June 3, 2016 Conference
Fellow and Resident Poster Program
Residents, fellows, and trainees from all the New England ophthalmologic teaching programs are invited and encouraged to submit abstracts for a scientific poster presentation contest to be conducted at the June 3, 2016, NEOS meeting. Posters will be judged on originality and scientific merit. Awards will be made for the first prize $500.00, second prize $300.00, third prize $200.00 and three honorable mentions of $50.00 each. Funding for the awards is derived from a gift to the NEOS Education Endowment Fund honoring the late Sanford Hecht, MD.
Retrospective, case-control study of pediatric patients with and without idiopathic intracranial hypertension (IIH) from the ophthalmology department at single tertiary care center was performed. Neuroimaging and clinical findings of 49 patients with IIH and 30 control patients were evaluated. Compared to controls, IIH patients had larger perioptic subarachnoid space, and higher incidences of posterior globe flattening, protrusion of the optic nerve head, and empty sella turcica. A perioptic subarachnoid space measurement of ≥ 5.2mm had a sensitivity of 82% and a specificity of 67% for predicting IIH. The presence of transverse sinus stenosis, Chiari malformation, skull base crowding, prominent arachnoid granulations, and ventriculomegaly did not reach significance. Several highly sensitive key radiographic findings in pediatric IIH were identified and models were developed for predicting pediatric IIH, including an enlarged perioptic subarachnoid space and posterior globe flattening.
Objective: To evaluate features corresponding to patient- reported visual function using the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ-25). Design: Noncomparative, retrospective case series. Setting: Vision Rehabilitation registry at Massachusetts Eye and Ear Infirmary, Boston. Participants: 47 patients from 111 eligible patients with bilateral advanced AMD. Mainoutcome measures: Clinical assessment included age, gender, type of AMD, best-corrected visual acuity(VA), history of medical conditions, contrast sensitivity (CS), visual field loss ,report of Charles Bonnet Syndrome(CBS), current treatment for AMD and NEI VFQ-25 scores. Results: Mean age of patients was 83.2 ± 6.1 years and NEI VFQ-25 mean total score was 55.3 ± 19.8. Multivariate analysis showed that history of diadbetes mellitus (DM) was associated with the total score(p=0.006). Seconary analysis for subcategories of NEI VFQ-25 scores showed that age (p=0.038), and presence of DM (p=0.009) was associated with the general health . Binocuar VA (p=0.007) was associated with general vision, DM was associated with increase report of ocular pain (p=0.016), CS was associated with scores on near activity (p=0.001), mental health(p=0.038), color vision (p=0.010) and peripheral vision (p=0.011). CBS was associated with the score in mental health (p=0.031) and peripheral vision (p=0.029) and dependency subscale was associated with DM (p=0.003) and malignancy (p=0.013). Conclusion and relevance: DM was the only factor associated with total score of the NEI VFQ-25 score. Among the clinical features, history of DM, binocular VA, CS, and report of CBS were associated with of patient reported visual function in the secondary analysis, suggesting that these clinical factors will aid in assessing disease impact of low vision in patients with advanced AMD.
Emily Cole, Sabin Dang, Eduardo Novais, Ricardo Louzada, Caroline Baumal, Andre Witkin, Nadia Waheed, Jay Duker, Elias Reichel
Purpose: To evaluate whether an automated ischemia segmentation algorithm for optical coherence tomography angiography (OCTA) can stratify disease severity of retinopathy in patients with diabetes. Methods: Seventy-eight eyes from 40 patients with diabetes imaged on the RTVue XR Avanti AngioVue® platform were selected for image analysis. The dataset was chosen from consecutively imaged diabetic patients at New England Eye Center. No images were excluded for poor quality scans or motion artifact. We developed an algorithm which quantified geographic patches of non-perfusion on OCTA. This algorithm was able to identify poor quality scans and scale internal parameters to optimize signal to noise, thus no scans were excluded due to poor scan quality. The patients were stratified into five groups: diabetes without clinical diabetic retinopathy, mild/moderate/severe nonproliferative diabetic retinopathy (NPDR), and proliferative diabetic diabetic retinopathy (PDR). For each eye, the algorithm provided an OCTA ischemia index (OII) at the level of the superficial plexus, deep plexus, and choriocapillaris. An automated measurement of the FAZ was made at the level of the superficial and deep plexus. A chart review was performed to determine previous treatments (focal laser, PRP, anti-VEGF) as well as presence or absence of diabetic macular edema. Results: The OII was validated with repeated measurements over 4 days from 10 normal eyes. The OII of the superficial plexus increases with worsening diabetic retinopathy severity, but this trend was not seen in the deep plexus or choriocapillaris. In the superficial plexus, there was a significant difference in the OII (p<.05) between diabetics without retinopathy and mild NPDR compared to all other groups. In the deep plexus, there was a significant difference in the OII between diabetics without retinopathy compared to those with retinopathy. Automated measurement of the FAZ showed a significantly larger FAZ in PDR compared to the other groups. Conclusions: Automated algorithms can be used to asses the degree of ischemia in OCTA images from patients with diabetic retinopathy and may discriminate between different levels of disease severity.
Eduardo Novais, ByungKun Lee, Nadia Waheed, Mehreen Adhi, Talisa E. de Carlo, Emily Cole, Eric Moult, WooJhon Choi, Jay Duker, James Fujimoto
Purpose: Cross-sectional, observational study to investigate total retinal blood flow (TRBF) using en face Doppler optical coherence tomography (OCT) in eyes with diabetic macular edema (DME), non-proliferative diabetic retinopathy (NPDR), and proliferative diabetic retinopathy (PDR). Methods: TRBF was measured in 33 eyes of 18 patients with diabetic retinopathy (DR) (8 females, age 64.5±12.9 years), and 16 eyes of 12 normal control subjects (8 females, age 59.3±10.4 years), using a 1050-nm swept-source OCT prototype operating at 400-kHz axial scan rate. Volumetric data comprising 600×80 axial scans over a 1.5mm×2mm area at the optic disc was repeatedly acquired 24 times in 3.4 seconds. TRBF was automatically calculated and averaged over the cardiac cycle (Fig. 1). The patients were stratified by disease severity into mild NPDR, moderate NPDR, and severe NPDR or PDR as well as by the presence or absence of DME. Among the 12 eyes with DME, 3 were not treated prior to imaging, while other 3 received anti-VEGF only, 4 received focal laser only, and 3 received both anti-VEGF and laser. Results: Mean TRBF in the normal group, the DME group, and the DR without DME group was 44.4±8.3µL/min, 29.3±9.4µL/min, and 51.7±16.4µL/min, respectively (Fig. 2A). TRBF was significantly lower in the eyes with DME compared to both the normal eyes (p≤0.001, Welch’s t-test) and the DR eyes without DME (p≤0.002). Within the 20 DR eyes without DME, TRBF in the mild NPDR, moderate NPDR, and severe NPDR/PDR groups was 45.4±9.18µL/min, 49.5±19.1µL/min, and 55.4±11.7µL/min, respectively. Within the 13 eyes with DME, TRBF in the mild NPDR, moderate NPDR, and severe NPDR/PDR groups was 32.3µL/min, 30.7±10.2µL/min, and 25.2±6.2µL/min, respectively (Fig. 2B). Conclusions: TRBF in DR patients was measured by high-speed en face Doppler OCT. A decrease in TRBF was observed in eyes with DME compared to DR eyes without DME and normal eyes. Further investigation is merited as our observations suggest the complex nature of TRBF changes associated with DR progression.
Abhishek Payal, Tulay Cakiner-Egilmez, Luis Gonzalez Gonzalez, Amy Chomsky, David Vollman, Elizabeth Baze, Mary G. Lawrence, Mary K. Daly
Methods: Retrospective analysis of 4923 cataract surgery cases from the de-identified Ophthalmic Surgery Outcomes Database (OSOD) Program of the Veterans Health Administration (VHA). Cases were grouped into those without (Group A) or with (Group B) dementia or cognitive impairment. A subset of 3154 cases who completed both pre- and postoperative National Eye Institute-Visual Function Questionnaire (NEI-VFQ-25) was analyzed for functional visual improvement. Outcomes included all subscales of vision related quality of life (VRQoL), best-corrected visual acuity (BCVA) and perioperative events. Follow-up period was ≥ 30 days. Data were analyzed using analysis of variance, effect sizes (ES), chi-square, nominal logistic regression and nonparametric tests. Correlation was estimated using Pearson’s correlation coefficient. Results: 4757 (96.6%) of 4923 cases were in Group A, 154 (3.1%) cases in Group B, and 12 (0.2%) had missing data. BCVA improved significantly from pre-to post-surgery in Group A (0.08 ± 0.23, P<.0001) and in Group B (0.14 ± 0.28, P<.0001). Dementia or cognitive impairment, as defined by the OSOD, was not associated with postoperative BCVA worse than 20/40 (A:6.35% vs B:9.23%, OR 1.13, 95% CI 0.53 – 2.15, P=.73). There was comparable improvement in both the groups from pre-to post-surgery in BCVA (P=.95) and in VFQ composite scores (P=.17). Compared to those without dementia, veterans with dementia improved most in the VFQ subscale of social functioning (adj. ES -0.002) and least in ocular pain (adj. ES -0.36). The improvement in BCVA correlated significantly with improvement in VFQ composite scores in Group A (r =0.17, P<.0001) but not in Group B (r=0.13, P=0.24). There were no significant differences in the occurrence of 30 perioperative events in those with and without dementia. Conclusions: Cataract surgery offers significant and comparable improvement in vision and VRQoL for eyes in both groups. Among veterans with dementia or cognitive impairment, there is no significant correlation between improvement in BCVA and VRQoL. Factors other than improvement in vision may be affecting the gains in VRQoL.
Emily Wright, Emily Cole, Thomas R. Hedges III, Laurel Vuong
Methods: Patients with a prior or new diagnosis of nAION were recruited. The following were acquired for both eyes in each patient: OCTA of the peripapillary vasculature using the Optovue RTVue XR Avanti AngioVue®; structural OCT images of the retinal nerve fiber layer (RNFL) and ganglion cell layer (GCC) using a Zeiss Cirrus 5000; Humphrey Visual Fields (HVF). OCTA images were qualitatively graded for peripapillary retinal capillary and peripapillary choriocapillaris perfusion by a masked reader who reported whether each quadrant had OCTA changes consistent with low flow. The findings were then compared to HVF findings and RNFL and GCC measurements to assess for correlation. Results: Five patients were recruited, two of whom had bilateral nAION. Among the 7 eyes with nAION, OCTA of the optic nerve head revealed radial peripapillary capillary dropout that correlate with HVF deficits as well as RNFL and GCC thinning on structural OCT. Additionally, in five of the seven eyes, OCTA of the peripapillary choriocapillaris demonstrated ischemic changes which correlated with HVF deficits as well as RNFL/GCC structural OCT findings. In the remaining two eyes, angiography of the choriocapillaris was unreliable due to overlying optic nerve edema and motion artifact. In patients with unilateral nAION, there was an appreciable difference in the flow signal in the peripapillary choriocapillaris and retinal capillaries between the two eyes, with the affected eye demonstrating a relative decreased flow signal and vascular density. Conclusions: Our findings suggest that flow to both the peripapillary choriocapillaris and the radial peripapillary retinal capillaries are affected in nAION eyes. This has been difficult to demonstrate with traditional angiography. With the depth encoded angiogram provided by OCTA we are able to visualize segmental hypoperfusion of the these regions. To our knowledge, this is the first report to describe these findings. We plan to further this work through quantification of areas of low flow.
AM session Practical Advice for the Management of Ocular Trauma and Emergencies
Eye trauma is a common combat injury in the deployed environment, with traumatic eye injury and penetrating ocular trauma representing a major cause of injury in the combat zone. The range of ocular injuries from blast and improvised explosive devices, which have unfortunately become frequent in recent military efforts, will be reviewed in this talk. Clinical photos and illustrations will be used to outline the U.S. military approach to taking care of the trauma patient from the point of injury, initial triage, and management, as well as reporting through the trauma network. Case based presentations will be used to illustrate key principles.
Eye trauma is an important cause of visual loss nationally and internationally. Globe rupture is often classified based on the location of the site of rupture as zone 1, a laceration involving the cornea, zone 2, a laceration involving the sclera up to 5mm from the limbus, or zone 3, a laceration 5mm or more posterior to the limbus. Visual prognosis varies based on the location and extent of the laceration, as does the technique for surgical repair. This talk will use clinical photos from the Iraq and Afghanistan conflict, and surgical illustrations to demonstrate and discuss fundamental techniques for closing corneal and scleral laceration as well as adnexal injuries.. Approaches to help in difficult cases including the management of complex globe lacerations will be described.
Eye trauma is a devastating, life changing event for many people. Early recognition of open globe injuries is essential for preserving future function of the injured eye. Endophthalmitis prevention is the main goal of early repair and delays of more than 24 hours put the patient at risk of vision loss. Early identification of major injuries and prompt referral to a center prepared to quickly provide appropriate care is critical. General ERs and non-ophthalmic providers may miss the signs of vision-threatening eye pathology such that on call ophthalmologists must maintain a high level of suspicion when called for consults. Patients presenting with 360 degrees of subconjunctival hemorrhage, misshapen or poorly reactive pupils, severe vision loss or a history of high energy injury should raise red flags. Patient education about simple eye safety measures is an important part of the public health duty every ophthalmologist bears.
Mass Casualty Events are associated with eye injuries in 10% of patients. These injuries can range from superficial trauma to serious open-globe injuries with large intra-ocular foreign bodies. Education of the EMS and emergency room staff about the importance of rigid eye shields is critical. Ophthalmologists should participate in hospital-based and city-wide planning for future events. In the event of a Mass Casualty Event in your city, activate your local emergency plan and get ready to work with first responders, emergency room staff, and trauma surgeons to triage and care for victims with eye injuries.
Management of a traumatic cataract is among the most challenging and technically demanding procedures for an anterior segment surgeon, requiring individualized decisions on when to operate, what procedure is best and how to handle complications. The associated trauma to the eye makes these cases highly variable and unpredictable. Careful pre-operative evaluation is critical. Intraoperative challenges may be encountered in every step of the procedure. The incision location, viscoelastic selection, capsulorrhexis technique, lens removal and IOL placement often deviate from the standard technique. Anterior capsule staining, capsule tension rings, iridoplasty, sutured or anterior chamber IOL are more commonly used in these cases compared to non-traumatic cataracts. Additionally, complications such as posterior capsule rupture, vitreous prolapse and/or vitreous loss are more common. Post-operatively, these eyes are more prone to glaucoma, IOL dislocation, and posterior segment complications.
There are many ways to treat retinal detachments, including laser demarcation, pneumatic retinopexy, scleral buckle, vitrectomy, and combined scleral buckle and vitrectomy. The surgical choice is often dictated by the morphology of the retinal detachment, surgeon’s preference, and OR availability. In appropriate cases, pneumatic retinopexy is emerging as an effective and preferred first-line treatment for retinal detachment, with very good visual and anatomic outcomes. Published primary success rates range from 68-84%. A recent study reported comparable success rates in retinal detachments with non-traditional criteria, such as pseudophakia, extensive lattice degeneration, and more than one break separated by more than one clock hour. Endophthalmitis is one of the most dreaded complications of cataract surgery. The Endophthalmitis Vitrectomy Study was published over 20 years ago, supporting the benefit of vitrectomy in cases with light perception vision or worse, and tap and injection of antibiotics in eyes with better vision. However, there has been significant advances in vitrectomy surgery since then, with smaller gauge vitrectomy and endoscopic vitrectomy, which may help improve outcomes in endophthalmitis cases. Dropped lens material happens occasionally during cataract surgery. Smaller cortical particles can sometimes be observed, whereas larger lens fragments or nuclear material often requires pars plana vitrectomy and lensectomy. Cataract surgeons should place a lens if possible (sulcus IOL or ACIOL) and perform an anterior vitrectomy if vitreous is coming forward. It also helps to suture the cataract wound. It is not advisable to go after lens fragment that fell into the vitreous cavity. Patients should be referred to a retinal surgeon, with plans for vitrectomy within a week. A recent meta-analysis found no difference between same day pars plana vitrectomy and delayed vitrectomy within one week of dropping lens material. There are several ways to fixate dislocated intraocular lenses, including suturing the lens to the sclera or iris. A recent technique allows sutureless scleral fixation of dislocated three-piece intraocular lenses with 27- or 25-gauge vitrectomy.
It is critical to be able to detect key clinical neuro-ophthalmic signs that suggest conditions requiring emergent diagnosis and treatment. Arterial dissection suggested by neck pain and ipsilateral Horner syndrome. The apraclonidine test can be helpful, but false negative results can occur acutely. For patients with isolated Horner syndrome, it is advisable to obtain an MRI of the brain, MRA of the neck, and imaging of the upper chest. Patients with acute carotid dissection often inpatient evaluation. Although adequate data are lacking, most patients are treated with either anticoagulation or antiplatelet medications for several months. Evaluation for PCOM aneurysm is definitely required in cases of partial third nerve palsy or complete third nerve palsy with pupillary dilation. Both CTA and MRA provide excellent resolution to detect intracranial aneurysms. Depending on the size and location, an aneurysm may be surgically clipped or endovascularly coiled. Small, asymptomatic aneurysms are often conservatively observed. Pituitary Apopolexy presents with a sudden headache, often with double vision and/or visual loss. Often the patient is not previously known to have a pituitary macroadenoma. Occasionally the lesion may be missed with a standard CT, and a CT or MRI with thin cuts through the cavernous sinus is necessary. Surgical resection is often necessary, especially if there is compression of the optic chiasm. Prompt attention to endocrine disturbances is critical. Giant Cell Arteritis may present with amaurosis, transient double vision, new headache and/or scalp tenderness. In very rare cases, both ESR and CRP may remain normal. When vision is threatened and a diagnosis of GCA is suspected, high dose corticosteroids must be administered promptly. Additional diagnostic studies, such as fluorescein angiogram and/or temporal artery ultrasound may aid in the diagnosis. When vision is threatened, corticosteroid treatment should be instituted immediately. Temporal artery biopsy should be performed within days of suspected diagnosis. Many patients require relatively high doses of steroids for about 12 or more months. A steroid-sparing agent such as methotrexate, mycophenolate, or azathioprine may be necessary to successfully wean the dose of steroids. Tocilizumab (an IL-6 antagonist) has been studied recently and appears promising. Transient monocular visual loss requires evaluation for embolic causes. Carotid ultrasound, CTA, or MRA, provide adequate screening for carotid stenosis. In most cases of symptomatic stenosis >70%, surgical therapy should be strongly considered. For the benefit (long-term stroke prevention) to outweigh the short-term risk, it is critical for the surgeon and institution to have very low complication rates, and the patient should have greater than 5 year survival. Carotid stenting has emerged as a promising option in many patients where risk of CEA is deemed to high. For nonsurgical cases, maximum medical therapy includes antiplatelet, high-dose statin therapy, and tobacco cessation.
One of the challenges in managing acutely elevated intraocular pressure is determining what constitutes a true glaucoma emergency, as this will guide treatment options (to a degree, at least). Several factors have to be taken into consideration - including the level of the intraocular pressure and the health of the optic nerve - when determining an appropriate intervention. The basic tenet (“get the pressure down!”) always holds true. How to get the pressure down, though, can vary based on the mechanism of intraocular pressure elevation and the urgency of the situation. This talk will cover a range of “glaucoma emergencies” that a provider may be confronted with in the office, provide a framework to think through these emergencies, and discuss treatment options.