International Conference on Ophthalmic Photography

Organized by
Australian Institute of Medical and Biological Illustration
Japanese Ophthalmic Photographers' Society
Ophthalmic Imaging Association
Ophthalmic Photographers' Society

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Thursday, 18 May 2006
Plenary Session 3
Imaging Technology and Applications I
2.00 OPS Continuing Education Credits
14:50 Introduction By Moderator
Gary S. Michalec
Veterans Administration Medical Center
Minneapolis, Minnesota, USA

14:55 Imaging Of Arcuate Retinotomy For Repair Of Very Large, Failed Macular Holes
Byron Wood, Steve Charles, Aneesh Nee
Charles Retina Institute
Memphis, Tennessee, USA
Purpose: To discuss the imaging modalities used in determining if making an arcuate retinotomy temporal to the macula can facilitate repair of very large macular holes that failed with conventional surgical therapy.
Methods: Conventional macular hole surgery using 25ga. sutureless techniques and forceps ILM peeling, followed by face-down positioning for at least 3 weeks failed to close very large macular holes in six patients. All patients had a second vitrectomy which included a further attempt at ILM peeling and the construction of an arcuate retinotomy temporal to the macula which was made by separating, rather than transecting nerve fibers. Pre and post-op OCTs, fundus photographs, and surgical videos were obtained.
Results: Four out of six patients had closed holes on post-operative clinical and OCT examination. One closed after a second vitrectomy with C3F8 and retinotomy, and one failed.
Conclusion: Arcuate retinotomy can be used to salvage selected cases of large, failed macular hole surgery. Various retinal imaging modalities are helpful in documenting closure of these holes, as well as providing valuable teaching materials.

15:10 Green Fluorescent Protein Imaging: An Ophthalmology Model
John C. Peterson, Paul L. Kaufman, Carol A. Rasmussen
University of Wisconsin
Madison, Wisconsin, USA
Purpose: To document the presence and location of Green Fluorescent Protein (GFP), a viral vector marker used in a gene-therapy model targeting the trabecular meshwork of non-human primates.
Materials and Methods: Topcon 50IA, 50EX fundus cameras and a Zeiss Photo slit-lamp biomicroscope were used with either silver-based color and black-and-white film, or a Nikon D1X digital SLR camera. A three-mirror gonio lens and a Swan Jacobs gonioprism were used to visualize the TM. Standard clinical filter sets were used that were close in wave-length specificity to the GFPs used in the viral constructs.
AdenoGFP or LentiGFP viral vectors were injected into the anterior chamber of cynomolgus monkeys (Macaca fascicularis). Gene transfer, as evidenced by the presence of fluorescence, was evaluated in vivo both by standard clinical ophthalmic instruments (slit lamp biomicroscope and lenses) and photographically.
Results: In eyes that received higher doses of the viral vectors, the original fundus camera system easily documented GFP expression in the trabecular meshwork. Those eyes developed unacceptable amounts of inflammation, however, necessitating dose refinements. While tolerated better by the eyes, the lower doses resulted in fainter GFP expression, which made imaging more problematic. The fainter expression also made photographic documentation of expression more critical as expression was no longer visible to an ophthalmologist using a gonio lens and a slit lamp. The digital system increased sensitivity over the film system but histopathology, done on some of the eyes, revealed expression that had not been captured with the flash-based camera systems.
Conclusions: Goals for the photographic systems include ease of use, availability of equipment, and quality of images. The current, fundus camera-based system works well for imaging dramatic amounts of GFP expression. As vectors more tolerable to the eye are developed and dosages are refined, expression is fainter and more difficult to image, requiring modifications to the system. Further studies will be devoted to increasing the precision of our imaging systems to reflect these realities.

15:25 Retinal Fluorescein Angiography And The Study Of Brain Damage During Cardiac Surgery
John V. Arnold
Hammersmith Hospital
London, England, UK
Introduction: It is more than 50 years since the introduction of the heart lung machine, enabling coronary artery bypass grafting and the replacement of defective valves in a non-beating heart.
Shortly after the first operation, reports of brain damage following the procedure began to emerge. Since the eye is an outgrowth of the brain and has the same blood supply, it is reasonable to assume that what occurs in the brain during surgery could be demonstrated by the use of retinal fluorescein angiography during bypass.
Methods: A Zeiss fundus camera was modified for use in the vertical position to enable fluorescein angiograms to be obtained during Cardio-Pulmonary Bypass (CPB) Microemboli were considered to be a major cause of the brain damage occurring during surgery.
Angiograms were obtained before, during and post bypass.
Results: The results of a study of a group of 10 patients found evidence of microemboli in all 10 (100%) when a bubble oxygenator was used in the bypass circuit.
A larger study comparing bubble oxygenators with flat sheet membrane oxygenators found that in the bubble group, there was still a 100% incidence but in the membrane group, more than half the angiograms were normal.
More recently, in a study comparing conventional bypass surgery (CPB) with Off Pump Coronary Artery Bypass (OPCAB) when the heart is still beating, in the CPB group 5/9 (55%) demonstrated evidence of microemboli while in the OPCAB group, 10/10 were normal.
Discussion: Retinal fluorescein angiography has been applied to the study of brain damage during cardiac surgery. This presentation will describe 20 years experience of the of this procedure.

15:40 Ophthalmic Imaging And The Anti-VEGF Revolution: A Beginner's Guide
Ethan R. Priel
MOR Institute
Bnei Brak, Israel
Purpose: To outline the primary imaging procedures most commonly used in association with the increasing use of intravitreal anti-angiogenesis drugs. As improvement in visual acuity (VA) and optical coherence tomography (OCT) results are being relied upon more and more in order to evaluate treatment progress, often ‘at the expense of’ fluorescein angiography (FA) and indocyanine-green angiography (ICGA), an understanding of the various treatment procedures and their anatomic and functional effects is needed. Imaging procedures used in the evaluation of this process will be discussed.
Materials and Methods: Itravitreal anti-vascular endothelial growth factor (Anti-VEGF) injections have been in use in ophthalmology for quite some time. A relative newcomer (bevacizumab – Avastin), not initially meant for ophthalmic use, has recently set this field of medical retina treatments on fire. Photographic, tomographic and VA results in a variety of retinal pathologies will be described, both before and after treatment.
Results: As the use of Avastin (and similar) drugs soars, ophthalmic imagers are called upon to document retinal and choroidal findings in new and creative ways. OCT use is being indicated more often than FAs or ICGs, and retinal thickness as well as the presence of intra-retinal fluid are used as a guide to success or failure of the treatment.
Conclusions: Ophthalmic imaging is already playing a major role in the rapidly changing field of treatment options for retinal ailments, including diabetic macular edema, edema associated with retinal vein occlusions and, of course, vision loss due to neovascular AMD.
The indication for intra-vitreal injections of Anti-VEGF drugs - such as Avastin - is dependant on specific results from a variety of imaging procedures which will be performed by ophthalmic imagers for years to come. A basic understanding of ‘what we are looking for’ is mandated.

Invited Lecture
16:00 Introduction
Ethan R. Priel
MOR Institute
Bnei Brak, Israel
16:05 New Approaches in Eye Imaging
Professor Giovanni Staurenghi, MD
Milan, Italy

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Thursday, 18 May 2006 Plenary Session 3 Imaging Technology and Applications I 2.00 OPS Continuing Education Credits
14:50	Introduction By Moderator Gary S. Michalec Veterans Administration Medical Center Minneapolis, Minnesota, USA
14:55	Imaging Of Arcuate Retinotomy For Repair Of Very Large, Failed Macular Holes Byron Wood, Steve Charles, Aneesh Nee Charles Retina Institute Memphis, Tennessee, USA Purpose: To discuss the imaging modalities used in determining if making an arcuate retinotomy temporal to the macula can facilitate repair of very large macular holes that failed with conventional surgical therapy. Methods: Conventional macular hole surgery using 25ga. sutureless techniques and forceps ILM peeling, followed by face-down positioning for at least 3 weeks failed to close very large macular holes in six patients. All patients had a second vitrectomy which included a further attempt at ILM peeling and the construction of an arcuate retinotomy temporal to the macula which was made by separating, rather than transecting nerve fibers. Pre and post-op OCTs, fundus photographs, and surgical videos were obtained. Results: Four out of six patients had closed holes on post-operative clinical and OCT examination. One closed after a second vitrectomy with C3F8 and retinotomy, and one failed. Conclusion: Arcuate retinotomy can be used to salvage selected cases of large, failed macular hole surgery. Various retinal imaging modalities are helpful in documenting closure of these holes, as well as providing valuable teaching materials.
15:10	Green Fluorescent Protein Imaging: An Ophthalmology Model John C. Peterson, Paul L. Kaufman, Carol A. Rasmussen University of Wisconsin Madison, Wisconsin, USA Purpose: To document the presence and location of Green Fluorescent Protein (GFP), a viral vector marker used in a gene-therapy model targeting the trabecular meshwork of non-human primates. Materials and Methods: Topcon 50IA, 50EX fundus cameras and a Zeiss Photo slit-lamp biomicroscope were used with either silver-based color and black-and-white film, or a Nikon D1X digital SLR camera. A three-mirror gonio lens and a Swan Jacobs gonioprism were used to visualize the TM. Standard clinical filter sets were used that were close in wave-length specificity to the GFPs used in the viral constructs. AdenoGFP or LentiGFP viral vectors were injected into the anterior chamber of cynomolgus monkeys (Macaca fascicularis). Gene transfer, as evidenced by the presence of fluorescence, was evaluated in vivo both by standard clinical ophthalmic instruments (slit lamp biomicroscope and lenses) and photographically. Results: In eyes that received higher doses of the viral vectors, the original fundus camera system easily documented GFP expression in the trabecular meshwork. Those eyes developed unacceptable amounts of inflammation, however, necessitating dose refinements. While tolerated better by the eyes, the lower doses resulted in fainter GFP expression, which made imaging more problematic. The fainter expression also made photographic documentation of expression more critical as expression was no longer visible to an ophthalmologist using a gonio lens and a slit lamp. The digital system increased sensitivity over the film system but histopathology, done on some of the eyes, revealed expression that had not been captured with the flash-based camera systems. Conclusions: Goals for the photographic systems include ease of use, availability of equipment, and quality of images. The current, fundus camera-based system works well for imaging dramatic amounts of GFP expression. As vectors more tolerable to the eye are developed and dosages are refined, expression is fainter and more difficult to image, requiring modifications to the system. Further studies will be devoted to increasing the precision of our imaging systems to reflect these realities.
15:25	Retinal Fluorescein Angiography And The Study Of Brain Damage During Cardiac Surgery John V. Arnold Hammersmith Hospital London, England, UK Introduction: It is more than 50 years since the introduction of the heart lung machine, enabling coronary artery bypass grafting and the replacement of defective valves in a non-beating heart. Shortly after the first operation, reports of brain damage following the procedure began to emerge. Since the eye is an outgrowth of the brain and has the same blood supply, it is reasonable to assume that what occurs in the brain during surgery could be demonstrated by the use of retinal fluorescein angiography during bypass. Methods: A Zeiss fundus camera was modified for use in the vertical position to enable fluorescein angiograms to be obtained during Cardio-Pulmonary Bypass (CPB) Microemboli were considered to be a major cause of the brain damage occurring during surgery. Angiograms were obtained before, during and post bypass. Results: The results of a study of a group of 10 patients found evidence of microemboli in all 10 (100%) when a bubble oxygenator was used in the bypass circuit. A larger study comparing bubble oxygenators with flat sheet membrane oxygenators found that in the bubble group, there was still a 100% incidence but in the membrane group, more than half the angiograms were normal. More recently, in a study comparing conventional bypass surgery (CPB) with Off Pump Coronary Artery Bypass (OPCAB) when the heart is still beating, in the CPB group 5/9 (55%) demonstrated evidence of microemboli while in the OPCAB group, 10/10 were normal. Discussion: Retinal fluorescein angiography has been applied to the study of brain damage during cardiac surgery. This presentation will describe 20 years experience of the of this procedure.
15:40	Ophthalmic Imaging And The Anti-VEGF Revolution: A Beginner's Guide Ethan R. Priel MOR Institute Bnei Brak, Israel Purpose: To outline the primary imaging procedures most commonly used in association with the increasing use of intravitreal anti-angiogenesis drugs. As improvement in visual acuity (VA) and optical coherence tomography (OCT) results are being relied upon more and more in order to evaluate treatment progress, often ‘at the expense of’ fluorescein angiography (FA) and indocyanine-green angiography (ICGA), an understanding of the various treatment procedures and their anatomic and functional effects is needed. Imaging procedures used in the evaluation of this process will be discussed. Materials and Methods: Itravitreal anti-vascular endothelial growth factor (Anti-VEGF) injections have been in use in ophthalmology for quite some time. A relative newcomer (bevacizumab – Avastin), not initially meant for ophthalmic use, has recently set this field of medical retina treatments on fire. Photographic, tomographic and VA results in a variety of retinal pathologies will be described, both before and after treatment. Results: As the use of Avastin (and similar) drugs soars, ophthalmic imagers are called upon to document retinal and choroidal findings in new and creative ways. OCT use is being indicated more often than FAs or ICGs, and retinal thickness as well as the presence of intra-retinal fluid are used as a guide to success or failure of the treatment. Conclusions: Ophthalmic imaging is already playing a major role in the rapidly changing field of treatment options for retinal ailments, including diabetic macular edema, edema associated with retinal vein occlusions and, of course, vision loss due to neovascular AMD. The indication for intra-vitreal injections of Anti-VEGF drugs - such as Avastin - is dependant on specific results from a variety of imaging procedures which will be performed by ophthalmic imagers for years to come. A basic understanding of ‘what we are looking for’ is mandated.
Invited Lecture
16:00	Introduction Ethan R. Priel MOR Institute Bnei Brak, Israel
16:05	New Approaches in Eye Imaging Professor Giovanni Staurenghi, MD Milan, Italy