2020 VISION Magazine

Artificial Intelligence is Shaping the Future of Eye Care â&#x20AC;&#x201D;And Duke is Leading the Way

24 2020 VOLUME 36

COVER STORY 2 Smarter. Faster. Stronger. Artificial Intelligence is Shaping the Future of Eye Care —and Duke is Leading the Way

28 New Faculty

8 Identical Twin Eye Images Lead to

34 Honors and Awards

Promising Alzheimer’s Discovery

1 Message from the Chair 30 News and Notes 40 Administration, Faculty and Staff

10 Next-Generation Treatment for Chronic Noninfectious Posterior Uveitis

11 Family Outside the U.S. Sought Duke Specialist

To Treat a Child with Severe Neurotrophic Keratopathy

12 First Genetic Association of Increased Risk of Glaucoma in African Ancestry Populations

14 Navigating Surgical Complexity in Adult Strabismus 15

Effective Diagnosis and Treatment of Ocular Surface Disease in Cataract and Refractive Surgery Patients

18 Still Rockin’

Sculptor Captures His Own Experience with Eye Disease

20 Duke Eye Center by the Numbers 22 Our Immune System Can See 24 Seeing the Future

Through a Transformative Pledge

26 Faced with Vision Loss, Young Man Bets on Himself Editor Tori Hall Writers Laura Ertel, Tori Hall, Lindsay Kenton, Samiha Khanna, Catherine Lewis Art Direction Pam Chastain Design Photography Kevin Caldwell Photography, Ben McKeown Photography, Madeline Gray Copyright 2020 © Duke Eye Center dukeeye.org

For questions, comments or to add or remove your name from our mailing list, please contact us. Office of Marketing and Communications Duke Eye Center 2351 Erwin Road Durham, NC 27710 e-mail: Duke_Eye_Center@duke.edu phone: 919.668.1345

From our Chair, Edward G. Buckley, MD

Proudly introducing VISION 2020!

am constantly amazed about the significant progress that has been made in the field of ophthalmology, with many of the advancements led by faculty and trainees of Duke Ophthalmology. I always look forward to sharing our most recent discoveries, inspirational patient stories and honors each year in VISION. Duke University has a long history of being on the forefront of medicine and engineering. In this issue, we share how Duke is leading the way in applications of artificial intelligence or “AI” to diagnose and manage ocular diseases. Duke is in a unique position—our clinician scientists can collaborate across campus with acclaimed engineers at Pratt School of Engineering. We are excited about the strides we are making to bring AI to the clinic, improve the patient experience and make more informed treatment decisions. Duke clinician-scientists Sharon Fekrat, MD, Dilraj Grewal, MD and colleagues published groundbreaking data showing that the loss of blood vessel density in the retina could be a signal of Alzheimer’s disease (AD). Their research prompted an invitation from the US Senate Committee on Aging, elevating the importance of this innovative discovery.

awards, delivered hundreds of presentations, and inducted into prominent ophthalmic societies and associations. For example, Daniel Stamer, PhD is serving as 2019 Association of Research in Vision and Ophthalmology (ARVO) president and Terry Kim, MD will become American Society of Cataract and Refractive surgery (ASCRS) president in 2020.

Glenn Jaffe, MD and collaborators published outcomes on the safety and efficacy of a next-generation treatment for posterior uveitis, a single fluocinolone acetonide intravitreal (FAi) insert, that revealed fewer recurrent episodes of inflammation, more visual acuity gain and less visual acuity loss than for participants who received the placebo.

I am confident that in the next decade and beyond Duke Ophthalmology faculty, trainees and staff will elevate our tradition of excellence. They continue to amaze me with their dedication to our core missions of research, education and patient care; which accelerates our unrelenting pursuit to provide the best care for our patients, teach the next leaders in ophthalmology and discover treatments and cures for blinding eye diseases.

A new ocular surface disease (OSD) algorithm was created in part by Duke cornea specialists Terry Kim, MD and Preeya Gupta, MD which emphasizes the use of efficient point-of-care testing for assessing OSD preoperatively. The pre-op testing can help improve refractive outcomes, improve the patient’s satisfaction and provide higher visual quality for the patient. Learn more about several innovative surgical techniques in the ever-evolving field of adult strabismus developed by Duke ophthalmologist Federico G. Velez, MD. Our faculty and trainees are dedicated to leadership roles in international societies, serve on governing advisory committees, have achieved prestigious

Best wishes for the year of vision—2020! Sincerely, Edward G. Buckley, MD Vice Dean for Education, School of Medicine Chair, Department of Ophthalmology Vice Chancellor for Duke-National University Singapore Affairs James P. and Joy Gills Professor of Ophthalmology Professor of Pediatrics Duke University Medical School

Smarter. Faster. Stronger. Artificial Intelligence is Shaping the Future of Eye Care —and Duke is Leading the Way BY LAURA ERTEL

Artificial intelligence (AI) leverages the growing power and speed of computers to solve complex problems. AI is transforming medical research and clinical practice—and ophthalmology is leading the way. “One of the most successful ways that AI has been applied recently is in the area of ‘computer vision,’ which is the assessment and interpretation of images,” explains Felipe Medeiros, MD, PhD, Joseph A.C. Wadsworth Professor of Ophthalmology. “We can apply sophisticated AI algorithms, such as ‘deep learning’ neural networks, which are capable of very complex pattern recognition tasks, to identify whether specific characteristics are present in an image or not.

“In ophthalmology we have a wealth of eye images—fundus photographs, optical coherence tomography (OCT), etc.—that are fundamental to the diagnosis, monitoring, and treatment of a number of eye diseases, so this field is ideally suited for deep learning applications,” says Medeiros, who is Duke Ophthalmology’s vice chair of technology and leads the clinical research unit. “The development of such applications has been increasing at an astounding rate. In several disciplines, including ophthalmology, researchers have proven that deep learning algorithms can actually outperform humans in some tasks.”

Minimizing mistakes, maximizing efficiency Deep learning algorithms not only reduce labor and equipment costs but can also eliminate errors that occur from the subjective interpretation of diagnostic images by humans. They can also bring screening and diagnosis to underserved areas where specialists may be limited.

Processing Laboratory at Duke a decade ago and has developed numerous ophthalmic image analysis tools that are freely shared online and used in multicenter clinical trials around the world. Duke University is also finding innovative ways to apply AI to a range of disciplines. In 2019, Duke appointed Lawrence Carin, PhD, one of the world’s leading experts on machine learning and artificial intelligence, as vice president of research. Duke Ophthalmology looks forward to collaborating with the AI Health Data Science Initiative, leveraging the university’s focus on artificial intelligence and its culture of multidisciplinary collaboration.

“There will always be a significant role for human contribution and physicians’ expertise, so there is no need to worry about a future in which patients are treated entirely by computers,” assures “Larry’s team members are experts in computer Eleonora Lad, MD, PhD, an associate professor of science; we have the top minds in ophthalmology,” ophthalmology and clinician-scientist at Duke who is Medeiros says. “We bring them clinical challenges, researching applications of AI to improve diagnosis and they bring us innovative ways of creating and treatment of age-related macular degeneration. “Physicians have limited time and bandwidth. Machine algorithms to solve them. Together, it’s a great fit that would be hard to find anywhere else.” learning can provide us with new information, faster, so we can make more informed diagnoses and Carin agrees. “Duke Ophthalmology is very well spend more time working with our patients on the positioned in this space, as it already has multiple best treatment plan.” clinician-scientists who recognize the opportunity and are engaged in leading research. Duke is also the home of leadership in the fundamentals of AI. By bringing Duke Ophthalmology and the broader Duke methodological AI leaders together, Duke is positioned to be a global leader on the Duke Ophthalmology has a long track record of application of AI to the transformation of developing AI technology to improve eye care. Sina ophthalmological care.” Farsiu, PhD, who holds joint appointments in Duke’s

Duke Ophthalmology at the forefront

Pratt School of Engineering and the Department of Ophthalmology, is a pioneer in the use of AI in ophthalmology. He established the Vision and Image

Duke Ophthalmology is applying AI to advance research and improve treatment for several common and important eye diseases. Some examples:

“By replacing optical components of ophthalmic imaging systems with computational components, we can make them much smaller, lighter, and more accessible.” Sina Farsiu, PhD Paul Ruffin Scarborough Associate Professor of Biomedical Engineering, and Associate Professor in Ophthalmology

Lawrence Carin, PhD Vice President of Research James L. Meriam Distinguished Professor of Electrical and Computer Engineering Sina Farsiu, PhD Paul Ruffin Scarborough Associate Professor of Biomedical Engineering, and Associate Professor in Ophthalmology

Eleonora Lad, MD, PhD Associate Professor of Ophthalmology

Felipe Medeiros, MD, PhD Joseph A.C. Wadsworth Distinguished Professor of Ophthalmology

been proven to accurately quantify the amount of damage a patient has in the optic nerve from just a fundus photograph, and tell us whether the patient is likely to have glaucoma or not.1 Using the power of AI, researchers were able to closely replicate OCT estimates of neural loss. The method also removed subjectivity, and even outperformed human specialists in the interpretation of fundus photographs for glaucoma.2 And, because photographs are less expensive and more widely available than OCT, this method offers the potential to bring improved screening and diagnosis to underserved locations.

Age-Related Macular Degeneration Once age-related macular degeneration (AMD) progresses to its late stages, there is no treatment for 85 percent of cases with the dry form (geographic atrophy), and loss of central vision is inevitable. Lad is on a mission to find biomarkers that predict disease progression, both to better understand the genesis and progression of disease and to test potential treatments on patients before vision loss becomes irreversible. AI is helping to speed that search.

Glaucoma is a leading cause of irreversible blindness in the world. Because the disease remains largely asymptomatic until late stages, there is a great need to develop affordable approaches for screening before visual impairment occurs—when early intervention can still save sight.

“The National Eye Institute’s multicenter, prospective, Age-Related Eye Disease Study 2 (AREDS2) is providing a true goldmine of data on aging and AMD, including several types of high-resolution retinal images and demographic, functional, and genetic data from study participants over several years. We are collaborating with Larry Carin’s team to mine the retinal images from this study and to develop deep learning algorithms to uncover biomarkers that indicate rapid disease progression,” Lad says.

Medeiros’ research team has developed several AI algorithms that promise to detect glaucoma more quickly and efficiently. One algorithm has

“It took years and much grant funding for research associates in Dr. Cynthia Toth’s lab to grade every OCT image from the study and develop a true

Glaucoma

Teaching a machine to learn

everaging artificial intelligence requires humans to teach computers how to recognize patterns in data. Duke faculty and staff feed in data from ophthalmic images, and program and refine complex algorithms (series of mathematical operations) that can help identify a variety of eye conditions. The training process begins slowly. Input an image into the computerâ&#x20AC;&#x2122;s algorithm. Let it guess whether a disease is present in that image or not. Confirm or correct and reweight the algorithmâ&#x20AC;&#x2122;s parameters as needed. Then another image. Then another. As the images build, the computer begins to see commonalities and differences, makes its own adjustments, and gets better at detecting which patterns indicate a disease and which do not. Eventually, nourished by data from hundreds and thousands of images, the computer becomes even better at recognizing complex patterns of disease presenceâ&#x20AC;&#x201D;and faster, and less expensive. Now it can be deployed to interpret new images it has never seen.

Neural Transfer Learning

Medeiros used an AI algorithm called neural transfer to transfer the painting style of famous artists DaVinci, Van Gogh, Picasso and Kandinsky to visualize how they would paint an optic nerve with glaucoma.

“The ultimate goal is to apply AI to clinical practice in ways that can improve patient care and satisfaction.” Felipe Medeiros, MD, PhD, Joseph A.C. Wadsworth Professor of Ophthalmology

encyclopedia of annotated OCT features that predict disease progression,” she notes. “Using deep learning/AI, we hope to do this much more quickly and inexpensively, so we can predict which patients would progress to vision loss over a timeframe as short as 1 to 2 years and can enroll them into promising clinical trials.”

Already, the team has created an algorithm capable of grading three-dimensional OCT images with 91 percent accuracy at predicting which patients will develop geographic atrophy within one year.

Imaging Technology AI’s computational techniques also enable Duke researchers to develop more elegant imaging modalities, notes Farsiu, whose Vision and Image Processing Laboratory was the first to develop a fully automatic deep learning algorithm that successfully uses clinical-grade OCT images of the retina to detect multiple diseases of the eye.

“After these algorithms are refined and validated, they can be incorporated into OCT machines,” Lad says. “Then, ophthalmologists and optometrists could screen their patients during routine exams, determine their risk of progression to advanced disease (neovascular or dry), and refer them to a retinal specialist.”

“By replacing optical components of ophthalmic imaging systems with computational components, we can make them much smaller, lighter, and more accessible,” he says. “For example, in collaboration with Joseph Izatt, PhD, we have been able to shrink an adaptive optics scanning laser ophthalmoscope from a desktop size down to a portable handheld unit, which allows us to use this tool on infants and children, who have a hard time sitting still in front of a traditional unit.”

Diabetic Retinopathy

Data Analysis for Clinical Trials

Farsiu—together with Duke Ophthalmology clinicianscientists Scott Cousins, MD, and Prithu Mettu, MD— developed the first algorithm that could distinguish AMD and diabetic retinopathy from each other, and from normal eyes, using OCT images.3 This was the first algorithm with the ability to process images from different centers with different imaging protocols.

Farsiu’s lab is also collaborating with retinal specialist and Duke Reading Center Director, Glenn Jaffe, MD, to use AI to rapidly analyze data in multicenter international clinical trials for new therapies for blinding diseases. In one study, Farsiu’s PhD student, Jessica Loo, developed a fully automatic algorithm that could replicate the result of the clinical trial without any human involvement. This is a transformative change from the standard method of data analysis, which requires a human expert to review a computer’s analysis of each image to correct its mistakes—a time-consuming and expensive task.

Farsiu’s postdoctoral mentee Reza Rasti, PhD—in collaboration with Michael Allingham, MD, PhD, Cousins, and Mettu, is now using AI to identify which diabetic retinopathy patients will respond best to anti-VEGF injections—before treatment starts. That means patients who would not respond well won’t have to go through this vision-saving, but complicated and expensive, treatment.

“These are preliminary results, which we will need to replicate in other clinical studies,” Farsiu notes. “But if we can successfully conduct the data analysis for an

entire clinical trial fully automatically without human involvement, and get the same results, that would significantly reduce the cost of trials, eliminate human error, and get promising treatments to patients faster.” The U.S. Food & Drug Administration, the agency within the U.S. Department of Health and Human Services that assures the safety and effectiveness of drugs and medical devices in clinical trials, also recognizes the power and promise of AI. The FDA has recently organized an Ophthalmic Imaging Collaborative Community group as a strategic priority for the agency. Lad is a key member of this effort, whose goal is to develop guidelines for the use of AI technologies in the diagnosis and treatment of patients with eye diseases. The ultimate goal, Medeiros notes, is to apply AI to clinical practice in ways that can improve patient care and satisfaction. That requires many stages and very diverse expertise. “First, we need to develop ideas to address clinically relevant questions. Then we need to gather the relevant data, build, refine, and validate the AI algorithms. And ultimately, we need to integrate those algorithms into clinical practice and prove that they lead to better patient outcomes.” The department envisions developing a comprehensive Center for Artificial Intelligence in Ophthalmology at Duke integrated with the university’s AI research enterprise, that would unite clinician-scientists, engineers, data scientists, and health outcomes researchers, with the goal of supporting AI initiatives through each stage, from idea through implementation. The center would also help researchers mine the vast amount of data and images stored within the Duke Eye Center’s electronic health records system. Increasingly, health care providers and researchers are seeing the opportunities that AI can open up. “Momentum is building,” Medeiros says. “This is a transformational moment in health care, and for all of us who are involved in patient care, artificial intelligence will help us do better medicine.”

Remote Diagnostics Shows Promise for Early Detection of Diabetic Retinopathy

uke Ophthalmology clinician-scientists are also using technology to improve early detection of diabetic retinopathy (DR) and improve visual outcomes. As reported in the May 2019 issue of JAMA Ophthalmology, Duke researchers found that using a combination of ocular imaging techniques to remotely screen diabetic patients for DR in primary care clinics is as effective as a traditional examination in identifying this sightthreatening disease.

Traditionally, a retinal imaging specialist uses expensive equipment in a dedicated imaging center or mobile van to take color fundus photography (CFP) through dilated pupils. Remote diagnosis, on the other hand, uses a combination of CFP and OCT on nondilated pupils to create a cross-section of the retina. Because this screening can be performed by non-expert imagers using less expensive equipment permanently located at a primary care clinic or other point of service, this approach can provide convenient, accessible, efficient, and lowcost screening while improving patient convenience and satisfaction. With this model, the physician could receive automated image interpretation and immediately refer at-risk patients to a specialist. “Combining CFP and OCT significantly improved screening outcomes and provided much better interpretability with the cross-section images—and it doesn’t require pupil dilation,” notes Majda Hadziahmetovic, MD, a Duke retinal specialist and lead author of the study. “Currently, less than 50 percent of patients at risk for developing diabetic retinopathy receive screening using the traditional model. Using this transformative care delivery model to provide high-quality community-based imaging and diagnosis of retinal diseases could help to better triage the two million people in the U.S. who have DR, especially elderly or immobile patients or those who live in rural areas with a shortage of ophthalmic experts.”

From Machine to Machine: An OCT-Trained Deep Learning Algorithm for Objective Quantification of Glaucomatous Damage in Fundus Photographs. Ophthalmology. Medeiros FA, Jammal AA, Thompson AC. 2019 Apr;126(4):513-521. doi: 10.1016/j.ophtha.2018.12.033. Epub 2018 Dec 20. 1

A Deep Learning Algorithm to Quantify Neuroretinal Rim Loss from Optic Disc Photographs. Am J Ophthalmol. Thompson AC, Jammal AA, Medeiros FA. 2019 May;201:9-18. doi: 10.1016/j.ajo.2019.01.011. Epub 2019 Jan 26. Human Versus Machine: Comparing a Deep Learning Algorithm to Human Gradings for Detecting Glaucoma on Fundus Photographs. Am J Ophthalmol. Jammal AA, Thompson AC, Mariottoni EB, Berchuck SI, Urata CN, Estrela T, Wakil SM, Costa VP, Medeiros FA. 2019 Nov 12. pii: S0002-9394(19)30543-4. doi: 10.1016/j.ajo.2019.11.006. [Epub ahead of print] PMID: 31730838 2

Fully Automated Detection of Diabetic Macular Edema and Dry Age-Related Macular Degeneration from Optical Coherence Tomography Images. Biomedical Optics Express. Srinivasan PP, Kim LA, Mettu PS, Cousins SW, Comer GM, Izatt JA, and Farsiu S. 2014 Oct;5(10), pp. 3568-3577. 3

Identical Twin Eye Images Lead to Promising Alzheimer’s Discovery

Loss of Blood Vessels in Retina May Signal Alzheimer’s Disease

pair of 96-year-old identical twins, one with advanced Alzheimer’s disease (AD), the other cognitively normal and two very different optical coherence tomography angiography (OCT-A) images. Using automated mapping of the superficial capillary plexus, the twin with advanced AD had a significantly reduced vessel density compared to her cognitively normal sister. This finding convinced Sharon Fekrat, MD, professor of ophthalmology, that retinal images could potentially become a

Sharon Fekrat, MD Professor of Ophthalmology

Dilraj Grewal, MD Associate Professor of Ophthalmology

biomarker for AD and she began her mission to recruit patients and test the theory. Nearly 6 million Americans live with Alzheimer’s disease. No viable treatments or noninvasive tools for early diagnosis exist. Fekrat, along with her colleagues at Duke Eye Center, are studying this and related retinal changes, such as the thinning of nerve layers, that could provide early signals of cognitive disease. Fekrat and Duke retina colleague Dilraj Grewal, MD, associate professor of ophthalmology, led a study published in Ophthalmology Retina that found decreased superficial retinal blood vessel density, as well as thinning of the ganglion cell

layer of the retina, in individuals with symptomatic Alzheimer’s disease compared to those with mild cognitive impairment and compared to cognitively healthy adult controls, even after controlling for age and sex. Ultimately the use of OCT-A alone, or in combination with multimodal retinal imaging, may be able to diagnose Alzheimer’s disease—perhaps even before a person begins to show signs of memory loss.

Retinal Blood Vessel Scan

In people with healthy brains, microscopic blood vessels form a healthy, dense web in the retina located at the back of the eye, as seen in 254 eyes of 133 cognitively healthy participants. But in 72 eyes of 39 individuals with Alzheimer’s disease, that web was less dense and even sparse, researchers say. The study found differences in the retinas of those with Alzheimer’s disease compared to cognitively healthy people and compared to mild cognitive impairment, often a precursor to AD. “We’re measuring blood vessels that can’t be seen during a regular eye exam and we’re doing that with noninvasive technology that takes high-resolution images of very small blood vessels within the retina in just a few minutes,” says Fekrat, senior author on the study. “We know that there are changes that occur in the small blood vessels of the brain in people with Alzheimer’s disease, and because the retina is an extension of the brain, we wanted to investigate whether these changes could be detected in the retina using a new technology that is less invasive and easy to obtain,” Fekrat continues. The study used a noninvasive technology called optical coherence tomography angiography (OCTA). OCTA machines use light waves that reveal blood flow in every layer of the retina. An OCTA scan could even reveal changes in tiny capillaries—most less than half the width of a human hair—before blood vessel changes show up on a brain scan such as an MRI or cerebral angiogram, which highlight only

Could An Eye Exam Reveal Alzheimer’s Disease? Study suggests loss of blood vessels in retina reflect changes in brain health

cognitively healthy adult

Blood vessels

FEWER

adult with Alzheimer’s disease MORE

larger blood vessels. Such techniques to study the brain are invasive and costly.

symptoms start and differentiate Alzheimer’s from other types of dementia.

“These changes in blood vessel density in the retina likely mirror what’s going on in the tiny blood vessels in the brain. We are now studying whether these retinal changes can be detected before someone, who has a higher genetic risk for Alzheimer’s, develops signs of memory loss,” Grewal comments.

Collaboration across disciplines is key to timely progress. Fekrat and Grewal’s clinical research team includes many individuals, such as:

Promise for the Future

Over 400 clinical trials for AD have failed and this may be due, in part, to the diagnosis of Alzheimer’s being made too late in the disease course. Alzheimer’s changes in the brain start about 20 years before symptoms of memory loss manifest. “Ultimately, the goal would be to use this technology to detect Alzheimer’s early, before symptoms of memory loss are evident, and enter participants into clinical trials earlier to study new Alzheimer’s treatments,” Fekrat said. Fekrat and Grewal and their team are collaborating with Duke computer engineers to train and test artificial intelligence deep learning models to predict the presence of Alzheimer’s disease before

Duke Ophthalmology Residents, Fellows and Faculty—Atalie C. Thompson, MD, MPH; C. Ellis Wisely, MD, MBA; Pam Bhullar, MD; Michael Quist, MD; Nora Lad, MD, PhD Duke Medical School Students—Cason Robbins, Srinath Soundararajan, Delaram Mirzania, James Powers, Stephen P. Yoon, Bryce W. Polascik Duke Neurology—Cynthia Dunn, PA; Brenda Plassman, PhD; James R. Burke, MD, PhD Duke Engineering and Biostatistics—Dong Wang, PhD; Ricardo Henao, PhD; and Lawrence Carin, PhD Duke Geriatrics—Heather Whitson, MD If you are interested in supporting this groundbreaking team and their work, contact Dr. Fekrat at 919-684-4524 to learn more.

Next-Generation Treatment for Chronic Noninfectious Posterior Uveitis Single Injectable Implant Reduces Risk for Recurrence Over Three-year Period

study to assess the safety and efficacy of an intraocular sustained drug delivery system to treat chronic noninfectious posterior uveitis revealed significant benefits for participants who received a single fluocinolone acetonide intravitreal (FAi) insert. Outcomes included fewer recurrent episodes of inflammation, more visual acuity gain, and less visual acuity loss than for participants who received placebo injections.

In the multicenter, randomized phase III clinical study published in Ophthalmology in April 2019, participants who received the 0.18 mg single FAi injection had no flares during the first year and had fewer side effects than those previously reported for the surgically placed 0.59 mg FAi implant. “This is the next generation of a sustained drug delivery system I’ve been working on with my collaborators for many years,” says Glenn Jaffe, MD, professor of ophthalmology and chief of the Duke department of ophthalmology

Glenn Jaffe, MD Professor of Ophthalmology

vitreoretinal division. The single FAi implant—the size of a grain of rice—is injected with a 25-gauge needle into the vitreous cavity to allow the fluocinolone acetonide to be released through the membrane at an initial rate of 0.2 mg daily and decreasing to 0.1 mg daily over the course of the study period. “The injectable implant has many advantages: You can place it in the office, with no surgery needed; you eliminate all the potential risks associated with being in the operating room; and it’s more cost-effective,” Jaffe adds.

Size comparison of 3-year injectable fluocinolone acetonide intravitreal implant 0.18 mg (left) and surgically implanted fluocinolone acetonide intravitreal implant 0.59 mg (right).

Uveitis is thought to account for about 10 percent of legal blindness in the United States, with approximately 30,000 new cases per year. Patients presenting at the Duke Eye Center subspecialty uveitis clinic with this sightthreatening disease tend to be ages 20 to 50— in their prime working years. “When these patients have recurrences and their vision decreases, there is the potential for additional complications or a further drop in vision, which has a big effect on their lives,” Jaffe says. “A single injection is overall much less disruptive than other treatments that involve multiple injections that may wear off and cause frequent recurrent episodes.” Jaffe says that while the risk for cataracts from the local corticosteroidal implant is present in both the surgically placed and injectable FAi implants, there is less risk of elevated eye pressure that requires surgical therapy with the lower-dose injectable implant, which lasts up to three years. The study showed that participants with the FAi insert experienced

recurrence at 28% after 6 months and 38% after 12 months. In comparison, participants receiving the placebo injection experienced significant uveitis recurrence, with 91% at six months and 98% at 12 months. Jaffe notes that additional data from the threeyear longitudinal study indicate that overall uveitis recurrence rates increased after two years, when the implant starts running out of medication. Another type of injectable implant that was not part of this study uses dexamethasone to treat uveitis, but it lasts for a much shorter period of time—only six weeks—and requires repeated injections compared with the single FAi implant. In the future, Jaffe’s team plans to investigate how the implant begins to react now that it is available for general use. “Collecting information on real-world behavior of the FAi will be important because it’ll give further information on how efficacious this type of implant is and its benefits compared to that of other treatments,” Jaffe says.

Family Outside the U.S. Sought Duke Specialist To Treat a Child with Severe Neurotrophic Keratopathy

six-yearold boy from Dubai began to develop progressive vision loss. A local ophthalmologist found him to have severely diminished visual acuity, and corneal ulcers in both eyes associated with complete anesthesia (i.e., numbness) of the cornea. He was diagnosed with neurotrophic keratopathy (NK), a degenerative condition of the cornea which results from loss of corneal nerves. Despite consulting with multiple eye specialists in the region and ophthalmologists in other countries, the family could not find a doctor who could offer a definitive solution. The family was concerned that the untreated condition would result in permanent blindness. While researching treatment options, the local physician identified Ilya M. Leyngold, MD, associate professor of ophthalmology and oculofacial plastic surgery specialist, who developed a novel corneal neurotization technique to treat NK. Recognizing the child’s long-term risks, Leyngold performed

a minimally invasive procedure to harvest and reposition his adjacent sensory nerves to the surface of each eye. Less than six months after the procedure, the boy has recovered much of his corneal sensation and his vision has drastically improved. During the minimally invasive procedure, Leyngold accessed the patient’s supraorbital sensory nerves that extend up toward the hairline underneath the forehead muscle by making a small incision in the crease of the upper eyelid. “We did not have to do an interposition nerve graft in this case,” Leyngold says. “I was able to directly harvest local sensory nerves situated

above the eye and relocate them to the surface of each eye.” After the supraorbital nerves were isolated, Leyngold secured enough of the tissue to rotate it, tunneling back down through the incision to access the conjunctival tissue lining the front surface of the eye. “Essentially we sutured the end of each nerve to the sclera underneath the conjunctiva adjacent to the cornea,” he says. The restoration of nerve function allows corneal nourishment to gradually begin again. The relocated nerves release trophic protein factors, neuropeptides that help the corneal surface regenerate properly. “We are able to restore the patient’s natural ability to maintain corneal integrity,” Leyngold says. Because of the patient’s young age, his recovery occurred faster than in an adult, Leyngold says. “Now he has been able to resume his normal visual activities without the difficulties he had prior to the surgery.”

Images of the cornea before and at first post-operative appointment

Leyngold continues to monitor the patient’s condition by studying images and test results provided by the local ophthalmologist and by remaining in contact

Ilya M. Leyngold, MD Associate Professor of Ophthalmology

with the boy’s father. The last follow up appointment was close to a year after surgery. During this examination his left cornea was completely clear and the right had only mild scarring with good clarity and integrity. He was able to fix and follow appropriately with both eyes. Corneal neurotization has revolutionized the treatment of NK because it provides a definitive solution to the disease, Leyngold says. Although the concept of neurotization has been described before, Leyngold developed the minimally invasive technique to perform the procedure, reducing the morbidity and risks of the surgery. “More patients will benefit from and have access to the procedure,” he says.

First Genetic Association of Increased Risk of Glaucoma in African Ancestry Populations

rimary Open Angle Glaucoma (POAG) is the most common form of glaucoma and the leading cause of irreversible blindness worldwide. It is well known that populations of “African populations hold a African ancestry have the highest prevalence and severity of POAG, treasure trove of unexplored often leading to blindness early in life. genomic information. These Studies of POAG have primarily focused on European and Asian populations, while findings could help change African populations have been understudied the way researchers perceive and under-represented in genomic research. A genome-wide association study that included 26,295 participants—believed to be the world’s largest dataset of people of African ancestry with glaucoma—found that genetic variation among the beta-amyloid producing gene is strongly associated with increased risk of POAG in people with

glaucoma and other diseases and may provide solutions to combat disease.” Michael Hauser, PhD Professor of Medicine

African ancestry. This high risk genetic variant is common in around 20 percent of African populations but essentially absent in all other ancestral groups, according to findings published in the November 2019 issue of the Journal of the American Medical Association (JAMA). Researchers have long speculated that glaucoma and Alzheimer’s disease (AD) may share common features. This study provides the first genetic evidence that betaamyloid deposits were increased in eye and brain tissues of African ancestry patients with POAG compared to unaffected individuals. The findings indicate that it may contribute to neuronal cell death in both diseases. These results are just the beginning of many expected valuable findings. “African populations hold a treasure trove of unexplored genomic information. These findings could help change the way researchers perceive glaucoma and other diseases and may provide solutions to combat disease,” said Michael Hauser, PhD, professor of medicine in the section of medical genetics, the study’s senior author. The research to investigate the association of glaucoma among people with African ancestry was initiated more than 20 years ago by the late R. Rand Allingham, MD, Barkhouser Professor of Ophthalmology Emeritus and former chief of glaucoma, along with Hauser, his long-time colleague and friend. They traveled around the world, developing partnerships with clinicians in Ghana, Nigeria, South Africa, and The Gambia to collect blood samples from glaucoma patients. “Allingham was determined to unravel the genetic basis for glaucoma and dedicated much of his career to this work. While it’s wonderful to have this publication to support our hard work, it’s unfortunate that he is not here to celebrate with us,” Hauser says. These significant findings support Researchers responsible for identifying the genetic variation the need to better understand the among the beta-amyloid producing gene that is strongly association of African ancestry and associated with increased risk of POAG in people with African disease. “I am happy to have played ancestry. From left: Tin Aung, PhD; Michael Hauser, PhD; the late a small role in this study, but elated R. Rand Allingham, MD and C. C. Khor, PhD. that Dr. Allingham’s tireless efforts in many African countries are finally being recognized. This paper represents the acknowledgement of his life’s work,” says Leon W. Herndon, Jr., MD, professor of ophthalmology and chief of the glaucoma division. Continued investigation of African ancestry and eye disease is being extended through a National Institutes of Health grant from the Human Heredity and Health in Africa (H3Africa) program. “Eyes of Africa: the Genetics of Blindness” funds the collection and analysis of samples in Nigeria, The Gambia, Malawi, and South Africa. This research was a joint effort involving Duke University, The Kathleen Price Bryan Brain Bank, the Alzheimer’s Disease Research Center, the Genome Institute of Singapore (GIS), the Singapore National Eye Center (SNEC), Singapore Eye Research Institute (SERI), partner institutions (including the University of California San Diego and the University of California San Francisco), and other leading eye centers around the world.

Navigating Surgical Complexity in Adult Strabismus

trabismus commonly presents in children, but the prevalence of this ocular alignment condition is increasing in adults, particularly in the elderly population. For the approximately 10 million adults in the United States with this condition, their cases often require complex surgical techniques to correct.

Federico G. Velez, MD, associate professor of ophthalmology who specializes in the surgical treatment of ocular misalignment and associated diplopia, describes several innovative surgical techniques in the ever-evolving field of adult strabismus that are less invasive and more selective than traditional treatments for complex cases. In a June 2019 study published in The Journal of American Association for Pediatric Ophthalmology and Strabismus, Velez and his colleagues introduced the concepts of anterior tuck of the superior oblique, selective transposition surgery, and adjustable

Before and after using a minimally invasive strabismus technique that gives patients a higher quality of life.

selective compartmental surgery. These highly selective surgical approaches make it possible for surgeons to operate on individual eye muscles, affecting fewer blood vessels and minimizing the risk for anterior segment ischemia. “These advanced anatomical concepts show that you don’t really need to operate on the entire muscle to see results,” he says. “Doing selective surgery preserves a lot of muscle that is not touched and results in a faster surgical procedure and better surgical alignment.” Velez says that sometimes surgery is not enough to correct strabismus. The adjustable transposition surgical technique enables surgeons to adjust the final position of the rectus muscle postoperatively, when the patient is awake, fine-tuning the alignment and achieving better surgical outcomes. This technique minimizes scar tissue formation and is particularly useful in patients who have lost movement due to head trauma or neurosurgical intervention, as they are able to recover some of the movement. Additionally, for patients with comorbidities that put them at high risk for complications with the use of topical anesthesia, Velez has pioneered at Duke a minimally invasive procedure in which patients can remain fully awake with no pain. This approach enables the surgeon to assess the patient’s alignment intraoperatively and determine whether further surgery is needed. “It is becoming almost the standard

Federico Velez, MD Associate Professor of Ophthalmology

for my practice in adults over age 50 or 60, and the experience of the patients has been very positive,” he says. The implications for older adults with strabismus are significant, Velez says. “Studies have shown that many people over the age of 65 will have some kind of problem related to ocular misalignment, which creates a higher risk for falls and fractures.” These minimally invasive techniques give hope to adult patients for a higher quality of life, Velez notes. In addition to correcting the ocular misalignment, surgical treatment can minimize the psychosocial comorbidities— such as anxiety, schizophrenia, depression, and mood disorders—that often present with the condition, and the associated diplopia that inhibits patients from doing their everyday activities, he adds. “Complicated forms of ocular misalignment require universitylevel expertise to treat surgically,” says Velez. “Very few people in the country are trained or feel comfortable doing such advanced techniques, but this is an expertise we have at Duke.”

Effective Diagnosis and Treatment of Ocular Surface Disease in Cataract and Refractive Surgery Patients

Duke Cornea Specialists Contribute to new ASCRS OSD Algorithm

ailure to treat ocular surface dysfunction (OSD) prior to cataract surgery can have a significant adverse effect on surgical planning and outcomes. However, despite the poor correlation between the symptoms of OSD and objective measures of the condition, presurgical testing is not typically performed in the absence of patient-reported symptoms.

Recent findings suggest that more patients should be screened. In a 2018 study published in the Journal of Cataract & Refractive Surgery1, found that as many as 80 percent of patients who present for cataract surgery evaluation have ocular surface dysfunction. “There are a number of studies showing that ocular surface dysfunction can negatively affect outcomes at the time of cataract surgery,” explains the study’s first author, Preeya K. Gupta, MD, associate professor of ophthalmology and corneal specialist at Duke Eye Center. “We’re trying to identify who’s more likely to have this problem, and, if someone is susceptible, treat them beforehand by doing a Preeya K. Gupta, MD better job of diagnosing.” Associate Professor of The study included 120 patients from two physicians’ practices at Duke and Weill Cornell Medicine. Researchers examined several measures of OSD: slitlamp evaluation findings of the corneal surface, OSDI or SANDE questionnaire score, tear osmolarity, and tear matrix metalloprotease-9 (MMP-9) test results.

Ophthalmology

Of the 56.7 percent of patients who had no preexisting diagnosis of the condition, 81 percent had at least one abnormal tear film test.

Terry Kim, MD Professor of Ophthalmology

Interestingly, traditional methods of screening, such as looking for corneal staining or using questionnaires, failed to identify many cases of the condition. By contrast, 83 percent of patients who scored “normal” on their questionnaire had either an abnormal osmolarity or abnormal MMP-9 test (or both). These results confirm that newer point-of-care tests such as tear osmolarity and MMP-9 allow for rapid and objective assessment of the ocular surface. Based on this study and other previously published data, a new consensus-based practical diagnostic OSD algorithm has been developed to specifically address this population, aiding surgeons in diagnosing and treating visually significant OSD before any form of refractive surgery is performed. The algorithm, presented by the American Society of Cataract and Refractive Surgery (ASCRS) Cornea Clinical Committee at the 2019 ASCRS Annual Meeting2, emphasizes the use of efficient point-of-care testing for assessing OSD preoperatively. While a number of tests are available, it may not always be clear how clinicians should incorporate these tests into practice.

ASCRS Preoperative OSD Algorithm

The ASCRS Cornea Clinical Committee includes Gupta and Terry Kim, MD, professor of ophthalmology and chief of cornea, external disease and refractive surgery at Duke Eye Center.

ASCRS OSD Evaluation Recommendations

The tear osmolarity and the inflammatory marker MMP-9 tests are recommended because they are readily available and streamlined. These tests are easy and efficient and take less than a minute for a technician to do. There is value in conducting more advanced testing in patients. For example, meibography shows through an infrared image what percentage of the meibomian glands are atrophied or lost. The ASCRS SPEED II Pre-Op Questionnaire that screens for dry-eye disease and helps identify the patient’s visual needs as it relates to cataract surgery planning is The new ASCRS also recommended. Following this algorithm is important to improve patient outcomes. With cataract surgery, there are many different intraocular lens implant options, and to be successful with the premium category of technology, you really need a pristine ocular surface. By diagnosing and treating dry-eye disease properly and earlier, there is an inherent improvement in the refractive outcomes of the cataract surgery, and the patient’s satisfaction and visual quality will be higher as a result.

algorithm

will aid surgeons in

diagnosing and treating visually significant OSD before any form of refractive surgery is performed, improving

Gupta says it is reasonable to recommend that cataract surgeons cataract surgery screen all patients prior to cataract surgery. “Ocular surface dysfunction due to dry eye disease is highly prevalent, and a lot of patients are undiagnosed,” she says. “If we’re not screening for them, we’re missing the opportunity to not only help patients’ eyes feel better but also to help them see better.”

Impact of Other Ocular Surface Disorders

“Eye care providers should also be aware of other ocular surface disorders that can affect pre-operative measurements taken in cataract and refractive surgery patients,” says Kim. In another study undertaken at Duke, lead author and Duke third-year resident, Mark Goerlitz-Jessen, MD, along with Gupta and Kim, found that corneal lesions like epithelial basement membrane dystrophy and Salzmann nodular degeneration can significantly alter keratometry measurements and recommend that these lesions also be addressed prior to surgery to obtain more reliable biometry results for surgical planning.3 Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. J Cataract Refract Surg. Gupta PK, Drinkwater OJ, VanDusen KW, Brissette AR, Starr CE. 2018 Sep;44(9):1090-1096. 1

An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. Starr CE, Gupta PK, Farid M, Beckman, KA, Chan CC, Yeu E, Gomes JAP, Ayers BD, Berdahl JP, Holland EJ, Kim T, Mah FS, ASCRS Cornea Clinical Committee. 2019 May;45(5):669-684. 2

Impact of epithelial basement membrane dystrophy and Salzmann nodular degeneration on biometry measurements. J Cataract Refract Surg. Goerlitz-Jessen MF, Gupta PK, Kim T. 2019 Aug; 45(8): 1119-1123. 3

Opposite page: The ASCRS preoperative OSD algorithm developed by the ASCRS Cornea Clinical Committee. Abbreviation Glossary: (ADDE = aqueous-deficient dry eye; CL = contact lens; DED = dry-eye disease; EBMD = epithelial basement membrane dystrophy; EDE = evaporative dry eye; IOL = intraocular lens; LLPP = Look, Lift, Pull, Push; LLT = lipid layer thickness; LRI = limbal relaxing incisions; LVC = laser vision correction; MGD = meibomian gland dysfunction; MMP-9 = matrix metalloproteinase-9; NI-TBUT = noninvasive tear breakup time; NVS-OSD = nonvisually significant ocular surface disease; OCT = optical coherence tomography; OSD = ocular surface disease; OSI = ocular scatter index; SPEED = Standard Patient Evaluation of Eye Dryness; TBUT = tear breakup time; TMH = tear meniscus height; VS-OSD = visually significant ocular surface disease).

outcomes.

18 Artwork by Paris Alexander

Still Rockin’

BY LAURA ERTEL

Sculptor Captures His Own Experience with Eye Disease

hen Paris Alexander’s vision started feeling a bit off four years ago, he thought he’d gotten a shard of stone in his eye. As a sculptor, that’s a hazard of the trade. But when the visual distortion didn’t subside, Alexander went to an ophthalmologist, where he got some surprising, disheartening news: The Raleigh artist was diagnosed with wet macular degeneration. “At first I was terrified,” he recalls. “Particularly as a visual artist, I thought this would be a ‘death sentence’ for me. But before I became a full-time artist, I had been a research specialist at the Duke Cancer Center, and I knew that people come to Duke from all over the world. So I immediately made an appointment with [retinal specialist] Michael Allingham, MD, and he started treating me right away to keep the abnormal blood vessel which causes the disease from growing or bleeding. “If I had waited to start treatment, I could be blind in one eye right now,” Alexander believes. “But because of Dr. Allingham’s quick action, as well as

ongoing monitoring and treatment, we’ve been able to keep the disease progression at bay for four years now, and Dr. Allingham tells me I should have many more years of normal sight. I am very fortunate that right now the disease has only manifested in one eye, and my vision is still 20/20 with my regular glasses.” Alexander goes to the Duke Eye Center of Cary, right near his home, for his monthly treatments. “I feel like I’m in really good hands,” he says. “If something like this had to happen to me, this is the best place for it to happen.” As a result of his early diagnosis and treatment, Alexander is able to pursue his craft unabated. His works have been exhibited in galleries, universities, hospitals, private residences, and museums around the world, with numerous public and private commissions. He is a long-time artist-in-residence at the North Carolina Museum of Art and teaches art classes for adults and children with and without vision challenges.

Michael Allingham, MD Assistant Professor of Ophthalmology

Alexander has created a sculpture based on his experience with macular degeneration. The two-sided piece, titled Prima Facie (Latin for “at first sight”), conveys the message that what you see at first might not be the whole picture. “I like to have little surprises in my work,” Alexander notes. “For this sculpture, on one side you see what looks like a normal eye. But on the other side, you see my eye under attack from these blood vessels trying to work their way into where they shouldn’t be.”

Prima Facie is currently on display in Alexander’s downtown Raleigh gallery. The sculptor hopes it will bring comfort to others who find themselves in a similar position. “I hope they realize they are not alone, and the situation might not be as dire as they initially fear.” “I love how Paris has captured his experience with macular degeneration through his art,” Allingham says. “He is a great example of how, if we can catch this disease at an early stage, we can preserve good vision and give people many more years of sight. His story shows how important an eye exam can be and how impactful treatment is for our patients.”

Alexander and Allingham during a follow up visit.

Locations 1 2 3 4 5 6 7 8 9 10

2019 Stats

Main Duke Eye Center Duke Medical Center Campus Page Road South Durham North Durham Cary

Plastics 8,563

Raleigh Winston-Salem

Neuro

Holly Springs

3,340

NC Eye Ear Nose and Throat (NCEENT)

Low Vision/ Vision Rehab

Pediatric

23,162

2,181

Arringdon (Winter 2020)

Glaucoma

Faculty, Trainees and Staff

428

health staff

clinical physicians

23 ophthalmology fellows 19 16 residents research scientists

52,915

Duke Eye Center NIH Funding Ranking

Retina

(2018)

41,600

14,783 Surgeries

Total Patients

203,685

Totalawarded NIHinGrants 2019

Comprehensive

38,228

Award Funding

Cornea

$16,896,560

33,696

Ranking

US News & World Report Best Hospitals in Ophthalmology

$10,415,340 Federal

$6,481,220 Non-Federal

Our Immune System Can “See” 22

cientists have known for many years that immune cells are in the retina and that their numbers increase in inherited retinal diseases. This increase is also observed in age-related macular degeneration (AMD) that affects millions of people in the U.S. alone.

This study reveals that the immune system is actually needed to help nerve cells in the retina respond appropriately for vision.

A new finding from a research team led by Daniel Saban, PhD, associate professor of ophthalmology, suggests that immune cells that protect us from infection might also help us see, in a study published in the journal Immunity. This study reveals that the immune system is actually needed to help nerve cells in the retina respond appropriately for vision.

The research also showed that these same exact immune cells, called microglia, also protect the retina in inherited diseases that cause blindness in mice.

This work may lead to a new understanding for the causes of vision loss in such inherited retinal diseases in patients, which affects several million worldwide. “Microglia are traditionally thought of in terms of protecting nerves from infection,” says Saban, senior author of the paper. “However, scientists are now appreciating that these immune cells also play key roles in supporting the function of nerves even when there is no infection present.”

The precise identity of these immune cells in the disease setting was unknown. Microglia are easily mistaken for another immune cell type that can come in from the blood, called monocytes. Also unclear in the field is whether these immune cells in retinal disease are part of a problem, or rather are perhaps acting in some protective manner against the disease. These questions are important as immune cells accumulate next the critical layer in disease, called the retinal pigmented epithelium. Deterioration of this layer is thought to be a major cause of vision loss in AMD. “Our study shows that microglia, not monocytes, accumulate next to the retinal pigmented epithelium in the diseases we tested in mice,” states one of the lead authors of this study, Chen Yu, PhD, postdoctoral associate in Saban’s lab. “In addition, we found that these microglia actually protect this layer.”

Since scientists are focused on trying to find out why the retinal pigmented epithelium deteriorates in AMD and how it can be protected to halt disease, these new findings may offer clues to the field.

Daniel Saban, PhD Associate Professor of Ophthalmology

The next steps for Saban’s team is to understand exactly how microglia protect this layer in disease and whether this system can be hacked for therapeutic purposes in retinal degenerative diseases The research was supported in part by BrightFocus, National Eye Institute/National Institutes of Health, and Research to Prevent Blindness.

Application of single cell RNA sequencing to understand the role of immune cells in retinal degenerative disorders. Image depicts our work flow, including enrichment of immune cells, RNA sequencing at the single cell level, bioinformatic analysis to identify novel subtypes of immune cells, and validation in tissues. This work identified a unique microglial subtype that restricts the progression of retinal degeneration.

Seeing the Future Through a Transformative Pledge BY JIM ROGALSKI

The blurred vision came without warning. “While on a trip in Europe, suddenly I couldn’t read the newspaper. It was like looking through tears,” remembers Elizabeth “Robin” Ives Hamme of Flat Rock, North Carolina.

Gene and Elizabeth “Robin” Ives Hamme

nce home, her long-time retinal cells, which provides enhanced ophthalmologist referred her neuroprotection to the retina. to a macular degeneration He also was able to offer a bit of hope specialist who, after in the form of a clinical trial he will examination, told her bluntly that she start soon. likely suffered from Stargardt disease, she would become blind over time, and “The trial is called SeaSTAR and will use an oral drug that will affect the there was nothing anyone could do to way the retina uses and recycles help her. vitamin A,” Iannaccone says. “It’s hoped “I was blown away and in utter shock,” that this medication will reduce the she says. “And I thought to myself, accumulation of a toxic compound that ‘That’s not good enough. I want a leads to Stargardt disease.” referral to Duke.’ ” Hamme says she is impressed with At Duke Eye Center she met Iannaccone’s steadfast commitment to Alessandro Iannaccone, MD, MS, finding a cure for her disease. FARVO, director of the Center for Retinal Degenerations and Ophthalmic “Every time something new comes up he’s right on top of it,” Hamme Genetic Diseases. says. “His care, thoroughness and “The first question I had for him was, compassion are not only first-rate, but ‘Am I going to go blind, when and how?’ ” he is really committed to discovering Hamme says. solutions.” “The first step was to confirm the Which is why she and her husband, diagnosis which was a complex Gene, have made a significant pledge process,” Iannaccone says. “Additional through their estate to establish testing also revealed a supplemental an endowment for hereditary and issue with the function of the degenerative retinal disease in the mitochondria—the energy machinery Duke Department of Ophthalmology. of our cells—and helped point in that “This planned gift is not about me,” direction. Ultimately, further testing she says. “I believe so completely did confirm the molecular diagnosis of that Dr. Iannaccone and his group Stargardt disease.” are worthy of being invested in so Once this was confirmed, Iannaccone they can help others in the future. He told her, ‘You’re not going to go blind. has a wonderful phrase about taking The greatest risk is losing central vision research from the bench to bedside, but not peripheral vision.’ “ He told her and I think that’s so important. He’s she was at risk of becoming legally blind working in real time to make advances.” but still able to see. Iannaccone says gifts like the Hamme’s Stargardt’s disease in its typical form is are crucial to allowing himself and inherited from each of the parents, who the mere handful of other retinal are unaware healthy carriers. It typically degeneration researchers throughout affects children and teens, but in many the country to pursue the discovery, instances can present as a late-onset and development of, treatments and form that will appear much later in cures for these incapacitating disorders. life. While there currently is no cure, “Their generosity will help to ensure Iannaccone has been treating Hamme that our center has the longevity and with a variety of dietary supplements future ability to foster and develop that help to maintain the function promising research,” he says. “We are of her photoreceptors and, in her very grateful.” special case, the mitochondria in her

Alessandro Iannaccone, MD, MS, FARVO Professor of Ophthalmology

“I believe so completely that Dr. Iannaccone and his group are worthy of being invested in so they can help others in the future. He has a wonderful phrase about taking research from the bench to bedside, and I think that’s so important.”

Faced With Vision Loss, Young Man Bets On Himself Duke Vision Rehab Program Helps Patients Regain Independence BY LAURA ERTEL

U 26

ntil age 18, Zeeshan Polani had perfect vision. Then suddenly, during his first year in college, he lost central vision in his left eye. The right eye soon followed. Doctors were perplexed. It wasn’t until a genetic test was performed that Polani was diagnosed with a rare disease called Leber’s hereditary optic neuropathy (LHON). Within months, Polani’s vision plummeted from 20/20 to 20/800. Suddenly, the active, upbeat, independent college student found himself legally blind from a disease for which there is no known treatment.

guidance of Division Chief, Diane B. Whitaker, OD, he gained strategies and tools to navigate the world with limited sight. “I knew I couldn’t let this defeat me; I had to keep moving,” Polani says. “I just told myself, ‘I’m going to figure this out.’”

Polani, a Durham native, withdrew from school. There were so many questions: How would he get to class, see the blackboard, read his textbooks? How could he find new ways to learn, when the traditional classroom setting didn’t meet his needs? How could he be a normal college student? Fortunately, Polani found his way to the Duke Vision Rehabilitation & Performance Division where, with the

Zeeshan Polani became legally blind after being diagnosed with Leber’s hereditary optic neuropathy (LHON) at the age of 18, during which he received care from Diane Whitaker, OD where he gained strategies and tools to navigate the world with limited sight.

Whitaker told Polani about a scholarship program for visually impaired students and helped him secure funding and re-enroll at North Carolina Central University. She and the Vision Rehab team set Polani up with a desktop digital video magnifier and handheld magnifiers and showed him how to use accessibility tools on his laptop to read his professors’ PowerPoint presentations and textbooks. Polani got additional assistance from NCCU’s Student Disabilities Service, and helped the school improve its resources for visually impaired students. An avid basketball player before LHON struck, he figured out how to play basketball again by relying on muscle memory and trial and error. “Dr. Whitaker said, ‘Here is the pathway to get you where you want to go.’ She showed me how I could live a normal life again,” he says. Four years after receiving his diagnosis, Polani graduated from NCCU. Although Within months, he was still legally blind, his vision Polani’s vision began creeping plummeted from back gradually. This type of 20/20 to 20/800. spontaneous Suddenly, the active, remission is very rare, and nearly upbeat, independent unheard of in college student found patients with his particular genetic himself legally blind mutation. Today, Polani’s vision has from a disease for improved to 20/25, which there is no and the Duke Vision Rehab team known treatment. is helping him resume driving safely after six years of visual impairment. “Our mission is to support those experiencing any stage of vision loss by equipping and empowering them so they can maintain their independence and participate in life in a meaningful way,” Whitaker says of the Vision Rehab Division, which also raises awareness about resources and advancing technologies available to the blind/visually impaired community. “Zeeshan is a wonderful example of the functional independence all of our patients experience, even if sight is not restored.”

Zeeshan at the driving simulator after regaining his sight. The driving simulator is one of many tools available in the Duke Vision Rehabilitation and Performance Clinc to assist in functional assessment.

Polani now works as a toxicologist, but his ultimate plan is to earn a master’s degree in health care administration and become a hospital administrator. “I’ve been through the health care system, and I see some of the flaws and I know how things should be. I’d like to get into a position where I can enact positive change.” His experience has inspired him to help others in his community, both through NCCU Student Disabilities Services and as a leader in a local service-based organization. Polani doesn’t know what the future will hold for his vision, so he is living one day at a time. “It’s all about perspective, appreciating the little things that others take for granted. God will only test you with things that you are uniquely able to handle. I’m very grateful for my family and friends, who have provided the love and support to help me through this. And I’m thankful for where I am, and I always bet on myself to handle what comes my way.”

New Faculty Yousef Aldairy, MD, is a Harvard and Duke fellowshiptrained retina specialist with expertise in the diagnosis and Aldairy treatment of condiRetina tions such as AMD, diabetic retinopathy, and retinal vascular diseases. Trained in the interpretation of retinal vascular imaging techniques, he specializes in the use of these imaging studies to guide injection and laser-based treatment of disease. He is involved in clinical trials and innovative therapies for the treatment of macular diseases and has special interest in advanced ocular imaging, specifically optical coherence tomography angiography.

Aldairy is a member of the American Society of Retina Specialists, American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology. Brad Barnett, MD, PhD, is a cornea surgeon who treats patients with cataracts, corneal diseases and ocular surface diseases Barnett such as dry eye Cornea disease. He focusses on developing novel therapeutics and drugdelivery strategies to treat ocular surface disease, as well as novel devices and surgical procedures to advance the effectiveness and safety of keratoplasty and cataract extraction and intraocular lens implantation. He is an inventor on numerous awarded patents and numerous pending patents and has extensively published in the fields of nanotechnology, biomaterials and pharmacology including manuscripts in Science and Nature Medicine. He was awarded a Howard Hughes Medical Fellowship, a Pfeiffer Foundation Fellowship

and the Claes Dohlman Fellowship. Barnett has received the Wilmer Eye Institute Richard Green Teaching Award and has also authored numerous book chapters on surgical technique and clinical imaging. Chantel Boisvert, MD, OD, received her medical degree from Laval University School of Medicine and completed Boisvert Chief, Neuro- her residency in ophthalmology ophthalmology at the University of Montreal Hospitals. She then completed two fellowshipsâ&#x20AC;&#x201D;one in pediatric ophthalmology and strabismus at UCSD Shiley Eye Center and the other in neuroophthalmology at USC Doheny Eye Center. Prior to joining Duke, she was associate clinical professor and director of medical education in ophthalmology at UCI Gavin Herbert Eye Institute. Her clinical interests include pediatric and adult neuro-ophthalmology and the evaluation and treatment of double vision. Boisvert has collaborated with neuroscientists and clinicians on research projects. She has extensive experience in the evaluation and treatment of refractive error and visual field assessment in non-human primates, some of her work has been presented to national veterinary medicine conferences. She has also collaborated on many different clinical trials involving the nervous system. Durga Borkar, MD, is a board-certified, fellowship-trained adult vitreoretinal surgeon. She completed her undergraduate Borkar and medical Medical Retina, school training Vitreoretinal at Northwestern Surgery University. After a general ophthalmology at Harvard Medical School-Mass Eye and Ear

Infirmary, she completed her vitreoretinal surgery fellowship at Wills Eye Hospital. Durgaâ&#x20AC;&#x2122;s practice is focused on injection and laser-based treatment of retinal disease in the clinic, as well as complex surgical cases in the operating room. She specializes in diabetic retinopathy, macular degeneration, retinal vascular occlusion, macular edema, macular holes, epiretinal membranes, vitreomacular traction, secondary intraocular lens placement, and complex retinal detachments, among others. She has co-authored over 50 peer-reviewed publications and several book chapters early in her career. She is the recipient of several awards for her excellence in research and clinical care, including the Heed Foundation Fellowship, the Society of Heed Fellows Award, and the AAO Advocacy Ambassador Award. Roshni RanjitReeves, MD, is an oculofacial surgeon. She completed a prestigious and rigorous Ranjit-Reeves fellowship training Oculofacial program at the Surgery Duke Eye Center after completing her ophthalmology residency in Tampa, Florida. She specializes in plastic surgery and reconstruction of the eyes and their surrounding structures including the eyelids, orbit, eye socket and lacrimal system. She is trained and well versed in laser and cosmetic surgery of the skin, injectable fillers, and neurotoxin for facial rejuvenation. In addition to performing aesthetic surgery on the skin to improve skin texture and reverse photo-aging with laser skin resurfacing, she also performs minimally invasive anti-aging procedures for facial rejuvenation such as injectable fillers and neurotoxins. Her academic interests include chemical properties of fillers

and neurotoxins and treatment regimens for skin of color. In addition to many peer-reviewed publications in aesthetics and orbital surgery, she has completed an ASOPRS thesis in carbon dioxide (CO2) periocular laser rejuvenation and hyperpigmentation trends with lower lid blepharoplasty. She has presented and served as a panel member and speaker at national meetings. Rosh is the oculofacial provider at Duke Eye Center of Winston-Salem. Joanne Wen, MD, is a board certified, Duke fellowshiptrained ophthalmologist specializing in the medical and surgical treatment Wen of glaucoma and Glaucoma and Cataracts cataracts. She is highly skilled and experienced in cataract and glaucoma surgery as well as anterior segment laser procedures. She has a variety of research interests including

using novel imaging techniques to diagnose glaucoma and developing new methods to measure eye pressure and the outflow facility of the eye. Wen is an active member in the American Glaucoma Society, American Academy of Ophthalmology and the Association for Research in Vision and Ophthalmology and has presented at a number of national conferences. Lloyd Williams, MD, PhD, is a fellowship-trained corneal ophthalmologist specializing in medical and surgical diseases of the Williams cornea and anterior Cornea segment of the eye. He completed a bachelor’s and master’s degrees in materials science and engineering. After doing medical research as an engineer, he went on to complete a master’s degree in physiology and a doctorate in neuroscience. Williams performs corneal transplants

including DSEK for corneal transplantation and cataract surgery including astigmatism and presbyopia correcting intraocular lenses and lens exchange. He also performs vision correction surgery and other anterior segment surgery including pterygium and conjunctival surgery. Williams is a member of the American Academy of Ophthalmology, the American Society of Cataract and Refractive Surgeons. Williams continues to be active in international ophthalmology and humanitarian work. He is the founder and chairman of the board of HelpMercy International and a founder of the MoranCore ophthalmology educational website.

DUKE EYE CENTER CONTINUES EXPANSION OF SATELLITE CLINICS

n recent years, Raleigh, Durham, Chapel Hill—also called the Triangle region—and surrounding areas have experienced exponential growth, with more than 113,000 people moving to North Carolina between 2017 and 2018. The area has also been ranked in the top 10 for best place to raise a family, live, work, and retire—the Triangle is a great place to be. It is with no surprise that Duke Eye Center treated more than 200,000 patients last year, a record-breaking number for the clinics. As a result, Duke Eye Center has set its focus on clinic expansion. To better serve the residents in the Triangle and beyond, a new Duke Eye Center clinic opened in Holly Springs, welcoming eight new faculty members to the team. Duke Eye Center of Winston Salem added new providers, and we look forward to opening a new expanded clinic in the Research Triangle Park area later in 2020. In addition, NC Eye Ear Nose

and Throat joined Duke Health in April 2019 helping to expand our ability to serve additional patients in our area. As North Carolina’s population growth continues to outpace the nation, Duke Eye Center will continue its efforts to meet the needs of the increasing patient population locally and beyond.

S. Grace Prakalapakorn, MD, MPH (left) with colleagues and the Orbis Flying Eye Hospital in Hue, Vietnam. Photo by Geoff Oliver Bugbee/Orbis

Duke Eye Center News and Notes 2020 GLOBAL MISSIONS S. Grace Prakalapakorn, MD, MPH, participated in an Orbis mission trip in Hue, Vietnam, where she conducted a Pediatric Ophthalmology Workshop as part of a three-week flying eye hospital program. The Orbis Flying Eye Hospital, once a cargo plane, is used as a teaching facility where doctors, nurses and medical technicians have received training onboard from some of the best ophthalmologists, nurses and biomedical engineers in the world. Prakalapakorn also volunteered through the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) Faculty Exchange program with partner hospital Tianjin Eye Hospital in Tianjin, China. She spent time lecturing, seeing patients and held hands-on workshops for local pediatric ophthalmologists.

S. Grace Prakalapakorn, MD, MPH

Leon W. Herndon, Jr., MD

Faramarz Hidaji, MD

Lloyd Williams, MD, PhD

Leon W. Herndon, Jr., MD, participated in a Cure Glaucoma Foundation Medical Mission trip in Lagos, Nigeria in Feb, 2019. The team lectured to over 100 ophthalmologists, and performed more than 100 glaucoma surgical procedures. Faramarz Hidaji, MD, recently completed a mission trip with Healing the Children in the Dominican Republic where 25 strabismus surgeries were performed. Lloyd Williams, MD, PhD, continues to be active in international ophthalmology and humanitarian work. He is the founder and chair of the board of HelpMercy International. HelpMercy International is focused on bringing light to the world through curing blindness in Sierra Leone and bringing clean water and health care to Manâ&#x20AC;&#x2122;Gunza Zambia.

DUKE CHOSEN AS LEAD SITE FOR APELLIS PHASE 3 STUDY

uke Eye Center was named the lead site for the phase III Apellis APL2-304 study of intravitreal APL-2 therapy in patients with geographic atrophy secondary to age-related macular degeneration, a study of 300+ patients to be enrolled at 53 international sites. Eleonora Lad, MD, PhD, will serve as the lead primary investigator (PI) for the trial. Duke was chosen due to the unique expertise amoung our faculty in visual function assessments for clinical trials of AMD.

Eye Center 27 Duke current interventional

trials Phase 1 trials opened in the last 3 years

FACULTY PARTICIPATE ON NATIONAL ADVISORY EYE COUNCIL FOR AMD RECOMMENDATIONS Catherine Bowes Rickman, PhD, professor of ophthalmology and Cynthia Toth, MD, Joseph AC Wadsworth professor of ophthalmology, were invited to participate in the AMD Pathobiology National Advisory Eye Council (NAEC) Working Group to investigate the current state of research on age-related macular degeneration (AMD), guide research directions, and expedite the development of new treatments. The ideas proposed by the panel were published in Nature Communications and suggests large-scale, integrated collaboration of leading clinicians, imaging experts, a wide variety of basic scientists, bioinformaticians and biostaticians. The experts also recommend creating a large biorepository of eye tissue from donors with and without AMD, generating multiple types of â&#x20AC;&#x2DC;omics data from disease and normal eye tissue, and designing computer models of the disease along with animal models.

Leon W. Herndon, Jr., MD, delivering the 2019 American Glaucoma Society (AGS) Surgery Day Lecture.

Catherine Bowes Rickman, PhD

Cynthia Toth, MD

Duke Eye Center News and Notes 2020

Duke Eye Center 2019 NIH Grants:

Duke Ophthalmology Faculty who have received Research to Prevent Blindness (RPB) Career Development Awards participated in RPB’s 30-year celebration of the award during the 2019 ARVO annual meeting. (L-R) Alessandro Iannaccone, MD, MS; Vadim Arshavsky, PhD; Catherine Bowes Rickman, PhD; Daniel Stamer, PhD; Vasantha Rao, PhD; Xi Chen, MD, PhD

DUKE OPHTHALMOLOGY EXPANDS INTERNATIONAL EDUCATION PROGRAM

ver the last year, Duke Ophthalmology faculty have led educational sessions at international society meetings and hosted international colleagues at Duke Eye Center—also called the Conference Exchange. One of our first outreach efforts includes a group of 10 faculty leading sessions in The Colombian Society of Ophthalmology—DUKE 2019 Course in Bogota, Colombia to share their knowledge and experiences with Latin American colleagues in various subspecialties of ophthalmology. The event featured Duke renowned ophthalmologists: Edward G. Buckley, MD; Scott W. Cousins, MD; Preeya K. Gupta, MD; Terry Kim, MD; Ilya Leyngold, MD; Felipe Medeiros, MD; Victor Perez, MD; S. Grace Prakalapakorn, MD, MPH; Federico Vélez, MD.

DUKE EYE CENTER OPHTHALMIC TECHNICIAN PROGRAM A GREAT CAREER IN LESS THAN A YEAR

he Duke Ophthalmic Technician Program is an affordable, accelerated 51-week certificate program with tremendous advantages and career advancement opportunities. High school graduates interested in an allied health career are encouraged to apply. Program Benefits:

 Ethan Ames with Sharon Freedman, MD



FREEDMAN PATIENT GIVES BACK



than Ames, a resident of Holly Springs, NC, and longtime patient of Sharon Freedman, MD, professor of ophthalmology and chief of the pediatrics division, chose to give back to Freedman and Duke Eye Center pediatric patients by donating eye patches to the clinic.



Ames was diagnosed with a pediatric cataract at the age of one. Freedman performed cataract surgery and subsequently six more surgeries over the next 17 years.

Ames chose to give



Certificate from Duke University School of Medicine Clinic rotations after 3 months of classroom time Hands-on experience in a fast-paced environment at a top ranked eye center Outstanding career advancement opportunities More than 90 percent of graduates placed within one month of graduation

We now offer two sessions! Application Deadlines: April 30, 2020 for July 2020 start October 31, 2020 for January 2021 start

back to what he calls “my amazing doctor, Sharon Freedman at Duke” for his senior project.

He chose to give back to what he calls “my amazing doctor, Sharon Freedman at Duke” for his senior project. His aim was to find a way to help children and families that are experiencing a financial burden due to surgeries and treatments. With the help of family and friends, Ames collected almost 100 packages of eye patches that are given to pediatric patients in need during their visit.

Visit dukeeyecenter.duke.edu/optech for more information.

Honors and Awards Sanjay Asrani, MD, received a Senior Achievement Award from the American Academy of Ophthalmology (AAO) this year. He also received a U.S. patent for a device to lower eye pressure. Edward Buckley, MD, will become Chair of the American Ophthalmology Society Council in 2020. He gave the 4th Kushner Medal Lecture and the 16th Annual American Eye Study Club Foundation Jerry and Donna Knauer Lecture.

Jiaxi Ding, MD, received an Achievement Award from the American Academy of Ophthalmology (AAO). Laura Enyedi, MD, received a 2019 Women in Ophthalmology (WIO) Mentorship Award. She was also named section editor of the AAO ONE Network for pediatric ophthalmology and strabismus. Sina Farsiu, PhD, was elevated by the Institute of Electrical and Electronics Engineers (IEEE) to an IEEE Fellow for contributions to multi-frame super resolution and ophthalmic image processing. Sharon Fekrat, MD, and Dilraj Grewal, MD, are among the first group of researchers whose proposal was

Dilraj Grewal, MD, U.S. Senator Susan Collins, and Sharon Fekrat, MD, at her invited presentation to the Senate Committee Special Committee on Aging in April 2019.

selected for funding through the Alzheimer’s Drug Discovery Foundation’s (ADDF) Diagnostics Accelerator. They will be evaluating multimodal retinal imaging in the diagnosis of Alzheimer’s disease and incorporating deep learning.

Leon W. Herndon, Jr., MD, was named by the dean of Duke University School of Medicine to chair the Department of Neurology’s 5-Year Review Committee.

Dilraj Grewal, MD, received a Senior Achievement Award from the American Academy of Ophthalmology (AAO). He was invited to speak at the Royal College of Ophthalmologists Annual Congress 2019 in Glasgow, UK, in May 2019.

Ilya Leyngold, MD, was promoted to associate professor of ophthalmology. He received the add American Society of Ophthalmic Plastic and Reconstructive Surgery before (ASOPRS) Research Award for the most outstanding original research paper of the year.

Preeya Gupta, MD, was named an emerging leader in The Ophthalmologist Power List 2019. She serves on the American Society of Cataract and Refractive Surgery (ASCRS) Corneal Clinical Committee.

Eleonora Lad, MD, PhD, was inducted into the prestigious Retina Society during the invitation-only, 2019 Annual Meeting. She was selected as Faculty for the Heed Society resident retreat. Lad was invited to serve on the Federal Drug Administration’s Ophthalmic Imaging Collaborative Community >

Duke Ophthalmology 2020 Events Controversies in Cornea and Cataract Surgery Saturday, February 22, 2020 Keynote Speaker: Richard L. Lindstorm, MD Professor of Ophthalmology, University of Minnesota, Minneapolis 6th Annual Fellows Advanced Vitreoretinal Surgery Course (fAVS) and Wetlab Friday, April 17 and Saturday April 18, 2020 Vision Quest Duke OpTech continuing education program May 2, 2020 Resident and Fellows Scientific Symposium Friday, June 5-6, 2020 Keynote Speaker: Todd P. Margolis, MD, PhD Alan A. and Edith Wolff Distinguished Professor and Chairman, ophthalmology and visual sciences Washington University Physicians 4th Annual Glaucoma Fellows Course Saturday, September 26, 2020 32nd Annual Glaucoma Symposium Saturday, September 26, 2020 Grand Roundsâ&#x20AC;&#x201D; now streamed liveâ&#x20AC;&#x201D; dukeeyecenter.duke.edu/ grandrounds April 14, 2020 April 23, 2019 May 7, 2020 Duke Community Events for Optometrists March 6, 2020 April 6, 2020 September 14, 2020 November 2, 2020 Visit dukeeyecenter.duke.edu for more information.

Honors and Awards group, which will identify and clarify important challenges, best practices, strategies and standards, and advance innovation for ophthalmic imaging. Goldis Malek, PhD, earned Association of Research and Vision in Ophthalmology (ARVO) Gold Fellow. She is serving as the Chair for the Retinal Cell Biology section of the ARVO Annual Meeting Program Committee (AMPC). Malek was invited to join the Foundation for Fighting Blindness Scientific Advisory Board. Miguel Materin, MD, received a Senior Achievement Award from the American Academy of Ophthalmology (AAO).

Prithu Mettu, MD, received The American Society of Retina Specialists (ASRS) Poster Award for the study, “Effects of the Mitochondria-Targeted Drug Elamipretide on LeakageIndependent Vision Loss in Fellow Eyes with Neovascular AMD in the ReCLAIM Study.” S. Grace Prakalapakorn, MD, MPH, received an Achievement Award from the American Academy of Ophthalmology (AAO). Daniel Saban, PhD, was appointed to the Editorial Board of the journal Cornea. He will give a keynote lecture at the Tear Film and Ocular Surface Society 2020 Conference. He

DUKE EYE CENTER

2018

2019 Faculty Promotions Mays A. Dairi, MD Associate Professor of Ophthalmology with Tenure Laura Enyedi, MD Professor of Ophthalmology Ilya Leyngold, MD Associate Professor of Ophthalmology Lejla Vajzovic, MD Associate Professor of Ophthalmology Robin R. Vann, MD Associate Professor of Ophthalmology

was also selected to receive a Research to Prevent Blindness (RPB) International Research Collaborators Award. W. Daniel Stamer, PhD, is the 2019-2020 ARVO president. He co-organized the 2019 International Society for Eye Research/BrightFocus Foundation Glaucoma Symposia, Atlanta, Georgia and was Keynote Lecturer for 2019 Translational Research Day, Moran Eye Center, Salt Lake City, Utah. Heather E. Whitson, MD, MHS, has been appointed deputy director of the Center for the Study of Aging and Human Development at Duke University. She is committee chair of the newly formed advisory committee for the Center for Vision and Population Health at Prevent Blindness (CVPH).

Trainee Awards Maria GomezCaraballo, BS, MS3, received the Duke Physician Scientists Institutional Award for her second third year of research in the lab of W. Daniel Stamer, PhD. Mark GoerlitzJessen, MD, PGY4, received the Best Paper of Session (BPOS) Award at the American Society of Cataract and Refractive Surgery (ASCRS) 2019 annual meeting for his paper, “The Impact of Epithelial Basement Membrane Dystrophy and Salzmann Nodular Degeneration on Biometry Measurements” in the session Pterygium, Salzmann’s, and Neoplasia.

Heed Fellows

Four Duke vitreoretinal surgery fellows and a glaucoma fellow have been named Heed Fellows. The Heed Society of Fellows provides funding to talented young ophthalmologists who are pursuing postgraduate fellowship training. Next page, clockwise from top left:

2019–2020 RESIDENTS

Kim to Become Next President of ASCRS Terry Kim, MD, will serve as president of the American Society of Cataract and Refractive Surgery (ASCRS) and will be inducted during the annual ASCRS Meeting in May 2020. As an internationally recognized cornea, cataract and refractive surgeon, Kim was invited to give the Rising Sun Lecture at the 32nd Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS) Meeting in Kyoto, Japan, as well as the Keynote Lecture for the 113th Korean Ophthalmology Symposium in Seoul, Korea.

   

Frank

Brodie, MD, MBA Cai, MD Ang Li, MD Katy Liu, MD, PhD Sophie

Society (AGS) at the 2019 mid-year forum. She was also selected to receive a Mentoring for the Advancement of Physician Scientists (MAPS) award.

VitreoRetinal Surgery Foundation (VRSF) Research Awards

Heed Resident Retreat Recipients

 

Jane

Kim, MD, PGY4 (below left) Ellis Wisley, MD, MBA, PGY4

Five Duke trainees have earned the 2019 VitreoRetinal Surgery Foundation (VRSF) Research award. This distinguished award includes grant support for research and travel funds for presentations at national meetings. Recipients were mentored by Lejla Vajzovic, MD, Sharon Fekrat, MD, FACS, and Dilraj Grewal, MD. Below, clockwise from top left:  Sophie Cai, MD, vitreoretinal surgery fellow  Suzanne Michalak MD, PGY3  Arathi Ponugoti, BS, MS3  Anthony Therattil, BS, MS3  Ellis Wisely, MD, MBA, PGY4

Henry Feng, MD Chief Resident

Third-Year Residents

Faith Birnbaum, MD Mark Goerlitz Jessen, MD Jane Kim, MD Nikolas Raufi, MD Obinna Umunakwe, MD, PhD Ellis Wisely, MD, MBA

Second-Year Residents

Pam K. Bhullar, MD Cassandra Brooks, MD Abhi Gudru, MD Suzanne Michalak, MD Matthew O’Sullivan, MD, PhD Michael Quist, MD

First-Year Residents

Amal Al-Lozi, MD Regina de Luna, MD Hesham Gabr, MD Priya Gupta, MD Kevin Jackson, MD Xinxin (Steph) Zhang, MD

2019–2020 CLINICAL FELLOWS Cornea

Andrew R. Davis, MD Nandini Venkateswaran, MD

Glaucoma

Lindsay E. Dawson, MD Matt Duggan, MD Jaehong Han, MD J. Minjy Kang, MD Ang Li, MD Katy Liu, MD, PhD Atalie Thompson, MD, MPH

Medical Retina

Kishan Govind, MD Joon-Bom (Albert) Kim, MD Marilyn Marquez, MD

Oculofacial

Anna Ginter, MD Leon Rafailov, MD - Plastics

Ophthalmic Oncology

Abbas Haider, MD, MBA

Pediatrics

Atalie Thompson, MD, MPH, had the highest ranked application for the AAO Advocacy Ambassador program and represented the American Glaucoma

Lucas Bonafede, MD Tanya Glaser, MD Michelle Go, MD, MS Megan X. Law, MD

Vitreoretinal Surgery Frank Brodie, MD, MBA Cindy Cai, MD Sophie Cai, MD Ananth Sastry, MD

Honors and Awards

ARVO President Reflects on Goals and Accomplishments W. Daniel Stamer, PhD, FARVO, began his one-year term as the Association for Research in Vision and Ophthalmology (ARVO) president at the commencement of the 2019 Annual Meeting in Vancouver. ARVO is the largest and most respected eye and vision research organization in the world, serving nearly 12,000 researchers from over 75 countries. Stamer also has been serving as the ARVO Physiology/ Pharmacology Section Trustee since 2015. He reflects on his career and why being involved in both basic and preclinical research has been significant to him. Get a glimpse into his professional background and his vision for ARVO during his tenure as president.

DUKE EYE CENTER

2020

What research or projects are you currently working on? For the past 25 years, I have been investigating and learning about the molecular mechanisms that regulate intraocular pressure. During the course of these investigations, I have also spearheaded the development of useful cell, organ and animal models to identify novel targets and test new therapeutics for glaucoma. I am fortunate that my research is both basic science and preclinical, enabling me to work closely with both academic and industry collaborators toward a common goal of bringing new treatments to patients with glaucoma. Significant for people with glaucoma, two new drugs (Rhopressa and Vyzulta) have been recently approved, both with activity in the diseased trabecular meshwork tissue responsible for ocular hypertension. I was fortunate to conduct some of the foundational

and preclinical research studies that supported activity and efficacy of these drugs in the trabecular meshwork. What have been some of the highlights of your career to date? First and foremost was the superb career guidance and scientific training I received during my early years as a researcher. Among many others that shaped my career, I am thankful to have been mentored by Bob Snyder, John Regan, Andrea Yool and David Epstein. Second, it was a privilege to pass on what I have learned and serve as primary advisor to nine postdoctoral fellows, plus six PhD and two MS students who did their thesis work in my laboratory. My third career highlight was the work I performed with Ross Ethier and Darryl Overby at Imperial College in London while on a sabbatical

that lead to earning the Lewis Rudin prize for glaucoma in 2012. Finally, I was thrilled with the opportunity to join an incredible group of clinician and research colleagues at the Duke Eye Center in 2011, where I was subsequently awarded a distinguished professorship and an endowed chair in 2014. How have you been involved with ARVO through the years? My first ARVO Annual Meeting was in Sarasota 28 years ago. Every year since 1991, I have attended and presented at ARVO meetings, which has provided me the opportunity to showcase my work, generate new ideas, plus develop friendships, collaborations and my professional network. It was an honor to be given the opportunity to give back to ARVO, first as an elected member of the AMPC, then appointed as a member of the editorial board of Investigative

Ophthalmology & Visual Science (IOVS) and finally elected as trustee, representing members of the PH section. As trustee, I served as chair of the finance committee and as chair of the awards committee for the ARVO Foundation. Finally, it has been a tremendous honor and privilege to be elected president, serving the membership of ARVO at the highest level. What are your goals and vision as ARVO president? There are three initiatives that have been focus areas for me as ARVO president. The first is continuing to improve the communication between vision scientists and eye banks to increase the quantity and quality of human eye tissue for research. In a recent IOVS paper, we documented the opinions of ARVO members who were surveyed about availability of human eye tissues for research, and are getting ready to launch an online tool on the ARVO website called “EyeFind” to help connect vision researchers and eye banks (PMID: 30304462). Moreover, we successfully created a new grant funding mechanism to help pay for human eye tissues used for the generation of preliminary data for grant applications. This program is managed by the ARVO foundation and our first call for applications occurs in early 2020. A second area of emphasis is helping bridge the void between basic vision research and technology commercialization with ARVO’s Bench to Bedside (B2B) initiative, which will premier in Baltimore at the 2020 Annual Meeting. ARVO’s new B2B

meeting will provide companies with an opportunity to share the trials and tribulations of taking a new discovery to the market with researchers. Additionally, the meeting will offer time for interactions between innovators and venture capitalists, including education on how to obtain funding and enter the beginning and middle phases of clinical trials. The third initiative involves ongoing efforts to improve ARVO’s international presence, given that one-half of our members are non-U.S. Our 2018 meeting in Hawaii facilitated an increase in participation from Asia and this past year we had our first meeting outside of the U.S., in Vancouver. Looking forward, ARVO is working to increase international participation by launching ARVO International, a meeting which will occur every two years, rotating between Europe, the Pacific Rim and Latin America. Our first ARVO International meeting will be in Hawaii October 15–18, 2020. What have you learned from your tenure as president and on the ARVO board of trustees? I learned that ARVO is a firstrate, well run organization that constantly strives to better serve its membership. I was very impressed with the professionalism of staff, ARVO leadership and the hard work and dedication of my fellow board members; who volunteer hundreds of hours of their precious time to serve their fellow ARVO members. For me, it was a true education and honor to serve with them these past five years.

Toth Receives Prestigious Accolades Cynthia Toth, MD, earned several prestigious awards. Research to Prevent Blindness (RPB) has granted Toth an RPB Stein Innovation Award. This award provides flexible funding to scientists actively engaged in research with the goal of understanding the visual system and the diseases that compromise its function. The award funding will support Toth’s work to advance the use of rapid, non invasive imaging with optical coherence tomography (OCT) to determine eye and brain injury. These OCT advancements will improve patient access to advanced imaging and clinicians’ ability to find and treat eye and brain injuries. She was selected for a 2019 Duke Clinical and Translational Science Institute (CTSI) Translational Accelerator Award, one of three awards given annually. Her project, Optical Assessment of Retinal Microvascular Ischemia in Cardiopulmonary Bypass, was one of three projects selected for the award. Recipients were selected for their outstanding potential to translate scientific discoveries into better outcomes in a clinical and population settings. Toth was a 2019 recipient received the of the Women in Ophthalmology (WIO) Scientific Contribution Award for her significant contributions in the field of ophthalmology.

Duke Eye Center Administration, Faculty and Staff FACULTY LEADERSHIP

Edward G. Buckley, MD Chair, Department of Ophthalmology

Vice Dean of Medical Education, Duke University School of Medicine Vice Chancellor Duke-NUS Affairs

Vice Chair of Strategy Director, Center for Macular Diseases Director, Ophthalmic Imaging Medical Director, Duke Eye Center Durham

Scott W. Cousins, MD

Felipe Medeiros, MD, PhD Vice Chair, Technology

Director, Clinical Research Unit

Eric A. Postel, MD Vice Chair, Clinical Affairs

Chief, Ambulatory Eye Surgery

Division Chiefs Chantel Boisvert, OD, MD – Neuro

Lejla Vajzovic, MD Director, Ophthalmology Continuing Education Program

Nathan Cheung, OD Director, Optometry Education

Victor Perez, MD

Director, Foster Center for Ocular Immunology

Jullia A. Rosdahl, MD, PhD

Director, Medical Student Education Director, Patient Education

Julie A. Woodward, MD

Director, Public Education Program Director, Ophthalmic Technician Program Faculty Liaison

ADMINISTRATION

Elizabeth Hunter, MHA, CFM

Adrienne Lloyd, MHA, FACHE

Ophthalmology

Chief Administrative Officer Director of Finance

Sharon Freedman, MD – Pediatric Ophthalmology and Strabismus Division

Leon W. Herndon, Jr., MD – Glaucoma Division

Tammy Clay, MHA Division Administrator

Martha Dellinger, MHA Division Administrator

Heidi Campbell, COT Director of Operations

Anupauma Horne, MD – Comprehensive Division

COMPREHENSIVE OPHTHALMOLOGY

Glenn Jaffe, MD – Vitreoretinal Division

Anna Bordelon, MD Assistant Professor of Ophthalmology

Terry Kim, MD – Cornea, External Disease and Refractive Surgery Division

Thomas S. Devetski, OD Assistant Professor of Ophthalmology

Diane Whitaker, OD – Vision Rehabilitation and Performance Division

Anupama Horne, MD Associate Professor of Ophthalmology

Thomas Hunter, MD Assistant Professor of Ophthalmology

Charlene James, OD Medical Instructor in the Department of

Nicola (Nicky) Kim, MD Associate Professor of Ophthalmology,

Julie Woodward, MD – Oculofacial Division

Cynthia A. Toth, MD Chair, Department APT Committee

Ophthalmology

Sanjay Asrani, MD

Medical Director Duke Eye Center, Cary

Laurie K. Pollock, MD Assistant Professor of Ophthalmology

Medical Director Duke Eye Center, Raleigh

William Rafferty, OD Assistant Professor of Ophthalmology

Medical Director Duke Eye Center, South Durham

Tina K. Singh, MD Assistant Professor of Ophthalmology

Robin R. Vann, MD Associate Professor of Ophthalmology

Christopher Boehlke, MD

Laura Enyedi, MD

Preeya Gupta, MD

Medical Director Duke Eye Center, Page Road, PDC At-Large Member

Robin R. Vann, MD Medical Director

Perioperative Services

Carol Ziel, MD Medical Director,

Duke Eye Center of Winston-Salem

Vadim Arshavsky, PhD Scientific Director of Research

Glenn J. Jaffe, MD Director, Duke Reading Center

Eleonora Lad, MD, PhD Associate Director, Clinical Research Unit

C atherine Bowes-Rickman, PhD Director, Third-Year Medical

Pratap Challa, MD Director, Residency Program

Sharon Fekrat, MD, FACS

Student Program

Professor of Ophthalmology Associate Professor of Surgery Director, Vitreoretinal Surgery Fellowship A ssociate Chief of Staff, Durham Veterans Affairs Medical Center

Goldis Malek, PhD Chair, Diversity and Inclusion Committee Kelly Muir, MD, MHSc Director, Ophthalmology Fellowship

Program Chief, Division of Ophthalmology, Durham Veterans Affairs Medical Center

Assoc. Medical Director, Main Eye Center

Dianna Seldomridge, MD, MBA

PDC Consulting Assistant Professor

CORNEA AND REFRACTIVE SURGERY

Bradley Barnett, MD, PhD Assistant Professor of Ophthalmology

Christopher S. Boehlke, MD Assistant Professor of Ophthalmology

Alan N. Carlson, MD Professor of Ophthalmology Melissa Daluvoy, MD

Assistant Professor of Ophthalmology

Preeya Gupta, MD Associate Professor of Ophthalmology Terry Kim, MD Professor of Ophthalmology, Anthony Kuo, MD Associate Professor of Ophthalmology, Assistant Professor Biomedical Engineering ++

Victor Perez, MD Stephen and Frances Foster Professor of Ocular Immunology and Inflammation

Terry Semchyshyn, MD Assistant Professor of Ophthalmology

Amanda Steele Johnson, OD Assistant Consulting Professor of

Kenneth Weinlander, MD Assistant Consulting Professor of

Ophthalmology Ophthalmology

Lloyd Williams, MD, PhD Assistant Professor of Ophthalmology

GLAUCOMA

Sanjay Asrani, MD Professor of Ophthalmology

Pratap Challa, MD Associate Professor of Ophthalmology

Jiaxi Ding, MD Assistant Professor of Ophthalmology

Divakar Gupta, MD Assistant Professor of Ophthalmology

Leon W. Herndon, Jr., MD Professor of Ophthalmology

Jill B. Koury, MD Assistant Professor of Ophthalmology

Stuart J. McKinnon, MD, PhD Associate Professor of Ophthalmology Felipe Medeiros, MD, PhD Joseph A. C. Wadsworth Professor of

Ophthalmology

Frank J. Moya, MD Assistant Professor of Ophthalmology

Kelly W. Muir, MD, MHSc Associate Professor of Ophthalmology

Jullia Rosdahl, MD, PhD Associate Professor of Ophthalmology

Henry Tseng, MD, PhD Assistant Professor of Ophthalmology

Molly M. Walsh, MD, MPH Assistant Professor of Ophthalmology

Joanne Wen, MD Associate Professor of Ophthalmology

Carol J. Ziel, MD Assistant Professor of Ophthalmology

Mays Dairi, MD Associate Professor of Ophthalmology

Sidney Gospe III, MD, PhD Assistant Professor of Ophthalmology

Jason Liss, MD Assistant Professor of Ophthalmology

Professor of Radiation Oncology ++

Prithu Mettu, MD Assistant Professor of Ophthalmology

Cynthia A. Toth, MD Joseph A.C. Wadsworth Professor of

Ophthalmology Professor in Biomedical Engineering++

Lejla Vajzovic, MD

Vadim Arshavsky, PhD Helena Rubinstein Foundation Professor of

Ophthalmology Professor of Pharmacology & Cancer Biology ++

Romain Cartoni, PhD Joint Appointments – Assistant Professor

of Ophthalmology, Assistant Professor of Pharmacology and Cancer Biology ++

Sina Farsiu, PhD Joint Appointments – Paul Ruffin Scarborough

Associate Professor of Biomedical Engineering and Associate Professor of Ophthalmology, Associate Professor in Electrical and Computer Engineering ++, Associate Professor in Computer Science++

Roshni Ranjit-Reeves, MD Assistant Consulting Professor of Ophthalmology

Julie A. Woodward, MD Professor of Ophthalmology

Professor in Dermatology ++

Nathan Cheung, OD Medical Instructor in the Department of

Laura B. Enyedi, MD Professor of Ophthalmology Professor in Pediatrics ++

Sharon F. Freedman, MD Professor of Ophthalmology Professor in Pediatrics ++

Faramarz Hidaji, MD Assistant Consulting Professor of S. Grace Prakalapakorn, Associate Professor of Ophthalmology MD, MPH Associate Professor in Pediatrics ++

Yos Priestley, OD, FAAO

Assistant Professor of Ophthalmology

Federico Velez, MD

Associate Professor of Ophthalmology

Associate Professor of Ophthalmology Associate Professor in Pathology ++

Pedro Gonzalez, PhD

Associate Professor of Ophthalmology Associate Professor in Pathology ++ of Ophthalmology, Assistant Professor of Neurobiology, Assistant Professor in the Duke Institute for Brain Sciences ++

Paloma Liton, PhD Associate Professor of Ophthalmology

Rupalatha Maddala, PhD Assistant Professor of Ophthalmology

Goldis Malek, PhD Associate Professor of Ophthalmology

V ITREORETINAL DISEASES AND SURGERY

Jeremy Kay, PhD Joint Appointments – Assistant Professor

Ophthalmology

Paulo Ferreira, PhD

Ophthalmology

Associate Professor in Pathology ++

P. Vasantha Rao, PhD Professor of Ophthalmology

Professor in Pharmacology & Cancer Biology ++

Daniel R. Saban, PhD, MS Associate Professor of Ophthalmology Nikolai Skiba, PhD Associate Professor of Ophthalmology

W. Daniel Stamer, PhD Joseph A.C. Wadsworth Research Professor of

Sandra Stinnett, DrPH Associate Professor of Biostatistics &

Ophthalmology Professor in Biomedical Engineering++

Bioinformatics Associate Professor in Ophthalmology ++

Yousef Aldairy, MD Medical Instructor in the Department of Ophthalmology

Michael Allingham, MD, PhD Assistant Professor of Ophthalmology

Durga Borkar, MD Assistant Professor of Ophthalmology

Associate Professor of Ophthalmology

Associate Professor in Cell Biology ++

Edward G. Buckley, MD James P. and Joy Gills Professor of Ophthalmology Professor in Pediatrics ++

Miguel Materin, MD Professor of Ophthalmology

Eric A. Postel, MD Professor of Ophthalmology

PEDIATRIC OPHTHALMOLOGY AND STRABISMUS

Ophthalmology

Eleonora Lad, MD, PhD Associate Professor of Ophthalmology

C atherine Bowes-Rickman, PhD Professor of Ophthalmology

Ophthalmology

Ilya Leyngold, MD Associate Professor of Ophthalmology

Glenn J. Jaffe, MD Robert Machemer, MD Professor of

Stefanie G. Schuman, MD Assistant Professor of Ophthalmology

OCULOPLASTICS

Ophthalmology

Landon Meekins, MD Medical Instructor in the Department of

Majda Hadziahmetovic, MD Medical Instructor in the Department of

RESEARCH OPHTHALMOLOGY

NEURO-OPHTHALMOLOGY Chantal Boisvert, OD, MD Associate Professor of Ophthalmology

Associate Professor of Surgery

Dilraj Grewal, MD Associate Professor of Ophthalmology

Diane Whitaker, OD Assistant Professor of Ophthalmology

Sharon Fekrat, MD, FACS Professor of Ophthalmology

VISION REHABILITATION AND PERFORMANCE

Ophthalmology Professor in Immunology ++

Alessandro Iannaccone, MD, Professor of Ophthalmology MS, FARVO

Associate Professor in Neurobiology ++

Xi Chen, MD, PhD Assistant Professor of Ophthalmology Scott W. Cousins, MD Robert Machemer, MD Professor of

Fulton Wong, PhD Professor Emeritus of Ophthalmology

Secondary appointment ++

Professor in Neurobiology and Pathology ++ Assistant Professor in Pathology ++

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Artificial intelligence (AI) based segmented ganglion cells. Credit: S. Soltanian-Zadeh, K. Kurokawa, Z. Liu, D.X. Hammer, D.T. Miller, S. Farsiu, â&#x20AC;&#x153;Fully automatic quantification of individual ganglion cells from AO-OCT volumes via weakly supervised learningâ&#x20AC;?, Ophthalmic Technologies, SPIE Photonics West, San Francisco CA, Feb. 2020.

2020 VISION Magazine

Articles inside

Effective Diagnosis and Treatment of Ocular Surface Disease in Cataract and Refractive Surgery Patients Duke Cornea Specialists Contribute to new ASCRS OSD Algorithm

30 Duke Eye Center News and Notes 2020

Seeing the Future Through a Transformative Pledge

Faced with Vision Loss, Young Man Bets on Himself

Our Immune System Can See

Still Rockin’ Sculptor Captures His Own Experience with Eye Disease

Effective Diagnosis and Treatment of Ocular Surface Disease in Cataract and Refractive Surgery Patients

First Genetic Association of Increased Risk of Glaucoma in African Ancestry Populations

Identical Twin Eye Images Lead to Promising Alzheimer’s Discovery

Navigating Surgical Complexity in Adult Strabismus

COVER STORY Smarter. Faster. Stronger. Artificial Intelligence is Shaping the Future of Eye Care —and Duke is leading the way

Family Outside the U.S. Sought Duke Specialist To Treat a Child with Severe Neurotrophic Keratopathy

Next-Generation Treatment for Chronic Noninfectious Posterior Uveitis