Faculty Bibliography

Purpose/UNASSIGNED:The aim of this study was to test the discomfort experienced during intravitreal injections with eyelid retraction between an eyelid speculum, cotton-tipped applicator (CTA), and unimanual eyelid retraction techniques. Methods/UNASSIGNED:In total, 99 patients receiving intravitreal bevacizumab were enrolled into this prospective study. Participants were randomized to one of the three methods, given subconjunctival 2% lidocaine and then injected in the superior temporal quadrant. Immediately after the procedure, each patient was given a visual analog scale (VAS) to rate their discomfort. Results/UNASSIGNED:The mean pain scores for eyelid retraction with unimanual, CTA, and speculum groups were 0.788 (standard deviation [SD] 0.70, 95% confidence interval [CI] 0.448-1.128), 0.945 (SD 1.28, 95% CI 0.600-1.291), and 1.561 (SD 1.28, 95% CI 1.210-1.912), respectively. A one-way analysis of variance (ANOVA) test revealed a significant difference between the groups (P = 0.006). Post hoc analysis also revealed a difference in mean pain scores between the speculum and both the CTA and the unimanual methods. Conclusion/UNASSIGNED:Our study shows that the unimanual and CTA methods for eyelid retraction are significantly less painful for patients compared to the speculum method. Patient comfort is of the utmost importance as intravitreal injections are performed millions of times a year with most patients requiring multiple injections.

Purpose : To characterize outcomes for patients with re-operated macular holes using a novel technique after failed closure in the initial surgery Methods : A retrospective chart review was conducted on 401 eyes that had undergone macular hole surgery in a private retina practice from 2013 to 2018. Those patients that underwent re-operation for persistently open macular hole were then identified. The initial macular hole surgery was done using pars plana vitrectomy (PPV), hyaloid elevation, internal limiting membrane (ILM) peeling with indocyanine green staining (ICG) with wide removal to the arcades, SF6 gas, and prone positioning for 6 days. For those patients that underwent a successive operation, 25-gauge PPV and a Tano diamond-dusted membrane scraper or Finesse flex loop was used to brush the retina in an outside-in manner in attempts to reduce the hole diameter. No attempt was made to restain the ILM, and C3F8 gas was used for re-operation. Age, race, gender, lens status, initial visual acuities before initial surgery, time to reoperation, and final visual outcomes were recorded. The optical coherence tomography (OCT) images of the initial hole and re-operated hole were analyzed. Results : Eight eyes were re-operated from 2013 2018. Visual outcomes improved by at least 3 lines from the initial prior to surgery to the most recent following re-operation in 7 (87.5%) patients, with all 8 (100%) eyes having macular hole closure. The re-operated eyes had larger hole diameters of >500 microns compared to eyes with successful primary macular hole operation. Conclusions : Previous studies have reported few techniques for re-operation include wider ILM peel/rexis and intraoperative macular hole fluid drainage. In this study, we utilized a technique of brushing the retina in an outside-in manner to help facilitate anatomic closure of the hole. Inner retinal brushing with hole diameter reduction and long-acting gas appears to be a successful treatment for persistent macular holes or possibly as initial surgery for large macular holes

Purpose : We primarily aim to determine the incidence of uveitis-glaucoma-hyphema (UGH) after surgical repair of late, in-the-bag posterior chamber intraocular lens (PCIOL) dislocations treated by PCIOL-capsular complex repositioning and iris-suture fixation technique. Secondarily, we aim to characterize the outcomes of patients with this complication. Methods : We retrospectively reviewed the course of 212 patients with a lens repositioning surgical procedure by a single-surgeon in a four-year period, from 2014-2018. 68 patients with a posteriorly dislocated, in the capsular bag, PCIOL treated with iris-sutured lens repositioning with a follow-up duration of at least 3 months were included. Patients with pre-existing UGH, early dislocation within three months of cataracts extraction, or with retained lens material were excluded. UGH was defined as iritis or a combination of hyphema, high intraocular pressure, or vitreous hemorrhage. Results : After a median follow-up of 8.0 months, six (8.8% of 68) patients developed UGH at a median onset of 82.5 days from surgery. Baseline characteristics of these patients were the following: mean age of 70, initial intraocular pressure (IOP) of 18 +/- 4, initial logarithm of the minimum angle of resolution visual acuity (logMAR VA) of 0.64 +/- 0.56, and 1-piece IOL dislocation (83.3%). UGH was treated with topical corticosteroids in 5 patients (83.3%) and pressure lowering drops in 4 patients (66.7%). No patient required reoperation, nor had diminished vision. At a median follow-up of 8.0 months within this cohort with UGH, the final logMAR VA was 0.22 +/- 0.06 (versus baseline, p=0.104), and the final IOP was 23 +/- 10 (versus baseline, p=0.193). Conclusions : UGH is a rare but notable complication of iris sutured PCIOL repositioning. Patients who develop UGH can be effectively treated with medical therapy without surgical intervention and achieve good final visual acuity outcomes. A syndrome combining signs of iritis, VH, hyphema, and sustained IOP elevation particularly with single piece PCIOLs should prompt consideration of a UGH diagnosis and early treatment intervention to optimize patient outcomes. Future prospective clinical trials are needed to compare overall complication rates and outcomes of in-the-bag lens repositioning surgery with scleral versus iris sutured fixation technique

Purpose : To study the clinic attendance rates and comorbidities in patients with and without diabetic retinopathy Methods : We conducted a retrospective review of all patients scheduled and attended a retina practice between January 2016 - December 2016. Patient charts were divided into nondiabetics, non-proliferative diabetic retinopathy(NPDR), and proliferative diabetic retinopathy(PDR). Attendance rate was calculated for non-diabetic patients and diabetic patient groups. Additional data collected included: history of prior laser procedures(PRP, focal),history of intra-vitreal injections, presence of DME, comorbidities including HTN,HLD,CVD requiring stent or surgery,CKD requiring dialysis, history of amputation, smoking status. Predictive factors for noncompliance were assessed. Results : There were 14,550 scheduled visits (10344 nondiabetics and 4206 diabetics). The no show rate for nondiabetics was 13.8% and was 10.2% for all diabetics. A subgroup analysis of a total of 1038 diabetic retinopathy patients (484 NPDR, 554 PDR) with 2978(1061 NPDR, 1917 PDR) visits were reviewed, with an overall no show rate of 10.5% in NPDR and 9.3% in PDR. There is a nonsignifiant trend towards higher attendance rates in patients with more scheduled visits (89.3% for 1-3, 92.1% for 4-6, and 93.2% for 7 or more scheduled visits; one-way ANOVA,F=2.06, p=0.13). There is a nonsignificant trend of increasing number of comorbidities associated with higher rates of no show visits (9.4% for 0, 7.9% for 1,10.7% for 2, 11.6% for 3, and 7.7% for 4 comorbidities). Smoking did not significantly affect show rates (nonsmokers 10.4%,former 8.0%,current 8.5%). Higher no show rates are found in NPDR and PDR patients with prior treatment with focal laser (13.4%vs7.8% for NPDR, p=0.013 and 12.1%vs8.7%,P=0.026). Prior treatment with anti- VEGF injections were associated with lower no show rates (6.5%vs10.5%, P< 0.05). Conclusions : Contrary to physician bias, patients without diabetes and those with varying degrees of diabetic retinopathy did not demonstrate differing levels of clinic attendance. Additionally, as the scheduled visits increased, patients with diabetic retinopathy were more likely to show, although this was not statistically significant. Medical comorbidities demonstrated a nonsignificant trend towards lower compliance with clinic attendance, which is important to reconcile when deciding a treatment paradigm

PURPOSE/OBJECTIVE:To evaluate the readability of online uveitis patient education materials. METHODS:A Google search in November 2016 was completed using search term "uveitis" and "uveitis inflammation." The top 50 websites with patient-centered information were selected and analyzed for readability using the Flesch-Kincaid Grade Level (FKGL), Flesch Reading Ease Score (FRES), Gunning FOG Index (GFI), and Simple Measure of Gobbledygook (SMOG). Statistical analysis was performed with two-tailed t-tests. RESULTS:The mean word count of the top 50 websites was 1162.7 words, and averaged 16.2 words per sentence. For these websites, the mean FRES was 38.0 (range 4-66, SD = 12.0), mean FKGL was 12.3 (range 6.8-19, SD = 2.4), mean SMOG score was 14.4 (range 9.8-19, SD = 1.8), and the mean Gunning FOG index was 14.0 (range 8.6-19, SD = 2.0). CONCLUSIONS:The majority of online patient directed uveitis materials are at a higher reading level than that of the average American adult.

Purpose: No clear guidelines exist regarding when to perform vitrectomy and membrane peel surgery for idiopathic epiretinal membranes. Here we analyzed a cohort of patients diagnosed with idiopathic epiretinal membranes and compared those who desired and were offered surgery versus those who were not. Since epiretinal membranes are generally non-progressive, surgery was only offered to patients who had significant symposium and diminished acuity. Methods: We retrospectively analyzed a consecutive series of 100 eyes from one vitreoretinal surgeon (79 patients) diagnosed with idiopathic epiretinal membranes who were referred from general ophthalmologists. For each eye we determined the best corrected visual acuity (BCVA, in LogMAR), central macular thickness (CMT) using SD-OCT (urn), age (years) and gender. Using Microsoft Excel using two-tailed t-tests we compared these parameters in patients who had and had not chosen to undergo surgery. In surgical patients, pre-op values were used. Exclusion criteria included patients with any other eye pathology that may have affected vision or macular thickness as well as surgical patients for whom we did not have pre-op data. Results: 21 eyes underwent surgery and 79 were observed. Mean age of patients undergoing surgery was 67.7 years (SD 7.65) and 71.9 years (SD 10.10) in those who opted against surgery (p=.048). Mean pre-op visual acuity in surgical patients was 0.57 (20/75; SD 0.27) compared to 0.27 (20/40+; SD 0.22) in non-surgical patients (p=<.0001). Central macular thickness was 531.4mum (SD 81.28) in surgical patients and 370.1 urn (SD 81.36) in non-surgical patients (p=<.0001). Conclusions: In our retrospectively examined cohort of 100 eyes with idiopathic epiretinal membrane, patients who were offered and accepted surgical treatment were significantly younger and had worse visual acuity and more distorted anatomy (greater central macular thickness) than those patients who did not undergo surgery

Purpose: Myopic foveoschisis (MF) in patients with myopic degeneration was not well appreciated prior to the advent of high resolution optical coherence tomography (OCT) imaging. Information is still limited on the clinical course of patients with MF. In our study we aim to provide additional data on the clinical outcomes of patients with MF. Methods: We performed a retrospective review of patients with a diagnosis of myopic degeneration with posterior staphyloma from a New York City retinal subspecialty practice to identify patients with evidence of MF present on OCT. In cases of MF the demographic data, clinical course, and imaging, including OCT and fluorescein angiography, were evaluated. Results: 196 patients with myopic degeneration and posterior staphyloma were identified: 9 eyes of 8 patients had MF on OCT. Age at incidence of MF ranged from 47 to 73 years old. Six were females, 2 were males. Mean follow up from incidence of MF was 47 months. Seven of the 8 patients had unilateral MF during the period of observation; one patient developed bilateral MF. Four of the 9 eyes underwent surgery. Of the 5 that did not receive surgery, 2 were noted to have anatomic improvement on OCT and maintained stable acuity and 3 demonstrated stable OCT findings but with a reduction in visual acuity. Of the 4 patients who underwent surgical intervention, 3 of the 4 had repair of macular hole, and one underwent repair of a subtotal retinal detachment. Time from development of MF to time of macular hole development was 4, 11, and 49 months in the 3 eyes. Two of the 3 eyes with macular holes had stable visual acuity following repair, one of the eyes showed improved visual acuity. The retinal detachment was repaired with anatomic improvement of the foveoschisis. Myopic choroidal neovascularization did not develop in any of the 9 eyes during the period of follow up. Conclusions: Our data are consistent with prior studies indicating that the course of MF is highly variable, ranging from nonprogression (3/9), spontaneous resolution (2/9) or macular hole formation (3/9). Surgical outcomes can be favorable

PURPOSE OF STUDY: EMSY, a putative DNA damage repair gene, is amplified in over 10% of high-grade serous ovarian carcinoma (HGSOC) cases. EMSY overexpression has been hypothesized to antagonize BRCA2 via direct interaction and compromise the homology-directed repair (HDR) of DNA double strand breaks. EMSY's role as a transcription factor has been described in a protein kinase AKT1 phosphorylation-dependent manner. The purpose of this study was to decipher EMSY's role in HDR and to assess the importance of its phosphorylation in this context. EXPERIMENTAL PROCEDURES: We measured HDR activity in several cell lines (U2OS osteosarcoma, H1299 non-small cell lung carcinoma and OVCAR8 HGSOC) using the DR-GFP reporter assay and RAD51 foci assessment. Endogenous immunoprecipitations (IPs) were performed with low stringency lysis buffer and protein A/G-plus agarose. V5-tagged EMSY constructs were made using the Invitrogen's Gateway TOPO cloning system. These constructs were further used to create EMSY phospho-mutants. Cells were transfected by either electroporation or FuGene reagent. For the in vitro kinase assays, EMSY constructs were sub-cloned and expressed in BL21 STAR bacteria and purified using Invitrogen's Champion pET102 Expression kit. Recombinant protein kinases were obtained from Active Motif and CellSignaling. Forskolin and H-89 were obtained from Santa Cruz Biotechnology. SUMMARY OF THE DATA: EMSY overexpression resulted in decreased HDR activity in all three DR-GFP cell lines, thus supporting the hypothesis that EMSY overexpression impairs HDR. V5-tagged EMSY overexpressing and endogenous immunoprecipitation experiments demonstrated no interaction between EMSY and BRCA2, suggesting EMSY's role in HDR to be BRCA2-independent. We confirmed that EMSY is phosphorylated by AKT1 at serine 209 phospho-site and identified a previously unknown phosphosite at threonine 207. We identified protein kinase A (PKA) as a kinase targeting EMSY T207. Furthermore, by performing both DR-GFP assay and RAD51 foci assessment in OVCAR8 cells that overexpress WT EMSY or either phospho-mutant, we demonstrated that mutant EMSY-S209A affects HDR activity similar to the WT EMSY while EMSYT207A does not. This suggests the importance of PKA and the T207 phospho site for the EMSY-driven HDR suppression. CONCLUSIONS: EMSY-overexpressing cells show decreased HDR activity, demonstrating EMSY's relevance to the HDR pathway. Our data support the notion that EMSYdriven HDR impairment is BRCA2-interaction-independent and challenges the currently held impression that EMSY overexpression mimics the BRCA2-depleted phenotype via direct interaction. We found a new phospho-site at EMSY T207 and identified PKA as a targeting kinase. Phosphorylation of EMSY at T207, but not S209 phospho-site is necessary for EMSY-driven suppression of HDR. We suggest that an increase in EMSY's T207 phosphorylation in patients bearing EMSY-amplified tumors could enhance BRCAness and render these patients more sensitive to drugs effective in HDR-impaired setting, such as PARP inhibitors