Volume 7, Number 2
May 2011


Inside This Issue 



On April 28, 2011, the New England Journal of Medicine published on-line the results of the much anticipated CATT study. This study hoped to finally answer the literally million (if not more) dollar question: What really is better, Avastin of Lucentis? The results should not be that surprising based on previous studies and years of clinical experience- they are relatively equivalent, with a huge cost discrepancy. I think it will be interesting to see in the next several months the fall out of this study, and how different providers interpret some of the results, such as the difference in anatomical structure and apparent increased systemic events with Avastin, and how it parlays to clinical practice. (Please see my synopsis as well as the website below.)


Were you surprised by the overall findings of the CATT Trial which revealed that Lucentis and Avastin had equivalent effects on visual acuity when administered according to the same schedule?

I encourage everyone to read Larry Alexander's thought provoking essay on the "Conundrum of AMD" in his president's message. There he discusses his thought on AMD, its progression, and our role in patient education to minimize its social and economic impact. And he does it in a way that only he can!

Also the ORS is proud to present first retina meeting developed through the cooperative efforts of optometrists and retinal specialists, August 26-28th at the Walt Disney World Yacht and Beach Club in Orlando Fl. The program is designed to bring a new educational format to the practitioners in the form of "quick hit" cutting-edge topics. See attached tentative agenda here. More details and registration info to follow.

Lastly, I hope everyone can join us on Wednesday, June 15th for the AOA specialty day in Salt Lake City The ORS will be providing 4 hours of quality CE including a look at the most up-to-date information regarding the "big hit" retinal and optic nerve diseases and a fact based approach of how to handle the more common, (or said another way the less esoteric), retinal and optic nerve problems.

You can register for the meeting at: http://www.optometricretinasociety.org/meeting.

Steven Ferrucci, O.D., F.A.A.O.
Editor in Chief



An Essay on the ARM Conundrum
The "So What" Epiphany

Larry J Alexander, OD FAAO
President Optometric Retina Society

April 2011


There are a number of issues flying about regarding the issue of age-related macular degeneration. Among those are macular pigment optical density testing, threshold macular function testing, genetic testing, utilization of high definition imaging devices to assist in diagnosis and management, nutritional supplementation, environmental risks, use of blue-blocker sunglasses, and the actual surgical intervention options when the horse is already out of the barn. In order to put this in perspective, this essay summarizes the issues involved and suggests an option to the "So What." The "So What" is in reference to the benefits of any of the above recommendations. For example, "so what" if the doctor recommends utilization of nutritional supplementation in an obese, smoking 68 year old female with confluent "soft" drusen? Will there be any benefit if her lifestyle is not altered? How would you recommend alteration of that lifestyle? Are you able to catch the horse just as it leaves the barn to minimize the risk of vision loss in the first eye and be way ahead of the game in the second eye?


Is ARM really an issue in America? In the case of Wet ARM, the initial presentation in the first eye is devastating. Over 80% of the first eyes are 20/200 or worse at the first visit. It has also been established in the MARINA study that earlier treatment in any eye with wet ARM results in significantly better usable vision. From 2004 prevalence data in the United States it is estimated that there are 1.75 million persons with advanced ARM and 7.31 million persons with intermediate ARM. That contrasts with 2.22 million persons with glaucoma and 20.475 million persons with cataracts. In the recent 2011 census the estimate of any ARM was 9.09 million with 1.12 million in the late stage. In this 2011 census persons over age 65 numbered 39.351 million. Both the prediction of ARM progression and the aspect of minimizing that risk involve, 1) Genetics 2) Environment and Behavior and 3) The Ocular Structure. ARM is a major issue in America and is a financial burden on the health care system. Genetics and the status of the virgin ocular structure is not controllable, but environmental and behaviors issues are.


Does genetics impact on the risk of the development of ARM? There are identifiable nuclear and mitochondrial genetic DNA alterations associated with the development of ARM. The alteration is identified as a Single Nucleotide Polymorphism or SNP representing a mis-sequencing of the genetic code. The identifiable alterations can predict individuals with susceptibility to inflammation, oxidation issues, and smoking-related issues with ARM. Behavioral intervention can thus be tailored to intervene and manage that patient. The ARMS2 gene and the CFH gene are the most important genetic influencers for ARM. Knowledge of the status of these genes allows the development of the odds ratio for the progression of ARM. Genetic testing is able to identify persons at risk of developing debilitating compromise of vision and affords the clinician the possibility of discovering the earliest forms of wet ARM to maximize interventive outcomes. This aspect of diagnosis is quantifiable. This quantification has the potential to motivate patient compliance.


Does the environment, or said another way the behavior of the patient, impact on the progression of ARM? Numbers of studies exist regarding the impact of behavior on the progression of ARM. Risk factors are listed in Table 1. Modification of these risk factors when taken in context with the gestalt of the patient is considered to be a critical aspect in the management to minimize progression.

Table 1: Environmental and Behavioral Risk Factors for the Progression of ARM

Modification of both behavior and environment will reduce the risk of progression of ARM but only in relationship to the gestalt of the patient. This modification can impact on the economic impact of vision loss in ARM. The modification of behavioral and environmental aspects of ARM are, in general, non quantifiable without measurement of ocular structure.


The trigger point for the suspicion of ARM is certainly the evaluation of the retina. I would argue that the ophthalmoscopic evaluation alone is not the most important component of the determination. A complete assessment of the status of the retinal pigment epithelium and the inner retinal pigment concentration becomes the "invisible" aspect of this evaluation that holds the most importance. Drusen have long been considered a critical risk factor but the presence of drusenoid deposits on the RPE are more related to the issue of numbers of drusen rather than just the presence of drusen. Approximately 90% of the white population over age 40 years has one or two small hard drusen in the macula. There is almost no risk of progression in these eyes but if the numbers increase to greater than 8 drusen there is a 2 to 3 fold increased risk for development of soft drusen or geographic ARM. Drusenoid pigment epithelial detachments, or soft drusen that demonstrate confluence are more indicative of progression especially associated with close proximity to the fovea. The status of retinal pigment epithelial abnormalities is a major factor in the development of progression of ARM. The subtleties of these RPE changes are only observable by spectral domain OCT. Table 2 illustrates the relationship of drusen and RPE disease to the progression of ARM in the AREDS. Both factors play into the progression therefore it is critical to evaluate both issues.

Table 2: Five Year Rates of Advanced ARMD in One or Both Eyes With Pigment Abnormalities Arch Ophthalmol 2005.
The "other" pigments involved in the progression toward visually debilitating ARM are the intra-retinal pigments. Lutein, zeaxanthin, and meso-zeaxanthin occur in the inner retinal layer of the macular zone and function to protect and preserve the photoreceptor function. Meso-zeaxanthin density peaks at the fovea and is a metabolic product derived from lutein. A number of studies attribute low concentration of these carotenoids to the progression of ARM. Additional reports substantiate the "protective" effects of the substances. These yellow carotenoids may be supplemented or obtained through diet and act to facilitate the blockage of short wavelength light in the retina as well as altering free radical accumulation. Using blue blocker lenses in glasses and rimmed caps can likewise minimize the blue light but this intervention does not exert the antioxidant effect available through lutein and zeaxanthin.

It has also been shown that macular pigment density is related to the consumption of omega fatty acids, most specifically the DHA component. The question then becomes how to quantify the degree of pigment. Macular Optical Pigment Density Testing (MPOD) provides that option and can measure both the baseline pigment density as well as the effects of intervention. This testing measures not only the effects of supplementation with carotenoids and fatty acids, but provides some indication of the effects of behavioral modification. Of even more importance MPOD testing provides the doctor and the patient a quantifiable component that may be altered. This quantification has the potential to motivate patient compliance.

Another mode of functional evaluation is threshold testing of function to ascertain early metamorphopsia evolution toward vision loss. Testing this function is limited to the non-specific use of home Amsler grid, which is less than effective than the office based testing procedures of preferential hyperacuity perimeter (PHP). PHP allows for full macular testing of the central 14 degrees to uncover the functional changes associated with the evolution of wet ARM. Variations of this office-based technology are now in development for home use. This quantification has the potential to motivate patient compliance.

Evaluation of the retina through observation, spectral domain imaging and macular pigment density testing affords the clinician an opportunity to evaluate the risk of progression toward vision loss as well as the effects of intervention. It affords the clinician tools to minimize the risk of progression towards wet ARM and potentially save the first eye.


Seddon et al in IOVS 2009 summarize the situation well and allow for the generation of the answer to the "So What" question.

"However, it remains unknown whether all these genetic and environmental factors act independently or jointly and to what extent they as a group can predict the occurrence of AMD or progression to advanced AMD from early and intermediate stages. Such information may be useful for screening those at high risk due to a positive family history or having signs of early or intermediate disease, among whom some progress to advanced stages of AMD with visual loss. Early detection could reduce the growing societal burden due to AMD by targeting and emphasizing modifiable habits earlier in life and recommending more frequent surveillance for those highly susceptible to the disease."

Stein et al in Arch Ophthalmol 2010 also contribute somewhat to the answer to the "So What" question.

In their article regarding the association between the use of glaucoma medications and mortality, they conclude that "There is a clear beneficial effect of the use of glaucoma medication on the likelihood of death. Patients taking topical PGAs, a-agonists and B-blockers for confirmed POAG associated with a 74% reduction in death." At face value one could assume that it is the medication creating the positive effect. I would posit that it is another issue.

An evaluation of the Stein article leads one to conclude that just involving the patient in using a glaucoma medication will minimize death. Glaucoma is quantifiable through IOP testing, visual field testing, retinal nerve fiber evaluation, and ganglion cell complex testing. The patient has a tangible sense of their disease when it is "bad enough to treat" and suggests to the patient that they must modify their behavior to prevent blindness. I would then posit that involvement of the patient in their ARM in a tangible and quantifiable manner would decrease the risk of progression to vision loss. Seddon suggests that it is the combination of many issues that lead to the progression toward vision loss in ARM. I would then posit that the "tunnel approach" to minimizing the risk of progression to vision loss with ARM is inappropriate. ARM is not MPOD alone, is not Spectral Domain OCT alone, is not Blue Blocker lenses alone, is not nutritional supplementation alone, is not weight loss alone, but rather a comprehensive approach to the diagnosis and management of ARM and it’s progression. I would suggest that the doctor must employ and document at a minimum these quantifiable issues:

The Minimum Evaluation for the Patient with ARM Potential

  • Family history analysis
  • Environmental and behavioral analysis
  • High resolution fundus evaluation-Fundus Lens evaluation
  • Spectral Domain OCT to assess the status of the Retinal Pigment Epithelium-Quantification
I would view the above factors as a minimal standard of care with one quantifiable protocol. From this the doctor must then share the quantifiable findings in written or visual form and recommend:
  • Appropriate recommendations for modification of both environment and behavior
  • Appropriate follow up examinations
To enhance this overall approach employment of other quantifiable issues may be:

The Ideal Evaluation for the Patient with ARM Potential
  • Family history analysis
  • Environmental and behavioral analysis
  • High resolution fundus evaluation-Fundus Lens evaluation
  • Spectral Domain OCT to assess the status of the Retinal Pigment Epithelium-Quantification
  • MPOD testing-Quantification
  • PHP testing-Quantification
  • Genetic testing-Quantification
From the information gathered the doctor and staff may then recommend in writing:
  • Environmental Alterations to Minimize Risk
  • Behavioral Alterations to Minimize Risk
  • Nutritional Supplementation to Minimize Risk
  • Surgical Intervention to Limit Progression
  • Appropriate Follow-Up Care

Addition of MPOD testing, and/or PHP testing, and/or Genetic testing would increase the strength of both the diagnosis patient compliance to intervention. This complement to the standard of care offers enhanced quantification of the issue of ARM. Supplying this to the patient in a written report along with appropriate follow-up would at least offer a chance to minimize loss of vision from ARM. ARM diagnosis and management is a complex concept for both the doctor and the patient and any quantification of the degree of compromise would lend well to the management of the patient Even with employment of all facets of care and intervention, patients will lose vision from ARM. The eye care practitioners must do all within their means to minimize this risk.


The "So What" is that one test or one intervention does not keep us from having over 80% of our patients from presenting with first eye at 20/200 in wet ARM. While encouraging the patient to lose weight and decrease their glycemic index would decrease the risk of progression, this is only one piece of the puzzle. The approach to the patient at risk of wet or geographic ARM must be multi-faceted. We must use our entire armamentarium of tests and technologies to discover the patients who will progress. We must involve the patient in the process and provide them quantifiable documentation of where they are and where they may go. We know that 1-2 small macular drusen will not progress to ARM and should not be even called ARM. We know that 3 large "soft" drusen are a significant risk and must watch those patients more carefully. But what about all of the other patients with variations of these two themes? What about the fact that most wet ARM presents without any ophthalmoscopically observable indication of retinal changes? The issue is complex and must be approached with care and consideration. The approach to saving vision from ARM must address 1) Genetics 2) Environment and Behavior and 3) The Ocular Structure. The "So What" is in the GESTALT with Quantification. An isolated approach in any of these three areas without quantification will not provide the maximum approach to patients with the threat of ARM. Quantification engages the patient in the process. Engaging the patient in the process will increase compliance. Increased compliance will decrease risk. Early intervention minimizes the loss and the clinician has to be the epicenter of this event.

Larry J. Alexander, O.D., F.A.A.O.



Walt Disney World Yacht and Beach Club
August 26-28, 2011

Announcing the first retina meeting developed through the cooperative efforts of optometrists and retinal specialists. A program designed to bring a new educational format to the practitioners in the form of "quick hit" cutting-edge topics. The Florida Retina Symposium combines the efforts of a successful national meeting (100 + attendees) with the efforts of a successful local meeting (75 + attendees). The meeting site is within the Disney World Village at The Yacht and Beach Club with an incredible room rate of $159 per night (standard rates of $345). We have added this rate availability to both Thursday and Sunday nights that is before and after the meeting. This allows for both doctors and our corporate partners to provide their families one last mini vacation before the school year starts.

This is a partnership opportunity to impact on a national and local group of practitioners who are at the upper level of eye care practice. These doctors are looking for cutting edge education and space age technology.

To register for the meeting, go to http://www.optometricretinasociety.org/meeting.


Ranibizumab and Bevacizumab for Neovascular Age-Related Macular Degeneration. The CATT Research Group. New England Journal of Medicine. 2011 (10.1056/NEJMoa1102673) accessed on line April 28, 2011, at NEJM.org

On April 28, 2011 The New England Journal of Medicine released the much awaited CATT Study (The Complications of Age-Related Macular Degeneration Treatment Trial). This study evaluated 1208 patients randomly assigned to receive intravitreal injections of either ranibizumab (Lucentis) or bevacizumab (Avastin) on either a monthly schedule or as needed with monthly evaluations. The primary outcome was the mean change in visual acuity at 1 year, with a non-inferiority limit of 5 letters on the eye chart.

Results reveled Avastin administered monthly was equivalent to Lucentis administered monthly, with 8.0 and 8.5 letters gained respectively. Avastin administered as needed was equivalent to Lucentis as needed, with 5.9 and 6.8 letters gained respectively. Lucentis given as needed had effects that were equivalent to Lucentis administered monthly. The comparison between Avastin as needed and monthly Avastin was inconclusive. The mean decrease in central retinal thickness was greater in the Lucentis monthly group (196 µm) than in the other groups,(152 to 168µm). Rates of death, myocardial infarction, and stroke were similar for patients receiving either agent; however the proportion of patients with serious systemic adverse events, primarily hospitalization, was higher with Avastin than with Lucentis (24.1vs. 19.0%). The authors suggested this requires further study.

One last finding compared the cost of the drugs per patient for year. This cost was $23,400 in the Lucentis monthly group; $13,800 in the Lucentis as needed group; $595 in the Avastin monthly group; and $385 in the Avastin as needed group. This cost differential has important economic implications when extrapolated to the estimated 250, 000 patients with neovascular AMD that are treated annually in the US.

Results for the second year of the study will be released next year.

Submitted by Steven Ferrucci, O.D., F.A.A.O.
ORS Fellow

A copy of the article may be accessed at http://www.nejm.org


Answer appears later in newsletter.


Estimating Risk for Progression to Advanced AMD

By Joseph Pizzimenti, O.D., F.A.A.O.
ORS Fellow

Many patients with Intermediate AMD or Advanced AMD in one eye (but not the other) ask about their chances of developing Advanced AMD. A simplified severity scale was developed from the AREDS to estimate likelihood of progression after five years. The system assigns one point per eye for each of the following:

At least one large drusen (> 125 micrometers—width of a retinal vein at the disc margin)
Any pigment abnormality, such as focal RPE clumping or atrophy

The system assigns to two points for the presence of advanced AMD in one eye (but not the other). The scale then sums retinal risk factors for both eyes. A five point scale (0-4) estimates the five-year risk of developing advanced AMD in at least one eye:

0 Points, 0.5% risk
1 Point, 3%
2 Points, 12%
3 Points, 25%
4 Factors, 50%

Using the AREDS-based scale, it is simple to calculate and describe to patients their risk of progression to advanced disease over a 5-year period.

Prentice's Rule Applied To Retinal Examination

By Leo Semes, O.D., F.A.A.O.

The high dioptric power lenses that we use for BIO and at the slit lamp for stereoscopic fundus examination have a wealth of advantages. Real image presentation, wide field and no limitation by the pupillary margin, to name a few.

In addition, when you are trying to reach the outer limits of the retina or trying to get around that stubborn anterior capsulotomy, invoke Prentice's Rule. Remember that one?

Prismatic power = Dioptric power X cm (from the optical center).

How it is applied here is that a slight displacement of the lens while you keep your visual axes steady will move your light source. Just follow it and you will get farther out in the ocular fundus.


Expanded 2-Year Follow-up of Ranibizumab Plus Prompt or Deferred Laser or Triamcinolone Plus Prompt Laser for Diabetic Macular Edema.

This report served to present the 2-year follow-up results of a previously reported multicenter, randomized clinical trial evaluating intravitreal 0.5 mg ranibizumab or 4 mg triamcinolone combined with grid/focal laser as compared with focal/grid laser alone for the treatment of diabetic macular edema (DME). A total of 854 eyes with visual acuity of 20/32 to 20/320 (approximate Snellen equivalent) with DME involving the fovea were randomized, treated, and followed to measure their visual acuity at a 2-year visit. At this follow-up, compared with the sham + prompt laser group, the mean change in the visual acuity letter score from baseline was 3.7 letters greater in the ranibizumab + prompt laser group, 5.8 letters greater in the ranibizumab + deferred laser group, and 1.5 letters worse in the triamcinolone + prompt laser group. After the 1- to 2-year visit in the ranibizumab + prompt or deferred laser groups, the median numbers of injections were 2 and 3 (potential maximum of 13), respectively. At the 2-year visit, the percentages of eyes with central subfield thickness ≥250 µm were 59% in the sham + prompt laser group, 43% in the ranibizumab + prompt laser group, 42% in the ranibizumab + deferred laser group, and 52% in the triamcinolone + prompt laser group. These expanded 2-year results reiterate the conclusions originally reported: Ranibizumab should be considered for patients with DME, including vision impairment with DME involving the center of the macula.

Elman, MJ; Bressler, NM; Qin, H et al. Expanded 2-Year Follow-up of Ranibizumab Plus Prompt or Deferred Laser or Triamcinolone Plus Prompt Laser for Diabetic Macular Edema. Ophthalmology. 2011;118(4):609-614.

Characteristics of Patients Losing Vision 2 Years of Monthly Dosing in the Phase III Ranibizumab Clinical Trials.

This study investigates, by retrospective analysis, the cause of visual acuity (VA) loss in patients with neovascular age-related macular degeneration (AMD) after 2 years of receiving monthly injections within the ranibizumab phase II trials. Data was reviewed from the Minimally Classic/Occult Trial of the Anti-VEGF Antibody Ranibizumab In the treatment of Neovascular AMD (MARINA) and Anti-VEGF Antibody for the Treatment of Predominantly Classic Choroidal Neovascularization in AMD (ANCHOR) trials. At month 24, percentage of ranibizumab-treated participants with loss of ≥15 letters VA was 9% in MARINA and 10% in ANCHOR, while percentage of ranibizumab-treated participants with gain of ≥15 letters VA was 30% in MARINA and 38% in ANCHOR. Common baseline characteristics among patients with VA loss included older age, better VA, and larger lesions. An increase in area of RPE abnormality accounted for VA loss in both MARINA and ANCHOR, however, in MARINA, the increase in total lesion area was attributable to an increase in the angiographic designation of atrophic scar, and in ANCHOR it was attributable to an increased area of choroidal neovascularization (CNV), but not an increased area of leakage. Increased areas of GA, fibrosis, and hemorrhage were not associated with VA loss. They concluded that VA loss after 2 years of monthly ranibizumab injections was due to the lesion characteristics commonly associated with suppressed CNV. Such lesion characteristics include pigmentary abnormalities, atrophic scarring, and the absence of leakage. They propose that future VA improvements in patients receiving ranibizumab therapy may require preservation of photoreceptor and RPE function rather than strategies that target CNV.

Rosenfeld, PJ; Shapiro, H; Tuomi, L et al. Characteristics of Patients Losing Vision 2 Years of Monthly Dosing in the Phase III Ranibizumab Clinical Trials. Ophthalmology. 2011;118(3):523-530.

Endopthalmitis after Intravitreal Anti-Vascular Endothelial Growth Factor Antagonists
A Six-Year Experience at a University Referral Center.

This retrospective study looked at all patients injected with Anti-VEGF antagonists from January 1, 2005, through December 31, 2010 to determine the rate of clinically suspected endophthalmitis post Anti-VEGF injection. A total of 60,322 intravitreal injections of VEGF antagonists were performed; 39,700 bevacizumab, 18,607 ranibizumab, and 2,015 pegaptanib injections. Twelve cases (0.02%) of 11 patients with clinically suspected and treated endophthalmitis were observed after anti-VEGF. Of the 12 cases of clinically suspected endophthalmitis, 7 had been treated with bevacizumab, 5 with ranibizumab, and none with pegatanib. Of the 7 patients with culture positive endophthalmitis, 5 cultures isolated various Streptococcus species (0.01%). The culture negative cases (n=5) had received on average 4.4 previous anti-VEGF injections. The culture positive cases (n=7) had received on average 6.9 previous anti-VEGF injections. The rate of clinically suspected endophthalmitis was 0.018% after bevacizumab and 0.027% after ranibizumab injections.

Moshfeghi, A; Rosenfeld, P; Flynn, H et al. Retina. 2011;31:662-668.

Monthly Ranibizumab for Nonproliferative Macular Telangiectasia Type 2: A 12-Month Prospective Study.

This prospective, nonrandomized clinical trial investigates the use intravitreal ranibizumab for the treatment of nonproliferative macular telangiectasia (MacTel) type 2. One eye (n=10) was injected with ranibizumab monthly for one year. The study concluded that at 12 months no significant changes were found in visual acuity compared to the fellow eye or baseline. Fluorescein angiography resulted in a decreased telangiectatic capillary appearance which correlated to topography findings related to reduction in macular thickness compared to the fellow eye or baseline findings. Three to 5 months after the last treatment angiographic appearance and retinal thickness were found to be back to similar results as baseline. This study provides evidence that monthly injections of ranibizumab may result in transient morphologic improvement but is not associated with clear functional improvement or benefit. The findings clearly implicate a pivotal role of VEGF in the underlying pathology and the atrophic retinal alterations may be irreversible in MacTel type 2. The study concluded that monthly intravitreal ranibizumab is not recommended for nonproliferative MacTel type 2.

Issa, PC; Finger, RP; Baumüller, S et al. Am J Ophthalmology. 2011;151(5):876-886.

Optical Coherence Tomography Enhanced Depth Imaging of Choroidal Tumors.

This pilot prospective case series evaluated spectral-domain OCT features of choroidal tumors imaged with enhanced depth imaging (EDI), a method where the OCT objective lens is pushed closer to the eye so the inverted image is obtained with improved resolution of the deeper layers of the choroid and sclera. All patients (n=23) underwent fundus photography, EDI SD-OCT, and ultrasonography. Qualitative analysis revealed: amelanotic nevi, homogenous and medium reflective band with visible choroidal vessels; melanotic nevi and choroidal melanomas, high reflective band in the anterior choroid with shadowing, and nonvisualization of choroidal vessels and inner sclera; choroidal hemangiomas, medium/low reflective band without shadowing; and choroidal metastasis, low reflective band in the deep choroid with enlargement of the suprachoroidal space. These specific EDI SD-OCT findings are most probably related to cellular composition, compactness of tissues, tumor vascularity, presence of light-reflecting/scattering melanin, and other factors. The study concluded that it is possible to identify qualitative measures for each of the choroidal tumors but more importantly small choroidal tumors, defined as <9.0 mm in diameter and <1.0 mm in thickness, that may be undetectable by ultrasonography were objectively be measured with EDI SD-OCT.

Torres, V; Brugnoni, N; Kaiser PK, et al. Am J Ophthalmology. 2011;151(4):586-59

Central Macular Splaying and Outer Retinal Thinning in Asymptomatic Sickle Cell Patients by Spectral-Domain Optical Coherence Tomography.

This prospective case series examined sickle cell patients (n=42) compared to healthy age, gender and race matched control patients (n=33) to investigate macular thinning on spectral domain OCT in asymptomatic sickle cell disease (SCD). Manual segmentation of SD-OCT images with asymptomatic SCD revealed significantly lower central macular thickness (CMT) and foveal splaying (thinning specifically in the parafoveal retina) as compared to the control group. Central macular thinning and foveal splaying represent either residua of or precursors to macular infractions. Although asymptomatic the presence of these SD-OCT findings may be indicative of ischemia attributable to vascular occlusions in capillaries surrounding the fovea, leading to ischemia in the central and peripheral retina regions. Detection of peripheral retinal ischemia and neovascularization can be difficult clinically and may not be readily captured by fluorescein angiography (FA) due to the far peripheral location. Alternatively, the study suggests presence of foveal thinning and foveal splaying findings on SD-OCT may serve as a screening tool to identify patients who would benefit from examination of the retinal periphery, either clinically or with wide-field FA.

Hoang, W; Chau, FY; Lim, J et al. Am J Ophthalmol. (2011); doi:10.1016/j.ajo.2010.12.010.

Myocardial Infarction and Cerebrovascular Accident in Patients with Retinal Vein Occlusion.

A retrospective study reviewed a national health care claims database to identify patients with history of retinal vein occlusion (RVO) compared to age and gender matched controls. Incidences of myocardial infarction and cerebrovascular accidents were recorded and the mean follow up time was approximately 18 months. Comorbidities such as angina, arrhythmia, diabetes, heart disease, hyperlipidemia, and hypertension were also recorded and significantly higher percentages for each category were found in the RVO group compared to controls. MI was more frequent in the RVO group only if the patient was under 65, but the difference in incidence was not statistically significant. The rate of CVA after adjustment for risk factors was nearly 2 times greater in the RVO group, regardless of patient age (adjusted RR 1.72, P = 0.001).

Werther W; Chu L; Holekamp N; et al. Arch Ophthalmol. 2011; 129 (3):326-331.

Telemedicine and Diabetic Retinopathy.

Severe vision loss from diabetes remains a leading cause of vision loss, and the diabetic population is expected to grow quickly, reaching 439 million by 2030. With the burden on ocular health care systems rising, ocular telemedicine programs may help address the expansive need for routine diabetic retinopathy screening in a highly sensitive and cost-effective manner. Using 22 non-mydriatic images per eye, the method uses trained observers to grade diabetic retinopathy (DR) and detect sight-threatening cases, defined as severe nonproliferative DR and/or presence of macular edema. Out of 316 eyes in 158 patients, there were no cases of sight-threatening DR that were identified by examiners that were not identified by the certified readers. Although this type of telemedicine requires higher initial financial outlay and operational costs, it resulted in savings of $13,748 per severe vision loss event averted.

Silva P; Cavallerano J; Aiello L; et al. Arch Ophthalmol. 2011; 129 (2). 236-242.

Retinal Pigment Epithelium Tears Secondary to Age-Related Macular Degeneration: A Simultaneous Confocal Scanning Laser Ophthalmoscopy and Spectral-Domain Optical Coherence Tomography Study.

28 eyes with retinal pigment epithelium (RPE) tears were observed with high resolution imaging. In cases with recent RPE tears (< 1 year old), preserved photoreceptors (PRs) and outer segment (OS) junction as well as external limiting membrane could be identified in the RPE-denuded area. In all eyes with older RPE-tears (> 1 year), no PRs or ELM could not be found and the retina overlying the denuded RPE was atrophic. Finding potentially viable photoreceptors in patients after a RPE tear may direct future therapies such as autologous transplantation of RPE.

Caramoy A; Kirchhof B; Fauser S. Arch Ophthalmol. 2011; 129 (5) 575-579.

Choroidal Thickness in Polypoidal Choroidal Vasculopathy and Exudative Age-related Macular Degeneration.

This observational, comparative case series demonstrates that the choroid in eyes with polypoidal choroidal vasculopathy (PCV) is thickened, in contrast with choroidal thinning observed in eyes with age-related macular degeneration (AMD). Choroidal thickness was measured using enhanced-depth imaging OCT in eyes with PCV (n=25), uninvolved fellow eyes with PCV (n=14), eyes with exudative AMD (n=30), eyes with early AMD (n=17), and eyes of aged-matched normals (n=20). Mean subfoveal choroidal thickenss thickness in eyes with PCV and in their uninvolved fellow eyes was 438.3±87.8 µm and 372.9±112.0 µm, respectively. These values were significantly greater than in eyes of age-matched normal subjects (224.8±52.9 µm) (P<0.001 and P = 0.003, respectively). Subfoveal choroidal thickness of eyes with exudative AMD (171.2±38.5 µm) and eyes with early AMD (177.4±49.7 µm) was thinner than that of age-matched normal subjects (P = 0.004 and P = 0.078, respectively). These findings suggest involvement of different pathogenic mechanisms in PCV as compared to exudative AMD.

Chung, SE; Kang, SW; Lee, JH et al. Choroidal Thickness in Polypoidal Choroidal Vasculopathy and Exudative Age-related Macular Degeneration. Ophthalmology. 2011;118(5):840-845.


This photo represents and amelanotic melanoma. Malignant melanoma of the choroid is a rare occurrence but it is the most common adult primary intraocular tumor in the United States. It has been reported that 1200 to 1500 new cases are diagnosed each year, with the incidence increasing as patients age. The median age at the time of diagnosis is about 55 years with men and women equally. Choroidal melanomas are much more common in white individuals than non-whites (8 times more common) and are rarely bilateral in presentation.

Choroidal melanomas are proposed to arise from pre-existing choroidal nevi. Choroidal nevi unlike melanomas are fairly common benign tumors of the posterior pole and have a variety in color presentation from a pigmented slate-grey to an amelanotic yellowish-white. Choroidal nevi increase in prevalence as patients age and has been reported to be as low as 6.5% and as high as 33% in the 6th to 9th decade of life with only 5-6% of these lesions being amelanotic in appearance. Nevi are rare in childhood. Nevi, like melanomas, are more common in whites than non-whites and most typically range in size from 1 to 10 mm in size, with the majority between 1.5 and 5 mm. Most nevi are generally flat with only 4.5 to 14.2% of nevi exhibit growth during a 5-year period. The majority of nevi remain benign with the risk of a "suspicious" nevus transforming into a malignant melanoma is approximately 0.02% over a 10 year period. Nevi are often associated with overlying drusen (incidence ranging from 27-50%) and more frequently observed in elevated nevi. The appearance of overlying drusen suggests chronicity to the lesion and is typically considered a good sign and a distinguishing feature from melanomas.

Like choroidal nevi, choroidal melanomas can range in color tremendously ranging from a dark brown to an amelanotic yellowish-white. The incidence of amelanotic melanomas has been reported to be 20-25% of all melanomas, and it is thought that amelanotic melanomas may arise from amelanotic nevi. Where drusen and RPE proliferation usually signify dormancy and associated with nevi, prominent vascularity, subretinal fluid and lipofuscin are indications of growth and potential malignancy. Lipofuscin is thought to be secondary to degeneration of the RPE within macrophages and manifests as orange clumps on the surface of melanomas. In amelanotic melanomas the lipfuscin may have a more golden brown appearance.

Choroidal melanomas may have a variety of symptoms depending on the size and location. Approximately 40% of cases of choroidal melanomas are asymptomatic at the time of diagnosis, while some patients experience photopsia, visual field defects, metamorphosis and decreased VA. Pain is not a characteristic symptom experienced. Choroidal melanomas typically appear as a discrete solid elevated subretinal mass. Multifocal melanomas are extremely rare. It is sometimes difficult to distinguish a small melanoma from a large nevus. The presence of orange lipofuscin pigment on the surface of the tumor or accumulation of subretinal fluid around the base of the lesion typically suggests malignancy. In approximately 20% of cases, a melanoma may break through Bruch's membrane becoming mushroom-shaped as it extends into the subretinal space. This mushroom configuration is characteristic of choroidal malignant melanomas and rarely seen in other choroidal tumors.

The Collaborative Ocular Melanoma Study (COMS) defined choroidal melanomas as small, medium and large.

Tumor size is strongly correlated with survival with the larger the tumor the greater chance of mortality. Small melanomas tend to be comprised of spindle cells and have a much more favorable prognosis of survival than larger tumors which are more likely to contain epithelial cells and carry the worst prognosis. The 15-year mortality rate for patients with small, spindle cell melanomas was 12% as compared to 75% for patients with large, mixed cell tumors. Pigmentation of the tumor has also been associated with survival. Heavy tumor pigmentation has been associated with poorer prognosis although not as significantly as compared to tumor size or cell type. The reported mortality for amelanotic lesions is approximately 19% and increases to 39% for lightly pigmented and 65% for heavily pigmented tumors.

Management of choroidal nevi typically consists of documentation (photos) and observation. Non-suspicious nevi should be observed on a yearly basis with fundus photography. Suspicious nevi should be documented with fundus photography and followed every 6 months for any changes in size. Fluorescein angiopgraphy and ultrasonography should also be used to monitor suspicious nevi for any growth changes.

Plaque radiotherapy (or brachytherapy) is currently the most common form of treatment for choroidal melanomas. Typically, small melanomas and most medium to large melanomas in eyes with some salvageable vision and any melanoma that occurs in a patients only useful eye. Iodine plaques are the most common radioactive source and possible complications include retinopathy, cataract formation, vitreous hemorrhage, anterior uveitis and scleral necrosis. Transpupillary thermotherapy (TTT) is a relatively new alternative treatment for small choroidal melanomas located in the posterior pole. The tumor is heated with near infrared radiation therapy delivered by a diode laser with the goal of creating a flat chorioretinal scar. Enucleation is reserved for approximately 20% of melanomas today and is typically for those tumors that are very large, or advanced. Enucleation is the preferred therapeutic modality when a lesion is too large for radiotherapy, has poor visual prognosis, involved the optic nerve and/or has produced a severe secondary glaucoma.

Metastatic assessment is mandatory for every patient diagnosed with a choroidal melanoma and should be repeated every 6-12 months. Despite treatment, up to 50% of patients with a choroidal melanoma will die from metastases within 10 years of diagnosis. the liver is the most common site of metastatic involvement but other organs such as the skin, lungs and bone may be affected.

Choroidal melanomas are a relatively rare but potentially fatal intraocular problem. Early diagnosis is a crucial component to the overall survival of the patient

As an aside, the patient was seen the next day by a local retinal specialist, who confirmed our findings. A referral was made to an ocular oncologist who confirmed an amelanotic melanoma, and the patient was scheduled for a radiation plaque. The patient unfortunately passed away prior to the surgery taking place.

Blair Lonsberry, M.S., O.D., MEd., F.A.A.O.
ORS Fellow


Corticosteroid Implant More Effective In Patients With Longer Duration Of DME

Two phase 3 clinical trials showed that patients who received fluocinolone acetonide implants for diabetic macular edema achieved better visual results if they had longer disease duration before treatment, Andrew N. Antoszyk, MD, said at the Association for Research in Vision and Ophthalmology meeting.

The FAME study included 956 patients with DME who were randomized to receive either 0.2 µg or 0.5 µg Iluvien (sustained release fluocinolone acetonide, Alimera Sciences) or control treatment.

Dr. Antoszyk presented results for a subgroup that included 536 patients who had been diagnosed with DME for 3 years or more at baseline and 416 patients who had been diagnosed for less than 3 years.

Of patients with DME for 3 years or more, 33.6% of those in Trial A (P < .001) and 42.4% of those in Trial B (P < .001) achieved a best corrected visual acuity improvement of at least 15 letters at 30 months. Positive visual acuity results maintained statistical significance at 36 months, Dr. Antoszyk said.

Researchers did not observe statistically significant gains in visual acuity in patients with DME for less than 3 years.

Adverse events occurred at nearly the same rate as those in the full study population and did not affect visual outcomes, according to Dr. Antoszyk. IOP increases of at least 30 mm Hg were observed in 14.8% of patients, of whom 5.3% underwent surgery to reduce IOP. Cataracts requiring surgery occurred in 85% of patients in the subgroup who had a natural lens in their eye at the start of the study.

Alimera has submitted a new drug application to the U.S. Food and Drug Administration for regulatory approval of low-dose Iluvien, as it met the primary endpoints for both Trial A and Trial B of the FAME study.


Anti-VEGF Agent Improves Visual Acuity, Quality Of Life In CRVO Patients

VEGF Trap-Eye was found to improve visual acuity in patients with macular edema secondary to central retinal vein occlusion, according to Julia A. Haller, MD, OSN Retina/Vitreous Board Member, said at the Association for Research in Vision and Ophthalmology meeting.

The COPERNICUS trial, a randomized, double-masked controlled phase 3 trial, included 189 patients who received six monthly 2-mg injections of VEGF Trap-Eye (aflibercept ophthalmic solution, Regeneron).The control group included 74 patients who received sham injections.

After the primary endpoint of 24 weeks, 56.1% of patients in the treatment group gained at least 15 letters of vision. Only 12.3% of patients in the sham treatment group achieved the same end result (P < .0001), Dr. Haller said.

Patients in the treatment group had a mean gain of 17.3 letters, compared with a mean loss of 4.0 letters in the sham treatment group.

The results echo the positive results of the GALILEO study.

Dr. Haller also noted a rapid decrease in central retinal thickness of 457.8 µm in the treatment group, compared with 144.8 µm in the sham group.

Quality of life, according to the NEI VFQ, significantly increased, improving 7.2 points in the treatment group and only 0.8 points in the sham group, Dr. Haller said


Wills Eye Institute, Retina Implant Plan First North American Clinical Trial Of Subretinal Implant

Retina Implant, the developer of a subretinal implant for the visually impaired, has chosen Wills Eye Institute to be the lead site of the first clinical trial of the device in North America, the company announced in a news release.

Retina Implant's proprietary technology will be evaluated in patients with retinitis pigmentosa, the release said.

"The results of the subretinal approach in Europe demonstrate the great potential this implant has to impact dramatically the quality of life for our patients here in the United States," Julia A. Haller, MD, ophthalmologist in chief at Wills Eye Institute, said in the release. "Patients involved in previous clinical trials have achieved extraordinary success in their ability to regain useful vision. It is this life-changing success we hope to replicate with our own patients as Wills becomes the first institution in the U.S. to offer Retina Implant's technology."

Retina Implant's subretinal implant technology has been in clinical trials for more than 6 years in Germany. The firm plans to expand its second human clinical trial into the United Kingdom this summer.

Results of Retina Implant's first human clinical trial showed that placement of the implant below the retina, in the macular region, enabled patients to recognize foreign objects and read letters.


MS Drug May Increase Risk Of Macular Edema In Patients With Diabetes, Uveitis

A newly approved multiple sclerosis drug poses a potential risk of macular edema in patients with diabetes mellitus and a history of uveitis, Robert C. Sergott, MD, said at the Wills Eye Institute Alumni Conference .

Gilenya (fingolimod, Novartis) is the first oral medication approved by the U.S. Food and Drug Administration for relapsing-remitting MS. The active ingredient regulates lymphocyte distribution and is believed to thwart lymphocyte migration from the lymph nodes and into the central nervous system.

Data on ocular complications were culled from two phase 3 FDA clinical trials for fingolimod. A 2-year trial compared fingolimod with placebo, and a 1-year trial compared fingolimod with interferon beta-1a, Dr. Sergott said.

Fingolimod was administered in 0.25-mg and 1.25-mg doses.

Fingolimod reduced the MS relapse rate and increased the percentage of patients without an MS relapse in both studies. The differences were statistically significant (P < .001).

In the 2-year trial, macular edema occurred in 0.4% of patients treated with fingolimod and 0.1% of patients who received the placebo, Dr. Sergott said.

Patients should undergo ophthalmic examination 3 or 4 months after initiation of fingolimod therapy; patients with diabetes mellitus or history of uveitis should have regular ophthalmic exams, Dr. Sergott said.

Visual acuity should be monitored at baseline and during routine exams, he said.


Ranibizumab Yields 15-Letter Gain In VA In Patients Treated For DME, Study Shows

Results of the second of two phase 3 clinical trials showed that ranibizumab met its primary endpoint in patients being treated for diabetic macular edema, according to a news release from Genentech.

The study showed a significant gain in visual acuity among patients who received injections of Lucentis (ranibizumab, Genentech) compared with patients who received sham injections, according to the release.

At 24 months, 42 of 125 patients (33.6%) who received a 0.3-mg injection of ranibizumab and 58 of 127 patients (45.7%) who received a 0.5-mg injection gained at least 15 letters of best corrected visual acuity over baseline. In contrast, 16 of 130 patients (12.3%) who received sham injections gained 15 lines or more.

Safety results were consistent with previous ranibizumab phase 3 trials, the release said.

Results of the study are scheduled to be presented in May at the Euretina meeting in London.

Results of the first phase 3 trial of ranibizumab for DME showed a rapid and sustained improvement in visual acuity that began 7 days after treatment and persisted for 24 months.

Both trials are being undertaken to support U.S. Food and Drug Administration approval of DME as an indication for ranibizumab. The anti-VEGF agent is approved by the FDA for wet age-related macular degeneration.


Expanded 2-year Follow-up Supports Ranibizumab for DME

Consistent best corrected visual acuity and safety results suggest that ranibizumab should be considered for the treatment of diabetic macular edema, a study in Ophthalmology found.

The Diabetic Retinopathy Clinical Research Network (DRCR.net) multicenter, randomized clinical trial assessed 854 eyes treated with either sham injection with prompt focal/grid laser, intravitreal 0.5 mg Lucentis (ranibizumab, Genetech) with prompt or deferred laser, or 4 mg triamcinolone with prompt laser.

At 24 months, the ranibizumab plus prompt laser group and the ranibizumab plus deferred laser group achieved mean visual acuity improvements of 3.7 and 5.8 letters, respectively, greater than improvements in the sham plus prompt laser group. Conversely, mean visual acuity for the triamcinolone group, compared with the sham plus laser group, was 1.5 letters lower. On average, patients in the ranibizumab plus prompt or deferred laser groups underwent two to three injections, and no systemic events that could be attributed to treatment were observed.

However, three eyes in the ranibizumab groups experienced injection-related endophthalmitis, while cataract surgery and elevated IOP were more prevalent in the triamcinolone group.


Pain Caused By Intravitreal Injection May Be Lessened Through Topical Anesthesia

Topical anesthesia may limit pain caused by intravitreal injections, a study in Retina found.

The prospective masked study used a randomized block design. Twenty-four patients were intravitreally injected four times in combination with four different types of anesthesia: topical proparacaine, topical tetracaine, lidocaine pledget and a subconjunctival injection of lidocaine. To prevent bias, the order of injections was different for each patient.

All patients received at least one intravitreal injection before the study, with a mean of 12.9 previous injections. Immediately after injection, patients were asked to grade their pain on a 0 to 10 scale for the injection as well as the anesthesia. The average combined pain scores for injection and anesthesia were 3.5 for proparacaine, 4.1 for tetracaine, 4.4 for lidocaine pledget and 3.8 for subconjunctival lidocaine.

Differences in pain grade were not statistically significant; neither were the individual injection or anesthesia pain scores.

Fifty-four percent of eyes that received subconjunctival lidocaine experienced subconjunctival hemorrhage. However, none of the other anesthesia methods was associated with this complication or any other complication.

The study authors suggested that future analyses assess pain experienced after the immediate post-injection period.


Anti-VEGF Monotherapy May Improve Visual Acuity More Effectively Than PDT Combined With Anti-VEGF

A study in Retina suggested that ranibizumab monotherapy may improve visual acuity to a greater extent than verteporfin photodynamic therapy in combination with ranibizumab for patients with neovascular age-related macular degeneration.

The open-label, prospective study included 20 eyes of 17 patients assigned to Lucentis (ranibizumab, Genentech) monotherapy and 20 eyes of 13 patients assigned to PDT with Visudyne (verteporfin, Novartis) in combination with intravitreal ranibizumab. Follow-up was 1 year.

Eyes in the monotherapy group received three monthly, consecutive ranibizumab injections, while eyes in the combination therapy group received a single session of verteporfin PDT with ranibizumab. Patients in each group were given as-needed ranibizumab injections during follow-up.

Although anatomical improvement was similar for the two groups, mean gain in visual acuity was 12 letters for the monotherapy group and 3.2 letters for the combination therapy group. Only one eye in the combination group lost more than 15 letters.

Despite better visual acuity outcomes, the monotherapy group was associated with a shorter interval between initial treatment and re-treatment, as well as more ranibizumab injections during re-treatment.

The study authors encouraged larger trials with longer follow-up to confirm these findings.


Vitamin D Shows Protective Effect Against Early AMD In Women

High concentrations of serum 25-hydroxyvitamin D may protect against early age-related macular degeneration in women younger than 75 years, according to a large observational study in Archives of Ophthalmology.

"Inflammation is thought to be involved in the pathogenesis of AMD. Vitamin D, because of its anti-inflammatory, immune-modulating properties, may suppress the cascade of destructive inflammation that occurs at the level of the retinal pigment epithelium-choroid interface in early stages of AMD," the authors said.

The Carotenoids in Age-Related Eye Disease Study (CAREDS) included 1,313 women aged 50 to 79 years who were enrolled in the multicenter Women's Health Initiative Observational Study (WHIOS).

Researchers evaluated samples from serum 25(OH)D assays, which reflect vitamin D exposure from food, supplements and sunlight. Stereoscopic fundus photographs determined early AMD status in 241 subjects.

Although multivariate models did not reveal a significant relationship between early AMD and 25(OH)D, there was a significant age interaction (P =.002) that suggested a selective mortality bias in older women, the study found.

Serum 25(OH)D decreased the odds of early AMD in 968 women younger than 75 years (P = .02) and increased the odds in 319 women older than 74 years (P = .05). Adjusting for body mass index and physical activity, which are predictors of 25(OH)D, attenuated the association in the younger age group.

Multivariate models also revealed that oral intake of vitamin D decreased the odds of AMD in subjects younger than 75 years, but direct sunlight exposure did not.

According to the authors, a prospective study is needed to confirm the association between vitamin D and AMD, and to understand how vitamin D and genetic and lifestyle factors could affect early AMD risk.


Brimonidine Reduces Subconjunctival Hemorrhage After Intravitreal Injection

Brimonidine 0.15% administered before intravitreal injection decreased the incidence, size and severity of post-injection subconjunctival hemorrhage, a study found.

Investigators set out to study vasoconstrictive effects produced by brimonidine. Brimonidine is most commonly used to reduce IOP, but it is also used to minimize bleeding in LASIK, cataract and strabismus surgery.

The prospective, randomized, double-masked study included 244 eyes of 244 patients who underwent injections of Avastin (bevacizumab, Genentech). Mean patient age was 61 years. A study group of 126 patients received Alphagan (brimonidine 0.15%, Allergan) 30 minutes before intravitreal injection. A control group of 118 patients received normal saline.

Size and severity of subconjunctival hemorrhage were assessed at 1 day and 7 days after injection. Hemorrhage severity was graded on a scale of 1 (mild) to 3 (severe).

Study results showed that 13.5% of eyes in the brimonidine group and 29.7% of eyes in the saline group developed subconjunctival hemorrhage after intravitreal injection. The difference was statistically significant (P = .003).

Subconjunctival hemorrhage remained in 14 eyes in the brimonidine group (11.1%) and in 26 eyes in the saline group (22%) at 1 week. The difference was statistically significant (P = .025), the authors reported.



In each issue, a Fellow of the Optometric Retinal Society will be highlighted. In this issue, Dr. Andrew S. Gurwood, O.D., F.A.A.O., Diplomate, will be highlighted.

Dr. Andrew S. Gurwood, O.D., F.A.A.O., Diplomate, is a Professor of Clinical Sciences, an attending optometric physician at The Eye Institute of the Pennsylvania College of Optometry at Salus University and a member of the clinical staff of Albert Einstein Medical Center, Department of Ophthalmology. He has lectured and published nationally and internationally on a wide range of subjects in the arena of ocular disease. His areas of active research include diseases of the anterior and posterior segment.

Doctor Gurwood earned a Diplomate from the American Academy of Optometry in the Section of Primary Care, where he serves as The Chair of The Section’s Written Examination Committee and as a member of the Oral Examination Committee. He also serves in The American Academy of Optometry as a member of the Scientific Program Committee and as the Chairperson of the Written Examination Committee for the Disease Section Diplomate in Retina.

Other accomplishments include being a founding member of The Optometric Retina Society, a member of The Optometric Glaucoma Society, a Charter (Founding) Member of The Optometric Dry Eye Society, an Abstract Writer for Optometry: The Journal of The American Optometric Association and Diagnostic Quiz Columnist for Review of Optometry Journal. He is a regularly invited contributor for the journal Primary Care Optometry News.

In 1998, he was recognized nationally as The American Optometric Association’s Young Optometrist of The Year and was recognized by the state of Pennsylvania as its OD of the year in 2006.

Dr. Gurwood is also a dedicated community servant. He is a member of The Abington Township Volunteer Fire Company (Roslyn) where he also serves as an Emergency Medical Technician and rope rescue technician. He is a ProBoard Certified Vehicle Rescue Technician, Rope Rescue Technician, a State EMT Instructor and recently has matriculated as Faculty of The Pennsylvania State Fire Academy, Lewistown, PA.



By Rex Ballinger, OD, FAAO
Chair, Membership Committee

Membership in the Society can provide several benefits. You may receive discounts at annual meetings. You’ll receive regular newsletters on new and exciting updates on retinal disease diagnosis and management as well as other newsy items of interest. And you’ll be associated with a body of knowledge and resources which can help you in many other ways. So consider membership in the Society. It will be worth your while in your quest for better understanding of the retina.

If your interests extend beyond the general, if you want to become part of the dynamic team involved in the Society to share your interest and enthusiasm with your colleagues, consider becoming a Fellow member. Details and applications can be found at www.optometricretinasociety.org



ICaps® Softgel AREDS Formula

Easier dosing ICaps Softgel ocular supplement AREDS formula is available from Alcon. Just 2 softgels deliver the same levels of vitamins and minerals tested in the AREDS study. With half as many pills to take, patients may be more likely to be compliant with your recommendations for ocular supplements. ICaps softgel design goes down easier with patients too.

The ICaps Softgel AREDS formula is part of a family of ICaps ocular supplements. The family also includes the ICaps MV multi-vitamin and the ICaps Lutein & Zeaxanthin formula. Together they support your patient care regimens.

The ICaps Softgel AREDS formula is recommended for patients who have been diagnosed with moderate to severe age-related macular changes. The ICaps MV multi-vitamin is for patients who care about ocular and systemic nutrition. It contains no beta carotene so it's safe even for patients who smoke. And the Lutein & Zeaxanthin tablet is recommended for patients who are concerned about and may be at risk for age-related macular changes but have not yet been diagnosed with them.

For more information, go to www.Icapsvitamins.com

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Editor in Chief
Steven Ferrucci, OD, FAAO

Mark T. Dunbar, OD, FAAO

Journal Reviewers
Katy Falk, OD
Hina Patel, OD
Jennifer Sinclair, OD
Erica Volker, OD

Art/Production Director
Joe Morris

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