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48th Annual Residents’ Days

June 15-16, 2012Jose Berrocal Auditorium

Bascom Palmer Eye InstituteMiami, Florida

BASCOM PALMER EYE INSTITUTE

Sponsored by theUniversity of Miami Miller School of Medicine

Presented byBascom Palmer Eye Institute Alumni Association

Department of OphthalmologyUniversity of Miami Miller School of Medicine

Table of Contents

Upcoming Courses .............................................................................................................. 1 Accreditation Information .................................................................................................. 3 Faculty Disclosure of Relationships .................................................................................... 5 Program Faculty .................................................................................................................. 8 Schedule of Events ............................................................................................................ 11 Infectious Keratitis Progressing to Endophthalmitis: a 15-year-study of Microbiology, Risk Factors, and Clinical Outcomes Christopher R. Henry, MD ................................................................................................. 18 Endogenous Endophthalmitis Caused by Yeast: Risk Factors, Management Strategies, and Visual Acuity Outcomes Jayanth Sridhar, MD .......................................................................................................... 20 Management of Submacular Hemorrhage Secondary to Neovascular Age-related Macular Degeneration with Anti-vascular Endothelial Growth Factor Monotherapy Gary Shienbaum, MD ........................................................................................................ 22 Clinical Outcomes of Optic Pit Maculopathy Jonathan H. Tzu, MD ......................................................................................................... 24 Retinal Detachment Caused By Giant Retinal Tears: Etiologies, Techniques and Outcomes Marco A. Gonzalez, MD .................................................................................................... 26 Glaucoma Tube Associated Endophthalmitis Avnish A. Deobhakta, MD ................................................................................................. 28 Intra-ocular Lens Implantation in the Pediatric Population Hassan A. Aziz, MD ............................................................................................................ 30 Anaerobic Bacteria Causing Endophthalmitis: Spectrum, Frequency and Sensitivities Andres Emanuelli, MD ...................................................................................................... 31 Systemic Complement Inhibition with Eculizumab for the Treatment of Geographic Atrophy in AMD: The COMPLETE Study Gene W. Chen, MD ........................................................................................................... 33 A Review of Femtosecond Assisted Anterior Lamellar Keratoplasty at Bascom Palmer Jane Fishler, MD ................................................................................................................ 35

Evaluation of Optic Disc Progression in Glaucoma using Spectral Domain Optical Coherence Tomography Ben J. Harvey, MD ............................................................................................................. 37 Evolving Fluoroquinolone Resistance Among Coagulase-Negative Staphylococcus Isolates Causing Endophthalmitis Andrew M. Schimel, MD ................................................................................................... 39 Vitrectomy and Membrane Peeling In Patients with Myopic Macular Retinoschisis Jonathan S. Chang, MD ..................................................................................................... 41 Molecular Mechanisms of Blood-Retina Barrier Permeability Daniel L. Chao, MD, PhD ................................................................................................... 43 Long Term Outcomes Of Anti-Vegf Therapy For Age Related Macular Degeneration Luis J. Haddock, MD .......................................................................................................... 45 Comparison of Blood Culture Bottles and Membrane Filter System for Culturing Vitreous Specimens Aleksandra V. Rachitskaya, MD ........................................................................................ 47 Correlations between Baseline Characteristics and Disease Progression in Eyes with Non-Exudative Age-Related Macular Degeneration: The Complete Study Mathew K. George, MD .................................................................................................... 49 Natural History of Glaucoma Drainage Implants and Penetrating Keratoplasty Jessica L. Chen, MD ........................................................................................................... 52 Clinical Outcomes of Immediate vs. Delayed Pars Plana Vitrectomy for Retained Lens Fragments over a 22-Year Period Yasha S. Modi, MD ............................................................................................................ 54 Treatment of Choroidal Melanoma with Adjuvant Bevacizumab Following Plaque Brachytherapy Enhances Tumor Volume Reduction and Resolution of Exudative Detachment Samuel K. Houston III, MD ................................................................................................ 56 Comparison of Corneal Stromal Bed Quality by Scanning Electron Microscopy Using Mechanical and Femtosecond Laser Keratomes Jessica H. Chow, MD ......................................................................................................... 59 A Comparative Analysis of OCT Findings in Posterior Uveitis Ashkan M. Abbey, MD ...................................................................................................... 61

Effect of Plate Location on Initial Glaucoma Drainage Device Success Rates Amy Z. Martino, MD.......................................................................................................... 63 Preparation Techniques and Intravitreal Injections: a Clinical and Microbiological Evaluation Roger A. Goldberg, MD, MBA ........................................................................................... 65 Outcomes Following Intravitreal Injection of Aflibercept in Patients with Exudative Disease Dimple Modi, MD .............................................................................................................. 67 In Vitro Collagen Cross Linking for Acanthamoeba Keratitis Ravi D. Patel, MD, MBA ..................................................................................................... 69 Anterior Segment OCT in Eyes with Cyclodialysis after Trabectome Glaucoma Surgery Robert M. Knape, MD ....................................................................................................... 71 Ophthalmology Specific Emergency Departments Utilization Review: A Multicenter Analysis Ryan F. Isom, MD .............................................................................................................. 73 Visual Field Outcomes in the Tube vs. Trabeculectomy Study Lauren S. Blieden, MD ....................................................................................................... 75 An Animal Model of Epithelial Downgrowth Matthew J. Weiss, MD ...................................................................................................... 76 Effect of VP/LP Shunts on Visual Function in Idiopathic Intracranial Hypertension Timothy W. Winter, DO .................................................................................................... 78 Evaluation of Intracorneal Ring Segment Placement with a 200 kHz Femtosecond Laser John W. French, MD .......................................................................................................... 80 Molecular Surveillance of Contact Lenses, Cases, and Solutions for the Presence of Free-living Amoeba among Patients with Infectious Keratitis Ryan C. Young, MD ............................................................................................................ 82 Clinical Course Of Unoperated Eyes With Vitreomacular Traction Syndrome Vishak John, MD ................................................................................................................ 84 Analysis of Epiretinal Membranes Using Spectral Domain Optical Coherence Tomography

Ajay E. Kuriyan, MD, MS ................................................................................................... 86 Total Thyroidectomy for the Treatment of Severe Progressive Thyroid Eye Disease Andrea Kossler, MD .......................................................................................................... 88

Outcomes of Adjustable Suture Strabismus Surgery: 2% Lidocaine vs. 2% Lidocaine with 0.4% Ropivacaine Kara M. Cavuoto, MD ........................................................................................................ 90 Anterior Segment OCT in the Diagnosis and Treatment of Subclinical Conjunctival Intraepithelial Neoplasms (CIN) Benjamin J. Thomas, MD .................................................................................................. 92 Changes in Clinical Practice: A Survey of the American Glaucoma Society Joseph Panarelli, MD ......................................................................................................... 94 Management of Acute Severe Ocular Surface Disorders, From the Bedside to the Bench Guillermo Amescua, MD ................................................................................................... 96 Factors Affecting DSAEK Lenticule Adhesion Ana Paula Canto, MD ........................................................................................................ 98 Antifungal Sensitivities in Culture Proven Exogenous Fungal Endophthalmitis Ruwan A. Silva, MD ......................................................................................................... 100 Mycobacterial Endophthalmitis David W. Parke III, MD .................................................................................................... 102 Optic Coherence Tomography (OCT) Findings in Posterior Uveitis Secondary to Syphilis Swetangi D. Bhaleeya, MD .............................................................................................. 103 Systemic Complement Inhibition with Eculizumab for the Treatment of Drusen in AMD: The COMPLETE Study Jyoti R. Dugar, MD........................................................................................................... 105 Differentiating Papilledema and Optic Disc Drusen Using Optical Coherence Tomography Kaushal M. Kulkarni, MD ................................................................................................. 107 Predictors of Ocular Surface Squamous Neoplasia Recurrence after Excisional Surgery Fasika Woreta, MD .......................................................................................................... 109 The Effect of Pulsed Light Therapy on Meibomian Gland Dysfunction and Dry Eye Syndrome Bradford W. Lee, MD, MSc ............................................................................................. 111 Orbital Trauma and Retrobulbar Hemorrhage at Bascom Palmer and Jackson Memorial Hospital Benjamin P. Erickson, MD ............................................................................................... 113

Comparison of Postoperative Pain and Surgical Outcomes with Two Different Types of Local Anesthesia for Conjunctival Mullerectomy Chad C. Zatezalo, MD ...................................................................................................... 114

Bascom Palmer Eye Institute, Department of Continuing Medical Education Program Schedule

Academic Year 2012-2013 XXXIV Inter-American Course in Clinical Ophthalmology Date: November 18-21, 2012

Location: Intercontinental Hotel, Miami, FL

Course Directors: Eduardo C. Alfonso, MD,

Paul F. Palmberg, MD, PhD, and Victor L. Perez, MD

CME Credits: N/A

Ophthalmic Imaging 2013: Optical Coherence Tomography (OCT) Applications and Future Technology Date: December 1, 2012

Location: The Breakers Hotel, Palm Beach, FL

Course Directors: Donald L. Budenz, MD, MPH

Carmen A. Puliafito, MD, MBA

Dr. Richard K. Lee, MD, PhD

Glaucoma 2.0 Date: January 26, 2013

Location: Bascom Palmer Eye Institute

Jose Berrocal Auditorium, Miami, FL

Course Directors: Richard K. Parrish, II, MD

Jeffrey L. Goldberg, MD, PhD Angiogenesis, Exudation, and Degeneration 2013 Date: February 9, 2013

Location: Mandarin Oriental Miami, Miami, FL

Course Directors: Harry W. Flynn, Jr, MD

Philip J. Rosenfeld, MD, PhD

Carmen A. Puliafito, MD, MBA

Cataract & Refractive Surgery Congress 2013 Date: February 23, 2013



Course Directors: Sonia H. Yoo, MD

William W. Culbertson, MD

2013 Vitreoretinal Course Update Date: TBD



Course Directors: Harry W. Flynn, Jr., MD

William E. Smiddy, MD

49th Annual Residents’ Days Date: June 14-15, 2013 Location: Bascom Palmer Eye Institute


Course Directors: Patrick E. Rubsamen, MD

48th ANNUAL RESIDENTS’ DAYS June 15-16, 2012

Bascom Palmer Eye Institute Miami, FL

ACCREDITATION The University of Miami Leonard M. Miller School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing education for physicians. CREDIT DESIGNATION University of Miami Leonard M. Miller School of Medicine designates this live activity for a maximum of 10.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. LEARNING OBJECTIVES Upon completion of the course, participants will be able to:

• Compare indications and techniques for vitreoretinal surgical procedures

• Diagnose ocular infectious diseases through the use of microbiology

• Identify ocular neoplasms and other corneal conditions

• Determine appropriate use of intraocular injections

• Examine diagnostic capabilities of imaging for glaucoma and formulate treatment plans based on imaging data

DOCUMENTATION OF ATTENDANCE FOR CME

1. Complete Credit Adjustment Form. 2. Certificates of Attendance will be e-mailed to attendees approximately 4 to 6 weeks after the

conference. EVALUATIONS Conference evaluations are a valuable tool in assisting to better serve you. An e-mail with a link to the electronic evaluation form will be sent to you at the end of the program. Please complete your evaluation form on-line. We welcome your comments and suggestions. You may access the evaluation by visiting: https://www.surveymonkey.com/s/48thResidentsDay or scanning the QR code pictured here. An outcome evaluation will be conducted 2 to 3 months following the course to measure the impact this activity has had in changing performance and patient outcomes. We encourage and appreciate your participation.

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https://www.surveymonkey.com/s/48thResidentsDay�

ACKNOWLEDGEMENTS

This CME Activity is partially supported by unrestricted educational grants from:

Alcon Allergan AMO Bausch & Lomb Merck

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Bascom Palmer Eye Institute Miami, FL

The following speakers and planners have indicated that they do not have relevant financial interests with commercial interests:

• Ashkan M. Abbey, MD

• Eduardo C. Alfonso, MD

• Guillermo Amescua, MD

• Hassan A. Aziz, MD

• James T. Banta, MD

• Swetangi D. Bhaleeya, MD

• Lauren S. Blieden, MD

• Ana Paula Canto, MD

• Kara M. Cavuoto, MD

• Jonathan S. Chang, MD

• Daniel L. Chao, MD, PhD

• Gene W. Chen, MD

• Jessica L. Chen, MD

• Jessica H. Chow, MD

• Avnish A. Deobhakta, MD

• Jyoti R. Dugar, MD

• Andres Emanuelli, MD

• Benjamin P. Erickson, MD

• Jane Fishler, MD

• John W. French, MD

• Steven J. Gedde, MD

• Mathew K. George, MD

• Roger A. Goldberg, MD, MBA

• Marco A. Gonzalez, MD

• Luis J. Haddock, MD

• Ben J. Harvey, MD

• Christopher R. Henry, MD

• Samuel K. Houston III, MD

• Carol L. Karp, MD

• Ryan F. Isom, MD

• Vishak J. John, MD

• Robert M. Knape, MD

• Kaushal M. Kulkarni, MD

• Ajay E. Kuriyan, MD

• Bradford W. Lee, MD

• Andrea Lora Kossler, MD

• Amy Z. Martino, MD

• Dimple Modi, MD

• Yasha S. Modi, MD

• Joseph Panarelli, MD

• David W. Parke III, MD

• Ravi D. Patel, MD

• Aleksandra V. Rachitskaya, MD

• Patrick E. Rubsamen, MD

• Andrew M. Schimel, MD

• Gary Shienbaum, MD

• Ruwan A. Silva, MD

• Jayanth Sridhar, MD

• Benjamin J. Thomas, MD

• Jonathan H. Tzu, MD

• Matthew J. Weiss, MD

• Timothy W. Winter, DO

• Fasika Woreta, MD

• Ryan C. Young, MD

• Chad C. Zatezalo, MD

The following speakers and planners have indicated relevant financial relationships with the following commercial interests:

Speaker Name Name(s) of Commercial Interest(s)/

Financial Relationship

Richard K. Lee, MD, PhD American Glaucoma Society: Grants/Research Support Merck: Consultant; Speaker’s Bureau

Philip J. Rosenfeld, MD, PhD

Acucela: Consultant Advanced Cell Technology: Grants/Research Support Alexion: Grants/Research Support Boehringer Ingelheim ThromboGenics: Advisory Board/Panel Carl Zeiss Meditec: Grants/Research Support, Lecture Fee Cheengdu Kanghong Biotech: Consultant GlaxoSmithKline: Grants/Research Support Oraya: Consultant Sucampo: Advisory Board/Panel

Sonia H. Yoo, MD Alcon: Consultant


Course Director

Patrick E. Rubsamen, MD Retina Group of Florida Boca Raton, Florida

Bascom Palmer Eye Institute Faculty Eduardo C. Alfonso, MD Professor and Chairman, Department of Ophthalmology James T. Banta, MD Associate Professor of Clinical Ophthalmology Steven J. Gedde, MD Professor of Ophthalmology Carol L. Karp, MD Professor of Clinical Ophthalmology Richard K. Lee, MD Associate Professor of Ophthalmology Philip J. Rosenfeld, MD, PhD Professor of Ophthalmology Sonia H. Yoo, MD Professor of Ophthalmology

Bascom Palmer Eye Institute Residents FIRST YEAR Hassan A. Aziz, MD Daniel L. Chao, MD, PhD Benjamin P. Erickson, MD Ajay E. Kuriyan, MD, MS Yasha S. Modi, MD Jayanth Sridhar, MD Ryan C. Young, MD

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SECOND YEAR Ashkan M. Abbey, MD Marco A. Gonzalez, MD Christopher R. Henry, MD Samuel K. Houston III, MD Bradford W. Lee, MD Benjamin J. Thomas, MD Jonathan H. Tzu, MD THIRD YEAR Jonathan S. Chang, MD Avnish A. Deobhakta, MD Roger A. Goldberg, MD, MBA Luis J. Haddock, MD Aleksandra V. Rachitskaya, MD Ruwan A. Silva, MD Matthew J. Weiss, MD CHIEF RESIDENTS Thomas S. Shane, MD Anita R. Shirodkar, MD

Bascom Palmer Eye Institute Fellows Guillermo Amescua, MD (Cornea) Swetangi D. Bhaleeya, MD (Uveitis) Lauren S. Blieden, MD (Glaucoma) Ana Paula Canto, MD (International Cornea) Kara M. Cavuoto, MD (Pediatrics) Gene W. Chen, MD (Medical Retina) Jessica L. Chen, MD (Glaucoma) Jessica H. Chow, MD (Cornea) Andres Emanuelli, MD (Retina) Jane Fishler, MD (Cornea) John W. French, MD (Cornea) Mathew K. George, MD (Medical Retina) Ben J. Harvey, MD (Glaucoma) Vishak John, MD (Retina) Robert M. Knape, MD (Glaucoma) Andrea Kossler, MD (Oculoplastics) Kaushal M. Kulkarni, MD (Neuro-ophthalmology) Amy Z. Martino, MD (Glaucoma) Dimple Modi, MD (Medical Retina) Joseph Panarelli, MD (Glaucoma)

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David W. Parke III, MD (Retina) Ravi D. Patel, MD (Cornea) Andrew M. Schimel, MD (Retina) Gary Shienbaum, MD (Retina) Timothy W. Winter, DO (Neuro-ophthalmology) Fasika Woreta, MD (Cornea) Chad C. Zatezalo, MD (Oculoplastics)

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48th Annual Residents’ Days

June 15-16, 2012 Bascom Palmer Eye Institute

Miami, FL Friday, June 15, 2012 (Subject to change) 7:30 am Registration and Continental Breakfast 8:00 Introduction/Welcome Eduardo C. Alfonso, MD and Patrick E. Rubsamen, MD Session I Moderator: Phillip J. Rosenfeld, MD, PhD Discussion will follow each presentation 8:10 Infectious Keratitis Progressing to Endophthalmitis: a 15-year-study of

Microbiology, Risk Factors, and Clinical Outcomes Christopher R. Henry, MD 8:22 Endogenous Endophthalmitis Caused by Yeast: Risk Factors, Management

Strategies, and Visual Acuity Outcomes Jayanth Sridhar, MD 8:34 Management of Submacular Hemorrhage Secondary to Neovascular Age-related

Macular Degeneration with Anti-vascular Endothelial Growth Factor Monotherapy

Gary Shienbaum, MD 8:46 Clinical Outcomes of Optic Pit Maculopathy Jonathan H. Tzu, MD 8:58 Retinal Detachment Caused By Giant Retinal Tears: Etiologies, Techniques and

Outcomes Marco A. Gonzalez, MD

9:10 Glaucoma Tube Associated Endophthalmitis Avnish A. Deobhakta, MD 9:22 Intra-ocular Lens Implantation in the Pediatric Population Hassan A. Aziz, MD 9:34 Anaerobic Bacteria Causing Endophthalmitis: Spectrum, Frequency and

Sensitivities Andres Emanuelli, MD 9:46 Systemic Complement Inhibition with Eculizumab for the Treatment of

Geographic Atrophy in AMD: The COMPLETE Study Gene W. Chen, MD 9:58 Break Session II Moderator: James T. Banta, MD Discussion will follow each presentation 10:20 A Review of Femtosecond Assisted Anterior Lamellar Keratoplasty at Bascom

Palmer Jane Fishler, MD 10:32 Evaluation of Optic Disc Progression in Glaucoma using Spectral Domain Optical

Coherence Tomography Ben J. Harvey, MD 10:44 Evolving Fluoroquinolone Resistance Among Coagulase-Negative Staphylococcus

Isolates Causing Endophthalmitis Andrew M. Schimel, MD 10:56 Vitrectomy and Membrane Peeling In Patients with Myopic Macular

Retinoschisis Jonathan S. Chang, MD 11:08 Molecular Mechanisms of Blood-Retina Barrier Permeability Daniel L. Chao, MD, PhD 11:20 Long Term Outcomes Of Anti-Vegf Therapy For Age Related Macular

Degeneration Luis J. Haddock, MD

11:32 Comparison of Blood Culture Bottles and Membrane Filter System for Culturing

Vitreous Specimens Aleksandra V. Rachitskaya, MD 11:44 Correlations between Baseline Characteristics and Disease Progression In Eyes

with Non-Exudative Age-Related Macular Degeneration: The Complete Study Mathew K. George, MD 11:56 Lunch Session III Moderator: Carol L. Karp, MD Discussion will follow each presentation 1:00 pm Natural History of Glaucoma Drainage Implants and Penetrating Keratoplasty Jessica L. Chen, MD 1:12 Clinical Outcomes of Immediate vs. Delayed Pars Plana Vitrectomy for Retained

Lens Fragments over a 22-Year Period Yasha S. Modi, MD 1:24 Treatment of Choroidal Melanoma with Adjuvant Bevacizumab Following Plaque

Brachytherapy Enhances Tumor Volume Reduction and Resolution of Exudative Detachment

Samuel K. Houston III, MD 1:36 Comparison of Corneal Stromal Bed Quality by Scanning Electron Microscopy

Using Mechanical and Femtosecond Laser Keratomes Jessica H. Chow, MD 1:48 A Comparative Analysis of OCT Findings in Posterior Uveitis Ashkan M. Abbey, MD 2:00 Effect of Plate Location on Initial Glaucoma Drainage Device Success Rates Amy Z. Martino, MD 2:12 Preparation Techniques and Intravitreal Injections: a Clinical and Microbiological

Evaluation Roger A. Goldberg, MD, MBA 2:24 Outcomes Following Intravitreal Injection of Aflibercept in Patients with

Exudative Disease Dimple Modi, MD

2:36 In Vitro Collagen Cross Linking for Acanthamoeba Keratitis Ravi D. Patel, MD, MBA 2:48 Break Session IV Moderator: Sonia H. Yoo, MD Discussion will follow each presentation 3:08 Anterior Segment OCT in Eyes with Cyclodialysis after Trabectome Glaucoma

Surgery Robert M. Knape, MD 3:20 Ophthalmology Specific Emergency Departments Utilization Review: A

Multicenter Analysis Ryan F. Isom, MD 3:32 Visual Field Outcomes in the Tube vs. Trabeculectomy Study Lauren S. Blieden, MD 3:44 An Animal Model of Epithelial Downgrowth Matthew J. Weiss, MD 3:56 Effect of VP/LP Shunts on Visual Function in Idiopathic Intracranial Hypertension Timothy W. Winter, DO 4:08 Evaluation of Intracorneal Ring Segment Placement with a 200 kHz Femtosecond

Laser John W. French, MD 4:20 Molecular Surveillance of Contact Lenses, Cases, and Solutions for the Presence

of Free-living Amoeba among Patients with Infectious Keratitis Ryan C. Young, MD 4:32 Clinical Course Of Unoperated Eyes With Vitreomacular Traction Syndrome Vishak John, MD 4:44 Adjourn

Saturday, June 16, 2012 7:30 am Registration and Continental Breakfast 8:00 Introduction/Welcome Eduardo C. Alfonso, MD and Patrick E. Rubsamen, MD Session I Moderator: Richard K. Lee, MD, PhD Discussion will follow each presentation 8:10 Analysis of Epiretinal Membranes Using Spectral Domain Optical Coherence

Tomography Ajay E. Kuriyan, MD, MS 8:22 Total Thyroidectomy for the Treatment of Severe Progressive Thyroid Eye

Disease Andrea Kossler, MD 8:34 Outcomes of Adjustable Suture Strabismus Surgery: 2% Lidocaine vs. 2%

Lidocaine with 0.4% Ropivacaine Kara M. Cavuoto, MD 8:46 Anterior Segment OCT in the Diagnosis and Treatment of Subclinical Conjunctival

Intraepithelial Neoplasms (CIN) Benjamin J. Thomas, MD 8:58 Changes in Clinical Practice: A Survey of the American Glaucoma Society Joseph Panarelli, MD 9:10 Management of Acute Severe Ocular Surface Disorders, From the Bedside to the

Bench

Guillermo Amescua, MD 9:22 Factors Affecting DSAEK Lenticule Adhesion Ana Paula Canto, MD 9:34 Antifungal Sensitivities in Culture Proven Exogenous Fungal Endophthalmitis Ruwan A. Silva, MD 9:46 Break

Session II Moderator: Steven J. Gedde, MD Discussion will follow each presentation 10:00 Mycobacterial Endophthalmitis David W. Parke III, MD 10:12 Optic Coherence Tomography (OCT) Findings in Posterior Uveitis Secondary to

Syphilis Swetangi D. Bhaleeya, MD 10:24 Systemic Complement Inhibition with Eculizumab for the Treatment of Drusen in

AMD: The COMPLETE Study Jyoti R. Dugar, MD 10:36 Differentiating Papilledema and Optic Disc Drusen Using Optical Coherence

Tomography Kaushal M. Kulkarni, MD 10:48 Predictors of Ocular Surface Squamous Neoplasia Recurrence after Excisional

Surgery Fasika Woreta, MD 11:00 The Effect of Pulsed Light Therapy on Meibomian Gland Dysfunction and Dry Eye

Syndrome Bradford W. Lee, MD, MSc 11:12 Orbital Trauma and Retrobulbar Hemorrhage at Bascom Palmer and Jackson

Memorial Hospital Benjamin P. Erickson, MD 11:24 Comparison of Postoperative Pain and Surgical Outcomes with Two Different

Types of Local Anesthesia for Conjunctival Mullerectomy Chad C. Zatezalo, MD 11:36 Best of Grand Rounds 12:00 pm Adjourn 12:05 BPEI ALUMNI ASSOCIATION BUSINESS MEETING 7:00 COCKTAILS /DINNER RITZ CARLTON, COCONUT GROVE

PRESENTATIONS

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Bascom Palmer Eye Institute Residents’ Days 2012 Resident, Fellow, and Alumni Research Presentations June 15-16, 2012

Infectious Keratitis Progressing To Endophthalmitis: A 15-Year-Study Of Microbiology, Associated Factors, And Clinical Outcomes

Christopher R. Henry, MD Primary Supervisor: Harry W. Flynn Jr., MD Co-Authors: Darlene Miller DHSc, Richard K. Forster MD, Eduardo C. Alfonso MD

Purpose: To describe the incidence, microbiology, associated factors and clinical outcomes of patients with infectious keratitis progressing to endophthalmitis. Methods: Non-randomized, retrospective, consecutive case series. Ocular microbiology and medical records were reviewed on all patients with positive corneal and intraocular cultures between January 1, 1995 and December 31, 2009 at the Bascom Palmer Eye Institute. Results: A total of 9934 corneal cultures were performed for suspected infectious keratitis. Only 49 eyes (0.5%) progressed to culture-proven endophthalmitis. Fungi (n=26) were the most common responsible organism followed by gram positive bacteria (n=13) and gram negative bacteria (n=10). Topical steroid use (37/49[76%]) was the most common associated factor identified in the current study, followed by previous surgery (30/49[61%]), corneal perforation (17/49[35%]), dry eye (15/49[31%]), relative immune compromise (10/49[20%]), organic matter trauma (9/49[18%]) and contact lens wear (3/49[6%]). There were 27 patients in which a primary infectious keratitis developed into endophthalmitis, and 22 patients in which an infectious keratitis adjacent to a previous surgical wound progressed into endophthalmitis. Patients in the primary keratitis group were more likely to be male (22/27[81%] vs. 8/22[36%], p=0.001), have history of organic matter trauma (8/27[30%] vs. 1/22[5%]), p=0.030), and have fungal etiology (21/27[78%] vs. 5/22[23%], p<0.001). Patients in the surgical-wound-associated group were more likely to use topical steroids (20/22[91%] vs.

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17/27[63%], p=0.024). Visual acuity of ≥20/50 was achieved in 7/49[14%] patients, but was <5/200 in 34/49[69%] patients at last follow up. Enucleation was performed in 15/49[31%] patients. Conclusion: Progression of infectious keratitis to endophthalmitis is relatively uncommon. The current study suggests that patients at higher risk for progression to endophthalmitis include patients using topical corticosteroids, patients with fungal keratitis, patients with corneal perforation, and patients with infectious keratitis developing adjacent to a previous surgical wound. Patients with sequential keratitis and endophthalmitis have generally poor visual outcomes. References: 1. Scott IU, Flynn HW Jr, Feuer W, et al. Endophthalmitis associated with microbial keratitis. Ophthalmology 1996;103:1864-70. 2. Wykoff CC, Flynn HW Jr, Miller D, et al. Exogenous fungal endophthalmitis: microbiology and clinical outcomes. Ophthalmology 2008;115:1501-7. 3 .Pflugfelder SC, Flynn HW Jr, Zwickey TA, et al. Exogenous fungal endophthalmitis. Ophthalmology 1988;95:19-30. 4. Dursun D, Fernandez V, Miller D, Alfonso EC. Advanced fusarium keratitis progressing to endophthalmitis. Cornea 2003;22:300-3.

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Endogenous Endophthalmitis Caused By Yeast: Risk Factors, Management Strategies, and Visual Acuity Outcomes

Jayanth S. Sridhar, MD Primary Supervisor: Harry W. Flynn Jr., MD Co-Authors: Darlene Miller DHSc, MPH, CIC, Thomas A. Albini, MD

Purpose: To report the risk factors, management strategies, and visual outcomes in patients with culture-proven endogenous endophthalmitis caused by yeast. Methods: A non-randomized consecutive case series of all patients with culture-proven unilateral or bilateral endogenous endophthalmitis caused by yeast at the Bascom Palmer Eye Institute between January 1, 1990 and December 31st, 2006. Results: Study criteria were met in 50 eyes of 38 patients. Patients had a mean follow-up of 16.7 months from presentation to last follow-up visit. Decreased vision was the most common presenting symptom (74.3%) followed by redness (46.1%) and pain (38.5%). 65.8% of patients had a current or recent (< 6 months) hospitalization at the time of diagnosis. Recent surgery was the most common identified risk factor (31.6%) followed by cancer (23.7%). None of the patients were diagnosed on routine screening for fungemia. Diffuse anterior and posterior inflammation was the most common finding on examination of affected eyes (64.7%) followed by focal posterior inflammation (23.5%). Hypopyon was noted in only 5.8% of affected eyes. Initial treatment consisted of a combination of medical and surgical treatment in 33.3% of eyes. 37.2% of eyes received medical treatment consisting of systemic antifungal therapy, intravitreal injection of antifungals, or both. 43.1% of eyes underwent vitrectomy with or without lensectomy, with or without intravitreal injection. The most common organism cultured by vitreous aspirate or vitrectomy specimen was Candida albicans (87.2%) followed by Candida tropicalis (7.7%) and Cryptococcus neoformans (5.1%). Blood cultures were positive in 17.9% of patients.

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Visual acuity on presentation was 20/200 or better in 41.3% of eyes. Visual acuity of 20/200 or better was present in 61.3% of eyes at last follow-up. Retinal detachment occurred in 29.4% of eyes. Conclusion: In this study of endogenous endophthalmitis caused by yeast, Candida albicans was the predominant etiology. Decreased vision was the most common presenting symptom. Endogenous endophthalmitis is associated with poor visual acuity outcomes despite early and appropriate management. Retinal detachment is a frequent event in the clinical course. References: Lingappan A, Wykoff CC, Albini TA, Miller D, Pathengay A, Davis JL, Flynn HW Jr. Endogenous fungal endophthalmitis: causative organisms, management strategies, and visual acuity outcomes. Am J Ophthalmol. 2012 Jan;153(1):162-6.e1. Epub 2011 Sep 13. Sallam A, Taylor SR, Khan A, McCluskey P, Lynn WA, Manku K, Pacheco PA, Lightman S. Factors determining visual outcome in endogenous Candida endophthalmitis. Retina. 2012 Jun;32(6):1129-34. Wykoff CC, Flynn HW Jr, Miller D, Scott IU, Alfonso EC. Exogenous fungal endophthalmitis: microbiology and clinical outcomes. Ophthalmology. 2008 Sep;115(9):1501-7, 1507.e1-2. Epub 2008 May 16.

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Management Of Submacular Hemorrhage Secondary To Neovascular Age-Related Macular Degeneration With Anti-Vascular Endothelial Growth Factor Monotherapy

Gary Shienbaum, MD Primary Supervisor: Harry W. Flynn Jr., MD Co-Authors: Carlos Alexandre De A. Garcia Filho, MD, Philip J. Rosenfeld, MD, PhD

Purpose: To report the visual and anatomic outcomes of anti-vascular endothelial growth factor (VEGF) monotherapy in the management of significant submacular hemorrhage secondary to neovascular age-related macular degeneration (AMD). Methods: Retrospective, interventional, consecutive case series. Thirteen eyes of 12 patients with neovascular AMD and fovea involving submacular hemorrhage comprising greater than 50% of the lesion area were evaluated. Treatment consisted of multiple injections of ranibizumab (9 eyes) or bevacizumab (4 eyes). Main outcome measures included mean visual acuity change from baseline, mean central lesion thickness change from baseline, mean number of injections at 6 months, and adverse events. Central lesion thickness was measured to be the distance from the internal limiting membrane to Bruchs membrane at the center of the fovea on spectral-domain optical coherence tomography (SD-OCT) images. Snellen visual acuity was converted to approximate ETDRS letter score for the purpose of statistical analysis. Results: The mean follow-up period was 9.3 months. The mean change in approximate ETDRS letter score from baseline was +12.2 letters at 3 months (P = 0.01), +23.3 letters at 6 months (P = 0.002), and +19.3 letters at 12 months follow-up (P = 0.04). The mean number of injections at 6 months was 4.7. The mean OCT central lesion thickness decreased from 766 μm to 332 μm at 6 months (P = 0.02).

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Conclusion: Eyes with submacular hemorrhage secondary to neovascular AMD may experience significant visual improvements when managed with anti-VEGF monotherapy. References: 1. Rosenfeld PJ, Brown DM, Heier JS, et al. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med 2006;355(14):1419-31. 2. Brown DM, Kaiser PK, Michels M, et al. Ranibizumab versus verteporfin for neovascular age-related macular degeneration. N Engl J Med 2006;355(14):1432-44. 3. Fine HF, Iranmanesh R, Del Priore LV, et al. Surgical outcomes after massive subretinal hemorrhage secondary to age-related macular degeneration. Retina 2010;30(10):1588-94. 4. Chang MA, Do DV, Bressler SB, Cassard SD, Gower EW, Bressler NM. Prospective one-year study of ranibizumab for predominantly hemorrhagic choroidal neovascular lesions in age-related macular degeneration. Retina 2010;30(8):1171-6. 5. Todorich B, Scott IU, Flynn HW, Johnson MW. Strategies in the management of submacular hemorrhage associated with choroidal neovascularization in the anti–vascular endothelial growth factor era. Retina 2011;31:1749-52.

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Clinical Outcomes of Optic Pit Maculopathy

Jonathan H. Tzu, MD Primary Supervisor: Harry W. Flynn, Jr., MD Co-Authors:

Purpose: To evaluate a series of patients with optic disc pit maculopathy in terms of their clinical characteristics including SD-OCT, clinical courses, and outcome of treatment if given. Methods: Retrospective review Inclusion criteria : diagnosis of optic disc pit at Bascom Palmer Eye Institute seen between the years 2001 and 2012. Exclusion criteria: 1) no OCT imaging 2)only one clinic visit with no follow up Two main groups: 1) patients with optic pit maculopathy that were observed without surgery, and 2) patients with optic pit maculopathy that received surgical intervention. Results: N = 27 Mean Age (years) 36.4 Mean on presentation (years) 27.3 Gender M = male, F = female M = 10 F = 13 Laterality RE = Right eye LE = Left eye RE = 11 LE = 16

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Bilateral (patients) 4/23 Location of pit Superotemporal = 1/27 Temporal = 12/27 Inferotemporal = 12/27 Inferior = 2/27 Macula involvement 20/27 (78%) Median follow up (months) 17.5 Observed patients: N=7 Visual acuity on presentation >20/200 – 3/7 20/200 or worse – 4/7 Final visual acuity >20/200 – 3/7 20/200 or worse – 4/7 Length of follow up Median = 16 Surgery patients: N= 10 (8 operated, 2 laser only) Visual acuity on presentation >20/200 – 6/10 20/200 or worse – 4/10 Final visual acuity >20/200 – 4/10 20/200 or worse – 6/10 Length of follow up Median = 19.5 months Conclusion: In the current study, patients with better than 20/200 initial visual acuity were often observed and remained stable during follow up. Surgical intervention in eyes with progressive or sustained visual loss had variable outcomes, with persistent intraretinal/subretinal fluid being a common occurrence. References: 1) Sugar HS. Congenital pits of the optic disc and their equivalents (congenital colobomas and colobomalike excavations) associated with submacular fluid. Am J Ophthalmol 1967;63:298-307. 2) Lincoff H, Lopez R, Kreissig I, Yannuzzi L, Cox M, Burton T. Retinoschisis associated with optic nerve pits. Arch Ophthalmol 1988;106:6-67. 3) Hirakata A, Okada AA, Hida T. Long-term results of vitrectomy without laser treatment for macular detachment associated with an optic disc pit. Ophthalmology 2005;112(8):1430-1435. 4) Lalwani GA, Punjabi OS, Flynn HW Jr, Knighton RW, Puliafito CA. Documentation optic nerve pit with macular schisis-like cavity by spectral domain OCT. Ophthalmic Surg Lasers Imaging 2007;38(3):262-264. 5) Imamura Y, Zweifel SA, Fujiwara T, Freund KB, Spaide RF. High-resolution optical coherence tomography findings in optic pit maculopathy. Retina 2010;30(7):1104-1112.

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Retinal Detachment Caused By Giant Retinal Tears: Techniques And Outcomes

Marco A. Gonzalez, MD Primary Supervisor: Harry W. Flynn, MD Co-Authors: William E. Smiddy, MD, Timothy G. Murray, MD, MBA, FACS, Thomas A. Albini, MD

Purpose: To evaluate surgical techniques and outcomes for patients with giant retinal tears (GRT) undergoing surgery. Methods: A non-comparative consecutive case series between 2005 and 2011. Results: With a mean follow-up of 16.1 months, 95 eyes of 95 patients were identified. Trauma (29.5%) was a common etiology. All patients underwent vitrectomy with gas or oil tamponade. 82.1% underwent scleral buckle. 62.1% had perfluorocarbon liquid use during surgery. 15.8% underwent re-operation for recurrence. 96% achieved anatomic success at last follow-up. Visual acuity outcomes were ≥ 20/200 in 81% (<4 clock hours) and 50% (≥4 clock hours). Conclusion: GRT patients undergoing surgery achieved high rates of anatomic success but visual outcomes were variable. Better visual outcomes were associated with smaller GRTs. References: Ang GS, Townend J, Noemi L. Epidemiology of Giant Retinal Tears in the United Kingdom: The British Giant Retinal Tear Epidemiology Eye Study (BGEES). Investigative Ophthalmology & Visual Science, September 2010, Vol. 51, No. 9

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Scott IU, Murray TG, Flynn HW Jr, Feuer WJ, Schiffman JC. Outcomes and complications associated with giant retinal tear management using perfluoro-n-octane. Ophthalmology. 2002;109:1828 –1833. Sirimaharaj M, Balachandran C, Chan WC, et al. Vitrectomy with short term postoperative tamponade using perfluorocarbon liquid for giant retinal tears. Br J Ophthalmol. 2005;89:1176–1179. Al-Khairi AM, Al-Kahtani E, Kangave D, Abu El-Asrar AM. Prognostic factors associated with outcomes after giant retinal tear management using perfluorocarbon liquids. Eur J Ophthalmol. 2008;18:270–277. Lee SY, Ong SG, Wong DW, Ang CL. Giant retinal tear management: an Asian experience. Eye. 2009;23(3):601– 605.

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Glaucoma Tube Associated Endophthalmitis

Avnish A. Deobhakta, MD Primary Supervisor: Harry W. Flynn Jr., MD Co-Authors: Michael R. Banitt, MD, MHA, Thomas A. Albini, MD, William E. Smiddy, MD

Purpose: To identify the risk factors, pathogens, treatment modalities, and subsequent clinical outcomes of patients with Glaucoma tube associated Endophthalmitis. Methods: A retrospective case series was done using the medical records of all patients at the Bascom Palmer Eye Institute diagnosed with endophthalmitis associated with a Glaucoma tube shunt between January 1, 1999 and July 31, 2011. Patients with culture-positive endophthalmitis were included in the study. Symptoms and signs at the time of diagnosis of endophthalmitis were documented. Diagnostic paracenteses of the vitreous was performed in all patients, and culture results were collected. The treatment regimen and clinical course were reviewed for all patients. Results: 9 patients were identified with endophthalmitis. The average time elapsed from tube placement to endophthalmitis was 20 months with a range of 1 week to 4 years. Median pre-infection visual acuity was 20/100 with a range of 20/50 to HM. Median post-infection visual acuity was 20/400 with a range of 20/60 to NLP. Average loss of vision was 3.4 lines, with one patient progressing to LP and two patients to NLP. 7 of 9 culture positive infections were of gram positive origin, a majority of which were Staphylococcus sp. One patient tested positive for atypical Mycobacerium. 3 of 7 patients had gram negative growth, two with Serratia marcescens and one with Proteus mirabilis. 5 of 9 patients had tube exposure. 2 patients required evisceration. 3 patients required tube removal. Conclusion: Glaucoma tube associated endophthalmitis is a rare and devastating event associated with severe vision loss. Gram positive organisms such as Staphylococcus sp.

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are often implicated, with a minority being caused by rare gram negative pathogens. In a majority of patients, graft erosion of the tube occurs and tube explantation or evisceration is necessary. References: 1. Al-Torbak AA, Al-Shahwan S, Al-Jadaan I, Al-Hommadi A, Edward DP. Endophthalmitis associated with the Ahmed glaucoma valve implant. Br J Ophthalmol. 2005 Apr;89(4):454-8. 2 Gedde SJ, Scott IU, Tabandeh H, Luu KK, Budenz DL, Greenfield DS, Flynn HW Jr. Late endophthalmitis associated with glaucoma drainage implants. Ophthalmology. 2001 Jul;108(7):1323-7. 3. Krebs DB, Liebmann JM, Ritch R, et al. Late infectious endophthalmitis from exposed glaucoma setons [case report]. Arch Ophthalmol 1992;110:174–5. 4. Al-Torbaq A, Edward DP. Delayed endophthalmitis in a child following an Ahmed Glaucoma Valve Implant. JAAPOS 2002;6:123–125. 5. Francis BA, Diloreto DA, Chong LP, et al. Late onset bacterial endophthalmitis following glaucoma drainage implantation. Ophthalmol Surg Lasers Imaging2003;34:128–30. .

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Intra-Ocular Lens Implantation In The Pediatric Population

Hassan A. Aziz, MD Primary Supervisor: Audina M. Berrocal, MD Co-Authors: Nikisha Kothari, MS; James T. Banta, MD; Kara M. Cavuoto, MD

Purpose: One of the most common pediatric intraocular surgeries throughout the world is cataract surgery. The surgery is not without risks, especially in such a young population. Our study will examine the clinical outcomes and rates of complicaitons in children (age birth to 9 yaers old) undergoing cataract surgery from year 2000-2009 at Bascom Palmer Eye Institute. Methods: An IRB-approved, consecutive retrospective case series. Records of Bascom Palmer Eye Institute were reviewed to identify pediatric cataract surgeries who underwent treatment by our faculty between 2000 and 2009. Results: To be presented. Conclusion: To be presented. References: To be presented.

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Anaerobic Bacteria Causing Endophthalmitis: Spectrum, Frequency And Sensitivities

Andrés Emanuelli, MD Primary Supervisor: Harry W. Flynn, MD Co-Authors: Darlene Miller, DHSc

Purpose: To report the spectrum, frequency and sensitivities of anaerobic bacteria causing endophthalmitis over the last 20 years. Methods: From the Microbiology Laboratory Department records, all anaerobic bacterial cases of endophthalmitis were reviewed between January 1, 1991 and September 30, 2011. All the vitreous isolates were tested for vancomycin, ceftazidime, gatifloxacin and moxifloxacin sensitivities at high and low dose. Results: Anaerobic bacteria accounted for 115 of 1386 (8.3%) in vitreous culture-positive endophthalmitis isolates from 1991 to 2011. The most common bacteria for the isolates was Propionibacterium acnes (89.4%). Other etiologies included, Bacteroides species (5.3%), Peptostreptococcus species (2.6%), Propionibacterium granulosum (0.9%), Propionibacterium avidum (0.9%), and Clostridum subterminale (0.9%). The sensitivities were as follows: 92% of the isolates were sensitive to vancomycin (222 µg/ml & 22 µg/ml), 66.7% were sensitive to high dose ceftazidime (5 µg/ml) and 33.3% were sensitives to low dose ceftazidime (0.5 µg/ml). The sensitivities to fluoroquinolones, was as follows: 41.7% of the isolates were sensitive to high dose moxifloxacin (1.1 mg/ml), 25% were sensitive to low dose moxifloxacin (0.11 mg/ml), 50% of the isolates were sensitive to high dose gatifloxacin (0.67 mg/ml), and 8.3% were sensitive to low dose gatifloxacin (0.07 mg/ml).

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Conclusion: In the current study, anaerobic bacteria account for less than 10% of culture positive endophthalmitis. The most common etiology was Propionibacterium acnes. Regarding the sensitivities, vancomycin was the most effective antibiotic against anaerobes pathogens. The fluoroquinolones had a variable effect in the high dose group, but were not generally effective in the low dose group. References: 1. Shirodkar AR, Pathengay A, Flynn HW Jr, et al. Delayed – versus cute-onset endophthalmitis after cataract surgery. Am J Ophthalmol. 2012 Mar;153 (3) :391-398..e2 2. Clark WL, Kaiser PK, Flynn HW Jr, et al. Treatment strategies and visual acuity outcomes in chronic postoperative Propionibacterium acnes endophthalmitis. Ophthalmology. 1999 Sep;106(9):1665-70 3. Fox GM, Joondeph BC, Flynn HW Jr, et al. Delayed-onset pseudophakic endophthalmitis. Am J Ophthalmol. 1991 Feb 15;111(2):163-73

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Systemic Complement Inhibition with Eculizumab for the Treatment of Geographic Atrophy in AMD: The COMPLETE Study

Gene W. Chen, MD Primary Supervisor: Philip J. Rosenfeld, MD, PhD Co-Authors: Zohar Yehoshua; Carlos Alexandre de Amorim Garcia Filho; Renata Portella Nunes MD; Dimple Modi; Jyoti R. Dugar; Mathew K. George; Ying Li; William Feuer; Fernando M. Penha; SriniVas Sadda; Kang Zhang; Giovanni Gregori; Andrew A. Moshfeghi; Philip J. Rosenfeld

Purpose: The COMPLement Inhibition with Eculizumab for the Treatment of Non-Exudative Age-Related Macular Degeneration (COMPLETE) Study was designed to prospectively evaluate the effect of eculizumab, an FDA-approved systemic inhibitor of complement component 5 (C5), on the growth rate of geographic atrophy (GA) in eyes of patients with non-exudative age-related macular degeneration (AMD). Methods: Patients with GA measuring at least 1.26 mm2, but no larger than 17 mm2, were randomized 2:1 to receive intravenous eculizumab or saline. The first 10 patients randomized to active treatment received 600 mg eculizumab for 4 weeks followed by 900 mg every 2 weeks until week 26, while the next 10 patients received 900 mg eculizumab for 4 weeks followed by 1200 mg every two weeks until week 26. After 26 weeks, patients were followed without treatment every 3 months for an additional 6 months. Ophthalmologic exam, normal and low luminance ETDRS visual acuity testing, and imaging studies were performed at baseline and at months 3, 6, 9, and 12. GA was studied using multiple imaging modalities. All patients were genotyped for the major AMD risk alleles. The primary endpoint was the change in area of GA at 6 months. Results: Thirty study eyes of 30 patients were enrolled and randomized 1:1:1 to the low dose, high dose, and placebo groups. At baseline, the mean areas of GA (SD) measured by SDOCT were 7.3 mm2 (4.8) and 4.7 (3.6) mm2 for the eculizumab and placebo groups, respectively (p=0.13). Baseline mean ETDRS visual acuity scores (SD) were 71.3 (7.8) and

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78.6 (5.2) letters for the eculizumab and placebo groups respectively, (p=0.01). Low and high dose eculizumab groups had similar areas of GA (p=0.44), but the high dose patients read 7 fewer letters (p=0.040). At baseline the mean low luminance visual acuity scores (SD) were48.1 (15.4) and 56.1 (11.7) letters for the eculizumab and placebo groups respectively, (p=0.16). In addition, 19 fellow eyes were found to meet entry criteria and will be evaluated as a secondary endpoint. All patients completed the infusions through 26 weeks and no drug-related adverse events were identified. Conclusion: Systemic complement inhibition with the FDA-approved C5 inhibitor known as eculizumab was well tolerated through 6 months. The outcome data describing the effect of eculizumab on the growth rates of GA will be presented. References: 1. Gregori, G., F. Wang, et al. (2011). "Spectral domain optical coherence tomography imaging of drusen in nonexudative age-related macular degeneration." Ophthalmology 118(7): 1373-1379. 2. Yehoshua, Z., F. Wang, et al. (2011). "Natural history of drusen morphology in age-related macular degeneration using spectral domain optical coherence tomography." Ophthalmology 118(12): 2434-2441. 3. Yehoshua, Z., P. J. Rosenfeld, et al. (2011). "Progression of geographic atrophy in age-related macular degeneration imaged with spectral domain optical coherence tomography." Ophthalmology 118(4): 679-686. 4. Sunness, J. S., G. S. Rubin, et al. (2008). "Low luminance visual dysfunction as a predictor of subsequent visual acuity loss from geographic atrophy in age-related macular degeneration." Ophthalmology 115(9): 1480-1488, 1488 e1481-1482. 5. Chen, Y., J. Zeng, et al. (2011). "Assessing susceptibility to age-related macular degeneration with genetic markers and environmental factors." Arch Ophthalmol 129(3): 344-351.

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A Review of Femtosecond Assisted Anterior Lamellar Keratoplasty at Bascom Palmer

Jane Fishler, MD Primary Supervisor: Sonia H. Yoo, MD Co-Authors: Ana P. Canto, MD, Pravin Vadavalli, MD

Purpose: To evaluate the results of femtosecond laser-assisted anterior lamellar keratoplasty (FALK) for anterior corneal pathologies. Methods: A retrospective, noncomparative, case series of six consecutive patients who underwent femtosecond laser assisted sutureless anterior lamellar keratoplasty by FS200 and Visumax femtosecond lasers. Best corrected visual acuity, need for adjunctive surgery and complications were reported. Results: Mean follow up ranged from 3 months to 1 year. No intraoperative complications were found. Best corrected visual acuity (BCVA) improved in 50% of the patients. One patient's BCVA remained unchanged and two patients' BCVA decreased. One average, 3 patients' (50%) BCVA improved by 6.6 lines, and 2 patients' (33%) BCVA dropped by 3.5 lines. In 2 eyes, adjuvant surgical procedures were performed (one treated with phototherapeutic keratectomy and the other with photorefractive keratectomy. No graft rejection, infection, or epithelial ingrowth was found in this case series of patients. Conclusion: Femtosecond laser assisted sutureless anterior lamellar keratoplasty by FS200 and Visumax lasers could improve the BCVA in patients with anterior lamellar pathologies. It is also a safe procedure with low rates of complications.

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References: 1. Shousha MA, Yoo SH, Kymionis GD, Ide T, Feuer W, Karp CL, O’Brien TP, Culbertson WW, Alfonso E. Long-term results of femtosecond laser-assisted sutureless anterior lamellar keratoplasty. Ophthalmology 2011;118:315-323. 2. Yoo SH, Hurmeric V. Femtosecond laser-assisted keratoplasty. Amer J Ophthalmology, 2011;151(2)189-191. 3. Yoo SH, Kymionis GD, Koreishi A, Ide T, Goldman D, Karp CL, O’Brien TP, Culbertson WW, Alfonso E. Femtosecond laser-assisted sutureless anterior lamellar keratoplasty. Ophthalmology 2008;115:1303-1307.

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Evaluation Of Optic Disc Progression In Glaucoma Using Spectral Domain Optical Coherence Tomography

Ben J. Harvey, MD Primary Supervisor: David S. Greenfield, MD Co-Authors: Iverson SM, Sehi M, Greenfield DS, and Advanced Imaging in Glaucoma Study (AIGS) Group1,2,3,4. 1) Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Palm Beach Gardens, FL; 2) Casey Eye Institute, Department of Ophthalmology, Oregon Health and Science University, Portland, OR; 3) UPMC Eye Center, Eye and Ear Institute, Ophthalmology and Visual Science Research Center, University of Pittsburgh School of Medicine, Pittsburgh, PA; 4) Doheny Eye Institute, Department of Ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles, California.

Purpose: To examine the rate of optic nerve head (ONH) progression measured using spectral domain optical coherence tomography (SDOCT) in glaucoma suspect and glaucomatous eyes with visual field progression. Methods: Both eyes of glaucoma suspect and glaucoma patients in Advanced Imaging in Glaucoma Study with ≥30 months of follow-up underwent standard automated perimetry (SAP, 24-2 SITA Standard) and SDOCT (RTVue, Optovue Inc, Fremont, CA) measurements every 6 months. Inclusion criteria consisted of age between 40 and 85 years, refractive error spherical equivalent between -8.00D and +4.00D, best corrected visual acuity ≥20/40, reliable SAP (<33% fixation loss, false positive and false negative rates) and no prior intraocular surgery except for uncomplicated cataract extraction. SDOCT Images obtained during eye movement, or images that were unfocused, poorly centered or had a scan score index of ≥30 were excluded. Functional progression was defined as a significant (p<0.05) negative slope of visual field index (VFI) over time.

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Results: One hundred sixty eyes consisting of 96 glaucoma suspect and 64 glaucomatous eyes were enrolled (mean age 64±9.2, mean follow-up 37.7±5.1 months). 21 eyes had SAP progression. Rates of ONH loss were significantly faster in progressing compared with non-progressing eyes for cup area (p=0.03), ONH volume (p=0.02), rim volume (p=0.007), and horizontal (p=0.02), vertical (p=0.006) and overall C/D ratios (p=0.01). Conclusion: Rate of ONH progression is faster in glaucoma suspect and glaucomatous eyes with SAP progression. References: 1. Keltner JL, Johnson CA, Anderson DR, et al. The Association between Glaucomatous Visual Fields and Optic Nerve Head Features in the Ocular Hypertension Treatment Study. Ophthalmology 2006;113:1603-12. 2. Medeiros FA, Zangwill LM, Alencar LM, et al. Detection of Glaucoma Progression with Stratus OCT Retinal Nerve Fiber Layer, Optic Nerve Head, and Macular Thickness Measurements. Am J Ophthalmol 2009;50:5741-8. 3. Chauhan BC, Nicolela MT, Artes PH. Incidence and Rates of Visual Field Progression after Longitudinally Measured Optic Disc Change in Glauycoma. Ophthalmology 2009;116:2110-8. 4. Johnson CA, Sample PA, Zangwill LM, et al. Structure and Function Evaluation (SAFE): II. Comparison of Optic Disk and Visual Field Characteristics. Am J Ophthalmol 2003;135:148-54. 5. Mansouri K, Leite MT, Medeiros FA, et al. Assessment of Rates of Structural Change in Glaucoma using Imaging Technologies. Eye 2011;25:269-77.

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Evolving Fluoroquinolone Resistance Among Coagulase-Negative Staphylococcus Isolates Causing Endophthalmitis

Andrew M. Schimel, MD Primary Supervisor: Harry W. Flynn Jr., MD Co-Authors: Darlene Miller, DHSc

Purpose: Endophthalmitis is a serious, sight-threatening condition resulting in substantial morbidity. With the widespread use of fluoroquinolone antibiotic eyedrops as a prophylactic agent, there is concern regarding increased frequency of fluoroquinolone resistance. We evaluated the evolution of fluoroquinolone resistance among coagulase-negative staphylococcus endophthalmitis isolates at the Bascom Palmer Eye Institute. We further reviewed the endophthalmitis isolates and antibiotic susceptibilities of all culture-proven cases of endophthalmitis over the past 10 years. Methods: The study was approved by the Institutional Review Board of the University of Miami School of Medicine Medical Sciences Subcommittee for the Protection of Human Subjects. This was a retrospective, noncomparative, consecutive case series. The microbiology was reviewed of all cases with culture-proven endophthalmitis (positive cultures from the vitreous cavity) at the Bascom Palmer Eye Institute between January 1, 1990, and July 1, 2011. Susceptibility testing of the intraocular isolates was performed using an automated system – the VITEK (Automatic Microbial System; Biomerieux Vitek, Hazelwood, Missouri, USA) or the E test (A, B, Biodisk; NA, Remel, Lenexa, Kansas, USA). Frozen isolates were reconstituted as needed to evaluate sensitivities of newer-generation fluoroquinolones to earlier cases. Results: During the 21.5 years of the current study, 168 patients were identified with culture-proven endophthalmitis caused by coagulase-negative staphylococcus. The increasing resistance rates for the various time periods are: 1990 – 1994 (N=29), 1995 – 1999 (N=23), and 2000 – 2004 (N=26), and 2005 – 2011 (N=89): ciprofloxacin resistance (10.3%, 17.4%, 38.4%), levofloxacin resistance (0%, 17%, 38.4%), moxifloxacin resistance

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(0%, 21.8%, 26.9%), gatifloxacin resistance (0%, 21.8%, 30.7%). The mean resistance rate for January 1st, 2005 – July 1st, 2011 (N=89) was 60.5% for ciprofloxacin, 58.6% for levofloxacin, 57.8% for moxifloxacin, and 60.5% for gatifloxacin Conclusion: In spite of the dual mechanisms of fluoroquinolones to avoid resistance to coagulase-negative staphylococcus, their frequency of resistance to these organisms is increasing. There is recent evidence that repeated exposure of ocular and nasopharyngeal flora to ophthalmic antibiotics, including fluoroquinolones, selects for resistant strains.1, 2 It has further been shown that resistant strains of coagulase-negative staphylococcus may be associated with greater ocular inflammation, virulence, and increased ocular infection rate than susceptible strains.3, 4 Fourth-generation fluoroquinolones are significantly more expensive than generic traditional antibiotic eyedrops such as gentamicin and polymyxin B/trimethaprim, which have been shown to cover endophthalmitis isolates at least as well.5 There are additional recent reports demonstrating that the fourth-generation fluoroquinolones achieve subtherapeutic levels in the aqueous humor and vitreous against the most frequently identified staphylococcal endophthalmitis isolates.6 Given the frequent and increasing resistance, subtherapeutic penetration and higher cost compared to other antibiotic eyedrops, the widespread perioperative and periprocedural use of fourth-generation fluoroquinolone antibiotic eyedrops should be reevaluated. References: 1. Kim SJ, Toma HS. Ophthalmic antibiotics and antimicrobial resistance a randomized, controlled study of patients undergoing intravitreal injections. Ophthalmology. Jul;118(7):1358-1363. 2. Kim SJ, Toma HS, Midha NK, Cherney EF, Recchia FM, Doherty TJ. Antibiotic resistance of conjunctiva and nasopharynx evaluation study: a prospective study of patients undergoing intravitreal injections. Ophthalmology. Dec;117(12):2372-2378. 3. Mino De Kaspar H, Hoepfner AS, Engelbert M, et al. Antibiotic resistance pattern and visual outcome in experimentally-induced Staphylococcus epidermidis endophthalmitis in a rabbit model. Ophthalmology. Mar 2001;108(3):470-478. 4. Miller D, Flynn PM, Scott IU, Alfonso EC, Flynn HW, Jr. In vitro fluoroquinolone resistance in staphylococcal endophthalmitis isolates. Arch Ophthalmol. Apr 2006;124(4):479-483. 5. Benz MS, Scott IU, Flynn HW, Jr., Unonius N, Miller D. Endophthalmitis isolates and antibiotic sensitivities: a 6-year review of culture-proven cases. Am J Ophthalmol. Jan 2004;137(1):38-42. 6. Donnenfeld ED, Comstock TL, Proksch JW. Human aqueous humor concentrations of besifloxacin, moxifloxacin, and gatifloxacin after topical ocular application. J Cataract Refract Surg. Jun;37(6):1082-1089.

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Vitrectomy and Membrane Peeling in Patients with Myopic Macular Retinoschisis

Jonathan S. Chang, MD Primary Supervisor: Harry W. Flynn, Jr., MD Co-Authors: Anita R. Shirodkar, MD, William E. Smiddy, MD

Purpose: To analyze anatomical and functional outcomes of surgical treatment for myopic macular retinoschisis with vitrectomy, membrane peeling and gas tamponade. Methods: Non-randomized consecutive case series of patients from January 1, 2002 – October 31, 2011 at the Bascom Palmer Eye Institute. All patients had fundus changes of high myopia and optical coherence tomography (OCT) findings of intraretinal schisis, with or without foveal detachment or macular hole. To qualify, patients were required to have had surgical intervention and at least 6 months of post-operative follow-up. Results: To be presented. Conclusion: To be presented. References: 1. Takano M et al. Foveal retinoschisis and retinal detachment in severely myopic eyes with posterior staphyloma. AJO 1999; 128(4):472-6. 2. Kuhn F. Internal limiting membrane removal for macular detachment in highly myopic eyes. AJO 2003; 135(4):547-9. 3. Kumagai K. et al. Factors correlated with postoperative visual acuity after vitrectomy and internal limiting membrane peeling for myopic foveoschisis. Retain 2010; 30(6):874-80.

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4. Kim SK., et al. Vitrectomy and Internal Limiting Membrane Peeling With and Without Gas Tamponade for Myopic Foveoschisis. AJO 2012’ 153(2):320-326e1.

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Molecular Mechanisms Of Blood-Retina Barrier Permeability

Daniel L. Chao, MD, PhD Primary Supervisor: Jeffrey L. Goldberg, MD, PhD Co-Authors: Enrique Salero, PhD

Purpose: Dysfunction of the blood retina barrier is central to the pathology of many retinal disorders. The goal of this study was to develop an in vitro assay to investigate molecules that regulate blood retina barrier permeability. Methods: Rat retinal capillary endothelial cells (RBE4) and human retinal pigment epithelial cells (ARPE-19) were seeded to form a monlayer over a semipermeable membrane. Blood retinal barrier integrity was measured using permeability to sodium fluoroscein as well as measurement of trans endothelial resistance (TER). Results: Both RBE4 and ARPE-19 monolayers are able to form tight junctions in vitro.Validation of these model was done be assaying sodium fluoroscein permeability and TER when adding molecules known to affect blood retina permeability such as vacular endothelial growth factor and glucocorticoids. Conclusion: An in vitro assay has been developed and validated that will allow for high thoroughput screening of molecules which affect blood retina barrier permeability. These may lead to new therapuetics which would be relevant for a host of ophthalmological diseases including retinal vascular disorders such as diabetic retinopathy as well as age related macular degeneration. References: 1. Cecchelli R, Berezowski V, Lundquist S, Culot M, Renftel M, Dehouck MP, Fenart L. Modelling of the blood-brain barrier in drug discovery and development. Nat Rev Drug Discov. 2007 Aug;6(8):650-61.

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2. Runkle EA, Antonetti DA. The blood-retinal barrier: structure and functional significance. Methods Mol Biol. 2011;686:133-48 3. Antonetti DA, Klein R, Gardner TW. Diabetic retinopathy. N Engl J Med. 2012 Mar 29;366(13):1227-39.

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Long Term Outcomes of Anti-VEGF Therapy for Age Related Macular Degeneration

Luis J. Haddock, MD Primary Supervisor: Philip J. Rosenfeld, MD, PhD Co-Authors:

Purpose: To review the long term outcomes of patients from the initial anti-VEGF trials of PRONTO, MARINA, ANCHOR and FVF 2425 Methods: Retrospective chart review was performed after IRB approval to record the visit dates, visual acuity, IOP, intravitreal injection frequency , medication injected, and OCT findings in patients with wet AMD that had more than 5 years of follow up from their initial injection. Results: Over 30 patients were found to meet the above criteria and visual acuity results were highly variable. Further details to be presented. Conclusion: Long term treatment with anti-VEGF for wet age related macular degeneration results in variable visual outcomes. Some patients were able to maintain excellent visual acuity while others showed progression of the geographic atrophy limiting their visual potential. Further results to be presented References: 1. Rosenfeld PJ, Brown DM, Heier JS, et al.; MARINA Study Group. Ranibizumab for neovascular age-related macular degeneration N Engl J Med. 2006;355:1419-31. 2. Brown DM, Kaiser PK, Michels M, et al; ANCHOR Study Group. Ranibizumab versus verteporfin for neovascular age-related macular degeneration. N Engl J Med. 2006;355:1432-44.

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3. Rosenfeld PJ, Moshfeghi AA, Puliafito CA. Optical coherence tomography findings after an intravitreal injection of bevacizumab (avastin) for neovascular age-related macular degeneration. Ophthalmic Surg Lasers Imaging. 2005;36:331-5. 4. CATT Research Group, Martin DF, Maguire MG, Ying GS, et al. Ranibizumab and bevacizumab for neovascular age-related macular degeneration. N Engl J Med. 2011;364:1897-908.

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Comparison of Blood Culture Bottles and Membrane Filter System for Culturing Vitreous Specimens

Aleksandra V. Rachitskaya, MD Primary Supervisor: Harry W. Flynn, Jr., MD Co-Authors: Darlene Miller, DHSc

Purpose: Diluted pars plana vitrectomy (PPV) vitreous samples are conventionally cultured using the membrane filter system (MFS). MFS needs to be set-up promptly and requires trained personnel and technical skills unavailable in most non-hospital settings and after hours and on weekends. Blood culture bottles (BCB), in comparison, are quick and simple to inoculate. The purpose of this study is to compare BCB with MFS for culturing PPV vitreous specimens. Methods: Retrospective review of PPV vitreous specimens from 3/07 to 5/11 cultured using both BCB and MFS. For MFS, vitreous effluent from the vitrectomy cassette was filtered through a 0.45 μm filter. The filter membrane was cut into parts and cultured on blood agar, chocolate agar, Sabouraud agar, Lowenstein-Jensen agar, and Thioglycolate broth. Approximately 10 cc of undiluted vitreous effluent was also injected into BCB. If growth was detected in BCB, a Gram-stained smear was prepared and appropriate subculture was set-up. Results: A total of 201 patients had vitreous wash samples processed from 3/07 to 5/11. Of those, 69 positive cultures were recorded using either MFS or BCB. By 48 hours, 52 organisms were recovered: 40 (77%) in both MFS and BCB, 8 (15%) only in MFS, and 4 (8%) only in BCB. The organisms that grew only in the MFS included: Methicillin-susceptible S. aureus, Mold x 2, Coagulase negative Staphylococcus species x 2, Yeast, Methicillin-susceptible S. epidermidis, and Mycobacterium. Those that grew

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only in the BCB included: Methicillin - resistant S. epidermidis x 2, Coagulase negative Staphylococcus species, Streptococcus species. By 2 weeks, 17 additional organisms were identified: 7 (41%) in both MFS and BCB, 5 (29%) only in MFS, and 5 (29%) only in BCB. The ones that grew only in the MFS included: Mycobacteria x 2 and Mold x 3. The ones that grew only in the BCB were: Propionibacterium acnes x 2, Coagulase negative Staphylococcal species, Gram-positive organism, Methicillin - resistant S. epidermidis. Conclusion: Based on the microbiological outcomes, BCB represent a viable and easy to set-up alternative or adjunct for culturing of PPV vitreous specimens in suspected infectious endophthalmitis as compared to traditional MFS that requires prompt attention of a trained laboratory personnel, which is not available at all times or in all ophthalmology settings. References: 1. Barza M, et al. Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the endophthalmitis vitrectomy study. Arch Ophthalmol. 1997;115(9):1142-1150. 2. Chiquet C, et al. Analysis of diluted vitreous samples from vitrectomy is useful in eyes with severe acute postoperative endophthalmitis. Ophthalmology. 2009;116(12):2437-41.e1. 3. Donahue SP, et al. Vitreous cultures in suspected endophthalmitis. biopsy or vitrectomy? Ophthalmology. 1993;100(4):452-455. 4. Eser I, et al. The use of blood culture bottles in endophthalmitis. Retina. 2007;27(7):971-973. 5. Forster RK. Etiology and diagnosis of bacterial postoperative endophthalmitis. Ophthalmology. 1978;85(4):320-326. 6. Joondeph BC, et al. A new culture method for infectious endophthalmitis. Arch Ophthalmol. 1989;107(9):1334-1337. 7. Kratz A, et al. Broth culture yield vs traditional approach in the work-up of endophthalmitis. Am J Ophthalmol. 2006;141(6):1022-1026. 8. Sharma S, et al. Sensitivity and predictability of vitreous cytology, biopsy, and membrane filter culture in endophthalmitis. Retina. 1996;16(6):525-529. 9. Tan HS, et al. The additional value of blood culture bottles in the diagnosis of endophthalmitis. Eye (Lond). 2011;25(8):1069-1073. 10. Yospaiboon Y, Sareet al. Blood culture and conventional media for vitreous culture in infectious endophthalmitis. J Med Assoc Thai. 2005;88(5):639-642.

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Correlations between Baseline Characteristics and Disease Progression in Eyes with Non-Exudative Age-Related Macular Degeneration: The Complete Study

Mathew K. George, MD Primary Supervisor: Philip J. Rosenfeld, MD, PhD Co-Authors: Mathew K. George; Zohar Yehoshua; Carlos Alexandre de Amorim Garcia Filho; Renata Portella Nunes MD; Dimple Modi; Gene W. Chen; Jyoti R. Dugar; Ying Li; William Feuer; Fernando M. Penha; SriniVas Sadda; Kang Zhang; Giovanni Gregori; Andrew A. Moshfeghi; Philip J. Rosenfeld

Purpose: The COMPLement Inhibition with Eculizumab for the Treatment of Non-Exudative Age-Related Macular Degeneration (COMPLETE) Study was designed to prospectively evaluate the effects of eculizumab, an FDA-approved systemic inhibitor of complement component 5 (C5), on the growth of geographic atrophy (GA) and drusen volume in eyes of patients with non-exudative age-related macular degeneration (AMD). Methods: Patients with eyes containing GA and eyes containing drusen were randomized 2:1 to receive intravenous eculizumab or placebo. In the GA cohort, the area of atrophy had to be at least 1.26 mm2, but no larger than 17 mm2 in size. In the drusen cohort, the drusen volume had to be at least 0.03 mm3 within the central 3 mm of the macula using spectral domain optical coherence tomography (SDOCT) imaging. The first 10 patients randomized to active treatment in each cohort received 600mg eculizumab for 4 weeks followed by 900mg every 2 weeks, while the next 10 patients received 900mg eculizumab for 4 weeks followed by 1200mg every two weeks. After 26 weeks, patients were followed without treatment every 3 months for 6 months. Ophthalmologic exam, ETDRS visual acuity testing, and imaging studies were performed. The primary endpoints were the change in area of GA and the change in drusen volume at 6 months. Baseline characteristics to be studied as predictors of disease progression included normal luminance and low luminance visual acuity scores, distance from the

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edge of GA to the foveal center, choroidal thickness measurements, C-reactive protein levels, glomerular filtration rates, and genotype profiles for the major AMD risk alleles Results: Thirty patients (study eyes) were enrolled in each cohort and randomized 1:1:1 to the low dose, high dose, and placebo groups. In the GA cohort at baseline, the mean areas of GA (SD) measured by SDOCT were 7.3 mm2 (4.8) and 4.7 (3.6) mm2 for the eculizumab and placebo groups, respectively (p=0.13). Baseline mean ETDRS visual acuity scores (SD) were 71.3 (7.8) and 78.6 (5.2) letters for the eculizumab and placebo groups, respectively (p=0.01). Low and high dose eculizumab groups had similar areas of GA (p=0.44), but the high dose patients read 7 fewer letters (p=0.040). At baseline, the mean low luminance visual acuity scores (SD) were 48.1 (15.4) and 56.1 (11.7) letters for the eculizumab and placebo groups respectively, (p=0.16). In addition, 19 fellow eyes were found to meet entry criteria and will be evaluated as a secondary endpoint. All patients completed their follow-up through 26 weeks. In the drusen cohort at baseline, the mean drusen areas (SD) were 2.1 mm2 (1.0) and 1.9 mm2 (0.7) for the eculizumab and placebo groups, respectively (p=0.80). The mean drusen volumes were 0.15 mm3 (0.17) and 0.12 mm3 (0.08) for each group, respectively (p=0.64). Low and high dose eculizumab groups did not differ significantly in drusen area and volume measurements, p=0.058 and p=0.077 respectively. Baseline mean ETDRS visual acuity scores were 80.9 (5.9) and 78.0 (10.0) letters for the eculizumab and placebo groups. The deficits in the low luminance visual acuity scores at baseline were 14.4 (4.9) and 15.5 (5.4) letters (p=0.58). In addition, 12 fellow eyes were found to meet entry criteria and will be evaluated as a secondary endpoint. Twenty-eight out of 30 patients (93%) completed the follow-up through 26 weeks. No drug-related adverse events were identified in either cohort. Conclusion: Systemic complement inhibition with the FDA-approved C5 inhibitor known as eculizumab was well tolerated through 6 months. The outcome data describing the correlations between baseline characteristics and disease progression will be presented. References: 1. Gregori, G., F. Wang, et al. (2011). "Spectral domain optical coherence tomography imaging of drusen in nonexudative age-related macular degeneration." Ophthalmology 118(7): 1373-1379. 2. Yehoshua, Z., F. Wang, et al. (2011). "Natural history of drusen morphology in age-related macular degeneration using spectral domain optical coherence tomography." Ophthalmology 118(12): 2434-2441. 3. Yehoshua, Z., P. J. Rosenfeld, et al. (2011). "Progression of geographic atrophy in age-related macular degeneration imaged with spectral domain optical coherence tomography." Ophthalmology 118(4): 679-686.

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4. Sunness, J. S., G. S. Rubin, et al. (2008). "Low luminance visual dysfunction as a predictor of subsequent visual acuity loss from geographic atrophy in age-related macular degeneration." Ophthalmology 115(9): 1480-1488, 1488 e1481-1482. 5. Chen, Y., J. Zeng, et al. (2011). "Assessing susceptibility to age-related macular degeneration with genetic markers and environmental factors." Arch Ophthalmol 129(3): 344-351.

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Natural History of Glaucoma Drainage Implants and Penetrating Keratoplasty

Jessica L. Chen, MD Primary Supervisor: Michael R. Banitt, MD, MHA Co-Authors: David Chu, MD, Anne Ko, MD, William Feuer, MS, Joyce Schiffman, MS, Richard K. Lee, MD, PhD

Purpose: To report the natural history of eyes with failed trabeculectomy requiring glaucoma drainage implant (GDI) followed by penetrating keratoplasty (PKP). Methods: Retrospective chart review of 24 eyes of 24 patients, with collection and analysis of data triggered by clinical event and/or procedure. Inclusion criteria were a history of prior trabeculectomy (>1) and subsequent GDI (>1) and PKP. Patients were excluded if there was preexisting corneal decompensation prior to GDI placement or tube-cornea touch. Primary data points included corneal and glaucoma diagnoses, visual acuity (VA), intraocular pressure (IOP), status of corneal transplant, timing of surgical interventions, requirement for additional surgery. Tube failure was defined as requirement of additional glaucoma surgery, and graft failure was defined as persistent edema as documented in clinic notes or need of additional PKP. Results: There was a high rate of corneal graft failure within the first 5 years after PKP, 73%. Graft failure can be early or late. The rate of GDI failure after PKP was 20% over 5 years. The majority of graft failures occurred at IOP between 0 and 22 mmHg. Conclusion: Although corneal graft survival in post-GDI eyes is 27% within the first 5 years, these eyes maintained good IOP control, which suggests that PKP failure is not due to damage from increased IOP. GDIs are a good option for IOP control in post-PKP patients.

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References: 1. Arroyave CP, et al. Corneal graft survival and intraocular pressure control after penetrating keratoplasty and glaucoma drainage device implantation. Ophthalmology. 2001 Nov;108(11):1978-85. 2. Lee RK, Fantes F. Surgical management of patients with combined glaucoma and corneal transplant surgery. Curr Opin Ophthalmol. 2003 Apr;14(2):95-9. 3. Alvarenga LS, et al. The long-term results of keratoplasty in eyes with a glaucoma drainage device. Am J Ophthalmol. 2004 Aug;138(2)200-5.

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Clinical Outcomes of Immediate Versus Delayed Pars Plana Vitrectomy for Retained Lens Fragments over a 22-Year Period

Yasha S. Modi, MD Primary Supervisor: Harry W. Flynn, MD Co-Authors: W.E. Smiddy, MD, T.G. Murray, MD, MBA, FACS, L. Olmos, MD

Purpose: To study visual acuity outcomes and adverse events in patients with retained lens fragments managed by pars plana vitrectomy (PPV). Methods: Retrospective, consecutive case series evaluating all cases of retained lens fragments that underwent PPV over a 22-year period (1990-2011) at the Bascom Palmer Eye Institute. Results: 594 patient met study inclusion criteria. To date 459 of the 594 patients have been evaluated spanning 18 years. Median follow-up time was 6.7 months (2 weeks – 8 years). The overall incidence of retinal detachment was 11.8 % (54/459) with 6.1 % (28/459) occurring before or during PPV and 5.7 % (26/459) occurring post-PPV. The primary causes of decreased vision (<20/40) included a prior history of RD (23 %), corneal edema (17%), persistent macular edema (12 %), POAG (10 %), and persistent RD (12 %). Conclusion: Retained lens fragments after cataract surgery is a serious and vision-threatening complication with long-term complications including CME, retinal detachment, and elevated IOP. This is the longest case series to date evaluating outcomes and adverse events in patients with retained lens fragments.

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References: 1. Moore JK, Scott IU, Flynn HW Jr, et al. Retinal detachment in eyes undergoing pars plana vitrectomy for revmoal of retained lens fragments. Ophthalmology 2003;110:709-714. 2. Blodi BA, Flynn HW Jr, Smiddy WE, et al. Clinical features and outcomes of pars plana vitrectomy in patients with retained lens fragments. Ophthalmology 2003;110:1567-1572. 3. Baker PS, Spirn MK, Kaiser RS, et al. 23-Guage transconjunctival pars plana vitrectomy for removal of retained lens fragments. American Journal of Ophthalmology 2011;152 (4): 624-7. 4. Colyer MH, Berinstein DM, Garfinkel RA, et al. Same-day versus delayed vitrectomy with lensectomy for the management of retained lens fragments. Retina 2011;31 (8): 153-40. 5. Vanner EA, Stewart MW, et al. Vitrectomy timing for retained lens fragments after surgery for age-related cataracts: A systematic Review and Meta-Analysis. American Journal of Ophthalmology 2011;152 (3):345-57.

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Treatment of Choroidal Melanoma with Adjuvant Bevacizumab Following Plaque Brachytherapy Enhances Tumor Volume Reduction and Resolution of Exudative Detachment

S.K. Steven Houston, MD Primary Supervisor: Timothy G. Murray, MD, MBA, FACS Co-Authors: Nisha Shah, Christina Decatur, Marcela Lonngi, William Feuer, Arnold M. Markoe

Purpose: To evaluate intravitreal bevacizumab as an adjuvant treatment to plaque brachytherapy in the treatment of choroidal melanoma. Methods: This is an IRB-approved, retrospective, consecutive case series of 124 patients treated from 2007 – 2009 for choroidal melanoma with plaque brachytherapy. Patients were treated with iodine-125 plaque brachytherapy with 2 mm margins and 85 Gy to the tumor apex. Consecutive patients were injected intravitreally with 2.5mg/0.1cc bevacizumab at a site away from the primary tumor and immediately following plaque removal. Choroidal melanomas were observed with indirect ophthalmoscopy, wide-angle photography, and ultrasound. Results: 124 patients met inclusion criteria and were included in the analysis. Mean patient age was 65.7 years, with mean tumor apical height of 4.0 mm (SD 2.7) and basal diameter of 12.7 mm (SD 3.0). Mean follow-up was 24 months. Prior to treatment, 100% of tumors had exudative retinal detachments, and pre-treatment visual acuity was 20/55 (median 20/40). Tumor control was 100% and metastasis was 0% at last follow-up. 89.8% had complete resolution of exudative retinal detachment (ERD), with a mean time to resolution of 3.36 months. At 1 month, 43% had complete resolution of ERD, which increased to 73% at 4 months. Visual acuity was 20/62 (median 20/40) at 4 months, with stabilization to 20/57 (median 20/40) at 8 months, 20/56 (median 20/30) at 12 months, and 20/68 (median 20/50) at 24 months. Tumor burden was shown to be

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reduced 22.2% at 3 months, 28.9% at 6 months, 39.3% at 12 months, and 52.2% at 24 months (all P < 0.001). Patients tolerated the procedure well without systemic side effects. Conclusion: Intravitreal bevacizumab may be used as an adjuvant agent when used following plaque brachytherapy. Treated choroidal melanomas show reduction in tumor burden as well as exudative retinal detachments. References: 1. Diener-West M, Earle JD, Fine SL, et al. The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma, III: initial mortality findings. COMS Report No. 18. Arch Ophthalmol 2001;119:969-982. 2. Jampol LM, Moy CS, Murray TG, et al. The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma: IV. Local treatment failure and enucleation in the first 5 years after brachytherapy. COMS report no. 19. Ophthalmology 2002;109:2197-2206. 3. Nath R, Anderson LL, Luxton G, Weaver KA, Williamson JF, Meigooni AS. Dosimetry of interstitial brachytherapy sources: recommendations of the AAPM Radiation Therapy Committee Task Group No. 43. American Association of Physicists in Medicine. Med Phys 1995;22:209-234. 4. Ray SK, Bhatnagar R, Hartsell WF, Desai GR. Review of eye plaque dosimetry based on AAPM Task Group 43 recommendations. American Association of Physicists in Medicine. Int J Radiat Oncol Biol Phys 1998;41:701-706. 5. The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma: V. Twelve-year mortality rates and prognostic factors: COMS report No. 28. Arch Ophthalmol 2006;124:1684-1693. 6. Wilson MW, Hungerford JL. Comparison of episcleral plaque and proton beam radiation therapy for the treatment of choroidal melanoma. Ophthalmology 1999;106:1579-1587. 7. Gunduz K, Shields CL, Shields JA, Cater J, Freire JE, Brady LW. Radiation complications and tumor control after plaque radiotherapy of choroidal melanoma with macular involvement. Am J Ophthalmol 1999;127:579-589. 8. Karlsson UL, Augsburger JJ, Shields JA, Markoe AM, Brady LW, Woodleigh R. Recurrence of posterior uveal melanoma after 60Co episcleral plaque therapy. Ophthalmology 1989;96:382-388. 9. Vrabec TR, Augsburger JJ, Gamel JW, Brady LW, Hernandez C, Woodleigh R. Impact of local tumor relapse on patient survival after cobalt 60 plaque radiotherapy. Ophthalmology 1991;98:984-988. 10. Harbour JW, Murray TG, Byrne SF, et al. Intraoperative echographic localization of iodine 125 episcleral radioactive plaques for posterior uveal melanoma. Retina 1996;16:129-134. 11. Shields CL, Cater J, Shields JA, et al. Combined plaque radiotherapy and transpupillary thermotherapy for choroidal melanoma: tumor control and treatment complications in 270 consecutive patients. Arch Ophthalmol 2002;120:933-940.

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12. Bartlema YM, Oosterhuis JA, Journee-De Korver JG, Tjho-Heslinga RE, Keunen JE. Combined plaque radiotherapy and transpupillary thermotherapy in choroidal melanoma: 5 years' experience. Br J Ophthalmol 2003;87:1370-1373. 13. Kreusel KM, Bechrakis N, Riese J, Krause L, Wachtlin J, Foerster MH. Combined brachytherapy and transpupillary thermotherapy for large choroidal melanoma: tumor regression and early complications. Graefes Arch Clin Exp Ophthalmol 2006;244:1575-1580. 14. Sagoo MS, Shields CL, Mashayekhi A, et al. Plaque radiotherapy for juxtapapillary choroidal melanoma: tumor control in 650 consecutive cases. Ophthalmology 118:402-407. 15. Barbazetto IA, Lee TC, Rollins IS, Chang S, Abramson DH. Treatment of choroidal melanoma using photodynamic therapy. Am J Ophthalmol 2003;135:898-899. 16. Horgan N, Shields CL, Mashayekhi A, et al. Periocular triamcinolone for prevention of macular edema after iodine 125 plaque radiotherapy of uveal melanoma. Retina 2008;28:987-995. 17. Garcia-Arumi J, Zapata MA, Balaguer O, Fonollosa A, Boixadera A, Martinez-Castillo V. Endoresection in high posterior choroidal melanomas: long-term outcome. Br J Ophthalmol 2008;92:1040-1045. 18. Querques G, Bux AV, Iaculli C, Delle Noci N. Local resection versus combined local resection and plaque radiotherapy in the treatment of choroidal melanoma. Eur J Ophthalmol 20:194-200. 19. Newman H, Finger PT, Chin KJ, Pavlick AC. Systemic bevacizumab (Avastin) for exudative retinal detachment secondary to choroidal melanoma. Eur J Ophthalmol 21:796-801. 20. Lima BR, Schoenfield LR, Singh AD. The impact of intravitreal bevacizumab therapy on choroidal melanoma. Am J Ophthalmol 151:323-328 e322. 21. Missotten GS, Notting IC, Schlingemann RO, et al. Vascular endothelial growth factor a in eyes with uveal melanoma. Arch Ophthalmol 2006;124:1428-1434. 22. Boyd SR, Tan D, Bunce C, et al. Vascular endothelial growth factor is elevated in ocular fluids of eyes harbouring uveal melanoma: identification of a potential therapeutic window. Br J Ophthalmol 2002;86:448-452. 23. Boutrid H, Pina Y, Cebulla CM, et al. Increased hypoxia following vessel targeting in a murine model of retinoblastoma. Invest Ophthalmol Vis Sci 2009;50:5537-5543. 24. Gragoudas ES, Egan KM, Saornil MA, Walsh SM, Albert DM, Seddon JM. The time course of irradiation changes in proton beam-treated uveal melanomas. Ophthalmology 1993;100:1555-1559; discussion 1560. 25. Abramson DH, Servodidio CA, McCormick B, Fass D, Zang E. Changes in height of choroidal melanomas after plaque therapy. Br J Ophthalmol 1990;74:359-362. 26. Harbour JW, Ahmad S, El-Bash M. Rate of resolution of exudative retinal detachment after plaque radiotherapy for uveal melanoma. Arch Ophthalmol 2002;120:1463-1469. 27. Kivela T, Eskelin S, Makitie T, Summanen P. Exudative retinal detachment from malignant uveal melanoma: predictors and prognostic significance. Invest Ophthalmol Vis Sci 2001;42:2085-2093.

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Comparison of Corneal Stromal Bed Quality by Scanning Electron Microscopy Using Mechanical and Femtosecond Laser Keratomes

Jessica H. Chow, MD Primary Supervisor: Sonia H. Yoo, MD Co-Authors: Noel Ziebarth, PhD

Purpose: To compare the roughness of the corneal stromal bed in porcine eyes using mechanical and femtosecond laser keratomes. Methods: Three groups of lamellar corneal cuts were compared. In Group 1, LASIK corneal flaps were created in porcine globes with a Moria microkeratome with a 320um head. In Group 2, LASIK corneal flaps at a depth of 120um were created in porcine globes with the VISUMAX femtosecond laser. Group 3 consisted of porcine corneal lenticules created using the Small Incision Lenticule Extraction (SMILE) study protocol. The corneal stromal beds were imaged with scanning electron microscopy (SEM). Qualitative and quantitative surface roughness was assessed, the latter using SPIP software for roughness analysis. Results: There was no difference in qualitative stromal bed roughness between the three groups. Quantitative results were also analyzed. Conclusion: The VISUMAX femtosecond laser and the Moria 320um head both produced smooth, good-quality, compact stromal beds. References: 1. Sarayaba MA, Ignacio TS, Binder PS, Tran, DB. Comparative Study of Stromal Bed Quality by Using Mechanical, IntraLase Femtosecond Laser 15- and 30-kHz Microkeratomes Cornea 2007;26:446–451.

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2. Sekundo W, Kunert K, Russmann C, Gille A, Bissmann W, Stobrawa G, Sticker M, Bischoff M, Blum M. First efficacy and safety study of femtosecond lenticule extraction for the correction of myopia: six-month results. J Cataract Refract Surg. 2008 Sep;34(9):1513-20.

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A Comparative Analysis of OCT Findings in Posterior Uveitis

Ashkan M. Abbey, MD Primary Supervisor: Thomas A. Albini, MD Co-Authors: Krishna Surapaneni

Purpose: To characterize and determine the prevalence of unique membranous structures seen on time-domain and spectral-domain optical coherence tomography (OCT) images of serous retinal detachments (RDs) in Vogt-Koyanagi-Harada (VKH) syndrome and compare these findings with serous RDs of other posterior uveitidies and central serous retinopathy (CSR). Methods: 40 eyes of 22 patients with serous RDs from VKH were compared with 40 eyes of 40 patients with serous RDs from CSR. OCT images of serous RDs from both groups were compared. Results: 33/40 (82.5%) VKH eyes with serous RDs showed a unique membranous and/or granular structure within the subretinal space. These OCTs demonstrate Irregular, hyperreflective deposits along the photoreceptor layer and retinal pigment epithelium. 17/40 (42.5%) CSR eyes with serous RDs showed similar deposits within the subretinal space. Conclusion: In a majority of the serous RDs shown in acute VKH, a unique membranous and/or granular structure was noted within the area of fluid on OCT. Further comparisons with OCT images of other causes of posterior uveitis will elucidate whether this structure is a pathognomic OCT finding of VKH.

References: 1. Ikewaki J, Kimoto K, Choshi T, Nagata M, Motomura Y, Tamura K, Shinoda K, Nakatsuka K. Optical coherence tomographic assessment of dynamic macular changes in patients with Vogt-Koyanagi-Harada disease. Int Ophthalmol. 2011 Feb;31(1):9-13. 2. Maruko I, Iida T, Sugano Y, Oyamada H, Sekiryu T, Fujiwara T, Spaide RF. Subfoveal choroidal thickness after treatment of Vogt-Koyanagi-Harada disease. Retina. 2011 Mar;31(3):510-7. 3. Ishihara K, Hangai M, Kita M, Yoshimura N. Acute Vogt-Koyanagi-Harada disease in enhanced spectral-domain optical coherence tomography. Ophthalmology. 2009 Sep;116(9):1799-807. Epub 2009 Jul 30. 4. Yamaguchi Y, Otani T, Kishi S. Tomographic features of serous retinal detachment with multilobular dye pooling in acute Vogt-Koyanagi-Harada disease. Am J Ophthalmol. 2007 Aug;144(2):260-5.


Effect of Plate Location on Initial Glaucoma Drainage Device Success Rates

Amy Z. Martino, MD Primary Supervisor: David S. Greenfield, MD Co-Authors: Shawn M. Iverson, DO; William J. Feuer, MS

Purpose: To compare the safety and intraocular pressure (IOP) lowering efficacy of initial glaucoma drainage device implantation performed at the superior and inferior limbus. Methods: A retrospective chart review was conducted to identify glaucoma patients that had undergone initial Baerveldt™ glaucoma drainage device (GDD) surgery at the inferior limbus between 2006 and 2010 for uncontrolled IOP. All eyes had a minimum of 6 months of postoperative follow-up. These eyes were matched using 2:1 frequency matched to eyes with GDD implantation performed at the superior limbus to within 5 years of age and 6 months of follow-up in a roughly 2:1 ratio to create a comparison group. Data extracted from the medical record consisted of demographic information, presence of diabetes or hypertension, use of anticoagulation medication, prior glaucoma surgery, type of glaucoma, preoperative and postoperative IOP, visual acuity, and number of anti-glaucoma medications. Statistical methods consisted of Student’s t-tests, chi-squared test, and Kaplan-Meier time to failure analysis.ere to enter methods Results: Fifty eyes (17 inferior, 33 superior) of 43 patients (mean age 68.4 and 72.8 years, respectively) were enrolled. Mean postoperative follow-up in the inferior and superior GDD groups (26.2 ± 15.2 and 23.9 ± 10.43 months) was similar (p=0.54). Preoperative glaucoma diagnoses among both groups consisted of POAG (74%), CACG (10%), and other (16%) and were similar among both groups (p=0.21). Prior glaucoma filtering surgery had been performed in 8/17 (47%) and 11/33 (33%) eyes (p=0.34) with inferior and superior GDD implants, respectively. Mean preoperative IOP (mmHg) in the superior GDD group (26 ± 10) was significantly (p=0.02) greater than the inferior GDD

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group (21 ± 6); the mean number of preoperative anti-glaucomatous medication was similar in both groups (p=0.9), 3.5± 1.2 for inferior GDD and 3.4±0.8 for superior GDD. The mean postoperative intraocular pressure (mmHg) at 6, 12, 18, and 24 months was similar (all p>0.05) in the inferior GDD (16 ± 6, 15 ± 5, 16 ± 6, 15 ± 7) and the superior GDD group (13 ± 4, 13 ± 4, 17 ± 7, and 20 ± 9). The mean number of postoperative medications used in both groups was similar (p=0.5), averaging 2.4 ± 1.6 in the inferior GDD group and 2.7±1.5 in the superior GDD group. The frequency and types of postoperative complications in both groups were similar. re to enter results Conclusion: No differences were observed in the safety and IOP lowering efficacy of initial GDD implantation performed at the superior and inferior limbus in this cohort here to enter conclusion References: 1. Krishna R, Godfrey DG, Budenz DL, Escalona E, Gedde SJ, Greenfield DS, Feuer W, Scott IU. Intermediate-term Outcomes of 350-mm2 Baerveldt Glaucoma Implants. Ophthalmology 2001;108:621-6. 2. Wilson MR, Mendis U, Smith SD et al. Ahmed Glaucoma Valve Implant vs Trabeculectomy in the Surgical Treatment of Glaucoma: A Randomized Clinical Trial. Am J Ophthalmol 2000;130:267-73. 3. Budenz DL, Barton K, Feuer WJ, et al. Treatment Outcome in the Ahmed Baerveldt Comparison Study after 1 Year of Follow-up. Ophthalmology 2011;118:443-52. 4. Harbick KH, Sidoti PA, Budenz DL, Venkatrman A, Bruther M, Grayson DK, Ko A, Yi GN. Outcomes of inferonasal Baerveldt glaucoma drainage implant surgery. J Glaucoma 2006;15:7-12. 5. Sidoti PA. Inferonasal Placement of Aqueous Shunts. J Glaucoma 2004;13:520-3. 6. Rachmiel R, Trope G, Buys Y, et al. Intermediate-term Outcome and Success of Superior Versus Inferior Ahmed Glaucoma Valve Implantation. J Glaucoma 2008;17:584-90.

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Preparation Techniques and Intravitreal Injections: A Clinical and Microbiological Evaluation

Roger A. Goldberg, MD, MBA Primary Supervisor: Harry W. Flynn, Jr., MD Co-Authors: Ryan F. Isom, Darlene Miller, Serafin Gonzalez, Sander R. Dubovy, Jared L. Matthews, Paulo M. Bispo

Purpose: To report the long-term outcomes, microbiological profile, and possible contamination sources of an endophthalmitis outbreak. Methods: Non-comparative case series; PCR sequencing; medical records and investigative reports were reviewed Results: 12 patients were affected by this outbreak: eight (67%) underwent pars plana vitrectomy (PPV), and seven (58%) underwent evisceration or enucleation. After eight months, only one patient regained pre-injection visual acuity. DNA analysis confirmed microbiological testing identifying a common strain of Streptococcus. Issues with syringe preparation and environmental sterility were cited as possible sources of contamination at the compounding pharmacy. Conclusion: Contamination likely occurred at the compounding pharmacy. PPV did not improve visual outcomes. References: 1. Goldberg RA, Flynn HW, Isom RF, et al. An Outbreak of Streptococcus Endophthalmitis After Intravitreal Injection of Bevacizumab. Am J Ophthalmol 2012;153:204–208. 2. Gonzalez S, Rosenfeld PJ, Stewart MW, et al. Perspective: Avastin Doesn’t Blind People, People Blind People. Am J Ophthalmol 2012;153:196–203.

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3. McCannel CA. Meta-analysis of endophthalmitis following intravitreal injection of anti-VEGF agents: causative organisms and possible prevention strategies. Retina 2011;31(4):654–661. 4 Moshfeghi AA, Rosenfeld PJ, Flynn HW Jr, et al. Endophthalmitis after intravitreal anti-vascular endothelial growth factor antagonists: a six-year experience at a university referral center. Retina 2011;31(4):662– 668. 5. The CATT Research Group. Ranibizumab and bevacizumab for neovascular age-related macular degeneration. N Engl J Med 2011;364(20):1897–1908.

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Outcomes Following Intravitreal Injection of Aflibercept in Patients with Exudative Disease

Dimple Modi, MD, MPH Primary Supervisor: Philip J. Rosenfeld, MD, PhD Co-Authors: Gene Chen, MD, Jyoti Dugar, MD, Mathew George, MD, Renata Portella Nunes, MD, Giovanni Gregori, PhD

Purpose: To determine if intravitreal injections of aflibercept (Eylea, Regeneron Pharmaceuticals, Inc) result in visual acuity improvement and a decrease in injection frequency in patients who had received prior injections of bevacizumab (Avastin, Genentech/Roche) or ranibizumab (Lucentis, Genentech/Roche) for persistent macular fluid at intervals no greater than 6 weeks for the treatment of neovascular age-related macular degeneration (AMD). Methods: IRB approval was obtained for a retrospective chart review of patients undergoing treatment with inhibitors of vascular endothelial growth factor (VEGF). Patients from one physician's clinic (PJR) were identified as having received anti-VEGF therapy for least one year at intervals no greater than 6 weeks apart before being switched to aflibercept. Visual acuity, the time interval between injections, and the characteristics of optical coherence tomography (OCT) imaging of the neovascular lesions were collected. Pertinent OCT characteristics included quantification of the volume and area of retinal pigment epithelial detachments (PEDs). Results: A total of 49 eyes from 43 patients were evaluated. Of these 49 eyes, 41 eyes were found to have vascularized PEDs at the start of aflibercept therapy. The response of these PEDs to aflibercept therapy were followed and the change in the volume and area of these lesions will be presented. Conclusion: Aflibercept therapy is believed to result in an increase in the treatment interval compared with bevacizumab or ranibizumab therapy. This is believed to be due to the higher affinity of aflibercept for VEGF compared with the other drugs.4,5

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Whether this increased binding affinity also results in an improvement in the volume and area of PEDs will be presented. References: 1. Rosenfeld, P. J., D. M. Brown, et al. (2006). "Ranibizumab for neovascular age-related macular degeneration." N Engl J Med 355(14): 1419-1431. 2. Brown, D. M., M. Michels, et al. (2009). "Ranibizumab versus verteporfin photodynamic therapy for neovascular age-related macular degeneration: Two-year results of the ANCHOR study." Ophthalmology 116(1): 57-65 e55. 3. Martin, D. F., M. G. Maguire, et al. (2012). "Ranibizumab and Bevacizumab for Treatment of Neovascular Age-Related Macular Degeneration: Two-Year Results." Ophthalmology. 4. Chakravarthy, U., S. P. Harding, et al. (2012). "Ranibizumab versus Bevacizumab to Treat Neovascular Age-related Macular Degeneration: One-Year Findings from the IVAN Randomized Trial." Ophthalmology. 5. Stewart, M. W., P. J. Rosenfeld, et al. (2012). "Pharmacokinetic rationale for dosing every 2 weeks versus 4 weeks with intravitreal ranibizumab, bevacizumab, and aflibercept (vascular endothelial growth factor trap-eye)." Retina 32(3): 434-457.

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In-Vitro Collagen Crosslinking for Treatment of Acanthamoeba Keratitis

Ravi D. Patel, MD, MBA Primary Supervisor: Terrence P. O'Brien, MD Co-Authors: Darlene Miller, PhD, Noel Ziebarth, PhD, Michael Lorenzo

Purpose: To evaluate the in vitro effect of collagen crosslinking with riboflavin and ultraviolet light (UVA 378 nm) on Acanthamoeba polyphaga keratitis. Methods: Cadaveric corneal buttons were harvested from the Florida Lion Eye Bank from tissue designed for research purposes. The 16 corneas were randomized into two groups. All 16 corneas were infected with 1000 cysts/0.03mL Page's Saline Solution of Acanthamoeba polyphaga and then incubated for 48 hours and then cultured to ensure viable cysts. Group 1 had 8 corneas which were dehydrated with Sodium Chloride 5% and Glycerin 98.5% drops and then saturated with Riboflavin 0.1% for 30 minutes. Group B had 8 corneas which were dehydrated with Sodium Chloride 5% and Glycerin 98.5%. All 16 corneas were crosslinked using a homemade light source of ultraviolet light for 30 minutes during which Group 1 corneas were given both Sodium Chloride 5% as well as Riboflavin 0.1% and Group two were given Sodium Chloride 5% only during the treatment. The 16 buttons were once again incubated in a moist chamber for 48 hours, again cultures were obtained and corneal buttons were analyzed histologically Results: Groups A and B were not statistically dissimilar in baseline characteristics. In all cases cysts were detected 48 hours after infection. After crosslinking the rate of culture positive keratitis was 37.5% in Group 1 and 37.5% in Group 2. There was no difference in culture positive keratitis between treatment Group 1 and control Group 2. Histological analysis was completed. Conclusion: The results obtained in our study show that a single 30 minute dose of crosslinking cannot achieve eradication of Acanthamoeba polyphaga. However, in vitro

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results do not always indicate in vivo efficacy, so future studies should test the validity of this treatment for Acanthamoeba keratitis. References: del Buey MA, Cristóbal JA, Casas P, Goñi P, Clavel A, Mínguez E, Lanchares E, García A, Calvo B. Evaluation of in vitro efficacy of combined riboflavin and ultraviolet a for Acanthamoeba isolates. Am J Ophthalmol. 2012 Mar;153(3):399-404. Epub 2011 Oct 11. Morén, Håkan MD; Malmsjö, Malin MD, PhD; Mortensen, Jes MD; Öhrström, Arne MD, PhD. Riboflavin and Ultraviolet A Collagen Crosslinking of the Cornea for the Treatment of Keratitis. Cornea. January 2010 - Volume 29 - Issue 1 - pp 102-104 Kashiwabuchi RT, Carvalho FRS, Khan YA, de Freitas D, Foronda AS, Hirai FE, Campos MS, McDonnell PJ. Invest. Ophthalmol. Vis. Sci. December 9, 2011 vol. 52 no. 13 9333-9338 Assessing Efficacy of Combined Riboflavin and UV-A Light (365 nm) Treatment of Acanthamoeba Trophozoites Invest. Ophthalmol. Vis. Sci. December 9, 2011 vol. 52 no. 13 9333-9338

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Anterior Segment OCT in Eyes with Cyclodialysis after Trabectome Glaucoma Surgery

Robert M. Knape, MD Primary Supervisor: Michael R. Banitt, MD Co-Authors: Fouad E. Sayyad, MD

Purpose: The Trabectome® (NeoMedix, Inc., Tustin, CA) is a novel surgical device used to perform ab interno trabeculotomy. An electrosurgical bipolar instrument is used to unroof Schlemm's canal and expose aqueous collector channels. The purpose of this study is to utilize Spectral-Domain high resolution anterior segment optical coherence tomography (AS-OCT) to evaluate the iridocorneal angle in patients with a cyclodialysis cleft after Trabectome glaucoma surgery. Methods: All Trabectome® glaucoma surgeries performed at the Bascom Palmer Eye Institute were reviewed with the operating surgeons. All cases were performed in conjunction with phacoemulsification cataract surgery. Three patients were noted to have a cyclodialysis cleft after Trabectome® glaucoma surgery. AS-OCT and full ophthalmic examination with gonioscopy were performed in the study patients. Subsequent examinations followed the postoperative course. Results: Patient 1 • Received laser photocoagulation x 2 • Cyclodialysis cleft resolved on gonioscopy on POM #4 • Cyclodialysis cleft still minimally patent on AS-OCT on POM #7 and POM #10 Patient 2 • Observation • Cyclodialysis cleft resolved on gonioscopy on POM #5 • Cyclodialysis cleft resolved on AS-OCT on POM #7 Patient 3

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• Observation • Cyclodialysis cleft resolved on both gonioscopy and AS-OCT on POM #1 Conclusion: • Cyclodialysis is a rare event seen in combination phacoemulsification-Trabectome® surgery • Cyclodialysis can be noted intraoperatively or postoperatively • High resolution AS-OCT in this study revealed variably sized areas of persistent cyclodialysis despite apparent resolution on gonioscopy • AS-OCT can guide postoperative management of hypotony associated with cyclodialysis • Laser photocoagulation or observation are reasonable treatment options • Outcomes in patients with cyclodialysis after combination phacoemulsification-Trabectome® in this study were excellent with no long-term sequelae References: 1. Mosaed S, Dustin L, Minckler DS. Comparative outcomes between newer and older surgeries for glaucoma. Trans Am Ophthalmol Soc. 2009 Dec;107:127-33. Review. 2. Jea SY, Francis BA, Vakili G, et al. Ab interno trabeculectomy versus trabeculectomy for open-angle glaucoma. Ophthalmology. 2012 Jan;119(1):36-42. Epub 2011 Oct 7. 3. Vold SD. Ab interno trabeculotomy with the trabectome system: what does the data tell us? Int Ophthalmol Clin. 2011 Summer;51(3):65-81. Review. No abstract available. 4. Minckler D, Dustin L, Mosaed S, et al. (2001.) Trabectome Update: 2004-2010. Poster presented at American Glaucoma Society 2010 Meeting in Naples, FL. 5. Mosaed S, Rhee DJ, Filippopoulos T et al. Trabectome outcomes in adult open-angle glaucoma patients: one-year follow-up. Clin Surg Ophthalmol. 2010;28:5–9.

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Ophthalmology Specific Emergency Departments Utilization Review: A Multicenter Analysis

Ryan F. Isom, MD Primary Supervisor: James T. Banta, MD Co-Authors: Joyce Schiffman, MS, Matthew Gardiner, MD

Purpose: To determine the utilization of the Bascom Palmer and Massachusetts Eye and Ear Infirmary ophthalmology specific emergency rooms and identify areas where efficiency and cost-effective care may be enhanced. Methods: Prospective survey of residents, fellows, and attendings in the ER for each patient visit over a period of at least 30 days. The survey contained information on the date of service, time of day, gender, age, duration of symptoms, physician referral, insurance status, preliminary diagnosis, and follow up date. The physician was also asked to classify the visit as emergent or non-emergent. Results: To be presented. Conclusion: To be presented. References: Fenton S, Jackson E, Fenton M. An audit of the ophthalmic division of the accident and emergency department of the Royal Victoria Eye and Ear Hospital, Dublin. Ir Med J. 2001 Oct;94(9):265-6. Hau S, Ioannidis A, Masaoutis P, Verma S. Patterns of ophthalmological complaints presenting to a dedicated ophthalmic Accident & Emergency department: inappropriate use and patients' perspective. Emerg Med J. 2008 Nov;25(11):740-4.

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Prendiville C, Nasser QJ, McGettrick P. Patients presenting to an Ophthalmic Emergency Department after 5pm. Ir Med J. 2008 Apr;101(4):116-8. Vernon SA. Analysis of all new cases seen in a busy regional centre ophthalmic casualty department during 24-week period. J R Soc Med. 1983 Apr;76(4):279-82.

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Visual Field Outcomes in the Tube vs. Trabeculectomy Study

Lauren S. Blieden, MD Primary Supervisor: Steven J. Gedde, MD Co-Authors: Steven J. Gedde, Joyce C. Schiffman, William J. Feuer, Phil Chen, Douglas Anderson

Purpose: To review the visual field examinations collected as part of the Tube vs. Trabeculectomy Study (TVT) and determine whether there was significant difference between the two study groups. Methods: Visual fields were collected at yearly visits from all patient enrolled in the TVT study. These visual fields were analyzed for reliability and progression based on mean deviation as a marker of progression. Some patients in the study were unable to perform visual fields for various reasons which were documented by the primary opthalmologist (i.e. loss of fixation, corneal decompensation, etc). Results: To be determined. Conclusion: To be determined. References:

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An Animal Model of Epithelial Downgrowth

Matthew J. Weiss, MD Primary Supervisor: Jeffery L. Goldberg, MD, PhD Co-Authors: Jessica Weinstein, MS

Purpose: In this project we will attempt to create a practical animal model for epithelial downgrowth. Methods: Rodent corneal epithelial cells were cultured them in vitro. During this period they were transfected the cells with lentivirus GFP. The resulting labeled epithelial cells were then placed in suspension and injected sterilely into the anterior chamber of living adult rats. The rats were then followed for one day, one week and one month to allow for the development of intraocular epithelial membranes analogous to those seen in human epithelial downgrowth. Epithelial cells were then examined through both immunohistological and immunofluorescence techniques, using a combination of serial sectioning. Results: Pending. Conclusion: Pending. References: 1) Burris, T. et al. Model of Epithelial Downgrowth: 1. Clinical Correlations and Light Microscopy. Cornea 1983 2: 277-87. 2) Burris, T. et al. Model of Epithelial Downgrowth: 2. Scanning and Transmission Electron Microscopy of Corneal Epithelialization. Cornea 1984 3: 141-51 3) Burris, T. et al. Long-term Evaluation of Epithelial Downgrowth Models. Cornea 1986 5(4): 211-21. 4) Forster, RK. Corneoscleral block excision of postoperative anterior chamber cysts. Transactions of the American Ophthalmologic Society. 1995; 93: 97-104.

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5) Pai, et al. MUC16 as a Sensitive and Specific Marker for Epithelial Downgrowth. Arch Ophthalmol. 2010;128(11):1407-1412. 6) Smith et al. Specular Microscopy of Epithelial Downgrowth. Arch Ophthalmol 1978; 96:1222-1224. 7) Vargas, et al. Epithelial Downgrowth after Clear Cornea Phacoemulsification. Ophthalmology 2002;109:2331–2335. 8) Weiner MJ, Trentacoste J, Pon DM. Epithelial downgrowth: a 30-year clinicopathological review. British Journal of Ophthalmology.1989;73:6-11.

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Effect of Vp/Lp Shunts on Visual Function in Idiopathic Intracranial Hypertension

Timothy W. Winter, DO Primary Supervisor: Byron L. Lam, MD Co-Authors: Laura Huang, Sudarshan Ranganathan, William Feuer, Mike Tawfik, Giovanni Gregori

Purpose: Evaluate long-term visual function in patients with cerebrospinal fluid shunt (CFS) placement for Idiopathic Intracranial Hypertension (IIH). Methods: Retrospective chart review from a single institution with diagnosis of IIH beginning January 2000 to December 2010. Evaluation included history of visual and non-visual symptoms, presence of co-morbid diseases affecting the visual pathway, use of medications, self-reported height/weight, presence of neuro-imaging (including MRV to evaluate for central venous sinus thrombosis), lumbar puncture opening pressure, presence of ventro- or lumboperitoneal CFS placement, and presence of re-operations for shunt failure. Additionally, a specialized neuro-ophthalmic examination was performed, Humphrey and/or Goldmann visual fields, and optical coherence tomography of macula/retinal nerve fiber layer. Results: To be presented. Conclusion: To be presented. References: 1. Banta JT, Farris BK. Pseudotumor cerebri and optic nerve sheath decompression. Ophthalmology, October 2000;17(10):1907-12. 2. Brazis PW. Clinical review: The surgical treatment of idiopathic pseudotumor cerebri (idiopathic intracranial hypertension). Cephalgia, 2008;28:1361-1373.

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3. Feldon SE. Visual outcomes comparing surgical techniques for management of severe idiopathic intracranial hypertension. Neurosurg Focus, 2007;23(5):E6,1-7. 4. Uretsky S. Surgical interventions for idiopathic intracranial hypertension. Current Opinion in Ophthalmology, 2009;20:451-55. 5. McGirt MJ, Woodworth G, Thomas G, Miller N, Williams M, Rigamonti D. Cerebrospinal fluid shunt placement for pseudotumor cerebri-associated intractable headache: Predictors of treatment response and an analysis of long-term outcomes. J Neurosurg, 2004;101:627-32.

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Evaluation of Intracorneal Ring Segment Placement with a 200 Khz Femtosecond Laser

John W. French, MD Primary Supervisor: Sonia H. Yoo, MD Co-Authors: Kemel Ozulken, MD

Purpose: This present study aims at presenting high-speed femtosecond laser assisted Intacs segment implantation. Methods: Nineteen eyes of fifteen patients with keratoconus, clear central corneas, and contact lens intolerance had implantation of a symmetrical 0.45 mm Intacs segment (Addition Technology, Inc.) using 200 kHz femtosecond laser (WaveLight GmbH, Erlangen, Germany). The outcome of the procedure was evaluated in terms of uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), average keratometry value (K value) and spheric equivalent (SE). Results: We did not observe any intra or postoperative complications. Intacs implantation after tunnel creation with 200 kHz femtosecond laser was performed easily. At postoperative complete examination, clinically significant improvement was observed in mean UCVA which improved from 0.95± 0.39 to 0.66± 0.28 logMAR mean BSCVA improved from 0.46± 0.13 to 0.29± 0.21 logMAR, mean spherical equivalent considerably reduced from -7.15 ± 4.57 to -4.38±4.07 and K value reduced from 52.39 ± 5.79 to 49.78±6.84 D Improvement in parameters remained stable during the 3-month follow up period. Conclusion: Using a 200 kHz femtosecond laser in the channel creation for Intacs implantation makes the procedure faster compared to slower femtosecond laser systems without increasing the risk of operative and postoperative complications and provides good visual and refractive outcomes.

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References: 1) Pearson RM. Kalt, keratoconus, and contact lens. Optom Vis Sci. 1989; 66:643-646. 2) Rabinowitz YS. Keratoconus. Surv Ophthalmol 1998; 42:297-319. 3) Alió JL, Shabayek MH. Corneal higher order aberrations: a method to grade keratoconus. J Refract Surg 2006; 22:539-545. 4) Gobbe M, Guillon M. Corneal wavefront aberration measurements to detect keratoconus patients. Con Lens Anterior Eye 2005; 28: 57-66. 5) Ohguro N, Mastuda M, Shimomura Y, et al. Effects of penetrating keratoplasty rejection on the endothelium of the donor cornea and recipient peripheral cornea. Am J Ophthalmol. 2000; 129:468-471.

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Molecular Surveillance of Contact Lenses, Cases, and Solutions for the Presence of Free-Living Amoeba among Patients with Infectious Keratitis

Ryan C. Young, MD Primary Supervisor: Harry W. Flynn, MD Co-Authors: Jorge Maestre-Mesa, Eduardo C. Alfonso, MD, Darlene Miller, DHSc

Purpose: To determine the prevalence of free-living amoeba among patients’ contact lenses, cases, and solutions and to compare multiplex PCR with traditional culture techniques in the detection of free-living amoeba among patients with infectious keratitis. Methods: We evaluated the efficacy of a multiplex PCR assay for the detection of free-living amoeba (Acanthamoeba, Vahlkampfia, Naegleria, and Hartmanella) and compared PCR results with cultures of 187 contact lenses and lens cases and 47 contact lens solutions collected within the last 5 years. Results: Free-living amoeba were isolated in 27 of 187 contact lenses and cases by combined PCR and culture techniques, for an overall prevalence of 14.4%. 10 cases of amoeba (9 verified Acanthamoeba and one unidentified free-living amoeba) were identified by culture techniques alone (5.3%), while 17 cases of amoeba (8 Acanthamoeba and 9 Hartmanella) were identified by multiplex PCR (9.1%) (χ2 = 12.213, p = 0.0005). The sensitivity and specificity of culture, using PCR as the gold standard, were 23.5% and 96.%, respectively. Acanthamoeba was isolated in one of 47 contact lens solutions by PCR, for a prevalence of 2.1%. All cultures of contact lens solutions were negative for free-living amoeba. Among the 187 patients with contact lenses and cases cultured, 42 had corneal cultures done, of which 5 were positive for Acanthamoeba for a prevalence of 11.9%. Three of the 5 cases were confirmed by

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cultures of contact lens cases. No cases of Vahlkampfia or Naegleria were identified in this study. Conclusion: Acanthamoeba and Hartmanella were more frequently isolated by PCR than by traditional culture techniques. Multiplex PCR assay is a useful adjunct to traditional culture techniques for the detection of free-living amoeba in contact lenses, cases, and solutions in patients with recalcitrant infectious keratitis. Hartmanella may be a more frequent cause of amoebic keratitis than previously recognized in South Florida. References: Dart KJG, Saw VPJ, Kilvington S. Acanthamoeba Keratitis: Diagnosis and Treatment Update 2009. Am J Ophthalmol 2009;148:487-499.

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Clinical Course of Unoperated Eyes with Vitreomacular Traction Syndrome

Vishak J. John, MD Primary Supervisor: Harry W. Flynn, Jr., MD Co-Authors: William E. Smiddy, MD

Purpose: To investigate the clinical course of patients with Vitreomacular Traction Syndrome [VMTS] on OCT who did not undergo any surgical intervention. Methods: Retrospective, non-consecutive, case series of patients of two vitreoretinal surgeons at Bascom Palmer Eye Institute [HF&WS]. Patients with VMTS noted on SD-OCT were included. Results: • 49 study eyes in 35 patients analyzed • Mean age of 75.6 years [range 41—92] • Race:21 White, 10 Hisp, 2 Black, 2 Asian • Mean follow up time: 21 months [1-91 ] • Over the course of the study, •2/16 [12%] pts with Stage 1 resolved spontaneously •5/27[19%] with Stage 2 resolved spontaneously •4/6 [66%] with Stage 3 resolved spontaneously Conclusion: • Patients with VMTS diagnosed by OCT but with minimal or non-progressive symptoms should be considered for noninterventional observation rather than surgery or pharmacologic injection • 11/49 eyes [22%] resolved spontaneously • Surgery or pharmacotherapy can be considered for eyes with progressive visual and anatomic worsening.

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References: 1. Schneider EW, et al. Emerging nonsurgical methods for the treatment of vitreomacular adhesion: a review. Clin Ophthalmol. 2011;5:1151-65. Epub 2011 Aug 18. 2.Mirza RG, Johnson MW, Jampol LM. Optical coherence tomography use in evaluation of the vitreoretinal Interface: a review. Surv Ophthalmol. 2007 Jul-Aug;52(4):397-421. 3. Ocriplasmin for the treatment of symptomatic VMA: MIVI-TRUST Phase 3 data. Provided by Thrombogenics.

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Analysis of Epiretinal Membranes Using Spectral Domain Optical Coherence Tomography (OCT)

Ajay E. Kuriyan, MD Primary Supervisor: William E. Smiddy, MD Co-Authors: Delia Cabrera DeBuc, PhD, Wei Gao, PhD, Yuduan Gao, MD

Purpose: To use spectral domain optical coherence tomography (SD-OCT) to determine differences in reflectivity and thickness between normal control eyes and eyes before and after epiretinal membrane (ERM) removal. Methods: Thirty-six eyes with idiopathic ERM and 12 normal fellow eyes were imaged preoperatively and postoperatively using SD-OCT. Differences in preoperative and postoperative best corrected visual acuity (BCVA, logMAR) were analyzed using a paired t-test. The thickness and reflectivity of each foveal SD-OCT image were assessed using a custom-built algorithm. Differences in reflectivity and thickness between the control, pre-operative ERM patients, and post-operative ERM patients were analyzed using a one-way ANOVA with post-hoc Newman-Keuls test. Receiver operating characteristic (ROC) curves were constructed to describe the ability of each parameter to discriminate between the normal, pre-operative ERM, and post-operative ERM eyes . A p-value or asymptotic significance less than 0.05 was considered statistically significant. Results: There was an improvement (p = 0.007) in postoperative BCVA (logMAR, mean: 0.37, SD: 0.20) compared to preoperative BCVA (logMAR, mean: 0.50, SD: 0.25). Preoperative (p = 0.02) and postoperative (p = 0.02) ERM patients had lower foveal mean reflectance (MR) than normal eyes. Preoperative ERM patients (p = 0.02) had higher foveal total reflectance (TR) than normal eyes. There was no statistically significant difference in foveal TR between postoperative ERM patients and normal eyes. Preoperative (p = 0.0001) and postoperative (p = 0.002) ERM patients had thicker foveal retinas than normal eyes. Postoperative ERM patients had a decrease in foveal retina thickness compared to preoperative ERM patients (p = 0.0001). ROC analysis comparing

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pre- and postoperative foveal SD-OCTs estimated an area under the ROC (AUROC) of 0.68 (asymptomatic sig. = 0.009) for TR and 0.83 (asymptomatic sig. = 0.000) for thickness. Similarly, when comparing preoperative foveal and normal and SD-OCTs, an AUROC of 0.74 (asymptomatic sig. = 0.015) for TR and 0.97 (asymptomatic sig. = 0.000) for thickness was estimated. Conclusion: ERM-peeling surgery resulted in significantly improved BCVA. Decreased MR, TR, and thickness are seen when comparing SD-OCTs of pre-operative ERM patients to normal eyes. ERM surgery results in improvement of SD-OCT TR and thickness. These changes measured by SD-OCT may represent anatomical recovery of the retina once traction is released by epiretinal-peeling surgery and may contribute to improved BCVA. References: 1. Gao W, Tátrai E, Ölvedy V, et al. Investigation of changes in thickness and reflectivity from layered retinal structures of healthy and diabetic eyes with optical coherence tomography. J. Biomedical Science and Engineering 2011;4:657–665. 2. Inoue M, Morita S, Watanabe Y, et al. Inner segment/outer segment junction assessed by spectral-domain optical coherence tomography in patients with idiopathic epiretinal membrane. Am J Ophthalmol 2010;150:834–839. 3. Legarreta JE, Gregori G, Knighton RW, et al. Three-Dimensional spectral-domain optical coherence tomography images of the retina in the presence of epiretinal mambranes. Am J Ophthalmol 2008;145:1023–1030. 4. Michalewski J, Michalewska Z, Cisiecki S, Nawrocki J. Morphologically functional correlations of macular pathology connected with epiretinal membrane formation in spectral optical coherence tomography (SD-OCT). Graefe’s Arch Clin Exp Ophthalmol 2007;245:1623–1631. 5. Oster SF, Mojana F, Brar M, et al. Disruption of the photoreceptor inner segment/outer segment layer on spectral domain-optical coherence tomography is a predictor of poor visual acuity in patients with epiretinal membranes. Retina 2010;30:713–718. 6. Smiddy WE, Maguire AM, Green RW, et al. Idiopathic epiretinal membranes ultrastructural characteristics and clinicopathologic correlation. Ophthalmology 1989;96:811–821. 7. Suh MH, Seo JM, Park KH, Yu HG. Associations between macular findings by optical coherence tomography and visual outcomes after epiretinal membrane removal. Am J Ophthalmol 2009;147:473–480.

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Total Thyroidectomy for the Treatment of Severe Progressive Thyroid Eye Disease

Andrea Lora Kossler, MD Primary Supervisor: David T. Tse, MD Co-Authors:

Purpose: To investigate whether bilateral total thyroidectomy (TT) is effective in halting the progression of severe thyroid associated ophthalmopathy in patients already treated with maximal medical therapy or radioactive iodine (RAI) treatment. Methods: 20 patients with severe progressive thyroid associated ophthalmopathy despite anti-thyroid drug treatment, euthyroid state, or radioactive iodine treatment underwent bilateral total thyroidectomy. The ophthalmopathy was classified as severe based on decrease in visual acuity, afferent pupil defect, restriction of extraocular movements, visual field compromise, and optic nerve changes. Orbital ultrasound (US), magnetic resonance imaging (MRI), or computed tomographic (CT) scan was used to further evaluate the extent of orbital disease and optic nerve compression. Finally, immunologic markers including TSI and TBII were compared before and after thyroidectomy. Results: Total thyroidectomy was accomplished with very low morbidity and provided a reduction in TSI and TBII levels with an improvement or stabilization in thyroid associated ophthalmopathy in the majority of patients in this study. Conclusion: Total thyroidectomy is effective and should be considered as treatment for patients with severe progressive thyroid associated ophthalmopathy despite radioactive iodine therapy, euthyroid state, or anti-thyroid drug treatment.

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References: 1. Menconi F. Marino M. Pinchera A. Rocchi R. Mazzi B. Nardi M. Bartalena L. Marcocci C. Effects of total thyroid ablation versus near-total thyroidectomy alone on mild to moderate Graves orbitopathy treated with intravenous glucocorticoids. Journal of Clinical Endocrinology & Metabolism. 92(5):1653-8, 2007 May. 2. Nart A. Uslu A. Aykas A. Yuzbasioglu F. Dogan M. Demirtas O. Simsek C. Total thyroidectomy for the treatment of recurrent graves disease with ophthalmopathy. Asian Journal of Surgery. 31(3):115-8, 2008 Jul. 3. Marushak D. Faurschou S. Blichert-Toft M. Regression of ophthalmopathy in Graves disease following thyroidectomy. A systematic study of changes of ocular signs. Acta Ophthalmologica. 62(5):767-79, 1984

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Outcomes of Adjustable Suture Strabismus Surgery with 2% Lidocaine Versus 2% Lidocaine with 0.4% Ropivacaine

Kara M. Cavuoto, MD Primary Supervisor: Hilda Capo, MD Co-Authors: Howard Palte, MD, Steven Gayer, MD, Raina Moyer

Purpose: The local anesthetic agent ropivacaine provides longer sensory blockade duration than lidocaine without prolonging motor blockade, which could be advantageous to the strabismus surgeon. Our study seeks to precisely define the recovery of extraocular muscle function and sensory acquisition (pain) in patients undergoing elective adjustable suture strabismus surgery with lidocaine versus lidocaine with ropivacaine blockade. Methods: The study is a prospective, randomized, double-blinded clinical study. Patients will be randomized to anesthetic blockade with either 2% lidocaine or 2% lidocaine with 0.4% ropivacaine. Lancaster red-green testing will be conducted preoperatively, and at two, four, and six hours after the surgical procedure to evaluate recovery of muscle function. Pain will be assessed at similar intervals using the Visual Analog Pain scale. Results: A series of patients will be presented in both the lidocaine alone and in the lidocaine with ropivacaine arms of the study. Conclusion: Patients randomized to the lidocaine plus ropivacaine group may have a decreased need for additional analgesia post-operatively while still maintaining the same level of comfort and success of suture adjustment.

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References: Brown Dr, Pacheco EM, Repka MX. Recovery of extraocular muscle function after adjustable suture strabimus surgery under local anesthesia. J Pediatr Ophthalmol Strabismus. 1992;29(1):16-20. Walters G, Stewart OG, Bradbury JA. The use of subtenon ropivacaine in managing strabismus with adjustable sutures. J AAPOS. 2001 Apr;5(2):95-7.

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Anterior Segment OCT in the Diagnosis and Treatment of Subclinical Conjunctival Intraepithelial Neoplasms (CIN)

Benjamin J. Thomas, MD Primary Supervisor: Carol L. Karp, MD Co-Authors: Patrick Oellers, MD

Purpose: To examine the clinical features of the use of ultra high-resolution, anterior segment OCT (UHR-OCT) in the detection, monitoring, and differentiation of conjunctival neoplasms, especially in the setting of subclinical disease. Methods: Retrospective case series. Results: The cases of 16 patients with varying presentations of ocular surface neoplastic disease were reviewed. Using UHR-OCT, an experienced observer was able to detect conjunctival intraepithelial neoplasms (CIN) which are subclinical in presentation, monitor these lesions to full resolution, and differentiate epithelial neoplasms from other forms of ocular surface disease, including subepithelial scarring, Salzmann's nodular degeneration, and conjunctival melanoma. Conclusion: Anterior segment UHR-OCT can be used to effectively detect subclinical presentations of CIN and monitor these lesions until full resolution, when performed by an experienced observer. Additionally, this imaging modality can be used to differentiate epithelial neoplasms from other ocular surface neoplastic and degenerative diseases. References: Wang J, et al. Ultra-high resolution optical coherence tomography for imaging the anterior segment of the eye. Ophthalmic Surg Lasers Imaging. 2011;42 Suppl:S15-27.

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Kieval JZ, et al. Ultra-high resolution optical coherence tomography for differentiation of ocular surface squamous neoplasia and pterygia. Ophthalmology. 2012;119(3):481-486. Shousha MA, et al. Diagnosis and management of conjunctival and corneal intraepithelial neoplasia using ultra high-resolution optical coherence tomography. Ophthalmology. 2011;118(8):1531-1537. Vajzovic LM, et al. Ultra high-resolution anterior segment optical coherence tomography in the evaluation of anterior corneal dystrophies and degenerations. Ophthalmology. 2011;118(7):1291-1296. Epub 2011 Mar 21.

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Changes in Clinical Practice: A Survey of the American Glaucoma Society

Joseph F. Panarelli, MD Primary Supervisor: Michael R. Banitt, MD, MHA Co-Authors: Donald L. Budenz, MD, Paul Sidoti MD, Kuldev Singh MD

Purpose: To determine the clinical impact of eight randomized, multicenter, clinical trials in glaucoma. Methods: An electronic survey consisting of 26 total questions was generated and emailed to the 894 members on the AGS listserv. Each participant was asked to answer two study specific questions as well as one general question common to all 8 studies. The final two questions were to determine the participants’ type of practice and number years in practice. A 5-point Likert scale was used for rating individuals’ responses. Results: There were 206 total responses received with 193 unique IP addresses identified. The individual response rate was 23% (206 out of 894). 46.4% of participants were clinicians in academic practice while 53.6% were in private practice. The greatest number of responses came from clinicians in practice over twenty years. Mean Likert scores based upon the standard question for each RCT showed that the OHTS study had the greatest clinical impact while the EGPS had the least. Conclusion: In conclusion, it is often difficult to translate how the results of an RCT affect clinical practice, but clinician surveys are one tool that can give meaningful results. This survey provides a subjective assessment of 8 large-scale, randomized, multicenter, clinical trials in glaucoma. Although responses may have been influenced by features of the study itself, several interesting trends were identified by this survey. The practice of evidence-based medicine is subject to individual and community biases in addition to objective data presented in the literature.

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References: 1. De Moraes CG, Ritch R, Liebmann JM. Bridging the major prospective National Eye Institute-sponsored glaucoma clinical trials and clinical practice. J Glaucoma. 2011 Jan;20(1):1-2. 2. Singh K. The randomized clinical trial: beware of limitations. J Glaucoma. 2004 Apr;13(2):87-9. 3. Schwartz AL. Argon Laser Trabeculoplasty in Glaucoma: What’s Happening (Survey Results of the American Glaucoma Society Members). J Glaucoma 1993; 2(4): 329-336 4. Mansberger SL, Cioffi GA. The probability of glaucoma from ocular hypertension determined by ophthalmologists in comparison to a risk calculator. J Glaucoma. 2006;15(5):426–31. 5. Caprioli J. The Tube Versus Trabeculectomy Study: why its Findings May Not Change Clinical Practice. American Journal of Ophthalmology. 2011 151(5): 742-3

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Management of Acute Severe Ocular Surface Disorders from the Bedside to the Bench

Guillermo Amescua, MD Primary Supervisor: Victor L. Perez, MD Co-Authors: Nicholas Cutrufello

Purpose: Establish a mouse model of alkali ocular surface burns to study the wound healing mechanism after a chemical burn and also to study the role of amniotic membrane transplantation (AMT) in corneal wound healing after an alkali burn. Methods: C57B6 mice were used to create a standardized model of chemical burns that can consistently develop limbal stem cell deficiency. Different dilution of an alkali substance at different exposure times were tested in order to obtain LSCD and avoiding corneal perforation. Also, with the use of Enhanced Green Fluorescent Protein technology, C57B6 chimeric EGFP mice were developed and used to test the innate immune response after a chemical burns and the role of amniotic membrane. Results: A consistent mouse model of LSCD after a chemical burn was developed. The early use of Amniotic membrane grafting after a chemical burns improved the epithelium healing time, decreases corneal neovascularization and may decrease corneal scarring. Conclusion: Our animal data correlates with the clinical data that shows that early medical and surgical intervention with AMT in patients with severe ocular surface burns improved the clinical prognosis. The new eye model can be used to better understand the wound healing mechanisms and possible areas of intervention to improve the outcomes.

References: 1.Gregory DG, Treatment of acute Stevens-Johnson syndrome and toxic epidermal necrolysis using amniotic membrane: a review of 10 consecutive cases.Ophthalmology. 2011 May;118(5):908-14 2.Tandon R, Gupta N, Kalaivani M, Sharma N, Titiyal JS, Vajpayee RB.Amniotic membrane transplantation as an adjunct to medical therapy in acute ocular burns.Br J Ophthalmol. 2011 Feb;95(2):199-204 3.Fu Y, Gregory DG, Sippel KC, Bouchard CS, Tseng SC.The ophthalmologist's role in the management of acute Stevens-Johnson syndrome and toxic epidermal necrolysis.Ocul Surf. 2010 Oct;8(4):193-203.


Factors Affecting DSAEK Lenticule Adhesion

Ana Paula F.S. Canto, MD Primary Supervisor: Michael R. Banitt, MD Co-Authors: Sonia H. Yoo, MD, Pravin Vaddavalli, MD

Purpose: To determ in vitro the estimation of the minimum IOP required for optimal donor adhesion during DSAEK and the effect of corneal massage and venting incisions on donor adhesion during DSAEK. Methods: Graded increase in intraocular pressure with an air bubble was performed in 10 in vitro DSAEK surgeries. Areas of donor non-adhesion were measured on serial high-resolution spectral domain OCT. Serial high-resolution spectral domain OCT imaging was performed before and after corneal massage and venting incisions in 10 in vitro DSAEK surgeries and areas of donor non-adhesion were measured. Results: An air bubble with IOP at 30mmHg for 5 minutes achieved optimal adhesion, which improved over an hour compared to reducing the pressure to 10mmHg or by an air fluid exchange. Corneal surface massage did not seem to improve adhesion but venting incisions followed by surface massage resulted in better donor adhesion. Conclusion: In this in vitro study, we found that the minimum intraocular pressure required by an air bubble in the anterior chamber to achieve optimal adhesion in DSAEK surgery was 30 minutes and further increase in pressure did not improve adhesion significantly. It was also seen that leaving an air bubble in the anterior chamber for an hour, improved adhesion compared to exchanging it for fluid after 5 minutes. We also found that corneal surface massage did not reduce interface fluid gaps and had no role to play in improving donor adhesion by itself but did result in both reduced interface gaps and better donor adhesion if done following corneal venting incisions.

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References: To be presented.

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Management of Acute Severe Ocular Surface Disorders, from the Bedside to the Bench

Ruwan A. Silva, MD, MPhil Primary Supervisor: Harry W. Flynn, MD Co-Authors: Charles C. Wykoff, MD, PhD Darlene Miller, DHSc, MPH

Purpose: To report the fungal species isolated from ocular specimens in a large series of patients with exogenous fungal endophthalmitis. Methods: Retrospective, single institution, consecutive case series. The microbiologic and medical records of all patients treated at the Bascom Palmer Eye Institute between January 1, 1990, and June 30, 2010, for culture-proven exogenous fungal endophthalmitis were reviewed. Results: From 151 culture proven cases of fungal endophthalmitis, exogenous fungal endophthalmitis occurred in 85 eyes, including 32 cases (38%) associated with fungal keratitis and 38 cases (45%) occurring after penetrating ocular trauma or intraocular surgery. Twenty five distinct species were isolated. Thirty three percent (28/85) of exogenous fungal endophthalmitis cases were caused by yeast species and 67% (57/85) were caused by mold species. In total, 5 yeast species and 20 mold species were isolated. The most common yeasts were Candida albicans (19/28) and Candida parapsilosis (5/28) accounting for 86% (24/28) of cases. The most common molds were Fusarium oxysporum (12/57), Fusarium species (7/57), Aspergillus fumigatus (6/57) and Aspergillus terreus (5/57) accounting for 53% (30/57) of cases. Conclusion: This report highlights the differences between the clinical categories of

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exogenous fungal endophthalmitis. Although 76% of all cases were caused by molds, most commonly Fusarium and Aspergillus, the most common fungal species varied by clinical category. References: 1. Hariprasad, S.M., et al., Voriconazole in the treatment of fungal eye infections: a review of current literature. Br J Ophthalmol, 2008. 92(7): p. 871-8. 2. Varma, D., et al., Use of voriconazole in candida retinitis. Eye (Lond), 2005. 19(4): p. 485-7.3. 3. Rychener, R.O., Intra-Ocular Mycosis. Trans Am Ophthalmol Soc, 1933. 31: p. 477-96. 4. O'Day, D.M., et al., Intraocular penetration of systemically administered antifungal agents. Curr Eye Res, 1985. 4(2): p. 131-4. 5. Baldinger, J., et al., Retinal toxicity of amphotericin B in vitrectomised versus non-vitrectomised eyes. Br J Ophthalmol, 1986. 70(9): p. 657-61.

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Mycobacterial Endophthalmitis

D Wilkin Parke III, MD Primary Supervisor: Thomas A. Albini, MD Co-Authors: Harry W. Flynn Jr, MD, Milan Shah, MD

Purpose: To review all recent cases of culture-proven mycobacterial endophthalmitis at Bascom Palmer Eye Institute. Methods: Retrospective chart review of consecutive patients with culture-proven mycobacterial endophthalmitis from 1990 to 2012. Results: To be presented. Conclusion: To be presented. References: To be presented.

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OCT Findings in Posterior Uveitis Secondary to Syphilis

Swetangi D. Bhaleeya, MD Primary Supervisor: Thomas A. Albini, MD Co-Authors: Janet L. Davis, MD; Jane Fishler, MD

Purpose: To analyze optical coherence tomography (OCT) findings in syphilis posterior uveitis. Methods: A retrospective chart review was performed of 20 patients with laboratory-confirmed syphilis uveitis. Those with ocular inflammation limited to the anterior segment were excluded. Cases with no OCT at the time of active inflammation were also excluded. Demographic data such as age and gender were noted. Clinical exam findings at the time of presentation and at last follow-up visit were recorded. OCT scans were reviewed and key findings were noted. Results: Of the 20 laboratory-confirmed cases of syphilis uveitis reviewed, 7 cases (12 eyes) were included. All 7 patients were male with a mean age of 46. Five of the 7 patients had bilateral involvement. Four out of seven were HIV positive. Fifty-seven percent (n=4) of the patients tested positive for both RPR and FTA-ABS, whereas two had a non-reactive RPR but reactive FTA-AB. Three patients had chorioretinitis, two had retinal vasculitis, one had neuroretinitis, and one had optic neuritis. A variety of OCT findings were seen. Central retinal thickness ranged from 167 to 558 microns. Three eyes revealed subretinal fluid, two had foveal thinning, one had shallow retinal pigment epithelial (RPE) detachments, and one showed inner retinal hyperreflectivity. Conclusion: Multiple OCT findings were observed in posterior segment syphilitic uveitis. Shallow neurosensory detachment was the most common finding in this small case series. OCT maybe a useful imaging modality to monitor response to treatment in syphilis posterior uveitis that have findings of neurosensory retinal detachement.

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References: 1. Fonollosa A, Giralt J, Pelegrıń L, Sańchez-Dalmau B, Segura A, Garcıá-Arumı´ J, et al. Ocular syphilis—back again: understanding recent increases in the incidence of ocular syphilitic disease. Ocul Immunol Inflamm. 2009;17:207–12. 2. Browning DJ. Posterior segment manifestations of active ocular syphilis, their response to a neurosyphilis regimen of penicillin therapy, and the influence of human immunodeficiency virus status on response. Ophthalmology. 2000;107:2015–23. 3. Brito P, Penas S, Carneiro A, Palmares J, Reis FF. Spectral-domain optical coherence tomography features of acute syphilitic posterior placoid chorioretinitis: the role of autoimmune response in pathogenesis. Case Report Ophthalmol. 2011 Jan 25;2(1):39-44 4. Meira-Freitas D, Farah ME, Höfling-Lima AL, Aggio FB. Optical coherence tomography and indocyanine green angiography findings in acute syphilitic posterior placoid choroidopathy: case report. Arq Bras Oftalmol. 2009 Nov-Dec;72(6):832-5. 5. Zorn C, Kook P, Glaser E, Feucht N, Lanzl I, Maier M, Lohmann CP. Spectral domain OCT in patients with unclear uveitis. Ophthalmologe. 2011 Aug;108(8):766-9

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Systemic Complement Inhibition with Eculizumab for the Treatment of Drusen in AMD: The COMPLETE Study

Jyoti R. Dugar, MD Primary Supervisor: Philip J. Rosenfeld, MD, PhD Co-Authors: Zohar Yehoshua, M.D.; Carlos Alexandre de Amorim Garcia Filho, M.D.; Renata Portella Nunes, M.D.; Mathew K. George, M.D.; Dimple Modi, M.D.; Gene W. Chen, M.D.; Ying Li, M.D.; William Feuer, M.D.; Fernando M. Penha, M.D.; SriniVas Sadda, M.D.; Kang Zhang, M.D.; Giovanni Gregori, M.D.; Andrew A. Moshfeghi, M.D.

Purpose: The COMPLement Inhibition with Eculizumab for the Treatment of Non-Exudative Age-Related Macular Degeneration (COMPLETE) Study was designed to prospectively evaluate the effect of eculizumab, an FDA-approved systemic inhibitor of complement component 5 (C5), on drusen area and volume in eyes of patients with non-exudative age-related macular degeneration (AMD). Methods: Patients with eyes containing drusen were randomized 2:1 to receive intravenous eculizumab or placebo. The drusen volume measured at least 0.03 mm3 within the central 3 mm of the macula using SDOCT imaging. The first 10 patients randomized to active treatment received 600mg eculizumab for 4 weeks followed by 900mg every 2 weeks, while the next 10 patients received 900mg eculizumab for 4 weeks followed by 1200mg every two weeks. After 26 weeks, patients were followed without treatment every 3 months for 6 months. Ophthalmologic exam, ETDRS visual acuity testing, and imaging studies were performed. Genotyping was performed on all patients. Primary endpoint was the change in drusen volume at 6 months. Results: Thirty patients (study eyes) were enrolled and randomized 1:1:1 to the low dose, high dose, and placebo groups. At baseline, the mean drusen areas (SD) were 2.1 mm2 (1.0) and 1.9 mm2 (0.7) for the eculizumab and placebo groups, respectively (p=0.80). The mean drusen volumes were 0.15 mm3 (0.17) and 0.12 mm3 (0.08) for each group respectively (p=0.64). Low and high dose eculizumab groups did not differ

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significantly in drusen area and volume measurements, p=0.058 and p=0.077 respectively. Baseline mean ETDRS visual acuity scores were 80.9 (5.9) and 78.0 (10.0) letters for the eculizumab and placebo groups. The deficits in the low luminance visual acuity scores at baseline were 14.4 (4.9) and 15.5 (5.4) letters (p=0.58). In addition, 12 fellow eyes were found to meet entry criteria and will be evaluated as a secondary endpoint. Twenty-eight out of 30 patients (93%) completed the follow-up through 26 weeks. No drug-related adverse events were identified through 6 months. Conclusion: Systemic complement inhibition with the FDA-approved C5 inhibitor known as eculizumab was well tolerated through 6 months. The outcome data describing the effect of eculizumab on drusen area and volume will be presented. References: 1. Gregori, G., F. Wang, et al. (2011). "Spectral domain optical coherence tomography imaging of drusen in nonexudative age-related macular degeneration." Ophthalmology 118(7): 1373-1379. 2. Yehoshua, Z., F. Wang, et al. (2011). "Natural history of drusen morphology in age-related macular degeneration using spectral domain optical coherence tomography." Ophthalmology 118(12): 2434-2441. 3. Yehoshua, Z., P. J. Rosenfeld, et al. (2011). "Progression of geographic atrophy in age-related macular degeneration imaged with spectral domain optical coherence tomography." Ophthalmology 118(4): 679-686. 4. Sunness, J. S., G. S. Rubin, et al. (2008). "Low luminance visual dysfunction as a predictor of subsequent visual acuity loss from geographic atrophy in age-related macular degeneration." Ophthalmology 115(9): 1480-1488, 1488 e1481-1482. 5. Chen, Y., J. Zeng, et al. (2011). "Assessing susceptibility to age-related macular degeneration with genetic markers and environmental factors." Arch Ophthalmol 129(3): 344-351.

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Differentiating Papilledema and Optic Disc Drusen Using Optical Coherence Tomography

Kaushal M. Kulkarni, MD Primary Supervisor: Byron L. Lam, MD Co-Authors: Joshua Pasol, MD, Byron L. Lam, MD

Purpose: To determine whether spectral domain optical coherence tomography (SD-OCT) can be used to reliably differentiate papilledema from buried optic nerve head drusen (ONHD). Methods: Patients with papilledema due to idiopathic inracranial hypertension and patients with buried ONHD diagnosed by B-scan ultrasonagraphy were recruited from the neuro-ophthalmology service. Each patient underwent a complete neuro-ophthalmic exam, automated visual field testing, color fundus photography, autofluorescence of the optic disc, nerve fiber layer analysis, and SD-OCT through the optic nerve head. The images were qualitatively assessed to identify differentiating features between the two groups. Results: Eyes with buried ONHD typically demonstrate an irregular peripapillary retinal contour with a subretinal hyporeflective space on SD-OCT. Eyes with optic disc elevation due to papilledema may demonstrate elevation of the peripapillary retina with inward angulation of the retinal pigment epithelium. Conclusion: SD-OCT may have utility in differentiating papilledema from buried ONHD. However, B-scan ultrasonagrphy remains the most reliable method.

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References: 1. Wester ST, Fantes FE, Lam BL, Anderson DR, McSoley JJ, Knighton RW. Characteristics of optic nerve head drusen on optical coherence tomography images. Ophthalmic Surg Lasers Imaging 2010;41:83-90. 2. Kupersmith MJ, Sibony P, Mandel G, Durbin M, Kardon RH. Optical coherence tomography of the swollen optic nerve head: deformation of the peripapillary retinal pigment epithelium layer in papilledema. Invest Ophthalmol Vis Sci 2011;52:6558-64. 3. Lee KM, Woo SJ, Hwang JM. Differentiation of optic nerve head drusen and optic disc edema with spectral-domain optical coherence tomography. Ophthalmology 2011;118:971-7 4. Sarac O, Tasci YY, Gurdal C, Can I. Differentiation of Optic Disc Edema From Optic Nerve Head Drusen With Spectral-Domain Optical Coherence Tomography. J Neuroophthalmol 2012 Mar 31 [Epub ahead of print]. 5. Johnson LN, Diehl ML, Hamm CW, Sommerville DN, Petroski GF. Differentiating optic disc edema from optic nerve head drusen on optical coherence tomography. Arch Ophthalmol 2009;127:45-9.

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Predictors of Ocular Surface Squamous Neoplasia Recurrence after Excisional Surgery

Fasika A. Woreta, MD, MPH Primary Supervisor: Carol L. Karp, MD Co-Authors: Patrick Oellers, Anat Gallor, Julia Stein, Andrew Kao, Amany Abdelaziz,William Feuer, Sander Dubovy

Purpose: To identify predictors of ocular surface squamous neoplasia (OSSN) recurrence after surgical excision. Methods: Retrospective chart review of 389 patients with OSSN excised at the Bascom Palmer Eye Institute from January 1, 2001 to September 20,2010. Results: Of the 389 completely excised OSSN lesions, forty-four (11%) recurred during follow-up, with a mean time to recurrence of 2.5 years. The presence of positive surgical margins (HR=2.73,p=.008) and tarsal involvement (HR=4.12,p=0.007) were associated with an increased risk of tumor recurrence (HR=2.73, p=0.008). Treatment with adjuvant cryotherapy significantly decreased the risk of tumor recurrence (HR=0.51,p=0.03). In those patients with postiive margins, the use of topical inteferon therapy reduced the recurrence rate to a level similar to that of patients with negative margins. Conclusion: Patients with OSSN should be monitored carefully for recurrence after surgical excision. Adjuvant cryotherapy should be performed to decrease the risk of tumor recurrence. In patients with high risk OSSN characateristics such as positive surgical margins or tarsal involveent, post-operative adjuvant therapy should be considered.

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References: 1. Karp CL, Galor A, Chhabra S, et al. Subconjunctival/perilesional recombinant interferon alpha2b for ocular surface squamous neoplasia: a 10-year review. Ophthalmology 2010;117(12):2241-6. 2. Kiire CA, Srinivasan S, Karp CL. Ocular surface squamous neoplasia. International ophthalmology clinics 2010;50(3):35-46. 3. Sudesh S, Rapuano CJ, Cohen EJ, et al. Surgical management of ocular surface squamous neoplasms: the experience from a cornea center. Cornea 2000;19(3):278-83. 4. Karp C, Gupta A. Current strategies for surgical management for conjunctival and corneal intraepithelial neoplasia. Annals of ophthalmology 2009;41(2):72-6.

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The Effect of Pulsed Light Therapy on Meibomian Gland Dysfunction and Dry Eye Syndrome

Bradford W. Lee, MD, MSc Primary Supervisor: Wendy W. Lee, MD, MS Co-Authors: Fouad El Sayyad, Mohammed Gomaa, Samantha Herretes, Hilal Ozturk, Victor L. Perez

Purpose: Our primary aim is to determine whether pulsed light therapy (PLT) is effective in reducing symptoms and improving clinical stigmata of dry eye syndrome (DES) associated with meibomian gland dysfunction (MGD) in patients with facial rosacea. Our secondary aim is to compare the efficacy of PLT versus conservative treatment (i.e. warm eyelid compresses/massage, eyelid hygiene, and artificial tears) and whether PLT has an adjunctive benefit in patients already on conservative treatment. Methods: We are conducting a prospective randomized controlled trial with three arms: conservative therapy (i.e. warm compresses/massage BID, baby shampoo lid scrubs, and preservative-free artificial tears) + sham light treatment, conservative therapy + pulsed light therapy (PLT), and PLT only. Subjects are being recruited from the cornea and oculoplastics clinics at Bascom Palmer Eye Institute with chief complaints of dry eyes and must have meibomian gland disease as well as oculofacial rosacea. All subjects undergo baseline evaluation for DES with the Ocular Surface Disease Index (OSDI) questionnaire, evaluation of tear properties (tear breakup time, Schirmer's Test, osmolarity), staining of the cornea and conjunctiva with fluoresceine and lissamine green, and grading of the meibomian glands and their secretions. Primary outcomes will be anatomical improvement of the meibomian glands and their secretions. All subjects will come for their initial visit and treatment session, followed by two subsequent treatment sessions spaced 2-4 weeks apart. Following this, subjects in all groups undergo a post-treatment DES evaluation.

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Results: To be announced at Residents Day. Conclusion: Pulsed light therapy is a new technology used in the treatment of rosacea and telangiectasias that may have potential applications in the treatment of DES related to MGD and ocular rosacea. Further studies will be needed to confirm its safety, efficacy, and ideal treatment regimen in the periocular region for this off-label indication. References: 1. Tomlinson A, Bron AJ, Korb DR, et al. The International Workshop on Meibomian Gland Dysfunction: Report of the Diagnosis Subcommittee. Invest Ophthalmol & Vis Sci. 2011 Mar 30;52(4):2006-49. 2. Geerling G, Tauber J, Baudouin C, et al. The International Workshop on Meibomian Gland Dysfunction: Report of the Subcommittee on Management and Treatment of Meibomian Gland Dysfunction. 2011 Mar 30;52(4):2050-64. 3. Toyos R. Intense, Pulsed Light for Dry Eye Syndrome. Cataract & Refractive Surgery Today. 2009 April: 71-73. 4. Papageorgiou P, Clayton W, Norwood S, et al. Treatment of rosacea with intense pulsed light: significant improvement and long-lasting results. British Journal of Dermatology. 2008 Sep;159(3):628-32. 5. Babilas P, Schremi S, Szeimies RM, et al. Intense pulsed light (IPL): a review. Lasers Surg Med. 2010 Feb;442(2):93-104.

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Orbital Trauma and Retrobulbar Hemorrhage at Bascom Palmer and Jackson Memorial Hospital

Benjamin P. Erickson, MD Primary Supervisor: Wendy W. Lee, MD Co-Authors:

Purpose: To elucidate the clinical characteristics and outcomes of patients with orbital fractures and retrobulbar hemorrhage presenting to Bascom Palmer Eye Institute and Jackson Memorial Hospital emergency services, and to refine evidence-based treatment algorithms. Methods: Retrospective review of clinical documentation and imaging for consecutive adult patients presenting to the Bascom Palmer emergency department, Ryder Trauma Center, and Jackson Memorial Hospital emergency wards with orbital fractures and/or retrobulbar hemorrhage from 2010 onward. Calculations were performed with SPSS software using a variety of stastical tests. Results: Full results to be presented. Conclusion: Full conclusions to be presented. References: References to be presented.

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Comparison of Postoperative Pain and Surgical Outcomes with Two Different Types of Local Anesthesia for Conjunctival Mullerectomy

Chad C. Zatezalo, MD Primary Supervisor: Wendy W. Lee, MD, MS Co-Authors: Sara Wester, MD

Purpose: To evaluate postoperative pain and surgical outcomes with two different types of anesthesia for ptosis correction via conjunctival mullerectomy. Methods: Prospective Randomized Double Arm Comparative Study. Results: TBA. Conclusion: TBA. References: 1. Mercandetti M, Putterman AM, Cohen ME, Mirante JP, Cohen AJ. Internal levator advancement by Muller’s muscle-conjunctival resection: technique and review. Arch Facial Plast Surg. 2001 Apr-Jun;3(2):104-10. 2. Beard C. Muller’s superior tarsal muscle: anatomy, physiology and clinical significance. Ann Plast Surg. 1985;14:324-333

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