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Rapid Fire Grand RoundsCOPE#52118- PO
Walter O. Whitley, OD, MBA, FAAO
Director of Optometric Services
Virginia Eye Consultants
Residency Program Supervisor
PCO at Salus University
Disclosures
• Alcon
• Allergan
• Bausch and Lomb
• Biotissue
• Beaver-Visitec
• Ocusoft
• Publications
– Advanced Ocular Care – Co-Chief Medical Editor
– Review of Optometry – Contributing Editor
– Optometry Times – Editorial Advisory Board
Walter O. Whitley, OD, MBA, FAAO has received consulting
fees, honorarium or research funding from:
• Science Based Health
• Shire
• Sun Pharmaceuticals
• TearLab Corporation
• Tearscience
Virginia Eye ConsultantsTertiary Referral Eye Care Since 1963
• John D. Sheppard, MD, MMSc
• Stephen V. Scoper, MD
• David Salib, MD
• Elizabeth Yeu, MD
• Thomas J. Joly, MD, PhD
• Dayna M. Lago, MD
• Constance Okeke, MD, MSCE
• Esther Chang, MD
• Jay Starling, MD
• Samantha Dewundara, MD
• Rohit Adyanthaya, MD
• Albert Cheung, MD
• Walter Whitley, OD, MBA, FAAO
• Mark Enochs, OD
• Chris Kuc, OD, FAAO
• Cecelia Koetting, OD, FAAO
• Leanna Olennikov, OD
• Chris Kruthoff, OD
• Jillian Janes, OD
Pearls on Optometric Co-management
• Get to know your surgeon
• Convey patient preferences, observations and
conditions to your surgeon
• Inform your patients on your role in perioperative
care
• Successful co-management is the result of
continuous communication
2
Today’s Optometrists
“To be on the cutting edge of optometry, you need to be on the
cutting edge of science and technology.”
US-ODE-16-E-5238 6
TODAY’S CATARACT PATIENT
Active Outgoing Still
working
Digitally
savvy
1. Centers for Disease Control and Prevention website. http://www.cdc.gov/healthcommunication/pdf/audience/audienceinsight_boomers.pdf. Accessed December 21, 2016.
2. Hill W. Distribution of corneal astigmatism in normal adult population. Keratometry database: http://www.doctor-hill.com/iol-main/astigmatism_chart.htm. Accessed January 13, 2017.
3. AcrySof® IQ Toric IOL Directions for Use. Alcon data on file, 2009.
• In 2015, people aged 50 and older represented 45% of the US
population1
• There were approximately 4 million cataract procedures in 2015 and
that number is expected to grow by 3% in 20166
Why Become Involved?
• By 2020 the U.S. population over 65 will
double from current levels – 12.9% of
total population
• CMS allows ODs/MDs to bill for non-
covered services
• Tangible vs. Intangible benefits
• Patient expectations are at an all-
time high for refractive surgery
• Positive experiences with LASIK
have produced high expectations,
at a minimum achieving:
– 92.6% of LASIK patients with vision of
20/40 or better*
– 95.4% of patients satisfied with their
outcome after LASIK surgery**
• Cataract surgery outcomes may
not be meeting the target of ±0.5D
that is considered the standard
High Patient Expectations in Cataract
Refractive Surgery
*“LASIK Surgery Statistics.” Docshop.com. http://www.docshop.com/education/vision/refractive/lasik/statistics
**Solomon, K et al. (2009) “LASIK world literature review: quality of life and patient satisfaction.” Ophthalmology. 16(4):691-701
***Graph: Data from Dr. Warren Hill & Behndig A, et al. Aiming for emmetropia after cataract surgery: Swedish National Cataract Register study. J Cataract Refract Surg. 2012;38(7):1181-6.
41%
71%
97%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
±0.25D ±0.5D ±1.0D
Cataract Outcomes***
88/13
VRN13066SK
3
What Do Our Patients Know About
Cataracts?
• What is a cataract?
• When do I need cataract surgery?
• How is the surgery done?
• Who do I go to?
• What are my options?
• Will I need glasses?
• Will I still see you after the surgery?
Advanced Technology:
The Players
SYMFONY First Extended Depth of Focus Lens (EDOF)
Coupling of two new principles:
– Diffractive echelette to elongate the range of focus
– Reduction in chromatic aberration to increase
contrast sensitivity
Different than a MF-IOL:
– Rather than splitting incoming light into two focal
points, it elongates depth of focus
– Not affected by pupil diameter
4
Glare and Halos
Tecnis Symfony
• First EDOF IOL approved in the US
• Available in both toric and non-toric
• Offers patients extended range of vision
• Lower glare/halo side effect profile
AcrySof® IQ ReSTOR® IOL1,2,3
RES14040SK-D 161. AcrySof® IQ ReSTOR® +2.5 D IOL Directions for Use.2. AcrySof® IQ ReSTOR® +3.0 D IOL Directions for Use. 3. Data on Fil
e, Alcon Inc.
Parameter
SV25T0Model
numberSN6AD1
+2.5 DADD power @ IOL plane
+3.0 D
+2.0 DADD power
@ Spectacle Plane
+2.5 D
0.94 mmCentral ring
diameter0.86 mm
7 # rings 9
8.4 mm2Apodized
Diffractive Area
10.2 mm2
Dist: 69%
Near: 18.0%
Energy
distribution (3 mm)
Dist: 59%
Near: 25.5%
-0.2µmAsphericity -0.1µm
+2.5 D +3.0 D
5
Defocus Curves1,2
RES14040SK-D 171. AcrySof® IQ , AcrySof® IQ ReSTOR® +3.0 D 2. AcrySof® IQ ReSTOR® +2.5 Directions for
.
Introducing…..Restor Toric
http://www.alconsurgical.ca/images/CataractIOLs/Calculator_Product_Sp
ec_image3.JPG
“The Pipeline”: Future IOLs
• Akkommodative 1CU (Human Optics)
• Tetraflex IOL (Lenstec)
• Sarfarazi Elliptical IOL (B&L)
• Synchrony (Visiogen)
• FlexOptic Lens (Quest Vision
Technologies)
• NuLens (NuLens)
• FluidVision IOL (PowerVision)
• LiquiLens (Vision Solutions)
• Smart IOL (Medenium)
• Light Adjustable Lens (Calhoun Vision)
Setting Expectations
• Individual patient perceptions vary
• Best vision after bilateral implantation
• Glare/Halos
• Lighting considerations
• Readers
• Possibility of refinement
6
Preparation for Ocular Surgery
• Optimize the Ocular Surface
• Normalize the Lids
• Prepare the Cornea
• Eliminate Intra-ocular
Inflammation
• Control Glaucoma
• Satisfy the Macula
• Evaluate the Retinal Periphery
• Patient Education
Ocular Pathology
• Chair time about source(s) of “BLURRY VISION”
• Cataract surgery can worsen DED for months
after surgery
• Refractive cataract surgery: quality of vision may
require chronic DED Rx
• Cyclosporine ophthalmic emulsion 0.05%,
lifetegrast 5%, Topical amniotic membrane drops
Cat Sx and OSD
Management of Patient Expectations
Testing only when Patients
Complain of Dryness is Insufficient
• > 40% of people with
objective evidence of dry
eye are asymptomatic1
• Cataract surgery patients
often complain of
fluctuating vision rather
than dryness or FBS2
13%
28%
59%
010203040506070
Most orall thetime
Some ofthe time
Never
Do you have FBS?
Despite a lack of discomfort, dryness or FBS, >60% of subjects had significant signs of OSD2
1. Bron AJ, Tomlinson A, Foulks GN, et al. The Ocular Surface 2014; In press.2. Trattler W, Reilly C, Goldberg D, et al. Prospective Health Assessment of Cataract Patients Ocular Surface Study; Poster, ASCRS 2011.
7
Dry Eye Prevalence in Patients
Scheduled for Cataract Surgery
• Study Design: Prospective, multicenter, observational,
pilot study (N=143) of which 136 met the inclusion criteria
at 9 sites across the United States to determine the
incidence and severity of Dry Eye Disease in consecutive
patients 55 and older scheduled for cataract surgery (68
male and 68 female patients)
• Primary outcome measure: Incidence of Dry Eye as
evaluated by grade on International Task Force (ITF) level
• Secondary outcome measures: TBUT, corneal staining
with fluorescein, and conjunctival staining with lissamine1. Trattler WB, et al. Clinical Study Report: Cataract and Dry Eye: prospective health assessment of cataract patients ocular surface study. 2010.
Dry Eye Prevalence in Patients
Schedule for Cataract Surgery• 80% of Patients had dry eye severity score of Level 2 or
Higher
• Tear Break Up Time: 62.9% with < 5 sec
• 76.8% of eyes were positive for Nafl corneal staining
• Only 22.1% (30 pts) received a previous Dx of Dry Eye
27
• Ocular surface must be optimized pre-operatively for
accurate keratometry
Cataract Surgery and Dry Eye
Photo accessed from http://i1.ytimg.com/vi/IFRJw1xeVJI/hqdefau lt.jpg on 12/28/1528
Goal of Therapy:
Stabilize Interblink Tear Film
8
“Hot spots” and “Flat spots”are Abnormal
Irregularly Shaped or Smudgy Placido Disk is Abnormal!
Take a Closer Look if Average K Values are Different
9
Dry Eye Preparation for
Cataract Sx Measurements
1. Frequent NPAT use
2. Topical steroid course
- Fluoromethalone, loteprednol
- PF Dexamethasone 0.01% to 0.1%
3. Upper and/or lower punctal occlusion
4. MGD management: MiboFlo, Lipiflow
5. Prokera Self-retaining AMT
6. Address any other issues, i.e. blepharospasms, lag ophthalmos, filamentary keratitis
Case Example
• 71 yo WF, physician’s wife, presents for
evaluation of blurred vision
• Guillan Barre Syndrome distant past Lag
ophthalmos R > L
• “Another MD has been treating my dry eye for
one year and says I’m still not ready for cataract
surgery”
• Meds: clonidine, Crestor, Fentanyl, Cymbalta,
Lasix, Dilaudid, Cymbalta, Fioricet
• 2+ MGD with telangiectasia
• Poor blink rate
• Lag OD > OS (1-2mm)
• Diffuse 2-3+ stain within central and inferior
cornea OD, +KNV with ant stromal scar inferior
periphery
Case Example
10
• ACUTE preparation for cataract surgery different
from chronic management of DED
– Topical steroid drops and/or ointment: First line
therapy
– Aggressive NPAT
– Lipiflow thermal pulsation
– If imaging unimproved after 3-4 weeks, consider
Prokera AMG
Management of Patient Expectations
• Treatment
– Fire/Ice Mask bid, Ocusoft Plus lid wipes
– Loteprednol ointment qhs x 1 week
– PF Dexamethasone 0.1% qid
– Aggressive lubrication
After 2 weeks, minimal improvement, and Prokera
self-retaining AMT placed
Case Example
Case Example
• Patient returned 1 week later for Prokera
removal OD
• Cataract surgery measurements acquired the
day after
S/P Prokera Self-retaining AMT
Pre-Prokera
s/p Prokera
(placed for 5
days)
11
• Lid hygiene
• BlephEx
• ABx/steroid ointment bid
• Demodex treatment
• Wait 1-2 months before
cataract sx: ? Bacteria
released from lid hygiene
Blepharitis
4141
• 69% of patients with bacterial endophthalmitis were culture-positive
Endophthalmitis Vitrectomy Study
1. Han DP, Wisniewski SR, Wilson LA, et al. Spectrum and susceptibilities of microbiologic isolates in the endophthalmitis vitrectomy study. Am J Ophthalmol 1996;122(1):1-17.2. Speaker MG, Milch FA, Shah MK, et al. Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. Ophthalmology. 1991;98:639-649.
24%
Other
Gram-positive
organisms
70%
6%
Gram-positive
coagulase-negative
organisms (Staphylococcus
epidermidis)
Gram-negative
organisms
Call to Action!!!
OSDI SPEED
ARE MIGS THE ANSWER?
12
Case Presentation
• CC: vision cloudy OS>OD
• HPI: 68 yo WM presents for cataract evaluation
with h/o controlled moderate OAG OS>OD
• Current meds: Levobunolol QD OU, Travatan
qhs OU, Optive
• POHx: SLT OU 2007
• FamHx: mother with glaucoma
Case Presentation
• BCVA : 20/40 OD, 20/50 OS
• Present Rx: OD -0.50+1.00 x 075
OS -1.00 +0.75 x 110
• Keratometry: OD 43.67/44.00 x 055
OS 43.25/44.37 x 85
• IOP: OD 14, OS 14 (Applanation)
• CCT: OD 527, OS 512
• Tmax: OD 20; OS 24
• Gonioscopy: OU open to scleral spur
• SLE 2+ NS OU
Case Presentation
• Dilated Fundus Exam:
• Optic Nerve:CDR OD: 0.55 / 0.5
(thin rim infer/sup)
CDR OS: 0.7 / 0.65
• Macula: OU Flat
• Vessels: WNL
• Periphery: WNL
13
What Do You Get When You Add?
+
=
Case Presentation
• Diagnosis: VS Cataract OU, Controlled
Glaucoma
• Type of Glaucoma: open angle glaucoma
– Stage of Glaucoma: Moderate to severe
OS>OD
– What is the target pressure? Low teens OU
– Is current treatment adequate? Yes
Which Comes First,
The Chicken or the Egg?
• Glaucoma Evaluation First
– Permanent loss of vision if not controlled
• Cataract Evaluation Second
– Cataract surgery is an elective procedure and
can wait
• Consider combined procedure
Patient Compliance and Dosing
• Literature review of 76 studies show– Compliance increases
with decreased dosage regimen and complexity1
– 79% compliance with QD regimen vs 51% for QID regimens (p=0.001)1
– Simpler, less-frequent dosing results in better compliance in a variety of therapeutic classes1
Com
plia
nce
Dosing
(Times/day)
1. Claxton et al. Clinical Therapeutics. 2001; 23:1296-1310.
14
How Adherent are Glaucoma
Patients with QD Medication?
Minimally Invasive Glaucoma
Surgery (MIGS)
Ab Externo
• Canaloplasty
• Stegmann Canal
Expander
• Gold Microshunt
Ab Interno
• Glaukos iStent
• Neomedix
Trabectome
• Excimer laser
trabeculotomy
• Hydrus Microstent
• Cypass Microstent***
• Kahook Dual Blade
• Xen Gel Stent***
Trabecular Bypass Devices
• These procedures facilitate the flow of
aqueous into Schlemm’s canal by:
– Shunting the canal
• Express MiniShunt (Alcon)
– Stenting the canal
• iStent (Glaukos Corp)
– Divert aqueous into the suprachoroidal space
• Cypass Microshunt (Alcon)
– Divert aqueous into the subconjunctival space
• Xen Gen Stent (Allergan)
PN: 400-0135-2013-US Rev. 0 Release Date: 08/27/2013
Photo accessed from http://www.downstate.edu/ophthalmology/patient-info/patient-info-
glaucoma.html on 11/4/16
Anatomical Considerations
15
Are Patients Interested in MIGS?
• 28pts
• 79% did not mind
instilling drops
• 64% did not mind
wearing glasses
• 86% were interested in
reducing their need for
topical medications
Combined Phaco / Trabectome
Trabectome - IOP & Glaucoma Medication Use
Outcome
Mean pre-op IOP
Mean IOPs with standard deviations at various intervals after surgery over 72 months
Mean pre-op medication use
Mean medication use after surgery over 72 months
IOP (mmHg)
Glaucoma Medication
Use
Combined Phaco / iStent
16
US IDE Trial - Primary Endpoint
61
0
20
40
60
80
100
Cataract Surgery iStent
Percent of Patients With IOP ≤21 mm Hg Without Medication Use
50%
72%
®
The XEN® Gel Stent
• A glaucoma implant designed to reduce intraocular pressure in eyes suffering from refractory glaucoma1
• 6-mm length, 45-micron inner diameter—about the length of an eyelash1,2
• Composed of gelatin, cross-linked with glutaraldehyde1
1. XEN® Directions for Use; 2. Vogt et al. In: Blume-Peytavi et al, eds. Hair Growth and Disorders. 2008.
The XEN® Procedure
1. XEN® Directions for Use.
In the clinical investigation, standard ophthalmic surgery
techniques, viscoelastic, and mitomycin C (0.2 mg/mL)
were used before injection.1
The XEN® Procedure Creates a Low-Lying,
Ab-interno Bleb in Refractory Glaucoma1
• Example of elevated, cystic bleb2
1. Dapena and Ros. Revista Española de Glaucoma e Hipertensión Ocular. 2015; 2. Errico et al. Clin
Ophthalmol. 2011.
Ab-Externo Bleb
Suture wounds2
Dissected tenon
capsule layer2
Diffuse, mildly
elevated bleb2
Ab-Interno Bleb
• Low-lying and diffuse1
Controlled flow through lumen
restriction1
Tenon capsule
adhesions intact1
Undistrubed, low-lying
drainage space1
17
XEN® Ab-interno Bleb Examples
Post-op day 1 Post-op month 12 Post-op month 18
Actual patient. Images courtesy of: Francisco Millan, MD, and Vanessa Vera, MD.
Cypass Microstent
• Ab-interno insertion
into the supraciliary
space
• Fenestrated
microstent made of
biocompatible
polyimide material
• Magnetic resonance
safe
Why Target the Uveoscleral Outflow
Pathway?• Uveoscleral outflow: considered
pressure independent and
contributes up to 50% of total
aqueous outflow.2
• Aqueous percolates through the
ciliary body and exits into the
suprachoroidal space,
primarily through the sclera and
choroidal blood vessels.3
• The highest point of resistance
is the ciliary body, which is
thought to regulate this
drainage.3
Clinical Data Delivers superior, long-
term IOP-lowering efficacy Two-year COMPASS Trial is the largest MIGS randomized controlled trial
completed to date Landmark FDA study with two-year follow-up on >500 patients with baseline/terminal washout
• 72.5% of eyes achieved a
≥20% reduction
in unmedicated
diurnal IOP
at 2 years*
• 61.2% of eyes maintained an
unmedicated
diurnal IOP
range between
6 and 18 mmHg
at 24 months
(a 41% increase)*
*Prospective, randomized, multicenter clinical trial in patients (n=505) with open-angle glaucoma undergoing cataract surgery randomized to
microstent (n=374) or phacoemulsification (n=131).
Primary outcome measure was unmedicated diurnal IOP reduction at 24 months versus cataract surgery alone at baseline. Secondary outcomes
measures included mean change in 24 month
DIOP from baseline and 24 month unmedicated mean IOP (between 6 mmHg to 18 mmHg) versus cataract surgery alone. Medication use at 24
months was also analyzed. The primary and
secondary effectiveness analyses were performed using intent to treat (ITT) population.
18
Demonstrated safety as compared to
cataract surgery alone
Intraoperative adverse events▪
A total of ▪ 25 intraoperative were reported in 20 out of 374 CyPass subjects (5.3%)
Incidence of postoperative ▪
adverse events
39▪ % of CyPass® Micro-Stent patients
36▪ % of Control patients
Postoperative AEs were ▪
generally manageable and transient and did not negatively affect functional outcomes such as visual acuity
Adverse Event, %
CyPass®
Micro-Stent
+ Phaco
n=374
Phaco only
n=131
Blepharitis 1.9% 0.0%
Corneal abrasion 1.9% 1.5%
Corneal edema 3.5% 1.5%
Conjunctivitis 1.1% 2.3%
Cyclodialysis cleft 1.9% 0.0%
Hyphema, intraoperative 2.7% 0.0%
Hypotony IOP <6 mmHg 2.9% 0.0%
IOL complication 1.1% 0.0%
IOP elevation, ≥10 mmHg above
baseline4.3% 2.3%
Iritis 8.6% 3.8%
Loss of BCVA; ≥10 letters read 8.8% 15.3%
Maculopathy/retinopathy
(cystoid, diabetic, other)3.2% 3.1%
Microstent obstruction 2.1% N/A
Subconjunctival hemorrhage 2.1% 0.8%
Surgical reintervention 5.1% 5.3%
Worsening of ocular symptoms 5.6% 3.1%
Visual field loss progression 6.7% 9.9% Safety Population, events occurring at rate of 1.0% or greater
How To Choose Which Procedure?
• Discuss with your surgeon which
procedures they perform?
• Based on Stage and Severity
– Moderate to advanced cases – Trabectome
– Early to Moderate – iStent, Xen, Cypass
– ? multiple iStents off label
– iStent inject shows promise
Post-operative Cataract IOP Spikes in
Glaucoma Patients
• Adequate control prior to surgery
– Additional drops
– SLT prior
• Consideration of combined glaucoma and
cataract procedures
• Aggressive treatment perioperatively
– Diamox at the end of the case, early post-op
• Closer follow-up post-operatively
POSTOP MANAGEMENT
PEARLS
19
Traditional Cataract Surgery:
Common Complications
10-40% PCO 2-12% CME
4-10% K endo loss1-5% Vitreous prolapse Photo Accessed from Dr. John Marinelli
What to Look for After Cataract
Surgery?
1 • day – low IOP
• 3-7 days – Endophthalmitis
• 4-6 weeks – CME
2 • months – Posterior capsule opacification
Postoperative Pearls for
Advanced Technology IOLs
• Remind patient that it is normal for vision to be
blurry and eyes out of balance
• Avoid “buyer’s remorse”
• 5% of patients experience halos
• Bilateral implants
• Use -2.25D Glasses to reassure decision
• Crystalens considerations
• Communication with surgeon / referral center
• Check toric axis at one week
What to Look for After
Toric IOL Surgery?
• Crossed Cyl effect
– +sphere – double the astigmatism
– ie. +100-200x130
– Can dilate in one week if suspicious
• Consider posterior corneal astigmatism
20
Case Example DC
• CC: Decreased VA OD, > 2 yrs, progressive, affects near and far, Glare OD>OS
• BCVA OD 20/70-2 PH 20/60
OS 20/25-2 BAT 20/50-
• SLE: Cataracts OD>OS
• 12/02/08 – Unremarkable Cataract Sx OD
Postoperative Day 1
• Pain last night, today better
• UCVA OD: 20/40 PH 20/30
• IOP - 18 at 1:55pm
• SLE:
– Wound secure
– 2+ SPK
– AC well formed with about 1+ cell
– IOL well centered in pupil
Postoperative Medication
Review medications
No restrictions on physical activity
Remind patient that it is normal for vision to be blurry and eyes out of balance
F/U 1 week
Fax results to surgeon if co-managed
21
Weekend Emergency
• CC: VA decreased and foggy, no pain
• BCVA: OD 20/200 PH/NI
• IOP: 10 mmHg
• SLE: 3-4+ cells / deep / PVD / 3+ Vitritis / Dot hemes / whitening throughout periphery
• A: Increased post op inflammation OD
• P: Omnipred q1h OD, Nevanac TID, VigamoxTID / F/u tomorrow
Thoughts???
Sudden decrease in vision•
Increase in inflammation•
No PVD noted previously•
No pain / discomfort•
Dot hemorrhages in the periphery•
Differentials
TASS Endophthalmitis
Taken from http://www.retinalphysician.com/article.aspx?article=100059
What is the Most Common Organism
Found in Bacterial Endophthalmitis?
• S. aureus
• S. epidermidis
• S. pneumonia
• H. influenza
22
Endophthalmitis Vitrectomy Study
• 69% of patients with bacterial endophthalmitis were culture-positive
1. Han DP, Wisniewski SR, Wilson LA, et al. Spectrum and susceptibilities of microbiologic isolates in the endophthalmitis vitrectomy study. Am J Ophthalmol 1996;122(1):1-17.2. Speaker MG, Milch FA, Shah MK, et al. Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. Ophthalmology. 1991;98:639-649.
24%
Other
Gram-positive
organisms
70%
6%
Gram-positive
coagulase-negative
organisms (Staphylococcus
epidermidis)
Gram-negative
organisms
Endophthalmitis Vitrectomy Study
VA
Outomes
Presenting
VA
20/40 or
better
20/100 or
better
Les than
5/100
Recommen
d Treatment
HM or better TAP 62% 84% 3% TAP
PPV 66% 86% 5%
Light
Perception
TAP 11% 30% 47% PPV
PPV 33% 56% 20%
PPV = pars plana vitrectomy and intravitreal injection of antibiotics
TAP = vitreous tap and intravitreal injection of antibiotics
http://www.nei.nih.gov/neitrials/viewstudyweb.aspx?id=29#Results
Next Day Visit
• Increase in pain today
• OD VA: 20/400 NI w/ Pinhole
• SLE: Central K stain w/ Dendritic appearance / 2+ Cells in AC / 3 + Cells in Vitreous / Dot hemorrhages / Retinal whitening
What’s She Have????
Possible Acute Retinal Necrosis◦ Foscarnet 2.4 mg/ 0.1cc injected intravitreally
◦ Vicodin 5/325 1 tab every 4-6 hrs PRN
◦ Valtrex 1000mg every 8 hrs for 10 days
◦ Ordered blood cultures, fungal, PCR for VZV, HSV I, HSV 2, gram stain, CBC, Chem 7, ESR, and C-reactive protein
Cannot r/o bacterial endophthalmitis◦ Recommend intravitreal injections of Vancomycin
1mg/0.1cc and Ceftazidime 2.25 mg/ 0.1 cc.
◦ Vitreous specimen sent to lab
◦ Monitor very closely
23
Lab Reports Acute Retinal Necrosis
Definition◦ Necrotizing herpetic retinitis. May present
unilaterally or bilaterally (20%)
Epidemiology◦ Usually occurs in young, healthy adults. ◦ Less common are elderly and
immunocompromised◦ Caused by infection with HZV or HSV
History◦ Iritis or episcleritis◦ Rapid decline in VA with intense vitritis
Acute Retinal Necrosis
Important Clinical Signs◦ Vitritis with peripheral
retinal whitening that coalesces
Associated signs◦ Iridocyclitis,
photophobia, vitritis, optic neuritis, and retinal arteriolitis
Taken from www.emedicine.medscape.com/article/1223047-media on October 19, 2009
Acute Retinal Necrosis
Diagnosis
◦ Diagnosis based on
clinical exam
◦ Polymerase chain
reaction
◦ Retinal biopsy
Management◦ Systemic antiviral
treatment
◦ IV acyclovir 10mg/km tidfor 7 to 10 days
◦ Followed by 3 month course of acyclovir po
800mg five times per day
◦ Risk of RD is 8 to 12 weeks
◦ Laser photocoagulation
◦ Pars Plana Vitrectomy
24
Clinical Pearls
If patient calls with symptom of sudden
decrease VA or pain during the first week: the
doctor must see the patient
Treat as infectious until proven otherwise
Importance of communicating with surgeon
Common Corneal Procedures
Corneal • crosslinking
Penetrating • keratoplasty
Descemet’s• stripping endothelial keratoplasty
Pterygium• surgery
Superficial keratectomy•
Corneal Crosslinking
• CXL increases the rigidity of the cornea
• Indications:
– Corneal ectatic disorders
– Post-LASIK ectasia
– Infectious keratitis
– Advanced corneal edema
Photo accessed from http://www.mccarthyeye.com/corneal-cross-linking.php
Patient Selection
• CCT > 400 μ
– Less than 400 μ, hypotonic
riboflavin to induce swelling
• K’s < 60.00 D
– May not flatten enough for
significant improvement
• POcHx
– HSV
– Dry eye syndrome
25
OD → post-CXL
2.8D flattening
OS → untreated
2.6 D steepening
POM 18 after C3R OD onlyRaiskup-Wolf F. J Cataract Refract Surg 2008;
34:796-801
Corneal Crosslinking Complications
• Treatment failure – 7.6%
– Risk factors - 35 yrs or older / VA 20/25 or better / Ks
>58D
• Postoperative infection/ulcer
• Stromal haze
• Increased IOP
What’s new in CXL?
• CXL and other corneal refractive treatments
– Topo-guided PRK
– Corneal ring segment
• Trans-epithelial treatments: “epithelium on”
• CXL for microbial keratitis
• CXL for corneal edema
• Other advances and applications
Background
26
ABC’s of Corneal Transplants
• PK
• DALK
• PLK / DLEK
• DSEK / DSAEK
• DMEK / DMAEK
Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2880365/ on 10/3/11
Penetrating Keratoplasty
Descemet’s Stripping Endothelial
Keratoplasty (DSEK)
• Sutureless transplant of the posterior cornea
• Replaces diseased portion of cornea with donor
graft
• Donor tissue obtained by
– Manual dissection
– Microkeratome dissection
– Femtosecond laser
1. Photos accessed from http://www.moria-surgical.com/ on 8/26/11
2. Photos accessed from http://www.alcon.com/en/alcon-products/refractive-surgery.aspx
Indications for DSEK/DSAEK
1. http://emedicine.medscape.com/article/1193218-overview
2. http://webeye.ophth.uiowa.edu/eyeforum/cases/case5.htm
27
Advantages of DSEK/DSAEK vs. PK
• Sutures
• Visual recovery
• Astigmatism / ametropia
• Epithelial complications
• Corneal allograft rejection
• Wound strength
• Globe stability
• Length of surgery
• Intraoperative complications
• Post op visits
DSEK/DSAEK Complications
• Caused by any of the following
– Graft-recipient interface
– Fragile graft tissue
– Graft location
– Glaucoma
– Infection
– CME
– Retinal detachment
Miller, J. Accessed from http://www.revoptom.com/content/d/technology/c/16179/
Graft Rejection
Keratic• precipitates (EK/PK)
Stromal• edema (EK/PK)
Subepithelial• infiltrates (PK)
Gray epithelial line (PK)•
Price, F. Accessed on October 1, 2011 from http://one.aao.org/lms/courses/dsek/LO15.htm
Allan BDS, Terry MA, Price FW, et al. Corneal transplant rejection rate and severity after endothelial keratoplasty. Cornea.
2007;26:1039–1042
Graft Failure
• Primary vs. Iatrogenic (EK)
• Dehiscence (EK)
• Edematous cornea
(EK/PK)
• Scarring (PK)
• Vascularization (PK)
• Astigmatism (PK)
28
Case Example
• 65 YOWF Referred for Cataract Sx
– Blurred VA X 6 months Dist / Near
Stand-Alone vs. Combined
Procedures
Significance of the cataract•
Does the cornea need surgical •
intervention?
Sequential versus triple procedure•
Convenience, cost, visual recovery•
NO MORE TEARS
• 67 year old white female – OS has been
tearing for 3 weeks, some burning and
irritation, h/o allergies
• Ocular Medications – Visine prn
• Meds: OTC Zyrtec, lisinopril
• NKDA
• Assessment: Epiphora OS
Case Example
29
1. History
2. Lid Exam, Palpation of Lacrimal Sac
3. Slit Lamp Exam
4. Schirmer Tear Testing
5. Dye Disappearance Test & Jones I
6. Lacrimal Irrigation, Probing, & Jones II
7. Lower Lid Taping
8. Nasal Speculum Exam
9. Radiography
9 Steps to Evaluating the Tearing Patient
History1.
Lid Exam2.
Dye Disappearance Test3.
Lacrimal Irrigation4.
Not all steps are needed in every patient
The Big Four
• Usually will distinguish hyperlacrimation from
reduced excretion:
– Hyperlacrimation associated with discomfort
• Blepharitis—itch, burn
• Allergic conjunctivitis—itch
• Corneal foreign body—pain
• Trichiasis—irritation
• Dry Eyes—FB sensation, burn
• Iritis—ache, photophobia
• Photosensitivity--photophobia
Step 1: History
• Usually will distinguish hyperlacrimation from reduced excretion:– Hyperlacrimation associated with discomfort
– Hyperlacrimation usually not monocular
– Hyperlacrimation rarely causes frank epiphora
• Prior treatment:– Artificial tears, allergy drops
– Punctal plugs, lacrimal probings
Step 1: History
30
• Time course, duration– Severe epiphora, intermittent: lacrimal stone
– Duration less than 6 months: may benefit from probing or intubation
– “Slowly progressive” does not really help distinguish between PANDO and secondary (neoplasia, infiltration)
• Associated disorders– Previous surgery, trauma
– Previous infections (conjunctivitis, dacryocystitis, sinusitis)
– Facial nerve palsy
Step 1: History
• Facial musculature
• CNVII weakness
• Lid laxity
• Ectropion
• Entropion
• Lacrimal sac palpation
Step 2. Lid Exam
• Canalicular punctal size, position
• Tear meniscus
• Lid motion during blink
• Conjunctivochalasis
• Ocular Surface
• Everted upper lid for papillae
• Lid margin, lashes for blepharitis
Step 3. Slit Lamp Exam
• Functional tear drainage test, positive result could be due to:– Tear lake malposition
– Poor tear pump function
– Punctal stenosis or blockage of canaliculus, sac or NLD
Step 5. Dye Disappearance Test
31
So what is positive? •
Three possible outcomes•
Free flow to nose– —No obstruction (beyond punctum)
Reflux out upper – punctum upon irrigating lower—obstruction beyond common canaliculus
Resistance to irrigation or reflux around –irrigation cannula—canalicular obstruction
Step 6. Lacrimal Irrigation Rational Treatment of The Tearing Patient
Tearing
Hypersecretion
History
Slit Lamp Exam
Reduced excretion
History
Dye Disappearance
Schirmer
Dry EyesCorneal
ExposureBlepharitis Allergy
Trichiasis
Entropion
Art tears
Punctal plugs
Lid
Tightening
Lid scrubs
Compresses
Abx
Topical or
systemic Tx
Lash
Removal or
Lid surgery
SLE Lid exam
Reduced excretion
History
Dye Disappearance
Rational Treatment of The Tearing Patient
Tearing
Hypersecretion
History
Slit Lamp Exam
Reduced excretion
History
Dye Disappearance
Speculum
Nasal blockSac or NLD
block
Canaliculus
block
Punctal
malposition
Punctal
stenosis
ENT Referral Probing
DCR
Jones tube
Trephination
Medial
ectropion
repair
Punctoplasty
Irrigation SLE
Radiology
Rational Treatment of The Tearing Patient
Tearing
Hypersecretion
History
Slit Lamp Exam
Reduced excretion
History
Dye Disappearance
SLE
ConjuctivochalasisLid laxity
CNVII palsy
Ectropion
Entropion
Conjunctival
resection Lid
tightening
Ectropion
or Entropion
repair
Lid exam
Lid taping
32
Chemical Burns
• Emergency!!! - Every minute counts
• Do not waste time on Hx and PE
• Alkali burns more common and worse than acid
– Alkali
• Household cleaners, fertilizers, drain cleaners
– Acid
• Industrial cleaners, batteries, vegetable
preservatives
Chemical Burns
• Absolute Emergency
• Immediate irrigation
• Check VA
• Check pH if possible
Photo accessed from http://www.globalspec.com/ImageRepository/LearnMore/20124/PH-
Scale3125510458de479190dd027baaf7a2c2.png
Hughes Classifications of Ocular Burns
• Grade 1 (Very good prognosis) – No corneal opacity nor limbal ischemia.
• Grade 2 (Good prognosis)– Corneal haze but iris details are clear. Less than
1/3 cornea limbus ischemia.
• Grade 3 (Guarded prognosis)– Sufficient corneal haze to obscure iris details. 1/3
to 1/2 of cornea limbus ischemia
• Grade 4 (Poor prognosis)– Opaque cornea without view of iris or pupil. More
than 1/2 of cornea limbus ischemia.
Management of Chemical Burns
• Debride necrotic tissue
• Frequent ATS
• Bandage contact lens
• Quinolone: 1 gtt 4-6x/day (prevents infection)
• Prednisolone phosphate: 1 gtt q 1-2 hr while awake (reduces inflammation)
• Vitamin C: 1-2 gm po QD (reduces corneal thinning/ulceration)
• 10% sodium citrate: 1 gtt q 2 hr while awake (chelates Ca++ and impairs
PMN chemotaxis)
• Scopolamine 0.25%: 1 gtt TID (reduces pain/scarring with AC
inflammation)
• 10% Mucomyst (n-acetyl-cysteine): 1 gtt 6x/day (mucolytic agent and
collagenase inhibitor)
• Oral pain meds
• Doxycycline 100 mg po bid (collagenase inhibitor)
• Glaucoma gtts/oral diamox if IOP elevated
• Significant injury may require admission
33
Pearls - Prevention is KEY!!!
• Know the potential eye safety dangers
• All chemical injuries should be lavaged immediately
• Extent of damage is dependent on concentration and pH of acid or base
• Eliminate hazards before starting work
• Use protective measures
You’ve Got to be Kidding Me!
27• yowm presents with red, painful, blurry VA
OS. Started 10 days ago after returning from a
trip to Italy. Taking 500mg Naprosyn for HA.
Health • – Unremarkable
Vasx• : OD 20/20-3 OS 20/25-3 with NI
IOP: • 9 / 10
SLE: •
OD Mild – limbal flush / 1+ Cells
OS – 2+ Inj / 2+ Cells
What is Your Treatment?
• Prednisolone acetate 1% vs. difluprednate
0.05% vs. loteprednol etabonate .5%
• Homatropine 5% vs. Scopolamine 0.25% vs.
Atropine 1%
• Would you consider lab testing?
• Would you prescribe an oral medication?
Case #3
• Acute, bilateral non-granulomatous,
anterior uveitis OU
• Cause???
• Treatment
– Difluprednate qid OD, q2h OS
– Cyclopentolate 2% TID OU
34
Screening Tests for Syphilis
Venereal Disease Research Lab (VDRL)•
VDRL may become non– -reactive in latent
syphilis or after successful treatment
False positives may occur in:–
Pregnancy•
Infectious mononucleosis•
Systemic lupus • erythematosis
Rapid Plasma • Reagin (RPR)
Alternative to VDRL–
Fluorescent Treponemal Antibody
Absorption (FTA-ABS)
• Detects specific antibodies against T pallidum
• Confirms diagnosis of syphilis– More specific than VDRL
– More sensitive in primary syphilis
• Test may remain positive for life
• Reactive: – Primary syphilis 95%
– Secondary 100%
– Late latent 100%
– Tertiary 96%
– False positives may occur in pregnancy and SLE
Syphilis
• STD caused by T pallidum / great imitator / any tissue and organ
• Sexually active / multiple partners
• Systemic Sx – Depends on stage – primary - painless ulcer /
secondary - skin rash palms, soles, trunk / tertiary - neurosyphilis
• All types of ocular inflammation
• Labs
– VDRL / RPR
– FTA – ABS
– ESR elevated
• Tx – penicillin therapy
• Good prognosis if treated early
35
So He Has an Allergy to PCN?
• Augenbraun M, Workowski K. Ceftriaxone
therapy for syphilis: report from the
emerging infections network. Clin Infect
Dis. 1999 Nov. 29(5):1337-8
– Tetracycline, erythromycin, and ceftriaxone
have shown antitreponemal activity in clinical
trial
Comanagement Pearls
• Communication is key!
• Opportunity to provide cutting edge
technology
• Importance of your recommendation
• Patient education is critical!
Comanagement Pearls
• Identify potential causes of surgical
complications
• Educate your patients your role within
medical eye care
• We are all judged by the visual outcomes
our patients. Comfort and quality of vision
is the key!
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