Anton M. Kolomeyer

Ocular telehealth screenings in an urban community.

The current U.S. economic recession has resulted in a loss of income, housing, and healthcare coverage. Our major goal in this socioeconomic setting was to provide ophthalmic remote health screenings for urban soup kitchen and homeless populations in order to identify and refer undetected vision-threatening disease (VTD). We assessed visual acuity, blood pressure, pulse/oxygen saturation, body mass index, and intraocular pressure for 341 participants at soup kitchens as part of the homeless outreach program in Newark, NJ. History of diabetes, hypertension, and smoking, last ocular examination, and ocular history were noted. Imaging was performed with an 8.2 megapixel non-mydriatic retinal camera with high-speed Internet ready for off-site second opinion image evaluation. Positive VTD findings were identified in 105 participants (31%) (mean age, 53.6 years), of whom 78% were African American, 73% males, and 62% smokers. We detected glaucoma in 34 participants (32%), significant cataract in 22 (21%), diabetic retinopathy in 5 (5%), optic atrophy in 1 (1%), age-related macular degeneration in 1 (1%), and other retinal findings in 43 (41%). The incidence of VTDs was higher among this cohort than among study groups in previous screenings (31% vs. 12%). This finding shows an increase in ocular morbidity in a younger, at-risk population with elevated rates of hypertension, diabetes, and smoking. Functional visual impairment was 2.5 times higher than the national average (16% vs. 6.4%). Comprehensive, community-based screenings can provide more sensitive detection of VTDs in high-risk groups with low access to ophthalmic care and can be an integral part of recession solutions for improving healthcare.

Characterization of conditioned media collected from cultured adult versus fetal retinal pigment epithelial cells.

PURPOSE To characterize trophic factor secretion of cultured adult and fetal retinal pigment epithelial (RPE) cells and to assess the impact on porcine retinal survival in vitro. METHODS Conditioned media (CM) were collected from cultured adult and fetal RPE cells and analyzed for trophic factor composition and concentration by multiplex ELISA. Trophic factor receptor occupancy was calculated to evaluate the potential biological effectiveness of the differences in trophic factor concentrations. Retina-preserving activity of the collected CM was evaluated using an in vitro model of degenerating porcine retina. Isobaric tag for relative and absolute quantification (iTRAQ) was used to identify additional proteins with a potential effect on porcine retinal survival. RESULTS The overall trophic factor secretion profile of cultured fetal RPE cells remained stable over multiple passages and extended culture duration. Compared with CM from adult RPE cells, fetal RPE-CM had significantly higher concentrations of vascular endothelial growth factor-A (VEGF-A), brain-derived neurotrophic factor (BDNF), and pigment epithelium-derived factor (PEDF) and significantly lower concentrations of leukemia inhibitory factor (LIF), basic fibroblast growth factor (bFGF), and nerve growth factor (NGF). Fetal RPE-CM was significantly better than adult RPE-CM at improving degenerating porcine retina survival. iTRAQ analysis identified insulin-like growth factor binding protein-3 (IGFBP-3), semaphorin-3B, transforming growth factor (TGF)-β, hepatoma-derived growth factor (HDGF), and gelsolin as factors potentially contributing to this activity. Co-culture of fetal RPE and porcine retina was significantly better than fetal RPE-CM at preserving porcine retinal survival. CONCLUSIONS Adult and fetal RPE cells have significantly different trophic factor secretion profiles, which correlate with differences in their ability to support porcine retina survival. Combined with trophic factor receptor occupancy calculations, these data implicate VEGF-A and PEDF as key RPE-derived factors promoting preservation of retinal structure and function.

360° retinectomy for the treatment of complex retinal detachment.

Purpose: To review the anatomical and functional outcomes of eyes that underwent 360° retinectomy for a variety of indications and compare them with previously published results. Methods: Retrospective case series. We reviewed the data of 40 patients (41 eyes) who underwent pars plana vitrectomy and 360° retinectomy. The principal indication for surgery in this series was retinal detachment after penetrating trauma (26 of 41 eyes [63%]). Anatomical success was defined as complete retinal reattachment or attachment posterior to the scleral buckle, if present. Results: Thirty of the 41 eyes (73%) had follow-up of at least 6 months after 360° retinectomy, and of these, 11 eyes (37%) had recurrent retinal detachment. Seven of the latter eyes underwent repeat pars plana vitrectomy with anatomical success in 6 eyes (86%). Overall, anatomical success was achieved in 25 of 30 eyes (83%) with follow-up of ≥6 months after ≥1 operations (including 360° retinectomy). Visual results were limited with only 4 of 35 eyes (11%) in which visual acuity could be tested achieving ambulatory vision, which may reflect the preponderance of posttraumatic retinal detachments in this series. Conclusion: The anatomical results of this series are comparable with those in the reported literature and indicate that vitrectomy with 360° retinectomy can be beneficial in the management of complex retinal detachments in otherwise unsalvageable eyes.

Placement of ProKera in the management of ocular manifestations of acute Stevens-Johnson syndrome in an outpatient.

Purpose: To report the clinical use of ProKera (Bio-Tissue, Inc., Miami, FL) under topical anesthesia in an outpatient for the management of ocular manifestations of acute Stevens-Johnson syndrome (SJS). Methods: Interventional case report. Results: A 19-year-old woman developed acute SJS with ocular involvement after ingestion of oral antibiotics. Slit-lamp examination performed 2 weeks later showed severe inflammation and areas of ulceration along all 4 lids and complete, bilateral sloughing of bulbar and palpebral conjunctivae, including the limbus. ProKera was placed under topical anesthesia without sedation in both eyes instead of an amniotic membrane due to excess risk of general anesthesia. Three weeks after placement, slit-lamp examination showed complete re-epithelialization of both corneas and conjunctivae, with only trace conjunctival injection and minor limbal epithelial irregularities. Three months postprocedure, there were no signs of clinically significant scarring, and the visual acuity (VA) was 20/20 bilaterally. Fourteen months postprocedure, VA remained stable, and the patient did not have dry eye, photophobia, clinically significant scarring, or symblepharon. Conclusions: ProKera placement performed under topical anesthesia may be appropriate for the treatment of ocular surface manifestations of acute SJS particularly in those patients followed in an outpatient setting with milder forms of disease and/or with contraindications to general anesthesia.

Characterization of Conditioned Media Collected from Aged versus Young Human Eye Cups

PURPOSE To characterize secretion of in situ retinal pigment epithelium (RPE) from healthy, aged adult, age-related macular degeneration (AMD) adult, and fetal donor eyes and to assess the impact on retinal survival in vitro. METHODS Conditioned medium (CM) was collected from adult and fetal donor eyes and analyzed for trophic factor composition by multiplex ELISA. Trophic factor receptor occupancy was calculated to evaluate differences in trophic factor concentrations. RPE trophic factor mRNA expression was quantified by real-time PCR. Retina-preserving activity of the collected CM was evaluated using degenerating porcine retina in vitro. RESULTS Compared with CM from adult donors, AMD donor CM contained a significantly higher concentration of brain-derived neurotrophic factor (BDNF), whereas fetal donor CM contained significantly higher concentrations of hepatocyte growth factor (HGF) and pigment epithelium-derived factor (PEDF). No consistent correlation was found between trophic factor mRNA expression and protein secretion. Non-RPE components of the RPE-Bruchs membrane-choroid-sclera complex were major contributors of vascular endothelial growth factor-A (VEGF-A). CM of fetal donors was significantly better than CM of adult or AMD donors at improving the survival of degenerating porcine retina. CONCLUSIONS RPE cells of adult and fetal eyes have significantly different trophic factor production capabilities, which correlated with changes in preservation of porcine retina. Combined with trophic factor receptor occupancy calculations, these data may implicate HGF and PEDF as key factors promoting the preservation of retinal structure and function.

Treatment of Chronic, Noninfectious, Nonnecrotizing Scleritis with Tumor Necrosis Factor Alpha Inhibitors

Abstract Purpose: To evaluate the use of TNF-alpha inhibitors for non-infectious, non-necrotizing scleritis. Methods: We conducted a retrospective chart review of patients with non-infectious, non-necrotizing scleritis treated at our institutions from 2002 to 2012. Results: Seventeen patients (26 eyes) were included. Ten patients were started on infliximab and seven on adalimumab; five patients were treated with both TNF-alpha inhibitors on separate occasions. All patients had an associated autoimmune disease. Control of active inflammation for at least 2 months was achieved in 15 (88%) of 17 patients. Seven out of eight patients successfully tapered concurrent corticosteroid use. Only one patient discontinued TNF-alpha inhibitor use due to an allergic reaction. Conclusions: TNF-alpha inhibitors appear to have a role in managing non-infectious, non-necrotizing scleritis refractory to initial therapy, mainly by reducing inflammation and decreasing concurrent CS use.

Organotypic culture of full-thickness adult porcine retina.

There is a recognized demand for in vitro models that can replace or reduce animal experiments. Porcine retina has a similar neuronal structure to human retina and is therefore a valuable species for studying mechanisms of human retinal injury and degenerative disease. Here we describe a cost-effective technique for organotypic culture of adult porcine retina isolated from eyes obtained from an abattoir. After removing the anterior segment, a trephine blade was used to create multiple neural retina-Bruchs membrane-RPE-choroid-sclera explants from the posterior segment of adult porcine eyes. A piece of sterile filter paper was used to lift the neural retina off from each explant. The filter paper-retina complex was cultured (photoreceptor side up) atop an insert, which was held away from the bottom of the culture dish by a custom-made stand. The stand allows for good circulation of the culture medium to both sides of the retina. Overall, this procedure is simple, reproducible, and permits preservation of native retinal structure for at least seven days, making it a useful model for a variety of morphological, pharmacological, and biochemical studies on mammalian retina.

Combined pars plana vitrectomy and pars plana Baerveldt tube placement in eyes with neovascular glaucoma.

Purpose: To describe characteristics and outcomes of combined pars plana vitrectomy and Baerveldt tube insertion procedure from 2005 to 2010 in eyes with neovascular glaucoma. Methods: Seventy-nine patients (89 eyes) with ≥2 months of follow-up were included. Outcome measures were visual acuity, intraocular pressure (IOP), number of glaucoma medications, and complications. Changes in mean logMAR visual acuity, IOP, and glaucoma medications were compared by a two-tailed t-test. Results: Mean patient age was 69.0 years. Forty-three (54%) were male. Mean follow-up time was 19.9 months. Most common causes of neovascular glaucoma was diabetes (n = 63 [71%]) and central retinal vein occlusion (n = 21 [24%]). Eighty-six eyes (97%) underwent a 250 mm2 Baerveldt drainage device and 3 (3.4%) a 350 mm2 Baerveldt. Forty-five (51%) 20-gauge, 12 (13%) 23-gauge, and 32 (36%) 25-gauge pars plana vitrectomies were performed. Fifty-two eyes (58%) preoperatively and 23 (33%) postoperatively received intraocular injections for rubeosis and macular edema. Mean ± standard deviation logMAR visual acuity at 18-, 24-, 36-, and 48-month follow-up time points was significantly better than preoperative vision (P < 0.05). Preoperative versus final IOP and number of glaucoma medications were significantly decreased (P < 0.05). Fourteen eyes (16%) had a final visual acuity of no light perception. Most common complications included transient ocular hypertension (n = 82 [92%]), transient hypotony (n = 20 [22%]), hyphema (n = 19 [21%]), corneal edema (n = 17 [19%]), and vitreous hemorrhage (n = 14 [16%]). The frequency of transient hypotony, vitreous hemorrhage, and rubeosis was significantly (P < 0.05) higher in 20-gauge versus 23-/25-gauge pars plana vitrectomy eyes. Nine eyes (10%) required return to the operating room after combined procedure, including 4 eyes (4.5%) for retinal detachment and 3 (3.4%) for high IOP due to tube occlusion. Three eyes (3.4%) developed endophthalmitis and 2 (2.2%) progressed to being pre/phthisical (none were enucleated). Conclusion: Combined pars plana vitrectomy and Baerveldt glaucoma shunt may be a useful procedure in reducing IOP and number of glaucoma medications in eyes with neovascular glaucoma along with stabilizing visual acuity in a majority of these eyes. Further studies are warranted to verify and expand on these findings.

Topical cyclosporine a 1% for the treatment of chronic ocular surface inflammation.

Objective: To evaluate the use of topical cyclosporine A (CsA) 1% emulsion in the treatment of chronic ocular surface inflammation (OSI). Methods: We conducted a retrospective chart review of patients with various forms of OSI treated with topical CsA 1% from 2001 to 2012. Results: Twenty-nine patients (52 eyes) with various forms of OSI, including epidemic keratoconjunctivitis (n=14), chronic follicular conjunctivitis (n=12), Thygeson superficial punctate keratopathy (n=2), and vernal keratoconjunctivitis (n=1), were included. Twenty-seven patients had inflammation refractory to prior therapies. Twenty-four patients received concurrent medications with CsA 1%. Twenty-three of 24 patients on concurrent corticosteroids (CS) were able to taper their use while receiving CsA 1%. Thirteen patients experienced ocular discomfort with CsA 1%; one patient discontinued therapy all together as a result of these side effects; another switched to CsA 0.5% with improvement of adverse symptoms. Inflammation was controlled in 22 (92%) of the 24 patients who received CsA 1% for at least 2 months in duration. Conclusion: Topical CsA 1% helps to control inflammation and spares CS use in patients with chronic OSI.

Mycophenolate Mofetil in the Treatment of Chronic Non-infectious, Non-necrotizing Scleritis

Purpose: To determine the effectiveness and corticosteroid (CS) sparing capabilities of mycophenolate mofetil (MMF) in the treatment of chronic non-infectious, non-necrotizing scleritis. Methods: A retrospective chart review of patients treated for scleritis at the Institute of Ophthalmology and Visual Science at New Jersey Medical School was performed. Only those patients taking MMF for greater than or equal to six consecutive months were included. Main outcome measures were rate of inflammation control, CS, and MMF discontinuation, as well as visual acuity and side effects. Results: Twenty-two patients (32 eyes) were included in the study. Mean ± SD age was 53.5 ± 13.3 years. Twenty (91%) patients had previously failed some form of immunomodulatory therapy. After 6, 12, 18, and 24 months of consecutive MMF treatment, 91–100% of patients achieved inflammation control. Mean time to resolution of inflammation was 2.8 months, while mean duration of inflammation control was 14.8 months. CS sparing was achieved in 100% of patients at each time point, with mean starting CS dose decreased by 91% at final visit. Vision was stable or improved in 24 (75%) eyes. Fourteen (64%) patients reported side effects including leucopenia (n = 7), gastrointestinal upset (n = 4), abnormal liver function tests (n = 3), and abnormal renal function tests (n = 2). None required hospitalization or medical treatment. Four (18%) patients discontinued MMF due to side effects (n = 3) and treatment ineffectiveness (n = 1). Conclusion: MMF is an effective and well-tolerated therapy that can successfully reduce inflammation and decrease CS use in the treatment of chronic non-infectious, non-necrotizing scleritis.