Asrs Annu MTG 2011 Program

The American Society of Retina Specialists is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide
continuing medical education for physicians.
Welcome to Boston and the ASRS 29th Annual Meeting!

Our annual meeting is successful for both our society and our patients because it provides us a collegial open education forum in which to network and collaborate with peers in many practice settings from all around the world. This years attendance includes U.S. colleagues representing 43 states and Puerto Rico and also colleagues from 34 countries. Our meeting also provides us with a unique opportunity to connect with old acquaintances and make new friends. To each of more than 700 members and physician guests and 300 corporate representatives, I want to welcome you to the city of Boston. With nearly 100 papers, over 200 posters, 24 instructional courses, and 29 new films, this years educational program spans a wide spectrum of topics and features the latest research in our field. New this year, are special instructional courses on Saturday afternoon, from 1:00-4:15 pm. The first hour will be devoted to a discussion of the advantages and challenges of retinal surgicenters. The remaining time will be split between a series of updates in subspecialties outside of retina which are designed to help us take better care of our patients and to prepare for recertification. These updates are presented by outstanding faculty from Massachusetts Eye and Ear Infirmary and Tufts Medical Center. The reviews will include: cornea/anterior segment, oculoplastics/orbit, pediatric ophthalmology, and glaucoma. The Retina Case Conference will take place late Saturday afternoon. Our Welcome Dinner will follow at the Top of the Hub, in the adjacent Prudential Building with panoramic views of Boston. We hope you will join us to celebrate our great successes this year. The Sunday morning scientific session will feature the macular degeneration papers including a presentation of the VIEW and CATT study results. This will be followed by the Pyron Award Lecture honoring Drs. Jeanne Bennett and Albert Maguire, and the Founders Award Lecture presented by Dr. Bill Mieler. Sunday morning concludes with the ASRS Business Meeting. The Young Physicians Section hosts lunch. For those who no longer qualify as a young physician, we have good news. For your convenience, box lunches will be provided Sunday, Monday and Tuesday in the exhibit hall. Sunday afternoon features diabetic retinopathy presentations including the RISE/RIDE, Da Vinci and DRCR Network studies following by vitreoretinal surgery papers including the MIVI trials. At the conclusion of the Sunday sessions, The American Retina Foundation hopes to see all of us at the RunWalk for the Retina. Our Sunday evening is free to explore the beautiful sights of Boston! Monday will be another day of outstanding presentations with retinal vein occlusion treatment including the Galileo/ Copernicus results and intravitreal dexamethasone implant followed by new imaging studies. A panel discussion about the optimal ways to treat macular edema from vein occlusion and diabetic retinopathy in the anti-VEGF era will be followed by the special socioeconomic session and the pediatric retina session. Monday lunch features the Women in Retina (WinR) Symposium. The afternoon will begin with sessions on macular degeneration including use of high dose ranibizumab for eyes not responding to conventional dosing. Monday afternoon will conclude with the wine and cheese poster reception where you can talk informally with the poster authors about their studies. Tuesday morning will begin with the ocular oncology papers followed by additional papers on macular degeneration and vitreoretinal surgery. A panel discussion will review avoidance and management of vitreoretinal surgery complications. Tuesday afternoon will feature 19 courses including a wet lab for learning anterior segment surgery techniques and the always popular Retinaws. For those athletically inclined, separate golf and tennis tournaments will be offered on Tuesday afternoon. Tuesday concludes with our spectacular Gala Dinner and Umbo Lounge. Wednesday morning will begin with papers on the use of enhanced depth imaging in eyes with hereditary diseases and improved anesthesia techniques for intravitreal injection. The treatment of diabetic macular edema with panretinal laser and anti-VEGF drugs guided by wide field angiography will be discussed. The final session will highlight new treatment strategies for severe traumatic injuries from the military and new methods to treat leaking sclerotomies. The Wednesday session will end at 12 noon. I hope all of you will enjoy this beautiful city and plan your free time to take a walk on the Freedom Trail, enjoy some shopping at Faneuil Hall, hop on the T for a quick ride to the Kennedy Library and Museum, or have a great meal right in Back Bay. Enjoy the meeting!
John T. Thompson, MD
Program Chair and President-Elect
MISSION STATEMENT
The mission of the American Society of Retina Specialists is to provide a collegial open forum for education, to advance the understanding and treatment of vitreoretinal diseases, and to enhance the ability of its members to provide the highest quality of patient care.
Contents
asrs 29th annual MeeTing
Program Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Financial Interest Disclosures . . . . . . . . . . . . . . . . . . 6 Scientific Report Guidelines . . . . . . . . . . . . . . . . . . . . 8 Continuing Medical Education. . . . . . . . . . . . . . . . . 10
TuesDay, augusT 23
Symposium 10: Ocular Oncology . . . . . . . . . . . . . . 55 Symposium 11: Macular Degeneration III . . . . . . . 58 Symposium 12: Vitreoretinal Surgery III . . . . . . . . 64 Instructional Courses . . . . . . . . . . . . . . . . . . . . . . . . 68
Program by Day saTurDay, augusT 20

Instructional Courses . . . . . . . . . . . . . . . . . . . . . . . . 11 Retina Case Conference . . . . . . . . . . . . . . . . . . . . . . 12
WeDnesDay, augusT 24
Symposium 13: Hereditary/ Inflammatory/Diabetic Retinopathy . . . . . . . . . . . 73 Symposium 14: Vitreoretinal Surgery IV . . . . . . . . 79
sunDay, augusT 21
Symposium 1: Macular Degeneration I . . . . . . . . . 13 CATT Mini-symposium . . . . . . . . . . . . . . . . . . . . . . . . 16 Symposium 2: Awards and Special Presentations . . . . . . . . . . . . . . . . . . . . . . . . 16 Young Physicians Section Symposium . . . . . . . . . 17 Symposium 3: Diabetic Retinopathy . . . . . . . . . . . 18 Symposium 4: Vitreoretinal Surgery I . . . . . . . . . . 24
scienTific PosTers
Macular Degeneration. . . . . . . . . . . . . . . . . . . . . . . . 83 Diabetic Retinopathy/ Hereditary/Inflammatory. . . . . . . . . . . . . . . . . . . . . 99 Vitreoretinal Surgery . . . . . . . . . . . . . . . . . . . . . . . 119 Retinal Vascular/Imaging. . . . . . . . . . . . . . . . . . . . 151 Practice Management and Socioeconomics . . . . . . . . . . . . . . . . . . . . . . . . 180 Pediatric Retina ROP . . . . . . . . . . . . . . . . . . . . . . 180 Ocular Oncology. . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
MonDay, augusT 22
Special Interest Groups Breakfast . . . . . . . . . . . . . 31 Symposium 5: Retinal Vascular/Imaging . . . . . . . 31 Symposium 6: Socioeconomics . . . . . . . . . . . . . . . 38 Symposium 7: Pediatric Retina . . . . . . . . . . . . . . . . 40 Women in Retina (WinR) Symposium . . . . . . . . . . . 42 Symposium 8: Macular Degeneration II . . . . . . . . . 43 Symposium 9: Vitreoretinal Surgery II . . . . . . . . . . 50
filM fesTival
Introduction and 2011 Entries . . . . . . . . . . . . . . . 189 2010 Award Winners . . . . . . . . . . . . . . . . . . . . . . . . 193
inDex
Financial Interest Disclosures . . . . . . . . . . . . . . . . 195 Participant Index . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
The American Society of Retina Specialists is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The American Society of Retina Specialists designates this live educational activity for a maximum of 29.5 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity.
Program Overview
EvENT LocATioNS
All events take place at the Sheraton Boston Hotel unless otherwise noted. Breaks Exhibit Hall D, Hynes Convention Center cocktail reception 2nd Floor, Republic Ballroom continental Breakfast Exhibit Hall D, Hynes Convention Center exhibits Exhibit Hall D, Hynes Convention Center film festival Theater 2nd Floor, Back Bay Ballroom A gala Dinner and umbo lounge 2nd Floor, Grand and Constitution Ballrooms guest Breakfast 5th Floor, Riverway instructional courses 2nd, 3rd, 5th Floors new Member reception 5th Floor, Pool Deck PaT survey Exhibit Hall D, Hynes Convention Center retina case conference 2nd Floor, Grand Ballroom run/Walk for the retina Joseph Lee Playground Park scientific Posters Exhibit Hall D, Hynes Convention Center speaker ready room 3rd Floor, Gardner Room special interest groups Breakfast Constitution Ballroom Welcome reception and Dinner Top of the Hub Skywalk Observatory at the Prudential Center Women in retina (Winr) symposium and lunch 2nd Floor, Constitution Ballroom young Physicians section (yPs) symposium and lunch 2nd Floor, Constitution Ballroom
SATURDAY, AUGUST 20
1:00-4:15 PM
9:30-10:05
Refreshment Breaks/Exhibits
10:05 aM-12:00 PM
Instructional Courses
1:00-2:00
SYMPOSIUM 2: Awards and Special Presentations

10:05-10:40
Advantages and Challenges of Retinal Surgicenters

David Callanan, MD, Wayne A. Solley, MD, Pravin U. Dugel, MD and Jeff Brockette 2:15-4:15
PYRON AWARD LECTURE The Evolution of Retinal Gene Therapy: From DNA to FDA
Jean Bennett, MD, PhD and Albert M. Maguire, MD 10:40-11:15
SUBSPECIALTY REVIEWS Cornea/Anterior Segment

Roberto Pineda, II, MD
Glaucoma
Cynthia Mattox, MD
Oculoplastics and Orbit

Suzanne K. Freitag, MD
FOUNDERS AWARD LECTURE Treatment and Prevention of Endophthalmitis: Past, Present, and Future
William F. Mieler, MD 11:15-11:30
Pediatrics
Mitchell B. Strominger, MD 4:30-6:30
American Retina Foundation Report Young Physicians Section Crystal Apple Award Presentation PAT Survey Presentation
11:30 aM-12:00 PM
Retina Case Conference

7:00-10:00
Welcome Reception and Dinner
SUNDAY, AUGUST 21
7:00-7:30 aM
ASRS Business Meeting

Members only 12:00-1:15
Continental Breakfast/Exhibits
7:30-9:30
SYMPOSIUM 1: Macular Degeneration I

8:35-9:05
CATT Mini-symposium
9:05-9:30
Young Physicians Section Symposium and Lunch CRYSTAL APPLE AWARD LECTURE Surgical Delivery of Human Adult Stem Cells for Atrophic AMD: Rationale and Preliminary Experience
Allen C. Ho, MD 12:00-1:15
Macular Degeneration Panel: How Do You Treat Choroidal Neovascularization Following CATT Study Results?
Lunch in Exhibit Hall

1:20-3:02
SYMPOSIUM 3: Diabetic Retinopathy
3:02-3:35
11:10-11:16
8:20-10:10
Refreshment Breaks/Exhibits
3:35-5:45
Discussion
11:16 aM-12:16 PM
SYMPOSIUM 11: Macular Degeneration III

10:10-10:35
SYMPOSIUM 4: Vitreoretinal Surgery I

5:30-6:30
SYMPOSIUM 7: Pediatric Retina

12:16-1:25
Refreshment Break/Exhibits
10:35 aM-12:00 PM
American Retina Foundations Run/Walk for the Retina

5:45
Women in Retina (WinR) Symposium and Lunch

12:16-1:25
SYMPOSIUM 12: Vitreoretinal Surgery III

12:00-1:20
Free Evening

1:33-3:35

12:00
MoNDAY, AUGUST 22
6:15-7:15 aM
SYMPOSIUM 8: Macular Degeneration II

3:35-4:10
Golf and Tennis Tournament Departures

Exact times to be announced.
Special Interest Groups Breakfast

7:00-7:30
4:10-5:18
1:30-5:45
INSTRUCTIONAL COURSES Continental Breakfast/Exhibits

7:30-10:05
SYMPOSIUM 9: Vitreoretinal Surgery II

5:20-6:40
Refer to Scientific Program for course descriptions and times. 7:00 PM-1:00 aM
SYMPOSIUM 5: Retinal Vascular/Imaging

10:05-10:40
Poster Session and Exhibit Hall Wine and Cheese Reception

6:00
Cocktail Reception, Gala Dinner and Umbo Lounge
10:40-11:16
WEDNESDAY, AUGUST 24
American Retina Foundations North End Secrets, Saints, and Sips Crawl
6:40 8:00-8:30 aM
SYMPOSIUM 6: Socioeconomics
10:40-10:50
Continental Breakfast/Exhibits
8:30-10:20
Pharmacotherapy for Neovascular AMD 100% Part B Fee-For-Service Medicare Claims Data 2008-2009
Ross J. Brechner, MD, MS, MPH 10:50-11:00
Free Evening
6:45
SYMPOSIUM 13: Hereditary/Inflammatory/ Diabetic Retinopathy

10:20-10:50
New Member Reception Refreshment Break/Exhibits
TUESDAY, AUGUST 23
7:00-7:30 aM
The Value Modifier: Payment for Quality and Efficiency

William L. Rich, III, MD 11:00-11:10
10:50 aM-12:00 PM
SYMPOSIUM 14: Vitreoretinal Surgery IV

12:00
Continental Breakfast/Exhibits Scope of Practice Battles and the Retina Specialist

David W. Parke II, MD 7:30-8:20
Meeting Adjourns
SYMPOSIUM 10: Ocular Oncology
Financial Interest Disclosures

The American Society of Retina Specialists (ASRS) seeks to balance the important benefits of physicianindustry relationships with the significant risk that the financial goals of industry may conflict with the professional goals of ASRS members. In doing so, the ASRS recognizes that it has a profound duty to its members, the larger medical community and the public to ensure the integrity of all of its scientific, educational, and advocacy activities and materials. Any relevant financial relationships a CME presenter has had with manufacturers of commercial ophthalmic products or providers of commercial ophthalmic services within the past 12 months. The ASRS defines relevant financial relationships as those with a commercial ophthalmic interest and the opportunity to affect the content of CME about the products or services of that commercial ophthalmic interest. CME presenters who report they have no known relevant financial relationships to disclose will declare No Financial Relationships.
noTe: All presenters are required to report financial
educational content Development

As the ACCME accredited provider for the ASRS 29th Annual Meeting, the American Society of Retina Specialists requires all Program committee members, abstract graders, staff, and any others in a position to control the educational content to disclose any commercial financial interests prior to the development of educational content. A process for resolution of conflict of interest is used for those committee members who do have financial interests related to the development of content. Program committee members, abstract graders, and staff members who fail to provide financial disclosures are not permitted to participate in the abstract grading process or the development of educational content.
disclosures, using the codes below, as part of the abstract submission process. An individuals financial disclosure for the ASRS 29th Annual Meeting will be indicated by an asterisk (*) in the Scientific Program and cross-referenced in the Participants Financial Disclosure Index. (See the Participant Index tab of the Scientific Program). Any presenter not listed with an asterisk, or not listed by name on the Participants Financial Disclosure list, informed the American Society Retina of Specialists that they have no relevant financial disclosures to report.
Description of financial interest Presenters

The ASRS considers financial relationships to create actual conflicts of interest when Presenters or their immediate family (defined as spouse, domestic partner, parent, child or spouse of child, or sibling or spouse of sibling of the Presenter) have both a financial relationship with a commercial interest and the opportunity to affect ASRS policy or the content of CME about the products or services of that commercial interest. The potential for Presenter to maintain or increase the value of the financial relationship with the commercial interest creates an incentive to influence the content of the CME an incentive to insert commercial bias. All presenters of CME content should familiarize themselves with the new ASRS Policy on Financial Disclosures and Resolution of Conflicts of Interest, which may be viewed in their entirety on the ASRS website at www.asrs.org. All ASRS members presenting CME are required to disclose to the activity audience the following information prior to beginning their presentation:
TyPes of relaTionsHiP(s) A Advisory Board B Board of Directors C Consultant E Employee F Founder I Investigator SP Speaker SH Stockholder O Other naTure of coMPensaTion E Equipment (dept or practice) G Grants H Honoraria IP Intellectual Property Rights NC No Compensation Received OB Other Financial Benefit R Royalty RF Residency or Fellowship Program Funding S Salary ST Stock SO Stock Options
name John T. Thompson, MD, Chair
commercial interest NIH Genentech Regeneron ArcticDx NeoVista Bausch + Lomb Synergetics Notal Vision Genentech No Financial Disclosures ArcticDx Bausch + Lomb Clarus Acuity Group Eyetech Genentech Insight Instruments OptiMedica Synergetics Alcon Bausch + Lomb DRCR Digital Healthcare i2i Innovative Ideas Lux Biosciences MacuSight Merck & Co., Inc. NEHEP/NEI/NIH Neurotech Pfizer Retinal Dis Image Analysis Reading Center Second Sight SurModics Pharmaceuticals TDNMI Therapeutic Nanoparticle and Molecular Imaging Vitreo Retinal Technologies Alcon
Type of relationship I I I A, C, SH A, C, I A, C, SP A, C, SH A, C SP, I
compensation G G G H, ST G, H H IP, R, H H G, H
Carl C. Awh, MD
Brett T. Foxman, MD Tarek S. Hassan, MD
C, SH C, SP SH C, A C C C, SH C C C C SH E C C C C C C C C C, SH C C C A
H, ST H ST H H H H, ST H H H H ST S H H H H H H H H H, ST H H H H
Suber S. Huang, MD, MBA
Timothy G. Murray, MD, MBA STAFF Jill F. Blim Executive Vice President Robyn Lira Manager, Membership and Communication Kristen A. Weber Director of Education
No Financial Disclosures
Scientific Report Guidelines

guidelines for the scientific report of studies and conduct of research involving Human subjects
The goal of the ASRS 29th Annual Meeting in Boston is to enhance the competence of the vitreoretinal specialists to diagnose and treat vitreous and retinal disorders and diseases using the most advanced concepts and techniques available. The ASRS 29th Annual Meeting in Boston will provide a forum for the rapid dissemination of the most recent scientific research results to the target audience in attendance. Its purpose is to allow the presentation of new and ongoing research data to assist the practicing vitreoretinal specialist with the advancement of knowledge and skills in their field. The ASRS 29th Annual Meeting contains papers, posters, and panel presentations that may include research conducted on human subjects. All members are responsible for declaring whether or not their presentation involves research involving human subjects, and should adhere to the accepted ethics of such research. The ASRS supports the regulations defined by the Office of Human Subjects of the National Institutes of Health, and the Office for Human Research Protections of the Department of Health and Human Resources. Listed below are guidelines and resources designed to assist members to adhere to scientific reporting requirements at the ASRS Annual Meeting.
Definitions of research and Human subjects

research: Research is any systematic
(1) the design of a study is consistent with sound scientific principles and ethical norms; (2) the necessary elements of informed consent have been fulfilled, and (3) appropriate safeguards are taken to prevent harm or undue risks to participants. Local hospital or institutional IRBs are typically willing to review with clinical research conducted both at their hospital as well as within the private office setting.
investigation designed to develop or contribute to generalizable knowledge. Obvious research is the study of techniques, drugs and devices as part of prospective institutional or collaborative clinical trial. Less obvious, but still falling into this category, are retrospective chart reviews, uncontrolled evaluations of off label drugs and devices, and prospective evaluations of new surgical techniques and devices.
Human subjects: A human subject is a living individual about whom an investigator obtains either:
exemptions from irB activity

Not all research that involves data collected on human subjects requires IRB approval. Studies involving human tissue obtained from established cell lines not linked to patient identification e.g. human RPE cultures are exempt. Another exemption is the retrospective collection of data from existing records such as office charts, provided that subjects cannot be identified directly or through identifiers such as name codes linked to the subjects. Chart reviews conducted by students or office staff in which confidential information is kept on the chart, and possibly viewed by non-physicians, remains a grey area. When in doubt, the researcher should obtain the advice from a local IRB. Other exemptions involve surveys and anonymous patient interviews, data from deceased individuals, and reviews of pathologic specimens provided that no link to patient identification is present or kept during the review.
(1) data through interaction or intervention with the individual, or (2) identifiable private information. In many cases, the determination of whether a particular research activity involves human subjects is not difficult, but in some cases, the line is blurred. This is often the case involving a retrospective review of office and hospital charts on existing data. When it is not clear to an investigator whether research activities involve human subjects, he or she is encouraged to seek the advice of a local Institutional Review Board (IRB).
institutional review Boards (irB)

An IRB is a group of diverse individuals charged to protect human subjects and promote ethical research. The IRBs evaluate and approve that:
investigational use of Marketed Drugs, Biologics and Medical Devices

The reporting of investigational use of products in an off label capacity differs from the situation described above. Investigational use suggests the use of an approved product in the context of a clinical study protocol. When the principal intent of the investigational use of a test article is to develop information about the products safety or efficacy, submission of an IND or IDE may be required. The clinical investigation of an off label application does not require submission of an IND if all of the following conditions are met: (1) it is not intended to be reported to FDA in support of a new indication for use or to support any other significant change in the labeling for the drug; (2) it is not intended to support a significant change in the advertising for the product; (3) it is conducted in compliance with the requirements for IRB review and informed consent, and (4) does not involve a route of administration or dosage level that significantly increases the risks (or decreases the acceptability of the risks) associated with the use of the drug product. The last requirement often applies to medications and devices not intended for intraocular use. Again, the researcher should seek the advice of a local IRB when in doubt.
resources
Several on-line resources are available for researchers that provide additional help and guidelines in determining when research may require IRB approval and IDE/IND applications. An excellent computer based tutorial is available at the NIH website at http://ohsr.od.nih.gov. This tutorial gives an overview of concepts, principles, and issues related to protection of human participants, and is intended to act as a companion piece to local IRB policy, as well as local, state, and federal regulations applicable to human research. Presenters at the ASRS 29th Annual Meeting have a fundamental responsibility to safeguard the rights and welfare of the people participating in their research activities. Studies involving human subjects require special protections, depending on the nature of the study, such as informed consent, IRB approval, and protection of confidentiality, unless waived. If presenters are going to present data from patients, they will be required to include (on disclosure slide for those giving paper presentations, or printed on the poster) Data from human research is presented.
off-label use of Marketed Drugs, Biologics and Medical Devices

If physicians use a product for an indication not in the approved labeling, they have the responsibility to be well informed about the product, to base its use on firm scientific rationale, and to maintain records of the products use and effects. Use of a marketed product in this manner when the intent is the practice of medicine does not require the submission of an Investigational New Drug Application (IND), Investigational Device Exemption (IDE) or review by an IRB. However, the institution at which the product will be used may, under its own authority, require IRB review. Presentations at the ASRS 29th Annual Meeting on such off label use may however fall outside the practice of medicine definition as defined below.
Continuing Medical Education

The American Society of Retina Specialists is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The American Society of Retina Specialists designates this live educational activity for a maximum of 29.5 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity. The Retina Case Conference, scientific sessions, and panel discussions are identified for credit. One credit is awarded for each hour of participation. Please see page 7 for financial interest disclosures of program committee members, abstract graders, and those involved with managing program content. For an up-to-date listing, please visit www.asrs.org. in the United States (U.S. Members). U.S. members of the ASRS have completed one or more years of a vitreoretinal disease fellowship and are engaged in an active retinal specialty practice or are a memberin-training in a vitreoretinal fellowship program.
Types of activities Provided
tiveness with which the educational goals are met. Suggestions for the improvement of future educational programs and the identification of specific educational needs are also requested.
cME credit Awards

CME credit certificates will be mailed to registrants after the meeting. The number of hours awarded will be based on documentation of attendance provided by the registrant on a form which will be available at the meeting.
To accomplish the goals of the ASRS CME Program, the ASRS organizes scientific meetings and instructional courses.
content
cME Mission Statement

Purpose
The scope of the ASRS CME Program includes the presentation of scientific papers, panel discussions, posters, videos by vitreoretinal specialists from around the world on topics concerning the diagnosis and management of vitreoretinal disorders, and topics concerning the business of medicine. These activities are presented at the Annual Meeting and at adjunctive meetings approved by the American Society of Retina Specialists Board of Directors.
expected results
Educational objectives and Goals

The purpose of the ASRS 29th Annual Meeting is to enhance the competence of vitreoretinal specialists in the diagnosis and treatment of vitreous and retinal disorders using the most advanced concepts and techniques. The ASRS 29th Annual Meeting will provide a forum for the rapid dissemination of the most recent scientific research results to the target audience in attendance. Its purpose is to allow the presentation of new and ongoing research data to assist the practicing vitreoretinal specialist with the advancement of knowledge and skills in their medical field. Upon completion of the scientific sessions, the participant shall be able to: describe the findings, diagnosis and treatment of various vitreoretinal disorders such as macular degeneration, choroidal neovascularization, diabetic retinopathy, venous occlusive disease, macular holes, epiretinal membranes, ocular inflammatory disease, retinal oncology, and retinal detachment.
The American Society of Retina Specialists (ASRS) is a non-profit corporation, which provides a scientific forum designed to promote the sharing of 1) new scientific research of vitreoretinal diseases and surgery and 2) ideas for optimization of clinical practice. The overall goal of the ASRS CME Program is to provide CME activities that will address the professional practice gaps of ASRS members by offering activities that aid in enhancing our participants competence in the fields of vitreoretinal diseases, surgery, and practice management.
Target audience
The expected results of the ASRS CME Program are enhancements in our physician participants competence. The ASRS educational content is expected to provide the members of the American Society of Retina Specialists with expanded knowledge to enable them to diagnose and treat vitreoretinal diseases with the most advanced concepts and techniques available.
cMe evaluation forms
The ASRS CME audience is the portion of the Societys membership that is licensed to practice medicine
CME evaluation forms for each symposium will be emailed prior to each session. In accordance with the ACCME Criteria and Guidelines, we ask that all attendees evaluate each presentation and identify the effec-
10
Saturday, August 20
Saturday, August 20
1:00-4:15 pM 2:15-4:15 pM
instructional courses
Sheraton Boston Hotel, Constitution Ballroom
subspecialty reviews
Ophthalmology subspecialities continue to enjoy important advances in the diagnosis and treatment of ocular disorders. The American Society of Retina Specialists presents the most important advances in retina at our annual meeting and other educational forums. Our members may not be as familiar with important progress in areas outside of retina. This course will help to update our members about important developments in the past 5 years in cornea/external disease, glaucoma, oculoplastics and pediatric ophthalmology from subspecialty faculty at Massachusetts Eye and Ear Infirmary and Tufts University.
1:00-2:00 pM
advantages and challenges of retinal surgicenters

David Callanan, MD*, (Arlington, TX), Wayne A. Solley, MD*, (Arlington, TX), Pravin U. Dugel, MD* (Phoenix, AZ), Jeff Brockette (Arlington, TX)
2:15-2:45 pM
David Callanan, MD Wayne A. Solley, MD Pravin U. Dugel, MD
cornea/ anterior segment

Roberto Pineda, II, MD* (Boston, MA)
Ambulatory surgicenters (ASC) are being used with increased frequency by retina specialists. Some advantages include a more pleasant patient experience, faster turnaround for patients and physicians, more physician control of OR and potential ASC ownership with a share of profits. Disadvantages include less flexible scheduling of emergency cases, inability to use expensive surgical adjuncts, reluctance of surgicenters to update equipment after initial purchases and difficulty performing more complex surgeries on patients with multiple medical problems. This course will examine the pros and cons of using an ASC for vitreoretinal surgery.
2:45-3:15 pM
glaucoma
Cynthia Mattox, MD* (Boston, MA)
3:15-3:45 pM
oculoplastics and orbit

Suzanne K. Freitag, MD (Boston, MA)
3:45-4:14 pM
Pediatrics
Mitchell B. Strominger, MD (Boston, MA)
11
reTina case conference
4:30-6:30 pM
MODERATORS
Retina case conference

PresenTers 4:30 PM Carol L. Shields, MD (Philadelphia, PA) 4:35 PM Yoreh Barak, MD (Louisville, KY) Shlomit Schaal, MD, PhD Todd J. Purkiss Melissa G. Tong, MD 4:40 PM Sunir J. Garg, MD (Philadelphia, PA) Jeffrey L. Lipkowitz, MD Nikolas London, MD 4:45 PM Shree K. Kurup, MD (Winston Salem, NC) 4:50 PM Rishi P. Singh, MD (Cleveland, OH) Nathan C. Steinle, MD Careen Lowder Peter K. Kaiser, MD Daniel F. Martin, MD 4:55 PM Guillermo Salcedo-Villanueva, MD (Mexico City, MX) Juan Manuel Jimenez-Sierra, MD Virgilio Morales-Canton, MD Efrain Romo-Garcia, MD 5:00 PM Gustavo Barreto Melo, MD (Aracaju, Sergipe, BR) Eduardo C. Souza, MD
Carl C. Awh, MD
William F. Mieler, MD
Richard F. Spaide, MD
5:05 PM Cyrus M. Shroff, MD (New Delhi, IN) Sima Das, MD Jyotirmay Biswas, MD Shishir Narain, MD Charu Gupta, MD Daraius Shroff, MD, FRCS 5:10 PM Hua Gao, MD, PhD (West Bloomfield, MI) Hua Gao, MD, PhD 5:15 PM Boris Josue Bajaire, MD (Santaf de Bogota, CO) Diego F. Paipilla 5:20 PM J. Fernando Arevalo, MD (Caracas, VE) 5:25 PM Mallika Goyal, MD (Hyderabad, IN) 5:30 PM Geoffrey G. Emerson, MD, PhD (Minneapolis, MN) 5:35 PM Sumit P. Shah, MD (Boston, MA) Jay S. Duker, MD Elias Reichel, MD 5:40 PM Julie M. Rosenthal, MD (Portland, OR) Peter Francis
5:45 PM Vassiliki Poulaki, MD, PhD (Boston, MA) 5:50 PM Alex Yuan, MD (Cleveland, OH) Justis P. Ehlers, MD 5:55 PM Franco M. Recchia, MD (Nashville, TN) 6:00 PM Emmanouil Mavrikakis, MD, PhD (Athens, GR) Varun Chaudhary 6:05 PM Jerry A. Shields, MD (Philadelphia, PA)
6: 10 pM
Discussion
6:30 pM
adjourn
7:00-10:00 pM
Welcome reception and Dinner

Top of the Hub Skywalk Observatory at the Prudential Center
12
Sunday, August 21
Sunday, August 21
7:00-7:30 AM
continental Breakfast and exhibits

Hynes Convention Center, Hall D
7:30-9:30 AM
Symposium 1: Macular Degeneration i

Moderators: Tarek S. Hassan, MD and David F. Williams, MD, MBA Related poster abstracts are on pages 83-98.
was created to allow placement of the microcather into the subretinal space. The microcatheter was advanced to the macular region under direct vision through the pupillary aperature and wide view opthalmoscopy. After injection of the CNTO 2476, the microcatheter was withdrawn and surgical closure performed.
conclusion
7:30 AM
Unmet medical needs will drive demand for innovative solutions. Cell-based products combined with safe and effective delivery systems targeted to the retina have the potential to satisfy some of these needs. An ongoing clinical trial of CNTO 2476 will show one approach using a cell therapy administered directly adjacent to the diseased posterior retina.
opening remarks
Suber S. Huang, MD, MBA, ASRS President John T. Thompson, MD, ASRS Vice President and Program Chair
7:43 AM
7:35 AM
Phase i clinical Trial using Human umbilical Tissue-Derived cells (cnTo 2476) administered sub-retinally to Treat geographic atrophy secondary to aMD
Tom S. Chang, MD* (Pasadena, CA), Michael A. Samuel, MD*, Allen Ho*, Paul Williamson, MD, Sicco Popma, MD, Ian Harris, MD
clinical applications of a novel sD-ocT algorithm Designed to Measure the area and volume of retinal Pigment epithelial Deformations
Zohar Yehoshua, MD* (Miami, FL), Fenghua Wang, MD, Giovanni Gregori, Fernando M. Penha, MD, PhD, William Feuer, Philip J. Rosenfeld, MD, PhD*
PurPose Human umbilical tissue-derived cells preserved photoreceptors in a rodent model of retinal degeneration (Lund RD et al.). Cell-based therapy targets pathologic microenvironments with trophic factors or by replacing diseased tissue. Targeted delivery creates a local pharmacodynamic effect, mitigates potential safety issues with systemic use and unfavorable risk benefit ratio of surgical procedures. MeTHoD
PurPose A novel algorithm was developed to measure the area and volume of retinal pigment epithelial detachments and drusen imaged with spectral domain OCT (SD-OCT) for use in the routine clinical care of patients, especially those undergoing anti-VEGF therapy, and for use in clinical trials. MeTHoD
Phase 1/2a, Multicenter, Randomized, Dose Escalation Study Evaluating a Single, Subretinal Administration of Human Umbilical Tissue-Derived Cells (CNTO 2476) in Subjects with Geographic Atrophy (GA) Secondary to AMD. Primary objective is safety assesment of CNTO 2476, using a subretinal microcatheter delivery system (MDS). Secondary objectives are clinical response assessment, visual function and MDS performance. Inclusion criteria are age 50 years, bilateral geographic atrophy (GA) by AMD with macular involvement and a suitable surgical candidate. Subjects will receive one of 4 doses by a trans-scleral sub-retinal microcatheterization and evaluated for efficacy and safety for 5 years.
Eyes with drusen and retinal pigment epithelial detachments secondary to AMD were enrolled in an IRB-approved, prospective study at the Bascom Palmer Eye Institute. These eyes were scanned using the Cirrus SD-OCT instrument (Carl Zeiss Meditec, Dublin, CA). A novel algorithm was then used to quantitatively assess the area and volume measurements of these lesions. Changes in PED area and volume measurements were assessed after anti-VEGF therapy in a subset of patients. The measurements were analyzed using a suitable scale transformation, in particular, a square-root transformation was use for area measurements and a cube-root transformation was used for volume measurements.
resulTs Six eyes from six patients have been enrolled and received microcatheter administration of CNTO2476 to the subretinal space. The administration procedure involved trans-scleral placement of the microcather through a 3-4 mm sclerotmomy over the peripheral retina. A choroidotomy
143 eyes were enrolled with drusen volumes ranging from 0.0009 mm3 to 0.7479 mm3. On average, drusen volume and area increased over time with the magnitude of this increase dependent on the length of follow-up (p=0.001). In eyes with decreasing drusen volume, the magnitude of the decrease was dependent on the baseline drusen volume (p=0.001), and independent of the length of follow-up. 63 eyes with PED were enrolled. Both the qualitative appearance and the quantitative measurements of the PED area and volume were highly reproresulTs
* Financial interest disclosed
13
Macular DegeneraTion i 7:309:30 AM
ducible. 31 eyes had anti-VEGF therapy with the mean PED area changing from 6.22 mm2 to 5.53 mm2 (p=0.078), and the PED volume changing from 1.17 mm3 to 0.74 mm3 (p=0.04). We found that an increase in area or volume of the PED without the recurrence of sub/intraretinal fluid was useful in predicting the need for re-treatment at the next follow-up visit when using OCT-guided therapy. SD-OCT imaging of RPE deformations was highly reproducible. Drusen morphology is dynamic with a tendency for drusen to increase in volume and area over time. PEDs measurements were useful for following disease progression and deciding when to retreat eyes undergoing OCT-guided antiVEGF therapy. This novel algorithm should also be a valuable quantitative tool in designing clinical trials for AMD.
conclusion
(p=0.4614), and did not correlate with the number of re-treatments (p=0.552). Neither visual acuity at baseline (p=0.618), last follow-up (p=0.174), or the change in visual acuity over time (p=0.429) correlated significantly with SCT.
conclusion
Although choroidal thickness decreased over time in eyes with neovascular AMD, intravitreal anti-VEGF therapy did not appear to accelerate or otherwise alter this decline.
7:59 AM
Discussion
8:05 AM
The role of genetics and smoking in response to anti-vegf Therapy for Wet aMD
Jaclyn L. Kovach, MD (Naples, FL), William Cade, Bill Scott*, Anita Agarwal*, Stephen G. Schwartz, MD*, MBA, Kelly Taylor, Gaofeng Wang, Jonathan Haines, Margaret Pericak-Vance*
7:51 AM
effect of anti-vegf Therapy on choroidal Thickness in Patients with neovascular aMD

Srinivas Sadda, MD* (Los Angeles, CA), Emma McDonnell, MD, Florian Heussen, Humberto Ruiz-Garcia, MD, Yanling Ouyang, Ramsudha Narala, MD, Alexander Craig Walsh, MD*
PurPose
What is the relationship between high-risk genetic polymorphisms and smoking history and the response to antiVEGF therapy in wet AMD?
PurPose Choroidal thickness has been shown to decrease in some diseases following treatment (e.g. PDT), and choroidal thinning has been associated with decreased vision. In this study, we evaluate the changes in choroidal thickness as measured by spectral domain optical coherence tomography (SD-OCT) in patients with neovascular age-related macular degeneration (NVAMD) undergoing chronic anti-VEGF therapy. MeTHoD Patients with a diagnosis of NVAMD in at least one eye and serial SD-OCT volume scans obtained over a minimum 12 month follow-up period were retrospectively collected. For each case, subfoveal choroidal thickness (SCT) was measured from Bruchs membrane to the choroid-sclera junction in validated OCT review software, both at baseline and at the last follow-up date after start of therapy. SCT measurements were performed independently and adjudicated by two masked reading center graders. Only cases in which the full extent of the choroid was visible were included in subsequent quantitative analyses. SCT measurements were correlated with other patient and treatment characteristics. resulTs 94 eyes of 59 patients with a mean follow-up of 22.4 months met the inclusion criteria. Mean age was 83.3 years and 56 % were female. Eyes in the treatment group received a mean of 7.8 intravitreal anti-VEGF injections. SCT at baseline was 134.7 m (SD 58.0) for untreated eyes and 140.2 m (SD 62.3) in the treated group (p=0.6583). The average reduction in SCT over time was observed to be 13.5 m (p<0.0001) and 10.0 m (p=0.0088) for the respective groups. However, change in SCT did not differ significantly between the two groups
MeTHoD
Case series of 52 patients with wet AMD treated with an anti-VEGF agent, bevacizumab and/or ranibizumab, for at least 1 year. Genotypes at ARMS2 A69S and CFH Y402H were identified from DNA analysis with genomic screen and participants completed a smoking history questionnaire. Patients had been treated with anti-VEGF therapy for at least one year. Response to treatment was dichotomized into those that gained at least 2 lines of Snellen vision and had a reduction in intraretinal or subretinal fluid (responders) and those that maintained or lost vision and had persistent, recurrent or increased intraretinal or subretinal fluid (non-responders).
resulTs
Of the 52 total patients with wet AMD (diagnosed grade 5 AMD in at least 1 eye), 37 (71%) are non-responders compared to 15 (29%) responders. We found that responders were more likely to have at least one risk allele for both genes (CFH and ARMS2) and non-responders were more likely to have no risk alleles (p=0.02683). A higher proportion of responders than non-responders carry at least one risk allele at ARMS2 (85% vs. 55%), at CFH (100% vs. 81%) or at both genes (87% vs. 51%). No significant association was detected between response to treatment and the individual risk factors (Fishers exact test p-values: CFH-0.0933, ARMS2-0.0891, Smoking (past)-0.7455, Smoking (present)-1). We found a statistically significant association between CFH and ARMS2 risk alleles and a positive response to anti-VEGF treatment. Expanding our sample size and testing other high risk alleles will further elucidate the relationship between genetic AMD risk factors and treatment response.
conclusion
14 SCIENTIFIC PAPER ABSTRACTS
SCIENTIFIC PAPER ABSTRACTS
8:13 AM
8:21 AM
genotypic analysis of subtypes of choroidal neovascularization and Their response to anti-vegf Monotherapy
Mark H. Nelson, MD* (Winston-Salem, NC), Seanna R. Grob, MD, Matt Bedell, MD, Guy Hughes, MD, Clara Lee, MD, Bin Lin, MD, Robert Shaw, MD, Peter Shaw, MD, Sara Bozorg, MD, Igor Kozak, MD, Henry Ferreyra, MD, William R. Freeman, MD, Kang Zhang, MD, PhD
analysis of 2457 Patients in the Phase 3 view 1 and view 2 studies comparing vegf Trap-eye and ranibizumab in neovascular aMD
Jeffrey S. Heier, MD* (Boston, MA), Ursula Schmidt-Erfurth, MD*
PurPose Genotypic analysis of different subtypes of choroidal neovascularization gives an insight into the mechanisms of treatment response with the goal of providing targeted patient therapy for AMD. MeTHoD This study is a retrospective analysis of 281 eyes from 240 patients with Exudative ARMD treated with anti-VEGF monotherapy. Visual acuity was measured using ETDRS charts and the exam and imaging was used to determine diagnosis and choroidal neovascularization subtype. Twelve single nucleotide polymorphisms (SNPs) in genes CFH, HTRA1, C5, C2, and VEGF were genotyped. The patients were considered nonresponders to anti-VEGF monotherapy if their visual acuity did not improve by 1 ETDRS line or if their foveal thickness did not decrease as a result of therapy. Chi-squared tests were used for analysis of genetic data. resulTs Of the 240 patients, 62.5% were females and 37.5% were males with a mean age of 81. 10.8% were current smokers, 55.4% were past smokers, and 33.8% never smoked. Mean baseline VA was 20/100 and current VA for responders was 20/50 and 20/200 for non-responders. Of the subtypes that were compared, 23% of patients had occult, 51% had classic, and 30% had polypoidal choroidal vascuopathy (PCV). Genotypes were compared between the subtypes and statistical significance was achieved for the comparison of classic to occult with C3rs2230199 with an allelic p-value of 0.026, with occult having a higher frequency of the risk allele. In addition, when comparing classic to PCV, statistical significance was achieved for CFHrs7542235 with a p-value of 0.024. Significance was not achieved for the SNPs analyzed when comparing all responders to non-responders. conclusion This study suggests that there may be differences in genotypic frequency of risk alleles between choroidal neovascularization subtypes and genotypes and may affect the patient response to anti-VEGF monotherapy. Further studies on more candidate genes with a larger patient population will provide more information about the mechanism and effects of genotype on treatment.
PurPose
VIEW 1 and VIEW 2, evaluating VEGF Trap-Eye (VTE) vs ranibizumab, are the two largest prospective interventional studies of patients with neovascular age-related macular degeneration (AMD). Data from the 1-year results of these phase 3 studies were combined to provide a comprehensive data set to further analyze the efficacy and safety of VTE relative to the current standard of care (ranibizumab). VIEW 1 and VIEW 2 were designed as non-inferiority studies, with the non-inferiority margin set at 10%. A total of 2457 patients were randomized in the two studies to VTE 0.5 mg every month (0.5q4), 2 mg every month (2q4), 2 mg every 2 months following 3 monthly doses (2q8;) or to 0.5 mg ranibizumab every month (Rq4). The primary outcome of the combined analysis reported here was the proportion of patients who maintained visual acuity (avoided loss of <15 ETDRS letters) at 1 year. Secondary outcomes included the mean change from baseline in best-corrected visual acuity (BCVA) in ETDRS letters and the proportion of patients who gained 15 letters.
MeTHoD
resulTs
Proportions of patients losing <15 letters were 96.1%, 95.4%, 95.3%, and 94.4% for 0.5q4, 2q4, 2q8 and Rq4, respectively. All VTE groups, including VTE dosed 2 mg every 2 months, met the non-inferiority test compared with ranibizumab dosed monthly. Mean changes from baseline in BCVA at Week 52 were +8.3, +9.3, +8.4, and +8.7 letters for 0.5q4, 2q4, 2q8 and Rq4, respectively. Incidences of ocular treatment-emergent adverse events (TEAEs) were similar across treatment arms. The most frequent ocular TEAEs were conjunctival hemorrhage, eye pain, macular degeneration, retinal hemorrhage, and reduced visual acuity. The results of this analysis are consistent with those reported previously for each study. All VTE groups, including 2 mg dosed every 2 months, were non-inferior to ranibizumab. VTE was generally well tolerated and had a generally favorable safety profile. These results further indicate VEGF Trap-Eye may provide predictable therapy for wet AMD with every-2-months dosing.
conclusion
8:29 AM
Discussion
15
caTT 8:359:05 AM
8:35-9:05 AM
10:05 AM-12:00 pM
cATT Mini-symposium
The CATT study evaluated 1208 patients with neovascular macular degeneration who were randomly assigned to monthly ranibizumab, monthly bevacizumab, as needed ranibizumab or as needed bevacizumab with monthly office visits. The primary outcome measure was mean change in visual acuity for each of the four groups at one year. This symposium will review the CATT study results to allow clinicians to incorporate this information into the management of patients with choroidal neovascularization associated with age-related macular degeneration.
8:35 AM
Symposium 2: Awards and Special presentations

Moderators: Suber S. Huang, MD, MBA and John T. Thompson, MD
10:05 AM
introduction of gertrude D. Pyron award recipients: Jean Bennett, MD, PhD and albert M. Maguire, MD
Suber S. Huang, MD, MBA
caTT: Background and study Design

David F. Williams, MD, MBA* (Minneapolis, MN)
10:10 AM reTina researcH founDaTion Pyron aWarD lecTure
The evolution of retinal gene Therapy: from Dna to fDa

Jean Bennett, MD, PhD and Albert M. Maguire, MD* (Philadelphia, PA)
8:43 AM
caTT: visual and anatomic results

Glenn J. Jaffe, MD* (Durham, NC)
8:51 AM
caTT: adverse events and applications to clinical Practice

Daniel F. Martin, MD (Cleveland, OH)
8:59 AM
Gene therapy has the potential to reverse disease or prevent further deterioration of vision in patients with currently incurable retinal disease. Two decades ago, the idea of retinal gene therapy was pure fantasy. Since that time, many of the relevant genes have been identified and cloned, gene delivery toolkits have been developed, and surgical skills have been applied to demonstrate that gene delivery can halt and even reverse blindness. The recent demonstration of safe and stable recovery of retinal/visual function in children and adults with congenital blindness has fueled excitement about gene therapy applications to other blinding diseases.
resulTs To
Discussion
9:05 AM
Panel Discussion: How Do you Treat choroidal neovascularization following caTT study results?
Moderator: David M. Brown, MD Panelists: Jeffrey S. Heier, MD, Glenn J. Jaffe, MD, Daniel F. Martin, MD, David F. Williams, MD, MBA
move to the point where a retina specialist can write a prescription for gene therapy to a visually impaired patient will require considerable effort and changes in the policies of regulatory agencies. The FDA is re-evaluating the traditional outcome measures used to develop ocular medications to assure that these measures are appropriate for a diverse set of blinding conditions. The progress in genetics, gene delivery, retinal surgery, and re-evaluation of drug development issues will help to expand our armamentarium and provide options for reversing blindness that seemed like science fiction a couple of decades ago.
9:3010:05 AM
refreshment Break and exhibits

AWARDS AND SPECIAL PRESENTATIONS
10:40 AM
11:25 AM
introduction of founders award recipient: William f. Mieler, MD

John T. Thompson, MD
PaT survey Presentation

J. Michael Jumper, MD
11:30 AM 10:45 AM founDers aWarD lecTure
asrs Business Meeting

Members only
Treatment and Prevention of endophthalmitis: Past, Present, and future

William F. Mieler, MD* (Chicago, IL)
12:001:15 pM
lunch in exhibit Hall

12:001:15 pM
young Physicians section symposium and lunch

The treatment of endophthalmitis has evolved considerably over the past 35 years. While most interest has centered on post-cataract endophthalmitis, infections are also seen in the setting of open-globe injuries, associated with glaucoma filtration surgery, occur following intravitreal injections, and develop from endogenous settings. Approximately 30 years ago, the introduction of intravitreal antibiotics led to a marked improvement in visual and anatomic outcomes. Starting in the late 1980s, the Endophthalmitis Vitrectomy Study (EVS) helped to refine and standardize the treatment of postoperative infections, though it still left numerous questions regarding the best management of these challenging cases. Over the past 15 years, there have been significant advances in anti-microbial therapy, and these new developments have aided our management of endophthalmitis. This presentation will summarize and review the progress which has been made in the treatment and prevention of endophthalmitis, and will discuss expectations for the future.
11:15 AM crysTal aPPle aWarD lecTure
surgical Delivery of Human adult stem cells for atrophic aMD: rationale and Preliminary experience
Allen C. Ho, MD* (Philadelphia, PA)
Cellular therapies, and in particular stem cell therapies, have the potential to replace or restore function to diseased tissue in a variety of human diseases. Stem cells may be sourced from human embryos or from adult sources such as bone, blood, corneal limbus, or umbilical cord. First in human delivery of human adult umbilical stem cells was performed for retinitis pigmentosa by a transvitreal surgical approach. A new surgical approach is evolving to deliver subretinal human adult umbilical stem cells via a specially designed subretinal catheter and injection system for patients with atrophic age related macular degeneration. Surgical aims of the new approach are to minimize delivery of stem cells into the vitreous space and to keep them in the subretinal space. Safety goals for the technique remain primary at this time. Efficacy goals include a reduction in the rate of progression of geographic atrophy and changes in visual acuity.
american retina foundation report

The American Retina Foundation
11:20 AM
young Physicians section crystal apple award Presentation to allen c. Ho, MD

Jonathan L. Prenner, MD ASRS Young Physicians Section Committee, Chair
17
DiaBeTic reTinoPaTHy 1:203:02 PM
1:20 pM-3:02 pM
1:28 pM
Symposium 3: Diabetic Retinopathy

Moderators: David S. Boyer, MD and John S. Pollack, MD Related poster abstracts are on pages 99-106.
one iluvien (0.2 g/d fluocinolone acetonide) insert Provides improvement in visual acuity over 36 Months in Diabetic Macular edema: faMe subanalyses
David S. Boyer, MD* (Los Angeles, CA)
1:20 pM
Dexamethasone intravitreal implant Plus laser Photocoagulation vs. Monotherapy with laser for Treatment of Diffuse Diabetic Macular edema
Baruch Kuppermann, MD*, PhD (Irvine, CA), David Callanan, MD*, Sunil Gupta, Thomas Ciulla, MD, David Boyer, MD*, Ching-Chi Liu, Jean Lou, Xiao-Yan Li*, David Hollander, MD, Rhett Schiffman, Scott Whitcup, MD*
PurPose
The purpose of the FAME (Fluocinolone Acetonide in Diabetic Macular Edema) program was to determine the efficacy of ILUVIEN (0.2 g/d fluocinolone acetonide, FAc) nonbioerodible insert for improving visual acuity (VA) in patients with diabetic macular edema (DME) over 36 mo. Here, key subanalyses of the FAME data are presented to further highlight strategies for appropriate clinical use. The FAME program consisted of 2 randomized, prospective, multicenter, phase 3, double-masked, shamcontrolled, parallel-group trials evaluating 2 doses of FAc in patients with DME who had received prior macular laser treatment. A total of 956 patients were randomized 2:2:1 to 0.2 g/d FAc (n = 376), 0.5 g/d FAc (n = 395), or sham control (n = 185). Six weeks after randomization all patients were eligible for rescue laser therapy. The primary study endpoint was the proportion of patients with 15-letter improvement in VA at 24 mo. Here, we present a post-hoc analysis of efficacy in the subset of patients receiving only 1 study treatment over 36 mo.
To compare the efficacy and safety of combination therapy with dexamethasone intravitreal implant (DEX implant) plus laser photocoagulation versus laser alone for treatment of diffuse diabetic macular edema (DDME).
PurPose MeTHoD This masked study randomized (1:1) DDME patients with central retinal thickness (CRT) of 275 m on temporal domain optical coherence tomography and best-corrected visual acuity (BCVA) of 34 to 70 letters to receive DEX implant at day 0 followed by laser photocoagulation at month 1 (n=126) or sham at day 0 and laser at month 1 (n=127). If needed, patients were retreated with DEX implant at month 6 or 9 and with laser at months 4, 7, and 10. The primary outcome was the proportion of patients with BCVA improvement 10 letters from baseline at month 12. Efficacy outcomes were reported for 99 combination patients and 101 laser-alone patients with confirmed DDME at baseline. resulTs At month 12, the proportion of patients with 10letter improvement from baseline BCVA was 28% in the combination group and 24% in the laser group (P=.453). Compared with laser alone, patients treated with combination therapy had significantly higher mean increases from baseline BCVA at months 1, 4, 6, 7, and 9 (P<.05); AUC0-12 was 18432256 vs 8142539 for combination therapy vs laser alone (P<.001). Significantly greater mean reductions from baseline in central retinal thickness (CRT) at months 1, 4, and 9 (P<.045) and in diffuse leakage area based on fluorescein angiography at months 4, 6, 9, and 12 (P<.017) were also observed for combination therapy vs laser. Elevation of intraocular pressure (IOP) was the only adverse event that occurred significantly more in the combination group (25/125 [20%]; P<.001) than the laser group (2/127 [1.6%]), though at month 12, only 1% and 0% of patients, respectively, had 10 mm Hg increase from baseline IOP. conclusion DEX implant plus laser was well tolerated and improved BCVA, CRT, and leakage area more than laser alone in DDME patients.
MeTHoD
resulTs
Significantly more patients receiving 0.2 g/d FAc had 15-letter improvement in VA compared with sham control at 36 mo (28.7% vs 18.9%, P =.018). Only 1 study treatment (sham injection or FAc insert) was needed by 71.4% and 74.4% of patients in the control and 0.2 g/d FAc groups, respectively, by 36 mo. Significantly more patients receiving only 1 study treatment had 15-letter improvement in VA compared with control at 24 mo (35.5% vs 18.4%, P =.006) and 36 mo (36.7% vs 22.6%, P =.031). Improvements in best-corrected VA were significantly greater for patients receiving a single 0.2 g/d FAc insert vs 1 sham injection at 24 mo (7.2 vs 2.9, P =.029) and 36 mo (9.5 vs 4.3, P =.024). Mean center point retinal thickness decreased in all groups. By 36 mo, 80.0% of phakic patients in the 0.2 g/d FAc group underwent cataract surgery vs 27.3% of phakic controls, and 4.8% of patients in the 0.2 g/d FAc group required intraocular pressure (IOP)-lowering surgery vs 0.5% for controls.
conclusion
ILUVIEN (0.2 g/d FAc) provides rapid and sustained improvements in VA for 24-36 mo without the need for frequent injections. After 24 and 36 mo, a significantly greater percentage of patients with DME receiving a single ILUVIEN experienced 15-letter improvement in VA versus a single sham injection. ILUVIEN was well tolerated, with a low rate of incisional procedures required for elevated IOP.
1:36 pM
1:44 pM
randomized Trial to assess effects of intravitreal ranibizumab or Triamcinolone acetonide on DMe after focal/grid laser in eyes also receiving PrP
Andrew N. Antoszyk, MD* (Charlotte, NC)
expanded 2-year follow-up of a Trial evaluating ranibizumab Plus Prompt or Deferred laser or Triamcinolone Plus Prompt laser for DMe
Thomas W. Stone, MD* (Lexington, KY)
PurPose Randomized trial evaluating the short term effects of intravitreal ranibizumab or triamcinolone in eyes receiving focal/grid laser for diabetic macular edema (DME) and panretinal photocoagulation (PRP) for diabetic retinopathy. MeTHoD Three hundred forty-five eyes with a visual acuity (Snellen equivalent) of 20/320 or better, center-involved DME receiving focal/grid laser, and diabetic retinopathy receiving prompt PRP were prospectively randomized to sham (n=123) at baseline and 4 weeks, 0.5-mg ranibizumab (n=113) at baseline and 4 weeks, or 4-mg triamcinolone at baseline and sham at 4 weeks (n=109). Follow-up visits were conducted at 1, 4, 14 (primary outcome), 34, and 56 weeks after randomization. Treatment was at investigator discretion after the 14-week visit. resulTs Mean changes (standard deviation) in visual acuity letter score from baseline were significantly better in the ranibizumab (+111, P<0.001) and triamcinolone (+211, P<0.001) groups compared with the sham group (-414) at the 14-week visit. Reduction in mean central subfield thickness mirrored the visual acuity outcomes. These results were not maintained by 56 weeks. One eye (0.9%, 95% CI: 0.02% to 4.7%) developed endophthalmitis after receiving ranibizumab. Arterial thromboembolic events occurred in 4%, 7%, and 3% of the sham, ranibizumab, and triamcinolone groups, respectively. conclusion Focal/grid laser for DME had an average loss of vision with little thinning of the retina, short term, when PRP also was given. Addition of 1 intravitreal triamcinolone or 2 ranibizumab injections in eyes receiving focal/grid laser for DME and PRP had superior VA and OCT CSF thickness outcomes by 14 weeks, effects were not maintained by 56 weeks with discontinuation of treatments after 4 weeks.
PurPose
To report 2-year expanded follow-up of a trial evaluating intravitreal 0.5-mg ranibizumab or 4-mg triamcinolone combined with focal/grid laser compared with focal/grid laser alone for treatment of diabetic macular edema (DME).
MeTHoD
Eight hundred and fifty four study eyes of 691 participants with visual acuity (approximate Snellen equivalent) of 20/32 to 20/320 and DME involving the fovea were enrolled in a multicenter, randomized clinical trial. Expanded 2-year data were available for 642 eyes among 526 participants.
resulTs
At the 2-year visit, compared with the sham+prompt laser (SPL) group (N=211), the mean difference in the change in VA letter score from baseline was +3.7 (95% CI adjusted for multiple comparisons [aCI]: -0.4 to +7.7) letters in the ranibizumab+prompt laser (RPL) group (N=136), +5.8 (95% aCI: +1.9 to +9.8) letters in the ranibizumab+deferred laser (RDL) group (N=139), and -1.5 (95% aCI: -5.5 to +2.4) letters in the triamcinolone+prompt laser (TPL) group (N=142). After the 1-through the 2-year visit in the RPL and RDL groups, median numbers of injections were 2 and 3. At the 2-year visit, percentages of eyes with central subfield thickness 250m were 59% in the SPL group, 43% in the RPL group, 42% in the RDL group, and 52% in the TPL group. No systemic events attributable to study treatments were apparent. Three eyes (0.8%) of 375 participants had endophthalmitis in the ranibizumab groups while elevated intraocular pressure and cataract surgery were more frequent in the TPL group. Two-year expanded results reinforce conclusions originally reported; ranibizumab should be considered for patients with DME and characteristics similar to the cohort in this clinical trial, including vision impairment with DME involving the center of the macula.
conclusion
1:52 pM
Discussion
19
2:00 pM
Mean change in Bcva from Baseline over Time in the rise Trial
Two-year efficacy and safety outcomes of rise and riDe Two Phase 3 randomized controlled Trials of ranibizumab for Diabetic Macular edema
Quan Nguyen, MD, MSC* (Baltimore, MD), David M. Brown, MD*, Linda Yau, MD*, Jason S. Ehrlich, MD*, J. Jill Hopkins, MD*
PurPose DME is a leading cause of visual loss in working-aged adults in the developed world. Vascular endothelial growth factor (VEGF) is directly involved in the pathogenesis of DME. The RISE and RIDE trials were designed to assess the efficacy and safety of monthly intravitreal ranibizumab (RBZ) injections compared to sham injections in patients with DME. MeTHoD RISE and RIDE were methodologically identical, prospective, double-masked, phase 3 sham-controlled trials. Patients with DME who met prespecified eligibility criteria (RISE, n=377; RIDE, n=382) including BCVA 20/40-20/320 Snellen equivalent and central subfield thickness 275m on time-domain optical coherence tomography (OCT) were randomized 1:1:1 to receive monthly RBZ (0.5mg or 0.3mg) or sham injections. The need for macular rescue laser was assessed monthly starting at month 3. The primary efficacy outcome was the proportion of patients gaining 15 ETDRS letters in BCVA from baseline at month 24. Safety was assessed based on ocular and systemic adverse events (AEs). resulTs At the month-24 primary efficacy endpoint, the proportion of subjects gaining 15 letters in RISE was 18.1% (23/127) in the sham group, 44.8% (56/125) in the 0.3 mg group (P<0.0001 vs. sham), and 39.2% (49/125) in the 0.5 mg group (P=0.0002 vs. sham). In RIDE, the corresponding numbers were 12.3% (16/130), 33.6% (42/125), and 45.7% (58/127) respectively for sham, 0.3 mg RBZ, and 0.5mg RBZ. In RISE mean change from baseline BCVA letter score at month 24 was 12.5 and 11.9 in the 0.3 mg and 0.5 mg RBZ groups, and 2.6 in the sham group (P<0.0001 for each RBZ group vs. sham; Figure 1). Mean foveal thickness decreased by 133.6 m in the sham group and 250.6 to 253.1 m in the ranibizumab groups (P<0.0001 for each RBZ group vs. sham; Figure 2). In both RISE and RIDE, ocular and systemic AEs were generally consistent with prior studies of RBZ. AEs associated with diabetic retinopathy (such as vitreous hemorrhage) were less common in patients treated with ranibizumab.
Mean change in ocT central foveal Thickness (cfT) over Time in the rise Trial
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subgroup analyses of efficacy outcomes in rise and riDe Two Phase 3 randomized controlled Trials of ranibizumab for Diabetic Macular edema
Dennis M. Marcus, MD* (Augusta, GA), Pamela Wong*, J. Jill Hopkins, MD*, Jason S. Ehrlich, MD*
PurPose
RISE and RIDE were methodologically identical, prospective, double-masked, phase 3 trials designed to assess the efficacy and safety of monthly intravitreal (IVT) ranibizumab injections in patients with DME. We conducted a series of prespecified subgroup analyses to examine the effect of demographic and baseline characteristics on the efficacy of ranibizumab and sham injections in DME patients.
In RISE and RIDE, patients with DME treated with monthly RBZ experienced rapid, sustained, and statistically significant improvements in BCVA and OCT compared to subjects in the sham injection group. Incidence of ocular AEs was consistent with prior clinical trials involving intravitreal injections. Overall rates of ATEs were similar to those reported in other Phase III studies of DME with RBZ.
conclusion
MeTHoD
Eligible patients with study eye BCVA 20/40-20/320 Snellen equivalent and center subfield thickness 275m on optical coherence tomography (OCT) were randomized 1:1:1 to receive monthly ranibizumab (0.5mg or 0.3mg) or sham injections. Starting at month 3 eligible patients could receive rescue
laser. The primary efficacy outcome was the proportion of patients gaining 15 Early Treatment Diabetic Retinopathy Study (ETDRS) letters in BCVA from baseline at month 24. Prespecified variables for subgroup analyses included demographics (age, gender, race), baseline BCVA (>55 or 55 ETDRS letters), baseline HbA1c (>8% or 8%), focal edema at baseline, and prior therapy for DME.
resulTs RISE study results are presented here. In RISE, 377 eligible patients were randomized to sham (n=127), 0.3 mg ranibizumab (n=125) or 0.5 mg ranibizumab (n=125). At month 24 the overall proportion of 15-letter gainers was 18.1% in the sham group, 44.8% in the 0.3 mg group (P<0.0001 vs. sham) and 39.2% in the 0.5 mg group (P=0.0002 vs. sham). Within each treatment group, neither a history of prior therapy for DME (yes/no) nor baseline HgbA1C (>8%/8%) appeared to affect the relative proportions of patients improving by 15 letters from baseline at month 24. Patients with relatively good baseline BCVA (>55 letters) were less likely to achieve a 15 gain at Month 24 than patients with worse baseline BCVA (55 letters), but the results still favored ranibizumab over sham regardless of baseline BCVA (Table). Results of additional subgroup analyses from both the RISE and RIDE studies will be presented. conclusion DME patients treated with monthly ranibizumab experienced statistically significant BCVA improvements compared to subjects in the sham group. In the RISE study, some baseline patient characteristics (particularly baseline BCVA) had an effect on outcomes, but no prespecified subgroup was identified in which sham patients had better outcomes than ranibizumab-treated patients.
subgroup analysis of 15 letter gains from baseline at month 24 in the rise study
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aggressive anti-vegf Treatment is necessary to control Diabetic Macular edema: Month-36 outcomes of the reaD-2 study
Thomas Gerald Chu, MD, PhD* (Los Angeles, CA), Diana Do*, Quan Dong Nguyen*, Afsheen Khwaja, Roomasa Channa, Yasir Sepah, MD, David S. Boyer, MD*, Jeffrey S. Heier, MD*, Jennifer I. Lim, MD, Peter A. Campochiaro, MD*
PurPose
The READ-2 clinical trial was initially designed to be completed in 2 years. A study amendment was offered to patients upon completion of month 24 to be followed and treated for an additional year, the purpose of which was to see whether patients with residual macular edema could benefit from more frequent monthly dosing of ranubizumab, if foveal thickness was >250 m.
MeTHoD
A randomized prospective clinical trial, the READ-2 trial, compared ranibizumab (RBZ) injections (group 1) to laser (group 2) and RBZ + laser (group 3) for 6 months in patients with diabetic macular edema; patients were then seen every 2 months (groups 1 and 2) or 3 months (group 3) and received assigned treatment or RBZ for foveal thickness (FTH) > 250 m. A one year extension was offered to patients with monthly visits. Patients who developed recurrent macular edema could receive the following: Group 1 study eyes could receive monthly injections of RBZ; Group 2 study eyes receive monthly RBZ or laser every 3 months: Group 3 study eyes could receive monthly RBZ and laser every 3 months.
resulTs
Of the 30, 24, and 25 patients in groups 1, 2, and 3 who continued after M24, 28, 22 and 24 completed M36. The mean improvement in BCVA between baseline and M36 was 10.3, 1.4, 9.5 letters, compared to 7.1, 3, and 7.1 in the same patients at M24. The percentage of patients who gained 3 lines from baseline was 35.7, 9.1, and 25 at M36 compared to 25, 9.1, and 20.8 at M24. With a mean number of injections of 5.5, 4.6, and 2.9, mean FTH was reduced from 352.4, 300.7, and 249.8 m at M24 to 282.3, 264.7, and 214.5 m at M36. The percentage of patients with FTH 250 m was 39.3, 68.2, 87.5 at M36 compared to 32.1, 45.4, and 66.7 at M24. There were no drug related ocular or systemic adverse events. A protocol amendment study for an additional 12 months allowing prn RBZ treatment every month instead of every 2 months resulted in a significant reduction in mean FTH and improvement in BCVA in groups 1 and 3. The results suggest that many patients with recurrent or persistent diabetic macular edema could benefit from more frequent injections of RBZ to optimally control edema and maximize vision.
conclusion
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Discussion
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effects of ranibizumab on Patient-reported visual function Through 24 Months in Patients with vision impairment from Diabetic Macular edema
Neil M. Bressler, MD* (Baltimore, MD), Rohit Varma, Paul Lee, Ivan J. Suner, MD, Chantal Dolan, James Ward, Jason S. Ehrlich, MD*, Shoshana Colman
PurPose To examine the impact of intravitreal ranibizumab on patient-reported visual function using the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25) through 24 months in patients with vision impairment from clinically significant diabetic macular edema (DME) involving the center of the macula. MeTHoD Two multicenter Phase III trials (RISE and RIDE) enrolled participants with vision impairment from DME (approximate Snellen equivalent 20/40 or worse) involving the center of the macula. In RISE, subjects were randomized 1:1:1 to receive monthly sham injections (n=127), or monthly intravitreal injections of 0.3-mg (n=125) or 0.5-mg (n=125) ranibizumab for 24 months, in one eye (the study eye). From month 3, study participants could receive laser if OCT was 250m with <50m change from the prior month, no laser for DME had been applied in the prior 3 months, and the evaluating physician deemed laser therapy to be beneficial. The NEI VFQ-25 was administered at 0, 6, 12, 18, and 24 months. resulTs In RISE, in approximately 21% of the cases in each arm, the study eye was the better-seeing eye. In each treatment arm, the mean visual acuity (approximate Snellen equivalent) at baseline was 20/80 while the mean NEI VFQ-25 composite score ranged from 64.3 to 69.1 points. In both ranibizumabtreated groups, patients reported greater mean improvements in the NEI VFQ-25 overall composite score compared with sham patients at 24 months (P=0.010, P=0.034 for 0.3mg and 0.5 mg groups, respectively, Figure). Substantial differences were noted as early as 6 months after randomization. Results from RIDE as well as global ranibizumab data (RESTORE) will also be presented and discussed. conclusion At 24 months and as early as 6 months, patients with vision impairment from DME treated monthly with ranibizumab report greater improvements in patient-reported visual function. These findings are consistent with results at 12 months reported from RESTORE in which the initial visual acuity (approximate Snellen equivalent) was 20/50 and ranibizumab was compared with laser treatment for DME.
Mean NEI VFQ-25 composite scores are shown by study group up to 24 months. Last observation carried forward method was used to impute for missing values.
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Primary intravitreal Bevacizumab Plus glP or Primary intravitreal Bevacizumab or glP for DDMe: The Pan-american collaborative retina study group
J. Fernando Arevalo, MD (Caracas, Venezuela), Andres Lasave, Lihteh Wu, MD, Manuel Diaz-Llopis, Roberto Gallego-Pinazo, MD, Arturo Alezzandrini, MD, Maria Berrocal, MD*
PurPose
To evaluate the anatomical and functional outcomes at 24 months of follow up in patients with diffuse diabetic macular edema (DDME) treated with primary intravitreal bevacizumab (IVB) plus grid laser photocoagulation (GLP) or primary IVB alone or GLP alone.
MeTHoD
Retrospective interventional comparative multicenter study. We reviewed the clinical records of all consecutive patients with DDME treated with IVB, GLP or combined IVB plus GLP. ETDRS best-corrected visual acuity (BCVA) and central macular thickness (CMT) with optical coherence tomography (OCT) were obtained at baseline, 1, 3, 6, 12 and 24 months of follow up. Re-treatment was based on clinical or OCT-based evidence of persistent macular edema or deterioration in BCVA. In addition, BCVA and CMT were compared among the three groups using the ANOVA method.
resulTs We included 418 eyes of 318 patients. One hundred forty-one eyes of 120 patients with DDME were treated with primary IVB alone (Group A), 120 eyes of 94 patients with GLP therapy (Group B), and 157 eyes of 104 patients were treated with IVB plus GLP (Group C). The total number of injection was 5.8 3.2 in Group A and 6.2 4.9 in Group C.
In Group A, BCVA improved from logMAR from 0.87 0.4 to 0.65 0.4 (p < 0.0001); in Group B, BCVA improved from logMAR from 0.76 0.35 to 0.62 0.43 (p= 0.0061); and in Group C, BCVA improved from logMAR from 0.76 0.45 to 0.60 0.39 (p = 0.0009). The improvement rate was similar among the three groups (ANOVA; p=0.41). In Group A, there was a decrease from 446.2 155.8 um to 273.8 79 um (p < 0.0001), in Group B from 379.1 91 m to 271 78.6 m (p < 0.0001), and Group C from 415.5 144.8 m to 333 138.5 m (p < 0.0001). The comparison among three groups showed higher CMT decrease in group A than in groups B and C (ANOVA; p < 0.001).
conclusion Primary IVB with or without GLP seems to have similar efficacy to provide stability or improvement in BCVA as compared to GLP alone in patients with DDME at 24 months. CMT improved in all treatment groups at 24 months of follow up. However, primary IVB alone produced greater decrease in CMT than treatments in Group B and C. GLP did not decrease the number of injections in group C.
Mean improvements in BCVA in the VTE groups at Week 24 were 8.6, 11.4, 8.5, and 10.3 letters for 0.5q4, 2q4, 2q8, and 2PRN, respectively, versus 2.5 letters for the laser group (P<0.01 for each VTE group versus laser). Mean improvements in BCVA in the VTE groups at Week 52 were 11.0, 13.1, 9.7, and 12.0 letters for 0.5q4, 2q4, 2q8, and 2PRN, respectively, versus -1.3 letters for laser (P<0.0001 for each VTE group versus laser). Proportions of patients with gains in BCVA of 15 ETDRS letters in the VTE groups at Week 52 were 41%, 46%, 24%, and 42% versus 11% for laser. VEGF Trap-Eye was generally well tolerated. The most frequent ocular adverse events were conjunctival hemorrhage, eye pain, ocular hyperemia, and increased intraocular pressure.
resulTs conclusion
VEGF Trap-Eye provided significant benefit in the treatment of DME. Significant gains in BCVA from baseline achieved at Week 24 were maintained or improved up at Week 52 in all VEGF Trap-Eye groups, including the group receiving 2 mg VEGF Trap-Eye every 2 months.
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Discussion
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one-year results of the Da vinci study of vegf Trap-eye in Diabetic Macular edema
Diana V. Do, MD* (Baltimore, MD), Ursula Schmidt-Erfurth, MD*, Quan Nguyen, MD*, MSc, Jeffrey S. Heier, MD*

PurPose To compare different doses and dose regimens of VEGF Trap-Eye (VTE) versus laser photocoagulation in patients with diabetic macular edema (DME). VEGF Trap-Eye is an intravitreally administered fusion protein that inhibits the vascular endothelial growth factor A (VEGF-A) and placental growth factor. MeTHoD A total of 219 patients were randomized and treated with 1 of 5 regimens: VTE 0.5 mg every 4 weeks (0.5q4); 2 mg every 4 weeks (2q4); 2 mg every 8 weeks following 3 initial monthly doses (2q8); 2 mg as needed following 3 initial monthly doses (2PRN); or laser photocoagulation. The change in best-corrected visual acuity (BCVA) was measured at Week 24 (the primary endpoint) and at Week 52. Additional secondary endpoints assessed at Week 52 included the proportion of patients who gained 15 ETDRS letters in BCVA and mean change in central retinal thickness (CRT) from baseline.
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viTreoreTinal surgery 3:355:45 PM
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Symposium 4: vitreoretinal Surgery i

Moderators: G. William Aylward, MD and Pravin U. Dugel, MD Related poster abstracts are on pages 119-150.
a Detailed evaluation of Brilliant Blue g Dye in chromovitrectomy

Eduardo Rodrigues, MD (Florianopolis, Brazil), Fernando Penha, MD, Mauricio Maia, Milton Moraes-Junior, MD, Magno Ferreira, MD, Michel Farah, MD, PhD
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a comparison of indocyanine green, Trypan Blue and Brilliant Blue for Macular Hole surgery
Cyrus M. Shroff, MD (New Delhi, India), Neelam Atri, MD, Charu Gupta, MD, A.K. Singh, MD, Bhavana Sharma, MD, Daraius Shroff, MD, FRCS
PurPose
Brilliant blue G (BBG) arises as excellent novel dye in chromovitrectomy. This work aims to present a detailed investigation of the vital dye BBG in a variety of research settings as laboratory of biochemistry, cell-culture model, rabbit toxicity model, and clinical study in patients. The paper investigates various aspects of BBG: 1. Biochemistry profile of the blue dye in regard to pH, osmolarity, binding properties, and formation of decomposition products (DPs); 2. Effect of the dilution in saline solution, 5% glucose, or deuterated water; 3 In-vitro retinal pigment epithelium (RPE) toxicity in ARPE-19 cell-culture model in various concentrations and in comparison to other dyes; 4. Intravitreal retinal toxicity in rabbits; 5. An interventional prospective study in patients that examined the binding properties of the dye diluted in saline or 5% glucose to epiretinal membranes (ERMs) and internal limiting membranes (ILMs) of macular hole surgeries in fifty-one patients.
MeTHoD
PurPose To study the outcome of macular hole surgery using three different dyes to stain the ILM, and to compare the efficacy of Brilliant blue to the conventionally used dyes Trypan Blue and Indocyanine green. MeTHoD Retrospective non-randomized comparative analysis between three groups 1. Trypan Blue 2. Indocyanine Green and 3.Brilliant blue. 104 patients of idiopathic macular hole who underwent vitrectomy and ILM peeling were included. Pre- and post-operative best-corrected visual acuity, lens status and Optical Coherence Tomography were done for all patients. 66 patients underwent ILM staining with Trypan Blue (TB), 24 patients with Indocyanine Green (ICG) staining and 17 patients with Brilliant Blue (BB). resulTs Mean pre and post operative log MAR best corrected visual acuity (BCVA) was 0.870.38 and 0.380.30 in the TB group (p<.001), 0.900.28 and 0.440.24 in ICG group and 0.660.27 and 0.370.21 in the BB group (p<.001). Post operatively all eyes had BCVA 20/200, 36 eyes (54.5%) in the TB group, 10 eyes (41.7%) in the ICG group and 7 eyes (41.2%) in the BB group achieved BCVA 20/40. No patient had post operative retinal detachment. conclusion There was no statistical difference in the visual outcome between the three groups. (P= 0.228) Brilliant Blue stained ILM well facilitating complete and atraumatic removal. Moreover, in the Brilliant Blue group the absence of fluid-air exchange during staining reduced the chances of lenticular haze during surgery as compared to TB group.
resulTs
BBG is an anionic aminotryarylmethane dye with great affinity to collagen. The pH of BBG varies from 6.9 to 7.2, while the osmolarity ranges from 291 to 205 mOsm. In contrast to indocyanine green (ICG), BBG generates no significant DPs; 2. BBG in deuterated water promotes faster and more concentrated reach of dye onto the macula Fig. 1; 3. BBG induces no reduction in RPE cell viability lower then 0.25%, differently from ICG toxic in all concentrations; 4. In the lower concentration 0.05%, BBG promotes no significant histology alterations; however, at 0.5% BBG causes diffuse vacuolization and edema of the photoreceptors Fig. 2, confirmed by eletrorretinography; 5. BBG has been an appropriate dye for ILM in the majority (82%) of surgeries, however, in 45% of surgeries it has been considered not enough for ERMs visualization. There is a tendency of BBG to stain the ILM better with saline solution over glucose 5% (P= 0.64). BBG diluted in deuterated water promotes excellent ILM coloring. BBG became the state-of-the-art dye for ILM identification. Differences in staining properties may imply that brilliant blue should not be considered as first-line stain for ERMs surgery. Deuterated water may be the best solvent for the novel blue agent. At clinically used concentrations under 0.05%, the blue dye poses little or no risk of retinal toxicity.
conclusion
tively) was noted. Nevertheless, the C-ERM group had a statistically significantly better outcome. In the T-ERM group, 4 eyes developed a full thickness macular hole and needed additional treatments while no significant complications were reported in the C-ERM group.
conclusion
Laboratory picture revealing the differences in dye drop. Left: BBG diluted in saline mixes with vitreous solution. Right: BBG diluted in deuterated water falls into the posterior area enabling faster and more selective epirretinal coloring.
The SD-OCT characteristics of lamellar macular hole have prognostic value related to anatomic and functional outcome after surgery.
Classic epiretinal membrane (C-ERM) in lamellar macular hole
Histology examination of BBG. Upper image: BBG at 0.05% induced no significant retinal damage. Lower image: BBG at 0.5% promoted outer retina vacuolization and edema. Such finding may explain the recently reported clinical observations of outer retinal edema after BBB use in patients.
Thick epiretinal membrane (T-ERM) in lamellar macular hole
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vitrectomy for lamellar Macular Hole: some sD-ocT characteristics Have a Prognostic value for the Postoperative outcome
Grazia Pertile, MD (Negrar, Italy), Matteo Cereda, MD, Barbara Parolini, MD
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Discussion
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Surgery for lamellar macular hole is still controversial. The aim of the study was to identify prognostic factors based on OCT findings that can guide this therapeutic decision.
PurPose MeTHoD Forty eyes with a lamellar macular hole diagnosed with Spectral-Domain optical coherence tomography (SD-OCT) (Heidelberg Engineering, Heidelberg, Germany) and recent visual loss were included in this study. Twenty-six eyes had a thin epiretinal membrane with tangential traction classic epiretinal membrane (C-ERM) and 14 eyes presented thick, moderately reflectant tissue on the edge of the lamellar hole (TERM). All the eyes underwent pars plana vitrectomy with ERM and internal limiting membrane peeling. Air tamponade was used after surgery in all cases. BCVA, a complete ophthalmologic examination and OCT were performed before the surgery and at 3,6 and12 months after the surgery. resulTs The mean postoperative BCVA was 0.05 logMar in the C-ERM group and 0.2 LogMar in the T-ERM group. In both groups a statistically significant improvement compared with the pre-operative BCVA (0.3 LogMar and 0.4 LogMar respec-
ocriplasmin, a Pharmacologic option for the Treatment of symptomatic vitreomacular adhesions (svMa): Phase iii clinical Trials results
Pravin U. Dugel, MD* (Phoenix, AZ)
PurPose
The purpose of this study was to evaluate the safety and efficacy of a single dose of 125g ocriplasmin for the treatment of sVMA at day 28. Patients with vitreomacular traction, full thickness macular hole, and epiretinal membrane were included.
MeTHoD
These studies (MIVI-006 & MIVI-007) were randomized, placebo-controlled, double-masked, multicenter trials, investigating a single dose of 125g (100 l) intravitreal injection of ocriplasmin for treatment of vitreomacular
25
adhesion as compared to a 100 l placebo intravitreal injection. The primary endpoint was nonsurgical resolution of fVMA at day 28, determined by Central Reading Centre OCT evaluation. Secondary endpoint assessments included total posterior vitreous detachment (PVD) at day 28, nonsurgical FTMH closure, avoidance of vitrectomy, visual acuity, and VFQ-25.
resulTs 652 eyes were treated at clinical sites in Europe and the United States. 464 eyes were randomized to receive a single dose of 125g ocriplasmin and 188 eyes received 100 l of placebo. Patient age range was 18 to 93 years. At day 28 VMA resolution was achieved in 26.5% of ocriplasmin treated eyes and 10.1% of eyes receiving placebo (p<0.001). Of treatment responders, 74% achieved VMA resolution by day 7. The proportion of eyes that achieved total posterior vitreous detachment at day 28 was 13.4% in the ocriplasmin group and 3.7% in the placebo group (p<0.001). Closure of full thickness macular hole was achieved by day 28 in 40.6% of eyes treated with ocriplasmin and 10.6% of eyes in the placebo group (p<0.001).
resulTs
652 eyes (age 18-93) were enrolled by 90 investigators at clinical sites in Europe and the United States. 464 eyes were randomized to receive a single dose of 125g ocriplasmin and 188 eyes received a 100 l placebo injection. By month 6, VMA resolution was achieved in 26.9% of ocriplasmin treated eyes and 13.3% of eyes receiving placebo (p<0.001). At 1 month and 6 months following treatment 40.6% of eyes receiving ocriplasmin achieved closure of full thickness macular hole (FTMH), compared to 10.6% (p<0.001) at 1 month and 17.0% (p=0.004) at 6 months for placebo. Significant improvement of 2 or more lines (10 letters) in visual acuity (28.0%, p=0.003) and 3 or more lines (12.3%, p=0.024) of visual acuity was observed in ocriplasmin group. Patients treated with ocriplasmin demonstrated significant improvement in visual function as compared to placebo.
conclusion
The MIVI-TRUST program is the largest Phase III program ever conducted to evaluate a pharmacologic intervention for the treatment of symptomatic vitreomacular adhesion. The significant clinical results observed in these trials indicate that ocriplasmin can potentially become the first pharmacologic option for the treatment of symptomatic vitreomacular adhesion including macular holes.
conclusion
A single dose of 125g ocriplasmin intravitreal injection achieved clinically significant and sustained anatomical and visual acuity results in eyes with vitreomacular traction, full thickness macular hole, & epiretinal membrane as compared to a 100 l placebo injection. Treatment was well tolerated by patients and appears to be a minimally invasive pharmacologic option for the treatment of sVMA.
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Discussion
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Treatment of symptomatic vitreomacular adhesions with ocriplasmin: 6 Month outcomes from the Mivi-TrusT Phase iii Program
Peter K. Kaiser, MD* (Cleveland, OH)
optic nerve Pit with Macular Detachment (fluid origin and Better Management)
Ehab N. El-Rayes, MD (Cairo, Egypt)
PurPose PurPose The purpose of this study was to evaluate the safety and efficacy of a single dose of 125g ocriplasmin for the treatment of sVMA at day 28. Patients were then followed up to 6 months to assess the durability of primary and secondary efficacy outcomes and safety. Patients with vitreomacular traction, full thickness macular hole, and epiretinal membrane were included. MeTHoD These studies (MIVI-006 & MIVI-007) were randomized, placebo-controlled, double-masked, multicenter trials, investigating a single dose of 125g (100 l) intravitreal injection of ocriplasmin for treatment of vitreomacular adhesion as compared to a 100 l placebo intravitreal injection. The primary endpoint was nonsurgical resolution of fVMA at day 28, determined by Central Reading Centre OCT evaluation. Secondary endpoint assessments included total PVD at day 28, nonsurgical FTMH closure, avoidance of vitrectomy, visual acuity, and VFQ-25. Eyes were followed for 6 months.
Chronic serous macular detachment, macular retinoschesis and cystic degeneration of the inner retina are complication of fluid access from the pit damaging the macula. In this study we report cases of managing the fluid intraoperatively decreasing the risk of vision threatening complication, this fluid was analyzed to trace the source of this fluid.
MeTHoD
We report 6 eyes of 4 patients with macular detachment due to optic nerve pits. 2 eyes were managed with vitrectomy ,laser and air. The other 4 eyes were treated with vitrectomy and aspiration of the viscous intra as well as sub retinal fluid with 38 gauge translocation canula to dry the macular intraoperatively. The collected fluid was sent for analysis , including B.trace protein detection. OCT was done on day 3 and one week then monthly for 3 month. Successful macular attachment with layer restoration was immediately achieved in all 4 eyes with in the first week on OCT in the eyes that had aspiration. All eyes had rapid improvement in visual acuity and fundus appearance. In the
resulTs
vitrectomy without aspiration eyes , complete macular attachment was seen by one month in one eye and up to 2 month in the second eye ,with residual intra-retinal cysts. The intra retinal fluid was noted to decrease gradually over 3 month period. Sub retinal fluid analysis showed positive B trace protein in 2 eyes (50%), in favor of CSF fluid component access to submacular space.
conclusion Intraoperative aspiration of intra and sub retinal fluid leads to immediate restoration of macular structure. This reflects on visual function improvement. Fluid analysis showed that there is contact between the CSF to sub retinal space. Vitrectomy with aspiration sub retinal fluid should be consideration as the line of management of macular detachment due to optic pit.
and analyzing only one eye per patient, Crystalens was associated with a higher RD rate than ReSTOR (OR 4.6, 95% CI 0.8-26.2), although the difference did not reach statistical significance due to small sample size (p=0.087).
conclusion
Compared to multifocal IOL (ReSTOR), accommodative IOL (Crystalens) implantation with cataract surgery may be associated with a higher rate of postoperative RD. Due to the relatively small sample size and the retrospective nature of this study, these results will need to be verified by future studies.
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Discussion
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retinal Detachments following cataract surgery with Presbyopia-correcting intraocular lenses

Michael M. Lai, MD, PhD (Chevy Chase, MD), Janine Collinge, MD, Neil F. Martin, MD
comparison of Pars Plans vitrectomy With and Without scleral Buckle for the repair of Primary rhegmatogenous retinal Detachment
Joseph Moisseiev, MD (Tel Aviv, Israel), Michael Kinori, MD, Elad Moisseiev, MD, Nadav Shoshani, MD, Ido Fabian, MD, Alon Skaat, MD, Adiel Barak, MD*, Anat Loewenstein, MD*
To determine the incidence of retinal detachment (RD) following cataract surgery with implantation of multifocal (ReSTOR) or accommodative (Crystalens) intraocular lens (IOL), and to compare the rates of post-cataract RD between these two types of IOLs.
PurPose MeTHoD This is a retrospective cohort study consisting of consecutive eyes that underwent cataract surgery by a single surgeon between 2004 and 2010. All eyes were implanted with either a ReSTOR (Alcon) multifocal IOL or a Crystalens (Bausch & Lomb) accommodative IOL. Eyes with history of RD or retinal tear prior to cataract surgery, or follow-up less than 3 months after cataract surgery were excluded from the study. The primary outcome was the rate of RD following cataract surgery with each type of IOLs. The RD rates were compared between the two groups to determine whether significant differences exist. resulTs
PurPose
To compare pars plana vitrectomy (PPV) with combined PPV and scleral buckle (PPV/SB) for the repair of noncomplex primary rhegmatogenous retinal detachment (RRD).
MeTHoD
A retrospective review of the charts of 469 patients that underwent vitrectomy for primary RRDs in two major medical centers in Israel. Included in this study are 181 eyes with non-complicated RRD and at least 3 months of follow up. There were 96 eyes in the PPV group and 85 eyes in PPV/SB group.
resulTs
315 eyes with ReSTOR multifocal IOL and 172 eyes with Crystalens accommodative IOL met the inclusion and exclusion criteria. The two groups were similar with respect to mean axial length, follow-up duration, and final best-corrected visual acuity. There were no intraoperative complications including capsular rupture in any eye. During the follow-up period (mean = 25.7 months), 2 eyes (0.6%) in the multifocal IOL group and 7 eyes (4.1%) in the accommodative group developed RD (p=0.0112, Fishers exact test). The mean time to RD was 13 months following cataract surgery (range 1-37 months). When using logistic regression modeling adjusting for the effects of age, gender, axial length, and follow-up duration,
Single surgery anatomic success (SSAS) was achieved in 81.3% and 87.1% in the PPV and PPV/SB groups, respectively (P=NS). Final anatomic success rates were 98.9% and 98.8%, respectively (P=NS). Final visual acuity (logMAR) was 0.41 in the PPV group and 0.53 in the PPV/SB group (P=NS). The final VA was significantly better than the pre-operative VA in both group (P<0.0001). In detachments caused by inferior tears SSAS were 80.9% and 81.5% in the PPV and PPV/SB groups, respectively (P=NS). In phakic eyes SSAS was 92% and 87.5% and in pseudophakic eyes 77.5% and 86.7%, in the PPV and PPV/SB groups, respectively (P=NS). The re-attachment rate and the final VA were similar in both groups. The addition of SB did not improve the results, and was associated with slightly lower visual acuity than with PPV alone. Tear location or lens status had no significant effect on success rates. It is likely that in eyes undergoing PPV for primary RRD addition of a SB is not warranted.
conclusion
27
4:53 pM
5:01 pM
retinal Detachment repair: a comparison of Pneumatic retinopexy, Pars Plana vitrectomy and scleral Buckling within a group Private Practice
Robert L. Avery, MD (Santa Barbara, CA), Maan Nasir, MD, Dante Pieramici, MD, Alessandro Castellarin, MD, Robert See, MD, Stephen Couvillion, MD, Melvin Rabena
scleral Buckling surgery for Treatment of rhegmatogenous retinal Detachment

Kourous A. Rezaei, MD* (Harvey, IL), Anna Gabrielian, MD
PurPose
To compare visual and anatomical outcomes including the incidence of recurrent detachment between four different surgical approaches to repair primary rhegmatogenous retinal detachment (RRD): scleral buckle (SB), primary pars plana vitrectomy (PPV), pneumatic retinopexy (PR) and combination primary pars plana vitrectomy with scleral buckling (PPV+SB).
PurPose MeTHoD A retrospective review was conducted on consecutive eyes that underwent surgical repair for primary (RRD) over the past 10 years within a group private practice. Cases with ruptured globe, penetrating injury, giant retinal tear (> 3 clock hours), proliferative diabetic retinopathy, stage C or worse proliferative vitreoretinopathy (PVR), or less than 3 month follow-up were excluded. Analysis of preoperative characteristics included vision, PVR status, vitreous hemorrhage (VH), lens status, and extent of detachment. Postoperative adverse events analyzed were recurrent retinal detachment, number of retinal reattachment procedures, development of PVR, VH and epiretinal membrane. resulTs Entry criteria were met by 793 eyes with primary RRD; 72 eyes were repaired by pneumatic retinopexy (PR), 91 by scleral buckle (SB) only, 533 by combined pars plana vitrectomy and scleral buckle (PPV+SB) and 91 by pars plana vitrectomy only (PPV). There were 472 (57.8%) phakic eyes, 353 (44.5%) pseudophakic eyes, and 4 (0.5%) eyes were aphakic at the time of initial repair. The macula was attached in 536 (67.6%) eyes. Preoperatively proliferative vitreoretinopathy (grade B or less) was found in 122 (15.4%) eyes, vitreous hemorrhage was present in 71 (8.9%) eyes. The mean length of follow-up was 28 months. Redetachment rates were 6.1% (48/793) for the entire group and 31.9% (PR), 9.9% (SB), 2.4% (PPV+SB) and 3.1% (PPV). Final anatomic success rate was 100% with an average of 1.17 additional reattachment surgeries performed on the 48 failed cases. conclusion Patients undergoing PR had higher redetachment rates than other groups, but had good final visual and anatomic outcomes. As a non-randomized trial, there was probably a selection bias with more difficult cases undergoing PPV+SB. Despite a higher incidence of PVR, VH, and macula off detachment in the PPV+SB group, this group had the highest success rate with 97.6% reattachment with one surgery.
To review the characteristics and outcomes of patients who underwent scleral buckling surgery for repair of rhegmatogenous retinal detachment.
MeTHoD
A retrospective chart review was conducted on patients who underwent primary scleral buckling (SB) surgery from 2005 to 2009 by ten surgeons. Patients with <6 months of follow-up were excluded. Data collected on each patient included: duration of follow-up, age, sex, lens status, presence of posterior vitreous detachment (PVD), vitreous hemorrhage (VH), lattice degeneration, myopia, proliferative vitreoretinopathy (PVR), status of the macula, number of retinal breaks, extent of detachment, pre-operative and final visual acuity (VA), the number of procedures needed to reattach the retina, and the final anatomic status of the retina. 135 eyes of 133 patients were evaluated.
resulTs
Mean follow-up was 29.8 months (6-62). 5.2% of the eyes were pseudophakic, 31.1% had lattice degeneration, and 10.4% had PVR upon presentation. The mean number of breaks was 1.8 (1-6) and the mean extent of detachment was 4.9 clock hours (1.5-12). On presentation macula was off in 67 eyes (49.6%). Reattachment rate after one procedure was 87.4% (118/135), while overall reattachment rate was 100%. Seventeen eyes (12.6%) required more than one procedure to reattach the retina. Three eyes (2.2%) developed epiretinal membranes requiring surgery, two eyes (1.5%) required SB removal, and one eye (0.7%) developed macular hole. The mean VA at presentation was 20/100 (20/15-light perception (LP)) and mean final VA was 20/40 (20/20-2/200). In macula off patients, the mean initial VA was 20/100 (20/15-LP), and the mean final VA was 20/40 (20/15-2/200). 62.7% of macula off patients had final VA of 20/40 or better, while 72% of macula on patients had final VA of 20/40 or better. Our findings further confirm that primary scleral buckling procedure leads to successful anatomic reattachment with significant visual improvement. In 87.4% of the eyes the retina was re-attached with a single procedure. 62.7% of macula off patients recovered a visual acuity of 20/40 or better.
conclusion
5:09 pM
5:17 pM
cost-effectiveness analysis of vitrectomy vs. scleral Buckle for repair of rhegmatogenous retinal Detachment
Jay M. Stewart, MD (San Franciso, CA), Michael I. Seider, MD, Ayman Naseri, MD*, Travis C. Porco, MD
outcomes of vitrectomy and Pars Plana lensectomy for Dropped cataractous lens Material in Previously vitrectomized eyes
Tarek S. Hassan, MD* (Royal Oak, MI)
PurPose Many RRDs are suitable for repair with either PPV or SB. These two approaches generally achieve final anatomic success at similar rates. Anecdotally, PPV may be superseding SB in many practices and training programs. We have performed a cost-effectiveness analysis so that clinicians and others can factor this information into their surgical planning if they so choose. MeTHoD The relative effectiveness of primary SB versus PPV in phakic or pseudophakic patients was derived from the largest published randomized trial comparing these surgical interventions (Heimann et al, Ophthalmology 2007). The costs for each procedure were determined by CPT code as the Medicarereimbursed physician fee, the surgical center fee, and anesthesia fee using published 2010 rates adjusted for the San Francisco, CA, region. Costs associated with procedures required to achieve final success including additional retina-affecting interventions and cataract surgery were assigned at an estimated average frequency. resulTs As a single procedure, primary repair of RRD with PPV costs $4,164, and SB costs $3,584. SB generally requires more secondary procedures to achieve final reattachment but is less likely to drive a need for cataract surgery. Returning to the operating room for a second vitreoretinal surgery costs an extra $3,811, while performing in-office gas injection costs $1,183. Cataract surgery costs $1,973. If these additional procedures are performed at an average frequency, PPV is $92 cheaper than SB in pseudophakic patients and $500-1000 more expensive than SB in phakic patients. conclusion At current Medicare reimbursement rates, primary PPV as a single procedure is more costly than SB for repair of RRD. The overall cost-effectiveness is determined by the primary surgery and the number of secondary procedures. In phakic patients primary SB is substantially more cost-effective than PPV for treating RRD, while in pseudophakic patients PPV is slightly more cost-effective than SB.
PurPose
To present the first consecutive series that reports the visual acuity (VA) and anatomic outcomes of vitrectomy (VIT) with pars plana lensectomy (PPL) for dropped cataractous lens material from complicated cataract surgery in previously vitrectomized eyes, and, to describe the impact of the lens dislocation and second vitreous surgery on the course of the existing vitreoretinal condition. We retrospectively reviewed the records of all consecutive phakic eyes (n=23) that underwent VIT in our practice between 1/1/00 and 1/1/11 for routine indications VH/PDR (8), RD (7), ERM (6), macular hole (1), CSDME (1) that then, later, underwent VIT, PPL by us for dislocated lens material from complicated phacoemulsification with their anterior segment surgeons after recovery from the initial VIT. No eye had any known history of lens trauma, including intraoperatively during the initial VIT and postoperatively before cataract extraction. VA, anatomic outcomes, complications, and an assessment of the alteration of the expected postoperative course of the initial VIT are presented.
MeTHoD
resulTs
Ten women and 13 men (mean age = 64 yrs) underwent VIT, PPL for dropped lens material after complicated phacoemulsification in their previously vitrectomized eyes. No mean VA improvement was seen after the initial VIT (preop = 20/490, postop = 20/390) due to significant cataract formation. All eyes had standard phacoemulsification with anterior segment surgeons (at a mean of 8.2 mos) but suffered dislocation of crystalline lens material (estimated, 5-100% nucleus, mean = 47%) into the vitreous cavity. All eyes then had VIT, PPL within 5 days of lens dislocation. At the latest f/u visit (mean = 20.6 mos, range = 3-86 mos), mean VA improved from 20/564 to 20/73 (p<0.0001), with increased VA noted in 22/23 eyes. Post-VIT, PPL complications included PVR (1 eye, h/o prior PVR), ERM (1 eye, h/o prior ERM), macular hole (1 eye, h/o prior RD); these eyes were successfully repaired with one additional VIT. CME developed in 3 eyes and then resolved with successful medical therapy. This is the first report to describe a consecutive series of eyes that had current VIT, PPL techniques for dropped cataractous lens material in previously vitrectomized eyes. Good outcomes were achieved, though the proliferative complications in previously stable eyes suggest that the cataract dislocation (and possibly its repair) may have contributed to worsening the patients overall course.
conclusion
29
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5:33 pM
Torsional Phacoemulsification facilitates removal of Posterior segment retained lens Material during Pars Plana vitrectomy
Sunir J. Garg, MD* (Philadelphia, PA), Richard G. Lane, MD, Allen Chiang, MD, Jason Hsu, MD, Marc J. Spirn, MD, Carl D. Regillo, MD, Joseph I. Maguire, MD*, James F. Vander, MD, Richard S. Kaiser, MD, Arunan Sivalingam, MD
Discussion
5:30 pM
4K Twilight run/Walk for the retina

Sponsored by the American Retina Foundation
5:45 pM
free evening
8:00-10:00 pM
PurPose To determine the utility of the OZil torsional phacoemulsification hand piece instead of the Fragmatome during pars plana vitrectomy (PPV) for the removal of posterior segment retained lens material. MeTHoD This was a retrospective case series of all eyes that underwent PPV for retained lens material between September and March 2011. Following 23-gauge PPV, the torsional phacoemulsification hand piece (OZil, Alcon, Fort Worth, TX) without the irrigating sleeve was inserted through a 20-gauge sclerotomy for the removal of posterior segment retained lens material. Retained lens fragments were graded by nuclear density (1 to 4+) and size as a percentage of the total cataract. Primary outcome measures consisted of total ultrasound time, phaco time, and torsional time. Secondary outcome measures included intraoperative complications or mechanical malfunctions (e.g., hand piece clogging). resulTs All 16 eyes successfully underwent pars plana lensectomy (PPL) with the OZil hand piece. Mean nuclear density was 3.78+ and mean size was 51% of the total cataract. Mean total ultrasound time was 33.9 seconds, mean phaco time was 9 seconds, and mean torsional time was 24.7 seconds. All cases demonstrated excellent followability based on independent observations by the various surgeons. In one case, 2 inferior retinal breaks were identified during PPV, but were unrelated to PPL. No other intraoperative complications or mechanical issues were observed. In particular, clogging of the hand piece by nuclear material was not seen in any case. conclusion Use of the OZil torsional emulsification hand piece during PPV for retained lens material represents a novel approach with advantages over the conventional Fragmatome, including improved followability and efficient removal of dense lens material due to the addition of torsional ultrasonic movement.
fellows in Training (fiT) reception

Sonsie Restaurant, 327 Newburg Street, Boston
Monday, August 22
Monday, August 22
6:15-7:15 AM 7:00-7:30 AM
Special interest Groups Breakfast

roundtable Discussion groups
Republic Ballrooms AB
Organizer: Sophie J. Bakri, MD

7:30-10:05 AM
Symposium 5: Retinal vascular/imaging

Moderators: Mathew W. MacCumber, MD, PhD and Virgilio Morales-Canton, MD Related poster abstracts are on pages 151-179.
Wake up to a casual roundtable discussion and jumpstart your senses with fresh perspectives on a variety of conditions, treatment, and procedures for the practicing retinal specialist. Attendees are asked to pick and sign up for a breakfast table topic of their choice on the first day of the meeting. Each table will have an expert in the field help direct the topic discussion in a casual relaxed atmosphere. Topics will include: CATT Trial Diabetic Macular Edema: Treatment Algorithms Diabetic Retinopathy and Diabetic Edema: A Comprehensive Evidence-Based Approach Diabetic Vitrectomy: Approaches in the Era of AntiVEGF Therapy and Small Gauge Vitrectomy Electronic Medical Records Epiretinal Membranes and Vitreomacular Traction Macular Holes and Lamellar Holes Management of Anti-VEGF Non-Responders in AMD Managing Posterior Uveitis: Current Approaches and New Treatments in the Pipeline New Drugs in AMD New Tools in Vitrectomy: Pearls for Endoillumination OCT and Autofluorescence Ocular Inflammation: Endophthalmitis and Posterior Uveitis Ocular Oncology Payment Reform: Bundling, ACOs and Value Based Payments Pediatric Retina: The Role of Laser, Anti-VEGF, and Surgery Proliferative Vitreoretinopathy in as Few Operations as Possible Retinal Coding/Office Management Retinal Drug Delivery: The Pipeline Retinal Vein Occlusions: The Role of Laser, Steroids and Anti-VEGF Therapy Scleral Buckles, Pneumatic or Vitrectomy for Retinal Detachment? Small Gauge Vitrectomy Treatment Algorithms for Wet AMD: Which Anti-VEGF and When? Vitreoretinal Surgery in an ASC
7:30 AM
The effect of Posterior vitreous Detachment on anti-vegf Treatment of Macular edema secondary to retinal vascular occlusion
Nancy M. Holekamp, MD* (St. Louis, MO)
PurPose
There is an emerging literature that suggests that vitreous anatomy, specifically the presence or absence of posterior vitreous detachment (PVD), may play a role in exudative AMD. The purpose of this study is to determine if the presence or absence of PVD plays a role in the treatment of macular edema due to retinal vascular occlusive disease with 6 monthly intravitreal ranibizumab injections.
MeTHoD
Consecutive patients meeting the following inclusion criteria were enrolled in the study: best-corrected visual acuity of 20/40-20/800, perfused macular edema secondary to BRVO or CRVO, and duration of symptoms less than 6 months. At baseline, month 4, and month 7, each patient underwent 3 examination techniques to determine the presence of absence of posterior vitreous detachment: slit-lamp biomicroscopy, b-scan ultrasound, and spectral-domain OCT. Each patient received 6 monthly injections of intravitreal ranibizumab. Key endpoints of the study were the number of patients gaining 3 or more lines of best-corrected visual acuity and the failure to gain best-corrected visual acuity.
resulTs
Thirty of 31 patients enrolled in the trial completed all study visits. Seventeen eyes had macular edema due to a branch retinal vein occlusion (BRVO) and 13 eyes had macular edema due to a central retinal vein occlusion (CRVO). Mean patient age was 70.9 years (range 19-90 years). For eyes with BRVO, median visual acuity was 20/63 (range 20/40-20/200). For eyes with CRVO, median visual acuity was 20/163 (range 20/50 to 20/800). Sixteen eyes had a PVD, (11 BRVO and 5 CRVO, mean age 74.2 years) and 14 eyes had no PVD (6 BRVO and 8 CRVO, mean age 61.1 years) at the initial visit. Three eyes
31
reTinal vascular/iMaging 7:3010:05 AM
with no PVD at the initial visit developed a PVD by the final visit at month 7. The percentage of patients gaining 3 or more lines of vision were: BRVO/PVD+: 27%, BRVO/PVD -: 33%, CRVO/PVD+ 60%, CRVO/PVD-: 87.5%. The percentage of eyes with no visual improvement were: BRVO/PVD+: 36%, BRVO/PVD-: 17%, CRVO/PVD+: 20%, CRVO/PVD-: 0%.
conclusion The eyes that responded best to 6 monthly intravitreal ranibizumab injections had macular edema due to CRVO and had no PVD. The eyes that responded the least well to 6 monthly intravitreal ranibizumab injections had macular edema due to BRVO and had a PVD. Vitreous anatomy may play a role in the response to anti-VEGF therapy for macular edema due to retinal vascular occlusive disease.
exhibited greater improvement in BCVA compared to those with >90-day duration. Specifically, the additional BCVA gain was up to 3.4 letters for DEX and 1.3 letters for sham BRVO patients. The observed difference was consistent at all visits. When duration of ME was analyzed as a continuous variable and with adjustment for treatment, age and baseline BCVA, the effect was borderline significant at day 60 (P=0.053) when peak effect was seen, and at day 180 (P=0.051) which is the maximum time for drug effect. Results for CRVO showed larger variations due to small sample sizes and natural history of the disease. Analysis of 15-letter improvement in BCVA provided similar results for duration effect.
conclusion
7:38 AM
greater Benefit from Dexamethasone intravitreal implant Treatment started early following onset of Macular edema Due to Branch retinal vein occlusion
Julia A. Haller, MD* (Philadelphia, PA), Baruch D. Kuppermann, MD*, PhD, Francesco Bandello*, Jenny Jiao*, Xiao-Yan Li*, Scott M. Whitcup, MD*
Analysis of pooled data from two phase 3 trials indicates that BRVO patients with shorter duration of disease (eg, 90 days) at study entry exhibited greater improvement in BCVA comparing to patients with longer duration of disease (eg, >90 days). These results suggest that early treatment with DEX implant may provide greater clinical benefit in patients with ME due to BRVO.
7:46 AM
anatomic outcomes in Bravo and cruise: resolution rates of cystoid Macular edema and subretinal fluid with ranibizumab for retinal vein occlusion
Robert B. Bhisitkul, MD (San Francisco, CA), Peter Campochiaro, MD*, Howard Shapiro*, Namrata Saroj*, Roman Rubio*
This study retrospectively examined treatment outcomes by duration of disease from two phase 3 studies of dexamethasone intravitreal (DEX) implant (Ozurdex) 0.7 mg compared with sham procedure in patients with vision loss caused by macular edema (ME) following branch or central retinal vein occlusion (BRVO; CRVO).
PurPose MeTHoD Patients 18 years with ME involving the fovea due to BRVO or CRVO, best-corrected visual acuity (BCVA) between 34 (20/200) and 68 (20/50) letters, and retinal thickness 300 m were enrolled. Patients were randomly assigned to treatment with DEX implant 0.7 mg or sham procedure. The primary outcome was 15-letter improvement from baseline in BCVA at day 180. Secondary outcomes included mean BCVA change from baseline and other BCVA variables. The effect of duration of ME on BCVA improvement was examined using multiple linear regression models based on pooled data from two phase 3 trials. Duration of ME was analyzed as a binary (90 days or >90 days) as well as a continuous variable. resulTs Of 427 patients receiving DEX implant and 426 receiving sham, 67% had BRVO and 33% had CRVO. The mean duration was 5.3 months for BRVO and 4.9 months for CRVO. Sixteen percent of patients entered the study with a duration 90 days. BRVO patients with 90-day duration
PurPose
In BRAVO and CRUISE, RBZ treatment for retinal vein occlusion (RVO) resulted in significant improvements in visual acuity and macular edema. Two subcomponents of increased central foveal thickness (CFT), cystoid macular edema (CME) and subretinal fluid (SRF), were independently assessed by OCT to determine their incidence and to compare resolution rates at 7 days to 12 months with RBZ therapy.
MeTHoD
BRAVO (branch RVO) and CRUISE (central RVO) were phase III, multicenter, randomized studies to evaluate the efficacy and safety of intravitreal RBZ. Patients received monthly RBZ (0.3 mg or 0.5 mg) or sham treatment for an initial 6-month period; for a further 6 months all groups including sham were eligible for PRN RBZ. A post-hoc data analysis was performed using time-domain OCT images collected at days 0 and 7, and months 6 and 12. Two anatomic subcomponents, CME and SRF, were graded in a masked fashion at the Wisconsin Reading Center.
resulTs
CME improved rapidly in both studies. In the 0.3 mg and 0.5 mg RBZ groups in CRUISE, 70.1% and 61.0% of patients, respectively, had no CME by day 7, compared with 1.5% and 1.6% at baseline. Comparable results were seen in the RBZ groups in BRAVO (60.0% and 55.7% with no CME at day
7 compared with 2.3% and 1.5% at baseline). These improvements were similar in the 0.5 mg, but not 0.3 mg, RBZ group at 6 and 12 months in both studies. In CRUISE, the percentage of 0.3 mg and 0.5 mg RBZ patients with no SRF improved from 39.2% and 41.4% at baseline to 55.9% and 61.0% at Day 7, and to 92.7% and 94.6% by month 6. Similar results were seen in the RBZ groups in BRAVO at months 6 and 12. In both studies, SRF resolution was attained in 90% to 98% of RBZ patients at month 12. Treatment of RVO patients with RBZ significantly improved both CME and SRF, but each subcomponent displayed different response patterns. CME responded rapidly to treatment as early as 7 days, but did not resolve in all patients. Conversely, improvements in SRF were less rapid, but resolution in almost all patients was observed at 6 months and maintained through to 12 months.
conclusion
7:54 AM
variable schedule intravitreal injection, efficacy, and safety of ranibizumab in Patients with retinal vein occlusion in the Horizon extension study
Dante J. Pieramici, MD* (Santa Barbara, CA), Linda Yau, MD*, Tatiana Beres, MD, Phillip Lai, MD*
PurPose
RBZ administration to RVO patients results in significant visual improvements. We evaluated efficacy and safety, as well as explored associations between number of injections and visual outcomes and predictors for the number of injections, in the first 12 months of HZN, an open-label PRNdosing extension trial following the 12-month BRAVO and CRUISE studies.
MeTHoD
Table 1. CRUISE Study: Percentage of patients with no CME or SRF on OCT (n (%) = number (percentage) of patients with absence of CME or SRF; N = number of patients assessed at timepoint).
HZN RVO was an open-label, single-arm, multicenter extension for patients who completed BRAVO or CRUISE. Enrolled patients received intravitreal RBZ (0.5 mg) at 30-day intervals if they met PRN criteria (central subfield thickness 250 m or macular edema that affected visual acuity) and were followed for up to 24 months or study termination (30 days after FDA approval of RBZ for RVO). Efficacy outcome included mean change from HZN baseline in best corrected visual acuity (BCVA) at Month 12 (M12). Post-hoc analyses of the association between number of injections and efficacy outcomes and predictors for the number of injections were explored by statistical modeling.
Table 2. BRAVO Study: Percentage of patients with no CME or SRF on OCT (n (%) = number (percentage) of patients with absence of CME or SRF; N = number of patients assessed at timepoint).
resulTs HZN RVO enrolled 608 patients (n=304 each from BRAVO and CRUISE) with 205 (67%) BRAVO and 181 (60%) CRUISE patients completing M12 of HZN. Mean study duration was 14 months for all patients. BCVA remained stable over the first 12 months of HZN in BRAVO patients, with mean changes for the randomized groups in BRAVO of +1 to -2 letters from HZN baseline. In CRUISE patients, mean reductions of 45 letters from HZN baseline were observed by M12. BRAVO patients received a mean of 2.5 injections and CRUISE patients received a mean of 3.8 injections of 0.5 mg RBZ through M12 in HZN. 66% (135/205) of BRAVO patients and 80% (145/181) of CRUISE patients received at least 1 injection in HZN. Among patients who received at least 1 RBZ injection in HZN, over 50% (163/280) received 4 or fewer injections during the first 12 months in HZN. Association between number of injections and change from baseline in BCVA and predictors for the number of injections will be presented. conclusion
RBZ administration using HZN trial-specified PRN dosing maintained BCVA for BRAVO patients, but resulted in a mean decrease of 4-5 letters for CRUISE patients by M12 of HZN. The majority of patients who completed M12 of HZN received 4 and 27% received no injections in the study. Ocular and systemic adverse event rates were similar to previous RBZ trials and no new safety events were identified.
33
8:02 AM
8:20 AM
initial Treatment of Macular edema secondary to retinal vein occlusion with intravitreal Bevacizumab
Michael J. Davis, MD* (Arcadia, CA), Ritchie Yuson, MD, Michael A. Samuel, MD*, Tom S. Chang, MD*
The 6-Month (Primary endpoint) results of the Phase 3 galileo study: vegf Trap-eye in crvo
Jean-Francois Korobelnik, MD* (Bordeaux, France)
PurPose
PurPose What is the most effective initial treatment regimen with intravitreal bevacizumab injection for the treatment of macular edema secondary to retinal vein occlusion with regards to improvement in visual acuity, decrease in central foveal thickness, minimizing recurrences and maximizing remission? MeTHoD This is a retrospective, chart review of patients with macular edema secondary to branch (n=51) and central retinal vein occlusion (n=64) treated primarily and solely with intravitreal bevacizumab from 2004-2011. A total of 115 eyes were included. Visual acuity (VA) and OCT central foveal thickness (CFT) were reviewed. The initial response to treatment with number of injections, remission rate and time to recurrence were analyzed. resulTs The mean VA on presentation was 20/100 for BRVO and 20/400 for CRVO. The mean CFT on presentation was 404. 67 microns for BRVO and 465. 29 microns for CRVO. After initial bevacizumab treatment, 72.6% of BRVO and 42.9% of CRVO patients had an improvement. The mean number of injections for initial treatment was 2.47 0.92 (range 15) for BRVO and 2.39 1.06 (range 16) for CRVO. The greatest VA improvement was after 3 injections for BRVO, with a mean gain of 4 lines, and 4 injections for CRVO, with a mean gain of 2.5 lines. The greatest CFT response in both groups was after 4 injections, with a decrease of 352 microns and 102 microns for BRVO and CRVO, respectively. The length of remission was longest after 3 initial injections for both groups (215 days for BRVO and 65 days for CRVO). The recurrence rates were higher for patients that received 3 injections (18.5% for BRVO and 42.9% for CRVO) and were the least for patients who had 4 or more injections (0% for BVO and 20% for CRVO). conclusion Patients with RVO tend to respond best to at least 3 initial injections with regards to mean VA improvement and mean OCT response and have a longer remission period. Recurrence rates were higher with those receiving 3 injections when compared to those who received at least 4 injections. Bevacizumab treatment with at least 3 injections followed by as needed treatment is an effective regimen.
VEGF Trap-Eye is an intravitreally administered fusion protein designed to bind the pro-angiogenic factors vascular endothelial growth factor A (VEGF-A) and placental growth factor with higher affinity than their native receptors. This study evaluated the efficacy and safety of intravitreal VEGF Trap-Eye in patients with macular edema secondary to central retinal vein occlusion (CRVO) to week 24.
MeTHoD
In this double-masked, multi-center, controlled Phase 3 study, 177 patients were randomized to 2 mg VEGF Trap-Eye or sham injections every 4 weeks. The primary endpoint is the proportion of patients who gained 15 ETDRS letters from baseline at Week 24. Secondary outcomes at week 24 include the change from baseline in best-corrected visual acuity, scored based on the number of ETDRS letters read correctly. Week 24 data will be available at the time of presentation. Efficacy and safety results will be discussed. Primary and secondary endpoints results of this study should provide important information about the efficacy and safety of VEGF Trap-Eye for the treatment of patients with CRVO.
resulTs
conclusion
8:28 AM
vegf Trap-eye in crvo: 1-year results of the Phase 3 coPernicus study

W. Lloyd Clark, MD* (West Columbia, SC), Julia A. Haller, MD*, David S. Boyer, MD*, Jeffrey S. Heier, MD*, David B. Brown, MD*, Robert Vitti, MD
PurPose
To evaluate the efficacy and safety of VEGF Trap-Eye in patients with macular edema secondary to central retinal vein occlusion (CRVO). VEGF Trap-Eye is an intravitreally administered fusion protein designed to bind all isoforms of VEGF-A and placental growth factor that are involved in abnormal angiogenesis.
MeTHoD
8:10 AM
In this randomized, double-masked, controlled, Phase 3 study, patients received 6 monthly injections of either 2 mg VEGF Trap-Eye (114 patients) or sham injections (73 patients). Through Week 24 to Week 52, patients received either 2 mg VEGF Trap-Eye as-needed (PRN) or sham injections according to retreatment criteria. The primary endpoint was the proportion of patients who gained 15 ETDRS letters from baseline at Week 24. A key secondary outcome measure was the change in best-corrected visual acuity from baseline to Week 24. Week 52 data will be available at the time of presentation, and these results will be reported and discussed.
Discussion
resulTs Results at Week 24 showed statistically significant differences between the two groups: 56.1% of VEGF Trap-Eye patients gained 15 ETDRS letters from baseline, compared with 12.3% of sham patients (p<0.0001). VEGF Trap-Eye patients gained a mean of 17.3 letters of vision compared with a mean loss of 4.0 letters with sham injection (p<0.001). The most common treatment-emergent adverse events (AEs) among all patients were conjunctival hemorrhage, visual acuity reduced, and eye pain. Proportions of patients who experienced serious ocular AEs were 3.5% in the VEGF Trap-Eye group and 13.5% in the sham group. The incidence of non-ocular serious AEs was generally well balanced between the treatment and sham groups. conclusion Dosing monthly with 2 mg VEGF Trap-Eye in patients with macular edema secondary to CRVO resulted in a statistically significant improvement in visual acuity compared with control sham treatment. VEGF Trap-Eye was generally well tolerated and had a generally favorable safety profile.
8:44 AM
Discussion
8:50 AM
sD-ocT analysis of subretinal Deposits in Patients with acute central serous retinopathy
Gennady Landa, MD (New York, NY), Jonathan Barnett, MD, Patricia Garcia, Katy Tai, MD, Richard B. Rosen, MD*
PurPose
To perform qualitative and quantitative analysis of subretinal protein deposits, seen in acute central serous retinopathy (CSR) patients, using high resolution SD-OCT, in order to investigate whether protein deposits present have any significant impact on best corrected visual acuity (BCVA). Patients presenting to the Retina Center of the New York Eye and Ear Infirmary between July 2009 and July 2010 with evidence of acute CSR were included. SD-OCT was performed and multiple parameters were measured: central total retinal thickness, central neurosensory retinal thickness, maximum vertical and horizontal lengths of subfoveal subretinal fluid and thickness of any subfoveal protein deposit (PD) layer, if present. Additionally, height and width of any PED present subfoveally, was measured.
8:36 AM
index for the Quantification of retinal non-perfusion in Branch retinal vein occlusion
Pradeep Prasad, MD (Los Angeles, CA), Andrew Kaines, Irena Tsui, Gad Heilweil, Jean-Pierre Hubschman, Steven Schwartz
MeTHoD
PurPose To quantify retinal non-perfusion in patients with branch retinal vein occlusion and to evaluate the relationship between macular edema and neovascularization with different levels of non-perfusion MeTHoD Ultra wide-field fluorescein angiograms from patients with BRVO not previously treated with focal macular laser, scatter photocoagulation or intravitreal pharmacotherapy were graded for the presence of non-perfusion, neovascularization and macular edema. Areas of non-perfusion were quantitatively measured and a retinal ischemic index calculated, defined as the total area of non-perfused retina divided by the total area of retina visualized. The sensitivity and specificity of various degrees of non-perfusion for the presence of neovascularization and macular edema were calculated. resulTs 25 angiograms from 25 patients were analyzed. Neovascularization and macular edema were seen in 28% and 80% of patients, respectively. Ischemic index values ranged from 0.1% to 30%. An ischemic index of 7% was 100% sensitive and 79% specific for the presence of neovascularization and 50% sensitive and 100% specific for the presence of macular edema. Increasing ischemic index was significantly associated with neovascularization in all patients (p < 0.01) and macular edema in patients with major BRVO (p =0.028). conclusion Retinal non-perfusion can be quantified utilizing ultra wide-field fluorescein angiography and may help riskstratify BRVO patients for the development of neovascularization and macular edema.
resulTs
38 patients with acute CSR were included. Four types of PD, based on their shape and appearance (hanging, integrated, scattered, and massive), were noted. At least one type of PDs was seen at baseline SD-OCT exam in 84. 2% (32/38) eyes. PD subfoveal thickness could be measured in 20 (52.6%) out of 38 eyes. A significant correlation was found between the subfoveal thickness of PD layer and baseline/final visual acuities: (r = 0.60, p = <0.001 and r = 0.45, p = 0.008, respectively). Those eyes with PDs which demonstrated a resolution of CSR (resolved subgroup, n = 11) at 3 ( 1) months of follow-up, had a significantly thinner (p = 0.003) subfoveal thickness of the PD layer at baseline exam (28.8 12.5 m) than the unresolved group of eyes (n = 21)(57.0 27.2 m). At final follow-up, a significant difference (p=0.012) in BCVA was found between the resolved and unresolved subgroups. The final BCVA in eyes with and without PED at baseline was not significantly different (p=0.19). The thickness of subfoveal protein deposits at baseline appears to be an important parameter related to the BCVA and time of CSR resolution, whereas the presence of PED at baseline didnt have an impact on the final BCVA.
conclusion
35
8:58 AM
low Dose oral Methotrexate for the Treatment of chronic central serous retinopathy (csr)
Armando L. Oliver, MD (San Juan, PR), David Callanan, MD*, Shree K. Kurup, MD*
PurPose To evaluate if weekly, low dose, oral methotrexate is effective in helping patients with chronic CSR achieve improvement in visual acuity and reabsorption of subretinal fluid. MeTHoD Retrospective review of all patients who had used low dose oral methotrexate as treatment for chronic CSR in 3 different centers. Patients who had history of photodynamic therapy with verteporfin where excluded from the analysis. VA as well as OCT central macular thickness and total volume parameters were recorded from each visit and subjected to statistical analysis. The percentage of patients achieving resolution of CSR (defined as the absence of sub-retinal fluid on all OCT cross sections) was also calculated. CBC and Serum Chemistry results were reviewed to identify patients who had potentially developed systemic toxicity secondary to the use of methotrexate. resulTs Nine patients were treated with methotrexate for chronic CSR and met the criteria for our analysis. The mean duration of CSR in these patients was 28 months. The mean starting dose of oral methotrexate was 7.04mg (range 5-10mg) and the mean final dose was 7. 27mg (range 5-10mg). The mean duration of treatment was 89 days. The mean VA improved from 20/67 at baseline to 20/35 at 8 weeks (p = 0.0076, paired t-test). The mean central macular thickness improved from 309 microns at baseline to 213 microns at 8 weeks (p = 0.001, paired t-test). The mean total macular volume improved from 8.14 to 7. 21 at 8 weeks (p = 0.0161, paired t-test). 83% of the patients who had completed the treatment regimen achieved total resolution of sub-retinal fluid. None of the patients developed CBC or serum chemistry abnormalities suggestive of methotrexate toxicity. conclusion Our study suggests that the use of weekly, low dose, oral methotrexate is beneficial for the treatment of chronic CSR. Patients in our cohort had a significant improvement VA as well as central macular thickness and total macular volume as measured by OCT. A randomized controlled clinical trial is warranted to better understand the effects of methotrexate in patients with this condition.
Vertical OCT Cross-sections of a 58 year old man with history of chronic CSR OS. The patient achieved total resolution of the subretinal fluid for the first time ever in 3 years after being treated with weekly low dose oral methotrexate.
9:06 AM
The expanded spectrum of focal choroidal excavation

K. Bailey Freund, MD* (New York, NY), Ron Margolis, MD, Sri Krishna Mukkamala, Lee M. Jampol, MD, Richard F. Spaide, MD*, Michael D. Ober, MD*, John Alan Sorenson, MD, Ronald Gentile, MD*, Joel A. Miller, MD, Jerome Sherman*
PurPose
To describe the clinical and multimodal imaging findings in patients with focal choroidal excavation (FCE).
MeTHoD
This study was a retrospective observational case series. The medical records of 12 patients (13 eyes) with FCE were reviewed. Clinical histories and multimodal imaging findings including color photography, fundus autofluorescence (FAF), fluorescein angiography (FA), indocyanine green angiography (ICGA), spectral domain optical coherence tomography (SDOCT) and enhanced depth imaging SD-OCT (EDI-OCT) were analyzed. The mean age of patients was 45 years. 5 patients were Asian. Mean visual acuity was 20/31. Mean refractive error was -4.75 D. Unilateral lesions were seen in 11 of the 12 patients, and 1 patient had bilateral involvement. All lesions involved the fovea and manifested varying degrees of pigmentary changes that were usually hypoautofluorescent on FAF imaging. Most lesions appeared hypofluorescent with ICGA, but FA findings varied with the degree of RPE alterations. In 7 eyes, OCT showed the outer retinal layers conforming to the RPE within the excavation. In the other 6 eyes, OCT demonstrated a separation between the outer retina and RPE within the excavation. In 7 eyes studied with EDI-OCT, there was no evidence of scleral ectasia. Mean choroidal thickness of the uninvolved choroid was thicker than normal at 319 um. All lesions remained stable except in 1 eye that had additional findings of CSC and secondary type 2 neovascularization. One patient had a history of CSC in the fellow eye.
resulTs
conclusion FCE is a newly described idiopathic entity in which there are one or more focal areas of choroidal excavation. In some patients, there may be an association with CSC. Although most lesions remain stable, secondary choroidal neovascularization may occur.
resulTs
This analysis showed a high likelihood that the SDOCT bands attributed to the external limiting membrane (the 1st, innermost band) and to the retinal pigment epithelium (RPE) the 4th, outermost band) are correctly attributed. Comparative analysis showed that the 2nd band, often attributed to the boundary between inner and outer segments of the photoreceptors, actually aligns with the ellipsoid portion of the inner segments. The 3rd band corresponded to an ensheathment of the cone outer segments by apical processes of the RPE in a structure known as the contact cylinder. Anatomic attributions and subsequent pathophysiologic assessments pertaining to the 2nd and 3rd outer retinal hyper-reflective bands may not be correct. This analysis has identified testable hypotheses for the actual correlates of the 2nd and 3rd bands; the 2nd band corresponds to the ellipsoid and the 3rd band appears to be the contact cylinder.
conclusion
33-year-old male with focal choroidal excavation. (Top) Photograph, fundus autofluorescence image, and fluorescein angiogram (late venous & recirculation phase). (Bottom) Spectral domain OCT scan through the fovea shows a conforming focal choroidal excavation.
62-year-old female with focal choroidal excavation. (Left) Photograph shows atrophic retinal pigment epithelium changes beneath the fovea. (Right-top) Time domain OCT scan from 2003 shows a non-conforming focal choroidal excavation. (Right-bottom) Spectral domain optical coherence tomography scan from 2009 shows findings similar to the scan taken 6 years earlier.
OCT of the perifoveal region with a highlighted box 10 pixels wide used to create the longitudinal reflective profile (LRP). The 1st band of the OCT represents the ELM and the 4th band was aligned to the RPE. The 2nd band corresponded very closely with the ellipsoid section of the IS. The 3rd band encompassed the region of the cone OS/contact cylinder region.
9:14 AM
anatomic correlates to the Bands seen in the outer retina by ocT: literature review and Model
Richard F. Spaide, MD* (New York, NY), Christine A. Curcio
OCT of the perifoveal region with a highlighted box 10 pixels wide used to create the longitudinal reflective profile (LRP). The 1st band of the OCT represents the ELM and the 4th band was aligned to the RPE. The 2nd band corresponded very closely with the ellipsoid section of the IS. The 3rd band merged with the 4th band as cone OS/contact cylinder region is in direct contact with the RPE.
PurPose
To evaluate the validity of commonly used anatomic designations for the 4 hyper-reflective outer retinal bands seen in current generation optical coherence tomography (OCT), a scale model of outer retinal morphology was created using published information for direct comparison to OCT scans.
9:22 AM
intra-operative sD-ocT
Sunil Srivastava, MD (Cleveland, OH), Robin Ray, MD, G. Baker Hubbard, MD, Jonathan Sears, MD, Rishi P. Singh, MD, Daniel F. Martin, MD, Peter K. Kaiser, MD*, Justis P. Ehlers, MD
Articles and books concerning histology of the outer retina from 1900 until 2009 were evaluated, and data were used to create a scale model drawing. Boundaries between outer retinal tissue compartments described by the model were compared with intensity variations of representative spectral domain (SD) OCT scans using longitudinal reflectance profiles to determine the region of origin of the hyper-reflective outer retinal bands.
MeTHoD
PurPose
Spectral domain optical coherence tomography (SDOCT) offers high resolution imaging of the retinal anatomy. Due to this high resolution anatomic information, SD-OCT may be a useful component to operative decision making. This study reviewed the microstructural changes in retinal anatomy identified with intra-operative SD-OCT during vitreoretinal surgical procedures.
37
MeTHoD A retrospective review was performed on patients who underwent surgery and intra-operative SD-OCT scanning. Two prototype mounting systems were used to attach a hand-held SD-OCT probe to the operating microscope. Images were typically obtained prior to retrobulbar block, before and after critical surgical maneuvers (e.g., membrane peel) and at completion of surgery. Images were analyzed to identify changes in retinal anatomy. Postoperative images were reviewed when available and compared to intra-operative images.
10:40-11:16 AM
Symposium 6: Socioeconomics
Moderators: Lawrence S. Halperin, MD and Reginald J. Sanders, MD Related poster abstract is on page 180.
10:40 AM
Intraoperative imaging was successfully performed on 55 patients. Poor quality images were uncommon and were usually due to media opacity (e.g., hemorrhage, corneal edema). Changes in retinal microstructure were seen in all cases involving membrane peeling. All epiretinal membrane cases developed subretinal hyporeflectance after epiretinal membrane peeling which increased in size with internal limiting membrane (ILM) peeling. All macular holes exhibited changes in anatomic configuration following ILM peeling, including enlargement of the subretinal fluid cuff at the edges of the hole. In complex retinal detachment cases, intra-operative SD-OCT identified tissue planes for dissection and revealed corrugations in the inner retina after dissection or development of subretinal hyporeflectance after membrane peeling. Imaging through perfluorocarbon liquid revealed persistence of subfoveal subretinal fluid in macula-involving retinal detachments.
resulTs
Pharmacotherapy for neovascular aMD 100% Part B fee-for-service Medicare claims Data 2008-2009
Ross J. Brechner, MD, MS (Stat.), MPH (Catonsville, MD) Lead Medical Officer, National Centers for Medicare, Philip J. Rosenfeld, MD, PhD*
PurPose
To describe the usage patterns and potential complications of pharmacological treatments for neovascular age-related macular degeneration among all the Medicare fee-for-service (FFS) beneficiaries in 2008 and 2009.
MeTHoD
Intra-operative SD-OCT imaging was successfully performed during surgery. The use of a microscope mount facilitated fast reproducible imaging during surgery. Changes in the retinal microstructure were identified during surgery that have not been previously described and may have functional consequences. Intra-operative SD-OCT imaging is a useful imaging adjuvant during vitreoretinal surgery
conclusion
One hundred percent of all FFS Medicare beneficiaries having undergone pharmacological treatment for wet AMD were identified. The data collected for each visit for a given beneficiary included age, race, gender, Medicare region, state/zip code of residence, date of visit, whether or not the beneficiary had a treatment, the type and amount of drug, dollars paid by Medicare, and complications. The main outcome measures were the number and rate of treatments, the types of drugs used for treatment, payments for these drugs, incidence of Wet AMD and complications from treatment.
9:30 AM
resulTs
Discussion
9:40AM
Panel Discussion: How Do you Treat retinal vein occlusions and Diabetic Macular edema?
Moderator: Peter K. Kaiser, MD* Panelists: Neil M. Bressler, MD*, K. Bailey Freund, MD* Julia A. Haller, MD* and Dante J. Pieramici, MD
10:05-10:40 AM

Of 222,886 unique beneficiaries (UB) in 2008, 146,276 (64%) received bevacizumab (BEV) and 80,929 (36%) received ranibizumab (RAN). Comparable numbers in 2009 were 251,774 (UB), 166,684 (BEV: 60%) and 91,188 (RAN: 40%). The number of incident cases of wet AMD treated with either anti-VEGF drug in 2009 was over 107,129. Of 824,525 intravitreal injections (IVTs) in 2008, 480,025 were BEV (58%) and 336,898 were RAN (41%). Of 1,028,187 IVTs in 2009, 608,878 were BEV (60%) and 400,328 (40%) were RAN. Total payments by Medicare in 2008/2009 were $20,290,952/ $24,970,468 for BEV and $536,642,693/$673,978,477 for RAN. In 78% of the states, the rate of injection was higher for bevacizumab. Endophthalmitis occurred in 1,121 of the unique beneficiaries representing a rate of approximately 1 in 300 beneficiaries.
In 2008/2009, BEV was used at a higher rate than RAN for wet AMD. Even though BEV accounted for 59.6% of all injections in 2008-2009, Medicare paid over $500 million more for RAN than BEV each year. Despite its off-label designation, BEV is currently the standard-of-care treatment for neovascular AMD in the U.S. Additional ocular and systemic diagnoses associated with IVTs will be presented.
conclusion
11:00 AM
scope of Practice Battles and the vitreoretinal specialist

David W. Parke, II, MD (San Francisco, CA) Executive Vice President and CEO American Academy of Ophthalmology
10:50 AM
The value Modifier: Payment for Quality and efficiency

William L. Rich, III, MD (Falls Church, VA) Medical Director of Health Policy American Academy of Ophthalmology
The US ophthalmologic and optometric communities probably spend a combined $4 million annually on scope of practice battles. This does not count the innumerable hours of time spent by dedicated professionals on both sides of the issue. Scope of practice battles have been going on longer than the conflict in Iraq or Afghanistan. Were it a military operation, it would rank behind the Hundred Year War as the second longest campaign in history. Scope of practice has devolved into an issue regarding the right to perform surgery in an environment between professions where surgical privileges are determined not by a logical, evidence-based process taking into account knowledge, skills acquisition, competence, and experience but by politics. As a politically-based process, all of the above factors are significantly devalued and the relevant factors become money, relationships, and perceived political power. The pawn in the process is the patient. Healthcare reform and cost and access issues become new weapons in the political scope of practice debate. I will address the following issues from the standpoint of a vitreoretinal surgeon: Why is the battle still being fought? What tactics do physicians face and what have we found to be effective? What have ophthalmologists achieved? What does this mean for the vitreoretinal specialist?
11:10 AM
Run away costs Health care spending caused decreases in disposable personal income 43 million uninsured Perceived poor quality and safety Little comparative effectiveness research Disparities of care

The biggest drivers of escalating costs are new technology, payments that reward volume and unexplained variation in how services are delivered. Quality of care is a huge problem in the United States with only 50% of process of care validated by NIH clinical trials adopted into practice within ten years. The Value Modifier is part of the PPACA and is an attempt to address costs, variation and quality. Beginning in 2015 CMS will begin measuring physicians on their ability to achieve meaningful quality outcomes in a cost effective manner for selected high impact diseases. Those whose resource use is high will see their payments cut for all clinical services in the ensuing year. This will immediately stimulate physicians to consider the evidence base, cost and volume of their resource use. In effect, CMS has made the physician the prudent buyer of services.
Discussion
39
PeDiaTric reTina 11:16 AM12:16 PM
11:16 AM-12:16 pM
11:24 AM
Symposium 7: pediatric Retina

Moderators: Antonio Capone, Jr., MD and Kimberly A. Drenser, MD Related poster abstracts are on pages 180-185.
Bevacizumab vs. laser ablation for Treatment-warranted roP: recommendations Based on the BeaT-roP experience
Khaled A. Tawansy, MD (Los Angeles, CA), Enrique Ariza, MD, Natalia Matti, MD
11:16 AM
comparison of systemic Morbidity associated with laser ablation of Threshold and Pre-threshold Type 1 roP using sedative vs. non-sedative anesthesia
Natalia Matti, MD (Los Angeles, CA), Enrique Ariza, MD, Khaled A. Tawansy, MD
PurPose
To review 150 cases of posterior ROP in the BEATROP Study randomized to bevacizumab versus laser and an additional 150 cases of traditional ROP treated with standard laser ablation in order to weigh advantages and pitfalls of each modality and develop a treatment paradigm.
PurPose To review experience over past decade of one pediatric retina group performing laser ablation in a variety of clinical settings, including hospitals that routinely sedate or intubate preemies and others who have adopted a minimally sedative protocol that includes use of acetaminophen 15mg/kg orally and suckling using sugar on a pacifier or finger. MeTHoD Retrospective ophthalmic and medical chart review of 100 consecutive cases receiving ablative laser in each of 4 possible clinical settings: 1) hospitals that routinely sedate and intubate, 2) hospitals that routinely sedate without intubation, 3) hospitals that routinely use the acetaminophen and sugar protocol with narcotics or sedatives available if needed, and 4) an outpatient clinic where sedation of neonates is not permitted. More critically ill preemies that were already intubated at the time of ablation were excluded from this analysis. resulTs Of 100 neonates intubated for laser in group one, 7 developed cardiopulmonary complications (3 developed pneumonia). In group two, 4 of 100 required urgent intubation after sedation induced apnea by administration of fentanyl (did not occur with midazolam alone). Of the 100 babies in group three receiving acetaminophen and sugar for laser, 98 tolerated the procedure, while 2 required intra-venous sedation. All of the neonates in group four who received ablation in the office tolerated the procedure with acetaminophen/sugar protocol; these were less critically ill and older neonates.Duration of the procedure lasted a mean of 55 minutes for group 1, 36 minutes for group 2, 29 minutes for group 3, and 21 minutes for group 4.Mean length of stay in the hospital post laser was 42 days in group one, 31 days in group two, 20 days in group three, and 0 days in group four.None of the eyes treated with laser for type 1 ROP progressed to retinal detachment and all had resolution of ROP. conclusion Minimally sedative laser for ROP using a protocol that involves a combination of oral acetaminophen and suckling on a sugar pacifier can be performed reliably and with good structural and visual outcome; it may be associated with a lower incidence of systemic complications than intubation or deeper sedation, especially when fentanyl is used.
MeTHoD
Retrospective review of charts with collection of parameters including Zone (I, IIp, IIm, IIa, and III), Stage (IIV), Level of Plus (0-2), Vascular Activity Score (VAS 0-10, see abstract), category of ROP (traditional, aggressive posterior, or smoldering), gestational age, post-conception age, systemic morbidity associated with the treatment and anatomic and functional response to therapy. Included were cases that had persistence or recurrence and required re-treatment with either modality.
resulTs
Traditional laser ablation when applied to disease located anterior to the equator was relatively non-traumatic (fewer than 500 burns per eye) with minimal systemic morbidity and prompt resolution of disease, absence of persistent peripheral non-perfusion or late recurrence, and good long-term visual and functional outcomes. Disease posterior to the equator or associated with a VAS of 6 or more responded well to bevacizumab 0.6 mg injected intra-vitreal with most minimal trauma and opportunity for continued development of intrinsic vessels to the periphery, minimizing visual field loss and myopia. These cases required closer and more continued long-term follow up to prevent potential late detachment or macular dragging associated with an avascular periphery (smoldering ROP). Rare cases that demonstrated ROP progression after bevacizumab responded well to ablative laser, while those that progressed despite laser had only fleeting and incomplete response to bevacizumab. Bevacizumab is first line therapy for AP ROP. Follow up is required until retinal vessels reach the ora serrata or late fibrovascular proliferation needs ablation.Anterior cases respond well to laser. Equivocal cases are better treated with bevacizumab and cases of posterior pre-threshold ROP may be observed until more significant plus and neovascularization develops.
conclusion
11:32 AM
11:46 AM
regression Patterns after intravitreal Bevacizumab for Zones i and Posterior ii stage 3 Plus roP
Amin Kherani, MD (Calgary, Canada), Khaled A. Tawansy, MD
anatomic and visual outcomes of surgical intervention for familial exudative vitreoretinopathy
Caesar K. Luo, MD (Royal Oak, MI), S. Chien Wong, MBBS, FRCSEd (ophth), MRCOphth, Tushar M. Ranchod, MD, Lawrence U. Ho, MD, Kimberly A. Drenser, MD*, Antonio Capone, MD, Michael T. Trese, MD*
PurPose
To review the outcomes of surgery for retinal detachment (RD) in familial exudative vitreoretinopathy (FEVR).
PurPose To study the effect of intra-vitreal bevacizumab on timing and extent of retinal vascular development in posterior ischemic ROP, regression of plus, resolution or cicatrization of neovascularization, recovery of intrinsic retinal vessels, and late complications associated with persistent peripheral nonperfusion and/or fibrovascular proliferation including macular dragging and retinal detachment. MeTHoD Retrospective review of clinical notes, fundus drawings, photographs, and fluorescein angiograms of 30 preemies who received bilateral intra-vitreal bevacizumab at a dose of 0.625 mg as first-line therapy for ROP Stage 3 Plus Zone II and IIp (diameter < 3X fovea to disc) within or outside of the BEATROP study. Patients were followed indefinitely until retinal vessels reached the ora serrata or complications occurred, sometimes requiring treatment. resulTs Intravitreal bevacizumab resulted within 48 hours in uniform resolution of plus disease and diminution of flat and elevated neovascularization in the absence of cicatrization (crunch phenomenon). Retinal vascular development was simultaneously stunted, without progression until 4 weeks after injection. In 48/60 (80%) eyes, retinal vessels extended to within 2 disc diameters of the ora serrata by 60 weeks post conception; while the remaining 12/60 (20%) had persistent peripheral non-perfusion, 4 (33%) had silent abrupt termination of vessels in a brush-border pattern, while the remaining 8 (67%) had vascular changes, including dilated and leaky endterminal buds (2/12, 17%), an active ridge with fluorescein staining (2/12, 17%), and fibrous contraction with macular dragging (2/12, 17%) or retinal detachment(2/12, 17%). 2 cases of retinal detachment onset was later than in non-bevacizumab eyes(52 vs. 41 weeks) and associated with less vascular activity and multiple ridges(stuttering growth pattern). conclusion Posterior ischemic ROP receiving bevacizumab respond with regression of plus and neovascularization; some develop late complications associated with a smoldering form of ROP, with late macular dragging and retinal detachment. Close follow up beyond 60 weeks post conception is warranted, until retinal vessels reach the ora serrata or intervention for vascular or fibrous complications present
MeTHoD
A retrospective, noncomparative interventional case series of 102 eyes of 71 patients with RD associated with FEVR requiring vitrectomy or scleral buckle surgery from 1984 to 2009. Patients with less than 6 months of follow-up were excluded. Birth histories, interventions, anatomical and visual outcomes were reviewed. Anatomical success was defined as either partial or complete retinal reattachment. Median age at the time of surgery was 1.1 years (IQR 0.3-6.1). Median follow-up was 45 months (IQR 26-86). At presentation, extent of RD was as follows: 7% (7/102) of eyes with stage 3 (macular-sparing), 48% (49/102) of eyes with stage 4 (macular-involving) and 45% (46/102) of eyes with stage 5 (total). Of these, 13% (13/102) had prior unsuccessful vitrectomy or scleral buckling surgery. Anatomical success or stabilization was achieved in 83% (83/102) of eyes after a mean of 1.4 (SD 0.67) procedures. In surgery naive eyes, final retinal reattachment was achieved in 43% (13/30) of eyes having vitrectomy alone and 50% (2/4) of eyes having scleral buckle alone. Of the 45 eyes with visual acuity follow-up data, 40% (18/45) improved and 27% (12/45) remained stable. In stage 5 eyes, partial or complete retinal reattachment occurred in 61% (28/46), vision improved in 24% and 88% (23/26) maintained at least light perception vision with a median of 75 months follow-up.
resulTs
conclusion
Patients with macular-involving and macularsparing RDs in FEVR can be treated successfully with vitrectomy or scleral buckling surgery. The risk of blindness from surgery is low.
11:40 AM
Discussion
41
PeDiaTric reTina 11:16 AM12:16 PM
11:54 AM
12:02 pM
Wnt-directed vascular remodeling in a Model of retinopathy

Kimberly A. Drenser, MD* (Royal Oak, MI), Michael T. Trese, MD*, Antonio Capone, Jr., MD*, Clayton Tokunaga
angiogenesis and angiomaintenance in Pediatric retinal Disease

Michael T. Trese, MD* (Royal Oak, MI), Antonio Capone, Jr., MD*, Kimberly A. Drenser, MD*
PurPose Capillary drop-out and ischemia due to various forms of retinopathy remains an untreated event. The purpose of this study was to evaluate the ability to drive vascular remodeling through Wnt-induced pathways.
PurPose
To demonstrate the role of Wnt signaling in development of and maintenance of the retinal vasculature including FEVR, ROP, Norrie disease, and juvenile diabetic retinopathy. Both animal models of retinal vasculature and capillary development by the oxygen induced retinopathy model and human angiographic study in FEVR and ROP are used to demonstrate capillary loss and disease progression. The correlation between Wnt signaling mutations and disease severity will be presented showing animal data of treatment with Norrin to drive Wnt signaling blocks these disease processes.
MeTHoD
A mouse model of oxygen-induced retinopathy was used to study normal and abnormal vascular growth and remodeling. Eyes received intravitreal injections with either PBS (control), norrin (specific Wnt activator), or DKK1 (Wnt canonical inhibitor) and evaluated for non-vascular retina, neovascular tufts, and capillary bed remodeling.
MeTHoD resulTs Eyes treated with norrin showed a statistically significant difference in the areas of avascular retina and neovascular tufts. Vascularized retina increased by 30% in norrin treated eyes compared to PBS control eyes and similarly demonstrated a decrease in neovascular tufts. Interestingly, DKK1 treated eyes showed increased vascular retina compared to control eyes, but also showed a decrease in the level of capillary remodeling, indicating that norrin works by canonical and non-canonical Wnt signaling. conclusion Wnt signaling plays an important role in vascular growth and remodeling in the retina. Additionally, it appears that specific Wnt activation, such as that seen with norrin, more precisely drives appropriate capillary formation. It may be possible to promote vascular growth in a controlled fashion without inducing neovascular changes.
resulTs
Data showing Norrin treatment as an intravitreal injection can alter capillary development in the OIR model suggests that other vascular diseases may be amenable to Wnt modulator. In addition, capillary dropout is seen preceding disease reactivation in FEVR. Also, the severity of disease such as ROP and FEVR and diabetes may be in part mediated by Wnt signaling mutations. Wnt signaling appears to be involved in retinal vessel development and maintenance. These mutations in the face of premature birth or diabetes may contribute to more severe disease and may be able to be treated with Norrin.
conclusion
12:10 pM
Discussion
12:16-1:25 pM

12:16-1:25 pM
Women in retina (Winr) symposium and lunch Balancing career and family
Susan B. Bressler, MD (Baltimore, MD)
1:33-3:35 pM
1:41 pM
Symposium 8: Macular Degeneration ii

Moderators: Harry W. Flynn, MD and Jonathan L. Prenner, MD Related poster abstracts are on pages 83-98.
ophthalmic antibiotic use and Multidrug resistant staphylococcus epidermidis: a controlled, longitudinal study
Stephen J. Kim, MD (Nashville, TN), Sarita Dave, Hassanain S. Toma
1:33 pM
aMD: update on nature, nurture and Prediction Models for clinical Management and Trials
Johanna M. Seddon, MD* (Boston, MA)
PurPose
To analyze the emergence of multidrug resistant Staphylococcus epidermidis after repeated conjunctival exposure to topical macrolide or fluoroquinolone antibiotics.
MeTHoD
PurPose To assess risk and protective factors for AMD; to develop algorithms based on these factors to estimate rates of progression to geographic atrophy and neovascular disease; to apply this information for use in managing patients and for planning clinical trials. MeTHoD Using our AMD databases, we have shown that smoking, higher body mass index, and unhealthy diet and lifestyles influence susceptibility to onset and progression of AMD. We have assessed multiple risk prediction models (1-5) incorporating these variables. We evaluated an expanded model of progression to geographic atrophy and neovascular disease which included 2937 individuals and 819 progressors, with longer follow-up, time varying analyses, additional baseline ocular phenotype data, and validation in a test sample.
This was a prospective study involving 48 eyes of 24 patients undergoing serial unilateral intravitreal (IVT) injections for choroidal neovascularization (CNV). Subjects received 4 consecutive monthly unilateral IVT injections and then were treated as needed. Each subject was randomly assigned to 1 of 4 antibiotics (azithromycin 1%, gatifloxacin 0.3%, moxifloxacin 0.5%, ofloxacin 0.3%). Conjunctival cultures of the treated and untreated fellow eye (control) were taken at baseline and following each injection. All bacterial isolates were tested for antibiotic susceptibility to 16 different antibiotics using the Kirby-Bauer disc diffusion technique. After 4 consecutive treatments, a total of 58 isolates of S. epidermidis were each isolated from control and treated eyes. Resistance to 3 antibiotics was present in 69% of S. epidermidis isolated from control eyes compared to 90% from treated eyes (P < 0.02). A total of 46 and 38 isolates of S. epidermidis were cultured from control and treated eyes respectively from their 5th until final injection. Resistance to 5 antibiotics was present in 48% of control eyes compared to 71% of treated eyes (P < 0.05). In a significant number of fluoroquinolone-treated eyes, S. epidermidis developed resistance to 3rd (P < 0.01) and 4th (P < 0.01) generation fluoroquinolones and developed resistance to trimethoprim/sulfamethoxazole (P < 0.01), gentamicin (P < 0.03), and clindamycin (P < 0.05). A significant number of azithromycin-treated eyes developed S. epidermidis resistant to macrolides (P < 0.01) and to trimethoprim/sulfamethoxazole (P < 0.02) and doxycycline (P < 0.01).
resulTs
1) Nature Genetics 2006; 38:1055-1059 2) Hum Heredity 2006: 61:157-165 3) JAMA 2007; 287:1793-1800 4) IOVS 2009:50:5818-5827 5) IOVS 2009; 50: 2044-2053.
resulTs
Age, smoking, body mass index, and genetic variants in 5 genes, as well as AMD status in the fellow eye and drusen size at baseline were collectively associated with progression to advanced stages of AMD. Knowledge of genetic variants added to the predictive models. The AUC, a measure of the model, was excellent (0.915).
conclusion
conclusion Factors reflective of nature and nurture were incorporated into our expanded algorithms for risk prediction. The models and risk scores we developed may be useful for AMD surveillance and for designing clinical trials.
Conjunctival S. epidermidis repeatedly exposed to fluoroquinolone or azithromycin antibiotics rapidly develop resistance. Co-resistance to other antibiotics was also observed.
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Discussion
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Macular DegeneraTion ii 1:333:35 PM
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Prophylaxis for endophthalmitis associated with intravitreal injection: antisepsis and antibiotics
Harry W. Flynn, MD* (Miami, FL), Charles C. Wykoff, MD, PhD, Philip J. Rosenfeld, MD, PhD*
using a standard protocol including a drop of 5% povidone iodine prior to injection and a drop of topical fluoroquinolone after. Topical antibiotics, either fluoroquinolone or polymyxin B/trimethoprim, were used 4 times a day for 4 days after each injection. At the time of enrollment, the inferior fornix of both eyes was swept with a culture swab prior to use of povidone iodine; fellow eyes served as a control group. The culture and sensitivity data from the study and control eyes was gathered and analyzed.
resulTs
PurPose To discuss clinical issues related to the use of antisepsis and antibiotics for the prophylaxis of endophthalmitis following intravitreal injections. MeTHoD Review of medical literature with an emphasis on author-selected studies. resulTs Povidone-iodine (PI) confers broad spectrum microbicidal activity with a rapid kill time ranging from 15 to 120 seconds for concentrations of 10% to 0.1%. There are no reported cases of resistance to its bactericidal effects. PI is inexpensive and widely available.
40 patients (80 eyes) were enrolled in the study. 29 patients had used polymyxin B/trimethoprim drops while 11 used fluoroquinolone drops after each prior injection. 58 bacterial colonies were isolated from 50 eyes, with no difference between study and control eyes (p=0.01). Coagulase-negative staphylococcus accounted for 41 of the 58 bacterial colonies (71%); other species included staphylococcus aureus, staphylococcus lugdunensis, streptococcus mitis, and coryneform bacteria. There was a 63.6% resistance rate to fluoroquinolones among study eyes, compared to 32.1% among control eyes (p<0.05). In the subset of 11 study eyes using fluoroquinolone drops for 4 days after injection, there was an 87.5% resistance rate (p=0.012).
In comparison, topical antibiotics have significantly longer kill-times than PI and likely have insufficient time to achieve adequate biological effect when given immediately prior to injection. When applied before the day of injection, topical antibiotics are no more effective than immediate pre-injection topical PI in reducing conjunctival bacterial counts. Repeated exposure of ocular flora to topical antibiotics selects for resistant strains. Topical antibiotics have poor intravitreal penetration and are unlikely to achieve therapeutic levels post-injection. Moreover, antibiotics are variably expensive and also may be difficult for patients to procure and apply.
conclusion The retina communitys standard practice for of using periocular antisepsis and antibiotics for the prevention of endophthalmitis related to intravitreal injections continues to evolve. The current literature and clinical experience suggest that the rationale and clinical use of PI without antibiotics is increasing.
conclusion
Use of fluoroquinolone drops after intravitreal injection leads to increased resistance in the conjunctival flora, with even higher rates when fluoroquinolone drops are used for 4 days after injection. Repeated use of topical antibiotics after intravitreal injections may have a detrimental effect on eye health by breeding antibiotic resistance in the bacterial flora.
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understanding and reporting visual acuity Measurements in Publications of clinical research in retina
Susan B. Bressler, MD* (Baltimore, MD), Mariana Silva Lopes, Shiri Zayit-Soudry, MD, Ala Moshiri, Neil M. Bressler, MD*, Ala Moshiri, MD
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PurPose
changes in antibiotic resistance Patterns of conjunctival flora Due to repeated use of Topical antibiotics after intravitreal injection
Eugene A. Milder, MD (Philadelphia, PA), James F. Vander, MD*, Chirag P. Shah, MD*, Sunir J. Garg, MD*
To investigate methods used to report visual acuity in the published retina literature in the United States, and evaluate understanding of those methods among ophthalmologists at various stages in their careers.
MeTHoD
PurPose To determine the change in conjunctival bacterial flora and antibiotic resistance patterns due to repeated short courses of topical antibiotics after intravitreal injections for exudative AMD. MeTHoD Patients with unilateral exudative AMD who had received at least three prior intravitreal injections were enrolled in this cross-sectional study. Each injection was administered
All retina papers published in 2008 among four leading American clinical journals (Ophthalmology, Archives of Ophthalmology, American Journal of Ophthalmology, and Retina) were reviewed. The full text of each paper was examined by at least two authors, and each method of visual acuity reporting used was recorded. Five residents, four ophthalmologists in retina training, and five full-time retina faculty at an academic institution were surveyed to evaluate their ability to interpret various visual acuity methods.
resulTs Among 356 retina papers, 206 reported visual acuity, including 172 (83%) which used visual acuity as an outcome measure. Snellen acuities were reported in 175 (85%) of the 206 papers. Other methods included a letter score based on the log of the minimal angle of resolution (logMAR) in 106 papers (51.5%), a letter score derived from the number of letters read on an Early Treatment Diabetic Retinopathy Study (ETDRS) chart in 67 papers (32.5%), decimal notation in 13 papers (6.3%), and fractions other than Snellen equivalent in 1 paper (0.5%). Among the 140 papers using notations other than Snellen, 31 (22.1%) did not provide a Snellen equivalent. The majority of physicians surveyed, regardless of level of training, were unable to translate an ETDRS letter score or logMAR value to an approximate Snellen equivalent correctly. conclusion Many publications in major ophthalmic journals in the US describing clinical research in retina do not provide Snellen equivalent of letter scores derived from an ETDRS chart or logMAR values. Journals should consider requiring Snellen equivalents until data show a greater understanding or facility with letter scores or logMAR values.
with a total of 14.5 7.8 by the end of follow-up. The incidence rate of visual loss to 20/200 or worse among patients with neovascular AMD initially treated with intravitreal ranibizumab was 11.8% per person-year. Kaplan-Meier analysis showed that 25% of these patients will reach 20/200 or worse by 1 year, 50% by 3.5 years, and 75% by 5 years. The percentage of macular fibrosis and RPE atrophy progressed over time, with threequarters of eyes having evidence of either. Eyes with significant amounts of fibrosis, RPE atrophy, or both were more likely to progress to poor visual acuity.
conclusion
This cohort among the first neovascular AMD patients treated with multiple ranibizumab injections experienced significant visual loss with extended follow-up due to subretinal fibrosis and RPE atrophy, despite initial visual gains. Future studies evaluating treatment modalities to prevent or retard fibrosis and atrophy may complement anti-VEGF treatment and maximize long-term visual outcomes.
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Discussion
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long-term outcomes of neovascular aMD Treated with ranibizumab

Chirag P. Shah, MD (Boston, MA), Carolyn Chen, MD, Jordana Firestone Goren, MD, Kitia Paul, MD, Jeffrey S. Heier, MD*
Kaplan-Meier curve showing proportion of patients reaching 20/200 visual acuity or worse by year of follow-up.
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To describe the long-term visual and anatomic outcomes of patients enrolled initially in 2128 and 2425 Phase I/II trials, the first clinical trials evaluating multi-dose ranibizumab for neovascular AMD. These trials enrolled patients between 2001 and 2002.
PurPose MeTHoD This is a single-center retrospective case series of 34 patients with neovascular AMD enrolled originally in trials 2128 and 2425 at Ophthalmic Consultants of Boston, Boston, MA, from July 3, 2001 to January 15, 2011. Trial 2128 included patients with subfoveal, predominantly or minimally classic neovascular AMD. Visual acuity ranged from 20/40 to 20/400. Trial 2425 included patients with subfoveal neovascular lesions that did not meet treatment criteria for laser or PDT. Visual acuity ranged from 20/40 to 20/100. The long-term outcomes measures included visual acuity, degree of subretinal fibrosis and retinal pigment epithelium atrophy, timing and total number of ranibizumab injections. resulTs Patients were followed for an average of 80.5 25.3 months (range 27 to 110 months). An average of 11.4 4.8 ranibizumab injections were administered in the first two years,
long-term results of anti-vegf Therapy for choroidal neovascularization associated with aMD
John T. Thompson, MD* (Towson, MD), Erica A. Conlan, MD
PurPose
To evaluate the long-term results of anti-VEGF therapy for neovascular age-related macular degeneration and the effects of extended dosing in eyes which attain good versus poor visual acuities from treatment.
MeTHoD
Visual acuity was measured in a retrospective case series of 183 consecutive eyes treated with either intravitreal bevacizumab (63 eyes or 34.4%), ranibizumab (108 eyes or 59%) or both (12 eyes or 6.6%) for subfoveal choroidal neovascularization (CNV) arising from age-related macular degeneration. Eyes were treated with dosing every 4-6 weeks with ranibizumab or bevacizumab for the first year following by
45
extended dosing (every 2 months or less frequently) if stable during subsequent years. If eyes developed decreased visual acuity or signs of recurrent activity of CNV, dosing every 4-6 weeks was repeated for 3 doses followed by attempts at repeat extended dosing.
resulTs Mean visual acuity was 20/125 -2 at baseline, 20/100 -1 at 3 months (P<.001), 20/100 +2 at 1 year (P<.001), 20/100 -1 at 2 years (P=.002), 20/100 at 3 years (P=.036) and 20/125 +1 at 4 years (P=.73). The visual acuity was 20/100 or better in 137/183 eyes (74.9%). This subgroup was 20/100 +1 at baseline, 20/63 at 3 months (P<.001), 20/63 +2 at 1 year (P<.001), 20/63 -2 at 2 years (P.002), 20/80 +2 at 3 years (P=.039) and decreased to 20/100 at 4 years (P=.59). 66 eyes (48.2%) developed a 3-line loss and recovered in only 19/66 eyes (28.8%) with regular anti-VEGF dosing. The 3-line loss occurred during regular dosing (q 4-6 weeks) in 19/66 eyes (28.8%), extended dosing (< 6 weeks) in 40/66 eyes (60.6%) and both in 7/66 eyes (10.6%). 46 eyes (25.1%) never achieved a visual acuity of 20/100 or better. This subgroup was 20/400 at baseline, 20/400 at 3 months (P=.733), 20/400 +2 at 1 year (P=.273), 20/320 -2 at 2 years (P=.58), 20/320 -1 at 3 years (P=.695) and 20/320 at 4 years (P=.159).
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analysis of intraocular Pressure in eyes receiving Monthly intravitreal ranibizumab in the Marina and ancHor Trials
Sophie J. Bakri, MD* (Rochester, MN), Darius M. Moshfeghi, MD*, Steven Francom, MD*, Daniel Reshef, MD*, Roman Rubio*, Phillip Lai, MD*
PurPose
RBZ administration to AMD patients results in significant visual improvements. In the MARINA and ANCHOR trials there were no long-term increases in mean pre-injection IOP from baseline. Recent publications have reported increased IOP during RBZ treatment. We performed a post-hoc analysis to characterize pre-injection IOP in the study eye during the two Phase III AMD trials: MARINA and ANCHOR.
MeTHoD
The initial visual acuity gains during regular antiVEGF dosing diminish during extended dosing, but the gains were significant for 3 years. Eyes with visual acuities of 20/100 or better have a higher risk of visual acuity loss with extended dosing. Many eyes with good visual acuities require long-term regular dosing of intravitreal anti-VEGF drugs to minimize visual acuity losses.
conclusion
All safety evaluable patients (those who received at least 1 injection and had a Month 1 IOP recorded in the study eye) were included in this analysis. Pre-injection IOP for study eyes in MARINA and ANCHOR were reviewed at Day 0 and at each monthly visit through Month 24 (M24). Analyses included highest pre-injection IOP; occurrence at 1 study visit of an absolute IOP 21, 25, and 30 mmHg; IOP increase from baseline of 6, 8 and 10 mmHg; and an IOP increase from baseline of 6 or 8 mmHg concurrent with an absolute IOP of 21 or 25 mmHg; new glaucoma medications that were used greater than 45 days; and glaucoma filtration surgeries.
resulTs
A total of 1124 patients were included in this analysis. The majority of study eyes had a highest post-baseline preinjection IOP measurement of 21 mmHg (Fig.1). When compared to sham/PDT, eyes in the RBZ groups had higher rates of any occurrences at 1 study visit of IOP 21, 25 and 30 mmHg; IOP increase from baseline of 6, 8 and 10 mmHg; and combinations of an IOP increase from baseline of 6 or 8 mmHg concurrent with an absolute IOP of 21 or 25 mmHg. These differences were significant (p<0.05) for all comparisons except IOP 30 mmHg and IOP increase from baseline 10 mmHg (Table 1). New glaucoma medications were initiated in the study eye in 5.3% of sham/PDT, 7.5% of 0.3mg RBZ and 7.2% of 0.5mg RBZ patients (not significant). No patient required glaucoma filtration surgery in the study eye. During the 24 mo. treatment period, more RBZtreated eyes had increases in pre-injection IOP than sham/ PDT-treated eyes. Differences in rates between RBZ and sham/PDT-treated eyes for the IOP endpoints ranged from 1.3%-14.2%. Less than 8% of all study eyes required chronic glaucoma medications; none required glaucoma filtration surgery. IOP should be evaluated prior to and after RBZ injection.
conclusion
Fig. 1: Distribution of the Highest Pre-injection IOP in the Study Eye during the 24-month treatment period of MARINA and ANCHOR.
MeTHoD 349 NVAMD patients (474 eyes) that presented to a single physician over a 6-month period were retrospectively assessed for baseline demographic/clinical information, exam findings, total number of bevacizumab and ranibizumab injections and sustained IOP elevation (>21 mmHg for 2+ consecutive visits). The frequency and odds ratio of sustained IOP elevation was stratified by number of injections. Association between each possible confounder (demographic or clinical characteristic) and the dependent and independent variables were assessed individually. A multivariate, logistic regression was performed to determine if total number of injections showed an association with sustained IOP elevation. resulTs
39 eyes (8.2%) experienced sustained IOP elevation. Eyes with 31 injections had a greater odds ratio (7.973, CI 1.75-36.44, p=0.007) compared to 10 injections. The following showed an association with sustained IOP elevation: total number of injections (OR 1.664, p=0.004, univariate analysis), history of intravitreal steroid injections (OR 2.894, p=0.006), history of IOP elevation soon after intravitreal steroid injection (OR 3.437, p=0.038), history of glaucoma (p=0.009, Fishers exact test), prior eye surgery other than cataract extraction (OR 4.448, p=0.033) and prior posterior capsulotomy (OR 2.982, p=0.026). Of these factors, only prior intravitreal steroids (p < 0.0001) and IOP elevation soon after intravitreal steroid injection (p=0.001) were found to be also associated with the total number of injections. After adjusting for these confounders, the association between total number of injections and sustained IOP elevation was still statistically significant (p=0.013). Our results suggest that a greater number of injections may increase the risk for sustained IOP elevation in eyes with neovascular AMD receiving intravitreal anti-VEGF therapy. Eyes having received prior intravitreal steroid injections and those which have experienced IOP elevations soon after receiving intravitreal steroids may be at greater risk for this complication of treatment.
Table 1: Rates of pre-injection IOP at 1 study visit.
conclusion
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frequency and clinical Predictors of sustained intraocular Pressure elevation Due to intravitreal anti-vascular endothelial growth factor Therapy
Quan V. Hoang, MD, PhD (New York, NY), Luis S. Mendonca, MD, Kara Dellatorre, MD, Jesse Jung, MD, Angela J. Tsuang, MD, K. Bailey Freund, MD*
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Discussion
PurPose Intraocular pressure (IOP) elevations as a complication of anti-vascular endothelial growth factor (VEGF) injections were not noted in ANCHOR and MARINA trials, but recent reports suggest sustained ocular hypertension can occur. We assess for frequency and predictive factors related to IOP elevations in neovascular age-related macular degeneration (NVAMD) patients receiving anti-VEGF injections.
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Double-dose ranibizumab for choroidal neovascularization assoc. with aMD Minimally responsive to Prior -vegf Treatment
Carolyn Chen, MD (Boston, MA), Jeffrey S. Chang, MD, Chirag P. Shah, MD, Kavita Bhavsar, Jeffrey S. Heier, MD*
increased Dose ranibizumab for Persistent choroidal neovascular activity in neovascular aMD
Jared S. Nielsen, MD* (West Des Moines, IA), Tyler A. Fick, MD, Kyle A. Alliman, MD, David D. Saggau, MD
PurPose To evaluate the efficacy of double-dose (1 mg) injections of intravitreal ranibizumab for choroidal neovascularization (CNV) minimally responsive to prior ranibizumab or bevacizumab treatments. MeTHoD A retrospective, non-randomized, consecutive, interventional case series was conducted among all patients treated by one researcher (JSH) at Ophthalmic Consultants of Boston, Boston, MA, between Dec. 2009, and Mar. 2011. All patients receiving at least one double-dose ranibizumab injection (1.0 mg in 1.0 mL) for CNV were included. Patients receiving double-dose ranibizumab for conditions other than neovascular AMD, retinal angiomatous proliferation (RAP), or idiopathic polypoidal choroidal vasculopathy (IPCV) were excluded. Prior treatments, visual acuity (VA) and central foveal thickness (CFT), determined by spectral domain optical coherence tomography, were recorded and analyzed. resulTs Thirty eyes in 29 patients received double-dose ranibizumab after minimal anatomic and visual response to multiple previous ranibizumab (0.5 mg in 0.5 mL) and/or bevacizumab (1.25 mg) injections. Most eyes had neovascular AMD (19); six had RAP and five had IPCV. During the two standard-dose treatments (mean 10.3 weeks) prior to treatment with double-dose ranibizumab, mean VA declined from 20/66 (logMAR=0.52) to 20/83 (logMAR=0.62; p = 0.48), and CFT increased from 344 to 373 microns (p = 0.981). Following one double-dose ranibizumab injection, mean VA improved to 20/71 (logMAR= 0.55, p = 0.067), and mean CFT decreased significantly to 338 microns (p = 0.03). No adverse events were noted. conclusion Patients recalcitrant or minimally responsive to multiple prior ranibizumab and/or bevacizumab treatments for CNV experienced an improvement in CFT after a single double-dose ranibizumab injection. VA also improved with borderline stat. significance. These findings suggest that there may be a subset of patients poorly responsive to standard dose that may benefit from double-dose ranibizumab.
PurPose
AntiVEGF therapy with intravitreal injection (IVI) of bevacizumab 1.25mg or ranibizumab 0.5mg is the standard of care for nvAMD treatment. While most patients respond to conventional dose therapy, CNV activity can persist despite monthly IVI. Patients with CNV activity while on monthly conventional dose therapy may benefit from increased dose (0.7 or 1.0) ranibizumab (IDR) using 0.7 or 1.0mg.
MeTHoD
We performed a retrospective electronic record review of eyes treated with IDR for persistent CNV activity despite conventional antiVEGF therapy. Subjects were excluded if: vision <20/400 in the treated eye, follow-up after IDR <12 weeks, prior IVI <22 or >34 days before IDR, confounding ocular disease, irregular IDR treatment intervals, or adjunctive therapy (steroids, PDT, or thermal laser) during or <3 months prior to IDR. Demographic information, treatment, visual acuity, exam, and OCT data were collected. Each IDR injection including the dose and any complications were noted.
resulTs
89 eyes of 32 male and 57 female nvAMD patients, mean age 80.9 (SD9.1), treated with IDR were identified. Eyes had received antiVEGF therapy for a mean of 75.4 (SD55.1) weeks before IDR. Prior therapy is summarized in Table 1. Subjects received IDR for a mean of 40.5 (SD17.3) weeks (range 12-65 weeks). A total of 923 IDR were injected, an average of 10.5 (SD4.2) IDR IVI per eye. IDR was administered monthly. If CNV activity resolved then IVI intervals were extended in some cases. LogMar VA prior to IDR was 0.33 (SD0.27), snellen 20/43. IDR acuity improved in 36% of eyes, maintained in 42%, and worsened in 22%. Overall mean logMAR VA remained stable at 0.32 (SD0.30). Initial OCT findings and clinical response are summarized in Table 2. OCT improved in 61 (68.5%) eyes, remained stable in 15 (16.9%) eyes, and declined in 13 (13.5%) eyes. For eyes with sdOCT (n=82) mean central subfield thickness (CST) was 344.1 (SD65.4) and improved to 312.5 (SD68.2); t-test p<0.0001. Eyes with persistent CNV activity despite monthly conventional dose antiVEGF therapy can benefit from IDR. Two subjects with a prior history of CAD suffered non-fatal arterial thromboembolic events while receiving IDR. It is uncertain if these events are related to IDR. IDR can be performed without increasing injection frequency or cost and may improve clinical outcomes.
conclusion
QM vs.PRN for either 2.0 MG or 0.5 MG eyes showed no significant differences (all p>0.05). There were significant decreases between pre and post-RI measurements for PED height,1-mm, PED A2, & SRF in 2.0 MG eyes, and for PED height, 1-mm, PED A2, PED GLD, CNV A2, SRF & CME in 0.5 MG eyes (all p<0.05). There were also greater VA improvement and much earlier decreases in PED height & SRF (Week 4 or 8) in 2.0 MG eyes compared with 0.5 MG eyes (all p<0.05). Resolution of PED was more consistent in 2.0 MG eyes compared with 0.5 MG eyes(p=0.04). Three eyes (0.5 MG PRN, 2.0 MG QM, 2.0 MG PRN) formed an RPE tear and in 1 eye cataract worsened (0.5 MG QM).
conclusion
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Management of vascularized Pigment epithelial Detachments Due to aMD with High (2.0 mg) vs. conventional-dose (0.5 mg) ranibizumab
Clement K. Chan, MD* (Palm Springs, CA), Prema Abraham, MD, David Sarraf, MD*, Asha S.O. Nuthi DO*, Steven G. Lin, MD*, Colin A. McCannel, MD*
High-dose (2.0MG) but not 0.5 MG ranibizumab led to significantly improved post-RI vision in eyes with vPED. Visual recovery and decreased vPED dimensions also developed substantially earlier in the course of the study in 2.0 MG eyes than in 0.5 MG eyes. There was more consistent flattening of PED in 2.0 MG eyes but not in 0.5 MG eyes. The safety profile was similar for both medication doses.
PurPose To investigate the efficacy and safety of 2.0 MG vs. 0.5 MG ranibizumab injections (RI), and monthly (QM) vs. as needed (PRN) reinjection protocol for treating vPED due to AMD in a prospective randomized clinical trial. MeTHoD The RI groups were:1) 0.5 MG monthly (QM) x 12 months (M), 2) 0.5 MG QM x 4 M followed by PRN injections to 12 M, 3) 2.0 MG QM x 12 M, 4) 2.0 MG QM x 4 M followed by PRN injections to 12 M. Primary outcome measures were pre- & post-RI (last visit) ETDRS visual acuity (VA). Secondary measures were pre-and post OCT central 1-mm thickness; PED height; surface area (A2), greatest linear diameter (GLD) of PED & choroidal neovascularization (CNV); subretinal fluid (SRF); cystoid macular edema(CME); adverse events. Baseline & follow-up VA, biomicroscopy, fundus photography, fluorescein angiography & OCT were done to set schedule. Statistics included ANOVA, T-Test, Wilcoxon Signed Ranks, Mann-Whitney & Fisher tests.
Substantial VA improvement much earlier in the post-treatment course (Week-8) was noted for eyes receiving 2.0MG ranibizumab (P=0.008) in comparison to 0.5MG ranibizumab (p=0.08). Final VA was also better than pre-treatment VA for the 2.0 MG eyes (p=0.004), but not the 0.5 MG eyes (p=0.26).
More rapid decreases in post-treatment PED heights (Week-4) were noted for eyes receiving 2.0MG ranibizumab (p=0.016) in comparison to eyes receiving 0.5MG ranibizumab (p=0.29).
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Discussion
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There were 38 eyes in 38 patients (12 men) with mean age of 79.3 years & mean follow-up of 8.9 months. Mean ETDRS VA post-RI was better than pre-RI for 2.0 MG eyes (65.414.4 [20/50] vs. 58.410.8 [20/71], p=0.004), but not for 0.5 MG eyes (p=0.26). Comparison of other post-RI results for 2.0 MG vs. s0.5 MG eyes, and comparison of results between
resulTs

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viTreoreTinal surgery ii 4:105:18 PM
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4:18 pM
Symposium 9: vitreoretinal Surgery ii

Moderators: Mark S. Humayun, MD, PhD and Timothy G. Murray, MD, MBA Related poster abstracts are on pages 119-150.
implications of 23/25+ gauge Microincisional vitrectomy surgery with adjunctive intravitreal steroid Pharmacotherapy
Timothy G. Murray, MD, MBA* (Miami, FL), Robert A. Sisk, MD, Charles C. Wykoff, MD, PhD, David W. Parke III, MD, Audina M. Berrocal, MD, Samuel K. Houston
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Management of aqueous Misdirection syndrome (aMs) role of Pars Plana vitrectomy

Pramod S. Bhende, MBBS (Chennai, India), Vijaya Lingam, MD*, B. Shantha, MD, Ronnie George, MD
PurPose
Recent concerns have focused on incidence of immediate post operative hypotony/endophthalmitis and late development of secondary glaucoma associated with pars plana vitrectomy. We report a consecutive series of 23/25+ MIVS surgery using intra-operative triamcinilone acetonide with extended followup focused on IOP, retinal anatomy, and visual function.
MeTHoD PurPose To report anatomical and functional outcome in eyes that underwent combined surgery for management of aqueous misdirection syndrome. MeTHoD Retrospective, noncomparative, interventional case series of 23 patients (26 eyes) diagnosed as AMS and refractory to medical and conventional surgical therapy. All eyes underwent initial pars plana anterior vitrectomy, anterior chamber reformation (pseudophakic eyes) and phacoemulsification + IOL implantation (phakic eyes) followed by completion of vitrectomy including induction of posterior vitreous detachment. At conclusion a communication was established between the anterior and the posterior chambers to allow free flow of fluid through the peripheral iridotomy and posterior capsulotomy. resulTs All surgeries were performed by a single surgeon using the above described approach. All eyes had at least one filtration procedure prior to surgery for AMS. Mean interval between primary filtration surgery and diagnosis of AMS was 14.01 weeks and between diagnosis of ASM and vitrectomy was 16.37 wks. Mean preoperative and final IOP was 16.97 and 12.75 mm of Hg. 20 eyes did not need any anti glaucoma medication after surgery. Ultrasound biomicroscopy (UBM) was done in 19 eyes both pre and post operatively and showed reversal of anterior rotation of ciliary processes in all cases following surgery. At mean follow up of 104.35 weeks, all the eyes had well-formed central anterior chamber. Vision was maintained or improved in 23 eyes. Late complications included corneal decompensation in 3 and choroidal detachment in 2 eyes. conclusion Creation of single cavity using a combined procedure of complete vitrectomy (with phacoemulsification in phakic eyes) and a peripheral iridotomy with posterior capsulotomy using the parsplana route can yield excellent anatomical outcome in phakic and pseudophakic eyes with AMS.
An IRB approved retrospective review of a consecutive series of 327 eyes undergoing 23/25+ gauge MIVS surgery with intraoperative triamcinolone acetonide within the Ocular Oncology Service at the Bascom Palmer Eye Institute. Preoperative evaluation included OCT evaluation, fundus photography and/or ultrasound. Extended followup included visual function, IOP evaluation and macular imaging with OCT/fundus photography. A standard surgical procedure employed oblight trocar insertion, pars plana vitrectomy, removal of the posterior hyaloid with, or without ERM/ILM peeling, and placement of intravitreal triamcinolone acetonide 4 mg. All cases were evaluated for surgical complications.
resulTs
327 surgical procedures were performed on 299 patients. Mean patient age was 68 years (18 to 96 years) with surgical indications including radiation associated retinal detachment (54.2%), VMT/ERM/CME (21.6%), diabetic retinopathy (15.9%) and exudative neovascular AMD related retinal detachment (8.3%). Mean followup was 23 months (12 to 60 months). No cases of endophthalmitis were seen (0/327). Hypotony occurred in 1/2% (4/327). Mean IOP was 15.7 mm Hg at baseline, 17.6 at one day, 15.6 at one month, 14.8 at three months, 14.9 at 6 months, 15.0 at 12 months and 15.8 at 24 months. The subset of patients with elevated IOP (>25 mm Hg) was 5.3% at baseline, 2.4% at 1 month, 1.2% at 6 months, 1.1 % at 12 months, and 0.9% at 24 months. One patient underwent glaucoma surgery (1/327, 0.003%). 23/25+ MIVS utilizing intraoperative triamcinolone acetonide appears to have a low complication rate without significant concerns for hypotony, choroidal detachment, retinal detachment or endophthalmitis. Concerns for secondary glaucoma associated with primary pars plana vitrectomy appear to be ameliorated by the use of 23/25+ MIVS surgery with adjunctive intravitreal triamcinolone acetonide.
conclusion
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4:40 pM
vitrectomy and Pars Plana Baerveldt implant with ripcord Technique for Treatment of complex glaucoma
Maan A. Nasir, MD (Santa Barbara, CA), Alessandro Castellarin, MD, Dante J. Pieramici, MD, Robert F. See, MD, Stephen S. Couvillion, MD, Melvin D. Rabena
a novel surgical approach to the Treatment of Blinding Macular Disease

Suber S. Huang, MD, MBA* (Cleveland, OH)
PurPose PurPose To evaluate the efficacy of vitrectomy and pars plana Baerveldt implants utilizing a ripcord technique in patients with elevated intraocular pressure (IOP) unresponsive to maximal medical treatment. MeTHoD A retrospective study of consecutive eyes undergoing pars plana Baerveldt implantation for glaucoma. In all patients, a novel ripcord technique was utilized to control the timing of opening the tube and lowering the IOP. Pre- and post-operative analysis includes IOP, number of glaucoma medications, and ocular adverse events. Complete Success is defined as a final IOP 6x21 mmHg, with no glaucoma medication; Qualified Success as IOP 6x21mmHg with at least one glaucoma medication; Qualified Failure as IOP 6>x>21mmHg and Complete Failure as an eye progressing to no light perception (NLP), phthisis bulbi, or requiring a second surgery to control IOP. resulTs Inclusion criteria were met in 119 eyes; 69 with neovascular glaucoma (NVG) and 50 eyes without NVG. Many of the non-NVG eyes had corneal transplants as pars plana placement of tubes may reduce graft failure. Mean follow up was 26 months and the ripcord was removed a mean of 46 days after implantation. At the last follow-up visit (LFV), the mean IOP was 12.8 mmHg compared to 32.1 mmHg before surgery and 21.1 mmHg at day 1 after surgery. The mean number of glaucoma medications at LFV was 0.9 compared to 2.6 at the preoperative visit. Complete Success was found in 47.8% (57/119) of eyes; Qualified Success in 38.7% (46/119); Qualified Failure in 3.4% (4/119); and Complete Failure in 10.1% (12/119). Of the 12 complete failures, 5 had NLP vision all felt to be due to progression of underlying disease rather than IOP control, and 3 of these eyes developed phthisis. Surgery was required due to hypotony (1), elevated IOP despite implant (4), and tube erosion requiring replacement (2). conclusion
Can magnetic nanoparticles be used to deliver therapeutic drug/genes to treat diseases of the retina and macula?
MeTHoD
Green-fluorescence protein (GFP) plasmids were associated with paramagnetic nanoparticles. Gene delivery was then targeted to cultured human diploid retinal pigment epithelial (ARPE-19) cells by application of a magnetic field. Fluorescence microscopy was used to assay cells for GFP expression. Magnetic nanoparticles were then tagged with red fluorescence and delivered to cultured ARPE-19 cells with application of a magnetic field. Uptake of particles into cells was detected using fluorescence microscopy. This procedure was repeated using Polyethylenamine (PEI)-GFP nanoparticles complexes as a standard control. Transfection efficiencies were compared using fluorescence microscopy. Micrographs quantitating transfection efficiency of ARPE-19 cells using GFP-magnetic nanoparticle complexes will be presented and demonstrate significantly higher integration than that of PEI-RPE nanoparticles. In addition, fluorescently tagged magnetic nanoparticles showed nearly diffuse uptake by ARPE-19 cells. Finally, transfection of ARPE19 cells using GFP-magnetic nanoparticle complexes required only 15 minutes of incubation time while exposed to magnetic field in order to achieve optimal gene delivery. In contrast, PEIGFP nanoparticle complexes required 4 hours (as per standard protocol) of incubation time to achieve optimal delivery.
resulTs
conclusion
We describe a novel approach to biologic therapy to the macula using two kinds of nanoparticles. Selective delivery to retinal tissue layers will be clinically useful in patients with genetic, degenerative, and apoptotic mechanisms for disease. The ability to target specific cell types in the retina will be a step towards improved methods of treating retina blinding disease.
Vitrectomy and pars plana Baerveldt implantation with a novel ripcord technique appears to be an effective method to control IOP in patients with complex glaucoma. The pars plana approach also permits simultaneous treatment of associated posterior segment pathology.
4:34 pM
Discussion
51
viTreoreTinal surgery ii 4:105:18 PM
4:48 pM
4:56 pM
intraocular lens Placement via a novel, sutureless, scleral fixation Technnique

Jonathan L. Prenner, MD* (Lawrenceville, NJ), Harold Wheatley, MD, Howard P. Fine, MD*, Connors Daniel, MD, Daniel B. Roth, MD*
outcomes and lens stability in combined Transconjunctival sutureless vitrectomy and cataract surgery with Toric intraocular lens implantation
Christopher D. Riemann, MD (Cincinnati, OH), Matthew F. Appenzeller, MD, Daniel M. Miller*, Michael R. Petersen, MD, PhD, Robert E. Foster, MD, Christine Hunt
PurPose To report the outcomes of a study cohort treated with a novel, sutureless, scleral fixated intraocular lens placement technique. MeTHoD Six eyes of 6 patients were included. Four eyes were aphakic and 2 eyes had a dislocated 3-piece IOL. A 25-g PPV was performed in all eyes. Dislocated IOLs were freed from residual lens capsule so that the haptics were accessible. A 20-g ciliary sulcus sclerotomy (CSS) was created 2 mm from the limbus at six and twelve oclock. A 23-g trochar blade was used to create a 3 mm partial thickness scleral tunnel into the opening of each CSS. For aphakic eyes, a foldable 3-piece IOL was inserted through the clear cornea. Dislocated IOLs were brought into the pupillary axis. A 25-g forceps was used to externalize each haptic via the CSS. The haptics were then placed into the 23-g tunnels. resulTs All eyes were followed for at least three months. At that time point, all eyes demonstrated well-positioned IOLs without evidence of decentration or dislocation. None of the intrascleral haptics became exposed or intruded. Five out of six eyes had uncomplicated postoperative courses. One eye with a dislocated IOL had a vitrectomy for epiretinal membrane prior to the lens repositioning procedure. This eye had documented CME both before and after the IOL was repositioned. The same eye also developed transient hypotony (IOP=6), which resolved spontaneously three weeks after the procedure. Visual acuity improved significantly in all eyes, as would be expected after treating their state of functional aphakia with the placement of a centered, sulcus based IOL. conclusion Sutureless scleral fixation appears to be a reasonable way to secure an IOL in the posterior chamber. This technique allows for efficient posterior chamber IOL placement and avoids the potential complications of anterior chamber IOLs, as well as the complication of scleral fixation sutures breaking after sutured scleral fixation techniques.
PurPose
To report the outcomes of combined transconjunctival sutureless pars plana vitrectomy and cataract surgery with toric intraocular lens implantation. A retrospective analysis of 46 consecutive eyes of 42 patients who underwent combined simultaneous small incision cataract surgery with toric intraocular lens implantation, and transconjunctival sutureless vitrectomy surgery from April 2007 to May 2010. Anatomic results, post operative uncorrected visual acuity, astigmatism, and rotational stability of the intraocular lens are evaluated.
MeTHoD
resulTs
Preoperative visual acuity was 0.33 0.16 LogMar and improved to 0.11 0.13 postoperatively (p < 0.000000001). Preoperative astigmatism was 1.75 1.0 diopters (range 0-3.75 diopters) and improved to 0.5 0.75 diopters (range 0-2.5 diopters) postoperatively (p < 0.000000001). Final measured postoperative IOL axis deviation from target axis was 5 6 degrees (range 0-32). Final IOL axis was within five degrees of target in 38 (83%) eyes, within 10 degrees of target in 42 (91%) eyes, and was within 15 degrees of target in 43 (93%) eyes. Toric lens implantation is reasonable for select patients undergoing combined cataract surgery and transconjunctival sutureless vitrectomy. As combined phaco-vitrectomy continues to increase in popularity, it is important for retinal surgeons to maintain standard of care from both the anterior and posterior segment perspective. This includes offering toric IOL implantation when appropriate.
conclusion
Pre and post operative visual acuity in 46 eyes undergoing combined CE/IOL and TSV with toric IOL implantation.
and chlorophyll were the best dyes to stain de ILM. Chlorophyll allows intensely staining (comparable with ICG, tested before in cadaveric eyes) in 25% of the eyes and moderately in 75% of the eyes. Cochineal stains intensely in 50% of the eyes, 37,5% moderately and 12.5% poorly. Light microscopic and ultra structural studies confirmed removal of the ILM in all cases.
conclusion
Natural vital dyes allow staining of the vitreous and ILM in human cadaveric eyes and may be a useful tool for vitreoretinal surgery. Cochineal was the best dye to stain the vitreous and ILM, following extract of haematoxylon campechianum and fustec wood for vitreous and chlorophyll for ILM.
Pre and post operative astigmatism in 46 eyes undergoing combined CE/IOL and TSV with toric IOL implantation.
5:04 pM
Posterior Hyaloid Detachment and Peeling of the internal limiting Membrane assisted by 10 Different natural vital Dyes: a Post-mortem Pilot study
Magno A. Ferreira, MD (Uberlandia, Brazil), Raquel Ferreira, Michel Farah, MD, PhD, Eduardo Rodrigues, MD, Acacio Filho, MD, Cristiane Peris, MD, Eber Ferreira, MD, Jane Chen, MD, Mauricio Maia
PurPose To determine whether natural dyes from the extract of ten different sources (pomegranate, haematoxylon campechianum, chlorophyll, cochineal, hibiscus, indigo, paprika, rosella, fustec wood and grape) stains and facilitates posterior hyaloid detachment and peeling of the retinal internal limiting membrane (ILM) in human eyes. MeTHoD Open sky vitrectomy including removal of the posterior hyaloid and ILM was performed in 80 cadaveric eyes. Ten different dyes were injected into the posterior vitreous cavity to promote hyaloid detachment and after this procedure each specific dye was injected to perform the ILM removal. The dyes were allowed to settle on the macula for 5 minutes and were then removed by mechanical aspiration. Peeling of the ILM was initiated and completed with intraocular forceps. Specimens were submitted to light and electron microscopy.
5:12 pM
Discussion
5:20-6:40 pM
Poster session and exhibit Hall Wine and cheese reception

6:00-8:00 pM
Bostons north end secrets, saints and sips crawl

Sponsored by the American Retina Foundation
The natural dyes were a useful tool to allow the posterior vitreous detachment and internal limiting membrane peeling. Extract of haematoxylon campechianum, cochineal and fustec wood allows posterior vitreous detachment in 100% of the cases. The results of posterior hyaloid detachment assisted by these vital dyes were comparable with posterior hyaloid detachment assisted by triamcinolone previously performed in such model for comparison purposes. Cochineal
resulTs
6:40 pM
free evening
6:45-8:30 pM
asrs new Member reception

5th Floor, Pool Deck
53
NOTES
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54
Tuesday, August 23
Tuesday, August 23
7:00-7:30 AM
conclusion

7:30-8:20 AM
Symposium 10: ocular oncology

Moderators: Tara A. McCannel, MD, PhD and Carol L. Shields, MD Related poster abstracts are on pages 186-188.
Based on previous studies, systemic metastasis from uveal melanoma occurs in 8% and 15% of patients at 3 and 5 years, respectively. The current results suggest that pars plana vitrectomy in eyes with treated posterior uveal melanoma does not increase the risk of metastasis. Additionally, there were no cases of local tumor recurrence.
7:38 AM
Plaque radiotherapy for Juxtapapillary, circumpapillary, and epipapillary choroidal Melanoma. analysis of 650 cases
Carol L. Shields, MD (Philadelphia, PA), Mandeep Sagoo, Arman Mashayekhi, MD, Lydia Komarnicky, Jerry A. Shields, MD, Linda Komarnicky, MD
7:30 AM
safety of Pars Plana vitrectomy in eyes with Treated Posterior uveal Melanoma
Alok S. Bansal, MD (Philadelphia, PA), Carlos Bianciotto, Joseph I. Maguire, MD*, Carl D. Regillo, MD, Jerry A. Shields, MD, Carol L. Shields, MD
PurPose Vitreous hemorrhage (VH) after treated choroidal melanoma can reduce visual acuity and can be treated with pars plana vitrectomy (PPV). There have been concerns regarding tumor dissemination with vitreous surgery. The purpose of this study is to determine the rates of systemic metastasis, local tumor recurrence, and enucleation in eyes with treated posterior uveal melanoma undergoing PPV for VH.
PurPose
To evaluate efficacy of plaque radiotherapy for juxtapapillary, circumpapillary, and epipapillary choroidal melanoma.
MeTHoD
Retrospective case review of 650 consecutive eyes with juxtapapillary, 37 with circumpapillary, and 141 with epipapillary choroidal melanoma.
Single-center, retrospective review of 45 cases of posterior uveal melanoma treated with plaque radiotherapy that subsequently underwent PPV for VH. Baseline patient information included patient age, tumor thickness, interval between tumor treatment and VH, and interval between VH and PPV. Main outcomes evaluated were systemic metastasis, local tumor recurrence, and enucleation at last follow up.
MeTHoD resulTs 45 eyes underwent PPV for VH after plaque radiotherapy for posterior uveal melanoma. At baseline, mean patient age was 58 years old (21-81 years), mean tumor thickness 4.9 mm (1.5-10.5 mm), mean interval between plaque therapy and VH was 21 months (1-81 mos.), and mean interval between VH and PPV was 17 months (0-126 mos.). The mean follow-up after PPV was 43 months (5-130 mos.). 3 of 45 eyes (7%) developed systemic metastasis with a mean time from PPV to metastasis of 37 months (5-71 mos.). In these 3 eyes, the mean time from plaque treatment to metastasis was 60 months (36-95 mos). No eyes developed local tumor recurrence after PPV. 5 of 45 eyes (11%) were enucleated with a mean time from PPV to enucleation of 9 months (3-21 mos.).
resulTs
Of 650 eyes with juxtapapillary melanoma, the median basal tumor diameter was 10 mm and thickness 4 mm. Kaplan-Meier estimates for tumor recurrence, metastasis, and death were 14%, 11%, and 4% at 5 years and 21%, 24%, and 9% at 10 years, respectively. Using multivariable analysis, factors predictive of tumor recurrence included foveolar involvement (relative risk (RR) 5.07, p<0.001) and greater tumor thickness (RR 1.29 per mm, p<0.001). The factor predictive of metastasis included greater tumor base (RR 1.21 per mm increase, p<0.001). Of 37 eyes with melanoma encircling the disc (circumpapillary), tumor recurrence, metastasis, and death were found in 14%, 4%, and 0% at mean 52 months follow up. Of 141 eyes with melanoma overhanging the disc (epipapillary), tumor recurrence, metastasis, and death were found in 10%, 13%, and 3% at mean follow up of 56 months. Patients with juxtapapillary, circumpapillary, and epipapillary choroidal melanoma face enucleation unless custom designed radiotherapy can be provided. Plaque radiotherapy provides tumor control in nearly 80% or more of affected patients at 10 years follow up. Melanoma-related death is approximately 9% or less for each group, mostly related to tumor size.
conclusion
55
10 ocular oncology 7:308:20 AM

7:46 AM
conclusion
sufficiency of fnaB aspirates of Posterior uveal Melanoma for cytodiagnosis vs. geP class and relative Prognostic significance of these Tests
Zelia M. Correa, MD, PhD (Cincinnati, OH), James J. Augsburger, MD, J. William Harbour, MD*
This study confirmed that GEP classification of posterior uveal melanoma cells obtained by FNAB is feasible in almost all cases, including most in which FNAB yields an insufficient aspirate for cytodiagnosis. The study also confirmed that GEP classification is substantially better than cytologic classification for predicting subsequent metastasis and metastatic death.
PurPose To determine the relative sufficiency of paired aspirates of posterior uveal melanomas obtained by fine needle aspiration biopsy (FNAB) for cytopathologic classification and gene expression profile (GEP) classification, and to determine the relative prognostic significance of these different classifications for predicting subsequent patient death from metastasis. MeTHoD Prospective non-randomized IRB-approved single center longitudinal clinical study of 159 patients with posterior uveal melanoma sampled by FNAB in at least two tumor sites at one center between 09/2007 and 12/2010. Cases were analyzed with regard to sufficiency of the obtained aspirates for cytopathologic classification and GEP classification. Cumulative actuarial survival curves of subgroups of these patients based on their cytopathologic versus GEP-assigned categories were computed by the Kaplan-Meier method. The endpoint for this survival analysis was death from metastatic uveal melanoma. resulTs FNAB yielded an insufficient aspirate for cytodiagnosis in 34 of 159 cases (21.4%). FNAB aspirates were insufficient for GEP in 1 of 159 cases (0.6%) (P < 0.001). Six of 34 cases (17.6%) with an insufficient aspirate for cytodiagnosis proved to be Class 2 tumors by GEP and 43 of 104 cases (34.7%) that yielded a sufficient aspirate for cytodiagnosis were Class 2 by GEP. Currently 11 of 49 Class 2 tumors (22.4%) but 2 of 109 Class 1 tumors (1.8%) developed metastasis. Eleven of 125 cases (8.2%) with a sufficient aspirate for cytodiagnosis while 2 of 34 cases (5.9%) with an insufficient aspirate for cytodiagnosis developed metastasis. Cumulative 3-year mortality from metastasis was 4.5% for those with an insufficient aspirate for cytology versus 21.4% for those with sufficient aspirates (log rank P = 0.39). Three year mortality from metastasis was 4.3% for the those with insufficient/unsatisfactory aspirate for GEP versus 35.2% for those with a sufficient aspirate (log rank P = 0.005).
Crosstabulation of method of testing versus sufficiency of FNAB aspirates of posterior uveal melanomas.
Three-year mortality rate from metastasis (n=159 patients) reflecting the prognostic significance of GEP classification of posterior uveal melanomas.
7:54 AM
8:02 AM
safety of fine needle aspiration Biopsy in choroidal Melanoma

Tara A. McCannel, MD, PhD* (Los Angeles, CA), Melinda Y. Wu, MD, Barry L. Burgess, MD
changing concepts regarding Management of orbital extension of uveal Melanoma

Jerry A. Shields, MD (Philadelphia, PA), Carol L. Shields, MD
PurPose The safety of FNAB in choroidal melanoma remains controversial. Orbital dissemination, local treatment failure, and an increased risk of metastatic spread have been speculated with FNAB but their true occurrence has not been reported. We sought to report on the local and systemic follow-up of patients undergoing transscleral FNAB with brachytherapy for treatment of choroidal melanoma. MeTHoD All patients with choroidal melanoma treated with iodine-125 brachytherapy and intraoperative FNAB from January 2005 to January 2010 with at least one year of clinical follow-up were included. Outcomes examined were endophthalmitis, orbital dissemination, local treatment failure, rhegmatogenous retinal detachment, monosomy 3 status, and choroidal melanoma metastasis. resulTs 175 patients with a follow-up interval of between 1 and 6 years (mean 2.7 years) were included. For tumors of height less than 3.0 mm, between 3.0 mm and 5.0 mm, and greater than 5.0 mm, sufficient biopsy material for FISH was obtained in 59%, 72%, and 91%, respectively. There was no case of postoperative endophthalmitis; no patient developed orbital dissemination; no patient developed local treatment failure; and 3 patients developed rhegmatogenous retinal detachment within one year of treatment. Fourteen patients developed metastasis. Of the 14, 8 had monosomy 3 of the primary tumor, 2 had disomy 3, 1 had trisomy 3, and 2 patients had insufficient material for FISH. The cumulative 5-year metastatic rate using a Kaplan-Meier plot was 12.3%. conclusion
PurPose
There is widespread belief that extraocular extension (EOE) of uveal melanoma requires orbital exenteration. However, it is now recognized that many patients with EOE already have subclinical distant metastases. Hence, orbital exenteration seems excessive and less aggressive treatment seems advisable in most cases.
MeTHoD
The authors developed a classification of EOE of uveal melanoma and surveyed 30 years experience with its management.
resulTs
Among >10,000 patients with uveal melanoma, EOE occurred in < 5%. EOE was classified according to size, location, and how and when it was detected. Treatment evolved over the years and varied, depending on the clinical situation. Small and medium sized EOE were managed by enucleation with localized conjunctivectomy / tenonectomy or plaque radiotherapy. Large or extra large anterior circumscribed EOE were managed by modified enucleation. Large or extra-large posterior circumscribed lesions were managed by modified enucleation via a lateral orbitotomy, lateral rectus muscle disinsertion, eye removal with long section of optic nerve, and hydroxyapatite implant. Large and extra large poorly circumscribed lesions were managed by eyelid-sparing orbital exenteration. Less than 5% of patients with EOE required orbital exenteration. Based on current knowledge of metastatic behavior, the method of treatment appeared to have no adverse effect on systemic prognosis. There are several options to orbital exenteration for EOE of uveal melanoma. More than 95% of patients are currently managed with methods other than orbital exenteration, thus preserving eyes and vision.
Transscleral FNAB with iodine-125 brachytherapy was found to be a safe procedure. The cumulative 5-year rate of metastasis was no greater than that reported by the Collaborative Ocular Melanoma Study (13% for medium-sized tumors). Rhegmatogenous retinal detachment may occur in young patients secondary to posterior vitreous detachment induced by tumor response to radiation, unrelated to FNAB.
conclusion
8:10 AM
Discussion
57
11 Macular DegeneraTion iii 8:2010:10 AM

8:20-10:10 AM 8:28 AM
Symposium 11: Macular Degeneration iii

Moderators: Carl C. Awh, MD and Trexler T. Topping, MD Related poster abstracts are on pages 83-98.
Treat and extend Dosing Has fewer submacular Hemorrhages and Better visual acuity in neovascular aMD Treated with ranibizumab compared to Prn Dosing
John H. Niffenegger, MD (Sarasota, FL), Keye L. Wong, MD
8:20 AM
results from the PDex and luceDex Prospective randomized Pilot studies for eyes with neovascular aMD
PurPose
Tushar M. Ranchod, MD (Walnut Creek, CA), Subhransu K. Ray, MD, PhD, Stewart A. Daniels, MD, Craig J. Leong, MD, Daniel Ting, MD, PhD, Allen Z. Verne, MD
This retrospective study investigated the frequency of submacular hemorrhage in eyes treated with ranibizumab when given Treat and Extend dosing compared with PRN dosing (treatment as needed). Secondary outcomes were the effect of hemorrhage and dosing on visual acuity, the average number of examinations and injections, and the occurrence complications. In this consecutive retrospective case series all patients age 50 years or older with a diagnosis of neovascular age-related macular degeneration (AMD) and treatment in 2008 with ranibizumab were identified. Eyes with active primary or recurrent neovascular AMD were reviewed. In Treat and Extend, the interval of treatment was increased one to two weeks if the eye was dry on OCT, there was no new blood and no visual acuity loss. In PRN, treatment was given if there was evidence of progression, fluid, hemorrhage or drop in vision. Treat and Extend was compared to PRN dosing. Snellen Acuity was converted to LogMAR for analysis. Eyes given combination treatment were excluded.
The PDex study compared monthly intravitreal ranibizumab to triple therapy utilizing intravitreal ranibizumab, reduced-fluence photodynamic therapy (PDT) and intravitreal dexamethasone. The LuceDex study compared intravitreal ranibizumab to combination therapy employing intravitreal ranibizumab and intravitreal dexamethasone.
PurPose MeTHoD PDex subjects were randomized between triple therapy with reduced-fluence PDT, ranibizumab and dexamethasone (Group I, therapy repeated on indication) and ranibizumab monotherapy (Group II, 12 monthly injections). LuceDex subjects were randomized between combination therapy with intravitreal ranibizumab and dexamethasone (Group I) and intravitreal ranibizumab monotherapy (Group II). All study eyes received four monthly treatments followed by monthly treatment on indication. Primary outcomes in both studies were safety and ETDRS best-refracted visual acuity. resulTs A total of 60 patients were enrolled in the PDex study and 40 patients in the LuceDex study. In the PDex study, eyes gained an average of 8.7 and 8.9 ETDRS letters in Groups I and II respectively at month 12. No more than zero ETDRS letters were lost in 77% of Group I eyes and 71% of Group II eyes. Group I patients received an average of only 3.4 treatments by Month 12, compared to the 12 treatments for Group II.
MeTHoD
resulTs
462 patients were identified (average follow-up 1.9 years). Submacular hemorrhage was less frequent in the Treat and Extend eyes (2.6%) compared to PRN (6.7%) at year one and at year 2 (2.9% and 11.8% respectively). Average visual acuity was less affected by submacular hemorrhage in the Treat and Extend eyes compared the PRN eyes. The 5 Treat and Extend eyes suffering hemorrhage in year 2 were stable at 2 years follow-up compared to baseline. The 20 PRN eyes developing a hemorrhage in year 2 lost 1.9 lines on average. Treat and Extend nave eyes had greater improvement in average visual acuity (2.6 lines) compared to PRN (1.1 lines). The mean number of examinations was greater in Treat and Extend eyes (7.7) compared to the PRN eyes (5.6) in year 2. Treatment was more frequent in the Treat and Extend eyes in the second year with 7.4 treatments compared 2.8 in the PRN eyes. Endophthalmitis occurred in 0.88 cases per 1000 injections per year. One eye had a retinal break.
In the LuceDex study, eyes gained an average of 11.1 and 5.9 ETDRS letters in Groups I and II respectively at month 12 (p<0.23). No more than zero ETDRS letters were lost in 88% of Group I eyes and 70% of Group II eyes. The average number of treatments per study eye by Month 12 was 7.1 in Group I and 6.6 in Group II. None of the Group I vs. Group II outcomes reached statistical significance for either study.
conclusion PDex and LuceDex demonstrated safety and noninferiority of combination therapies compared to ranibizumab monotherapy. The PDex study demonstrated non-inferiority in visual and anatomical outcomes utilizing triple therapy with a reduction in total treatments. The LuceDex study suggested that serial intravitreal dexamethasone injections may be safe with a trend towards better visual outcomes.
conclusion
Treat and Extend dosing yielded fewer submacular hemorrhages and better visual acuity results in eyes with neovascular AMD treated with ranibizumab compared to eyes given PRN dosing. Complications of endophthalmitis and retinal break were rare.
8:36 AM
8:44 AM
alternating Bi-monthly intravitreal ranibizumab and Bevacizumab for refractory exudative aMD
Andre J. Witkin, MD (Phildelphia, PA), Sunir J. Garg, MD*, Joseph I. Maguire, MD*, Richard S. Kaiser, MD*, Jason Hsu, MD, James F. Vander, MD, Allen Ho, MD*
Discussion
8:50 AM
vitreomacular adhesion is not a further risk factor for aMD

Emilia Maggio, MD (Negrar, Italy), Antonio Polito, MD, Andrea Giani, Barbara Parolini, MD, Grazia Pertile, MD
PurPose PurPose To describe visual acuity and optical coherence tomography (OCT) results of an eight week series of alternating bi-monthly ranibizumab/bevacizumab intravitreal injections in patients with refractory exudative age-related macular degeneration (AMD) MeTHoD Study Design: Retrospective interventional case series. Patients included had exudative AMD with no change in visual acuity along with persistent macular fluid despite at least 6 monthly injections of either ranibizumab or bevacizumab. These patients started receiving bi-monthly alternating ranibizumab/ bevacizumab intravitreal injections; four injections were given over 8 weeks in all patients. Snellen visual acuity (converted to logMAR), central foveal thickness, and central foveal choroidal neovascular (CNV) thicknesses were recorded at each visit. resulTs Nineteen eyes of 19 patients were included in the study. Patients had previously received a mean of 22 (range 11 to 41) intravitreal injections of anti-VEGF medications. At enrollment, mean visual acuity was logMAR 0.642 (Snellen 20/88), mean central foveal thickness was 186 m, and mean central foveal CNV thickness was 448 m. After 8 weeks of bimonthly anti-VEGF injections, mean visual acuity significantly improved to logMAR 0.505 (Snellen 20/64) (p = 0.001). Mean central foveal thickness decreased to 164 m (p = 0.08), and mean central foveal CNV thickness significantly decreased to 378 m (p = 0.02). conclusion An eight week series of bi-monthly intravitreal anti-VEGF therapy in patients who have no visual acuity improvement with the standard monthly regimen can improve visual acuity, and this regimen should be considered for patients with refractory exudative AMD.
To evaluate the role of abnormal and persistent vitreomacular adhesion (VMA) in the pathogenesis of age-related macular degeneration (AMD) and in the response to antivascular endothelial growth factor (anti-VEGF) therapy.
MeTHoD
A total of 200 eyes with neovascular AMD, 198 with nonexudative AMD and 203 included as control group were examined with Spectral Domain scanning laser ophthalmoscope and optical coherence tomography. All patients were studied to identify the presence of VMA. Main outcome measures were the number of eyes with posterior vitreous detachment (PVD), vitreomacular traction (VMT), and persistent vitreomacular adhesion to the macula with a nontractional configuration (VMANT). Together the VMANT and VMT subgroups formed the VMA group. Characteristics of the vitreoretinal interface in eyes affected by neovascular AMD exhibiting a resistance to therapy with anti-VEGF were carefully evaluated.
resulTs
VMA was present in 59 (29,5 %) eyes with neovascular AMD, 52 (26,2%) with nonexudative AMD and in 66 (32,5 %) control eyes. VMT was present in 6 (3 %) eyes with neovascular AMD, 5 (2,5%) with nonexudative AMD and in 7 (3,4 %) control eyes. In the group affected by neovascular AMD, eyes with VMA have not been found to have a different response to anti-VEGF therapy.
conclusion
Eyes with AMD do not exhibit a higher prevalence of vitreoretinal interface abnormalities compared to elder normal eyes. The results of the study suggest that persistent VMA may not have a role in the pathogenesis of neovascular AMD nor in the resistance to anti-VEGF therapy. Surgically induced PVD is not a sufficiently supported strategy for the treatment of the disease.
OCT images from patient #13. Images are from time of enrollment, and from 1 and 2 months after starting bi-weekly injections. All images are horizontal images through the fovea, taken with the Zeiss Cirrus SDOCT. Note complete resolution after 2 months of hyporeflective fluid causing a large pigment epithelial detachment at the time of enrollment.
59

8:58 AM
simple estimation of clinically-relevant lesion volumes using sD-ocT in neovascular aMD

Alexander C. Walsh, MD* (Los Angeles, CA), Yanling Ouyang, Srinivas R. Sadda, MD*, Florian Heussen
PurPose To evaluate simple methods of estimating the volume of clinically-relevant features such as cystoid macular edema (CME), subretinal fluid (SRF) and pigment epithelial detachments (PED) using spectral domain OCT (SD-OCT) in neovascular AMD (NVAMD). MeTHoD Cases with CME, SRF or PEDs were randomly selected from a database of NVAMD patients imaged with macular cube SD-OCT scans over a 3 year period. A cross-sectional analysis was performed for single visits while patients with 3 or more follow-up visits were analyzed in a longitudinal analysis (LA) group. The volume of each feature (CME, SRF, PED) was measured by manually outlining them on OCT B-scans using custom software. Simplified measurements were made by estimating the maximum height of each feature as well as the # of B-scans and A-scans involved by each feature. The manually-measured volumes were correlated with the simplified measures and automated measurements from the OCT machines. resulTs A total of forty-five visits for 25 patients were included in this study. The CSA group was comprised of 26 scans from 26 eyes of 25 patients and the LA group had 24 scans from 5 eyes of 5 patients. Table 1 shows the correlations between manual grading and the simplified and automated measurements. In the CSA group, the single simplified measures that correlated best with manual grading were maximum lesion height for CME and SRF(r2 values of 0.95 and 0.86) and Bscan count for PED volume (r2 value =0.79). In the LA group, B-scan count correlated well with SRF volume (r2=0.97) while maximum height correlated with CME and PED volume (r2=0.98 and 0.43 respectively). The sensitivity and specificity for detection of changes in these features was also much higher for simplified measures than for the automated measurements produced by the OCT machines (Table 2). conclusion These data suggest that simplified estimators of SRF, CME and PED volumes from SD-OCT images exist in cases of NVAMD and are accessible for use by clinicians without the need for specialized software or time-consuming manual segmentation. These simple approaches could enhance quantitative disease monitoring strategies in clinical trials and clinical management of patients being treated for NVAMD.
Table 1: Correlation between manual volumetric grading and both simplified and automated measurements for both the CSA and LA groups. Correlations shown are r-squared values.
Table 2. Sensitivity and specificity values for detection of changes in SRF and CME values using simplified measurements (left half) and automated measurements (FCS and MV shown in right half).
9:06 AM
Pearl study: continuous Monthly ranibizumab injections for Polypoidal choroidal vasculopathy with active exudation or Bleeding (1 year results)
Raymond Wee, MD (Aiea, HI), Gregg T. Kokame, MD*, MMM, James C. Lai, MD, Ling Yeung, MD, Kyla Teramoto, MD
PurPose
What is the short-term efficacy and safety of monthly intravitreal injections of ranibizumab in patients with polypoidal choroidal vasculopathy?
MeTHoD
Prospective, open-label trial of monthly intravitreal ranibizumab (0.5 mg) injections for PCV in 13 eyes of 13 patients. Primary outcome measure was stabilization of vision (<15 ETDRS letters lost) after 12 monhs. Secondary outcome measures included incidence of ocular and systemic adverse events, and changes in subretinal hemorrhage, central foveal thickness, and polypoidal complexes on ICG angiography after 12 months.
resulTs Mean VA at baseline was Snellen 20/100 with a median Snellen 20/80. Baseline findings included 9/13 eyes wih subretinal fluid (69%), 6/13 eyes with RPED (46%), and 7/13 eyes with subretinal exudates (54%). 5/13 eyes (38%) presented with significant macular edema, as defined as central foveal thickness on OCT greater than 250 microns. No patient lost >15 letters at 6 or 12 months. Mean VA at 12 months was Snellen 20/63 with a median of Snellen 20/63. 3/13 eyes (23%) gained 15 letters, 11/13 eyes (85%) gained 5 or more letters, 1/13 eyes (8%) remained unchanged, and 1/13 eyes (8%) lost <5 letters. Subretinal fluid decreased in 2/9 eyes (22%), resolved in 4/9 eyes (44%) and increased in 3/9 eyes (33%). Subretinal hemorrhage resolved in 9/9 eyes (100%). Polypoidal complexes decreased in 5/13 eyes (38%), remained unchanged in 4/13 eyes (31%), and increased in 4/13 eyes (31%).
13 (77%) became inactive after an average of 9.4 months following additional retreatment. For all patients, mean best visual acuity of 20/70 improved to 20/60. Overall, 91% of all patients had an improvement or stabilization in vision. Mean central OCT thickness decreased from 290 80um to 220 55um in all patients (p<0.001). There were no complications related to injections or laser treatments.
conclusion
RAPTraP treatment appears to offer long term anatomic and visual stability utilizing a less intrusive, nonrepetitive and more cost effective method of treating RAP. Our results suggest additional controlled studies are warranted to further evaluate this new technique
9:22 AM
Continuous monthly intravitreal ranibizumab is safe and well tolerated in eyes with PCV. Twelve month results show stabilization of vision, complete resolution of subretinal hemorrhage, and resolution of macular edema. Polypoidal lesions decreased in 5/13 (38%) eyes, but branching choroidal vessels persisted. Further investigation with high-dose ranibizumab or combination with PDT is indicated.
conclusion
Discussion
9:30 AM
intravitreal Tnf-alpha inhibitors for refractory neovascular aMD: a Pilot study from the Pan american collaborative retina study (Pacores) group
Lihteh Wu, MD (San Jose, Costa Rica), J. Fernando Arevalo, MD, Erick Hernandez-Bogantes, Caio V.S. Regatieri, Jose A. Roca, MD, Michel Eid Farah, MD, PhD
9:14 AM
raPTraP: reduction by intravitreal Bevacizumab Preceding Thermal laser Photocoagulation for retinal angiomatous Proliferation
PurPose
Susan M. Malinowski, MD (Southfield, MI), Felise M. Barte, MD, Michael D. Ober, MD*
To report the short term visual and anatomic outcomes following intravitreal injections of 2 different tissue necrosis factor (TNF) inhibitors in eyes with choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD) refractory to anti-VEGF agents.
MeTHoD
To report our experience with the RAPTraP protocol (Reduction by intravitreal bevacizumab preceding thermal laser photocoagulation) for the treatment of retinal angiomatous proliferation (RAP).
PurPose MeTHoD This is a retrospective analysis of vision and anatomic responses of patients with newly diagnosed, untreated RAP treated with RAPTraP therapy a novel combination of one intravitreal bevacizumab injection followed by one session of laser photocoagulation. A bevacizumab injection (1.25mg) was given within 2 weeks of diagnosis. Imaging was repeated within 3 weeks after injection and thermal laser was applied. All patients had a minimum 1year follow up. resulTs Thirty three lesions of 26 patients received one RAPTraP treatment. Intravitreal bevacizumab was given an average of 8.8 days (range: 0-41d) following initial diagnosis. Laser ablation was performed an average of 3.4 weeks (range: 1.7-8weeks) following bevacizumab injection. Average follow up was 20.3 months (12.2mo-44mo). Twenty lesions (60%) remained inactive with only a single treatment. Thirteen lesions recurred after an average of 10.7 months. Ten of the
A multicenter retrospective interventional case series of 20 eyes with refractory CNV that were injected with adalimumab (n=4 for 2 mg) or infliximab (n=8 for 1 mg; n=8 for 2 mg). The main outcome measures were the best corrected visual acuity (BCVA) and the central macular thickness (CMT) at 3 months of follow-up.
resulTs
The mean log MAR BCVA changed from 1.04 0.23 at baseline to 1.06 0.51 at 3 months (p=0.9375) in the 1mg infliximab group; 0.94 0.48 at baseline to 0.85 0.43 in the 2 mg infliximab group (p=0.4375) and 1.58 0.50 at baseline to 1.38 0.43 in the adalimumab group (p=0.500). The mean CMT changed from 387 54 m at baseline to 342 108 m (p=0.2898) in the 1mg infliximab group; 301 42 m at baseline to 284 73 m (p=0.7548) in the 2 mg infliximab group and remained unchanged at 348 106 m (p=0.308) in the adalimumab group. Adverse events included uveitis in 37.5% (6/16) of eyes injected with infliximab. Intravitreal infliximab and adalimumab do not appear to benefit eyes with refractory CNV secondary to AMD. Intravitreal injections of infliximab may elicit a severe intraocular inflammatory reaction.
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conclusion

9:38 AM 9:46 AM
new Developments in information Display Technology and reading Performance in Patients with aMD
Mark S. Blumenkranz, MD (Palo Alto, CA), Anne E. Fung, MD, Daniel Palanker, Neil Friedman, MD, Patrick Coady, MD
The use of a flash recovery Testing Device to Differentiate Between Patients With or Without Macular Disease
Daniel B. Roth, MD* (Lakewood, NJ), Anmol Gupta, MD, Ankit Shah, MD, Howard F. Fine, MD, Jonathan L. Prenner, MD*, William J. Feuer
PurPose There is a need to quantify the effects of macular disease on reading performance, compared to conventional printed materials. We studied the relationship between standard ETDRS visual acuity (VA) and various other tests of near visual function with standard printed materials and compared them with a specialized back-illuminated liquid crystal display (LCD) in patients with macular disease. MeTHoD Thirty consecutive patients with macular disease and vision better than 20/400 and 20 normal controls were recruited. Their distance visual acuity was measured in both eyes with ETDRS letter charts at 4 meters. Near vision was measured with both a Rosenbaum Card and a specially programmed vision test on an iPhone at a distance of 14. Both near vision tests were performed using the patients current correction. Statistical methods were employed to compare various measures of visual function. resulTs Distance vision correlated with the near card at the level r=0.83, and the LCD near screen displaying black fonts on white background correlated well (r=0.89) with the printed card. In evaluating the accuracy of the backlit near test, 45% of eyes were within 0.1 LogMar and 70% of eyes within 0.2 LogMar of the distance vision measured by ETDRS chart. The near test overestimated in all eyes outside 0.2 LogMar of the ETDRS chart. Reading inverted letters (white letters on black screen) on the LCD screen provided results closer to the ETDRS chart - (55% within 0.1 LogMar and 76% within 0.2 LogMar). Decreases in contrast sensitivity at near were detected in eyes with more advanced macular disease, particularly those with less than 20/40, with changes of dark letters on light background being more discriminant than light letters on black background. In addition, there was a tendency for decreased VA with blue fonts, compared to red fonts. conclusion Measurement of near visual acuity appears to be a viable alternative or supplement to ETDRS distance vision in patients with macular disease. The psycho-physics of computer screens may be impactful in assessing treatment outcomes and in optimizing digital reading devices. More frequent testing may facilitate greater individualization of treatment regimens with anti VEGF agents.
PurPose
Flash recovery testing is a semi-objective test for macular function, as macular disease can prolong recovery time. A novel hand-held device, named the macular adaptometer, was used to determine whether flash recovery testing can provide a useful indicator of macular health and disease.
MeTHoD
Flash recovery testing after a bright flash was performed on 481 eyes in 275 patients. Information regarding visual acuity, intraocular pressure, ocular diagnosis, medical history, history of glaucoma or retinal detachment, smoking and alcohol use, use of eyedrops, use of glasses for distance, difficulty with dark adaptation, was also collected. Linear regression analyses were performed to determine statistically significant correlations between recovery time and variables such as age, visual acuity, and IOP. One-sided t-test was used to determine whether any of the variables or diseased states was associated with a statistically significant prolonged recovery time.
resulTs
Normal subjects mean recovery time was 9.8 seconds (5.8 SD). After controlling for visual acuity, subjects with dry AMD (n=67) had a mean recovery time of 15.4 seconds ( 11.9 SD) and subjects with wet AMD (n=63) had a mean recovery time of 20.6 seconds (12.3 SD), which was significantly different than normal (p<0.001). Other diagnoses associated with lengthened recovery times included proliferative diabetic retinopathy (p=.015), diabetic macular edema (p=.032), cystoid macular edema (p=.022), and epiretinal membrane (p=.020). Drusen alone or nonproliferative diabetic retinopathy did not prolong recovery times (p>0.05). Statistically significant correlations were observed between recovery time and age (r=0.27, p<0.001), logMAR visual acuity (r=.030, p<0.001), and logMAR near visual acuity (r=0.37, p<0.001). Among medical and eye history variables, only COPD appeared to be associated with a longer recovery time (p=.017). Flash recovery testing with the macular adaptometer may be an effective and inexpensive method to identify patients with macular disease in a primary care setting, by screening for a prolonged recovery time after a bright flash.
conclusion
9:54 AM
10:02 AM
a community-based survey of genetic risk for advanced aMD: implications for sight-preserving Practice guidelines
Carl C. Awh, MD (Nashville, TN)
Discussion
10:10-10:35 AM

PurPose The genetic risk for AMD measured in a large group of retina and general eye care patients may differ from that known for the general population. If these differences correlate with clinical staging, it may provide further support for the use of genetic testing to better identify patients at risk and to guide individual management strategies. MeTHoD Retrospective review of 1074 pts tested from 10/2010 to 02/2011 (final results will be include additional 1000+ pts) with MaculaRisk obtained from retina, and general eye care practices. All were age > 65 and signed informed consent. We surveyed validated genetic risk factors. These included Complement Factor H haplotype markers(1) (rs1048663, rs412852, rs3766405, rs11582939, rs1066420), the ARMS2 insertion/deletion polymorphism(2) NM_001099667.1: c.**372_815del443ins54), the mitochondrial A4917G polymorphism(3) (rs28357980), complement factor 3(4) (rs2230199) and hx of smoking(5). Genotype and smoking hx were used to stratify patients into one of 5 risk categories. resulTs Individuals were Caucasian (92%), African American (3.8%), Asian (0.5%) and Latino (2.6%). Clinical distribution was: AREDS cat 1 (4.4%), AREDS cat 2 (66%), AREDS category 3 (21%), AREDS category 4a, 4b (6.6%), and unknown (2.1%). Smoking history was: never (55%), quit (37%), and current (8%). Using an algorithm to stratify observed genetic AMD risk we compared this to predicted population average genetic risk based on the known frequency of risk alleles in populations of northern European ancestry using HapMap frequency data. There was a displacement of risk scores toward higher levels in our study set. Only 37% of our population fell into the lowest 50% of populationpredicted risk (a reduction of 26%) and 31.8% of study individual fell into the highest 20% of predicted risk (a 66.5% increase). Among individuals with AREDS cat 3 and 4 AMD, the average genetic risk exceeded average population risk, although some individuals were found to have lower than average genetic risk. conclusion Although individuals with advanced AMD may have variable degrees of genetic risk, the average genetic risk for this group of patients is higher than normal. The ability to correlate clinical findings with genetic risk for advanced AMD may lead to individualized management strategies and an overall reduction in vision loss.
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12 viTreoreTinal surgery iii 10:35 AM12:00 PM

10:35 AM-12:00 pM
conclusion
Symposium 12: vitreoretinal Surgery iii

Moderators: G. Philip Matthews, MD and Paul E. Tornambe, MD Related poster abstracts are on pages 119-150.
Dealing with the modified cutters we achieved a small gauge vitrectome with a greater suction power but a similar safety in comparison with the standard models. However, whether improved performance characteristics will result in improved clinical results , will require additional study and clinical correlation.
10:35 AM
10:43 AM
Performance of a Modified vitrectomy Probe in small gauge (g) vitrectomy: an experimental and clinical study
Stanislao Rizzo, MD (Pisa, Italy), Michele Palla, MD, Federica Genovesi-Ebert, MD, Gualtiero Fantoni, MD, Jonathan Ciampi, MD, Giovanni Vozzi, MD
a new Dual Port vitreous cutter for vitrectomy surgery

Luiz H. Lima, MD (Sau Paulo, Brazil), Charles DeBoer, Prashant Bhadri, MD, Matthew McCormick, MD, Ralph Kerns, MD, Mark S. Humayun, MD, PhD*
PurPose PurPose 25 and 23 gauge new generation vitrectors of 2 major factories have been modified in order to improve their effectiveness The performance of all modified probes were compared in vitro and in vivo with the corresponding commercially available ones. The study was performed in collaboration with the Engineering Department of Pisa University without any commercial research support. MeTHoD Changes carried out concerned only the cutters, machines and softwares were not involved. In the experimental study main outcome measures were evaluation of flow/minute and probe strength. Vitrectomy systems were set at fixed parameters (5000 cuts/min, 650-600 mmHg vacuum) and every pair of probes (standard vs modified) were compare analyzing: time taken to aspire 10 cc of BSS. To test strength, cutters were inspected under the microscope, after 120 minutes of work. to check wear and tear. Clinically, we compared standard and modified 25 an 23 gauge cutters during vitreoretinal surgery (40 cases) by evaluating vitrectomy time, and incidence of complications. resulTs In vitro all modified cutters showed a significant increase of the flow/min in comparison with the standard probes. Both in modified 23 and 25 gauge probes the aspiration time of 10 cc of BSS were significantly reduced in comparison with standard ones, about 50% less dealing with both the brands. Standard 23 gauge needed 44 seconds (sec) vs modified 23-g 25 sec (P<.0001). Standard 25 gauge took 70 seconds (sec) vs modified 25-g 44 sec (P<.0001).No damage to the probes was shown. In vivo we evaluated during the surgery vitrectomy times that were respectively: with standard 25 g (10 cases) 764 seconds 200 vs modified 25.g (10 cases) 512 190; with Standard 23 g (10 cases): 711 seconds 230 vs modified 23.g (10 cases) 490 190. No intraoperative complications occurred in both groups.
To evaluate and compare the performance of several designs of dual port (DP) vitreous cutter tips with a standard single port (SP) tip.
MeTHoD
In a pilot study, five designed and fabricated 20-gauge pneumatic vitreous DP cutter tips with different sizes and port positions (180 degrees 0.0125 DP, same-side up 0.020 DP, 180 degrees 0.024 DP, 180 degrees up 0.020 DP, and 180 degrees 0.020 DP) were compared with a normal SP control tip and evaluated by the measurement of water and porcine vitreous flow rates, and surgical examination in enucleated porcine eyes. With each cutter, five trials were performed at 1,500 cuts per minute (CPM) at vacuum levels of 100, 200, 300, 400, and 550 mmHg. For instruments tested in water at 1,500 CPM, the 180 degrees 0.024 DP, 180 degrees 0.020 DP, 180 degrees 0.0125 DP, 180 degrees up 0.020, and same-side up 0.020 DP tips had higher flow rates than those of the 180 degrees 0.016 DP, 180 degrees 0.006 DP, and SP tips at 1,500 CPM for all tested vacuum levels (P<0.05). For vitreous flow rate performed at 1,500 CPM, the 180 degrees 0.024 DP tip had the best performance at vacuum levels of 100, 200, 300, and 400 mmHg, and the 180 degrees 0.020 DP tip had the highest vitreous flow at 550 mmHg of vacuum (P<0.05). The 180 degrees 0.006 DP and same-side up 0.020 DP tips had the lowest vitreous flow rates at all vacuum levels (P<0.05). With reference to surgical evaluation, most of surgeons (90%) classified the 180 degrees 0.020 DP and 180 degrees 0.024 DP tips as better than SP tip for bulk vitreous removal. The SP tip was considered by all surgeons to perform better than the DP tips for shaving the vitreous base. The DP cutter system has the potential to increase the flow rates depending on the size and position of the extra port. In the future, the DP cutter may allow the surgeon to perform bulk vitrectomy more efficiently.
resulTs
conclusion
resulTs
The five study tips along with a control tip.
No difficulty with completion of surgery was encountered using either system. The average time of vitrectomy was 32.6 minutes for the (V) group and 32.9 minutes for the (P) group. Five (5) inadvertent intra-operative retinal breaks occurred in the (V) group (0.25breaks/case) and three (3) inadvertent intra-operative breaks occurred in the (P) group (0.187 breaks/case). The use of hand instruments was required in both groups, but only for membrane peeling in macula cases. Dissection of fibrovascular tissue was successfully accomplished in both groups using the vitrectomy handpiece alone. However, the cutter speed was able to be greatly reduced in the (P) group (1000cpm) without causing an inadvertent break or a subjective change in the retinal mobility. No attempt was made to reduce the cutter speed using the (V) system, because of retinal stability due to flow concerns. Post-operative complications occurred in 3 of 20 eyes in the (V) group and 2 of 16 eyes in the (P) group. Both vitrectomy systems provide for the performance of safe retinal surgery. There was no statistical difference noted in operative time, retinal tears or postoperative complications. The peristaltic (P) group allowed for a greater range of cut rates without an increase in complications. The peristaltic system may allow for greater utility and flexibility and warrants further investigation.
conclusion
10:59 AM
Vitreous flow rates of the tested DP and SP tips operated at 1,500 CPM and various vacuum pressures with a 20-gauge Accurus handpiece. Each bar represents five trials performed for that cutter tip.
slow Motion videography analysis of Pars Plana lensectomy

Kirk H. Packo, MD* (Chicago, IL), David Buboltz, Dina Joy K. Abulon, Aditi Ray, MD
10:51 AM
flow-controlled vitrectomy
Keith A. Warren, MD* (Overland Park, KS)
PurPose
PurPose
To determine the safety and efficacy of flow-controlled vitrectomy surgery compared to standard vacuum based vitrectomy.
Both ultrasonic fragmentation and vitrectomy probe lens removal begin by aspiration of lens to the port, followed by either cavitation or sectioning into small pieces. Flow decreases but surges occur when the port is not occluded (occlusion break). Dangerous swings in intraocular pressure (IOP) and flow can occur. This study compares the maneuvers with suggestions for the safest parameters.
MeTHoD
: Thirty-six consecutive eyes (36) with a wide variety of retinal pathology underwent surgery using either a venturi vacuum based (V) or peristaltic pump based (P) vitrectomy unit. Twenty (20) patients had surgery using the venturi vacuum system (V) (ALCON), and sixteen (16) patients had surgery using a peristaltic pump system (P) (DORC). All patients were pretreated with a fourth generation flouroquinolone and then underwent the standard three port vitrectomy. Patients were followed for a minimum of six (6) weeks and outcomes evaluated included: Length of surgery, incidence of retina breaks, need for hand-held instruments and complications.
MeTHoD
Pig eyes were microwaved to create cortical cataracts. Following vitrectomy, the cataract was dislocated with either 23 ga or 25+ ga UltraVit vitrectomy probes from the Constellation Vision System (Alcon Surgical, Ft. Worth, TX). Transducers and flow sensors measured IOP and flow rates. Lensectomies were performed with 20 ga ultrasonic fragmentors (frag) at various powers, vacuums, and pulse modes, or with 23 ga and 25+ ga vitrectomy probes at various vacuums and cut rates. Slow motion videography using the Phantom v210 high speed digital camera (Vision Research, Inc., Wayne, NJ) at 1000 fps was synchronized with the fluidic data, and analyzed during the occlusion break (OB).
65
12 viTreoreTinal surgery iii 10:35 AM12:00 PM

resulTs When lens material occludes the port of any instrument (frag or vit probe), the flow consistently decreases while IOP rises. When lens material no longer occludes the port (during OB), flow into the port quickly rises and IOP drops. The maximum IOP swing seen during OB was 55 mm Hg. Swings in IOP & flow were the greatest using the frag, and least with the 25+ vit probe. More stable IOP and flow is consistently seen using vit probes compared to the frag. High cut rates provided the most stable fluidics, while still allowing easy lens removal. Low cut rates were not needed, and in fact gave greater fluid surges and IOP swings with each OB. The acoustic wave emanating from the frag was also recorded while inducing cavitation in gelatin cubes and seen to move forward from the tip but also laterally from the shaft. This contributes to material being shattered forward, away from the frag tip during operation. conclusion
11:07 AM
Discussion
11:15 AM
The current role of scissors in Diabetic Traction retinal Detachment surgery

Steve T. Charles, MD* (Memphis, TN)
PurPose
In contrast to removing vitreous, removing lens material results in large swings in flow and IOP, with more unstable fluidics. 20 ga frag removal can give dangerous surges in fluid following the occlusion break. Removal of lens material with small gauge vitrectomy probes allows more fluidic stability. Changing to low cut rates for lens is not needed, and creates greater fluid surges.
Many anecdotal reports have suggested that higher cutting rates (5000 cuts/minute), ports closer to the tip, smaller diameter cutters (25 gauge) and technique evolution have eliminated the need for scissors in diabetic traction retinal detachment surgery. The purpose of this study was to determine if scissors are still necessary and if so the optimal scissors configuration and technique. Observational, single surgeon series encompassing 35 years of diabetic traction retinal surgery (2000 total cases), eight years (400 cases) using 25 gauge sutureless surgery (Alcon Accurus, later Constellation vitrectomy system), 15 years exclusively using curved scissors (Alcon 25 gauge DSP) instead of horizontal or vertical scissors and 15 years of using endophotocoagulation instead of diathermy for hemostasis.
MeTHoD
resulTs
Laboratory set up for porcine vitrectomy-lensectomy with continuous IOP and flow data using LabView digital recorders, synchronized with Phantom high speed videography at 1,000 frames per second (fps).
foldback cutter delamination and cutter segmentation between epicenters was effective for non-tabletop TRDs with less rigid epiretinal membrane (ERM), 2. conformal cutter delamination was necessary for rigid ERM, 3. delamination with curved 25G scissors was the best approach for tabletop TRDs, especially with rigid ERM combined with thin, atrophic retina. Curved scissors were found to be more effective than vertical or horizontal scissors for both segmentation and delamination because they conformed to the curvature of the retina and blade thickness is less than blade width making insertion in the potential space between ERM and retina safer. Higher cutting rates (5000 cuts/minute), ports closer to the tip, and smaller diameter cutters (25 gauge) have reduced the need for scissors in diabetic TRD surgery but scissors are required for most tabletop TRDs. It was found that curved scissors were more effective than vertical or horizontal and endophotocoagulation was better than diathermy for hemostasis.
conclusion
Still capture images of 20 fragmentor, 25 ga Ultravit vitrectomy probe and 23 ga Ultravit vitrectomy probe at the point of the occlusion break (when lens material no longer occludes the port).
11:23 AM
11:31 AM
Does suturing of 23-gauge sclerotomies reduce Post-operative vitreous Hemorrhage in Diabetic vitrectomy?
G. Baker Hubbard, MD (Atlanta, GA), Leon O. Charkoudian, MD
Discussion
11:35 AM
Panel Discussion: Management of surgical complications: a Bad Day in the or i Wish i Had stayed in Bed
Moderator: Kirk H. Packo, MD* Panelists: Mark S. Blumenkranz, MD, Steve T. Charles, MD, Dean Eliott, MD, and G. Baker Hubbard, III, MD
To determine if suturing 23-gauge sclerotomies reduces the rate of significant post-operative VH in diabetic patients. To explore associations between post-operative VH and other variables including pre-operative bevacizumab use, intraoperative membrane dissection, post-operative hypotony, and surgeon.
PurPose
12:00-1:20 pM

12:00-5:30 pM
Retrospective chart review. All patients undergoing 23-gauge vitrectomy at The Emory Eye Center for PDR were identified from September 2009 through March 2011. For sutured sclerotomies, a single interrupted polyglactin or plain gut suture was placed trans-conjunctivally though all wounds. The primary outcome was the presence or absence of significant VH at the one-month (28-41 day) post-operative visit. Significant VH was defined as obscuration of the posterior pole such that fundus details (cup/disc, 2nd order vessels) could not be determined.
MeTHoD resulTs Sixty-six cases met the study criteria. Overall, rates of significant VH at the one-month post-operative visit were 24% in the sutured group and 24% in the unsutured group. Postoperative hypotony was rare (1 in 66 total cases; occurred in the unsutured group) and did not result in significant post-operative VH. Rates varied slightly by surgeon. All cases of significant post-operative VH (16 of 16) involved intra-operative membrane dissection. One-third of all membrane dissection cases resulted in significant post-operative VH (16 of 48). Pre-operative bevacizumab was associated with an increased relative risk of significant post-operative VH (RR = 1.9). conclusion Suturing 23-gauge sclerotomies did not reduce the rates of significant post-operative diabetic VH. Post-operative hypotony was rare. Intra-operative membrane dissection and pre-operative bevacizumab use were associated with increased risk of significant post-operative hemorrhage, though the latter likely included selection bias.
golf and Tennis Tournaments

Exact departure times and locations to be announced
67
insTrucTional courses 1:305:45 PM
1:30-5:45 pM
instructional courses
Sheraton Boston Hotel, 2nd, 3rd and 5th Floors (various rooms)
1:30-2:30 pM
The Fens
Practical evidence-based Pearls in the Diagnosis and Management of endophthalmitis

Mallika Goyal, MD (Hyderabad, India) Alay Banker, MD, Pramod Bhende, MBBS, S. Natarajan, MD
using a model eye. Specifically, we will demonstrate techniques for addressing anterior PVR, dislocated IOLs, endophthalmitis, cycltic membranes with hypotony, pediatric retinal detachments, and intraocular foreign bodies. In addition, we will discuss the potential for adding posterior endoscopic cyclophotocoagulation (ECP) to the management of glaucoma patients with or without underlying retinal disease. The workshop will end with a panel discussion to present cases and address audience questions.
eDucaTional oBJecTive
The goal of the course is to teach the audience how to address complex retinal surgery using an endoscopic viewing system. We will review steps on how to achieve the best orientation and field of view as well as a review of the endoscopic literature.
synoPsis Clinical manifestations of endophthalmitis vary depending on the mode of infection and the virulence of the organism. These and several other factors help personalize a management plan. Infection following intravitreal injections has clinical features different from that following cataract surgery. Endogenous endophthalmitis is a clinical challenge that requires a high index of suspicion. Early diagnosis maybe aided by Fundus Fluorescein Angiography that reveals characteristic changes more dramatic and extensive than the lesions seen clinically. Culture of vitreous is negative in upto 40% cases. DNA chip analysis gives a higher rate of success and can complement conventional microbiology. Fungal endophthalmitis needs aggressive and prolonged therapy. Antifungals of different groups may work synergistically, hence combination of intravitreal antifungals maybe more effective than any single drug. These and several other evidence-based pearls will be presented and discussed. eDucaTional oBJecTive To highlight: 1. Specifics in the diagnosis and management of endophthalmitis based on the mode of infection and etiology. 2. Role of Fundus Fluorescein Angiography in the early diagnosis of endogenous endophthalmitis. 3. DNA chip analysis in the identification of causative organism, specifically in culture-negative cases. 4. Efficacy of prolonged combination therapy for fungal endophthalmitis.
1:30-2:30 pM
Fairfax
intraocular Tumors and Pseudotumors: rapid fire cases and clinical Pearls
Jerry A. Shields, MD (Philadelphia, PA) Carol L. Shields, MD
synoPsis
The course will consist of rapid fire cases of intraocular lesions likely to be seen in a retinal practice. For each case, the instructors show a slide quickly and raise questions about diagnosis and management with active audience participation. This is followed by a few quick teaching pearls. The sequence will be repeated for each subsequent case. It is entertaining, fun, and educational.
To update retinal specialists on new, interesting, and useful information about selected benign and malignant tumors and pseudotumors of choroid, retina, RPE, and vitreous.
1:30-2:30 pM
Back Bay B
1:30-2:30 pM
Public Garden
is endoscopic retinal surgery right for you?

Thomas Lee, MD (Los Angeles, CA) Victor Gonzalez, MD* Jeffrey S. Heier, MD*
enzymatic Management of symptomatic vitreomacular adhesion

Michael Trese, MD (Royal Oak, MI)*
synoPsis
This workshop will present the advantages of endoscopic retinal surgery and how it can be used in conjunction with a standard wide angle viewing system for retinal detachment surgery. The course will review the basic techniques with extensive use of surgical videos as well as a live demonstration
synoPsis
This course is directed toward the use of enzymatic agents to liquefy the vitreous gel centrally or to attempt to lyse the symptomatic vitreomacular adhesion. Different techniques will be described to maximize the enzymatic and mechanical effects including use of the quadraport needle. Enzymes such as Ocriplasmin (microplasmin) and Plasmin will be discussed.
INSTRUCTIONAL COURSES
eDucaTional oBJecTive The attendee will gain an understanding of enzymatic manipulation of the vitreous and why delivery is an important aspect of use of enzymatic agents in the vitreous cavity, timing of injections, and use as a primary or adjunctive therapy for symptomatic vitreomacular adhesion.
This course will educate the attendee in applications of various retinal detachment repair techniques, including scleral buckle, vitrectomy, and pneumatic retinopexy. State of the art techniques including small gauge surgery, complications and current outcome measures will be described and discussed.
1:30-3:30 pM
Republic
1:30-3:30 pM
Constitution A
retinaws: When the going gets Tough, the Tough get going, challenging cases in vitreoretinal surgery
Kourous Rezaei, MD (Harvey, IL)* Anna Gabrielian, MD
Moxie with the Masters

Paul Tornambe, MD (Poway, CA)* Gabriela Lopezcarasa Hernandez, MD Calvin Mein, MD Kang Zhang, MD
synoPsis synoPsis Retina specialists often work in a shark-infested world. Unexpected events are a fact of life. Learning how not to get bit is an effective way to practice safely and efficiently. This course consists of video presentations describing challenging cases and unexpected events during retinal surgery. Faculty share their experience to predict, treat, and prevent unexpected outcomes during retinal detachment surgery, diabetic vitrectomy surgery, small gauge surgery, and complex vitreoretinal surgery. The pit falls associated with using perfluorocarbon liquid, silicone oil, and various intraocular gases will be discussed.
The purpose of this audience interactive course is to present interesting cases, unknowns, or problems encountered daily in the retina specialists practice for the group to discuss. The Masters are the audience, the case presenters are facilitators.
The goal of this course is to share interesting cases with fellow retina specialists for their opinions and management. Most cases will have take home messages and news you can use.
2:45-3:45 pM
Back Bay B
Attendees will become familiar with a variety of complicated events during retinal surgery. They learn how to predict, treat, and prevent unexpected events during and after vitreoretrinal surgery.
scleral Tunneling Techniques for the vitreoretinal surgeon: 20-g sutureless vitrectomy and sutureless scleral Buckling surgery
Kanishka T. Jayasundera, MD (Ann Arbor, MI) John C. Chen, MD, FRCS(C), I. Galic, MD, FRCS(C), Mikael Sebag, MD
1:30-3:30 pM
Commonwealth
contemporary Management of retinal Detachment repair: Techniques, outcomes, and case studies
Gaurav Shah, MD (Jacksonville, FL)* Thomas Aaberg, MD, Kevin Blinder, MD,* Pravin Dugel, MD, Dean Eliott, MD, J. Jumper, MD, John Mason, MD, Robert Mittra, MD, Franco Recchia, MD, Asheesh Tewari, MD, David Wong, MD, FRCS(C), Peter Stalmans, MD, PhD*
synoPsis
synoPsis This course will educate the attendee in applications of various retinal detachment repair techniques, including scleral buckle, vitrectomy, and pneumatic retinopexy. State of the art techniques including small gauge surgery, complications and current outcome measures will be described and discussed. Pediatric retinal detachments will be discussed and management will be presented. Various cases of retinal detachment and management with audience response system will be utilized to gauge the changing nature of detachment repair. Audience participation will be significant along with faculty interaction.
This is an interactive session with surgical videos and panel discussion on the pearls and pitfalls of scleral tunneling techniques for sutureless 20-gauge vitrectomy and sutureless scleral buckling surgery. Sutureless 20-gauge vitrectomy (steps of technique:conjunctival peritomy, construction of tunneled sclerotomies, vitrectomy techniques, including removal of intraocular foreign bodies, closure of sclerotomies and peritomy). Pearls and pitfalls of transconjuctival 20-gauge sutureless vitrectomy techniques will be discussed. Sutureless scleral buckling (steps of technique: construction of scleral loops in four quadrants for scleral buckle placement, silicone sleeve for tying buckle, closure of peritomy). The additional steps of combined surgery (vitrectomy and scleral buckling, vitrectomy and phacoemusification) will be discussed.
To teach the techniques and advantages of scleral tunneling used for 20-G sutureless vitrectomy and sutureless scleral buckling surgery.
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2:45-3:45 pM
Fairfax
2:45-3:45 pM
The Fens
Pneumatic retinopexy: Pearls and Pitfalls

Peter Kertes, MD, FRCS(C) (Toronto, ON) Robert Devenyi, MD, MBA, FRCS(C)* Wai-Ching Lam, MD, FRCS(C) Matthew Schlenker, MD
Managing corneal opacities and Temporary Kerato-prosthesis surgery for vitreo-retinal surgeon
Shashi Ganti, MD, MBA (Fresno, CA), Dinesh Chawla, MD, Christopher Ta
synoPsis synoPsis This course will outline a simplified technique for office based pneumatic retinopexy, discuss clinical examination techniques and provide an approach to extended indications. In addition, management of complications will be discussed including: new/missed retinal breaks, persistent subretinal fluid, fish eggs, subretinal gas and prehyaloidal gas. Audience participation will be encouraged and a comprehensive handout will be provided. eDucaTional oBJecTive At the conclusion of the course the participant will be able to identify appropriate patients for this technique, understand the fundamental principles necessary for success of pneumatic retinopexy and manage subsequent complications.
This Course may be complementary to Anterior Segment Surgery Course. Didactic, technique and Wet lab will be offered. Steps of Corneal trephining followed by placement of Landers Temporary non-disposable Keratoprosthesis and parsplana 23G Vitrectomy. Preparation of Donor button, trephinition and Suturing the donor button on to the recipient after removal of the Temporary Keratoprosthesis with Interrupted Sutures. Above steps will be discussed with video and didactic presentation, followed by Wet lab. The level and depth of discussion can be tailored to the degree of participants enthusiasm.
Understanding cornea and learn anterior segment surgery in case of emergency when we are marooned in the OR. Knowledge of the steps of surgery and final outcome is expected of the participants at the conclusion of the course.
2:45-3:45 pM
Public Garden
2:45-3:45 pM
Back Bay A
electronic Health record The Basics

Colin A. McCannel, MD* (Los Angeles, CA)
icg imaging for the Diagnosis and Management of exudative aMD

Mark Nelson, MD (Winston-Salem, NC)*
synoPsis The Health Information Technology for Economic and Clinical Health (HITECH) Acts limited window in time to obtain stimulus funds for adopting an Electronic Health Record (EHR) has created an atmosphere of haste and confusion. A wide range of topics will be covered including: meaningful use, selection criteria that should be considered, possible impact on the practice and work flow, information technology considerations and the importance of EHR standards. eDucaTional oBJecTive At the end of this course, the participants will have a working knowledge of what the characteristics of a good EHR might be, an understanding of the relative benefits and disadvantages of various EHR technologies, and the impact on a practices productivity and workflow. The participants will also understand the key aspects of the HITECH Act and meaningful use.
synoPsis
ICG videoangiography with concurrent spectraldomain OCT elucidates the choroidal origin of occult and classic neovascularization. More importantly, it identifies antiVEGF resistant lesions, namely arteriolarized neovascularization and polypoidal vasculopathy, both of which are responsible for patients who are classified as anti-VEGF resistant and antiVEGF dependent during the course of anti-VEGF monotherapy.
ICG imaging is critical for determining the presence of anti-VEGF resistant lesions and will be instrumental in creating strategy for anti-VEGF resistant and anti-VEGF dependent patients.
INSTRUCTIONAL COURSES
3:45-5:45 pM
Back Bay CD
4:00-5:00 pM
Fairfax
anterior segment surgery for the vitreoretinal surgeon: Discussion and Wetlab
Carl C. Awh, MD* (Nashville, TN)
Pathogenesis, imaging and Treatment of Dry aMD: 2011

Jaclyn Kovach, MD (Naples, FL) William Scott* Kimberly Stepien, MD
synoPsis A didactic and hands-on review of current techniques and devices for cataract surgery, complications of cataract surgery, and combined cataract-vitrectomy cases. Participants will be able to perform surgery with state-of-the-art equipment in a wetlab setting.
synoPsis
Current knowledge of the pathogenesis of dry agerelated macular degeneration (AMD) including known genetic associations will be reviewed. Current and future treatment options will be discussed in detail.
To educate vitreoretinal surgeons about current techniques for cataract and lens implant surgery, to better improve their ability to manage the complications of cataract and related surgeries.
At the conclusion of this course, the participant will have an updated understanding of the pathogenesis of dry AMD, current imaging modalities, and emerging treatment options.
4:00-5:00 pM 3:45-5:45 pM
Commonwealth Back Bay B
asrs research and Development committee symposium: clinical Trials unplugged: real, Practical Questions and answers
Pravin U. Dugel, MD* (Phoenix, AZ) David Boyer, MD*, David Brown, MD*, Jeffrey S. Heier, MD*, Allen Ho, MD*, Peter Kaiser, MD*, Dan Martin, MD, William Mieler, MD*, Timothy G. Murray, MD, MBA*, Guarav Shah, MD*, Michael Singer, MD*
eMr How to choose the right one for you

Sanjay Logani, MD, MBA* (Northridge, CA)
synoPsis
synoPsis An unprecedented number of clinical trials will conclude this year. Synthesizing and comparing the data, planning for changes in practice patterns and predicting the economic implications will be both necessary and challenging. The purpose of this symposium is to go beyond the podium presentation. The PI will be questioned by respected experts not involved in the trial as well as by the audience. eDucaTional oBJecTive 1. Judge the merits of each trial in an objective and critical manner. 2. Ask the PI direct questions with unparalleled access. 3. Prepare for the practice pattern and economic implications of each trial.
The government stimulus program for using EMR has begun. EMR has become a requirement for future healthcare services but remains difficult to understand. Retina specialists need to know how to identify and implement EMR packages that meet stimulus requirements. We have over 9 years of experience in successfully using EMR in an ophthalmic multispecialty, multi-location practice setting. The instructor intends to discuss and inform attendees on what it will take to qualify for the full government incentive package. They will learn how to select an efficient and cost effective Ophthalmic EMR package. Instruction will cover: 1. Important selection criteria to evaluate Ophthalmic EMRs 2. Demonstrating meaningful use of an EMR for an Ophthalmic office 3. How to do a cost/ benefit analysis of Ophthalmic EMR systems The instructor will discuss and inform attendees on what it will take to qualify for the full government incentive package.
1. How to evaluate different EMR packages. 2. How to select the right EMR for your practice. 3. How to avoid the wrong EMR for your practice. 4. When is the best time to buy EMR?
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4:00-5:00 pM
The Fens
4:00-5:00 pM
Back Bay A
natural language Processing enables retina specialists to use eHr More effectively and efficiently
James Maisel, MD* (Hicksville, NY)
laser Treatment of Diabetic Macular edema Maximizing vision improvement and edema reduction While Minimizing injury
Stephen Sinclair, MD* (Media, PA) Jose Cardillo, MD Jeffrey Luttrull, MD
Natural Language Processing (NLP) allows physicians to dictate and convert unstructured text to structured data. These include SNOMED, ICD-9, ICD-10, CPT-4, RxNorm and LOINC. The standardized structured terminology can be output from a data repository into EHRs to meet interoperability requirements, provide billing and coding solutions, or allow data mining for secondary uses
synoPsis
Show the audience via a live demonstration how NLP facilitates generating structured medical codes for retina specialists from dictation. Explain how the above method can increase the efficiency of data capture in certain cases. Educate the audience on the different medical codes that can be generated from NLP and their clinical uses for EHR interoperability and secondary uses.
synoPsis
Ophthalmologists have utilized primarily focal/grid laser with sub- or supra-threshold, continuous wave photocoagulation to treat diabetic macular edema while some have begun to use low intensity, high density micropulse laser painting. The techniques and outcomes of both types will be discussed including results of randomized trials and personal observations.
Provide understanding of the techniques, rationale, indications, and expected structural and vision outcomes of both laser treatments that will improve case and treatment selection to maximize results
7:00 pM1:00 AM
4:00-5:00 pM
Public Garden
cocktail reception, gala Dinner and umbo lounge

Republic, Grand and Constitution Ballrooms
Past, Present and future of antiangiogenic Therapy for the Treatment of retinopathy of Prematurity
Maria Martinez-Castellanos, MD (Toluca, Mexico) Alay Banker, MD Robison Chan, MD Hugo Quiroz-Mercado, MD
synoPsis We will discuss the role that antiangiogenic therapy has in the treatment for retinopathy of prematurity (ROP) from its basis to the potential use of the pharmacologic agents in this blinding disease. We will divide the course as follows: History of antiangiogenic drugs in ROP Antiangiogenic therapy in ROP, 5 years of experience in two continents Use of new technologies in the diagnosis, research and data sharing in ROP A blink into the future in the treatment of ROP. eDucaTional oBJecTive The use of pharmacologic agents to treat ROP has been growing as a snow ball worldwide. In this course we will discuss the use of antiangiogenic therapy among two groups that have been using this therapy for the last 5 years, the findings, complications, variations in the techniques, follow up and where the future is going to take us in the treatment of a blinding disease.
Wednesday, August 24
Wednesday, August 24
8:00-8:30 AM
conclusion

8:30-10:20 AM
Choroidal thickness as measured by SD-OCT EDI is reduced in patients with RP, and increased in patients with Stargardt disease. Visual acuity does not correlate with choroidal thickness measurements in the patients enrolled in this study.
Symposium 13: Hereditary/inflammatory/ Diabetic Retinopathy

Moderators: Dean Eliott, MD and Philip J. Ferrone, MD Related poster abstracts are on pages 99-118.
8:38 AM
analysis of long-term outcomes for intravitreal Bevacizumab Treatment of choroidal neovascularization secondary to ocular Histoplamosis syndrome
Daniel M. Miller, MD, PhD* (Cincinnati, OH), Douglas Cionni, MD, Shawn A. Lewis, MD, Michael K. Petersen, MD, PhD, Robert E. Foster, MD, Christopher D. Riemann, MD, Robert A. Sisk, MD, Robert K. Hutchins, MD
8:30 AM
enhanced Depth imaging ocT in Hereditary retinal Diseases

Dilsher S. Dhoot, MD (Cleveland, OH), Siya Huo, MD, Peter K. Kaiser, MD*, Elias Traboulsi, MD
PurPose
To assess the long-term outcomes of intravitreal bevacizumab (IVB) in the treatment of choroidal neovascularization (CNV) secondary to presumed ocular histoplasmosis syndrome (POHS). Consecutive, interventional case series involving 104 eyes in 95 patients who received injections of IVB alone or in combination with photodynamic therapy (IVB/PDT) for treatment of subfoveal or juxtafoveal CNV secondary to POHS with at least 12 months of follow up from January 2006 through January 2010. Only subfoveal and juxtafoveal lesions were included in the analysis. Exclusion criteria included extrafoveal POHS CNV, prior vitrectomy, concomitant diabetic retinopathy, retinal vein occlusion, or CNV secondary to any other cause, and ARMD. Similarly, subjects with inherited retinal degeneration or any other visually significant maculopathy were excluded.
To investigate the spectral-domain ocular coherence tomography (SD-OCT) features of the choroid in hereditary retinal diseases using enhanced depth imaging (EDI) technique.
PurPose MeTHoD EDI SD-OCT imaging was performed on 21 patients with inherited retinal diseases, using the Spectralis OCT. Subfoveal choroidal thickness (CT) measurements were obtained. Measurements were taken at 1000 m intervals of a horizontal section from 3 mm nasal and temporal to the fovea. Patients were grouped based on their primary diagnosis, which included 15 patients with retinitis pigmentosa (RP), 5 patients with Stargardt macular dystrophy, and one patient with choroideremia. Statistical analysis was performed to evaluate CT at each location and to correlate CT with visual acuity, retinal thickness, outer retinal features on OCT, and clinical appearance. resulTs Mean ages were 45.8 years for the RP patients and 33.2 years for the Stargardt patients. The choroideremia patient was 15 years of age. Mean visual acuity was 20/49 in the RP patients, 20/148 in the Stargardt patients, and 20/22 in the choroideremia patient. Mean choroidal thickness measurements were 224.6 106 m in the RP patients, 385.2 177 m in the Stargardt patients, and 413 14 m in the choroideremia patient. RP patients tended to have thinner choroids than age matched controls, while the Stargardt and choroideremia patients had thicker choroids than controls. There was no correlation between subfoveal choroidal thickness and visual acuity in any of the patient groups.
MeTHoD
resulTs
Seventy-seven eyes received IVB monotherapy and 27 eyes underwent combination IVB/PDT treatment. For both groups, the average pretreatment logMAR vision was 0.66 (Snellen Equivalent 20/131) with a final logMAR vision of 0.46 (Snellen Equivalent 20/58). The mean follow-up was 28.0 months with an average of 3.09 intravitreal bevacizumab injections per year. There was no significant difference in initial vision, final vision, or number of eyes with a 3-line gain between the IVB monotherapy and IVB/PDT groups. Thirtyeight percent (39/104) of eyes gained 3-lines or more and 81.2% (84/104) of subjects had at least stable vision or better vision at one year. The proportion of subjects maintaining a 3-line gain in vision was relatively preserved at 2 years (29.8%, 17/57) and 3 years (30.3%, 10/32) follow-up. There was no increase in the proportion of subjects losing 3-lines of vision or more over 3 years of follow-up.
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13 HereDiTary/inflaMMaTory/DiaBeTic reTinoPaTHy 8:3010:20 AM

conclusion There is no significant difference in visual acuity outcomes between IVB monotherapy versus IVB/PDT combination therapy for POHS CNV. IVB is an effective treatment for CNV secondary to POHS resulting in a long-term stabilizing effect on visual acuity. resulTs
50 patients were recruited. Patients discomfort score (1=none to 5=extremely severe) during the preparation was 2.0 (s.d.=1.1) vs 1.9 (s.d.=0.8,) in the Q-tip vs gel group, respectively (P=0.4, paired t-test). Discomfort score during the injection was 1.7 (s.d.=1.0) in the Q-tip group vs 2.0 (s.d.=0.9) in the gel group (P=0.058, paired t-test.) Mean IOP immediately after injection was 41.1 mmHg (s.d.=8, range=21 to 68) vs 46 (s.d.=10, range=29 to 69) in the Q-tip vs gel eyes respectively (P=0.002). There was significantly less SCH (P=0.031, paired t-test) and corneal staining (P=0.001, paired t-test) in the gel group. When asked the next day, patients reported significantly less discomfort in the gel group vs the Q-tip group (1.5 vs 1.8, P=0.036)
conclusion The data suggest patients prefer the gel preparation, however, the Q-tips produce a lower IOP elevation.
8:58 AM
ranibizumab Dose comparison for the Treatment of Diabetic Macular edema

Post-treatment fluorescein angiograms for a subject treated with intravitreal bevacizumab over a 4 year time period. There is a linear growth in CNV size and surrounding RPE abnormalities despite successful treatment with intravitreal bevacizumab. Her visual was preserved at 20/30 after 4 years of follow-up.
Philip J. Ferrone, MD* (Great Neck, NY), Jonathan Jonisch, MD
8:46 AM
Discussion
PurPose
8:50 AM
To compare ranibizumab dose response in the treatment of clinically significant diabetic macular edema. Investigator sponsored, prospective, randomized clinical trial. Eyes with clinically significant macular edema secondary to diabetic retinopathy were randomized to one of two groups, 0.5mg or 1.0mg ranibizumab at baseline. During the first year, three monthly injections were given followed by asneeded injections on alternate months. Starting at month 12, patients were followed monthly and could receive as-needed treatments at these visits. An amendment allowed treatment with 2.0mg ranibizumab in patients who had completed at least 12 months of follow-up.
clinical comparison of Two anesthetic Preparations for intravitreal injection

Ninel Z. Gregori, MD (Miami, FL), Matthew Weiss, MD, Raquel Goldhardt, MD
MeTHoD
PurPose To determine which of two topical anesthetic preparations patients prefer for intravitreal injections of ranibizumab with a 32 gauge needle. One preparation was a topical application utilizing three Q-tips soaked in 4% lidocaine; the other was application of 3.5% lidocaine hydrochloride ophthalmic gel. MeTHoD Randomized prospective clinical trial. Patients who had at least 3 previous intravitreal ranibizumab injections were divided into two strata and randomized to receive one of the two anesthetic preparations in each eye (bilateral stratum) or on subsequent visits in one eye (unilateral stratum). Bilateral stratum consisted of patients receiving an injection in each eye on the same day. Patients discomfort level, overall satisfaction with the preparation and injection, as well intraocular pressure (IOP), corneal staining, and subconjunctival hemorrhage (SCH) were compared. The patients were also asked which preparation method they preferred.
resulTs
A 24-month interim analysis was performed. Both groups had similar baseline characteristics. At Month 24, significant visual acuity gains from baseline were observed in both 0.5mg and 1.0 mg groups. There was a significant mean decrease in central foveal thickness in both the 0.5mg and 1.0mg groups. In the 0.5mg group, a smaller proportion of patients gained 15 or more ETDRS letters compared to patients in the 1.0mg group. The average number of injections in the 0.5mg group was similar as compared to the 1.0mg group. Fourteen patients received 2.0mg ranibizumab starting at or after month 24. In this subset, visual and anatomic outcomes were maintained through follow-up. When compared to the 12 months preceding the transition to the 2.0mg dose, the average time (days) between treatments increased in both groups (0.5mg vs 2.0mg: 54 vs 75 days; and, 1.0mg vs 2.0mg: 68 vs 73 days).
Treatment of CSDME with 1.0 mg of ranibizumab resulted in a statistically significant improvement in visual acuity from baseline. There was a trend towards greater improvement in ETDRS vision and decreased macular edema with 1.0 mg ranibizumab versus 0.5 mg ranibizumab at 24 months. The 2.0 mg dose showed a trend towards a longer treatment interval.
conclusion
conclusion
The use of ranibizumab for center-involved DME in eyes with vision impairment offer not only improved clinical outcomes but also savings in areas to help offset the cost of the new treatment. The decreasing number of injections given over time in the DRCR.net study coupled with the maintenance of vision, suggest that costs savings will continue over time.
9:14 AM 9:06 AM
economic analysis of Treatment with ranibizumab with Prompt or Deferred laser vs. laser alone for Diabetic Macular edema
Jennifer K. Sun, MD* (Boston, MA), Neil M. Bressler, MD*, Adam R. Glassman, MD, Michael OGrady, MD
erythropoietin levels in the vitreous fluid of non-diabetic Patients and Diabetic Patients with Progressive stages of Diabetic retinopathy
Nikolaos Trichopoulos, MD (San Antonio, TX), Dip Jadav, MD, Neeru Kumar, MD, Randolph Glickman, MD
PurPose Results from the Diabetic Retinopathy Clinical Research Network (DRCR.net) demonstrated conclusively that treatment with ranibizumab with prompt or deferred laser provides superior visual acuity outcomes than treatment with prompt laser alone for center-involved DME. The purpose of this study is to determine potential federal and state government costs and savings associated with this treatment. MeTHoD Potential costs and savings were estimated using Congressional Budget Office and the Office of the Actuary at the Centers for Medicare and Medicaid Services style techniques to measure change in spending and savings associated with improved clinical outcomes without evaluating quality of life measures. Billing associated with ranibizumab+prompt laser, ranibizumab+deferred laser, and prompt laser alone were simulated; including initial office visits, follow-up, testing, medication, laser procedures, and ranibizumab treatments. Medicare codes and payment amounts were used for consistency and replicability. Economic modeling was based on the 2 complete years of DRCR.net clinical trial data. resulTs Over 2 years, ranibizumab therapy for DME and its associated clinical costs are estimated to require approximately $26,000 more per patient treated with ranibizumab+prompt laser or ranibizumab+deferred laser as compared with standard laser treatment alone. Concurrently, ranibizumab is expected to reduce rates of visual impairment and therefore the potential to displace costs elsewhere in the system. For those individuals who would have to leave the labor force and go on Social Security Disability, the ranibizumab treatment over 2 years could reduce costs by about $45,000. This would include maintaining approximately $17,605 in federal income, social security and Medicare taxes and $3,138 in state income taxes and $24,108 in Social Security disability benefits that would not need to be paid. Not all patients will fit this maximum offset scenario, but many should have at least some combination of tax and disability offsets.
PurPose
EPO is reported to have angiogenic activity but its role in retinal neovascularization is not completely understood. The purpose of this study was to evaluate whether the levels of EPO are elevated in the vitreous fluid of patients with DR. We hypothesized that EPO is progressively increased in advanced stages of DR. We also assessed if DR is associated with the presence of inflammatory markers.
MeTHoD
Prospective analysis of undiluted vitreous samples was performed in discarded vitreous fluid of 34 patients undergoing scheduled vitrectomies. Patients with retinal vascular abnormalities other than DR (e.g. central retinal vein occlusion) were excluded. Twelve patients were non-diabetics and 22 had diabetes mellitus (DM). Four of these 22 DM patients did not have DR, 5 had non-proliferative diabetic retinopathy (NPDR) and 13 had proliferative diabetic retinopathy (PDR) with or without vitreous hemorrhage. All vitreous samples were analyzed for EPO content; while a subset of 6 samples were screened for a panel of pro-inflammatory cytokines, using enzyme-linked immunosorbent assay kits.
resulTs
A clear difference in the amount of vitreous EPO was found between non-diabetics (n = 12), diabetics with NPDR or no DR (n = 9), and diabetics with proliferative retinopathy (PDR) (n=13). Figure 1 shows histogram plots of the measured EPO levels in each of these 3 patient groups. Average EPO levels were as follows: non-diabetics: 11.17 5.50 mIU/ml; diabetics with NPDR or no DR: 33.87 33.78 mIU/ml; and diabetics with PDR: 186.91 153.05 mIU/ml. A Mann-Whitney nonparametric test was used to compare these differences. The EPO levels of the non-diabetics and the diabetics with NPDR or no DR did not differ significantly from each other (p > 0.05). In contrast, there were significant differences between the EPO levels of the diabetics with PDR and the diabetics with NPDR or no DR (p .009) and the non-diabetics (p .001). There was a two-fold increased level of the pro-inflammatory cytokine, IL-8, in samples from eyes with PDR, compared to vitreous from non-DM patients (figure 2).
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conclusion Our findings suggest that EPO is increasingly elevated as a consequence of the ischemia induced by worsening stages of DR. EPO may serve as an indicator for advancement of ischemic ocular damage. Whether inhibition of EPO could provide a new therapeutic strategy in precluding or arresting pathologic angiogenesis in DR, and if chronic inflammation stimulates EPO production, remain to be determined.
9:30 AM
changes in Macular Microvasculature in eyes with Diabetic Macular edema Treated with ranibizumab over a 24-month Period
Homayoun Tabandeh, MD* (Los Angeles, CA), Jang Won Heo, MD, Jeong Hee Lee, MD, Yasir J. Sepah, MD, Roomasa Channa, Morgan Renner, MD, Ahmed Fahmy, MD, Afsheen Khwaja, Zubir Rentiya, MD, David S. Boyer, MD*, Quan Dong Nguyen*, Diana V. Do, MD*
PurPose
To evaluate the changes in macular vasculature of eyes with diabetic macular edema (DME) treated with ranibizumab (RBZ).
Figure 1. Histogram plots comparing EPO levels in the three patient groups. Top: non-diabetics, n = 12. Middle: diabetics with no retinopathy or NPDR only, n = 9. Bottom: diabetics with PDR, n = 13. The level of EPO in the vitreous of diabetics with PDR was significantly greater than that of either the diabetics with no DR or NPDR only, or the non-diabetic patients (p 0.009, Mann-Whitney test).
Fluorescein angiograms (FA) from patients in the Ranibizumab for Edema of the mAcula in Diabetes: Protocol 2 (READ-2 Study) were analyzed in the Reading Center (RIRRC) by 3 independent graders. In the READ-2 study, 126 patients with DME were randomized (1:1:1) to receive 0.5 mg of RBZ (group 1), focal/grid laser photocoagulation (group 2), or a combination of RBZ and focal/grid laser (group 3). After month 6, majority of subjects received monotherapy with RBZ. FA at baseline (BL) and month 24 were analyzed for 39 randomly selected subjects. Three variables were evaluated: areas of capillary non-perfusion, source and type of leakage, and number of MAs contributing to leakage.
MeTHoD resulTs
At month 24, the area of capillary non-perfusion did not change in any group when compared with BL. There was no change in the pattern of leakage in 83%, 55.6%, and 45.5% of eyes in groups 1, 2, and 3, respectively. The average number of leaking MAs decreased by 15.6% (group 1), 21.6% (group 2), and 9.2% (group 3). There was no statistically significant difference among the three groups in their longitudinal changes (BL to M24) based on the three defined variables (p=0.657, 0.332, 0.304). Analyses showed that vascular endothelial growth factor (VEGF) inhibition over 24 months with RBZ in eyes with DME did not result in increased capillary non-perfusion within the macula. In addition, RBZ injections appeared to decrease the number of leaking MAs. Further studies are needed in a larger study population to determine the effects of chronic VEGF suppression in eyes with DME.
conclusion
Figure 2. Relative expression levels of pro-inflammatory cytokines in three diabetic patients with PDR and high levels of EPO, and in three non-diabetic patients with low levels of EPO. There was a clear, two-fold difference in the relative expression level of IL-8 between the diabetics with PDR and non-diabetics.
9:22 AM
Discussion
9:38 AM
9:46 AM
The effect of Bevacizumab on fibro-angiogenic growth factors in Proliferative Diabetic retinopathy: a randomized, Double-masked, controlled study
Dean Eliott, MD (Boston, MA), Elliott H. Sohn, MD, Leo A. Kim, MD, PhD, Hani Suleni-Had, MD, Michael Javaheri, MD, Shikun He, MD, David Hinton, MD
Panretinal Photocoagulation (PrP) vs. PrP Plus intravitreal ranibizumab for High-risk Proliferative Diabetic retinopathy
Rodrigo Jorge, MD*, (Ribeirao Preto, Brazil), Jos Ramos-Filho, Felipe P. Almeida, Jefferson A. Ribeiro, Rogerio A. Costa, MD, PhD, Ingrid U. Scott, MD, MPH, Andre Messias
PurPose
The exact mechanisms underlying the pathogenesis of TRD in PDR are unclear. VEGF and connective tissue growth factor (CTGF) are mediators of angiogenesis and fibrosis, respectively, and both are increased in eyes with PDR. The purpose of this study was to assess the effect of preoperative intravitreal bevacizumab on VEGF and CTGF in eyes with TRD and to determine postoperative outcome.
PurPose MeTHoD In this prospective trial, 20 eyes of 19 patients were randomized (10 in each arm) to receive 1.25mg intravitreal bevacizumab or sham injection 3-7 days prior to vitrectomy for TRD. Patient and surgeon were masked to treatment. Fundus photographs and spectral-domain OCT were obtained at the time of injection and on the day of surgery. Degree of vascularity and fibrosis were assessed at the time of injection and again at surgery. Amount of intraoperative bleeding was recorded. Aqueous samples were collected prior to injection and during surgery. Undiluted vitreous samples and fibrovascular membranes were also obtained. Enzyme linked immunosorbent assays for VEGF and CTGF were performed. resulTs Five eyes had decreased vascularization of membranes from pre-injection to time of surgery, and all of these eyes were in the treatment arm. Only 1 eye in the treatment group had severe intraoperative bleeding compared with 5 eyes in the control group. Median vitreous levels of VEGF (pg/mL) were significantly lower in the treatment group (undetectable with the conditions applied) than the control group (397, p=0.03). Aqueous levels of CTGF were strongly correlated with those in the vitreous of controls (p<0.001). Median vitreous levels of CTGF (pg/mL) were 980 in the treatment group and 1235 in the control group (p=0.38). There was a significant correlation between VEGF and CTGF levels in the vitreous of the treatment group (p=0.01) that was not observed in the control group. conclusion Intravitreal bevacizumab (1.25mg) administered within 3-7 days of vitrectomy in eyes with TRD due to PDR reduces vitreous levels of VEGF and produces a clinically observable alteration in fibrovascular membranes. There is a positive correlation between VEGF and CTGF levels in eyes treated with bevacizumab. Aqueous CTGF is a useful surrogate marker for vitreous CTGF in these eyes.
To evaluate the effects of panretinal photocoagulation (PRP) compared with PRP plus intravitreal injection of 0.5 mg of ranibizumab (IVR) in patients with high-risk proliferative diabetic retinopathy (PDR).
MeTHoD
Prospective study including patients with high-risk PDR and no prior laser treatment randomly assigned to receive PRP (PRP group) or PRP plus IVR (PRPplus group). PRP was administered in two sessions (weeks 0 and 2), and IVR was administered at the end of the first laser session in the PRPplus group. Ophthalmic evaluations including best corrected visual acuity measured according to the methods used in the Early Treatment Diabetic Retinopathy Study (BCVA), fluorescein angiography to measure area of fluorescein leakage (FLA), and optical coherence tomography (OCT) for assessment of central subfield macular thickness (CSMT), were performed at baseline and at weeks 16 (2), 32 (2) and 48 (2).
resulTs
Twenty-nine out of 40 patients (n=29 eyes) completed the 48-week study follow-up period. At baseline, meanSE FLA (mm2) was 9.01.3 and 11.71.3 (p=0.15); BCVA(logMAR) was 0.310.05 and 0.27 0.06 (p=0.66); and CSMT(m) was 216.310.7 and 24936 (p=0.39), in the PRP and PRPplus groups, respectively. There was a statistically significant (p<0.05) FLA reduction at all study visits in both groups, with the reduction observed in the PRPplus group statistically significantly larger than that in the PRP group at week 48 (p=0.02). BCVA worsening was observed at 16, 32 and 48 weeks after treatment in the PRP group (p<0.05), while no statistically significant BCVA changes were observed in the PRPplus group. A statistically significant CSMT increase was observed in the PRP group at all study visits (p<0.05), while a significant decrease in CSMT was observed in the PRPplus group at week 16 (p<0.05), and no statistically significant difference in CSMT from baseline was observed at weeks 32 and 48. IVR after PRP was associated with a larger reduction in FLA at week 48 compared to PRP alone in eyes with high-risk PDR, and the adjunctive use of IVR appears to protect against the modest visual acuity loss and macular swelling observed in eyes treated with PRP alone.
conclusion
77

9:54 AM 10:02 AM
combination Treatment using anti-vegf Therapy and sustained release Dexamethasone 0.7 mg for retinal vascular Disease Twelve Month results
Michael A. Singer, MD* (San Antonio, TX), Darren J. Bell, MD, Paul Woods, MD, Beatrice Guajardo, MD
Diabetic Macular edema (DMe) is a Peripheral retinal Disorder and Peripheral PrP Directed to areas of Poor Perfusion Positively affects DMe
Paul G. Tornambe, MD* (Poway, CA)
PurPose The purpose of the study is to evaluate the effects of repeated use of combination therapy (Anti-VEGF and Dexamethasone 0.7mg sustained release implant) for the treatment of Retinal Vein Occlusion in terms of visual acuity and OCT central field thickness over a twelve month period. MeTHoD The study is a prospective open label pilot extention to the orignial combination study presented last year. Patients with both CRVO and BRVO received Anti-VEGF injection followed by Dexamethasone 0.7mg sustained release implant two weeks later. Previously treated and naive patients were included.
PurPose
In eyes with DME, peripheral retinal ischemia elaborates cytokines, such as VEGF, which affects vascular permeability. PRP directed to these ischemic areas, downregulates cytokine production which decreases vascular leakage, and positively affects macular edema without repeated VEGF-I injections nor direct macular photocoagulation.
MeTHoD
Best corrected visual acuity (Snellen), Cirrus OCT, and IOP measurements were obtained at every visit. Patients were retreated if OCT central field thickness increased by 50 microns from previous measurements of if vision decreased by six letters. IOP greater than 22 was treated with topical medication. Patients were converted to FDA approved Randibizumab from Bevacizumab if insurance permitted. 58 patients had combination therapy. 28 pateints of the original 32 had at least 12 months of follow up. 33 patients had Bevacizumab initally, 9 had Randibixumab and 16 switched during the study. Mean visual acuity improved by 11 letters in month 1, 15 letters in month 3, 18 letters in month 6, 13 letters in month 8, 13 letters in month 12. Three line or more gains in visual acuity were 38% in month 1, 35% in month 3, 40% in month 6, 46 % in month 8, and 34% in month 12. Mean OCT Thickness decreased by 140 um at 2 weeks, 144um month 1, 96 um in month 3, 93um in month 6, 173um in month 9.159 um in month 12. Patients with OCT thickness <300 um were seen 54% at 2 weeks, 80% month 1, 65% in month 3, 59% in month 6, 55% in month 9, 74% in month in 12. Mean time to those retreated was 17 weeks in the 1st cycle, and in the 16 weeks in the 2nd cycle. 18 patients (30%) were treated once. IOP >23 was seen in 17% (10/58) in the 1st 6 months, and 18% (18/45) in the 2nd 6 months.
resulTs conclusion Combination therapy using Anti-VEGF agents and Dexamethasone 0.7mg sustained release implant, can provide sustained increases in visual acuity as well as reduction in central field thickness over time in patients with retinal vein occlusion. In addition, this therapy can provide predictable intervals for reinjection. The IOP profile is similar to other Dexamethasone implant studies.
10 eyes with severe recalcitrant DME underwent wide field FA which demonstrated untreated peripheral retinal ischemia and retinal vascular leakage. Scatter laser photocoagulation was delivered only to the areas of peripheral ischemia, and no laser treatment was applied to the macular region. In some cases the macular edema acutely increased in the treated eye and in the fellow untreated eye, suggesting PRP initially upregulates VEGF and may have a X-over effect. An IVt VEGF-I injection to the treated eye quickly reversed the macula edema in both the treated eye and also decreased the edema in the fellow untreated eye, suggesting a cross over effect for laser aggravated DME. Peripheral laser PRP directed by wide field FA to ischemic retina, with no macular laser PC, ultimately positively affected diabetic macular edema in all eyes treated. Initially PRP upregulates VEGF production and increases macular edmea. A VEGF-I given prior to and a month or two after PRP (1) addressed VEGF associated DME and blunted the upregulated PRP VEGF effect and (2) allowed time for the PRP down regulating VEGF effect to develop. This study suggests that peripheral ischemic retina elaborates cytokines, including VEGF, which induces vascular permeability and macular leakage. PRP to only ischemic peripheral retina ultimately decreases cytokine production and resolves macular edema. This treatment approach should decrease the number of VEGF-I injections to control DME and avoids the secondary damaging effects of laser photocoagulation in the macular region.
resulTs
conclusion
DME is a peripheral retinal disorder. PRP to preipheral ischemic retina using widefield FA ultimately decreases diabetic macular edmea. PRP initially upregulates VEGF, therefore a VEGF-I should be injected prior to PRP and for a month or two following PRP. This treatment approach should decrease the number of injections needed to control DME and avoids direct macular photocoagulation entirely.
10:50 AM-12:00 pM
Symposium 14: vitreoretinal Surgery iv

Moderators: Francesco Boscia, MD* and Peter Stalmans, MD* Related poster abstracts are on pages 119-150.
10:50 AM
S OCT, Left Eye: 65 y/o diabetic female S/P PRP, PPV, 3 IVTA OS and 3 Avastin injections OS with persistent DME. Pre PRP OS directed laser to untreated mid peripheral and peripheral ischemic retina. Note florid CME.
endoscopic vitrectomy vs. Temporary Keratoprosthesis vitrectomy for severe combined corneal and Posterior segment ocular Trauma
Dal W. Chun, MD (Washington, DC), Marcus H. Colyer, MD
PurPose
S OCT Left Eye: 8 weeks s/p Peripheral PRP directed laser to untreated mid peripheral and peripheral ischemic retina (432 spots). CME has decreased dramatically.
To report the baseline characteristics and the three and six month functional and anatomic outcomes following endoscopic vitrectomy (EV) compared to temporary keratoprosthesis vitrectomy (TKV) in eyes with severe combined corneal and posterior segment ocular trauma.
10:10 AM
MeTHoD
Discussion
10:20-10:50 AM

Retrospective, comparative, interventional case series. All of the eyes that underwent secondary repair with either TKV or EV for severe ocular trauma at Walter Reed Army Medical Center from March 2003 to October 2010 were reviewed. Eight eyes of eight patients that underwent TKV were assigned to Group 1. Nine eyes of eight patients that underwent EV were assigned to Group 2. Ocular trauma variables, baseline characteristics, surgical variables, and 3 and 6 month postoperative functional and anatomic outcomes were compared between the two groups using the Wilcoxon rank sum test and the Fischer exact test.
resulTs
The groups were similar with respect to the ocular trauma variables. Median baseline logMAR was 3.0 in both groups but macular retinal detachment (RD) and peripheral RD were more common in Group 1 (P = 0.015 and 0.050, respectively). The median time from injury to surgery was significantly longer in Group 1 (38 days) than in Group 2 (14 days) (P = 0.034). The median surgical time was also longer in Group 1 (8.4 hours) than in Group 2 (2.8 hours) (P < 0.0005). The surgical variables differed only in the rates of macular membrane peeling (P = 0.029) and perfluoro-n-octane use (P < 0.0005) which were more common in Group 1. At 3 months, median logMAR was 3.0 in Group 1 and 2.0 in Group 2 (P = 0.34). At 6 months, there was a trend toward better median logMAR in Group 2 (1.3) than in Group 1 (3.0) (P = 0.093). The functional and anatomic success rates were similar (P = 0.64 and 0.62, respectively) although there was a trend toward more failures in Group 1 than in Group 2 (P = 0.082).
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conclusion The results of this study suggest that EV is comparable to TKV. An advantage of EV is that it allows earlier intervention without complex corneal surgery. Prompt diagnosis and treatment of occult pathology may result in less surgical manipulation and time. The disadvantages of EV include limited image quality, dynamic intraocular perspective, and difficulty of performing bimanual surgery.
11:06 AM
novel Technical Developments to improve surgical safety During (Phaco) vitrectomy

Peter Stalmans, MD, PhD* (Leuven, Belgium)
10:58 AM
operations iraqi freedom and enduring freedom 2003-2009: The Walter reed experience
Marcus H. Colyer, MD (Washington, DC), Dal W. Chun, MD, Farhad Safi, Michael Smith, Michael Mines
PurPose During (phaco)vitrectomy, the surgeon can encounter several intra-operative complications: posterior capsule aspiration and rupture during lens surgery, aspiration of retinal tissue in the vitrectome during vitreous base shaving and intraoperative pressure alterations leading to hypotony (inducing eye collaps and even subchoroidal haemorrhage) or hypertony (compromising the retinal perfusion). MeTHoD
Several soft- and hardware features were developed on the Dual Associate device (DORC): 1. During phaco surgery, a vacuum sensor monitors the amount of aspiration that is generated by the venturi system. A threshold vacuum setting is programmed, resulting in a high vacuum during tip occlusion to ease the lens removal while an automated reduced vacuum level is generated without tip occlusion. 2. For using the vitrectome in close proximity to the retina, a persistalic pump system with a preset fluid flow and automated vacuum adaptation was designed. 3. A feedback system between the aspiration rate (vitrectome) and the infusion rate (air-driven infusion line) was developed.
PurPose To report the injury patterns and visual outcomes of patients evaluated by the Walter Reed Army Medical Center Ophthalmology Service between 2003 and 2009. MeTHoD Retrospective, noncomparative case series of 783 eyes of 574 military healthcare beneficiaries who were evaluated by the Walter Reed Army Medical Center Ophthalmology Service from January 2002 through March 2009 with a diagnosis of ocular trauma. Injury characteristics, specific surgical techniques employed, and postoperative visual and anatomic outcomes at 6 months and final followup were evaluated. resulTs The median ocular trauma score was 8026 (range 12-100). Closed globe injuries comprised 347 eyes (44%) while open globe injuries occurred in 289 eyes (37%). Of eyes sustaining closed globe injuries, zone 1 and 2 injuries occurred in 158 eyes (20%), while zone 3 injuries occurred in 199 eyes (25%). Intraocular foreign bodies were present in 118 eyes with open globe injuries (15%), while perforating injuries occurred in 74 eyes (9.5%). Simple penetrating injuries occurred in 41 eyes (5%), while blunt-force globe ruptures occurred in 54 eyes (6.9%). Orbital or eyelid injuries were present in 421 eyes (54%) while neuro-ophthalmic injuries occurred in 176 eyes (23%). In total, 336 surgical procedures were performed on 237 patients. The average initial logMAR was 0.75 1.0, while at 6 months average best corrected visual acuity was 0.39 0.74. At final follow-up, 425 patients (54%) were achieved 20/40 or better visual acuity. conclusion Nearly 10% of all casualties Operation Iraqi Freedom and Operation Enduring Freedom sustained some degree of ocular injuries, and nearly half of those patients have been treated at the Walter Reed Army Medical Center. Fortunately, the majority of patients retain excellent vision; however, devastating ocular injuries have occurred.
resulTs
1. Using the threshold venturi setting during lens segment removal, aspiration of the lens pieces is facilitated because of the amount of vacuum available, but the threshold system also avoids aspiration of the posterior lens capsule. 2. The peristaltic vitrectomy setting results in a constant fluid flow, which is the key factor to avoid inadvertent retinal aspiration when the vitrectome opening is moved in and out the remaining peripheral vitreous during vitreous base shaving. The automated vacuum level control avoids variations in flow rate during this delicate intra-ocular maneuver. 3. By developing a feedback system between the vitrectome aspiration and infusion rate, a highly stable intra-ocular pressure is obtained, regardless of the amount or speed of fluid aspirated from the eye, and without need to change the intra-ocular pressure settings during the procedure.
conclusion
The newly developed features provide an improved safety during vitrectomy, by avoiding surgical damage to the eye: An extremely stable anterior chamber is obtained during phaco surgery.
Inadvertent aspiration of the retina with the vitrectome is avoided. During vitrectomy, the intra-ocular pressure is kept at a constant level, regardless of the amount of aspiration generated by the vitrectome.
11:14 AM
A ring is containing the PEG hydrogel polymer sealant over the 20 gauge sclerotomy until it jellify.
11:28 AM
Discussion
11:20 AM
cauterization of leaking sclerotomies after 23-gauge Transconjunctival Pars Plana vitrectomy

Francesco Boscia, MD* (Bari, Italy)
Polyethylene glycol (Peg) Hydrogel Polymer sealant for sclerotomy closure: Preliminary in vivo clinical results
Fabio Patelli, MD (Milan, Italy), Seenu M. Hariprasad, MD*, Enrico Giacomotti, Paolo Radice, Sandro Vergani
PurPose
To evaluate efficacy and safety of bipolar cauterization to ensure wound closure of leaking sclerotomies in 23-gauge transconjunctival sutureless pars plana vitrectomy (TSV).
MeTHoD PurPose To test a PEG-based hydrogel bandage for effectively securing sutureless pars plana vitrectomy incisions. This would entail the sealant preventing the entry of surface fluid as well as the leakage of intraocular fluid in the early postoperative period. This is relevant as entry of fluid and leakage of intraocular fluid are associated with postoperative endophthalmitis and hypotony respectively MeTHoD Sealing of 23g and 20g sclerotomies after vitrectomy surgery using PEG hydrogel polymer sealant will be presented. Use of PEG Sclerotomy Sealant in conditions of intravitreal Balanced Salt Solution (BSS), air and silicone oil fill will be presented. Video, as well as, application techniques will be reviewed. resulTs The application of PEG Hydrogel sealant was successful in all eyes tested with various substitutes. In sclerotomies leaking BSS, the gel time of PEG hydrogel sealant is longer, therefore surface must be dry for successful application. Once gelled, PEG Hydrogel sealant successfully secured all the sclerotomies tested. conclusion The use of a hydrogel bandage to close sutureless sclerotomies is an alternative to sutures. Closure of sutureless sclerotomies may reduce the entry of ocular surface fluid into these incisions and prevent leakage of intraocular fluid in the immediate post operative period. Incision closure may reduce the incidence of post operative endophthalmitis and hypotony in sutureless vitreous surgery.
One-hundred-thirty-six eyes of 136 patients with a variety of pathologies were enrolled and monitored for a mean follow-up of 19.44 weeks (range 12-53 weeks). Eighty-nine eyes were operated on with the Constellation system (Alcon, Inc, Forth Worth, TX), and 47 with the PentaSys 2 platform (Fritz Ruck GmbH, Germany). Vitreous was removed entirely with triamcinolone staining. At the end of the procedure, when leakage was observed, bipolar cauterization was applied on sclerotomy. Number of persistent leakage with ensuing sutured sclerotomies was recorded. Postoperative IOP, hypotony (<6 mmHg), Seidel positivity, conjunctival blebs, and complications were evaluated at hour 6, day 1 and 3.
resulTs
A total of 240/408 (58.8%) sclerotomies showing leakage at the end of the procedure were included. Only 7/240 (2,9%) sclerotomies needed sutures because of intraoperative leakage even after cauterization. At 6 and 24 hours, hypotony occurred in 6/132 (5%) and 2/132 (1.5%) eyes, respectively. Postoperatively, no leakage and/or conjunctival blebs were observed. In only one case (1/233, 0.43%) a positive Seidel was observed, that needed suturing. Mean intraocular pressure did not vary significantly at any postoperative time point. No complication was recorded. Bipolar cauterization of sutureless sclerotomies is a simple, safe and effective method to obtain complete sclerotomy closure in leaking sclerotomies after 23-gauge TSV, without significant postoperative complications.
conclusion
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14 viTreoreTinal surgery iv 10:50 AM12:00 PM

11:36 AM
MeTHoD
a Minimally invasive intravitreal subconjuctival Jet injector

Gholam A. Peyman, MD* (Phoenix, AZ), Kamran Hosseini, MD*, Michel Cormier, MD*
PurPose To evaluate a minimally invasive intravitreal and subconjuctival jet injector for the administration of a pharmacological agents in the vitreous or in the subconjuctival space. MeTHoD The system is equipped with a microneedle in communication with an internal formulation chamber that is adapted to receive and contain the pharmacological agents. A piercing depth limiting flange restricts the penetration depth of the microneedle into the sclera to < 0.1mm, and simultaneously defines the location of the pars plana from the limbus. The injection is achieved using a defined pressure. The system was evaluate on the enucleated rabbit eye and in vivo on rabbit eyes. resulTs When activated by the operator, the system forces, with pressure of <1000 Psi, the medication through the remaining scleral thickness into the vitreous cavity in a few microseconds. At low jet pressures, (<400 PSi) it produced readily a subconjuctival injection.. There were not wet injection of the medication outside the conjunctiva. No intraoperative or short term post-operative complications related to the lens or retinal injury was observed by clinical or histological examination of the eyes. conclusion The device simplifies both intravitreal and subconjuctival injection of a medication. Because the needle does not enter the eye, it may reduce patients apprehension of having one or multiple intraocular injections.
A retrospective literature review of randomized, controlled US clinical trials was performed. A total of 432 patients received difluprednate, and dosing regimens were as follows: twice-daily (n=111) or four times daily (n=107) postoperatively, twice-daily (n=81) or four times daily (n=83) preoperatively, and four times daily (n=50) as treatment for anterior uveitis. The mean exposure to difluprednate was 27.1 days. A criterion increase in IOP was defined as a value of 21 mmHg and change from baseline 10 mm Hg at the same visit. The total number and percentage of patients treated with difluprednate that experienced a criterion increase in IOP was identified for each clinical trial.
resulTs
In two phase 3 trials, 3/111 (2.7%) patients receiving postoperative difluprednate BID and 3/107 (2.8%) patients receiving the drug QID after surgery had a rise in IOP. In two phase 3b studies, treatment with difluprednate began one day prior to surgery; the BID arm (n=81) included 3 patients (3.7%) and the QID arm (n=83) included 5 patients (6.0%) with a rise in IOP. The rates of IOP increase in the aforementioned studies were comparable to the respective placebo arms. Lastly, in an anterior uveitis study of QID difluprednate, 3/50 (6.0%) patients had a rise in IOP, which was comparable to 2/40 patients (5%) in the comparator group that received prednisolone acetate 1.0% eight times daily (Table 1). Overall, the incidence of clinically significant IOP increases for these studies ranged from 2.7%-6.0%. Increases either resolved spontaneously or were treated with IOP-lowering medications. Additionally, mean IOP remained similar to baseline measures throughout the trial periods. An overall low incidence of clinically significant IOP rises in patients receiving treatment with difluprednate was observed in a retrospective review of five clinical trials. Difluprednate ophthalmic emulsion, 0.05%, is a potent steroid being used to treat inflammation, and further study regarding its use and safety profile in the posterior segment is warranted.
conclusion
11:44 AM
a retrospective clinical Trial review of the incidence of intraocular Pressure rises with Difluprednate ophthalmic emulsion, 0.05%, Treatment
Andrew A. Moshfeghi, MD, MBA* (Palm Beach Gardens, FL), Thomas A. Albini, MD*
PurPose Difluprednate is increasingly being used to treat posterior segment inflammation. It has been studied perioperatively and in uveitis, and most recently demonstrated efficacy in two small case series of diabetic macular edema. Because it is a potent steroid, IOP elevation is a concern. This review will identify the incidence of IOP increases observed in difluprednate clinical trials.
11:52 AM
Discussion
12:00 pM
closing remarks and Meeting adjourns
Scientific Posters
Scientific Posters
Macular. .Degeneration. . . . . . ................. ..............................
AMD Neovascular
POSTERS 101-127
CONCLUSION
Classical music has a trend to decrease anxiety in patients without decreasing perceived pain. Patients who listened to music during intravitreal injections desired to have music played for future injections. Music therapy is a low-cost and easy intervention with minimal risks that may be helpful in reducing anxiety during intravitreal injections in an outpatient setting.
101
102
Effects of Music Therapy on Patients Receiving Intravitreal Injections: A Randomized Clinical Trial
Ron A. Adelman, MD, MPH (New Haven, CT), Xuejing Chen, MD, Veena S. Rao, Rajeev K. Seth, MD
Sixty Month Follow-up Data in Patients Receiving Anti-VEGF Therapy for Exudative AMD
Mathew W. Aschbrenner, MD (St. Louis, MO), Daniel P. Joseph, MD, PhD*
PURPOSE
To determine visual acuity (VA) and central macular thickness (CMT) in patients with wet age-related macular degeneration (AMD) receiving bevacizumab and/or ranibizumab with five year (60 month) follow-up.
To study the effects of classical music on anxiety, perceived pain and satisfaction of patients undergoing intravitreal injections in the outpatient setting.
PURPOSE METHOD Randomized clinical trial. Patients who were scheduled for intravitreal injections were randomized into a music therapy group receiving music or a control group not receiving music. Prior to the injection, each patient filled out an English version of the state portion of the State Trait Anxiety Inventory (STAI-S). Patients in the music therapy group listened to classical music from an Internet radio site as they waited for and during the procedure. Patients in the control group underwent the procedure in the same setting without music. Afterwards, all patients filled out the STAI-S again, as well as an additional satisfaction and pain survey with a visual analog scale (VAS). RESULTS The main outcome measures were self-reported satisfaction and pain levels, as well as anxiety derived from the STAI-S scores. Sixty nine patients participated, with 35 patients (57% female, 43% male) in the music therapy group and 34 patients (41% female, 59% male) in the control group.
METHOD
Retrospective chart review of eligible patients with wet AMD treated with either bevacizumab or ranibizumab on or before 11.1.2005 with follow-up of five years or 60 months at a single institution. Snellen VA was recorded for each visit and converted to logMAR. VA at first injection, 6, 12, 18, 24, 30, 36, 42, 48, 54 and 60 month follow-up visits were analyzed. CMT was recorded using optical coherence tomography (OCT) at first injection, 12, 24, 36, 48 and 60 month follow-up. Values were compared using paired T-test.
RESULTS
The mean ages for the music therapy group and control group were 72 and 72 respectively. There was a trend toward a greater decrease in anxiety after the injection in the music therapy group as compared to the control group (p = 0.058). Furthermore, subjects in the music therapy group (83%) requested music in future injections more frequently than those in the control group (59%) (p = 0.0356). Both the music therapy group and control group were similar in their reported levels of pain during the procedure (p = 0.638).
Nine eyes had a mean logMAR VA 0.65 (sd 0.27) at initial injection. Mean logMAR VA at six, 12, 18, 24, 30, 36, 42, 48, 54, 60 months was 0.49 (sd 0.12), 0.53 (sd 0.15), 0.66 (sd 0.35), 0.53 (sd 0.37), 0.63 (sd 0.43), 0.58 (sd 0.45), 0.58 (sd 0.29), 0.57 (sd 0.45), 0.56 (sd 0.42), 0.64 (sd 0.45) respectively. There was no statistically significant change in VA at 60 months (p=0.429). At 60 months, 33.3%, 77.8% and 100% of patients had maintained Snellen VA of 20/40, 20/100 and 20/400. Mean CMT was 328 m (sd 17) at the initial injection visit. Mean CMT was 212 m (sd 28) 215 m (sd 34) 195 m (sd 26) 197 m (sd 29) 192 m (sd 20) at follow-up visits 12, 24, 36, 48 and 60 months. The difference in CMT between initial visit and 60 month followup was statistically significant (p=<.001). Mean follow-up was 7.7 weeks (sd 2.2). Patients received intravitreal bevacizumab or ranibizumab at a mean of 47.7% of visits. To date, there are no known studies analyzing VA of patients treated with anti-VEGF agents with 60 month follow-up. In this study, VA was maintained by giving treatment on an as needed basis. This study also showed CMT was significantly decreased at 60 months. Thus, anti-VEGF treatment on an as needed basis can achieve improvement in macular anatomy and maintain VA over five years.
CONCLUSION
83
AMD NEOVASCULAR
103
PURPOSE
Hypoxia Induces a Post-transcriptional Regulator, SIRT1 (Histone Deactylase; HDAC) Mediated VEGF Activation in Choroidal Retinal Neovascularisation
Sankarathi Balaiya, PhD (Jacksonville, FL), Vijay Khetpal, MD*, K.V. Chalam, MD, PhD, MBA, FRCS(C)
To evaluate choroidal thickness using spectral domain optical coherence tomography (SD-OCT) imaging both before and six months after initiation of treatment with intravitreal anti-vascular endothelial growth factor (anti-VEGF) in patients with neovascular age-related macular degeneration (AMD).
METHOD
PURPOSE Hypoxia, a critical pathological factor in retinal diseases including AMD, up regulates angiogenic growth factors like erythropoietin (EPO), vascular endothelial growth factor (VEGF) and promotes neovascularization. Hypoxia changes cellular redox state and activate class III HDACs, sirtulin1 (SIRT1). Activated SIRT 1 signals HIF2 (hypoxia inducible factor) which transactivate VEGF and EPO. METHOD Choroidal endothelial cells (RF/6A) were maintained in a semi-confluent state in an appropriate condition. Hypoxia was induced by exposing the cells to cobalt chloride for 24 hours and confirmed by flow cytometric analysis. The role of Sirt1 in cell viability was evaluated using WST-1 assay with and without blocking Sirt1 inhibitor, sirtinol. The activation of HIF-2 during hypoxia in presence or absence of SIRT1 was noted using immunoblot analysis. VEGF levels were quantified using enzyme linked immunosorbent assay (ELISA). RESULTS Flow cytometric analysis confirmed the induction of hypoxia by cell cycle arrest at starting at 200 M concentration of cobalt chloride. In comparison to control, the viability of choroidal endothelial cell decreased to 46.2% after blocking SIRT 1 activity. However, the viability significantly increased to 55.2% and 52.4% after inducing hypoxia at 100 and 200 M concentrations respectively, compared to control (p<0.01). After the induction of hypoxia, immunoblot analysis showed a four-fold increased expression of HIF-2 and the expression was suppressed by blocking SIRT 1 activity (p=0.01). VEGF levels decreased after blocking sirt1 activity in hypoxic cells, compared to control. CONCLUSION Activation of SIRT1 during pathological hypoxia leads to VEGF induced choroidal endothelial cell proliferation, a cell culture model of choroidal neovascularisation. Further detailed mechanistic evaluation of SIRT1 in choroidal neovascularisation may serve as a therapeutic target for age related macular degeneration.
For this prospective case-control investigation, 22 eyes of 22 patients with neovascular AMD were identified prior to first-time anti-VEGF treatment. All patients with concomitant ocular pathologies were excluded. Twenty healthy eyes of 20 subjects without ocular pathology were also identified. Patients were imaged with SD-OCT prior to first time treatment with anti-VEGF, 3 and 6 months subsequently. Healthy eyes were imaged at the time of identification and 6 months subsequently. Sub-foveal choroidal thickness measurements were manually performed by two independent observers. Two-way ANOVA with Bonferronis post-test and paired t-tests were used to compare measurements.
RESULTS
A total of 22 eyes of 22 patients were included in this study. Twenty two patients were scanned at 3 months and 17 patients were scanned at 6 months. 5 patients were lost to follow-up. Average age of patients is 79 (range 66-88). Subfoveal choroidal thickness was thinner at 6 months by 18.0m (95% CI 4.7m to 31.3m) compared with pre-treatment. No significant difference between pre-treatment and 3 months was observed 13.7m (95% CI -2.0 m to 29.5 m). Subfoveal choroidal thickness in healthy eyes did not decrease over 6 months p=0.722. Over a three month period, treatment with intravitreal anti-VEGF for neovascular AMD is not associated with significant choroidal thinning. However, over 6 months, use of intravitreal anti-VEGF is associated with significant thinning of the choroid where choroidal thickness of healthy eyes over 6months remains stable. This may have implications for the physiologic functions of the choroid.
CONCLUSION
104
Analysis of Intravitreal Anti-VEGF on Choroidal Thickness in Neovascular AMD Using SD-OCT

Caio V. Regatieri, MD, PhD (Boston, MA), Lauren A. Branchini, BA, Mehreen Adhi, MD Ignacio Flores-Moreno, Varsha Manjunath, BS, J.G. Fujimoto, Jay S. Duker, MD*
Graph of mean choroidal thickness in normal subjects and diabetic patients. Mean choroidal thickness at each of the 11 locations measured at 500 m (0.5 mm) intervals temporal (T) and nasal (N). NPDR: non-proliferative diabetic retinopathy; DME: diabetic macular edema; PDR: proliferative diabetic retinopathy. P-value represents the result of statistical analyses (ANOVA).
84 SCIENTIFIC POSTER ABSTRACTS
SCIENTIFIC POSTER ABSTRACTS
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Impact of Availability of Anti-VEGF Therapy on Legal Blindness and Other Levels of Visual Impairment Due to Neovascular AMD
John P. Campbell, MD (Baltimore, MD), Susan B. Bressler, MD*, Neil M. Bressler, MD*
OCT in the Management of Neovascular AMD: A Comparison of Spectral-domain and Time-domain Retinal Imaging Systems
David M. Brown, MD* (Houston, TX), James C. Major, MD, PhD*, Angeline Mariani, MD
PURPOSE Theoretical modeling suggests that anti-VEGF therapy may reduce the frequency of legal blindness substantially due to choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD), assuming access to and application of monthly ranibizumab for 2 years. This study was performed to determine if this hypothesis is supported by outcomes noted within a clinical setting. METHOD A retrospective cohort study of patients with incident neovascular AMD in 2002 and 2008. Main eligibility criteria were as follows: age > 50; incident CNV due to AMD in 2002 or 2008, and at least 12 months of follow-up. The primary outcome was prevalence of legal blindness (20/200 or worse in the better-seeing eye). Secondary outcomes included prevalence of moderate visual impairment or worse (20/80 or worse in the better-seeing eye) or mild visual impairment or worse (20/40 or worse in the better-seeing eye) at two years. Additional outcomes included the percentage of patients with 20/200 or worse, 20/80 or worse, or 20/40 or worse in the study eye at two years. RESULTS The 2002 cohort consisted of 91 eyes of 84 patients; the 2008 cohort had 43 eyes of 41 patients. Two years after presentation, the prevalence of legal blindness was 29% (95% confidence interval [CI]: 19% to 39%) in the 2002 cohort and 2% (95% CI: 0.1% to 13%) in the 2008 cohort, a 95% reduction in odds of legal blindness (P = 0.006) in the 2008 cohort relative to the 2002 cohort (95% CI: 59% to 99.5%); the prevalence of moderate visual impairment or worse was 45% (95% CI: 34% to 56%) in the 2002 cohort and 17% (95% CI: 5% to 29%) in the 2008 cohort, a 78% risk reduction (95% CI: 33% to 92%) in odds of moderate visual impairment (P= 0.007); a difference in the prevalence of mild visual impairment or worse between the two cohorts was not identified. The reduction in prevalence of 20/200 or worse, 20/80 or worse, and 20/40 or worse in study eyes 2 years after presentation of CNV in the study eyes appeared similar to the results for the better-seeing eyes of each subject. CONCLUSION Although there are several limitations to this retrospective study, the conclusions provide additional evidence that AMD no longer may be the leading cause of blindness among people in the United States over age 50, especially if access and application of ranibizumab as often as every month is available.
PURPOSE
Most patients with neovascular AMD are treated with intravitreal anti-VEGF agents guided by ocular coherence tomography (OCT). To assess the relative sensitivity of commonly available OCT machines and to test the hypothesis that spectral domain (SD) OCT would detect more disease than time-domain (TD) OCT, we performed a head to head comparison in a population with a high prevalence of retinal pathology. Stratus 512 A-scan 6-line OCT scans, Cirrus HD 512 x 128 macular thickness cube scans, Cirrus HD 5-line raster scans, Spectralis OCT high resolution 6-line 20 degree radial scans with 9x averaging, Spectralis OCT high resolution 7-line Raster scans with 15x averaging, and a custom Spectralis OCT high speed 49 scan 20x20 degree macular volume scan with 9x averaging were performed on 50 patients at each exam in the prospective Super Dose Anti-VEGF (SAVE) trial evaluating 2.0 mg ranibizumab for refractory neovascular AMD and were analyzed independently for signs of disease. Comparisons between time-domain and spectral-domain were made with Fisher exact test.
METHOD
RESULTS
Out of 191 total visits, the Stratus identified evidence of disease activity on 72.4% of exams where pathology was visualized by any machine (118/163), the SD Cirrus HD identified pathology on 93.9% (153/163) of exams (p<0.001 compared to Stratus), and SD Spectralis OCT 99.4% (162/163) of exams (p<0.001 compared to Stratus). As many practitioners base retreatment decisions only on pathology above the RPE, classification of disease was defined as the presence of intraretinal cysts or subretinal fluid. Stratus imaging failed to identify a cyst in 36.1% of exams positive on any machine (30/83) and failed to identify subretinal fluid in 33.6% of exams positive for such on any machine (39/116) (p<0.001). Sensitivity for identifying subretinal fluid and intraretinal cysts is shown in the figure below. With both spectral-domain machines, examination of all lines of the cube was most likely to identify pathology.
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CONCLUSION In a population with a high prevalence of pathology, spectral-domain OCT (SD Cirrus HD and SD Spectralis OCT) significantly identified more disease activity than the highest resolution scan available on the time-domain Stratus machine. For the most vigilant screening and management of neovascular AMD, careful examination of all lines of the spectral-domain cubes is recommended.
the patient-reported symptoms prior to initial injection. Multivariate regression analysis demonstrates one additional week of symptoms prior to treatment will lead to 0.55 weeks less for injection interval. When an arbitrary cutoff of 4 weeks of symptoms prior to treatment versus subjects with >4 weeks of symptoms prior to treatment was analyzed, the mean time to repeat injection was 10.92 weeks versus 5.75 weeks (p<0.0001), respectively. Ranibizumab dose did not appear to influence timing of the second injection.
CONCLUSION
In the first study to evaluate a higher dose of ranibizumab using a purely PRN dosing regimen for wet AMD, baseline characteristic analysis suggests patient-reported duration of symptoms is predictive in the timing of the second ranibizumab injection. Long-term data from this trial is needed to better define predictive factors and ranibizumab treatment interval.
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Neovascular AMD OCT pathology identified by TD or SD OCT scanning in the SAVE 2.0 mg ranibizumab trial for recalcitrant AMD.
Resveratrol Inhibits Proliferation of Choroidal Endothelial Cells in Hypoxia: A Model for Neovascular AMD
K.V. Chalam, MD, PhD, MBA, FRCS(C) (Jacksonville, FL), Vijay Khetpal, MD, Sankarathi Balaiya
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Predictive Factors for Repeat Dosing in Wet AMD: Results from the DODO Trial
Brandon G. Busbee, MD (Nashville, TN)*, Chengqing Wu, MD, Mary Ann McCain, MD
PURPOSE
PURPOSE This report from the DODO (double dose) trial evaluates baseline characteristics, including duration of symptoms and baseline ETDRS score, and ranibizumab dose (0.5mg, 1.0mg or 2.0mg) for their effect on the timing of the second ranibizumab injection for nave wet AMD. METHOD This is an on-going prospective single-masked, singlecenter, randomized two-year trial comparing 0.5mg, 1.0mg and 2.0mg PRN ranibizumab injections for nave wet AMD. Following the initial injection at baseline, additional injections are given only if ETDRS vision decreased by 5 letters or optical coherence tomography (OCT) demonstrated recurrent fluid. During the first 6 months of this trial, subjects are evaluated bimonthly. Baseline factors, including weeks of patient-reported symptoms prior to the initial treatment and baseline ETDRS score, and ranibizumab dose were analyzed as potential predictors of timing for the second ranibizumab injection. RESULTS 25 subjects were included in this analysis. The only baseline characteristic that was significantly correlated with the interval between first and second ranibizumab injections was
Resveratrol, a common antioxidant present in red wine and natural plants has been shown to be anti-angiogenic in carcinoma and modulates vascular endothelial cell function in diverse angiogenic beds. We evaluated its role in regulation of choroidal endothelial cell proliferation after chronic hypoxia, a cell culture model of age related macular degeneration.
METHOD
Choroidal endothelial cells (RF/6A) were maintained in a semi-confluent state. Hypoxia was induced using cobalt chloride at two different concentrations to mimic lower and higher hypoxia (200 and 400M) and degree of hypoxia was confirmed with flow cytometric analysis. Cells were then exposed to escalating doses of resveratrol from 2, 4, 8, 12g/ml and cell viability was analysed by WST-1 assay. Following optimization, the effect of resveratrol (4 and 12g/ml) on hypoxic cells was evaluated. Further, hypoxia induced VEGF release from choroidal endothelial cells was assessed with ELISA. We observed a dose dependent increase of cell viability (127.431.6%, 136.331.8%, 132.92.5% and 115.62.3% at doses of 2, 4, 8 and 12g/ml) of hypoxic choroidal endothelial cells (200 M) that were exposed to resveratrol compared to controls. Similar trend continued at higher levels of hypoxia
RESULTS
(400 M). Cell viability decreased to 45.42.7% after severe hypoxia but was rescued with addition of resveratrol at 4g/ml to 76.15.6% (p value <0.01). The VEGF levels proportionately decreased from 20.783.8pg/ml to 13.444.6pg/ml after addition of resveratrol (4g/ml).
CONCLUSION Exudative AMD is characterized by hypoxic proliferation of choroidal endothelial cells. Resveratrol inhibits hypoxia induced proliferation of choroidal endothelial cells and has potential to be of therapeutic use in exudative form of age related macular degeneration.
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Epimacular Brachytherapy in Treated AMD Patients: The MERITAGE Study 18 Month Results
Pravin U. Dugel, MD* (Phoenix, AZ), Tim Jackson, MD, Michael Bennett, MD, Adiel Barak*, MD, Dov Weinberger, MD
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PURPOSE
Visual Outcomes of Intravitreal Anti-VEGF Therapy for Neovascular AMD with Advanced Visual Loss at Initial Presentation
Nauman A. Chaudhry, MD (New London, CT), Homayoun Tabandeh, MD*, Veronica A. Kon-Jara, MD, David S. Boyer, MD*, Nikolas London, MD, Thomas G. Chu, MD, PhD*
To assess the safety and efficacy of epimacular brachytherapy (EMBT) in previously treated neovascular age-related macular degeneration (nAMD) patients. 53 patients with previously treated classic, minimally classic and occult lesions were enrolled. Patients had received a mean of 12 injections prior to enrolment. Patients underwent pars plana vitrectomy and 24 Gray beta irradiation, using an investigational device to deliver Strontium-90 brachytherapy (NeoVista). Anti-VEGF injections were administered if there was a 5 ETDRS letter loss, >50 micron central retinal thickness increase on optical coherence tomography (OCT), new macular hemorrhage, or new lesion activity, visible with fundus fluorescein angiography (FFA). The response to EMBT according to lesion type was studied.
METHOD
PURPOSE Many clinical studies that established the beneficial effect of intravitreal anti-VEGF therapy did not include the cohort of patients with poor presenting visual acuity. The purpose of the current study is to report outcomes of intravitreal anti-VEGF therapy for Neovascular AMD (nvAMD) in patients with presenting best corrected visual acuity (BCVA) < 20/400. METHOD Retrospective case series. Inclusion criteria: patients with previously untreated nvAMD and presenting BCVA <20/400. Exclusion criteria: subretinal fibrosis involving central fovea, subfoveal hemorrhage greater than 1 disc area, presence of other ocular pathology reducing vision. RESULTS Twenty two eyes of 22 patients, mean age 80.6 (range 70-97) years. BCVA at presentation was 20/400 in 7 (32%), and worse than 20/400 in 15 (68%) patients. Treatment included ranibizumab in 11, bevacizumab in 8, and ranibizumab and bevacizumab in 3 patients. At the last follow-up (mean 16.1 months) BCVA was >20/40 in 5 (22%), 20/50-20/100 in 3 (14%), 20/200 in 4 (18%), 20/400 in 6 (27%), and <20/400 in 4 (18%) eyes. Mean number of injections was 7.3 injections. CONCLUSION In the absence of subfoveal fibrosis or extensive subretinal hemorrhage, anti-VEGF therapy may be beneficial in patients with previously untreated nvAMD and severe vision loss. Treatment decisions should not be based on presenting visual acuity but on the characteristics of the lesion. Larger, prospective studies are needed to better answer this important clinical question.
RESULTS
18 months after EMBT, a mean of 5.6 anti-VEGF injections, including the mandated injection at baseline, was required.18% of patients remained injection free and 47% improved vision (mean improvement 7.5 letters). 84% of patients did not lose more than 15 ETDRS letters. At 12 months 67% of patients with a classic lesion component and 100% with a predominantly classic lesion showed complete lesion regression. Patients requiring chronic anti-VEGF treatment represent a rapidly growing population. This is the first study with the longest follow-up in these difficult patients who bear the burden of our current, unsustainable monotherapy treatment. EMBT not only reduced the treatment burden, but also improved vision and caused significant neovascular membrane lesion regression in selected patients.
CONCLUSION
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Comparison of Anti-VEGF Agents Administered by PRN Dosing for the Treatment of Neovascular AMD
Alan J. Franklin, MD, PhD (Mobile, AL), John P. Myers, MD, Magdalena Shuler, MD, Neel M. Kumar, Sunil Gupta
Comparison of Intravitreal Bevacizumab and Ranibizumab 12 month data for the treatment of neovascular AMD. Intravitreal injection of both Bev and Ran improved Logmar vision by 1 line, 0.09, p=0.98. The difference in OCT thickness was also similar for Bev, 37 microns, and Ran 54 microns, p =0.50. However, the treatment burden of Bev was significantly less than Ran, 6.01 vs. 7.35 injections, p<0.05.
PURPOSE This study aims to compare the efficacy of bevacizumab alone or mixed with low dose triamcinolone with ranibizumab. To determine the relative effectiveness of these treatments we collected 3, 6, and 12 month data that included visual acuity, central OCT thickness, treatment burden as well as incidence of CNVM in the fellow eye over a two year period. METHOD This is a retrospective chart review of approximately 130 patients who received either intravitreal injection of bevacizumab or ranibizumab in a treat and extend algorithim as well as 300 patients who received intravitreal injection of bevacizumab combined with 750 micrograms of triamcinolone in a PIER-type protocol of every three month injection for the treatment of neovascular AMD. We measured Snellen visual acuity, central macular thickness analyzed by time domain OCT at 3, 6, and 12 months after new onset of CNVM. We also compared the treatment burden amongst each group over the initial 12 months of treament as well as incidence of new neovascularization in the fellow eye over 2 years.
Comparison of Intravitreal anti-VEGF treat and extend vs. PIER-type algorithim 12 month data for the treatment of neovascular AMD. Intravitreal injection of both Bev and Ran improved Logmar vision by 1 line, 0.09, and was superior to a PIER type approach Logmar 0.01, p<0.05. However, the change in OCT thickeness was similar 47 microns for treat and extend, and PIER type protocol 25 microns, p=0.19.
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We compared patients who received intravitreal injections of bevacizumab (Bev), bevacizumab with triamcinolone (Bev + TA), or ranibizumab (Ran). Patients were similar with respect to initial visual acuity, OCT thickness, sex, and eye affected, whereas patients that received Ran tended to be older than those injected with Bev or Bev + TA. After 1 year patients in the Bev and Ran groups had an almost identical improvement in Logmar visual acuity, 0.09 p=0.98. The average change in Central OCT thickness was similar with a 37 and 54 micron reduction for Bev and Ran, respectively, p=0.50. Patients with Bev required less injections over the first year to achieve these results, 6.01 vs. 7.35, p<0.05. However, diminishing the treatment further by administering Bev + TA in a PIER-type protocol, 5.23 injections over 1 year, led only to visual stabilization, Logmar difference 0.01, p<0.05 compared to Bev and Ran together. Finally, incidence of new CNVM in the fellow eye was similar in all groups.
RESULTS CONCLUSION On average patients who received intravitreal bevizumab or ranibizumab for new onset neovascular AMD gained one line of vision, Logmar 0.09, and the visual benefit from each of these ani-VEGF agents was virtually identical, p=0.98. Less injections of bevacizumab 6.01 vs. 7.35, p <0.05 were needed to achieve this goal. A PIER type approach with 5.23 injections was less effective, Logmar change 0.01.
Validity of Administrative Databases in Characterizing Veterans with Neovascular AMD

Paul B. Greenberg, MD* (Providence, RI), Victoria L. Tseng, MD, Wen-Chih Wu, MD, Lan Jiang, MD, Peter D. Friedmann, MD
PURPOSE
To evaluate the accuracy of VHA national coding databases by comparing characteristics of neovascular AMD patients identified using administrative coding data versus a content-based chart review.
METHOD
Neovascular AMD patients at the Providence VA Medical Center (PVAMC) were identified using International Classification of Diseases-Modification 9 (ICD-9) codes. A content-based chart review was performed on this cohort to identify patients treated with ranibizumab or pegaptanib; these charts were then reviewed for demographics, systemic comorbidities from the Charlson Comorbidity Index (CCI), and arterial thromboembolic events (ATEs) within one year of first AMD treatment. The National Patient Care Database (NPCD) was used to identify the same parameters at PVAMC using administrative codes. Coding data was compared against chart data for accuracy, sensitivity, and specificity.
RESULTS
Of 434 patients from chart review and 424 patients from coding review, the two methods found 405 common patients with a new diagnosis of neovascular AMD from 20022009. Identification of AMD treatment with ranibizumab or pegaptanib, systemic comorbidities, and ATE incidence was compared. Accuracy was highest identifying systemic comor-
bidities in pegaptanib-treated patients (1.00) and the study population (0.99), and lowest identifying ATEs in pegaptanibtreated patients (0.50). Sensitivity was highest identifying pegaptanib-treated patients (1.00; 95% confidence interval [CI] 0.46,1.00) and ranibizumab-treated patients (0.90; 95% CI 0.77,0.96), and lowest identifying ATEs in ranibizumabtreated patients (0.00; 95% CI 0.00,0.8). Specificity was highest identifying systemic comorbidities in ranibizumab-treated patients (1.00; 95% CI 0.05,1.00) and the study population (0.99; 95% CI 1.00,1.00), and lowest identifying ATEs in pegaptanib-treated patients (0.50; 95% CI 0.13,0.86). With chart content as the gold standard, coding data is excellent in identifying neovascular AMD diagnosis and treatment. However, coding data is poor in identifying ATE incidence after AMD treatment. These findings suggest that administrative data should be interpreted with caution and validated against chart content when being used as the sole data source in retrospective research studies.
CONCLUSION
with a resolution of fluid with more frequent dosing required continued frequent injections to maintain vision and anatomic stability.
CONCLUSION
An increase in the frequency of anti-VEGF dosing can result in the restoration of macular anatomy and a reduction of CMT in treatment-refractory AMD patients. This treatment alternative should be considered in patients who are non-responsive to conventional dosing regimens.
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One-year Results of Intravitreal Ranibizumab for Polypoidal Choroidal Vasculopathy

Young Jung Roh, MD (Seoul, South Korea), Hyun-Wok Ryu
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Frequent Dosing of Intravitreal Anti-VEGF Agents for Treatment Refractory Neovascular AMD
Yu Hyon Kim, MD (Portland, OR), Christina J. Flaxel, MD, Peter Francis, Thomas S. Hwang, MD
PURPOSE
To evaluate the efficacy of intravitreal ranibizumab administration with three initial monthly injections for the treatment of polypoidal choroidal vasculopathy (PCV) in Korean.
METHOD
PURPOSE This study evaluates the effects of shorter (2-3 weeks) than conventional monthly dosing interval of intravitreal anti VEGF agents for treatment refractory neovascluar age related macular degeneration. METHOD A retrospective chart review was conducted on AMD patients who were receiving anti-VEGF treatments (bevacizumab or ranibizumab) from January 2009 to March 2011 at The Casey Eye Institute. Patients who received frequent anti-VEGF treatment (2 to 3 week dosing intervals) versus a conventional treatment regimen (4-6 week dosing intervals) for at least 3 consecutive injections at any time during the treatment course were included in the study. Visual acuity, central macular thickness (CMT), as measured on SD OCT, and the resolution of subretinal or intraretinal fluid were analyzed. RESULTS 8 eyes of 8 patients were included in the study. The average number of consecutive injections was 6.13 (range 3-17). The mean number of injections prior to increasing the dosing frequency was 25 injections (range: 8 - 49). Mean visual acuity prior to the increase in frequency was logMAR 0.407 (SD=0.123) and after the increased frequency was logMAR 0.365 (SD=0.132) (p=0.132). The mean central macular thickness (CMT) as measured on SD-OCT before the increase was 352.2 um (SD=56.1) and after the increase was 294.3 um (SD=63.9) (p=0.055). The mean decrease in CMT was 67.5um. Seven out of 8 patients demonstrated a decrease in CMT on SD OCT after increasing the dosing frequency. More frequent injections resulted in the resolution of intraretinal or subretinal fluid in 6 out of 8 patients. Two out of the 6 patients
A retrospective chart review of 20 patients (21 eyes) with PCV was conducted. Patients received three initial monthly intravitreal injections (0.5 mg) of ranibizumab and monitored monthly for 12 months. Reinjection of ranibizumab after three initial monthly loading was administered on asneeded basis guided by optical coherence tomography(OCT), fluorescein angiography(FAG) and indocyanine green angiography(ICGA). The main outcome measures were the change of mean best corrected Snellen visual acuity and central macular thickness by OCT, the changes of polyps and branching vascular network, and total number of injections received by patients during the 12 months.
The mean best corrected Snellen visual acuities at baseline, 1 month, 3 months, 6 months, 9 months, and 12 months after primary injection were 0.590.43, 0.440.38, 0.450.44, 0.430.35, 0.440.43, 0.380.35 logMAR, respectively and showed significant improvement at 1,6,9 and 12 months (p<0.05, Wilcoxon signed-ranks test). The mean CMT at baseline, 1 month, 3 months, 6 months, 9 months, and 12 months was 289.91114.24m, 201.1396.38m, 173.2255.57m, 181.7078.38m, 167.9056.65m, 171.4546.35m respectively, and showed significant reduction (p<0.05, Wilcoxon signed-ranks test). Polypoidal lesions disappeared on ICGA in 3 eyes (14.2%) and a branching vascular network remained in 18 eyes (85.7%). On the average, additional 1.30 injections were given after initial three injections over the 12 months.
RESULTS CONCLUSION
Intravitreal ranibizumab administration with three initial monthly injections for the treatment of PCV resulted in visual and anatomical improvement over one year follow-up.
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Anti-VEGF Monotherapy for Neovascular AMD in Vitrectomized Eyes

Kamal Kishore, MD, MBBS (Peru, IL), Sachin Jain, MD
A Pilot Study of Pharmacogenetics as a Predictor of Outcome in Patients Receiving Intravitreal Anti-VEGF Therapy in AMD
John W. Kitchens, MD* (Lexington, KY), Edward Wood, MD, William J. Wood, MD, Rick D. Isernhagen, MD, Thomas W. Stone, MD*, Nawal Kassem, MD, Lang Li, MD, Bryan Schneider, MD
PURPOSE Intravitreal injections of anti-VEGF medications have revolutionized the management of N-AMD. Pivotal studies that led to the FDA approval of ranibizumab excluded eyes with prior vitrectomy. It is well established that an intravitreal drug is cleared faster in vitrectomized eyes. We, therefore, conducted a chart review to evaluate the efficacy of anti-VEGF monotherapy in such eyes. METHOD A retrospective chart review of 9 eyes with N-AMD that had undergone a PPV and were treated with anti-VEGF monotherapy was performed. Four eyes were treatment nave, having undergone a PPV for macular hole (MH), macular pucker, retinal detachment and endophthalmitis 7,22,48 and 22 months prior to the onset of N-AMD. Five eyes were being treated for N-AMD with anti-VEGF monotherapy at the time of PPV, which was performed 3-47 mos (mean 15) after the diagnosis of N-AMD for VMT (2 eyes), endophthalmitis (2 eyes) and MH (1 eye). Complete eye examination, FA and OCT were performed and monthly anti-VEGF monotherapy was initiated, or continued. Eyes with > 6months follow-up were included. RESULTS Treatment nave group: Baseline Snellen VA at the time of diagnosis of N-AMD was 20/25, 20/70, 20/400 and 20/25 respectively. All eyes had a PCIOL. Three had occult CNVM and 1 classic. Treatment consisted of monthly intravitreal injections of bevacizumab (3 eyes) and ranibizumab (one eye). After 15, 25, 21 and 6 mos (mean 17) follow-up, all eyes showed improved or stable vision. A total of 14, 21, 16, and 5 injections were given respectively. Case 1 was switched to ranibizumab after 9 bevacizumab injections. Case 3 also required 2 intravitreal triamcinolone injections and a PDT.
PURPOSE
Inhibition of VEGF is the standard therapy for wet AMD. The arbitrary duration of therapy and heterogeneous effectiveness necessitates the need for predictive biomarkers. Prior studies have demonstrated that SNPs in CFH and ARMS2 were correlated with progression to wet AMD. This study compares candidate genotypes with outcome for patients receiving intraocular anti-VEGF therapy.
METHOD
Patients were identified by chart review and were characterized by one of 4 possible clinical outcomes with antiVEGF treatments: 1) indefinite responders, 2) delayed relapser, 3) immediate relapser, and 4) never responder. Saliva was collected from the identified patients and DNA was extracted using Oragene DNA sample collection kit by DNA Genotek. Samples were then genotyped for candidate SNPs in the VEGF, CFH, and LOC387715 genes by Taqman-based Real TimePCR. Genotypes and phenotypes were compared using a chi-square test. 99 of 100 patients that were recruited were successfully genotyped for all SNPs. The distribution of the 4 clinical outcomes was: indefinite responder (35%), delayed relapser (16%), immediate relapser (27%) and never responder (20%). Patients who carried the LOC387715 TT genotype were significantly more likely to be classified as a never responder (9/16) compared to those with alternate genotypes (12/84); p-value=0.0007. VEGF and CFH genotypes did not correlate with therapeutic outcome. Our results suggest that those patients with AMD that carry the LOC387715 TT genotype not only have a higher risk for progressive AMD, but also have a markedly higher likelihood of not responding to standard anti-VEGF therapy. Alternative therapies for this genetic subgroup should be investigated.
RESULTS
CONCLUSION
Eyes with prior N-AMD: VA after PPV was 20/400, 20/200. 20/80, 20/400 and 20/60. Three eyes were treated with bevacizumab, and two with ranibizumab. Case 3 was switched to ranibizumab after 9 bevacizumab injections, and was treated with PDT after 5 ranibizumab injections. Final VA was 20/200 in 3 eyes,counting fingers in one (Case 3) and 20/30 in one (Case 5). Poor VA was due to central GA in 3 eyes and unresponsive CNVM in one (Case 3).
CONCLUSION Monthly injections of anti-VEGF agents can control N-AMD in most vitrectomized eyes. Both treatment nave and those with pre-existing N-AMD had a good response, with resolution of subretinal and intraretinal fluid and improvement or stabilization of VA in most eyes. Poor visual outcome was mostly due to central geographic atrophy, and rarely due to progression of N-AMD.
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Triple Combination Therapy for Anti-VEGF Non-responders: A Retrospective Case Series

Jacob C. Lee, MD (Toronto, Canada), Wai-Ching Lam, MD, FRCS(C)
PURPOSE
To report the effects of triple combination therapy with verteporfin photodynamic therapy (PDT), anti-vascular endothelial growth factor (anti-VEGF), and dexamethasone on a series of patients with neovascular AMD non-responsive to anti-VEGF monotherapy.
METHOD A retrospective, observational, single center case series. 9 consecutive patients with neovascular AMD who demonstrated poor anatomical response to 3 or more monthly intravitreal anti-VEGF injections were offered triple therapy with verteporfin half-fluence PDT, anti-VEGF, and intravitreal dexamethasone from October 2008 to October 2010 at the Toronto Western Hospital. After 3 or more treatments of antiVEGF monotherapy, poor anatomical response was defined as central foveal thickness (CFT> 250 microns, and/or a change of CFT in response to anti-VEGF monotherapy < 50 microns. Vision and CFT were measured prior to initiation of triple therapy, and at 2 and 3 month follow-up visits. RESULTS The average number of anti-VEGF injections prior to initiation of triple combination therapy was 10.0. At the three month follow-up visit: 88.9% of the patients had stable or improved vision. The mean change in central foveal thickness was 194.8 microns. 77.8% of patients had decreased CFT. CONCLUSION Previous studies investigated combination therapy and found limited statistical differences between combination therapy and monotherapy ranibizumab when used as the primary treatment. Our case series shows patients who fail to demonstrate an appropriate response to anti-VEGF monotherapy may benefit with an anatomic response and visual stability from triple combination therapy.
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Oral Zeaxanthin Improves Anatomic and Visual Outcome of Triple Therapy for Subfoveal CNV in AMD, Prelim. Report
Enrique Peralta, MD (St. Louis, MO), R. Joseph Olk, MD, Samir I. Sayegh, MD, PhD, Dennis Gerhardt, MD
PURPOSE
This consecutive case-controlled study was undertaken to determine whether the addition of 20mg of daily oral zeaxanthin would improve the anatomic and visual outcome in eyes with subfoveal CNV treated with triple therapy intravitreal bevacizumab, intravitreal dexamethasone, and either protodynamic therapy with Visudyne (classic CNV) or largespot diode laser (occult CNV).
METHOD
143 eyes of 129 patients were placed on 20mg/day of oral zeaxanthin and sequentially treated with intravitreal bevacizumab, intravitreal dexamethasone, and either photodynamic therapy with Visudyne (classic CNV) or large-spot diode laser (occult CNV) and followed for up to two years. Additional cycles of treatment were applied every six to eight weeks until the eyes were deemed stable anatomically and visually. Criteria for retreatment included residual macular fluid on clinical examination, increased central foveal thickness on OCT, persistent leakage on Fluorescein Angiography, persistent plaque on ICG angiography, and /or worsening of visual acuity.
RESULTS
90% of eyes had stable or improved vision: 10% improved 3 or more lines (15 letters ETDRS), and 10% were worse by 3 or more lines. Of 116 eyes with occult CNV, 89 eyes (77%) required 1 cycle of treatment; 19 eyes (16%) 2 cycles; and 8 eyes (7%) 3 or 4 cycles to stabilize. Of 27 eyes with classic CNV, 23 eyes (85%) required 1 cycle: 3 eyes (11%) 2 cycles; and 1 eye (4%) 3 cycles. Overall, the number of treatment cycles for occult CNV were 1.7 at one year; 2.1 at two years. The number of treatment cycles for classic CNV was 1.55 at one year; 1.60 at two years. Compared to previously reported series of triple-therapy by the same authors, the addition of 20mg/day of oral zeazanthin reduces the number of treatment cycles on average by 25% at one year and 33% at two years with comparable visual results. These results suggest that the addition of 20mg./ day oral zeaxanthin to patients undergoing triple-therapy for exudative age related macular degeneration reduces the number of treatment cycles required to achieve anatomic stabilization with comparable visual results.
CONCLUSION
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A Closer Look at the Visual Landscape of Anti-VEGF Therapy of Wet Macular Degeneration: Lessons from OCT/SLO Microperimetry on Function and Fixation
Richard B. Rosen, MD* (New York, NY), Gennady Landa, MD, Thomas O. Muldoon, MD, Patricia Garcia, Katy Tai, MD, Ronald C. Gentile, MD*, Alfonso Ponce
Retrospective Study of Long-term Efficiency of PDT of Central Serous Chorioretinopathy

Masaaki Saito, MD (New York, NY), David W. Switzer, MD, Richard F. Spaide, MD,* Jason Slakter, MD*, K. Bailey Freund, MD*, Irene A. Barbazetto, MD, Lawrence A. Yannuzzi, MD
PURPOSE
PURPOSE Anti-VEGF therapy of choroidal neovascularization produces functional-anatomic changes in the visual world of patients which are incompletely described by visual acuities or OCT imaging alone. OCT/SLO microperimetry was performed serially on nave patients initiating ranibizumab therapy to test its value in elucidating the relationship between thickness, visual field, visual acuity and fixation. METHOD Prospective case series of 10 patients with nave CNV secondary to AMD receiving monthly intravitreal ranibizumab (0.5 mg/0.05 mL) injections during the first four months of treatment. Best-corrected visual acuity (BCVA), assessed using the Early Treatment Diabetic Retinopathy Study (ETDRS) chart, microperimetry (MP) and central retinal thickness (CRT), obtained using the OCT/SLO-MP (OPKO Health, Miami, FL) were recorded at baseline and at months 1, 2, 3 and 4 follow-up examinations. Fixation location and spread was assessed serially from tracking recordings on SLO maps and compared to visual acuity changes and OCT profiles. RESULTS Ten patients (age, 75.88.3 years) had a Mean BCVA of 62.418.8 letters at baseline and 72.313.4 letters (P = 0.02) at month 4. Mean BCVA improved after 1st and 2nd injections but not after 3rd and 4th injections. Mean MP scores at baseline were 8.754.9 and 11.55.5 (P=0.016) at month 4. Mean Retinal Sensitivity progressively improved during the first four months of treatment most significantly following the 1st and 4th injections. Central Retinal Thickness decreased from 340.652.9 at baseline to 264.038.2 at 4 months (P = 0.01). Monthly analysis of mean CRT change showed substantial improvement following the 1st injection only. Mean MP and ETDRS scores showed significant correlation (r = 0.69, p<0.001), as did MP and central macular thickness (r = 0.528, p=0.01). ETDRS scores and central macular thickness showed limited correlation(r=0.33, p=0.043). Fixation location varied according to the distance of the membrane from the center of the anatomic fovea. CONCLUSION Microperimetry appears to correlate better with CRT than ETDRS and may provide better indication of retinal functional improvements in neovascular AMD patients treated with Ranibizumab. The ability to track visual sensitivity, structure, and fixation appears to paint a more accurate picture of the patients visual lanscape than conventional visual acuity testing.
To examine the long-term efficiency of photodynamic therapy (PDT) in central serous chorioretinopathy (CSC) patients.
METHOD
All patients with CSC treated with PDT from December 4, 2001 to January 27, 2011 were retrospectively reviewed. All patients had PDT guided by indocyanine green (ICG) angiography findings of hyperpermeability. Eyes with pre-existing choroidal neovascularization (CNV) were excluded. Eyes were retreated with PDT if there was not a complete resolution of subretinal fluid as determined by optical coherence tomography. Risk factors were evaluated with logistic regression and visual acuity outcomes were assessed with generalized estimating equation (GEE) analysis.
RESULTS
There were 77 patients with mean age 59 years collected over 41 months. Of 94 eyes, 33 had classic CSC and 61 had chronic CSC. A single PDT session was used for 68 eyes, in which visual acuity changed from 20/80 (logMAR 0.594) to 20/60 (logMAR 0.47, P<.001). CNV developed in 3 eyes (4.4%). The remaining 26 eyes had >1 PDT session (range=2-5, mean 2.54). The mean visual acuity in the multiply treated eyes was 20/147 at baseline (logMAR 0.866) and was 20/152 (logMAR 0.882) at follow-up, a change that was not significant (P=.79). Of the 26 eyes with >1 PDT, 11 eyes got CNV (42.3%, P<.001) as compared with single treatment. By logistic regression, the predictors of secondary CNV were longer follow-up time and having >1 PDT. Full vs. half-fluence PDT was not a significant predictor for CNV development. GEE analysis showed the 2 significant predictors of follow-up visual acuity were pre-treatment acuity and having only 1 PDT treatment as compared with multiple PDT treatments. PDT as guided by ICG angiography in a single session was associated with a long-term improvement in visual acuity in treated CSC patients. Caution should be taken when considering any additional PDT sessions as there appears to be a significant increase in risk of developing secondary CNV with longer follow-up times, without evidence of improved visual acuity from the additional treatment.
CONCLUSION
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122
Prospective Analysis of the Incidence and Risk Factors of RPE Tears in Eyes with Fibrovascular Pigment Epithelial Detachment and AMD
Clement K. Chan, MD* (Palm Springs, CA), David Sarraf, MD*, Abraham Prema, MD, Asha Nuthi DO, Steven G. Lin, MD*, Sharon Theodore, MD, Colin A. McCannel, MD*
Nonarteritic Anterior Ischemic Optic Neuropathy Associated with Intravitreal Anti-Vascular Endothelial Growth Factor Therapy
Stephen G. Schwartz, MD, MBA* (Naples, FL), Kara Dellatorre, MD, Ninel Gregori, MD, Zohar Yehoshua, MD*, K. Bailey Freund, MD*
PURPOSE To prospectively determine the incidence and risk factors for RPE tears in eyes with fibrovascular PED and exudative AMD. METHOD Eyes with exudative AMD and FV PED were prospectively randomized into groups receiving either 0.5 or 2.0 MG ranibizumab. Baseline and follow-up ETDRS VA, fluorescein angiography, and OCT imaging were done to a set schedule. All PEDs were analyzed with pre and post OCT and FA to determine PED height and surface area (A2), greatest linear diameter (GLD) of PED and choroidal neovascularization (CNV), and severity of subretinal fluid (SRF) and cystoid macular edema. The group of eyes with RPE tear was compared to the group of eyes without RPE tear to prospectively determine high risk factors for tear formation. Statistical analysis included Wilcoxon Signed Ranks and Mann-Whitney tests. RESULTS A total of 38 eyes in 38 patients with mean follow-up of 8.9 months were randomized. Three eyes suffered RPE tears (1 grade-2 tear, 1 grade-3 tear and 1 grade-4 tear) for an incidence of 8%. Two eyes had received 2 MG ranibizumab and 1 eye had received 0.5 MG. Each PED that tore was noted to have an early grade-1 tear at baseline upon retrospective analysis. Baseline logMarVA was nearly identical (p=1.00) between the RPE tear (0.60 or 20/80) and non-tear (0.60 or 20/79) groups but was statistically worse (p=0.025) in the tear group (0.83 or 20/134) versus the non-tear group (0.43 or 20/54) at the most recent visit. Baseline PED height was significantly greater (P=0.046) in the RPE tear group (661 microns) versus the non-tear group (441 microns) as was PED SA and severity of SRF. Baseline PED GLD was also significantly greater (p=0.018) in the tear (5050 microns) versus the nontear (3778 microns) group. CONCLUSION
PURPOSE
To describe 4 eyes of 4 patients who developed nonarteritic anterior ischemic optic neuropathy (NAION) while receiving intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy for neovascular age-related macular degeneration (AMD). This was a retrospective review of 4 eyes of 4 patients who developed NAION while receiving intravitreal anti-VEGF therapy for neovascular AMD. All patients underwent complete ophthalmological examination. Medical history, ophthalmic history, and follow-up data were reviewed in an attempt to identify potential risk factors for this treatmentrelated adverse event.
METHOD
RESULTS
There were 3 males and 1 female, all Caucasian. The median age was 81 years. All patients had a disc at risk. Two patients had hypertension, and two patients had no pertinent past medical history. The affected eyes had received a median of 12 previous anti-VEGF injections prior to the onset of NAION. Patient #1 received 8 doses of bevacizumab 1.25 mg/0.05 ml and later developed NAION following a single dose of bevacizumab 2.5 mg/0.1 ml. Patient #2 received 31 anti-VEGF injections at monthly intervals and then developed NAION following 4 injections of bevacizumab 1.25 mg/0.05 ml at 2-week intervals. Patient #3 received 7 injections of standard-dose antiVEGF agents followed by 8 doses of bevacizumab 2.5 mg/0.1 ml prior to developing NAION. Patient #4 developed NAION after 5 monthly doses of ranibizumab 0.5 mg/0.05ml. Median visual acuity was 20/70 prior to developing NAION, 20/80 on presentation with NAION, and 20/100 at the last recorded follow-up (median 9 months). This small case series suggests that NAION may be a rare adverse event associated with intravitreal anti-VEGF therapy. Higher or more frequent dosing of bevacizumab may possibly increase the risk of NAION. While our sample size is too small to draw definitive conclusions, we advise caution when considering more aggressive anti-VEGF treatment strategies in patients with risk factors for NAION. See images on next page.
CONCLUSION
To our knowledge, this is the first study evaluating the incidence and risk factors of RPE tears in AMD eyes with FV PED in a prospective manner. The incidence of RPE tears was almost 10%. PED height 600 microns and GLD 5000 microns constitute a high risk for RPE tears. Careful study for presence of early grade-1 tears in evolution in eyes with highrisk PED is warranted before treatment.
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reduction in CRT after the DEX implant, and vision remained stable through week 26. The most commonly reported ocular adverse events were conjunctival hemorrhage (13.6%), increased IOP (6.8%), conjunctival edema (4.5%), dry eye (4.5%), and vitreous hemorrhage (4.5%).
CONCLUSION
Fundus photograph of patient #3. Note pallid disc edema.
Fluorescein angiogram of patient #3. Note hyperfluoresence of optic disc.
123
Intravitreal DEX implant monotherapy significantly improved mean CRT in patients with CNV secondary to AMD. The addition of DEX implant to repeated ranibizumab injections safely improved macular edema and visual acuity, and decreased the number of ranibizumab injections than are typically required in ranibizumab monotherapy.
Dexamethasone Implant Monotherapy or As an Adjunct to Ranibizumab to Treat Choroidal Neovascularization Due to AMD
Michael A. Singer, MD* (San Angonio, TX), Sunil S. Patel, MD, PhD*, Harvey S. Uy, MD, Xiao-Yan Li, MD*, Ching-Chi Liu, Scott M. Whitcup, MD*
124
Outcomes of Cataract Surgery in Patients with Neovascular AMD in the Era of Anti-VEGF Therapy
Homayoun Tabandeh, MD* (Los Angeles, CA), Nauman A. Chaudhry, MD, David S. Boyer, MD*, Veronica A. Kon-Jara, MD, Harry W. Flynn, MD*
PURPOSE This study assessed the short-term efficacy of intravitreal (DEX) implant (Ozurdex) 0.7 mg alone or as an adjunct to ranibizumab in treatment-naive patients with subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). METHOD A total of 44 treatment-naive patients with subfoveal CNV secondary to AMD in 1 eye, with a total lesion size of 12 Macular Photocoagulation Study disc areas (approximately 30.48 mm2), central retinal thickness (CRT) of 300 m, and best-corrected visual acuity (BCVA) of 19 to 75 letters (baseline) were enrolled. Patients received DEX implant 0.7 mg on day 1 and intravitreal ranibizumab (0.5 mg/500 L) at week 2 or 3 if BCVA worsened by 5 letters or from week 4 on for wet AMD at the investigators discretion. The mean change in CRT at week 4, BCVA, macular leakage, and the total number of ranibizumab injections during the 26-week study were assessed.
PURPOSE
To evaluate visual outcomes, choroidal neovascular complex (CNV) status, and adverse events in patients with visually significant cataract and neovascular age-related macular degeneration (nvAMD) who underwent cataract surgery. Retrospective consecutive case series: Thirty four eyes of 32 patients with nvAMD treated by anti-VEGF therapy who underwent cataract surgery. Outcome measures: Best corrected snellen visual acuity (BCVA), number of intravitreal injections, status of choridal neovascular complex (CNV), peri-operative adverse events.
METHOD
RESULTS
DEX implant reduced CRT by 40.3, 62.0, 124.6, and 133.7 m at weeks 1, 4, 8, and 26, respectively (P<.001 for all vs baseline). A 15-letter improvement in BCVA from baseline was noted in 4.5% of eyes at week 4, 20.5% at week 22 (peak response), and 15.9% at week 26. The percentage of patients with a 10% decrease in macular leakage by fluorescein angiography was 39.5% at week 4 and 74.4% at week 26. Increases of 10% in macular leakage occurred in 2.3% and 7.0% of patients at weeks 4 and 26, respectively. With the addition of DEX implant, 38.6% of patients required 1 to 3 injections and 3 patients (6.8%) did not require any ranibizumab during the 6-month study. In these patients, there was a large
RESULTS
BCVA at the time of cataract surgery was 20/40 in 3 (9%) eyes, 20/50 to 20/100 in 19 (56%) eyes, and 20/200 in 12 (35%) eyes. Mean pre-cataract surgery LogMAR equivalent was 0.75 + 0.42 (range 0.1-2.3). At the last follow-up (mean 13.5, range 6-39 months) the BCVA was 20/40 in 15 (44%) eyes, 20/50 to 20/100 in 11 (32%) eyes, and 20/200 in 8 (24%) eyes. The BCVA had significantly improved compared to prior to cataract surgery with a mean change in LogMAR equivalent of 0.23 + 0.25 (p<0.0001) at 2 months, 0.22 + 0.34 (p=0.001) at 6 months, and 0.19 + 0.51 (p=0.01) at last followup. Subjects received an average of 0.34 injections / month after cataract surgery compared to 0.47 injections / month prior to cataract surgery. Of the 24 eyes that were in a drug-free
phase, recurrence of leakage requiring anti-VEGF therapy occurred in 9 (38%) at 2 months, 18 (75%) at 6 months, and 21 (88%) at the last follow-up. Perioperative macular adverse events did not occur in any of the eyes. In the era of anti-VEGF therapy cataract surgery is associated with significant visual improvement in patients with nvAMD and visually significant cataract. Cataract surgery does not appear to be associated with significantly higher rate of recurrence or increased frequency of intravitreal injections in the intermediate term.
CONCLUSION
126
Comparison of Intravitreal Bevacizumab and Ranibizumab in the Treatment of Exudative AMD

Joo Yong Lee, MD (Seoul, South Korea), Soo Geun Joe, MD, Seung Jae Yang, MD, Young Hee Yoon, MD
PURPOSE
To compare the effect of ranibizumab and bevacizumab for treatment of exudative age-related macular degeneration (AMD) in patients who received bevacizumab injections followed by ranibizumab injection. Retrospective chart review was used to identify patients who were diagnosed with exudative AMD in the interval from August 2006 to March 2010.All enrolled patients received intravitreal bevacizumab and next intravitreal ranibizumab. Two or more injections of each drug were given, and mean follow-up period of each drug treatment was 6 months. Best-corrected visual acuity (BCVA) and central foveal thickness (CFT) measured by optical coherence tomography (OCT) were recorded at the initial and all subsequent visits.
125
METHOD
Retinal Venular Caliber Predicts Visual Outcome Following Intra-vitreal Ranibizumab Injection Treatments for Neovascular AMD
Sanjeewa S. Wickremasinghe, MBBS (Melbourne, Australia), Lucy Busija, Robyn H. Guymer, Tien Y. Wong, Salmaan H. Qureshi
PURPOSE To examine whether baseline retinal vascular caliber predicts visual response to intravitreal ranibizumab injections in patients with neovascular age-related macular degeneration (AMD). METHOD In this prospective cohort study, 107 eyes of 101 patients with neovascular AMD received three intravitreal injections of ranibizumab according to a loading dose regime at baseline , 1 and 2 months, followed by pro re nata dosing up to one year. Retinal vascular caliber was measured from digital fundus photographs at baseline and summarized as central retinal artery equivalent (CRAE) and venular equivalent (CRVE), representing average caliber of arterioles and venules, respectively. Visual outcome at 12 months was assessed and the relation to baseline retinal vascular caliber was determined. RESULTS After accounting for age, gender, CNV size and number of injections, patients who deteriorated in visual acuity at 12 months had significantly larger baseline CRVE, 237.07 (31.26)m, than those who were stable, 210.99 (26.44)m and those who improved, 223.85 (26.44)m p=0.012). Baseline CRAE was not significantly different in those whose vision improved (147.27m, 95% CI, 141.40, 153.13), compared to those who were stable (142.63m, 95% CI, 137.23, 148.04) and those who deteriorated (146.34m, 95%CI, 139.65, 153.04). CONCLUSION In eyes with neovascular AMD treated with intravitreal ranibizumab, larger baseline retinal venular caliber was significantly associated with a poorer response to treatment. Larger venular caliber, possibly reflecting underlying levels of retinal ischemia or inflammation in patients with neovascular AMD, may be useful to predict visual outcomes.
RESULTS
A total of 49 eyes of 49 patients were treated with bevacizumab and next switched to ranibizumab. During the period of bevacizumab treatment, a mean of 3.4 bevacizumab injections were given. While mean logMAR visual acuity worsened after initial improvement, mean CFT decreased from 289.2 m at baseline to 275.6 m at 6months. During the period of ranibizumab treatment, a mean of 4.2 ranibizumab injections were given. Mean logMAR visual acuity improved from 0.65 to 0.63 and mean CFT decreased from 294.7 m at baseline to 243.4 m at 6 months. Intravitreal ranibizumab was even more superior to intravitreal bevacizumab when given without drug-free interval. Treatment with bevacizumab or ranibizumab appeared to stabilize visual acuity in patients with exudative AMD. However, ranibizumab was more effective in decreasing CFT, at least over a short-term follow-up period.
CONCLUSION
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127
Effect of Patient Induced Risk Factors in Enhancing the Incidence of Bacterial Endophthalmitis Following Intravitreal Injection Therapy
Shashi D. Ganti, MD, MBA (Fresno, CA), Dinesh K. Chawla, MD
AMD Non-Neovascular
POSTERS 128-133
128
Tight Junctions of Human Embryonic Stem Cell Derived RPE

Ron A. Adelman, MD, MPH (New Haven, CT), Shaomin Peng, Caihong Qiu, MD, Lina Li, MD, Lawrence J. Rizzolo
PURPOSE Standard risk of Endophthalmitis following Intravitreal Injection is reported from 0.1 to 1.6 percent. We studied aassociated precipitating risk factors and condition. We report in our series from two retina practices a pooled risk of Endophthalmitis of 0.172 percent. When patient induced risk factors were disregarded the incidence reduced to 0.05 percent (p=.015).
We report a prospective interventional case series of patients who underwent intravitreal injection therapy. As per protocol all patients received standard written post intravitreal injection instructions. The patients who developed endophthalmitis were seen immediately, a vitreous tap was performed with culture and sensitivity test, microscopic analysis and intravitreal antibiotics were injected as per standard endophthalmitis protocol.
METHOD RESULTS 1750 injections were given to 262 patients for WAMD (195) CSDME (22) PDR (37) RVO 8, Ranibizumab 754, Bevacuzimab 908, Triamcinolone (88). 3 patients developed endophthalmitis. Patient 1: 69 yr psychologist received intravitreal bevacizumab for WAMD, 5 days following injection he was loading hay from his truck when a branch with spores hit his treated eye, 6th day post injection, it became painful and was hand motions from 20/80. Vit tap grew Staph Epidermides and post treatment vision improved to 20/40. Patient 2: 75 yr had intravitreal Ranibizumab for WAMD. She wiped her treated eye after defecation without washing her hands same day post injection. Developed painful loss of vision. Culture was positive for Ent. Faecalis. Vit tap injections and vitrectomy resulted in NLP. Patient 3: 69 yr received Triamcinolone for CSDME developed redness pain with dense vitreous opacity 5 days post injection. Tap was negative and injection of antibiotics cleared vitreous opacity and acuity to 20/40. CONCLUSION Increased incidence of Endophthalmitis is seen when patient induced factors were considered. S.Fecalis is rare, precipitated by patient hygiene. S Epiderm patient sustained penetrating injury with sharp plant produce. Third patient, probably a sterile reaction, discounting these factors the adjusted incidence is zero if third case is considered sterile reaction. We updated post op instructions.
PURPOSE
Age-related macular degeneration (AMD) is the leading cause of blindness in patients over 60 in the world. Human embryonic stem cells (hESC) may serve as unlimited donor source of retinal pigment epithelium (RPE) cells for transplantation. This report characterizes the tight junctions of RPE derived from hESC.
METHOD
Embryoid bodies (EBs) from the H1 line were formed in knockout medium with 10nM nicotinamide. A week later, EBs were plated on laminin-coated culture dishes for 6 weeks. To promote RPE differentiation 140ng/ml activin A was added during the third and fourth weeks. Monolayers of pigmented epithelial cells were isolated and cultured on laminin-coated Transwell filters for 6-8weeks. The transepithelial electrical resistance (TER) was used to assess the function of tight junctions. Gene expression of claudins and occludin was examined by quantitative real-time RT-PCR, and protein expression was examined by immunoblotting and confocal, immunofluorescence microscopy.
RESULTS
The hESC-derived RPE cells exhibit the polygonal monolayer morphology with melanin granules and RPE-specific gene markers such as RPE65, Bestrophin, CRALBP, Otx2, MITF, tyrosinase and PEDF. The TER was ~250xcm2. Like native fetal RPE, Claudin-19 mRNA was the most prominent mRNA and was >30x claudin-3, >100x claudin-1, and >900x claudin-2. Other claudins were evident that are not normally expressed by native hfRPE included claudins-5, -6, -14, -15, and -18. Claudin-19 was evident by immunoblotting and localized to tight junctions by immunofluorescence. Claudin-3 localized to the tight junction and the rest of the lateral membrane. The hESC-derived RPE cells express appropriate RPE markers, including claudin-19 as the predominant claudin. Other native claudins were also evident but in low amounts relative to native tissue and they are not restricted to tight junctions. Non-native claudins were also evident, which may indicate that cells within this population are not properly differentiated.
CONCLUSION
129
Short-term Effects of Oral Antioxidant Supplementation on Oxidative Stress Biomarker Levels

Milam A. Brantley, MD, PhD (Nashville, TN), Melissa P. Osborn, MD, Kasra A. Rezaei, MD, Barton J. Sanders, MD, Jiyang Cai, MD, Paul Sternberg, MD
and not included in the exclusion criteria. Exclusion criteria: patients having ocular diseases other than AMD,any significant media opacity precluding the biomicroscopy and fundus photography. Subjects underwent signed informed consent, refraction, BCVA examination, PHP evaluation, amslers grid examination (black grid on white background), dilatation and fundus biomicroscopy, Stratus Optical Coherence Tomography (OCT) and fundus photography on Zeiss Visupac.
RESULTS
PURPOSE Oxidative stress has been implicated in the pathogenesis of age-related macular degeneration (AMD), and AREDS supplements have been shown to decrease risk of AMD progression. We have demonstrated that long-term supplementation prevents age-related blood plasma oxidation. Our aim is to determine the short-term effects of antioxidant supplementation on plasma biomarkers of oxidative stress. METHOD Eighteen subjects, 11 with intermediate or advanced AMD (AREDS categories 3 or 4) and 7 controls, were admitted to the Vanderbilt General Clinical Research Center and placed on a controlled diet for 7 days. Antioxidant supplements were stopped two weeks prior to study enrollment. Dietary supplementation with 500 mg vitamin C, 400 IU vitamin E, 15 mg -carotene, 80 mg zinc oxide, and 2 mg cupric oxide per day was instituted on study day 3. Blood was drawn on study days 3 and 7, and plasma concentrations of the thiol metabolites cysteine (Cys), cystine (CySS), and glutathione (GSH) as well as the lipid peroxidation products isoprostane (isoP) and isofuran (isoF) were determined. RESULTS A 5-day course of AREDS supplements significantly lowered mean plasma levels of CySS in participants on a regulated diet (p = 0.034). None of the other biomarkers demonstrated a significant change.
Total 50 subjects were studied 35 males and 15 females. Age group 50-68 years. 14 patient were diagnosed as having Wet AMD on OCT. 36 patients were Dry AMD. PHP had higher sensitivity and specificity with higher accuracy than amslers in detecting wet AMD from Dry AMD. Also it is good adjuvant tool in diagnosing wet AMD. Preferential hyperacuity perimeter has good sensitivity and specificity as compared to amslers grid in diagnosing early detection of wet AMD from Dry AMD.
CONCLUSION
131
Novel Methods to Enhance Reading Ability in Patients with Macular Disease

Daniel B. Roth, MD *(Lakewood, NJ), Ankit Shah, MD, Howard F. Fine, MD, Jonathan L. Prenner, MD*, William J. Feuer
PURPOSE
Patients with reduced visual acuity often complain about difficulty with reading tasks. We sought to determine whether reading magnification incorporated into reading glasses or back illuminated reading material would significantly enhance reading performance.
This pilot interventional study indicates that antioxidant supplements can modify plasma levels of CySS in one week, suggesting that this oxidative stress biomarker could help predict how likely an individual is to benefit from AREDS supplementation. Further, CySS may be useful for the evaluation of new AMD therapies, particularly those hypothesized to affect redox status.
CONCLUSION
METHOD
130
To Compare the Efficacy of Preferential Hyperacuity Perimeter with Amsler Grid in Detecting Early Wet AMD in Cases of Dry AMD
S. Natarajan, MD (Mumbai, India), Kumaramanick G., MD, Sharmila S. Pawar, MD, Arindam Chakravarti, Purshottam Naidu, MD
All patients were asked to quantify their relative difficulty with reading books, newspaper or mail on a scale of 1 through 10. The nature of the patients macular disease was determined and best corrected distance visual acuity was obtained. Near vision testing was performed with the Rosenbaum near vision card with patients wearing (1) their own spectacle correction for reading, (2) over the counter (OTC) +3.00 or +4.00 reading glasses, and (3) a dual lens magnification reading aid. Near vision tests were repeated with all three spectacles with a back illuminated near card projected from the iPhone.
PURPOSE Efficacy of Preferential Hyperacuity Perimeter (PHP) as an adjuvant tool in diagnosing Wet AMD in cases of Dry AMD. METHOD Prospective non-randomized study in Aditya Jyot Eye Hospital, India over period of 6 months. 50 patients were studied. Inclusion criteria: Age >50 years. BCVA>20/160. Patients diagnosed of having dry AMD or other eye Wet AMD
RESULTS 75 eyes of 42 patients were evaluated. Mean LogMar near visual acuity of patients with their own reading spectacles was 0.54 (SD=0.38), slightly worse than with OTC readers, where LogMar acuity was 0.50 (SD=0.37); however this difference was not significant (p=0.38). Dual lens magnification did not offer an advantage in reading ability compared with patients own correction or OTC readers. Mean LogMar acuity using the back illuminated iPhone was 0.40 (SD=0.31) using patients own reading glasses and 0.38 (SD=0.29) using OTC readers, significantly better than similar conditions with the
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AMD NON-NEOVASCULAR
Rosenbaum near card. Patients read 1.5 lines better with the iPhone than the near card using their own spectacle correction (P <0.001) and 1.0 line better with the iPhone using OTC readers (P <0.001). The level of improvement in reading ability with the iPhone near vision testing was significantly greater in patients with poor visual acuity (20/100) than in eyes with better visual acuity (>20/100). Back illuminated devices may offer a significant advantage to aid patients with reduced visual acuity function better and read with less difficulty.
CONCLUSION
CONCLUSION
In a small pilot study, intravitreal Procrit appears to slow GA progression and vision loss. OCT and CDVF appear useful for mapping preserved retina and vision, monitoring disease progression, and may aid in prediction of future GA growth.
133
Choroidal Thickness and Early AMD

David W. Switzer, MD (New York, NY), Luis S. Mendonca, MD, Masaaki Saito, MD, Sandrine A. Zweifel, MD, Richard F. Spaide, MD*
132
Intravitreal Procrit in Eyes with Geographic Atrophy Secondary to AMD

PURPOSE
Stephen H. Sinclair, MD* (Media, PA), Carolyn Majcher, MD
To investigate the association of fundus features and choroidal thickness in eyes with early age-related macular degeneration (AMD).
METHOD
PURPOSE To investigate intravitreal Procrit stabilization of atrophic AMD GA and central discriminant visual field (CDVF) progression and to correlate OCT findings with CDVF and patterns of GA progression. METHOD Retrospective pilot study of patients with GA AMD in at least one eye with the fovea threatened or recently involved. Follow-up examinations every 4 months included OCT, fluorescein angiography, and CDVF. OCT images were analyzed for loss or disruption of the inner-segment/outer-segment junction (IS/OS junction), loss of outer plexiform layer (OPL), and RPE redundancy/thickening. Primary outcome was rate of GA progression in treated eyes compared with rates prior to treatment. Secondary outcomes were rate of GA progression in treated eyes compared to 5 atrophic fellow eyes, and the change in CDVF Global Macular Acuity (GMA) in treated eyes compared with change prior to treatment. RESULTS Eight eyes of 8 patients were treated for an average of 1.54 yrs with mean 9.6 injections. Seven of these eyes had been examined for an average of 1.3 years prior to treatment with a mean decline in ETDRS VA prior to treatment of 0.054logMAR compared with 0.161logMar during treatment. The mean GA enlargement prior to treatment was 2.55mm/yr (initial GA size of 7.50mm) compared with an enlargement during treatment of 2.06mm/yr. The mean change in the CDVF GMA during treatment in 5 eyes was an improvement of 0.185 logMAR compared to a mean 0.082 decline for 3 eyes prior to treatment. In the 5 fellow eyes with GA (followed for a mean of 2.6yrs), the mean rate of GA progression was 2.25mm/yr. GA was characterized by OCT loss of OS/IS junction and OPL. Disruption of the IS/OS junction often extended beyond GA while RPE thickening often lined the edge. Best indicators of future GA progression were loss of OPL or RPE abnormalities. CDVF scotomas corresponded with OCT OS/IS junction loss.
Consecutive patients with AMD were evaluated in a retrospective observational case series at a retinal practice over 2 months. Eyes were excluded for late AMD, myopia >6D, past vitreoretinal surgery, or disease that could affect the macular function. Multimodal fundus imaging, including enhanced depth optical coherence tomography, was reviewed for: -zone peripapillary atrophy (-PPA), drusen, central foveal thickness, subfoveal choroidal thickness (SFCT), subretinal drusenoid deposits (SDD), and outer retinal characteristics. Correlations were calculated among the measured variables and SFCT. Generalized estimating equations were used to identify predictors of visual acuity. There were 91 eyes with mean visual acuity 20/31 (logMAR 0.193). Generalized estimating equation analysis showed only age significantly predicted visual acuity. Thinner SFCT was associated with increasing age (P=.004), increasing myopic refractive error (P=.023), -PPA (P<.001), glaucoma (P=.003), SDD (P=.023), and absence of drusen (<.001). Analysis of outer retinal OCT features in eyes without late AMD showed that some eyes had an absence of the 3rd band attributed to overlap of outer segments and retinal pigment epithelium apical processes, a structure known as the contact cylinder. Eyes without this band had a significantly decreased SFCT (174.8m) as compared with eyes having the band (222.6m, P=.022). Twenty-five eyes (27.8%) met the criteria for age-related choroidal atrophy (SFCT<125m), and these eyes were less likely to have drusen (P=.02), and more likely to have SDD (P=.019). Patients with SFCT less than the median (187.3m) were more likely to have glaucoma (P=.001).
RESULTS
CONCLUSION
In AMD, general eye findings may be, in part, classified by choroidal thickness. There appears to be an association of thinner choroid with SDD, -PPA, glaucoma, and loss of the contact cylinder. Relatively thicker choroid did not show an association with glaucoma, but did show an association with drusen. These findings have an impact on ideas concerning the pathogenesis of glaucoma and AMD.
Diabetic Retinopathy/ Hereditary/Inflammatory. . .........................................................

Diabetic Retinopathy
POSTERS 201-215
202
Preoperative and Intraoperative Intravitreal Bevacizumab Only Transiently Inhibits Worsening of Diabetic Macular Edema Following Cataract Extraction
Michael A. Albert, MD (Birmingham, AL), Joshua Hicks, MD, Richard M. Feist, MD, Dustin L. Pomerleau, MD, Tracy Emond, Lindsey Wallace, MD, John O. Mason, MD, Martin L. Thomley, MD
201
Macular Tractional Retinoschisis in Proliferative Diabetic Retinopathy

Chung-May Yang, MD (Taipei, Taiwan), Chien-Chia Su
PURPOSE
PURPOSE To evaluate the clinical manifestations and surgical outcome of macular tractional retinoschisis in proliferative diabetic retinopathy.
Worsening of diabetic macular edema (DME) is well documented after cataract extraction (CE). Our study seeks to clarify both the efficacy and optimal timing of intravitreal bevacizumab (IVB) in this context.
A retrospective review was conducted on cases with macular tractional retinoschisis in proliferative diabetic retinopathy confirmed by optical coherence tomography (OCT) at a single institution between January 2007 and August 2010. Except those with localized subfoveal fluid, all cases with traction detachment were excluded. Demographic data, clinical pictures, surgical results, and optical coherence tomographic findings were recorded and analysed.
METHOD RESULTS Twenty eyes in 18 patients were included. The mean follow-up duration was 15.95 17.23 months. All had predominantly non-active fibrous proliferation. Three patterns were noted by OCT: diffuse elevation, localized elevation, and more elevation at periphery; associated macular abnormalities included inner macular cyst (40.91%), lamellar hole (13.64%), foveal detachment (9.09%), and macular hole (4.55%); serial optical coherence tomographies in some cases showed that macular structures might alter over time. Sixteen cases had surgery. Visual acuity improved statistically after surgery. Six of 16 cases showed persistent residual schisis on postoperative OCT, 2 cases developed lamellar hole after surgery. CONCLUSION Unique features exist in macular tractional retinoschisis in proliferative diabetic retinopathy. Macular changes may evolve over time. Vitreous surgery may improve visual function despite persistent schisis or other macular changes in some cases.
METHOD
We performed a retrospective review of patients with DME who also underwent CE between 2006 and 2010. Study inclusion criteria were documented best-corrected visual acuity (BCVA) and OCT preop and at 1 and 3 month postop intervals. Subjects were stratified into 3 groups: those receiving preop (within 1 month of surgery) IVB, those receiving intraop (not treated with IVB in the 6 weeks prior to surgery), and a control group. Patients receiving treatments other than IVB within 3 months of surgery or any DME therapy during followup were excluded. The outcome measures were change in logMAR BCVA, central subfield thickness (CST), and total macular volume (TMV).
RESULTS
Of 184 eyes initially evaluated, a total of 88 eyes of 66 patients met the inclusion criteria (39 preop IVB, 27 intraop IVB, and 22 control eyes). There was no statistically significant difference in the preop BCVA, CST, or TMV of the 3 groups. At 1 month postop, the mean (95% CI) in CST for the preop IVB group was +47um (+14 to +79um) vs. +133um (+71 to +195um) in controls (p=0.02) and +16um (-33 to +64um) in the intraop IVB group (p=0.30 vs. preop IVB, 0.005 vs. controls). The mean TMV for the preop IVB group was +0.03 cubic mm (-0.68 to +0.75 cubic mm) vs. +1.72 cubic mm (+0.99 to +2.45 cubic mm) in controls (p=0.002) and +0.14 cubic mm (-0.43 to +0.71 cubic mm) in the intraop IVB group (p=0.80 vs. preop IVB, 0.002 vs. controls). There was no statistically significant difference in BCVA at 1 month or in BCVA, CST or TMV at 3 months postop. CST and TMV increase in patients with DME after CE. At 1 month postop, there is a transient reduction in the magnitude of this increase in patients receiving preoperative and intraoperative IVB. This effect subsides after 3 months and does not correlate well with BCVA outcomes.
CONCLUSION
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DIABETIC RETINOPATHy
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Results of 23 Gauge Bimanual Vitreous Surgery for Very Advanced Proliferative Diabetic Retinopathy with Severe Tractional Retinal Detachment
Ching Chen, MD (Jackson, MS), Zachary M. Robertson, MD
Comparison of Flash Electroretinogram Changes after PRP for Diabetic Retinopathy in Patients Treated with Standard Laser and PASCAL Laser
Siddharth Dikshit, DO (Hyderabad, India), Subhadra Jalali, Raja Narayanan, MBBS
PURPOSE
PURPOSE To report the surgical outcomes and complications of bimanual 23 Gauge vitreous surgery using chandelier light for very advanced proliferative diabetic retinopathy (PDR) with severe tractional retinal detachment (TRD). METHOD This is a retrospective case series study. Between January 2008 and July 2010, 60 eyes of 50 patients with advanced PDR and severe TRD were operated by a single surgeon (CJC). 23-G pars plana vitrectomy and bimanual surgery were performed with the self retention chandelier light. Demographic data of the patients, pre-operative visual acuity (VA), extent of the TRD, intra-operative complications, postoperative VA, retinal anatomic outcomes and complications were obtained for analysis. RESULTS There were 52% male, 96% black and 17% bilateral TRD in the study.Mean follow-up was 10m and mean age was 49y.Preoperative iris rubeosis occurred in 10%, vitroeus hemorrhage (VH) in 75%. 82% were phakic. TRD involved up to equator and beyond in 62%. Iatrogenic tear occurred in 33%. Intraop. perfluoron was used in 20%, Silicone oil in 52%, and C3F8 gas tamponade in 48%. Postop. VH occurred in 42%, glaucoma in 17%. Initial anatomic success was 88% and final success after additional surgeries was 95%. Mean Preoperative LogMAR VA was +1.71 and postoperative VA was +1.32. VA was stablized in 23%, improved in 62% and decreased in 15%. Extent of TRD is significantly correlated to Postop. VA (p=0.002). Preop. VA is positively correlated with Postop. VA (P=0.000). Postop. VH is significantly negative correlated with Postop. VA (p=0.000). Patients with C3F8 is significantly positive correlated with better Postop. VA (p=0.012). Use of perfluoron and iatrogenic tear have no effect on postop. VA. CONCLUSION The risks of intra- and post-operative complications are relatively high in patients with advanced PDR and severe TRD. Bimanual 23G vitreous surgery is extremely helpful in difficult membrane dissection. The anatomic success rate is high. The VA can be stabilized or improved in majority of patients. Postoperative visual improvement is positively related to the preoperative visual function.
1. To compare significance of Flash-ERG changes after Scatter PRP with 532nm YAG laser in Diabetic Retinopathy in patients treated with Standard laser and PASCAL laser. 2. To compare the changes in visual acuity and central foveal thickness, and, need for Add PRP in the two groups. The study was a prospective randomized controlled trial. Patients with hazy media, prior vitreo-retinal surgery, intra-vitreal anti-VEGF in previous 3 months, neovascular glaucoma, TRD were excluded. The patients were randomized to receive PRP on PRP on either Standard Frequency Doubled Nd:YAG or PASCAL Laser. A flash ERG (MetroVision) was performed prior to PRP, immediately after PRP, one month after PRP and 3 months after PRP (primary end-point). Visual acuity using ETDRS chart at 4m and central foveal thickness using RTVue (Optovue Inc.) was performed at baseline, 1 month and 3 months. Need for add PRP was assessed based on fundus photographs by a masked observer.
METHOD
RESULTS
The baseline characteristics of the two groups were well matched. 9 patients (16 eyes) in PASCAL group and 5 patients (10 eyes) in Zeiss group were included. There was a reduction in amplitude and prolongation of implicit time in photopic as well as scotopic waves, including a and b waves on Flash ERG in both the groups. There was no statistically significant difference in the reduction of waves between the 2 groups. The logMAR visual acuity before and after laser PRP were 0.20 and 0.25 in the PASCAL group (p= 0.125) and 0.6 and 0.4 in the Zeiss group (p= 0.29). The central foveal thickness before and after laser PRP were 163.026.0 and 177.068.0 in the PASCAL group (p= 0.414) and 212.0166.5 and 0.45 in the Zeiss group (p= 0.29). The total energy delivered per eye in the PASCAL group was 33.611.7 J and 89.96.9 J in the standard laser group (p=0.002) Add PRP was needed in 6/16 eyes in PASCAL group and 2/10 eyes in Zeiss group, with no significant difference (p=0.4777).
CONCLUSION
This was the first attempt of direct objective evaluation of the difference between two systems on the collateral damage. Reduction in amplitude and prolongation of implicit time was found across all waves in Flash ERG. However, there was no significant detectable difference in the two arms. There was no difference in adverse effect profile and central foveal thickness.
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Ranibizumab for the Treatment of Persistent Diabetic Retinal Neovascularization as Assessed by Super Wide-Field Angiography
Anna Gabrielian, MD (Chicago, IL), Ryah P. Basham*, Mathew W. MacCumber, MD, PhD*
Baseline fluorescein angiogram of the study eye at 43.9 seconds of transit. Areas of retinal neovascularization are selected and numbered.
To compare the efficacy of intravitreal ranibizumab (IVR) versus additional panretinal photocoagulation (PRP) for persistent retinal neovascularization (NV) after PRP for proliferative diabetic retinopathy (PDR). Concomitant macular edema (ME) after IVR was also studied in these patients.
PURPOSE METHOD Open-label, prospective, Phase I/II study of a single injection of IVR for persistent(>3 mo) NV due to PDR. 8 subjects previously treated with PRP (~1200 500m burns), were randomized to 0.5mg IVR or more PRP (~500 200m burns). ETDRS best corrected visual acuity (BCVA), Optos color photos and fluorescein angiogram (OFA), and optical coherence tomography (OCT) were taken at baseline, and monthly for 6 mos. Patients with tractional retinal detachment (TRD), pregnancy, and previous anti-VEGF intravitreal injections and/or vitrectomy were excluded. Primary outcome measures were change in area of NV and ME (measured by OFA and OCT). Secondary measures were change in BCVA and rate of complications. RESULTS Six patients received IVR and two received additional PRP. The percentage change in area of NV as measured by Optos FA in patients who had IVR showed an 84.1% decrease at 4 weeks and a 29.8% increase by 6 months. For patients who had additional laser, the percent change in area of NV showed a 52.6% increase at 4 weeks and a 55.4% increase by 6 months. The percentage change of ME at 4 weeks, as measured by OCT, showed a 7.2% decrease in the IVR group and 8.4% decrease in the PRP group. The percentage change of ME at 6 months showed a 34.5% increase in the IVR group and 2.1% decrease in the PRP group. The mean change in BCVA at 1 month showed two lines gained from baseline in the IVR group and no change from baseline in the PRP group. At 6 months, the IVR group had gained three lines from baseline and the PRP group had gained two lines from baseline. There were no PDR complications in the IVR group. One patient in the PRP group developed vitreous hemorrhage. CONCLUSION Intravitreal ranibizumab in patients with persistent NV despite standard PRP reduced area of NV to a greater extent and sooner than additional PRP at 4 weeks and at 6 months. Concomitant macular edema in the patients treated with IVR improved minimally at 4 weeks.
Six months after a single intravitreal injection of ranibizumab. Fluorescein angiogram of the study eye at 39 seconds of transit. Areas of retinal neovascularization are selected and numbered.
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An Interim Analysis of the Efficacy of Pegaptanib Sodium Injections Every 4 Weeks vs. 6 Weeks on OCT and BCVA During 24 Weeks in Patients with DME
Victor H. Gonzalez, MD (McAllen, TX)*, Valmore A. Semidey, MD*, Denisse Cornu, MD
PURPOSE
To perform an interim analysis of the effect that the administration of intravitreal Pegaptanib sodium injections every 4 weeks as compared to every 6 weeks could have on OCT Central Subfield Thickness (CST) in patients with Diabetic Macular Edema (DME) at their first follow-up visit during an ongoing 24 week trial.
METHOD
After IRB approval, 48 eyes diagnosed with DME by a Retina specialist, and who have not undergone intravitreal injections of Anti-VEGF, steroids or macular laser treatment for at least 3 months prior to baseline, were randomly assigned 2:1 to receive 0.3 mg of intravitreal pegaptanib sodium every 4 weeks (32 patients) or every 6 weeks (16 patients) during a total of 24 weeks. An interim analysis was performed at the first follow-up visit for each of these groups, where we obtained OCT-CST and ETDRS-BCVA. 32 patients treated every 4 weeks had a median improvement in VA of +3.8 letters from baseline BCVA with 34% of these improving more than 5 letters; compared to a median of 0 letter gain in the 6 week group with 18.8% improving more than 5 letters of BCVA. OCT-CST in the 4 week arm improved by a median of 62 m with 28.1% of these improving more than 100 m from baseline whereas the 6 week group showed a median improvement of 26.5 m, where 12.5% averaged an improvement of 100 m or better.
RESULTS
101
CONCLUSION Preliminary results show that administering 0.3 mg pegaptanib sodium every 4 or 6 weeks is beneficial in DME, although greater extent improvement was seen in the 4-week group. We could attribute this to various causes; waning of drug effect during the 4th-6th week period, or better initial VA and OCT profile in the 6-week group, limiting the percentage of improvement in either of these variables.
207
Combination Therapy with Computer Guided Focal NAVILAS Laser Treatment and Intravitreal Anti-VEGF Therapy in the Treatment of Diabetic Macular Edema
Armin Afshar, MD (Chicago, IL), Rama D. Jager, MD, MBA, Madhu Amara, MD, Sandeep Grandhe, MD, Ravi D. Patel, MD
Sample image of the NAVILAS planning screen
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PURPOSE To report a case series of patients treated with NAVILAS computer-navigated focal laser treatment and intravitreal bevacizumab in the management of diabetic macular edema (DME).
The Effect of Glycemic Control on Visual and Anatomical Outcomes in Response to Therapy for Diabetic Macular Edema
Tamer A. Macky, MD, PhD, FRCS(Ed) (Cairo, Egypt), Mohamed M. Mahgoub, MD, PhD, FRCSEd.
A retrospective, noncomparative, interventional case series of eyes that underwent combined NAVILAS computer navigated focal laser treatment and intravitreal bevacizumab injections for diabetic macular edema was reviewed. Patients received intravitreal bevacizumab (1.25 mg/0.05 ml) and underwent computer-navigated NAVILAS focal laser treatment. Pretreatment NAVILAS planning with typical laser settings of 70 mW power,100 m size, 70 ms duration resulted in pale, clinically visible lesions. Best-corrected visual acuity and average foveal thickness using spectral domain OCT were measured immediately before laser treatment and at visits up to the 6 months.
METHOD RESULTS Over 80 eyes have been treated as of March 2011. Of those, 12 eyes of 10 patients had 6 month follow-up and were reviewed. Mean ( SD) foveal thickness at baseline was 352 64 microns that decreased to 323 48 microns at 6 months (p=ns). Mean visual acuity improved slightly from 20/60 at baseline to 20/50 at 6 months in treated eyes (p=0.04). Average macular volume also decreased significantly. The average number of injections at 6 months was 1.6 1.6. The average number of laser spots administered was 101 (range = 18-372). No adverse effects were observed in association with either intravitreal injection or with NAVILAS laser treatment. CONCLUSION Intravitreal bevacizumab used in combination with NAVILAS computer guided focal laser treatment appears to be safe and effective in eyes with diabetic macular edema at 6 months follow-up. NAVILAS focal laser treatment appears safe and effective in the short term and has the potential to have significant long-term advantages when combined with antiVEGF therapy.
PURPOSE
To evaluate the visual and anatomical response to therapy in patients with diabetic macular edema in relation to their glycemic control using glycosolated hemoglobin measurements (HbA1c). Patients with diabetic macular edema (DME) with central foveal thickness (CFT) > 250m with no proliferative disease had their HbA1c measured at baseline and 3 months. CFT optical coherence tomography (OCT), and best corrected visual acuity (BCVA) in logMARs were measured at baseline, 1, and 3 months. Exclusion criteria: laser or intravitreal injections within 6 months, hard exudates within 500um of the foveal center, or macular traction. Therapy included laser and intravitreal anti VEGFs. HbA1c graded as: G1=<7, G2= 7-7.9, G3= 8-8.9, G4 = >9; and as: low <8, high 8. HbA1c levels (baseline, 3 months) and its relation to CFT and LogMAR BCVA (at baseline, 1 and 3 months) were analyzed.
METHOD
RESULTS
Fifty two eyes of 52 patients were included with mean age 56 (30-81), male: female ratio 2:3. Mean LogMAR BCVA and CFT: baseline 0.75 and 423.8310m; 1 month: 0.47 and 293.3369m; and 3 months: 0.47 and 324.4076m. Mean HbA1c was 8.131.2 (6.4-10.5) and 7.631.0 (6.2-9.7) at baseline and 3 months, respectively. Baseline HbA1c gradings: G1=23.1%, G2=23.1%, G3=30.8%, G4=23.1%, low=46.2% and high=53.8%; and at 3 months: G1=30.8%, G2=30.8%, G3=30.8%, G4=7.7%, low= 61.5%, high=38.5%. There was no statistically significant difference between any of the HbA1c grades/levels (at baseline and 3 months) and the logMAR BCVAs and CFTs at baseline, 1 and 3 months. However, there were positive correlations between baseline HbA1c levels and each of: baseline LogMAR BCVA (p value=0.024), baseline CFT (p value<0.001) and 3 months LogMAR BCVA (p value=0.008). Patients with improved HbA1c by 3 months did not show any correlation with logMAR BCVA and CFT at 3 months (p values 0.159, and 0.322).
Patients with lower HbA1c appeared to have better visual acuity and lower CFT value at baseline. This group of patients showed a significantly better visual acuity and non significantly better CFT at 3 months as compared to baseline. Although rigorous glycemic control with improved HbA1c at 3 months did not result in a significantly better outcomes, yet a longer follow-up period is needed.
CONCLUSION
CONCLUSION
Although the timing and amount of treatment following these guidelines is likely to be similar to that based on a web-based real time data entry system, it is unknown if following this clinical protocol would result in better, same, or worse outcomes compared with the DRCR.net results. If a webbased algorithm is not practical clinically, then this approach may be a practical clinical alternative.
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Rationale of Diabetic Retinopathy Clinical Research Network Intravitreal Anti-VEGF Treatment and Follow-up of Center-involved Diabetic Macular Edema
Michael Elman, MD (Baltimore, MD), Raj Maturi, MD,* Neil M. Bressler, MD*
PURPOSE A web-based real time data entry system was used to determine standardized guidance for intravitreal injections, focal/grid laser, and follow-up intervals (1-4 months). Duplication of this algorithmic approach is not practical in clinical settings, this report provides guidelines from DRCR.net investigators to assist ophthalmologists in providing anti-VEGF and focal/grid laser treatment for DME. METHOD The DRCR.net conducted a comparative effectiveness randomized multi-center clinical trial in 854 study eyes of 691 study participants to evaluate 3 different treatments, including intravitreal 0.5-mg ranibizumab combined with prompt or deferred (>24 weeks) focal/grid laser or 4-mg triamcinolone combined with prompt focal/grid laser, compared with sham injections with prompt focal/grid laser alone for treatment of diabetic macular edema (DME). The underlying rationale for this trials retreatment algorithm was used to develop clinical guidelines for providing anti-VEGF and focal/grid laser for DME without a web-based real time data entry system.
DRCR.net required 4 injections every 4 weeks initially; it is not known whether a different number of injections initially would have worked as well. Defined as >10% decrease in central subfield thickness on OCT or visual acuity improvement of 5 or more letters. a If focal/grid laser was deferred initially, it may be added if edema still present and there is no improvement from injections.
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Examining Recalcitrant Diabetic Macular Edema with Optos Wide-Field Fluorescein Angiography
Ravi D. Patel, MD (Chicago, IL), Seenu M. Hariprasad, MD*
The DRCR.net trial found intravitreal ranibizumab with prompt or deferred laser was more effective through at least 1 year compared with prompt laser alone for the treatment of DME involving the central macula, although uncommonly associated with endophthalmitis. Guidelines for achieving this treatment benefit in clinical practice, based on the underlying rationale of the DRCR.net treatment algorithm, include repeating treatment monthly as long as there is improvement in edema compared with the previous month, if treatment is not repeated because of success or lack of improvement, treatment is resumed if edema recurs or worsens. If the retina remains flat (or not worse) after treatment is deferred, the follow-up interval could be doubled, up to 4 months. Focal/grid laser can be added initially or deferred for at least 6 months and then considered only if edema persists or is not improving from injections; laser can be repeated as often as every 4 months if there is edema to treat.
RESULTS
PURPOSE
This study has 2 objectives: i) to study the peripheral angiographic features of patients with recalcitrant diabetic macular edema (DME) and peripheral retinal nonperfusion in non-proliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR) and ii) to demonstrate the diagnostic value of WFFA in elucidating the role of subtle peripheral pathology in diabetic retinopathy. This is a retrospective observational case series of approximately 30 eyes of 60 patients who have been diagnosed with DME for at least 2 years at an academic institution. Protocols were approved by the institutional review board at the study site, and consent was obtained from each patient. A retrospective review of all Optos WFFA and spectral domain OCT (SD-OCT) was performed at baseline (1 clinic visit).
METHOD
103
Three study cohorts were enrolled. Cohort 1 (control) subjects were diagnosed with NPDR without DME. Cohort 2 subjects were diagnosed with NPDR and recalcitrant DME. Cohort 3 subjects diagnosed with PDR and recalcitrant DME with or without previous pan retinal photocoagulation (PRP).
RESULTS Our preliminary data demonstrates an increased incidence of peripheral nonperfusion on Optos wide-field fluorescein angiography with recalcitrant DME (on SD-OCT) in all non-control cohorts. Further statistical analysis is to follow. Also, the diagnostic value of the WFFA was demonstrated by detecting subtle peripheral neovascularization that was not found on clinical exam. CONCLUSION WFFA is an excellent diagnostic instrument that provides a reproducible method to detect subtle peripheral neovascularization in diabetic retinopathy. Areas of untreated retinal nonperfusion may generate biochemical mediators that promote ischemia and recalcitrant DME. Targeted retinal photocoagulation to ischemic retina will likely show improvement of recalcitrant DME.
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Ultra Wide Field Fluorescein Angiography Accurately Evaluates Macular Pathology in Diabetic Retinopathy
John D. Pitcher, MD (Los Angeles, CA), Valentina Franco-Cardenas, MD, Irena Tsui, MD, Gad Heilweil, MD, Jean-Pierre Hubschman, MD, Steven D. Schwartz, MD*
PURPOSE
High resolution fluorescein angiography correlates well with spectral domain optical coherence tomography (SD-OCT) when assessing macular pathology in patients with diabetic retinopathy (DR). Ultra wide field fluorescein angiography (UWFFA) has proven useful for detecting peripheral pathology. Validation for macular pathology in DR with UWFFA is to date uncertain.
METHOD
A retrospective imaging review, which included all patients diagnosed with DR who underwent UWFFA and SD-OCT on the same day, was performed. UWFFA was graded for presence of macular leakage (petalloid or diffuse pattern) and ischemic abnormalities of the foveal avascular zone (FAZ). SD-OCT was evaluated for signs of diabetic macular edema (cystoid or diffuse type), foveal thickness, average macular thickness, ganglion cell layer (GCL) atrophy and evidence of epiretinal traction (ERM). Imaging reviews were performed by two separate vitreoretinal specialists who were blind to each others results.
Optos Wide-Field Fundus photo of a patient with mild recalcitrant diabetic macular edema and presumed quiescent PDR s/p PRP on clinical exam.
RESULTS
Optos Wide-Field Fluorescein Angiogram of a patient with recalcitrant diabetic macular edema and presumed quiescent PDR s/p PRP with fronds of neovascularization not detected on clinical exam.
Inclusion criteria were met by 216 eyes. Angiographic leakage on UWFFA was present in 132 eyes (61%) and 112 eyes (52%) had macular edema on SD-OCT (p<0.0001) with a kappa agreement (K) =0.59. Petalloid angiographic leakage on UWFFA correlated with cystoid macular edema on SDOCT (p<0.0001) (K=0.61). Diffuse angiographic leakage correlated with diffuse macular edema (p<0.0001) (K=0.46). The sensitivity of UWFFA for detection of any type of macular leakage was 89.3%, with a specificity of 69.2%. GCL atrophy presented with an abnormal FAZ on UWFFA (p<0.0001) (K=0.77) and ERM correlated well with any type of leakage in UWFFA (p< 0.0001). Any type of leakage detected in UWFFA had an increased foveal thickness (360.6123 vs 27353 ) and macular thickness average (36775 vs 30633) in SD-OCT when compared against the non leaking group (p<0.0001). The K value for agreement between graders was 0.55 for all UWFFA parameters and 0.64 for all OCT parameters. The presence of macular pathology in this cohort of patients was high, allowing us to study the utility of UWFFA in diabetic maculopathy. UWFFA provided accurate angiographic macular assessment which closely correlated with SD-OCT findings. UWFFA seems to provide clinically useful angiographic macular data.
CONCLUSION
RESULTS
Late macular leakage in a diffuse pattern on ultra wide field fluorescein angiography (a) in a patient with corresponding diffuse diabetic macular edema on SD-OCT (b).
The baseline visual acuity and central macular thickness were similar between the 2 groups (visual acuity: 0.730.37 in IVTA group and 0.650.40 in IVB group (p=0.06), central macular thickness: 438141m in IVTA group and 415115m in IVB group (p=0.051). The Log MAR visual acuity improved to 0.640.35, 0.590.36, and 0.620.41 in IVTA group (p<0.001 each) after 1, 3, and 6 months. But in IVB group, Log MAR visual acuity improved to 0.620.34, 0.590.38, and 0.600.38 after 1, 3, and 6 months without statistic significance (p=0.15, 0.09 and 0.12). The CMT reduced to 29750m, 344136m, and 347131m in IVTA group (p<0.001 each) after 1, 3, and 6 months. Also in IVB group, CMT improved to 285103m, 28666 m and 28332 m after 1,3, and 6 months (p= 0.05, 0.03, 0.03). During the follow-up period, one eye in IVTA group underwent cataract surgery and one eye in IVTA group had high intraocular pressure controlled with topical medication.
CONCLUSION
Late macular leakage in a petalloid pattern on ultra wide field fluorescein angiography (a) in a diabetic patient with corresponding cystoid macular edema on SD-OCT (b).
In DME patients, single IVTA showed significant therapeutic effect in aspect of both anatomical and functional outcome for 6 months. But single IVB showed limited improvement of functional outcome, although IVB had anatomical improvement.
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Intravitreal Triamcinolone vs. Intravitreal Bevacizumab Injection for Chronic Diffuse Diabetic Macular Edema: Which Was Really Better?
Su Jeong Song, MD, PhD (Seoul, South Korea), Man Mook Ha, MD, Jung Hoon Bae, MD
Factors Associated with Changes in Visual Acuity and OCT Thickness at One year after Ranibizumab Treatment for Diabetic Macular Edema
John Wells, MD* (West Columbia, SC)
To compare the effect of IVTA and IVB for chronic diffuse diabetic macular edema.
PURPOSE METHOD
PURPOSE
We retrospectively reviewed medical records of 84 patients with DME who received single IVTA (4mg/0.1ml) or IVB (1.25mg/0.05ml) for the first time. All patients were followed up at least 6 months. Ophthalmic evaluation was performed at baseline and at 1, 3, 6 months after each injection. Changes of visual acuity (Log MAR) and central macular thickness (CMT) using optic coherence tomography were evaluated. Clinical evidence of complications was also recorded.
A Diabetic Retinopathy Clinical Research Network multicenter randomized clinical trial found ranibizumab, with immediate or deferred focal/grid laser, to be superior to laser alone for center involving DME. We sought to identify factors associated with improvement in visual acuity (VA) and optical coherence tomography (OCT) central subfield (CSF) thickness at 1 year following ranibizumab treatment. As 1-year outcomes were similar, data from the two ranibizumab arms in the trial (361 eyes total) were pooled for analysis. Regression models were used to evaluate baseline demographic, systemic, ocular, OCT, and fundus photographic factors for association with VA/OCT improvement from baseline to 1 year. Evolution of CSF measurements relative to baseline at months 4, 8, and 12 were evaluated for effect on VA at 1 year.
METHOD
105
RESULTS Despite evaluating 37 baseline factors, no factor other than baseline VA affected the magnitude of change in visual acuity from baseline to 1 year, in eyes that started with centerinvolved DME causing vision impairment. Eyes with baseline VA letter score of < 66 letters, in which the average letter score was 56 (20/80) had a median 13 letter gain (25th and 75th quartiles: +7, +20) compared to a median 6 letter gain (+1, +11) in those with a letter score > 66 (P<0.001), in which the average letter score was 72 (20/40).VA of >20/32 at 1 year was achieved by 76% of eyes with a letter score 66 at baseline compared to 38% of eyes < 66 (P<0.001). Baseline CSF thickness was the only consistent baseline predictor of 1-year CSF thickness outcomes. Eyes with baseline CSF thickness < 400 m had median improvement of 71 m while eyes with 400 m had median of 219 m improvement (P<0.001). CONCLUSION No factors were found that suggested a clinical scenario for which anti-VEGF would not be recommended. Eyes with better baseline VA are more likely to have better final VA while those with worse baseline VA have greater improvement. This emphasizes that baseline VA must be considered when comparing percentage of eyes with improvement or worsening following treatments for DME across trials.
between groups (P>0.05). The DRT type was associated with a greater reduction in the CFT and greater BCVA improvement than the CME or SRD types.
CONCLUSION
Three monthly injections of intravitreal bevacizumab seems to be effective treatment in the first 6 months, but the therapeutic effect is temporary and repeated injections of bevacizumab should be considered to maintain the therapeutic effect after 6 months. In addition, intravitreal injection of bevacizumab was more effective in the DRT type than in the CME or SRD types of DME.
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Internal Tamponade in Proliferative Diabetic Retinopathy Surgery

Raja G. Zhioua, MD (Tunis, Tunisia), Imene Letaief, Amel Ouertani
PURPOSE
To analyse results and complications of vitrectomy using internal tamponade (gas or silicone oil SO) in proliferative diabetic retinopathy (PDR).
METHOD
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The Effect of Intravitreal Bevacizumab Based on OCT Patterns of Diabetic Macular Edema
Seung-Young Yu, MD (Seoul, South Korea), Moo Sang Kim, MD, Young Gun Kim, MD, Hyung-Woo Kwak, MD
PURPOSE To compare the effects of intravitreal bevacizumab on different morphologic patterns of diabetic macular edema (DME) classified using optical coherence tomography (OCT).
231 primary vitrectomies for PDR were retrospectively reviewed. Endo tamponade with SO or gas was used in 95 eyes (41%) of which we review clinical records. These eyes presented intraocular hemorrhage with fibrovascular proliferation or tractional retinal detachment (RD) with or without rhegmatogenous element. Eyes were assigned in 2 groups of vitreoretinal attachments (VRA). Group1 with absent or mild VRA attending one or 2 vascular arcads (48 eyes). Group 2 with severe VRA attending 3 vascular arcads or more or VRA reaching the periphery of the retina (47 eyes). Anatomic outcome and postoperative complications were analysed. Mean follow-up was 20 months.
Medical records for 65 eyes of 48 patients were retrospectively reviewed, and each subject was classified as one of three DME types according to the OCT features: diffuse retinal thickening (DRT), cystoid macular edema (CME), serous retinal detachment (SRD). Subjects were given three monthly intravitreal injections of bevacizumab (1.25 mg/0.05 ml). The clinical course of best-corrected visual acuity (BCVA) with a logarithm of the minimum angle of resolution chart and central foveal thickness (CFT) using OCT was monitored for 12 months after the injections. On follow-up, injections were repeated if DME was aggravated.
METHOD RESULTS
RESULTS
45 males and 45 females were included in our study with mean age of 82 years (range: 20-82 years). Gas was used in 20 eyes and SO in 75 eyes. Rubeosis was present in 1eye in gas group (5%) and 6 eyes in SO group (8%). Rhegmatogenous elements (combined RD or iatrogenic breaks) were present in 47 eyes (gas was used in 10 eyes and SO was used in 37 eyes). In G2 with severe vitreoretinal proliferation internal tamponade by SO (42 eyes 56% ) was used more frequently than gas (5 eyes 25%) with significant statistically difference (P=0,02). SO was removed in 49 /75 (65,3%). Anatomical success achieved 85% in gas group (17/20) and 78.6% in SO group (59/75). Postoperative complications included cataract in 31 eyes (40% in gas group and 47% in SO group), ocular hypertension in 17 eyes (25% in gas group and 24.4% in SO group) and postoperative fibrovascular reproliferation in 14 eyes (15% gas group and 17% SO group).
Of the 65 eyes with DME, 29 eyes were of the DRT type, 21 of the CME type, and 15 of the SRD type. Before the injection, CFT and BCVA were, respectively, 377.1145.9 m and 0.540.36 in the DRT type, 427.7143.1 m and 0.590.42 in the CME type, and 485.1187.1 m and 0.650.27 in the SRD type; there was no significant difference in CFT and BCVA between DME types (P>0.05). At 6 months, the changes in BCVA and CFT differed significantly between OCT types (P<0.05). At 12 months, changes in CFT and BCVA from baseline were not significantly different
CONCLUSION
During diabetic vitrectomy it may be necessary to use internal tamponade We obtained better anatomical results using gas than SO which can be explained by the use of SO in eyes with more severe fibrovascular proliferation but the post operative complications were similar.
Hereditary Retinal Disease

216
Inflammatory and Infectious Diseases

POSTERS 217-238
Spectral Domain Optical Coherence Tomographic Study of Cystoid Macula Edema Associated with Retinitis Pigmentosa
Young Hee Yoon, MD (Songpa-ku, South Korea), Yoon Jeon Kim, Jee Taek Kim, MD, Soo Geun Joe, MD, Joo Yong Lee, MD, Ju Byung Chae, MD
217
Is It Advanced Posterior Uveitis or End Stage Disease: Who Do you Not Treat? Multiple Case Scenarios, Two year Follow-up Analyzed by an Expert Panel
Shree K. Kurup, MD* (Winston Salem, NC), David Callanan, MD*, Sofia N. Androudi, MD, PhD, Anita Agarwal*, Sunir J. Garg, MD*, Kishan Govind, MD, David Hinkle, MD, Michael Samson, MD, Andres Emanuelli, MD, Nida Sen, MD, Craig M. Greven, MD
PURPOSE To see the frequency of cystoid macular edema (CME) among patients with retinitis pigmentosa (RP), and to investigate the correlation of visual acuity with CME and other macular microstructural features assessed by spectral domainoptical coherence tomography (SD-OCT). METHOD Retrospective case series. Among 100 patients who were diagnosed to have RP, the presence of cystoids macular edema was identified using SD-OCT. Several parameters including central retinal thickness (CRT), photoreceptor (PR) thickness, and the status of PR IS/OS junction at the fovea were also assessed. The correlation between best corrected visual acuity (BCVA) and each parameter was analyzed. RESULTS Thirty eight eyes from 27 patients (21.7%) had CME. While no correlation was noted between BCVA and age (p=0.217), the presence of cystoid macular edema (p=0.520), close correlation was observed between BCVA and CRT in eye with CME (p<0.001). Eyes with CME were frequently associated epiretinal membrane or vitreomacular traction (60.6%, p=0.043). Also there was a high correlation between the presence of ME and the disruptive status of IS/OS (p=0.007), PR thickness (p=0.015). As in other conditions, the IS/OS absent group had a significantly worse BCVA than the IS/OS present (either discontinuous or distinct) groups (p<0.001). CONCLUSION The presence of CME in eyes with RP was not necessarily associated with the loss of visual acuity. However, increase in CRT was highly correlated with the disruption of PR IS/OS, resulting in subsequent visual loss in eyes with CME among RP patients.
PURPOSE
Would there be symmetry of opinion by experts (Macula Society and Uveitis Study Group) in various clinical scenarios predicting the course of patients with advanced uveitis and could this study uncover some tips and therapy to avoid overlooking potentially treatable disease in the daily retina practice? Study design: Prospectively collected data with retrospective analysis by a masked expert team with attention to the worse eye in bilateral uveitis to prognosticate response to therapy. Selection criteria: 1. Asymmetrically affected eyes with severe posterior uveitis. 2. Each of these patients primary reason for therapy in was to improve VA in the lesser affected eye. 3. All patients were to receive standard of care immunomodulatory therapy. Exclusion: 1. Inclusion in another study or experimental protocol. 2. Inability to provide imaging data. 3. Any patient that potentially could not receive immunomodulatory drugs. N: 80 Clinical scenarios derived from nineteen eyes of ten patients.
METHOD
RESULTS
The visual acuity (VA) at 6 month was underestimated by approximately 3 Snellen lines (0.27 LogMAR units [SD = 0.66]). At 12 months the visual acuity was underestimated (0.24 LogMAR units (SD = 0.66) approximately 2.5 Snellen lines. When compared to the actual VA, it showed that it mainly stabilized at 6 months. The mean difference when comparing actual VA at 6 months vs. 12 months was just 0.06 LogMAR units (SD = 0.03). At two years the projected divergence between the evaluator curve and actual VA curve was even more pronounced. There was a distinct bias towards a conservative estimation of the predicted therapeutic response in the vast majority of the panel.
107
INFLAMMATORy AND INFECTIOUS DISEASES
CONCLUSION It is likely there are patients with advanced uveitis who could be visually rehabilitated to some extent if therapeutic options were addressed. Some of these patients may not be expecting any improvement in the worse eye due to duration of symptoms. It is relevant for the retinal specialist to be wary of posterior uveitis that may masquerade as end stage disease and request a second opinion.
METHOD
Retrospective review of the medical records of 3 patients who developed endophthalmitis out of 3000 consecutive intravitreal bevacizumab injections for CNVM from September 2005 to March 2011. Two patients had myopiaassociated CNVM and one patient had wet age-related macular degeneration. All were pseudophakic. Each patient required 2 interventions: vitreous tap and intravitreal antimicrobials and pars plana vitrectomy with antimicrobials injection. Intravitreal bevacizumab was added at the last intervention. Microbiologic evaluation of vitreous specimens was done. Main outcome variables were visual acuity and CNVM status measured with SD-OCT after infection resolution.
RESULTS
Serpiginous choroiditis involving fovea. Therapy coincided with VA 20/400 improving to 20/40 due to recovery of part of fovea over 6 months.
Important features specific to our cases included rapid vision loss over hours, complete absence of pain, dense vitreous exudates at presentation with minimal anterior chamber inflammation, suboptimal response to intravitreal antimicrobials alone, and the need for pars plana vitrectomy even when the first intervention was within 3 hours of presentation. These features are different from those expected in post-operative endophthalmitis where pain, and anterior chamber inflammation are common and vitrectomy may not be necessary in a proportion of cases treated with intravitreal antimicrobials. These differences maybe attributed to the fact that during intravitreal injection organisms are introduced into the vitreous, whereas during cataract surgery the anterior chamber is the site of inoculation. Injection of an anti-VEGF agent along with antimicrobials at the end of vitrectomy resulted in a dry macula at the time of infection resolution in each of our cases.
CONCLUSION
Graph illustrating the ACTUAL (lower line extending 2 years) visual acuity and PERCEIVED or PROJECTED (upper line) by the panel. The slopes diverge over time. The VA is in logMAR (negative slope)This composite graph represents the output from ten institutions.
Endophthalmitis following intravitreal injections presents with rapidly progressing painless vision loss and significant vitreous inflammation. Pars plana vitrectomy with antimicrobials rather than intravitreal antibiotics alone should be the procedure of first choice. Intravitreal anti-VEGF agent can be administered at the last intervention for simultaneous management of CNVM.
218
Endophthalmitis Following Intravitreal Anti-VEGF Injections: Specific Clinical Features and Management
Mallika Goyal, MD (Hyderabad, India)
Case 2. Myopia-associated CNVM with fluid before bevacizumab injection.
PURPOSE 1. To analyse the presentation, clinical features, management and response to treatment of endophthalmitis following intravitreal anti-VEGF injections as opposed to postoperative infection. 2. To enable co-management of the primary problem of CNVM along with the infection. 3. To prolong the duration of action of anti-VEGF agent in a vitrectomised eye after infection resolution.
Case 2. Dry Macula three weeks following pars plana vitrectomy with antimicrobials with bevacizumab injection.
219
Post-viral Fever Neuroretinitis Successful Treatment with Bevacizumab: A Case Series

Guruprasad S. Ayachit MBBS, MS (Hubli, India)
PURPOSE To determine the safety and efficacy of intravitreal Bevacizumab in presumed post-viral fever neuroretinitis. METHOD In this prospective non randomised interventional study between Feb 09 and Dec 10, 26 eyes of 18 patients presenting with visual symptoms due to neuroretinitis developing few weeks after an episode of viral fever with arthralgia & rashes were considered for intravitreal Bevacizumab. Patients underwent baseline ophthalmic examination,fundus photography and OCT on day 1,and thereafter at 1 week, 1 month and 3 months. Fluorescein Angiography was performed in 4 patients. All eyes received 1.25 mg of intravitreal bevacizumab. Improvement in visual acuity & reduction in macular edema /OCT thickness/volume were the main outcome measures. Minimum follow-up was for 3 months. RESULTS Visual acuity improved from mean 1.62 LogMar at baseline to 1.21 at 1 week, 0.84 at 1 month and 0.7 LogMar at 3 months (p < 0.05). Central macular thickness reduced from mean 596 microns at baseline to 356 at 1 week, 227 at 1 month and 181 microns at 3 months (p < 0.0001). Volume reduced from mean 10.85 cu.mm at baseline to 9.51 at 1 week, 7.88 at 1 month and 6.50 cu.mm at 3 months (p < 0.0001). Only one eye had a second injection for unsatisfactory improvement. All fundus signs especially macular edema steadily subsided in all eyes. Faster resolution was seen in eyes given bevacizumab within 2 weeks of onset of symptoms. Epiretinal membrane was noted in 3 eyes in which the initial affection was severe. There was no recurrence of retinal edema noted in any eye in the long term. There were no complications related to the injection in any. CONCLUSION Intravitreal 1.25 mg bevacizumab is safe, consistently effective and a one time treatment option in presumed post-viral fever neuroretinitis. Injection within two weeks of onset gives better outcomes. A randomised control or comparative study is necessary to establish the superiority of bevacizumab over other methods of therapy.
Post Injection clinical course. Note the rapid resolution of retinal signs.
Post injection macular OCT. Note the steep reduction of macular thickness.
220
Endogenous Endophthalmitis: Clinical Features, Etiologic Organisms, Fundus Fluorescein Angiographic Features and Management
Mallika Goyal, MD (Hyderabad, India)
PURPOSE
Delayed diagnosis of endogenous endophthalmitis has an adverse implication on visual prognosis. This series highlights: 1. Characteristic FFA features that can help in early diagnosis; 2. Use of DNA chip analysis to expedite and improve identification of etiological organism; and 3. The prolonged and aggressive nature of therapy that maybe indicated for fungal endophthalmitis.
109
METHOD Retrospective consecutive review of the records of 9 patients with endogenous endophthalmitis treated from September 2007 to March 2011 at our Retina Service. FFA was used to confirm the clinical suspicion in 5 cases. DNA chip analysis was used when conventional microbiological evaluation was negative. Oral fluoroquinolones or voriconazole were used for systemic therapy in patients without antecedent or associated systemic infection. Vitreous tap with intravitreal antimicrobials or pars plana vitrectomy with intravitreal antimicrobials were performed where systemic therapy alone was inadequate. Combined intravitreal amphotericin B and voriconazole were used for fungal endophthalmitis. RESULTS Age ranged from 8 years to 52 years; one patient was immunocompromised (acute lymphoblastic leukaemia); three patients were diabetic; both cases of fungal endophthalmitis occurred in young immunocompetent people; antecedent or associated systemic infection was identifiable in 4 of 9 cases (3 bacterial and one fungal). FFA findings were characteristic and more dramatic and extensive than the lesions seen clinically allowing early confirmation of diagnosis. DNA chip analysis gave the microbiological diagnosis within 24 hours in 4 cases where conventional modalities were negative. One patient with candida endophthalmitis with no systemic infection required aggressive ocular therapy for 8 months and systemic therapy for a year (Images 1 and 2). Combination of intravitreal amphotericin B and voriconazole was used when amphotericin alone gave inadequate response. CONCLUSION Endognous Endophthalmitis is an ophthalmic emergency. Our series highlights the need for very high index of suspicion even in young and immunocompetent patients. FFA can aid in early clinical diagnosis. DNA chip analysis can complement the conventional microbiology evaluation. Fungal endophthalmitis may need prolonged and aggressive therapy with combination antifungals for several months.
221
Bevacizumab Injection Induces Inflammatory Response in Quiescent Eyes with Toxoplasmosis

Nancy Kunjukunju, MD (Kansas City, MO), Anthony D. Mazzulla, MD*, Laurence W. Arend, MD
PURPOSE
Bevacizumab may reactivate inflammatory conditions when used in quiescent eyes. Restrospective case analysis of two patients.
METHOD RESULTS
Case 1: An 84-year-old female, with CNVM secondary to toxoplasmosis with no evidence of active inflammation, received eight intravitreal bevacizumab injections off-label without issue. After her ninth injection she developed a severe inflammatory response and was treated for presumed endophthalmitis. Cultures were negative and a repeat injection of bevacizumab one year later caused a similar inflammatory response. Subsequent to these episodes, she has been treated with ranibizumab with no increase in inflammation. Case 2: A 75-year-old patient, with CNVM secondary to agerelated macular degeneration and an inactive toxoplasmosis lesion, received three ranibizumab injections without incident before being switched to bevacizumab. After her second bevacizumab injection, she developed a severe inflammatory response with reactivation of her toxoplasmosis lesion. Cultures were negative and the inflammation resolved. Her third injection of bevacizumab reactivated the inflammation.
CONCLUSION
Bevacizumab may need to be reevaluated as an off-label intravitreal agent for the treatment of cystoid macular edema, choroidal and retinal neovascularization resulting from or associated with uveitic conditions.
222
Concordance of Anti-retinal Antibody Testing Between Laboratories in Patients Suspected to Have Autoimmune or Cancer-associated Retinopathy
Sepideh Faez, MD (Boston, MA), Lucia Sobrin, MD
Endogenous candida endophthalmitis in a 26 year old immunocompetent patient.
PURPOSE
To report the concordance of anti-retinal antibody (ARA) testing between two laboratories for patients with non-paraneoplastic autoimmune retinopathy (npAIR) or cancer-associated retinopathy (CAR).
METHOD
Resolution of infection after 8 months of systemic and intravitreal antifungal therapy.
We retrospectively reviewed the medical records of patients seen on the Uveitis/Retina Services of the Massachusetts Eye and Ear Infirmary between 2008 and 2010 who were suspected to have either npAIR or CAR based on clinical examination. We included the seven npAIR/CAR patients who had their serum samples sent to two different laboratories for ARA testing by Western blot (WB) and/or immunohistochemistry (IHC). The concordance rate for detection of ARA between the two laboratories was calculated.
RESULTS Of the seven patients, four had CAR and three had npAIR. Using WB, the first laboratory detected ARA in six of the seven patients. Using a similar WB protocol, the second laboratory detected ARA in three patients and an equivocal ARA result in another patient. The concordance rate for detection of any ARA was 43% between the two laboratories. Of patients with concordant positive results, only one had the same ARA detected by the two laboratories. That patient had antibodies against a protein (enolase) that has been well established in the pathogenesis of CAR. IHC was used by the two laboratories only to confirm some of the positive WB results. Among those who had positive WB results by both labs (n=3), only one patient received the confirmatory IHC by both labs; the result was positive in both cases. CONCLUSION The concordance rate for ARA detection by WB between two laboratories was 43%. The variability in results for ARA testing currently limits the utility of this method for the confirmation of CAR and npAIR diagnoses.
CONCLUSION
Endogenous endophthalmitis from Streptococcus pneumoniae often takes on an aggressive clinical course and is associated with a poor visual prognosis and multiple systemic co-morbidities compared to more common pathogens such as Candida spp and Staphylococcus aureas.
224
223
Endogenous Streptococcus Pneumoniae Endophthalmitis in a 40 year-old Man

Gaurav Gupta, MD (Providence, RI), Enchun M. Liu, MD
Efficacy of Intravitreal Moxifloxacin vs. Intravitreal Vancomycin + Ceftazidime in the Treatment of Acute Bacterial Endophthalmitis in an Animal Model
Tania N. Adabache-Guel, MD (Mexico City, Mexico), Blanca B. Figueroa-Magana, MD, Armando Meza-De Regil, MD, Adriana Perez Reguera-Gutierrez, MD, Virgilio Morales-Canton, MD, Juan Manuel Jimenez-Sierra, MD, Jose Guerrero-Naranjo, MD, Jans Fromow-Guerra, MD, PhD, Gerardo Garcia-Aguirre, MD, Hugo Quiroz-Mercado, MD, Jose Dalma-Weiszhausz, MD
PURPOSE
Is intravitreal moxiflacin more effecive and secure than the conventional treatment for endophthalmitis?
PURPOSE To present a case of endogenous endophthalmitis in an immunocompetent patient with streptococcus bacteremia. METHOD
METHOD
Case report.
RESULTS A 40 year old immunocompetent man presented with one day history of enlarging central scotoma and counting fingers vision in his right eye. He also complained of intermittent fevers, malaise and joint pain. His fundus had a large, elevated area of retinal whitening, intraretinal hemorrhages, and arteriolar sheathing (Fig 1). The patient was hospitalized for systemic evaluation of a possible source of an intraocular infection. Blood cultures were positive for Streptococcus pneumonia; additional imaging showed a right pleural effusion, thoracic spinal diskitis, and left knee effusion. The patient was promptly treated with vitrectomy and intravitreal antibiotics salvaging his eye; unfortunately his vision declined to no light perception. A trans-esophageal echocardiogram revealed two aortic valve vegetations, consistent with endocarditis. Three weeks later, despite systemic intravenous vancomycin, he began exhibiting signs of heart failure necessitating an aortic valve replacement.
Phase 1: We injected intravitreal moxifloxacin (MXF) at a dose of 0.5mg/0.1mL. Electroretinograms were performed at baseline, 7, 14, 21 and 30 days posterior to injection. Phase 2: We inoculated a 4.9.x105 colony-forming units (CFU) of Pseudomonas aeruginosa and 1.8X 105 UFC of Staphylococcus epidermidis. Treatment was either intravitreal MXF at a dose of 0.5mg/0.1mL or vancomycin 1 mg/0.1ml plus ceftazidime 2.25 mg/0.1ml (V+C). The groups were: 1) S. epidermidis and MXF; 2) S. epidermidis and V+C; 3) P.aeruginosa and MXF and 4)P.aeruginosa and V+C. Clinical response to treatment, number of CFU in the vitreous humour and histopathological changes were analyzed.
RESULTS
Phase 1: In the ERG the mean postinjection A and B wave were of 13.60V and 36.80V respectively, with no statistically significant difference.The histopathological analysis showed no damage. Phase 2: Groups 1, 2, 3 and 4 the mean number of CFU posttreament were 1.9x101, 0, 0, 1.86x101 respectively. Comparing CFU in group 1 and 2 a statistically significant difference was observed (p 0.012) and also between groups 3 and 4 (p 0.002), in favor of moxifloxacino. Intravitreal moxifloxacin is safer and more efficient than vancomycin plus ceftazidima for the treatment of acute bacterial endophthalmitis in an animal model. See images on next page.
CONCLUSION
111
RESULTS
Mean best-corrected visual acuity from a baseline of 20/38 (range: 20/20 to 20/100) to a final acuity of 20/24 (range: 20/13 to 20/80). Mean central subfield thickness on OCT decreased from a baseline of 349 (range: 242 to 442) to a final OCT thickness of 258 (range: 214 to 310). No patients lost vision. There were no systemic or ocular adverse events observed. Interim results indicate that ranibizumab is safe and efficacious in the treatment of choroidal neovascularization secondary to Ocular Histoplasmosis Syndrome.
CONCLUSION
Hematoxylin-eosin staining of the retina at the posterior pole high magnification (40X). Marked loss of architecture of the retina and the presence of an extensive acute inflammatory infiltrate in the vitreous infiltrate all layers.
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The Role of SD-OCT in the Evaluation and Management of Infectious Retinitis

Manjot Gill, MD (Chicago, IL), Sudhi Kurup, MD
PURPOSE
Hematoxylin-eosin staining of the retina at the posterior pole high magnification (40X). Showing extensive acute inflammatory infiltrate in vitreous, extending throughout the thickness of the retina and choroid.
225
The purposes of this study are (1) to compare SDOCT images of retinal lesions with clinical exam and fundus photography to evaluate for any added benefit in identifying and describing retinitis lesions and (2) to evaluate for changes on SD-OCT images to assess for any additional insight on disease progression or response to therapy. This is a retrospective chart review with a prospective arm (given the rarity of retinitis cases). Inclusion criteria include patients above the age of 18 years with diagnosed or probable infectious retinitis (including cytomegalovirus, herpes simplex, varicella zoster, toxoplasmosis) that have obtained full ophthalmologic exam including dilated fundus exam, fundus photography and SD-OCT imaging of the affected area. Exclusion criteria include those patients unable to obtain SD-OCT given significant media opacity.
Interim Results of the LOHS Study: Ranibizumab in the Treatment of Choroidal Neovascularization Secondary to Ocular Histoplasmosis
John W. Kitchens, MD* (Lexington, KY), Edward Wood, MD, William J. Wood, MD, Thomas W. Stone, MD*, Rick D. Isernhagen, MD
METHOD
RESULTS PURPOSE To determine the level of safety and efficacy of ranibizumab for the treatment choroidal neovascularization secondary to Ocular Histoplasmosis. METHOD An open-label, randomized, prospective study comparing two different dosing strategies of 0.5 mg of ranibizumab. Group A received a single injection followed by PRN retreatment. Group B received 3 injections followed by PRN retreatment. Visual acuity, change in OCT and need for retreatment were analyzed as well as ocular and systemic complications.
Patients with CMV retinitis and toxoplasmosis were evaluated by SD-OCT at the time of diagnosis and during their follow-up. Qualitatively, the imaging helped identify affected from unaffected retina as well as demonstrating the layers of the retina involved. The OCT images provided serial qualitative evaluation to assess response to therapy. SD-OCT also helped differentiate lesions such as cotton-wool spots that may mimic active retinitis. There was also added information obtained regarding vitreo-retinal interface abnormalities.
CONCLUSION
SD-OCT has had a significant impact in the evaluation of the posterior segment. There may be a role for its use in helping evaluate and manage patients with infectious retinitis by delineating the area of involvement, differentiating lesions that may mimic retinits and monitoring the effect of therapy.
gained vision with intravitreal bevacizumab, and the patient with leukemia did the same after oral corticosteroids.
CONCLUSION
1) Apart from the classical causes of exudative retinal detachment: malignant hypertension, eclampsia and renal failure; there are others not so common entities that can lead to this disease. 2) Usually the prognosis is good after the proper treatment is installed. 3) An extensive laboratory w/u is mandatory for completing the diagnosis. 4) OCT and FA are indispensable tools.
Serial fundus photography of CMV retinitis.
OS picture of a 47 y.old woman with choroidal breast metastasis. It is visible an extensive macular serous detachment.
Serial SD-OCT of affected area of CMV retinitis.
227
Bilateral Serous Macular Detachment: Four Uncommon Etiologies

Armando G. Sandoval, MD (Quito, Ecuador), Jeffrey L. Lipkowitz, MD, Sandra X. Larco, Andrea E. Ayala, MD, Juan J. Chiriboga, MD
PURPOSE To present 4 different etiology cases of Bilateral Serous Macular Detachment: VKH, metastatic breast carcinoma, rheumatoid arthritis, myeloblastic leukemia, seen by the authors in the last 2 years, and how it was managed.
Stratus OCT of OS of a 28 year old woman with severe serous retinal detachment due to VKH , before treatment.
228
Review of clinical charts of four private practice patients with serous macular detachment in the past 2 years in Quito, Ecuador and Lawrenceville, NJ, due to different etiologies: VKH type 1, metastatic breast carcinoma, rheumatoid arthritis and leukemia, that were treated medically with systemic steroids or intravitreal bevacizumab plus the specific disease treatment. All were adults from 20 to 50 years old, 3 of them women and one man (leukemia). There was a bilateral macular exudative serous detachment in all of the cases.
METHOD RESULTS Concerning to the serous macular detachment, all improved after treatment. The VKH case recovered vision with oral prednisone during one year with tapering doses.The choroidal breast metastasis patient passed away 5 weeks after recognizing the ocular disease,but the SRD had a significant resolution after intravitreal bevacizumab. The AR case also
Posterior Segment Manifestations of Scleritis: Etiology, Associated Systemic Conditions and Treatment
Hassan T. Rahman, MD (Atlanta, GA), Sunil Srivastava, MD, Chris S. Bergstrom, MD, Jonathan Waltuck, MD, Steven Yeh, MD
PURPOSE
Posterior segment manifestations of scleritis are likely under-recognized and may contribute to visual morbidity. We characterize a series of patients with scleritis and posterior segment disease.
METHOD
Retrospective, interventional consecutive case series of patients with scleritis and posterior segment disease were identified from a database of uveitis patients at a single tertiary referral center. Records were reviewed for visual acuity, etiology and type of scleritis, posterior segment manifestations, associated systemic diagnoses, and need for steroid-sparing immunosuppression.
113
RESULTS 13 patients with scleritis and posterior segment disease were identified. Scleritis classifications included diffuse anterior (46%), nodular anterior (31%), posterior (15%) and scleromalacia perforans (15%). Systemic associations were identified in 46% of patients including chronic demyelinating inflammatory polyneuropathy, rheumatoid arthritis, and relapsing polychondritis. Posterior manifestations (# of eyes) included exudative RD (4), subretinal/choroidal granulomas (4), disc edema (3), panuveitis (3), retinal vasculitis (2), orbital pseudotumor (1), central serous retinopathy (1), and VMT/ERM (3). 85% of eyes (17/20) maintained or improved vision 2 lines during follow-up. 3 eyes lost 2-lines of vision. The mean follow-up period was 9.5 months. 92% of patients required systemic corticosteroid, and 84% required steroid-sparing agents including MTX, mycophenolate, azathioprine, and rituximab, and adalimumab. 25% of patients required 2 or more steroid-sparing agents.
METHOD
Retrospective chart review. Data extraction included demographic information, clinical and medical history, and clinical examination findings including slit-lamp biomicroscopy and dilated ophthalmoscopy. Ophthalmic imaging was also extracted.
RESULTS
A 44-year-old male being treated for Lyme disease for 6 weeks with doxycycline presented with blurred vision. Examination revealed both aqueous and vitreous cell along with retinal vascular sheathing. Fluorescein angiography demonstrated optic nerve hyperfluorescence. Laboratory studies indicated positive Lyme titer, Lyme IgM Western blot, and Babesiosis IgM titers. Resolution of inflammation and improvement of optic nerve involvement was demonstrated at 6 weeks time following treatment with a 10 day course of Atovaquone and Azithromycin. As babesiosis and Lyme disease are transmitted by the same tick vector, the ophthalmologist should consider coinfection in patients with Lyme-associated uveitis in patients that are recalcitrant to standard therapy.
Posterior segment disease in patients presenting with scleritis may result in significant visual morbidity. The majority of these patients require steroid-sparing immunosuppression to stabilize inflammation and prevent visual loss.
CONCLUSION
CONCLUSION
230
Prevalence of Smoking in Patients with Vogt-Koyanagi-Harada Syndrome

Heitor Panetta, MD (Campinas, Brazil), Rafael S. Zacchia, MD, Ricardo Y. Abe, MD, Sergio Paiva, MD, Rodrigo P.C. Lira, MD
PURPOSE
To evaluate the prevalence of smoking in patients with Vogt-Koyanagi-Harada (VKH) Syndrome and to compare with the Brazilian population. We conducted a prospective case series of 17 patients with VKH Syndrome, in Campinas, Brazil. We used a questionnaire on habits related to smoking. It was used data from Vigitel (Surveillance System of Risk Factors for Chronic Diseases and Protection through Telephone Interviews) to determine the prevalence of smoking in Brazilian population (15.5%).
METHOD
RESULTS
229
Resolution of Lyme-associated Uveitis after Detection and Treatment of Babesia Coinfection

Babak Roobini, MD (Stony Brook, NY), Thomas J. Federici, MD, Julie Tsai
The study found a smoking prevalence of 29.4% (5/17) in patients with VKH syndrome. All patients had been smokers before the diagnosis of VKH. There was no significant difference in gender distribution between groups, 3/5 women among smokers and 8/12 women among nonsmokers (p < 0.605). There was a tendency for smokers to be older (55 3 years old in the smokers versus 43 17 years old in the nonsmokers p < 0.227).
CONCLUSION
PURPOSE
To describe a case of Lyme disease presenting with uveitis in which resolution occurred only after detection and treatment of Babesia coinfection was initiated.
Cigarette smoking is more prevalent in patients with VKH syndrome and it may be a risk factor for this disease.
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232
Intravitreal Clindamycin and Dexamethasone for Toxoplasmic Retinochoroiditis

Alay S. Banker, MD (Ahmedabad, India), J. Fernando Arevalo, MD, Martin A. Serrano, MD, Rohan Chauhan, MD
Wide-field Fundus Photography and Fluorescein Angiography in the Diagnosis and Management of Retinal Vasculitis
Yasir J. Sepah MBBS (Baltimore, MD), John P. Campbell, MD, Henry A. Leder, MD, Theresa Gan, MD, Brian Cho, MD, Elham Hatef, MD, Mohamed Ibrahim, MD, Roomasa Channa, Abeer Akhtar, MD, Diana Do*, Quan Dong Nguyen *
PURPOSE To report anatomic and functional outcomes of intravitreal clindamycin and dexamethasone for the treatment of toxoplasmic retinochoroiditis (TRC). METHOD Retrospective study of 16 patients with mean age 38.88 years (21-68 years, Male : Female 6:10) with TRC (3: subfoveal, 7: juxtafoveal, 6: extrafoveal) treated with intravitreal clindamycin (1.5 mg/0.1 ml) and dexamethasone (400 g/0.1 ml). Outcome measures included resolution of TRC, changes in BCVA, OCT, fundus photos, fluorescein angiography and assessment of adverse events. RESULTS Resolution of TRC was achieved in all cases with a mean number of injections of 3.2 (range: 15 injections). Mean visual acuity improved to 0.67 from 1.15 LogMAR. At mean 14.7 months (2-36 months) a significant reduction in CMT by OCT was observed. No ocular or systemic adverse events or recurrences were observed.
PURPOSE
To determine the utility of wide-field imaging and wide-field fluorescein angiography system in the diagnosis and management of non-infectious retinal vasculitis. In this prospective, comparative study of patients with non-infectious retinal vasculitis, at baseline, and at scheduled follow-up visits, patients underwent wide-field pseudo-color imaging and angiography performed with Optos P200 System. Participating investigators were asked to determine disease activity and management changes based on exam alone, wide-field pseudo-color images, and wide-field angiography. Management decisions at each time point were compared to determine the influence of wide-field imaging on the clinicians decisions for diagnosis and treatment. Disease activity, retinal non-perfusion, and changes over time were separately evaluated.
METHOD
Intravitreal injection of clindamycin and dexamethasone may be an acceptable alternative to the classic treatment in ocular toxoplasmosis. It may offer the patient more convenience, a safer systemic side effect profile, greater availability, and fewer follow-up visits and hematologic evaluations.
CONCLUSION
RESULTS
22 patients have been enrolled with a diagnosis of retinal vasculitis. Diagnoses included: idiopathic (7); panuveitis (6); Wegener (1); Behcet (3); Sarcoid (3); Intermediate uveitis (1); and optic neuritis (1) associated retinal vasculitis. 8 patients had evidence of active vasculitis on clinical exam alone, while 12 had evidence of active vasculitis on wide field fluorescein angiography but not on clinical exam. One patient had peripheral non-perfusion requiring scattered laser directed by the angiogram. Subsequent visits demonstrated improvement in 3 of 4 patients and stability in 1 patient.
CONCLUSION
Additional information provided by wide field imaging may allow earlier detection of active vasculitis which may lead to earlier treatment and better patient outcomes. Further studies are indicated to support our initial findings.
Pre-treatment acute toxoplasmic retinochoroiditis
Post-treatment healed lesion
115
233
RESULTS
Recurence of Active Disease in Birdshot Choroidopathy Following Treatment with Local Sustained Delivery of Fluocinolone Acetonide
Thomas A. Albini, MD *(Miami, FL), Sunil Srivastava, MD, Quan Dong Nguyen*, David Callanan, MD*, Debra Goldstein, MD
Two middle-aged female patients presented with unilateral decreased vision and clinical findings consistent with stellate neuroretinitis. A thorough diagnostic evaluation for known causes of neuroretinitis was negative in each case. Radiography, ultrasonography, and fluorescein angiography revealed findings consistent with a diagnosis of posterior scleritis in each patient. This is the first report of posterior scleritis causing stellate neuroretinitis. In patients with stellate neuroretinitis of unknown etiology, posterior scleritis should be considered in the differential diagnosis.
CONCLUSION
PURPOSE To describe the clinical outcomes of the subgroup of patients with birdshot choroidopathy enrolled in the sustained delivery fluocinolone acetonide (Retisert) randomized clinical trials. METHOD Data from 3 separate randomized controlled clinical trials performed from 2000-2005 was compiled. Patients with evidence of birdshot choroidopathy were identified from the data set and analyzed. Outcome measures analyzed included recurrence rates, ETDRS visual acuity, time to first recurrence, visual fields, angiographic evidence of leakage and ERG. RESULTS A total of 39 patients were identified, 31 patients were randomized to receive fluocinolone acetonide implantation and 8 randomized to standard of care (SOC) medications. Only one eye from each group was used as the study eye. Data was also collected on the fellow eye in the implant group. The average patient age was 46. 26 patients were female, 13 were male. Logmar baseline vision in the implant group was .5067, in the standard of care group was .635 and the fellow eye of the implant group was .2467. 36 month visual acuity results revealed stabilization in the implant group and worsening in both the SOC and fellow eye groups. Recurrence rates over 3 years in the implant group was 22%, 62% in the SOC group and 46% in the fellow eye group. Average time to recurrence was 603 days in the implant group, 430 days in the SOC group and 118 days in the fellow eye group. CONCLUSION In the subgroup of patients with birdshot choroidopathy, eyes implanted with the fluocinolone acetonide implant maintained stable vision over a period of 36 months with a lower recurrence rate and longer time to recurrence in comparision to eyes treated with standard of care medications and fellow non-implanted eyes.
(A) CT scan shows smooth crescenteric thickening of the posterior wall of the right globe consistent with posterior scleritis. (B) Red free photograph shows obscuration of the optic disc margin, inferior disc hemorrhage, hard exudates in a stellate pattern, and choroidal folds inferiorly. (C) FA shows optic disc leakage and illustrates more clearly the choroidal folds.
(A) Color photograph of the left eye shows obscured disc margins, tortuous veins, and hard exudates in a stellate pattern. (B) B-scan ultrasound shows a T-sign consistent with posterior scleritis. (C) Color photograph 2 months after initiation of systemic steroids shows significant resolution of findings. (D) B-scan ultrasound shows resolution of the T-sign.
235
Multimodality Diagnostic Imaging in Unilateral Acute Idiopathic Maculopathy

John F. Payne, MD* (Atlanta, GA), Cecilia S. Jung, MD, Chris S. Bergstrom, MD, Blaine E. Cribbs, MD, Jiong Yan, MD, G. Baker Hubbard, MD, Timothy W. Olsen, MD, Steven Yeh, MD
234
Stellate Neuroretinitis Associated with Posterior Scleritis

Darin R. Goldman, MD (Los Angeles, CA), Mark W. Johnson, MD, David Sarraf, MD*
PURPOSE
To describe the clinical features and imaging characteristics in unilateral acute idiopathic maculopathy (UAIM).
METHOD
PURPOSE To describe two cases of stellate neuroretinitis associated with posterior scleritis. METHOD
A retrospective review of four patients diagnosed with UAIM. Clinical characteristics (age, symptoms, ocular/medical history, Snellen visual acuity (VA), and funduscopic features) and images from spectral-domain optical coherence tomography (sd-OCT), fundus autofluorescence (FAF), fluorescein (FA), and indocyanine green (ICG) angiography were analyzed.
Retrospective observational case series.

RESULTS The median age at presentation was 31 years, and the median interval between symptom onset and presentation was four weeks. Associated systemic findings included a viral prodrome (50%), hand-foot-mouth disease (25%), and positive Coxsackie virus titers (50%). The median presenting VA was 20/400 (range 20/701/400), which improved to 20/30 (range 20/2020/60) at final follow-up. The median follow-up time was 6 weeks. Early in the disease course, the central macula developed irregular areas of white-grey discoloration. Following recovery, the macula had a stippled retinal pigment epithelium with by rarefaction and hyperplasia. FA demonstrated irregular early hyperfluorescence and late subretinal hyperfluorescence. SD-OCT showed a partially reversible disruption of the outer photoreceptor layer. FAF initially revealed stippled autofluorescence that eventually became more hypoautofluorescent. ICG showed moth-eaten appearing choroidal vasculature, suggestive of inflammation. CONCLUSION The imaging characteristics highlight the structural changes during the active and resolution phases of UAIM. The visual recovery correlates with structural changes and suggests that the pathogenesis involves inflammation of the inner choroid, retinal pigment epithelium, and outer photoreceptor complex that is partially reversible.
236
Inhibition of Ocular Inflammation in Endotoxininduced Uveitis with the Calcium Channel Blocker Nilvadipine But Not Diltiazem
Takashi Koto, MD, PhD (Tokyo, Japan), Atsuro Uchida, MD, Makoto Inoue, MD
PURPOSE
Calcium channel blockers (CCBs), widely used for hypertensive patients, have recently been shown to inhibit atherosclerosis due to their anti-oxidative action. The aim of the present study was to examine whether CCBs nilvadipine and diltiazem reduce ocular inflammation in endotoxin-induced uveitis (EIU).
METHOD
EIU was induced in male C57/B6 mice by a single intraperitoneal injection of LPS. Animals had received intraperitoneal injections of nilvadipine, diltiazem or vehicle for 5 days until LPS application. Twenty-four hours after EIU induction, adherent leukocytes to the retinal vasculature were counted with a concanavalin A lectin perfusion-perfusion labeling technique. Protein concentration in the aqueous humor was measured to assess blood-ocular barrier breakdown. Retinal levels of ICAM-1 and MCP-1 were analyzed by ELISA. LPSstimulated generation of superoxide in murine microvascular endothelial cells was examined with nitroblue tetrazolium assay.
RESULTS
Compared to vehicle treatment, application with nilvadipine, but not diltiazem, led to significant suppression of EIU-associated retinal leukocyte adhesion together with anteriorchamber protein leakage, retinal expression of ICAM-1 and MCP-1, and LPS-induced superoxide generation in vitro. These results demonstrate the inhibitory effect of the CCB nilvadipine on the pathogenesis of ocular inflammation through the suppression of inflammation-related molecules.
CONCLUSION
(A) Fundus photograph 1 week after symptom onset shows granular hyperpigmention of the retina and RPE. (B) FA shows late staining and mild leakage in the central macula. (C) ICG angiography demonstates a moth-eaten choroidal vascular appearance and dilated choroidal vessels. (D) FAF shows a stippled autofluorescense. (E) Sd-OCT demonstrates disruption and irregularity of the photoreceptor layer Suppression of Retinal Leukocyte Adhesion with Nilvadipine but not Diltiazem.
Color fundus photograph, FAF, and sd-OCT findings one week (A) and two months (B) after symptom onset. There is loss of the grey-white discoloration and an increase in retinal pigment hyperplasia later in the disease course. The FAF images show more hypoautofluorescence. Sd-OCT reveals disruption of the photoreceptor layer (arrows), which is partially restored (arrowheads) at the two month visit.
117
237
238
Potential for Iatrogenic Contamination of Intravitreal Needles During Injection

John O. Mason, MD (Birmingham, AL), Duncan A. Friedman, MD, MPH, Tracy L. Emond, Lindsey Wallace, MD, Dustin L. Pomerleau, MD
Bacterial Dispersal Detectable in the Area of Injection Associated with Speech during Simulated Intravitreal Injection
Colin A. McCannel, MD* (Los Angeles, CA), Joanne C. Wen, MD, Brian Mochon, Omai Garner, MD
PURPOSE Endophthalmitis is a devastating complication of any intravitreal injection. The current literature indicates that oral flora from clinicians could contaminate needles, increasing the possibility of endophthalmitis. We sought to determine if iatrogenic needle contamination plays a significant role during intravitreal injections. METHOD Using a previously described experimental culture method, we exposed sterilized 30 gauge needles to different potential sources of contamination. Cultures were taken from needles in three conditions: 1) taken directly from the package, 2) a physician speaking directly in front of the needle for 30 seconds, and 3) needles exposed to the same physicians breathing for 30 seconds. These needles were then inoculated onto blood and chocolate agar and allowed to incubate at 37 degrees for 6 days. A control throat swab was also cultured using this same method.
PURPOSE
To investigate the amount of detectable bacterial dispersal associated with speech in various conditions during a simulated intravitreal injection. In the setting of simulated intravitreal injection, fifteen healthy volunteers stood adjacent to an examination chair with an open blood agar plate affixed near the head rest. The following conditions were tested while the volunteer read a 5 minute script: facing the blood agar plate with and without a facemask, without a facemask with the face turned to the side, and while reclined in an ophthalmic exam chair with an open blood agar plate secured to the forehead (patient condition). Additionally, the volunteer stood in silence for 5 minutes facing an open blood agar plate. Total number of colony forming bacteria per plate were counted and identified.
METHOD
RESULTS
A total of 45 plates were divided evenly between the 3 conditions (15 blood and chocolate plates per group). None of the plates in Group 1 (sterile needle) grew positive cultures. Only one plate in each of the other groups grew a colony forming unit. The control swab grew 335 and 180 colony forming units on blood and chocolate agar, respectively. Compared to the control swab, the experimental groups had a significant absence of growth (p<0.0001). The control swab grew predominantly Gram positive organisms.
RESULTS CONCLUSION Needles exposed to normal conditions during office based injections (i.e. talking and breathing) did not yield substantial growth of colony forming units. Compared to direct throat culture, there was a significant absence of growth from any of the needles inoculated onto culture media. It appears normal oral flora may not be a major source for needle contamination during intravitreal injections.
With no facemask, 12 of 15 plates grew at least 1 bacterial colony [mean=10.5 colonies per plate (cpp), range= 0-63]. When a facemask was worn, 3 of 15 plates had growth (mean=0.3 cpp, range=0-2). With the face turned away from the plate, 10 of 15 plates had growth (mean=1.8 cpp, range= 0-6). When the volunteer stood in silence, 4 of 15 plates had growth (mean=0.33 cpp, range=0-2). With the volunteer reclined in the patients position, 7 of 15 plates had growth (mean=1.5 cpp, range=0-13). Significantly higher bacterial growth was found in the no facemask condition compared to either facemask and silence (each p<0.001), and in the face turn condition compared to either facemask or silence (each p<0.05). Bacterial growth was not significantly different comparing the conditions facemask, silence, and room control. Growth was significantly greater in the patient condition compared to the room control (p=0.015). Wearing a facemask or remaining silent significantly decreases the amount of bacterial growth due to dispersal associated with speech. Physicians performing intravitreal injections should consider either minimizing speech or wearing a facemask, and advising patients to be silent to minimize the amount of oropharyngeal bacterial dissemination from speech during intravitreal injections.
CONCLUSION
Vitreoretinal. .Surgery. . . ............................ .................

Complications of Anterior Segment Surgery
POSTERS 301-302
301
Outcomes of 23-g Vitrectomy for Resistantpseudomonas Cluster Endophthalmitis Following Cataract Surgery
Alay Banker, MD (Ahmedabad, India), Rohan Chauhan, MD
Pre-operative cornea on presentation
To describe outcomes of 23-G vitrectomy in acute cluster endophthalmitis.

PURPOSE
Post-operative cornea at 12 weeks
302
This is a consecutive case series of eyes having acute cluster endophthalmitis following cataract surgery. All eyes underwent primary 23-G vitrectomy and intravitreal antibiotics with meticulous anterior chamber clean-up without removal of IOL, on same day.. Anterior chamber fibrin and vitreous samples were subjected to microbiological examination. Repeat intravitreal injections or surgery were performed if there was no improvement or worsening of inflammation. Outcome measures included resolution of infection and visual improvement.
METHOD
Early Postoperative Serous Macular Detachment Following Phacoemulsification

Osman Cekic (Istanbul, Turkey), Murat Aslankurt, MD, Inayet Andi, MD, Osman Dursun, MD
Nine eyes with acute cluster endophthalmitis that underwent primary 23-G vitrectomy were included in the study. Presenting visual acuities in all eyes ranged from light perception to hand movement. All eyes demonstrated severe vitritis (+4), 7 had hypopyon, and 5 eyes had significant AC fibrin and corneal involvement. Thorough cleaning of the anterior chamber with removal of fibrin was achieved in all eyes with help of 23-G forceps. Microbiological examination revealed gram-negative short rods suggestive of pseudomonas organisms. Sensitivity reports showed resistance to Vancomycin and Ceftazidime. Four eyes needed repeat intravitreal injections. Three eyes needed repeat vitrectomy and silicone oil. At 12 weeks, all eyes showed complete resolution of inflammation and visual acuity improved to 20/63 or better in 7/9 eyes (range: 20/200-20/32).
RESULTS CONCLUSION Primary 23-G vitrectomy surgery is effective even in severe acute postoperative cluster endophthalmitis. It is extremely safe, efficacious and helps in early healing even in such severly inflammed eyes. Primary removal of intraocular lens may not be required even in severe endophthalmitis cases.
PURPOSE
To report a new entity of serous macular detachment that developed next day after uneventful cataract extraction with phacoemulsification.
METHOD
In 8 eyes of 8 patients (6 male, 2 female) that underwent uneventful phacoemulsification and intraocular lens implantation, visual acuity improvement could not be achieved at the first postoperative day. All eyes had normal appearing macula preoperatively. Optical coherence tomography imaging revealed serous macular detachment with intraretinal fluid accumulation postoperatively. Patients received standard antibiotic and steroid eye drops for four weeks after the surgery. No significant anterior chamber reaction was observed postoperatively. Complete recovery of early postoperative macular edema happened within first to fourth week after phacoemulsification. No risk factor could be identified. Baseline median Snellen best-corrected visual acuity (0.35) decreased to 0.2 at the first day and increased to 0.9 at first week postoperatively (P<0.001). Median central macular thickness at first day (530 micron) decreased to 257 micron at first postoperative week (P<0.001).
RESULTS
CONCLUSION
Early postoperative serous macular detachment with intraretinal fluid accumulation, which was transient in our series, may occur after phacoemulsification without any identifiable risk factor.
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MACULAR HOLES AND MACULAR PUCKER EPIRETINAL MEMBRANE
Macular Holes and Macular Pucker Epiretinal Membrane

POSTERS 303-319
CONCLUSION
303
ILM peeling with dye assistance was found to induce higher closure rates that when the ILM peeling is performed with no dye. No statistically significant difference was found when comparing the use of ICG and BB. Functional results evaluated by BCVA were not statistically significant between the different groups.
To Peel or Not to Peel the Internal Limiting Membrane in Macular Hole Surgery: Results from the PanAmerican Collaborative Retina Study Group (PACORES)
Arturo A. Alezzandrini, MD (Buenos Aires, Argentina), J. Fernando Arevalo, MD, Lihteh Wu, MD, Maria H. Berrocal*, MD, Jose A. Roca, MD, Maria Belen Garcia
304
Description of Specific Foveal Configurations Predisposing to the Development of Macular Holes

Yoreh Barak, MD (Louisville, KY), Mark P. Sherman, MD, Shlomit Schaal, MD, PhD
PURPOSE To evaluate the anatomical and functional outcomes at 24 months of follow-up in patients with macular hole (MH) stages II, III & IV that were treated with pars plana vitrectomy (PPV) plus internal limiting membrane (ILM) peeling with and without dye assistance. METHOD Retrospective, interventional, multicenter study. We reviewed the clinical records of all consecutive patients with macular hole treated with PPV with ILM peeling. ETDRS Best Corrected Visual Acuity (BCVA), central macular thickness measured by optical coherence tomography (OCT) and the presence of adverse effects were evaluated at baseline, 1, 6, 12 and 24 months of follow-up to compare the effectiveness of each technique. All eyes were divided in 3 groups. Group 1: 47 eyes with PPV and ILM peeling without any dye assistance. Group 2: 69 eyes with PPV and ILM peeling with Indocianine Green assistance. Group 3: 47 eyes with PPV and ILM peeling with Briliant Blue assistance. RESULTS The anatomical results in Group 1 were: Primary anatomical MH closure was obtained in 36 of 47 eyes (76.6 %); in Group 2 MH closure was obtained in 64 of 69 eyes (92.8%) and in Group 3 MH closure was obtained in 45 of the 47 eyes (95.7%). The results of Visual Acuity in Group 1 was Mean BCVA was 20/100 ETDRS and gained a mean of 4.36 letters from baseline, in Group 2 Mean BCVA was 20/100 ETDRS and gained a mean of 2.87 letters from baseline. In Group 3 Mean BCVA was 20/80 ETDRS from baseline and gained a mean of 3.79 letters from baseline. Analysis perfomed on the final Visual Acuity results showed no statistically significance amongst the different groups (p>0.05). However, MH closure rate was statistically significant when results were analized between Group 1 and Groups 2 and 3 (p<0.05). When comparing Group 2 and Group 3, no statistically significant results were found, so as to benefit the use of one dye over the other.
PURPOSE
To clinically recognize and to mathematically analyze specific anatomic foveal configurations predisposing to the formation of macular holes using optical coherence tomography (OCT) imaging of patients prior to the formation of macular holes.
METHOD
3882 OCT foveal thickness maps of 647 patients with macular holes were analyzed. 96 foveal maps of 16 patients were identified prior to the formation of macular holes. Maps were analyzed using several measurements: (1) Retinal thickness around the fovea at 50 micron consecutive intervals (2) Maximal foveal slope at two intervals lateral to the central foveal depression, and (3) Central length of foveal depression. Using automated regression software Eureqa (version 0.82 beta) the mathematical analog of the foveal configuration was analyzed and the equation to describe the mathematical relationship in a 0.083 fit was derived for pre-macular-hole foveas in comparison to age matched foveas.
RESULTS
Pre-macular hole anatomical configuration was found to be significantly different from normal foveal anatomy for maximal slope (P<0.05) and for central length of foveal depression (P<0.05). The mathematical regression function for normal fovea followed a first order cosine curve of level 11 complexity. The mathematical regression function for premacular-hole fovea followed a complex sine curve of level 30 complexity. Normal foveas had higher symmetry (0.860.1 P=0.03) along the midline whereas pre-macular hole foveas had steeper maximal slopes (200.1 P=0.01). 75% of pre-macular hole patients had similar foveal configuration in the fellow eye, 50% of these indeed consequently developed bi-lateral macular holes. Pre-macular hole foveal anatomical configuration was found to be significantly different from normal foveal configuration. The ability to identify a suspicious macular configuration on OCT scans may allow early diagnosis, followup and better management of macular-hole-prone patients.
CONCLUSION
10 patients with minimum of 4 month postoperative follow-up had visual improvement of at least two lines on the Snellen chart, one had unchanged visual acuity, and one had worsened vision.
Figure 1. OCT image of pre-macular-hole configuration (A) demonstrating a-symmetrical foveal slopes with a steep maximal slope compared to a control (B).
CONCLUSION
The demographic of our study populations mirrors the ethnicity profile of Bronx County, New York according to Census 2010 data. The prevalence of bilateral IMH among our mostly non-Caucasian patient population is similar to previously report data, whereas female-to-male ratio is lower. Our study supports that there is no racial predilection for bilateral IMH.
Figure 2. The mathematical regression function for pre-macular-hole fovea (A) followed a complex sine curve. The mathematical regression function for normal fovea (B) followed a first order cosine curve.
306
305
Bilaterality and Characteristics of Idiopathic Macular Holes in a Mostly Non-Caucasian Population

Lynn L. Huang, MD, MPH (Bronx, NY), Anurag Shrivastava, MD, Irena Tsui, MD
Understanding Macular Holes: Macular Holes that Develop after Retinal Detachment Repair
Peter J. Kertes, MD, FRCS(C) (Toronto, Canada), Matthew B. Schlenker, MD, Robert G. Devenyi, MD, MBA, FRCS(C)*, Wai-Ching Lam, MD, FRCS(C)
PURPOSE
What is the incidence, characteristics, and outcomes of macular holes (MH) that arise in eyes that have been treated for retinal detachment (RD)?
PURPOSE Previous epidemiologic data on bilaterality of macular holes varies widely between 1% to 25% among different demographics. The latest population-based study by McCannel et al reports an 11.7% prevalence in Olmsted County, Minnesota. This study describes the bilaterality and characteristics of idiopathic macular holes (IMH) among a large series of non-Caucasian patients in Bronx, New York. METHOD A retrospective chart review was done of 136 patients with the clinical diagnosis of macular hole among 15,600 patient visits between December 1, 2007 and September 7, 2010 at the Montefiore Medical Center Eye Institute. Optical coherence tomography (OCT) data, when available, was used as adjunct information in staging of the disease. The prevalence of bilateral IMH and their characteristics were described among the 74 patients with available medical record and no other identifiable cause. RESULTS Among 74 patients in our study, 39% were AfricanAmericans, 30% were Hispanic, 14% were mixed-racial, 11% were Caucasian, 4% were Asian, and 3% were undetermined. Average age was 70.7 years (SD=14.9). Female-to-male ratio was 1.7: 1. Median visual acuity was 20/70 at the time of diagnosis or presentation. Nine (12.2%) of 74 patients had macular hole in the fellow eye. Of the 58 patients with documented staging by OCT or clinical exam, full-thickness IMH were found in 33 (57.9%) of 58 first eyes, and in 1 (22.5%) of 8 second eyes. Twelve (16.2%) patients underwent surgery for macular hole repair in one eye. Among them, 8 of
METHOD
We performed a retrospective, consecutive case series and identified 18 patients who developed a new full-thickness MH after prior RD management over a 4.5 year period. Inclusion criteria: a newly diagnosed MH after RD management by either Pneumatic Retinopexy (PR), Pars Plana Vitrectomy (PPV), or Scleral Buckle. Data collected: past ocular history, management and visual outcome of their RD, and management and visual outcome of their MH. All patients were offered surgery to repair their MH, which was performed on 14 patients after RD repair, and 2 in combination with RD repair after a failed PR. MH repair surgery included PPV, Internal Limiting Membrane peeling, and Gas Fluid exchange.
RESULTS
18 full-thickness MHs were detected from 985 eyes (1.9% incidence). On RD presentation 14/18 RDs involved the macula. 16/18 patients had best corrected visual acuity (BCVA) of 20/200 or worse. 10/18 RDs required multiple procedures to achieve reattachment. Post-RD BCVA was 20/200 or worse in 15/18 patients. The median time to MH diagnosis after RD repair was 1 month (range: 2 days53 months), and from MH diagnosis to MH repair 1.75 months (range: 3 weeks-8 months). 14/16 eyes (89%) undergoing surgical repair achieved MH closure, 1 requiring multiple PPVs. 11 saw at least one Snellen line improvement (median 1, range: 1-6), 2 lost vision (1 and 2 Snellen lines respectively), and 3 remained unchanged at a median follow-up of 3 months (1 month-25 months). 6 patients had at least 20/80 BCVA at last follow-up.
121
CONCLUSION RDs preceding MHs are often severe macula-off RDs requiring multiple interventions for repair. Post-MH repair closure rates are similar to rates for idiopathic MHs. Visual outcomes are moderate and coincide with the degree of impairment post-RD repair. The findings suggest other pathogenic mechanisms besides vitreofoveal traction may be leading to these MHs, such as cystoid macular edema.
Characteristics and Outcomes of Patients with Macular Holes Following Management for Retinal Detachments.
vitrectomy or comorbid retinal disease other than macular pucker were excluded. Patients without successful hole closure postoperatively were also excluded from the study. Macular hole size, duration of symptoms, BCVA, and anatomical appearance on optical coherence tomography (OCT) testing were analyzed preoperatively, and at 1, 3, and 6 months postoperative intervals.
RESULTS
Two-hundred and twenty-two eyes were screened for inclusion and those without optical coherence tomography at all pre- and postop intervals were excluded. A total of 80 eyes (74 patients) were included. There were 53 females and 17 males with a mean age of 69. The mean preop macular hole size was 484.38 diameters. Mean preop BCVA was 20/200. Two eyes (2.5%) developed an outer foveal defect within 3 weeks of vitrectomy surgery; 1 resolved at 1 month postop and the other was resolved at 6 months postop. Both eyes with outer foveal defects had BCVA of 20/50 at 6 months postop. The mean postop BCVA for all eyes at 1, 3, and 6 months postop was 20/100, 20/70, and 20/50, respectively. There were no other complications in any eye postoperatively. The incidence of outer foveal defects following macular hole repair surgery may be significantly lower than previously reported. Further investigation is warranted utilizing standardized OCT instrumentation and methods for analyzing and interpreting anatomic findings after successful macular hole repair.
CONCLUSION
308
Proposed mechanism of macular hole (MH) formation post-retinal detachment (RD) repair. (A) Sagittal cut of a macula-off RD with cystoid macular edema. (B) After the retina is reattached cystoid pockets of fluid become under tension, and the overlying retina becomes stretched and weakened. (C) Some inner retina dehisces leading to a lamellar MH. (D) Further dehiscence leads to a full thickness MH
Clinical Comparison of Macular Hole Repair Utilizing Indocyanine Green Prepared with Sodium Based Fluid (BSS) vs. Sodium-free Fluid (D5W)
Kirk H. Packo, MD* (Chicago, IL), Alexander L. Grigalunas, MD
307
Incidence of Postoperative Outer Layer Foveal Defect Following Idiopathic Macular Hole Repair
John O. Mason, MD (Birmingham, AL), Dustin L. Pomerleau, MD, Tracy Emond, Lindsey Wallace, MD, Shilpa Reddy, MD, Richard M. Feist, MD, Martin L. Thomley, MD, Michael A. Albert, MD
PURPOSE
The potential toxic nature of ICG for ILM peeling has been widely debated. The RPE takes up ICG via a sodium driven pump. It has been suggested that reconstituting ICG powder with a sodium-free fluid such as D5W rather than BSS minimizes this RPE uptake and may give superior results. This retrospective review compares consectuive cases of macular hole repair using these two ICG formulations.
METHOD PURPOSE The incidence of outer layer foveal defect following vitrectomy with internal limiting membrane peeling and macular hole repair has been reported as high as 59% in recent literature. Our study seeks to determine if the risk for this type of anatomic finding is indeed that high for our patient population. METHOD A retrospective chart review was performed of all patients with an idiopathic macular hole who underwent pars plana vitrectomy with internal limiting membrane peeling from January 2008 to October 2010. Patients with a history of prior
All idiopathic macular holes operated on by a single surgeon (KHP) from 1997 to 2010 were reviewed. Patients with concurrent ocular disease or less than 6 mo follow-up were excluded. Holes repaired prior to July 2003 utilized ICG assisted ILM peeling in which the dye was prepared with BSS, containing sodium at an isotonic concentration. Holes repaired subsequently utilized ICG dye prepared with D5W, containing no sodium, however still isotonic to vitreous. Results were compared assesing anatomic closure of the hole, and pre-op and 6 mo post-op vision converted to logMar scale. Results were stratified to lens status to avoid bias by post-op cataract formation.
RESULTS 52 eyes met the inclusion criteria. 22 eyes had ILM peeling assited by ICG prepared with BSS (sodium based) and 19 eyes had ILM peeling assisted by ICG prepared with D5W (sodium free). In the ICG-BSS group, primary hole closure occured in 20/22; hole failed primary closure in 2/22; and 2 re-opened late. In the ICG-D5W group, primary hole closure occured in all 19, with no late reopenings. In the ICG-BSS group, the mean preop acuity was 0.8344 (20/137); at 6 months this improved to mean 0.6716 (20/93); at the final acuity following cataract extractions, the mean acuity was 0.3348 (20/43). In the ICG-D5W goup, the mean preop acuity was 0.6942 (20/100); at 6 months this improved to mean 0.6529 (20/90); at the final acuity following cataract extractions, the mean acuity was 0.5046 (20/64). With BSS, 2 eyes ended with less acuity at final visit (one substantially), while with D5W only one eye worsened mildy. Due to small numbers, no statistical significance was seen.
309
Non-supine Positioning is Preferred Over Face-down Positioning and Provides an Equivalent Closure Rate in 25 and 23 Gauge Macular Hole Surgery
Dustin L. Pomerleau, MD (Birmingham, AL), Christopher J. Compton, MD, Richard M. Feist, MD, Richard Feist, Jr., MD, Tracy L. Emond, Lindsey Wallace, MD, John O. Mason, MD, Martin L. Thomley, MD, Michael A. Albert, MD
PURPOSE
Face-down positioning after macular hole (MH) surgery has been thought to achieve hole closure, but recent publications have called this into question. Our study seeks to determine if strict face-down positioning is necessary in 25 or 23 gauge macular hole repair and whether patients prefer shortterm face-down or long-term non-supine positioning.
METHOD
In this study, no difference in primary hole closure or final mean acuity was found between ICG-BSS anad ICGD5W surgeries. In the ICG-BSS group, two eyes worsend, with one substantially (20/100 to 20/400). Only one eye worsened with ICG-D5W suggesting that D5W may prevent occasional severe visual loss. Lack of significance prevents conclusion. Further comparison data is indicated.
CONCLUSION
Retrospective chart review of all MH repairs by 4 surgeons in a single practice from 2006 to 2008. Inclusion criteria were preoperative documentation of patient demographics, lens status, macular hole diameter, and preoperative OCT, vitrectomy with gas tamponade and ILM peeling, and follow-up of 12 weeks or until complete hole closure. Patients were given a postoperative survey about their positioning preference between strict face-down positioning for 7 days with a short-term acting gas or non-supine positioning for 30 days with a long-acting gas. A total of 52 eyes (52 patients) met inclusion criteria. All patients had 25 or 23 gauge vitrectomy with peeling of the ILM with closure in 50 of the 52 eyes. Thirty-one patients were instructed to position face-down at all times and 21 patients to merely avoid supine positioning. There was no significant difference in the positioning groups with respect to age, gender, MH diameter, central subfield thickness, total macular volume, preoperative or final visual acuity, hole closure rate, or duration of follow-up. Given the choice, 15 of 31 patients (47%) in the face-down group reported that they would prefer non-supine positioning for macular hole repair, even if longer positioning was required, versus all 21 patients in the non-supine group. Seventeen of 21 phakic patients (81%) in the face-down positioning group required cataract extraction before their final visit.
RESULTS
Preoperative acuity (logMar) compared to postoperative acuity (logMar) at the final visit after correcting for cataract formation with extractions iin the ICG-BSS group. Data points above the line indicate improvement. Two eyes worsened, with one substantially (20/100 to 20/400) although the holes were closed in both.
CONCLUSION
Non-supine positioning with a long-acting gas tamponade provides an equivalent MH closure rate to facedown positioning with a short-acting gas tamponade, and is preferable to most patients. Strict face-down positioning does not appear to significantly mitigate cataract formation.
Preoperative acuity (logMar) compared to postoperative acuity (logMar) at the final visit after correcting for cataract formation with extractions in the ICG-D5W group. Data points above the line indicate improvement. Only one eye worsened slightly.
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Macular Hole Surgery Using Silicone Oil as Internal Tamponade Agent

Bhavin Shah, MD (Hyderabad, Indonesia), Raja Narayanan, MBBS, Siddharth Dikshit, DO
twelve months postoperatively. Correlation analysis was conducted between VA at baseline and one year with seven preoperative OCT parameters: manually measured MH height nasally/temporally, MH minimum/base width, total width of the inner segment (IS) outer segment (OS) defect, and distance of IS/OS defect to temporal/nasal aspect of the MH.
RESULTS
PURPOSE To evaluate the efficacy of silicone oil as an internal tamponade for macular hole closure during idiopathic macular hole surgery. METHOD Eight eyes of 8 patients who underwent pars plana vitrectomy with dye assisted internal limiting membrane peeling with silicone oil injection for idiopathic macular hole were studied retrospectively. Patients who had severe spondylosis, had an immediate need to travel by air, or had only one functional eye underwent silicone oil injection instead of gas tamponade. ILM peeling was performed in all cases. Optical coherence tomography (6mm line scan), best corrected visual acuity, intraocular pressure measurement using Goldmann applanation tonometer were performed. Macular hole closure rate was the primary outcome measure. The secondary outcome measure was the best corrected visual acuity. RESULTS The median age of patients in this study was 63 years. Five patients were males and 3 were females. The mean macular hole diameter at baseline was 855m. The mean macular hole index was 0.50. The hole closure rate was 100% (8/8). The mean logMAR best corrected visual acuity at baseline was 0.9 and at last follow-up was 0.85. The mean follow-up period was 5.33 months (range 37 months). The mean intraocular pressure at baseline was 15 mmHg and at last follow-up was 13 mmHg.
Data from 36 eyes from 36 patients were included. All had successful closure of the macular hole. Table 1 contains a summary of the values for the OCT parameters that were recorded. One way ANOVA showed that there was a statistically significant correlation between the preoperative IS/OS loss width and preoperative VA, the final VA at one year and the change in VA at 1 year (p<0.05). There was no statistically significant correlation between MH nasal height, MH temporal height, MH base width or MH minimum width to the preoperative visual acuity, the one year VA or the change in VA at one year. The length of the IS/OS defect preoperatively was the strongest predictor for both preoperative VA and VA one year after anatomically successful macular hole repair in this study. This suggests that despite the macular hole size the appearance of the IS/OS segments should be evaluated by SD-OCT to predict the likelihood of visual recovery after macular hole repair.
CONCLUSION
Silicone oil may be used as internal tamponade for macular hole closure in selected cases where gas may be relatively contraindicated.
CONCLUSION
Table 1: Shows the mean and standard deviation for each of the measured macular hole parameters.
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Spectral Domain OCT Based Predictors of Visual Acuity Outcomes in Full Thickness Macular Hole Repair Surgery
Sumit Sharma, MD (Cleveland, OH), Jack Shao, MD, Peter Kaiser, MD, Rishi Singh, MD, Jonathan Sears, MD, Justis Ehlers, MD, Daniel Martin, MD, Sunil Srivastava, MD
Trypan Blue vs. Brilliant Blue for Macular Hole Surgery

Daraius Shroff, MD, FRCS (Delhi, India), Neelam Atri, MD, Bhavana Sharma, MD, A. K. Singh, MD, Charu Gupta, MD, Cyrus M. Shroff, MD
PURPOSE
To study the anatomical and functional outcome of macular hole surgery using two different dyes to stain the ILM. Retrospective non-randomized comparative analysis between study group (Brilliant Blue) and control group (Trypan Blue). 80 patients of idiopathic macular hole who underwent surgery from January 2008 to September 2010 were included. Pre- and post-operative best-corrected visual acuity, lens status and optical coherence tomography were done for all patients. 80 patients underwent vitrectomy and ILM peeling. Cataract surgery was combined in 29 cases. 66 patients underwent ILM staining with Trypan Blue (TB), and 14 patients with Brilliant Blue (BB).
PURPOSE To identify features of pre-operative spectral domain optical coherence tomography (SD-OCT) scans that may predict the level of visual acuity (VA) improvement one year after macular hole (MH) surgery. METHOD This is a retrospective, interventional, consecutive case series of patients with idiopathic MH who underwent vitrectomy for MH repair and had a preoperative SD-OCT on the Cirrus HD-OCT (Carl Zeiss Meditec). All patients underwent dilated ophthalmoscopic exam, SD-OCT, and protocol ETDRS VA (converted to logMAR), preoperatively as well as at six and
METHOD
RESULTS Mean pre and post operative logMAR best corrected visual acuity (BCVA) was 0.870.38 and 0.380.30 in the TB group (p<.001) respectively, and 0.660.27 and 0.370.21 in the BB group (p<.001). Post operatively 64 eyes (97%) in the TB group and 14 eyes (100%) had BCVA 20/200 (p = .679), 36 eyes (54.5%) in the TB group and 7 eyes (41.2%) in the BB group achieved BCVA 20/40 (p = .238). 77 of 80 (96.3%) macular holes closed while 3 (3.8%) remained open. No patient had post operative retinal detachment. CONCLUSION There was no statistical difference in the functional outcome between the two groups. However, Brilliant Blue stains ILM better facilitating complete and less traumatic removal. Moreover, in the Brilliant Blue group the absence of fluid-air exchange during staining reduced the chances of lenticular haze during surgery.
operative visual acuity of 0.39. One patient needed additional surgical management to achieve successful outcome. All eyes (100%) achieved SD-OCT confirmed anatomical closure at six months. There was no case of post operative endophthalmitis or post-operative hypotony.
CONCLUSION
23-G phaco-vitrectomy is a safe and effective method in the management of idiopathic full thickness macular holes. A high anatomical closure rate with significant visual acuity improvement can be attained with ILM peel and C3F8 gas tamponade without the need of head posturing even in patients with a long duration of symptoms.
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Pars Plana Vitrectomy with Membrane Peeling for Diffuse and Focal Epiretinal Membranes: A Comparative Study
Osman Cekic, MD, PhD (Istanbul, Turkey), Mehmet Cakir, Ahmet T. Yazici, Kemal Yuksel, MD
Anatomical and Visual Outcomes of Idiopathic Macular Hole Surgery with 23G Phaco-vitrectomy, ILM Peel and C3f8 Gas Tamponade without Head Posturing
Malhar Soni DO, MS, DNB, FRCS (England, UK), Gregory Ho Yen, MD, Minas Georgopoulos, MD
PURPOSE
To compare the results of pars plana vitrectomy with membrane peeling in eyes with focal and diffuse epiretinal membrane.
METHOD PURPOSE To evaluate the anatomical and visual outcomes of 23-gauge transconjunctival sutureless phaco-vitrectomy (TSPV) for idiopathic full thickness macular holes (FTMH) undergoing internal limiting membrane (ILM) peel and C3F8 gas tamponade without head posturing.
A retrospective comparative study. Medical records of 68 eyes of 65 consecutive patients (mean age 65 years) who underwent vitrectomy and membrane peeling for diffuse and focal epiretinal membranes were included. A complete ophthalmological examination and optical coherence tomography measurements were performed at baseline and postoperatively.
Retrospective analysis of a consecutive case series. 50 eyes of 50 consecutive patients underwent 23-gauge transconjunctival sutureless phaco-vitrectomy, brilliant blue stained internal limiting membrane peel and 16% C3F8 gas tamponade surgery for Spectral Domain Optical Coherence Tomography (SD-OCT) confirmed idiopathic stage II-IV macular holes. All patients were given the opportunity for surgery regardless of the duration of their symptoms. The patients were not advised to perform any head-posturing post-operatively except to avoid lying on their back. The main outcome measures were visual acuity and SD-OCT confirmed anatomical success at six months follow-up.
METHOD RESULTS The mean duration of symptoms for 50 patients was 8.6 months. The mean age for this group was 70.5 years. There were 4 eyes (8%) with stage II, 36 eyes (72%) with stage III and 10 eyes (20%) with stage IV idiopathic full thickness macular holes. Forty nine (98%) out of fifty eyes achieved successful anatomical macular hole closure with one surgery. The mean pre-operative visual acuity of 0.82 improved to mean post-
RESULTS
The mean follow-up was 12 months (range, 8 to 22 months). Epiretinal membrane was classified as primary in 35 eyes, and as secondary in 33 eyes. Preoperative and final postoperative visual acuity were significantly higher in eyes with secondary epiretinal membrane than that with primary epiretinal membrane (P<0.05 and P<0.01, respectively). Preoperative macular volume was significantly higher in eyes with primary epiretinal membrane than that with secondary membrane (P<0.01). No difference was found in postoperative visual acuity and mean macular volume values between eyes with focal adherence and diffuse adherence pattern (P>0.05). Preoperative and postoperative visual acuity were significantly higher in eyes with intact inner segment/outer segment (IS/OS) junction than in patients with disrupted IS/OS junction (P<0.05 and P<0.05, respectively). Pars plana vitrectomy and membrane peeling improves visual acuity and restores macular thickness in eyes with both diffuse and focal epiretinal membrane.
CONCLUSION
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METHOD
Visual and Anatomic Outcomes of Epiretinal Membrane Peel after Retinal Detachment Repair in a Teaching Institution
Andres Emanuelli, MD (Miami, FL), Ninel Gregori, MD
The present study was designed as an interventional retrospective case series, including patients affected by CHRRPE who underwent a vitrectomy and ERM removal with a minimum follow-up of 12 months. The following data were collected for each patient: anterior segment examination, pre- and post-operative best-corrected visual acuity (BCVA), intraocular pressure (IOP), fundus examination, photography and fundus fluorescein angiography (FA), spectral domain optical coherence tomography (SD-OCT). All cases underwent standard 3-port 25 gauge vitrectomy with an ERM peeling, without a tamponade.
PURPOSE To assess visual and anatomic outcomes after epiretinal membrane (ERM) surgery in patients with prior retinal detachment (RD) surgery repair. METHOD Patients who had undergone pars plana vitrectomy (PPV)/membrane peel(MP) for ERM after RD repair were identified and the charts were reviewed. We compared the Snellen best corrected visual acuity (BCVA), OCT characteristics at pre-op and post-op visits (1, 3, 6 months), lens status, surgical dates, dates and characteristics of prior retinal detachment repair. The OCT obtained at each visit was analyzed to document the presence and location of retinal fluid and to assess the appearance of IS/OS junction. The time course of recovery of the IS/OS junction, central foveal thickness (CFT), macular volume (MV) and BCVA during the postoperative period was studied. RESULTS Eight patients were identified, 6 with macula-off and 2 with macula-on RD. Median BCVA improved from 20 letters at pre-op to 40, 40, 58 letters at 1, 3, and 6 months, respectfully. By 6-months, the CFT and MV improved in all eyes. A normal IS/OS junction and CFT seemed to correlate significantly with BCVA. CONCLUSION VA can improve significantly after ERM peel in patients with history of retinal detachment repair. VA and OCT improvements are seen through at least 6 months after surgery.
RESULTS
Four patients were included in the present study. There were 2 men (50%) and 2 women (50%). All patients were phakic. The mean age was 19.5-year (3.9 SD, min: 15, max: 21). The mean follow-up time was 16.5 months (3.4 SD, min: 13, max: 21). All the lesions considered were unilateral. The mean pre-operative BCVA was 0.19 (0.09 SD), ranging from 0.125 to 0.32 (median: 0.16), and post-operative BCVA was 0.52 (0.34 SD), ranging from 0.2 to 1.0 (median: 0.45). The BCVA improved in all the patients after the surgeries and remained stable up to the last follow-up. The FA presented decrease of dye leakage at the late phases. In addition, the retinal vessels tortuosities got better in all the cases after the surgical procedure (Figure 1). SD-OCT proved that ERM were completely removed in all their components (Figure 2), with an evident restoring of the physiologic retinal morphology and a decrease of underlying retina edema. No serious adverse event was recorded to date. CHRRPE is a unilateral benign tumor leading to a malformation both of the RPE and the neurosensory retina. In the present study, we have treated 4 patients with vitrectomy and ERM peeling, evaluating the long-term follow-up. The BCVA improved in all patients, as well as the retinal morphology. Therefore, patients with CHRRPE and ERM may benefit from surgery as early as possible.
CONCLUSION
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Long-term Surgical Outcome of Epiretinal Membranes Associated with Hamartomas of the Retina and Retinal Pigment Epithelium
Cesare M.C. Mariotti, MD (Ancona, Italy), Piergiorgio Neri, MD, Andrea Saitta, MD, Michele Nicolai, MD, Alfonso Giovannini, MD
Figure 1. Selected case 1: The comparison between pre-operative (A) and post-operative (B) fundus photography shows the improvement of retinal morphology, with an evident reduction of epiretinal traction.
Combined Hamartomas of Retina and Retinal Pigment Epithelium (CHRRPE) are unfrequent benign tumors, presenting proliferation of retinal pigment epithelium (RPE) and glyal tissue. These tumors lead to retinal anomalies, particularly epiretinal membranes (ERM), compromising visual acuity. The aim of this study was to evaluate the long-term outcome of surgical management in CHRRPE complicated by ERM.
PURPOSE
0.2. Final visual acuity depends statistically significant on maximum retinal thickness (p=0.008). Neither subfoveal pigment deposits, nor the type of epiretinal membrane adhesion to the retina have an influence on postoperative visual acuity.
CONCLUSION
Careful analysis of three dimensional SD-OCT scans may enable better surgery planning and may enable to presume the final outcome, having in mind that photoreceptor defects and maximum retinal thickness are the most important prognostic factors.
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Figure 2. Selected case 2: OCT showing an evident ERM with underlying retina edema (A). After surgery, the retinal morphology appears restored, with recovery of physiological foveal depression (B).
Visual Prognosis after Idiopathic Epiretinal Membrane Surgery Based on High Resolution SD-OCT
Amar Patel, MD* (New York, NY), Madhavi Kurli, MD, Richard B. Rosen, MD*
317
SD-OCT in Epiretinal Membranes Before and After Surgery

Jerzy Nawrocki, MD, PhD (Lodz, Poland), Janusz Michalewski, MD, PhD, Magdalena Siwinska, MD, Zofia Michalewska, MD, PhD
PURPOSE
To evaluate features of spectral-domain optical coherence tomography (SD-OCT) of eyes before and after epiretinal membrane surgery and correlate these with visual outcomes.
METHOD
PURPOSE To describe retinal morphology before and after surgery for idiopathic epiretinal membranes. Additionally to evaluate factors responsible for the final visual outcome. METHOD A retrospective study of 150 eyes followed with spectral domain optical coherence tomography (SD-OCT) for a period of 12-38 months. In all eyes pars plana vitrectomy with internal limiting membrane peeling was performed. Following factors were evaluated: central and maximum retinal thickness, photoreceptor defects, number of points of adhesion between epiretinal membranes and the retinal surface, posterior hyaloid status, presence of subfoveal deposits, presence of intraretinal cystoid spaces and changes in particular retinal layers in the fovea. Those factors were statistically correlated with pre- and postoperative visual acuity. RESULTS Increased preoperative central and maximum retinal thickness (p=0.04) and photoreceptor defects (p=0.03) were associated with worse final visual outcome. Eyes with multiple points of adhesion between epiretinal membranes and retinal surface were more likely to have decreased visual acuity postoperatively. Postoperative visual acuity was found to be negatively correlated with photoreceptor defects (p=0.02), preoperative maximum retinal thickness (p=0.01) and central retinal thickness (p=0.03). All eyes having final visual acuity >0.6 had initial visual acuity >0.2 and no photoreceptor defects. Eyes with visual a photoreceptor defect larger than 1000m were more probable to have final visual acuity below
Preoperative and postoperative SD-OCT images were analyzed and visual acuities were collected retrospectively in all patients who underwent surgery for idiopathic epiretinal membranes from January 2008 to December 2010 at our institution. SD-OCT features analyzed were internal limiting membrane (ILM) profile (normal ILM or ILM distortion), integrity of the external limiting membrane (ELM) (normal ELM line or ELM line disruption), integrity of the inner segment and outer segment junction (IS/OS) (normal IS/OS line or IS/OS line disruption), and foveal contour (normal foveal contour or loss of foveal contour with or without intraretinal edema).
RESULTS
There were 34 surgeries performed on 34 patients (18 male, 16 female). Mean age was 64 years (range=43-80 years; SD=9.0 years). At postoperative month 3, 85.3% (29/34) of eyes had an improvement in best-corrected visual acuity (BCVA) while 2 patients had no change in visual acuity and the remaining 3 patients had a decline in visual acuity. The baseline ILM profile and foveal contour had no significant influence on BCVA at 3 months (P>0.05) whereas the baseline integrity of the ELM (P=0.020) and IS/OS junction (P=0.013) significantly influenced BCVA at 3 months. Additionally, postoperative integrity of the ELM (P=0.0050), IS/OS junction (P=0.0039), and foveal contour (P=0.0081) significantly influenced BCVA at 3 months. Preoperative integrity of the ELM and IS/OS junction may be prognostic factors for visual outcomes after epiretinal membrane surgery. Furthermore, evaluating the ELM, IS/OS junction, and foveal contour postoperatively may help to explain poor visual recovery.
CONCLUSION
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Intraoperative SD-OCT Evaluation of Internal Limiting Membrane Stripping in Macular Hole and Macular Pucker Repair
Joshua Robinson, MD (Atlanta, GA), Robin Ray, MD, Chris S. Bergstrom, MD, G. Baker Hubbard, MD, Hans Grossniklaus, Sunil Srivastava, MD
Retinal Detachment
POSTERS 320-342
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PURPOSE To correlate intraoperative spectral domain optical coherence tomography (SD-OCT) with histopathologic findings of internal limiting membrane (ILM) resection during pars plana vitrectomy for full-thickness macular hole (FTMH) and macular pucker (MP) repair. METHOD A retrospective chart review was performed and identified 14 patients that underwent vitreoretinal surgery for macular pucker (n=8) or full-thickness macular hole (n=6). All surgeries were performed by experienced vitreoretinal surgeons (SS, GBH, CB) utilizing 20-guage, 23-guage, or 25-guage techniques. Indocyanine Green or Triamcinolone Acetonide was employed to stain the ILM per surgeon preference. Intraoperative SD-OCT imaging was obtained using a Bioptigen Spectral Domain Ophthalmic Imaging System (Bioptigen Inc.) before and after each membrane peel. Tissue specimens from each membrane peel were submitted for light and electron microscopy. RESULTS In all 6 FTMH cases and 2 of the eight MP cases, the ILM and associated epiretinal membrane (ERM) were peeled simultaneously. In the remainder of MP cases, the ILM and ERM were peeled separately. Five of the 6 FTMH cases were associated with an identifiable ILM edge on intraoperative SD-OCT, with all but one case demonstrating ILM on light and electron microscopy. Of the 14 submitted MP tissue samples (2 membranes from 2 single peel cases, and 12 membranes from 6 separate peel cases), 11 were recovered and analyzed. For all 11 cases, light and electron microscopic findings were consistent with clinical impression; however, in only one case could a definite ILM edge be identified on SD-OCT. All of the cases lacking an identifiable ILM edge on SD-OCT demonstrated a highly corrugated post-peel retinal surface with identifiable epiretinal membrane edges. Those cases correlated with a visible ILM edge on SD-OCT tended to have a much smoother post-peel retinal surface. CONCLUSION Identification of an ILM edge on intra-operative SD-OCT was a reliable indicator of ILM resection in FTMH repair associated with mild epiretinal membranes without underlying retinal distortion, but not in cases of macular pucker repair associated with dense epiretinal membranes and highly corrugated retinal surfaces.
A Study of Macula off Retinal Detachments Allowing Slow Subretinal Absorption of Fluid with Gas Tamponade
Sean David Adrean, MD (Fullerton, CA), Scott Grant, MD
PURPOSE
The purpose of this study was to retrospectively review the last 125 macula off retinal detachments repaired with a vitrectomy, to determine if the visual results were superior to previously reported studies by not flattening the posterior pole with perfluorocarbons or with a drainage retinotomy, but allowing subretinal reabsorption of the fluid with the assistance of a gas tamponade.
METHOD
This study retrospectively examined 125 macula off retinal detachments. Patients were excluded: if they did not have at least 6 months of follow-up, if they developed proliferative vitreoretinopathy (PVR), if the duration of the retinal detachment was longer than 6 weeks, if they had a previous vitrectomy or scleral buckle surgery, if they had significant macular pathology affecting the visual outcome. Seventy patients were identified that underwent a vitrectomy with or without a scleral buckle, with laser or cryotherapy, air-fluid exchange and gas injection. The pre-op visual acuity (Va) was compared to the post-op Va at 6 months and final Va.
RESULTS
The average duration of the retinal detachment was 9 days with a range of 1 day to 4 weeks. The average age of the study population was 64.5 years of age with 30.6% females. Overall initial repair rate was 91.9% with 8.1% of patients developing PVR. 35.5% of patients had a vitrectomy alone while 64.5% had a vitrectomy with scleral buckle. 45% of patients were phakic at the time of surgery and 40% of those patients had subsequent cataract surgery. Pre-operatively the average visual acuity was 20/400, post-operative visual acuity was 20/50 and final best correct visual acuity was 20/40. The visual acuity improvement was statistically significant (p<0.0001). The median visual acuity at 6 months was 20/40 and the median final visual acuity was 20/30. Leaving fluid in the macula at the end of the surgery may allow the RPE pump to effectively remove the fluid in a more physiologic manner, allowing for better visual recovery.
CONCLUSION
321
Macula-on Rhegmatogenous Retinal Detachments: Does Time to Surgery Matter?

Arghavan Almony, MD (St. Louis, MO), Daniel P. Joseph, MD, PhD
injected gas, repeating the procedure several times until the eye was filled completely with gas. After the retina was attached we treated with laser barrage.
RESULTS
We had 14 patients (14 eyes) underwent an in office fluid gas exchange the push pull technique due to RD in a vitrectomized eye. Average age was 69.8 years. The mean follow-up was 12.2 (7-24) months. In 10 eyes (71.4%) the retina remain attached after the procedure. In 4 eyes the retina reattached only after an additional surgery vitrectomy and silicon injection. No complications were observed.
PURPOSE To determine if time to surgical repair of macula-on rhegmatogenous retinal detachments (RRD) affects anatomic and visual outcomes. METHOD Retrospective review of 68 eyes with macula-on RRD. The eyes were divided into three groups: Group 1 (18 eyes) included eyes that had emergent surgical repair of the retinal detachment within eight hours of presentation; Group 2 (36 eyes) included eyes that had urgent surgical repair, 8-24 hours after presentation; Group 3 (14 eyes) included eyes that received surgical repair from 2-10 days after presentation. RESULTS The median initial visual acuity was 20/30 and the median final visual acuity was 20/40. The change in visual acuity from presentation to final follow-up was worst in Group 1, which lost an average 1.2 lines per eye compared with Group 2 which lost only 0.2 lines. Overall, 22.2% of Group 1 eyes lost 3 lines of vision compared with only 11.1% in Group 2 and 7.1% in Group 3. Furthermore, 72.2% of Group 1 eyes achieved 20/50 final visual acuity compared with >90% of Group 2 and 3 eyes. The mean follow-up was 8.9 months. CONCLUSION In this study, emergent repair of macula-on retinal detachments does not seem to yield superior visual or anatomic outcomes.
CONCLUSION The Push Pull Technique offers a good alternative for revitrectomy in selected patients with RD in vitrectomized eyes. Failure to achieve retinal attachment by this technique does not reduce the revitrectomy recovery rats. The advantages over surgery are: simple procedure, time saving, few complications and faster recovery.
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Visual Outcomes after Primary Repair of Chronic vs. Super-chronic Macula-off Rhegmatogenous Retinal Detachments in an Underserved Population
Danielle S. Strauss, MD (New York, NY), Tahsin Choudhury, Shantan Reddy, MD, MPH
PURPOSE
322
Push Pull Technique for Retinal Detachment in Vitrectomized Eyes

Amir Bukelman, MD (Rehovot, Israel), Yoel Grinwalled, Ofer Daphna, Ayala Pollack, MD
It has been reported that the chronicity of an RRD is a negative prognostic factor for anatomic success and visual improvement following surgical repair. Previous studies have not compared visual acuity outcomes in patients who underwent pars plana vitrectomy for repair of chronic (>14 days-3 months) RRDs with patients who underwent the same procedure for super-chronic detachments (>3 months old).
METHOD
PURPOSE To investigate the safety and efficacy of an in office fluid gas exchange (push pull technique) for the treatment of post vitrectomy retinal detachment (RD) complications. METHOD A retrospective computer search from 2005 till the end of 2010 of post vitrectomy patients who developed retinal detachment (RD), that underwent an in office push pull technique which is fluid gas exchange. A 10ml syringe containing 5ml of 16% PFP was used. We entered the eye from bellow through the pars-plana, withdraw some fluid and
A total of 12 eyes with macula-off RRDs which underwent pars plana vitrectomy, with or without scleral buckling were studied. The eyes were divided into two groups based on time from presentation of symptoms to surgery. Chronic retinal detachment was defined as greater than 2 weeks (range 15-50 days), and Super-Chronic retinal detachment was defined as greater than 3 months duration (range 97-3650 days). LogMar best corrected visual acuity (BCVA) was compared pre-operatively and at the 3 month post-operative visit. Retinal detachments with greater than grade A PVR and those that needed silicone oil placement were excluded. Twelve eyes had repair of a retinal detachment with a mean time from symptoms to surgery of 32.7 days (SD 14.1) in the chronic group, and a mean time of 842.2 days (SD 1404.1) in the super-chronic group, P = 0.19. The mean pre-operative BCVA was not statistically different between the chronic group and the super-chronic group (2.0 (SD1.0), vs. 1.4 (SD1.1), P=0.37). At the 3 month post-surgical follow-up visit, the
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RESULTS
RETINAL DETACHMENT
LogMAR BCVA was also not statistically significant between the two groups with BCVA of 1.5 (SD 0.9) in the chronic group and 0.9(0.6) in the super-chronic group, P=0.29. A similar mean gain in BCVA in both groups was observed. The chronic group gained 0.5 (SD 0.4) and the super-chronic gained 0.4 (SD 0.5), P=0.84. Repair of super-chronic RRDs over three months old can improve visual acuity and visual recovery may not be significantly different from chronic RRDs that have not been detached for as long. Photoreceptor loss that occurs with retinal detachments may slow with time. Clinicians should be aware of the benefit of repairing long-standing RRDs which are not uncommon in the underserved population.
CONCLUSION
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Decreased Mechanical Stiffness of Detached Retina Causes Increased Expression of Genes Implicated in Proliferative Vitreoretinopathy (PVR)
William J. Foster, MD, PhD, FRCS(C) (Houston, TX), Joshua Davis, MD, Paul A. Janmey, MD, Deborah C. Otteson, MD
PURPOSE
324
HSO as First Choice in Complicated Retinal Detachment: Checkmate in Two Moves!

Cesare Forlini, MD (Ravenna, Italy), Paolo Rossini, Matteo Forlini, Adriana Bratu
Retinal detachment is known to be associated with an increase in the production in CTGF. We provide evidence for a model where retinal stiffness influences the expression of genes implicated in PVR. A conditionally-immortalized Mller cell line was cultured on laminin-coated substrates of differing elastic modulus. Real-time PCR was performed in triplicate for CTGF. Analytic calculations were performed to evaluate the change in local elastic modulus in detached and attached retina.
METHOD
RESULTS
PURPOSE To show our strategy in complicated RD, with high possibility to develope PVR and RD recurrence. In such cases, our first choice is to use HSO as tamponde agent to ensure an efficient tamponade action around and the inferior sectors and to reallocate to the top eventual recurrence to treat in a second time. METHOD 24 selected patients, with high risk of PVR recurrence (>C3) were treated with heavy silicon oil (Densiron 68, Fluoron); a 23 gauge vitrectomy with ILM peeling, prior staining with ICG or Brilliant Peel; use of endolaser on present break(s) and at 360; PFCL or air-HSO exchange. All scleralaccesses are always sutured at the end of the operation, with transconjuntival 8-0 suture. HSO is maintained within a period among 60 and 90 days. The removal is performed through the active aspiration (vacuum 500-600 mmHg) with 20 or 23 gauge transconjuntival system. RESULTS Recurrence at the superior retina was present in 7 cases (30%) between 9 and 3 oclock, at the moment of the second procedure performed among 60-90 days from the first operation. In 3 cases it was used 1000 cs oil, in 4 cases gas mix (C2F6 15%). Of the 3 cases were tamponade with 1000cs oil 2 cases had to be re-operated with the use of 1000 cs oil. 4 cases are highlighted of exudation in anterior chamber over the anterior and posterior surface of the IOL, associated to increase of intraocular pressure, all well controlled with medical therapy. CONCLUSION The surgical strategy has allowed to reduce further operations with reallocating critic area to superior sectors and to manage recurrence more easily (using different tamponade substances) and interrupting the multiple inferior recurrence chain. The strategy of using HSO as first choice in case of complicated R.D. allows to ensure the anatomical and functional success in two passages.
Analytic calculations, utilizing the method of images and elasticity theory, predict that the tissue stiffness experienced by Mller cells will decrease when the retina becomes detached. Expression of CTGF mRNA, as measured by quantitative real-time PCR, increases by 103-fold (p=0.04) as substrate stiffness decreases over the predicted stiffness range.
CONCLUSION
Increased expression of CTGF, as found in retinal detachment in PVR, can be accounted for by mechanotransduction, the increase in gene expression when the retina is relatively softer during retinal detachment. These findings help to explain the increased PVR in patients with areas of chronic retinal detachment.
326
High Percentage of Patients with Retinal Detachments Presenting to a Large Public Hospital Fail to Return for Treatment
Susan K. Gelman, MD, MPH (New York, NY), Carolyn P. Graeber, MD, Ilyse Haberman, MD, Jenna Friedenthal, MD, Shantan Reddy, MD, MPH
PURPOSE
The purpose of this study is to review demographics, clinical characteristics and compliance with follow-up care of underprivileged patients with a retinal detachment (RD) treated by a level I public trauma center.
METHOD A retrospective review was performed of 81 consecutive patients presenting with a loss of vision from a RD to a large New York City public hospital between 2003 and 2010, with New York University Institutional Review Board approval. Factors including age, gender, type of RD (rhegmatogenous (RRD), tractional (TRD), or serous (SRD); acute or chronic; macula on
or off), visual acuity in LogMar (pre-operative, best-corrected post-operative), and compliance with follow-up were studied. IBM SPSS Statistics 19 (Somers, NY) was used for data analysis.
RESULTS Positive outcomes were obtained after surgical repair of an acute RD at our public hospital. Patients with an acute macula-on RD who underwent surgical repair had improved mean visual acuity (0.85 versus 0.71 LogMar) as well as patients with an acute macula-off RD (1.66 versus 1.21 LogMar). Younger age and early repair were correlated with better results.
within the pit, endolaser and gas tamponade. We compare preand post-operative visual acuity, fundus photographs and optical coherence tomography imaging for each of these patients.
RESULTS
Of 81 patients with a diagnosis of RD, 26 (32.1%) failed to return for treatment, including 7 of 19 (36.8%) with a maculaon RD, and 15 of 44 (34.1%) with a rhegmatogenous retinal detachment. These patients received multiple certified letters and calls indicating the need for follow-up. Mean presenting visual acuity and age of those lost to follow-up was not significantly different than those compliant with follow-up.
CONCLUSION A large percentage of patients with an RD, including those with macula-on RDs, chose not to return for follow-up care. Language and/or socioeconomic barriers may make it less likely for underprivileged patients to return for needed urgent treatment. Improved measures to increase compliance should be developed to prevent patient disability and increased costs.
In 3 of 4 cases, optical coherence tomography imaging showed complete resolution of the RD which was maintained at the most recent follow-up visit, and in the remaining case with a short 6 month follow-up period, the subretinal fluid had markedly decreased although residual macular detachment persisted. In 3 of 4 cases the visual acuity was improved at the latest visit compared with the pre-operative visual acuity, and in the remaining case where visual acuity was reduced this could be explained by cataract that had increased after vitrectomy. Figures 1 and 2 (attached) show the pre- and post-operative fundus photographs and optical coherence tomography images for case 1 and case 4 respectively, demonstrating the maculopathy and its resolution after surgery. We present similar image compilations for the remaining two cases. These four cases of optic disc pits with associated RD are unique as for all there was clear glial tissue visible over the optic disc pit with demonstrable traction. Treatment by surgical removal of this tissue produced good visual and anatomical outcomes. For patients with glial tissue adherent to the optic disc pit, vitrectomy with surgical removal of this tissue may be indicated.
CONCLUSION
327
Figure 1. Patient 1s left fundus. A, B, photograph and OCT preoperatively showed a temporal optic disc pit, macular detachment, schisis and traction. VA was 20/70. C, D, photograph and OCT 54 months after vitrectomy and peeling of the glial tissue within the pit. The subretinal fluid and schisis have resolved and there is sub-foveal debris and an epiretinal membrane. VA is 20/30.
Glial Tissue Peeling for Retinal Detachment Associated with Optic Disc Pit
Emily Gregory-Roberts MBBS, BSc (New York, NY), Carlos Mateo, MD, Stanley Chang, MD
PURPOSE Pits of the optic nerve head are associated with retinal detachment (RD). The pathogenesis is unclear and it remains unclear what surgical treatment is most effective. Some patients have glial tissue in the optic nerve pit which may contribute to the development of RD. We assess the efficacy of surgical peeling of the glial tissue within the pit for treatment of RD in these patients. METHOD
We report a retrospective case series of 4 patients from 2 centers who presented with RD associated with an optic nerve head pit, with glial tissue evident in the pit. We assess the efficacy of treatment by vitrectomy, peeling of the glial tissue
Patient 4s left fundus. A, B, photograph and OCT preoperatively showed macular schisis and detachment, and an optic disc pit with tissue in and over the disc cup. VA was 20/600. C, D, photograph and OCT 6 months after vitrectomy and peeling of the glial tissue overlying the pit. There is reduction in the subretinal fluid and schisis, although the macula remains detached. VA is 20/100.
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Retinal Detachment after Posterior Vitreous Detachment Combined with Vitreous Hemorrhage
Guillermo Iribarren, MD (Buenos Aires, Argentina), Marcelo Valeiras, MD, Uriel Rubin, MD, Diego Bar, MD
OCT and Fundus Autofluorescence Abnormalities Are Associated with Visual Outcome in Rhegmatogenous Retinal Detachment
Szilard Kiss, MD (New York, NY), Guilleherme Favarone, MD, Robison Chan, MD, Jane Myung, MD*, Anton Orlin, MD, Minhee Cho, MD, Donald DAmico, MD
PURPOSE To describe the incidence and surgical outcomes of patients with retinal detachment after acute posterior vitreous detachment combined with vitreous hemorrhage. METHOD Retrospective review of patients with retinal detachment between 2005 and 2010. Inclusion criteria were patients with regmatogenous retinal detachment after acute posterior vitreous detachment with vitreous hemorrhage. Complete eye examination including ultrasound was performed in all cases. Results include final mean visual acuities, number of eyes with at least one retinal tear, location of retinal tears, number of eyes that developed retinal detachment and number of eyes repaired with scleral buckling surgery and or pars plana vitrectomy. 11 eyes of 11 patients were selected.. Three were female and eight male, with a mean age of 61 6 years. Mean follow-up time 39.9 months. RESULTS In 7 cases retinal tears where detected and treated with laser or cryotherapy and the mean time to retinal detachment was 36 days. The remaining 4 cases had a dense hemorrhage mean time to retinal detachment, 9 days. Total number of retinal breaks found was 15, 7 (46.6%) located in superior temporal cuadrant, 3 ( 20%) superior nasal, 3 ( 20%) at the 12 oclock hour , 1 at the 6 oclock hour and 1 temtporal inferior. Three cases had 2 breaks. Two patients were treated with scleral buckling , two cases with primary vitrectomy and the remaining seven cases with vitrectomy combined with encircling band. In all cases we were able to find at least one retinal tear prior or during the surgical procedure. Mean initial visual acuity was 20/496, final visual acuity was 20/123. 6 of the 11 patients required at least 2 surgical procedures to reattach the retina. In those cases with one surgical procedure mean final visual acuity was 20/39. Overall mean number of surgeries was 1.7. CONCLUSION Acute, spontaneous, nontraumatic posterior vitreous detachment combined with hemorrhage is associated with a high incidence of retinal tears and detachment. Close follow-up with clinical examination and ultrasonography is necessary. Aggressive management with early vitrectomy should be considered to find and treat the retinal breaks and prevent retinal detachment.
PURPOSE
Visual recovery after rhegmatogenous retinal detachment (RD) repair can vary depending on clinical and anatomic factors. We investigated ultra wide-field fundus autofluorescence (AF) and spectral domain optical coherence tomography (OCT) abnormalities, pre- and postoperatively, in patients with RRD and correlated these findings with visual outcome.
METHOD
Six patients, (4 female, 2 male) aged 25 to 69 years presenting to Weill Cornell Medical Center with non-traumatic RD were included in a retrospective, single-center, consecutive case series. All patients underwent pre- and postoperative visual acuity (VA) testing, slit lamp biomicroscopy and dilated fundus examination. Symptom duration prior to presentation ranged from 3 to 7 days. Spectral-domain OCT (Heidelberg Engineering, Inc., Vista, CA) and ultra wide-field AF (Optos, Marlborough, MA) were performed pre- and postoperatively. 5 patients (macula-off RD) underwent PPV; 1 (maculaon RD) had scleral buckle. Anatomical success was achieved in all. Pre-op VA ranged from 20/20 to finger counting, post-op VA from 20/20 to 20/100. Pre-op OCT revealed subretinal fluid (SRF) underneath the fovea. In the areas of SRF, there was disturbance of the external limiting membrane (ELM) and disruption of the inner/outer segment (IS/OS) with increased reflectivity of photoreceptors. 3 patients with worst VA had retinal thickening, cystic changes in the plexiform layers and corrugations of the outer retina. Pre-op AF showed hyper-AF at the edge of SRF extending beyond the RD; areas with detached retina were hypo-AF. Post-op OCT showed improvements in outer retinal architecture in all patients. Patients with the best VA had normalization of ELM, IS/OS and photoreceptors and resolution of SRF. Post-op AF revealed persistent abnormalities (alternating circumferential lines of hypo-/hyper-AF) in 3 patients with the worst VA. Pre-op OCT showing increased retinal thickness, cystic changes and corrugations were associated with worse VA compared to disruption of IS/OS and ELM alone. Pre-op hyperAF extended past the detachment, signifying dysfunction even in attached retina. Persistent post-op OCT and AF abnormalities were associated with worse VA. OCT and AF may provide prognostic parameters for visual outcome in RD.
RESULTS
CONCLUSION
CONCLUSION
Relaxing retinectomies may be required in cases of retinal detachment with severe proliferation to allow complete retinal attachment. Many of these eyes are end-stage and would undoubtedly progress to a degenerative state. By restoring retinal anatomic integrity, a significant portion of these eyes can be maintained and in some cases improved vision, though minimal, can be achieved.
Upper left: Hypo-AF of RD with adjacent hyper-AF in bordering attached retina. Lower left: OCT with thickened retina, outer retinal cysts, outer retinal corrugations, photoreceptor and IS/OS abnormalities. Upper right: Post-PPV, AF anomalies (circular hypo- and hyper-AF) persist in reattached retina. Lower right: OCT with attached retina, resolved cysts, and variable reflectivity of IS/OS.
331
Outcomes in Small Incision Pars Plana Vitrectomy without Scleral Depressed Trimming of Vitreous Base for Rhegmatogenous Retinal Detachment
Nikolas London, MD (Philadelphia, PA), Homayoun Tabandeh, MD*, Thomas Gerald Chu, MD, PhD*, David S. Boyer, MD*
330
The Utility of Relaxing Retinectomies in Repair of Recurrent Retinal Detachments with Severe Proliferative Vitreoretinopathy
Jennifer I. Lim, MD (Chicago, IL), Daniel F. Kiernan, MD
PURPOSE
To describe the visual acuity and anatomic outcomes of small incision pars plana vitrectomy for rhegmatogenous retinal detachment without scleral depressed trimming of vitreous base.
The purpose of this study is to retrospectively review cases in which retinal detachment surgery was performed in the setting of severe proliferation and examine the preoperative and surgical differences between cases that required relaxing retinectomies and those that did not to achieve anatomic retinal attachment.
PURPOSE METHOD A retrospective review of all cases with severe proliferative vitreoretinopathy and/or retinal incarceration with retinal detachment that underwent surgical repair by one surgeon over a 40 month period was performed. All cases that required a relaxing retinectomy to achieve retinal reattachment were identified. The preoperative characteristics, surgical techniques, and postoperative course and outcomes were reviewed for these cases and compared with cases that did not necessitate retinectomy. RESULTS Fifty-six eyes were identified with severe proliferative retinopathy and retinal detachment that underwent surgical repair. Of these, 21 cases required relaxing retinectomies. Eighteen of these eyes showed retinal attachment at follow-up. Vision in these eyes was 20/400 on average (range 20/200 hand motions). Three eyes were complicated by recurrent detachment. Two of these underwent re-operation and achieved anatomically successful attachment. One eye remained chronically detached and maintained light perception vision. Two eyes progressed to no light perception and phthisis bulbi. One eye developed epithelial downgrowth and was treated with 5FU and remained attached. Of the eyes that did not necessitate retinectomy, 29 maintained retinal attachment at follow-up with vision averaging counting fingers (range 20/100 - hand motions). Three of these underwent reoperation and achieved anatomic attachment.
METHOD
Retrospective consecutive case series of all cases of rhegmatogenous retinal detachment who underwent PPV between January 2007 through September 2010. During the study period the surgical technique included small incision PPV (25G or 23G) in all cases. Scleral depressed vitreous base dissection was performed only in cases with anterior proliferative vitreoretinopathy (PVR). Exclusion criteria included age <18, follow-up <3 months, and presence of proliferative diabetic retinopathy. Outcome measures included retinal reattachment status and best corrected Snellen visual acuity (BCVA).
RESULTS
Data were obtained on 156 eyes of 152 patients, with a mean patient age of 62.2 years (range 19-90 years). The mean follow-up was 13.9 months (range 3-41 months). The retina detachment involved the macula in 115 (74%) eyes. Forty nine eyes were pseudophakic. Twenty seven eyes were highly myopic. Giant retinal tear was present in 7 eyes. PVR ranged from none to closed-funnel total RD. The retina was reattached with one procedure in 146 (94%) cases. Final reattachment was achieved in 154 (99%) eyes. The BCVA at baseline was >20/40 in 34 (22%) eyes, 20/50-20/100 in 14(9%) eyes, 20/200-20/400 in 27 (17%) eyes, and <20/400 in 81 (52%) eyes. At the last followup the BCVA was >20/40 in 68 (44%) eyes, 20/50-20/100 in 37 (24%) eyes, 20/200-20/400 in 25 (16%) eyes, and <20/400 in 26 (16%) eyes.
CONCLUSION
Small incision PPV without scleral depressed vitreous base trimming for rhegmatogenous retinal detachment is associated with good anatomic outcomes and functional improvement.
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The New 25g Plus System Competes with the 23/20g System to Treat Rhegmatogenous Retinal Detachments
Cesare M.C. Mariotti, MD (Ancona, Italy), Francesca Viti, MD, Michele Nicolai, MD, Andrea Saitta, MD
Conservative Management vs. Early Vitrectomy in Patients Presenting with Fundus-obscuring Hemorrhagic Posterior Vitreous Detachment
Alexander Melamud, MD, MA, (Sterling, VA), Neha Serrano, MD
The 25g Plus system gives the same anatomical results as the 23/20g systems for all cases of retinal diseases that require vitreoretinal surgery. In addition, it no longer gives any particular technical problems in spite of its smaller size. It allows for a bi-manual approach, perfect illumination and easy silicon oil injection and removal.
PURPOSE METHOD Non-randomized restrospective study. A total of 97 eyes with rhegmatogenous retinal detachment were recruited from January 2009 to September 2010 and had a minimum follow-up of 6 months. All patients were treated with the 25g plus system. Local-regional anesthesia was done for all eyes. All phakic eyes had to undergo cataract surgery. All eyes underwent a complete vitrectomy. Perfluocarbon liquids were used during all surgeries and then a PFCL-Air exchange was performed. At the end of the surgery the appropriate tamponade was injected in all eyes (PDMS in 45 eyes, C3F8 in 37, air in 15). Laser retinopexy was done in all eyes. RESULTS Surgery was performed on 97 eyes with rhegmatogenous retinal detachment. PDMS was used as a tamponade in 45 eyes. C3F8 was used as a tamponade in 37 eyes and 32 had anatomical success after the first surgery. Air was used as a tamponade in 15 eyes, 14 of which had anatomical success after the first surgery. 5 eyes with the C3F8 tamponade had a recurrent retinal detachment and PDMS was used to reattach the retina. 1 eye with the air tamponade had a recurrent retinal detachment and PDMS was used as new tamponade. Of these, 44 resulted in anatomical success after the silicon oil was removed. The silicon oil is still in 7 eyes because they had a recurrent retinal detachment with PVR. They underwent a relaxing retinotomy with the 25g vitrectome. 92.8% of eyes had an anatomical success after the first surgery with the 25g Plus system. CONCLUSION The 25g Plus system offered: excellent management of complete vitrectomy; peripheral retinal shaving and vitreous traction release; retinotomy with vitrectome with silicon oil in the eye; bi-manual approach with 25G chandelier; easy oil injection and removal; endolaser photocoagulation; better sclerotomy closure without sutures (sutureless sclerotomies); and less inflammatory reaction.
PURPOSE
1) To identify the incidence of retinal detachments (RD) and retinal tears (RT) in a population of patients presenting with an acute, fundus-obscuring vitreous hemorrhage (VH) due to PVD. 2) To determine whether patients who undergo early PPV benefit from improved visual acuity outcomes as compared to patients who are treated with conservative management.
METHOD
From 20032010, patients presenting within 1 week of symptom onset with VH were retrospectively identified. Eyes were excluded if there was < 2 months of follow-up, if the VH was not fundus-obscuring (better than 20/400 vision) or if history of: retinopathy or macular degeneration in either eye; RD, RT, vein occlusion, macroaneurysm, trauma, uveitis, or eye surgery (except uncomplicated cataract surgery) in the affected eye. Data on PPV timing, visual acuity, and other factors were collected. Visual outcomes in eyes which had PPV at 7days of presentation were compared to those who did not (later or no PPV) using the Students t-test and risk ratio. RT and RD incidence was also calculated.
RESULTS
In total, of 41 eyes identified, 26.8% (n=11), 36.6% (n=15), and 46.3% (n=19) had retinal detachment, retinal tears, and underwent PPV, respectively. When eyes in the early PPV group (n=6) were compared to all other eyes (n=35) there was a trend toward better final visual acuity but the results were not statistically significant [t=-1.11 P=0.27; risk ratio (RR) 1.46 Confidence Limit (CL):0.58;3.67]. However, when eyes in the early PPV group were compared to eyes that underwent PPV more than 7 days after presentation (n=13), there was a statistically significant difference with better vision noted in eyes that underwent early PPV (t=2.21, P=0.04; RR 3.25 CL:0.72;14.64). Eyes presenting with acute, fundus-obscuring PVD have a high incidence of retinal tears and detachment. In these cases, early PPV might result in better visual acuity outcomes.
CONCLUSION
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Scleral Buckling for Retinal Detachment Results of 150 Consecutive Eyes

Naveenam Srinivasa Muralidhar, MD (Bangalore, India), Hemanth Murthy, MD, Manoj Gautam, MD
Segmental Buckling without Encircling Band for Primary Rhegmatogenous Retinal Detachment
Raja Narayanan MBBS (Hyderabad, India), Bhavin Shah, MD, Jay Kumar Chhablani, MD, Baruch D. Kuppermann, MD, PhD*
PURPOSE Vitrectomy has become more popular as primary surgery for retinal detachment. We want to study the efficacy of scleral buckling surgery for uncomplicated RRD. METHOD Records of consecutive patients who underwent surgery for rhegmatogenous retinal detachment were scrutinized. All patients who underwent scleral buckling as a primary procedure with a minimum follow-up of 3 months were taken up for retrospective analysis. Intervention: All the patients underwent cryotherapy and scleral buckling with or without drainage of sub retinal fluid. In all the patients, the eye was encircled with a 42 band. The 42 band itself was used as buckling and encircling element. Air injection was done in some eyes. The main outcome measure was retinal reattachment with the primary surgery. Secondary outcome measures were the profile of detachment and visual outcome.
PURPOSE
To study the anatomic and visual outcome of segmental buckling without encircling band for primary rhegmatogenous retinal detachment (RRD)
METHOD
Seventeen eyes of 17 patients who underwent segmental buckling without encircling band for primary RRD were studied retrospectively. Approval for the study was obtained from the institutional review board. Patients with single retinal breaks or multiple breaks within 3 clock hours were included. Patients with a history of trauma, proliferative vitreoretinopathy grade C or worse were excluded. The retinal reattachment rate after the first surgery was the primary outcome measure. Gain in best corrected visual acuity (BCVA) was the secondary outcome measure. Mean age of presentation was 35.28 yrs with 4 women and 13 men. Mean duration of decreased vision was 137.5 days with 6 patients had history of trauma. The median preoperative best corrected visual acuity was 20/800 (range: 20/30-20/4000). At presentation, the macula was detached in 13 eyes with total retinal detachment (RD) in 3 eyes. Mean number of breaks was 1.1. There were no intra-operative complications. The mean follow-up was 212 days (7months). Sixteen (94.1%) patients had attached retina till last follow-up with median BCVA of 20/50 (20/20-20/2000).
RESULTS
150 eyes of 149 patients were available for analysis. 88 were males and 61 were females. Average follow-up was 9 months. 107 (72%) patients were phakic, 34 (23%) pseudophakic, 4 (2.6%) aphakic and 1 (0.7%) had subluxated lens. Horse shoe tear was the most common type of primary break, being seen in 38% of the eyes. Pre operatively, macula was detached in 119 eyes (79.3%) and attached in 31 eyes (20.7%). In 131 eyes (87%) primary surgery was successful in attaching the retina, while 19 eyes (13%) required secondary procedure. Out of the 19 eyes, in 17 eyes retina got attached with the second surgery, while in two eyes retina remained detached. Visual acuity improved in 111 eyes (74%), stable in 34 eyes (22.7%) and worsened in 5 eyes (3%).
RESULTS CONCLUSION Scleral buckling is very effective for rhegmatogenous retinal detachment and can achieve success rate close to 90%. Scleral buckling should be considered as a primary procedure for uncomplicated rhegmatogenous retinal detachment.
CONCLUSION
Segmental buckling without encircling band is a safe procedure with good anatomic and visual success in selected eyes with primary RRD.
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Macular Morphology in SD-OCT after Scleral Buckling or Primary Vitrectomy

Jerzy Nawrocki, MD, PhD (Lodz, Poland), Dominik Odrobina, MD, PhD, Janusz Michalewski, MD, PhD, Slawomir Cisiecki, MD, PhD, Maciej Bednarski, MD, Zofia Michalewska, MD, PhD
PURPOSE
To compare spectral domain optical coherence (SD-OCT) after scleral buckling (SB) and primary pars plana vitrectomy (pppV).
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METHOD This is a single center, prospective analysis of 132 eyes after SB and 121 eyes after pppV, which were evaluated with SD- OCT 1, 3 and 12 months after surgery. Patients with rhegmatogenous retinal detachment with no prior surgery except phacoemulsification were included. The type of surgery performed was chosen by the surgeon. Following data were compared: initial and final visual acuity, type of retinal detachment, number of procedures performed, epiretinal membrane, macular oedema, photoreceptor and external limiting membrane defects, subretinal fluid, retinal pigment epithelium defects, central retinal thickness. RESULTS Mean initial visual acuity was 0,05 in the pppV group and 0,26 in the SB group. Mean final visual acuity was 0,15 and 0,32 respectively. Mean improvement of visual acuity in the pppV group was 0,1 and in the SB group 0,6. The mean number of additional procedures including silicone oil removal was 1,2 after pppV and 1,0, after SB, which was not statistically significant (=0,2). Photoreceptor and external limiting membrane defects were present in 63% of patients after pppV and in 24% after SB. Epiretinal membranes were present in 62% of cases in the SB group and 55% of pppV group. Thinning of the fovea was observed in 13% of the SB group and 3% of the pppV group. Macular oedema was observed in 30% of patients after SB and in 18% of patients after pppV. Mean central retinal thickness was similar in both groups (pppV: 273um, SB: 277um). Subretinal fluid was present in 30% of patients after SB and 18% of patients after pppV. CONCLUSION The most important factor correlating with postoperative visual acuity was the size of photoreceptor defects, which occurred more often in patients after pppV. Other changes of retinal morphology were noted more often in the scleral buckling group but did not statisticaly significant influence visual acuity. Central retinal thickness had a tendency to normalize during 12 months after surgery.
duration. No patient had a retinal break greater than 30 or RRD larger than 2 quadrants. The surgical procedure included Peribulbar, drainage of subretinal fluid, and the placement of the segmental buckle in all patients. Cryopexy or laserpexy was performed around the break. The outcomes were the 1-week, 1-month and 6-month reattachment rates, best-corrected visual acuity (with ETDRS charts), rate of subsequent operations, and postoperative complications.
RESULTS
We enrolled 100 eyes of 100 patients scheduled to undergo scleral buckle surgery. The demographic data were mean age 53 (SD=12) years old, mean symptoms duration of 12 (SD=9) days, 54 (54%) males, and 72 (72%) patients with RD affecting macula. The 1-week, 1-month, and 6-month anatomical success rates were 93% (93 patients), 100%, and 100%, respectively. Seven (7%) patients underwent one additional retinal detachment surgery (pars plan vitrectomy) after primary failure at 1-week follow-up. The preoperative, 1-month, and 6-month best correct visual acuity were 20/100, 20/80, and 20/50, respectively (Table 1 and Figure 1). The postoperative complications were: eyelid edema in 10% of the patients (this patients received cryopexy), transient ocular hypertension (duration < 7 days) in 5%, macular pucker (these patients had RD affecting macula before surgery) in 3%, transient diplopia (duration < 30 days) in 3%, hyphema (<0.5mm) in 1%. It is not time to forget scleral buckle surgery. Most of the adverse events in this study related to segmental scleral buckle were minor postoperative complications, mainly eyelid edema. It still is as good and a cheaper option to vitrectomy. The results suggest that in patients with uncomplicated retinal detachment, segmental scleral buckle provide satisfactory anatomical and functional success.
CONCLUSION
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Segmental Scleral Buckle Still is a Good Option for Treatment of Uncomplicated Retinal Detachment: A Case Series
Heitor Panetta, MD (Campinas, Brazil), Iuuki Takasaka, MD, Fernando Chaves, MD, Andrea Torigoe, MD, Valdir Balarin, MD, Rodrigo P.C. Lira, MD
PURPOSE The objective of this prospective case series was to describe the reattachment rate and visual acuity results of patients with uncomplicated rhegmatogenous retinal detachment (RRD) who underwent segmental scleral buckle surgery. METHOD Inclusion criteria were primary RRD with a single peripheral retinal break. All patients had phakia, were 18 years or older, had partial or total PVD, and had visual loss or symptoms (floaters and photopsia) of less than 30 days
338
Treatment of Choroidal Neovascularization in Central Serous Chorioretinopathy by Intravitreal Bevacizumab

Avinash Pathangey, MD (Hyderabad, India), Rajeev R. Pappuru, MD, Mudit Tyagi, MD, Raja Narayanan MBBS, Annie Mathai, MD, Ajit B. Majji, MD
PURPOSE Choroidal neovascular membranes (CNV) associated with chronic central serous chorioretinopathy (CSC) are predominantly classic membraes. Photodynamic therapy has been the standard of care for these membranes. There are few case report To evaluate the efficacy of Bevacizumab in choroidal neovascular membrane associated with chronic central serous chorioretinopathy. METHOD Retrospective chart review of 7 eyes of 7 patients with CNV associated with chronic CSC diagnosed by fluorescein angiogram and optical choherence tomography. Chronic CSC was diagnosed by documented episode of central serous chorioretinopathy with a previous history of a focal leak from the level of the RPE on fluorescein angiographic examination along with resolution of the sub-retinal fluid in the macular area. Patients who received photodynamic therapy previously were excluded. Response to intravitreal bevacizumab 1.25 mg was assessed by visual acuity and optical coherence tomography.
Pre-treatment OCT showing sub-retinal tissue with sub-retinal fluid, and cystoid changes in retina which were reduced in post-treatment OCT.
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Evolving Retinal Detachment Repair Paradigms 1: Understanding How Globe Geometry Impacts Retinal Detachment Repair
Robert I. Park, MD (Asheville, NC)
Best corrected visual acuity (BCVA) ranged from 7/200 to 20/40 at presentation. Improvement or stabilization of Snellens visual acuity noted in all patients (Table 1). Subretinal fluid resolved in all patients.
RESULTS CONCLUSION
PURPOSE
Intravitreal bevacizumab for CNV associated with chronic CSC showed anatomical and visual improvement.
Increased intraretinal stress is a factor in RT/RD development. Traditional models of RT/RD consider vitreoretinal traction the inciting factor in RT/RD. MRI-based biomechanical analysis allows calculation of the additional inherent intraretinal stress that increases the risk for RT/RD in myopes. New guidelines for scleral buckle encircling band use are proposed.
METHOD
Globe dimensions, including axial length, vertical/ horizontal equatorial diameters, and retinal thicknesses from surface coil MRI scans were used to calculate the intraretinal stress in emmetropic and myopic (-4,-8,-12,-16D) eyes. Intraretinal stress was first calculated for the various measured retinal diameters while keeping retinal thickness constant. Intraretinal stress was then calculated for various retinal thicknesses while keeping ocular diameter constant. A combined model of varying thicknesses and diameters was then used to calculate combined intraretinal stress. Intraretinal stresses were then compared to that of an emmetropic eye.
RESULTS
Compared to emmetropic eyes, myopic eyes have increased axial length and increased vertical and horizontal equatorial diameters. Retinal thickness diminishes with increased diameter only in the horizontal dimension. Intraretinal stress increased for myopes (refractive error: -4,-8,-12,-16D) as compared to emmetropes: horizontally, 1%, 3%, 4%, and 6%; and vertically, 3%, 6%, 10%, and 13%. Intraretinal stress increased with myopic retinal thinning only in the horizontal dimension 9%, 19%, 32%, 48%, respectively. The combined effect of myopic increased diameter and retinal thinning (refractive error: -4,-8,-12,-16D) was an increase in intraretinal stress of: horizontally 10%, 22%, 38%, 56% and vertically 3%, 6%, 10%, 13%.
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CONCLUSION Decreased retinal thickness and increased retinal diameter cause increased intraretinal stress in myopia. Measurement of retinal thickness and equatorial diameter may be useful in deciding how to repair RDs especially in myopes. Strategies to reduce intraretinal stress, i.e. encircling band scleral buckles, should be considered in eyes with decreased retinal thickness or increased diameters.
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Management of Retinal Detachments in Adolescents with Self-injurious Behavior

Robert Andrew Sisk, MD (Cincinnati, OH), William W. Motley, MD*, Michael Yang, MD, Constance E. West, MD
340
23-gauge Pars Plana Vitrectomy Alone vs. 23-gauge Pars Plana Vitrectomy and Scleral Buckle for Primary Repair of Pseudophakic Retinal Detachment
Vikram J. Setlur, MD (Philadelphia, PA), Jason Hsu, MD, Sunir J. Garg *, Caesar K. Luo, MD
PURPOSE
To assess the outcomes of retinal detachment (RD) repairs among a cohort of cognitively impaired adolescents with persistent self-injurious behavior (SIB), and describe a protocol for ensuring desired early postoperative positioning in eyes with silicone oil (SO) tamponade.
METHOD
To evaluate primary reattachment rates for two similar groups of patients who received either 23-gauge PPV or 23gauge PPV/SB for repair of pseudophakic RRD. This study also compares visual acuity outcomes and complication rates between 23-gauge PPV and PPV/SB.
PURPOSE METHOD A retrospective review was performed examining 113 eyes of 110 patients who underwent either 23-gauge PPV or PPV/SB for repair of pseudophakic RRD. All vitrectomy surgeries were done using 23-gauge instrumentation, endolaser, and intraocular gas tamponade. There were 70 eyes in the PPV group and 43 eyes in the PPV/SB group. Minimum follow-up was 3 months. Patients with prior vitrectomy, prior scleral buckle, or grade C PVR or worse were excluded. RESULTS The 23-gauge PPV group achieved primary anatomical success in 58 out of 70 cases (83%). Primary success in the PPV/SB group occurred in 36 of 43 cases (84%). Final anatomical success was achieved in all 113 cases (100%). The difference in primary success rates was not statistically significant (P = 1.000, Fisher exact test). Average visual acuity for macula-on RRDs in the PPV group showed a +0.07 improvement in the logarithm of the minimum angle of resolution (logMAR) (P = 0.58) versus a +1.34 improvement (P = 0.0001) in macula-off PPV cases. SB/PPV macula-on cases showed a decrease in logMAR visual acuity by -0.06 (P = 0.38) while macula-off SB/PPV cases improved by +1.28 (P = 0.002). The number of detachments with multiple breaks was higher in the PPV/SB group (58%) versus PPV alone (33%) (P = 0.0145). There were no significant complications in either group. Two eyes in the PPV/SB group had post-operative hypotony while no eyes the PPV only group developed hypotony. CONCLUSION 23-gauge PPV and PPV/SB are both effective procedures for primary repair of pseudophakic retinal detachment with good success rates and a low incidence of serious complications. There was no statistically significant difference for primary or final anatomical outcomes between 23-gauge PPV and PPV/SB.
Retrospective, consecutive, interventional case series of 9 eyes of 9 patients at a single pediatric multispecialty hospital who underwent repair of self-induced, traumatic RD September 2009 to January 2011. Scleral buckling and/or vitrectomy with SO tamponade were used for primary repair. Additional procedures were performed as indicated. 3 patients were kept intubated and sedated overnight to facilitate postoperative prone positioning. A multidisciplinary team of behavioral specialists, psychiatrists, and pediatric ophthalmologists was employed to limit self-injurious behavior and maximize visual recovery. Main outcome measures were retinal attachment and postoperative complications.
RESULTS
Complete retinal reattachment was initially achieved in all 9 eyes. 6 (67%) eyes had chronic RD at initial presentation, and 7 (78%) patients had limited vision from chronic RD in the fellow eye. Proliferative vitreoretinopathy (PVR) led to recurrent RD in 4 (44%) eyes at a mean of 2.7 months. Final total or partial retinal attachment was achieved in 67% and 33%, respectively, with a mean of 1.6 procedures. SO emulsification led to progressive glaucoma in 4 (50%) of 8 eyes, requiring SO exchange (2 eyes) or removal (2 eyes). Recurrent RD developed in both patients after SO was removed, despite retinal anatomic stability for greater than 6 months. A mean of 4 medications were required to limit SIB in addition to behavioral therapy and protective orthotic devices. All patients were actively self-injurious prior to surgery, and all had severe cognitive impairment. 3 were victims of past domestic abuse; 5 lived in foster care; 7 were nonverbal; and 5 had neuromuscular disease.
CONCLUSION
Cognitively impaired adolescents with SIB typically presented with severe visual impairment from chronic RD in one or both eyes. Despite initial anatomic success, PVR and continued self-abuse led to a high rate of recurrent RD. Long-term SO tamponade may prevent recurrent RD but is associated with progressive glaucoma.
342
Barriers to Access Health Services for Persons with Rhegmatogenous Retinal Detachment in Sao Paulo, Brazil
Leandro C. Zacharias, MD (Sao Paulo, Brazil), Tatiana Tanaka, MD, Suellen T. Shibata, MD, Thiago A. Leite, MD, Pedro Carricondo, MD*, Walter Y. Takahashi, MD*
Retinal Instrumentation and Devices

POSTERS 343-349
343
PURPOSE To verify the access barriers that patients with retinal detachment face to arrive to a reference center and to evaluate what the patients know about this disease. METHOD We performed a transversal study that applied a questionary to 65 patients of the Clinical Hospital of the University of Sao Paulo with the diagnosis of rhegmatogenous retinal detachment (RD) between February and August 2010.
Newly Designed Miniaturized Light Weight Wide Angle Contact Lens for Digital Fluorescien Angiographic Evaluation of Retinal Ischemia
K.V. Chalam, MD, PhD, MBA, FRCS (C) (Jacksonville, FL), Vijay Khetpal, MD, Ravi Radhakrishnan, MD
PURPOSE
The reasons for not performing the surgery in other services were: 88% of the patients were referred directly to our Clinical Hospital. 47% were referred to us because there was no vitreoretinal surgeon at the original service; 24% of the patients did not have money to pay for the surgery or had no health insurance, and 3% of the patients had no coverage at the health insurance plan for the procedure. The lag time between the first symptom and the arrival at our service was: 4 patients arrived in one day, 14 patients between 2 and 7 days, 19 patients between 8 and 15 days; 15 patients between 16 and 30 days; 8 patients between 31 and 90 days; 3 patients between 91 and 180 days; and 2 patients after more than 180 days. The reasons for the delay were: 70% did not know how serious the pathology was; 56% thought that it had spontaneous cure; 16% had no money to pay for an ophthalmic evaluation; 10% did not know where to go, and 24% for other reasons.
RESULTS CONCLUSION Educational programs focusing on the symptoms of the disease and measures to optimize the referral to specialized services are needed in order to accelerate the attendance and treatment of the patients with RD in Brazil. That would contribute to improve the final visual recovery and the quality of life of the patients. Our data may reflect the reality found in other countries in South America.
Scanning laser ophthalmoscopy (SLO) allows dynamic high resolution retinal images using lower retinal irradiances. Accessory contact lenses significantly enlarge area of imaging with a five fold increase in the field of view and assess peripheral circulation. We designed and evaluated a novel miniaturized wide field contact lens system and compared it to the Staurenghi 230 SLO Retina Lens.
METHOD
The novel lens consisted of an integrated three element convex-concave system with lens powers of 160D and 40D with a plano contact lens element. FA as well as ICG was performed using Heidelberg retina angiograph (Heidelberg Engineering), with wide field novel contact lens in a variety of retinal disorder including diabetic and sickle cell retinopathy, vascular occlusions, and a range of chorio-retinopathies. The images were compared to the commercially available Staurenghi 150 Contact Lens system. The angiography images obtained from the two systems were compared for size of the field, image resolution, details of peripheral vasculature, extent of capillary nonperfusion and ease of use. The newly designed lens increased the SLOs 30 imaging fields to 150. It was 70% less in weight ( 86g vs 36g) and 25% shorter in length (7.6 cm vs 5.7 cm). Peripheral retinal and choroidal findings can be readily observed and recorded in both systems. Peripheral images obtained with this miniaturized lens were found to be free of spherical aberrations with excellent resolution of peripheral vasculature compared to Staurenghi lens (Figure. 1A, B). The novel lens system is smaller in size (Figure. 2) and allowed easier handling and better patient comfort compared to Staurenghi lens. Retinal and choroidal abnormalities, including neovascularization and capillary nonperfusion, are easily detected and documented well beyond the range of conventional fundus cameras and SLOs.
RESULTS
139
RETINAL INSTRUMENTATION AND DEVICES
The novel design of low weight miniaturized wide field imaging lens offered readily obtainable, cost effective high resolution peripheral retinal imaging vascular details superior to manual photomontages and Staurenghi contact lens system. This system was helpful in estimating the area of nonperfusion in retinal vasculopathies including DR, Sickle cell retinopathy and vascular occlusions.
CONCLUSION
RESULTS
A total of 20 minutes and 20 seconds were required for bubble extraction in case 1, whereas case 2 required 65 minutes. Those values were very similar to the ones obtained by applying the Hagen-Pouseuille equation (19 minutes for case 1 and 63.3 minutes for case 2). The use of a larger caliber 18G cannula is a valid method for extracting heavy silicone oil with some advantages over smaller caliber cannulas such as 23G in these case reports.
CONCLUSION
Wide field late fluorescein angiography using A. staurenghi contact lens and B. newly designed contact wide field lens system.
Dimensions of the 18 Ga cannula
Size comparision of the two contact lens system staurenghi (right) and newly designed system (left).
344
Heavy Silicone Oil (Densiron 68) Extraction with 18G Cannula vs. Extraction with a 23G Cannula. Case Reports
Sergio E. Hernandez-Da Mota, MD (Morelia, Mexico)
Dimensions of the 23 Ga cannula
345
To compare the extraction of heavy silicone oil (HSO) with a 18G cannula versus a 23G cannula.
PURPOSE METHOD Interventional case reports. In case 1, a 18G cannula was used to extract heavy silicone oil. In case 2, a 23G cannula was used instead. The time required for the bubble extraction and the total surgery times were measured. These were then compared with the Hagen-Pouseuille equation to check for consistency.
Comparison of Blade and Incision Architecture Between New 25- and 23-ga Microvitreoretinal Blades and Current Sclerotomy Entry Systems
Makoto Inoue, MD (Tokyo, Japan), Dina Joy Abulon, David Buboltz, Akito Hirakata, MD
PURPOSE
To compare the blade sharpness and incision architecture of various 25- and 23-ga sutureless trocar and microvitreoretinal (MVR) blades at oblique and straight angles of entry.
METHOD The 25- and 23-ga test samples of 7 different types of trocar-cannula system included new and conventional MVR blade designs, conventional beveled trocar blades, and roundtipped trocars (23-ga only). A Scanning Electron Microscope (SEM) imaged cutting surfaces of each blade. In another test, high magnification imaging measured the incision length and linearity of straight and obliquely angled incisions through a circular silicon coupon (n=10). Wound proof pressure testing was conducted on sclerotomy sites after simulated vitrectomy in enucleated porcine eyes (n=4). RESULTS Incision shape and SEM analysis showed distinct differences in blade design and incision geometry: conventional beveled trocar blades generated asymmetrical chevron-shaped incisions, round-tipped trocar blades generated semi-circular incisions, new symmetrical MVR blades generated linear incisions, while a conventional MVR blade design generated a flattened M-shaped incision. The new 25-ga symmetrical MVR blade generated the smallest wound geometry with an incision length of 19.9 0.9 m (straight incision), linearity measurement of 0.2 0.1 m (straight incision), oblique incision length of 18.2 1.1 m, and oblique linearity measurement of 0.8 0.2 m (all P<0.05). In wound leakage tests the new symmetrical MVR blades leaked the least in every test (4 tests per blade). CONCLUSION Compared to all blades, the new symmetrical MVR blades suggest better wound architecture by generating less wound leakage, shorter incision lengths, and more linear wound apposition.
347
Choroidal-scleral Junction Continuity and Outer Choroidal Vessel Visualization Across Spectral Domain OCT Platforms
Phoebe Lin, MD, PhD (Durham, NC), Priyatham Mettu, MD, Sina Farsiu, MD, Prithvi Mruthyunjaya, MD
PURPOSE
To determine how visualization of the choroidalscleral junction (CSJ) and outer choroidal vessels in three different SD-OCT platforms using manual and automated enhanced depth imaging (EDI) differed from upright modes and affected choroidal thickness measurements. In a prospective comparative series, 22 eyes from 12 normal subjects had 9 mm horizontal scans using 7 SD-OCT techniques: Bioptigen, Cirrus, Spectralis (upright and inverted), and Spectralis automated EDI mode. The choroid borders were manually segmented by 2 masked observers. Average choroidal thickness across a fovea-centered 4 mm segment was determined with MATLAB. Image quality was defined by the percentage of images with >90% continuity of the CSJ. The number of large outer choroidal vessels ( 200 m in diameter) was determined for each image using MATLAB. Statistics: paired t-test and Pearson correlation for inter-observer correlation (IOC) (p< 0.05 was statistically significant).
METHOD
RESULTS
346
Evaluation of a Novel, Non Contact, Automated Focal Laser with Integrated (NAVILAS) Fluorescein Angiography for Diabetic Macular Edema
Vijay Khetpal, MD (Jacksonville, FL), Ravi Radhakrishnan, MD, Ravi Keshavamurthy MBBS, MD, K.V. Chalam, MD, PhD, MBA, FRCS(C)
PURPOSE To evaluate the safety of a novel laser delivery system NAVILAS (OD-OS Teltow, Germany) that combines automated laser delivery with color fundus photography, fluorescein angiography (FA), fundus autofluorescence (FAF) and infra-red imaging with a frequency doubled YAG laser. METHOD Diabetic macular edema (DME) is a leading cause of blindness and focal macular laser photocoagulation is the standard of care in the treatment of DME. In this prospective pilot study, we treated 12 patients with the NAVILAS system for DME. Image overlays and tracking system allowed accurate delivery of laser spots of varying size, duration and power. RESULTS All patients tolerated the procedure well and no inadvertent foveal burns or damage to the lens was noted. CONCLUSION In our pilot study, NAVILAS a novel integrated laser delivery system proves to be safe and effective and no complications were noted during the treatment of diabetic macular edema.
CSJ continuity scores were higher for inverted (and EDI) vs upright modes: Bioptigen (67% vs 29%, p=0.02), Spectralis (72% vs 28%, p=0.004), Spectralis EDI (61%, p=0.04). The opposite was true in Cirrus images, in which the inverted mode is falsely pixilated: Cirrus (0% vs 58%, p<0.001). The average number of large choroidal vessels visualized were: Bioptigen upright 2.7 vs. inverted 5.9 (p<0.0001), Spectralis upright 4 vs. inverted 11.3 (p<0.0001) vs. EDI 7.3 (p=0.0002 compared with upright, p=0.0001 compared with inverted), and Cirrus upright 6.7 (p<0.0001 compared with Bioptigen upright, p=0.135 compared with Bioptigen inverted). Mean choroidal thickness was highest in Spectralis inverted (242.2 m) and EDI modes (234.7 m) compared with upright Spectralis images (203.8 m) (p=0.05 and 0.03, respectively). Choroidal thickness in Cirrus upright images (mean 226.8 m) compared favorably to Spectralis inverted images (p=0.282). The best visualization of large outer choroidal vessels and CSJ occurred by either manual inversion or automated enhanced depth SD-OCT modes. In these optimized modes, choroidal thickness measurements were also greatest. Future choroidal imaging studies should incorporate these SD-OCT modes to better discern the relationship of choroidal structures.
CONCLUSION
141
RETINAL INSTRUMENTATION AND DEVICES
348
349
Vitreous Cutter Velocities: Dual Pneumatic Drive vs. Single Pneumatic Drive with Spring Return
Christopher D. Riemann, MD (Cincinnati, OH), Jianbo Zhou, Dina Joy K. Abulon, David C. Buboltz
Topical Aqueous Suppression Does Not Affect Duration of Intraocular Gas Tamponade Following Vitrectomy
Chirag Shah, MD (Boston, MA), Jason Hsu, MD, Marc Spirn, MD, Larry Donoso, MD, Sunir Garg, MD*
PURPOSE Cutter closing velocity affects tissue cutting shear rate, duty cycle and flow rate of vitreous cutters and has an impact on the cutting effectiveness of a vitreous cutter. High speed video of cutter movement in-vitro was generated to investigate cutter dynamics for two types of vitreous cutters single pneumatic drive and spring return (SPDSR) and dual pneumatic drive (DPD) mechanisms. METHOD High speed video of the cutter movement through the probe port was captured at 25,000 fps. The SPDSR probes were run at 2500 cpm. The DPD probes were run at 2500 and 5000 cpm in core and shave modes. Six each of 25, 23, and 20 gauge probes for both types were tested. The cutter movement was analyzed from the captured video frames to calculate the cutter closing and opening velocities and the durations of different phases (fully open, closing, fully closed, and opening of the port) in a cut cycle. RESULTS Closing/opening velocities (mm/s) for SPDSR probes at 2500 cpm were 165/79 for 25ga probes, 168/78 for 23ga probes, and 188/73 for 20ga probes. Closing/opening velocities (mm/s) for DPD probes at 2500 cpm (core duty cycle) were 338/304 for 25ga probes, 335/266 for 23ga probes, and 276/236 for 20ga probes. Closing/opening velocities (mm/s) for DPD probes at 2500 cpm (shave duty cycle) were 440/224 for 25ga probes, 405/212 for 23ga probes, and 336/209 for 20ga probes. Closing/opening velocities (mm/s) for DPD probes at 5000 cpm were 472/362 for 25ga probes, 453/319 for 23ga probes, and 371/287 for 20ga probes. The percentage of the time a port was fully open in a cut cycle at 2500 cpm was 26%, 38%, and 34% for the 25G, 23G, and 20G SPDSR probes, respectively; and 66%, 67%, and 62% for the 25G, 23G, and 20G DPD probes (core mode), respectively. CONCLUSION The DPD cutter closing and opening velocities are much higher than the SPDSR cutter creating a greater tissue cutting shear rate. For the DPD probes, the closing velocities are higher in smaller gauges, at the higher cut rate, and in the shave mode. The DPD probes in the core mode open the port fully much longer than the SPDSR probes.
PURPOSE
To determine if topical aqueous suppression affects the duration of intraocular sulfur hexafluoride (SF6) gas tamponade after pars plana vitrectomy. This prospective randomized controlled trial included patients undergoing 23-gauge pars plana vitrectomy with air fluid exchange and 20% SF6 gas tamponade. All sclerotomies were sutured. Eyes were randomized to receive either topical dorzolamide 2%-timolol 0.5% twice a day or no drops. The primary outcome was duration of SF6 gas tamponade.
METHOD
RESULTS
Twenty-one patients were recruited; four were excluded for non-compliance with dorzolamide-timolol drops. Eight patients were randomized to the treatment group with dorzolamide-timolol and nine patients were randomized to the control group. There was no difference in duration of SF6 gas tamponade between the two groups (p = 0.35). The mean gas duration was 17.1 1.6 days in the dorzolamide-timolol group with a range of 1520 days. The mean was 18.1 2.4 days in the control group with a range of 1624 days. The mean difference was -1.0 days with a 95% confidence interval of -3.2 to 1.2 days. The study was 93% powered to detect a four-day increase in gas duration. Secondary analyses did not reveal a difference in SF6 duration based on lens status, presence of diabetes or hypertension, vitrectomy vs. combined buckle with vitrectomy, or patient age.
CONCLUSION
Topical aqueous suppression with dorzolamidetimolol does not significantly affect duration of SF6 gas tamponade following pars plana vitrectomy.
Surgical Techniques and Maneuvers

POSTERS 350-362
351
Incidence of Steroid Induced Ocular Hypertension Using Either Difluprednate or Prednisolone Acetate after Vitreoretinal Surgery
Daniel Connors (New Brunswick, NJ), Jonathan Prenner, MD*, Howard Fine, MD, Harold Wheatley, MD, Daniel Roth, MD*
350
Clinical Outcomes of Bromfenac Ophthalmic Solution 0.09% Qd vs. Nepafenac 0.1% Tid for Treatment of Ocular Inflammation Associated with Ocular Surgery
Melissa Cable, MD (Independence, MO)*, Timothy Stout, MD*
PURPOSE
Difluprednate (DP) is a new generation topical ophthalmic corticosteroid that has potent anti-inflammatory effects. We sought to determine if an increased incidence of steroid responsive ocular hypertension existed in postoperative patients treated with DP as compared with those treated with prednisolone acetate (PA).
PURPOSE To investigate whether topical bromfenac 0.09% solution qd is as efficacious as topical nepafenac 0.1% tid in patients undergoing uncomplicated cataract surgery by one surgeon. METHOD This randomized, prospective, investigator-masked study comprised 18 patients undergoing uncomplicated cataract surgery randomized to receive bromfenac 0.09% qd or nepafenac 0.1% tid beginning 3 days prior to surgery, on the day of surgery and 21 days subsequently. 10 patients completed six week postoperative evaluations. Outcomes were measured by observing ETDRS visual acuity, summed ocular inflammation score, and optical coherence tomography measurements of retinal thickness and volume. RESULTS Both treatment groups had similar baseline measurements of mean macular volume, mean letters read and mean cell score with one outlying value in the bromfenac group with poor baseline acuity due to posterior subcapsular cataract. Outcomes in mean macular volume, mean letters read and mean cell score were not statistically different in the postoperative period through six weeks. CONCLUSION
METHOD
A retrospective chart review was performed on a consecutive series of 127 surgical patients who were treated for a host of vitreoretinal pathologies. Over a two-month period, we began using DP instead of PA after the majority of our surgery patients. We compared both the change in intraocular pressure (IOP) and the maximum IOP (Tmax) in patients treated with DP and PA. We also examined the rate of ocular anti-hypertensive drug initiation in each group. Patients with known glaucoma pre-operatively were excluded from the study cohort.
RESULTS
In the initial postoperative period, bromfenac 0.09% solution qd and nepafenac 0.1% suspension tid were equally effective in reducing summed ocular inflammation, in ETDRS visual acuities, and in mean macular volume. Either medication may be considered after uncomplicated phacoemulsification. Bromfenac may be preferred due to less frequent dosing.
Eighty-nine patients were treated with DP and 38 patients were treated with PA. Mean baseline IOP was similar in the two groups (DP=17.32, PA=17.31, P=.99). No statistically significant difference in IOP change existed between the two groups (DP=+9.47, PA=+7.72, P=. 32). No statistically significant difference in Tmax existed between the two groups (DP=27.68, PA=25.34, P=.22). No statistically significant difference in the rate of anti-hypertensive drug initiation existed between the two groups (DP=23.6%, PA=23.6%, P=.99). Subgroup analyses by surgical indication and procedure did not demonstrate and statistically significant difference between DP and PA groups. Difluprednate is a potent, new generation topical corticosteroid. Despite the potency of the drug, patients treated with DP in the postoperative setting did not demonstrate a statistically significant difference in terms of IOP elevation compared with those treated with PA. Surgeons take on no greater risk in terms of IOP rise by using DP instead of PA.
CONCLUSION
143
SURGICAL TECHNIQUES AND MANEUVERS
352
354
Feasibility and Outcomes of Silicone Oil Removal with 25 Gauge Instrumentation Following Rhegmatogenous Retinal Detachment Repair
Dilsher S. Dhoot, MD (Cleveland, OH), Alex Yuan, MD, Jonathan Sears, MD, Rishi P. Singh, MD
Comparison of Iatrogenic Peripheral Retinal Tears Between Small (23- or 25-) Gauge and 20-Gauge Vitrectomies
Hua Gao, MD (West Bloomfield, MI), PhD, Sweta Tarigopula, MD, Shareef Ahmed, MD, Anju G. Aggarwal, MD, Uday R. Desai, MD, Paul A. Edwards, MD
PURPOSE
To report the feasibility and outcomes of silicone oil removal using a 25 gauge vitrectomy system.
PURPOSE METHOD Nine patients (9 eyes) underwent silicone oil removal in a prospective, interventional case series at a single institution, between October 2010 and March 2010. A 25-gauge system featuring a 25 gauge silicone oil injection cannula (Synergetics, OFallon, MO) was utilized for active removal of 1000 centistokes (cSt) silicone oil. Visual acuity, intraocular pressure (IOP), total silicone oil removal time, complications, and number of sutured sites were recorded in each case. RESULTS Mean active silicone oil removal time was 6 minutes and 15 seconds (SD, 64.5 seconds). 56% of the silicone oil removal sclerotomies were sutureless. Of those sclerotomies that did require suturing, a single interrupted transconjunctival scleral suture was effective at closing the sclerotomy. Mean preoperative IOP was 12 mmHg (range, 7.5-18 mmHg). Mean one day and one week post-operative IOP was 9 (range, 5-13 mmHg) and 11.7 (range, 8-22 mmHg), respectively. No cases of post operative hypotony (IOP < 5 mmHg) were noted. Mean pre-operative visual acuity was 20/515. No intraoperative or postoperative surgical complications were identified. One patient was noted to have minimal residual oil in the anterior chamber on clinical exam. Mean one day, one week, and one month post-operative visual acuity was 20/3828, 20/1150, and 20/486 respectively. Mean three month post-operative visual acuity was 20/542, where data available. CONCLUSION We report on a new method for active removal of 1,000 cSt silicone oil using a commercially available 25 gauge system. Larger randomized trials comparing 20G to 25G removal would be necessary to validate whether the technique leads to similar outcomes.
Iatrogenic peripheral retinal tears related to sclerotomy during vitrectomy are the most common iatrogenic retinal tears reported previously. The purpose of this study was to compare the incidence of these retinal tears in small (23or 25-) gauge to 20-gauge pars plana vitrectomy.
METHOD
This is a retrospective comparative study comprising 377 eyes who underwent pars plana vitrectomy for variety of retinal disorders, such as proliferative diabetic retinopathy, macular pucker or macular hole, and retinal detachment, etc. 226 eyes underwent 23- or 25-gauge pars plana vitrectomy and 151 eyes underwent 20-gauge vitrectomy. The main outcome measure was the presence of iatrogenic retinal tears around sclerotomy found intraoperatively.
RESULTS
In 151 eyes with 20-gauge vitrectomies, iatrogenic retinal tears related to sclerotomy were found in 11 eyes (7.28%). In 226 eyes with small gauge (23- or 25-gauge) vitrectomies, this type of iatrogenic retinal tears was only found in 3 eyes (1.32%). There is a much lower incidence of iatrogenic retinal tears related to sclerotomy in small gauge vitrectomy compared to 20-gauge vitrectomy (p=0.0052). Small gauge vitrectomy appears safer in iatrogenic retinal tears around sclerotomy than 20-gauge vitrectomy. It is likely that trocars prevent potential tractions on the vitreous base from instruments when they are inserted into or withdrawn from eyes. This is probably why small gauge vitrectomy causes much less iatrogenic retinal tears than 20-gauge vitrectomy without trocar protection.
CONCLUSION
355
356
Endoscopic Cyclophotocoagulation Via Pars Plana for the Treatment of Complicated Glaucoma
Victor Hugo Gonzalez, MD (McAllen, TX)*, Denisse Cornu, MD, Valmore Adrian Semidey, MD*, Veronica M. Calderon, MD
Experience with Polydimethylsiloxane Perfluorohexyloctane (Densiron-68) in Proliferative Vitreoretinopathy

Sergio E. Hernandez-Da Mota, MD (Morelia, Mexico)
PURPOSE To evaluate the efficacy and safety of ECP via pars plana in achieving an IOP reduction in patients with glaucoma. METHOD After IRB approval, retrospective consecutive case series of 20 eyes from 20 patients with different mechanism glaucomas [COAG, NVG, Mixed mechanism glaucoma (MMG) and Traumatic glaucoma (TG)], on topical medication and/or post glaucoma drainage device surgery with a minimum of three months follow-up post ECP were identified. Eyes underwent 180 degrees ECP via pars plana approach by a vitreoretinal surgeon (VHG) during vitreous surgery for a variety of indications using a standardized protocol. Preoperative and 3 months postoperative IOP, topical medication requirements and safety were reviewed. RESULTS patients who underwent ECP had the following characteristics: 9 (45%) with COAG, 7 (35%) with NVG, 3 (15%) with MMG and 1(5%) with TG. 14 (70%) were pseudophakic, 2 (10%) aphakic and 4 (20%) phakic. Preoperative IOP ranged from 12-66 mmHg (mean 27.9 mmHg). Of these patients 19 (95%) were using 3 glaucoma meds and 1 (5%) with only 1 med. 15 patients (75%) had a VA of 20/400 or worse, 4 (20%) of 20/200-20/50 and 1 (5%) of 20/40 or better. 3 months postoperative IOP range of 2-23 (mean 11.65mmHg) in which 17 patients (85%) had an IOP improvement of >10 mmHg. Of the total patients, 11(55%) continued using 3 meds, 2(10%) with 2 meds, 2(10%) with one med and 5(25%) discontinued the usage of all glaucoma meds. No significant ECP related adverse events were noted. CONCLUSION In this retrospective case series pars plana ECP appears to be an effective and safe procedure for the management of various glaucomas encountered during vitreous surgery. Further controlled, randomized studies are warranted to validate our findings.
PURPOSE
To describe the rate of retinal reattachment and improvement in best corrected visual acuity (BCVA) in patients with complicated retinal detachment (RD) and heavy silicon oil (HSO) Densiron-68. Design: Retrospective, longitudinal case series study. Participants: Twelve eyes of 12 patients with RD complicated with proliferative vitreoretinopathy (PVR) grade B or greater were included. Methods: Pars plana vitrectomy (PPV) and polydimethylsiloxane/perfluorohexyloctane intravitreal injection was performed in all patients. Retinal reattachment rate, pre and postoperative best corrected visual acuity (BCVA) was evaluated as well as complications. Retinal reattachment was achieved in 10 cases (83.3%). Mean pre-operative BCVA was 2.59 logMAR (SD 0.71) (SE 0.2) while average final BCVA was 1.57 logMAR (SD 1.27) (SE 0.36) (p=0.004, paired samples t test) (CI 95% 0.39-1.64).
METHOD
RESULTS
CONCLUSION
Although some complications were present in some patients, Densiron-68 proved to be effective enough in some RD complicated with PVR, with a high reattachment rate in this case series.
Preoperative retinal detachment with proliferative vitreoretinopathy.
Postoperative image of reattached retina with Densiron.
145
357
358
Reproducing Image of Subjective Visual Sensations Experienced during Vitreous Surgery

Makoto Inoue, MD (Tokyo, Japan), Kei Shinoda, MD, Toru Noda, MD, Kazuhiko Ohnuma, MD, Akito Hirakata, MD
Vitreo-retinal Surgery in the Osteo-Odonto-Keratoprosthesis Patient: Indications and Techniques

Laurence Lim MBBS, FRCSEd (Singapore, Singapore), Edmund Wong MBBS, MMed, FRCS, Donald Tan*, Doric Wong
PURPOSE Visual sensations experienced by patients during cataract surgery or vitreous surgery have been described. Patients sometimes describe that they observed that the instruments inside their eyes were moving or the membrane-like material was peeled during the surgery. The aim of this study is to reproduce the visual sensations experienced by patients during vitreous surgery. METHOD A fluid-filled model eye with a translucent posterior eye wall and the frosted inner (retinal) surface was used. The images projected on the retinal surface could be observed from the backside of the model eye. On the retinal surface, a thin plastic sheet was attached to simulate an epiretinal membrane. The model eye was placed under a surgical microscope and surgical procedure was simulated through three scleral ports like standard pars plana vitrectomy. A flat contact lens was placed on the corneal surface of the model eye and the intraocular images from the backside were recorded with a simultaneous observation of the procedures through the surgical microscope. RESULTS Analysis of the images from backside revealed that triamcinolone crystals were observed as moving black particles and intraocular instruments were observed as a black shaft. When the intraocular instruments were inserted from the port, the black shaft was observed to move from the periphery to the center of the visual field. When the epiretinal membrane was peeled, the instruments was observed more focused and the color of the tip of the forceps was observed to be silver when the forceps was attached at the retinal surface of the model eye. CONCLUSION Patients visual sensations may be precisely reproduced with the model eye. Closer the instruments were located at the retinal surface, more focused objects were observed and the colors of the instruments could be identified.
PURPOSE
To describe the indications for vitreo-retinal (VR) surgery associated with OOKP implantation, and to discuss the surgical approaches with particular emphasis on achieving intra-operative visualization through opaque media.
METHOD
This was a retrospective review of all patients who had undergone OOKP surgery performed from 2003 to 2010 at the Singapore National Eye Centre. All study subjects were identified from the Singapore OOKP database, a prospective database tracking OOKP procedures performed at our centre since 2003. OOKP procedures were performed for severe ocular surface disease according to the indications and techniques described in the Rome-Vienna Protocol. Patient demographics, indications for VR surgery, surgical outcomes, and intraoperative and post-operative complications were documented. Operative techniques were reviewed from the surgical records, and any subsequent surgeries were also recorded.
RESULTS 34 patients underwent OOKP, and VR surgery was indicated in 10 (29.4%). The indications for and approaches to surgery were retinal detachment repair using an Eckardt temporary keratoprosthesis (TKP) in 4 cases, assessment of retina and optic nerve health prior to OOKP surgery using either a TKP(2 cases) or endoscopically(1 case), endoscopic cyclophotocoagulation for intractable glaucoma(1 case), endoscopic trimming of retro-prosthetic membrane(1 case), and vitrectomy for endophthalmitis with visualization through the OOKP optic using the binocular indirect viewing system in 1 case. In all cases, VR surgical aims were achieved with a single procedure. Post-operative vitreous hemorrhage occurred in 16 patients (47.1%) but all resolved spontaneously. Successful OOKP implantation did not differ between eyes that did and did not undergo VR surgery (81.8% vs. 90%; p=0.49), nor were there any differences in anatomical success with TKP utilization.(83.4% without vs. 87.5% with, p=0.63). CONCLUSION
OOKPs represent the last hope for restoration of vision in severe ocular surface disease, and the VR surgeon is frequently called upon in the assessment and management of these patients. TKP and endoscopic vitrectomy are valuable surgical tools in these challenging cases, improving functional outcomes without compromising OOKP success.
The image projected on the retinal surface of the model eye is captured from the backside of the model eye during an epiretinal membrane is peeled off.
359
Semiquantitative Assessment of the Visual Angle and Imaging Quality of a Grating Target in a Human Eye Model Viewed Through Wide-angle Viewing Systems
Yusuke Oshima, MD, PhD* (Suita, Japan), Jiro Hidaka, MD, Makoto Inoue, MD, Kohji Nishida, MD
Cross-sectional schematic drawing of the model eye based on the Gullstrand model eye.
PURPOSE To evaluate the field of view and the quality of the image of a grating target placed in a model eye viewed through wide-angle viewing systems. METHOD An angle scale for evaluating the field of view and a United States Air Force resolution target was placed on the inner surface of a model eye with human corneal aberrations (Fig 1 and 2). The visual angles and contrasts of the gratings were evaluated and compared to those obtained through contact (ClariVit) or non-contact type (RESIGHT, BIOM, OFFISS, or MERLIN) wide-angle viewing systems with changing intraocular parameters including the pupil size, lens status, and intraocular tamponades. RESULTS The widest field of view was achieved through noncontact-type wide-angle viewing systems: 100 degrees in a fluid-filled aphakic eye with the OFFISS and 125 degrees in an air-filled aphakic eye with the RESIGHT. The mean visual angle representing the field of view through panoramic viewing systems is limited significantly (P=0.014) by the pupil size in each system. Although the grating images located at the posterior pole were clear when observed through either the contact type or non-contact type of wide-angle viewing system, those at the periphery were blurred and defocused with any of the non-contact type systems but less so with the contact-type system. The contrast decreased significantly (P<0.001) at low frequencies when viewed through the non-contact type system in an air-filled pseudophakic eye. CONCLUSION The non-contact type of panoramic viewing system achieves the widest field of view but blurs the quality of the grating images at the periphery. The contact type system may allow better visualization at the periphery by neutralizing optical aberrations and corneal surface irregularities.
A, Superficial view of the model eye with a chandelier fiber passing through the insertion port for wide-angle endoillumination. B, Inner view of the model eye through the wide-angle viewing system. The angle scale and United States Air Force grating target are glued to the posterior surface of the model eye from the central bottom to the periphery.
360
Bevacizumab Followed by 23-gauge Transcleral Bimanual Vitrectomy for Retinal Detachment in a Case of Multiple Large Retinal Angiomas
Daraius Shroff, MD, FRCS, (New Delhi, India) Charu Gupta, MD, A.K. Singh, MD, Neelam Atri, MD, Bhavana Sharma, MD, Cyrus M. Shroff, MD
PURPOSE
To describe the outcome of intravitreal bevacizumab followed by the surgical management of a case of total retinal detachment with multiple large retinal angiomas with bimanual 23 gauge vitrectomy.
METHOD
Interventional case report. A 24-year-old man presented with a sudden drop in vision. On fundus examination he had a total Retinal detachment with multiple large angiomas at the posterior pole, as well as in the periphery. Intravitreal bevacizumab 1.25mg was injected 4 days prior to surgery. Bimanual 23 gauge vitrectomy was performed with chandelier illumination. This facilitated membrane dissection around the angiomas with minimal trauma to the lesions. Intraoperative bleeding was minimal and was controlled by increasing infusion pressure. Intraoperative cryotherapy was done to the peripheral angiomas. The retina settled well, and silicon oil was injected.
147
RESULTS Bimanual surgery enabled atraumatic and more complete membrane dissection in this case of a complex retinal detachment associated with multiple angiomas. There was no significant intra or post operative bleeding. The BCVA at 6 weeks improved from 20/400 to 20/80 and the retina was well attached.
361
Sutureless Vitrectomy Incision Architecture in Vivo Using Fourier Domain OCT

Anderson G. Teixeira Pinto, MD (Brasilia, Brazil), Flavio A. Rezende, MD, PhD, Camila Salaroli, Nonato Souza, Pinto Francisco, Norma Allemann
Modified bimanual 23G transcleral vitrectomy preceded by intravitreal bevacizumab enabled us to achieve a good anatomical and functional result in a total retinal detachment associated with multiple large angiomas.
CONCLUSION
PURPOSE
To investigate the in vivo incision architecture using Fourier Domain optical coherence tomography (FD-OCT) in 23-gauge and 25-gauge sutureless vitrectomy.
METHOD
A prospective observational study of 21 eyes of 20 patients that underwent 25-gauge (10 eyes) or 23-gauge (11 eyes) transconjunctival sutureless pars plana vitrectomy was performed. The three sclerotomies sites in each eye were analyzed by Corneal Adapter Model (CAM) RTVue FD-OCT with wound cross-section images (longitudinal and transversal) on days one, seven, and 28 post-operatively. Wound length, thickness, and diameter were compared.
RESULTS
Pre operative fundus photograph showing multiple large angiomas with total retinal detachment.
All patients completed 4 weeks of follow-up and all surgeries lasted less than 60 minutes. Three-port vitrectomy incisions were analyzed separate in length, thickness, diameter and angle for 25-gauge [e.g. infero-temporal mean incision length was 0.942 +0.126 (range, 0.775-1.137) with a mean thickness of 0.026 +0.06 mm (range, 0.019-0.038) and mean incision diameter was 0.228 +0.020 mm (range 0.197-0.261)] and 23-gauge [infero-temporal mean incision length was 1.218 +0.168 (range, 1.026-1.540) with a mean thickness of 0.057 +0.019 mm (range, 0.035-0.103) and mean incision diameter was 0.361 +0.025 mm (range 0.337-0.417)]. The mean incision angle was 31 degrees for 23-gauge and 22 degrees for 25-gauge. Wound thickness (P < 0.001), diameter (P < 0.001), and angle (p < 0.05) differences between 25-gauge and 23-gauge incisions were found to be statistically significant. No statistical difference was found in incision length among different quadrants or between 23- and 25-gauges. The 23-gauge and 25-gauge architectural wound construction was well visualized using FD-OCT. Statistical differences between the two gauges were observed in the diameter and thickness throughout the study period.
Post operative fundus photograph showing attached retina, laser and cryo reaction aroung the angiomas and silicon oil in situ.
CONCLUSION
Seven days post-operative.
362
Fibrovascular Ingrowth Post-Transconjunctival 25-gauge Vitrectomy for Diabetic Vitreous Hemorrhage

Cynthia Xin-ya Qian, MD (Montreal, QC), Marie-Claude Robert, MD, Flavio Rezende, MD, PhD
Trauma
POSTERS 363-365
363
Traumatic Ruptured Globes at a City Hospital in Manhattan from 2006 to 2010

Carolyn Page Graeber, MD (New York, NY), Jenna B. Friedenthal, MD, Susan Koreen Gelman, MD, MPH, Ilyse D. Haberman, MD, Shantan Reddy, MD, MPH
To report 2 cases of fibrovascular ingrowth posttransconjunctival 25-ga PPV highlighting the surgical management with a modified transcleral 25-ga PPV.
PURPOSE METHOD Two patients with proliferative diabetic retinopathy in both eyes were approached with transconjunctival 25-ga PPV for dense vitreous hemorrhage (VH) and tractional retinal detachment. After 10 months, both patients developed recurrent VH. They were managed with in-office gas-fluid exchange and anti-vascular endothelium growth factor (VEGF) intravitreal injection. Soon after gas bubble resorption, the VH recurred. Close observation with color external photos detected engorged episcleral vessels superotemporally and ultrasound biomicroscopy (UBM) confirmed the presence of fibrovascular ingrowth (FVI) at the sclerotomy site in both patients. They were reoperated with a modified 25-ga PPV. RESULTS The modified 25-ga PPV technique consisted of conjunctival peritomy at the FVI site and where the pars plana incisions were to be made. Tenons capsule was removed, transcleral cryotherapy and external cautery were applied to the engorged episcleral vessels. The 25-ga cannulas were placed in bare sclera and extensive vitrectomy with vitreous base shaving was carried out. After VH removal, additional panphotocoagulation was done, endolaser was performed at the FVI region, and the cases were completed followed by anti-VEGF intravitreal injection. One year post-modified 25-ga PPV, both patients improved visual acuity and remained without VH. Post-operative UBM demonstrated complete FVI regression without any residual traction at the site. CONCLUSION Although FVI is a well recognized cause of VH recurrences following conventional 20-ga vitrectomy, the present report seems to be the first to confirm FVI post-smallgauge vitrectomy. A modified 25-ga PPV technique seems to be a feasible alternative to treat FVI in these cases.
PURPOSE
RGs secondary to trauma are the source of significant visual morbidity and can ultimately lead to loss of the eye. What characteristics of RGs that present to a Level I trauma center are correlated with better visual outcomes and with greater change in preversus post-operative visual acuity?
METHOD
The charts of consecutive RGs that were evaluated in the Bellevue Hospital Emergency Room between April 2006 and June 2010 were retrospectively reviewed with New York University Internal Review Board approval. Pre-operative, postoperative and change in visual acuity (measured in LogMar) were compared with numerous factors to determine predictors of better post-operative results.
RESULTS
Of 41 RGs included, 74% were men, 49% were right eyes, 98% were traumatic, and 9.8% were enucleated or eviscerated. Removal of the eye was not significantly correlated with location of the rupture (p=0.171). Visual acuity improved significantly after surgical repair (2.85 vs 2.13 LogMar, p=0.001). Patients with pre-operative vision of count fingers or better had better post-operative visual acuity (0.46 vs 2.65 LogMar, p<0.001) and had greater change in preversus post-operative visual acuity than those who had hand motion or worse (1.41 vs. 0.50 LogMar, p=0.035). Mean follow-up was 4.0 months, with 11 patients (27%) being lost to follow-up after 1 week. Patients who were lost to followup had worse best corrected post-operative visual acuity than those that were not (3.36 vs. 1.80 LogMar, p<0.001) and their change in preversus post-operative visual acuity trended toward less change than those who were not (p=0.067).
CONCLUSION
Surgical repair of RGs at an urban trauma center resulted in significant improvement in vision. Patients with better pre-operative vision had both a greater change in vision and a better overall visual outcome than those that had low pre-operative vision. Patients with poor vision after repair were less likely to follow-up and had less change in their preversus post-operative vision.
149
TRAUMA
364
365
Early Limited Core Vitrectomy in Double Penetrating Globe Injuries

Julia Paula Shulman, MD (Salt Lake City, UT), Roger Harrie, MD, Mary Elizabeth Hartnett, MD
Posterior Segment Intraocular Foreign Bodies. Clinical and Epidemiological Features. 2007-2009
Luis M. Suarez Tata, MD (Miami, FL), Moravia Suarez-Tata, Reinaldo Garcia, Leonidas Rodriguez, Natassha Portillo, MD
To present the visual and anatomic outcomes of three patients with double penetrating or perforating injuries of the globe with extensive corneal trauma that underwent early limited core vitrecomy without a keratoprosthesis to prevent a tractional detachment.
PURPOSE METHOD An IRB approved, retrospective chart review of 3 patients from the Moran Eye Center, all of whom underwent corneal laceration repair by an anterior segment surgeon and were referred to the retina service for management of posterior segment pathology. RESULTS Patients were 9 months, 3 years and 21 years old. The mechanism of injury in two of the patients was a knife injury to the eye; the infant suffered trauma from a weed wacker cord hitting and perforating the globe. There was extensive anterior segment trauma in all three cases with corneal and lens involvement. Limited vitrectomies without removal of the core vitreous and posterior hyaloid were performed within 6 days of the initial ruptured globe repair. A keratoprosthesis was not done in any case because of the concern of graft rejection, particularly in the infant and pediatric patients. One patient developed retinal traction that was observed with serial ultrasounds for 2 months, prior to repeat vitrectomy, endolaser and gas. All patients remain attached at postoperative follow-up of 6 months. CONCLUSION In this series, eyes maintained retinal attachment even though only limited vitrectomies were performed due to poor visualization of the posterior segment in the setting of double penetrating globe injury. Further study is warranted to assess long-term outcomes with this approach that may provide better corneal recovery particularly in pediatric patients. PURPOSE
To evaluate the epidemiologic factors, associated ocular involvement and visual results in patients with intraocular foreign bodies lodged in the posterior segment. In this retrospective study, the clinical records of 28 patients admitted Service Vitreous-Retina with intraocular foreign bodies between January 2007 and December 2009. Using the OTS classification for ocular injuries (United States Eye Injury Registry). We evaluated the visual outcome and various pre-, intra- and postoperative clinical factors, Complications and final visual acuity. Factors at presentation were evaluated for prognostic value towards visual outcome. Statistical analysis was done using Univariate and Multivariate analysis.
METHOD
RESULTS
All the patients were males, with a mean age of 28 years (range: 5-56 yrs) and an average follow-up period of 25.02 months. The foreign bodies were caused by accidents and work accidents in 92.8% involved ferromagnet metal. All patients underwent vitrectomy to remove the intraocular foreign body. Final visual acuity was equal to or greater than 0.4 in 39,29% of the patients and there was no light perception in 10.71%. The principal complications were vitreous haemorrhagies (64,29%) and endophthalmitis (28,57%) and the principal late complications were local retinal detachment with PVR (17,86%), pthisis bulbi (10,71%). Most of the IOFB are found in young males as a consequence of work accidents without protection. All require vitrectomy to remove the foreign body and even though good visual results are obtained in many cases, other cases suffer severe visual loss. We concluded size of IOFB, endophthalmitis, are statistically significant factors affecting outcome in posterior segment intraocular foreign bodies.
CONCLUSION
Retinal. .Vascular/Imaging. . . ............... .......................................

Retinal Vascular Disease
POSTERS 401-429
402
Reversibility of Isotretinoin Retinal Toxicity

Thomas Federici, MD (Stony Brook, NY)
PURPOSE
To describe a case of reversible retinal toxicity secondary to isotretinoin use.
401
Cystoid Macular Edema Associated with Paclitaxel Therapy for Breast Cancer: A Case Report and Review
Daniel Adelberg, MD (Mesa, AZ)
METHOD
Retrospective case review. Data extracted from the chart included demographic information, medical and ophthalmologic history, and clinical findings from slit-lamp biomicroscopy and dilated ophthalmoscopy.
RESULTS
PURPOSE To determine the etiology and management of cystoid macular edema in patients being managed with breast carcinoma. METHOD Two female patients presented with bilateral cystoid macular edema. Both patients were receiving paclitaxel and bevacizumab chemotherapy for breast carcinoma. Both patients were phakic, had no prior intraocular surgery and other causes of cystoid macular edema were not identified. Management included discontinuation of paclitaxel and alteration of their chemotherapy by their oncologist, and topical nonsteroidal antiinflammatory therapy with bromfenac twice daily. Clinical assessment included visual acuity, fundus examination, and spectral domain optical coherence tomography (OCT). A retrospective chart and medical literature review was performed. RESULTS The patients were both female , with age of 49 and 74 years. Follow-up was 27 and 12 months , respectively. Visual acuity improved in one patient from 20/60 to 20/40 OD, and was unchanged in left eye at 20/50. The second patient had visual acuity improved from 20/300 to 20/40 OD and 20/200 to 20/60 OS. A decrease in central macular thickness (CMT) of 159 microns and 156 microns in the right and left eye respectively in the first patient, with the second patient decreasing 3 microns OD and 33 microns OS. Both patients had complete resolution of cystoid macular edema on spectral OCT. One patient underwent fluorescein angiography without evidence of cystoid macular edema at last follow-up visit. A review of the medical literature revealed a prior publication of the association of paclitaxel with cystoid macular edema. CONCLUSION Cystoid macular edema is associated with paclitaxel, and successful management included discontinuation of paclitaxel and concomitant therapy with bromfenac in two patients. It is important to recognize this uncommon cause of cystoid macular edema in patients with breast carcinoma so that an accurate diagnosis can lead to improved vision in these challenging patients.
A 17-year-old white girl with facial acne developed prolonged retinal photostress recovery after 8 weeks of isoretinoin use. Three weeks following discontinuing the medication, visual recovery following photostress improved to baseline. Visual acuity measured 20/20 OU and color plates were full OU (8/8). Slit-lamp bimicroscopy and dilated ophthalmoscopy were unrevealing. The patient declined any further investigation.
CONCLUSION
Prolonged retinal photostress recovery may an early indicator of isotretinoin-associated retinal toxicity. Discontinuation of therapy at the advent of this symptom/sign may prevent permanent visual loss.
403
Cystoid Macular Edema Secondary to Nab-Paclitaxel (Abraxane) Therapy: Clinical Experience with Bevacizumab
Hassan Rahman, MD (Atlanta, GA), Steven Yeh, MD, Chris Bergstrom, MD
PURPOSE
CME is a rarely reported side effect of nanoparticle albumin bound (nab)-paclitaxel therapy an antimitotic agent used for breast cancer. We describe a patient with bilateral CME secondary to Abraxane that was minimally responsive to bevacizumab. This lack of efficacy and knowledge of the mechanism of paclitaxel may provide insights into the mechanisms of CME without angiographic leakage. Retrospective, interventional case report of a patient with bilateral CME after starting Abraxane therapy for recurrent breast cancer treated with intravitreal bevacizumab (1.25mg/0.05mL) every 4 weeks. Records were reviewed for visual acuity and macular edema as assessed by spectral-domain optical coherence tomography (SD-OCT).
METHOD
RESULTS
A 73-year-old patient with recurrent, metastatic breast cancer presented with bilateral visual loss 3 months after nab-paclitaxel was initiated. Baseline VA was 20/100 OD and 20/200 OS. Fundus exam showed marked CME OU. Fluorescein angiography was notable for the marked absence of petalloid late phase leakage characteristic of vascular, ischemic, and inflammatory causes of CME. SD-OCT showed marked cystoid spaces predominantly involving the outer and inner nuclear layers with central subfield thicknesses (CST) of 398
151
RETINAL VASCULAR/IMAGING
um OD and 441 um OS. Serial intravitreal bevacizumab injections (OD 2 injections, OS 3 injections) were administered on a q 4 week basis with an improvement and stabilization of VA at 20/50 OD and 20/70 OS. However, CME on SD-OCT persisted with CST of 492 um OD and 478 um OS.
CONCLUSION The pathogenesis of CME without leakage is poorly understood; however, fluid accumulation in Muller cells due to toxicity has been proposed. The persistence of CME suggests that additional non-VEGF-mediated mechanisms are involved. Improved understanding of the mechanisms underlying paclitaxel-associated CME is needed, especially in patients with limited systemic options for metastatic carcinoma.
Eyes with acute (2) or chronic (6) CSC were included. Snellen visual acuity, complete ophthalmic examination, fluorescein angiography and optical coherence tomography were performed at baseline and throughout follow-up, as were liver function tests. Patients were treated with rifampin 600 mg per day then re-examined at approximately weeks 1, 8 and 12. The primary endpoint was reduction in retinal pigment epithelial (RPE) leakage and sub-retinal fluid (SRF). The secondary endpoint was lines of vision gained.
RESULTS
Figure 1: Spectral domain OCT imaging shows significant CME on presentation for the right eye (A) and persistent CME despite 2 intravitreal bevacizumab injections (B). The left eye on presentation (C) shows relatively unaffected CME despite 3 intravitreal bevacizumab injections (D).
Mean follow-up was 13 weeks (5-24). 1 patient selfdiscontinued rifampin after 3 weeks of treatment. 1 patient developed choroidal neovascularization after 8 weeks, was treated with intravitreal bevacizumab and excluded from further analysis. 1 patient developed hepatitis after 24 weeks as a result of concomitant alcohol consumption and withheld from further treatment. Other observed side effects included headache (1) and nausea (1). 4 of 8 patients experienced a reduction or resolution of SRF during treatment: 3 had chronic CSC (including 1 with leopard-spot pattern appearance), 1 had acute CSC and experienced a more rapid improvement than would be expected from the natural course of the disease. 2 patients showed no effect of therapy and in 2 the effect was equivocal. Overall, central macular thickness decreased in 6 patients and remained stable in 2. Visual acuity remained unchanged in 5 patients and improved in 3. The results of this small case series suggest that rifampin may potentially benefit some patients with CSC. Acute episodes appear to respond most favorably. Chronic SRF may decrease gradually during treatment, while sub-RPE fluid often persists. Vision typically remains stable or improves over the course of therapy. A larger, controlled, prospective study of rifampin for CSC is warranted.
CONCLUSION
Figure 2: Fluorescein angiography reveals normal vascular filling in the early frames (A) with only minimal leakage evident in the late frames (B). The right eye had similar findings.
404
Early Experience with Rifampin for Treatment of Central Serous Chorioretinopathy

Zac Ravage, MD (Chicago, IL), Kirk Packo, MD*
SD-OCT of the right eye of a patient with acute central serous chorioretinopathy on presentation.
PURPOSE We have previously described a case of chronic CSC responsive to rifampin. The effect was thought to occur via hepatic enzyme induction with a reduction in systemic cortisol levels. To further assess its efficacy, rifampin was offered as offlabel therapy to patients with CSC. We describe the findings from our early experience in these cases. METHOD A retrospective interventional case series of 8 patients treated with off-label rifampin for CSC was performed. 7 patients were male, 1 female. Mean age was 53 years (45-71).
The same eye after 1 week of treatment with rifampin. Significantly less sub-retinal fluid and fibrin were present.
405
Retinal Bioavailability of a DHEA Synthetic Analogue in the Rat Retina after Parenteral Administration
Miltiadis Tsilimbaris, MD, PhD (Heraklion, Greece), Chrysanthi Tsika, MD, Pavlina Tsoka, MD, Manolis Tzatzarakis, MD, Ioannis Charalampopoulos, MD, Achilleas Gravanis, MD
any treatment other than IVB prior to IVTA, or if their last follow-up prior to IVTA was over 9 weeks.
RESULTS
PURPOSE To evaluate the retinal bioavailability of a synthetic Dehydroepiandrosterone (DHEA) analogue, a molecule with potential anti-apoptotic action, after systemic administration. METHOD 8 Sprague Dawley rats were injected intraperitoneally with 10
A total of 18 eyes of 18 patients with CRVO met the inclusion criteria. Average age of patients was 62.8 years. The mean number of IVB injections was 4.6 and mean time between IVB injections was 5.9 weeks. The average time interval between IVB and IVTA was 5.2 weeks. The mean number of IVTA injections was 1.8. The mean logMAR visual acuity improved from 1.22 (~20/330) to 1.16 (~20/290, p<0.317) following treatment with IVTA. Macular thickness on OCT decreased from a mean of 495 m to 399 m (p<0.05) following treatment with IVTA. No cases of endophthalmitis, retinal detachment, or neovascularization were noted. Intravitreal triamcinolone acetonide appears to be effective in additionally reducing macular edema secondary to CRVO in patients with a suboptimal response to multiple intravitreal bevacizumab injections; however this did not translate into a significant improvement in vision.
CONCLUSION
mg of the analogue in1 ml of an ethanol/Water For Injection (WFI) solution. The synthetic neurosteroid was injected in 2 rats at each time point at the same concentration every time. The animals were euthanized at 15, 30, 60 and 120 min. The eyes were enucleated and the retina was isolated from the eye cup with an eye sponge with suitable handling. After appropriate preparation, the samples were measured with HPLC LC/MS.
RESULTS The recovery of the method was 82.9%. The Limit Of Quantification (LOQ) was 5ng/ml. The substance was detected at 60 and 120 min in mean concentrations of 46.9 ng/ml and 183.8 ng/ml respectively. At the time points 15 and 30 no substance was detected with this method. No substance was detected in the blind samples.
407
Intravitreal Ranibizumab after Suboptimal Response to Multiple Intravitreal Bevacizumab Treatments in Retinal Vein Occlusions
Rayan A. Alshareef, MD (Philadephia, PA), Richard S. Kaiser, MD, Jason Hsu, MD, Marc J. Spirn, MD, Mitchell Fineman, MD, Sunir J. Garg, MD*
PURPOSE
The synthetic DHEA analogue was successfully detected in the rat retina with an LC/MS HPLC method. The molecule seems to reach the retina in approximately one hour after systemic administration and is still detected there after two hours. Further investigation is obligatory for complete data of the pharmacokinetics of the substance in the rat retina.
CONCLUSION
To evaluate the effect of intravitreal ranibizumab (IVR) for treating macular edema secondary to retinal vein occlusion after suboptimal response to multiple treatments with intravitreal bevacizumab (IVB).
METHOD
406
Intravitreal Triamcinolone Acetonide after Suboptimal Response to Multiple Intravitreal Bevacizumab Treatments in Central Retinal Vein Occlusion
Rayan A. Alshareef, MD (Philadelphia, PA), Marc J. Spirn, MD, Jason Hsu, MD, Richard Kaiser, MD, Sunir J. Garg, MD*
A retrospective chart review of patients who had IVB and IVR injections for the treatment of macular edema secondary to either central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO). Inclusion criteria included patients diagnosed with CRVO or BRVO and who had been treated with at least 2 or more IVB injections prior to IVR. Outcomes included change in visual acuity, central foveal thickness on optical coherence tomography (OCT), number of injections and time between injections. Patients were excluded if they had received any treatment other than bevacizumab prior to ranibizumab, or if the last follow-up prior to ranibizumab was over 9 weeks.
RESULTS
To evaluate the effect of intravitreal triamcinolone acetonide (IVTA) for treating macular edema secondary to central retinal vein occlusion (CRVO) after suboptimal response to multiple treatments with intravitreal bevacizumab (IVB).
PURPOSE METHOD A retrospective chart review of 128 patients who had IVB and IVTA for the treatment of CRVO was performed. Inclusion criteria included patients diagnosed with CRVO and who had 2 IVB injections prior to IVTA. Outcomes included change in visual acuity, central foveal thickness on optical coherence tomography (OCT), number of injections and time between injections. Patients were excluded if they had received
AA total of 40 eyes with CRVO and 30 eyes with BRVO of 69 patients met the inclusion criteria. The mean number of IVB injections was 6.2 (CRVO group) and 4.5 (BRVO group). In the CRVO group, mean time between IVB injections was 6.7 weeks and the mean time between IVB and IVR was 6.5 weeks, compared with 7.6 and 6.8 weeks, respectively, in the BRVO group. The mean number of IVR injections was 2.7 in the CRVO group and 2.6 in the BRVO group. In the CRVO group, mean logMAR visual acuity improved from 0.987 (~20/200) to 0.904 (~20/160, p<0.025) following treatment with IVR and macular thickness on OCT decreased from a mean of 400 m to 270.4 m following treatment with IVR
153
(p<0.001). In the BRVO group, mean logMAR visual acuity improved from 0.734 (~20/110) to 0.650 (~20/90, p<0.324) following treatment with IVR and macular thickness on OCT decreased from a mean of 377.3 m to 297 m following treatment with IVR (p<0.006). Intravitreal ranibizumab appears to be effective in additionally reducing macular edema secondary to CRVO and BRVO in patients with a suboptimal response to multiple bevacizumab injections. In the subset of CRVO patients, intravitreal ranibizumab appeared to have a modest impact with regard to improving visual acuity.
CONCLUSION
Visual Acuity and Central OCT thickness results following anti-VEGF and Ozurdex combination treatment for macular edema secondary to retinal vein occlusions. Combination therapy caused a dramatic reduction of central macular thickness by OCT analysis and and average improvement in vision at 1 and 3 months post-treatment. Both of these positive effects were significantly attenuated at 6 months.
408
409
Combination Anti-VEGF and Sustained Release Steroid for the Treatment of Macular Edema Secondary to Retinal Vein Occlusions
Alan J. Franklin, MD (Mobile, AL), Magdalena Shuler, MD, John P. Myers, MD, Neel M. Kumar, Sunil Gupta
Peripheral Polypoidal Choroidal Vasculopathy: A Report of 10 Eyes

Darin R. Goldman, MD (Los Angeles, CA), K. Bailey Freund, MD*, Colin A. McCannel, MD*, David Sarraf, MD*
PURPOSE PURPOSE The purpose of this study is to analyze visual acuity, central OCT thickness, and treatment burden of intravitreal anti-VEGF injections combined with sustained release intravitreal dexamethasone, Ozurdex. METHOD This is a retrospective chart review of approximately 20 patients who received intravitreal anti-VEGF in combination with Ozurdex for the treatment of macular edema secondary to retinal vein occlusions. Both new onset vein occlusions and patients chronic recalcitrant macular edema were studied. Both BRVO and CRVO patients were studied although a majority of patients analyzed suffered from CRVO. We measured Snellen visual acuity, central macular thickness analyzed by time domain OCT, and treatment burden at 1, 3, 6, and 12 months after initial combination treatment. Data analysis was masked so that the investigators were unaware of patient identities. RESULTS
Polypoidal choroidal vasculopathy (PCV) is characterized by polyp-like vascular abnormalities predominantly found in the macula and peri-papillary regions. More uncommonly, polypoidal lesions can be found peripherally. We sought to further describe the clinical spectrum of this peripheral variation of PCV.
A retrospective chart review of 8 unique patients (10 eyes) diagnosed with peripheral PCV was conducted. Each case was diagnostically confirmed with indocyanine green angiography and/or fluorescein angiography and optical coherence tomography. The clinical presentation, natural history, and clinical outcome with and without interventional management were studied.
METHOD RESULTS
Initial visual acuity was Logmar 0.97, 20/188. Combination anti-VEGF and Ozurdex improved visual acuity at 1, 3 month, Logmar 0.85 and 0.79, respectively, post-treatment. At 6 months post-treatment the average vision gain was lost so that Logmar vision fell to 1.08. Most patients required retreatment 4-6 months after the initial Ozurdex administration. Central OCT thickness was dramatically reduced at 1 month, average 266 micron reduction, 3 months 246 micron reduction. At 6 month a persistent central OCT reduction of 107 microns was still observed. The average treatment burden was 3 injections, that included Ozurdex administration, over 6 months.
Patients with peripheral PCV were more likely to be male, Caucasian, asymptomatic, and to have the concomitant diagnosis of age-related macular degeneration. The mean age was 70 years (range, 59-82 years) with a mean follow-up of 32.5 months (range, 4-91 months). Four patients had unilateral involvement with minimal subretinal hemorrhage that resolved spontaneously, one patient had unilateral involvement outside the macula that responded to anti-VEGF therapy, one patient had unilateral involvement with subretinal hemorrhage threatening the macula that responded to anti-VEGF therapy, and two patients had extensive subretinal hemorrhage bilaterally requiring surgical intervention. All patients with multiple lesions in an eye also had bilateral lesions (2 of 8 patients). Lesions were most commonly located in the temporal periphery (8 of 10 eyes). We describe the largest case series to date of peripheral PCV, which represents a unique form of type I neovascularization of the retina. While most eyes with peripheral PCV experience a benign course and resolve spontaneously without sequelae, a subset of eyes can experience maculathreatening hemorrhage and require therapy with laser, anti-VEGF injections, or surgical intervention.
Combination intravitreal anti-VEGF and Ozudex led to a dramatic reduction of central OCT thickness and overall visual improvement at 1 and 3 months post-treatment. These effects waned at 6 months post-treatment so that most patients required retreatment between 4 and 6 months. On average, 3 intravitreal administrations that included Ozurdex were performed over the initial 6 month follow-up.
CONCLUSION
CONCLUSION
Right eye (A) Color fundus photograph shows dry AMD in the macula. Superonasal to the optic disk there is an area of subretinal and sub-RPE hemorrhage. (B) ICG angiography shows areas of blockage from hemorrhage and two nodular polypoidal lesions that hyperfluoresce. (C) OCT scanning through the polypoidal lesions shows their location in the sub-retinal pigment epithelial space.
54.8 letters (20/80) in the DEX implant and sham arms, respectively. At day 7, mean improvement in BCVA was 5.3 letters and 1.6 letters in the DEX implant and sham arms, respectively (P.001). For BRVO patients, mean improvement in BCVA was 5.1 letters and 2.3 letters in the DEX implant and sham arms (P.001), respectively, and, for CRVO patients, 5.8 letters and 0.08 letters in the DEX implant and sham arms (P.001), respectively. The proportion of eyes achieving improvement in BCVA of 10 letters from baseline at day 7 in the DEX implant and sham procedure arms were 27% and 11%, respectively (P.001). The proportion achieving 15-letter BCVA improvement was 10% and 5% in the DEX implant and sham arms (P=.025) in BRVO patients and 11% and 2% (P=.002) in CRVO patients, respectively.
CONCLUSION
Right Eye (A) Color fundus photograph, FA, and ICGA showing multiple areas of subretinal and sub-RPE hemorrhage at presentation. (B) Montage color fundus photograph. (C) Enlargement of previous hemorrhages encroaching into the macula three months later. (D) The areas of subretinal and sub-RPE hemorrhage have mostly resolved six months after treatment with intravitreal bevacizumab.
Significant improvements in BCVA were noted as early as 7 days after treatment with DEX implant in patients with RVO. More than one-quarter of patients achieved improvements of 10 letters within 1 week of treatment. These results suggest that corticosteroids used to treat ME in patients with RVO provide rapid relief of symptoms of vision loss.
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Dexamethasone Intravitreal Implant Rapidly Improves Best-Corrected Visual Acuity in Patients with Retinal Vein Occlusion
Julia A. Haller, MD* (Philadelphia, PA), Francesco Bandello*, Anat Loewenstein, MD*, Baruch D. Kuppermann, MD, PhD*, Jenny Jiao*, Xiao-Yan Li, MD*, Scott Whitcup, MD*
Ranibizumab for Cystic Macular Edema Secondary to Adult Onset Coats Disease 12 Months Results of a Prospective Study
Irene A. Barbazetto, MD (New York, NY), James M. Klancnik, MD, Michael J. Cooney, MD, Lawrence A. Yannuzzi, MD
PURPOSE
To investigate the safety and efficacy of intravitreal ranibizumab injections for cystic macular edema secondary to adult onset Coats disease.
PURPOSE This study evaluated the safety and efficacy of dexamethasone intravitreal (DEX) implant (Ozurdex) 0.7 mg compared with sham procedure in patients with vision loss due to macular edema (ME) following branch or central retinal vein occlusion (BRVO; CRVO). We now present efficacy outcomes after 7 days of treatment. METHOD Two identical 6-month, randomized, prospective, multicenter, masked, parallel-group, clinical trials recruited patients aged 18 years with ME involving the fovea due to BRVO or CRVO, best-corrected visual acuity (BCVA) between 34 letters (20/200) and 68 letters (20/50), and retinal thickness 300 m. Patients received either DEX implant 0.7 mg or sham procedure. The primary outcome was time to 15-letter BCVA improvement from baseline. Secondary outcomes included mean change from baseline BCVA and proportion of eyes achieving improvement of 10 or 15 letters from baseline BCVA. RESULTS 427 patients (68% BRVO; 32% CRVO) received DEX implant and 426 (66% BRVO; 34% CRVO) received sham procedure. Baseline mean BCVA was 54.3 letters (20/80) and
Five patients (4 male, 1 female; age 26 to 54 years/ mean: 44 years) were enrolled in a prospective, non-randomized, interventional case study. All patients received 3 initial doses of ranibizumab with monthly PRN treatment thereafter. Monthly follow-up examinations included clinical examination, best corrected visual acuity (VA), and optical coherence tomography (OCT).
METHOD
Patients received an average of 8 injections (3-12) over 12 months. Mean visual acuity was 0.49 (LogMar) at baseline, 0.41 at 1 week, 0.42 at 1 month and 0.45 at 12 months. Central macular thickness (CMT) measured 390, 265, 350 and 408 m respectively. Treatment was well tolerated with adverse events limited to surface irritations following injections.
RESULTS CONCLUSION
Mono-therapy with ranibizumab may not allow for long-term control of CME in adult onset Coats disease. Although improvements in VA and CMT were seen after one week in some cases, these results were not sustained over 1 and 12 months.
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412
METHOD
Visual Acuity Outcomes with Intravitreal Bevacizumab for the Treatment of Macular Edema Secondary to Vein Occlusion
John Mose Roberts, MD (Brookfield, IL), Jonathan Crews, Omar Al-Heeti, MD, Jeff Wongskhaluang, MD, Richard M. Ahuja, MD
PURPOSE To assess the visual outcomes in patients with macular edema secondary to retinal vein occlusion treated with primary intravitreal bevacizumab. METHOD This is a retrospective interventional case series of patients with macular edema secondary to retinal vein occlusion who presented at (Stroger) Cook County Hospital from September 2009 to March 2011. Patients with previous treatment for macular edema were excluded. All patients had a complete ophthalmic exam and fluorescein angiography. Central macular thickness (CMT) was measured by Stratus Optical Coherence Tomography (OCT). Patients with a visual acuity of <20/40 Snellen received intravitreal injections of bevacizumab 0.05ml (1.25 mg per 0.05 ml). Patients were retreated every 2 months with intravitreal bevacizumab if macular edema was present on OCT with a CMT > 250um. RESULTS 15 eyes of 14 patients were included. The number of injections ranged from 1 to 6 (mean 3.3 injections). Vision improved in 12 eyes, remained unchanged in one eye and decreased in 2 eyes. Baseline visual acuity ranged from hand movements to 20/50, and endpoint visual acuity ranged from counting fingers at 3 feet to 20/40 over an average of 8.2 months (range 3 to 20 months). No adverse events were noted during the study period. CONCLUSION Intravitreal bevacizumab appears to be an efficacious treatment for macular edema secondary to retinal vein occlusion. However, multiple injections may be required. This short-term study cannot determine the need for re-treatments. Additional studies are needed to determine long-term safety and efficacy.
A retrospective, case review was performed on four patients with sickle cell disease that were referred for preventive retinal screening. SD-OCT revealed marked retinal thinning. A full ophthalmic examination including best corrected visual acuity, tonometry, slit lamp examination and dilated fundus examination was performed. SD- OCT Wide field angiography using a Staurenghi 230 SLO Retinal Lens and SD-OCT using the Heidelberg Spectralis was obtained on each patient.
RESULTS
Temporal thinning measured 133 microns compared to 320 in normal subjects (P value <0.01). All patients exhibited marked temporal retinal capillary nonperfusion. (Figs 1) None of them were clinically symptomatic. Ages ranged from 16- 44. All were males, wide field angiography demonstrated peripheral capillary dropout with early neovascularization and temporal thinning on SD-OCT. A wide-field angiography revealed bilateral peripheral retinal ischemia and neovascularization that correlated with temporal retinal thinning (noted on SD-OCT). Temporal retinal thinning in asymptomatic sickle cell patients is a useful clinical sign in predicting peripheral ischemia. Wide field angiography is a useful additional adjunct in delineating and quantifying the degree of peripheral ischemia and guide the treatment including panretinal retinal photocoagulation in proliferative sickle cell retinopathy.
CONCLUSION
Late wide field fluorescein angiography of right and left eye indicating temporal peripheral ischemia in both eyes.
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Serial SD-OCT Following Treatment of Retinal Vein Occlusion with Dexamethasone Intravitreal Implant
Bryan M. Kim, MD (Chicago, IL), Jonathan Jonisch, MD, Kevin Blinder, MD*, Gaurav K. Shah, MD*
Ultra-wide Angle Fluorescein Angiography Revealed Peripheral Retinal Ischemia Correlates with Retinal Thinning in Asymptomatic Sickle Cell Patients
Vijay Khetpal, MD (Jacksonville, FL), Ravi Radhakrishnan, MD, K.V. Chalam, MD, PhD, MBA, FRCS(C)
PURPOSE
To describe the changes in vision and optical coherence tomography (OCT) measurements in the immediate weeks following treatment of retinal vein occlusion (RVO) with dexamethasone intravitreal implant (DEX; Ozurdex); as well as observed duration of effect and timing for retreatment.
PURPOSE Proliferative sickle cell retinopathy develops secondary to sickling of the red blood cells (RBCs) and leads to capillary occlusion and consecutive non perfusion and neovascularization. Vasoocclusion of the central retinal artery and its tributaries after sickling episodes compromise vasculature of the inner retinal circulation and lead to ischemia and loss of inner retinal layers.
METHOD
Prospective study. Patients with macular edema (ME) due to BRVO (n=12 injections) or CRVO (n=9 injections) were treated with DEX implant. Following treatment, ETDRS vision and spectral domain OCT measurements were taken at weeks 1, 2, 3, 4, 6, 8, 10, 12, 16, 20, and 24. Patients were retreated with repeat injection prior to week 24 if there was loss of efficacy, defined as 30% or greater increase in central OCT
thickness from peak, or loss of 10 or more letters. Two-sample T-tests were used to compare outcomes between the BRVO and CRVO patient groups.
RESULTS Mean baseline acuity was 45.118.3 letters (BRVO) and 49.720.3 letters (CRVO). Mean baseline central retinal thickness (CRT) was 645.0136.2 m (BRVO) and 777.8311.9 m (CRVO). 40% of BRVO patients had previous focal laser, and all patients had been treated with intravitreal bevacizumab. CRT significantly decreased at week 1 (484.4308.1 m, p=0.02). Time to peak visual improvement among all patients was 7.903.64 weeks, and time to peak OCT response was 7.303.25 weeks. Neither significantly differed between BRVO vs. CRVO (p=0.36 and p=0.06). Retreatment with DEX was required in 70% of patients, and ME recurred at 11.23.43 weeks in BRVO. In CRVO, retreatment was required in 80% of patients, and ME recurred at 13.42.51 weeks. There was no significant difference in duration of effect of DEX in BRVO vs. CRVO (p=0.08). 2 patients with BRVO and 1 patient with CRVO had IOP30 mmHG; all 3 patients had preexisting glaucoma and were controlled by topical medications.
415
Intravitreal Ranibizumab Therapy for Persistent Cystoid Macular Edema Secondary to Retinal Vein Occlusions Following Standard Bevacizumab Therapy
Veronica A. Kon-Jara, MD (New Haven, CT), Nauman A. Chaudhry, MD, Travis A. Meredith, MD, Maurice B. Landers, MD, Odette M. Houghton, MD
PURPOSE
Intravitreal bevacizumab is an important therapeutic modality for the treatment of cystoid macular edema (CME) from retinal vein occlusions (RVO). Some of these eyes only show a partial response despite continuous bevacizumab therapy. We describe the visual and anatomic response of intravitreal ranibizumab for persistent CME after suboptimal response to intravitreal bevacizumab therapy.
METHOD
This study provides OCT data not available in the original Ozurdex vein occlusion study. OCT thickness decreased 1 week post-treatment in both groups. Visual and OCT responses peaked at 8 weeks. ME returned approximately 12 weeks post-treatment. Augmenting DEX with complementary or repeat treatments at or before 12 weeks may help sustain its effect, especially in previously treated eyes.
CONCLUSION
BRVO OCT central retinal thickness and ETDRS vision letter score by week
Retrospective chart review. Patients with diagnosis of RVO who had a complete ophthalmological examination, fundus photography, SD optical coherence tomography (OCT) and fluorescein angiography (FA) were selected. 12 patients with significant residual macular edema after consecutive treatments with bevacizumab met the inclusion criteria. Intravitreal injections of 0.5 mg of ranibizumab were performed monthly in a standard sterile fashion.
RESULTS
Eight patients with central retinal vein occlusion (CRVO) and 4 patients with branch retinal vein occlusion (BRVO) were identified. All patients had received an average of 7.66 intravitreal injections of 1.25 mg bevacizumab, had a mean central macular thickness (CMT) of 675.43 microns, and a mean visual acuity (VA) of 20/200. After a mean of 1.6 injections of ranibizumab 0.5 mg, the mean CMT decreased to 292.8 microns and the VA improved to 20/70. Further followup will be provided.
CONCLUSION
CRVO OCT central retinal thickness and ETDRS vision letter score by week
Intravitreal ranibizumab may be an effective rescue therapy in cases of CME secondary to RVO with suboptimal or partial response to intravitreal bevacizumab. This appears to be more common in eyes with CRVO. A prospective clinical trial with larger sample size is needed to answer this important clinical question. See images on next page.
157
METHOD
Open label, prospective, randomized pilot study involving six patients with three patients randomized to treatment and three to observation. An interim analysis will be presented of six patients (3 treated and 3 control) with ETDRS visual acuity and spectral domain central subfield thickness data.
RESULTS
CONCLUSION
To be determined in assessing safety and efficacy of high dose ranibizumab 2.0mg in Idiopathic Parafoveal Telangiectasia.
417
Intravitreal Bevacizumab for Macular Edema Associated with Macular Telangiectasia

Patient with Central Retinal Vein Occlusion: Initial macular edema of 1008 microns. After 3 consecutive injections of 1.25 mg intravitreal bevacizumab: Persistence of macular edema (815 microns).
Nikolas London, MD (Philadelphia, PA), Mitchell S. Fineman, MD, Richard S. Kaiser, MD, Marc J. Spirn, MD
PURPOSE
Does anti-VEGF therapy benefit patients with macular edema associated with parafoveal telangiectasis?
METHOD
We performed a retrospective review of patients with PFT who were treated with intravitreal bevacizumab (IVB) at the Retina Service of the Wills Eye Institute. LogMAR bestcorrected visual acuity was recorded for all follow-up visits. Optical coherence tomography (OCT) obtained at baseline was compared to scans obtained at follow-up visits. Twenty-three eyes of 21 patients were identified, with an mean age of 61 years, and 8 of the 21 patients were women. Follow-up ranged from 1 to 36 months (average 12.8 months) and the mean number of injections was 2.6. The mean baseline visual acuity (VA) was 20/80, 20/60 at month 1, 20/60 at month 6, 20/50 at month 12, and 20/100 at month 24. Overall, 11/23 eyes showed any improvement in VA after the initial injection. Five of the 11 eyes with any improvement in VA had at least a doubling of the visual angle, and a single patient improved from 20/400 to 20/50 after one injection. OCT data were available for 15 eyes at both baseline and 1-month followup. In these eyes, the average OCT central retinal thickness changed from 249m at baseline to 235m at 1-month followup. OCT data were available for 5 of the 11 eyes that showed an apparent improvement in VA. In these eyes the average baseline thickness improved from 267m to 229m after a single injection.
RESULTS
One month later, response to intravitreal ranibizumab (429 microns).
416
High Dose Ranibizumab for the Treatment of Idiopathic Parafoveal Telangiectasia [HD-LIPT] Trial: An Interim Analysis
Arthur Korotkin, MD* (Fort Collins, CO), Kent R. Crews, MD
CONCLUSION
PURPOSE Does treatment of patients with non-proliferative Idiopatic Parafoveal Telangiectasia with ranibizumab 2.0mg improve vision or reduce retinal thickness as measured by spectral-domain OCT?
Bevacizumab for macular edema associated with nonproliferative PFT appears to have a variable effect on VA, and no clear effect on retinal thickness. Future directions will include evaluation of angiographic and OCT changes, with particular attention to differences between IVB-responders and non-responders. Our hope is to identify PFT patients who may benefit from anti-VEGF therapy.
418
Pars Plana Vitrectomy with Multiple Transvenous Chorioretinotomies for Macular Edema Complicating Retinal Vein Occlusion
Jeffrey K. Luttrull, MD (Ventura, CA), Charles Spink, MA, CRA
Pt A: Fundus fluorescein (left) and indocyanine green (right) angiograms 25 months postoperatively demonstrating resolution of a CRVO by multiple surgical chorioretinal anastomoses. Duration of disease preoperatively 22 months. Preop CFT 1046um; final postop CFT 147um. Preop injections 15/22 months; postop injections 0/25 months. VA preop CF; final postop VA 20/30.
PURPOSE To review the results of pars plana vitrectomy with multiple transvenous chorioretinotomies (MTC) to create chorioretinal anastomoses (CRA) for treatment of macular edema due to central and branch retinal vein occlusions. METHOD A retrospective review of all patients undergoing MTC for branch (BRVO) and central retinal vein occlusions (CRVO) was performed. All eyes underwent a standard procedure: Following vitrectomy, a branch retinal vein in the distribution of the obstruction was identified and a site for TVC was chosen and marked with a ring of endophotocoagulation. The intraocular pressure was elevated and the retinal vein completely transected at each marked site with a 20g MVR blade penetrated through the retinal vein and underlying choroid into the sclera. Air-fluid exchange was performed followed by overnight prone positioning. RESULTS 16 eyes of 16 patients operated between August 2008 and January 2011 including 3 BRVO and 13 CRVO (5 ischemic) were included. MTC was performed 131 months (avg. 12) after diagnosis. Postop follow-up ranged 331 months (avg. 17). At least one CA was created in each eye. Intravitreal drug injections (bevacizumab and/or steroid) decreased postoperatively (P=0.0007). 7 eyes required no further injections postoperatively, 3 eyes only one. VA improved 3 or more lines in 7 eyes (310 lines); was unchanged in 6; and worsened in 3 (3 to 4 lines) (P=0.012). Central foveal thickness decreased an average 254 um (P=0.003). Postoperative complications included one epiretinal membrane and one vitreous hemorrhage requiring surgery. CONCLUSION
Pt. B: Pre- (top) and postoperative (bottom) SD-OCT 6 weeks following vitrectomy with multiple transvenous chorioretinotomies for a central retinal vein occlusion 30 months in duration preoperatively.
419
Bevacizumab for Choroidal Neovascular Membrane (CNVM) Secondary to Idiopathic Macular Telangiectasia (IMT)
Naveenam Srinivasa Muralidhar, MD (Bangalore, India), Hemanth Murthy, MD, Kavitha S. Rao, MD, Manoj Gautam, MD
PURPOSE
Vitrectomy with multiple transvenous chorioretinotomies to create chorioretinal venous anastomoses may be useful in the management of retinal vein occlusions, reducing macular edema, improving visual acuity, and reducing or eliminating the need for long-term medical therapy.
Bevacizumab has been used to treat CNVM due to a variety of etiologies. We wanted to analyze the efficacy of intravitreal bevacizumab in the treatment of CNVM due to IMT. We report the clinical, visual and OCT outcome of eyes with CNVM due to IMT treated by intravitreal Bevacizumab.
METHOD
Retrospective analysis of all patients of CNVM due to IMT were analyzed. Patients who had received any other treatment like photodynamic therapy, transpupilary thermotherapy were excluded. The diagnosis was established by Fluorescein angiography (FFA) and Optical Coherence photography (OCT). 1.25 mg of Bevacizumab was injected intravitreally under topical anesthesia with strict aseptic precautions. Vision and OCT were repeated at every visit. Decision to repeat the injection was based on OCT scan findings suggestive of incomplete resolution or recurrence on follow-up visits. prn dosing was used in most cases and loading dose concept was not followed.
159
RESULTS 10 eyes of 8 patients fulfilled all the criteria and were available for analysis. Three were males and 5 were females. Two patients received injections in both the eyes, but at different times as the involvement was at different times. Mean age was 46.5 years (range 45 to 62 years). follow-up ranged from 4 months to 44 months, mean being 19.1 months. Six patients were diabetic and 3 were hypertensive. Vision improved in 9 out of 12 eyes (75 %), remained stable in 3 eyes (25 %). Vision improved by 2 lines or more (Snellen Chart) in 5 eyes (50 %). OCT showed regression in all the eyes at last follow-up. Mean number of injection was 2 (range 1-3). CONCLUSION Intravitreal Bevacizumab is highly efficacious in treatment of CNVM secondary to IMT. Long term stability seems to be achieved by relatively less number on injections compared to CNVM due to age related macular degeneration.
421
Progression of Ischaemic Maculopathy Following Multiple Intravitreal Bevacizumab for Recurrent Macular Edema from Central Retinal Vein Occlusion
Ogugua Ndubuisi Okonkwo, MD, FRCS (Edin) (Lagos, Nigeria), Kunle O. Hassan, Olufemi O. Oderinlo
PURPOSE
420
Efficacy of Anti-VEGF Therapy in Subretinal Neovascularisation Secondary to Macular Telangiectasia Type 2

Raja Narayanan MBBS (Hyderabad, India), Manish Sinha, MD, Vivek Dave, MD, Jay Chhablani, MD, Baruch D. Kuppermann, MD, PhD*
Intravitreal Anti-VEGF have been used for the treatment of macular oedema secondary to retinal vein occlussion with good results. Often multiple treatment is required, especially for recurrent or chronic oedema. In the situation of macular oedema and significant macular ischaemia are multiple injections of Anti VEGF safe?
METHOD
PURPOSE To evaluate the efficacy of intravitreal anti-vascular endothelial growth factor (VEGF) in the treatment of subretinal neovascularisation (SRNVM) secondary to macular telangiectasia (mactel) type 2. METHOD A retrospective chart review of consecutive patients with mactel and SRNVM who were examined between January 2007 and January 2010 was performed. Patients with diabetic retinopathy, age-related macular degeneration or any other macular pathology were excluded. The mean change in best corrected visual acuity at the final visit was the primary outcome measure. The mean number of intravitreal injections, retinal thickness on optical coherence tomography and intraocular pressure were the secondary outcomes. RESULTS A total of 14 eyes of 14 patients were included in the study. The mean age of the patients was 53.64 years (range 44-65). There were 8 females and 6 males. Five patients had a history of diabetes mellitus. Six patients received ranibizumab and 8 patients received bevacizumab. Two patients received additional verteporfin photodynamic therapy (PDT). The average follow-up duration was 13.1 months (range 3-42 months). The mean baseline decimal visual acuity was 0.14 0.15 (Snellen equivalent 20/150) and the mean final visual acuity was 0.27 0.17 (Snellen equivalent 20/70) and this difference was statistically significant (p=0.013). The mean number of intravitreal injections was 1.8 and there were no significant complications CONCLUSION Intravitreal anti-VEGF therapy appears to be effective and safe in SRNVM secondary to mactel.
A single case report of a 74 year old hypertensive male, bilateral psedophake. Suffered ischaemic central retinal vein occlussion of the left eye and developed macular oedema with reduction of vision to counting fingers. Fundus flourescein angiography revealed areas of perifoveal capillary loss and an irregular FAZ. Responded favourably to initial 3 doses of intravitreal bevacizumab 1.25mg injection with resolution of macular oedema on OCT and improved visual acuity to 6/36. Macular edema recurred with CRT (Central Retinal Thickness) on OCT increasing from 269 to 596. Decision was taken to have a second regimen of monthly injections of 1.25mg bevacizumab for 3 months.
RESULTS
Three monthly injections of intravitreal bevacizumab 1.25mg were again given. Vision stabilized at 6/36 during this period until a day after the third injection. He was noted to have a drastic drop in visual acuity on the first day post the last dose of injection to Hand Motion only. Despite dissappearance of macular oedema, proven by OCT, vision remained poor. Flourescein angiography revealed progression of foveal ischaemia. This was attributed to the intravitreal bevacizumab injection and probably may not have occurred if the last dose of intravitreal bevacizumab was not given. There may therefore have been a cumulative damaging effect of the multiple doses of bevacizumab causing a progression of macular ischamia. Multiple intravitreal bevacuzimab, should probably be used with caution in patients with vein occlussion and macular ischaemia. Mechanisms induced by this intravitreal injection can result in worsening of ischaemia, progression to the macular and irreversible loss of vision. Further studies to better characterize the risk factors for this subset of patients and modify treatment is required.
CONCLUSION
422
423
VOILA: Branch Vein Occlusion Treated with Intravitreal Bevacizumab and Focal Laser Photocoagulation
Anu Singla Patel, MD (Royal Oak, MI), Susan M. Malinowski, MD
Reduced Central Retinal Thickness with Dexamethasone Intravitreal Implant in Patients With Macular Edema Due to Retinal Vein Occlusion
Srinivas Reddy Sadda, MD* (Los Angeles, CA), Ronald P. Danis, MD, Jenny Jiao*, Xiao-Yan Li, MD*, Scott Whitcup, MD*
To describe the efficacy of intravitreal bevacizumab followed by focal laser photocoagulation for the treatment of cystoid macular edema (CME) in branch retinal vein occlusion based on visual acuity and mean OCT thickness.
PURPOSE METHOD A retrospective chart review was performed on patients diagnosed with macular edema from branch retinal vein occlusion. Patients included in the study received intravitreal bevacizumab until resolution of edema and hemorrhage allowed for focal laser photocoagulation. Each patient underwent fluorescein angiography and OCT at initial examination and OCT at each subsequent visit. Major outcome measures included visual acuity (VA) and mean OCT thickness. Patients who received any other treatment prior to focal laser photocoagulation were excluded. RESULTS 16 patients with macular edema secondary to branch retinal vein occlusion from 2006 to the present were examined. The average length of follow-up was 24.5 months (range 9-49 months). Pretreatment VA ranged from 20/30 to counting fingers (average 20/80) and mean OCT thickness was 356.6. Patients were re-evaluated 2-6 weeks after initial intravitreal bevacizumab. There was a significant improvement in VA (improvement to 20/40, p=.0073) and mean OCT thickness (258.7, p=<.0001). 8 patients experienced recurrence of CME after the initial treatment cycle (range 6 weeks to 36 months) and were re-treated as necessary. At final follow-up, visual acuity ranged from 20/20 to counting fingers, average 20/30 (p=.05) and mean OCT thickness was 266.4 (p=.0002). CONCLUSION Initial treatment of CME with intravitreal bevacizumab followed by focal laser photocoagulation can significantly improve VA and decrease CME. The combination of initial improvement in VA and long term efficacy of focal laser photocoagulation make this sequence of treatment a valuable, cost effective, initial treatment algorithm. A prospective trial to clarify these findings is warranted. PURPOSE
This study evaluated the efficacy and safety of intravitreal implanted sustained-released dexamethasone (DEX; Ozurdex) 0.7 mg compared with sham procedure in patients with macular edema (ME) resulting from branch or central retinal vein occlusion (BRVO; CRVO). Changes in central retinal thickness (CRT) and visual acuity were determined 90 and 180 days after insertion of the implant. Adults with ME involving the fovea due to RVO, a best-corrected visual acuity (BCVA) of 34 letters (20/200) to 68 letters (20/50), and retinal thickness 300 m were randomized to intravitreal DEX implant (n=427) or sham procedure (n=426). CRT was measured by optical coherence tomography (OCT) at baseline and months 3, 6, 9, and 12. At day 180, eligible patients (BCVA <84 letters or CRT >250 m) received DEX implant and were followed in an open-label, 6-month, extension study. Correlation between changes in CRT and changes in BCVA during the initial phase and the extension phase were determined using the Pearson correlation coefficient.
METHOD
RESULTS
Ninety days after insertion of DEX implant 0.7 mg, CRT was reduced by a mean of 208 m vs 85 m in the sham group (P<.001). The percentage of patients with CRT <250 m was 36% in the DEX implant group, and 16% in the sham group (P<.001). The decrease in baseline CRT was correlated with an improvement in BCVA (90 days: slope = -0.013 letters/m, P<.001; 180 days: slope = -0.016 letters/m, P<.001). At day 180, a total of 341 of 427 DEX implant patients received a second DEX implant (DEX/DEX) and 326 of 426 sham patients received their first DEX implant (sham/DEX). On day 90 of the open-label phase, 53% of DEX/DEX and 58% of the sham/DEX patients had a CRT <250 m. The treatment effect decreased substantially 180 days after each treatment cycle. Multiple linear regression analysis indicated that a difference in baseline CRT of 100 m was correlated with changes in BCVA ranging from approximately 0.5 letters at day 30 to 1.5 letters at day 180 (P<.001).
CONCLUSION
A significant reduction in OCT-measured CRT was observed in the eyes of patients with ME secondary to RVO at 90 days after intravitreal insertion of sustained-release dexamethasone implant, but this effect lessened by day 180. DEX implant reduced CRT similarly after each of 2 treatment phases. Baseline CRT and the change from baseline CRT correlated with the changes in BCVA.
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424
Long Term Natural History of Idiopathic Macular Telangiectasia

Shantanu Reddy Neravetla, MD (Springfield, OH), Vivek Dave, MD, Mudit Tyagi, MD, Benjamin Nicholson, MD, Jay Chhablani, MD, Raja Narayanan MBBS
injected at the same sitting with 1.25 mg (0.05ml) bevacizumab, combined with 2 mg (0.05ml) triamcinolone. The visual and anatomical responses were evaluated.
RESULTS
PURPOSE To describe the baseline characteristics of eyes with idiopathic juxtafoveal retinal telangiectasia (MacTel) in a tertiary care center in South India. METHOD Ninety eyes of 45 patients were evaluated retrospectively. Patients with a minimum of 2 years follow-up were included in the study. RESULTS The mean age at baseline was 60.4 years. There were 25 females and 20 males in the study. Ten patients had diabetes at baseline. At baseline 33 eyes showed intraretinal pigments; 18 eyes showed parafoveal graying; 15 eyes had subretinal neovascularization. The average follow-up period was 33 months (range 18-223 months). The mean visual acuity at baseline was 20/40 and at last follow-up was 20/50. At final follow-up, 31 eyes maintained the same visual acuity as baseline. Three eyes out of the 75 non-neovascular MacTel eyes at baseline developed subretinal neovascularization during follow-up period (incidence of 1.3% per year). Photodynamic therapy or intravitreal anti-vascular endothelial growth factor agents or a combination of both were the mode of treatment for the subretinal neovascularization.
Mean duration of follow-up after first intravitreal injection was 5 months (range 1-12 months) Mean number of combined therapy intravitreal injections were 1.24 per patient. The Central macular thickness reduced significantly from its average baseline value of 540 120 m to 268 77 m at 1 month post injection (p < 0.05) as well as at the time of last follow-up (average CMT 244 45 m; p < 0.005). The visual acuity increased from 0.2 0.15 decimal units (approx 20/100) at baseline to 0.47 0.27 decimal units (approx 20/40) at 1 month follow-up and continued to improve to 0.59 0.33 decimal units (approx 20/33) at the last visit. Three patients with IOP more than 21mm Hg were controlled with topical medication. There was no significant increase in cataract progression in any eye requiring surgical intervention. No other injection related complication was observed. Combination therapy seems a safe option for macular edema in BRVO. Combining drugs with different modes of action seemed to increase the longevity of the drug effect and may decrease chances of tachyphylaxis. The lower dose (2mg) of steroid used decreased the chance of steroid related complications while still being efficacious. Larger prospective studies are required to validate our observations.
CONCLUSION
426
This is the largest study of macular telangiectasia from the Indian subcontinent describing the natural history of the disease over a 3-year period. Visual acuity remained stable over the study period.
CONCLUSION
Intravitreal Bevacizumab Treatment for Macular Edema Due to Branch Retinal Vein Occlusion
Ruth Axer Siegel, MD (Petah Tikva, Israel), Ayelet Dresnik, MD, Karin Mimouni, MD, Dan Bourla, MD, Elite Bor, MD, Dov Weinberger, MD
425
Combined Intravitreal Bevacizumab and Triamcinolone Acetonide as Primary Therapy for Macular Edema in Branch Retinal Vein Occlusion
Cyrus M. Shroff, MD (New Delhi, India), Daraius Shroff, MD, FRCS, Charu Gupta, MD, A. K. Singh, MD, Neelam Atri, MD, Prashant Naithani, MD, Bhavana Sharma, MD
PURPOSE
Current proven treatments for BRVO induced macular edema are laser, intravitreal steroids, and monthly ranibizumab injections. We report the functional and anatomical outcome of intravitreal bevacizumab (IVB) treatment in a cohort of patients with macular edema due to BRVO in a tertiary retina clinic. Retrospective analysis of the medical records of all consecutive patients who received IVB due to BRVO induced macular edema from 2/07 till 8/10 was performed. The patients received 3 to 4 loading doses of IVB (1.25 mg), and were followed every 6 to 8 weeks. IVB was repeated when macular edema was present. Grid laser photocoagulation was performed as well when macular edema persisted after 4 to 6 bevacizumab injections.
METHOD
PURPOSE
To evaluate the safety and efficacy of combined intravitreal bevacizumab (1.25mg) and triamcinolone acetonide (2 mg) for treatment of macular edema in branch retinal vein occlusion.
Retrospective case series of 25 treatment naive eyes of patients with macular edema secondary to branch retina vein occlusion at a tertiary eye centre in North India Patients were
METHOD
RESULTS
The cohort included 45 eyes of 45 patients, with a mean age of 70.7 years, mean follow-up of 18.8 months, and mean number of injections of 8.8. 14 patients (33%) received
grid laser treatment before the IVB, while 23 patients (51%) received grid laser during the study period. The mean initial logMAR VA was 0.63 (mean snellen VA 6/43); the mean final logMAR VA was 0.4 (mean snellen VA 6/21), p<0.0005. The mean initial and final central maculal thickness (CMT) were 382.2 and 320.5 microns respectively (p=0.028). Positive correlations were found between the initial VA and the initial and final CMT (p=0.004), between initial and final VA (p<0.0005), and between the gain in VA and the reduction in the CMT (p=0.03). No correlations were found between the initial or final VA and laser treatment before or during the study.
CONCLUSION IVB for the management of BRVO, with and without laser treatment, reduced CMT and improved visual function.
428
Collateral Vessel Presence in Branch and Central Retinal Vein Occlusions: The BRAVO and CRUISE Trials
Rishi Singh, MD (Cleveland, OH), Linda Yau, MD*, Wendy Yee Murahashi, MD
PURPOSE
427
To examine the incidence of collateral vessels over time and the potential impact on visual acuity (VA) outcomes in patients with branch or central retinal vein occlusion (RVO) receiving sham or intravitreal (IVT) ranibizumab (RBZ) during the BRAVO or CRUISE trials.
Intravitreal Bevacizumab Treatment for Macular Edema Due to Central Retinal Vein Occlusion
Ruth Axer Siegel, MD (Petah Tikva, Israel), Assaf Dotan, MD, Dan Bourla, MD, Karin Mimouni, MD, Elite Bor, MD, Dov Weinberger, MD
METHOD
PURPOSE We report the visual acuity (VA) and anatomical outcome of a cohort of 35 patients who received intravitreal bevacizumab (IVB) as a treatment for central vein occlusion (CRVO) induced macular edema. METHOD Retrospective analysis of the medical records of all consecutive patients who received IVB due to CRVO induced macular edema from 2/07 till 8/10 and were followed for at least 6 months in Rabin medical center, Beilinson campus, was performed. The patients received 3 to 4 loading doses of IVB (1.25 mg), and were followed every 6 to 8 weeks. IVB was repeated when macular edema was present. RESULTS The cohort included 35 eyes of 35 patients, with a mean age of 65.5 years, and a mean follow-up time of 17.7 months, and mean number of injections of 9.3.
BRAVO and CRUISE (phase 3 randomized studies) evaluated the efficacy and safety of monthly IVT injections of 0.3-mg or 0.5-mg RBZ in patients with branch (BRAVO; n=397) or central (CRUISE; n=392) RVO. In both trials, the initial 6-mo sham-injection-controlled treatment period was followed by 6 mo of PRN treatment in all arms, in which shamtreated patients could receive 0.5-mg RBZ. Fundus photography (graded by the Univ of WI Reading Center) was used to assess collateral vessel presence on the optic disc and within the retina in the study eye at baseline (BL), 6 and 12 mo. Mean change from BL in best-corrected VA for patients with and without collateral vessels was also evaluated. The mean ages (SD) of enrolled patients from BRAVO and CRUISE were 66.4 (11.9) and 67.6 (12.5) yrs, respectively. Mean time from RVO diagnosis to study entry was 3.6 months for BRAVO patients and 3.2 months for CRUISE patients. Mean baseline VA (SD) was 54.6 (12.3) ETDRS letters in BRAVO and 48.3 (14.7) ETDRS letters in CRUISE. No difference was observed in the presence of collateral vessels on the disc or within the retina between the sham and RBZ arms (Table). The observed presence of collateral vessels on the disc declined over time in BRAVO while a mild increase in the presence was observed in CRUISE. Conversely, the observed presence of collateral vessels within the retina increased in BRAVO and decreased in CRUISE post-baseline. Additionally, the presence or absence of collateral vessels on the optic disc did not appear to impact VA outcomes in BRAVO or CRUISE (Figure A and B).
RESULTS
The mean initial logMAR visual acuity (VA) was 0.9, and the mean initial Snellen VA was 6/98 , with improvement to 0.7, and 6/65 at the final visit (p= 0.009). Positive correlation was found between the initial and final VA (p<0.0005). The mean initial central retinal thickness (CRT) was 489.5 microns, and the final CRT was 395 microns (p=0.24). Positive correlation was found between the gain in VA and the reduction in CRT (p<0.0001). No correlation was found between the VA and the number of injections. IVB for the management of CRVO, improved visual acuity and .reduced CRT. Patients with better initial VA had better final VA.
CONCLUSION
CONCLUSION
Treatment with ranibizumab did not appear to consistently affect incidence of collateral vessels on the optic disc or within the retina in patients from BRAVO or CRUISE. The presence of collateral vessels did not appear to impact visual acuity outcomes in BRAVO or CRUISE. See images on next page.
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Comparison of Intravitreal Ranibizumab and Bevacizumab for the Treatment of Macular Edema Secondary to Retinal Venous Occlusive Disease
Alex Yuan, MD (Cleveland, OH), Baseer Ahmad, MD, Rishi Singh, MD, Peter K. Kaiser, MD, Daniel F. Martin, MD, Jonathan Sears, MD, Andrew P. Schachat, MD, Justis P. Ehlers, MD
PURPOSE Recent studies suggest that vascular endothelial growth factor (VEGF) inhibitors (e.g., ranibizumab, bevacizumab) can be an important therapeutic modality in the treatment of retinal vein occlusions (RVO). Comparative studies of the various VEGF inhibitors have been lacking. This study aims to compare the efficacy of bevacizumab and ranibizumab in RVO. METHOD
A retrospective comparative case series was conducted identifying eyes with macular edema secondary to RVO treated with ranibizumab or bevacizumab. Study eyes with macular edema from other concurrent causes (choroidal neovascularization, diabetes) and eyes with follow-up <3 months were excluded. Three separate cohorts were identified: anti-VEGF treatment nave eyes treated with ranibizumab (R) or bevacizumab (B), and eyes treated initially with bevacizumab and then switched to ranibizumab (C). Clinical variables including visual acuity, central subfield thickness (CST), and adverse events were analyzed. Students t-test or Fishers exact test were used, as appropriate.
Mean change in best-corrected visual acuity from baseline for patients receiving sham or ranibizumab with and without collateral vessels on the optic disc in (A) BRAVO and (B) CRUISE.
RESULTS
Eleven eyes were identified in the R-group and were matched to 12 eyes in the B-group. There were no significant differences (p>0.05) in the visual and anatomic outcomes, including mean line change [+3.21.3 (R) vs +5.02.0 (B); meanstd error], eyes gaining 3 lines [6/11 (R) vs 8/12 (B)], eyes losing 3 lines [0/11 (R) vs 1/12 (B)], and mean change in CST [-148100 m (R) vs -15291 m (B)]. There were 20 eyes in the crossover (C) group. Prior to crossover, the mean number of bevacizumab injections was 4.70.8. The mean time between the last bevacizumab treatment and the first ranibizumab treatment was 515 days. During initial bevacizumab therapy, there was a significant gain of 2.20.9 lines of vision [p=0.03]. After crossover to ranibizumab, there were no significant changes (p>0.05) in lines gained 0.00.1, or CST -1238 m.
CONCLUSION
Collateral vessel formation in BRAVO and CRUISE trials.
Ranibizumab and bevacizumab appear to be effective in treating macular edema secondary to retinal venous occlusive disease. Though small in size, this study suggests outcomes are comparable. Additionally, switching treatment from bevacizumab to ranibizumab did not result in significant changes in visual acuity.
Imaging Digital Angiography

POSTERS 430-457
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Fundus Autofluorescence Imaging Characteristics of Retinal Arteriolar Emboli (Hollenhorst Plaques) and Clinical Correlations
Andrew J. Barkmeier, MD (Rochester, MN)
Grading the Severity of Posterior Staphyloma Using SD-OCT Imaging and Correlation with Macular Disease Including Vitreomacular Traction and Schisis
Robert Beardsley, MD (Westwood, CA), David Sarraf, MD*
PURPOSE
The purpose of this research is to evaluate posterior staphylomata imaged with SD-OCT and to determine the incidence of associated macular pathology including schisis, epiretinal membrane, and macular hole. Additionally, we seek to develop a novel grading system for the classification of staphylomata and the corresponding incidence of macular pathology using SD-OCT imaging with each grade.
Retinal arteriolar emboli may exhibit either hyper- or hypoautofluorescence on Heidelberg Fundus Autofluorescence testing. The purpose of this study is to investigate autofluorescence characteristics of these emboli correlate with clinical characteristics, investigations, and outcomes.
PURPOSE METHOD A retrospective, single-institution review was conducted on the medical records of 18 consecutive patients with retinal embolic disease having received Heidelberg fundus autofluorescence (FAF) imaging. Case series inclusion criteria included retinal embolic disease (CRAO, BRAO, cilioretinal arterial occlusion, and asymptomatic Hollenhorst plaques) with at least one visible embolic plaque on color photography and FAF imaging of the same location. Patient demographic and clinical data were recorded including plaque characteristics, results of embolic investigations, and outcomes. Institutional Review Board approval was obtained for this study. RESULTS 18 patients meeting inclusion criteria were identified with a mean age of 71.6 8.7 years and 8.5 11.2 months follow-up (range: 0-47). Ratios between sex (10 M, 8 F) and involved eye (9 R, 9 L) were typical. 8 emboli were located within the superior vasculature (3 on nerve, 4 superotemporal, 1 superonasal), 9 were inferior (1 on nerve, 8 inferotemporal), and one was within a cilioretinal arteriole. 10 emboli exhibited hyperAF while 8 were hypoAF. Internal carotid arterial peak systolic velocity (PSV) on Doppler ultrasonography was not significantly different between emboli that were hyperAF (92 28 cm/sec) vs. those that were hypoAF (112 50 cm/sec, p=0.28). 3 hypoAF plaques were associated with a PSV 140 cm/sec ( 50% stenosis) vs. 1 hyperAF plaque (no pts with PSV 230 / stenosis 70-99%). 8 of 10 patients diagnosed with arteriolar occlusion had hyperAF emboli. Only one patient had a clinical embolic event during follow-up (TIA 18 months later, hypoAF embolus). CONCLUSION Hyperautofluorescent emboli were more likely to be associated with clinical arteriolar occlusion than were hypoautofluorescent emboli. (8/10 vs 2/8). No significant differences in embolic clinical investigations were noted between groups and the rate of significant carotid stenosis was low. Retinal arteriolar embolus size and composition likely affect fundus autofluorescence characteristics.
METHOD
A retrospective review 150 images with maculainvolving posterior staphylomata imaged by a Cirrus SD-OCT (Carl Zeiss Meditec) system that were evaluated for posterior vitreous detachment, vitreomacular traction, epiretinal membrane, macular schisis, and lamellar and full thickness macular hole. Poor quality images and partially visualized staphylomata were excluded. A best fit circle was aligned with the steepest curve of each staphylomata and arc of curvature and best fit circle radius were calculated. The staphylomata were stratified into 5 grades and the incidence of the macular pathologies was correlated to each grade. Statistical analysis was done using Cochrane-Armitage Trend testing.
RESULTS A total of 150 images from 93 patients were examined each of which had a posterior staphyloma. There were 60 with a depth of <500 microns (Grade 1), 63 with a depth of 500 to 999 microns (Grade 2), 23 with a depth of 1000 to 1499 microns (Grade 3), 1 with a depth of 1500 to 1999 microns (Grade 4), and 3 with a depth of greater than 2000 microns (Grade 5). The overall incidence of macular schisis was 20% (25/150) and was significantly greater with Grade 2 (17.4%) and Grade 3 (34.8%) staphylomata versus Grade 1 staphylomata (8.3%) (p=0.008). The overall incidence of epiretinal membrane was 36% (54/150) and was greater in Grade 2 (44%) and Grade 3 (35%) versus Grade 1 (27%) though the trend failed to reach statistical significance (p=0.14). The incidence of VMT, lamellar hole, and FTMH similarly was increased in higher grade staphylomata though not significantly. CONCLUSION
Imaging of staphylomata via SD-OCT can be a valuable tool for determining risk stratification for varying macular diseases. Increased grade of posterior staphyloma correlated to significantly increased incidence of macular pathology. We postulate that macular schisis may develop in eyes with higher grade posterior staphyloma and disproportionate anterior vitreomacular traction.
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IMAGING DIGITAL ANGIOGRAPHy
432
Effect of Wide-field Fundus Photography and Fluorescein Angiography System on the Management of Posterior Uveitis
Millena G. Bittencourt, MD (Baltimore, MD), John P. Campbell, MD, Henry A. Leder, MD, Theresa Gan, MD, Yasir Sepah MBBS, Elham Hatef Naimi, Brian Cho, MD, Mohamed Ibrahim, MD, Roomasa Channa, Abeer Akhtar, MD, Quan Dong Nguyen*
teristics such as shape of the choroid sclera junction and distribution location and caliber of large choroidal vessels. Thickness of the large vessel layer was measured by two independent observers in three locations: at the fovea, 750 m temporal to the fovea, and 750 m nasal to the fovea. Custom software was used to calculate the ratio between stroma and large vessel lumen area.
RESULTS
PURPOSE To determine whether the use of wide-field fundus imaging system alters the management of patients with posterior uveitis. METHOD In this prospective, observational study of patients with posterior uveitis, at baseline, and at scheduled follow-up visits, patients receive wide-field pseudo-color imaging and fluorescein angiography (FA) following their routine evaluation. Participating investigators successively determine disease activity and management changes based on exam alone, exam and limited (60 degree FA), and then with the addition of wide-field pseudocolor images, and wide-field FA (performed with Optos P200 System). Management decisions at each time point are compared to determine whether the wide-field imaging system alters initial management decisions made without wide-field images. RESULTS Twenty-eight patients have been enrolled to date. At the enrollment visit, current management was altered in 4/28 (14%) of patients based on examination findings alone, with or without 60 degree FA (25 of 28 patients received FA). Management was altered in 13/28 (46%) patients based on the addition of wide-field SLO imaging and FA (P < 0.01).
The 42 subjects had a mean age of 51.6 years. With regard to categorical observations, 100% of subjects had a bowl shape to the choroid-sclera junction. 97.6% of subjects had a smooth continuum of choroidal vessel size from large at the choroid sclera junction to small at Bruchs membrane. 98.8% of subjects had an even distribution of choroidal vessels in the nasal-temporal axis. The thickness of the large vessel layer at the fovea was 204.3m 65.9m (mean SD), 750m temporal to the fovea was 203.7m 60.3m and 750m nasal to the fovea was 198.6m 62.5m. Large vessel measurements had strong inter-observer correlation (r = 0.90, P < .0001). The software generated ratio of stromal area to large vessel lumen area had a mean of 0.27 and standard deviation of 0.08. We report a novel way to characterize the choroid in healthy eyes which includes qualitative description, manual measurement of choroidal layers and automated software analysis. Further investigation using this protocol in eyes with disease affecting the choroid such as age related macular degeneration, diabetes and central serous retinopathy are needed.
CONCLUSION
Our results suggest that wide-field imaging may alter management decisions compared to standard-of-care imaging and clinical examination. Such difference may be due to peripheral retinal imaging and angiographic findings not easily visualized or identified without wide-field imaging. Additional studies are indicated to determine whether these findings may be able to improve patient outcomes.
CONCLUSION
433
Software to calculate the ratio between choroidal stroma and large vessel lumen area A: spectral domain optical coherence tomograph of a normal eye. Blue box represents the selection of subfoveal choroid area to be analyzed B: magnified section of subfoveal choroidal area C: Area of subfoveal choroid after software analysis. White area represents stroma, black area represents large vessel lumen.
Choroidal Morphology of Healthy Eyes Using SD-OCT

Lauren Ann Branchini, BA (Boston, MA), Mehreen Adhi, MD, Caio Regatieri, MD, PhD, Namrata Nandakumar, MD, Jonathan Liu, J.G. Fujimoto, Jay S. Duker, MD*
PURPOSE To characterize the morphology of the choroid in healthy eyes using SD-OCT. Techniques used include qualitative description, manual measurement of large choroidal vessels as well as novel automated software techniques which calculate the ratio between the choroidal stromal area and large vessel lumen area. METHOD In this cross sectional study, 42 eyes of 42 subjects with no ocular disease underwent SD-OCT. Two independent observers evaluated the choroid for morphological charac-
Measurement of large choroidal vessel layer on a spectral domain optical coherence tomograph of a healthy eye. Red lines demonstrate measurement from the interface of the choroid and sclera to the inner most limit of the closest large choroidal vessel at the fovea, 750 um temporal to the fovea, and 750 um nasal to the fovea.
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435
Variability in Choroidal Thickness Using Spectralis SD-OCT

Jans Fromow-Guerra, MD, PhD (Mexico City, Mexico), Virgilio Morales-Canton, MD, Jose Guerrero-Naranjo, MD, Gerardo Garcia-Aguirre, MD, Maria A. MartinezCastellanos, MD, Juan Manuel Jimenez-Sierra, MD, Carlos Gustavo Sanchez Bermudez, MD, Ricardo Leal-Rodriguez, MD
Integrative Advancements for Intraoperative OCT

Justis P. Ehlers, MD (Shaker Heights, OH), Sunil Srivastava, MD, Yuankai Tao, MD, Joseph I. Izatt, MD, Cynthia Ann Toth, MD
PURPOSE To assess intraobserver and interobserver variability in choroidal thickness measurements by two different techniques using Heidelberg Spectralis SD-OCT to determine which is best for establishing normality. METHOD We studied healthy and diabetic patients who underwent OCT within a 5 X 30-degree area centered at the fovea using Spectralis SD OCT. Each image was obtained with 1 00 averaged scans using Automatic Real-Time software. Each patient was scanned with conventional technique and with inverted Enhanced Depth Imaging (EDI) technique. Measurements were performed three times by 2 independent observers. Intraclass Correlation Coefficient (ICC) was used to assess the level of intraobserver agreement. For assessing interobserver variability the Limit of agreement (LoA95%), Bland-Altman plots, ICC and Pearson correlation coefficients were used. RESULTS We studied fifty-two eyes from 26 subjects. Choroidal thickness measurements had a mean ICC of 0.756 for observer 1 and 0.857 for observer 2. The mean 95 % LoA range was shorter for EDI (-69 to 77 m) than for conventional technique (-120 to 94 m). Choroidal thickness measurements had a stronger inter-observer agreement for EDI than for conventional technique (r= 0.80 vs. r=0.35 p=<.0001). CONCLUSION The EDI technique demonstrated lower variability and a stronger inter-observer correlation for choroidal thickness measurements than the conventional technique. EDI technique should be chosed for establishing normal variation than conventional technique.
PURPOSE
The cross-sectional anatomic information obtained with OCT provides a natural complement to the retinal surgeon. However, current OCT systems do not allow for visualization of real-time motion. In addition, current intraocular instruments limit visualization of underlying tissues. This study aims to demonstrate OCT-based visualization of intraoperative motion and OCT-compatible instrumentation.
METHOD
A prototype operating microscope-mounted spectral domain OCT (MMOCT) system was used to concurrently acquire volumetric OCT images while performing operative maneuvers in cadaveric porcine eyes. Multiple scanning protocols were tested, including variations in orientation, dimension, and sampling rate. Custom image processing was developed to optimize visualization. Based on known OCT characteristics of materials currently used in instruments, novel materials were selected for OCT imaging and their reflectivity characteristics were tested. Based on these characteristics, optimal materials were selected and prototype instrumentation was constructed from these materials. Using the MMOCT system, a customized scan protocol was developed. The optimized protocol imaged an 8 mm x 0.4 mm field-of-view with 256 A-scans x 5 B-scans. This protocol allowed for real-time capture of instrument maneuvers and tissue manipulations. Tissue deformation and translational motion of the instrument were well-visualized. Following acquisition, custom image processing algorithms resulted in improved signal strength, robust visualization of instrument-tissue interaction, video-rate display of instrument maneuvers, and reduced instrument shadowing artifacts. Materials were identified with optimal OCT reflectivity profiles and selected for instrument construction. Utilizing the novel materials, OCT-compatible instrumentation demonstrated improved instrument visualization and reduced shadowing of underlying tissues compared to standard metallic instruments. This allowed for enhanced visualization of instrument/tissue interactions. OCT-compatible instrumentation and highresolution imaging of real-time intraocular surgical maneuvers are possible. Both of these advancements are critical components to the feasibility of seamless integration of OCT into the surgical environment.
RESULTS
CONCLUSION
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Assessment of an Angiographic Ischemic Index Based on Common Retinal Vascular Diseases

Valentina Franco-Cardenas, MD (Los Angeles, CA), Irena Tsui, MD, Gad Heilweil, MD, Jean-Pierre Hubschman, MD, Pradeep Prasad, Steven Schwartz, MD*
PURPOSE Calculating an ischemic index (ISI) using ultra wide field fluorescein angiography (UWFFA) in eyes with retinal vascular disease may be clinically useful. Retinal non-perfusion may be closely associated with vision threatening complications such as neovascularization or macular edema. The purpose of this study is to investigate the reproducibility a calculated ISI with UWFFA.
Ischemic index (ISI) was calculated as a percentage: Ischemic area/Total area*100. Fifteen pictures of UWFFA taken during the transit fase were chosen, including 5 BRVO, 5 CRVO and 5 DR. Ten graders were asked to calculate the ISI on pictures provided both digitally and on paper to assess the intragrader and intergrader agreement.
437
Rules for grading an ISI were created. Ten graders were asked to grade 15 different UWFFA images for ISI. Images were provided digitally and on paper and were graded on two different days. Images consisted of 5 eyes with diabetic retinopathy (DR), 5 eyes with branch retinal vein occlusion (BRVO) and 5 eyes with central retinal vein occlusion (CRVO). To assess intragrader and intergrader agreement and variability among the different diseases, an intraclass correlation coefficient (ICC) was calculated. Before calculating the ISI, graders were asked to predict the value of the ISI and choose their preferred treatment, based solely on the angiographic data.
METHOD RESULTS Intragrader agreement and variability for the ISI had an ICC of 0.82 + 0.11 over all. By disease ISI ICC was DR 0.25 +0.22, BRVO 0.72 +0.29 and CRVO 0.95 +0.5. Intergrader agreement and variability in calculating an ISI had an ICC in DR of <0.01-0.2, BRVO of 0.5-0.6, and in CRVO of 0.8-0.9 when performed on paper and digitally. High concordance was observed between predicted and calculated ISI. The most commonly recommended treatment was laser photocoagulation, followed by a combination of laser treatment and anti-vascular endothelial growth factor. CONCLUSION Intra and intergrader agreement and variability was high when calculating an ISI in BRVO and CRVO images, proving ISI to be a useful and reliable tool for assessing retinal non-perfusion. Agreement was not reached in DR images in this small cohort. Strong trends towards concordance were seen among more experienced graders suggesting ISI calculation for DR may need more training.
A New Endpoint for Longitudinal Measurements of Geographic Atrophy

Ron P. Gallemore, MD (Torrance, CA), Madeline Eells, Josh O. Wallsh, MD
PURPOSE
To demonstrate the loss of macular tissue over time, volumetrically, using high resolution optical coherence tomography (HR-OCT) in patients with geographic atrophy (GA) secondary to age-related macular degeneration.
METHOD
A prospective study of patients with GA using average macular volume (AMV) within a designated 3-mm diameter circle centered on the fovea measured with HR-OCT over time (7-30 mo). Patients with confounding diagnoses associated with macular edema were excluded. This data was then used to determine the change in macular volume per year, as well as the percent change in volume over time. The macular volume decreased significantly from 1.92 to 1.86 cubic mm over the period of time (p < 0.05), which correlated with an average decrease in AMV of 0.0470.011 cubic mm/year (n=11). From the same population, the percent decrease in AMV over time was 2.480.55 percent/year.
RESULTS
CONCLUSION
HR-OCT can be used to measure macular volume, which in turn was found to decrease significantly over time in patients with geographic atrophy. Macular volume is a novel endpoint for demonstrating the loss of macular tissue in GA and may be useful in clinical trials assessing therapies for this disorder.
438
Correlation of Fundus Autofluorescence with SD-OCT Findings and Functional Changes in Eyes with Central Serous Chorioretinopathy
Soo Geun Joe, MD (Seoul, South Korea), Sung Jae Yang, Joo Yong Lee, MD, Ju Byung Chae, MD, Young Hee Yoon, MD
foveal architecture, RPE, and Inner-Outer segment junction of central photoreceptors. Measurement of foveal thickness was also performed with auto segmentation. OCT findings were correlated with best corrected visual acuity and electrophysiological studies.
RESULTS
PURPOSE To investigate correlations between autofluorescence (AF) findings and clinical progression in patients with central serous chorioretinopathy (CSC). METHOD Medical records of 21 eyes with complete resolution of CSC were reviewed retrospectively. Data obtained from complete ophthalmologic examinations and from use of spectral domain optical coherence tomography (SD-OCT) and AF including both short wave length AF (SW-AF) and near infrared AF (NIR-AF) before and after the resolution of CSC, were analyzed. RESULTS Initial best corrective visual acuity was 0.27 0.29 (logMAR) and 0.15 0.17 (logMAR) after healing of CSC. Increased AF intensity in inferior macular (IAF) on both SW-AF and NIR-AF was related to duration of CSC (p=0.019; p=0.009, respectively). IAF on SW-AF also showed correlation with the height of subretinal fluid checked with SD-OCT (p=0.03) but that of NIR-AF did not. Inner and outer segment junction of photoreceptor (IS/OS) status after healing of CSC was associated with IAF on SW-AF and IAF on NIR-AF (p=0.031; p=0.045, respectively). CONCLUSION Image from AF including both SW-AF and IAF on NIR-AF could be useful methods which express the disease status of CSC and predict disease progression.
Eight patients (Sixteen eyes) with diagnosis of rod monochromatism (complete and incomplete) were evaluated, 5 males (62.5%) and 3 females (37.5%). The mean age was 20.6 years (4-42), the average BCVA was 20/100, the mean central thickness was 186.3 28.5 m ; the foveal depression was normal in all patients; absence of the IS/OS junction was observed in the foveal region in both eyes on 4 patients (50%), which did not correlated with BCVA. None of the patients had epiretinal membrane, cystoid macular edema or retinal pigment epithelium abnormalities.
CONCLUSION
Advanced Imaging techniques such as the SD-OCT are helpful for the structural analysis of the retinal architecture in a wide spectrum of retinal diseases including the congenital retinal disorders. In this study we did not find a consistent structural anomaly in patients with the same diagnosis. A larger population of patients should be evaluated and compared with a control group.
440
Real Time Intra-Surgical Imaging of Vitreoretinal Manipulations Using a Microscope-Mounted OCT System
Paul Hahn, MD, PhD (Durham, NC), Justin Migacz, MD, Rachelle OConnell, MD, Joseph I. Izatt, MD, Cynthia Ann Toth, MD
439
Analysis of SD-OCT Characteristics in Patients with Rod Monochromatism

Carlos Gustavo Sanchez Bermudez, MD (Mexico City, Mexico), Tania Adabache-Guel, MD, Juan Manuel Jimenez-Sierra, MD, Virgilio Morales-Canton, MD, Jose Guerrero-Naranjo, MD, Hugo QuirozMercado, MD, Guillermo Salcedo-Villanueva, MD, Maria Martinez-Castellanos, MD
PURPOSE
Optical coherence tomography (OCT) has revolutionized diagnostic retinal imaging but thus far has been limited primarily to the clinic setting. We have recently developed a microscope-mounted OCT (MMOCT) system to enable real time intra-surgical retinal imaging. The purpose of this study is to investigate the utility of this system for imaging vitreoretinal surgical manipulations.
PURPOSE To evaluate structural changes by spectral domain optical coherence tomography (OCT) by observation of the central retinal architecture in patients with rod monochromatism (achromatopsia) in Mexican individuals. METHOD Descripitive, transversal study. Eight patients with rod monochromatism were included; the diagnosis was established by means of visual acuity, standard electroretinogram, and color vision tests. SD-OCT was performed in all patients with the Spectralis OCT (Heidelberg Engineering). The examination included a central linear 100-frame scan and 25 x 25 30-frame volume cube. Images were analyzed by direct observation of the
METHOD
A custom MMOCT scanner was constructed to mount onto a Leica surgical microscope and interface optically and mechanically with an Oculus Binocular Indirect Ophthalmo Microscope (BIOM). We tested the ability of the MMOCT system to visualize surgical maneuvers in model eyes with various instruments in real-time. We also examined post-processing modifications for their ability to improve visualization. MMOCT enables non-contact cross-sectional imaging of retinal structures during surgical manipulations including brushing of the retinal surface with the Tano scraper and grasping of superficial retinal layers with intraocular forceps.
RESULTS
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These manipulations can be effectively visualized in real-time with unprocessed video-rate serial B-scans. Post-processing modifications can improve image resolution, permit threedimensional spatial visualization, and limit artifact including complex conjugate reflections and shadowing from surgical instrumentation. MMOCT may be useful for real time, crosssectional retinal imaging during surgical manipulations. Further refinement of instrumentation, hardware, and software is currently underway and will likely be important in improving imaging quality, resolution, and speed.
CONCLUSION
remnants of ERM and ILM were removed in all cases during the surgery. In 1 case of ERM, the ERM was not clearly dissected from the nerve fiber layer and was removed around the fovea only. On the other hand, there were some limitations in the use of a handheld SD-OCT intraoperatively. OCT had to be taken separately from the microscopic view and the fundus view of the OCT was limited within 6 mm and it was difficult to find the foveal center without the optic disc.
CONCLUSION
Intraoperative use of a handheld SD-OCT is helpful to perform the macular surgery more precisely even though there are some limitations. More improvements are needed in the hardware and software of SD-OCT for an intraoperative use.
442
Short-term Results of the Prospective Retinal and Optic Nerve Vitrectomy Evaluation (PROVE) Study: A Controlled Clinical Trial
Maziar Lalezary, MD (Nashville, TN), Rahul K. Reddy, MD, Edward Cherney, MD, Franco M. Recchia, MD, Karen Joos, MD, Jeffery A. Kammer, MD, Rachel Kuchtey, MD, Stephen J. Kim, MD
PURPOSE
Visualization of a diamond-dusted Tano scraper brushing against the surface of a cadaveric fresh porcine retina. Orthogonal views of summed images provide spatial orientation of maneuvers performed under the surgical microscope.
441
Intraoperative Use of a Handheld SD-OCT for Macular Surgery

Atsushi Hayashi, MD (Toyama, Japan), Takaaki Yagou, Tatsuya Yunoki, Miyako Oka
Long-term complications of pars plana vitrectomy (PPV) such as open-angle glaucoma and indocyanine green (ICG) toxicity remain unknown. The PROVE Study is an ongoing prospective, controlled clinical trial designed to assess changes in structure and function of the macula and optic nerve following PPV. Three-month interim data of our study cohort is presented here.
METHOD
PURPOSE To examine usefulness of SD-OCT images during macular surgery. METHOD
Interventional case series. Ten patients who underwent vitrectomy at Toyama University Hospital were included in this study. Five patients had an idiopathic macular hole and 5 patients had an epiretinal membrane (ERM). A handheld SDOCT, iVue (Optovue Inc.) was used intraoperatively. OCT images were taken before and after removal of ERM and internal limiting membrane (ILM) with the software of retinal map scan or cross scan.
Patients without glaucoma or prior PPV undergoing unilateral PPV were eligible. Enrollment goal is 80 eyes of 40 subjects. Both eyes are examined by a retina and glaucoma specialist pre-operatively (baseline), at 3-months post-operatively and then yearly for 5 years. The following data are recorded; intraocular pressure (IOP), corneal thickness (CCT), gonioscopy (GON), Humphrey visual field (HVF), fundus photography, and optical coherence tomography (OCT). The primary outcomes of this analysis are IOP, CCT, GON, HVF mean deviation (MD) and pattern standard deviation (PSD), cup-disc ratio (CDR), peripapillary retinal nerve fiber layer (RNFL), and macular central subfield thickness (CST). Forty eyes of 20 subjects have completed 3-month follow-up. Surgical indications were macular hole (MH; 7 eyes), epiretinal membranes (ERM; 8), and vitreous opacities (VO; 5). At baseline, mean IOP, CCT, MD, PSD and GON were similar among all eyes. No statistically significantly change following surgery was detected in these outcomes. One study eye developed a paracentral scotoma presumably due to intraoperative optic nerve contusion. No significant progression of cupping was observed in study eyes at 3 months. Baseline mean RNFL thickness (m) was 93 10 and 90 6 for study and fellow eyes, respectively and 88 11 and 91 7 at 3-months, respectively. In 14 eyes that underwent membrane peeling,
RESULTS
RESULTS
Intraoperative SD-OCT images were successfully taken in all patients. ERM were imaged similarly to the preoperative and remnants of the ERM or ILM were clearly detected on the surface of the retina. With the aid of the OCT images the
mean RNFL was 6 m thinner compared with fellow eyes (P=0.01). Mean baseline CST (m) of 8 subjects with ERM was 404 for study eyes and 260 for fellow eyes; while mean CST decreased 83 m at 3 months in study eyes, it remained 75 m thicker when compared with fellow control eyes (P<0.01).
CONCLUSION In this ongoing prospective study, short-term analysis suggests no significant change in IOP, CCT, GON, HVF (MD & PSD), or CDR following PPV. However, peripapillary RNFL thinning was observed in eyes that underwent membrane peeling and macular thickness (CST) remained significantly increased at 3 month in these eyes. Long-term follow-up of our study cohort should provide further insight.
Non-invasive multispectral mosaic image of human choroid.
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Non-invasive Multi-spectral Fundus Imaging is a Useful Tool for Structural and Functional Evaluation of the Choroidal Vasculature
Brian C. Leonard, MD* (Ottawa, Canada), Alan Boate, MD, Richard Clayton, MD*, Jeremy Gribben, MD*, Stuart Coupland, MD, Bernard Hurley, MD, John Hamilton, MD, David Priest, MD*, Robert G. Devenyi, MD*, MBA, FRCS(C)
444
Retinal Thickness Layer Analysis of ETDRS Regions in SD-OCT Maps for Diabetic NPDR Eyes with or without CSDME Using a Novel Thickness Analysis Program
Jennifer I. Lim, MD (Chicago, IL), Ruth U. Zelkha, Mahnaz Shahidi, MD
PURPOSE To examine the structural and functional characteristics of the choroidal vasculature in a broad variety of pathologic conditions using non-invasive multi-spectral fundus imaging. METHOD Both eyes of 58 patients with posterior polar and mid-peripheral choroidal pathology were assessed with clinical examination, color fundus photography, spectral domain optical coherence tomography and fluorescein angiography. Multispectral fundus imaging was performed using a wavelength range of 450 nm to 900 nm with four million pixel spatial resolution through a 41 degree field, with images acquired by a polychromatic camera and processed with dedicated software. RESULTS Multi-spectral imaging provided high resolution en face and stereo structural images slices through wavelength specific tissue depths, from vitreomacular interface to deep choroid, in a broad variety of choroidal disease. The choroidal vasculature and choroidal pathology were imaged clearly through retinal pigment epithelium. Tissue oxygenation mapping was imaged by software analysis of the ratio of oxygenated hemoglobin to deoxygenated hemoglobin in retinal and choroidal structures. Many of the diagnostic insights provided by this technology were not evident in clinical examination, spectral domain optical coherence tomography or fluorescein angiography. CONCLUSION Multi-spectral fundus imaging may provide a non-invasive high resolution alternative to fluorescein angiography.
PURPOSE
To compare thickness of inner and outer retinal layers in nine macular subfield areas from SD-OCT images amongst three groups of eyes: non-proliferative diabetic retinopathy (NPDR) with clinically significant diabetic macular edema (CSDME), NPDR without CSDME and normals.
METHOD
Patients with NPDR and normal subjects underwent SD-OCT imaging. The ILM, OPL and RPE boundaries were manually drawn for each of 19 raster SD-OCT images. A computerized algorithm was used to calculate the inner retinal (IRT=ILM to OPL) and outer retinal (ORT= ONL to RPE distance) thickness values. Total retinal thickness (TRT) was calculated as the sum of the IRT and the ORT. Maps of IRT, ORT and TRT were generated and the average thickness of each of the nine ETDRS macular subfields was calculated. IR, ORT and TRT values obtained in NPDR with CSDME, NPDR without CSDME and normal eyes were compared using analysis of variance (ANOVA). Thickness data were obtained in 26 NPDR with CSDME (age 65 8 years), 8 NPDR without CSDME (age 66 7 years) and 15 normals (age 52 6 years). Overall, retinal thickness was lowest in normal eyes and highest in NPDR with CSDME eyes. In the foveal areas, TRT was 337 14 microns, 276 25 microns and 266 18 microns in NPDR with CSDME, NPDR without CSDME and normal eyes respectively. Statistically significant differences were found for IRT in the foveal area (p=0.03), ORT in the temporal parafoveal area (p=0.04) and TRT in the foveal, temporal parafoveal and perifoveal areas (p<=0.02).
RESULTS
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CONCLUSION In NPDR with CSDME eyes, inner retinal thickening is responsible for the majority of retinal thickening. In both NPDR with and without CSDME, temporal macular thickening was found as compared with controls.
CONCLUSION
Intraretinal crystalline deposits localized to the outer nuclear and outer plexiform layers can be detected in eyes with a history of neovascular age-related macular degeneration, often after treatment with a variety of different modalities. Potential etiologies of these deposits include residual lipid material, degenerated Mller cell elements, and an external factor such as diet.
Retinal thickness maps for a normal control eye.
Retinal thickness maps for a NPDR with CSDME eye.
445
Intraretinal Crystalline Deposits in Neovascular AMD

Luiz H. Lima, MD (Sao Paulo, Brazil), James M. Klancnik, MD, K. Bailey Freund, MD* Richard F. Spaide, MD,
This 74-year-old female patient had a CNV diagnosed 4 years ago. Initially, she was treated with 1 session of PDT. Following PDT she started treatment with injections of intravitreal ranibizumab. The VA was 20/200. (A) In 2006, the fundus photograph revealed a prominent lipid extravasation associated with a CNV in the superior macula. (B) One year later, there was a decrease in the amount of lipid exudation and crystalline deposits were observed in the superior macula. (C) After a total lipid reabsorption, the crystalline deposits became more evident in the superior macula. (D) Observe the retinal crystalline deposits in a magnified view.
PURPOSE The purpose of this study was to describe intraretinal crystalline deposits detected in eyes with neovascular agerelated macular degeneration. METHOD A retrospective review of patients seen during a 6month period with the diagnosis of neovascular age-related macular degeneration was performed to identify patients with intraretinal crystalline deposits, defined as pinpoint refractile bodies within the neurosensory retina. The characteristics of the deposits, including their shape, size, distribution, and location within the retina, were determined by analyzing color and red-free fundus photographs and spectral domain-optical coherence tomography images.
Fourteen eyes of 13 patients with neovascular agerelated macular degeneration manifesting intraretinal crystalline deposits were identified. The patients had no history of ocular or systemic disease or prior medication use known to be associated with intraretinal crystals. Intravitreal antivascular endothelial growth factor injection was used in 10 eyes, laser photocoagulation in 3 eyes, and intravitreal triamcinolone in 1 eye. The retinal crystals were detected in the macula overlying or adjacent to the areas of choroidal neovascularization. The crystalline deposits could be localized with spectral domainoptical coherence tomography to both the outer nuclear and the outer plexiform layers.
RESULTS
(A) Fundus photograph from an 86-year-old female patient with a CNV diagnosed 6 years previously when she started treatment with photodynamic therapy PDT and injections of intravitreal triamcinolone. Two years following that, she received 25 injections of either intravitreal ranibizumab or bevacizumab and crystalline deposits were noted nearby to and overlying the CNV scar. She had resolution of her exudative manifestations with recurring episodes of CNV. (B) Magnified view of fundus photograph showing retinal crystals in the vicinity of the CNV. The best-corrected visual acuity (VA) was 20/60. (C) Series of four spectral domain optical coherence tomography (SD-OCT) scans showing crystalline deposits in the outer plexiform layer (arrows).
446
Serial Wide-field Fluorescein Angiography of Preproliferative (Ischemic) CRVO Treated with Ranibizumab
James C. Major, MD, PhD* (Houston, TX), Angeline Mariani, MD, Eric Kegley, MD, David M. Brown, MD*
PURPOSE Preproliferative (Ischemic) Central Retinal Vein Occlusion (CRVO) results in vascular insult to the entire retinal circulation. Classically regarded as a single insult, it is unknown if progressive changes occur to the retinal circulation over time when treated with intravitreal anti-VEGF therapy. Wide-field serial angiography was used to assess the posterior as well as the peripheral retinal vascular changes. METHOD Wide-field fluorescein angiography was performed serially in 10 patients with pre-proliferative CRVO who were treated in the 3 year prospective Rubeosis Anti-VEGF (RAVE) trial evaluating intravitreal ranibizumab. Angiography was performed utilizing the Staurenghi lens and a scanning laser ophthalmoscope (Heidelberg Spectralis HRA) to allow 150 degree imaging. Patients received monthly ranibizumab for 9 consecutive months followed by an observation period (month 9-12), and then two subsequent years of observation with PRN therapy. RESULTS Vascular pruning of the peripheral retinal circulation was commonly seen as well as progressive loss of the secondary and tertiary arterioles and venules while on monthly ranibizumab therapy. In the observation periods, posterior neovascularization was common. CONCLUSION The retinal vasculature in preproliferative/ proliferative CRVO (ischemic CRVO) undergoes progressive degradation despite intensive ranibizumab therapy. When ranibizumab is discontinued, posterior neovascularization is common.
Fluorescein angiography exhibiting posterior neovascularization after discontinuation of monthly intravitreal ranibizumab treatment.
447
The Rate of Adverse Reactions to Intravenous Fluorescein Angiography in a Pediatric Population

Emmanouil Mavrikakis, MD, PhD (Athens, Greece), Anne De Silva, MD, Cynthia VanderHoven, Wai-Ching Lam, MD, FRCS(C)
PURPOSE
To report the incidence of adverse effects to intravenous fluorescein angiography (IVFA) among a pediatric population in an out-patient clinical setting
METHOD
Retrospective chart review of all adverse reactions to IVFA performed at a childrens hospital between January 1992 and May 2009. Patients 18 years and younger were seen for a variety of retina conditions and all reactions to IVFA using 10% fluorescein were documented. A total of 373 fluorescein angiograms were included.
RESULTS
75 (20.1%) adverse reactions were documented, most of which were mild. Nausea and/or vomiting were the most common mild reactions (14.48%). There were no severe reactions or mortalities.
CONCLUSION
Pediatric population may experience a higher overall adverse reaction rate to IVFA as compared to reported adult rates (1.1%-5.17%). Nausea and/or vomiting are the most commonly experienced reactions in both adult and pediatric population. IVFA remains a safe and valuable diagnostic procedure for the evaluation of pediatric retina conditions.
Fluorescein angiography exhibiting progressive capillary dropout and pruning of the peripheral retinal vasculature by month 6 despite monthly intravitreal ranibizumab.
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449
Histopathologic Correlation of Retinal Layers on SD-OCT in Post-mortem Human Eyes

Christine Nichols Kay, MD (Iowa City, IA) Ryan M. Tarantola, Robert F. Mullins
OCT Features of Choroidal Neovascularization Secondary to Chronic Central Serous Chorioretinopathy

Rajeev R. Pappuru MS (Hyderabad, India), Mudit Tyagi, MD, Raja Narayanan MBBS, Annie Mathai, Avinash Pathangey, MD, Ajit B. Majji, MD, Subhadra Jalali, Taraprasad Das, MD*
PURPOSE PURPOSE To correlate histopathologic evaluation of retinal anatomy with spectral domain optical coherence tomography (OCT) findings in post-mortem human eyes. Prior studies have correlated histopathology to OCT in rats and monkeys. We believe this to be the first histopathologic correlation to same eye high definition OCT imaging in human eyes. METHOD Four human eyes were obtained from the Iowa Lions Eyebank. Eyes were imaged within 5 hours of death with spectral domain OCT and tissue was subsequently fixed and evaluated histopathologically. RESULTS Retinal layers seen on spectral domain OCT were correlated with retinal layers seen with histopathology. Retinal pigment epithelium, outer and inner retina, nerve fiber layer, and retinal vessels could be correlated in these images. CONCLUSION Direct correlation between histopathology and spectral domain OCT provides valuable information into anatomic identity of layers seen with high definition current day OCT technology. We believe this to be the first correlation of post-mortem high definition OCT to histopathology in same eye human subjects.
Choroidal neovascularization (CNV) secondary to chronic central serous chorioretinopathy (CSC) is a rare complication. Optical coherence tomography (OCT) has been used to image retinal structures in eyes with Chronic CSC and CNVM with different pathologies. We describe OCT features of CNVM secondary to chronic CSC. A retrospective review of medical records of choroidal neovascularisation secondary to chronic central serous chorioretinopathy(CSC) imaged with optical coherence tomography was performed. Patients had a history of episode of CSC diagnosed based on documented angiographic leakage in the past, or typical findings of retinal pigment epithelium changes including diffuse retinal pigment epithelial atrophy or retinal pigment epithelium tract in both or either macula, and consistent findings in fundus fluorescein angiogram.
METHOD
RESULTS
Nineteen patients were evaluated, 17 men and 2 women; age range, 2561 years [mean, 42.36 years with a SD of 10.89]). The mean BCVA was 20/50 (range, 20/20 to 20/200). Three patients had a prior history of focal laser. The interval between laser and detection of CNV was 2-3 months. All the CNV were of subretinal membranes, predominantly subfoveal (63%). The mean foveal thickness was 239.6m (range 124677m). All patients had a presence of subretinal fluid and subretinal tissue. Seven eyes (35%) had a serous pigment epithelial detachment (PED). No fibrovascular PED was noted. Intra-retinal cystic changes were noted in 6 eyes (30%).
CONCLUSION
CNV secondary to Chronic CSC present as type 2 membranes. Fibro-vascular PEDs are not seen in these cases.
Spectralis OCT image of post-mortem human eye, superotemporal macula.
OCT showing type 2 choroidal neovascular membrane with intraretinal cystoid changes.
Histopathology in anatomically correlated location in superotemporal macula of same human eye. Layers including nerve fiber layer, inner retinal layers, outer retinal layers, and retinal pigment epithelium can be identified. A retinal vessel can be correlated to the vessel visualized on OCT.
450
Logarithmic Transformation of SD-OCT Data in Uveitis-Associated Macular Edema

John F. Payne, MD (Atlanta, GA), Beau B. Bruce, MD, Lee B.K. Lyndon, MD, Steven Yeh, MD
PURPOSE Logarithmic transformation of retinal thickness was recently shown to provide analytic advantages over central subfield thickness (CST) in evaluating clinically relevant changes in retinal thickness. The purpose of this study was to evaluate the utility of logarithmic transformation of spectraldomain OCT (logSD-OCT) in evaluating clinically relevant changes in macular edema secondary to uveitis. METHOD Patients with noninfectious uveitis-associated macular edema at our institution between August 2010 and March 2011 were identified. Only those with SD-OCT imaging were included. The clinical diagnoses, visual acuities, and CST results, as measured by the Zeiss Cirrus HD-OCT manufacturers software, were recorded. Logarithmic transformation of CST (logSD-OCT) was performed. Frequency histograms were plotted for CST and logSD-OCT. Skewness and kurtosis of both data sets were determined. A linear mixed effects model was created to account for within patient correlation and correlation of the logarithm of the minimum angle of resolution (logMAR) visual acuity with logSD-OCT was performed.
Distribution of SD-OCT central subfield thickness measurements (top) shows a positive skew, whereas logarithmic transformation of the central subfield thickness (logSD-OCT, bottom) shows a more normal distribution.
451
A total of 98 SD-OCT images from 34 patients were analyzed. Eight men and 26 women were included, and the mean age at examination was 40 years (range: 11-69 years). Anatomic diagnoses included anterior/intermediate uveitis (23%), intermediate uveitis (21%), posterior uveitis (12%), and panuveitis (44%). Logarithmic transformation of SD-OCT data provided a more normal distribution than CST (Figure 1). Skewness and kurtosis of CST data were 1.04 and 0.37, respectively. Skewness and kurtosis of logSD-OCT data were 0.40 and -0.48, respectively. There was a significant correlation between logSD-OCT and logMAR visual acuity. For each 0.1 unit increase in the logSD-OCT the logMAR visual acuities increased (worsened) by 0.082 units (95%CI: 0.57-1.07, p<0.001).
RESULTS CONCLUSION
SD-OCT and Infrared Imaging of Leukemic Infiltration of the Choroid

Ravi Radhakrishnan, MD (Jacksonville, FL), Jayson Edwards, MD, Vijay Khetpal, MD, K.V. Chalam, MD, PhD, MBA, FRCS(C)
PURPOSE
To identify unique characteristics of infrared, autofluorescence, and spectral-domain optical coherence tomography (SD-OCT) imaging in a patient with leukemic infiltration of the choroid.
METHOD
Logarithmic transformation of SD-OCT measurements provided a more normal distribution and positively correlated with logMAR visual acuity. This transformation of SD-OCT retinal thickness measurements may be valuable for the assessment of clinically meaningful SD-OCT changes in uveitis research.
A patient with a known diagnosis of metastatic leukemia underwent complete ophthalmological examination, infrared (IR) fundus photography, fundus autofluorescence (FAF) imaging, fluorescein angiography and SD-OCT (Spectralis, Heidelberg Engineering).
RESULTS
A 42 y.o. African American woman with a history of diabetes mellitus, hypertension, t-cell leukemia complained of blurry vision for one month and was referred to the department of ophthalmology. FAF showed a patchy areas of decreased FAF
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signal. IR showed wrinkling of the RPE and areas of decreased signal near the optic nerve. Areas of decreased signal corresponded to areas of subretinal fluid. Fluorescein angiography showed a multifocal hyperfluorescence in early phase with pooling of fluoresecein dye in late phases. SD-OCT revealed multiple areas of subretinal fluid overlying thickened choroid. The thickened infiltrated choroid may serve as the pathogenesis for the areas of subsensory detachment secondary to poorly functioning RPE pumps. Thickened choroid in the area of leukemic infiltration alters permeability that results in patchy sensory retinal detachments. In addition, RPE wrinkling noted on infrared photography served as an anatomical marker for dysfunctional RPE.
CONCLUSION
452
Choroidal Thickness in Patients with Diabetic Retinopathy Analyzed by SD-OCT

Caio V. Regatieri, MD, PhD (Boston, MA), Lauren Branchini, BA, Jay S. Duker, MD*, Jill Carmodu, MD
PURPOSE
Clinical and experimental studies suggested that choroidal vasculopathy in diabetes may play a role in the pathogenesis of diabetic retinopathy. Therefore this study was design to examine choroidal thickness in patients with diabetes using spectral-domain optical coherence tomography (SD-OCT).
METHOD
Autofluorescence showing multiple patchy areas of decreased signal.
Forty-nine patients (49 eyes) with diabetes and 24 age-matched normal subjects underwent high-definition raster scanning using SD-OCT with frame enhancement software. Patients with diabetes were classified into three groups: 11 patients with mild or moderate non-proliferative diabetic retinopathy and no macular edema (NPDR), 18 patients with NPDR and diabetic macular edema (DME) and 20 patients with treated proliferative diabetic retinopathy and no DME (PDR). Choroidal thickness was measured from the posterior edge of the retinal pigment epithelium to the choroid/sclera junction at 500m intervals up to 2500m temporal and nasal to the fovea.
RESULTS
SD-OCT showing evidence of a thickened choroid with a subsensory retinal detachment. Infrared imaging shows wrinkling of the retinal pigment epithlium.
Reliable measurements of choroidal thickness were obtainable in 75.3% of eyes examined. Mean choroidal thickness showed a pattern of thinnest choroid nasally, thickening in the subfoveal region, and then thinning again temporally. There was a statistically significant difference between choroidal thickness of normal subjects and patients in the DME group (P< 0.001) and PDR group (P< 0.001). Mean subfoveal choroidal thickness was thinner in patients with diabetic macular edema (63.3 m, 27.2% - P < 0.05) or PDR (69.6 m, 30.0% - P < 0.01), compared with normal subjects. No correlation between central foveal thickness of the retina and central foveal choroidal thickness was observed in DME group. Choroidal thickness can be measured using SDOCT high-definition raster scans in the majority of diabetic eyes. Choroidal thickness is altered in diabetes and may be related to the degree of severity of retinopathy. The presence of macular edema is associated with a significant decrease in the choroidal thickness.
CONCLUSION
RESULTS
Graph of mean choroidal thickness in normal subjects and diabetic patients. Mean choroidal thickness at each of the 11 locations measured at 500 m (0.5 mm) intervals temporal (T) and nasal (N). NPDR: non-proliferative diabetic retinopathy; DME: diabetic macular edema; PDR: proliferative diabetic retinopathy. P-value represents the result of statistical analyses (ANOVA).
Ten eyes (10 patients) and 20 eyes (19 patients) were included in the acute and chronic groups, respectively. There was no difference in age between the acute and chronic groups (65.3 6.1 years acute; 67.7 5.9 years chronic). Two patients in the acute group and 1 patient of the chronic group were using systemic steroids. The average time to resolution of the SRD was higher in the chronic group (18.85 weeks) when compared to the acute group (15.2 weeks). In the chronic group, SD-OCT images demonstrated a higher percentage of eyes with PED (60%, chronic vs. 40% acute) and RPE thickening (45%chronic vs. 20%- acute). Retinal cystic changes were observed in two patients in the chronic group. Choroidal thickness was significantly in eyes with active and inactive CSC when compared to normal subjects (P<0.001). Further, there was a difference between subfoveal choroidal thickness in subjects that were active vs. inactive. (328 52.9 m, active vs. 311.1 59.18, inactive; P=0.030).
CONCLUSION
453
SD-OCT Characteristics of Central Serous Chorioretinopathy in Older Adults

Caio V. Regatieri, MD, PhD (Boston, MA), Lauren Ann Branchini, BA, Jay S. Duker, MD*
CSC in older adults should be remembered as part of the differential diagnosis of neovascular AMD. The choroid has been shown to be significantly thicker in CSC which may help to differentiate CSC from neovascular AMD. SD-OCT findings are the same in this population of older subjects with CSC as observed in young patients though PED and RPE thickening are more common in chronic CSC.
454
Comparison of Choroidal Visibility and Thickness Using Two SD-OCT Instruments with Different Wavelength Light Sources
Humberto Ruiz-Garcia, MD (Los Angeles, CA), Florian M. Heussen, Ramsudha Narala, MD, Emma McDonnell, MD, Srinivas R. Sadda, MD*
PURPOSE The purpose of this study was to describe clinical findings including spectral domain optical coherence tomographic (SD-OCT) imaging cheracteristics of both the retina and choroid in patients older than 60 years presenting with central serous chorioretinopathy (CSC). METHOD Thirty eyes (29 patients) with findings consistent with central serous chorioretinopathy were divided into 2 groups according to the duration of symptons: acute (<4months) or chronic (>4months). SD-OCT images were captured during active (with serous retinal detachment-SRD) and inactive (without SRD) phase. Extensive chart review was performed. Retinal characteristics, such as retinal pigmented epithelial detachment (PED) and retinal pigmented epithelium (RPE) thickening were observed. The choroidal thickness was measured in 10 patients at 500-m intervals up to 2500 m temporal and nasal to the fovea. Additionally, these measurements were compared with those of 24 age matched normal subjects.
PURPOSE
To evaluate the effect of spectral domain optical coherence tomography (SD-OCT) light source wavelength (840 nm vs. 1050 nm) and B-scan averaging on the visibility and thickness measurements of the choroid.
METHOD
Retrospective study of 50 eyes of 31 patients that underwent volume scanning without averaging and highdefinition raster scanning with frame 4x averaging using the Cirrus HD-OCT (Zeiss-Meditec, 840nm) and a prototype OCT from Zeiss operating at 1050nm. Choroidal thickness was measured at the foveal center. Cases with partial choroidal visibility were noted and thickness measurements to the extent of the visible choroid were made. All eyes were measured by two independent observers. Choroidal thickness and the percent of cases with full choroidal visibility were compared between devices and scanning protocols. Choroidal thickness measurements were also correlated with age and visual acuity.
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RESULTS The mean age of the patients was 65 years (range=21 to 100 years), and 48% (n=15) were women. The choroid was fully visible in 60% (25/42) of eyes by non-averaged 1050nm SD-OCT imaging, in 40% (17/42) by non-averaged 840nm SD-OCT, in 82% (36/44) by averaged 1050nm SD-OCT, and in 61% (27/44) by averaged 840nm SD-OCT. Mean choroidal thickness did not differ significantly between eyes with fully or partially visible choroids. Univariate regression identified a linear relationship between age and choroidal thickness when measured using the averaged 1050nm scans (r=-2.48, p=0.005), but no relationship was found between choroidal thickness and visual acuity.
455
Retinal Nerve Fiber Layer Thickness Analysis with SD-OCT for Assessment of Glaucoma Cormorbid to Retinal Pathology
Raymond N. Sjaarda, MD (Towson, MD)
PURPOSE
The use of a longer wavelength light source (1050nm) than the conventional wavelength (840nm) used in commercially available SD-OCT instruments allows for deeper penetration and improved visualization of the choroid. The enhanced visualization effect appears to be additive to other enhancement strategies such as b-scan averaging.
CONCLUSION
To evaluate the benefit of retinal nerve fiber layer (RNFL) thickness analysis with spectral domain optical coherence tomography (SD-OCT) in assessing glaucoma as a condition comorbid to primary retinal pathology.
METHOD
Retrospective review of a consecutive series of patients undergoing analysis of the RNFL thickness by SD-OCT as part of a comprehensive examination assessing for comorbid conditions during evaluation of the primary suspected retinal pathology in a private referral retina practice.
RESULTS
Foveal scan of an eye with geographic atrophy shows fully visible choroid when imaged with the 1050nm (A) and the 840nm (B) light source instruments. This is due to increased penetration of light with pigment atrophy. Notice however, that with the 1050nm instrument vessels penetrating the sclera can be visualized as hyporeflective structures.
Of the 120 patients evaluated for comorbid glaucoma 25 (21%) were being followed for ocular hypertension/glaucoma suspect/glaucoma. Of these 25 patients, 22 had RNFL thickness below normative values, 2 were borderline, and 1 had normal thickness. Of the 95 patients without prior ocular hypertension/ glaucoma, 21 wee found to have normal RNFL thickness, 60 had thickness below normal values, and 14 were borderline. Of the 60 patients were abnormally low values 45 were referred to a comprehensive ophthalmologist or glaucoma specialist for further evaluation and management. Subsequent therapeutic interventions included new medications in 6 patients and iridotomy in 4 patients. Evaluation of the RNFL by SD-OCT is useful in evaluating eyes with clinical findings suspicious for comorbid glaucoma in patients referred with retinal pathology.
CONCLUSION
Foveal scan of an eye with fibrovascular PED shows better penetration and detail of the choroidal vasculature with the 1050nm (A) instrument than with the 840nm conventional instrument (B).
456
SD-OCT Features of Intra Retinal Silicone Oil in Eyes Following Silicone Oil Removal
Malhar Soni DO, MS, DNB, FRCS (London, England)
PURPOSE
To describe the Spectral-domain optical coherence tomography features of intraretinal silicone oil following silicone oil removal, in patients with a history of silicone oil tamponade for retinal detachment.
METHOD We retrospectively reviewed consecutive series of ten eyes in ten patients who underwent retinal detachment repair with silicone oil tamponade at our department. All eyes underwent complete PFCL removal at the time of silicone oil injection. All patients were examined with spectral-domain optical coherence tomography at 3 and 6 months after silicone oil removal. C-scans were correlated with their corresponding B-scans, infra-red imaging and fundus photograph. The presence of intra retinal silicone oil was compared with visual acuity, duration of silicone oil tamponade and number of previous vitreo-retinal procedures before silicone oil removal. RESULTS Five out of ten eyes had intra retinal optically empty vacuoles at the posterior pole on SD-OCT assessment which were also seen on infrared imaging. The appearance of well defined, isolated, cystic spaces without surrounding tissue change was typical of intraretinal silicone oil. The characteristic cystic spaces showed no significant change over an 24-month period in one eye. The mean duration of tamponade was 5.9 months and the timing of SD-OCT ranged from 3 to 24 months post silicone oil removal. The median number of vitreo-retinal procedures prior to silicone oil removal was 3 in patients with intraretinal oil. Visual outcome was <20/80 in all cases.
457
Comparing Adaptive Optics Imaging Modalities in Genetic Ocular Diseases Is Information Lost with Better Resolution?
Kimberly G. Stepien, MD (Milwaukee, MI), Brett Schroeder, MD, Jungtae Rha, Adam Dubis, Robert Cooper, MD, Alfredo Dubra, MD, Joseph Carroll*
PURPOSE
Both flood illuminated adaptive optics (AO-Flood) and adaptive optics scanning laser ophthalmoscopes(AOSLO) allow for high resolution in vivo visualization of individual retina cells. However, analyses of images from the same subject obtained by AO-flood and AOSLO have not been reported. Here we compare AO-Flood and AOSLO images in patients with no ocular pathology and with genetic ocular diseases.
METHOD
Spectral-domain optical coherence tomography should be routinely considered in eyes with silicone oil tamponade to detect intraretinal migration of silicone oil. This may help in making a case for early removal of silicone oil to prevent unexplained vision loss in such eyes. Prospective studies are needed to confirm whether this phenomenon has a demonstrable effect on macular function.
CONCLUSION
AO-Flood and AOSLO images were obtained in 5 subjects (2 normal, 1 albinism, 1 choroideremia, and 1 achromatopsia). Subjects eyes were dilated using a combination of phenylephrine hydrochloride (2.5%) and tropicamide (1%), and head stabilization was achieved using a dental impression on a bit bar for each system. Individual frames from each AO system were registered and then averaged using a custom MatLab-based algorithm for subsequent analysis. Individual cones in each image were identified using a semi-automated cone identification program and cone density measurements were obtained in all images. Resulting images were also inspected for further qualitative differences.
B-scan SD-OCT image showing well-defined optically empty vacuoles without surrounding tissue changes.
Cone photoreceptor density values between the AOflood and AOSLO imaging systems were in good agreement with average difference of approximately 5% (2,200 cones/mm2) with the exception of the patient with achromatopsia where AOSLO images were severely distorted due to nystagmus. Likely due to the fact that AOSLO images are acquired confocally which improves axial resolution, the AOSLO consistently had higher cone density measurements. The AOSLO also allowed for consistent visualization of rod photoreceptors, especially farther from the fovea. In AO-Flood images of the patients with genetic ocular diseases, heterogeneous photoreceptor structure changes and patterns were observed. These were not seen on AOSLO, likely are related to the process of retina degeneration, and are of unknown significance. AO-flood images were not distorted or blurred by nystagmus, even in the achromatopsia patient, due to the short exposure used to capture the images.
RESULTS CONCLUSION
En-face imaging of optically empty vacuoles at various levels of retina.
Adaptive optics retina imaging can play a role in further understanding of photoreceptor pathology in genetic ocular diseases. Elucidating the different information provided by various AO imaging modalities is necessary for better understanding of their clinical utility for assessment of genetic ocular diseases.
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PRACTICE MANAGEMENT AND SOCIOECONOMICS
Practice Management and. .Socioeconomics. . . . . ....... ....................................

501
Pediatric. .Retina. .. .ROP. . . .................... .............. . ........

POSTERS 601-612
601
Integration of a Telemedicine Diabetic Retinopathy Assessment System with an Electronic Personal Health Record
Ingrid Zimmer-Galler, MD (Baltimore, MD), Jay Braman, MD, Gary Gregory, MD
Four Port Pars Plana Vitrectomy for Stage 4B and 5 Retinopathy of Prematurity (ROP)
Pramod S. Bhende MBBS (Chennai, India), Lingam Gopal, MBBS, Tarun Sharma, MBBS
PURPOSE PURPOSE Microsoft HealthVault is on an-line platform to store and maintain personal electronic health and fitness information. The purpose of this project was to develop an interface to allow patients with diabetes to access, review, share, store and manage their relevant retinal imaging data captured via a telemedicine diabetic retinopathy assessment system in the primary care setting. METHOD An interface was produced with the Microsoft HealthVault Software Development Kit to directly upload the retinal image files, composite images and assessment and referral recommendation reports from an established telemedicine diabetic retinopathy screening program into the patients HealthVault file repository. Additionally, an entry into the HealthVault supported subset of the Continuity of Care Record has been written to allow identification of retinal abnormalities that have been detected during the assessment of the retinal images. Submission of the diabetic retinopathy assessment information to a personal HealthVault account is at the discretion of the patient. RESULTS This project demonstrates that remotely obtained retinal images and reports from a telemedicine system to screen for diabetic retinopathy can be stored and shared in individual accounts on the Microsoft HealthVault platform. In turn, this platform allows patients to use the retinal image information to complement clinical and laboratory records and be utilized as a resource for patient care, comparison at future follow-up evaluations, access by multiple physician specialties and patient education. The HealthVault platform becomes an especially powerful diabetes management tool when retinal assessment information is linked with other devices allowing glucose monitoring and tracking weight and physical activity.
To evaluate feasibility of 4 port bimanual parsplana vitrectomy (PPV) using chandelier illumination in eyes with stage 4B /5 ROP having very severe, florid and extensive fibrovascular proliferation.
METHOD
A retrospective analysis of records of eyes undergoing four port PPV for stage 4B and 5 ROP. Seven eyes of five infants underwent four port PPV. The fourth port was for 25G Chandelier light, placed at 12o clock or in inferotemporal quadrant.
RESULTS
Six eyes had stage 4B ROP while one had stage 5 ROP. All the eyes had prior laser ablation. 3 eyes had intravitreal anti VEGF injections 5-7 days before surgery. In three eyes, 23G instruments were used while in the rest, 20G instruments were used besides the Chandelier illuminator. Surgery could be completed in all the eyes without any intra or post operative sclerotomy related complications.
CONCLUSION
Four port PPV is a feasible option in selected eyes with ROP needing surgery. 25G Chandelier light through 4th port gives excellent illumination to facilitate true bimanual membrane dissection in these technically challenging eyes.
602
The ROP Treatment Dilemma in the Time of Bevacizumab

Audina M. Berrocal, MD (Miami, FL), Darius Moshfeghi, MD*, Elias Mavrofrides, MD, Ditte Hess
PURPOSE
This demonstration is the first known integration of a telemedicine diabetic retinopathy program within a globally available, open access electronic personal health record.
CONCLUSION
How should we follow babies in clinic who were treated with bevacizumab and are not completely vascularized with a persistent ridge?
METHOD Observational study of three babies treated in the community with bevacizumab that are followed in an outpatient clinic setting with serial photographs and/or fluorescein angiograms. RESULTS Serial photographs in the outpatient clinic show the persistence and reactivation of the ridge in Zone 2 ROP. Laser supplementation may be the best option in these babies that are not completely vascularized.
CONCLUSION
Our results suggest no significant difference between bevacizumab and ranibizumab in treatment-requiring ROP. Antiangiogenic therapy is a promising therapy for patients with stage III ROP. Further studies are needed to establish the ideal time of treatment, long term safety and efficacy issues, and whether it should be used as standalone therapy, or as adjuvant to laser and/or cryotherapy.
Bevacizumab has a role in the treatment of Zone 1/Aggressive ROP as shown by the BEAT-ROP study, but laser supplementation of those children who dont vascularize completely might be a better option.
CONCLUSION
604
Adverse Events After Off-label Intravitreal Bevacizumab in the Treatment of Retinopathy of Prematurity
Jose Guerrero-Naranjo, MD (Mexico City, Mexico), Olivia Baldivieso-Hurtado, MD, Gerardo GarciaAguirre, MD, Virgilio Morales-Canton, MD, Hugo Quiroz-Mercado, MD, Robison V.P. Chan, MD, Maria A. Martinez-Castellanos, MD
603
Comparison of Short Term Outcomes after Intravitreal Bevacizumab vs. Ranibizumab in the Treatment of Stage III Retinopathy of Prematurity
Gerardo Garcia-Aguirre, MD (Mexico City, Mexico), Hugo Quiroz-Mercado, MD, Jans Fromow-Guerra, MD, PhD, Jose Guerrero-Naranjo, MD, Virgilio MoralesCanton, MD, Jose Dalma-Weiszhausz, MD, Maria A. Martinez-Castellanos, MD
PURPOSE
To describe the ocular and systemic adverse events of intravitreal bevacizumab (IB) used off-label in the treatment of Retinopathy of Prematurity (ROP).
METHOD
PURPOSE To compare ophthalmologic and neurodevelopmental findings after intravitreal injection of bevacizumab vs. ranibizumab as monotherapy in treatment-requiring retinopathy of prematurity (ROP) in a three-year follow-up. METHOD Retrospective analysis of patients who received intravitreal injections of bevacizumab or ranibizumab as monotherapy for stage III ROP. Neovascular regression, neurodevelopmental outcomes, anatomical and functional findings were recorded. RESULTS Six patients (twelve eyes) were included. Three patients (six eyes) received off-label bevacizumab (0.03ml), the same number of patients and eyes received off-label ranibizumab (0.03ml). At a 3 years of follow-up, regression of neovascularization and normal vascular growth was found in all patients, no systemic complications were recorded and neurodevelopmental findings were normal. No ocular adverse events were recorded in any of the two groups. Best corrected visual accuity with adler charts were in average logMar 0.2 (range 0.3-0.0)
Retrospective analysis of the records of 195 patients with ROP (stage 3, threshold, pre-threshold, 4a and 4b) who underwent IB (0.05cc or 0.03cc) from September 2005 to October 2010. Baseline characteristics of each infant and adverse events during and/or after treatment were collected. Follow-up of the injection was at least of 3 months.
RESULTS
We had a total of 52 local adverse events (26.6%) including worsening of prior retinal detachment (2%) in stage 4 retinopathy, peripheral fibrous avascular membrane (1%), self-resolving vitreous hemorrhage (1.5%), avascular retina in the extreme periphery (4.1%) and subconjunctival hemorrhage (6.1%). Three patients (1.5%) died. One by sepsis by P. aeruginosa 2 months after injection, 1 by neuro-infection after a ventriculo-peritoneal shunt 6 months after injection, 1 by multiorganic disfunction secondary to blood transfusion 1 week after injection.
CONCLUSION
The use of IB appears to be safe for type 1 prethreshold and threshold ROP. With regard to systemic adverse events, we believe that systemic abnormalities in children treated with intravitreal bevacizumab for ROP may be a sequelae of prematurity itself and not related to the medication.
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605
Foveal Development in ROP Patients Treated with Bevacizumab

Geeta A. Lalwani, MD* (Miami, FL), Elias Mavrofrides, MD, Ditte Hess, Audina Berrocal, MD
9-10), and mean anatomic success was determined for each group. All eyes receiving bevacizumab had a reduction of VAS by a mean of 4.5 points (2-8). A linear relationship was discovered between VAS and retinal reattachment rate for eyes undergoing vitrectomy for retinal detachment in vascularly active ROP, and the use of bevacizumab correlated with lower VAS and better surgical success.
CONCLUSION
PURPOSE To determine whether the foveal avascular zone is altered by use of bevacizumab for ROP. METHOD This study includes 3 patients with threshold ROP whom underwent fluorescein angiography and/or OCT for persistance of disease following treatment with bevacizumab. RESULTS Fluorescein angiography in all 3 treated patients revealed a poorly defined foveal avascular zone with late leakage. CONCLUSION
VAS may be a useful quantitative measure of ROP disease vascular activity that can estimate anatomic prognosis with vitreous surgery in the setting of retinal detachment and help guide use of anti-VEGF therapy.
607
Retinal Vascular Changes Following Intravitreal Anti-VEGF Therapy for Treatment Requiring Retinopathy of Prematurity
Maria A. Martinez-Castellanos, MD (Toluca, Mexico), Mario J. Saravia, MD, Robison V.P. Chan, MD, Virgilio Morales-Canton, MD, Gerardo Garcia-Aguirre, MD, Jose Guerrero-Naranjo, MD, Gabriela Lopezcarasa Hernandez, MD, Hugo Quiroz-Mercado, MD
The use of bevacizumab for threshold ROP could alter foveal anatomy. Further clinical studies are warranted.
606
Vascular Activity Score (VAS) as a Marker of Disease Burden and Prognosis in Neonatal ROP
Adrian M. Lavina, MD (Palm Beach Garden, FL), Khaled A. Tawansy, MD
PURPOSE
To describe the retinal vascular morphology in eyes treated with intravitreal bevacizumab (IB) for treatment requiring retinopathy of prematurity (ROP).
METHOD
Prospective, nonrandomized case series. We included 10 patients (20 eyes) diagnosed with stage 3, threshold or prethreshold ROP. Fundus photographs and Fluorangiography (FA) were obtained before and after IB treatment using a widefield digital pediatric imaging system. Before treatment, FA showed vascular abnormalities, including capillary non-perfusion throughout the vascularized retina, shunting in the vascularized retina, a demarcation line, and limited vessel development, new vessels leakage, and avascular periphery. After the treatment with the suppression of VEGF, FA showed obliteration of abnormal new vessels, followed by involution of the neovascularization, flattening of the demarcation line and subsequent growth of vessels to the capillary-free zones. During the following weeks large areas devoid of microvessels were seen, 6 months post intravitreal injection of bevacizumab, vascular remodeling was seen with uneven spacing of the retinal capillaries and vascular loops in the areas that were previously devoid of vessels. In some patients, the retinal vessels in the far periphery never developed. Subsequently, these patients did not develop pathological neovascularization.
RESULTS
To describe experience at one clinical center with multiple surgeons of a quantitative grading system that correlates to disease burden, need for intervention with laser ablation or anti-VEGF therapy, and prognosis with surgery.
PURPOSE METHOD A quantitative grading scale was devised based on retrospective observations from 100 consecutive eyes with ROP that underwent wide-field photographic imaging and fluorescein angiography. Five vascular activity parameters were given a score from 0 to 2: Activity of tunica vasculosa lentis and hyaloidal artery, extent of plus, width-height of ridge, presence of pre-retinal or vitreous hemorrhage, and extent of intra/extra-retinal neovascularization. The resulting cumulative score was used as a prognosis factor of anatomic success in 310 eyes that underwent vitreous surgery for ROP retinal detachment and in 20 eyes that had the score modified by intra-vitreal bevacizumab therapy before surgery. RESULTS A VAS of 0-10 was given for each eye that underwent vitreous surgery based on independent study of the wide-field photographs and fluorescein angiograms. In eyes that underwent bevazicumab therapy, VAS was determined on the day of injection and at vitreous surgery 5 to 10 days later. Eyes were then divided into 5 groups based on score (0-2, 3-4, 5-6, 7-8,
CONCLUSION
Our study shows that even when the vascular pattern is abnormal after IB therapy, the creation of small vessels, the establishment of directional flow, the association with mural cells and the adjustment of vascular density to meet the requirements of the retina have been accomplished. Longer follow-up is needed of prospective multicenter studies to determine the safety profile of IB for ROP.
608
609
OCT Imaging Findings after Intravitreal Bevacizumab for Treatment-requiring Retinopathy of Prematurity, Case Series
Virgilio Morales-Canton, MD (Mexico City, Mexico), Maria A. Martinez-Castellanos, MD, Jose GuerreroNaranjo, MD, Jans Fromow-Guerra, MD, PhD, Veronica Giordano, MD, Gerardo Garcia-Aguirre, MD
Surgical Case Series: Perfluorocarbon Liquid Infusion-assisted External Drainage of Subretinal Exudate in Advanced Coats Disease
Franco M. Recchia, MD (Nashville, TN), Maziar Lalezary, MD
PURPOSE To describe the morphological features of the macula in patients treated with intravitreal bevacizumab (IB) for retinopathy of prematurity (ROP) assessed by optical coherence tomography (OCT). METHOD Six patients of different ages all treated for ROP stage III with IB underwent dilated fundus image and OCT imaging evaluation with a handheld device (I-vue, Optovue, Inc.).
PURPOSE
Coats disease, especially in younger children, has a poor natural history. Therapeutic goals are optimization of vision, comfort and cosmesis through reduction of exudation and avoidance of neovascular glaucoma and require serial exams and treatments under anesthesia. We describe a surgical treatment of total exudative detachment in Coats disease and present outcomes in a series of patients. Retrospective review of consecutive patients with advanced Coats disease treated with this surgical technique. In brief, an encircling element was placed followed by pars plana vitrectomy, with or without lensectomy, with simultaneous perfluorocarbon liquid infusion and trans-scleral drainage of subretinal fluid and lipid exudates. Primary outcomes were globe salvage and patient comfort at one year postoperatively. Secondary outcomes were: intraoperative complications; retinal reattachment at 3 and 12 months; additional interventions.
Six patients were included. One at a 4 year follow-up after receiving bevacizumab as treatment for ROP stage III in both eyes, macular morphology was found with no structural changes, the central thickness was of 230um. A 2nd patient at 1 year follow-up, presented with no changes in macular morphology and central thickness of 140um. The third case was evaluated at 2 month follow-up after receiving IB, with no macular abnormalities. The last 3 babies were screened after finding macular leakage in the fluorescein angiogram 2 weeks after intravitreal treatment, with no abnormalities in the macular architecture.
RESULTS CONCLUSION The use of IB shows no structural damage to the retinal layers as shown in OCT at different follow-up visits in these six cases. Macular leakage seems to be secondary to inmaturity of superficial plexus vessels rather than vascular abnormalities. The OCT in this short study shows us previously unknown valuable information in the follow-up of patients with new modalities of treatment for ROP.
METHOD
RESULTS
Four boys (ages 2 mos-12 yrs) with unilateral advanced Coats disease (3 with Stage 3B and one with Stage 4) were included. All eyes underwent the described technique without intraoperative complications. Post-operative follow-up ranged from 12-34 months (mean, 19 months). All patients attained globe salvage and were comfortable at one year postoperatively. At 3 months, all eyes achieved successful retinal reattachment. At 12 months, three eyes maintained successful reattachment while one patient developed a localized peripheral detachment following head trauma. Three of four eyes have undergone successful removal of silicone oil. While no eyes displayed disease progression following surgery, one child required laser therapy for residual disease and another had mild subretinal fluid accumulation following silicone oil removal. In the most advanced case (5 year-old boy with glaucoma due to Stage 4 disease), no further treatment was necessary for control of intraocular pressure. The surgical technique described (combined scleral buckling, pars plana vitrectomy, and perfluorocarbon liquid-assisted external drainage of sub-retinal fluid) was effective in achieving therapeutic goals in this small series of patients with advanced Coatsdisease. This alternative approach may reduce the need for serial examinations, treatments, and exposure to anesthesia.
Fluorescein angiography post intravitreal bevacizumab that shows parietal leakage.
CONCLUSION
OCT image of same case that demonstrate a normal macular area.
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PEDIATRIC RETINA ROP
610
611
Comparison of Bevacizumab and Laser Therapy for the Treatment of Retinopathy of Prematurity
Dustin Pomerleau, MD (Birmingham, AL), Richard Feist, MD, Tracy L. Emond, Lindsey Wallace, MD, John O. Mason, MD, Martin L. Thomley, MD, Michael A. Albert, MD, Thomas A. Finley, MD
Malaria Retinopathy in a 7 year Old Child from the Ecuadorian Tropics

Armando G. Sandoval, MD (Quito, Ecuador), Geoconda Leon, MD, Sandra X. Larco, Andrea E. Ayala, MD, Juan J. Chiriboga, MD
PURPOSE Retinal laser is the current gold-standard for treatment of retinopathy of prematurity (ROP). Evidence exists that intravitreal bevacizumab (IVB) may provide equivalent results to laser therapy. Our study seeks to compare outcomes of the two modalities within a single practice. METHOD Retrospective review of all babies referred to a multiphysician retina practice for ROP from 2000 to 2008. Eyes were classified into 3 treatment groups: observation, IVB, and laser. Groups were compared with respect to baseline characteristics and outcome at 8 weeks follow-up (no ROP, relative regression, stable, relative progression (including macular dragging & traction without retinal detachment), and progression to stage 4A or greater (including surgical & endstage ROP). Relative regression and progression were defined as: a change in ROP stage, resolution or new onset of plus disease, or specific documentation by examiner that the number of clock-hours of ROP had changed since baseline. RESULTS Two-hundred-fifteen eyes of 107 children were screened for inclusion and 172 eyes of 89 children were included. Seventy-three eyes were observed, 32 eyes received IVB, and 67 eyes were treated with laser. There were no statistically significant differences in gender distribution, gestational age at birth, or birth weight between the groups. At the time of treatment there was no statistically significant difference in the mean stage/zone of ROP or the proportion of patients with plus disease when comparing the IVB and laser groups. At 8 wk post-treatment 10 eyes (31.3%) receiving IVB had relative regression of ROP and 22 eyes (68.8%) had no ROP. Fifteen eyes (22.4%) receiving laser had relative regression of ROP and 26 eyes (38.8%) had no ROP. Seventeen eyes (25.4%) receiving laser had relative progression of ROP. None of the eyes receiving IVB progressed, p=<0.001 for all comparisons. There was no statistically significant difference in mortality between the treatment groups, p=0.22. CONCLUSION Intravitreal bevacizumab causes regression or complete resolution of ROP in the majority of patients, and may reduce progression of ROP compared to laser therapy.
PURPOSE
1) To present a clinical case of presumed Malaria Retinopathy in a child from the Ecuadorian Tropics, who has pigmented maculopathy and disc pallor in one eye with poor vision , and reduced vision in the fellow eye. 2) To review the main features of Malaria Retinopathy.
METHOD
Review of clinical chart of a 7 year old boy from La Concordia , a city in the tropical region of Santo DomingoEcuador, who had malaria since he was born , needing intensive treatment the first month in the hospital and then ambulatorily for 2 years. His mother, while pregnant also had malaria and received treatment from the first to the sixth month. Ophthalmological findings: BCVA OD: LogMAR 0,3 (20/40), OS: LogMAR > 1,3 (CF 30cm). OS with sensorial exotropia of -45 . Fundus: OD normal , OS: disc pallor and pigmented maculopathy in a horizontal spindle fashion.
RESULTS
Retrospective revision of the clinical chart revealed plasmodium falciparum malaria in the boy and his mother, that was treated according to the WHO recommendations. The strabismus was present since the 6th month of life and was surgically corrected in January 2011. The reduced vision in OD, -2,00x10 = 20/40 (LogMAR 0,3) can be attributed to amblyopia or an organic cause (cerebral malaria or malaria retinopathy?). 1) OS fundus suggests a sequel of malaria retinopathy, and the normal appearance of OD doesnt rule out malaria retinopathy that solved with time. 2) Bulls eye maculopathy is not associated with prophylactic Rx of malaria, like in rheumatological diseases, because the dosages are relatively small and drugs are used in a short time. 3) MR occurs in around 60% of children with cerebral malaria.
CONCLUSION
METHOD
OS picture showing severe disc pallor and pigmented maculopathy in a horizontal spindel fashion.
Mice were exposed to hyperoxia as per the standard oxygen induced retinopathy model for 120 hours from postnatal day 7 to post-natal day 12. The mice were sacrificed 24 hours after they had returned to normoxia, the eyes were enucleated and the retinas were snap frozen. Subsequently the mRNA was extracted and microarray analysis was performed (Mouse 430 array, Affymetrix). Microarray studies were performed on 3 mice, each from a separate litter, from both BALB/c and C57BL/6 strains. Normoxic controls were also studied. Limma was used for array normalization.
RESULTS
Using an F2 intercross we have previously found quantitative trait loci (QTL) that are associated with retinal avascular area at post-natal day 16. The 1.8-LOD support intervals for these loci are: on chromosome 7, 88.3-146.2 Mbp and, on chromosome 9, 18.6-95.9 Mbp. Transcripts were identified which (i) demonstrated 2-fold greater expression in either C57BL/6 or BALB/c retinas compared to the other strain after exposure to the oxygen induced retinopathy model, and (ii) had an adjusted P-value of < 0.001. Three genes that map within the chromosome 7 QTL were differentially expressed between C57BL/6 and BALB/c according to these criteria. These were: Tyr, Hdfgrp3 and Nmb. Sixteen genes that map within the chromosome 9 QTL were differentially expressed.
OD picture: normal appearance.
612
Correlation of Microarray Gene Expression Results with Quantitative Trait Loci for Retinal Avascular Area in the Oxygen Induced Retinopathy Model
Robert Symons MBBS, PhD (Prairie Village, KS), Bliss OBryhim, MD
CONCLUSION
The genes coding for the transcripts identified here are candidate quantitative trait genes for the QTL on chromosome 7 and 9.
PURPOSE To use microarrays to identify candidate genes for quantitative trait loci that determine the difference in retinal avascular area at post-natal day 16 between BALB/c and C57BL/6 mice exposed to the oxygen induced retinopathy model.
185
OCULAR ONCOLOGy
Ocular. .Oncology. . . . .............. .....................

POSTERS 701-705
Comparative Expected Survival of Chromosomal and Transcriptional Subgroups of Posterior Uveal Melanoma Patients
701
Expected Long-term Survival Prognosis of Posterior Uveal Melanoma Patients Whose Tumor Cells Exhibit Disomy 3 and/or Class 1 Gene Expression Profile
Zelia M. Correa, MD, PhD (Cincinnati, OH), James J. Augsburger, MD
702
Intravitreal Bevacizumab for Choroidal Metastases Secondary to Adenocarcinoma of the Lung

Manjot K. Gill, MD (Chicago, IL), Lee Jampol, MD, Ankur Shah, MD
PURPOSE To estimate the projected long term survival of patients with a posterior uveal melanoma whose tumor cells exhibit disomy 3 and/or a class 1 gene expression profile (GEP) using a hypothetical survival modeling assuming two distinct survival distributions and outcomes based on data obtained from published AFIP data. METHOD Hypothetical survival modeling of patients with primary uveal melanoma assuming two distinct survival distributions. Modeling attempted to predict the expected long-term survival of disomy 3 and/or class 1 GEP patients by making the combined subgroups survival distribution mirror that of patients without known chromosomal or GEP status. Shortterm survival curves for patients evaluated by chromosomal testing and/or GEP were obtained from recently published articles, and long-term survival curves for patients without known chromosomal or GEP status were obtained from published AFIP data. Authors will discuss potential explanations for early and late appearing metastasis in these patients. RESULTS Survival modeling predicted that approximately 15 to 25% of patients with primary choroidal or ciliary body melanoma whose tumor cells have been categorized by chromosomal testing or gene expression profiling as disomy 3 or class 1 cases will ultimately develop uveal melanoma metastasis; however, most of these patients will not exhibit this metastasis until more than 5 years after treatment of the primary intraocular tumor. CONCLUSION Current short-term predictions of survival prognosis of patients with uveal melanomas associated with disomy 3 and/or class 1 GEP are likely to be substantial underestimates of these patients long-term survival prognosis. Meanwhile, patients with such tumors should be more cautiously advised about their risk of developing future metastasis. PURPOSE
To present a case of choroidal metastases from lung adenocarcinoma treated with intravitreal bevacizumab prior to external beam radiotherapy and systemic chemotherapy.
METHOD
Retrospective interventional case report of a 72-yearold male who presented with decreased visual acuity and a relative scotoma in his left eye. No significant past ocular or medical history was present.
RESULTS Clinical exam revealed a pale elevated subretinal lesion in the macula of the left eye with fovea-involving subretinal fluid (SRF). SD-OCT confirmed choroidal elevation with SRF. Fluorescein angiography revealed early blockage with gradual increase in hyperfluorescence. Ultrasound showed an irregular solid mass with moderate to high internal reflectivity. Systemic workup revealed primary adenocarcinoma of the lung with metastases to the brain, scapula, ribs, and vertebrae. The patient was treated with 2 injections of intravitreal bevacizumab to the left eye (1.25 mg followed by 2.5 mg) and 1 treatment in the right eye (1.25 mg) for an additional metastatic lesion. Exam of the left eye 1 week following the first injection did reveal onset of pigmentary changes. However given persistent SRF and deterioration of visual acuity, external beam radiation and systemic chemotherapy were initiated, which yielded resolution of SRF, involution of the lesions, and restoration of visual acuity.
Although anti-vascular endothelial growth factor (anti-VEGF) therapy may represent a therapeutic option for choroidal metastases, with a favorable side effect profile, enthusiasm for positive results should be tempered. Treatment with anti-VEGF agents may instead have a more adjunctive role to more established treatment modalities such as external radiotherapy and systemic chemotherapy.
CONCLUSION
complications, and outcome to include survival, globe conservation and visual function. All eyes received intra-arterial chemotherapy associated with pre, and post, chemotherapy direct transpupillary laser therapy.
RESULTS
Fundus photo shows a large, elevated, pale subretinal lesion in the superotemporal macula of the left eye. This eye was subsequently injected with intravitreal bevacizumab.
26 intra-arterial chemotherapy (IAC) procedures were performed in 17 eyes of 15 children. Mean age at IAC treatment was 38 months (6 to 84 months). All 17 eyes presented with advanced vitreous seeding (RE Stage Vb). Mean follow-up was 12 months (3 to 24 months). IAC Melphalan dose ranged from 3.0 to 7.5 mg. 76% of IAC treated eyes were salvaged (13/17 eyes). Treatment with higher dose 7.5 mg Melphalan was associated with avoidance of enucleation (0% versus 36%, p <.05). Complications were IAC procedure specific and were not associated with dose delivery. All eyes undergoing enucleation presented with clinically persistent viable tumor associated with subretinal/preretinal hemorrhage. Histopathology of all 4 enucleated eyes confirmed viable retinoblastoma. Intra-arterial chemotherapy using selective ophthalmic artery delivery effectively treats advanced intraocular retinoblastoma. Higher melphalan dosing (7.5 mg) and repetitive treatment at/or above 5.0 mg melphalan improved tumor control and globe salvage. Combining high dose IAC with focal laser tumor treatment appears promising as both a primary, and salvage therapy for pediatric RB.
CONCLUSION
704
Fundus photo showing pigmentation over the macular lesion 1 week following injection of 1.25 mg/0.1ml intravitreal bevacizumab in the left eye.
Retrospective Review of Proton Beam Therapy for Ocular Melanoma

F. Ryan Prall, MD (Indianapolis, IN), Nam Keun Yoon, Nam Keun Yoon, MD, Clement K. Chan, MD*, Ramin Monshizadeh, MD, John P. Carlson, MD, Richard D. Pesavento, MD, Mark Schneider, Joseph T. Fan, MD
703
Strategies for Chemotherapeutic Dosing Utilizing Intra-arterial Melphalan Chemotherapy for Primary and Rescue Treatment of Pediatric Retinoblastoma
Timothy G. Murray, MD, MBA (Miami, FL), Mohammad Ali Aziz-Sultan, MD, Cristina E. Fernandes, MD, Lejla Mutapcic, Samuel Houston
PURPOSE
To evaluate the clinical outcomes of patients treated with proton beam radiation for ocular melanoma at a single facility. Retrospective chart review.
METHOD RESULTS
PURPOSE This study evaluated a clinical dose and scheduling strategy for advanced retinoblastoma treatment utilizing intra-arterial chemotherapy. METHOD IRB approved retrospective review of a consecutive case series of children treated with advanced intraocular retinoblastoma using intra-arterial chemotherapy. All patients receiving intra-arterial chemotherapy were evaluated. Data collection included demographics, staging, prior treatment, intra-arterial chemotherapy treatment number, treatment dose,
Over a 16 year period 138 patients were treated. Follow-up data was obtained for 77 patients with an average follow-up of 43 months. Twenty seven patients had tumors within the posterior pole and most (50 of 77) were mediumsized. Two mortalities occurred resulting in a 10-year disease specific survival of 96.4%. There were 11 treatment failures (Kaplan-Meier 10-year success rate: 78.1%) and 10 cases of neovascular glaucoma.
CONCLUSION
Proton Beam therapy is one option in the treatment of ocular melanoma and outcomes are comparable to plaque brachytherapy and enucleation.
187
OCULAR ONCOLOGy
705
Ophthalmoscopic Differentiation of Coats Disease and Retinoblastoma

Jerry A. Shields, MD (Philadelphia, PA), Carol L. Shields, MD
PURPOSE Coats disease is often confused clinically with retinoblastoma. It is important for clinical and medicolegal reasons to differentiate them. This study was to delineate the features that differentiate Coats disease and retinoblastoma. METHOD Approximately 1400 patients wih retinoblastoma and 175 with Coats disease had detailed fundus drawings, fundus photography, fluorescein angiography, and ultrasonography These were reviewed to establish clinical criteria that serve to differentiate these conditions. Coats disease is often confused clinically with retinoblastoma. It is important for clinical and medicolegal reasons to differentiate them. This study was to delineate the features that differentiate Coats disease and retinoblastoma. RESULTS Features that differed in Coats disease and retinoblastoma included the nature of the pupillary reflex, color of subretinal fluid, and caliber and distribution of the retinal blood vessels. The pupillary reflex and color of subretinal material is generally yellow in Coats disease and white to gray with retinoblastoma. Macular involvement with Coats disease shows irregular lipoproteinaceous exudation, whereas macular involvement with retinoblastoma shows a distinct white mass. The retinal blood vessels in Coats disease disease are irregular in caliber, often with aneurysms, whereas in retinoblastoma the retinal vessels are uniformly dilated and more tortuous. The blood vessels in Coats disease tend to remain visible from the posterior pole to the peripheral fundus, whereas those retinoblastoma tend to disappear into the adjacent neoplasm. CONCLUSION Despite their superficial similarities, Coats disease and retinoblastoma usually have different clinical features. Recognition of these differences can avoid erroneous diagnosis, misdirected therapy, and legal repercussions.
Film Festival
13th Annual ASRS Film Festival

Lights, Camera, Action
A picture is worth a thousand words A moving picture priceless One of the strongest of media for medical and surgical education will be at your fingertips at the 29th Annual Meeting 29 films were submitted for what promises to be an outstanding Film Festival. The festival will showcase the observational skills, innovation, and creativity within our ranks in a most entertaining venue. Showings of the Film Festival will take place each day of the meeting in the Film Festival Theater. The opportunity to watch the Film Festival within the comfort of your hotel room is also available. Sit back, and enjoy some popcorn while you attend this years premiere. Each film will be judged according to overall appeal, clinical value, special effects, production quality, and entertainment. A panel of judges will rate and score each film. The coveted Rhett Buckler Award an impressive 8-pound, 24 carat gold-plated statuette, will be bestowed upon the top films. The winners will be announced on Tuesday, August 23, at the Gala Dinner. Please join us for an exciting viewing of films. It promises to be educational and entertaining! Well supply the popcorn!
Film Festival Entries

Amazing Visual Recovery after Surgery for Some Monstrous Intraocular Foreign Bodies
Guruprasad S. Ayachit, MBBS, MS (Hubli, India)
SYNOPSIS Large intraocular foreign bodies are quite frequently encountered. Many times it is a mystery as to how they entered the eye and more surprising is the good visual recovery after surgical management. The videos of surgery for removal of five different monstrous foreign bodies are compiled in this presentation. The need for customization and improvisation of techniques to suit individual cases will be highlighted.
Active Silicone Oil (SO) Removal with a Modified Vacuum Syringe

Boris Josue Bajaire, MD (Santafe de Bogota, Colombia), Elena Oudovitchenko, MD, Andres Salguero, MD, Diego F. Paipilla
SYNOPSIS The number of indications for the use of SO has increased in vitreo-retinal surgery. We developed a simple active technique for SO removal based on a 5ml standard syringe with an 18G cannula. The oil is suctioned into the syringe by the pulling effect of a spring assembled along the pistons axis. No abrupt change in the intra-ocular pressure is produced, without any complication or device failure. 4 minutes is the average time for SO removal, which is in the range of other active techniques.
The Aahs and Oohs with First Time Use of Constellation Vitrectomy System
Alay S. Banker, MD (Ahmedabad, India), Rohan Chauhan, MD
SYNOPSIS To demonstrate first experinces with Constellation Vitrectomy System. The video demonstrates controlled base excision of vitreous even in a mobile retina in a case of giant retinal tear and how even the finest tissue attached to the edges of macular hole can be dissected safely. However, due to the valve mechanism, while doing silicone oil injection the IOP suddenly increases. Sudden failure of dual mode led to complications like accidental suction of retinal tissue and increased IOP.
Management of Combined Exposure, Intrusion and Infection of Solid Silicone Scleral Buckle
Pramod S. Bhende, MBBS (Chennai, India), Muna Bhende, MD
Brett T. Foxman, MD
Film Festival Program Subcommittee Chair
SYNOPSIS Buckle migration, intrusion, exposure and infection are known complications of scleral buckle surgery. Managing each of these is challenging and involves significant risk to the eye and vision. We present a patient who reported with a combination of all these in the only seeing eye including the extremely rare intracorneal migration of the encircling band. The surgical maneuvers used to successfully manage the case, including the use of fibrin glue with scleral patch graft will be demonstrated.
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FILM FESTIVAL ENTRIES
Into the Deep with DSEK

Kevin J. Blinder, MD* (St. Louis, MO), Kamalesh J. Ramaiya, Gaurav K. Shah, MD*
SYNOPSIS A 40 y/o male status post trauma and RD repair subsequently developed corneal decompensation. A DSEK procedure was performed for visual rehabilitation. Postoperative day number one the graft was found on the surface of the macula. This surgical clip describes our solution to removing the DSEK graft despite an extremely poor view. Visualization with both the BIOM and the endoscope are demonstrated. Successful removal to the DSEK graft is revealed.
conclusion may all be too true. In a symbolic way, a controller in a mtro station in Paris reflects the discouragement we feel as we face the constant rush of injection after injection. Follow the lyrics for a first class voyage in the depths of le Mtro des Lilas.
Clove Hitch Scleral Fixation of Dislocated Toric IOL

Joao Luiz Lobo Ferreira, MD (Florianopolis, Brazil)
Removal of a Posttraumatic Intraocular Eyelash from a Driven Tunnel Within the Vitreous Body by Using 23-gauge Vitrectomy Instruments
Osman Cekic (Istanbul, Turkey), Ahmet Yazici, Mehmet Cakir, Kemal Yuksel, MD, Ugur H. Celik, MD
SYNOPSIS Surgical approach: 25-Gauge ppv, clear cornea temporary externalization of the haptics of dislocated toric IOL, scleral fixation of the IOL using 10-0 prolene, clove hitch knot at the external face of the haptic. IOL positioning was based on the haptic location at the pre op SITE program. OD refraction: pre op 2.75 -3.00 x 20; dislocated IOL: -1.75 -3.00 X 165; post operative refraction of OD was -2.75 (VA 20/40 -2). IOL repositioning was adequate and stable.
SYNOPSIS We describe a rapid, effective and safe technique for the removal of intraocular foreign bodies by creating a narrow tunnel within the vitreous body. No entire vitrectomy is performed. With this technique, most of the vitreous body remains intact and the crystalline lens is preserved. Shortened operation time also minimizes the risk of light toxicity to the macula.
Innovator or Heretic?
Cesare Forlini, MD (Ravenna, Italy), Adriana Bratu, MD, Matteo Forlini, MD, Paolo Rossini, MD
ILM Peeling for Dummies

Martin Charles, MD (Buenos Aires, Argentina)
SYNOPSIS This video is an allegorical representation of a comparison between Casanova and the surgeon in finding their way. Very often the bureaucratic machine criticizes and inhibits this kind of surgeon (like the Inquisition did with Casanova), and tries to obstruct his/her creativity.How should we consider this kind of surgeon, an innovator or a heretic? Is the Inquisition time over? Or are we still living in the Inquisition age?
SYNOPSIS This video will review all the tips for performing a successful ILM peeling, from methods of visualization to surgical technique, showing how to avoid difficulties that new surgeons have during their first steps on this surgery.
Temporary Keratoprosthesis in the Pole to Pole Surgery in Severe Trauma Cases

Cesare Forlini, MD (Ravenna, Italy), Adriana Bratu, MD, Matteo Forlini, MD, Paolo Rossini, MD
Value of Digital Fluorescein Videoangiography in Diagnosis of Optic Nerve Lesions

Ching J. Chen, MD (Jackson, MS), Heather Hancock, MD, Zachary Robertson, MD, Matthew Olsen, MD
SYNOPSIS This video will illustrate the scanning laser ophthalmoscope based diagital fluorescein videoangiography (DFVA) on 3 cases of optic disc lesion, 2 with pulsatile nature and one without. DFVA provides a real time observation of a dynamic process of retinal blood flow. It proved to be very helpful in confirming a diagnosis of a suspicious lesion by a regular fluorescein angiography. It is a very helpful teaching tool to provide real time information of pulsatile optic disc lesion.
SYNOPSIS This video shows the use of temporary keratoprosthesis (TKP) for the visualization of intraocular structures during PPV in eyes with corneal and retinal pathologies and make possible to manage both in a single surgical procedure. We use 25G anterior chamber infusion and open sky vitrectomy, TKP with mini-invasive 25/23G system for exploration and reconstruction. We try to give a chance to the patients to obtain a useful visual acuity
Submacular Surgery in the Anti-VEGF Therapy Era

Valentina Franco-Cardenas, MD (Los Angeles, CA), Jean-Pierre Hubschman, MD, Steven D. Schwartz, MD*
Le Poinonneur des Lilas

Gilles Desroches, MD, FRCS(C) (Ottawa, Canada)
SYNOPSIS Who would have guessed? Serge Gainsbourg, the French singer, had foreseen the plight of retinal surgeons 60 years before intraocular injections were popular. The spirited rhythm of the song reflects our crazy pace. The dramatic
SYNOPSIS Anti-VEGF therapy is the treatment of choice for choroidal neovascular membranes (CNV). Submacular surgery as a treatment for CNV has been abandoned. In very specific, well selected cases where massive subretinal hemorrhage occurs, surgical intervention may have a role. Addressing these cases in a surgical way, has to do with the fact that blood in the subretinal space may be toxic. We present cases of CNV and massive submacular hemorrhage managed with both Anti-VEGF therapy and surgery.
190 FILM FESTIVAL
Staged Surgical Management of Retinal Detachment Resulting from Intrusion of a Miragel Explant
Quan V. Hoang, MD, PhD (New York, NY), Gregory Chang, MD, Stanley Chang, MD
Silicon Oil Removal: The Final Hurdle

Manish Nagpal, MD* (Gujarat, India), Pravin Jain, MD
SYNOPSIS A 67 year-old man presented 21 years after retinal detachment repair OD with a vision of hand motions resulting from intrusion of a Miragel explant into the eye with lens contact. A staged repair was offered for retinal re-detachment and cataract. The patient initially underwent a lensectomy and Miragel explant removal internally via fragmatome. Uncontrolled bleeding developed. 9 days later, subretinal tissue plasminogen activator was employed to complete the detachment repair.
SYNOPSIS Silicon oil is an important adjunct during vitrectomy and needs mandatory removal. Silicon oil removal (SOR) determines the final visual outcomes of the eye. In this video we present the approach to SOR surgery. We use a 3 port pars plana approach for SOR using wide angle viewing systems and also demonstrate various adjunct procedures such as cataract surgery, membrane removal, Sub retinal oil removal, endolaser etc. Steps to reduce risk of redetachment are also discussed.
Drainage of Choroidals with a Guarded Needle Technique: An Insiders View

John W. Kitchens, MD* (Lexington, KY), James C. Pate, MD, Daniel Prescott, MD
23 Gauge Bimanual Membrane Peeling for Diabetic Combined Retinal Detachment Using Chandelier Illumination
Raja Narayanan, MBBS (Hyderabad, India), Chinmaya Sahu, MD, Mudit Tyagi, MD
SYNOPSIS A view inside the eye as a choroidal detachment is drained using a novel approach with a guarded 26 gauge needle.
Iatrogenic Subretinal Gas in a Patient with Post Trabeculectomy Hypotony: A Simplified Technique for Gas Evacuation
Patrick C. Mitchell (Calgary, Canada), Amin Kherani, MD
SYNOPSIS A 48 year old, diabetic presented with diminution of vision in the right eye since 3 months. Her vision was 1.77 on the logMAR chart. Fundus examination revealed presence of combined retinal detachment with fibrovascular proliferation at the disc and macula. A bimanual 23 Gauge membrane peeling was done for the patient using chandelier illumination. The video will highlight that it is possible to attempt such difficult diabetic cases using 23 Gauge Vitrectomy using Bimanual approach.
SYNOPSIS A 16 year old female with a history of intermediate uveitis of the right eye underwent trabeculectomy for medically uncontrolled glaucoma. Post trabeculectomy she experienced prolonged severe hypotony. She had been previously vitrectomized for treatment of a retinal detachment. Intravitreal injection of 0.3cc of 100% C3F8 was attempted in the office but the gas went subretinal due to hypotony. This video demonstrates successful evacuation of the subretinal gas via an external drainage approach.
Non Full Thickness Macular Holes. A Closer Look!

Jerzy Nawrocki, MD, PhD (Lodz, Poland), Janusz Michalewski, MD, PhD, Zofia Nawrocka, MD, Zofia Michalewska, MD, PhD
The Art of Non-kissing

Sandra Rocio Montezuma, MD (Minneapolis, MN)
SYNOPSIS A new theory of idiopathic non full thickness macular holes based on spectral domain OCT observations and clinical appearance before and during surgery. All these entities are caused by vitreoretinal traction, which produces local internal limiting membrane (ILM) defect in the fovea. These leads to epiretinal membrane (ERM) formation around the ILM defect in the fovea. During the maturation of the membrane different appearances in the fovea may be observed. Healing after surgery is presented.
SYNOPSIS An 86-year-old woman status post Baerveldt valve had kissing choroidals and underwent choroidal drainage. She presented with pain, visual acuity of light perception, recurrent kissing choroidals, flat anterior chamber, dislocated IOL and retinal detachment. This film entry illustrates a technique to successfully treat complicated hemorrhagic choroidals. She underwent choroidal drainage, anterior segment reconstruction, valve revision, intraocular lens removal and retinal detachment repair.
New Technology for Fixating the Dislocated Intraocular Lens

Jeffrey L. Olson, MD (Aurora CO), Michael Erlanger, MD
SYNOPSIS This video details a new surgical technique and novel surgical instrumentation using a 30-gauge injectable shape memory alloy clip to fixate a dislocated intraocular lens. This new technology allows the surgeon to fixate the haptic of the lens to the mid-peripheral iris in less than 60 seconds, compared to the 10 to 15 minutes per suture for conventional iris fixation techniques. The video demonstrates the device in the laboratory and the technique in a surgical setting.
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When the Instruments Are Not Enough!! There Are Eyes Longer Than My Forceps...
Sergio Rojas (Cuernauaca Moreios, Mexico)
More Elusive Than the Scarlet Pimpernel! Finding the Correct Surgical Plane in Diabetic Vitrectomy and Other Surgical Pearls
Cyrus M. Shroff, MD (New Delhi, India), Neelam Atri, MD, Charu Gupta, MD, A. K. Singh, MD, Bhavana Sharma, MD, Daraius Shroff, MD, FRCS
SYNOPSIS Patient with atrophy of the retinal pigment epithelium with a market posterior staphyloma at the presence of subretinal fluid associated with macular hole, takes ultrasound scans showing a 34 mm axial length and OCT where there is presence of epiretinal membrane. He was scheduled for 23 gauge vitrectomy surgery. At the time of surgery is difficult to reach the surface of the retina because our instruments measure 32mm long and the length of the eye is larger.
SYNOPSIS This video is a compilation of various surgical clips highlighting some of the surgical nuances of diabetic vitrectomy. Included are tips for the identification of vitreoschisis and the correct surgical cleavage plane, bimanual membrane dissection and hemostasis techniques, and tackling combined TRDs with macular hole.
Combined CRVO and Cilioretinal Artery Occlusion with Video Fluorescein Angiography of Pulsating Cilioretinal Artery
David Sarraf, MD* (Los Angeles, CA), Pradeep S. Prasad, MD
A Simple Alternative to Flute Cannula for the Vitreo-retinal Surgical Procedures

Malhar Soni, DO, MS, DNB, FRCS (London, United Kingdom)
SYNOPSIS Angiographic pulsations within the cilioretinal artery have been described as a pathognomonic feature in patients with combined cilioretinal artery and central retinal vein occlusion. We present a video fluorescein angiogram demonstrating alternating perfusion and nonperfusion of the cilioretinal artery in a young patient with CRVO.
SYNOPSIS The video demonstrates the construction and use of an inexpensive and disposable alternative to the flute cannula for Vitreo- retinal surgical procedures. This cannula can be assembled using a 20, 23, 25 or 27 gauge blunt/soft tip cannula and a leur 3-way tap. This model also aids the introduction of dye in the vitreous cavity. This instrument is as safe and effective as the original and benefits from being inexpensive and easily constructed from components ubiquitous to surgical units.
Novel Instrument for Defining Sclerotomies in Small Gauge Vitrectomy Surgery

Samir Sayegh, MD, PhD (Champaign, IL), R. Olk, MD
Vitreo-lenticular Interface Its Surgical Importance

Malhar Soni, DO, MS, DNB, FRCS (London, United Kingdom)
SYNOPSIS This film presents the evolution of fixation systems for 23G and 25G vitrectomies culminating in the development of a novel instrument (Sayeghs Vitroretinal Fixation System) for fixating the globe and facilitating positioning of 23G and higher trocar systems in a rational, safe and efficient manner
23-Gauge Chromovitrectomy for Macular Schisis in Optic Disc Pit: Triamcinolone Assisted Vitrectomy, Followed by Brilliant Blue Guided ILM Peeling
Cyrus M. Shroff, MD (New Delhi, India), Charu Gupta, MD, A K Singh, MD, Neelam Atri, MD, Gagan Bhatia, MD, Daraius Shroff, MD, FRCS
SYNOPSIS This video demonstrates the importance of identification and surgical removal of Weigerts ligament of the vitreous in eyes with proliferative vascular diseases undergoing vitrectomy for vitreous haemorrhage. The video illustrates signs to visualise the vitreo-lenticular interface and describes technique to remove it. It helps in better visualisation of retina during surgery and helps in avoiding non-resolving vitreous cavity haemorrhage and aqueous misdirection syndrome in vitrectomised eyes.
Techniques for Improving Intraoperative Visualization of Surgical Planes in Complex Anterior Pediatric Retinal Detachments
S. Chien Wong, MBBS, FRCSEd (Ophth) (Troy, MI), Caesar K. Luo, MD, MRCOphth, Antonio Capone, MD
SYNOPSIS Presenting the surgical management of macular schisis associated with optic disc pit. The patient underwent triamcinolone assisted 23-Gauge vitrectomy to ensure complete removal of cortical vitreous. This was followed by brilliant blue staining and ILM peeling using a Tano membrane scraper and end grasping forceps. Intraoperative diode endolaser was done to the margin of the pit, with C3F8 gas injection. Post operative OCT showed restoration of foveal dip. Vision improved from 20/80 to 20/30.
SYNOPSIS Complex anterior pediatric tractional retinal detachments in diseases such as retinopathy of prematurity and familial exudative vitreoretinopathy pose specific intraoperative challenges relating to identification of surgical planes. The risk of iatrogenic full-thickness retinal break is high and resulting outcomes are often poor. In this video, we illustrate how the innovative use of illumination can improve visualization, leading to more precise and safer manipulation of surgical planes.
192 FILM FESTIVAL
2010 Film Festival Award Winners

A replay of the award-winning films from the 12th Annual Film Festival in Vancouver. BEST OF SHOW Journey through a Normal Day of a Retina Surgeon
Virgilio Morales-Canton, MD (Mexico City, Mexico)
Sutureless Intraocular Lens Fixation of a Dislocated Intraocular Lens-capsular Bag-capsular Tension Ring Complex
R. Kim, MBBS, DO, DNB (Madurai, India), Babu Naresh, MD
SYNOPSIS This video demonstrates how everyday events on the life of a retina surgeon may influence the surgical technique and the final outcome. A regular day may change your surgical maneuvers!
SYNOPSIS We report a technique for sutureless fixation of a 3-piece dislocated in the ciliary sulcus in an eye with dislocated IOL-capsular bag-capsular complex. This secondary procedure was performed 16 months after initial surgery in an eye with traumatic zonular dialysis. The same lens was used after separating it from the CB-CTR complex through a pars plana approach. This sutureless technique using 20 and 23-gauge vitrectomy to reinstall a dislocated PCIOL required no special haptic architecture.
Intraocular Cysticercosis Delivered Whole Via Pars Plana Vitrectomy

Thomas M. OHearn, MD (San Marino, CA), Dean Eliott, MD, Rizwan A. Bhatti, MD, Narsing Rao, MD
Heavy Brilliant Blue: a New Dye for Peeling the Internal Limiting Membrane
Murat Oncel, MD (Istanbul, Turkey)
SYNOPSIS A 17 year old Hispanic male presented with 3 weeks of decreased vision in his left eye to CF. Dilated exam revealed a 7mm mobile, light sensitive, cyst within the vitreous cavity. A pars plana vitrectomy, pars plana lensectomy and scleral buckle was performed with removal of the cyst whole, without rupture of the cyst wall. Histological analysis was consistent with a cysticercosis cyst. His vision improved to 20/25 and his systemic work up was negative for any further cysticercosis infection.
SYNOPSIS In order to have a better staining effect with normal BB and prevent the staining of the posterior capsule of the lens, air-fluid exchange is performed before staining. With the use of heavy BB, there is no need to perform air-fluid exchange. After turning off the infusion, dye is injected under fluid. Staining effect is better than normal BB in fluid filled eyes. Stains the ILM much better than trypan blue, comparable to ICG, making the ILM peeling procedure easier, safer and faster.
Gnasty Stoma
Aziz A. Khanifar, MD (New York, NY), R.V. Paul Chan, MD, Grant D. Aaker, MD
A Technique in Iridodialysis Repair and Suture Intraocular Lens Implantation

David T. W. Wong, MD, FRCS (C) (Toronto, Canada)
SYNOPSIS A 37-year old Ecuadorian man presented to the emergency room with uveitic glaucoma secondary to an intravitreal parasite in his left eye. Our film will demonstrate our findings with fundus photography, fluorescein angiography, ultrasonography, and spectral domain optical coherence tomography. Furthermore, the surgical video of the worms removal via 23- gauge pars plana vitrectomy will be shown. Pathologic analysis was consistent with Gnathostoma species.
SYNOPSIS A simplified technique for suturing intraocular abexternal lenses in vitrectomized eyes is also applied to repairing an iridodialysis is presented in a combined method in a severe blunt trauma case.
Transconjunctival Drainage of Serous and Hemorrhagic Choroidal Detachment

Flavio A. Rezende, MD, PhD (Blainville, Canada)
SYNOPSIS The film aims to describe a choroidal drainage technique with minimal trauma to the conjunctiva on glaucoma patients. It also illustrates the differences between this technique and the previously described ones. Pearls and cautions to master this procedure will be highlighted.
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Vitreoretinal Surgery for Subretinal Hidden Foreign Bodies

Javier Elizalde, MD, PhD (Barcelona, Spain)
2012 Call for Films

You are invited to prepare your film entries and contribute to this wonderful tradition of excellence in film. Submit a film to the 2012 Film Festival and you may just be a proud winner of the coveted Rhett Buckler Award! Deadline for submission of 2012 films will be announced on the ASRS website, www.asrs.org.
SYNOPSIS Management of intraocular foreign bodies is a surgical challenge for the ophthalmologist: a wide array of potential clinical complications may be associated to these cases, patients affected are usually young and surgery must be carried out at the right time. The author includes in this video the preoperative appearance, the surgical technique and the final outcome of two very unusual and difficult cases, in which the metallic foreign body was deeply located within the subretinal space.
Giant Retinal Tear! Size Does Matter

Manish Nagpal, MD (Gujarat, India), Nilesh Chaudhari, MD
SYNOPSIS Giant retinal tears (GRT) are characterised by tears greater than 90 degrees. In this video we present a variety of complex presentations of GRT, which include extensive PVR and those with associated nucleus drop. Various surgical techniques and manouevers using Perfluorocarbon liquid (PFCL), Air PFCL exchange, Silicon oil including bimanual approach are demonstrated. Allied procedures such as Silicon oil removal and laser prophylaxis of lesions in the other eye are also shown.
Management of Posterior Dislocated Lens with Phakofragmentation, Ultra High Speed Vitrectomy and Foldable Suture in Posterior Chamber Lens Implant
Ching J. Chen, MD (Jackson, MS), Michael Palmer, MD, Kevin Kosek, MD
SYNOPSIS This video will illustrate the technique of removal of posterior dislocated lens or fragments of lens by a new generation phako-fragmentation and high speed vitrectomy system. We will also demonstrate the technical detail of creating the scleral flap, passing the scleral suture, attachment of suture to the implant, folding and insertion of the implant through the small clear corneal incision, and fixation of the implant by anchoring suture to the scleral bed.
194 FILM FESTIVAL
Participant Index
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The American Society of Retina Specialists (ASRS) seeks to balance the important benefits of physicianindustry relationships with the significant risk that the financial goals of industry may conflict with the professional goals of ASRS members. In doing so, the ASRS recognizes that it has a profound duty to its members, the larger medical community and the public to ensure the integrity of all of its scientific, educational, and advocacy activities and materials. Any relevant financial relationships a CME presenter has had with manufacturers of commercial ophthalmic products or providers of commercial ophthalmic services within the past 12 months. The ASRS defines relevant financial relationships as those with a commercial ophthalmic interest and the opportunity to affect the content of CME about the products or services of that commercial ophthalmic interest. CME presenters who report they have no known relevant financial relationships to disclose will declare No Financial Relationships.
NOTE: All presenters are required to report financial
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As the ACCME accredited provider for the ASRS 29th Annual Meeting, the American Society of Retina Specialists requires all Program committee members, abstract graders, staff, and any others in a position to control the educational content to disclose any commercial financial interests prior to the development of educational content. A process for resolution of conflict of interest is used for those committee members who do have financial interests related to the development of content. Program committee members, abstract graders, and staff members who fail to provide financial disclosures are not permitted to participate in the abstract grading process or the development of educational content.
disclosures, using the codes below, as part of the abstract submission process. An individuals financial disclosure for the ASRS 29th Annual Meeting will be indicated by an asterisk (*) in the Scientific Program and cross-referenced in the Participants Financial Disclosure Index. (See the Participant Index tab of the Scientific Program). Any presenter not listed with an asterisk, or not listed by name on the Participants Financial Disclosure list, informed the American Society Retina of Specialists that they have no relevant financial disclosures to report.
Description of Financial Interest Presenters

The ASRS considers financial relationships to create actual conflicts of interest when Presenters or their immediate family (defined as spouse, domestic partner, parent, child or spouse of child, or sibling or spouse of sibling of the Presenter) have both a financial relationship with a commercial interest and the opportunity to affect ASRS policy or the content of CME about the products or services of that commercial interest. The potential for Presenter to maintain or increase the value of the financial relationship with the commercial interest creates an incentive to influence the content of the CME an incentive to insert commercial bias. All presenters of CME content should familiarize themselves with the new ASRS Policy on Financial Disclosures and Resolution of Conflicts of Interest, which may be viewed in their entirety on the ASRS website at www.asrs.org. All ASRS members presenting CME are required to disclose to the activity audience the following information prior to beginning their presentation:
TyPES OF RELATIONSHIP(S) A Advisory Board B Board of Directors C Consultant E Employee F Founder I Investigator SP Speaker SH Stockholder O Other NATURE OF COMPENSATION E Equipment (dept or practice) G Grants H Honoraria IP Intellectual Property Rights NC No Compensation Received OB Other Financial Benefit R Royalty RF Residency or Fellowship Program Funding S Salary ST Stock SO Stock Options
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Financial Interest or Relationship Disclosures

Agarwal, Anita Artic DX . . . . . . . . . . . . . . . . . . . . . . . . . . . O/IP Albini, Thomas A. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . A, SP/H Antoszyk, Andrew N. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, I/H Alimera Sciences . . . . . . . . . . . . . . . . . . . C, I/H Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C, I/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C, I, O, SP/H Apte, Rajendra S. Alimera . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, C/H Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A, C/H Baxter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, C/H Eyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . A, C/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A, C/H Opthotech . . . . . . . . . . . . . . . . . . . . . . . . . C/SO Awh, Carl Artic DX . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SH/SO, H Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . C/H Synergetics . . . . . . . . . . . . . . . . . . . . . . . . C, I/G, H NotalVision . . . . . . . . . . . . . . . . . . . . . . . . C, Sh, I/S, SO Volk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C,S Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C, I/G, H Bakri, Sophie J. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G Bandello, Francesco Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB/H Allegan . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB/H Bayer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB/H Neovista. . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB/H Barak, Adiel Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Neovista. . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Optical Imaging. . . . . . . . . . . . . . . . . . . . . I/G Ora Bio . . . . . . . . . . . . . . . . . . . . . . . . . . . . SH/SO Basham, Ryah P. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/H, I/G Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/G Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G Bennett, Jean Sano-Aventis . . . . . . . . . . . . . . . . . . . . . A/H Avalanche Biotechnologies . . . . . . . . . . A/SO Berrocal, Maria H. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H, S Alimera . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Bhisitkul, Robert B. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A, I/G Santen, Inc. . . . . . . . . . . . . . . . . . . . . . . . . c/H Structus Medical . . . . . . . . . . . . . . . . . . . F/SO Blinder, Kevin J. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/H Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/H Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . C/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . SP/H iScience . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Johnson & Johnson . . . . . . . . . . . . . . . . . C/H Ocusoft . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Blumenkranz, Mark S. Avalanche . . . . . . . . . . . . . . . . . . . . . . . . . B, F, SH/ST Digisight . . . . . . . . . . . . . . . . . . . . . . . . . . . B, F, SH/ST Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C/RF Optimedica . . . . . . . . . . . . . . . . . . . . . . . . B, F, SH/IP, R, ST Peak Surgical . . . . . . . . . . . . . . . . . . . . . . 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SP/H QLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . A/H Bressler, Neil M. Abbott Medial Optics . . . . . . . . . . . . . . . I/G Alimeria Sciences. . . . . . . . . . . . . . . . . . . I/G Allergan USA . . . . . . . . . . . . . . . . . . . . . . . I/G Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . I/G Carl Zeiss Meditec . . . . . . . . . . . . . . . . . . I/G Dingnos . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G ForSight Labs . . . . . . . . . . . . . . . . . . . . . . I/G Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/G Genzyme . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Lumenis . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Notal Vision . . . . . . . . . . . . . . . . . . . . . . . . I/G Novartis Pharma . . . . . . . . . . . . . . . . . . . I/G Ora . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Pzer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G QLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G Research to Prevent Blindness. . . . . . . I/G Steba Biotech . . . . . . . . . . . . . . . . . . . . . . I/G The Emmes Corporation. . . . . . . . . . . . . I/G Bressler, Susan B. Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . I/G Emmes Corp . . . . . . . . . . . . . . . . . . . . . . . I/G Genetech . . . . . . . . . . . . . . . . . . . . . . . . . . I/G GlaxoSmithKline . . . . . . . . . . . . . . . . . . . . C/H Notal Vision . . . . . . . . . . . . . . . . . . . . . . . . I/G Novartis . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G QLT Ophthalmics . . . . . . . . . . . . . . . . . . . I/G Brown, David M. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G, A/H, C/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A/H, C/H, I/G, SP/H Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . C/H, I/G Busbee, Brandon G. Akorn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O/I Genentech. . . . . . . . . . . . . . . . . . . . . . . . . SP/H, A/H, I/G Synergetics . . . . . . . . . . . . . . . . . . . . . . . . C/H Cable, Melissa Morrison Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/E, SP/H Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/H Bausch and Lomb. . . . . . . . . . . . . . . . . . . I/G ISTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H, I/G Callanan, David Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/H Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/H Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . A, C/H, SP/H Forsight Labs. . . . . . . . . . . . . . . . . . . . . . . C/SO Lux Biosciences . . . . . . . . . . . . . . . . . . . . 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Devenyi, Robert G. Annidis Health Systems Corp . . . . . . . . E/S Do, Diana V. Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/G Heidelberg . . . . . . . . . . . . . . . . . . . . . . . . . I/G Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G Drenser, Kimberly A. Focus ROP . . . . . . . . . . . . . . . . . . . . . . . . . F/SO Retinal Solutions . . . . . . . . . . . . . . . . . . . F/SO Synergetics . . . . . . . . . . . . . . . . . . . . . . . . C/R Dugel, Pravin U. Abbott Medical Optics . . . . . . . . . . . . . . C/H Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H ArticDX . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C/H Macusight . . . . . . . . . . . . . . . . . . . . . . . . . C/H Neovista. . . . . . . . . . . . . . . . . . . . . . . . . . . C/SO Duker, Jay S. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/O Carl Zeiss Meditec . . . . . . . . . . . . . . . . . . G EMD Serono . . . . . . . . . . . . . . . . . . . . . . . . IP Genentech. . . . . . . . . . . . . . . . . . . . . . . . . IP Hemera. . . . . . . . . . . . . . . . . . . . . . . . . . . . SH/S Merck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IP Novartis . . . . . . . . . . . . . . . . . . . . . . . . . . . IP Ophthotech . . . . . . . . . . . . . . . . . . . . . . . . IP OptiVue . . . . . . . . . . . . . . . . . . . . . . . . . . . G Paloma Pharmaceuticals . . . . . . . . . . . . G Topcon Medical Systems, Inc. . . . . . . . . G Ehrlich, Jason S. Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/S Roche Group . . . . . . . . . . . . . . . . . . . . . . . SH/ST, SO Ferrone, Philip J. Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A, I, SP/G, H Fine, Howard Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C/H Ophthotech . . . . . . . . . . . . . . . . . . . . . . . . C/H Flynn, Harry W. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Allegan . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Pzer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Santen . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Francom, Steven F. Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/S, SO Freund, K. Bailey Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Alimera . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A/H Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . C/H Garg, Sunir J. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/H, I/G, SP/H Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A, A/H, SP/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/G Lux. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G QLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G Gentile, Ronald C. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/G Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G Siron Therapeutics . . . . . . . . . . . . . . . . . I/G University of WI . . . . . . . . . . . . . . . . . . . . I/G
Glaser, Bert M. Ocular Proteomics . . . . . . . . . . . . . . . . . . E/NC Gonzalez, Victor Hugo EndoOptiks . . . . . . . . . . . . . . . . . . . . . . . . C/H Eyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C, I/G, H ISTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/H Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G Greenberg, Paul B. Genentech-PBG . . . . . . . . . . . . . . . . . . . . I/OB Gribben, Jeremy Annidis Health Systems Corp . . . . . . . . E/S Haller, Julia A. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C/H Harbour, J. William Castle Biosciences . . . . . . . . . . . . . . . . . O/IP Hariprasad, Seenu M. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/H Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/H Bayer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C, SP/H Ocular - Therpetuix . . . . . . . . . . . . . . . . . C/SH Optos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . C/H Hassan, Tarek S. ArticDX . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SH/H, ST Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . C, SP/H Clarus Acuity Group. . . . . . . . . . . . . . . . . SH/ST Eyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . C, A/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C/H Insight Instruments . . . . . . . . . . . . . . . . . C/H OptiMedica . . . . . . . . . . . . . . . . . . . . . . . . C, SH/H, ST Synergetic . . . . . . . . . . . . . . . . . . . . . . . . . C/H Heier, Jerey S. Acucela . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Alcon Laboratories . . . . . . . . . . . . . . . . . C, I/GH Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C, I/G, H Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . C/H Fovea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C, A/OB, CP/NC, SP, I/G, H Genzyme . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB GlaxoSmithKline . . . . . . . . . . . . . . . . . . . . C/OB Heidelberg Engineering . . . . . . . . . . . . . C, SP/H iScience . . . . . . . . . . . . . . . . . . . . . . . . . . . C/G, H Lpath. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB, H NeoVista . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB, SP, I/G, H Neurotech . . . . . . . . . . . . . . . . . . . . . . . . . I, G Notal Vision . . . . . . . . . . . . . . . . . . . . . . . . C/H Novartis Pharmaceuticals . . . . . . . . . . . C, I/G, H Oraya Therapeutics . . . . . . . . . . . . . . . . . C/H, C/OB Paloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB, I/G, H Pzer Opthalmics. . . . . . . . . . . . . . . . . . . C, I/G, H, SP Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . C/OB, SP/NC, I/G, H Sequenom . . . . . . . . . . . . . . . . . . . . . . . . . C/OB Vision Care Opthalmic Technologies . . C/OB, C/G, H Hess, Ditte Charity Medical Systems . . . . . . . . . . . . C/H Hines, Joshua Ocular Proteomics . . . . . . . . . . . . . . . . . . E/NC
Ho, Allen C. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I, SP, C/G, H Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I, C/G, H Centocor/Johnson & Johnson . . . . . . . I/G Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I, SP, C/G, H GSK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Macusight . . . . . . . . . . . . . . . . . . . . . . . . . I/GO Merck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H NEI/NIH. . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G NeoVisa . . . . . . . . . . . . . . . . . . . . . . . . . . . I/GO Ophthotech . . . . . . . . . . . . . . . . . . . . . . . . I, C/G, H Optherion. . . . . . . . . . . . . . . . . . . . . . . . . . C/H Oraya. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Paloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H PRN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G QLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I, C/G Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I, C/G, H Thrombogenics. . . . . . . . . . . . . . . . . . . . . C/H Holekamp, Nancy M. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Genetech . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Sequenom . . . . . . . . . . . . . . . . . . . . . . . . . A/H Hopkins, J. Jill Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/S, SO Hosseini, Kamran KMG Pharma . . . . . . . . . . . . . . . . . . . . . . . F/IP, S Huang, Suber S. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . C/H DRCR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Digital Healthcare . . . . . . . . . . . . . . . . . . SH/ST i2i Innovative Ideas . . . . . . . . . . . . . . . . . E/S Lux Biosciences . . . . . . . . . . . . . . . . . . . . C/H MacuSight . . . . . . . . . . . . . . . . . . . . . . . . . C/H Merck & Co., Inc. . . . . . . . . . . . . . . . . . . . . C/H NEHEP/NEI/NIH . . . . . . . . . . . . . . . . . . . . C/H Neurotech . . . . . . . . . . . . . . . . . . . . . . . . . C/H Pzer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Retinal Dis Image Analysis Reading Center . . . . . . . . . . . . . . . . . . . . C/H Second Sight. . . . . . . . . . . . . . . . . . . . . . . C/H SurModics Pharmaceuticals . . . . . . . . . C, SH, H, ST TDNMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Therapeutic Nanoparticle and Molecular Imaging . . . . . . . . . . . . . . C/H Vitreo Retinal Technologies. . . . . . . . . . C/H Jiao, Jenny Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/NC, E/S Jorge, Rodrigo Novartis . . . . . . . . . . . . . . . . . . . . . . . . . . . O/OB Kaiser, Peter K Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Arctic DX . . . . . . . . . . . . . . . . . . . . . . . . . . C/SO Bausch and Lomb. . . . . . . . . . . . . . . . . . . C/H Bayer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Carl Zeiss Meditec . . . . . . . . . . . . . . . . . . SP/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A/H Novartis . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Ophthotech . . . . . . . . . . . . . . . . . . . . . . . . C/H Optovue . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/H Oraya. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . C/H SKS Ocular. . . . . . . . . . . . . . . . . . . . . . . . . F, SH/ST Topcon . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/H Kitchens, John W. Synergetics . . . . . . . . . . . . . . . . . . . . . . . . C/H
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Financial Interest or Relationship Disclosures

Kokame, Gregg T. Acucela . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A, I/G, H Macusight . . . . . . . . . . . . . . . . . . . . . . . . . I/G Pzer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G QLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, I/G, H Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . A, I/G, H Santen . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/S Korobelnik, Jean-Francois Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Bayer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Novartis . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Thea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/G Korotkin, Arthur Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/G Kuppermann, Baruch D. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Alimera . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I, H, C/G Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . C/H Eyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Fovea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/G Glaukos. . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H GlaxoSmithKline . . . . . . . . . . . . . . . . . . . . I/G Lpath. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Neovista. . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Ocucare . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Ophthotech . . . . . . . . . . . . . . . . . . . . . . . . C/H Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G ThromboGenics . . . . . . . . . . . . . . . . . . . . I/G Kurup, Shree K. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/NC Eyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Forsight Labs. . . . . . . . . . . . . . . . . . . . . . . I/G Pzer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Kymes, Steve Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . E, C/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E, C/H Pzer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E, C/H Lai, Phillip Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/SO, ST, SO Lalwani, Geeta A. Genetech . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/H Leonard, Brian C. Annidis Health Systems . . . . . . . . . . . . . C/SO Li, Xiao-yan Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . E/NC Allergan, Inc. . . . . . . . . . . . . . . . . . . . . . . . E/NC Lin, Steven G. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I ThromboGenics . . . . . . . . . . . . . . . . . . . . I Loewenstein, Anat Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Alimera . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H ForsightLabs . . . . . . . . . . . . . . . . . . . . . . . C/H Lumenis . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Notal Vision . . . . . . . . . . . . . . . . . . . . . . . . C/H Novartis . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Orabio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Logani, Sanjay Doctorsoft Corp . . . . . . . . . . . . . . . . . . . . SH/ST MacCumber, Mathew W. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G ArticDx . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/G Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A, I, SP/H, G GlaxoSmithKline . . . . . . . . . . . . . . . . . . . . I/G Optos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/G Sequenom . . . . . . . . . . . . . . . . . . . . . . . . . A/G Maguire, Joseph I. Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A, SP/H Maisel, James M. ZyDoc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B, F, SP, SH/IP, ST Major, James C. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/H Marcus, Dennis M. Alimera . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Eli Lilly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A, C, I/H, G NeoVista . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Pzer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G Santen . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Thrombogenics. . . . . . . . . . . . . . . . . . . . . I/G Mattox, Cynthia Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Transcend . . . . . . . . . . . . . . . . . . . . . . . . . I/G Maturi, Raj K. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . O/G Eli Lilly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C Lux Biosciencs . . . . . . . . . . . . . . . . . . . . . I/G Novagli . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Pzer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G McCannel, Colin A. Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/OB, I/G Savvient . . . . . . . . . . . . . . . . . . . . . . . . . . . SH/ST Mieler, William F. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . H/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C/H Miller, Daniel M. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, C, SP, I/H, OB Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/OB Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/OB Moshfeghi, Andrew A. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Alimera Sciences . . . . . . . . . . . . . . . . . . . C/H Convene . . . . . . . . . . . . . . . . . . . . . . . . . . . F, SH/ST Eyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A, C, I, SP/G, H Oraya. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/NC RAM Corporate Advisors . . . . . . . . . . . . A, C/ST Realm Global . . . . . . . . . . . . . . . . . . . . . . . A, SH/SO Thrombogenics. . . . . . . . . . . . . . . . . . . . . I/G Moshfeghi, Darius M. Insitu Therapeutics . . . . . . . . . . . . . . . . . F, SH/SO MyWhiteCoat . . . . . . . . . . . . . . . . . . . . . . C, SH/ST Ocubell . . . . . . . . . . . . . . . . . . . . . . . . . . . . F, SH/ST Oraya Therapeutics . . . . . . . . . . . . . . . . . C, SH/SO Motley, William Walker Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/H Mullins, Robert Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Murray, Timothy G. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Myung, Jane Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/H, I/G Allergon . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/G Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G Nagpal, Manish Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/H Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H, B/H Bayer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Optimedica . . . . . . . . . . . . . . . . . . . . . . . . A, SP/H, SO Topcon Medical Systems, Inc. . . . . . . . . SP/H Naseri, Ayman Alcon Laboratories . . . . . . . . . . . . . . . . . C/OB Alimera Sciences . . . . . . . . . . . . . . . . . . . C Allergan, Inc. . . . . . . . . . . . . . . . . . . . . . . . C/S FocusRop LLC . . . . . . . . . . . . . . . . . . . . . . O/R Genentech. . . . . . . . . . . . . . . . . . . . . . . . . O/G GlaxoSmithKline . . . . . . . . . . . . . . . . . . . . O/G Ophthotech . . . . . . . . . . . . . . . . . . . . . . . . O/G Retinal Solutions . . . . . . . . . . . . . . . . . . . O/R Thrombogenics. . . . . . . . . . . . . . . . . . . . . O/G Transcend Medical. . . . . . . . . . . . . . . . . . C/H Nelson, Mark H. Eyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Heidelberg Engineering . . . . . . . . . . . . . C/H Novartis . . . . . . . . . . . . . . . . . . . . . . . . . . . A/G QLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/H Nguyen, Quan Dong Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . C/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/G GenentechSpouse. . . . . . . . . . . . . . . . . I/G Heidelberg Engineering . . . . . . . . . . . . . I/G Pzer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G RegeneronSpouse . . . . . . . . . . . . . . . . . I/G Santen . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H, I/G Nielsen, Jared S. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Nuthi, Asha S.D. Alimera Sciences . . . . . . . . . . . . . . . . . . . I Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I Genetech . . . . . . . . . . . . . . . . . . . . . . . . . . I, G NEI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I ThromboGenics . . . . . . . . . . . . . . . . . . . . I Ober, Michael D. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H OD-OS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/SO Oshima, yusuke Alcon Japan. . . . . . . . . . . . . . . . . . . . . . . . E/H Carl Zeiss Meditec . . . . . . . . . . . . . . . . . . SP/H DORC International BV . . . . . . . . . . . . . . C, SP/H Santen Pharmaceutical . . . . . . . . . . . . . SP/H Topcon Medical Laser System . . . . . . . A/H Packo, Kirk H. Alcon Surgical . . . . . . . . . . . . . . . . . . . . . . A, C, I/G, H, S Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/G Thrombogenics. . . . . . . . . . . . . . . . . . . . . I/G Patel, Amar Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H OD-OS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/SO, H
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Patel, Sunil S. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, C/G, I/G Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C, C/G, I/G,H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A/H, G, I/GH Opthotech . . . . . . . . . . . . . . . . . . . . . . . . . C/SO, G, S, A, SH/G, SO Pericak-Vane, Margaret Arctic DX . . . . . . . . . . . . . . . . . . . . . . . . . . O/IP, SH/S Perry-Ecker, Stephanie Ocular Protemics . . . . . . . . . . . . . . . . . . . E/NC Peyman, Gholam A. K.M.G. Pharma . . . . . . . . . . . . . . . . . . . . . A/IP Pieramici, Dante Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I, SP, C Alimera Sciences . . . . . . . . . . . . . . . . . . . I, SP, C Neovista/Topcon . . . . . . . . . . . . . . . . . . . I QLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I Pineda, Roberto Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Prenner, Jonathan L. Alimeria . . . . . . . . . . . . . . . . . . . . . . . . . . . CH Neovista. . . . . . . . . . . . . . . . . . . . . . . . . . . C, SH/SO Opthotech . . . . . . . . . . . . . . . . . . . . . . . . . S, SH/S, SO Priest, David Annidis Health Systsems . . . . . . . . . . . . E/S Reshef, Daniel S. Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/S, SO Rezaei, Kourous A. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, AP/G, H, OB AlconSpouse. . . . . . . . . . . . . . . . . . . . . . SP/H BMC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . SP, I/G, H Rosen, Richard B. Claritin . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/S Genentech. . . . . . . . . . . . . . . . . . . . . . . . . SP/G OD-OS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/S Opko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/S Topcon . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/H Rosenfeld, Philip J. Bristol Meyers Squibb . . . . . . . . . . . . . . . C/S Carl Zeiss Meditec . . . . . . . . . . . . . . . . . . SP/H Chengdu. . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Oraya. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Roth, Daniel B. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . SP/H Notal Vision . . . . . . . . . . . . . . . . . . . . . . . . C, SP/H QLT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H, SP/H Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . A/H Rubio, Roman Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E, SH/S, ST, SO Roche Group . . . . . . . . . . . . . . . . . . . . . . . SH/ST, SO Sadda, Srinivas Reddy Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H, G Carl Zeiss Meditec . . . . . . . . . . . . . . . . . . O/G Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C/H, G Heidelberg Engineering . . . . . . . . . . . . . A/H Optos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O/G Optovue . . . . . . . . . . . . . . . . . . . . . . . . . . . O/G Samuel, Michael A. Iscience . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Johnson & Johnson . . . . . . . . . . . . . . . . . C/H
Saroj, Namrata Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/S, SO Sarraf, David Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G Schmidt-Erfurth, Ursula M. Alcon Laboratories . . . . . . . . . . . . . . . . . C, C/OB, I/G, SP/H Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . C/H Bayer Healthcare . . . . . . . . . . . . . . . . . . . C, SP/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/G Heidelberg Engineering . . . . . . . . . . . . . I/G Novartis . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/H Pzer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G, SP/H Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G Santen . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Schwartz, Stephen G. Bauch & Lomb. . . . . . . . . . . . . . . . . . . . . . SP/H University of Miami . . . . . . . . . . . . . . . . . E/IP Scott, William K. Artic DX . . . . . . . . . . . . . . . . . . . . . . . . . . . O/R Seddon, Johanna M. Genetech . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Tufts Medical Center . . . . . . . . . . . . . . . I/P Semidey, Valmore Adrian Eyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . C/OB Shah, Gaurav K. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/E Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/E Bausch and Lomb. . . . . . . . . . . . . . . . . . . C/E DORC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/E Heidelberg Engineering . . . . . . . . . . . . . C/E I Science. . . . . . . . . . . . . . . . . . . . . . . . . . . C/E Shapiro, Howard Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/S Sherman, Jerome Carl Zeiss Meditec . . . . . . . . . . . . . . . . . . Sp/H Topcon . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sp/H Sinclair, Stephen H. Vimetrics LLC . . . . . . . . . . . . . . . . . . . . . . B/SH, SH/IP, ST Singer, Michael A. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A, C, SP, I/G, H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A, C, SP, I/G, H Neovista. . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Optos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Reneneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G Slakter, Jason S. Novartic Pharmaceuticals . . . . . . . . . . . O/G QLT Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . O/G Solley, Wayne A. Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/H, G Spaide, Richard F. Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C/G GlaxoSmithKline . . . . . . . . . . . . . . . . . . . . C/G Heidelberg . . . . . . . . . . . . . . . . . . . . . . . . . C/G Topcon Inc . . . . . . . . . . . . . . . . . . . . . . . . . C/G Stalmans, Peter Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . I/E Thrombogenics. . . . . . . . . . . . . . . . . . . . . I/E Stone, Thomas W. Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/OP National Eye Intitute . . . . . . . . . . . . . . . . I/OP
Stout, Timothy M. Eyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Sun, Jennifer K. Abbott Laboratories . . . . . . . . . . . . . . . . A/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . A/H, G Novartis . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Tabandeh, Homayoun Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Takahashi, Walter y. Novartis . . . . . . . . . . . . . . . . . . . . . . . . . . . C/H Tan, Donald Acufocus . . . . . . . . . . . . . . . . . . . . . . . . . . I/G Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/H Bausch + Lomb . . . . . . . . . . . . . . . . . . . . . C, SP/H Carl Zeiss Meditec . . . . . . . . . . . . . . . . . . I/G Network Medical Products . . . . . . . . . . O/R Santen Pharmaceutical . . . . . . . . . . . . . C, SP/H Thompson, John T. Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/G National Institute of Health . . . . . . . . . I/G Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G Tornambe, Paul E. Alimera . . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H Optos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/H Trese, Michael T. Alcon Laboratories . . . . . . . . . . . . . . . . . C/OB Alimera Sciences . . . . . . . . . . . . . . . . . . . C Allergan, Inc. . . . . . . . . . . . . . . . . . . . . . . . C/S FocusRop LLC . . . . . . . . . . . . . . . . . . . . . . C/R Genentech. . . . . . . . . . . . . . . . . . . . . . . . . O/G GlaxoSmithKline . . . . . . . . . . . . . . . . . . . . O/G Novartis . . . . . . . . . . . . . . . . . . . . . . . . . . . O/OB Ophthotech . . . . . . . . . . . . . . . . . . . . . . . . O/G Retinal Solutions . . . . . . . . . . . . . . . . . . . O/R Thrombogenics. . . . . . . . . . . . . . . . . . . . . O/G Walsh, Alexander Craig Topcon Medical Systems . . . . . . . . . . . . O/R Warren, Keith A. Alcon Labs . . . . . . . . . . . . . . . . . . . . . . . . . C, SP/H DORC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C, SP/H Wells, John A. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A/H DRCR.net . . . . . . . . . . . . . . . . . . . . . . . . . . I/NC Eyetech . . . . . . . . . . . . . . . . . . . . . . . . . . . A, C, I/H Genentech. . . . . . . . . . . . . . . . . . . . . . . . . I/G Regeneron . . . . . . . . . . . . . . . . . . . . . . . . . I/G Whitcup, Scott M. Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . E, S, ST, SO/S Williams, David F. Genentech. . . . . . . . . . . . . . . . . . . . . . . . . C/H Wong, Pamela Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/S yau, Linda Genentech. . . . . . . . . . . . . . . . . . . . . . . . . E/SO, ST, S yehoshua, Zohar Carl Zeiss Meditec . . . . . . . . . . . . . . . . . . I/G yooh, young Hee Alcon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP/H Allergan . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/H Bayer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A, SP/H
199
Participant Index
A
Aaberg, Jr., Thomas 69 Abe, Ricardo 114 Abraham, Prema 49, 93 Abulon, Dina Joy 65, 140, 142 Adabache-Guel, Tania 111, 169 Adelberg, Daniel 151 Adelman, Ron 83, 96 Adhi, Mehreen 84, 166 Adrean, Sean 128 Afshar, Armin 102 Agarwal, Anita 14, 107 Aggarwal, Anju 144 Ahmad, Baseer 164 Ahmed, Shareef 144 Ahuja, Richard 156 Akhtar, Abeer 115, 166 Albert, Jr., Michael 99, 122, 123, 184 Albini, Thomas 82, 116 Alezzandrini, Arturo 22, 120 Al-Heeti, Omar 156 Allemann, Norma 148 Alliman, Kyle 48 Almeida, Felipe 77 Almony, Arghavan 129 Alshareef, Rayan 153 Amara, Madhu 102 Andi, Inayet 119 Androudi, Sofia 107 Antoszyk, Andrew 19 Appenzeller, Matthew 52 Arend, Laurence 110 Arevalo, J. 12, 22, 61, 115, 120 Ariza, Enrique 40 Aschbrenner, Mathew 83 Aslankurt, Murat 119 Atri, Neelam 24, 124, 147, 162, 192 Augsburger, James 56, 186 Avery, Robert 28 Awh, Carl 7, 12, 58, 63, 71 Ayachit, Guruprasad 109, 189 Ayala, Andrea 113, 184 Aylward, G. 24 Aziz-Sultan, Mohammad Ali 187 Bor, Elite 162, 163 Boscia, Francesco 79, 81 Bourla, Dan 162, 163 Boyer, David 18, 21, 34, 71, 76, 87, 94, 133 Bozorg, Sara 15 Braman, Jay 180 Branchini, Lauren 84, 166, 176, 177 Brantley, Jr., Milam 97 Bratu, Adriana 130, 190 Brechner, Ross 5, 38 Bressler, Neil 22, 38, 44, 75, 85, 103 Bressler, Susan 42, 44, 85 Brown, David 16, 20, 34, 71, 85, 173 Bruce, Beau 175 Buboltz, David 65, 140, 142 Bukelman, Amir 129 Burgess, Barry 57 Busbee, Brandon 86 Busija, Lucy 95 Cooney, Michael 155 Cooper, Robert 179 Cormier, Michel 82 Cornu, Denisse 101, 145 Correa, Zelia 56, 186 Costa, Rogerio 77 Coupland, Stuart 171 Couvillion, Stephen 28, 51 Crews, Jonathan 156 Crews, Kent 158 Cribbs, Blaine 116 Curcio, Christine 37 Finley, Thomas 184 Flaxel, Christina 89 Flores-Moreno, Ignacio 84 Flynn, Jr., Harry 43, 44, 94 Forlini, Cesare 130, 190 Forlini, Matteo 130, 190 Foster, Robert 52, 73 Foster, William 130 Foxman, Brett 7, 189 Francis, Peter 12, 89 Francisco, Pinto 148 Franco-Cardenas, Valentina 104, 168, 190 Francom, Steven 46 Franklin, Alan 88, 154 Freeman, William 15 Freund, K. Bailey 36, 38, 47, 92, 93, 154, 172 Friedenthal, Jenna 130, 149 Friedman, Duncan 118 Friedman, Neil 62 Friedmann, Peter 88 Fromow-Guerra, Jans 111, 167, 181, 183 Fujimoto, J.G. 84, 166 Fung, Anne 62
D
Dalma-Weiszhausz, Jose 111, 181 DAmico, Donald 132 Daniel, Connors 52, 143 Daniels, Stewart 58 Danis, Ronald 161 Daphna, Ofer 129 Das, Sima 12 Das, Taraprasad 174 Dave, Sarita 43 Dave, Vivek 160, 162 Davis, Joshua 130 Davis, Michael 34 De Silva, Anne 173 DeBoer, Charles 64 Dellatorre, Kara 47, 93 Desai, Uday 144 Desroches, Gilles 190 Devenyi, Robert 70, 121, 171 Dhoot, Dilsher 73, 144 Diaz-Llopis, Manuel 22 Dikshit, Siddharth 100, 124 Do, Diana 21, 23, 76, 115 Dolan, Chantal 22 Donoso, Larry 142 Dotan, Assaf 163 Drenser, Kimberly 40, 41, 42 Dresnik, Ayelet 162 Dubis, Adam 179 Dubra, Alfredo 179 Dugel, Pravin 11, 24, 25, 69, 71, 87 Duker, Jay 12, 84, 166, 176, 177 Dursun, Osman 119
C
Cable, Melissa 143 Cade, William 14 Cai, Jiyang 97 Cakir, Mehmet 125, 190 Calderon, Veronica 145 Callanan, David 4, 11, 18, 36, 107, 116 Campbell, John 85, 115, 166 Campochiaro, Peter 21, 32 Capone, Jr., Antonio 40, 42 Cardillo, Jose 72 Carlson, John 187 Carmodu, Jill 176 Carricondo, Pedro 139 Carroll, Joseph 179 Castellarin, Alessandro 28, 51 Cekic, Osman 119, 125, 190 Celik, Ugur 190 Cereda, Matteo 25 Chae, Ju Byung 107, 169 Chakravarti, Arindam 97 Chalam, K. 84, 86, 139, 141, 156, 175 Chan, Clement 49, 93, 187 Chan, Robison 72, 132, 181, 182 Chang, Gregory 191 Chang, Jeffrey 48 Chang, Stanley 131, 191 Chang, Tom 13, 34 Channa, Roomasa 21, 76, 115, 166 Charalampopoulos, Ioannis 153 Charkoudian, Leon 67 Charles, Martin 190 Charles, Steve 66, 67 Chaudhary, Varun 12 Chaudhry, Nauman 87, 94, 157 Chauhan, Rohan 115, 119, 189 Chaves, Fernando 136 Chawla, Dinesh 70, 96 Chen, Carolyn 45, 48 Chen, Ching 100, 190, 194 Chen, Jane 53 Chen, John 69 Chen, Xuejing 83 Cherney, Edward 170 Chhablani, Jay 135, 160, 162 Chiang, Allen 30 Chiriboga, Juan 113, 184 Cho, Brian 115, 166 Cho, Minhee 132 Choudhury, Tahsin 129 Chu, Thomas 21, 87, 133 Chun, Dal 79, 80 Ciampi, Jonathan 64 Cionni, Douglas 73 Cisiecki, Slawomir 135 Ciulla, Thomas 18 Clark, W. 34 Clayton, Richard 171 Coady, Patrick 62 Collinge, Janine 27 Colman, Shoshana 22 Colyer, Marcus 79, 80 Compton, Christopher 123 Conlan, Erica 45 Connors, Daniel 52, 143
G
G. Kumaramanick 97 Gabrielian, Anna 28, 69, 101 Galic, I. 69 Gallego-Pinazo, Roberto 22 Gallemore, Ron 168 Gan, Theresa 115, 166 Ganti, Shashi 70, 96 Gao, Hua 12, 144 Garcia, Maria Belen 120 Garcia, Patricia 35, 92 Garcia, Reinaldo 150 Garcia-Aguirre, Gerardo 111, 167, 181, 182, 183 Garg, Sunir 12, 30, 44, 59, 107, 138, 142, 153 Garner, Omai 118 Gautam, Manoj 135, 159 Gelman, Susan 130, 149 Genovesi-Ebert, Federica 64 Gentile, Ronald 36, 92 George, Ronnie 50 Georgopoulos, Minas 125 Gerhardt, Dennis 91 Giacomotti, Enrico 81 Giani, Andrea 59 Gill, Manjot 112, 186 Giordano, Veronica 183 Giovannini, Alfonso 126 Glassman, Adam 75 Glickman, Randolph 75 Goldhardt, Raquel 74 Goldman, Darin 116, 154 Goldstein, Debra 116 Gonzalez, Victor 68, 101, 145 Gopal, Lingam 180 Goren, Jordana 45 Govind, Kishan 107 Goyal, Mallika 12, 68, 108, 109 Graeber, Carolyn 130, 149 Grandhe, Sandeep 102 Grant, Scott 128 Gravanis, Achilleas 153 Greenberg, Paul 88 Gregori, Giovanni 13 Gregori, Ninel 74, 93, 126 Gregory, Gary 180 Gregory-Roberts, Emily 131 Greven, Craig 107 Gribben, Jeremy 171 Grigalunas, Alexander 122 Grinwalled, Yoel 129 Grob, Seanna 15 Grossniklaus, Hans 128 Guajardo, Beatrice 78 Guerrero-Naranjo, Jose 111, 167, 169, 181, 182, 183 Gupta, Anmol 62 Gupta, Charu 12, 24, 124, 147, 162, 192 Gupta, Gaurav 111 Gupta, Sunil 18, 88, 154 Guymer, Robyn 95
B
Bae, Jung Hoon 105 Bajaire, Boris 12, 189 Bakri, Sophie 31, 46 Balaiya, Sankarathi 84, 86 Balarin, Valdir 136 Baldivieso-Hurtado, Olivia 181 Bandello, Francesco 32, 155 Banker, Alay 68, 72, 115, 119, 189 Bansal, Alok 55 Bar, Diego 132 Barak, Adiel 27, 87 Barak, Yoreh 12, 120 Barbazetto, Irene 92, 155 Barkmeier, Andrew 165 Barnett, Jonathan 35 Barte, Felise 61 Basham, Ryah 101 Beardsley, Robert 165 Bedell, Matt 15 Bednarski, Maciej 135 Bell, Darren 78 Bennett, Jean 4, 16 Bennett, Michael 87 Beres, Tatiana 33 Bergstrom, Chris 113, 116, 128, 151 Berrocal, Audina 50, 180, 182 Berrocal, Maria 22, 120 Bhadri, Prashant 64 Bhatia, Gagan 192 Bhavsar, Kavita 48 Bhende, Muna 189 Bhende, Pramod 50, 68, 180, 189 Bhisitkul, Robert 32 Bianciotto, Carlos 55 Biswas, Jyotirmay 12 Bittencourt, Millena 166 Blinder, Kevin 69, 156, 190 Blumenkranz, Mark 62, 67 Boate, Alan 171
E
Edwards, Jayson 175 Edwards, Paul 144 Eells, Madeline 168 Ehlers, Justis 12, 37, 124, 164, 167 Ehrlich, Jason 20, 22 Eliott, Dean 67, 69, 73, 77, 193 Elman, Michael 103 El-Rayes, Ehab 26 Emanuelli, Andres 107, 126 Emerson, Geoffrey 12 Emond, Tracy 99, 118, 122, 123, 184 Erlanger, Michael 191
F
Fabian, Ido 27 Faez, MD Sepideh 110 Fahmy, Ahmed 76 Fan, Joseph 187 Fantoni, Gualtiero 64 Farah, Michel 24, 53, 61 Farsiu, Sina 141 Favarone, Guilleherme 132 Federici, Thomas 114, 151 Feist, Richard 99, 122, 123, 184 Fernandes, Cristina 187 Ferreira, Eber 53 Ferreira, Joao 190 Ferreira, Magno 24, 53 Ferreira, Raquel 53 Ferreyra, Henry 15 Ferrone, Philip 73, 74 Feuer, William 13, 62, 97 Fick, Tyler 48 Figueroa-Magana, Blanca 111 Filho, Acacio 53 Fine, Howard 52, 62, 97, 143 Fineman, Mitchell 153, 158
200
H
Ha, Man Mook 105 Haberman, Ilyse 130, 149 Hahn, Paul 169 Haines, Jonathan 14 Haller, Julia 32, 34, 38, 155 Halperin, Lawrence 38 Hamilton, John 171 Hancock, Heather 190 Harbour, J. William 56 Hariprasad, Seenu 81, 103 Harrie, Roger 150 Harris, Ian 13 Hartnett, Mary 150 Hassan, Kunle 160 Hassan, Tarek 7, 13, 29 Hatef, Elham 115, 166 Hayashi, Atsushi 170 He, Shikun 77 Heier, Jeffrey 15, 16, 21, 23, 34, 45, 48, 68, 71 Heilweil, Gad 35, 104, 168 Heo, Jang won 76 Hernandez-Bogantes, Erick 61 Hernandez-Da Mota, Sergio 140, 145 Hess, Ditte 180, 182 Heussen, Florian 14, 60, 177 Hicks, Joshua 99 Hidaka, Jiro 147 Hinkle, David 107 Hinton, David 77 Hirakata, Akito 140, 146 Ho Yen, Gregory 125 Ho, Allen 4, 13, 17, 59, 71 Ho, Lawrence 41 Hoang, Quan 47, 191 Holekamp, Nancy 31 Hollander, David 18 Hopkins, J. Jill 20 Hosseini, Kamran 82 Houghton, Odette 157 Houston, Samuel 50, 187 Hsu, Jason 30, 59, 138, 142, 153 Huang, Lynn 121 Huang, Suber 7, 13, 16, 51 Hubbard, G. Baker 37, 67, 116, 128 Hubschman, Jean-Pierre 35, 104, 168, 190 Hughes, Guy 15 Humayun, Mark 50, 64 Hunt, Christine 52 Huo, Siya 73 Hurley, Bernard 171 Hutchins, Robert 73 Hwang, Thomas 89
K
Kaiser, Peter 12, 26, 37, 38, 71, 73, 124, 164 Kaiser, Richard 30, 59, 153, 158 Kammer, Jeffery 170 Kassem, Nawal 90 Kegley, Eric 173 Kerns, Ralph 64 Kertes, Peter 70, 121 Keshavamurthy, Ravi 141 Kherani, Amin 41, 191 Khetpal, Vijay 84, 86, 139, 141, 156, 175 Khwaja, Afsheen 21, 76 Kiernan, Daniel 133 Kim, Bryan 156 Kim, Jee Taek 107 Kim, Leo 77 Kim, Moo Sang 106 Kim, Stephen 43, 170 Kim, Yoon Jeon 107 Kim, Young Gun 106 Kim, Yu Hyon 89 Kinori, Michael 27 Kishore, Kamal 90 Kiss, Szilard 132 Kitchens, John 90, 112, 191 Klancnik, Jr., James 155, 172 Kokame, Gregg 60 Komarnicky, Linda 55 Komarnicky, Lydia 55 Kon-Jara, Veronica 87, 94, 157 Korobelnik, Jean-Francois 34 Korotkin, Arthur 158 Koto, Takashi 117 Kovach, Jaclyn 14, 71 Kozak, Igor 15 Kuchtey, Rachel 170 Kumar, Neel 88, 154 Kumar, Neeru 75 Kunjukunju, Nancy 110 Kuppermann, Baruch 18, 32, 135, 155, 160 Kurli, Madhavi 127 Kurup, Shree 12, 36, 107 Kurup, Sudhi 112 Kwak, Hyung-Woo 106
Liu, Enchun 111 Liu, Jonathan 166 Loewenstein, Anat 27, 155 Logani, Sanjay 71 London, Nikolas 12, 87, 133, 158 Lopezcarasa Hernandez, Gabriela 69, 182 Lou, Jean 18 Lowder, Careen 12 Luo, Caesar 41, 138, 192 Luttrull, Jeffrey 72, 159 Lyndon, Lee 175
Murray, Timothy 7, 50, 71, 187 Murthy, Hemanth 135, 159 Mutapcic, Lejla 187 Myers, John 88, 154 Myung, Jane 132
N
Nagpal, Manish 191, 194 Naidu, Purshottam 97 Naimi, Elham Hatef 166 Naithani, Prashant 162 Nandakumar, Namrata 166 Narain, Shishir 12 Narala, Ramsudha 14, 177 Narayanan, Raja 100, 124, 135, 137, 160, 162, 174, 191 Naseri, Ayman 29 Nasir, Maan 28, 51 Natarajan, S. 68, 97 Nawrocka, Zofia 191 Nawrocki, Jerzy 127, 135, 191 Nelson, Mark 15, 70 Neravetla, Shantanu 162 Neri, Piergiorgio 126 Nguyen, Quan Dong 21, 76, 115, 116, 166 Nichols Kay, Christine 174 Nicholson, Benjamin 162 Nicolai, Michele 126, 134 Nielsen, Jared 48 Niffenegger, John 58 Nishida, Kohji 147 Noda, Toru 146 Nuthi, Asha 49, 93
M
MacCumber, Mathew 31, 101 Macky, Tamer 102 Maggio, Emilia 59 Maguire, Albert 1, 4, 16 Maguire, Joseph 30, 55, 59 Mahgoub, Mohamed 102 Maia, Mauricio 24, 53 Maisel, James 72 Majcher, Carolyn 98 Majji, Ajit 137, 174 Major, Jr., James, 85, 173 Malinowski, Susan 61, 161 Manjunath, Varsha 84 Marcus, Dennis 20 Margolis, Ron 36 Mariani, Angeline 85, 173 Mariotti, Cesare 126, 134 Martin, Daniel 12, 16, 37, 124, 164 Martin, Neil 27 Martinez-Castellanos, Maria 72, 169, 181, 182, 183 Mashayekhi, Arman 55 Mason, III, John 69, 99, 118, 122, 123, 184 Mateo, Carlos 131 Mathai, Annie 137, 174 Matthews, G. 64 Matti, Natalia 40 Maturi, Raj 103 Mavrikakis, Emmanouil 12, 173 Mavrofrides, Elias 180, 182 Mazzulla, Anthony 110 McCain, Mary Ann 86 McCannel, Colin 49, 70, 93, 118, 154 McCannel, Tara 55, 57 McCormick, Matthew 64 McDonnell, Emma 14, 177 Mein, Calvin 69 Melamud, Alexander 134 Melo, Gustavo 12 Mendonca, Luis 47, 98 Meredith, Travis 157 Messias, Andre 77 Mettu, Priyatham 141 Meza-De Regil, Armando 111 Michalewska, Zofia 127, 135, 191 Michalewski, Janusz 127, 135, 191 Mieler, William 4, 12, 17, 71 Migacz, Justin 169 Milder, Eugene 44 Miller, Daniel 52, 73 Miller, Joel 36 Mimouni, Karin 162, 163 Mines, Michael 80 Mitchell, Patrick 191 Mittra, Robert 69 Mochon, Brian 118 Moisseiev, Elad 27 Moisseiev, Joseph 27 Monshizadeh, Ramin 187 Montezuma, Sandra Rocio 191 Moraes-Junior, Milton 24 Morales-Canton, Virgilio 12, 31, 111, 167, 169, 181, 182, 183, 193 Moshfeghi, Andrew 82 Moshfeghi, Darius 46, 180 Moshiri, Ala 44 Motley, William 138 Mruthyunjaya, Prithvi 141 Mukkamala, Sri Krishna 36 Muldoon, Thomas 92 Mullins, Robert 174 Murahashi, Wendy Yee 163 Muralidhar, Naveenam 135, 159
O
OGrady, Michael 75 Ober, Michael 36, 61 OBryhim, Bliss 185 OConnell, Rachelle 169 Oderinlo, Olufemi 160 Odrobina, Dominik 135 Ohnuma, Kazuhiko 146 Oka, Miyako 170 Okonkwo, Ogugua 160 Oliver, Armando 36 Olk, R. 91, 192 Olsen, Matthew 190 Olsen, Timothy 116 Olson, Jeffrey 191 Orlin, Anton 132 Osborn, Melissa 97 Oshima, Yusuke 147 Otteson, Deborah 130 Oudovitchenko, Elena 189 Ouertani, Amel 106 Ouyang, Yanling 14, 60
L
Lai, James 60 Lai, Michael 27 Lai, Phillip 33, 46 Lalezary, Maziar 170, 183 Lalwani, Geeta 182 Lam, Wai-Ching 70, 90, 121, 173 Landa, Gennady 35, 92 Landers, Maurice 157 Lane, Richard 30 Larco, Sandra 113, 184 Lasave, Andres 22 Lavina, Adrian 182 Leal-Rodriguez, Ricardo 167 Leder, Henry 115, 166 Lee, Clara 15 Lee, Jacob 90 Lee, Jeong Hee 76 Lee, Joo Yong 95, 107, 169 Lee, Paul 22 Lee, Thomas 68 Leite, Thiago 139 Leon, Geoconda 184 Leonard, Brian 171 Leong, Craig 58 Letaief, Imene 106 Lewis, Shawn 73 Li, Lang 90 Li, Lina 96 Li, Xiao-Yan 18, 32, 94, 155, 161 Lim, Jennifer 21, 133, 171 Lim, Laurence 146 Lima, Luiz 64, 172 Lin, Bin 15 Lin, Phoebe 141 Lin, Steven 49, 93 Lingam, Vijaya 50 Lipkowitz, Jeffrey 12, 113 Lira, Rodrigo 114, 136 Liu, Ching-Chi 18, 94
I
Ibrahim, Mohamed 115, 166 Inoue, Makoto 117, 140, 146, 147 Iribarren, Guillermo 132 Isernhagen, Rick 90, 112 Izatt, Joseph 167, 169
P
Packo, Kirk 65, 67, 122, 152 Paipilla, Diego 12, 189 Paiva, Sergio 114 Palanker, Daniel 62 Palla, Michele 64 Panetta, Heitor 114, 136 Pappuru, Rajeev 137, 174 Park, Robert 137 Parke, III, David 50 Parke, II, David 5, 39 Parolini, Barbara 25, 59 Pate, James 191 Patel, Amar 127 Patel, Anu 161 Patel, Ravi 102, 103 Patel, Sunil 94 Patelli, Fabio 81 Pathangey, Avinash 137, 174 Paul, Kitia 45 Pawar, Sharmila 97 Payne, John 116, 175 Peng, Shaomin 96 Penha, Fernando 13, 24 Peralta, Enrique 91 Perez Reguera-Gutierrez, Adriana 111 Pericak-Vance, Margaret 14 Peris, Cristiane 53 Pertile, Grazia 25, 59
J
Jackson, Tim 87 Jadav, Dip 75 Jager, Rama 102 Jain, Pravin 191 Jain, Sachin 90 Jalali, Subhadra 100, 174 Jaffe, Glenn 16 Jampol, Lee 36, 186 Janmey, Paul 130 Javaheri, Michael 77 Jayasundera, Kanishka 69 Jiang, Lan 88 Jiao, Jenny 32, 155, 161 Jimenez-Sierra, Juan Manuel 12, 111, 167, 169 Joe, Soo Geun 95, 107, 169 Johnson, Mark 116 Jonisch, Jonathan 74, 156 Joos, Karen 170 Jorge, Rodrigo 77 Joseph, Daniel 83, 129 Jumper, J. Michael 17 Jung, Cecilia 116 Jung, Jesse 47
201
Participant Index
Pesavento, Richard 187 Petersen, Michael 52, 73 Peyman, Gholam 82 Pieramici, Dante 28, 33, 38, 51 Pitcher, III, John 104 Polito, Antonio 59 Pollack, Ayala 129 Pollack, John 18 Pomerleau, Dustin 99, 118, 122, 123, 184 Ponce, Alfonso 92 Popma, Sicco 13 Porco, Travis 29 Portillo, Natassha 150 Poulaki, Vassiliki 12 Prall, F. Ryan 187 Prasad, Pradeep 35, 168, 192 Prema, Abraham 49, 93 Prenner, Jonathan 17, 43, 52, 62, 97, 143 Prescott, Daniel 191 Priest, David 171 Purkiss, Todd 12
S
Sadda, Srinivas 14, 60, 161, 177 Safi, Farhad 80 Saggau, David 48 Sagoo, Mandeep 55 Sahu, Chinmaya 191 Saito, Masaaki 92, 98 Saitta, Andrea 126, 134 Salaroli, Camila 148 Salcedo-Villanueva, Guillermo 12, 169 Suleni-Had, Hani 77 Salguero, Andres 189 Samson, Michael 107 Samuel, Michael 13, 34 Sanchez Bermudez, Carlos Gustavo 167, 169 Sanders, Barton 97 Sanders, Reginald 38 Sandoval, Armando 113, 184 Saravia, Mario 182 Saroj, Namrata 32 Sarraf, David 49, 93, 116, 154, 165, 192 Sayegh, Samir 91, 192 Schaal, Shlomit 12, 120 Schachat, Andrew 164 Schiffman, Rhett 18 Schlenker, Matthew 70, 121 Schmidt-Erfurth, Ursula 15, 23 Schneider, Bryan 90 Schneider, Mark 187 Schroeder, Brett 179 Schwartz, Stephen 14, 93 Schwartz, Steven 35, 104, 168, 190 Scott, Bill 14 Scott, Ingrid 77 Scott, William 14, 71 Sears, Jonathan 37, 124, 144, 164 Sebag, Mikael 69 Seddon, Johanna 43 See, Robert 28, 51 Seider, Michael 29 Semidey, Valmore 101, 145 Sen, Nida 107 Sepah, Yasir 21, 76, 115, 166 Serrano, Martin 115 Serrano, Neha 134 Seth, Rajeev 83 Setlur, Vikram 138 Shah, Ankit 62, 97 Shah, Ankur 186 Shah, Bhavin 124, 135 Shah, Chirag 44, 45, 48, 142 Shah, Gaurav 69, 156, 190 Shah, Sumit 12 Shahidi, Mahnaz 171 Shantha, B., 50 Shao, Jack 124 Shapiro, Howard 32 Sharma, Bhavana 24, 124, 147, 162, 192 Sharma, Sumit 124 Sharma, Tarun 180 Shaw, Peter 15 Shaw, Robert 15 Sherman, Jerome 36 Sherman, Mark 120 Shibata, Suellen 139 Shields, Carol 12, 55, 57, 68, 188 Shields, Jerry 12, 55, 57, 68, 188 Shinoda, Kei 146 Shoshani, Nadav 27 Shrivastava, Anurag 121 Shroff, Cyrus 12, 24, 124, 147, 162, 192 Shroff, Daraius 12, 24, 124, 147, 162, 192 Shuler, Magdalena 88, 154 Shulman, Julia 150 Siegel, Ruth 162, 163 Silva Lopes, Mariana 44 Sinclair, Stephen 72, 98 Singer, Michael 71, 78, 94 Singh, A.K. 24, 124, 147, 162, 192
Q
Qian, Cynthia Xin-ya 149 Qiu, Caihong 96 Quiroz-Mercado, Hugo 72, 111, 181, 182 Qureshi, Salmaan 95
R
Rabena, Melvin 28, 51 Radhakrishnan, Ravi 139, 141, 156, 175 Radice, Paolo 81 Rahman, Hassan 113, 151 Ramaiya, Kamalesh 190 Ramos-Filho, Jos 77 Ranchod, Tushar 41, 58 Rao, Kavitha 159 Rao, Veena 83 Ravage, Zac 152 Ray, Aditi 65 Ray, Robin 37, 128 Ray, Subhransu 58 Recchia, Franco 12, 69, 170, 183 Reddy, Rahul 170 Reddy, Shantan 129, 130, 149 Reddy, Shilpa 122 Regatieri, Caio 61, 84, 166, 176, 177 Regillo, Carl 30, 55 Reichel, Elias 12 Renner, Morgan 76 Rentiya, Zubir 76 Reshef, Daniel 46 Rezaei, Kasra 97 Rezaei, Kourous 28, 69 Rezende, Flavio 148, 149, 193 Rha, Jungtae 179 Ribeiro, Jefferson 77 Rich, III, William 5, 39 Riemann, Christopher 52, 73, 142 Rizzo, Stanislao 64 Rizzolo, Lawrence 96 Robert, Marie-Claude 149 Roberts, Jr., John 156 Robertson, Zachary 100, 190 Robinson, Joshua 128 Roca, Jose 61, 120 Rodrigues, Eduardo 24, 53 Rodriguez, Leonidas 150 Roh, Young Jung 89 Rojas, Sergio 192 Romo-Garcia, Efrain 12 Roobini, Babak 114 Rosen, Richard 35, 92, 127 Rosenfeld, Philip 13, 38, 44 Rosenthal, Julie 12 Rossini, Paolo 130, 190 Roth, Daniel 52, 62, 97, 143 Rubin, Uriel 132 Rubio, Roman 32, 46 Ruiz-Garcia, Humberto 14, 177 Ryu, Hyun-Wok 89
Singh, Rishi 12, 37, 124, 144, 163, 164 Sinha, Manish 160 Sisk, Robert 50, 73, 138 Sivalingam, Arunan 30 Siwinska, Magdalena 127 Sjaarda, Raymond 178 Skaat, Alon 27 Slakter, Jason 92 Smith, Michael 80 Sobrin, Lucia 110 Sohn, Elliott 77 Song, Su Jeong 105 Soni, Malhar 125, 178, 192 Sorenson, John 36 Souza, Eduardo 12 Souza, Nonato 148 Spaide, Richard 12, 36, 37, 92, 98, 172 Spink, Charles 159 Spirn, Marc 30, 142, 153, 158 Srivastava, Sunil 37, 113, 116, 124, 128, 167 Stalmans, Peter 69, 79, 80 Steinle, Nathan 12 Stepien, Kimberly 71, 179 Sternberg, Jr., Paul 97 Stewart, Jay 29 Stone, Thomas 19, 90, 112 Stout, Timothy 143 Strauss, Danielle 129 Su, Chien-Chia 99 Suarez Tata, Luis 150 Suarez-Tata, Moravia 150 Sun, Jennifer 75 Suner, Ivan 22 Switzer, Jr., David 92, 98 Symons, Robert 185
V
Valeiras, Marcelo 132 Vander, James 30, 44, 59 VanderHoven, Cynthia 173 Varma, Rohit 22 Vergani, Sandro 81 Verne, Allen 58 Viti, Francesca 134 Vitti, Robert 34 Vozzi, Giovanni 64
W
Wallace, Lindsey 99, 118, 122, 123, 184 Wallsh, Josh 168 Walsh, Alexander 14, 60 Waltuck, Jonathan 113 Wang, Fenghua 13 Wang, Gaofeng 14 Ward, James 22 Warren, Keith 65 Wee, Raymond 60 Weinberger, Dov 87, 162, 163 Weiss, Matthew 74 Wells, III, John 105 Wen, Joanne 118 West, Constance 138 Wheatley, Harold 52, 143 Whitcup, Scott 18, 32, 94, 155, 161 Wickremasinghe, Sanjeewa 95 Williams, David 13, 16 Williamson, Paul 13 Witkin, Andre 59 Wong, David 69, 193 Wong, Doric 146 Wong, Edmund 146 Wong, Keye 58 Wong, Pamela 20 Wong, S. 41, 192 Wong, Tien 95 Wongskhaluang, Jeff 156 Wood, Edward 90, 112 Wood, William 90, 112 Woods, Paul 78 Wu, Chengqing 86 Wu, Lihteh 22, 61, 120 Wu, Melinda 57 Wu, Wen-Chih 88 Wykoff, Charles 44, 50
T
Ta, Christopher 70 Tabandeh, Homayoun 76, 87, 94, 133 Tai, Katy 35, 92 Takahashi, Walter 139 Takasaka, Iuuki 136 Tan, Donald 146 Tanaka, Tatiana 139 Tao, Yuankai 167 Tarantola, Ryan 174 Tarigopula, Sweta 144 Tawansy, Khaled 40, 41, 182 Taylor, Kelly 14 Teixeira Pinto, Anderson 148 Teramoto, Kyla 60 Tewari, Asheesh 69 Theodore, Sharon 93 Thomley, Martin 99, 122, 123, 184 Thompson, John 1, 7, 13, 16, 17, 45 Ting, Daniel 58 Tokunaga, Clayton 42 Toma, Hassanain 43 Tong, Melissa 12 Topping, Trexler 58 Torigoe, Andrea 136 Tornambe, Paul 64, 69, 78 Toth, Cynthia 167, 169 Traboulsi, Elias 73 Trese, Michael 41, 42, 68 Trichopoulos, Nikolaos 75 Tsai, Julie 114 Tseng, Victoria 88 Tsika, Chrysanthi 153 Tsilimbaris, Miltiadis 153 Tsoka, Pavlina 153 Tsuang, Angela 47 Tsui, Irena 35, 104, 121, 168 Tyagi, Mudit 137, 162, 174, 191 Tzatzarakis, Manolis 153
y
Yagou, Takaaki 170 Yan, Jiong 116 Yang, Chung-May 99 Yang, Michael 138 Yang, Sung Jae 95, 169 Yannuzzi, Lawrence 92, 155 Yau, Linda 20, 33, 163 Yazici, Ahmet 125, 190 Yeh, Steven 113, 116, 151, 175 Yehoshua, Zohar 13, 93 Yeung, Ling 60 Yoon, Nam Keun 187 Yoon, Young Hee 95, 107, 169 Yu, Seung-Young 106 Yuan, Alex 12, 144, 164 Yuksel, Kemal 125, 190 Yunoki, Tatsuya 170 Yuson, Ritchie 34
Z
Zacchia, Rafael 114 Zacharias, Leandro 139 Zayit-Soudry, Shiri 44 Zelkha, Ruth 171 Zhang, Kang 15, 69 Zhioua, Raja 106 Zhou, Jianbo 142 Zimmer-Galler, Ingrid 180 Zweifel, Sandrine 98
U
Uchida, Atsuro 117 Uy, Harvey 94
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Asrs Annu MTG 2011 Program

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The American Society of Retina Specialists is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide

continuing medical education for physicians.

Welcome to Boston and the ASRS 29th Annual Meeting!

Program by Day saTurDay, augusT 20

SYMPOSIUM 2: Awards and Special Presentations

Advantages and Challenges of Retinal Surgicenters

SUBSPECIALTY REVIEWS Cornea/Anterior Segment

Oculoplastics and Orbit

Retina Case Conference

Welcome Reception and Dinner

ASRS Business Meeting

SYMPOSIUM 1: Macular Degeneration I

Lunch in Exhibit Hall

SYMPOSIUM 3: Diabetic Retinopathy

SYMPOSIUM 11: Macular Degeneration III

SYMPOSIUM 4: Vitreoretinal Surgery I

SYMPOSIUM 7: Pediatric Retina

American Retina Foundations Run/Walk for the Retina

Women in Retina (WinR) Symposium and Lunch

SYMPOSIUM 12: Vitreoretinal Surgery III

Lunch in Exhibit Hall

Lunch in Exhibit Hall

SYMPOSIUM 8: Macular Degeneration II

Golf and Tennis Tournament Departures

Special Interest Groups Breakfast

INSTRUCTIONAL COURSES Continental Breakfast/Exhibits

SYMPOSIUM 9: Vitreoretinal Surgery II

SYMPOSIUM 5: Retinal Vascular/Imaging

Poster Session and Exhibit Hall Wine and Cheese Reception

Cocktail Reception, Gala Dinner and Umbo Lounge

SYMPOSIUM 13: Hereditary/Inflammatory/ Diabetic Retinopathy

New Member Reception Refreshment Break/Exhibits

The Value Modifier: Payment for Quality and Efficiency

SYMPOSIUM 14: Vitreoretinal Surgery IV

Continental Breakfast/Exhibits Scope of Practice Battles and the Retina Specialist

SYMPOSIUM 10: Ocular Oncology

Financial Interest Disclosures

educational content Development

Description of financial interest Presenters

name John T. Thompson, MD, Chair

Type of relationship I I I A, C, SH A, C, I A, C, SP A, C, SH A, C SP, I

Brett T. Foxman, MD Tarek S. Hassan, MD

Suber S. Huang, MD, MBA

Scientific Report Guidelines

Definitions of research and Human subjects

exemptions from irB activity

institutional review Boards (irB)

investigational use of Marketed Drugs, Biologics and Medical Devices

off-label use of Marketed Drugs, Biologics and Medical Devices

Continuing Medical Education

cME credit Awards

cME Mission Statement

Educational objectives and Goals

advantages and challenges of retinal surgicenters

cornea/ anterior segment

oculoplastics and orbit

reTina case conference

Retina case conference

Welcome reception and Dinner

continental Breakfast and exhibits

Symposium 1: Macular Degeneration i

Macular DegeneraTion i 7:309:30 AM