E Syllabus C

Bascom Palmer Eye Institute
& Pan-American Association

of Ophthalmology
Joint XLIV Inter-American Course in Clinical

Ophthalmology (CURSO) and
XXVI Pan-American Regional Course
XLIV Curso Interamericano de Oftalmología Clínica

(CURSO) y XXVI Curso Regional Panamericano
October 16 - 19, 2022

16 - 19 de octubre de 2022
INDICE / TABLE OF CONTENTS
Enlace directo al hacer clic sobre el nombre del conferencista

Click on speaker name to link to page
Patrocinadores / Educational Supporters .......................................................................................... 5

Calendario de Eventos / Upcoming Events ........................................................................................ 6
Expositores Comerciales / Exhibitors ................................................................................................. 8
Rifa / Raffle ........................................................................................................................................ 11
Program (Español) .............................................................................................................................. 13
Program (English) ............................................................................................................................... 24
Conferencistas / Speakers ................................................................................................................. 34
Teleoftalmología (Opcional) / Telemedicine (Optional) .......................................................................... 39
Electrofisiología (Opcional) / Electrophysiology (Optional) ..................................................................... 41
Cataract I
Gibbons, Allister G. ................................................................................................................................... 45
Tomografía de Coherencia Optica / Optical Coherence Tomography (OCT)

Burnier, Miguel, N. ............................................................................................................................ 47
Retina I
Arevalo, J. Fernando. ......................................................................................................................... 50
Goldhardt, Raquel .............................................................................................................................. 58
Flynn Jr., Harry ................................................................................................................................... 68
Smiddy, William E. ............................................................................................................................. 73
Retina II
Haddock, Luis, J. ................................................................................................................................. 79
Glaucoma II
Greenfield, David S. ........................................................................................................................... 89
Superficie Ocular / Córnea - Ocular Surface / Cornea
Perez, Victor L. ................................................................................................................................... 91
Galor, Anat.......................................................................................................................................... 94
Dantas, Paulo E.C ............................................................................................................................... 102
Cataratas II / Cataract II
Amescua, Guillermo .......................................................................................................................... 106
Oftalmología Pediátrica / Pediatric Ophthalmology

Zhu, Angela Y. .................................................................................................................................... 111
Fernandez, Angela M. ........................................................................................................................ 114
Warman, Roberto. ............................................................................................................................. 116
Oculoplástica / Oculoplastics
Johnson, Thomas E. ........................................................................................................................... 119
Oncología / Oncology
Burnier, Miguel N. ............................................................................................................................. 121
Uveítis
Goldhardt, Raquel .............................................................................................................................. 127
Davis, Janet. L ..................................................................................................................................... 132
Arevalo, J. Fernando ........................................................................................................................... 137
Neuro Oftalmología / Neuro Ophthalmology

Jiang, Hong ........................................................................................................................................ 150
Vila Delgado, Mariam ......................................................................................................................... 154
XLIV Curso Interamericano de Oftalmología Clínica (CURSO)
XXVI Curso Regional Panamericano
16 - 19 de octubre de 2022
DIRECTORES DEL CURSO / COURSE DIRECTORS
Dr. Eduardo C. Alfonso

Director, Bascom Palmer Eye Institute
Chair, Dept. of Ophthalmology
University of Miami Miller School of Medicine
Co-Medical Director, University of Miami
Hospital and Clinics UHealth
Kathleen and Stanley J. Glaser Endowed
Professor in Ophthalmology
Dr. Carol L. Karp

Professor of Ophthalmology
Richard K. Foster Chair in Ophthalmology
Dr. Ronald and Alicia Lepke Endowed
Professor in Corneal and External Diseases
University of Miami Miller School of Medicine
Dr. Paul F. Palmberg

University of Miami School of Medicine
Dr. Guillermo Amescua

Associate Professor of Clinical
Ophthalmology
Medical Director of Ocular Surface
Program
University of Miami Miller School of
Medicine
Joint XLIV Inter-American Course in Clinical Ophthalmology (CURSO)

And XXVI Pan-American Regional Course
October 16 – 19, 2022
Apoyo Educativo y Auspiciadores / Educational Supporters and Sponsors
Alcon Vision LLC
Bausch & Lomb Americas, Inc.
Carl Zeiss Meditec, Inc.
Haag Streit
Johnson & Johnson Surgical Vision, Inc.
Optos
Regeneron Pharmaceuticals, Inc.
Roland Consult Stasche & Finger GmbH

Global Center of Ophthalmic Education
Program Schedule
Academic Year 2022-2023
Joint XLIV Inter-American Course in Clinical Ophthalmology and XXVI Pan-American Regional Course
Date: October 16-19, 2022
Location: DoubleTree by Hilton Hotel Miami Airport & Convention Center
Course Directors: Eduardo C. Alfonso, MD
Guillermo Amescua, MD
Carol L. Karp, MD
Paul F. Palmberg, MD, PhD
CME Credits: N/A
Practical Applications of Optical Coherence Tomography Technologies in the Diagnosis and

Management of Ocular Disease
Date: December 3, 2022
Location: The Breakers Palm Beach
Course Co-Directors: Richard K. Lee, MD, PhD
Jorge A. Fortun, MD
Swarup S. Swaminathan, MD
CME Credits: 7.25
Glaucomania 2023: The Saga Continues

Date: January 21, 2023
Location: Bascom Palmer Eye Institute, Berrocal Auditorium
Course Directors: Ta Chen Peter Chang, MD
Sarah R. Wellik, MD
Luis E. Vazquez, MD, PhD
CME Credits: 7.75
Angiogenesis, Exudation, and Degeneration 2023- VIRTUAL EDITION

Date: February 10-11, 2023
Location: Live-streamed
Course Directors: Philip J. Rosenfeld, MD, PhD
Harry W. Flynn, Jr., MD
Thomas A. Albini, MD
CME Credits: 13.0
Interactive Consultations in Cornea, Cataract and Refractive Surgery 2023

Date: February 24-25, 2023
Course Directors: Kendall E. Donaldson, MD, MS
Anat Galor, MD, MSPH
CME Credits: TBD
Bascom Palmer Diagnostic Clinical Ultrasound Course
Date: March 11, 2023
Course Directors: Luis J. Haddock, MD
Zelia M. Correa, MD, PhD
Yale L. Fisher, MD
CME Credits: TBD
The 2023 Nasser Al-Rashid Orbital Research Colloquium

Date: April 29, 2023
Course Directors: David T. Tse, MD
Daniel Pelaez, PhD
CME Credits: N/A
59th Annual Residents’ Days

Date: June 16-17, 2023
Course Directors: Harry W. Flynn, Jr. MD
Steven J. Gedde, MD
CME Credits: TBD
Expositores Comerciales / Exhibitors
Enlace directo al plano al hacer click aqui / click here to link to floorplan
ACM LIGHT, LLC Alcon Vision, LLC

c.fernandez@acmlight.com Alcon.com
Booth(s): 315 Booth(s): n/a
AO Lab (American Ophthalmic Lab) Appasamy Associates

aolabllc@yahoo.com raginikr@aol.com
Booth(s): 120 Booth(s): 220,222,224
Aurolab Aurora Surgical

aurolab@aurolab.com Ljonsson@aurorasurgical.com
Booth(s): 412 Booth(s): 325
Babyeyewear Bascom Palmer Eye Institute

goldenbluevision@yahoo.com kdavila@med.miami.edu
Cambrian Medical Chona Surgical Co.

sales@cambrianmed.com chonasurg@yahoo.co.in
Creative Latin Media (CLM) DELOALTO

mpabon@clatinmedia.com DELOALTOBS@GMAIL.COM
Device Optical Diagnosys, LLC

rmazur@deviceoptical.com agatha@diagnosysllc.com
Booth(s): 419,421 Booth(s): 521
Epsilon EyeKon Medical

msonija@hotmail.com monica@eyekonmedical.com
Booth(s): 301,400 Booth(s): 425
Florida Lions Eye Bank Franja Corporation

efcaraza@med.miami.edu dianarojas@franjapublicaciones.com
Geuder AG Guerra & Guerra INC

mweis@geuder.de oguerra@gueguein.com
Booth(s): 313 Booth(s): 409,411
INTRASEG Italian Eyewear
intraseg.sales@gmail.com eyewear@gate.net
Jaypee Brothers Medical Publishers Johnson & Johnson Surgical Vision, Inc.
sheyla@jphmedical.com Booth(s): E
Booth(s): 121
Katena/Corza Keeler Inc.

kaitlin.nowicki@corza.com sbreen@keelerusa.com
Latam Optical Mayoristas de Opticas, Inc. (MDO)

mportillo@latamoptical.com doralice.gonzalez@gmail.com
Booth(s): 618 Booth(s): 225,324
Medilex LLC Oftalmedia, LLC

rogelio.dossantos@medilexonline.com sales@oftalmedia.com
Booth(s): 512,514 Booth(s): 414
Olleyes Inc Optimetrics, Inc.

fernandezj@olleyes.com amado@optimetrics.com
Booth(s): 305,307 Booth(s): 522,524
Optos Ophthalmological Society of the West Indies

ladams@optos.com (OSWI)
Booth(s): G infoatoswi@gmail.com
Booth(s): 110
PAAO Piazza Optical

terri.grassi@paao.org silvano@piazzaoptical.com
Booth(s): 102 Booth(s): 319,321
Prime Ophthalmic Quantel

primeophthalmic@gmail.com ipiot@quantelmedical.fr
Rocol Roland Consult Stasche & Finger GmbH

ktouchie@rocol.com.co o.stasche@roland-consult.de
Booth(s): 611 Booth(s): H
RUMEX International Co. S4Optik LATAM

i.zagidullina@rumex.com llopez@s4optik.com.mx
Booth(s): 402 Booth(s): 403,405
Segal Optiks Pvt.Ltd. Speedway Surgical Co.
chetan@segal.co.in Sales@speedwaydelhi.com
Booth(s): 119 Booth(s): 418,420
Stallion Medical Inc Star Optical LLC

sales@stallionmed.com staropti@bellsouth.net
Booth(s): 125 Booth(s): 219,221,318,320
Surgi Edge Topcon Healthcare

surgiedge@gmail.com dturner@topcon.com
Booth(s): 415 Booth(s): 309,313
UHealth International Unique Optics

mwirks@med.miami.edu info@uniqueoptics.com
Booth(s): 106 Booth(s): 501,600
Virtual Vision Health Winfame Instruments

matteo@virtualvision.health austinwang@winfameusa.com
RIFA / RAFFLE
El Curso Interamericano se agrada en reconocer a las siguientes empresas por su apoyo a esta
conferencia virtual y su participación en la rifa. El listado en la parte inferior indica los nombres
de las empresas que están participando. Nuestro sistema automatizado estará registrando su
nombre al visitar cada stand virtual y de allí se sacará el ganador de cada empresa. ¡BUENA
SUERTE!
The Inter-American course would like to acknowledge the following companies for their support
of this virtual conference and for their participation in the Exhibitor’s raffle. The list below
includes the participating companies. Our automated system will register your name as you visit
each virtual booth and the winner will be selected from there. GOOD LUCK!
DOMINGO / SUNDAY
Empresa / Company Articulo / Item Precio / Retail Price
Aurora Surgical Gift Certificate $100 USD
Bascom Palmer Eye Institute Free Registration for CURSO 2023 $650 USD
Chona Surgical Cataract surgery set $1,800 USD
Device Optical Keeler Vista Pocket Ophtalmoscope $350 USD
Jaypee Highlights Textbook: Cirugía Refractiva $145 USD
Medilex Volk 3-mirror $442 USD
Slit-lamp smart phone digital
Optimetrics $195 USD
adapter
OSWI Free registration to OSWI 2023 $425 USD
Stallion Medical Stallion Elite Instruments Titanium $150 USD
Surgi Edge Surgical Instrument $100 USD
LUNES / MONDAY
Chona Surgical Cataract Surgery Set $1,800 USD
Jaypee Highlights Textbook: SMILE $125 USD
Medilex Volk 60D $424 USD
Olleyes Gift Card $100 USD
Optimetrics Slit-lamp smart phone digital adapter $195 USD
RIFA / RAFFLE
MARTES / TUESDAY
Chona Surgical Cataract Surgery Set $1,800 USD
Medilex Volk 28D $385 USD
MIERCOLES / WEDNESDAY
Jaypee Highlights Manual Practico $100 USD

Free registration to OSWI 2023
OSWI $433 USD
OSWI polo shirt and mask
SESION CONJUNTA: XLIV CURSO INTERAMERICANO DE OFTALMOLOGIA CLINICA
Y XXVI CURSO REGIONAL PANAMERICANO
DEL 16 AL 19 DE OCTUBRE DE 2022
PROGRAMA
Sujeto a Cambios
Sábado, 15 de octubre de 2022
3:00 – 5:00 pm Inscripción temprana
Domingo, 16 de octubre de 2022
7:50 am Inscripción y desayuno continental
8:50 Palabras de bienvenida

Dr. Eduardo C. Alfonso, Dra. Carol L. Karp y Dr. Paul F. Palmberg, PhD
Cataratas I
Moderador: Dr. Allister G. Gibbons
9:00 Cirugía de glaucoma microinvasiva (MIGS) combinada con cirugía de cataratas

Dr. Juan F. Batlle
9:10 Perdidos en el espacio refractivo

Dr. Ellen Koo
9:20 Cirugía de cataratas combinada y DSO (Denudamiento sólamente de la

membrana de Descemet)
Dr. Paulo E. C. Dantas
9:30 Manejo de una clínica o quirófano de cataratas de alto volumen

Dr. Rahul S. Tonk, MBA
9:40 Mesa redonda

Panel: Dr. Allister G. Gibbons, Dr. Juan F. Batlle, Dr. Rahul S. Tonk, MBA,
Dr. Paulo E. C. Dantas, Dra. Ellen Koo
9:50 Cirugía de cataratas en la córnea irregular

Dra. Neda Shamie
10:00 Cómo maximizar los resultados con los LIO tóricos y algunas consideraciones
especiales
Dr. Allister G. Gibbons
10:10 Diagnóstico y manejo de la iritis idiopática persistente después de cirugía de

cataratas
Dr. Víctor L. Perez
10:20 Mesa redonda

Panel: Dr. Allister G. Gibbons, Dr. Juan F. Batlle, Dra. Neda Shamie, Dra. Victoria
Chang, Dr. Víctor L. Perez
Tomografía de coherencia óptica (OCT)

Moderador: Dr. Richard K. Lee, PhD
10:30 Introducción
Dr. Richard K. Lee, PhD
10:33 Fundamentos de la imagenología neurooftalmológica

Dr. Carlos E. Mendoza
10:53 Fundamentos de imagenología para el diagnóstico y tratamiento del glaucoma

Dr. Luis E. Vazquez, PhD
11:13 Fundamentos de imagenología en enfermedades de la retina

Dr. Jorge A. Fortun
11:33 Imagenología en enfermedad de los párpados

Dr. Miguel N. Burnier
11:43 Imagenología en enfermedad del segmento anterior

Dra. Carol L. Karp
11:53 Preguntas y respuestas
12:00 pm Fotografía del grupo
12:30 Visita a los exhibidores/Almuerzo
Retina I
Moderador: Dr. William E. Smiddy
2:00 Vitrectomía en casos de edema macular diabético que no responde a la terapia

medicamentosa: ¿Es la cirugía beneficiosa?
Dr. J. Fernando Arevalo, PhD, FACS, FASRS
2:15 ¿Qué papel juegan las nuevas terapias?
Dra. Raquel Goldhardt, FACS
2:30 Estado actual del tratamiento de la retinopatía diabética

Dr. Harry W. Flynn, Jr.
2:45 Nueva información sobre las membranas epirretinianas

Dr. William E. Smiddy
3:00 Ronda clínica

Moderador: Dr. William E. Smiddy
Panel: Dr. J. Fernando Arevalo, PhD, FACS, FASRS, Dra. Raquel Goldhardt, FACS,
Dr. Harry W. Flynn, Jr. y Dr. Luis J. Haddock
3:30 Receso
Retina II
Moderador: Dr. Luis J. Haddock
4:00 Retinocoroiditis por toxoplasma

Dr. Miguel Burnier, M.Sc., PhD, FRCSC
4:15 Retinopexia neumática y nuevas terapias en el manejo de la retinopatía

diabética
Dr. Nicolas A. Yannuzzi
4:30 Pros y contras en el manejo de los puntos flotantes en el vítreo

Dr. Jayanth Sridhar
4:45 Actualización en el manejo de la retinopatía drepanocítica

Dr. Luis J. Haddock
5:30 Ceremonia de apertura y rifa
Lunes, 17 de octubre de 2022
7:00 am Desayuno continental
8:00 Videos de glaucoma

Glaucoma I
Moderador: Dr. Paul F. Palmberg, PhD
9:00 Nuevos resultados con el uso de ciclofotocoagulación en glaucoma

Dr. Richard K. Lee, PhD
9:20 Conferencia magistral en memoria del Dr. Francisco E. Fantes

Inteligencia artificial en glaucoma: Guía para para clínicos pensantes
Dr. Felipe Medeiros, PhD
10:00 Pros y contras de la telemedicina en glaucoma

Dra. Alana Grajewski
10:30 Receso
Glaucoma II
Moderadora: Dra. Elena Bitrian
11:00 Glaucoma y envejecimiento

11:20 Avances emergentes en glaucoma

Dr. David S. Greenfield
11:40 Cuestiones prácticas para detectar la progresión del glaucoma

12:00 Los expedientes X – Casos de los que aprendemos
Córnea y enfermedades externas

Moderador: Dr. Guillermo Amescua
2:00 Introducción
2:05 Cómo mejorar los resultados de la queratoplastia endotelial

Dr. Neda Shamie
2:15 Queratopatía tóxica central (CTK), queratitis estromal intralamelar inducida por
presión (PISK), queratoplastia endotelial lamelar profunda (DLEK): diagnóstico,
tratamiento y prevención de problemas corneales
2:25 Inmunología del transplante corneal:
¿Cómo maximizar la supervivencia del injerto?
2:35 Casos clínicos/mesa redonda

Caso 1: Queratitis infecciosa
Caso 2: Transplante de córnea
Caso 3: Inmunología de la córnea
Caso 4: Ectasia corneal
Caso 5: Distrofia corneal
3:30 Receso
Simposio de enfermedades de la superficie ocular

Moderador: Dr. Alfonso L. Sabater, PhD
4:00 Introducción
Dr. Alfonso L. Sabater, PhD
4:05 Manejo de pacientes con enfermedad de ojo seco que no responden al

tratamiento
4:15 Caso 1: Deficiencias sistémicas

Case 2: Enfermedades oculocutáneas
4:35 La función de los mecanismos neuropáticos en la enfermedad de ojo seco

Dr. Anat Galor
4:45 Caso 3: Dolor sin puntilleo

Caso 4: Puntilleo sin dolor
5:05 Síndrome de Stevens‐Johnson: La historia sin fin

5:15 Caso 5: Quemaduras oculares

Caso 6: Lentes de contacto especializados
5:30 Rifa
Martes, 18 de octubre, 2022
8:00 Videos de cataratas

Cirugía Refractiva I
Moderadora: Dra. Kendall E. Donaldson, MS
9:00 Error refractivo residual después de cirugía de cataratas: ¿Y ahora qué?

Dra.Neda Shamie
9:10 Cirugía de cataratas después de queratotomía radial

Dr. William W. Culbertson, IV
9:20 Nuestra experiencia y resultados con la extracción lenticular por incisión

pequeña (SMILE)
Dr. Juan F. Batlle
9:30 Mesa redonda
9:45 Problemas comunes después de LASIK y cómo arreglarlos

9:55 Evaluación diagnóstica de la calidad de las imágenes

Dra.Kendall E. Donaldson, MS
10:05 El paciente insatisfecho: Cuando los lentes intraoculares de tecnología avanzada

(ATIOLS) no cumplen su cometido
Dra. Neda Shamie
10:15 Mesa Redonda
10:30 Receso
Cirugía refractiva II: Casos clínicos y mesa redonda

Moderador: Dr. Rahul S. Tonk, MBA
11:00 Cómo sobreponerse a un astigmatismo de pesadilla

Dra. Kendall E. Donaldson, MS
11:15 Hidropesía en el ojo post‐LASIK: ¿Qué hacer?

Dra. Neda Shamie
11:30 Estado actual de los lentes intraoculares multifocales

Dra. Kendall E. Donaldson, MS
11:45 Lentes de contacto implantables (ICL) peliagudos y pegajosos

Dr. Juan F. Batlle
12:00 Láseres y queratoplastia lamelar
Dra. Florence Cabot
12:15 El paciente insatisfecho con su LIO fotoajustable(LAL): ¿Y ahora qué?

Dra. Neda Shamie
Cataratas II
Moderador: Dr. Jaime D. Martinez
2:00 Situaciones especiales durante la facoemulsificación. ¿Qué hacer cuando…?

Dr. Juan F. Batlle
2:10 Cirugía de cataratas en pacientes con carcinoma escamoso de la superficie

ocular
Dra. Carol L. Karp
2:20 Manejo de la disfotopsia

2:30 Mesa redonda

Panel: Dr. Jaime D. Martinez, Dr. Juan F. Batlle, Dr. Carol L. Karp,
Dr. Rahul S. Tonk, MBA, Dr. Guillermo Amescua, Dr. Zubair Ansari,
Dra. Neda Shamie y Dra. Florence Cabot
2:40 Cirugía de cataratas en pacientes con enfermedad severa de la superficie ocular

2:50 Comparación entre facoemulsificadores

Dr. Zubair Ansari
3:00 El arte de encontrar el LIO perfecto en cirugía de cataratas

Dra. Neda Shamie
3:10 Presentación de un caso clínico de cirugía de cataratas

Dra. Florence Cabot
3:20 Mesa redonda

Panel: Dr. Jaime D. Martinez, Dr. Juan F. Batlle, Dra. Carol Karp,
Dr. Rahul S. Tonk, MBA, Dr. Guillermo Amescua, Dr. Ansari Zubair,
Dra. Neda Shamie y Dra. Florence Cabot.
3:30 Receso
Simposio de oftalmología pediátrica
Moderadora: Dra. Hilda Capo
Problemas en el paraíso pediátrico
4:00 Introducción
4:01 Retos en las pruebas genéticas para enfermedades hereditarias de la retina y el

nervio óptico
4:09 Problemas del segmento anterior y posterior

Dra Audina M. Berrocal
4:17 Problemas del segmento anterior pediátrico I

Dra. Angela Y. Zhu
4:25 Problemas del segmento anterior pediátrico II

Dr. Ta Chen Peter Chang
4:33 Problemas de trauma ocular en pediatría

Dra. Kara M. Cavuoto
4:41 Problemas con el trauma de los músculos oculares

Dra. Hilda Capo
4:49 Presentación de la oradora invitada, Dra. Angela M. Fernández

Dra. Hilda Capo
4:51 Problemas del párpado pediátrico

Dra. Angela M. Fernandez
4:59 Problemas con el manejo de la ambliopía

Dra. Michelle Falcone
5:07 Dilemas en el control de la miopía: MiSight ó Atropina al 0.01 y al 0.05%

Dr. Roberto Warman

Panel
5:30 Rifa
7:00 La fiesta: Coctel y baile

Miércoles, 19 de octubre, 2022
Simposio de oculoplastia
Moderador: Dr. Thomas E. Johnson
8:00 Casos difíciles de oculoplastia: Presentaciones de los fellows con mesa redonda
de profesores
9:00 Casos difíciles en oftalmopatía tiroidea

Dra. Sara T. Wester, FACS
9:13 Perlas en blefaroplastia del párpado inferior

Dr. Nathan W. Blessing
9:26 Perlas en blefaroplastia del párpado superior

Dr. Chris R. Alabiad
9:39 Reparación de defectos óseos orbitarios complejos

Dr. Thomas E. Johnson
9:52 Actualización en carcinoma quístico adenoide de la glándula lagrimal

Dr. David T. Tse
10:05 Reconstrucción palpebral de Moh

Dr. Brian C. Tse
10:30 Receso
Oncología ocular
Moderadora: Dra. Carol L. Karp
11:00 Tumores de la conjuntiva

Dra. Carol L. Karp
11:10 Linfoma intraocular

Dr. Miguel N. Burnier, Jr. MSc, PhD
11:20 Nuevos tratamientos del hemangioma coroideo

Dra. Zelia M. Correa, PhD
11:30 Tumores orbitarios

Dr. Sander R. Dubovy
11:40 Tratamientos del melanoma uveal más allá del ojo
Dra. Zelia M. Correa, PhD
11:50 Biopsias tradicionales, líquidas y ópticas

Dr. Miguel N. Burnier, Jr. MSc, PhD
12:05 Más sobre tumores de la conjuntiva

Dra. Carol L. Karp
12:15 Mesa redonda
Simposio de uveítis
Moderadora: Dra. Raquel Goldhardt, FACS
2:00 Ojo y riñón: ¿Cuál es la conexión?

Dr. Anat Galor, MSPH
2:12 Síntomas oftálmicos en COVID

Dra. Raquel Goldhardt, FACS
2:24 Síndrome de Susac

Dr. Janet L. Davis
2:36 Abordaje multidisciplinario en el tratamiento de la uveítis idiopática juvenil

2:48 Controversia en el manejo de la necrosis retiniana aguda

Dr. Thomas A. Albini
3:00 Complicaciones del segmento posterior de la uveítis

Dr. J. Fernando Arévalo, PhD, FACS, FASRS
3:30 Receso
Neurooftalmología
Moderador: Dr. Carlos E. Mendoza
Casos difíciles en neurooftalmología
4:00 Palabras de bienvenida

4:05 Caso difícil de neurooftalmología II
Dr. Hong Jiang
4:17 Caso difícil de neurooftalmología III

Dr. Mariam Vila Delgado
4:29 Caso difícil de neurooftalmología IV

4:41 Caso difícil de neurooftalmología V + Actualización sobre terapia genética en

neuropatía óptica hereditaria de Leber (LHON)
Dr. Byron L. Lam
Simposio de telemedicina y oftalmología global

Moderadores: Dr. Zubair Ansari y Dra. Giselle Ricur, MBA, MSc, FATA
5:10 Cuidado virtual de los ojos en tiempos inciertos: un abordaje práctico

Dra. Giselle Ricur, MBA, MSc, FATA
5:20 Un despertar global ‐ Tendencias en la oftalmología global

Dr. Zubair Ansari
5:30 Rifa
JOINT XLIV INTER-AMERICAN COURSE IN CLINICAL OPHTHALMOLOGY (CURSO)
AND XXVI PAN-AMERICAN REGIONAL COURSE
OCTOBER 16-19, 2022
PROGRAM
Subject to Change
Saturday, October 15, 2022
3:00 – 5:00 pm Early Registration
Sunday, October 16, 2022
7:50 am Registration and Continental Breakfast
8:50 Welcome Remarks

Eduardo C. Alfonso, MD, Carol L. Karp, MD, and Paul F. Palmberg, MD, PhD
Cataract I
Moderator: Allister G. Gibbons, MD
9:00 MIGS Combined with Cataract Surgery

Juan F. Batlle, MD
9:10 Going Down the Refractive Rabbit Hole

Ellen Koo, MD
9:20 Combined Cataract Surgery and DSO

Paulo E. C. Dantas, MD
9:30 Running a High-volume Cataract Clinic/OR?

Rahul S. Tonk, MD, MBA
9:40 Panel Discussion

Panel: Allister G. Gibbons, MD, Juan F. Batlle, MD, Rahul S. Tonk, MD, MBA,
Paulo E. C. Dantas, MD, Ellen Koo, MD
9:50 Cataract Surgery in the Irregular Cornea

Neda Shamie, MD
10:00 Maximizing Toric IOL Outcomes and Some Special Considerations

Allister G. Gibbons, MD
10:10 Diagnosis and Management of Idiopathic Persistent Iritis after Cataract Surgery
Victor L. Perez, MD

Panel: Allister G. Gibbons, MD, Juan F. Batlle, MD, Neda Shamie, MD, Victoria
Chang, MD, Victor L. Perez, MD
Optical Coherence Tomography (OCT)

Moderator: Richard K. Lee, MD, PhD
10:30 Introduction
Richard K. Lee, MD, PhD
10:33 Primer on Neuro-ophthalmologic Imaging

Carlos E. Mendoza, MD
10:53 Primer on Imaging for Glaucoma Diagnosis and Treatment

Luis E. Vazquez, MD, PhD
11:13 Primer on Imaging for Retinal Diseases

Jorge A. Fortun, MD
11:33 Imaging for Eyelid Disease

Miguel N. Burnier, MD
11:43 Imaging for Anterior Segment Disease

Carol L. Karp, MD
11:53 Questions and Answers
12:00 pm Group Photograph
12:30 Exhibits/Lunch
Retina I
Moderator: William E. Smiddy, MD
2:00 Vitrectomy for DME Unresponsive to Pharmacologic Therapy – Is Surgery

Beneficial?
J. Fernando Arevalo, MD, PhD, FACS, FASRS
2:15 What is the Role of New Therapies?

Raquel Goldhardt, MD, FACS
2:30 Current Status of Treatment of DR

Harry W. Flynn, Jr., MD
2:45 What is New in ERMs
William E. Smiddy, MD
3:00 CURSO Clinic

Moderator: William E. Smiddy, MD
Panel: J. Fernando Arevalo, MD, PhD, FACS, FASRS, Raquel Goldhardt, MD, FACS,
Harry W. Flynn, Jr., MD, and Luis J. Haddock, MD
3:30 Refreshment Break
Retina II
Moderator: Luis J. Haddock, MD
4:00 Toxoplasma Retinochoroiditis

Miguel Burnier MD, M.Sc., PhD, FRCSC
4:15 Pneumatic Retinopexy and new therapies for management of RD

Nicolas A. Yannuzzi, MD
4:30 Management of Vitreous Floaters Pros and Cons

Jayanth Sridhar, MD
4:45 Update on the Management of Sickle Cell Retinopathy

Luis J. Haddock, MD
5:30 Opening Ceremony and Raffle
Monday, October 17, 2022
7:00 am Continental Breakfast
8:00 Glaucoma Videos
Glaucoma I
Moderator: Paul F. Palmberg, MD, PhD
9:00 New Results on Cyclophotocoagulation in Glaucoma

9:20 Francisco E. Fantes, MD Distinguished Lecture

Artificial Intelligence in Glaucoma: A Guide for Thinking Clinicians
Felipe Medeiros, MD, PhD
10:00 The Promise and the Problems with Telehealth in Glaucoma

Alana Grajewski, MD
Glaucoma II
Moderator: Elena Bitrian, MD
11:00 Glaucoma and Aging

11:20 Emerging Breakthroughs in Glaucoma

David S. Greenfield, MD
11:40 Practical Questions on Detecting Glaucoma Progression

12:00 The X-Files – Cases that Teach
Cornea and External Diseases

Moderator: Guillermo Amescua, MD
2:00 Introduction
2:05 Improving Outcomes in Endothelial Keratoplasty

Neda Shamie, MD
2:15 CTK, PISK, DLEK: Diagnosing, Treating

and preventing the Ks
2:25 Immunology of Corneal Transplantation:

How to Maximize Graft Survival?
Victor L. Perez, MD
2:35 Clinical Cases/Discussion

Case 1: Infectious Keratitis
Case 2: Corneal Transplantation
Case 3: Corneal Immunology
Case 4: Corneal Ectasia
Case 5: Corneal Dystrophy

Ocular Surface Diseases Symposium
Moderator: Alfonso L. Sabater, MD, PhD
4:00 Introduction
Alfonso L. Sabater, MD, PhD
4:05 Management of Non-Responding Dry Eye Disease Patients

Victor L. Perez, MD
4:15 Case 1: Systemic Deficiencies

Case 2: Oculocutaneous Disorders
4:35 The Role of Neuropathic Mechanisms in Dry Eye Disease

Anat Galor, MD
4:45 Case 3: Pain without Stain

Case 4: Stain without Pain
5:05 Stevens-Johnson Syndrome: A Never-ending Story

5:15 Case 5: Ocular Burns

Case 6: Specialty Contact Lenses
5:30 Raffle
Tuesday, October 18, 2022
8:00 Cataract Videos
Refractive Surgery I
Moderator: Kendall E. Donaldson, MD, MS
9:00 Residual Refractive Error Post Cataract Surgery: Now What?

Neda Shamie, MD
9:10 Cataract Surgery after Previous RK

William W. Culbertson, IV, MD
9:20 Our Experience and Outcomes with SMILE

Juan F. Batlle, MD
9:30 Discussion
9:45 Common Problems after LASIK and How to Fix Them
9:55 Diagnostic Assessment of Image Quality

Kendall E. Donaldson, MD, MS
10:05 The Unhappy Patient: When ATIOLS Are a Miss

Neda Shamie, MD
10:15 Discussion
Refractive Surgery II: Clinical Cases and Discussion

Moderator: Rahul S. Tonk, MD, MBA
11:00 Overcoming an Astigmatism Nightmare

11:15 Hydrops in a Post LASIK Eye: What to Do?

Neda Shamie, MD
11:30 Current State of Multifocal Intraocular Lenses

11:45 A Tricky, Sticky ICL

Juan F. Batlle, MD
12:00 Lasers and Lamellar Keratoplasty

Florence Cabot, MD
12:15 An Unhappy LAL Patient: Now What?

Neda Shamie, MD
Cataract II
Moderator: Jaime D. Martinez, MD
2:00 Special Situations in Phacoemulsification Surgery. What Should You Do If?

Juan F. Batlle, MD
2:10 Cataract Surgery in Patients with Ocular Surface Squamous Carcinoma

Carol L. Karp, MD
2:20 Management of Dysphotopsia

Panel: Jaime D. Martinez, MD, Juan F. Batlle, MD, Carol L. Karp, MD,
Rahul S. Tonk, MD, MBA, Guillermo Amescua, MD, Zubair Ansari, MD,
Neda Shamie, MD, and Florence Cabot, MD
2:40 Cataract Surgery in Patients with Severe Ocular Surface Disease

2:50 Comparing Phacoemulsification Machines

Zubair Ansari, MD
3:00 The Art of Matchmaking in Cataract Surgery

Neda Shamie, MD
3:10 Clinical Case Cataract Surgery

Florence Cabot, MD

Panel: Jaime D. Martinez, MD, Juan F. Batlle, MD, Carol Karp, MD,
Rahul S. Tonk, MD, MBA, Guillermo Amescua, MD, Ansari Zubair, MD,
Neda Shamie, MD, and Florence Cabot, MD
Pediatric Ophthalmology Symposium

Moderator: Hilda Capo, MD
Problems in Pediatric Paradise
4:00 Introduction
4:01 Challenges in Genetic Testing for Inherited Retinal and Optic Nerve Diseases
4:09 Problems in Anterior and Posterior Segment

Audina M. Berrocal, MD
4:17 Problems in Pediatric Anterior Segment I

Angela Y. Zhu, MD
4:25 Problems in Pediatric Anterior Segment II

Ta Chen Peter Chang, MD
4:33 Problems in Pediatric Eye Trauma

Kara M. Cavuoto, MD
4:41 Problems in Ocular Muscle Trauma
Hilda Capo, MD
4:49 Introduction of Invited Speaker: Dr. Angela M. Fernandez

Hilda Capo, MD
4:51 Problems in Pediatric Eyelids

Angela M. Fernandez, MD
4:59 Problems in Amblyopia Management

Michelle Falcone, MD
5:07 Dilemmas in Myopia Control: MiSight versus Atropine 0.01 and 0.05%
Roberto Warman, MD

Panel
5:30 Raffle
7:00 “La Fiesta” Cocktail Reception and Dance
Wednesday, October 19, 2022
Oculoplastics Symposium
Moderator: Thomas E. Johnson, MD
8:00 Challenging Oculoplastic Cases: Fellow Presentations with Faculty Discussions
9:00 Challenging Thyroid Eye Disease Cases

Sara T. Wester, MD, FACS
9:13 Lower Eyelid Blepharoplasty Pearls

Nathan W. Blessing MD
9:26 Upper Eyelid Blepharoplasty Pearls

Chris R. Alabiad, MD
9:39 Repairing Complex Orbital Bony Defects

Thomas E. Johnson, MD
9:52 Update on Adenoid Cystic Carcinoma of the Lacrimal Gland
David T. Tse, MD
10:05 Moh’s Eyelid Reconstruction

Brian C. Tse, MD
Ocular Oncology
Moderator: Carol L. Karp, MD
11:00 Conjunctival Tumors

Carol L. Karp. MD
11:10 Intraocular Lymphoma

Miguel N. Burnier, Jr. MSc, PhD
11:20 New Treatments for Choroidal Hemangioma

11:30 Orbital Tumors

Sander R. Dubovy, MD
11:40 Treatments for Uveal Melanoma Beyond the Eye

11:50 Traditional, Liquid, and Optical Biopsies

Miguel N. Burnier, Jr. MSc, PhD
12:05 More on Conjunctival Tumors

Carol L. Karp, MD
12:15 Discussion
Uveitis Symposium
Moderator: Raquel Goldhardt, MD, FACS
2:00 The Eye and the Kidney: What’s the Connection?

2:12 COVID Eye

2:24 Susac Syndrome

Janet L. Davis, MD
2:36 A Multi-Disciplinary Approach for the Treatment of Juvenile Idiopathic Uveitis
Victor L. Perez, MD
2:48 Controversy in the Management of ARN (Acute Retinal Necrosis)

3:00 Posterior Segment Complications of Uveitis

Neuro-Ophthalmology
Moderator: Carlos E. Mendoza, MD
Challenging Cases in Neuro-Ophthalmology
4:00 Opening Remarks

4:05 Challenging Case in Neuro-Ophthalmology II

Hong Jiang, MD
4:17 Challenging Case in Neuro-Ophthalmology III

Mariam Vila Delgado, MD
4:29 Challenging Case in Neuro-Ophthalmology IV

4:41 Challenging Case in Neuro-Ophthalmology V + Update in LHON Gene Therapy

Byron L. Lam, MD
Telehealth and Global Ophthalmology Symposium

Moderators: Zubair Ansari, MD and Giselle Ricur, MD, MBA, MSc, FATA
5:10 Virtual Eyecare in Times of Uncertainty: A Practical Approach

Giselle Ricur, MD, MBA, MSc, FATA
5:20 A Global Awakening - Trends in Global Ophthalmology

Zubair Ansari, MD
5:30 Raffle
Guest Faculty / Conferencistas Invitados

Chairman of Ophthalmology
Johns Hopkins Bayview Medical Center
Edmund F. and Virginia B. Ball Professor of Ophthalmology
The Wilmer Eye Institute-Johns Hopkins University School of Medicine
Baltimore, MD, USA
Chair, Pan-American Ophthalmological Foundation
Juan F. Batlle, MD
Chief of Ophthalmology, Dr. Elias Santana Hospital
President, Laser Center
Santo Domingo, Dominican Republic
Voluntary Associate Professor
Bascom Palmer Eye Institute, Miami, FL
Miguel N. Burnier, Jr., MSc, PhD, FRCSC, FARVO

Director, Training & Development, RI-MUHC
Professor of Ophthalmology, Pathology, Medicine, Oncology, and Surgery
Director, The MUHC-McGill University Ocular Pathology & Translational Research Laboratory
McGill University
Montreal, Canada
Immediate Past President, Pan-American Association of Ophthalmology (PAAO)
Paulo E.C. Dantas, MD, PhD

President, 2022-2025, Pan-American Association of Ophthalmology
Editor-in-Chief, The Pan-American Journal of Ophthalmology
Clinical and Surgical Cornea and External Disease
Oftalmologistas Asociados of São Paulo and Sorocaba Eye Hospital
Angela Maria Fernandez, MD

Chief, Pediatric Ophthalmology and Strabismus, Central Military Hospital
Professor of Ophthalmology Nueva Granada Military University
Associated Ophthalmologist, Fundación Santa Fe de Bogota
Professor of Ophthalmology, University Los Andes
Bogota, Colombia
Felipe A. Medeiros, MD, PhD

Joseph A.C. Wadsworth Distinguished Professor of Ophthalmology
Professor in the Department of Electrical and Computer Engineering
Professor of Biostatistics & Bioinformatics
Duke University
Durham, NC, USA
Victor L. Pérez, MD
Stephen and Frances Foster Distinguished Professor of
Ocular Immunology and Inflammation
Duke University School of Medicine
Durham, NC, USA
Neda Shamie, MD
Maloney-Shamie Vision Institute
Los Angeles, CA, USA
Roberto Warman, MD
Director, Division of Ophthalmology
Nicklaus Children’s Hospital
Miami, FL, USA
Voluntary Assistant Professor
Bascom Palmer Eye Institute, Miami, FL
Bascom Palmer Eye Institute Faculty / Profesorado
Chris R. Alabiad, MD
Professor of Clinical Ophthalmology
Zubair Ansari, MD
Assistant Professor of Clinical Ophthalmology
Audina M. Berrocal, MD
Elena Bitrian, MD
Associate Professor of Clinical Ophthalmology
Nathan W. Blessing, MD
Florence Cabot, MD
Hilda Capo, MD
John T. Flynn Chair in Ophthalmology
Kara M. Cavuoto, MD
Ta Chen Peter Chang, MD


William W. Culbertson, IV, MD

Lou Higgins Chair in Ophthalmology
Janet L. Davis, MD
Leach Chair in Ophthalmology

Sander R. Dubovy, MD
Victor T. Curtin Chair in Ophthalmology
Michelle Falcone, MD
Harry W. Flynn, Jr. MD

J. Donald M. Gass Chair in Ophthalmology
Jorge A. Fortun, MD

Allister G. Gibbons, MD

Alana L. Grajewski, MD
Kolokotrones Endowed Chair in Ophthalmology
Douglas R. Anderson Chair in Ophthalmology
Luis J. Haddock, MD
Hong Jiang, MD, PhD

Ellen Koo, MD
Byron L. Lam, MD
Robert Z. & Nancy J. Greene Chair in Ophthalmology

Associate Professor of Ophthalmology
Walter g. Ross Distinguished Chair in Ophthalmic Research
Jaime D. Martinez, MD
Giselle Ricur, MD
Executive Director, Virtual Care
Alfonso L. Sabater, MD, PhD

Assistant Professor of Ophthalmology
William E. Smiddy, MD
M. Brenn Green Chair in Ophthalmology
Jayanth Sridhar, MD
Rahul S. Tonk, MD
Brian C. Tse, MD
David T. Tse, MD
Dr. Nasser Ibrahim Al-Rashid Chair in Ophthalmology
Luis Vazquez, MD, PhD

Mariam Vila Delgado, MD

Neuro-Ophthalmology Fellow
Sara T. Wester, MD. FACS

Nicolas A. Yannuzzi, MD
Angela Y. Zhu, MD
TELEOFTALMOLOGIA / TELEMEDICINE
(Sesión Opcional / Optional Track)
TeleOftalmología en Tiempos de Incertidumbre: Un Enfoque Práctico

Virtual Eyecare in Times of Uncertainty: A Practical Approach
Lunes, 17 de Octubre de 2022 / Monday, October 17, 2022
12:30 pm – 2:00 pm
Ubicación / Location:
MACC 1, 2nd Floor, DoubleTree by Hilton Hotel Miami Airport and Convention Center
Coordinadora y Moderadora / Course Coordinator and Moderator:

Executive Director, Virtual Care, Bascom Palmer Eye Institute, University of Miami
Conferencistas Invitados / Guest Faculty:
Alexandre Chater Taleb, MD, PhD

Hospital de Olhos de Aparecida de Goiânia/GO, Goias, Brasil
Kim Grinfeder, PhD

Director of the Interactive Media Program
University of Miami, Miami, Florida
Profesorado / Bascom Palmer Eye Institute Faculty:
Mohamed Abou Shousha, MD, PhD

Florence Cabot, MD
Alana L. Grajewski, MD
Professor of Clinical Ophthalmology, Kolokotrones Endowed Chair in Ophthalmology
Director, Samuel & Ethel Balkan International Pediatric Glaucoma Center
Natalie Townsend, OD
Sonia H. Yoo, MD
Professor of Ophthalmology, Greentree Hickman Chair in Ophthalmology
PROGRAMA
Sujeto a Cambios
12:30 pm Introducción: Teleoftalmología ¿dónde estamos ahora?

12:40 ¿Cuáles son los desafíos más importantes?
Sonia H. Yoo, MD y Natalie Townsend, OD
12:50 ¿Qué estrategias podemos implementar para mitigar los desafíos?
Alana L. Grajewski, MD y Carlos E. Mendoza-Santiesteban, MD
1:00 Tecnologías Disruptivas Aplicadas
Florence Cabot, MD, and Mohamed Abou Shousha, MD, PhD
1:10 Nuevos Modelos de Atención en Salud Visual
1:20 Llegando a los que más nos necesitan
1:30 Nuevos Paradigmas en Educación Médica:
El Metaverso mas allá de la Nueva Normalidad
Kim Grenfeder, MSc
1:45 Sesión de Preguntas y Respuestas
2:00 Cierre
PROGRAM
Subject to Change
12:30 pm Introduction: Teleophthalmology, Where Are We Now?

12:40 What Are the Current Challenges?
Sonia H. Yoo, MD and Natalie Townsend, OD
12:50 What Strategies Can We Use to Mitigate the Challenges?
Alana L. Grajewski, MD and Carlos E. Mendoza, MD
1:00 Levering Off Disruptive Technologies
Florence Cabot, MD, and Mohamed Abou Shousha, MD, PhD
1:10 New Delivery Modalities for Eye Care
1:20 Reaching Out to Those that Need Us the Most
1:30 New Paradigms in Medical Education:
The Metaverse Beyond the New Normal
Kim Grinfeder, PhD
2:00 Adjourn
ELECTROFISIOLOGIA / ELECTROPHYSIOLOGY
(Sesión Opcional / Optional Track)
La Electrofisiología Visual en los Tiempos de la Terapia de Genes

Martes 18 de octubre de 2022 / Tuesday, October 18, 2022
8:00 am – 4:00 pm
Ubicación / Location:
MACC 1, 2nd Floor, DoubleTree by Hilton Hotel Miami Airport and Convention Center
Coordinador y Moderador / Course Coordinator and Moderator:
Bascom Palmer Eye Institute, University of Miami
Conferencista Invitado / Guest Speaker:
Thomas R. Hedges III, M.D.

Professor of Ophthalmology and Neurology
Tufts University
Director of Neuro-ophthalmology
New England Eye Center
Boston, MA, USA
Conferencistas del Bascom Palmer Eye Institute / Speakers
Tamara Juvier, MD
Maja Kostic, MD
Byron L. Lam, MD
Robert Z. & Nancy J. Greene Chair in Ophthalmology
PROGRAMA
Sujeto a cambios
8:00 am Comentarios de Apertura

Sesión I: La electrofisiología visual no es tan complicada;

solo se necesita entender algunos principios básicos
8:05 Generalidades, modalidades, técnicas de registro, resultados normales, correlación con

autofluorescencia retinal y tomografía de coherencia óptica
Sesión II: Explorando la retina: Electrorretinograma (ERG) de campo completo,

ERG multifocal (mfERG) y electrooculograma (EOG)
8:45 ERG de campo completo

Dr. Byron L. Lam
9:10 ERG multifocal y EOG

Dr. Byron L. Lam
9.30 Presentación de Casos

Dr. Byron L. Lam, Dr. Carlos E. Mendoza, y Dra. Maja Kostic
9.55 Discusión
10:00 Estudios multicéntricos de terapia génica para enfermedades retinales hereditarias

Dr. Byron L. Lam
10:30 Receso
Sesión III: ¿Y qué acerca del resto de la vía visual? ERG a patrón (ERGp), Potencial Evocado Visual (PEV),
agudeza visual objetiva (SWEEP PEV) y campo visual objetivo (PEVmf)
11:00 ERG a Patrón

Dra. Tamara Juvier
11:15 PEV a flash, PEV a patrón, Sweep PEV y PEV Multifocal

11.55 Discusión
12.00 pm Presentación de Casos

Dra. Tamara Juvier, Dra. Maja Kostic y Dr. Carlos E. Mendoza
12:30 Almuerzo con los expertos: Preguntas y respuestas durante el almuerzo

Expertos: Dr. Byron L. Lam, Dra. Tamara Juvier, Dra. Maja Kostic y
1.30 Curso práctico
4.00 Clausura
PROGRAM
Subject to change
8:00 am Opening Remarks

Session I: Visual Electrophysiology Is Not That Complicated:

You Only Need to Understand Some Basic Principles
8:05 Overview, Testing Modalities, Recording Techniques, Normal Results

Correlation with AF and OCT
Session II: Exploring the Retina: Full Field ERG, Multifocal ERG, and EOG
8:45 Full-Field ERG

Byron L. Lam, MD
9:10 Multifocal ERG and EOG

Byron L. Lam, MD
9.30 Case Presentations

Byron L. Lam MD, Carlos E. Mendoza MD, and Maja Kostic, MD
9.55 Discussion
10:00 Current Clinical Trials of Gene Therapy for Inherited Retinal Diseases
Byron L. Lam, MD
Session III: What About the Rest of the Visual Pathway?

PERG, VEP, Objective Visual Acuity (Sweep VEP), and Objective Visual Field (mfVEP)
11:00 Pattern ERG

Tamara Juvier, MD
11:15 Flash VEP, Pattern VEP, Sweep VEP, and Multifocal VEP
11.55 Discussion
12.00 pm Case Presentations

Tamara Juvier, MD, Maja Kostic, MD, and Carlos E. Mendoza, MD
12:30 Lunch with The Experts:

Questions and Answers during lunch
Experts: Byron L. Lam, MD, Tamara Juvier, MD, and Carlos E. Mendoza, MD
1.30 Hands-on Course
4:00 Adjourn
Conferencias / Presentations
Dr. Allister G. Gibbons
Allister G. Gibbons, MD and Victoria Chang, MD
Título: Cómo maximizar los resultados de las lentes intraoculares tóricas y algunas
consideraciones especiales
En esta presentación se tratarán las estrategias para optimizar los resultados de la cirugía de
cataratas en pacientes con astigmatismo que usan lentes intraoculares (LIO) tóricas. Los temas
que se abordarán son la determinación de la orientación y la potencia tórica, la selección de
candidatos idóneos para las LIO tóricas, el astigmatismo en la superficie posterior de la córnea,
cómo minimizar la rotación postoperatoria y cuánta rotación postoperatoria debería dar lugar a
una corrección.
Title: Maximizing Toric IOL Outcomes and Some Special Considerations
In this presentation, strategies to optimize the outcomes of cataract surgery in patients with
astigmatism using toric intraocular lenses (IOLs) will be discussed. Topics to be addressed
include determination of toric power and orientation, selection of good candidates for toric
IOLs, astigmatism of the cornea’s posterior surface, how to minimize postoperative rotation,
and how much postoperative rotation should trigger a correction.
Dr. Miguel N. Burnier, Jr.
Bergeron S, Miyamoto D, Sanft DM, et al. Novel application of anterior segment optical coherence
tomography for periocular imaging. Canadian journal of ophthalmology Journal canadien
d'ophtalmologie. 2019;54(4):431-437
Bergeron S, Arthurs BA, Sanft DM, et al. Optical coherence tomography of peri-ocular skin
cancers: an optical biopsy. Ocul Oncol Pathol. 2021; 7(2): 149-158.
IMAGING FOR EYELID DISEASE:

OPTICAL BIOPSIES
Miguel N. Burnier Jr., MD, PhD, FRCSC

Director, Training & Development, MUHC‐RI
Professor of Ophthalmology, Pathology, Medicine, Oncology, Surgery
Chair, Department of Ophthalmology (1993‐2008)
Director, The MUHC‐McGill University Ocular Pathology & Translational Research Laboratory
Editor‐in‐Chief, Emeritus, CJO
Past‐President, PAAO
Member of Executive Board, PAAO
Member, AOI Chair# XLV OCT imaging to assess peri‐ocular skin
FARVO, Fellow of ARVO
Member, CAHS – Canadian Academy of Health Sciences cancers using the anterior segment lens
Professor, Honoris Causa – EPM ‐ UNIFESP
1 2
OCT AND HISTOPATHOLOGY

OCT – NORMAL SKIN
Dermatoscope + Camera OCT

Digital Scanner epidermis
hair follicle
vessel
sebaceous
gland
https://web.duke.edu/histology/NormalBody/Skin/Skin.html#webslide58
3 4
81 year‐old male, RLL nodular lesion, 1 year duration, Clinical diagnosis: BCC
OCT AND HISTOPATHOLOGY
Clinical Dermoscopy OCT Histopathology
81F, RLL: PMHx: len go maligna – R arm; BCC – nose (2010)
70M, RLL: kerato c plaque for 6 mo. PMHx: immunosuppressed (liver transplant); AKs, BCCs tumor nest
tumor nest
tumor cleft
tumor cleft
72F, RLL: perlaceous nodule for 12mo. PMHx: recurrent lesion
5 6
1
70 year‐old male, RLL plaque lesion, 6 month duration 69 year‐old female, LUL papular lesion, 3 month duration
Clinical diagnosis: BCC vs SCC, immunocompromised liver transplant patient Clinical diagnosis: SGC?
loss of
DEJ
prominent DEJ hyper‐reflective ovoid loss of
hyper‐reflective ovoid
structures DEJ
structures
epidermal epidermal
thickening thickening
prominent
DEJ
7 8
78 year‐old male, Right Upper Eyelid Lesion
cystic wall
mucin cystic wall

mucin
tumor nest
• Head and neck regions
• Slow growing, malignant tumors
• Simulates breast & colorectal metastasis
• CK7Marker– skin adnexal origin
9 10
OCT ALGORITHM
‐
ARTIFICIAL
INTELLIGENCE
11 12
2
Dr. J. Fernando Arevalo
Financial Interests to Disclose
Vitrectomy for DME • Abbvie: Consultant/Advisor
unresponsive to pharmacologic • GENENTECH: Consultant/Advisor
• Springer SBM LLC: Patents/Royalty
therapy-is Surgery beneficial?
• THEA Laboratories: Consultant/Advisor
J. Fernando Arevalo, MD PhD FACS FASRS • Topcon Medical Systems Inc.: Grant Support
The Edmund F. and Virginia B. Ball Professor of Ophthalmology • DORC: Consultant/Advisor
Chairman of Ophthalmology at Johns Hopkins Bayview
Medical Center
• EyePoint Pharmaceuticals: Consultant/Advisor
Wilmer Eye Institute, Johns Hopkins University • Alimera Sciences Inc.: Consultant/Advisor
Baltimore, Maryland, USA
DME: Changing Paradigms

Introduction
• Private insurers and national Vitrectomy for DME
health care systems will be
unable to sustain anti-VEGF
costs
• A long-lasting, reasonably
priced treatment for DME is
needed
Vitrectomy for DME Vitrectomy for DME

Introduction Introduction
• Current Treatments
• Conditions resulting in ME are –Laser
major causes of visual –Anti-VEGF
impairment, with significant –Steroids
impact on quality of life –Surgery
• Remove Traction
• DME • Elimination of Vasoproliferative factors
• Improve Oxygenation
Surgical Indications Vitrectomy for DME
• Vitreoretinal interface • Chronic DME Introduction
change –Unresponsive to • PPV increases oxygen
–VMT other treatments concentration in the vitreous
–ERM –No obvious and retina of diabetic eyes
–Attached Hyaloid vitreoretinal
–Taut Hyaloid
interface change • Several retrospective and
prospective studies have shown
that vitrectomy significantly
decreases DME
Vitrectomy for DME

Introduction
• Many of these studies lacked
consistent enrollment criteria, Haller JA, Qin H, Apte RS, et al on behalf of the Diabetic
control groups, standardized Retinopathy Clinical Research Network (DRCR.net).
measurements of VA, and SD-OCT Vitrectomy outcomes in eyes with diabetic macular edema
and vitreomacular traction. Ophthalmology 2010;117(6):1087-
• Vitrectomy for the treatment of DME 1093.
is not yet supported by good clinical
evidence

Introduction Introduction
• The DRCR.net showed that vitrectomy
• The trial enrolled only “eyes that in
effectively decreases DME but only eyes with the estimation of the investigator
vitreomacular traction experienced an would not benefit from any other
average of 3 letters improvement in VA therapy” thereby including eyes
• The proportion of 10-letter gainers exceeded that may have been the least likely
that of 10-letter losers by 38% to 22% to benefit from vitrectomy
Vitrectomy for DME
Introduction
• Included eyes without vitreomacular traction,
average central subfield thickness improved
from 412 µm to 278 µm at 6 months but
median VA remained unchanged at 20/80
• Greater improvements in visual acuity
Flaxel CJ, Edward AR, Aiello LP, et al. Factors associated with occurred in eyes with worse initial VA and
visual acuity outcomes after vitrectomy for diabetic macular epiretinal membranes
edema: diabetic retinopathy clinical research network. Retina
2010;30(9):1488-1495.

OCT OCT
• Older trials such as those performed • More recent trials have attempted to
by the DRCR.net used TD-OCT to correlate the integrity of the ELM and IS/OS
lines, as visualized by SD-OCT, with visual
evaluate the macula improvement after vitrectomy
• TD-OCT accurately and reproducibly • Eyes with significant pre-vitrectomy defects
measures macular thickness but is in the ELM and/or IS/OS often experience
incapable of evaluating outer retinal favorable resolution of macula edema but
morphology do not achieve improved visual acuity
Vitrectomy for DME

OCT
• In a retrospective analysis of eyes that
underwent vitrectomy for DME, those with
intact IS/OS lines improved by an average of
13.3 letters whereas those with IS/OS
defects improved by only 3.9 letters
Chhablani JK, Kim JS, Cheng L, et al. External limiting • Therefore, outer segment findings on SD-
membrane as a predictor of visual improvement in diabetic OCT may be used to select patients who
macular edema after pars plana vitrectomy. Graefes Arch Clin would be expected to do well visually after
Exp Ophthalmol 2012;250(10):1415-1420. vitrectomy
Normal Structure Abnormal Structure Normal Structure
Abnormal Structure Abnormal Structure
Abnormal Structure
Adelman et al. Strategy for the management of

diabetic macular edema: the European vitreo-retinal
society macular edema study. Biomed Res Int.
2015;2015:352487. doi: 10.1155/2015/352487. Epub
2015 Jan 28.
• 86 retina specialists from 29 countries provided
Adelman et al. Strategy for the management of diabetic macular edema: clinical information on 2,603 patients with
the European vitreo-retinal society macular edema study. Biomed Res Int. macular edema including 870 patients with DME
2015;2015:352487. doi: 10.1155/2015/352487. Epub 2015 Jan 28.
• In their DME study, treatment with vitrectomy
and ILM peeling alone resulted in the better
visual improvement compared to other
therapies
Selected Cases
Fluorescein Angiogram + OCT Fluorescein Angiogram + OCT
Before Treatment: No Macular Traction After Surgical Treatment
BCVA = 20/200
BCVA = 20/30
BCVAOD = 20/30 (3 weeks)

6 months follow up
Cystoid macular edema refractory to laser, Cystoid macular edema refractory to laser,
anti-VEGF, triamcinolone and anti-VEGF and triamcinolone and no
no evidence of macular traction evidence of macular traction
BCVA = 20/40
BCVA = 20/100 12 months follow-up
Surgical management of macular edema Vitrectomy for DME

Protect the macula - early treatment Summary
OCT Electron • Costs associated with vitrectomy management of
Microscopic DME are generally “front loaded”
• 2-year costs associated with vitrectomy
management of DME may be only 1/10 of those
incurred by anti-VEGF therapy
• If vitrectomy were shown to be as effective as
ranibizumab/aflibercept therapy, it would be far
more cost effective
Vitrectomy for DME

Summary
• Vitrectomy for DME has been not been
adequately studied in eyes that still have the
potential for visual improvement
• A multi-center, prospective trial of vitrectomy for
eyes with DME and good visual potential as
determined by findings on pre-operative SD-OCT
is needed
Dr. Raquel Goldhardt
New Role, New Hope? Relevant Financial
Neovascular Age‐Related Macular Disclosures
Degeneration
Raquel Goldhardt, MD FACS None

1 2
Reduction in Blindness Incidence After the

AMD TREATMENT:
Introduction of Anti‐VEGF Therapy
inject often to maintain gain
REDUCE
INJECTION
FREQUENCY
Bloch S,et al. Am J Ophthalmol. 2012 Skaat A,et al. Am J Ophthalmol 2012
Borooah S,et al. Eye (Lond.). 2015 Bressler NM,et al. Arch Ophthalmol. 2011
3 4
Globally Increasing Importance

of Age‐Related Macular Disease
AMD ‐ 2015:
4th most common cause of blindness globally
3rd most common cause for moderate to severe visual impairment
Globally
2040 → 288 million people
Jonas JB et al. Updates on the Epidemiology of Age‐Related Macular Degeneration. Asia Pac J Ophthalmol. Nov‐Dec 2017;6(6):493‐497
Rein DB et al. Vision Health Cost‐Effectiveness Study Group. Arch Ophthalmol. 2009 Apr;127(4):533‐40.
Wong WL et al. Lancet Glob Health 2014 Feb;2(2):e106‐16. Epub 2014 Jan 3.
5 6
1
FINAL THOUGHTS ‐ CATT 5‐Year Data
50% of the eyes had 20/40 or better
✔At year 5: VA gains at years 1 and 2 were lost
✔Over or under treatment???
✔83% patients had fluid on OCT (61% IRF)
✔CNVM size grew by 50%
✔GA more common with monthly treatment
Anti‐VEGF treatment resulted
in an initial improvement in visual acuity Year 2: 20%
however, Year 5: 41% year
this was not maintained over time 47% if monthly injections first 2 years
Holz FG et al. Multi‐country real‐life experience of anti‐vascular endothelial growth factor therapy for wet age‐related macular degeneration. Br J Ophthalmol. 2015 Feb;99(2):220‐6
7 8
 7‐8 injections
 During the first year
 5‐6 injections
 During the second year
• Apolipoprotein B100 as a biomarker?
Frequent follow‐up • The researchers hypothesized this protein may help protect
patients from developing wet AMD.
with OCT
Singer MA, Awh CC, Sadda S, et al. HORIZON: an open‐label extension trial of ranibizumab for choroidal neovascularization secondary to age‐related macular degeneration. Ophthalmology. 2012;119(6)1175‐1183.
Could 30% of the patients stop intravitreal injections?
CATT Research Group. Ranibizumab and bevacizumab for neovascular age‐related macular degeneration. N Engl J Med. 2011;364(20):1897‐1908.
Rofagha S, Bhisitkul RB, Boyer DS, et al. Seven‐year outcomes in ranibizumab‐treated patients in ANCHOR, MARINA, and HORIZON: a multicenter cohort study (SEVEN‐UP). Ophthalmology. 2013;120(11):2292‐2299.
9 10
LUMINOUS Summary of Long‐term Studies
Holz FG, et al. Retina. 2020. Qin VL,et al. Retina. 2018
11 12
Promising and Emerging Therapies
Is the FUTURE now?

Monotherapy Sustained–delivery
 Brolucizumab ?  PDS
 Abicipar Pegol ‐ DARPins  NT‐503 ECT
New challenges 

Graybug
Faricimab ‐ RG7716 Gene Therapy
 Biosimilar SB11 (Ranibizumab)  RGX‐314
 ADVM‐022
13 14
Anti‐VEGF A: Brolucizumab (RTH258) Brolucizumab 6mg versus Aflibercept 2mg

Comparable efficacy at 96 weeks
 Brolucizumab 6.0mg dose group
 less IRF and or SRF
 continued to demonstrate CRT reductions
 fewer had sub‐RPE fluid
2019
Dugel P, et al. HAWK and HARRIER. Ophthalmology Jan 2021.
15 16
Anti‐VEGF: Brolucizumab (RTH258) Anti‐VEGF: Brolucizumab (RTH258)

60/1088 Brolucizumab‐treated eyes 60/1088 Brolucizumab‐treated eyes
Incidence of definitive/probable IOI: 4.6% Incidence of definitive/probable IOI: 4.6%
IOI + vasculitis: 3.3%
IOI + vasculitis + occlusion: 2.1% DO NOT USE IT IN PATIENTS IOI + vasculitis: 3.3%
IOI + vasculitis + occlusion: 2.1%
Moderate visual acuity loss: 0.74% Moderate visual acuity loss: 0.74%
WITH PREVIOUS UVEITIS
8/729 Aflibercept‐treated eyes 8/729 Aflibercept‐treated eyes
Incidence of IOI: 1.1% Incidence of IOI: 1.1%
Moderate visual acuity loss: 0.14% Moderate visual acuity loss: 0.14%
Ophthalmology. 2020;127(10):1345‐1359 Ophthalmology. 2020;127(10):1345‐1359

Ophthalmology. 2021;128(7):1050‐1059 Ophthalmology. 2021;128(7):1050‐1059
17 18
Monotherapy: DARPins Abicipar Pegol 2mg
Designed Ankyrin Repeat Protein
CEDAR study & SEQUOIA study
Abicipar Pegol 2mg Higher target binding affinity →6‐8 abicipar injections vs 13 ranibizumab injections
Novel anti‐VEGF‐A and 165 than antibodies or antibody fragment
→possible 12 weeks interval after loading dose ‐> 50% fewer injections!
→increased incidence of intraocular inflamma on
Phase 3:
50% less injections in the 1st yr
Abicipar: 6‐8 injections
Ranibizumab: 13 injections
Kunimoto et al. Ophthalmology 2020.
19 20
Graybug GB‐102 sunitinib maleate Faricimab (RG7716)

Tyrosine kinase inhibitor
Microparticle of a pan‐VEGF inhibitor Bispecific Monoclonal Antibody
ALTISSIMO Phase 2b
Potential for twice per year treatment Anti‐VEGFA Fab + Anti‐Ang2 Fab + modified Fc
55% of GB‐102 1 mg patients 〄Angiopoietin pathway
receiving
Terminated treatment for
2020 Impairs growth and development of NV
After an12m or longer,

interim Decreases vascular leakage
Injected via all while
safety analysismaintaining 〄 Modified Fc portion
27‐gauge needle VA and CRT Reduce systemic exposure Severe disease
Reduce inflammatory potential Difficult to treat
Regula JT, et al. EMBO Mol Med. 2016;8(11):1265‐1288.
21 22
Faricimab (RG7716)
〄Phase 3 studies
TENAYA
LUCERNE 80% faricimab group
extended from
q12 or q16
Heier Js. Presented at: Angiogenesis, Exudation, and Degeneration 2021
23 24
Faricimab Phase 3 ‐ SUMMARY KSI‐301 Trials
Anti‐VEGFA Fab + Anti‐Ang2 Fab + modified Fc
Heier J. Presented at : Angiogenesis, Exudation, and Degeneration 2021. Do D. Presented at Angiogenesis, Exudation and Degeneration 2021 Virtual Meeting; February 12‐13, 2021
25 26
New Treatment Paradigm: DELIVERY SYSTEMS

KSI‐301 Trial Phase 1b Results
Ocular Gene Therapy
DAZZLE study
KSI‐301 vs Aflibercept
Do D. Presented at Angiogenesis, Exudation and Degeneration 2021 Virtual Meeting; February 12‐13, 2021
Clinical Trials.gov
27 28
New Treatment Paradigm: DELIVERY SYSTEMS • New Treatment Paradigm: DELIVERY SYSTEMS
Ocular Gene Therapy? Ocular Gene Therapy?

After 1 injection of ADVM‐022,
patients in cohort 1 did NOT need any
 OPTIC study supplemental injections for
15 months or longer
‐Vector: ADVM‐022
‐Continuous delivery of aflibercept
‐Single in‐office intravitreal injection
o RGX‐314 subretinal and suprachoroidal trials
o ADVM‐022 intravitreal Inflammation was managed with steroid eye drops
Busbee BB, et al; for the OPTIC Investigators. Presented at ARVO 2021 Virtual; May 1‐7,221.
29 30
RGX‐314 subretinalDelivery
Subretinal gene therapy
Subretinal Delivery is being tested in the first pivotal gene therapy trial
The ATM O SPH ERE trialw illevaluate adm inistration of RG X-314

via subretinaland suprachoroidalinjection
Ho A. Presented at Angiogenesis, Exudation and Degeneration 2021 Virtual Meeting; February 12‐13, 2021 Ho A. Presented at Angiogenesis, Exudation and Degeneration 2021 Virtual Meeting; February 12‐13, 2021
31 32
Port Delivery System With Ranibizumab Port Delivery System with Ranibizumab ‐ PDS
Patients were previously treated
Reservoir:
• Permanent, refillable intraocular implant
• Customized formulation of ranibizumab
• Surgically placed at the pars plana Goal is the
• Refills performed in‐office
MAINTENANCE
LADDER trial ‐ Phase 2
Enables Ranibizumab in the device (10, 40 and 100 mg/ml) vs monthly Ranibizumab
the continuous delivery ARCHWAY trial ‐ Phase 3
of ranibizumab Ranibizumab in the device (10, 40 and 100 mg/ml) vs monthly Ranibizumab
into the vitreous
PORTAL trial – Extension Phase 3
Campochiaro PA, et el. Ophthalmology 2019
Patients who have completed ARCHWAY or LADDER
33 34
PDS – Mechanism of Continuous Delivery:

Ongoing PDS Trials
Passive Diffusion
Delivery over
4‐6 months
Regillo C. Presented at: Angiogenesis, Exudation, and Degeneration 2019 Meeting
35 36
TAKE HOME POINTS
Needed:
 New agents or drug delivery systems with increased durability
 Reduce treatment burden and avoiding under‐treatment
Promising:
 Emerging therapies
 Gene therapy is happening NOW
37 38
NEW TREATMENT PARADIGM

NT‐503 ECT
Encapsulated Cell Technology SUSTAINED‐DELIVERY TREATMENTS
Soluble VEGF receptor
o In vitro: picomolar affinity to human VEGF‐A
Similar to aflibercept Ranibizumab Port Delivery System RPDS
700 times greater affinity than ranibizumab NT‐503 vitreous implant
o Phase 2 was initiated Posterior MicroPump Drug Delivery System
o NT‐503 vs aflibercept q8weeks
o High rate of rescue events
39 40
Posterior MicroPump
Drug Delivery System X‐82 oral therapy
 31 gauge needle to fill and refill the implant Tyrogenex
 Capable of use from more than 7 years
• JAMA
• Apex Study
41 42
MONTHLY NEW TREATMENT PARADIGM
Appears to optimize
PRN visual outcomes
 Require monthly monitoring
 Strict retreatment guidelines to avoid visual loss
SUSTAINED‐DELIVERY TREATMENTS
Ranibizumab Port Delivery System RPDS
TREAT AND EXTEND NT‐503 vitreous implant
 Reduce cost Posterior MicroPump Drug Delivery System
 Reduce treatment burden
 Still requires frequent monitoring
GB‐102 sunitinib maleate – GrayBug Vision
43 44
Combination: E10030
Conbercept (KH‐902) Anti‐PDGF aptamer and ranibizumab
Approved for wet AMD in China + +Upregulation
FOVISTA
of Platelet‐Derived Growth
• Fusion molecule
Factor +
 Make new vessels more resistant to anti‐VEGF
• Combines IgG Fc and VEGF receptors 1 and 2  Associated with development of fibrosis
• High affinity for
– all VEGF A/B isoforms
– placental growth factor
Phoenix trial
Nguyen TT, Guymer R. Expert Rev Clin Pharmacol. 2015;8(5):541‐8. doi: 10.1586/17512433.2015.1075879. Epub 2015 Aug 10.
Phase 3
Li X, Xu G, Wang Y et al. Safety and efficacy of conbercept in neovascular age‐related macular degeneration. Expert Rev Clin Pharmacol 2015;8:5:541‐8.
Zhang J et al. BMC Ophthalmol. 2018 Jun 15;18(1):142. doi: 10.1186/s12886-018-0807-1
45 46
ICON-1 OHR‐102
Antiinflammatory Squalamine
Antiangiogenic • Phase 2
• VA improvements and ↓ re nal thickness
• Phase 2 IMPACT
• Classic CNVM
Squalamine + Ranib Ranibizumab
Phase 3 of the MAKO trial failed
+11 letters +5 letters
3 lines gain 44% 29%
http://www.healio.com/ophthalmology/retina‐vitreous/news/online/%7B9bddd150‐4ada‐4ac3‐
81fc‐e0fbe621b4f6%7D/protein‐targets‐tissue‐factor‐angiogenesis‐in‐cnv‐related‐to‐amd
47 48
ENCAPSULATED CELL THERAPY
ECT – Neurotech Pharmaceuticals
PAN‐90806
by PanOptica Consistent delivery for 2 years at least
Low sustained dose of drug
Data on file. Neurotech Pharmaceuticals.
49 50
USA blindness due to AMD

54% among Caucasians
28.6% among Hispanics
4.4% African Americans
Globally
2020 →196 million people
2040 → 288 million people
Congdon N et al. Eye Diseases Prevalence Research Group. Arch Ophthalmol. 2004 Apr;122(4):477‐85.
Rein DB et al. Vision Health Cost‐Effectiveness Study Group. Arch Ophthalmol. 2009 Apr;127(4):533‐40.
Wong WL et al. Lancet Glob Health 2014 Feb;2(2):e106‐16. Epub 2014 Jan 3.
51
Dr. Harry Flynn, Jr.
Current Status of DR Treatment: Disclosures
Update on DRCR Clinical Trials
• H Flynn:
– Member of DRCR DSMC
– Not an official representative of DRCR network
– Presentation based on published manuscripts and
personal opinions
– No financial disclosures
Harry W. Flynn Jr., M.D., Viet Chau M.D. • V Chau: None
Inter‐American Curso and PAAO 2022
1 2
Latest Clinical Trial Results DRCR Protocol W

• Protocol W • Objective: To study the
efficacy of aflibercept in
• Protocol AB prevention of PDR & CI‐
DME in high‐risk eyes.
• Protocol AC
3 4
Protocol W: Study Design Time to Development of DME or PDR

Randomized Multicenter Clinical Trial (N = 64 Sites)
 ≥18 years old w/T1DM or T2DM

 Severe NPDR in at least 1 eye* 2 mg Primary
 DRSS between 43 and 53 on reading Intravitreous Outcome
center gradingꝉ Aflibercept
 No NV on FA in 7 modified ETDRS fields Cumulative
 BCVA letter score ≥79 (20/25 or better) probability of
Sham
 No hx of DME/DR treatment within 12 development of PDR
Injection or CI‐DME with
months and ≤4 prior injections
 No prior PRP vision loss
*NPDR determined by investigator; eyes with CI‐DME or CST greater than machine and gender‐specific OCT thresholds were excluded.
ꝉAfter 9 months of recruitment the lower cutoff was modified from 47B
Adapted from DRCR.net Public Website DRCR.net Public Website
5 6
Mean VA Letter Score Change from Baseline Protocol W Conclusions
• In eyes with moderate to severe NPDR, rates of PDR/CI‐DME
development lower with periodic aflibercept treatment compared
with sham through 2 years.
• Preventative treatment with aflibercept did not confer VA benefit
compared with anti‐VEGF initiated after PDR or DME
development through 2 years.
• 4‐year results will be important for determining whether
preventing PDR and CI‐DME improves long‐term VA (in press).
DRCR.net Public Website
7 8
DRCR Protocol AB Protocol AB: Study Design

 205 adults with T1DM Outcomes
• Objective: To compare
or T2DM Primary
initial treatment with  One study eye with 2 mg Aflibercept
Average VA Over 24
(Vitrectomy prn*)
intravitreal aflibercept vitreous hemorrhage Weeks
from PDR (Area Under the Curve)
vs. vitrectomy + PRP
1. Causing vision
for vitreous impairment Secondary
Vitrectomy and PRP Treatment With
hemorrhage in PDR. (20/32 or worse) (Aflibercept prn*)
Vitrectomy or
2. Requiring Aflibercept During
intervention *Based on pre‐specified
Follow‐up
study guidelines
Adapted from DRCR.net Public Website
9 10
Mean Visual Acuity Letters Over Time Protocol AB: Visual Acuity at 2 Years
Letter Score Snellen
100 Primary Outcome
20/10
20/32 or Better (Good Vision)
20/200 or Worse (Poor VA)
80 20/25
62% 68%
% of Eyes
% of Eyes
60 Aflibercept vs. Vitrectomy + PRP 20/63

adjusted difference over 24 weeks:
‐5.0 letters
40 95% CI = ‐10.2 to 0.3 letters 20/160
P = .06
3% 11%
20 Vitrectomy + PRP 20/400
N = 105 N = 87
N = 100 Aflibercept N = 90 Initial Initial Vitrectomy Initial Initial Vitrectomy
0 <20/800 Aflibercept with PRP Aflibercept with PRP
0 4 12 24 36 52 68 84 104
N = 90 N = 87 N = 90 N = 87
Error bars represent 95% confidence Intervals Weeks
DRCR.net Public Website DRCR.net Public Website
11 12
48y/M male,
VH – OD 2 years after PPV
VA ‐20/40 VA ‐ 20/25
IVA X 5 but VH increased with VA ‐ HM

PPV performed
13 14
Protocol AB Conclusions
DRCR Protocol AC
• Intravitreal aflibercept or PPV + PRP are
comparable first‐line options for the treatment of • Objective: To study the
VH from PDR with similar VA over 24 weeks. efficacy of initiating
aflibercept monotherapy vs.
• Eyes with initial PPV + PRP had faster recovery of bevacizumab (and switching
vision to aflibercept if needed) in
• Approximately 1/3 of the eyes in each group treating eyes with CI‐DME
received the alternative treatment (aflibercept or and moderate vision loss.
PPV + PRP).
15 16
Protocol AC: Study Design Mean Change in VA From Baseline Over 2 Years
 ≥ 18 yo w/T!DM or T2DM
 RTC 312 eyes
 CI‐DME with CST above gender Aflibercept Monotherapy
specific thresholds on OCT*
 VA 20/50 to 20/320 Primary Outcome:
 No history of anti‐VEGF for Mean change in VA
DME within 12 months or any Bevacizumab over 2 years (AUC)
other treatment for DME First (+aflibercept if
within 4 months needed)
* For Zeiss Cirrus, ≥ 290 µm for females and ≥ 305 µm for males. For Heidelberg Spectralis, ≥ 305 µm for females and ≥ 320 µm for males
Adapted from DRCR.net Public Website DRCR.net Public Website
17 18
Mean Change in CST From Baseline Over 2 Years Protocol AC Conclusions
• No significant difference in VA over 2 years in eyes
treated with aflibercept monotherapy compared
with eyes treated with bevacizumab first with switch
to aflibercept in cases of suboptimal response.
19 20
Current Status of DR Treatment:

Update on DRCR Clinical Trials References
• Summary:
1. Maturi RK, Glassman AR, Josic K, Antoszyk AN, Blodi BA, Jampol LM, Marcus DM, Martin DF, Melia M, Salehi‐
Had H, Stockdale CR, Punjabi OS, Sun JK, DRCR Retina Network. Effect of Intravitreous Anti–Vascular
Endothelial Growth Factor vs Sham Treatment for Prevention of Vision‐Threatening Complications of Diabetic
Retinopathy: The Protocol W Randomized Clinical Trial. JAMA Ophthalmol. 2021 Jul 1;139(7):701‐712. doi:
– Protocol W: reduced rates of PDR/CI‐DME but no 2.
10.1001/jamaophthalmol.
Antoszyk AN, Glassman AR, Beaulieu WT, Jampol LM, Jhaveri CD, Punjabi OS, Salehi‐had H, Wells JA 3RD,
VA benefit in Aflibercept treatment group Maguire MG, Stockdale CR, Martin DF, Sun JK. Effect of intravitreous aflibercept vs vitrectomy with panretinal
photocoagulation on visual acuity in patients with vitreous hemorrhage from proliferative diabetic
retinopathy: A randomized clinical trial. JAMA. 2020; 324(23):2383‐2395. doi: 10.1001/jama.2020.23027
– Protocol AB: Aflibercept or PPV+ PRP are 3. Glassman AR, Beaulieu WT, Maguire MG, Antoszyk AN, Chow CC, Elman MJ, Jampol LM, Salehi‐Had H, Sun JK,
for the DRCR Retina Network. Visual acuity, vitreous hemorrhage, and other ocular outcomes after vitrectomy
comparable first line options for VH from PDR vs aflibercept for vitreous hemorrhage due to diabetic retinopathy: A secondary analysis of a randomized
clinical trial. JAMA Ophthalmol.doi:10.1001/jamaophthalmol.2021.1110
4. Jhaveri CD, Glassman AR, Ferris FL, Liu D, Maguire MG, Allen JB, Baker CW, Browning D, Cunningham MA,
– Protocol AC: Aflibercept monotherapy similar Friedman SM, Jampol LM, Marcus DM, Martin DF, Preston CM, Stockdale CR, Sun JK, DRCR Retina
Network. Aflibercept monotherapy versus bevacizumab first followed by aflibercept if needed for treatment
outcomes to bevacizumab first/later switch of center‐involved diabetic macular edema. NEJM. Published online July 14, 2022. DOI:
10.1056/NEJMoa2204225
21 22
4
Dr. William E. Smiddy
Natural History, Surgical
Timing, and Long Term Results The authors have no financial
for Idiopathic Epiretinal disclosures
Membrane
ABDULLA R. SHAHEEN MD, HASENIN AL-KERSAN MD,
HARRY W FLYNN JR MD, WILLIAM E. SMIDDY MD
1 2
ERMs- Management ERM peeling in eyes

Michels RG. AJO 1981;92:628
with good VA
20/100 or worse preop

 Thompson JT, et al. Retina 2005;25:875.
 90% of 50 eyes improved 2 lines
 initial VA (>20/50), yields excellent postop
Generally to about 20/30-20/100
VAThe threshold
20/40) at 2.4 for
yrs surgery has
been

(mean
 Progressive NS Cataracts; 8% RD/breaks
 continually
Reilly lowered, presumably
G. Retina 2015;35:1817. with
the
 140 lower
eyes VAcomplication rates
>20/50 mean 20/30 inherent in
@1yr
small gauge techniques, but is the
rationale of sooner surgery = better
results a valid driver?
3 4
Progresson of ERMs Epiretinal Membrane

 Byon IS, et al. Ophthalmologica 2015;234:91  A common condition (up to 29% prevalence) that only causes
 6/62 (10%) VA decline by 2 lines substantial visual symptoms in a small subset
 Metamorphopsia, loss of vision
 Lee SM, et al. Retina 2018;38:541  Largest etiologic subset is idiopathic – likely related to PVD
 16% of 131 eyes over a mean 31 mos progressed  A common component of surgical schedule
 Luu KY, et al. Eye 2019;33:714.  Visual acuity, symptoms usually improve about 50%
 Better postop VA a/w shorter duration, better preop VA
 Initial
symptoms and initial lens status most important
Acceptably low complication rates (~1% RD)
predictors of progression 
 Chua PY, et al. Eye 2021 (July)
5 6
Our Hypothesis (bias) ERM: Natural history and surgical timing
 While surgical  Purpose

instrumentation and  To define the rates of
techniques probably allow progression of ERMs with
a lower VA threshold for good initial vision
undergoing surgery,
 To evaluate visual outcomes
 Since ERMs do not typically in eyes operated after later
progress (5-10%), pre- ERM progression
empting deterioration is not
a good rationale
7 8
Table 1: Initial Characteristics of Study Participants in the Natural History Arm Groups
ERMs: Methods Results – Natural

Unoperated Group Deferred Surgical Group P-value
(369) (44)
Age, years, mean (SD) 74(9) 71(6) .0428
History
Gender, N (%) .7491
Male 164 (44%) 21 (48%)
Laterality .0782
Right eye 188 (51%) 29 (66%)
 Incident ERMs in 2 surgeons’ practice (After EHR, 2014-2019)- 2899 Fellow eye involvement 112/369 (30%) 14/44 (32%) .8632
 Excluded non-idiopathic (1045), < 1 year follow-up (1055), previous ERM peel (137), and Positive history of ocular surgery 193/369 (52%) 18/44 (41%) .2015
other (14)  44 (10.7%) of 313 deferred Cataract extraction

Glaucoma procedure
180
1
17
0
 Definitions; subgroups studied: surgery eyes were Cataract extraction and glaucoma procedure
Ocular comorbidities
12
112/369 (30%)
1
8/44 (18%) .1142
 Initial observation (413) operated, at a mean of 18.1 Glaucoma

Macular degeneration
36 (32%)
47 (42%)
5 (63%)
1 (12%)
 Never operated (369) months after presentation Posterior capsular opacification 0 0

Both macular degeneration and glaucoma 10 (9%) 0
 Deferred ERM surgery (44)  Later surgery more frequent Others
Symptomatic at initial
19 (17%)
139/369 (38%)
2 (25%)
37/44 (84%) <.0001

 What was rate of worsening to require surgery >6 mos if younger, more symptoms, Blurred central vision
Metamorphopsia
36 (26%)
37 (27%)
6 (16%)
14 (38%)
 Nested controls (later had surgery vs immediate surgery) poorer initial VA Generalized loss of vision 54 (39%) 10 (27%)
Immediate ERM surgery (within 6 months) (280)

More than one of the above symptoms 9 (6%) 7 (19%)

Decision for surgery due to
Others 3 (2%) 0

Endpoints
Initial lens status .2974

perceived worsening Phakic 179/369 (49%) 25/44 (57%)
 Later surgery Cataract at initial 171/179 (96%) 25 (100%)
 BCVA – were the deferred surgical eyes disadvantaged?

symptoms… Pseudophakic
With open capsule
190/369 (51%)
63 (33%)
19/44 (43%)
7 (37%)
Visual acuity at initial, median (IQR) logMAR 0.18(0.05-0.30) 0.30(0.05-0.40) .0012

and Snellen equivalent 20/30(20/22 - 20/40) 20/40 (20/22 – 20/50)
9 10
ERMs - VA course Nested Case-Control Study

Table 4: Initial Characteristics and Visual Acuity of Participants in the Nested Case (Deferred Surgical Group) - Control (Immediate Surgical Group) Study
Table 2: Visual Acuity and Change in Visual Acuity at Different Time Points for the Natural History (Deferred and Cases (44) Controls (44) P-value
Age, years, mean (SD) 71(6) 71(10) .927
Unoperated) Cohort
Deferred cohort
Gender, N (%) 1.0

44 cases with
Male 21 (48%) 22 (50%)
generally started Phakic

Visual Acuity
Pseudophakic
 Laterality
Right eye 29 (66%) 25 (57%)
.512
worse, got deferred surgery

Time Point Fellow eye involvement 14/44 (32%) 6/44 (14%) .073
Unoperated P-value Unoperated P-value Positive history of ocular surgery 18/44 (41%) 22/44 (50%) .521
Deferred (25) Deferred (19)
additionally (179) (190) Cataract extraction 17 18
worse, then Matched wth 44 of

Glaucoma procedure 0 2
At initial
0.30 (0.18,0.44) 0.10(0,0.18)
.0001
0.30 (0.18,0.36) 0.18(0.10,0.40)
.4092  Cataract extraction and glaucoma
procedure
1 1
improved
the immediate cases
Other 0 1
20/40 20/25 20/40 20/30 Ocular comorbidities 8/44 (18%) 11/44 (25%) .605
VA stable in never 0.44 (0.36,0.71) NA 0.52 (0.4,0.6) NA Glaucoma 5 (63%) 2 (18%)

 At
NA NA
by date of surgery
Macular degeneration 1 (12%) 3 (27%)
preoperative* 20/55 NA 20/66 NA
operated subset
Posterior capsular opacification 0 4 (36%)
0.10(0,0.3) Both macular degeneration and 0 1 (9%)

0.40 (0.18,0.54) <.0001 0.30 (0.18, 0.40) 0.30(0.10,0.40)
Most apparent
posterior capsular opacification
Differed only by
At final visit .3780
 
20/50 20/25 20/40 20/40 Others 2 (25%) 1 (9%)
in Having symptoms at time 37/44 (84%) 44/44 (100%) .012*
pseudophakic
Initial BCVA –
final BCVA
-0.10(-0.3,0.09) 0(-0.10,0.08) .0654 0(-0.24,0.12) 0(-0.18,0) .9471 symptoms at of diagnosis
Blurred central vision
Metamorphopsia
6 (16%)
14 (38%)
4 (9%)
7 (16%)
subset Data are median (interquartile range) unless otherwise indicated and are presented as logMAR in the top row and
Snellen equivalent in the row below.
baseline (by Generalized loss of vision
More than one of the above
symptoms
10 (27%)
7 (19%)
25 (57%)
7 (16%)
*A comparison of preoperative and final BCVA values in pseudophakic and phakic deferred subgroups revealed a
statistically significant improvement in the former (p=0.0082), but not in the latter (p=0.0540) after ERM peeling.
definition) Others
Initial lens status (phakic vs
pseudophakic)
0 1 (2%)
.669
Phakic 25/44 (57%) 22 (50%)

Cataract at initial 25 (100%) 18 (82%) .201
Pseudophakic 19/44 (43%) 22 (50%)
With open capsule 7 (37%) 4 (18%)
11 12
ERMs – operated VA course ERM: Natural history and surgical timing
 Deferring surgery until symptoms worsened yielded about the same VA
improvement and results as in controls that were immediately operated
Table 5: Visual Acuity and Change in Visual Acuity at Different Time Points for the Nested Case (Deferred) – Control
(Immediate) Groups
SUMMARY:
Visual Acuity
Time Point
Phakic
Immediate
Pseudophakic
Immediate
 rate of deferred surgery was 10.7% (44/413) among eyes initially
Deferred (25)
(22)
P-value Deferred (19)
(22)
P-value
presenting with relatively good VA and symptoms
0.30 (0.18,0.44) 0.48 (0.34,0.59) 0.30 (0.18,0.36) 0.44(0.36,0.62)
At initial 0.0035* 0.0011
At
20/40 20/60
0.44 (0.36,0.71) 0.48(0.35,0.59)
20/40
0.52 (0.4,0.6)
20/55
0.44(0.39,0.60)
 The VA improvement after surgery was similar to that among eyes
0.8476 0.5043
preoperative 20/55 20/60
0.40 (0.18,0.54) 0.16(0.05,0.34)
20/66
0.3 (0.18, 0.40)
20/55
0.23(0.10,0.33)
with symptoms sufficient to undergo immediate surgery
At final visit 0.0065* 0.4550
20/50 20/29 20/40 20/34
Initial BCVA –
-0.10(-0.3,0.09) 0.32 <0.0001* 0(-0.24,0.12) 0.21 0.0003
final BCVA
Initial BCVA – -0.16 (-0.45, - 0 (0,0) <0.0001* -0.22(-0.44, - 0(0,0) <0.0001
preoperative 0.04) 0.08)
BCVA
Preoperative 0.06 (- 0.15 (-0.32, 0.7236 0.12(0,0.23) 0.22(0.13,0.39) 0.0278
BCVA – One- 0.27,0.30) 0.36)
year
postoperative
BCVA
Preoperative 0.04 (0, 0.24) 0.29 (0.13, 0.0047 0.22(0.14,0.31) 0.20(0.11,0.44) 0.7045
BCVA – Final 0.44)
BCVA
Data are median (interquartile range) unless otherwise indicated and are presented as logMAR in the top row and
Snellen equivalent in the row below.
13 14
62 Y/F, OD 20/25 After 24 Mos

Conclusion
Baseline ‐ 20/40
 ERM symptoms do not progress very
frequently
 Thus, early surgery does not “prevent” VA loss
 Early surgery might result in up to 90%
undergoing surgery needlessly
 Deferring PPV/MP until symptoms are
worse does not disadvantage the final VA
results 24 months follow‐up ‐ 20/40
LOOK AT THE ELLIPSOID LAYER (EZ)!

15 16
iERMs and Good VA: But if you do ERM peeling…

Conclusions
“Operate early, before worsening” is not an established Long term outcomes ERM peel
rationale
 Probably better preop VA yields better postop VA (slightly)
 But iERMs are stable (once formed)
 Careful delineation of the type and timing of symptoms
can aid in decision regarding MP (look at the EZ layer)
 Decision should be based on present circumstances, not
concern over future deterioration/prevention
17 18
Long term results of iERM Surgery Methods
 Bouwens MD, de Jong F, Mulder P, van Meurs JC. Results of macular pucker surgery:
1‐ and 5‐year follow‐up. Graefes Arch Clin Exp Ophthalmol 2008;246(12):1693‐7.  Identified patients undergoing surgery for iERM from 2003-2013 with
 107 eyes; Prospective, consecutive study Rotterdam Eye Hospital follow-up information in University EHR (“go live” May, 2014)
 Preoperative, 1‐year, 5‐year after ERM peel with CE/IOL  Idiopathic cases only
 57 (53%) patients with 5‐year examination:  Minimum 5 years follow-up visit information
 1/3 of 50 non‐returnees were dissatisfied
 Collated at preop, 1, 2, 3, 5, 8, 10-year visits
 1 line mean improvement at 5yrs cf 1‐yr; 28/57 no change; 12% improved 2 lines
 logMAR BCVA
 Pesin SR, Olk RJ, Grand MG, et al. Vitrectomy for premacular fibroplasia. Prognostic
 OCT features: ellipsoid zone (EZ), external limiting membrane (ELM)
factors, long‐term follow‐up, and time course of visual improvement.
Ophthalmology 1991;98(7):1109‐14.  Subgroups: IOL at baseline, Preop BCVA > or <.3
 270, consecutive, all causes, retrospectively evaluated
 58% improve (of 81 (30%) eyes 3-5 yr f/u); mean +2.1 line improvement cf
preop; not apparently improved after 1-2 years (after CE mostly done)
19 20
iERM cohort
Epiretinal Membrane Cohort
 55 eyes of 49 pts (of 301 idiopathic ERMs, 18%)
 Mean age 70.2+6.8 yrs
 Mean f/u 8.6+2.6 yrs (median 9; range 5-16)
 51% OS; 46% female
 47% pseudophakic
 Phakic CE timing: 39% 1st yr, 46% 2nd yr
 Mean preop logMAR BCVA 0.56 (20/72);0.32 (20/42) at 10 yrs
 3 (6%) recurrent ERM; no RDs
For reference, 20/40 = 0.3 logMAR; 20/60 = 0.48 logMAR
21 22
iERM: Comparison between logMAR BCVA in IOL patients

logMAR BCVA (N=19) Mean ±SD p-value
iERM cohort, VA vs EZ restoration
Preoperative BCVA 0.55±0.26 logMAR BCVA
BCVA at 1 year 0.35±0.30 0.016 EZ integrity Mean± SD p-value
BCVA at 1 year Improved(N=9) 0.17±0.14

BCVA at 1 year 0.33±0.26 <0.001
Not Improved(N=6) 0.74±0.30
BCVA at 2 years 0.30±0.25 0.041
BCVA at 2 year Improved(N=9) 0.17±0.11
0.001
BCVA at 2 years 0.30±0.25
BCVA at 3 years 0.26±0.26 0.006 BCVA at 3 years Improved(N=9) 0.11±0.12
0.001
BCVA at 1 year 0.33±0.26 BCVA at 5 years Improved(N=11) 0.15±0.13
BCVA at 3 years 0.26±0.26 0.006 <0.001
BCVA at 8 years Improved(N=11) 0.18±0.18
0.002
Same pattern for ELM restoration
23 24
67F with ERM shows improved EZ and Strengths and limitations
ELM 6 yrs after MP
 Cohort of long-term follow-up (~9years mean)
20/80 20/30  Largest >5 years in literature
 OCT correlation
 Electronic record-based ascertainment
 Limitations
 Proportion of follow-up low/Retrospective
 Elderly population
 Mobile demographic
 Possibly bias towards better result returning
 Retrospective
Zeyer JC, et al. Retina 2021;41:505 – Dome shaped configuration = better prognosis
25 26
Long term results after iERM

surgery (mean ~9yrs)
 Idiopathic epiretinal membranes (55)
 VA improvement during first 3 years; VA
stabilization up to 10 yrs
 Poorer preop VA (IOL) a/w greater
improvement (p=.013), but only 1st yr
 Lower RD rate than historical (0), but 6%
recurrent ERMs
 Improved EZ and ELM correlated with better
postop VA, improved VA
 Conclusion: long term visual
results with ERM surgery are
stable and satisfactory
27
Dr. Luis J. Haddock
Sickle Cell Retinopathy
Medical and Surgical Management Objectives
Update
• Review pathophysiology
• Review Classification
• Review medical management
• Discuss vitreoretinal surgical considerations
Curso Interam ericano BPEI 2022

M iam i, FL
Luis J. Haddock
Associate Professor of Ophthalmology
Palm Beach Gardens, FL
1 2
Sickle Cell Disease Sickle Cell Disease

• Group of hemoglobinopathies: • SCD – autosomal recessive inheritance
– 1/500 African American births
– Abnormal proteins cause RBCs to adopt anomalous shape in hypoxia and acidosis – 250,000 births worldwide / year
– Defective oxygen transport due to obstruction of small blood vessels
• SS disease: Hb S + Hb S
– 0.15% of African Americans, lower life expectancy
• Normal adult RBC (Hb A) • SC disease: Hb S + Hb C
– ⍺ subunits (2) – Compound heterozygous variant, 1/12 African Americans
– β subunits (2) – Less systemic morbidity, normal life expectancy
– By age 24-26, 43% of HbSC have developed PSR ( vs. 13% in HbSS)
– Heme molecule
• Sickle cell trait: Hb A + Hb S
– Symptom-free carrier state, generally asymptomatic
• Hb S – valine for glutamic acid (β chain)
Sickle β+/0 thalassemia: One parent with B thalassemia trait and other parent with Sickle cell trait
• Hb C – lysine for glutamic acid (β chain) •
3 4
Pathophysiology
• Hb S polymerization
– Deoxygenation exposes hydrophobic molecules
– Associate with adjacent hydrophobic molecules
– Results in rigid fibers of Hb S
• Elongated, sickle shape
Jee et al. PLoS ONE 12(8): e0183320
5 6
Non-Proliferative Sickle Cell Retinopathy
Why is Retinopathy More Common in HbSC?
• HbSS 3% vs. HbSC 33%
• HbSS have lower hematocrit and lower blood viscosity

– Relative protection against vaso-occlusion
• HbSC have longer life expectancy

Salmon Patch Hemorrhages Black Sunburst
• Sub-ILM • Flat, stellate, or round hyperpigmentation
• HbSC have partial vascular occlusion
• Arise from hemorrhages into the retina • Results when IRH tracks down to
– More chronic hypoxic state
adjacent to areas of non-perfusion subretinal space
– Triggers a steady state of release of angiogenic growth factors and inflammatory
cytokines • “Blowout” of occluded arteriole • Histopathology: focal RPE hypertrophy
7 9
Non Proliferative Sickle Cell Retinopathy Peripheral Retinal Schisis
Iridescent Spots
• Refractile spots represent hemosiderin-laden macrophages
• Located within schisis cavity resulting after intraretinal

hemorrhage resolves
Schubert HD. Arch Ophthalm ol. 2005;123(11):1607-1609
10 11
OCT – Foveal “Splaying”

• N = 82 eyes, prospective, observational series
• Deep capillary plexus non-perfusion correlates with areas of macular thinning on OCT
• Retinal thickness correlated with vascular density
• Foveal pit blunting

• Found in temporal subfields due to watershed zone
Asymptomatic patients
Hoang et al. AJO 2011
12 13
Macular Infarction
Witkin et al. Arch Ophthalmol. 2006 May; 124(5): 746–747.
14 15
Proliferative Sickle Cell Retinopathy Stage 1- PSR

Peripheral arterial occlusions
Goldberg Classification System
Stage I Peripheral arterial occlusions
Stage II Peripheral AV anastomoses
Stage III Neovascular and fibrous

proliferations
Stage IV Vitreous hemorrhage
Stage V Retinal detachment

Vaso-occlusion occurs primarily in the peripheral temporal retina
Chronic ischemia + increased number of occludable bifurcation sites à decreased perfusion
16 17
Stage 2- PSR Stage 3- PSR

Neovascular and fibrous proliferations
Peripheral AV anastomoses
• Leakage on FA – true neovascularization
• Most common in temporal retina

• Vascular remodeling at the border of
perfused and nonperfused retina • Over time has vitreous traction à VH/RD
• AV anastomoses form connections between • Most sea fans are found at the border of
occluded arterioles and adjacent terminal perfused and nonperfused retina
venules
• Grow toward the ora serrata
• No leakage on FA
• Early vascular lesions are derived from • Arise from venous aspect approx. 18
months following the formation of AV
preexisting mature blood vessels with
anastomoses
an intact blood–retinal barrier
18 19
Autoinfarction of Sea Fan NV Stage IV
Vitreous hemorrhage
• Spontaneous regression of PSR may occur in about 32-40% of eyes
• Mechanism not clearly understood

– Persistent repetitive vaso-occlusion within the vascular channels of the NV +
vitreous traction resulting in possible sluggish flow and subsequent • Results from vitreous traction
occlusion
Nagpal et al – Spontaneous regression of PSR. AM J Ophthalmol 1975
20 21
22 23
Stage V
Retinal Detachment – TRD/RRD
• Retrospective, case-controlled
• N=64
• Result from chronic VH and resultant
vitreous membranes
• Evaluated the predictive value of
temporal macular thinning for the
• Retinal breaks:
presence of peripheral NV
• Atrophy/thinning from ischemia
• Traction • Temporal thinning not sensitive to
use as screening tool
Sickle Cell vs. Diabetic Retinopathy
• TRD in PSR: peripheral
• TRD in PDR: posterior pole
Hood et al. Ophthalmic Surg Lasers Imaging Retina. 2016;47:27-34
24 25
• 28 y/o male with vision changes
• VA OD: 20/40. OS: 20/30
Stage 4 OS
Stage 3 OD
26 27
28 29
30 31
Management
Scatter Laser Photocoagulation
Observation
• SC Retinopathy without NV
• Indicated for small, flat, asymptomatic peripheral lesions
– Low risk of spontaneous hemorrhage
– Relatively high probability of autoinfarction
Treatment indications
Stage III PSR
• Rapid growth of a sea fan
• Large, elevated sea fans • Treat ischemic retina
• Spontaneous hemorrhage • Shunt oxygenated blood to healthy retina
• Bilateral proliferative disease • Reduces demand for oxygen
• Decreases stimulus for VEGF
Goal: Prevent Stage III to progress onto Stage V • FA- guided treatment
• Consider laser in fellow eyes if hx of RD
32 33
Intravitreal Anti-VEGF for Stage III

• Evidence from Case Reports
Meta-analysis of two large RCT (Jampol et al 1983, Farber et al. 1991)

238 patients (121 males, 117 females)
• Regression of PSR
• Farber – 30/99 with complete regression in laser vs 17/75 in group
• Jampol – 78/87 with complete closure of NV, no data for control
• Development of new PSR
• Farber –34/99 laser eyes (34.3%) vs 31/75 control (41.3%) (p = 0.3)
• Jampol –12/25 (48%) in laser group vs 9/20 (45%) in control (p = 0.64)
• Vision loss > 3 lines
• Farber – 3/99 (3%) vs 9/75 (12%) in control group. P =0.019
• Jampol – 1/87 (1.14%) in laser vs 6/80 (7.5%) in control group. P = 0.07
• Vitreous Hemorrhage
• Farber – 12/99 (12%) laser eyes vs 19/75 (25.3%) control
• Jampol – 3/87 (3.4%) in laser vs 22/80 (27.5%) control (P = 0.002)
Regression of Stage III PSR
Siqueira et al. Acta Ophthalmologica Scandinavica 2006
34 35
Survey of Practice Pattern in PSR (2021) Vitreoretinal Surgical Considerations

• Non perfusion without NV • Moshiri et al.: Pre-operative anti-VEGF
– 63% observe – Partial regression of sea fan NV
• NV – Lowers risk of intraoperative bleeding
– 66.3% perfom laser
– 13.7% observe • Ensure adequate intraop hydration, oxygenation, and IOP management
– 5% use anti-VEGF • Consider general anesthesia to reduce risk of sickling from orbital
• VH compression from block
– 70% perform laser
– 16.8% use anti-VEGF
• Scleral buckling may provide peripheral support for peripheral
vasoproliferative tractional membranes: Avoid high buckles
M ishra K, Bajaj R, Scott AW. Variable Practice Patterns for M anagem ent of Sickle Cell
Retinopathy. O phthalm ol Retina. 2021 Jul;5(7):715-717
36 37
• 11 eyes, HbSC
• 9 eyes with TRD/RRD 28 eyes (10 observation, 18 surgery): 2009

• Surgical outcomes:
• 2 eyes with VH only
• 83% improved VA
• RD management: • 1/18 required second PPV (PVR, oil)
• 6/9 SB/PPV
• 3/9 PPV only • 7/18 iatrogenic breaks with delamination
• VA improved in 10/11 cases • Conclusion
• Role of prophylactic blood
• A high rate of iatrogenic retinal tears in atrophic, ischemic peripheral
transfusion questioned
retina using delamination (tangential peeling)
• Authors recommend segmentation (removal of anterior–posterior
traction) techniques instead of delamination
Pulido et al. Arch Ophthalmol 1988; 106:1553-1557 Williamson et al. Eye (2009) 23, 1314–1320
38 39
• 15 eyes, retrospective series: 2014 • 71 eyes

• Mean age 48 • Visual and anatomical outcomes of primary vitrectomy, follow up 26 months
• 9/14 HbSC
• Mean follow up: 26.7 months • Surgical indications:
• All eyes (15) underwent PPV [20 G (5), 23 G (3), 25 G (5)] • TRD (17), TRD/RRD (16), RRD (5), VH (19), ERM (6), MH (8)
• Indications: • Overall significant BCVA improvement

• 8 TRD/RRD [2 had SB]
• 6 VH • 23 G vs. 20 G
• 1 ERM • No significant diff. in BCVA or reattachment rates
• No difference in iatrogenic breaks (3 each)
Factors contributing to iatrogenic
• Recurrent RD in 50% • Retinal Detachments (n = 38)
tears and high recurrent rates:
• All involved PVR • Younger patients, phakic • Recurrent rate 29%
• Managed with SB (2), Retinectomy (1) • PSR tractional points are more • BCVA improvement, but not significant
• Choice of tamponade: SO (2), Gas (2) peripheral/anterior
Chen et al. Am J Ophthalmol 2014;157:870–875 Ho et al. Eye (2018) 32:1449–1454
40 41
Case 1
42 43
VA: 20/200
44 45
Surgery
s/p 25g PPV/EL/FAX/14%C3F8 OS for

NCVH/Sickle Ret/TRD with hole
46 47
3years after surgery

VA 20/20 OS
49 51
Take Home Points
PSR is m ost com m on in HbSC
Chronic ischem ia leading to vaso-occlusion initial step in pathophysiology
Sea-fan NV 32% autoinfarction – O K to observe
O CT/O CTA – m acular splaying /PAM M
Surgical M anagem ent
• Higher rates of recurrency

• M ay consider scleral buckling – peripheral pathology
Thank you
• Pre-operative anti-VEGF; General anesthesia; avoid high buckles
52 53
References
Thank you Dr Jose D Diaz
• Jee et al. PLoS ONE 12(8): e0183320

• Schubert HD. Arch Ophthalmol. 2005;123(11):1607-1609
• Hoang et al. AJO 2011
• Hussnain et al. BMJ Case Rep 2017 Apr 26;2017
• Hood et al. Ophthalmic Surg Lasers Imaging Retina. 2016;47:27-34
• Witkin et al. Arch Ophthalmol. 2006 May; 124(5): 746–747.
• Han et al. AJO 2017;177:90–99
• Farber et al. Arch Oph 1991; 109: 363-367.
• Siqueira et al. Acta Ophthalmologica Scandinavica 2006
• Mitropolous et al. Case Reports in Ophthalmological Medicine Volume 2014
• Pulido et al. Arch Ophthalmol 1988; 106:1553-1557
• Williamson et al. Eye (2009) 23, 1314–1320
• Chen et al. Am J Ophthalmol 2014;157:870–875
• Ho et al. Eye (2018) 32:1449–1454
54
Dr. David S. Greenfield
Título: Nuevos avances en el glaucoma
Profesor de oftalmología
Douglas R. Anderson, catedrático en oftalmología
Vicepresidente de asuntos académicos
Miami, FL
El glaucoma es una neuropatía óptica que constituye la segunda causa de ceguera en el mundo. Se trata
de una enfermedad irreversible que afecta a casi el 15% de la población mayor de 85 años y se
caracteriza por una neurodegeneración progresiva de las células ganglionares de la retina y sus axones y
un patrón específico de daños en la papila óptica y el campo visual. Los mecanismos fisiopatológicos de
la neurodegeneración glaucomatosa no se conocen bien. La presión intraocular (PIO) elevada es el factor
de riesgo conocido más importante para el inicio y la evolución de la enfermedad que se puede
modificar. En esta presentación se revisarán los nuevos avances en el campo del glaucoma que tienen
importantes implicaciones diagnósticas y terapéuticas. Hablaremos de los nuevos avances en el campo
de la obtención de imágenes diagnósticas del segmento posterior, la medición de la PIO durante 24
horas, la administración constante del tratamiento para reducir la PIO, la neuroprotección para el
glaucoma y las nuevas innovaciones quirúrgicas.
Title: Emerging Breakthroughs in Glaucoma

Douglas R. Anderson Chair in Ophthalmology
Vice Chair for Academic Affairs
Miami, FL
Glaucoma is an optic neuropathy that is the second leading cause of blindness worldwide. It is an
irreversible disease that affects nearly 15% of the general population over the age of 85 and is
characterized by progressive neurodegeneration of retinal ganglion cells and their axons and a specific
pattern of optic nerve head and visual field (VF) damage. The pathophysiologic mechanisms of
glaucomatous neurodegeneration are incompletely understood. Elevated intraocular pressure (IOP) is the
most important known risk factor for disease onset and progression that is amenable to modification. This
presentation will review emerging breakthroughs in the field of glaucoma that have important diagnostic
and therapeutic implications. We will discuss novel developments in the field of posterior segment
imaging, 24-hour IOP measurement, sustained delivery of IOP lowering therapy, glaucoma
neuroprotection, and new surgical innovations.
Dr. Victor L. Perez
Diagnosis and Management of Idiopathic Persistent Iritis after Cataract Surgery
Victor L. Perez, MD
• IPICS is a distinct clinical anterior uveitis entity most common in African

American and female patients without a recognized etiology: +ANA.
• Characterized by onset of iritis after CE which commonly rebounds after tapering

topical steroids with a persistent duration.
• A chronic course and a high rate of ocular hypertension and CME complications
associated with prolonged topical steroid treatment.
• We propose a strict systematic treatment with an algorithm which begins with

slow tapering of steroids over two months, and if iritis flares, systemic medication
should be introduced escalating from Meloxicam to Methotrexate.
Immunology of Corneal Transplantation: How to Maximize Graft Survival?

Victor L. Perez, MD
• Basic Models of In Vivo Visulaziation of Immune Responses in The Eye will open
new ways of thinking about anti-rejection therapy.
• Aggressive Immune Suppression and Multi-Disciplinary Approach.
• Dual Role of Immunity and Neovascularization in Transplantation:

• need to control inflammation and agents with dual action are critical.
• Limbal Stem Cell Deficiency: need to perform limbal stem cell transplant
• Aggressive Immune Suppression and Multi-Disciplinary Approach.
• Neurotrophic Cornea: Close and Protect, enhance nerve growth or health (rNGF,
PRGF), Corneal Neurotization and use devices
Management of Non-Responding Dry Eye Disease Patients
Victor L. Perez, MD
• La evaluación del paciente con Ojo Seco o alteraciones de la superficie ocular

debe ser como en “Glaucoma”: Sistemática, estandarizada y validada.
• Control de la Inflamacion es esencial. Desarollo de Nuevos Anti-Inflamatorios

inteligentes.
• Lubricacion es un paso importante en el tratamiento: Lubricacion regenerativa y

sintetica.
• Biologicas: Suero Autologo y PRGF (Plasma y plaquetas) funcionan.
• Mejoras en el diagnóstico conduciran a terapia personalizada para ojo seco en el

futuro.
A Multi-Disciplinary Approach for the Treatment of Juvenile Idiopathic Uveitis

Victor L. Perez, MD
• Our approach to Juvenil Idiopathic Uveitis shares and demonstrate the positive
results of a multidisciplinary clinic that utilizes a novel approach of having a
pediatric rheumatologist and ocular immunologist working in the same clinic and
sharing input at the same patient visit to provide the patients with a “one-stop
shop” experience.
• Adalimumab-based therapy (ADA) allowed remission to be achieved in 75% of

patients at 3 and 6 months and 65% of patients at 12 months.
• Recurrence of uveitis was seen in 13% at 6 months and 25% at 12 months.
• Factors associated with achieving remission were the presence of glaucoma

(likely due to earlier initiation of aggressive therapy) and patients that had less
than 3 flare episodes in the 2-years prior to initiating ADA-based therapy.
• Patients with persistent uveitis on ADA-based therapy tested positive for

Adalimumab antibodies and therefore, need to be measured in juvenile idiopathic
uveitis patients on this therapy if increased flare ups start to occur.
Dr. Anat Galor
 Consultant
 Oyster Point
Anat Galor MD, MSPH
Staff Physician, Miami VAMC  Novaliq
 Dompe
University of Miami  Novartis
 Tarsus
agalor@med.miami.edu
1 2
Dry eye
 Its all in the name! Dry eye symptoms
 Its not one disease.
Symptoms Signs
Pain Vision related
Goal: Let’s change the

paradigm!
3 4
Pain is “an unpleasant sensory and

Ocular surface pain
emotional experience associated with
actual or potential tissue damage.”
Many different words
International Association for the Study of Pain (IASP)
5 6
ATD/EDE
LASIK
Anatomy TBI
Ocular surface pain
Cat Ext
Toxicity FM
Tear Toxicity
dysfunction
Migraine
Nerve
Anatomy abnormalities
7 8
Dry eye Dry eye Dry eye Just like diabetic

neuropathy!
Anatomy Anatomy Anatomy
Toxicity Toxicity Toxicity
LASIK LASIK
Cat Ext Cat Ext
9 10
“My eyes feel

dry” (burning,
aching…)
Nerve status has to be

considered when
evaluating a pt with
“dry eye”
11 12
13 14
38 y.o. WF “I had LASIK one

year ago and my eyes are
Elyana Locatelli, BS
Research associate really dry."
Miami VA Medical Center,
University of Miami
22 23
 Sarcoidosis (confirmed by biopsy) –  “DE” symptoms present before but

lung involvement, no ocular worsening s/p LASIK OU
involvement  Failed Restasis (burning)
 Using inhaled steroids  Using Artificial tears
 H/o arthritis
 Migraines (2‐3x/ wk)
 Topiramate (prophylactic)
 Tylenol (abortive)
24 25
“Lights kill
81.25 me!”
“I’m so
sensitive to
Nociceptive wind and AC”
vs. “It feels like
√ Painful dry eye Neuropathic pins and
symptoms needles”
26 27
+ detectable
Exam begins when step
MMP‐9 on
into room
ocular surface
Anatomy OK
OD OS
OD 2
OS 3
28 29
What about the eyelids?

OD
OS
Not bad!
OD OS
Not bad!
OD OS
Anterior blepharitis 0 0
Eyelid Vascularity 1 1
Gland inspissation 0 0
Meibum quality 0 0
30 31
√ ATD
1 3 3 1
0 0
0 2 0 0 0 0
1 2
32 33
Pain persists
after anesthesia
Pain? 8 6 Dendritic
cells
5
1 2 3 4 5 6 7 8 9 10 Nerve
density
provoked or increased by
34 35
+ Dry mouth Yes! There is a nociceptive

source! ATD!
Co‐morbid Sjögrens? ATD Neuropathic
Likely? Likely?
PSP, SP‐1, CA‐6 Ab SS‐A and SS‐B
• SP1 IgM ab 73.2 • SS‐A/Ro <1.0  Low tear  Light/wind
• CA VI IgG ab: 19.5 • SS‐B/La <1.0 production sensitivity
• PSP IgA ab: 17.6  Sarcoidosis  Persistent pain
• PSP IgM ab: 25.6 ButMarker
 + Early pts are allowed to have
more than one problem!
36 37
Ocular surface
inflammation Abnormal nerves
Anti‐inflammatory √ Autologous Serum

Tears (AST) √
Failed cyclosporine 0.05% ‐
> lifitegrast
38 39
”My eyes burn and I taste something unpleasant

when I use Xiidra and my eyes still feel dry.”
OD 1
Telangiectasias IPL laser √ Inflammation better!
Ocular surface
inflammation
Cyclosporine
0.09%
√ OS 1
40 41
“ My eyes still feel dry and I am still SO "I feel much better with the
sensitive to wind and light!” botox injections. I already
know when it’s almost time “I am so happy with my
for it because I start to feel current treatment. I am
my migraines returning.
Abnormal Botulinum finally able to tear with
They went from 2‐3x/week
nerves toxin injection √ to only 1x/month. “
emotion for the first
time in years.”
42 43
Approved for chronic migraine. All improve with botulinum toxin given for
chronic migraine.
37 sites ~155 Units Independent of tear volume. Diel. Ophthalmology. 2018.

Diel. Br J Ophthalmol. 2019.
44 45
Modified
migraine  Treatments that improve pain outside
protocol the eye can be considered for ocular
pain with presumed neuropathic
contributors.
• 35 units: 7 injection sites  Everyone loves botulinum toxin!
• 5 units in procerus
• 10 units in corrugators
• 20 units in frontalis muscles
46 49
 Painful dry eye symptoms can have

multiple etiologies.
 Evaluate and address each
component.
 Multiple modalities available to treat
nerves‐> think holistically.
130
Dr. Paulo E.C. Dantas
1 0 /6 /2 0 2 2
CTK
Central toxic keratopathy
DLEK, CTK and PISK

Treating and preventing the K’s
Paulo E C Dantas, MD, PhD

São Paulo, Brasil
1 4
PIS PISK
Pressure-induced Stromal Keratitis
Steroid Anti-glaucoma drops Inflammatory

Start IOP response response cells interface Incidence
DLK 24 TO 48
0,13% to 18,9%
Diﬀuse lamellar hours after Normal YES NO YES
(3)
keratitis surgery
CTK 2 to 6 days 0,2% to 0,77%

Central toxic Normal YES NO YES
after surgery (1)
keratopathy
PIS PISK
Pressure- > 1 week after
High NO YES NO Unknown (2)
induced Stromal surgery
Keratitis K
1. Morshifar M et al. Central toxic keratopathy. Curt Op Ophthalmol. 2010;21:27hir

2. Tourtas K et al. Pressure-induced interlamellar stromal keratitis after LASIK. Cornea 2011;30:920rta
3. Smith RJ et all. Diffuse lamellar keratitis. A new syndrome in lamellar refractive surgery. Ophthalmology 1998;175:1721h
2 5
UTILIZAÇÃO 0 X - AUMENTO 1.000 X UTILIZAÇÃO 2 X - AUMENTO 1.000 X UTILIZAÇÃO 4 X - AUMENTO 1.000 X
DLK 1
Diﬀuse lamellar keratitis
Stage 3
UTILIZAÇÃO 0 X - AUMENTO 350 X UTILIZAÇÃO 2 X - AUMENTO 350 X UTILIZAÇÃO 4 X - AUMENTO 350 X
UTILIZAÇÃO 0 X - AUMENTO 50 X
UTILIZAÇÃO 2 X - AUMENTO 50 X UTILIZAÇÃO 4 X - AUMENTO 50 X
3 6
1 0 /6 /2 0 2 2
Steven Johnson Syndrome Combined cataract surgery and DSO

A never ending story
Paulo E C Dantas, MD, PhD Paulo E C Dantas, MD, PhD

São Paulo, Brasil São Paulo, Brasil
7 10
Paulo Elias Correa Dantas, MD

DGNS Oftalmologistas Associados, São Paulo, Brasil
Sorocaba Eye Hospital, São Paulo, Brasil
Fuchs Dystrophy and cataract
Surgical intervention for Stevens-Johnson Syndrome
A never ending story…
DMEK
Combined or sequential?
Chemical burn Ocular cicatricial Auto-immune

Stevens-Johnson Thermal bur
pemphigoid diseases
8 11
Combined vs. Sequential 2
Gerrit Melles
Cataract extraction first, or DMEK first?
If the cataract is advanced, we will ask the patient to

return to his or her referring ophthalmologist for a
cataract extraction.
We tell the patient that his or her vision may improve or

decline after the cataract surgery, depending on the
severity of the corneal dystrophy. If indicated, we can
perform (advanced) DMEK surgery starting six weeks
after the cataract operation.
We can also perform (advanced) DMEK in the absence

of cataracts. A cataract extraction is not a prerequisite
for DMEK surgery.
9 12
1 0 /6 /2 0 2 2
KeraNet Pool
42 experienced corneal surgeons responded
Sequential Combined
22
21
21 52,3%
20
47,7%
19
Sequential Combined
13
KeraNet Pool
42 experimented corneal surgeons responded
DMEK First Cataract first
18
14
18,2% 81,8%%
0
DMEK First Cataract first
14
15
Cataract Surgery in Severe
Ocular Surface Disease

Associate Professor
Director, Ocular Surface Service
Director, Ocular Microbiology Laboratory
1 2
The Ocular Surface is…like a garden! Limbal Stem Cell Deficiency (LSCD)
• Needs to be wet and well nourished

• Smooth and soft Conjunctivalization of the cornea, vascularization, chronic inflammation,
• Well protected and persistent epithelial defects (Tseng et al1994)
• Every structure counts
Tsubota et al in: Ocular Surface Disease. Holland and Mannis 2001
3 4
5 6
Ocular Surface: The Enemy Ocular Surface Clinic: The Enemy
• Congenital • Ocular Cicatricial Pemphigoid
• Severe Dry Eye
• Trauma
– Secondary Sjörgens
• Autoimmune • Stevens Johnson Syndrome
• Atopic • Atopic Disease
• Infectious • LSCD
• GVHD
• Iatrogenic • Congenital/Genetics
• Metabolic
7 8
Surgical plan Cas #1

OD OS
VA HM 20/600
PIO 7 5
Lens White Cataract PCIOL
Optimizar la superficie ocular a base de

controlar los agentes causales y las
comorbilidades
Espana et al. Eye 2004
9 10
OD OS
Caso #1 Caso #1
11 12
After 5 months of immunosupression: Mycophenolate
AVMC post-operatoria OD = 20/250

13 14
Case 2
• Monocular patient
• OCP
Post op Vasc 20/250, scleral lens 20/50

15 16
17 18
Conclusion Thank you/Muchas Gracias
• Inflammation
• Epithelium
• OR planning
• Post op management
19 20
Dr. Angela Y. Zhu
Resumen del Curso 2022
Angela Zhu, MD
Título: “Problemas en el segmento anterior en la población pediátrica, Parte I: Historia de tres córneas”
Palabras clave: queratoconjuntivitis, granuloma, lesiones corneales inflamatorias
Objetivos:
• Presentar 3 casos diferentes de lesiones corneales inflamatorias pediátricas.

• Revisar las modalidades de pruebas diagnósticas complementarias y las opciones actuales
de tratamiento de estas afecciones.
• Hablar sobre las posibles complicaciones que amenazan la visión y destacar las diferencias
entre el tratamiento específico de cada afección.
Resumen:
Un bebé de 4 meses, un niño de 15 meses y un niño de 2 años presentaron enrojecimiento unilateral

persistente, fotofobia y opacificación corneal progresiva. El bebé de 4 meses presentó 2 meses de
enrojecimiento inferior del ojo derecho, sensibilidad a la luz, lagrimeo y lesión corneal y conjuntival
“blanco-amarillenta” que no mejoraron con la aplicación de antibióticos tópicos durante 1 mes. El niño
de 15 meses presentó 2 meses de inflamación del ojo izquierdo, fotofobia, enrojecimiento difuso y
opacificación corneal progresiva que no mejoraron tras la aplicación de ungüento y gotas antibióticas
tópicas y gotas antihistamínicas. El niño de 2 años presentó un año de episodios recurrentes de
inflamación del ojo izquierdo, enrojecimiento, sensibilidad a la luz y opacificación corneal; se notifica
mejoría de los episodios con tratamientos tópicos con antibióticos, esteroides y antihistamínicos, pero
siempre reaparecen y los síntomas persisten a pesar del tratamiento. Todos los pacientes fueron
examinados con anestesia, con imágenes diagnósticas y pruebas de laboratorio, según lo indicado
debido a la dificultad de la exploración clínica en el contexto de fotofobia significativa. Tras el inicio del
tratamiento médico adecuado, todos los pacientes presentaron mejoría en signos y síntomas, pero
siguen teniendo un alto riesgo de sufrir complicaciones visuales derivadas de ambliopía secundaria a
opacidades corneales, empeoramientos recurrentes de la enfermedad y el glaucoma y las cataratas
posteriores debido al uso crónico de esteroides.
Abstract for Curso 2022
Angela Zhu, MD
Title: “Problems in Pediatric Anterior Segment, Part I: A Tale of Three Corneas”
Key words: keratoconjunctivitis, granuloma, inflammatory corneal lesions
Objectives:
• To present 3 different cases of pediatric inflammatory corneal lesions

• To review diagnostic ancillary testing modalities and current management options for these
conditions
• To discuss potential vision-threatening complications and highlight differences between the
unique management of each condition
Abstract:
A 4-month-old boy, 15-month-old boy, and 2-year-old boy all presented with persistent unilateral
redness, photophobia, and progressive corneal opacification. The 4-month-old boy presented with 2
months of right eye inferior redness, light sensitivity, tearing, and “yellow-white” corneal and
conjunctival lesion, not improved with topical antibiotics for 1 month. The 15-month-old boy presented
with 2 months of left eye swelling, photophobia, diffuse redness, and progressive corneal opacification,
not improved after topical antibiotic drops/ointment and antihistamine drops. The 2-year-old boy
presented with 1 year of recurrent episodes of left eye swelling, redness, light sensitivity, and corneal
opacification; reports episodes improve with courses of topical antibiotic, steroid, and antihistamine
treatment, but always recur and symptoms persist despite treatment. All patients underwent
examination under anesthesia with diagnostic imaging and lab testing as indicated due to difficulty with
clinic examination in setting of significant photophobia. After initiation of appropriate medical
management, all patients had improvement in their signs and symptoms but remain high-risk for visual
complications resulting from amblyopia secondary to corneal opacities, recurrent disease flares, and
subsequent glaucoma and cataracts secondary to chronic steroid use.
Dr. Angela M. Fernandez
Dr. Angela M. Fernandez
Syllabus
Pediatric Eyelid Problems

Eyelid problems are frequent in infancy. Among these, infectious diseases are common,
due to the contamination susceptibility of patients of this age group. Toy and other object
manipulation, interaction with active infection patients or asymptomatic carriers, and
subsequent eye rubbing, promote frequent and recurrent infections in the different age
groups under 18 years of age. Understanding the course, contamination pathways,
appropriate antibiotic treatment and additional therapeutic tips, will contribute to a
successful outcome.
Problemas palpebrales en la infancia

Las alteraciones palpebrales son frecuentes en la infancia. Dentro de estas, los
procesos infecciosos son comunes debido a la capacidad de contaminación de los
pacientes en esta edad. Prácticas como manipulación de juguetes u otros objetos, la
interacción con pacientes con infecciones activas o portadores asintomáticos, y el
posterior frote de los ojos, promueven infecciones frecuentes y recurrentes en los
diferentes grupos de edades en menores de 18 años. Entender el curso de la
enfermedad infecciosa, sus rutas de contaminación, y las estrategias coadyuvantes
en el tratamiento antibiótico específico, contribuyen a una terapia exitosa y una
recuperación efectiva de la enfermedad.
Dr. Roberto Warman
Curso Interamericano
Epidemia Mundial de Miopía
2022
• Dilemas en el Control de la Miopía

• MiSight vs Atropina 0.01% y 0.05%
• Roberto Warman MD • Miopía vs Miopía Patológica

• Ann Mueller • Extremo en países Asiáticos pero con presentación Global
• Crisis para el año 2050 pero implicaciones inmediatas
1 2
Potenciales Complicaciones de la Miopía Patológica Tratamientos Históricos
• Desprendimiento de retina • Lentes bifocales o progresivos

• Maculopatía miópica • Atropina al 1%
• Asociación con glaucoma • Disminuir la lectura
• Asociación con cataratas • Ortoqueratología
• Otras asociaciones
• Cada dioptría extra de miopía aumenta las probabilidades
3 4
Tratamientos Actuales Sulfato de Atropina y Control de la Miopía
• Sulfato de Atropina 0.01% • Atom 1 y Atom 2:estudio de Singapore

• Sulfato de Atropina 0.05% • Lamp: estudio de Hong Kong
• Otras concentraciones de Sulfato de Atropina • Dosis bajas no hay rebote al suspender
• Lentes de contacto desechables MiSight • 65-70% exitoso
• Lentes de Contacto Multifocales
• En USA no hay fármaco comercial solo diluyendo y Off label FDA
• Anteojos Essilor Stellest y Miyosmart Hoya
• Exposición al sol
• Ortoqueratología
5 6
Lentes de Contacto MiSight Experiencia en Población del Sur de la Florida
• Unico aprobado por FDA para uso en USA en este momento • Estudio no es randomizado
• Estudio multinacional prospectivo patrocinado por la companía • Experiencia comienza sólo con atropina 0.01% y después de la
• 65-70% efectivo publicación de LAMP menores de 12 años con 0.05%
• Mismo material de otros lentes desechables diarios de uso • Misight aparece durante COVID en el 2020 y experiencia menor y
frecuente limitada
• Inicialmente solo graduación -2.00 a -6.00 recientemente • Data con A-Scan limitada por falta de cooperación
expandido a -8.00
• Sólo enmascara astigmatismo muy bajo
7 8
DATA Preguntas para Estudios Subsecuentes
• Se actualiza el día de la presentación • Desde que edad se debe comenzar tratamiento?

• Los Sindromes con degeneración retiniana responden al tratamiento? I.E
Stickler’s y ROP
• Comenzar con miopía muy baja o sin ella si hay historia importante de
Miopía patológica en familiares cercanos?
• Cuál es el umbral de cambio en la miopía en un año para comenzar?
• Cuando combinar atropina con MiSight?
• A que edad se debe suspender?
• Mínimo tiempo de tratamiento para determinar si es efectivo y
continuarlo?
9 10
• Muchas Gracias
11
Dr. Thomas E. Johnson
RESUMEN DEL CURSO 2022
Reparación de defectos óseos orbitales complejos
Las fracturas del suelo óseo y de la pared medial son secuelas frecuentes de los traumatismos orbitarios.
La mayoría de las reparaciones de fracturas son simples. Sin embargo, las fracturas complejas pueden
presentar retos importantes. En esta charla se explicarán algunas fracturas orbitarias complejas o poco
frecuentes y sus hallazgos clínicos, y se describirán las técnicas paso a paso para evaluar y reparar estos
complejos defectos óseos orbitarios.
ABSTRACT CURSO 2022
Repairing Complex Orbital Bony Defects
Fractures of the bony floor and medial wall are often the sequelae of orbital trauma. Most fracture
repairs are straight-forward. However, complex fractures can present significant challenges. This talk
will illustrate some complex or unusual orbital fractures, their clinical findings, and describe step by step
techniques to evaluate and repair these complex orbital bony defects.
Dr. Miguel N. Burnier, Jr.
TRADITIONAL, OPTICAL & LIQUID BIOPSIES:
A PATIENT‐CENTRIC JOURNEY
Traditional Biopsy Ocular Biopsies

‐ Incisional & ‐ Diagnostic H&E stain
excisional vitrectomy ‐ Special stains
‐ Fine needle ‐ Chorioretinal ‐ Immunohistochemical
aspiration biopsy markers & panel
TRADITIONAL, LIQUID & OPTICAL
BIOPSIES ‐ Core biopsy
Miguel N. Burnier Jr., MD, PhD, FRCSC
Director, Training & Development, MUHC‐RI
Professor of Ophthalmology, Pathology, Medicine, Oncology, Surgery
Chair, Department of Ophthalmology (1993‐2008)
Optical Biopsies Liquid Biopsies
Director, The MUHC‐McGill University Ocular Pathology & Translational Research Laboratory
Editor‐in‐Chief, Emeritus, CJO ‐ Retinal OCT ‐ Blood & other fluids
Past‐President, PAAO ‐ CMCs, DNA,
Member of Executive Board, PAAO ‐ New software & extracellular vesicles
Member, AOI Chair# XLV
FARVO, Fellow of ARVO lenses (exosomes)
Member, CAHS – Canadian Academy of Health Sciences
Professor, Honoris Causa – EPM ‐ UNIFESP
1 2
Immunohistochemistry – Sebaceous Carcinoma
Adipophilin
T Milman, MJ Schear, RC Eagle. Diagnostic utility of adipophilin immunostain in periocular
carcinomas. Ophthalmology. 2014 Apr;121(4):964-71
3 4
Diagnostic Vitrectomy CLINICAL HISTORY 23 year old male, no past medical history
OD: Normal exam, 20/20, IOP: 14 mmHg
 Vitreous specimen OS
 Centrifuge -1000 rpm –
VA 20/80
8 minutes
 Smear slides – Giemsa IOP 30 mmHg
 Special stains - PAS, GMS
 Immunohistochemistry 4+ cells, no KPs

SLE
 Cell block Mildly ↓ corneal
sensation
FUNDUS  2+ vitreous cells
Primary Intraocular Lymphoma  No disc edema, retinitis,

Retina & CNS vasculitis
CD20 Diagnosis: Posterior uveitis – topical

prednisolone q2h and IOP meds
5 6
Case Presentation 23 year-old Uveitis OS
 Lost to follow-up.
 Deterioration of  Total retinal detachment
vision OS.  360°peripheral
 Pain & recurrent whitening/necrosis
inflammation.  Large, peripheral tears
 Retinal detachment.  No mass observed, normal
 ARN as differential choroid
diagnosis.  360°retinectomy,
 Surgery to repair perfluoron, laser, silicone oil
retinal detachment  Cassette sent for
was indicated. pathology
 Started on Valtrex
Orellana ME, Brimo F, Auger M, Galic J, Deschenes J, Burnier MN Jr. Diagn Cytopathol 2010 38(1):59-64
7 8
Retinoblastoma in an adult patient

Handling of Chorioretinal Biopsy
Specimen
RETINA
1 2 3
CHOROID
1 - 4% Glutaraldehyde - Formalin 1 - Histopathology - TEM -PCR
2 - Frozen sections - Formalin 2 - Immune-pathology - In Situ Hybridization
3 - Microbiology - tissue culture 3 - Virus, bacteria, fungus, parasite
9 10
CD20
Multiple lesions between
RPE & Bruch’s membrane
Carlos Augusto Moreira Neto – The histopathology & OCT

CD3
Correlation in eye bank eyes, PhD Thesis, EPM 2017
11 12
 62 year-old man
 Decreased visual acuity OS
 History of systemic B-cell OD
lymphoma - remission 7 years
OS
OS
13 14
Bergeron S, Miyamoto D, Sanft DM, et al. Novel application of anterior segment optical coherence
tomography for periocular imaging. Canadian journal of ophthalmology Journal canadien
d'ophtalmologie. 2019;54(4):431-437
LIQUID BIOPSY IN OPHTHALMOLOGY
Bergeron S, Arthurs BA, Sanft DM, et al. Optical coherence tomography of peri-ocular skin
cancers: an optical biopsy. Ocular Oncology and Pathology. 2020, in press
• Uveal melanoma is a systemic disease
• Onset of primary tumor?
• Metastatic disease to the liver
• TNM ‐ TCMcsM
• All patients have circulating malignant cells
Nested RT-PCR
OCT imaging to assess peri‐ocular skin CJO Editorial: Circulating uveal melanoma cells: should we test for them?
cancers using the anterior segment lens Bruno F. Fernandes, Rubens N. Belfort, Sebastian Di Cesare, and Miguel N. Burnier Jr.
CJO 43:155‐8 2008.
15 16
WHAT ARE LIQUID BIOPSIES? WHAT ARE LIQUID BIOPSIES?

Exosomes: Exosomes:
Small membrane‐ Small membrane‐
derived vesicles derived vesicles
that contain
functional
Liquid biopsy is a simple and non‐invasive that contain
functional
Circulating
biomolecules that
reflect their cell of
alternative to surgical biopsies that
Circulating
biomolecules that
reflect their cell of
origin
tumor cells
(CTCs):
origin
enables us to discover a range of
tumor cells
(CTCs):
Tumor cells that
detach from the
Circulating nucleic
information
Tumor cells that
detach from the about a tumor through a
Circulating nucleic
tumor and tumor and
enter circulation acids: enter circulation simple blood sample
acids:
Small fragments Small fragments
of nucleic acids of nucleic acids
released into released into
blood (e.g. ctDNA) blood (e.g. ctDNA)
17 18
LIQUID BIOPSY – EXOSOMES
THE POTENTIAL APPLICATIONS OF LIQUID BIOPSIES
• Patients of different stages of UM – no evidence of metastatic
disease:
• 54 year‐old male, radiation, 10 years survival ‐ 1
Unknown exact location of tumor or difficult to sample • 65 year‐old male with a large nevus (2mm thickness) ‐ 2
• 61 year‐old male, radiation, 6 years survival – 3
• 68 year‐old male, radiation, 17 years survival UM + Prostate cancer – 4*
Serial biopsies are not always feasible • 89 year‐old female, enucleation, 23 years survival ‐ 5
0.35
0.30
Detect disease, relapse or metastasis prior to imaging
Tumor Volume (cm3)

* PSA < 0.2 at the time of 0.25
or symptoms blood collection 0.20
0.15
0.10
Monitor genomic changes in tumor over time
0.05
0.00
Modify treatment according to molecular changes – 1 2 3 4 5
personalized medicine
Exosomes + Rabbit Animal model UM
19 20
MUHC – McGill University Ocular Pathology &

Translational Research Laboratory
Clinical – Liquid biopsy study

‐ 40 Nevi
‐ Size & Thickness
‐ Subretinal fluid
‐ Orange pigment
‐ Surrounding halo absence
‐ Drusen absence
‐ Peripheral blood
‐ Isolate & characterize
exosomes by proteomics
21 22
TRADITIONAL, OPTICAL & LIQUID BIOPSIES:

CONCLUSION: THE VALUE OF LIQUID BIOPSIES A PATIENT‐CENTRIC JOURNEY
Traditional & Ocular Biopsies

Noninvasive approach to monitor disease H&E, special stains, Immunohistochemical panel
Detect the disease progression before Diagnosis & Prognosis

symptoms appear
Optical & Liquid Biopsies
Study the biology of the disease over time OCT, special software, CMCs, DNA, Exosomes
Modify treatment according to biology – Prognosis & Recurrences

Personalized Medicine Surgical margins
Disease progression
Treatment & Personalized Medicine
23 24
25
Dr. Raquel Goldhardt
Since December 2019 …
COVID-EYE
Raquel Goldhardt, MD FACS
1 in 10 people exposed to Covid‐19
experience at least one eye problem
1 2
Ophthalmologists may be the Etiology

first medical professional to • SARS‐CoV‐2
– novel enveloped
evaluate a patient with COVID‐19 – positive single‐stranded RNA beta coronavirus
– originally linked to an outbreak in Wuhan of China's Hubei province
• Suspected route of transmission

– Direct contact with mucous membranes
• including the eye
• Coronaviruses can cause severe ocular disease in animals

• Ocular manifestations in humans are typically mild and rare
3 4
•. 2020
Epidemiology
•. 2020
Ocular surface and cornea

•.
• Follicular conjunctivitis
As of 21 August 2022 • Viral keratoconjunctivis
 Follicular conjunctivitis more common
593 million confirmed cases in the middle phase of the disease
 Conjunctival swab remain
6.4 million deaths + for about 5 days
have been reported globally • Hemorrhagic and pseudomembranous conjunctivitis

• Conjunctivitis in children Cheema et al, J Ophthalmol. 2020
Navel at al, Am J Ophthalmol Case Rep 2020
.
5 6
•. 2020
•. 2020
Multisystemic Inflammatory Syndrome in Children
Ocular surface MIS‐Cand cornea Episclera / Sclera
•.
• Follicular conjunctivitis
• Viral keratoconjunctivis
 Follicular conjunctivitis more common 29‐year‐old man 31 yo female
Initially with cough and myalgia
in the middle phase of the disease Redness and foreign body sensation
No fever
 Conjunctival swab remain Symptoms started 2 days before
3 days later:
7 days later:
‐ red eye
+ for about 5 days ‐ headache ‐ FBS 67‐year‐old woman
‐ shortness of breath ‐ epiphora 3 weeks after viral symptoms
‐ cough ‐ photophobia ‐ Diffuse chemosis, engorgement of superficial and
• Hemorrhagic and pseudomembranous conjunctivitis ‐ fever (39.2 °C)
RT‐PCR (nasopharyngeal) + COVID‐19
deep episcleral vessels with episcleral and scleral
edema, peripheral ED in the OS
• Conjunctivitis in children
‐ 1 week later: necrotic areas
‐ 3 months: improvement after IST and biologic agents
Pouletty et al Annals of the Rheumatic Diseases
Angurana et al Indian J Pediatr. 2022
Otaif et al., Am J Ophthalmol Case Rep. 2020

Mendez Mangana et al Acta Ophthalmol 2020
Feizi et al, Cornea. 2021
7 8
Anterior Chamber Posterior Segment Manifestations

Vascular – Inflammatory ‐ Neuronal
19 seconds
• Acute anterior uveitis

– in isolation
– in association with COVID‐19 related
multi‐system inflammatory disease
47 seconds
– Reactivation of idiopathic AU s/p COVID
Mazzotta C, Giancipoli E. Int Med Case Rep J. 2020 Walinjkar et al., Indian J Ophthalmol. 2020
Bettach E et al J Med Virol. 2021 Gaba et al. Am J Case Rep. 2020
Yahalomi T et al. Am J Ophthalmol Case Rep. 2020
9 10
Posterior Segment Manifestations Posterior Segment Manifestations

Vascular – Inflammatory ‐ Neuronal Vascular – Inflammatory – Neuronal AMN and PAMM
43 seconds Murchison AP et al. Clin Neurol Neurosurg. 2021
Montesel A et al. Front Pharmacol. 2020
Acharya et al. IDCases. 2020
4 minutes and 22 seconds
Gascon et al. Ocul Immunol Inflamm. 2020
11 12
Posterior Segment Manifestations Posterior Segment Manifestations
Vascular – Inflammatory – Neuronal Purtcher‐like Vascular – Inflammatory Serpiginous Choroiditis
Bottini AR et al. Case Rep Ophthalmol Med. 2021 Providência J et al. Eur J Ophthalmol. 2022
13 14
Neuro‐Ophthalmic Manifestations Neuro‐Ophthalmic Manifestations

Optic Neuritis Optic Neuritis
Falcone et al. JAAPOS. 2020

Sawalha et al. J Investig Med High Impact Case Rep. 2020
Belghamaidi et al. Am J Case Rep. 2020
Palao M et al. Mult Scler Relat Disord. 2020
Dinkin et al. Neurology. 2020
15 16
Visual Cortex Orbit and Ocular Adnexa

• Acute stroke affecting the
posterior visual pathways
– Incidence of stroke is 7.6 X higher than that of
patients with influenza and has been
occurring in a far younger than average
patient population without classic vascular
risk factors
– Homonymous visual field deficits Systematic review 101 cases:
82 cases were from India and 19 from the rest of the world
Case: Bilateral posterior cerebral artery ischemic strokes presenting as a • Predominantly male (79%) ‐> 80% of which had diabetes and 15% with concomitant DKA
homonymous visual field defect in a 12‐year old patient with • Nearly 60% of the cases reported rhino‐orbital involvement
multisystem inflammatory syndrome related to COVID‐19 • Mortality in 30% of the cases
Turbin et al. Orbit. 2020 Sen et al. Indian J Ophthalmol. 2021
Singh et al. Diabetes Metab Syndr. 2021 Werthman‐Ehrenreich A. Am J Emerg Med. 2021
17 18
Pearls and Issues
• Ocular shedding of SARS‐CoV‐2 via tears
• Conjunctivitis or tearing can be the first presentation and even sole manifestation in a patient with the
COVID‐19 infection
• Every structure of the eye can be affected • Nicholas Reyes, MD, MS

• Anat Galor, MD, MSPH
• SARS‐CoV‐2 may trigger or exacerbate inflammatory/demyelinating disease
• Patients may present with chemosis in advanced cases or follicular conjunctivitis
• Ocular examination: ALWAYS wear gloves and extension instruments (cotton swabs, etc.) to avoid direct
contact with secretions
• Continue to practice telemedicine when possible
• Physicians most at risk of becoming infected: ophthalmologists, otolaryngologists, and anesthesiologists
19 20
Dr. Janet L. Davis
Susac Syndrome - Curso 2022
Susac Syndrome
• Too rare to be relevant? Or overlooked?
Classic Triad:
Endothelialitis
Encephalopathy
Susac Syndrome Retinal arteriolar occlusions
Janet Davis MD Sensorineural hearing loss
Professor
Curso November 2021
9/12/22 Davis JL BPEI 1 9/12/22 Davis JL BPEI 2
1 2
Index Miami Case – 38-year-old healthy man Classic findings and essential testing
• 11/15/2015:
• Multiple strokes • Encephalopathy MRI of brain with contrast
• Cerebral vasculitis • Personality changes Hyperintense T2 round lesions in
Oral prednisone • Stroke corpus collosum
• 12/4/2015: • Headache (new, severe) O
• Vision loss
• Hearing loss • Retinal vasculopathy Wide angle fluorescein angiography P
BRAO, SAWH H
• Diagnosis SUSAC • Branch retinal arteriolar occlusions T
• Arteriolar wall hyperfluorescence
• Retinal thinning
OCT and OCTA H
Thinning and decreased vascularity O

TREATMENT
• IV steroids then oral • Sensorineural hearing loss
• IVIG every 2 wks • Deafness Audiometry
• Mycophenolate 3g/d • Tinnitus Tinnitus, hearing loss, vertigo
• Rituximab q 2 mo • Vestibular
• Bactrim TIW
Doing well on 8/10/2016 with no new occlusions
3 4
European Diagnostic Criteria Brain: Pathognomonic corpus collosum infarcts

• Reference cohort of 32 patients • Definite Susac: • 39-year-old man with severe headache, photopsias, and sudden onset
• Definite Susac syndrome 1. Brain symptoms and imaging of hearing loss in the right ear
• Mean age 30.5 +/-9.6 years 2. Retinal angiographic findings or Rennebohm R, Susac JO, Eagan RA, Daroff RB. Susac’s
branch retinal ischemia
• Female: male ratio 2.2 : 1 Syndrome – An Update. J Neurol Sci. 2010 Dec 15;299(1-
2):86-91. doi: 10.1016/j.jns.2010.08.032.
No symptoms needed
• Anti-endothelial antibodies in 25% No vitreous or anterior cell
• Non-specific CSF findings 3. Vestibulocochlear symptoms Low frequency hearing loss
supported by specific testing Cochlear infarction
• Probable Susac: 2/3 criteria
Rennebohm RM, Lubow M,
• Possible Susac: in the differential Ruisin J, Martin L,
Gryzbowski DM, Susac JO.
Kleffner I et al. J Neurol Neurosurg Psych 2016 87(12):1287
Pedi Rheum 2008. doi 10.1
9/12/22 Davis JL BPEI 5
186/546-0096-6-3
9/12/22 Davis JL BPEI T2 weighted scan 6
5 6
Janet L Davis - BPEI Miami FL

Ear: Hearing loss with tinnitus Retina: Sudden onset field defect and headaches
• Low frequency hearing loss
• Cochlear infarction
• Vestibular symptoms
• Rennebohm RM, Lubow M,

Ruisin J, Martin L, Gryzbowski
DM, Susac JO. Pedi Rheum 2008.
doi 10.1 186/546-0096-6-3
Subtle retinal findings
Cotton wool patches
No vitreous cell
7 9
Wide-field angiography Segmental arteriolar wall hyperfluorescence

Indicated in all suspected cases to enable diagnosis Microangiopathy, capillary closure
10 11
Acute arteriolar inflammation during treatment Recanalization without sheathing

Response: high dose corticosteroids, shortened interval of IViG, increased mycophenolate
Thinning on map

Recurrent SAWH in same arteriole
12 13

Tapered to IvIG infusions and IV corticosteroids

with asymptomatic recurrence in same arteriole
Gass Plaques
• Considered pathognomonic
• Not hyperfluorescent or seen on
angiography
• Not on occluded arterioles
• Similar in appearance to Kyrieleis
plaques seen in infections
Progressive arteriolar narrowing SAWH on FA 46 seconds SAWH on FA 11 minutes
J Neurol Sci 2010 299:97-100

14 15
Susac with Acute Macular Neuroretinitis OCTA confirmation of capillary closure

Infrared
OCTA deep capillary structure OCTA avascular structure C scan
Carmen Alba-Linero 1, John Paul Liscombe-Sepúlveda 2, Victor Llorenç 3, Joan GiraltJosa 3, Alfredo Adán. Eur J Ophthalmol
. 2020 Oct 26;1120672120965482. doi: 10.1177/1120672120965482.
16 17
Anatomic and functional correlation

Alexandre G B Azevedo 1, Luiz H Lima 1, Léo
Müller 1, Flávio Rezende Filho 2, Cláudio
Zett 1 3, André Maia 1, Luiz Roisman
Anatomical and functional correlation in
Susac syndrome: multimodal imaging
assessment
Int J Retina Vitreous

. 2017 Oct 16;3:39.
doi: 10.1186/s40942-017-0092-
Treatment of Susac
9.eCollection 2017.
18 19

• Anti-endothelial antibodies Guidelines based on severity

• Intravenous immunoglobulin
SUSAC SYNDROME • B cell inhibitor
Cytolytic endotheliopathy • CD8+ T cells directed against antigen on Rennebohm RA,
Internal vessel swelling endothelial cells Asdaghi N,
Srivastasa S,
with occlusion • Conventional immunosuppressive drugs Gertner E.
No leak, stain only • Binding of T cells to endothelium Guidelines for

Treatment of
CNS and ear affected in • Anti-alpha 4 integrins monoclonal Susac. Int J
Stroke 2020
most cases antibodies 15(5): 484
• Natalizumab
Based on similarities
to juvenile
dermatomymyositis
20 21
Conclusion
• Like all rare disorders, clinician must recognize it first
• Onset of the triad of findings can be asynchronous or incomplete
• Consultation with neurologist essential
9/12/22 Davis JL BPEI 22
22

Dr. J. Fernando Arevalo
9/12/22
Financial Interests to Disclose

Posterior Segment Complications • Abbvie: Consultant/Advisor
of Uveitis • GENENTECH: Consultant/Advisor
• Springer SBM LLC: Patents/Royalty
J. Fernando Arevalo, MD PhD FACS FASRS
• THEA Laboratories: Consultant/Advisor
The Edmund F. and Virginia B. Ball Professor of • Topcon Medical Systems Inc.: Grant Support
Ophthalmology • DORC: Consultant/Advisor
Chairman of Ophthalmology at Johns Hopkins Bayview
Medical Center • EyePoint Pharmaceuticals: Consultant/Advisor
Wilmer Eye Institute, Johns Hopkins University • Alimera Sciences Inc.: Consultant/Advisor
Baltimore, Maryland, USA
Co-author Uveitis Complications

Introduction
Uveitis is responsible for an estimated 10%

Andres F. Lasave, MD of blindness in the developed world and up
Clinica Privada de Ojos, Vitreoretinal Division, to 25% in the developing world
Mar del Plata, Buenos Aires, Argentina
The chronic inflammation resulting from
untreated or poorly controlled uveitis is the
main cause of ocular complications, visual
disability, and potential blindness
Uveitis Complications
Introduction
Most severe complications in posterior

uveitis include: chronic macular edema,
retinal scarring, retinal detachment, Uveitic Macular edema
epiretinal membrane, macular hole,
persistent vitreous opacities, and choroidal
neovascularization
9/12/22
Uveitis Complications Uveitis Complications

Uveitic Macular Edema Uveitic Macular Edema
Uveitic macular edema (UME) is a common Poor visual prognostic indicators include
complication and cause of visual impairment in
patients with posterior uveitis, occurring in 33–
46 % of all patients Advanced age
Prolonged duration of uveitis
It is can persist after control of inflammation, Prolonged presence of edema
causing long-standing irreversible changes and Enlarged foveal avascular zone
photoreceptor damage Incomplete vitreous detachment
Chronic Voght Koyanagi Harada Disease

Uveitic Macular Edema
Nummular scarsfundus
Sunset glow and chorioretinal atrophy
in chronic VKH
The linked image cannot
reveal window defects
be displayed. The file
may have been moved,
renamed, or deleted.
Verify that the link
points to the correct file
and location.
BCVA 20/150 Dexa implant
Month 2
Baseline
BCVA 20/30 The critical treatment principle for uveitic ME is to
ensure that the underlying uveitic process is
Dexa implant completely controlled
BCVA 20/80
Sustained control of uveitis, sometimes requiring

use of systemic immunomodulatory therapy, will
BCVA 20/100 Month 5 often be sufficient to also eliminate ME
However, UME does not correlate with degree of

Month 1 active inflammation and may be diagnosed in up to
29% of patients despite an overall inactivity of their
uveitis
Chronic Uveitic Macular Edema
BCVA 20/30 2 m onths after second dex im plant
2
Visual improvement occurs more often when

CME has been present for less than 12 months
compared to longer than 24 months
Retinal Scarring
Chronic edema can lead to permanent
photoreceptor damage, retinal atrophy, and
fibrosis, such that normal vision may not return
even with resolution of edema
21 year-old female
Uveitis Complications BCVA OS 20/200

Retinal Scarring Retinal Scarring BCVA OS 20/40
Uveitis causes spotty areas of scarring that can Retinal Scarring

lead to vision loss
The degree of vision loss depends on the amount

and location of the scarring
The linked image cannot The linked image cannot

be displayed. The file be displayed. The file
may have been moved, may have been moved,
renamed, or deleted. renamed, or deleted.
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AMPPME 1 year of follow up Verify that the link
and location. and location.
9 year-old girl
Retinal Scarring with macular involve
Retinal Scarring BCVA OS CF
202324 Galban, Aylen Yasmin 10-17-2016 12:1:57
202324 Galban, Aylen Yasmin 10-17-2016 12:1:57
Ocular Sarcoid

Diffuse Retinal Scarring may have been moved,
5 yearsVerify
ofthatfollow
the link
7 years of follow upVerify that the link
and location. and location.
9/12/22
Retinal Scarring
Retinal Detachment

Lesions become totally healed with scar, may have been moved,
Verify that the link Verify that the link
they show total hypoautofluoresce points to the correct file
and location.
and location.
Retinal Detachment
Rhegmatogenous retinal detachment is an uncommon
finding in uveitis patients
A higher incidence was seen in patients with active

panuveitis and infectious uveitis
Graefes Arch Clin Exp Ophthalmol 2019; 257: 1857-1861
The risk is specifically higher in patients with acute reti- Retrospective study of 707 patients (1042) eyes with uveitis
nal necrosis, reaching 20–73%
15 (1.4%) eyes with RRD where the most common cause was infectious (ARN)
The linked image cannot
be displayed. The file
may have been moved, Poor visual prognosis due to high frequency of postoperative PVR
Schoenberger S, Kim S, Thorne J, et al. Diagnosis and treatment of acute retinal necrosis: a report by the American Academy of renamed, or deleted.
Ophthalmology. Ophthalmology. 2017;124(3):362–92. Verify that the link
and location.
26 year-old-male
Retinal detachment
Toxocara posterior Giant retinal break
granuloma OD
visual loss OD 1 week ago
BCVA OD Hand motion

OS 20/25
•
Granuloma
• SLE: OU Cornea sp
No cells in AC
Cataract N3+ OD
4
9/12/22
Day 4 post op Month 3 post op
28 year-old male
The choice of retinal tamponade depends visual loss OS

on the degree and severity of the Multifocal Retinitis
contracture and proliferative retinopathy
O ptic D isc Inflam m ation
BCVA OS: 20/60
O clussive vasculitis
However, considering that postoperative

PVR develops in 37% of uveitis patients,
compared to 9% of non-uveitis patients,
most surgeons prefer the use of silicone oil
for achieving tamponade
Rhegmatogenous Retinal Detachment
Endovenous Acyclovir 10mg/kg/ 8 hs Day 10 during Acyclovir therapy 8 weeks after endovenous acyclovir therapy
5
9/12/22
Month 1 post combined Month 12 follow up

SB + VPP
Oral Valacyclovir 1 gr /day Oral Valacyclovir 1 gr /day
BCVA 20/80 BCVA 20/80
Retinal Detachment
Although retinal detachment repair with pars plana

vitrectomy, scleral buckle, long-acting gas, or
silicone oil tamponade has been successful, many
patients require more than one surgery, and visual Epiretinal Membrane
acuity may remain poor after surgery despite
successful reattachment
35 year-old female
Multifocal Choroiditis On SBC MTX since 2 years
Uveitis Complications Visual distortion OD
Epiretinal Membrane BCVA 20/100 BCVA 20/30
Chronic inflammation can result in epiretinal membrane

(ERM) formation
ERM causes surface wrinkling on the retina and

worsening of cystoid macular edema
Longer duration of ERM correlates with increased

thickness, and thicker ERMs correlate with decreased
visual acuity
6
Multifocal Choroiditis Thick epiretinal m em brane
BCVA 20/100
Month 1 post PPV
Outer retinal layers
One of the most important predictors of visual recovery after uveitic

ERM peeling is the integrity of the ellipsoid zone
BCVA 20/30

Epiretinal Membrane Epiretinal Membrane
A mean of 3 or more Snellen lines visual However, surgical decision-making should be
improvement was reported in 71% of patients tailored based on symptoms, degree of functional
during the first 3 months after ERM surgery limitations and presence or absence of active
inflammation
In addition, PPV may also have many additional
benefits in these uveitis patients including
clearance of inflammatory mediators and removal
of vitreous opacities that obscure the fundus and
impair vision
Tanawade RG, Tsierkezou L, Bindra MS, Patton NA, Jones NP. Visual outcomes of pars plana vitrectomy with epiretinal membrane peel in patients with uveitis. Retina. 2015;35(4):736– 41
Macular Hole
Inflammation-related macular hole (MH) is a rare
sequel of posterior uveitis with a prevalence of
Inflammation-related 2.5% among uveitis patients
macular hole
Guarded visual prognosis
They are associated with less favorable functional

and anatomical results compared to idiopathics
MHs
Liu T, Bi H, Wang X, Gao Y, Wang G, Ma W. Macular abnormalities in Chinese patients with uveitis. Optom Vis Sci. 2015;92 (8):858–862
Ebrahimi Z et al. Treatment of Inflammatory Macular Hole: Case Series and Review of Literature. Ocul Immunol Inflamm. 2021 Apr 7:1-7
7
9/12/22
22 year-old female
Uveitis Complications Visual loss OS 2 months ago
SLE: Bilateral KP fine
Macular Hole
OD flare OS cells 0.5 in AC
Behçet’s disease and toxoplasmosis are the most common
etiology of uveitis associated with inflammatory MH
FO Chorioretinal scars in OS Cho
Retinochoroidal atrophy and macular ischemia in the setting
BCVA OD 20/20 BCVA OS 20/200
of chronic posterior uveitis is an explanation for the poor
visual recovery after surgery in these patients
Ebrahimi Z et al. Treatment of Inflammatory Macular Hole: Case Series and Review of Literature. Ocul Immunol Inflamm. 2021 Apr 7:1-7.
BCVA OS 20/200
PPD 15mm
She was on TB therapy since 3 weeks

ago
Ocul Im m unol Inflam m 2021; 7:1-7
BCVA OS Counter Fingers
86 eyes from 27 articles with MH secondary to uveitis that

received either conservative medical treatment alone or PPV
with adequate follow-up were identified
Conservative medical treatment was employed in 34.9%, while

PPV was performed in 65.1% of eyes
2 months later
Macular Hole
Conservative medical control of uveitis should be
Ocul Im m unol Inflam m 2021; 7:1-7
attempted at first as it may lead to closure of
inflammatory MHs, and is required in most cases if
surgery is contemplated
Inflammation-related MHs were closed in 40% of eyes after Patients with inflammatory macular hole respond
conservative therapy and in 87.5% of eyes after PPV well to PPV, with good anatomical and visual acuity
outcomes
Visual improvement occurred in most eyes (83.9%) that had
successful closure of their MH
Callaway NF, Gonzalez MA, Yonekawa Y, Faia LJ, Mandelcorn ED, Khurana RN, Saleh MGA, Lin P, Sobrin L, Albini TA. OUTCOMES OF PARS PLANA VITRECTOMY FOR MACULAR HOLE IN
PATIENTS WITH UVEITIS. Retina. 2018 Sep;38 Suppl 1(Suppl 1):S41-S48.
8
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Vitreous Opacities
Significant vitreous opacities and debris are
sometimes seen in patients with intermediate and
panuveitis
Vitreous Opacities
These opacities can interfere with vision and also
block the view to the retina at the time of exam or
during imaging studies
Vitrectomy in these patients can improve posterior

visualization as well as patient’s vision
BCVA OD : CF
72 year-old female
Uveitis Complications Progressive visual loss BCVA OD
Vitreous Opacities
SLE OD: Cornea fine KPs
They may complain of decreased vision due to
cataract formation or floaters due to vitreous Cells in AC 1 +
opacities
Some authors have also advocated vitrectomy not

only to clear the opacities, but also to improve
Toxoplasmic
macular edema and ocular inflammation
Acute Retinal Necrosis
Bactrim F plus oral Clindamycin Vitreous cells 2+

Haze 3+ Retinitis
Gutfleisch M, Spital G, Mingels A, et al. Pars plana vitrectomy with intravitreal triamcinolone: effect on uveitic cystoid macular oedema and treatment limitations. Br J Ophthalmol. + 2 IVC
2007;91(3):345–8.
6 months of follow-up
Healed nasal lesion Vitreous Opacities
BCVA: CF
Surgery in the management of posterior uveitis can
be divided based on indication, either for
therapeutic or diagnostic purposes or to manage
its complications
Vitrectomy is one of the modality to manage

vitreoretinal complications associated with uveitis
9
9/12/22
Vitreous Opacities
In patients with visually significant vitreous
opacities, pars plana vitrectomy can be offered as a
combined procedure to optimize vision outcomes
Pre PPV
3 weeks post PPV
Inflammatory CNV
BCVA: CF BCVA: 20/40

Inflammatory CNV Inflammatory CNV
Choroidal neovascularization (iCNV) can be a The reported incidence of inflammatory CNV
severe sight-threatening sequela across all forms of posterior uveitis is low with a
two-year incidence of 2.7%
iCNV represent the third most common cause of
CNV after age-related macular degeneration and
pathologic myopia However the rates of inflammatory CNV
development vary significantly according to the
specific disease
Typically occur in young patients and the visual
prognosis is guarded, despite diverse treatment
strategies
Baxter SL, et al. Risk of choroidal neovascularization among the uveitides. Am J Ophthalmol 2013;156:468–77.
10
9/12/22
The most frequently identified cause of iCNV is multifocal choroiditis

(22–50%) and punctate inner choroiditis (PIC) (28-100%) Uveitis Complications
Inflammatory CNV
Inflammatory CNV typically occurs in a younger
demographic and therefore the most common
subtype is type 2 neovascularization, unlike that
noted in the AMD population
Baxter SL, et al. Risk of choroidal neovascularization among the uveitides. Am J Ophthalmol 2013;156:468–77.
Type 2 NV is located in the sub-neurosensory retina compartment and

is correlated with the dye based angiographic feature of classic or well
defined neovascularization
Type 2 or Classic CNV
BCVA 20/200 Baseline
After 3 intravitreal inyections of Anti VEGF
Type 2 CNV abnormal growth of vessels from the choroidal vasculature to the BCVA 20/25 12 months of follow up
neurosensory retina through the Bruch's membrane
11
9/12/22
Subretinal or intraretinal fluid may be a useful biomarker of both

Uveitis Complications activity and treatment response, especially in extra or foveal
Inflammatory CNV lesions where central visual acuity may be preserved
Unlike CNV due to AMD, iCNV is associated with a

better prognosis and requires less injections for BCVA OD: 20/30 BCVA OD: 20/30
stabilization
This may be attributed to the type 2 NV pattern, smaller

size, association with younger patients with healthier
RPE and a good response to the associated
angiostatic effect of the corticosteroids
Yuxtafoveal Inflammatory CNV
Evolution
Leal I, Sousa DC, Costa J, Vaz-Carneiro A. Analysis of the cochrane review: Cortisteroid implants for chronic non-infectious Uveitis. Cochrane database syst rev. 2016;2:CD010469.
130.Acta Medica Port. 2018;31(5):243–6.

Inflammatory CNV Conclusions
Underlying inflammatory activity is a modifiable Uveitis complications are common and may result
risk factor for inflammatory CNV, therefore in severe and permanent visual impairment
inflammation control is crucial in the prevention of
progressive structural and functional macular
damage They may occur during the acute, active phase or
even when remission of the inflammatory process
has been achieved
Leal I, Sousa DC, Costa J, Vaz-Carneiro A. Analysis of the cochrane review: Cortisteroid implants for chronic non-infectious Uveitis. Cochrane database syst rev. 2016;2:CD010469.
130.Acta Medica Port. 2018;31(5):243–6.
Conclusions
Posterior uveitis complications can cause

cumulative structural ocular damage that may
require escalation of medical or surgical therapy
and lead to increased visual morbidity if not
addressed
Therefore early detection and adequate

management is crucial to reduce the risk of
irreversible visual loss
12
Dr. Hong Jiang
Atypical Optic Neuritis Post‐CVOID‐19 Infection
No financial disclosure
Hong Jiang, MD PhD
Associate Professor
Department of Neurology
University of Miami, Miller School of Medicine
21 YOM presented with painless gradual central vision loss in the left eye for 8 months. Additional History
COVID
Severe cough central scotoma OS
OS: HM
OD: transient vision
PMH: Plaque psoriasis
Casirivimab & Progressive enlarged blurry for seconds x1
Imdevimab IV and dense
Meds: cortisone cream as needed;
July 2021 January 2022 August 2022
POH: none
August‐October 2021 July 2022
Mild central blurry OS OS: CF

SH: Does not smoke and drink. Marijuana once a week.
Spontaneously resolved
FH: none
Exam Anterior Segment Exam

• Visual Acuity OD OS
– OD: 20/20 L/L Normal Normal
– OS: HM C/S White and quiet White and quiet
• IOP 16/15 K Clear Clear
• Color: 14/0 A/C Deep and quiet Deep and quiet
• Pupils 4‐>3 round, L

V
Clear
Normal
Clear
Normal
+ APD OS
• EOMs full OU
1
Posterior Segment Exam
OD OS
Disc normal Temporal pallor
Macula Normal Normal
Vessels Normal Normal
Periphery Normal Normal
Neuroimaging Work up
• MRI brain/orbit W WO gad; MRA brain WO gad: normal • Transferred for inpatient workup
• LP with CSF studies
– Opening pressure: 20 CmH2O
– zero cells, normal protein and glucose, and
negative meningitis PCR panel
Lab Workup Disease Course
Serum CSF OS: HM

OD: transient vision blurry
COVID central scotoma OS for seconds x1
Severe cough Progressive enlarged and Start IVMP 1 gm/d x 5d OS:20/350
• CBC, CMP, PT/INR:wnl • HepC: neg • Culture neg Casirivimab & Imdevimab IV dense Followed by Oral Pred taper Central scotoma
• ESR, CRP: wnl • COVID Ag: neg • VDRL neg
• MOG, NMO: neg • Blood cx: neg • Coccidioides neg July 2021 January 2022 August 19, 2022 September 13,2022
• ANA: neg • QuantiFERON‐TB: neg • Meningitis encephalitis panel
• ANCA: neg • Lyme: neg neg
• NeoEncephalitis • RPR: neg • Fungitell: neg
Paraneoplastic Eval: neg • MMA/homocysteine: wnl • MOG Ab: neg August‐October 2021 July 2022 August 21,2022 September 22, 2022
• Hypercoagulable panel: • Brucella AB neg • NMO Ab: neg
Mild central blurry OS OS: CF ecc OS: 20/150
• Lupus anticoagulant: neg • Flow cytometry: neg OS: CF
Central scotoma
Spontaneously resolved Day 3 IV MP
• ACE: wnl • Oligoclonal banding: neg
• HIV: neg • Beta2 microtubulin: wnl
Atypical Chronic Optic Neuritis Post‐COVID‐19 Infection Summary of previous case reports of optic neuritis
associated with COVID‐19
Painless insidiously
Onset 4 weeks
progressive central Negative MOG Ab Eye pain, worse on movement
after COVID‐19
vision loss for 1 and AQP4‐IgG
infection Acute onset
year
Before or after respiratory symptoms
Optic nerve enhancement on MRI

No optic nerve
Responded to Hx: plaque
enhancement on Many with positive MOG Ab
steroid treatment psoriasis
MRI
Landis et al. JNO 2022 42(1):18‐25 14
Post COVID ‐‐‐ Lingering Inflammation Take Home Messages

Chronic
activation of COVID‐19 has been implicated in
microglia in the
brain triggering or exacerbating
inflammatory processes Fear of the infection
leading to autoimmune diseases: Think of COVID should not the leading
• MS, MOGAD, NMO, factor in therapeutic
Continuous
low‐level viral Changes in the
sarcoidosis, etc. Test COVID
replication or
production of
immune system
• chronic production
decision‐making.
of cytokines
viral toxins
Zacharias et al., Autoimmun Rev. 2021;20(9):102883; Gracia-Ramos et al. Cells. 2021;10(12):3592
3
Dr. Mariam Vila Delgado
Infantile Nystagmus • No conflict of interest to declare
Lost to Follow‐Up
Mariam S. Vilá‐Delgado, MD
Neuro‐Ophthalmology
Pediatric Ophthalmology and Strabismus
1 2
HPI History
• CC: 13 months old boy with nystagmus Past Medical History Urticaria
• HPI Meds None
– 2 months: mother noticed shaking of the eyes, described as Past Surgical History Circumcision
intermittent small side to side movements of both eyes, stable Past OPH History None
from onset No FH of blindness, congenital nystagmus,
– 13 months: referred to pediatric ophthalmology was found with Family History
or retinal dystrophies
binocular small amplitude horizontal nystagmus with some
Negative for: head bobbing, nyctalopia or
rotary component OS>OD and referred to neuro ophthalmology
for further work up Review of Systems photophobia, milestone regression,
vomits, behavioral changes
– 14 months: presented to the neuro‐ophthalmology, mother
reported improvement of ~50% in the nystagmus over time
3 4
Exam Fundus Photo

Visual Acuity (Teller Acuity Cards) – tested at 55cm OD: 4.8 cy/cm OS: 4.8 cy/cm OU: 6.5 cy/cm
Intraocular pressure (iCare) OD: 12, OS: 12
Pupils OD: 32, OS: 32 – no APD
Full, X(T)’15
Binocular, conjugate, horizontal nystagmus
Motility – Hirschberg
with torsional component OS>OD, small
amplitude, variable frequency
External Exam WNL OU
Anterior Segment WNL OU
Posterior Segment WNL OU
5 6
Plan Interval Update
•
• MRI and EUA was offered to mother, but she 24 months
– Admitted to local pediatric hospital for recurrent vomits. Patient was sometimes grabbing his head and
screaming with no apparent reason. DCH with a gastroenteritis diagnosis after neurology,
decided to defer, and a 4‐month follow up was gastroenterology, and endocrinology inpatient evaluation. Brain MRI was never performed.
– Follow up appointments with neurology and endocrinology‐ MRI recommended, patient LTFU
scheduled with strict return precautions • 27 months
– Admitted to JMH for increased thirst and urinary frequency. He was drinking ten 12oz bottles of water
per day. Parents report he would wake up in the middle of the night almost every hour to drink water.
Parents also reported increased frequency of the episodes where the patient would grab his head and
• Patient was LTFU x 10 months…

scream associated with episodic vomiting.
7 8
Brain MRI
W W/O Contrast
• 3.6 x 2.9 x 4.5 cm sellar/suprasellar mass
• High T1 and T2 signal rim enhancing
enhancing components and internal cystic
components, likely with proteinaceous
material.
• Layering hemorrhage within the tumor and
multiple foci of susceptibility which may be
related to calcifications within the tumor.
• Mild to moderate enlargement of the lateral
ventricles.
•
•
Imaging characteristics most consistent with a
craniopharyngioma.
Poor visualization of the optic chiasm
NYSTAGMUS IN CHILDHOOD
presumably due to compression.
9 10
Differential Diagnosis Epidemiology

INS represents
87% of all
• Prevalence: 17 for every 10,000 in pediatric
pediatric patients
with nystagmus population
– Acquired nystagmus is estimated to comprise 17%
of nystagmus in children and 40% in adults
11 12
History Clinical Examination
• Onset: <3 months for INS • Nystagmus
– Laterality: Bilateral or unilateral
–
• Prenatal history: Hypoxia, prematurity, IVH
Conjugacy: conjugate vs dysconjugate
– Direction: INS tends to be horizontal, uniplanar but can have a small vertical or rotational component
– Amplitude: larger amplitude usually suggest poorer vision
• Family History: Idiopathic nystagmus often occurs in •

– Latent component: increase in amplitude on covering one eye is seen in FMNS and INS, fast phase away from occluded side
Visual acuity
an X‐linked pattern •
•
Orthoptic examination: strabismus and AHP
Color vision
• Neurological deficits: CP, metabolic diseases, or other •
•
Examination of light sensitivity and nyctalopia
Structural examination
causes of developmental delay –
–
Size: microphthalmia or buphthalmos
Media: opacities occluding visual axis
– Seizures, ataxia, myoclonus, localizing neurological signs –
–
Iris transillumination: albinism
Foveal hypoplasia: missing foveal reflex and abnormal vessels in the foveal area
• History of photophobia or nyctalopia •

– Optic nerve hypoplasia or atrophy: particularly if it is bilateral
Refractive error
• Paradoxical pupillary response: sign of retinal diseases
13 14
INS workup
algorithm
Dumitrescu, A. V., Scruggs, B. A., & MD, A. V. D. (2020, February 13). Clinical guidelines: Childhood
nystagmus workup. American Academy of Ophthalmology. Retrieved May 16, 2022, from
https://www.aao.org/disease‐review/clinical‐guidelines‐childhood‐nystagmus‐workup
15 16
Back to our patient

• 3/26 patients (12%) had • 23/148 (15.5%) children
significant MRI findings had abnormal intracranial
and all three had findings on MRI 04/29/2022
Drainage of the
06/06/2022 07/2022 08/2022
10/2022
Monitor with
temporal ONH pallor – 6 abnormal signal lesion cyst with
placement of an
N‐O follow up,
nystagmus slightly
Frontal
craniotomy for
Endoscopic
procedure for
serial MRI and
consider RT if
noted during clinical – 5 Chiari malformation Ommaya reservoir
improved. tumor resection hydrocephalus
recurrence
examination. – 3 optic pathway glioma
– 2 suprasellar mass – 1 septo‐optic dysplasia
– 1 periventricular – 1 diffuse hypomyelination
leukomalacia
– 1 periventricular
leukomalacia
Shammari MA, Elkhamary SM, Khan AO. Intracranial pathology in young children with apparently isolated nystagmus. J Pediatr Ophthalmol Strabismus.
2012 Jul‐Aug;49(4):242‐6. doi: 10.3928/01913913‐20120221‐03. Epub 2012 Feb 28. PMID: 22372717.
Batmanabane V, Heon E, Dai T, Muthusami P, Chen S, Reginald A, Radhakrishnan S, Shroff M. The role of MR imaging in investigating isolated pediatric
nystagmus. Pediatr Radiol. 2016 Nov;46(12):1721‐1727. doi: 10.1007/s00247‐016‐3669‐9. Epub 2016 Aug 12. PMID: 27518079.
17 18
Take Home Points References
• All types of nystagmus require a step‐by‐step workup, • Batmanabane V, Heon E, Dai T, Muthusami P, Chen S, Reginald A, Radhakrishnan S, Shroff M. The role of MR
imaging in investigating isolated pediatric nystagmus. Pediatr Radiol. 2016 Nov;46(12):1721‐1727. doi:
directed by clinical examination 10.1007/s00247‐016‐3669‐9. Epub 2016 Aug 12. PMID: 27518079.
• Dumitrescu, A. V., Scruggs, B. A., & MD, A. V. D. (2020, February 13). Clinical guidelines: Childhood nystagmus
• Currently there are no definite workup algorithms for workup. American Academy of Ophthalmology. Retrieved May 16, 2022, from https://www.aao.org/disease‐
nystagmus in childhood •
review/clinical‐guidelines‐childhood‐nystagmus‐workup
Nuijts MA, Veldhuis N, Stegeman I, van Santen HM, Porro GL, Imhof SM, Schouten‐van Meeteren AYN. Visual
– Neuroimaging is a key element with an abnormal result in functions in children with craniopharyngioma at diagnosis: A systematic review. PLoS One. 2020 Oct
1;15(10):e0240016. doi: 10.1371/journal.pone.0240016. PMID: 33002047; PMCID: PMC7529266.
12‐15% of patients • Shammari MA, Elkhamary SM, Khan AO. Intracranial pathology in young children with apparently isolated
• Low threshold for investigation should be consider if nystagmus. J Pediatr Ophthalmol Strabismus. 2012 Jul‐Aug;49(4):242‐6. doi: 10.3928/01913913‐20120221‐03.
Epub 2012 Feb 28. PMID: 22372717.
observation is chosen • Udaka YT, Packer RJ. Pediatric Brain Tumors. Neurol Clin. 2018 Aug;36(3):533‐556. doi:
10.1016/j.ncl.2018.04.009. PMID: 30072070.
19 20
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Bascom Palmer Eye Institute

& Pan-American Association

Joint XLIV Inter-American Course in Clinical

XLIV Curso Interamericano de Oftalmología Clínica

October 16 - 19, 2022

Enlace directo al hacer clic sobre el nombre del conferencista

Patrocinadores / Educational Supporters .......................................................................................... 5

Tomografía de Coherencia Optica / Optical Coherence Tomography (OCT)

Oftalmología Pediátrica / Pediatric Ophthalmology

Neuro Oftalmología / Neuro Ophthalmology

DIRECTORES DEL CURSO / COURSE DIRECTORS

Dr. Eduardo C. Alfonso

Dr. Carol L. Karp

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Joint XLIV Inter-American Course in Clinical Ophthalmology (CURSO)

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Sábado, 15 de octubre de 2022

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9:00 Cirugía de glaucoma microinvasiva (MIGS) combinada con cirugía de cataratas