Advances in Ophthalmology - Spring 2016

THE UNIVERSITY OF MICHIGAN KELLOGG EYE CENTER

ADVANCES IN OPHTHALMOLOGY

Cagri Besirli, M.D., Ph.D.

Filling the Gap in Care for Premature Babies Kellogg Partners with Michigan Hospitals to Screen Infants for Blinding Eye Disease

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etinopathy of prematurity (ROP) occurs when abnormal blood vessels grow over the retina and cause blindness in premature babies.

ROP is on the rise as more babies are surviving due to advances in neonatal care. On the decline, however, are ophthalmologists available to care for these babies.

That is where Kellogg steps in. A team of ophthalmologists, led by pediatric retina specialist Cagri G. Besirli, M.D., Ph.D., provides ROP exams and treatment for babies at Sparrow Hospital in Lansing and St. Joseph Mercy Hospital in Ypsilanti. Kellogg also supports an ROP telemedicine screening program with Marquette General Hospital in Marquette, Michigan.

Babies born before 31 weeks and weighing less than 1,500 grams undergo repeated screenings to monitor for ROP. Images of the babies’ eyes are taken using a pediatric retinal imaging system. At Sparrow, Kellogg retina specialist Anjali Shah, M.D., provides ROP exams. When treatment is needed, Drs. Shah and Besirli perform laser therapy or direct intraocular injections. At St. Joseph, Kellogg pediatric ophthalmologist Shreya S. Prabhu, M.D., performs ROP exams and Dr. Besirli handles treatment. Retinal images are

reviewed locally by the team to guide follow-up and treatment decisions.

Because Marquette General Hospital lacks providers to screen for ROP, it taps Kellogg’s expertise via telemedicine. Images are taken and uploaded to Kellogg’s electronic medical records system for review

by Dr. Besirli and Kellogg pediatric ophthalmologist Steven M. Archer, M.D. If a baby needs urgent care, Kellogg calls Marquette to discuss next steps.

“Before starting this program, babies born in the Marquette area were transferred to Ann Arbor for care and often stayed alone for several weeks for repeated screenings,” says Dr. Besirli. “Now we are able to delay the transfer process until treatment is necessary, allowing the babies to stay home with their families longer and be monitored back at home after treatment.”

Dr. Besirli envisions that Kellogg will support more hospitals in the future and collaborate with nearby hospitals to establish a regional center where ROP images are evaluated. “There is a gap to fill in caring for these babies and using telemedicine to bridge this gap is the best option,” he says.

Kellogg Presents Oculoplastics Symposium at the Annual University of São Paulo Ophthalmology Congress in Brazil César A. Briceño, M.D., led the Kellogg team in presenting an oculoplastics symposium at the annual University of São Paulo Ophthalmology Congress in São Paulo, Brazil, in December 2015. Over 1,000 ophthalmologists from Brazil attended.

“It was an honor to be invited by the Congress to organize the symposium, the second largest ophthalmology meeting in Brazil,” says Dr. Briceño. “The Kellogg team provided didactic lectures on topics such as pediatric orbital masses and thyroid eye disease, as well as videos on surgical instruction. This was an opportunity for a true two-way exchange with our colleagues in Brazil.”

Dr. Briceno also discussed joint research protocols with Richard Y. Hida, M.D., Assistant Professor, Department of Ophthalmology, Irmandade da Santa Casa de Misericórdia de São Paulo, a major teaching hospital in São Paulo. “If we want to develop strong, sustainable research enterprises with institutions around the world, it is important that we start with solid interpersonal relationships and solid educational exchanges,” says Dr. Briceño. “Without that, the research enterprise is unsustainable. Kellogg has a strong presence in Africa,

César Briceño, M.D., and Christine Nelson, M.D., FACS

Asia, and Europe with ongoing research projects, yet we are virtually non-existent in South America. It’s time to change that.”

Also presenting from Kellogg were Christine C. Nelson, M.D., FACS, Raymond S. Douglas, M.D., Ph.D., and David N. Zacks, M.D., Ph.D. Dr. Zacks lectured on the Argus II® retinal implant and his research in developing a photoreceptor protective agent for use in retinal detachment. “This was an excellent forum for sharing our experience with the Argus II® implant with the retina community in Brazil,” he says.

“It was also good to update the audience on my research and to get feedback from this highly skilled group.”

Dr. Briceño also explored opportunities for Brazilian trainees to visit Kellogg through international observerships. To date, five trainees from the University of São Paulo are slated to come for one-month experiences.

Kellogg Investigates New Drug to Treat Patients with Geographic Atrophy

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ge-related macular degeneration (AMD) causes progressive damage to the macula, the part of the retina associated with visual acuity. AMD is the leading cause of irreversible vision loss in people aged 50 years and older.

It is estimated that approximately 15 million Americans suffer from AMD.

The early stage of the disease is referred to as dry AMD. “In early dry AMD, we see small yellow deposits, called drusen, that form under the retina,” says Mark W. Johnson, M.D., Professor. “As the disease progresses, some patients develop an advanced stage known as geographic atrophy (GA), which is characterized by the loss of light-sensitive cells in the macula.

Individuals affected may have challenges with reading, driving and performing daily activities.”

There is currently no proven treatment for GA in patients with dry AMD. Dr. Johnson and colleagues are participating in an international multicenter clinical trial to determine whether a new drug called

lampalizumab, administered via intravitreal injections, can halt or slow the progression of GA in dry AMD patients. Titled A Study Investigating the Safety and Efficacy of Lampalizumab Intravitreal Injections in Patients with Geographic Atrophy Secondary to AgeRelated Macular Degeneration (SPECTRI), the trial is a Phase III, doubled-masked, multicenter, randomized, sham injection-controlled study evaluating the efficacy and safety of the drug.

“This drug has the potential to markedly improve the quality of life for dry AMD patients who might otherwise progress to legal blindness from GA,” says Dr. Johnson. “Although the drug is not expected to reverse existing areas of GA, there is very favorable preliminary clinical trial data. We look forward to the results of the study with great anticipation.”

Enrollment for the trial is open to patients who meet study criteria. Kellogg hopes to enroll 8-10 participants in the study, which will treat and follow patients for two years. To date, there are 936 participants enrolled in 155 sites globally. Sponsored by Hoffmann La Roche, the trial was initiated in October 2014 and concludes in November 2017.

Worldwide Scientific Collaborations Kellogg Studies Have Revealed New Genetic Clues for Glaucoma and Age-Related Macular Degeneration

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or more than 25 years, Julia E. Richards, Ph.D., the Harold F. Falls Professor of Ophthalmology Julia Richards, Ph.D. John Heckenlively, M.D. and Visual Sciences, has studied genetic risk factors associated with glaucoma, a group of eye diseases that can result in damage to the optic nerve Center for Retinal and Macular Degeneration, studies and blindness if left untreated. It is estimated that over genetic risk factors associated with age-related macular three million Americans suffer from glaucoma. degeneration (AMD), a disorder that causes damage

In the past three years, Dr. Richards has collaboto the macula, a small area near the center of the retina rated with glaucoma specialists Sayoko E. Moroi, M.D., needed for sharp, central vision. It is estimated that Ph.D., and Paul R. Lichter, M.D., M.S. over 2.1 million Americans over the Their work has led to a partnership age of 50 have AMD. By pooling data from researchers with the International Glaucoma GeMost recently, Dr. Heckenlively netics Consortium, a team of scientists around the world, we have been able and colleagues partnered with the from four continents. In their most to detect genetic factors that could not International AMD Genomics recent collaboration with the ConsorConsortium, a team of scientists from tium, Kellogg scientists identified three be detected when looking at smaller around the world that has identified new genes that serve as risk factors for 16 new genetic variations for the sample sizes available to any one primary open-angle glaucoma. disease. Their findings, based on the

Using genome-wide technologies, collection and analysis of genetic research group. they have studied data on more than data from 43,566 individuals, nearly six million genetic variants identified in — Julia E. Richards, Ph.D. doubles the number of genetic regions more than 35,000 subjects to evaluate associated with the disease. the association of these genetic variants with glaucoma.

“With the identification of 52 major genetic vari“By pooling data from researchers around the world, ants in AMD, it will be possible to investigate how we have been able to detect genetic factors that could the expression of these genes interacts with the known not be detected when looking at smaller sample sizes aging genes, changes in the retinal mitochondrial available to any one research group,” says Dr. Richards. genome, and expression of genes from the telomere

John R. Heckenlively, M.D., the Paul R. Lichter region (tips of chromosomes), which are known to Professor of Ophthalmic Genetics and Director of the change with the aging process,” says Dr. Heckenlively.

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OPHTHALMOLOGY PROGRAM

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Department of Ophthalmology and Visual Sciences 1000 Wall Street, Ann Arbor, MI 48105 www.kellogg.umich.edu

Kellogg Now Performing 3-D Navigated Small-Incision Orbital Surgery

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lon Kahana, M.D., Ph.D., Associate Professor, reports that Kellogg has acquired ground-breaking technology that allows surgeons to perform stereotactic 3-D navigated small-incision orbital surgery. Although such technology has been used in neurosurgery and spinal surgery, Kellogg is the first eye center in the United States to use a stereotactic face mask for orbital surgery. Stereotactic surgery uses Cartesian coordinates to define points in computerized three-dimensional space during orbital surgery and correlate these points to a CT or MRI scan.

“Surgery in the orbit can be risky,” says Dr. Kahana. “Given the orbit’s tightly enclosed neurovascular and muscular structures, its proximity to vital brain structures, and the need to operate behind the eye, it is one of the most anatomically challenging operating sites in the body.”

Standard navigation systems require immobilization of the head and direct contact between the stereotactic tool and the roof of the skull. “Our stereotactic navigation system utilizes an adhesive face mask with embedded LEDs that avoids the need for head immobilization or bone contact,” says Dr. Kahana. “With a mask, stereotaxy is less invasive, and the head can be rotated easily to assist with proper surgical positioning throughout the surgery.”

Alon Kahana, M.D., Ph.D.

The new system gives surgeons a clearer view of the orbit and leads to faster, safer and more precise surgeries than traditional non-navigated methods. In addition to improving patient care, the system is also an important teaching tool that allows Kellogg faculty to instruct trainees in real time instead of relying on two-dimensional computer images or physical models of the skull.

A manuscript describing Dr. Kahana’s initial experience with this system was recently published in the journal of Ophthalmic Plastic and Reconstructive Surgery.