2017 National Optometry Workforce Study
Published 2020 by David Heath
Co-Author(s): Jennifer Spangler, Timothy Wingert, Mamie OD, Earl Smith, Lori Grover,, John Flanagan
Program Number: 200001
Article Type: Scientific Program
Purpose: Planning for the effective delivery of eye care, on all levels, depends upon an accurate and detailed knowledge of the optometric workforce and an understanding of demographic/behavioral trends to meet future needs of the public.The purpose of this study was to assess the current and future supply of doctors of optometry and to examine in-depth trends related to: 1) demographic shifts; 2) genderbased disparities; 3) differences in practice behaviors in between self-employed versus employed optometrists; and 4) the concept of "excess capacity"� within the profession.
Methods: The 2017 National Optometry Workforce Survey (31 items) was fielded to 4,050 optometrists, randomly sampled from a population of 45,033 optometrists contained in the AOA’s Optometry Master Data File. To ensure a representative sample, the study applied a stratified-sampling method. For comparative purposes, a number of questions replicated the 2012 Lewin Study[1], while others examined key trends.
Results: With a response rate of 29 percent, (1,158 responses), the sample ensured a 95 percent confidence interval with a margin of error of < 5 percent. Key results include finding no significant differences between men and women for hours worked (38.9 versus 37.5), productivity (patient visits/hour - 2.0 versus 1.9), or career options/prof growth satisfaction with 65 percent for both. The data indicates a likely range of
“additional patient” capacity of 2.29-2.57 patients/week, (5.05M-5.65M annually profession-wide).
Conclusion: The optometric workforce for the next decade is projected to grow 0.6-0.7 percent more annually than the U.S. population. The study found “additional capacity” for the profession more limited than previously suggested.[2] Findings also illustrate an evolving/equitable workforce based on gender, both in terms of productivity and satisfaction. The trends toward employed versus self-employed was marked with 44 percent reporting they are employed, up from 29 percent in 2012.
Methods: The 2017 National Optometry Workforce Survey (31 items) was fielded to 4,050 optometrists, randomly sampled from a population of 45,033 optometrists contained in the AOA’s Optometry Master Data File. To ensure a representative sample, the study applied a stratified-sampling method. For comparative purposes, a number of questions replicated the 2012 Lewin Study[1], while others examined key trends.
Results: With a response rate of 29 percent, (1,158 responses), the sample ensured a 95 percent confidence interval with a margin of error of < 5 percent. Key results include finding no significant differences between men and women for hours worked (38.9 versus 37.5), productivity (patient visits/hour - 2.0 versus 1.9), or career options/prof growth satisfaction with 65 percent for both. The data indicates a likely range of
“additional patient” capacity of 2.29-2.57 patients/week, (5.05M-5.65M annually profession-wide).
Conclusion: The optometric workforce for the next decade is projected to grow 0.6-0.7 percent more annually than the U.S. population. The study found “additional capacity” for the profession more limited than previously suggested.[2] Findings also illustrate an evolving/equitable workforce based on gender, both in terms of productivity and satisfaction. The trends toward employed versus self-employed was marked with 44 percent reporting they are employed, up from 29 percent in 2012.
2020 and Beyond Surgical Innovations and Updates
Published 2020 by Walter Whitley
Co-Author(s): Justin Schweitzer, Josh Johnston, Derek Cunningham
Article Type: Lectures & Workshops
This course will discuss numerous innovations in ophthalmic surgery and optometry�s role in the peri-operative management. Topics include an overview of surgical technologies from cataract to glaucoma to retina to cornea to oculoplastics. A discussion of advanced surgical options, indications for surgery, advantages and disadvantages of the procedure and post-operative care will be covered.
25 Secondary Glaucoma Facts An Evidence Based Overview
Published 2020 by Edward Chu
Co-Author(s): NULL
Article Type: Lectures & Workshops
This course will present 25 facts about secondary glaucoma (pseudoexfoliation, pigment dispersion, traumatic, uveitic, steroid-induced, neovascular) that will help optometrists diagnose, manage, and treat the disease based on clinical evidence and recommended standards of care. The design of the course is to provide a broad overview of secondary glaucoma studies and findings that impact patient care and management. It will include risk factors for secondary glaucoma development, important clinical findings, and other tips for improving patient outcomes.
45Degree Horizontal Gaze Angle Estimation Among Police Officers vs Optometrists vs Optometry Students
Published 2020 by Suzanne Falkowski
Co-Author(s): Christopher Borgman, Michael Christensen
Program Number: 205051
Article Type: Scientific Program
Purpose: This study compares the ability of optometry students, optometry faculty members, and police officers to estimate a horizontal gaze angle of 45 degrees. This angle estimation is used by police officers for the Horizontal Gaze Nystagmus test as part of their standard field sobriety testing performed at roadside.
Methods: There were 30 participants in each group (90 subjects total). Police officers are members of the Memphis Police Department. Optometry students are part of the Class of 2022 at Southern College of Optometry. Data was collected during their second year. Faculty are also from Southern College of Optometry. A vision disk was used to measure the approximated angles by placing it on the researcher’s forehead. The participants were instructed to estimate 45 degrees from straight primary gaze. The participant’s finger was used as the target for the researcher to follow out to where the participant estimated 45 degrees to be. The measurement was taken 3 times on each side, alternating from left to right. The data was analyzed using a mixed effects linear regression model with a random subject-specific intercept to compare within- and between-groups.
Results: On average, participants in each group tended to provide under-target estimates of the desired 45-degree angle. Findings from the statistical model show that there were significant differences by Occupation Group (overall contrast x2 = 9.29; p< .01), especially between police officer and faculty groups. Students fell between the two groups. Data showed less under-targeting after the first measurement (overall contrast x2 = 14.61; p< .001). It also depended on the side of the measurement. Left-side angle measurements were under-targeted less (by about 2.6 degrees) than right-side measurements (p< .001).
Results: On average, police officers underestimated the 45-degree angle, while faculty had the highest rates of accuracy (45° +/- 3°) in judging the angle, but also tended to over-estimate. Students fell between police officers and faculty in accuracy.
Methods: There were 30 participants in each group (90 subjects total). Police officers are members of the Memphis Police Department. Optometry students are part of the Class of 2022 at Southern College of Optometry. Data was collected during their second year. Faculty are also from Southern College of Optometry. A vision disk was used to measure the approximated angles by placing it on the researcher’s forehead. The participants were instructed to estimate 45 degrees from straight primary gaze. The participant’s finger was used as the target for the researcher to follow out to where the participant estimated 45 degrees to be. The measurement was taken 3 times on each side, alternating from left to right. The data was analyzed using a mixed effects linear regression model with a random subject-specific intercept to compare within- and between-groups.
Results: On average, participants in each group tended to provide under-target estimates of the desired 45-degree angle. Findings from the statistical model show that there were significant differences by Occupation Group (overall contrast x2 = 9.29; p< .01), especially between police officer and faculty groups. Students fell between the two groups. Data showed less under-targeting after the first measurement (overall contrast x2 = 14.61; p< .001). It also depended on the side of the measurement. Left-side angle measurements were under-targeted less (by about 2.6 degrees) than right-side measurements (p< .001).
Results: On average, police officers underestimated the 45-degree angle, while faculty had the highest rates of accuracy (45° +/- 3°) in judging the angle, but also tended to over-estimate. Students fell between police officers and faculty in accuracy.
5year Outcomes of Microinvasive Glaucoma Surgery with iStent injecti®i 2supndsupGeneration Trabecular Microbypass Stent Combined with Topical Prostaglandin
Published 2020 by Damon Dierker
Co-Author(s): NULL
Program Number: 205401
Article Type: Scientific Program
Purpose: To assess long-term outcomes following standalone implantation of 2nd-generation trabecular micro-bypass stents (iStent inject®) combined with travoprost in subjects with open-angle glaucoma (OAG) on 2 preoperative medications (meds). The combination of these treatments targets two different outflow pathways: conventional trabecular outflow via trabecular micro-bypass stents and uveoscleral outflow via prostaglandin analogue eye drop.
Methods: This 5-year prospective single-arm study enrolled subjects with OAG on 2 ocular hypotensive meds and with preoperative intraocular pressure (preop IOP) of 18-30 mmHg (medicated) and 22-38 mmHg (post-washout). Subjects underwent standalone implantation of iStent inject and started topical travoprost on postoperative Day 1. Annual medication washouts were performed. Assessments included IOP, meds, adverse events, best-corrected visual acuity (BCVA), visual fields (VF), cup-to-disc (C:D) ratio, and slit-lamp, gonioscopic, optic nerve, and funduscopic examinations. This study was carried out in accordance with the tenets of the Declaration of Helsinki and applicable local regulations.
Results: All 53 enrolled subjects underwent uncomplicated iStent inject implantation and completed 5 years of follow-up. At M60 postop, mean IOP on travoprost reduced to 12.0 mmHg, a 39% reduction vs preop IOP of 19.7 mmHg on 2 meds (p<0.0001). At M61 (after washout), mean unmedicated IOP was 16.1 mmHg, a 35% reduction vs preop washout IOP of 24.9 mmHg (p<0.0001). Mean medicated IOP remained ≤13.0 mmHg at all postop visits through M60. 92.5% of eyes achieved M60 IOP ≤18 mmHg on travoprost and 88.7% achieved IOP ≤15 mmHg on travoprost. 4 eyes required additional medication, but all remaining eyes were on travoprost alone throughout the study. BCVA, C:D, and VF were stable through 5 years; no eyes had secondary glaucoma surgery.
Results: In this study in glaucomatous eyes with IOP not controlled on 2 meds, the combination of standalone iStent inject implantation with topical prostaglandin – thereby enhancing both trabecular and uveoscleral outflow - resulted in significant and sustained 5-year IOP and med reductions with a favorable safety profile. This corroborates the growing evidence base for this device in treating glaucoma.
Methods: This 5-year prospective single-arm study enrolled subjects with OAG on 2 ocular hypotensive meds and with preoperative intraocular pressure (preop IOP) of 18-30 mmHg (medicated) and 22-38 mmHg (post-washout). Subjects underwent standalone implantation of iStent inject and started topical travoprost on postoperative Day 1. Annual medication washouts were performed. Assessments included IOP, meds, adverse events, best-corrected visual acuity (BCVA), visual fields (VF), cup-to-disc (C:D) ratio, and slit-lamp, gonioscopic, optic nerve, and funduscopic examinations. This study was carried out in accordance with the tenets of the Declaration of Helsinki and applicable local regulations.
Results: All 53 enrolled subjects underwent uncomplicated iStent inject implantation and completed 5 years of follow-up. At M60 postop, mean IOP on travoprost reduced to 12.0 mmHg, a 39% reduction vs preop IOP of 19.7 mmHg on 2 meds (p<0.0001). At M61 (after washout), mean unmedicated IOP was 16.1 mmHg, a 35% reduction vs preop washout IOP of 24.9 mmHg (p<0.0001). Mean medicated IOP remained ≤13.0 mmHg at all postop visits through M60. 92.5% of eyes achieved M60 IOP ≤18 mmHg on travoprost and 88.7% achieved IOP ≤15 mmHg on travoprost. 4 eyes required additional medication, but all remaining eyes were on travoprost alone throughout the study. BCVA, C:D, and VF were stable through 5 years; no eyes had secondary glaucoma surgery.
Results: In this study in glaucomatous eyes with IOP not controlled on 2 meds, the combination of standalone iStent inject implantation with topical prostaglandin – thereby enhancing both trabecular and uveoscleral outflow - resulted in significant and sustained 5-year IOP and med reductions with a favorable safety profile. This corroborates the growing evidence base for this device in treating glaucoma.
A Blinkassisted Corneasparing Wearable Thermal Eyelid Device and Meibomian Gland Clearance for the Safe and Effective Treatment of Dry Eye Disease A Prospective Randomized Controlled Trial OLYMPIA
Published 2020 by Bobby Saenz
Co-Author(s): Paul Karpecki, Marc Bloomenstein, Edward Holland
Program Number: 205085
Article Type: Scientific Program
Purpose: To study the safety and effectiveness of single treatment of TearCare®, Sight Sciences (TC) in treating the signs and symptoms of dry eye associated with meibomian gland dysfunction (MGD) in comparison with single treatment of LipiFlow®, Johnson & Johnson (LF).
Methods: Subjects with signs and symptoms of DED and MGD (N=136) were randomized 1:1 to a single treatment of either TC or LF in this prospective, masked, multi-center trial at 10 US sites. Key inclusion criteria were regular use of lubricating drops, Ocular Surface Disease Index (OSDI) score between 23 to 79, Meibomian gland secretion score (MGSS) ≤12, TBUT of ≤7, Best corrected visual acuity (BCVA) of 20/100 or better and at least 15 expressible glands in each lower eyelid. Subjects were seen at Baseline and post treatment Day 1, Week 2 and Month 1. TBUT and MGSS were measured as primary endpoints. Corneal conjunctival staining, number of meibomian glands yielding clear and any liquid were collected as secondary signs. Symptoms were recorded in form of OSDI, Symptom Assessment in Dry Eye (SANDE) and Eye Dryness Severity (EDS) questionnaires. Adverse events (AE) were recorded for safety. Non-inferiority of TC compared to LF in improving TBUT and MGSS was evaluated at 1 month.
Results: Both groups demonstrated significant improvements in mean TBUT and MGS, 3.0±4.4 and 11.2±11.1 in the TC group and 2.6±3.3 and 11.09±10.4 in the LF group (P<.0001). In TC group mean corneal and conjunctival staining was reduced respectively by 0.3±1.2 and 0.7±2.2; the mean number of expressible glands and glands expressing clear liquid increased respectively by 4.3±3.6 and 1.8±3.7. In TC group there was an improvement in mean SANDE, EDS and OSDI scores respectively by 38.2±31.0, 35.4±34.1 and 27.9±20.6. There weren’t statistically detectable differences for any
Results: compared to LF group. However, the TC group demonstrated consistently greater improvements in all signs and symptoms. Notably, TC group had a statistically significantly higher proportion of subjects (72%) improving by at least 1 OSDI category than did the LF group (59%); p<0.04. Device related ocular AEs were reported in 2 subjects (loss of VA) of TC group and 3 subjects (loss of VA, corneal abrasion and foreign body sensation) of LF group.
Results: A single treatment of TearCare® safely and successfully treats signs and symptoms of DED in subjects with MGD. The non-inferiority objective was met. A greater proportion of subjects in the TearCare group reported better symptomatic relief compared to the LipiFlow group assessed by patient reported outcomes. Statistically significantly higher number of subjects in TearCare group showed clinically meaningful improvement in symptoms as shown by OSDI.
Methods: Subjects with signs and symptoms of DED and MGD (N=136) were randomized 1:1 to a single treatment of either TC or LF in this prospective, masked, multi-center trial at 10 US sites. Key inclusion criteria were regular use of lubricating drops, Ocular Surface Disease Index (OSDI) score between 23 to 79, Meibomian gland secretion score (MGSS) ≤12, TBUT of ≤7, Best corrected visual acuity (BCVA) of 20/100 or better and at least 15 expressible glands in each lower eyelid. Subjects were seen at Baseline and post treatment Day 1, Week 2 and Month 1. TBUT and MGSS were measured as primary endpoints. Corneal conjunctival staining, number of meibomian glands yielding clear and any liquid were collected as secondary signs. Symptoms were recorded in form of OSDI, Symptom Assessment in Dry Eye (SANDE) and Eye Dryness Severity (EDS) questionnaires. Adverse events (AE) were recorded for safety. Non-inferiority of TC compared to LF in improving TBUT and MGSS was evaluated at 1 month.
Results: Both groups demonstrated significant improvements in mean TBUT and MGS, 3.0±4.4 and 11.2±11.1 in the TC group and 2.6±3.3 and 11.09±10.4 in the LF group (P<.0001). In TC group mean corneal and conjunctival staining was reduced respectively by 0.3±1.2 and 0.7±2.2; the mean number of expressible glands and glands expressing clear liquid increased respectively by 4.3±3.6 and 1.8±3.7. In TC group there was an improvement in mean SANDE, EDS and OSDI scores respectively by 38.2±31.0, 35.4±34.1 and 27.9±20.6. There weren’t statistically detectable differences for any
Results: compared to LF group. However, the TC group demonstrated consistently greater improvements in all signs and symptoms. Notably, TC group had a statistically significantly higher proportion of subjects (72%) improving by at least 1 OSDI category than did the LF group (59%); p<0.04. Device related ocular AEs were reported in 2 subjects (loss of VA) of TC group and 3 subjects (loss of VA, corneal abrasion and foreign body sensation) of LF group.
Results: A single treatment of TearCare® safely and successfully treats signs and symptoms of DED in subjects with MGD. The non-inferiority objective was met. A greater proportion of subjects in the TearCare group reported better symptomatic relief compared to the LipiFlow group assessed by patient reported outcomes. Statistically significantly higher number of subjects in TearCare group showed clinically meaningful improvement in symptoms as shown by OSDI.
A CIN to Miss
Published 2020 by Akirta Sran
Co-Author(s): NULL
Article Type: Residents Day
Abstract: Conjunctival intraepithelial neoplasia (CIN), a common non-invasive single cell mutation of the ocular surface, is often found in older, light skinned, fair-eyed individuals. This case will discuss the diagnosis and treatment of bilateral CIN.
Case History: 95yo Caucasian Female
Cc: Blur with bifocals
Systemic hx:
-Hypothyroidism s/p thyroidectomy
-Breast cancer s/p radiation
-Hysterectomy
-Stroke
Ocular hx:
-Cataract extraction/PCIOL OU
-Macular degeneration OU
Medications:
-Levothyroxine
-AREDS2
Pertinent Findings: -VA: 20/30-2 OD/OS
-Anterior Segment:
Bilateral temporal bulbar conjunctival white keratinized lesions with jagged edges crossing the limbus onto the cornea OD>OS, (+) fluorescein staining, mild vascularization
OD: 1.7mm H at the widest superior edge x 2.6mm V
OS: 1mm V x 0.5mm H
-IOP 31/26mmHg OD/OS with GAT
-Gonioscopy:
Open to CBB 360 (-) PXE, PS, PAS, PDS. Temporal angle pigmentation, fine vessels, and areas of attachment OD/OS
-Anterior segment OCT/photos acquired
Differential Diagnosis: Ocular Surface Squamous Neoplasia (OSSN)
-Conjunctival Intraepithelial Neoplasia (CIN)
---Simple Dysplasia
---Carcinoma in situ
-Squamous Cell Carcinoma (SCC)
Benign Lesions
-Pinguecula
-Pterygium
-Pannus
-Amelanotic Conjunctival Nevus
Other Malignant Lesions
-Amelanotic Conjunctival Melanoma
-Conjunctival Lymphoma
Diagnosis and Discussion: -Cross over onto the cornea ruled out pinguecula. Atypical for pannus, the lesions were elevated, located at the limbus, and minimally vascularized. While pterygia are wing-shaped and usually nasal, these lesions were oval, temporal, and distinctly leukoplakic, unlike amelanotic conjunctival melanomas which are often yellowish with significant vascularization, and lymphoma which are typically pink.
-Clinical appearance guided the initial diagnosis of OSSN with high suspicion for CIN
-CIN is a subtype of OSSN, occurring when the ocular surface epithelium is dysplastic. Abnormal cells invade superficially.
-Typically unilateral in middle aged to elderly patients at the limbus with possible extension onto the corneal epithelium
-Can be categorized as papilliform, leukoplakic or gelatinous, appearing slightly elevated, sessile or flesh-like; stains with rose bengal dye
-Differentiating stages of CIN cannot be completed clinically and must involve histopathological analysis
-Causes include: UV exposure, (+) human immunodeficiency virus (HIV), (+) human papillomavirus infection
Treatment, Management: -Patient was referred to cornea/glaucoma and ocular oncology: latanoprost qhs OU was initiated with an IOP of 14/15mmHg at 2-week f/u, and excisional biopsy was ordered to confirm histopathology/treatment plan for CIN
-S/p biopsy, typical management of CIN includes cryotherapy
Depending on
Results:, additional treatments may be added:
-Interferon (IFN) alpha-2B
-mitomycin C (MMC) 0.04%
-fluorouracil (5-FU) 1%
Results: -CIN can be asymptomatic, but redness, irritation, or pain are commonly reported
-Elderly, immunocompromised, or HIV positive individuals are more susceptible
-Limbal presentation is pathognomonic
-Recurrences are common and not always correlated with the category of CIN; therefore, all CIN patients should be followed yearly at a minimum
-CIN can progress to SCC, which can lead to metastasis or vision loss Bibliography: -Bellerive C, Berry JL, Polski A, Singh AD. Conjunctival Squamous Neoplasia. Cornea 2018;37:1287"�91.
-Kiire CA, Dhillon B. The aetiology and associations of conjunctival intraepithelial neoplasia. British Journal of Ophthalmology 2006;90:109"�13.
-Sayed-Ahmed IO, Palioura S, Galor A, Karp CL. Diagnosis and Medical Management of Ocular Surface Squamous Neoplasia. Expert Rev Ophthalmol 2016;12:11"�9.
-Shields CL, et al. Conjunctival Tumors: Review of Clinical Features, Risks, Biomarkers, and Outcomes"�The 2017 J. Donald M. Gass Lecture. Asia Pac. J. Ophthalmol. (Phila) 2017;6:109"�120.
-Shields CL, Demirci H, Karatza E, Shields JA. Clinical survey of 1643 melanocytic and nonmelanocytic conjunctival tumors. Ophthalmology. 2004; 111:1747"�1754.
Case History: 95yo Caucasian Female
Cc: Blur with bifocals
Systemic hx:
-Hypothyroidism s/p thyroidectomy
-Breast cancer s/p radiation
-Hysterectomy
-Stroke
Ocular hx:
-Cataract extraction/PCIOL OU
-Macular degeneration OU
Medications:
-Levothyroxine
-AREDS2
Pertinent Findings: -VA: 20/30-2 OD/OS
-Anterior Segment:
Bilateral temporal bulbar conjunctival white keratinized lesions with jagged edges crossing the limbus onto the cornea OD>OS, (+) fluorescein staining, mild vascularization
OD: 1.7mm H at the widest superior edge x 2.6mm V
OS: 1mm V x 0.5mm H
-IOP 31/26mmHg OD/OS with GAT
-Gonioscopy:
Open to CBB 360 (-) PXE, PS, PAS, PDS. Temporal angle pigmentation, fine vessels, and areas of attachment OD/OS
-Anterior segment OCT/photos acquired
Differential Diagnosis: Ocular Surface Squamous Neoplasia (OSSN)
-Conjunctival Intraepithelial Neoplasia (CIN)
---Simple Dysplasia
---Carcinoma in situ
-Squamous Cell Carcinoma (SCC)
Benign Lesions
-Pinguecula
-Pterygium
-Pannus
-Amelanotic Conjunctival Nevus
Other Malignant Lesions
-Amelanotic Conjunctival Melanoma
-Conjunctival Lymphoma
Diagnosis and Discussion: -Cross over onto the cornea ruled out pinguecula. Atypical for pannus, the lesions were elevated, located at the limbus, and minimally vascularized. While pterygia are wing-shaped and usually nasal, these lesions were oval, temporal, and distinctly leukoplakic, unlike amelanotic conjunctival melanomas which are often yellowish with significant vascularization, and lymphoma which are typically pink.
-Clinical appearance guided the initial diagnosis of OSSN with high suspicion for CIN
-CIN is a subtype of OSSN, occurring when the ocular surface epithelium is dysplastic. Abnormal cells invade superficially.
-Typically unilateral in middle aged to elderly patients at the limbus with possible extension onto the corneal epithelium
-Can be categorized as papilliform, leukoplakic or gelatinous, appearing slightly elevated, sessile or flesh-like; stains with rose bengal dye
-Differentiating stages of CIN cannot be completed clinically and must involve histopathological analysis
-Causes include: UV exposure, (+) human immunodeficiency virus (HIV), (+) human papillomavirus infection
Treatment, Management: -Patient was referred to cornea/glaucoma and ocular oncology: latanoprost qhs OU was initiated with an IOP of 14/15mmHg at 2-week f/u, and excisional biopsy was ordered to confirm histopathology/treatment plan for CIN
-S/p biopsy, typical management of CIN includes cryotherapy
Depending on
Results:, additional treatments may be added:
-Interferon (IFN) alpha-2B
-mitomycin C (MMC) 0.04%
-fluorouracil (5-FU) 1%
Results: -CIN can be asymptomatic, but redness, irritation, or pain are commonly reported
-Elderly, immunocompromised, or HIV positive individuals are more susceptible
-Limbal presentation is pathognomonic
-Recurrences are common and not always correlated with the category of CIN; therefore, all CIN patients should be followed yearly at a minimum
-CIN can progress to SCC, which can lead to metastasis or vision loss Bibliography: -Bellerive C, Berry JL, Polski A, Singh AD. Conjunctival Squamous Neoplasia. Cornea 2018;37:1287"�91.
-Kiire CA, Dhillon B. The aetiology and associations of conjunctival intraepithelial neoplasia. British Journal of Ophthalmology 2006;90:109"�13.
-Sayed-Ahmed IO, Palioura S, Galor A, Karp CL. Diagnosis and Medical Management of Ocular Surface Squamous Neoplasia. Expert Rev Ophthalmol 2016;12:11"�9.
-Shields CL, et al. Conjunctival Tumors: Review of Clinical Features, Risks, Biomarkers, and Outcomes"�The 2017 J. Donald M. Gass Lecture. Asia Pac. J. Ophthalmol. (Phila) 2017;6:109"�120.
-Shields CL, Demirci H, Karatza E, Shields JA. Clinical survey of 1643 melanocytic and nonmelanocytic conjunctival tumors. Ophthalmology. 2004; 111:1747"�1754.
A Case Report of Pigmented Paravenous Retinochoroidal Atrophy
Published 2020 by Jolinda Tam
Co-Author(s): Andrea Yiasemis
Program Number: 205314
Article Type: Scientific Program
Purpose: Pigmented paravenous retinochoroidal atrophy (PPRCA) is an uncommon, non-progressive condition that commonly affects both eyes symmetrically. Individuals affected by PPRCA are typically asymptomatic, whereby the discovery of the pigment accumulation along the retinal veins is incidental. However, this is an atypical case of an individual with asymmetric presentation who is also symptomatic.
Case Report: A 57-year-old Caucasian male presents for a comprehensive eye exam with concern that he cannot see things on the ground while walking. He reports being diagnosed with retinitis pigmentosa when he was approximately 37 years old. Vision is correctable to 20/20 OD and OS, dilated fundus examination reveals prominent bone spicules along the retinal veins, far more extensive in the OD than OS. Goldmann visual field
Results: in field defects fairly consistent with areas of retinal pigment epithelium (RPE) dropout as seen on fundus autofluorescence (FAF).
Results: Though PPRCA is commonly thought to be bilateral and symmetrical, our patient has an asymmetrical presentation. Additionally, it is thought that most individuals affected by this condition are asymptomatic, whereas, our patient presented with concern of a reduced inferior visual field. Goldmann was completed to assess if the patient qualified for low vision services. Given his findings, we were able to help him obtain orientation and mobility training with the yellow cane. Even though PPRCA is not known to commonly cause the individual any visual impairment, it is important to assess this on a case by case fashion.
Case Report: A 57-year-old Caucasian male presents for a comprehensive eye exam with concern that he cannot see things on the ground while walking. He reports being diagnosed with retinitis pigmentosa when he was approximately 37 years old. Vision is correctable to 20/20 OD and OS, dilated fundus examination reveals prominent bone spicules along the retinal veins, far more extensive in the OD than OS. Goldmann visual field
Results: in field defects fairly consistent with areas of retinal pigment epithelium (RPE) dropout as seen on fundus autofluorescence (FAF).
Results: Though PPRCA is commonly thought to be bilateral and symmetrical, our patient has an asymmetrical presentation. Additionally, it is thought that most individuals affected by this condition are asymptomatic, whereas, our patient presented with concern of a reduced inferior visual field. Goldmann was completed to assess if the patient qualified for low vision services. Given his findings, we were able to help him obtain orientation and mobility training with the yellow cane. Even though PPRCA is not known to commonly cause the individual any visual impairment, it is important to assess this on a case by case fashion.
A Case Report of Retrograde TransSynaptic Degeneration as Documented by Optical Coherence Tomography
Published 2020 by Anne Bertolet
Co-Author(s): Rachel Druckenbrod
Program Number: 205425
Article Type: Scientific Program
Purpose: The purpose of this case is to demonstrate retrograde trans-synaptic degeneration (RTSD) in a patient with a left inferior paracentral defect after an ischemic stroke of the right occipital lobe. Only recently was RTSD demonstrated using optical coherence tomography (OCT) technology and this case shows statistically significant changes of the ganglion cell layer (GCL) thickness over the first year in quadrants corresponding to the right occipital lobe.
Case Report: A 73-year old white male presented to the eye clinic after noticing a new black spot in his vision after an initial ‘white out’ of vision three days prior. He denied any other acute neurological symptoms. His previous ocular history included a retinal hole of his right eye. His medical history was significant for prostate cancer s/p prostatectomy and radiation therapy, monoclonal gammopathy of uncertain significance, and hyperlipidemia for which he was taking 10mg of simvastatin. The eye exam revealed a left inferior paracentral visual field defect in both eyes. Ocular health was otherwise unremarkable. He was sent for an emergent stroke workup. Brain imaging revealed restricted diffusion of the medial inferior right occipital lobe, approximately 1.6cm in size. No underlying cause was identified, and the patient was discharged on clopidogrel and an increased statin dose. Our patient was seen in the eye clinic 13 months later with significant changes in GCL thickness on OCT measurements comparing the affected retinal hemispheres (temporal of the right eye and nasal of the left eye) with the unaffected hemispheres (p=0.01, t-test). This was stable with repeat imaging 16 months after initial presentation (p=0.006, t-test). Greatest thinning was noted in the superior temporal quadrant of the right eye and the superior nasal quadrant of the left eye (-8um and -8.75um, respectively at 16 months), corresponding to the left inferior paracentral visual field defect. Mild thinning was also noted in the inferior temporal quadrant of the right eye and the inferior nasal quadrant of the left eye (-4.5um and -4um, respectively at 16 months) though no visual field defect was noted to be present in the corresponding quadrant. Unaffected quadrants showed minimal changes after 16 months (Right: -1.25um inferior nasal and -1.5um superior nasal; Left: -0.75um inferior temporal and -1.5um superior temporal).
Results: This case demonstrates RTSD with statistically significant changes in GCL measurements over the first year after an acute brain lesion, even in areas not directly corresponding to a detectable visual field defect. The role of OCT in the workup of visual cortex brain lesions and understanding visual recovery potential is still being explored. Eyecare providers should consider OCT as an adjunct when patients present with new homonymous visual field defects.
Case Report: A 73-year old white male presented to the eye clinic after noticing a new black spot in his vision after an initial ‘white out’ of vision three days prior. He denied any other acute neurological symptoms. His previous ocular history included a retinal hole of his right eye. His medical history was significant for prostate cancer s/p prostatectomy and radiation therapy, monoclonal gammopathy of uncertain significance, and hyperlipidemia for which he was taking 10mg of simvastatin. The eye exam revealed a left inferior paracentral visual field defect in both eyes. Ocular health was otherwise unremarkable. He was sent for an emergent stroke workup. Brain imaging revealed restricted diffusion of the medial inferior right occipital lobe, approximately 1.6cm in size. No underlying cause was identified, and the patient was discharged on clopidogrel and an increased statin dose. Our patient was seen in the eye clinic 13 months later with significant changes in GCL thickness on OCT measurements comparing the affected retinal hemispheres (temporal of the right eye and nasal of the left eye) with the unaffected hemispheres (p=0.01, t-test). This was stable with repeat imaging 16 months after initial presentation (p=0.006, t-test). Greatest thinning was noted in the superior temporal quadrant of the right eye and the superior nasal quadrant of the left eye (-8um and -8.75um, respectively at 16 months), corresponding to the left inferior paracentral visual field defect. Mild thinning was also noted in the inferior temporal quadrant of the right eye and the inferior nasal quadrant of the left eye (-4.5um and -4um, respectively at 16 months) though no visual field defect was noted to be present in the corresponding quadrant. Unaffected quadrants showed minimal changes after 16 months (Right: -1.25um inferior nasal and -1.5um superior nasal; Left: -0.75um inferior temporal and -1.5um superior temporal).
Results: This case demonstrates RTSD with statistically significant changes in GCL measurements over the first year after an acute brain lesion, even in areas not directly corresponding to a detectable visual field defect. The role of OCT in the workup of visual cortex brain lesions and understanding visual recovery potential is still being explored. Eyecare providers should consider OCT as an adjunct when patients present with new homonymous visual field defects.
A Case of Enucleation Following Poorly Controlled Ocular Surface Disease Status Post Dacryoadenectomy
Published 2020 by Rachel Sequeira
Co-Author(s): NULL
Article Type: Residents Day
Abstract: The lacrimal gland is a necessary component in maintaining tear film stability and ocular health. This paper reviews the potential sequelae of severe ocular surface disease, including enucleation, following dacryoadenectomy.
Case History: A 61-year-old Israelian woman presents in November 2019 for a follow-up with symptoms of worsening ocular dryness and pain OS>OD. Current treatment is Lotemax QD, lid hygiene, hot compresses, Ocunox QHS, Hylo gel BID, Systane Ultra PRN, and autologous serum (AS) QID. She presented initially in June 2019 for a second opinion on filamentary keratitis secondary to aqueous deficiency following a left dacryoadenectomy in 2003. She had been seeing a local ophthalmologist and using Systane Ultra 20x per day and AS QID OS. She had cataract surgery OD 2018 and lower punctum cauterization OS. Medical history positive for vasculitis, arthritis, hypertension, and hypercholesteremia, and medications include risedronate, Adalat, Prednisone, colchicine, candesartan, amlodipdine, atorvastatin, rabeprazole, Omega 3, calcium, and vitamins B6, D and 12.
Pertinent Findings: Entering VAs are 20/25 OD and 20/150 OS; PHNI. Pupils are normal. Longstanding mild ptosis and proptosis OS; mild new upper and lower eyelid edema and hyperemia OS. Slit lamp reveals extensive inferior lid notching, thick, telangiectatic lid margins, 2+ Demodex blepharitis, 80% inspissated or missing glands, poor meibum expression, large tear film mucous strands, and grade 3+ coalescent patches of SPK OU. Filaments noted OS with a small central area of subepithelial haze from prior HSV keratitis (HSK). Posterior segment: clear and centered PCIOL OD, and 3+ NS OS, rest unremarkable.
Differential Diagnosis: Primary: severe ocular surface disease (OSD) from dacryoadenectomy OS and associated filamentary keratitis, MGD, prior HSK OS, cataract OS.
Diagnosis and Discussion: The lacrimal gland is integral in maintaining homeostasis of the lacrimal functional unit.1 While typical dry eye disease (DED) may not be associated with increased risk of infectious keratitis, atypical severe DED secondary to dacryoadenectomy likely does.2 Thus, following lacrimal gland removal, DED should be aggressively treated to restore ocular surface homeostasis and prevent opportunistic infections that could lead to permanent vision loss.1
Treatment, Management: Filaments debrided in-office. Management: lid wipes, Lotemax gel QD, Ocunox QHS, AS QID, Hylo QID, and hot compresses BID. Cataract extraction and upper punctum cauterization OS are scheduled. 2 months later, patient is referred back to ophthalmology after HSK returns as a dendritic ulcer and resolves with a central scar and decreased VA. Cataract surgery is cancelled. Irreversible vision loss and the pain associated with recurrent ulcers and filamentary keratitis led to eventual enucleation. This patient's DED extends from 2003. To improve homeostasis earlier, punctal occlusion, topical steroids and cyclosporine, oral tetracycline, and AS should have been initiated immediately. Amniotic membranes and scleral lenses may also delay the need for enucleation and should have been considered along with prophylactic antivirals given the prior HSK and steroid use.2,3
Results: There are a variety of options disposable to treat DED, but the underlying cause should be considered in order to tailor treatment accordingly. This case demonstrates the serious consequences that can arise from poorly controlled OSD due to dacryoadenectomy, and the need for aggressive therapeutic intervention. Bibliography: 1.Barabino, S., Chen, Y., Chauhan, S., & Dana, R. (2012). Ocular surface immunity: homeostatic mechanisms and their disruption in dry eye disease. Progress in Retinal and Eye Research, 31, 271-285.
2.Narayanan, S. et al (2013). Dry eye disease and microbial keratitis: is there a connection? The Ocular Surface, 11(2), 75-92.
3.McDonald, M.B. et al (2018). Treatment outcomes in the dry eye amniotic membrane (DREAM) study. Clinical Ophthalmology, 12, 677-681.
Case History: A 61-year-old Israelian woman presents in November 2019 for a follow-up with symptoms of worsening ocular dryness and pain OS>OD. Current treatment is Lotemax QD, lid hygiene, hot compresses, Ocunox QHS, Hylo gel BID, Systane Ultra PRN, and autologous serum (AS) QID. She presented initially in June 2019 for a second opinion on filamentary keratitis secondary to aqueous deficiency following a left dacryoadenectomy in 2003. She had been seeing a local ophthalmologist and using Systane Ultra 20x per day and AS QID OS. She had cataract surgery OD 2018 and lower punctum cauterization OS. Medical history positive for vasculitis, arthritis, hypertension, and hypercholesteremia, and medications include risedronate, Adalat, Prednisone, colchicine, candesartan, amlodipdine, atorvastatin, rabeprazole, Omega 3, calcium, and vitamins B6, D and 12.
Pertinent Findings: Entering VAs are 20/25 OD and 20/150 OS; PHNI. Pupils are normal. Longstanding mild ptosis and proptosis OS; mild new upper and lower eyelid edema and hyperemia OS. Slit lamp reveals extensive inferior lid notching, thick, telangiectatic lid margins, 2+ Demodex blepharitis, 80% inspissated or missing glands, poor meibum expression, large tear film mucous strands, and grade 3+ coalescent patches of SPK OU. Filaments noted OS with a small central area of subepithelial haze from prior HSV keratitis (HSK). Posterior segment: clear and centered PCIOL OD, and 3+ NS OS, rest unremarkable.
Differential Diagnosis: Primary: severe ocular surface disease (OSD) from dacryoadenectomy OS and associated filamentary keratitis, MGD, prior HSK OS, cataract OS.
Diagnosis and Discussion: The lacrimal gland is integral in maintaining homeostasis of the lacrimal functional unit.1 While typical dry eye disease (DED) may not be associated with increased risk of infectious keratitis, atypical severe DED secondary to dacryoadenectomy likely does.2 Thus, following lacrimal gland removal, DED should be aggressively treated to restore ocular surface homeostasis and prevent opportunistic infections that could lead to permanent vision loss.1
Treatment, Management: Filaments debrided in-office. Management: lid wipes, Lotemax gel QD, Ocunox QHS, AS QID, Hylo QID, and hot compresses BID. Cataract extraction and upper punctum cauterization OS are scheduled. 2 months later, patient is referred back to ophthalmology after HSK returns as a dendritic ulcer and resolves with a central scar and decreased VA. Cataract surgery is cancelled. Irreversible vision loss and the pain associated with recurrent ulcers and filamentary keratitis led to eventual enucleation. This patient's DED extends from 2003. To improve homeostasis earlier, punctal occlusion, topical steroids and cyclosporine, oral tetracycline, and AS should have been initiated immediately. Amniotic membranes and scleral lenses may also delay the need for enucleation and should have been considered along with prophylactic antivirals given the prior HSK and steroid use.2,3
Results: There are a variety of options disposable to treat DED, but the underlying cause should be considered in order to tailor treatment accordingly. This case demonstrates the serious consequences that can arise from poorly controlled OSD due to dacryoadenectomy, and the need for aggressive therapeutic intervention. Bibliography: 1.Barabino, S., Chen, Y., Chauhan, S., & Dana, R. (2012). Ocular surface immunity: homeostatic mechanisms and their disruption in dry eye disease. Progress in Retinal and Eye Research, 31, 271-285.
2.Narayanan, S. et al (2013). Dry eye disease and microbial keratitis: is there a connection? The Ocular Surface, 11(2), 75-92.
3.McDonald, M.B. et al (2018). Treatment outcomes in the dry eye amniotic membrane (DREAM) study. Clinical Ophthalmology, 12, 677-681.
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