June 5, 2020 Conference

AM - Ocular Trauma: What We Should Know for our Next Patient

Program Objectives
The content and format of this educational activity has been specifically designed to fill the practice gaps in the audience’s current potential scope of professional activities by: 1. Providing information useful and applicable to both comprehensive and subspecialist NEOS ophthalmologists in the subject of ocular trauma. 2. Covering a wide variety of eye trauma topics including initial triaging, treatment, and management of ocular injuries including topics in oculoplastics and the management of trauma sequelae. 3. Presenting eye injuries in intimate partner abuse and strategies for eye trauma prevention.
Welcome Remarks
Mary K. Daly

Introduction of Session
Fina Barouch

Triage, evaluation, and surgical preparation of the eye trauma patient
Matthew Gardiner

The on-call ophthalmologist should be uniquely adept at assessing ocular trauma. Physicians must be comfortable with identifying, triaging and knowing when to refer trauma victims for more specialized care. The patient must be evaluated as a whole first to check for life-threatening injuries. Many seemingly isolated eye injuries are associated with occult CNS trauma that can be easily missed. Once the patient has been stabilized medically, there is a core group of diagnoses that must be identified quickly and treated or referred promptly. The exam must be complete and thorough with equal attention paid to the apparently uninjured eye. Having a robust protocol for the evaluation and preparation of open globe patients for the OR is critical for good outcomes. Even patients being transferred to another facility for repair must have an established checklist of items set in motion by the referring physician. With a careful, methodical approach, patients can retain excellent visual function even after devastating injuries.

Antibiotic prophylaxis in eye trauma patients and treatment of traumatic eye infections
Miriam Barshak

Eye trauma increases the risks of ocular infections, including keratitis and endophthalmitis. Effective prevention and medical treatment of these infections requires the ability to identify high-risk patients, understand the microbiology and antibiotic options that provide both appropriate spectrum of coverage and adequate delivery to the site of concern, and pursue the interventions that may be beneficial. This talk will highlight new literature on infections following eye trauma, which focuses on updating understanding of the microbiology and approaches to prevention--including systemic and intraocular antibiotics, sealing small corneal perforations with a stromal cefuroxime hydration technique--and treatment, including antibiotics and interventions. This talk will also review newer antibiotics that may be considered for gram positive bacteria particularly in regard to the concern about hemorrhagic occlusive retinal vasculitis (HORV) following intraocular vancomycin injections.

Midnight Approach to Lid Lacerations and Orbital Trauma
Michael E. Migliori

Acute eyelid and orbital trauma can pose significant challenges, and if the ophthalmologist on call for the emergency department is not comfortable with managing these injuries, these cases can also induce significant anxiety. This presentation will try to alleviate some of that anxiety by helping to identify those cases that are true emergencies, those that may need urgent or semi-urgent intervention, and those that can be referred for later follow up.

Introduction of Guest of Honor
Fina Barouch

Traumatic Cataract Surgery and Iris Reconstruction, Part 1
James Banta

Closed and open globe injuries can lead to symptomatic iris damage and traumatic cataract.  Through a series of video case presentations, the management of these complex patients will be discussed.  Specific topics regarding anterior segment repair will include surgical repair of iridodialysis and traumatic mydriasis, and the Siepser sliding knot technique.  Specific topics regarding traumatic cataract surgery will include the use of trypan blue and intraretinal scissors to accomplish a capsulorhexis, visco-compartmentalization of vitreous prolapse, the use of anterior vitrectomy via the pars plana vitrectomy, slow motion phaco settings, capsular tension rings, and alternate fixation techniques in the absence of adequate capsular support.

Traumatic Posterior Eye Injuries
Lucy Young

Ocular trauma is a common cause of visual loss. Prior to examination, a detailed history is crucial and may offer clues to the nature of the ocular injury. The initial examination should be as thorough as possible but it is important to avoid any further trauma to the globe. Computed tomography and ultrasonography can be very useful when there is no visualization of the posterior segment. Injuries such as commotio retinae, choroidal rupture, retinitis sclopetaria, optic nerve avulsion, vitreous hemorrhage and macular hole do not require immediate attention. However, retinal tears in the presence of vitreous hemorrhage, intraocular foreign bodies, macula-sparing retinal detachment and traumatic endophthalmitis are indications for urgent vitreoretinal surgical intervention. Accurate diagnosis and timely management of posterior segment injuries may reduce the magnitude of visual loss in injured eyes.

Traumatic optic neuropathy and ocular motor dysfunction
Crandall Peeler

Some degree of vision loss due to optic nerve injury is thought to occur in 2-5% of all head injury cases (1). The most common mechanism of injury is “indirect,” with impact forces transmitted via bone from the brow to the optic foramen. These forces cause vision loss through compression, stretching, or contusion of the optic nerve but often leave no ophthalmoscopic or radiographic signs of injury in the acute phase (2). “Direct” injury to the optic nerve by penetrating objects entering the orbit or optic canal is less common but important to rule out as surgical intervention can sometimes recover vision in these cases. Ocular motor dysfunction from injury to cranial nerves III, IV, or VI may also occur in the setting of trauma. Cranial nerve IV is most susceptible to injury even from relatively mild head trauma given the close anatomic relationship of its posterior decussation to the tentorium. Cranial nerves III and VI may be injured in more severe head trauma from traction or disruption at their peripheral attachments to the skull base or centrally from brainstem shearing or hemorrhage. The aim of this talk is to provide an overview of traumatic optic neuropathy and ocular motor palsies with a focus on imaging and treatment options.

Traumatic Glaucoma
Christopher Teng

The incidence of ocular trauma is around 2.5 million patients every year in the United States. The risk of developing glaucoma after penetrating injury in the United States is estimated to be 2.67% while it is 3.39% after blunt trauma. This constitutes a fair number of patients at risk for glaucoma after eye trauma. This talk will briefly review ocular trauma, and discuss various manifestations of traumatic glaucoma, such as traumatic iritis, hyphema, angle recession glaucoma, and inflammatory glaucoma. It will discuss imaging techniques such as UBM and anterior segment OCT to aide in the diagnosis of angle recession glaucoma and will show a case and video on cataract surgery in a patient with phacoantigenic glaucoma after penetrating trauma.

Intimate Partner Violence - What an Ophthalmologist Needs to Know
Judith Linden

Studies show 1 in 4 women, and 1 in 5 men in the U.S. report being a victim of IPV in their lifetime. Intimate partner violence (IPV) is more prevalent in patients presenting for medical treatment. One study showed 38% or patients in a family medicine clinic, and 40% or women in the ED reported lifetime IPV. Although IPV can affect all patients of any demographic, including gender, age, socio-economic status or race, the prevalence is somewhat higher in certain populations, including those with trauma, women, younger age, lower socioeconomic status, and those with mental health issues and disabilities. Although physicians are often uncomfortable inquiring about IPV, studies show that most women prefer to be asked. This talk will assist the ophthalmologist in confidently inquiring about IPV, and supporting the patient in an effective, trauma-informed manner, whether the patient chooses to disclose the violence or not. I will discuss targeted screening, available resources, and engaging a team of support.

Traumatic Cataract Surgery and Iris Reconstruction, Part 2
James Banta

Closed and open globe injuries can lead to symptomatic iris damage and traumatic cataract.  Through a series of video case presentations, the management of these complex patients will be discussed.  Specific topics regarding anterior segment repair will include surgical repair of iridodialysis and traumatic mydriasis, and the Siepser sliding knot technique.  Specific topics regarding traumatic cataract surgery will include the use of trypan blue and intraretinal scissors to accomplish a capsulorhexis, visco-compartmentalization of vitreous prolapse, the use of anterior vitrectomy via the pars plana vitrectomy, slow motion phaco settings, capsular tension rings, and alternate fixation techniques in the absence of adequate capsular support.

Panel - Ocular Trauma: What Would you Do?
Fina Barouch

PM - Advanced Topics in Strabismus

Program Objectives The content and format of this educational activity has been specifically designed to fill the practice gaps in the audience’s current potential scope of professional activities by: 1. Addressing advanced techniques in treating complicated strabismus 2. Identifying methods of determining success of strabismus surgery 3. Identifying functional impact of strabismus on patients
Introduction of Session
Oren L. Weisberg

Partial Tendon Recession for Small-Angle Vertical Strabismus
Catherine Choi

There are few reliable treatment options for small vertical deviations in patients who prefer to be spectacle-free. A partial tendon recession procedure is one surgical option, and this study evaluated its effectiveness in correcting small vertical deviations. This study is an institutional retrospective consecutive series of 56 procedures in 47 patients. Change in vertical deviation in primary position was evaluated, as was prism diopter change per millimeter of partial tendon recession. Separate analyses were performed to compare outcomes in patients with thyroid eye disease and those who underwent re-operations on the same muscle. The average preoperative vertical deviation was 4.3 ± 1.8 prism diopters (PD) of deviation and the average postoperative vertical deviation was 0.0 ± 2.3 PD, p < 0.0001. There was an average of 1.5 prism diopters of change per millimeter of partial tendon recession. 62% of post-operative patients were orthophoric in the overall sample. 60% of thyroid patients were orthophoric post-operatively versus 63% of non-thyroid patients. 29% of the re-operated patients were orthophoric post-operatively versus 67% of non-re-operated patients. 82% of patients had no vertical diplopia after one procedure and did not require a second surgery or prism correction in glasses. Preoperative vertical deviation had a more significant correlation with postoperative alignment than did the actual amount of surgical recession. Our results also suggest outcomes in re-operated muscles are less predictable. There was no significant difference in post-operative outcome between patients with thyroid eye disease and those without. In this sample of patients, a partial tendon recession effectively corrected small vertical deviations and is a treatment option to consider in patients who prefer spectacle independence.

Botox for Esotropia in Children
Melanie Kazlas

Adjustable Sutures
Gena Heidary

Reconsidering rectus muscle resection in Graves' ophthalmopathy
Sylvia Yoo

Select patients with strabismus due to Graves' ophthalmology may be treated with rectus muscle resections, if indicated, after careful preoperative assessment.

Nasal Transposition of the Split Lateral Rectus Muscle for Correction of Third-Nerve-Palsy-Associated Strabismus
Ankoor Shah

Strabismus associated with third-nerve palsy may be lead to amblyopia, diplopia, lack of binocularity, and disfigurement. Surgery may improve these issues, but the surgical correction of complete and near-complete palsy is difficult. Over the last fifty years, many different techniques have been introduced, and each has its advantages. This talk will introduce the latest surgical innovation in the field, nasal transposition of the split lateral rectus muscle, and it will review the technique, outcomes data, and risks of the procedure. The viewer will leave with a new surgical tool for this difficult condition.

Goal-Determined Metrics to Assess Outcomes of Strabismus Surgery
Linda Dagi

Psychosocial and Functional Benefits in Adult Strabismus Surgery
Jennifer Galvin

PM - Aiming for 20/20: Hot topics in Uveitis Diagnosis and Management

Program Objectives: The content and format of this educational activity has been specifically designed to fill the practice gaps in the audience’s current potential scope of professional activities: 1. Diagnosis and treatment of pediatric uveitis 2. Advances in the diagnosis and treatment of viral associated uveitis 3. Understand the Emerging causes of uveitis
Introduction of Session
Ninani Kombo

Our goal is to help attendees become informed about the Diagnosis and treatment of pediatric uveitis, advances in the diagnosis and treatment of viral associated uveitis, understand the Emerging causes of infectious uveitis, become familiar with the diagnosis and treatment options for Cancer Associated Retinopathies

Pediatric Uveitis: Epidemiology and Workup
Ninani Kombo

Pediatric Uveitis: Updates in Treatment
KC LaMattina

Most pediatric uveitis in the United States is noninfectious and chronic in nature. This makes the understanding of steroid-sparing agents and the treatment algorithm for their utilization critical. This talk will summarize the standard and newer therapeutic agents utilized in the treatment of noninfectious pediatric uveitis.

Which Herpes Virus is the Culprit?
Lana Rifkin

Uveitis: What Not To Miss
Paul A. Gaudio

Infectious Retinitis in 2020
Jay Duker

Paraneoplastic Retinopathies: Diagnosis and Treatment
Lucia Sobrin

This presentation will provide an update on the diagnosis and treatment of paraneoplastic retinopathies. The approach to the diagnosis including the importance of ruling out other potential mimickers will be reviewed. The appropriate interpretation of anti-retinal antibodies will be covered. The options for treatment will be discussed with an emphasis on recent results with rituximab therapy.

The Mission is Remission: A Pathway to prevention of Blindness from Uveitis
C. Stephen Foster

PM - Cutting edge and investigational therapies in Neuro-Ophthalmology

Program Objectives The content and format of this educational activity has been specifically designed to fill the practice gaps in the audience’s current potential scope of professional activities by: 1. Cross-specialty discussions 2. Update on treatments and when to refer patients 3. Deeper focus on particular conditions
Introduction of Session
Crandall Peeler

Teprotumumab for Treatment of Thyroid Eye Disease
Elizabeth Houle

Treatment if GCA in the Era of Tocilizumab
Elizabeth Fortin

What You Need to Know About Sarcoid Optic Neuropathy
Sashank Prasad

Novel Biologic Treatments for Neuromyelitis Optica: Satralizumab, Inebilizumab, and Eculizumab
Marc Bouffard

Neuroprotection in Non-arteritic Anterior Ischemic Optic Neuropathy (NAION)
Danielle Rudich

The Utility of OCT-Angiography in Neuro-Ophthalmology
Eric Gaier

New Surgical Treatments for Idiopathic Intracranial Hypertension
Laurel Vuong

To review new surgical treatments for idiopathic intracranial hypertension and to review updates on current optics and how they compare to each other.


Introduction of Session
Donna Siracuse-Lee

Ocular Syphilis Trend in Urban Underserved Community in the United States
Ka Yi Emily Tam, Gabrielle Fridman, Alexander Port, Nicole Siegel

Purpose: This study aims to describe the risk factors, presentation and prevalence of thus resurfacing disease. Methods: Retrospective chart review was performed on patients with diagnosis codes correlating with syphilis or syphilis related ocular diseases at Boston Medical Center, an urban teaching hospital, between 2010-2019. Results: 229 tested positive for syphilis and 40 patients were diagnosed with ocular syphilis. Among patients with ocular syphilis, 50% had vision 20/60 or better. 50% presented with anterior uveitis as their initial presentation. 49% patients had involvement of posterior segment. Neovascular glaucoma, papillitis, vasculitis, and retinal detachment were rarer presentations. Conclusion: This study provides insight to recognize ocular manifestations of this resurgent disease.


Shared Medical Appointments in Ophthalmology
Ka Yi Emily Tam, Madhura Shah, Sofia De Arrigunaga, Haben Kefella, Scarlet Soriano, Susannah G. Rowe

Purpose: Shared medical appointments (SMAs) are becoming popular as a tool in primary care to improve access. As little is known about its potential in ophthalmology, this study describes the feasibility of conducting SMAs in ophthalmologic practice. Methods: Glaucoma patients who were not compliant with glaucoma medications were recruited to participate, and a total of 5 patients attended the SMA. The 1.5 hour session included a basic eye exam, glaucoma education, peer to peer discussion, demonstration of eye use, medication refill, and pre and post survey administration for patients and staff members. Results: Positive responses from patients and staff members (physicians, ophthalmic technicians, pharmacists) alike demonstrate that SMAs would be a feasible option in ophthalmology practice. Conclusions: SMAs are a new concept to ophthalmology. As more programs incorporate SMAs into their visits, ophthalmologists should consider the role of SMAs in advancing patient care.


Features of pentosan polysulfate sodium-associated maculopathy in a diverse patient population
Gabrielle Fridman, Ka Yi Emily Tam, Alexander Port, Nicole Siegel

Purpose: To characterize clinical features of presumed pentosan polysulfate sodium (PPS)-associated maculopathy in a diverse patient population. Methods: Retrospective chart review of 254 charts. The electronic medical record (EMR) was queried to identify all patients with a history of pentosan polysulfate sodium exposure and a documented dilated eye examination between 2011-2019. Patient demographics, ocular findings, PPS exposure and dosage were reviewed. Subjects were included in analysis if PPS exposure, eye examination and optical coherence tomography (OCT) imaging were documented in the EMR. Results: Seven patients were identified who had both exposure to PPS and a pigmentary maculopathy on the fundus exam (Table 1). Similar to prior reports, our patients described symptoms of blurry vision at either distance or near despite having excellent Snellen best corrected visual acuity (BCVA). Age of presentation was comparable to prior reports with a mean of 53 years and a range from 43 to 73 years. All patients showed macular retinal pigment epithelium (RPE) mottling or atrophy on the clinical exam and OCT. Unique to our series we identified a larger proportion of non-Caucasian females and the second male, to the authors knowledge, to be affected by PPS. Conclusions: PPS-associated maculopathy is a recently described condition with poorly characterized risk factors and natural history. PPS-maculopathy appears to affect both men and women. Clinicians should inquire about PPS, which is most commonly prescribed for interstitial cystitis, in patients with macular changes or RPE atrophy of unclear cause or atypical presentation. Increased awareness of this condition will help to ensure proper screening, diagnosis and treatment. Further investigation is warranted to elucidate the pathophysiology as well as establish screening and treatment guidelines.


Central Geographic Atrophy vs. Neovascular Age-related Macular Degeneration: Differences in Longitudinal Vision-related Quality of Life
Aneesha Ahluwalia, Liangbo (Linus) Shen, Lucian Del Priore

Objective: Prior studies of vision-related quality of life (VRQoL) have examined advanced AMD as a single group or focused on neovascular AMD (nAMD), despite the fact that advanced AMD can refer to either central geographic atrophy (GA) or nAMD. We compared the natural progression of VRQoL in central GA versus nAMD. Methods: We included Age-Related Eye Disease Study (AREDS) participants with central GA (n=206) or nAMD (n=198) who completed the National Eye Institute Visual Function Questionnaire (NEI-VFQ). The rate of change of VRQoL was calculated as the slopes of linear models fit to longitudinal individual-level NEI-VFQ scores. Multivariable regressions identified factors associated with experiencing a decline in VRQoL during the study period and cross-sectional VRQoL score. Results: In nAMD, there was a minor decline in VRQoL prior to conversion but a significantly steeper decline after conversion (0.49 ± 2.91 vs. 3.30 ± 5.58 NEI-VFQ units/year; p<0.001). For central GA, the rate of VRQoL decline was similar before and after the development of advanced disease (1.99 ± 4.97 vs. 1.68 ± 4.65 NEI-VFQ units/year; p=0.66). Prior to conversion to advanced disease, the rate of VRQoL decline was greater for patients destined to develop central GA versus nAMD (p=0.007), while post-conversion, the rate was greater in nAMD compared with central GA (p=0.012). Female gender (OR 2.61, 95% CI 1.38-5.06; p=0.0029) and higher baseline VRQoL score (OR 1.03, 95% CI 1.01-1.06; p=0.0058) were independently associated with experiencing a longitudinal decline in VRQoL. Conclusion: The natural progression of VRQoL differed in central GA versus nAMD, both before and after the conversion to advanced disease, suggesting that future studies should separate these phenotypes. Females and those with a higher baseline VRQoL were more likely to experience a longitudinal decline in VRQoL after conversion to advanced disease.


An Eye for Detail: Examining the role of corneal Schwann cells
Gwendolyn Schultz, Paola Bargagna-Mohan, Bruce Rheaume, Paul Robson, Royce Mohan

Purpose: The cornea is densely innervated by an intricate network of nerve axons. Injury to the central cornea, whether by surgical procedure or by accident, can disrupt these axons and lead to a loss of sensitivity. However little is known about corneal Schwann cells (cSCs), the resident glial cells which protect and support corneal axons. Specifically, we were interested in the contributions of cSCs to axon regeneration as this has never before been explored. To study this unique cell population, we used single cell RNA-sequence (scRNA-seq) analysis and validated our findings using antibody staining in whole corneal tissue. Methods: We employed rabbit corneas to derive a single cell preparation that was subjected to droplet-based scRNA-seq (10X Genomics) generating data on 7,555 individual cells. The entire procedure was replicated from a different batch of corneas generating data on another 10,057 individual cells. The gene expression matrix output from CellRanger (10X Genomics) of the aggregated data was subjected to unsupervised clustering and dimensionality reduction. Specifically, the 1500 most highly variable genes were used for neighborhood graph generation (using 20 nearest-neighbors) and dimensionality reduction with UMAP. A specific SC cluster represented by conserved SC-genes was obtained. Antibody staining for the cSC proteins L1CAM, SCN7a, and SOX10 was done using corneas from wild-type adult C57/Bl6 mice and whole mount stained tissue was subjected to confocal microscopy. To model corneal injury, wild-type adult C57Bl6 male and female mice were subjected to a penetrating stab injury under systemic and ocular anesthesia that produced a focal lesion through the epithelium, basement membrane and a significant part of the corneal stroma. Eyes were enucleated at 4 and 7 days post injury and whole corneas were stained using antibodies. B3-tubulin was used for marking axons. Results: The scRNA seq analysis of rabbit corneas produced 4 cell clusters, including those representing keratocytes, epithelial cells, inflammatory cells, and Schwann cells. The corneal SC cell cluster revealed that Scn7A, Plp1, Gfra3, Sox10, and L1cam transcripts were highly expressed, identifying for the first time targets for investigation. In undisturbed central corneas, cSC markers showed distinct staining around axon processes co-stained for ?3-tubulin. SOX10 staining was distinctly nuclear in SCs. Following injury to the cornea in which axons are severed, cSCs remained at the injury site. In injured corneas, we also found co-staining for alpha-smooth muscle actin co-staining with cSC markers revealing some cSCs had differentiated into myofibroblastic cells. Conclusions: cSCs are closely associated with nerve axons in the central cornea. Upon injury, these cells remain at the injury site. Our characterization of these cells will allow us to study how these glial cells respond to corneal injury, and how their role can inform clinical practice.


Oral AREDS Supplements (Antioxidants and Zinc) Do Not Significantly Affect the Geographic Atrophy Growth Rate in the Central Zone
Liangbo (Linus) Shen, Mengyuan Sun, Aneesha Ahluwalia, Benjamin Young, Michael Park, Lucian Del Priore

Purpose: Previous studies demonstrated that the total GA area was a poor predictor of visual acuity,1-3 but it is unclear if GA area in a macular subfield can provide a much better predictive power for visual acuity. Moreover, the impact of oral antioxidants on GA progression in the macular center is unknown. Methods: We manually segmented GA lesions on 1654 visits of 365 eyes with GA using data from the Age-Related Eye Disease Study (AREDS). We determined GA areas in 9 macular subfields (defined by the Early Treatment Diabetic Retinopathy Study grid) and correlated them with VA using a multivariate linear mixed model. Patients were assigned by AREDS into 1 of 4 oral supplements (placebo, antioxidants, zinc, and antioxidants plus zinc). Results: The total GA area correlated poorly with VA (r2 = 0.07). Among 9 subfields, only the central zone had a significant association between GA area and VA (P < 0.001). By varying the diameter of the central zone from 0 to 10 mm, we determined 1 mm as the optimal diameter for the central zone that had the highest correlation (r2) with VA (r2 = 0.45). The decline rate of central residual area was comparable between placebo and supplements (placebo: 0.074 mm2/year [95%CI = 0.059-0.090]; antioxidants: 0.067 mm2/year [95%CI = 0.049-0.086]; zinc: 0.066 mm2/year [95%CI = 0.051-0.082]; antioxidants + zinc: 0.061 mm2/year [95%CI = 0.046-0.078]; P = 0.41-0.64). Conclusion: GA area in the central 1 mm zone is significantly correlated with VA and may serve as a surrogate anatomic endpoint in trials. Oral supplements do not affect the GA growth rate within the central 1 mm zone.


Ophthalmic Medication Expenditures and Out-of-pocket Spending: An analysis of US prescriptions from 2007-2016
Evan Chen, Ninani Kombo, Christopher Teng, Prithvi Mruthyunjaya, Kristen Nwanyanwu, Ravi Parikh

Objective: To estimate temporal trends in total and out-of-pocket (OOP) expenditures for ophthalmic prescription medications among adults in the United States. Design: A retrospective longitudinal cohort study. Participants: Participants in the 2007-2016 Medical Expenditure Panel Survey (MEPS), age 18 years or older. The MEPS is a nationally representative survey of the non-institutionalized, civilian US population. Methods: We estimated trends in national and per capita annual ophthalmic prescription expenditures by pooling data into 2-year cycles and using weighted linear regressions. We also identified characteristics associated with greater total or OOP expenditure with multivariable weighted linear regression. Costs were adjusted to 2016 US dollars using the Gross Domestic Product Price Index. Main Outcome Measures: Trends in total and OOP annual expenditures for ophthalmic medications from 2007-2016 as well as factors associated with greater expenditure. Results: From 2007-2016, 9,989 (4.2%) MEPS participants reported ophthalmic medication prescription use. Annual ophthalmic medication utilization increased from 10.0 to 12.2 million individuals from 2007-2008 to 2015-2016. In this same time period, national expenditures for ophthalmic medications increased from $3.39 billion to $6.08 billion and OOP expenditures decreased from $1.34 to $1.18 billion. While the average number of ophthalmic prescriptions did not change over the study period (4.2, p=0.10), the average expenditure per prescription increased significantly from $72.30 to $116.42 (p<0.001). Per capita expenditure increased from $338.72 to $499.42 (p<0.001) and per capita OOP expenditure decreased from $133.48 to $96.67 (p<0.001) from 2007-2008 to 2015-2016 respectively. In 2015-2016, dry eye (29.5%) and glaucoma (42.7%) medications accounted for 72.2% of all ophthalmic medication expenditures. Patients who were older than 65 (p<0.001), uninsured (p<0.001), and visually impaired (p<0.001) were significantly more likely to have greater OOP spending on ophthalmic medications. Conclusion: Total ophthalmic medication expenditure in the United States increased significantly over the last decade while OOP expenses decreased. Increases in coverage, copayment assistance and utilization of expensive brand drugs may be contributing to these trends. Policy makers and physicians should be aware that rising overall drug expenditures may ultimately increase indirect costs to the patient and offset a decline in OOP prescription drug spending.


Evaluation of retinal nerve fiber layer, ganglion cell-inner plexiform layer, and optic nerve head in glaucoma suspects with varying myopia
Gregg Miller, Abu-Qamar Omar, Sarwat Salim

Purpose: To assess the effect of myopia on retinal nerve fiber layer (RNFL), ganglion cell-inner plexiform layer (GCIPL), and optic nerve head (ONH) parameters in glaucoma suspects. Methods: 76 eyes studied with Cirrus-HD OCT were divided into low (LM; n=27), moderate (MM; n=25), and high myopia (HM; n=24). OCT parameters were correlated with spherical equivalent (SE) and evaluated with area under the receiver operating characteristic (AUROC) curves. Results: In MM and HM, SE was positively correlated with thinning of average, minimum, and non-temporal GCIPL (p<0.05 for all) except for inferior in MM (p=0.15). In HM, the correlation was shown for average and non-temporal RNFL (p<0.05 for all) except for inferior (p=0.06). SE was not correlated with ONH parameters in MM or HM (p>0.05). The highest AUROCs for RNFL and GCIPL parameters were for superior (0.82) and superonasal (0.80) regions respectively, with comparable diagnostic ability (p=0.74). Conclusion: Myopia is associated with thinning of average RNFL, average and minimum GCIPL, and non-temporal parameters of both GCIPL and RNFL, warranting consideration of refractive status in glaucoma suspects. Acknowledgements: This research was supported, in part, by an RPB Challenge grant made to the Department of Ophthalmology, Tufts Medical Center.


Epidemiology of United States Inpatient Open Globe Injury from 2009-2013
Vivian Paraskevi Douglas, Neha Siddiqui, Evan Chen, Ravi Parikh, KONSTANTINOS DOUGLAS, Paula Feng, Grayson Armstrong

Design: A retrospective cohort study using the National Inpatient Sample (NIS) from 2009-2013. Methods: Patients with a primary diagnosis of OGI using ICD codes were assessed in the NIS dataset, a nationally representative sample of inpatient stays. Sociodemographic characteristics, including age, gender, race, ethnicity, insurance status/type, and income quartile were stratified for comparison. Annual prevalence rates were calculated using 2010 US Census data. Statistical analysis included Chi square tests, ANCOVA, and Tukey HSD tests. Results: A total of 4,935 US inpatient hospital discharge records met inclusion/exclusion criteria. The estimated national prevalence of OGI during the 5 year period from 2009-2013 was 24,671 (95% confidence interval [CI] 21,056-28,286). The overall annual prevalence rate was 1.60 per 100,000 per year (CI 1.55-1.64). Overall, average annual prevalence rates were highest among patients 85+ (9.12, CI 8.33-9.98), on Medicare (3.88, CI 3.67-4.09), males (2.32, CI 2.21-2.38), African Americans (2.26, CI 2.16-2.47), and Native Americans (1.88, CI 1.43-2.46). Overall OGI rates were lowest among Caucasians (1.20, CI 1.16-1.25), females (0.92, CI 0.87-0.96), those with private insurance (0.87, CI 0.83-0.92), and Asians (0.69, CI 0.58-0.85). Being in the lowest income quartile was a risk factor for OGI (p<0.05). Conclusions: Open globe injuries (OGI) are one of the most preventable eye injury types which can limit the quality of life and also have significant economic burden on patients and the health care system.1,2 Several countries have characterized OGI incidence in hopes to guide public health measures.2,3 This study demonstrates that OGIs disproportionately affect those 85+, young males, elderly females, patients of African American descent, on Medicare, and in the lowest income quartile. Further studies should delineate causes for socioeconomic differences in OGI to guide future public health measures.


Genomic-Metabolomic Associations in Age-Related Macular Degeneration (AMD)
Ines Lains, Shujian Zhu, Wonil Chung, Rachel S Kelly, Archana Nigalye, Raviv Katz, John Miller, Demetrios Vavvas, Ivana K. Kim, Joan Miller, Jessica Lasky-Su, Liming Liang, Deeba Husain

Purpose: Age-related macular degeneration (AMD) is a multifactorial disease comprising environmental and genetic risk factors. Thirty-four loci with more than 7,000 single nucleotide polymorphisms (SNPs) have been linked with AMD risk, but the functional consequences of most of them remains to be established. The assessment of genetic-metabolite associations (i.e. metabolite quantitative trait loci, mQTL) can provide unique insights into causal mechanisms of AMD. This study aimed to analyze associations between established AMD risk SNPs and plasma metabolites (mQTL) in a cohort of AMD patients and controls. Methods: Prospective, cross-sectional, multicenter study (Boston, United States and Coimbra, Portugal). We included subjects with AMD and controls without any vitreoretinal disease (> 50 years old); AMD grading was performed according to the AREDS classification scheme. Fasting blood samples were collected and analyzed by ultra-performance liquid chromatography and high-resolution mass spectrometry for metabolomic profiling, and by an Illumina Omni express platform for SNPs profiling. Analyses of mQTL of endogenous metabolites were conducted using linear regression models adjusted for age, sex, smoking, 10 metabolites principal components (PCs) and 10 SNP PCs. These models were first performed for each cohort and then combined by meta-analysis. Results: We included 388 patients with AMD and 98 controls; after quality control, data on 544 plasma metabolites was considered. Meta-analysis identified 66 significant mQTL (p<10-5), correspondent to 9 metabolites and 7 genes. The most significant associations (false discovery rate < 0.05) were seen between SNPs in the LIPC gene and phosphatidylethanolamine metabolites, and SNPs in the ASPM gene and the branched-chain amino acids leucine, isoleucine and valine. Pathway analysis integrating all the metabolites and genes of interest mapped to the glycerophospholipid, as well as to the alanine, aspartate and glutamate metabolite pathways. No common mQTL were found between AMD cases and controls. Conclusion: To our knowledge, this is the first study on metabolomic-genomic associations in AMD. Our results suggest that AMD risk loci are associated with levels of specific lipid and amino acids plasma metabolites, furthering our understanding of their biological effect. This increases our understanding on the biological relevance of AMD-risk SNPs and offers new potential therapeutic targets, as we strive for precise treatment options for this blinding disease.


Topographic Variation of Retinal and Choroidal Vascular Density in Normal Eyes using Optical Coherence Tomography Angiography
Michael Park, Benjamin Young, Liangbo (Linus) Shen, Ron Adelman, Lucian Del Priore

PURPOSE: Optical coherence tomography angiography has become widely used by clinicians and researchers to qualitatively and quantitatively describe the retinal vasculature in normal eyes and eyes with chorioretinal pathology, including diabetic retinopathy, macular degeneration, and retinal artery and vein occlusions. A detailed study establishing a normative vascular topography map for each of the vascular layers has not yet been done. This study was performed to establish a normative, continuous vessel density topography map of the superficial and deep vascular plexus, as well as the choriocapillaris layer in normal eyes using OCT angiography imaging. DESIGN: Retrospective cohort study METHODS: 8x8 mm OCT angiography images centered on the fovea from 14 normal eyes (13 patients) were analyzed. A continuous vessel density curve as a function of distance from foveal center was generated for the superficial and deep retinal vasculature, and the choriocapillaris layers. The transition point, defined as the point of greatest slope change, was determined for each of the density curves. We determined the vascular density along different meridians and used this data to determine the vessel density in the nasal, superior, temporal, inferior quadrants in all 3 layers. RESULTS: The transition point occurred at different distances from the foveal center for each layer, at 587.9 microns, 881.8 microns, and 1986.5 microns from foveal center for the superficial, deep, and choriocapillaris layers, respectively. For the superficial plexus, the nasal quadrant had the greatest vessel density (p<0.0008). For the deep plexus, the nasal, superior, and temporal quadrants had greater vessel density compared to the inferior quadrant (p<0.0091). For the choriocapillaris layer, the temporal quadrant had greater vessel density compared to the nasal and superior quadrants (p<0.0073) but was not significantly different than the inferior quadrant (p=0.2738). CONCLUSION: Our study provides a normative, continuous vessel density topography map using OCT angiography of normal eyes. This vascular density map may be a valuable tool to determine baseline values for these parameters, and to determine the changes in these parameters in different chorioretinal diseases.


Short-term Surgical Outcomes of Glaucoma Drainage Device Implant after Failed Trabectome Surgery
Marez Megalla, Yapei Zhang, Ji Liu

Methods: Retrospective chart review of GDD implantation after failed trabectome during 2013-2019. Outcome measures were intraocular pressure (IOP), number of IOP-lowering medications and surgical complications at 12 months after GDD. Unpaired t-test was used for statistical analysis. Results: Fourteen eyes were included. The interval time between trabectome and GDD ranged from 7 days to 32 months (14.875±9.07). The average IOP was 27.14±8.37mmHg with 2.9±0.7 medications prior to trabectome, and 27.8±7.62 with 3.3±0.9 medications prior to GDD (pre-GDD). After GDD surgery, average IOP was reduced to 14.7±4.8mmHg (p=<0.00001) with 2±1.7 medications (p=0.008 vs pre-GDD) at the 12-month visit. No major surgical complications were documented for either trabectome or GDD surgery. Discussion: Trabectome surgery has been found effective in treating open angle glaucoma,1 Studies assessing the effectiveness of trabectome during GDD and after failed GDD have also shown significant reductions in IOP.2,3 However, some eyes may fail to respond to the primary trabectome surgery. It is unclear if these eyes would respond to sequential GDD. Our data indicated placement of a GDD after failed trabectome still resulted in significantly reduced IOP and medication usage without major surgical complications. Conclusion: Trabectome failure did not affect surgical outcomes of sequential GDD surgery, which can serve as a rescue for further IOP control.


Association of Posterior Polar Cataract on the Formation of Posterior Capsular Opacification
Marez Megalla, Ninani Kombo

Methods: A retrospective chart review done at a tertiary care center from 2011-2019 was conducted. Patients who had PPC and subsequent cataract extraction without surgical disruption of the posterior capsule were included. Visual acuity prior to and post cataract extraction, type of intraocular lens placed, the development of PCO, time to formation, and severity of PCO were assessed. Unpaired t-test was used for statistical analysis. Results: Of 179 patients identified, 80 patients met inclusion criteria. There was about equal prevalence of PPC among males and females. Time to follow up ranged from 1 month to 60 months. All lenses placed were acrylic. There was a low rate of PCO formation among our patient population and most were not visually significant. Conclusions: The rate of formation of visually significant PCO after successful surgical extraction of PPC is low.


Neuro-ophthalmic Manifestations of Checkpoint Inhibitors
Marez Megalla, Anita Kohli, Adeniyi Fisayo

Introduction: Checkpoint inhibitors, such as ipilimumab, nivolimumab, and pembrolizumab, have been reported to cause ophthalmic adverse events. While myasthenia gravis induced by these medications has been previously documented, other neuro-ophthalmic manifestations have been rarely reported. This study aims to identify those rarer manifestations. Methods A retrospective chart review of patients on checkpoint inhibitors who developed neuro-ophthalmic adverse events was undertaken. Visual acuity, color vision, pupillary reactivity, slit lamp and fundus examination, as well as ophthalmic imaging modalities (visual fields, optical coherence tomography, etc) were analyzed. Results Five patients were identified with neuro-ophthalmic manifestations, four of which carried a melanoma diagnosis. Four patients were treated with combination therapy of ipilimumab and nivolimumab. Optic neuritis was present in 2 patients, ocular myasthenia in 3 patients, and giant cell like vasculitis in 1 patient. One optic neuritis patient and one ocular myasthenia gravis patient had been previously reported.1 Treatment modalities included intravenous immunoglobulins, topical and oral steroids and resulted in resolution in all patients, although one patient continued to have poor visual acuity after the inciting event. Conclusions Neuro-ophthalmic manifestations including optic neuritis and giant cell like vasculitis can occur following use of checkpoint inhibitors.


Novel surgical device to allow precise localization and safe drainage of subretinal fluid during scleral buckling surgery
Kevin Ma, Wen Hu, Jan Kylstra

Purpose: Drainage of subretinal fluid is an important step of scleral buckling surgery in the repair of rhegmatogenous retinal detachments. External needle drainage under indirect ophthalmoscopy is a useful technique to achieve drainage of subretinal fluid. However, this method can be challenging due to the difficulty in determining the exact needle position and entry site. Methods: We present a novel surgical device to allow for safer and faster drainage of subretinal fluid during scleral buckling surgery. Results: The novel device features a blunt scleral depressor tip from which a drainage needle can be manually advanced. While the operator is directly examining the retina, the blunt tip is first used to perform scleral depression externally, allowing for precise localization of the desired drainage site. Once the desired location is identified, the spring-loaded needle can be advanced in a controlled fashion, which then pierces the wall of the globe and allows the subretinal fluid to passively egress. The rate of fluid egress can be titrated via the occlusion of a connecting channel from the lumen of the syringe using the index finger. Conclusion: The device allows for precise identification and placement of the needle insertion site under direct visualization of the retina, controlled drainage of fluid while the intraocular pressure is maintained, and assessment of the adequacy of drainage in real time.


Hecht Poster Contest Winners - Announced 1PM with Video Reveal
Donna Siracuse-Lee