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Contents

        Associate Editors vii
        Contributors ix

        Preface xxxv

        Myron Yanoff
         Looking Backward and Forward

        Optometry

        Bioptic Driving in the United States

        Laura Windsor and Richard Windsor
        The concept of bioptic driving began in the United States after the development of a practical bioptic system by William Feinbloom, OD, PhD. A bioptic telescope is a telescope mounted in or at the top of the spectacle lenses, allowing the wearer to view underneath it, through the carrier lenses, and to intermittently tip their head down to quickly view through the telescope. The bioptic telescope is used for spotting signs, traffic lights, and other objects in the distance when driving. Mild to moderately visually impaired patients have been using bioptics for more than 50 years to drive. Most states have regulations on bioptic driving, but the rules vary greatly. Proper candidate selection, fitting of the bioptic, and training are crucial for the driver’s success and safety on the road. Patients should be considered on a case-by-case basis to determine their eligibility to drive. More naturalistic research, that is, in the real world, is needed to further validate the safety of bioptic driving, the training needed, and to look at state vision regulations for driving.
         Introduction 1
         History of bioptics and driving in the United States 2
        A legal pathway for bioptic driving 3
         Controversies and research in bioptic driving 4
        Wearing the bioptic only to obtain licensure 4
        Ring scotoma of the telescope 5
        Bioptic driving safety 5
         Bioptics in the United States 6
        Visual acuities 7
        Visual fields 8
        Bioptic training 8
        Nighttime driving 8
        Bioptic telescope requirements 8
         Ocular conditions and ability to drive 8
         Other factors in patient selection for bioptic driving 14
        Visual processing skills and cognitive abilities 14
        Motor skills and functioning 15
        Age and maturity 15
        Medical and medication history 15
        Emotional/mental status 15
        Family support 15
         Designing the bioptic system 16
        Power and position of the telescope 16
        Field of view through the telescope 17
        Adaptability of the bioptic for light and glare issues 17
         Training the bioptic driver 18
        Training to use the bioptic 19
        Training with the certified driver rehabilitation specialist 19
        After bioptic licensure 20
         Vehicle modifications for bioptic drivers 21
        Vehicle selection 21
        Global positioning systems 21
        Speedometer 21
        Windshield and dash glare 21
         The Indiana program for visually impaired drivers 22
        Part 1: waivered drivers 22
        Part 2: bioptic drivers 22
         The faces of bioptic driving 23
        Dr. Dennis Kelleher: first legally licensed bioptic driver in the United States 26
         Future research in bioptic driving 26
         Summary 27
         Clinics care points 27
        Disclosure 27

        The Use of B-Scan Ultrasound in Primary Eye Care

        Elena Z. Biffi, Benjamin Young, Joseph Edward Kane Jr., and Mehdi Najafi
        B-scan ultrasound has been a part of an eye care provider’s armamentarium of ophthalmic imaging techniques dating back to at least the 1950s. Even with the advent of newer imaging devices, B-scan ultrasonography serves an important adjunct role in assessment of various ophthalmic conditions. Relatively benign ocular conditions as well as potentially life-threatening pathologies may be identified and assessed using this procedure. A thorough understanding of the principles and practical applications of B-scan ultrasonography is essential to maximize use of this technique in patient management.
         Introduction 31
         Indications and contraindications 32
         Principles of B-scan ultrasound examination 33
        B-scan description 33
        Probe positions and image interpretation 34
        Clinical examination principles 36
         B-scan applications in clinical care 36
        Vitreous diseases 36
        Retinal diseases 39
        Choroidal diseases 42
        Optic nerve diseases 44
         Advances in ultrasonography 46
         Summary 47
         Clinics care points 47
         Disclosure 47

        Nonsurgical Treatment of Strabismus

        Marie I. Bodack
        Nonsurgical treatment options for esotropia and exotropia may be indicated for some patients to improve outcomes presurgery or postsurgery or in lieu of surgery. The ideal outcome is for a patient to have binocularity and excellent alignment. Current nonsurgical treatment options for patients with esotropia and exotropia include lenses, prisms, occlusion, and vision therapy.
         Introduction 51
         Significance/present relevance 52
        Esotropia 52
        Observation 52
        Lens correction 53
        Occlusion 55
        Prism correction 56
        Vision therapy/orthoptics 57
        Exotropia 59
        Observation 59
        Lenses 60
        Overminus lenses 60
        Occlusion 61
        Prism 63
         Summary 64
         Clinics care points 65
         Disclosure 66

        Pediatric

        Update on Pediatric Optic Neuritis

        Sravanthi Vegunta
        Pediatric optic neuritis (ON) is a condition with a broad differential including demyelinating syndromes, astrocytopathies, and infectious processes. Many retrospective studies have been published on the similarities and differences between pediatric ON secondary to clinically isolated syndrome, multiple sclerosis, myelin oligodendrocyte glycoprotein, and neuro-myelitis optica spectrum disorder. The presentations, visual outcomes, and laboratory testing, and imaging findings have significant overlap but important differences. This article details how to distinguish between various causes of autoimmune ON to provide the appropriate acute and chronic therapies to patients. Gaps in our current knowledge and suggestions for future studies are discussed.
         Introduction 71
         Significance 72
        Overview of pediatric optic neuritis 72
        Multiple sclerosis-associated optic neuritis 76
        Myelin oligodendrocyte glycoprotein-associated disease optic neuritis 76
        Neuromyelitis optica spectrum disorder optic neuritis 80
         Other causes of optic neuritis 83
        Relevance and future avenues to consider 84
         Summary 84
        Acknowledgments 85

        Genetics of Congenital Cataract

        Reddin Ahmad, Suzannah Bell, and Mariya Moosajee
        Up to 40,000 children are born with cataracts annually worldwide. In the UK, children presenting with bilateral cataract most commonly have a genetic basis. Mutations in genes involved in lens-specific proteins or regulation of eye development can cause isolated cataract, those associated with more complex ocular defects and/or syndromic features. Early surgery and frequent follow-up are vital to avoid amblyopia and optimize visual potential. Routine genetic testing is important to allow accurate diagnosis and personalized management of patients including tailored genetic counseling. Multidisciplinary care is vital, including clinical genetic and ophthalmic teams, pediatricians, school, and local pediatric visual support services.
         Introduction 89
         Cause and classification 90
         Significance 91
         Nonsyndromic congenital cataract 91
        Crystallins 91
        Cytoskeletal structural proteins 95
        Membrane proteins 95
        Transcription factors 98
         Syndromic congenital cataract 110
        Down syndrome (Trisomy 21) 110
        Patau syndrome (Trisomy 13) 110
        Lowe syndrome 110
        Norrie disease 110
        Nance-Horan syndrome 111
        Myotonic dystrophy 1 111
        Neurofibromatosis type 2 111
        Zellweger spectrum disorder 111
        Rothmund-Thompson syndrome 112
        Cockayne syndrome 112
        Cerebrotendinous xanthomatosis 112
        Galactosemia 112
         Acquired causes 112
        Congenital infections 112
        Trauma 113
         Other common causes of cataract in children 113
        Uveitic cataract and steroid-related cataract 113
        Radiation cataract 113
         Relevance 113
        Management of childhood cataract 113
         Genetic testing 114
         Multidisciplinary care 114
         Summary 114
         Clinics care points 115
        Disclosure 115

        Pediatric Graft-Versus-Host Disease

        Kerri McInnis-Smith, Holly K. Miller, and Aparna Ramasubramanian
        Even with the support of evidence-based medicine available, the proper diagnosis and treatment of graft-versus-host disease (GVHD) and its ophthalmologic manifestations, especially in the pediatric population, is quite nuanced. The wide array of disease presentations, the existence of confounding factors such as underlying disease and concurrent treatment, and the challenge of children accurately conveying their symptoms can further contribute to the difficulty in effectively managing young patients with chronic GVHD. Clinicians must consider the expert recommendations for management while choosing diagnostic approaches and therapeutic regimens according to the individual patient.
         Background 119
        Hematopoietic stem cell transplant 120
        Pathophysiology of systemic GVHD 121
        Incidence of Chronic GVHD 121
        Diagnosis and Classification of Systemic GVHD 122
        Grading of Systemic Disease Severity 124
        Risk Factors for Systemic GVHD 125
        Prognosis 125
        Ocular GVHD 125
        Mainstays and recent developments in therapy 130
         Summary 135
         Clinics care points 135
         Disclosure 135

        Ophthalmic Pathology & Ocular Oncology

        Fluorescence In Situ Hybridization in Ocular Oncology

        Seema Sen, Shahzan Anjum, and Mehar Chand Sharma
        Fluorescence in situ hybridization is a useful tool to visualize and map the genetic material in an individual's cells, including specific genes or portions of genes. This technique has diagnostic and prognostic implications for a variety of ocular malignant tumors because genetic mutations detected by FISH provide useful information for better management including targeted therapy. Chromosomal abnormalities including t(14;18) translocation in lymphoma, monosomy of chromosome 3 in uveal melanoma, and t(6;9) translocation in adenoid cystic carcinoma of lacrimal gland are some of the common genetic hallmarks of these malignancies.
         Introduction 139
         Significance of fluorescence in situ hybridization 140
        General Principle of Fluorescence In Situ Hybridization 141
        Detailed Fluorescence In Situ Hybridization Protocol for Tissue Sections 141
        Ocular Lymphomas 142
        Uveal Melanomas 143
        Adenoid Cystic Carcinoma 144
         Present relevance and future of fluorescence in situ hybridization 145
         Clinics care points 146
         Disclosure 148

        Intra-arterial Chemotherapy for Retinoblastoma: An Update

        Bhavna Chawla, Navneet Sidhu, and Shailesh Gaikwad
        Retinoblastoma is the most common primary intraocular tumor in children. It also is one of the most successfully treated tumors using various treatment strategies. Conventional globe salvage treatments include the use of focal therapies in combination with systemic chemotherapy. Intra-arterial chemotherapy (IAC) is a comparatively newer treatment modality used primarily for globe salvage in refractory retinoblastoma. It involves the direct administration of chemotherapy drugs into the ophthalmic artery to achieve a high local intraocular concentration. IAC has been found to successfully treat retinoblastoma, and a few newer modifications are being tried. Our article discusses the significance of IAC, technique employed, drugs used, and newer advances in its administration.
         Introduction 151
         History 152
         Intra-arterial chemotherapy terminology 153
         Procedure 153
         Intra-arterial chemotherapy drugs 154
         Significance of intra-arterial chemotherapy 155
         Complications of intra-arterial chemotherapy 156
        Local 156
        Systemic 156
         What’s new in intra-arterial chemotherapy? 157
        Treatment Approaches 157
        Drugs 157
        Patient profile 157
         Summary 157
         Clinics care points 158
        Disclosure 159

        Advances in Pediatric Periocular Vascular Neoplasms

        Kasturi Bhattacharjee, Aditi Mehta, and Vatsalya Venkatraman
        Pediatric periocular vascular neoplasms originate from transformed endothelial cells showing increased proliferation. Commonest of these is infantile hemangioma, which presents in the first year of life. The lesion exhibits initial rapid growth followed by spontaneous regression. Locally infiltrative and malignant tumors, although rare, may exhibit metastatic potential. Neoplasms need to be differentiated from congenital vascular malformations, which are noninvoluting, exhibit growth commensurately with age, and do not demonstrate endothelial proliferation. Timely treatment of periocular lesions obscuring the visual axis helps prevent amblyopia. Systemic involvement or presence of large lesions (>5 cm) warrants assessment of cardiac function as the high-flow lesions may produce high-output cardiac failure. Mass effect of extensive perioral/nasal/subglottic lesions may compromise the airway. A multidisciplinary approach is important for optimizing treatment outcomes. Propranolol has gained FDA approval in 2017 as the first-line therapy for infantile hemangioma. In contrast, malformations are difficult to treat, and therapy mostly is symptomatic.
         Introduction 161
         Significance 162
        Vascular tumors 162
        Vascular malformations 165
        Secondary orbital involvement 169
         Present relevance and future avenues to consider 170
         Summary 173
         Clinics care points 174
        Disclosure 174

        Cataract & Refractive Surgery

        Femtosecond Laser-Assisted Cataract Surgery

        Emily Chang and Amy Zhang
        Since femtosecond laser-assisted cataract surgery (FLACS) first became commercially available approximately a decade ago, it has continued to provoke much interest as well as controversy. As femtosecond laser technology continues to evolve, FLACS has shown to be a safe alternative to the conventional phacoemulsification surgery. However, the successful adoption of a new technology requires both cost efficiency and significant improvement over conventional techniques. This article summarizes the utilization of femtosecond laser technology in certain steps of cataract surgery and reviews its safety and efficacy in each step.
         Introduction 177
         Femtosecond laser technology 178
         Clear corneal incision 178
         Anterior capsulectomy 179
         Nuclear fragmentation 181
         Astigmatism management 183
         Summary 183
         Clinics care points 184
         Disclosure 184

        Advanced Technology Intraocular Lenses

        Mariam S. Hamid, Man Li Jin, and Kevin J. Everett
        Recently developed advanced technology intraocular lenses (IOLs) aim to provide patients with the ability to see in-focus images at multiple distances to mimic the natural accommodative function of the eye. Multifocal IOLs use diffractive, refractive, or hybrid technologies to allow images from multiple focal points to be simultaneously focused on the retina. This inadvertently causes photic side effects including glare or haloes and reduced contrast sensitivity, and therefore, careful patient selection and consent are indicated. Extended depth-of-focus IOLs use a single, elongated focal point to reduce photic side effects, though often at the expense of near vision compared with multifocal IOLs. This article will review recent developments in advanced technology IOLs such as multifocal, accommodative, and extended depth-of-focus IOLs and discuss their visual outcomes and side effects.
         Introduction 187
         Significance 188
        Accommodative Lenses 188
        Multifocal Lenses 189
        Optical Side Effects in Multifocal Intraocular Lenses 191
        Extended-Vision Intraocular Lens 192
        Monofocal Intraocular Lenses with Increased Depth of Focus 193
        Light Adjustable Intraocular Lenses 193
        Phakic Intraocular Lenses 194
         Discussion, future considerations, and summary 194
         Clinics care points 197

        Vitreoretinal Disease

        Diagnostic and Treatment Considerations for Macular Holes

        Rupak Bhuyan, Jeffrey Brown, and Robin Ginsburg
        Video content accompanies this article at http://www.advancesinophthalmology.com
        Macular holes are foveal neurosensory disruptions that can impair vision and cause symptoms such as metamorphopsia and scotomas. Stages 1A and 1B should be observed. Stage 2 can be treated with multiple modalities including topical dehydration agents, pneumatic vitreolysis, and surgery. Surgery remains the most used treatment, because it can prevent additional vision loss from progression to stages 3 and 4. Surgery is also the recommended treatment of stages 3 and 4. Inverted internal limiting membrane flaps, human amniotic membrane plugs, mesenchymal stem cell injections, and autologous retinal transplants are newer adjunctive treatments that offer encouraging results.
         Introduction 201
         Significance 203
        Nonsurgical treatment 203
        Surgery 204
         Present relevance and future avenues 211
        Topical agents 211
        Ocriplasmin 212
        Pneumatic vitreolysis 212
        Internal limiting membrane staining 213
        Glial plug after internal limiting membrane manipulation 213
        Intraoperative optical coherence tomography 213
        Autologous mesenchymal stem cell transplantation 213
        Autologous retinal transplantation 214
         Summary 214
         Clinical care points 216
         Disclosure 216
         Supplementary data 216

        Peripheral Retinal Degenerations and Treatment Options

        George Jiao, Marib Akanda, and Ronni M. Lieberman
        There are numerous pathologies that can be found in the peripheral retina, including degenerative disease. Involvement of the vitreoretinal interface and certain intraretinal degenerations can lead to retinal tears or detachments. The standard of care for diagnosing and monitoring these peripheral retinal degenerations is dilated fundus examination, but current technologies may aid us when the diagnosis is unclear. Prophylactic treatments may be warranted in many cases of predisposing lesions. Definite treatments for retinal tears are important in preventing retinal detachments.
         Introduction 219
         Benign lesions 220
        Peripheral retinal drusen 220
        Paving-stone (cobblestone) degeneration 220
        Retinal pigment epithelium hyperplasia 220
        Retinal pigment epithelium hypertrophy 221
        Peripheral cystoid degeneration 222
        Snowflake degeneration 222
        Pars plana cysts 222
        Pearl degeneration 222
        White-with-pressure and white-without-pressure 222
         Lesions predisposing to retinal detachment 223
        Lattice degeneration 223
        Senile retinoschisis 224
        Vitreoretinal tufts 226
        Meridional folds 226
        Enclosed ora bays 226
        Peripheral retinal excavations 226
        Chorioretinal atrophy 227
        Dark-without-pressure 227
        Snail track degeneration 227
         Retinal Tears and Holes 228
        Dialysis 228
        Horseshoe tear 228
        Operculated round tear 229
        Atrophic round hole 230
         Treatment options for lattice peripheral degeneration 231
         Summary 232
         Clinics care points 232
        Disclosure 233

        Update on Retinal and Ocular Imaging

        Samuel Gelnick, Minh Trinh, and Ronni M. Lieberman
        Retinal imaging has experienced rapid growth over the past decades. An increase in resolution, field of view, and accessibility has led to an increase in the use of retinal imaging in clinical practice across all specialties of ophthalmology. Understanding the advantages and disadvantages of these retinal imaging modalities is crucial to obtaining the appropriate studies to diagnose and monitor retinal pathologies. In this article, we review common imaging modalities, including their evolution and clinical applications.
         Background and introduction 237
         Optical coherence tomography 238
         Fundus photography 242
         Artificial intelligence–deep learning 246
         Adaptive optics 247
         Teleophthalmology 248
        Types of teleophthalmology 249
         Diabetic screening 249
         Retinopathy of prematurity 249
         Future directions 249
         Clinics care points 250
        Disclosure 250

        Glaucoma

        30-Gauge Needle in Glaucoma/Anterior Segment Management

        Ramesh Ayyala, Alireza Baradaran-Rafii, and Jacob Liechty
        Video content accompanies this article at http://www.advancesinophthalmology.com
        Many clinical presentations and complications of glaucoma, whether acute or chronic, including bleb fibrosis, encapsulation, and so forth along with anterior segment surgeries can be managed at the slit lamp with the help of a 30 gauge (G) needle. This article presents the indications and techniques involved in the use of 30G needle at the slit lamp in the management of a myriad of ophthalmologic presentations and complications.
         Introduction 253
         Preparation of the patient 254
         Follow-up after slit lamp procedures 254
         Indications and procedure description 254
        Bleb needling revision for scarred, fibrosed blebs 254
        Bleb needling revision for encapsulating/encapsulated blebs following Ahmed glaucoma valve implantation 256
        Paracentesis to decrease intraocular pressure 257
        Anterior chamber reformation 257
        Suturing at the slit lamp 258
        Suture removal 258
        Injections 258
        Ahmed glaucoma valve removal 259
        Unplugging sclerotomy 259
         Corneal procedures 259
        DSEAK-related issues and 30G needle 259
        Vitreous strand release 260
        Astigmatic keratotomy 260
         Summary 261
        Disclosure 261
         Supplementary data 261

        Neuro-ophthalmology

        Screening for Plaquenil

        Pushpinder Kanda, Stuart Coupland, Chloe Gottlieb, Lynca Kantungane, and Rustum Karanjia
        Hydroxychloroquine use needs to be carefully monitored for retinal toxicity that can lead to significant visual impairment. This review summarizes the current screening guidelines and imaging modalities recommended by the American Academy of Ophthalmology and highlights future research trends for improving test sensitivity. It also discusses the utility of using mfERG for detecting early retinopathy and research supporting its use as a primary screening tool.
         Introduction 263
         Plaquenil screening modalities 266
         Automated visual fields 267
         Spectral-domain optical coherence tomography 270
         Fundus autofluorescence 270
         Multifocal electroretinogram 271
         Current trends and future research 273
         Summary 275
         Clinics care points 276
        Disclosure 276

        Update on Optic Neuritis in Adults: Multiple Sclerosis, Neuromyelitis Optica Spectrum Disorder, and Myelin Oligodendrocyte Glycoprotein Antibody–Associated Disease

        Serena Li, Rahul A. Sharma, and Benson S. Chen
        This review provides an update on the diagnosis and management of inflammatory optic neuritis in adults, focusing on presentations associated with multiple sclerosis, neuromyelitis optica spectrum disorder, and myelin oligodendrocyte glycoprotein antibody–associated disease. Clinical clues that enable early recognition of these distinct disorders are discussed, including patient demographics, clinical features, and radiologic findings. The use of corticosteroids, plasmapheresis, and other acute management treatment strategies for optic neuritis are appraised, followed by an overview of long-term management, specifically strategies for immunosuppression including when to initiate and with which therapies. Finally, prognosis and future avenues are considered.
         Introduction 280
         Diagnosis 280
        Demographics 280
        Clinical features 282
        Radiologic features 283
         Acute management 284
         Long-term management 286
        Clinically isolated syndrome and multiple sclerosis 287
        Neuromyelitis optica spectrum disorder 288
        Myelin oligodendrocyte glycoprotein antibody associated diseases 289
         Prognosis 289
         Future avenues 290
         Summary 291
         Clinics care points 291
        Disclosure 292

        Efficacy and Safety of Tocilizumab in the Treatment of Ocular Manifestations in Giant Cell Arteritis

        Nooran Badeeb and Rustum Karanjia
        Vision loss in GCA is an ophthalmic emergency that requires prompt medical intervention. The goal of the treatment is to preserve the remaining vision and prevent further systemic complications. Corticosteroids are the first-line treatment for GCA but are prone to cause iatrogenic side effects. In this review, we discuss the role of other immunosuppressant medications, especially Tocilizumab in controlling cases of GCA with ocular involvement and review the literature on the indication, guidelines of administration, and safety of Tocilizumab.
         Introduction 295
         Methodology 296
        Selection criteria 297
         Results 297
         Significance 297
        Visual outcomes reported with Tocilizumab 299
        Duration of treatment with Tocilizumab 305
        Administration of Tocilizumab 306
        Safety and side effects of Tocilizumab 306
         Summary 307
         Clinics care points 307
        Acknowledgments 308
        Disclosure 308

        Coronavirus Disease 2019–Related Health Disparities in Ophthalmology with a Retrospective Analysis at a Large Academic Public Hospital

        Y. Grace Chung, Christie M. Person, Jacquelyn O’Banion, and Susan A. Primo
        The coronavirus disease 2019 pandemic has disproportionately affected racial and ethnic minorities in the United States. Although recent meta-analyses have identified the prevalence of ocular manifestations in severe acute respiratory syndrome coronavirus 2 infection, no studies with these potential findings have been implemented in examining ophthalmic disparities in racial and ethnic minorities. It is additionally clear that patient access to eye care from coronavirus disease 2019 has been disproportionate in underserved communities. Large public hospitals and urban academic medical centers provide a unique opportunity to further study ocular disease presentation and health disparities from coronavirus disease 2019 in these populations.
         Introduction 312
         Significance 313
        COVID-19 disproportionate impact 313
        COVID-19 related health care disparities in ophthalmology 313
        COVID-19 related ophthalmic manifestations 314
         Relevance and future avenues 318
         Conclusion 319
         Summary 320
        Disclosure 320

        Cornea and External Diseases

        Stepwise Approach to the Diagnosis and Management of Dry Eye and Ocular Surface Disease

        Jennifer B. Nadelmann, Angela Gupta, Caroline W. Chung, and Stephen E. Orlin
        Dry eye disease (DED) is a multifactorial disorder caused by abnormalities of the tear film that causes damage to the ocular surface. Screening tools are helpful in making the diagnosis and in determining disease severity. It is important to take a careful history and to evaluate meibomian gland physiology, tear film quality, meibomian gland status, and tear production. Clinicians should take a stepwise approach in treating DED. Treatments vary for evaporative dry eye, aqueous deficiency, and/or inflammatory DED. For patients with symptoms that have not improved following conservative measures, prescription medications, blood products, procedures or devices can be considered.
         Introduction 325
         Significance 326
        Approach to diagnosis 326
        Clinical examination 330
        Approach to treatment 331
         Recent and upcoming innovations 336
        Diagnostic imaging 336
        Pipeline treatments 337
         Summary 338
         Clinics care points 339
        Disclosure 339

        Update on the Classification and Management of Corneal Dystrophies

        Vivian L. Qin, Devin Cohen, Tomas Andersen, and Stephen E. Orlin
        The most recent IC3D classification (2015) categorizes the corneal dystrophies based on genetic, clinical, and histologic characteristics. Here we review the classification of the corneal dystrophies as epithelial and subepithelial, epithelial-stromal TGFB1, stromal, and endothelial. We discuss the variety of available medical and surgical treatment modalities based on symptomatology and anatomic area of the cornea affected. We explore the recent advancements in the area of corneal regeneration without the use of donor grafts, including injection of cultured endothelial cells and gene therapy.
         Introduction 345
         Significance/in-depth analysis 347
        Epithelial and Subepithelial Dystrophies 347
        Epithelial-Stromal TGFB1 dystrophies 349
        Stromal Dystrophies 353
        Endothelial Dystrophies 356
         Relevance and future avenues 358
         Summary 361
         Clinics care points 363
         Disclosure 363

        Surgical Management of the Aphakic Eye

        Tianyu Liu, Brian J. Nguyen, Samantha L. Marek, and Stephen E. Orlin
        Current approaches to the surgical correction of aphakia include anterior chamber intraocular lenses (IOLs), iris-fixated IOLs, sulcus IOLs, and scleral-fixated IOLs with or without sutures. Anterior chamber and iris-fixated IOLs are technically easier to place but are associated with risks including corneal decompensation, uveitis, and glaucoma. Sulcus placement of IOLs can achieve physiologic positioning of the lens but requires adequate capsular support. Overall, current approaches to correction of aphakia have comparable efficacy and safety outcomes, and the advantages and disadvantages of each technique should be considered in light of patient and surgeon factors in surgical planning.
         Introduction 367
         Significance and in-depth analysis of the topic 368
        Epikeratophakia 368
        Anterior chamber intraocular lenses 368
        Iris-fixated intraocular lenses 369
        Sulcus placement of intraocular lenses 370
        Sutured scleral-fixated intraocular lenses 372
        Sutureless scleral-fixated intraocular lenses 374
         Current relevance and future avenues 376
        Minimizing suture erosion with scleral pockets and Z-sutures 376
        Modifications of the Yamane sutureless fixation technique 378
        Correction of pediatric aphakia 378
         Summary 379
         Clinics care points 380
        Disclosure 380

        Oculoplastics

        Teprotumumab: A Major Advance in the Treatment of Thyroid Eye Disease Management

        Caroline Y. Yu, Jamie A. Keen, and Erin M. Shriver
        Thyroid eye disease (TED) is an uncommon orbital inflammatory disease that can lead to disfigurement and permanent vision loss. Traditional therapies such as glucocorticoids and orbital radiation primarily were used to treat inflammation during the active phase of the disease. Teprotumumab, the first Food and Drug Administration-approved medication for TED, targets the insulin-like growth factor-1 receptor and has been shown to decrease proptosis, diplopia, and clinical activity score. In this review, the pathophysiology and treatment landscape of TED are summarized, and the mechanism, clinical data, and associated adverse events of teprotumumab are described in detail.
         Introduction 383
         Pathophysiology of thyroid eye disease: the role of insulin-like growth factor 1 receptor 385
         Treatment landscape for thyroid eye disease—anti-inflammatory therapies 385
         Teprotumumab: mechanism of action 387
         Safety profile of teprotumumab 387
         Clinical effect of teprotumumab 388
         Clinical applications of teprotumumab: future avenues 390
         Clinics care points 395
         Disclosure 396

        Diagnosis and Management of Irritated Eyelids

        Christine Ryu and Rao V. Chundury
        Eyelid irritation is one of the most common complaints encountered by eye care providers. The cause can be divided into 5 broad categories of blepharitis, immunologic, inflammatory, infectious, and neoplastic. Some of the most common causes include staphylococcal blepharitis, seborrheic dermatitis, posterior blepharitis, allergic contact dermatitis, atopic dermatitis, and rosacea. Steroids have been the first-line treatment of immunologic and inflammatory conditions, but newer steroid-sparing agents such as pimecrolimus and tacrolimus also are proving effective. Patients with atypical presentations or symptoms refractory to treatment should be evaluated for possible malignancies.
         Introduction 401
         Significance 402
        Blepharitis 402
        Immunologic 403
        Inflammatory 413
        Infectious 414
        Neoplastic 414
         Present relevance and future avenues 419
        Blepharitis 419
        Immunologic 421
        Inflammatory 421
        Infectious 424
        Neoplastic 424
         Summary 425
         Clinics care points 427
        Disclosure 428

        Uveitis

        Uveitic Glaucoma

        Erick Rivera-Grana and Stephanie M. Llop
        Uveitic glaucoma is a complex disease whose pathogenesis and treatment differ greatly from other glaucoma syndromes. Intraocular pressure elevation can be due to open-angle, closed-angle, or mixed mechanisms and steroid-induced processes. Up to 20% of patients with uveitis develop glaucoma. It is important to adequately recognize the differences in the treatment of this disease to accurately manage both glaucoma and ocular inflammation. We provide a review of the most common inflammatory etiologies that cause glaucoma and different treatment modalities used to manage it, both medical and surgical.
         Introduction 433
         Significance 434
        Pathogenesis 434
        Signs and symptoms 435
        Uveitis etiologies associated with uveitic glaucoma 436
         Present relevance and future directions to consider or investigate 440
        Standard treatment approaches 440
        Treatments apart from well-known intraocular pressure medications and filtering surgery 442
         Summary 445
         Clinics care points 446
        Disclosure 446

        Solo Private Practice Journey

        Priya Kalyam
        On completing medical training, physicians have little to no experience with choosing their future job. Much of their experience has been tied up with choosing a career and then competing for the best training experience. This article provides the author’s insight into the path of entering solo practice.
         IntroductionI
        A step forwardI
        Opening the practiceII
        Day-to-day lifeIII
        Things I wish I focused on during residencyIV
         SummaryIV
        DisclosureIV