resge in ight - Kresge Eye Institute

SKBreakthrough Developments in Ophthalmology from DMC Kresge Eye InstituteR E S G E I N I G H TVolume 1 No. 3Taking the Guesswork outof Glaucoma TreatmentLatest Vitrectomy InnovationResident Program Reachesto RussiaDETROIT MEDICAL CENTER

W elcome to DMC Kresge Eye InstituteThis edition of InSight is very special as it coincides with the60th anniversary of Kresge Eye Institute. Since 1948, Kresgehas truly been a leader in ophthalmologic care, research,and medical education – and we are not slowing down. Thestories we will share with you this time around are reflectiveof the quality that has been a hallmark of Kresge for the pastsix decades.In this edition we feature our unique partnership withbasic scientists at Wayne State University, the integratednature of which facilitates a collaborative approach togroundbreaking research. One example of the collaboration is Gabriel Sosne, M.D.,a comprehensive ophthalmologist with an active clinical practice who also performslaboratory research in Scott Hall at the Wayne State University School of Medicine.Dr. Sosne is translating the results of his laboratory investigation on a substancethat promotes healing of corneal wounds to a clinical trial on patients with cornealerosions following vitrectomy surgery. Important clinical research is being led byKresge Eye Institute glaucoma specialist Dr. Bret Hughes. Dr. Hughes recentlyserved as KEI principal investigator in the NIH Ocular Hypertension TreatmentStudy -- the largest-ever national longitudinal study of high eye pressure and thedevelopment of glaucoma. Preliminary results from the study show that in AfricanAmericans pressure-lowering eye drops reduce the development of primary openangle glaucoma by almost 50 percent. Dr. Hughes is a national leader in glaucomaresearch and has received the American Academy of Ophthalmology AchievementAward.In addition to new research, our physicians continue to lead the way withinnovative applications of existing technology and treatments. In this edition youwill see just a few examples: Dr. Gregory Van Stavern is using optical coherencetomography (OCT) to track the progression of multiple sclerosis. Retina specialistTamer Mahmoud, M.D. skillfully used a fluocinolone intravitreal implant in abreakthrough multi-procedure surgery which restored vision in a patient blindfrom complications of severe uveitis. Dr. Asheesh Tewari is working with devicemanufacturers to develop and test a new generation of vitrectomy instrumentation.Kresge ophthalmologists also continue to be global teachers. Since the 1990s, Dr.James Puklin has been instrumental in bringing ophthalmologists from Russiato study at Kresge. In this edition you will hear the experience from one of thesephysicians currently here to conduct research on artificial vision.I am truly honored to share with you these latest breakthroughs in research andclinical care. As always, I invite your comments and observations and can bereached at gabrams@med.wayne.edu.Dr. Gary AbramsDirector, Kresge Eye InstituteThe David Barsky, MD Professor and Chair of OphthalmologyWayne State University School of Medicine

Kresge Eye Institute SpecialistsGary W. Abrams, M.D.Vitreoretinal Diseasesand SurgeryMonica Y. Alexander, M.D.GlaucomaEvan H. Black, M.D.Oculoplastics andOrbital SurgeryChristopher J. Cheyer, M.D.Oculoplastics andOrbital SurgeryRobert N. Frank, M.D.Medical Diseasesof the RetinaConrad L. Giles, M.D.Pediatric OphthalmologyAnju Goyal, M.D.GlaucomaBret A. Hughes, M.D.GlaucomaRaymond Iezzi, M.D.Vitreoretinal Diseasesand SurgeryJo D. Issacson, M.D.ComprehensiveOphthalmologyMark S. Juzych,M.D., M.H.S.A.GlaucomaTamer H. Mahmoud, M.D., Ph.D.Vitreoretinal Diseasesand SurgerySusan H. McCutcheon,O.D.Well Eye CareMark L. McDermott,M.D., M.B.A.Cataract and CornealSurgeryPatrick L. Murphy, M.D.Vitreoretinal Diseases andSurgeryJames E. Puklin, M.D.Vitreoretinal Diseasesand SurgeryJohn M. Ramocki, M.D.Oculoplastics,Comprehensive Ophthalmologyand Cataract SurgeryJohn D. Roarty, M.D.PediatricOphthalmologyGabriel Sosne, M.D.Cataract Surgeryand ComprehensiveOphthalmologyAsheesh Tewari, M.D.Vitreoretinal Diseasesand SurgeryGregory P. Van Stavern, M.D.Neuro-OphthalmologyJayne S. Weiss, M.D.Refractive, Corneal andCataract SurgeryElizabeth Hakim Yates, O.D.Well Eye Carewww.dmc.org

Partnership Expands Research, RecruitingSince 1966 DMC Kresge Eye Institute and Wayne State UniversitySchool of Medicine have been partners, with Kresge’s clinicalophthalmologists managing care at WSU and DMC, as well asserving as WSU faculty members. Many staff members hold jointappointments at Kresge and WSU’s Department of Anatomy andCell Biology.While both organizations haveemphasized research, a fewyears ago Kresge’s director, GaryW. Abrams, M.D., and LindaD. Hazlett, Ph.D., distinguishedprofessor and chair, WSUDepartment of Anatomy andCell Biology, decided that morecould be done to integrate theirefforts.“Traditionally, the basic sciencedepartments in medical schoolshave focused on the mechanisms ofbiologic processes and diseases. Theclinical departments have physicianswho treat and study the clinical aspects of disease,” says Dr. Abrams. “A few yearsago we looked at trying to integrate all vision research so that basic and clinicalresearch was better focused on creating solutions for people with vision problems.”Dr. Hazlett noted that WSU and Kresge “had common goals in vision researchand common needs for faculty recruitment.”“It’s been a very productive interaction that has allowed us to enhance research atboth institutions,” comments Dr. Abrams. “We’ve become the model for otherdepartments at Wayne State, which are now looking to link basic science departmentswith clinical departments.”As recognition of their success, the departments were co-recipients of a 2004 GraduateProgram Enhancement Award fromthe WSU Provost, allowing them to recruitnew staff. Researchers hired as a result ofthat funding have developed protocolsthat are now showing promising results innational clinical trials.The partnership has also allowed the twoto attract numerous grants from the NationalInstitutes of Health and the NationalEye Institute, such as a $2.091 millionCore Center grant. This grant, for whichDr. Hazlett serves as the PI, provides facilitiesand state-of-the-art instrumentationto foster further research efforts in vision.Only 35 centers in the United Stateshave received a Core Center grant, whichrequires eight R01 research grants to apply.Investigators in vision from WayneState, Michigan State, Oakland University,University of Chicago and Penn State are active participants, holding 19 NEI R01research grants.“Our goal is to take our findings from the lab into the clinic, using the stronginteractions among our basic and clinical scientists to perform translational researchwith the goal of making meaningful advances in patient care,” Dr. Abrams says.

Tracking Multiple SclerosisProgression with OCTOften, optic neuritis, or inflammation of the optic nerve,is the first reported symptom that leads to a diagnosis ofmultiple sclerosis. According to the National MultipleSclerosis Society, 55 percent of people with MS will havean episode of optic neuritis.A researcher at KEI is working on several fronts to find treatments for MS and away to predict disease progression. Gregory Van Stavern, M.D., associate professorin the departments of Ophthalmology, Neurology and Neurosurgery, is an investigatorin the FREEDOMS study, a Phase III clinical trial to evaluate the effectivenessand safety of fingolimod. Begun in 2006, the 24-month study has enrolled 1,250patients worldwide. Results of the Phase II study were released in April and showednearly 70 percent of MS patients taking fingolimod were relapse free after threeyears of daily oral treatment.Dr. Van Stavern is using optical coherence tomography (OCT) as an outcomemarker in the trial. “OCT can track the damage to axons and myelin in the opticalnerve fibers to see if the disease is progressing. In addition, OCT is faster, cheaperand more repeatable than MRI studies.“Ideally, we could use OCT to predict theprogression of MS, prevent attacks withmedication and prevent long-term disability.”Optical coherence tomography, or OCT, is a non-invasivetechnique commonly used to obtain high-resolutionimages of the retina. OCT can measure the retinal nervefiber layer thickness that may change with glaucoma andother diseases of the optic nerve. Dr. Van Stavern is nowusing it to track progression of optical nerve damage inmultiple sclerosis patients.www.dmc.org

T aking the Guesswork Out of Glaucoma TreatmentA National Institute of Health study just concluding has takensome of the guesswork out of treating glaucoma. Glaucomais elevated eye pressure which can cause damage to the opticnerve, resulting in blindness. The largest-ever longitudinalstudy of high eye pressure and the development of glaucoma --the Ocular Hypertension Treatment Study (OHTS) -- studied1,637 patients at medical centers nationwide, includingDMC Kresge Eye Institute.“OHTS sought to prove if usingmedication in the form of eyedrops to lower eye pressure preventsor delays the developmentof primary open-angle glaucomain people with ocular hypertension,”says Bret A. Hughes, M.D.,associate professor of ophthalmologyat Wayne State UniversitySchool of Medicine and principalinvestigator for the OHTS studyat KEI. “OHTS also identifiedrisk factors for the developmentof glaucoma. In addition it helpedclinicians estimate, based on risk, which patients might benefit from earlyprophylactic medical treatment, preventing vision loss.”Previous studies had not conclusively proven that treatment delayed or preventedglaucoma, however those studies had design problems.Begun in 1996, OHTS first followed patients randomized into treatment andobservation groups for five years. In 2002, the study published initial results in theArchives of Ophthalmology showing that using eye drops to lower eye pressure waseffective in delaying or preventing the onset of POAG.Because glaucoma is a leading cause of blindness and visual impairment amongAfrican Americans, researchers wanted a more definitive answer about the effects ofearly treatment in this subgroup. After initial results, researchers continued to followthe African Americans in OHTS. Final results clearly showed that in African Americanspressure-lowering eye drops reduced the development of primary open-angleglaucoma by almost 50 percent.OHTS also helped determine baseline factors that predicted the developmentof POAG:- increasing age- larger cup-to-disc ratios- higher intraocular pressure (IOP)- abnormal peripheral vision test- thin central corneas“OHTS has changed patient care significantly as it helps us to delineate who totreat based on these risk factors. It gives us additional risk factors to look at beyondabsolute IOP levels,” Dr. Hughes comments. “It also will help patients avoid unnecessarytreatment, and the resulting possible side effects and unnecessary expense.”Because age is at the top of the risk factors, it is recommended that people age 60and above, and African Americans age 40 and above, have an annual eye examwhich includes glaucoma eye pressure check, corneal thickness measurement, opticnerve evaluation and peripheral vision testing

H‘appy medium’ is latest innovation in vitrectomyWhen 25-gauge pars plana vitrectomy was introducedsix years ago, it brought many improvements in patientoutcomes after retinal surgery. The smaller scleralincisions meant the three surgicalports would seal without sutures,reducing patient discomfort,speeding recovery and decreasingsurgical times. Also, since suturesare not used, there is minimalinduced postoperative astigmatism.But the move from 20-gauge to 25-gaugeinstruments had some drawbacks, notes AsheeshTewari, M.D., a retinal surgeon at DMC KresgeEye Institute and an assistant professor in theophthalmology department at Wayne StateUniversity School of Medicine.“With the more-delicate instruments, flexibilitybecame a problem,” Dr. Tewari notes. “It wasmore difficult to perform complicated surgicalmaneuvers, such as removing peripheral vitreousand repairing complex retinal detachments.”As a response, 23-gauge instrumentation wasdeveloped several years ago as a “happy medium.”Dr. Tewari was one of the first in the United Statesto use 23-gauge instruments when they becameavailable.Dr. Tewari joined KEI in 2007 and performs about 95 percent of hisvitrectomies using the new technology, or more than 20 cases per month.“Outcomes are just as good as with 20-gauge instrumentation and you’re gettingthe same effect in time savings and patientcomfort as 25-gauge,” he comments. “Thesurgery is still sutureless and the more-rigidinstrumentation allows greater rotation ofthe eye and the ability to perform a morecompletevitrectomy. In addition, with newerwide-angle light probes, there is improvedvisibility of the peripheral retina and thelarger vitrectors allow for optimum removalof vitreous gel.” At the same time, patientshave a quicker postoperative recovery and aremore comfortable after retinal surgery.Dr. Tewari is currently working with devicemanufacturers to develop and test a newgeneration of vitrector with a significantlyfaster cut rate.“We’ve learned that if we pull too muchwhen aspirating with the vitrector, it createsretinal tears. With the higher-speed cuttersthe action is more like shaving off smallerbits of tissue, which improves outcomes.”www.dmc.org

New Use of Retisert Implant Allows Combined Cataract, Glaucoma SurgeryWhen Ella* first came toDMC Kresge Eye Instituteher vision was limited tovisualizing hand motionOD and 20/80 OS dueto granulomatous uveiticglaucoma. The patient’s longterminflammation had causedadvanced glaucoma andcataracts. Despite an Ahmedvalve placement and medicalmanagement with high doses of oral prednisone for two years, the 50-yearoldpatient’s vision did not improve.Now, following an innovative surgical procedure by retinal specialist Tamer Mahmoud,M.D., Ph.D., the patient is back to work after years on disability and reports vision of20/30 OD and 20/25 OS one year post-operatively.Dr. Mahmoud, an assistant professor of ophthalmology at Wayne State UniversitySchool of Medicine and a retinal specialist on staff at DMC Kresge Eye Institute,recognized that performing the lensectomy and vitrectomy that the patient neededwould be complicated, given the active, long-term inflammation. High doses ofsteroid would be needed, which the patient was not tolerating well. The procedures aretraditionally done successively in eyes with advanced disease.Dr. Mahmoud decided to combine acataract extraction and intraocular lensimplant, a vitrectomy, a repositioning ofthe Ahmed tube and Retisert implant in asingle procedure.“As an academic eye center we wereable to bring in an advanced teamof subspecialist surgeons – cataract,glaucoma and myself as the retinasurgeon – to perform this combinedprocedure on each eye successively,” Dr.Mahmoud says. “The Retisert implantallows a more aggressive surgical approachand has expanded treatment options forpatients.”Following the procedure, Ella was ableto stop oral prednisone and glaucoma eye drops and has had remarkable functionaloutcomes.“Despite years of inflammation, she regained vision, which was unexpected,”comments Dr. Mahmoud. “Previously, we would have expected permanent vision lossin this type of case and told the patient there was nothing we could do. This procedureis giving a whole group of patients hope for treatment.”Since FDA approval three years ago, the use of a fluocinolone intravitreal implant(Retisert®) has been used to treat chronic noninfectious posterior uveitis and had beenimplanted in combination with glaucoma procedures. “The advantage of Retisert is thedelivery of steroid directly to the eye, avoiding systemic complications,”Dr. Mahmoud says.Ella’s case has been presented for publication and Dr. Mahmoud has since performedsimilar procedures in additional patients.*Not patient’s real name

C ataract Patient Shares Experience in VideoBetty Allen has worked at the John D. Dingell VA Medical Center on the DMC campus for 31 years as an MRI and CT technician,so she knew how to handle rush hour traffic. So when she started staying at work late to avoid driving in traffic, she knew she had aproblem with her eyesight.“If I had to read a street sign I would park the car, get out and walk up to it,” Allen, 64, recalls.“Glare or rain made the letters run together.”Cataracts were clouding her vision so that she also had difficultyseeing a computer screen at work.She finally went to see Anju Goyal, M.D., a cataract and glaucomaspecialist at DMC Kresge Eye Institute. In April 2008,Dr. Goyal performed a cataract extraction with intraocularlens implant in Allen’s right eye. In September, Allen wentback for her second surgery.“I could hardly wait forthe second surgery.”“I could hardly wait for the second surgery,” she says. “Forboth surgeries, I had the procedure on a Tuesday and was backat work on Friday. I could have gone back sooner, because Ifelt great.”“Dr. Goyal was very thorough and explained what she wasdoing. Everyone at Kresge was very nice and helpful.”Allen was so pleased with the outcome at Kresge that sheagreed to be featured in a video that is currently available inthe medical library on www.dmc.org.www.dmc.org

are Infection Threatens Patient’s Sight and LifeDonald Barrick’s father and grandfather had chronic pancreatitis, sowhen Barrick developed the same hereditary condition he knew hewould be seeing a lot of doctors. He didn’t know that an ophthalmologistwould save his life.After seven years with pancreatitis, Barrick, 45, had a peripherallyinserted central catheter (PICC) to receive parenteral feeding and painmedication. Early in 2008 his vision unexpectedly began to deteriorate.By April he was so sick he had to quit work.“I went blind in my right eye to where I could just see some light,” Barrick recalls.He also began hallucinating and was extremely ill, his wife, Tammy, adds.“He was so sick we signed him up for hospice thinking that the pancreatitis wasjust getting worse,” Tammy says. “But my gut instinct told me something else waswrong so we took him off hospice and took him to Harper Hospital.”Residency Program Reaches to RussiaMarianna Ivanova, M.D., a second-year ophthalmology resident from Moscow,(standing) spent a week at the DMC Kresge Eye Institute in September. She wasone of 12 Russian medical students and physicians who visited in 2008 thanksto the efforts of James Puklin, M.D., professor of ophthalmology at Wayne StateUniversity School of Medicine. Dr. Puklin has since the early 1990s broughtRussian medical students, physicians and scientists to the United States for shorttermeducational opportunities.Dr. Ivanova is conducting research for her doctoral thesis on artificial vision to treatblindness using cortical implants, also a specialty of the Ligon Research Center ofVision at KEI.“Kresge is on the cutting edge of the problem of how to connect microelectrodearrays to living brain tissue to correct blindness,” she says. “We are working on thesame problems in our research, so it was very helpful for me to meet physicians hereand discuss our approaches.”After ER physicians and two other ophthalmologists couldn’t diagnose Donald’scondition, he went to DMC Kresge Eye Institute. “Dr. (James) Puklin examinedmy eyes and saw what was wrong.”“Donald had developed a fungal infection through his PICC line that affected hisentire body, including his eyes,” explains Dr. Puklin, professor of ophthalmology atWayne State University School of Medicine. “I performed a vitrectomy and aspirateda portion of one of the yeast infections. Donald was admitted to the hospitalfor systemic cultures and IV antifungal and antibiotic agents. Because of his chronicinfection and very weak immune system associated with his pancreatitis he was soill that he appeared to be facing imminent death.”After seven days in the hospital, Barrick recovered. “As soon as the eye patches wereremoved I could see, although it was blurry,” he says. “A week later it was a lot betterand four weeks later I could read letters on the eye chart.”“If Dr. Puklin hadn’t found that infection, I wouldn’t be alive today,” Barrick states.“I have a 9-year-old daughter and an 11-year-old son. I’m only 45 years old. Eventhough I am sick, I am happy I can see and live a normal life as much as possible.”

TheSpecialty Hospitals of the Detroit Medical CenterFrom treating soldiers during the Civil War at Harper Hospital to the world’s first cardiacbypass pump at that same hospital fifty years ago, from the founding of Children’s Hospitalin the 1880’s to today’s visionary research at Kresge Eye Institute, the Detroit MedicalCenter has a proud 140-plus year history of medical excellence and advancement.But 2008 has been especially momentous for the DMC.• Only system in U.S. with four hospitals on Leapfrog Group honor roll ofAmerica’s Top Hospitals for patient safety• Three DMC hospitals named to America’s Best Hospitals 2008 byU.S.News & World Report• Cardio Team One TM , the nation’s first on-site 24/7 interventional cardiologyteam, established at Harper University HospitalAchievements like that are nothing new for this system where excellence is expected. TheDMC is the leading academically integrated system in metropolitan Detroit, partneringfor decades with the Wayne State University School of Medicine, and the largest healthcareprovider in southeast Michigan. DMC has more than 2,000 licensed beds and 3,000affiliated physicians, many of whom are recognized national experts and on the list ofAmerica’s Best Doctors.Today, this non-profit healthcare system casts a wide focus on specialty care at individualspecialty hospitals, such as women’s care and high-risk pregnancy at Hutzel Women’sHospital or advanced physical therapy at the Rehabilitation Institute of Michigan.We invite you to explore some of the remarkable advancements taking place atThe Specialty Hospitals of the Detroit Medical Center. Welcome to the DMC.DMC Rehabilitation Institute of Michigan is one of the nation’s largest hospitals specializingin rehabilitation medicine and research. The Institute is home to many innovativeprograms, including the Center for Spinal Cord Injury Recovery.DMC Kresge Eye Institute is known internationally for its contributions to ophthalmology.Kresge’s clinical specialties include glaucoma, cataract surgery, cornea transplantation,retinal, vitreal and macular diseases, and more. KEI houses the Ligon Research Center ofVision, studying artificial vision and all areas of vision research.DMC Harper University Hospital has distinguished itself in surgical medicine and is knownfor its clinical expertise, innovative research and advanced education. In 2008, U.S.News &World Report ranked Harper as one of the top 30 hospitals in Neurology and Neurosurgery.A Leapfrog Group Top Hospital, Harper is home to the revolutionary Cardio Team One,the new standard of excellence in heart care.DMC Hutzel Women’s Hospital is nationally recognized for cutting-edge research in highriskobstetrics, gynecology, and more. Home to the National Institutes of Health (NIH)Perinatology Research Branch (PRB), Hutzel is recognized as a leader in women’s health byphysicians and researchers across the country.DMC Children’s Hospital of Michigan, with more than 33 clinical specialties, is aninternational leader in pediatric and adolescent medicine. Experts in pediatric critical care,rehabilitation, neonatal and perinatal medicine provide care for thousands of childrenevery year. Children’s ranked among the nation’s top 30 hospitals in U.S.News & WorldReport’s 2008 edition of America’s Best Children’s Hospitals in Cancer, Neurology andNeurosurgery. Children’s is also a 2008 Leapfrog Top Hospital and has been designatedwith Magnet Hospital status for nursing and overall excellence.DMC Detroit Receiving Hospital is Michigan’s first Level 1 Trauma Center. Receiving’semergency department treats more than 85,000 patients annually, and trains nearly60% of Michigan’s emergency physicians. It is the state’s largest burn center and MetroDetroit’s first certified primary stroke center. Recognized as a Top Hospital by theLeapfrog Group.DMC Sinai-Grace Hospital is DMC’s largest hospital. As a full-service communityhospital located in northwest Detroit, Sinai-Grace offers a comprehensive heart center,cancer care, gerontology, emergency medicine, and obstetrics/gynecology. Advancesin care and technology helped place Sinai-Grace on U.S.News & World Report’s 2008rankings among the best hospitals in the nation for Neurology and Neurosurgery.DMC Surgery Hospital in Madison Heights is the first regional hospital focused onorthopaedics. It is staffed by the top surgeons and sports medicine doctors in southeastMichigan and is also a major surgical site for Children’s Hospital of Michigan.DMC Huron Valley-Sinai Hospital, in Oakland County, has earned recognition as oneof the area’s and the nation’s top hospitals for patient satisfaction. This hospital featuresthe Harris Birthing Center with all private birthing suites, a regional specialty center,the Charach Cancer Center, (a part of the Barbara Ann Karmanos Cancer Center), theKrieger Center for Senior Adults, state-of-the-art surgical suites, cardiac services, andcomprehensive inpatient and outpatient diagnostic care.In Partnership: The Barbara Ann Karmanos Cancer Center provides patientsthroughout Michigan and beyond with comprehensive cancer care certified by theNational Cancer Institute (NCI) and backed by state-of-the-science cancer research.www.dmc.org

Founded in 1948, Kresge Eye Institute was the first comprehensiveeye care facility in Michigan. Today, Kresge hasgrown into one of the nation’s leading centers for ophthalmologicresearch, prevention and treatment of disorders of the visual system,offering the most advanced medicaland surgical eye care available.4717 St. Antoine Blvd.Detroit, MI 48201(313) 577-8900www.kresgeeye.orgwww.dmc.orgA better way to see better.