The view of a proposed virtual reality simulator. 

(Images courtesy of Fares Antaki, MD, CM)

In an event modeled after the television program 

, 3 presenters at the annual meeting of the Canadian Ophthalmological Society took part in a retina research competition, dubbed the Lions’ Lair, where a top prize of $35,000 was awarded to the winning pitch.

Fares Antaki, MD, CM, chief resident at the Department of Ophthalmology at the University of Montreal in Canada, pitched a project for a virtual reality (VR) simulator designed to enhance retinal surgery training.

During his presentation, Antaki touched upon the work of David Kasner, MD; and Robert Machemer, MD, who are considered the fathers of pars plana vitrectomy. 

He went on to discuss the Halsted apprenticeship model that has been employed in vitreoretinal surgery where “see 1, do 1, teach 1,” has been the guiding principle. Incorporating technology into vitreoretinal teaching can supplement this model through “see 1, simulate 1, do 1, and teach 1,” Antaki explained.

Factors to consider in IOP elevations associated with vitreoretinal treatments

Vitreoretinal surgery training is not commonly provided during ophthalmology residency and requires several years of preparation to master the necessary skills, Antaki noted. 

High-fidelity VR simulation provides a safe environment to learn and practice without risk for patients. 

With the imminent transition to new competency-based, medical educational models in Canada, the integration of VR simulation can be useful to administer proficiency-based tests to ensure trainees are ready to perform procedures on patients, Antaki explained.

An example of VR in ophthalmic education is the Eyesi simulator. Antaki first encountered the Eyesi simulator in his native Syria, when the Orbis Flying Eye Hospital visited Aleppo in 2007 and 2008. 

The passengers in the plane were on a mission to share knowledge and train local eye doctors through lectures, workshops, and hands-on training.

“Looking back at this moment, I realized that as soon as the plane left Syria, the local doctors could no longer train using simulation,” Antaki said. “This is because simulators like the Eyesi have a very high purchase price, limiting their worldwide adoption. Moreover, the size and weight of the Eyesi are limiting factors with respect to accessibility and mobility.”

The proposed VR simulator would be compatible with commercially available headsets such as HTC Vive and Oculus Quest, as well as commercially available instruments such as touch haptic devices and touch controllers, Antaki said. 

Improving macular pathology detection in telemedicine screening

Since the 1970s, VR headsets have steadily decreased in weight and improved in computing capacity. 

VR headsets have moved beyond academic labs and are commercially available, with prices ranging from $400 to $1200.

“By leveraging on the powerful processors, cameras, and sensors of those VR headsets, we believe that we can build a fully immersive, low-cost, portable vitreoretinal surgery VR simulator,” Antaki said.

Ophthalmologists will work with an engineering team to help develop the training modules, according to Antaki. 

The senior principal investigator is Karim Hammamji, MD, FRCSC, chief of the Retina Division at the University of Montreal and vitreoretinal surgeon at the Centre Hospitalier de l’Université de Montréal. 

The engineering team is composed of Benoît Ozell, PhD, professor and director of the Research Laboratory for Computer Graphics and Virtual/Augmented Reality at the University of Montreal, and Cédryk Doucet, BSc, a computer engineering graduate whose master’s thesis will focus on developing the VR simulator.

Ophthalmology: A pioneer in the field of artificial intelligence

Antaki will conduct a 2-phase study in which the 18-month first phase will focus on simulator development. 

The simulator will be developed jointly with the engineering team through iterative feedback with the ophthalmology team. 

This process will ensure the simulator is testing 4 fundamental skills that are used during vitreoretinal surgery.

“We will provide feedback to improve the simulator during the initial phases of its construction,” Antaki said.

The 4 training modules will simulate core vitrectomy and posterior vitreous detachment induction, peripheral shaving, endolaser and membrane peeling, according to Antaki.

Scheduled to last 9 months, the second phase is a validation phase that will involve construct validity and skills transfer. Two prospective, controlled interventional trials will be carried out.

“The trials will first prove construct validity and skills transfer,” Antaki said. “We will also collect information on personal and environmental presence during simulation to determine how realistic our simulator is.”

Targeting human retinal progenitor cell injections for RP

Antaki also explained how the startup funds would be allocated.

“Some of the money will be used to pay for personnel, but most of the money will be used to pay for the virtual reality headsets, the haptic feedback devices, and the virtual reality workstation,” he said. “With this funding, we will improve access to vitreoretinal surgery training.”

When asked by one of the judges of the competition if this technology could be used for other training purposes, such as learning cataract surgery, Antaki responded that it could.

“Our focus at this time is vitreoretinal surgery, but the opportunities are immense (to use the technology for other learning),” he said.

Antaki has no financial disclosures related to this content. Antaki’s pitch proved to be the winner of the competition, earning $35,000 (CAD$). It was also judged by the audience to be the winner, earning an additional $5000.

Articles

Pilot study shows promise of teaching surgeons with technology.

Virtual reality simulator will boost vitreoretinal surgery training

Videos

Lisa Nijm, MD, JD, discusses the brand-new Real World Ophthalmology conference, designed to support ophthalmologists starting practice.

Discussing Real World Ophthalmology with Dr. Lisa Nijm, creator of the conference

 surgeries (MIGS)—and the reason we push them earlier in the disease course—is their safety and the predictable postoperative recovery. In the past, we had fewer options, most of which were more invasive.

As a result, we had to delay surgery for years while patients suffered the discomfort, inconvenience, and expense of multiple medications, until finally those medications were no longer enough and surgery was unavoidable. 

Now we can skip years of suffering and better manage glaucoma by making MIGS part of the treatment equation.

MIGS helping to personalize glaucoma surgery options

Historically, we were hesitant to go into the subconjunctival pathway with trabeculectomy or tube shunt because of the often slow and variable nature of visual recovery and complex postoperative management. 

Instead, we waited until glaucoma progressed and the target pressure was aggressively low, often near the 10 to 12 mm Hg range.

Thankfully, with the options available today, we no longer need to wait so long to perform subconjunctival surgery for patients who need it, and with this earlier intervention, we have a better chance of achieving target IOPs because they are not so aggressively low.


Visual recovery and conventional pathway MIGS


With conventional pathway MIGS, such as stenting (iStent; Glaukos, Hydrus; Ivantis), viscodilating (iTrack; Nova Eye Medical, OMNI; Sight Sciences), stripping (Kahook Dual Blade goniotomy; New World Medical), cutting/GATT (OMNI), and others, visual recovery is generally not a major concern. 

Pressurizing the eye intraoperatively usually prevents intraoperative and postoperative hyphema, although if it does still occur, it usually clears up in a short period of time.

The mechanisms that make visual recovery so seamless for conventional pathway MIGS are also the reason they are not always the best option: 

The episcleral venous pressure is a floor we cannot cross, so it is hard to reach target pressures below the low to mid-teens. 

Patient glaucoma management focuses on pivotal studies

This floor, however, also means we do not get hypotony or flat chambers, which are often the cause of postoperative vision issues. Unfortunately, some of our patients need those lower target pressures. 

We also do not know where the resistance to outflow is located in our patients with glaucoma; in some, the distal channels are also collapsed or atrophied. In these cases, we are not able to achieve the IOP control we need through the conventional outflow system. 

We need to turn to a subconjunctival procedure to bypass the conventional pathway.


Vision after trabeculectomy or tube shunt surgery


Common causes of postoperative visual acuity changes are hypotony, choroidals, maculopathy, and ocular surface problems. 

With trabeculectomy and tube shunt, all of these problems are possible, so it is difficult to gauge how long visual recovery will take with each patient. 

Depending on how flat the chamber becomes and the position of the iris lens diaphragm complex, a return to baseline vision may take 1 week to 1 month or even longer. 

Restoring vision in glaucoma: more than meets the eye

A nonvalve tube might open up in a month and a half or even earlier when the suture dissolves, and that sudden change in IOP can cause a sudden shift in chamber depth and thus a change in vision. 

In addition, postoperative drops can prolong recovery by destabilizing the ocular surface.

In the case of weeks or months of recovery, patients are generally not happy with their vision. IOP can be unstable, so they require multiple office visits, and they often call the office with questions about vision problems and irritation from eye drop medications. 

The recovery process may still be going on when it’s time for the patient to schedule surgery on the fellow eye, which can make them reluctant to do so.

As an experienced glaucoma specialist, I still marvel at the high potential for variability of each step for a trabeculectomy. 

Study: Lower IOP, medication burden in OAG patients

I use various techniques to manage outcomes by controlling the size, thickness, and shape of the flap; titrating the flow by suture placement and tension; and trying to aggressively bring down the IOP yet prevent chambers from flattening postoperatively. 

It takes time to build that comfort and skill set, and not all patients have access to surgeons who have completed 1000-plus trabeculectomy procedures.

For these and a variety of additional reasons, a less invasive and more predictable subconjunctival procedure is needed to allow access for more patients than traditional surgeries.

Faster visual recovery from subconjunctival MIGS


When we want to reach a lower pressure, avoid being beholden to conventional pathways where levels and locations of resistance can be uncertain, and follow a more predictable visual recovery than we get with traditional subconjunctival procedures; subconjunctival MIGS can deliver the benefits with few limitations.

The Xen Gel Stent (Allergan) uses the same bypass mechanism as trabeculectomy, but the only outflow created is a 45 μ lumen, rather than a larger, less consistent hole in the sclera with a variable flap. 

Micro-bypass stent implant during cataract surgery: lower IOP, fewer medications

With less structural deformation of the sclera, there is less chance of flat chambers postoperatively. 

Even if numerical hypotony occurs, the chambers do not flatten as much because they retain greater structural integrity. 

There is less concern that deformation of the eye will shift the iris lens diaphragm and cause a myopic shift or, in a pseudophakic patient, move or decenter a toric lens.

Based on the approval trial, Xen has demonstrated a high safety profile with few complications.

The less invasive nature of Xen means the eye remains stable, with less inflammation in the anterior chamber and conjunctiva, often because there is no peripheral iridotomy, and if implanting from an external approach, intraoperative flattening of the anterior chamber is rare.

Since flow occurs through a single point around 5 mm posterior to the limbus, rather than in multiple directions closer to the limbus as in a trabeculectomy, the bleb forms more posteriorly and often with a lower profile, resulting in a quieter bleb and shorter-duration steroid use after surgery. 

With fewer steroids and thus fewer topical preservatives, the ocular surface tends not to experience less disruption and resulting postoperative vision fluctuation. 

Xen has also been shown to cause less endothelial cell loss than trabeculectomy, which could be an issue as patients get older and have other corneal risk factors.

Although postoperative bleb needling is sometimes needed, my postoperative bleb needling rates have dropped significantly (now less than 10%) with changes in technique, intraoperative confirmation of a freely mobile stent, and use of an intraoperative needling if resistance is found.

If needling is required, it is a different type of intervention than a trabeculectomy needling. We do not see a sudden drop in IOP, so there is less change in chamber depth that could affect visual recovery.

Glaucoma + nutrition: why what you eat matters

In the end, Xen reaches similarly low pressures as traditional subconjunctival surgeries with a predictable postoperative course, resulting in fewer visits (1 week and 1 month) and calls to my practice.

Because of the high safety profile and rapid visual recovery, I have now offered Xen to patients who are refractory to drops despite their level of glaucoma severity. 

For instance, a patient with mild or moderate open-angle glaucoma who is taking 4 classes of medications, has a history of a previous MIGS, has stable IOP and visual folds, but is not compliant with drops would not typically have been a subconjunctival bypass candidate in the past, but this patient is now a perfect candidate for a Xen. Welcome to the interventional glaucoma mind-set.




Inder Paul Singh, MD, is president of The Eye Centers of Racine and Kenosha, Wisconsin. He is a consultant to Alcon, Allergan, Bausch + Lomb, Ellex, Glaukos, Iantech, New World Medical, Omeros, Shire, and Zeiss.


1. Francis BA, Hong B, Winarko J, Kawji S, Dustin L, Chopra V. Vision loss and recovery after trabeculectomy: risk and associated risk factors. 

. 2011;129(8):1011-1017. doi:10.1001/archophthalmol.2011.182

2. Birchall W, Bedggood A, Wells AP. Do scleral flap dimensions influence reliability of intraocular pressure control in experimental trabeculectomy? 

. 2007;21(3):402-407. doi:10.1038/sj.eye.6702253

3. Reitsamer H, Vera V, Ruben S, et al. Three-year effectiveness and safety of the Xen gel stent as a solo procedure or in combination with phacoemulsification in open-angle glaucoma: a multicentre study.

. Published online May 10, 2021. doi:10.1111/aos.14886

4. Olgun A, Duzgun E, Yildiz AM, Atmaca F, Yildiz AA, Sendul SY. Xen Gel Stent versus trabeculectomy: short-term effects on corneal endothelial cells. 

. 2021;31(2):346-353. doi:10.1177/1120672120924339

5. Marcos Parra MT, Salinas López JA, López Grau NS, Ceausescu AM, Pérez Santonja JJ. Xen implant device versus trabeculectomy, either alone or in combination with phacoemulsification, in open-angle glaucoma patients. 

 2019;257(8):1741-1750. doi:10.1007/s00417-019-04341-y

Speed the return to baseline visual acuity—and make your patients happy.

The path to faster visual recovery following glaucoma surgery

The Gilbert Family Foundation, a private nonprofit established by Jennifer and Dan Gilbert to accelerate a cure for neurofibromatosis type 1 (NF1), today announced funding of a new $5.4 million clinical study.

The study, to be led by investigators at Children’s Hospital of Philadelphia and the Stanford University School of Medicine, aims to understand the mechanisms of vision loss caused by NF1-associated optic pathway gliomas, or NF1-OPGs.

Nearly 20% of children with NF1 will develop an OPG, a tumor located along the visual pathway, which can cause permanent vision loss ranging from mild deficit to complete blindness. In April 2019, the Gilbert Family Foundation launched its Vision Restoration Initiative to fund research focused on developing innovative therapies that either repair or replace damaged visual systems caused by NF1-OPGs.

Jennifer Gilbert, co-founder of the Gilbert Family Foundation, noted that one in five NF1 patients develop OPGs, and many end up with chronic vision loss, a symptom that can have devastating effects on quality of life.

“We are working to put an effective cure for NF1-OPG-related vision loss and blindness within reach,” Gilbert said in a statement. "This study is a major milestone for our Vision Restoration Initiative as we strive to unlock life-changing therapies and support future research.”

Through a combination of established and novel visual function testing methods, this study will define the functional, structural, metabolic and patient-reported components of NF1-OPG-induced vision loss. Findings are expected to inform the development of future therapies, validate existing models of the disease, and help identify new metrics for evaluating the efficacy of vision restoration treatments, including those developed within the Gilbert Family Foundation’s Vision Restoration Initiative and in both pre-clinical animal models and human clinical trials.

The study, formally titled “Identifying Biomarkers for Visual Restoration Strategies in NF1-OPGs,” will be led by Robert Avery, DO, Pediatric Neuro-Ophthalmologist at Children’s Hospital of Philadelphia and Assistant Professor of Ophthalmology and Neurology at the Perelman School of Medicine at the University of Pennsylvania, and Jeffrey Goldberg, MD, PhD, professor and chairman of Ophthalmology at Stanford University School of Medicine.

As members of the Vision Restoration Initiative “dream team,” both study leaders not only have extensive experience with the techniques used in the study, but also understand the direct connection to and impact on the strategies being developed within the Vision Restoration Initiative.

“Our data on variance and test-retest reliability will be critical to powering endpoint analyses in early-phase clinical trials for new candidate therapies for NF1-OPG vision neuroprotection and restoration anticipated in the coming years,” Goldberg said in a statement. “Our novel and broad approach should identify biomarkers that are relevant in humans and can subsequently drive animal testing by using those biomarkers in pre-clinical therapeutic studies.”

According to the foundation, this study will last approximately 3 years, with patient recruitment beginning in late 2021 or early 2022.

"As the Vision Restoration Initiative’s first comprehensive human study, this project will provide a new understanding of vision loss from NF1-OPGs,” Avery said in a statement. “We're moving closer to our goal of ultimately preventing and even reversing the lifelong vision loss from these tumors.”

Children’s Hospital of Philadelphia and Stanford University School of Medicine will lead the $5.4 million study ,with patient recruitment beginning in late 2021 or early 2022.

Gilbert Family Foundation funds clinical study to understand vision loss from NF1 optic pathway glioma 

AbbVie and REGENXBIO on Monday unveiled a partnership to develop and commercialize RGX-314, a potential one-time gene therapy for the treatment of wet age-related macular degeneration (wet AMD), diabetic retinopathy (DR) and other chronic retinal diseases.

According to the companies, RGX-314 is currently being evaluated in patients with wet AMD in a pivotal trial utilizing subretinal delivery, and in patients with wet AMD and DR in two separate Phase II clinical trials utilizing in-office suprachoroidal delivery.

The companies noted that under the collaboration, REGENXBIO will be responsible for completion of the ongoing trials of RGX-314. AbbVie and REGENXBIO will collaborate and share costs on additional trials of RGX-314, including the planned second pivotal trial evaluating subretinal delivery for the treatment of wet AMD and future trials.

Moreover, AbbVie will lead the clinical development and commercialization of RGX-314 globally. REGENXBIO shall participate in U.S. commercialization efforts as provided under a mutually agreed upon commercialization plan.

“We are committed to finding solutions for patients living with difficult-to-treat retinal diseases and to helping preserve and protect our patients from visual impairment and devastating vision loss,” Tom Hudson, MD, senior vice president, Research and Development, chief scientific officer, AbbVie, said in a statement. “In collaboration with REGENXBIO, we aim to make a remarkable impact for the millions of patients suffering from vision loss associated with retinal diseases.”

Kenneth T. Mills, president and chief executive officer of REGENXBIO, said AbbVie is a strong, complementary partner for REGENXBIO.

“We expect to leverage AbbVie’s global developmental and commercial infrastructure within eye care with our expertise in AAV gene therapy clinical development and deep in-house knowledge of manufacturing and production to continue the development of RGX-314,” Mills said in a statement.

During a conference call on Monday, Mills also lauded the qualities that AbbVie will bring to the partnership.

“We chose to partner with AbbVie, certainly due to their strength and their global commercialization reach and the fact that they have one of the largest eyecare franchises in the world,” he said during the call.

Under the terms of the agreement, AbbVie will pay REGENXBIO a $370 million upfront payment with the potential for REGENXBIO to receive up to $1.38 billion in additional development, regulatory and commercial milestones. REGENXBIO and AbbVie will share equally in profits from net sales of RGX-314 in the U.S. AbbVie will pay REGENXBIO tiered royalties on net sales of RGX-314 outside the U.S. In addition, REGENXBIO will lead the manufacturing of RGX-314 for clinical development and U.S. commercial supply, and AbbVie will lead manufacturing of RGX-314 for commercial supply outside the U.S. 

The transaction is expected to close by the end of 2021, subject to the satisfaction of customary closing conditions, including applicable regulatory approvals.

REGENXBIO has begun ATMOSPHERE, a subretinal pivotal trial in neovascular AMD.

RGX-314 is being investigated as a potential one-time treatment for wet AMD, diabetic retinopathy, and other chronic retinal conditions. RGX-314 consists of the NAV AAV8 vector, which encodes an antibody fragment designed to inhibit vascular endothelial growth factor (VEGF). RGX-314 is believed to inhibit the VEGF pathway by which new, leaky blood vessels grow and contribute to the accumulation of fluid in the retina.1

Investigators will evaluate 2 doses of RGX-314 compared with monthly injections of ranibizumab in pseudophakic patients with a baseline VA of 20/32 to 20/160.

The study will enroll about 300 patients at 60 clinical sites. The primary end point is the mean change in BCVA relative to ranibizumab at week 54.

REGENXBIO is also conducting studies using the in-office SCS Microinjector to deliver RGX-314 to the suprachoroidal space in patients with neovascular AMD and 

Upcoming results from these suprachoroidal programs will be announced for the phase 2 AAVIATE (neovascular AMD; NCT04514653) and ALTITUDE (diabetic retinopathy; NCT04567550) trials.

Penn JS, Madan A, Caldwell RB, et al. Vascular endothelial growth factor in eye disease. Prog Retin Eye Res. 2008;27(4):331-71.

AbbVie and REGENXBIO announced a strategic partnership to develop and commercialize RGX-314, an investigational gene therapy for wet age-related macular degeneration, diabetic retinopathy and other chronic retinal diseases.

Companies announce eye care collaboration

Corneal collagen crosslinking (CXL) in pediatric and young adult patients with keratoconus can stabilize, and in some cases even improve, corneal keratometry and vision out to 2 years postoperatively, according to study results presented by Solin Saleh, MD.

Saleh, who recently completed her pediatric ophthalmology fellowship at the Byers Eye Institute at Stanford University School of Medicine in California, reported the study results at the ASCRS 2021 annual meeting in July.

The study, which was designed by Edward E. Manche, MD, consisted of a retrospective chart review of patients 22 years or younger who had undergone CXL for progressive keratoconus at the Byers Eye Institute during the previous 7 years. 

All CXL procedures were performed by Manche.

Edward Manche, MD, discusses results from his ASCRS 2021 presentation regarding outcomes of corneal crosslinking keratoconus in a pediatric population.

The investigators evaluated the patient records to identify changes in visual and corneal parameters, including best-corrected visual acuity (CDVA) and maximum keratometry (Kmax) out to 2 years after CXL.

The findings are important because although keratoconus generally is diagnosed during puberty, it can be more severe and progress more quickly when identified in younger children who may need corneal transplantation if the disease is not addressed, Saleh said.


Saleh reported that 86 eyes of 71 consecutive patients underwent CXL during the study period. 

The patients ranged in age from 12 to 22 years (mean 16.4 ± 2.5 years) at the time of surgery. 

Bilateral CXL was performed in 8 patients. Of the study sample, 57 eyes had completed a minimum of 1 year of follow-up and 24 eyes had completed 2 years of follow-up.

She reported that the mean preoperative CDVA was logMAR 0.38 ± 0.32 (Snellen acuity 20/48), with mean postoperative CDVA of 0.29 ± 0.31 (20/39) and 0.31 ± 0.31 (20/41) at 12 and 24 months postoperatively. 

Examining 10-year postop data on epi-off CXL for keratoconus, ectasia

Compared with preoperative mean Kmax, there was an improvement of –0.8 D to a mean postoperative Kmax of 59.1 ± 9.1 D at 12 months and –1.3 D to 59.7 ± 8.8 D at 24 months.

The authors concluded that CXL was both safe and effective to perform in this young patient population. 

The procedure stabilized the cornea in these children and young adults, and in some cases the vision and the keratometry values improved.

The authors urged surgeons to consider CXL for treating pediatric patients with early keratoconus to prevent ongoing disease progression, especially given the risk of visual morbidity in children.

This article is adapted from Saleh’s presentation at the American Society of Cataract and Refractive Surgery annual meeting. She has no financial interest in this subject matter.


Manche has no financial disclosures related
to this content.

CXL is safe, effective to perform on younger population, study results show.

Collagen crosslinking provides corneal stability in young patients


Posterior capsular rupture (PCR) is the most frequent complication during cataract surgery in patients treated previously with intravitreal anti-vascular endothelial growth factor (VEGF) injections for age-related macular degeneration (AMD), according to Marta Belmonte-Grau, MD.

During a presentation at the EURETINA 2021 Virtual Congress, Belmonte-Grau reported that this was especially true for patients with a posterior subcapsular cataract and likely the result of needle-induced trauma to the posterior capsule during injection. Belmonte-Grau is from the Hospital Universitario de la Princesa, Madrid.

Belmonte-Grau and her colleagues retrospectively reviewed the charts of patients undergoing phacoemulsification at their institution. 

They evaluated patient age, gender, operated eye, presence of risk factors for surgical complications, duration of intravitreal treatment (≤6 or >6 months), number of preoperative intravitreal injections (≤10 or >10), surgeon experience (≤5 or >5 years), and initial/final visual acuity (VA). All patients had received previous anti-VEGF injections for AMD. The primary outcome measure was the occurrence of intraoperative PCR.

A total of 550 cataract surgeries were reviewed, with 83 eyes (15.09%; 57 women, 26 men; mean age, 84.52 years) having received previous intravitreal injections.

The investigators identified 20 eyes with a posterior subcapsular cataract (24.10%), 3 eyes (3.60%) with poor dilation, 2 eyes (2.40%) with mature cataract, and 1 eye (1.20%) with pseudoexfoliation syndrome.

“Patients with posterior subcapsular cataract had an odds ratio of 5.67 (95% confidence interval [CI], 5.67-5.67; p<0.05) for occurrence of an intraoperative complication,” investigators reported. “Regarding the complication rate, complications developed in 10 eyes (12.05%) during cataract surgery. The most frequent cause was dislocation of the nucleus into the vitreous (n=5, 6%) followed by PCR (n=3, 3.60%) and zonular disinsertion (n=2, 2.40%).”

Univariate analysis showed increased VA 6 months postoperatively (mean gain, 0.43 line). Surgeon experience and number of previous intravitreal injections were not significant risk factors for PCR.

With cataract surgery the most frequently performed surgery and the aging of the population, elderly women are the typical patients treated with intravitreal injections for AMD, Belmonte-Grau explained.

“PCR occurs more frequently during cataract surgery in patients who were treated previously with intravitreal injections and especially those with a posterior subcapsular cataract, probably caused by needle-induced trauma to the posterior capsule during injection,” she concluded. “We emphasize thorough evaluation of the cataract preoperatively in these patients. A large majority of the complications had to be treated with vitrectomy, so this eventuality must be included in the informed consent and the information provided to patients.”

Marta Belmonte-Grau, MD discusses the potential risk for posterior capsular rupture during cataract surgery. 

Study targets intravitreal injections for AMD, PCR risks

He is director of The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of Ophthalmology Times.


Born in Ohio in 1822, Hiram Ulysses Grant went on to lead the Union Army to victory during the American Civil War. A national hero, he became the 18th president of the United States. 

During his time in office, he created the Justice Department and used it to aggressively suppress the Ku Klux Klan.

Almost famous: Ophthalmologist gained worldwide attention in 1910

William Halsey Jr, born in New Jersey in 1882, became the second-highest ranking American naval officer in the Pacific in World War II. 

Described as “flamboyant, vulgar, aggressive, and spectacularly ugly,” the admiral was loved by his troops. 

An intelligence officer described the reaction to the news that Admiral Halsey had been ordered to take command during the Guadalcanal campaign: 

“One minute, we were too limp with malaria to crawl out of our foxholes. The next, we were running around, whooping like kids.”

Halsey’s leadership is credited with turning impending defeat into a major Allied victory. He was decorated with the Navy Cross, the Navy Distinguished Service Medal, and the Army Distinguished Service Medal.

Joe Jamail Jr, born in Texas in 1925, served in the US Marine Corps for over 2 years in the Pacific in World War II before becoming an attorney. 

He became known as the “King of Torts” in recognition of his victories against large corporations, winning more than 200 verdicts, or settlements, of at least $1 million. 

Living forward: We still have to understand backward

 proclaimed him the nation’s richest practicing lawyer, and 

 magazine estimated his net worth at $1.65 billion.

Aside from military service, what do these 3 gentlemen have in common? 

The common thread that strikes me is that all 3—while enrolled in the schools that would prepare them for their subsequent meteoric careers—were considered mediocre by their professors. 

At West Point Military, Grant proved himself a talented horseman, but ranked in the bottom half of the class, which prevented him from qualifying for a position in the cavalry upon graduation. 

Halsey proved himself a talented athlete at the US Naval Academy in Annapolis, Maryland, but graduated in the bottom third of his class. And as a law student at the University of Texas at Austin, Jamail’s professor flunked him in the class on torts.

How could their professors have failed to recognize the future superstars they would become? 

Are the traits that allow doing well in class so different from those that predict 

Do our professors value the wrong things? 

Or is it the case that these young men matured and blossomed later in life, finally focusing on what was needed to rise to the top of their respective professions?

I wonder about this when it comes to how we train our young physicians and surgeons. 

In your residency, did your faculty emphasize the right things? Did they recognize your future promise?

Do grades predict performance?

Orbital lymphoma has presented a new face that physicians should recognize, according to Jane S. Kim, MD, from the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor.

Ptosis does not operate in a vacuum and can be associated with numerous other conditions, some of which can be life-threatening. In most cases, involutional ptosis is associated with levator dehiscence, but unilateral ptosis can be the first symptom related to other causes that are traumatic, myogenic, neurogenic, or mechanical in nature.

In the case under discussion, the patient was a 65-year-old woman whose history included hyperlipidemia, hypothyroidism, and chronic migraines. She presented with a 9-month duration of left-sided ptosis, which was more marked at the end of the day and with fatigue. She did not experience pain, diplopia, muscle weakness, dysarthria, dysphagia, difficulty breathing, or other focal neurologic deficits, according to Kim.

The physical examination revealed no palpable adnexal masses, orbital rim deformities, or relative proptosis. There was no prolapsed lacrimal gland or conjunctival mass visible on lid eversion and no palpable preauricular or cervically lymphadenopathy.

However, there was mildly increased resistance to retropulsion noted on the left compared to the right eye and mild fullness of the left superior sulcus.

The visual acuity was 20/20 bilaterally; intraocular pressures were in the normal range; pupils showed no afferent defect; ocular motility was normal, as was the fundus, cornea, and anterior chamber appearance.

The clinical examination also showed that margin-to-reflex distance 1 was 3.5 mm on the right and 0.5 mm in the left affected eye, and the levator function of that eye was 11 mm in contrast to greater than 14 mm in the fellow eye.

Magnetic resonance imaging (MRI) showed a well-demarcated tumor that involved the markedly enlarged left lacrimal gland with molding to adjacent ocular structures without bony erosion. There was inferior displacement of the left globe with a mass effect on the superior rectus-levator complex, Kim described.

A biopsy of the left lacrimal gland showed mantle cell lymphoma. Other testing showed no systemic involvement.

Unilateral ptosis can be the first symptom related to other causes that are traumatic, myogenic, neurogenic, or mechanical in nature.

Do grades predict performance?

Orbital lymphoma: masquerading as involutional ptosis

Windows to the soul, eyes are key to meaningful conversation