New and chronic patients with advanced glaucoma present a host of difficulties for managing providers. Is the patient stable? What testing is helpful? Is the patient at risk for loss of functional vision? Do they need surgery? Is surgery too risky? What other factors besides their intraocular pressure are important to consider? What topics should be discussed with the patient and family?

Dr. Jordan Stanley, glaucoma specialist from Marietta, GA will spend the  first half of the presentation reviewing the management strategies for patients with advanced end stage glaucoma. These patients offer an array of challenges in management because typical diagnostic modalities can be limited or have high variability. They can also be burdened with multiple ocular comorbidities which may make diagnosing the responsible mechanism for visual decline difficult. Advanced glaucoma has natural fluctuations in symptoms making it difficult to distinguish progression from fluctuation for both patient and provider. This virtual activity will review these issues and some tips for managing these complex patients. The second half will address when elevated intraocular pressure and cataract surgery overlap. This will address intraoperative issues that can arise including suprachoroidal hemorrhage and pre-operative glaucoma conditions that benefit from cataract surgery.

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Presenter: Jordan Stanley, MD

Panelists: Zachary Vest, MD + Anjali Sheth, MD + Arvind Neelakantan, MD + Carl Sloan, MD

PART ONE: Prem Subramanian, MD: Diplopia: Recognizing Urgent Cases and Fellow Travelers. Patients often present to an eye care provider with new onset diplopia, and the provider must determine the urgency of obtaining additional investigations including blood tests and neuroimaging. Additionally, further history and examination beyond the typical eye exam may be needed to arrive at a diagnosis. Once a cause is found, treatment may require a multidisciplinary approach both acutely and long-term. An approach to evaluating the patient with diplopia will be presented in a case-based format with emphasis upon both “red flags” that should lead to rapid workup and “green flags” that are typically reassuring signs.

PART TWO: Salil Shukla, MD: Lamellar Macular Holes. In the OCT era the lamellar macular hole has been observed as a distinct clinical entity, albeit overlapping with vitreomacular interface disorders and degenerative macular disease. The diagnosis of lamellar macular hole is nuanced, with imaging findings often out of proportion to symptoms and concurrent macular diagnoses often present on OCT. Management options are limited as surgical intervention does not reliably improve vision. We will discuss the pathophysiology, presentation, diagnosis, and management of lamellar macular holes with an emphasis on OCT.

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Transforming your practice workplace through Lean implementation leads to higher patient satisfaction through more efficient workflow. Learn first hand from our clinical managers how they directed a thorough examination of Colorado Retina's workflow to pinpoint the inefficiencies, created solutions for those inefficiencies and how we prepared for the transition to a Lean mindset across each of our five Denver Metro clinics and thirteen clinical teams. This presentation will take a in-depth look at our real examples, successes and errors, leading to a successful Lean implementation practice-wide.

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In the November monthly edition of Ophthalmic Surgery Grand Rounds (OSxGR), vitreoretinal specialist, Dr. Adam Martidis, MD will cover pre and post-operative surgical advancements and management of a variety of common retinal procedures. Earlier tools and techniques used in vitreoretinal surgery were revolutionary in their time, but today's options have set the bar higher. Through the presentation of surgical videos, Dr. Martidis will educate on modern surgical tools and techniques that effectively address multiple sight-threatening retinal diseases and conditions. In the hour, surgical repairs of epiretinal membranes, macular holes, vitreous hemorrhages, retinal detachments, retained lens material, and other complex surgical cases such as TRD and PVR will be presented. Dr. Martidis will deep dive into preoperative measures to reduce the risk of postoperative infection and postoperative care with subsequent examination instructions to reduce future complications.

Clinical trials provide essential foundational knowledge regarding dosing, patient selection, safety, and efficacy of novel treatments. In CRA’s October edition of Virtual Visionaries Drs. Eva Kim and Murtaza Adam will first review the overall process that a unapproved drug or device completes before its approval by the Food and Drug Administration. Salient clinical trials addressing anterior segment pathology will then be discussed by Dr. Kim and important research for posterior segment disease will be reviewed by Dr. Adam. We look forward to an enlightening and interactive discussion with our audience and expert panel!

Cataract surgery is the most commonly performed surgical procedure in the US, mainly using an intravenous (IV) sedative. While this practice is ultimately safe and effective, oral sedation for cataract surgery is proving to be a more reasonable alternative.

Specialists Drs. William Richheimer and Robert G. Fante, will provide a review of oral sedation for cataract surgery, breaking down the patient satisfaction rate, benefits to the surgeon and healthcare system in terms of cost and space saving measures, and potential downfalls. A single surgeon case series using oral sedation for cataract surgery will be reviewed, showing while the surgeons preference should still govern anesthesia choice, for many utilizing oral sedation, the method is safe and comfortable for the vast majority of cataract surgery patients.

Stem cell therapy has been a long pursued “Holy Grail” in the field of medicine. Much progress has been made in the past 20 years, but many unknowns remain. The retina is a primary target for stem cell research; it is an immune-privileged site, an examiner can look through the pupil directly onto neuro and vascular tissue for assessment of therapeutic effect, and patients have a second eye which can act as a control. Eye specialists, Dr. Curtis Hagedorn and Dr. Bill Richheimer will explore the unfortunate cases of intravitreal autologous stem cell injections that resulted in multiple PVR detachments in FL, as well as the promise associated with clinical applications of stem cell transplantation/therapy. Past, present, and future stem cell therapy research for retinal disease will be discussed, emphasizing the importance of good stewardship of these powerful tools as desperate patients seek our guidance in this emerging field.

Glaucoma specialists, Zachary Vest, MD and Shamil Patel, MD will address the decision making process for patients with glaucoma who have had prior incisional surgery, and options for obtaining a lower IOP. The talk will explore techniques for revision of trabeculectomy and prior glaucoma tube shunt, as well as address the roll of newer surgical techniques and their success in the setting of prior traditional surgeries. Teaching by means of real surgical videos and slide presentation, along with panel discussions.

Presenters: Zachary Vest, MD + Shamil Patel, MD
Panelists: Dean Carlson, MD + Oluwatosin Smith, MD

Endocrinologist, Dr. Kelsi Deaver will kick off this hour long CE/CME course with all things you need to know about diabetic management, including how to appropriately ask patients about A1C’s, current treatment and monitoring options of diabetes, and new advances within the field of endocrinology. Dr. Miriah Teeter will then dive into diabetic retinopathy, the leading cause of vision loss and one of the most common problems that we treat for patients in clinic at Colorado Retina. The presentation will focus on the underlying pathophysiology of diabetic retinopathy and directly correlate this with targeted treatments for retinal complications. Advancements in clinical imaging has contributed to improved, individualized management. Appropriate monitoring, imaging, and referral to retinal specialists for treatment improve visual outcomes and quality of life for our diabetic patients.

In this one hour presentation, Murtaza “Moo” Adam will discuss the bizarre world that lies beyond the “looking glass” of the ophthalmic operating microscope. In a world that is both backwards and bizarre, the vitreous cavity presents unique and foreboding challenges for even the most experienced surgeons. With a panel of expert ophthalmologists by his side, Dr. Adam will explore surgical dilemmas relating to complex intraocular lens cases, combined diabetic tractional/rhegmatogenous detachments, and suprachoroidal hemorrhages. With this inaugural presentation of the Ophthalmic Surgery Grand Rounds, we look forward to an exciting evening exploring what lies beyond the 128 diopter “looking glass” with you!

Over the course of an hour, we will dive into the many manifestations of ocular tumors, starting with orbital tumors. Orbital tumors are one of most commonly initially missed ophthalmic diseases seen in clinical practice by Oculoplastic Surgeons. Oculoplastic Surgeon, Dr. Chris Thiagarajah will perform a review of orbital tumors, what to look for, how to diagnose, and key findings. Ocular Oncologist, Dr. Peter Hovland, will then spend the last half of the course presenting an overview of intraocular tumors, exploring eye cancer diagnosis based on patient history and examination, and diagnostic imaging (widefield photography and angiography, ultrasonography, and optical coherence tomography (OCT). By seeking early detection of orbital and intraocular tumors, optometrists and ophthalmologists assist in providing better treatments with lower morbidity and mortality.

PRESENTERS: Peter Hovland, MD, PhD - Ocular Oncologist/Vitreoretinal Specialist at Colorado Retina Associates & Christopher Thiagarajah, MD, FACS - Oculoplastic Surgeon at Park Avenue Oculoplastics

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Uveitis, a general, yet highly complex term for a group of inflammatory diseases with no one size-fits all description, responsible for between 10-15 percent of all cases of blindness in the US. Caused by inflammatory responses, uveitis is not just limited to the uvea, having the potential to wreak havoc throughout the eye and in other parts of the body.

Colorado Retina's uveitis gurus, Dr. Mark Dacey and Dr. Ashleigh Levison, over the course of an hour will explore a variety of uveitis manifestations, underlying systemic diseases, presentation patterns and symptoms, the lengthy road to proper diagnosis, current treatment options, and the vision-threatening implications these diseases can have for patients. Dr. Dacey and Dr. Levison will also cover a few of their most peculiar cases that are not to be missed.

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Colorado Retina & Mile High Eye Institute teamed up to review Optical Coherence Tomography (OCT), an emerging technology for performing high-resolution cross-sectional optical imaging.

Dr. Zak Vest, of MHEI and Dr. Brian Joondeph, of CRA, will provide a brief review of OCT technology, covering the technical aspects of OCT and potential issues that arise while interpreting data. We will dive into OCT output, how to correctly read OCT data findings, signal strength for reliability, and provide education of how to efficiently utilize OCT technology for treatment guidance of glaucoma and diseases of the retina, including AMD and diabetic retinopathy. We will also cover the anatomic measuring capabilities of the current devices in service as well as an overview of their normative database.

PRESENTERS
Murtaza Adam, MD, Peter Hovland, MD, PhD

Dr. Adam reviewed the many inherited, toxic, and idiopathic maculopathies that can mimic age-related macular degeneration (AMD) in the clinic.

Dr. Hovland wrapped up with content on surgical approaches for retinal detachments. He reviewed the types of retinal detachments there are, issues related to intraocular pressure, and special management of patients with retinal detachments who live at altitude.

PRESENTER
Murtaza Adam, MD

Protocols have changed significantly during the COVID-19 pandemic. Which of those procedures are here to stay and which will disappear as the pandemic subsides? NRR host John Kitchens, MD, invites Murtaza “Moo” Adam, MD; David R.P. Almeida, MD, PhD, MBA; and Christina Weng, MD, MBA, to discuss which changes implemented in 2020 will be permanent fixtures in retina practice. Watch the whole discussion back now! 

PRESENTERS
Murtaza Adam, MD & Salil Shukla, MD

Review of common and uncommon peripheral retinal findings found on routine funduscopic imaging and exams, including vitreous base pathology, vascular disease, neoplasms, degenerative disease, and variations of normal anatomy. Differential diagnoses, associated findings, and recommendations for management will be covered.