Clinical Professor, Ophthalmology
Honors & Awards
AOA, University of North Carolina at Chapel Hill (2001)
Honor Award, American Academy of Ophthalmology (1993)
Stanford Ophthalmology Resident Teaching Award, Stanford University School of Medicine (2009)
Fellowship: Massachusetts Eye and Ear Infirmary Ophthalmic Training (1978) MA
Internship: California Pacific Medical Center Internal Medicine Residency (1973) CA
Fellowship, Mass Eye & Ear Infirmary, Harvard, and Retina Associates, Boston, MA, Vitreoretinal Surgery (1978)
Medical Education: University of North Carolina at Chapel Hill (1972) NC
Board Certification: Ophthalmology, American Board of Ophthalmology (1978)
Residency, Ochsner Clinic, New Orleans, LA, Ophthalmology (1976)
Residency: Alton Ochsner Med Foundation (1976) LA
Internship, San Francisco Childrens Hospital and Adult Medical Center, Internal Medicine (1973)
MD, University of North Carolina at Chapel Hill, Medicine (1972)
Current Research and Scholarly Interests
-Retinal Vascular Disease
-Retinopathy of Prematurity
-Sustained Release Drug Delivery Systems
Effects of Myo-inositol on Type 1 Retinopathy of Prematurity Among Preterm Infants <28 Weeks' Gestational Age: A Randomized Clinical Trial.
2018; 320 (16): 1649–58
Importance: Previous studies of myo-inositol in preterm infants with respiratory distress found reduced severity of retinopathy of prematurity (ROP) and less frequent ROP, death, and intraventricular hemorrhage. However, no large trials have tested its efficacy or safety.Objective: To test the adverse events and efficacy of myo-inositol to reduce type 1 ROP among infants younger than 28 weeks' gestational age.Design, Setting, and Participants: Randomized clinical trial included 638 infants younger than 28 weeks' gestational age enrolled from 18 neonatal intensive care centers throughout the United States from April 17, 2014, to September 4, 2015; final date of follow-up was February 12, 2016. The planned enrollment of 1760 participants would permit detection of an absolute reduction in death or type 1 ROP of 7% with 90% power. The trial was terminated early due to a statistically significantly higher mortality rate in the myo-inositol group.Interventions: A 40-mg/kg dose of myo-inositol was given every 12 hours (initially intravenously, then enterally when feeding; n=317) or placebo (n=321) for up to 10 weeks.Main Outcomes and Measures: Type 1 ROP or death before determination of ROP outcome was designated as unfavorable. The designated favorable outcome was survival without type 1 ROP.Results: Among 638 infants (mean, 26 weeks' gestational age; 50% male), 632 (99%) received the trial drug or placebo and 589 (92%) had a study outcome. Death or type 1 ROP occurred more often in the myo-inositol group vs the placebo group (29% vs 21%, respectively; adjusted risk difference, 7% [95% CI, 0%-13%]; adjusted relative risk, 1.41 [95% CI, 1.08-1.83], P=.01). All-cause death before 55 weeks' postmenstrual age occurred in 18% of the myo-inositol group and in 11% of the placebo group (adjusted risk difference, 6% [95% CI, 0%-11%]; adjusted relative risk, 1.66 [95% CI, 1.14-2.43], P=.007). The most common serious adverse events up to 7 days of receiving the ending dose were necrotizing enterocolitis (6% for myo-inositol vs 4% for placebo), poor perfusion or hypotension (7% vs 4%, respectively), intraventricular hemorrhage (10% vs 9%), systemic infection (16% vs 11%), and respiratory distress (15% vs 13%).Conclusions and Relevance: Among premature infants younger than 28 weeks' gestational age, treatment with myo-inositol for up to 10 weeks did not reduce the risk of type 1 ROP or death vs placebo. These findings do not support the use of myo-inositol among premature infants; however, the early termination of the trial limits definitive conclusions.
View details for PubMedID 30357297
- Prethreshold retinopathy of prematurity: VEGF inhibition without VEGF inhibitors JOURNAL OF PERINATOLOGY 2018; 38 (10): 1295–1300
ROP - Guided Embryology for Retinal Vessels
ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2018
View details for Web of Science ID 000442912508080
Retina (Philadelphia, Pa.)
2018; 38 (5): e36–e37
View details for PubMedID 29547455
- Regarding 'Advances of optical coherence tomography in myopia and pathologic myopia'. Eye (London, England) 2017
Effect of oral niacin on central retinal vein occlusion.
Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie
Niacin, a treatment for dyslipidemia, is known to induce vasodilation as a secondary effect. Previous instances of patients with chronic central retinal vein occlusion (CRVO) and cystoid macular edema (CME) have been observed to spontaneously improve when placed on systemic niacin for hypercholesterolemia. The purpose of this study was to evaluate the effects of niacin on CRVO and associated ocular complications.A prospective, single-center, non-randomized, interventional case series of niacin for CRVO was conducted. Best-correct visual acuity (BCVA), central macular thickness (CMT), and ocular complications were analyzed in 50 patients over 1 year. Eight patients were controls.The mean initial logMAR BCVA was 0.915, and improved with niacin to 0.745 (P = 0.12), 0.665 (P = 0.02) and 0.658 (P = 0.03) after 3, 6, and 12 months of follow-up, respectively. At baseline, mean CMT was 678.9 μm, and improved to 478.1 μm (P = 0.001), 388.6 μm (P < 0.001), and 317.4 μm (P < 0.001) for the same time points. The control group had a mean initial logMAR BCVA of 1.023, which gradually deteriorated to 1.162 (P = 0.36) after 12 months, and baseline CMT of 700.0 μm at baseline, which gradually improved to 490.9 μm (P = 0.06) after 12 months. Panretinal photocoagulation for neovascularization was required in 5 patients (13.2%) receiving niacin and 3 (37.5%) controls.These data suggest that niacin may be associated with functional and anatomic improvements in eyes with CRVO. Future investigations will help ascertain whether there is a role for niacin as an adjunct therapy to intravitreal injections in the management of CRVO.
View details for DOI 10.1007/s00417-017-3606-0
View details for PubMedID 28161829
- Potentially Reversible Effect of Niacin Therapy on Edema From Retinal Vein Occlusion JAMA OPHTHALMOLOGY 2016; 134 (7): 839-840
Peripheral Avascular Retina in a Term Male Neonate With Microvillus Inclusion Disease and Pancreatic Insufficiency
OPHTHALMIC SURGERY LASERS & IMAGING RETINA
2015; 46 (5): 589-591
The authors present the first case of peripheral avascular retina in a term male neonate with pancreatic exocrine insufficiency, atypical microvillus inclusion disease, flat tympanograms, and recurrent urinary tract infections. Clinical examination showed avascular peripheral retina to posterior zone II temporally, with a flat stage 1-like demarcation line, and no plus disease. Genetic testing results were normal. The patient developed peripheral neovascularization and underwent panretinal photocoagulation. This case likely represents mild Norrie disease, familial exudative vitreoretinopathy, or incontinentia pigmenti due to a Wnt signaling abnormality. While these conditions are usually more severe, a variable spectrum of Wnt abnormalities exists throughout the body.
View details for DOI 10.3928/23258160-20150521-14
View details for Web of Science ID 000359292500014
View details for PubMedID 26057766
Complete visual recovery after incipient crao due to ocular hypoperfusion in a patient with moyamoya disease.
Retinal cases & brief reports
2013; 7 (3): 248-251
The purpose of this study was to report a case of an impending central retinal artery occlusion with hypoperfusion in a moyamoya patient.A young, surgically revascularized moyamoya patient experienced severe unilateral vision loss from 20/25 to hand motions because of impending central retinal artery occlusion. The patient was treated with a combination of intermittent ocular massage, intraocular pressure-lowering medications, and aspirin.A case of a moyamoya patient at Stanford University Medical Center.Visual acuity was restored to baseline by improving the ocular arterial-venous gradient after prompt administration of ocular massage, intraocular pressure-lowering drops, and aspirin.This dramatic result suggests that, if performed in a timely manner, augmentation of ocular perfusion can result in complete restoration of vision in some cases of incipient central retinal artery occlusion.
View details for DOI 10.1097/ICB.0b013e31828eef20
View details for PubMedID 25391116
Pseudoduplication of the optic disk.
Retinal cases & brief reports
2011; 5 (2): 144-145
The purpose of this study was to report a case of a chorioretinal coloboma mimicking a second optic disk in an asymptomatic 12-year-old boy.This is a case report.An asymptomatic 12-year-old boy presented with a chorioretinal coloboma of the right eye giving the impression of a second optic disk. The patient also had a superior visual field defect.True optic nerve duplication is a rare entity that can be mimicked by other etiologies, including choroidal colobomas and postinflammatory lesions, requiring careful examination by clinicians.
View details for DOI 10.1097/ICB.0b013e3181cc2135
View details for PubMedID 25389885
Visual disturbance as initial presentation of hairy cell leukemia
EUROPEAN JOURNAL OF OPHTHALMOLOGY
2009; 19 (2): 318-320
Hairy cell leukemia (HCL) is a rare disorder that occasionally has visual symptoms after diagnosis. The authors present a case of HCL in which bilateral visual symptoms led to the initial diagnosis.Observational case report.Bilateral decreased vision to 20/30 in the right eye and 20/40 in the left due to intraretinal and preretinal hemorrhages with no other systemic signs or symptoms prompted a hematologic evaluation in which HCL was found to be the causative disorder in a previously healthy 41-year-old man.The authors present a rare case in which bilateral visual complaints led to the diagnosis of HCL. Thus, though uncommon, HCL should be considered in the differential diagnosis of otherwise unexplained retinal hemorrhages.
View details for PubMedID 19253258
Images in clinical medicine. Macular hemorrhage from bungee jumping.
New England journal of medicine
2007; 357 (3)
View details for PubMedID 17634454
Macular hemorrhage from bungee jumping
NEW ENGLAND JOURNAL OF MEDICINE
2007; 357 (3): E3-E3
View details for Web of Science ID 000248115100010
Rethinking stop-ROP: Is it worthwhile trying to modulate excessive VEGF levels in prethreshold ROP eyes by systemic intervention? A review of the role of oxygen, light adaptation state, and anemia in prethreshold ROP
RETINA-THE JOURNAL OF RETINAL AND VITREOUS DISEASES
2006; 26 (7): S18-S23
To review systemic modifiable factors that might downregulate pathologic levels of vascular endothelial growth factor (VEGF) in prethreshold retinopathy of prematurity (ROP), and thereby reduce the risk of blindness in affected infants.Review of the author's clinical experience as compared to the STOP-ROP study, and discussion and literature review of the potential effects of oxygen supplementation, light adaptation state, and correction of severe anemia on the course of prethreshold retinopathy of prematurity (ROP).Moderate oxygen supplementation, combined with light adaptation to reduce retinal oxygen consumption and correction of severe anemia, were associated, in the author's experience, with improvement in the clinical course of prethreshold ROP. Withdrawal of these measures was often associated with deterioration of ROP.Systemic measures can be taken that may reduce the risk of blindness in infants with prethreshold ROP. For those infants who require laser treatment for threshold ROP, prior efforts to moderate excessive levels of VEGF may improve the chances of a successful surgical result, by slowing the momentum of the disease.
View details for Web of Science ID 000247086400006
View details for PubMedID 16946672
Effect of higher levels of supplemental oxygen on the conversion rate of prethreshold retinopathy of prematurity (ROP) to threshold disease.
ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2001: S683–S683
View details for Web of Science ID 000168392103638
Diffuse unilateral hemorrhagic retinopathy associated with accidental perinatal strangulation - A clinicopathologic report
RETINA-THE JOURNAL OF RETINAL AND VITREOUS DISEASES
2001; 21 (3): 252-255
To report an unusual case of diffuse retinal hemorrhage associated with strangulation in a neonate with a tightly wrapped nuchal cord around his neck at birth who was noted to have eyelid and subconjunctival petechial hemorrhages upon delivery.Clinical diagnostic examination as well as postmortem gross and histopathologic examination of ocular and central nervous system structures was performed.Funduscopic and gross pathologic examination of the eyes revealed extensive unilateral retinal hemorrhage of the right eye only. This was corroborated by histopathologic studies, which revealed unilateral diffuse hemorrhage throughout all nuclear layers of the retina with a particularly dense nerve fiber layer and sub-internal limiting membrane hemorrhage in the macula along with extraocular muscle and episcleral hemorrhage. Clinical, gross, and microscopic examination also revealed multiple areas of hemorrhage involving the right side of the brain and throughout the cerebellum.Although retinal findings in nonaccidental trauma are common, accidental strangulation retinopathy in neonates is a rare occurrence. To the authors' knowledge, this case is the only documented histopathologic study of hemorrhagic retinopathy associated with strangulation in the literature.
View details for Web of Science ID 000169241600010
View details for PubMedID 11421016
- What can we learn from STOP-ROP and earlier studies? PEDIATRICS 2000; 105 (2): 420-422
- Retinal Surgery Anesthesiologist's Manual of Surgical Procedures edited by Jaffe, R., Samuels, S. Lippincott, Williams & Wilkins. 1999; 2: 112–116
Supplemental oxygen may decrease progression of prethreshold disease to threshold retinopathy of prematurity.
Journal of perinatology
1997; 17 (6): 434-438
The optimum level of oxygen saturation for infants with prethreshold retinopathy of prematurity (ROP) is unknown. We reviewed our conversion rate from prethreshold to threshold ROP between 1985 and 1993 during which time target levels of oxygen saturation rose in a stepwise fashion. A retrospective study of 153 infants with prethreshold ROP was performed at Stanford University between 1985 and 1993 that showed that target minimum oxygen saturation rose from 92% (1985-1987) to 95% (1988) to 96% (1989) to 99% (1990-1993). In addition, we looked at 26 infants between 1994 and 1996 who were excluded from the STOP-ROP study and who were not receiving supplemental oxygen in an effort to maintain equipoise for that study. Infant characteristics were tabulated, and rates of progression from prethreshold to threshold ROP were calculated. Rates of progression to threshold varied little between 1985 and 1989 (average 37%), but dropped to 7% for the period between 1990 and 1993. From 1994 through 1996 the rate of progression to threshold disease rose again, to 38%. Moderate supplemental oxygen (target saturation 99% with PO2 no higher than 100 mm Hg) was associated with regression of prethreshold ROP, without appearing to arrest retinal vascular maturation.
View details for PubMedID 9447528
- Supplemental Oxygen and Light for Prethreshold Retinopathy of Prmaturity Retinopathy of Prematurity edited by Shapiro, M., Biglan, A., Miller, M. Kugler Publications. 1995: 137–138
FLUORESCEINATED DEXTRANS AS MARKERS OF RETINAL NEOVASCULAR MEMBRANES
ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 1992: 1082–82
View details for Web of Science ID A1992HK13501947
SUSTAINED-RELEASE OF GANCICLOVIR FROM POLY (ORTHO ESTER) POLYMER
ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 1991: 883–83
View details for Web of Science ID A1991FC76201056
BACTEROIDES-FRAGILIS ENDOPHTHALMITIS - A CASE-REPORT
CANADIAN JOURNAL OF OPHTHALMOLOGY-JOURNAL CANADIEN D OPHTALMOLOGIE
1990; 25 (4): 208-209
Bacteroides fragilis is an infrequent anaerobic ocular pathogen. Nevertheless, this organism is of particular significance because it may be resistant to many antibiotics that are typically effective against anaerobes. We present what is to the best of our knowledge the first reported case of B. fragilis endophthalmitis. The endophthalmitis presented in a 95-year-old man following extracapsular cataract extraction with posterior chamber intraocular lens implantation.
View details for PubMedID 2191760
Retinopathy of prematurity.
1990; 17 (3): 127-133
Retinopathy of prematurity has reappeared in the neonatal nursery after largely disappearing 35 years ago. The major factor in its reemergence is the progressive improvement in neonatal care, resulting in salvage of infants who formerly would have been lost. Oxygen is now recognized to be but one of many interacting factors in the development of retinopathy of prematurity, with extreme immaturity being the primary factor. Methods of examination, classification and treatment of retinopathy of prematurity are discussed.
View details for PubMedID 2194177
COMPLICATIONS OF CRYORETINAL ABLATION FOR STAGE-3 RETINOPATHY OF PREMATURITY
SLACK INC. 1989: A203–A203
View details for Web of Science ID A1989R585101188
RETINAL FOLDS IN THE SHAKEN BABY SYNDROME
AMERICAN JOURNAL OF OPHTHALMOLOGY
1988; 106 (4): 423-425
We examined two children with presumed shaken baby syndrome. Both children suffered severe, indirect closed head trauma with intracranial hemorrhage, sharply increased intracranial pressure, and extensive neurologic damage. In addition to extensive retinal and preretinal hemorrhages, bilateral symmetric white ring-shaped retinal folds were seen encircling the macula outside the vascular arcades. These retinal folds may be a hallmark of shaking injuries in child abuse victims.
View details for PubMedID 3177559
- 5-Fluorouracil Buckles and Retinal Pigment Epithelium (RPE) Proliferation In Situ Proliferative Vitreoretinopathy (PVR) edited by Freeman, H., Tolentino, F. Springer-Verlag. 1988: 134–139
VISUAL ELECTRICAL EVOKED-POTENTIALS - EVALUATION OF OCULAR INJURIES
1987; 37 (1): 123-128
Clinical neurophysiologists may be asked to participate in the evaluation of patients with injured eyes. We describe a method for eliciting evoked potentials of cerebral origin using electrical pulse stimuli delivered to the globe of the eye through a contact lens electrode mounted on the cornea. These visual electrical evoked potentials (VEEPs) are contrasted with conventional flash visual evoked potentials in normal subjects and in 19 eyes of 17 patients with severe ocular damage, mostly recent trauma. The findings suggest that the site of transcorneal electrical excitation is not the photoreceptors, but more likely one of the nerve cell layers of the retina. VEEP recordings offer a way to circumvent the opacification of the ocular media by blood, which may otherwise hamper the evaluation of retinal function in the injured eye. Preserved VEEP response does not necessarily predict the capacity to recover visual function. Absent VEEP response is an unfavorable prognostic sign, which may be considered in arriving at a decision about enucleation.
View details for Web of Science ID A1987F561100021
View details for PubMedID 3796828
- Use of poly(ortho esters) for the controlled release of 5-fluorouracil and a LHRH analog Journal of Controlled Release 1987; 6 (1): 217-224
4-PORT BIMANUAL VITRECTOMY
ARCHIVES OF OPHTHALMOLOGY
1986; 104 (7): 1088-1089
A further subdivision of functions during vitrectomy surgery has been enabled. By means of a separate, suture-secured fiberoptic endoilluminator and a modified infusion cannula located in the inferior quadrants, two superior sclerotomies are kept free for the use of a variety of simple and complex instruments, alone or in combination. Included among these are vitreous scissors, forceps, picks, spatulas, diathermy probes, and endophotocoagulators.
View details for Web of Science ID A1986D042900041
View details for PubMedID 3729782
- Sustained Release of Fluorouracil by Ethylene Vinyl Acetate Copolymer in a Fibroblast Model of Proliferative Vitreoretinopathy Modern Concepts in Vitreoretinal Diseases edited by Neetens, A. University of Antwerp Press. 1985: 331–332
ALPHA-INTERFERON ADMINISTRATION IN CYTOMEGALOVIRUS RETINITIS
ANTIMICROBIAL AGENTS AND CHEMOTHERAPY
1984; 25 (1): 25-28
Four patients, including three with the acquired immunodeficiency syndrome (AIDS), were treated with high-dose, buffy coat-derived alpha-interferon for progressive cytomegalovirus retinitis. Two of these patients had decreased viruria during therapy and the other two had increased viruria. There was evidence of progression of disease despite therapy in all patients, although the retinitis eventually became quiescent in the patient without AIDS. The severe immunosuppression encountered in AIDS patients complicates the management of cytomegalovirus and other opportunistic infections.
View details for Web of Science ID A1984RY30400007
View details for PubMedID 6322678
View details for PubMedCentralID PMC185427
RETINAL NEOVASCULARIZATION AND OCULAR TOXOPLASMOSIS
AMERICAN JOURNAL OF OPHTHALMOLOGY
1984; 98 (5): 585-589
Retinal neovascularization, a rare complication of ocular toxoplasmosis, is a source of vitreous hemorrhage. We examined three patients (all women, 70, 36, and 19 years old) with inactive toxoplasmosis scars associated with occlusion of a retinal arteriole or venule passing through the scar, capillary nonperfusion, and adjacent retinal neovascularization. In two patients photocoagulation of the ischemic areas produced a cessation of hemorrhage and the disappearance of neovascularization. In the third case, the neovascular frond was avulsed from its supplying retinal arteriole without treatment.
View details for Web of Science ID A1984TS83000008
View details for PubMedID 6208784
INTEGRATED PROJECTION OF FUNDUS PHOTOGRAPHS DURING MACULAR PHOTOCOAGULATION
ARCHIVES OF OPHTHALMOLOGY
1984; 102 (3): 464-465
Macular photocoagulation requires precise localization of abnormalities to be treated, in order to accomplish the aims of therapy without unnecessarily damaging adjacent tissue. A method is described by which a color fundus photo or a fluorescein image can be projected through a beam splitter into the ocular of a laser slit lamp, thus affording an image congruent with the surgeon's view of the patient's macula.
View details for Web of Science ID A1984SG02800026
View details for PubMedID 6703999
LINEAR-ARRAY MULTIPLE TRANSDUCER ULTRASONIC EXAMINATION OF THE EYE
1983; 90 (3): 266-271
Dynamic ultrasonic imaging adds a time dimension to the clinical diagnosis of ocular pathology. A recent development in this area of ophthalmic sonography has been the introduction of an electronically scanned, multiple transducer system that provides improved real-time imaging of ocular tissue motion. This paper discusses clinical observations made in a variety of ophthalmic conditions with a high speed, linear array ultrasound system and discusses briefly the apparatus and special examination techniques needed to make these observations. Clinical subjects include vitreo-retinal adhesions: the clear cortical vitreous network; vitreous hemorrhage, opacities and membranes; shallow, fixed, and mobile retinal detachments; blood vessels within ocular tumors and the evaluation of intraocular foreign bodies.
View details for Web of Science ID A1983QM43200012
View details for PubMedID 6866450
INCIDENCE OF ACTIVE PROLIFERATIVE RETROLENTAL FIBROPLASIA (RLF) IN INFANTS LESS-THAN-OR-EQUAL-TO 1000 GRAMS
SLACK INC. 1983: A113–A113
View details for Web of Science ID A1983PU88600671
TRAUMA-INDUCED ENDOPHTHALMITIS CAUSED BY ACINETOBACTER-ANITRATUS
BRITISH JOURNAL OF OPHTHALMOLOGY
1983; 67 (2): 124-126
A 56-year-old man sustained an intraocular injury by a piece of steel followed by endophthalmitis, which resolved after lensectomy, vitrectomy, and intravitreal injections of gentamicin. Acinetobacter anitratus was the organism responsible for the endophthalmitis. It is a Gram-negative polymorphic organism that can resemble several other pathogens and possesses unpredictable antibiotic susceptibility. A. anitratus is an important cause of nosocomial infection but has not previously been reported as a cause of endophthalmitis following trauma.
View details for Web of Science ID A1983PY70700011
View details for PubMedID 6600400
View details for PubMedCentralID PMC1039980
DOWNS-SYNDROME - 10-YEAR GROUP STUDY
ANNALS OF OPHTHALMOLOGY
1977; 9 (12): 1493-1497
Thirty individuals with the clinical diagnosis of Down's syndrome received ophthalmologic examination periodically over 10 years at a state school for exceptional children. External examination, retinoscopy, anterior segment evaluation, ophthalmoscopy, and tonometry were usually done. The ages at present range from 10 to 50 years. The sex ratio was 80% male and 20% female. Three subjects died during the course of the study. The most frequent ocular anomalies were oblique fissures, refractive error, blepharoconjunctivitis, epicanthus, and Brushfield's spots. All of these occurred in 50% or more of the subjects.
View details for Web of Science ID A1977EH12400001
View details for PubMedID 147042