Day 1 :
Time : 10:00-10:45
Rolando Toyos is an American Physician and Medical Director who specializes in Ophthalmology. He developed the use of intense pulsed light for the treatment of dry eye conditions such as meibomian gland dysfunction.
Introduction: This project was undertaken to assess the clinical value of using a new transscleral cyclophotocoagulation device in patients with mild to severe glaucoma including those who have unsuccessfully undergone other procedures. This is a one year update of earlier reported data.
Method: This is a single site review of 26 eyes of 20 patients, 4 eyes were classified as mild glaucoma, 5 as moderate and 18 as severe or end stage glaucoma. Two eyes of one patient were lost to follow up. All eyes but 3 had previously undergone phacoemulsification and SLT or MLT. 4 eyes had previously undergone trabeculectomy.
Results: Patients undergoing the procedure had an average IOP of 25.6 and were on an average of 3 IOP lowering meds. After the procedure, patients were started on difluprednate hourly for the first day then tapered over 3 weeks. Average IOP drop at POD 1 was 20% and 34% at pod7 (using an average 1.3 IOP lowering meds). At POD14, average IOP from baseline was 8% using one IOP lowering medication. At one month, IOP was down by 20% and average number of IOP reducing medications was 1.2. At 6-12 months, the average IOP lowering was 30% compared with baseline IOP on and average of 1.8 medications. There were no serious adverse events.
Conclusion: Patients with glaucoma of varying severities are able to safely undergo transscleral cyclophotocoagulation. On average, IOPs were reduced by 30% over one years’ time and number of IOP lowering medications was reduced by 60%. Further study is required to determine ideal treatment guidelines.
Time : 10:45-11:30
Hugo Quiroz-Mercado is an Ophthalmologist specializing in Diabetic Retinopathy and Retinopathy Prematurity as the Director of Ophthalmology Service at Hugo Quiroz-Mercado. With over 25 years of practice experience, he has held previous appointments as the Director of the Retina Department and Chief of the Experimental Surgery Laboratory at Luis Sanchez Hospital for the Prevention of Blindness, as well as Professor of Ophthalmology at the Facultad de Medicine Universidad Autonoma de Mexico.
Researchers have long known that integrins serve as “bridges” between cells and regulate how cells interact with each other and with the extracellular matrix. There are 27 known integrins, each named for a specific alpha-beta combination. Integrins have been associated with angiogenesis, inflammation, and thrombosis, so it makes sense to investigate them as potential treatments for ocular disorders. However, finding agents that can inhibit integrins has been challenging. One integrin antagonist, lifitegrast (Xiidra, Shire), recently received US Food and Drug Administration approval for the treatment of dry eye. ALG-1001 (Luminate, Allegro Ophthalmics) has the potential to target four different integrin sites. This agent has two mechanisms of action. First, it inhibits three integrins considered to be angiogenic; angiogenesis is a key factor in AMD, DME, and RVO. Integrins are known to work both upstream and downstream of the VEGF pathway. Second, ALG-1001 inhibits an integrin-mediated pathway of the vitreoretinal interface, making it capable of inducing posterior vitreous detachment (PVD).
Anti-edematous Effect: ALG-1001 seems to have clear anti-edematous and antiproliferative effects. Its mechanism is quite different from that of anti-VEGF agents; therefore, this compound has potential as both adjunctive and standalone therapy. It addresses the goal of using multiple therapeutic approaches with different mechanisms of action that target different aspects of disease. Because ALG-1001 inhibits multiple integrins, including αvβ3, αvβ5, and α5β1, it may be able to prevent new blood vessel formation while concurrently stopping leakage from existing blood vessels. Early study results have suggested that this combination of integrin inhibition may be potent enough to be used as monotherapy for DME and AMD. What is particularly interesting, however, is that these early data also suggest that anti-integrin therapy may be effective for patients who have not been successfully managed with anti-VEGF treatments alone. A phase 1 study of ALG-1001 in DME enrolled 15 patients with poor vision and substantial intraretinal fluid who had undergone more than 10 anti-VEGF injections. In this trial, eight of the 15 (53%) patients improved by 3 to 5 lines in visual acuity testing; four (50%) of these patients improved from legal blindness to functional vision in the range of 20/40 to 20/60. Additionally, more than half the patients in this phase 1 trial experienced a 30% to 80% reduction in central macular thickness. The substantial improvement seen in these patients has driven the ongoing investigation of ALG-1001 for treatment of DME.
Vitreolysis Effect: Vitreomacular traction (VMT) is a pathology associated with the vitreoretinal interface. In a normally aging eye, the vitreoretinal interface gradually releases. In eyes with VMT, although the rest of the vitreous is released from the retina, a residual area of adhesion remains. It is extremely difficult to effect that release without causing damage to the retina. From a pharmacologic standpoint, it has recently become possible to use an enzyme to achieve vitreomacular detachment, although surgical removal of the adhesion remains the standard of care. Inducing a posterior vitreous detachment (PVD) in a patient with a normal vitreoretinal interface can be viewed as assisting part of the spectrum of normal vitreous aging. There are numerous hypotheses about how the vitreous releases, and some suggest that overstimulating VEGF could create a depot of sorts at the vitreoretinal interface, possibly causing disease to progress. There is a significant body of evidence that suggests that inducing a PVD may inhibit the progression of retinal disease, particularly DR. We know that, in proliferative DR (PDR), blood vessels grow onto the vitreous scaffolding. But if the vitreous has undergone a PVD and elevated itself, there would be no scaffolding for vessels to grow onto. In theory, this could stop the proliferation from occurring. Or it might cause the growth to behave more like coral branching out from the seabed, doing little damage because it is not causing traction. In the phase 1 study of ALG-1001 in DME, researchers noted a high rate of PVD. Evidence suggests that ALG-1001 inhibits a fourth integrin—α3β1—and, by doing so, aids in the breakdown of vitreous and its separation from the retina. This separation should move the hypothesized VEGF depot away from the retina, which would, in theory, prevent further damage.
Phase 2 Studies: ALG-1001 is being evaluated in several ongoing studies. DEL MAR is a phase 2b study evaluating ALG-1001 as monotherapy, as well as in combination therapy with anti-VEGF agents, and as a treat-and-maintain therapy. According to the manufacturer, results are anticipated as early as Q4 2016. DEL MAR has enrolled almost 120 patients. Efficacy endpoints include mean change in visual acuity and central retinal thickness (as measured by optical coherence tomography) at weeks 16 and 20. The study is evaluating 1.0, 2.0, and 3.0 mg of ALG-1001 in comparison with bevacizumab (Avastin, Genentech). A second arm of the study is evaluating ALG-1001 as an adjunctive therapy after treatment with any anti-VEGF agent, and a third arm is evaluating ALG-1001 in combination with bevacizumab. The last two arms are enrolling an additional 75 patients. The PACIFIC study is another phase 2b trial, enrolling about 100 subjects with nonproliferative DR without PVD to evaluate ALG-1001 as a standalone therapy. The trial will assess whether induction of PVD can inhibit progression to PDR. The PACIFIC trial will evaluate four doses of ALG-1001: 1.0, 2.0, 3.0, and 4.0 mg, with balanced saline solution as a placebo. Results from PACIFIC are expected in the first half of 2017, according to the manufacturer. The main endpoint is PVD induction based on optical coherence tomography and/or B-scan ultrasound. Another prospective, randomized, double-masked phase 2b study evaluated ALG-1001 in patients with vitreomacular adhesion (VMA) and VMT. Topline results indicate that this study met its endpoint, with 50% of patients who received the highest dose of ALG-1001 achieving release of VMT or VMA by day 90, compared with 9.7% of those receiving saline solution as placebo (P =.0129). The study randomly assigned 106 patients to receive ALG-1001 2.0, 2.5 mg, 3.2 mg, or placebo. The drug was well tolerated, with no drug-related toxicity or inflammation noted with repeated injections.
Conclusions: It is hoped that the reporting of the full datasets of these studies will reinforce the concept that, although these are small studies, ALG-1001 appears to be effective in a significant subset of patients with AMD or DME. The larger VMT study seems to suggest that ALG-1001 can effect vitreous release in a significant subset of patients. ALG-1001 shows promising efficacy, with mechanisms of action that are distinct from those of anti-VEGF therapy. This gives hope that the compound may become a new weapon in our armamentarium that may be complementary or additive to anti-VEGF therapy. If the results from DEL MAR, PACIFIC, and other future studies confirm early findings, ALG-1001 may become a viable alternative approach to both pharmacologic vitreolysis and treatment of AMD, DME, and DR.
- Retina and Retinal Neurodegeneration | Neuro-Optometry | Optical Coherence Tomography
Andrea Lorena Bergon
Universidad de Moron (UM), Argentina
Dr Sandra Young is currently an optometrist at Visionary Kitchen: A Cookbook for Eye Health, USA, she is specialized at treating Dry eyes and she is a currently a member of Ocular Nutrition Society.
1. What is dry eye? And, who is affected? Symptoms and prevalence of dry eye Patients with: advancing age, hormonal imbalances, diabetes, autoimmune disease, rosacea, pharmacological side effects, ocular trauma 2. Tears and their function Basal tears, reflex tears, emotional tears Tear film: inner mucin, middle aqueous, outer lipid 3. Dry eye categories A. Aqueous tear production deficiency Autoimmune disease: rheumatoid arthritis, lupus, Sjogren’s syndrome Medications: antihistamines, beta blockers, diuretics, sleep aides, some pain relievers Decreased corneal sensation: herpes zoster, refractive surgery, diabetes Systemic dehydration: drink water! B. Excessive tear evaporation Meibomian gland dysfunction (MGD) Lipid layer: decreased lipid production or excessive production Scarring: ocular pemphigoid, trauma 4. Nutritional goals for dry eye Tamp down ocular and systemic inflammation Improve tear film composition A “dry eye” diet should include: · Omega-3 fatty acids: ALA, EPA, DHA Improve tear film stability and lid inflammation Especially important for MGD Food sources of omega-3 fatty acids · Omega-6 fatty acids: GLA Tamps down inflammation How to include GLA in your diet · Omega-7 fatty acids Improves tear osmolarity How to include omega-7 fatty acids in your diet · Vitamins A, C, D, E, phytonutrients Support of ocular surface and tear film Anti-inflammatory, antioxidant effects How to include Vitamins A, C, D, E, phytonutrients in your diet · Probiotics Gut health and inflammation Foods to promote gut health
Otica Yamasaki, Brazil
- Optical Instruments | Common Eye Disorders and their Diagnosis
Otica Yamasaki, Brazil
Alexandria University, Egypt
Faculty of Ophthalmology at Alexandria University, Egypt
Background: Proliferative Diabetic Retinopathy (PDR) is one of the leading causes of blindness. The role of microRNA-200b (miRNA-200b) in the pathogenesis of PDR has been suggested in diabetic animal models. The aim of this study was to assess miRNA-200b expression level for the first time in the vitreous of patients with PDR and to study its relation to vascular endothelial growth factor (VEGF) as one of the pathogenic mechanisms in PDR.
Methods: Quantitative reverse transcription polymerase chain reaction (qRT-PCR) was used to measure miRNA-200b expression in the vitreous samples obtained from 29 eyes with PDR and from 30 eyes with idiopathic macular hole, as a control group. In addition, enzyme linked immunosorbent assay was used to measure VEGF in these vitreous samples.
Results: MicroRNA-200b expression was increased by about 5-folds in the vitreous samples from eyes with PDR compared with the controls (P=<0.001). Logistic regression analysis revealed for the first time that vitreous miRNA-200b was an independent risk factor for the development of PDR. VEGF level in the vitreous was significantly higher than controls (P=<0.001), but no significant correlation was found between miRNA-200b and VEGF.
In Conclusion: MiRNA-200b and VEGF were significantly increased in the vitreous of eyes with PDR, but in a non-correlated pattern. Overexpressed miRNA-200b independently increased the risk of PDR occurrence. Further studies are needed to identify the miRNA-200b targeted genes involved in the pathogenesis of PDR and examine the potential role of miRNA-200b as a target for PDR treatment.
Suzanne W Sherman is working as an Instructor in Optometric Science in Ophthalmology at Columbia University Medical Center. She is board certified from the American Board of Optometry and National Board of Examiners in Optometry (NBEO). She is graduated from SUNY College of Optometry and completed a residency in Ocular Disease and Primary Care from Bronx Lebanon Hospital Center.
Scleral contact lenses have been a part of management and treatment of corneal disease since the 19th century. Due to difficulty with manufacturing, improper fitting and poor patient comfort, scleral lenses were not as frequently used as rigid gas permeable lenses. Significant advances in technology have allowed scleral lenses to become a more important player in the management of diverse groups of conditions. The development of high Dk lens material, the same used for rigid gas permeable lenses, has reduced hypoxic related complications that prevented scleral lenses from being the primary lens used for corneal conditions. These new lenses have increased oxygen permeability, tear flow and are able to vault the limbus appropriately preventing limbal cell damage. The enhancement in design features of scleral lenses is evidenced by the various eye conditions treated, including ocular surface disease, keratoconus, pellucid marginal degeneration, post-operative or post-trauma corneal disease, and irregular astigmatism. By creating a smooth refractive surface, scleral lenses have optimized visual performance and clarity. Scleral lenses have given patients increased options for visual enhancement without requiring surgery or the need for glasses. This lecture will guide practitioners through a basic scleral lens fitting starting from lens selection to fit evaluation.
Universidad de Moron (UM) , Argentina
Andrea Lorena Bergon is presently an optician at Berprot Centro Optico in Argentina. She is a Specialist in Contact Lenses and as well as an Ocularist. She Graduated at the Universidad de Morón, School of Natural, Chemestry and Exact Sciences- Buenos Aires, Argentina. With degree as: Technical Optrician. Postgrade in Specialization in Contact Lenses. Specialist in the fabrication of prosthetic eye. Technical director in Berprot Optical Center.
This is the case of female 10 month-old patient, who is brought by her parents for consultation after she had been diagnosed left microphthalmia at birth in Teodoro Shestakof Hospital, in San Rafael, Mendoza.
The baby girl were not under any kind of treatment in her first months of life, so I started rehabilitation of the orbit cavity when I received her.
In the first meeting parents bring TAC report: no bone alterations in either orbit structure. Microphthalmia with slight deformation of left eye globe, maximum transversal diameter of eye globe 12 mm and 9 mm anteroposterior. Extrinsic musculature and optical nerve impress by this method of normal characteristics, without retrobulbar lesions. Optical ducts, preserved. In addition to Magnetic Resonance , it is reported to observe reduction of volume of the left eyeball with alteration of its signal intensity, resulting in Ptisis bulbi.
In the anamnesis the cavity is underdeveloped, with conjunctival sac and narrow palpebral groove due to the lack of stimulation for the development and growth of these structures.
Considering the size and deformation of the orbital cavity, rehabilitation started, using visualization technique and molding the first wax shaper, of 18mm as the largest horizontal diameter and 12 mm the vertical largest one.
Then the first medical device was made with thermo-curable polymer and it was placed in the patient for one week
In the first control there was good acceptance, passing to a progressive increase of 2mm in both diamters, vertical and horizontal, every 15 days, checking the tissue expansion and tolerance to change in each control.
After the forth change of shape, the patient interrupted controls for 60 days and stop using the shaper due to the fact that because of lack of bigger size and child’s friction the shaper had been ejected. When the patient attended a new control, the problem was the last shaper couldn’t be used as the cavity had retracted, thus being as in the situation of the second shaper of the treatment, observing a regression in the tissue rehab.
Then parents realized the importance of the continuity of the treatment and the commitment needed so as to have good results.
Today, a year later, the patient is wearing a customized prosthetic eye, with stable cavity and considerable facial symmetry with his age and a new control in a year’s time.
King Saudi University, King Saudi Arabia
Safiah H Mulla is a Faculty Staff in the Department of Optometry, King Saud University, Riyadh, Saudi Arabia, where she has been a Member of the Academic Staff since 1997. She holds a BSc (1987) in Optometry from King Saud University and MSc (2007) in Clinical Vision Science from Dalhousie University. From 1990 to 1997, she was running an Optometry clinic at Security Forces Hospital, Outpatient Department, Riyadh, Saudi Arabia. In 2000, she has received a scholarship to Canada to get a diploma in Orthoptic and Master’s degree in Clinical Vision Science. She is also a Board Member for the Saudi Association of Optometry and Vision Science as well as a certified Orthoptist.
Introduction: This study is a comparison between the Visual Acuity (VA) measurements with the preliterate LogMAR LEA symbols VA chart (LH) and the standardized Early Treatments for Diabetic Retinopathy Study VA chart (ETDRS) in young children to help further define reported validity limitations of the former.
Methods: 40 healthy and visually normal children age 40 to 83 months were recruited in a cross-sectional prospective study with all participants being required of being able to recognize the 10 Sloan letters. Under a standardized and controlled clinical setting, VA was measured monoculary and randomly using both the LEA and the ETDRS charts.
Results: VA scores of the two charts were highly correlated with a clinically insignificant over estimation of 0.04 LogMAR in the LEA chart scores regardless of the subjects’ age or gender. The two charts were in total agreements in the detection of subjects’ inter-ocular difference.
Conclusion: This study indicates that the preliterate LEA chart can provide a valid alternative to the ETDRS chart among normal preschoolers.
Raghudeep Eye Clinic, India
Raghuveer Singh has completed his studies from School of Optometry at Global Hospital Institute of Ophthalmology. He is working as Optometrist at L V Prasad Eye Institute (LVPEI) and Senior Clinical Consultant Optometrist at Raghudeep Eye Clinic.
Purpose: To compare corneal aberrations with Rose K2 vs. Rose K2 XL lenses fitted in keratoconus.
Methods: Five patients (8 eyes) were evaluated for corneal aberrations in Keratoconus with Rose K2 vs. semi-scleral lenses; using itracey. A comprehensive ophthalmic examination was performed on all patients, which included the uncorrected and corrected visual acuity, bio-microscopy, pentacam and fundus examination.
Results: A total of 8 eyes statistically showed significant HOA (p<0.008), Coma (p<0.01), Trefoil (p<0.04) pre and post lenses. No significant HOA, Coma and Trefoil (p>0.05) compared with Rose K2 and Rose K2 XL.
Conclusions: This study identified Coma more reduced with semi-scleral lenses, but not significant.