OphthalmologyUpdateFall 2005

4 OCULOPLASTICSURGERY

Technique OffersImproved Repair of Malpositioned Lower Lid after Blepharoplasty

3 6 16AMD RESEARCH

Cleveland Clinic Research Team Receives$6 Million Grant

UVEITIS

Uveitis Trials Seek to Improve Risk-BenefitProfile of TreatmentOptions

PEARL

Tips for New Users of the Femtosecond Laser

Eye with diffuse diabetic macular edema. Cole Eye Institute researchers are seeking new ways to treat the epidemic of diabetic eye disease. Story, Page 2.

Inside

2

Seeking Better Treatment for theEpidemic of Diabetic Eye Disease

MACULAR EDEMA REPRESENTS THE LEAD-

ING CAUSE OF VISION LOSS IN PATIENTS

WITH DIABETIC RETINOPATHY. CURRENTLY,

FOCAL LASER PHOTOCOAGULATION IS

THE STANDARD FOR TREATING DIABETIC

MACULAR EDEMA (DME). HOWEVER, FEW

PATIENTS UNDERGOING THAT TREATMENT

EXPERIENCE ANY SIGNIFICANT IMPROVE-

MENT IN VISION, AND A LARGE PROPORTION

ARE REFRACTORY TO THE LASER AND

EXPERIENCE PROGRESSIVE VISION LOSS.

Faced with the limitations of cur-rent interventions and the growingepidemic of diabetes, researchers havebeen motivated to find better thera-peutic alternatives for DME. Locallyadministered corticosteroids have garnered significant attention due totheir potential both to improve vision

and to address the underlying diabeticretinopathy. At The Cole Eye Institute,Peter K. Kaiser, M.D., and colleagueshave been pioneers in investigating that therapy.

Like other clinician-researchers in this field, Dr. Kaiser has been eval-uating intravitreal corticosteroids.However, he has particularly champi-oned administration via a posteriorsubtenon route because of its relativelymore favorable safety profile.

While a posterior subtenon injec-tion may lead to ptosis, it carries alower risk of IOP increase and catarac-tous lens change. Most importantly,however, it essentially eliminates thepotential for infectious endophthalmitisand pseudoendophthalmitis that canoccur with any intravitreal injection,explains Dr. Kaiser.

“With its better safety profile, thesubtenon’s injection may even be con-sidered a reasonable option in eyes with earlier DME and relatively goodvision in which any potential benefit of intravitreal steroid treatment mightbe outweighed by the risk of endoph-thalmitis,” he says.

A recent publication authored byDr. Kaiser and colleague Sophie J. Bakri,M.D., illustrates the favorable efficacyand safety outcomes associated withposterior subtenon triamcinolone ace-tonide injection [Am J Ophthalmol2005;139:290-294]. That paper was aretrospective review of one-year resultsfrom a series of 63 eyes of 50 patientswith refractory diabetic macular edemain whom previous laser treatment had failed. Ten eyes received a secondinjection because of persistent edema.

In that cohort, mean visual acuityimproved from 20/80 at baseline to20/50 at one month, increased to 20/65at three months and remained stablethereafter. At study completion, 21% of

eyes had a significant increase in visionof three or more lines, and during theentire 12-month period, only a singlepatient had a significant decrease invision of three or more lines.

“Those results are particularlyimpressive considering that the patientswere not benefiting from laser treatmentand likely had permanent photoreceptordamage. Perhaps steroid treatmentadministered earlier in the course of thedisease might have resulted in evengreater improvement in vision,” Dr.Kaiser says.

The only adverse events noted inthis series were ptosis in two eyes (4%)and a significant increase in mean IOPat three months. However, mean IOPdid not differ significantly from base-line at any other visit, and the onlyintervention needed to control elevatedIOP was temporary use of topical dropsby three patients.

In a subsequent randomized study that will be published soon, 56patients were treated with subtenon’striamcinolone acetonide or laser photo-coagulation. Patients enrolled in thattrial could have any clinically signifi-cant macular edema with or withoutprior treatment. They were treated onetime, and during follow-up of one year,the patients who received the steroidinjection benefited with better visualand anatomic outcomes.

Approximately 30% of triamci-nolone-treated patients achieved anincrease of three or more lines of visualacuity, and OCT evaluations and fluo-rescein angiography favored the steroidtreatment for reducing macular thick-ness and resolving leakage. In thatstudy, the subtenon’s steroid injectionalso demonstrated acceptable safety.

Continued on page 5

Patient with diabetic macular edema before

(above) and after (below) posterior subtenon

steroid injection.

3

Cleveland Clinic AMD Research Team Receives $6 Million Grant

CLEVELAND CLINIC INVESTIGATORS STUDYING NOVEL APPROACHES TO DETERMINE WHO

IS AT RISK OF DEVELOPING AGE-RELATED MACULAR DEGENERATION HAVE RECEIVED A

$6 MILLION GRANT FROM OHIO’S BIOMEDICAL RESEARCH AND TECHNOLOGY TRANSFER

PARTNERSHIP PROGRAM.

The Cleveland Clinic Cole EyeInstitute received the grant along with partners Case Western ReserveUniversity, Wright State University,Alcon Ltd., PrognostiX Inc. and FrantzBiomarkers Inc. The program is a ThirdFrontier Project to support biomedicaland biotechnology research leading to Ohio commercialization and long-term improvements to the health ofstate residents.

“We are very excited about receiv-ing this grant from the state to researchand prevent the leading cause of visionloss in those ages 60 and up,” said HilelLewis, M.D., Chairman of The Cole Eye Institute and the study’s principalinvestigator. “We believe the work bythe team could assist in the develop-ment of biomarkers to determine whichpatients will develop AMD. We willthen have a target to develop pharma-cological agents to prevent the disease.”

About 30% of people over age 75currently suffer from AMD, and another23% will develop the disease withinfive years.

This research project builds onrecent novel findings that protein alter-ations caused by oxidative damage mayoffer a diagnostic target for identifyingpatients at risk for developing AMDbefore any visual loss occurs, explainsJoe G. Hollyfield, Ph.D., one of theinvestigators at the Cole Eye Institute.

“This program will seek to definewith proteomic technology the bio-markers for AMD in blood samples. Itwill identify the genetic basis for AMDusing as targets a number of genesinvolved in protection against oxidativedamage. It will identify new animal

models with cone photoreceptor dam-age that can be used as models fortesting drugs that can alter the courseof AMD. It will define the mechanismof angiogenic stimulation in AMD byoxidized proteins with the ultimate aimof developing new drugs that alter thissignaling pathway.”

Other investigators from the ColeEye Institute are Bela Anand-Apte,M.B.B.S., Ph.D., Sherry Ball, Ph.D., John W. Crabb, Ph.D., Stephanie A.Hagstrom, Ph.D., Neal S. Peachey,Ph.D., and Victor L. Perez, M.D. Addi-

• Characterizing protein and lipidoxidative changes in retina, retinalpigment epithelium and Bruch’smembrane associated with AMD to help identify preventative drug targets.

• Developing a blood test for AMDbased on proteomic patterns and biomarkers to allow identification of at-risk patients prior to clinicalevidence of the disease.

• Identifying therapeutic agents forAMD using a retinal light damageanimal model. An in vivo rodentmodel will be used to validate similarities with AMD in oxidativedamage and to identify agents thatprevent retinal protein oxidativedamage and AMD.

• Developing new animal models for AMD using mutagenesis. Sinceefficacy can only be studied usinganimal models that share all or someof the clinical characteristics ofAMD, researchers are trying to iden-tify mice with inherited forms of

Specific research goals of the project:

cone degeneration resembling thedegeneration that occurs in AMDand develop outcome measures specific for cone-mediated visualfunction in mice.

• Identifying genes involved in AMDthrough proteomic analysis ofaffected eyes. The appearance ofthese proteins in AMD tissues and their modifications providesimportant clues to the underlyingpathogenic mechanisms involved in AMD.

• Elucidating the pathways involved in angiogenesis in the outer retina.

• Developing an animal model ofinflammatory-induced AMD againstoxidative modified proteins in drusenand Bruch’s membrane to facilitatethe characterization of inflammatorysignals involved in the progression of AMD.

• Pursuing a retinal stem cell initiativeto restore vision in AMD patients byreplacing lost photoreceptors.

tional co-principal investigators areDaniel T. Organisciak, Ph.D., fromWright State University and RobertSalomon, Ph.D., from Case WesternReserve University.

According to Dr. Lewis, theseinvestigators have a proven trackrecord of interaction over several yearsthat has generated the early data thatmade this initiative possible.

“The focus and capabilities of thesescientists are unique worldwide. Also,our unique patient base of 140,000patient visits a year, with 20% of thembeing AMD patients, allows many participants with AMD and their unaf-fected family members to be involved,”he says. ■

4

Technique Offers Improved Repair of Malpositioned Lower Lid after Blepharoplasty

Procedure Also Useful for Cosmetic Surgery Patients Unhappy with Mid-Face Aging

Successful surgical repair of themalpositioned lower lid may be chal-lenging. However, at The Cole EyeInstitute, oculoplastic surgeon Julian D.Perry, M.D., performs a procedure basedon reconstructive techniques to specifi-cally address the underlying anatomicproblems. The surgery involves lysis ofexisting lamellar adhesions and liftingof tissue from the midface into the eye-lid area to safely and effectively restorethe normal position, shape and functionof the lower lid without leaving anyvisibly significant scar.

Based on the favorable outcomesachieved in reconstructive cases, Dr.Perry has also expanded the applicationof this surgery and is offering it to cos-metically motivated patients seekingrejuvenation of aging-related midfaceand lower lid abnormalities.

“A key feature of this technique isthat it recruits tissues into the eyelidarea, including fatty tissues that cancorrect any existing hollowness and theappearance of dark circles below theeye. For reconstructive cases, the tech-nique avoids the need for a skin graftthat may correct eyelid and lateral canthal malposition but leave a cosmet-ically unacceptable result due to colorand texture mismatching relative tosurrounding skin,” Dr. Perry says.

LOWER LID RETRACTION IS A NOT UNCOMMON COMPLICATION OF LOWER LID BLEPHAROPLASTY

THAT CAN HAVE DISTRESSING FUNCTIONAL AND AESTHETIC CONSEQUENCES. THE INCREASED

CORNEAL EXPOSURE RESULTING FROM COMPROMISED LID FUNCTION CAN LEAD TO OCULAR

DRYNESS, REDNESS, EPIPHORA AND DISCOMFORT, AND THE SCLERAL SHOW AND ROUNDED

OUTER CANTHAL ANGLE THAT ARE FEATURES OF LOWER LID RETRACTION GIVE AFFECTED

PATIENTS AN UNACCEPTABLE SAD APPEARANCE.

Figure 2:

A. Preoperative photograph of a typical patient with post-

blepharoplasty lower eyelid retraction. Note the inferior

scleral show and the lateral canthal dystopia.

B. Postoperative photograph demonstrates excellent lower

eyelid position after midface elevation with hard palate

graft.

Figure 1: An artist's illustration shows the sub-orbicularis

oculi fat (SOOF) advanced superiorly to the cuff of perios-

teum along the orbital rim with multipoint fixation.

Figure A

Figure B

5

The procedure he performs involvesa “swinging eyelid approach” to releasethe lower lid and lyse scar tissue thatmay be inhibiting upward movement or tethering the eyelid to the inferiororbital rim. It begins with the creationof a small, 10mm, lateral canthal inci-sion that is continued just under thetarsus and through the conjunctiva andlower lid retractors. Dr. Perry notes thatthese cases typically involve middlelamellar cicatrices, which are lysed witha sharp dissection to just inferior to theorbital rim with care taken to remainanterior to the orbital septum.

Next, the cheek is mobilized. First,the periosteum is incised a few millime-ters outside the arcus marginalis alongthe maxilla and zygoma, leaving a cuffof periosteum for anchoring the subpe-riosteal myocutaneous flap sutures.Then, using a periosteal elevator, sub-periosteal dissection is achieved torelease all of the cheek tissues from the maxilla and zygoma.

“To maximize elevation of thecheek tissues, it is critical to make theincision just on the inferior aspect ofthe periosteum and to take the dissec-tion inferiorly all the way to the buccalsulcus and laterally toward the mas-seter muscle,” Dr. Perry says.

Then, the cheek tissues are sus-pended to the remaining cuff ofperiosteum using four to six absorbable,horizontal mattress sutures that areadvanced superiorly from the suborbic-ularis oculi fat to the periosteum. Toprevent retraction recurrence, Frostsutures are placed to suspend the lowerlid to the brow and keep the tissues onstretch. The sutures are removed afterone week.

When the procedure is performedfor cosmetic indications, it is oftencombined with additional surgery. Thatmight include endoscopic browlifting to lift the lateral brow and lateral cheekarea, lower lid fat repositioning toachieve a smooth lower lid contour orplacement of a cheek implant.

“However, many of the patientswho are undergoing the cheeklift pro-cedure for a reconstructive indicationalready had cosmetic surgery here andhave a strong desire for further aestheticimprovement. Therefore, we also oftencombine the reconstructive procedurewith additional techniques in thosecases as well to achieve an overallenhanced cosmetic outcome,” Dr. Perry says.

While the results of these proce-dures have been excellent in Dr. Perry’shands, he cautions that the surgery istechnically challenging and has a steeplearning curve.

“The development of postopera-tive contour abnormalities is verycommon when this procedure is doneby surgeons who have not yet mas-tered the technique,” he said.

He also notes that candidates for this surgery need to be carefullyapprised of those risks and the morbid-ity associated with the procedure.

“It is important to have a lengthydiscussion with patients to establishtheir goals and set realistic expectations,and they must be highly motivated. Dueto the extensive dissection, patientsneed to appreciate that this surgeryresults in more swelling and bruisingand requires a longer postoperativehealing period compared with a simpleblepharoplasty,” he concludes. ■

“Complication rates were relativelylow and events were generally limitedto increases in IOP and cataract pro-gression,” Dr. Kaiser says.

The National Eye Institute-fundedDiabetic Retinopathy Clinical ResearchNetwork is sponsoring two, multicenter,prospective, randomized, controlledclinical trials designed to obtain betterevidence for assessing the role oflocally administered corticosteroids for the management of DME. At TheCole Eye Institute, Dr. Kaiser and Chair-man Hilel Lewis, M.D., are serving asinvestigators for two of those trials.One study is comparing intravitreal triamcinolone acetonide to laser pho-tocoagulation and the second israndomly assigning patients to laserphotocoagulation or anterior or poste-rior peribulbar triamcinolone acetonidealone or followed one month later by laser photocoagulation.

Dr Kaiser and The Cole Eye Insti-tute have also been selected as a studysite for the Allergan-sponsored PhaseIII study evaluating its bioerodable, sustained-release intravitreal dexa-methasone implant (Posurdex) for thetreatment of diffuse, refractory DME. In this three-year trial, patients arebeing randomly assigned to one of twodoses of the steroid implant or a shamdevice if they have failed previous lasertreatment and have persistent DME. Re-treatment with the steroid implantcan occur at six-month intervalsdepending on the response. ■

Seeking Better Treatment for the Epidemic of Diabetic Eye DiseaseContinued from page 2

Uveitis Trials Seek to Improve Risk-Benefit Profile of Treatment Options

6

Due to the serious toxicity associ-ated with long-term corticosteroid use,other systemic immunosuppressivemedications are often added as corti-costeroid-sparing agents. However, theyalso can present significant safety con-cerns, and all of these conventionallyused agents are nonspecific in theiranti-inflammatory action.

At The Cole Eye Institute, ophthal-mologist Careen Y. Lowder, M.D., Ph.D.,is actively involved in clinical researchtrials aiming to identify new treatmentalternatives for uveitis that offer a morefavorable risk:benefit profile than cur-rent options.

“Treatment for noninfectiousuveitis has been less than optimal, duein part to the less-than-favorable safetyprofiles of available nonspecific agentsand the fact that we lack a good under-standing of the pathophysiology of thiscondition. Ongoing studies evaluatingalternative treatment modalities arevery important in allowing us to findoptions that could spare our patientsfrom the morbidity of existing therapiesand helping us to determine whatmight be the best modality for manag-ing this vision-threatening disease,” Dr. Lowder says.

An advance in treatment occurredrecently when the FDA approved theintravitreal fluocinolone acetonideimplant 0.59 mg (Retisert, Bausch &

Lomb) for marketing in the managementof chronic, noninfectious posterioruveitis. Dr. Lowder was an investigatorin one of the pivotal clinical studiesthat demonstrated the implant waseffective in controlling the uveitis,reduced recurrence rates and the needfor adjunctive therapy compared with a preimplantation baseline period andwas associated with a significantincrease in vision.

In an effort to find treatments that more specifically target mediatorsof the immune response in uveitis,researchers have also been interested inthe use of anti-tumor necrosis factoralpha (TNFa) agents. Dr. Lowder hasalso been evaluating that category ofbiological agents in her own practiceand as an investigator in industry-sponsored trials.

At the 2005 annual meeting of the Association for Research in Visionand Ophthalmology, she reported theresults of a retrospective analysis com-paring outcomes in patients treatedwith infliximab (Remicade, Centocor) or etanercept (Enbrel, Amgen).

The study included 20 patients, ofwhom 18 had an underlying systemicdisorder. Sixteen patients in the seriesreceived infliximab for a mean of 16months, including five who were previ-ously taking etanercept; nine patientswere treated with etanercept for a meanduration of 22 months.

The results showed more inflix-imab-treated patients had an initialresponse to treatment with completeelimination of inflammation within 3months. Thereafter, infliximab was alsofavored in analyses of proportions ofpatients who achieved a 50% or greaterreduction in uveitis episodes, completecontrol of ocular inflammation at thelast visit and a decrease in topicalsteroid use.

“Based on our data, we believeinfliximab should be considered as afirst-line therapy when contemplatinganti-TNFa therapy in patients withrecalcitrant ocular inflammation. How-ever, this is a cautious recommendationrecognizing the relatively limited expe-rience with this agent with respect topatient population size and follow-upduration,” Dr. Lowder says.

Before After

These figures show before and after

antiTNFa treatment photographs

of a patient with birdshot chori-

oretinopathy. Note that the yellowish

“birdshot-like” lesions disappear fol-

lowing treatment.

NON-INFECTIOUS UVEITIS IS A RELATIVELY

UNCOMMON OCULAR CONDITION, BUT CAR-

RIES A HEAVY TOLL WITH RESPECT TO ITS

POTENTIALLY DEVASTATING EFFECTS ON

VISION AND QUALITY OF LIFE. WHEN THE

DISEASE INVOLVES THE ANTERIOR SEGMENT

ONLY, TOPICAL THERAPY MAY BE EFFEC-

TIVE. HOWEVER, FOR CASES OF CHRONIC,

VISION-THREATENING INTERMEDIATE

UVEITIS, POSTERIOR UVEITIS, AND PAN-

UVEITIS, ORAL CORTICOSTEROIDS ARE THE

MAINSTAY OF TREATMENT.

Before After

Clinical CaseA 78-YEAR-OLD BLACK FEMALE UNDER-

WENT UNCOMPLICATED LEFT CATARACT

EXTRACTION AND INTRAOCULAR LENS

PLACEMENT IN THE LEFT EYE AT THE COLE

EYE INSTITUTE. OCULAR HISTORY WAS

UNREMARKABLE AND MEDICAL HISTORY

WAS SIGNIFICANT FOR HYPERTENSION

AND ARTHRITIS.

After an uncomplicated postopera-tive period, topical medications werediscontinued and uncorrected visualacuity was 20/20 in the left eye. Sixmonths after surgery, the patient pre-

sented with left eye pain. Examination revealed a mild non-granulomatous anterioruveitis (Figure 1). Topical corticosteroids were restarted and the pain and inflammationsubsided. Three months later, the patient returned with similar symptoms and againwas found to have a mild anterior chamber reaction. The remaining exam was unre-markable. What are the possible etiologies for persistent or recurrent anterior chamberinflammation after cataract surgery and what further tests should be obtained?

See Part II on page 8

7

By Anat Galor, M.D., and Victor L. Perez, M.D.

Ophthalmic PuzzlerPart I

Figure 1: Slit lamp examination with a mild

non-granulomatous anterior uveitis.

Previously, Dr. Lowder participatedin a Centocor-sponsored Phase I trial of an investigational human mono-clonal antibody to TNFa. Now, The Cole Eye Institute is also one of threeinvestigational sites that will be par-ticipating in a Phase II trial of theanti-TNFa agent adalimumab (Humira,Abbott) for the treatment of vision-threatening, refractory, autoimmuneuveitis. That open-label study willenroll up to 30 subjects; patients whohave a response to treatment will

continue to receive subcutaneousinjections of adalimumab every twoweeks for a total of 26 weeks.

“We are very excited about thisstudy because adalimumab offers thepotential benefit of being a fullyhumanized monoclonal antibody incontrast to the chimeric mouse-human-ized infliximab. We know that patientsreceiving infliximab may develop neutralizing antibodies if it is notadministered concomitantly with low-dose immunosuppressive therapy and

that those antibodies can lead to loss oftherapeutic effect. We are hopeful thatbecause adalimumab does not containany animal protein, that problem willbe avoided,” Dr. Lowder says. ■

8

Differential DiagnosisAlthough an underlying cause is oftennot identified in cases of a postsurgicalpersistent or recurrent non-granuloma-tous anterior uveitis, it is important toconsider secondary causes includinginfectious and inflammatory etiologies.Possible infectious etiologies includeorganisms associated with late endoph-thalmitis (i.e. Propionibacterium acnes),viruses (i.e. herpes) or unrecognizedsystemic infections (i.e. syphilis, tuberculosis). Possible inflammatory etiologies include both local (i.e. Fuchs’heterochromic cyclitis) and systemicconditions such as sarcoidosis, HLAB27-associated uveitis and collagenvascular disease.

Further testing to evaluate thecause of our patient’s inflammationincluded a complete blood count, erythrocyte sedimentation rate, antinu-clear antibody, urinalysis and chestradiograph, which were all normal. A fluorescent treponemal antibodyabsorption (FTA ABS) test and rapidplasma reagin (RPR) test were obtainedand returned positive.

DiagnosisThe microhemagglutination test for Treponema pallidum (MHA-TP) wasobtained and also returned positive,confirming the final diagnosis ofsyphilitic anterior uveitis.

DiscussionTreponema pallidum, the causativeagent of syphilis, is a small bacterium(5-15 µm) in the same family as Borrelia and Leptospira. The name“syphilis” was derived in 1530 from anItalian poem by Hiero Fracastor about a shepherd named Syphilis who carriedthe affliction. Uveitis is the most com-mon eye manifestation and, prior to1940, syphilis was the leading cause ofuveitis. Currently, it is estimated thatless than 2% of all uveitis cases are dueto syphilis.1

Although syphilis is no longer acommon cause of uveitis, every uveitispatient must be tested. Syphilis is oneof the few treatable uveitis entities inwhich the ocular disease can be diag-nosed and treated. Latent syphilis is themost common stage when uveitis pre-sents. During this stage, the disease isnot clinically detectable and the infec-tion is not contagious. Syphilis is the“great masquerader” and ocular presen-tations vary, including unilateral orbilateral disease, anterior, posterior orpanuveitis and granulomatous or non-granulomatous inflammation.1

Serological tests include those not specific and those specific for tre-ponemal antigens. The levels of thenon-specific tests (VDRL and RPR) dropin latent disease after treatment, whilespecific tests (FTA ABS, MTA TP)remain positive for life. It is thereforenecessary to evaluate all uveitispatients with a specific treponemal test.

TreatmentThe presence of neurosyphilis must beconsidered in all patients with syphiliticuveitis and a cerebral spinal fluid (CSF)evaluation is warranted. Treatment forlatent syphilis involves three weeklyintramuscular injections of Penicillin G.Treatment for neurosyphilis is moreextensive with intravenous Penicillin Gevery 4 hours for 10-14 days. Adequacyof treatment is assessed by resolution of clinical findings and a decline inserologic titers of the nonspecific tests(RPR, VDRL). The specific treponemaltests remain positive for life.1

Follow-upOur patient declined a CSF evaluation.She was treated for presumed latentsyphilis with intramuscular injectionsof Penicillin G and followed clinicallywith serologic markers. One year aftertreatment, the patient remains asymp-tomatic with good vision and norecurrent inflammation. ■

Reference

1 Foster CS, Vitale AT. Diagnosis andTreatment of Uveitis, Chapter 15,Syphilis. Philadelphia: W.B. SaundersCompany, 2002: 237-244.

Ophthalmic PuzzlerPart II (Continued from page 7)

9

February 16, 2006GENETIC REGULATION OF THE EYE’S AXIAL LENGTH

Olof H. Sundin, Ph.D.Assistant Professor of OphthalmologyWilmer Eye InstituteThe Johns Hopkins University School of MedicineBaltimore, MD

March 16, 2006IS IT FEASIBLE TO GENERATE AN ARTIFICIAL CORNEA?

James D. Zieske, Ph.D. Associate ProfessorDepartment of OphthalmologySchepens Eye Research InstituteHarvard Medical SchoolBoston, MA

April 20, 2006THE ROLE OF CELL DEATH LIGANDS IN CONTROLLING ANGIOGENESIS IN THE EYE

Thomas A. Ferguson, Ph.D. Professor Department of Ophthalmology and Visual SciencesDepartment of Pathology and Immunology Washington University of St. Louis, School of Medicine St. Louis, MO

May 18, 2006 MATRIX METALLOPROTEINASES IN THE EYE

M. Elizabeth Fini, Ph.D. Professor and Scientific DirectorBascom Palmer Eye InstituteWalter G. Ross Chair in Ophthalmic ResearchUniversity of Miami, Miller School of MedicineMiami, FL

June 8, 2006MOLECULAR BASIS OF CORNEAL CLARITY AND AVASCULARITY IN THE CORNEA

Dimitri T. Azar, M.D. Associate Chief of Ophthalmology Director or Cornea, External and Refractive Surgery Harvard Medical SchoolMassachusetts Eye and Ear Infirmary Boston, MA

July 20, 2006CELLULAR REMODELING OF THE RETINA IN RESPONSE TO DETACHMENT

Steven K. Fisher, Ph.D. ProfessorDepartment of Molecular, Cellular and Developmental BiologyNeuroscience Research InstituteUniversity of California, Santa BarbaraSanta Barbara, CA

THE COLE EYE INSTITUTE DISTINGUISHED LECTURE SERIES PROVIDES

A FORUM FOR RENOWNED RESEARCHERS IN THE VISUAL SCIENCES

TO PRESENT THEIR LATEST FINDINGS. THIS SERIES OF LECTURES

FEATURES ADVANCES IN MANY AREAS OF OPHTHALMIC RESEARCH

PRESENTED BY NOTED BASIC AND CLINICAL SCIENTISTS FROM

THROUGHOUT THE WORLD. AMPLE OPPORTUNITY FOR QUESTIONS

AND ANSWERS IS PROVIDED.

ALL LECTURES ARE HELD ON THURSDAYS FROM 7 TO 8 A.M. IN THE

JAMES P. STORER CONFERENCE ROOM ON THE FIRST FLOOR OF THE

COLE EYE INSTITUTE, CLEVELAND CLINIC FOUNDATION. REGISTRATION

IS NOT REQUIRED. FOR QUESTIONS, PLEASE CALL 216/444-5832.

September 15, 2005 USING EXPERIMENTAL GENETICS TO UNDERSTAND MECHANISMS OF GLAUCOMA

Simon W.M. John, Ph.D.Associate InvestigatorHoward Hughes Medical InstituteJackson LaboratoryBar Harbor, ME

October 27, 2005 DYNAMIC REORGANIZATION AT THE CORNEAL STROMAL CELL INTERFACE AFTER WOUNDING

Sandra K. Masur, Ph.D.Professor, OphthalmologyAssociate Professor, Physiology/Biophysics and Center for Anatomy and Functional MorphologyAssociate Dean for Faculty DevelopmentDepartment of OphthalmologyMount Sinai School of MedicineNew York, NY

November 17, 2005USE OF THE MOUSE MODEL TO UNDERSTAND HERITABLE FORMS OF RETINAL DEGENERATION

Patsy M. Nishina, Ph.D.Staff ScientistThe Jackson LaboratoryBar Harbor, ME

January 19, 2006ON AND OFF PATHWAYS IN THE RETINA AND VISUAL SYSTEM

Ralph F. Nelson, Ph.D. Senior InvestigatorBasic Neurosciences ProgramNational Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesda, MD

Distinguished Lecture Series

10

GENETICS

STUDIES OF THE MOLECULAR GENETICS OF EYE DISEASESObjective: To map the genes for inheritedeye diseases. To screen candidate genes formutations in a variety of genetic ocular disorders, including ocular malformations,congenital cataracts and retinal dystrophies. Contact: E. Traboulsi, M.D., at 216/444-4363or S. Crowe, C.O.T., at 216/445-3840

THE GENETICS OF STRABISMUSObjective: To discover the genes that causesome strabismus syndromes, includingthose for accommodative esotropia, con-genital esotropia, congenital ocular fibrosissyndrome, intermittent exotropia, Brownsyndrome and Duane syndrome. Contact: E. Traboulsi, M.D., at 216/444-4363or S. Crowe, C.O.T., at 216/445-3840

PEDIATRICS

INFANT APHAKIA TREATMENT STUDYObjective: To determine whether infantswith a unilateral congenital cataract aremore likely to develop better vision follow-ing cataract extraction surgery if (1) theyundergo the primary implantation of an IOL or if (2) they are treated primarily witha contact lens. Contact: E. Traboulsi, M.D., at 216/444-4363or S. Crowe, C.O.T., at 216/445-3840

REFRACTIVE SURGERY

VISION THERAPY: A PROGRESSIVE CONTROLLEDSTUDY ON THE EFFECTIVENESS OF VISION THERAPY IN ELIMINATING ASTHENOPIA IN ASYMPTOMATIC POPULATIONEligibility Criteria: Patients who are 18 to35 years of age and have any of the follow-ing symptoms: eye strain, occasional blurredvision when using a computer or perform-ing other near work, occasional headaches,have words run together or fall asleep whendoing prolonged computer work or nearwork. If eligible, participation will involveapproximately three visual assessments atthe Cleveland Clinic Division of Ophthal-mology at Beachwood and requiredequipment for therapy. Compensation of$100 will be allotted for travel expenses.Contact: D. Tucker, O.D., at 216/831-0120or L. Slaby, C.O.A., at 330/963-4843

LADARVISION SYSTEM USE OF THE REFRACTIVEDATA FROM A WAVEFRONT MEASUREMENTDEVICE (WMD) FOR THE CORRECTION OFREFRACTIVE ERROR-LASIK Rationale: In an effort to improve outcomesin LASIK surgery, Alcon Surgical has developed a product, the LADARWave Custom Cornea Wavefront System, designedto measure refractive errors, including amethod of characterizing aberrations of thevisual system, generically referred to as aWavefront Measurement Device (WMD).This clinical study is currently enrollingonly hyperopic patients.Contact: R. Krueger, M.D., at 216/445-8585or R. Scott at 216/444-0680

ACRYSOF ANGLE-SUPPORTED PHAKICINTRAOCULAR LENSObjective: To collect information on thesafety and effectiveness of the artificial lens ACRYSOF for the correction of severemyopia. This study lens will be implantedbehind the cornea in the anterior chamber.The lens is made of a soft acrylic materialthat allows the lens to be folded for implan-tation and therefore can be inserted througha smaller incision than other rigid lensdesigns. Participation in this study will last about 3 years.Contact: R. Krueger, M.D., at 216/445-8585or R. Scott at 216/444-0680

RETINAL DISEASES

A PHASE III, MULTI-CENTER, RANDOMIZED,DOUBLE-MASKED, ACTIVE TREATMENT -CONTROLLED STUDY OF THE EFFICACY ANDSAFETY OF RHUFAB V2 (RANIBIZUMAB)COMPARED WITH VERTEPORFIN (VISUDYNE)PHOTODYNAMIC THERAPY IN SUBJECTS WITHPREDOMINANTLY CLASSIC SUBFOVEALNEOVASCULAR AGE-RELATED MACULARDEGENERATIONObjective: To evaluate the efficacy of intravitreal injections of ranibizumabadministered monthly compared withverteporfin PDT in preventing vision loss, as measured by the proportion of subjectswho lose fewer than 15 letters in visual acu-ity at 12 months compared with baseline.Contact: P. Kaiser, M.D., at 216/444-6702 orL. Holody, C.O.A., at 216/445-3762

PROTOCOL B7A-MC-MBDL REDUCTION IN THEOCCURRENCE OF CENTER-THREATENINGDIABETIC MACULAR EDEMAObjective: The primary objective of thisstudy is to test the hypothesis that oral

administration of 32 mg per day of Rubox-istaurin for approximately 36 months willreduce, relative to placebo, the occurrenceof center-threatening diabetic macularedema as assessed by fundus photographyin patients with non-clinically significantmacular edema and nonproliferative dia-betic retinopathy at baseline. Contact: P. Kaiser, M.D., at 216/444-6702 or C. Rosal, R.N., B.S.N., at 216/445-1256

A PHASE II RANDOMIZED, DOSE-RANGING,DOUBLE-MASKED, MULTI-CENTER TRIAL, IN PARALLEL GROUPS, TO DETERMINE THESAFETY, EFFICACY AND PHARMACOKINETICS OF INTRAVITREOUS INJECTIONS OFPEGAPTANIB SODIUM COMPARED TO SHAMINJECTION FOR 30 WEEKS IN PATIENTS WITHRECENT VISION LOSS DUE TO MACULAREDEMA SECONDARY TO CRVOObjective: To determine the effectiveness of pegaptanib sodium in improving visionin patients with CRVO. Injections or shaminjection will be every 6 weeks with oneweek post-injection checks throughout thestudy. The study will last one year. Patientsmust have been diagnosed with CRVOwithin the last 6 months.Contact: H. Lewis, M.D., at 216/444-0430or L. Schaaf, R.N., at 216/445-4086

AN EVALUATION OF EFFICACY AND SAFETY OFPOSTERIOR JUXTASCLERAL ADMINISTRATIONSOF ANECORTAVE ACETATE FOR DEPOT SUSPEN-SION (15 MG OR 30 MG) VERSUS SHAMADMINISTRATION IN PATIENTS AT RISK FORDEVELOPING SIGHT-THREATENING CHOROIDALNEOVASCULARIZATION DUE TO EXUDATIVEAGE-RELATED MACULAR DEGENERATION(AMD) AARTObjective: To evaluate the effectiveness of anecortave acetate in stopping the pro-gression of the “dry” or early form of AMDto the “wet” or advanced form. Depotadministration or sham treatment (like aninjection) will be every six months for fouryears for a total of nine visits. Patientsmust have “wet” AMD in one eye and “dry”AMD in the other. Vision in the “dry” eyemust be equivalent to 20/40 or better.Contact: P. Kaiser, M.D., at 216/444-6702 or L. Schaaf, R.N., at 216/445-4086

THE STANDARD CARE VERSUSCORTICOSTEROID FOR RETINAL VEINOCCLUSION STUDYObjective: To evaluate the effectiveness oftriamcinolone acetonide injections for treat-ment of macular edema versus standard

Cole Eye Institute

Clinical TrialsThe following studies are currently enrolling.All have been approved by the InstitutionalReview Board.

Ophthalmic

Continuing Medical Education

11

Programs in Ophthalmic Education2005–2006

PHYSICIANS ARE CORDIALLY INVITED TO ATTEND THE FOLLOWING OPHTHALMIC CONTINUING

MEDICAL EDUCATION COURSES AT THE CLEVELAND CLINIC COLE EYE INSTITUTE. ALL COURSES

WILL BE HELD IN THE JAMES P. STORER CONFERENCE CENTER ON THE FIRST FLOOR.

For all courses listed, registration fee is $100. Receive a $25 discount by registering online.

For more information, contact Jane Sardelle, Program Coordinator, at 216/444-2010 or800/223-2273, ext. 42010, or sardelj@ccf.org.

Saturday, September 10, 20058:00 a.m. to 3:00 p.m.

SPECIAL CONSIDERATIONS IN THE SURGICALMANAGEMENT OF GLAUCOMA

Course Directors: Edward J. Rockwood, M.D. Glaucoma DepartmentCole Eye Institute

Scott D. Smith, M.D., M.P.H.Glaucoma DepartmentCole Eye Institute

Guest Faculty:Paul F. Palmberg, M.D., Ph.D.ProfessorCataracts & Intraocular Lens GlaucomaBascom Palmer Eye InstituteMiami, FL

Gregory L. Skuta, M.D.James P. Luton Clinical Professor

of OphthalmologyDean A. McGee Eye InstituteOklahoma City, OK

Description:Designed for comprehensive ophthal-mologists, this course will includepresentations and discussions on thesurgical management of glaucoma,including trabeculectomy with andwithout antifibrosing agents, variousglaucoma implant surgical procedures,combined cataract and glaucomasurgery, non-penetrating glaucoma filtering surgery and other moreunusual combined procedures such as glaucoma implants and pars plana

vitrectomy, with or without penetratingkeratoplasty. The management of com-plications of glaucoma filtering surgerywill be discussed.

At the conclusion of this course, participants should be able to:1. Review the indications, preoperative

management, intraoperative care and postoperative management ofpatients undergoing glaucoma filter-ing surgery, including trabeculectomy,glaucoma implants and lasercyclophotocoagulation.

2. Identify and manage postoperativeglaucoma surgical complications.

3. Examine the role of mitomycin C and5-fluorouracil in glaucoma filteringsurgery and their risks and benefits.

4. Discuss special management ofpatients with less-common glaucoma,such as neovascular glaucoma andglaucoma associated with uveitis.

5. Assess patients with cataract andglaucoma and discuss surgical optionsin the management of the patientwith cataract and glaucoma.

Saturday, November 19, 20058:00 a.m. to 3:00 p.m.

COSMETIC OCULOPLASTIC SURGERY UPDATE FOR THE COMPREHENSIVEOPHTHALMOLOGIST

Course Director: Julian D. Perry, M.D.Ophthalmic Plastic and Orbital SurgeryCole Eye Institute

treatment. Patients will have 11 to 13 visits over a period of up to three years.Contact: P. Kaiser, M.D., at 216/444-6702or L. Holody, C.O.A., at 216/445-3762

A SIX-MONTH PHASE III, MULTI-CENTER,MASKED, RANDOMIZED, SHAM-CONTROLLEDTRIAL (WITH SIX-MONTH OPEN-LABELEXTENSION) TO ASSESS THE SAFETY AND EFFICACY OF 700 µG AND 350 µGDEXAMETHASONE POSTERIOR SEGMENT DRUG DELIVERY SYSTEMObjective: To evaluate the safety and efficacy of the 700 µg DEX PS DDSApplicator System and 350 µg DEX PSDDS Applicator System compared with aSham DEX PS DDS Applicator System(needle-less applicator) for six months inpatients with macular edema followingbranch retinal vein occlusion or centralretinal vein occlusion. The safety of the700 µg DEX PS DDS Applicator Systemwill be assessed for an additional 6months in patients who qualify for treat-ment in an open-label safety extension.Contact: P. Kaiser, M.D., at 216/444-6702or L. Schaaf, R.N., at 216/445-4086

GLAUCOMA

ADVANCED IMAGING FOR GLAUCOMAObjective: Advanced Imaging for Glaucoma (AIG) is a multi-center bioengi-neering partnership sponsored by theNational Eye Institute. This partnershipincludes four clinical centers: the Cleve-land Clinic Foundation (CCF), University of Pittsburgh Medical Center/University ofPittsburgh School of Medicine (UPMC), theUniversity of Miami (Bascom Palmer EyeInstitute) and the University of SouthernCalifornia. The goal of the partnership is to develop advanced imaging technologiesto improve the detection and managementof glaucoma. The advanced imaging technologies include optical coherencetomography, scanning laser polarimetryand scanning laser tomography. The technologies will be evaluated in a longi-tudinal five-year clinical trial composed of glaucoma suspects, glaucoma patientsand normal subjects. Contact: S. Smith, M.D., M.P.H., at216/444-4821 or R. Scott 216/444-0680

Guest Faculty:Kathleen Archer, M.D.ASOPRS, Secretary of EducationSurgical Eye AssociatesHouston, TX

Raymond S. Douglas, M.D., Ph.D. Shorr-Douglas FACE Institute

of Beverly Hills Assistant Clinical Professor Jules Stein Eye Institute/UCLA Director, Orbital and Ophthalmic Plastic

and Reconstructive SurgeryGreater Los Angeles Veterans

Administration HospitalLos Angeles, CA

Christine Nelson, M.D.Co-Director of Ophthalmic Plastic

and Orbital SurgeryUniversity of Michigan

Kellogg Eye CenterAnn Arbor, MI

Description:In order to continue to deliver high-quality care, the comprehensiveophthalmologist must understand andapply recent advances in cosmeticoculoplastic surgery. This one-daycourse is designed specifically for thecomprehensive ophthalmologist with aninterest in cosmetic oculoplastic surgery.

The course will focus on current mini-mally invasive techniques to rejuvenatethe eyelids and upper face. Specialemphasis will be placed on reviewingtechniques performed by the compre-hensive ophthalmologist, includingBotox injections, the use of wrinklefillers, blepharoplasty and ptosis repair.Slide and video presentations willreview basic concepts as well as recentinnovations in surgical instrumentationand techniques. This course is designedto identify and treat cosmetic oculo-plastic conditions in order to obtainbetter results.

At the conclusion of this course, participants should be able to:1. Apply recent advances in cosmetic

oculoplastic surgery.2. Review new modifications for ptosis

repair and blepharoplasty.3. Describe the mechanism of action and

concepts underlying Botox injection.4. Discuss the use of various wrinkle

filler substances in the eyelid andfacial regions.

5. Improve blepharoplasty results by applying current oculoplastic concepts.

6. Evaluate several controversial issuesin cosmetic oculoplastic surgery.

Saturday, December 3, 20057:00 a.m. to 4:00 p.m.

CURRENT CONCEPTS IN THE PATHOGENESISAND MANAGEMENT OF AMBLYOPIA

Course Directors:Elias I. Traboulsi, M.D.Head, Pediatric Ophthalmology and

Adult Strabismus DepartmentCole Eye Institute

Andreas Marcotty, M.D.Pediatric Ophthalmology and

Adult Strabismus DepartmentCole Eye Institute

Guest Faculty:Eugene M. Helveston, M.D.Emeritus Professor of OphthalmologyIndiana University School of MedicineIndianapolis, IN

Evelyn A. Paysse, M.D.Associate Professor of Ophthalmology

& PediatricsCullen Eye InstituteBaylor College of MedicineHouston, TX

Lawrence Tychsen, M.D.Professor Ophthalmology, Neurobiology, PediatricsWashington University

School of MedicineOphthalmology & Visual ScienceChildren’s HospitalSt. Louis, MO

Description:Amblyopia is the leading cause of treat-able and preventable monocular visionloss in children and young adults. Thepast two decades have witnessed a sig-nificant expansion in understandingcortical cellular and biophysicalprocesses that underlie amblyopia. Clinical trials sponsored by the NationalInstitutes of Health have shown theeffectiveness of pharmacological penal-ization in treating amblyopia and haverevolutionized the clinical managementof this disorder. This course, designedfor general and pediatric ophthalmolo-gists, will cover the most recent researchand clinical advances in the under-standing and management of amblyopiaas presented by leaders in the field.

At the conclusion of this course, participants should be able to:1. Describe the impact of amblyopia

on vision in the United States andaround the world.

2. Identify the most current theories onthe neuropathology of amblyopia.

3. Recognize and make clinical decisionson the use of patching and pharma-cologic penalization in the treatmentof amblyopia.

Saturday, February 11, 20067:00 a.m. to 2:00 p.m.

SIXTH UVEITIS UPDATE

Course Directors:Careen Y. Lowder, M.D., Ph.D.Uveitis DepartmentCole Eye Institute

Victor L. Perez, M.D.Cornea and Uveitis DepartmentsCole Eye Institute

Guest Faculty:Janet L. Davis, M.D.ProfessorBascom Palmer Eye InstituteMiami, FL

12

Ophthalmic

Continuing Medical Education (continued)

13

Douglas A. Jabs, M.D., M.B.A.Alan C. Woods ProfessorDepartments of Ophthalmology

and MedicineThe Johns Hopkins University

School of MedicineBaltimore, MD

James Rosenbaum, M.D.The Edward E. Rosenbaum Professor

of Inflammation ResearchProfessor of Ophthalmology,

Medicine and Cell BiologyOregon Health & Sciences UniversityPortland, OR

Russell Van Gelder, M.D., Ph.D.Associate ProfessorWashington UniversitySt. Louis, MO

Cleveland Clinic Faculty:Gary S. Hoffman, M.D. Chairman and Harold C. Schott ChairDepartment of Rheumatic and

Immunologic DiseasesDirector, Center for Vasculitis Care

and Research

Brian Mandell, M.D., Ph.D.Education Program DirectorDepartment of Rheumatic and

Immunologic DiseasesSenior Associate Program DirectorInternal Medicine Residency Program

Description:This course will present comprehensiveophthalmologists with information onthe newest medical and surgical modali-ties in the treatment of patients withinflammatory and infectious ocular dis-eases. Special emphasis will be placedon the pathophysiology of diseases andevidence-based treatments. Case presen-tations will allow audience participationand interaction with faculty.

At the conclusion of this course, participants should be able to:1. Review the use of nonspecific drugs,

including immunosuppressive therapy.

2. Describe the current clinical trials inocular inflammatory diseases.

3. Identify newer therapies for noninfec-tious posterior uveitis syndromes.

4. Evaluate and determine which laboratory tests to order in patientswith uveitis.

5. Diagnose and formulate a treatmentplan for patients with various uveitissyndromes.

Saturday, March 4, 20067:00 a.m. to 1:30 p.m.

NEURO-OPHTHALMOLOGY UPDATE: IN CASE, AFTER CASE, AFTER CASE …

Course Director: Gregory S. Kosmorsky, D.O.Department of Neuro-OphthalmologyCole Eye Institute

Guest Faculty:Eric Eggenberger, D.O.Professor, Department of Neurology

and OphthalmologyMichigan State UniversityEast Lansing, MI

Steven Galetta, M.D.Van Meter Professor of NeurologyDirector, Neuro-Ophthalmology DivisionUniversity of Pennsylvania

School of MedicinePhiladelphia, PA

Steven A. Newman, M.D.ProfessorDepartment of OphthalmologyUniversity of Virginia Medical CenterCharlottesville, VA

Description:This course will feature a panel ofexperts who will present a breadth of neuro-ophthalmologic cases fromthe “sublime to the ridiculous.”Entirely case based, this discussion ofclinical pearls and literature reviewswill help neuro-ophthalmologists, general ophthalmologists and neurolo-gists recognize and treat a broad rangeof neuro-ophthalmologic disorders.

At the conclusion of this course, participants should be able to:1. Identify common neuro-ophthalmo-

logic disorders.2. Evaluate the most appropriate diag-

nostic approach for various signs andsymptoms.

3. Organize seemingly disparate signsand symptoms into a cogent neuro-ophthalmic diagnosis.

Saturday, April 8, 20067:00 a.m. to 5:00 p.m.

REFRACTIVE SURGERY: BEYOND LASIK AND EXCIMER LASERS

Course Director: Ronald R. Krueger, M.D., M.S.E.Medical Director, Refractive SurgeryCole Eye Institute

Cole Eye Institute Faculty:Steven E. Wilson, M.D.Director, Corneal ResearchCole Eye Institute

Guest Faculty:Randall J. Olson, M.D.John A. Moran Presidential ProfessorChair of Ophthalmology and

Visual SciencesDirector, John A. Moran Eye CenterUniversity of UtahSalt Lake City, UT

Yaron S. Rabinowitz, M.D.Director of Ophthalmology Research Cedars-Sinai Medical CenterClinical Professor of OphthalmologyUniversity of California Los AngelesSchool of MedicineLos Angeles, CA

Description:There is more to refractive surgery thanjust LASIK and excimer lasers. Thiscourse will cover the various otherfuturistic technologies used, includingsynthetic implants and femtosecondlasers.

14

At the conclusion of this course, participants should be able to:1. Identify and differentiate keratoconus

suspect patients seeking refractivesurgery.

2. Review the treatment options for keratoconus suspect patients.

3. Describe the benefits and limitationsof using femtosecond lasers in refrac-tive surgery.

4. Determine the indications, techniquesand complications of phakic IOLs.

5. Identify the indications, techniquesand complications of presbyopic lensexchange.

6. Review the status of accommodatingand multifocal IOLs.

Saturday, May 20, 20067:00 a.m. to 5:00 p.m.

NEW DEVELOPMENTS IN RETINA: TRIALS, DRUGS AND NEW TECHNIQUES

Course Directors:Peter K. Kaiser, M.D.Vitreoretinal DepartmentCole Eye Institute

Jonathan E. Sears, M.D.Vitreoretinal DepartmentCole Eye Institute

Guest Faculty:Allen C. Ho, M.D.Professor of OphthalmologyThomas Jefferson UniversityRetina ServiceWills Eye HospitalPhiladelphia, PA

Jason S. Slakter, M.D.Vitreous-Retina-Macula Consultants

of New YorkClinical Professor of OphthalmologyNew York UniversityNew York, NY

Description:This meeting is designed for retinal spe-cialists and general ophthalmologistswho diagnose and treat retinal disease.The lectures will update participants on the newest clinical trials in retinaespecially in age-related macular degen-eration and diabetic retinopathy. Inaddition, faculty members, who are allexperts in the field of retina, will offercurrent treatment options for vitreoreti-nal conditions normally seen in clinicalpractice with particular emphasis on thenewly released drugs.

At the conclusion of this course, participants should be able to:1. Describe recent clinical trials in

age-related macular degeneration and diabetic retinopathy.

2. Distinguish the differences betweenthe new anti-VEGF drugs.

3. Compare various treatment modalitiesand clinical trial results.

4. Describe the use of steroids in age-related macular degeneration anddiabetic retinopathy.

5. Explain how new imaging devices areenhancing retinal diagnosis.

Friday, June 16, 2006 7:00 a.m. to midnight

ANNUAL RESEARCH, RESIDENTS & ALUMNI MEETING

Course Directors: Hilel Lewis, M.D.Chairman, Division of OphthalmologyDirector, Cole Eye Institute

Careen Y. Lowder, M.D., Ph.D.Uveitis DepartmentCole Eye Institute

Keynote Speaker:Paul R. Lichter, M.D.F. Bruce Fralick Professor

of OphthalmologyChair, Department of Ophthalmology

and Visual SciencesDirector, University of Michigan

Kellogg Eye CenterAnn Arbor, MI

Description:This program provides a scientific forumto present clinical and basic scienceresearch of the Cole Eye Institute resi-dents, fellows, staff, alumni and invitedophthalmologists.

The goal of this meeting is to pursueand present the highest-quality, original,thought-provoking clinical researchpapers. In addition to the educationalaspects of the program and learningabout new and ongoing investigations,this event offers an excellent opportu-nity to meet current residents, fellows,new faculty and invited ophthalmolo-gists and to make and renewfriendships.

At the conclusion of this course, participants should be able to:1. Recognize the most up-to-date

concepts and treatments in researchand clinical ophthalmology.

2. Identify current basic science researchin age-related macular degeneration.

3. Explain the rationale and status ofthe most current treatments foruveitic and diabetic macular edema.

4. Discuss outcomes of complicatedglaucoma and cataract surgery.

5. Describe the latest techniques inrefractive surgery.

Ophthalmic

Continuing Medical Education (continued)

15

Cole Eye Institute

Staff

Hilel Lewis, M.D.Chairman, Division of OphthalmologyDirector, Cole Eye InstituteSpecialty/Research Interests: Vitreoretinalsurgery for complicated retinal detachmentand trauma, age-related macular degenera-tion, diabetic retinopathy, retinalphotocoagulation, instrument development

Bela Anand-Apte, M.B.B.S., Ph.D.Ophthalmic Research DepartmentResearch Interest: Angiogenesis

John W. Crabb, Ph.D.Ophthalmic Research DepartmentResearch Interests: Age-related maculardegeneration, inherited retinal diseases

Marc A. Feldman, M.D.Ophthalmic Anesthesia Specialty Interests: Ophthalmic surgeryanesthesia, preoperative assessment, resi-dent education

Richard E. Gans, M.D., F.A.C.S.Comprehensive Ophthalmology DepartmentSpecialty Interests: Cataract, glaucoma,diabetes

Philip N. Goldberg, M.D.Comprehensive Ophthalmology DepartmentSpecialty Interests: Cataract, glaucoma

Froncie A. Gutman, M.D.Vitreoretinal DepartmentSpecialty Interests: Retinal vascular dis-eases, laser therapy, diabetic retinopathy

Stephanie A. Hagstrom, Ph.D.Ophthalmic Research DepartmentResearch Interests: Inherited forms of retinal degeneration, including maculardegeneration and retinitis pigmentosa

Joe G. Hollyfield, Ph.D.Ophthalmic Research DepartmentResearch Interests: Retinal degeneration,retinal diseases

Bennie H. Jeng, M.D.Cornea and External Disease DepartmentSpecialty/Research Interests: Corneal trans-plantation, ocular surface disease, limbalstem cell transplantation, artificial corneas,eyebanking, cataracts

Peter K. Kaiser, M.D.Vitreoretinal DepartmentSpecialty/Research Interests: Vitreoretinaldiseases, age-related macular degeneration,retinal detachment, diabetic retinopathy,endophthalmitis, posterior segment com-plications of anterior segment surgery

Gregory S. Kosmorsky, D.O.Neuro-Ophthalmology DepartmentSpecialty Interests: Neuro-ophthalmology,cataract, refractive surgery

Ronald R. Krueger, M.D., M.S.E.Refractive Surgery DepartmentSpecialty/Research Interests: Refractivesurgery, lasers, refractive corneal pathol-ogy, lamellar corneal transplants,investigational clinical trials

Roger H.S. Langston, M.D.Cornea and External Disease DepartmentSpecialty Interests: Cornea and externaldisease, corneal transplantation

Careen Y. Lowder, M.D., Ph.D.Uveitis DepartmentSpecialty/Research Interests: Uveitis,intraocular inflammatory diseases, pathology

Andreas Marcotty, M.D.Pediatric Ophthalmology and Strabismus DepartmentSpecialty Interests: Pediatric ophthalmol-ogy, adult strabismus

Shari Martyn, M.D.Comprehensive Ophthalmology DepartmentSpecialty Interests: Cataract, glaucoma,diabetes

David M. Meisler, M.D.Cornea and External Disease DepartmentSpecialty/Research Interests: Corneal andexternal disease, inflammatory and infec-tious diseases of the cornea, cornealtransplantation, refractive surgery

Michael Millstein, M.D.Comprehensive Ophthalmology DepartmentSpecialty Interests: Cataract, glaucoma,refractive surgery

Neal S. Peachey, Ph.D.Ophthalmic Research DepartmentResearch Interests: Visual loss associatedwith hereditary retinal degeneration

Victor L. Perez, M.D.Cornea and External Disease DepartmentSpecialty/Research Interests: Medical andsurgical treatments of autoimmune inflam-matory conditions of the cornea andocular surface, uveitis, corneal transplan-tation, cataract surgery

Julian D. Perry, M.D.Oculoplastic and Orbital Surgery DepartmentSpecialty/Research Interests: Aestheticfacial surgery/fat transplantation andrepositioning, acellular human dermalgraft matrix, new bovine hydroxyapatiteorbital implant, thyroid eye disease/rate ofstrabismus after decompression surgery fordysthyroid orbitopathy

216/444-2020The Cleveland ClinicCole Eye Institutewww.clevelandclinic.org/eye

Edward J. Rockwood, M.D.Glaucoma DepartmentSpecialty/Research Interests: Glaucoma,glaucoma laser surgery, combined cataractand glaucoma surgery, glaucoma filteringsurgery with antimetabolite therapy, glau-comatous optic nerve damage, congenitalglaucoma

Allen S. Roth, M.D.Comprehensive Ophthalmology DepartmentSpecialty Interests: Corneal transplanta-tion, refractive surgery, cataract andimplant surgery

Jonathan E. Sears, M.D.Vitreoretinal DepartmentSpecialty/Research Interests: Pediatric andadult vitreoretinal diseases, pediatric reti-nal detachment, inherited vitreoretinaldisorders, retinopathy of prematurity, otheracquired proliferative diseases

David B. Sholiton, M.D.Comprehensive Ophthalmology DepartmentSpecialty Interests: Cataract and implantsurgery, glaucoma, oculoplastics

Arun D. Singh, M.D.Ophthalmic Oncology DepartmentSpecialty/Research Interests: Adult andpediatric ocular tumors, uveal melanoma,genetics of retinoblastoma, retinal capil-lary hemangioma, von Hippel-Lindaudisease

Scott D. Smith, M.D., M.P.H.Glaucoma DepartmentSpecialty/Research Interests: Glaucoma,cataract, prevention of eye disease, inter-national ophthalmology, congenitalglaucoma

Elias I. Traboulsi, M.D.Pediatric Ophthalmology and Strabismus Department Center for Genetic Eye DiseasesSpecialty/Research Interests: Ocular dis-eases of children, genetic eye diseases,strabismus, retinoblastoma, congenitalcataracts, childhood/congenital glaucoma

Steven E. Wilson, M.D.Cornea and External Disease and Refractive Surgery DepartmentsSpecialty/Research Interests: Corneal andexternal disease, corneal transplantation,refractive surgery, corneal healing

By Marcelo V. Netto, M.D., and Steven E. Wilson, M.D.THE FEMTOSECOND LASER HAS BEEN TOUTED TO PROVIDE INCREASED SAFETY AND REPRO-

DUCIBILITY. AFTER PERFORMING MORE THAN 500 PROCEDURES, WE OFFER THESE SUGGESTIONS:

■ Mild-to-moderate postoperative dis-comfort and inflammation is frequentlynoted after femtosecond laser-LASIKand is attributable to greater inflam-mation induced by epithelial injury.Corticosteroids such as prednisoloneacetate 1% should be applied topicallyevery hour for at least the first dayafter surgery, with taper over oneweek. Otherwise, there is a high risk of diffuse lamellar keratitis.

■ Laser settings such as raster energy and side cut energy must be optimizedfor each laser. Lower energy levelsdecrease inflammation by reducingepithelial injury. However, if energylevels are too low, it becomes difficultor impossible to lift the flap.

■ The flap should be lifted only after thecomplete disappearance of cavitationbubbles in order to facilitate the liftingprocess, provide more accurate cornealthickness measurement, reduce the riskof intra-operative excimer laser eye-tracking issues and facilitate customcorneal ablation since residual bubblesor scraping away bubbles with a spatula are likely to alter the baselinewavefront pattern of the cornea.

■ Relifting of a femtosecond flap forenhancement is often more challengingthan relifting a microkeratome flap dueto increased healing at the flap edge

and within the interface. Occasionally,adhesion is so great the flap cannot be relifted. Then, consideration can begiven to recutting the flap, but there isa risk of intersecting cuts yielding sliv-ers of stroma that can be displaced,resulting in irregular astigmatism.

■ Attempting to cut a deeper flap withthe femtosecond laser following a thinor otherwise defective LASIK flap pre-viously generated with amicrokeratomeor the femtosecond laser might not bepossible. The original lamellar interfacetends to absorb pulses from the fem-tosecond laser and prevent the creationof a deeper flap. Unpublished studieshave suggested that a difference of atleast 80 µm should be the goal if recutis attempted, although problems maystill occur and there is no accurateway of measuring the thickness of theprevious defective flap.

The femtosecond laser seems toreduce intraoperative LASIK complica-tions, especially in corneas that have amean corneal curvature greater than 48D or less than 42 D. Careful patientselection and attentive postoperative careare mandatory for this procedure.

Dr. Netto is a Cornea and RefractiveSurgery Fellow and Dr. Wilson is Direc-tor of Cornea Research and RefractiveSurgery Staff at The Cole Eye Institute.

Ophthalmic PearlFemtosecond Laser: Tips for New Users

Ophthalmology Update, a publication of The ClevelandClinic Cole Eye Institute, provides information forophthalmologists about state-of-the-art diagnosticand management techniques and current research.Please direct any correspondence to:

Steven E. Wilson, M.D.Cole Eye Institute / i32The Cleveland Clinic Foundation9500 Euclid AvenueCleveland, Ohio 44195Phone 216/444-5887Fax 216/445-8475

Director and Division ChairmanHilel Lewis, M.D.

Editor-in-ChiefSteven E. Wilson, M.D.

Editorial BoardJulian D. Perry, M.D.Jonathan E. Sears, M.D.

Managing EditorBeth Thomas Hertz

Art DirectorBarbara Ludwig Coleman

PhotographersTami FeckoDon GerdaDeborah Ross

The Cleveland Clinic Foundation is an independent,not-for-profit, multispecialty academic medical center.It is dedicated to providing quality specialized careand includes an outpatient Clinic, a hospital with approximately 927 staffed beds, an Education Divisionand a Research Institute.

Ophthalmology Update is written for physicians andshould be relied upon for medical education purposesonly. It does not provide a complete overview of thetopics covered and should not replace the independentjudgment of a physician about the appropriateness orrisks of a procedure for a given patient.

Physicians who wish to share this information withpatients need to make them aware of any risks orpotential complications associated with any procedures.

© The Cleveland Clinic Foundation, 2005

Non-Profit Org.U.S. Postage

PAIDCleveland, OH

Permit No. 4184

9500 Euclid Avenue / W14Cleveland, OH 44195