SlideShare ist ein Scribd-Unternehmen logo

Aao sub retina_2012_syllabus

•
•
Mohammed Fouad
Mohammed Fouad
Gesundheit & Medizin
1 von 169
Downloaden Sie, um offline zu lesen
©2012 American Academy of Ophthalmology. All rights reserved. No portion may be reproduced without express written consent of the American Academy of Ophthalmology. Retina 2012 The Winds of Change Program Directors Joan W Miller MD and Tarek S Hassan MD In conjunction with the American Society of Retina Specialists, the Macula Society, the Retina Society, and Club Jules Gonin McCormick Place Chicago, Illinois Friday – Saturday, November 9 – 10, 2012 Presented by The American Academy of Ophthalmology Sponsored by an unrestricted educational grant by Genentech and Regeneron Retina 2012 Planning Group Joan W Miller MD Program Director Tarek S Hassan MD Program Director Pravin U Dugel MD Peter K Kaiser MD Former Program Directors 2011 Allen C Ho MD Joan W Miller MD 2010 Daniel F Martin MD Allen C Ho MD 2009 Antonio Capone Jr MD Daniel F Martin MD 2008 M Gilbert Grand MD Antonio Capone Jr MD 2007 John T Thompson MD M Gilbert Grand MD 2006 Emily Y Chew MD John T Thompson MD 2005 Michael T Trese MD Emily Y Chew MD 2004 William F Mieler MD Michael T Trese MD 2003 Kirk H Packo MD William F Mieler MD 2002 Mark S Blumenkranz MD Kirk H Packo MD 2001 George A Williams MD Mark S Blumenkranz MD 2000 Julia A Haller MD George A Williams MD 1999 Stanley Chang MD Julia A Haller MD 1998 Harry W Flynn Jr MD Stanley Chang MD 1997 H MacKenzie Freeman MD Harry W Flynn Jr MD 1996 H MacKenzie Freeman MD 1995 Thomas M Aaberg Sr MD Paul Sternberg Jr MD Subspecialty Day Advisory Committee William F Mieler MD Associate Secretary Donald L Budenz MD MPH Daniel S Durrie MD Robert S Feder MD Leah Levi MBBS R Michael Siatkowski MD Jonathan B Rubenstein MD Secretary for Annual Meeting Staff Melanie R Rafaty CMP, Director, Scientific Meetings Ann L’Estrange, Scientific Meetings Specialist Brandi Garrigus, Presenter Coordinator Debra Rosencrance CMP CAE, Vice President, Meetings & Exhibits Patricia Heinicke Jr, Editor Mark Ong, Designer Gina Comaduran, Cover Design
ii 2012 Subspecialty Day  |  Retina Dear Colleague: On behalf of the American Academy of Ophthalmology and the American Society of Retina Spe- cialists, the Macula Society, the Retina Society, and Club Jules Gonin, it is our pleasure to welcome you to Chicago and to Retina 2012: The Winds of Change. The standard components of Retina Subspecialty Day are the lectures and panel discussions pre- sented by leading experts from around the world. We have created opportunities for lively and spirited discussions of controversial issues, including a rapid-fire presentation of “My Coolest Surgical Video” by innovative surgical leaders, with commentary by an expert panel and followed by an audience vote, debate teams presenting arguments on contested topics in the management of diabetic retinopathy with audience pre- and post-debate voting, and expert panels on surgi- cal complications. We continue the tradition of holding discussion panels on the topics of AMD management, retinal vein occlusion, pediatric retinal surgery, and tumor management. We include “best of” approaches to create a core program that addresses what’s new in clinical practice, as well as practical issues that retina specialists face daily—from the status of new treatments for diabetic retinopathy to what health care reform means for the field of retina. Two sessions are reserved for presentation of late-breaking developments. The Schepens Lecture—delivered this year by Alan Bird MD on “Potential Therapeutic Approaches to AMD”—is certain to be a highlight. Finally, we include the popular Break With the Experts program on Friday from 3:12 to 3:54, which allows participants to move freely from topic to topic at their leisure and to interact with our faculty on a much more personal level. Our goal is that attendees will find Retina 2012: The Winds of Change to be an informative, interactive, and entertaining experience as we present new and useful informa- tion to benefit their professional lives. We thank the dedicated Academy Subspecialty Day staff and the Program Committee for their tireless work. Above all, we thank the outstanding faculty for their enthusiastic efforts in preparing their presentations and course materials to provide the most up-to- date and comprehensive review on the diagnosis and management of vitreoretinal diseases. We strive for continual improvement of the Subspecialty Day Meetings and request that you assist us by completing the evaluation. We carefully review all comments to better understand your needs so please take a few moments to indicate the strengths and shortcomings of this program and sug- gest new ways to meet the needs of our international audience. Again, we welcome you to Retina 2012: The Winds of Change. We hope you find it intellectually stimulating, educational and enjoyable. Sincerely, Joan W Miller MD Tarek S Hassan MD Program Director Program Director
2012 Subspecialty Day  |  Retina iii Retina 2012 Contents Program Directors’ Welcome Letter   ii CME  iv The Charles L Schepens MD Lecture   v Faculty Listing  vi Program Schedule  xxiii Section I: Vitreoretinal Surgery, Part I   1 Cool Surgical Video Panel   13 The Charles L Schepens MD Lecture   14 Section II: Non-neovascular AMD   15 Section III: Late Breaking Developments, Part I   34 Section IV: Pediatric Retina   35 Section V: Inherited Retinal Diseases   43 Section VI: Retinal Vein Occlusion   51 Section VII: Business of Retina   52 Section VIII: Neovascular AMD   63 Section IX: Imaging  86 Section X: Oncology  105 Section XI: Late Breaking Developments, Part II   118 Section XII: Diabetes  119 Section XIII: Vitreoretinal Surgery, Part II   129 Faculty Financial Disclosure   131 Presenter Index  139 Electronic version of Syllabi available at www.aao.org / 2012syllabi
iv 2012 Subspecialty Day  |  Retina CME Credit Academy’s CME Mission Statement The purpose of the American Academy of Ophthalmology’s Continuing Medical Education (CME) program is to pres- ent ophthalmologists with the highest quality lifelong learning opportunities that promote improvement and change in physi- cian practices, performance or competence, thus enabling such physicians to maintain or improve the competence and profes- sional performance needed to provide the best possible eye care for their patients. 2012 Retina Subspecialty Day Meeting Learning Objectives Upon completion of this activity, participants should be able to: • Explain the current management of macular edema sec- ondary to retinal occlusive disease and diabetic retinopa- thy • Explain the pathobiology and management of atrophic and exudative AMD and other causes of CNV • Identify emerging developments in retinal imaging • Describe new vitreoretinal surgical techniques and instru- mentation • Identify new developments in hereditary retinal degenera- tions, pediatric retinal diseases, and ocular oncology 2012 Retina Subspecialty Day Meeting Target Audience The intended target audience for this program is vitreoretinal specialists, members in fellowship training and general ophthal- mologists who are engaged in the diagnosis and treatment of vitreoretinal diseases. 2012 Retina Subspecialty Day CME Credit The American Academy of Ophthalmology is accredited by the Accreditation Council for Continuing Medical Education to pro- vide continuing medical education for physicians. The American Academy of Ophthalmology designates this live activity for a maximum of 14 AMA PRA Category 1 Cred- its™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Scientific Integrity and Disclosure of Financial Interest The American Academy of Ophthalmology is committed to ensuring that all continuing medical education (CME) informa- tion is based on the application of research findings and the implementation of evidence-based medicine. It seeks to promote balance, objectivity and absence of commercial bias in its con- tent. All persons in a position to control the content of this activ- ity must disclose any and all financial interests. The Academy has mechanisms in place to resolve all conflicts of interest prior to an educational activity being delivered to the learners. Attendance Verification for CME Reporting Before processing your requests for CME credit, the Academy must verify your attendance at Subspecialty Day and/or the Joint Meeting. In order to be verified for CME or auditing purposes, you must either: • Register in advance, receive materials in the mail and turn in the Final Program and/or Subspecialty Day Syllabus exchange voucher(s) onsite; • Register in advance and pick up your badge onsite if mate- rials did not arrive before you traveled to the meeting; • Register onsite; or • Use your ExpoCard at the meeting. CME Credit Reporting Grand Concourse Level 2.5; Academy Resource Center, Hall A - Booth 508 Attendees whose attendance has been verified (see above) at the 2012 Joint Meeting can claim their CME credit online during the meeting. Registrants will receive an e-mail during the meeting with the link and instructions on how to claim credit. Onsite, you may report credits earned during Subspecialty Day and/or the Joint Meeting at the CME Credit Reporting booth. Academy Members: The CME credit reporting receipt is not a CME transcript. CME transcripts that include 2012 Joint Meet- ing credits entered onsite will be available to Academy members on the Academy’s website beginning Dec. 3, 2012. NOTE: CME credits must be reported by Jan. 16, 2013. After the 2012 Joint Meeting, credits can be claimed at www.aao.org/cme. The Academy transcript cannot list individual course atten- dance. It will list only the overall credits spent in educational activities at Subspecialty Day and/or the Joint Meeting. Nonmembers: The Academy will provide nonmembers with verification of credits earned and reported for a single Academy- sponsored CME activity, but it does not provide CME credit transcripts. To obtain a printed record of your credits, you must report your CME credits onsite at the CME Credit Reporting booths. Proof of Attendance The following types of attendance verification will be available during the Joint Meeting and Subspecialty Day for those who need it for reimbursement or hospital privileges, or for nonmem- bers who need it to report CME credit: • CME credit reporting/proof-of-attendance letters • Onsite Registration Form • Instruction Course Verification Visit the Academy’s website for detailed CME reporting infor- mation.
2012 Subspecialty Day  |  Retina v The Charles L Schepens MD Lecture Potential Therapeutic Approaches to AMD Friday, November 9, 2012 9:31 AM – 9:46 AM Alan C Bird MD
vi 2012 Subspecialty Day  |  Retina Thomas M Aaberg Jr MD Ada, MI Founder and President Retina Specialists of Michigan Assistant Clinical Professor of Ophthalmology Michigan State University Gary W Abrams MD Detroit, MI Professor of Ophthalmology Kresge Eye Institute Wayne State University David H Abramson MD FACS New York, NY Chief, Ophthalmic Oncology Service Memorial Sloan-Kettering Cancer Center Professor of Ophthalmology Weill Cornell University Lloyd P Aiello MD PhD Boston, MA Professor of Ophthalmology Harvard Medical School Head, Section of Eye Research, and Director, Beetham Eye Institute Joslin Diabetes Center Arthur W Allen Jr MD San Francisco, CA Vice Chairman Department of Ophthalmology California Pacific Medical Center President Pacific Eye Associates J Fernando Arevalo MD FACS Riyadh, Saudi Arabia Professor of Ophthalmology Wilmer Eye Institute and Johns Hopkins University School of Medicine Chief of Vitreoretina Division The King Khaled Eye Specialist Hospital Riyadh, Kingdom of Saudi Arabia Jorge G Arroyo MD Brookline, MA Associate Professor of Ophthalmology Harvard Medical School Director of Retina Service Beth Israel Deaconess Medical Center Marcos P Avila MD Goiania, Brazil Full Professor of Ophthalmology and Head of the Ophthalmology Department Universidade Federal de Goiás Carl C Awh MD Nashville, TN President Tennessee Retina, PC Faculty
2012 Subspecialty Day  |  Retina Faculty Listing vii James W Bainbridge MA PhD FRCOphth London, United Kingdom Professor of Retinal Studies University College Consultant Ophthalmologist Moorfields Eye Hospital Sophie J Bakri MD Rochester, MN Professor of Ophthalmology Mayo Clinic Francesco M Bandello MD FEBO Milano, Italy Full Professor and Chairman Department of Ophthalmology University Vita Salute Scientific Institute, San Raffaele, Milan MD, FEBO University Vita Salute No photo available Francine Behar-Cohen MD Paris, France Audina M Berrocal MD Miami, FL Associate Professor of Ophthalmology Bascom Palmer Eye Institute University of Miami Staff Physician Miami Children’s Hospital Maria H Berrocal MD San Juan, PR Assistant Professor University of Puerto Rico Susanne Binder MD Vienna, Austria Professor of Ophthalmology Department of Ophthalmology Rudolf Foundation Clinic Professor of Ophthalmology The Ludwig Boltzmann Institute for Retinology and Biomicroscopic Laser Surgery Alan C Bird MD London, England Emeritus Professor of Ophthalmology University College, London No photo available Barbara Ann Blodi MD Madison, WI Professor of Ophthalmology University of Wisconsin Codirector Fundus Photograph Reading Center University of Wisconsin
viii Faculty Listing 2012 Subspecialty Day  |  Retina Mark S Blumenkranz MD Palo Alto, CA Professor and Chairman Stanford University School of Medicine David S Boyer MD Los Angeles, CA Clinical Professor of Ophthalmology University of Southern California Keck School of Medicine Partner, Retina Vitreous Associates Medical Group No photo available Periklis Brazitikos MD Thessaloniki, Greece Associate Professor of Ophthalmology Aristotle University of Thessaloniki Neil M Bressler MD Baltimore, MD The James P Gills Professor of Ophthalmology Johns Hopkins University School of Medicine Chief, Retina Division Wilmer Eye Institute David M Brown MD Houston, TX Associate Clinical Professor of Opthalmology Weill Cornell College of Medicine, The Methodist Hospital Director of Clinical Research Retina Consultants of Houston Alexander J Brucker MD Philadelphia, PA Professor of Ophthalmology Scheie Eye Institute University of Pennsylvania Brandon G Busbee MD Nashville, TN Retina Specialist Tennessee Retina Antonio Capone Jr MD Royal Oak, MI Professor of Ophthalmology William Beaumont Hospital-Oakland University School of Medicine Codirector, Fellowship in Vitreoretinal Diseases and Surgery Associated Retinal Consultants Usha Chakravarthy MBBS PhD Belfast, Northern Ireland Professor of Ophthalmology and Vision Science Queen’s University of Belfast
2012 Subspecialty Day  |  Retina Faculty Listing ix Wiley Andrew Chambers MD McLean, VA Clinical Professor of Ophthalmology The George Washington University R V Paul Chan MD New York, NY St Giles Associate Professor of Pediatric Retina Weill Cornell Medical College Stanley Chang MD New York, NY KK Tse and Ku Teh Ying Professor of Ophthalmology Columbia University Tom S Chang MD Arcadia, CA Partner Retina Institute of California Steven T Charles MD Memphis, TN Adjunct Professor of Ophthalmology Columbia College of Physicians and Surgeons Clinical Professor of Ophthalmology University of Tennessee, Memphis Emily Y Chew MD Bethesda, MD Deputy Director of Division of Epidemiology and Clinical Applicatons National Eye Institute, National Institutes of Health N H Victor Chong MD Oxford, United Kingdom Head of Department Oxford Eye Hospital Clinical Senior Lecturer in Ophthalmology University of Oxford David R Chow MD North York, ON, Canada Assistant Professor of Ophthalmology University of Toronto Codirector Toronto Retina Institute Mina Chung MD Rochester, NY Associate Professor of Ophthalmology Flaum Eye Institute University of Rochester
x Faculty Listing 2012 Subspecialty Day  |  Retina Carl C Claes MD Schilde, Belgium Head of Vitreoretinal Surgery Saint Augustinus Hospital (Wilrijk/ Antwerp) No photo available Karl G Csaky MD PhD Dallas, TX Vitreoretinal Specialist Texas Retina Associates Christine Curcio PhD Birmingham, AL Professor of Ophthalmology University of Alabama at Birmingham Donald J D’Amico MD New York, NY Professor and Chairman Department of Ophthalmology Weill Cornell Medical College Ophthalmologist-in-Chief New York-Presbyterian Hospital Kimberly A Drenser MD PhD Royal Oak, MI Vitreoretinal Surgeon Associated Retinal Consultants Associate Professor Eye Research Institute Oakland University Pravin U Dugel MD Phoenix, AZ Managing Partner Retinal Consultants of Arizona Clinical Associate Professor of Ophthalmology Doheny Eye Institute Keck School of Medicine University of Southern California Jay S Duker MD Boston, MA Director, New England Eye Center Tufts Medical Center Professor and Chair Department of Ophthalmology No photo available Alexander M Eaton MD Fort Myers, FL Claus Eckardt MD Frankfurt, Germany Professor of Ophthalmology Klinikum Frankfurt Höchst
2012 Subspecialty Day  |  Retina Faculty Listing xi Ehab N El Rayes MD PhD Cairo, Egypt Professor of Ophthalmlogy, Retina Service Institute of Ophthalmology Vitreoretinal Consultant International Eye Hospital Dean Eliott MD Boston, MA Associate Director, Retina Service Massachusetts Eye and Ear Infirmary Harvard Medical School Daniel D Esmaili MD Boston, MA Instructor in Ophthalmology Massachusetts Eye and Ear Infirmary Sharon Fekrat MD Durham, NC Associate Professor of Ophthalmology Albert Eye Research Institute Duke University Eye Center Chief, Ophthalmology Durham Veterans Affairs Medical Center Frederick L Ferris MD Waxhaw, NC Director, Division of Epidemiology and Clinical Applications National Eye Institute, National Institutes of Health Philip J Ferrone MD Great Neck, NY Partner Long Island Vitreoretinal Consultants Assistant Professor of Ophthalmology Columbia University Marta Figueroa MD Madrid, Spain Director of Vitreoretinal Department Vissum Madrid Professor of Ophthalmology University of Alcalá de Henares Paul T Finger MD New York, NY Director The New York Eye Cancer Center Clinical Professor of Ophthalmology New York University School of Medicine Harry W Flynn Jr MD Miami, FL Professor of Ophthalmology Bascom Palmer Eye Institute University of Miami
xii Faculty Listing 2012 Subspecialty Day  |  Retina William R Freeman MD La Jolla, CA Professor of Ophthalmology University of California, San Diego Director Jacobs Retina Center Shiley Eye Center University of California, San Diego K Bailey Freund MD New York, NY Clinical Associate Professor of Ophthalmology New York University Partner Vitreous Retina Macula Consultants of New York Thomas R Friberg MD Pittsburgh, PA Professor of Bioengineering and Ophthalmology University of Pittsburgh Director of Retina Service UPMC Eye Center Anne E Fung MD San Francisco, CA Medical Retina Consultant Pacific Eye Associates Director, Barkan Research Society California Pacific Medical Center No photo available Brenda L Gallie MD Toronto, ON, Canada Professor of Ophthalmology University of Toronto Head, Retinoblastoma Program Hospital for Sick Children Alain Gaudric MD Paris, France Professor of Ophthalmology Hopital Lariboisiere, AP-HP Université Paris-Diderot No photo available Andre V Gomes MD São Paulo, Brazil No photo available Christine R Gonzales MD Ashland, OR Evangelos S Gragoudas MD Boston, MA Professor of Ophthalmology Harvard Medical School Director, Retina Service Massachusetts Eye and Ear Infirmary M Gilbert Grand MD St Louis, MO Retina Surgeon Retina Consultants, The Retina Institute Professor of Clinical Ophthalmology Washington University School of Medicine
2012 Subspecialty Day  |  Retina Faculty Listing xiii Julia A Haller MD Philadelphia, PA Ophthalmologist-in-Chief Wills Eye Hospital Professor and Chair of Ophthalmology Jefferson Medical College Thomas Jefferson University Dennis P Han MD Milwaukee, WI Jack A and Elaine D Klieger Professor of Ophthalmology Medical College of Wisconsin Head, Vitreoretinal Section Froedert The Medical College Eye Institute Tarek S Hassan MD Royal Oak, MI Professor of Ophthalmology Oakland University, William Beaumont School of Medicine Director of Vitreoretinal Program Partner, Associated Retinal Consultants Jeffrey S Heier MD Boston, MA Director, Vitreoretina Service Ophthalmic Consultants of Boston Assistant Professor in Ophthalmology Tufts University School of Medicine Allen C Ho MD Philadelphia, PA Director of Retina Research Mid Atlantic Retina and Wills Eye Institute Professor of Ophthalmology Thomas Jefferson University Frank G Holz MD Bonn, Germany Professor of Ophthalmology University of Bonn, Germany Suber S Huang MD MBA Cleveland, OH Director, Center Retina and Macular Disease University Hospitals Eye Institute Searle Professor and Vice Chair Department of Ophthalmology and Visual Sciences Case Western Reserve University School of Medicine Mark S Humayun MD PhD Los Angeles, CA Professor of Ophthalmology, Biomedical Engineering and Cell Neurobiology Doheny Eye Institute Keck School of Medicine University of Southern California Michael S Ip MD Madison, WI Associate Professor of Ophthalmology University of Wisconsin-Madison
xiv Faculty Listing 2012 Subspecialty Day  |  Retina No photo available Timothy L Jackson MBChB London, England Consultant Ophthalmic Surgeon King’s College Hospital HEFCE Senior Clinical Lecturer King’s College London Glenn J Jaffe MD Durham, NC Professor of Ophthalmology Duke University No photo available Martine J Jager MD Oegstgeest, Netherlands Senior Medical Specialist Leiden University Medical Center, Leiden Mark W Johnson MD Ann Arbor, MI Professor of Ophthalmology and Visual Sciences University of Michigan Director, Retina Service W K Kellogg Eye Center No photo available J Michael Jumper MD San Francisco, CA West Coast Retina Medical Group, Inc. Kazuaki Kadonosono MD Yokohama, Japan Professor of Ophthalmology Yokohama City University Peter K Kaiser MD Cleveland, OH Professor of Ophthalmology Cleveland Clinic Lerner College of Medicine Director, Digital OCT Reading Center Cole Eye Institute Ivana K Kim MD Boston, MA Associate Professor of Ophthalmology Harvard Medical School Retina Service Massachusetts Eye and Ear Infirmary Judy E Kim MD Milwaukee, WI Professor of Ophthalmology Medical College of Wisconsin
2012 Subspecialty Day  |  Retina Faculty Listing xv No photo available John W Kitchens MD Lexington, KY Baruch D Kuppermann MD PhD Irvine, CA Professor and Chief, Retina Service Gavin Herbert Eye Institute University of California, Irvine No photo available Timothy Y Lai MD FRCOphth FRCS Tsimshatsui, Kowloon, Hong Kong Honorary Clinical Associate Professor The Chinese University of Hong Kong Director, 2010 Retina and Macula Centre Jennifer Irene Lim MD Chicago, IL Professor of Ophthalmology, Director, Retina Service, and Marion H Schenk Esq Chair in Ophthalmology Illinois Eye and Ear Infirmary University of Illinois at Chicago Anat Loewenstein MD Tel Aviv, Israel Director of Ophthalmology Tel Aviv Medical Center Professor of Ophthalmology Vice Dean, Sackler Faculty of Medicine, Tel Aviv University Ian M MacDonald MD Edmonton, AB, Canada Professor of Ophthalmology University of Alberta Maureen G Maguire PhD Philadelphia, PA Professor of Ophthalmology University of Pennsylvania Daniel F Martin MD Cleveland, OH Chairman, Cole Eye Institute Cleveland Clinic Carlos Mateo MD Barcelona, Spain Associate Professor of Ophthalmology Instituto de Microcirugía Ocular of Barcelona
xvi Faculty Listing 2012 Subspecialty Day  |  Retina William F Mieler MD Chicago, IL Professor and Vice Chairman Department of Ophthalmology and Visual Sciences University of Illinois at Chicago Joan W Miller MD Boston, MA Henry Willard Williams Professor of Ophthalmology Harvard Medical School Chief and Chair of Ophthalmology Massachusetts Eye and Ear Infirmary Harvard Medical School Darius M Moshfeghi MD Palo Alto, CA Associate Professor of Ophthalmology Stanford University School of Medicine Director of Telemedicine and Director of Pediatric Vitreoretinal Surgery Byers Eye Institute Stanford University School of Medicine No photo available Shizuo Mukai MD Boston, MA Assistant Professor in Ophthtalmology Harvard Medical School Surgeon in Ophthalmology Massachusetts Eye and Ear Infirmary Timothy G Murray MD MBA Miami, FL Professor of Ophthalmology and Radiation Oncology Bascom Palmer Eye Insitute University of Miami Miller School of Medicine Annabelle A Okada MD Tokyo, Japan Professor of Ophthalmology Kyorin University School of Medicine Timothy W Olsen MD Atlanta, GA F Phinizy Calhoun Sr Professor and Chairman of Ophthalmology Emory University Jeffrey L Olson MD Englewood, CO Associate Professor of Ophthalmology University of Colorado, Rocky Mountain Lions Eye Institute Yusuke Oshima MD Suita, Osaka, Japan Associate Professor of Ophthalmology Osaka University Graduate School of Medicine
2012 Subspecialty Day  |  Retina Faculty Listing xvii Andrew J Packer MD Hartford, CT Clinical Professor University of Connecticut School of Medicine Kirk H Packo MD Indian Head Park, IL Professor and Chairman Department of Ophthalmology Rush University Medical Center Partner, Illinois Retina Associates David W Parke II MD San Francisco, CA Executive Vice President and CEO American Academy of Ophthalmology Fabio Patelli MD Garbagnate Milanese, Italy Ophthalmologist, Vitreoretinal Surgeon Milano Retina Center Director, Vitreoretinal Service Igea Clinic, Milan No photo available Grazia Pertile MD Negrar, Verona, Italy Director, Department of Ophthalmology Sacro Cuore Hospital, Negrar (VR) Italy Dante Pieramici MD Santa Barbara, CA Assistant Clinical Professor Doheny Eye Institute President, California Retina Research Foundation Eric A Pierce MD PhD Boston, MA Director, Ocular Genomics Institute Massacusetts Eye and Ear Infirmary Subhransu Ray MD PhD Moraga, CA Franco M Recchia MD Nashville, TN Associate, Tennessee Retina, P.C.
xviii Faculty Listing 2012 Subspecialty Day  |  Retina Carl D Regillo MD FACS Bryn Mawr, PA Professor of Ophthalmology Thomas Jefferson University Director, Retina Service Wills Eye Institute Kourous Rezaei MD Harvey, IL Associate Professor of Ophthalmology Rush University Medical Center Partner, Illinois Retina Associates William L Rich MD Falls Church, VA Medical Director for Health Policy American Academy of Ophthalmology Clinical Instructor Department of Ophthalmology Georgetown University Stanislao Rizzo MD Pisa, Italy Director U.O. Chirurgia Oftalmica Azienda Ospedaliero Universitaria Pisana Michael A Romansky JD Chevy Chase, MD Washington Counsel and Vice President for Corporate Development Outpatient Ophthalmic Surgery Society No photo available Richard B Rosen MD New York, NY Vice Chairman and Surgeon Director, Director of Retina and Director of Research New York Eye and Ear Infirmary Professor of Ophthalmology New York Medical College Philip J Rosenfeld MD PhD Miami, FL Professor of Ophthalmology Bascom Palmer Eye Institute University of Miami Miller School of Medicine Alan J Ruby MD Novi, MI Associated Retinal Consultants, Royal Oak, MI Professor of Ophthalmology Oakland University William Beaumont School of Medicine Srinivas R Sadda MD Los Angeles, CA Associate Professor of Ophthalmology University of Southern California Director, Doheny Image Reading Center Doheny Eye Institute
2012 Subspecialty Day  |  Retina Faculty Listing xix Andrew P Schachat MD Cleveland, OH Vice Chairman for Clinical Affairs Cole Eye Institute, Cleveland Clinic Professor of Ophthalmology Lerner College of Medicine No photo available Amy C Schefler MD Houston, TX Clinical Assistant Professor Weill Medical College of Cornell University Associate Partner Retinal Consultants of Houston Ursula M Schmidt-Erfurth MD Vienna, Austria Professor of Ophthalmology Medical University of Vienna Chair Department of Ophthalmology and Optometry No photo available Hendrik PN Scholl MD Baltimore, MD The Dr. Frieda Derdeyn Bambas Professor of Ophthalmology Wilmer Eye Institute John Hopkins University School of Medicine Steven D Schwartz MD Los Angeles, CA Ahmanson Professor of Ophthalmology and Chief, Retina Division Jules Stein Eye Institute, University of California, Los Angeles (UCLA) Professor of Ophthalmology David Geffen School of Medicine at UCLA Jonathan E Sears MD Cleveland, OH Associate Professor of Ophthalmology Cole Eye Institute, Cleveland Clinic Associate Professor of Cell Biology Cell Biology, Cleveland Clinic Gaurav K Shah MD St Louis, MO Clinical Professor of Ophthalmology and Visual Sciences The Retina Institute Carol L Shields MD Philadelphia, PA Codirector, Oncology Service Wills Eye Institute Professor of Ophthalmology Thomas Jefferson University Hospital Jerry A Shields MD Philadelphia, PA Director, Oncology Service Wills Eye Institute Professor of Ophthalmology Thomas Jefferson University
xx Faculty Listing 2012 Subspecialty Day  |  Retina Michael A Singer MD San Antonio, TX Ophthalmologist, Managing Partner and Director of Clinical Trials Medical Center Ophthalmology Associates Assistant Clinical Professor University of Texas Health Science Center, San Antonio Lawrence J Singerman MD Cleveland, OH Founder, Retina Associates of Cleveland Clinical Professor of Ophthalmology Case Western Reserve University School of Medicine Arun D Singh MD Cleveland, OH Director, Ophthalmic Oncology Cole Eye Institute Professor of Ophthalmology Cleveland Clinic Rishi P Singh MD Cleveland, OH Staff Physician Cole Eye Institute Cleveland Clinic Foundation Jason S Slakter MD New York, NY Clinical Professor of Ophthalmology New York University School of Medicine Partner, Vitreous Retina Macula Consultants of New York No photo available Rachel Smith MD PhD Atlanta, GA Gisele Soubrane MD PhD Paris, France Professor of Ophthalmology Department of Ophthalmology University Paris Descartes, France MD, PhD, FEBO, FARVO Hotel Dieu de Paris Richard F Spaide MD New York, NY Ophthalmology Vitreous, Retina and Macula Consultants of New York Sunil K Srivastava MD Cleveland, OH Staff Physician Cole Eye Institute Cleveland Clinic Foundation
2012 Subspecialty Day  |  Retina Faculty Listing xxi Giovanni Staurenghi MD Milan, Italy Professor of Ophthalmology Department of Clinical Science “Luigi Sacco” Paul Sternberg MD Nashville, TN Professor and Chairman, Vanderbilt Eye Institute Vanderbilt University School of Medicine Associate Dean for Clinical Affairs Vanderbilt University School of Medicine John T Thompson MD Baltimore, MD Partner, Retina Specialists Assistant Professor The Wilmer Institute of The Johns Hopkins University No photo available Trexler M Topping MD Boston, MA Associate Clinical Professor of Ophthalmology Tufts University School of Medicine Instructor in Ophthalmology Harvard Medical School Cynthia A Toth MD Durham, NC Professor of Ophthalmology Duke University Medical Center Professor of Biomedical Engineering Pratt School of Engineering Duke University Michael T Trese MD Royal Oak, MI President, Associated Retinal Consultants, PC Chief, Pediatric and Adult Vitreoretinal Surgery Beaumont Eye Institute Wm Beaumont Hospital Jan C Van Meurs MD Rotterdam, Netherlands Vitreoretinal Surgeon The Rotterdam Eye Hospital Professor Erasmus University Luk H Vandenberghe PhD Boston, MA Lecturer in Ophthalmology Massachusetts Eye and Ear Infirmary Harvard Medical School Alexander C Walsh MD Los Angeles, CA Assistant Professor of Ophthalmology Keck School of Medicine University of Southern California
xxii Faculty Listing 2012 Subspecialty Day  |  Retina David F Williams MD Minneapolis, MN Partner, VitreoRetinal Surgery, P.A. Assistant Clinical Professor of Ophthalmology University of Minnesota George A Williams MD Royal Oak, MI Professor and Chair, Department of Ophthalmology Oakland University William Beaumont School of Medicine Lihteh Wu MD San Jose, Costa Rica Associate Surgeon Instituto de Cirugia Ocular Associate Professor University of Costa Rica Lawrence A Yannuzzi MD New York, NY Vice Chairman, Department of Ophthalmology, and Director of Retinal Services Manhattan Eye, Ear and Throat Hospital/North Shore Hospital Professor of Clinical Ophthalmology College of Physicians and Surgeons Columbia University Young Hee Yoon MD Seoul, Republic of Korea Professor of Ophthalmology Asan Medical Center, University of Ulsan, College of Medicine David N Zacks MD PhD Ann Arbor, MI Associate Professor of Ophthalmology and Visual Sciences University of Michigan, Kellogg Eye Center
2012 Subspecialty Day  |  Retina xxiii Retina 2012: The Winds of Change FRIDAY, NOVEMBER 9, 2012 7:00 AM REGISTRATION/MATERIAL PICKUP/CONTINENTAL BREAKFAST 8:00 AM Opening Remarks Joan W Miller MD* Tarek S Hassan MD* Section I: Vitreoretinal Surgery, Part I Moderators: Tarek S Hassan MD*, Young Hee Yoon MD* 8:05 AM Vitreoretinal Instrument Update David R Chow MD* 1 8:15 AM Role of Retinectomy in Vitreoretinal Surgery Dean Eliott MD* 2 8:22 AM Current Role of Endoscopy in Vitreoretinal Surgery Jorge G Arroyo MD 4 8:29 AM Treatment of Suprachoroidal Hemorrhages John W Kitchens MD* 6 8:36 AM Recurrent Retinal Detachment: Does Initial Treatment Matter? Gaurav K Shah MD* 7 8:43 AM Chromovitrectomy 2012 Lihteh Wu MD* 9 8:50 AM Vitrectomy for Lamellar Macular Hole Periklis Brazitikos MD* 11 Cool Surgical Video Panel Moderator: Tarek S Hassan MD* Panelists: Maria H Berrocal MD*, Mark S Humayun MD PhD*, Fabio Patelli MD, Steven D Schwartz MD* 8:57 AM My Coolest Surgical Video Carlos Mateo MD 13 8:59 AM Discussion 9:01 AM My Coolest Surgical Video Yusuke Oshima MD* 13 9:03 AM Discussion 9:05 AM My Coolest Surgical Video Kazuaki Kadonosono MD 13 9:07 AM Discussion 9:09 AM My Coolest Surgical Video Ehab N El Rayes MD PhD 13 9:11 AM Discussion 9:13 AM My Coolest Surgical Video Claus Eckardt MD* 13 9:15 AM Discussion 9:17 AM My Coolest Surgical Video J Fernando Arevalo MD FACS 13 9:19 AM Discussion 9:21 AM My Coolest Surgical Video Carl C Claes MD* 13 9:23 AM Discussion 9:25 AM Audience Vote * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest.
xxiv Program Schedule 2012 Subspecialty Day  |  Retina * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. The Charles L Schepens MD Lecture 9:26 AM Introduction of the 2012 Schepens Lecturer David W Parke II MD* 9:31 AM Potential Therapeutic Approaches to AMD Alan C Bird MD 14 9:46 AM REFRESHMENT BREAK and RETINA EXHIBITS Section II: Non-neovascular AMD Moderators: Sophie J Bakri MD*, Francesco M Bandello MD FEBO* 10:30 AM Pathogenesis of AMD Christine Curcio PhD* 15 10:40 AM Genetic Testing−Pro Mark S Blumenkranz MD* 17 10:47 AM Genetic Testing−Con Frederick L Ferris MD* 20 10:54 AM Audience Vote 10:55 AM Rapid-fire Phase 2 Trials, Part I David M Brown MD* 21 11:02 AM Rapid-fire Phase 2 Trials, Part II Philip J Rosenfeld MD PhD* 21 11:09 AM Neuroprotection for AMD David N Zacks MD PhD* 28 11:16 AM Cell-Based Therapies for AMD Allen C Ho MD* 29 11:23 AM Advocating for Patients George A Williams MD* 32 11:28 AM LUNCH and RETINA EXHIBITS Section III: Late Breaking Developments, Part I Moderators: Alexander J Brucker MD*, Paul Sternberg MD 1:00 PM A Multi-state Outbreak of Fungal Endophthalmitis Associated With Rachel Smith MD MPH 34 Contaminated Ophthalmologic Products From a Single Compounding Pharmacy 1:07 PM Responder Analysis of the INTREPID Study of Stereotactic Radiotherapy Timothy L Jackson MBChB* 34 for Wet Age-Related Macular Degeneration 1:14 PM First-in-Human Results of a Refillable Drug Delivery Implant Providing Anat Loewenstein MD* 34 Release of Ranibizumab in Patients with Wet AMD 1:21 PM The Use of Anterior Segment OCT to Help Predict Steroid Responders Michael A Singer MD* 34 After Intravitreal Injections 1:28 PM New Insight in the Physiopathology of CSCR: Therapeutic Application Francine Behar-Cohen MD 34 1:35 PM Baseline Anatomic Features Predictive of Pharmacologic VMA Subhransu Ray MD PhD* 34 Resolution in the Phase III Ocriplasmin Clinical Trial Program Section IV: Pediatric Retina Moderators: Shizuo Mukai MD, Amy C Schefler MD 1:42 PM Update on the Study of Telemedicine for ROP Darius M Moshfeghi MD* 35 1:49 PM Ophthalmic Insurer Perspectives on the Use of Telemedicine for Screening and Diagnosis of ROP and Bevacizumab for ROP Arthur W Allen Jr MD 36 1:56 PM Update on the Multicenter Study of Anti-VEGF Treatment for ROP (BLOCK-ROP)* Michael T Trese MD 38 2:03 PM Microplasmin for Pediatric Vitrectomy Study Kimberly A Drenser MD PhD* 39 2:10 PM Familial Exudative Vitreoretinopathy: Diagnosis, Management With Wide-Angle Angiography, and Long-term Surgical Results Franco M Recchia MD* 40
2012 Subspecialty Day  |  Retina Program Schedule xxv * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. 2:17 PM Surgical Video Panel Moderator: Antonio Capone Jr MD* Panelists: Audina M Berrocal MD*, R V Paul Chan MD, Philip J Ferrone MD*, Jonathan E Sears MD Section V: Inherited Retinal Diseases Moderators: Marcos P Avila MD, Michael A Singer MD* 2:37 PM Update on Gene Therapy Trials in Progress James W Bainbridge MA PhD FRCOphth*43 2:44 PM Upcoming Trials in Retinal Degeneration Ian M MacDonald MD* 44 2:51 PM Phase 1b Data for 091001, a Synthetic Retinoid for the Treatment of Leber Congenital Amaurosis and Retinitis Pigmentosa Hendrik PN Scholl MD* 46 2:58 PM Genetic Testing for Patients With Retinal Degeneration Eric A Pierce MD PhD 47 3:05 PM Optogenetics: A New Approach to Retinitis Pigmentosa Luk H Vandenberghe PhD* 49 Break With the Experts Moderators: M Gilbert Grand MD, Andrew J Packer MD 3:12 PM − 3:54 PM Exhibit Hall E Topic V01: AMD Susanne Binder MD David S Boyer MD* David M Brown MD* Emily Y Chew MD Philip J Rosenfeld MD PhD* Jason S Slakter MD* Topic V02: New Instrumentation David R Chow MD* Topic V03: Diabetic Retinopathy Carl C Awh MD* Carl G Csaky MD PhD* Mark W Johnson MD* Jennifer Irene Lim MD* Topic V04: Business of Retina Alan J Ruby MD* George A Williams MD* Topic V05: Endophthalmitis Harry W Flynn Jr MD* Topic V06: Trauma Carl C Claes MD* Topic V07: Intraocular Tumors Ivana K Kim MD* Timothy G Murray MD MBA* Topic V08: Macular Surgery Periklis Brazitikos MD* Carlos Mateo MD Yusuke Oshima MD* Cynthia A Toth MD* Topic V09: Ocular Imaging Srinivas R Sadda MD* Richard F Spaide MD* Sunil K Srivastava MD Alexander C Walsh MD* Topic V10: Pediatric Retinal Disease Kimberly A Drenser MD PhD* Philip J Ferrone MD* Topic V11: Gene Therapy James W Bainbridge MA PhD* FRCOphth
xxvi Program Schedule 2012 Subspecialty Day  |  Retina * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. Topic V12: Enzymatic Vitrectomy Michael T Trese MD* Topic V13: Retinal Detachment Gary W Abrams MD* J Fernando Arevalo MD FACS Claus Eckardt MD* Dean Eliott MD* Topic V14: Vascular Occlusions Michael S Ip MD* Sharon Fekrat MD Carl D Regillo MD FACS* Section VI: Retinal Vein Occlusion Moderator: Donald J D’Amico MD* 3:54 PM Retinal Vein Occlusion Panel Panelists: Barbara Ann Blodi MD, Sharon Fekrat MD, Michael S Ip MD*, Carl D Regillo MD FACS*, Rishi P Singh MD* 51 Section VII: Business of Retina Moderators: William R Freeman MD*, Anne E Fung MD* 4:14 PM The Future of Health Care: Survival of the Fittest David W Parke II MD* 52 4:21 PM Accountable Care Organizations: In or Out? William L Rich MD 54 4:28 PM ASC for Retina: Is It Time? Michael A Romansky JD 56 4:35 PM ASC for Retina: Balancing Quality With Profit Alan J Ruby MD* 57 4:42 PM The Office of the Inspector General and Bevacizumab vs. Ranibizumab: No Good Deed Goes Unpunished George A Williams MD* 58 4:49 PM Managing a Large Modern Practice: Practice Informatics and IT Trexler M Topping MD* 59 4:56 PM Post-marketing Surveillance Wiley Andrew Chambers MD 60 5:03 PM Closing Remarks Joan W Miller MD* Tarek S Hassan MD* 5:04 PM ADJOURN SATURDAY, NOVEMBER 10, 2012 7:00 AM CONTINENTAL BREAKFAST 8:00 AM Opening Remarks Joan W Miller MD* Tarek S Hassan* Section VIII: Neovascular AMD Moderators: Andrew P Schachat MD, Gisele Soubrane MD PhD* 8:05 AM Non-inferiority Trials and Subgroups: How to Interpret What You Are About to Hear Maureen G Maguire PhD* 63 8:12 AM CATT: Year 2 Daniel F Martin MD 65 8:19 AM IVAN: Year 1 Usha Chakravarthy MBBS PhD*66 8:26 AM MANTA: Year 1 Susanne Binder MD 68
2012 Subspecialty Day  |  Retina Program Schedule xxvii * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. 8:33 AM VIEW: Year 2 Jeffrey S Heier MD* 69 8:40 AM HARBOR: Year 2 Brandon G Busbee MD* 70 8:47 AM How Do I Incorporate What I Just Heard Into My Practice? Peter K Kaiser MD* 73 8:54 AM Aspirin and AMD: What Do I Tell My Patients? Emily Y Chew MD 74 9:01 AM Radiation for CNV: Cabernet /MERITAGE/ INTREPID Timothy L Jackson MBChB* 76 9:08 AM Polypoidal Vasculopathy: Anti-VEGF, Photodynamic Therapy, Timothy Y Lai MD and Steroids FRCOphth FRCS* 77 9:15 AM Anti-Platelet Derived Growth Factor: Where Do We Stand? Pravin U Dugel MD* 80 9:22 AM Long-term Delivery Strategies for Neovascular AMD David S Boyer MD* 81 9:29 AM What’s Next in the Neovascular AMD Pipeline? Jason S Slakter MD* 82 9:36 AM Panel: Management of Neovascular AMD in 2012 Moderator: Lawrence A Yannuzzi MD Panelists: Glenn J Jaffe MD*, J Michael Jumper MD, Annabelle A Okada MD*, Lawrence J Singerman MD*, Giovanni Staurenghi MD* 9:56 AM REFRESHMENT BREAK and JOINT MEETING EXHIBITS Section IX: Imaging Moderators: Daniel D Esmaili MD, Timothy W Olsen MD* 10:40 AM Imaging the Choroid: What You Need to Know Before Deep “C” Diving Richard F Spaide MD* 86 10:47 AM When Should I Be Using Fundus Autofluorescence? Frank G Holz MD* 89 10:54 AM What’s Next in Imaging? Srinivas R Sadda MD* 94 11:01 AM Intraoperative OCT: Is It Actually Useful? Sunil K Srivastava MD 97 11:08 AM Adaptive Optics: Ready for Prime Time? Judy E Kim MD* 99 11:15 AM Simple Estimation of Fluid Volumes in Neovascular AMD Alexander C Walsh MD* 102 11:22 AM Panel: How Do You Prefer to Image Disease X? Moderator: Jay S Duker MD* Panelists: Mina Chung MD*, Thomas R Friberg MD*, Alain Gaudric MD*, Richard B Rosen MD*, Ursula M Schmidt-Erfurth MD* Section X: Oncology Moderators: K Bailey Freund MD*, Martine J Jager MD* 11:42 AM Germline BAP1 Mutations in Ocular Melanoma and Other Malignancies Ivana K Kim MD* 105 11:49 AM Practical Approaches to Needle Biopsy and Genetic Diagnosis for Ocular Melanoma Thomas M Aaberg Jr MD* 106 11:56 AM New Imaging Techniques for Ocular Tumors Timothy G Murray MD MBA*115 12:03 PM Follow-up After Intra-arterial Chemotherapy for Retinoblastoma Carol L Shields MD 116 12:10 PM Panel: Tumor Management: Radiation, Retinopathy, and Masquerade Moderator: Evangelos S Gragoudas MD* Panelists: David H Abramson MD FACS, Paul T Finger MD*, Brenda L Gallie MD, Jerry A Shields MD, Arun D Singh MD 12:30 PM LUNCH and JOINT MEETING EXHIBITS
xxviii Program Schedule 2012 Subspecialty Day  |  Retina * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. Section XI: Late Breaking Developments, Part II Moderators: Tom S Chang MD, Suber S Huang MD MBA* 1:55 PM Phase I Study of CNTF for Mactel Emily Y Chew MD 118 2:02 PM Long-term Effects of Intravitreal Ranibizumab on Diabetic Retinopathy Michael S Ip MD* 118 Severity and Progression 2:09 PM A Phase 1 Study Targeting Tissue Factor With a Single Dose of Christine R Gonzales MD* 118 Intravitreal HI-Con1 for Exudative Macular Degeneration 2:23 PM A Novel Intravitreal Injection Device Alexander M Eaton MD* 118 2:16 PM New Surgical Technique and New Instrumentation for Safe, Atraumatic Jeffrey L Olson MD* 118 Removal of Intraocular Foreign Bodies 2:28 PM ARGUS II Mark S Humayun MD PhD* 118 Section XII: Diabetes Moderators: Dennis P Han MD*, Peter K Kaiser MD* I Use the DRCR.net Guidelines in My Clinical Practice (Yes/No) 2:35 PM Coin Toss and Audience Vote 2:37 PM Pro Neil M Bressler MD* 119 2:40 PM Con Harry W Flynn Jr MD* 119 2:43 PM Rebuttal, Pro Mark W Johnson MD* 121 2:44 PM Rebuttal, Con Jennifer Irene Lim MD* 121 2:45 PM Audience Vote Subthreshold Laser Is an Important Treatment for Macular Edema (Yes/No) 2:46 PM Audience Vote 2:47 PM Pro N H Victor Chong MD* 122 2:51 PM Con Lloyd P Aiello MD PhD* 122 2:55 PM Audience Vote I Still Use Scissors in Diabetic Vitrectomy (Yes/No) 2:56 PM Audience Vote 2:57 PM Pro Steven T Charles MD* 123 3:01 PM Con Carl C Awh MD* 123 3:05 PM Audience Vote Anti-VEGF Is the Ideal Treatment for Diabetic Macular Edema (Yes/No) 3:06 PM Coin Toss and Audience Vote 3:08 PM Pro Julia A Haller MD* 124 3:11 PM Con Baruch D Kuppermann MD PhD*124 3:14 PM Rebuttal, Pro Karl G Csaky MD PhD* 128 3:15 PM Rebuttal, Con Dante Pieramici MD* 128
2012 Subspecialty Day  |  Retina Program Schedule xxix * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. 3:16 PM Audience Vote 3:17 PM REFRESHMENT BREAK and JOINT MEETING EXHIBITS Section XIII: Vitreoretinal Surgery, Part II Moderators: Kirk H Packo MD*, Kourous Rezaei MD* 4:00 PM Surgical Complications Video, Part I 129 Moderator: Kirk H Packo MD* Panelists: Gary W Abrams MD*, Marta Figueroa MD*, William F Mieler MD*, Stanislao Rizzo MD, John T Thompson MD* 4:40 PM Surgical Complications Video, Part II 129 Moderator: Kourous Rezaei MD* Panelists: Stanley Chang MD*, Andre V Gomes MD*, Grazia Pertile MD, Jan C Van Meurs MD*, David F Williams MD* 5:20 PM Closing Remarks Joan W Miller MD* Tarek S Hassan MD* 5:22 PM ADJOURN
2012 Subspecialty Day  |  Retina Section I: Vitreoretinal Surgery, Part I 1 Vitreoretinal Instrument Update David R Chow MD Notes
2 Section I: Vitreoretinal Surgery, Part I 2012 Subspecialty Day  |  Retina Role of Retinectomy in Vitreoretinal Surgery Dean Eliott MD I. Retinectomy: Excision of Retina A. Removal of anterior flap of retinal tear in primary retinal detachment B. Removal of retinal incarceration in traumatic or surgical wound C. Removal of fibrotic, contracted retina in prolifera- tive retinopathy (PVR) or proliferative diabetic reti- nopathy (PDR) II. Retinotomy: Creating a Hole in the Retina (retinal inci- sion only, no excision) A. Drainage retinotomy: 1. To remove subretinal fluid 2. Drainage site is located posteriorly when perfluo- rocarbon liquid is not used to reattach the retina. 3. Drainage site is located anteriorly when perfluo- rocarbon use results in anteriorly loculated sub- retinal fluid. B. Access retinotomy: To remove choroidal neovas- cular membrane (CNVM), subretinal hemorrhage, subretinal membranes, retained subretinal perfluo- rocarbon liquid, subretinal foreign body, or to inject subretinal tissue plasminogen activator III. Retinectomy Surgical Technique: General Principles A. Lensectomy in phakic eyes B. Consider scleral buckle to support vitreous base (except in cases with 360-degree retinectomy) C. Retinectomy is performed after attempted complete epiretinal membrane removal; if retinectomy is done before complete epiretinal membrane removal, fur- ther epiretinal membrane removal may be difficult. D. Orientation: Circumferential, posterior to vitreous base E. Location 1. Avoid retinectomy edge near 6 o’clock position. 2. Most common retinectomy location is inferiorly with edges at 3 o’clock and 9 o’clock. F. Size 1. Retinectomy should extend into normal retina surrounding areas of traction. 2. Most common retinectomy size is 6 clock hours or 180 degrees. 3. If greater than 270 degrees, extend the retinec- tomy to 360 degrees. G. Hemostasis: Diathermy is used to delineate intended edge and to prevent intraoperative bleeding. H. Instruments: Vitrectomy probe or scissors are used to cut retina. I. Adjuvants: May consider perfluorocarbon liquid to stabilize posterior retina. J. Complete excision of anterior retina to prevent post- operative proliferation with resultant traction on the retinectomy edge or ciliary body K. Retinopexy: 360-degree endolaser with confluent endolaser to the retinectomy edge L. Extended tamponade: C3F8 gas or silicone oil 1. Silicone Oil Study showed equal efficacy in eyes with retinectomy. 2. Recent studies favor silicone oil over gas. 3. Redetachment occurs in 4%-25% after oil removal. IV. Incidence of Retinectomy A. PVR 1. Early studies: Retinectomy performed in 2%-8% 2. Silicone Oil Study (1993): Retinectomy per- formed in 29% overall a. Group 1 (no previous vitrectomy): Retinec- tomy performed in 20% b. Group 2 (previous vitrectomy): Retinectomy performed in 42% 3. Recent studies: Retinectomy performed more commonly, in up to 64% B. PDR 1. Primary vitrectomy: Retinectomy performed in 5% 2. Reoperation vitrectomy: Retinectomy performed in 25% V. Complications of Retinectomy A. Hemorrhage 1. Usually due to incomplete diathermy 2. Postoperative fibrous proliferation may occur in areas of blood. B. Hypotony 1. Reported in 2%-43% after 180-360 degree retinectomy and in 17%-20% after 360-degree retinectomy 2. Retinectomy exposes retinal pigment epithelium (RPE) and allows posterior outflow and absorp- tion of intraocular fluid by the choroid.
2012 Subspecialty Day  |  Retina Section I: Vitreoretinal Surgery, Part I 3 3. Recurrent fibrous proliferation with resultant ciliary body traction may also lead to hypotony. C. Visual field defect D. Recurrent fibrous proliferation 1. Surgery for macular pucker reported in 22%- 43%. 2. Severe fibrous proliferation may lead to recurrent retinal detachment and/or hypotony. E. Persistent traction occurs when size of retinectomy is inadequate. F. RPE/choroidal damage may occur when excising retina in area of shallow detachment. G. Retained subretinal perfluorocarbon more likely to occur in cases with large retinectomy; consider saline rinse or small-gauge vitrectomy with valved cannulas for prevention. H. Neovascularization 1. CNVM may rarely occur at edge of retinectomy. 2. Anterior retinal and/or iris neovascularization may occur when anterior retina is incompletely excised. VI. Retinectomy in PDR A. Small posterior focal retinectomy: To relieve persis- tent traction on pre-existing or iatrogenic breaks B. Large peripheral retinectomy: To remove massive fibrous proliferation caused by severe ischemia Selected Readings 1. Machemer R. Retinotomy. Am J Ophthalmol. 1981; 768-774. 2. Machemer R, McCuen BW, de Juan E. Relaxing retinotomies and retinectomies. Am J Ophthalmol. 1986; 102:7-12. 3. Han DP, Lewis MT, Kuhn EM, et al. Relaxing retinotomies and retinectomies: surgical results and predictors of visual outcomes. Arch Ophthalmol. 1990; 109:694-697. 4. Iverson DA, Ward TG, Blumenkranz MS. Indications and results of relaxing retinotomy. Ophthalmology 1990; 1298-1304. 5. Morse LS, McCuen BW, Machemer R. Relaxing retinotomies: anal- ysis of anatomic and visual results. Ophthalmology 1990 ;97:642- 648. 6. Federman JL, Eagle RC. Extensive peripheral retinectomy com- bined with posterior 360 retinotomy for retinal reattachment in advanced proliferative vitreoretinopathy cases. Ophthalmology 1990; 97:1305-1320. 7. Lewis H, Aaberg TM, Abrams GW. Causes of failure after initial vitreoretinal surgery for severe proliferative vitreoretinopathy. Am J Ophthalmol. 1991; 111:8-14. 8. Lewis H, Aaberg TM. Causes of failure after repeat vitreoretinal surgery for recurrent proliferative vitreoretinopathy. Am J Ophthal- mol. 1991; 111:15-19. 9. Blumenkranz MS, Azen SP, Aaberg TM, et al.; Silicone Study Group. Relaxing retinotomy with silicone oil or long-acting gas in eyes with severe proliferative vitreoretinopathy (Silicone Study Report #5). Am J Ophthalmol. 1993; 116:557-564. 10. Bourke RD, Cooling RJ. Vascular consequences of retinectomy. Arch Ophthalmol. 1996; 114:155-160. 11. Abrams GW, Garcia-Valenzuela E, Nanda SK. Retinotomies and Retinectomies. In: Ryan SJ, ed. Retina 3rd ed. CV Mosby; 2000:2311-2343. 12. Joussen AM, Walter P, Jonescu-Cuypers CP, et al. Retinectomy for treatment of intractable glaucoma: long term results. Br J Ophthal- mol. 2003; 87:1094-1103. 13. Tseng JJ, Barile GR, Schiff WM, Akar Y, Vidne-Hay O, Chang S. Influence of relaxing retinotomy on surgical outcomes in prolifera- tive vitreoretinopathy. Am J Ophthalmol. 2005; 140:628-636. 14. Quiram PA, Gonzales CR, Hu W, et al. Outcomes of vitrectomy with inferior retinectomy in patients with recurrent rhegmatog- enous retinal detachments and proliferative vitreoretinopathy. Oph- thalmology 2006; 113:2041-2047. 15. Grigoropoulos VG, Benson S, Bunce C, Charteris DG. Functional outcome and prognostic factors in 304 eyes managed by retinec- tomy. Graefes Arch Clin Exp Ophthalmol. 2007; 245:641-649. 16. Gupta B, Mokete B, Laidlaw DAH, Williamson TH. Severe folding of the inferior retina after relaxing retinectomy for proliferative vit- reoretinopathy. Eye 2008; 22:1517-1519. 17. de Silva DJ, Kwan A, Bunce C, Bainbridge J. Predicting visual out- come following retinectomy for retinal detachment. Br J Ophthal- mol. 2008; 92:954-958. 18. Tsui I, Schubert HD. Retinotomy and silicone oil for detachments complicated by anterior inferior proliferative vitreoretinopathy. Br J Ophthalmol. 2009; 93:1228-1233. 19. Tan HS, Mura M, Oberstein SYL, de Smet MD. Primary retinec- tomy in proliferative vitreoretinopathy. Am J Ophthalmol. 2010; 149:447-452. 20. Kolomeyer AM, Grigorian RA, Mostafavi D, Bhagat N, Zarbin MA. 360 degree retinectomy for the treatment of complex retinal detachment. Retina 2011; 31:266-274.
4 Section I: Vitreoretinal Surgery, Part I 2012 Subspecialty Day  |  Retina Current Role of Endoscopy in Vitreoretinal Surgery Jorge G Arroyo MD Endoscope, Illuminator, and Laser E2 EndoOptiks Laser and Endoscopy System This system is a combined diode laser and endoscopy unit with laser output, pulse width, light, and aiming beam intensity con- trollable on the touch pad or with a foot pedal. It uses a 810-nm diode laser, 175 watt or 300 watt xenon light source, high-reso- lution camera, and footswitch controller. It is the only autoclav- able endoscope available on the market. The traditional endoscope probes come in a 19.5-gauge probe that originally had 10,000 pixels with a 125-degree field of view. The high-resolution probes now have 17,000 pixels with 140-degree field of view, which are a significant improvement. A 23-gauge endoscope probe is also now available. With only 6000 pixels, the view is modest at best. A 300-watt xenon light source is needed to adequately illuminate structures. The laser probe works adequately for endolaser but is quite limited for other tasks. The gradient index (GRIN) lens system provides higher reso- lution but narrower field of view, is significantly less convenient, and has a greater cost. The camera is attached directly to the hand probe, cannot be autoclaved, and must be covered with sterile drape during surgery. Endoscopy-Assisted Vitrectomy Endoscopy through a 19.5-gauge or 23-gauge sclerotomy pro- vides additional benefits compared to the coaxial microscope view. An endoscope provides the ability to see the posterior seg- ment structures independent of corneal or lens clarity. Therefore, endoscopy is especially useful in cases with significant corneal scarring, anterior segment scars, hemorrhage, or lenticular opacities. Another advantage of endoscopy-assisted vitrectomy is that given the location of your sclerotomies, your perspective can be changed very easily and quickly. The various endoscopes have differing amounts of degree of field of view, extending between 90 and 140 degrees of view. It is important to note that the wider field of view makes use of an endoscope during vitrectomy much more feasible and safe. Finally, the endoscope also provides high magnification, depending on how close you are to the object in view. This fea- ture is quite helpful in identifying small retinal breaks or small intraocular foreign bodies, as well as other parts of surgery. Endoscopy-Assisted Vitrectomy Endoscopy-assisted vitrectomy may be particularly helpful in cases with ischemic retinopathies such as proliferative diabetic retinopathy or central retinal vein occlusions, uncontrolled glau- coma, or neovascular glaucoma. There are a number of papers looking at endoscopy-assisted vitrectomy in cases of pseudopha- kic retinal detachment and retained lens material or intraocular foreign bodies. We have found the endoscope to be vital in the treatment of patients who have permanent keratoprostheses and in some cases of trauma associated with corneal opacification and endophthalmitis. Endoscopic Membrane Peeling The endoscope can certainly assist in the peeling of both epireti- nal and internal limiting membranes. Injecting indocyanine green or other dyes can be safely accomplished with the endoscope. The high level of magnification that can be obtained helps in identifying the edge of a membrane prior to peeling. However, the relatively small field of view at these higher levels of magni- fication and the lack of stereopsis does make membrane peeling significantly more challenging compared to traditional coaxial microscopy. Anterior Segment Endoscopic Cyclophotocoagulation The combined endoscope and laser probe has most commonly been used to perform anterior segment endoscopic cyclophoto- coagulation (ECP) in patients with glaucoma. This procedure is typically performed after cataract surgery or in patients who are pseudophakic. However, it has been performed in phakic patients as well. After injecting a significant amount of a viscoelastic between the iris and intraocular lens, the endoscopic laser probe is inserted through a cataract wound and used to treat the anterior ciliary processes for approximately 8 clock hours. This will be shown in a video during the talk. If 12 clock hours of treatment are needed, a secondary limbal wound needs to be created. Pars Plana ECP The pars plana approach for ECP allows for a much more exten- sive treatment of the ciliary processes. Once the vitrectomy is completed, the endoscopic laser probe is inserted through the sclerotomy and used to visualize the pars plana and the ciliary processes. The laser power setting is typically set at 0.35 watts, and the duration is set at continuous. Depending on the proxim- ity of the laser probe to the ciliary processes, a moderately white blanching of the ciliary processes can be obtained. We treat the entire ciliary processes as far anteriorly and as far posteriorly as possible. In patients with a significant amount of pigmentation or in cases where the power is too high or in cases where probe is too close to the ciliary processes, a vapor bubble can be uninten- tionally created due to the conversion of aqueous into steam. In these cases, increasing the distance between the laser probe and the ciliary processes or decreasing the laser power helps prevent this from occurring. Typically, we treat 12 clock hours of the cili- ary processes, and this requires a second port, typically 6 hours away from the first port to be created. Additionally, the endoscopy laser probe can be used to apply excellent peripheral almost confluent panretinal photocoagula- tion treatment from the equator to the ora serrata 360 degrees around. We do find that the 810-nanometer diode laser does
2012 Subspecialty Day  |  Retina Section I: Vitreoretinal Surgery, Part I 5 produce a very intense laser burn. If needed, an argon laser can be attached to the endoscopic laser probe fiber and used to apply argon green laser spots. Conclusions Overall, the endoscopic laser probe provides excellent visualiza- tion and field of view, especially in cases with corneal, anterior segment, or lenticular opacities. The laser probe and endoscope also allow excellent peripheral panretinal photocoagulation treatment to be performed in patients with peripheral ischemic retinopathies. We have found that 12 clock hours of ECP treat- ment primarily in patients with neovascular glaucoma effectively lowers the IOP without resulting in hypotony. The intense laser burns created by the diode 810-nanometer laser can be mitigated by connecting an argon green laser source to the laser fiber in this system. Finally, the endoscopic laser probe is only marginally adequate for membrane peeling. Future Given the fact that the 23-gauge endoscope provides a subopti- mal view, we expect continued improvements in the resolution of this system, especially given the fact that the ease of use of a 23-gauge probe would be extremely helpful and advantageous to the surgeon. The high magnification and variable perspective of the endoscope may also make it amenable to retinal vascular cannulation and subretinal injection of cells or other agents in the future. Selected Readings 1. Chen J, Cohn RA, Lin SC, Cortes AE, Alvarado JA. Endoscopic photocoagulation of the ciliary body for treatment of refractory glaucomas. Am J Ophthalmol. 1997; 124(6):787-796. 2. Al Sabti K, Raizada S, Al AbdulJalil T. Cataract surgery assisted by anterior endoscopy. Br J Ophthalmol. 2009; 93:531-534. 3. Sabti KA, Raizada A, Kandari JA, Wani V, Gayed I, Kumar N. Applications of endoscopy in vitreoretinal surgery. Retina 2008; 28(1):159-166.
6 Section I: Vitreoretinal Surgery, Part I 2012 Subspecialty Day  |  Retina Treatment of Suprachoroidal Hemorrhages John W Kitchens MD Notes
2012 Subspecialty Day  |  Retina Section I: Vitreoretinal Surgery, Part I 7 Recurrent Retinal Detachment: Does Initial Treatment Matter? Gaurav K Shah MD, Almony Arghavan MD, Kevin Blinder MD, Ahmad Baseer MD I. Trends in Retinal Detachment Repair II. Current Surgical Methods for Retinal Detachment Repair A. Pneumatic retinopexy B. Scleral buckling procedure C. Primary pars plana vitrectomy D. Combined scleral buckling procedure and pars plana vitrectomy III. Preoperative factors for surgical decision making A. Extent of retinal detachment B. Location of retinal breaks C. Lens status D. Myopia E. Lattice degeneration F. Status of fellow eye IV. Retrospective study A. To identify differences among eyes that failed initial surgical repair of rhegmatogenous retinal detach- ment (RRD) B. 286 consecutive cases C. Initial surgical repair of RRD 1. Determined by surgeon preference 2. Proliferative vitreoretinopathy excluded 3. Scleral buckle (SB): 63 eyes 4. Pars plana vitrectomy (PPV): 88 eyes 5. Combined SB/PPV: 135 eyes D. Data 1. Age 2. Sex 3. Phakic status 4. Macula status 5. Extent of RRD 6. Location of break 7. Presence of lattice degeneration 8. Presence of high myopia 9. History of RRD in fellow eye E. Results 1. Single operation success rate 2. Recurrent retinal detachment a. Days to first recurrent retinal detachment b. Total number of procedure c. Secondary procedure d. Secondary cataract e. Conclusions 1. Single operation success rate 2. Patients that fail a primary scleral buckle a. Require fewer number of secondary proce- dures b. Require a lower rate of silicone oil injection c. Have a lower incidence of cataract formation d. Require a lower rate of PPL 3. Scleral buckling surgery still remains an integral part of retinal detachment repair surgery. Selected Readings 1. Almony A, Nudleman E, Shah GK, et al. Techniques, rationale, and outcomes of internal limiting membrane peeling. Retina 2012; 32:877-891. 2. Schwartz SG, Kuhl DP, McPherson AR, Holz ER, Mieler WF. Twenty-year follow-up for scleral buckling. Arch Ophthalmol. 2002; 120:325-329. 3. Richardson EC, Verma S, Green WT, Woon H, Chignell AH. Pri- mary vitrectomy for rhegmatogenous retinal detachment: an analy- sis of failure. Eur J Ophthalmol. 2000; 10:160-166. 4. Campo RV, Sipperley JO, Sneed SR, et al. Pars plana vitrectomy without scleral buckle for pseudophakic retinal detachments. Oph- thalmology 1999; 106:1811-1816. 5. Brazitikos PD, Androudi S, Christen WG, Stangos NT. Primary pars plana vitrectomy versus scleral buckle surgery for the treat- ment of pseudophakic retinal detachment: a randomized clinical trial. Retina 2005; 25:957-964. 6. Sharma YR, Karunanithi S, Azad RV, et al. Functional and ana- tomic outcome of scleral buckling versus primary vitrectomy in pseudophakic retinal detachment. Acta Ophthalmol Scand. 2005; 83:293-297. 7. Weichel ED, Martidis A, Fineman MS, et al. Pars plana vitrectomy versus combined pars plana vitrectomy-scleral buckle for primary repair of pseudophakic retinal detachment. Ophthalmology 2006; 113:2033-2040. 8. Stangos AN, Petropoulos IK, Brozou CG, Kapetanios AD, Wha- tham A, Pournaras CJ. Pars-plana vitrectomy alone vs vitrectomy with scleral buckling for primary rhegmatogenous pseudophakic retinal detachment. Am J Ophthalmol. 2004; 138:952-958. 9. Heimann H, Bartz-Schmidt KU, Bornfeld N, Weiss C, Hilgers RD, Foerster MH; Scleral Buckling versus Primary Vitrectomy in Rheg- matogenous Retinal Detachment Study Group. Scleral buckling
8 Section I: Vitreoretinal Surgery, Part I 2012 Subspecialty Day  |  Retina versus primary vitrectomy in rhegmatogenous retinal detachment: a prospective randomized multicenter clinical study. Ophthalmology 2007; 114:2142-2154. 10. Goto T, Nakagomi T, Iijima H. A comparison of the anatomic successes of primary vitrectomy for rhegmatogenous retinal detach- ment with superior and inferior breaks. Acta Ophthalmol. 2012; 13:1755. 11. Mehta S, Blinder KJ, Shah GK, Grand MG. Pars plana vitrectomy versus combined pars plana vitrectomy and scleral buckle for pri- mary repair of rhegmatogenous retinal detachment. Can J Ophthal- mol. 2011; 46:237-241. 12. Azad RV, Chanana B, Sharma YR, Vohra R. Primary vitrectomy versus conventional retinal detachment surgery in phakic rheg- matogenous retinal detachment. Acta Ophthalmol Scand. 2007; 85:540-545. 13. Sun Q, Sun T, Xu Y, et al. Primary vitrectomy versus scleral buck- ling for the treatment of rhegmatogenous retinal detachment: a meta-analysis of randomized controlled clinical trials. Curr Eye Res. 2012; 37:492-499.
2012 Subspecialty Day  |  Retina Section I: Vitreoretinal Surgery, Part I 9 Chromovitrectomy 2012 A Focus on Brilliant Blue G and Other Novel Dyes Lihteh Wu MD, Mauricio Maia MD, Michel E Farah MD, Cristian Carpentier MD, Arturo Alezzandrini MD, Maria H Berrocal MD, J Fernando Arevalo MD; for the Pan American Collaborative Retina Study (PACORES) Group Introduction The vitreous is composed mostly (98%) of water, with the remainder consisting of macromolecules such as collagen fibrils and hyaluronan. As we age, the vitreous undergoes several biochemical changes that lead to progressive liquefaction of the vitreous gel. This eventually leads to a posterior vitreous detachment (PVD). An anomalous PVD may occur when there is no clean separation along the vitreoretinal interface. Surgical, histopathological, and imaging advances over the past 2 decades have demonstrated that traction along the vitreoretinal interface induced by an anomalous PVD plays an important role in several diseases. Depending on where in the eye the strongest vitreoreti- nal adhesion is, an anomalous PVD may evolve into several clini- cal conditions. For instance, if the strongest adhesions are found in the retinal periphery, a tear or detachment ensues. If strong adhesions are found in the macula, epiretinal membrane (ERM), macular hole (MH), and the vitreomacular traction syndrome (VMTS) may develop.1,2 Release of this traction by removal of the offending tissues has been advocated as a solution. There are 3 tissues of particular interest to the vitreoretinal surgeon, namely the posterior hyaloid, ERM, and the internal limiting membrane (ILM). One of the major difficulties encountered by vitreoretinal surgeons in dealing with these tissues is that these are usually thin, transparent, and difficult to visualize. Staining of these transparent tissues with vital dyes during vitrectomy greatly simplifies the procedure. The term “chromo­ vitrectomy” has been used to describe the use of vital dyes to stain transparent tissues to facilitate their manipulation dur- ing vitreous surgery.3 Over the past decade several substances, including indocyanine green (ICG), trypan blue (TB), and bril- liant blue G (BB), have been used during vitrectomy as staining agents. Their staining capabilities have been confirmed, but con- cerns over retinal toxicity remain.4 Posterior Hyaloid Traction exerted by the posterior hyaloid has been implicated in the pathogenesis of several conditions such as proliferative vit- reoretinopathy (PVR), proliferative diabetic retinopathy (PDR), penetrating trauma, and MH. Therefore the surgical goal of any vitrectomy should be posterior hyaloid separation and removal of as much vitreous as possible. Despite the development of sev- eral surgical techniques, at times the surgeon may not know for sure if the posterior hyaloid has been removed. In patients with conditions that are characterized by break- down of the blood–retinal barrier such as PVR, uveitis, retinal vein occlusions, and diabetic retinopathy, a preoperative intra- venous injection of fluorescein sodium 1 to 2 days prior to the scheduled vitrectomy stains the vitreous a greenish color, facili- tating its identification. Blood in the vitreous cavity coats the vitreous by adhering to its collagen fibrils. The normally transparent vitreous becomes opaque, making it easier to visualize and remove. In eyes with no pre-existing vitreous hemorrhage, a small amount of autolo- gous blood may be injected into the vitreous cavity to coat the vitreous.5 Triamcinolone acetonide (TA) is a well-tolerated cortico- steroid that has been used in the pharmacological treatment of several diseases such as uveitis, diabetic macular edema (DME), and retinal vein occlusions. Once injected into the vitreous cav- ity, the triamcinolone particles adhere to the vitreous gel, making its visualization and identification easy. As an added benefit, its use during vitrectomy may improve outcomes by reducing the breakdown of the blood–retinal barrier and preretinal fibrosis. Currently this is the most widely used technique to visualize the posterior hyaloid.4,5 A comparative study of fluorescein, ICG, TA, and TB con- cluded that TA highlighted the vitreous best.6 A recent study demonstrated that a 20% solution containing the natural dyes lutein and zeaxanthin precipitates on the vitreous surface, stain- ing it orange.7 Epiretinal Membranes Refinements in instrumentation and surgical techniques over the past 2 decades have made ERM removal a typical indication for macular surgery. Clinically significant ERMs range from dense opaque tissues to fine transparent membranes. Given their trans- parent nature, fine ERMs pose a challenge even to experienced surgeons. TB binds to degenerated cell elements. It does not stain live cells or tissues with intact cell membranes, since there is no uptake of the dye. Cataract surgeons have long used 0.06% TB to stain the anterior capsule during phacoemulsification. ERMs stain prominently with 0.15% TB. Clinical studies suggest that TB is relatively safe at these doses; however, animal and in vitro studies show that a dose-dependent toxicity may appear above 0.3%. TB remains the dye of choice when peeling ERMs.4,8 Internal Limiting Membrane (ILM) The ILM is made up of the basement membrane of the Müller cells. In eyes with anomalous PVD, glial cells can migrate onto the surface of the ILM, which serves as a scaffold for cellular proliferation. This cellular proliferation may exert macular trac- tion and contribute to the pathogenesis of ERMs, MH, VMTS, and DME, among other entities.9 In idiopathic macular holes it is generally agreed that ILM peeling is important in achieving closure of large and chronic holes.10 Tangential traction from the ILM has been implicated in the pathogenesis of macular holes. An autopsy study of a patient who had undergone successful macular hole closure showed an area of absent ILM surrounding the sealed macular hole.11 In contrast, a histopathological specimen of an eye with a reopened macular hole revealed an ERM with ILM surrounding the open macular hole.12 In other conditions such as DME and ERM, peeling of the ILM is controversial. Surgical specimens from removed ERMs
10 Section I: Vitreoretinal Surgery, Part I 2012 Subspecialty Day  |  Retina often show fragments of the ILM interspersed among the ERM. ILM peeling may reduce the risk of recurrence following ERM removal. By removing the ILM one can be assured that the ERM is completely removed. In a recent prospective study by the Pan American Collaborative Retina Study Group, it was found that there was little correlation between the surgeon’s unaided observation and the brilliant blue stained observation of the ILM. Thus if the surgeon believes that ILM peeling is important in epimacular membrane surgery, staining should be strongly encouraged. The first vital dye to be used to stain the ILM was ICG.13 As the ICG binds to the ILM, the biomechanical stiffness of the ILM increases, making peeling of the ILM much easier.14 However, the initial enthusiasm that greeted the use of ICG has been tem- pered following numerous reports of toxicity.4 A meta-analysis of chromovitrectomy with ICG compared to peeling of the ILM without staining in macular hole surgery showed similar ana- tomic outcomes in both groups. However, the functional results were much worse in eyes where ICG was used to stain the ILM.15 To avoid toxicity ICG should be used at the lowest possible con- centration. The surgery should be swift and illumination used sparingly. BB also has a high affinity for the ILM. In animal and in vitro studies, BB appears to be relatively safe at doses up to 0.25 mg/mL.4 However, contact with the retinal pigment epi- thelium (RPE) should be avoided since RPE atrophy has been documented following subretinal migration of BB. In general BB appears to be a safer alternative than ICG for ILM peeling. TB does not stain the ILM as well as BB or ICG.8 Different dyes including indigo carmine, fast green, light green, bromophenol blue, and evans blue are under investiga- tion.16 Toxicity The toxic effects of any vital dye depend on the dye concentra- tion, the osmolarity of the dye solution, the dye exposure time, and the illumination time. Recommendations to avoid toxicity include paying close attention to achieving dilutions with physi- ological osmolarities. The lowest concentration that will achieve staining should be used. The light pipe should remain far from the macula to avoid any light toxicity and photodynamic effect of the dye.4 Macular holes pose a particular problem since the bare RPE of the floor of the hole may come in contact with any dye and produce potential RPE toxicity. Some have suggested covering the hole with blood, viscoelastic, or perfluorocarbon liquid. Conclusions Transparent tissues such as the posterior hyaloid, ERM, and the ILM play an important role in several diseases of the posterior pole. Surgical removal of these tissues is a principal surgical objective. Staining of these tissues with a variety of vital dyes facilitates their identification and removal. Several dyes are cur- rently in routine clinical use; however, the ideal staining agent has not yet been found. Any dye that is injected intravitreally has the potential to become toxic. References 1. Sebag J. Anatomy and pathology of the vitreo-retinal interface. Eye (Lond) 1992; 6(pt 6):541-552. 2. Sebag J. Anomalous posterior vitreous detachment: a unifying con- cept in vitreo-retinal disease. Graefes Arch Clin Exp Ophthalmol. 2004; 242:690-698. 3. Rodrigues EB, Meyer CH, Kroll P. Chromovitrectomy: a new field in vitreoretinal surgery. Graefes Arch Clin Exp Ophthalmol. 2005; 243:291-293. 4. Farah ME, Maia M, Rodrigues EB. Dyes in ocular surgery: prin- ciples for use in chromovitrectomy. Am J Ophthalmol. 2009; 148:332-340. 5. Schmidt JC, Chofflet J, Horle S, Mennel S, Meyer CH. Three simple approaches to visualize the transparent vitreous cortex during vit- reoretinal surgery. Dev Ophthalmol. 2008; 42:35-42. 6. Guo S, Tutela AC, Wagner R, Caputo AR. A comparison of the effectiveness of four biostains in enhancing visualization of the vit- reous. J Pediatric Ophthalmol Strabismus 2006; 43:281-284. 7. Sousa-Martins D, Maia M, Moraes M, et al. Use of lutein and zeaxanthin alone or combined with brilliant blue to identify intra- ocular structures intraoperatively. Retina Epub ahead of print 26 March 2012. doi 10.1097/IAE.0b013e318239e2b6. 8. Farah ME, Maia M, Furlani B, et al. Current concepts of trypan blue in chromovitrectomy. Dev Ophthalmol. 2008; 42:91-100. 9. Almony A, Nudleman E, Shah GK, et al. Techniques, rationale, and outcomes of internal limiting membrane peeling. Retina 2012; 32:877-891. 10. Mester V, Kuhn F. Internal limiting membrane removal in the man- agement of full-thickness macular holes. Am J Ophthalmol. 2000; 129:769-777. 11. Funata M, Wendel RT, de la Cruz Z, Green WR. Clinicopathologic study of bilateral macular holes treated with pars plana vitrectomy and gas tamponade. Retina 1992; 12:289-298. 12. Fekrat S, Wendel RT, de la Cruz Z, Green WR. Clinicopathologic correlation of an epiretinal membrane associated with a recurrent macular hole. Retina 1995; 15:53-57. 13. Burk SE, Da Mata AP, Snyder ME, Rosa RH Jr, Foster RE. Indo- cyanine green-assisted peeling of the retinal internal limiting mem- brane. Ophthalmology 2000; 107:2010-2014. 14. Wollensak G. Biomechanical changes of the internal limiting mem- brane after indocyanine green staining. Dev Ophthalmol. 2008; 42:82-90. 15. Rodrigues EB, Meyer CH. Meta-analysis of chromovitrectomy with indocyanine green in macular hole surgery. Ophthalmologica 2008; 222:123-129. 16. Rodrigues EB, Penha FM, Farah ME, et al. Preclinical investigation of the retinal biocompatibility of six novel vital dyes for chromovit- rectomy. Retina 2009; 29:497-510.
2012 Subspecialty Day  |  Retina Section I: Vitreoretinal Surgery, Part I 11 Vitrectomy for Lamellar Macular Hole Periklis Brazitikos MD Lamellar macular hole (MH) is a distinct clinical entity, defined as absence of the inner macular tissue in the foveola region (ie, break of the inner retinal layers and intraretinal splitting) not extending to the level of the retinal pigment epithelium (RPE); lamellar MH occurs via interruption of the typical MH formation process or by the unroofing of the central fovea in chronic cystoid macular edema (CME).1-3 Despite the original description from Gass in 1976,1 the lamellar MH entity was not completely understood until recently with the widespread use of OCT; previously misdiagnosed cases of lamellar MHs can now be identified and their characteristics described very accurately.4-6 Tomographic studies of lamellar MHs with respect to their natural evolution7 or surgical outcomes8-10 are limited, retrospective in nature,8 and involve usually a limited number of patients.9,10 The clinical diagnosis of lamellar MHs was done in the pre- OCT era based only on biomicroscopy and fluorescein angiogra- phy. A small number of studies exist on lamellar MH entity, and those dated before the OCT advent are of little value nowadays, since lamellar MH is mainly an OCT-based diagnosis;11,12 in particular, there are studies in the literature from the past decade on macular pseudoholes (MPHs) that can now be reidentified as studies referring to lamellar MHs.12 Furthermore, with the wide- spread use of tomography, even the Gass theory of Mueller cell proliferation above the fovea, leading to a centripetal tangential traction on the fovea as the principal initiating step in the forma- tion of MHs, has been brought into question.13 In the present study, we report our results of surgical intervention / observation in a series of patients diagnosed with lamellar MH. It has been reported that most lamellar MH patients have mild complaints of metamorphopsia and limited central visual acuity (VA) loss, which uncommonly progresses to further dete- rioration of VA.7 In a very recent study by Theodossiadis and associates,7 the authors studied the natural course of lamellar MH in 41 cases and found an increase in the lamellar MH diameter by an aver- age of 13.7% and deterioration in best-corrected VA (BCVA) in 22% of the cases studied, over a period of 37.1 months. Visual deterioration could be possibly related—as the authors con- clude—to the enlargement of the lamellar MH diameter. Surgical treatment of lamellar MHs remains controversial, and some authors believe that there is no proof that surgi- cal intervention is helpful,6,10 whereas other studies8-11 found vitrectomy with epiretinal membrane (ERM)–internal limiting membrane (ILM) removal to be beneficial with respect to the VA result and foveal OCT appearance. In the report by Witkin and associates,11 4 patients under- went vitrectomy for lamellar MH, with only 1 case being judged anatomically and visually successful. Two of their patients devel- oped full-thickness MHs after vitrectomy. Conversely, Hirakawa and associates9 recently reported 2 patients with improved vision after vitrectomy with ILM peeling and gas tamponade for lamel- lar MH. Kokame achieved similar results in a case report of a single patient.10 The largest study reported so far, by Garretson and associates,8 found vitrectomy beneficial for 93% of their patient cohort, with a mean gain of 3 Snellen lines of VA. In our study,14 BCVA improved in 17 out of the 20 cases (85%) operated with a lamellar MH associated with an ERM; 3 cases retained the same BCVA postoperatively. Mean BCVA improvement was 2.6 Snellen lines, which was statistically sig- nificant (P = .002, paired t test). None of the cases deteriorated in terms of BCVA. Our hypothesis for the beneficial role of vitrectomy in lamel- lar MHs is that the ERM-ILM removal releases the tangential traction to the edges of the lamellar MH. Even in cases in which the lamellar MH still persists after surgical intervention, the surgically removed ERM-ILM prevents further lamellar MH stretching and VA deterioration, and so even in these cases there is a beneficial role of the surgical approach. Although there is no evidence that C3F8 use and facedown position are necessary in lamellar MH surgery, we decided to follow the same surgical approach we routinely use in cases of full-thickness MHs. Posterior vitreous detachment was present in all but 1 of our study cases of lamellar MHs with an ERM. Little information exists with respect to this finding in the literature. To our knowl- edge, in the only study reported,8 the authors presume retrospec- tively from the patients’ perioperative report that vitreous was attached in 17 out of the 27 patients (in the remaining 10 cases, there was no perioperative note on the vitreous attachment). In our patient cohort, vitreous was detached in almost all cases (except from cases with lamellar MH secondary to CME), and we believe that this feature represents another diagnostic crite- rion of the lamellar MHs. With respect to the presence of an ERM, most of the recent OCT studies7-11 report ERMs in the majority of patients with lamellar MHs; our belief is that ERM represents another distinct feature of lamellar MHs. Many of the ERMs associated with a lamellar MH have an unusual thickened appearance of moderate reflectivity on ultrahigh-resolution OCT.11 The high prevalence of ERMs in lamellar MHs suggests that ERM contraction plays a role in lamellar hole formation; removal of the ERM is manda- tory to improve the surgical results and to stabilize or improve the VA in these cases. References 1. Gass JD. Lamellar macular hole: a complication of cystoid macular edema after cataract extraction. Arch Ophthalmol. 1976; 94:793- 800. 2. Allen AW, Gass JD. Contraction of a perifoveal epiretinal mem- brane simulating a macular hole. Am J Ophthalmol. 1976; 82:684- 691. 3. Gass JD. Lamellar macular hole: a complication of cystoid macular edema after cataract extraction. Arch Ophthalmol. 1976; 94:793- 800. 4. Takahashi H, Kishi S. Tomographic features of a lamellar macular hole formation and a lamellar hole that progressed to full-thickness macular hole. Am J Ophthalmol. 2000;130:677-679. 5. Hee MR, Puliafito CA, Wong C, et al. Optical coherence tomogra- phy of macular holes. Ophthalmology 1995; 102:748-756.
12 Section I: Vitreoretinal Surgery, Part I 2012 Subspecialty Day  |  Retina 6. Haouchine B, Massin P, Tadayoni R, et al. Diagnosis of macular pseudoholes and lamellar macular holes by optical coherence tomography. Am J Ophthalmol. 2004; 138:732-739. 7. Theodossiadis PG, Grigoropoulos VG, Emfietzoglou I, et al. Evolu- tion of lamellar macular hole studied by optical coherence tomogra- phy. Graefes Arch Clin Exp Ophthalmol. 2009; 247:13-20. 8. Garretson BR, Pollack JS, Ruby AJ, et al. Vitrectomy for a symp- tomatic lamellar macular hole. Ophthalmology 2008; 115:884- 886. 9. Hirakawa M, Uemura A, Nakano T, et al. Pars plana vitrectomy with gas tamponade for lamellar macular holes. Am J Ophthalmol. 2005; 140:1154-1155. 10. Kokame GT, Tokuhara KG. Surgical management of inner lamellar macular hole. Ophthalmic Surg Lasers Imaging. 2007; 38:61-63. 11. Witkin AJ, Ko TH, Fujimoto JC, et al. Redefining lamellar holes and the vitreomacular interface: an ultra-high resolution optical coherence tomography study. Ophthalmology 2006; 113:388-397. 12. Massin P, Paques M, Masri H, et al. Visual outcome of surgery for epiretinal membranes with macular pseudoholes. Ophthalmology 1999; 106:580-585. 13. Gass JD. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Am J Ophthalmol. 1995; 119:752- 759. 14. Androudi S, Stangos A, Brazitikos P. Lamellar macular holes: tomo- graphic features and surgical outcome. Am J Ophthalmol. 2009; 148:420-426.
2012 Subspecialty Day  |  Retina Cool Surgical Video Panel 13 My Coolest Surgical Video The Use of Viscoelastics in Severe Trauma Cases Carlos Mateo MD I Shrunk the Gauge . . . Yusuke Oshima MD The Development of Retinal Endovascular Surgery Kazuaki Kadnosono MD Suprachoroidal Buckling, Indications, Evaluation and Technique Ehab N El Rayes MD PhD My Coolest Surgical Video Claus Eckardt MD Proliferative Vitreoretinopathy (PVR) after Vitrectomy with Silicone Oil for Retinal Detachment Associated with Giant Retinal Tear J Fernando Arevalo MD FACS My Coolest Surgical Video Carl C Claes MD
14 The Charles L Schepens MD Lecture 2012 Subspecialty Day  |  Retina Potential Therapeutic Approaches to AMD Therapeutic Targets for Early Age-Related Macular Disease Alan C Bird MD Changes in age-related macular disease (AMD) may affect cho- roid, Bruch membrane, the retinal pigment epithelium (RPE), and photoreceptor cells. The nature of the changes and the mechanisms by which they are generated are partly understood and have given rise to novel forms of treatment that are under trial. It is hoped that these will cause slowing or reversal of these changes with consequent reduction or abolishment of the risk of loss of central vision. Early histological studies indicated that photoreceptor loss may occur early in the disease process, and these findings accord with functional studies that reveal up to 3.4 log units of photopic function in eyes with early AMD but normal visual acuity. Both functional and histological data indicate that rod loss is greater than cone loss. It is widely believed that photoreceptor loss may be due to lack of metabolic support consequent upon thickening of Bruch membrane or RPE dysfunction. A recent histological study supports the view that major photoreceptor loss may occur early in disease, implying that the functional loss is due to cell loss, at least in part. In addition, the changes vary from one donor to another. In particular there is an inverse relationship between Bruch membrane thickening and RPE autofluorescence. Finally, photoreceptor loss may occur in the absence of obvious physical changes in other tissues. These findings imply that specific therapeutic approaches may not be suitable for all cases. If these conclusions are correct, better phe- notyping will be needed to select cases for therapeutic trials and monitor therapeutic effect.
2012 Subspecialty Day  |  Retina Section II: Non-neovascular AMD 15 Pathogenesis of AMD Christine A Curcio PhD Introduction “The best approach to improve care for our patients is to follow the biology.”1 Determining the composition of signature lesions was a means to identifying affected pathways in diseases like Alzheimer disease and atherosclerosis. For AMD, key lesions are drusen and basal linear deposit (BlinD), two forms (lump and layer) of the same lipid-rich material. Major constituents of drusen are now known. The first testable biochemical model for the main pathway has been articulated.2 Non-neovascular AMD is a metabolic and vascular disease affecting the photoreceptor support system—retinal pigment epi- thelium (RPE) and choroid—secondarily causing photoreceptor degeneration. Bruch membrane (BM), the choroid’s inner wall, is a subendothelial space, substrate for RPE attachment, and route for outer retinal nutrition and metabolite removal. Drusen and BlinD form on BM’s inner surface, outside the blood–retina bar- rier and within the systemic circulation. AMD’s largest risk factor is aging, suggesting that older eyes harbor clues to lesion pathogenesis. Major genetic risk factors include the alternative complement pathway and cholesterol and lipoprotein metabolism, among others.3,4 There is no consistent relationship between AMD and any measure of plasma athero- genic or antiatherogenic lipoproteins. Nor have plasma-lipid lowering statins proven consistently beneficial. BM Lipoproteins: Main Pathway of Drusen Nineteenth-century pathologists described drusen as fatty glob- ules.5 Early discovery is a surrogate for abundance. Histochemi- cally detectable esterified and unesterified cholesterol is present in all drusen.6 Lipids are the most abundant druse component, representing ≥ 40% of hard druse volume.7 Apolipoprotein immunoreactivity decreases in macular drusen, suggesting that high-risk drusen have proportionally higher lipid content.8 Soft drusen, oily and biomechanically unstable, are present in macula only.9 The backdrop to druse biogenesis is a marked accumulation of oil red O binding neutral lipid within macular BM throughout adulthood in normal eyes, thought to create a hydrophobic bar- rier.10 This process superficially resembles, but is distinct from, systemic perifibrous lipid accumulation, whereby plasma apoB- lipoproteins insudate into and bind to dense connective tissue in normal arterial intima (plus cornea, sclera, and tendons), set- ting up atherosclerotic plaques in hemodynamically vulnerable locales.11 Lipid-preserving ultrastructure, histochemistry, comprehen- sive lipid profiling, and gene expression combine with epidemiol- ogy to indicate that the RPE constitutively secretes large apoB containing lipoproteins into BM for clearance. These intraocular lipoproteins are 60-80 nm diameter spherical particles with neu- tral lipid cores rich in esterified cholesterol and surfaces contain- ing apoB-100, apoA-I, apoE, and apoC-I. They accumulate in the BM elastic layer starting in early adulthood, filling in toward the RPE. In older persons, a layer of almost pure lipoprotein par- ticles on BM inner surface (“lipid wall”) separates the RPE basal lamina from BM and represents the direct precursor to BlinD. RPE expresses genes for apoB and for microsomal triglyceride transfer protein, required for apoB lipidation and secretion, a combination signifying a constitutive lipoprotein secretor. RPE cell lines secrete apoB. Highly differentiated polarized RPE secrete apoE-immunoreactive particles, ultrastructurally identi- cal to lipoprotein-containing structures in native BM, which are capable of binding exogenously applied complement.12 Lipid profiling of BM lipoproteins indicates that the major fatty acid is linoleate, implicating diet as the upstream source of this constitu- ent, rather than photoreceptor outer segments, rich in docosa- hexaenoate. Functional consequences of the oil spill in BM include impaired transport of large molecules or multimolecular com- plexes including plasma lipoproteins delivering lipophilic essen- tials like carotenoids and vitamin E to RPE and photoreceptors via LDL and SRB-I receptors. Complexes of this size and physi- ological relevance can cross BM at higher rates than in arterial intima and block transport of subsequent particles,13 providing proof-of-principle for a hydrophobic barrier. Other conse- quences are the formation of highly toxic, proinflammatory / proangiogenic compounds like linoleate hydroperoxide and 7-ketocholesterol,14,15 known troublemakers from atheroscle- rotic plaque. Additional abundant protein components of drusen include TIMP-3 and many proteins of the complement cascade, includ- ing the terminal component membrane attack complex (C5b- 9).16,17 Advanced glycation end products likely enhance retention of lipoproteins18 that activate complement. Amyloid β-peptide is a volumetrically small druse component of interest because of its significance in Alzheimer disease.19 One large age-related change that does not appear directly related to druse biogenesis is RPE lipofuscin, rich in bis-retinoids. Lipofuscin granules appear in a small proportion (6%) of iso- lated drusen or shed into basal laminar deposits of eyes with advanced disease. Macular topographies of lipofuscin accumula- tion and RPE-BM pathology are not correlated.20 In vivo hyper- autofluorescence in AMD eyes can be accounted for by vertically superimposed RPE cells.21 Thus lipofuscin is not a significant druse constituent or an obvious predisposing factor. AMD Lesions in the Subretinal Space Remarkably, high-resolution imaging and new histopathology suggest a process parallel to that in BM involving cholesterol- containing deposits in the subretinal space. Subretinal drusenoid debris (SDD) is an organized, extracellular lesion at the RPE’s apical aspect first described in 198822 and later correlated with reticular pseudodrusen.23,24 Histologically detectable in 87% of a small AMD series, SDD is abundant in the rod-rich perifovea, in contrast to BlinD, abundant under the cone-rich fovea.25 This first linkage of lesion topography to rods and cones suggests involvement of differential aspects of photoreceptor physiology, such as cholesterol homeostasis of outer segment membranes.
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus
Aao sub retina_2012_syllabus

Empfohlen

Changing the Future of Primary Ciliary Dyskinesia (PCD): PCD Clinical Centers...
Changing the Future of Primary Ciliary Dyskinesia (PCD): PCD Clinical Centers...Changing the Future of Primary Ciliary Dyskinesia (PCD): PCD Clinical Centers...
Changing the Future of Primary Ciliary Dyskinesia (PCD): PCD Clinical Centers...PCD Foundation
 
RETINA COMPANY SHOWCASE - Bausch + Lomb
RETINA COMPANY SHOWCASE - Bausch + LombRETINA COMPANY SHOWCASE - Bausch + Lomb
RETINA COMPANY SHOWCASE - Bausch + LombHealthegy
 
Pediatric ophthalmology-2011-syllabus
Pediatric ophthalmology-2011-syllabusPediatric ophthalmology-2011-syllabus
Pediatric ophthalmology-2011-syllabusMohammed Fouad
 
Courses
CoursesCourses
CoursesZainabBadshah2
 
June 2019 - Dentists' Quarterly
June 2019 - Dentists' QuarterlyJune 2019 - Dentists' Quarterly
June 2019 - Dentists' QuarterlyAlexandra Gonzalez
 
Docmode ppt1
Docmode ppt1Docmode ppt1
Docmode ppt1AnkitaBhujade1
 
2012 05 21 cyp update v2
2012 05 21 cyp update v22012 05 21 cyp update v2
2012 05 21 cyp update v2Navy CYP
 
Clincal Geriatrics Brochure
Clincal Geriatrics BrochureClincal Geriatrics Brochure
Clincal Geriatrics BrochureUC San Diego - Clinical Geriatrics Symposium 2015
 

Empfohlen

Changing the Future of Primary Ciliary Dyskinesia (PCD): PCD Clinical Centers...
Changing the Future of Primary Ciliary Dyskinesia (PCD): PCD Clinical Centers...Changing the Future of Primary Ciliary Dyskinesia (PCD): PCD Clinical Centers...
Changing the Future of Primary Ciliary Dyskinesia (PCD): PCD Clinical Centers...PCD Foundation
 
RETINA COMPANY SHOWCASE - Bausch + Lomb
RETINA COMPANY SHOWCASE - Bausch + LombRETINA COMPANY SHOWCASE - Bausch + Lomb
RETINA COMPANY SHOWCASE - Bausch + LombHealthegy
 
Pediatric ophthalmology-2011-syllabus
Pediatric ophthalmology-2011-syllabusPediatric ophthalmology-2011-syllabus
Pediatric ophthalmology-2011-syllabusMohammed Fouad
 
Courses
CoursesCourses
CoursesZainabBadshah2
 
June 2019 - Dentists' Quarterly
June 2019 - Dentists' QuarterlyJune 2019 - Dentists' Quarterly
June 2019 - Dentists' QuarterlyAlexandra Gonzalez
 
Docmode ppt1
Docmode ppt1Docmode ppt1
Docmode ppt1AnkitaBhujade1
 
2012 05 21 cyp update v2
2012 05 21 cyp update v22012 05 21 cyp update v2
2012 05 21 cyp update v2Navy CYP
 
Clincal Geriatrics Brochure
Clincal Geriatrics BrochureClincal Geriatrics Brochure
Clincal Geriatrics BrochureUC San Diego - Clinical Geriatrics Symposium 2015
 
Clincal Geriatrics Brochure
Clincal Geriatrics BrochureClincal Geriatrics Brochure
Clincal Geriatrics BrochureAndrew Michael
 
Docmode courses ppt
Docmode courses pptDocmode courses ppt
Docmode courses pptvarsha arolla
 
FL Dept Quality Assurance
FL Dept Quality AssuranceFL Dept Quality Assurance
FL Dept Quality AssuranceMichael B. Reiner, Ph.D.
 
Ram+Fund+Spring+2014+Presentation+Book
Ram+Fund+Spring+2014+Presentation+BookRam+Fund+Spring+2014+Presentation+Book
Ram+Fund+Spring+2014+Presentation+BookCarlos A Then
 
Canada retina
Canada retinaCanada retina
Canada retinaHà Thanh
 
NUS PRIME (Zubin)
NUS PRIME (Zubin)NUS PRIME (Zubin)
NUS PRIME (Zubin)Zubin Daruwalla
 
Ocular Imaging Challenge Webinar
Ocular Imaging Challenge Webinar Ocular Imaging Challenge Webinar
Ocular Imaging Challenge Webinar health2dev
 
World Congress on Nephrology 2019 brochure
World Congress on Nephrology 2019 brochureWorld Congress on Nephrology 2019 brochure
World Congress on Nephrology 2019 brochureFMNephrology
 
P&S
P&SP&S
P&Sbowden9
 
U.S. Residencies Promoting International Training
U.S. Residencies Promoting International TrainingU.S. Residencies Promoting International Training
U.S. Residencies Promoting International TrainingSusan Umfer
 
Lessons from Early Intervention in Psychosis
Lessons from Early Intervention in Psychosis Lessons from Early Intervention in Psychosis
Lessons from Early Intervention in Psychosis Sarah Amani
 
Ophthalmic public health report
Ophthalmic public health reportOphthalmic public health report
Ophthalmic public health reportevolutio Care Innovations Ltd
 
3rd-World-Diabetes-Congress-2022.pdf
3rd-World-Diabetes-Congress-2022.pdf3rd-World-Diabetes-Congress-2022.pdf
3rd-World-Diabetes-Congress-2022.pdfDBWCPRGeneric
 
Winthrop 2012 annual report designed by Curran & Connors
Winthrop 2012 annual report designed by Curran & ConnorsWinthrop 2012 annual report designed by Curran & Connors
Winthrop 2012 annual report designed by Curran & ConnorsStephen Seligson
 
16th wccn
16th wccn16th wccn
16th wccnPankaj Umrao
 
Med view 2011 information sheet (Kings)
Med view 2011 information sheet (Kings)Med view 2011 information sheet (Kings)
Med view 2011 information sheet (Kings)Welling School Sixth Form
 
Med view 2011 information sheet
Med view 2011 information sheetMed view 2011 information sheet
Med view 2011 information sheetWelling School Sixth Form
 
Med view 2011 information sheet
Med view 2011 information sheetMed view 2011 information sheet
Med view 2011 information sheetWelling School Sixth Form
 
SJCCF Call for Presenters & Speakers 2012
SJCCF Call for Presenters & Speakers 2012SJCCF Call for Presenters & Speakers 2012
SJCCF Call for Presenters & Speakers 2012Wilma Colon-Ariza
 
MCI brochure 2004
MCI brochure 2004MCI brochure 2004
MCI brochure 2004wef
 
Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...
Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...
Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...Namrata Singh
 
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...Sheetaleventcompany
 

Weitere ähnliche Inhalte

Ähnlich wie Aao sub retina_2012_syllabus

Clincal Geriatrics Brochure
Clincal Geriatrics BrochureClincal Geriatrics Brochure
Clincal Geriatrics BrochureAndrew Michael
 
Ram+Fund+Spring+2014+Presentation+Book
Ram+Fund+Spring+2014+Presentation+BookRam+Fund+Spring+2014+Presentation+Book
Ram+Fund+Spring+2014+Presentation+BookCarlos A Then
 
Canada retina
Canada retinaCanada retina
Canada retinaHà Thanh
 
Ocular Imaging Challenge Webinar
Ocular Imaging Challenge Webinar Ocular Imaging Challenge Webinar
Ocular Imaging Challenge Webinar health2dev
 
World Congress on Nephrology 2019 brochure
World Congress on Nephrology 2019 brochureWorld Congress on Nephrology 2019 brochure
World Congress on Nephrology 2019 brochureFMNephrology
 
U.S. Residencies Promoting International Training
U.S. Residencies Promoting International TrainingU.S. Residencies Promoting International Training
U.S. Residencies Promoting International TrainingSusan Umfer
 
Lessons from Early Intervention in Psychosis
Lessons from Early Intervention in Psychosis Lessons from Early Intervention in Psychosis
Lessons from Early Intervention in Psychosis Sarah Amani
 
3rd-World-Diabetes-Congress-2022.pdf
3rd-World-Diabetes-Congress-2022.pdf3rd-World-Diabetes-Congress-2022.pdf
3rd-World-Diabetes-Congress-2022.pdfDBWCPRGeneric
 
Winthrop 2012 annual report designed by Curran & Connors
Winthrop 2012 annual report designed by Curran & ConnorsWinthrop 2012 annual report designed by Curran & Connors
Winthrop 2012 annual report designed by Curran & ConnorsStephen Seligson
 
SJCCF Call for Presenters & Speakers 2012
SJCCF Call for Presenters & Speakers 2012SJCCF Call for Presenters & Speakers 2012
SJCCF Call for Presenters & Speakers 2012Wilma Colon-Ariza
 
MCI brochure 2004
MCI brochure 2004MCI brochure 2004
MCI brochure 2004wef
 

Ähnlich wie Aao sub retina_2012_syllabus (20)

Clincal Geriatrics Brochure
Clincal Geriatrics BrochureClincal Geriatrics Brochure
Clincal Geriatrics Brochure
 
Docmode courses ppt
Docmode courses pptDocmode courses ppt
Docmode courses ppt
 
FL Dept Quality Assurance
FL Dept Quality AssuranceFL Dept Quality Assurance
FL Dept Quality Assurance
 
Ram+Fund+Spring+2014+Presentation+Book
Ram+Fund+Spring+2014+Presentation+BookRam+Fund+Spring+2014+Presentation+Book
Ram+Fund+Spring+2014+Presentation+Book
 
Canada retina
Canada retinaCanada retina
Canada retina
 
NUS PRIME (Zubin)
NUS PRIME (Zubin)NUS PRIME (Zubin)
NUS PRIME (Zubin)
 
Ocular Imaging Challenge Webinar
Ocular Imaging Challenge Webinar Ocular Imaging Challenge Webinar
Ocular Imaging Challenge Webinar
 
World Congress on Nephrology 2019 brochure
World Congress on Nephrology 2019 brochureWorld Congress on Nephrology 2019 brochure
World Congress on Nephrology 2019 brochure
 
P&S
P&SP&S
P&S
 
U.S. Residencies Promoting International Training
U.S. Residencies Promoting International TrainingU.S. Residencies Promoting International Training
U.S. Residencies Promoting International Training
 
Lessons from Early Intervention in Psychosis
Lessons from Early Intervention in Psychosis Lessons from Early Intervention in Psychosis
Lessons from Early Intervention in Psychosis
 
Ophthalmic public health report
Ophthalmic public health reportOphthalmic public health report
Ophthalmic public health report
 
3rd-World-Diabetes-Congress-2022.pdf
3rd-World-Diabetes-Congress-2022.pdf3rd-World-Diabetes-Congress-2022.pdf
3rd-World-Diabetes-Congress-2022.pdf
 
Winthrop 2012 annual report designed by Curran & Connors
Winthrop 2012 annual report designed by Curran & ConnorsWinthrop 2012 annual report designed by Curran & Connors
Winthrop 2012 annual report designed by Curran & Connors
 
16th wccn
16th wccn16th wccn
16th wccn
 
Med view 2011 information sheet (Kings)
Med view 2011 information sheet (Kings)Med view 2011 information sheet (Kings)
Med view 2011 information sheet (Kings)
 
Med view 2011 information sheet
Med view 2011 information sheetMed view 2011 information sheet
Med view 2011 information sheet
 
Med view 2011 information sheet
Med view 2011 information sheetMed view 2011 information sheet
Med view 2011 information sheet
 
SJCCF Call for Presenters & Speakers 2012
SJCCF Call for Presenters & Speakers 2012SJCCF Call for Presenters & Speakers 2012
SJCCF Call for Presenters & Speakers 2012
 
MCI brochure 2004
MCI brochure 2004MCI brochure 2004
MCI brochure 2004
 

Kürzlich hochgeladen

Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...
Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...
Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...Namrata Singh
 
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...Sheetaleventcompany
 
Call Girls Rishikesh Just Call 9667172968 Top Class Call Girl Service Available
Call Girls Rishikesh Just Call 9667172968 Top Class Call Girl Service AvailableCall Girls Rishikesh Just Call 9667172968 Top Class Call Girl Service Available
Call Girls Rishikesh Just Call 9667172968 Top Class Call Girl Service Availableperfect solution
 
Call girls Service Phullen / 9332606886 Genuine Call girls with real Photos a...
Call girls Service Phullen / 9332606886 Genuine Call girls with real Photos a...Call girls Service Phullen / 9332606886 Genuine Call girls with real Photos a...
Call girls Service Phullen / 9332606886 Genuine Call girls with real Photos a...call girls hydrabad
 
Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...
Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...
Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...Sheetaleventcompany
 
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...Sheetaleventcompany
 
💚Reliable Call Girls Chandigarh 💯Niamh 📲🔝8868886958🔝Call Girl In Chandigarh N...
💚Reliable Call Girls Chandigarh 💯Niamh 📲🔝8868886958🔝Call Girl In Chandigarh N...💚Reliable Call Girls Chandigarh 💯Niamh 📲🔝8868886958🔝Call Girl In Chandigarh N...
💚Reliable Call Girls Chandigarh 💯Niamh 📲🔝8868886958🔝Call Girl In Chandigarh N...Sheetaleventcompany
 
Kolkata Call Girls Naktala 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Girl Se...
Kolkata Call Girls Naktala 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Girl Se...Kolkata Call Girls Naktala 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Girl Se...
Kolkata Call Girls Naktala 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Girl Se...Namrata Singh
 
Cheap Rate Call Girls Bangalore {9179660964} ❤️VVIP BEBO Call Girls in Bangal...
Cheap Rate Call Girls Bangalore {9179660964} ❤️VVIP BEBO Call Girls in Bangal...Cheap Rate Call Girls Bangalore {9179660964} ❤️VVIP BEBO Call Girls in Bangal...
Cheap Rate Call Girls Bangalore {9179660964} ❤️VVIP BEBO Call Girls in Bangal...Sheetaleventcompany
 
Call Girls in Lucknow Just Call 👉👉 8875999948 Top Class Call Girl Service Ava...
Call Girls in Lucknow Just Call 👉👉 8875999948 Top Class Call Girl Service Ava...Call Girls in Lucknow Just Call 👉👉 8875999948 Top Class Call Girl Service Ava...
Call Girls in Lucknow Just Call 👉👉 8875999948 Top Class Call Girl Service Ava...Janvi Singh
 
Call Girl In Chandigarh 📞9809698092📞 Just📲 Call Inaaya Chandigarh Call Girls ...
Call Girl In Chandigarh 📞9809698092📞 Just📲 Call Inaaya Chandigarh Call Girls ...Call Girl In Chandigarh 📞9809698092📞 Just📲 Call Inaaya Chandigarh Call Girls ...
Call Girl In Chandigarh 📞9809698092📞 Just📲 Call Inaaya Chandigarh Call Girls ...Sheetaleventcompany
 
Circulatory Shock, types and stages, compensatory mechanisms
Circulatory Shock, types and stages, compensatory mechanismsCirculatory Shock, types and stages, compensatory mechanisms
Circulatory Shock, types and stages, compensatory mechanismsMedicoseAcademics
 
Goa Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Goa No💰Advanc...
Goa Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Goa No💰Advanc...Goa Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Goa No💰Advanc...
Goa Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Goa No💰Advanc...Sheetaleventcompany
 
Difference Between Skeletal Smooth and Cardiac Muscles
Difference Between Skeletal Smooth and Cardiac MusclesDifference Between Skeletal Smooth and Cardiac Muscles
Difference Between Skeletal Smooth and Cardiac MusclesMedicoseAcademics
 
Call Girls in Lucknow Just Call 👉👉8630512678 Top Class Call Girl Service Avai...
Call Girls in Lucknow Just Call 👉👉8630512678 Top Class Call Girl Service Avai...Call Girls in Lucknow Just Call 👉👉8630512678 Top Class Call Girl Service Avai...
Call Girls in Lucknow Just Call 👉👉8630512678 Top Class Call Girl Service Avai...soniyagrag336
 
ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM.pptx
ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM.pptxANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM.pptx
ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM.pptxSwetaba Besh
 
Independent Bangalore Call Girls (Adult Only) 💯Call Us 🔝 7304373326 🔝 💃 Escor...
Independent Bangalore Call Girls (Adult Only) 💯Call Us 🔝 7304373326 🔝 💃 Escor...Independent Bangalore Call Girls (Adult Only) 💯Call Us 🔝 7304373326 🔝 💃 Escor...
Independent Bangalore Call Girls (Adult Only) 💯Call Us 🔝 7304373326 🔝 💃 Escor...Sheetaleventcompany
 
7 steps How to prevent Thalassemia : Dr Sharda Jain & Vandana Gupta
7 steps How to prevent Thalassemia : Dr Sharda Jain & Vandana Gupta7 steps How to prevent Thalassemia : Dr Sharda Jain & Vandana Gupta
7 steps How to prevent Thalassemia : Dr Sharda Jain & Vandana GuptaLifecare Centre
 
Call 8250092165 Patna Call Girls ₹4.5k Cash Payment With Room Delivery
Call 8250092165 Patna Call Girls ₹4.5k Cash Payment With Room DeliveryCall 8250092165 Patna Call Girls ₹4.5k Cash Payment With Room Delivery
Call 8250092165 Patna Call Girls ₹4.5k Cash Payment With Room DeliveryJyoti singh
 
Ahmedabad Call Girls Book Now 8980367676 Top Class Ahmedabad Escort Service A...
Ahmedabad Call Girls Book Now 8980367676 Top Class Ahmedabad Escort Service A...Ahmedabad Call Girls Book Now 8980367676 Top Class Ahmedabad Escort Service A...
Ahmedabad Call Girls Book Now 8980367676 Top Class Ahmedabad Escort Service A...Genuine Call Girls
 

Kürzlich hochgeladen (20)

Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...
Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...
Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...
 
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
 
Call Girls Rishikesh Just Call 9667172968 Top Class Call Girl Service Available
Call Girls Rishikesh Just Call 9667172968 Top Class Call Girl Service AvailableCall Girls Rishikesh Just Call 9667172968 Top Class Call Girl Service Available
Call Girls Rishikesh Just Call 9667172968 Top Class Call Girl Service Available
 
Call girls Service Phullen / 9332606886 Genuine Call girls with real Photos a...
Call girls Service Phullen / 9332606886 Genuine Call girls with real Photos a...Call girls Service Phullen / 9332606886 Genuine Call girls with real Photos a...
Call girls Service Phullen / 9332606886 Genuine Call girls with real Photos a...
 
Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...
Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...
Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...
 
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
 
💚Reliable Call Girls Chandigarh 💯Niamh 📲🔝8868886958🔝Call Girl In Chandigarh N...
💚Reliable Call Girls Chandigarh 💯Niamh 📲🔝8868886958🔝Call Girl In Chandigarh N...💚Reliable Call Girls Chandigarh 💯Niamh 📲🔝8868886958🔝Call Girl In Chandigarh N...
💚Reliable Call Girls Chandigarh 💯Niamh 📲🔝8868886958🔝Call Girl In Chandigarh N...
 
Kolkata Call Girls Naktala 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Girl Se...
Kolkata Call Girls Naktala 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Girl Se...Kolkata Call Girls Naktala 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Girl Se...
Kolkata Call Girls Naktala 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Girl Se...
 
Cheap Rate Call Girls Bangalore {9179660964} ❤️VVIP BEBO Call Girls in Bangal...
Cheap Rate Call Girls Bangalore {9179660964} ❤️VVIP BEBO Call Girls in Bangal...Cheap Rate Call Girls Bangalore {9179660964} ❤️VVIP BEBO Call Girls in Bangal...
Cheap Rate Call Girls Bangalore {9179660964} ❤️VVIP BEBO Call Girls in Bangal...
 
Call Girls in Lucknow Just Call 👉👉 8875999948 Top Class Call Girl Service Ava...
Call Girls in Lucknow Just Call 👉👉 8875999948 Top Class Call Girl Service Ava...Call Girls in Lucknow Just Call 👉👉 8875999948 Top Class Call Girl Service Ava...
Call Girls in Lucknow Just Call 👉👉 8875999948 Top Class Call Girl Service Ava...
 
Call Girl In Chandigarh 📞9809698092📞 Just📲 Call Inaaya Chandigarh Call Girls ...
Call Girl In Chandigarh 📞9809698092📞 Just📲 Call Inaaya Chandigarh Call Girls ...Call Girl In Chandigarh 📞9809698092📞 Just📲 Call Inaaya Chandigarh Call Girls ...
Call Girl In Chandigarh 📞9809698092📞 Just📲 Call Inaaya Chandigarh Call Girls ...
 
Circulatory Shock, types and stages, compensatory mechanisms
Circulatory Shock, types and stages, compensatory mechanismsCirculatory Shock, types and stages, compensatory mechanisms
Circulatory Shock, types and stages, compensatory mechanisms
 
Goa Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Goa No💰Advanc...
Goa Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Goa No💰Advanc...Goa Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Goa No💰Advanc...
Goa Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Goa No💰Advanc...
 
Difference Between Skeletal Smooth and Cardiac Muscles
Difference Between Skeletal Smooth and Cardiac MusclesDifference Between Skeletal Smooth and Cardiac Muscles
Difference Between Skeletal Smooth and Cardiac Muscles
 
Call Girls in Lucknow Just Call 👉👉8630512678 Top Class Call Girl Service Avai...
Call Girls in Lucknow Just Call 👉👉8630512678 Top Class Call Girl Service Avai...Call Girls in Lucknow Just Call 👉👉8630512678 Top Class Call Girl Service Avai...
Call Girls in Lucknow Just Call 👉👉8630512678 Top Class Call Girl Service Avai...
 
ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM.pptx
ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM.pptxANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM.pptx
ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM.pptx
 
Independent Bangalore Call Girls (Adult Only) 💯Call Us 🔝 7304373326 🔝 💃 Escor...
Independent Bangalore Call Girls (Adult Only) 💯Call Us 🔝 7304373326 🔝 💃 Escor...Independent Bangalore Call Girls (Adult Only) 💯Call Us 🔝 7304373326 🔝 💃 Escor...
Independent Bangalore Call Girls (Adult Only) 💯Call Us 🔝 7304373326 🔝 💃 Escor...
 
7 steps How to prevent Thalassemia : Dr Sharda Jain & Vandana Gupta
7 steps How to prevent Thalassemia : Dr Sharda Jain & Vandana Gupta7 steps How to prevent Thalassemia : Dr Sharda Jain & Vandana Gupta
7 steps How to prevent Thalassemia : Dr Sharda Jain & Vandana Gupta
 
Call 8250092165 Patna Call Girls ₹4.5k Cash Payment With Room Delivery
Call 8250092165 Patna Call Girls ₹4.5k Cash Payment With Room DeliveryCall 8250092165 Patna Call Girls ₹4.5k Cash Payment With Room Delivery
Call 8250092165 Patna Call Girls ₹4.5k Cash Payment With Room Delivery
 
Ahmedabad Call Girls Book Now 8980367676 Top Class Ahmedabad Escort Service A...
Ahmedabad Call Girls Book Now 8980367676 Top Class Ahmedabad Escort Service A...Ahmedabad Call Girls Book Now 8980367676 Top Class Ahmedabad Escort Service A...
Ahmedabad Call Girls Book Now 8980367676 Top Class Ahmedabad Escort Service A...
 

Aao sub retina_2012_syllabus

  • 1. ©2012 American Academy of Ophthalmology. All rights reserved. No portion may be reproduced without express written consent of the American Academy of Ophthalmology. Retina 2012 The Winds of Change Program Directors Joan W Miller MD and Tarek S Hassan MD In conjunction with the American Society of Retina Specialists, the Macula Society, the Retina Society, and Club Jules Gonin McCormick Place Chicago, Illinois Friday – Saturday, November 9 – 10, 2012 Presented by The American Academy of Ophthalmology Sponsored by an unrestricted educational grant by Genentech and Regeneron Retina 2012 Planning Group Joan W Miller MD Program Director Tarek S Hassan MD Program Director Pravin U Dugel MD Peter K Kaiser MD Former Program Directors 2011 Allen C Ho MD Joan W Miller MD 2010 Daniel F Martin MD Allen C Ho MD 2009 Antonio Capone Jr MD Daniel F Martin MD 2008 M Gilbert Grand MD Antonio Capone Jr MD 2007 John T Thompson MD M Gilbert Grand MD 2006 Emily Y Chew MD John T Thompson MD 2005 Michael T Trese MD Emily Y Chew MD 2004 William F Mieler MD Michael T Trese MD 2003 Kirk H Packo MD William F Mieler MD 2002 Mark S Blumenkranz MD Kirk H Packo MD 2001 George A Williams MD Mark S Blumenkranz MD 2000 Julia A Haller MD George A Williams MD 1999 Stanley Chang MD Julia A Haller MD 1998 Harry W Flynn Jr MD Stanley Chang MD 1997 H MacKenzie Freeman MD Harry W Flynn Jr MD 1996 H MacKenzie Freeman MD 1995 Thomas M Aaberg Sr MD Paul Sternberg Jr MD Subspecialty Day Advisory Committee William F Mieler MD Associate Secretary Donald L Budenz MD MPH Daniel S Durrie MD Robert S Feder MD Leah Levi MBBS R Michael Siatkowski MD Jonathan B Rubenstein MD Secretary for Annual Meeting Staff Melanie R Rafaty CMP, Director, Scientific Meetings Ann L’Estrange, Scientific Meetings Specialist Brandi Garrigus, Presenter Coordinator Debra Rosencrance CMP CAE, Vice President, Meetings & Exhibits Patricia Heinicke Jr, Editor Mark Ong, Designer Gina Comaduran, Cover Design
  • 2. ii 2012 Subspecialty Day  |  Retina Dear Colleague: On behalf of the American Academy of Ophthalmology and the American Society of Retina Spe- cialists, the Macula Society, the Retina Society, and Club Jules Gonin, it is our pleasure to welcome you to Chicago and to Retina 2012: The Winds of Change. The standard components of Retina Subspecialty Day are the lectures and panel discussions pre- sented by leading experts from around the world. We have created opportunities for lively and spirited discussions of controversial issues, including a rapid-fire presentation of “My Coolest Surgical Video” by innovative surgical leaders, with commentary by an expert panel and followed by an audience vote, debate teams presenting arguments on contested topics in the management of diabetic retinopathy with audience pre- and post-debate voting, and expert panels on surgi- cal complications. We continue the tradition of holding discussion panels on the topics of AMD management, retinal vein occlusion, pediatric retinal surgery, and tumor management. We include “best of” approaches to create a core program that addresses what’s new in clinical practice, as well as practical issues that retina specialists face daily—from the status of new treatments for diabetic retinopathy to what health care reform means for the field of retina. Two sessions are reserved for presentation of late-breaking developments. The Schepens Lecture—delivered this year by Alan Bird MD on “Potential Therapeutic Approaches to AMD”—is certain to be a highlight. Finally, we include the popular Break With the Experts program on Friday from 3:12 to 3:54, which allows participants to move freely from topic to topic at their leisure and to interact with our faculty on a much more personal level. Our goal is that attendees will find Retina 2012: The Winds of Change to be an informative, interactive, and entertaining experience as we present new and useful informa- tion to benefit their professional lives. We thank the dedicated Academy Subspecialty Day staff and the Program Committee for their tireless work. Above all, we thank the outstanding faculty for their enthusiastic efforts in preparing their presentations and course materials to provide the most up-to- date and comprehensive review on the diagnosis and management of vitreoretinal diseases. We strive for continual improvement of the Subspecialty Day Meetings and request that you assist us by completing the evaluation. We carefully review all comments to better understand your needs so please take a few moments to indicate the strengths and shortcomings of this program and sug- gest new ways to meet the needs of our international audience. Again, we welcome you to Retina 2012: The Winds of Change. We hope you find it intellectually stimulating, educational and enjoyable. Sincerely, Joan W Miller MD Tarek S Hassan MD Program Director Program Director
  • 3. 2012 Subspecialty Day  |  Retina iii Retina 2012 Contents Program Directors’ Welcome Letter   ii CME  iv The Charles L Schepens MD Lecture   v Faculty Listing  vi Program Schedule  xxiii Section I: Vitreoretinal Surgery, Part I   1 Cool Surgical Video Panel   13 The Charles L Schepens MD Lecture   14 Section II: Non-neovascular AMD   15 Section III: Late Breaking Developments, Part I   34 Section IV: Pediatric Retina   35 Section V: Inherited Retinal Diseases   43 Section VI: Retinal Vein Occlusion   51 Section VII: Business of Retina   52 Section VIII: Neovascular AMD   63 Section IX: Imaging  86 Section X: Oncology  105 Section XI: Late Breaking Developments, Part II   118 Section XII: Diabetes  119 Section XIII: Vitreoretinal Surgery, Part II   129 Faculty Financial Disclosure   131 Presenter Index  139 Electronic version of Syllabi available at www.aao.org / 2012syllabi
  • 4. iv 2012 Subspecialty Day  |  Retina CME Credit Academy’s CME Mission Statement The purpose of the American Academy of Ophthalmology’s Continuing Medical Education (CME) program is to pres- ent ophthalmologists with the highest quality lifelong learning opportunities that promote improvement and change in physi- cian practices, performance or competence, thus enabling such physicians to maintain or improve the competence and profes- sional performance needed to provide the best possible eye care for their patients. 2012 Retina Subspecialty Day Meeting Learning Objectives Upon completion of this activity, participants should be able to: • Explain the current management of macular edema sec- ondary to retinal occlusive disease and diabetic retinopa- thy • Explain the pathobiology and management of atrophic and exudative AMD and other causes of CNV • Identify emerging developments in retinal imaging • Describe new vitreoretinal surgical techniques and instru- mentation • Identify new developments in hereditary retinal degenera- tions, pediatric retinal diseases, and ocular oncology 2012 Retina Subspecialty Day Meeting Target Audience The intended target audience for this program is vitreoretinal specialists, members in fellowship training and general ophthal- mologists who are engaged in the diagnosis and treatment of vitreoretinal diseases. 2012 Retina Subspecialty Day CME Credit The American Academy of Ophthalmology is accredited by the Accreditation Council for Continuing Medical Education to pro- vide continuing medical education for physicians. The American Academy of Ophthalmology designates this live activity for a maximum of 14 AMA PRA Category 1 Cred- its™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Scientific Integrity and Disclosure of Financial Interest The American Academy of Ophthalmology is committed to ensuring that all continuing medical education (CME) informa- tion is based on the application of research findings and the implementation of evidence-based medicine. It seeks to promote balance, objectivity and absence of commercial bias in its con- tent. All persons in a position to control the content of this activ- ity must disclose any and all financial interests. The Academy has mechanisms in place to resolve all conflicts of interest prior to an educational activity being delivered to the learners. Attendance Verification for CME Reporting Before processing your requests for CME credit, the Academy must verify your attendance at Subspecialty Day and/or the Joint Meeting. In order to be verified for CME or auditing purposes, you must either: • Register in advance, receive materials in the mail and turn in the Final Program and/or Subspecialty Day Syllabus exchange voucher(s) onsite; • Register in advance and pick up your badge onsite if mate- rials did not arrive before you traveled to the meeting; • Register onsite; or • Use your ExpoCard at the meeting. CME Credit Reporting Grand Concourse Level 2.5; Academy Resource Center, Hall A - Booth 508 Attendees whose attendance has been verified (see above) at the 2012 Joint Meeting can claim their CME credit online during the meeting. Registrants will receive an e-mail during the meeting with the link and instructions on how to claim credit. Onsite, you may report credits earned during Subspecialty Day and/or the Joint Meeting at the CME Credit Reporting booth. Academy Members: The CME credit reporting receipt is not a CME transcript. CME transcripts that include 2012 Joint Meet- ing credits entered onsite will be available to Academy members on the Academy’s website beginning Dec. 3, 2012. NOTE: CME credits must be reported by Jan. 16, 2013. After the 2012 Joint Meeting, credits can be claimed at www.aao.org/cme. The Academy transcript cannot list individual course atten- dance. It will list only the overall credits spent in educational activities at Subspecialty Day and/or the Joint Meeting. Nonmembers: The Academy will provide nonmembers with verification of credits earned and reported for a single Academy- sponsored CME activity, but it does not provide CME credit transcripts. To obtain a printed record of your credits, you must report your CME credits onsite at the CME Credit Reporting booths. Proof of Attendance The following types of attendance verification will be available during the Joint Meeting and Subspecialty Day for those who need it for reimbursement or hospital privileges, or for nonmem- bers who need it to report CME credit: • CME credit reporting/proof-of-attendance letters • Onsite Registration Form • Instruction Course Verification Visit the Academy’s website for detailed CME reporting infor- mation.
  • 5. 2012 Subspecialty Day  |  Retina v The Charles L Schepens MD Lecture Potential Therapeutic Approaches to AMD Friday, November 9, 2012 9:31 AM – 9:46 AM Alan C Bird MD
  • 6. vi 2012 Subspecialty Day  |  Retina Thomas M Aaberg Jr MD Ada, MI Founder and President Retina Specialists of Michigan Assistant Clinical Professor of Ophthalmology Michigan State University Gary W Abrams MD Detroit, MI Professor of Ophthalmology Kresge Eye Institute Wayne State University David H Abramson MD FACS New York, NY Chief, Ophthalmic Oncology Service Memorial Sloan-Kettering Cancer Center Professor of Ophthalmology Weill Cornell University Lloyd P Aiello MD PhD Boston, MA Professor of Ophthalmology Harvard Medical School Head, Section of Eye Research, and Director, Beetham Eye Institute Joslin Diabetes Center Arthur W Allen Jr MD San Francisco, CA Vice Chairman Department of Ophthalmology California Pacific Medical Center President Pacific Eye Associates J Fernando Arevalo MD FACS Riyadh, Saudi Arabia Professor of Ophthalmology Wilmer Eye Institute and Johns Hopkins University School of Medicine Chief of Vitreoretina Division The King Khaled Eye Specialist Hospital Riyadh, Kingdom of Saudi Arabia Jorge G Arroyo MD Brookline, MA Associate Professor of Ophthalmology Harvard Medical School Director of Retina Service Beth Israel Deaconess Medical Center Marcos P Avila MD Goiania, Brazil Full Professor of Ophthalmology and Head of the Ophthalmology Department Universidade Federal de Goiás Carl C Awh MD Nashville, TN President Tennessee Retina, PC Faculty
  • 7. 2012 Subspecialty Day  |  Retina Faculty Listing vii James W Bainbridge MA PhD FRCOphth London, United Kingdom Professor of Retinal Studies University College Consultant Ophthalmologist Moorfields Eye Hospital Sophie J Bakri MD Rochester, MN Professor of Ophthalmology Mayo Clinic Francesco M Bandello MD FEBO Milano, Italy Full Professor and Chairman Department of Ophthalmology University Vita Salute Scientific Institute, San Raffaele, Milan MD, FEBO University Vita Salute No photo available Francine Behar-Cohen MD Paris, France Audina M Berrocal MD Miami, FL Associate Professor of Ophthalmology Bascom Palmer Eye Institute University of Miami Staff Physician Miami Children’s Hospital Maria H Berrocal MD San Juan, PR Assistant Professor University of Puerto Rico Susanne Binder MD Vienna, Austria Professor of Ophthalmology Department of Ophthalmology Rudolf Foundation Clinic Professor of Ophthalmology The Ludwig Boltzmann Institute for Retinology and Biomicroscopic Laser Surgery Alan C Bird MD London, England Emeritus Professor of Ophthalmology University College, London No photo available Barbara Ann Blodi MD Madison, WI Professor of Ophthalmology University of Wisconsin Codirector Fundus Photograph Reading Center University of Wisconsin
  • 8. viii Faculty Listing 2012 Subspecialty Day  |  Retina Mark S Blumenkranz MD Palo Alto, CA Professor and Chairman Stanford University School of Medicine David S Boyer MD Los Angeles, CA Clinical Professor of Ophthalmology University of Southern California Keck School of Medicine Partner, Retina Vitreous Associates Medical Group No photo available Periklis Brazitikos MD Thessaloniki, Greece Associate Professor of Ophthalmology Aristotle University of Thessaloniki Neil M Bressler MD Baltimore, MD The James P Gills Professor of Ophthalmology Johns Hopkins University School of Medicine Chief, Retina Division Wilmer Eye Institute David M Brown MD Houston, TX Associate Clinical Professor of Opthalmology Weill Cornell College of Medicine, The Methodist Hospital Director of Clinical Research Retina Consultants of Houston Alexander J Brucker MD Philadelphia, PA Professor of Ophthalmology Scheie Eye Institute University of Pennsylvania Brandon G Busbee MD Nashville, TN Retina Specialist Tennessee Retina Antonio Capone Jr MD Royal Oak, MI Professor of Ophthalmology William Beaumont Hospital-Oakland University School of Medicine Codirector, Fellowship in Vitreoretinal Diseases and Surgery Associated Retinal Consultants Usha Chakravarthy MBBS PhD Belfast, Northern Ireland Professor of Ophthalmology and Vision Science Queen’s University of Belfast
  • 9. 2012 Subspecialty Day  |  Retina Faculty Listing ix Wiley Andrew Chambers MD McLean, VA Clinical Professor of Ophthalmology The George Washington University R V Paul Chan MD New York, NY St Giles Associate Professor of Pediatric Retina Weill Cornell Medical College Stanley Chang MD New York, NY KK Tse and Ku Teh Ying Professor of Ophthalmology Columbia University Tom S Chang MD Arcadia, CA Partner Retina Institute of California Steven T Charles MD Memphis, TN Adjunct Professor of Ophthalmology Columbia College of Physicians and Surgeons Clinical Professor of Ophthalmology University of Tennessee, Memphis Emily Y Chew MD Bethesda, MD Deputy Director of Division of Epidemiology and Clinical Applicatons National Eye Institute, National Institutes of Health N H Victor Chong MD Oxford, United Kingdom Head of Department Oxford Eye Hospital Clinical Senior Lecturer in Ophthalmology University of Oxford David R Chow MD North York, ON, Canada Assistant Professor of Ophthalmology University of Toronto Codirector Toronto Retina Institute Mina Chung MD Rochester, NY Associate Professor of Ophthalmology Flaum Eye Institute University of Rochester
  • 10. x Faculty Listing 2012 Subspecialty Day  |  Retina Carl C Claes MD Schilde, Belgium Head of Vitreoretinal Surgery Saint Augustinus Hospital (Wilrijk/ Antwerp) No photo available Karl G Csaky MD PhD Dallas, TX Vitreoretinal Specialist Texas Retina Associates Christine Curcio PhD Birmingham, AL Professor of Ophthalmology University of Alabama at Birmingham Donald J D’Amico MD New York, NY Professor and Chairman Department of Ophthalmology Weill Cornell Medical College Ophthalmologist-in-Chief New York-Presbyterian Hospital Kimberly A Drenser MD PhD Royal Oak, MI Vitreoretinal Surgeon Associated Retinal Consultants Associate Professor Eye Research Institute Oakland University Pravin U Dugel MD Phoenix, AZ Managing Partner Retinal Consultants of Arizona Clinical Associate Professor of Ophthalmology Doheny Eye Institute Keck School of Medicine University of Southern California Jay S Duker MD Boston, MA Director, New England Eye Center Tufts Medical Center Professor and Chair Department of Ophthalmology No photo available Alexander M Eaton MD Fort Myers, FL Claus Eckardt MD Frankfurt, Germany Professor of Ophthalmology Klinikum Frankfurt Höchst
  • 11. 2012 Subspecialty Day  |  Retina Faculty Listing xi Ehab N El Rayes MD PhD Cairo, Egypt Professor of Ophthalmlogy, Retina Service Institute of Ophthalmology Vitreoretinal Consultant International Eye Hospital Dean Eliott MD Boston, MA Associate Director, Retina Service Massachusetts Eye and Ear Infirmary Harvard Medical School Daniel D Esmaili MD Boston, MA Instructor in Ophthalmology Massachusetts Eye and Ear Infirmary Sharon Fekrat MD Durham, NC Associate Professor of Ophthalmology Albert Eye Research Institute Duke University Eye Center Chief, Ophthalmology Durham Veterans Affairs Medical Center Frederick L Ferris MD Waxhaw, NC Director, Division of Epidemiology and Clinical Applications National Eye Institute, National Institutes of Health Philip J Ferrone MD Great Neck, NY Partner Long Island Vitreoretinal Consultants Assistant Professor of Ophthalmology Columbia University Marta Figueroa MD Madrid, Spain Director of Vitreoretinal Department Vissum Madrid Professor of Ophthalmology University of Alcalá de Henares Paul T Finger MD New York, NY Director The New York Eye Cancer Center Clinical Professor of Ophthalmology New York University School of Medicine Harry W Flynn Jr MD Miami, FL Professor of Ophthalmology Bascom Palmer Eye Institute University of Miami
  • 12. xii Faculty Listing 2012 Subspecialty Day  |  Retina William R Freeman MD La Jolla, CA Professor of Ophthalmology University of California, San Diego Director Jacobs Retina Center Shiley Eye Center University of California, San Diego K Bailey Freund MD New York, NY Clinical Associate Professor of Ophthalmology New York University Partner Vitreous Retina Macula Consultants of New York Thomas R Friberg MD Pittsburgh, PA Professor of Bioengineering and Ophthalmology University of Pittsburgh Director of Retina Service UPMC Eye Center Anne E Fung MD San Francisco, CA Medical Retina Consultant Pacific Eye Associates Director, Barkan Research Society California Pacific Medical Center No photo available Brenda L Gallie MD Toronto, ON, Canada Professor of Ophthalmology University of Toronto Head, Retinoblastoma Program Hospital for Sick Children Alain Gaudric MD Paris, France Professor of Ophthalmology Hopital Lariboisiere, AP-HP Université Paris-Diderot No photo available Andre V Gomes MD São Paulo, Brazil No photo available Christine R Gonzales MD Ashland, OR Evangelos S Gragoudas MD Boston, MA Professor of Ophthalmology Harvard Medical School Director, Retina Service Massachusetts Eye and Ear Infirmary M Gilbert Grand MD St Louis, MO Retina Surgeon Retina Consultants, The Retina Institute Professor of Clinical Ophthalmology Washington University School of Medicine
  • 13. 2012 Subspecialty Day  |  Retina Faculty Listing xiii Julia A Haller MD Philadelphia, PA Ophthalmologist-in-Chief Wills Eye Hospital Professor and Chair of Ophthalmology Jefferson Medical College Thomas Jefferson University Dennis P Han MD Milwaukee, WI Jack A and Elaine D Klieger Professor of Ophthalmology Medical College of Wisconsin Head, Vitreoretinal Section Froedert The Medical College Eye Institute Tarek S Hassan MD Royal Oak, MI Professor of Ophthalmology Oakland University, William Beaumont School of Medicine Director of Vitreoretinal Program Partner, Associated Retinal Consultants Jeffrey S Heier MD Boston, MA Director, Vitreoretina Service Ophthalmic Consultants of Boston Assistant Professor in Ophthalmology Tufts University School of Medicine Allen C Ho MD Philadelphia, PA Director of Retina Research Mid Atlantic Retina and Wills Eye Institute Professor of Ophthalmology Thomas Jefferson University Frank G Holz MD Bonn, Germany Professor of Ophthalmology University of Bonn, Germany Suber S Huang MD MBA Cleveland, OH Director, Center Retina and Macular Disease University Hospitals Eye Institute Searle Professor and Vice Chair Department of Ophthalmology and Visual Sciences Case Western Reserve University School of Medicine Mark S Humayun MD PhD Los Angeles, CA Professor of Ophthalmology, Biomedical Engineering and Cell Neurobiology Doheny Eye Institute Keck School of Medicine University of Southern California Michael S Ip MD Madison, WI Associate Professor of Ophthalmology University of Wisconsin-Madison
  • 14. xiv Faculty Listing 2012 Subspecialty Day  |  Retina No photo available Timothy L Jackson MBChB London, England Consultant Ophthalmic Surgeon King’s College Hospital HEFCE Senior Clinical Lecturer King’s College London Glenn J Jaffe MD Durham, NC Professor of Ophthalmology Duke University No photo available Martine J Jager MD Oegstgeest, Netherlands Senior Medical Specialist Leiden University Medical Center, Leiden Mark W Johnson MD Ann Arbor, MI Professor of Ophthalmology and Visual Sciences University of Michigan Director, Retina Service W K Kellogg Eye Center No photo available J Michael Jumper MD San Francisco, CA West Coast Retina Medical Group, Inc. Kazuaki Kadonosono MD Yokohama, Japan Professor of Ophthalmology Yokohama City University Peter K Kaiser MD Cleveland, OH Professor of Ophthalmology Cleveland Clinic Lerner College of Medicine Director, Digital OCT Reading Center Cole Eye Institute Ivana K Kim MD Boston, MA Associate Professor of Ophthalmology Harvard Medical School Retina Service Massachusetts Eye and Ear Infirmary Judy E Kim MD Milwaukee, WI Professor of Ophthalmology Medical College of Wisconsin
  • 15. 2012 Subspecialty Day  |  Retina Faculty Listing xv No photo available John W Kitchens MD Lexington, KY Baruch D Kuppermann MD PhD Irvine, CA Professor and Chief, Retina Service Gavin Herbert Eye Institute University of California, Irvine No photo available Timothy Y Lai MD FRCOphth FRCS Tsimshatsui, Kowloon, Hong Kong Honorary Clinical Associate Professor The Chinese University of Hong Kong Director, 2010 Retina and Macula Centre Jennifer Irene Lim MD Chicago, IL Professor of Ophthalmology, Director, Retina Service, and Marion H Schenk Esq Chair in Ophthalmology Illinois Eye and Ear Infirmary University of Illinois at Chicago Anat Loewenstein MD Tel Aviv, Israel Director of Ophthalmology Tel Aviv Medical Center Professor of Ophthalmology Vice Dean, Sackler Faculty of Medicine, Tel Aviv University Ian M MacDonald MD Edmonton, AB, Canada Professor of Ophthalmology University of Alberta Maureen G Maguire PhD Philadelphia, PA Professor of Ophthalmology University of Pennsylvania Daniel F Martin MD Cleveland, OH Chairman, Cole Eye Institute Cleveland Clinic Carlos Mateo MD Barcelona, Spain Associate Professor of Ophthalmology Instituto de Microcirugía Ocular of Barcelona
  • 16. xvi Faculty Listing 2012 Subspecialty Day  |  Retina William F Mieler MD Chicago, IL Professor and Vice Chairman Department of Ophthalmology and Visual Sciences University of Illinois at Chicago Joan W Miller MD Boston, MA Henry Willard Williams Professor of Ophthalmology Harvard Medical School Chief and Chair of Ophthalmology Massachusetts Eye and Ear Infirmary Harvard Medical School Darius M Moshfeghi MD Palo Alto, CA Associate Professor of Ophthalmology Stanford University School of Medicine Director of Telemedicine and Director of Pediatric Vitreoretinal Surgery Byers Eye Institute Stanford University School of Medicine No photo available Shizuo Mukai MD Boston, MA Assistant Professor in Ophthtalmology Harvard Medical School Surgeon in Ophthalmology Massachusetts Eye and Ear Infirmary Timothy G Murray MD MBA Miami, FL Professor of Ophthalmology and Radiation Oncology Bascom Palmer Eye Insitute University of Miami Miller School of Medicine Annabelle A Okada MD Tokyo, Japan Professor of Ophthalmology Kyorin University School of Medicine Timothy W Olsen MD Atlanta, GA F Phinizy Calhoun Sr Professor and Chairman of Ophthalmology Emory University Jeffrey L Olson MD Englewood, CO Associate Professor of Ophthalmology University of Colorado, Rocky Mountain Lions Eye Institute Yusuke Oshima MD Suita, Osaka, Japan Associate Professor of Ophthalmology Osaka University Graduate School of Medicine
  • 17. 2012 Subspecialty Day  |  Retina Faculty Listing xvii Andrew J Packer MD Hartford, CT Clinical Professor University of Connecticut School of Medicine Kirk H Packo MD Indian Head Park, IL Professor and Chairman Department of Ophthalmology Rush University Medical Center Partner, Illinois Retina Associates David W Parke II MD San Francisco, CA Executive Vice President and CEO American Academy of Ophthalmology Fabio Patelli MD Garbagnate Milanese, Italy Ophthalmologist, Vitreoretinal Surgeon Milano Retina Center Director, Vitreoretinal Service Igea Clinic, Milan No photo available Grazia Pertile MD Negrar, Verona, Italy Director, Department of Ophthalmology Sacro Cuore Hospital, Negrar (VR) Italy Dante Pieramici MD Santa Barbara, CA Assistant Clinical Professor Doheny Eye Institute President, California Retina Research Foundation Eric A Pierce MD PhD Boston, MA Director, Ocular Genomics Institute Massacusetts Eye and Ear Infirmary Subhransu Ray MD PhD Moraga, CA Franco M Recchia MD Nashville, TN Associate, Tennessee Retina, P.C.
  • 18. xviii Faculty Listing 2012 Subspecialty Day  |  Retina Carl D Regillo MD FACS Bryn Mawr, PA Professor of Ophthalmology Thomas Jefferson University Director, Retina Service Wills Eye Institute Kourous Rezaei MD Harvey, IL Associate Professor of Ophthalmology Rush University Medical Center Partner, Illinois Retina Associates William L Rich MD Falls Church, VA Medical Director for Health Policy American Academy of Ophthalmology Clinical Instructor Department of Ophthalmology Georgetown University Stanislao Rizzo MD Pisa, Italy Director U.O. Chirurgia Oftalmica Azienda Ospedaliero Universitaria Pisana Michael A Romansky JD Chevy Chase, MD Washington Counsel and Vice President for Corporate Development Outpatient Ophthalmic Surgery Society No photo available Richard B Rosen MD New York, NY Vice Chairman and Surgeon Director, Director of Retina and Director of Research New York Eye and Ear Infirmary Professor of Ophthalmology New York Medical College Philip J Rosenfeld MD PhD Miami, FL Professor of Ophthalmology Bascom Palmer Eye Institute University of Miami Miller School of Medicine Alan J Ruby MD Novi, MI Associated Retinal Consultants, Royal Oak, MI Professor of Ophthalmology Oakland University William Beaumont School of Medicine Srinivas R Sadda MD Los Angeles, CA Associate Professor of Ophthalmology University of Southern California Director, Doheny Image Reading Center Doheny Eye Institute
  • 19. 2012 Subspecialty Day  |  Retina Faculty Listing xix Andrew P Schachat MD Cleveland, OH Vice Chairman for Clinical Affairs Cole Eye Institute, Cleveland Clinic Professor of Ophthalmology Lerner College of Medicine No photo available Amy C Schefler MD Houston, TX Clinical Assistant Professor Weill Medical College of Cornell University Associate Partner Retinal Consultants of Houston Ursula M Schmidt-Erfurth MD Vienna, Austria Professor of Ophthalmology Medical University of Vienna Chair Department of Ophthalmology and Optometry No photo available Hendrik PN Scholl MD Baltimore, MD The Dr. Frieda Derdeyn Bambas Professor of Ophthalmology Wilmer Eye Institute John Hopkins University School of Medicine Steven D Schwartz MD Los Angeles, CA Ahmanson Professor of Ophthalmology and Chief, Retina Division Jules Stein Eye Institute, University of California, Los Angeles (UCLA) Professor of Ophthalmology David Geffen School of Medicine at UCLA Jonathan E Sears MD Cleveland, OH Associate Professor of Ophthalmology Cole Eye Institute, Cleveland Clinic Associate Professor of Cell Biology Cell Biology, Cleveland Clinic Gaurav K Shah MD St Louis, MO Clinical Professor of Ophthalmology and Visual Sciences The Retina Institute Carol L Shields MD Philadelphia, PA Codirector, Oncology Service Wills Eye Institute Professor of Ophthalmology Thomas Jefferson University Hospital Jerry A Shields MD Philadelphia, PA Director, Oncology Service Wills Eye Institute Professor of Ophthalmology Thomas Jefferson University
  • 20. xx Faculty Listing 2012 Subspecialty Day  |  Retina Michael A Singer MD San Antonio, TX Ophthalmologist, Managing Partner and Director of Clinical Trials Medical Center Ophthalmology Associates Assistant Clinical Professor University of Texas Health Science Center, San Antonio Lawrence J Singerman MD Cleveland, OH Founder, Retina Associates of Cleveland Clinical Professor of Ophthalmology Case Western Reserve University School of Medicine Arun D Singh MD Cleveland, OH Director, Ophthalmic Oncology Cole Eye Institute Professor of Ophthalmology Cleveland Clinic Rishi P Singh MD Cleveland, OH Staff Physician Cole Eye Institute Cleveland Clinic Foundation Jason S Slakter MD New York, NY Clinical Professor of Ophthalmology New York University School of Medicine Partner, Vitreous Retina Macula Consultants of New York No photo available Rachel Smith MD PhD Atlanta, GA Gisele Soubrane MD PhD Paris, France Professor of Ophthalmology Department of Ophthalmology University Paris Descartes, France MD, PhD, FEBO, FARVO Hotel Dieu de Paris Richard F Spaide MD New York, NY Ophthalmology Vitreous, Retina and Macula Consultants of New York Sunil K Srivastava MD Cleveland, OH Staff Physician Cole Eye Institute Cleveland Clinic Foundation
  • 21. 2012 Subspecialty Day  |  Retina Faculty Listing xxi Giovanni Staurenghi MD Milan, Italy Professor of Ophthalmology Department of Clinical Science “Luigi Sacco” Paul Sternberg MD Nashville, TN Professor and Chairman, Vanderbilt Eye Institute Vanderbilt University School of Medicine Associate Dean for Clinical Affairs Vanderbilt University School of Medicine John T Thompson MD Baltimore, MD Partner, Retina Specialists Assistant Professor The Wilmer Institute of The Johns Hopkins University No photo available Trexler M Topping MD Boston, MA Associate Clinical Professor of Ophthalmology Tufts University School of Medicine Instructor in Ophthalmology Harvard Medical School Cynthia A Toth MD Durham, NC Professor of Ophthalmology Duke University Medical Center Professor of Biomedical Engineering Pratt School of Engineering Duke University Michael T Trese MD Royal Oak, MI President, Associated Retinal Consultants, PC Chief, Pediatric and Adult Vitreoretinal Surgery Beaumont Eye Institute Wm Beaumont Hospital Jan C Van Meurs MD Rotterdam, Netherlands Vitreoretinal Surgeon The Rotterdam Eye Hospital Professor Erasmus University Luk H Vandenberghe PhD Boston, MA Lecturer in Ophthalmology Massachusetts Eye and Ear Infirmary Harvard Medical School Alexander C Walsh MD Los Angeles, CA Assistant Professor of Ophthalmology Keck School of Medicine University of Southern California
  • 22. xxii Faculty Listing 2012 Subspecialty Day  |  Retina David F Williams MD Minneapolis, MN Partner, VitreoRetinal Surgery, P.A. Assistant Clinical Professor of Ophthalmology University of Minnesota George A Williams MD Royal Oak, MI Professor and Chair, Department of Ophthalmology Oakland University William Beaumont School of Medicine Lihteh Wu MD San Jose, Costa Rica Associate Surgeon Instituto de Cirugia Ocular Associate Professor University of Costa Rica Lawrence A Yannuzzi MD New York, NY Vice Chairman, Department of Ophthalmology, and Director of Retinal Services Manhattan Eye, Ear and Throat Hospital/North Shore Hospital Professor of Clinical Ophthalmology College of Physicians and Surgeons Columbia University Young Hee Yoon MD Seoul, Republic of Korea Professor of Ophthalmology Asan Medical Center, University of Ulsan, College of Medicine David N Zacks MD PhD Ann Arbor, MI Associate Professor of Ophthalmology and Visual Sciences University of Michigan, Kellogg Eye Center
  • 23. 2012 Subspecialty Day  |  Retina xxiii Retina 2012: The Winds of Change FRIDAY, NOVEMBER 9, 2012 7:00 AM REGISTRATION/MATERIAL PICKUP/CONTINENTAL BREAKFAST 8:00 AM Opening Remarks Joan W Miller MD* Tarek S Hassan MD* Section I: Vitreoretinal Surgery, Part I Moderators: Tarek S Hassan MD*, Young Hee Yoon MD* 8:05 AM Vitreoretinal Instrument Update David R Chow MD* 1 8:15 AM Role of Retinectomy in Vitreoretinal Surgery Dean Eliott MD* 2 8:22 AM Current Role of Endoscopy in Vitreoretinal Surgery Jorge G Arroyo MD 4 8:29 AM Treatment of Suprachoroidal Hemorrhages John W Kitchens MD* 6 8:36 AM Recurrent Retinal Detachment: Does Initial Treatment Matter? Gaurav K Shah MD* 7 8:43 AM Chromovitrectomy 2012 Lihteh Wu MD* 9 8:50 AM Vitrectomy for Lamellar Macular Hole Periklis Brazitikos MD* 11 Cool Surgical Video Panel Moderator: Tarek S Hassan MD* Panelists: Maria H Berrocal MD*, Mark S Humayun MD PhD*, Fabio Patelli MD, Steven D Schwartz MD* 8:57 AM My Coolest Surgical Video Carlos Mateo MD 13 8:59 AM Discussion 9:01 AM My Coolest Surgical Video Yusuke Oshima MD* 13 9:03 AM Discussion 9:05 AM My Coolest Surgical Video Kazuaki Kadonosono MD 13 9:07 AM Discussion 9:09 AM My Coolest Surgical Video Ehab N El Rayes MD PhD 13 9:11 AM Discussion 9:13 AM My Coolest Surgical Video Claus Eckardt MD* 13 9:15 AM Discussion 9:17 AM My Coolest Surgical Video J Fernando Arevalo MD FACS 13 9:19 AM Discussion 9:21 AM My Coolest Surgical Video Carl C Claes MD* 13 9:23 AM Discussion 9:25 AM Audience Vote * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest.
  • 24. xxiv Program Schedule 2012 Subspecialty Day  |  Retina * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. The Charles L Schepens MD Lecture 9:26 AM Introduction of the 2012 Schepens Lecturer David W Parke II MD* 9:31 AM Potential Therapeutic Approaches to AMD Alan C Bird MD 14 9:46 AM REFRESHMENT BREAK and RETINA EXHIBITS Section II: Non-neovascular AMD Moderators: Sophie J Bakri MD*, Francesco M Bandello MD FEBO* 10:30 AM Pathogenesis of AMD Christine Curcio PhD* 15 10:40 AM Genetic Testing−Pro Mark S Blumenkranz MD* 17 10:47 AM Genetic Testing−Con Frederick L Ferris MD* 20 10:54 AM Audience Vote 10:55 AM Rapid-fire Phase 2 Trials, Part I David M Brown MD* 21 11:02 AM Rapid-fire Phase 2 Trials, Part II Philip J Rosenfeld MD PhD* 21 11:09 AM Neuroprotection for AMD David N Zacks MD PhD* 28 11:16 AM Cell-Based Therapies for AMD Allen C Ho MD* 29 11:23 AM Advocating for Patients George A Williams MD* 32 11:28 AM LUNCH and RETINA EXHIBITS Section III: Late Breaking Developments, Part I Moderators: Alexander J Brucker MD*, Paul Sternberg MD 1:00 PM A Multi-state Outbreak of Fungal Endophthalmitis Associated With Rachel Smith MD MPH 34 Contaminated Ophthalmologic Products From a Single Compounding Pharmacy 1:07 PM Responder Analysis of the INTREPID Study of Stereotactic Radiotherapy Timothy L Jackson MBChB* 34 for Wet Age-Related Macular Degeneration 1:14 PM First-in-Human Results of a Refillable Drug Delivery Implant Providing Anat Loewenstein MD* 34 Release of Ranibizumab in Patients with Wet AMD 1:21 PM The Use of Anterior Segment OCT to Help Predict Steroid Responders Michael A Singer MD* 34 After Intravitreal Injections 1:28 PM New Insight in the Physiopathology of CSCR: Therapeutic Application Francine Behar-Cohen MD 34 1:35 PM Baseline Anatomic Features Predictive of Pharmacologic VMA Subhransu Ray MD PhD* 34 Resolution in the Phase III Ocriplasmin Clinical Trial Program Section IV: Pediatric Retina Moderators: Shizuo Mukai MD, Amy C Schefler MD 1:42 PM Update on the Study of Telemedicine for ROP Darius M Moshfeghi MD* 35 1:49 PM Ophthalmic Insurer Perspectives on the Use of Telemedicine for Screening and Diagnosis of ROP and Bevacizumab for ROP Arthur W Allen Jr MD 36 1:56 PM Update on the Multicenter Study of Anti-VEGF Treatment for ROP (BLOCK-ROP)* Michael T Trese MD 38 2:03 PM Microplasmin for Pediatric Vitrectomy Study Kimberly A Drenser MD PhD* 39 2:10 PM Familial Exudative Vitreoretinopathy: Diagnosis, Management With Wide-Angle Angiography, and Long-term Surgical Results Franco M Recchia MD* 40
  • 25. 2012 Subspecialty Day  |  Retina Program Schedule xxv * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. 2:17 PM Surgical Video Panel Moderator: Antonio Capone Jr MD* Panelists: Audina M Berrocal MD*, R V Paul Chan MD, Philip J Ferrone MD*, Jonathan E Sears MD Section V: Inherited Retinal Diseases Moderators: Marcos P Avila MD, Michael A Singer MD* 2:37 PM Update on Gene Therapy Trials in Progress James W Bainbridge MA PhD FRCOphth*43 2:44 PM Upcoming Trials in Retinal Degeneration Ian M MacDonald MD* 44 2:51 PM Phase 1b Data for 091001, a Synthetic Retinoid for the Treatment of Leber Congenital Amaurosis and Retinitis Pigmentosa Hendrik PN Scholl MD* 46 2:58 PM Genetic Testing for Patients With Retinal Degeneration Eric A Pierce MD PhD 47 3:05 PM Optogenetics: A New Approach to Retinitis Pigmentosa Luk H Vandenberghe PhD* 49 Break With the Experts Moderators: M Gilbert Grand MD, Andrew J Packer MD 3:12 PM − 3:54 PM Exhibit Hall E Topic V01: AMD Susanne Binder MD David S Boyer MD* David M Brown MD* Emily Y Chew MD Philip J Rosenfeld MD PhD* Jason S Slakter MD* Topic V02: New Instrumentation David R Chow MD* Topic V03: Diabetic Retinopathy Carl C Awh MD* Carl G Csaky MD PhD* Mark W Johnson MD* Jennifer Irene Lim MD* Topic V04: Business of Retina Alan J Ruby MD* George A Williams MD* Topic V05: Endophthalmitis Harry W Flynn Jr MD* Topic V06: Trauma Carl C Claes MD* Topic V07: Intraocular Tumors Ivana K Kim MD* Timothy G Murray MD MBA* Topic V08: Macular Surgery Periklis Brazitikos MD* Carlos Mateo MD Yusuke Oshima MD* Cynthia A Toth MD* Topic V09: Ocular Imaging Srinivas R Sadda MD* Richard F Spaide MD* Sunil K Srivastava MD Alexander C Walsh MD* Topic V10: Pediatric Retinal Disease Kimberly A Drenser MD PhD* Philip J Ferrone MD* Topic V11: Gene Therapy James W Bainbridge MA PhD* FRCOphth
  • 26. xxvi Program Schedule 2012 Subspecialty Day  |  Retina * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. Topic V12: Enzymatic Vitrectomy Michael T Trese MD* Topic V13: Retinal Detachment Gary W Abrams MD* J Fernando Arevalo MD FACS Claus Eckardt MD* Dean Eliott MD* Topic V14: Vascular Occlusions Michael S Ip MD* Sharon Fekrat MD Carl D Regillo MD FACS* Section VI: Retinal Vein Occlusion Moderator: Donald J D’Amico MD* 3:54 PM Retinal Vein Occlusion Panel Panelists: Barbara Ann Blodi MD, Sharon Fekrat MD, Michael S Ip MD*, Carl D Regillo MD FACS*, Rishi P Singh MD* 51 Section VII: Business of Retina Moderators: William R Freeman MD*, Anne E Fung MD* 4:14 PM The Future of Health Care: Survival of the Fittest David W Parke II MD* 52 4:21 PM Accountable Care Organizations: In or Out? William L Rich MD 54 4:28 PM ASC for Retina: Is It Time? Michael A Romansky JD 56 4:35 PM ASC for Retina: Balancing Quality With Profit Alan J Ruby MD* 57 4:42 PM The Office of the Inspector General and Bevacizumab vs. Ranibizumab: No Good Deed Goes Unpunished George A Williams MD* 58 4:49 PM Managing a Large Modern Practice: Practice Informatics and IT Trexler M Topping MD* 59 4:56 PM Post-marketing Surveillance Wiley Andrew Chambers MD 60 5:03 PM Closing Remarks Joan W Miller MD* Tarek S Hassan MD* 5:04 PM ADJOURN SATURDAY, NOVEMBER 10, 2012 7:00 AM CONTINENTAL BREAKFAST 8:00 AM Opening Remarks Joan W Miller MD* Tarek S Hassan* Section VIII: Neovascular AMD Moderators: Andrew P Schachat MD, Gisele Soubrane MD PhD* 8:05 AM Non-inferiority Trials and Subgroups: How to Interpret What You Are About to Hear Maureen G Maguire PhD* 63 8:12 AM CATT: Year 2 Daniel F Martin MD 65 8:19 AM IVAN: Year 1 Usha Chakravarthy MBBS PhD*66 8:26 AM MANTA: Year 1 Susanne Binder MD 68
  • 27. 2012 Subspecialty Day  |  Retina Program Schedule xxvii * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. 8:33 AM VIEW: Year 2 Jeffrey S Heier MD* 69 8:40 AM HARBOR: Year 2 Brandon G Busbee MD* 70 8:47 AM How Do I Incorporate What I Just Heard Into My Practice? Peter K Kaiser MD* 73 8:54 AM Aspirin and AMD: What Do I Tell My Patients? Emily Y Chew MD 74 9:01 AM Radiation for CNV: Cabernet /MERITAGE/ INTREPID Timothy L Jackson MBChB* 76 9:08 AM Polypoidal Vasculopathy: Anti-VEGF, Photodynamic Therapy, Timothy Y Lai MD and Steroids FRCOphth FRCS* 77 9:15 AM Anti-Platelet Derived Growth Factor: Where Do We Stand? Pravin U Dugel MD* 80 9:22 AM Long-term Delivery Strategies for Neovascular AMD David S Boyer MD* 81 9:29 AM What’s Next in the Neovascular AMD Pipeline? Jason S Slakter MD* 82 9:36 AM Panel: Management of Neovascular AMD in 2012 Moderator: Lawrence A Yannuzzi MD Panelists: Glenn J Jaffe MD*, J Michael Jumper MD, Annabelle A Okada MD*, Lawrence J Singerman MD*, Giovanni Staurenghi MD* 9:56 AM REFRESHMENT BREAK and JOINT MEETING EXHIBITS Section IX: Imaging Moderators: Daniel D Esmaili MD, Timothy W Olsen MD* 10:40 AM Imaging the Choroid: What You Need to Know Before Deep “C” Diving Richard F Spaide MD* 86 10:47 AM When Should I Be Using Fundus Autofluorescence? Frank G Holz MD* 89 10:54 AM What’s Next in Imaging? Srinivas R Sadda MD* 94 11:01 AM Intraoperative OCT: Is It Actually Useful? Sunil K Srivastava MD 97 11:08 AM Adaptive Optics: Ready for Prime Time? Judy E Kim MD* 99 11:15 AM Simple Estimation of Fluid Volumes in Neovascular AMD Alexander C Walsh MD* 102 11:22 AM Panel: How Do You Prefer to Image Disease X? Moderator: Jay S Duker MD* Panelists: Mina Chung MD*, Thomas R Friberg MD*, Alain Gaudric MD*, Richard B Rosen MD*, Ursula M Schmidt-Erfurth MD* Section X: Oncology Moderators: K Bailey Freund MD*, Martine J Jager MD* 11:42 AM Germline BAP1 Mutations in Ocular Melanoma and Other Malignancies Ivana K Kim MD* 105 11:49 AM Practical Approaches to Needle Biopsy and Genetic Diagnosis for Ocular Melanoma Thomas M Aaberg Jr MD* 106 11:56 AM New Imaging Techniques for Ocular Tumors Timothy G Murray MD MBA*115 12:03 PM Follow-up After Intra-arterial Chemotherapy for Retinoblastoma Carol L Shields MD 116 12:10 PM Panel: Tumor Management: Radiation, Retinopathy, and Masquerade Moderator: Evangelos S Gragoudas MD* Panelists: David H Abramson MD FACS, Paul T Finger MD*, Brenda L Gallie MD, Jerry A Shields MD, Arun D Singh MD 12:30 PM LUNCH and JOINT MEETING EXHIBITS
  • 28. xxviii Program Schedule 2012 Subspecialty Day  |  Retina * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. Section XI: Late Breaking Developments, Part II Moderators: Tom S Chang MD, Suber S Huang MD MBA* 1:55 PM Phase I Study of CNTF for Mactel Emily Y Chew MD 118 2:02 PM Long-term Effects of Intravitreal Ranibizumab on Diabetic Retinopathy Michael S Ip MD* 118 Severity and Progression 2:09 PM A Phase 1 Study Targeting Tissue Factor With a Single Dose of Christine R Gonzales MD* 118 Intravitreal HI-Con1 for Exudative Macular Degeneration 2:23 PM A Novel Intravitreal Injection Device Alexander M Eaton MD* 118 2:16 PM New Surgical Technique and New Instrumentation for Safe, Atraumatic Jeffrey L Olson MD* 118 Removal of Intraocular Foreign Bodies 2:28 PM ARGUS II Mark S Humayun MD PhD* 118 Section XII: Diabetes Moderators: Dennis P Han MD*, Peter K Kaiser MD* I Use the DRCR.net Guidelines in My Clinical Practice (Yes/No) 2:35 PM Coin Toss and Audience Vote 2:37 PM Pro Neil M Bressler MD* 119 2:40 PM Con Harry W Flynn Jr MD* 119 2:43 PM Rebuttal, Pro Mark W Johnson MD* 121 2:44 PM Rebuttal, Con Jennifer Irene Lim MD* 121 2:45 PM Audience Vote Subthreshold Laser Is an Important Treatment for Macular Edema (Yes/No) 2:46 PM Audience Vote 2:47 PM Pro N H Victor Chong MD* 122 2:51 PM Con Lloyd P Aiello MD PhD* 122 2:55 PM Audience Vote I Still Use Scissors in Diabetic Vitrectomy (Yes/No) 2:56 PM Audience Vote 2:57 PM Pro Steven T Charles MD* 123 3:01 PM Con Carl C Awh MD* 123 3:05 PM Audience Vote Anti-VEGF Is the Ideal Treatment for Diabetic Macular Edema (Yes/No) 3:06 PM Coin Toss and Audience Vote 3:08 PM Pro Julia A Haller MD* 124 3:11 PM Con Baruch D Kuppermann MD PhD*124 3:14 PM Rebuttal, Pro Karl G Csaky MD PhD* 128 3:15 PM Rebuttal, Con Dante Pieramici MD* 128
  • 29. 2012 Subspecialty Day  |  Retina Program Schedule xxix * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. 3:16 PM Audience Vote 3:17 PM REFRESHMENT BREAK and JOINT MEETING EXHIBITS Section XIII: Vitreoretinal Surgery, Part II Moderators: Kirk H Packo MD*, Kourous Rezaei MD* 4:00 PM Surgical Complications Video, Part I 129 Moderator: Kirk H Packo MD* Panelists: Gary W Abrams MD*, Marta Figueroa MD*, William F Mieler MD*, Stanislao Rizzo MD, John T Thompson MD* 4:40 PM Surgical Complications Video, Part II 129 Moderator: Kourous Rezaei MD* Panelists: Stanley Chang MD*, Andre V Gomes MD*, Grazia Pertile MD, Jan C Van Meurs MD*, David F Williams MD* 5:20 PM Closing Remarks Joan W Miller MD* Tarek S Hassan MD* 5:22 PM ADJOURN
  • 30.
  • 31. 2012 Subspecialty Day  |  Retina Section I: Vitreoretinal Surgery, Part I 1 Vitreoretinal Instrument Update David R Chow MD Notes
  • 32. 2 Section I: Vitreoretinal Surgery, Part I 2012 Subspecialty Day  |  Retina Role of Retinectomy in Vitreoretinal Surgery Dean Eliott MD I. Retinectomy: Excision of Retina A. Removal of anterior flap of retinal tear in primary retinal detachment B. Removal of retinal incarceration in traumatic or surgical wound C. Removal of fibrotic, contracted retina in prolifera- tive retinopathy (PVR) or proliferative diabetic reti- nopathy (PDR) II. Retinotomy: Creating a Hole in the Retina (retinal inci- sion only, no excision) A. Drainage retinotomy: 1. To remove subretinal fluid 2. Drainage site is located posteriorly when perfluo- rocarbon liquid is not used to reattach the retina. 3. Drainage site is located anteriorly when perfluo- rocarbon use results in anteriorly loculated sub- retinal fluid. B. Access retinotomy: To remove choroidal neovas- cular membrane (CNVM), subretinal hemorrhage, subretinal membranes, retained subretinal perfluo- rocarbon liquid, subretinal foreign body, or to inject subretinal tissue plasminogen activator III. Retinectomy Surgical Technique: General Principles A. Lensectomy in phakic eyes B. Consider scleral buckle to support vitreous base (except in cases with 360-degree retinectomy) C. Retinectomy is performed after attempted complete epiretinal membrane removal; if retinectomy is done before complete epiretinal membrane removal, fur- ther epiretinal membrane removal may be difficult. D. Orientation: Circumferential, posterior to vitreous base E. Location 1. Avoid retinectomy edge near 6 o’clock position. 2. Most common retinectomy location is inferiorly with edges at 3 o’clock and 9 o’clock. F. Size 1. Retinectomy should extend into normal retina surrounding areas of traction. 2. Most common retinectomy size is 6 clock hours or 180 degrees. 3. If greater than 270 degrees, extend the retinec- tomy to 360 degrees. G. Hemostasis: Diathermy is used to delineate intended edge and to prevent intraoperative bleeding. H. Instruments: Vitrectomy probe or scissors are used to cut retina. I. Adjuvants: May consider perfluorocarbon liquid to stabilize posterior retina. J. Complete excision of anterior retina to prevent post- operative proliferation with resultant traction on the retinectomy edge or ciliary body K. Retinopexy: 360-degree endolaser with confluent endolaser to the retinectomy edge L. Extended tamponade: C3F8 gas or silicone oil 1. Silicone Oil Study showed equal efficacy in eyes with retinectomy. 2. Recent studies favor silicone oil over gas. 3. Redetachment occurs in 4%-25% after oil removal. IV. Incidence of Retinectomy A. PVR 1. Early studies: Retinectomy performed in 2%-8% 2. Silicone Oil Study (1993): Retinectomy per- formed in 29% overall a. Group 1 (no previous vitrectomy): Retinec- tomy performed in 20% b. Group 2 (previous vitrectomy): Retinectomy performed in 42% 3. Recent studies: Retinectomy performed more commonly, in up to 64% B. PDR 1. Primary vitrectomy: Retinectomy performed in 5% 2. Reoperation vitrectomy: Retinectomy performed in 25% V. Complications of Retinectomy A. Hemorrhage 1. Usually due to incomplete diathermy 2. Postoperative fibrous proliferation may occur in areas of blood. B. Hypotony 1. Reported in 2%-43% after 180-360 degree retinectomy and in 17%-20% after 360-degree retinectomy 2. Retinectomy exposes retinal pigment epithelium (RPE) and allows posterior outflow and absorp- tion of intraocular fluid by the choroid.
  • 33. 2012 Subspecialty Day  |  Retina Section I: Vitreoretinal Surgery, Part I 3 3. Recurrent fibrous proliferation with resultant ciliary body traction may also lead to hypotony. C. Visual field defect D. Recurrent fibrous proliferation 1. Surgery for macular pucker reported in 22%- 43%. 2. Severe fibrous proliferation may lead to recurrent retinal detachment and/or hypotony. E. Persistent traction occurs when size of retinectomy is inadequate. F. RPE/choroidal damage may occur when excising retina in area of shallow detachment. G. Retained subretinal perfluorocarbon more likely to occur in cases with large retinectomy; consider saline rinse or small-gauge vitrectomy with valved cannulas for prevention. H. Neovascularization 1. CNVM may rarely occur at edge of retinectomy. 2. Anterior retinal and/or iris neovascularization may occur when anterior retina is incompletely excised. VI. Retinectomy in PDR A. Small posterior focal retinectomy: To relieve persis- tent traction on pre-existing or iatrogenic breaks B. Large peripheral retinectomy: To remove massive fibrous proliferation caused by severe ischemia Selected Readings 1. Machemer R. Retinotomy. Am J Ophthalmol. 1981; 768-774. 2. Machemer R, McCuen BW, de Juan E. Relaxing retinotomies and retinectomies. Am J Ophthalmol. 1986; 102:7-12. 3. Han DP, Lewis MT, Kuhn EM, et al. Relaxing retinotomies and retinectomies: surgical results and predictors of visual outcomes. Arch Ophthalmol. 1990; 109:694-697. 4. Iverson DA, Ward TG, Blumenkranz MS. Indications and results of relaxing retinotomy. Ophthalmology 1990; 1298-1304. 5. Morse LS, McCuen BW, Machemer R. Relaxing retinotomies: anal- ysis of anatomic and visual results. Ophthalmology 1990 ;97:642- 648. 6. Federman JL, Eagle RC. Extensive peripheral retinectomy com- bined with posterior 360 retinotomy for retinal reattachment in advanced proliferative vitreoretinopathy cases. Ophthalmology 1990; 97:1305-1320. 7. Lewis H, Aaberg TM, Abrams GW. Causes of failure after initial vitreoretinal surgery for severe proliferative vitreoretinopathy. Am J Ophthalmol. 1991; 111:8-14. 8. Lewis H, Aaberg TM. Causes of failure after repeat vitreoretinal surgery for recurrent proliferative vitreoretinopathy. Am J Ophthal- mol. 1991; 111:15-19. 9. Blumenkranz MS, Azen SP, Aaberg TM, et al.; Silicone Study Group. Relaxing retinotomy with silicone oil or long-acting gas in eyes with severe proliferative vitreoretinopathy (Silicone Study Report #5). Am J Ophthalmol. 1993; 116:557-564. 10. Bourke RD, Cooling RJ. Vascular consequences of retinectomy. Arch Ophthalmol. 1996; 114:155-160. 11. Abrams GW, Garcia-Valenzuela E, Nanda SK. Retinotomies and Retinectomies. In: Ryan SJ, ed. Retina 3rd ed. CV Mosby; 2000:2311-2343. 12. Joussen AM, Walter P, Jonescu-Cuypers CP, et al. Retinectomy for treatment of intractable glaucoma: long term results. Br J Ophthal- mol. 2003; 87:1094-1103. 13. Tseng JJ, Barile GR, Schiff WM, Akar Y, Vidne-Hay O, Chang S. Influence of relaxing retinotomy on surgical outcomes in prolifera- tive vitreoretinopathy. Am J Ophthalmol. 2005; 140:628-636. 14. Quiram PA, Gonzales CR, Hu W, et al. Outcomes of vitrectomy with inferior retinectomy in patients with recurrent rhegmatog- enous retinal detachments and proliferative vitreoretinopathy. Oph- thalmology 2006; 113:2041-2047. 15. Grigoropoulos VG, Benson S, Bunce C, Charteris DG. Functional outcome and prognostic factors in 304 eyes managed by retinec- tomy. Graefes Arch Clin Exp Ophthalmol. 2007; 245:641-649. 16. Gupta B, Mokete B, Laidlaw DAH, Williamson TH. Severe folding of the inferior retina after relaxing retinectomy for proliferative vit- reoretinopathy. Eye 2008; 22:1517-1519. 17. de Silva DJ, Kwan A, Bunce C, Bainbridge J. Predicting visual out- come following retinectomy for retinal detachment. Br J Ophthal- mol. 2008; 92:954-958. 18. Tsui I, Schubert HD. Retinotomy and silicone oil for detachments complicated by anterior inferior proliferative vitreoretinopathy. Br J Ophthalmol. 2009; 93:1228-1233. 19. Tan HS, Mura M, Oberstein SYL, de Smet MD. Primary retinec- tomy in proliferative vitreoretinopathy. Am J Ophthalmol. 2010; 149:447-452. 20. Kolomeyer AM, Grigorian RA, Mostafavi D, Bhagat N, Zarbin MA. 360 degree retinectomy for the treatment of complex retinal detachment. Retina 2011; 31:266-274.
  • 34. 4 Section I: Vitreoretinal Surgery, Part I 2012 Subspecialty Day  |  Retina Current Role of Endoscopy in Vitreoretinal Surgery Jorge G Arroyo MD Endoscope, Illuminator, and Laser E2 EndoOptiks Laser and Endoscopy System This system is a combined diode laser and endoscopy unit with laser output, pulse width, light, and aiming beam intensity con- trollable on the touch pad or with a foot pedal. It uses a 810-nm diode laser, 175 watt or 300 watt xenon light source, high-reso- lution camera, and footswitch controller. It is the only autoclav- able endoscope available on the market. The traditional endoscope probes come in a 19.5-gauge probe that originally had 10,000 pixels with a 125-degree field of view. The high-resolution probes now have 17,000 pixels with 140-degree field of view, which are a significant improvement. A 23-gauge endoscope probe is also now available. With only 6000 pixels, the view is modest at best. A 300-watt xenon light source is needed to adequately illuminate structures. The laser probe works adequately for endolaser but is quite limited for other tasks. The gradient index (GRIN) lens system provides higher reso- lution but narrower field of view, is significantly less convenient, and has a greater cost. The camera is attached directly to the hand probe, cannot be autoclaved, and must be covered with sterile drape during surgery. Endoscopy-Assisted Vitrectomy Endoscopy through a 19.5-gauge or 23-gauge sclerotomy pro- vides additional benefits compared to the coaxial microscope view. An endoscope provides the ability to see the posterior seg- ment structures independent of corneal or lens clarity. Therefore, endoscopy is especially useful in cases with significant corneal scarring, anterior segment scars, hemorrhage, or lenticular opacities. Another advantage of endoscopy-assisted vitrectomy is that given the location of your sclerotomies, your perspective can be changed very easily and quickly. The various endoscopes have differing amounts of degree of field of view, extending between 90 and 140 degrees of view. It is important to note that the wider field of view makes use of an endoscope during vitrectomy much more feasible and safe. Finally, the endoscope also provides high magnification, depending on how close you are to the object in view. This fea- ture is quite helpful in identifying small retinal breaks or small intraocular foreign bodies, as well as other parts of surgery. Endoscopy-Assisted Vitrectomy Endoscopy-assisted vitrectomy may be particularly helpful in cases with ischemic retinopathies such as proliferative diabetic retinopathy or central retinal vein occlusions, uncontrolled glau- coma, or neovascular glaucoma. There are a number of papers looking at endoscopy-assisted vitrectomy in cases of pseudopha- kic retinal detachment and retained lens material or intraocular foreign bodies. We have found the endoscope to be vital in the treatment of patients who have permanent keratoprostheses and in some cases of trauma associated with corneal opacification and endophthalmitis. Endoscopic Membrane Peeling The endoscope can certainly assist in the peeling of both epireti- nal and internal limiting membranes. Injecting indocyanine green or other dyes can be safely accomplished with the endoscope. The high level of magnification that can be obtained helps in identifying the edge of a membrane prior to peeling. However, the relatively small field of view at these higher levels of magni- fication and the lack of stereopsis does make membrane peeling significantly more challenging compared to traditional coaxial microscopy. Anterior Segment Endoscopic Cyclophotocoagulation The combined endoscope and laser probe has most commonly been used to perform anterior segment endoscopic cyclophoto- coagulation (ECP) in patients with glaucoma. This procedure is typically performed after cataract surgery or in patients who are pseudophakic. However, it has been performed in phakic patients as well. After injecting a significant amount of a viscoelastic between the iris and intraocular lens, the endoscopic laser probe is inserted through a cataract wound and used to treat the anterior ciliary processes for approximately 8 clock hours. This will be shown in a video during the talk. If 12 clock hours of treatment are needed, a secondary limbal wound needs to be created. Pars Plana ECP The pars plana approach for ECP allows for a much more exten- sive treatment of the ciliary processes. Once the vitrectomy is completed, the endoscopic laser probe is inserted through the sclerotomy and used to visualize the pars plana and the ciliary processes. The laser power setting is typically set at 0.35 watts, and the duration is set at continuous. Depending on the proxim- ity of the laser probe to the ciliary processes, a moderately white blanching of the ciliary processes can be obtained. We treat the entire ciliary processes as far anteriorly and as far posteriorly as possible. In patients with a significant amount of pigmentation or in cases where the power is too high or in cases where probe is too close to the ciliary processes, a vapor bubble can be uninten- tionally created due to the conversion of aqueous into steam. In these cases, increasing the distance between the laser probe and the ciliary processes or decreasing the laser power helps prevent this from occurring. Typically, we treat 12 clock hours of the cili- ary processes, and this requires a second port, typically 6 hours away from the first port to be created. Additionally, the endoscopy laser probe can be used to apply excellent peripheral almost confluent panretinal photocoagula- tion treatment from the equator to the ora serrata 360 degrees around. We do find that the 810-nanometer diode laser does
  • 35. 2012 Subspecialty Day  |  Retina Section I: Vitreoretinal Surgery, Part I 5 produce a very intense laser burn. If needed, an argon laser can be attached to the endoscopic laser probe fiber and used to apply argon green laser spots. Conclusions Overall, the endoscopic laser probe provides excellent visualiza- tion and field of view, especially in cases with corneal, anterior segment, or lenticular opacities. The laser probe and endoscope also allow excellent peripheral panretinal photocoagulation treatment to be performed in patients with peripheral ischemic retinopathies. We have found that 12 clock hours of ECP treat- ment primarily in patients with neovascular glaucoma effectively lowers the IOP without resulting in hypotony. The intense laser burns created by the diode 810-nanometer laser can be mitigated by connecting an argon green laser source to the laser fiber in this system. Finally, the endoscopic laser probe is only marginally adequate for membrane peeling. Future Given the fact that the 23-gauge endoscope provides a subopti- mal view, we expect continued improvements in the resolution of this system, especially given the fact that the ease of use of a 23-gauge probe would be extremely helpful and advantageous to the surgeon. The high magnification and variable perspective of the endoscope may also make it amenable to retinal vascular cannulation and subretinal injection of cells or other agents in the future. Selected Readings 1. Chen J, Cohn RA, Lin SC, Cortes AE, Alvarado JA. Endoscopic photocoagulation of the ciliary body for treatment of refractory glaucomas. Am J Ophthalmol. 1997; 124(6):787-796. 2. Al Sabti K, Raizada S, Al AbdulJalil T. Cataract surgery assisted by anterior endoscopy. Br J Ophthalmol. 2009; 93:531-534. 3. Sabti KA, Raizada A, Kandari JA, Wani V, Gayed I, Kumar N. Applications of endoscopy in vitreoretinal surgery. Retina 2008; 28(1):159-166.
  • 36. 6 Section I: Vitreoretinal Surgery, Part I 2012 Subspecialty Day  |  Retina Treatment of Suprachoroidal Hemorrhages John W Kitchens MD Notes
  • 37. 2012 Subspecialty Day  |  Retina Section I: Vitreoretinal Surgery, Part I 7 Recurrent Retinal Detachment: Does Initial Treatment Matter? Gaurav K Shah MD, Almony Arghavan MD, Kevin Blinder MD, Ahmad Baseer MD I. Trends in Retinal Detachment Repair II. Current Surgical Methods for Retinal Detachment Repair A. Pneumatic retinopexy B. Scleral buckling procedure C. Primary pars plana vitrectomy D. Combined scleral buckling procedure and pars plana vitrectomy III. Preoperative factors for surgical decision making A. Extent of retinal detachment B. Location of retinal breaks C. Lens status D. Myopia E. Lattice degeneration F. Status of fellow eye IV. Retrospective study A. To identify differences among eyes that failed initial surgical repair of rhegmatogenous retinal detach- ment (RRD) B. 286 consecutive cases C. Initial surgical repair of RRD 1. Determined by surgeon preference 2. Proliferative vitreoretinopathy excluded 3. Scleral buckle (SB): 63 eyes 4. Pars plana vitrectomy (PPV): 88 eyes 5. Combined SB/PPV: 135 eyes D. Data 1. Age 2. Sex 3. Phakic status 4. Macula status 5. Extent of RRD 6. Location of break 7. Presence of lattice degeneration 8. Presence of high myopia 9. History of RRD in fellow eye E. Results 1. Single operation success rate 2. Recurrent retinal detachment a. Days to first recurrent retinal detachment b. Total number of procedure c. Secondary procedure d. Secondary cataract e. Conclusions 1. Single operation success rate 2. Patients that fail a primary scleral buckle a. Require fewer number of secondary proce- dures b. Require a lower rate of silicone oil injection c. Have a lower incidence of cataract formation d. Require a lower rate of PPL 3. Scleral buckling surgery still remains an integral part of retinal detachment repair surgery. Selected Readings 1. Almony A, Nudleman E, Shah GK, et al. Techniques, rationale, and outcomes of internal limiting membrane peeling. Retina 2012; 32:877-891. 2. Schwartz SG, Kuhl DP, McPherson AR, Holz ER, Mieler WF. Twenty-year follow-up for scleral buckling. Arch Ophthalmol. 2002; 120:325-329. 3. Richardson EC, Verma S, Green WT, Woon H, Chignell AH. Pri- mary vitrectomy for rhegmatogenous retinal detachment: an analy- sis of failure. Eur J Ophthalmol. 2000; 10:160-166. 4. Campo RV, Sipperley JO, Sneed SR, et al. Pars plana vitrectomy without scleral buckle for pseudophakic retinal detachments. Oph- thalmology 1999; 106:1811-1816. 5. Brazitikos PD, Androudi S, Christen WG, Stangos NT. Primary pars plana vitrectomy versus scleral buckle surgery for the treat- ment of pseudophakic retinal detachment: a randomized clinical trial. Retina 2005; 25:957-964. 6. Sharma YR, Karunanithi S, Azad RV, et al. Functional and ana- tomic outcome of scleral buckling versus primary vitrectomy in pseudophakic retinal detachment. Acta Ophthalmol Scand. 2005; 83:293-297. 7. Weichel ED, Martidis A, Fineman MS, et al. Pars plana vitrectomy versus combined pars plana vitrectomy-scleral buckle for primary repair of pseudophakic retinal detachment. Ophthalmology 2006; 113:2033-2040. 8. Stangos AN, Petropoulos IK, Brozou CG, Kapetanios AD, Wha- tham A, Pournaras CJ. Pars-plana vitrectomy alone vs vitrectomy with scleral buckling for primary rhegmatogenous pseudophakic retinal detachment. Am J Ophthalmol. 2004; 138:952-958. 9. Heimann H, Bartz-Schmidt KU, Bornfeld N, Weiss C, Hilgers RD, Foerster MH; Scleral Buckling versus Primary Vitrectomy in Rheg- matogenous Retinal Detachment Study Group. Scleral buckling
  • 38. 8 Section I: Vitreoretinal Surgery, Part I 2012 Subspecialty Day  |  Retina versus primary vitrectomy in rhegmatogenous retinal detachment: a prospective randomized multicenter clinical study. Ophthalmology 2007; 114:2142-2154. 10. Goto T, Nakagomi T, Iijima H. A comparison of the anatomic successes of primary vitrectomy for rhegmatogenous retinal detach- ment with superior and inferior breaks. Acta Ophthalmol. 2012; 13:1755. 11. Mehta S, Blinder KJ, Shah GK, Grand MG. Pars plana vitrectomy versus combined pars plana vitrectomy and scleral buckle for pri- mary repair of rhegmatogenous retinal detachment. Can J Ophthal- mol. 2011; 46:237-241. 12. Azad RV, Chanana B, Sharma YR, Vohra R. Primary vitrectomy versus conventional retinal detachment surgery in phakic rheg- matogenous retinal detachment. Acta Ophthalmol Scand. 2007; 85:540-545. 13. Sun Q, Sun T, Xu Y, et al. Primary vitrectomy versus scleral buck- ling for the treatment of rhegmatogenous retinal detachment: a meta-analysis of randomized controlled clinical trials. Curr Eye Res. 2012; 37:492-499.
  • 39. 2012 Subspecialty Day  |  Retina Section I: Vitreoretinal Surgery, Part I 9 Chromovitrectomy 2012 A Focus on Brilliant Blue G and Other Novel Dyes Lihteh Wu MD, Mauricio Maia MD, Michel E Farah MD, Cristian Carpentier MD, Arturo Alezzandrini MD, Maria H Berrocal MD, J Fernando Arevalo MD; for the Pan American Collaborative Retina Study (PACORES) Group Introduction The vitreous is composed mostly (98%) of water, with the remainder consisting of macromolecules such as collagen fibrils and hyaluronan. As we age, the vitreous undergoes several biochemical changes that lead to progressive liquefaction of the vitreous gel. This eventually leads to a posterior vitreous detachment (PVD). An anomalous PVD may occur when there is no clean separation along the vitreoretinal interface. Surgical, histopathological, and imaging advances over the past 2 decades have demonstrated that traction along the vitreoretinal interface induced by an anomalous PVD plays an important role in several diseases. Depending on where in the eye the strongest vitreoreti- nal adhesion is, an anomalous PVD may evolve into several clini- cal conditions. For instance, if the strongest adhesions are found in the retinal periphery, a tear or detachment ensues. If strong adhesions are found in the macula, epiretinal membrane (ERM), macular hole (MH), and the vitreomacular traction syndrome (VMTS) may develop.1,2 Release of this traction by removal of the offending tissues has been advocated as a solution. There are 3 tissues of particular interest to the vitreoretinal surgeon, namely the posterior hyaloid, ERM, and the internal limiting membrane (ILM). One of the major difficulties encountered by vitreoretinal surgeons in dealing with these tissues is that these are usually thin, transparent, and difficult to visualize. Staining of these transparent tissues with vital dyes during vitrectomy greatly simplifies the procedure. The term “chromo­ vitrectomy” has been used to describe the use of vital dyes to stain transparent tissues to facilitate their manipulation dur- ing vitreous surgery.3 Over the past decade several substances, including indocyanine green (ICG), trypan blue (TB), and bril- liant blue G (BB), have been used during vitrectomy as staining agents. Their staining capabilities have been confirmed, but con- cerns over retinal toxicity remain.4 Posterior Hyaloid Traction exerted by the posterior hyaloid has been implicated in the pathogenesis of several conditions such as proliferative vit- reoretinopathy (PVR), proliferative diabetic retinopathy (PDR), penetrating trauma, and MH. Therefore the surgical goal of any vitrectomy should be posterior hyaloid separation and removal of as much vitreous as possible. Despite the development of sev- eral surgical techniques, at times the surgeon may not know for sure if the posterior hyaloid has been removed. In patients with conditions that are characterized by break- down of the blood–retinal barrier such as PVR, uveitis, retinal vein occlusions, and diabetic retinopathy, a preoperative intra- venous injection of fluorescein sodium 1 to 2 days prior to the scheduled vitrectomy stains the vitreous a greenish color, facili- tating its identification. Blood in the vitreous cavity coats the vitreous by adhering to its collagen fibrils. The normally transparent vitreous becomes opaque, making it easier to visualize and remove. In eyes with no pre-existing vitreous hemorrhage, a small amount of autolo- gous blood may be injected into the vitreous cavity to coat the vitreous.5 Triamcinolone acetonide (TA) is a well-tolerated cortico- steroid that has been used in the pharmacological treatment of several diseases such as uveitis, diabetic macular edema (DME), and retinal vein occlusions. Once injected into the vitreous cav- ity, the triamcinolone particles adhere to the vitreous gel, making its visualization and identification easy. As an added benefit, its use during vitrectomy may improve outcomes by reducing the breakdown of the blood–retinal barrier and preretinal fibrosis. Currently this is the most widely used technique to visualize the posterior hyaloid.4,5 A comparative study of fluorescein, ICG, TA, and TB con- cluded that TA highlighted the vitreous best.6 A recent study demonstrated that a 20% solution containing the natural dyes lutein and zeaxanthin precipitates on the vitreous surface, stain- ing it orange.7 Epiretinal Membranes Refinements in instrumentation and surgical techniques over the past 2 decades have made ERM removal a typical indication for macular surgery. Clinically significant ERMs range from dense opaque tissues to fine transparent membranes. Given their trans- parent nature, fine ERMs pose a challenge even to experienced surgeons. TB binds to degenerated cell elements. It does not stain live cells or tissues with intact cell membranes, since there is no uptake of the dye. Cataract surgeons have long used 0.06% TB to stain the anterior capsule during phacoemulsification. ERMs stain prominently with 0.15% TB. Clinical studies suggest that TB is relatively safe at these doses; however, animal and in vitro studies show that a dose-dependent toxicity may appear above 0.3%. TB remains the dye of choice when peeling ERMs.4,8 Internal Limiting Membrane (ILM) The ILM is made up of the basement membrane of the Müller cells. In eyes with anomalous PVD, glial cells can migrate onto the surface of the ILM, which serves as a scaffold for cellular proliferation. This cellular proliferation may exert macular trac- tion and contribute to the pathogenesis of ERMs, MH, VMTS, and DME, among other entities.9 In idiopathic macular holes it is generally agreed that ILM peeling is important in achieving closure of large and chronic holes.10 Tangential traction from the ILM has been implicated in the pathogenesis of macular holes. An autopsy study of a patient who had undergone successful macular hole closure showed an area of absent ILM surrounding the sealed macular hole.11 In contrast, a histopathological specimen of an eye with a reopened macular hole revealed an ERM with ILM surrounding the open macular hole.12 In other conditions such as DME and ERM, peeling of the ILM is controversial. Surgical specimens from removed ERMs
  • 40. 10 Section I: Vitreoretinal Surgery, Part I 2012 Subspecialty Day  |  Retina often show fragments of the ILM interspersed among the ERM. ILM peeling may reduce the risk of recurrence following ERM removal. By removing the ILM one can be assured that the ERM is completely removed. In a recent prospective study by the Pan American Collaborative Retina Study Group, it was found that there was little correlation between the surgeon’s unaided observation and the brilliant blue stained observation of the ILM. Thus if the surgeon believes that ILM peeling is important in epimacular membrane surgery, staining should be strongly encouraged. The first vital dye to be used to stain the ILM was ICG.13 As the ICG binds to the ILM, the biomechanical stiffness of the ILM increases, making peeling of the ILM much easier.14 However, the initial enthusiasm that greeted the use of ICG has been tem- pered following numerous reports of toxicity.4 A meta-analysis of chromovitrectomy with ICG compared to peeling of the ILM without staining in macular hole surgery showed similar ana- tomic outcomes in both groups. However, the functional results were much worse in eyes where ICG was used to stain the ILM.15 To avoid toxicity ICG should be used at the lowest possible con- centration. The surgery should be swift and illumination used sparingly. BB also has a high affinity for the ILM. In animal and in vitro studies, BB appears to be relatively safe at doses up to 0.25 mg/mL.4 However, contact with the retinal pigment epi- thelium (RPE) should be avoided since RPE atrophy has been documented following subretinal migration of BB. In general BB appears to be a safer alternative than ICG for ILM peeling. TB does not stain the ILM as well as BB or ICG.8 Different dyes including indigo carmine, fast green, light green, bromophenol blue, and evans blue are under investiga- tion.16 Toxicity The toxic effects of any vital dye depend on the dye concentra- tion, the osmolarity of the dye solution, the dye exposure time, and the illumination time. Recommendations to avoid toxicity include paying close attention to achieving dilutions with physi- ological osmolarities. The lowest concentration that will achieve staining should be used. The light pipe should remain far from the macula to avoid any light toxicity and photodynamic effect of the dye.4 Macular holes pose a particular problem since the bare RPE of the floor of the hole may come in contact with any dye and produce potential RPE toxicity. Some have suggested covering the hole with blood, viscoelastic, or perfluorocarbon liquid. Conclusions Transparent tissues such as the posterior hyaloid, ERM, and the ILM play an important role in several diseases of the posterior pole. Surgical removal of these tissues is a principal surgical objective. Staining of these tissues with a variety of vital dyes facilitates their identification and removal. Several dyes are cur- rently in routine clinical use; however, the ideal staining agent has not yet been found. Any dye that is injected intravitreally has the potential to become toxic. References 1. Sebag J. Anatomy and pathology of the vitreo-retinal interface. Eye (Lond) 1992; 6(pt 6):541-552. 2. Sebag J. Anomalous posterior vitreous detachment: a unifying con- cept in vitreo-retinal disease. Graefes Arch Clin Exp Ophthalmol. 2004; 242:690-698. 3. Rodrigues EB, Meyer CH, Kroll P. Chromovitrectomy: a new field in vitreoretinal surgery. Graefes Arch Clin Exp Ophthalmol. 2005; 243:291-293. 4. Farah ME, Maia M, Rodrigues EB. Dyes in ocular surgery: prin- ciples for use in chromovitrectomy. Am J Ophthalmol. 2009; 148:332-340. 5. Schmidt JC, Chofflet J, Horle S, Mennel S, Meyer CH. Three simple approaches to visualize the transparent vitreous cortex during vit- reoretinal surgery. Dev Ophthalmol. 2008; 42:35-42. 6. Guo S, Tutela AC, Wagner R, Caputo AR. A comparison of the effectiveness of four biostains in enhancing visualization of the vit- reous. J Pediatric Ophthalmol Strabismus 2006; 43:281-284. 7. Sousa-Martins D, Maia M, Moraes M, et al. Use of lutein and zeaxanthin alone or combined with brilliant blue to identify intra- ocular structures intraoperatively. Retina Epub ahead of print 26 March 2012. doi 10.1097/IAE.0b013e318239e2b6. 8. Farah ME, Maia M, Furlani B, et al. Current concepts of trypan blue in chromovitrectomy. Dev Ophthalmol. 2008; 42:91-100. 9. Almony A, Nudleman E, Shah GK, et al. Techniques, rationale, and outcomes of internal limiting membrane peeling. Retina 2012; 32:877-891. 10. Mester V, Kuhn F. Internal limiting membrane removal in the man- agement of full-thickness macular holes. Am J Ophthalmol. 2000; 129:769-777. 11. Funata M, Wendel RT, de la Cruz Z, Green WR. Clinicopathologic study of bilateral macular holes treated with pars plana vitrectomy and gas tamponade. Retina 1992; 12:289-298. 12. Fekrat S, Wendel RT, de la Cruz Z, Green WR. Clinicopathologic correlation of an epiretinal membrane associated with a recurrent macular hole. Retina 1995; 15:53-57. 13. Burk SE, Da Mata AP, Snyder ME, Rosa RH Jr, Foster RE. Indo- cyanine green-assisted peeling of the retinal internal limiting mem- brane. Ophthalmology 2000; 107:2010-2014. 14. Wollensak G. Biomechanical changes of the internal limiting mem- brane after indocyanine green staining. Dev Ophthalmol. 2008; 42:82-90. 15. Rodrigues EB, Meyer CH. Meta-analysis of chromovitrectomy with indocyanine green in macular hole surgery. Ophthalmologica 2008; 222:123-129. 16. Rodrigues EB, Penha FM, Farah ME, et al. Preclinical investigation of the retinal biocompatibility of six novel vital dyes for chromovit- rectomy. Retina 2009; 29:497-510.
  • 41. 2012 Subspecialty Day  |  Retina Section I: Vitreoretinal Surgery, Part I 11 Vitrectomy for Lamellar Macular Hole Periklis Brazitikos MD Lamellar macular hole (MH) is a distinct clinical entity, defined as absence of the inner macular tissue in the foveola region (ie, break of the inner retinal layers and intraretinal splitting) not extending to the level of the retinal pigment epithelium (RPE); lamellar MH occurs via interruption of the typical MH formation process or by the unroofing of the central fovea in chronic cystoid macular edema (CME).1-3 Despite the original description from Gass in 1976,1 the lamellar MH entity was not completely understood until recently with the widespread use of OCT; previously misdiagnosed cases of lamellar MHs can now be identified and their characteristics described very accurately.4-6 Tomographic studies of lamellar MHs with respect to their natural evolution7 or surgical outcomes8-10 are limited, retrospective in nature,8 and involve usually a limited number of patients.9,10 The clinical diagnosis of lamellar MHs was done in the pre- OCT era based only on biomicroscopy and fluorescein angiogra- phy. A small number of studies exist on lamellar MH entity, and those dated before the OCT advent are of little value nowadays, since lamellar MH is mainly an OCT-based diagnosis;11,12 in particular, there are studies in the literature from the past decade on macular pseudoholes (MPHs) that can now be reidentified as studies referring to lamellar MHs.12 Furthermore, with the wide- spread use of tomography, even the Gass theory of Mueller cell proliferation above the fovea, leading to a centripetal tangential traction on the fovea as the principal initiating step in the forma- tion of MHs, has been brought into question.13 In the present study, we report our results of surgical intervention / observation in a series of patients diagnosed with lamellar MH. It has been reported that most lamellar MH patients have mild complaints of metamorphopsia and limited central visual acuity (VA) loss, which uncommonly progresses to further dete- rioration of VA.7 In a very recent study by Theodossiadis and associates,7 the authors studied the natural course of lamellar MH in 41 cases and found an increase in the lamellar MH diameter by an aver- age of 13.7% and deterioration in best-corrected VA (BCVA) in 22% of the cases studied, over a period of 37.1 months. Visual deterioration could be possibly related—as the authors con- clude—to the enlargement of the lamellar MH diameter. Surgical treatment of lamellar MHs remains controversial, and some authors believe that there is no proof that surgi- cal intervention is helpful,6,10 whereas other studies8-11 found vitrectomy with epiretinal membrane (ERM)–internal limiting membrane (ILM) removal to be beneficial with respect to the VA result and foveal OCT appearance. In the report by Witkin and associates,11 4 patients under- went vitrectomy for lamellar MH, with only 1 case being judged anatomically and visually successful. Two of their patients devel- oped full-thickness MHs after vitrectomy. Conversely, Hirakawa and associates9 recently reported 2 patients with improved vision after vitrectomy with ILM peeling and gas tamponade for lamel- lar MH. Kokame achieved similar results in a case report of a single patient.10 The largest study reported so far, by Garretson and associates,8 found vitrectomy beneficial for 93% of their patient cohort, with a mean gain of 3 Snellen lines of VA. In our study,14 BCVA improved in 17 out of the 20 cases (85%) operated with a lamellar MH associated with an ERM; 3 cases retained the same BCVA postoperatively. Mean BCVA improvement was 2.6 Snellen lines, which was statistically sig- nificant (P = .002, paired t test). None of the cases deteriorated in terms of BCVA. Our hypothesis for the beneficial role of vitrectomy in lamel- lar MHs is that the ERM-ILM removal releases the tangential traction to the edges of the lamellar MH. Even in cases in which the lamellar MH still persists after surgical intervention, the surgically removed ERM-ILM prevents further lamellar MH stretching and VA deterioration, and so even in these cases there is a beneficial role of the surgical approach. Although there is no evidence that C3F8 use and facedown position are necessary in lamellar MH surgery, we decided to follow the same surgical approach we routinely use in cases of full-thickness MHs. Posterior vitreous detachment was present in all but 1 of our study cases of lamellar MHs with an ERM. Little information exists with respect to this finding in the literature. To our knowl- edge, in the only study reported,8 the authors presume retrospec- tively from the patients’ perioperative report that vitreous was attached in 17 out of the 27 patients (in the remaining 10 cases, there was no perioperative note on the vitreous attachment). In our patient cohort, vitreous was detached in almost all cases (except from cases with lamellar MH secondary to CME), and we believe that this feature represents another diagnostic crite- rion of the lamellar MHs. With respect to the presence of an ERM, most of the recent OCT studies7-11 report ERMs in the majority of patients with lamellar MHs; our belief is that ERM represents another distinct feature of lamellar MHs. Many of the ERMs associated with a lamellar MH have an unusual thickened appearance of moderate reflectivity on ultrahigh-resolution OCT.11 The high prevalence of ERMs in lamellar MHs suggests that ERM contraction plays a role in lamellar hole formation; removal of the ERM is manda- tory to improve the surgical results and to stabilize or improve the VA in these cases. References 1. Gass JD. Lamellar macular hole: a complication of cystoid macular edema after cataract extraction. Arch Ophthalmol. 1976; 94:793- 800. 2. Allen AW, Gass JD. Contraction of a perifoveal epiretinal mem- brane simulating a macular hole. Am J Ophthalmol. 1976; 82:684- 691. 3. Gass JD. Lamellar macular hole: a complication of cystoid macular edema after cataract extraction. Arch Ophthalmol. 1976; 94:793- 800. 4. Takahashi H, Kishi S. Tomographic features of a lamellar macular hole formation and a lamellar hole that progressed to full-thickness macular hole. Am J Ophthalmol. 2000;130:677-679. 5. Hee MR, Puliafito CA, Wong C, et al. Optical coherence tomogra- phy of macular holes. Ophthalmology 1995; 102:748-756.
  • 42. 12 Section I: Vitreoretinal Surgery, Part I 2012 Subspecialty Day  |  Retina 6. Haouchine B, Massin P, Tadayoni R, et al. Diagnosis of macular pseudoholes and lamellar macular holes by optical coherence tomography. Am J Ophthalmol. 2004; 138:732-739. 7. Theodossiadis PG, Grigoropoulos VG, Emfietzoglou I, et al. Evolu- tion of lamellar macular hole studied by optical coherence tomogra- phy. Graefes Arch Clin Exp Ophthalmol. 2009; 247:13-20. 8. Garretson BR, Pollack JS, Ruby AJ, et al. Vitrectomy for a symp- tomatic lamellar macular hole. Ophthalmology 2008; 115:884- 886. 9. Hirakawa M, Uemura A, Nakano T, et al. Pars plana vitrectomy with gas tamponade for lamellar macular holes. Am J Ophthalmol. 2005; 140:1154-1155. 10. Kokame GT, Tokuhara KG. Surgical management of inner lamellar macular hole. Ophthalmic Surg Lasers Imaging. 2007; 38:61-63. 11. Witkin AJ, Ko TH, Fujimoto JC, et al. Redefining lamellar holes and the vitreomacular interface: an ultra-high resolution optical coherence tomography study. Ophthalmology 2006; 113:388-397. 12. Massin P, Paques M, Masri H, et al. Visual outcome of surgery for epiretinal membranes with macular pseudoholes. Ophthalmology 1999; 106:580-585. 13. Gass JD. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Am J Ophthalmol. 1995; 119:752- 759. 14. Androudi S, Stangos A, Brazitikos P. Lamellar macular holes: tomo- graphic features and surgical outcome. Am J Ophthalmol. 2009; 148:420-426.
  • 43. 2012 Subspecialty Day  |  Retina Cool Surgical Video Panel 13 My Coolest Surgical Video The Use of Viscoelastics in Severe Trauma Cases Carlos Mateo MD I Shrunk the Gauge . . . Yusuke Oshima MD The Development of Retinal Endovascular Surgery Kazuaki Kadnosono MD Suprachoroidal Buckling, Indications, Evaluation and Technique Ehab N El Rayes MD PhD My Coolest Surgical Video Claus Eckardt MD Proliferative Vitreoretinopathy (PVR) after Vitrectomy with Silicone Oil for Retinal Detachment Associated with Giant Retinal Tear J Fernando Arevalo MD FACS My Coolest Surgical Video Carl C Claes MD
  • 44. 14 The Charles L Schepens MD Lecture 2012 Subspecialty Day  |  Retina Potential Therapeutic Approaches to AMD Therapeutic Targets for Early Age-Related Macular Disease Alan C Bird MD Changes in age-related macular disease (AMD) may affect cho- roid, Bruch membrane, the retinal pigment epithelium (RPE), and photoreceptor cells. The nature of the changes and the mechanisms by which they are generated are partly understood and have given rise to novel forms of treatment that are under trial. It is hoped that these will cause slowing or reversal of these changes with consequent reduction or abolishment of the risk of loss of central vision. Early histological studies indicated that photoreceptor loss may occur early in the disease process, and these findings accord with functional studies that reveal up to 3.4 log units of photopic function in eyes with early AMD but normal visual acuity. Both functional and histological data indicate that rod loss is greater than cone loss. It is widely believed that photoreceptor loss may be due to lack of metabolic support consequent upon thickening of Bruch membrane or RPE dysfunction. A recent histological study supports the view that major photoreceptor loss may occur early in disease, implying that the functional loss is due to cell loss, at least in part. In addition, the changes vary from one donor to another. In particular there is an inverse relationship between Bruch membrane thickening and RPE autofluorescence. Finally, photoreceptor loss may occur in the absence of obvious physical changes in other tissues. These findings imply that specific therapeutic approaches may not be suitable for all cases. If these conclusions are correct, better phe- notyping will be needed to select cases for therapeutic trials and monitor therapeutic effect.
  • 45. 2012 Subspecialty Day  |  Retina Section II: Non-neovascular AMD 15 Pathogenesis of AMD Christine A Curcio PhD Introduction “The best approach to improve care for our patients is to follow the biology.”1 Determining the composition of signature lesions was a means to identifying affected pathways in diseases like Alzheimer disease and atherosclerosis. For AMD, key lesions are drusen and basal linear deposit (BlinD), two forms (lump and layer) of the same lipid-rich material. Major constituents of drusen are now known. The first testable biochemical model for the main pathway has been articulated.2 Non-neovascular AMD is a metabolic and vascular disease affecting the photoreceptor support system—retinal pigment epi- thelium (RPE) and choroid—secondarily causing photoreceptor degeneration. Bruch membrane (BM), the choroid’s inner wall, is a subendothelial space, substrate for RPE attachment, and route for outer retinal nutrition and metabolite removal. Drusen and BlinD form on BM’s inner surface, outside the blood–retina bar- rier and within the systemic circulation. AMD’s largest risk factor is aging, suggesting that older eyes harbor clues to lesion pathogenesis. Major genetic risk factors include the alternative complement pathway and cholesterol and lipoprotein metabolism, among others.3,4 There is no consistent relationship between AMD and any measure of plasma athero- genic or antiatherogenic lipoproteins. Nor have plasma-lipid lowering statins proven consistently beneficial. BM Lipoproteins: Main Pathway of Drusen Nineteenth-century pathologists described drusen as fatty glob- ules.5 Early discovery is a surrogate for abundance. Histochemi- cally detectable esterified and unesterified cholesterol is present in all drusen.6 Lipids are the most abundant druse component, representing ≥ 40% of hard druse volume.7 Apolipoprotein immunoreactivity decreases in macular drusen, suggesting that high-risk drusen have proportionally higher lipid content.8 Soft drusen, oily and biomechanically unstable, are present in macula only.9 The backdrop to druse biogenesis is a marked accumulation of oil red O binding neutral lipid within macular BM throughout adulthood in normal eyes, thought to create a hydrophobic bar- rier.10 This process superficially resembles, but is distinct from, systemic perifibrous lipid accumulation, whereby plasma apoB- lipoproteins insudate into and bind to dense connective tissue in normal arterial intima (plus cornea, sclera, and tendons), set- ting up atherosclerotic plaques in hemodynamically vulnerable locales.11 Lipid-preserving ultrastructure, histochemistry, comprehen- sive lipid profiling, and gene expression combine with epidemiol- ogy to indicate that the RPE constitutively secretes large apoB containing lipoproteins into BM for clearance. These intraocular lipoproteins are 60-80 nm diameter spherical particles with neu- tral lipid cores rich in esterified cholesterol and surfaces contain- ing apoB-100, apoA-I, apoE, and apoC-I. They accumulate in the BM elastic layer starting in early adulthood, filling in toward the RPE. In older persons, a layer of almost pure lipoprotein par- ticles on BM inner surface (“lipid wall”) separates the RPE basal lamina from BM and represents the direct precursor to BlinD. RPE expresses genes for apoB and for microsomal triglyceride transfer protein, required for apoB lipidation and secretion, a combination signifying a constitutive lipoprotein secretor. RPE cell lines secrete apoB. Highly differentiated polarized RPE secrete apoE-immunoreactive particles, ultrastructurally identi- cal to lipoprotein-containing structures in native BM, which are capable of binding exogenously applied complement.12 Lipid profiling of BM lipoproteins indicates that the major fatty acid is linoleate, implicating diet as the upstream source of this constitu- ent, rather than photoreceptor outer segments, rich in docosa- hexaenoate. Functional consequences of the oil spill in BM include impaired transport of large molecules or multimolecular com- plexes including plasma lipoproteins delivering lipophilic essen- tials like carotenoids and vitamin E to RPE and photoreceptors via LDL and SRB-I receptors. Complexes of this size and physi- ological relevance can cross BM at higher rates than in arterial intima and block transport of subsequent particles,13 providing proof-of-principle for a hydrophobic barrier. Other conse- quences are the formation of highly toxic, proinflammatory / proangiogenic compounds like linoleate hydroperoxide and 7-ketocholesterol,14,15 known troublemakers from atheroscle- rotic plaque. Additional abundant protein components of drusen include TIMP-3 and many proteins of the complement cascade, includ- ing the terminal component membrane attack complex (C5b- 9).16,17 Advanced glycation end products likely enhance retention of lipoproteins18 that activate complement. Amyloid β-peptide is a volumetrically small druse component of interest because of its significance in Alzheimer disease.19 One large age-related change that does not appear directly related to druse biogenesis is RPE lipofuscin, rich in bis-retinoids. Lipofuscin granules appear in a small proportion (6%) of iso- lated drusen or shed into basal laminar deposits of eyes with advanced disease. Macular topographies of lipofuscin accumula- tion and RPE-BM pathology are not correlated.20 In vivo hyper- autofluorescence in AMD eyes can be accounted for by vertically superimposed RPE cells.21 Thus lipofuscin is not a significant druse constituent or an obvious predisposing factor. AMD Lesions in the Subretinal Space Remarkably, high-resolution imaging and new histopathology suggest a process parallel to that in BM involving cholesterol- containing deposits in the subretinal space. Subretinal drusenoid debris (SDD) is an organized, extracellular lesion at the RPE’s apical aspect first described in 198822 and later correlated with reticular pseudodrusen.23,24 Histologically detectable in 87% of a small AMD series, SDD is abundant in the rod-rich perifovea, in contrast to BlinD, abundant under the cone-rich fovea.25 This first linkage of lesion topography to rods and cones suggests involvement of differential aspects of photoreceptor physiology, such as cholesterol homeostasis of outer segment membranes.