Wen-Shin Lee, MD

All Publications

• Using Electronic Health Record Data to Determine the Safety of Aqueous Humor Liquid Biopsies for Molecular Analyses. Ophthalmology science Wolf, J., Chemudupati, T., Kumar, A., Franco, J. A., Montague, A. A., Lin, C. C., Lee, W. S., Fisher, A. C., Goldberg, J. L., Mruthyunjaya, P., Chang, R. T., Mahajan, V. B. 2024; 4 (5): 100517

  Abstract

  Knowing the surgical safety of anterior chamber liquid biopsies will support the increased use of proteomics and other molecular analyses to better understand disease mechanisms and therapeutic responses in patients and clinical trials. Manual review of operative notes from different surgeons and procedures in electronic health records (EHRs) is cumbersome, but free-text software tools could facilitate efficient searches.Retrospective case series.A total of 1418 aqueous humor liquid biopsies from patients undergoing intraocular surgery.Free-text EHR searches were performed using the Stanford Research Repository cohort discovery tool to identify complications associated with anterior chamber paracentesis and subsequent endophthalmitis. Complications of the surgery unrelated to the biopsy were not reviewed.Biopsy-associated intraoperative complications and endophthalmitis.A total of 1418 aqueous humor liquid biopsies were performed by 17 experienced surgeons. EHR free-text searches were 100% error-free for surgical complications, >99% for endophthalmitis (<1% false positive), and >93.6% for anesthesia type, requiring manual review for only a limited number of cases. More than 85% of cases were performed under local anesthesia without ocular muscle akinesia. Although the most common indication was cataract (50.1%), other diagnoses included glaucoma, diabetic retinopathy, uveitis, age-related macular degeneration, endophthalmitis, retinitis pigmentosa, and uveal melanoma. A 50- to 100-μL sample was collected in all cases using either a 30-gauge needle or a blunt cannula via a paracentesis. The median follow-up was >7 months. There was only one minor complication (0.07%) identified: a case of a small tear in Descemet membrane without long-term sequelae. No other complications occurred, including other corneal injuries, lens or iris trauma, hyphema, or suprachoroidal hemorrhage. There was no case of postoperative endophthalmitis.Anterior chamber liquid biopsy during intraocular surgery is a safe procedure and may be considered for large-scale collection of aqueous humor samples for molecular analyses. Free-text EHR searches are an efficient approach to reviewing intraoperative procedures.Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

  View details for DOI 10.1016/j.xops.2024.100517

  View details for PubMedID 38881613

  View details for PubMedCentralID PMC11179400

• Preparing the Ocular Surface for a Boston Keratoprosthesis Type 1 Through En Bloc Minor Salivary Gland Transplantation and Mucous Membrane Grafting in End-Stage Stevens-Johnson Syndrome. Cornea Arboleda, A., Phansalkar, R., Amescua, G., Lee, W. S., Brandt, J. D., Mannis, M. J., Kossler, A. L., Lin, C. C. 2023

  Abstract

  This case describes the successful visual restoration of a patient with end-stage Stevens-Johnson syndrome (SJS) with a severely keratinized ocular surface.This study is a case report.A 67-year-old man with SJS secondary to allopurinol sought visual rehabilitation options. His ocular surface was severely compromised from sequelae of chronic SJS, leaving him with light perception vision bilaterally. The left eye was completely keratinized with severe ankyloblepharon. The right eye had failed penetrating keratoplasty, limbal stem cell deficiency, and a keratinized ocular surface. The patient declined both a Boston type 2 keratoprosthesis and a modified osteo-odonto keratoprosthesis. Therefore, a staged approach was pursued with (1) systemic methotrexate to control ocular surface inflammation, (2) minor salivary gland transplant to increase ocular surface lubrication, (3) lid margin mucous membrane graft to reduce keratinization, and finally, (4) Boston type 1 keratoprosthesis for visual restoration. After minor salivary gland transplant and mucous membrane graft, the Schirmer score improved from 0 mm to 3 mm with improvement in ocular surface keratinization. This approach successfully restored the vision to 20/60, and the patient has retained the keratoprosthesis for over 2 years.Sight restoration options are limited in patients with end-stage SJS with a keratinized ocular surface, aqueous and mucin deficiency, corneal opacification, and limbal stem cell deficiency. This case demonstrates successful ocular surface rehabilitation and vision restoration in such a patient through a multifaceted approach that resulted in successful implantation and retention of a Boston type 1 keratoprosthesis.

  View details for DOI 10.1097/ICO.0000000000003262

  View details for PubMedID 37159138

• Intraoperative optical coherence tomography-guided deep anterior lamellar keratoplasty. Taiwan journal of ophthalmology Lin, C. C., Lee, W. S. 2023; 13 (1): 106-109

  Abstract

  Gauging stromal dissection depth is crucial to successfully perform deep anterior lamellar keratoplasty (DALK) surgery. Intraoperative optical coherence tomography (iOCT) offers a promising tool to aid DALK surgery but visualization of surgical maneuvers is impaired due to artifacts from metallic instruments. We describe a novel surgical technique utilizing suture-assisted iOCT guidance that facilitates clear visualization of corneal dissection planes during DALK. A stromal dissection tunnel is performed with a Fogla probe and its depth is subsequently identified by threading a 1 cm segment of 8-0 nylon into the tunnel. In contrast to the Fogla probe, the 8-0 nylon is conspicuously highlighted on iOCT. If the tunnel is too superficial, a separate, deeper stromal tunnel can be created and visualized again with the 8-0 nylon suture and iOCT. This iterative process facilitates a deep stromal dissection, increasing the probability of successful big-bubble formation and Descemet baring DALK surgery. This technique was utilized for a successful big-bubble DALK in a patient with severe keratoconus.

  View details for DOI 10.4103/tjo.TJO-D-22-00151

  View details for PubMedID 37252175

  View details for PubMedCentralID PMC10220450

• Intraoperative optical coherence tomography-guided deep anterior lamellar keratoplasty TAIWAN JOURNAL OF OPHTHALMOLOGY Lin, C., Lee, W. 2023; 13 (1): 106-109

  View details for DOI 10.4103/tjo.TJO-D-22-00151

  View details for Web of Science ID 000961070300019

• Structural and Metabolic Imaging after Short-term Use of the Balance Goggles System in Glaucoma Patients: A Pilot Study. Journal of glaucoma Sun, M. T., Beykin, G., Lee, W. S., Sun, Y., Chang, R., Nunez, M., Li, K. Z., Knasel, C., Rich, C., Goldberg, J. L. 2022

  Abstract

  Short-term use of the Balance Goggles System in glaucoma patients was not associated with observable changes in conventional OCT imaging but metabolic imaging using peripapillary flavoprotein fluorescence may represent a useful adjuctive investigation.To determine whether the intraocular pressure (IOP)-lowering effects of the Balance Goggles System (BGS) are accompanied by changes in retinal thickness measured by ocular coherence tomography, retinal vascular density measured by OCT-angiography, or novel peripapillary metabolic profiling using flavoprotein fluorescence (FPF) measured by a fundus camera.Prospective comparative case-series.8 eyes from 8 patients with open-angle glaucoma ranging from mild to severe.In this prospective, single-center, open-label, non-randomized, single-arm study patients received a baseline evaluation including retinal imaging, then one hour of negative pressure application through the BGS, followed by repeat retinal imaging. Participants then used the BGS at home for 1 month and underwent a repeat evaluation at the conclusion of the trial.Changes in nerve fiber layer thickness, OCTA vascular parameters and FPF scores.Mean baseline IOP was 18.0±3.1 mmHg and there was no significant change in IOP at follow-up. At 1 month compared to baseline, there was a statistically significant improvement in FPF optic nerve head rim scores (12.7±11.6 to 10.5±7.5; P=0.04). Additionally, there was there was a trend towards an increase in RNFL thickness after 1 month (69.5±14.2 to 72.0±13.7; P=0.1), but there were no statistically significant differences observable with any of the OCTA vascular parameters either at 1 hour or after 1 month.There were no significant changes observable using conventional OCT imaging following short-term use of the BGS, although metabolic imaging using FPF may be a useful potential biomarker to complement existing investigations. Additional studies are warranted to further investigate these changes.

  View details for DOI 10.1097/IJG.0000000000002066

  View details for PubMedID 35696700

• Efficacy of Netarsudil as an Additional Therapy for Glaucoma in Patients Already on Maximally Tolerated Medical Therapy Villegas, N. C., Lee, W. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2021

  View details for Web of Science ID 000690761400725

• Effectiveness of Netarsudil as an Additional Therapy for Glaucoma in Patients Already on Maximally Tolerated Medical Therapy. Clinical ophthalmology (Auckland, N.Z.) Villegas, N. C., Lee, W. 2021; 15: 4367-4372

  Abstract

  Purpose: This study seeks to evaluate the effectiveness of netarsudil (Rhopressa) in patients with inadequately controlled IOP on otherwise maximally tolerated medical therapy.Methods: This is a retrospective study of patients started on netarsudil at Stanford University. Exclusion criteria included glaucoma surgery or laser within 6 months of starting netarsudil and other modifications to the baseline medication regimen within 4 weeks of starting netarsudil. The primary outcome was treatment success, defined as IOP reduction meeting a predetermined target, and no further medication, laser, or surgery recommended subsequent to starting netarsudil.Results: Sixty-two eyes were included, and 36 (58%) achieved treatment success at first follow-up. Mean baseline IOP was 19.5 ± 5.6 mmHg on a mean of 3.5 ± 0.7 ocular hypotensive medications. The mean change in IOP from baseline to first follow-up was -3.53 mmHg (-17%). In patients who achieved treatment success, mean IOP change was -5.22 mmHg (-28.0%). Of the eyes with baseline IOP ≤ 20 mmHg, 69% achieved treatment success, compared to only 17% of eyes with baseline IOP ≥ 21 mmHg (P < 0.05).Conclusion: Netarsudil is effective in lowering IOP for patients on otherwise maximally tolerated medical therapy, for which glaucoma laser or surgery would have been the only remaining therapeutic options. Treatment success was more likely in eyes with baseline IOP under 20 mmHg.

  View details for DOI 10.2147/OPTH.S337105

  View details for PubMedID 34754176

• An Open-Label Phase Ib Study to Evaluate Retinal Imaging After Short-term Use of the Balance Goggles System (BGS) in Patients with Glaucoma Li, Z., Knasel, C., Nunez, M., Beykin, G., Goldstein, A., Fisher, A. C., Singh, K., Sun, Y., Chang, R. T., Lee, W., Goldberg, J. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2020

  View details for Web of Science ID 000554528303047

• Cataract Surgery and Rate of Visual Field Progression in Primary Open-Angle Glaucoma AMERICAN JOURNAL OF OPHTHALMOLOGY Kim, J., Rabiolo, A., Morales, E., Fatehi, N., Lee, W., Yu, F., Afifi, A. A., Nouri-Mahdavi, K., Caprioli, J. 2019; 201: 19–30

  Abstract

  To test the hypothesis that cataract surgery slows the apparent rate of visual field (VF) decay in primary open-angle glaucoma patients compared with rates measured during cataract progression.Retrospective cohort study.Consecutive open-angle glaucoma patients who underwent cataract surgery and who had ≥4 VFs and ≥3 years of follow-up before and after surgery were retrospectively reviewed. Mean deviation (MD) rate, visual field index (VFI) rate, pointwise linear regression (PLR), pointwise rate of change (PRC), and the Glaucoma Rate Index (GRI) were compared before and after cataract surgery.A total of 134 eyes of 99 patients were included. Median (interquartile range) follow-up was 6.5 (4.7-8.1) and 5.3 (4.0-7.3) years before and after cataract surgery, respectively. All intraocular pressure (IOP) parameters (mean IOP, standard deviation of IOP, and peak IOP) significantly improved (P < .001) after cataract surgery. All VF indices indicated an accelerated VF decay rate after cataract surgery: MD rate (-0.18 ± 0.40 dB/year vs -0.40 ± 0.62 dB/year, P < .001), VFI rate (-0.44% ± 1.09%/year vs -1.19% ± 1.85%/year, P < .001), GRI (-5.5 ± 10.8 vs -13.5 ± 21.5; P < .001), and PRC (-0.62% ± 2.47%/year before and -1.35% ± 3.71%/year after surgery; P < .001) and PLR (-0.20 ± 0.82 dB/year before and -0.42 ± 1.16 dB/year after surgery; P < .001) for all VF locations. Worse baseline MD and postoperative peak IOP were significantly associated with the postoperative VF decay rate and the change in the decay rate after cataract surgery.Although all IOP parameters improved after cataract surgery, VFs continued to progress. Cataract surgery does not slow the apparent rate of glaucomatous VF decay as compared to rates measured during the progression of the cataract.

  View details for DOI 10.1016/j.ajo.2019.01.019

  View details for Web of Science ID 000468253700003

  View details for PubMedID 30703355

• Comparison of simulated keratometric changes following wavefront-guided and wavefront-optimized myopic laser-assisted in situ keratomileusis CLINICAL OPHTHALMOLOGY Lee, W., Manche, E. E. 2018; 12: 613–19

  Abstract

  The aim of the study was to determine and compare the relationship between change in simulated keratometry (K) and degree of refractive correction in wavefront-guided (WFG) and wavefront-optimized (WFO) myopic laser-assisted in situ keratomileusis (LASIK).A total of 51 patients were prospectively randomized to WFG LASIK in one eye and WFO LASIK in the contralateral eye at the Byers Eye Institute, Stanford University. Changes in simulated K and refractive error were determined at 1 year post-operatively. Linear regression was employed to calculate the slope of change in simulated K (ΔK) for change in refractive error (ΔSE). The mean ratio (ΔK/ΔSE) was also calculated.The ratio of ΔK to ΔSE was larger for WFG LASIK compared to WFO LASIK when comparing the slope (ΔK/ΔSE) as determined by linear regression (0.85 vs 0.83, p = 0.04). Upon comparing the mean ratio (ΔK/ΔSE), subgroup analysis revealed that ΔK/ΔSE was larger for WFG LASIK for refractive corrections of >3.00 D and >4.00 D (0.89 vs 0.83; p = 0.0323 and 0.88 vs 0.83; p = 0.0466, respectively). Both linear regression and direct comparison of the mean ratio (ΔK/ΔSE) for refractive corrections <4.00 D and >4.00 D revealed no difference in ΔK/ΔSE between smaller and larger refractive corrections.WFO LASIK requires a smaller amount of corneal flattening compared to WFG LASIK for a given degree of refractive correction. For both, there was no significant difference in change in corneal curvature for a given degree of refractive error between smaller and larger corrections.

  View details for PubMedID 29636597

• Phototherapeutic keratectomy for epithelial basement membrane dystrophy. Clinical ophthalmology (Auckland, N.Z.) Lee, W., Lam, C. K., Manche, E. E. 2017; 11: 15-22

  Abstract

  The purpose of this study was to evaluate the long-term efficacy of phototherapeutic keratectomy (PTK) in treating epithelial basement membrane dystrophy (EBMD).Preoperative and postoperative records were reviewed for 58 eyes of 51 patients with >3 months follow-up (range 3-170 months) treated for EBMD with PTK after failure of conservative medical treatment at Byers Eye Institute of Stanford University. Symptoms, clinical findings, and corrected distance visual acuity (CDVA) were assessed. The primary outcome measure was symptomatic recurrence as measured by erosions or visual complaints >3 months after successful PTK.For eyes with visual disturbances (n=30), preoperative CDVA waŝ20/32 (0.24 Log-MAR, SD 0.21) and postoperative CDVA was ~20/25 (0.07 LogMAR, SD 0.12; P<0.0001). Twenty-six eyes (86.7%) responded to treatment, with symptomatic recurrence in 6 eyes (23.1%) at an average of 37.7 months (SD 42.8). For eyes with painful erosions (n=29), preoperative CDVA was ~20/25 (0.12, SD 0.19) and postoperative CDVA was ~20/20 (0.05. SD 0.16; P=0.0785). Twenty-three eyes (79.3%) responded to treatment, with symptomatic recurrence in 3 eyes (13.0%) at an average of 9.7 months (SD 1.5). The probability of being recurrence free after a successful treatment for visual disturbances and erosions at 5 years postoperatively was estimated at 83.0% (95% confidence interval 68.7%-97.0%) and 88.0% (95% confidence interval 65.3%-96.6%), respectively.The majority of visual disturbances and painful erosions associated with EBMD respond to PTK. For those with a treatment response, symptomatic relief is maintained over long-term follow-up.

  View details for DOI 10.2147/OPTH.S122870

  View details for PubMedID 28031698

• Comparison of Simulated Keratometric Changes Following Wavefront-Guided and Wavefront-Optimized Myopic Photorefractive Keratectomy JOURNAL OF REFRACTIVE SURGERY Lee, W., Manche, E. E. 2016; 32 (8): 542-548

  Abstract

  To determine the relationship between change in simulated keratometry and corrected refractive error in both wavefront-guided and wavefront-optimized myopic photorefractive keratectomy (PRK), and to determine whether there is a difference in this relationship between these two ablation profiles.Sixty-eight patients received wavefront-guided PRK in one eye and wavefront-optimized PRK in the contralateral eye. The changes in simulated keratometry and corresponding refractive changes for both were determined at 1 year postoperatively. Linear regression was employed to calculate the slope of change in simulated keratometry (ΔK) for change in refractive error (ΔSE) for both wavefront-guided and wavefront-optimized PRK and compared. The mean ratio ΔK/ΔSE was also calculated for both wavefront-guided and wavefront-optimized PRK and compared.There was no significant difference in the ratio of ΔK to ΔSE between wavefront-optimized and wavefront-guided PRK by both linear regression modeling and comparison of the mean ratio ΔK/ΔSE. Linear regression modeling revealed that the ratio of ΔK/ΔSE was greater for small amounts of change in refractive error and smaller for large amounts of change in refractive error. This trend was only statistically significant for the wavefront-optimized group when comparing the means of the ratio ΔK/ΔSE (P = .0287).The change in corneal curvature induced for a given degree of refractive correction was similar for both wavefront-optimized and wavefront-guided PRK. For both, a proportionally smaller amount of corneal flattening was required for larger degrees of refractive correction compared to smaller degrees. [J Refract Surg. 2016;32(8):542-548.].

  View details for DOI 10.3928/1081597X-20160525-01

  View details for Web of Science ID 000384899900005

  View details for PubMedID 27505315