Wills Conference HERO

76th Annual

Wills Eye Conference

March 7-9, 2024
Philadelphia, PA


The Free Paper Presentations will be held in the Sara and Noel Simmonds Auditorium of Wills Eye Hospital. The best paper presented by a resident will receive the Shipman Award. The best paper presented by a fellow will receive the McDonald Award.

Author Affiliation Key: R-resident, F-fellow


Opening Remarks
Sunir J. Garg, MD, FACS and Zeba A. Syed, MD, Conference Co-Chairs


Small Aperture Intraocular Lenses in Irregular Corneas
Matthew Santos, MD (F), Brandon D. Ayres, MD [Cornea & External Disease]

Purpose: To review the outcomes of the small aperture intraocular lens (IC-8, Apthera) in patients with irregular corneas.
Methods: A retrospective chart review was performed of patients with irregular corneal astigmatism receiving small aperture intraocular lenses in otherwise uncomplicated cataract surgery. Data obtained include type of corneal pathology, pre-operative visual acuity, post-operative visual acuity at months one, three, and six.
Results: Fifteen eyes of eleven patients were included in the review. The most common cause of irregular astigmatism was keratoconus (9), followed by post-refractive surgery (1 post-RK and 2 post-LASIK). One eye had post-LASIK ectasia, one with scarring following HSV keratitis, and one with scarring after a pterygium excision. There were four patients who underwent IC-8 lens placement in both eyes. Of these four patients, one later elected for lens exchange in their dominant eye. Further data analysis and follow-up will help evaluate the success in achieving refractive targets in these patients.
Conclusions: The small aperture intraocular lens (IC-8, Apthera) is an option for optimizing uncorrected visual outcomes for patients with irregular corneal astigmatism. The most common use of this lens in our study is with a low myopic target in the non-dominant eye. One in four patients with bilateral IC-8 lens placement opted for intraocular lens exchange.


Demographics And Complications Of Crosslinking For Keratoconus
Weijie Lin, MD (F), Zeba A. Syed, MD [Cornea & External Disease]

Purpose: Keratoconus (KCN) is a bilateral, progressive ectatic disorder characterized by thinning and steepening of the cornea, leading to irregular astigmatism and loss of vision. Progression of disease can be stabilized with corneal crosslinking (CXL), which can increase the biomechanical stability. Successful CXL procedures can result in arrest of KCN. Complications of CXL are rare, but they can include persistent epithelial defects, infectious keratitis, corneal opacity, and decreased visual acuity. Although reviews and limited case series of complications of CXL have been reported, there are limited studies of large-scale reports for crosslinking complications and overall demographics of patients who undergo crosslinking.
Methods: This is a retrospective study that will involve the collection of data from chart review. Patient records were pulled from April 2019 to September 2023, for demographic characteristics, clinical measures, topography/tomography measures, and outcomes up to the postoperative visit at 3-6months. Overall reporting of statistical measures was performed.
Results: Of 172 crosslinking patient records reviewed thus far, 8 experienced complications resulting in vision loss, progression of KCN, or further procedures. Of these, 3 cases resulted in progression, with one progressing to hydrops and another which underwent a repeat crosslinking procedure. One case resulted in a corneal ulcer (MRSA). The rate of persistent epithelial defect (>2weeks) was 4.1%, and the rate of persistent corneal haze (documented >3months) was 64.2%, although most were recorded as “mild” and only 3 cases resulted in loss of vision (more than 2 lines on Snellen chart). Average age at time of crosslinking was 27.65 years. Self-reported race was unknown/declined (68.2%), white (15.3%), black (12.4%), Asian (2.4%), multiracial (1%). Self-reported ethnicity was Hispanic in 5.9%.
Conclusions: Complications of crosslinking are rare but can result in serious vision loss. Progression is typically halted by crosslinking, but some cases did still progress. Further data collection and analysis will attempt to determine if any factors are correlated with adverse outcomes of crosslinking.


Review Of Post Operative Outcomes in Patients Who Received Corneal Collagen Crosslinking Under General Anesthesia
Megan Haghnegahdar, MD (F), Brandon D. Ayres, MD [Cornea & External Disease]

Purpose: Corneal collagen cross-linking is a procedure typically performed in the office for treatment of keratoconus (KCN) and post-LASIK ectasia. Occasionally the procedure is performed under general anesthesia (GA) in the operating room for patients with various behavior constraints, such as Down syndrome, autism spectrum disorder, or young age. The purpose of this study is to evaluate post operative outcomes in patients who have undergone corneal collagen cross-linking under GA.
Methods: A retrospective review was performed of the medical records of 24 patients who had undergone corneal collagen cross-linking under GA at a single institution.
Results: 29 eyes were included in the study. 28 eyes had a diagnosis of KCN and one had a pre operative diagnosis of post-myopic LASIK ectasia. Most cases were performed under GA due to behavioral constraints. Most common causes of behavioral constraints were a diagnosis of Down syndrome, autism spectrum disorder, and young age. 4 of the total eyes (13.7%) had post operative complications, including residual epithelial defect, a post operative ulcer, acute hydrops, and irregular epithelium. Average pre operative and post operative best corrected visual acuity (BCVA) was unchanged at 20/30. There were no significant differences in change in BCVA in the group of Down syndrome patients compared to rest of the sample or in the group of younger age patients compared to the rest of the sample.
Conclusions: Corneal collagen cross-linking under general anesthesia is not without risk, with a relatively high complication rate in our study. Efforts should be made to avoid corneal collagen cross-linking under general anesthesia. An option for patients with behavior limitations is to administer a midazolam-ketamine-ondansetron sublingual tablet to allow in-office procedures. If the procedure must be done under general anesthesia, then one could consider alternating treatment between both eyes in one setting to limit UV exposure time and to minimize administration of GA.


Incidence And Outcomes Of Recurrent Retinal Detachment After Cataract Surgery In Eyes With Prior Retinal Detachment Repair
Bita Momenaei, MD (F), Jason Hsu, MD [Retina and Vitreous]

Purpose: Rhegmatogenous retinal detachment (RD) is a serious condition that often requires surgical repair to restore or prevent vision loss. Many patients are phakic at the time of RD repair and will require cataract surgery thereafter. Redetachment after cataract surgery is a concern. The overall risk of RD is greater in patients who have undergone cataract surgery than those who have not, with an estimated incidence of 0.36–2.9% of cases within 10 years of phacoemulsification. However, little is known regarding the incidence, characteristics, and treatment outcomes of redetachment after cataract surgery in those with prior history of RD repair in the same eye. Therefore, the purpose of this study was to assess the incidence, timing and outcomes of recurrent RD following phacoemulsification.
Methods: A retrospective review of phakic eyes that underwent successful RD repair with pneumatic retinopexy (PR), scleral buckle (SB), pars plana vitrectomy (PPV), or combined PPV/SB followed by subsequent cataract surgery between April 2012 and January 2023 was performed. Patients with multiple retinal detachment surgeries prior to cataract extraction and those with silicone oil tamponade before cataract surgery were excluded. Eyes that redetached were matched 2:1 with eyes that did not redetach after cataract surgery.The primary outcome measures of this study involve assessing the incidence of redetachment following cataract surgery, both overall and following each type of initial RD repair.
Results: 763 patients were included. The mean (SD) duration of follow-up was 48.4 (29.1) months. The overall incidence of retinal redetachment after cataract surgery was 2.5%. The rate of redetachment based on the type of initial RD repair was 9.1% (1/11), 5.3% (2/38), 2.8% (9/317), and 1.8% (7/397) for PR, SB, PPV, and combined PPV/SB, respectively (P=0.24). The median (IQR) duration between the cataract surgery and first redetachment was 301 (104-1222) days. Single surgery anatomic success (SSAS) for the RD repair after cataract surgery was achieved in 89.5% at 3 months and 73.7% at the final visit. Final anatomic success rate for reattachment was 100%. The median (IQR) logMAR visual acuity at the final visit significantly decreased compared to vision after cataract surgery (P=0.001).
Conclusions: Recurrent RD was not uncommon in patients with a prior history of RD repair after cataract extraction. Reoperation resulted in relatively favorable anatomic success but there were declines in visual acuity.


Demographics And Clinical Characteristics Of Adult-Onset Comitant Esotropia (AOCET)
Laurel Lam, BS (F) [Strabismus]

Purpose: AOCET is a nonaccommodative esotropia associated with diplopia, and without known history of childhood strabismus. Though previously rare, recent studies have reported an increased incidence. Sagging Eye Syndrome has emerged as the leading cause of acquired diplopia. This study aims to investigate the changing demographics of AOCET.
Methods: Our retrospective review identified 76 adults (mean age: 40.6 14.9) who presented with AOCET between 2016-2022. Patients with history of ocular trauma, concussion, childhood strabismus, or prior strabismus surgery were excluded. Patients were categorized into younger (age 18-40) and older (age >40) groups.
Results: Our cohort revealed an equal distribution of males (35/76, 46.1%) and females (41/76, 53.9%) (p=0.21). Mean refractive error was -3.5 D in the older group versus -2.6 D in the younger group (p=0.34). Mean distance esotropia was 20 and 22 in the older and younger groups, respectively (p=0.11). The most common ethnicity was unknown (37, 48.7%) followed by white (33, 43.4%). Mean diplopia duration was 3.5 ± 6.3 years. Mean presenting esotropia was 21.5 ± 13.8 at distance and 17.1 ± 15.3 at near. 2 (2.6%) had monovision. 27 (35.5%) had thyroid workup, of which 1 was abnormal. Of 46 (60.5%) that had neuroimaging, 2 were abnormal.
Conclusions: In our study, we found an equal sex distribution among AOCET patients. Thyroid workup was more common in the older group, whereas neuroimaging was more prevalent in the younger group. The majority of our population had myopia. Those with more advanced myopia presented with greater mean distance esotropia.


Clinical Characteristics Of Diplopia Patients Presenting To A Tertiary Referral Center
Betul Bayraktutar, MD (F), Laurel Lam, BS, Jade Minor, MD, Maureen Lloyd, MD, Kammi Gunton, MD [Strabismus]

Purpose: To describe the clinical characteristics of patients who presented to a tertiary care center with double vision.
Methods: Patients who presented to Wills Eye Hospital with the symptom of double vision between January 2022 and December 2022 were recruited. Demographic features of patients, type of diplopia (binocular vs monocular vs both), etiology of diplopia, history of childhood strabismus and/or amblyopia, and need for neuroimaging and their results were recorded.
Results: Medical charts of 109 adult patients (55 female, 54 male) with double vision or diplopia diagnosis were reviewed. The mean age of the patients was 50.9±20.7 years. 95 patients had binocular diplopia, 10 patients had monocular diplopia, and 4 had both binocular and monocular diplopia. Although an underlying systemic or neurological disease and decompensated strabismus were identified as the leading cause of diplopia, a broad variety of etiologies were identified. However, a broad a variety of etiology was noted. Neuroimaging was ordered in 42 patients.
Conclusions: Double vision can be caused by a variety of etiologies. In a tertiary care center the most common etiology was identified as underlying systemic/neurological disease or decompensated strabismus. In some of the patients, the etiology may not be determined despite extensive work-up. 


The Utility Of Orbital Color Doppler Imaging In The Identification Of A Pre-Clinical Crao In A Patient With Amaurosis Fugax
Danijel Pericic, MD (F), Sarah Thornton, MD, Ari August, BA [Neuro-Ophthalmology]

Purpose: Amaurosis fugax is commonly caused by thromboembolism from ipsilateral carotid disease, although retinal emboli are not always visible on fundus examination. Orbital color Doppler imaging (CDI) is a non-invasive tool to detect retrobulbar plaques, which can help guide further workup and management. Here we describe a patient presenting with transient vision loss found to have a retrobulbar embolus on CDI, who later developed a central retinal artery occlusion (CRAO) and CDI revealed the embolus had shifted to further occlude blood flow.
Methods: Single case report of a 47-year-old Caucasian male presented with 7 episodes of amaurosis in his left eye. We review his admission for stroke workup including MRI of the brain and orbits with and without contrast, MRA of the head and neck, TTE, lower extremity ultrasound, and bloodwork. CDI was performed during his initial amaurotic episode, as well as during his second admission when he had clinical evidence of a CRAO in his left eye.
Results: Initial visual acuity was 20/20 in both eyes with full color plates and no APD. CDI revealed a hyper-reflective spherical particle in the retrobulbar course of the left CRA most consistent with an embolus, located 2.8mm posterior to the optic nerve head. Eight days later he re-presented with a visual acuity of 20/400 in the left eye with an APD. Repeat CDI showed the retrobulbar embolus had migrated anteriorly and was now 1.8mm posterior to the optic nerve head and caused a decrease in both the systolic and diastolic CRA velocities. The CRA systolic and diastolic velocities in the unaffected right eye increased. The patient was found to have a calcified bicuspid aortic valve and an aortic root aneurysm with severe aortic calcifications as the source of his embolus.
Conclusions: CDI is a useful and non-invasive tool to identify retrobulbar emboli in patients who present with amaurosis fugax. It may also be used as objective clinical evidence of decreased blood flow relative to the contralateral unaffected eye in patients with amaurosis fugax.


Advances In Eyelid And Periocular Reconstruction:  Introducing The Ultra-Thick Umbilical Cord Allograft
Karine Shebaclo, MD (F), Jacqueline Carrasco MD and Mary Stefanyszyn MD [Oculoplastics]

Purpose: Ultra-thick human amniotic membrane tissue (UT-hAMT) has seldom been described in the oculoplastic literature for the use of periorbital reconstruction. We propose a novel method for the repair of refractory cicatricial lower eyelid retraction in patients. 
Methods: A single-center retrospective chart review was performed to identify patients who underwent reconstruction of the lower eyelids using (UT-hAMT). These patients were selected based on refractive lower eyelid retraction that was not successfully addressed with prior medical or surgical interventions.
Results: Twenty-four patients received UT-hAMT for refractory cicatricial ectropion. Using our novel technique, thirty UT-hAMT were implanted for the reconstruction of lower eyelids with successful deepening of shortened fornices, re-attachment of lower eyelid retractors, and correction of anterior lamellar scarring. Patient demographics, preoperative and postoperative photos were collected. The primary outcome was the successful rate of the successful intervention. Approximately 94% of patients with refractory lower eyelid retraction were successfully corrected using our novel UT-hAMT. 91.5% of patients noted resolution of epiphora and exposure keratitis. Only three eyelids required further minor revisions but were successful after the final intervention using the same technique.
Conclusions: Cryopreserved ultra-thick human umbilical amnion is an excellent first-line surgical intervention that demonstrates ideal postoperative outcomes in the management of refractory lower eyelid retraction repair, forniceal reconstruction, anterior lamellar shortening. Further studies from our institution aim to elucidate the histopathology behind its remarkable capacity for conjunctival regeneration as well as its anti-inflammatory and anti-fibrotic properties in the periorbita.


Impact of Ergonomics Intervention on Disability and Neck-Pain Indices among Ophthalmology Resident and Fellow Physicians
Marius Heersink, MD (R), Collin Richards, MD, Elizabeth Derham, MD, Janine Tabas, MD, Frank Mellon, DPT [Other]

 Purpose: The aim of this study was to evaluate the prevalence of physical disability and neck-pain prevalence among ophthalmology resident and fellow physicians currently in training and measure if physical-therapy evaluation and prescribed exercise routine improved disability and neck-pain scores. 
Methods: This prospective, cross-sectional study was conducted using two indices of self-reported physical disability and neck pain. Participants were recruited from the current residents and fellows at Wills Eye Hospital in Philadelphia, PA during the 2022-2023 academic year. All residents and fellows were asked to participate on a voluntary basis for a 1 hour ergonomics and posture assessment with a licensed Doctor of Physical Therapy (DPT) and then subsequently prescribed an exercise routine and/or given written ergonomics suggestions. Participants completed a pre-assessment disability survey and then post-assessment disability survey 3 to 4 months after initial assessment. Subjects were also asked to complete a satisfaction survey 3 to 4 months after initial assessment. 
Results: 21 resident physicians and 3 fellow physicians completed the surveys and physical therapy assessments. Of the respondents, all reported minimal back pain disability pre- and post-assessment. 41.6% of respondents reported at least mild neck-pain complaints pre-assessment. Post-assessment, 20.8% of respondents reported at least mild neck-pain related complaints. Paired T-test was used to assess whether the physical-therapy assessment and intervention made a statistically significant difference in self-reported back and neck pain. Physical therapy assessment/intervention was determined to make a non-significant improvement in back pain, while assessment/intervention made a significant improvement in self-reported neck-pain (p<0.05).  70.8% of respondents reported wanting more physical therapy assessment/intervention to be offered on a regular basis, while 83.3% of respondents reported that the physical-therapy assessment had a positive impact on occupational ergonomics. 91.6% of respondents reported that occupational ergonomics was important to career satisfaction and longevity. 
Conclusions: The prevalence of neck pain among ophthalmology resident and fellow physicians is high. Physical therapy intervention appears to make a significant difference in self-reported neck pain at 3 months post-intervention and most participants view physical therapy as beneficial for occupational longevity.


Sympathetic Ophthalmia In Patients With Enucleation Or Evisceration: Pathology Laboratory And Iris® Registry Experience
Kaylene Carter, MD (R), Khanh Bui, BS, Tatyana Milman, MD, Ralph Eagle, MD, James Dunn, MD [Pathology]

Purpose: Sympathetic ophthalmia (SO) is a rare bilateral granulomatous panuveitis that can follow surgical or nonsurgical ocular trauma in one eye. Because its diagnosis requires clinical-pathologic correlation, the true incidence of SO is unknown, and there is a need to understand the recent trends in risk factors and frequency of this condition.
Methods: Pathology records of all enucleated or eviscerated (ENEV) eyes at three pathology laboratories were reviewed. Data collected included patient demographics, procedure indication, pathology diagnosis, and clinical history of trauma and uveitis. IRIS® Registry (Intelligent Research in Sight) was searched for all patients with SO, acquired absence of eye (AAE), and/or ENEV. Data obtained included patient demographics, ocular procedures, and preoperative diagnoses within 30 days of AAE/ENEV.
Results: In the pathology laboratory setting, the incidence of SO over a 36-year period in patients who underwent ENEV was 0.2%; the 5-year incidence ranged from 0.0 to 0.3%. Among the 20 eyes with SO, the inciting event was surgical trauma in 50%, nonsurgical trauma in 45%, and missing/undetermined in 5%. SO was suspected preoperatively in 7/20 patients. Clinical concern for SO and ruptured globe were indications for ENEV in 0.5% and 10% patients, respectively. In the IRIS Registry, 0.7% of patients with AAE/ENEV had diagnosis of SO. The frequency of SO between 2015 and 2020 was 0.01%; of these 7,371 cases, 3% had AAE/ENEV. In 25,975 patients with available data, injury and SO were listed as diagnoses less than 30 days prior to AAE/ENEV in 4% and 0.2% cases, respectively.
Conclusions: The frequency of SO in recent decades has been low. Most cases of SO are not managed with eye removal. In histopathology-confirmed SO, surgical trauma is as frequent as nonsurgical trauma as an inciting etiology of disease.




Does Melanoma Tumor Size Matter In Long Term Patient Outcomes: A Simplified  Approach
Rolika Bansal, MD (F), Hidayet Sener, MD, Hartej Singh, BS. Carol Shields, MD [Tumor]

Purpose: To estimate metastasis-free-survival of patients with uveal melanoma on the basis of tumor thickness classified as small (0.0-3.0mm), medium (3.1-8.0mm) and large (>8.1mm).
Methods: Retrospective study of 8034 cases over 35 years at a single ocular oncology referral centre evaluated for the primary endpoint of cumulative incidence of metastasis using non-conditional and conditional outcomes at 3-years, 5-years, and 10-years. Cox proportional risk regression analysis was performed.
Results: The mean thickness for small, medium and large tumors was 2.5mm, 5.0mm and 10.2mm respectively. A comparison (small vs. medium vs. large melanoma) revealed small tumors likely to be detected in females and younger cases ( p < 0.001). Large tumors were more likely to have Bruch’s membrane rupture and extraocular extension (p < 0.001). The 25-year non-conditional metastasis was (5% vs. 12% vs. 21%), and for those who survived five years without metastasis, the 25-year incidence of metastasis was (6% vs. 118% vs. 20%). For patients who maintained 3-year/5-year/10-year metastasis-free-survival, hazard ratio of large vs medium were (2.22p <0.0001)/ 2.22 (p <0.0001)/ 2.52(p <0.0001), and hazard ratio medium vs small were (2.19p <0.0001)/ 2.24, p <0.0001/ 2.24, p <0.0001), respectively.
Conclusions: A comparison of uveal melanoma metastasis, classified on the basis of small, medium and large thickness, revealed small melanomas were more likely to be detected in younger individuals and females. Larger melanomas were more likely to have poorer prognosis and have a higher tendency to develop metastasis over time.


Conditional And Non-Conditional Outcomes Of Uveal Melanoma By Millimeter In Thickness In 8034 Patients
Hidayet Sener, MD (F) Rolika Bansal, MD, Thomas Catapano, MD, Carol Shields, MD [Tumor]

Purpose: The prognosis of uveal melanoma is influenced by molecular markers, tumor thickness and other factors. Tumor thickness is a measurable factor, available for most patients. In this study we explore each millimeter increase in melanoma thickness as it impacts conditional and unconditional outcomes.
Methods: A retrospective study involving 8034 uveal melanoma patients, spanning from 1972 to 2007 was performed for non-conditional and conditional cumulative incidence of metastasis of uveal melanoma for each 1 mm increment at 3-years, 5-years and 10-years.
Results: Non-conditional incidence of metastasis at 5-, 10-, 15- and 30-years was (8%, 11%, 12% and 12%). Conditional cumulative incidence of metastasis with 5-year and 10-year survival showed 30-year risk of metastasis reduced to 10% and 8%, respectively. Specifically with 1-mm increments in tumor thickness, conditional survival showed increasing risk for metastatic disease, and the longer the patient survived without metastasis, the lower the risk for ultimate metastasis.
Conclusions: This study highlights the point that uveal melanoma with increasing thickness demonstrates poorer prognosis. However, the longer metastasis-free intervals were associated with a lower risk of ultimate metastatic disease, highlighting the importance of conditional metastasis. 


Topical 5-Fluorouracil 1% For Ocular Surface Squamous Neoplasia: Primary Versus Secondary Treatment
Irwin Leventer, BA (F), Hartej Singh, BS, Bahram Pashaee, MPH, Sara Lally, MD,Carol Shields, MD [Tumor]

Purpose: Ocular surface squamous neoplasia (OSSN) is a spectrum of malignancies that generally includes conjunctival intraepithelial neoplasia (CIN) and squamous cell carcinoma (SCC). OSSN can be treated with topical therapies including interferon a-2b (IFN), mitomycin-C (MMC), or 5-fluorouracil 1% (5FU). Recently, due to unavailability of IFN and MMC associated toxicity, therapy has shifted towards 5FU. Herein, we compare the use of 5FU 1% as a primary versus (vs.) secondary treatment regimen in eyes with moderate to extensive OSSN.
Methods: Retrospective cohort study of 73 consecutive patients with unilateral moderate to extensive OSSN treated with 5FU 1% (4 times daily for 2 weeks with an option for 2-weekly extension) at a single tertiary ocular oncology center from 2016 to 2023.
Results: In the 73 patients analyzed, a comparison (primary vs. secondary treatment) revealed no difference in mean tumor basal dimension (19.6 vs. 17.2 mm, p=0.46), thickness (3.7 vs. 3.4 mm, p=0.64), or tumor extent (4.4 vs. 4.5 clock hours, p=0.92). The primary treatment group showed greater complete tumor control (77% vs. 38%, p=0.04). Multivariable comparative analysis (primary vs. secondary treatment) showed primary treatment more likely to achieve complete tumor control (p=0.01). There was no difference in the complication rate from 5FU treatment between the groups. There was no difference in visual outcome, tumor-related metastasis (0%) or death (0%).
Conclusions: Topical 5FU 1% is efficacious and safe as a primary or secondary topical treatment modality for moderate to extensive OSSN. It is an efficient replacement of IFN and MMC, with excellent outcomes and often complete resolution in patients with moderate to extensive OSSN.


Conjunctival Melanoma: Features, Biomarker And Outcomes Based On Iris Color In 700 Consecutive Patients
Thomas Catapano, BS (F), Vijitha Vempuluru, MD, Deepthi Kurian, MD. Sara Lally, MD, Carol Shields, MD [Tumor]

Purpose: Race, ethnicity and iris color are risk factors for cutaneous and uveal melanoma. The impact of iris color on outcomes of conjunctival melanoma has not been explored. This study was carried out to determine whether iris color affects outcomes in conjunctival melanoma.
Methods: A retrospective cohort of 700 consecutive patients with conjunctival melanoma treated at a single ocular oncology center, between January 1966 and March 2023, were grouped based on iris color (blue, green or brown).
Results: A comparative analysis (blue vs. green vs. brown iris color) revealed patients with green irides presenting with conjunctival melanoma at a younger median age (64.6 vs 57.4 vs 59.8 years, p=0.001) and brown irides additionally showed complexion associated melanosis (1 % vs 1 % vs 6 %, p= <0.001). No differences were noted in the tumor characteristics based on iris color. Tumor biomarkers were available in 106 (15%) and NF1 gene mutation was noted frequently in blue irides (7% vs 2% vs 2%, p value = 0.005) with no difference between the occurrence of BRAF, N-RAS and ATRX mutations per iris color. Kaplan–Meier estimates at 20-years showed no differences per iris color for vision loss, tumor control, recurrence, exenteration, metastasis or death.
Conclusions: Patients with green irides presented at a younger age than others and those with blue irides had a higher rate of NF1 positivity. Iris color did not impact outcomes in conjunctival melanoma.


Impact Of Iris Color On Uveal Melanoma-Related Outcomes In 7245 Patients At A Single Ocular Oncology Center
Hartej Singh, BS (F), Alexandra Zaloga, BA, Deepthi Kurian, MD, Carol Shields, MD [Tumor]

Purpose: To determine the relationship between iris color and uveal melanoma related metastasis and death in a large cohort of patients from a single ocular oncology center.
Methods: Retrospective case series with 7245 consecutive patients diagnosed with uveal melanoma over 35 years.
Results: Out of 7245 patients, iris color was blue in 51% (n=3702), brown 29% (n=2085) or green 20% (n=1458). Blue irides presented with more post-equatorial tumors with proximity to the foveola and optic disc compared to brown irides. At a mean follow-up of 75 months, there was no statistically significant difference in metastasis based on iris color. On univariate analysis, blue irides had higher incidence of uveal melanoma related death compared to green and brown irides (8%, 6% and 7% respectively, p value=0.02). Kaplan-Meier event free survival at 20-years from uveal melanoma related death significantly differed between blue and green irides (p value=0.007) with highest survival in green irides. On multivariate analysis, iris color was not predictive of uveal melanoma related death.
Conclusions: Iris color was not predictive of uveal melanoma related metastasis or death. However, Kaplan-Meier survival at 20-years was poorest for those with blue irides when compared to green irides.


Comparative Analysis Of Outcomes In Pigmented Versus Non-Pigmented Uveal Melanoma
Miguel Hernandez-Emanuelli, MD (F), Samuel Goldstein, BS, Ferris Bayasi, MD, Rolika Bansal, MD, Carol Shields, MD [Tumor]

Purpose: To assess and compare the clinical features and outcomes associated with degree of tumor pigmentation in patients with uveal melanoma.
Methods: Comparative analysis of patient demographics, tumor characteristics, treatment approach, and clinical outcomes between pigmented (>80% pigmentation by surface area), partially pigmented (20-80%), and nonpigmented tumors (<20%).
Results: Among 7245 eyes with uveal melanoma, tumors were pigmented (n=4,016; 55%), partially pigmented (n=2,139; 30%) or non-pigmented (n=1,090; 15%). Pigmented uveal melanoma were significantly associated with extraocular extension, earlier tumor recurrence and more anterior tumor epicenter location (p<0.001). Pigmented uveal melanoma had highest 10-year metastasis rate (12%) (p<0.001). Kaplan-Meier survival curves showed differences in melanoma-related metastasis (p<0.0001) and melanoma-related death (p=0.0013). Multivariate Cox regression analysis for melanoma-related metastasis showed pigmented with 29% higher relative risk of developing metastasis compared to partially pigmented uveal melanoma
Conclusions: Pigmented uveal melanoma is more often associated with extraocular extension, earlier tumor recurrence and anterior tumor epicenter. The pigmented uveal melanoma also demonstrate a higher 10-year rate of metastatic disease and have decreased metastatic survival relative to partially pigmented and non-pigmented uveal melanoma.


Choroidal Lymphoma: Clinical Features And Outcomes In A Large Cohort
Athar Shadmani, MD (F), Miguel Hernandez-Emanuelli, MD, Irwin leventer, BA, Deepthi Kurian, MD, Carol Shields, MD [Tumor] 

 Purpose: Choroidal lymphoma can originate in the eye as primary lymphoma or can originate systemically and secondarily invade the eye.
Methods: A comparative analysis of primary versus secondary lymphoma of 59 consecutive patients was carried out.
Results: Of the 59 study patients, lymphoma was primary in the eye in 69% (n=41) and secondary to systemic lymphoma in 31% (n=18). A comparison of primary versus (vs.) secondary lymphoma revealed primary lymphoma with longer duration of ocular symptoms (17 vs. 5 months), more unilateral involvement (56% vs. 20%), less poor vision of 20/200 or worse (12% vs. 46%), and less anterior chamber reaction (14% vs. 30%), hyphema (0% vs. 15%), and iris (4% vs. 20%) or ciliary body component (8% vs. 30%). Of those with primary choroidal lymphoma, systemic lymphoma was detected in no patient over 50-months follow up.
Conclusions: A comparison of primary versus secondary choroidal lymphoma revealed primary lymphoma with low-grade tumor features, and with little to no risk for systemic lymphoma.


A Novel Approach To Estimating Choroidal Lesion Thickness Using 2D Ultra-Widefield Optomap Images
Michael Yu, MD (F) [Tumor] 

Purpose: Tumor thickness is a well-established risk factor for transformation of choroidal nevus (CN) into choroidal melanoma (CM) and thus plays an important role in risk stratification of melanocytic choroidal lesions (MCL). Currently, B-scan ultrasonography is the most reliable method for measuring tumor thickness, but its utility in screening may be limited. Herein, we describe a novel technique for rapid extraction of tumor thickness data from 2D ultra-widefield (UWF) dual-wavelength scanning laser ophthalmoscope Optomap images (Optos PLC, Dunfermline, Fife, Scotland, UK).
Methods: Patients with clinically diagnosed MCL underwent complete clinical examination, UWF imaging, and standardized B-scan ultrasonography (Ellex Medical, Adelaide, Australia). The UWF images were post-processed to isolate the green-wavelength-only image. Using Image J (National Institutes of Health, Bethesda, MD, USA), average pixel intensities within the lesion and of the adjacent retina were obtained, and the difference between both values calculated (“pixel intensity difference”; average lesion intensity minus average adjacent retina intensity). The pixel intensity difference was plotted against the reference standard for tumor thickness as measured by standardized B-scan ultrasonography. The significance of the relationship between both variables was assessed by linear regression analysis.
Results: A total of 141 MCL (16 CM and 125 CN) of 141 patients were evaluated. Mean ultrasonographic thickness was 1.2 mm (median: 0.8, range: 0.5-7.3). Mean pixel intensity difference was 6.7 (median: 3.8, range: -20.0 – 55.0). The linear correlation coefficient for tumor thickness to intensity difference was 0.85 (p<0.001), indicating a strong positive correlation between tumor thickness and tumor brightness on green-wavelength imaging (Figure 1). Coefficient of determination (R2) was 0.74. A pixel intensity difference threshold of >10 conferred a 100.0% sensitivity and 97.4% specificity for detection of tumors with thickness >2 mm.
Conclusions: Choroidal tumor thickness can be rapidly and reliably estimated using 2D UWF images. With additional validation, this method could augment future high-throughput screening and risk stratification of MCL with UWF images alone.


Computational Insights Into The Binding Specificity Of Pros1-Mertk In Uveal Melanoma
Mak Djulbegovic, MD (F), David Taylor Gonzalez, BS. Vladimir Uversky, PhD, Carol Shields, MD, Carol Karp, MD [Other]

Purpose: Protein S (PROS1), a vitamin-K-dependent plasma protein, plays a crucial role in hemostasis by acting as a cofactor in the coagulation cascade. Beyond its traditional role, PROS1 has gained attention for its involvement in cell signaling, particularly as an agonist for the TAM family of receptor tyrosine kinases, including Mer-tyrosine kinase (MERTK). Notably, PROS1 is upregulated in class 2 uveal melanomas, particularly in cases with BRCA1-Associated Protein 1 (BAP1) deficiency, leading to the activation of MERTK. The PROS1-MERTK protein-protein interaction (PPI) is thought to promote a tumor immune micro-environment (TIME), allowing for the proliferation of uveal melanoma. Thus, targeting the PROS1-MERTK PPI is an attractive target for immunotherapy development. Our current project aims to comprehensively characterize PROS1 by analyzing its interactions with all high-confidence binding partners. We hypothesize that PROS1 harbors specific amino acid residues dedicated to engaging with MERTK, distinct from those involved in its other high-confidence interactions.
Methods: In our comprehensive analysis of PROS1 interactions, we initially utilized the Search Tool for the Retrieval of Interacting Genes/Proteins (STRING) database to explore PROS1’s high-confidence interactions, with a focus on MERTK. We set a minimum interaction score of 0.950 to ensure only the highest confidence interaction partners were identified. Following the identification of key protein-protein interactions, we proceeded to generate high-resolution structural predictions of each PPI with ColabFold, in conjunction with UCSF’s ChimeraX-1.6.1 and the AlphaFold2 multimer model. Our analytical approach was further refined through quantitative analysis of each interaction face. We calculated the number of molecular contacts based on Van der Waals (VDW) overlap, setting a threshold of greater than or equal to -0.40 angstroms. This method enabled a precise representation of atomic interactions and provided a deeper understanding of the specific binding interfaces of PROS1, especially with MERTK.
Results: Our STRING analysis confirmed high-confidence PPIs for PROS1, with the interactions scored as follows: PROS1-MERTK (0.988), PROS1-GGCX (0.963), PROS1-TYRO3 (0.986), PROS1-F5 (0.972), and PROS1-C4B (0.978). Utilizing the ColabFold platform along with UCSF’s ChimeraX-1.6.1 and the AlphaFold2 multimer models, we achieved high-resolution structural visualizations for the complexes formed by PROS1 with its interacting partners MERTK, F5, TYRO3, GGCX, and C4B. Comparative analysis of PROS1’s conformational stability in complex with each protein was conducted, with the baseline per-residue confidence score (pLDDT) for unbound PROS1 at 85.06 serving as a benchmark. Post-binding pLDDT scores indicated varying degrees of structural integrity, with the PROS1-MERTK complex showing a pLDDT of 79.10, suggesting a relatively high model confidence. In contrast, the PROS1-C4B complex exhibited a lower pLDDT score of 65.41, indicating lower model confidence. The number of contacts at each interaction face ranged widely, with PROS1-GGCX forming the most contacts (798) and PROS1-F5 the fewest (191).
Conclusions: Our computational analysis has shown evidence of the conformational versatility of PROS1 within its protein-protein interaction network, revealing a diverse binding profile. The observed variability in pLDDT scores and contact point numbers for each PPI highlights the intricate complexity of PROS1’s interactions. Although we have laid the foundational understanding of PROS1’s binding diversity, there is a need to elucidate the specific amino acid residues that characterize each interaction interface. Future work will need to map these residues to understand their unique or shared roles across various complexes but will also employ molecular dynamics simulations to explore the structural fluctuations and stability of these PPIs. These detailed insights are crucial to understanding how the specific interactions within the PROS1-MERTK PPI contribute to the establishment of a TIME that facilitates the progression of uveal melanoma.






Ahmed Clearpath Versus Baerveldt Glaucoma Implant: A Retrospective Non-Inferiority Comparative Study
Wesam Shamseldin Shalaby, MD, PhD (F), Rohit Reddy, BS, Ping Huang, MD, Reza Razeghinejad, MD, Michael Pro, MD [Glaucoma]

Purpose: Ahmed ClearPath (ACP, New World Medical Inc., Rancho Cucamonga, CA, USA) is a new non-valved glaucoma drainage device (GDD) that was recently approved by the FDA in 2019. Available in either 350 mm2 or 250 mm2 models, the ACP is packaged with a 23-gauge needle and a pre-threaded 4-0 polypropylene stent suture to facilitate creation of a sclerostomy and minimize the risk of hypotony. ACP features a curved, flexible plate to facilitate positioning and to conform to the shape of the globe. Studies that investigated its outcomes are limited, and none compared it with other GDDs. The purpose of this study is to compare the safety and efficacy of the ACP vs. the Baerveldt glaucoma implant (BGI; Advanced Medical Optics, Santa Ana, CA, USA), which is currently the most widely used non-valved GDD.
Methods: Design: Single-center, retrospective, comparative study. Participants: Consecutive patients aged =18 years who underwent ACP or BGI surgery (250 mm2 or 350 mm2 models) for glaucoma (baseline IOP >21 mmHg on maximum tolerated medical therapy) at Wills Eye Hospital (2020-2023), and had =6 months of follow-up, and no prior GDD implantation. Outcome Measures: The primary outcome measure was surgical failure at the end of follow-up, defined as intraocular pressure (IOP) >21 or <6 mmHg at 2 consecutive visits, progression to no light perception (NLP) vision, glaucoma reoperation, or implant removal. Secondary outcome measures included the rate of postoperative complications and changes in visual acuity (VA), IOP, and glaucoma medications.
Results: 128 eyes of 113 patients (63 ACP, 65 BGI) with similar baseline characteristics and a mean follow-up of 19.6±10.8 months were included. Surgical failure occurred in 12 eyes (9.4%) with no difference between ACP and BGI groups (9.5% vs. 9.2%, P=0.980). Failure reasons were IOP >21 mmHg (3/12), glaucoma reoperation (5/12), and tube removal (4/12). Kaplan-Meier survival analysis showed similar cumulative rate of surgical failure in both groups (P=0.871). Final IOP, VA, and complication rate were similar in both groups, but medication number was significantly lower with ACP (P=0.013). Diplopia was significantly associated with the 350mm2 model of either implant (P=0.004). Univariate logistic regression analysis did not identify either tube type or plate size as predictors of surgical failure.
Conclusions: To our knowledge, this is the first study to compare the recently approved ACP with the most commonly used non-valved tube shunt BGI. Our results showed that both the ACP and BGI had comparable surgical success and IOP reduction in eyes with glaucoma at a mean follow-up duration of 20 months, with less dependence on medications in the ACP eyes. Need for glaucoma reoperation, and major postoperative complications were comparable in both groups. Both the 250 mm2 and 350 mm2 models had similar outcomes in terms of efficacy and safety, except that postoperative diplopia was significantly associated with the use of 350 mm2 mod


Accuracy Of Eye Care Providers And Trainees Cup-To-Disc Ratio Assessment Using A Simplified Optic Nerve Head Model 
Justin Shortell, MD (F), Wesam Shalaby, MD, PhD, Aditi Mahajan, BA, Jonathan Myers, MD, Dilru Amarasekera, MD [Glaucoma]

Purpose: It is not a common skill in life to measure the ratio in size of a smaller circle within a larger circle. Therefore, it is possible that some early trainees may be able to accurately identify the borders of the optic nerve rim, but incorrectly guess the C/D ratio due to a lack in experience in this niche role of object size comparison. Multiple studies indicate that interobserver variability in measuring c/d ratios are much larger than the intra-observer variability and that the intra-observer variability increased as education levels decreased. This study will assess inter and intra-user variability in cup-to-disc (C/D) ratio measurements amongst trainees and eye care providers using a one-dimensional optic nerve head model that eliminates medical variables.
Methods: A survey will be sent to medical trainees and eye care providers containing multiple images of two precisely measured circles superimposed on each other, simulating an optic nerve head of varying C/D ratios. Simulated centered, horizontally displaced, and vertically elongated cups will be tested. Sixty different examples with varying C/D ratios from these 3 categories will be included in the survey and participants will be asked to calculate the average cup-to-disc ratio to the closest degree of 0.05. The responses will be compiled and analyzed to compare accuracy, inter and intra-user variability amongst different levels of training and sub-specialization.
Results: Pending.
Conclusions: Pending. The authors hypothesize decreased accuracy in C/D ratio measurements in early trainees, despite the simplified model removing medical variables.


Frequency Of Anti-Vegf Injections Before And After Pars Plana Vitrectomy In Eyes With Neovascular Age-Related Macular Degeneration
Turner Wibbelsman, MD (R), Bita Momenaei, MD, Roselind Ni, BS, Anthony Obeid, MD, MPH, Michael Cohen, MD [Retina]

Purpose: A number of clinical trials have established the role of anti-VEGF therapy for neovascular age-related macular degeneration (nAMD). These pivotal trials have shown sustained improvement with regulated treatment regimens. Pars plana vitrectomy (PPV) is a common procedure used to treat a variety of vitreoretinal pathology. It has been theorized that removal of the vitreous affects the pharmacokinetics of anti-VEGF in the eye. This may lead to an increased frequency of anti-VEGF administration to maintain visual acuity. One small study demonstrated a paradoxical increase in the interval between injections after RRD repair in eyes being treated for nAMD. We aim to evaluate a large cohort to determine the frequency of anti-VEGF treatment before and after PPV.
Methods: This retrospective cohort study included 18 eyes with nAMD being treated with anti-VEGF injections that underwent PPV. Indications for PPV were recorded. At the five visits before (Pre-5, Pre-4, Pre-3, Pre-2, and Pre-1) and after PPV (Post-1, Post-2, Post-3, Post-4, Post-5, and final), functional and anatomic (optical coherence tomography) outcomes were assessed. The interval between visits was recorded. Statistical analyses included paired t-test, McNemar’s test, and generalized estimating equations.
Results: The most common indications for PPV included 5 (28%) exudative/hemorrhagic retinal detachments (RD), 5 (28%) dislocated lens/retained lens fragments, and 3 (17%) rhegmatogenous RDs. In the visits preceding vitrectomy, there were average intervals of 50.7 (±24.0), 55.8 (±26.2), 58.9 (±28.5), and 58.9 (±35.5) days between the visits [Pre-5 to Pre-4], [Pre-4 to Pre-3], [Pre-3 to Pre-2], and [Pre-2 to Pre-1], respectively. After vitrectomy, the intervals between visits were 39.8 (±13.3), 46.7 (±24.0), 40.8 (±18.2), and 42.6 (±18.4) days between the [Post-1 to Post 2], [Post-2 to Post-3], [Post-3 to Post-4] and [Post-4 to Post-5] visits, respectively. When comparing the intervals between visits before vitrectomy to those after vitrectomy, there was a significant difference, p=0.03.
Conclusions: A shortening of treatment intervals was observed after PPV in eyes receiving anti-VEGF injections for nAMD. After PPV, close monitoring of anti-VEGF treatment response is prudent given the potential pharmacokinetic effects of post-vitrectomy physiology.


Long-Term Visual Field Progression In Patients With Optic Disc Drusen With Or Without Glaucoma
Rohit Reddy, BS (F), Wesam Shalaby, MD, PhD, Qiang Zhang, PhD, Jonathan Myers, MD, Ping Huang, MD [Glaucoma]

Purpose: Optic disc drusen (ODD) are deposits composed of proteinaceous material within the optic nerve head that are known to cause visual field (VF) defects. However, longitudinal VF progression in patients with ODD, particularly in those with a concurrent glaucoma diagnosis, is poorly understood. This study aims to characterize VF deterioration in patients with ODD with or without glaucoma and identify possible factors associated with faster rates of VF progression.
Methods: This was a single-center, retrospective, comparative study including patients with a diagnosis of ODD, with = 2 reliable standard automated perimetry (SAP) tests obtained either by Humphrey or Octopus, and = 12 months of follow-up. Rates of change in SAP mean deviation (MD) were obtained by linear mixed model regression and categorized as slow (<0.5 dB/year) or moderate/fast (>0.5 dB/year). Characteristics at baseline including demographics, glaucoma diagnosis, comorbid conditions, intraocular pressure (IOP), use of pressure-lowering medications, retinal nerve fiber layer (RNFL) thickness, and past ocular surgery were compared between groups.
Results: 82 eyes of 45 patients were included with a mean age of 56.6 ± 16.0 years and mean follow-up time of 53.7 ± 40.0 months (range 13.0-181.0 months). 65 eyes were classified as slow and 17 eyes were classified as moderate/fast. Glaucoma was diagnosed in 33/65 eyes (50.8%) in the slow group and 8/17 eyes (47.1%) in the moderate/fast group, with no significant difference. No significant differences in demographics, medical and surgical history, or mean IOP existed at baseline between groups. Patients in the moderate/fast group were on more glaucoma medications (1.29 vs. 0.40, P=0.003) and had a lower RNFL thickness (65.7 µm vs. 80.2 µm, P=0.032) at baseline compared to the slow group.
Conclusions: The moderate/fast progression group had lower RNFL thickness and more glaucoma medications at baseline compared to the slow group, regardless of glaucoma diagnosis. These results suggest the importance of close monitoring for ODD patients and potential treatment consideration for those with significant RNFL thinning, even with normal IOP.


Incidence Of And Risk Factors For Early Post-Operative Intraocular Pressure Elevation Following Goniotomy
Teresa Horan, MD (F), Wesam Shamseldin Shalaby, MD, PhD, Steven Chang, MPH, Tina Xia, MD, Dilru Amarasekera, MD [Glaucoma]

Purpose: Goniotomy is becoming an increasingly popular MIGs procedure for patients with glaucoma, especially those undergoing cataract surgery. This study aims to determine the incidence of and risk factors for early post-operative intraocular pressure (IOP) elevation following various goniotomy procedures.
Methods: This is a retrospective chart review of patients at a large tertiary eye hospital who received goniotomy with or without phacoemulsification. Goniotomy types include gonioscopy-assisted transluminal trabeculotomy (GATT), OMNI, Kahook, SION, and bent needle goniotomy. Patients over age 18 who experienced post-operative IOP elevation >10 mmHg from baseline in the first month were identified. Demographics collected include age, gender, race, type and severity of glaucoma, prior intraocular surgery, pre-operative IOP, and type of goniotomy. Twelve months of post-operative data including IOP and medications were reviewed. IOP elevation timing and treatment required for reduction were recorded.
Results: There were 409 goniotomy procedures performed between 1/1/2021 and 12/31/2022. Further data and analyses will be presented pending additional review.
Conclusions: Pending.


Utilization Of An Eye Emergency Room Resulting in Glaucoma Care Referral
Sunidhi Ramesh, MD (R), Robert Abishek, BA, Elliot Cherkas, MD, Wesam Shalaby, MD, Qiang Zhang, PhD, Christine Chung, MD, Nadia Haqqie, MD, Natasha Kolomeyer, MD, Daniel Lee, MD, Reza Razeghinejad, MD, Jonathan S. Myers, MD, Aakriti Shukla, MD [Glaucoma]

Purpose: To describe the demographic factors and clinical characteristics associated with the utilization of an eye emergency room resulting in glaucoma care referral.
Design: Retrospective case series.
Subjects: All patients seen at the Wills Eye Emergency Room (ER) from October 1, 2020, to March 31, 2021, who were referred for glaucoma care.
Methods and Measures: Demographic data were collected. Legal blindness in one or both eyes was defined as BCVA ≤20/200.1 Residence in an underserved area was based on rural-urban commuting area code classifications, and socioeconomic disadvantage was based on area deprivation index (ADI) percentiles
Results: 7438 patients presented to the ER during the study period, and 192 (2.6%) were referred for glaucoma care. Of the 108 patients who provided ophthalmic history, 76 (70.4%) patients (40.8% unilaterally blind and 5.3% bilaterally blind) received a new diagnosis of definite or suspected glaucoma in the ER. 43 of 192 (22.4%) patients required urgent glaucoma procedural intervention after the ER visit; 28 (65.1%) were given a new diagnosis of definite or suspected glaucoma in the ER. 31 of 192 (16.2%) patients were uninsured; they were more likely to be younger in age (54.4 ± 14.5 years vs. 61.8 ± 15.7 years; P=0.016) and to speak a primary language other than English (16.1% vs. 5.6%; P=0.042) as compared to insured patients.
Conclusion: Over a 6-month period, glaucoma represented a small subset of ER visits but resulted in a new diagnosis of definite or suspected glaucoma in the majority of cases, of whom 46% were unilaterally or bilaterally legally blind. Almost two thirds of those with a new diagnosis required an urgent glaucoma procedural intervention after the ER visit. Our analysis highlights the need for identifying high-risk patients, enhancing access to office-based eye care, and emphasizes the crucial role of accessible care for glaucoma patients, particularly those with severe disease, urgent clinical needs, or lack of health insurance.


Selective Laser Trabeculoplasty Efficacy In Pseudophakic Patients With Trabecular Microbypass Stents
 Bryce Hwang, MD (R), Mark Pyfer, MD, FACS [Glaucoma]

Purpose: Selective laser trabeculoplasty (SLT) and trabecular micro bypass stent (Glaukos iStent®) are both effective treatments for mild to moderate primary open-angle glaucoma (POAG). A single small previous retrospective cohort studied the efficacy of SLT after first-generation trabecular micro bypass stent placement and found SLT was beneficial in eyes with trabecular micro bypass stents; however, the effect of lens status and second-generation trabecular micro bypass stents were not assessed. Other studies have investigated the efficacy of trabecular micro bypass stents after SLT. Our study aims to characterize the efficacy of SLT after trabecular micro bypass stent placement in pseudophakic patients.
Methods: A retrospective cohort study from a single surgeon will be conducted. We will include pseudophakic patients over the age of 18 years who undergo SLT for mild to moderate POAG. The cohort will be matched 1 to 2 with patients who did and did not undergo placement of a trabecular micro bypass stent. The primary outcome measure will be the difference in intraocular pressure (IOP) before SLT and 4-8 weeks after SLT. Secondary outcome measures will be the change in the number of glaucoma medications after SLT and the IOP at 3 months, 6 months, and 1 year after SLT. A multivariate logistic regression with the post-SLT IOP as the dependent variable and patient age, sex, type of stent placed, number of stent placed, and previous SLT as independent variables will be conducted.
Results: We anticipate there will be 30 patients who undergo SLT after iStent placement. Results are being collected.
Conclusions: We hypothesize that SLT will be efficacious in pseudophakic eyes with trabecular micro bypass stents; and that SLT will have an additive but not a synergistic effect. 


Retrospective Comparison Of Trabecular Micro-Bypass Stent Vs Excisional Goniotomy Combined With Cataract Surgery
Kaitlyn Brettin, MD (R), Mark F. Pyfer, MD, FACS [Glaucoma]

Purpose: Minimally invasive glaucoma surgery (MIGS) combined with cataract extraction has increased the surgical options for patients with mild-moderate glaucoma plus visually significant cataract. In the US, insurance reimbursement changes have decreased access to trabecular micro-bypass stent (Glauokos iStent) over the past 2 years, therefore excisional goniotomy (Kahook Dual Blade) was substituted for those patients. We sought to determine the outcome of KDB goniotomy vs trabecular micro-bypass stent combined with cataract surgery during this time period. Setting: Wills Eye Hospital, Philadelphia PA USA and nearby private clinics.
Methods: We will compare patients who underwent combined trabecular micro-bypass stent inject or KDB goniotomy for mild-moderate glaucoma combined with cataract surgery between 1 Jan 2021 – 2023. Visual acuity (VA), intraocular pressure (IOP) and number of glaucoma medications were obtained preoperatively and at 1 day, 1-2 weeks, 3, 6 and 12 months postop. Complications, total operative time, secondary interventions, and subjective visual complaints will be recorded. Statistical analysis will be performed using t-test and ANOVA to compare the 2 groups.
Results: Preliminary data from 140 patients who underwent combined iStent inject or KDB goniotomy for mild-moderate glaucoma combined with cataract surgery between 1 Jan 2021 – 31 Dec 2022 revealed that 64 patients underwent iStent and 76 patients underwent 30 degree KDB goniotomy combined with phaco cataract extraction / IOL implantation. Significant IOP reduction was achieved in both groups (2.3mmHg iStent vs 2.7mmHg KDB) at the 6 month visit, with average medications reduced in both groups. These differences were not statistically significant. There was also no significant difference in postop hyphema (<3%) and prolonged postop inflammation beyond 1 month (<4%). We will also analyze an additional year of follow up data in the same fashion.
Conclusions: Initial analysis suggested that combined phacoemulsification CE plus iStent trabecular micro-bypass stent or KDB goniotomy yielded similar results in terms of IOP reduction, decrease in glaucoma medications required, and postop complications. We plan to analyze an additional year of follow up data to compare longer term outcomes, thus final conclusions pending further data collection and analysis.




Characteristics Of Enrolled And Lost To Follow Up Participants In Diabetic Retinopathy Clinical Research (Drcr) And Diabetic Macular Edema Clinical Trials
Theodore Bowe, MD (R), Ajay Kuriyan, MD [Retina and Vitreous]

Purpose: Diabetic macular edema (DME) is not equally prevalent by race, ethnicity, or gender in the USA.1 Clinical trials have led to improvement in the management of DME. There is little data on the demographics of participants included in DME clinical trials. The first of our two studies evaluates the differences in enrollment of racial and ethnic minorities and women in landmark DME clinical trials compared to demographics of patients undergoing treatment for DME from the IRIS® (Intelligent Research in Sight) Registry. The second evaluates the characteristics of participants who enrolled in, but did not complete, the trials.
Methods: The first study compiled data from Diabetic Retinopathy Clinical Research (DRCR) clinical trials and industry sponsored trials with data reported between Jan 1, 2000 and Jan 1, 2020 and with subjects that met the criteria for treatment of DME. The primary outcome was enrollment fraction defined as the number of trial enrollees divided by the reference sample size of DME patients undergoing treatment from published IRIS® Registry data. Enrollment fraction was compared between different races and between genders. The second outcome of interest was completion of the clinical trial to the first data report, with the two groups being compared on age, race/ethnicity, length of diagnosis of DM, HgA1c, BP, presenting VA, DRSS, and presence or absence of other medical comorbidities.
Results: For our first analysis ten clinical trials met our inclusion criteria. Five were part of the DRCR and 5 were industry-sponsored trials. Compared to enrollment fraction of 2.63% among Whites, lower enrollment fractions were found in Black patients (1.78%) and in Hispanic patients (1.49%). Men were more likely to enroll in the clinical trials compared to women (enrollment fraction, 2.21% vs 1.83%, respectively). For our second study, eight clinical trials had the data of interest. 82.2% of subjects completed the studies. Participants who were lost to follow up were more likely to be younger, Hispanic or Black, to have Type 1 Diabetes as compared to Type 2, have higher HgA1c, higher blood pressure, higher diabetic retinopathy severity score, and worse baseline visual acuity.
Conclusions: Subjects who participated in 10 major DME clinical trials were disproportionately White and male, as compared to the population undergoing treatment for DME. DME clinical trial results should be generalized with caution, and further efforts are necessary to align the demographics of the DME clinical trial participants to the demographics of real-world patients requiring DME treatment. Participants who were lost to follow up during DRCR clinical trials tended to be younger, minorities, with more severe diabetes and diabetic retinopathy. This study highlights the importance of ensuring that representative population is maintained through the end of the study period.


Retinal Detachment After Commotio Retinae: Prevalence And Clinical Characteristics
Olufemi Adams, MD (F), Hana Mansour, MD, Yoshihiro Yonekawa, MD [Retina and Vitreous]

Purpose: Blunt ocular trauma encompasses various injuries affecting different parts of the eye due to incidents like sports-related trauma, falls, or assaults. This trauma can result in posterior segment complications, such as commotion retinae and severe conditions such as retinal detachments. Given the rarity of retinal detachment post-commotio retinae and its impact on visual outcomes, this study aims to describe its rate and clinical characteristics to enhance understanding and management strategies for this condition.
Methods: A single center, retrospective chart review of all patients who presented with commotio retinae between January 2015, and June 2022. Those who had ruptured globe, prior retinal detachment (RD) or who concomitantly presented with RD, and those with history of vitreoretinal surgery were excluded.
Results: 380 eyes of 380 patients were diagnosed with commotio retinae after blunt trauma. Mean (SD) follow up duration was 409 (590) days. During follow up, 16 (4.22%) patients developed RD post-commotio. RD developed 36±68 days post-commotio [range 1 to 237 days]. Mean (SD) log MAR visual acuity (VA) [Snellen] at presentation was worse in eyes that subsequently developed RD 0.93 (0.84) [20/170] compared to non-RD 0.44 (0.64) [20/55] (p= 0.013). 15 (100%) were macula-sparing, 9 (60%) were from retinal dialyses, 8 (53.3%) had tears, and the average number of tears was 1.75, and average extent was 2.78 clock hours. Ten (62.5%) were focal and treated with demarcation laser photocoagulation and needed no further treatment. Two (12.5%) underwent vitrectomy with silicone oil tamponade.
Conclusions: Most cases of commotio retinae are self-limited and do not result in long-term complications. However, 4% of patients in our cohort developed subsequent retinal detachment. Patients should be followed closely and counseled accordingly.


Characteristics Of Geographic Atrophy In Eyes With Dry Age-Related Macular Degeneration Compared To Macular Atrophy In Fellow Eyes With Neovascular Age-Related Macular Degeneration
Hana Mansour, MD (F), Jason Hsu, MD [Retina and Vitreous]

Purpose: Geographic atrophy (GA) secondary to age-related macular degeneration (AMD) is a progressive degenerative ocular disease that leads to irreversible vision loss. While the exact cause of GA remains a topic of debate, a combination of oxidative stressors, environmental factors, genetic predisposition, and the complement system contributes to its onset and progression. The aim of this study is to investigate the natural history and anatomic characteristics of GA in eyes with dry AMD (dAMD) compared to fellow eyes with macular atrophy associated and concurrent neovascular AMD (nAMD) treated with anti-vascular endothelial growth factor (VEGF) injections.
Methods: This is a single center, retrospective chart review of patients with nAMD in one eye and dAMD in the fellow eye. Data were recorded at two time points (#1 and #2) one year apart. Two independent graders reviewed the images to measure atrophy size and grade it based on the Consensus on Atrophy Meeting group criteria. The change in atrophy was calculated as the difference in atrophy size between the two time points. A square root transformation (SQRT) was also performed to report the change in atrophy size.
Results: 208 eyes of 104 patients were included in this study: 104 eyes had dAMD and 104 fellow eyes had nAMD. Mean (SD) age was 87.5 (6.3) years and 68.3% (71 of 104) were females. Mean (SD) atrophy size was 14.05 (9.96) mm2 in dAMD eyes and 14.14 (9.26) mm2 in nAMD eyes (p= 0.95) at time point #1, and 16.92 (10.83) mm2 in dAMD eyes and 17.35 (11.03) mm2 in nAMD eyes (p= 0.78) at time point #2. Mean (SD) atrophy growth rate was 3.08 (2.52) mm2/year in the nAMD eyes and 2.77 (1.88) mm2/year in the dAMD eyes (p= 0.32). Using the SQRT, the growth rates were 0.40 (0.24) mm/year in nAMD and 0.38 (0.22) mm/year in dAMD (p= 0.55).
Conclusions: GA in eyes with dAMD and macular atrophy in fellow eyes with nAMD exhibit similar growth rates. This suggests a rationale for considering complement inhibition in eyes with nAMD and macular atrophy.


Accuracy And Readability Of After Visit Summaries For Retinal Conditions Generated By A Large Language Model 
Nikhil Bommakanti, MD (F), Yoshihiro Yonekawa, MD [Retina and Vitreous]

Purpose: After-visit summaries (AVS) can strengthen doctor-patient communication and improve health outcomes. Legislation mandates patient access to clinical notes, which may be difficult to understand. Artificial intelligence chatbots can answer questions in retina, and may be able to generate accurate AVS for common retinal conditions.
Methods: Common retinal conditions were selected by a fellowship-trained retina specialist. Two clinical notes written between 2020 and 2023 were randomly selected for each condition and were graded by three clinical retinal fellows as “appropriate” or “inappropriate” based on the accuracy of the described diagnosis, treatment plan, and follow up plan. Notes were further classified as “omits key information,” “inaccurate summary,” or “hallucination.” Reading level of the responses was assessed using the Flesch-Kincaid readability test.
Results: 34 AVS were generated from 34 clinical notes describing 17 retinal conditions. 21 (62%) AVS were accurate. Of the inaccurate AVS, 2 (6%) omitted key information, 19 (56%) included incorrect information, and 13 (39%) hallucinated information (multiple classifications were allowed). All responses were at or below the sixth grade reading level based on Flesch-Kincaid Grade Level.
Conclusions: Large language models can be used to create clinical after visit summaries, which may improve doctor-patient communication and health outcomes. Further work is necessary to ensure the output is completely accurate.


Random Allelic Expression In Inherited Retinal Disease Genes
Collin Richards, MD (R), Jose Pulido, MD, MS, MBA, MPH [Retina and Vitreous]

Purpose: Inherited retinal diseases (IRD) are a significant contributor to visual loss in children and young adults, falling second only to diabetic retinopathy. Understanding the pathogenic mechanisms of IRDs remains paramount. Some autosomal genes exhibit random allelic expression (RAE), similar to X-chromosome inactivation. This study identifies RAE genes in IRDs.
Methods: Genes in the Retinal Information Network were cross-referenced with recent literature to identify expression profiles, RAE or biallelic expression (BAE). Loss-of-function intolerance (LOFI) was determined by cross-referencing the existing literature. Molecular and biological pathways that are significantly enriched were evaluated using gene ontology.
Results: 184 IRD-causing genes were evaluated. 31 (16.8%) genes exhibited RAE. LOFI was exhibited in 6/31 (19.4%) of RAE genes and 18/153 (11.8%) of BAE genes. Brain tissue exhibited BAE in 107/128 (83.6%) genes for both sexes. Molecular pathways significantly enriched among BAE genes were photoreceptor activity, tubulin binding, and nucleotide/ribonucleotide binding. Biologic pathways significantly enriched for RAE genes were equilibrioception, parallel actin filament bundle as-sembly, photoreceptor cell outer segment organization, and protein depalmitoylation.
Conclusions: Allele-specific expression may be a mechanism underlying IRD phenotypic variability, with clonal populations of embryologic precursor cells exhibiting RAE. Brain tissue preferentially exhibited BAE, possibly due to selective pressures against RAE. Pathways critical for cellular and visual function were enriched in BAE, which may offer a survival benefit.


Characterizing Patients With A History Of Diabetic Retinopathy: A Survey Study
Anthony Obeid, MD, MPH (F), Bita Momenaei, MD, Allen Ho, MD [Retina and Vitreous]

Purpose: The purpose of this study is to evaluate sociodemographic characteristics and overall health burden of patients with a known history of diabetic retinopathy.
Methods: This is a survey study conducted on patients with diabetic retinopathy at the Retina Service of Wills Eye Hospital. All subjects were asked to participate in a survey of 30 questions related to their demographics, their diabetes diagnosis and management, and their ability to access to healthcare-related resources.
Results: A total of 240 patients answered the survey. 18.0% of patients had a total annual household income of <$25,000, and 38.1% of patients had a total household income of <$50,000. There were 79 (32.9%) patients that considered their diabetes as severe and 23 (9.6%) as very severe. There were 13 (5.4%) patients that were not sure about the severity of their diabetes. There were 21 (8.8%) patients that did not know the severity of their diabetic retinopathy. There were 25 (10.4%) patients undergoing dialysis for end-stage renal disease.
Conclusions: Patients with diabetic retinopathy may have several socioeconomic and health burdens which may prevent them from receiving appropriate care.


The Role of Tenecteplase and Orbital Color Doppler Imaging for Central Retinal Artery Occlusion in an Ophthalmic Emergency Department 
Erik Massenzio MD (R); Lawrence Chiang, Christian Raimondo, Khan Bui, David Xu MD [Retina and Vitreous]

Purpose: To determine the natural course and clinical characteristics of acute central retinal artery occlusion (CRAO) and the efficacy of intravenous Tenecteplase (TNK).
Methods: Retrospective cohort study of 87 patients with CRAO who presented to the Wills ER.
Results: 35 patients who presented within 24 hours with non-cilioretinal artery sparing CRAO returned to clinic. Without TNK, 0 had visual recovery (defined as VA greater than 20/100); however, 22% (2 out of 9) of those who had received TNK and recovered to 20/40.  Orbital color doppler findings of retrobulbar embolus (p=0.002) and no central retinal artery flow (p = 0.035) were associated with development of neovascularization.
Conclusions: Treatment of CRAO with Tenecteplase may be a viable option, and orbital color doppler imaging may help predict development of neovascularization.


Histopathologic Confirmation of Lymphocytic Infiltration of the Optic Nerve and Inner Retina in Birdshot Chorioretinopathy   
Linnet Rodriguez MD (F), Diva R. Salomao MD, James P. Dunn MD, Adnan Tufail MD, Jose S. Pulido MD [Retina and Vitreous]

Purpose: To describe new histological findings involving the inner retina in birdshot chorioretinopathy.  
Design: Evaluation of the inner retinal pathology of the eye of a patient with bilateral birdshot chorioretinopathy who underwent enucleation for a unilateral ciliochoroidal melanoma. Methods: A middle-aged female who was HLA-A29 positive and was diagnosed with bilateral birdshot chorioretinopathy and ciliochoroidal melanoma.  
Outcome measures:  To report on the inner retinal histopathological finding of birdshot chorioretinopathy.  
Results: Histopathological sections showed focal perivascular lymphocytic infiltration at the optic nerve head that extended into the adjacent inner retina, mainly involving the ganglion and nerve fiber layers.   
Conclusion: This is the first report of histopathological findings in birdshot chorioretinopathy that demonstrates lymphocytic infiltration of the inner retinal layers. We have previously shown that birdshot chorioretinopathy has multiple foci of lymphocytes in the choroid. Our patient also had a perivascular lymphocytic infiltration of the optic nerve and retinal vessels. This inflammatory infiltration may lead to bipolar and Muller cell dysfunction that ultimately results in an electronegative ERG.


Long-term Stability, Sterility, and Cost-effectiveness of Commercially Available 0.05% Chlorhexidine Gluconate as Antisepsis Before Intravitreal Injection 
Asad F. Durrani, MD (F), Bita Momenaei, MD; Gagan Kaushal, PhD, Sunir J. Garg, MD [Retina and Vitreous]

 Purpose: Commercially available chlorhexidine gluconate (CHG) has a beyond-use date of 24 hours, limiting its use as antisepsis before intravitreal injections (IVIs) due to cost. This study sought to evaluate the stability and sterility of 0.05% CHG at 0, 3, 7, 15, and 30 days after opening and perform a cost analysis comparing CHG to betadine for antisepsis before IVIs.
Design: Experimental study. 
Subjects, Participants, and/or Controls: 0.05% CHG in 1 milliliter syringes stored at room temperature (25 degrees Celsius with 60% relative humidity) or refrigerated (2 to 6 degrees Celsius). 
Methods, Intervention, or Testing: Turbidity, pH, and high-performance liquid chromatography (HPLC) were used to assess stability. Sterility testing was performed in accordance with United States Pharmacopeia guidelines. A cost analysis was performed comparing the cost of CHG and betadine for antisepsis before IVIs.
Main Outcome Measures: Stability and sterility of 0.05% CHG at 0, 3, 7, 15, and 30 days. The cost of using CHG compared to betadine for antisepsis before IVIs. 
Results: 0.05% CHG remained stable throughout the study period. All samples had measured turbidity less than 0.5 nephelometric turbidity units. The pH of all samples remained between 5.0 and 7.0 in accordance with the manufacturer’s accepted range for pH. HPLC confirmed stability at all time points under both temperature conditions with an average concentration at day 30 relative to day 0 of 98.52±4.16% and 99.99±3.38 % at room temperature and at 2 to 6 degrees Celsius, respectively. Cost analysis found the average cost per month for a busy retina clinic using betadine to be $267.68 and $1,853 for 0.05% CHG when opening a new bottle daily due to its limited beyond-use date, a 692% increase in cost. Using the results of this study, the cost of 0.05% CHG decreased to $125.97 per month. 
Conclusions: Commercially available 0.05 % CHG remains stable and sterile up to 30 days after opening. The ability to use CHG up to 30 days after its opening significantly decreases its cost to retina practices and makes it a cost-effective alternative to betadine for antisepsis before IVIs.




Closing Remarks