ho, Lawrence 41Hoang, Quan 47, 191Holekamp, Nancy 31Hollander, David 18Hopkins, J. Jill 20Hosseini, Kamran 82Houghton, Odette 157Houston, Samuel 50, 187Hsu, Jason 30, 59, 138, 142, 153Huang, Lynn 121Huang, Suber 7, 13, 16, 51Hubbard, G. Baker 37, 67, 116, 128Hubschman, Jean-Pierre 35, 104, 168, 190Hughes, Guy 15Humayun, Mark 50, 64Hunt, Christine 52Huo, Siya 73Hurley, Bernard 171Hutchins, Robert 73Hwang, Thomas 89

IIbrahim, Mohamed 115, 166Inoue, Makoto 117, 140, 146, 147Iribarren, Guillermo 132Isernhagen, Rick 90, 112Izatt, Joseph 167, 169

JJackson, Tim 87Jadav, Dip 75Jager, Rama 102Jain, Pravin 191Jain, Sachin 90Jalali, Subhadra 100, 174Jaffe, Glenn 16Jampol, Lee 36, 186Janmey, Paul 130Javaheri, Michael 77Jayasundera, Kanishka 69Jiang, Lan 88Jiao, Jenny 32, 155, 161Jimenez-Sierra, Juan Manuel 12, 111, 167, 169Joe, Soo Geun 95, 107, 169Johnson, Mark 116Jonisch, Jonathan 74, 156Joos, Karen 170Jorge, Rodrigo 77Joseph, Daniel 83, 129Jumper, J. Michael 17Jung, Cecilia 116Jung, Jesse 47

KKaiser, Peter 12, 26, 37, 38, 71, 73, 124, 164Kaiser, Richard 30, 59, 153, 158Kammer, Jeffery 170Kassem, Nawal 90Kegley, Eric 173Kerns, Ralph 64Kertes, Peter 70, 121Keshavamurthy, Ravi 141Kherani, Amin 41, 191Khetpal, Vijay 84, 86, 139, 141, 156, 175Khwaja, Afsheen 21, 76Kiernan, Daniel 133Kim, Bryan 156Kim, Jee Taek 107Kim, Leo 77Kim, Moo Sang 106Kim, Stephen 43, 170Kim, Yoon Jeon 107Kim, Young Gun 106Kim, Yu Hyon 89Kinori, Michael 27Kishore, Kamal 90Kiss, Szilard 132Kitchens, John 90, 112, 191Klancnik, Jr., James 155, 172Kokame, Gregg 60Komarnicky, Linda 55Komarnicky, Lydia 55Kon-Jara, Veronica 87, 94, 157Korobelnik, Jean-Francois 34Korotkin, Arthur 158Koto, Takashi 117Kovach, Jaclyn 14, 71Kozak, Igor 15Kuchtey, Rachel 170Kumar, Neel 88, 154Kumar, Neeru 75Kunjukunju, Nancy 110Kuppermann, Baruch 18, 32, 135, 155, 160Kurli, Madhavi 127Kurup, Shree 12, 36, 107Kurup, Sudhi 112Kwak, Hyung-Woo 106

LLai, James 60Lai, Michael 27Lai, Phillip 33, 46Lalezary, Maziar 170, 183Lalwani, Geeta 182Lam, Wai-Ching 70, 90, 121, 173Landa, Gennady 35, 92Landers, Maurice 157Lane, Richard 30Larco, Sandra 113, 184Lasave, Andres 22Lavina, Adrian 182Leal-Rodriguez, Ricardo 167Leder, Henry 115, 166Lee, Clara 15Lee, Jacob 90Lee, Jeong Hee 76Lee, Joo Yong 95, 107, 169Lee, Paul 22Lee, Thomas 68Leite, Thiago 139Leon, Geoconda 184Leonard, Brian 171Leong, Craig 58Letaief, Imene 106Lewis, Shawn 73Li, Lang 90Li, Lina 96Li, Xiao-Yan 18, 32, 94, 155, 161Lim, Jennifer 21, 133, 171Lim, Laurence 146Lima, Luiz 64, 172Lin, Bin 15Lin, Phoebe 141Lin, Steven 49, 93Lingam, Vijaya 50Lipkowitz, Jeffrey 12, 113Lira, Rodrigo 114, 136Liu, Ching-Chi 18, 94

Liu, Enchun 111Liu, Jonathan 166Loewenstein, Anat 27, 155Logani, Sanjay 71London, Nikolas 12, 87, 133, 158Lopezcarasa Hernandez, Gabriela 69, 182Lou, Jean 18Lowder, Careen 12Luo, Caesar 41, 138, 192Luttrull, Jeffrey 72, 159Lyndon, Lee 175

MMacCumber, Mathew 31, 101Macky, Tamer 102Maggio, Emilia 59Maguire, Albert 1, 4, 16Maguire, Joseph 30, 55, 59Mahgoub, Mohamed 102Maia, Mauricio 24, 53Maisel, James 72Majcher, Carolyn 98Majji, Ajit 137, 174Major, Jr., James, 85, 173Malinowski, Susan 61, 161Manjunath, Varsha 84Marcus, Dennis 20Margolis, Ron 36Mariani, Angeline 85, 173Mariotti, Cesare 126, 134Martin, Daniel 12, 16, 37, 124, 164Martin, Neil 27Martinez-Castellanos, Maria 72, 169, 181,182, 183Mashayekhi, Arman 55Mason, III, John 69, 99, 118, 122, 123, 184Mateo, Carlos 131Mathai, Annie 137, 174Matthews, G. 64Matti, Natalia 40Maturi, Raj 103Mavrikakis, Emmanouil 12, 173Mavrofrides, Elias 180, 182Mazzulla, Anthony 110McCain, Mary Ann 86McCannel, Colin 49, 70, 93, 118, 154McCannel, Tara 55, 57McCormick, Matthew 64McDonnell, Emma 14, 177Mein, Calvin 69Melamud, Alexander 134Melo, Gustavo 12Mendonca, Luis 47, 98Meredith, Travis 157Messias, Andre 77Mettu, Priyatham 141Meza-De Regil, Armando 111Michalewska, Zofia 127, 135, 191Michalewski, Janusz 127, 135, 191Mieler, William 4, 12, 17, 71Migacz, Justin 169Milder, Eugene 44Miller, Daniel 52, 73Miller, Joel 36Mimouni, Karin 162, 163Mines, Michael 80Mitchell, Patrick 191Mittra, Robert 69Mochon, Brian 118Moisseiev, Elad 27Moisseiev, Joseph 27Monshizadeh, Ramin 187Montezuma, Sandra Rocio 191Moraes-Junior, Milton 24Morales-Canton, Virgilio 12, 31, 111, 167,169, 181, 182, 183, 193Moshfeghi, Andrew 82Moshfeghi, Darius 46, 180Moshiri, Ala 44Motley, William 138Mruthyunjaya, Prithvi 141Mukkamala, Sri Krishna 36Muldoon, Thomas 92Mullins, Robert 174Murahashi, Wendy Yee 163Muralidhar, Naveenam 135, 159

Murray, Timothy 7, 50, 71, 187Murthy, Hemanth 135, 159Mutapcic, Lejla 187Myers, John 88, 154Myung, Jane 132

NNagpal, Manish 191, 194Naidu, Purshottam 97Naimi, Elham Hatef 166Naithani, Prashant 162Nandakumar, Namrata 166Narain, Shishir 12Narala, Ramsudha 14, 177Narayanan, Raja 100, 124, 135, 137, 160,162, 174, 191Naseri, Ayman 29Nasir, Ma’an 28, 51Natarajan, S. 68, 97Nawrocka, Zofia 191Nawrocki, Jerzy 127, 135, 191Nelson, Mark 15, 70Neravetla, Shantanu 162Neri, Piergiorgio 126Nguyen, Quan Dong 21, 76, 115, 116, 166Nichols Kay, Christine 174Nicholson, Benjamin 162Nicolai, Michele 126, 134Nielsen, Jared 48Niffenegger, John 58Nishida, Kohji 147Noda, Toru 146Nuthi, Asha 49, 93

OO’Grady, Michael 75Ober, Michael 36, 61O’Bryhim, Bliss 185O’Connell, Rachelle 169Oderinlo, Olufemi 160Odrobina, Dominik 135Ohnuma, Kazuhiko 146Oka, Miyako 170Okonkwo, Ogugua 160Oliver, Armando 36Olk, R. 91, 192Olsen, Matthew 190Olsen, Timothy 116Olson, Jeffrey 191Orlin, Anton 132Osborn, Melissa 97Oshima, Yusuke 147Otteson, Deborah 130Oudovitchenko, Elena 189Ouertani, Amel 106Ouyang, Yanling 14, 60

PPacko, Kirk 65, 67, 122, 152Paipilla, Diego 12, 189Paiva, Sergio 114Palanker, Daniel 62Palla, Michele 64Panetta, Heitor 114, 136Pappuru, Rajeev 137, 174Park, Robert 137Parke, III, David 50Parke, II, David 5, 39Parolini, Barbara 25, 59Pate, James 191Patel, Amar 127Patel, Anu 161Patel, Ravi 102, 103Patel, Sunil 94Patelli, Fabio 81Pathangey, Avinash 137, 174Paul, Kitia 45Pawar, Sharmila 97Payne, John 116, 175Peng, Shaomin 96Penha, Fernando 13, 24Peralta, Enrique 91Perez Reguera-Gutierrez, Adriana 111Pericak-Vance, Margaret 14Peris, Cristiane 53Pertile, Grazia 25, 59

201

202

Pesavento, Richard 187Petersen, Michael 52, 73Peyman, Gholam 82Pieramici, Dante 28, 33, 38, 51Pitcher, III, John 104Polito, Antonio 59Pollack, Ayala 129Pollack, John 18Pomerleau, Dustin 99, 118, 122, 123, 184Ponce, Alfonso 92Popma, Sicco 13Porco, Travis 29Portillo, Natassha 150Poulaki, Vassiliki 12Prall, F. Ryan 187Prasad, Pradeep 35, 168, 192Prema, Abraham 49, 93Prenner, Jonathan 17, 43, 52, 62, 97, 143Prescott, Daniel 191Priest, David 171Purkiss, Todd 12

QQian, Cynthia Xin-ya 149Qiu, Caihong 96Quiroz-Mercado, Hugo 72, 111, 181, 182Qureshi, Salmaan 95

RRabena, Melvin 28, 51Radhakrishnan, Ravi 139, 141, 156, 175Radice, Paolo 81Rahman, Hassan 113, 151Ramaiya, Kamalesh 190Ramos-Filho, José 77Ranchod, Tushar 41, 58Rao, Kavitha 159Rao, Veena 83Ravage, Zac 152Ray, Aditi 65Ray, Robin 37, 128Ray, Subhransu 58Recchia, Franco 12, 69, 170, 183Reddy, Rahul 170Reddy, Shantan 129, 130, 149Reddy, Shilpa 122Regatieri, Caio 61, 84, 166, 176, 177Regillo, Carl 30, 55Reichel, Elias 12Renner, Morgan 76Rentiya, Zubir 76Reshef, Daniel 46Rezaei, Kasra 97Rezaei, Kourous 28, 69Rezende, Flavio 148, 149, 193Rha, Jungtae 179Ribeiro, Jefferson 77Rich, III, William 5, 39Riemann, Christopher 52, 73, 142Rizzo, Stanislao 64Rizzolo, Lawrence 96Robert, Marie-Claude 149Roberts, Jr., John 156Robertson, Zachary 100, 190Robinson, Joshua 128Roca, Jose 61, 120Rodrigues, Eduardo 24, 53Rodriguez, Leonidas 150Roh, Young Jung 89Rojas, Sergio 192Romo-Garcia, Efrain 12Roobini, Babak 114Rosen, Richard 35, 92, 127Rosenfeld, Philip 13, 38, 44Rosenthal, Julie 12Rossini, Paolo 130, 190Roth, Daniel 52, 62, 97, 143Rubin, Uriel 132Rubio, Roman 32, 46Ruiz-Garcia, Humberto 14, 177Ryu, Hyun-Wok 89

SSadda, Srinivas 14, 60, 161, 177Safi, Farhad 80Saggau, David 48Sagoo, Mandeep 55Sahu, Chinmaya 191Saito, Masaaki 92, 98Saitta, Andrea 126, 134Salaroli, Camila 148Salcedo-Villanueva, Guillermo 12, 169Suleni-Had, Hani 77Salguero, Andres 189Samson, Michael 107Samuel, Michael 13, 34Sanchez Bermudez, Carlos Gustavo 167, 169Sanders, Barton 97Sanders, Reginald 38Sandoval, Armando 113, 184Saravia, Mario 182Saroj, Namrata 32Sarraf, David 49, 93, 116, 154, 165, 192Sayegh, Samir 91, 192Schaal, Shlomit 12, 120Schachat, Andrew 164Schiffman, Rhett 18Schlenker, Matthew 70, 121Schmidt-Erfurth, Ursula 15, 23Schneider, Bryan 90Schneider, Mark 187Schroeder, Brett 179Schwartz, Stephen 14, 93Schwartz, Steven 35, 104, 168, 190Scott, Bill 14Scott, Ingrid 77Scott, William 14, 71Sears, Jonathan 37, 124, 144, 164Sebag, Mikael 69Seddon, Johanna 43See, Robert 28, 51Seider, Michael 29Semidey, Valmore 101, 145Sen, Nida 107Sepah, Yasir 21, 76, 115, 166Serrano, Martin 115Serrano, Neha 134Seth, Rajeev 83Setlur, Vikram 138Shah, Ankit 62, 97Shah, Ankur 186Shah, Bhavin 124, 135Shah, Chirag 44, 45, 48, 142Shah, Gaurav 69, 156, 190Shah, Sumit 12Shahidi, Mahnaz 171Shantha, B., 50Shao, Jack 124Shapiro, Howard 32Sharma, Bhavana 24, 124, 147, 162, 192Sharma, Sumit 124Sharma, Tarun 180Shaw, Peter 15Shaw, Robert 15Sherman, Jerome 36Sherman, Mark 120Shibata, Suellen 139Shields, Carol 12, 55, 57, 68, 188Shields, Jerry 12, 55, 57, 68, 188Shinoda, Kei 146Shoshani, Nadav 27Shrivastava, Anurag 121Shroff, Cyrus 12, 24, 124, 147, 162, 192Shroff, Daraius 12, 24, 124, 147, 162, 192Shuler, Magdalena 88, 154Shulman, Julia 150Siegel, Ruth 162, 163Silva Lopes, Mariana 44Sinclair, Stephen 72, 98Singer, Michael 71, 78, 94Singh, A.K. 24, 124, 147, 162, 192

Singh, Rishi 12, 37, 124, 144, 163, 164Sinha, Manish 160Sisk, Robert 50, 73, 138Sivalingam, Arunan 30Siwinska, Magdalena 127Sjaarda, Raymond 178Skaat, Alon 27Slakter, Jason 92Smith, Michael 80Sobrin, Lucia 110Sohn, Elliott 77Song, Su Jeong 105Soni, Malhar 125, 178, 192Sorenson, John 36Souza, Eduardo 12Souza, Nonato 148Spaide, Richard 12, 36, 37, 92, 98, 172Spink, Charles 159Spirn, Marc 30, 142, 153, 158Srivastava, Sunil 37, 113, 116, 124, 128, 167Stalmans, Peter 69, 79, 80Steinle, Nathan 12Stepien, Kimberly 71, 179Sternberg, Jr., Paul 97Stewart, Jay 29Stone, Thomas 19, 90, 112Stout, Timothy 143Strauss, Danielle 129Su, Chien-Chia 99Suarez Tata, Luis 150Suarez-Tata, Moravia 150Sun, Jennifer 75Suner, Ivan 22Switzer, Jr., David 92, 98Symons, Robert 185

TTa, Christopher 70Tabandeh, Homayoun 76, 87, 94, 133Tai, Katy 35, 92Takahashi, Walter 139Takasaka, Iuuki 136Tan, Donald 146Tanaka, Tatiana 139Tao, Yuankai 167Tarantola, Ryan 174Tarigopula, Sweta 144Tawansy, Khaled 40, 41, 182Taylor, Kelly 14Teixeira Pinto, Anderson 148Teramoto, Kyla 60Tewari, Asheesh 69Theodore, Sharon 93Thomley, Martin 99, 122, 123, 184Thompson, John 1, 7, 13, 16, 17, 45Ting, Daniel 58Tokunaga, Clayton 42Toma, Hassanain 43Tong, Melissa 12Topping, Trexler 58Torigoe, Andrea 136Tornambe, Paul 64, 69, 78Toth, Cynthia 167, 169Traboulsi, Elias 73Trese, Michael 41, 42, 68Trichopoulos, Nikolaos 75Tsai, Julie 114Tseng, Victoria 88Tsika, Chrysanthi 153Tsilimbaris, Miltiadis 153Tsoka, Pavlina 153Tsuang, Angela 47Tsui, Irena 35, 104, 121, 168Tyagi, Mudit 137, 162, 174, 191Tzatzarakis, Manolis 153

UUchida, Atsuro 117Uy, Harvey 94

VValeiras, Marcelo 132Vander, James 30, 44, 59VanderHoven, Cynthia 173Varma, Rohit 22Vergani, Sandro 81Verne, Allen 58Viti, Francesca 134Vitti, Robert 34Vozzi, Giovanni 64

WWallace, Lindsey 99, 118, 122, 123, 184Wallsh, Josh 168Walsh, Alexander 14, 60Waltuck, Jonathan 113Wang, Fenghua 13Wang, Gaofeng 14Ward, James 22Warren, Keith 65Wee, Raymond 60Weinberger, Dov 87, 162, 163Weiss, Matthew 74Wells, III, John 105Wen, Joanne 118West, Constance 138Wheatley, Harold 52, 143Whitcup, Scott 18, 32, 94, 155, 161Wickremasinghe, Sanjeewa 95Williams, David 13, 16Williamson, Paul 13Witkin, Andre 59Wong, David 69, 193Wong, Doric 146Wong, Edmund 146Wong, Keye 58Wong, Pamela 20Wong, S. 41, 192Wong, Tien 95Wongskhaluang, Jeff 156Wood, Edward 90, 112Wood, William 90, 112Woods, Paul 78Wu, Chengqing 86Wu, Lihteh 22, 61, 120Wu, Melinda 57Wu, Wen-Chih 88Wykoff, Charles 44, 50

yYagou, Takaaki 170Yan, Jiong 116Yang, Chung-May 99Yang, Michael 138Yang, Sung Jae 95, 169Yannuzzi, Lawrence 92, 155Yau, Linda 20, 33, 163Yazici, Ahmet 125, 190Yeh, Steven 113, 116, 151, 175Yehoshua, Zohar 13, 93Yeung, Ling 60Yoon, Nam Keun 187Yoon, Young Hee 95, 107, 169Yu, Seung-Young 106Yuan, Alex 12, 144, 164Yuksel, Kemal 125, 190Yunoki, Tatsuya 170Yuson, Ritchie 34

ZZacchia, Rafael 114Zacharias, Leandro 139Zayit-Soudry, Shiri 44Zelkha, Ruth 171Zhang, Kang 15, 69Zhioua, Raja 106Zhou, Jianbo 142Zimmer-Galler, Ingrid 180Zweifel, Sandrine 98

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